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
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<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
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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: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>
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<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>
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<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>
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<div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
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<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>
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<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>
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<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>
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<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>
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<div xmlns="http://www.w3.org/1999/xhtml"><span>Fahrt mit Sondersignal ins USZ.</span></div>
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<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>
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