RTF Note

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 10/8/2020
  • SDWG: 12/17/2020

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.4.202:2016-11-01 (Companion Guide Appendix A)

Reference to full CDA sample:

  • N/A

Validation location

Comments

  • This is an example of how to include rich text in a C-CDA Note Activity.

Custodian

  • Matt Szczepankiewicz, mszczepa@epic.com (GitHub: mjszczep)

Keywords

  • Note, Note Activity, Notes, RTF, Rich Text

Permalink

  • TBD

 

Example: download example view on GitHub 

<section>
    <!-- Notes Section -->
    <templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
    <code code="34746-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Nurse Note"/>
    <title>Nursing Notes</title>
    <text>
        <list>
            <!-- This is the Plain Text representation of the RTF, it must FULLY preserve the meaning of the embedded RTF. -->
            <!-- Systems receiving a section with RTF SHALL be capable of displaying the section.text. -->
            <item ID="note1"> 
                <caption>Nursing Note written by Nick Nurse</caption>
                <paragraph>0700-1900 Nursing Note: Patient’s vital signs were stable as documented throughout shift on 2L Oxygen via nasal cannula. His lungs are diminished with scattered crackles. Bowel sounds are active and the patient had a bowel movement x 2 today, both soft. Incontinent of urine and wearing a diaper. Skin intact at this time. Skin color is pale. 2+ non-pitting edema noted in bilateral calves and ankles. Assessed patient and reconciled medications. Spoke with daughter, pt’s power of attorney, to provide updates and education on the patient's condition. Laboratory obtained morning labs without problem and vascular therapy placed a new 18g peripheral IV as the previous one was due for a change. Pt took all morning meds without problem. Reoriented patient and provided opportunities for toileting and for making needs known every 1-2 hours today to lessen risk of fall.</paragraph>
            </item>
        </list>
    </text>
    <!-- When converting RTF to Plain Text, it's important to preserve the meaning in RTF. For example, strikethrough and other formatting which change the meaning SHALL be considered -->
    <!-- Systems that render RTF (OPTIONAL) should use caution since malicious content may be embedded in RTF-->
    <!-- Note Activity (extra markup removed to focus on <text>) -->
    <entry typeCode="DRIV">
        <act classCode="ACT" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
            <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
                <translation code="34746-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Nurse Note" />
            </code>
            <!-- This Base64 example includes line breaks which is optional --> 
            <text mediaType="text/rtf" representation="B64">
                e1xydGYxXGFuc2lcYW5zaWNwZzEyNTJcZGVmZjBcbm91aWNvbXBhdFxkZWZsYW5nMTAzM3tcZm9u
                dHRibHtcZjBcZm5pbFxmY2hhcnNldDAgQ2FsaWJyaTt9fQ0Ke1xjb2xvcnRibCA7XHJlZDUxXGdy
                ZWVuNTFcYmx1ZTUxO30NCntcKlxnZW5lcmF0b3IgUmljaGVkMjAgMTAuMC4xODM2Mn1cdmlld2tp
                bmQ0XHVjMSANClxwYXJkXHNhMjAwXHNsMjc2XHNsbXVsdDFcY2YxXGJcZjBcZnMyMlxsYW5nOSAw
                NzAwLTE5MDAgTnVyc2luZyBOb3RlOiBcY2YwXGIwIFBhdGllbnRccnF1b3RlIHMgdml0YWwgc2ln
                bnMgd2VyZSBzdGFibGUgYXMgZG9jdW1lbnRlZCB0aHJvdWdob3V0IHNoaWZ0IG9uIDJMIE94eWdl
                biB2aWEgbmFzYWwgY2FubnVsYS4gSGlzIGx1bmdzIGFyZSBkaW1pbmlzaGVkIHdpdGggc2NhdHRl
                cmVkIGNyYWNrbGVzLiBCb3dlbCBzb3VuZHMgYXJlIGFjdGl2ZSBhbmQgdGhlIHBhdGllbnQgaGFk
                IGEgYm93ZWwgbW92ZW1lbnQgeCAyIHRvZGF5LCBib3RoIHNvZnQuIEluY29udGluZW50IG9mIHVy
                aW5lIGFuZCB3ZWFyaW5nIGEgZGlhcGVyLiBTa2luIGludGFjdCBhdCB0aGlzIHRpbWUuIFNraW4g
                Y29sb3IgaXMgcGFsZS4gMisgbm9uLXBpdHRpbmcgZWRlbWEgbm90ZWQgaW4gYmlsYXRlcmFsIGNh
                bHZlcyBhbmQgYW5rbGVzLiBBc3Nlc3NlZCBwYXRpZW50IGFuZCByZWNvbmNpbGVkIG1lZGljYXRp
                b25zLiBTcG9rZSB3aXRoIGRhdWdodGVyLCBwdFxycXVvdGUgcyBwb3dlciBvZiBhdHRvcm5leSwg
                dG8gcHJvdmlkZSB1cGRhdGVzIGFuZCBlZHVjYXRpb24gb24gdGhlIHBhdGllbnQncyBjb25kaXRp
                b24uIExhYm9yYXRvcnkgb2J0YWluZWQgbW9ybmluZyBsYWJzIHdpdGhvdXQgcHJvYmxlbSBhbmQg
                dmFzY3VsYXIgdGhlcmFweSBwbGFjZWQgYSBuZXcgMThnIHBlcmlwaGVyYWwgSVYgYXMgdGhlIHBy
                ZXZpb3VzIG9uZSB3YXMgZHVlIGZvciBhIGNoYW5nZS4gUHQgdG9vayBhbGwgbW9ybmluZyBtZWRz
                IHdpdGhvdXQgcHJvYmxlbS4gUmVvcmllbnRlZCBwYXRpZW50IGFuZCBwcm92aWRlZCBvcHBvcnR1
                bml0aWVzIGZvciB0b2lsZXRpbmcgYW5kIGZvciBtYWtpbmcgbmVlZHMga25vd24gZXZlcnkgMS0y
                IGhvdXJzIHRvZGF5IHRvIGxlc3NlbiByaXNrIG9mIGZhbGwuXHBhcg0KfQ0KAA==
                <reference value="#note1"/>
            </text>
            <!-- Author Participant information here -->
        </act>
    </entry>
</section>

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