1 | <?xml version="1.0" encoding="UTF-8"?>
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2 | <?xml-stylesheet type="text/xsl" href="cda.xsl"?>
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3 | <!--WV Added new munltiple documentation of added have to do with encounter times, etc.-->
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4 |
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5 | <!--
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6 | ********************************************************
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7 | CDA Header
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8 | ********************************************************
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9 | -->
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10 |
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11 | <!--
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12 | ******************
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13 | Document Information
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14 | **********************
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15 | -->
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16 | <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">
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17 | <!-- Created with XML Copy Editor Open Source Sourceforge project. -->
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18 | <!--WVP This is the clinical document type ID-->
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19 | <realmCode code="US"/>
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20 | <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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21 | <!-- QRDA Category I generic template ID. -->
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22 | <!--WVP these next two lines are fixed-->
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23 | <templateId root="2.16.840.1.113883.10.20.12" />
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24 | <!--only in the july spec so not sure if it should be here-->
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25 | <templateId root="2.16.840.1.113883.3.249.11.100.1"/>
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26 | <!--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-->
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27 | <!-- WV? for this group of 10 documents we are submitting-->
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28 | <id root="2.16.840.1.113883.3.543" extension="01.01.01.100000001.1"/>
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29 | <!--WVP next two lines fixed-->
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30 | <code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
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31 | <title>QRDA Incidence Report</title>
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32 | <!--WVV time-->
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33 | <effectiveTime value="20100703"/>
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34 | <!--WVP for next two lines-->
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35 | <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
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36 | <languageCode code="en-US"/>
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37 | <!--WV? Don't change this in the document set we are working on-->
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38 | <setId root="2.16.840.1.113883.3.543" extension="01.01.01.100000001"/>
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39 | <versionNumber value="1"/>
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40 | <!--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-->
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41 |
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42 | <!--
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43 | *******************
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44 | Patient Information
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45 | ****************
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46 | -->
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47 | <!-- This is the patient for which the report is describing. -->
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48 | <recordTarget>
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49 | <patientRole>
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50 | <!--WVV Id coding system is in the downloadable resoure and SSN is the extension. Edit the extension here-->
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51 | <!--Can't change during the reporting period-->
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52 | <id root="2.16.840.1.113883.4.1" extension="002386407"/>
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53 | <!--WVV address is not required-->
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54 | <addr>
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55 | <streetAddressLine>1200 Sanders Lane</streetAddressLine>
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56 | <city>Rockville</city>
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57 | <state>MD</state>
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58 | <postalCode>20850</postalCode>
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59 | </addr>
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60 | <patient>
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61 | <!-- WVV something called use="L" found in some samples - not sure what it is or need for it -->
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62 | <name>
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63 | <!-- WV Edit -->
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64 | <given>Jody</given>
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65 | <family>Jones</family>
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66 | </name >
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67 |
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68 | <!--VV Gender code can be M, F or UN for undifferentiated-->
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69 | <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
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70 | <!--WVV Birth Time at least to the day-->
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71 | <birthTime value="19450101"/>
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72 | <!--WVV Edit-->
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73 | <!--WVV race is in there too, tab L in downloadable resources 2054-5 is Back or African American -->
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74 | <!--WVV 2106-3 is white and there are no hispanic and a huge number of indian tribes-->
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75 | <raceCode code="2106.3" codeSystem="2.16.840.1.113883.5.104"/>
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76 | <!--WVVEdit from downloadable resource tab M for Ethnicity -->
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77 | <!--WV 2186-5 is Not Hispanic or Latino -->
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78 | <ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.5.50"/>
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79 | </patient>
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80 | <!--WV Added to sample document and required NPI as extension and root is permanent-->
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81 | <providerOrganization>
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82 | <id root="2.16.840.1.113883.4.6" extension="6558574524" />
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83 | <name>WorldVistA Test Clinic</name>
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84 | <!--WVV address of organization which must have NPI is optional-->
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85 | <addr>
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86 | <streetAddressLine>123 Maple Ave</streetAddressLine>
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87 | <city>Gaithersburg</city>
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88 | <state>MD</state>
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89 | <postalCode>20877</postalCode>
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90 | </addr>
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91 | <!--WVP required asOrganizationPartOf added to sample-->
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92 | <asOrganizationPartOf>
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93 | <wholeOrganization>
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94 | <!--WVV tax ID (SS# or EIN)for the organizaton is the extension and the root is required and WVP2.16.840.1.113883.4.2-->
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95 | <id root="2.16.840.1.113883.4.2" extension="002345678"/>
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96 | </wholeOrganization>
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97 | </asOrganizationPartOf>
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98 | </providerOrganization>
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99 | </patientRole>
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100 | </recordTarget>
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101 |
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102 | <!--
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103 | *****************************
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104 | Author
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105 | **************
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106 | -->
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107 | <!-- This example assumes the doctor is creating the report and it is Required. -->
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108 | <author>
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109 | <!--WVV Edit time has to be precise at least to the day-->
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110 | <time value="20100703" />
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111 | <assignedAuthor>
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112 | <!--WVP eventually id this is required, the root is fixed -->
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113 | <!--andn the extension is the SOFTWARE version number assigned by CMS to WV EHR-->
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114 | <id root="2.16.840.1.113883.3.249.6" extension="100001" />
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115 | <!--WVVassignedPerson not required-->
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116 | <assignedPerson>
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117 | <name>
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118 | <!--WV Edit-->
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119 | <given>Nancy</given>
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120 | <family>Anthracite</family>
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121 | <suffix>MD</suffix>
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122 | </name>
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123 | </assignedPerson>
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124 | <representedOrganization>
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125 | <!--WV? id root is OID for the organization so I made one up for this document set-->
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126 | <id root="2.16.840.1.113883.3.543" extension="1558574526" />
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127 | <name>WorldVistA Test Clinic</name>
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128 | </representedOrganization>
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129 | </assignedAuthor>
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130 | </author>
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131 | <!-- The reporting healthcare facility is represented using the CCD "Source of Information" construct, via the Informant participant. -->
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132 | <informant>
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133 | <assignedEntity>
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134 | <!--WV this null flavor is required as is-->
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135 | <id nullFlavor="NA"/>
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136 | <representedOrganization>
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137 | <!--WV root is the OID of the organization. ID is required but name is not and id is OID stated earlier-->
