[942] | 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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[944] | 4 | <CCRDocumentObjectID>d4196be2-8a2b-44c2-ab9f-9c633af36a58</CCRDocumentObjectID>
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[942] | 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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[944] | 10 | <ExactDateTime>2010-09-08T19:47:15-05:00</ExactDateTime>
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[942] | 11 | </DateTime>
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| 12 | <Patient>
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| 13 | <ActorID>ACTORPATIENT_100839</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_100839</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>2010-09-04T00:00:00-05:00</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_991</ActorID>
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| 59 | </Actor>
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| 60 | </Source>
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| 61 | </Problem>
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| 62 | <Problem>
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| 63 | <CCRDataObjectID>PROBLEM2</CCRDataObjectID>
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| 64 | <DateTime>
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| 65 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 66 | </DateTime>
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| 67 | <Type>
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| 68 | <Text>Problem</Text>
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| 69 | </Type>
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| 70 | <Description>
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| 71 | <Text>Congestive Heart Failure (ICD-9-CM 428.0)</Text>
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| 72 | <Code>
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| 73 | <Value>428.0</Value>
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| 74 | <CodingSystem>ICD9CM</CodingSystem>
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| 75 | </Code>
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| 76 | </Description>
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| 77 | <Status>
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| 78 | <Text>Active</Text>
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| 79 | </Status>
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| 80 | <Source>
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| 81 | <Actor>
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| 82 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 83 | </Actor>
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| 84 | </Source>
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| 85 | </Problem>
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| 86 | <Problem>
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| 87 | <CCRDataObjectID>PROBLEM3</CCRDataObjectID>
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| 88 | <DateTime>
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| 89 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 90 | </DateTime>
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| 91 | <Type>
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| 92 | <Text>Problem</Text>
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| 93 | </Type>
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| 94 | <Description>
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| 95 | <Text>Postmyocardial infarction syndrome (ICD-9-CM 411.0)</Text>
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| 96 | <Code>
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| 97 | <Value>411.0</Value>
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| 98 | <CodingSystem>ICD9CM</CodingSystem>
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| 99 | </Code>
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| 100 | </Description>
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| 101 | <Status>
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| 102 | <Text>Active</Text>
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| 103 | </Status>
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| 104 | <Source>
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| 105 | <Actor>
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| 106 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 107 | </Actor>
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| 108 | </Source>
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| 109 | </Problem>
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| 110 | </Problems>
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| 111 | <Procedures>
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| 112 | <Procedure>
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| 113 | <CCRDataObjectID>PROCEDURE_4056_27</CCRDataObjectID>
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| 114 | <DateTime>
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| 115 | <Type>
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| 116 | <Text>Procedure Date</Text>
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| 117 | </Type>
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| 118 | <ExactDateTime>2010-09-04T00:00:00-05:00</ExactDateTime>
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| 119 | </DateTime>
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| 120 | <Description>
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| 121 | <Text>INTERMEDIATE (15min)</Text>
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| 122 | <Code>
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| 123 | <Value>99213</Value>
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| 124 | <CodingSystem>CPT-4</CodingSystem>
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| 125 | </Code>
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| 126 | </Description>
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| 127 | <Status>
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| 128 | <Text>Completed</Text>
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| 129 | </Status>
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| 130 | <Source>
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| 131 | <Actor>
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| 132 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 133 | </Actor>
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| 134 | </Source>
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| 135 | </Procedure>
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| 136 | <Procedure>
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| 137 | <CCRDataObjectID>PROCEDURE_4055_24</CCRDataObjectID>
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| 138 | <DateTime>
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| 139 | <Type>
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| 140 | <Text>Procedure Date</Text>
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| 141 | </Type>
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| 142 | <ExactDateTime>2010-08-28T00:00:00-05:00</ExactDateTime>
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| 143 | </DateTime>
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| 144 | <Description>
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[944] | 145 | <Text>EXPANDED, HX & EXAM</Text>
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[942] | 146 | <Code>
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| 147 | <Value>99202</Value>
