The Master Data Model for Veteran Care

Developer Documentation » VDM » V_Immunization-9000010_11

V Immunization (9000010.11)

In order to preserve the continuity of files shared by the Indian Health Service and the Department of Veterans Affairs, this file includes fields used by Indian Health Service that will not be used by the Department of Veterans Affairs. These fields may point to other files and routines not deployed by the Department of Veterans Affairs. Inclusion of these fields, as designed, was approved by the DBA. These fields were initially introduced with the release of the VISTA IMMUNIZATION ENHANCEMENTS 1.0 (PX1201) for the VistA Immunization Enhancements Project. Additional fields may be included in later enhancements. This file contains immunizations specific to a particular visit for a particular patient. This file contains one record for each immunization. In the VA, if a CPT code is entered into PCE that represents an immunization, than an immunization will automatically be entered in the V Immunization file. And vice versa, if an immunization is entered into PCE that has a related CPT code, then a V CPT entry will automatically be created with the CPT code for the immunization. The PCE Code Mapping file contains the definitions of what immunization is related to what CPT code, and vice versa.

Global: ^AUPNVIMM(

Domain: Non-Clinical

Properties

Label/Field Name Field # Description Datatype Attributes Range
Immunization
  immunization
.01 This is the type of immunization that was given to the patient at the
encounter.
POINTER INDEXED
REQUIRED
Immunization-9999999_14
Patient Name
  patient_name
.02 This is the patient who was given the immunization. POINTER REQUIRED Patient_ihs-9000001
Visit
  visit
.03 This is the encounter defined in the Visit file that represents when and
where the immunization was given.
POINTER INDEXED
REQUIRED
Visit-9000010
Series
  series
.04 This field allows the provider to specify which series of immunization
type was given to the patient.
ENUMERATION   COMPLETE: C
PARTIALLY COMPLETE: P
SERIES 8: 8
SERIES 7: 7
SERIES 6: 6
SERIES 5: 5
SERIES 4: 4
SERIES 3: 3
SERIES 2: 2
SERIES 1: 1
BOOSTER: B
Lot
  lot
.05 This Indian Health Service field indicates the lot number associated
with this immunization.
POINTER   Immunization_Lot-9999999_41
Reaction
  reaction
.06 This is the reaction that may have been observed by the provider as a
result of the immunization given.
ENUMERATION   IRRITABILITY: 2
ANAPHYLAXIS OR COLLAPSE: 9
NONE: 0
FEVER: 1
LETHARGY: 6
RESPIRATORY DISTRESS: 10
OTHER: 11
VOMITING: 4
ARTHRITIS OR ARTHRALGIAS: 8
LOCAL REACTION OR SWELLING: 3
RASH OR ITCHING: 5
CONVULSIONS: 7
Contraindicated
  contraindicated
.07 This field allows the immunization to be recorded as contraindicated.
Reminders will include a check to see if the previous immunization was
contraindicated before creating reminders.
ENUMERATION   NO (OK TO USE IN THE FUTURE): 0
YES (DO NOT REPEAT THIS VACCINE).: 1
Dose Override
  dose_override
.08 This Indian Health Service field indicates the dose override status of
this immunization.
ENUMERATION   @: 0
INVALID--ADMIN ERROR: 4
FORCED VALID: 9
INVALID--DEFECTIVE: 2
INVALID--EXPIRED: 3
INVALID--BAD STORAGE: 1
Injection Site
  injection_site
.09 This Indian Health Service field identifies the body site where the
immunization was administered.
ENUMERATION   Left Arm Intradermal: LID
Both Thighs IM: BTI
Oral: O
Left Delt IM: LDI
Nasal: IN
Right Arm SQ: RAS
Left Thigh SQ: LTS
Right Thigh IM: RTI
Left Arm SQ: LAS
Left Thigh IM: LTI
Right Thigh SQ: RTS
Right Delt IM: RDI
Right Arm Intradermal: RID
Volume
  volume
.11 This Indian Health Service field indicates the volume of vaccine
administered for this immunization.
NUMERIC    
Date Of Vac Info Statement
  date_of_vac_info_statement
.12 This Indian Health Service field indicates the date the vaccine
information statement associated with this immunization was
offered/given to the patient.
DATE-TIME    
Created By V Cpt Entry
  created_by_v_cpt_entry
.13 This Indian Health Service field identifies the V CPT entry, if any,
that created this V Immunization entry.
NUMERIC    
Vac Eligibility
  vac_eligibility
.14 This Indian Health Service field indicates the Vaccine for Children
(VFC) Program eligibility for this patient on this visit.
     
