MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.3|
PID||0493575^^^2^ID 1|454721||Publius^Jack^^^^^A|Public^JOHN^^^^|19451231|M| Public^JOHN^^^^ |B|254 E 238 ST^^EUCLID^OH^44123^USA||(216)731-4359^^PRN^test@there.com|||M|NON|400003403~1129086|585323322||||Mars Colony|1|3
MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.3|
PID||0493575^^^2^ID 1|454721||Public^JOHN^Quincy^III^Dr.^M.D.^L|Public^JOHN^^^^|19451231|M||B|254 E 238 ST^^EUCLID^OH^44123^USA||(216)731-4359^^PRN|||M|NON|400003403~1129086|585323322||||Mars Colony|1|3
MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1816457|D|2.3|
EVN|A04|199912271408|||CHARRIS
PID||0493575^^^2^ID 1|454521||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M|Buck^Jack^^^^^A|B|254 E 238 ST^^EUCLID^OH^44123^USA||(216)731-4359^^PRN|||M|NON|400003403~1129086|999-23-3322||||Easter Island|1|3
NK1||CONROY^MARI^^^^|SPO||(216)731-4359||EC|||||||||||||||||||||||||||
PV1||O|168   ~219~C~PMA^^^^^^^^^||||277^ALLEN FADZL^BONNIE^^^^|||||||||| ||2688684|||||||||||||||||||||||||199912271408||||||002376853
MSH|^~\&||GA0000||VAERS PROCESSOR|20010331605||ORU^RO1|20010422GA03|T|2.3.1|||AL|
PID|||1234^^^^SR~1234-12^^^^LR~00725^^^^MR||Doe^John^Fitzgerald^JR^^^L||20001007|M||2106-3^White^HL70005|123 Peachtree St^APT 3B^Atlanta^GA^30210^^M^^GA067||(678) 555-1212^^PRN|
NK1|1|Jones^Jane^Lee^^RN|VAB^Vaccine administered by (Name)^HL70063|
NK1|2|Jones^Jane^Lee^^RN|FVP^Form completed by (Name)-Vaccine provider^HL70063|101 Main Street^^Atlanta^GA^38765^^O^^GA121||(404) 554-9097^^WPN|
ORC|CN|||||||||||1234567^Welby^Marcus^J^Jr^Dr.^MD^L|||||||||Peachtree Clinic|101 Main Street^^Atlanta^GA^38765^^O^^GA121|(404) 554-9097^^WPN|101 Main Street^^Atlanta^GA^38765^^O^^GA121|
OBR|1|||^CDC VAERS-1 (FDA) Report|||20010316|
OBX|1|NM|21612-7^Reported Patient Age^LN||05|mo^month^ANSI|
OBX|1|TS|30947-6^Date form completed^LN||20010316|
OBX|2|FT|30948-4^Vaccination adverse events and treatment, if any^LN|1|fever of 106F, with vomiting, seizures, persistent crying lasting over 3 hours, loss of appetite|
OBX|3|CE|30949-2^Vaccination adverse event outcome^LN|1|E^required emergency room/doctor visit^NIP005|
OBX|4|CE|30949-2^Vaccination adverse event outcome^LN|1|H^required hospitalization^NIP005|
OBX|5|NM|30950-0^Number of days hospitalized due to vaccination adverse event^LN|1|02|d^day^ANSI|
OBX|6|CE|30951-8^Patient recovered^LN||Y^Yes^ HL70239|
OBX|7|TS|30952-6^Date of vaccination^LN||20010216|
OBX|8|TS|30953-4^Adverse event onset date and time^LN||200102180900|
OBX|9|FT|30954-2^Relevant diagnostic tests/lab data^LN||Electrolytes, CBC, Blood culture|
