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Template Immunization Entry 2016‑11‑12

Id2.16.756.5.30.1.1.10.4.89
ref
ch-pcc-
Effective Date2016‑11‑12
Statusactive ActiveVersion Label2016
Namechpcc_entry_ImmunizationDisplay NameImmunization Entry
Description
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".
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.4.89
LabelIHE PCC TF2 Rev.11, 6.3.4.17
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 9 templates
Used by as NameVersion
2.16.756.5.30.1.1.10.3.47Containmentactive Immunizations Section - coded (2016)2016‑11‑12
Uses as NameVersion
2.16.756.5.30.1.1.10.4.2Containmentactive Annotation Comments (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.94Containmentactive Manufactured Product (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.95Containmentactive Target Of The Immunization - Medication Target (2018)DYNAMIC
2.16.756.5.30.1.1.10.4.96Containmentactive Recommendation Category - Criterion (2018)DYNAMIC
2.16.756.5.30.1.1.10.4.101Containmentactive Immunization Performer - performer Containment (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.119Containmentactive Immunization Series Number (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.120Containmentactive Reaction Observation (2016)DYNAMIC
2.16.756.5.30.1.1.10.9.14Includedraft Narrative Text Reference (2021)DYNAMIC
2.16.756.5.30.1.1.10.9.54Containmentactive Author Compilation with id, name, addr and telecom (2020)DYNAMIC
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.12 Immunizations (DYNAMIC)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
Example
General structure
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.89"/>  <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"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#im-1"/>  </text>  <statusCode code="completed"/>  <effectiveTime value="20180410145514+02:00"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <approachSiteCode code="your code" codeSystem="2.16.840.1.113883.5.1052"/>  <doseQuantity nullFlavor="UNK"/>  <consumable typeCode="CSM">
    <!-- template 2.16.756.5.30.1.1.10.4.94 'Manufactured Product' -->
  </consumable>  <performer>
    <!-- template 2.16.756.5.30.1.1.10.4.101 'Immunization Performer - performer Containment' -->
  </performer>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.54 'Author Compilation with id, name, addr and telecom' -->
  </author>  <entryRelationship typeCode="SUBJ">
    <!-- template 2.16.756.5.30.1.1.10.4.119 'Immunization Series Number' -->
  </entryRelationship>  <entryRelationship typeCode="RSON">
    <!-- template 2.16.756.5.30.1.1.10.4.95 'Target Of The Immunization - Medication Target' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ">
    <!-- template 2.16.756.5.30.1.1.10.4.2 'Annotation Comments' -->
  </entryRelationship>  <entryRelationship typeCode="CAUS">
    <!-- template 2.16.756.5.30.1.1.10.4.120 'Reaction Observation' -->
  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Example
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>
    <assignedAuthor>
      <id root="2.51.1.3" extension="7608888888888"/>      <addr use="WP">
        <streetName>Doktorgasse</streetName>        <houseNumber>2</houseNumber>        <city>Musterhausen</city>        <postalCode>8888</postalCode>        <country>CH</country>      </addr>      <telecom value="tel:+41.32.234.55.66" use="WP"/>      <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>
ItemDTCardConfDescriptionLabel
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
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1FEVN
@negationInd
bl1 … 1R

For administered immunizations: negationInd='false'

For undesired immunizations: negationInd='true'

hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.17
@root
uid1 … 1F2.16.756.5.30.1.1.10.4.89
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.17
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.12
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.17
@root
uid1 … 1F2.16.840.1.113883.10.20.1.24
hl7:id
II1 … 1RImmunization event ID, assigned by the software application.IHE PCC TF2 Rev.11, 6.3.4.17
@root
uid1 … 1RMUST 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
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Choice1 … 1Elements to choose from:
  • hl7:code
  • hl7:code
hl7:code
CD0 … 1IHE PCC TF2 Rev.11, 6.3.4.17
@code
cs1 … 1FIMMUNIZ
@codeSystem
oid1 … 1F2.16.840.1.113883.5.4
@codeSystemName
st1 … 1FActCode
@displayName
st0NPNP/not present
hl7:code
CD0 … 1IHE PCC TF2 Rev.11, 6.3.4.17
@code
cs1 … 1R
@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
@codeSystemName
st1 … 1FSNOMED CT
@displayName
st1 … 1R
 CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.69 Special Case Medication (DYNAMIC)
Included1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
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
ED1 … 1MCDA‑CH V2
hl7:reference
TEL1 … 1MThe 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 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
hl7:statusCode
CS1 … 1M

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

IHE PCC TF2 Rev.11, 6.3.4.17
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
TS.CH.TZ1 … 1RDate of the immunization.IHE PCC TF2 Rev.11, 6.3.4.17
hl7:priorityCode
CE1 … 1R

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
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
hl7:routeCode
CE1 … 1R

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
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.79 RouteOfAdministration (Immunization) (DYNAMIC)
hl7:approachSiteCode
CD0 … *

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
CONF0 … 1F2.16.840.1.113883.5.1052
hl7:doseQuantity
IVL_PQ0 … 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 … 1RVaccine
Contains 2.16.756.5.30.1.1.10.4.94 Manufactured Product (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
@typeCode
cs1 … 1FCSM
hl7:performer
0 … *This MAY be used to indicate who has administered the immunization.
Contains 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 … *CThe author of the statement SHALL be specified either here or in one of the ancestors.
Contains 2.16.756.5.30.1.1.10.9.54 Author Compilation with id, name, addr and telecom (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
 Schematron assertrolered error 
 test(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::*/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement SHALL be specified either here or in one of the ancestors. It shall contain the time, id, name, addr and telecom elements as specified in IHE PCC TF Vol. 2, section 6.3.4.1 Authors and Informants. 
 Schematron assertroleyellow info 
 test(not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement is specified by the ancestor section. 
 Schematron assertroleyellow info 
 test(not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:ClinicalDocument/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement is specified by the author in the document header. 
hl7:entryRelationship
0 … *Immunization series number, if applicable.
Contains 2.16.756.5.30.1.1.10.4.119 Immunization Series Number (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
@typeCode
cs1 … 1FSUBJ
hl7:entryRelationship
0 … *Target of the immunization (the disease against which the immunization provides protection). Reference to Medication Target (Target of the immunization).
Contains 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
cs1 … 1FRSON
hl7:entryRelationship
0 … *Comments and remarks.
Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
@typeCode
cs1 … 1FSUBJ
hl7:entryRelationship
0 … *Adverse reactions caused by the immunization.
Contains 2.16.756.5.30.1.1.10.4.120 Reaction Observation (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
where [@typeCode='CAUS']
@typeCode
cs1 … 1FCAUS
hl7:precondition
0 … *Recommendation-Category according to the swiss vaccination plan.
Contains 2.16.756.5.30.1.1.10.4.96 Recommendation Category - Criterion (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.17
 Schematron assertrolered error 
 test(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:performer 
 MessageAfter 15.4.2020, the performer is required for each immunization. 
 Schematron assertrolered error 
 test(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or (string-length(hl7:effectiveTime/@value)>7) 
 MessageAfter 15.4.2020, the date with precision of day is required for each immunization. 
 Schematron assertrolered error 
 test(substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:consumable/hl7:manufacturedProduct/hl7:manufacturedMaterial/hl7:lotNumberText/text() 
 MessageAfter 15.4.2020, the lot number is required for each immunization.