4.3.

Section Narrative Block

The Section.text field is used to store narrative to be rendered, as

described above in CDA Conformance ( 1.3 ), and is therefore referred to
as the CDA Narrative Block. The narrative schema defined for CDA R3 has
been aligned with a subset of the elements found in HTML, in order to
simplify content generation and presentation. One notable exception is the
continued reliance on <footnote> and <footnoteRef>, which are typically
not included in clinical notes, but were retained for backwards comparability
and continued support of SPL.

The CDA Narrative Block schema can be found here.

The content model of the CDA Narrative Block schema is specially hand
crafted to meet the requirements outlined above (see Human Readability
and Rendering CDA Documents ( 1.2.3 )). The schema is will be registered
as a MIME type (text/x-hl7-text+xml-r2), which is the fixed media type for
Section.text. Components of the schema are described in the sections that
follow.

4.3.5.1

<contentspan> - content wrapping

The CDA <contentspan> element is used to wrap a string of text so that it

can be explicitly referenced, or so that it can suggest rendering
characteristics. The <contentspan> element can nest recursively, which
enables wrapping a string of plain text down to as small a chunk as desired.

The <contentspan> element contains an optional identifier, that can serve

as the target of a reference. All values of attributes of type XML ID must be
unique within the document (per the W3C XML specification). The
originalText component of a RIM attribute present in any CDA entry can
make explicit reference to the identifier, thereby indicating the original text
associated with the attribute in the CDA entry.
Example 5

<section>

<code code="10153-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Past Medical History</title>
<text>
There is a history of <content span
IDid="a1">Asthma</contentspan>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="195967001"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Asthma">
<originalText>
<reference value="#a1"/>
</originalText>
</code>
<statusCode code="completed"/>
</observation>
</entry>
</section>
There is no requirement that CDA entries must reference into the CDA
Narrative Block. The referencing mechanism can be used where it is
important to represent the original text component of a coded CDA entry.

The <content> element contains an optional "revised" attribute that can be

valued with "insert" or "delete", which can be used to indicate narrative
changes from the last version of a CDA document. The attribute is limited
to a single generation, in that it only reflects the changes from the
preceding version of a document. If applied, it needs to be used in
conjunction with standard CDA revision tracking. Changes to a CDA
document that has been released for patient care still require a formal
versioning and revision, and the revised document can optionally carry the
"revised" attribute to show the delta in the narrative. Receivers are required
to interpret the "revised" attribute when rendering by visually distinguishing
or suppressing deleted narrative.

4.3.5.2

<linkHtmla> - anchor element

The CDA <linkHtmla> is a generic referencing mechanism, similar, but not

identical, to the HTML anchor tag. It can be used to reference identifiers
that are either internal or external to the document.

Multimedia that is integral to a document, and part of the attestable

content of the document requires the use of the a supporting reference to

an ObservationMedia CDA entry, which is referenced by the
<renderMultiMediaimg> narrative element (see <renderMultiMediaimg> (
4.3.5.6 7 )).
Multimedia that is simply referenced by the document and not an integral
part of the attested document can use the <linkHtml><img> element
without a corresponding reference to an ObservationMedia or
RegionOfInterest CDA entry.

The source of a link uses the linkHtmla.href attribute. The target of an

internal reference is an identifier of type XML ID, which can exist on other
elements in the same or a different narrative block, or XML ID attribute of
type xs:ID attributes that have been added to the <section>,
<ObservationMedia>, or <renderMultiMedia>any narrative elements of the
CDA Narrative Schema providing an attribute of type xs:ID. The use of the
linkHtmla.name attribute is deprecated, because attributes of type XML ID
provide an alternative and more consistent target for referencing. Following
the conventions of HTML, an internal link is prefaced with the pound sign,
as shown in the following example.
Example 6

<section ID="SECT001">
<code code="10164-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>History of Present Illness</title>
<text>Mr. Smith is a 57 year old male presenting with
chest pain. He sustained a myocardial infarction 3
years
ago, ...
</text>
</section>
...
<section ID="SECT003">
<code code="10153-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Past Medical History</title>
<text>History of coronary artery disease, as noted
<linkHtml a href="#SECT001">above</linkHtmla>.</text>
</section>
CDA links do not convey shareable meaning. Shareable semantics are only
achieved by the inclusion of CDA entries and their associated formalized
relationships. There is no requirement that a receiver render an internal or

external anchor link, or the target of an external link.

4.3.5.3

<sub> and <sup> - superscript & subscript

The CDA <sub> and <sup> elements are used to indicate subscripts and
superscripts, respectively.

Receivers are required to interpret these elements when rendering by

visually distinguishing subscripted and superscripted characters.

4.3.5.4

<br> - line break

The CDA <br/> element is used to indicate a hard line break. It differs from
the CDA <paragraph> element in that the <br/> element has no content.
Receivers are required to interpret this element when rendering so as to
represent a line break.