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138 | <id root="2.16.840.1.113883.3.543" extension="1558574526" />
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139 | <name>World VistA Test Clinic</name>
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140 | </representedOrganization>
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141 | </assignedEntity>
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142 | </informant>
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143 |
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144 | <!-- This example assumes that the institution responsible for the data is serving as custodian. -->
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145 | <!--WV This element is required as is the sSD which is not stated if it is an OID but assumed it is-->
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146 | <!--WV Name is not required, only ID is required.-->
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147 | <custodian>
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148 | <assignedCustodian>
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149 | <representedCustodianOrganization>
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150 | <id root="2.16.840.1.113883.3.543" extension="1558574526" />
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151 | <name>WorldVistA Test Clinic</name>
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152 | </representedCustodianOrganization>
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153 | </assignedCustodian>
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154 | </custodian>
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155 |
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156 | <!-- In this example, the author is also serving as legal authenticator. -->
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157 | <!--WV section is this is not required-->
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158 | <legalAuthenticator>
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159 | <time value="20100703" />
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160 | <!--WV the signature code of S is required-->
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161 | <signatureCode code="S" />
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162 | <assignedEntity>
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163 | <!--WV document does not specify the requirements of the id but it is required-->
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164 | <!--WVP and the sample suggests it is the number below and extension is ???-->
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165 | <id root="2.16.840.1.113883.3.543" extension="111111" />
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166 | <assignedPerson>
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167 | <name>
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168 | <given>Nancy</given>
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169 | <family>Anthracite</family>
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170 | <suffix>MD</suffix>
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171 | </name>
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172 | </assignedPerson>
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173 | <representedOrganization>
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174 | <!--WV? and is fixed for the WorldVistA Test Clinic in this submitted document series-->
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175 | <id root="2.16.840.1.113883.3.543" extension="1558574526" />
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176 | <name>WorldVistA Test Clinic</name>
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177 | </representedOrganization>
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178 | </assignedEntity>
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179 | </legalAuthenticator>
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180 |
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181 |
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182 |
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183 | <!--Added to sample as it is new since 2008-->
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184 | <!--WVP permanent for participant in the primary care provider participant-->
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185 | <!--WVP performer type codes are numerous but PRF is performer or the person who did it-->
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186 | <participant typeCode="PRF">
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187 | <!--WVP required as is for function-->
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188 | <!-- WVP I believe PCP is primary care provider but not sure-->
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189 | <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
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190 | <!--WVP Associated Entity is required ti be there with this PROV-->
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191 | <associatedEntity classCode="PROV">
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192 | <!--WV? OID of the provider fixed for this series of documents-->
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193 | <id root="2.16.840.1.113883.3.249.6" extension="111111" />
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194 | <!--WV associated person is not required so presumabley the code will suffice not sure??-->
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195 | <associatedPerson>
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196 | <name>
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197 | <prefix>Dr.</prefix>
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198 | <given>Nancy</given>
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199 | <family>Anthracite</family>
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200 | </name>
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201 | </associatedPerson>
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202 | </associatedEntity>
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203 | </participant>
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204 |
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205 | <!--The service event is the encounter that describes tehe encunter as well as the provider, location and time-->
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206 | <!--!There can be one or more documentation elements depending on the number of encounters during the reporting period-->
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207 | <!--WVV IMPORTANT!! The encounter codeds are recorded here-->
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208 | <!-- They are in appendix B of the downloadable resource document-->
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209 | <!-- Each documentation of is a single service event-->
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210 |
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211 | <!--Occurence of Measures episode documention-->
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212 | <!--Like an encounter section only for QRDA-->
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213 | <!--Same doctor, same clinic, different date and different enconter code-->
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214 |
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215 |
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216 | <!--First Visit documentationOf section-->
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217 |
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218 | <documentationOf>
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219 | <serviceEvent>
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220 | <!--WV serviceEvent codes from Tab B from the downloadabe resource coding system is -->
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221 | <!--WVF codeSystem is 2.16.840.1.113883 -->
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222 | <!--WV code root shall be WVP 2.16.840.1.113883.6.12 and the extension shall be the encounter code -->
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223 | <!-- WV? like the length of visit and complexity codes for example-->
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224 |
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225 | <code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
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226 | <effectiveTime>
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227 | <!--WV Edit-->
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228 | <!-- 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-->
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229 | <low value="20100205"/>
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230 | <high value="20100205"/>
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231 | </effectiveTime>
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232 | <performer typeCode="PRF">
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233 | <assignedEntity>
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234 | <!-- WV? Provider NPI Required root 2.16.840.1.113883.9.96 is ?? and the NPI is an extension for the provider-->
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235 | <!--This is variable but may remain unchanged for this document set-->
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236 | <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
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237 | <!--<id root="2.16.840.1.113883.3.543" extension="1457402711"/>-->
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238 | <!--WV this element should be present and the code is probably for a General Physician for!-->
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239 | <!--It may be the type of provider as the example as I think 2.16.840.1.113883.6.69is the NDC-->
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240 | <!-- codeSystemName is SNOMED CT and code is an 8 digit num and display name is for a physician-->
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241 | <!--O6120 is SPECIALIZED PHYSICIAN when I looked it up so I don't know where to look for this 8 digit number-->
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242 | <!-- http://terminology.vetmed.vt.edu/SCT/menu.cfm to look up codes-->
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243 | <!--59058001 is general physician ;Family Medicine specialist is 62247001-->
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244 | <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
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245 | <addr>
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246 | <streetAddressLine>123 Maple Ave</streetAddressLine>
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247 | <city>Gaithersburg</city>
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248 | <state>MD</state>
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249 | <postalCode>20877</postalCode>
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250 | </addr>
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251 | <assignedPerson>
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252 | <name>
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253 | <given>Nancy</given>
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254 | <family>Anthracite</family>
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255 | <suffix>MD</suffix>
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256 | </name>
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257 | </assignedPerson>
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258 | </assignedEntity>
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259 | </performer>
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260 | </serviceEvent>
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261 | </documentationOf>
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262 |
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263 |
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264 | <!--Second Visit documentationOf section-->
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265 |
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266 | <documentationOf>
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267 | <serviceEvent>
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268 | <!--WV serviceEvent codes from Tab B from the downloadabe resource coding system is -->
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269 | <!--WVF codeSystem is 2.16.840.1.113883 -->
