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

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: 1b Einsatzprotokoll - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="1b-Einsatzprotokoll-Composition"/>
  <language value="de-CH"/>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient">
    <valueReference>🔗 
      <reference value="Practitioner/1-InformationRecipientSpitalarzt"/>
    </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:b5e2bd3b-f670-4b0c-a62d-38303baac826"/>
  </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-ThomasMueller"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/1-Einsatz"/>
  </encounter>
  <date value="2016-12-10T13:40:00.000+01:00"/>
  <author>🔗 
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T13:13:05.000+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="2016-12-10T13:13:05.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-NotarztPierreUrgentiste"/>
  </author>
  <author>🔗 
    <reference value="PractitionerRole/1-NotarztPierreUrgentiste-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="2016-12-10T13:40:00.000+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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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 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>
    </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>
    <entry>🔗 
      <reference value="Observation/1b-DepartureFromTarget"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/1b-OperationalReadiness"/>
    </entry>
  </section>
  <section>
    <title value="Administrativ"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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 Müller</td></tr></tbody></table></div>
    </text>
  </section>
  <section>
    <title value="Vorbehandlung"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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>Thomas Müller 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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <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>