source: qrda/CCR/M1-QRDA/PAT_100848_CCR_V1_0_0.xml@ 1154

Last change on this file since 1154 was 983, checked in by George Lilly, 14 years ago

testing QRDA Incidence documents for PQRI Measure 1
File size: 9.0 KB
RevLine 
[983]1<?xml version="1.0" encoding="UTF-8"?>
2<?xml-stylesheet type="text/xsl" href="ccr.xsl"?>
3<ContinuityOfCareRecord xmlns="urn:astm-org:CCR">
4<CCRDocumentObjectID>33f5b05b-e101-4530-9b91-97203c8b71e6</CCRDocumentObjectID>
5<Language>
6<Text>English</Text>
7</Language>
8<Version>V1.0</Version>
9<DateTime>
10<ExactDateTime>2010-10-18T15:37:06-05:00</ExactDateTime>
11</DateTime>
12<Patient>
13<ActorID>ACTORPATIENT_100848</ActorID>
14</Patient>
15<From>
16<ActorLink>
17<ActorID>ACTORPROVIDER_1</ActorID>
18</ActorLink>
19<ActorLink>
20<ActorID>ACTORSYSTEM_1</ActorID>
21</ActorLink>
22</From>
23<To>
24<ActorLink>
25<ActorID>ACTORPATIENT_100848</ActorID>
26<ActorRole>
27<Text>Patient</Text>
28</ActorRole>
29</ActorLink>
30</To>
31<Purpose>
32<Description>
33<Text>CEND PHR</Text>
34</Description>
35</Purpose>
36<Body>
37<Problems>
38<Problem>
39<CCRDataObjectID>PROBLEM1</CCRDataObjectID>
40<DateTime>
41<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
42</DateTime>
43<Type>
44<Text>Problem</Text>
45</Type>
46<Description>
47<Text>Diabetes Mellitus without mention of Complication, type II or unspecified type,</Text>
48<Code>
49<Value>250.00</Value>
50<CodingSystem>ICD9CM</CodingSystem>
51</Code>
52</Description>
53<Status>
54<Text>Active</Text>
55</Status>
56<Source>
57<Actor>
58<ActorID>ACTORPROVIDER_991</ActorID>
59</Actor>
60</Source>
61</Problem>
62<Problem>
63<CCRDataObjectID>PROBLEM2</CCRDataObjectID>
64<DateTime>
65<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
66</DateTime>
67<Type>
68<Text>Problem</Text>
69</Type>
70<Description>
71<Text>Sprains (ICD-9-CM 848.9)</Text>
72<Code>
73<Value>848.9</Value>
74<CodingSystem>ICD9CM</CodingSystem>
75</Code>
76</Description>
77<Status>
78<Text>Active</Text>
79</Status>
80<Source>
81<Actor>
82<ActorID>ACTORPROVIDER_10000000183</ActorID>
83</Actor>
84</Source>
85</Problem>
86</Problems>
87<Procedures>
88<Procedure>
89<CCRDataObjectID>PROCEDURE_4108_8</CCRDataObjectID>
90<DateTime>
91<Type>
92<Text>Procedure Date</Text>
93</Type>
94<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
95</DateTime>
96<Description>
97<Text>Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
98<Code>
99<Value>84295</Value>
100<CodingSystem>CPT-4</CodingSystem>
101</Code>
102</Description>
103<Status>
104<Text>Completed</Text>
105</Status>
106<Source>
107<Actor>
108<ActorID>ACTORPROVIDER_10000000020</ActorID>
109</Actor>
110</Source>
111</Procedure>
112<Procedure>
113<CCRDataObjectID>PROCEDURE_4093_5</CCRDataObjectID>
114<DateTime>
115<Type>
116<Text>Procedure Date</Text>
117</Type>
118<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
119</DateTime>
120<Description>
121<Text>INTERMEDIATE (15min)</Text>
122<Code>
123<Value>99213</Value>
124<CodingSystem>CPT-4</CodingSystem>
125</Code>
126</Description>
127<Status>
128<Text>Completed</Text>
129</Status>
130<Source>
131<Actor>
132<ActorID>ACTORPROVIDER_10000000183</ActorID>
133</Actor>
134</Source>
135</Procedure>
136</Procedures>
137<Encounters>
138<Encounter>
139<CCRDataObjectID>ENCOUNTER_4108</CCRDataObjectID>
140<DateTime>
141<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
142</DateTime>
143<Type>
144<Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
145</Type>
146<Description>
147<Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
148</Description>
149<Location>
