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

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: 1 Einsatzprotokoll - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="1-Einsatzprotokoll-Composition"/>
  <meta>
    <profile
             value="http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"/>
  </meta>
  <language value="de-CH"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="de-CH" lang="de-CH"><p class="res-header-id"><b>Generated Narrative: Composition 1-Einsatzprotokoll-Composition</b></p><a name="1-Einsatzprotokoll-Composition"> </a><a name="hc1-Einsatzprotokoll-Composition"> </a><a name="1-Einsatzprotokoll-Composition-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Language: de-CH</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ch-ems-composition.html">CH EMS Composition Profile</a></p></div><p><b>EPR Information Recipient</b>: <a href="Practitioner-1-InformationRecipientSpezialarzt.html">Practitioner Spezialarzt Hans </a></p><p><b>EPR Information Recipient</b>: <a href="Organization-1-InformationRecipientUSZ.html">Organization USZ</a></p><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.5.0/NamingSystem-uri.html" title="As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt 

This oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid: 

Note that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR.

This OID may also be used in CD.codeSystem.">Uniform Resource Identifier (URI)</a>/urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 67796-3}, {http://snomed.info/sct 371535009}">EMS Patient Care Report</span></p><p><b>encounter</b>: <a href="Encounter-1-Einsatz.html">Encounter: identifier = urn:oid:2.16.756.5.30.1.9999999999.1#S12345678; status = finished; class = emergency (ActCode#EMER); period = 2016-12-10 --&gt; (ongoing)</a></p><p><b>date</b>: 2016-12-10 12:05:00+0100</p><p><b>author</b>: </p><ul><li><a href="Practitioner-1-SaniPetraMuster.html">Practitioner Petra Muster </a></li><li><a href="PractitionerRole-1-SaniPetraMuster-PR.html">PractitionerRole Caregiver</a></li><li><a href="Practitioner-1-NotarztHansNotarzt.html">Practitioner Hans Notarzt </a></li><li><a href="PractitionerRole-1-NotarztHansNotarzt-PR.html">PractitionerRole Physician</a></li></ul><p><b>title</b>: Einsatzprotokoll Rettungsdienst</p><p><b>confidentiality</b>: normal</p><h3>Attesters</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td>Legal</td><td>2016-12-10 12:13:05+0100</td><td><a href="Practitioner-1-SaniPetraMuster.html">Practitioner Petra Muster </a></td></tr></table><p><b>custodian</b>: <a href="Organization-1-Rettungsdienst.html">Organization Rettungsdienst Schutz und Rettung Zürich</a></p></div>
  </text>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient">
    <valueReference>🔗 
      <reference value="Practitioner/1-InformationRecipientSpezialarzt"/>
    </valueReference>
  </extension>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient">
    <valueReference>🔗 
      <reference value="Organization/1-InformationRecipientUSZ"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="67796-3"/>
      <display value="EMS Patient Care Report"/>
    </coding>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="371535009"/>
      <display value="Transfer summary report"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/1-PeterMuster"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/1-Einsatz"/>
  </encounter>
  <date value="2016-12-10T12:05:00.000+01:00"/>
  <author>🔗 
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T12:13:05.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-SaniPetraMuster"/>
  </author>
  <author>🔗 
    <reference value="PractitionerRole/1-SaniPetraMuster-PR"/>
  </author>
  <author>🔗 
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T12:13:05.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-NotarztHansNotarzt"/>
  </author>
  <author>🔗 
    <reference value="PractitionerRole/1-NotarztHansNotarzt-PR"/>
  </author>
  <title value="Einsatzprotokoll Rettungsdienst"/>
  <confidentiality value="N">
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode">
      <valueCodeableConcept>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="17621005"/>
          <display value="Normal"/>
        </coding>
      </valueCodeableConcept>
    </extension>
  </confidentiality>
  <attester>
    <mode value="legal"/>
    <time value="2016-12-10T12:13:05.000+01:00"/>
    <party>🔗 
      <reference value="Practitioner/1-SaniPetraMuster"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/1-Rettungsdienst"/>
  </custodian>
  <section>
    <title value="Einsatz"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100001"/>
        <display value="Einsatz"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Einsatz</th></tr><tr><td>Einsatzdatum</td><td>10.12.2016</td></tr><tr><td>Einsatznummer</td><td>S12345678</td></tr><tr><td>aufbietende Organisation</td><td>7601002156370 (SNZ)</td></tr><tr><td>augebotene Organisation</td><td>7601002156363 (Rettungsdienst Schutz &amp; Rettung Zürich)</td></tr><tr><td>Team</td><td>Petra Muster, GLN 7601003330434, Betreuerin / Hans Beispiel, GLN 7601000028105, Betreuer</td></tr><tr><td>Einsatzort</td><td>Zürich, Waldrand (47.392115, 8.553192)</td></tr><tr><td>Zielort</td><td>USZ Notfall</td></tr></tbody></table><table><tbody><tr><th>Alarm</th><th>Status DP</th><th>Status 1</th><th>Status 2</th><th>Kontakt Patient</th><th>Status 3</th><th>Status 4</th><th>Status 5</th><th>Status 6</th></tr><tr><th id="alarm">12.09</th><th id="disposition">12.11</th><th id="rollout">12.13</th><th id="arrivalonscene">12.17</th><th id="arrivalpatient">12.22</th><th id="departurefromscene">12.48</th><th id="arrivalattarget">12.54</th><th id="departurefromtarget">-</th><th id="operationalreadiness">-</th></tr></tbody></table></div>
