1.4 KiB
1.4 KiB
1 | Test Procedure for §170.304.h Clinical Summaries |
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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 #1|Office Visit #1 for Jonas Barnaby |
6 | Patient |
7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
8 | Jonas Barnaby|07/14/1961|Male|969988999|Medical Record Number|478 Charles Street, |
9 | 12:30:24|Williamsport, |
10 | Pennsylvania|17701 |
11 | 570-857-8593 |
12 | “Source” for all data for this patient: Marcus Welby, MD |
13 | Problem List |
14 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
15 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/20/2010 |
16 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
17 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/20/2010 |
18 | Medication List |
19 | RxNorm |
20 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
21 | Code |
22 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/20/2010|Active |
23 | Medication Allergy List |
24 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
25 | Drug Allergy|293597001|Codeine|Hives|06/27/1996 |
26 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994 |
27 | Diagnostic Test Results |
28 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
29 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|178 mg/dl|07/20/2010 |