Changeset 997


Ignore:
Timestamp:
Nov 1, 2010, 9:21:38 PM (14 years ago)
Author:
George Lilly
Message:

current QRDA submissions

Location:
qrda/CCR/M1-QRDA
Files:
15 added
4 edited

Legend:

Unmodified
Added
Removed

  • qrda/CCR/M1-QRDA/PAT_100146_QRDA_V1_0_0.xml

    r983 r997  
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    88<code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
    99<title>QRDA Incidence Report</title>
    … …  
    9898</associatedEntity>
    9999</participant>
    100 <documentationOf>
    101 <serviceEvent>
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    103 <effectiveTime>
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    105 <high value="20100205"/>
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    111 <addr>
    112 <streetAddressLine>123 Maple Ave</streetAddressLine>
    113 <city>Gaithersburg</city>
    114 <state>MD</state>
    115 <postalCode>20877</postalCode>
    116 </addr>
    117 <assignedPerson>
    118 <name>
    119 <given>Nancy</given>
    120 <family>Anthracite</family>
    121 <suffix>MD</suffix>
    122 </name>
    123 </assignedPerson>
    124 </assignedEntity>
    125 </performer>
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    134 </effectiveTime>
    135 <performer typeCode="PRF">
    136 <assignedEntity>
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    138 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    139 <addr>
    140 <streetAddressLine>123 Maple Ave</streetAddressLine>
    141 <city>Gaithersburg</city>
    142 <state>MD</state>
    143 <postalCode>20877</postalCode>
    144 </addr>
    145 <assignedPerson>
    146 <name>
    147 <given>Nancy</given>
    148 <family>Anthracite</family>
    149 <suffix>MD</suffix>
    150 </name>
    151 </assignedPerson>
    152 </assignedEntity>
    153 </performer>
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    159103<section>
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     104<templateId root="2.16.840.1.113883.3.249.11.50"/>
    161105<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
    162106<title>Measure set: CMS EHR Measure Set</title>
    … …  
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     128<templateId root="2.16.840.1.113883.3.249.11.58"/>
     129<templateId root="2.16.840.1.113883.3.249.11.59"/>
     130<templateId root="2.16.840.1.113883.3.249.11.60"/>
    177131<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
    178132<title>Measure Section</title>
    … …  
    190144<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
    191145<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
     146<item>CMS Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older</item>
     147<item>CMS Measure #47: Advance Care Plan </item>
     148<item>CMS Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older</item>
     149<item>CMS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up </item>
     150<item>CMS Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening</item>
     151<item>CMS Measure #0013: Hypertension (HTN): Blood Pressure Measurement - QRDA Cat I template </item>
     152<item>CMS Measure #0022: Drugs to be avoided in the Elderly </item>
     153<item>CMS Measure #0024: Body Mass Index (BMI) 2 through 18 years of age </item>
     154<item>CMS Measure #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention</item>
     155<item>CMS Measure #0038: Childhood Immunization Status - QRDA Cat I template</item>
    192156</list>
    193157</text>
    194158<entry typeCode="DRIV">
    195159<act classCode="ACT" moodCode="DEF">
    196 <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
    197160<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    198161<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
    … …  
    202165<entry typeCode="DRIV">
    203166<act classCode="ACT" moodCode="DEF">
    204 <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
    205167<code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
    206168<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
    … …  
    210172<entry typeCode="DRIV">
    211173<act classCode="ACT" moodCode="DEF">
    212 <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
    213174<code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    214175<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
    … …  
    218179<entry typeCode="DRIV">
    219180<act classCode="ACT" moodCode="DEF">
    220 <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
    221181<code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
    222182<text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
    … …  
    226186<entry typeCode="DRIV">
    227187<act classCode="ACT" moodCode="DEF">
    228 <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
    229188<code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
    230189<text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
    … …  
    234193<entry typeCode="DRIV">
    235194<act classCode="ACT" moodCode="DEF">
    236 <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
    237195<code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients &gt;= 50 Years"/>
    238196<text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
    … …  
    242200<entry typeCode="DRIV">
    243201<act classCode="ACT" moodCode="DEF">
    244 <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
    245202<code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
    246203<text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
    … …  
    250207<entry typeCode="DRIV">
    251208<act classCode="ACT" moodCode="DEF">
    252 <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
    253209<code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
    254210<text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
    … …  
    258214<entry typeCode="DRIV">
    259215<act classCode="ACT" moodCode="DEF">
    260 <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
    261216<code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
    262217<text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
    … …  
    266221<entry typeCode="DRIV">
    267222<act classCode="ACT" moodCode="DEF">
    268 <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
    269223<code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
    270224<text>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)</text>
    … …  
    274228<entry typeCode="DRIV">
    275229<act classCode="ACT" moodCode="DEF">
    276 <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
    277230<code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
     231<text>Documents whether provider has adopted and is using ePrescribing</text>
     232<statusCode code="completed"/>
     233</act>
     234</entry>
     235<entry typeCode="DRIV">
     236<act classCode="ACT" moodCode="DEF">
     237<code code="PQRI-39" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older"/>
     238<text>Percentage of patients who had a DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months before the end of the measurement period</text>
     239<statusCode code="completed"/>
     240</act>
     241</entry>
     242<entry typeCode="DRIV">
     243<act classCode="ACT" moodCode="DEF">
     244<code code="PQRI-47" codeSystem="2.16.840.1.113883.3.249.12" displayName="Advance Care Plan"/>
     245<text>Percentage of patients age 65 and older who have an advanced care plan or surrogate decision maker documented in the medical record or documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.</text>
     246<statusCode code="completed"/>
     247</act>
     248</entry>
     249<entry typeCode="DRIV">
     250<act classCode="ACT" moodCode="DEF">
     251<code code="PQRI-48" codeSystem="2.16.840.1.113883.3.249.12" displayName="Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older"/>
     252<text>Percentage of patients equal to or older than 65 years of age at the beginning of the measurement perion who were assesed for the presence or absence of urinary incontinence within 12 months.</text>
     253<statusCode code="completed"/>
     254</act>
     255</entry>
     256<entry typeCode="DRIV">
     257<act classCode="ACT" moodCode="DEF">
     258<code code="PQRI-128" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"/>
     259<text>Percentage of patients aged 18 yesrs and older with a calculate BMI in the past 6 months or during the current visit documented in the medical record and if the most recent BMI is ourtide parameters, a follow-up plan is documented. Ages 65 and older BMI equal to or greater than 30 or less than 22 and ages 18-64, BMI greater than or equal to 25 or less than 18.5</text>
     260<statusCode code="completed"/>
     261</act>
     262</entry>
     263<entry typeCode="DRIV">
     264<act classCode="ACT" moodCode="DEF">
     265<code code="PQRI-173" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Unhealthy Alcohol Use - Screening"/>
     266<text>Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic method within 24 months</text>
     267<statusCode code="completed"/>
     268</act>
     269</entry>
     270<entry typeCode="DRIV">
     271<act classCode="ACT" moodCode="DEF">
     272<code code="PQRI-13" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hypertension (HTN): Blood Pressure Measurement"/>
     273<text>Percentage of patients aged 18 years and older with a diagnosis of hypertension in the beginning of the measurement period with a blood pressure recoreded.</text>
     274<statusCode code="completed"/>
     275</act>
     276</entry>
     277<entry typeCode="DRIV">
     278<act classCode="ACT" moodCode="DEF">
     279<code code="PQRI-22" codeSystem="2.16.840.1.113883.3.249.12" displayName="Drugs to be avoided in the elderly"/>
     280<text>Percentage of patients aged 65 years and older who received at least one drug to be acoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period</text>
     281<statusCode code="completed"/>
     282</act>
     283</entry>
     284<entry typeCode="DRIV">
     285<act classCode="ACT" moodCode="DEF">
     286<code code="PQRI-24" codeSystem="2.16.840.1.113883.3.249.12" displayName="BMI age 2-18 years of age"/>
     287<text>Percentage of children 2-18 years of age at the beginning of the measurement period whose weight is classified based on BMI percentile for age and gender.</text>
     288<statusCode code="completed"/>
     289</act>
     290</entry>
     291<entry typeCode="DRIV">
     292<act classCode="ACT" moodCode="DEF">
     293<code code="PQRI-28" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive care and Screening: Tobacco Use: Screening and Cessation Intervention"/>
     294<text>Percentage of patients aged 18 years of older who were screened about tobacco use at least once during the two year measurement preoid AND who received cessation counseling if identified as a tobacco user.</text>
     295<statusCode code="completed"/>
     296</act>
     297</entry>
     298<entry typeCode="DRIV">
     299<act classCode="ACT" moodCode="DEF">
     300<code code="PQRI-38" codeSystem="2.16.840.1.113883.3.249.12" displayName="Childhood immumnization status"/>
     301<text>Percentage of children who turn two years of age during the measurement period who have had four DTaP/DT, three IPV, one MMR and three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday</text>
     302<statusCode code="completed"/>
     303</act>
     304</entry>
     305<entry typeCode="DRIV">
     306<act classCode="ACT" moodCode="DEF">
     307<code code="" codeSystem="2.16.840.1.113883.3.249.12" displayName=""/>
    278308<text>Documents whether provider has adopted and is using ePrescribing</text>
