CH EMS (R4)
1.9.0-cibuild - ci-build
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 15:53:22+0000
Profile: CH EMS Document Profile
Final Document at 2016-12-10 12:40:00+0100 by Practitioner Petra Muster , PractitionerRole Caregiver for Anonymous Patient Male, DoB Unknown ( Medical record number) 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 | wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350 |
| 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 | 12.18 | 12.48 | 12.54 | 13.25 | 13.40 |
Breathing: Der Patient hat eine unauffällige Spontanatmung
Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm
Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor
| Airways | Die Atemwege sind nicht verlegt |
|---|---|
| GCS | Total 9 Augenöffnung bei Ansprache (3), gibt Einzelworte von sich (3), Dekortikationsstarre (3) |
| AVPU | V (=reagiert auf laute Ansprache) |
| Verdachtsdiagnose |
|---|
| Stroke (I63) |
Schmerz 4
| GCS |
|---|
| Total 10 Augenöffnung bei Ansprache (3), Konversationsfähig aber desorientiert (4), Dekortikationsstarre (3) |
| NACA |
| NACA: III |
| Zustand |
| der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert |
Übergabe an USZ Effekten sowie Wertsachenverzeichnis
Entry 1 - fullUrl = http://test.fhir.ch/r4/Composition/2b-Einsatzprotokoll-Composition
Resource Composition:
Generated Narrative: Composition 2b-Einsatzprotokoll-Composition
EPR Information Recipient: Practitioner Spezialarzt Hans
EPR Information Recipient: Organization USZ
identifier: Uniform Resource Identifier (URI)/urn:uuid:b4044742-ab2c-49f6-8151-0e2be5d3f923
status: Final
type: EMS Patient Care Report
date: 2016-12-10 12:40:00+0100
author:
title: Einsatzprotokoll Rettungsdienst
Attesters
Mode Time Party Legal 2016-12-10 12:13:05+0100 Practitioner Petra Muster custodian: Organization Rettungsdienst Schutz und Rettung Zürich
Entry 2 - fullUrl = http://test.fhir.ch/r4/Encounter/2-Einsatz
Resource Encounter:
Generated Narrative: Encounter 2-Einsatz
identifier:
urn:oid:2.16.756.5.30.1.9999999999.1/S12345678status: completed
class: emergency
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
basedOn: ServiceRequest: status = completed; intent = order
participant
CH EMS Extension Team Role: Caregiver
participant
CH EMS Extension Team Role: Caregiver
Locations
Location Location Sternen Oerlikon
Entry 3 - fullUrl = http://test.fhir.ch/r4/Patient/2-PatientUnbekannt
Resource Patient:
Generated Narrative: Patient 2-PatientUnbekannt
Anonymous Patient Male, DoB Unknown ( Medical record number)
Entry 4 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-InformationRecipientSpezialarzt
Resource Practitioner:
Generated Narrative: Practitioner 1-InformationRecipientSpezialarzt
identifier: GLN/7601000404268
name: Spezialarzt Hans
Entry 5 - 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 6 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-SaniPetraMuster
Resource Practitioner:
Generated Narrative: Practitioner 1-SaniPetraMuster
identifier: GLN/7601003330434
name: Petra Muster
Entry 7 - 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 8 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberPetraMuster
Resource Practitioner:
Generated Narrative: Practitioner 1-TeamMemberPetraMuster
identifier: GLN/7601003330434
name: Petra Muster
Entry 9 - fullUrl = http://test.fhir.ch/r4/Practitioner/1-TeamMemberHansBeispiel
Resource Practitioner:
Generated Narrative: Practitioner 1-TeamMemberHansBeispiel
identifier: GLN/7601000211804
name: Hans Beispiel
Entry 10 - 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 11 - 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 12 - fullUrl = http://test.fhir.ch/r4/ServiceRequest/2-AufbietendeOrganisation
Resource ServiceRequest:
Generated Narrative: ServiceRequest 2-AufbietendeOrganisation
status: Completed
intent: Order
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
requester: Organization SNZ
Generated Narrative: Organization #2-informant
identifier: GLN/7601002156370
name: SNZ
Entry 13 - fullUrl = http://test.fhir.ch/r4/Location/2-Einsatzort
Resource Location:
Generated Narrative: Location 2-Einsatzort
name: Sternen Oerlikon
address: Schaffhauserstr. 350 Zürich 8050 CH
Entry 14 - 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 15 - fullUrl = http://test.fhir.ch/r4/Observation/2-Alarm
Resource Observation:
Generated Narrative: Observation 2-Alarm
status: Final
code: alarm
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:09:00+0100
Entry 16 - fullUrl = http://test.fhir.ch/r4/Observation/2-Disposition