150<Actor>
151<ActorID>ACTORORGANIZATION_1</ActorID>
152</Actor>
153</Location>
154<Practioner>
155<Actor>
156<ActorID>ACTORPROVIDER_10000000020</ActorID>
157</Actor>
158</Practioner>
159<Source>
160<Actor>
161<ActorID>ACTORPROVIDER_10000000020</ActorID>
162</Actor>
163</Source>
164<CommentID>NOTE_4108</CommentID>
165</Encounter>
166<Encounter>
167<CCRDataObjectID>ENCOUNTER_4093</CCRDataObjectID>
168<DateTime>
169<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
170</DateTime>
171<Type>
172<Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
173<Code>
174<Value>99213</Value>
175<CodingSystem>CPT-4</CodingSystem>
176</Code>
177</Type>
178<Description>
179<Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
180<Code>
181<Value>99213</Value>
182<CodingSystem>CPT-4</CodingSystem>
183</Code>
184</Description>
185<Location>
186<Actor>
187<ActorID>ACTORORGANIZATION_1</ActorID>
188</Actor>
189</Location>
190<Practioner>
191<Actor>
192<ActorID>ACTORPROVIDER_10000000183</ActorID>
193</Actor>
194</Practioner>
195<Source>
196<Actor>
197<ActorID>ACTORPROVIDER_10000000183</ActorID>
198</Actor>
199</Source>
200<CommentID>NOTE_4093</CommentID>
201</Encounter>
202</Encounters>
203</Body>
204<Actors>
205<Actor>
206<ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
207<Organization>
208<Name>CAMP MASTER</Name>
209</Organization>
210<Address>
211<Type>
212<Text>Office</Text>
213</Type>
214<Line1>VA MEDICAL CENTER</Line1>
215<City>ALBANY</City>
216<State>NEW YORK</State>
217<PostalCode>12180</PostalCode>
218</Address>
219<Source>
220<Actor>
221<ActorID>ACTORSYSTEM_1</ActorID>
222</Actor>
223</Source>
224</Actor>
225<Actor>
226<ActorObjectID>ACTORPATIENT_100848</ActorObjectID>
227<Person>
228<Name>
229<CurrentName>
230<Given>FEMALE-B</Given>
231<Family>MEASURE-ONE</Family>
232</CurrentName>
233</Name>
234<DateOfBirth>
235<ExactDateTime>1960-01-01</ExactDateTime>
236</DateOfBirth>
237<Gender>
238<Text>FEMALE</Text>
239<Code>
240<Value>F</Value>
241<CodingSystem>HL7 AdministrativeGender</CodingSystem>
242</Code>
243</Gender>
244</Person>
245<IDs>
246<Type>
247<Text>SSN</Text>
248</Type>
249<ID>345097898</ID>
250<Source>
251<Actor>
252<ActorID>ACTORPATIENT_100848</ActorID>
253</Actor>
254</Source>
255</IDs>
256<Address>
257<Type>
258<Text>Home</Text>
259</Type>
260</Address>
261<Source>
262<Actor>
263<ActorID>ACTORPATIENT_100848</ActorID>
264</Actor>
265</Source>
266</Actor>
267<Actor>
268<ActorObjectID>ACTORPROVIDER_1</ActorObjectID>
269<Person>
270<Name>
271<CurrentName>
272<Given>ONE</Given>
273<Family>PROGRAMMER</Family>
274<Title>COMPUTER SPECIALIST</Title>
275</CurrentName>
276</Name>
277</Person>
278<Specialty>
279<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
280</Specialty>
281<Address>
282<Type>
283<Text>Work</Text>
284</Type>
285<Line1>VA MEDICAL CENTER</Line1>
286<City>ALBANY</City>
287<State>NY</State>
288<PostalCode>12180</PostalCode>
289</Address>
290<Telephone>
291<Value>6655544</Value>
292<Type>
293<Text>Office</Text>
294</Type>
295</Telephone>
296<Source>
297<Actor>
298<ActorID>ACTORSYSTEM_1</ActorID>
299</Actor>
300</Source>
301<InternalCCRLink>
302<LinkID>ACTORORGANIZATION_1</LinkID>
303<LinkRelationship>representedOrganization</LinkRelationship>
304</InternalCCRLink>
305</Actor>
306<Actor>
307<ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
308<Person>
309<Name>
310<CurrentName>
311<Given>NANCY</Given>
312<Family>ANTHRACITE</Family>
313</CurrentName>
314</Name>
315</Person>
316<Specialty>
317<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
318</Specialty>