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| 148 | <CodingSystem>CPT-4</CodingSystem>
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| 149 | </Code>
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| 150 | </Description>
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| 151 | <Status>
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| 152 | <Text>Completed</Text>
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| 153 | </Status>
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| 154 | <Source>
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| 155 | <Actor>
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| 156 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 157 | </Actor>
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| 158 | </Source>
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| 159 | </Procedure>
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| 160 | <Procedure>
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| 161 | <CCRDataObjectID>PROCEDURE_4047_14</CCRDataObjectID>
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| 162 | <DateTime>
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| 163 | <Type>
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| 164 | <Text>Procedure Date</Text>
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| 165 | </Type>
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| 166 | <ExactDateTime>2010-07-31T00:00:00-05:00</ExactDateTime>
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| 167 | </DateTime>
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| 168 | <Description>
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| 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>
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| 170 | <Code>
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| 171 | <Value>99213</Value>
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| 172 | <CodingSystem>CPT-4</CodingSystem>
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| 173 | </Code>
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| 174 | </Description>
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| 175 | <Status>
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| 176 | <Text>Completed</Text>
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| 177 | </Status>
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| 178 | <Source>
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| 179 | <Actor>
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| 180 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 181 | </Actor>
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| 182 | </Source>
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| 183 | </Procedure>
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| 184 | <Procedure>
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| 185 | <CCRDataObjectID>PROCEDURE_4046_7</CCRDataObjectID>
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| 186 | <DateTime>
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| 187 | <Type>
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| 188 | <Text>Procedure Date</Text>
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| 189 | </Type>
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| 190 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 191 | </DateTime>
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| 192 | <Description>
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| 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>
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| 194 | <Code>
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| 195 | <Value>99214</Value>
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| 196 | <CodingSystem>CPT-4</CodingSystem>
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| 197 | </Code>
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| 198 | </Description>
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| 199 | <Status>
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| 200 | <Text>Completed</Text>
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| 201 | </Status>
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| 202 | <Source>
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| 203 | <Actor>
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| 204 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 205 | </Actor>
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| 206 | </Source>
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| 207 | </Procedure>
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| 208 | <Procedure>
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| 209 | <CCRDataObjectID>PROCEDURE_4046_8</CCRDataObjectID>
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| 210 | <DateTime>
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| 211 | <Type>
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| 212 | <Text>Procedure Date</Text>
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| 213 | </Type>
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| 214 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 215 | </DateTime>
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| 216 | <Description>
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| 217 | <Text>Hemoglobin; Glycosylated (A1c) (CPT-4 83036)</Text>
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| 218 | <Code>
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| 219 | <Value>83036</Value>
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| 220 | <CodingSystem>CPT-4</CodingSystem>
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| 221 | </Code>
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| 222 | </Description>
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| 223 | <Status>
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| 224 | <Text>Completed</Text>
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| 225 | </Status>
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| 226 | <Source>
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| 227 | <Actor>
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| 228 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 229 | </Actor>
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| 230 | </Source>
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| 231 | </Procedure>
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| 232 | <Procedure>
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| 233 | <CCRDataObjectID>PROCEDURE_4046_9</CCRDataObjectID>
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| 234 | <DateTime>
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| 235 | <Type>
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| 236 | <Text>Procedure Date</Text>
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| 237 | </Type>
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| 238 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 239 | </DateTime>
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| 240 | <Description>
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| 241 | <Text>Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704)</Text>
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| 242 | <Code>
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| 243 | <Value>83704</Value>
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| 244 | <CodingSystem>CPT-4</CodingSystem>
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| 245 | </Code>
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| 246 | </Description>
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| 247 | <Status>
