[983] | 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>b315d695-9575-425e-9e78-26475b38323e</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>2010-10-18T15:37:59-05:00</ExactDateTime>
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| 11 | </DateTime>
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| 12 | <Patient>
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| 13 | <ActorID>ACTORPATIENT_100855</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_100855</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>2010-10-14T00:00:00-05:00</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_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>2010-10-14T00:00:00-05:00</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 (ICD-9-CM 250.00)</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_10000000020</ActorID>
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| 83 | </Actor>
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| 84 | </Source>
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| 85 | </Problem>
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| 86 | <Problem>
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| 87 | <CCRDataObjectID>PROBLEM3</CCRDataObjectID>
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| 88 | <DateTime>
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| 89 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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| 90 | </DateTime>
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| 91 | <Type>
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| 92 | <Text>Problem</Text>
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| 93 | </Type>
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| 94 | <Description>
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| 95 | <Text>Diabetes Mellitus without mention of Complication, type II or unspecified type,</Text>
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| 96 | <Code>
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| 97 | <Value>250.00</Value>
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| 98 | <CodingSystem>ICD9CM</CodingSystem>
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| 99 | </Code>
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| 100 | </Description>
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| 101 | <Status>
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| 102 | <Text>Active</Text>
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| 103 | </Status>
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| 104 | <Source>
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| 105 | <Actor>
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| 106 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 107 | </Actor>
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| 108 | </Source>
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| 109 | </Problem>
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| 110 | </Problems>
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| 111 | <Procedures>
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| 112 | <Procedure>
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| 113 | <CCRDataObjectID>PROCEDURE_4127_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>2010-10-14T00:00:00-05:00</ExactDateTime>
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| 119 | </DateTime>
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| 120 | <Description>
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| 121 | <Text>LIMITED (10min)</Text>
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| 122 | <Code>
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| 123 | <Value>99212</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_10000000020</ActorID>
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| 133 | </Actor>
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| 134 | </Source>
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| 135 | </Procedure>
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| 136 | <Procedure>
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| 137 | <CCRDataObjectID>PROCEDURE_4110_4</CCRDataObjectID>
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| 138 | <DateTime>
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| 139 | <Type>
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| 140 | <Text>Procedure Date</Text>
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| 141 | </Type>
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| 142 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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| 143 | </DateTime>
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| 144 | <Description>
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| 145 | <Text>INTERMEDIATE (20min)</Text>
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| 146 | <Code>
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| 147 | <Value>99202</Value>
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| 148 | <CodingSystem>CPT-4</CodingSystem>
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| 149 | </Code>
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| 150 | </Description>
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| 151 | <Status>
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| 152 | <Text>Completed</Text>
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| 153 | </Status>
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| 154 | <Source>
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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 | </Source>
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| 159 | </Procedure>
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| 160 | </Procedures>
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| 161 | <Encounters>
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| 162 | <Encounter>
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| 163 | <CCRDataObjectID>ENCOUNTER_4127</CCRDataObjectID>
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| 164 | <DateTime>
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| 165 | <ExactDateTime>2010-10-14T00:00:00-05:00</ExactDateTime>
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| 166 | </DateTime>
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| 167 | <Type>
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| 168 | <Text>***ESTABLISHED PATIENT*** LIMITED (10min)</Text>
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| 169 | <Code>
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| 170 | <Value>99212</Value>
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| 171 | <CodingSystem>CPT-4</CodingSystem>
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| 172 | </Code>
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| 173 | </Type>
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| 174 | <Description>
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| 175 | <Text>***ESTABLISHED PATIENT*** LIMITED (10min)</Text>
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| 176 | <Code>
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| 177 | <Value>99212</Value>
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| 178 | <CodingSystem>CPT-4</CodingSystem>
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| 179 | </Code>
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| 180 | </Description>
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| 181 | <Location>
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| 182 | <Actor>
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| 183 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 184 | </Actor>
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| 185 | </Location>
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| 186 | <Practioner>
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| 187 | <Actor>
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| 188 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 189 | </Actor>
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| 190 | </Practioner>
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| 191 | <Source>
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| 192 | <Actor>
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| 193 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 194 | </Actor>
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| 195 | </Source>
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| 196 | <CommentID>NOTE_4127</CommentID>
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| 197 | </Encounter>
