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>7c24c1e0-f73d-4160-9421-5f8b6cf8c7ea</CCRDocumentObjectID>
|
---|
5 | <Language>
|
---|
6 | <Text>English</Text>
|
---|
7 | </Language>
|
---|
8 | <Version>V1.0</Version>
|
---|
9 | <DateTime>
|
---|
10 | <ExactDateTime>2010-09-13T16:17:26-05:00</ExactDateTime>
|
---|
11 | </DateTime>
|
---|
12 | <Patient>
|
---|
13 | <ActorID>ACTORPATIENT_100839</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_100839</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>2010-09-04T00:00:00-05:00</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_991</ActorID>
|
---|
59 | </Actor>
|
---|
60 | </Source>
|
---|
61 | </Problem>
|
---|
62 | <Problem>
|
---|
63 | <CCRDataObjectID>PROBLEM2</CCRDataObjectID>
|
---|
64 | <DateTime>
|
---|
65 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
66 | </DateTime>
|
---|
67 | <Type>
|
---|
68 | <Text>Problem</Text>
|
---|
69 | </Type>
|
---|
70 | <Description>
|
---|
71 | <Text>Congestive Heart Failure (ICD-9-CM 428.0)</Text>
|
---|
72 | <Code>
|
---|
73 | <Value>428.0</Value>
|
---|
74 | <CodingSystem>ICD9CM</CodingSystem>
|
---|
75 | </Code>
|
---|
76 | </Description>
|
---|
77 | <Status>
|
---|
78 | <Text>Active</Text>
|
---|
79 | </Status>
|
---|
80 | <Source>
|
---|
81 | <Actor>
|
---|
82 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
83 | </Actor>
|
---|
84 | </Source>
|
---|
85 | </Problem>
|
---|
86 | <Problem>
|
---|
87 | <CCRDataObjectID>PROBLEM3</CCRDataObjectID>
|
---|
88 | <DateTime>
|
---|
89 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
90 | </DateTime>
|
---|
91 | <Type>
|
---|
92 | <Text>Problem</Text>
|
---|
93 | </Type>
|
---|
94 | <Description>
|
---|
95 | <Text>Postmyocardial infarction syndrome (ICD-9-CM 411.0)</Text>
|
---|
96 | <Code>
|
---|
97 | <Value>411.0</Value>
|
---|
98 | <CodingSystem>ICD9CM</CodingSystem>
|
---|
99 | </Code>
|
---|
100 | </Description>
|
---|
101 | <Status>
|
---|
102 | <Text>Active</Text>
|
---|
103 | </Status>
|
---|
104 | <Source>
|
---|
105 | <Actor>
|
---|
106 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
107 | </Actor>
|
---|
108 | </Source>
|
---|
109 | </Problem>
|
---|
110 | </Problems>
|
---|
111 | <Procedures>
|
---|
112 | <Procedure>
|
---|
113 | <CCRDataObjectID>PROCEDURE_4056_27</CCRDataObjectID>
|
---|
114 | <DateTime>
|
---|
115 | <Type>
|
---|
116 | <Text>Procedure Date</Text>
|
---|
117 | </Type>
|
---|
118 | <ExactDateTime>2010-09-04T00:00:00-05:00</ExactDateTime>
|
---|
119 | </DateTime>
|
---|
120 | <Description>
|
---|
121 | <Text>INTERMEDIATE (15min)</Text>
|
---|
122 | <Code>
|
---|
123 | <Value>99213</Value>
|
---|
124 | <CodingSystem>CPT-4</CodingSystem>
|
---|
125 | </Code>
|
---|
126 | </Description>
|
---|
127 | <Status>
|
---|
128 | <Text>Completed</Text>
|
---|
129 | </Status>
|
---|
130 | <Source>
|
---|
131 | <Actor>
|
---|
132 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
133 | </Actor>
|
---|
134 | </Source>
|
---|
135 | </Procedure>
|
---|
136 | <Procedure>
|
---|
137 | <CCRDataObjectID>PROCEDURE_4055_24</CCRDataObjectID>
|
---|
138 | <DateTime>
|
---|
139 | <Type>
|
---|
140 | <Text>Procedure Date</Text>
|
---|
141 | </Type>
|
---|
142 | <ExactDateTime>2010-08-28T00:00:00-05:00</ExactDateTime>