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| 248 | <Text>Completed</Text>
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| 249 | </Status>
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| 250 | <Source>
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| 251 | <Actor>
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| 252 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 253 | </Actor>
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| 254 | </Source>
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| 255 | </Procedure>
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| 256 | <Procedure>
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| 257 | <CCRDataObjectID>PROCEDURE_4046_10</CCRDataObjectID>
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| 258 | <DateTime>
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| 259 | <Type>
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| 260 | <Text>Procedure Date</Text>
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| 261 | </Type>
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| 262 | <ExactDateTime>2010-07-05T00:00:00-05:00</ExactDateTime>
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| 263 | </DateTime>
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| 264 | <Description>
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| 265 | <Text>Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414)</Text>
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| 266 | <Code>
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| 267 | <Value>78414</Value>
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| 268 | <CodingSystem>CPT-4</CodingSystem>
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| 269 | </Code>
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| 270 | </Description>
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| 271 | <Status>
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| 272 | <Text>Completed</Text>
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| 273 | </Status>
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| 274 | <Source>
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| 275 | <Actor>
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| 276 | <ActorID>ACTORPROVIDER_991</ActorID>
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| 277 | </Actor>
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| 278 | </Source>
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| 279 | </Procedure>
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| 280 | </Procedures>
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| 281 | <Encounters>
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| 282 | <Encounter>
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| 283 | <CCRDataObjectID>ENCOUNTER_4056</CCRDataObjectID>
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| 284 | <DateTime>
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| 285 | <ExactDateTime>2010-09-04T00:00:00-05:00</ExactDateTime>
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| 286 | </DateTime>
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| 287 | <Type>
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| 288 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
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| 289 | <Code>
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| 290 | <Value>99213</Value>
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| 291 | <CodingSystem>CPT-4</CodingSystem>
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| 292 | </Code>
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| 293 | </Type>
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| 294 | <Description>
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| 295 | <Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
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| 296 | <Code>
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| 297 | <Value>99213</Value>
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| 298 | <CodingSystem>CPT-4</CodingSystem>
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| 299 | </Code>
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| 300 | </Description>
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| 301 | <Location>
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| 302 | <Actor>
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| 303 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 304 | </Actor>
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| 305 | </Location>
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| 306 | <Practioner>
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| 307 | <Actor>
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| 308 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 309 | </Actor>
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| 310 | </Practioner>
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| 311 | <Source>
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| 312 | <Actor>
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| 313 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 314 | </Actor>
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| 315 | </Source>
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| 316 | </Encounter>
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| 317 | <Encounter>
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| 318 | <CCRDataObjectID>ENCOUNTER_4055</CCRDataObjectID>
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| 319 | <DateTime>
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| 320 | <ExactDateTime>2010-08-28T00:00:00-05:00</ExactDateTime>
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| 321 | </DateTime>
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| 322 | <Type>
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[944] | 323 | <Text>OFFICE VISIT - NEW PT EXPANDED, HX & EXAM</Text>
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[942] | 324 | <Code>
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| 325 | <Value>99202</Value>
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| 326 | <CodingSystem>CPT-4</CodingSystem>
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| 327 | </Code>
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| 328 | </Type>
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| 329 | <Description>
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[944] | 330 | <Text>OFFICE VISIT - NEW PT EXPANDED, HX & EXAM</Text>
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[942] | 331 | <Code>
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| 332 | <Value>99202</Value>
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| 333 | <CodingSystem>CPT-4</CodingSystem>
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| 334 | </Code>
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| 335 | </Description>
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| 336 | <Location>
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| 337 | <Actor>
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| 338 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 339 | </Actor>
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| 340 | </Location>
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| 341 | <Practioner>
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| 342 | <Actor>
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| 343 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 344 | </Actor>
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| 345 | </Practioner>
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| 346 | <Source>
