1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1
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Immunization Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1
The Immunization Summary Content Module draws from two HL7 Version 3 message standards - Immunizations and Care Provision - and from one HL7 Version 2 standard.
Immunizations contains a message information model which handles detailed immunization information only. It includes history of administered vaccines with such details as lot number, who administered the shot, and so forth. The Immunization Summary Option of IC is based upon the PCC-2 Immunization Summary template, with additions to harmonize it with the HL7 Version 3 Immunizations standard (POIZ).
Care Provision contains a message information model (Care Record) which handles immunizations as well as other information related to the patient's care. For example, it includes medical history, medications, allergies, vital signs, and so forth. The PCC-2 Immunization Summary is contained within Care Record.
Standards
| CareRecord | HL7 Care Provision Care Record (DSTU) |
| PIOZ | HL7 Version 3 Standard: Immunization, Release 1 DSTU Ballot 3 - May 2008 |
Data Element Index
| Data Element | Care Record | POIZ | PCC Template |
|---|---|---|---|
| History of Immunizations | |||
| Immunization Record ID | id | id | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Negation Indicator | negationInd | negationInd | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Description | text | text | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Immunization Date | effectiveTime | effectiveTime | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Dose Quantity | doseQuantity.value - units | doseQuantity.value - units | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Route | routeCode | routeCode | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Approach Site | approachSiteCode | approachSiteCode | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Vaccine Code | consumable. administerableMaterial. administerableMaterial. code | consumable. administerableMedication. administerableMedicine. code | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Vaccine Name | consumable. administerableMaterial. administerableMaterial. name | consumable. administerableMedication. administerableMedicine. name | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Vaccine Lot # | consumable. administerableMaterial. administerableMaterial. lotNumberText | consumable. administerableMedication. administerableMedicine. lotNumberText | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Vaccine Expiration Date | consumable. administerableMaterial. administerableMaterial. expirationTime | consumable. administerableMedication. administerableMedicine. expirationTime | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Manufacturer ID | consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. manufacturer.id | consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. manufacturer.id | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Manufacturer Name | consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. manufacturer. name | consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. manufacturer. name | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Vaccine Lot # Recalled Effective Date | consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. effectiveTime | consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. effectiveTime | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
| Vaccine Lot # Recalled Code | consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. code | consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. code | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
| Vaccine Lot # Recalled Noted Time | consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. value | consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. value | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
| Adverse Event Code | entryRelationship. observation. code | entryRelationship. observation. code | 1.3.6.1.4.1.19376.1.5.3.1.4.5 |
| Adverse Event Time | entryRelationship. observation. effectiveTime | entryRelationship. observation. effectiveTime | 1.3.6.1.4.1.19376.1.5.3.1.4.5 |
| Adverse Event Severity | entryRelationship. observation. entryRelationship. observation. code | entryRelationship. observation. entryRelationship. observation. code | 1.3.6.1.4.1.19376.1.5.3.1.4.1 |
| Performer Person ID | performer. assignedEntity. id | performer. assignedEntity. id | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Performer Person Name | performer. assignedEntity. assignedPerson. name | performer. assignedEntity. assignedPerson. name | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Performer Organization ID | performer. assignedPerson. representedOrganization. id | performer. assignedPerson. representedOrganization. id | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Performer Organization Name | performer. assignedPerson. representedOrganization. name | performer. assignedPerson. representedOrganization. name | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
| Author | author | author | no template -- see below |
| Informant | informant | informant | no template -- see below |
| Vaccine Information Statement Given | observation. code | observation. code | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
| VIS Version | observation. value | observation. value | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
| Comments about Shot | annotation. text | annotation. text | 1.3.6.1.4.1.19376.1.5.3.1.4.2 |
Specification
| Data Element Name | Opt | Template ID |
|---|---|---|
| Immunization Entry The Care Record message shall contain a record of patient immunizations provided or not given with the reason that the immunization was not provided. |
R | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
Conformance
Care Record messages that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in <careProvisionEvent> element of the message. This is shown in the sample message below.
