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<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>
<content ID="immunSect"/>
<table border="1" width="100%">
<thead>
<tr>
<th>Vaccine</th>
<th>Lot Number</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="immun1">
<td ID="ImmunizationProduct_100">Influenza Virus Vaccine</td>
<td>1</td>
<td>8/15/2010</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
<!-- ** 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="20100815"/>
<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="88" codeSystem="2.16.840.1.113883.12.292"
displayName="Influenza virus vaccine" codeSystemName="CVX">
<originalText>
<reference value="#ImmunizationProduct_100"/>
</originalText>
</code>
<lotNumberText>1</lotNumberText>
</manufacturedMaterial>
<!-- Optional manufacturerOrganization
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>-->
</manufacturedProduct>
</consumable>
<!-- Optional Performer -->
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.19.5.9999.456" extension="2981824"/>
<addr>
<streetAddressLine>1021 Health Drive</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99099</postalCode>
<country>US</country>
</addr>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<given>Amanda</given>
<family>Assigned</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1394"/>
<name>Good Health Clinic</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<!-- Optional Author -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20100815"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Family Medicine" />
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</substanceAdministration>
</entry>
</section>
</component>