CDA Structured Text

CDA Structured Text

CDA Structured Text

Classes involved in structured text & coded entries

CDA Structured Text

• Crossed out classes are• NonXMLBody – used as an alternative to the text section e.g. a

.pdf file• CodedEntry Choice – used to carry coded clinical statements in

support of text section

CDA Structured Text

• Classes needed for adding a text section

CDA Structured Text

<structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> <id root="7AFDCAD6-1CE3-45A6-A176-DDAC27F46C87"/> <component typeCode="COMP" contextConductionInd="true"> <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16

extension="COCD_TP146229GB01#Section1"/>

• An XML fragment (Generic CDA) covering these 5 classes

CDA Structured Text

• NonCodedCDA only has one TextSection template choice

• Up to 6 levels of nesting allowed in this template (h1 – h6)

CDA Structured Text

• Each Section class has the same attributes• Each component class has the same attributes• Multiple sections allowed within other sections (e.g. 0..* section2 allowed under a section1)• Author class allowed at Section 1 only (& applies to all sub-sections). Next slide looks at Author choice

CDA Structured Text

• Author choice • These templates are the same as used in the Document Author participation

CDA Structured Text

Only use the author participationIf the author of a section is NOT the same as the document author

If an author is specified for a text section, it also applies to all sub-sections

CDA Structured Text

Attribute ValueclassCode FIXED to “DOCSECT”

moodCode FIXED to “EVN”

id A generated DCE UUID (each section must have its own generated DCE UUID)

code A code to represent this section type (e.g. it’s an Allergy Section)

title Title that renders out for the section

text Section text

templateId FIXED to whatever the model says for the section level e.g. “COCD_TP146229GB01#Section1”

CDA Structured Text

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#Section1"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3099"/> <title>Admission Details</title> <text> <content styleCode="bold">Method of Admission: </content>Elective<br/> <content styleCode="bold">Source of Admission: </content>General Practitioner referral (routine) </text></section>

CDA Structured Text

Attribute ValuetypeCode FIXED to “COMP”

contextConductionInd FIXED to “true”

templateId FIXED to whatever the model says for the section level e.g. “COCD_TP146229GB01#component1”

<component typeCode="COMP" contextConductionInd="true"><npfitlc:contentId

root="2.16.840.1.113883.2.1.3.2.4.18.16“ extension="COCD_TP146229GB01#Section1"/>

For other sections

For a Section1 (every section1 or h1 is a new instance of the template

<component typeCode="COMP" contextConductionInd="true"><templateId root="2.16.840.1.113883.2.1.3.2.4.18.2“ extension="COCD_TP146229GB01#component1"/>

CDA Structured Text

<text>

• Format of the text governed by a schema (NarrativeBlock.xsd)

• Enforces formatting of the text sections (i.e. what tags can be used where)

The narrative block schema and narrative block pack was shown at this point. The schema and pack shows the structured text tags, and rules for structured text tags.

CDA Structured Text

Example. At this point the presentation ClinicalDocumentToStructuredText.pptx was shown

CDA Structured Text

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