source: qrda/CCR/M1-QRDA/M1-PAT_100839_QRDA_V1_0_0.xml@ 1252

Last change on this file since 1252 was 997, checked in by George Lilly, 14 years ago

current QRDA submissions
File size: 62.6 KB
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1<?xml version="1.0" encoding="utf-8"?>
2<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">
3 <realmCode code="US"/>
4 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
5 <templateId root="2.16.840.1.113883.10.20.12"/>
6 <templateId root="2.16.840.1.113883.3.249.11.100.1"/>
7 <id root="2.16.840.1.113883.3.543" extension="@@@UUID-DOC@@@"/>
8 <code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
9 <title>QRDA Incidence Report</title>
10 <effectiveTime value="20100703"/>
11 <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
12 <languageCode code="en-US"/>
13 <setId root="2.16.840.1.113883.3.543" extension="@@@UUID-SET@@@"/>
14 <versionNumber value="1"/>
15 <recordTarget>
16 <patientRole>
17 <id extension="002030004" root="SSN"/>
18 <addr use="H">
19 <streetAddressLine/>
20 <city/>
21 <state/>
22 <postalCode/>
23 </addr>
24 <telecom/>
25 <patient>
26 <name>
27 <given>JODY</given>
28 <given>JEAN</given>
29 <family>JONES</family>
30 </name>
31 <administrativeGenderCode displayName="FEMALE" code="F" codeSystemName="HL7 AdministrativeGender" codeSystem=""/>
32 <birthTime value="19450101120000"/>
33 </patient>
34 </patientRole>
35 </recordTarget>
36 <author>
37 <time value="20100703"/>
38 <assignedAuthor>
39 <id root="2.16.840.1.113883.3.249.6" extension="100001"/>
40 <assignedPerson>
41 <name>
42 <given>Nancy</given>
43 <family>Anthracite</family>
44 <suffix>MD</suffix>
45 </name>
46 </assignedPerson>
47 <representedOrganization>
48 <id root="2.16.840.1.113883.3.543" extension="1558574526"/>
49 <name>WorldVistA Test Clinic</name>
50 </representedOrganization>
51 </assignedAuthor>
52 </author>
53 <informant>
54 <assignedEntity>
55 <id nullFlavor="NA"/>
56 <representedOrganization>
57 <id root="2.16.840.1.113883.3.543" extension="1558574526"/>
58 <name>World VistA Test Clinic</name>
59 </representedOrganization>
60 </assignedEntity>
61 </informant>
62 <custodian>
63 <assignedCustodian>
64 <representedCustodianOrganization>
65 <id root="2.16.840.1.113883.3.543" extension="1558574526"/>
66 <name>WorldVistA Test Clinic</name>
67 </representedCustodianOrganization>
68 </assignedCustodian>
69 </custodian>
70 <legalAuthenticator>
71 <time value="20100703"/>
72 <signatureCode code="S"/>
73 <assignedEntity>
74 <id root="2.16.840.1.113883.3.543" extension="111111"/>
75 <assignedPerson>
76 <name>
77 <given>Nancy</given>
78 <family>Anthracite</family>
79 <suffix>MD</suffix>
80 </name>
81 </assignedPerson>
82 <representedOrganization>
83 <id root="2.16.840.1.113883.3.543" extension="1558574526"/>
84 <name>WorldVistA Test Clinic</name>
85 </representedOrganization>
86 </assignedEntity>
87 </legalAuthenticator>
88 <participant typeCode="PRF">
89 <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
90 <associatedEntity classCode="PROV">
91 <id root="2.16.840.1.113883.3.249.6" extension="111111"/>
92 <associatedPerson>
93 <name>
94 <prefix>Dr.</prefix>
95 <given>Nancy</given>
96 <family>Anthracite</family>
97 </name>
98 </associatedPerson>
99 </associatedEntity>
100 </participant>
101 <component>
102 <structuredBody>
103 <component>
104 <section>
105 <templateId root="2.16.840.1.113883.3.249.11.50"/>
106 <code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
107 <title>Measure set: CMS EHR Measure Set</title>
108 <text>2010 Measures Set Measures</text>
109 <component>
110 <section>
111 <templateId root="2.16.840.1.113883.3.249.11.2"/>
112 <code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