    279309<statusCode code="completed"/>
    … …  
    302332<component>
    303333<section>
    304 <templateId root="2.16.840.1.113883.10.20.1.13"/>
    305 <code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
    306 <title>Purpose</title>
    307 <text>CEND PHR</text>
     334<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
     335<title>Patient Data</title>
    308336</section>
    309337</component>
    310 <component>
    311 <section>
    312 <templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
    313 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
    314 <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
    315 <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
    316 <title>Problems</title>
    317 <text>
    318 <table>
    319 <tbody>
    320 <tr>
    321 <th>Type</th>
    322 <th>Date</th>
    323 <th>Code</th>
    324 <th>Description</th>
    325 <th>Status</th>
    326 <th>Source</th>
    327 </tr>
    328 <tr>
    329 <td>Problem</td>
    330 <td>
    331 <table>
    332 <tbody>
    333 <tr xmlns="">
    334 <td>Oct 13, 2010</td>
    335 </tr>
    336 </tbody>
    337 </table>
    338 </td>
    339 <td>250.02 (ICD9CM)
    340                 </td>
    341 <td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
    342 <td>Active</td>
    343 <td>NANCY  ANTHRACITE   </td>
    344 </tr>
    345 <tr>
    346 <td>Problem</td>
    347 <td>
    348 <table>
    349 <tbody>
    350 <tr xmlns="">
    351 <td>Oct 4, 2010</td>
    352 </tr>
    353 </tbody>
    354 </table>
    355 </td>
    356 <td>250.00 (ICD9CM)
    357                 </td>
    358 <td ID="PROBLEM2">Diabetes Mellitus</td>
    359 <td>Active</td>
    360 <td>MATTHEW M KING   </td>
    361 </tr>
    362 </tbody>
    363 </table>
    364 </text>
    365 <entry typeCode="DRIV">
    366 <act classCode="ACT" moodCode="EVN">
    367 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    368 <id root="PROBLEM1" extension="CCRObjectID"/>
    369 <code nullFlavor="NA"/>
    370 <performer typeCode="PRF">
    371 <assignedEntity>
    372 <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
    373 <addr use="WP">
    374 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    375 <city>ALBANY</city>
    376 <state>NY</state>
    377 <postalCode>12180</postalCode>
    378 </addr>
    379 <telecom/>
    380 <assignedPerson>
    381 <name>
    382 <given>NANCY</given>
    383 <family>ANTHRACITE</family>
    384 </name>
    385 </assignedPerson>
    386 </assignedEntity>
    387 </performer>
    388 <entryRelationship typeCode="SUBJ">
    389 <observation classCode="OBS" moodCode="EVN">
    390 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
    391 <id root="PROBLEM1" extension="CCRObjectID"/>
    392 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    393 <text>
    394 <reference value="#PROBLEM1"/>
    395 </text>
    396 <statusCode code="completed"/>
    397 <effectiveTime>
    398 <low value="20101013"/>
    399 <high nullFlavor="UNK"/>
    400 </effectiveTime>
    401 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.02" codeSystemName="ICD9CM" codeSystem=""/>
    402 <entryRelationship typeCode="REFR">
    403 <observation classCode="OBS" moodCode="EVN">
    404 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    405 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    406 <statusCode code="completed"/>
    407 <value>
    408 <originalText>Active</originalText>
    409 </value>
    410 </observation>
    411 </entryRelationship>
    412 </observation>
    413 </entryRelationship>
    414 </act>
    415 </entry>
    416 <entry typeCode="DRIV">
    417 <act classCode="ACT" moodCode="EVN">
    418 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    419 <id root="PROBLEM2" extension="CCRObjectID"/>
    420 <code nullFlavor="NA"/>
    421 <performer typeCode="PRF">
    422 <assignedEntity>
    423 <id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
    424 <addr use="WP">
    425 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    426 <city>ALBANY</city>
    427 <state>NY</state>
    428 <postalCode>12180</postalCode>
    429 </addr>
    430 <telecom/>
    431 <assignedPerson>
    432 <name>
    433 <given>MATTHEW</given>
    434 <given>M</given>
    435 <family>KING</family>
    436 </name>
    437 </assignedPerson>
    438 </assignedEntity>
    439 </performer>
    440 <entryRelationship typeCode="SUBJ">
    441 <observation classCode="OBS" moodCode="EVN">
    442 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
    443 <id root="PROBLEM2" extension="CCRObjectID"/>
    444 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    445 <text>
    446 <reference value="#PROBLEM2"/>
    447 </text>
    448 <statusCode code="completed"/>
    449 <effectiveTime>
    450 <low value="2010104"/>
    451 <high nullFlavor="UNK"/>
    452 </effectiveTime>
    453 <value displayName="Diabetes Mellitus" code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
    454 <entryRelationship typeCode="REFR">
    455 <observation classCode="OBS" moodCode="EVN">
    456 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    457 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    458 <statusCode code="completed"/>
    459 <value>
    460 <originalText>Active</originalText>
    461 </value>
    462 </observation>
    463 </entryRelationship>
    464 </observation>
    465 </entryRelationship>
    466 </act>
    467 </entry>
    468338</section>
    469339</component>
    470 <component>
    471 <section>
    472 <templateId root="2.16.840.1.113883.10.20.1.12"/>
    473 <code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
    474 <title>Procedures</title>
    475 <text>
    476 <table>
    477 <tbody>
    478 <tr>
    479 <th>Type</th>
    480 <th>Date</th>
    481 <th>Code</th>
    482 <th>Description</th>
    483 <th>Location</th>
    484 <th>Substance</th>
    485 <th>Method</th>
    486 <th>Position</th>
    487 <th>Site</th>
    488 <th>Status</th>
    489 <th>Source</th>
    490 </tr>
    491 <tr id="PROCEDURE_4141_10">
    492 <td/>
    493 <table>
    494 <tbody>
    495 <tr xmlns="">
    496 <td>Procedure Date:
    497           </td>
    498 <td>Oct 14, 2010</td>
    499 </tr>
    500 </tbody>
    501 </table>
    502 <td>99242 (CPT-4)
    503                 </td>
    504 <td>INTERMEDIATE (30min)</td>
    505 <td/>
    506 <td/>
    507 <td/>
    508 <td/>
    509 <td/>
    510 <td>Completed</td>
    511 <td>NANCY  ANTHRACITE   </td>
    512 </tr>
    513 <tr id="PROCEDURE_4092_7">
    514 <td/>
    515 <table>
    516 <tbody>
    517 <tr xmlns="">
    518 <td>Procedure Date:
    519           </td>
    520 <td>Oct 4, 2010</td>
    521 </tr>
    522 </tbody>
    523 </table>
    524 <td>99213 (CPT-4)
    525                 </td>
    526 <td>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)</td>
    527 <td/>
    528 <td/>
    529 <td/>
    530 <td/>
    531 <td/>
    532 <td>Completed</td>
    533 <td>MATTHEW M KING   </td>
    534 </tr>
    535 </tbody>
    536 </table>
    537 </text>
    538 <entry typeCode="DRIV">
    539 <procedure classCode="PROC" moodCode="EVN">
    540 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    541 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    542 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    543 <id root="PROCEDURE_4141_10" extension="CCRObjectID"/>
    544 <code displayName="INTERMEDIATE (30min)" code="99242" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    545 <text>
    546 <reference value="#PROCEDURE_4141_10"/>
    547 </text>
    548 <statusCode code="completed"/>
    549 <effectiveTime>
    550 <low value="20101014"/>
    551 <high nullFlavor="UNK"/>
    552 </effectiveTime>
    553 </procedure>
    554 </entry>
    555 <entry typeCode="DRIV">
    556 <procedure classCode="PROC" moodCode="EVN">
    557 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    558 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    559 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    560 <id root="PROCEDURE_4092_7" extension="CCRObjectID"/>
    561 <code displayName="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)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    562 <text>
    563 <reference value="#PROCEDURE_4092_7"/>
    564 </text>
    565 <statusCode code="completed"/>
    566 <effectiveTime>
    567 <low value="2010104"/>
    568 <high nullFlavor="UNK"/>
    569 </effectiveTime>
    570 </procedure>
    571 </entry>
    572340</section>
    573341</component>
    574 <component>
    575 <section>
    576 <templateId root="2.16.840.1.113883.3.88.11.83.127" assigningAuthorityName="HITSP/C83"/>
    577 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3" assigningAuthorityName="IHE PCC"/>
    578 <templateId root="2.16.840.1.113883.10.20.1.3" assigningAuthorityName="HL7 CCD"/>
    579 <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
    580 <title>Encounters</title>
    581 <text>
    582 <table>
    583 <tbody>
    584 <tr>
    585 <th>Type</th>
    586 <th>Date</th>
    587 <th>Location</th>
    588 <th>Status</th>
    589 <th>Practitioner</th>
    590 <th>Description</th>
    591 <th>Indications</th>
    592 <th>Source</th>
    593 </tr>
    594 <tr id="ENCOUNTER_4141">
    595 <td>***NEW PATIENT*** INTERMEDIATE (30min)</td>
    596 <td/>
    597 <td/>
    598 <td/>
    599 <td/>
    600 <td>***NEW PATIENT*** INTERMEDIATE (30min)</td>
    601 <td/>
    602 <td>NANCY  ANTHRACITE   </td>
    603 </tr>
    604 <tr id="ENCOUNTER_4092">
    605 <td> 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)</td>
    606 <td/>
    607 <td/>
    608 <td/>
    609 <td/>
    610 <td> 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)</td>
    611 <td/>
    612 <td>MATTHEW M KING   </td>
    613 </tr>
    614 <tr id="ENCOUNTER_4091">
    615 <td> 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)</td>
    616 <td/>
    617 <td/>
    618 <td/>
    619 <td/>
    620 <td> 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)</td>
    621 <td/>
    622 <td>MATTHEW M KING   </td>
    623 </tr>
    624 </tbody>
    625 </table>
    626 </text>
    627 <entry typeCode="DRIV">
    628 <encounter classCode="ENC" moodCode="EVN">
    629 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    630 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    631 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    632 <id root="ENCOUNTER_4141" extension="CCRObjectID"/>
    633 <code displayName="***NEW PATIENT*** INTERMEDIATE (30min)" code="99242" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    634 <text>
    635 <reference value="#ENCOUNTER_4141"/>
    636 </text>
    637 <effectiveTime>
    638 <low value="20101014"/>
    639 <high nullFlavor="UNK"/>
    640 </effectiveTime>
    641 </encounter>
    642 </entry>
    643 <entry typeCode="DRIV">
    644 <encounter classCode="ENC" moodCode="EVN">
    645 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    646 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    647 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    648 <id root="ENCOUNTER_4092" extension="CCRObjectID"/>
    649 <code displayName=" 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)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    650 <text>
    651 <reference value="#ENCOUNTER_4092"/>
    652 </text>
    653 <effectiveTime>
    654 <low value="2010104"/>
    655 <high nullFlavor="UNK"/>
    656 </effectiveTime>
    657 </encounter>
    658 </entry>
    659 <entry typeCode="DRIV">
    660 <encounter classCode="ENC" moodCode="EVN">
