Difference between revisions of "NIST-Inpatient-test-patient-5"

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As a new user and proponent of the WorldVistA Electronic Health Record, I will document on this page my personal experience using the software on a test system in my home.
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Patient Summary Record Test Data – Set #5
 +
{| border="1" |
 +
!colspan="6"|Patient
 +
|-
 +
!scope="col"|Name
 +
!scope="col"|Date/Time of Birth
 +
!scope="col"|Gender
 +
!scope="col"|Identification Number
 +
!scope="col"|Identification Number Type
 +
!scope="col"|Address/Phone
 +
|----
 +
|Christine Taylor
 +
|09/22/1965 <br>16:48:25
 +
|Female
 +
|9787478034
 +
|Medical Record Number
 +
|754 Angel Street <br>Marshalltown<br>Iowa 50158<br> 641-544-9988
 +
|----
 +
|}
 +
“Source” for all data for this patient: Kathryn Thomson, MD
 +
{| border="1" |
 +
!colspan="5"|Problem List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Diagnosis
 +
|540.0
 +
|Acute Appendicitis
 +
|Resolved
 +
|01/09/2010
 +
|----
 +
|Diagnosis
 +
|434.91
 +
|Cerebrovascular Accident (Stroke)
 +
|Resolved
 +
|07/09/2009
 +
|----
 +
|Diagnosis
 +
|250.02
 +
|Diabetes Mellitus, Type 2
 +
|Active
 +
|03/30/2009
 +
|----
 +
|Symptom
 +
|401.9
 +
|Hypertension, Essential
 +
|Chronic
 +
|02/25/2008
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code*
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Disorder
 +
|74400008
 +
|Appendicitis
 +
|Resolved
 +
|01/09/2010
 +
|----
 +
|Disorder
 +
|230690007
 +
|Cerebrovascular Accident (Stroke)
 +
|Resolved
 +
|07/09/2009
 +
|----
 +
|Disorder
 +
|44054006
 +
|Diabetes Mellitus, Type 2
 +
|Active
 +
|03/30/2009
 +
|----
 +
|Disorder
 +
|59621000
 +
|Essential Hypertension
 +
|Chronic
 +
|02/25/2008
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="10"|Medication List
 +
|----
 +
!scope="col"|RxNorm Code
 +
!scope="col"|Product
 +
!scope="col"|Generic Name
 +
!scope="col"|Brand Name
 +
!scope="col"|Strength
 +
!scope="col"|Dose
 +
!scope="col"|Route
 +
!scope="col"|Frequency
 +
!scope="col"|Date Started
 +
!scope="col"|Status
 +
|----
 +
|309362
 +
|Medication
 +
|clopidogrel
 +
|Plavix
 +
|75 mg
 +
|1 Tablet
 +
|PO
 +
|QD
 +
|07/15/2009
 +
|Active
 +
|----
 +
|205875
 +
|Medication
 +
|glyburide
 +
|Diabeta
 +
|2.5 mg
 +
|1 Tablet
 +
|PO
 +
|Q AM
 +
|03/30/2009
 +
|Active
 +
|----
 +
|209834
 +
|Medication
 +
|docusate
 +
|Colace
 +
|100 mg
 +
|1 Capsule
 +
|PO
 +
|BID
 +
|03/30/2009
 +
|Active
 +
|----
 +
|200801
 +
|Medication
 +
|furosemide
 +
|Lasix
 +
|20 mg
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|02/25/2008
 +
|Active
 +
|----
 +
|628958
 +
|Medication
 +
|potassium chloride
 +
|Klor-Con
 +
|10 mEq
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|02/25/2008
 +
|Active
 +
|----
 +
|884175
 +
|Medication
 +
|clonidine hydrochloride
 +
|Catapres
 +
|0.1 mg
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|02/25/2008
 +
|Active
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="5"|Medication [[Allergy~|Allergy]] List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code
 +
!scope="col"|Medication/Agent
 +
!scope="col"|Reaction
 +
!scope="col"|Date Recorded
 +
|----
 +
|Drug [[Allergy~|Allergy]]
 +
|293620004
 +
|Indomethacin
 +
|Rash, dizziness, headache
 +
|06/05/2008
 +
|----
 +
|Drug [[Allergy~|Allergy]]
 +
|294506009
 +
|Ampicillin
 +
|Diarrhea, nausea, vomiting
 +
|05/25/1997
 +
|----
 +
|Drug [[Allergy~|Allergy]]
 +
|91939003
 +
|Sulfonamides
 +
|Hives, photosensitivity
 +
|08/25/1989
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="5"|Diagnostic Test Results
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|LOINC Code
 +
!scope="col"|Test (Normal Range)
 +
!scope="col"|Result
 +
!scope="col"|Date Performed
 +
|----
 +
|Chemistry
 +
|14771-0
 +
|Fasting Blood Glucose (70–100 mg/dl)
 +
|126 mg/dl
 +
|07/15/2010
 +
|----
 +
|Chemistry
 +
|2823-3
 +
|Potassium (3.5–5.3 mg/dl)
 +
|4.3 mg/dl
 +
|07/15/2010
 +
|----
 +
|Chemistry
 +
|14927-8
 +
|Triglycerides (&lt;150 mg/dl)
 +
|178 mg/dl
 +
|07/15/2010
 +
|----
 +
|Imaging
 +
|42272-5
 +
|Chest X-ray, PA &amp; Lateral
 +
|The heart outline is normal<br> and the hilar and <br>mediastinal vessels are<br> of normal appearance
 +
|02/25/2008
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="5"|Procedure List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Surgical
 +
|47.09
 +
|Emergency Appendectomy
 +
|Completed
 +
|01/09/2010
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|CPT Code*
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Surgical
 +
|44950
 +
|Emergency Appendectomy
 +
|Completed
 +
|01/09/2010
 +
|----
 +
|}
 +
[https://trac.opensourcevista.net/browser/hData/trunk/test-patients/NIST-Inpatient-test-patient-5.csv CSV format of this data]
  
