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 - Organizer

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 used for an organizer and components; the ID values are meant to be unique across the whole document  -->
    <table>
      <tbody>
        <tr>
          <td>
            <content ID="ResultOrganizerCodeTextReference1">Lorem ipsum dolor sit amet</content>
          </td>
          <td>labetText: DD-mmm-YYYY
            
            <br/>
            <!--  ...  -->
          </td>
          <td>
            <!--  ...  --></td>
        </tr>
        <tr ID="ResultComponentFullTextReference1">
          <td/>
          <td>
            <content ID="ResultComponentCodeTextReference1">Proin iaculis tempus justo</content>
            <content ID="simpleObservationValueReference1">Duis id consequat arcu, sit amet fermentum leo.</content>
            <content> nn</content>
            <content> UCUM_Units</content>
            <content ID="ResultComponentInterpretationCodeTextReference1"> (Semper)</content>
          </td>
          <td>
            <content ID="ResultComponentReferenceRangeTextReference1">
              <content>labelText: </content>
              <content>111</content>
              <content>{MG/DL}</content>
              <content> - </content>
              <content>222</content>
              <content>{MG/DL}</content>
            </content>
            <br/>
            <content>labeltext: </content>
            <content ID="ResultComponentMethodCodeTextReference1">Elementum </content>
            <br/>
            <content>labelText: </content>
            <content ID="ResultComponentSiteCodeTextReference1">Tincidunt </content>
            <br/>
            <!--  ...  -->
          </td>
        </tr>
      </tbody>
    </table>
  </text>
  <!--  This illustrates an organizer. In C-CDA this is most typically used for Results and Vital Signs, but may be used in other sections  -->
  <entry>
    <!--  Example, from results: Complete Blood Count  -->
    <!--  Acts other than observation are allowed  -->
    <!--  ...  -->
    <organizer moodCode="EVN" classCode="BATTERY">
      <!--  ...  -->
      <code displayName="lorem ipsum" codeSystem="1.2.3.4.5.6.7.8.42"
            code="nnnn">
        <originalText>
          <reference value="#ResultOrganizerCodeTextReference1"/>
        </originalText>
      </code>
      <statusCode code="completed"/>
      <!--  ...  -->
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <!--  ...  -->
          <code xsi:type="CD" displayName="proin iaculis"
                codeSystem="1.2.3.4.5.6.7.8.42" code="nnnn">
            <originalText>
              <reference value="#ResultComponentCodeTextReference1"/>
            </originalText>
          </code>
          <!--  Example, from results: WBC 21 10^3/ul (High) Range: 100   mg/dL - 900 mg/dL Method: PICC Line Site: Site Right Arm Comments: Specimen Lysed  -->
          <text xsi:type="ED">
            <reference value="#ResultComponentFullTextReference1"/>
          </text>
          <!--  ....  -->
          <value xsi:type="CD" displayName="duis id consequat"
                 codeSystem="1.2.3.4.5.6.7.8.42" code="3456">
            <!--  If some of the human readable text is a representation of the value, we SHOULD include a reference to that text using the originalText/reference construct
                 if, however, the value is bound to some constant by an Implementation Guide and it is not represented in the human readable text, then the originalText/reference SHALL NOT be present
                  -->
            <originalText>
              <!--  notice that the referenced text is similar to but different than the @displayName  of the code element
                   from an interoperability perspective, this pattern is a SHOULD as access to the human readable text reflecting the (code, codeSystem) in use is beneficial to consuming systems
                   Example referenced content, using Tobacco Use: Ex-heavy cigarette smoker 20 to 39 per day
                   (where the (code, codeSystem) on the value element would be (266924008, 2.16.840.1.113883.6.96))  -->
              <reference value="#simpleObservationValueReference1"/>
            </originalText>
          </value>
          <interpretationCode codeSystem="2.16.840.1.113883.5.83" code="S">
            <originalText>
              <reference
                         value="#ResultComponentInterpretationCodeTextReference1"/>
            </originalText>
          </interpretationCode>
          <methodCode displayName="elementum "
                      codeSystem="2.16.840.1.113883.6.96" code="nnnn">
            <originalText>
              <reference value="#ResultComponentMethodCodeTextReference1"/>
            </originalText>
          </methodCode>
          <targetSiteCode displayName="tincidunt "
                          codeSystem="2.16.840.1.113883.6.96" code="nnnn">
            <originalText>
              <reference value="#ResultComponentSiteCodeTextReference1"/>
            </originalText>
          </targetSiteCode>
          <!--  ...  -->
          <referenceRange>
            <observationRange>
              <text>
                <reference
                           value="#ResultComponentReferenceRangeTextReference1"/>
              </text>
              <value xsi:type="IVL_PQ">
                <low value="111" unit="UCUM_UNIT"/>
                <high value="222" unit="UCUM_UNIT"/>
              </value>
            </observationRange>
          </referenceRange>
        </observation>
      </component>
    </organizer>
  </entry>
</section>