<H3>Special Instructions</H3> <p>CRD Form Fillers and Form Managers which support the CCD option run this test.</p> <H3>Description</H3> <p>This test asks Form Fillers to create pre-population data for two subjects/patients and then verifies that this data is sent back correctly by the Form Manager in the form returned to the Form Filler.</p> <p>Data to be used in this test follows: </p> <table width="1005" border="3" cellspacing="0" cellpadding="0"> <tr> <td width="99" bgcolor="#CCCCCC"> <div align="center"> <strong>Data Element </strong> </div> </td> <td width="177" bgcolor="#CCCCCC"> <div align="center"> <strong>Template ID </strong> </div> </td> <td width="243" bgcolor="#CCFFCC"> <div align="center"> <strong>data for subject Miguel </strong> </div> </td> <td width="2" bgcolor="#CCFFCC">'</td> <td width="35" bgcolor="#CCFFCC"> <p align="center"> <strong>Eval:<br/> Y/N</strong> </p> </td> <td width="243" bgcolor="#FFFFCC"> <div align="center"> <strong>data for subject Kendra </strong> </div> </td> <td width="42" bgcolor="#FFFFCC"> <div align="center"> <strong>Eval: Y/N </strong> </div> </td> <td width="142" bgcolor="#CCCCCC"> <div align="center"> <strong>Evaluator's Comments</strong> </div> </td> </tr> <tr> <td>Date of Birth </td> <td>patientRole/patient/birthTime</td> <td>19440404</td> <td>'</td> <td>'</td> <td>19660606</td> <td>'</td> <td>'</td> </tr> <tr> <td>Gender</td> <td> <p>patientRole/patient/<br/> administrativeGenderCode</p> </td> <td>M</td> <td>'</td> <td>'</td> <td>F</td> <td>'</td> <td>'</td> </tr> <tr> <td>Ethnicity</td> <td>patientRole/patient/<br/> ethnicGroupCode</td> <td>2149-3 (Mexican American)</td> <td>'</td> <td>'</td> <td>(none)</td> <td>'</td> <td>'</td> </tr> <tr> <td>Race</td> <td>patientRole/patient/raceCode</td> <td>2106-3 (White) </td> <td>'</td> <td>'</td> <td>2029-7 (Asian Indian) </td> <td>'</td> <td>'</td> </tr> <tr> <td>Active Problems </td> <td> <p>component/section/entry/act/<br/> entryRelationship/observation</p> </td> <td> <p>Knee strain </p> </td> <td>'</td> <td>'</td> <td> <p>Chronic Migraine Headaches </p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Past Medical History </td> <td> <p>component/section/entry/act/<br/> entryRelationship/observation</p> </td> <td>Patient is recovering from a salomnella infection from eating raw eggs. </td> <td>'</td> <td>'</td> <td> <p>Patient suffers from asthma. </p> <p>Patient experiences arthritis in her left foot that was broken in the past.</p> <p>Patient was a pack-a-day tobacco smoker for 10 years. She quit smoking in 1990. </p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Procedures and Interventions </td> <td>component/section/entry/<br/> procedure</td> <td> <p>MRI of left knee </p> </td> <td>'</td> <td>'</td> <td> <p>Head CT </p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Social History </td> <td>component/section</td> <td>text="Miguel is a tri-athlete <br/> who runs at least 5 miles a day." </td> <td>'</td> <td>'</td> <td>text="Patient is a foster mother caring for a 3-month infant." </td> <td>'</td> <td>'</td> </tr> <tr> <td>Current Medications </td> <td>component/section/entry/<br/> substanceAdminstration</td> <td> <p>Augmentin 125 Mg Chew</p> <p>Freq: twice/day. Start: 11-Feb-09. Status: active </p> </td> <td>'</td> <td>'</td> <td> <p>Albuterol Sulfate 108 MCG/ACT AERS</p> <p>Freq: 2 puffs q6hrs pm. Start: 21-Feb-09. Status: active </p> <p>=================</p> <p>Naproxen Sodium 550 MG TABS</p> <p>Take one tablet by mouth every six hours as needed.</p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Vital Signs </td> <td>component/section/entry/<br/> organizer/<br/> component/observation/</td> <td> <p>code/code=8380-6</p> <p>code/displayName=<br/> INTRAVASCULAR SYSTOLIC</p> <p>code/codeSystem=<br/> 2.16.840.1.113883.6.1</p> <p>value/value=68</p> <p>value/unit=mm[Hg]</p> <p>===========================</p> <p>code/code=8462-4</p> <p>code/displayName=<br/> INTRAVASCULAR DIASTOLIC</p> <p>code/codeSystem=<br/> 2.16.840.1.113883.6.1</p> <p>value/value=108</p> <p>value/unit=mm[Hg]</p> <p>=========</p> <p>Pulse: 82 / minute</p> <p>Respiration: 29 / minute </p> </td> <td>'</td> <td>'</td> <td> <p>code/code=8380-6</p> <p>code/displayName=<br/> INTRAVASCULAR SYSTOLIC</p> <p>code/codeSystem=<br/> 2.16.840.1.113883.6.1</p> <p>value/value=102</p> <p>value/unit=mm[Hg]</p> <p>===========================</p> <p>code/code=8462-4</p> <p>code/displayName=<br/> INTRAVASCULAR DIASTOLIC</p> <p>code/codeSystem=<br/> 2.16.840.1.113883.6.1</p> <p>value/value=140</p> <p>value/unit=mm[Hg]</p> <p>======</p> <p>Pulse: 86 / minute</p> <p>Respiration: 30 / minute </p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Physical Exam</td> <td>component/section</td> <td> <p>code/code=10210-3</p> <p>code/displayName=<br/> GENERAL STATUS</p> <p>code/codesSystem=<br/> 2.16.840.113883.6.1</p> <p>text="This is a very healthy patient." </p> </td> <td>'</td> <td>'</td> <td>None</td> <td>'</td> <td>'</td> </tr> <tr> <td>Allergies and Other Adverse Reactions </td> <td>component/section/entry/act/<br/> entryRelationship/observation</td> <td> <p>Milk Products - active allergy</p> <p>Peanuts - active allergy </p> </td> <td>'</td> <td>'</td> <td> <p>Laytex - active allergy </p> </td> <td>'</td> <td>'</td> </tr> <tr> <td>Coded Results </td> <td>'</td> <td>'</td> <td>'</td> <td>'</td> <td>'</td> <td>'</td> <td>'</td> </tr> </table> <H3>Evaluation</H3> <Evaluation> <p>The Connectathon Monitor will check for correct exchange of the pre-population data contained in the test description. </p> <p>The table in the test description contains all "R" and "R2" elements in the CCD option. The connectathon monitor will use this table to record (Y/N) which elements were successfully exchanged.</p> <p>The Connectathon Monitor may ask the Form Filler to request the forms for the test patients again in his/her presence, or to send data for an additional subject/patient and observe the transfer real-time.</p> <p>On the <strong>Form Filler</strong>, the Connectathon monitor will observe that a form is returned with the data in the Test Description pre-populated on the form. The Form Filler should be able to add additional data, or change existing fields, and then submit the completed form back to the Form Manager.</p> </Evaluation>