7c24c1e0-f73d-4160-9421-5f8b6cf8c7ea English V1.0 2010-09-13T16:17:26-05:00 ACTORPATIENT_100839 ACTORPROVIDER_10000000020 ACTORSYSTEM_1 ACTORPATIENT_100839 Patient CEND PHR PROBLEM1 2010-09-04T00:00:00-05:00 Problem Diabetes Mellitus without mention of Complication, type II or unspecified type, 250.00 ICD9CM Active ACTORPROVIDER_991 PROBLEM2 2010-07-05T00:00:00-05:00 Problem Congestive Heart Failure (ICD-9-CM 428.0) 428.0 ICD9CM Active ACTORPROVIDER_991 PROBLEM3 2010-07-05T00:00:00-05:00 Problem Postmyocardial infarction syndrome (ICD-9-CM 411.0) 411.0 ICD9CM Active ACTORPROVIDER_991 PROCEDURE_4056_27 Procedure Date 2010-09-04T00:00:00-05:00 INTERMEDIATE (15min) 99213 CPT-4 Completed ACTORPROVIDER_10000000020 PROCEDURE_4055_24 Procedure Date 2010-08-28T00:00:00-05:00 EXPANDED, HX & EXAM 99202 CPT-4 Completed ACTORPROVIDER_10000000020 PROCEDURE_4047_14 Procedure Date 2010-07-31T00:00:00-05:00 Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213) 99213 CPT-4 Completed ACTORPROVIDER_10000000020 PROCEDURE_4046_7 Procedure Date 2010-07-05T00:00:00-05:00 Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214) 99214 CPT-4 Completed ACTORPROVIDER_991 PROCEDURE_4046_8 Procedure Date 2010-07-05T00:00:00-05:00 Hemoglobin; Glycosylated (A1c) (CPT-4 83036) 83036 CPT-4 Completed ACTORPROVIDER_991 PROCEDURE_4046_9 Procedure Date 2010-07-05T00:00:00-05:00 Lipoprotein, Blood; Quantitation of Lipoprotein particle Numbers and Lipoprotein particle Subclasses (Eg, by Nuclear Magnetic Resonance Spectroscopy) (CPT-4 83704) 83704 CPT-4 Completed ACTORPROVIDER_991 PROCEDURE_4046_10 Procedure Date 2010-07-05T00:00:00-05:00 Determination of Central C-V Hemodynamics (Non-Imaging) (CPT-4 78414) 78414 CPT-4 Completed ACTORPROVIDER_991 ENCOUNTER_4056 2010-09-04T00:00:00-05:00 ***ESTABLISHED PATIENT*** INTERMEDIATE (15min) 99213 CPT-4 ***ESTABLISHED PATIENT*** INTERMEDIATE (15min) 99213 CPT-4 ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4055 2010-08-28T00:00:00-05:00 OFFICE VISIT - NEW PT EXPANDED, HX & EXAM 99202 CPT-4 OFFICE VISIT - NEW PT EXPANDED, HX & EXAM 99202 CPT-4 ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 NOTE_4055 ENCOUNTER_4054 2010-08-27T00:00:00-05:00 C&P EXAMINATION REPORTS C&P EXAMINATION REPORTS ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4053 2010-08-27T00:00:00-05:00 NURSING TITLES NURSING TITLES ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4052 2010-08-14T00:00:00-05:00 ADDENDUM ADDENDUM ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4049 2010-08-25T00:00:00-05:00 ADDICTION SEVERITY INDEX ADDICTION SEVERITY INDEX ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4048 2010-08-14T00:00:00-05:00 INTERDISCIPLINARY MEMBER INTERDISCIPLINARY MEMBER ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 ENCOUNTER_4047 2010-07-31T00:00:00-05:00 Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213) 99213 CPT-4 Office/Outpatient Visit of an Established Patient requiring (2 of 3) an Expanded History, an Exam and Medical Decision Making of Low Complexity (CPT-4 99213) 99213 CPT-4 ACTORORGANIZATION_1 ACTORPROVIDER_10000000020 ACTORPROVIDER_10000000020 NOTE_4047 ENCOUNTER_4046 2010-07-05T00:00:00-05:00 Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214) 99214 CPT-4 Office/Outpatient Visit of an Established Patient requiring (2 of 3) a Detailed History, an Exam and Medical Decision Making of Moderate Complexity (CPT-4 99214) 99214 CPT-4 ACTORORGANIZATION_1 ACTORPROVIDER_991 ACTORPROVIDER_991 NOTE_4046 ACTORORGANIZATION_1 CAMP MASTER