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270 | <!--WV code root shall be WVP 2.16.840.1.113883.6.12 and the extension shall be the encounter code -->
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271 | <!-- WV? like the length of visit and complexity codes for example-->
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272 |
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273 | <code code="99204" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
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274 | <effectiveTime>
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275 | <!--WV Edit-->
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276 | <!-- 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-->
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277 | <low value="20100703"/>
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278 | <high value="20100703"/>
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279 | </effectiveTime>
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280 | <performer typeCode="PRF">
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281 | <assignedEntity>
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282 | <!-- WV? Provider NPI Required root 2.16.840.1.113883.9.96 is ?? and the NPI is an extension for the provider-->
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283 | <!--This is variable but may remain unchanged for this document set-->
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284 | <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
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285 | <!--<id root="2.16.840.1.113883.3.543" extension="1457402711"/>-->
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286 | <!--WV this element should be present and the code is probably for a General Physician for!-->
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287 | <!--It may be the type of provider as the example as I think 2.16.840.1.113883.6.69is the NDC-->
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288 | <!-- codeSystemName is SNOMED CT and code is an 8 digit num and display name is for a physician-->
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289 | <!--O6120 is SPECIALIZED PHYSICIAN when I looked it up so I don't know where to look for this 8 digit number-->
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290 | <!-- http://terminology.vetmed.vt.edu/SCT/menu.cfm to look up codes-->
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291 | <!--59058001 is general physician ;Family Medicine specialist is 62247001-->
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292 | <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
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293 | <addr>
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294 | <streetAddressLine>123 Maple Ave</streetAddressLine>
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295 | <city>Gaithersburg</city>
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296 | <state>MD</state>
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297 | <postalCode>20877</postalCode>
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298 | </addr>
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299 | <assignedPerson>
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300 | <name>
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301 | <given>Nancy</given>
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302 | <family>Anthracite</family>
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303 | <suffix>MD</suffix>
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304 | </name>
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305 | </assignedPerson>
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306 | </assignedEntity>
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307 | </performer>
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308 | </serviceEvent>
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309 | </documentationOf>
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310 | <!--
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311 | ********************************************************
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312 | CDA Body
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313 | ********************************************************
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314 | -->
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315 | <component>
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316 | <structuredBody>
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317 | <!--
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318 | ********************************************************
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319 | Measure Set Section
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320 | ********************************************************
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321 | -->
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322 | <component>
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323 | <section>
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324 | <!-- WVP QRDA Category I measure-specific template ID for 2010 #1. -->
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325 | <!--WP Next 3 lines do not change during the reporting period, for the measures section-->
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326 | <templateId root="2.16.840.1.113883.3.249.11.12" />
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327 | <code code="55185-3" codeSystem="2.16.840.1.113883.6.1" />
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328 | <title>Measure set: CMS EHR Measure Set</title>
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329 | <text>2010 Measures Set Measures</text>
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330 | <!--
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331 | ***************************************************
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332 | Measure Section
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333 | ***************************************************
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334 | -->
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335 | <component>
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336 | <section>
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337 | <!--template ID for each measure being reported-->
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338 | <templateId root="2.16.840.1.113883.3.249.11.2" />
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339 | <templateId root="2.16.840.1.113883.3.249.11.3" />
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340 | <templateId root="2.16.840.1.113883.3.249.11.4" />
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341 | <templateId root="2.16.840.1.113883.3.249.11.5" />
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342 | <templateId root="2.16.840.1.113883.3.249.11.6" />
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343 | <templateId root="2.16.840.1.113883.3.249.11.7" />
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344 | <templateId root="2.16.840.1.113883.3.249.11.8" />
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345 | <templateId root="2.16.840.1.113883.3.249.11.9" />
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346 | <templateId root="2.16.840.1.113883.3.249.11.10" />
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347 | <templateId root="2.16.840.1.113883.3.249.11.11" />
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348 | <templateId root="2.16.840.1.113883.3.249.11.15" />
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349 | <code code="55186-1" codeSystem="2.16.840.1.113883.6.1" />
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350 | <title>Measure Section</title>
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351 | <!--Here is where the HTML begins for the above and it is optional-->
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352 | <text>
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353 | <list>
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354 | <item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
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355 | <item>CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus</item>
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356 | <item>CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus</item>
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357 | <item>CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)</item>
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358 | <item>CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)</item>
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359 | <item>CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years</item>
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360 | <item>CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older</item>
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361 | <item>CMS Measure #112: Preventive Care and Screening: Screening Mammography</item>
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362 | <item>CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening</item>
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363 | <item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
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364 | <item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
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365 | </list>
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366 | </text>
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367 | <!--Begin listing of acts-->
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368 | <entry typeCode="DRIV">
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369 | <act classCode="ACT" moodCode="DEF">
|
---|
370 | <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
|
---|
371 | <code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
|
---|
372 | <text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
|
---|
373 | <statusCode code="completed"/>
|
---|
374 | </act>
|
---|
375 | </entry>
|
---|
376 | <entry typeCode="DRIV">
|
---|
377 | <act classCode="ACT" moodCode="DEF">
|
---|
378 | <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
|
---|
379 | <code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
|
---|
380 | <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>
|
---|
381 | <statusCode code="completed"/>
|
---|
382 | </act>
|
---|
383 | </entry>
|
---|
384 | <entry typeCode="DRIV">
|
---|
385 | <act classCode="ACT" moodCode="DEF">
|
---|
386 | <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
|
---|
387 | <code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
|
---|
388 | <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>
|
---|
389 | <statusCode code="completed"/>
|
---|
390 | </act>
|
---|
391 | </entry>
|
---|
392 | <entry typeCode="DRIV">
|
---|
393 | <act classCode="ACT" moodCode="DEF">
|
---|
394 | <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
|
---|
395 | <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)"/>
|
---|
396 | <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>
|
---|
397 | <statusCode code="completed"/>
|
---|
398 | </act>
|
---|
399 | </entry>
|
---|
400 | <entry typeCode="DRIV">
|
---|
401 | <act classCode="ACT" moodCode="DEF">
|
---|
402 | <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
|
---|
403 | <code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
|
---|
404 | <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>
|
---|
405 | <statusCode code="completed"/>
|
---|
406 | </act>
|
---|
407 | </entry>
|
---|
408 | <entry typeCode="DRIV">
|
---|
409 | <act classCode="ACT" moodCode="DEF">
|
---|
410 | <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
|
---|
411 | <code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients >= 50 Years"/>
|
---|
412 | <text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
|
---|
413 | <statusCode code="completed"/>
|
---|
414 | </act>
|
---|
415 | </entry>
|
---|
416 | <entry typeCode="DRIV">
|
---|
417 | <act classCode="ACT" moodCode="DEF">
|
---|
418 | <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
|
---|
419 | <code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
|
---|
420 | <text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
|
---|
421 | <statusCode code="completed"/>
|
---|
422 | </act>
|
---|
423 | </entry>
|
---|
424 | <entry typeCode="DRIV">
|
---|
425 | <act classCode="ACT" moodCode="DEF">
|
---|
426 | <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
|
---|
427 | <code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
|
---|
