460 lines
25 KiB
XML
460 lines
25 KiB
XML
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<?xml version="1.0" encoding="utf-8"?>
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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
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<realmCode code="US"/>
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<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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<templateId root="2.16.840.1.113883.10.20.12"/>
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<templateId root="2.16.840.1.113883.3.249.11.100.1"/>
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<id root="2.16.840.1.113883.3.543" extension="@@@UUID-DOC@@@"/>
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<code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report"/>
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<title>QRDA Incidence Report</title>
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<effectiveTime value="20100703"/>
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<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
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<languageCode code="en-US"/>
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<setId root="2.16.840.1.113883.3.543" extension="@@@UUID-SET@@@"/>
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<versionNumber value="1"/>
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<recordTarget>
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<patientRole>
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<id extension="666000200" root="SSN"/>
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<addr use="H">
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<streetAddressLine>Any Street</streetAddressLine>
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<city>Any Town</city>
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<state>WEST VIRGINIA</state>
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<postalCode/>
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</addr>
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<telecom use="" value="tel:+1-222-555-8235"/>
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<patient>
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<name>
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<given>MALE-D</given>
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<family>MEASURE-TWO</family>
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</name>
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<administrativeGenderCode displayName="MALE" code="M" codeSystemName="HL7 AdministrativeGender" codeSystem=""/>
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<birthTime value="19600101120000"/>
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</patient>
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</patientRole>
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</recordTarget>
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<author>
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<time value="20100703"/>
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<assignedAuthor>
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<id root="2.16.840.1.113883.3.249.6" extension="100001"/>
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<assignedPerson>
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<name>
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<given>Nancy</given>
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<family>Anthracite</family>
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<suffix>MD</suffix>
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</name>
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</assignedPerson>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
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<name>WorldVistA Test Clinic</name>
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</representedOrganization>
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</assignedAuthor>
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</author>
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<informant>
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<assignedEntity>
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<id nullFlavor="NA"/>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
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<name>World VistA Test Clinic</name>
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</representedOrganization>
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</assignedEntity>
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</informant>
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<custodian>
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<assignedCustodian>
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<representedCustodianOrganization>
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<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
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<name>WorldVistA Test Clinic</name>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<legalAuthenticator>
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<time value="20100703"/>
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<signatureCode code="S"/>
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<assignedEntity>
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<id root="2.16.840.1.113883.3.543" extension="111111"/>
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<assignedPerson>
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<name>
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<given>Nancy</given>
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<family>Anthracite</family>
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<suffix>MD</suffix>
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</name>
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</assignedPerson>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
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<name>WorldVistA Test Clinic</name>
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</representedOrganization>
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</assignedEntity>
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</legalAuthenticator>
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<participant typeCode="PRF">
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<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
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<associatedEntity classCode="PROV">
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<id root="2.16.840.1.113883.3.249.6" extension="111111"/>
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<associatedPerson>
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<name>
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<prefix>Dr.</prefix>
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<given>Nancy</given>
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<family>Anthracite</family>
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</name>
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</associatedPerson>
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</associatedEntity>
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</participant>
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<component>
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<structuredBody>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.249.11.50"/>
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<code code="55185-3" codeSystem="2.16.840.1.113883.6.1"/>
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<title>Measure set: CMS EHR Measure Set</title>
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<text>2010 Measures Set Measures</text>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.249.11.2"/>
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<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
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<title>Measure Section</title>
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<text>
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<list>
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<item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
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</list>
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</text>
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<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="DEF">
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<id root="2.16.840.1.113883.3.249.11.2"/>
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<code code="PQRI-1" codeSystem="2.16.840.1.113883.3.249.12" displayName="Hemoglobin A1c Poor Control in Diabetes Mellitus"/>
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<text>Percentage of patients 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1C greater than 9.0%</text>
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<statusCode code="completed"/>
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</act>
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</entry>
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<component>
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<section>
