723 lines
38 KiB
XML
723 lines
38 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="c9bec8aa-e5e7-11df-ba06-3b3edcef0468"/>
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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="c9bec8aa-e5e7-11df-ba06-3b3edcef0468"/>
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<versionNumber value="1"/>
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<recordTarget>
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<patientRole>
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<id extension="002030004" root="2.16.840.1.113883.4.1"/>
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<addr use="H">
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<streetAddressLine/>
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<city/>
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<state/>
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<postalCode/>
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</addr>
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<telecom/>
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<patient>
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<name>
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<given>JODY</given>
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<given>JEAN</given>
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<family>JONES</family>
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</name>
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<administrativeGenderCode displayName="FEMALE" code="F" codeSystemName="HL7 AdministrativeGender" codeSystem="2.16.840.1.113883.5.1"/>
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<birthTime value="19450101120000"/>
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<raceCode code="2076-8" codeSystem="2.16.840.1.113883.5.104"/>
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<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.5.50"/>
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</patient>
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<providerOrganization>
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<!-- NPI for the provider and this is a real number-->
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<id root="2.16.840.1.113883.4.6" extension="1558574525" />
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<name>WorldVistA Test Clinic</name>
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<!--WVV Address of organization is optional except for the STATE-->
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<addr>
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<state>MD</state>
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<postalCode>20877</postalCode>
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</addr>
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<!--WVP required asOrganizationPartOf added to sample-->
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<asOrganizationPartOf>
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<wholeOrganization>
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<!-- Tax ID is the extension and this is a dummy numbers-->
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<id root="2.16.840.1.113883.4.2" extension="226864459"/>
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</wholeOrganization>
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</asOrganizationPartOf>
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</providerOrganization>
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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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||
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<id root="2.16.840.1.113883.3.543" extension="111111"/>
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<assignedPerson>
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||
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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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||
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<id root="2.16.840.1.113883.3.543" extension="1558574526"/>
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||
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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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||
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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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||
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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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<documentationOf>
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<serviceEvent>
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<code displayName="EXPANDED, HX & EXAM" code="99202" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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<effectiveTime>
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||
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<low value="20100828"/>
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<high value="20100828"/>
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</effectiveTime>
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<performer typeCode="PRF">
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||
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<assignedEntity>
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||
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<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
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||
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<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
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||
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<addr>
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<streetAddressLine>123 Maple Ave</streetAddressLine>
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<city>Gaithersburg</city>
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<state>MD</state>
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<postalCode>20877</postalCode>
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</addr>
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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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</assignedEntity>
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</performer>
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</serviceEvent>
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</documentationOf>
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<documentationOf>
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<serviceEvent>
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<code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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||
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<effectiveTime>
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||
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<low value="20101017"/>
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||
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<high value="20101017"/>
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||
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</effectiveTime>
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||
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<performer typeCode="PRF">
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||
|
|
<assignedEntity>
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||
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|
<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
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||
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<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
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||
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<addr>
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||
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<streetAddressLine>123 Maple Ave</streetAddressLine>
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||
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<city>Gaithersburg</city>
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||
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<state>MD</state>
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||
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<postalCode>20877</postalCode>
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||
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</addr>
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||
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<assignedPerson>
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||
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<name>
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||
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<given>Nancy</given>
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<family>Anthracite</family>
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||
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<suffix>MD</suffix>
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</name>
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</assignedPerson>
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</assignedEntity>
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</performer>
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</serviceEvent>
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</documentationOf>
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<documentationOf>
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||
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<serviceEvent>
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||
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|
<code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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||
|
|
<effectiveTime>
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||
|
|
<low value="20101006"/>
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<high value="20101006"/>
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</effectiveTime>
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<performer typeCode="PRF">
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<assignedEntity>
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<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
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|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
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||
|
|
<addr>
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||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
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||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
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||
|
|
</addr>
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||
|
|
<assignedPerson>
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||
|
|
<name>
|
||
|
|
<given>Nancy</given>
|
||
|
|
<family>Anthracite</family>
|
||
|
|
<suffix>MD</suffix>
|
||
|
|
</name>
|
||
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|
