| 1 | <?xml version="1.0" encoding="UTF-8"?>
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| 2 | <?xml-stylesheet type="text/xsl" href="ccr.xsl"?>
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| 3 | <ContinuityOfCareRecord xmlns="urn:astm-org:CCR">
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| 4 | <CCRDocumentObjectID>d010c8bd-eda0-4e36-8a53-c7c677666b29</CCRDocumentObjectID>
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| 5 | <Language>
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| 6 | <Text>English</Text>
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| 7 | </Language>
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| 8 | <Version>V1.0</Version>
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| 9 | <DateTime>
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| 10 | <ExactDateTime>2010-10-18T15:33:12-05:00</ExactDateTime>
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| 11 | </DateTime>
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| 12 | <Patient>
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| 13 | <ActorID>ACTORPATIENT_100146</ActorID>
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| 14 | </Patient>
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| 15 | <From>
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| 16 | <ActorLink>
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| 17 | <ActorID>ACTORPROVIDER_1</ActorID>
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| 18 | </ActorLink>
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| 19 | <ActorLink>
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| 20 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 21 | </ActorLink>
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| 22 | </From>
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| 23 | <To>
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| 24 | <ActorLink>
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| 25 | <ActorID>ACTORPATIENT_100146</ActorID>
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| 26 | <ActorRole>
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| 27 | <Text>Patient</Text>
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| 28 | </ActorRole>
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| 29 | </ActorLink>
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| 30 | </To>
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| 31 | <Purpose>
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| 32 | <Description>
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| 33 | <Text>CEND PHR</Text>
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| 34 | </Description>
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| 35 | </Purpose>
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| 36 | <Body>
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| 37 | <Problems>
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| 38 | <Problem>
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| 39 | <CCRDataObjectID>PROBLEM1</CCRDataObjectID>
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| 40 | <DateTime>
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| 41 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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| 42 | </DateTime>
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| 43 | <Type>
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| 44 | <Text>Problem</Text>
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| 45 | </Type>
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| 46 | <Description>
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| 47 | <Text>Diabetes Mellitus without mention of Complication, type II or unspecified type,</Text>
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| 48 | <Code>
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| 49 | <Value>250.02</Value>
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| 50 | <CodingSystem>ICD9CM</CodingSystem>
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| 51 | </Code>
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| 52 | </Description>
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| 53 | <Status>
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| 54 | <Text>Active</Text>
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| 55 | </Status>
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| 56 | <Source>
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| 57 | <Actor>
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| 58 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 59 | </Actor>
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| 60 | </Source>
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| 61 | </Problem>
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| 62 | <Problem>
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| 63 | <CCRDataObjectID>PROBLEM2</CCRDataObjectID>
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| 64 | <DateTime>
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| 65 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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| 66 | </DateTime>
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| 67 | <Type>
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| 68 | <Text>Problem</Text>
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| 69 | </Type>
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| 70 | <Description>
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| 71 | <Text>Diabetes Mellitus</Text>
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| 72 | <Code>
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| 73 | <Value>250.00</Value>
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| 74 | <CodingSystem>ICD9CM</CodingSystem>
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| 75 | </Code>
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| 76 | </Description>
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| 77 | <Status>
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| 78 | <Text>Active</Text>
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| 79 | </Status>
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| 80 | <Source>
