wiki conversion of NIST Inpatient test cases completed
This commit is contained in:
george
parent
cf10324d16
commit
33c5495f04
|
|
@ -6,10 +6,7 @@ Patient Summary Record Test Data
|
|||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Ann Toliver|07/16/1950|Female|989285998|Medical Record Number|353 Wine Street
|
||||
14:15:12|Flint,
|
||||
Michigan|48503
|
||||
810-673-8378
|
||||
Ann Toliver|07/16/1950<br>14:15:12|Female|989285998|Medical Record Number|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
|
||||
|
||||
“Source” for all data for this patient: Fatima Goyal, MD
|
||||
|
||||
|
|
@ -17,21 +14,15 @@ Problem List
|
|||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|428.0|Congestive Heart Failure|Active|02/22/2010
|
||||
Diagnosis|410.90|Acute Myocardial Infarction|Resolved|09/16/2007
|
||||
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|42343007|Congestive Heart Failure|Active|02/22/2010
|
||||
Disorder|57054005|Acute Myocardial Infarction|Resolved|09/16/2007
|
||||
|
||||
Medication List
|
||||
RxNorm
|
||||
|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
Code
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
201372|Medication|captopril|Capoten|25 mg|Tablet|PO|TID|02/25/2010|Active
|
||||
200820|Medication|spironolactone|Aldactone|25 mg|Tablet|PO|QID|02/25/2010|Active
|
||||
309888|Medication|digoxin|Lanoxin|125 mcg|Tablet|PO|QD|02/25/2010|Active
|
||||
potassium
|
||||
628958|Medication|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2010|Active
|
||||
chloride
|
||||
200820|Medication|spironolactone|Aldactone|25 mg|Tablet|PO|QID|02/25/2010|Active 309888|Medication|digoxin|Lanoxin|125 mcg|Tablet|PO|QD|02/25/2010|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2010|Active
|
||||
198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|09/20/2007|Active
|
||||
|
||||
Medication Allergy List
|
||||
|
|
@ -41,15 +32,11 @@ Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
|
|||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Enlarged cardiac silhouette,
|
||||
Imaging|24648-8|Chest X-ray, PA|02/24/2010
|
||||
lung fields clear
|
||||
Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>lung fields clear |02/24/2010
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|138 mg/dl|02/24/2010
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|02/24/2010
|
||||
Chemistry|2075-0|Chloride (95-107 mEq/L)|98 mEq/L|02/24/2010
|
||||
Enlarged cardiac silhouette,
|
||||
Imaging|24648-8|Chest X-ray, PA|horizontal lines in the periphery|02/22/2010
|
||||
of lower posterior lung fields
|
||||
Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields |02/22/2010
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|126 mg/dl|02/22/2010
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.0 mg/dl|02/22/2010
|
||||
Chemistry|2075-0|Chloride (95-107 mEq/L)|94 mEq/L|02/22/2010
|
||||
|
|
@ -58,7 +45,6 @@ Procedure List
|
|||
Type|ICD-9 Code|Procedure|Status|Date Performed
|
||||
Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
|
||||
Cardiac|37.21|Cardiac catheterization|Completed|10/01/2006
|
||||
|
||||
Type|CPT Code*|Procedure|Status|Date Performed
|
||||
Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
|
||||
Cardiac|93501|Cardiac catheterization|Completed|10/01/2006
|
||||
|
|
|
|||
|
|
|
@ -0,0 +1,245 @@
|
|||
* indicates alternative standard code per certification criteria
|
||||
|
||||
Patient Summary Record Test Data – Set #1
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|John D. Smith
|
||||
|07/04/1960 10:15:02
|
||||
|Male
|
||||
|999999999
|
||||
|Medical Record Number
|
||||
|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: John Fitzgerald, MD
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|Problem List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Diagnosis
|
||||
|250.02
|
||||
|Diabetes Mellitus, Type 2
|
||||
|Active
|
||||
|09/16/2009
|
||||
|----
|
||||
|Condition
|
||||
|272.4
|
||||
|Hyperlipidemia
|
||||
|Active
|
||||
|05/05/2002
|
||||
|----
|
||||
|Finding
|
||||
|414.01
|
||||
|Coronary Artery Disease (CAD)
|
||||
|Chronic
|
||||
|05/05/2002
|
||||
|----
|
||||
|Symptom
|
||||
|401.9
|
||||
|Hypertension, Essential
|
||||
|Active
|
||||
|05/05/2002
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|44054006
|
||||
|Diabetes Mellitus, Type 2
|
||||
|Active
|
||||
|09/16/2009
|
||||
|----
|
||||
|Disorder
|
||||
|55822004
|
||||
|Hyperlipidemia
|
||||
|Active
|
||||
|05/05/2002
|
||||
|----
|
||||
|Disorder
|
||||
|53741008
|
||||
|Coronary Arteriosclerosis
|
||||
|Chronic
|
||||
|05/05/2002
|
||||
|----
|
||||
|Disorder
|
||||
|59621000
|
||||
|Essential Hypertension
|
||||
|Active
|
||||
|05/05/2002
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|205875
|
||||
|Medication
|
||||
|glyburide
|
||||
|Diabeta
|
||||
|2.5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|Q AM
|
||||
|09/16/2009
|
||||
|Active
|
||||
|----
|
||||
|617314
|
||||
|Medication
|
||||
|atorvastatin calcium
|
||||
|Lipitor
|
||||
|10 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|Q Day
|
||||
|05/05/2002
|
||||
|Active
|
||||
|----
|
||||
|200801
|
||||
|Medication
|
||||
|furosemide
|
||||
|Lasix
|
||||
|20 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|05/05/2002
|
||||
|Active
|
||||
|----
|
||||
|628958
|
||||
|Medication
|
||||
|potassium chloride
|
||||
|Klor-Con
|
||||
|10 mEq
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|05/05/2002
|
||||
|Active
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
|
||||
|----
|
||||
|Drug Allergy
|
||||
|293597001
|
||||
|Codeine
|
||||
|Hives
|
||||
|06/27/1996