</assignedPerson>
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||
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|
</assignedEntity>
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||
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|
</performer>
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||
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|
</serviceEvent>
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||
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|
</documentationOf>
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||
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<documentationOf>
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||
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<serviceEvent>
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||
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|
<code displayName="INTERMEDIATE (15min)" code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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||
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|
<effectiveTime>
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||
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|
<low value="20100904"/>
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||
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<high value="20100904"/>
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||
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|
</effectiveTime>
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||
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<performer typeCode="PRF">
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<assignedEntity>
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||
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<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
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||
|
|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
|
||
|
|
<addr>
|
||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
|
||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
|
||
|
|
</addr>
|
||
|
|
<assignedPerson>
|
||
|
|
<name>
|
||
|
|
<given>Nancy</given>
|
||
|
|
<family>Anthracite</family>
|
||
|
|
<suffix>MD</suffix>
|
||
|
|
</name>
|
||
|
|
</assignedPerson>
|
||
|
|
</assignedEntity>
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||
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|
</performer>
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||
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|
</serviceEvent>
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||
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|
</documentationOf>
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||
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|
<documentationOf>
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||
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|
<serviceEvent>
|
||
|
|
<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"/>
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||
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|
<effectiveTime>
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||
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|
<low value="20100731"/>
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||
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<high value="20100731"/>
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||
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|
</effectiveTime>
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||
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|
<performer typeCode="PRF">
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||
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<assignedEntity>
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||
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|
<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
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||
|
|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
|
||
|
|
<addr>
|
||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
|
||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
|
||
|
|
</addr>
|
||
|
|
<assignedPerson>
|
||
|
|
<name>
|
||
|
|
<given>Nancy</given>
|
||
|
|
<family>Anthracite</family>
|
||
|
|
<suffix>MD</suffix>
|
||
|
|
</name>
|
||
|
|
</assignedPerson>
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||
|
|
</assignedEntity>
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||
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|
</performer>
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||
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|
</serviceEvent>
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||
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|
</documentationOf>
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||
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|
<documentationOf>
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||
|
|
<serviceEvent>
|
||
|
|
<code displayName="EXTENDED (25min)" code="99214" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
|
||
|
|
<effectiveTime>
|
||
|
|
<low value="20101016"/>
|
||
|
|
<high value="20101016"/>
|
||
|
|
</effectiveTime>
|
||
|
|
<performer typeCode="PRF">
|
||
|
|
<assignedEntity>
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||
|
|
<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
|
||
|
|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
|
||
|
|
<addr>
|
||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
|
||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
|
||
|
|
</addr>
|
||
|
|
<assignedPerson>
|
||
|
|
<name>
|
||
|
|
<given>Nancy</given>
|
||
|
|
<family>Anthracite</family>
|
||
|
|
<suffix>MD</suffix>
|
||
|
|
</name>
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||
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|
</assignedPerson>
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||
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</assignedEntity>
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||
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</performer>
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</serviceEvent>
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||
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</documentationOf>
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||
|
|
<documentationOf>
|
||
|
|
<serviceEvent>
|
||
|
|
<code displayName="EXTENDED (25min)" code="99214" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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||
|
|
<effectiveTime>
|
||
|
|
<low value="20101015"/>
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||
|
|
<high value="20101015"/>
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||
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|
</effectiveTime>
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||
|
|
<performer typeCode="PRF">
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||
|
|
<assignedEntity>
|
||
|
|
<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
|
||
|
|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
|
||
|
|
<addr>
|
||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
|
||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
|
||
|
|
</addr>
|
||
|
|
<assignedPerson>
|
||
|
|
<name>
|
||
|
|
<given>Nancy</given>
|
||
|
|
<family>Anthracite</family>
|
||
|
|
<suffix>MD</suffix>
|
||
|
|
</name>
|
||
|
|
</assignedPerson>
|
||
|
|
</assignedEntity>
|
||
|
|
</performer>
|
||
|
|
</serviceEvent>
|
||
|
|
</documentationOf>
|
||
|
|
<documentationOf>
|
||
|
|
<serviceEvent>
|
||
|
|
<code displayName="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)" code="99214" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
|
||
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|
<effectiveTime>
|
||
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|
<low value="20100917"/>
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||
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|
<high value="20100917"/>
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||
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</effectiveTime>
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||
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<performer typeCode="PRF">
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||
|
|
<assignedEntity>
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||
|
|
<id root="2.16.840.1.113883.4.6" extension="1558574525"/>
|
||
|
|
<code code="62247001" codeSystem="2.16.840.1.113883.6.69" codeSystemName="SNM CT" displayName="Internal Medician Specialist"/>
|
||
|
|
<addr>
|
||
|
|
<streetAddressLine>123 Maple Ave</streetAddressLine>
|
||
|
|
<city>Gaithersburg</city>
|
||
|
|
<state>MD</state>
|
||
|
|
<postalCode>20877</postalCode>
|
||
|
|
</addr>
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<item>CMS Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus</item>
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<item>Reporting Period Jan 1, 2010 to Dec 31, 2010</item>
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<state>NY</state>
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<postalCode>12180</postalCode>
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||
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|
</addr>
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<telecom/>
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|
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<assignedPerson>
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<name>
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<prefix>Scholar Extraordinaire</prefix>
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<telecom/>
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|
|
<family>PROVIDER</family>
|
||
|
|
</name>
|
||
|
|
</assignedPerson>
|
||
|
|
</assignedEntity>
|
||
|
|
</performer>
|
||
|
|
<entryRelationship typeCode="SUBJ">
|
||
|
|
<observation classCode="OBS" moodCode="EVN">
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
|
||
|
|
<templateId root="2.16.840.1.113883.3.249.11.100.8"/>
|
||
|
|
<id root="PROBLEM5" extension="CCRObjectID"/>
|
||
|
|
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNM"/>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<effectiveTime>
|
||
|
|
<low value="20100705"/>
|
||
|
|
<high value="20100705"/>
|
||
|
|
</effectiveTime>
|
||
|
|
<value xsi:type="CD" displayName="Postmyocardial infarction syndrome (ICD-9-CM 411.0)" code="411.0" codeSystemName="I9" codeSystem="2.16.840.1.113883.6.103"/>
|
||
|
|
<entryRelationship typeCode="REFR">
|
||
|
|
<observation classCode="OBS" moodCode="EVN">
|
||
|
|
<templateId root="2.16.840.1.113883.10.20.1.50"/>
|
||
|
|
<templateId root="2.16.840.1.113883.3.249.11.100.12"/>
|
||
|
|
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
|
||
|
|
<statusCode code="completed"/>
|
||
|
|
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active" codeSystemName="SNM" />
|
||
|
|
</observation>
|
||
|
|
</entryRelationship>
|
||
|
|
</observation>
|
||
|
|
</entryRelationship>
|
||
|
|
</act>
|
||
|
|
</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="c9bec8aa-e5e7-11df-ba06-3b3edcef0468"/>
|
||
|
|
<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="002030004"/>
|
||
|
|
<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>
|