Index: qrda/CCR/M1-QRDA/PAT_100146_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100146_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100146_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,494 @@ + + + +d010c8bd-eda0-4e36-8a53-c7c677666b29 + +English + +V1.0 + +2010-10-18T15:33:12-05:00 + + +ACTORPATIENT_100146 + + + +ACTORPROVIDER_1 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100146 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2010-10-13T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus without mention of Complication, type II or unspecified type, + +250.02 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000020 + + + + +PROBLEM2 + +2010-10-04T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus + +250.00 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000183 + + + + + + +PROCEDURE_4141_10 + + +Procedure Date + +2010-10-14T00:00:00-05:00 + + +INTERMEDIATE (30min) + +99242 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + +PROCEDURE_4092_7 + + +Procedure Date + +2010-10-04T00:00:00-05:00 + + +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) + +99213 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000183 + + + + + + +ENCOUNTER_4141 + +2010-10-14T00:00:00-05:00 + + +***NEW PATIENT*** INTERMEDIATE (30min) + +99242 +CPT-4 + + + +***NEW PATIENT*** INTERMEDIATE (30min) + +99242 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + + + +ENCOUNTER_4092 + +2010-10-04T00:00:00-05:00 + + + 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) + +99213 +CPT-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) + +99213 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000183 + + + + +ACTORPROVIDER_10000000183 + + +NOTE_4092 + + +ENCOUNTER_4091 + +2010-10-04T00:00:00-05:00 + + + 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) + +99213 +CPT-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) + +99213 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000183 + + + + +ACTORPROVIDER_10000000183 + + +NOTE_4091 + + + + + +ACTORORGANIZATION_1 + +CAMP MASTER + +
+ +Office + +VA MEDICAL CENTER +ALBANY +NEW YORK +12180 +
+ + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100146 + + + +MALE-D +MEASURE-TWO + + + +1960-01-01 + + +MALE + +M +HL7 AdministrativeGender + + + + + +SSN + +666000200 + + +ACTORPATIENT_100146 + + + +
+ +Home + +Any Street +Any Town +WEST VIRGINIA +
+ +222-555-8235 + +Residential Telephone + + + +222-555-7720 + +Work Telephone + + + + +ACTORPATIENT_100146 + + + + +ACTORPROVIDER_1 + + + +ONE +PROGRAMMER +COMPUTER SPECIALIST + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ +6655544 + +Office + + + + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000020 + + + +NANCY +ANTHRACITE + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000183 + + + +MATTHEW +M +KING + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORSYSTEM_1 + +WorldVistA EHR/VOE +1.0 + + + +ACTORSYSTEM_1 + + + + + + +@@COMMENTOBJECTID@@ + +@@CMTDATETIME@@ + + + +@@ACTORSOURCEID@@ + + + + +NOTE_4091 + +2010-10-04T00:00:00-05:00 + + + +PLACE DIABETIC ORDERS HERE. +PATIENT HBA1C RESULTS + PATIENTS HBA1C IS GREATER THAN 9% + HBA1C VALUE: 9.1 + *** No Outpatient measurements *** + + + + +ACTORPROVIDER_10000000183 + + + + +NOTE_4092 + +2010-10-04T00:00:00-05:00 + + + +PATIENT MAMMOGRAM INFORMATION: + PATIENT HAD A SCREENING MAMMOGRAM. + RESULT NEM (No Evidence of Malignancy) + DATE OF PROCEDURE: September 6, 2010 + + + + +ACTORPROVIDER_10000000183 + + + + + Index: qrda/CCR/M1-QRDA/PAT_100146_QRDA_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100146_QRDA_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100146_QRDA_V1_0_0.xml (revision 983) @@ -0,0 +1,683 @@ + + + + + + + + +QRDA Incidence Report + + + + + + + + + +Any Street +Any Town +WEST VIRGINIA + + + + + +MALE-D +MEASURE-TWO + + + + + + + + + + + + + +World VistA Test Clinic + + + + + + + +WorldVistA Test Clinic + + + + + + + + + + + +Dr. +Nancy +Anthracite + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + +
+ + +Measure set: CMS EHR Measure Set +2010 Measures Set Measures + +