428 | <text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
|
---|
429 | <statusCode code="completed"/>
|
---|
430 | </act>
|
---|
431 | </entry>
|
---|
432 | <entry typeCode="DRIV">
|
---|
433 | <act classCode="ACT" moodCode="DEF">
|
---|
434 | <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
|
---|
435 | <code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
|
---|
436 | <text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
|
---|
437 | <statusCode code="completed"/>
|
---|
438 | </act>
|
---|
439 | </entry>
|
---|
440 | <entry typeCode="DRIV">
|
---|
441 | <act classCode="ACT" moodCode="DEF">
|
---|
442 | <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
|
---|
443 | <code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
|
---|
444 | <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>
|
---|
445 | <statusCode code="completed"/>
|
---|
446 | </act>
|
---|
447 | </entry>
|
---|
448 | <entry typeCode="DRIV">
|
---|
449 | <act classCode="ACT" moodCode="DEF">
|
---|
450 | <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
|
---|
451 | <code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
|
---|
452 | <text>Documents whether provider has adopted and is using ePrescribing</text>
|
---|
453 | <statusCode code="completed"/>
|
---|
454 | </act>
|
---|
455 | </entry>
|
---|
456 | <!--
|
---|
457 | *******************************
|
---|
458 | Reporting Parameters Section
|
---|
459 | *****************************
|
---|
460 | -->
|
---|
461 | <component>
|
---|
462 | <section>
|
---|
463 | <code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
464 | <title>Reporting Parameters</title>
|
---|
465 | <text>
|
---|
466 | <list>
|
---|
467 | <item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
|
---|
468 | </list>
|
---|
469 | </text>
|
---|
470 | <entry>
|
---|
471 | <act classCode="ACT" moodCode="EVN">
|
---|
472 | <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/>
|
---|
473 | <effectiveTime>
|
---|
474 | <low value="20100101"/>
|
---|
475 | <high value="20101231"/>
|
---|
476 | </effectiveTime>
|
---|
477 | </act>
|
---|
478 | </entry>
|
---|
479 | </section>
|
---|
480 | </component>
|
---|
481 | <!--
|
---|
482 | ********************************************************
|
---|
483 | Patient Data
|
---|
484 | ********************************************************
|
---|
485 | -->
|
---|
486 | <component>
|
---|
487 | <section>
|
---|
488 | <code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
489 | <title>Patient Data</title>
|
---|
490 | </section>
|
---|
491 | </component>
|
---|
492 | <!--
|
---|
493 | **************************************************
|
---|
494 | PROBLEM SECTION
|
---|
495 | **************************************************
|
---|
496 | -->
|
---|
497 | <component>
|
---|
498 | <section>
|
---|
499 | <!--Problems are observations and the next two lines are fixed -WVP-->
|
---|
500 | <templateId root="2.16.840.1.113883.10.20.1.11"/>
|
---|
501 | <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
|
---|
502 | <title>Problems</title>
|
---|
503 | <text>
|
---|
504 | <table border="1" width="100%">
|
---|
505 | <tbody>
|
---|
506 | <tr>
|
---|
507 | <th>Condition</th>
|
---|
508 | <th>Effective Dates</th>
|
---|
509 | <th>Condition Status</th>
|
---|
510 | </tr>
|
---|
511 | <tr>
|
---|
512 | <td>Diabetes mellitus</td>
|
---|
513 | <td>1995</td>
|
---|
514 | <td>Active/Chronic</td>
|
---|
515 | </tr>
|
---|
516 | <tr>
|
---|
517 | <td>Congestive Heart Failure</td>
|
---|
518 | <td>2007</td>
|
---|
519 | <td>Active/Chronic</td>
|
---|
520 | </tr>
|
---|
521 | <tr>
|
---|
522 | <td>Myocardial Infactioon</td>
|
---|
523 | <td>1996</td>
|
---|
524 | <td>Resolved</td>
|
---|
525 | </tr>
|
---|
526 | </tbody>
|
---|
527 | </table>
|
---|
528 | </text>
|
---|
529 | <!--DRIV is derived from and both source and target are observations Next three lines are WVP-->
|
---|
530 | <entry typeCode="DRIV">
|
---|
531 | <act classCode="ACT" moodCode="EVN">
|
---|
532 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
|
---|
533 | <!-- Problem act template -->
|
---|
534 | <!--This is a UID for this problem-->
|
---|
535 | <id root="82dd6640-8669-11df-a4ee-0800200c9a66"/>
|
---|
536 | <code nullFlavor="NA"/>
|
---|
537 | <!--relates an aCT to a subject act that the first act is primarily concerned with-->
|
---|
538 | <entryRelationship typeCode="SUBJ">
|
---|
539 | <observation classCode="OBS" moodCode="EVN">
|
---|
540 | <!--10.20.1.50 is for observation-->
|
---|
541 | <templateId root="2.16.840.1.113883.10.20.1.28"/>
|
---|
542 | <!-- Problem observation template -->
|
---|
543 | <id root="82dd6641-8669-11df-a4ee-0800200c9a66"/>
|
---|
544 | <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
|
---|
545 | <statusCode code="completed"/>
|
---|
546 | <effectiveTime>
|
---|
547 | <low value="19950101"/>
|
---|
548 | </effectiveTime>
|
---|
549 | <!--CD is a concept descriptor and the code systeem is ICD9 for 6.103 -->
|
---|
550 | <value xsi:type="CD" code="250.00" codeSystem="2.16.840.1.113883.6.103" displayName="Diabetes Mellitus"/>
|
---|
551 | <!--REFR is refers to-->
|
---|
552 | <entryRelationship typeCode="REFR">
|
---|
553 | <!-- EVN is event or a service that actually happens-->
|
---|
554 | <observation classCode="OBS" moodCode="EVN">
|
---|
555 | <!--10.20.1.50 is observation template OID-->
|
---|
556 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
|
---|
557 | <!-- Problem status observation template -->
|
---|
558 | <!--33999-4 is for status template-->
|
---|
559 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
|
---|
560 | <statusCode code="completed"/>
|
---|
561 | <!--55561003 is fro active CE is for coded with equivalents data type and 6.96 is SNOMED CT-->
|
---|
562 | <value xsi:type="CE" code="90734009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chronic"/>
|
---|
563 | </observation>
|
---|
564 | </entryRelationship>
|
---|
565 | </observation>
|
---|
566 | </entryRelationship>
|
---|
567 | </act>
|
---|
568 | </entry>
|
---|
569 | <!--DRIV is derived from and both source and target are observations Next three lines are WVP-->
|
---|
570 | <entry typeCode="DRIV">
|
---|
571 | <act classCode="ACT" moodCode="EVN">
|
---|
572 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
|
---|
573 | <!-- Problem act template -->
|
---|
574 | <!--This is a UID for this problem-->
|
---|
575 | <id root="82dd6642-8669-11df-a4ee-0800200c9a66"/>
|
---|
576 | <code nullFlavor="NA"/>
|
---|
577 | <!--relates an aCT to a subject act that the first act is primarily concerned with-->
|
---|
578 | <entryRelationship typeCode="SUBJ">
|
---|
579 | <observation classCode="OBS" moodCode="EVN">
|
---|
580 | <!--10.20.1.50 is for observation-->
|
---|
581 | <templateId root="2.16.840.1.113883.10.20.1.28"/>
|
---|
582 | <!-- Problem observation template -->
|
---|
583 | <id root="82dd6643-8669-11df-a4ee-0800200c9a66"/>
|
---|
584 | <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
|
---|
585 | <statusCode code="completed"/>
|
---|
586 | <effectiveTime>
|
---|
587 | <low value="20070101"/>
|
---|
588 | </effectiveTime>
|
---|
589 | <!--CD is a concept descriptor and the code systeem is ICD9 for 6.103 -->
|
---|
590 | <value xsi:type="CD" code="428.0" codeSystem="2.16.840.1.113883.6.103" displayName="Congestive Heart Failure"/>
|
---|
591 | <!--REFR is refers to-->
|
---|
592 | <entryRelationship typeCode="REFR">
|
---|
593 | <!-- EVN is event or a service that actually happens-->
|
---|
594 | <observation classCode="OBS" moodCode="EVN">
|
---|
595 | <!--10.20.1.50 is observation template OID-->
|
---|
596 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
|
---|
597 | <!-- Problem status observation template -->
|
---|
598 | <!--33999-4 is for status template-->
|
---|
599 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
|
---|
600 | <statusCode code="completed"/>
|
---|
601 | <!--55561003 is fro active CE is for coded with equivalents data type and 6.96 is SNOMED CT-->
|
---|
602 | <value xsi:type="CE" code="90734009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chronic"/>
|
---|
603 | </observation>
|
---|
604 | </entryRelationship>
|
---|
605 | </observation>
|
---|
606 | </entryRelationship>
|
---|
607 | </act>
|
---|
608 | </entry>
|
---|
609 | <entry typeCode="DRIV">
|
---|
610 | <act classCode="ACT" moodCode="EVN">
|
---|
611 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
|
---|
612 | <!-- Problem act template -->
|
---|
613 | <!--This is a UID for this problem-->
|
---|
614 | <id root="82dd6640-8669-11df-a4ee-0800200c9a66"/>
|
---|
615 | <code nullFlavor="NA"/>
|
---|
616 | <!--relates an aCT to a subject act that the first act is primarily concerned with-->
|
---|
617 | <entryRelationship typeCode="SUBJ">
|
---|
618 | <observation classCode="OBS" moodCode="EVN">
|
---|
619 | <!--10.20.1.50 is for observation-->
|
---|
620 | <templateId root="2.16.840.1.113883.10.20.1.28"/>
|
---|
621 | <!-- Problem observation template -->
|
---|
622 | <id root="82dd6641-8669-11df-a4ee-0800200c9a66"/>
|
---|
623 | <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
|
---|
624 | <statusCode code="completed"/>
|
---|
625 | <effectiveTime>
|
---|
626 | <low value="19960101"/>
|
---|
627 | </effectiveTime>
|
---|
628 | <!--CD is a concept descriptor and the code systeem is ICD9 for 6.103 -->
|
---|
629 | <value xsi:type="CD" code="412" codeSystem="2.16.840.1.113883.6.103" displayName="Old Myocardial Infarction"/>
|
---|
630 | <!--REFR is refers to-->
|
---|
631 | <entryRelationship typeCode="REFR">
|
---|
632 | <!-- EVN is event or a service that actually happens-->
|
---|
633 | <observation classCode="OBS" moodCode="EVN">
|
---|
634 | <!--10.20.1.50 is observation template OID-->
|
---|
635 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
|
---|
636 | <!-- Problem status observation template -->
|
---|
637 | <!--33999-4 is for status template-->
|
---|
638 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
|
---|
639 | <statusCode code="completed"/>
|
---|
640 | <!--55561003 is fro active CE is for coded with equivalents data type and 6.96 is SNOMED CT-->
|
---|
641 | <value xsi:type="CE" code="73425007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Inactive"/>
|
---|
642 | </observation>
|
---|
643 | </entryRelationship>
|
---|
644 | </observation>
|
---|
645 | </entryRelationship>
|
---|
646 | </act>
|
---|
647 | </entry>
|
---|
648 | </section>
|
---|
649 | </component>
|
---|
650 | <!--
|
---|
651 | *********************************************
|
---|
652 | Medication Section
|
---|
653 | *********************************************
|
---|
654 | -->
|
---|
655 | <component>
|
---|
656 | <section>
|
---|
657 | <!--<templateId root="2.16.840.1.113883.3.88.11.83.112" assigningAuthorityName="HITSP/C83"/>-->
|
---|
658 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.19" assigningAuthorityName="IHE PCC"/>-->
|
---|
659 | <templateId root="2.16.840.1.113883.10.20.1.8" assigningAuthorityName="HL7 CCD"/>
|
---|
660 | <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medication use"/>
|
---|
661 | <title>Medications</title>
|
---|
662 | <text>
|
---|
663 | <table border="1" width="100%">
|
---|
664 | <thead>
|
---|
665 | <tr>
|
---|
666 | <th>Medication</th>
|
---|
667 | <th>Date</th>
|
---|
668 | <th>Status</th>
|
---|
669 | <th>Form</th>
|
---|
670 | <th>Strength</th>
|
---|
671 | <th>Quantity</th>
|
---|
672 | <th>SIG</th>
|
---|
673 | <th>Refills</th>
|
---|
674 | <th>Prescribed by</th>
|
---|
675 | </tr>
|
---|
676 | </thead>
|
---|
677 | <tbody>
|
---|
678 | <tr>
|
---|
679 | <td>GLYBURIDE-METFORMIN 2.5 mg-500 mg oral tablet</td>
|
---|
680 | <td>7-3-2010</td>
|
---|
681 | <td>ACTIVE</td>
|
---|
682 | <td>TABLET</td>
|
---|
683 | <td>2.5/500 MG</td>
|
---|
684 | <td>90 TAB</td>
|
---|
685 | <td> ONE BY MOUTH Q12H</td>
|
---|
686 | <td>two</td>
|
---|
687 | <td>Nancy Anthracite, MD</td>
|
---|
688 | </tr>
|
---|
689 | <tr>
|
---|
690 | <td>ATENOLOL 100MG TAB</td>
|
---|
691 | <td>7-3-2010</td>
|
---|
692 | <td>ACTIVE</td>
|
---|
693 | <td>TAB</td>
|
---|
694 | <td>100 MG</td>
|
---|
695 | <td>90 TAB</td>
|
---|
696 | <td>ONE TAB (BY MOUTH) QD</td>
|
---|
697 | <td>TWO</td>
|
---|
698 | <td>Nancy Anthracite, MD</td>
|
---|
699 | </tr>
|
---|
700 | <tr>
|
---|
701 | <td>LISINOPRIL 20MG TAB</td>
|
---|
702 | <td>7-3-2010</td>
|
---|
703 | <td>ACTIVE</td>
|
---|
704 | <td>TAB</td>
|
---|
705 | <td>20 MG</td>
|
---|
706 | <td>90 TAB</td>
|
---|
707 | <td>20 MG ORAL (BY MOUTH) QAM</td>
|
---|
708 | <td>2</td>
|
---|
709 | <td>Nancy Anthracite, MD</td>
|
---|
710 | </tr>
|
---|
711 | </tbody>
|
---|
712 | </table>
|
---|
713 | </text>
|
---|
714 | <entry typeCode="DRIV">
|
---|
715 | <!-- WVP EVN mood code is for event or a service that actually happens-->
|
---|
716 | <substanceAdministration classCode="SBADM" moodCode="EVN">
|
---|