    661 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    662 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    663 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    664 <id root="ENCOUNTER_4091" extension="CCRObjectID"/>
    665 <code displayName=" 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)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    666 <text>
    667 <reference value="#ENCOUNTER_4091"/>
    668 </text>
    669 <effectiveTime>
    670 <low value="2010104"/>
    671 <high nullFlavor="UNK"/>
    672 </effectiveTime>
    673 </encounter>
    674 </entry>
    675 </section>
    676 </component>
    677 </section>
    678 </component>
    679 </section>
    680 </component>
    681342</structuredBody>
    682343</component>

  • qrda/CCR/M1-QRDA/PAT_100848_QRDA_V1_0_0.xml

    r983 r997  
    9898</associatedEntity>
    9999</participant>
    100 <documentationOf>
    101 <serviceEvent>
    102 <code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
    103 <effectiveTime>
    104 <low value="20100205"/>
    105 <high value="20100205"/>
    106 </effectiveTime>
    107 <performer typeCode="PRF">
    108 <assignedEntity>
    109 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
    110 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    111 <addr>
    112 <streetAddressLine>123 Maple Ave</streetAddressLine>
    113 <city>Gaithersburg</city>
    114 <state>MD</state>
    115 <postalCode>20877</postalCode>
    116 </addr>
    117 <assignedPerson>
    118 <name>
    119 <given>Nancy</given>
    120 <family>Anthracite</family>
    121 <suffix>MD</suffix>
    122 </name>
    123 </assignedPerson>
    124 </assignedEntity>
    125 </performer>
    126 </serviceEvent>
    127 </documentationOf>
    128 <documentationOf>
    129 <serviceEvent>
    130 <code code="99204" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
    131 <effectiveTime>
    132 <low value="20100703"/>
    133 <high value="20100703"/>
    134 </effectiveTime>
    135 <performer typeCode="PRF">
    136 <assignedEntity>
    137 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
    138 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    139 <addr>
    140 <streetAddressLine>123 Maple Ave</streetAddressLine>
    141 <city>Gaithersburg</city>
    142 <state>MD</state>
    143 <postalCode>20877</postalCode>
    144 </addr>
    145 <assignedPerson>
    146 <name>
    147 <given>Nancy</given>
    148 <family>Anthracite</family>
    149 <suffix>MD</suffix>
    150 </name>
    151 </assignedPerson>
    152 </assignedEntity>
    153 </performer>
    154 </serviceEvent>
    155 </documentationOf>
    156100<component>
    157101<structuredBody>
    158102<component>
    159103<section>
    160 <templateId root="2.16.840.1.113883.3.249.11.12"/>
     104<templateId root="2.16.840.1.113883.3.249.11.50"/>
    161105<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
    162106<title>Measure set: CMS EHR Measure Set</title>
    … …  
    175119<templateId root="2.16.840.1.113883.3.249.11.11"/>
    176120<templateId root="2.16.840.1.113883.3.249.11.15"/>
     121<templateId root="2.16.840.1.113883.3.249.11.51"/>
     122<templateId root="2.16.840.1.113883.3.249.11.52"/>
     123<templateId root="2.16.840.1.113883.3.249.11.53"/>
     124<templateId root="2.16.840.1.113883.3.249.11.54"/>
     125<templateId root="2.16.840.1.113883.3.249.11.55"/>
     126<templateId root="2.16.840.1.113883.3.249.11.56"/>
     127<templateId root="2.16.840.1.113883.3.249.11.57"/>
     128<templateId root="2.16.840.1.113883.3.249.11.58"/>
     129<templateId root="2.16.840.1.113883.3.249.11.59"/>
     130<templateId root="2.16.840.1.113883.3.249.11.60"/>
    177131<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
    178132<title>Measure Section</title>
    … …  
    190144<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
    191145<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
     146<item>CMS Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older</item>
     147<item>CMS Measure #47: Advance Care Plan </item>
     148<item>CMS Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older</item>
     149<item>CMS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up </item>
     150<item>CMS Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening</item>
     151<item>CMS Measure #0013: Hypertension (HTN): Blood Pressure Measurement - QRDA Cat I template </item>
     152<item>CMS Measure #0022: Drugs to be avoided in the Elderly </item>
     153<item>CMS Measure #0024: Body Mass Index (BMI) 2 through 18 years of age </item>
     154<item>CMS Measure #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention</item>
     155<item>CMS Measure #0038: Childhood Immunization Status - QRDA Cat I template</item>
    192156</list>
    193157</text>
    194158<entry typeCode="DRIV">
    195159<act classCode="ACT" moodCode="DEF">
    196 <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
    197160<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    198161<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
    … …  
    202165<entry typeCode="DRIV">
    203166<act classCode="ACT" moodCode="DEF">
    204 <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
    205167<code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
    206168<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
    … …  
    210172<entry typeCode="DRIV">
    211173<act classCode="ACT" moodCode="DEF">
    212 <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
    213174<code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    214175<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
    … …  
    218179<entry typeCode="DRIV">
    219180<act classCode="ACT" moodCode="DEF">
    220 <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
    221181<code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
    222182<text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
    … …  
    226186<entry typeCode="DRIV">
    227187<act classCode="ACT" moodCode="DEF">
    228 <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
    229188<code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
    230189<text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
    … …  
    234193<entry typeCode="DRIV">
    235194<act classCode="ACT" moodCode="DEF">
    236 <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
    237195<code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients &gt;= 50 Years"/>
    238196<text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
    … …  
    242200<entry typeCode="DRIV">
    243201<act classCode="ACT" moodCode="DEF">
    244 <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
    245202<code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
    246203<text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
    … …  
    250207<entry typeCode="DRIV">
    251208<act classCode="ACT" moodCode="DEF">
    252 <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
    253209<code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
    254210<text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
    … …  
    258214<entry typeCode="DRIV">
    259215<act classCode="ACT" moodCode="DEF">
    260 <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
    261216<code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
    262217<text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
    … …  
    266221<entry typeCode="DRIV">
    267222<act classCode="ACT" moodCode="DEF">
    268 <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
    269223<code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
    270224<text>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)</text>
    … …  
    274228<entry typeCode="DRIV">
    275229<act classCode="ACT" moodCode="DEF">
    276 <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
    277230<code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
     231<text>Documents whether provider has adopted and is using ePrescribing</text>
     232<statusCode code="completed"/>
     233</act>
     234</entry>
     235<entry typeCode="DRIV">
     236<act classCode="ACT" moodCode="DEF">
     237<code code="PQRI-39" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older"/>
     238<text>Percentage of patients who had a DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months before the end of the measurement period</text>
     239<statusCode code="completed"/>
     240</act>
     241</entry>
     242<entry typeCode="DRIV">
     243<act classCode="ACT" moodCode="DEF">
     244<code code="PQRI-47" codeSystem="2.16.840.1.113883.3.249.12" displayName="Advance Care Plan"/>
     245<text>Percentage of patients age 65 and older who have an advanced care plan or surrogate decision maker documented in the medical record or documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.</text>
     246<statusCode code="completed"/>
     247</act>
     248</entry>
     249<entry typeCode="DRIV">
     250<act classCode="ACT" moodCode="DEF">
     251<code code="PQRI-48" codeSystem="2.16.840.1.113883.3.249.12" displayName="Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older"/>
     252<text>Percentage of patients equal to or older than 65 years of age at the beginning of the measurement perion who were assesed for the presence or absence of urinary incontinence within 12 months.</text>
     253<statusCode code="completed"/>
     254</act>
     255</entry>
     256<entry typeCode="DRIV">
     257<act classCode="ACT" moodCode="DEF">
     258<code code="PQRI-128" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"/>
     259<text>Percentage of patients aged 18 yesrs and older with a calculate BMI in the past 6 months or during the current visit documented in the medical record and if the most recent BMI is ourtide parameters, a follow-up plan is documented. Ages 65 and older BMI equal to or greater than 30 or less than 22 and ages 18-64, BMI greater than or equal to 25 or less than 18.5</text>
     260<statusCode code="completed"/>
     261</act>
     262</entry>
     263<entry typeCode="DRIV">
     264<act classCode="ACT" moodCode="DEF">
     265<code code="PQRI-173" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Unhealthy Alcohol Use - Screening"/>
     266<text>Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic method within 24 months</text>
     267<statusCode code="completed"/>
     268</act>
     269</entry>
     270<entry typeCode="DRIV">
     271<act classCode="ACT" moodCode="DEF">
     272<code code="PQRI-13" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hypertension (HTN): Blood Pressure Measurement"/>
     273<text>Percentage of patients aged 18 years and older with a diagnosis of hypertension in the beginning of the measurement period with a blood pressure recoreded.</text>
     274<statusCode code="completed"/>
     275</act>
     276</entry>
     277<entry typeCode="DRIV">
     278<act classCode="ACT" moodCode="DEF">
     279<code code="PQRI-22" codeSystem="2.16.840.1.113883.3.249.12" displayName="Drugs to be avoided in the elderly"/>
     280<text>Percentage of patients aged 65 years and older who received at least one drug to be acoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period</text>
     281<statusCode code="completed"/>
     282</act>
     283</entry>
     284<entry typeCode="DRIV">
     285<act classCode="ACT" moodCode="DEF">
     286<code code="PQRI-24" codeSystem="2.16.840.1.113883.3.249.12" displayName="BMI age 2-18 years of age"/>
     287<text>Percentage of children 2-18 years of age at the beginning of the measurement period whose weight is classified based on BMI percentile for age and gender.</text>
     288<statusCode code="completed"/>
