Narrative Reference - Observation

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Example metadata last updated 2017-09-11 05:11:32.420000 UTC

Approval Status: Approved

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

No validation URL supplied

Certification

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)

Full sample: This sample will not validate

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 is used for a simple observation; the ID values are meant to be unique across the whole document -->
			<table>
				<tbody>
					<tr ID="simpleObservationFullTextReference1">
						<td>Lorem ipsum dolor sit amet, consectetur adipiscing elit.</td>
						<td ID="simpleObservationCodeReference1">Proin facilisis iaculis nisi, luctus aliquam metus.</td>
						<td ID="simpleObservationValueReference1">Duis id consequat arcu, sit amet fermentum leo.</td>
						<td>labetText: DD-mmm-YYYY</td>
					</tr>
				</tbody>
			</table>
		</text>
		<!-- This entry shows a simple observation.  In C-CDA terms this might be an Advance Directive Observation, Caregiver Characteristics, Characteristics of Home Environment, Smoking Status, Tobacco Use, etc.... -->
		<entry>
			<observation classCode="OBS" moodCode="EVN">
				<!-- ... -->
				<code code="2345" codeSystem="1.2.3.4.5.6.7.8.42" displayName="proin facilisis">
					<!--If some of the human readable text is a representation of the code, we SHOULD include a reference to that text using the originalText/reference construct 
									if, however, the code 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
									-->
									<reference value="#simpleObservationCodeReference1"/>
					</originalText>
				</code>
				<!-- when present, the text/reference points to the entire text of the act 
									from an interoperability perspective, this pattern is a MAY as access to the entire human readable text of the act is sometimes useful, but generally not programatically useful (NLP may be needed)
							-->
				<text>
					<!-- notice that the ID containing the referenced value is on an element that includes all text of the act.
										in this case, the element is a tr, but might be a table, tbody, etc....elements that typically wrap more entire concepts, not just pieces of content
									Example referenced content, using Tobacco Use: Ex-heavy cigarette smoker 20 to 39 per day Recorded: Jan-1988 Comment: suspect still smoking on occasion.
								-->
					<reference value="#simpleObservationFullTextReference1"/>
				</text>
				<effectiveTime value="YYYMMDD"/>
				<!-- ... -->
				<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>
			</observation>
		</entry>
	</section>
</component>
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