source: ccr2ccd-xslt/trunk/make/qrda-header.xsl@ 1787

Last change on this file since 1787 was 981, checked in by George Lilly, 14 years ago

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[881]1<?xml version="1.0" encoding="UTF-8"?>
2<!--
3Conversion of CCR to Level 3 CCD
4
5Orginal Author: Ken Miller
6Solventus LLC
7ken.miller@solventus.coms
8
9Contributors:
10Richard Braman, EHR Doctors, Inc rbraman@ehrdoctors.com
11George Lilly (WorldVistA glilly@glilly.net)
[882]12Nancy Antracite, WorldVistA
[881]13xxxx - Oroville Hospital
14
15Date: 2010-05-5
16Version: 0.1
17
18License :
19
20 This program is free software: you can redistribute it and/or modify
21 it under the terms of the GNU General Public License as published by
22 the Free Software Foundation, either version 3 of the License, or
23 (at your option) any later version.
24
25 This program is distributed in the hope that it will be useful,
26 but WITHOUT ANY WARRANTY; without even the implied warranty of
27 MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
28 GNU General Public License for more details.
29
30 You should have received a copy of the GNU General Public License
31 along with this program. If not, see http://www.gnu.org/licenses.
32
33-->
34<xsl:stylesheet version="1.0" xmlns="urn:hl7-org:v3" xmlns:xsl="http://www.w3.org/1999/XSL/Transform" xmlns:a="urn:astm-org:CCR" xmlns:date="http://exslt.org/dates-and-times"
35xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" exclude-result-prefixes="a date">
36 <xsl:import href="./templates/cdavocablookup.xsl"/>
37 <xsl:import href="./templates/hl7oidlookup.xsl"/>
38 <xsl:import href="./templates/code.xsl"/>
39 <xsl:import href="./templates/actor.xsl"/>
40 <xsl:import href="./templates/datetime.xsl"/>
41 <xsl:import href="./templates/problemDescription.xsl"/>
42
43 <xsl:output method="xml" encoding="utf-8" version="1.0" indent="yes"/>
44 <xsl:template match="/">
45<!--WV Added new munltiple documentation of added have to do with encounter times, etc.-->
46
47<!--
48********************************************************
49CDA Header
50********************************************************
51-->
52
53<!--
54******************
55Document Information
56**********************
57-->
58<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
59 <!-- Created with XML Copy Editor Open Source Sourceforge project. -->
60<!--WVP This is the clinical document type ID-->
61 <realmCode code="US"/>
62 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
63 <!-- QRDA Category I generic template ID. -->
64 <!--WVP these next two lines are fixed-->
65 <templateId root="2.16.840.1.113883.10.20.12" />
66 <!--only in the july spec so not sure if it should be here-->
67 <templateId root="2.16.840.1.113883.3.249.11.100.1"/>
68 <!--WVV 2.16.840.1.113883.3.543 is fixed and is the beginninng of WorldVistAs OID, change the extension for a new document and the version for changes to this one-->
[981]69 <id>
70 <xsl:attribute name="root">
71 <xsl:value-of select="/a:ContinuityOfCareRecord/a:CCRDocumentObjectID"></xsl:value-of>
72 </xsl:attribute>
73 </id>
[881]74 <!--WVP next two lines fixed-->
75 <code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
76 <title>QRDA Incidence Report</title>
77 <!--WVV time-->
78 <effectiveTime value="20100703"/>
79 <!--WVP for next two lines-->
80 <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
81 <languageCode code="en-US"/>
82 <!--WV? Don't change this in the document set we are working on-->
83 <setId root="2.16.840.1.113883.3.543" extension="01.01.01.100000001"/>
84 <versionNumber value="1"/>
85 <!--WVP I made one up but we will have to have an OID for the Clincal Document SET which we will make up for ourselves eventually-->
86
87 <!--
88 *******************
89 Patient Information
90 ****************
91 -->
92 <!-- This is the patient for which the report is describing. -->
93 <recordTarget>
[981]94<patientRole>
95 <xsl:call-template name="ccdPatientRole">
96 <xsl:with-param name="ccrActorObjectID" select="/a:ContinuityOfCareRecord/a:Patient[1]/a:ActorID"/>
97 </xsl:call-template>
98 </patientRole>
[881]99 </recordTarget>
100
101<!--
102*****************************
103Author
104**************
105-->
106 <!-- This example assumes the doctor is creating the report and it is Required. -->
107 <author>
108 <!--WVV Edit time has to be precise at least to the day-->
109 <time value="20100703" />
110 <assignedAuthor>
111 <!--WVP eventually id this is required, the root is fixed -->
112 <!--andn the extension is the SOFTWARE version number assigned by CMS to WV EHR-->
113 <id root="2.16.840.1.113883.3.249.6" extension="100001" />
114 <!--WVVassignedPerson not required-->
115 <assignedPerson>
116 <name>
117 <!--WV Edit-->
118 <given>Nancy</given>
119 <family>Anthracite</family>
120 <suffix>MD</suffix>
121 </name>
122 </assignedPerson>
123 <representedOrganization>
124 <!--WV? id root is OID for the organization so I made one up for this document set-->
