| Item |
DT |
Card |
Conf |
Description |
Label |
hl7:substanceAdministration
|
|
|
|
R |
An immunization is a substance administration event. An immunization entry may be
a record of why a specific immunization was not performed. In this case, negationInd
shall be set to "true", otherwise, it shall be false.
|
(EntryImmunizations) |
 |
@classCode
|
|
|
1 .. 1 |
F |
SBADM |
|
@moodCode
|
|
|
1 .. 1 |
F |
EVN |
|
@negationInd
|
|
bl |
1 .. 1 |
R |
|
| |
Example |
<substanceAdministration typeCode="SBADM" moodCode="EVN" negationInd="true{{!}}false">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12"/>
<id root="" extension=""/>
<code code="IMMUNIZ" codeSystem="1.3.5.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode"/>
<text>
<reference value="#xxx"/>
</text> <statusCode code="completed"/>
<effectiveTime value=""/>
<!-- The reasonCode would normally provide a reason why the immunization was
not performed. It isn't supported by CDA R2, and so
comments will have to suffice.
<reasonCode code='' codeSystem='' codeSystemName='ActNoImmunizationReasonIndicator'/>
-->
<routeCode code="" codeSystem="" codeSystemName="RouteOfAdministration"/>
<approachSiteCode code="" codeSystem="" codeSystemName="HumanSubstanceAdministrationSite"/>
<doseQuantity value="" units=""/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
<code code="" codeSystem="" codeSystemName="">
<originalText>
<reference value="#yyy"/>
</originalText> </code> </manufacturedMaterial> </manufacturedProduct> </consumable> <!-- An optional entry relationship that provides prescription activity -->
<entryRelationship typeCode="REFR">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/>
<!-- ... -->
</entryRelationship> <!-- An optional entry relationship that identifies the immunization series number -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.46"/>
<code code="30973-2" displayName="Dose Number" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<value xsi:type="INT" value=""/>
</observation> </entryRelationship> <entryRelationship inversionInd="false" typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<id root="" extension=""/>
</observation> </entryRelationship> <!-- Optional <entryRelationship> element containing comments -->
</substanceAdministration> |
|
hl7:templateId
|
|
II |
1 .. 1 |
M |
|
(EntryImmunizations) |
 |
|
@root
|
|
|
1 .. 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.12 |
|
hl7:templateId
|
|
II |
1 .. 1 |
M |
|
(EntryImmunizations) |
|
|
@root
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.10.20.1.24 |
|
hl7:id
|
|
II.EPSOS |
1 .. 1 |
M |
|
(EntryImmunizations) |
|
hl7:code
|
|
CD.EPSOS |
1 .. 1 |
M |
This required element records that the act was an immunization. The substance administration
act must have a <code> element with code and codeSystem attributes present. If no
coding system is used by the source, then simply record the code exactly as shown
above. This <code> element shall not be used to record the type of vaccine used from
a vocabulary of drug names.
|
codeSystem
|
codeSystemName
|
Description
|
|
1.3.5.1.4.1.19376.1.5.3.2
|
ActCode
|
The IMMUNIZ term from the IHE ActCode vocabulary.
|
|
(EntryImmunizations) |
|
|
@code
|
|
|
1 .. 1 |
F |
IMMUNIZ |
|
|
@codeSystem
|
|
|
1 .. 1 |
F |
1.3.5.1.4.1.19376.1.5.3.2 (IHEActCode) |
|
hl7:text
|
|
ED |
1 .. 1 |
R |
The URI given in the value attribute of the <reference> element points to an element
in the narrative content that contains the complete text describing the immunization
activity.
|
(EntryImmunizations) |
|
hl7:statusCode
|
|
CS |
1 .. 1 |
R |
The statusCode shall be set to "completed" for all immunizations.
|
(EntryImmunizations) |
|
|
@code
|
|
|
1 .. 1 |
F |
completed |
|
|
@codeSystem
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.14 (ActStatus) |
|
hl7:effectiveTime
|
|
|
1 .. 1 |
R |
The effectiveTime element shall be present and should contain a time value that indicates
the date of the substance administration. If the date is unknown, this shall be recorded
using the nullFlavor attribute, with the reason that the information is unknown being
specified. Otherwise, the date shall be recorded, and should have precision of at
least the day.
|
(EntryImmunizations) |
|
hl7:routeCode
|
|
CE |
0 .. 1 |
R |
See routeCode under the Medication Item Entry Content module.
|
(EntryImmunizations) |
| |
CONF |
|
|
hl7:approachSiteCode
|
|
CD |
0 .. * |
R |
The <approachSiteCode> element describes the site of immunization administration.