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| 198 | <Encounter>
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| 199 | <CCRDataObjectID>ENCOUNTER_4110</CCRDataObjectID>
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| 200 | <DateTime>
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| 201 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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| 202 | </DateTime>
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| 203 | <Type>
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| 204 | <Text>***NEW PATIENT*** INTERMEDIATE (20min)</Text>
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| 205 | <Code>
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| 206 | <Value>99202</Value>
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| 207 | <CodingSystem>CPT-4</CodingSystem>
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| 208 | </Code>
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| 209 | </Type>
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| 210 | <Description>
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| 211 | <Text>***NEW PATIENT*** INTERMEDIATE (20min)</Text>
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| 212 | <Code>
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| 213 | <Value>99202</Value>
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| 214 | <CodingSystem>CPT-4</CodingSystem>
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| 215 | </Code>
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| 216 | </Description>
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| 217 | <Location>
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| 218 | <Actor>
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| 219 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 220 | </Actor>
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| 221 | </Location>
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| 222 | <Practioner>
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| 223 | <Actor>
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| 224 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 225 | </Actor>
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| 226 | </Practioner>
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| 227 | <Source>
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| 228 | <Actor>
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| 229 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 230 | </Actor>
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| 231 | </Source>
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| 232 | <CommentID>NOTE_4110</CommentID>
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| 233 | </Encounter>
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| 234 | </Encounters>
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| 235 | </Body>
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| 236 | <Actors>
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| 237 | <Actor>
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| 238 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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| 239 | <Organization>
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| 240 | <Name>CAMP MASTER</Name>
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| 241 | </Organization>
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| 242 | <Address>
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| 243 | <Type>
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| 244 | <Text>Office</Text>
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| 245 | </Type>
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| 246 | <Line1>VA MEDICAL CENTER</Line1>
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| 247 | <City>ALBANY</City>
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| 248 | <State>NEW YORK</State>
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| 249 | <PostalCode>12180</PostalCode>
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| 250 | </Address>
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| 251 | <Source>
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| 252 | <Actor>
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| 253 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 254 | </Actor>
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| 255 | </Source>
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| 256 | </Actor>
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| 257 | <Actor>
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| 258 | <ActorObjectID>ACTORPATIENT_100855</ActorObjectID>
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| 259 | <Person>
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| 260 | <Name>
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| 261 | <CurrentName>
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| 262 | <Given>FEMALE-E</Given>
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| 263 | <Family>MEASURE-ONE</Family>
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| 264 | </CurrentName>
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| 265 | </Name>
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| 266 | <DateOfBirth>
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| 267 | <ExactDateTime>1960-01-01</ExactDateTime>
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| 268 | </DateOfBirth>
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| 269 | <Gender>
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| 270 | <Text>FEMALE</Text>
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| 271 | <Code>
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| 272 | <Value>F</Value>
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| 273 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
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| 274 | </Code>
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| 275 | </Gender>
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| 276 | </Person>
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| 277 | <IDs>
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| 278 | <Type>
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| 279 | <Text>SSN</Text>
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| 280 | </Type>
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| 281 | <ID>498212298</ID>
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| 282 | <Source>
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| 283 | <Actor>
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| 284 | <ActorID>ACTORPATIENT_100855</ActorID>
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| 285 | </Actor>
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| 286 | </Source>
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| 287 | </IDs>
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| 288 | <Address>
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| 289 | <Type>
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| 290 | <Text>Home</Text>
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| 291 | </Type>
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| 292 | </Address>
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| 293 | <Source>
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| 294 | <Actor>
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| 295 | <ActorID>ACTORPATIENT_100855</ActorID>
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| 296 | </Actor>
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| 297 | </Source>
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| 298 | </Actor>
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| 299 | <Actor>
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| 300 | <ActorObjectID>ACTORPROVIDER_1</ActorObjectID>
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| 301 | <Person>
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| 302 | <Name>
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| 303 | <CurrentName>
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| 304 | <Given>ONE</Given>
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| 305 | <Family>PROGRAMMER</Family>
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| 306 | <Title>COMPUTER SPECIALIST</Title>
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| 307 | </CurrentName>
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| 308 | </Name>
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| 309 | </Person>
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| 310 | <Specialty>
