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| | ==Profile Abstract== | | ==Profile Abstract== |
| − | The Immunization Content Profile (IC) | + | ===The Immunization Content Profile (IC)=== |
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| | The Immunization Content Profile defines standard immunization data content for Immunization Information Systems (IISs), other public health systems, electronic medical records (EMR) systems, Health Information Exchanges, and others wishing to exchange immunization data electronically in a standard format. | | The Immunization Content Profile defines standard immunization data content for Immunization Information Systems (IISs), other public health systems, electronic medical records (EMR) systems, Health Information Exchanges, and others wishing to exchange immunization data electronically in a standard format. |
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| | ==Issue Log== | | ==Issue Log== |
| | ===Open Issues=== | | ===Open Issues=== |
| − | # In preparation for the development of this profile, the compatibility of HL7 Version 3 POIZ and CareRecord were analyzed. The standards were found to be highly compatible. A few differences were identified and referred back to the HL7 Public Health and Emergency Response (PHER) Work Group for resolution through comments on both Draft Standards for Trial Use (DSTU). The approach taken in the Immunization Content (IC) Profile is to update the current Immunization Summary template provided in QED to contain all the fields in POIZ and to use POIZ tags (in order to best reflect terminology created by immunization and public health domain experts). The updated template is the equivalent of a POIZ template on CareRecord. | + | Public comment is solicited on all of the following issues: |
| − | # Care Management (CM) provides the notification-based integration profile for HL7 V2 immunization messages (VXQ/VXX/VXR). Query for Existing Data (QED) provides a query-based integration profile for the HL7 V3 portions of this profile, but doesn't include an option for HL7 V2. Thus, we still don't have a query option for V2. We are asking for public comment on this point. | + | # In preparation for the development of this profile, the compatibility of HL7 Version 3 POIZ and CareRecord were analyzed. The standards were found to be highly compatible. A few differences were identified and referred back to the HL7 Public Health and Emergency Response (PHER) Work Group for resolution through comments on both Draft Standards for Trial Use (DSTU). The approach taken in the Immunization Content (IC) Profile is to update the current PCC-2 Immunization Summary template to contain all the fields in POIZ that are also supported in CareRecord. Template for Immunizations needs to be fixed to include Lot #, Manufacturer, and Expiration Date, and a few other items. The updated template is the equivalent of a POIZ template on CareRecord. This update needs to be completed by the appropriate means. |
| − | # This IC profile contains three options for each actor. This has been thought to be problematic because two systems implementing different options may not be able to communicate. Another approach would be to break this profile into two, one for HL7 Version 2, and one for HL7 Version 3 (combining the Immunization Summary and Care Record options into one). Public comment on this issue is sought. | + | # Template for Advanced Directives needs to be fixed to include Immunization Refusal Reasons. |
| − | # We see this as a two-part exercise: (1) update of the existing IHE Immunization Summary template to reflect missing POIZ fields; and (2) creation of a new profile that includes Allergies, Problems, etc. - something that looks more like a discharge summary or a transfer of care summary, etc. | + | # It is expected that ballot comments on the CareRecord DSTU within HL7 will include requests to add elements available in POIZ but not accommodated in CareRecord. Assuming those elements are eventually added, this IC profile will have to be updated to also include them. |
| | + | # Not enough is said about precisely how the HL7 Version 2 messages are to be used. HL7 Version 2 couples content more tightly with message syntax than Verion 3. Care Management (CM) provides the notification-based integration profile, and Query for Existing Data (QED) provides a query-based integration profile for the HL7 V3 portions of this profile. However, it is unclear how CM and QED will handle V2. V2.3.1 messages blend identity resolution, which is outside the scope of this profile, with transmission of clinical data; how will this be handled? Also, if a Version 2 Implementation Guide is referenced, how will updates to that document be handled? |
| | + | # This IC profile contains three options for each actor. This has been thought to be problematic because two systems implementing different options may not be able to communicate. Another approach would be to break this profile into two or even three profiles, i.e. , one for HL7 Version 2, and one or two for HL7 Version 3 (depending upon whether the Immunization Summary and Care Record options are combined). |
| | + | # Implementation of this profile within PCC Volumes I and II will involve a two-part exercises: (1) update of the existing PCC-2 Immunization Summary template to reflect missing POIZ fields; and (2) creation of a new profile for the Care Record Option that includes Allergies, Problems, etc. - something that looks more like a discharge summary or a transfer of care summary, etc. |
| | # We assume we can use the Simple Observation template of Care Record to record Vaccine Information Statement Given (VIS Given) and VIS Version fields. Is this the best approach? | | # We assume we can use the Simple Observation template of Care Record to record Vaccine Information Statement Given (VIS Given) and VIS Version fields. Is this the best approach? |
| | | | |
| − | ===Notes to Author/Editor (do not include in final drafts)===
| + | |
| − | # V2.3.1 messages blend identity resolution with transmission of clinical data. Profiles such as QED and CM do not handle identity management; this is the purview of PIX and PDQ. How then is this aspect of HL7 Version 2.3.1 to be handled?
| |
| − | # Note that HL7 "V2" below refers to "V2.3.1". Note that an implementation guide for HL7 V2.5 is also under development in the U.S. Centers for Disease Control (CDC).
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| − | # Address how to handle updates to referenced V2 Guides.
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| − | # Template for Advanced Directives needs to be fixed to include Immunization Refusal Reasons.
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| − | # Template for Immunizations needs to be fixed to include Lot #, Manufacturer, and Expiration Date.
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| | | | |
| | ===Closed Issues=== | | ===Closed Issues=== |
| − | # Important elements are currently missing from the PCC QED immunization template, for example, the person who gave the shot. CareRecord can include person who administered vaccine in Performer role. This will be resolved by updating the current immunization template.