125 <id root="2.16.840.1.113883.3.543" extension="1558574526" />
126 <name>WorldVistA Test Clinic</name>
127 </representedOrganization>
128 </assignedAuthor>
129 </author>
130 <!-- The reporting healthcare facility is represented using the CCD "Source of Information" construct, via the Informant participant. -->
131 <informant>
132 <assignedEntity>
133 <!--WV this null flavor is required as is-->
134 <id nullFlavor="NA"/>
135 <representedOrganization>
136 <!--WV root is the OID of the organization. ID is required but name is not and id is OID stated earlier-->
137 <id root="2.16.840.1.113883.3.543" extension="1558574526" />
138 <name>World VistA Test Clinic</name>
139 </representedOrganization>
140 </assignedEntity>
141 </informant>
142
143 <!-- This example assumes that the institution responsible for the data is serving as custodian. -->
144 <!--WV This element is required as is the sSD which is not stated if it is an OID but assumed it is-->
145 <!--WV Name is not required, only ID is required.-->
146 <custodian>
147 <assignedCustodian>
148 <representedCustodianOrganization>
149 <id root="2.16.840.1.113883.3.543" extension="1558574526" />
150 <name>WorldVistA Test Clinic</name>
151 </representedCustodianOrganization>
152 </assignedCustodian>
153 </custodian>
154
155 <!-- In this example, the author is also serving as legal authenticator. -->
156 <!--WV section is this is not required-->
157<legalAuthenticator>
158 <time value="20100703" />
159 <!--WV the signature code of S is required-->
160 <signatureCode code="S" />
161 <assignedEntity>
162 <!--WV document does not specify the requirements of the id but it is required-->
163 <!--WVP and the sample suggests it is the number below and extension is ???-->
164 <id root="2.16.840.1.113883.3.543" extension="111111" />
165 <assignedPerson>
166 <name>
167 <given>Nancy</given>
168 <family>Anthracite</family>
169 <suffix>MD</suffix>
170 </name>
171 </assignedPerson>
172 <representedOrganization>
173 <!--WV? and is fixed for the WorldVistA Test Clinic in this submitted document series-->
174 <id root="2.16.840.1.113883.3.543" extension="1558574526" />
175 <name>WorldVistA Test Clinic</name>
176 </representedOrganization>
177 </assignedEntity>
178 </legalAuthenticator>
179
180
181
182 <!--Added to sample as it is new since 2008-->
183 <!--WVP permanent for participant in the primary care provider participant-->
184<!--WVP performer type codes are numerous but PRF is performer or the person who did it-->
185 <participant typeCode="PRF">
186 <!--WVP required as is for function-->
187 <!-- WVP I believe PCP is primary care provider but not sure-->
188 <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
189 <!--WVP Associated Entity is required ti be there with this PROV-->
190 <associatedEntity classCode="PROV">
191 <!--WV? OID of the provider fixed for this series of documents-->
192 <id root="2.16.840.1.113883.3.249.6" extension="111111" />
193 <!--WV associated person is not required so presumabley the code will suffice not sure??-->
194 <associatedPerson>
195 <name>
196 <prefix>Dr.</prefix>
197 <given>Nancy</given>
198 <family>Anthracite</family>
199 </name>
200 </associatedPerson>
201 </associatedEntity>
202 </participant>
203
204 <!--The service event is the encounter that describes tehe encunter as well as the provider, location and time-->
205 <!--!There can be one or more documentation elements depending on the number of encounters during the reporting period-->
206 <!--WVV IMPORTANT!! The encounter codeds are recorded here-->
207 <!-- They are in appendix B of the downloadable resource document-->
208 <!-- Each documentation of is a single service event-->
209
210<!--Occurence of Measures episode documention-->
211<!--Like an encounter section only for QRDA-->
212<!--Same doctor, same clinic, different date and different enconter code-->
213
214
215 <!--First Visit documentationOf section-->
216
217 <documentationOf>
218 <serviceEvent>
219 <!--WV serviceEvent codes from Tab B from the downloadabe resource coding system is -->
220 <!--WVF codeSystem is 2.16.840.1.113883 -->
221 <!--WV code root shall be WVP 2.16.840.1.113883.6.12 and the extension shall be the encounter code -->
222 <!-- WV? like the length of visit and complexity codes for example-->
223
224 <code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
225 <effectiveTime>
226 <!--WV Edit-->
227 <!-- This has to be precise at least to the day. Something with time would be better. Not sure of the necessary format so did not add time-->
228 <low value="20100205"/>
229 <high value="20100205"/>
230 </effectiveTime>
231 <performer typeCode="PRF">
232 <assignedEntity>
233 <!-- WV? Provider NPI Required root 2.16.840.1.113883.9.96 is ?? and the NPI is an extension for the provider-->
234 <!--This is variable but may remain unchanged for this document set-->
235 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
236 <!--<id root="2.16.840.1.113883.3.543" extension="1457402711"/>-->
