CH EMS (R4)
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CH EMS (R4), published by IVR Interverband für Rettungswesen. This guide is not an authorized publication; it is the continuous build for version 1.9.0-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7ch/ch-ems/ and changes regularly. See the Directory of published versions

Example Bundle: 1 Einsatzprotokoll

Document Subject

Unable to resolve subject ''

Document Content

Einsatz

Einsatz
Einsatzdatum10.12.2016
EinsatznummerS12345678
aufbietende Organisation7601002156370 (SNZ)
augebotene Organisation7601002156363 (Rettungsdienst Schutz & Rettung Zürich)
TeamPetra Muster, GLN 7601003330434, Betreuerin / Hans Beispiel, GLN 7601000028105, Betreuer
EinsatzortZürich, Waldrand (47.392115, 8.553192)
ZielortUSZ Notfall
AlarmStatus DPStatus 1Status 2Kontakt PatientStatus 3Status 4Status 5Status 6
12.0912.1112.1312.1712.2212.4812.54--

Administrativ

Person/Organsiation
EhefrauErika Muster

Vorbehandlung

-

Anamnese

Geschehen
Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.
Symptome
Starke Schmerzen in der Brust und im linken Oberarm verspürt

Allergien

  • Baumpollen
  • bekannte Unverträglichkeitsreaktion auf einzelne Medikamente

preMedication

  • Aspirin cardio 100, 1 Tbl/Tag

Medizinische Vorgeschichte

  • Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio

Weitere

  • Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen
  • Peter Muster hat keine Patientenverfügung erstellt
  • es sind keine anderen medizinische Probleme bekannt

Befund

Blutdruck 120/80 mmHg gemessen am rechten Arm / Schmerz 5

GCS
Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ motor. Reaktion befolgt Antweisungen 6) um 12:25

Disability

Diagnosen

Verdachtsdiagnose
akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW

Massnahmen

Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray

Todesfall

-

Transport

Fahrt mit Sondersignal ins USZ.

Übergabe

Schmerz 4

GCS
15(4/5/6) um 13.03
NACA
NACA: III
Zustand
der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert

Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis

Kommentar

-

Additional Resources Included in Document

Entry 1 - fullUrl = http://test.fhir.ch/r4/Composition/1-Einsatzprotokoll-Composition

Resource Composition:

Generated Narrative: Composition 1-Einsatzprotokoll-Composition

Language: de-CH

Profile: CH EMS Composition Profile

Security Label: N (Details: [not stated] code N)

EPR Information Recipient: Practitioner Spezialarzt Hans

EPR Information Recipient: Organization USZ

identifier: Uniform Resource Identifier (URI)/urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78

status: Final

type: EMS Patient Care Report

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

date: 2016-12-10 12:05:00+0100

author:

title: Einsatzprotokoll Rettungsdienst

Attesters

-ModeTimeParty
*Legal2016-12-10 12:13:05+0100Practitioner Petra Muster

custodian: Organization Rettungsdienst Schutz und Rettung Zürich

Entry 2 - fullUrl = http://test.fhir.ch/r4/Encounter/1-Einsatz

Resource Encounter:

Generated Narrative: Encounter 1-Einsatz

identifier: urn:oid:2.16.756.5.30.1.9999999999.1/S12345678

status: completed

class: emergency

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

basedOn: ServiceRequest: status = completed; intent = order

participant

CH EMS Extension Team Role: Caregiver

participant

CH EMS Extension Team Role: Caregiver

participant

CH EMS Extension Team Role: Physician

Locations

-Location
*Location Waldrand

Entry 3 - fullUrl = http://test.fhir.ch/r4/Patient/1-PeterMuster

Resource Patient:

Generated Narrative: Patient 1-PeterMuster

Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

Other Id:Medical record number/762354
Contact DetailBahnhofstrasse Zürich 8003 Schweiz (home)
Contact:
  • Erika Muster
Place of Origin according to eCH-0011Musterdorf ZH

Entry 4 - fullUrl = http://test.fhir.ch/r4/Coverage/1-CoveragePeterMuster

Resource Coverage:

