[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>
|
---|
| 436 | PATIENT 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>
|
---|
| 455 | PATIENT 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>
|
---|