237 <!--WV this element should be present and the code is probably for a General Physician for!-->
238 <!--It may be the type of provider as the example as I think 2.16.840.1.113883.6.69is the NDC-->
239 <!-- codeSystemName is SNOMED CT and code is an 8 digit num and display name is for a physician-->
240 <!--O6120 is SPECIALIZED PHYSICIAN when I looked it up so I don't know where to look for this 8 digit number-->
241 <!-- http://terminology.vetmed.vt.edu/SCT/menu.cfm to look up codes-->
242 <!--59058001 is general physician ;Family Medicine specialist is 62247001-->
243 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
244 <addr>
245 <streetAddressLine>123 Maple Ave</streetAddressLine>
246 <city>Gaithersburg</city>
247 <state>MD</state>
248 <postalCode>20877</postalCode>
249 </addr>
250 <assignedPerson>
251 <name>
252 <given>Nancy</given>
253 <family>Anthracite</family>
254 <suffix>MD</suffix>
255 </name>
256 </assignedPerson>
257 </assignedEntity>
258 </performer>
259 </serviceEvent>
260 </documentationOf>
261
262
263 <!--Second Visit documentationOf section-->
264
265 <documentationOf>
266 <serviceEvent>
267 <!--WV serviceEvent codes from Tab B from the downloadabe resource coding system is -->
268 <!--WVF codeSystem is 2.16.840.1.113883 -->
269 <!--WV code root shall be WVP 2.16.840.1.113883.6.12 and the extension shall be the encounter code -->
270 <!-- WV? like the length of visit and complexity codes for example-->
271
272 <code code="99204" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
273 <effectiveTime>
274 <!--WV Edit-->
275 <!-- This has to be precise at least to the day. Something with time would be better. Not sure of the necessary format so did not add time-->
276 <low value="20100703"/>
277 <high value="20100703"/>
278 </effectiveTime>
279 <performer typeCode="PRF">
280 <assignedEntity>
281 <!-- WV? Provider NPI Required root 2.16.840.1.113883.9.96 is ?? and the NPI is an extension for the provider-->
282 <!--This is variable but may remain unchanged for this document set-->
283 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
284 <!--<id root="2.16.840.1.113883.3.543" extension="1457402711"/>-->
285 <!--WV this element should be present and the code is probably for a General Physician for!-->
286 <!--It may be the type of provider as the example as I think 2.16.840.1.113883.6.69is the NDC-->
287 <!-- codeSystemName is SNOMED CT and code is an 8 digit num and display name is for a physician-->
288 <!--O6120 is SPECIALIZED PHYSICIAN when I looked it up so I don't know where to look for this 8 digit number-->
289 <!-- http://terminology.vetmed.vt.edu/SCT/menu.cfm to look up codes-->
290 <!--59058001 is general physician ;Family Medicine specialist is 62247001-->
291 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
292 <addr>
293 <streetAddressLine>123 Maple Ave</streetAddressLine>
294 <city>Gaithersburg</city>
295 <state>MD</state>
296 <postalCode>20877</postalCode>
297 </addr>
298 <assignedPerson>
299 <name>
300 <given>Nancy</given>
301 <family>Anthracite</family>
302 <suffix>MD</suffix>
303 </name>
304 </assignedPerson>
305 </assignedEntity>
306 </performer>
307 </serviceEvent>
308 </documentationOf>
309 <!--
310********************************************************
311CDA Body
312********************************************************
313-->
314 <component>
315 <structuredBody>
316 <!--
317 ********************************************************
318 Measure Set Section
319 ********************************************************
320 -->
321 <component>
322 <section>
323 <!-- WVP QRDA Category I measure-specific template ID for 2010 #1. -->
324 <!--WP Next 3 lines do not change during the reporting period, for the measures section-->
325 <templateId root="2.16.840.1.113883.3.249.11.12" />
326 <code code="55185-3" codeSystem="2.16.840.1.113883.6.1" />
327 <title>Measure set: CMS EHR Measure Set</title>
328 <text>2010 Measures Set Measures</text>
329 <!--
330 ***************************************************
331 Measure Section
332 ***************************************************
333 -->
334 <component>
335 <section>
336 <!--template ID for each measure being reported-->
337 <templateId root="2.16.840.1.113883.3.249.11.2" />
338 <templateId root="2.16.840.1.113883.3.249.11.3" />
339 <templateId root="2.16.840.1.113883.3.249.11.4" />
340 <templateId root="2.16.840.1.113883.3.249.11.5" />
341 <templateId root="2.16.840.1.113883.3.249.11.6" />
342 <templateId root="2.16.840.1.113883.3.249.11.7" />
343 <templateId root="2.16.840.1.113883.3.249.11.8" />
344 <templateId root="2.16.840.1.113883.3.249.11.9" />
345 <templateId root="2.16.840.1.113883.3.249.11.10" />
346 <templateId root="2.16.840.1.113883.3.249.11.11" />
347 <templateId root="2.16.840.1.113883.3.249.11.15" />
348 <code code="55186-1" codeSystem="2.16.840.1.113883.6.1" />
349 <title>Measure Section</title>
350 <!--Here is where the HTML begins for the above and it is optional-->
351 <text>
352 <list>
353 <item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
