472 lines
9.0 KiB
XML
472 lines
9.0 KiB
XML
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<?xml version="1.0" encoding="UTF-8"?>
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<?xml-stylesheet type="text/xsl" href="ccr.xsl"?>
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<ContinuityOfCareRecord xmlns="urn:astm-org:CCR">
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<CCRDocumentObjectID>33f5b05b-e101-4530-9b91-97203c8b71e6</CCRDocumentObjectID>
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<Language>
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<Text>English</Text>
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</Language>
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<Version>V1.0</Version>
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<DateTime>
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<ExactDateTime>2010-10-18T15:37:06-05:00</ExactDateTime>
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</DateTime>
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<Patient>
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<ActorID>ACTORPATIENT_100848</ActorID>
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</Patient>
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<From>
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<ActorLink>
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<ActorID>ACTORPROVIDER_1</ActorID>
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</ActorLink>
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<ActorLink>
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<ActorID>ACTORSYSTEM_1</ActorID>
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</ActorLink>
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</From>
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<To>
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<ActorLink>
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<ActorID>ACTORPATIENT_100848</ActorID>
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<ActorRole>
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<Text>Patient</Text>
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</ActorRole>
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</ActorLink>
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</To>
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<Purpose>
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<Description>
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<Text>CEND PHR</Text>
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</Description>
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</Purpose>
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<Body>
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<Problems>
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<Problem>
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<CCRDataObjectID>PROBLEM1</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text>Problem</Text>
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</Type>
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<Description>
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<Text>Diabetes Mellitus without mention of Complication, type II or unspecified type,</Text>
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<Code>
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<Value>250.00</Value>
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<CodingSystem>ICD9CM</CodingSystem>
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</Code>
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</Description>
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<Status>
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<Text>Active</Text>
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</Status>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_991</ActorID>
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</Actor>
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</Source>
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</Problem>
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<Problem>
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<CCRDataObjectID>PROBLEM2</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text>Problem</Text>
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</Type>
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<Description>
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<Text>Sprains (ICD-9-CM 848.9)</Text>
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<Code>
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<Value>848.9</Value>
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<CodingSystem>ICD9CM</CodingSystem>
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</Code>
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</Description>
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<Status>
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<Text>Active</Text>
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</Status>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000183</ActorID>
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</Actor>
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</Source>
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</Problem>
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</Problems>
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<Procedures>
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<Procedure>
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<CCRDataObjectID>PROCEDURE_4108_8</CCRDataObjectID>
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<DateTime>
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<Type>
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<Text>Procedure Date</Text>
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</Type>
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<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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<Code>
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<Value>84295</Value>
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<CodingSystem>CPT-4</CodingSystem>
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</Code>
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</Description>
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<Status>
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<Text>Completed</Text>
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</Status>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000020</ActorID>
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</Actor>
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</Source>
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</Procedure>
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<Procedure>
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<CCRDataObjectID>PROCEDURE_4093_5</CCRDataObjectID>
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<DateTime>
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<Type>
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<Text>Procedure Date</Text>
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</Type>
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<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>INTERMEDIATE (15min)</Text>
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<Code>
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<Value>99213</Value>
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<CodingSystem>CPT-4</CodingSystem>
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</Code>
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</Description>
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<Status>
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<Text>Completed</Text>
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</Status>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000183</ActorID>
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</Actor>
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</Source>
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</Procedure>
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</Procedures>
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<Encounters>
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<Encounter>
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<CCRDataObjectID>ENCOUNTER_4108</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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</Type>
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<Description>
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<Text> Sodium; serum, plasma or whole blood (CPT-4 84295)</Text>
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</Description>
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<Location>
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<Actor>
