CH EMS (R4)
2.1.0-ci-build - ci-build
CH EMS (R4), published by IVR Interverband für Rettungswesen. This guide is not an authorized publication; it is the continuous build for version 2.1.0-ci-build 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
Document Details
Last updated: 2020-04-24 07:53:22+0000
Final Document at 2016-12-10 13:05:00+0100 by Practitioner Petra Muster , PractitionerRole Caregiver (person), Practitioner Pierre Urgentiste , PractitionerRole Physician (occupation) for Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070) in encounter Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)
Document Subject
Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Other Id: | Medical record number/762354 | ||
Contact Detail | Bahnhofstrasse Zürich 8003 Schweiz (home) | ||
Third Party: |
| ||
Place of Origin according to eCH-0011 | Musterdorf ZH |
Document Content
Einsatz | |
---|---|
Einsatzdatum: | 10.12.2016 |
Einsatznummer: | S12345678 |
Aufbietende Organisation: | SNZ (GLN 7601002156370) |
Aufgebotene Organisation: | Rettungsdienst Schutz und Rettung Zürich (GLN 7601002156363) |
Teammitglieder: | Petra Muster (Rettungssanitäterin), Hans Transportsanitäter (Transportsanitäter), Pierre Urgentiste (Notarzt) |
Einsatzort: | Zürich, Waldrand (47.392115, 8.553192) |
Zielort: | Universitätsspital Zürich, Notfall |
Alarmierungszeit: | Dispositionszeit: | Ausrückzeit: | Ankunftszeit am Einsatzort: | Ankunftszeit beim Patienten: | Abfahrtszeit vom Einsatzort: | Ankunftszeit am Zielort: |
---|---|---|---|---|---|---|
12:09 | 12:11 | 12:13 | 12:17 | 12:22 | 12:48 | 12:54 |
Beteiligte Person | |
---|---|
Ehefrau: | Erika Müller |
Ereignis: |
---|
Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen. |
Symptome: |
---|
Starke Schmerzen in der Brust und im linken Oberarm verspürt. |
Zeitpunkt des Befundes: 12:25
Blutdruck: | GCS: | Weiteres: |
---|---|---|
120/80 mmHg, gemessen am rechten Arm | Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6) | Schmerz: 5 |
Verdachtsdiagnose: |
---|
Akuter transmuraler Myokardinfarkt der Vorderwand (ACS/STEMI VW) |
GCS: | NACA: | Zustand: | Weiteres: |
---|---|---|---|
Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6) | III | Zustand des Patienten hat sich im Verlaufe des Einsatzes verbessert | Schmerz: 4 |
Übergabe an USZ mit Wertsachenbeutel mit Portemonnaie, Handy, Uhr, Schlüssel, Bargeld sowie Wertsachenverzeichnis.
Entry 2 - fullUrl = http://test.fhir.ch/r4/Encounter/1-Einsatz
Resource Encounter:
CH EMS Extension: Valuables Patient: wallet
CH EMS Extension: Valuables Patient: Handy
CH EMS Extension: Valuables Patient: wrist watch
CH EMS Extension: Valuables Patient: Schlüssel
CH EMS Extension: Valuables Patient: Bargeld
identifier: Einsatznummer/S12345678
status: completed
class: emergency
subject: Thomas Müller (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: Betreuer
participant
CH EMS Extension: Team Role: Betreuer
participant
CH EMS Extension: Team Role: Ärztin / Arzt
Locations
Location Location Waldrand
Entry 3 - fullUrl = http://test.fhir.ch/r4/Patient/1-ThomasMueller
Resource Patient:
Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Other Id: Medical record number/762354 Contact Detail Bahnhofstrasse Zürich 8003 Schweiz (home) Third Party:
- Erika Müller
Place of Origin according to eCH-0011 Musterdorf ZH
Entry 4 - fullUrl = http://test.fhir.ch/r4/Coverage/1-CoverageThomasMueller
Resource Coverage:
identifier:
urn:oid:2.16.756.5.30.1.123.100.1.1.1
/80756003760012390001status: Active
beneficiary: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
name: KPT
Entry 5 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-InformationRecipientSpitalarzt
Resource Practitioner:
identifier: GLN/7601000404268
name: Spitalarzt Claude
Entry 6 - fullUrl = http://test.fhir.ch/r4/Organization/1-InformationRecipientUSZ
Resource Organization:
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:
identifier: GLN/7601003330434
name: Petra Muster
Qualifications
Code Rettungssanitäter/in HF
Entry 8 - fullUrl = http://test.fhir.ch/r4/PractitionerRole/1-SaniPetraMuster-PR
Resource PractitionerRole:
practitioner: Practitioner Petra Muster
code: Betreuer
Entry 9 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-NotarztPierreUrgentiste
Resource Practitioner:
identifier: GLN/7601000028105
name: Pierre Urgentiste
Qualifications
Code Notarzt/Notärztin SGNOR
Entry 10 - fullUrl = http://test.fhir.ch/r4/PractitionerRole/1-NotarztPierreUrgentiste-PR
Resource PractitionerRole:
practitioner: Practitioner Pierre Urgentiste
code: Ärztin / Arzt
Entry 11 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberPetraMuster
Resource Practitioner:
identifier: GLN/7601003330434
name: Petra Muster
Qualifications
Code Rettungssanitäter/in HF
Entry 12 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberHansTransportsanitaeter
Resource Practitioner:
identifier: GLN/7601000211804
name: Hans Transportsanitäter
Qualifications
Code Transportsanitäter/in FA
Entry 13 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberPierreUrgentiste
Resource Practitioner:
identifier: GLN/7601000028105
name: Pierre Urgentiste
Qualifications
Code Notarzt/Notärztin SGNOR
Entry 14 - fullUrl = http://test.fhir.ch/r4/Organization/1-Rettungsdienst
Resource Organization:
identifier: GLN/7601002156363
name: Rettungsdienst Schutz und Rettung Zürich
Entry 15 - fullUrl = http://test.fhir.ch/r4/Organization/1-TeamRettungsdienst
Resource Organization:
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:
status: Completed
intent: Order
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
requester: Organization SNZ
insurance: Coverage: identifier = urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756003760012390001; status = active
identifier: GLN/7601002156370
name: SNZ
Entry 17 - fullUrl = http://test.fhir.ch/r4/Location/1-Einsatzort
Resource Location:
name: Waldrand
address: Zürich 8044 CH
Positions
Longitude Latitude 8.553192 47.392115
Entry 18 - fullUrl = http://test.fhir.ch/r4/Location/1-Zielort
Resource Location:
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:
status: Final
code: Alarmierungszeit
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:09:00+0100
Entry 20 - fullUrl = http://test.fhir.ch/r4/Observation/1-Disposition
Resource Observation:
status: Final
code: Dispositionszeit
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:11:00+0100
Entry 21 - fullUrl = http://test.fhir.ch/r4/Observation/1-Rollout
Resource Observation:
status: Final
code: Ausrückzeit
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:13:00+0100
Entry 22 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalOnScene
Resource Observation:
status: Final
code: Ankunftszeit am Einsatzort
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:17:00+0100
Entry 23 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalPatient
Resource Observation:
status: Final
code: Ankunftszeit beim Patienten
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:22:00+0100
Entry 24 - fullUrl = http://test.fhir.ch/r4/Observation/1-DepartureFromScene
Resource Observation:
status: Final
code: Abfahrtszeit vom Einsatzort
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:48:00+0100
Entry 25 - fullUrl = http://test.fhir.ch/r4/Observation/1-ArrivalAtTarget
Resource Observation:
status: Final
code: Ankunftszeit am Zielort
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:54:00+0100
Entry 26 - fullUrl = http://test.fhir.ch/r4/Observation/1-Anamnese
Resource Observation:
status: Final
code: Event (event)
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
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:
status: Final
code: Clinical finding (finding)
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: Starke Schmerzen in der Brust und im linken Oberarm verspürt.