113 <title>Measure Section</title>
114 <text>
115 <list>
116 <item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
117 </list>
118 </text>
119 <entry typeCode="DRIV">
120 <act classCode="ACT" moodCode="DEF">
121 <id root="2.16.840.1.113883.3.249.11.2"/>
122 <code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
123 <text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
124 <statusCode code="completed"/>
125 </act>
126 </entry>
127 <component>
128 <section>
129 <code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
130 <title>Reporting Parameters</title>
131 <text>
132 <list>
133 <item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
134 </list>
135 </text>
136 <entry>
137 <act classCode="ACT" moodCode="EVN">
138 <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/>
139 <effectiveTime>
140 <low value="20100101"/>
141 <high value="20101231"/>
142 </effectiveTime>
143 </act>
144 </entry>
145 </section>
146 </component>
147 <component>
148 <section>
149 <code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
150 <title>Patient Data</title>
151 </section>
152 </component>
153 <component>
154 <section>
155 <templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
156 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
157 <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
158 <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
159 <title>Problems</title>
160 <text>
161 <table>
162 <tbody>
163 <tr>
164 <th>Type</th>
165 <th>Date</th>
166 <th>Code</th>
167 <th>Description</th>
168 <th>Status</th>
169 <th>Source</th>
170 </tr>
171 <tr>
172 <td>Problem</td>
173 <td>
174 <table>
175 <tbody>
176 <tr xmlns="">
177 <td>Oct 16, 2010</td>
178 </tr>
179 </tbody>
180 </table>
181 </td>
182 <td>401.9 (ICD9CM)
183 </td>
184 <td ID="PROBLEM1">HTN (ICD-9-CM 401.9)</td>
185 <td>Active</td>
186 <td>MATTHEW M KING </td>
187 </tr>
188 <tr>
189 <td>Problem</td>
190 <td>
191 <table>
192 <tbody>
193 <tr xmlns="">
194 <td>Oct 14, 2010</td>
195 </tr>
196 </tbody>
197 </table>
198 </td>
199 <td>453.8 (ICD9CM)
200 </td>
201 <td ID="PROBLEM2">ANY DEEP VEIN THROMBOSIS</td>
202 <td>Active</td>
203 <td>MATTHEW M KING </td>
204 </tr>
205 <tr>
206 <td>Problem</td>
207 <td>
208 <table>
209 <tbody>
210 <tr xmlns="">
211 <td>Sep 04, 2010</td>
212 </tr>
213 </tbody>
214 </table>
215 </td>
216 <td>250.00 (ICD9CM)
217 </td>
218 <td ID="PROBLEM3">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
219 <td>Active</td>
220 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
221 </tr>
222 <tr>
223 <td>Problem</td>
224 <td>
225 <table>
226 <tbody>
227 <tr xmlns="">
228 <td>Jul 05, 2010</td>
229 </tr>
230 </tbody>
231 </table>
232 </td>
233 <td>428.0 (ICD9CM)
234 </td>
235 <td ID="PROBLEM4">Congestive Heart Failure (ICD-9-CM 428.0)</td>
236 <td>Active</td>
237 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
238 </tr>
239 <tr>
240 <td>Problem</td>
241 <td>
242 <table>
243 <tbody>
244 <tr xmlns="">
245 <td>Jul 05, 2010</td>
246 </tr>
247 </tbody>
248 </table>
249 </td>
250 <td>411.0 (ICD9CM)
251 </td>
252 <td ID="PROBLEM5">Postmyocardial infarction syndrome (ICD-9-CM 411.0)</td>
253 <td>Active</td>
254 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
255 </tr>
256 </tbody>
257 </table>
258 </text>
259 <entry typeCode="DRIV">
260 <act classCode="ACT" moodCode="EVN">
261 <templateId root="2.16.840.1.113883.10.20.1.27"/>
262 <id root="PROBLEM1" extension="CCRObjectID"/>
263 <code nullFlavor="NA"/>
264 <performer typeCode="PRF">
265 <assignedEntity>
266 <id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
267 <addr use="WP">
268 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
269 <city>ALBANY</city>
270 <state>NY</state>