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<ActorID>ACTORORGANIZATION_1</ActorID>
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</Actor>
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</Location>
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<Practioner>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000020</ActorID>
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</Actor>
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</Practioner>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000020</ActorID>
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</Actor>
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</Source>
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<CommentID>NOTE_4108</CommentID>
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</Encounter>
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<Encounter>
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<CCRDataObjectID>ENCOUNTER_4093</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
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<Code>
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<Value>99213</Value>
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<CodingSystem>CPT-4</CodingSystem>
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</Code>
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</Type>
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<Description>
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<Text>***ESTABLISHED PATIENT*** INTERMEDIATE (15min)</Text>
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<Code>
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<Value>99213</Value>
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<CodingSystem>CPT-4</CodingSystem>
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</Code>
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</Description>
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<Location>
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<Actor>
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<ActorID>ACTORORGANIZATION_1</ActorID>
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</Actor>
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</Location>
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<Practioner>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000183</ActorID>
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</Actor>
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</Practioner>
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<Source>
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<Actor>
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<ActorID>ACTORPROVIDER_10000000183</ActorID>
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</Actor>
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</Source>
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<CommentID>NOTE_4093</CommentID>
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</Encounter>
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</Encounters>
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</Body>
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<Actors>
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<Actor>
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<ActorObjectID>ACTORORGANIZATION_1</ActorObjectID>
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<Organization>
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<Name>CAMP MASTER</Name>
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</Organization>
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<Address>
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<Type>
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<Text>Office</Text>
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</Type>
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<Line1>VA MEDICAL CENTER</Line1>
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<City>ALBANY</City>
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<State>NEW YORK</State>
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<PostalCode>12180</PostalCode>
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</Address>
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<Source>
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<Actor>
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<ActorID>ACTORSYSTEM_1</ActorID>
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</Actor>
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</Source>
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</Actor>
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<Actor>
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<ActorObjectID>ACTORPATIENT_100848</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>FEMALE-B</Given>
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<Family>MEASURE-ONE</Family>
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</CurrentName>
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</Name>
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<DateOfBirth>
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<ExactDateTime>1960-01-01</ExactDateTime>
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</DateOfBirth>
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<Gender>
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<Text>FEMALE</Text>
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<Code>
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<Value>F</Value>
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<CodingSystem>HL7 AdministrativeGender</CodingSystem>
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</Code>
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</Gender>
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</Person>
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<IDs>
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<Type>
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<Text>SSN</Text>
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</Type>
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<ID>345097898</ID>
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<Source>
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<Actor>
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<ActorID>ACTORPATIENT_100848</ActorID>
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</Actor>
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</Source>
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</IDs>
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<Address>
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<Type>
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<Text>Home</Text>
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</Type>
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</Address>
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<Source>
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<Actor>
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<ActorID>ACTORPATIENT_100848</ActorID>
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</Actor>
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</Source>
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</Actor>
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<Actor>
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<ActorObjectID>ACTORPROVIDER_1</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>ONE</Given>
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<Family>PROGRAMMER</Family>
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<Title>COMPUTER SPECIALIST</Title>
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</CurrentName>
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</Name>
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</Person>
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<Specialty>
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<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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</Specialty>
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<Address>
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<Type>
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<Text>Work</Text>
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</Type>
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<Line1>VA MEDICAL CENTER</Line1>
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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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</Address>
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<Telephone>
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<Value>6655544</Value>
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<Type>
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<Text>Office</Text>
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</Type>
