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ref Template  Immunizations

Id 1.3.6.1.4.1.19376.1.5.3.1.4.12 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntryImmunizations Display Name Immunizations
Description

An immunizations entry is used to record the patient's immunization history.
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.12
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 2 concepts
Id Name Data Set
epsos-dataelement-169 Vaccination date epSOS Data Set
epsos-dataelement-171 Vaccine description epSOS Data Set
Used by / Uses
Used by 0 transactions and 4 templates, Uses 4 templates
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.23 Containment draft Section Immunizations 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link draft epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link draft epSOS-Medication Related Overview 2013‑12‑20
Uses as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.7.2 Containment draft Immunization Product DYNAMIC
2.16.840.1.113883.10.20.1.46 Containment draft Position Of Vaccination DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment draft Problem DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment draft Comment DYNAMIC
Example
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"/>  <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>
notice There is an open issue with this item:
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.

(Entdotsons)
@classCode
 cs 1 … 1 F SBADM
@moodCode
 cs 1 … 1 F EVN
@negationInd
 bl 1 … 1 R
hl7:templateId
 II 1 … 1 M (Entdotsons)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.12
hl7:templateId
 II 1 … 1 M (Entdotsons)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.24
hl7:id
 II.EPSOS 1 … 1 M (Entdotsons)
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

IHEActCode

The IMMUNIZ term from the IHE ActCode vocabulary.

(Entdotsons)
@code
 CONF 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.

(Entdotsons)
 
target epsos-dataelement-171 Vaccine description epSOS Data Set
hl7:reference
 TEL 1 … 1 M (Entdotsons)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 CS 1 … 1 R

The statusCode shall be set to "completed" for all immunizations.

(Entdotsons)
@code
 CONF 0 … 1 F completed
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.

(Entdotsons)
 
target epsos-dataelement-169 Vaccination date epSOS Data Set
hl7:routeCode
 CE 0 … 1 R

See routeCode under the Medication Item Entry Content module.

(Entdotsons)
hl7:doseQuantity
 IVL_PQ 0 … 1 R

See doseQuantity under the Medication Item Entry Content module.

(Entdotsons)
hl7:consumable
 1 … 1 R

The <consumable> element shall be present, and shall contain a <manufacturedElement> element, conforming to the Product Entry Content Module template.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.7.2 Immunization Product (DYNAMIC) 		(Entdotsons)
treeblank where [@typeCode='CSM'] [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']]]
@typeCode
 cs 1 … 1 F CSM
hl7:entryRelationship
 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.


Contains 2.16.840.1.113883.10.20.1.46 Position Of Vaccination (DYNAMIC) 		(Entdotsons)
treeblank where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.1.46']]]
  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>
hl7:entryRelationship
 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.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC) 		(Entdotsons)
treeblank 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']]]
  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>
hl7:entryRelationship
 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.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 Comment (DYNAMIC) 		(Entdotsons)
treeblank 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']]]