     289</act>
     290</entry>
     291<entry typeCode="DRIV">
     292<act classCode="ACT" moodCode="DEF">
     293<code code="PQRI-28" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive care and Screening: Tobacco Use: Screening and Cessation Intervention"/>
     294<text>Percentage of patients aged 18 years of older who were screened about tobacco use at least once during the two year measurement preoid AND who received cessation counseling if identified as a tobacco user.</text>
     295<statusCode code="completed"/>
     296</act>
     297</entry>
     298<entry typeCode="DRIV">
     299<act classCode="ACT" moodCode="DEF">
     300<code code="PQRI-38" codeSystem="2.16.840.1.113883.3.249.12" displayName="Childhood immumnization status"/>
     301<text>Percentage of children who turn two years of age during the measurement period who have had four DTaP/DT, three IPV, one MMR and three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday</text>
     302<statusCode code="completed"/>
     303</act>
     304</entry>
     305<entry typeCode="DRIV">
     306<act classCode="ACT" moodCode="DEF">
     307<code code="" codeSystem="2.16.840.1.113883.3.249.12" displayName=""/>
    278308<text>Documents whether provider has adopted and is using ePrescribing</text>
    279309<statusCode code="completed"/>
    … …  
    302332<component>
    303333<section>
    304 <templateId root="2.16.840.1.113883.10.20.1.13"/>
    305 <code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
    306 <title>Purpose</title>
    307 <text>CEND PHR</text>
     334<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
     335<title>Patient Data</title>
    308336</section>
    309337</component>
    310 <component>
    311 <section>
    312 <templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
    313 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
    314 <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
    315 <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
    316 <title>Problems</title>
    317 <text>
    318 <table>
    319 <tbody>
    320 <tr>
    321 <th>Type</th>
    322 <th>Date</th>
    323 <th>Code</th>
    324 <th>Description</th>
    325 <th>Status</th>
    326 <th>Source</th>
    327 </tr>
    328 <tr>
    329 <td>Problem</td>
    330 <td>
    331 <table>
    332 <tbody>
    333 <tr xmlns="">
    334 <td>Oct 13, 2010</td>
    335 </tr>
    336 </tbody>
    337 </table>
    338 </td>
    339 <td>250.00 (ICD9CM)
    340                 </td>
    341 <td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
    342 <td>Active</td>
    343 <td>EIGHT  PROVIDER  Scholar Extraordinaire </td>
    344 </tr>
    345 <tr>
    346 <td>Problem</td>
    347 <td>
    348 <table>
    349 <tbody>
    350 <tr xmlns="">
    351 <td>Oct 5, 2010</td>
    352 </tr>
    353 </tbody>
    354 </table>
    355 </td>
    356 <td>848.9 (ICD9CM)
    357                 </td>
    358 <td ID="PROBLEM2">Sprains (ICD-9-CM 848.9)</td>
    359 <td>Active</td>
    360 <td>MATTHEW M KING   </td>
    361 </tr>
    362 </tbody>
    363 </table>
    364 </text>
    365 <entry typeCode="DRIV">
    366 <act classCode="ACT" moodCode="EVN">
    367 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    368 <id root="PROBLEM1" extension="CCRObjectID"/>
    369 <code nullFlavor="NA"/>
    370 <performer typeCode="PRF">
    371 <assignedEntity>
    372 <id extension="ACTORPROVIDER_991" root="CCRActorID"/>
    373 <addr use="WP">
    374 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    375 <city>ALBANY</city>
    376 <state>NY</state>
    377 <postalCode>12180</postalCode>
    378 </addr>
    379 <telecom/>
    380 <assignedPerson>
    381 <name>
    382 <prefix>Scholar Extraordinaire</prefix>
    383 <given>EIGHT</given>
    384 <family>PROVIDER</family>
    385 </name>
    386 </assignedPerson>
    387 </assignedEntity>
    388 </performer>
    389 <entryRelationship typeCode="SUBJ">
    390 <observation classCode="OBS" moodCode="EVN">
    391 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
    392 <id root="PROBLEM1" extension="CCRObjectID"/>
    393 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    394 <text>
    395 <reference value="#PROBLEM1"/>
    396 </text>
    397 <statusCode code="completed"/>
    398 <effectiveTime>
    399 <low value="20101013"/>
    400 <high nullFlavor="UNK"/>
    401 </effectiveTime>
    402 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
    403 <entryRelationship typeCode="REFR">
    404 <observation classCode="OBS" moodCode="EVN">
    405 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    406 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    407 <statusCode code="completed"/>
    408 <value>
    409 <originalText>Active</originalText>
    410 </value>
    411 </observation>
    412 </entryRelationship>
    413 </observation>
    414 </entryRelationship>
    415 </act>
    416 </entry>
    417 <entry typeCode="DRIV">
    418 <act classCode="ACT" moodCode="EVN">
    419 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    420 <id root="PROBLEM2" extension="CCRObjectID"/>
    421 <code nullFlavor="NA"/>
    422 <performer typeCode="PRF">
    423 <assignedEntity>
    424 <id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
    425 <addr use="WP">
    426 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    427 <city>ALBANY</city>
    428 <state>NY</state>
    429 <postalCode>12180</postalCode>
    430 </addr>
    431 <telecom/>
    432 <assignedPerson>
    433 <name>
    434 <given>MATTHEW</given>
    435 <given>M</given>
    436 <family>KING</family>
    437 </name>
    438 </assignedPerson>
    439 </assignedEntity>
    440 </performer>
    441 <entryRelationship typeCode="SUBJ">
    442 <observation classCode="OBS" moodCode="EVN">
    443 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
    444 <id root="PROBLEM2" extension="CCRObjectID"/>
    445 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    446 <text>
    447 <reference value="#PROBLEM2"/>
    448 </text>
    449 <statusCode code="completed"/>
    450 <effectiveTime>
    451 <low value="2010105"/>
    452 <high nullFlavor="UNK"/>
    453 </effectiveTime>
    454 <value displayName="Sprains (ICD-9-CM 848.9)" code="848.9" codeSystemName="ICD9CM" codeSystem=""/>
    455 <entryRelationship typeCode="REFR">
    456 <observation classCode="OBS" moodCode="EVN">
    457 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    458 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    459 <statusCode code="completed"/>
    460 <value>
    461 <originalText>Active</originalText>
    462 </value>
    463 </observation>
    464 </entryRelationship>
    465 </observation>
    466 </entryRelationship>
    467 </act>
    468 </entry>
    469338</section>
    470339</component>
    471 <component>
    472 <section>
    473 <templateId root="2.16.840.1.113883.10.20.1.12"/>
    474 <code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
    475 <title>Procedures</title>
    476 <text>
    477 <table>
    478 <tbody>
    479 <tr>
    480 <th>Type</th>
    481 <th>Date</th>
    482 <th>Code</th>
    483 <th>Description</th>
    484 <th>Location</th>
    485 <th>Substance</th>
    486 <th>Method</th>
    487 <th>Position</th>
    488 <th>Site</th>
    489 <th>Status</th>
    490 <th>Source</th>
    491 </tr>
    492 <tr id="PROCEDURE_4108_8">
    493 <td/>
    494 <table>
    495 <tbody>
    496 <tr xmlns="">
    497 <td>Procedure Date:
    498           </td>
    499 <td>Oct 13, 2010</td>
    500 </tr>
    501 </tbody>
    502 </table>
    503 <td>84295 (CPT-4)
    504                 </td>
    505 <td>Sodium; serum, plasma or whole blood (CPT-4 84295)</td>
    506 <td/>
    507 <td/>
    508 <td/>
    509 <td/>
    510 <td/>
    511 <td>Completed</td>
    512 <td>NANCY  ANTHRACITE   </td>
    513 </tr>
    514 <tr id="PROCEDURE_4093_5">
    515 <td/>
    516 <table>
    517 <tbody>
    518 <tr xmlns="">
    519 <td>Procedure Date:
    520           </td>
    521 <td>Oct 5, 2010</td>
    522 </tr>
    523 </tbody>
    524 </table>
    525 <td>99213 (CPT-4)
    526                 </td>
    527 <td>INTERMEDIATE (15min)</td>
    528 <td/>
    529 <td/>
    530 <td/>
    531 <td/>
    532 <td/>
    533 <td>Completed</td>
    534 <td>MATTHEW M KING   </td>
    535 </tr>
    536 </tbody>
    537 </table>
    538 </text>
    539 <entry typeCode="DRIV">
    540 <procedure classCode="PROC" moodCode="EVN">
    541 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    542 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    543 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    544 <id root="PROCEDURE_4108_8" extension="CCRObjectID"/>
    545 <code displayName="Sodium; serum, plasma or whole blood (CPT-4 84295)" code="84295" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    546 <text>
    547 <reference value="#PROCEDURE_4108_8"/>
    548 </text>
    549 <statusCode code="completed"/>
    550 <effectiveTime>
    551 <low value="20101013"/>
    552 <high nullFlavor="UNK"/>
    553 </effectiveTime>
    554 </procedure>
    555 </entry>
    556 <entry typeCode="DRIV">
    557 <procedure classCode="PROC" moodCode="EVN">
    558 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    559 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    560 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    561 <id root="PROCEDURE_4093_5" extension="CCRObjectID"/>
    562 <code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    563 <text>
    564 <reference value="#PROCEDURE_4093_5"/>
    565 </text>
    566 <statusCode code="completed"/>
    567 <effectiveTime>
    568 <low value="2010105"/>
    569 <high nullFlavor="UNK"/>
    570 </effectiveTime>
    571 </procedure>
    572 </entry>
    573340</section>
    574341</component>
    575 <component>
    576 <section>
    577 <templateId root="2.16.840.1.113883.3.88.11.83.127" assigningAuthorityName="HITSP/C83"/>
    578 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3" assigningAuthorityName="IHE PCC"/>
    579 <templateId root="2.16.840.1.113883.10.20.1.3" assigningAuthorityName="HL7 CCD"/>
    580 <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
    581 <title>Encounters</title>
    582 <text>
    583 <table>
    584 <tbody>
    585 <tr>
    586 <th>Type</th>
    587 <th>Date</th>
    588 <th>Location</th>
    589 <th>Status</th>
    590 <th>Practitioner</th>
    591 <th>Description</th>
    592 <th>Indications</th>
    593 <th>Source</th>
    594 </tr>
    595 <tr id="ENCOUNTER_4108">
    596 <td> Sodium; serum, plasma or whole blood (CPT-4 84295)</td>
    597 <td/>
    598 <td/>
    599 <td/>
    600 <td/>
    601 <td> Sodium; serum, plasma or whole blood (CPT-4 84295)</td>
    602 <td/>
    603 <td>NANCY  ANTHRACITE   </td>
    604 </tr>
    605 <tr id="ENCOUNTER_4093">
    606 <td>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</td>
    607 <td/>
    608 <td/>
    609 <td/>
    610 <td/>
    611 <td>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</td>
    612 <td/>
    613 <td>MATTHEW M KING   </td>
    614 </tr>
    615 </tbody>
    616 </table>
    617 </text>
    618 <entry typeCode="DRIV">
    619 <encounter classCode="ENC" moodCode="EVN">
    620 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    621 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    622 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    623 <id root="ENCOUNTER_4108" extension="CCRObjectID"/>
    624 <code>
    625 <originalText> Sodium; serum, plasma or whole blood (CPT-4 84295)</originalText>
    626 </code>
    627 <text>
    628 <reference value="#ENCOUNTER_4108"/>
    629 </text>
    630 <effectiveTime>
    631 <low value="20101013"/>
