1.3.6.1.4.1.19376.1.5.3.1.4.12

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Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12

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

Uses

See Templates using Immunizations

Specification

Immunizations 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='2.16.840.1.113883.5.4' codeSystemName='ActCode'/> <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'/> <approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/> <doseQuantity value='' units=''/> <consumable typeCode='CSM'> <manufacturedProduct classCode='MANU'> <manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'> <code code='' codeSystem='' codeSystemName=''> <originalText><reference value='#yyy'/></originalText> </code> </manufacturedLabeledDrug> </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 typeCode='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='true' typeCode='CAUS'> <observation typeCode='OBS' moodCode='EVN'> <id root='' extension=''/> </observation> </entryRelationship> <!-- Optional <entryRelationship> element containing comments --> </substanceAdministration>

<substanceAdministration typeCode='SBADM' moodCode='EVN' negationInd='true|false'>

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.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>

The <templateId> element identifies this <substanceAdministration> as an immunization, allowing for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.4.12'.

<id root=' ' extension=' '/>

This shall be the identifier for the immunization event.

<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>

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. Another coding system that may be used for codes for immunizations are the CPT-4 codes for immunization procedures. This <code> element shall not be used to record the type of vaccine used from a vocabulary of drug names.

Vaccination Codes

codeSystem	codeSystemName	Description
2.16.840.1.113883.5.4	IMMUNIZ	The IMMUNIZ term from the HL7 ActCode vocabulary.
2.16.840.1.113883.6.12	C4	Current Procedure Terminology 4 (CPT-4) codes.

<text><reference value='#xxx'/><text>

In a CDA document, 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. In an HL7 message, the content of the text element shall contain the complete text describing the immunization activity.

<statusCode code='completed'/>

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

<effectiveTime value=' '/>

The effectiveTime element shall be present and should contain a time value that indicates the date of the substance administration. If the date is unkown, 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.

<routeCode code=' ' codeSystem=' ' codeSystemName='RouteOfAdministration'/>

See routeCode under Medications.

<approachSiteCode code=' ' codeSystem=' ' codeSystemName='HumanSubstanceAdministrationSite'/>

See approachSiteCode under Medications.

<doseQuantity value=' ' units=' '/>

See doseQuantity under Medications.

<consumable typeCode='CSM'>

See consumable under Medications.

<code code=' ' codeSystem=' ' codeSystemName=' '>

The code used for an immunization may use code systems other than what might be used for other medications, such as the CDC maintained CVX codes. Code systems that describe vaccination procedure (such as CPT-4) shall not be used to describe the vaccine entry.

Example Vaccine Vocabularies

codeSystem	codeSystemName	Description
2.16.840.1.113883.6.59	CVX	CDC Vaccine Codes
2.16.840.1.113883.6.88	RxNorm	RxNorm
2.16.840.1.113883.6.63	FDDC	First DataBank Drug Codes
2.16.840.1.113883.6.96	SNOMED-CT	SNOMED Controlled Terminology

See also code under Medications.

<entryRelationship typeCode='REFR'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related Supply entry

<entryRelationship typeCode='SUBJ'>
 <observation classCode='OBS' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.46'/>

This optional entry relationship may be present to indicate that position of this immunization in a series of immunizations.

<code code='30973-2' displayName='Dose Number' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

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.

<statusCode code='completed'/>

The <statusCode> element shall be present, and must be recorded exactly as shown above. This element indicates that the observation has been completed.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and shall indicate the immunization series number in the value attribute.

<entryRelationship inversionInd='true' typeCode='CAUS'>

This repeatable element should be used to identify adverse reactions caused by the immunization.

<observation typeCode='OBS' moodCode='EVN'>

This element is required, and provides a pointer to the the adverse reaction caused by the immunization.

<id root=' ' extension=' '/>

This 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 this element was found.

<!-- Optional <entryRelationship> element containing comments -->

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 explaination for why the immunization did not take place . Other comments may also be present.