717 | <!--WVP Substance Adminstration Template 10.20.1.24 what is administered but 10.20.1.34 would be for supply activity-->
|
---|
718 | <templateId root="2.16.840.1.113883.10.20.1.24" assigningAuthorityName="CCD"/>
|
---|
719 | <templateId root="2.16.840.1.113883.3.249.19.5.10" extension="10016"/>
|
---|
720 | <!--<id root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1" assigningAuthorityName="IHE PCC"/>-->
|
---|
721 | <!--<id root="MED1" extension="CCRObjectID"/>-->
|
---|
722 | <id root="2.16.840.1.113883.19.5.10" extension="100016"/>
|
---|
723 | <statusCode code="completed"/>
|
---|
724 | <effectiveTime xsi:type="IVL_TS">
|
---|
725 | <low value="20100703"/>
|
---|
726 | <high nullFlavor="UNK"/>
|
---|
727 |
|
---|
728 | </effectiveTime>
|
---|
729 | <effectiveTime xsi:type="PIVL_TS" operator="A">
|
---|
730 | <period value="12" unit="h"/>
|
---|
731 | </effectiveTime>
|
---|
732 | <!--SHOULD have this routeOfAdminstartionbut I can't find the codes for it-->
|
---|
733 | <!--Downloadable resource is missing them-->
|
---|
734 | <!--<routeCode displayName="" code="" codeSystemName="2.16.840.1.113883.5.112"/>-->
|
---|
735 | <doseQuantity value="1">
|
---|
736 | <!--Unit was missing from generated CCD MG was added (hope it is right!)-->
|
---|
737 | <low value="1" unit="TAB"/>
|
---|
738 | <high value="1" unit="TAB"/>
|
---|
739 | </doseQuantity>
|
---|
740 | <consumable>
|
---|
741 | <manufacturedProduct>
|
---|
742 | <!--<templateId root="2.16.840.1.113883.3.88.11.83.8.2" assigningAuthorityName="HITSP C83"/>-->
|
---|
743 | <templateId root="2.16.840.1.113883.10.20.1.53" assigningAuthorityName="CCD"/>
|
---|
744 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2" assigningAuthorityName="IHE PCC"/>-->
|
---|
745 | <manufacturedMaterial>
|
---|
746 | <!--this will be right RxNorm in 2011-->
|
---|
747 | <!--Other options to use
|
---|
748 | 00087607311 glyBURIDE-metformin 2.5 mg-500 mg oral tablet
|
---|
749 | 00087607411 glyBURIDE-metformin 5 mg-500 mg oral tablet
|
---|
750 | 00087607731 glipiZIDE-metformin 2.5 mg-500 mg oral tablet
|
---|
751 | 00087607831 glipiZIDE-metformin 5 mg-500 mg oral tablet
|
---|
752 | 00087608131 glipiZIDE-metformin 2.5 mg-250 mg oral tablet-->
|
---|
753 |
|
---|
754 | <code code="00087607411" displayName="glyburide-metformin 2.5 mg-500 mg oral tablet" codeSystemName="NDC" codeSystem="2.16.840.1.113883.6.69">
|
---|
755 | <!--<name/>-->
|
---|
756 | <originalText>glyburide-metformin</originalText>
|
---|
757 | </code>
|
---|
758 | </manufacturedMaterial>
|
---|
759 | </manufacturedProduct>
|
---|
760 | </consumable>
|
---|
761 | </substanceAdministration>
|
---|
762 | </entry>
|
---|
763 | <entry typeCode="DRIV">
|
---|
764 | <substanceAdministration classCode="SBADM" moodCode="EVN">
|
---|
765 | <templateId root="2.16.840.1.113883.10.20.1.24" assigningAuthorityName="CCD"/>
|
---|
766 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1" assigningAuthorityName="IHE PCC"/>-->
|
---|
767 | <!--<id root="MED2" extension="CCRObjectID"/>-->
|
---|
768 | <id root="2.16.840.1.113883.19.5.10" extension="100016"/>
|
---|
769 | <statusCode code="completed"/>
|
---|
770 | <effectiveTime xsi:type="IVL_TS">
|
---|
771 | <low value="20100701"/>
|
---|
772 | <high nullFlavor="UNK"/>
|
---|
773 | </effectiveTime>
|
---|
774 | <effectiveTime xsi:type="PIVL_TS" operator="A">
|
---|
775 | <period value="12" unit="h"/>
|
---|
776 | </effectiveTime>
|
---|
777 | <!--SHOULD have this routeOfAdminstartionbut I can't find the codes for it-->
|
---|
778 | <!--Downloadable resource is missing them-->
|
---|
779 | <!--<routeCode displayName="" code="" codeSystemName="2.16.840.1.113883.5.112"/>-->
|
---|
780 | <doseQuantity value="1">
|
---|
781 | <!--Unit was missing from generated CCD MG was added (hope it is right!)-->
|
---|
782 | <low value="1" unit="TAB"/>
|
---|
783 | <high value="1" unit="TAB"/>
|
---|
784 | </doseQuantity>
|
---|
785 | <consumable>
|
---|
786 | <manufacturedProduct>
|
---|
787 | <!--<templateId root="2.16.840.1.113883.3.88.11.83.8.2" assigningAuthorityName="HITSP C83"/>-->
|
---|
788 | <templateId root="2.16.840.1.113883.10.20.1.53" assigningAuthorityName="CCD"/>
|
---|
789 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2" assigningAuthorityName="IHE PCC"/>-->
|
---|
790 | <manufacturedMaterial>
|
---|
791 | <!--not valid until 2011-->
|
---|
792 | <!--<code displayName="ATENOLOL 100MG TAB" code="197379" codeSystemName="RXNORM" codeSystem=""/>-->
|
---|
793 | <!--Other Options
|
---|
794 | 00005321843 atenolol 25 mg oral tablet Atenolol
|
---|
795 | 00005321934 atenolol 50 mg oral tablet Atenolol
|
---|
796 | 00005321943 atenolol 50 mg oral tablet Atenolol
|
---|
797 | 00005322034 atenolol 100 mg oral tablet Atenolol
|
---|
798 | 00005322043 atenolol 100 mg oral tablet Atenolol
|
---|
799 | -->
|
---|
800 | <code code="00005322034" displayName="ATENOLOL 100MG TAB" codeSystemName="NDC" codeSystem="2.16.840.1.113883.6.69">
|
---|
801 | <!--<name/>-->
|
---|
802 | <originalText>atenolol</originalText>
|
---|
803 | </code>
|
---|
804 | </manufacturedMaterial>
|
---|
805 | </manufacturedProduct>
|
---|
806 | </consumable>
|
---|
807 | </substanceAdministration>
|
---|
808 | </entry>
|
---|
809 | <entry typeCode="DRIV">
|
---|
810 | <substanceAdministration classCode="SBADM" moodCode="EVN">
|
---|
811 | <templateId root="2.16.840.1.113883.10.20.1.24" assigningAuthorityName="CCD"/>
|
---|
812 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1" assigningAuthorityName="IHE PCC"/>
|
---|
813 | <id root="2.16.840.1.113883.19.5.10" extension="100016"/>
|
---|
814 | <statusCode code="completed"/>
|
---|
815 | <effectiveTime xsi:type="IVL_TS">
|
---|
816 | <low value="20100703"/>
|
---|
817 | <high nullFlavor="UNK"/>
|
---|
818 | </effectiveTime>
|
---|
819 | <!--<routeCode displayName="" code="" codeSystemName="2.16.840.1.113883.5.112"/>-->
|
---|
820 | <doseQuantity>
|
---|
821 | <low value="20" unit="MG"/>
|
---|
822 | <high value="20" unit="MG"/>
|
---|
823 | </doseQuantity>
|
---|
824 | <consumable>
|
---|
825 | <manufacturedProduct>
|
---|
826 | <templateId root="2.16.840.1.113883.3.88.11.83.8.2" assigningAuthorityName="HITSP C83"/>
|
---|
827 | <templateId root="2.16.840.1.113883.10.20.1.53" assigningAuthorityName="CCD"/>
|
---|
828 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2" assigningAuthorityName="IHE PCC"/>
|
---|
829 | <!--Other options
|
---|
830 | 00006001528 lisinopril 2.5 mg oral tablet
|
---|
831 | 00006001531 lisinopril 2.5 mg oral tablet
|
---|
832 | 00006001558 lisinopril 2.5 mg oral tablet
|
---|
833 | 00006001928 lisinopril 5 mg oral tablet
|
---|
834 | 00006001954 lisinopril 5 mg oral tablet
|
---|
835 | 00006001958 lisinopril 5 mg oral tablet
|
---|
836 | 00006001972 lisinopril 5 mg oral tablet
|
---|
837 | 00006001982 lisinopril 5 mg oral tablet
|
---|
838 | 00006001987 lisinopril 5 mg oral tablet
|
---|
839 | 00006001994 lisinopril 5 mg oral tablet
|
---|
840 | 00006010628 lisinopril 10 mg oral tablet
|
---|
841 | 00006010631 lisinopril 10 mg oral tablet
|
---|
842 | 00006010654 lisinopril 10 mg oral tablet
|
---|
843 | 00006010658 lisinopril 10 mg oral tablet
|
---|
844 | 00006010672 lisinopril 10 mg oral tablet
|
---|
845 | 00006010682 lisinopril 10 mg oral tablet
|
---|
846 | 00006010686 lisinopril 10 mg oral tablet
|
---|
847 | 00006010687 lisinopril 10 mg oral tablet
|
---|
848 | 00006010694 lisinopril 10 mg oral tablet
|
---|
849 | -->
|
---|
850 |
|
---|
851 |
|
---|
852 | <manufacturedMaterial>
|
---|
853 | <code displayName="LISINOPRIL 10 MG TAB" code="00006010628" codeSystemName="NDC" codeSystem="2.16.840.1.113883.6.69">
|
---|
854 | <originalText>lisinopril</originalText>
|
---|
855 | </code>
|
---|
856 | </manufacturedMaterial>
|
---|
857 | </manufacturedProduct>
|
---|
858 | </consumable>
|
---|
859 | </substanceAdministration>
|
---|
860 | </entry>
|
---|
861 | </section>
|
---|
862 | </component>
|
---|
863 | <!--
|
---|
864 | ******************************
|
---|
865 | Results Section
|
---|
866 | ***********************
|
---|
867 | -->
|
---|
868 | <component>
|
---|
869 | <section>
|
---|
870 | <templateId root="2.16.840.1.113883.10.20.1.14"/>
|
---|
871 | <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
|
---|
872 | <title>Results</title>
|
---|
873 | <text>
|
---|
874 | <table border="1" width="100%">
|
---|
875 | <tbody>
|
---|
876 | <tr>
|
---|
877 | <th>Test</th>
|
---|
878 | <th>Date</th>
|
---|
879 | <th>Result</th>
|
---|
880 | <th>Ref. Range</th>
|
---|
881 |
|
---|
882 | </tr>
|
---|
883 |
|
---|
884 | <tr>
|
---|
885 | <td>Calculated LDL</td>
|
---|
886 | <td>7-3-2010</td>
|
---|
887 | <td>LDL CHOLESTEROL 90 MG/DL</td>
|
---|
888 | <td>0-130</td>
|
---|
889 |
|
---|
890 | </tr>
|
---|
891 | <tr>
|
---|
892 | <td>HEMOGLOBIN A1C 9.1 percent H</td>
|
---|
893 | <td>7-3-2010</td>
|
---|
894 | <td>A1C 9.1 percent H</td>
|
---|
895 | <td>3.5-6.0</td>
|
---|
896 | </tr>
|
---|
897 | <tr>
|
---|
898 | <td>EJECTION FRACTION</td>
|
---|
899 | <td>20100210</td>
|
---|
900 | <td>39%</td>
|
---|
901 | <td>55-75</td>
|
---|
902 | </tr>
|
---|
903 |
|
---|
904 | </tbody>
|
---|
905 | </table>
|
---|
906 | </text>
|
---|
907 |
|
---|
908 | <entry contextConductionInd="true" typeCode="DRIV">
|
---|
909 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
910 | <templateId root="2.16.840.1.113883.10.20.1.32"/>
|
---|
911 | <id root="38eb54f1-888c-11df-a4ee-0800200c9a66"/>
|
---|
912 | <code code="27571006" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" displayName="chemistry"/>
|
---|
913 | <statusCode code="completed"/>
|
---|
914 | <effectiveTime value="201007031300"/>
|
---|
915 | <!--LDL -->
|
---|
916 | <component>
|
---|
917 | <observation classCode="OBS" moodCode="EVN">
|
---|
918 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
919 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
920 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
921 | <!--WV GUID goes below-->
|
---|
922 | <id root="a32801b1-8855-11df-a4ee-0800200c9a66"/>
|
---|
923 | <code displayName="CALCULATED LDL IN MG/DL" code="13457-7" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
924 | <!--WV Some other alternatives-->
|
---|
925 | <!--<code displayName="DIRECTLY MEASURED LDL IN MG/DL" code="18262-6" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>-->
|
---|
926 | <!--<code displayName="LDL CHOLESTEROL, NO METHOD, MG/DL" code="2089-1" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>-->
|
---|
927 |
|
---|
928 | <text>
|
---|
929 | <reference value="90 mg/dl"/>
|
---|
930 | </text>
|
---|
931 | <effectiveTime value="201007031300"/>
|
---|
932 | <value xsi:type="PQ" value="90" unit="MG/DL"/>
|
---|
933 | <referenceRange>
|
---|
934 | <observationRange>
|
---|
935 | <text>0-130</text>
|
---|
936 | </observationRange>
|
---|
937 | </referenceRange>
|
---|
938 | </observation>
|
---|
939 | </component>
|
---|
940 | </organizer>
|
---|
941 | </entry>
|
---|
942 |
|
---|
943 | <!--
|
---|
944 | ********************************
|
---|
945 | Hemoglobin A1C in Hematology
|
---|
946 | ***********************************
|
---|
947 | -->
|
---|
948 | <entry typeCode="DRIV">
|
---|
949 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
950 | <templateId root="2.16.840.1.113883.10.20.1.32"/>
|
---|
951 | <id root="38eb54f7-888c-11df-a4ee-0800200c9a66"/>
|
---|
952 | <code code="272275004" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" displayName="hematology"/>
|
---|
953 | <statusCode code="completed"/>
|
---|
954 | <effectiveTime value="201007031300"/>
|
---|
955 | <component>
|
---|
956 | <observation classCode="OBS" moodCode="EVN">
|
---|
957 | <!--<templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>-->
|
---|
958 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
959 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>-->
|
---|
960 | <id root="a32801b6-8855-11df-a4ee-0800200c9a66"/>
|
---|
961 | <code displayName="HEMOGLOBIN A1C By UNKNOWN METHOD" code="4548-4" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
962 | <text>
|
---|
963 | <reference value="9.1 percent"/>
|
---|
964 | </text>
|
---|
965 |
|
---|
966 |
|
---|
967 | <value xsi:type="PQ" value="9.1" unit="%"/>
|
---|
968 | <interpretationCode displayName="Abnormal High" code="H" codeSystemName="2.16.840.1.113883.5.83"/>
|
---|
969 | <referenceRange>
|
---|
970 | <observationRange>
|
---|
971 | <text>3.5-6.0</text>
|
---|
972 | </observationRange>
|
---|
973 | </referenceRange>
|
---|
974 | </observation>
|
---|
975 | </component>
|
---|
976 | </organizer>
|
---|
977 | </entry>
|
---|
978 |
|
---|
979 |
|
---|
980 | <!--
|
---|
981 | ******************************
|
---|
982 | ejection fraction
|
---|
983 | *******************************
|
---|
984 | THIS IS WHERE THE PROBLEM IS WITH STATUS
|
---|
985 | cvc-complex-type.2.4.a: Invalid content was found starting with element 'observation'. One of '{"urn:hl7-org:v3":statusCode}' is expected.
