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>d998b4a0-d1cc-427d-a1fd-35209e48d626</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>2010-09-20T18:15:09-05:00</ExactDateTime>
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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 | <Result>
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131 | <CCRDataObjectID>RESULT_2</CCRDataObjectID>
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132 | <DateTime>
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133 | <Type>
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134 | <Text>Assessment Time</Text>
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135 | </Type>
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136 | <ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
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137 | </DateTime>
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138 | <Description>
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139 | <Text>Gen Chem Specimen</Text>
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140 | <Code>
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141 | <Value>81323.0000</Value>
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142 | <CodingSystem>99VA64</CodingSystem>
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143 | </Code>
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144 | </Description>
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145 | <Source>
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146 | <Actor>
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147 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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148 | </Actor>
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149 | </Source>
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150 | <Test>
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151 | <CCRDataObjectID>RESULTTEST_2_1</CCRDataObjectID>
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152 | <DateTime>
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153 | <Type>
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154 | <Text>Assessment Time</Text>
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155 | </Type>
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156 | <ExactDateTime>2010-09-16T10:45:00-05:00</ExactDateTime>
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157 | </DateTime>
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158 | <Description>
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159 | <Text>HEMOGLOBIN A1C</Text>
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160 | <Code>
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161 | <Value>CH462</Value>
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162 | <CodingSystem>99VA63</CodingSystem>
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163 | </Code>
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164 | </Description>
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165 | <Status>
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166 | <Text>F</Text>
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167 | </Status>
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168 | <Source>
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169 | <Actor>
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170 | <ActorID>ACTORORGANIZATION_500</ActorID>
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171 | </Actor>
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172 | </Source>
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173 | <TestResult>
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174 | <Value>9.6</Value>
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175 | <Units>
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176 | <Unit>%</Unit>
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177 | </Units>
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178 | </TestResult>
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179 | <NormalResult>
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180 | <Normal>
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181 | <Description>
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182 | <Text>3.5-6</Text>
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183 | </Description>
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184 | <Source>
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185 | <Actor>
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186 | <ActorID>ACTORORGANIZATION_500</ActorID>
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187 | </Actor>
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188 | </Source>
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189 | </Normal>
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190 | </NormalResult>
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191 | <Flag>
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192 | <Text>H</Text>
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193 | </Flag>
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194 | </Test>
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195 | </Result>
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196 | </Results>
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197 | <Procedures>
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198 | <Procedure>
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199 | <CCRDataObjectID>PROCEDURE_4067_7</CCRDataObjectID>
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200 | <DateTime>
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201 | <Type>
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202 | <Text>Procedure Date</Text>
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203 | </Type>
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204 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
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205 | </DateTime>
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206 | <Description>
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207 | <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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208 | <Code>
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209 | <Value>99213</Value>
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210 | <CodingSystem>CPT-4</CodingSystem>
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211 | </Code>
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212 | </Description>
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213 | <Status>
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214 | <Text>Completed</Text>
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215 | </Status>
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216 | <Source>
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217 | <Actor>
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218 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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219 | </Actor>
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220 | </Source>
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221 | </Procedure>
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222 | <Procedure>
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223 | <CCRDataObjectID>PROCEDURE_4066_4</CCRDataObjectID>
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224 | <DateTime>
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225 | <Type>
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226 | <Text>Procedure Date</Text>
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227 | </Type>
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228 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
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229 | </DateTime>
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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 | <Status>
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238 | <Text>Completed</Text>
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239 | </Status>
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240 | <Source>
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241 | <Actor>
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242 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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243 | </Actor>
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244 | </Source>
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245 | </Procedure>
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246 | </Procedures>
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247 | <Encounters>
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248 | <Encounter>
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249 | <CCRDataObjectID>ENCOUNTER_4067</CCRDataObjectID>