|
||||
|----
|
||||
|Drug Allergy
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|03/15/1994
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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)
|
||||
|178 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|14682-9
|
||||
|Creatinine (0.5–1.4 mg/dl)
|
||||
|1.0 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|14937-7
|
||||
|BUN (7–30 mg/dl)
|
||||
|18 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|2951-2
|
||||
|Sodium (135–146 mg/dl)
|
||||
|141 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|4.3 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|14647-2
|
||||
|Total cholesterol (<200 mg/dl)
|
||||
|162 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|14646-4
|
||||
|HDL cholesterol (?40 mg/dl)
|
||||
|43 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|2089-1
|
||||
|LDL cholesterol (<100 mg/dl)
|
||||
|84 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Chemistry
|
||||
|14927-8
|
||||
|Triglycerides (<150 mg/dl)
|
||||
|177 mg/dl
|
||||
|09/16/2009
|
||||
|----
|
||||
|Imaging
|
||||
|24648-8
|
||||
|Chest X-ray, PA
|
||||
|No disease is seen in the<br>lung fields or pleura
|
||||
|09/16/2009
|
||||
|----
|
||||
|}
|
||||
|
||||
|
|
@ -0,0 +1,47 @@
|
|||
* indicates alternative standard code per certification criteria
|
||||
|
||||
Patient Summary Record Test Data – Set #1
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
John D. Smith|07/04/1960 10:15:02|Male|999999999|Medical Record Number|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
|
||||
|
||||
“Source” for all data for this patient: John Fitzgerald, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009
|
||||
Condition|272.4|Hyperlipidemia|Active|05/05/2002
|
||||
Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
|
||||
Symptom|401.9|Hypertension, Essential|Active|05/05/2002
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009
|
||||
Disorder|55822004|Hyperlipidemia|Active|05/05/2002
|
||||
Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
|
||||
Disorder|59621000|Essential Hypertension|Active|05/05/2002
|
||||
|
||||
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|09/16/2009|Active
|
||||
617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active
|
||||
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|293597001|Codeine|Hives|06/27/1996
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|178 mg/dl|09/16/2009
|
||||
Chemistry|14682-9|Creatinine (0.5–1.4 mg/dl)|1.0 mg/dl|09/16/2009
|
||||
Chemistry|14937-7|BUN (7–30 mg/dl)|18 mg/dl|09/16/2009
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|141 mg/dl|09/16/2009
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|09/16/2009
|
||||
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009
|
||||
Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009
|
||||
Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009
|
||||
Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009
|
||||
Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009
|
||||
|
||||
|
|
|
@ -0,0 +1,262 @@
|
|||
TD170.306.f.: Exchange clinical information and patient summary record
|
||||
|
||||
* indicates alternative standard code per certification criteria
|
||||
|
||||
Patient Summary Record Test Data – Set #1
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Ann Toliver
|
||||
|07/16/1950<br>14:15:12
|
||||
|Female
|
||||
|989285998
|
||||
|Medical Record Number
|
||||
|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Fatima Goyal, MD
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|Problem List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Diagnosis
|
||||
|428.0
|
||||
|Congestive Heart Failure
|
||||
|Active
|
||||
|02/22/2010
|
||||
|----
|
||||
|Diagnosis
|
||||
|410.90
|
||||
|Acute Myocardial Infarction
|
||||
|Resolved
|
||||
|09/16/2007
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|42343007
|
||||
|Congestive Heart Failure
|
||||
|Active
|
||||
|02/22/2010
|
||||
|----
|
||||
|Disorder
|
||||
|57054005
|
||||
|Acute Myocardial Infarction
|
||||
|Resolved
|
||||
|09/16/2007
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|201372
|
||||
|Medication
|
||||
|captopril
|
||||
|Capoten
|
||||
|25 mg
|
||||
|Tablet
|
||||
|PO
|
||||
|TID
|
||||
|02/25/2010
|
||||
|Active
|
||||
|----
|
||||
|200820
|
||||
|Medication
|
||||
|spironolactone
|
||||
|Aldactone
|
||||
|25 mg
|
||||
|Tablet
|
||||
|PO
|
||||
|QID
|
||||
|02/25/2010
|
||||
|Active
|
||||
|----
|
||||
|309888
|
||||
|Medication
|
||||
|digoxin
|
||||
|Lanoxin
|
||||
|125 mcg
|
||||
|Tablet
|
||||
|PO
|
||||
|QD
|
||||
|02/25/2010
|
||||
|Active
|
||||
|----
|
||||
|628958
|
||||
|Medication
|
||||
|potassium chloride
|
||||
|Klor-Con
|
||||
|10 mEq
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|02/25/2010
|
||||
|Active
|
||||
|----
|
||||
|198039
|
||||
|Medication
|
||||
|nitroglycerin
|
||||
|Nitroglycerin
|
||||
|400 mcg
|
||||
|1 Tablet
|
||||
|SL
|
||||
|As needed
|
||||
|09/20/2007
|
||||
|Active
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
|
||||
|----
|
||||
|Drug Allergy
|
||||
|293586001
|
||||
|Aspirin
|
||||
|Wheezing
|
||||
|03/02/2007
|
||||
|----
|
||||
|Drug Allergy
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|04/25/1994
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Imaging
|
||||
|24648-8
|
||||
|Chest X-ray, PA
|
||||
|Enlarged cardiac silhouette, <br>lung fields clear
|
||||
|02/24/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2951-2
|
||||
|Sodium (135–146 mg/dl)
|
||||
|138 mg/dl
|
||||
|02/24/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|4.3 mg/dl
