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<!-- conforms to Immunizations section with entries optional -->
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2015-08-01"/>
<!-- Immunizations section with entries required -->
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2015-08-01"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of immunizations"/>
<table border="1" width="100%">
<tr ID="immun1">
<td> Unknown Immunization Status</td>
<td>Nov 1999</td>
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="false" nullFlavor="NI">
<!-- We selected NI for this example, C-CDA R2 may describe other appropriate nullFlavors -->
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2015-08-01"/>
<!-- **** Immunization activity template **** -->
<id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f88"/>
<!-- No information on whether the patient received a vaccination -->
<reference value="#immun1"/>
<!-- Link to narrative stating no information on whether the patient received a vaccination -->
<statusCode code="completed"/>
<effectiveTime value="199911"/>
<!-- Date which you do not know whether or not patient received a vaccination -->
<manufacturedProduct classCode="MANU">
<!-- ** Immunization medication information ** -->
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2014-06-09"/>
<!-- Needed to use nullFlavor of OTH since templates requires CVX in code element-->
<code nullFlavor="OTH">
<!-- Optional original text -->
<translation code="71181003" displayName="vaccine"
codeSystemName="SNOMED CT"/>