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ref Template  Immunization Entry

Id 2.16.756.5.30.1.1.10.4.89
ref
ch-pcc-
 		Effective Date 2016‑11‑11
Status pending Under pre-publication review Version Label 2016
Name chpcc_entry_Immunization Display Name Immunization Entry
Description
An immunizations entry is used to record the patient's immunization history. An immunization is a substance administration event. An immunization entry may also be used to report a specific immunization that was not performed (e.g. undesired immunization). In this case, negationInd shall be set to "true", otherwise, it shall be "false".
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.89
Label IHE PCC TF2 Rev.11, 6.3.4.17
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 6 templates, Uses 7 templates
Used by as Name Version
2.16.756.5.30.1.1.10.3.47 Containment pending Immunizations Section - coded (2016) 2016‑11‑11
2.16.756.5.30.1.1.10.1.15 link pending Immunization Certificate (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.16 link pending Immunization Administration (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.17 link pending Immunization Recommendation Request (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.18 link pending Immunization Recommendation Response (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.19 link pending Vaccination Record (2018) 2018‑04‑19
Uses as Name Version
2.16.756.5.30.1.1.10.9.14 Include active Narrative Text Reference (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.94 Containment pending Manufactured Product (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.101 Containment pending Immunization Performer - performer Containment (2016) DYNAMIC
2.16.756.5.30.1.1.10.9.48 Containment active Author Compilation with name (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.95 Containment pending Target Of The Immunization - Medication Target (2018) DYNAMIC
2.16.756.5.30.1.1.10.4.2 Containment pending Annotation Comments (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.96 Containment pending Recommendation Category - Criterion (2018) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.12 (DYNAMIC)
Specialization: template 2.16.840.1.113883.10.12.308 (2005‑09‑07)
Example
General structure
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.89"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12"/>  <templateId root="2.16.840.1.113883.10.20.1.24"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#im-1"/>  </text>  <statusCode code="completed"/>  <effectiveTime value="20180410145514+02:00"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity nullFlavor="UNK"/>  <consumable typeCode="CSM">
    <!-- template 2.16.756.5.30.1.1.10.4.94 'Manufactured Product' -->
  </consumable>  <performer>
    <!-- include template 2.16.756.5.30.1.1.10.4.101 'Immunization Performer - performer Containment' -->
  </performer>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.48 'Author Compilation with name' -->
  </author>  <entryRelationship typeCode="RSON">
    <!-- template 2.16.756.5.30.1.1.10.4.95 'Target Of The Immunization - Medication Target' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ">
    <!-- template 2.16.756.5.30.1.1.10.4.2 'Annotation Comments' -->
  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Example
BOOSTRIX Polio
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12"/>  <templateId root="2.16.840.1.113883.10.20.1.24"/>  <templateId root="2.16.756.5.30.1.1.10.4.89"/>  <id root="4a641cee-aa60-09a6-b0ab-8d534c7c9e0d"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#is10"/>  </text>  <statusCode code="completed"/>  <effectiveTime value="20180604"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="NA"/>  <doseQuantity nullFlavor="UNK"/>  <consumable typeCode="CSM">
    <manufacturedProduct>
      <templateId root="2.16.756.5.30.1.1.10.4.94"/>      <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"/>      <id root="2.51.1.1" extension="7680006370012"/>      <manufacturedMaterial>
        <code code="J07CA02" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC"/>        <name>BOOSTRIX Polio Inj Susp</name>      </manufacturedMaterial>      <manufacturerOrganization>
        <name use="L">GlaxoSmithKline AG</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <performer>
    <time value="20180604"/>    <assignedEntity>
      <id root="2.51.1.3" extension="7608888888888"/>      <assignedPerson>
        <name use="L">
          <given>Allzeit</given>          <family>Bereit</family>          <prefix qualifier="AC">Dr. med.</prefix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="2.51.1.3" extension="7608888888888"/>        <name use="L">Gruppenpraxis CH</name>        <telecom value="tel:+41.32.234.55.66" use="WP"/>        <telecom value="fax:+41.32.234.55.67" use="WP"/>        <telecom value="mailto:bereit@gruppenpraxis.ch" use="WP"/>        <telecom value="http://www.gruppenpraxis.ch" use="WP"/>        <addr use="WP">
          <streetName>Doktorgasse</streetName>          <houseNumber>2</houseNumber>          <city>Musterhausen</city>          <postalCode>8888</postalCode>          <country>CH</country>        </addr>      </representedOrganization>    </assignedEntity>  </performer>  <author>
    <functionCode code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician">
      <translation code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical doctors"/>    </functionCode>    <time value="20180604"/>    <assignedAuthor>
      <id root="2.51.1.3" extension="7608888888888"/>      <assignedPerson>
        <name use="L">
          <given>Allzeit</given>          <family>Bereit</family>          <prefix qualifier="AC">Dr. med.</prefix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="2.51.1.3" extension="7608888888888"/>        <name use="L">Gruppenpraxis CH</name>        <telecom value="tel:+41.32.234.55.66" use="WP"/>        <telecom value="fax:+41.32.234.55.67" use="WP"/>        <telecom value="mailto:bereit@gruppenpraxis.ch" use="WP"/>        <telecom value="http://www.gruppenpraxis.ch" use="WP"/>        <addr use="WP">
          <streetName>Doktorgasse</streetName>          <houseNumber>2</houseNumber>          <city>Musterhausen</city>          <postalCode>8888</postalCode>          <country>CH</country>        </addr>      </representedOrganization>    </assignedAuthor>  </author>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>      <templateId root="2.16.840.1.113883.10.20.1.40"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        <reference value="#is16"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a641d8e-aa60-09a6-b7fb-8d534c7c9e0d"/>      <code code="76668005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diphterie"/>      <text>
        <reference value="#is11"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a64209a-aa60-09a6-d5fd-8d534c7c9e0d"/>      <code code="127786006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Tetanus"/>      <text>
        <reference value="#is12"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a642130-aa60-09a6-a82a-8d534c7c9e0d"/>      <code code="39343008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Keuchhusten"/>      <text>
        <reference value="#is13"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="RSON" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.95"/>      <id root="4a6421d0-aa60-09a6-e59e-8d534c7c9e0d"/>      <code code="72093006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Kinderlähmung"/>      <text>
        <reference value="#is14"/>      </text>      <statusCode code="completed"/>    </observation>  </entryRelationship>  <precondition>
    <criterion>
      <templateId root="2.16.756.5.30.1.1.10.4.96"/>      <code code="41501" codeSystem="2.16.756.5.30.1.127.3.3.4" displayName="Empfohlene Basisimpfungen"/>      <text>
        <reference value="#is15"/>      </text>    </criterion>  </precondition></substanceAdministration>
Item DT Card Conf Description Label
hl7:substanceAdministration
 An immunizations entry is used to record the patient's immunization history. An immunization is a substance administration event. An immunization entry may also be used to report a specific immunization that was not performed (e.g. undesired immunization). In this case, negationInd shall be set to "true", otherwise, it shall be "false". IHE PCC TF2 Rev.11, 6.3.4.17
@moodCode
 cs 1 … 1 F EVN
@negationInd
 bl 1 … 1 R

