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

2 Einsatzprotokoll - JSON Representation

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{
  "resourceType" : "Composition",
  "id" : "2-Einsatzprotokoll",
  "meta" : {
    "profile" : [
      "http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"
    ]
  },
  "language" : "de-CH",
  "text" : {
    "status" : "generated",
    "div" : "<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>: 2-Einsatzprotokoll</p><p><b>meta</b>: </p><p><b>language</b>: de-CH</p><p><b>identifier</b>: id: urn:uuid:662e3c16-0aac-11e8-ba89-0ed5f89f718b</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-2-Einsatz.html\">Generated Summary: id: 2-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, 11:05:00 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></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, 11:13:05 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>"
  },
  "extension" : [
    {
      "url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid",
      "valueIdentifier" : {
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:uuid:662e3c16-0aac-11e8-ba89-0ed5f89f718b"
      }
    },
    {
      "url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber",
      "valueUnsignedInt" : 1
    },
    {
      "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:662e3c16-0aac-11e8-ba89-0ed5f89f718b"
  },
  "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/2-PatientUnbekannt"
  },
  "encounter" : {
    "reference" : "Encounter/2-Einsatz"
  },
  "date" : "2016-12-10T12:05:00.000+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"
    }
  ],
  "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" : "2016-12-10T12:13:05.000+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\">\n                <table>\n                    <tbody>\n                        <tr>\n                            <th>Einsatz</th>\n                        </tr>\n                        <tr>\n                            <td>Einsatzdatum</td>\n                              <!-- cdachems-dataelement-54 -->\n                            <td>10.12.2016</td>\n                        </tr>\n                        <tr>\n                            <td>Einsatznummer</td>\n                              <!-- cdachems-dataelement-54 -->\n                            <td>S12345678</td>\n                        </tr>\n                        <tr>\n                            <td>aufbietende Organisation</td>\n                            <td>7601002156370 (SNZ)</td>\n                        </tr>\n                        <tr>\n                            <td>augebotene Organisation</td>\n                            <td>7601002156363 (Rettungsdienst Schutz &amp; Rettung Zürich)</td>\n                        </tr>\n                        <tr>\n                            <td>Team</td>\n                            <td>Petra Muster, GLN 7601003330434, Betreuerin \n                                <br/>\n                                 Hans Beispiel, GLN 7601000028105, Betreuer \n                            </td>\n                        </tr>\n                        <tr>\n                            <td>Einsatzort</td>\n                            <td>wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350</td>\n                        </tr>\n                        <tr>\n                            <td>Zielort</td>\n                            <td>USZ Notfall</td>\n                        </tr>\n                    </tbody>\n                </table>\n                <table>\n                    <tbody>\n                        <tr>\n                            <th>Alarm</th>\n                            <th>Status DP</th>\n                            <th>Status 1</th>\n                            <th>Status 2</th>\n                            <th>Kontakt Patient</th>\n                            <th>Status 3</th>\n                            <th>Status 4</th>\n                            <th>Status 5</th>\n                            <th>Status 6</th>\n                        </tr>\n                        <tr>\n                            <th id=\"alarm\">12.09</th>\n                            <th id=\"disposition\">12.11</th>\n                            <th id=\"rollout\">12.13</th>\n                            <th id=\"arrivalonscene\">12.17</th>\n                            <th id=\"arrivalpatient\">12.18</th>\n                            <th id=\"departurefromscene\">12.48</th>\n                            <th id=\"arrivalattarget\">12.54</th>\n                            <th id=\"departurefromtarget\"/>\n                            <th id=\"operationalreadiness\"/>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
      },
      "entry" : [
        {
          "reference" : "Encounter/2-Einsatz"
        },
        {
          "reference" : "Observation/1-Alarm"
        },
        {
          "reference" : "Observation/1-Disposition"
        },
        {
          "reference" : "Observation/1-Rollout"
        },
        {
          "reference" : "Observation/1-ArrivalOnScene"
        },
        {
          "reference" : "Observation/2-ArrivalPatient"
        },
        {
          "reference" : "Observation/1-DepartureFromScene"
        },
        {
          "reference" : "Observation/1-ArrivalAtTarget"
        }
      ]
    },
    {
      "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\">\n                <span> - </span>\n            </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\">\n                <span> - </span>\n            </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\">\n                <span> - </span>\n            </div>"
      }
    },
    {
      "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\">\n                <p>Breathing:Der Patient hat eine unauffällige Spontanatmung</p>\n                <p>Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; \n                        Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm</p>\n                <p>Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor</p>\n                <table>\n                    <tbody>\n                        <tr>\n                            <th>Airways</th>\n                            <td id=\"airways\">Die Atemwege sind nicht verlegt</td>\n                        </tr>\n                        <tr>\n                            <th>GCS</th>\n                            <td id=\"gcs1\">Total 9 Augenöffnung bei Ansprache (3), gibt\n                                 Einzelworte von sich (3), Dekortikationsstarre (3)\n                            </td>\n                        </tr>\n                        <tr>\n                            <th>AVPU</th>\n                            <td id=\"avpu\">V (=reagiert auf laute Ansprache)</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
      },
      "section" : [
        {
          "title" : "Airway",
          "entry" : [
            {
              "reference" : "Observation/2-AirwaysBefund"
            }
          ]
        },
        {
          "title" : "Disability",
          "entry" : [
            {
              "reference" : "Observation/2-GCSBefund"
            },
            {
              "reference" : "Observation/2-AVPUBefund"
            }
          ]
        }
      ]
    },
    {
      "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\">\n                <table>\n                    <tbody>\n                        <tr>\n                            <th>Verdachtsdiagnose</th>\n                        </tr>\n                        <tr>\n                            <td id=\"diagnose1\">Stroke (I63)</td>\n                        </tr>\n                    </tbody>\n                </table>\n            </div>"
      },
      "entry" : [
        {
          "reference" : "Observation/2-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\">\n                <span> Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen. </span>\n            </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\">\n                <span> - </span>\n            </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\">\n                <span> Fahrt mit Sondersignal ins USZ. </span>\n            </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\">\n                <p>Schmerz 4</p>\n                <table>\n                    <tbody>\n                        <tr>\n                            <th>GCS</th>\n                        </tr>\n                        <tr>\n                            <td id=\"gcs2\">Total 10 Augenöffnung bei Ansprache (3),\n\t\t\t\t\t\t\t\t\t\tKonversationsfähig aber desorientiert (4),\n\t\t\t\t\t\t\t\t\t\tDekortikationsstarre (3)</td>\n                        </tr>\n                        <tr>\n                            <th>NACA</th>\n                        </tr>\n                        <tr>\n                            <td id=\"naca\">NACA: III</td>\n                        </tr>\n                        <tr>\n                            <th>Zustand</th>\n                        </tr>\n                        <tr>\n                            <td id=\"statusdischarge\">der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert</td>\n                        </tr>\n                    </tbody>\n                </table>\n                <p> Übergabe an USZ Effekten sowie Wertsachenverzeichnis </p>\n            </div>"
      },
      "entry" : [
        {
          "reference" : "Observation/1-ZustandUebergabe"
        },
        {
          "reference" : "Observation/1-NACAUebergabe"
        },
        {
          "reference" : "Observation/2-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\">\n                <span> - </span>\n            </div>"
      }
    }
  ]
}