Existing Wording: However the content (the set of attested resources, and their order) and the presentation of the document cannot change.

Proposed Wording: However the content (the set of attested resources, and their order) and the presentation of the document cannot change substantially (such that it changes the clinical meaning of the content).

Comment:

Early parts of the page refer to the document having "fixed" presentation and 2.3.0.1 says "the presentation of the document cannot change." However, 2.3.0.1.1 allows for different stylesheets besides those specified in the document. Even though it says the specified stylesheets SHOULD be used, that is not a SHALL. So if someone uses a different stylesheet, the presentation of the document might change, which contradicts the earlier statements. The proposed wording was borrowed from 2.3.0.1.1. However, more specific guidance is needed on what types of changes are permissible or not via stylesheets. E.g., "cosmetic" changes such as branding a document with your logo, or increasing the font size, seem innocuous and should be permissible. However, suppressing any of the narrative should be prohibited. What about rendering additional data that is in the structured elements but not in the narrative (is this OK)? Etc.