chpcc_entry_Immunization

Template Immunization Entry 2021‑02‑18 09:05:06

2.16.840.1.113883.3.1937.99.61.19.10.63

Gültigkeit ab

2021‑02‑18 09:05:06

Status

Entwurf

Versions-Label

1.0.0

Name

chpcc_entry_Immunization

Bezeichnung

Immunization Entry

Beschreibung

Kontext

Elternknoten des Template-Element mit Id 2.16.840.1.113883.3.1937.99.61.19.10.63

Label

IHE PCC TF2 Rev.11, 6.3.4.17

Klassifikation

CDA Entry Level Template

Offen/Geschlossen

Offen (auch andere als die definierten Elemente sind erlaubt)

Benutzt von / Benutzt

Benutzt von 0 Transactions und 0 Templates, Benutzt 7 Templates

Benutzt	als	Name	Version
2.16.756.5.30.1.1.10.4.2	Containment	Annotation Comments (2016)	DYNAMIC
2.16.756.5.30.1.1.10.4.94	Containment	Manufactured Product (2016)	DYNAMIC
2.16.756.5.30.1.1.10.4.95	Containment	Target Of The Immunization - Medication Target (2018)	DYNAMIC
2.16.756.5.30.1.1.10.4.96	Containment	Recommendation Category - Criterion (2018)	DYNAMIC
2.16.756.5.30.1.1.10.4.101	Containment	Immunization Performer - performer Containment (2016)	DYNAMIC
2.16.756.5.30.1.1.10.9.14	Inklusion	Narrative Text Reference (2021)	DYNAMIC
2.16.756.5.30.1.1.10.9.48	Containment		DYNAMIC

Beziehung

Spezialisierung: Template 2.16.756.5.30.1.1.10.4.89 (2016‑11‑11)
Spezialisierung: Template 1.3.6.1.4.1.19376.1.5.3.1.4.12 (DYNAMIC)
Spezialisierung: Template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)

ref

ad1bbr-

Beispiel

General structure

Beispiel

BOOSTRIX Polio

<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12"/>  <templateId root="2.16.840.1.113883.10.20.1.24"/>  <templateId root="2.16.756.5.30.1.1.10.4.89"/>  <id root="4a641cee-aa60-09a6-b0ab-8d534c7c9e0d"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#is10"/>  </text>  <statusCode code="completed"/>  <effectiveTime value="20180604"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="NA"/>  <doseQuantity nullFlavor="UNK"/>  <consumable typeCode="CSM">
    <manufacturedProduct>
      <templateId root="2.16.756.5.30.1.1.10.4.94"/>      <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"/>      <id root="2.51.1.1" extension="7680006370012"/>      <manufacturedMaterial>
        <code code="J07CA02" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC"/>        <name>BOOSTRIX Polio Inj Susp</name>      </manufacturedMaterial>      <manufacturerOrganization>
        <name use="L">GlaxoSmithKline AG</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <performer>
    <time value="20180604"/>    <assignedEntity>
      <id root="2.51.1.3" extension="7608888888888"/>      <assignedPerson>
        <name use="L">
          <given>Allzeit</given>          <family>Bereit</family>          <prefix qualifier="AC">Dr. med.</prefix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="2.51.1.3" extension="7608888888888"/>        <name use="L">Gruppenpraxis CH</name>        <telecom value="tel:+41.32.234.55.66" use="WP"/>        <telecom value="fax:+41.32.234.55.67" use="WP"/>        <telecom value="mailto:bereit@gruppenpraxis.ch" use="WP"/>        <telecom value="http://www.gruppenpraxis.ch" use="WP"/>        <addr use="WP">
          <streetName>Doktorgasse</streetName>          <houseNumber>2</houseNumber>          <city>Musterhausen</city>          <postalCode>8888</postalCode>          <country>CH</country>        </addr>      </representedOrganization>    </assignedEntity>  </performer>  <author>
    <functionCode code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician">
      <translation code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical doctors"/>    </functionCode>    <time value="20180604"/>    <assignedAuthor>
      <id root="2.51.1.3" extension="7608888888888"/>      <assignedPerson>
        <name use="L">
          <given>Allzeit</given>          <family>Bereit</family>          <prefix qualifier="AC">Dr. med.</prefix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="2.51.1.3" extension="7608888888888"/>        <name use="L">Gruppenpraxis CH</name>        <telecom value="tel:+41.32.234.55.66" use="WP"/>        <telecom value="fax:+41.32.234.55.67" use="WP"/>        <telecom value="mailto:bereit@gruppenpraxis.ch" use="WP"/>        <telecom value="http://www.gruppenpraxis.ch" use="WP"/>        <addr use="WP">
          <streetName>Doktorgasse</streetName>          <houseNumber>2</houseNumber>          <city>Musterhausen</city>          <postalCode>8888</postalCode>          <country>CH</country>        </addr>      </representedOrganization>    </assignedAuthor>  </author>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>      <templateId root="2.16.840.1.113883.10.20.1.40"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        <reference value="#is16"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a641d8e-aa60-09a6-b7fb-8d534c7c9e0d"/>      <code code="76668005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diphterie"/>      <text>
        <reference value="#is11"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a64209a-aa60-09a6-d5fd-8d534c7c9e0d"/>      <code code="127786006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Tetanus"/>      <text>
        <reference value="#is12"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a642130-aa60-09a6-a82a-8d534c7c9e0d"/>      <code code="39343008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Keuchhusten"/>      <text>
        <reference value="#is13"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a6421d0-aa60-09a6-e59e-8d534c7c9e0d"/>      <code code="72093006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Kinderlähmung"/>      <text>
        <reference value="#is14"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <precondition>
    <criterion>
      <templateId root="2.16.756.5.30.1.1.10.4.96"/>      <code code="41501" codeSystem="2.16.756.5.30.1.127.3.3.4" displayName="Empfohlene Basisimpfungen"/>      <text>
        <reference value="#is15"/>      </text>    </criterion>  </precondition></substanceAdministration>

