1.4 KiB
1.4 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 #3|Office Visit #1 for Barbara Simpson |
| 6 | Patient |
| 7 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 8 | Barbara Simpson|10/12/1956 19:47:01|Female|9688675266|Medical Record Number|996 Dalton Street,<br>Fargo,<br>North Dakota 54102<br>701-366-5534 |
| 9 | “Source” for all data for this patient: Robert James, MD |
| 10 | Problem List |
| 11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 12 | Diagnosis|486|Pneumonia|Active|07/02/2010 |
| 13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 14 | Disorder|233604007|Pneumonia|Active|07/02/2010 |
| 15 | Medication List |
| 16 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 17 | 308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|07/02/2010|Active |
| 18 | Medication Allergy List |
| 19 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 20 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009 |
| 21 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988 |
| 22 | Diagnostic Test Results |
| 23 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 24 | Imaging|42272-5|Chest X-ray, PA & Lateral|Bilateral Pneumonia|07/02/2010 |
| 25 | Cardiology|34534-8|Electrocardiogram|Sinus Tachycardia|07/02/2010 |