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| 81 | <Actor>
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| 82 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 83 | </Actor>
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| 84 | </Source>
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| 85 | </Problem>
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| 86 | </Problems>
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| 87 | <Procedures>
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| 88 | <Procedure>
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| 89 | <CCRDataObjectID>PROCEDURE_4141_10</CCRDataObjectID>
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| 90 | <DateTime>
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| 91 | <Type>
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| 92 | <Text>Procedure Date</Text>
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| 93 | </Type>
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| 94 | <ExactDateTime>2010-10-14T00:00:00-05:00</ExactDateTime>
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| 95 | </DateTime>
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| 96 | <Description>
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| 97 | <Text>INTERMEDIATE (30min)</Text>
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| 98 | <Code>
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| 99 | <Value>99242</Value>
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| 100 | <CodingSystem>CPT-4</CodingSystem>
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| 101 | </Code>
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| 102 | </Description>
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| 103 | <Status>
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| 104 | <Text>Completed</Text>
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| 105 | </Status>
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| 106 | <Source>
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| 107 | <Actor>
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| 108 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 109 | </Actor>
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| 110 | </Source>
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| 111 | </Procedure>
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| 112 | <Procedure>
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| 113 | <CCRDataObjectID>PROCEDURE_4092_7</CCRDataObjectID>
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| 114 | <DateTime>
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| 115 | <Type>
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| 116 | <Text>Procedure Date</Text>
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| 117 | </Type>
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| 118 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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| 119 | </DateTime>
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| 120 | <Description>
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| 121 | <Text>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)</Text>
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| 122 | <Code>
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| 123 | <Value>99213</Value>
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| 124 | <CodingSystem>CPT-4</CodingSystem>
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| 125 | </Code>
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| 126 | </Description>
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| 127 | <Status>
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| 128 | <Text>Completed</Text>
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| 129 | </Status>
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| 130 | <Source>
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| 131 | <Actor>
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| 132 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 133 | </Actor>
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| 134 | </Source>
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| 135 | </Procedure>
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| 136 | </Procedures>
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| 137 | <Encounters>
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| 138 | <Encounter>
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| 139 | <CCRDataObjectID>ENCOUNTER_4141</CCRDataObjectID>
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| 140 | <DateTime>
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| 141 | <ExactDateTime>2010-10-14T00:00:00-05:00</ExactDateTime>
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| 142 | </DateTime>
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| 143 | <Type>
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| 144 | <Text>***NEW PATIENT*** INTERMEDIATE (30min)</Text>
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| 145 | <Code>
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| 146 | <Value>99242</Value>
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| 147 | <CodingSystem>CPT-4</CodingSystem>
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| 148 | </Code>
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| 149 | </Type>
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| 150 | <Description>
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| 151 | <Text>***NEW PATIENT*** INTERMEDIATE (30min)</Text>
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| 152 | <Code>
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| 153 | <Value>99242</Value>
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| 154 | <CodingSystem>CPT-4</CodingSystem>
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| 155 | </Code>
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| 156 | </Description>
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| 157 | <Location>
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| 158 | <Actor>
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| 159 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 160 | </Actor>