| + | # Where CareRecord and POIZ have different tags for the same elements, we have chosen to use the CareRecord tags in the templates and sample messages. The other possibility is to use the POIZ tags, which may be more meaningful to immunization domain experts. However, we felt that the POIZ tag names and definitions within the HL7 POIZ HMD were not significantly more descriptive to warrant "breaking" software that currently parses Care Record messages and may expect Care Record tags. |
| − | # Where CareRecord and POIZ have different tags for the same elements, we have chosen to use the CareRecord tags in the templates and sample messages. | |
| | | | |
| | =Volume I= | | =Volume I= |
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| | ===Dependencies=== | | ===Dependencies=== |
| | <pre>Add the following row(s) to the list of dependencies</pre> | | <pre>Add the following row(s) to the list of dependencies</pre> |
| − | {|style='background-color:#7f7f7f;' align='center' border='1' cellspacing='0' | + | {{T|Integration Profile|Dependency|Dependency Type|Purpose|Rows= |
| − | !Integration Profile
| + | {{R|Immunization Content (IC)|Care Management (CM)|The Content Creator actor of the IC profile must be grouped with the Clinical Data Source Actor of the CM profile|The IC profile defines the content sent in the PCC-11 transaction specified in the CM profile}} |
| − | !Dependency
| + | {{R|Immunization Content (IC)|Care Management (CM)|The Content Consumer actor of the IC profile must be grouped with the Care Manager Actor of the CM profile|The IC profile defines the content recieved in the PCC-11 transaction specified in the CM profile}} |
| − | !Dependency Type
| + | {{R|Immunization Content (IC)|ATNA|Actors the IC profile shall implement the Secure Node Actor of the ATNA profile|Ensures that transmissions and changes to patient health information are logged in an audit repository, and that communication is secured between nodes.}} |
| − | !Purpose
| + | {{R|Immunization Content (IC)|ATNA|Actors the IC profile shall implement the Time Client Actor of the CT profile|Ensures that concistent time is used in all messages.}} |
| − | |- style='background-color:#ffffff;' align='center' | + | }} |
| − | |Immunization Content | |
| − | |ATNA | |
| − | | |
| − | CT
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| − | | | |
| − | | | |
| − | |- | |
| − | |}
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| | ==The Immunization Content Profile (IC)== | | ==The Immunization Content Profile (IC)== |
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| | The following progression of use cases is illustrated in the drawing below. | | The following progression of use cases is illustrated in the drawing below. |
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| − | {{Fixme|insert Drawing for Public Comment here}}
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| | ====Use Case 1: Immunization Information System Participation==== | | ====Use Case 1: Immunization Information System Participation==== |
| | Various provider organizations - airport flu shot clinics, storefront vaccine clinics, and hospital vaccine clinics - wish to submit immunization histories for patients to a regional Immunization Information System (IIS) with appropriate patient consent. The provider IT departments configure HL7 Verion 2.3.1 connections with the IIS. Each time immunizations are recorded, records of the administered vaccines are automatically sent to the IIS using an HL7 version 2.3.1 standard format. | | Various provider organizations - airport flu shot clinics, storefront vaccine clinics, and hospital vaccine clinics - wish to submit immunization histories for patients to a regional Immunization Information System (IIS) with appropriate patient consent. The provider IT departments configure HL7 Verion 2.3.1 connections with the IIS. Each time immunizations are recorded, records of the administered vaccines are automatically sent to the IIS using an HL7 version 2.3.1 standard format. |
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| | !Actor | | !Actor |
| | !Option | | !Option |
| − | !Section
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| | |+Immunization Content Options | | |+Immunization Content Options |
| | |- style='background-color:#ffffff;' align='center' | | |- style='background-color:#ffffff;' align='center' |
| | |Content Consumer | | |Content Consumer |
| − | |Immunization Summary Option [[#note1|(1)]]<br/> | + | |No Options Defined |
| − | Care Record Option [[#note1|(1)]]<br/>
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| − | HL7 V2 Option [[#note1|(1)]]<br/>
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| − | |PCC TF-1: X.X.X<br/>
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| − | PCC TF-1: X.X.X<br/>
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| − | PCC TF-1: X.X.X
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| | |- style='background-color:#ffffff;' align='center' | | |- style='background-color:#ffffff;' align='center' |
| | |Content Creator | | |Content Creator |
| | |Immunization Summary Option [[#note1|(1)]]<br/> | | |Immunization Summary Option [[#note1|(1)]]<br/> |
| − | Care Record Option [[#note1|(1)]]<br/>
| + | Immunization Detail Option [[#note1|(1)]]<br/> |
| − | HL7 V2 Option [[#note1|(1)]]<br/>
| + | V2 Immunization Update Option [[#note1|(1)]]<br/> |
| − | |PCC TF-1: X.X.X<br/>
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| − | PCC TF-1: X.X.X<br/>
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| − | PCC TF-1: X.X.X
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| | |} | | |} |
| | | | |
| − | Note <sup ID=note1>1</sup>: The Actor shall support at least one of these options. | + | ''Note <sup ID=note1>(1)</sup>: The Actor shall support at least one of these options.'' |
| − | | |
| − | | |
| − | <!--
| |
| − | === Grouping ===
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| − | ==== Content Bindings with XDS, XDM and XDR====
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| − | It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:
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| − | * A registry/repository-based infrastructure is defined by the IHE [[Cross Enterprise Document Sharing]] (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
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| − | * A media-based infrastructure is defined by the IHE [[Cross Enterprise Document Media Interchange]] (XDM) profile.
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| − | * A reliable messaging-based infrastructure is defined by the IHE [[Cross Enterprise Document Reliable Interchange]] (XDR) profile.
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| − | * All of these infrastructures support Security and privacy through the use of the [[Consistent Time]] (CT) and [[Audit Trail and Node Authentication]] (ATNA) profiles.
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| − | For more details on these profiles, see the [[Frameworks#IHE_IT Infrastructure_Technical_Framework|IHE IT Infrastructure Technical Framework]].
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| − | | |
| − | Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.
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| − | | |
| − | ==== Cross Enterprise Document Sharing, Media Interchange and Reliable Messages ====
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| − | Actors from the ITI XDS, XDM and XDR profiles embody the [[Content Creator]] and [[Content Consumer]] sharing function of this profile. A [[Content Creator]] or [[Content Consumer]] must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.
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| − | | |
| − | ==== [[Notification of Document Availability]] (NAV) ====
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| − | A Document Source should provide the capability to issue a [[Send Notification]] Transaction per the ITI [[Notification of Document Availability]] (NAV) Integration Profile in order to notify one or
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| − | more [[Document Consumer]](s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that
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| − | an acknowledgement should be returned when it has received and processed the notification.
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| − | A Document Consumer should provide the capability to receive a [[Receive Notification]] Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The [[Send Acknowledgement]] option may be used to issue a Send Acknowledgement to a [[Document Source]] that the notification was received and processed.
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| − | | |
| − | ==== [[Document Digital Signature]] (DSG)====
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| − | When a [[Content Creator]] Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a [[Document Source]].
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| − | When a [[Content Consumer]] Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.
