Narrative Reference - Procedure

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 6/1/2017
  • SDWG: 7/6/2017

C-CDA 2.1 Example:

  • Applies to all C-CDA/CDA templates with this entry type

Reference to full CDA sample:

  • This sample will not validate

Validation location

  • Not applicable

Comments

  • This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

Custodian

  • Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) (original design courtesy of George Cole)

Keywords

  • narrative, narrative-entry, linking text

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Links

 

Example: download example view on GitHub 

<component>
	<!-- The following section is fictitious - it exists solely for the purpose of showing examples of text/reference and originalText/reference from discrete entry children. As such, many elements are omitted and replaced by ... comments. The text and content in the discrete entry elements does not use actual clinical content, but instead relies on filler text commonly used in publishing and graphic design. -->
	<section>
		<!--  ... -->
		<text>
			<!-- The text in this section is created strictly to illustrate how discrete entry child elements make references into the human readable text.  -->
			<!-- this table is used for a simple procedure; the ID values are meant to be unique across the whole document -->
			<table>
				<tbody>
					<tr ID="procedureFullTextReference1">
						<td ID="procedureCodeTextReference1">Vestibulum nunc nisl</td>
						<td>labelText: mmm DD YYYY</td>
						<br/>
						<td>
							labelText: 
							<content ID="procedureSiteCodeReference1">Vulputate eget  </content>
						</td>
						<td>
							labeltext: 
							<content ID="procedureMethodCodeReference1">Ornare eget </content>
							<br/>
						</td>
					</tr>
				</tbody>
			</table>
		</text>
		<!-- This illustrates a simple procedure. In C-CDA there are several procedure templates but we'll focus on Procedure Activity Procedure -->
		<entry>
			<procedure classCode="PROC" moodCode="EVN">
				<!-- ... -->
				<!-- the code of a procedure is significant, so also the originalText/refernece is a SHOULD -->
				<code code="5678" codeSystem="1.2.3.4.5.6.7.8.42" displayName="praesent efficitur">
					<originalText>
						<reference value="#procedureCodeTextReference1"/>
					</originalText>
				</code>
				<!-- we may reference the entire text of the procedure
									Example: Appendectomy Date: Feb 3rd 2013 Site: Right Abdomen Method: Transverse Incision Comments: patient is NPO
							-->
				<statusCode/>
				<text>
					<reference value="#procedureFullTextReference1"/>
				</text>
				<effectiveTime value="YYYYMMDD"/>
				<!-- ... -->
				<!-- when the method of a procedure is reflected in the human readable text we SHOULD have originalText/reference -->
				<methodCode code="6789" codeSystem="1.2.3.4.5.6.7.8.42" displayName="ornare eget">
					<originalText>
						<reference value="#procedureMethodCodeReference1"/>
					</originalText>
				</methodCode>
				<!-- when the target site of a procedure is reflected in the human readable text we SHOULD have originalText/reference -->
				<targetSiteCode code="7890" codeSystem="1.2.3.4.5.6.7.8.42" displayName="vulputate eget">
					<originalText>
						<reference value="#procedureSiteCodeReference1"/>
					</originalText>
				</targetSiteCode>
				<!-- ... -->
			</procedure>
		</entry>
	</section>
</component>

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