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| 161 | </Location>
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| 162 | <Practioner>
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| 163 | <Actor>
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| 164 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 165 | </Actor>
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| 166 | </Practioner>
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| 167 | <Source>
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| 168 | <Actor>
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| 169 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 170 | </Actor>
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| 171 | </Source>
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| 172 | </Encounter>
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| 173 | <Encounter>
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| 174 | <CCRDataObjectID>ENCOUNTER_4092</CCRDataObjectID>
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| 175 | <DateTime>
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| 176 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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| 177 | </DateTime>
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| 178 | <Type>
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| 179 | <Text> 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)</Text>
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| 180 | <Code>
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| 181 | <Value>99213</Value>
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| 182 | <CodingSystem>CPT-4</CodingSystem>
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| 183 | </Code>
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| 184 | </Type>
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| 185 | <Description>
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| 186 | <Text> 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)</Text>
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| 187 | <Code>
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| 188 | <Value>99213</Value>
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| 189 | <CodingSystem>CPT-4</CodingSystem>
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| 190 | </Code>
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| 191 | </Description>
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| 192 | <Location>
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| 193 | <Actor>
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| 194 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 195 | </Actor>
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| 196 | </Location>
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| 197 | <Practioner>
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| 198 | <Actor>
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| 199 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 200 | </Actor>
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| 201 | </Practioner>
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| 202 | <Source>
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| 203 | <Actor>
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| 204 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 205 | </Actor>
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| 206 | </Source>
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| 207 | <CommentID>NOTE_4092</CommentID>
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| 208 | </Encounter>
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| 209 | <Encounter>
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| 210 | <CCRDataObjectID>ENCOUNTER_4091</CCRDataObjectID>
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| 211 | <DateTime>
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| 212 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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| 213 | </DateTime>
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| 214 | <Type>
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| 215 | <Text> 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)</Text>
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| 216 | <Code>
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| 217 | <Value>99213</Value>
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| 218 | <CodingSystem>CPT-4</CodingSystem>
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| 219 | </Code>
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| 220 | </Type>
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| 221 | <Description>
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| 222 | <Text> 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)</Text>
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| 223 | <Code>
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| 224 | <Value>99213</Value>
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| 225 | <CodingSystem>CPT-4</CodingSystem>
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| 226 | </Code>
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| 227 | </Description>
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| 228 | <Location>
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| 229 | <Actor>
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| 230 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 231 | </Actor>
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| 232 | </Location>
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| 233 | <Practioner>
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| 234 | <Actor>
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| 235 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 236 | </Actor>
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| 237 | </Practioner>
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| 238 | <Source>
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| 239 | <Actor>
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| 240 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 241 | </Actor>