|
||||
|02/24/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2075-0
|
||||
|Chloride (95-107 mEq/L)
|
||||
|98 mEq/L
|
||||
|02/24/2010
|
||||
|----
|
||||
|Imaging
|
||||
|24648-8
|
||||
|Chest X-ray, PA
|
||||
|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields
|
||||
|02/22/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2951-2
|
||||
|Sodium (135–146 mg/dl)
|
||||
|126 mg/dl
|
||||
|02/22/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|3.0 mg/dl
|
||||
|02/22/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2075-0
|
||||
|Chloride (95-107 mEq/L)
|
||||
|94 mEq/L
|
||||
|02/22/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Procedure List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Cardiac
|
||||
|00.66
|
||||
|Percutaneous transluminal coronary angioplasty
|
||||
|Completed
|
||||
|09/17/2007
|
||||
|----
|
||||
|Cardiac
|
||||
|37.21
|
||||
|Cardiac catheterization
|
||||
|Completed
|
||||
|10/01/2006
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|CPT Code*
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Cardiac
|
||||
|92982
|
||||
|Percutaneous transluminal coronary angioplasty
|
||||
|Completed
|
||||
|09/17/2007
|
||||
|----
|
||||
|Cardiac
|
||||
|93501
|
||||
|Cardiac catheterization
|
||||
|Completed
|
||||
|10/01/2006
|
||||
|----
|
||||
|
|
@ -0,0 +1,51 @@
|
|||
TD170.306.f.: Exchange clinical information and patient summary record
|
||||
|
||||
* indicates alternative standard code per certification criteria
|
||||
|
||||
Patient Summary Record Test Data – Set #1
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Ann Toliver|07/16/1950<br>14:15:12|Female|989285998|Medical Record Number|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
|
||||
|
||||
“Source” for all data for this patient: Fatima Goyal, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|428.0|Congestive Heart Failure|Active|02/22/2010
|
||||
Diagnosis|410.90|Acute Myocardial Infarction|Resolved|09/16/2007
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|42343007|Congestive Heart Failure|Active|02/22/2010
|
||||
Disorder|57054005|Acute Myocardial Infarction|Resolved|09/16/2007
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
201372|Medication|captopril|Capoten|25 mg|Tablet|PO|TID|02/25/2010|Active
|
||||
200820|Medication|spironolactone|Aldactone|25 mg|Tablet|PO|QID|02/25/2010|Active
|
||||
309888|Medication|digoxin|Lanoxin|125 mcg|Tablet|PO|QD|02/25/2010|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2010|Active
|
||||
198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|09/20/2007|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|293586001|Aspirin|Wheezing|03/02/2007
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>lung fields clear |02/24/2010
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|138 mg/dl|02/24/2010
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|02/24/2010
|
||||
Chemistry|2075-0|Chloride (95-107 mEq/L)|98 mEq/L|02/24/2010
|
||||
Imaging|24648-8|Chest X-ray, PA|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields |02/22/2010
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|126 mg/dl|02/22/2010
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.0 mg/dl|02/22/2010
|
||||
Chemistry|2075-0|Chloride (95-107 mEq/L)|94 mEq/L|02/22/2010
|
||||
|
||||
Procedure List
|
||||
Type|ICD-9 Code|Procedure|Status|Date Performed
|
||||
Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
|
||||
Cardiac|37.21|Cardiac catheterization|Completed|10/01/2006
|
||||
Type|CPT Code*|Procedure|Status|Date Performed
|
||||
Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|09/17/2007
|
||||
Cardiac|93501|Cardiac catheterization|Completed|10/01/2006
|
||||
|
|
|
@ -0,0 +1,297 @@
|
|||
Patient Summary Record Test Data – Set #2
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Ruth Warholde
|
||||
|05/20/1954<br>23:59:45
|
||||
|Female
|
||||
|9836469798
|
||||
|Medical Record Number
|
||||
|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385
|
||||
|----
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Jackson Shoals, MD
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|Problem List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Diagnosis
|
||||
|780.2
|
||||
|Syncope and collapse, vasovagal attack
|
||||
|Active
|
||||
|02/15/2010
|
||||
|----
|
||||
|Diagnosis
|
||||
|434.91
|
||||
|Cerebrovascular Accident (Stroke)
|
||||
|Resolved
|
||||
|07/09/2009
|
||||
|----
|
||||
|Diagnosis
|
||||
|599.0
|
||||
|Urinary tract infection
|
||||
|Recurrent
|
||||
|09/22/2008
|
||||
|----
|
||||
|Diagnosis
|
||||
|496.0
|
||||
|Chronic Obstructive Pulmonary Disease
|
||||
|Chronic
|
||||
|08/12/2007
|
||||
|----
|
||||
|Symptom
|
||||
|401.9
|
||||
|Hypertension, essential
|
||||
|Chronic
|
||||
|05/16/2006
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|398665005
|
||||
|Vasovagal syncope
|
||||
|Active
|
||||
|02/15/2010
|
||||
|----
|
||||
|Disorder
|
||||
|230690007
|
||||
|Cerebrovascular Accident (Stroke)
|
||||
|Resolved
|
||||
|07/09/2009
|
||||
|----
|
||||
|Disorder
|
||||
|197927001
|
||||
|Recurrent urinary tract infection
|
||||
|Recurrent
|
||||
|09/22/2008
|
||||
|----
|
||||
|Disorder
|
||||
|13645005
|
||||
|Chronic Obstructive Lung Disease
|
||||
|Chronic
|
||||
|08/12/2007
|
||||
|----
|
||||
|Disorder
|
||||
|59621000
|
||||
|Essential Hypertension
|
||||
|Chronic
|
||||
|05/16/2006
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|209834
|
||||
|Medication
|
||||
|docusate
|
||||
|Colace
|
||||
|100 mg
|
||||
|1 Capsule
|
||||
|PO
|
||||
|BID
|
||||
|02/16/2010
