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rejected Template  Immunization Recommendation Entry

Id 2.16.756.5.30.1.1.10.4.93
ref
ch-pcc-
 		Effective Date 2016‑11‑11
Other versions this id:
Status rejected Rejected Version Label 2016
Name chpcc_entry_ImmunizationRecommendation Display Name Immunization Recommendation Entry
Description
An immunization recommendation entry is used to record the patient's immunization plan. An immunization recommendation is a substance administration proposal or a documentation of an intended, but not yet administered immunization. An immunization recommendation entry may also be a record of a specific immunization that shouldn't performed. In this case, negationInd shall be set to "true", otherwise, it shall be "false".
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.93
Label IHE PCC TF2 Rev.11, 6.3.4.49
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 6 templates
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 active Manufactured Product (2016) DYNAMIC
2.16.756.5.30.1.1.10.9.48 Containment active Author Compilation with name (2020) DYNAMIC
2.16.756.5.30.1.1.10.4.95 Containment rejected Target Of The Immunization - Medication Target (2018) DYNAMIC
2.16.756.5.30.1.1.10.4.2 Containment active Annotation Comments (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.96 Containment active Recommendation Category - Criterion (2018) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.12.2 IHE Immunization Recommendation (DYNAMIC)
ref
IHE-PCC-

Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
General
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <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>  <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
REVAXIS, Dosis zu 0.5 ml
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity>
    <low value="0.3" unit="ml"/>    <high value="0.4" unit="ml"/>  </doseQuantity>  <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="7680006460010"/>      <manufacturedMaterial>
        <code code="J07CA01" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC Code" displayName="diphtheria-poliomyelitis-tetanus"/>        <name>REVAXIS Inj Susp m Nadeln</name>        <lotNumberText>G7237</lotNumberText>      </manufacturedMaterial>      <manufacturerOrganization>
        <name>Sanofi-Aventis (Suisse) SA</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <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">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.2"/>      <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"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        Dosierung: abhängig vom Alter und den Risiken (siehe Factsheet Schweizerischer Impfplan)        <reference value="#narrtextref1"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Example
HAVRIX Erwachsene 1440 U/1 ml, Dosis 0.5 ml
<substanceAdministration classCode="SBADM" moodCode="PRP" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.93"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12.2"/>  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <id root="2.999" extension="your id"/>  <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#imr-1"/>  </text>  <statusCode code="active"/>  <priorityCode nullFlavor="UNK"/>  <routeCode nullFlavor="UNK"/>  <doseQuantity value="0.5" unit="ml"/>  <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="7680005580054"/>      <manufacturedMaterial>
        <code code="J07BC02" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC Code" displayName="hepatitis A, inactivated, whole virus"/>        <name>HAVRIX 1440 Inj Susp</name>        <lotNumberText>X2124</lotNumberText>      </manufacturedMaterial>      <manufacturerOrganization>
        <name>GlaxoSmithKline AG</name>      </manufacturerOrganization>    </manufacturedProduct>  </consumable>  <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">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.756.5.30.1.1.10.4.2"/>      <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"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/>      <text>
        Dosierung: eine Dosis zur Primovakzination; Auffrischimpfung innert 6 bis 12 Monaten nach der Primovakzination        <reference value="#narrtextref2"/>      </text>      <statusCode code="completed"/>    </act>  </entryRelationship>  <precondition>
    <!-- template 2.16.756.5.30.1.1.10.4.96 'Recommendation Category - Criterion' -->
  </precondition></substanceAdministration>
Item DT Card Conf Description Label
hl7:substanceAdministration
 		An immunization recommendation entry is used to record the patient's immunization plan. An immunization recommendation is a substance administration proposal or a documentation of an intended, but not yet administered immunization. An immunization recommendation entry may also be a record of a specific immunization that shouldn't performed. In this case, negationInd shall be set to "true", otherwise, it shall be "false". IHE PCC TF2 Rev.11, 6.3.4.49
@moodCode
 		cs 1 … 1 R
  • INT: Intended but not yet administered immunization
  • PRP: recommended immunization (proposal)
  CONF
@moodCode shall be "INT"
or
@moodCode shall be "PRP"
@negationInd
 		bl 1 … 1 R
  • false: For intended or proposed immunizations.
  • true: For immunizations that shouldn't be administered
hl7:templateId
 		II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.49
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.4.93
hl7:templateId
 		II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.49
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.12.2
hl7:templateId
 		II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.49
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.25
hl7:id
 		II 1 … 1 R Immunization recommendation ID, assigned by the software application. IHE PCC TF2 Rev.11, 6.3.4.49
@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   MUST contain 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, 6.3.4.49
@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, 6.3.4.49
@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 'active' for all immunization recommendations.

 IHE PCC TF2 Rev.11, 6.3.4.49
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20023 ActStatusActive (DYNAMIC)
Choice 1 … 1 Elements to choose from:
  • hl7:effectiveTime[(local-name-from-QName(resolve-QName(@xsi:type,.))='TS' and namespace-uri-from-QName(resolve-QName(@xsi:type,.))='urn:hl7-org:v3')]
  • hl7:effectiveTime[(local-name-from-QName(resolve-QName(@xsi:type,.))='IVL_TS' and namespace-uri-from-QName(resolve-QName(@xsi:type,.))='urn:hl7-org:v3')]
hl7:effectiveTime
 		TS.CH.TZ 0 … 1 C Date on which the immunization administration is recommended. IHE PCC TF2 Rev.11, 6.3.4.49
@xsi:type
 		1 … 1 F TS
hl7:effectiveTime
 		IVL_TS.CH.TZ 0 … 1 C Period in which the immunization administration is recommended. IHE PCC TF2 Rev.11, 6.3.4.49
@xsi:type
 		1 … 1 F IVL_TS
hl7:low
 		TS.CH.TZ IHE PCC TF2 Rev.11, 6.3.4.49
hl7:high
 		TS.CH.TZ IHE PCC TF2 Rev.11, 6.3.4.49
hl7:priorityCode
 		CE 1 … 1 R

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

Recommendation for eVACDOC: @nullFlavor='UNK'

 IHE PCC TF2 Rev.11, 6.3.4.49
  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 relevant for the recommendation, the code MAY be drawn from the HL7 value set.

Recommendation for eVACDOC: @nullFlavor='NA'

 IHE PCC TF2 Rev.11, 6.3.4.49
  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 relevant for the recommendation, it MAY be recorded according to the HL7 value set.

Recommendation for eVACDOC: omit

 IHE PCC TF2 Rev.11, 6.3.4.49
@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 relevant for the recommendation, 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, 6.3.4.49
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, 6.3.4.49
@typeCode
 		cs 1 … 1 F CSM
hl7:author
 		0 … * This MAY be used to indicate who has documented the immunization recommendation. 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, 6.3.4.49
hl7:entryRelationship
 		0 … * Target of the recommended 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, 6.3.4.49
@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, 6.3.4.49
@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, 6.3.4.49