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>33f5b05b-e101-4530-9b91-97203c8b71e6</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>2010-10-18T15:37:06-05:00</ExactDateTime>
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11 | </DateTime>
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12 | <Patient>
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13 | <ActorID>ACTORPATIENT_100848</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_100848</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>250.00</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_991</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>2010-10-05T00:00:00-05:00</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>Sprains (ICD-9-CM 848.9)</Text>
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72 | <Code>
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73 | <Value>848.9</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_4108_8</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>2010-10-13T00:00:00-05:00</ExactDateTime>
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95 | </DateTime>
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96 | <Description>
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97 | <Text>Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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98 | <Code>
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99 | <Value>84295</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_4093_5</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>2010-10-05T00:00:00-05:00</ExactDateTime>
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119 | </DateTime>
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120 | <Description>
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121 | <Text>INTERMEDIATE (15min)</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_4108</CCRDataObjectID>
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140 | <DateTime>
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141 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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142 | </DateTime>
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143 | <Type>
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144 | <Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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145 | </Type>
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146 | <Description>
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147 | <Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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148 | </Description>
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149 | <Location>
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150 | <Actor>
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151 | <ActorID>ACTORORGANIZATION_1</ActorID>
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152 | </Actor>
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153 | </Location>
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154 | <Practioner>
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155 | <Actor>
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156 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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157 | </Actor>
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158 | </Practioner>
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159 | <Source>
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160 | <Actor>
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161 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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162 | </Actor>
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163 | </Source>
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164 | <CommentID>NOTE_4108</CommentID>
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165 | </Encounter>
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166 | <Encounter>
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167 | <CCRDataObjectID>ENCOUNTER_4093</CCRDataObjectID>
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168 | <DateTime>
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169 | <ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
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170 | </DateTime>
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171 | <Type>
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172 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
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173 | <Code>
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174 | <Value>99213</Value>
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175 | <CodingSystem>CPT-4</CodingSystem>
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176 | </Code>
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177 | </Type>
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178 | <Description>
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179 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</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 | </Description>
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185 | <Location>
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186 | <Actor>
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187 | <ActorID>ACTORORGANIZATION_1</ActorID>
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188 | </Actor>
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189 | </Location>
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190 | <Practioner>
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191 | <Actor>
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192 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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193 | </Actor>
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194 | </Practioner>
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195 | <Source>
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196 | <Actor>
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197 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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198 | </Actor>
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199 | </Source>
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200 | <CommentID>NOTE_4093</CommentID>
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201 | </Encounter>
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202 | </Encounters>
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203 | </Body>
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204 | <Actors>
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205 | <Actor>
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206 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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207 | <Organization>
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208 | <Name>CAMP MASTER</Name>
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209 | </Organization>
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210 | <Address>
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211 | <Type>
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212 | <Text>Office</Text>
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213 | </Type>
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214 | <Line1>VA MEDICAL CENTER</Line1>
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215 | <City>ALBANY</City>
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216 | <State>NEW YORK</State>
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217 | <PostalCode>12180</PostalCode>
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218 | </Address>
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219 | <Source>
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220 | <Actor>
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221 | <ActorID>ACTORSYSTEM_1</ActorID>
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222 | </Actor>
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223 | </Source>
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224 | </Actor>
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225 | <Actor>
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226 | <ActorObjectID>ACTORPATIENT_100848</ActorObjectID>
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227 | <Person>
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228 | <Name>
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229 | <CurrentName>
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230 | <Given>FEMALE-B</Given>
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231 | <Family>MEASURE-ONE</Family>
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232 | </CurrentName>
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233 | </Name>
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234 | <DateOfBirth>
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235 | <ExactDateTime>1960-01-01</ExactDateTime>
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236 | </DateOfBirth>