|
||||
|Active
|
||||
|----
|
||||
|205326
|
||||
|Medication
|
||||
|lisinopril
|
||||
|Zestril
|
||||
|30 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/15/2009
|
||||
|Active
|
||||
|----
|
||||
|309362
|
||||
|Medication
|
||||
|clopidogrel
|
||||
|Plavix
|
||||
|75 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/15/2009
|
||||
|Active
|
||||
|----
|
||||
|197361
|
||||
|Medication
|
||||
|amlodipine
|
||||
|Norvasc
|
||||
|5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/15/2009
|
||||
|Active
|
||||
|----
|
||||
|539712
|
||||
|Medication
|
||||
|nitrofurantoin
|
||||
|Macrobid
|
||||
|100 mg
|
||||
|1 Capsule
|
||||
|PO
|
||||
|QD
|
||||
|09/22/2008
|
||||
|No Longer Active
|
||||
|----
|
||||
|836370
|
||||
|Medication
|
||||
|ipratropium bromide monhydrate
|
||||
|Atrovent inhaler
|
||||
|18 mcg/puff
|
||||
|2 puffs
|
||||
|By oral inhalation
|
||||
|QID
|
||||
|08/14/2007
|
||||
|Active
|
||||
|----
|
||||
|884175
|
||||
|Medication
|
||||
|clonidine hydrochloride
|
||||
|Catapres
|
||||
|0.1 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|BID
|
||||
|05/16/2006
|
||||
|Active
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
|
||||
|----
|
||||
|Drug Allergy
|
||||
|293620004
|
||||
|Indomethacin
|
||||
|Nausea, vomiting, rash, dizziness, headache
|
||||
|03/25/2003
|
||||
|----
|
||||
|Drug Allergy
|
||||
|91939003
|
||||
|Sulfonamides
|
||||
|Hives, photosensitivity
|
||||
|07/26/1999
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Imaging
|
||||
|11539-4
|
||||
|CT, head
|
||||
|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease.
|
||||
|02/24/2010
|
||||
|----
|
||||
|Hematology
|
||||
|718-7
|
||||
|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
|
||||
|13 g/dl
|
||||
|02/17/2010
|
||||
|----
|
||||
|Hematology
|
||||
|4544-3
|
||||
|Hematocrit (male: 40-54% female: 36-48%)
|
||||
|38%
|
||||
|02/17/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2951-2
|
||||
|Sodium (135–146 mg/dl)
|
||||
|136 mg/dl
|
||||
|02/17/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|2823-3
|
||||
|Potassium (3.5–5.3 mg/dl)
|
||||
|3.9 mg/dl
|
||||
|02/17/2010
|
||||
|----
|
||||
|Imaging
|
||||
|34534-8
|
||||
|Electrocardiogram
|
||||
|Normal Sinus Rhythm
|
||||
|02/15/2010
|
||||
|----
|
||||
|Microbiology
|
||||
|630-4
|
||||
|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)
|
||||
|Negative: No growth
|
||||
|10/02/2008
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|66.39
|
||||
|Bilateral tubal ligation
|
||||
|Completed
|
||||
|06/14/1990
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|CPT Code*
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Surgical
|
||||
|58600
|
||||
|Bilateral tubal ligation
|
||||
|----
|
||||
|
|
@ -0,0 +1,53 @@
|
|||
Patient Summary Record Test Data – Set #2
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Ruth Warholde|05/20/1954<br>23:59:45|Female|9836469798|Medical Record Number|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385
|
||||
|
|
||||
|
||||
“Source” for all data for this patient: Jackson Shoals, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|780.2|Syncope and collapse, vasovagal attack|Active|02/15/2010
|
||||
Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
|
||||
Diagnosis|599.0|Urinary tract infection|Recurrent|09/22/2008
|
||||
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|08/12/2007
|
||||
Symptom|401.9|Hypertension, essential|Chronic|05/16/2006
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|398665005|Vasovagal syncope|Active|02/15/2010
|
||||
Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
|
||||
Disorder|197927001|Recurrent urinary tract infection|Recurrent|09/22/2008
|
||||
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|08/12/2007
|
||||
Disorder|59621000|Essential Hypertension|Chronic|05/16/2006
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active
|
||||
205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active
|
||||
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
|
||||
197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
|
||||
539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008|No Longer Active
|
||||
836370|Medication|ipratropium bromide monhydrate|Atrovent inhaler|18 mcg/puff|2 puffs|By oral inhalation|QID|08/14/2007|Active
|
||||
884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Imaging|11539-4|CT, head|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease. |02/24/2010
|
||||
Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|13 g/dl|02/17/2010
|
||||
Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|38%|02/17/2010
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|136 mg/dl|02/17/2010
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.9 mg/dl|02/17/2010
|
||||
Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010
|
||||
Microbiology|630-4|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)|Negative: No growth|10/02/2008
|
||||
|
||||
Procedure List
|
||||
Type|ICD-9 Code|Procedure|Status|Date Performed
|
||||
Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990
|
||||
Type|CPT Code*|Procedure|Status|Date Performed
|
||||
Surgical|58600|Bilateral tubal ligation|
|
||||
|
|
|
@ -0,0 +1,229 @@
|
|||
Patient Summary Record Test Data – Set #3
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Lorraine Blevins
|
||||
|04/16/1957<br>20:15:35
|
||||
|Female
|
||||
|967385998
|
||||
|Medical Record Number
|
||||
|1020 Stuart Street<br>Morton, <br>Illinois 61550<br> 309-374-8938
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Louis Randolph, MD
