CH EMS (R4)
1.9.0 - CI build

CH EMS (R4), published by IVR Interverband für Rettungswesen. This is not an authorized publication; it is the continuous build for version 1.9.0). This version is based on the current content of https://github.com/hl7ch/ch-ems/ and changes regularly. See the Directory of published versions

1 Einsatzprotokoll - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "1-Einsatzprotokoll"];
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition";
       fhir:index 0;
       fhir:link <http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition>     ]
  ];
  fhir:Resource.language [ fhir:value "de-CH"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"de-CH\" lang=\"de-CH\"><p><b>Generated Narrative</b></p><p><b>id</b>: 1-Einsatzprotokoll</p><p><b>meta</b>: </p><p><b>language</b>: de-CH</p><p><b>identifier</b>: id: 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\">Generated Summary: id: 1-Einsatz; id: S12345678; status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode EMER}\">emergency</span>; period: 2016-12-10 --&gt; (ongoing)</a></p><p><b>date</b>: Dec 10, 2016, 11:05:00 AM</p><p><b>author</b>: </p><ul><li><a href=\"Practitioner-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster </a></li><li><a href=\"PractitionerRole-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; <span title=\"Codes: {http://snomed.info/sct 133932002}\">Caregiver</span></a></li><li><a href=\"Practitioner-1-NotarztHansNotarzt.html\">Generated Summary: id: 1-NotarztHansNotarzt; id: 7601000028105; Hans Notarzt </a></li><li><a href=\"PractitionerRole-1-NotarztHansNotarzt.html\">Generated Summary: id: 1-NotarztHansNotarzt; <span title=\"Codes: {http://snomed.info/sct 309343006}\">Physician</span></a></li></ul><p><b>title</b>: Einsatzprotokoll Rettungsdienst</p><p><b>confidentiality</b>: N</p><h3>Attesters</h3><table class=\"grid\"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>Dec 10, 2016, 11:13:05 AM</td><td><a href=\"Practitioner-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster </a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-1-Rettungsdienst.html\">Generated Summary: id: 1-Rettungsdienst; id: 7601002156363; name: Rettungsdienst Schutz und Rettung Zürich</a></p></div>"
  ];
  fhir:DomainResource.extension [
     fhir:index 0;
     fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid" ];
     fhir:Extension.valueIdentifier [
       fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ];
       fhir:Identifier.value [ fhir:value "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78" ]     ]
  ], [
     fhir:index 1;
     fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber" ];
     fhir:Extension.valueUnsignedInt [ fhir:value "1"^^xsd:nonNegativeInteger ]
  ], [
     fhir:index 2;
     fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient" ];
     fhir:Extension.valueReference [
       fhir:Reference.reference [ fhir:value "Practitioner/1-InformationRecipientSpezialarzt" ]     ]
  ], [
     fhir:index 3;
     fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient" ];
     fhir:Extension.valueReference [
       fhir:Reference.reference [ fhir:value "Organization/1-InformationRecipientUSZ" ]     ]
  ];
  fhir:Composition.identifier [
     fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ];
     fhir:Identifier.value [ fhir:value "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78" ]
  ];
  fhir:Composition.status [ fhir:value "final"];
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a loinc:67796-3;
       fhir:Coding.system [ fhir:value "http://loinc.org" ];
       fhir:Coding.code [ fhir:value "67796-3" ];
       fhir:Coding.display [ fhir:value "EMS Patient Care Report" ]     ], [
       fhir:index 1;
       a sct:371535009;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ];
       fhir:Coding.code [ fhir:value "371535009" ];
       fhir:Coding.display [ fhir:value "Transfer summary report" ]     ]
  ];
  fhir:Composition.subject [
     fhir:Reference.reference [ fhir:value "Patient/1-PeterMuster" ]
  ];
  fhir:Composition.encounter [
     fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ]
  ];
  fhir:Composition.date [ fhir:value "2016-12-10T12:05:00.000+01:00"^^xsd:dateTime];
  fhir:Composition.author [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time" ];
       fhir:Extension.valueDateTime [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ]     ];
     fhir:Reference.reference [ fhir:value "Practitioner/1-SaniPetraMuster" ]
  ], [
     fhir:index 1;
     fhir:Reference.reference [ fhir:value "PractitionerRole/1-SaniPetraMuster" ]
  ], [
     fhir:index 2;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time" ];
       fhir:Extension.valueDateTime [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ]     ];
     fhir:Reference.reference [ fhir:value "Practitioner/1-NotarztHansNotarzt" ]
  ], [
     fhir:index 3;
     fhir:Reference.reference [ fhir:value "PractitionerRole/1-NotarztHansNotarzt" ]
  ];
  fhir:Composition.title [ fhir:value "Einsatzprotokoll Rettungsdienst"];
  fhir:Composition.confidentiality [
     fhir:value "N";
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           a sct:17621005;
           fhir:Coding.system [ fhir:value "http://snomed.info/sct" ];