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| 242 | </Source>
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| 243 | <CommentID>NOTE_4091</CommentID>
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| 244 | </Encounter>
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| 245 | </Encounters>
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| 246 | </Body>
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| 247 | <Actors>
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| 248 | <Actor>
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| 249 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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| 250 | <Organization>
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| 251 | <Name>CAMP MASTER</Name>
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| 252 | </Organization>
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| 253 | <Address>
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| 254 | <Type>
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| 255 | <Text>Office</Text>
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| 256 | </Type>
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| 257 | <Line1>VA MEDICAL CENTER</Line1>
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| 258 | <City>ALBANY</City>
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| 259 | <State>NEW YORK</State>
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| 260 | <PostalCode>12180</PostalCode>
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| 261 | </Address>
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| 262 | <Source>
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| 263 | <Actor>
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| 264 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 265 | </Actor>
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| 266 | </Source>
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| 267 | </Actor>
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| 268 | <Actor>
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| 269 | <ActorObjectID>ACTORPATIENT_100146</ActorObjectID>
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| 270 | <Person>
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| 271 | <Name>
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| 272 | <CurrentName>
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| 273 | <Given>MALE-D</Given>
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| 274 | <Family>MEASURE-TWO</Family>
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| 275 | </CurrentName>
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| 276 | </Name>
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| 277 | <DateOfBirth>
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| 278 | <ExactDateTime>1960-01-01</ExactDateTime>
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| 279 | </DateOfBirth>
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| 280 | <Gender>
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| 281 | <Text>MALE</Text>
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| 282 | <Code>
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| 283 | <Value>M</Value>
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| 284 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
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| 285 | </Code>
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| 286 | </Gender>
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| 287 | </Person>
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|---|
| 288 | <IDs>
|
|---|
| 289 | <Type>
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| 290 | <Text>SSN</Text>
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| 291 | </Type>
|
|---|
| 292 | <ID>666000200</ID>
|
|---|
| 293 | <Source>
|
|---|
| 294 | <Actor>
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| 295 | <ActorID>ACTORPATIENT_100146</ActorID>
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| 296 | </Actor>
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| 297 | </Source>
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| 298 | </IDs>
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| 299 | <Address>
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|---|
| 300 | <Type>
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| 301 | <Text>Home</Text>
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| 302 | </Type>
|
|---|
| 303 | <Line1>Any Street</Line1>
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| 304 | <City>Any Town</City>
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| 305 | <State>WEST VIRGINIA</State>
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| 306 | </Address>
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| 307 | <Telephone>
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| 308 | <Value>222-555-8235</Value>
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|---|
| 309 | <Type>
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| 310 | <Text>Residential Telephone</Text>
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|---|
| 311 | </Type>
|
|---|
| 312 | </Telephone>
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|---|
| 313 | <Telephone>
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| 314 | <Value>222-555-7720</Value>
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| 315 | <Type>
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| 316 | <Text>Work Telephone</Text>
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|---|
| 317 | </Type>
|
|---|
| 318 | </Telephone>
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| 319 | <Source>
|
|---|
| 320 | <Actor>
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| 321 | <ActorID>ACTORPATIENT_100146</ActorID>
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| 322 | </Actor>
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|---|
| 323 | </Source>
|
|---|
| 324 | </Actor>
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|---|
| 325 | <Actor>
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| 326 | <ActorObjectID>ACTORPROVIDER_1</ActorObjectID>
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|---|