|
---|
143 | </DateTime>
|
---|
144 | <Description>
|
---|
145 | <Text>EXPANDED, HX & EXAM</Text>
|
---|
146 | <Code>
|
---|
147 | <Value>99202</Value>
|
---|
148 | <CodingSystem>CPT-4</CodingSystem>
|
---|
149 | </Code>
|
---|
150 | </Description>
|
---|
151 | <Status>
|
---|
152 | <Text>Completed</Text>
|
---|
153 | </Status>
|
---|
154 | <Source>
|
---|
155 | <Actor>
|
---|
156 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
157 | </Actor>
|
---|
158 | </Source>
|
---|
159 | </Procedure>
|
---|
160 | <Procedure>
|
---|
161 | <CCRDataObjectID>PROCEDURE_4047_14</CCRDataObjectID>
|
---|
162 | <DateTime>
|
---|
163 | <Type>
|
---|
164 | <Text>Procedure Date</Text>
|
---|
165 | </Type>
|
---|
166 | <ExactDateTime>2010-07-31T00:00:00-05:00</ExactDateTime>
|
---|
167 | </DateTime>
|
---|
168 | <Description>
|
---|
169 | <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>
|
---|
170 | <Code>
|
---|
171 | <Value>99213</Value>
|
---|
172 | <CodingSystem>CPT-4</CodingSystem>
|
---|
173 | </Code>
|
---|
174 | </Description>
|
---|
175 | <Status>
|
---|
176 | <Text>Completed</Text>
|
---|
177 | </Status>
|
---|
178 | <Source>
|
---|
179 | <Actor>
|
---|
180 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
181 | </Actor>
|
---|
182 | </Source>
|
---|
183 | </Procedure>
|
---|
184 | <Procedure>
|
---|
185 | <CCRDataObjectID>PROCEDURE_4046_7</CCRDataObjectID>
|
---|
186 | <DateTime>
|
---|
187 | <Type>
|
---|
188 | <Text>Procedure Date</Text>
|
---|
189 | </Type>
|
---|
190 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
191 | </DateTime>
|
---|
192 | <Description>
|
---|
193 | <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>
|
---|
194 | <Code>
|
---|
195 | <Value>99214</Value>
|
---|
196 | <CodingSystem>CPT-4</CodingSystem>
|
---|
197 | </Code>
|
---|
198 | </Description>
|
---|
199 | <Status>
|
---|
200 | <Text>Completed</Text>
|
---|
201 | </Status>
|
---|
202 | <Source>
|
---|
203 | <Actor>
|
---|
204 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
205 | </Actor>
|
---|
206 | </Source>
|
---|
207 | </Procedure>
|
---|
208 | <Procedure>
|
---|
209 | <CCRDataObjectID>PROCEDURE_4046_8</CCRDataObjectID>
|
---|
210 | <DateTime>
|
---|
211 | <Type>
|
---|
212 | <Text>Procedure Date</Text>
|
---|
213 | </Type>
|
---|
214 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
215 | </DateTime>
|
---|
216 | <Description>
|
---|
217 | <Text>Hemoglobin; Glycosylated (A1c) (CPT-4 83036)</Text>
|
---|
218 | <Code>
|
---|
219 | <Value>83036</Value>
|
---|
220 | <CodingSystem>CPT-4</CodingSystem>
|
---|
221 | </Code>
|
---|
222 | </Description>
|
---|
223 | <Status>
|
---|
224 | <Text>Completed</Text>
|
---|
225 | </Status>
|
---|
226 | <Source>
|
---|
227 | <Actor>
|
---|
228 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
229 | </Actor>
|
---|
230 | </Source>
|
---|
231 | </Procedure>
|
---|
232 | <Procedure>
|
---|
233 | <CCRDataObjectID>PROCEDURE_4046_9</CCRDataObjectID>
|
---|
234 | <DateTime>
|
---|
235 | <Type>
|
---|
236 | <Text>Procedure Date</Text>
|
---|
237 | </Type>
|
---|
238 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
239 | </DateTime>
|
---|
240 | <Description>
|
---|
241 | <Text>Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704)</Text>