Import From Outside Registry
  import_from_outside_registry
.15 This Indian Health Service field indicated the import status of this
immunization from an outside registry.
ENUMERATION   IMPORTED: 1
NOT IMPORTED: 0
EDITED AFTER IMPORT: 2
Ndc
  ndc
.16 This Indian Health Service field identifies the National Drug Code
(NDC) for this vaccine.
     
Administrative Notes
  administrative_notes
1 This Indian Health Service field is a free text field used to document
administrative information about this immunization.
STRING    
Vis Offered/given To Patient
  vis_offered_given_to_patient
2 This is the Vaccine Information Statement (VIS) that was offered to the
patient prior to the administration of the immunization, along with the
date/time it was offered.
OBJECT   Vis_Offered_given_To_Patient-9000010_112
Other Diagnosis
  other_diagnosis
3 This is a list of diagnoses for this immunization event, in addition to
the Primary Diagnosis selected for this event.
POINTER   Icd_Diagnosis-80
Remarks
  remarks
1101 This is additional comments or remarks related to the immunization given
to the patient.
STRING    
Event Date And Time
  event_date_and_time
1201 This is the date and time the immunization was given. This date and time
may be different from the visit date and time. For example, for clinic
appointment visits, the visit date and time is the date and time of the
appointment, not the time the provider performed the clinical event.

The date may be an imprecise date.