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|Problem List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Diagnosis
|
||||
|715.35
|
||||
|Right hip osteoarthritis
|
||||
|Resolved
|
||||
|02/12/2010
|
||||
|----
|
||||
|Finding
|
||||
|414.01
|
||||
|Coronary Artery Disease (CAD)
|
||||
|Chronic
|
||||
|05/05/2002
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|239872002
|
||||
|Right hip osteoarthritis
|
||||
|Resolved
|
||||
|02/12/2010
|
||||
|----
|
||||
|Disorder
|
||||
|53741008
|
||||
|Coronary Arteriosclerosis
|
||||
|Chronic
|
||||
|05/05/2002
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|855320
|
||||
|Medication
|
||||
|warfarin
|
||||
|Coumadin
|
||||
|3 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|02/15/2010
|
||||
|Active
|
||||
|----
|
||||
|209613
|
||||
|Medication
|
||||
|bisacodyl
|
||||
|Dulcolax
|
||||
|5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|02/15/2010
|
||||
|Active
|
||||
|----
|
||||
|309362
|
||||
|Medication
|
||||
|clopidogrel
|
||||
|Plavix
|
||||
|75 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|05/15/2002
|
||||
|Active
|
||||
|----
|
||||
|197361
|
||||
|Medication
|
||||
|amlodipine
|
||||
|Norvasc
|
||||
|5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/15/2009
|
||||
|Active
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
|
||||
|----
|
||||
|Drug Allergy
|
||||
|91939003
|
||||
|Sulfonamides
|
||||
|Hives, photosensitivity
|
||||
|06/06/1998
|
||||
|----
|
||||
|Drug Allergy
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|04/25/1994
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Imaging
|
||||
|37721-8
|
||||
|X-ray, 2 views, Right Hip
|
||||
|Subchondral sclerosis,<br> increased density in<br>subchondral bone
|
||||
|02/12/2010
|
||||
|----
|
||||
|Imaging
|
||||
|24648-8
|
||||
|Chest X-ray, PA
|
||||
|No disease is seen in<br> the lung fields or pleura
|
||||
|06/05/2009
|
||||
|----
|
||||
|Hematology
|
||||
|718-7
|
||||
|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
|
||||
|11.2 g/dl
|
||||
|06/05/2009
|
||||
|----
|
||||
|Hematology
|
||||
|4544-3
|
||||
|Hematocrit (male: 40-54% <br>female: 36-48%)
|
||||
|34%
|
||||
|06/05/2009
|
||||
|----
|
||||
|Coagulation
|
||||
|34714-6
|
||||
|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5)
|
||||
|3.1
|
||||
|06/05/2009
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|81.51
|
||||
|Total Hip Replacement, Right
|
||||
|Completed
|
||||
|02/14/2010
|
||||
|----
|
||||
|Cardiac
|
||||
|37.21
|
||||
|Cardiac catheterization
|
||||
|Completed
|
||||
|05/05/2002
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|CPT Code*
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Surgical
|
||||
|27130
|
||||
|Total Hip Replacement, Right
|
||||
|Completed
|
||||
|02/14/2010
|
||||
|----
|
||||
|Cardiac
|
||||
|93501
|
||||
|Cardiac catheterization
|
||||
|Completed
|
||||
|05/05/2002
|
||||
|----
|
||||
|
|
@ -0,0 +1,43 @@
|
|||
Patient Summary Record Test Data – Set #3
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Lorraine Blevins|04/16/1957<br>20:15:35|Female|967385998|Medical Record Number|1020 Stuart Street<br>Morton, <br>Illinois 61550<br> 309-374-8938
|
||||
|
||||
“Source” for all data for this patient: Louis Randolph, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|715.35|Right hip osteoarthritis|Resolved|02/12/2010
|
||||
Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|239872002|Right hip osteoarthritis|Resolved|02/12/2010
|
||||
Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
855320|Medication|warfarin|Coumadin|3 mg|1 Tablet|PO|QD|02/15/2010|Active
|
||||
209613|Medication|bisacodyl|Dulcolax|5 mg|1 Tablet|PO|QD|02/15/2010|Active
|
||||
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|05/15/2002|Active
|
||||
197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|06/06/1998
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Imaging|37721-8|X-ray, 2 views, Right Hip|Subchondral sclerosis,<br> increased density in<br>subchondral bone|02/12/2010
|
||||
Imaging|24648-8|Chest X-ray, PA|No disease is seen in<br> the lung fields or pleura|06/05/2009
|
||||
Hematology|718-7|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)|11.2 g/dl|06/05/2009
|
||||
Hematology|4544-3|Hematocrit (male: 40-54% <br>female: 36-48%)|34%|06/05/2009
|
||||
Coagulation|34714-6|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5) |3.1|06/05/2009
|
||||
|
||||
Procedure List
|
||||
Type|ICD-9 Code|Procedure|Status|Date Performed
|
||||
Surgical|81.51|Total Hip Replacement, Right|Completed|02/14/2010
|
||||
Cardiac|37.21|Cardiac catheterization|Completed|05/05/2002
|
||||
Type|CPT Code*|Procedure|Status|Date Performed
|
||||
Surgical|27130|Total Hip Replacement, Right|Completed|02/14/2010
|
||||
Cardiac|93501|Cardiac catheterization|Completed|05/05/2002
|
||||
|
|
|
@ -0,0 +1,206 @@
|
|||
Patient Summary Record Test Data – Set #4
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|Paul Jackson
|
||||
|03/08/1962<br>14:25:50
|
||||
|Male
|
||||
|998777349
|
||||
|Medical Record Number
|
||||
|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
|
||||
|----
|
||||
|}
|
||||
|
||||
“Source” for all data for this patient: Mary Pfiffer, MD
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|Problem List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Diagnosis
|
||||
|410.90
|
||||
|Acute Myocardial Infarction
|
||||
|Resolved
|
||||
|07/12/2010
|
||||
|----
|
||||
|Finding
|
||||
|414.01
|
||||
|Coronary Artery Disease (CAD)
|
||||
|Chronic
|
||||
|07/05/2000
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code*
|
||||