For administered immunizations: negationInd='false'

For undesired immunizations: negationInd='true'
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.17
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.89
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.17
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.12
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.17
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.24
hl7:id
 II 1 … 1 R Immunization ID, assigned by the software application. IHE PCC TF2 Rev.11, 6.3.4.17
@root
 uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
 st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
Choice 1 … 1 Elements to choose from:
  • hl7:code[(@code='IMMUNIZ' and @codeSystem='2.16.840.1.113883.5.4')]
  • hl7:code[@codeSystem='2.16.840.1.113883.6.96' or concat(@code,@codeSystem)=doc('include/voc-2.16.756.5.30.1.1.11.69-DYNAMIC.xml')//valueSet[1]/conceptList/concept/concat(@code,@codeSystem)]
hl7:code
 CD 0 … 1 IHE PCC TF2 Rev.11, 6.3.4.17
@code
 cs 1 … 1 F IMMUNIZ
@codeSystem
 oid 1 … 1 F 2.16.840.1.113883.5.4
@codeSystemName
 st 1 … 1 F ActCode
@displayName
 st 0 NP NP/not present
hl7:code
 CD 0 … 1 IHE PCC TF2 Rev.11, 6.3.4.17
@code
 cs 1 … 1 R
@codeSystem
 oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
 st 1 … 1 F SNOMED CT
@displayName
 st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.69 Special Case Medication (DYNAMIC)
Included 1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:text
 ED 1 … 1 M CDA‑CH V2
hl7:reference
 TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
 1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
hl7:statusCode
 CS 1 … 1 M