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| 311 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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| 312 | </Specialty>
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| 313 | <Address>
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| 314 | <Type>
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| 315 | <Text>Work</Text>
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| 316 | </Type>
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| 317 | <Line1>VA MEDICAL CENTER</Line1>
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| 318 | <City>ALBANY</City>
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| 319 | <State>NY</State>
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| 320 | <PostalCode>12180</PostalCode>
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| 321 | </Address>
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| 322 | <Telephone>
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| 323 | <Value>6655544</Value>
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| 324 | <Type>
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| 325 | <Text>Office</Text>
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| 326 | </Type>
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| 327 | </Telephone>
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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_10000000020</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>NANCY</Given>
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| 344 | <Family>ANTHRACITE</Family>
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| 345 | </CurrentName>
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| 346 | </Name>
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| 347 | </Person>
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| 348 | <Specialty>
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| 349 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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| 350 | </Specialty>
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| 351 | <Address>
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| 352 | <Type>
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| 353 | <Text>Work</Text>
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| 354 | </Type>
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| 355 | <Line1>VA MEDICAL CENTER</Line1>
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| 356 | <City>ALBANY</City>
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| 357 | <State>NY</State>
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| 358 | <PostalCode>12180</PostalCode>
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| 359 | </Address>
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| 360 | <Source>
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| 361 | <Actor>
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| 362 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 363 | </Actor>
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| 364 | </Source>
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| 365 | <InternalCCRLink>
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| 366 | <LinkID>ACTORORGANIZATION_1</LinkID>
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| 367 | <LinkRelationship>representedOrganization</LinkRelationship>
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| 368 | </InternalCCRLink>
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| 369 | </Actor>
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| 370 | <Actor>
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| 371 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
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| 372 | <InformationSystem>
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| 373 | <Name>WorldVistA EHR/VOE</Name>
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| 374 | <Version>1.0</Version>
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| 375 | </InformationSystem>
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| 376 | <Source>
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| 377 | <Actor>
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| 378 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 379 | </Actor>
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| 380 | </Source>
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| 381 | </Actor>
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| 382 | </Actors>
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| 383 | <Comments>
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| 384 | <Comment>
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| 385 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
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| 386 | <DateTime>
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| 387 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
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| 388 | </DateTime>
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| 389 | <Source>
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| 390 | <Actor>
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| 391 | <ActorID>@@ACTORSOURCEID@@</ActorID>
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| 392 | </Actor>
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| 393 | </Source>
|
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| 394 | </Comment>
|
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| 395 | <Comment>
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| 396 | <CommentObjectID>NOTE_4110</CommentObjectID>
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| 397 | <DateTime>
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| 398 | <ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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| 399 | </DateTime>
|
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| 400 | <Description>
|
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| 401 | <Text>
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| 402 | PATIENT HBA1C RESULTS
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| 403 | PATIENTS HBA1C IS GREATER THAN 9%
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| 404 | HBA1C VALUE: 9.3
|
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| 405 | *** No Outpatient measurements ***
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| 406 | </Text>
|
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| 407 | </Description>
|
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| 408 | <Source>
|
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| 409 | <Actor>
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| 410 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 411 | </Actor>
|
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| 412 | </Source>
|
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| 413 | </Comment>
|
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| 414 | <Comment>
|
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| 415 | <CommentObjectID>NOTE_4127</CommentObjectID>
|
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| 416 | <DateTime>
|
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| 417 | <ExactDateTime>2010-10-14T00:00:00-05:00</ExactDateTime>
|
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| 418 | </DateTime>
|
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| 419 | <Description>
|
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| 420 | <Text>
|
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| 421 | PATIENT HBA1C RESULTS
|
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| 422 | PATIENTS HBA1C IS GREATER THAN 9%
|
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| 423 | HBA1C VALUE: 9.1
|
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| 424 | *** No Outpatient measurements ***
|
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| 425 | </Text>
|
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| 426 | </Description>
|
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| 427 | <Source>
|
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| 428 | <Actor>
|
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| 429 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 430 | </Actor>
|
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| 431 | </Source>
|
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| 432 | </Comment>
|
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| 433 | </Comments>
|
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| 434 | </ContinuityOfCareRecord>
|
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