Resource Observation:
Generated Narrative: Observation 2-Disposition
status: Final
code: disposition
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:11:00+0100
Entry 17 - fullUrl = http://test.fhir.ch/r4/Observation/2-Rollout
Resource Observation:
Generated Narrative: Observation 2-Rollout
status: Final
code: rollout
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:13:00+0100
Entry 18 - fullUrl = http://test.fhir.ch/r4/Observation/2-ArrivalOnScene
Resource Observation:
Generated Narrative: Observation 2-ArrivalOnScene
status: Final
code: arrival on scene
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:17:00+0100
Entry 19 - fullUrl = http://test.fhir.ch/r4/Observation/2-ArrivalPatient
Resource Observation:
Generated Narrative: Observation 2-ArrivalPatient
status: Final
code: arrival patient
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:18:00+0100
Entry 20 - fullUrl = http://test.fhir.ch/r4/Observation/2-DepartureFromScene
Resource Observation:
Generated Narrative: Observation 2-DepartureFromScene
status: Final
code: departure from scene
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:48:00+0100
Entry 21 - fullUrl = http://test.fhir.ch/r4/Observation/2-ArrivalAtTarget
Resource Observation:
Generated Narrative: Observation 2-ArrivalAtTarget
status: Final
code: arrival at target
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 11:54:00+0100
Entry 22 - fullUrl = http://test.fhir.ch/r4/Observation/2b-DepartureFromTarget
Resource Observation:
Generated Narrative: Observation 2b-DepartureFromTarget
status: Final
code: departure from target
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 12:25:00+0100
Entry 23 - fullUrl = http://test.fhir.ch/r4/Observation/2b-OperationalReadiness
Resource Observation:
Generated Narrative: Observation 2b-OperationalReadiness
status: Final
code: operational readiness
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: 2016-12-10 12:40:00+0100
Entry 24 - fullUrl = http://test.fhir.ch/r4/Observation/2-AirwaysBefund
Resource Observation:
Generated Narrative: Observation 2-AirwaysBefund
status: Final
code: Finding of respiratory obstruction
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
effective: 2016-12-10 11:25:00+0100
value: No pathologic finding
Entry 25 - fullUrl = http://test.fhir.ch/r4/Observation/2-GCSBefund
Resource Observation:
Generated Narrative: Observation 2-GCSBefund
status: Final
code: Glasgow coma score total
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
effective: 2016-12-10 11:25:00+0100
value: 9 {score} (Details: UCUM code{score} = '{score}')
component
code: Glasgow coma score motor
value: 3 (Flexion to pain)
component
code: Glasgow coma score verbal
value: 3 (Inappropriate words)
component
code: Glasgow coma score eye opening
value: 3 (Eye opening to verbal command)
Entry 26 - fullUrl = http://test.fhir.ch/r4/Observation/2-AVPUBefund
Resource Observation:
Generated Narrative: Observation 2-AVPUBefund
status: Final
code: Level of Responsiveness (AVPU)
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
effective: 2016-12-10 11:25:00+0100
value: Reaktion nur bei lauter Ansprache
Entry 27 - fullUrl = http://test.fhir.ch/r4/Observation/2-Diagnose
Resource Observation:
Generated Narrative: Observation 2-Diagnose
status: Final
code: probable diagnosis
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
effective: 2016-12-10 11:25:00+0100
performer: Practitioner Petra Muster
value: Hirninfarkt
Entry 28 - fullUrl = http://test.fhir.ch/r4/Observation/2-ZustandUebergabe
Resource Observation:
Generated Narrative: Observation 2-ZustandUebergabe
status: Final
code: Vital status at discharge
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: Improved
Entry 29 - fullUrl = http://test.fhir.ch/r4/Observation/2-NACAUebergabe
Resource Observation:
Generated Narrative: Observation 2-NACAUebergabe
status: Final
code: Injury severity score NACA
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
value: mässige bis schwere Störung
Entry 30 - fullUrl = http://test.fhir.ch/r4/Observation/2-GCSUebergabe
Resource Observation:
Generated Narrative: Observation 2-GCSUebergabe
status: Final
code: Glasgow coma score total
subject: Anonymous Patient Male, DoB Unknown ( Medical record number)
effective: 2016-12-10 12:03:00+0100
value: 10 {score} (Details: UCUM code{score} = '{score}')
component
code: Glasgow coma score motor
value: 3 (Flexion to pain)
component
code: Glasgow coma score verbal
value: 4 (Confused)
component
code: Glasgow coma score eye opening
value: 3 (Eye opening to verbal command)