[952] | 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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[953] | 4 | <CCRDocumentObjectID>39c741b2-2a16-4a90-8908-58ef8cfd300b</CCRDocumentObjectID>
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[952] | 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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[953] | 10 | <ExactDateTime>2010-09-20T19:21:02-05:00</ExactDateTime>
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[952] | 11 | </DateTime>
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| 12 | <Patient>
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| 13 | <ActorID>ACTORPATIENT_100676</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_10000000020</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_100676</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>2010-09-16T00:00:00-05:00</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_10000000183</ActorID>
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| 59 | </Actor>
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| 60 | </Source>
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| 61 | </Problem>
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| 62 | </Problems>
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| 63 | <Results>
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| 64 | <Result>
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| 65 | <CCRDataObjectID>RESULT_1</CCRDataObjectID>
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| 66 | <DateTime>
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| 67 | <Type>
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| 68 | <Text>Assessment Time</Text>
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| 69 | </Type>
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| 70 | <ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
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| 71 | </DateTime>
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| 72 | <Description>
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| 73 | <Text>Gen Chem Specimen</Text>
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| 74 | <Code>
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| 75 | <Value>81323.0000</Value>
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| 76 | <CodingSystem>99VA64</CodingSystem>
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| 77 | </Code>
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| 78 | </Description>
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| 79 | <Source>
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| 80 | <Actor>
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| 81 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 82 | </Actor>
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| 83 | </Source>
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| 84 | <Test>
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| 85 | <CCRDataObjectID>RESULTTEST_1_1</CCRDataObjectID>
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| 86 | <DateTime>
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| 87 | <Type>
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| 88 | <Text>Assessment Time</Text>
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| 89 | </Type>
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| 90 | <ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
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| 91 | </DateTime>
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| 92 | <Description>
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| 93 | <Text>HEMOGLOBIN A1C</Text>
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| 94 | <Code>
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| 95 | <Value>CH462</Value>
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| 96 | <CodingSystem>99VA63</CodingSystem>
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| 97 | </Code>
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| 98 | </Description>
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| 99 | <Status>
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| 100 | <Text>F</Text>
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| 101 | </Status>
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| 102 | <Source>
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| 103 | <Actor>
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| 104 | <ActorID>ACTORORGANIZATION_500</ActorID>
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| 105 | </Actor>
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| 106 | </Source>
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| 107 | <TestResult>
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| 108 | <Value>9.6</Value>
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| 109 | <Units>
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| 110 | <Unit>%</Unit>
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| 111 | </Units>
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| 112 | </TestResult>
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| 113 | <NormalResult>
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| 114 | <Normal>
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| 115 | <Description>
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| 116 | <Text>3.5-6</Text>
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| 117 | </Description>
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| 118 | <Source>
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| 119 | <Actor>
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| 120 | <ActorID>ACTORORGANIZATION_500</ActorID>
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| 121 | </Actor>
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| 122 | </Source>
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| 123 | </Normal>
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| 124 | </NormalResult>
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| 125 | <Flag>
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| 126 | <Text>H</Text>
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| 127 | </Flag>
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| 128 | </Test>
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| 129 | </Result>
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| 130 | </Results>
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| 131 | <Procedures>
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| 132 | <Procedure>
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| 133 | <CCRDataObjectID>PROCEDURE_4067_7</CCRDataObjectID>
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| 134 | <DateTime>
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| 135 | <Type>
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| 136 | <Text>Procedure Date</Text>
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| 137 | </Type>
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| 138 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
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| 139 | </DateTime>
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| 140 | <Description>
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| 141 | <Text>Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</Text>
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| 142 | <Code>
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| 143 | <Value>99213</Value>
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| 144 | <CodingSystem>CPT-4</CodingSystem>
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| 145 | </Code>
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| 146 | </Description>
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| 147 | <Status>
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| 148 | <Text>Completed</Text>