271 <postalCode>12180</postalCode>
272 </addr>
273 <telecom/>
274 <assignedPerson>
275 <name>
276 <given>MATTHEW</given>
277 <given>M</given>
278 <family>KING</family>
279 </name>
280 </assignedPerson>
281 </assignedEntity>
282 </performer>
283 <entryRelationship typeCode="SUBJ">
284 <observation classCode="OBS" moodCode="EVN">
285 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
286 <templateId root="2.16.840.1.113883.3.249.11.100.8"/>
287 <id root="PROBLEM1" extension="CCRObjectID"/>
288 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
289 <statusCode code="completed"/>
290 <text>
291 <reference value="#PROBLEM1"/>
292 </text>
293 <effectiveTime>
294 <low value="20101016"/>
295 <high nullFlavor="UNK"/>
296 </effectiveTime>
297 <value displayName="HTN (ICD-9-CM 401.9)" code="401.9" codeSystemName="ICD9CM" codeSystem=""/>
298 <entryRelationship typeCode="REFR">
299 <observation classCode="OBS" moodCode="EVN">
300 <templateId root="2.16.840.1.113883.10.20.1.50"/>
301 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
302 <statusCode code="completed"/>
303 <value>
304 <originalText>Active</originalText>
305 </value>
306 </observation>
307 </entryRelationship>
308 </observation>
309 </entryRelationship>
310 </act>
311 </entry>
312 <entry typeCode="DRIV">
313 <act classCode="ACT" moodCode="EVN">
314 <templateId root="2.16.840.1.113883.10.20.1.27"/>
315 <id root="PROBLEM2" extension="CCRObjectID"/>
316 <code nullFlavor="NA"/>
317 <performer typeCode="PRF">
318 <assignedEntity>
319 <id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
320 <addr use="WP">
321 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
322 <city>ALBANY</city>
323 <state>NY</state>
324 <postalCode>12180</postalCode>
325 </addr>
326 <telecom/>
327 <assignedPerson>
328 <name>
329 <given>MATTHEW</given>
330 <given>M</given>
331 <family>KING</family>
332 </name>
333 </assignedPerson>
334 </assignedEntity>
335 </performer>
336 <entryRelationship typeCode="SUBJ">
337 <observation classCode="OBS" moodCode="EVN">
338 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
339 <templateId root="2.16.840.1.113883.3.249.11.100.8"/>
340 <id root="PROBLEM2" extension="CCRObjectID"/>
341 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
342 <statusCode code="completed"/>
343 <text>
344 <reference value="#PROBLEM2"/>
345 </text>
346 <effectiveTime>
347 <low value="20101014"/>
348 <high nullFlavor="UNK"/>
349 </effectiveTime>
350 <value displayName="ANY DEEP VEIN THROMBOSIS" code="453.8" codeSystemName="ICD9CM" codeSystem=""/>
351 <entryRelationship typeCode="REFR">
352 <observation classCode="OBS" moodCode="EVN">
353 <templateId root="2.16.840.1.113883.10.20.1.50"/>
354 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
355 <statusCode code="completed"/>
356 <value>
357 <originalText>Active</originalText>
358 </value>
359 </observation>
360 </entryRelationship>
361 </observation>
362 </entryRelationship>
363 </act>
364 </entry>
365 <entry typeCode="DRIV">
366 <act classCode="ACT" moodCode="EVN">
367 <templateId root="2.16.840.1.113883.10.20.1.27"/>
368 <id root="PROBLEM3" extension="CCRObjectID"/>
369 <code nullFlavor="NA"/>
370 <performer typeCode="PRF">
371 <assignedEntity>
372 <id extension="ACTORPROVIDER_991" root="CCRActorID"/>
373 <addr use="WP">
374 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
375 <city>ALBANY</city>
376 <state>NY</state>
377 <postalCode>12180</postalCode>
378 </addr>
379 <telecom/>
380 <assignedPerson>
381 <name>
382 <prefix>Scholar Extraordinaire</prefix>
383 <given>EIGHT</given>
384 <family>PROVIDER</family>
385 </name>
386 </assignedPerson>
387 </assignedEntity>
388 </performer>
389 <entryRelationship typeCode="SUBJ">
390 <observation classCode="OBS" moodCode="EVN">