Generated Narrative: Coverage 1-CoveragePeterMuster

identifier: urn:oid:2.16.756.5.30.1.123.100.1.1.1/80756003760012390001

status: Active

beneficiary: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

Generated Narrative: Organization #kpt

name: KPT

Entry 5 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-InformationRecipientSpezialarzt

Resource Practitioner:

Generated Narrative: Practitioner 1-InformationRecipientSpezialarzt

identifier: GLN/7601000404268

name: Spezialarzt Hans

Entry 6 - fullUrl = http://test.fhir.ch/r4/Organization/1-InformationRecipientUSZ

Resource Organization:

Generated Narrative: Organization 1-InformationRecipientUSZ

identifier: GLN/7601002155939

name: USZ

Contacts

-Address
*Rämistrasse 100 Zürich 8091 CH

Entry 7 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-SaniPetraMuster

Resource Practitioner:

Generated Narrative: Practitioner 1-SaniPetraMuster

identifier: GLN/7601003330434

name: Petra Muster

Entry 8 - fullUrl = http://test.fhir.ch/r4/PractitionerRole/1-SaniPetraMuster-PR

Resource PractitionerRole:

Generated Narrative: PractitionerRole 1-SaniPetraMuster-PR

practitioner: Practitioner Petra Muster

code: Caregiver

Entry 9 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-NotarztHansNotarzt

Resource Practitioner:

Generated Narrative: Practitioner 1-NotarztHansNotarzt

identifier: GLN/7601000028105

name: Hans Notarzt

Entry 10 - fullUrl = http://test.fhir.ch/r4/PractitionerRole/1-NotarztHansNotarzt-PR

Resource PractitionerRole:

Generated Narrative: PractitionerRole 1-NotarztHansNotarzt-PR

practitioner: Practitioner Hans Notarzt

code: Physician

Entry 11 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberPetraMuster

Resource Practitioner:

Generated Narrative: Practitioner 1-TeamMemberPetraMuster

identifier: GLN/7601003330434

name: Petra Muster

Entry 12 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberHansBeispiel

Resource Practitioner:

Generated Narrative: Practitioner 1-TeamMemberHansBeispiel

identifier: GLN/7601000211804

name: Hans Beispiel

Entry 13 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberHansNotarzt

Resource Practitioner:

Generated Narrative: Practitioner 1-TeamMemberHansNotarzt

identifier: GLN/7601000028105

name: Hans Notarzt

Entry 14 - fullUrl = http://test.fhir.ch/r4/Organization/1-Rettungsdienst

Resource Organization:

Generated Narrative: Organization 1-Rettungsdienst

identifier: GLN/7601002156363

name: Rettungsdienst Schutz und Rettung Zürich

Entry 15 - fullUrl = http://test.fhir.ch/r4/Organization/1-TeamRettungsdienst

Resource Organization:

Generated Narrative: Organization 1-TeamRettungsdienst

identifier: GLN/7601002156363

name: Rettungsdienst Schutz und Rettung Zürich

Contacts

-Address
*Bahnhofquai 3, Amtshaus I Zürich 8001 CH

Entry 16 - fullUrl = http://test.fhir.ch/r4/ServiceRequest/1-AufbietendeOrganisation

Resource ServiceRequest:

Generated Narrative: ServiceRequest 1-AufbietendeOrganisation

status: Completed

intent: Order

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

requester: Organization SNZ

insurance: Coverage: identifier = urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756003760012390001; status = active

Generated Narrative: Organization #1-informant

identifier: GLN/7601002156370

name: SNZ

Entry 17 - fullUrl = http://test.fhir.ch/r4/Location/1-Einsatzort

Resource Location:

Generated Narrative: Location 1-Einsatzort

name: Waldrand

address: Zürich 8044 CH

Positions

-LongitudeLatitude
*8.55319247.392115

Entry 18 - fullUrl = http://test.fhir.ch/r4/Location/1-Zielort

Resource Location:

