NIST-EP-Patient-2-Visit-1

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 #1 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	493.00	Asthma, unspecified	Active	07/19/2009
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	195967001	Asthma	Active	07/19/2009

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
206833	Medication	metaproterenol sulfate	Alupent Inhalation Aerosol	15 mg/ml	2 Puffs	Inhaled	Q4h	07/19/2009	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
Imaging	24648-8	Chest X-ray, PA	Increased bronchial wall markings, patchy infiltrates	07/19/2009

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