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250 | <DateTime>
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251 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
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252 | </DateTime>
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253 | <Type>
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254 | <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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255 | <Code>
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256 | <Value>99213</Value>
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257 | <CodingSystem>CPT-4</CodingSystem>
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258 | </Code>
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259 | </Type>
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260 | <Description>
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261 | <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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262 | <Code>
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263 | <Value>99213</Value>
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264 | <CodingSystem>CPT-4</CodingSystem>
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265 | </Code>
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266 | </Description>
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267 | <Location>
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268 | <Actor>
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269 | <ActorID>ACTORORGANIZATION_1</ActorID>
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270 | </Actor>
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271 | </Location>
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272 | <Practioner>
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273 | <Actor>
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274 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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275 | </Actor>
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276 | </Practioner>
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277 | <Source>
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278 | <Actor>
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279 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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280 | </Actor>
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281 | </Source>
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282 | <CommentID>NOTE_4067</CommentID>
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283 | </Encounter>
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284 | <Encounter>
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285 | <CCRDataObjectID>ENCOUNTER_4066</CCRDataObjectID>
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286 | <DateTime>
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287 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
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288 | </DateTime>
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289 | <Type>
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290 | <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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291 | <Code>
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292 | <Value>99214</Value>
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293 | <CodingSystem>CPT-4</CodingSystem>
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294 | </Code>
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295 | </Type>
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296 | <Description>
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297 | <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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298 | <Code>
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299 | <Value>99214</Value>
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300 | <CodingSystem>CPT-4</CodingSystem>
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301 | </Code>
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302 | </Description>
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303 | <Location>
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304 | <Actor>
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305 | <ActorID>ACTORORGANIZATION_1</ActorID>
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306 | </Actor>
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307 | </Location>
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308 | <Practioner>
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309 | <Actor>
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310 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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311 | </Actor>
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312 | </Practioner>
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313 | <Source>
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314 | <Actor>
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315 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
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316 | </Actor>
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317 | </Source>
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318 | <CommentID>NOTE_4066</CommentID>
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319 | </Encounter>
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320 | </Encounters>
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321 | </Body>
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322 | <Actors>
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323 | <Actor>
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324 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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325 | <Organization>
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326 | <Name>CAMP MASTER</Name>
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327 | </Organization>
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328 | <Address>
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329 | <Type>
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330 | <Text>Office</Text>
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331 | </Type>
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332 | <Line1>VA MEDICAL CENTER</Line1>
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333 | <City>ALBANY</City>
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334 | <State>NEW YORK</State>
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335 | <PostalCode>12180-0097</PostalCode>
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336 | </Address>
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337 | <Source>
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338 | <Actor>
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339 | <ActorID>ACTORSYSTEM_1</ActorID>
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340 | </Actor>
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341 | </Source>
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342 | </Actor>
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343 | <Actor>
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344 | <ActorObjectID>ACTORORGANIZATION_500</ActorObjectID>
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345 | <Organization>
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346 | <Name>CAMP MASTER</Name>
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347 | </Organization>
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348 | <Address>
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349 | <Type>
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350 | <Text>Office</Text>
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351 | </Type>
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352 | <Line1>VA MEDICAL CENTER</Line1>
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353 | <City>ALBANY</City>
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354 | <State>NEW YORK</State>
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355 | <PostalCode>12180-0097</PostalCode>
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356 | </Address>
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357 | <Source>
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358 | <Actor>
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359 | <ActorID>ACTORSYSTEM_1</ActorID>
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360 | </Actor>
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361 | </Source>
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362 | </Actor>
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363 | <Actor>
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364 | <ActorObjectID>ACTORPATIENT_100676</ActorObjectID>