    632 <high nullFlavor="UNK"/>
    633 </effectiveTime>
    634 </encounter>
    635 </entry>
    636 <entry typeCode="DRIV">
    637 <encounter classCode="ENC" moodCode="EVN">
    638 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    639 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    640 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    641 <id root="ENCOUNTER_4093" extension="CCRObjectID"/>
    642 <code displayName="***ESTABLISHED PATIENT*** INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    643 <text>
    644 <reference value="#ENCOUNTER_4093"/>
    645 </text>
    646 <effectiveTime>
    647 <low value="2010105"/>
    648 <high nullFlavor="UNK"/>
    649 </effectiveTime>
    650 </encounter>
    651 </entry>
    652 </section>
    653 </component>
    654 </section>
    655 </component>
    656 </section>
    657 </component>
    658342</structuredBody>
    659343</component>

  • qrda/CCR/M1-QRDA/PAT_100849_QRDA_V1_0_0.xml

    r983 r997  
    9898</associatedEntity>
    9999</participant>
    100 <documentationOf>
    101 <serviceEvent>
    102 <code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
    103 <effectiveTime>
    104 <low value="20100205"/>
    105 <high value="20100205"/>
    106 </effectiveTime>
    107 <performer typeCode="PRF">
    108 <assignedEntity>
    109 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
    110 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    111 <addr>
    112 <streetAddressLine>123 Maple Ave</streetAddressLine>
    113 <city>Gaithersburg</city>
    114 <state>MD</state>
    115 <postalCode>20877</postalCode>
    116 </addr>
    117 <assignedPerson>
    118 <name>
    119 <given>Nancy</given>
    120 <family>Anthracite</family>
    121 <suffix>MD</suffix>
    122 </name>
    123 </assignedPerson>
    124 </assignedEntity>
    125 </performer>
    126 </serviceEvent>
    127 </documentationOf>
    128 <documentationOf>
    129 <serviceEvent>
    130 <code code="99204" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
    131 <effectiveTime>
    132 <low value="20100703"/>
    133 <high value="20100703"/>
    134 </effectiveTime>
    135 <performer typeCode="PRF">
    136 <assignedEntity>
    137 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
    138 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    139 <addr>
    140 <streetAddressLine>123 Maple Ave</streetAddressLine>
    141 <city>Gaithersburg</city>
    142 <state>MD</state>
    143 <postalCode>20877</postalCode>
    144 </addr>
    145 <assignedPerson>
    146 <name>
    147 <given>Nancy</given>
    148 <family>Anthracite</family>
    149 <suffix>MD</suffix>
    150 </name>
    151 </assignedPerson>
    152 </assignedEntity>
    153 </performer>
    154 </serviceEvent>
    155 </documentationOf>
    156100<component>
    157101<structuredBody>
    158102<component>
    159103<section>
    160 <templateId root="2.16.840.1.113883.3.249.11.12"/>
     104<templateId root="2.16.840.1.113883.3.249.11.50"/>
    161105<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
    162106<title>Measure set: CMS EHR Measure Set</title>
    … …  
    175119<templateId root="2.16.840.1.113883.3.249.11.11"/>
    176120<templateId root="2.16.840.1.113883.3.249.11.15"/>
     121<templateId root="2.16.840.1.113883.3.249.11.51"/>
     122<templateId root="2.16.840.1.113883.3.249.11.52"/>
     123<templateId root="2.16.840.1.113883.3.249.11.53"/>
     124<templateId root="2.16.840.1.113883.3.249.11.54"/>
     125<templateId root="2.16.840.1.113883.3.249.11.55"/>
     126<templateId root="2.16.840.1.113883.3.249.11.56"/>
     127<templateId root="2.16.840.1.113883.3.249.11.57"/>
     128<templateId root="2.16.840.1.113883.3.249.11.58"/>
     129<templateId root="2.16.840.1.113883.3.249.11.59"/>
     130<templateId root="2.16.840.1.113883.3.249.11.60"/>
    177131<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
    178132<title>Measure Section</title>
    … …  
    190144<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
    191145<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
     146<item>CMS Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older</item>
     147<item>CMS Measure #47: Advance Care Plan </item>
     148<item>CMS Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older</item>
     149<item>CMS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up </item>
     150<item>CMS Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening</item>
     151<item>CMS Measure #0013: Hypertension (HTN): Blood Pressure Measurement - QRDA Cat I template </item>
     152<item>CMS Measure #0022: Drugs to be avoided in the Elderly </item>
     153<item>CMS Measure #0024: Body Mass Index (BMI) 2 through 18 years of age </item>
     154<item>CMS Measure #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention</item>
     155<item>CMS Measure #0038: Childhood Immunization Status - QRDA Cat I template</item>
    192156</list>
    193157</text>
    194158<entry typeCode="DRIV">
    195159<act classCode="ACT" moodCode="DEF">
    196 <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
    197160<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    198161<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
    … …  
    202165<entry typeCode="DRIV">
    203166<act classCode="ACT" moodCode="DEF">
    204 <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
    205167<code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
    206168<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
    … …  
    210172<entry typeCode="DRIV">
    211173<act classCode="ACT" moodCode="DEF">
    212 <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
    213174<code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    214175<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
    … …  
    218179<entry typeCode="DRIV">
    219180<act classCode="ACT" moodCode="DEF">
    220 <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
    221181<code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
    222182<text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
    … …  
    226186<entry typeCode="DRIV">
    227187<act classCode="ACT" moodCode="DEF">
    228 <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
    229188<code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
    230189<text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
    … …  
    234193<entry typeCode="DRIV">
    235194<act classCode="ACT" moodCode="DEF">
    236 <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
    237195<code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients &gt;= 50 Years"/>
    238196<text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
    … …  
    242200<entry typeCode="DRIV">
    243201<act classCode="ACT" moodCode="DEF">
    244 <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
    245202<code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
    246203<text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
    … …  
    250207<entry typeCode="DRIV">
    251208<act classCode="ACT" moodCode="DEF">
    252 <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
    253209<code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
    254210<text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
    … …  
    258214<entry typeCode="DRIV">
    259215<act classCode="ACT" moodCode="DEF">
    260 <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
    261216<code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
    262217<text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
    … …  
    266221<entry typeCode="DRIV">
    267222<act classCode="ACT" moodCode="DEF">
    268 <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
    269223<code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
    270224<text>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)</text>
    … …  
    274228<entry typeCode="DRIV">
    275229<act classCode="ACT" moodCode="DEF">
    276 <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
    277230<code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
     231<text>Documents whether provider has adopted and is using ePrescribing</text>
     232<statusCode code="completed"/>
     233</act>
     234</entry>
     235<entry typeCode="DRIV">
     236<act classCode="ACT" moodCode="DEF">
     237<code code="PQRI-39" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older"/>
     238<text>Percentage of patients who had a DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months before the end of the measurement period</text>
     239<statusCode code="completed"/>
     240</act>
     241</entry>
     242<entry typeCode="DRIV">
     243<act classCode="ACT" moodCode="DEF">
     244<code code="PQRI-47" codeSystem="2.16.840.1.113883.3.249.12" displayName="Advance Care Plan"/>
     245<text>Percentage of patients age 65 and older who have an advanced care plan or surrogate decision maker documented in the medical record or documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.</text>
     246<statusCode code="completed"/>
     247</act>
     248</entry>
     249<entry typeCode="DRIV">
     250<act classCode="ACT" moodCode="DEF">
     251<code code="PQRI-48" codeSystem="2.16.840.1.113883.3.249.12" displayName="Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older"/>
     252<text>Percentage of patients equal to or older than 65 years of age at the beginning of the measurement perion who were assesed for the presence or absence of urinary incontinence within 12 months.</text>
     253<statusCode code="completed"/>
     254</act>
     255</entry>
     256<entry typeCode="DRIV">
     257<act classCode="ACT" moodCode="DEF">
     258<code code="PQRI-128" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"/>
     259<text>Percentage of patients aged 18 yesrs and older with a calculate BMI in the past 6 months or during the current visit documented in the medical record and if the most recent BMI is ourtide parameters, a follow-up plan is documented. Ages 65 and older BMI equal to or greater than 30 or less than 22 and ages 18-64, BMI greater than or equal to 25 or less than 18.5</text>
     260<statusCode code="completed"/>
     261</act>
     262</entry>
     263<entry typeCode="DRIV">
     264<act classCode="ACT" moodCode="DEF">
     265<code code="PQRI-173" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Unhealthy Alcohol Use - Screening"/>
     266<text>Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic method within 24 months</text>
     267<statusCode code="completed"/>
     268</act>
     269</entry>
     270<entry typeCode="DRIV">
     271<act classCode="ACT" moodCode="DEF">
     272<code code="PQRI-13" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hypertension (HTN): Blood Pressure Measurement"/>
     273<text>Percentage of patients aged 18 years and older with a diagnosis of hypertension in the beginning of the measurement period with a blood pressure recoreded.</text>
     274<statusCode code="completed"/>
     275</act>
     276</entry>
     277<entry typeCode="DRIV">
     278<act classCode="ACT" moodCode="DEF">
     279<code code="PQRI-22" codeSystem="2.16.840.1.113883.3.249.12" displayName="Drugs to be avoided in the elderly"/>
     280<text>Percentage of patients aged 65 years and older who received at least one drug to be acoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period</text>
     281<statusCode code="completed"/>
     282</act>
     283</entry>
     284<entry typeCode="DRIV">
     285<act classCode="ACT" moodCode="DEF">
     286<code code="PQRI-24" codeSystem="2.16.840.1.113883.3.249.12" displayName="BMI age 2-18 years of age"/>
