40 lines
2.9 KiB
Plaintext
40 lines
2.9 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 #1 Office Visit #1 for Jonas Barnaby
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Patient
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Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
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Jonas Barnaby 07/14/1961 Male 969988999 Medical Record Number 478 Charles Street,
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12:30:24 Williamsport,
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Pennsylvania 17701
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570-857-8593
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“Source” for all data for this patient: Marcus Welby, MD
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Problem List
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Type ICD-9 Code Patient Problem Status Date Diagnosed
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Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 07/20/2010
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 44054006 Diabetes Mellitus, Type 2 Active 07/20/2010
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Medication List
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RxNorm
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Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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Code
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205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 07/20/2010 Active
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Medication Allergy List
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Type SNOMED Code Medication/Agent Reaction Date Recorded
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Drug Allergy 293597001 Codeine Hives 06/27/1996
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Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/15/1994
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 178 mg/dl 07/20/2010 |