TEMPLATE NES Vaccination Record (NES Vaccination Record)

TEMPLATE ID	NES Vaccination Record
Concept	NES Vaccination Record
Description	This template is for recording the details required for vaccination events including administration events and records where the vaccination event was 'not done'. The template is authored to support NHS Education Scotland (NES) to manage its national record of citizens vaccinations. It is aligned to the FHIR immunization profile but has additional elements to support extensions used in NES's vaccine records database. Initial template version is to support a mapping between NES's 'NCDS' vaccines data base and the NES openEHR CDR.
Use	May be used to store data from external data sources (via mappings) or may be used directly in applications and interfaces to allow direct recording of vaccination events.
Misuse	This template may not be suitable for using outside of NHS Scotland organisations.
Purpose	This template is for recording the details required for vaccination events including administration events and records where the vaccination event was 'not done'. The template is authored to support NHS Education Scotland (NES) to manage its national record of citizens vaccinations. It is aligned to the FHIR immunization profile but has additional elements to support extensions used in NES's vaccine records database. Initial template version is to support a mapping between NES's 'NCDS' vaccines data base and the NES openEHR CDR.
References
Authors	date: 2021-11-08
Other Details Language	date: 2021-11-08
OtherDetails Language Independent	{PARENT:MD5-CAM-1.0.1=863626A39C0307FD80604D88B28C6DB0, original_language=ISO_639-1::en, MD5-CAM-1.0.1=e96537d0ac673887231b7a64c9ba2833, sem_ver=5.1.0, build_uid=c4d04b87-044f-4c48-88a0-45be5303603a}
Keywords	vaccine, vaccination, immunise, immunisation, immunization, immunize
Language used	en
Citeable Identifier	1051.57.288
All	OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.vaccination_record.v0, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0], code=at0000, itemType=COMPOSITION, level=0, text=NES Vaccination Record, description=Vaccination record, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/context[at0002]/other_context[at0003]/items[openEHR-EHR-CLUSTER.xds_metadata.v0], code=at0000, itemType=CLUSTER, level=2, text=XDS Metadata, description=Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/context[at0002]/other_context[at0003]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Document type, description=The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard., comment=for example: Pulmonary History and Physical, Discharge Summary, Ultrasound Report. These codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms Default value: Immunization record (record artifact), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=1, text=Vaccination management, description=Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Vaccine name, description=Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity., comment=For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1], code=at0000, itemType=CLUSTER, level=3, text=Medication, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0151], code=at0151, itemType=ELEMENT, level=4, text=Manufacturer, description=The manufacturer of the medication or medication component., comment=For example: 'Abbott'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0150], code=at0150, itemType=ELEMENT, level=4, text=Batch ID, description=The identifier assigned to the production batch by the manufacturer during production., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Identifier , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Expiry, description=The expiry date and/or time of the medication or medication component, as given by the manufacturer or individual preparing the mixture., comment=Any other form of expiry date, such as time from production or depending on storage environment, can be inserted using a specific CLUSTER archetype in the Substance Details slot or added as part of the Description. For example: '2017-05-23'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0], code=at0000, itemType=CLUSTER, level=3, text=Medication supply amount, description=Details related to the amount of a medication, vaccine or other therapeutic item to be supplied or supplied to the patient, as part of authorisation, dispensing or administration., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0]/items[at0161], code=at0161, itemType=ELEMENT, level=4, text=Amount description, description=A narrative representation of the amount The amount of medication, vaccine or therapeutic good intended to be supplied or actually supplied., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0021], code=at0021, itemType=ELEMENT, level=3, text=Reason, description=Reason that the pathway step for the identified medication was carried out., comment=For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=3, text=Administration details, description=Details of body site and administration of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=4, text=Route, description=The route by which the ordered item was, or is to be, administered into the subject's body., comment=Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0141], code=at0141, itemType=ELEMENT, level=4, text=Body site, description=Structured description of the site of administration of the ordered item., comment=For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.nes_vaccination_event_details.v0], code=at0000, itemType=CLUSTER, level=3, text=NES Vaccination event details, description=NES Vaccination event details, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.nes_vaccination_event_details.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Vaccination administration purpose, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Primary course dose Booster dose , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=Dose number, description=The sequence number specific to the pathway step being recorded., comment=For example: Vaccine sequence number., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=Note, description=Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed., comment=For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0103], code=at0103, itemType=ELEMENT, level=3, text=Appointment ID, description=Unique identifier for the medication order., comment=Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[openEHR-EHR-CLUSTER.nes_vaccination_protocol.v0], code=at0000, itemType=CLUSTER, level=3, text=nes_vaccination_protocol, description=NDS_Immunisation_Protocol. a small cluster to support recording additional details about immunization events., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[openEHR-EHR-CLUSTER.nes_vaccination_protocol.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Target disease, description=Coded or textual data for the diseases against which the vaccination is intended to confer immunity., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[openEHR-EHR-CLUSTER.nes_vaccination_protocol.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Country of vaccination, description=To record the country of vaccination, ideally using a terminology value set., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set:* external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.vaccination_record.v0]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[openEHR-EHR-CLUSTER.nes_vaccination_protocol.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Vaccination centre, description=A text element for the name or other description of the vaccination centre where this vaccination record originated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]