OBR|2|||30955-9^All vaccines given on date listed in #10^LN|
OBX|1|CE30955-9&30956-7^Vaccine type^LN|1|08^HepB-Adolescent/pediatric^CVX|
OBX|2|CE|30955-9&30957-5^Manufacturer^LN|1|MSD^Merck^MVX|
OBX|3|ST|30955-9&30959-1^Lot number^LN|1|MRK12345|
OBX|4|CE|30955-9&30958-3^ Route^LN|1|IM^Intramuscular ^HL70162|
OBX|5|CE|30955-9&31034-2^Site^LN|1|LA^Left arm^ HL70163|
OBX|6|NM|30955-9&30960-9^Number of previous doses^LN|1|01I
OBX|7|CE|CE|30955-9&30956-7^Vaccine type^LN|2|50^DTaP-Hib^CVX|
OBX|8|CE|30955-9&30957-5^ Manufacturer^LN|2|WAL^Wyeth_Ayerst^MVX|
OBX|9|ST|30955-9&30959-1^Lot number^LN|2|W46932777|
OBX|10|CE|30955-9&30958-3^ Route^LN|2|IM^Intramuscular^HL70162|
MSH|^~\&||GA0000||VAERS PROCESSOR|20010331605||ORU^R01|20010422GA03|T|2.3.1|||AL|
PID|||1234^^^^SR~1234-12^^^^LR~00725^^^^MR||Doe^John^Fitzgerald^JR^^^L||20001007|M||2106-3^White^HL70005|123 Peachtree St^APT 3B^Atlanta^GA^30210^^M^^GA067||(678) 555-1212^^PRN|
NK1|1|Jones^Jane^Lee^^RN|VAB^Vaccine administered by (Name)^HL70063|
NK1|2|Jones^Jane^Lee^^RN|FVP^Form completed by (Name)-Vaccine provider^HL70063|101 Main Street^^Atlanta^GA^38765^^O^^GA121||(404) 554-9097^^WPN|
ORC|CN|||||||||||1234567^Welby^Marcus^J^Jr^Dr.^MD^L|||||||||Peachtree Clinic|101 Main Street^^Atlanta^GA^38765^^O^^GA121|(404) 554-9097^^WPN|101 Main Street^^Atlanta^GA^38765^^O^^GA121|
OBR|1|||^CDC VAERS-1 (FDA) Report|||20010316|
OBX|1|NM|21612-7^Reported Patient Age^LN||05|mo^month^ANSI|
OBX|1|TS|30947-6^Date form completed^LN||20010316|
OBX|2|FT|30948-4^Vaccination adverse events and treatment, if any^LN|1|fever of 106F, with vomiting, seizures, persistent crying lasting over 3 hours, loss of appetite|
OBX|3|CE|30949-2^Vaccination adverse event outcome^LN|1|E^required emergency room/doctor visit^NIP005|
OBX|4|CE|30949-2^Vaccination adverse event outcome^LN|1|H^required hospitalization^NIP005|
OBX|5|NM|30950-0^Number of days hospitalized due to vaccination adverse event^LN|1|02|d^day^ANSI|
OBX|6|CE|30951-8^Patient recovered^LN||Y^Yes^ HL70239|
OBX|7|TS|30952-6^Date of vaccination^LN||20010216|
OBX|8|TS|30953-4^Adverse event onset date and time^LN||200102180900|
OBX|9|FT|30954-2^Relevant diagnostic tests/lab data^LN||Electrolytes, CBC, Blood culture|
OBR|2|||30955-9^All vaccines given on date listed in #10^LN|
OBX|1|CE30955-9&30956-7^Vaccine type^LN|1|08^HepB-Adolescent/pediatric^CVX|
OBX|2|CE|30955-9&30957-5^Manufacturer^LN|1|MSD^Merck^MVX|
OBX|3|ST|30955-9&30959-1^Lot number^LN|1|MRK12345|
OBX|4|CE|30955-9-3^ Route^LN|1|IM^Intramuscular ^HL70162|
OBX|5|CE|30955-9&31034-2^Site^LN|1|LA^Left arm^ HL70163|
OBX|6|NM|30955-9&30960-9^Number of previous doses^LN|1|01I
