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Template Immunization Recommendation Entry 2016‑11‑12

Id2.16.756.5.30.1.1.10.4.93
ref
ch-pcc-
Effective Date2016‑11‑12
Statusactive ActiveVersion Label2016
Namechpcc_entry_ImmunizationRecommendationDisplay NameImmunization Recommendation Entry
Description
An immunization recommendation entry is used to record the patient's immunization plan. An immunization recommendation is a substance administration proposal or a documentation of an intended, but not yet administered immunization. An immunization recommendation entry may also be a record of a specific immunization that shouldn't performed. In this case, negationInd shall be set to "true", otherwise, it shall be "false".
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.4.93
LabelIHE PCC TF2 Rev.11, 6.3.4.49
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 7 templates
Used by as NameVersion
2.16.756.5.30.1.1.10.3.48Containmentactive Immunization Recommendations 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
2.16.756.5.30.1.1.10.4.119Containmentactive Immunization Series Number (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 1.3.6.1.4.1.19376.1.5.3.1.4.12.2 IHE Immunization Recommendation (DYNAMIC)
ref
IHE-PCC-

Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
General structure
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity nullFlavor="UNK"/>  <consumable typeCode="CSM">
    <!-- template 2.16.756.5.30.1.1.10.4.94 'Manufactured Product' -->
  </consumable>  <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>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Example
REVAXIS, Dosis zu 0.5 ml
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity>
    <low value="0.3" unit="ml"/>    <high value="0.4" unit="ml"/>  </doseQuantity>  <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="7680006460010"/>      <manufacturedMaterial>
        <code code="J07CA01" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC Code" displayName="diphtheria-poliomyelitis-tetanus"/>        <name>REVAXIS Inj Susp m Nadeln</name>        <lotNumberText>G7237</lotNumberText>      </manufacturedMaterial>      <manufacturerOrganization>
        <name>Sanofi-Aventis (Suisse) SA</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.54 'Author Compilation with id, name, addr and telecom' -->
  </author>  <entryRelationship typeCode="RSON">
    <!-- template 2.16.756.5.30.1.1.10.4.95 'Target Of The Immunization - Medication Target' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.2"/>      <templateId root="2.16.840.1.113883.10.20.1.40"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        Dosierung: abhängig vom Alter und den Risiken (siehe Factsheet Schweizerischer Impfplan)        <reference value="#narrtextref1"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Example
HAVRIX Erwachsene 1440 U/1 ml, Dosis 0.5 ml
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity value="0.5" unit="ml"/>  <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="7680005580054"/>      <manufacturedMaterial>
        <code code="J07BC02" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC Code" displayName="hepatitis A, inactivated, whole virus"/>        <name>HAVRIX 1440 Inj Susp</name>        <lotNumberText>X2124</lotNumberText>      </manufacturedMaterial>      <manufacturerOrganization>
        <name>GlaxoSmithKline AG</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.54 'Author Compilation with id, name, addr and telecom' -->
  </author>  <entryRelationship typeCode="RSON">
    <!-- template 2.16.756.5.30.1.1.10.4.95 'Target Of The Immunization - Medication Target' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.2"/>      <templateId root="2.16.840.1.113883.10.20.1.40"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        Dosierung: eine Dosis zur Primovakzination; Auffrischimpfung innert 6 bis 12 Monaten nach der Primovakzination        <reference value="#narrtextref2"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
An immunization recommendation entry is used to record the patient's immunization plan. An immunization recommendation is a substance administration proposal or a documentation of an intended, but not yet administered immunization. An immunization recommendation entry may also be a record of a specific immunization that shouldn't performed. In this case, negationInd shall be set to "true", otherwise, it shall be "false".IHE PCC TF2 Rev.11, 6.3.4.49
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1R
  • INT: Intended but not yet administered immunization
  • PRP: recommended immunization (proposal)
 CONF
@moodCode shall be "INT"
or
@moodCode shall be "PRP"
@negationInd
bl1 … 1R
  • false: For intended or proposed immunizations.
  • true: For immunizations that shouldn't be administered
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.49
@root
uid1 … 1F2.16.756.5.30.1.1.10.4.93
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.49
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.12.2
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.49
@root
uid1 … 1F2.16.840.1.113883.10.20.1.25
hl7:id
II1 … 1RImmunization recommendation ID, assigned by the software application.IHE PCC TF2 Rev.11, 6.3.4.49
@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 MUST contain 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, 6.3.4.49
@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, 6.3.4.49
@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 'active' for all immunization recommendations.

IHE PCC TF2 Rev.11, 6.3.4.49
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20023 ActStatusActive (DYNAMIC)
hl7:effectiveTime
IVL_TS.CH.TZ0 … 1CPeriod in which the immunization administration is recommended.IHE PCC TF2 Rev.11, 6.3.4.49
@xsi:type
1 … 1FIVL_TS
hl7:low
TS.CH.TZIHE PCC TF2 Rev.11, 6.3.4.49
hl7:high
TS.CH.TZIHE PCC TF2 Rev.11, 6.3.4.49
hl7:priorityCode
CE1 … 1R

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

Recommendation for eVACDOC: @nullFlavor='UNK'

IHE PCC TF2 Rev.11, 6.3.4.49
 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 relevant for the recommendation, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='NA'

IHE PCC TF2 Rev.11, 6.3.4.49
 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 relevant for the recommendation, it MAY be recorded according to the HL7 value set.

Recommendation for eVACDOC: omit

IHE PCC TF2 Rev.11, 6.3.4.49
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.1052
hl7:doseQuantity
IVL_PQ0 … 1

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

Recommendation for eVACDOC: omit

IHE PCC TF2 Rev.11, 6.3.4.49
hl7:consumable
1 … 1RVaccine
Contains 2.16.756.5.30.1.1.10.4.94 Manufactured Product (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.49
@typeCode
cs1 … 1FCSM
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, 6.3.4.49
 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, 6.3.4.49
@typeCode
cs1 … 1FSUBJ
hl7:entryRelationship
0 … *Target of the recommended 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, 6.3.4.49
@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, 6.3.4.49
@typeCode
cs1 … 1FSUBJ
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, 6.3.4.49