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| 149 | </Status>
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| 150 | <Source>
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| 151 | <Actor>
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| 152 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 153 | </Actor>
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| 154 | </Source>
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| 155 | </Procedure>
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| 156 | <Procedure>
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| 157 | <CCRDataObjectID>PROCEDURE_4066_4</CCRDataObjectID>
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| 158 | <DateTime>
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| 159 | <Type>
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| 160 | <Text>Procedure Date</Text>
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| 161 | </Type>
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| 162 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
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| 163 | </DateTime>
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| 164 | <Description>
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| 165 | <Text>Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214)</Text>
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| 166 | <Code>
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| 167 | <Value>99214</Value>
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| 168 | <CodingSystem>CPT-4</CodingSystem>
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| 169 | </Code>
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| 170 | </Description>
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| 171 | <Status>
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| 172 | <Text>Completed</Text>
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| 173 | </Status>
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| 174 | <Source>
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| 175 | <Actor>
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| 176 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 177 | </Actor>
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| 178 | </Source>
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| 179 | </Procedure>
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| 180 | </Procedures>
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| 181 | <Encounters>
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| 182 | <Encounter>
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| 183 | <CCRDataObjectID>ENCOUNTER_4067</CCRDataObjectID>
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| 184 | <DateTime>
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| 185 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
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| 186 | </DateTime>
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| 187 | <Type>
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| 188 | <Text> Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</Text>
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| 189 | <Code>
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| 190 | <Value>99213</Value>
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| 191 | <CodingSystem>CPT-4</CodingSystem>
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| 192 | </Code>
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| 193 | </Type>
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| 194 | <Description>
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| 195 | <Text> Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213)</Text>
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| 196 | <Code>
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| 197 | <Value>99213</Value>
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| 198 | <CodingSystem>CPT-4</CodingSystem>
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| 199 | </Code>
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| 200 | </Description>
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| 201 | <Location>
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| 202 | <Actor>
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| 203 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 204 | </Actor>
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| 205 | </Location>
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| 206 | <Practioner>
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| 207 | <Actor>
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| 208 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 209 | </Actor>
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| 210 | </Practioner>
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| 211 | <Source>
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| 212 | <Actor>
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| 213 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 214 | </Actor>
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| 215 | </Source>
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| 216 | <CommentID>NOTE_4067</CommentID>
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| 217 | </Encounter>
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| 218 | <Encounter>
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| 219 | <CCRDataObjectID>ENCOUNTER_4066</CCRDataObjectID>
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| 220 | <DateTime>
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| 221 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
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| 222 | </DateTime>
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| 223 | <Type>
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| 224 | <Text> Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214)</Text>
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| 225 | <Code>
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| 226 | <Value>99214</Value>
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| 227 | <CodingSystem>CPT-4</CodingSystem>
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| 228 | </Code>
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| 229 | </Type>
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| 230 | <Description>
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| 231 | <Text> Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214)</Text>
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| 232 | <Code>
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| 233 | <Value>99214</Value>
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| 234 | <CodingSystem>CPT-4</CodingSystem>
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| 235 | </Code>
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| 236 | </Description>
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| 237 | <Location>
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| 238 | <Actor>
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| 239 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 240 | </Actor>
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| 241 | </Location>
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| 242 | <Practioner>
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| 243 | <Actor>
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| 244 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 245 | </Actor>
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| 246 | </Practioner>
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| 247 | <Source>
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| 248 | <Actor>
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| 249 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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| 250 | </Actor>
