CH EMS (R4)
1.9.0-cibuild - 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 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
Document Details
Generated Narrative: Bundle Einsatzprotokoll Rettungsdienst
Last updated: 2020-04-24 07:53:22+0000
Profile: CH EMS Document Profile
Final Document at 2016-12-10 12:40:00+0100 by Practitioner Petra Muster , PractitionerRole Caregiver, Practitioner Hans Notarzt , PractitionerRole Physician for Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070) in 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)
Document Subject
Unable to resolve subject ''
Document Content
Einsatz | |
---|---|
Einsatzdatum | 10.12.2016 |
Einsatznummer | S12345678 |
aufbietende Organisation | 7601002156370 (SNZ) |
augebotene Organisation | 7601002156363 (Rettungsdienst Schutz & Rettung Zürich) |
Team | Petra Muster, GLN 7601003330434, Betreuerin / Hans Beispiel, GLN 7601000028105, Betreuer |
Einsatzort | Zürich, Waldrand (47.392115, 8.553192) |
Zielort | USZ Notfall |
Alarm | Status DP | Status 1 | Status 2 | Kontakt Patient | Status 3 | Status 4 | Status 5 | Status 6 |
---|---|---|---|---|---|---|---|---|
12.09 | 12.11 | 12.13 | 12.17 | 12.22 | 12.48 | 12.54 | 13.25 | 13.40 |
Person/Organsiation | |
---|---|
Ehefrau | Erika Muster |
Geschehen |
---|
Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen. |
Symptome |
---|
Starke Schmerzen in der Brust und im linken Oberarm verspürt |
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 |
Verdachtsdiagnose |
---|
akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW |
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
Entry 1 - fullUrl = http://test.fhir.ch/r4/Composition/1b-Einsatzprotokoll-Composition
Resource Composition:
Generated Narrative: Composition 1b-Einsatzprotokoll-Composition
EPR Information Recipient: Practitioner Spezialarzt Hans
EPR Information Recipient: Organization USZ
identifier: Uniform Resource Identifier (URI)/urn:uuid:b5e2bd3b-f670-4b0c-a62d-38303baac826
status: Final
type: EMS Patient Care Report
date: 2016-12-10 12:40:00+0100
author:
- Practitioner Petra Muster
- PractitionerRole Caregiver
- Practitioner Hans Notarzt
- PractitionerRole Physician
title: Einsatzprotokoll Rettungsdienst
Attesters
Mode Time Party Legal 2016-12-10 12:40:00+0100 Practitioner 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
/S12345678status: 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 Detail Bahnhofstrasse Zürich 8003 Schweiz (home) Contact:
- Erika Muster
Place of Origin according to eCH-0011 Musterdorf 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
/80756003760012390001status: 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)
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
Longitude Latitude 8.553192 47.392115
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)
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)
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)
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)
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)
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)
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)
value: 2016-12-10 11:54:00+0100
Entry 26 - fullUrl = http://test.fhir.ch/r4/Observation/1b-DepartureFromTarget
Resource Observation:
Generated Narrative: Observation 1b-DepartureFromTarget
status: Final
code: departure from target
subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:25:00+0100
Entry 27 - fullUrl = http://test.fhir.ch/r4/Observation/1b-OperationalReadiness
Resource Observation:
Generated Narrative: Observation 1b-OperationalReadiness
status: Final
code: operational readiness
subject: Peter Muster (official) Male, DoB: 1961-10-01 ( urn:oid:2.16.756.5.32#7562295883070)
value: 2016-12-10 12:40:00+0100
Entry 28 - 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)
value: Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.
Entry 29 - 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)
value: Starke Schmerzen in der Brust und im linken Oberarm verspürt
Entry 30 - 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)
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 31 - 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)
effective: 2016-12-10 11:25:00+0100
performer: Practitioner Hans Notarzt
value: ST elevation (STEMI) myocardial infarction of anterior wall
Entry 32 - 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)
value: Improved
Entry 33 - 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)
value: mässige bis schwere Störung
Entry 34 - 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)
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)