|
---|
242 | <Code>
|
---|
243 | <Value>83704</Value>
|
---|
244 | <CodingSystem>CPT-4</CodingSystem>
|
---|
245 | </Code>
|
---|
246 | </Description>
|
---|
247 | <Status>
|
---|
248 | <Text>Completed</Text>
|
---|
249 | </Status>
|
---|
250 | <Source>
|
---|
251 | <Actor>
|
---|
252 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
253 | </Actor>
|
---|
254 | </Source>
|
---|
255 | </Procedure>
|
---|
256 | <Procedure>
|
---|
257 | <CCRDataObjectID>PROCEDURE_4046_10</CCRDataObjectID>
|
---|
258 | <DateTime>
|
---|
259 | <Type>
|
---|
260 | <Text>Procedure Date</Text>
|
---|
261 | </Type>
|
---|
262 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
263 | </DateTime>
|
---|
264 | <Description>
|
---|
265 | <Text>Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414)</Text>
|
---|
266 | <Code>
|
---|
267 | <Value>78414</Value>
|
---|
268 | <CodingSystem>CPT-4</CodingSystem>
|
---|
269 | </Code>
|
---|
270 | </Description>
|
---|
271 | <Status>
|
---|
272 | <Text>Completed</Text>
|
---|
273 | </Status>
|
---|
274 | <Source>
|
---|
275 | <Actor>
|
---|
276 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
277 | </Actor>
|
---|
278 | </Source>
|
---|
279 | </Procedure>
|
---|
280 | </Procedures>
|
---|
281 | <Encounters>
|
---|
282 | <Encounter>
|
---|
283 | <CCRDataObjectID>ENCOUNTER_4056</CCRDataObjectID>
|
---|
284 | <DateTime>
|
---|
285 | <ExactDateTime>2010-09-04T00:00:00-05:00</ExactDateTime>
|
---|
286 | </DateTime>
|
---|
287 | <Type>
|
---|
288 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
|
---|
289 | <Code>
|
---|
290 | <Value>99213</Value>
|
---|
291 | <CodingSystem>CPT-4</CodingSystem>
|
---|
292 | </Code>
|
---|
293 | </Type>
|
---|
294 | <Description>
|
---|
295 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
|
---|
296 | <Code>
|
---|
297 | <Value>99213</Value>
|
---|
298 | <CodingSystem>CPT-4</CodingSystem>
|
---|
299 | </Code>
|
---|
300 | </Description>
|
---|
301 | <Location>
|
---|
302 | <Actor>
|
---|
303 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
304 | </Actor>
|
---|
305 | </Location>
|
---|
306 | <Practioner>
|
---|
307 | <Actor>
|
---|
308 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
309 | </Actor>
|
---|
310 | </Practioner>
|
---|
311 | <Source>
|
---|
312 | <Actor>
|
---|
313 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
314 | </Actor>
|
---|
315 | </Source>
|
---|
316 | </Encounter>
|
---|
317 | <Encounter>
|
---|
318 | <CCRDataObjectID>ENCOUNTER_4055</CCRDataObjectID>
|
---|
319 | <DateTime>
|
---|
320 | <ExactDateTime>2010-08-28T00:00:00-05:00</ExactDateTime>
|
---|
321 | </DateTime>
|
---|
322 | <Type>
|
---|
323 | <Text>OFFICE VISIT - NEW PT EXPANDED, HX & EXAM</Text>
|
---|
324 | <Code>
|
---|
325 | <Value>99202</Value>
|
---|
326 | <CodingSystem>CPT-4</CodingSystem>
|
---|
327 | </Code>
|
---|
328 | </Type>
|
---|
329 | <Description>
|
---|
330 | <Text>OFFICE VISIT - NEW PT EXPANDED, HX & EXAM</Text>
|
---|
331 | <Code>
|
---|
332 | <Value>99202</Value>
|
---|
333 | <CodingSystem>CPT-4</CodingSystem>
|
---|
334 | </Code>
|
---|
335 | </Description>
|
---|
336 | <Location>
|
---|
337 | <Actor>
|
---|
338 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
339 | </Actor>
|
---|
340 | </Location>
|
---|
