421 lines
15 KiB
XML
421 lines
15 KiB
XML
<?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="2.16.840.1.113883.3.249.11.100.1"/>
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<id root="eb60a84e-ae24-4f77-a649-ccfeb10a373f"/>
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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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<versionNumber value="1"/>
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<recordTarget>
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<patientRole>
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<id extension="345982321" 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>MALE-A</given>
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<family>MEASURE-ONE</family>
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</name>
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<administrativeGenderCode displayName="MALE" code="M" codeSystemName="HL7 AdministrativeGender" codeSystem="2.16.840.1.113883.5.1"/>
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<birthTime value="1960111200"/>
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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-->
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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-->
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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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<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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<documentationOf>
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<serviceEvent>
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<code displayName="COMPREHENSIVE (45min)" code="99204" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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<effectiveTime>
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<low value="20101013"/>
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<high value="20101013"/>
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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>
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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="LIMITED (10min)" code="99212" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"/>
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<effectiveTime>
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<low value="20101014"/>
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<high value="20101014"/>
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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>
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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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<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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<templateId root="2.16.840.1.113883.3.249.11.3"/>
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<templateId root="2.16.840.1.113883.3.249.11.4"/>
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<templateId root="2.16.840.1.113883.3.249.11.5"/>
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<templateId root="2.16.840.1.113883.3.249.11.6"/>
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<templateId root="2.16.840.1.113883.3.249.11.7"/>
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<templateId root="2.16.840.1.113883.3.249.11.8"/>
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<templateId root="2.16.840.1.113883.3.249.11.9"/>
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<templateId root="2.16.840.1.113883.3.249.11.10"/>
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<templateId root="2.16.840.1.113883.3.249.11.11"/>
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<templateId root="2.16.840.1.113883.3.249.11.15"/>
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<templateId root="2.16.840.1.113883.3.249.11.51"/>
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<templateId root="2.16.840.1.113883.3.249.11.52"/>
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<templateId root="2.16.840.1.113883.3.249.11.53"/>
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<templateId root="2.16.840.1.113883.3.249.11.54"/>
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<templateId root="2.16.840.1.113883.3.249.11.55"/>
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<templateId root="2.16.840.1.113883.3.249.11.56"/>
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<templateId root="2.16.840.1.113883.3.249.11.57"/>
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<templateId root="2.16.840.1.113883.3.249.11.58"/>
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<templateId root="2.16.840.1.113883.3.249.11.59"/>
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<templateId root="2.16.840.1.113883.3.249.11.60"/>
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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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<item>CMS Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus</item>
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<item>CMS Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus</item>
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<item>CMS Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)</item>
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<item>CMS Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)</item>
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<item>CMS Measure #110: Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years</item>
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<item>CMS Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older</item>
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<item>CMS Measure #112: Preventive Care and Screening: Screening Mammography</item>
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<item>CMS Measure #113: Preventive Care and Screening: Colorectal Cancer Screening</item>
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<item>CMS Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)</item>
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<item>CMS Measure eRx:Adoption/Use of Medication Electronic Prescribing Measure</item>
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<item>CMS Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older</item>
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<item>CMS Measure #47: Advance Care Plan </item>
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<item>CMS Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older</item>
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<item>CMS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up </item>
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<item>CMS Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use - Screening</item>
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<item>CMS Measure #0013: Hypertension (HTN): Blood Pressure Measurement - QRDA Cat I template </item>
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<item>CMS Measure #0022: Drugs to be avoided in the Elderly </item>
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<item>CMS Measure #0024: Body Mass Index (BMI) 2 through 18 years of age </item>
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<item>CMS Measure #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention</item>
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<item>CMS Measure #0038: Childhood Immunization Status - QRDA Cat I template</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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<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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<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="EVN">
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<id root="PROBLEM1" extension="CCRObjectID"/>
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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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<id root="PROBLEM1" extension="CCRObjectID"/>
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<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNM"/>
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<reference value="#PROBLEM1"/>
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<statusCode code="completed"/>
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<effectiveTime>
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<low value="20101014"/>
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<high value="20101014"/>
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</effectiveTime>
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<value xsi:type="CD" displayName="Diabetes (ICD-9-CM 250.00)" code="250.00" codeSystemName="I9" codeSystem="2.16.840.1.113883.6.103"/>
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<entryRelationship typeCode="REFR">
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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 xsi:type="CD" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active" codeSystemName="SNM">
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<originalText>Active</originalText>
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</value>
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</observation>
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<act classCode="ACT" moodCode="EVN">
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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_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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<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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<id root="PROBLEM2" extension="CCRObjectID"/>
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<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNM"/>
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<text>
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<reference value="#PROBLEM2"/>
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</text>
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<statusCode code="completed"/>
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<effectiveTime>
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<low value="20101013"/>
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<high value="20101013"/>
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</effectiveTime>
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<value xsi:type="CD" displayName="Nonproliferative Diabetic retinopathy NOS (ICD-9-CM 362.03)" code="362.03" codeSystemName="I9" codeSystem="2.16.840.1.113883.6.103"/>
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<entryRelationship typeCode="REFR">
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<observation classCode="OBS" moodCode="EVN">
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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 xsi:type="CD" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active" codeSystemName="SNM">
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<originalText>Active</originalText>
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</observation>
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<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment Sources"/>
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<title>Payers</title>
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<entry typeCode="DRIV">
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<templateId root="2.16.840.1.113883.10.20.1.20"/>
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<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment sources"/>
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<statusCode code="completed"/>
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<entryRelationship typeCode="COMP">
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<id root="dbbb6311-8a4d-11df-a4ee-0800200c9c66"/>
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<code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4" displayName="Public Healthcare"/>
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|
<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="345982321"/>
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|
<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/>
|
|
</participantRole>
|
|
</participant>
|
|
</act>
|
|
</entryRelationship>
|
|
</act>
|
|
</entry>
|
|
</section>
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|
</component>
|
|
</section>
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|
</component>
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|
</section>
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|
</component>
|
|
</structuredBody>
|
|
</component>
|
|
</ClinicalDocument>
|