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<code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
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<title>Reporting Parameters</title>
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<text>
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<list>
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<item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
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</list>
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</text>
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<entry>
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<act classCode="ACT" moodCode="EVN">
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<code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters"/>
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<effectiveTime>
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<low value="20100101"/>
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<high value="20101231"/>
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</effectiveTime>
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</act>
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</entry>
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</section>
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</component>
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<component>
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<section>
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<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
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<title>Patient Data</title>
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</section>
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</component>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
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<templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
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<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
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<title>Problems</title>
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<text>
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<table>
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<tbody>
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<tr>
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<th>Type</th>
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<th>Date</th>
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<th>Code</th>
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<th>Description</th>
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<th>Status</th>
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<th>Source</th>
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</tr>
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<tr>
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<td>Problem</td>
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<td>
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<table>
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<tbody>
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<tr xmlns="">
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<td>Oct 13, 2010</td>
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</tr>
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</tbody>
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</table>
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</td>
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<td>250.02 (ICD9CM)
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</td>
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<td ID="PROBLEM1">Diabetes Mellitus without mention of Complication, type II or unspecified type,</td>
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<td>Active</td>
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<td>NANCY ANTHRACITE </td>
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</tr>
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<tr>
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<td>Problem</td>
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<td>
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<table>
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<tbody>
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<tr xmlns="">
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<td>Oct 04, 2010</td>
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</tr>
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</tbody>
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</table>
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</td>
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<td>250.00 (ICD9CM)
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</td>
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<td ID="PROBLEM2">Diabetes Mellitus</td>
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<td>Active</td>
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<td>MATTHEW M KING </td>
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</tr>
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</tbody>
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</table>
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</text>
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<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.27"/>
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<id root="PROBLEM1" extension="CCRObjectID"/>
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<code nullFlavor="NA"/>
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<performer typeCode="PRF">
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<assignedEntity>
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<id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
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<addr use="WP">
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<streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
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<city>ALBANY</city>
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<state>NY</state>
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<postalCode>12180</postalCode>
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</addr>
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<telecom/>
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<assignedPerson>
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<name>
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<given>NANCY</given>
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<family>ANTHRACITE</family>
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</name>
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</assignedPerson>
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</assignedEntity>
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</performer>
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<entryRelationship typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
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<templateId root="2.16.840.1.113883.3.249.11.100.8"/>
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<id root="PROBLEM1" extension="CCRObjectID"/>
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<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
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<statusCode code="completed"/>
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<text>
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<reference value="#PROBLEM1"/>
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</text>
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<effectiveTime>
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<low value="20101013"/>
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<high nullFlavor="UNK"/>
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</effectiveTime>
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<value displayName="Diabetes Mellitus without mention of Complication, type II or unspecified type," code="250.02" codeSystemName="ICD9CM" codeSystem=""/>
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<entryRelationship typeCode="REFR">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.50"/>
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<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
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<statusCode code="completed"/>
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<value>
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<originalText>Active</originalText>
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</value>
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</observation>
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</entryRelationship>
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</observation>
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</entryRelationship>
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</act>
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</entry>
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<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.27"/>
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<id root="PROBLEM2" extension="CCRObjectID"/>
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<code nullFlavor="NA"/>
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<performer typeCode="PRF">