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| − | -->
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| − | | |
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| − | | |
| − | | |
| − | =Volume II=
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| − | ===Immunization Content===
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| − | ==== Standards ====
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| − | <!--; [http://www.hl7.org/v3ballot/html/infrastructure/cda.htm CDAR2] : Clinical Document Architecture, Release 2, 2005 HL7
| |
| − | ; [http://www.hl7.org/documentcenter/public/standards/informative/crs.zip CRS] : Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
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| − | ; [http://www.hl7.org/Library/Committees/structure/CCD%2E01Dec2006%2EDRAFT%2Ezip CCD] : ASTM/HL7 Continuity of Care Document (Draft)-->
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| − | | |
| − | ; [http://www.cdc.gov/vaccines/programs/iis/stds/downloads/hl7guide.pdf Implementation Guide for Immunization Data Transactions Using V 2.3.1 of the Health Level Seven (HL7) Standard Protocol] : Implementation Guide for Immunization Data Transactions Using V 2.3.1 of the Health Level Seven (HL7) Standard Protocol.
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| − | ; [http://hssp-rlus.wikispaces.com/September2006BallotedSFM HSSP Retrieve, Locate and Update Service] : Implementation Service Functional Model (SFM), balloted HL7 Draft Standard for Trial Use (DSTU) HL7.
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| − | ; [http://www.omg.org/cgi-bin/doc?health/2007-09-01 HSSP Retrieve, Locate and Update Service] : Initial submission to OMG includes a profile that demonstrates immunization data retrieval and update in conformance to SFM
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| − | ; [http://www.hl7.org/v3ballot/html/welcome/environment/index.htm HL7 V3 Immunizations (Click on Universal Domains, Immunizations) ] : HL7 Version 3 Standard: Immunization, Release 1 DSTU Ballot 3 - May 2008
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| − | ; [http://www.hl7.org/v3ballot/html/welcome/environment/index.htm HL7 V3 Care Provision (Click on Universal Domains, Care Provision)] : HL7 Version 3 Standard: Care Provision, Release 1 Last Ballot: DSTU Ballot 3 - September 2007
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| − | | |
| − | ==== Data Element Index ====
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| − | {| cellspacing=0 border=1 align='center'
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| − | !style='background-color:#cfcfcf' |Data Elements
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| − | !style='background-color:#cfcfcf' |Element from Care Record Root
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| − | !style='background-color:#cfcfcf' |Element from POIZ Root
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| − | !style='background-color:#cfcfcf' |Other Reference
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| − | |-
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| − | | '''Patient Elements for Immunization Content'''|| || ||
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| − | |-
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| − | |Patient ID ||patient.id||subject.id||not required for Vaccine Decision Support
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| − | |-
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| − | |DOB ||patient.birthTime||subject.birthTime ||only required for Vaccine Decision Support
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| − | |-
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| − | |Gender ||patient.administrativeGender||subject.administrativeGender||only required for Vaccine Decision Support
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| − | |-
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| − | | || || ||
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| − | |-
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| − | |'''History of Immunizations'''|| || ||
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| − | |-
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| − | |Immunization Record ID ||id ||id || instance identifier
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| − | |-
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| − | |Negation Indicator ||negationInd ||negationInd ||
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| − | |-
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| − | |Description ||text ||text ||
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| − | |-
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| − | |Immunization Date ||effectiveTime ||effectiveTime ||
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| − | |-
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| − | |Confidentiality Code || ||confidentialityCode || not defined in Care Record
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| − | |-
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| − | |Uncertainty Code ||||uncertaintyCode || not defined in Care Record
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| − | |-
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| − | |Dose Quantity ||doseQuantity.value - units||doseQuantity.value - units ||
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| − | |-
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| − | |Route ||routeCode ||routeCode ||
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| − | |-
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| − | |Approach Site ||approachSiteCode ||approachSiteCode ||
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| − | |-
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| − | |Vaccine Code ||consumable. administerableMaterial. administerableMaterial. code||consumable. administerableMedication. administerableMedicine. code || CDC CVX code in US
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| − | |-
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| − | |Vaccine Name ||consumable. administerableMaterial. administerableMaterial. name ||consumable. administerableMedication. administerableMedicine. name||
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| − | |-
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| − | |Vaccine Lot # ||consumable. administerableMaterial. administerableMaterial. lotNumberText||consumable. administerableMedication. administerableMedicine. lotNumberText ||
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| − | |-
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| − | |Vaccine Expiration Date ||consumable. administerableMaterial. administerableMaterial. expirationTime ||consumable. administerableMedication. administerableMedicine. expirationTime ||
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| − | |-
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| − | |Manufacturer ID ||consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. manufacturer.id ||consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. manufacturer.id || CDC MVX code in US
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| − | |-
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| − | |Manufacturer name ||consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. manufacturer. name ||consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. manufacturer. name ||
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| − | |-
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| − | |Vaccine Lot # Recalled Effective Date ||consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. effectiveTime||consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. effectiveTime || Date Recall was effective
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| − | |-
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| − | |Vaccine Lot # Recalled Code ||consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. code||consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. code||SNOMED code for vaccine recalled
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| − | |-
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| − | |Vaccine Lot # Recalled Noted Time ||consumable. administerableMaterial. administerableMaterial. asMedicineManufacturer. entryRelationship. observation. value||consumable. administerableMedication. administerableMedicine. asMedicineManufacturer. entryRelationship. observation. value||Date Recall was noted
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| − | |-
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| − | |Adverse Event ||entryRelationship. observation. code ||entryRelationship. observation. code || 6.4.4.15.8 - Observation w/SNOMED code
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| − | |-
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| − | |Adverse Event Time ||entryRelationship. observation. effectiveTime||entryRelationship. observation. effectiveTime|| 6.4.4.15.8
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| − | |-
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| − | |Adverse Event Severity||entryRelationship. observation. entryRelationship. observation. code||entryRelationship. observation. entryRelationship. observation. code|| 6.4.4.15.8
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| − | |-
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| − | |Performer ID ||performer. assignedEntity. id ||performer. assignedEntity. id ||
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| − | |-
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| − | |Performer Name ||performer. assignedEntity. assignedPerson. name ||performer. assignedEntity. assignedPerson. name ||
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| − | |-
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| − | |Performer Organization ID ||performer. assignedPerson. representedOrganization. id ||performer. assignedPerson. representedOrganization. id ||
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| − | |-
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| − | |Performer Organization Name ||performer. assignedPerson. representedOrganization. name ||performer. assignedPerson. representedOrganization. name ||