| 327 | <Person>
|
|---|
| 328 | <Name>
|
|---|
| 329 | <CurrentName>
|
|---|
| 330 | <Given>ONE</Given>
|
|---|
| 331 | <Family>PROGRAMMER</Family>
|
|---|
| 332 | <Title>COMPUTER SPECIALIST</Title>
|
|---|
| 333 | </CurrentName>
|
|---|
| 334 | </Name>
|
|---|
| 335 | </Person>
|
|---|
| 336 | <Specialty>
|
|---|
| 337 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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|---|
| 338 | </Specialty>
|
|---|
| 339 | <Address>
|
|---|
| 340 | <Type>
|
|---|
| 341 | <Text>Work</Text>
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|---|
| 342 | </Type>
|
|---|
| 343 | <Line1>VA MEDICAL CENTER</Line1>
|
|---|
| 344 | <City>ALBANY</City>
|
|---|
| 345 | <State>NY</State>
|
|---|
| 346 | <PostalCode>12180</PostalCode>
|
|---|
| 347 | </Address>
|
|---|
| 348 | <Telephone>
|
|---|
| 349 | <Value>6655544</Value>
|
|---|
| 350 | <Type>
|
|---|
| 351 | <Text>Office</Text>
|
|---|
| 352 | </Type>
|
|---|
| 353 | </Telephone>
|
|---|
| 354 | <Source>
|
|---|
| 355 | <Actor>
|
|---|
| 356 | <ActorID>ACTORSYSTEM_1</ActorID>
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|---|
| 357 | </Actor>
|
|---|
| 358 | </Source>
|
|---|
| 359 | <InternalCCRLink>
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|---|
| 360 | <LinkID>ACTORORGANIZATION_1</LinkID>
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|---|
| 361 | <LinkRelationship>representedOrganization</LinkRelationship>
|
|---|
| 362 | </InternalCCRLink>
|
|---|
| 363 | </Actor>
|
|---|
| 364 | <Actor>
|
|---|
| 365 | <ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
|
|---|
| 366 | <Person>
|
|---|
| 367 | <Name>
|
|---|
| 368 | <CurrentName>
|
|---|
| 369 | <Given>NANCY</Given>
|
|---|
| 370 | <Family>ANTHRACITE</Family>
|
|---|
| 371 | </CurrentName>
|
|---|
| 372 | </Name>
|
|---|
| 373 | </Person>
|
|---|
| 374 | <Specialty>
|
|---|
| 375 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
|---|
| 376 | </Specialty>
|
|---|
| 377 | <Address>
|
|---|
| 378 | <Type>
|
|---|
| 379 | <Text>Work</Text>
|
|---|
| 380 | </Type>
|
|---|
| 381 | <Line1>VA MEDICAL CENTER</Line1>
|
|---|
| 382 | <City>ALBANY</City>
|
|---|
| 383 | <State>NY</State>
|
|---|
| 384 | <PostalCode>12180</PostalCode>
|
|---|
| 385 | </Address>
|
|---|
| 386 | <Source>
|
|---|
| 387 | <Actor>
|
|---|
| 388 | <ActorID>ACTORSYSTEM_1</ActorID>
|
|---|
| 389 | </Actor>
|
|---|
| 390 | </Source>
|
|---|
| 391 | <InternalCCRLink>
|
|---|
| 392 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
|---|
| 393 | <LinkRelationship>representedOrganization</LinkRelationship>
|
|---|
| 394 | </InternalCCRLink>
|
|---|
| 395 | </Actor>
|
|---|
| 396 | <Actor>
|
|---|
| 397 | <ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
|
|---|
| 398 | <Person>
|
|---|
| 399 | <Name>
|
|---|
| 400 | <CurrentName>
|
|---|
| 401 | <Given>MATTHEW</Given>
|
|---|
| 402 | <Middle>M</Middle>
|
|---|
| 403 | <Family>KING</Family>
|
|---|
| 404 | </CurrentName>
|
|---|
| 405 | </Name>
|
|---|
| 406 | </Person>
|
|---|
| 407 | <Specialty>
|
|---|
| 408 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
|---|
| 409 | </Specialty>
|
|---|
| 410 | <Address>
|
|---|
| 411 | <Type>
|
|---|
| 412 | <Text>Work</Text>
|
|---|
| 413 | </Type>
|
|---|
| 414 | <Line1>VA MEDICAL CENTER</Line1>
|
|---|
| 415 | <City>ALBANY</City>
|
|---|
| 416 | <State>NY</State>
|
|---|
| 417 | <PostalCode>12180</PostalCode>
|
|---|
| 418 | </Address>
|
|---|
| 419 | <Source>
|
|---|
| 420 | <Actor>
|
|---|
| 421 | <ActorID>ACTORSYSTEM_1</ActorID>
|
|---|
| 422 | </Actor>
|
|---|
| 423 | </Source>
|
|---|
| 424 | <InternalCCRLink>
|
|---|
| 425 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
|---|
| 426 | <LinkRelationship>representedOrganization</LinkRelationship>
|
|---|
| 427 | </InternalCCRLink>
|
|---|
| 428 | </Actor>
|
|---|
| 429 | <Actor>
|
|---|
| 430 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
|
|---|
| 431 | <InformationSystem>
|
|---|
| 432 | <Name>WorldVistA EHR/VOE</Name>
|
|---|
| 433 | <Version>1.0</Version>
|
|---|
| 434 | </InformationSystem>
|
|---|
| 435 | <Source>
|
|---|
| 436 | <Actor>
|
|---|
| 437 | <ActorID>ACTORSYSTEM_1</ActorID>
|
|---|
| 438 | </Actor>
|
|---|
| 439 | </Source>
|
|---|
| 440 | </Actor>
|
|---|
| 441 | </Actors>
|
|---|
| 442 | <Comments>
|
|---|
| 443 | <Comment>
|
|---|
| 444 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
|
|---|
| 445 | <DateTime>
|
|---|
| 446 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
|
|---|
| 447 | </DateTime>
|
|---|
| 448 | <Source>
|
|---|
| 449 | <Actor>
|
|---|
| 450 | <ActorID>@@ACTORSOURCEID@@</ActorID>
|
|---|
| 451 | </Actor>
|
|---|
| 452 | </Source>
|
|---|
| 453 | </Comment>
|
|---|
| 454 | <Comment>
|
|---|
| 455 | <CommentObjectID>NOTE_4091</CommentObjectID>
|
|---|
| 456 | <DateTime>
|
|---|
| 457 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
|
|---|
| 458 | </DateTime>
|
|---|
| 459 | <Description>
|
|---|
| 460 | <Text>
|
|---|
| 461 | PLACE DIABETIC ORDERS HERE.
|
|---|
| 462 | PATIENT HBA1C RESULTS
|
|---|
| 463 | PATIENTS HBA1C IS GREATER THAN 9%
|
|---|
| 464 | HBA1C VALUE: 9.1
|
|---|
| 465 | *** No Outpatient measurements ***
|
|---|
| 466 | </Text>
|
|---|
| 467 | </Description>
|
|---|
| 468 | <Source>
|
|---|
| 469 | <Actor>
|
|---|
| 470 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
|---|
| 471 | </Actor>
|
|---|
| 472 | </Source>
|
|---|
| 473 | </Comment>
|
|---|
| 474 | <Comment>
|
|---|
| 475 | <CommentObjectID>NOTE_4092</CommentObjectID>
|
|---|
| 476 | <DateTime>
|
|---|
| 477 | <ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
|
|---|
| 478 | </DateTime>
|
|---|
| 479 | <Description>
|
|---|
| 480 | <Text>
|
|---|
| 481 | PATIENT MAMMOGRAM INFORMATION:
|
|---|
| 482 | PATIENT HAD A SCREENING MAMMOGRAM.
|
|---|
| 483 | RESULT NEM (No Evidence of Malignancy)
|
|---|
| 484 | DATE OF PROCEDURE: September 6, 2010
|
|---|
| 485 | </Text>
|
|---|
| 486 | </Description>
|
|---|
| 487 | <Source>
|
|---|
| 488 | <Actor>
|
|---|
| 489 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
|---|
| 490 | </Actor>
|
|---|
| 491 | </Source>
|
|---|
| 492 | </Comment>
|
|---|
| 493 | </Comments>
|
|---|
| 494 | </ContinuityOfCareRecord>
|
|---|
