495 lines
9.9 KiB
XML
495 lines
9.9 KiB
XML
<?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>d010c8bd-eda0-4e36-8a53-c7c677666b29</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>2010-10-18T15:33:12-05:00</ExactDateTime>
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</DateTime>
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<Patient>
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<ActorID>ACTORPATIENT_100146</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_100146</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>250.02</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_10000000020</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>2010-10-04T00:00:00-05:00</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</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_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_4141_10</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>2010-10-14T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>INTERMEDIATE (30min)</Text>
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<Code>
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<Value>99242</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_4092_7</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>2010-10-04T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>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)</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_4141</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-14T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text>***NEW PATIENT*** INTERMEDIATE (30min)</Text>
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<Code>
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<Value>99242</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>***NEW PATIENT*** INTERMEDIATE (30min)</Text>
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<Code>
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<Value>99242</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_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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</Encounter>
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<Encounter>
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<CCRDataObjectID>ENCOUNTER_4092</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text> 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)</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> 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)</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_4092</CommentID>
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</Encounter>
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<Encounter>
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<CCRDataObjectID>ENCOUNTER_4091</CCRDataObjectID>
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<DateTime>
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<ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Type>
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<Text> 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)</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> 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)</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_4091</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_100146</ActorObjectID>
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<Person>
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<Name>
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<CurrentName>
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<Given>MALE-D</Given>
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<Family>MEASURE-TWO</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>MALE</Text>
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<Code>
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<Value>M</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>666000200</ID>
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<Source>
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<Actor>
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<ActorID>ACTORPATIENT_100146</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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<Line1>Any Street</Line1>
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<City>Any Town</City>
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<State>WEST VIRGINIA</State>
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</Address>
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<Telephone>
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<Value>222-555-8235</Value>
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<Type>
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<Text>Residential Telephone</Text>
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</Type>
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</Telephone>
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<Telephone>
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<Value>222-555-7720</Value>
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<Type>
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<Text>Work Telephone</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>ACTORPATIENT_100146</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>ACTORSYSTEM_1</ActorObjectID>
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<InformationSystem>
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<Name>WorldVistA EHR/VOE</Name>
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<Version>1.0</Version>
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</InformationSystem>
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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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</Actors>
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<Comments>
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<Comment>
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<CommentObjectID>@@COMMENTOBJECTID@@</CommentObjectID>
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<DateTime>
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<ExactDateTime>@@CMTDATETIME@@</ExactDateTime>
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</DateTime>
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<Source>
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<Actor>
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<ActorID>@@ACTORSOURCEID@@</ActorID>
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</Actor>
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</Source>
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</Comment>
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<Comment>
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<CommentObjectID>NOTE_4091</CommentObjectID>
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<DateTime>
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<ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>
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PLACE DIABETIC ORDERS HERE.
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PATIENT HBA1C RESULTS
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PATIENTS HBA1C IS GREATER THAN 9%
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HBA1C VALUE: 9.1
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*** No Outpatient measurements ***
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</Text>
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</Description>
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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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</Comment>
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<Comment>
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<CommentObjectID>NOTE_4092</CommentObjectID>
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<DateTime>
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<ExactDateTime>2010-10-04T00:00:00-05:00</ExactDateTime>
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</DateTime>
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<Description>
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<Text>
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PATIENT MAMMOGRAM INFORMATION:
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PATIENT HAD A SCREENING MAMMOGRAM.
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RESULT NEM (No Evidence of Malignancy)
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DATE OF PROCEDURE: September 6, 2010
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</Text>
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</Description>
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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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</Comment>
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</Comments>
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</ContinuityOfCareRecord>
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