Narrative Dictation as Part of a Consolidated CDA Explained

Overview

The objective is to produce compliant Consolidated CDA (C-CDA) documents and fulfill meaningful use stage 2.  In order to do this, the document must be split into different sections.  The sections are nothing more than the way the reports are typically structured now with headings.  History of Present Illness, Allergies, Assessment, Procedure Performed are all examples of different sections.  If the latest Gen6 ITE is used and the template assigned to a CDA document type this will force the MT to create a CDA compliant document in the ITC, but if we've all done our jobs right then he/she should hardly have to pay attention, it will all just work.

Summary

• Each type of CDA document requires different sections to be compliant, and sometimes certain sections aren't allowed.  For example, Allergies probably isn't allowed in a DICOM imaging document for instance.
  • Each section can further be broken down into additional structured data.  For Meaningful Use Stage 2 that includes Medications, Allergies, Prior conditions, and Smoking status.  These correspond to the tabs on the EMR screen in the ITC. 
  • The codes and structure of that data is much more strict.  
  • Free narrative is not acceptable in C-CDA, like it does for the rest of the sections. 
  • Every section, even the ones that have structured data, are also allowed to have narrative text.  It is even common for a section to contain only narrative (HPI, Plan, etc).
• In order to accomplish this "sectioning" of the documents and to allow the input of narrative in a familiar way (on the document canvas), a new type of field is now in the InfraWare Template Editor (ITE). 
  • This new type of field is a CDA section field.  The CDA section field takes the place of headings.  These section fields can display anything (HPI, instead of History of Present Illness), but there is underlying code that will map that field back to a certain CDA section.
    

Example 

The following is a sample part of a document:

       History of Present Illness: The patient presented with a history of diabetes and hypertension. 

       Plan:  I came up with a plan.

The two words in bold would be CDA section fields.  To get the narrative for the "History of present illness" section, the text that is between that CDA field and the next one is pulled.  In this case, it would be "The patient presented with a history of diabetes and hypertension."  For the last field in the document the text from that last field to the end of the document would be pulled. 

Note: 

• If strict CDA compliance is turned on for the template, in the ITC all of the required sections for the CDA Doc Type chosen must be completed. 
• The entire structured data object (narratives + structured entries like medications) will be created right there in the ITC. 
• You may notice some flashing when you click on the EMR button in the ITC.  This is the ITC finding and figuring out all of the sections and their narratives.