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

1b Einsatzprotokoll - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="1b-Einsatzprotokoll"/>
  <meta>
    <profile
             value="http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"/>
  </meta>
  <language value="de-CH"/>
  <text>
    <status value="generated"/>
    <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>: 1b-Einsatzprotokoll</p><p><b>meta</b>: </p><p><b>language</b>: de-CH</p><p><b>identifier</b>: id: 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">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, 11:40:00 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, 11:40:00 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>
  </text>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid">
    <valueIdentifier>
      <system value="urn:ietf:rfc:3986"/>
      <value value="urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"/>
    </valueIdentifier>
  </extension>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber">
    <valueUnsignedInt value="2"/>
  </extension>
  <extension
             url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient">
    <valueReference>
      <reference value="Practitioner/1-InformationRecipientSpezialarzt"/>
    </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>
<!--  CDA: recordTarget  -->
  <subject>
    <reference value="Patient/1-PeterMuster"/>
  </subject>
  <encounter>
    <reference value="Encounter/1-Einsatz"/>
  </encounter>
  <date value="2016-12-10T12:40:00.000+01:00"/>
<!--  CDA: author.assignedAuthor  -->
  <author>
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T12:13:05.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-SaniPetraMuster"/>
  </author>
<!--  CDA: author.functionCode  -->
  <author>
    <reference value="PractitionerRole/1-SaniPetraMuster"/>
  </author>
<!--  CDA: author.assignedAuthor  -->
  <author>
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T12:13:05.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-NotarztHansNotarzt"/>
  </author>
<!--  CDA: author.functionCode  -->
  <author>
    <reference value="PractitionerRole/1-NotarztHansNotarzt"/>
  </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>
<!--  CDA: legalAutenticator  -->
  <attester>
    <mode value="legal"/>
    <time value="2016-12-10T12:40:00.000+01:00"/>
    <party>
      <reference value="Practitioner/1-SaniPetraMuster"/>
    </party>
  </attester>
<!--  CDA: custodian.assignedCustodian.representedCustodian  -->
<!--  cdachems-dataelement-61 aufgebotene Organisation  -->
  <custodian>
    <reference value="Organization/1-Rettungsdienst"/>
  </custodian>
<!--  Section Einsatz  -->
  <section>
    <title value="Einsatz"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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>
                <!-- cdachems-dataelement-54 -->
              <td>10.12.2016</td>
            </tr>
            <tr>
              <td>Einsatznummer</td>
                <!-- cdachems-dataelement-54 -->
              <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 
                <br/>
                                 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>
    </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 Adminstrativ  -->
  <section>
    <title value="Administrativ"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Muster</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
  </section>
<!--  Section Vorbehandlung  -->
  <section>
    <title value="Vorbehandlung"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Anamnese  -->
  <section>
    <title value="Anamnese"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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>Peter Muster 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 Befund  -->
  <section>
    <title value="Befund"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 
          <br/>
                           Schmerz 5                  
          <br/>
        </p>
        <table>
          <tbody>
            <tr>
              <th>GCS</th>
            </tr>
            <tr>
              <td id="gcs1">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
    <section>
      <title value="Disability"/>
    <!--  cdachems-dataelement-108 GCS  -->
      <entry>
        <reference value="Observation/1-GCSBefund"/>
      </entry>
    </section>
  </section>
<!--  Section Diagnosen  -->
  <section>
    <title value="Diagnosen"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Massnahmen  -->
  <section>
    <title value="Massnahmen"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Todesfall  -->
  <section>
    <title value="Todesfall"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Transport  -->
  <section>
    <title value="Transport"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Übergabe  -->
  <section>
    <title value="Übergabe"/>
    <code>
      <coding>
        <system value="urn:oid:2.16.756.5.30.1.143.5.1"/>
        <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 Bemerkungen  -->
  <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>