!scope="col"|Patient Problem
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Diagnosed
|
||||
|----
|
||||
|Disorder
|
||||
|57054005
|
||||
|Acute Myocardial Infarction
|
||||
|Resolved
|
||||
|07/12/2010
|
||||
|----
|
||||
|Disorder
|
||||
|53741008
|
||||
|Coronary Arteriosclerosis
|
||||
|Chronic
|
||||
|07/05/2000
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|----
|
||||
|198039
|
||||
|Medication
|
||||
|nitroglycerin
|
||||
|Nitroglycerin
|
||||
|400 mcg
|
||||
|1 Tablet
|
||||
|SL
|
||||
|As needed
|
||||
|07/15/2010
|
||||
|Active
|
||||
|----
|
||||
|309362
|
||||
|Medication
|
||||
|clopidogrel
|
||||
|Plavix
|
||||
|75 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/05/2000
|
||||
|Active
|
||||
|----
|
||||
|197361
|
||||
|Medication
|
||||
|amlodipine
|
||||
|Norvasc
|
||||
|5 mg
|
||||
|1 Tablet
|
||||
|PO
|
||||
|QD
|
||||
|07/05/2000
|
||||
|Active
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Medication Allergy List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|Date Recorded
|
||||
|----
|
||||
|Drug Allergy
|
||||
|91936005
|
||||
|Penicillin
|
||||
|Rash and anaphylaxis
|
||||
|07/12/2010
|
||||
|----
|
||||
|Drug Allergy
|
||||
|294506009
|
||||
|Ampicillin
|
||||
|Diarrhea, nausea, vomiting
|
||||
|03/28/2000
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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
|
||||
|14647-2
|
||||
|Total cholesterol (<200 mg/dl)
|
||||
|220 mg/dl
|
||||
|07/15/2010
|
||||
|----
|
||||
|Chemistry
|
||||
|14927-8
|
||||
|Triglycerides (<150 mg/dl)
|
||||
|165 mg/dl
|
||||
|07/15/2010
|
||||
|----
|
||||
|Imaging
|
||||
|42272-5
|
||||
|Chest X-ray, PA & Lateral
|
||||
|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance
|
||||
|07/15/2010
|
||||
|----
|
||||
|Hematology
|
||||
|718-7
|
||||
|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
|
||||
|12.8 g/dl
|
||||
|2/18/2010
|
||||
|----
|
||||
|Hematology
|
||||
|4544-3
|
||||
|Hematocrit (male: 40-54% female: 36-48%)
|
||||
|44%
|
||||
|2/18/2010
|
||||
|----
|
||||
|}
|
||||
|
||||
{| border="1"|
|
||||
!colspan="5"|Procedure List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|ICD-9 Code
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Cardiac
|
||||
|00.66
|
||||
|Percutaneous transluminal coronary angioplasty
|
||||
|Completed
|
||||
|07/15/2010
|
||||
|----
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|CPT Code*
|
||||
!scope="col"|Procedure
|
||||
!scope="col"|Status
|
||||
!scope="col"|Date Performed
|
||||
|----
|
||||
|Cardiac
|
||||
|92982
|
||||
|Percutaneous transluminal coronary angioplasty
|
||||
|Completed
|
||||
|07/15/2010
|
||||
|----
|
||||
|
|
@ -0,0 +1,40 @@
|
|||
Patient Summary Record Test Data – Set #4
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
Paul Jackson|03/08/1962<br>14:25:50|Male|998777349|Medical Record Number|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
|
||||
|
||||
“Source” for all data for this patient: Mary Pfiffer, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010
|
||||
Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010
|
||||
Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000
|
||||
|
||||
Medication List
|
||||
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
||||
198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active
|
||||
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active
|
||||
197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010
|
||||
Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010
|
||||
Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance |07/15/2010
|
||||
Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|12.8 g/dl|2/18/2010
|
||||
Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|44%|2/18/2010
|
||||
|
||||
Procedure List
|
||||
Type|ICD-9 Code|Procedure|Status|Date Performed
|
||||
Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010
|
||||
Type|CPT Code*|Procedure|Status|Date Performed
|
||||
Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010
|
||||
|
|
|
@ -0,0 +1,266 @@
|
|||
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 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
|
||||
|
||||
{| border="1"|
|
||||
!colspan="6"|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 List
|
||||
|----
|
||||
!scope="col"|Type
|
||||
!scope="col"|SNOMED Code
|
||||
!scope="col"|Medication/Agent
|
||||
!scope="col"|Reaction
|
||||
!scope="col"|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
|
||||
|----
|
||||
|}
|
||||
|
||||
{| 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 (<150 mg/dl)
|
||||
|178 mg/dl
|
||||
|07/15/2010
|
||||
|----
|
||||
|Imaging
|
||||
|42272-5
|
||||
|Chest X-ray, PA & Lateral
|
||||
|The heart outline is normal<br> and the hilar and mediastinal<br> vessels are 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
|
||||
|----
|
||||
|}
|
||||
|
||||
|
||||
|
|
@ -0,0 +1,49 @@
|
|||
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<br> and the hilar and mediastinal<br> 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
|
||||
|
||||
|
||||
|
|
|
@ -0,0 +1,139 @@
|
|||
#!/usr/bin/perl -w
|
||||
#this program converts a csv file of patient data to wikitext format
|
||||
#
|
||||
#this software is copyright George Lilly 2010 and is available as GPL
|
||||
#its home is https://trac.opensourcevista.net/browser/hData/trunk/test-patients
|
||||
#
|
||||
#purpose: convert csv file to wikitext
|
||||
#Second part of a chain of conversions which will create
|
||||
#hData versions of the test patients. Also generate wiki-formatted versions
|
||||
#to put on VistAPedia.