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| − | |-
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| − | |Author ID ||author. assignedEntity. id ||author. assignedEntity. id ||
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| − | |-
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| − | |Author Name ||author. assignedEntity. assignedPerson. name ||author. assignedEntity. assignedPerson. name ||
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| − | |-
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| − | |Informant Name ||informant. assignedEntity. assignedPerson. name ||informant. assignedEntity. assignedPerson. name ||
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| − | |-
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| − | |Informant Mode ||||informant. modeCode || written/verbal/electronic
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| − | |-
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| − | |Informant Source ||||informant. informationSource. code || patient/relative/provider
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| − | |-
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| − | |Informant Name||informant. relatedEntity. assignedPerson. name|| || Care Record also defines options for informant by electronic data transfer
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| − | |-
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| − | |Reason Not Administered || ||reason. noImmunizationReason. reasonCode ||
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| − | |-
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| − | |Vaccine Information Statement Given ||observation. code ||observation. code ||
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| − | |-
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| − | |VIS Version ||observation. value ||observation. value ||
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| − | |-
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| − | |Shot Comments / Notes ||annotation. text ||annotation. text ||
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| − | |}
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| | <br> | | <br> |
| − | {| cellspacing=0 border=1 align='center'
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| − | !style='background-color:#cfcfcf' |Data Elements
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| − | !style='background-color:#cfcfcf' |Other Reference
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| − | !style='background-color:#cfcfcf' |Care Record Element
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| − | |-
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| − | | || ||
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| − | |-
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| − | | '''Existing Problem Record Data Elements''' || use as-is||templateId=1.3.6.1.4.1.19376.1.5.3.1.4.5
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Allergy and Intolerance Data Elements'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.6
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| − | |-
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| − | |Allergen Substance || substance causing allergy (allergy to eggs must be noted) ||intolerances.participant.code
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| − | |-
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| − | |Allergic Reaction History || ||intolerances.reactions
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| − | |-
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| − | |Severity || ||intolerances.severity
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| − | |-
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| − | |Clinical Status || ||intolerances.clinicalStatus
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| − | |-
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| − | |Comments || ||intolerances.comments
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Medications Data Elements'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.7
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Simple Observations for Labs'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.13
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Vital Signs Data Elements'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
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| − | |-
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| − | |Observation Code || LOINC: 8310-5 body temp (must be noted if reason for not immunizing) ||vitalSigns.code
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| − | |-
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| − | |Observation Value - Units || ||vitalSigns.value
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Pregnancy Data Elements'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.13.5
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| − | |-
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| − | | || ||
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| − | |-
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| − | |'''Existing Advanced Directives Data Elements'''|| use as-is||templateId= 1.3.6.1.4.1.19376.1.5.3.1.4.13.7
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| − | |-
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| − | |Scope (Refusal Reason Code) || <additions to list of SNOMED code(s) to include IZ Refusal Reasons> ||advanceDirectives.code
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| − | |}
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| − |
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| | <br> | | <br> |
| | + | ==== Immunization Summary Option ==== |
| | + | The Immunization Summary Option is based upon HL7 Version 3. It includes information about immunization history of a patient. |
| | + | ==== Immunization Detail Option ==== |
| | + | The Immunization Detail Option is also based upon HL7 Version 3. It includes all of the requirements of the Immunization Summary Option, plus ancillary information to support decisions about the treatment of a patient related to immunizations. For example, it includes the patient's allergies, which may be relevant in deciding whether or not to give certain vaccines. |
| | + | ==== V2 Immunization Update Option ==== |
| | + | The V2 Immunization Update Option is for backwards compatibility with existing HL7 Version 2.3.1 immunization messaging. |
| | | | |
| − | ==== Document Specification ==== | + | === Grouping === |
| − | =====Immunization Summary Option=====
| + | ==== Care Management (CM) ==== |
| − | The following table shows the data elements used from the existing PCC-2 Immunization Summary Template, plus modifications required for use in this IC profile.
| + | The [[Content Creator]] of this profile must be grouped with the [[Clinical Data Source]] of the Care Management profile. The Clinical Data Source actor must implement the V2 Care Management Update Option. |
| − | {| cellspacing=0 border=1 align='center'
| |
| − | ! style='background-color:#cfcfcf'|Data Element
| |
| − | ! style='background-color:#cfcfcf'|Opt
| |
| − | ! style='background-color:#cfcfcf'|PCC-2 Section
| |
| − | ! style='background-color:#cfcfcf' |Template ID
| |
| − | |+ Immunization Summary Option - Updated Constraints
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''History of Immunizations''' ||R|| ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Immunization Record ID ||R||6.4.4.17.4 || 1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Negation Indicator ||R||6.4.4.17.2 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Description ||R||6.4.4.17.6 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Immunization Date ||R||6.4.4.17.8 || 1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Dose Quantity ||R2||6.4.4.17.11 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Route ||R2||6.4.4.17.9 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Approach Site ||R2||6.4.4.17.10 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Vaccine Code ||R||6.4.4.17.12 / 6.4.4.19.3 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Vaccine Name ||R2||6.4.4.17.12 / 6.4.4.19.3 ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Vaccine Lot # ||R2||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Vaccine Expiration Date ||R2||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Manufacturer ID ||R2||needs to be added || 1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Manufacturer Name ||O||needs to be added || 1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Vaccine Lot # Recalled Effective Date ||R2||6.4.4.20 ||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |Vaccine Lot # Recalled Code ||R2||6.4.4.20 ||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |Vaccine Lot # Recalled Noted Time ||O||6.4.4.20 ||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |Adverse Event Code ||R2||6.4.4.15.5 ||1.3.6.1.4.1.19376.1.5.3.1.4.5
| |
| − | |-
| |
| − | |Adverse Event Time||R2||6.4.4.15.2 ||1.3.6.1.4.1.19376.1.5.3.1.4.5
| |
| − | |-
| |
| − | |Adverse Event Severity||R2||6.4.4.15.11 ||1.3.6.1.4.1.19376.1.5.3.1.4.1
| |
| − | |-
| |
| − | |Performer Person ID ||R2||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Performer Person Name ||O||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Performer Organization ID ||R2||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Performer Organization Name ||O||needs to be added ||1.3.6.1.4.1.19376.1.5.3.1.4.12
| |
| − | |-
| |
| − | |Author||R2||6.4.4.1|| no template -- see below
| |
| − | |-
| |
| − | |Informant||R2||6.4.4.1|| no template -- see below
| |
| − | |-
| |
| − | |Vaccine Information Statement Given||R2||6.4.4.20 ||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |VIS Version||R2||6.4.4.20 ||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |Comments about Shot||R2||6.4.4.6||1.3.6.1.4.1.19376.1.5.3.1.4.2
| |
| − | |}
| |
| − | <br>
| |
| − | =====Care Record Option=====
| |
| − | The following table describes the Care Record Option. It includes the Immunization Summary Option just described in its entirety. It also makes use of other existing PCC-2 templates as indicated. These templates are used unmodified from their present form, except that optionality of fields is specified in the table below.
