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 - Procedure

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 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>
          <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 moodCode="EVN" classCode="PROC">
      <!--  ...  -->
      <!--  the code of a procedure is significant, so also the originalText/refernece is a SHOULD  -->
      <code displayName="praesent efficitur" codeSystem="1.2.3.4.5.6.7.8.42"
            code="5678">
        <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  -->
      <text>
        <reference value="#procedureFullTextReference1"/>
      </text>
      <!--  ...  -->
      <!--  when the method of a procedure is reflected in the human readable text we SHOULD have originalText/reference  -->
      <methodCode displayName="ornare eget" codeSystem="1.2.3.4.5.6.7.8.42"
                  code="6789">
        <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 displayName="vulputate eget"
                      codeSystem="1.2.3.4.5.6.7.8.42" code="7890">
        <originalText>
          <reference value="#procedureSiteCodeReference1"/>
        </originalText>
      </targetSiteCode>
    </procedure>
  </entry>
</section>