It may be coded to a controlled vocabulary that lists such sites (e.g., SNOMED-CT).
The <originalText> element contains a URI in the value attribute of the <reference>
that points to the text in the narrative identifying the site.
|
(EntryImmunizations) |
|
|
@codeSystem
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.1052 (ActSite) |
| |
Example |
<approachSiteCode code=" " codeSystem=" " codeSystemName="HumanSubstanceAdministrationSite">
<originalText>
<reference value=" "/>
</originalText></approachSiteCode> |
|
hl7:doseQuantity
|
|
IVL_PQ |
0 .. 1 |
R |
See doseQuantity under the Medication Item Entry Content module.
|
(EntryImmunizations) |
|
hl7:doseQuantity
|
|
RTO_PQ_PQ |
0 .. 1 |
R |
See doseQuantity under the Medication Item Entry Content module.
|
(EntryImmunizations) |
|
hl7:consumable
where
[hl7:manufacturedProduct [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'
and hl7:templateId/@root='2.16.840.1.113883.10.20.1.53']] |
|
|
1 .. 1 |
R |
The <consumable> element shall be present, and shall contain a <manufacturedElement>
element, conforming to the Product Entry Content Module template.
|
(EntryImmunizations) |
|
|
@typeCode
|
|
|
1 .. 1 |
F |
CSM |
| |
Contains |
1.3.6.1.4.1.19376.1.5.3.1.4.7.2 Immunization Product (DYNAMIC)
|
|
hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.1.46']] |
|
|
0 .. 1 |
R |
This optional entry relationship may be present to indicate that position of this
immunization in a series of immunizations. The <code> element shall be present and
must be recorded with the code and codeSystem attributes shown above. This element
indicates that the observation describes the dose number for the immunization. The
<statusCode> element shall be present, and must be recorded exactly as shown above.
This element indicates that the observation has been completed. The <value> element
shall be present, and shall indicate the immunization
series number in the value attribute.
|
(EntryImmunizations) |
| |
Example |
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.46"/>
<code code="30973-2" displayName="Dose Number" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<value xsi:type="INT" value=" "/>
</observation></entryRelationship> |
| |
Contains |
2.16.840.1.113883.10.20.1.46 Position Of Vaccination (DYNAMIC)
|
|
hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.5' and hl7:templateId/@root='2.16.840.1.113883.10.20.1.28']] |
|
|
0 .. * |
R |
This repeatable element should be used to identify adverse reactions caused by the
immunization. The <observation> element provides a pointer to the adverse reaction
caused by the immunization. The template IDs describe that it points to a conforming
Problem Entry Content Module that also conform to the CCD Reaction template.
The <id> element is required, and gives the identifier of the adverse reaction. The
adverse reaction pointed to by this element shall be described in more detail using
the Allergies entry, elsewhere in the document where the Allergies and Intolerances
section is found.
|
(EntryImmunizations) |
| |
Example |
<entryRelationship inversionInd="false" typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<id root=" " extension=" "/>
</observation></entryRelationship> |
| |
Contains |
1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC)
|
|
hl7:entryRelationship
where
[hl7:act [hl7:templateId/@root='2.16.840.1.113883.10.20.1.40' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']] |
|
|
0 .. * |
R |
An immunization entry can have negationInd set to true to indicate that an immunization
did not occur. In this case, it shall have at least one comment that provides an explanation
for why the immunization did not take place. Other comments may also be present.
|
(EntryImmunizations) |
| |
Contains |
1.3.6.1.4.1.19376.1.5.3.1.4.2 Comment (DYNAMIC)
|
|
hl7:entryRelationship
where
[hl7:manufacturedProduct [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'
and hl7:templateId/@root='2.16.840.1.113883.10.20.1.53']] |
|
|
0 .. * |
R |
The product entry describes an immunization used in a <substanceAdministration> act.
It adopts the constraints of the ASTM/HL7 Continuity of Care Document.
|
(EntryImmunizations) |
| |
Example |
<!-- Within a CDA Document -->
<manufacturedProduct>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="" displayName="" codeSystem="" codeSystemName="">
<originalText>
<reference value=""/>
</originalText> </code> <name/>
</manufacturedMaterial></manufacturedProduct> |
| |
Contains |
1.3.6.1.4.1.19376.1.5.3.1.4.7.2 Immunization Product (DYNAMIC)
|
Template Immunizations