Office VA MEDICAL CENTER ALBANY NEW YORK 12180-0097
ACTORSYSTEM_1 ACTORPATIENT_100839 JODY JEAN JONES 1945-01-01 FEMALE F HL7 AdministrativeGender SSN 002030004 ACTORPATIENT_100839
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ACTORPATIENT_100839 ACTORPROVIDER_10000000020 SYSTEM MANAGER Physicians (M.D. and D.O.)-Physician/Osteopath
Work VA MEDICAL CENTER ALBANY NY 12180-0097
ACTORSYSTEM_1 ACTORORGANIZATION_1 representedOrganization ACTORPROVIDER_991 EIGHT PROVIDER Scholar Extraordinaire Physicians (M.D. and D.O.)-Physician/Osteopath
Work VA MEDICAL CENTER ALBANY NY 12180-0097
ACTORSYSTEM_1 ACTORORGANIZATION_1 representedOrganization ACTORSYSTEM_1 WorldVistA EHR/VOE 1.0 ACTORSYSTEM_1 @@COMMENTOBJECTID@@ @@CMTDATETIME@@ @@ACTORSOURCEID@@ NOTE_4046 2010-07-05T00:00:00-05:00 ADDING CLINICAL MEASURES FOR TESTING Measure 1 Measure 2 Measure 3 Measure 5 Measure 7 Measure 124 ------------------------------------------Measure #1 Data for Jones-- ENCOUNTER CODE 99214 DX CODE 250.00 NUMERATOR INCLUSION A1C CODE 83036 DOCUMENTATION: HBA1c > 9% PROBLEM (Our patient is less than 9.0%) --------------------------------------------------- Measure #2 Data for Jones-- ENCOUNTER CODE 99214 DX CODE 250.00 NUMERATOR INCLUSION LDL CODE 83704 DOCUMENTATION: LDL < 100 mg/dl LDL from Lab Package ------------------------------------------------------- Measure #3 Data for Jones-- ENCOUNTER CODE 99214 DX CODE 250.00 NUMERATOR: DOCUMENTATION: Systolic (SNOMED) CODE 271649006 or 72313002 AND Systolic BP <140 mmHg (from Vitals-Bottom number of BP) Diastolic (SNOMED) CODE 271650006 AND Diastolic BP < 80 (From Vitals Package-Top number of BP) NOTE: SNOMED CODES ARE NOT ACCESSIBLE IN VISTA ------------------------------------------------------- Measure #5 Data for Jones-- ENCOUNTER CODE 99214 DX CODE 428.0 EJRC FRAC CODE 83704 AND Documentation of LVEF < 40% Need Health Factor for this NUMERATOR INCLUSION TOPIC_DRUG_CODES = ACE/ARB (NOT AVAILABLE IN VISTA) ------------------------------------------------------- Measure #7 Data for Jones-- ENCOUNTER CODE 99214 dx 411.0, 412.00 procedure: 78414 NUMERATOR INCLUSION TOPIC_DRUG_CODES = BETA BLOCKERS ------------------------------------------------------------- Measure #124 ENCOUNTER CODE 99214 NUMERATOR CODE G8447 ------------------------------------------------------------- ACTORPROVIDER_991 NOTE_4047 2010-07-31T00:00:00-05:00 TESTING ENCOUNTERS ACTORPROVIDER_10000000020 NOTE_4055 2010-08-28T00:00:00-05:00 SMOKING PQRI CAT CURRENT EVERY DAY SMOKER 07/31/2010 CURRENT SMOKING STATUS UNKNOWN 08/25/2010 CURRENT SOME DAY SMOKER 08/27/2010 PPD ========================================= ACTORPROVIDER_10000000020