Item

Kard

Konf

Beschreibung

Label

hl7:substanceAdministration

An immunizations entry is used to record the patient's immunization history. An immunization is a substance administration event. An immunization entry may also be used to report a specific immunization that was not performed (e.g. undesired immunization). In this case, negationInd shall be set to "true", otherwise, it shall be "false".

IHE PCC TF2 Rev.11, 6.3.4.17

@moodCode

1 … 1

EVN

@negationInd

1 … 1

For administered immunizations: negationInd='false'

For undesired immunizations: negationInd='true'

hl7:templateId

1 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@root

uid

1 … 1

2.16.840.1.113883.3.1937.99.61.19.10.63

hl7:templateId

1 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@root

uid

1 … 1

2.16.756.5.30.1.1.10.4.89

hl7:templateId

1 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@root

uid

1 … 1

1.3.6.1.4.1.19376.1.5.3.1.4.12

hl7:templateId

1 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@root

uid

1 … 1

2.16.840.1.113883.10.20.1.24

hl7:id

1 … 1

Immunization ID, assigned by the software application.

IHE PCC TF2 Rev.11, 6.3.4.17

@root

uid

1 … 1

MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.

@extension

0 … 1

Contains the ID itself. The ID MUST be unique within the system that issued the ID.

Auswahl

1 … 1

Elemente in der Auswahl:

hl7:code
hl7:code

hl7:code

0 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@code

1 … 1

IMMUNIZ

@codeSystem

oid

1 … 1

2.16.840.1.113883.5.4

@codeSystemName

1 … 1

ActCode

@displayName

NP/nicht anwesend

hl7:code

0 … 1

IHE PCC TF2 Rev.11, 6.3.4.17

@code

1 … 1

@codeSystem

oid

1 … 1

2.16.840.1.113883.6.96

@codeSystemName

1 … 1

SNOMED CT

@displayName

1 … 1

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 2.16.756.5.30.1.1.11.69 Special Case Medication (DYNAMIC)

Eingefügt

1 … 1

von 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
en-US The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.

hl7:text

1 … 1

CDA‑CH V2

hl7:reference

TEL

1 … 1

The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']

CDA‑CH V2

@value

1 … 1

Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.