341 | <Practioner>
|
---|
342 | <Actor>
|
---|
343 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
344 | </Actor>
|
---|
345 | </Practioner>
|
---|
346 | <Source>
|
---|
347 | <Actor>
|
---|
348 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
349 | </Actor>
|
---|
350 | </Source>
|
---|
351 | <CommentID>NOTE_4055</CommentID>
|
---|
352 | </Encounter>
|
---|
353 | <Encounter>
|
---|
354 | <CCRDataObjectID>ENCOUNTER_4054</CCRDataObjectID>
|
---|
355 | <DateTime>
|
---|
356 | <ExactDateTime>2010-08-27T00:00:00-05:00</ExactDateTime>
|
---|
357 | </DateTime>
|
---|
358 | <Type>
|
---|
359 | <Text>C&P EXAMINATION REPORTS</Text>
|
---|
360 | </Type>
|
---|
361 | <Description>
|
---|
362 | <Text>C&P EXAMINATION REPORTS</Text>
|
---|
363 | </Description>
|
---|
364 | <Location>
|
---|
365 | <Actor>
|
---|
366 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
367 | </Actor>
|
---|
368 | </Location>
|
---|
369 | <Practioner>
|
---|
370 | <Actor>
|
---|
371 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
372 | </Actor>
|
---|
373 | </Practioner>
|
---|
374 | <Source>
|
---|
375 | <Actor>
|
---|
376 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
377 | </Actor>
|
---|
378 | </Source>
|
---|
379 | </Encounter>
|
---|
380 | <Encounter>
|
---|
381 | <CCRDataObjectID>ENCOUNTER_4053</CCRDataObjectID>
|
---|
382 | <DateTime>
|
---|
383 | <ExactDateTime>2010-08-27T00:00:00-05:00</ExactDateTime>
|
---|
384 | </DateTime>
|
---|
385 | <Type>
|
---|
386 | <Text>NURSING TITLES</Text>
|
---|
387 | </Type>
|
---|
388 | <Description>
|
---|
389 | <Text>NURSING TITLES</Text>
|
---|
390 | </Description>
|
---|
391 | <Location>
|
---|
392 | <Actor>
|
---|
393 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
394 | </Actor>
|
---|
395 | </Location>
|
---|
396 | <Practioner>
|
---|
397 | <Actor>
|
---|
398 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
399 | </Actor>
|
---|
400 | </Practioner>
|
---|
401 | <Source>
|
---|
402 | <Actor>
|
---|
403 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
404 | </Actor>
|
---|
405 | </Source>
|
---|
406 | </Encounter>
|
---|
407 | <Encounter>
|
---|
408 | <CCRDataObjectID>ENCOUNTER_4052</CCRDataObjectID>
|
---|
409 | <DateTime>
|
---|
410 | <ExactDateTime>2010-08-14T00:00:00-05:00</ExactDateTime>
|
---|
411 | </DateTime>
|
---|
412 | <Type>
|
---|
413 | <Text>ADDENDUM</Text>
|
---|
414 | </Type>
|
---|
415 | <Description>
|
---|
416 | <Text>ADDENDUM</Text>
|
---|
417 | </Description>
|
---|
418 | <Location>
|
---|
419 | <Actor>
|
---|
420 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
421 | </Actor>
|
---|
422 | </Location>
|
---|
423 | <Practioner>
|
---|
424 | <Actor>
|
---|
425 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
426 | </Actor>
|
---|
427 | </Practioner>
|
---|
428 | <Source>
|
---|
429 | <Actor>
|
---|
430 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
431 | </Actor>
|
---|
432 | </Source>
|
---|
433 | </Encounter>
|
---|
434 | <Encounter>
|
---|
435 | <CCRDataObjectID>ENCOUNTER_4049</CCRDataObjectID>
|
---|
436 | <DateTime>
|
---|
437 | <ExactDateTime>2010-08-25T00:00:00-05:00</ExactDateTime>
|
---|
438 | </DateTime>
|
---|
439 | <Type>
|
---|
440 | <Text>ADDICTION SEVERITY INDEX</Text>
|
---|
441 | </Type>