319<Address>
320<Type>
321<Text>Work</Text>
322</Type>
323<Line1>VA MEDICAL CENTER</Line1>
324<City>ALBANY</City>
325<State>NY</State>
326<PostalCode>12180</PostalCode>
327</Address>
328<Source>
329<Actor>
330<ActorID>ACTORSYSTEM_1</ActorID>
331</Actor>
332</Source>
333<InternalCCRLink>
334<LinkID>ACTORORGANIZATION_1</LinkID>
335<LinkRelationship>representedOrganization</LinkRelationship>
336</InternalCCRLink>
337</Actor>
338<Actor>
339<ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
340<Person>
341<Name>
342<CurrentName>
343<Given>MATTHEW</Given>
344<Middle>M</Middle>
345<Family>KING</Family>
346</CurrentName>
347</Name>
348</Person>
349<Specialty>
350<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
351</Specialty>
352<Address>
353<Type>
354<Text>Work</Text>
355</Type>
356<Line1>VA MEDICAL CENTER</Line1>
357<City>ALBANY</City>
358<State>NY</State>
359<PostalCode>12180</PostalCode>
360</Address>
361<Source>
362<Actor>
363<ActorID>ACTORSYSTEM_1</ActorID>
364</Actor>
365</Source>
366<InternalCCRLink>
367<LinkID>ACTORORGANIZATION_1</LinkID>
368<LinkRelationship>representedOrganization</LinkRelationship>
369</InternalCCRLink>
370</Actor>
371<Actor>
372<ActorObjectID>ACTORPROVIDER_991</ActorObjectID>
373<Person>
374<Name>
375<CurrentName>
376<Given>EIGHT</Given>
377<Family>PROVIDER</Family>
378<Title>Scholar Extraordinaire</Title>
379</CurrentName>
380</Name>
381</Person>
382<Specialty>
383<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
384</Specialty>
385<Address>
386<Type>
387<Text>Work</Text>
388</Type>
389<Line1>VA MEDICAL CENTER</Line1>
390<City>ALBANY</City>
391<State>NY</State>
392<PostalCode>12180</PostalCode>
393</Address>
394<Source>
395<Actor>
396<ActorID>ACTORSYSTEM_1</ActorID>
397</Actor>
398</Source>
399<InternalCCRLink>
400<LinkID>ACTORORGANIZATION_1</LinkID>
401<LinkRelationship>representedOrganization</LinkRelationship>
402</InternalCCRLink>
403</Actor>
404<Actor>
405<ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
406<InformationSystem>
407<Name>WorldVistA EHR/VOE</Name>
408<Version>1.0</Version>
409</InformationSystem>
410<Source>
411<Actor>
412<ActorID>ACTORSYSTEM_1</ActorID>
413</Actor>
414</Source>
415</Actor>
416</Actors>
417<Comments>
418<Comment>
419<CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
420<DateTime>
421<ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
422</DateTime>
423<Source>
424<Actor>
425<ActorID>@@ACTORSOURCEID@@</ActorID>
426</Actor>
427</Source>
428</Comment>
429<Comment>
430<CommentObjectID>NOTE_4093</CommentObjectID>
431<DateTime>
432<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
433</DateTime>
434<Description>
435<Text>
436PATIENT MAMMOGRAM INFORMATION:
437 PATIENT HAD A SCREENING MAMMOGRAM.
438 RESULT NEM (No Evidence of Malignancy)
439 DATE OF PROCEDURE: September 9, 2010
440</Text>
441</Description>
442<Source>
443<Actor>
444<ActorID>ACTORPROVIDER_10000000183</ActorID>
445</Actor>
446</Source>
447</Comment>
448<Comment>
449<CommentObjectID>NOTE_4108</CommentObjectID>
450<DateTime>
451<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
452</DateTime>
453<Description>
454<Text>
455PATIENT HBA1C RESULTS
456 PATIENTS HBA1C IS GREATER THAN 9%
457 HBA1C VALUE: 9.2
458
459 Measurement DT BP PULSE WEIGHT
460 LB(KG)[BMI]
461 10/05/2010 12:52 130/90 89 138(62.60)[23]
462</Text>
463</Description>
464<Source>
465<Actor>
466<ActorID>ACTORPROVIDER_10000000020</ActorID>
467</Actor>
468</Source>
469</Comment>
470</Comments>
471</ContinuityOfCareRecord>
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