|
---|
986 | -->
|
---|
987 |
|
---|
988 | <entry contextConductionInd="true" typeCode="DRIV">
|
---|
989 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
990 | <templateId root="2.16.840.1.113883.10.20.1.32"/>
|
---|
991 | <id root="38eb54f1-888c-11df-a4ee-0800200c9a66"/>
|
---|
992 | <code code="363679005" codeSystemName="SNOMED CT" displayName="IMAGING"/>
|
---|
993 | <statusCode code="completed"/>
|
---|
994 |
|
---|
995 | <component>
|
---|
996 | <observation classCode="OBS" moodCode="EVN">
|
---|
997 | <!--<templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>-->
|
---|
998 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
999 | <!--<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>-->
|
---|
1000 | <id root="38eb54f2-888c-11df-a4ee-0800200c9a66"/>
|
---|
1001 | <code code="250908004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="LEFT VERTRICULAR EJECTION FRACTION"/>
|
---|
1002 | <text>LEFT VERTRICULAR EJECTION FRACTION</text>
|
---|
1003 | <effectiveTime value="201002101300"/>
|
---|
1004 | <value xsi:type="PQ" value="39" unit="%"/>
|
---|
1005 | <referenceRange>
|
---|
1006 | <observationRange>
|
---|
1007 | <text>55-75</text>
|
---|
1008 | </observationRange>
|
---|
1009 | </referenceRange>
|
---|
1010 | </observation>
|
---|
1011 | </component>
|
---|
1012 | </organizer>
|
---|
1013 | </entry>
|
---|
1014 |
|
---|
1015 | </section>
|
---|
1016 | </component>
|
---|
1017 | <!--
|
---|
1018 | ******************************
|
---|
1019 | Procedures Section
|
---|
1020 | **********************
|
---|
1021 | -->
|
---|
1022 | <component>
|
---|
1023 | <section>
|
---|
1024 | <templateId root="2.16.840.1.113883.10.20.1.12"/>
|
---|
1025 | <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of procedures"/>
|
---|
1026 | <title>Procedures</title>
|
---|
1027 | <text>
|
---|
1028 | <table border="1" width="100%">
|
---|
1029 | <tbody>
|
---|
1030 | <tr>
|
---|
1031 | <th>Procedure</th>
|
---|
1032 | <th>Date </th>
|
---|
1033 | <th>Ordered By</th>
|
---|
1034 | <th>Performed By</th>
|
---|
1035 | </tr>
|
---|
1036 | <tr>
|
---|
1037 | <td>Mammogram</td>
|
---|
1038 | <td>2-10-2010</td>
|
---|
1039 | <td>Nancy Anthracite, MD</td>
|
---|
1040 | <td>Grover, Christie & Merritt</td>
|
---|
1041 | </tr>
|
---|
1042 | <tr>
|
---|
1043 | <td>Colonoscopy</td>
|
---|
1044 | <td>2-18-2010</td>
|
---|
1045 | <td>Nancy Anthracite, MD</td>
|
---|
1046 | <td>John Gallager, MD</td>
|
---|
1047 | </tr>
|
---|
1048 | </tbody>
|
---|
1049 | </table>
|
---|
1050 | </text>
|
---|
1051 |
|
---|
1052 | <!--There are three options to choose from here those being Acts, Observations
|
---|
1053 | or Procedures. Uncomment the one you need. These are in Tab M of the Downloadable Resource-->
|
---|
1054 | <!--<entry typeCode="DRIV"/>
|
---|
1055 | <procedure classCode="PROC" moodCode="EVN/>"
|
---|
1056 | <templateId root="2.16.840.1.113883.10.20.1.29"/>-->
|
---|
1057 | <!-- this is a purpose type of activity and a problem is a Problem Activity with a different template-->
|
---|
1058 | <!--<act classCode="ACT" moodCode="EVN">
|
---|
1059 | <templateId root="2.16.840.1.113883.10.20.1.30"/>-->
|
---|
1060 | <!--There are lots of observation templates as well. This is the Result observation which I hope is right-->
|
---|
1061 | <!--<observation classCode="OBS" moodCode="EVN">
|
---|
1062 | <templateId root="2.16.840.1.113883.10.20.1.31"/>-->
|
---|
1063 |
|
---|
1064 | <entry typeCode="DRIV">
|
---|
1065 | <procedure classCode="PROC" moodCode="EVN">
|
---|
1066 | <templateId root="2.16.840.1.113883.10.20.1.29"/>
|
---|
1067 | <id root="a32801b9-8855-11df-a4ee-0800200c9a66"/>
|
---|
1068 | <code code="24623002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="SCREENING MAMMOGRAPHY"/>
|
---|
1069 | <statusCode code="completed"/>
|
---|
1070 | <effectiveTime value="20100210"/>
|
---|
1071 | <participant typeCode="DEV">
|
---|
1072 | <participantRole classCode="MANU">
|
---|
1073 | <templateId root="2.16.840.1.113883.10.20.1.52"/>
|
---|
1074 | <id root="7eedbc62-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1075 | </participantRole>
|
---|
1076 | </participant>
|
---|
1077 | </procedure>
|
---|
1078 |
|
---|
1079 |
|
---|
1080 |
|
---|
1081 |
|
---|
1082 | </entry>
|
---|
1083 | </section>
|
---|
1084 | </component>
|
---|
1085 |
|
---|
1086 |
|
---|
1087 |
|
---|
1088 | <!--
|
---|
1089 | *********************************************
|
---|
1090 | Immunization Section
|
---|
1091 | ***********************************************
|
---|
1092 | -->
|
---|
1093 | <component>
|
---|
1094 | <section>
|
---|
1095 | <templateId root="2.16.840.1.113883.10.20.1.6"/>
|
---|
1096 | <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
|
---|
1097 | <title>History of Immunizations</title>
|
---|
1098 | <text>
|
---|
1099 | <table border="1" width="100%">
|
---|
1100 | <thead>
|
---|
1101 | <tr>
|
---|
1102 | <th>Vaccine</th>
|
---|
1103 | <th>Date</th>
|
---|
1104 | <th>Status</th>
|
---|
1105 | </tr>
|
---|
1106 | </thead>
|
---|
1107 | <tbody>
|
---|
1108 | <tr>
|
---|
1109 | <td>Influenza virus vaccine, split</td>
|
---|
1110 | <td>Oct. 15. 2009</td>
|
---|
1111 | <td>Completed</td>
|
---|
1112 | </tr>
|
---|
1113 | <tr>
|
---|
1114 | <td>Pneumococcal vaccine</td>
|
---|
1115 | <td>Jan. 10,2010</td>
|
---|
1116 | <td>Completed</td>
|
---|
1117 | </tr>
|
---|
1118 | </tbody>
|
---|
1119 | </table>
|
---|
1120 | </text>
|
---|
1121 | <entry typeCode="DRIV">
|
---|
1122 | <substanceAdministration classCode="SBADM" moodCode="EVN">
|
---|
1123 | <templateId root="2.16.840.1.113883.10.20.1.24"/>
|
---|
1124 | <!-- WVP Medication activity template -->
|
---|
1125 | <id root="2.16.840.1.113883.3.543" extension="01.02.03.100020"/>
|
---|
1126 |
|
---|
1127 | <statusCode code="completed"/>
|
---|
1128 | <effectiveTime xsi:type="IVL_TS">
|
---|
1129 | <center value="20091015"/>
|
---|
1130 | </effectiveTime>
|
---|
1131 | <routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
|
---|
1132 | <consumable>
|
---|
1133 | <manufacturedProduct>
|
---|
1134 | <templateId root="2.16.840.1.113883.10.20.1.53"/>
|
---|
1135 | <!-- Product template -->
|
---|
1136 | <manufacturedMaterial>
|
---|
1137 | <!--Code is from table D Downloadabe Resource CVX code system is 6.59-->
|
---|
1138 | <code code="15" codeSystem="2.16.840.1.113883.6.59" displayName="INFLUENZA VIRUS VACCIINE, SPLIT">
|
---|
1139 | <originalText>INFLUENZA VIRUS VACCIINE, SPLIT</originalText>
|
---|
1140 | </code>
|
---|
1141 | </manufacturedMaterial>
|
---|
1142 | </manufacturedProduct>
|
---|
1143 | </consumable>
|
---|
1144 | </substanceAdministration>
|
---|
1145 | </entry>
|
---|
1146 | <entry typeCode="DRIV">
|
---|
1147 | <substanceAdministration classCode="SBADM" moodCode="EVN">
|
---|
1148 | <templateId root="2.16.840.1.113883.10.20.1.24"/>
|
---|
1149 | <!-- WVP Medication activity template -->
|
---|
1150 | <id root="2.16.840.1.113883.3.543" extension="01.02.03.100021"/>
|
---|
1151 |
|
---|
1152 | <statusCode code="completed"/>
|
---|
1153 | <effectiveTime xsi:type="IVL_TS">
|
---|
1154 | <center value="20100110"/>
|
---|
1155 | </effectiveTime>
|
---|
1156 | <routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
|
---|
1157 | <consumable>
|
---|
1158 | <manufacturedProduct>
|
---|
1159 | <!-- WVP Product template -->
|
---|
1160 | <templateId root="2.16.840.1.113883.10.20.1.53"/>
|
---|
1161 | <manufacturedMaterial>
|
---|
1162 | <!--Code is from table D Downloadabe Resource CVX code system is 6.59-->
|
---|
1163 | <code code="33" codeSystem="2.16.840.1.113883.6.59" displayName="PNEUMOCCAL VACCINE">
|
---|
1164 | <originalText>PNEUMOCCAL VACCINE</originalText>
|
---|
1165 | </code>
|
---|
1166 | </manufacturedMaterial>
|
---|
1167 | </manufacturedProduct>
|
---|
1168 | </consumable>
|
---|
1169 | </substanceAdministration>
|
---|
1170 | </entry>
|
---|
1171 | </section>
|
---|
1172 | </component>
|
---|
1173 | <!--
|
---|
1174 | *****************************************************
|
---|
1175 | Vital Signs Section
|
---|
1176 | ****************************************
|
---|
1177 | -->
|
---|
1178 | <component>
|
---|
1179 | <section>
|
---|
1180 | <templateId root="2.16.840.1.113883.10.20.1.16"/>
|
---|
1181 | <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
|
---|
1182 | <title>Vital Signs</title>
|
---|
1183 | <text>
|
---|
1184 | <table border="1" width="100%">
|
---|
1185 | <tbody>
|
---|
1186 | <tr>
|
---|
1187 | <th>Date</th>
|
---|
1188 | <th>Vital Sign</th>
|
---|
1189 | <th>Result</th>
|
---|
1190 | <th>Source</th>
|
---|
1191 | </tr>
|
---|
1192 | <tr>
|
---|
1193 | <td>2-5-2010</td>
|
---|
1194 | <td>Systolic Blood Pressure</td>
|
---|
1195 | <td>130</td>
|
---|
1196 | <td>WorldVistA Test Clinic</td>
|
---|
1197 |
|
---|
1198 | </tr>
|
---|
1199 | <tr>
|
---|
1200 | <td>2-5-2010</td>
|
---|
1201 | <td>Diastolic Blood Pressure</td>
|
---|
1202 | <td>78</td>
|
---|
1203 | <td>WorldVistA Test Clinic</td>
|
---|
1204 | </tr>
|
---|
1205 | <tr>
|
---|
1206 | <td>2-5-2010</td>
|
---|
1207 | <td>Heart Rate</td>
|
---|
1208 | <td>55</td>
|
---|
1209 | <td>WorldVistA Test Clinic</td>
|
---|
1210 | </tr>
|
---|
1211 | <tr>
|
---|
1212 | <td>7-3-2010</td>
|
---|
1213 | <td>Systolic Blood Pressure</td>
|
---|
1214 | <td>128</td>
|
---|
1215 | <td>WorldVistA Test Clinic</td>
|
---|
1216 |
|
---|
1217 | </tr>
|
---|
1218 | <tr>
|
---|
1219 | <td>7-3-2010</td>
|
---|
