Immunization not given Patient refused

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Example metadata last updated 2017-12-11 19:21:12.037000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 10/29/2015
  • SDWG: 11/12/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This is an example of how an author can record a patient refused an immunization.

Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)

Full sample: Immunizations in empty CCD

Example: download example view on GitHub

<component>
    <section>
        <!-- conforms to Immunizations section with entries optional -->
        <templateId root="2.16.840.1.113883.10.20.22.2.2"/>
        <templateId root="2.16.840.1.113883.10.20.22.2.2" extension="2015-08-01"/>
        <!-- Immunizations section with entries required -->
        <templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
        <templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2015-08-01"/>
        <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
            displayName="History of Immunizations"/>
        <title>Immunizations</title>
        <text><paragraph ID="immun1">Patient objected to <content ID="ImmunizationProduct_1">influenza, intradermal, quadrivalent</content> on 11/15/2015</paragraph></text>
        <entry typeCode="COMP">
            <!-- negationInd=true indicates substance was NOT given at this date-->
            <substanceAdministration classCode="SBADM" moodCode="EVN"
                negationInd="true">
                <!-- ** Immunization activity ** -->
                <templateId root="2.16.840.1.113883.10.20.22.4.52"/>
                <templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/>
                <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
                <text>
                    <reference value="#immun1"/>
                </text>
                <!-- Indicates the status of the substanceAdministartion -->
                <statusCode code="completed"/>
                <effectiveTime value="20151115"/>
                <consumable>
                    <manufacturedProduct classCode="MANU">
                        <!-- ** Immunization medication information ** -->
                        <templateId root="2.16.840.1.113883.10.20.22.4.54"/>
                        <templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/>
                        <manufacturedMaterial>
                            <code code="166" codeSystem="2.16.840.1.113883.12.292"
                                displayName="influenza, intradermal, quadrivalent, preservative free"
                                codeSystemName="CVX">
                                <originalText>
                                    <reference value="#ImmunizationProduct_1"/>
                                </originalText>
                            </code>
                            <!-- DSTU comment relaxing lotNumber requirement -->
                            <!-- http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=995 -->
                            <!-- <lotNumberText>1</lotNumberText> -->
                        </manufacturedMaterial>
                        
                    	<!-- Optional manufacturerOrganization
                    				<manufacturerOrganization>
                     				   <name>Health LS - Immuno Inc.</name>
                   					 </manufacturerOrganization>-->
                    </manufacturedProduct>
                </consumable>
                <entryRelationship typeCode="RSON">
                    <observation classCode="OBS" moodCode="EVN">
                        <!-- Immunization Refusal Reason  -->
                        <!-- Included the reason since it may be relevant to a future clinician or quality measurement -->
                        <templateId root="2.16.840.1.113883.10.20.22.4.53"/>
                        <id root="c1296315-9a6d-45a2-aac0-ee225d375409"/>
                        <code displayName="Patient Objection" code="PATOBJ"
                            codeSystemName="HL7 ActNoImmunizationReason" codeSystem="2.16.840.1.113883.5.8"/>
                        <statusCode code="completed"/>
                    </observation>								
                </entryRelationship>
            </substanceAdministration>
        </entry>
    </section>        
</component>
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