    </text>
    <entry>🔗 
      <reference value="Encounter/1-Einsatz"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-Alarm"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-Disposition"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-Rollout"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-ArrivalOnScene"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-ArrivalPatient"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-DepartureFromScene"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-ArrivalAtTarget"/>
    </entry>
  </section>
  <section>
    <title value="Administrativ"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100003"/>
        <display value="Administrativ"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Person/Organsiation</th></tr><tr><td>Ehefrau</td><td>Erika Muster</td></tr></tbody></table></div>
    </text>
  </section>
  <section>
    <title value="Vorbehandlung"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100004"/>
        <display value="Vorbehandlung"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Anamnese"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100005"/>
        <display value="Anamnese"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Geschehen</th></tr><tr><td id="anamnesis">Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td></tr></tbody></table><table><tbody><tr><th>Symptome</th></tr><tr><td id="symptom">Starke Schmerzen in der Brust und im linken Oberarm verspürt</td></tr></tbody></table><h4>Allergien</h4><ul><li>Baumpollen</li><li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li></ul><h4>preMedication</h4><ul><li>Aspirin cardio 100, 1 Tbl/Tag</li></ul><h4>Medizinische Vorgeschichte</h4><ul><li>Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio</li></ul><h4>Weitere</h4><ul><li>Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen</li><li>Peter Muster hat keine Patientenverfügung erstellt</li><li>es sind keine anderen medizinische Probleme bekannt</li></ul></div>
    </text>
    <entry>🔗 
      <reference value="Observation/1-Anamnese"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-Symptome"/>
    </entry>
  </section>
  <section>
    <title value="Befund"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100006"/>
        <display value="Befund"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Blutdruck 120/80 mmHg gemessen am rechten Arm / Schmerz 5</p><table><tbody><tr><th>GCS</th></tr><tr><td id="gcs1">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ motor. Reaktion befolgt Antweisungen 6) um 12:25</td></tr></tbody></table></div>
    </text>
    <section>
      <title value="Disability"/>
      <entry>🔗 
        <reference value="Observation/1-GCSBefund"/>
      </entry>
    </section>
  </section>
  <section>
    <title value="Diagnosen"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100007"/>
        <display value="Diagnosen"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Verdachtsdiagnose</th></tr><tr><td id="diagnose1">akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW</td></tr></tbody></table></div>
    </text>
    <entry>🔗 
      <reference value="Observation/1-Diagnose"/>
    </entry>
  </section>
  <section>
    <title value="Massnahmen"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100008"/>
        <display value="Massnahmen"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray</span></div>
    </text>
  </section>
  <section>
    <title value="Todesfall"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100009"/>
        <display value="Todesfall"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Transport"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100010"/>
        <display value="Transport"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>Fahrt mit Sondersignal ins USZ.</span></div>
    </text>
  </section>
  <section>
    <title value="Übergabe"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <code value="1100011"/>
        <display value="Übergabe"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Schmerz 4</p><table><tbody><tr><th>GCS</th></tr><tr><td id="gcs2">15(4/5/6) um 13.03</td></tr><tr><th>NACA</th></tr><tr><td id="naca">NACA: III</td></tr><tr><th>Zustand</th></tr><tr><td id="statusdischarge">der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert</td></tr></tbody></table><p>Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis</p></div>
    </text>
    <entry>🔗 
      <reference value="Observation/1-ZustandUebergabe"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-NACAUebergabe"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1-GCSUebergabe"/>
    </entry>
  </section>
  <section>
    <title value="Kommentar"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48767-8"/>
        <display value="Annotation comment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
</Composition>