Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2"
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m (New page: {{Care Record|Immunization Detail|1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2|Comment| Standards= {{Std|CareRecord}} {{Std|PIOZ|HL7 Version 3 Standard: Immunization, Release 1 DSTU Ballot 3 - May 2...) |
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− | ====Sample Message for Immuniziation Detail ==== | + | =====Sample Message for Immuniziation Detail ===== |
− | <controlActProcess moodCode="EVN"> | + | <controlActProcess moodCode="EVN"> |
<subject> | <subject> | ||
<registrationEvent> | <registrationEvent> | ||
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</registrationEvent> | </registrationEvent> | ||
</subject> | </subject> | ||
− | </controlActProcess> | + | </controlActProcess> |
Revision as of 13:42, 2 June 2008
Immunization Detail Specification 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2
The Immunization Detail Content Module extends the Immunization Summary to contain additional data elements needed to provide immunization decision support.
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 | PCC Template ID |
---|---|
History of Immunizations | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
Authors and Informants | Authors and Informants |
Problem Entry | 1.3.6.1.4.1.19376.1.5.3.1.4.5 |
Allergies and Intolerances | 1.3.6.1.4.1.19376.1.5.3.1.4.6 |
Medications | 1.3.6.1.4.1.19376.1.5.3.1.4.7 |
Lab Results | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
Vital Signs | 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 |
Pregnancy Observation | 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 |
Advance Directive Observation | 1.3.6.1.4.1.19376.1.5.3.1.4.13.7 |
Comments | 1.3.6.1.4.1.19376.1.5.3.1.4.2 |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
History of Immunizations | R | 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
Problem Entry | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.5 |
Allergies and Intolerances | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.6 |
Medications | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.7 |
Lab Results | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.13 |
Vital Signs | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 |
Pregnancy Observation | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 |
Advance Directive Observation | R2 | 1.3.6.1.4.1.19376.1.5.3.1.4.13.7 |
Comments | O | 1.3.6.1.4.1.19376.1.5.3.1.4.2 |
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. A Care Record message may conform to more than one template. This content module inherits from the Immunization Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.
<careProvisionEvent> <templateId root="Immunization Detail"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1"/><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 History of Immunizations element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Problem Entry element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Allergies and Intolerances element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Medications element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Lab Results element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Vital Signs element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Pregnancy Observation element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Required if known Advance Directive Observation element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/> : </pertinentInformation3> <pertinentInformation3> : <!-- Optional Comments element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/> : </pertinentInformation3> </careProvisionEvent> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:careProvisionEvent'> Error: The Immunization Detail can only be used on Care Provision Events. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1"]'> Error: The parent template identifier for Immunization Detail is not present. </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 Detail must contain a(n) History of Immunizations Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Problem Entry Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.6"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Allergies and Intolerances Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Medications Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Lab Results Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13.1"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Vital Signs Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13.5"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Pregnancy Observation Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13.7"]'> <!-- Alert on any missing required if known elements --> Warning: The Immunization Detail should contain a(n) Advance Directive Observation Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.2"]'> <!-- Note any missing optional elements --> Note: This Immunization Detail does not contain a(n) Comments Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 </assert> </rule> </pattern>
Sample Message for Immuniziation Detail
<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"/>
<patientPerson>
<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'>
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