391 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
392 <templateId root="2.16.840.1.113883.3.249.11.100.8"/>
393 <id root="PROBLEM3" extension="CCRObjectID"/>
394 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
395 <statusCode code="completed"/>
396 <text>
397 <reference value="#PROBLEM3"/>
398 </text>
399 <effectiveTime>
400 <low value="20100904"/>
401 <high nullFlavor="UNK"/>
402 </effectiveTime>
403 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
404 <entryRelationship typeCode="REFR">
405 <observation classCode="OBS" moodCode="EVN">
406 <templateId root="2.16.840.1.113883.10.20.1.50"/>
407 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
408 <statusCode code="completed"/>
409 <value>
410 <originalText>Active</originalText>
411 </value>
412 </observation>
413 </entryRelationship>
414 </observation>
415 </entryRelationship>
416 </act>
417 </entry>
418 <entry typeCode="DRIV">
419 <act classCode="ACT" moodCode="EVN">
420 <templateId root="2.16.840.1.113883.10.20.1.27"/>
421 <id root="PROBLEM4" extension="CCRObjectID"/>
422 <code nullFlavor="NA"/>
423 <performer typeCode="PRF">
424 <assignedEntity>
425 <id extension="ACTORPROVIDER_991" root="CCRActorID"/>
426 <addr use="WP">
427 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
428 <city>ALBANY</city>
429 <state>NY</state>
430 <postalCode>12180</postalCode>
431 </addr>
432 <telecom/>
433 <assignedPerson>
434 <name>
435 <prefix>Scholar Extraordinaire</prefix>
436 <given>EIGHT</given>
437 <family>PROVIDER</family>
438 </name>
439 </assignedPerson>
440 </assignedEntity>
441 </performer>
442 <entryRelationship typeCode="SUBJ">
443 <observation classCode="OBS" moodCode="EVN">
444 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
445 <templateId root="2.16.840.1.113883.3.249.11.100.8"/>
446 <id root="PROBLEM4" extension="CCRObjectID"/>
447 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
448 <statusCode code="completed"/>
449 <text>
450 <reference value="#PROBLEM4"/>
451 </text>
452 <effectiveTime>
453 <low value="20100705"/>
454 <high nullFlavor="UNK"/>
455 </effectiveTime>
456 <value displayName="Congestive Heart Failure (ICD-9-CM 428.0)" code="428.0" codeSystemName="ICD9CM" codeSystem=""/>
457 <entryRelationship typeCode="REFR">
458 <observation classCode="OBS" moodCode="EVN">
459 <templateId root="2.16.840.1.113883.10.20.1.50"/>
460 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
461 <statusCode code="completed"/>
462 <value>
463 <originalText>Active</originalText>
464 </value>
465 </observation>
466 </entryRelationship>
467 </observation>
468 </entryRelationship>
469 </act>
470 </entry>
471 <entry typeCode="DRIV">
472 <act classCode="ACT" moodCode="EVN">
473 <templateId root="2.16.840.1.113883.10.20.1.27"/>
474 <id root="PROBLEM5" extension="CCRObjectID"/>
475 <code nullFlavor="NA"/>
476 <performer typeCode="PRF">
477 <assignedEntity>
478 <id extension="ACTORPROVIDER_991" root="CCRActorID"/>
479 <addr use="WP">
480 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
481 <city>ALBANY</city>
482 <state>NY</state>
483 <postalCode>12180</postalCode>
484 </addr>
485 <telecom/>
486 <assignedPerson>
487 <name>
488 <prefix>Scholar Extraordinaire</prefix>
489 <given>EIGHT</given>
490 <family>PROVIDER</family>
491 </name>
492 </assignedPerson>
493 </assignedEntity>
494 </performer>
495 <entryRelationship typeCode="SUBJ">
496 <observation classCode="OBS" moodCode="EVN">
497 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
498 <templateId root="2.16.840.1.113883.3.249.11.100.8"/>
499 <id root="PROBLEM5" extension="CCRObjectID"/>
500 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
501 <statusCode code="completed"/>
502 <text>
