Id1.3.6.1.4.1.19376.1.5.3.1.4.12Effective Date2013‑12‑20
Statusdraft DraftVersion Label
NameEntryImmunizationsDisplay NameImmunizations
Description

An immunizations entry is used to record the patient's immunization history.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.12
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
epsos-dataelement-169draft Vaccination date draft epSOS Data Set
epsos-dataelement-171draft Vaccine description draft epSOS Data Set
Used by / Uses
Used by 7 transactions and 18 templates, Uses 4 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.9Transactiondraft IHE Emergency Department Referral2017‑03‑30 09:26:33
1.3.6.1.4.1.19376.1.5.3.1.4.12Transactiondraft IHE PHR Extract2017‑03‑30 09:29:02
1.3.6.1.4.1.19376.1.5.3.1.4.11Transactiondraft IHE Immunization Content2017‑03‑30 09:28:26
2.16.840.1.113883.3.1937.777.11.4.12Transactiondraft Return PS of country A2012‑05‑02
2.16.840.1.113883.3.1937.777.11.4.23Transactiondraft Return MRO2013‑11‑02
2.16.840.1.113883.3.1937.777.11.4.21Transactiondraft Send HCER to country A2013‑11‑02
1.3.6.1.4.1.19376.1.5.3.1.4.4Transactiondraft IHE Referral Summary2016‑09‑29 13:42:51
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkdraft epSOS-Patient Summary2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkretired epSOS-Patient Summary2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkretired eHDSI Patient Summary2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.4linkdraft epSOS-Health Care Encounter Report2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4linkretired epSOS-Health Care Encounter Report2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.1.5linkdraft epSOS-Medication Related Overview2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5linkretired epSOS-Medication Related Overview2018‑11‑14 09:03:13
1.3.6.1.4.1.19376.1.5.3.1.1.3linkactive IHE Referral Summary Document (2014)2016‑09‑29 13:41:44
1.3.6.1.4.1.19376.1.5.3.1.1.5linkactive IHE PHR Extract Specification (2016)2017‑03‑20 14:10:24
1.3.6.1.4.1.19376.1.5.3.1.1.9.40Containmentactive IHE Procedure Care Plan Section (2016)2017‑03‑24 10:20:07
1.3.6.1.4.1.19376.1.5.3.1.1.10linkactive IHE Emergency Department Referral Specification (2016)2017‑03‑20 10:34:16
1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2linkactive IHE Immunization Content Specification (2016)2017‑03‑20 09:59:31
1.3.6.1.4.1.19376.1.5.3.1.3.23Containmentdraft Section Immunizations2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23Containmentretired eHDSI Immunizations2020‑04‑16 12:18:30
1.3.6.1.4.1.19376.1.5.3.1.3.36Containmentactive IHE Coded Care Plan Section (2016)2017‑03‑24 10:39:19
1.3.6.1.4.1.19376.1.9.1.1.1linkdraft Pharmacy Prescription Document (PRE2016)2016‑01‑07 22:13:03
1.3.6.1.4.1.19376.1.9.1.1.4linkdraft Community Medication Administration Document Content Module (rev. 1.1)2018‑03‑02 14:08:00
1.3.6.1.4.1.19376.1.9.1.1.6linkdraft IHE Community Medication Treatment Plan Document Content Module (Rev. 1.3)2017‑04‑03 07:57:37
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.2Containmentdraft CommentDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5Containmentdraft ProblemDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.7.2Containmentdraft Immunization ProductDYNAMIC
2.16.840.1.113883.10.20.1.46Containmentdraft Position Of VaccinationDYNAMIC
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>
ItemDTCardConfDescriptionLabel
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.

Entrdotsions
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1FEVN
@negationInd
bl1 … 1R
hl7:templateId
II1 … 1MEntrdotsions
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.12
hl7:templateId
II1 … 1MEntrdotsions
@root
uid1 … 1F2.16.840.1.113883.10.20.1.24
hl7:id
II.EPSOS1 … 1MEntrdotsions
hl7:code
CD.EPSOS1 … 1M

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.

Entrdotsions
@code
CONF1 … 1FIMMUNIZ
@codeSystem
1 … 1F1.3.5.1.4.1.19376.1.5.3.2
hl7:text
ED1 … 1R

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.

Entrdotsions
 
target
epsos-dataelement-171draft Vaccine description draft epSOS Data Set
hl7:reference
TEL1 … 1MEntrdotsions
@value
1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1R

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

Entrdotsions
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
1 … 1R

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.

Entrdotsions
 
target
epsos-dataelement-169draft Vaccination date draft epSOS Data Set
hl7:routeCode
CE0 … 1R

See routeCode under the Medication Item Entry Content module.

Entrdotsions
hl7:doseQuantity
IVL_PQ0 … 1R

See doseQuantity under the Medication Item Entry Content module.

Entrdotsions
hl7:consumable
1 … 1R

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)		Entrdotsions
@typeCode
cs1 … 1FCSM
hl7:entryRelationship
0 … 1R

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)		Entrdotsions
 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)		Entrdotsions
 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"/>    <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)		Entrdotsions