Narrative Reference - Encounter

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Example metadata last updated 2017-09-11 05:11:32.452000 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 an encounter; the ID values are meant to be unique across the whole document -->
			<table>
				<tbody>
					<tr ID="encounterFullTextReference1">
						<td ID="encounterCodeReference1">Praesent vitae dignissim risus
							<br/>
							<!-- ... -->
						</td>
						<td>
							mightBeSomeDate 
							<br/>
							mightbeSomeProviderName
							<br/>
							mightbeSomeFacilityName
							<br/>
							mightbeSomeAddress
							<br/>
							mightbeSomePhoneNumber
						</td>
						<td>labelText: mmm DD YYYY</td>
					</tr>
				</tbody>
			</table>
		</text>
		<!-- This illustrates a simple encounter. In C-CDA the encounter activity may be in an Encounters Section, or ir may be the child of other acts -->
		<entry>
			<encounter classCode="ENC" moodCode="EVN">
				<!-- ... -->
				<!-- the code of an encounter provides us with the encounter type, and SHOULD have an originalText/reference as we expect the human readable to reflect the type of encounter -->
				<code code="4567" codeSystem="1.2.3.4.5.6.7.8.42" displayName="praesent vitae">
					<originalText>
						<!-- Example of referenced text: ED Visit 
											note that the reference is does not include the label in the human readable content; we do not want the reference to return labelText: ED Visit
									-->
						<reference value="#encounterCodeReference1"/>
					</originalText>
				</code>
				<!-- a reference to the entire human readable text of the encounter is useful -->
				<text>
					<!-- Example of referenced text: ED Visit Encounter Reason: Acute Anxiety Encounter Diagnosis: Acute onset Anxiety 10/11/14 Acupun, Allison Rex ED 3000 New Bern Ave Raleigh 27610 tel:+1-(919)350-8000 Discharge Disposition: Discharged/transferred to an intermediate-care facility (ICF) Comments: noted uncontrollable rocking -->
					<reference value="#encounterFullTextReference1"/>
				</text>
				<!-- ... -->
				<effectiveTime value="YYYMMDD"/>
			</encounter>
		</entry>
	</section>
</component>
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