1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2

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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

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 of the document is for use as an immunization record necessary 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.

LOINC Code

The LOINC code for this document is 11369-6 HISTORY OF IMMUNIZATIONS

Standards

CDAR2	HL7 CDA Release 2.0
CCD	ASTM/HL7 Continuity of Care Document

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
Care Plan	The care plan, if present, should include the schedule for future immunizations

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 List	R2	1.3.6.1.4.1.19376.1.5.3.1.3.6
History of Past Illness	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
Allergies and Intolerances	R2	1.3.6.1.4.1.19376.1.5.3.1.3.13
Medications	R2	1.3.6.1.4.1.19376.1.5.3.1.3.19
Lab Results	R2	1.3.6.1.4.1.19376.1.5.3.1.4.13
Coded Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Pregnancy History When present, the pregnancy history section shall contain a Pregnancy Observation using the 11449-6 PREGNANCY STATUS code from LOINC to indicate whether the patient is pregnant.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Coded Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.35
Care Plan If present, this section shall contain	O	1.3.6.1.4.1.19376.1.5.3.1.3.31

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample Immunization Detail Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2'/>
  <id root=' ' extension=' '/>
  <code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Immunization Detail</title>
  <effectiveTime value='20240419012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required History of Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Problem List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required if known Allergies and Intolerances Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required if known Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
        <!-- Required if known Lab Results Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required if known Coded Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required if known Pregnancy History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/>
        <!-- Required if known Coded Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Optional Care Plan Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

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:ClinicalDocument'>
     Error: The Immunization Detail can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "11369-6"]'>
     Error: The document type code of a Immunization Detail must be 11369-6
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </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 Document 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document should contain a(n) Problem List 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document should contain a(n) History of Past Illness 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document 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 Document 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document should contain a(n) Coded 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document should contain a(n) Pregnancy History 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.35"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Immunization Detail Document should contain a(n) Coded Advance Directives 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This Immunization Detail Document does not contain a(n) Care Plan 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>