+ + + + + + + + + + + + +Measure Section + + +CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus +CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus +CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus +CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) +CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) +CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years +CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older +CMS Measure #112: Preventive Care and Screening: Screening Mammography +CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening +CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) +CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0% + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL) + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) + + + + + + + +Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy + + + + + + + +Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy + + + + + + + +Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) + + + + + + + +Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine + + + + + + + +Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months + + + + + + + +Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening + + + + + + + +Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR) + + + + + + + +Documents whether provider has adopted and is using ePrescribing + + + + +
+ +Reporting Parameters + + +Reporting Period Jan 1, 2010 to Dec 31, 2010 + + + + + + + + + + + +
+ + +
+ + +Purpose +CEND PHR +
+ + +
+ + + + +Problems + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionStatusSource
Problem + + + + + + +
Oct 13, 2010
+		250.02 (ICD9CM) + Diabetes Mellitus without mention of Complication, type II or unspecified type,ActiveNANCY ANTHRACITE
Problem + + + + + + +
Oct 4, 2010
+		250.00 (ICD9CM) + Diabetes MellitusActiveMATTHEW M KING
+ + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +NANCY +ANTHRACITE + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +MATTHEW +M +KING + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + +
+ + +
+ + +Procedures + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionLocationSubstanceMethodPositionSiteStatusSource
+ + + + + + + +
Procedure Date: + Oct 14, 2010
+		99242 (CPT-4) + INTERMEDIATE (30min) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + +
Procedure Date: + Oct 4, 2010
+		99213 (CPT-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) + + + + +CompletedMATTHEW M KING
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + +
+ + + + +Encounters + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateLocationStatusPractitionerDescriptionIndicationsSource
***NEW PATIENT*** INTERMEDIATE (30min) + + + +***NEW PATIENT*** INTERMEDIATE (30min) +NANCY ANTHRACITE
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) + + + + 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) +MATTHEW M KING
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) + + + + 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) +MATTHEW M KING
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ +
+ + + + Index: qrda/CCR/M1-QRDA/PAT_100848_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100848_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100848_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,471 @@ + + + +33f5b05b-e101-4530-9b91-97203c8b71e6 + +English + +V1.0 + +2010-10-18T15:37:06-05:00 + + +ACTORPATIENT_100848 + + + +ACTORPROVIDER_1 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100848 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2010-10-13T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus without mention of Complication, type II or unspecified type, + +250.00 +ICD9CM + + + +Active + + + +ACTORPROVIDER_991 + + + + +PROBLEM2 + +2010-10-05T00:00:00-05:00 + + +Problem + + +Sprains (ICD-9-CM 848.9) + +848.9 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000183 + + + + + + +PROCEDURE_4108_8 + + +Procedure Date + +2010-10-13T00:00:00-05:00 + + +Sodium; serum, plasma or whole blood (CPT-4 84295) + +84295 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + +PROCEDURE_4093_5 + + +Procedure Date + +2010-10-05T00:00:00-05:00 + + +INTERMEDIATE (15min) + +99213 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000183 + + + + + + +ENCOUNTER_4108 + +2010-10-13T00:00:00-05:00 + + + Sodium; serum, plasma or whole blood (CPT-4 84295) + + + Sodium; serum, plasma or whole blood (CPT-4 84295) + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + +NOTE_4108 + + +ENCOUNTER_4093 + +2010-10-05T00:00:00-05:00 + + +***ESTABLISHED PATIENT*** INTERMEDIATE (15min) + +99213 +CPT-4 + + + +***ESTABLISHED PATIENT*** INTERMEDIATE (15min) + +99213 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000183 + + + + +ACTORPROVIDER_10000000183 + + +NOTE_4093 + + + + + +ACTORORGANIZATION_1 + +CAMP MASTER + +
+ +Office + +VA MEDICAL CENTER +ALBANY +NEW YORK +12180 +
+ + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100848 + + + +FEMALE-B +MEASURE-ONE + + + +1960-01-01 + + +FEMALE + +F +HL7 AdministrativeGender + + + + + +SSN + +345097898 + + +ACTORPATIENT_100848 + + + +
+ +Home + +
+ + +ACTORPATIENT_100848 + + + + +ACTORPROVIDER_1 + + + +ONE +PROGRAMMER +COMPUTER SPECIALIST + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ +6655544 + +Office + + + + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000020 + + + +NANCY +ANTHRACITE + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000183 + + + +MATTHEW +M +KING + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_991 + + + +EIGHT +PROVIDER +Scholar Extraordinaire + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORSYSTEM_1 + +WorldVistA EHR/VOE +1.0 + + + +ACTORSYSTEM_1 + + + + + + +@@COMMENTOBJECTID@@ + +@@CMTDATETIME@@ + + + +@@ACTORSOURCEID@@ + + + + +NOTE_4093 + +2010-10-05T00:00:00-05:00 + + + +PATIENT MAMMOGRAM INFORMATION: + PATIENT HAD A SCREENING MAMMOGRAM. + RESULT NEM (No Evidence of Malignancy) + DATE OF PROCEDURE: September 9, 2010 + + + + +ACTORPROVIDER_10000000183 + + + + +NOTE_4108 + +2010-10-13T00:00:00-05:00 + + + +PATIENT HBA1C RESULTS + PATIENTS HBA1C IS GREATER THAN 9% + HBA1C VALUE: 9.2 + + Measurement DT BP PULSE WEIGHT + LB(KG)[BMI] + 10/05/2010 12:52 130/90 89 138(62.60)[23] + + + + +ACTORPROVIDER_10000000020 + + + + + Index: qrda/CCR/M1-QRDA/PAT_100848_QRDA_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100848_QRDA_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100848_QRDA_V1_0_0.xml (revision 983) @@ -0,0 +1,660 @@ + + + + + + + + +QRDA Incidence Report + + + + + + + + + + + + + + + + + +FEMALE-B +MEASURE-ONE + + + + + + + + + + + + + +World VistA Test Clinic + + + + + + + +WorldVistA Test Clinic + + + + + + + + + + + +Dr. +Nancy +Anthracite + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + +
+ + +Measure set: CMS EHR Measure Set +2010 Measures Set Measures + +
+ + + + + + + + + + + + +Measure Section + + +CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus +CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus +CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus +CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) +CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) +CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years +CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older +CMS Measure #112: Preventive Care and Screening: Screening Mammography +CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening +CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) +CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0% + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL) + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) + + + + + + + +Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy + + + + + + + +Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy + + + + + + + +Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) + + + + + + + +Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine + + + + + + + +Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months + + + + + + + +Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening + + + + + + + +Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR) + + + + + + + +Documents whether provider has adopted and is using ePrescribing + + + + +
+ +Reporting Parameters + + +Reporting Period Jan 1, 2010 to Dec 31, 2010 + + + + + + + + + + + +