     287<text>Percentage of children 2-18 years of age at the beginning of the measurement period whose weight is classified based on BMI percentile for age and gender.</text>
     288<statusCode code="completed"/>
     289</act>
     290</entry>
     291<entry typeCode="DRIV">
     292<act classCode="ACT" moodCode="DEF">
     293<code code="PQRI-28" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive care and Screening: Tobacco Use: Screening and Cessation Intervention"/>
     294<text>Percentage of patients aged 18 years of older who were screened about tobacco use at least once during the two year measurement preoid AND who received cessation counseling if identified as a tobacco user.</text>
     295<statusCode code="completed"/>
     296</act>
     297</entry>
     298<entry typeCode="DRIV">
     299<act classCode="ACT" moodCode="DEF">
     300<code code="PQRI-38" codeSystem="2.16.840.1.113883.3.249.12" displayName="Childhood immumnization status"/>
     301<text>Percentage of children who turn two years of age during the measurement period who have had four DTaP/DT, three IPV, one MMR and three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday</text>
     302<statusCode code="completed"/>
     303</act>
     304</entry>
     305<entry typeCode="DRIV">
     306<act classCode="ACT" moodCode="DEF">
     307<code code="" codeSystem="2.16.840.1.113883.3.249.12" displayName=""/>
    278308<text>Documents whether provider has adopted and is using ePrescribing</text>
    279309<statusCode code="completed"/>
    … …  
    302332<component>
    303333<section>
    304 <templateId root="2.16.840.1.113883.10.20.1.13"/>
    305 <code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
    306 <title>Purpose</title>
    307 <text>CEND PHR</text>
     334<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
     335<title>Patient Data</title>
    308336</section>
    309337</component>
    310 <component>
    311 <section>
    312 <templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
    313 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
    314 <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
    315 <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
    316 <title>Problems</title>
    317 <text>
    318 <table>
    319 <tbody>
    320 <tr>
    321 <th>Type</th>
    322 <th>Date</th>
    323 <th>Code</th>
    324 <th>Description</th>
    325 <th>Status</th>
    326 <th>Source</th>
    327 </tr>
    328 <tr>
    329 <td>Problem</td>
    330 <td>
    331 <table>
    332 <tbody>
    333 <tr xmlns="">
    334 <td>Oct 13, 2010</td>
    335 </tr>
    336 </tbody>
    337 </table>
    338 </td>
    339 <td>250.02 (ICD9CM)
    340                 </td>
    341 <td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
    342 <td>Active</td>
    343 <td>NANCY  ANTHRACITE   </td>
    344 </tr>
    345 </tbody>
    346 </table>
    347 </text>
    348 <entry typeCode="DRIV">
    349 <act classCode="ACT" moodCode="EVN">
    350 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    351 <id root="PROBLEM1" extension="CCRObjectID"/>
    352 <code nullFlavor="NA"/>
    353 <performer typeCode="PRF">
    354 <assignedEntity>
    355 <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
    356 <addr use="WP">
    357 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    358 <city>ALBANY</city>
    359 <state>NY</state>
    360 <postalCode>12180</postalCode>
    361 </addr>
    362 <telecom/>
    363 <assignedPerson>
    364 <name>
    365 <given>NANCY</given>
    366 <family>ANTHRACITE</family>
    367 </name>
    368 </assignedPerson>
    369 </assignedEntity>
    370 </performer>
    371 <entryRelationship typeCode="SUBJ">
    372 <observation classCode="OBS" moodCode="EVN">
    373 <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
    374 <id root="PROBLEM1" extension="CCRObjectID"/>
    375 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    376 <text>
    377 <reference value="#PROBLEM1"/>
    378 </text>
    379 <statusCode code="completed"/>
    380 <effectiveTime>
    381 <low value="20101013"/>
    382 <high nullFlavor="UNK"/>
    383 </effectiveTime>
    384 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.02" codeSystemName="ICD9CM" codeSystem=""/>
    385 <entryRelationship typeCode="REFR">
    386 <observation classCode="OBS" moodCode="EVN">
    387 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    388 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    389 <statusCode code="completed"/>
    390 <value>
    391 <originalText>Active</originalText>
    392 </value>
    393 </observation>
    394 </entryRelationship>
    395 </observation>
    396 </entryRelationship>
    397 </act>
    398 </entry>
    399338</section>
    400339</component>
    401 <component>
    402 <section>
    403 <templateId root="2.16.840.1.113883.10.20.1.12"/>
    404 <code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
    405 <title>Procedures</title>
    406 <text>
    407 <table>
    408 <tbody>
    409 <tr>
    410 <th>Type</th>
    411 <th>Date</th>
    412 <th>Code</th>
    413 <th>Description</th>
    414 <th>Location</th>
    415 <th>Substance</th>
    416 <th>Method</th>
    417 <th>Position</th>
    418 <th>Site</th>
    419 <th>Status</th>
    420 <th>Source</th>
    421 </tr>
    422 <tr id="PROCEDURE_4130_7">
    423 <td/>
    424 <table>
    425 <tbody>
    426 <tr xmlns="">
    427 <td>Procedure Date:
    428           </td>
    429 <td>Oct 14, 2010</td>
    430 </tr>
    431 </tbody>
    432 </table>
    433 <td>99202 (CPT-4)
    434                 </td>
    435 <td>INTERMEDIATE (20min)</td>
    436 <td/>
    437 <td/>
    438 <td/>
    439 <td/>
    440 <td/>
    441 <td>Completed</td>
    442 <td>NANCY  ANTHRACITE   </td>
    443 </tr>
    444 <tr id="PROCEDURE_4113_4">
    445 <td/>
    446 <table>
    447 <tbody>
    448 <tr xmlns="">
    449 <td>Procedure Date:
    450           </td>
    451 <td>Oct 13, 2010</td>
    452 </tr>
    453 </tbody>
    454 </table>
    455 <td>99202 (CPT-4)
    456                 </td>
    457 <td>INTERMEDIATE (20min)</td>
    458 <td/>
    459 <td/>
    460 <td/>
    461 <td/>
    462 <td/>
    463 <td>Completed</td>
    464 <td>NANCY  ANTHRACITE   </td>
    465 </tr>
    466 </tbody>
    467 </table>
    468 </text>
    469 <entry typeCode="DRIV">
    470 <procedure classCode="PROC" moodCode="EVN">
    471 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    472 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    473 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    474 <id root="PROCEDURE_4130_7" extension="CCRObjectID"/>
    475 <code displayName="INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    476 <text>
    477 <reference value="#PROCEDURE_4130_7"/>
    478 </text>
    479 <statusCode code="completed"/>
    480 <effectiveTime>
    481 <low value="20101014"/>
    482 <high nullFlavor="UNK"/>
    483 </effectiveTime>
    484 </procedure>
    485 </entry>
    486 <entry typeCode="DRIV">
    487 <procedure classCode="PROC" moodCode="EVN">
    488 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    489 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    490 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    491 <id root="PROCEDURE_4113_4" extension="CCRObjectID"/>
    492 <code displayName="INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    493 <text>
    494 <reference value="#PROCEDURE_4113_4"/>
    495 </text>
    496 <statusCode code="completed"/>
    497 <effectiveTime>
    498 <low value="20101013"/>
    499 <high nullFlavor="UNK"/>
    500 </effectiveTime>
    501 </procedure>
    502 </entry>
    503340</section>
    504341</component>
    505 <component>
    506 <section>
    507 <templateId root="2.16.840.1.113883.3.88.11.83.127" assigningAuthorityName="HITSP/C83"/>
    508 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3" assigningAuthorityName="IHE PCC"/>
    509 <templateId root="2.16.840.1.113883.10.20.1.3" assigningAuthorityName="HL7 CCD"/>
    510 <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
    511 <title>Encounters</title>
    512 <text>
    513 <table>
    514 <tbody>
    515 <tr>
    516 <th>Type</th>
    517 <th>Date</th>
    518 <th>Location</th>
    519 <th>Status</th>
    520 <th>Practitioner</th>
    521 <th>Description</th>
    522 <th>Indications</th>
    523 <th>Source</th>
    524 </tr>
    525 <tr id="ENCOUNTER_4130">
    526 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    527 <td/>
    528 <td/>
    529 <td/>
    530 <td/>
    531 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    532 <td/>
    533 <td>NANCY  ANTHRACITE   </td>
    534 </tr>
    535 <tr id="ENCOUNTER_4113">
    536 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    537 <td/>
    538 <td/>
    539 <td/>
    540 <td/>
    541 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    542 <td/>
    543 <td>NANCY  ANTHRACITE   </td>
    544 </tr>
    545 </tbody>
    546 </table>
    547 </text>
    548 <entry typeCode="DRIV">
    549 <encounter classCode="ENC" moodCode="EVN">
    550 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    551 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    552 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    553 <id root="ENCOUNTER_4130" extension="CCRObjectID"/>
    554 <code displayName="***NEW PATIENT*** INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    555 <text>
    556 <reference value="#ENCOUNTER_4130"/>
    557 </text>
    558 <effectiveTime>
    559 <low value="20101014"/>
    560 <high nullFlavor="UNK"/>
    561 </effectiveTime>
    562 </encounter>
    563 </entry>
    564 <entry typeCode="DRIV">
    565 <encounter classCode="ENC" moodCode="EVN">
    566 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    567 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    568 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    569 <id root="ENCOUNTER_4113" extension="CCRObjectID"/>
    570 <code displayName="***NEW PATIENT*** INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    571 <text>
    572 <reference value="#ENCOUNTER_4113"/>
    573 </text>
    574 <effectiveTime>
    575 <low value="20101013"/>
    576 <high nullFlavor="UNK"/>
    577 </effectiveTime>
    578 </encounter>
    579 </entry>
    580 </section>
    581 </component>
    582 </section>
    583 </component>
    584 </section>
    585 </component>
    586342</structuredBody>
    587343</component>

  • qrda/CCR/M1-QRDA/PAT_100855_QRDA_V1_0_0.xml

    r983 r997  
    9898</associatedEntity>
    9999</participant>
    100 <documentationOf>
    101 <serviceEvent>
    102 <code code="99202" codeSystem="2.16.840.1.113883.6.12" codeSystemName="C4"/>
    103 <effectiveTime>
    104 <low value="20100205"/>
    105 <high value="20100205"/>
    106 </effectiveTime>
    107 <performer typeCode="PRF">
    108 <assignedEntity>
    109 <id root="2.16.840.1.113883.3.543" extension="6558574524"/>
    110 <code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNOMED CT" displayName="Internal Medician Specialist"/>
    111 <addr>
    112 <streetAddressLine>123 Maple Ave</streetAddressLine>
    113 <city>Gaithersburg</city>
    114 <state>MD</state>
    115 <postalCode>20877</postalCode>
    116 </addr>
    117 <assignedPerson>
    118 <name>
    119 <given>Nancy</given>
    120 <family>Anthracite</family>
    121 <suffix>MD</suffix>
    122 </name>
    123 </assignedPerson>
    124 </assignedEntity>
    125 </performer>
    126 </serviceEvent>
    127 </documentationOf>
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    133 <high value="20100703"/>
    134 </effectiveTime>
