Section narrative text

[Category: Section Narrative Text; Original Post: 06-Feb-14]
The article What is the overall structure of a CDA document outlines the top-level XML syntax of a CDA document.  As explained, the CDA Body consists of a series of sections. Each section usually contains within it a series of structured entries with clinical statements – although these are not required by the CDA standard itself and might not always be present.

What is always required in every CDA document section is the narrative text. Everything that is clinically relevant and contained in the structured clinical statements of the section must also be captured in the narrative text. It is OK for the narrative text to include additional material not contained in the structured entries, but not the other way around. Refer to the article
What Must Be Contained in Section Narrative Text?, for an elaboration of how this guidance should be interpreted.

A short title for the section narrative text is provided in the title element under the section element that encapsulates each section of a CDA document.

The section narrative text itself goes into an element named text that is also directly under the section element.

Formatting the Section Narrative Text
Nested inside the text element can be a range of formatting elements that the CDA standard defines. These formatting elements are very reminiscent of HTML tags – but the syntax is not that of HTML and neither HTML, XHTML, nor any other standard can be used, only what CDA defines.

Below is a summary of the formatting elements defined by CDA for use in the section narrative text, and their relationship to HTML:

• Identical to HTML:
  
  
  
  • sub and sup (subscript and superscript)
  
  
  • br (line-break)
  
  
  • table, thead, tbody, tfoot, th, td, tr, colgroup, col, caption (tables)
  
  
  
  
• Similar to HTML (HTML approximate equivalent in parentheses):
  
  
  
  • paragraph (HTML: p)
  
  
  • content (HTML: span)
  
  
  • (HTML: ol)
  
  
  • (HTML: ul)
  
  
  • item (HTML: li)
  
  
  • linkHTML (HTML: a)
  
  
  • renderMultimedia (HTML: img)
  
  
  
  


• Unique to CDA section narrative text formatting:
  
  
  
  • footnote
  
  
  • footnoteRef
  
  
  
  

In conjunction with the formatting elements above, there is also a formatting attribute named styleCode that is analogous to the style attribute in HTML. An example of its use is shown below:

   
      
         This is rendered bold,
         
            This is rendered bold and italicized
         
         this is again rendered bold
      
      
         This is also bold and italicized
      
   

The recommended values for use in styleCode are summarized here:

• Font Styles
  
  
  
  • Bold
  
  
  • Underline
  
  
  • Italics
  
  
  • Emphasis
  
  
  
  


• Table Styles
  
  
  
  • Lrule
  
  
  • Rrule
  
  
  • Toprule
  
  
  • Botrule
  
  
  
  


• Ordered List Styles
  
  
  
  • Arabic
  
  
  • LittleRoman
  
  
  • BigRoman
  
  
  • LittleAlpha
  
  
  • BigAlpha
  
  
  
  


• Unordered List Styles
  
  
  
  • Disc
  
  
  • Circle
  
  
  • Square
  
  
  
  

Use of Other styleCode Values
The styleCode values above are the ones defined and recommended as part of the CDA specification. Thus, receivers that display CDA documents, XSL style sheets that interpret CDA documents, etc. are expected to correctly interpret these values and display the section text accordingly. However, it is also permissible, as per the rules of the CDA specification, to add additional styleCode values that have agreed meaning be specific senders and receivers of CDA documents.

In general, receivers are not expected to interpret such "custom" styleCode values, but they must not "choke" on receiving unrecognized styleCode values, either. This can be thought of as being analogous to class attributes on HTML elements. The class is ignored by those who do not have defined style sheets or other transforms that are aware of them and interpret/act on them.

The styleCode attribute can be placed on any sub-element of the text element that contains section narrative text, not just the content element, or lists and tables.

As a practical matter, however, there are some challenges for implementations that seek to use the full spectrum of the allowed usage of the styleCode attribute (custom values, use with any sub-element, etc.). Although receivers are required to ignore any unrecognized styleCode values or element contexts where styleCode is used and not commonly used, some (formally, faulty) implementations may not do so. In fact, the cda.xsl style sheet supplied in the official CDA and C-CDA download packages is reported to have some issues in this regard. Thus, for CDA documents intended for broad consumption, it is recommended to limit the use of styleCode to the elements (and with the values) explicitly noted above.

XML Mixed Content in Section Narrative Text
The example text element shown above has line breaks and indentation within it, which are ignored. The question of how line-breaks are interpreted in the text element of the example, is part of a broader issue of how "whitespace" (spaces, tab characters, line-break characters, etc.) is handled in text elements containing section narrative text.

The content of section narrative text is one of three places in CDA documents where XML "mixed content" is used. Refer to the article XML mixed content in CDA for an overview of this topic. Then continue on to the articles Whitespace in CDA mixed content elements and Interpreting whitespace in section narrative text elements for details of the implications of the text element of section narrative text being a "mixed content" element, in terms of how whitespace is interpreted.

Other CDA PRO Know Articles Referenced In This Article

• What is the high-level CDA document syntax?


• What XML knowledge is needed for CDA work?


• What Must Be Contained in Section Narrative Text?


• What is CDA?


• Clinical act statements


• XML mixed content in CDA


• Whitespace in CDA mixed content elements


• Interpreting whitespace in section narrative text