source: qrda/CCR/NQF-59-cohorts/PAT_100676_CCR_V1_0_0.xml@ 1482

Last change on this file since 1482 was 953, checked in by George Lilly, 14 years ago

re-extracted and the lab result is only reported once - operator error
File size: 9.4 KB
Line 
1<?xml version="1.0" encoding="UTF-8"?>
2<?xml-stylesheet type="text/xsl" href="ccr.xsl"?>
3<ContinuityOfCareRecord xmlns="urn:astm-org:CCR">
4<CCRDocumentObjectID>39c741b2-2a16-4a90-8908-58ef8cfd300b</CCRDocumentObjectID>
5<Language>
6<Text>English</Text>
7</Language>
8<Version>V1.0</Version>
9<DateTime>
10<ExactDateTime>2010-09-20T19:21:02-05:00</ExactDateTime>
11</DateTime>
12<Patient>
13<ActorID>ACTORPATIENT_100676</ActorID>
14</Patient>
15<From>
16<ActorLink>
17<ActorID>ACTORPROVIDER_10000000020</ActorID>
18</ActorLink>
19<ActorLink>
20<ActorID>ACTORSYSTEM_1</ActorID>
21</ActorLink>
22</From>
23<To>
24<ActorLink>
25<ActorID>ACTORPATIENT_100676</ActorID>
26<ActorRole>
27<Text>Patient</Text>
28</ActorRole>
29</ActorLink>
30</To>
31<Purpose>
32<Description>
33<Text>CEND PHR</Text>
34</Description>
35</Purpose>
36<Body>
37<Problems>
38<Problem>
39<CCRDataObjectID>PROBLEM1</CCRDataObjectID>
40<DateTime>
41<ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
42</DateTime>
43<Type>
44<Text>Problem</Text>
45</Type>
46<Description>
47<Text>Diabetes Mellitus without mention of Complication, type II or unspecified type,</Text>
48<Code>
49<Value>250.00</Value>
50<CodingSystem>ICD9CM</CodingSystem>
51</Code>
52</Description>
53<Status>
54<Text>Active</Text>
55</Status>
56<Source>
57<Actor>
58<ActorID>ACTORPROVIDER_10000000183</ActorID>
59</Actor>
60</Source>
61</Problem>
62</Problems>
63<Results>
64<Result>
65<CCRDataObjectID>RESULT_1</CCRDataObjectID>
66<DateTime>
67<Type>
68<Text>Assessment Time</Text>
69</Type>
70<ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
71</DateTime>
72<Description>
73<Text>Gen Chem Specimen</Text>
74<Code>
75<Value>81323.0000</Value>
76<CodingSystem>99VA64</CodingSystem>
77</Code>
78</Description>
79<Source>
80<Actor>
81<ActorID>ACTORPROVIDER_10000000183</ActorID>
82</Actor>
83</Source>
84<Test>
85<CCRDataObjectID>RESULTTEST_1_1</CCRDataObjectID>
86<DateTime>
87<Type>
88<Text>Assessment Time</Text>
89</Type>
90<ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
91</DateTime>
92<Description>
93<Text>HEMOGLOBIN A1C</Text>
94<Code>
95<Value>CH462</Value>
96<CodingSystem>99VA63</CodingSystem>
97</Code>
98</Description>
99<Status>
100<Text>F</Text>
101</Status>
102<Source>
103<Actor>
104<ActorID>ACTORORGANIZATION_500</ActorID>
105</Actor>
106</Source>
107<TestResult>
108<Value>9.6</Value>
109<Units>
110<Unit>%</Unit>
111</Units>
112</TestResult>
113<NormalResult>
114<Normal>
115<Description>
116<Text>3.5-6</Text>
117</Description>
118<Source>
119<Actor>
120<ActorID>ACTORORGANIZATION_500</ActorID>
121</Actor>
122</Source>
123</Normal>
124</NormalResult>
125<Flag>
126<Text>H</Text>
127</Flag>
128</Test>
129</Result>
130</Results>
131<Procedures>
132<Procedure>
133<CCRDataObjectID>PROCEDURE_4067_7</CCRDataObjectID>
134<DateTime>
135<Type>
136<Text>Procedure Date</Text>
137</Type>
138<ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
139</DateTime>
140<Description>
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>
142<Code>
143<Value>99213</Value>
144<CodingSystem>CPT-4</CodingSystem>
145</Code>
146</Description>
147<Status>
148<Text>Completed</Text>
149</Status>
150<Source>
151<Actor>