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    139 <addr>
    140 <streetAddressLine>123 Maple Ave</streetAddressLine>
    141 <city>Gaithersburg</city>
    142 <state>MD</state>
    143 <postalCode>20877</postalCode>
    144 </addr>
    145 <assignedPerson>
    146 <name>
    147 <given>Nancy</given>
    148 <family>Anthracite</family>
    149 <suffix>MD</suffix>
    150 </name>
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    152 </assignedEntity>
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    161105<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
    162106<title>Measure set: CMS EHR Measure Set</title>
    … …  
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     130<templateId root="2.16.840.1.113883.3.249.11.60"/>
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    178132<title>Measure Section</title>
    … …  
    190144<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
    191145<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
     146<item>CMS Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older</item>
     147<item>CMS Measure #47: Advance Care Plan </item>
     148<item>CMS Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older</item>
     149<item>CMS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up </item>
     150<item>CMS Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening</item>
     151<item>CMS Measure #0013: Hypertension (HTN): Blood Pressure Measurement - QRDA Cat I template </item>
     152<item>CMS Measure #0022: Drugs to be avoided in the Elderly </item>
     153<item>CMS Measure #0024: Body Mass Index (BMI) 2 through 18 years of age </item>
     154<item>CMS Measure #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention</item>
     155<item>CMS Measure #0038: Childhood Immunization Status - QRDA Cat I template</item>
    192156</list>
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    196 <id root="3944fd20-865c-11df-a4ee-0800200c9a66"/>
    197160<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    198161<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
    … …  
    202165<entry typeCode="DRIV">
    203166<act classCode="ACT" moodCode="DEF">
    204 <id root="3944fd21-865c-11df-a4ee-0800200c9a66"/>
    205167<code code="PQRI-2" codeSystem="2.16.840.1.113883.3.249.12" displayName="Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus"/>
    206168<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg./dL)</text>
    … …  
    210172<entry typeCode="DRIV">
    211173<act classCode="ACT" moodCode="DEF">
    212 <id root="3944fd22-865c-11df-a4ee-0800200c9a66"/>
    213174<code code="PQRI-3" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
    214175<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)</text>
    … …  
    218179<entry typeCode="DRIV">
    219180<act classCode="ACT" moodCode="DEF">
    220 <id root="3944fd23-865c-11df-a4ee-0800200c9a66"/>
    221181<code code="PQRI-5" codeSystem="2.16.840.1.113883.3.249.12" displayName="Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"/>
    222182<text>Percentage of patients 18 years and older with a diagnosis of heart frilure and LVSD who were prescribed ACE inhibitor or ARB therapy</text>
    … …  
    226186<entry typeCode="DRIV">
    227187<act classCode="ACT" moodCode="DEF">
    228 <id root="3944fd24-865c-11df-a4ee-0800200c9a66"/>
    229188<code code="PQRI-7" codeSystem="2.16.840.1.113883.3.249.12" displayName="Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction"/>
    230189<text>Percentage of patients 18 aged 18 years and older wit a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy</text>
    … …  
    234193<entry typeCode="DRIV">
    235194<act classCode="ACT" moodCode="DEF">
    236 <id root="3944fd25-865c-11df-a4ee-0800200c9a66"/>
    237195<code code="PQRI-110" codeSystem="2.16.840.1.113883.3.249.12" displayName="Influenza Immunization for Patients &gt;= 50 Years"/>
    238196<text>Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February)</text>
    … …  
    242200<entry typeCode="DRIV">
    243201<act classCode="ACT" moodCode="DEF">
    244 <id root="3944fd26-865c-11df-a4ee-0800200c9a66"/>
    245202<code code="PQRI-111" codeSystem="2.16.840.1.113883.3.249.12" displayName="Pneumonia Vaccination for Patients 65 Years and Older"/>
    246203<text>Percentage of patients afed 65 years and older who have ever received a pneumoccal vaccine</text>
    … …  
    250207<entry typeCode="DRIV">
    251208<act classCode="ACT" moodCode="DEF">
    252 <id root="3944fd27-865c-11df-a4ee-0800200c9a66"/>
    253209<code code="PQRI-112" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening Mammography"/>
    254210<text>Percentage of womaen aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months</text>
    … …  
    258214<entry typeCode="DRIV">
    259215<act classCode="ACT" moodCode="DEF">
    260 <id root="3944fd28-865c-11df-a4ee-0800200c9a66"/>
    261216<code code="PQRI-113" codeSystem="2.16.840.1.113883.3.249.12" displayName="Colorectal Cancer Screening"/>
    262217<text>Percentage of patients aged 50 through 80 who received the appropriate colorectal cancer screening</text>
    … …  
    266221<entry typeCode="DRIV">
    267222<act classCode="ACT" moodCode="DEF">
    268 <id root="3944fd29-865c-11df-a4ee-0800200c9a66"/>
    269223<code code="PQRI-124" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Electronic Health Records (EHR)"/>
    270224<text>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)</text>
    … …  
    274228<entry typeCode="DRIV">
    275229<act classCode="ACT" moodCode="DEF">
    276 <id root="3944fd30-865c-11df-a4ee-0800200c9a66"/>
    277230<code code="eRx" codeSystem="2.16.840.1.113883.3.249.12" displayName="Adoption/Use of Medication Electronic Prescribing Measure"/>
     231<text>Documents whether provider has adopted and is using ePrescribing</text>
     232<statusCode code="completed"/>
     233</act>
     234</entry>
     235<entry typeCode="DRIV">
     236<act classCode="ACT" moodCode="DEF">
     237<code code="PQRI-39" codeSystem="2.16.840.1.113883.3.249.12" displayName="Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older"/>
     238<text>Percentage of patients who had a DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months before the end of the measurement period</text>
     239<statusCode code="completed"/>
     240</act>
     241</entry>
     242<entry typeCode="DRIV">
     243<act classCode="ACT" moodCode="DEF">
     244<code code="PQRI-47" codeSystem="2.16.840.1.113883.3.249.12" displayName="Advance Care Plan"/>
     245<text>Percentage of patients age 65 and older who have an advanced care plan or surrogate decision maker documented in the medical record or documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.</text>
     246<statusCode code="completed"/>
     247</act>
     248</entry>
     249<entry typeCode="DRIV">
     250<act classCode="ACT" moodCode="DEF">
     251<code code="PQRI-48" codeSystem="2.16.840.1.113883.3.249.12" displayName="Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older"/>
     252<text>Percentage of patients equal to or older than 65 years of age at the beginning of the measurement perion who were assesed for the presence or absence of urinary incontinence within 12 months.</text>
     253<statusCode code="completed"/>
     254</act>
     255</entry>
     256<entry typeCode="DRIV">
     257<act classCode="ACT" moodCode="DEF">
     258<code code="PQRI-128" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"/>
     259<text>Percentage of patients aged 18 yesrs and older with a calculate BMI in the past 6 months or during the current visit documented in the medical record and if the most recent BMI is ourtide parameters, a follow-up plan is documented. Ages 65 and older BMI equal to or greater than 30 or less than 22 and ages 18-64, BMI greater than or equal to 25 or less than 18.5</text>
     260<statusCode code="completed"/>
     261</act>
     262</entry>
     263<entry typeCode="DRIV">
     264<act classCode="ACT" moodCode="DEF">
     265<code code="PQRI-173" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive Care and Screening: Unhealthy Alcohol Use - Screening"/>
     266<text>Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic method within 24 months</text>
     267<statusCode code="completed"/>
     268</act>
     269</entry>
     270<entry typeCode="DRIV">
     271<act classCode="ACT" moodCode="DEF">
     272<code code="PQRI-13" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hypertension (HTN): Blood Pressure Measurement"/>
     273<text>Percentage of patients aged 18 years and older with a diagnosis of hypertension in the beginning of the measurement period with a blood pressure recoreded.</text>
     274<statusCode code="completed"/>
     275</act>
     276</entry>
     277<entry typeCode="DRIV">
     278<act classCode="ACT" moodCode="DEF">
     279<code code="PQRI-22" codeSystem="2.16.840.1.113883.3.249.12" displayName="Drugs to be avoided in the elderly"/>
     280<text>Percentage of patients aged 65 years and older who received at least one drug to be acoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period</text>
     281<statusCode code="completed"/>
     282</act>
     283</entry>
     284<entry typeCode="DRIV">
     285<act classCode="ACT" moodCode="DEF">
     286<code code="PQRI-24" codeSystem="2.16.840.1.113883.3.249.12" displayName="BMI age 2-18 years of age"/>
     287<text>Percentage of children 2-18 years of age at the beginning of the measurement period whose weight is classified based on BMI percentile for age and gender.</text>
     288<statusCode code="completed"/>
     289</act>
     290</entry>
     291<entry typeCode="DRIV">
     292<act classCode="ACT" moodCode="DEF">
     293<code code="PQRI-28" codeSystem="2.16.840.1.113883.3.249.12" displayName="Preventive care and Screening: Tobacco Use: Screening and Cessation Intervention"/>
     294<text>Percentage of patients aged 18 years of older who were screened about tobacco use at least once during the two year measurement preoid AND who received cessation counseling if identified as a tobacco user.</text>
     295<statusCode code="completed"/>
     296</act>
     297</entry>
     298<entry typeCode="DRIV">
     299<act classCode="ACT" moodCode="DEF">
     300<code code="PQRI-38" codeSystem="2.16.840.1.113883.3.249.12" displayName="Childhood immumnization status"/>
     301<text>Percentage of children who turn two years of age during the measurement period who have had four DTaP/DT, three IPV, one MMR and three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday</text>
     302<statusCode code="completed"/>
     303</act>
     304</entry>
     305<entry typeCode="DRIV">
     306<act classCode="ACT" moodCode="DEF">
     307<code code="" codeSystem="2.16.840.1.113883.3.249.12" displayName=""/>
    278308<text>Documents whether provider has adopted and is using ePrescribing</text>
    279309<statusCode code="completed"/>
    … …  
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    305 <code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
    306 <title>Purpose</title>
    307 <text>CEND PHR</text>
     334<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
     335<title>Patient Data</title>
    308336</section>
    309337</component>
    310 <component>
    311 <section>
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    313 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
    314 <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
    315 <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
    316 <title>Problems</title>
    317 <text>
    318 <table>
    319 <tbody>
    320 <tr>
    321 <th>Type</th>