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| 347 | <Actor>
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| 348 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 349 | </Actor>
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| 350 | </Source>
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| 351 | <CommentID>NOTE_4055</CommentID>
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| 352 | </Encounter>
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| 353 | <Encounter>
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| 354 | <CCRDataObjectID>ENCOUNTER_4054</CCRDataObjectID>
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| 355 | <DateTime>
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| 356 | <ExactDateTime>2010-08-27T00:00:00-05:00</ExactDateTime>
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| 357 | </DateTime>
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| 358 | <Type>
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[944] | 359 | <Text>C&P EXAMINATION REPORTS</Text>
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[942] | 360 | </Type>
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| 361 | <Description>
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[944] | 362 | <Text>C&P EXAMINATION REPORTS</Text>
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[942] | 363 | </Description>
|
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| 364 | <Location>
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| 365 | <Actor>
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| 366 | <ActorID>ACTORORGANIZATION_1</ActorID>
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| 367 | </Actor>
|
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| 368 | </Location>
|
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| 369 | <Practioner>
|
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| 370 | <Actor>
|
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| 371 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
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| 372 | </Actor>
|
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| 373 | </Practioner>
|
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| 374 | <Source>
|
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| 375 | <Actor>
|
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| 376 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
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| 377 | </Actor>
|
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| 378 | </Source>
|
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| 379 | </Encounter>
|
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| 380 | <Encounter>
|
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| 381 | <CCRDataObjectID>ENCOUNTER_4053</CCRDataObjectID>
|
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| 382 | <DateTime>
|
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| 383 | <ExactDateTime>2010-08-27T00:00:00-05:00</ExactDateTime>
|
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| 384 | </DateTime>
|
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| 385 | <Type>
|
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| 386 | <Text>NURSING TITLES</Text>
|
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| 387 | </Type>
|
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| 388 | <Description>
|
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| 389 | <Text>NURSING TITLES</Text>
|
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| 390 | </Description>
|
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| 391 | <Location>
|
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| 392 | <Actor>
|
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| 393 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
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| 394 | </Actor>
|
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| 395 | </Location>
|
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| 396 | <Practioner>
|
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| 397 | <Actor>
|
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| 398 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
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| 399 | </Actor>
|
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| 400 | </Practioner>
|
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| 401 | <Source>
|
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| 402 | <Actor>
|
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| 403 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
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| 404 | </Actor>
|
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| 405 | </Source>
|
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| 406 | </Encounter>
|
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| 407 | <Encounter>
|
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| 408 | <CCRDataObjectID>ENCOUNTER_4052</CCRDataObjectID>
|
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| 409 | <DateTime>
|
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| 410 | <ExactDateTime>2010-08-14T00:00:00-05:00</ExactDateTime>
|
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| 411 | </DateTime>
|
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| 412 | <Type>
|
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| 413 | <Text>ADDENDUM</Text>
|
---|
| 414 | </Type>
|
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| 415 | <Description>
|
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| 416 | <Text>ADDENDUM</Text>
|
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| 417 | </Description>
|
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| 418 | <Location>
|
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| 419 | <Actor>
|
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| 420 | <ActorID>ACTORORGANIZATION_1</ActorID>
|
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| 421 | </Actor>
|
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| 422 | </Location>
|
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| 423 | <Practioner>
|
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| 424 | <Actor>
|
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| 425 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
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| 426 | </Actor>
|
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| 427 | </Practioner>
|
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| 428 | <Source>
|
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| 429 | <Actor>
|
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| 430 | <ActorID>ACTORPROVIDER_10000000020</ActorID>
|
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| 431 | </Actor>
|
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| 432 | </Source>
|
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| 433 | </Encounter>
|
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| 434 | <Encounter>
|
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| 435 | <CCRDataObjectID>ENCOUNTER_4049</CCRDataObjectID>
|
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| 436 | <DateTime>
|
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| 437 | <ExactDateTime>2010-08-25T00:00:00-05:00</ExactDateTime>
|
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| 438 | </DateTime>
|
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| 439 | <Type>
|
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| 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>
|
---|