Generated Narrative: Location 1-Zielort

identifier: GLN/7601002155939

name: Universitätsspital Zürich, Notfall

address: Rämistrasse 100 Zürich 8091 Switzerland

Entry 19 - fullUrl = http://test.fhir.ch/r4/Observation/1-Alarm

Resource Observation:

Generated Narrative: Observation 1-Alarm

status: Final

code: alarm

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:09:00+0100

Entry 20 - fullUrl = http://test.fhir.ch/r4/Observation/1-Disposition

Resource Observation:

Generated Narrative: Observation 1-Disposition

status: Final

code: disposition

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:11:00+0100

Entry 21 - fullUrl = http://test.fhir.ch/r4/Observation/1-Rollout

Resource Observation:

Generated Narrative: Observation 1-Rollout

status: Final

code: rollout

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:13:00+0100

Entry 22 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalOnScene

Resource Observation:

Generated Narrative: Observation 1-ArrivalOnScene

status: Final

code: arrival on scene

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:17:00+0100

Entry 23 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalPatient

Resource Observation:

Generated Narrative: Observation 1-ArrivalPatient

status: Final

code: arrival patient

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:22:00+0100

Entry 24 - fullUrl = http://test.fhir.ch/r4/Observation/1-DepartureFromScene

Resource Observation:

Generated Narrative: Observation 1-DepartureFromScene

status: Final

code: departure from scene

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:48:00+0100

Entry 25 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalAtTarget

Resource Observation:

Generated Narrative: Observation 1-ArrivalAtTarget

status: Final

code: arrival at target

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: 2016-12-10 11:54:00+0100

Entry 26 - fullUrl = http://test.fhir.ch/r4/Observation/1-Anamnese

Resource Observation:

Generated Narrative: Observation 1-Anamnese

status: Final

code: Event

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.

Entry 27 - fullUrl = http://test.fhir.ch/r4/Observation/1-Symptome

Resource Observation:

Generated Narrative: Observation 1-Symptome

status: Final

code: Clinical finding (finding)

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: Starke Schmerzen in der Brust und im linken Oberarm verspürt

Entry 28 - fullUrl = http://test.fhir.ch/r4/Observation/1-GCSBefund

Resource Observation:

Generated Narrative: Observation 1-GCSBefund

status: Final

code: Glasgow coma score total

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

effective: 2016-12-10 11:25:00+0100

value: 15 {score} (Details: UCUM code{score} = '{score}')

component

code: Glasgow coma score motor

value: 6 (Obeys commands)

component

code: Glasgow coma score verbal

value: 5 (Oriented)

component

code: Glasgow coma score eye opening

value: 4 (Eyes open spontaneously)

Entry 29 - fullUrl = http://test.fhir.ch/r4/Observation/1-Diagnose

Resource Observation:

Generated Narrative: Observation 1-Diagnose

status: Final

code: probable diagnosis

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

effective: 2016-12-10 11:25:00+0100

performer: Practitioner Hans Notarzt

value: ST elevation (STEMI) myocardial infarction of anterior wall

Entry 30 - fullUrl = http://test.fhir.ch/r4/Observation/1-ZustandUebergabe

Resource Observation:

Generated Narrative: Observation 1-ZustandUebergabe

status: Final

code: Vital status at discharge

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: Improved

Entry 31 - fullUrl = http://test.fhir.ch/r4/Observation/1-NACAUebergabe

Resource Observation:

Generated Narrative: Observation 1-NACAUebergabe

status: Final

code: Injury severity score NACA

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

value: mässige bis schwere Störung

Entry 32 - fullUrl = http://test.fhir.ch/r4/Observation/1-GCSUebergabe

Resource Observation:

Generated Narrative: Observation 1-GCSUebergabe

status: Final

code: Glasgow coma score total

subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)

encounter: Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

effective: 2016-12-10 12:03:00+0100

value: 15 {score} (Details: UCUM code{score} = '{score}')

component

code: Glasgow coma score motor

value: 6 (Obeys commands)

component

code: Glasgow coma score verbal

value: 5 (Oriented)

component

code: Glasgow coma score eye opening

value: 4 (Eyes open spontaneously)