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 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

Example Bundle: 1 Einsatzprotokoll


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 DetailBahnhofstrasse Zürich 8003 Schweiz (home)
Third Party:
  • Erika Müller
Place of Origin according to eCH-0011Musterdorf ZH

Document Content

Einsatz

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:
12:0912:1112:1312:1712:2212:4812:54

Administrativ

Beteiligte Person
Ehefrau:Erika Müller

Vorbehandlung

-

Anamnese

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

Allergien / Unverträglichkeiten:

  • Allergisch auf Baumpollen
  • bekannte Unverträglichkeitsreaktion auf einzelne Medikamente

Bestehende Medikation

  • Aspirin Cardio 100 (1 Tbl./Tag)

Medizinische Vorgeschichte:

  • Herzvorfall vor vier Jahren, der im Triemlispital in Zürich behandelt wurde

Weiteres:

  • Seit dem Frühstück um ca. 8 Uhr hat er nichts mehr gegessen
  • Thomas Müller hat keine Patientenverfügung erstellt
  • Es sind keine anderen medizinischen Probleme bekannt

Befund

Zeitpunkt des Befundes: 12:25

Blutdruck:GCS:Weiteres:
120/80 mmHg, gemessen am rechten ArmTotal 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)Schmerz: 5

Circulation

Disability

Diagnosen

Verdachtsdiagnose:
Akuter transmuraler Myokardinfarkt der Vorderwand (ACS/STEMI VW)

Massnahmen

Sofortige Infusion gelegt und Verabreichung einer ersten Dosis von 2 Hüben Nitrolingual-Spray um 12:30.

Todesfall

-

Transport

Fahrt mit Sondersignal ins USZ.

Übergabe

GCS:NACA:Zustand:Weiteres:
Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)IIIZustand des Patienten hat sich im Verlaufe des Einsatzes verbessertSchmerz: 4

Übergabe an USZ mit Wertsachenbeutel mit Portemonnaie, Handy, Uhr, Schlüssel, Bargeld sowie Wertsachenverzeichnis.

Kommentar

-

Additional Resources Included in Document


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 DetailBahnhofstrasse Zürich 8003 Schweiz (home)
Third Party:
  • Erika Müller
Place of Origin according to eCH-0011Musterdorf ZH

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

Resource Coverage:

identifier: urn:oid:2.16.756.5.30.1.123.100.1.1.1/80756003760012390001

status: 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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: 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


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

-LongitudeLatitude
*8.55319247.392115

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: 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:

status: Final

code: Clinical finding (finding)

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

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: 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:

status: Final

code: Glasgow coma score total

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

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: 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:

status: Final

code: Glasgow coma score total

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

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)

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

-RouteMethodDose
*intravenöse AnwendungInfusion1 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

-RouteMethodDose
*SublingualSpraying2 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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)


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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)


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)

encounter: Encounter: extension = wallet,Other,wrist watch,Other,Other; identifier = Einsatznummer: S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --> (ongoing)