Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2"

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{{Care Record|Immunization Detail|1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2|Comment|
 
{{Care Record|Immunization Detail|1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2|Comment|
 
Standards=
 
Standards=
−
{{Std|CareRecord}}
+
{{Std|CDAR2}}
−
{{Std|PIOZ|HL7 Version 3 Standard: Immunization, Release 1 DSTU Ballot 3 - May 2008|http://www.hl7.org/v3ballot/html/domains/uviz/uviz.htm}}
+
{{Std|CCD}}
 +
{{Std|POIZ}}
 +
|LOINC=|LOINCName=
 
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1|ParentName=Immunization Summary
 
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.18.1.1|ParentName=Immunization Summary
−
|The Immunization Detail Content Module extends the Immunization Summary to contain additional data elements needed to provide immunization decision support.
+
|The Immunization Detail Document Content Module is designed to document the record of a patient's immunizations.  Furthermore, it can include information relevant to a clinical decision support system that would generate an immunization forecast.  Within this document content module, the material necessary to generate an immunization record is required.  This record can be used to electronically exchange the immunization record of a patient.  Material needed for generating a vaccination forecast is required if known, as some of this information may not be provided to the generating application. 
 +
 
 +
A content creator actor that implements this content profile shall be able to demonstrate that it can create a document that is sufficient for use in immunization forecasting.  However, not all uses of this document content profile will be used for that purpose.  There are cases where the data produced is limited to a smaller set due to security and privacy considerations.  If for example, the purpose the document is for use as immunization record necessary to for enrollment in a school, the content creator actor needs to be able to conform to local law, regulation, and policy regarding the information that is permitted to be exchanged.
 
|Index=
 
|Index=
−
{{T|Data Element|PCC Template ID|Title=Immunization Detail Data Elements|Rows=
+
{{T|Data Element|Description|Title=Immunization Detail Data Elements|Rows=
−
{{R|History of Immunizations|1.3.6.1.4.1.19376.1.5.3.1.4.12}}
+
{{R|History of Immunizations|The information contained in this data element shall be able to record a list of immunizations for a patient. This list includes, for each immunization given, the date that it was given, the name of the immunization, a coded value for the immunization, the lot number of the vaccine, the manufacturer of the vaccine, the provider giving the immunization, any reactions or adverse events caused by the immunization, and the severity of those reactions, and if refused, the reason for the refusal.}}
−
{{R|Authors and Informants|Authors and Informants}}
+
{{R|Authors and Informants|The source of the information must be able to be recorded, including information obtained from a patient, parent or guardian, another provider, immunization registry, et cetera.  Within the IHE PCC technical framework, all coded entries may include the author or informant that provided the information being recorded.}}
−
{{R|Problem Entry|1.3.6.1.4.1.19376.1.5.3.1.4.5}}
+
{{R|History of Past Illness|The history of past illnesses is where clinical diagnoses relevant to vaccine forecasting may be provided. This can include a list of any previous illnesses which might convey immunity or otherwise influence the immunization forecast.}}
−
{{R|Allergies and Intolerances|1.3.6.1.4.1.19376.1.5.3.1.4.6}}
+
{{R|Problem List|The problem list must be able to include problems that are relevant to immunization forecast, including current illnesses, conditions, or risks (e.g., immunosuppression), that might be contraindications for providing an immunization.}}
−
{{R|Medications|1.3.6.1.4.1.19376.1.5.3.1.4.7}}
+
{{R|Allergies and Intolerances|This information includes a list of allergies or intolerances to substances commonly used in vaccinations, e.g. egg albumin, et cetera, as well as allergies or intolerances to other medications or immunizations}}
−
{{R|Lab Results|1.3.6.1.4.1.19376.1.5.3.1.4.13}}
+
{{R|Medications|The list of medications should include the list of relevant medications for the patient.}}
−
{{R|Vital Signs|1.3.6.1.4.1.19376.1.5.3.1.4.13.1}}
+
{{R|Lab Results|The laboratory results section can include information about antibody tests or titers that show that immunization has or has not been already conferred to a patient. This section may also include information about the results of point of care tests, such as a TB test.}}
−
{{R|Pregnancy Observation|1.3.6.1.4.1.19376.1.5.3.1.4.13.5}}
+
{{R|Vital Signs|Vital signs such as height and weight should be able to be reported to enable dosing calculations to be performed. Other vital signs such as tempurature may be included to enable a clinical decision support to identify potential situations such as fever that may be a contraindication for immunization.}}
−
{{R|Advance Directive Observation|1.3.6.1.4.1.19376.1.5.3.1.4.13.7}}
+
{{R|Pregnancy Observation|The pregnancy history section would include information relevant to the current pregnancy status for the patient, as this can also influence the type of vaccinations that may be proposed.}}
−
{{R|Comments|1.3.6.1.4.1.19376.1.5.3.1.4.2}}
+
{{R|Advance Directive Observation|Advance directives relevant to the provision of immunizations should be able to be included in the content when those directives would influence the immunizations proposed.}}
 +
{{R|Comments|Additional text comments should be supported in the content to enable providers to comment }}
 
