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Narrative Reference - SubstanceAdministration


Approval Status

  • Approval Status: Approved
  • Example Task Force: 6/1/2017
  • SDWG: 7/6/2017

C-CDA 2.1 Example:

  • Applies to all C-CDA/CDA templates with this entry type

Reference to full CDA sample:

  • This sample will not validate

Validation location

  • Not applicable

Comments

  • 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.

Custodian

  • Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) (original design courtesy of George Cole)

Keywords

  • narrative, narrative-entry, linking text

Permalink

Links

 

Example: download example view on GitHub

<component>
	<!-- 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>
		<!--  ... -->
		<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>
						<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 classCode="BATTERY" moodCode="EVN">
				<!-- ... -->
				<code code="nnnn" codeSystem="1.2.3.4.5.6.7.8.42" displayName="lorem ipsum">
					<originalText>
						<reference value="#ResultOrganizerCodeTextReference1"/>
					</originalText>
				</code>							
				<statusCode code="completed"/>
				<!-- ... -->
				<component>
					<observation classCode="OBS" moodCode="EVN">
						<!-- ... -->
						<code code="nnnn" codeSystem="1.2.3.4.5.6.7.8.42" displayName="proin iaculis">
							<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>
							<reference value="#ResultComponentFullTextReference1"/>
						</text>
						<!-- .... -->
						<value xsi:type="CD" code="3456" codeSystem="1.2.3.4.5.6.7.8.42" displayName="duis id consequat">
							<!--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 code="x" codeSystem="1.2.3.4.5.6.7.8.42" displayName="semper">
							<originalText>
								<reference value="#ResultComponentInterpretationCodeTextReference1"/>
							</originalText>
						</interpretationCode>
						<methodCode code="nnnn" codeSystem="2.16.840.1.113883.6.96" displayName="elementum ">
							<originalText>
								<reference value="#ResultComponentMethodCodeTextReference1"/>
							</originalText>
						</methodCode>
						<targetSiteCode code="nnnn" codeSystem="2.16.840.1.113883.6.96" displayName="tincidunt ">
							<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>
</component>
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