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</Telephone>
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<Source>
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<Actor>
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<ActorID>ACTORSYSTEM_1</ActorID>
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</Actor>
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</Source>
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<InternalCCRLink>
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<LinkID>ACTORORGANIZATION_1</LinkID>
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<LinkRelationship>representedOrganization</LinkRelationship>
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</InternalCCRLink>
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</Actor>
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<Actor>
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<ActorObjectID>ACTORPROVIDER_10000000020</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>NANCY</Given>
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<Family>ANTHRACITE</Family>
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</CurrentName>
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</Name>
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</Person>
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<Specialty>
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<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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</Specialty>
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<Address>
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<Type>
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<Text>Work</Text>
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</Type>
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<Line1>VA MEDICAL CENTER</Line1>
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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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</Address>
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<Source>
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<Actor>
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<ActorID>ACTORSYSTEM_1</ActorID>
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</Actor>
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</Source>
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<InternalCCRLink>
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<LinkID>ACTORORGANIZATION_1</LinkID>
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<LinkRelationship>representedOrganization</LinkRelationship>
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</InternalCCRLink>
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</Actor>
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<Actor>
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<ActorObjectID>ACTORPROVIDER_10000000183</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>MATTHEW</Given>
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<Middle>M</Middle>
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<Family>KING</Family>
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</CurrentName>
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</Name>
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</Person>
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<Specialty>
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<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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</Specialty>
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<Address>
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<Type>
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<Text>Work</Text>
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</Type>
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<Line1>VA MEDICAL CENTER</Line1>
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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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</Address>
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<Source>
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<Actor>
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<ActorID>ACTORSYSTEM_1</ActorID>
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</Actor>
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</Source>
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<InternalCCRLink>
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<LinkID>ACTORORGANIZATION_1</LinkID>
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<LinkRelationship>representedOrganization</LinkRelationship>
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</InternalCCRLink>
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</Actor>
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<Actor>
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<ActorObjectID>ACTORPROVIDER_991</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>EIGHT</Given>
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<Family>PROVIDER</Family>
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<Title>Scholar Extraordinaire</Title>
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</CurrentName>
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</Name>
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</Person>
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<Specialty>
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||
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<Text>Physicians (M.D. and D.O.)-Physician/Osteopath</Text>
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||
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</Specialty>
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||
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<Address>
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||
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<Type>
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||
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<Text>Work</Text>
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||
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</Type>
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||
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<Line1>VA MEDICAL CENTER</Line1>
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||
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<City>ALBANY</City>
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||
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|
<State>NY</State>
|
||
|
|
<PostalCode>12180</PostalCode>
|
||
|
|
</Address>
|
||
|
|
<Source>
|
||
|
|
<Actor>
|
||
|
|
<ActorID>ACTORSYSTEM_1</ActorID>
|
||
|
|
</Actor>
|
||
|
|
</Source>
|
||
|
|
<InternalCCRLink>
|
||
|
|
<LinkID>ACTORORGANIZATION_1</LinkID>
|
||
|
|
<LinkRelationship>representedOrganization</LinkRelationship>
|
||
|
|
</InternalCCRLink>
|
||
|
|
</Actor>
|
||
|
|
<Actor>
|
||
|
|
<ActorObjectID>ACTORSYSTEM_1</ActorObjectID>
|
||
|
|
<InformationSystem>
|
||
|
|
<Name>WorldVistA EHR/VOE</Name>
|
||
|
|
<Version>1.0</Version>
|
||
|
|
</InformationSystem>
|
||
|
|
<Source>
|
||
|
|
<Actor>
|
||
|
|
<ActorID>ACTORSYSTEM_1</ActorID>
|
||
|
|
</Actor>
|
||
|
|
</Source>
|
||
|
|
</Actor>
|
||
|
|
</Actors>
|
||
|
|
<Comments>
|
||
|
|
<Comment>
|
||
|
|
<CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
|
||
|
|
<DateTime>
|
||
|
|
<ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
|
||
|
|
</DateTime>
|
||
|
|
<Source>
|
||
|
|
<Actor>
|
||
|
|
<ActorID>@@ACTORSOURCEID@@</ActorID>
|
||
|
|
</Actor>
|
||
|
|
</Source>
|
||
|
|
</Comment>
|
||
|
|
<Comment>
|
||
|
|
<CommentObjectID>NOTE_4093</CommentObjectID>
|
||
|
|
<DateTime>
|
||
|
|
<ExactDateTime>2010-10-05T00:00:00-05:00</ExactDateTime>
|
||
|
|
</DateTime>
|
||
|
|
<Description>
|
||
|
|
<Text>
|
||
|
|
PATIENT MAMMOGRAM INFORMATION:
|
||
|
|
PATIENT HAD A SCREENING MAMMOGRAM.
|
||
|
|
RESULT NEM (No Evidence of Malignancy)
|
||
|
|
DATE OF PROCEDURE: September 9, 2010
|
||
|
|
</Text>
|
||
|
|
</Description>
|
||
|
|
<Source>
|
||
|
|
<Actor>
|
||
|
|
<ActorID>ACTORPROVIDER_10000000183</ActorID>
|
||
|
|
</Actor>
|
||
|
|
</Source>
|
||
|
|
</Comment>
|
||
|
|
<Comment>
|
||
|
|
<CommentObjectID>NOTE_4108</CommentObjectID>
|
||
|
|
<DateTime>
|
||
|
|
<ExactDateTime>2010-10-13T00:00:00-05:00</ExactDateTime>
|
||
|
|
</DateTime>
|
||
|
|
<Description>
|
||
|
|
<Text>
|
||
|
|
PATIENT HBA1C RESULTS
|
||
|
|
PATIENTS HBA1C IS GREATER THAN 9%
|
||
|
|
HBA1C VALUE: 9.2
|
||
|
|
|
||
|
|
Measurement DT BP PULSE WEIGHT
|
||
|
|
LB(KG)[BMI]
|
||
|
|
10/05/2010 12:52 130/90 89 138(62.60)[23]
|
||
|
|
</Text>
|
||
|
|
</Description>
|
||
|
|
<Source>
|
||
|
|
<Actor>
|
||
|
|
<ActorID>ACTORPROVIDER_10000000020</ActorID>
|
||
|
|
</Actor>
|
||
|
|
</Source>
|
||
|
|
</Comment>
|
||
|
|
</Comments>
|
||
|
|
</ContinuityOfCareRecord>
|