+ + +
+ + +Purpose +CEND PHR +
+ + +
+ + + + +Problems + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionStatusSource
Problem + + + + + + +
Oct 13, 2010
+		250.00 (ICD9CM) + Diabetes Mellitus without mention of Complication, type II or unspecified type,ActiveEIGHT PROVIDER Scholar Extraordinaire
Problem + + + + + + +
Oct 5, 2010
+		848.9 (ICD9CM) + Sprains (ICD-9-CM 848.9)ActiveMATTHEW M KING
+ + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +Scholar Extraordinaire +EIGHT +PROVIDER + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +MATTHEW +M +KING + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + +
+ + +
+ + +Procedures + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionLocationSubstanceMethodPositionSiteStatusSource
+ + + + + + + +
Procedure Date: + Oct 13, 2010
+		84295 (CPT-4) + Sodium; serum, plasma or whole blood (CPT-4 84295) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + +
Procedure Date: + Oct 5, 2010
+		99213 (CPT-4) + INTERMEDIATE (15min) + + + + +CompletedMATTHEW M KING
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + +
+ + + + +Encounters + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateLocationStatusPractitionerDescriptionIndicationsSource
Sodium; serum, plasma or whole blood (CPT-4 84295) + + + + Sodium; serum, plasma or whole blood (CPT-4 84295) +NANCY ANTHRACITE
***ESTABLISHED PATIENT*** INTERMEDIATE (15min) + + + +***ESTABLISHED PATIENT*** INTERMEDIATE (15min) +MATTHEW M KING
+ + + + + + + + + Sodium; serum, plasma or whole blood (CPT-4 84295) + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ +
+ + + + Index: qrda/CCR/M1-QRDA/PAT_100849_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100849_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100849_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,384 @@ + + + +97354999-51b7-4bad-8909-7ddc1e5cda1f + +English + +V1.0 + +2010-10-18T15:37:03-05:00 + + +ACTORPATIENT_100849 + + + +ACTORPROVIDER_1 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100849 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2010-10-13T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus without mention of Complication, type II or unspecified type, + +250.02 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000020 + + + + + + +PROCEDURE_4130_7 + + +Procedure Date + +2010-10-14T00:00:00-05:00 + + +INTERMEDIATE (20min) + +99202 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + +PROCEDURE_4113_4 + + +Procedure Date + +2010-10-13T00:00:00-05:00 + + +INTERMEDIATE (20min) + +99202 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + + + +ENCOUNTER_4130 + +2010-10-14T00:00:00-05:00 + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + +NOTE_4130 + + +ENCOUNTER_4113 + +2010-10-13T00:00:00-05:00 + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + +NOTE_4113 + + + + + +ACTORORGANIZATION_1 + +CAMP MASTER + +
+ +Office + +VA MEDICAL CENTER +ALBANY +NEW YORK +12180 +
+ + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100849 + + + +MALE-C +MEASURE-ONE + + + +1960-01-01 + + +MALE + +M +HL7 AdministrativeGender + + + + + +SSN + +345980099 + + +ACTORPATIENT_100849 + + + +
+ +Home + +
+ + +ACTORPATIENT_100849 + + + + +ACTORPROVIDER_1 + + + +ONE +PROGRAMMER +COMPUTER SPECIALIST + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ +6655544 + +Office + + + + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000020 + + + +NANCY +ANTHRACITE + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORSYSTEM_1 + +WorldVistA EHR/VOE +1.0 + + + +ACTORSYSTEM_1 + + + + + + +@@COMMENTOBJECTID@@ + +@@CMTDATETIME@@ + + + +@@ACTORSOURCEID@@ + + + + +NOTE_4113 + +2010-10-13T00:00:00-05:00 + + + +PLACE DIABETIC ORDERS HERE. +PATIENT HBA1C RESULTS + PATIENTS HBA1C IS GREATER THAN 9% + HBA1C VALUE: 9.2 + *** No Outpatient measurements *** + + + + +ACTORPROVIDER_10000000020 + + + + +NOTE_4130 + +2010-10-14T00:00:00-05:00 + + + +test note + + + + +ACTORPROVIDER_10000000020 + + + + + Index: qrda/CCR/M1-QRDA/PAT_100849_QRDA_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100849_QRDA_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100849_QRDA_V1_0_0.xml (revision 983) @@ -0,0 +1,588 @@ + + + + + + + + +QRDA Incidence Report + + + + + + + + + + + + + + + + + +MALE-C +MEASURE-ONE + + + + + + + + + + + + + +World VistA Test Clinic + + + + + + + +WorldVistA Test Clinic + + + + + + + + + + + +Dr. +Nancy +Anthracite + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + +
+ + +Measure set: CMS EHR Measure Set +2010 Measures Set Measures + +
+ + + + + + + + + + + + +Measure Section + + +CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus +CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus +CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus +CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) +CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) +CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years +CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older +CMS Measure #112: Preventive Care and Screening: Screening Mammography +CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening +CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) +CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0% + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL) + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) + + + + + + + +Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy + + + + + + + +Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy + + + + + + + +Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) + + + + + + + +Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine + + + + + + + +Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months + + + + + + + +Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening + + + + + + + +Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR) + + + + + + + +Documents whether provider has adopted and is using ePrescribing + + + + +
+ +Reporting Parameters + + +Reporting Period Jan 1, 2010 to Dec 31, 2010 + + + + + + + + + + + +
+ + +
+ + +Purpose +CEND PHR +
+ + +
+ + + + +Problems + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionStatusSource
Problem + + + + + + +
Oct 13, 2010
+		250.02 (ICD9CM) + Diabetes Mellitus without mention of Complication, type II or unspecified type,ActiveNANCY ANTHRACITE
+ + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +NANCY +ANTHRACITE + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + +
+ + +
+ + +Procedures + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionLocationSubstanceMethodPositionSiteStatusSource
+ + + + + + + +
Procedure Date: + Oct 14, 2010
+		99202 (CPT-4) + INTERMEDIATE (20min) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + +
Procedure Date: + Oct 13, 2010
+		99202 (CPT-4) + INTERMEDIATE (20min) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + +
+ + + + +Encounters + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateLocationStatusPractitionerDescriptionIndicationsSource
***NEW PATIENT*** INTERMEDIATE (20min) + + + +***NEW PATIENT*** INTERMEDIATE (20min) +NANCY ANTHRACITE
***NEW PATIENT*** INTERMEDIATE (20min) + + + +***NEW PATIENT*** INTERMEDIATE (20min) +NANCY ANTHRACITE
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ +
+ + + + Index: qrda/CCR/M1-QRDA/PAT_100855_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100855_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100855_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,434 @@ + + + +b315d695-9575-425e-9e78-26475b38323e + +English + +V1.0 + +2010-10-18T15:37:59-05:00 + + +ACTORPATIENT_100855 + + + +ACTORPROVIDER_1 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100855 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2010-10-14T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus without mention of Complication, type II or unspecified type, + +250.00 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000020 + + + + +PROBLEM2 + +2010-10-14T00:00:00-05:00 + + +Problem + + +Diabetes (ICD-9-CM 250.00) + +250.00 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000020 + + + + +PROBLEM3 + +2010-10-13T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus without mention of Complication, type II or unspecified type, + +250.00 +ICD9CM + + + +Active + + + +ACTORPROVIDER_10000000020 + + + + + + +PROCEDURE_4127_7 + + +Procedure Date + +2010-10-14T00:00:00-05:00 + + +LIMITED (10min) + +99212 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + +PROCEDURE_4110_4 + + +Procedure Date + +2010-10-13T00:00:00-05:00 + + +INTERMEDIATE (20min) + +99202 +CPT-4 + + + +Completed + + + +ACTORPROVIDER_10000000020 + + + + + + +ENCOUNTER_4127 + +2010-10-14T00:00:00-05:00 + + +***ESTABLISHED PATIENT*** LIMITED (10min) + +99212 +CPT-4 + + + +***ESTABLISHED PATIENT*** LIMITED (10min) + +99212 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + +NOTE_4127 + + +ENCOUNTER_4110 + +2010-10-13T00:00:00-05:00 + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + +***NEW PATIENT*** INTERMEDIATE (20min) + +99202 +CPT-4 + + + + +ACTORORGANIZATION_1 + + + + +ACTORPROVIDER_10000000020 + + + + +ACTORPROVIDER_10000000020 + + +NOTE_4110 + + + + + +ACTORORGANIZATION_1 + +CAMP MASTER + +
+ +Office + +VA MEDICAL CENTER +ALBANY +NEW YORK +12180 +
+ + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_100855 + + + +FEMALE-E +MEASURE-ONE + + + +1960-01-01 + + +FEMALE + +F +HL7 AdministrativeGender + + + + + +SSN + +498212298 + + +ACTORPATIENT_100855 + + + +
+ +Home + +
+ + +ACTORPATIENT_100855 + + + + +ACTORPROVIDER_1 + + + +ONE +PROGRAMMER +COMPUTER SPECIALIST + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ +6655544 + +Office + + + + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORPROVIDER_10000000020 + + + +NANCY +ANTHRACITE + + + + +Physicians (M.D. and D.O.)-Physician/Osteopath + +
+ +Work + +VA MEDICAL CENTER +ALBANY +NY +12180 +
+ + +ACTORSYSTEM_1 + + + +ACTORORGANIZATION_1 +representedOrganization + + + +ACTORSYSTEM_1 + +WorldVistA EHR/VOE +1.0 + + + +ACTORSYSTEM_1 + + + + + + +@@COMMENTOBJECTID@@ + +@@CMTDATETIME@@ + + + +@@ACTORSOURCEID@@ + + + + +NOTE_4110 + +2010-10-13T00:00:00-05:00 + + + +PATIENT HBA1C RESULTS + PATIENTS HBA1C IS GREATER THAN 9% + HBA1C VALUE: 9.3 + *** No Outpatient measurements *** + + + + +ACTORPROVIDER_10000000020 + + + + +NOTE_4127 + +2010-10-14T00:00:00-05:00 + + + +PATIENT HBA1C RESULTS + PATIENTS HBA1C IS GREATER THAN 9% + HBA1C VALUE: 9.1 + *** No Outpatient measurements *** + + + + +ACTORPROVIDER_10000000020 + + + + + Index: qrda/CCR/M1-QRDA/PAT_100855_QRDA_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_100855_QRDA_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_100855_QRDA_V1_0_0.xml (revision 983) @@ -0,0 +1,724 @@ + + + + + + + + +QRDA Incidence Report + + + + + + + + + + + + + + + + + +FEMALE-E +MEASURE-ONE + + + + + + + + + + + + + +World VistA Test Clinic + + + + + + + +WorldVistA Test Clinic + + + + + + + + + + + +Dr. +Nancy +Anthracite + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + + + + + + + + + + +123 Maple Ave +Gaithersburg +MD +20877 + + + +Nancy +Anthracite +MD + + + + + + + + + +
+ + +Measure set: CMS EHR Measure Set +2010 Measures Set Measures + +
+ + + + + + + + + + + + +Measure Section + + +CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus +CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus +CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus +CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) +CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) +CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years +CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older +CMS Measure #112: Preventive Care and Screening: Screening Mammography +CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening +CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) +CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0% + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL) + + + + + + + +Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) + + + + + + + +Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy + + + + + + + +Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy + + + + + + + +Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February) + + + + + + + +Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine + + + + + + + +Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months + + + + + + + +Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening + + + + + + + +Documents whether provider has adopted and is using health information technology. To qualify, the provider must havea adopted and be using a certified/qualified electronic health record (EHR) + + + + + + + +Documents whether provider has adopted and is using ePrescribing + + + + +
