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Converting a clinical document example to structured text

Converting a clinical document example to structured text. This set of slides show how an clinical document in, for example . pdf format, may be represented in CDA markup (CDA structured text). GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel:  01634111222.

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Converting a clinical document example to structured text

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  1. Converting a clinical document example to structured text This set of slides show how an clinical document in, for example .pdf format, may be represented in CDA markup (CDA structured text)

  2. GP Details: Medway Medical PracticeSpringer StreetMedwayME5 5TY Tel: 01634111222 NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County CourtWoodtownMedwayME5 FS3 Tel: 01634775667 Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Encounter Time: From 19-May-2011, 20:00 To 19-May-2011, 20:45 Encounter Procedures: colonoscopy Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust • Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required Primary Recipient: Mr Terence Hall - Specialist Nurse Practitioner, Medway PCTCopy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

  3. GP Details: Medway Medical PracticeSpringer StreetMedwayME5 5TY Tel: 01634111222 NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County CourtWoodtownMedwayME5 FS3 Tel: 01634775667 Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Encounter Time: From 19-May-2011, 20:00 To 19-May-2011, 20:45 Encounter Procedures: colonoscopy Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust • Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required Primary Recipient: Mr Terence Hall - Specialist Nurse Practitioner, Medway PCTCopy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

  4. GP Details: Medway Medical PracticeSpringer StreetMedwayME5 5TY Tel: 01634111222 NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County CourtWoodtownMedwayME5 FS3 Tel: 01634775667 Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Encounter Time: From 19-May-2011, 20:00 To 19-May-2011, 20:45 Encounter Procedures: colonoscopy Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust • Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required Primary Recipient: Mr Terence Hall - Specialist Nurse Practitioner, Medway PCTCopy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

  5. Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required <componenttypeCode="COMP"contextConductionInd="true"> <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <sectionclassCode="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> <contentstyleCode="bold">Method of Admission: </content>Elective<br/> <contentstyleCode="bold">Source of Admission: </content>General Practitioner referral (routine) </text> </section> </component>

  6. <componenttypeCode="COMP"contextConductionInd="true"> <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <sectionclassCode="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> <contentstyleCode="bold">Method of Admission: </content>Elective<br/> <contentstyleCode="bold">Source of Admission: </content>General Practitioner referral (routine) </text> </section> </component> XSLT <h1>Admission Details</h1> <span class="bold">Method of Admission: </span>Elective<br> <span class="bold">Source of Admission: </span>General Practitioner referral (routine)

  7. Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required <componenttypeCode="COMP"contextConductionInd="true"> <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <sectionclassCode="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-BFA1-57C3E64B30B7"/> <title>Clinical Information</title> ………..

  8. Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required <componenttypeCode="COMP"contextConductionInd="true"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <sectionclassCode="DOCSECT"moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3098"/> <title>Diagnosis at discharge</title> <text> <listlistType="unordered"> <item>Patient has rectal polyps</item> </list> </text> </section> </component>

  9. Clinical Report • Admission Details • Method of Admission: Elective • Source of Admission: General Practitioner referral (routine) • Clinical Information • Diagnosis at discharge • Patient has rectal polypsAllergies not previously known • NoneDischarge Medication • Medication ibuprofen • Dose: 800mg • Quantity: 24 • Continued medication: Yes • Advice, recommendations and future plan • Action List • Patient will be sent outpatient's appointment in 4 weeks • Pain relief to be prescribed by GP if required <componenttypeCode="COMP"contextConductionInd="true"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <sectionclassCode="DOCSECT"moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3096"/> <title>Discharge Medication</title> <text> <table border="1"> <thead><tr> <th>Medication Item</th> <th>Dose</th><th>Quantity</th> <th>To be continued?</th> </tr></thead> <tbody><tr> <td>ibuprofen</td><td>800mg</td><td>24</td><td>Yes</td> </tr></tbody> </table> </text> </section> </component>

  10. <componenttypeCode="COMP"contextConductionInd="true"> <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <sectionclassCode="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-BFA1-57C3E64B30B7"/> <title>Clinical Information</title> <componenttypeCode="COMP"contextConductionInd="true"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <sectionclassCode="DOCSECT"moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3098"/> <title>Diagnosis at discharge</title> <text> <listlistType="unordered"><item>Patient has rectal polyps</item> </list> </text> </section> </component> <componenttypeCode="COMP"contextConductionInd="true"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <sectionclassCode="DOCSECT"moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3097"/> <title>Allergies not previously known</title> <text> <contentstyleCode="italics">None</content><br/> </text> </section> </component> <componenttypeCode="COMP"contextConductionInd="true"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <sectionclassCode="DOCSECT"moodCode="EVN"> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> <id root="E27F4264-C005-4BC3-BFA1-57C3E64B3096"/> <title>Discharge Medication</title> <text> <table border="1"><thead<tr> <th>Medication Item</th><th>Dose</th><th>Quantity</th> <th>To be continued?</th> </tr></thead> <tbody><tr> <td>ibuprofen</td><td>800mg</td><td>24</td><td>Yes</td> </tr> </tbody> </table> </text> </section> </component> </section> </component>

  11. Using the NHS CFH example transform “CDA_NPfIT_Document_Renderer.xsl“ (from the Tooling Pack available on TRUD) NOTE: To render a document using the CFH example renderer, download the “NHS Interoperability Specifications Tooling Pack” under “NHS Message Specifications”. Read & follow the documentation on using the CDA Renderer tool included in the pack.

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