152<ActorID>ACTORPROVIDER_10000000183</ActorID>
153</Actor>
154</Source>
155</Procedure>
156<Procedure>
157<CCRDataObjectID>PROCEDURE_4066_4</CCRDataObjectID>
158<DateTime>
159<Type>
160<Text>Procedure Date</Text>
161</Type>
162<ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
163</DateTime>
164<Description>
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>
166<Code>
167<Value>99214</Value>
168<CodingSystem>CPT-4</CodingSystem>
169</Code>
170</Description>
171<Status>
172<Text>Completed</Text>
173</Status>
174<Source>
175<Actor>
176<ActorID>ACTORPROVIDER_10000000183</ActorID>
177</Actor>
178</Source>
179</Procedure>
180</Procedures>
181<Encounters>
182<Encounter>
183<CCRDataObjectID>ENCOUNTER_4067</CCRDataObjectID>
184<DateTime>
185<ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
186</DateTime>
187<Type>
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>
189<Code>
190<Value>99213</Value>
191<CodingSystem>CPT-4</CodingSystem>
192</Code>
193</Type>
194<Description>
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>
196<Code>
197<Value>99213</Value>
198<CodingSystem>CPT-4</CodingSystem>
199</Code>
200</Description>
201<Location>
202<Actor>
203<ActorID>ACTORORGANIZATION_1</ActorID>
204</Actor>
205</Location>
206<Practioner>
207<Actor>
208<ActorID>ACTORPROVIDER_10000000183</ActorID>
209</Actor>
210</Practioner>
211<Source>
212<Actor>
213<ActorID>ACTORPROVIDER_10000000183</ActorID>
214</Actor>
215</Source>
216<CommentID>NOTE_4067</CommentID>
217</Encounter>
218<Encounter>
219<CCRDataObjectID>ENCOUNTER_4066</CCRDataObjectID>
220<DateTime>
221<ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
222</DateTime>
223<Type>
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>
225<Code>
226<Value>99214</Value>
227<CodingSystem>CPT-4</CodingSystem>
228</Code>
229</Type>
230<Description>
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>
232<Code>
233<Value>99214</Value>
234<CodingSystem>CPT-4</CodingSystem>
235</Code>
236</Description>
237<Location>
238<Actor>
239<ActorID>ACTORORGANIZATION_1</ActorID>
240</Actor>
241</Location>
242<Practioner>
243<Actor>
244<ActorID>ACTORPROVIDER_10000000183</ActorID>
245</Actor>
246</Practioner>
247<Source>
248<Actor>
249<ActorID>ACTORPROVIDER_10000000183</ActorID>
250</Actor>
251</Source>
252<CommentID>NOTE_4066</CommentID>
253</Encounter>
254</Encounters>
255</Body>
256<Actors>
257<Actor>
258<ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
259<Organization>
260<Name>CAMP MASTER</Name>
261</Organization>
262<Address>
263<Type>
264<Text>Office</Text>
265</Type>
266<Line1>VA MEDICAL CENTER</Line1>
267<City>ALBANY</City>
268<State>NEW YORK</State>
269<PostalCode>12180-0097</PostalCode>
270</Address>
271<Source>
272<Actor>
273<ActorID>ACTORSYSTEM_1</ActorID>
274</Actor>
275</Source>
276</Actor>
277<Actor>
278<ActorObjectID>ACTORORGANIZATION_500</ActorObjectID>
279<Organization>
280<Name>CAMP MASTER</Name>
281</Organization>
282<Address>
283<Type>
284<Text>Office</Text>
285</Type>
286<Line1>VA MEDICAL CENTER</Line1>
287<City>ALBANY</City>
288<State>NEW YORK</State>
289<PostalCode>12180-0097</PostalCode>
290</Address>
291<Source>
292<Actor>
293<ActorID>ACTORSYSTEM_1</ActorID>
294</Actor>
295</Source>
296</Actor>
297<Actor>
298<ActorObjectID>ACTORPATIENT_100676</ActorObjectID>
299<Person>
300<Name>
301<CurrentName>
302<Given>OUTPATIENT</Given>
303<Family>SIXTYNINE</Family>
304</CurrentName>
305</Name>
306<DateOfBirth>