| |
| − | {| cellspacing=0 border=1 align='center'
| |
| − | ! style='background-color:#cfcfcf'|Data Element
| |
| − | ! style='background-color:#cfcfcf'|Opt
| |
| − | ! style='background-color:#cfcfcf'|PCC-2 Section
| |
| − | ! style='background-color:#cfcfcf' |Template ID
| |
| − | |+ Care Record Option - Updated Constraints
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Care Event''' ||R|| ||
| |
| − | |-
| |
| − | |Patient ID ||C|| ||Not Required for Vaccine Decision Support
| |
| − | |-
| |
| − | |DOB ||C|| ||'''Only''' Required for Vaccine Decision Support
| |
| − | |-
| |
| − | |Gender||C|| ||'''Only''' Required for Vaccine Decision Support
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''History of Immunizations''' ||R||6.4.4.17 ||1.3.6.1.4.1.19376.1.5.3.1.4.12 (updated - see above)
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Authors and Informants''' ||R2||6.4.4.1||<use as defined in PCC-2>
| |
| − | |-
| |
| − | |ID ||R|| ||
| |
| − | |-
| |
| − | |Address ||R|| ||
| |
| − | |-
| |
| − | |Telecom ||R|| ||
| |
| − | |-
| |
| − | |Role Code ||R2|| ||
| |
| − | |-
| |
| − | |Name ||O|| ||
| |
| − | |-
| |
| − | |Informant Mode ||R2|| ||
| |
| − | |-
| |
| − | |Informant Source ||R2|| ||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Problem Entry''' ||R2||6.4.4.14||1.3.6.1.4.1.19376.1.5.3.1.4.5
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Problem began ||R2|| ||
| |
| − | |-
| |
| − | |Problem ended ||R2|| ||
| |
| − | |-
| |
| − | |Problem Type ||R2|| ||
| |
| − | |-
| |
| − | |Confidentiality Code ||R2|| ||
| |
| − | |-
| |
| − | |Uncertainty Code ||R2|| ||
| |
| − | |-
| |
| − | |Problem Code ||R|| ||
| |
| − | |-
| |
| − | |Severity ||R2||6.4.4.3||1.3.6.1.4.1.19376.1.5.3.1.4.1
| |
| − | |-
| |
| − | |Clinical Status ||O||6.4.4.4||1.3.6.1.4.1.19376.1.5.3.1.4.1.1
| |
| − | |-
| |
| − | |Health Status ||O||6.4.4.5||1.3.6.1.4.1.19376.1.5.3.1.4.1.2
| |
| − | |-
| |
| − | |Comments ||O||6.4.4.6||1.3.6.1.4.1.19376.1.5.3.1.4.2
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Allergies and Intolerances''' ||R2||6.4.4.15||1.3.6.1.4.1.19376.1.5.3.1.4.6
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Intolerance Type ||R|| ||
| |
| − | |-
| |
| − | |Allergy Code ||R|| ||
| |
| − | |-
| |
| − | |Allergen Substance ||R2|| ||
| |
| − | |-
| |
| − | |Allergic Reaction History ||R2|| ||
| |
| − | |-
| |
| − | |Severity ||R2||6.4.4.3||1.3.6.1.4.1.19376.1.5.3.1.4.1
| |
| − | |-
| |
| − | |Clinical Status ||O||6.4.4.4||1.3.6.1.4.1.19376.1.5.3.1.4.1.1
| |
| − | |-
| |
| − | |Comments ||O||6.4.4.6||1.3.6.1.4.1.19376.1.5.3.1.4.2
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Medications''' ||R2||6.4.4.16||1.3.6.1.4.1.19376.1.5.3.1.4.7
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Description ||R2|| ||
| |
| − | |-
| |
| − | |Date Range ||R|| ||
| |
| − | |-
| |
| − | |Drug Code ||R2|| ||
| |
| − | |-
| |
| − | |Drug Name ||R2|| ||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Lab Results''' ||R2||6.4.4.16||1.3.6.1.4.1.19376.1.5.3.1.4.13
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Lab Code||R|| ||
| |
| − | |-
| |
| − | |Description ||R2|| ||
| |
| − | |-
| |
| − | |Date ||R|| ||
| |
| − | |-
| |
| − | |Result ||R2|| ||
| |
| − | |-
| |
| − | |Result Interpretation ||R2|| ||
| |
| − | |-
| |
| − | |Test Method||R2|| ||
| |
| − | |-
| |
| − | |Author||R2||6.4.4.1||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Vital Signs Organizer''' ||R2||6.4.4.21||1.3.6.1.4.1.19376.1.5.3.1.4.13.1
| |
| − | |-
| |
| − | |Observation Date ||R|| ||
| |
| − | |-
| |
| − | |Observation by ||R2|| ||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Vital Signs Observation'''||R2||6.4.4.22||1.3.6.1.4.1.19376.1.5.3.1.4.13.2
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Observation Code ||R||LOINC: 8310-5 body temp ||vitalSigns.code
| |
| − | |-
| |
| − | |Observation Value - Units||R|| ||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Pregnancy Observation''' ||R2||6.4.4.26||1.3.6.1.4.1.19376.1.5.3.1.4.13.5
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Observation Date||R|| ||
| |
| − | |-
| |
| − | |Pregnancy Info Type ||R2|| ||
| |
| − | |-
| |
| − | |Pregnancy Status ||R2|| ||
| |
| − | |-
| |
| − | |Pregnancy Info Type ||R2|| ||
| |
| − | |-
| |
| − | |Estimated Due Date ||R2|| ||
| |
| − | |-
| |
| − | | || || ||
| |
| − | |-
| |
| − | |'''Advance Directive Observation''' ||R2||6.4.4.28||1.3.6.1.4.1.19376.1.5.3.1.4.13.7
| |
| − | |-
| |
| − | |ID||R|| ||
| |
| − | |-
| |
| − | |Refusal Reason Code ||R||6.4.4.28.4|| <need to expand SNOMED list to include vaccines, refusal reasons, etc.>
| |
| − | |-
| |
| − | |Reason Code Permits Immunization? ||R2|| ||
| |
| − | |-
| |
| − | |Effective From Date ||R2|| ||
| |
| − | |-
| |
| − | |Effective Thru Date ||R2|| ||
| |
| − | |-
| |
| − | |Comments ||O||6.4.4.6||1.3.6.1.4.1.19376.1.5.3.1.4.2
| |
| − | |}
| |
| − | | |
| − | ==Immunization Content Section==
| |
| − | {| border=1 cellspacing=0
| |
| − | |-
| |
| − | !style='background-color:#cfcfcf;'|TemplateID
| |
| − | | colspan=2|1.3.6.1.4.1.19376.1.5.3.1.?.?