503 <reference value="#PROBLEM5"/>
504 </text>
505 <effectiveTime>
506 <low value="20100705"/>
507 <high nullFlavor="UNK"/>
508 </effectiveTime>
509 <value displayName="Postmyocardial infarction syndrome (ICD-9-CM 411.0)" code="411.0" codeSystemName="ICD9CM" codeSystem=""/>
510 <entryRelationship typeCode="REFR">
511 <observation classCode="OBS" moodCode="EVN">
512 <templateId root="2.16.840.1.113883.10.20.1.50"/>
513 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
514 <statusCode code="completed"/>
515 <value>
516 <originalText>Active</originalText>
517 </value>
518 </observation>
519 </entryRelationship>
520 </observation>
521 </entryRelationship>
522 </act>
523 </entry>
524 </section>
525 </component>
526 <component>
527 <section>
528 <templateId root="2.16.840.1.113883.10.20.1.12"/>
529 <code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
530 <title>Procedures</title>
531 <text>
532 <table>
533 <tbody>
534 <tr>
535 <th>Type</th>
536 <th>Date</th>
537 <th>Code</th>
538 <th>Description</th>
539 <th>Location</th>
540 <th>Substance</th>
541 <th>Method</th>
542 <th>Position</th>
543 <th>Site</th>
544 <th>Status</th>
545 <th>Source</th>
546 </tr>
547 <tr id="PROCEDURE_4209_46">
548 <td/>
549 <table>
550 <tbody>
551 <tr xmlns="">
552 <td>Procedure Date:
553 </td>
554 <td>Oct 17, 2010</td>
555 </tr>
556 </tbody>
557 </table>
558 <td>99213 (CPT-4)
559 </td>
560 <td>INTERMEDIATE (15min)</td>
561 <td/>
562 <td/>
563 <td/>
564 <td/>
565 <td/>
566 <td>Completed</td>
567 <td>MATTHEW M KING </td>
568 </tr>
569 <tr id="PROCEDURE_4207_43">
570 <td/>
571 <table>
572 <tbody>
573 <tr xmlns="">
574 <td>Procedure Date:
575 </td>
576 <td>Oct 16, 2010</td>
577 </tr>
578 </tbody>
579 </table>
580 <td>99214 (CPT-4)
581 </td>
582 <td>EXTENDED (25min)</td>
583 <td/>
584 <td/>
585 <td/>
586 <td/>
587 <td/>
588 <td>Completed</td>
589 <td>MATTHEW M KING </td>
590 </tr>
591 <tr id="PROCEDURE_4205_37">
592 <td/>
593 <table>
594 <tbody>
595 <tr xmlns="">
596 <td>Procedure Date:
597 </td>
598 <td>Oct 15, 2010</td>
599 </tr>
600 </tbody>
601 </table>
602 <td>99214 (CPT-4)
603 </td>
604 <td>EXTENDED (25min)</td>
605 <td/>
606 <td/>
607 <td/>
608 <td/>
609 <td/>
610 <td>Completed</td>
611 <td>MATTHEW M KING </td>
612 </tr>
613 <tr id="PROCEDURE_4099_34">
614 <td/>
615 <table>
616 <tbody>
617 <tr xmlns="">
618 <td>Procedure Date:
619 </td>
620 <td>Oct 06, 2010</td>
621 </tr>
622 </tbody>
623 </table>
624 <td>99213 (CPT-4)
625 </td>
626 <td>INTERMEDIATE (15min)</td>
627 <td/>
628 <td/>
629 <td/>
630 <td/>
631 <td/>
632 <td>Completed</td>
633 <td>MATTHEW M KING </td>
634 </tr>
635 <tr id="PROCEDURE_4068_30">
636 <td/>
637 <table>
638 <tbody>
639 <tr xmlns="">
640 <td>Procedure Date:
641 </td>
642 <td>Sep 17, 2010</td>
643 </tr>
644 </tbody>
645 </table>
646 <td>99214 (CPT-4)
647 </td>
648 <td>Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214)</td>
649 <td/>
650 <td/>
651 <td/>
652 <td/>
653 <td/>
654 <td>Completed</td>
655 <td>MATTHEW M KING </td>
656 </tr>
657 <tr id="PROCEDURE_4056_27">
658 <td/>
659 <table>
660 <tbody>
661 <tr xmlns="">
662 <td>Procedure Date:
663 </td>
664 <td>Sep 04, 2010</td>
665 </tr>
666 </tbody>
667 </table>
668 <td>99213 (CPT-4)
669 </td>
670 <td>INTERMEDIATE (15min)</td>
671 <td/>
672 <td/>
673 <td/>
674 <td/>
675 <td/>
676 <td>Completed</td>
677 <td>NANCY ANTHRACITE </td>
678 </tr>
679 <tr id="PROCEDURE_4055_24">
680 <td/>
681 <table>
682 <tbody>
683 <tr xmlns="">
684 <td>Procedure Date:
685 </td>
686 <td>Aug 28, 2010</td>
687 </tr>
688 </tbody>
689 </table>
690 <td>99202 (CPT-4)
691 </td>
692 <td>EXPANDED, HX &amp; EXAM</td>
693 <td/>
694 <td/>
695 <td/>
696 <td/>
697 <td/>
698 <td>Completed</td>
699 <td>NANCY ANTHRACITE </td>
700 </tr>