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How I became interested:
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--[[User:Glilly|Glilly]] 10:11, 21 Nov 2010 (PST)
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I suppose I am like the
 

Latest revision as of 01:28, 22 February 2012

Patient Summary Record Test Data – Set #5

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Christine Taylor 09/22/1965
16:48:25 		Female 9787478034 Medical Record Number 754 Angel Street
Marshalltown
Iowa 50158
641-544-9988

“Source” for all data for this patient: Kathryn Thomson, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 540.0 Acute Appendicitis Resolved 01/09/2010
Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/30/2009
Symptom 401.9 Hypertension, Essential Chronic 02/25/2008
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 74400008 Appendicitis Resolved 01/09/2010
Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/30/2009
Disorder 59621000 Essential Hypertension Chronic 02/25/2008
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 03/30/2009 Active
209834 Medication docusate Colace 100 mg 1 Capsule PO BID 03/30/2009 Active
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/25/2008 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 02/25/2008 Active
884175 Medication clonidine hydrochloride Catapres 0.1 mg 1 Tablet PO BID 02/25/2008 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293620004 Indomethacin Rash, dizziness, headache 06/05/2008
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 05/25/1997
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 08/25/1989
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 126 mg/dl 07/15/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 07/15/2010
Chemistry 14927-8 Triglycerides (<150 mg/dl) 178 mg/dl 07/15/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is normal
and the hilar and
mediastinal vessels are
of normal appearance 		02/25/2008
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Surgical 47.09 Emergency Appendectomy Completed 01/09/2010
Type CPT Code* Procedure Status Date Performed
Surgical 44950 Emergency Appendectomy Completed 01/09/2010

CSV format of this data

--Glilly 10:11, 21 Nov 2010 (PST)

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