1220 | <td>Diastolic Blood Pressure</td>
|
---|
1221 | <td>80</td>
|
---|
1222 | <td>WorldVistA Test Clinic</td>
|
---|
1223 | </tr>
|
---|
1224 | <tr>
|
---|
1225 | <td>7-3-2010</td>
|
---|
1226 | <td>Heart Rate</td>
|
---|
1227 | <td>57</td>
|
---|
1228 | <td>WorldVistA Test Clinic</td>
|
---|
1229 | </tr>
|
---|
1230 | </tbody>
|
---|
1231 | </table>
|
---|
1232 | </text>
|
---|
1233 |
|
---|
1234 |
|
---|
1235 | <!--Vital Signs from 2-5-2010 under an organizer follow. Onlty these 3 vistal signs are allowed-->
|
---|
1236 | <!--WVV Must change the UUIDs for the vital signs and the entries-->
|
---|
1237 |
|
---|
1238 | <entry typeCode="DRIV">
|
---|
1239 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
1240 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
---|
1241 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
1242 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
1243 | <id root="7eedbc60-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1244 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
|
---|
1245 | <statusCode code="completed"/>
|
---|
1246 | <effectiveTime>
|
---|
1247 | <low value="20100205"/>
|
---|
1248 | <high nullFlavor="UNK"/>
|
---|
1249 | </effectiveTime>
|
---|
1250 |
|
---|
1251 | <component>
|
---|
1252 | <observation classCode="OBS" moodCode="EVN">
|
---|
1253 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1254 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1255 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1256 | <id root="a32801b7-8855-11df-a4ee-0800200c9a66"/>
|
---|
1257 | <code displayName="SYSTOLIC BLOOD PRESSURE" code="72313002" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1258 | <value xsi:type="PQ" value="130" unit="MM/HG"/>
|
---|
1259 | </observation>
|
---|
1260 | </component>
|
---|
1261 |
|
---|
1262 | <component>
|
---|
1263 | <observation classCode="OBS" moodCode="EVN">
|
---|
1264 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1265 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1266 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1267 | <id root="a32801b8-8855-11df-a4ee-0800200c9a66"/>
|
---|
1268 | <code displayName="DIASTOLIC BLOOD PRESSURE" code="271649006" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1269 | <value xsi:type="PQ" value="78" unit="MM/HG"/>
|
---|
1270 | </observation>
|
---|
1271 | </component>
|
---|
1272 |
|
---|
1273 | <component>
|
---|
1274 | <observation classCode="OBS" moodCode="EVN">
|
---|
1275 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1276 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1277 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1278 | <id root="7eedbc64-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1279 | <code displayName="HEART RATE" code="364075005" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1280 | <value xsi:type="PQ" value="55" unit="/min"/>
|
---|
1281 | </observation>
|
---|
1282 | </component>
|
---|
1283 | </organizer>
|
---|
1284 | </entry>
|
---|
1285 |
|
---|
1286 | <!--Vital Signs from 7-3-2010 under an organizer follow. Onlty these 3 vistal signs are allowed-->
|
---|
1287 | <!--WVV Must change the UUIDs for the vital signs and the entries-->
|
---|
1288 |
|
---|
1289 | <entry typeCode="DRIV">
|
---|
1290 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
1291 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
---|
1292 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
1293 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
1294 | <id root="7eede370-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1295 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
|
---|
1296 | <statusCode code="completed"/>
|
---|
1297 | <effectiveTime>
|
---|
1298 | <low value="20100703"/>
|
---|
1299 | <high nullFlavor="UNK"/>
|
---|
1300 | </effectiveTime>
|
---|
1301 |
|
---|
1302 | <component>
|
---|
1303 | <observation classCode="OBS" moodCode="EVN">
|
---|
1304 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1305 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1306 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1307 | <id root="7eede371-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1308 | <code displayName="SYSTOLIC BLOOD PRESSURE" code="72313002" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1309 | <value xsi:type="PQ" value="128" unit="MM/HG"/>
|
---|
1310 | </observation>
|
---|
1311 | </component>
|
---|
1312 |
|
---|
1313 | <component>
|
---|
1314 | <observation classCode="OBS" moodCode="EVN">
|
---|
1315 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1316 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1317 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1318 | <id root="7eede372-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1319 | <code displayName="DIASTOLIC BLOOD PRESSURE" code="271649006" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1320 | <value xsi:type="PQ" value="80" unit="MM/HG"/>
|
---|
1321 | </observation>
|
---|
1322 | </component>
|
---|
1323 |
|
---|
1324 | <component>
|
---|
1325 | <observation classCode="OBS" moodCode="EVN">
|
---|
1326 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
1327 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
1328 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
1329 | <id root="7eede373-8a15-11df-a4ee-0800200c9a66"/>
|
---|
1330 | <code displayName="HEART RATE" code="364075005" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
|
---|
1331 | <value xsi:type="PQ" value="57" unit="/min"/>
|
---|
1332 | </observation>
|
---|
1333 | </component>
|
---|
1334 |
|
---|
1335 | </organizer>
|
---|
1336 | </entry>
|
---|
1337 | </section>
|
---|
1338 | </component>
|
---|
1339 |
|
---|
1340 | <!--
|
---|
1341 | ************************
|
---|
1342 | Structured Data Section
|
---|
1343 | *************************
|
---|
1344 | -->
|
---|
1345 |
|
---|
1346 | <component>
|
---|
1347 | <section>
|
---|
1348 | <!--Template ID is in the downloadable resource bottom of S tab -->
|
---|
1349 | <templateId root="2.16.840.1.113883.3.249.11.16"/>
|
---|
1350 | <code code="STRUCT" codeSystem="2.16.840.1.113883.3.249.12"/>
|
---|
1351 | <title> Structured data section </title>
|
---|
1352 | <text>
|
---|
1353 | <table border="1" width="100%">
|
---|
1354 | <tbody>
|
---|
1355 | <tr>
|
---|
1356 | <td>Certified System Used</td>
|
---|
1357 | <td>System Type</td>
|
---|
1358 | <td>Certification Type</td>
|
---|
1359 | <td>Encounter Date Used</td>
|
---|
1360 | </tr>
|
---|
1361 | <tr>
|
---|
1362 | <td>WorldVistA EHR</td>
|
---|
1363 | <td> EHR</td>
|
---|
1364 | <td>CCHIT Certified</td>
|
---|
1365 | <td>2-5-2010</td>
|
---|
1366 | </tr>
|
---|
1367 | <tr>
|
---|
1368 | <td>WorldVistA EHR</td>
|
---|
1369 | <td>EHR</td>
|
---|
1370 | <td>Qualified System</td>
|
---|
1371 | <td>7-3-2010</td>
|
---|
1372 | </tr>
|
---|
1373 | <tr>
|
---|
1374 | <td>Allscripts</td>
|
---|
1375 | <td>eRx</td>
|
---|
1376 | <td>Qualified</td>
|
---|
1377 | <td>7-3-2010</td>
|
---|
1378 | </tr>
|
---|
1379 | </tbody>
|
---|
1380 | </table>
|
---|
1381 | </text>
|
---|
1382 | <entry>
|
---|
1383 | <act classCode="ACT" moodCode="EVN">
|
---|
1384 | <templateId root="2.16.840.1.113883.3.249.11.13"/>
|
---|
1385 | <id root="2.16.840.1.113883.3.543" extension="0.01.02.100000001.1"/>
|
---|
1386 | <!--WV? this is in downloadable resource R and is the same for eRx and EHR-->
|
---|
1387 | <!--WV? The G code changes and that is in tab R for 2010 as well-->
|
---|
1388 | <!--There need to be two face to face encounters so this is one and the next one is one-->
|
---|
1389 | <!--Also reflected in the documentationOf part at the end of the header-->
|
---|
1390 | <code code="G8447" codeSystem="2.16.840.1.113883.6.14" displayName="Patient encounter was documented using a CCHIT certified EHR"/>
|
---|
1391 | <effectiveTime value="20100205"/>
|
---|
1392 | </act>
|
---|
1393 | </entry>
|
---|
1394 | <entry>
|
---|
1395 | <act classCode="ACT" moodCode="EVN">
|
---|
1396 | <templateId root="2.16.840.1.113883.3.249.11.13"/>
|
---|
1397 | <id root="2.16.840.1.113883.3.543" extension="0.01.02.100000001.2"/>
|
---|
1398 | <code code="G8448" codeSystem="2.16.840.1.113883.6.14" displayName="Patient encounter was documented using a Qualified (Non-CCHIT certified) EHR"/>
|
---|
1399 | <effectiveTime value="20100703"/>
|
---|
1400 | </act>
|
---|
1401 | </entry>
|
---|
1402 | <entry>
|
---|
1403 | <act classCode="ACT" moodCode="EVN">
|
---|
1404 | <templateId root="2.16.840.1.113883.3.249.11.14"/>
|
---|
1405 | <id root="2.16.840.1.113883.19.5" extension="96756615"/>
|
---|
1406 | <code code="G8553" codeSystem="2.16.840.1.113883.6.14" displayName="Electronic prescription has been generated using a qualified eRx system"/>
|
---|
1407 | <effectiveTime value="20100703"/>
|
---|
1408 | </act>
|
---|
1409 | </entry>
|
---|
1410 | </section>
|
---|
1411 | </component>
|
---|
1412 |
|
---|
1413 |
|
---|
1414 |
|
---|
1415 | <component>
|
---|
1416 | <section>
|
---|
1417 | <templateId root="2.16.840.1.113883.10.20.1.1"/>
|
---|
1418 | <code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Advance directives"/>
|
---|
1419 | <title/>
|
---|
1420 | </section>
|
---|
1421 | </component>
|
---|
1422 | <!--
|
---|
1423 | ************************************
|
---|
1424 | Payers section
|
---|
1425 |
|
---|
1426 | *******************************
|
---|
1427 | -->
|
---|
1428 |
|
---|
