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)

NHS Number: Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust Encounter Time: From 19-May-2011, 20:00 To 19- May-2011, 20:45 Encounter Procedures: colonoscopy Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 PCT Copy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

NHS Number: Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust Encounter Time: From 19-May-2011, 20:00 To 19- May-2011, 20:45 Encounter Procedures: colonoscopy Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 PCT Copy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

NHS Number: Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: Medway NHS Foundation Trust Document Date: 19-May-2011, 20:00 Report created By: Mary Jones (Nurse Practitioner) Medway NHS Foundation Trust Encounter Time: From 19-May-2011, 20:00 To 19- May-2011, 20:45 Encounter Procedures: colonoscopy Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 PCT Copy Recipient: Pauline Shelley - General Medical Practitioner, Medway Medical Practice

Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 <npfitlc:contentId root=" " extension="COCD_TP146229GB01#Section1"/> <templateId root=" " extension="COCD_TP146229GB01#Section1"/> Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine)

Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) <npfitlc:contentId root=" " extension="COCD_TP146229GB01#Section1"/> <templateId root=" " extension="COCD_TP146229GB01#Section1"/> Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) XSLT

Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 <npfitlc:contentId root=" " extension="COCD_TP146229GB01#Section1"/> <templateId root=" " extension="COCD_TP146229GB01#Section1"/> Clinical Information ………..

Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 <templateId root=" " extension="COCD_TP146229GB01#component1"/> <templateId root=" " extension="COCD_TP146229GB01#section2"/> Diagnosis at discharge Patient has rectal polyps

Clinical Report Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) Clinical Information Diagnosis at discharge Patient has rectal polyps Allergies not previously known None Discharge 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 <templateId root=" " extension="COCD_TP146229GB01#component1"/> <templateId root=" " extension="COCD_TP146229GB01#section2"/> Discharge Medication Medication Item Dose Quantity To be continued? ibuprofen 800mg 24 Yes

<npfitlc:contentId root=" " extension="COCD_TP146229GB01#Section1"/> <templateId root=" " extension="COCD_TP146229GB01#Section1"/> Clinical Information <templateId root=" " extension="COCD_TP146229GB01#component1"/> <templateId root=" " extension="COCD_TP146229GB01#section2"/> Diagnosis at discharge Patient has rectal polyps <templateId root=" " extension="COCD_TP146229GB01#component1"/> <templateId root=" " extension="COCD_TP146229GB01#section2"/> Allergies not previously known None <templateId root=" " extension="COCD_TP146229GB01#component1"/> <templateId root=" " extension="COCD_TP146229GB01#section2"/> Discharge Medication Medication Item Dose Quantity To be continued? ibuprofen 800mg 24 Yes

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.