701 <tr id="PROCEDURE_4047_14">
702 <td/>
703 <table>
704 <tbody>
705 <tr xmlns="">
706 <td>Procedure Date:
707 </td>
708 <td>Jul 31, 2010</td>
709 </tr>
710 </tbody>
711 </table>
712 <td>99213 (CPT-4)
713 </td>
714 <td>Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</td>
715 <td/>
716 <td/>
717 <td/>
718 <td/>
719 <td/>
720 <td>Completed</td>
721 <td>NANCY ANTHRACITE </td>
722 </tr>
723 <tr id="PROCEDURE_4046_7">
724 <td/>
725 <table>
726 <tbody>
727 <tr xmlns="">
728 <td>Procedure Date:
729 </td>
730 <td>Jul 05, 2010</td>
731 </tr>
732 </tbody>
733 </table>
734 <td>99214 (CPT-4)
735 </td>
736 <td>Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214)</td>
737 <td/>
738 <td/>
739 <td/>
740 <td/>
741 <td/>
742 <td>Completed</td>
743 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
744 </tr>
745 <tr id="PROCEDURE_4046_8">
746 <td/>
747 <table>
748 <tbody>
749 <tr xmlns="">
750 <td>Procedure Date:
751 </td>
752 <td>Jul 05, 2010</td>
753 </tr>
754 </tbody>
755 </table>
756 <td>83036 (CPT-4)
757 </td>
758 <td>Hemoglobin; Glycosylated (A1c) (CPT-4 83036)</td>
759 <td/>
760 <td/>
761 <td/>
762 <td/>
763 <td/>
764 <td>Completed</td>
765 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
766 </tr>
767 <tr id="PROCEDURE_4046_9">
768 <td/>
769 <table>
770 <tbody>
771 <tr xmlns="">
772 <td>Procedure Date:
773 </td>
774 <td>Jul 05, 2010</td>
775 </tr>
776 </tbody>
777 </table>
778 <td>83704 (CPT-4)
779 </td>
780 <td>Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704)</td>
781 <td/>
782 <td/>
783 <td/>
784 <td/>
785 <td/>
786 <td>Completed</td>
787 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
788 </tr>
789 <tr id="PROCEDURE_4046_10">
790 <td/>
791 <table>
792 <tbody>
793 <tr xmlns="">
794 <td>Procedure Date:
795 </td>
796 <td>Jul 05, 2010</td>
797 </tr>
798 </tbody>
799 </table>
800 <td>78414 (CPT-4)
801 </td>
802 <td>Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414)</td>
803 <td/>
804 <td/>
805 <td/>
806 <td/>
807 <td/>
808 <td>Completed</td>
809 <td>EIGHT PROVIDER Scholar Extraordinaire </td>
810 </tr>
811 </tbody>
812 </table>
813 </text>
814 <entry typeCode="DRIV">
815 <procedure classCode="PROC" moodCode="EVN">
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818 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
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820 <code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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825 <effectiveTime>
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835 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
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838 <text>
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840 </text>
841 <statusCode code="completed"/>
842 <effectiveTime>
843 <low value="20101016"/>
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848 <entry typeCode="DRIV">
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854 <code displayName="EXTENDED (25min)" code="99214" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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859 <effectiveTime>
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871 <code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
872 <text>
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876 <effectiveTime>
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882 <entry typeCode="DRIV">
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889 <text>
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891 </text>
892 <statusCode code="completed"/>
893 <effectiveTime>
894 <low value="20100917"/>
895 <high nullFlavor="UNK"/>
896 </effectiveTime>