| |
| − | |-
| |
| − | !style='background-color:#cfcfcf;'|Parent Template
| |
| − | | colspan=2|CCD 3.11(2.16.840.1.113883.10.20.1.6)
| |
| − | |-
| |
| − | !style='background-color:#cfcfcf;'|General Description
| |
| − | |colspan=2|This section shall contain a full description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Module. It shall also contain all known medical information which is relevant to past and future immunization decisions for the patient.
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !LOINC Code
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |11369-6
| |
| − | |align='center'|R
| |
| − | |HISTORY OF IMMUNIZATIONS
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Entries
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.?.?
| |
| − | |align='center'|R
| |
| − | |Immunization Content
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.?.?
| |
| − | |align='center'|R
| |
| − | |History of Immunizations (POIZ) <br> (if no immunizations have been given, that fact must be stated with negationInd = true, and NoImmunizationReason supplied)
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.5
| |
| − | |align='center'|R2
| |
| − | |Problems and Conditions
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |11.3.6.1.4.1.19376.1.5.3.1.4.6
| |
| − | |align='center'|R
| |
| − | |Allergies and Intolerances <br> (allergy to eggs must be specified, whether positive, negative, or unknown) <br> (any known reactions to vaccine events must be specified, and linked to the particular immunization event, if known)
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.7
| |
| − | |align='center'|R2
| |
| − | |Medications
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.13.1
| |
| − | |align='center'|R2
| |
| − | |Vital Signs Organizer
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.13.2
| |
| − | |align='center'|R2
| |
| − | |Vital Signs Observation
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.13.5
| |
| − | |align='center'|C
| |
| − | |Pregnancy Observation
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.13.7
| |
| − | |align='center'|R2
| |
| − | |Advance Directives and Consent Observation
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.1
| |
| − | |align='center'|R2
| |
| − | |Severity <br> (used in Problems and Allergies)
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.1.1
| |
| − | |align='center'|R2
| |
| − | |Clinical Status <br> (used in Problems and Allergies)
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.1.2
| |
| − | |align='center'|R2
| |
| − | |Health Status <br> (used in Problems)
| |
| − | |- style='background-color:#cfcfcf;'
| |
| − | !Sub-sub-sections
| |
| − | !Opt
| |
| − | !Description
| |
| − | |-
| |
| − | |1.3.6.1.4.1.19376.1.5.3.1.4.2
| |
| − | |align='center'|R2
| |
| − | |Comments <br> (used in POIZ, Problems, Allergies and Advance Directives)
| |
| − | |}
| |
| − | | |
| − | ==Parent Template==
| |
| − | {{Fixme|do we need this?}}
| |
| − | <pre>
| |
| − | <entry>An XML Example</entry>
| |
| − | </pre>
| |
| − | === entry ===
| |
| − | The parent of this template is CCD 3.11.
| |
| − | | |
| − | ==SampleMessages==
| |
| − | ===Sample V3 Message for Immunization History Only===
| |
| − | | |
| − | <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>
| |
| − |
| |
| − | <!-- zero or many representations of a substance administration -->
| |
| − | <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"/>
| |
| − | <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
| |
| − | <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'>
| |
| − | <!-- zero or one representation of the instance information of the administerableMaterial -->
| |
| − | <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" />
| |
| − | <code code="88" codeSystem="2.16.840.1.113883.6.59" displayName="FLU VAX"/>
| |
| − | <lotNumberText>ABC12345M</lotNumberText>
| |
| − | <expirationTime value='20080305'/>
| |
| − | <!-- Manufacturer of Vaccine -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or more representations of adverse events caused 6.4.4.15.8 -->
| |
| − | <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=''/>
| |
| − | <code code=' 12345678' displayName="edema with fever" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
| |
| − | <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>
| |
| − | <!-- zero or more representations of the severity of the above adverse event -->
| |
| − | <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"/>
| |
| − | <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or one representation of the person who administered the vaccine -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- exactly one Author of the Substance Administration -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or more representations of the source of information about the substanceAdministration -->
| |
| − | <!--<informant typeCode='INF'>
| |
| − | <relatedEntity classCode=' '>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <assignedPerson classCode='PSN'>
| |
| − | <determinerCode root=''/>
| |
| − | <name>…</name>
| |
| − | </assignedPerson>
| |
| − | </relatedEntity>
| |
| − | </informant>-->
| |
| − | <!--or the following-->
| |
| − | <!--<observation typeCode='OBS' moodCode='EVN'>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
| |
| − | <id root='' extension=''/>
| |
| − | <code code='' displayName='' codeSystem='' codeSystemName=''/>
| |
| − | <text>foo bar text</text>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value=''/>
| |
| − | <repeatNumber value=''/>
| |
| − | <value type=''/>
| |
| − | <interpretationCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <methodCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <targetSiteCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <author typeCode='AUT'>
| |
| − | <assignedEntity typeCode='ASSIGNED'>
| |
| − | <Person classCode='PSN'>
| |
| − | <determinerCode root=''/>
| |
| − | <name>…</name>
| |
| − | </Person>
| |
| − | </assignedEntity>
| |
| − | </author>
| |
| − | </observation>-->
| |
| − | <informant typeCode='INF'>
| |
| − | <time value=''/>
| |
| − | <!-- verbal paper electronicData etc. -->
| |
| − | <modeCode code="VERBAL|WRITTEN|ELECTRONIC" codeSystem="2.16.840.1.113883.5.1064" codeSystemName="Participation Mode"/>
| |
| − | <informationSource classCode="PRS | LIC | PAT" codeSystem="2.16.840.1.113883.5.110" codeSystemName="RoleClass">
| |
| − | <!-- someone with a personal relationship, such as mother -->
| |
| − | <code> role </code>
| |
| − | <!-- licensed entity, such as another provider -->
| |
| − | <code> role </code>
| |
| − | <!-- patient, no further information needed -->
| |
| − | </informationSource>
| |
| − | </informant>
| |
| − |
| |
| − | <!-- zero to many representations of Comments about this IZ Instance -->
| |
| − | <entryRelationship typeCode="SUBJ" inversionInd="true">
| |
| − | <observation classCode='COND' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.40'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' 48767-8' displayName=' Annotation Comment'
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value='20070911'/>
| |
| − | <text>
| |
| − | this child has extreme panic attacks at the sight of a needle.
