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Template _Immunization (harmonized) 2021‑07‑06 09:55:32

Id2.16.840.1.113883.3.1937.99.61.30.10.60Effective Date2021‑07‑06 09:55:32
Statusdraft DraftVersion LabelIAT
NameImmunizationIpsVsCcdaDisplay Name_Immunization (harmonized)
Description
C-CDA

An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received. An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 1) Date of administration 2) Vaccine manufacturer 3) Vaccine lot number 4) Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside 5) Vaccine information statement (VIS) a. Date printed on the VIS b. Date VIS given to patient or parent/guardian. This information should be included in an Immunization Activity when available. (Reference: [URL:http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/vacc_admin.pdf])

IPS

An Immunization entry describes immunization substance administrations that have actually occurred. 


Proposal
adopt the C-CDA description removing the references to US specific rules. example

An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received. An Immunization Activity is very similar to a Medication Activity with some key differentiators. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record.


ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.30.10.60
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 11 templates
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.17Containmentdraft Medication Supply Order (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.18Containmentdraft Medication Dispense (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.19Containmentdraft Indication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instruction (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.24Containmentdraft Drug Vehicle (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.25Containmentdraft Precondition for Substance Administration (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.53Containmentdraft Immunization Refusal Reason (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.54Containmentdraft Immunization Medication Information (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.118Containmentdraft Substance Administered Act (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
RelationshipAdaptation: template 2.16.840.1.113883.10.20.22.4.52 Immunization Activity (V3) (2015‑08‑01)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:substanceAdministration
ImmudotsCcda
@classCode
cs1 … 1FSBADM
 C-CDA = IPS 
@moodCode
cs1 … 1RC-CDA
SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC (CONF:1198-8827).

IPS
only EVN
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
@negationInd
bl1 … 1RC-CDA
SHALL contain exactly one [1..1] @negationInd (CONF:1198-8985).

IPS
Not explicitly specified
hl7:templateId
II1 … 1MImmudotsCcda
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.30.10.60
cda:id
II1 … *RC-CDA
SHALL contain at least one [1..*] id (CONF:1198-8829).

IPS
optional
ImmudotsCcda
hl7:code
CV1 … 1MImmudotsCcda
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19709 ActSubstanceAdministrationImmunizationCode (DYNAMIC)
cda:statusCode
CS1 … 1RC-CDA
SHALL contain exactly one [1..1] statusCode (CONF:1198-8833).

IPS
fixed to "complete" (under revision also for the IPS)
ImmudotsCcda
cda:effectiveTime
1 … 1RC-CDA
SHALL contain exactly one [1..1] effectiveTime (CONF:1198-8834).

IPS 
only TS
ImmudotsCcda
cda:repeatNumber
0 … 1C-CDA
MAY contain zero or one [0..1] repeatNumber (CONF:1198-8838).

In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series.

IPS
Not explicitly specified

ImmudotsCcda
cda:routeCode
0 … 1C-CDA
MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1198-8839).

IPS
Not explicitly specified


To Do
example or preferred binding to be specified
ImmudotsCcda
cda:approachSiteCode
CD0 … 1C-CDA
MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1198-8840).

IPS
Not explicitly specified

To Do
example or preferred binding to be specified
ImmudotsCcda
cda:doseQuantity
0 … 1RC-CDA
SHOULD contain zero or one [0..1] doseQuantity (CONF:1198-8841).

IPS
Not explicitly specified
ImmudotsCcda
@unit
cs0 … 1 C-CDA
The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1198-8842).

IPS
Not explicitly specified
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
cda:administrationUnitCode
CE0 … 1C-CDA
MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1198-8846).

IPS
Not explicitly specified

To Do
example or preferred binding to be specified
ImmudotsCcda
cda:consumable
1 … 1MC-CDA
contains: 2.16.840.1.113883.10.20.22.4.54 Immunization Medication Information (V2) (2014-06-09T00:00:00)

IPS

Contains 2.16.840.1.113883.10.22.4.16 IPS Immunization Medication Information (DYNAMIC)

Contains 2.16.840.1.113883.10.20.22.4.54 Immunization Medication Information (V2) (2014‑06‑09)
ImmudotsCcda
cda:performer
0 … 1RC-CDA
SHOULD contain zero or one [0..1] performer (CONF:1198-8849).

IPS
Not explicitly specified
ImmudotsCcda
cda:author
0 … *RC-CDA
SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31151).

IPS
SHOULD contain zero or more [0..*] 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)

Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
ImmudotsCcda
cda:participant
0 … *C-CDA
It represents the vehicle (e.g., saline, dextrose) for administering a medication.

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2015‑08‑13)
ImmudotsCcda
@typeCode
cs1 … 1FCSM
 C-CDA
SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8851).

IPS
Not explicitly specified
cda:entryRelationship
0 … *C-CDA
It represents the rationale for an action such as an encounter, a medication administration, or a procedure.

IPS
Not explicitly specified 
Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09)
ImmudotsCcda
@typeCode
cs1 … 1FRSON
 C-CDA
SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8854).

IPS
Not explicitly specified

cda:entryRelationship
0 … 1C-CDA
The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. 

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)
ImmudotsCcda
@typeCode
cs1 … 1FSUBJCONFdots8857
 SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8857).
@inversionInd
bl1 … 1FtrueCONFdots8858
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-8858).
cda:entryRelationship
0 … 1C-CDA
It records the intent to supply a patient with medications

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (V2) (2014‑06‑09)
ImmudotsCcda
@typeCode
cs1 … 1FREFR
 SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8861).
cda:entryRelationship
0 … 1C-CDA
It records the act of supplying medications (i.e., dispensing).

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (V2) (2014‑06‑09)
ImmudotsCcda
@typeCode
cs1 … 1FREFR
 SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8864).
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)ImmudotsCcda
@typeCode
cs1 … 1FCAUS
 SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8867).
cda:entryRelationship
0 … 1C-CDA
It documents the rationale for the patient declining an immunization.

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.53 Immunization Refusal Reason (2015‑08‑13)
ImmudotsCcda
@typeCode
cs1 … 1FRSON
 SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8989).
cda:entryRelationship
0 … *RC-CDA
The following entryRelationship is used to indicate a given immunization's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.118 Substance Administered Act (2015‑08‑13)
ImmudotsCcda
@typeCode
cs1 … 1FCOMP
 SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31511).
@inversionInd
bl1 … 1Ftrue
 SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1198-31512).
cda:sequenceNumber
0 … 1C-CDA
MAY contain zero or one [0..1] sequenceNumber (CONF:1198-31513).

IPS
Not explicitly specified
ImmudotsCcda
cda:precondition
0 … *C-CDA
The following entryRelationship is used to indicate a criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.

IPS
Not explicitly specified

Contains 2.16.840.1.113883.10.20.22.4.25 Precondition for Substance Administration (V2) (2014‑06‑09)
ImmudotsCcda
@typeCode
cs1 … 1FPRCN
 SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8870).