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
{
"resourceType" : "Composition",
"id" : "1b-Einsatzprotokoll-Composition",
"meta" : {
"profile" : [
🔗 "http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"
]
},
"language" : "de-CH",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"de-CH\" lang=\"de-CH\"><p class=\"res-header-id\"><b>Generated Narrative: Composition 1b-Einsatzprotokoll-Composition</b></p><a name=\"1b-Einsatzprotokoll-Composition\"> </a><a name=\"hc1b-Einsatzprotokoll-Composition\"> </a><a name=\"1b-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 \r\n\r\nThis 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: \r\n\r\nNote 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.\r\n\r\nThis OID may also be used in CD.codeSystem.\">Uniform Resource Identifier (URI)</a>/urn:uuid:b5e2bd3b-f670-4b0c-a62d-38303baac826</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 --> (ongoing)</a></p><p><b>date</b>: 2016-12-10 12:40:00+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 12:40:00+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>"
},
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient",
"valueReference" : {
🔗 "reference" : "Practitioner/1-InformationRecipientSpezialarzt"
}
},
{
"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"
},
{
"system" : "http://snomed.info/sct",
"code" : "371535009",
"display" : "Transfer summary report"
}
]
},
"subject" : {
🔗 "reference" : "Patient/1-PeterMuster"
},
"encounter" : {
🔗 "reference" : "Encounter/1-Einsatz"
},
"date" : "2016-12-10T12:40:00.000+01:00",
"author" : [
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T12:13:05.000+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" : "2016-12-10T12:13:05.000+01:00"
}
],
"reference" : "Practitioner/1-NotarztHansNotarzt"
},
{
🔗 "reference" : "PractitionerRole/1-NotarztHansNotarzt-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"
}
]
}
}
]
},
"attester" : [
{
"mode" : "legal",
"time" : "2016-12-10T12:40:00.000+01:00",
"party" : {
🔗 "reference" : "Practitioner/1-SaniPetraMuster"
}
}
],
"custodian" : {
🔗 "reference" : "Organization/1-Rettungsdienst"
},
"section" : [
{
"title" : "Einsatz",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100001",
"display" : "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 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\">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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100003",
"display" : "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 Muster</td></tr></tbody></table></div>"
}
},
{
"title" : "Vorbehandlung",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100004",
"display" : "Vorbehandlung"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Anamnese",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100005",
"display" : "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>Peter Muster 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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100006",
"display" : "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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100007",
"display" : "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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100008",
"display" : "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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100009",
"display" : "Todesfall"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Transport",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100010",
"display" : "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" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100011",
"display" : "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"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
}
]
}