| |
| − | </text>
| |
| − | </observation>
| |
| − | </entryRelationship>
| |
| − |
| |
| − | </substanceAdministration>
| |
| − | </careProvisionEvent>
| |
| − |
| |
| − | </subject2>
| |
| − | </registrationEvent>
| |
| − | </subject>
| |
| − | </controlActProcess>
| |
| − | | |
| − | ===Sample V3 Message for Full Immunization Care Record===
| |
| − | | |
| − | <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>
| |
| − |
| |
| − | <!-- zero or many representations of a substance administration -->
| |
| − | <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"/>
| |
| − | <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
| |
| − | <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'>
| |
| − | <!-- zero or one representation of the instance information of the administerableMaterial -->
| |
| − | <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" />
| |
| − | <code code="88" codeSystem="2.16.840.1.113883.6.59" displayName="FLU VAX"/>
| |
| − | <lotNumberText>ABC12345M</lotNumberText>
| |
| − | <expirationTime value='20080305'/>
| |
| − | <!-- Manufacturer of Vaccine -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or more representations of adverse events caused 6.4.4.15.8 -->
| |
| − | <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=''/>
| |
| − | <code code=' 12345678' displayName="edema with fever" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
| |
| − | <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>
| |
| − | <!-- zero or more representations of the severity of the above adverse event -->
| |
| − | <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"/>
| |
| − | <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or one representation of the person who administered the vaccine -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- exactly one Author of the Substance Administration -->
| |
| − | <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>
| |
| − |
| |
| − | <!-- zero or more representations of the source of information about the substanceAdministration -->
| |
| − | <!--<informant typeCode='INF'>
| |
| − | <relatedEntity classCode=' '>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <assignedPerson classCode='PSN'>
| |
| − | <determinerCode root=''/>
| |
| − | <name>…</name>
| |
| − | </assignedPerson>
| |
| − | </relatedEntity>
| |
| − | </informant>-->
| |
| − | <!--or the following-->
| |
| − | <!--<observation typeCode='OBS' moodCode='EVN'>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
| |
| − | <id root='' extension=''/>
| |
| − | <code code='' displayName='' codeSystem='' codeSystemName=''/>
| |
| − | <text>foo bar text</text>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value=''/>
| |
| − | <repeatNumber value=''/>
| |
| − | <value type=''/>
| |
| − | <interpretationCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <methodCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <targetSiteCode code='' codeSystem='' codeSystemName=''/>
| |
| − | <author typeCode='AUT'>
| |
| − | <assignedEntity typeCode='ASSIGNED'>
| |
| − | <Person classCode='PSN'>
| |
| − | <determinerCode root=''/>
| |
| − | <name>…</name>
| |
| − | </Person>
| |
| − | </assignedEntity>
| |
| − | </author>
| |
| − | </observation>-->
| |
| − | <informant typeCode='INF'>
| |
| − | <time value=''/>
| |
| − | <!-- verbal paper electronicData etc. -->
| |
| − | <modeCode code="VERBAL|WRITTEN|ELECTRONIC" codeSystem="2.16.840.1.113883.5.1064" codeSystemName="Participation Mode"/>
| |
| − | <informationSource classCode="PRS | LIC | PAT" codeSystem="2.16.840.1.113883.5.110" codeSystemName="RoleClass">
| |
| − | <!-- someone with a personal relationship, such as mother -->
| |
| − | <code> role </code>
| |
| − | <!-- licensed entity, such as another provider -->
| |
| − | <code> role </code>
| |
| − | <!-- patient, no further information needed -->
| |
| − | </informationSource>
| |
| − | </informant>
| |
| − |
| |
| − | <!-- zero to many representations of Comments about this IZ Instance -->
| |
| − | <entryRelationship typeCode="SUBJ" inversionInd="true">
| |
| − | <observation classCode='COND' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.40'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' 48767-8' displayName=' Annotation Comment'
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value='20070911'/>
| |
| − | <text>
| |
| − | this child has extreme panic attacks at the sight of a needle.
| |
| − | </text>
| |
| − | </observation>
| |
| − | </entryRelationship>
| |
| − |
| |
| − | </substanceAdministration>
| |
| − |
| |
| − | <!-- zero to many representations of Problems -->
| |
| − | <observation classCode='OBS' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.28'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' ' displayName=' '
| |
| − | codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
| |
| − | <value type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '>
| |
| − | <originalText><reference value=' '/></originalText>
| |
| − | </value>
| |
| − | <!-- zero or one <subjectOf typeCode='SUBJ' inversionInd='true'> elements containing severity -->
| |
| − | <!-- zero or one <subjectOf typeCode='REFR' inversionInd='false'> elements identifying the health status of concern -->
| |
| − | <!-- zero or one <subjectOf typeCode='REFR' inversionInd='false'> elements containing clinical status -->
| |
| − | <!-- zero to many <subjectOf typeCode='SUBJ' inversionInd='true'> elements containing comments -->
| |
| − | <subjectOf typeCode='SUBJ' inversionInd='true'>
| |
| − | <observation classCode='COND' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.40'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' 48767-8' displayName=' Annotation Comment'
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value='20070911'/>
| |
| − | <text>
| |
| − | this child has extreme panic attacks at the sight of a needle.
