NIST-Inpatient-test-patient-5: Difference between revisions

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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.
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]


How I became interested:
--[[User:Glilly|Glilly]] 10:11, 21 Nov 2010 (PST)
 
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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