CH EMS (R4)
2.1.0-ci-build - ci-build
CH EMS (R4)
2.1.0-ci-build - 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 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
{
"resourceType" : "Composition",
"id" : "1b-Einsatzprotokoll-Composition",
"language" : "de-CH",
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient",
"valueReference" : {
🔗 "reference" : "Practitioner/1-InformationRecipientSpitalarzt"
}
},
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient",
"valueReference" : {
🔗 "reference" : "Organization/1-InformationRecipientUSZ"
}
}
],
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:b5e2bd3b-f670-4b0c-a62d-38303baac826"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "67796-3",
"display" : "EMS patient care report - version 3 Document NEMSIS"
},
{
"system" : "http://snomed.info/sct",
"code" : "371535009",
"display" : "Transfer summary report (record artifact)"
}
],
"text" : "Einsatzprotokoll Rettungsdienst"
},
"subject" : {
🔗 "reference" : "Patient/1-ThomasMueller"
},
"encounter" : {
🔗 "reference" : "Encounter/1-Einsatz"
},
"date" : "2016-12-10T13:40:00.000+01:00",
"author" : [
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T13:13:05.000+01:00"
}
],
"reference" : "Practitioner/1-SaniPetraMuster"
},
{
🔗 "reference" : "PractitionerRole/1-SaniPetraMuster-PR"
},
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T13:13:05.000+01:00"
}
],
"reference" : "Practitioner/1-NotarztPierreUrgentiste"
},
{
🔗 "reference" : "PractitionerRole/1-NotarztPierreUrgentiste-PR"
}
],
"title" : "Einsatzprotokoll Rettungsdienst",
"confidentiality" : "N",
"_confidentiality" : {
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "17621005",
"display" : "Normal (qualifier value)"
}
],
"text" : "Normal"
}
}
]
},
"attester" : [
{
"mode" : "legal",
"time" : "2016-12-10T13:40:00.000+01:00",
"party" : {
🔗 "reference" : "Practitioner/1-SaniPetraMuster"
}
}
],
"custodian" : {
🔗 "reference" : "Organization/1-Rettungsdienst"
},
"section" : [
{
"title" : "Einsatz",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100001",
"display" : "intervention"
}
],
"text" : "Einsatz"
},
"text" : {
"status" : "generated",
"div" : "<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 & Rettung Zürich)</td></tr><tr><td>Team</td><td>Petra Muster, GLN 7601003330434, Betreuerin / Hans Transportsanitäter, 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\">13.25</th><th id=\"operationalreadiness\">13.40</th></tr></tbody></table></div>"
},
"entry" : [
{
🔗 "reference" : "Encounter/1-Einsatz"
},
{
🔗 "reference" : "Observation/1-Alarm"
},
{
🔗 "reference" : "Observation/1-Disposition"
},
{
🔗 "reference" : "Observation/1-Rollout"
},
{
🔗 "reference" : "Observation/1-ArrivalOnScene"
},
{
🔗 "reference" : "Observation/1-ArrivalPatient"
},
{
🔗 "reference" : "Observation/1-DepartureFromScene"
},
{
🔗 "reference" : "Observation/1-ArrivalAtTarget"
},
{
🔗 "reference" : "Observation/1b-DepartureFromTarget"
},
{
🔗 "reference" : "Observation/1b-OperationalReadiness"
}
]
},
{
"title" : "Administrativ",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100003",
"display" : "administrative"
}
],
"text" : "Administrativ"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Person/Organsiation</th></tr><tr><td>Ehefrau</td><td>Erika Müller</td></tr></tbody></table></div>"
}
},
{
"title" : "Vorbehandlung",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100004",
"display" : "pretreatment"
}
],
"text" : "Vorbehandlung"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Anamnese",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100005",
"display" : "anamnesis"
}
],
"text" : "Anamnese"
},
"text" : {
"status" : "generated",
"div" : "<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>Thomas Müller hat keine Patientenverfügung erstellt</li><li>es sind keine anderen medizinische Probleme bekannt</li></ul></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-Anamnese"
},
{
🔗 "reference" : "Observation/1-Symptome"
}
]
},
{
"title" : "Befund",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100006",
"display" : "findings"
}
],
"text" : "Befund"
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"section" : [
{
"title" : "Disability",
"entry" : [
{
🔗 "reference" : "Observation/1-GCSBefund"
}
]
}
]
},
{
"title" : "Diagnosen",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100007",
"display" : "diagnosis"
}
],
"text" : "Diagnosen"
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-Diagnose"
}
]
},
{
"title" : "Massnahmen",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100008",
"display" : "measures"
}
],
"text" : "Massnahmen"
},
"text" : {
"status" : "generated",
"div" : "<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>"
}
},
{
"title" : "Todesfall",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100009",
"display" : "death"
}
],
"text" : "Todesfall"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Transport",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100010",
"display" : "transport"
}
],
"text" : "Transport"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>Fahrt mit Sondersignal ins USZ.</span></div>"
}
},
{
"title" : "Übergabe",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100011",
"display" : "handover"
}
],
"text" : "Übergabe"
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-ZustandUebergabe"
},
{
🔗 "reference" : "Observation/1-NACAUebergabe"
},
{
🔗 "reference" : "Observation/1-GCSUebergabe"
}
]
},
{
"title" : "Kommentar",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48767-8",
"display" : "Annotation comment [Interpretation] Narrative"
}
],
"text" : "Kommentar"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
}
]
}