1. CDA Structured Text

3. Classes involved in structured text & coded entries

4. 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

5. CDA Structured Text Classes needed for adding a text section

6. CDA Structured Text An XML fragment (Generic CDA) covering these 5 classes

7. CDA Structured Text NonCodedCDA only has one TextSection template choice

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

9. 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

10. CDA Structured Text Author choice These templates are the same as used in the Document Author participation

11. CDA Structured Text Only use the author participation If 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

12. CDA Structured Text AttributeValue classCodeFIXED to “DOCSECT” moodCodeFIXED to “EVN” idA generated DCE UUID (each section must have its own generated DCE UUID) codeA code to represent this section type (e.g. it’s an Allergy Section) titleTitle that renders out for the section textSection text templateIdFIXED to whatever the model says for the section level e.g. “COCD_TP146229GB01#Section1”

13. CDA Structured Text Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine)

14. CDA Structured Text AttributeValue typeCodeFIXED to “COMP” contextConductionIndFIXED to “true” templateIdFIXED to whatever the model says for the section level e.g. “COCD_TP146229GB01#component1” <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

15. CDA Structured 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.

16. CDA Structured Text Example. At this point the presentation ClinicalDocumentToStructuredText.pptx was shown

17. CDA Structured Text -END-