354 <item>CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus</item>
355 <item>CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus</item>
356 <item>CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)</item>
357 <item>CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)</item>
358 <item>CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years</item>
359 <item>CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older</item>
360 <item>CMS Measure #112: Preventive Care and Screening: Screening Mammography</item>
361 <item>CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening</item>
362 <item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
363 <item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
364 </list>
365 </text>
366 <!--Begin listing of acts-->
367 <entry typeCode="DRIV">
368 <act classCode="ACT" moodCode="DEF">
369 <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
370 <code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
371 <text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
372 <statusCode code="completed"/>
373 </act>
374 </entry>
375 <entry typeCode="DRIV">
376 <act classCode="ACT" moodCode="DEF">
377 <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
378 <code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
379 <text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
380 <statusCode code="completed"/>
381 </act>
382 </entry>
383 <entry typeCode="DRIV">
384 <act classCode="ACT" moodCode="DEF">
385 <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
386 <code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
387 <text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
388 <statusCode code="completed"/>
389 </act>
390 </entry>
391 <entry typeCode="DRIV">
392 <act classCode="ACT" moodCode="DEF">
393 <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
394 <code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
395 <text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
396 <statusCode code="completed"/>
397 </act>
398 </entry>
399 <entry typeCode="DRIV">
400 <act classCode="ACT" moodCode="DEF">
401 <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
402 <code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
403 <text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
404 <statusCode code="completed"/>
405 </act>
406 </entry>
407 <entry typeCode="DRIV">
408 <act classCode="ACT" moodCode="DEF">
409 <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
410 <code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients >= 50 Years"/>
411 <text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
412 <statusCode code="completed"/>
413 </act>
414 </entry>
415 <entry typeCode="DRIV">
416 <act classCode="ACT" moodCode="DEF">
417 <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
418 <code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
419 <text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
420 <statusCode code="completed"/>
421 </act>
422 </entry>
423 <entry typeCode="DRIV">
424 <act classCode="ACT" moodCode="DEF">
425 <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
426 <code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
427 <text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
428 <statusCode code="completed"/>
429 </act>
430 </entry>
431 <entry typeCode="DRIV">
432 <act classCode="ACT" moodCode="DEF">
433 <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
434 <code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
435 <text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
436 <statusCode code="completed"/>
437 </act>
438 </entry>
439 <entry typeCode="DRIV">
440 <act classCode="ACT" moodCode="DEF">
441 <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
442 <code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
443 <text>Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR)</text>
444 <statusCode code="completed"/>
445 </act>
446 </entry>
447 <entry typeCode="DRIV">
448 <act classCode="ACT" moodCode="DEF">
449 <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
450 <code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
451 <text>Documents whether provider has adopted and is using ePrescribing</text>
452 <statusCode code="completed"/>
453 </act>
454 </entry>
455 <!--
456 *******************************
457 Reporting Parameters Section
458 *****************************
459 -->
460 <component>
461 <section>
462 <code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
463 <title>Reporting Parameters</title>
464 <text>
465 <list>
466 <item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
467 </list>
468 </text>
469 <entry>
470 <act classCode="ACT" moodCode="EVN">
471 <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/>
472 <effectiveTime>
473 <low value="20100101"/>
474 <high value="20101231"/>
475 </effectiveTime>
476 </act>
477 </entry>
478 </section>
479 </component>
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