Academic Medicine wiki-based narrative

The purpose of this page is to illustrate how a wiki-based clinical document might appear; the content is based on a series of notes that can found here. These details are derived from the de-identified EHR of a real patient but details have been changed such that any resemblance to a real patient is entirely coincidental.

Note: some of the links below are to external websites such as Wikipedia and the NCI Thesaurus. In a true medical wiki, these external links would likely be replaced with application programming interfaces (APIs), which would enforce HIPAA-compliant authentication and authorization.

Demographics

Note: the linked "Gender" is to a value set that specifies a set of structured choices for gender, as an example of how wiki-based formatting can be linked to structured concepts. Likewise, the "Race" and "Ethnicity" concepts can be linked directly to the CDC Race and Ethnicity Code Set Version 1.0, which is required for certified EHRs. Note also that some versions of wiki software can calculate dates, such as the current age based on DOB (not currently enabled here).

• Patient Name: PatientX
• Gender: Female
• DOB: January 1, 1960
• Race: White (2106-3)
• Ethnicity: Not Hispanic or Latino (2186-5)
  • Note that "concept codes" such as 2106-3 do not have to be shown, and can be toggled/hidden.

Active medical problems

This is the core of the medical wiki and could be arranged by subheadings, as here, or across multiple linked pages.

Resolved medical problems

Peripheral neuropathy

Notice how this problem is linked to the drug that caused it (on a separate page) and to the disease for which it was used.

• Cause: Paclitaxel (Taxol) chemotherapy, given for breast cancer
• Treatment: removal of paclitaxel from the treatment regimen
• Resolution: nearly complete, with some minor residual tingling in the fingertips

Allergies

• Morphine
  • Category: Medication
  • Reaction: Maculopapular rash
  • Level of certainty: Confirmed

Medications

This section illustrates a sortable table, which can be re-arranged by clicking on any of the columns. Notice that each drug name is linked to the structured concept of that drug in the RxNorm ontology. Here, aspirin is labeled as an NSAID, which is technically true but may not reflect the prescribed purpose. A user could update this drug class to anti-platelet medication.

Class of drug	Drug	Dose	Route	Frequency
Anti-diabetic	Metformin	500 mg	PO	once per day
Anti-hypertensive	Lisinopril	5 mg	PO	once per day
NSAID	Aspirin	81 mg	PO	once per day

Family history

• Mother: living, with dementia
• Father: d. of cerebral aneurysm, age 64
• Sister #1: alive and well
• Sister #2: alive and well

Social history

Alcohol

• Occasional drinks

Tobacco

• Former smoker
  • Smoked 1/2 PPD x 5 years
  • Quit 20 years ago