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. NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: 01634775667 GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: 01634111222 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

3. NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: 01634775667 GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: 01634111222 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

4. NHS Number: 993254128 Patient: Mr Mark Smith DoB: 01 January 1949 Gender: Male CONTACT DETAILS Address: 17, County Court Woodtown Medway ME5 FS3 Tel: 01634775667 GP Details: Medway Medical Practice Springer Street Medway ME5 5TY Tel: 01634111222 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

5. 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="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#Section1"/> Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine)

6. Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#Section1"/> Admission Details Method of Admission: Elective Source of Admission: General Practitioner referral (routine) XSLT

7. 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="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#Section1"/> Clinical Information ………..

8. 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="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> Diagnosis at discharge Patient has rectal polyps

9. 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="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> Discharge Medication Medication Item Dose Quantity To be continued? ibuprofen 800mg 24 Yes

10. <npfitlc:contentId root="2.16.840.1.113883.2.1.3.2.4.18.16" extension="COCD_TP146229GB01#Section1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#Section1"/> Clinical Information <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> Diagnosis at discharge Patient has rectal polyps <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> Allergies not previously known None <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#component1"/> <templateId root="2.16.840.1.113883.2.1.3.2.4.18.2" extension="COCD_TP146229GB01#section2"/> Discharge Medication Medication Item Dose Quantity To be continued? ibuprofen 800mg 24 Yes

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.