OBX|7|CE|CE|30955-9-7^Vaccine type^LN|2|50^DTaP-Hib^CVX|
OBX|8|CE|30955-9&30957-5^ Manufacturer^LN|2|WAL^Wyeth_Ayerst^MVX|
OBX|9|ST|30955-9-1^Lot number^LN|2|W46932777|
OBX|10|CE|30955-9&30958-3^ Route^LN|2|IM^Intramuscular^HL70162|
OBX|11|CE|30955-9&31034-2^Site^LN|2|LA^Left arm^HL70163|
OBX|12|NM|30955-9&30960-9^Number of previous doses^LN|2|01|
OBR|3|||30961-7^Any other vaccinations within 4 weeks prior to the date listed in #10|
OBX|1|CE|30961-7-7^Vaccine type^LN|1|10^IPV^CVX|
OBX|2|CE|30961-7&30957-5^Manufacturer^LN|1|PMC^Aventis Pasteur ^MVX|
OBX|3|ST|30961-7&30959-1^Lot number^LN|1|PMC123456|
OBX|4|CE|30961-7&30958-3^Route^LN|1|SC^Subcutaneaous^HL70162|
OBX|5|CE|30961-7&31034-2^Site^LN|1|LA^Left arm^HL70163|
OBX|6|NM|30961-7&30960-9^Number of previous doses^LN|1|01|
OBX|7|TS|30961-7&31035-9^date given^LN|1|20001216|
OBX|8|CE|30962-^Vaccinated at^LN||PVT^Private doctors office/hospital^NIP009|
OBX|9|CE|30963-3^Vaccine purchased with^LN||PBF^Public funds^NIP008|
OBX|10|FT|30964-1^Other medications^LN||None|
OBX|11|FT|30965-8^Illness at time of vaccination (specify)^LN||None|
OBX|12|FT|30966-6^Pre-existing physician diagnosed allergies, birth defects, medical conditions^LN||Past conditions convulsions|
OBX|13|CE|30967-4^Was adverse event reported previously^LN||N^no^NIP009|
OBR|4||30968-2^Adverse event following prior vaccination in patient^LN|
OBX|1|TX|30968-2&30971-6^Adverse event^LN||None|
OBR|5||30969-0^Adverse event following prior vaccination in brother^LN|
OBX|1|TX||30969-0&30971-6^Adverse event^LN||vomiting, fever, otitis media|
OBX|2|NM||30969-0&30972-4^Onset age^LN||04|mo^month^ANSI|
OBX|3|CE||30969-0&30956-7^Vaccine Type ^LN||10^IPV^CVX|
OBX|4|NM||30969-0&30973-2^Dose number in series^LN||02|
OBR|6|||30970-8^Adverse event following prior vaccination in sister^LN|
OBX|1|TX|30970-8&30971-6^Adverse event^LN||None|
OBR|7||^For children 5 and under|
OBX|1|NM|8339-4^Body weight at birth^LN||82|oz^ounces^ANSI|
OBX|2|NM|30974-0^Number of brothers and sisters^LN||2|
OBR|8|||^Only for reports submitted by manufacturer/immunization project|
OBX|1|ST|30975-7^Mfr./Imm. Proj. report no.^LN||12345678|
OBX|2|TS|30976-5^Date received by manufacturer/immunization project^LN||12345678|
OBX|3|CE|30977-3^15 day report^LN||N^No^HL70136|
OBX|4|CE|30978-1^Report type^LN||IN^Initial^NIP010|
MSH|^~\&||GA0000||MA0000|199705221605||VXQ^V01|19970522GA40|T|2.3.1|||AL
QRD|199705221605|R|I|19970522GA05|||25^RD|^KENNEDY^JOHN^FITZGERALD^JR|VXI^VACCINE INFORMATION^HL70048|^SIIS
QRF|MA0000||||256946789~19900607~MA~MA99999999~88888888~KENNEDY^JACQUELINE^LEE~BOUVIER~898666725~KENNEDY^JOHN^FITZGERALD~822546618