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<assignedEntity>
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<id extension="ACTORPROVIDER_10000000183" root="CCRActorID"/>
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<addr use="WP">
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<streetAddressLine>VA MEDICAL CENTER</streetAddressLine>
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<city>ALBANY</city>
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<state>NY</state>
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<postalCode>12180</postalCode>
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</addr>
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<telecom/>
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<assignedPerson>
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<name>
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<given>MATTHEW</given>
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<given>M</given>
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<family>KING</family>
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</name>
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</assignedPerson>
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</assignedEntity>
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</performer>
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<entryRelationship typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
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<templateId root="2.16.840.1.113883.3.249.11.100.8"/>
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<id root="PROBLEM2" extension="CCRObjectID"/>
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||
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<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
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<statusCode code="completed"/>
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<text>
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<reference value="#PROBLEM2"/>
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</text>
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<effectiveTime>
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<low value="20101004"/>
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<high nullFlavor="UNK"/>
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</effectiveTime>
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<value displayName="Diabetes Mellitus" code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
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<entryRelationship typeCode="REFR">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.50"/>
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<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
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<statusCode code="completed"/>
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<value>
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<originalText>Active</originalText>
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</value>
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</observation>
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</entryRelationship>
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</observation>
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</entryRelationship>
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</act>
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</entry>
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</section>
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</component>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.10.20.1.12"/>
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<code code="47519-4" codeSystem="2.16.840.1.113883.6.1"/>
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<title>Procedures</title>
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<text>
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<table>
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<tbody>
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<tr>
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<th>Type</th>
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<th>Date</th>
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<th>Code</th>
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<th>Description</th>
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<th>Location</th>
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<th>Substance</th>
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<th>Method</th>
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<th>Position</th>
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<th>Site</th>
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<th>Status</th>
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<th>Source</th>
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</tr>
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<tr id="PROCEDURE_4141_10">
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<td/>
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<table>
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<tbody>
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<tr xmlns="">
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<td>Procedure Date:
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</td>
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||
|
|
<td>Oct 14, 2010</td>
|
||
|
|
</tr>
|
||
|
|
</tbody>
|
||
|
|
</table>
|
||
|
|
<td>99242 (CPT-4)
|
||
|
|
</td>
|
||
|
|
<td>INTERMEDIATE (30min)</td>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td>Completed</td>
|
||
|
|
<td>NANCY ANTHRACITE </td>
|
||
|
|
</tr>
|
||
|
|
<tr id="PROCEDURE_4092_7">
|
||
|
|
<td/>
|
||
|
|
<table>
|
||
|
|
<tbody>
|
||
|
|
<tr xmlns="">
|
||
|
|
<td>Procedure Date:
|
||
|
|
</td>
|
||
|
|
<td>Oct 04, 2010</td>
|
||
|
|
</tr>
|
||
|
|
</tbody>
|
||
|
|
</table>
|
||
|
|
<td>99213 (CPT-4)
|
||
|
|
</td>
|
||
|
|
<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>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td/>
|
||
|
|
<td>Completed</td>
|
||
|
|
<td>MATTHEW M KING </td>
|
||
|
|
</tr>
|
||
|
|
</tbody>
|
||
|
|
</table>
|
||
|
|
</text>
|
||
|
|
<entry typeCode="DRIV">
|
||
|
|
<procedure classCode="PROC" moodCode="EVN">
|
||
|
|
<templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
|
||
|
|
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
|
||
|
|
<id root="PROCEDURE_4141_10" extension="CCRObjectID"/>
|
||
|
|
<code displayName="INTERMEDIATE (30min)" code="99242" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
|
||
|
|
<text>
|
||
|
|
<reference value="#PROCEDURE_4141_10"/>
|
||
|
|
</text>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<effectiveTime>
|
||
|
|
<low value="20101014"/>
|
||
|
|
<high nullFlavor="UNK"/>
|
||
|
|
</effectiveTime>
|
||
|
|
</procedure>
|
||
|
|
</entry>
|
||
|
|
<entry typeCode="DRIV">
|
||
|
|
<procedure classCode="PROC" moodCode="EVN">
|
||
|
|
<templateId root="2.16.840.1.113883.3.88.11.83.17" assigningAuthorityName="HITSP C83"/>
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.29" assigningAuthorityName="CCD"/>
|
||
|
|
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19" assigningAuthorityName="IHE PCC"/>
|
||
|
|
<id root="PROCEDURE_4092_7" extension="CCRObjectID"/>
|
||
|
|
<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"/>
|
||
|
|
<text>
|
||
|
|
<reference value="#PROCEDURE_4092_7"/>
|
||
|
|
</text>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<effectiveTime>
|
||
|
|
<low value="20101004"/>
|
||
|
|
<high nullFlavor="UNK"/>
|
||
|
|
</effectiveTime>
|
||
|
|
</procedure>
|
||
|
|
</entry>
|
||
|
|
</section>
|
||
|
|
</component>
|
||
|
|
<component>
|
||
|
|
<section>
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.9"/>
|
||
|
|
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment Sources"/>
|
||
|
|
<title>Payers</title>
|
||
|
|
<text/>
|
||
|
|
<entry typeCode="DRIV">
|
||
|
|
<act classCode="ACT" moodCode="DEF">
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.20"/>
|
||
|
|
<id root="2.16.840.1.113883.3.543" extension="@@@UUID-PAYER@@@"/>
|
||
|
|
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment sources"/>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<entryRelationship typeCode="COMP">
|
||
|
|
<act classCode="ACT" moodCode="EVN">
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.26"/>
|
||
|
|
<templateId root="2.16.840.1.113883.3.249.11.100.7"/>
|
||
|
|
<id root="dbbb6311-8a4d-11df-a4ee-0800200c9c66"/>
|
||
|
|
<code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Public Healthcare"/>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<performer typeCode="PRF">
|
||
|
|
<assignedEntity>
|
||
|
|
<id root="2.16.840.1.113883.12.86" extension="MC"/>
|
||
|
|
</assignedEntity>
|
||
|
|
</performer>
|
||
|
|
<participant typeCode="COV">
|
||
|
|
<participantRole>
|
||
|
|
<id root="2.16.840.1.113883.4.1" extension="@@SSN@@"/>
|
||
|
|
<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
|
||
|
|
</participantRole>
|
||
|
|
</participant>
|
||
|
|
</act>
|
||
|
|
</entryRelationship>
|
||
|
|
</act>
|
||
|
|
</entry>
|
||
|
|
</section>
|
||
|
|
</component>
|
||
|
|
</section>
|
||
|
|
</component>
|
||
|
|
</section>
|
||
|
|
</component>
|
||
|
|
</structuredBody>
|
||
|
|
</component>
|
||
|
|
</ClinicalDocument>
|