1429 | <component>
|
---|
1430 | <section>
|
---|
1431 | <templateId root="2.16.840.1.113883.10.20.1.9"/>
|
---|
1432 | <!-- 48768-6 is payment sources -->
|
---|
1433 | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources"/>
|
---|
1434 | <title>Payment Sources</title>
|
---|
1435 | <text>
|
---|
1436 | <table border="1" width="100%">
|
---|
1437 | <tbody>
|
---|
1438 | <tr>
|
---|
1439 | <th>Payer name</th>
|
---|
1440 | <th>Group/Type</th>
|
---|
1441 | <th>Primary Policy Owner/Responsible Party</th>
|
---|
1442 | <th>Covered party ID</th>
|
---|
1443 | <th>Payor Telephone</th>
|
---|
1444 | <th>Electronic Claims Payor Number</th>
|
---|
1445 | <th>Authorized</th>
|
---|
1446 | </tr>
|
---|
1447 | <tr>
|
---|
1448 | <td>Mail Handlers Benefit Plan</td>
|
---|
1449 | <td>454</td>
|
---|
1450 | <td>Jody Jean Jones</td>
|
---|
1451 | <td>8888888</td>
|
---|
1452 | <td>1-800-410-7778</td>
|
---|
1453 | <td>62413</td>
|
---|
1454 | <td>Colonoscopy</td>
|
---|
1455 | </tr>
|
---|
1456 | <tr>
|
---|
1457 | <td>Medicare</td>
|
---|
1458 | <td></td>
|
---|
1459 | <td>Jody Jean Jones</td>
|
---|
1460 | <td>002003004</td>
|
---|
1461 | <td></td>
|
---|
1462 | <td></td>
|
---|
1463 | <td>Colonoscopy</td>
|
---|
1464 | </tr>
|
---|
1465 | </tbody>
|
---|
1466 | </table>
|
---|
1467 | </text>
|
---|
1468 |
|
---|
1469 | <!--Mail Handlers-->
|
---|
1470 |
|
---|
1471 | <entry typeCode="DRIV">
|
---|
1472 | <!--WVP moodCode is DEF is definition to describe the characteristics of who must be involved in an act-->
|
---|
1473 | <act classCode="ACT" moodCode="DEF">
|
---|
1474 | <!--WVP coverage activity templats is the 10.20.1.20-->
|
---|
1475 | <templateId root="2.16.840.1.113883.10.20.1.20"/>
|
---|
1476 | <id root="d5dc6d50-890c-11df-a4ee-0800200c9a66"/>
|
---|
1477 | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment sources"/>
|
---|
1478 | <statusCode code="completed"/>
|
---|
1479 | <!--WVP COMP is has component like a sub service to this service-->
|
---|
1480 | <entryRelationship typeCode="COMP">
|
---|
1481 | <!-- WVP EVN for the act is event-->
|
---|
1482 | <act classCode="ACT" moodCode="EVN">
|
---|
1483 | <!--Policy activity is the 10.20.1.26 template-->
|
---|
1484 | <templateId root="2.16.840.1.113883.10.20.1.26"/>
|
---|
1485 | <!-- another random GUID-->
|
---|
1486 | <id root="d5dc6d51-890c-11df-a4ee-0800200c9a66"/>
|
---|
1487 | <!--WV variable and display name is in quotes AUTOPOL - "automobile" policy;EHCPOL additional insurance in addition to Medicare in this case-->
|
---|
1488 | <!--HSAPOL "Health Spending Account";PUBLICPOL "public healthcare" but not Medicare - maybe a state program for example-->
|
---|
1489 | <!--WBCPOL is "workers compensation"-->
|
---|
1490 | <code code="EHCPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Extended healthcare"/>
|
---|
1491 | <!--other statusCode normal, aborted, active, cancelled, completed, held, suspended, nullified, obsolete-->
|
---|
1492 | <statusCode code="completed"/>
|
---|
1493 | <!--WVP performer type codes are numerous but PRF is performer or the person who did it-->
|
---|
1494 | <performer typeCode="PRF">
|
---|
1495 | <assignedEntity>
|
---|
1496 | <!--another GUID??-->
|
---|
1497 | <id root="2.16.840.1.113883.12.86" extension="62413"/>
|
---|
1498 | <representedOrganization>
|
---|
1499 | <name>Mail Handler Benefit Plan</name>
|
---|
1500 | </representedOrganization>
|
---|
1501 | </assignedEntity>
|
---|
1502 | </performer>
|
---|
1503 | <participant typeCode="COV">
|
---|
1504 | <participantRole>
|
---|
1505 | <!--Cant find SELF in the reference documents so this might be variable, but I doubt it is-->
|
---|
1506 | <!-- I suspect this is shat is used whenever the person is the primary policy holder-->
|
---|
1507 | <!-- service deliver location role type is what the 5.111 code is and it is called a "RoleCode" in the downloadable resource-->
|
---|
1508 | <!-- in this case theextension is the patients SSN for a medicare patient-->
|
---|
1509 | <id root="2.16.840.1.113883.4.1" extension="002030004"/>
|
---|
1510 | <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
|
---|
1511 | </participantRole>
|
---|
1512 | </participant>
|
---|
1513 | <!--WVP REFR is "refers to" target act is refered to by the source act-->
|
---|
1514 | <entryRelationship typeCode="REFR">
|
---|
1515 | <act classCode="ACT" moodCode="EVN">
|
---|
1516 | <!--Authorization activity Template-->
|
---|
1517 | <templateId root="2.16.840.1.113883.10.20.1.19"/>
|
---|
1518 | <id root="2.16.840.1.113883.19.5.10" extension="100010"/>
|
---|
1519 | <code nullFlavor="NA"/>
|
---|
1520 | <!--WVP SUBJ is "has subject"-->
|
---|
1521 | <entryRelationship typeCode="SUBJ">
|
---|
1522 | <!--PROC is "procedure" and PRMS is "promise"-->
|
---|
1523 | <procedure classCode="PROC" moodCode="PRMS">
|
---|
1524 | <!--SNOMED code for colonoscopy-->
|
---|
1525 | <code code="73761001" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
|
---|
1526 | </procedure>
|
---|
1527 | </entryRelationship>
|
---|
1528 | </act>
|
---|
1529 | </entryRelationship>
|
---|
1530 | </act>
|
---|
1531 | </entryRelationship>
|
---|
1532 | </act>
|
---|
1533 | </entry>
|
---|
1534 | <!--Medicare-->
|
---|
1535 |
|
---|
1536 | <!--WVP - DRIV is derived from-->
|
---|
1537 | <entry typeCode="DRIV">
|
---|
1538 | <!--WVP moodCode is DEF is definition to describe the characteristics of who must be involved in an act-->
|
---|
1539 | <act classCode="ACT" moodCode="DEF">
|
---|
1540 | <!--WVP coverage activity templats is the 10.20.1.20-->
|
---|
1541 | <templateId root="2.16.840.1.113883.10.20.1.20"/>
|
---|
1542 | <id root="1751b180-8a54-11df-a4ee-0800200c9a66"/>
|
---|
1543 | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment sources"/>
|
---|
1544 | <statusCode code="completed"/>
|
---|
1545 | <!--WVP COMP is has component like a sub service to this service-->
|
---|
1546 | <entryRelationship typeCode="COMP">
|
---|
1547 | <!-- WVP EVN for the act is event-->
|
---|
1548 | <act classCode="ACT" moodCode="EVN">
|
---|
1549 | <!--Policy activity is the 10.20.1.26 template-->
|
---|
1550 | <templateId root="2.16.840.1.113883.10.20.1.26"/>
|
---|
1551 | <!-- another random GUID-->
|
---|
1552 | <id root="dbbb6311-8a4d-11df-a4ee-0800200c9a66"/>
|
---|
1553 | <!--WV variable and display name is in quotes AUTOPOL - "automobile" policy;EHCPOL additional insurance in addition to Medicare in this case-->
|
---|
1554 | <!--HSAPOL "Health Spending Account";PUBLICPOL "public healthcare" but not Medicare - maybe a state program for example-->
|
---|
1555 | <!--WBCPOL is "workers compensation"-->
|
---|
1556 | <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Public Healthcare"/>
|
---|
1557 | <!--other statusCode normal, aborted, active, cancelled, completed, held, suspended, nullified, obsolete-->
|
---|
1558 | <statusCode code="completed"/>
|
---|
1559 | <!--WVP performer type codes are numerous but PRF is performer or the person who did it-->
|
---|
1560 | <performer typeCode="PRF">
|
---|
1561 | <assignedEntity>
|
---|
1562 | <!--another GUID??-->
|
---|
1563 | <id root="2.16.840.1.113883.12.86" extension="MC"/>
|
---|
1564 | <representedOrganization>
|
---|
1565 | <name>CMS</name>
|
---|
1566 | </representedOrganization>
|
---|
1567 | </assignedEntity>
|
---|
1568 | </performer>
|
---|
1569 | <participant typeCode="COV">
|
---|
1570 | <participantRole>
|
---|
1571 | <!--Cant find SELF in the reference documents so this might be variable, but I doubt it is-->
|
---|
1572 | <!-- I suspect this is shat is used whenever the person is the primary policy holder-->
|
---|
1573 | <!-- service deliver location role type is what the 5.111 code is and it is called a "RoleCode" in the downloadable resource-->
|
---|
1574 | <id root="1751b180-8a54-11df-a4ee-0800200c9a66"/>
|
---|
1575 | <!-- in this case theextension is the patients SSN for a medicare patient so it is the same each time for one patient-->
|
---|
1576 | <id root="2.16.840.1.113883.4.1" extension="002030004"/>
|
---|
1577 | <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
|
---|
1578 | </participantRole>
|
---|
1579 | </participant>
|
---|
1580 | <!--WVP REFR is "refers to" target act is refered to by the source act-->
|
---|
1581 | <entryRelationship typeCode="REFR">
|
---|
1582 | <act classCode="ACT" moodCode="EVN">
|
---|
1583 | <!--Authorization activity Template-->
|
---|
1584 | <templateId root="2.16.840.1.113883.10.20.1.19"/>
|
---|
1585 | <id root="e1e0f7e0-8a53-11df-a4ee-0800200c9a66"/>
|
---|
1586 | <code nullFlavor="NA"/>
|
---|
1587 | <!--WVP SUBJ is "has subject"-->
|
---|
1588 | <entryRelationship typeCode="SUBJ">
|
---|
1589 | <!--PROC is "procedure" and PRMS is "promise"-->
|
---|
1590 | <procedure classCode="PROC" moodCode="PRMS">
|
---|
1591 | <!--SNOMED code for colonoscopy-->
|
---|
1592 | <code code="73761001" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
|
---|
1593 | </procedure>
|
---|
1594 | </entryRelationship>
|
---|
1595 | </act>
|
---|
1596 | </entryRelationship>
|
---|
1597 | </act>
|
---|
1598 | </entryRelationship>
|
---|
1599 | </act>
|
---|
1600 | </entry>
|
---|
1601 |
|
---|
1602 |
|
---|
1603 | </section>
|
---|
1604 | </component>
|
---|
1605 | </section>
|
---|
1606 | </component>
|
---|
1607 | </section>
|
---|
1608 | </component>
|
---|
1609 | </structuredBody>
|
---|
1610 | </component>
|
---|
1611 | </ClinicalDocument>
|
---|