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| 251 | </Source>
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| 252 | <CommentID>NOTE_4066</CommentID>
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| 253 | </Encounter>
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| 254 | </Encounters>
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| 255 | </Body>
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| 256 | <Actors>
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| 257 | <Actor>
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| 258 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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| 259 | <Organization>
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| 260 | <Name>CAMP MASTER</Name>
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| 261 | </Organization>
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| 262 | <Address>
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| 263 | <Type>
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| 264 | <Text>Office</Text>
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| 265 | </Type>
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| 266 | <Line1>VA MEDICAL CENTER</Line1>
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| 267 | <City>ALBANY</City>
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| 268 | <State>NEW YORK</State>
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| 269 | <PostalCode>12180-0097</PostalCode>
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| 270 | </Address>
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| 271 | <Source>
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| 272 | <Actor>
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| 273 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 274 | </Actor>
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| 275 | </Source>
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| 276 | </Actor>
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| 277 | <Actor>
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| 278 | <ActorObjectID>ACTORORGANIZATION_500</ActorObjectID>
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| 279 | <Organization>
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| 280 | <Name>CAMP MASTER</Name>
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| 281 | </Organization>
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| 282 | <Address>
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| 283 | <Type>
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| 284 | <Text>Office</Text>
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| 285 | </Type>
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| 286 | <Line1>VA MEDICAL CENTER</Line1>
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| 287 | <City>ALBANY</City>
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| 288 | <State>NEW YORK</State>
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| 289 | <PostalCode>12180-0097</PostalCode>
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| 290 | </Address>
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| 291 | <Source>
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| 292 | <Actor>
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| 293 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 294 | </Actor>
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| 295 | </Source>
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| 296 | </Actor>
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| 297 | <Actor>
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| 298 | <ActorObjectID>ACTORPATIENT_100676</ActorObjectID>
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| 299 | <Person>
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| 300 | <Name>
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| 301 | <CurrentName>
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| 302 | <Given>OUTPATIENT</Given>
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| 303 | <Family>SIXTYNINE</Family>
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| 304 | </CurrentName>
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| 305 | </Name>
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| 306 | <DateOfBirth>
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| 307 | <ExactDateTime>1945-03-09</ExactDateTime>
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| 308 | </DateOfBirth>
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| 309 | <Gender>
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| 310 | <Text>MALE</Text>
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| 311 | <Code>
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| 312 | <Value>M</Value>
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| 313 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
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| 314 | </Code>
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| 315 | </Gender>
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| 316 | </Person>
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| 317 | <IDs>
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| 318 | <Type>
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| 319 | <Text>SSN</Text>
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| 320 | </Type>
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| 321 | <ID>666000669</ID>
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| 322 | <Source>
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| 323 | <Actor>
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| 324 | <ActorID>ACTORPATIENT_100676</ActorID>
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| 325 | </Actor>
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| 326 | </Source>
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| 327 | </IDs>
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| 328 | <Address>
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| 329 | <Type>
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| 330 | <Text>Home</Text>
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| 331 | </Type>
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| 332 | <Line1>Any Street</Line1>
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| 333 | <City>Any Town</City>
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| 334 | </Address>
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| 335 | <Source>
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| 336 | <Actor>
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| 337 | <ActorID>ACTORPATIENT_100676</ActorID>
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| 338 | </Actor>
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| 339 | </Source>
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| 340 | </Actor>
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| 341 | <Actor>
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| 342 | <ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
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| 343 | <Person>
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| 344 | <Name>
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| 345 | <CurrentName>
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| 346 | <Given>SYSTEM</Given>
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| 347 | <Family>MANAGER</Family>
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| 348 | </CurrentName>
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| 349 | </Name>
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| 350 | </Person>
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| 351 | <Specialty>
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| 352 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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| 353 | </Specialty>
