127 lines
2.2 KiB
Plaintext
127 lines
2.2 KiB
Plaintext
Test Procedure for §170.304.h Clinical Summaries
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APPROVED (Pending) Version 1.0 July 21, 2010
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TD170.304.h.: Clinical summaries
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* indicates alternative standard code per certification criteria
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Clinical Summaries Test Data – Set #5|Office Visit #1 for Johnathan Stone
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Johnathan Stone
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|11/12/1966 08:18:08
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|Male
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|988772587
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|Medical Record Number
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|937 Sutter Street<br>Aurora,<br>Colorado 80011<br>303-544-9988
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|----
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|}
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“Source” for all data for this patient: Samuel Johnston, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|250.02
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|Diabetes Mellitus, Type 2
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|Active
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|07/17/2010
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|44054006
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|Diabetes Mellitus, Type 2
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|Active
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|07/17/2010
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|205875
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|Medication
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|glyburide
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|Diabeta
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|2.5 mg
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|1 Tablet
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|PO
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|Q AM
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|07/17/2010
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|03/25/1997
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|Drug Allergy
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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|04/25/1989
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Chemistry
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|14771-0
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|LOINC
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|Fasting Blood Glucose (70–100 mg/dl)
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|120 mg/dl
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|07/17/2010
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|----
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