|
---|
442 | <Description>
|
---|
443 | <Text>ADDICTION SEVERITY INDEX</Text>
|
---|
444 | </Description>
|
---|
445 | <Location>
|
---|
446 | <Actor>
|
---|
447 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
448 | </Actor>
|
---|
449 | </Location>
|
---|
450 | <Practioner>
|
---|
451 | <Actor>
|
---|
452 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
453 | </Actor>
|
---|
454 | </Practioner>
|
---|
455 | <Source>
|
---|
456 | <Actor>
|
---|
457 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
458 | </Actor>
|
---|
459 | </Source>
|
---|
460 | </Encounter>
|
---|
461 | <Encounter>
|
---|
462 | <CCRDataObjectID>ENCOUNTER_4048</CCRDataObjectID>
|
---|
463 | <DateTime>
|
---|
464 | <ExactDateTime>2010-08-14T00:00:00-05:00</ExactDateTime>
|
---|
465 | </DateTime>
|
---|
466 | <Type>
|
---|
467 | <Text>INTERDISCIPLINARY MEMBER</Text>
|
---|
468 | </Type>
|
---|
469 | <Description>
|
---|
470 | <Text>INTERDISCIPLINARY MEMBER</Text>
|
---|
471 | </Description>
|
---|
472 | <Location>
|
---|
473 | <Actor>
|
---|
474 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
475 | </Actor>
|
---|
476 | </Location>
|
---|
477 | <Practioner>
|
---|
478 | <Actor>
|
---|
479 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
480 | </Actor>
|
---|
481 | </Practioner>
|
---|
482 | <Source>
|
---|
483 | <Actor>
|
---|
484 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
485 | </Actor>
|
---|
486 | </Source>
|
---|
487 | </Encounter>
|
---|
488 | <Encounter>
|
---|
489 | <CCRDataObjectID>ENCOUNTER_4047</CCRDataObjectID>
|
---|
490 | <DateTime>
|
---|
491 | <ExactDateTime>2010-07-31T00:00:00-05:00</ExactDateTime>
|
---|
492 | </DateTime>
|
---|
493 | <Type>
|
---|
494 | <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>
|
---|
495 | <Code>
|
---|
496 | <Value>99213</Value>
|
---|
497 | <CodingSystem>CPT-4</CodingSystem>
|
---|
498 | </Code>
|
---|
499 | </Type>
|
---|
500 | <Description>
|
---|
501 | <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>
|
---|
502 | <Code>
|
---|
503 | <Value>99213</Value>
|
---|
504 | <CodingSystem>CPT-4</CodingSystem>
|
---|
505 | </Code>
|
---|
506 | </Description>
|
---|
507 | <Location>
|
---|
508 | <Actor>
|
---|
509 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
510 | </Actor>
|
---|
511 | </Location>
|
---|
512 | <Practioner>
|
---|
513 | <Actor>
|
---|
514 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
515 | </Actor>
|
---|
516 | </Practioner>
|
---|
517 | <Source>
|
---|
518 | <Actor>
|
---|
519 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
520 | </Actor>
|
---|
521 | </Source>
|
---|
522 | <CommentID>NOTE_4047</CommentID>
|
---|
523 | </Encounter>
|
---|
524 | <Encounter>
|
---|
525 | <CCRDataObjectID>ENCOUNTER_4046</CCRDataObjectID>
|
---|
526 | <DateTime>
|
---|
527 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
528 | </DateTime>
|
---|
529 | <Type>
|
---|
530 | <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>
|
---|
531 | <Code>
|
---|
532 | <Value>99214</Value>
|
---|
533 | <CodingSystem>CPT-4</CodingSystem>
|
---|
534 | </Code>
|
---|
535 | </Type>
|
---|
536 | <Description>
|
---|
537 | <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>
|
---|
538 | <Code>
|
---|
539 | <Value>99214</Value>
