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
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{| border="1" |
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How I became interested:
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!colspan="6"|Patient
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|-
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I suppose I am like the majority of people, I have always been in good health, had medical insurance and had very limited contact with the Health Care System, yet assumed I knew "how it all worked" if I did need to use it.
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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A recent health issue left me reeling with disbelief with regard to the lack of patient health information being readily available to the very health care providers who needed it. Every visit to a hospital, doctor, or clinic
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
 +
|Christine Taylor
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|09/22/1965 16:48:25
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|Female
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|9787478034
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|Medical Record Number
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|754 Angel Street Marshalltown Iowa 50158 641-544-9988
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|}
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“Source” for all data for this patient: Kathryn Thomson, MD
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{| border="1" |
 +
!colspan="5"|Problem List
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|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Diagnosis
 +
|540.0
 +
|Acute Appendicitis
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|Resolved
 +
|01/09/2010
 +
|----
 +
|Diagnosis
 +
|434.91
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|Cerebrovascular Accident (Stroke)
 +
|Resolved
 +
|07/09/2009
 +
|----
 +
|Diagnosis
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|250.02
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|Diabetes Mellitus, Type 2
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|Active
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|03/30/2009
 +
|----
 +
|Symptom
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|401.9
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|Hypertension, Essential
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|Chronic
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|02/25/2008
 +
|----
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!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
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|Active
 +
|03/30/2009
 +
|----
 +
|Disorder
 +
|59621000
 +
|Essential Hypertension
 +
|Chronic
 +
|02/25/2008
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="10"|Medication List
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|----
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!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
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|Plavix
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|75 mg
 +
|1 Tablet
 +
|PO
 +
|QD
 +
|07/15/2009
 +
|Active
 +
|----
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|205875
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|Medication
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|glyburide
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|Diabeta
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|2.5 mg
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|1 Tablet
 +
|PO
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|Q AM
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|03/30/2009
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|Active
 +
|----
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|209834
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|Medication
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|docusate
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|Colace
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|100 mg
 +
|1 Capsule
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|PO
 +
|BID
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|03/30/2009
 +
|Active
 +
|----
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|200801
 +
|Medication
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|furosemide
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|Lasix
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|20 mg
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|02/25/2008
 +
|Active
 +
|----
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|628958
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|Medication
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|potassium chloride
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|Klor-Con
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|10 mEq
 +
|1 Tablet
 +
|PO
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|BID
 +
|02/25/2008
 +
|Active
 +
|----
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|884175
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|Medication
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|clonidine hydrochloride
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|Catapres
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|0.1 mg
 +
|1 Tablet
 +
|PO
 +
|BID
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|02/25/2008
 +
|Active
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="5"|Medication Allergy List
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|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code
 +
!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|293620004
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|Indomethacin
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|Rash, dizziness, headache
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|06/05/2008
 +
|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|05/25/1997
 +
|----
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|Drug Allergy
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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|08/25/1989
 +
|----
 +
|}
 +
{| border="1" |
 +
!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
 +
!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
 +
|----
 +
|Chemistry
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|14771-0
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|Fasting Blood Glucose (70–100 mg/dl)
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|126 mg/dl
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|07/15/2010
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|----
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|Chemistry
 +
|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|4.3 mg/dl
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|07/15/2010
 +
|----
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|Chemistry
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|14927-8
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|Triglycerides (<150 mg/dl)
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|178 mg/dl
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|07/15/2010
 +
|----
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|Imaging
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|42272-5
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|Chest X-ray, PA & Lateral
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|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
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|02/25/2008
 +
|----
 +
|}
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{| border="1" |
 +
!colspan="5"|Procedure List
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|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
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|----
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|Surgical
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|47.09
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|Emergency Appendectomy
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|Completed
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|01/09/2010
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|----
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!scope="col"|Type
 +
!scope="col"|CPT Code*
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
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|Surgical
 +
|44950
 +
|Emergency Appendectomy
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|Completed
 +
|01/09/2010
 +
|----
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|}

Revision as of 18:03, 21 November 2010

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
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