307<ExactDateTime>1945-03-09</ExactDateTime>
308</DateOfBirth>
309<Gender>
310<Text>MALE</Text>
311<Code>
312<Value>M</Value>
313<CodingSystem>HL7 AdministrativeGender</CodingSystem>
314</Code>
315</Gender>
316</Person>
317<IDs>
318<Type>
319<Text>SSN</Text>
320</Type>
321<ID>666000669</ID>
322<Source>
323<Actor>
324<ActorID>ACTORPATIENT_100676</ActorID>
325</Actor>
326</Source>
327</IDs>
328<Address>
329<Type>
330<Text>Home</Text>
331</Type>
332<Line1>Any Street</Line1>
333<City>Any Town</City>
334</Address>
335<Source>
336<Actor>
337<ActorID>ACTORPATIENT_100676</ActorID>
338</Actor>
339</Source>
340</Actor>
341<Actor>
342<ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
343<Person>
344<Name>
345<CurrentName>
346<Given>SYSTEM</Given>
347<Family>MANAGER</Family>
348</CurrentName>
349</Name>
350</Person>
351<Specialty>
352<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
353</Specialty>
354<Address>
355<Type>
356<Text>Work</Text>
357</Type>
358<Line1>VA MEDICAL CENTER</Line1>
359<City>ALBANY</City>
360<State>NY</State>
361<PostalCode>12180-0097</PostalCode>
362</Address>
363<Source>
364<Actor>
365<ActorID>ACTORSYSTEM_1</ActorID>
366</Actor>
367</Source>
368<InternalCCRLink>
369<LinkID>ACTORORGANIZATION_1</LinkID>
370<LinkRelationship>representedOrganization</LinkRelationship>
371</InternalCCRLink>
372</Actor>
373<Actor>
374<ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
375<Person>
376<Name>
377<CurrentName>
378<Given>MATTHEW</Given>
379<Middle>M</Middle>
380<Family>KING</Family>
381</CurrentName>
382</Name>
383</Person>
384<Specialty>
385<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
386</Specialty>
387<Address>
388<Type>
389<Text>Work</Text>
390</Type>
391<Line1>VA MEDICAL CENTER</Line1>
392<City>ALBANY</City>
393<State>NY</State>
394<PostalCode>12180-0097</PostalCode>
395</Address>
396<Source>
397<Actor>
398<ActorID>ACTORSYSTEM_1</ActorID>
399</Actor>
400</Source>
401<InternalCCRLink>
402<LinkID>ACTORORGANIZATION_1</LinkID>
403<LinkRelationship>representedOrganization</LinkRelationship>
404</InternalCCRLink>
405</Actor>
406<Actor>
407<ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
408<InformationSystem>
409<Name>WorldVistA EHR/VOE</Name>
410<Version>1.0</Version>
411</InformationSystem>
412<Source>
413<Actor>
414<ActorID>ACTORSYSTEM_1</ActorID>
415</Actor>
416</Source>
417</Actor>
418</Actors>
419<Comments>
420<Comment>
421<CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
422<DateTime>
423<ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
424</DateTime>
425<Source>
426<Actor>
427<ActorID>@@ACTORSOURCEID@@</ActorID>
428</Actor>
429</Source>
430</Comment>
431<Comment>
432<CommentObjectID>NOTE_4066</CommentObjectID>
433<DateTime>
434<ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
435</DateTime>
436<Description>
437<Text>
438TEST FOR NUMERATOR DM HB&gt;9
439</Text>
440</Description>
441<Source>
442<Actor>
443<ActorID>ACTORPROVIDER_10000000183</ActorID>
444</Actor>
445</Source>
446</Comment>
447<Comment>
448<CommentObjectID>NOTE_4067</CommentObjectID>
449<DateTime>
450<ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
451</DateTime>
452<Description>
453<Text>
454 DM HBA1C MANAGEMENT:
455 PATIENT HBA1C RESULTS
456 DOCUMENTED HBA1C IS LESS THAN OR EQUAL TO 9%
457 HBA1C VALUE: 9.1
458 PATIENT HAS AN LDL &lt;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>
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