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365 | <Person>
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366 | <Name>
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367 | <CurrentName>
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368 | <Given>OUTPATIENT</Given>
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369 | <Family>SIXTYNINE</Family>
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370 | </CurrentName>
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371 | </Name>
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372 | <DateOfBirth>
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373 | <ExactDateTime>1945-03-09</ExactDateTime>
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374 | </DateOfBirth>
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375 | <Gender>
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376 | <Text>MALE</Text>
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377 | <Code>
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378 | <Value>M</Value>
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379 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
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380 | </Code>
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381 | </Gender>
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382 | </Person>
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383 | <IDs>
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384 | <Type>
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385 | <Text>SSN</Text>
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386 | </Type>
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387 | <ID>666000669</ID>
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---|
388 | <Source>
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---|
389 | <Actor>
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390 | <ActorID>ACTORPATIENT_100676</ActorID>
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391 | </Actor>
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392 | </Source>
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393 | </IDs>
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394 | <Address>
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---|
395 | <Type>
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396 | <Text>Home</Text>
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397 | </Type>
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398 | <Line1>Any Street</Line1>
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399 | <City>Any Town</City>
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400 | </Address>
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---|
401 | <Source>
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402 | <Actor>
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403 | <ActorID>ACTORPATIENT_100676</ActorID>
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404 | </Actor>
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405 | </Source>
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406 | </Actor>
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407 | <Actor>
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408 | <ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
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409 | <Person>
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410 | <Name>
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411 | <CurrentName>
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412 | <Given>SYSTEM</Given>
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413 | <Family>MANAGER</Family>
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414 | </CurrentName>
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415 | </Name>
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---|
416 | </Person>
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---|
417 | <Specialty>
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418 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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419 | </Specialty>
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---|
420 | <Address>
|
---|
421 | <Type>
|
---|
422 | <Text>Work</Text>
|
---|
423 | </Type>
|
---|
424 | <Line1>VA MEDICAL CENTER</Line1>
|
---|
425 | <City>ALBANY</City>
|
---|
426 | <State>NY</State>
|
---|
427 | <PostalCode>12180-0097</PostalCode>
|
---|
428 | </Address>
|
---|
429 | <Source>
|
---|
430 | <Actor>
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431 | <ActorID>ACTORSYSTEM_1</ActorID>
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432 | </Actor>
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433 | </Source>
|
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434 | <InternalCCRLink>
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435 | <LinkID>ACTORORGANIZATION_1</LinkID>
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436 | <LinkRelationship>representedOrganization</LinkRelationship>
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437 | </InternalCCRLink>
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438 | </Actor>
|
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439 | <Actor>
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---|
440 | <ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
|
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441 | <Person>
|
---|
442 | <Name>
|
---|
443 | <CurrentName>
|
---|
444 | <Given>MATTHEW</Given>
|
---|
445 | <Middle>M</Middle>
|
---|
446 | <Family>KING</Family>
|
---|
447 | </CurrentName>
|
---|
448 | </Name>
|
---|
449 | </Person>
|
---|
450 | <Specialty>
|
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451 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
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452 | </Specialty>
|
---|
453 | <Address>
|
---|
454 | <Type>
|
---|
455 | <Text>Work</Text>
|
---|
456 | </Type>
|
---|
457 | <Line1>VA MEDICAL CENTER</Line1>
|
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458 | <City>ALBANY</City>
|
---|
459 | <State>NY</State>
|
---|
460 | <PostalCode>12180-0097</PostalCode>
|
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461 | </Address>
|
---|
462 | <Source>
|
---|
463 | <Actor>
|
---|
464 | <ActorID>ACTORSYSTEM_1</ActorID>
|
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465 | </Actor>
|
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466 | </Source>
|
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467 | <InternalCCRLink>
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468 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
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469 | <LinkRelationship>representedOrganization</LinkRelationship>
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---|
470 | </InternalCCRLink>
|
---|
471 | </Actor>
|
---|
472 | <Actor>
|
---|
473 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
|
---|
474 | <InformationSystem>
|
---|
475 | <Name>WorldVistA EHR/VOE</Name>
|
---|
476 | <Version>1.0</Version>
|
---|
477 | </InformationSystem>
|
---|
478 | <Source>
|
---|
479 | <Actor>
|
---|
480 | <ActorID>ACTORSYSTEM_1</ActorID>
|
---|
481 | </Actor>
|
---|
482 | </Source>
|
---|
483 | </Actor>
|
---|
484 | </Actors>
|
---|
485 | <Comments>
|
---|
486 | <Comment>
|
---|
487 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
|
---|
488 | <DateTime>
|
---|
489 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
|
---|
490 | </DateTime>
|
---|
491 | <Source>
|
---|
492 | <Actor>
|
---|
493 | <ActorID>@@ACTORSOURCEID@@</ActorID>
|
---|
494 | </Actor>
|
---|
495 | </Source>
|
---|
496 | </Comment>
|
---|
497 | <Comment>
|
---|
498 | <CommentObjectID>NOTE_4066</CommentObjectID>
|
---|
499 | <DateTime>
|
---|
500 | <ExactDateTime>2010-09-16T00:00:00-05:00</ExactDateTime>
|
---|
501 | </DateTime>
|
---|
502 | <Description>
|
---|
503 | <Text>
|
---|
504 | TEST FOR NUMERATOR DM HB>9
|
---|
505 | </Text>
|
---|
506 | </Description>
|
---|
507 | <Source>
|
---|
508 | <Actor>
|
---|
509 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
---|
510 | </Actor>
|
---|
511 | </Source>
|
---|
512 | </Comment>
|
---|
513 | <Comment>
|
---|
514 | <CommentObjectID>NOTE_4067</CommentObjectID>
|
---|
515 | <DateTime>
|
---|
516 | <ExactDateTime>2010-09-17T00:00:00-05:00</ExactDateTime>
|
---|
517 | </DateTime>
|
---|
518 | <Description>
|
---|
519 | <Text>
|
---|
520 | DM HBA1C MANAGEMENT:
|
---|
521 | PATIENT HBA1C RESULTS
|
---|
522 | DOCUMENTED HBA1C IS LESS THAN OR EQUAL TO 9%
|
---|
523 | HBA1C VALUE: 9.1
|
---|
524 | PATIENT HAS AN LDL <100.
|
---|
525 | LDL VALUE: 95
|
---|
526 | </Text>
|
---|
527 | </Description>
|
---|
528 | <Source>
|
---|
529 | <Actor>
|
---|
530 | <ActorID>ACTORPROVIDER_10000000183</ActorID>
|
---|
531 | </Actor>
|
---|
532 | </Source>
|
---|
533 | </Comment>
|
---|
534 | </Comments>
|
---|
535 | </ContinuityOfCareRecord>
|
---|