|
---|
540 | <CodingSystem>CPT-4</CodingSystem>
|
---|
541 | </Code>
|
---|
542 | </Description>
|
---|
543 | <Location>
|
---|
544 | <Actor>
|
---|
545 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
---|
546 | </Actor>
|
---|
547 | </Location>
|
---|
548 | <Practioner>
|
---|
549 | <Actor>
|
---|
550 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
551 | </Actor>
|
---|
552 | </Practioner>
|
---|
553 | <Source>
|
---|
554 | <Actor>
|
---|
555 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
556 | </Actor>
|
---|
557 | </Source>
|
---|
558 | <CommentID>NOTE_4046</CommentID>
|
---|
559 | </Encounter>
|
---|
560 | </Encounters>
|
---|
561 | </Body>
|
---|
562 | <Actors>
|
---|
563 | <Actor>
|
---|
564 | <ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
|
---|
565 | <Organization>
|
---|
566 | <Name>CAMP MASTER</Name>
|
---|
567 | </Organization>
|
---|
568 | <Address>
|
---|
569 | <Type>
|
---|
570 | <Text>Office</Text>
|
---|
571 | </Type>
|
---|
572 | <Line1>VA MEDICAL CENTER</Line1>
|
---|
573 | <City>ALBANY</City>
|
---|
574 | <State>NEW YORK</State>
|
---|
575 | <PostalCode>12180-0097</PostalCode>
|
---|
576 | </Address>
|
---|
577 | <Source>
|
---|
578 | <Actor>
|
---|
579 | <ActorID>ACTORSYSTEM_1</ActorID>
|
---|
580 | </Actor>
|
---|
581 | </Source>
|
---|
582 | </Actor>
|
---|
583 | <Actor>
|
---|
584 | <ActorObjectID>ACTORPATIENT_100839</ActorObjectID>
|
---|
585 | <Person>
|
---|
586 | <Name>
|
---|
587 | <CurrentName>
|
---|
588 | <Given>JODY</Given>
|
---|
589 | <Middle>JEAN</Middle>
|
---|
590 | <Family>JONES</Family>
|
---|
591 | </CurrentName>
|
---|
592 | </Name>
|
---|
593 | <DateOfBirth>
|
---|
594 | <ExactDateTime>1945-01-01</ExactDateTime>
|
---|
595 | </DateOfBirth>
|
---|
596 | <Gender>
|
---|
597 | <Text>FEMALE</Text>
|
---|
598 | <Code>
|
---|
599 | <Value>F</Value>
|
---|
600 | <CodingSystem>HL7 AdministrativeGender</CodingSystem>
|
---|
601 | </Code>
|
---|
602 | </Gender>
|
---|
603 | </Person>
|
---|
604 | <IDs>
|
---|
605 | <Type>
|
---|
606 | <Text>SSN</Text>
|
---|
607 | </Type>
|
---|
608 | <ID>002030004</ID>
|
---|
609 | <Source>
|
---|
610 | <Actor>
|
---|
611 | <ActorID>ACTORPATIENT_100839</ActorID>
|
---|
612 | </Actor>
|
---|
613 | </Source>
|
---|
614 | </IDs>
|
---|
615 | <Address>
|
---|
616 | <Type>
|
---|
617 | <Text>Home</Text>
|
---|
618 | </Type>
|
---|
619 | </Address>
|
---|
620 | <Source>
|
---|
621 | <Actor>
|
---|
622 | <ActorID>ACTORPATIENT_100839</ActorID>
|
---|
623 | </Actor>
|
---|
624 | </Source>
|
---|
625 | </Actor>
|
---|
626 | <Actor>
|
---|
627 | <ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
|
---|
628 | <Person>
|
---|
629 | <Name>
|
---|
630 | <CurrentName>
|
---|
631 | <Given>SYSTEM</Given>
|
---|
632 | <Family>MANAGER</Family>
|
---|
633 | </CurrentName>
|
---|
634 | </Name>
|
---|
635 | </Person>
|
---|
636 | <Specialty>
|
---|
637 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
---|
638 | </Specialty>
|
---|
639 | <Address>
|
---|
640 | <Type>
|
---|
641 | <Text>Work</Text>
|
---|
642 | </Type>
|
---|
643 | <Line1>VA MEDICAL CENTER</Line1>
|
---|
644 | <City>ALBANY</City>
|
---|
645 | <State>NY</State>
|
---|
646 | <PostalCode>12180-0097</PostalCode>
|
---|
647 | </Address>
|
---|
