138157c7-3234-420e-82f9-fd23733c4538EnglishV1.02010-09-08T19:21:51-05:00ACTORPATIENT_100839ACTORPROVIDER_10000000020ACTORSYSTEM_1ACTORPATIENT_100839PatientCEND PHRPROBLEM12010-09-04T00:00:00-05:00ProblemDiabetes Mellitus without mention of Complication, type II or unspecified type,250.00ICD9CMActiveACTORPROVIDER_991PROBLEM22010-07-05T00:00:00-05:00ProblemCongestive Heart Failure (ICD-9-CM 428.0)428.0ICD9CMActiveACTORPROVIDER_991PROBLEM32010-07-05T00:00:00-05:00ProblemPostmyocardial infarction syndrome (ICD-9-CM 411.0)411.0ICD9CMActiveACTORPROVIDER_991PROCEDURE_4056_27Procedure Date2010-09-04T00:00:00-05:00INTERMEDIATE (15min)99213CPT-4CompletedACTORPROVIDER_10000000020PROCEDURE_4055_24Procedure Date2010-08-28T00:00:00-05:00EXPANDED, HX & EXAM99202CPT-4CompletedACTORPROVIDER_10000000020PROCEDURE_4047_14Procedure Date2010-07-31T00:00:00-05:00Office/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)99213CPT-4CompletedACTORPROVIDER_10000000020PROCEDURE_4046_7Procedure Date2010-07-05T00:00:00-05:00Office/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)99214CPT-4CompletedACTORPROVIDER_991PROCEDURE_4046_8Procedure Date2010-07-05T00:00:00-05:00Hemoglobin; Glycosylated (A1c) (CPT-4 83036)83036CPT-4CompletedACTORPROVIDER_991PROCEDURE_4046_9Procedure Date2010-07-05T00:00:00-05:00Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704)83704CPT-4CompletedACTORPROVIDER_991PROCEDURE_4046_10Procedure Date2010-07-05T00:00:00-05:00Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414)78414CPT-4CompletedACTORPROVIDER_991ENCOUNTER_40562010-09-04T00:00:00-05:00***ESTABLISHED PATIENT*** INTERMEDIATE (15min)99213CPT-4***ESTABLISHED PATIENT*** INTERMEDIATE (15min)99213CPT-4ACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40552010-08-28T00:00:00-05:00OFFICE VISIT - NEW PT EXPANDED, HX & EXAM99202CPT-4OFFICE VISIT - NEW PT EXPANDED, HX & EXAM99202CPT-4ACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020NOTE_4055ENCOUNTER_40542010-08-27T00:00:00-05:00C&P EXAMINATION REPORTSC&P EXAMINATION REPORTSACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40532010-08-27T00:00:00-05:00NURSING TITLESNURSING TITLESACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40522010-08-14T00:00:00-05:00ADDENDUMADDENDUMACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40492010-08-25T00:00:00-05:00ADDICTION SEVERITY INDEXADDICTION SEVERITY INDEXACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40482010-08-14T00:00:00-05:00INTERDISCIPLINARY MEMBERINTERDISCIPLINARY MEMBERACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020ENCOUNTER_40472010-07-31T00:00:00-05:00 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)99213CPT-4 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)99213CPT-4ACTORORGANIZATION_1ACTORPROVIDER_10000000020ACTORPROVIDER_10000000020NOTE_4047ENCOUNTER_40462010-07-05T00:00:00-05:00 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)99214CPT-4 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)99214CPT-4ACTORORGANIZATION_1ACTORPROVIDER_991ACTORPROVIDER_991NOTE_4046ACTORORGANIZATION_1CAMP MASTEROfficeVA MEDICAL CENTERALBANYNEW YORK12180-0097ACTORSYSTEM_1ACTORPATIENT_100839JODYJEANJONES1945-01-01FEMALEFHL7 AdministrativeGenderSSN002030004ACTORPATIENT_100839HomeACTORPATIENT_100839ACTORPROVIDER_10000000020SYSTEMMANAGERPhysicians (M.D. and D.O.)-Physician/OsteopathWorkVA MEDICAL CENTERALBANYNY12180-0097ACTORSYSTEM_1ACTORORGANIZATION_1representedOrganizationACTORPROVIDER_991EIGHTPROVIDERScholar ExtraordinairePhysicians (M.D. and D.O.)-Physician/OsteopathWorkVA MEDICAL CENTERALBANYNY12180-0097ACTORSYSTEM_1ACTORORGANIZATION_1representedOrganizationACTORSYSTEM_1WorldVistA EHR/VOE1.0ACTORSYSTEM_1@@COMMENTOBJECTID@@@@CMTDATETIME@@@@ACTORSOURCEID@@NOTE_40462010-07-05T00:00:00-05:00
ADDING CLINICAL MEASURES FOR TESTING
Measure 1
Measure 2
Measure 3
Measure 5
Measure 7
Measure 124
------------------------------------------Measure #1
Data for Jones--
ENCOUNTER CODE 99214
DX CODE 250.00
NUMERATOR INCLUSION
A1C CODE 83036
DOCUMENTATION:
HBA1c > 9% PROBLEM (Our patient is less than 9.0%)
---------------------------------------------------
Measure #2
Data for Jones--
ENCOUNTER CODE 99214
DX CODE 250.00
NUMERATOR INCLUSION
LDL CODE 83704
DOCUMENTATION:
LDL < 100 mg/dl LDL from Lab Package
-------------------------------------------------------
Measure #3
Data for Jones--
ENCOUNTER CODE 99214
DX CODE 250.00
NUMERATOR:
DOCUMENTATION:
Systolic (SNOMED) CODE 271649006 or 72313002
AND
Systolic BP <140 mmHg (from Vitals-Bottom number of BP)
Diastolic (SNOMED) CODE 271650006
AND
Diastolic BP < 80 (From Vitals Package-Top number of BP)
NOTE: SNOMED CODES ARE NOT ACCESSIBLE IN VISTA
-------------------------------------------------------
Measure #5
Data for Jones--
ENCOUNTER CODE 99214
DX CODE 428.0
EJRC FRAC CODE 83704
AND
Documentation of LVEF < 40% Need Health Factor for this
NUMERATOR INCLUSION
TOPIC_DRUG_CODES = ACE/ARB (NOT AVAILABLE IN VISTA)
-------------------------------------------------------
Measure #7
Data for Jones--
ENCOUNTER CODE 99214
dx 411.0, 412.00
procedure: 78414
NUMERATOR INCLUSION
TOPIC_DRUG_CODES = BETA BLOCKERS
-------------------------------------------------------------
Measure #124
ENCOUNTER CODE 99214
NUMERATOR CODE G8447
-------------------------------------------------------------
ACTORPROVIDER_991NOTE_40472010-07-31T00:00:00-05:00
TESTING ENCOUNTERS
ACTORPROVIDER_10000000020NOTE_40552010-08-28T00:00:00-05:00
SMOKING PQRI CAT
CURRENT EVERY DAY SMOKER 07/31/2010
CURRENT SMOKING STATUS UNKNOWN 08/25/2010
CURRENT SOME DAY SMOKER 08/27/2010
PPD
=========================================
ACTORPROVIDER_10000000020