}}
 
}}
−
|Entry|History of Immunizations|R|1.3.6.1.4.1.19376.1.5.3.1.4.12|
+
|Section|History of Immunizations|R|1.3.6.1.4.1.19376.1.5.3.1.3.23|
−
|Entry|Problem Entry|R2|1.3.6.1.4.1.19376.1.5.3.1.4.5|
+
|Section|Problem Entry|R2|1.3.6.1.4.1.19376.1.5.3.1.4.5|
−
|Entry|Allergies and Intolerances|R2|1.3.6.1.4.1.19376.1.5.3.1.4.6|
+
|Section|Allergies and Intolerances|R2|1.3.6.1.4.1.19376.1.5.3.1.4.6|
−
|Entry|Medications|R2|1.3.6.1.4.1.19376.1.5.3.1.4.7|
+
|Section|Medications|R2|1.3.6.1.4.1.19376.1.5.3.1.4.7|
−
|Entry|Lab Results|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13|
+
|Section|Lab Results|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13|
−
|Entry|Vital Signs|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.1|
+
|Section|Vital Signs|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.1|
−
|Entry|Pregnancy Observation|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.5|
+
|Section|Pregnancy Observation|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.5|
−
|Entry|Advance Directive Observation|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.7|
+
|Section|Advance Directive Observation|R2|1.3.6.1.4.1.19376.1.5.3.1.4.13.7|
−
|Entry|Comments|O|1.3.6.1.4.1.19376.1.5.3.1.4.2|
+
|Section|Comments|O|1.3.6.1.4.1.19376.1.5.3.1.4.2|
 
}}
 
}}
  

Revision as of 16:52, 24 July 2008

Comment.gif Immunization Detail Specification 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2

The Immunization Detail Document Content Module is designed to document the record of a patient's immunizations. Furthermore, it can include information relevant to a clinical decision support system that would generate an immunization forecast. Within this document content module, the material necessary to generate an immunization record is required. This record can be used to electronically exchange the immunization record of a patient. Material needed for generating a vaccination forecast is required if known, as some of this information may not be provided to the generating application.

A content creator actor that implements this content profile shall be able to demonstrate that it can create a document that is sufficient for use in immunization forecasting. However, not all uses of this document content profile will be used for that purpose. There are cases where the data produced is limited to a smaller set due to security and privacy considerations. If for example, the purpose the document is for use as immunization record necessary to for enrollment in a school, the content creator actor needs to be able to conform to local law, regulation, and policy regarding the information that is permitted to be exchanged.


Standards
CDAR2 HL7 CDA Release 2.0
CCD ASTM/HL7 Continuity of Care Document
POIZ [ ]
Data Element Index
Data Element Description
History of Immunizations The information contained in this data element shall be able to record a list of immunizations for a patient. This list includes, for each immunization given, the date that it was given, the name of the immunization, a coded value for the immunization, the lot number of the vaccine, the manufacturer of the vaccine, the provider giving the immunization, any reactions or adverse events caused by the immunization, and the severity of those reactions, and if refused, the reason for the refusal.
Authors and Informants The source of the information must be able to be recorded, including information obtained from a patient, parent or guardian, another provider, immunization registry, et cetera. Within the IHE PCC technical framework, all coded entries may include the author or informant that provided the information being recorded.
History of Past Illness The history of past illnesses is where clinical diagnoses relevant to vaccine forecasting may be provided. This can include a list of any previous illnesses which might convey immunity or otherwise influence the immunization forecast.
Problem List The problem list must be able to include problems that are relevant to immunization forecast, including current illnesses, conditions, or risks (e.g., immunosuppression), that might be contraindications for providing an immunization.
Allergies and Intolerances This information includes a list of allergies or intolerances to substances commonly used in vaccinations, e.g. egg albumin, et cetera, as well as allergies or intolerances to other medications or immunizations
Medications The list of medications should include the list of relevant medications for the patient.
Lab Results The laboratory results section can include information about antibody tests or titers that show that immunization has or has not been already conferred to a patient. This section may also include information about the results of point of care tests, such as a TB test.
Vital Signs Vital signs such as height and weight should be able to be reported to enable dosing calculations to be performed. Other vital signs such as tempurature may be included to enable a clinical decision support to identify potential situations such as fever that may be a contraindication for immunization.
Pregnancy Observation The pregnancy history section would include information relevant to the current pregnancy status for the patient, as this can also influence the type of vaccinations that may be proposed.
Advance Directive Observation Advance directives relevant to the provision of immunizations should be able to be included in the content when those directives would influence the immunizations proposed.
Comments Additional text comments should be supported in the content to enable providers to comment
Specification
Data Element Name Opt Template ID
History of Immunizations R 1.3.6.1.4.1.19376.1.5.3.1.3.23
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.

Sample Immunization Detail Document 
 <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>
    
 </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Immunization Detail  must contain a(n) History of Immunizations Section.
     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 Section.
     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 Section.
     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 Section.
     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 Section.
     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 Section.
     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 Section.
     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 Section.
     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 Section.
     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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