|
||||
#
|
||||
my($intbl) = "none";
|
||||
sub endtbl {
|
||||
print "\|\}\n";
|
||||
}
|
||||
sub dotr {
|
||||
print "\|----\n";
|
||||
}
|
||||
sub doetr {
|
||||
print "\|----\n";
|
||||
}
|
||||
sub spancol {
|
||||
my $tit = shift ;
|
||||
my $cols = shift;
|
||||
print "\{\| border=\"1\"\|\n";
|
||||
print "\!colspan=\"$cols\"\|$tit\n";
|
||||
}
|
||||
sub docol {
|
||||
my $tit = shift ;
|
||||
print "\!scope\=\"col\"\|$tit\n";
|
||||
}
|
||||
sub dorow {
|
||||
my $tit = shift ;
|
||||
print "\|$tit\n";
|
||||
}
|
||||
|
||||
|
||||
while(<STDIN>)
|
||||
{
|
||||
my($line) = $_;
|
||||
chomp($line);
|
||||
$line =~ s/ $//g;
|
||||
if (($line =~ m/^Patient/)&&($line !~ m/Summary/)) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Patient",6);
|
||||
# print "$line\n";
|
||||
$intbl = "Patient";
|
||||
}
|
||||
elsif (($intbl =~ "Patient")&&($line =~ m/^Name/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Problem List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Problem List",6);
|
||||
# print "$line\n";
|
||||
$intbl = "Problem List";
|
||||
}
|
||||
elsif (($intbl =~ "Problem List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Medication List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Medication List",10);
|
||||
# print "$line\n";
|
||||
$intbl = "Medication List";
|
||||
}
|
||||
elsif (($intbl =~ "Medication List")&&($line =~ m/^RxNorm/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Medication Allergy List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Medication Allergy List",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Medication Allergy List";
|
||||
}
|
||||
elsif (($intbl =~ "Medication Allergy List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Diagnostic Test Results/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Diagnostic Test Results",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Diagnostic Test Results";
|
||||
}
|
||||
elsif (($intbl =~ "Diagnostic Test Results")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Procedure List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Procedure List",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Procedure List";
|
||||
}
|
||||
elsif (($intbl =~ "Procedure List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif (($intbl !~ "none")&&($line =~ m/\|/)) {
|
||||
$_ = $line;
|
||||
push @rows, split(/\|/);
|
||||
dorow($_) for @rows ;
|
||||
doetr;
|
||||
@rows = ();
|
||||
}
|
||||
else {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
print "$line\n";
|
||||
$intbl = "none";
|
||||
}
|
||||
}
|
||||
|
|
@ -0,0 +1,139 @@
|
|||
#!perl -w
|
||||
#this program converts a csv file of patient data to wikitext format
|
||||
#
|
||||
#this software is copyright George Lilly 2010 and is available as GPL
|
||||
#its home is https://trac.opensourcevista.net/browser/hData/trunk/test-patients
|
||||
#
|
||||
#purpose: convert csv file to wikitext
|
||||
#Second part of a chain of conversions which will create
|
||||
#hData versions of the test patients. Also generate wiki-formatted versions
|
||||
#to put on VistAPedia.
|
||||
#
|
||||
my($intbl) = "none";
|
||||
sub endtbl {
|
||||
print "\|\}\n";
|
||||
}
|
||||
sub dotr {
|
||||
print "\|----\n";
|
||||
}
|
||||
sub doetr {
|
||||
print "\|----\n";
|
||||
}
|
||||
sub spancol {
|
||||
my $tit = shift ;
|
||||
my $cols = shift;
|
||||
print "\{\| border=\"1\"\|\n";
|
||||
print "\!colspan=\"$cols\"\|$tit\n";
|
||||
}
|
||||
sub docol {
|
||||
my $tit = shift ;
|
||||
print "\!scope\=\"col\"\|$tit\n";
|
||||
}
|
||||
sub dorow {
|
||||
my $tit = shift ;
|
||||
print "\|$tit\n";
|
||||
}
|
||||
|
||||
|
||||
while(<STDIN>)
|
||||
{
|
||||
my($line) = $_;
|
||||
chomp($line);
|
||||
$line =~ s/ $//g;
|
||||
if (($line =~ m/^Patient/)&&($line !~ m/Summary/)) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Patient",6);
|
||||
# print "$line\n";
|
||||
$intbl = "Patient";
|
||||
}
|
||||
elsif (($intbl =~ "Patient")&&($line =~ m/^Name/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Problem List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Problem List",6);
|
||||
# print "$line\n";
|
||||
$intbl = "Problem List";
|
||||
}
|
||||
elsif (($intbl =~ "Problem List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Medication List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Medication List",10);
|
||||
# print "$line\n";
|
||||
$intbl = "Medication List";
|
||||
}
|
||||
elsif (($intbl =~ "Medication List")&&($line =~ m/^RxNorm/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Medication Allergy List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Medication Allergy List",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Medication Allergy List";
|
||||
}
|
||||
elsif (($intbl =~ "Medication Allergy List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Diagnostic Test Results/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Diagnostic Test Results",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Diagnostic Test Results";
|
||||
}
|
||||
elsif (($intbl =~ "Diagnostic Test Results")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif ($line =~ m/^Procedure List/) {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
spancol("Procedure List",5);
|
||||
# print "$line\n";
|
||||
$intbl = "Procedure List";
|
||||
}
|
||||
