Section Code |
LOINC: 11369-6 (HISTORY OF IMMUNIZATIONS) |
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Description |
The Immunizations section is used to capture a history of immunizations given to the patient. It will contain a narrative of the immunizations given as well as substance administration entries for each vaccination. |
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CDA Level |
Level 3 Only |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.6 |
CCD 3.11 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.23 |
IHE PCC TF-2: 6.3.3.3.5 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Immunization |
2.16.840.1.113883.10.20.1.24 1.3.6.1.4.1.19376.1.5.3.1.4.12 |
3.4.2.10 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
ImmunizationsSectionProcessor.java |
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Additional Constraints |
- OpenSHR will only process immunization entries and sections marked with the IHE PCC template identifier and will not process sections with only the CCD template identifier.
- OpenSHR will only process immunizations with a moodCode=EVN (Event Occurrence), intent to administer vaccinations is not yet supported by OpenSHR
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Notes |
The immunizations given should be identified with appropriate substanceAdministration entries. If the patient's immunization history is unknown solicitors may choose to send, and OpenSHR will send, a single substanceAdministration entry with SNOMED code 182904002 (Drug Treatment Unknown) |
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Specification |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<!-- HL7 CCD Template Identifier - Immunizations -->
<templateId root="2.16.840.1.113883.10.20.1.6"/>
<!-- IHE PCC Template Identifier - History of Immunizations -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.23"/>
<!-- 1..1 Section Code-->
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF IMMUNIZATIONS"/>
<!-- 1..1 Title -->
<title language="en-US">...</title>
<!-- 1..1 Text (See general implementation notes for guidance) -->
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- 0..n Substance Administration entries representing immunizations given -->
<entry typeCode="DRIV" contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
</substanceAdministration>
</entry>
</section>
</component> |
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Example |
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The following example illustrates a patient record whose only registered immunization was an influenza virus vaccine given via intramuscular injection sometime November 1999. |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.6"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.23"/>
<id root="d5ebb566-173b-45eb-8b5f-2585454ddd35"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF IMMUNIZATIONS"/>
<title language="en-US">History of Immunizations</title>
<text mediaType="text/x-hl7-text+xml">
...
</text>
<entry typeCode="DRIV" contextConductionInd="true">
<!-- Substance Administration - Immunization Procedure -->
<substanceAdministration classCode="SBADM" moodCode="EVN">
<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"/>
<!-- Unique identifier of the administration in the source system -->
<id root="1.2.3.4.5.3" extension="222"/>
<!-- Procedure code was immunization -->
<code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Immunization"/>
<text>
<reference value="#obs684804cc"/>
</text>
<statusCode code="completed"/>
<!-- Immunization given sometime in November 1999-->
<effectiveTime xsi:type="SXCM_TS" value="199911"/>
<!-- Route code - Route of administration -->
<routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="2.16.840.1.113883.5.112" displayName="Intramuscular injection">
<originalText representation="TXT">Intramuscular injection</originalText>
</routeCode>
<!-- The drug that was administered -->
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
<!-- Drug administered - Influenza Virus Vaccine -->
<manufacturedMaterial classCode="MMAT">
<code code="88" codeSystem="2.16.840.1.113883.6.59" codeSystemName="HL-7 CVX" displayName="Influenza virus vaccine">
<originalText representation="TXT" language="en-US">
<reference value="#txt9428c829"/>
</originalText>
</code>
<name>Influenza virus vaccine</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component> |
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