           fhir:Coding.code [ fhir:value "17621005" ];
           fhir:Coding.display [ fhir:value "Normal" ]         ]       ]     ]
  ];
  fhir:Composition.attester [
     fhir:index 0;
     fhir:Composition.attester.mode [ fhir:value "legal" ];
     fhir:Composition.attester.time [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ];
     fhir:Composition.attester.party [
       fhir:Reference.reference [ fhir:value "Practitioner/1-SaniPetraMuster" ]     ]
  ];
  fhir:Composition.custodian [
     fhir:Reference.reference [ fhir:value "Organization/1-Rettungsdienst" ]
  ];
  fhir:Composition.section [
     fhir:index 0;
     fhir:Composition.section.title [ fhir:value "Einsatz" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100001" ];
         fhir:Coding.display [ fhir:value "Einsatz" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <table>\n          <tbody>\n            <tr>\n              <th>Einsatz</th>\n            </tr>\n            <tr>\n              <td>Einsatzdatum</td>\n                <!-- cdachems-dataelement-54 -->\n              <td>10.12.2016</td>\n            </tr>\n            <tr>\n              <td>Einsatznummer</td>\n                <!-- cdachems-dataelement-54 -->\n              <td>S12345678</td>\n            </tr>\n            <tr>\n              <td>aufbietende Organisation</td>\n              <td>7601002156370 (SNZ)</td>\n            </tr>\n            <tr>\n              <td>augebotene Organisation</td>\n              <td>7601002156363 (Rettungsdienst Schutz &amp; Rettung Zürich)</td>\n            </tr>\n            <tr>\n              <td>Team</td>\n              <td>Petra Muster, GLN 7601003330434, Betreuerin \n                <br/>\n Hans Beispiel, GLN 7601000028105, Betreuer \n              </td>\n            </tr>\n            <tr>\n              <td>Einsatzort</td>\n              <td>Zürich, Waldrand (47.392115, 8.553192)</td>\n            </tr>\n            <tr>\n              <td>Zielort</td>\n              <td>USZ Notfall</td>\n            </tr>\n          </tbody>\n        </table>\n        <table>\n          <tbody>\n            <tr>\n              <th>Alarm</th>\n              <th>Status DP</th>\n              <th>Status 1</th>\n              <th>Status 2</th>\n              <th>Kontakt Patient</th>\n              <th>Status 3</th>\n              <th>Status 4</th>\n              <th>Status 5</th>\n              <th>Status 6</th>\n            </tr>\n            <tr>\n              <th id=\"alarm\">12.09</th>\n              <th id=\"disposition\">12.11</th>\n              <th id=\"rollout\">12.13</th>\n              <th id=\"arrivalonscene\">12.17</th>\n              <th id=\"arrivalpatient\">12.22</th>\n              <th id=\"departurefromscene\">12.48</th>\n              <th id=\"arrivalattarget\">12.54</th>\n              <th id=\"departurefromtarget\"/>\n              <th id=\"operationalreadiness\"/>\n            </tr>\n          </tbody>\n        </table>\n      </div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Observation/1-Alarm" ]     ], [
       fhir:index 2;
       fhir:Reference.reference [ fhir:value "Observation/1-Disposition" ]     ], [
       fhir:index 3;
       fhir:Reference.reference [ fhir:value "Observation/1-Rollout" ]     ], [
       fhir:index 4;
       fhir:Reference.reference [ fhir:value "Observation/1-ArrivalOnScene" ]     ], [
       fhir:index 5;
       fhir:Reference.reference [ fhir:value "Observation/1-ArrivalPatient" ]     ], [
       fhir:index 6;
       fhir:Reference.reference [ fhir:value "Observation/1-DepartureFromScene" ]     ], [
       fhir:index 7;
       fhir:Reference.reference [ fhir:value "Observation/1-ArrivalAtTarget" ]     ]
  ], [
     fhir:index 1;
     fhir:Composition.section.title [ fhir:value "Administrativ" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100003" ];
         fhir:Coding.display [ fhir:value "Administrativ" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <table>\n          <tbody>\n            <tr>\n              <th>Person/Organsiation</th>\n            </tr>\n            <tr>\n              <td>Ehefrau</td>\n              <td>Erika Muster</td>\n            </tr>\n          </tbody>\n        </table>\n      </div>"     ]
  ], [
     fhir:index 2;
     fhir:Composition.section.title [ fhir:value "Vorbehandlung" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100004" ];
         fhir:Coding.display [ fhir:value "Vorbehandlung" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <span> - </span>\n      </div>"     ]
  ], [
     fhir:index 3;
     fhir:Composition.section.title [ fhir:value "Anamnese" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100005" ];
