CDA Examples
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CDA Examples, published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-Examples/ and changes regularly. See the Directory of published versions

Example: Narrative Reference - Encounter

Approval Status: Approved
Task Force Approval: 2017-06-01
SDWG Approval: 2017-07-06

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.


  <!--  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 xmlns="urn:hl7-org:v3">
  <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 an encounter; the ID values are meant to be unique across the whole document  -->
    <table>
      <tbody>
        <tr ID="encounterFullTextReference1">
          <td ID="encounterCodeReference1">Praesent vitae dignissim risus
            
            <br/>
            <!--  ...  -->
          </td>
          <td>mightBeSomeDate
            
            <br/>mightbeSomeProviderName
            
            <br/>mightbeSomeFacilityName
            
            <br/>mightbeSomeAddress
            
            <br/>mightbeSomePhoneNumber
          
          </td>
          <td>labelText: mmm DD YYYY</td>
        </tr>
      </tbody>
    </table>
  </text>
  <!--  This illustrates a simple encounter. In C-CDA the encounter activity may be in an Encounters Section, or ir may be the child of other acts  -->
  <entry>
    <!--  ...  -->
    <encounter moodCode="EVN" classCode="ENC">
      <!--  ...  -->
      <!--  the code of an encounter provides us with the encounter type, and SHOULD have an originalText/reference
           as we expect the human readable to reflect the type of encounter  -->
      <code displayName="praesent vitae" codeSystem="1.2.3.4.5.6.7.8.42"
            code="4567">
        <originalText>
          <!--  Example of referenced text: ED Visit
               note that the reference is does not include the label in the human readable content;
               we do not want the reference to return labelText: ED Visit  -->
          <reference value="#encounterCodeReference1"/>
        </originalText>
      </code>
      <!--  a reference to the entire human readable text of the encounter is useful  -->
      <text>
        <!--  Example of referenced text:
             ED Visit Encounter
             Reason: Acute Anxiety
             Encounter Diagnosis: Acute onset Anxiety
             10/11/14 Acupun, Allison Rex ED 3000 New Bern Ave Raleigh 27610 tel:+1-(919)350-8000
             Discharge Disposition: Discharged/transferred to an intermediate-care facility (ICF)
             Comments: noted uncontrollable rocking  -->
        <reference value="#encounterFullTextReference1"/>
      </text>
    </encounter>
  </entry>
</section>