4.3.5.5

<ins> and <del> - Deprecated

The CDA <ins> and <del> elements can be used to indicate narrative
changes from the last version of a CDA document. The usage of the
elements is limited to a single generation, in that it only reflects the
changes from the preceding version of a document. If applied, it needs to
be used in conjunction with standard CDA revision tracking. Changes to a
CDA document that has been released for patient care still require a formal
versioning and revision, and the revised document can optionally carry the
<ins> and / or <del> elements to show the delta in the narrative.
Receivers are required to interpret the <del> element when rendering by
visually distinguishing or suppressing deleted narrative.
We proposal to deprecate the use of <ins> and <del> with this revision, as
it is redundant with the normal versioning supported in the CDA header
using the relatedDocument / parentDocument elements.

4.3.5.65

<footnote> and <footnoteRef>

The CDA <footnote> element is used to indicate a footnote. The element

contains the footnote, inline with the flow of text to which it is applied.

The <footnoteRef> element can reference an existing footnote in the same

or different CDA Narrative Block of the same document. It can be used
when the same footnote is being used multiple times. The value of the
footnoteRef.IDREF must be an footnote.ID value in the same document.

Receivers are required to interpret these elements when rendering by

visually distinguishing footnoted text. The exact rendition is at the
discretion of the recipient, and might include a mark at the location of the
footnote with a hyperlink to the footnoted text, a simple demarcation (such
as "This is the text [this is the footnote] that is being footnoted"), etc.
Use Cases for footnote in clinical documents; have not been identified over
the course of the CDA R2. As a result, the use of <footnote> and
<footnoteRef> elements is deprecated in CDA R3.
Note: Implementation Guides are encouraged to prohibit the use of these
two elements in CDA R3 Implementation Guides, in order to simply the
processing requirements for narrative text.

4.3.5.6 7

<renderMultiMediaimg> - multimedia references

The CDA <renderMultiMediaimg> element is used to references external

multimedia. Direct references to external multimedia using <img> are not
assumed to be integral to or attested in the document and maybe excluded
in CDA document exchanges. Multimedia that is integral to a document,
and part of the attestable content of the document, must therefore
reference either a contained ObservationMedia or RegionOfInterest entry to
flag the multimedia as attested and and serves to show where the
referenced multimedia is to be rendered.

The <renderMultiMediaimg> element has an optional <caption>, and

contains a required referencedObjectsrc attribute (of type XML IDREFSURI),

the values of which must equal the XML ID value(s) of ObservationMedia or

RegionOfInterest CDA entries within the same document when flagging the
content as authenticated and integral to the documents interpretation. The
<img> element also contains a required alt attribute that needs to specify
the alternate text for an image.
Example 7

<section>
<code code="8709-8" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Skin exam</title>
<text>Erythematous rash, palmar surface, left index
finger.<renderMultiMedia img
referencedObjectsrc="#MM1" alt="image of:
left_hand_image.jpg" />
</text>
<entry>
<observationMedia classCode="OBS" moodCode="EVN"
ID="MM1">
<id root="2.16.840.1.113883.19.2.1"/>
<value xsi:type="ED" mediaType="image/jpeg">
<reference value="left_hand_image.jpeg"/>
</value>
</observationMedia>
</entry>
</section>

Multimedia that is simply referenced by the document and not an integral

part of the document must can use <linkHtmlaimg> or <img>, but must
not reference observationMedia or RegionOfInterest elements.

The expected behavior is that the referenced multimedia should be

rendered or referenced at the point of reference. Where a caption is
present, it must also be rendered. <renderMultiMediaimg> elements can
either reference a single ObservationMedia, or one or morea single
RegionOfInterest. If <renderMultiMedia> references a singleIn either case
the multimedia ObservationMedia, that ObservationMedia should be
rendered or referenced at the point of reference in the narrative text. If
<renderMultiMedia> references one or more RegionOfInterest, all
RegionOfInterests should be rendered or referenced at the point of
reference, atop the multimedia they are regions of.
If the <renderMultiMediaimg> needs to references more than one
RegionOfInterest, each RegionOfInterest must be a region on the same
multimedia and contained within a single Organizer element with a
classCode =GROUPER. The <img> will then reference the Organizer

entry.

4.3.5.7 8

<paragraph> - paragraphs

A CDA <paragraph> is similar to the HTML paragraph, which allows blocks

of narrative to be broken up into logically consistent structures. A CDA
<paragraph> element contains an optional caption, which if present must
come first before any other character data.

4.3.5.8 9

<list>Various list types

4.3.5.9.1

<ol> - ordered lists

A CDA <ol> is similar to the HTML order list element. The <ol> element
will contain 1 or more <li> list item elements.

4.3.5.9.2

<ul> - unordered lists

A CDA <ul> is similar to the HTML unordered list element. The <ul>
element will contain 1 or more <li> list item elements.

4.3.5.9.3

<dl> - definition lists

A CDA <dl> is similar to the HTML definition list element. The <dl>
element will contain 1 or more <dt> definition items and/or <dd> item
definitions. Together these elements can be used to construct lists of terms
with definitions.