         fhir:Coding.display [ fhir:value "Anamnese" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <table>\n          <tbody>\n            <tr>\n              <th>Geschehen</th>\n            </tr>\n            <tr>\n              <td id=\"anamnesis\">Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td>\n            </tr>\n          </tbody>\n        </table>\n        <table>\n          <tbody>\n            <tr>\n              <th>Symptome</th>\n            </tr>\n            <tr>\n              <td id=\"symptom\">Starke Schmerzen in der Brust und im linken Oberarm verspürt</td>\n            </tr>\n          </tbody>\n        </table>\n        <h4>Allergien</h4>\n        <ul>\n          <li>Baumpollen</li>\n          <li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li>\n        </ul>\n        <h4>preMedication</h4>\n        <ul>\n          <li>Aspirin cardio 100, 1 Tbl/Tag</li>\n        </ul>\n        <h4>Medizinische Vorgeschichte</h4>\n        <ul>\n          <li>Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio</li>\n        </ul>\n        <h4>Weitere</h4>\n        <ul>\n          <li>Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen</li>\n          <li>Peter Muster hat keine Patientenverfügung erstellt</li>\n          <li>es sind keine anderen medizinische Probleme bekannt</li>\n        </ul>\n      </div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Observation/1-Anamnese" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Observation/1-Symptome" ]     ]
  ], [
     fhir:index 4;
     fhir:Composition.section.title [ fhir:value "Befund" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100006" ];
         fhir:Coding.display [ fhir:value "Befund" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <p> Blutdruck 120/80 mmHg gemessen am rechten Arm \n          <br/>\n                           Schmerz 5                  \n          <br/>\n        </p>\n        <table>\n          <tbody>\n            <tr>\n              <th>GCS</th>\n            </tr>\n            <tr>\n              <td id=\"gcs1\">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25</td>\n            </tr>\n          </tbody>\n        </table>\n      </div>"     ];
     fhir:Composition.section.section [
       fhir:index 0;
       fhir:Composition.section.title [ fhir:value "Disability" ];
       fhir:Composition.section.entry [
         fhir:index 0;
         fhir:Reference.reference [ fhir:value "Observation/1-GCSBefund" ]       ]     ]
  ], [
     fhir:index 5;
     fhir:Composition.section.title [ fhir:value "Diagnosen" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100007" ];
         fhir:Coding.display [ fhir:value "Diagnosen" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <table>\n          <tbody>\n            <tr>\n              <th>Verdachtsdiagnose</th>\n            </tr>\n            <tr>\n              <td id=\"diagnose1\">akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW</td>\n            </tr>\n          </tbody>\n        </table>\n      </div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Observation/1-Diagnose" ]     ]
  ], [
     fhir:index 6;
     fhir:Composition.section.title [ fhir:value "Massnahmen" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100008" ];
         fhir:Coding.display [ fhir:value "Massnahmen" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <span> Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray </span>\n      </div>"     ]
  ], [
     fhir:index 7;
     fhir:Composition.section.title [ fhir:value "Todesfall" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100009" ];
         fhir:Coding.display [ fhir:value "Todesfall" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <span> - </span>\n      </div>"     ]
  ], [
     fhir:index 8;
     fhir:Composition.section.title [ fhir:value "Transport" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100010" ];
         fhir:Coding.display [ fhir:value "Transport" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <span> Fahrt mit Sondersignal ins USZ. </span>\n      </div>"     ]
  ], [
     fhir:index 9;
     fhir:Composition.section.title [ fhir:value "Übergabe" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ];
         fhir:Coding.code [ fhir:value "1100011" ];
         fhir:Coding.display [ fhir:value "Übergabe" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <p>Schmerz 4</p>\n        <table>\n          <tbody>\n            <tr>\n              <th>GCS</th>\n            </tr>\n            <tr>\n              <td id=\"gcs2\">15(4/5/6) um 13.03</td>\n            </tr>\n            <tr>\n              <th>NACA</th>\n            </tr>\n            <tr>\n              <td id=\"naca\">NACA: III</td>\n            </tr>\n            <tr>\n              <th>Zustand</th>\n            </tr>\n            <tr>\n              <td id=\"statusdischarge\">der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert</td>\n            </tr>\n          </tbody>\n        </table>\n        <p> Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis </p>\n      </div>"     ];
     fhir:Composition.section.entry [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Observation/1-ZustandUebergabe" ]     ], [
       fhir:index 1;
       fhir:Reference.reference [ fhir:value "Observation/1-NACAUebergabe" ]     ], [
       fhir:index 2;
       fhir:Reference.reference [ fhir:value "Observation/1-GCSUebergabe" ]     ]
  ], [
     fhir:index 10;
     fhir:Composition.section.title [ fhir:value "Kommentar" ];
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:48767-8;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "48767-8" ];
         fhir:Coding.display [ fhir:value "Annotation comment" ]       ]     ];
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ];
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n        <span> - </span>\n      </div>"     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.