49 lines
1.7 KiB
Plaintext
49 lines
1.7 KiB
Plaintext
Test Procedure for §170.304.i Exchange Clinical Information and Patient Summary Record
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APPROVED (Pending) Version 1.0 July 21, 2010
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Patient Summary Record Test Data – Set #2
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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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Ralph Johnson|06/28/1984|Male|9813466798|Medical Record Number|355 Elm Street
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13:20:10|Morton,
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Illinois|61550
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309-377-8365
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“Source” for all data for this patient: Carl Roberts, 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|493.00|Asthma, unspecified|Active|12/22/2009
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Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|08/10/2008
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|195967001|Asthma|Active|12/22/2009
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Disorder|44054006|Diabetes Mellitus, Type 2|Active|08/10/2008
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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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Alupent
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metaproterenol
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206833|Medication|Inhalation|15 mg/ml|2 Puffs|Inhaled|Q4h|12/22/2009|Active
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sulfate
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Aerosol
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205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|08/10/2008|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|91936005|Penicillin|Rash and anaphylaxis|08/10/2008
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Nausea, vomiting, rash,
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Drug Allergy|293620004|Indomethacin|03/25/2003
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dizziness, headache
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Diagnostic Test Results
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Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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Increased bronchial wall
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Imaging|24648-8|Chest X-ray, PA|02/16/2010
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markings, patchy infiltrates
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Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|70 mg/dl|12/22/2009
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Hematology|26449-9|Eosinophil Count (1 – 3 %)|2%|12/22/2009
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Imaging|24648-8|Chest X-ray, PA|Bronchial wall markings|12/22/2009
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