Schematron assert

role

error

test

starts-with(@value,'#')

Meldung

The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element.

Variable let

Name

idvalue

Value

substring-after(@value,'#')

Schematron assert

role

error

test

ancestor::hl7:structuredBody//*[@ID=$idvalue]

Meldung

No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').

hl7:statusCode

1 … 1

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

IHE PCC TF2 Rev.11, 6.3.4.17

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)

hl7:effectiveTime

TS.CH.TZ

1 … 1

Date of the immunization.

IHE PCC TF2 Rev.11, 6.3.4.17

hl7:priorityCode

1 … 1

If the priority for the immunization is known, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='UNK'

IHE PCC TF2 Rev.11, 6.3.4.17

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)

hl7:routeCode

1 … 1

If the route of administration is known, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='NA'

IHE PCC TF2 Rev.11, 6.3.4.17

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 2.16.756.5.30.1.1.11.79 RouteOfAdministration (Immunization) (DYNAMIC)

hl7:approachSiteCode

0 … *

If laterility of the administration is known, it MAY be recorded according to the HL7 value set.

Recommendation for eVACDOC: omit

IHE PCC TF2 Rev.11, 6.3.4.17

@codeSystem

CONF

0 … 1

2.16.840.1.113883.5.1052

hl7:doseQuantity

IVL_PQ

0 … 1

If dose quantity of the administration is known, it MAY be recorded according to the recommendations in the addendum "Darstellung Medikation" to the German "Arztbrief".

Recommendation for eVACDOC: @nullFlavor='UNK'

IHE PCC TF2 Rev.11, 6.3.4.17

hl7:consumable

1 … 1

Vaccine
Beinhaltet 2.16.756.5.30.1.1.10.4.94 Manufactured Product (DYNAMIC)

IHE PCC TF2 Rev.11, 6.3.4.17

@typeCode

1 … 1

hl7:performer

0 … *

This MAY be used to indicate who has administered the immunization.
Beinhaltet 2.16.756.5.30.1.1.10.4.101 Immunization Performer - performer Containment (DYNAMIC)

IHE PCC TF2 Rev.11, 6.3.4.17

hl7:author

0 … *

This MAY be used to indicate who has documented the immunization. This information supersedes any information recorded at higher level.
Beinhaltet

Fehler: Kann das Template "2.16.756.5.30.1.1.10.9.48" (DYNAMIC) nicht finden

IHE PCC TF2 Rev.11, 6.3.4.17

hl7:entryRelationship

0 … *

Target of the immunization (the disease against which the immunization provides protection). Reference to Medication Target (Target of the immunization).
Beinhaltet 2.16.756.5.30.1.1.10.4.95 Target Of The Immunization - Medication Target (DYNAMIC)

IHE PCC TF2 Rev.11, 6.3.4.17

@typeCode

1 … 1

RSON

hl7:entryRelationship

0 … *

Comments and remarks.
Beinhaltet 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC)

IHE PCC TF2 Rev.11, 6.3.4.17

@typeCode

1 … 1

SUBJ

hl7:precondition

0 … *

Recommendation-Category according to the swiss vaccination plan.
Beinhaltet 2.16.756.5.30.1.1.10.4.96 Recommendation Category - Criterion (DYNAMIC)

IHE PCC TF2 Rev.11, 6.3.4.17

Schematron assert

role

error

test

(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:performer

Meldung

After 15.4.2020, the performer is required for each immunization.

Schematron assert

role

error

test

(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or (string-length(hl7:effectiveTime/@value)>7)

Meldung

After 15.4.2020, the date with precision of day is required for each immunization.

Schematron assert

role

error

test

(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:consumable/hl7:manufacturedProduct/hl7:manufacturedMaterial/hl7:lotNumberText/text()

Meldung

After 15.4.2020, the lot number is required for each immunization.

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Template Immunization Entry 2021‑02‑18 09:05:06