    322 <th>Date</th>
    323 <th>Code</th>
    324 <th>Description</th>
    325 <th>Status</th>
    326 <th>Source</th>
    327 </tr>
    328 <tr>
    329 <td>Problem</td>
    330 <td>
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    333 <tr xmlns="">
    334 <td>Oct 14, 2010</td>
    335 </tr>
    336 </tbody>
    337 </table>
    338 </td>
    339 <td>250.00 (ICD9CM)
    340                 </td>
    341 <td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
    342 <td>Active</td>
    343 <td>NANCY  ANTHRACITE   </td>
    344 </tr>
    345 <tr>
    346 <td>Problem</td>
    347 <td>
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    350 <tr xmlns="">
    351 <td>Oct 14, 2010</td>
    352 </tr>
    353 </tbody>
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    355 </td>
    356 <td>250.00 (ICD9CM)
    357                 </td>
    358 <td ID="PROBLEM2">Diabetes (ICD-9-CM 250.00)</td>
    359 <td>Active</td>
    360 <td>NANCY  ANTHRACITE   </td>
    361 </tr>
    362 <tr>
    363 <td>Problem</td>
    364 <td>
    365 <table>
    366 <tbody>
    367 <tr xmlns="">
    368 <td>Oct 13, 2010</td>
    369 </tr>
    370 </tbody>
    371 </table>
    372 </td>
    373 <td>250.00 (ICD9CM)
    374                 </td>
    375 <td ID="PROBLEM3">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
    376 <td>Active</td>
    377 <td>NANCY  ANTHRACITE   </td>
    378 </tr>
    379 </tbody>
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    381 </text>
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    388 <assignedEntity>
    389 <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
    390 <addr use="WP">
    391 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    392 <city>ALBANY</city>
    393 <state>NY</state>
    394 <postalCode>12180</postalCode>
    395 </addr>
    396 <telecom/>
    397 <assignedPerson>
    398 <name>
    399 <given>NANCY</given>
    400 <family>ANTHRACITE</family>
    401 </name>
    402 </assignedPerson>
    403 </assignedEntity>
    404 </performer>
    405 <entryRelationship typeCode="SUBJ">
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    410 <text>
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    412 </text>
    413 <statusCode code="completed"/>
    414 <effectiveTime>
    415 <low value="20101014"/>
    416 <high nullFlavor="UNK"/>
    417 </effectiveTime>
    418 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
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    425 <originalText>Active</originalText>
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    437 <code nullFlavor="NA"/>
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    439 <assignedEntity>
    440 <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
    441 <addr use="WP">
    442 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    443 <city>ALBANY</city>
    444 <state>NY</state>
    445 <postalCode>12180</postalCode>
    446 </addr>
    447 <telecom/>
    448 <assignedPerson>
    449 <name>
    450 <given>NANCY</given>
    451 <family>ANTHRACITE</family>
    452 </name>
    453 </assignedPerson>
    454 </assignedEntity>
    455 </performer>
    456 <entryRelationship typeCode="SUBJ">
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    461 <text>
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    463 </text>
    464 <statusCode code="completed"/>
    465 <effectiveTime>
    466 <low value="20101014"/>
    467 <high nullFlavor="UNK"/>
    468 </effectiveTime>
    469 <value displayName="Diabetes (ICD-9-CM 250.00)" code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
    470 <entryRelationship typeCode="REFR">
    471 <observation classCode="OBS" moodCode="EVN">
    472 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    473 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    474 <statusCode code="completed"/>
    475 <value>
    476 <originalText>Active</originalText>
    477 </value>
    478 </observation>
    479 </entryRelationship>
    480 </observation>
    481 </entryRelationship>
    482 </act>
    483 </entry>
    484 <entry typeCode="DRIV">
    485 <act classCode="ACT" moodCode="EVN">
    486 <templateId root="2.16.840.1.113883.10.20.1.27"/>
    487 <id root="PROBLEM3" extension="CCRObjectID"/>
    488 <code nullFlavor="NA"/>
    489 <performer typeCode="PRF">
    490 <assignedEntity>
    491 <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
    492 <addr use="WP">
    493 <streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
    494 <city>ALBANY</city>
    495 <state>NY</state>
    496 <postalCode>12180</postalCode>
    497 </addr>
    498 <telecom/>
    499 <assignedPerson>
    500 <name>
    501 <given>NANCY</given>
    502 <family>ANTHRACITE</family>
    503 </name>
    504 </assignedPerson>
    505 </assignedEntity>
    506 </performer>
    507 <entryRelationship typeCode="SUBJ">
    508 <observation classCode="OBS" moodCode="EVN">
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    511 <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
    512 <text>
    513 <reference value="#PROBLEM3"/>
    514 </text>
    515 <statusCode code="completed"/>
    516 <effectiveTime>
    517 <low value="20101013"/>
    518 <high nullFlavor="UNK"/>
    519 </effectiveTime>
    520 <value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
    521 <entryRelationship typeCode="REFR">
    522 <observation classCode="OBS" moodCode="EVN">
    523 <templateId root="2.16.840.1.113883.10.20.1.50"/>
    524 <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
    525 <statusCode code="completed"/>
    526 <value>
    527 <originalText>Active</originalText>
    528 </value>
    529 </observation>
    530 </entryRelationship>
    531 </observation>
    532 </entryRelationship>
    533 </act>
    534 </entry>
    535338</section>
    536339</component>
    537 <component>
    538 <section>
    539 <templateId root="2.16.840.1.113883.10.20.1.12"/>
    540 <code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
    541 <title>Procedures</title>
    542 <text>
    543 <table>
    544 <tbody>
    545 <tr>
    546 <th>Type</th>
    547 <th>Date</th>
    548 <th>Code</th>
    549 <th>Description</th>
    550 <th>Location</th>
    551 <th>Substance</th>
    552 <th>Method</th>
    553 <th>Position</th>
    554 <th>Site</th>
    555 <th>Status</th>
    556 <th>Source</th>
    557 </tr>
    558 <tr id="PROCEDURE_4127_7">
    559 <td/>
    560 <table>
    561 <tbody>
    562 <tr xmlns="">
    563 <td>Procedure Date:
    564           </td>
    565 <td>Oct 14, 2010</td>
    566 </tr>
    567 </tbody>
    568 </table>
    569 <td>99212 (CPT-4)
    570                 </td>
    571 <td>LIMITED (10min)</td>
    572 <td/>
    573 <td/>
    574 <td/>
    575 <td/>
    576 <td/>
    577 <td>Completed</td>
    578 <td>NANCY  ANTHRACITE   </td>
    579 </tr>
    580 <tr id="PROCEDURE_4110_4">
    581 <td/>
    582 <table>
    583 <tbody>
    584 <tr xmlns="">
    585 <td>Procedure Date:
    586           </td>
    587 <td>Oct 13, 2010</td>
    588 </tr>
    589 </tbody>
    590 </table>
    591 <td>99202 (CPT-4)
    592                 </td>
    593 <td>INTERMEDIATE (20min)</td>
    594 <td/>
    595 <td/>
    596 <td/>
    597 <td/>
    598 <td/>
    599 <td>Completed</td>
    600 <td>NANCY  ANTHRACITE   </td>
    601 </tr>
    602 </tbody>
    603 </table>
    604 </text>
    605 <entry typeCode="DRIV">
    606 <procedure classCode="PROC" moodCode="EVN">
    607 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    608 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    609 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    610 <id root="PROCEDURE_4127_7" extension="CCRObjectID"/>
    611 <code displayName="LIMITED (10min)" code="99212" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    612 <text>
    613 <reference value="#PROCEDURE_4127_7"/>
    614 </text>
    615 <statusCode code="completed"/>
    616 <effectiveTime>
    617 <low value="20101014"/>
    618 <high nullFlavor="UNK"/>
    619 </effectiveTime>
    620 </procedure>
    621 </entry>
    622 <entry typeCode="DRIV">
    623 <procedure classCode="PROC" moodCode="EVN">
    624 <templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
    625 <templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
    626 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
    627 <id root="PROCEDURE_4110_4" extension="CCRObjectID"/>
    628 <code displayName="INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    629 <text>
    630 <reference value="#PROCEDURE_4110_4"/>
    631 </text>
    632 <statusCode code="completed"/>
    633 <effectiveTime>
    634 <low value="20101013"/>
    635 <high nullFlavor="UNK"/>
    636 </effectiveTime>
    637 </procedure>
    638 </entry>
    639340</section>
    640341</component>
    641 <component>
    642 <section>
    643 <templateId root="2.16.840.1.113883.3.88.11.83.127" assigningAuthorityName="HITSP/C83"/>
    644 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3" assigningAuthorityName="IHE PCC"/>
    645 <templateId root="2.16.840.1.113883.10.20.1.3" assigningAuthorityName="HL7 CCD"/>
    646 <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
    647 <title>Encounters</title>
    648 <text>
    649 <table>
    650 <tbody>
    651 <tr>
    652 <th>Type</th>
    653 <th>Date</th>
    654 <th>Location</th>
    655 <th>Status</th>
    656 <th>Practitioner</th>
    657 <th>Description</th>
    658 <th>Indications</th>
    659 <th>Source</th>
    660 </tr>
    661 <tr id="ENCOUNTER_4127">
    662 <td>***ESTABLISHED PATIENT*** LIMITED (10min)</td>
    663 <td/>
    664 <td/>
    665 <td/>
    666 <td/>
    667 <td>***ESTABLISHED PATIENT*** LIMITED (10min)</td>
    668 <td/>
    669 <td>NANCY  ANTHRACITE   </td>
    670 </tr>
    671 <tr id="ENCOUNTER_4110">
    672 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    673 <td/>
    674 <td/>
    675 <td/>
    676 <td/>
    677 <td>***NEW PATIENT*** INTERMEDIATE (20min)</td>
    678 <td/>
    679 <td>NANCY  ANTHRACITE   </td>
    680 </tr>
    681 </tbody>
    682 </table>
    683 </text>
    684 <entry typeCode="DRIV">
    685 <encounter classCode="ENC" moodCode="EVN">
    686 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    687 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    688 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    689 <id root="ENCOUNTER_4127" extension="CCRObjectID"/>
    690 <code displayName="***ESTABLISHED PATIENT*** LIMITED (10min)" code="99212" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    691 <text>
    692 <reference value="#ENCOUNTER_4127"/>
    693 </text>
    694 <effectiveTime>
    695 <low value="20101014"/>
    696 <high nullFlavor="UNK"/>
    697 </effectiveTime>
    698 </encounter>
    699 </entry>
    700 <entry typeCode="DRIV">
    701 <encounter classCode="ENC" moodCode="EVN">
    702 <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
    703 <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
    704 <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
    705 <id root="ENCOUNTER_4110" extension="CCRObjectID"/>
    706 <code displayName="***NEW PATIENT*** INTERMEDIATE (20min)" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
    707 <text>
    708 <reference value="#ENCOUNTER_4110"/>
    709 </text>
    710 <effectiveTime>
    711 <low value="20101013"/>
    712 <high nullFlavor="UNK"/>
    713 </effectiveTime>
    714 </encounter>
    715 </entry>
    716 </section>
    717 </component>
    718 </section>
    719 </component>
    720 </section>
    721 </component>
    722342</structuredBody>
    723343</component>
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