<careProvisionEvent>
<templateId root="Immunization Summary"/>
<recordTarget>
<patient>
<id extension="" root=""/>
<addr/>
<telecom use="" value=""/>
<statusCode code="active"/>
<patientPerson>
<name/>
<administrativeGenderCode code=""
codeSystem="2.16.840.1.113883.5.1"
codeSystemName="AdministrativeGender" displayName=""/>
<birthTime value=""/>
</patientPerson>
</patient>
</recordTarget>
<pertinentInformation3>
:
<!-- Required Immunization Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
:
</pertinentInformation3>
</careProvisionEvent>
|
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1'>
<rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1"]'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='../cda:careProvisionEvent'>
Error: The Immunization Summary can only be used on Care Provision Events.
</assert>}}
<assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.12"]'>
<!-- Verify that all required data elements are present -->
Error: The Immunization Summary must contain a(n) Immunization Entry Entry.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1
</assert>
</rule>
</pattern>
Sample Message for Immunization Summary
<controlActProcess moodCode="EVN">
<subject>
<registrationEvent>
<id root='903e67b1-3169-481e-b9e8-3fdfe84ceb8c'/>
<statusCode code="active"/>
<custodian>
<assignedEntity>
<id root="1.3.6.1.4.1.21367.2008.1.2.190"/>
<addr>
<streetAddressLine>987 Maple St.</streetAddressLine>
<streetAddressLine>Building 44-B</streetAddressLine>
<city>Sometown</city>
<state>CA</state>
<postalCode>12345</postalCode>
<country>USA</country>
</addr>
<telecom use="WP" value="123-456-7890"/>
<assignedOrganization>
<name>Connectathon</name>
</assignedOrganization>
</assignedEntity>
</custodian>
<subject2>
<careProvisionEvent>
<recordTarget>
<patient>
<id extension="NA5050" root="1.3.6.1.4.1.21367.2005.3.7"/>
<addr>
<state>CA</state>
<country>USA</country>
</addr>
<telecom use="HP" value=""/>
<statusCode code="normal"/>
<patientPerson>
<name use="L">
<given>ONE</given>
<family>QED</family>
</name>
<administrativeGenderCode code="F" displayName="Female" codeSystem='2.16.840.1.113883.5.1'
codeSystemName='AdministrativeGender'/>
<birthTime value="19300102"/>
</patientPerson>
</patient>
</recordTarget>
<substanceAdministration moodCode="EVN" negationInd="false" classCode="SBADM">
<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 extension="63" root="1.3.6.1.4.1.21367.2008.1.2.190.2"/>
<text>cvxCode</text>
<statusCode code="completed"/>
<effectiveTime value="20070911"/>
<routeCode nullFlavor="UNK"/>
<approachSiteCode nullFlavor="UNK"/>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<administerableMaterial classCode='ADMM' determinerCode='INSTANCE'>
<administerableMaterial classCode='MMAT' determinerCode='INSTANCE'>
<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" />
<lotNumberText>ABC12345M</lotNumberText>
<expirationTime value='20080305'/>
<asMedicineManufacturer classCode='MANU'>
<manufacturer classCode='ORG'>
<id root='2.16.840.1.113883.6.60' extension='SKB'/>
<name>Glaxo Smith Kline Beacham</name>
</manufacturer>
</asMedicineManufacturer>
</administerableMaterial>
</administerableMaterial>
<desc>influenza immunization has been administered</desc>
</consumable>
<entryRelationship inversionInd='false' typeCode='CAUS'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6.1'/>
<observation typeCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<id root= extension=/>
<statusCode code="completed"/>
<effectiveTime><low value="20070911"></low><high value="20070916"></high></effectiveTime>
<value type="CD" code="xxx" displayName="Edema with fever" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9CM"></value>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.55"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>
<text>moderately severe edema with moderate fever</text>
<statusCode code="completed"/>
<value type="CD" code="M" codeSystem="2.16.840.1.113883.5.1063" codeSystemName="ObservationValue"></value>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<performer typeCode='PRF'>
<assignedEntity typeCode="ASSIGNED">
<id root='1.2.3' extension="MUNB23"/>
<addr></addr>
<telecom use= value=/>
<assignedPerson>
<name><given>Bill</given><family>Munroe</family></name>
</assignedPerson>
<representedOrganization>
<name>ABC Healthcare</name>
</representedOrganization>
</assignedEntity>
</performer>
<author typeCode='AUT'>
<assignedEntity typeCode='ASSIGNED'>
<id root=' 1.2.3' extension=' SMIM01'/>
<assignedPerson classCode='PSN' determinerCode= root=>
<name><given>Mary</given><family>Smith</family></name>
</assignedPerson>
</assignedEntity>
</author>
<informant typeCode='INF'>