1.6 KiB
1.6 KiB
| 1 | Test Procedure for §170.304.h Clinical Summaries |
|---|---|
| 2 | APPROVED (Pending) Version 1.0 July 21, 2010 |
| 3 | TD170.304.h.: Clinical summaries |
| 4 | * indicates alternative standard code per certification criteria |
| 5 | Clinical Summaries Test Data – Set #4|Office Visit #2 for Susan Ellerby |
| 6 | Patient |
| 7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 8 | Susan Ellerby|12/08/1963 21:54:24|Female|925377799|Medical Record Number|483 Powell Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-9475 |
| 9 | “Source” for all data for this patient: Dorcas Wayne, MD |
| 10 | Problem List |
| 11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 12 | Symptom|401.9|Hypertension, Essential|Active|02/05/2010 |
| 13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 14 | Disorder|59621000|Essential Hypertension|Active|02/05/2010 |
| 15 | Medication List |
| 16 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 17 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/05/2010|Active |
| 18 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/05/2010|Active |
| 19 | Medication Allergy List |
| 20 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 21 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998 |
| 22 | Drug Allergy|293597001|Codeine|Hives|02/17/1992 |
| 23 | Diagnostic Test Results |
| 24 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 25 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|02/05/2010 |
| 26 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance|02/05/2010 |