Entry 28 - fullUrl = http://test.fhir.ch/r4/Observation/1-GCSBefund
Resource Observation:
status: Final
code: Glasgow coma score total
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
effective: 2016-12-10 12:25:00+0100
value: 15 {score} (Details: UCUM code{score} = '{score}')
component
code: Glasgow coma score motor
value: befolgt Aufforderungen
component
code: Glasgow coma score verbal
value: konversationsfähig, orientiert
component
code: Glasgow coma score eye opening
value: spontan
Entry 29 - fullUrl = http://test.fhir.ch/r4/Observation/1-Diagnose
Resource Observation:
status: Final
code: Verdachtsdiagnose
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
effective: 2016-12-10 12:25:00+0100
performer: Practitioner Pierre Urgentiste
value: ST elevation (STEMI) myocardial infarction of anterior wall
Entry 30 - fullUrl = http://test.fhir.ch/r4/Observation/1-ZustandUebergabe
Resource Observation:
status: Final
code: Vital status at discharge
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: verbessert
Entry 31 - fullUrl = http://test.fhir.ch/r4/Observation/1-NACAUebergabe
Resource Observation:
status: Final
code: Injury severity score NACA
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: mässige bis schwere Störung
Entry 32 - fullUrl = http://test.fhir.ch/r4/Observation/1-GCSUebergabe
Resource Observation:
status: Final
code: Glasgow coma score total
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
effective: 2016-12-10 13:03:00+0100
value: 15 {score} (Details: UCUM code{score} = '{score}')
component
code: Glasgow coma score motor
value: befolgt Aufforderungen
component
code: Glasgow coma score verbal
value: konversationsfähig, orientiert
component
code: Glasgow coma score eye opening
value: spontan
Entry 33 - fullUrl = http://test.fhir.ch/r4/Location/1-Rettungswagen
Resource Location:
name: Rettungswagen (Z-220)
Entry 34 - fullUrl = http://test.fhir.ch/r4/Observation/1-Blutdruck
Resource Observation:
status: Final
category: Vital Signs
code: Blood pressure panel with all children optional
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
effective: 2016-12-10 12:25:00+0100
bodySite: rechter Arm
method: nicht invasiv
component
code: Systolic blood pressure
value: 120 millimeter of mercury (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Diastolic blood pressure
value: 80 millimeter of mercury (Details: UCUM codemm[Hg] = 'mm[Hg]')
Entry 35 - fullUrl = http://test.fhir.ch/r4/MedicationAdministration/1-Infusion
Resource MedicationAdministration:
status: completed
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Dosages
Route Method Dose intravenöse Anwendung Infusion 1 Ampule (unit of presentation) (Details: SNOMED CT code732978007 = 'Ampule (unit of presentation)') code: FENTANYL Sintetica Inj Lös 0.5 mg/10ml
ingredient
Entry 36 - fullUrl = http://test.fhir.ch/r4/MedicationAdministration/1-Spray
Resource MedicationAdministration:
status: completed
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Dosages
Route Method Dose Sublingual Spraying 2 Actuation (unit of presentation) (Details: SNOMED CT code732981002 = 'Actuation (unit of presentation)') code: NITROLINGUAL Pumpspray
ingredient
Entry 37 - fullUrl = http://test.fhir.ch/r4/AllergyIntolerance/1-Baumpollen
Resource AllergyIntolerance:
clinicalStatus: Active
type: Allergy
code: Allergie gegen Baumpollen
patient: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Entry 38 - fullUrl = http://test.fhir.ch/r4/AllergyIntolerance/1-Medikamente
Resource AllergyIntolerance:
clinicalStatus: Active
type: Intolerance
code: Arzneimittel oder Medikament
patient: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
Entry 39 - fullUrl = http://test.fhir.ch/r4/MedicationStatement/1-AspirinCardio
Resource MedicationStatement:
status: active
status: recorded
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
effective: 2012-05 --> (ongoing)
dosage
timing: Morning, Once
DoseAndRates
Dose[x] 1 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') code: Aspirin Cardio 100
Entry 40 - fullUrl = http://test.fhir.ch/r4/Procedure/1-Transport
Resource Procedure:
status: Completed
category: Positioning patient (procedure)
code: liegend
subject: Thomas Müller (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)