| |
| − | </text>
| |
| − | </observation>
| |
| − | </subjectOf>
| |
| − |
| |
| − | </observation>
| |
| − |
| |
| − | <!-- zero to many representations of Allergies and Intolerances -->
| |
| − | <observation classCode='OBS' moodCode='EVN' negationInd='false'>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.18'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code
| |
| − | code='ALG|OINT|DALG|EALG|FALG|DINT|EINT|FINT|DNAINT|ENAINT|FNAINT'
| |
| − | codeSystem='2.16.840.1.113883.5.4'
| |
| − | codeSystemName='ObservationIntoleranceType'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime>
| |
| − | <low value=' '/>
| |
| − | <high value=' '/>
| |
| − | </effectiveTime>
| |
| − | <value type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '/>
| |
| − | <participant typeCode='CSM'>
| |
| − | <participantRole classCode='MANU'>
| |
| − | <playingEntity classCode='MMAT'>
| |
| − | <code code=' ' codeSystem=' '>
| |
| − | <originalText><reference value='#substance'/></originalText>
| |
| − | </code>
| |
| − | <name></name>
| |
| − | </playingEntity>
| |
| − | </participantRole>
| |
| − | </participant>
| |
| − | <!-- zero to many <entryRelationship> elements containing reactions (Adverse Events),
| |
| − | for example:
| |
| − | <entryRelationship typeCode='MFST'>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6.1'/>
| |
| − | <observation classCode='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'/>
| |
| − | :
| |
| − | </observation>
| |
| − | </entryRelationship>
| |
| − | -->
| |
| − | <!-- zero or one <subjectOf typeCode='SUBJ' inversionInd='true'> elements containing severity -->
| |
| − | <!-- zero or one <subjectOf typeCode='REFR' inversionInd='false'> elements containing clinical status -->
| |
| − | <!-- zero to many <subjectOf typeCode='SUBJ' inversionInd='true'> elements containing comments -->
| |
| − | <subjectOf typeCode='SUBJ' inversionInd='true'>
| |
| − | <observation classCode='COND' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.40'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' 48767-8' displayName=' Annotation Comment'
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value='20070911'/>
| |
| − | <text>
| |
| − | this child has extreme panic attacks at the sight of a needle.
| |
| − | </text>
| |
| − | </observation>
| |
| − | </subjectOf>
| |
| − | </observation>
| |
| − |
| |
| − | <!-- zero or many representations of a substance administration for medication -->
| |
| − | <substanceAdministration moodCode="EVN" negationInd="false" classCode="SBADM">
| |
| − | <templateId root="2.16.840.1.113883.10.20.1.24"/>
| |
| − | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
| |
| − | <id extension="63" root="1.3.6.1.4.1.21367.2008.1.2.190.2"/>
| |
| − | <code code="MEDICAT" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
| |
| − | <text>cvxCode</text>
| |
| − | <statusCode code="completed"/>
| |
| − | <effectiveTime value="20070911"/>
| |
| − | <consumable typeCode="CSM">
| |
| − | <administerableMaterial>
| |
| − | <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"/>
| |
| − | <administerableMaterial>
| |
| − | <code code="12345" codeSystem="2.16.840.1.113883.6.?.?" displayName="Penicillin">
| |
| − | <originalText>Penicillin</originalText>
| |
| − | </code>
| |
| − | </administerableMaterial>
| |
| − | <desc>patient given Penicillin</desc>
| |
| − | </administerableMaterial>
| |
| − | </consumable>
| |
| − | </substanceAdministration>
| |
| − |
| |
| − | <!-- zero to many representations of Lab Results -->
| |
| − | <observation classCode='OBS' moodCode='EVN' negationInd=' false'>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.28'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' ' displayName=' '
| |
| − | codeSystem='2.16.840.1.113883.?.?' codeSystemName='SNOMED CT'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
| |
| − | <value type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '>
| |
| − | <originalText><reference value=' '/></originalText>
| |
| − | </value>
| |
| − | <interpretationCode></interpretationCode>
| |
| − | <methodCode></methodCode>
| |
| − | <author></author>
| |
| − | </observation>
| |
| − |
| |
| − | <!-- zero to many representations of Vital Signs observed -->
| |
| − | <organizer classCode='CLUSTER' moodCode='EVN'>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.32'/>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.35'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
| |
| − | <id root='' extension=''/>
| |
| − | <code code='46680005' displayName='Vital signs'
| |
| − | codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value=''/>
| |
| − | <author classCode='AUT'>
| |
| − | <assignedAuthor typeCode='ASSIGNED'>
| |
| − | </assignedAuthor>
| |
| − | </author>
| |
| − | <component typeCode='COMP'>
| |
| − | <observation classCode='OBS' moodCode='EVN'>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.31'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <text><reference value='#xxx'/></text>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value=' '/>
| |
| − | <repeatNumber value=' '/>
| |
| − | <value type='PQ' value='' unit=''/>
| |
| − | <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
| |
| − | <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
| |
| − | <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
| |
| − | </observation>
| |
| − | </component>
| |
| − | </organizer>
| |
| − |
| |
| − | <!-- zero to many representations of Pregnancy Observations -->
| |
| − | <observation classCode='OBS' moodCode='EVN' negationInd=' false'>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.28'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' ' displayName=' '
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
| |
| − | <value type=' ' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '>
| |
| − | <originalText><reference value=' '/></originalText>
| |
| − | </value>
| |
| − | <author></author>
| |
| − | </observation>
| |
| − |
| |
| − | <!-- zero to many representations of Advanced Directives -->
| |
| − | <observation classCode='OBS' moodCode='EVN' negationInd=' false'>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.28'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' ' displayName=' '
| |
| − | codeSystem='2.16.840.1.113883.?.?' codeSystemName='SNOMED CT'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
| |
| − | <value type='BL' value='true|false'/>
| |
| − | <author></author>
| |
| − | <!-- zero to many <subjectOf typeCode='SUBJ' inversionInd='true'> elements containing comments -->
| |
| − | <subjectOf typeCode='SUBJ' inversionInd='true'>
| |
| − | <observation classCode='COND' moodCode='EVN' negationInd=' false|true '>
| |
| − | <templateId root='2.16.840.1.113883.10.20.1.40'/>
| |
| − | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
| |
| − | <id root=' ' extension=' '/>
| |
| − | <code code=' 48767-8' displayName=' Annotation Comment'
| |
| − | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| − | <statusCode code='completed'/>
| |
| − | <effectiveTime value='20070911'/>
| |
| − | <text>
| |
| − | This person is a strict vegetarian, and does not want any vaccines made from animals or animal substances.
| |
| − | </text>
| |
| − | </observation>
| |
| − | </subjectOf>
| |
| − | </observation>
| |
| − |
| |
| − | </careProvisionEvent>
| |
| − |
| |
| − | </subject2>
| |
| − | </registrationEvent>
| |
| − | </subject>
| |
| − | </controlActProcess>
| |
| − | | |
| − | ===Sample V2 Message===
| |
| | | | |
| − | See ''Implementation Guide for Immunization Data Transactions Using V 2.3.1 of the Health Level Seven (HL7) Standard Protocol'', referenced in Standards above.
| + | The [[Content Consumer]] Actor of this profile must be grouped with the [[Care Manager]] actor of the Care Management profile. |