648 | <Source>
|
---|
649 | <Actor>
|
---|
650 | <ActorID>ACTORSYSTEM_1</ActorID>
|
---|
651 | </Actor>
|
---|
652 | </Source>
|
---|
653 | <InternalCCRLink>
|
---|
654 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
---|
655 | <LinkRelationship>representedOrganization</LinkRelationship>
|
---|
656 | </InternalCCRLink>
|
---|
657 | </Actor>
|
---|
658 | <Actor>
|
---|
659 | <ActorObjectID>ACTORPROVIDER_991</ActorObjectID>
|
---|
660 | <Person>
|
---|
661 | <Name>
|
---|
662 | <CurrentName>
|
---|
663 | <Given>EIGHT</Given>
|
---|
664 | <Family>PROVIDER</Family>
|
---|
665 | <Title>Scholar Extraordinaire</Title>
|
---|
666 | </CurrentName>
|
---|
667 | </Name>
|
---|
668 | </Person>
|
---|
669 | <Specialty>
|
---|
670 | <Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
|
---|
671 | </Specialty>
|
---|
672 | <Address>
|
---|
673 | <Type>
|
---|
674 | <Text>Work</Text>
|
---|
675 | </Type>
|
---|
676 | <Line1>VA MEDICAL CENTER</Line1>
|
---|
677 | <City>ALBANY</City>
|
---|
678 | <State>NY</State>
|
---|
679 | <PostalCode>12180-0097</PostalCode>
|
---|
680 | </Address>
|
---|
681 | <Source>
|
---|
682 | <Actor>
|
---|
683 | <ActorID>ACTORSYSTEM_1</ActorID>
|
---|
684 | </Actor>
|
---|
685 | </Source>
|
---|
686 | <InternalCCRLink>
|
---|
687 | <LinkID>ACTORORGANIZATION_1</LinkID>
|
---|
688 | <LinkRelationship>representedOrganization</LinkRelationship>
|
---|
689 | </InternalCCRLink>
|
---|
690 | </Actor>
|
---|
691 | <Actor>
|
---|
692 | <ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
|
---|
693 | <InformationSystem>
|
---|
694 | <Name>WorldVistA EHR/VOE</Name>
|
---|
695 | <Version>1.0</Version>
|
---|
696 | </InformationSystem>
|
---|
697 | <Source>
|
---|
698 | <Actor>
|
---|
699 | <ActorID>ACTORSYSTEM_1</ActorID>
|
---|
700 | </Actor>
|
---|
701 | </Source>
|
---|
702 | </Actor>
|
---|
703 | </Actors>
|
---|
704 | <Comments>
|
---|
705 | <Comment>
|
---|
706 | <CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
|
---|
707 | <DateTime>
|
---|
708 | <ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
|
---|
709 | </DateTime>
|
---|
710 | <Source>
|
---|
711 | <Actor>
|
---|
712 | <ActorID>@@ACTORSOURCEID@@</ActorID>
|
---|
713 | </Actor>
|
---|
714 | </Source>
|
---|
715 | </Comment>
|
---|
716 | <Comment>
|
---|
717 | <CommentObjectID>NOTE_4046</CommentObjectID>
|
---|
718 | <DateTime>
|
---|
719 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
|
---|
720 | </DateTime>
|
---|
721 | <Description>
|
---|
722 | <Text>
|
---|
723 | ADDING CLINICAL MEASURES FOR TESTING
|
---|
724 | Measure 1
|
---|
725 | Measure 2
|
---|
726 | Measure 3
|
---|
727 | Measure 5
|
---|
728 | Measure 7
|
---|
729 | Measure 124
|
---|
730 | ------------------------------------------Measure #1
|
---|
731 | Data for Jones--
|
---|
732 | ENCOUNTER CODE 99214
|
---|
733 | DX CODE 250.00
|
---|
734 |
|
---|
735 | NUMERATOR INCLUSION
|
---|
736 | A1C CODE 83036
|
---|
737 |
|
---|
738 | DOCUMENTATION:
|
---|
739 | HBA1c > 9% PROBLEM (Our patient is less than 9.0%)
|
---|
740 | ---------------------------------------------------
|
---|
741 | Measure #2
|
---|
742 | Data for Jones--
|
---|
743 | ENCOUNTER CODE 99214
|
---|
744 | DX CODE 250.00
|
---|
745 |
|
---|
746 | NUMERATOR INCLUSION
|
---|