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903 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
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908 </text>
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910 <effectiveTime>
911 <low value="20100904"/>
912 <high nullFlavor="UNK"/>
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923 <text>
924 <reference value="#PROCEDURE_4055_24"/>
925 </text>
926 <statusCode code="completed"/>
927 <effectiveTime>
928 <low value="20100828"/>
929 <high nullFlavor="UNK"/>
930 </effectiveTime>
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933 <entry typeCode="DRIV">
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944 <effectiveTime>
945 <low value="20100731"/>
946 <high nullFlavor="UNK"/>
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950 <entry typeCode="DRIV">
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957 <text>
958 <reference value="#PROCEDURE_4046_7"/>
959 </text>
960 <statusCode code="completed"/>
961 <effectiveTime>
962 <low value="20100705"/>
963 <high nullFlavor="UNK"/>
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966 </entry>
967 <entry typeCode="DRIV">
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980 <high nullFlavor="UNK"/>
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989 <id root="PROCEDURE_4046_9" extension="CCRObjectID"/>
990 <code displayName="Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704)" code="83704" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
991 <text>
992 <reference value="#PROCEDURE_4046_9"/>
993 </text>
994 <statusCode code="completed"/>
995 <effectiveTime>
996 <low value="20100705"/>
997 <high nullFlavor="UNK"/>
998 </effectiveTime>
999 </procedure>
1000 </entry>
1001 <entry typeCode="DRIV">
1002 <procedure classCode="PROC" moodCode="EVN">
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1005 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
1006 <id root="PROCEDURE_4046_10" extension="CCRObjectID"/>
1007 <code displayName="Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414)" code="78414" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
1008 <text>
1009 <reference value="#PROCEDURE_4046_10"/>
1010 </text>
1011 <statusCode code="completed"/>
1012 <effectiveTime>
1013 <low value="20100705"/>
1014 <high nullFlavor="UNK"/>
1015 </effectiveTime>
1016 </procedure>
1017 </entry>
1018 </section>
1019 </component>
1020 <component>
1021 <section>
1022 <templateId root="2.16.840.1.113883.10.20.1.9"/>
1023 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment Sources"/>
1024 <title>Payers</title>
1025 <text/>
1026 <entry typeCode="DRIV">
1027 <act classCode="ACT" moodCode="DEF">
1028 <templateId root="2.16.840.1.113883.10.20.1.20"/>
1029 <id root="2.16.840.1.113883.3.543" extension="@@@UUID-PAYER@@@"/>
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1031 <statusCode code="completed"/>
1032 <entryRelationship typeCode="COMP">
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1038 <statusCode code="completed"/>
1039 <performer typeCode="PRF">
1040 <assignedEntity>
1041 <id root="2.16.840.1.113883.12.86" extension="MC"/>
1042 </assignedEntity>
1043 </performer>
1044 <participant typeCode="COV">
1045 <participantRole>
1046 <id root="2.16.840.1.113883.4.1" extension="@@SSN@@"/>
1047 <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
1048 </participantRole>
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1050 </act>
1051 </entryRelationship>
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1054 </section>
1055 </component>
1056 </section>
1057 </component>
1058 </section>
1059 </component>
1060 </structuredBody>
1061 </component>
1062</ClinicalDocument>
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