NIST-EP-Patient-2-Visit-2

Test Procedure for §170.304.h Clinical Summaries  APPROVED (Pending) Version 1.0  July 21, 2010  

TD170.304.h.: Clinical summaries

• indicates alternative standard code per certification criteria

Clinical Summaries Test Data – Set #2|Office Visit #2 for Robert Flint

Patient
Name	Date/Time of Birth	Gender	Identification Number	Identification Number Type	Address/Phone
Robert Flint	04/18/1983 20:18:04	Male	9813624798	Medical Record Number	747 Market Street, Morton, Illinois 61550 309-365-8298

“Source” for all data for this patient: Carl Roberts, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Diagnosis	250.02	Diabetes Mellitus, Type 2	Active	03/10/2010
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	44054006	Diabetes Mellitus, Type 2	Active	03/10/2010

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
205875	Medication	glyburide	Diabeta	2.5 mg	1 Tablet	PO	Q AM	03/10/2010	Active

Medication Allergy List
Type	SNOMED Code	Medication/Agent	Reaction	Date Recorded
Drug Allergy	91936005	Penicillin	Rash and anaphylaxis	08/10/2008
Drug Allergy	293620004	Indomethacin	Nausea, vomiting, rash, dizziness, headache	03/25/2003

Diagnostic Test Results
Type	LOINC Code	Test (Normal Range)	Result	Date Performed
Chemistry	14771-0	Fasting Blood Glucose (70–100 mg/dl)	150 mg/dl	03/10/2010
Imaging	24648-8	Chest X-ray, PA	The heart outline is normal and the hilar and mediastinal vessels are of normal appearance	03/10/2010

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