747 | LDL CODE 83704
|
---|
748 |
|
---|
749 | DOCUMENTATION:
|
---|
750 | LDL < 100 mg/dl LDL from Lab Package
|
---|
751 | -------------------------------------------------------
|
---|
752 | Measure #3
|
---|
753 | Data for Jones--
|
---|
754 | ENCOUNTER CODE 99214
|
---|
755 | DX CODE 250.00
|
---|
756 |
|
---|
757 | NUMERATOR:
|
---|
758 |
|
---|
759 | DOCUMENTATION:
|
---|
760 | Systolic (SNOMED) CODE 271649006 or 72313002
|
---|
761 | AND
|
---|
762 | Systolic BP <140 mmHg (from Vitals-Bottom number of BP)
|
---|
763 |
|
---|
764 | Diastolic (SNOMED) CODE 271650006
|
---|
765 | AND
|
---|
766 |
|
---|
767 | Diastolic BP < 80 (From Vitals Package-Top number of BP)
|
---|
768 | NOTE: SNOMED CODES ARE NOT ACCESSIBLE IN VISTA
|
---|
769 | -------------------------------------------------------
|
---|
770 | Measure #5
|
---|
771 | Data for Jones--
|
---|
772 | ENCOUNTER CODE 99214
|
---|
773 | DX CODE 428.0
|
---|
774 | EJRC FRAC CODE 83704
|
---|
775 | AND
|
---|
776 | Documentation of LVEF < 40% Need Health Factor for this
|
---|
777 |
|
---|
778 | NUMERATOR INCLUSION
|
---|
779 | TOPIC_DRUG_CODES = ACE/ARB (NOT AVAILABLE IN VISTA)
|
---|
780 |
|
---|
781 | -------------------------------------------------------
|
---|
782 |
|
---|
783 | Measure #7
|
---|
784 | Data for Jones--
|
---|
785 | ENCOUNTER CODE 99214
|
---|
786 | dx 411.0, 412.00
|
---|
787 | procedure: 78414
|
---|
788 |
|
---|
789 |
|
---|
790 | NUMERATOR INCLUSION
|
---|
791 | TOPIC_DRUG_CODES = BETA BLOCKERS
|
---|
792 | -------------------------------------------------------------
|
---|
793 | Measure #124
|
---|
794 | ENCOUNTER CODE 99214
|
---|
795 | NUMERATOR CODE G8447
|
---|
796 | -------------------------------------------------------------
|
---|
797 | </Text>
|
---|
798 | </Description>
|
---|
799 | <Source>
|
---|
800 | <Actor>
|
---|
801 | <ActorID>ACTORPROVIDER_991</ActorID>
|
---|
802 | </Actor>
|
---|
803 | </Source>
|
---|
804 | </Comment>
|
---|
805 | <Comment>
|
---|
806 | <CommentObjectID>NOTE_4047</CommentObjectID>
|
---|
807 | <DateTime>
|
---|
808 | <ExactDateTime>2010-07-31T00:00:00-05:00</ExactDateTime>
|
---|
809 | </DateTime>
|
---|
810 | <Description>
|
---|
811 | <Text>
|
---|
812 | TESTING ENCOUNTERS
|
---|
813 | </Text>
|
---|
814 | </Description>
|
---|
815 | <Source>
|
---|
816 | <Actor>
|
---|
817 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
818 | </Actor>
|
---|
819 | </Source>
|
---|
820 | </Comment>
|
---|
821 | <Comment>
|
---|
822 | <CommentObjectID>NOTE_4055</CommentObjectID>
|
---|
823 | <DateTime>
|
---|
824 | <ExactDateTime>2010-08-28T00:00:00-05:00</ExactDateTime>
|
---|
825 | </DateTime>
|
---|
826 | <Description>
|
---|
827 | <Text>
|
---|
828 | SMOKING PQRI CAT
|
---|
829 | CURRENT EVERY DAY SMOKER 07/31/2010
|
---|
830 | CURRENT SMOKING STATUS UNKNOWN 08/25/2010
|
---|
831 | CURRENT SOME DAY SMOKER 08/27/2010
|
---|
832 | PPD
|
---|
833 | =========================================
|
---|
834 | </Text>
|
---|
835 | </Description>
|
---|
836 | <Source>
|
---|
837 | <Actor>
|
---|
838 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
---|
839 | </Actor>
|
---|
840 | </Source>
|
---|
841 | </Comment>
|
---|
842 | </Comments>
|
---|
843 | </ContinuityOfCareRecord>
|
---|