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237 | <Gender>
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238 | <Text>FEMALE</Text>
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239 | <Code>
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240 | <Value>F</Value>
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241 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
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242 | </Code>
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243 | </Gender>
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244 | </Person>
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245 | <IDs>
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246 | <Type>
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247 | <Text>SSN</Text>
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248 | </Type>
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249 | <ID>345097898</ID>
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250 | <Source>
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251 | <Actor>
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252 | <ActorID>ACTORPATIENT_100848</ActorID>
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253 | </Actor>
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254 | </Source>
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255 | </IDs>
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256 | <Address>
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257 | <Type>
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258 | <Text>Home</Text>
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259 | </Type>
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260 | </Address>
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261 | <Source>
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262 | <Actor>
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263 | <ActorID>ACTORPATIENT_100848</ActorID>
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264 | </Actor>
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265 | </Source>
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266 | </Actor>
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267 | <Actor>
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268 | <ActorObjectID>ACTORPROVIDER_1</ActorObjectID>
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269 | <Person>
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270 | <Name>
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271 | <CurrentName>
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272 | <Given>ONE</Given>
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273 | <Family>PROGRAMMER</Family>
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274 | <Title>COMPUTER SPECIALIST</Title>
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275 | </CurrentName>
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276 | </Name>
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277 | </Person>
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278 | <Specialty>
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279 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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280 | </Specialty>
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281 | <Address>
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282 | <Type>
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283 | <Text>Work</Text>
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284 | </Type>
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285 | <Line1>VA MEDICAL CENTER</Line1>
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286 | <City>ALBANY</City>
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287 | <State>NY</State>
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288 | <PostalCode>12180</PostalCode>
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289 | </Address>
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290 | <Telephone>
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291 | <Value>6655544</Value>
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292 | <Type>
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293 | <Text>Office</Text>
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294 | </Type>
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295 | </Telephone>
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296 | <Source>
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297 | <Actor>
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298 | <ActorID>ACTORSYSTEM_1</ActorID>
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299 | </Actor>
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300 | </Source>
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301 | <InternalCCRLink>
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302 | <LinkID>ACTORORGANIZATION_1</LinkID>
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303 | <LinkRelationship>representedOrganization</LinkRelationship>
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304 | </InternalCCRLink>
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305 | </Actor>
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306 | <Actor>
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307 | <ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
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308 | <Person>
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309 | <Name>
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310 | <CurrentName>
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311 | <Given>NANCY</Given>
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312 | <Family>ANTHRACITE</Family>
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313 | </CurrentName>
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314 | </Name>
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315 | </Person>
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316 | <Specialty>
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317 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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318 | </Specialty>
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319 | <Address>
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320 | <Type>
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321 | <Text>Work</Text>
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322 | </Type>
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323 | <Line1>VA MEDICAL CENTER</Line1>
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324 | <City>ALBANY</City>
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325 | <State>NY</State>
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326 | <PostalCode>12180</PostalCode>
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327 | </Address>
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328 | <Source>
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329 | <Actor>
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330 | <ActorID>ACTORSYSTEM_1</ActorID>
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331 | </Actor>
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332 | </Source>
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333 | <InternalCCRLink>
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334 | <LinkID>ACTORORGANIZATION_1</LinkID>
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335 | <LinkRelationship>representedOrganization</LinkRelationship>
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336 | </InternalCCRLink>
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337 | </Actor>
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338 | <Actor>
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339 | <ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
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340 | <Person>
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341 | <Name>
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342 | <CurrentName>
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343 | <Given>MATTHEW</Given>
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344 | <Middle>M</Middle>
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345 | <Family>KING</Family>
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346 | </CurrentName>
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347 | </Name>
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348 | </Person>
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349 | <Specialty>
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350 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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351 | </Specialty>
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352 | <Address>
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353 | <Type>
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354 | <Text>Work</Text>
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355 | </Type>
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356 | <Line1>VA MEDICAL CENTER</Line1>