elsif (($intbl =~ "Procedure List")&&($line =~ m/^Type/)) {
|
||||
dotr;
|
||||
$_ = $line;
|
||||
push @cols, split(/\|/);
|
||||
docol($_) for @cols ;
|
||||
doetr;
|
||||
@cols = ();
|
||||
}
|
||||
elsif (($intbl !~ "none")&&($line =~ m/\|/)) {
|
||||
$_ = $line;
|
||||
push @rows, split(/\|/);
|
||||
dorow($_) for @rows ;
|
||||
doetr;
|
||||
@rows = ();
|
||||
}
|
||||
else {
|
||||
if ($intbl !~ "none") { endtbl; }
|
||||
print "$line\n";
|
||||
$intbl = "none";
|
||||
}
|
||||
}
|
||||
|
|
@ -0,0 +1,6 @@
|
|||
perl g.pl <NIST-Ambulatory-test-patient-1.csv >NIST-Ambulatory-test-patient-1-wiki.txt
|
||||
perl g.pl <NIST-Inpatient-test-patient-5.csv >NIST-Inpatient-test-patient-5-wiki.txt
|
||||
perl g.pl <NIST-Inpatient-test-patient-4.csv >NIST-Inpatient-test-patient-4-wiki.txt
|
||||
perl g.pl <NIST-Inpatient-test-patient-3.csv >NIST-Inpatient-test-patient-3-wiki.txt
|
||||
perl g.pl <NIST-Inpatient-test-patient-2.csv >NIST-Inpatient-test-patient-2-wiki.txt
|
||||
perl g.pl <NIST-Inpatient-test-patient-1.csv >NIST-Inpatient-test-patient-1-wiki.txt
|
||||
|
|
@ -0,0 +1,6 @@
|
|||
perl csv2wiki.pl <NIST-Ambulatory-test-patient-1.csv >NIST-Ambulatory-test-patient-1-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-5.csv >NIST-Inpatient-test-patient-5-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-4.csv >NIST-Inpatient-test-patient-4-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-3.csv >NIST-Inpatient-test-patient-3-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-2.csv >NIST-Inpatient-test-patient-2-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-1.csv >NIST-Inpatient-test-patient-1-wiki.txt
|
||||
|
|
@ -0,0 +1,6 @@
|
|||
perl csv2wiki.pl <NIST-Ambulatory-test-patient-1.csv >NIST-Ambulatory-test-patient-1-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-5.csv >NIST-Inpatient-test-patient-5-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-4.csv >NIST-Inpatient-test-patient-4-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-3.csv >NIST-Inpatient-test-patient-3-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-2.csv >NIST-Inpatient-test-patient-2-wiki.txt
|
||||
perl csv2wiki.pl <NIST-Inpatient-test-patient-1.csv >NIST-Inpatient-test-patient-1-wiki.txt
|
||||
|
|
@ -0,0 +1,47 @@
|
|||
* indicates alternative standard code per certification criteria
|
||||
|
||||
Patient Summary Record Test Data – Set #1
|
||||
|
||||
Patient
|
||||
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
||||
John D. Smith|07/04/1960 10:15:02|Male|999999999|Medical Record Number|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
|
||||
|
||||
“Source” for all data for this patient: John Fitzgerald, MD
|
||||
|
||||
Problem List
|
||||
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
||||
Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|09/16/2009
|
||||
Condition|272.4|Hyperlipidemia|Active|05/05/2002
|
||||
Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
|
||||
Symptom|401.9|Hypertension, Essential|Active|05/05/2002
|
||||
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
||||
Disorder|44054006|Diabetes Mellitus, Type 2|Active|09/16/2009
|
||||
Disorder|55822004|Hyperlipidemia|Active|05/05/2002
|
||||
Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
|
||||
Disorder|59621000|Essential Hypertension|Active|05/05/2002
|
||||
|
||||
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|09/16/2009|Active
|
||||
617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|05/05/2002|Active
|
||||
200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|05/05/2002|Active
|
||||
628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|05/05/2002|Active
|
||||
|
||||
Medication Allergy List
|
||||
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
||||
Drug Allergy|293597001|Codeine|Hives|06/27/1996
|
||||
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/15/1994
|
||||
|
||||
Diagnostic Test Results
|
||||
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
||||
Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|178 mg/dl|09/16/2009
|
||||
Chemistry|14682-9|Creatinine (0.5–1.4 mg/dl)|1.0 mg/dl|09/16/2009
|
||||
Chemistry|14937-7|BUN (7–30 mg/dl)|18 mg/dl|09/16/2009
|
||||
Chemistry|2951-2|Sodium (135–146 mg/dl)|141 mg/dl|09/16/2009
|
||||
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|09/16/2009
|
||||
Chemistry|14647-2|Total cholesterol (<200 mg/dl)|162 mg/dl|09/16/2009
|
||||
Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|43 mg/dl|09/16/2009
|
||||
Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|84 mg/dl|09/16/2009
|
||||
Chemistry|14927-8|Triglycerides (<150 mg/dl)|177 mg/dl|09/16/2009
|
||||
Imaging|24648-8|Chest X-ray, PA|No disease is seen in the<br>lung fields or pleura |09/16/2009
|
||||
|
||||
|
|
|
@ -0,0 +1,7 @@
|
|||
http://vistapedia.net/index.php?title=NIST-Inpatient-test-patient-4
|
||||
http://vistapedia.net/index.php?title=NIST-Inpatient-test-patient-5
|
||||
http://vistapedia.net/index.php?title=NIST-Inpatient-test-patient-3
|
||||
http://vistapedia.net/index.php?title=NIST-Inpatient-test-patient-2
|
||||
http://vistapedia.net/index.php?title=NIST-Inpatient-test-patient-1
|
||||
http://vistapedia.net/index.php?title=NIST_Ambulatory_Test_Patient_1
|
||||
http://vistapedia.net/index.php?title=NIST_Inpatients_Test_Patients:_Set_5
|
||||
Loading…
Reference in New Issue