+ +Reporting Parameters + + +Reporting Period Jan 1, 2010 to Dec 31, 2010 + + + + + + + + + + + +
+ + +
+ + +Purpose +CEND PHR +
+ + +
+ + + + +Problems + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionStatusSource
Problem + + + + + + +
Oct 14, 2010
+		250.00 (ICD9CM) + Diabetes Mellitus without mention of Complication, type II or unspecified type,ActiveNANCY ANTHRACITE
Problem + + + + + + +
Oct 14, 2010
+		250.00 (ICD9CM) + Diabetes (ICD-9-CM 250.00)ActiveNANCY ANTHRACITE
Problem + + + + + + +
Oct 13, 2010
+		250.00 (ICD9CM) + Diabetes Mellitus without mention of Complication, type II or unspecified type,ActiveNANCY ANTHRACITE
+ + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +NANCY +ANTHRACITE + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +NANCY +ANTHRACITE + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + + + + + + + + + + +VA MEDICAL CENTER +ALBANY +NY +12180 + + + + +NANCY +ANTHRACITE + + + + + + + + + + + + + + + + + + + + + + + + +Active + + + + + + + +
+ + +
+ + +Procedures + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateCodeDescriptionLocationSubstanceMethodPositionSiteStatusSource
+ + + + + + + +
Procedure Date: + Oct 14, 2010
+		99212 (CPT-4) + LIMITED (10min) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + +
Procedure Date: + Oct 13, 2010
+		99202 (CPT-4) + INTERMEDIATE (20min) + + + + +CompletedNANCY ANTHRACITE
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + +
+ + + + +Encounters + + + + + + + + + + + + + + + + + + + + + + + + +
TypeDateLocationStatusPractitionerDescriptionIndicationsSource
***ESTABLISHED PATIENT*** LIMITED (10min) + + + +***ESTABLISHED PATIENT*** LIMITED (10min) +NANCY ANTHRACITE
***NEW PATIENT*** INTERMEDIATE (20min) + + + +***NEW PATIENT*** INTERMEDIATE (20min) +NANCY ANTHRACITE
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ +
+ + + + Index: qrda/CCR/M1-QRDA/PAT_140_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_140_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_140_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,8313 @@ + + + +ac08ff2c-2d09-4a78-9a06-5f08155916c2 + +English + +V1.0 + +2010-06-22T19:59:57-05:00 + + +ACTORPATIENT_140 + + + +ACTORPROVIDER_10000000020 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_140 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2007-04-10T00:00:00-05:00 + + +Problem + + +Hypertension + +401.9 +ICD9CM + + + +Active/Chronic + + + +ACTORPROVIDER_10000000031 + + + + +PROBLEM2 + +2007-04-10T00:00:00-05:00 + + +Problem + + +Hyperlipidemia + +272.4 +ICD9CM + + + +Active/Chronic + + + +ACTORPROVIDER_10000000031 + + + + +PROBLEM3 + +2005-03-19T00:00:00-05:00 + + +Problem + + +Acute myocardial infarction, unspecified site, episode of care unspecified + +410.90 +ICD9CM + + + +Active + + + +ACTORPROVIDER_20029 + + + + +PROBLEM4 + +2004-03-09T00:00:00-05:00 + + +Problem + + +Chronic Systolic Heart failure + +428.22 +ICD9CM + + + +Active/Chronic + + + +ACTORPROVIDER_11745 + + + + +PROBLEM5 + +2004-03-31T00:00:00-05:00 + + +Problem + + +Diabetes Mellitus Type II or unspecified + +250.00 +ICD9CM + + + +Active/Chronic + + + +ACTORPROVIDER_20029 + + + + + + +ALERT1 + +2005-03-19T10:15:00-05:00 + + +Adverse Reaction + + +Patient has an ADVERSE reaction to PENICILLIN. + +282100009 +SNOMED CT + + + + +ACTORPROVIDER_20029 + + + + + +PRODUCT_125 + + +ACTORPROVIDER_20029 + + + + +PENICILLIN + + + + + + + +ITCHING,WATERING EYES + + + + +ALERT2 + +2007-12-17T15:33:00-05:00 + + +Allergy + + +Patient has an ALLERGIC reaction to CHOCOLATE. + +418634005 +SNOMED CT + + + + +ACTORPROVIDER_983 + + + + + +PRODUCT_3 + + +ACTORPROVIDER_983 + + + + +CHOCOLATE + +4636681 +VUID + + + + + + + + +DIARRHEA + +4637011 +VUID + + + + + + + +VITAL1 + + +OBSERVED + +2007-04-24T08:00:00-05:00 + + +WEIGHT + + + +ACTORSYSTEM_1 + + + +VITALTEST1 + +OBSERVED + + +WEIGHT + +107647005 +SNOMED + + + + +ACTORPROVIDER_10000000053 + + + +175 + +lbs + + + + + +VITAL2 + + +OBSERVED + +2007-04-11T07:45:00-05:00 + + +WEIGHT + + + +ACTORSYSTEM_1 + + + +VITALTEST2 + +OBSERVED + + +WEIGHT + +107647005 +SNOMED + + + + +ACTORPROVIDER_10000000053 + + + +184 + +lbs + + + + + +VITAL3 + + +OBSERVED + +2007-03-15T08:00:00-05:00 + + +WEIGHT + + + +ACTORSYSTEM_1 + + + +VITALTEST3 + +OBSERVED + + +WEIGHT + +107647005 +SNOMED + + + + +ACTORPROVIDER_10000000053 + + + +196 + +lbs + + + + + +VITAL4 + + +OBSERVED + +2005-03-16T06:00:00-05:00 + + +TEMPERATURE + + + +ACTORSYSTEM_1 + + + +VITALTEST4 + +OBSERVED + + +TEMPERATURE + +309646008 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +102.6 + +F + + + + + +VITAL5 + + +OBSERVED + +2005-03-16T06:00:00-05:00 + + +RESPIRATION + + + +ACTORSYSTEM_1 + + + +VITALTEST5 + +OBSERVED + + +RESPIRATION + +366147009 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +21 + + + + +VITAL6 + + +OBSERVED + +2005-03-16T06:00:00-05:00 + + +PAIN + + + +ACTORSYSTEM_1 + + + +VITALTEST6 + +OBSERVED + + +PAIN + +22253000 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +3 + + + + +VITAL7 + + +OBSERVED + +2005-03-16T01:00:00-05:00 + + +TEMPERATURE + + + +ACTORSYSTEM_1 + + + +VITALTEST7 + +OBSERVED + + +TEMPERATURE + +309646008 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +99 + +F + + + + + +VITAL8 + + +OBSERVED + +2005-03-16T01:00:00-05:00 + + +RESPIRATION + + + +ACTORSYSTEM_1 + + + +VITALTEST8 + +OBSERVED + + +RESPIRATION + +366147009 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +18 + + + + +VITAL9 + + +OBSERVED + +2005-03-16T01:00:00-05:00 + + +PAIN + + + +ACTORSYSTEM_1 + + + +VITALTEST9 + +OBSERVED + + +PAIN + +22253000 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +1 + + + + +VITAL10 + + +OBSERVED + +2005-03-15T11:03:00-05:00 + + +WEIGHT + + + +ACTORSYSTEM_1 + + + +VITALTEST10 + +OBSERVED + + +WEIGHT + +107647005 +SNOMED + + + + +ACTORPROVIDER_20391 + + + +199 + +lbs + + + + + +VITAL11 + + +OBSERVED + 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See attached scanned document for patient's +signature. + + + + +ACTORPROVIDER_11278 + + + + +NOTE_1968 + +2001-04-09T00:00:00-05:00 + + + +GASTROINTESTINAL: Denies. +GENITOURINARY: Denies nocturia. +HEMOPOIETIC: Denies anemia, or easy bruisability. +LYMPHATIC: Denies. +MUSCULOSKELETAL: chronic low back pain. +NEUROLOGIC: Denies history of coma, paralysis, epilepsy, or convulsions. +PSYCHIATRIC: Denies. + +PHYSICAL EXAMINATION: +GENERAL: This is a well-nourished, well-developed male in no apparent +Distress. He is alert and oriented to person, place, time and purpose. + + + + +ACTORPROVIDER_11740 + + + + +NOTE_3136 + +2004-04-02T00:00:00-05:00 + + + +HX: Patient was seen for hearing aid fitting and orientation. +The batteries supplied for this hearing aid were: za312. + +IMP: The veteran was seen for hearing aid fitting and orientation. A +complete orientation was performed, and the patient can insert the +aids(s), change the batteries, and adjust the volume. Response curves +were obtained using a real- ear probe microphone in-situ Measurement +System and indicated appropriate gain for the demonstrated hearing loss. +Care of the aid(s), warranty information and dangers of battery ingestion +were discussed with the veteran. + +REC: Continued use of present amplification is recommended + + + + +ACTORPROVIDER_11748 + + + + + Index: qrda/CCR/M1-QRDA/PAT_3_CCR_V1_0_0.xml =================================================================== --- qrda/CCR/M1-QRDA/PAT_3_CCR_V1_0_0.xml (revision 983) +++ qrda/CCR/M1-QRDA/PAT_3_CCR_V1_0_0.xml (revision 983) @@ -0,0 +1,7795 @@ + + + +f7e11811-2eca-4404-9716-0ff45787afd0 + +English + +V1.0 + +2010-06-22T19:59:12-05:00 + + +ACTORPATIENT_3 + + + +ACTORPROVIDER_10000000020 + + +ACTORSYSTEM_1 + + + + +ACTORPATIENT_3 + +Patient + + + + + +CEND PHR + + + + + +PROBLEM1 + +2010-03-31T00:00:00-05:00 + + +Problem + + +SOCIAL HISTORY + +799.9 +ICD9CM + + + +Active/Chronic + + + +ACTORPROVIDER_10000000020 + + + + 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