A CDA <list> is similar to the HTML list. A CDA <list> has an optional
caption, and contains one or more <item> elements. A CDA <item>
element contains an optional caption, which if present must come first
before any other character data. The required listType attribute specifies
whether the <list> is ordered or unordered (with unordered being the
default). Unordered lists are typically rendered with bullets, whereas
ordered lists are typically rendered with numbers, although this is not a
requirement.

4.3.5.9 10 <table>

The CDA <table> is similar to the HTML table. The table markup is for
presentation purposes only and, unlike a database table, does not possess
meaningful field names.

CDA modifies the strict XHTML table model by removing formatting tags
and by setting the content model of cells to be similar to the contents of
other elements in the CDA Narrative Block.

The table.border, table.cellspacing, and table.cellpadding attributes are

deprecated, because the styleCode attribute (see styleCode attribute (
4.3.5.11 ) provides a more consistent way for senders to suggest rendering
characteristics.

4.3.5.10 11 <caption>

The CDA <caption> is a label for a paragraph, list, list item, table, or table
cell. It can also be used within the <renderMultiMedia> element to indicate
a label for referenced ObservationMedia and RegionOfInterest entries. A
<caption> contains plain text and may contain links and footnotes.
Captions required for other CDA narrative elements will need to be
expressed as explicit narrative content with the document. E.g.
<p>Caption Text</p> any other narrative element here.

4.3.5.1211 styleCode attribute

The styleCode style attribute is used within the CDA Narrative Block to give
the instance author the ability to suggest rendering characteristics of the
nested character data. Receivers are not required to render documents
using the styles hints provided and can present stylized text in accordance
with their local style conventions.
The CDA R3 style attribute values will be one or more cascading style sheet
properties = value pairs, separated by semicolons, similar to HTML. E.g.
style=font-weight:bold;color:red - for red bold text.

The value set is drawn from the HL7 styleType vocabulary domain, and has
a CWE coding strength.
Table 89: Value set for styleCode (CWE)

Code

Definition

Font style (Defines font rendering characteristics.)

Bold

Render with a bold font.

Underline

Render with an underlines font.

Italics

Render italicized.

Emphasis

Render with some type of emphasis.

Table rule style (Defines table cell rendering characteristics.)

Lrule

Render cell with left-sided rule.

Table 89: Value set for styleCode (CWE)

Code

Definition

Rrule

Render cell with right-sided rule.

Toprule

Render cell with rule on top.

Botrule

Render cell with rule on bottom.

Ordered list style (Defines rendering characteristics for ordered

lists.)

Arabic

List is ordered using Arabic numerals: 1, 2, 3.

LittleRoman

List is ordered using little Roman numerals: i, ii, iii.

BigRoman

List is ordered using big Roman numerals: I, II, III.

LittleAlpha

List is ordered using little alpha characters: a, b, c.

BigAlpha

List is ordered using big alpha characters: A, B, C.

Unordered list style (Defines rendering characteristics for

unordered lists.)

Disc

List bullets are simple solid discs.

Table 89: Value set for styleCode (CWE)

Code

Definition

Circle

List bullets are hollow discs.

Square

List bullets are solid squares.

Local extensions to the styleType vocabulary domain must follow the

following convention: [x][A-Za-z][A-Za-z0-9]* (first character is "x", second
character is an upper or lower case A-Z, remaining characters are any
combination of upper and lower case letters or numbers).

The styleCode attribute can contain multiple values, separated by white

space. Where an element containing a styleCode attribute is nested within
another element containing a styleCode attribute, the style effects are
additive, as in the following example:
Example 8

<section>
<text><content styleCode="Bold">This is rendered bold,
<content styleCode="Italics">this is rendered bold
and
italicized,</content> this is rendered bold.
</content>
<content styleCode="Bold Italics">This is also
rendered
bold and italicized.</content>
</text>
</section>

4.3.5.13

Other CDA Elements & Attributes

The remaining elements and attributes used are modeled after the XHTML
1.0 Strict Schema. Conformant implementations will only use the elements
listed below:

4.3.5.12

Referencing in and out of the narrative block

NOTE: See entry ( 4.3.4.2 ) for a discussion of the relationships between
a section and its contained entries.
To summarize the mechanisms for referencing in and out of the CDA
Narrative Block:

CDA entries can point in to the <contentspan> element of the CDA

Narrative Block (see <contentspan> - content wrapping ( 4.3.5.1 )).

The <linkHtmla> - anchor element of the CDA Narrative Block can

reference targets that are either internal or external to the document
(see <linkHtmla> - anchor element ( 4.3.5.2 )).

The <footnoteRef> element of the CDA Narrative Block can

reference a <footnote> element in the same or different CDA Narrative
Block of the same document (see <footnote> and <footnoteRef> (
4.3.5.5 6 )).

The <renderMultiMediaimg> -multimedia references element of the

CDA Narrative Block can point out to CDA ObservationMedia and
RegionOfInterest entries of the same document (see
<renderMultiMediaimg> - multimedia references ( 4.3.5.6 7 )).