Date and time may be within 30 days before or after the visit date, with the
restriction the date cannot be a future date.
DATE-TIME    
Ordering Provider
  ordering_provider
1202 The field can be used to document the provider who ordered the
immunization.
POINTER   New_Person-200
Clinic
  clinic
1203 This Indian Health Service field indicates the clinic stop associated
with this visit.
POINTER   Clinic_Stop-40_7
Encounter Provider
  encounter_provider
1204 This is the provider who gave this
immunization.
POINTER   New_Person-200
Date/time Recorded
  date_time_recorded
1205 This timestamp field is the date and time of documentation of
administration of the immunization. This field is set automatically
when the EVENT DATE AND TIME is entered.
DATE-TIME    
Immunization Documenter
  immunization_documenter
1206 This is the person/provider who documented this immunization by entering
the data into the system by whatever means.
POINTER   New_Person-200
Lot Number
  lot_number
1207 This is the lot number of the Immunization entered for this event. It is
not designed to be edited manually, but automatically set when an
Immunization is selected.
POINTER INDEXED Immunization_Lot-9999999_41
Parent
  parent
1208 This Indian Health Service field indicates the parent immunization, if
any, associated with this immunization, such as for immunizations given
in series.
POINTER   V_Immunization-9000010_11
External Key
  external_key
1209 This Indian Health Service free text field identifies the external key
associated with this immunization.
STRING    
Outside Provider Name
  outside_provider_name
1210 This Indian Health Service field contains the name of the outside
provider associated with this immunization.
STRING    
Ancillary POV
  ancillary_pov
1213 This Indian Health Service field indicated the ancillary diagnosis
related to this immunization.
POINTER   Icd_Diagnosis-80
User Last Update
  user_last_update
1214 This Indian Health Service field indicates the user who last updated
information for this immunization.
POINTER   New_Person-200
Ordering Location
  ordering_location
1215 This Indian Health Service field indicated the hospital location ordering
this immunization.
POINTER   Hospital_Location-44
Date/time Entered
  date_time_entered
1216 This Indian Health Service field indicates the date and time that this
immunization information was entered into this record.
DATE-TIME    
Entered By
  entered_by
1217 This Indian Health Service field indicates the user who entered this
immunization record.
POINTER   New_Person-200
Date/time Last Modified
  date_time_last_modified
1218 This Indian Health Service field indicates the date and time this
immunization record was last modified.
DATE-TIME    
Last Modified By
  last_modified_by
1219 This Indian Health Service field indicates the user who last modified
this immunization record.
POINTER   New_Person-200
Timestamp
  timestamp
1221 Indicates the date/time the record was added or edited. DATE-TIME    
Event Information Source
  event_information_source
1301 This is the source of the information obtained for this immunization
event. If this is a new event for this patient, no entry is required.
POINTER   Immunization_Info_Source-920_1
Route Of Administration
  route_of_administration
1302 This is the method this vaccine was administered. Select from the list
provided.
POINTER   Imm_Administration_Route-920_2
Site Of Administration (body)
  site_of_administration_body
1303 This is the area of the patient’s body through which the vaccine was
administered.
POINTER   Imm_Administration_Site_body-920_3
Primary Diagnosis
  primary_diagnosis
1304 This is the primary (or initial) diagnosis for this immunization event. It
is selected from the ISC DIAGNOSIS file.
POINTER   Icd_Diagnosis-80
Dosage
  dosage
1312 This is the amount of this vaccine to be administered for this event.
It is free text, 3 to 30 characters, and should be in the format of an
amount followed by units of measure, such as “30 cc”.
STRING    
Snomed Ct
  snomed_ct
2601 This Indian Health Service field indicates the SNOMED Clinical Terms (CT)
that describe this immunization and their preferred terms.
OBJECT   Snomed_Ct-9000010_1126
Loinc Codes
  loinc_codes
2701 This Indian Health Service field is the LOINC codes that identifies this
immunization, along with their descriptions.
OBJECT   Loinc_Codes-9000010_1127
Edited Flag
  edited_flag
80101 This field is automatically set to 1 if PCE detects that any original
immunization data is being edited.
ENUMERATION   EDITED: 1
Audit Trail
  audit_trail
80102 This field is populated automatically by the PCE filing logic. The format
of the field is as follows: Pointer to PCE data source file_”-“A for Add
or E for Edit
” “DUZ of the person who entered the data”;”…
STRING    
Comments
  comments
81101 This is a comment related to the patient’s immunization. The provider may enter
this manually via the PCE User Interface.
STRING    
Verified
  verified
81201 This is used to note how the event was verified and is automatically
entered by the software.
ENUMERATION   VERIFIED BY PACKAGE: 2
ELECTRONICALLY SIGNED: 1
Package
  package
81202 This is the VistA package from which this immunization record
originated through PCE.
POINTER   Package-9_4
Data Source
  data_source
81203 This is the data source for this immunization, automatically entered
through the PCS software and uneditable by users.
POINTER   Pce_Data_Source-839_7

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Sub-Files

Vis Offered/given To Patient (9000010.112)

ID
Vis_Offered_given_To_Patient-9000010_112

Properties

Label/Field Name Field # Description Datatype Attributes Range
Vis Offered/given To Patient
  vis_offered_given_to_patient
.01 This is the name of the Vaccine Information Statement offered to or given
to the patient before administration of the immunization.
POINTER INDEXED
REQUIRED
Vaccine_Information_Statement-920
Date Vis Offered/given
  date_vis_offered_given
.02 This is the date the Vaccine Information Statement was offered to or
given to the patient.
DATE-TIME    

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Snomed Ct (9000010.1126)

ID
Snomed_Ct-9000010_1126

Properties

Label/Field Name Field # Description Datatype Attributes Range
Snomed Ct
  snomed_ct
.01 This Indian Health Service field indicates a SNOMED Clinical Term (CT)
that describes this immunization.
STRING INDEXED
REQUIRED
 

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Loinc Codes (9000010.1127)

ID
Loinc_Codes-9000010_1127

Properties

Label/Field Name Field # Description Datatype Attributes Range
Loinc Codes
  loinc_codes
.01 This Indian Health Service field is a LOINC code that identifies this
immunization.
STRING INDEXED
REQUIRED
 

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Document generated on August 31st 2017, 2:55:41 pm