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| 354 | <Address>
|
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| 355 | <Type>
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| 356 | <Text>Work</Text>
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| 357 | </Type>
|
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| 358 | <Line1>VA MEDICAL CENTER</Line1>
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| 359 | <City>ALBANY</City>
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| 360 | <State>NY</State>
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| 361 | <PostalCode>12180-0097</PostalCode>
|
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| 362 | </Address>
|
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| 363 | <Source>
|
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| 364 | <Actor>
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| 365 | <ActorID>ACTORSYSTEM_1</ActorID>
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| 366 | </Actor>
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| 367 | </Source>
|
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| 368 | <InternalCCRLink>
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| 369 | <LinkID>ACTORORGANIZATION_1</LinkID>
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| 370 | <LinkRelationship>representedOrganization</LinkRelationship>
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| 371 | </InternalCCRLink>
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| 372 | </Actor>
|
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| 373 | <Actor>
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| 374 | <ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
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| 375 | <Person>
|
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| 376 | <Name>
|
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| 377 | <CurrentName>
|
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| 378 | <Given>MATTHEW</Given>
|
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| 379 | <Middle>M</Middle>
|
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| 380 | <Family>KING</Family>
|
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| 381 | </CurrentName>
|
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| 382 | </Name>
|
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| 383 | </Person>
|
---|
| 384 | <Specialty>
|
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| 385 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
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| 386 | </Specialty>
|
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| 387 | <Address>
|
---|
| 388 | <Type>
|
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| 389 | <Text>Work</Text>
|
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| 390 | </Type>
|
---|
| 391 | <Line1>VA MEDICAL CENTER</Line1>
|
---|
| 392 | <City>ALBANY</City>
|
---|
| 393 | <State>NY</State>
|
---|
| 394 | <PostalCode>12180-0097</PostalCode>
|
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| 395 | </Address>
|
---|
| 396 | <Source>
|
---|
| 397 | <Actor>
|
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| 398 | <ActorID>ACTORSYSTEM_1</ActorID>
|
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| 399 | </Actor>
|
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| 400 | </Source>
|
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| 401 | <InternalCCRLink>
|
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| 402 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
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| 403 | <LinkRelationship>representedOrganization</LinkRelationship>
|
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| 404 | </InternalCCRLink>
|
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| 405 | </Actor>
|
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| 406 | <Actor>
|
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| 407 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
|
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| 408 | <InformationSystem>
|
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| 409 | <Name>WorldVistA EHR/VOE</Name>
|
---|
| 410 | <Version>1.0</Version>
|
---|
| 411 | </InformationSystem>
|
---|
| 412 | <Source>
|
---|
| 413 | <Actor>
|
---|
| 414 | <ActorID>ACTORSYSTEM_1</ActorID>
|
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| 415 | </Actor>
|
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| 416 | </Source>
|
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| 417 | </Actor>
|
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| 418 | </Actors>
|
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| 419 | <Comments>
|
---|
| 420 | <Comment>
|
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| 421 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
|
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| 422 | <DateTime>
|
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| 423 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
|
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| 424 | </DateTime>
|
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| 425 | <Source>
|
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| 426 | <Actor>
|
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| 427 | <ActorID>@@ACTORSOURCEID@@</ActorID>
|
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| 428 | </Actor>
|
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| 429 | </Source>
|
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| 430 | </Comment>
|
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| 431 | <Comment>
|
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| 432 | <CommentObjectID>NOTE_4066</CommentObjectID>
|
---|
| 433 | <DateTime>
|
---|
| 434 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
|
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| 435 | </DateTime>
|
---|
| 436 | <Description>
|
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| 437 | <Text>
|
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| 438 | TEST FOR NUMERATOR DM HB>9
|
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| 439 | </Text>
|
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| 440 | </Description>
|
---|
| 441 | <Source>
|
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| 442 | <Actor>
|
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| 443 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
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| 444 | </Actor>
|
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| 445 | </Source>
|
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| 446 | </Comment>
|
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| 447 | <Comment>
|
---|
| 448 | <CommentObjectID>NOTE_4067</CommentObjectID>
|
---|
| 449 | <DateTime>
|
---|
| 450 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
|
---|
| 451 | </DateTime>
|
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| 452 | <Description>
|
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| 453 | <Text>
|
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| 454 | DM HBA1C MANAGEMENT:
|
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| 455 | PATIENT HBA1C RESULTS
|
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| 456 | DOCUMENTED HBA1C IS LESS THAN OR EQUAL TO 9%
|
---|
| 457 | HBA1C VALUE: 9.1
|
---|
| 458 | PATIENT HAS AN LDL <100.
|
---|
| 459 | LDL VALUE: 95
|
---|
| 460 | </Text>
|
---|
| 461 | </Description>
|
---|
| 462 | <Source>
|
---|
| 463 | <Actor>
|
---|
| 464 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
---|
| 465 | </Actor>
|
---|
| 466 | </Source>
|
---|
| 467 | </Comment>
|
---|
| 468 | </Comments>
|
---|
| 469 | </ContinuityOfCareRecord>
|
---|