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357 | <City>ALBANY</City>
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358 | <State>NY</State>
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359 | <PostalCode>12180</PostalCode>
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360 | </Address>
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361 | <Source>
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362 | <Actor>
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363 | <ActorID>ACTORSYSTEM_1</ActorID>
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364 | </Actor>
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365 | </Source>
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366 | <InternalCCRLink>
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367 | <LinkID>ACTORORGANIZATION_1</LinkID>
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368 | <LinkRelationship>representedOrganization</LinkRelationship>
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369 | </InternalCCRLink>
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370 | </Actor>
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371 | <Actor>
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372 | <ActorObjectID>ACTORPROVIDER_991</ActorObjectID>
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373 | <Person>
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374 | <Name>
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375 | <CurrentName>
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376 | <Given>EIGHT</Given>
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377 | <Family>PROVIDER</Family>
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378 | <Title>Scholar Extraordinaire</Title>
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379 | </CurrentName>
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380 | </Name>
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381 | </Person>
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382 | <Specialty>
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383 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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384 | </Specialty>
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385 | <Address>
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386 | <Type>
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387 | <Text>Work</Text>
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388 | </Type>
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389 | <Line1>VA MEDICAL CENTER</Line1>
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390 | <City>ALBANY</City>
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391 | <State>NY</State>
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392 | <PostalCode>12180</PostalCode>
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393 | </Address>
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394 | <Source>
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395 | <Actor>
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396 | <ActorID>ACTORSYSTEM_1</ActorID>
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397 | </Actor>
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398 | </Source>
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399 | <InternalCCRLink>
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400 | <LinkID>ACTORORGANIZATION_1</LinkID>
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401 | <LinkRelationship>representedOrganization</LinkRelationship>
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402 | </InternalCCRLink>
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403 | </Actor>
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404 | <Actor>
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405 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
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406 | <InformationSystem>
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407 | <Name>WorldVistA EHR/VOE</Name>
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408 | <Version>1.0</Version>
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409 | </InformationSystem>
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410 | <Source>
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411 | <Actor>
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412 | <ActorID>ACTORSYSTEM_1</ActorID>
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413 | </Actor>
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414 | </Source>
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415 | </Actor>
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416 | </Actors>
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417 | <Comments>
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418 | <Comment>
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419 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
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420 | <DateTime>
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421 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
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422 | </DateTime>
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---|
423 | <Source>
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---|
424 | <Actor>
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425 | <ActorID>@@ACTORSOURCEID@@</ActorID>
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426 | </Actor>
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427 | </Source>
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428 | </Comment>
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429 | <Comment>
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430 | <CommentObjectID>NOTE_4093</CommentObjectID>
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431 | <DateTime>
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432 | <ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
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433 | </DateTime>
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434 | <Description>
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435 | <Text>
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436 | PATIENT MAMMOGRAM INFORMATION:
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437 | PATIENT HAD A SCREENING MAMMOGRAM.
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438 | RESULT NEM (No Evidence of Malignancy)
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439 | DATE OF PROCEDURE: September 9, 2010
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440 | </Text>
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441 | </Description>
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442 | <Source>
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443 | <Actor>
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444 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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445 | </Actor>
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446 | </Source>
|
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447 | </Comment>
|
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448 | <Comment>
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449 | <CommentObjectID>NOTE_4108</CommentObjectID>
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450 | <DateTime>
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451 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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452 | </DateTime>
|
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453 | <Description>
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454 | <Text>
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455 | PATIENT HBA1C RESULTS
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456 | PATIENTS HBA1C IS GREATER THAN 9%
|
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457 | HBA1C VALUE: 9.2
|
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458 |
|
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459 | Measurement DT BP PULSE WEIGHT
|
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460 | LB(KG)[BMI]
|
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461 | 10/05/2010 12:52 130/90 89 138(62.60)[23]
|
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462 | </Text>
|
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463 | </Description>
|
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464 | <Source>
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465 | <Actor>
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466 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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467 | </Actor>
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468 | </Source>
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469 | </Comment>
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470 | </Comments>
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471 | </ContinuityOfCareRecord>
|
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