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

 IHE PCC TF2 Rev.11, 6.3.4.17
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
 TS.CH.TZ 1 … 1 R Date of the immunization. IHE PCC TF2 Rev.11, 6.3.4.17
hl7:priorityCode
 CE 1 … 1 R

If the priority for the immunization is known, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='UNK'

 IHE PCC TF2 Rev.11, 6.3.4.17
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
hl7:routeCode
 CE 1 … 1 R

If the route of administration is known, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='NA'

 IHE PCC TF2 Rev.11, 6.3.4.17
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.79 RouteOfAdministration (Immunization) (DYNAMIC)
hl7:approachSiteCode
 CD 0 … *

If laterility of the administration is known, it MAY be recorded according to the HL7 value set.

Recommendation for eVACDOC: omit

 IHE PCC TF2 Rev.11, 6.3.4.17
@codeSystem
 CONF 0 … 1 F 2.16.840.1.113883.5.1052 (Act Site)
hl7:doseQuantity
 IVL_PQ 0 … 1

If dose quantity of the administration is known, it MAY be recorded according to the recommendations in the addendum "Darstellung Medikation" to the German "Arztbrief".

Recommendation for eVACDOC: @nullFlavor='UNK'

 IHE PCC TF2 Rev.11, 6.3.4.17
hl7:consumable
 1 … 1 R Vaccine
Contains 2.16.756.5.30.1.1.10.4.94 Manufactured Product (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [@typeCode='CSM'] [hl7:manufacturedProduct [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.94'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.53']]]
@typeCode
 cs 1 … 1 F CSM
hl7:performer
 0 … * This MAY be used to indicate who has administered the immunization.
Contains 2.16.756.5.30.1.1.10.4.101 Immunization Performer - performer Containment (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.101']]
hl7:author
 0 … * This MAY be used to indicate who has documented the immunization. This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.9.48 Author Compilation with name (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [hl7:functionCode [concat(@code,@codeSystem)=doc('include/voc-2.16.756.5.30.1.127.3.10.1.1.3-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code,@codeSystem) or @nullFlavor]]
hl7:entryRelationship
 0 … * Target of the immunization (the disease against which the immunization provides protection). Reference to Medication Target (Target of the immunization).
Contains 2.16.756.5.30.1.1.10.4.95 Target Of The Immunization - Medication Target (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [@typeCode='RSON'] [hl7:observation [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.95']]]
@typeCode
 cs 1 … 1 F RSON
hl7:entryRelationship
 0 … * Comments and remarks.
Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [@typeCode='SUBJ'] [hl7:act [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.2'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
@typeCode
 cs 1 … 1 F SUBJ
hl7:precondition
 0 … * Recommendation-Category according to the swiss vaccination plan.
Contains 2.16.756.5.30.1.1.10.4.96 Recommendation Category - Criterion (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.17
treeblank where [hl7:criterion [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.96']]]
  Schematron assert role red error  
  test (substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:performer  
  Message After 15.4.2020, the performer is required for each immunization.  
  Schematron assert role red error  
  test (substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or (string-length(hl7:effectiveTime/@value)>7)  
  Message After 15.4.2020, the date with precision of day is required for each immunization.  
  Schematron assert role red error  
  test (substring(/hl7:ClinicalDocument/hl7:effectiveTime/@value,1,6)<'20200415') or hl7:consumable/hl7:manufacturedProduct/hl7:manufacturedMaterial/hl7:lotNumberText/text()  
  Message After 15.4.2020, the lot number is required for each immunization.