48 lines
4.3 KiB
Plaintext
48 lines
4.3 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 |