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" : "2b-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 2b-Einsatzprotokoll-Composition</b></p><a name=\"2b-Einsatzprotokoll-Composition\"> </a><a name=\"hc2b-Einsatzprotokoll-Composition\"> </a><a name=\"2b-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:b4044742-ab2c-49f6-8151-0e2be5d3f923</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\">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></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 12:13:05+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:b4044742-ab2c-49f6-8151-0e2be5d3f923"
},
"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" : "2016-12-10T12:40:00.000+01:00",
"author" : [
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T12:40:00.000+01:00"
}
],
"reference" : "Practitioner/1-SaniPetraMuster"
},
{
🔗 "reference" : "PractitionerRole/1-SaniPetraMuster-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" : "2016-12-10T12:13:05.000+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\"><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>wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350</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\">12.18</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/2-Einsatz"
},
{
🔗 "reference" : "Observation/2-Alarm"
},
{
🔗 "reference" : "Observation/2-Disposition"
},
{
🔗 "reference" : "Observation/2-Rollout"
},
{
🔗 "reference" : "Observation/2-ArrivalOnScene"
},
{
🔗 "reference" : "Observation/2-ArrivalPatient"
},
{
🔗 "reference" : "Observation/2-DepartureFromScene"
},
{
🔗 "reference" : "Observation/2-ArrivalAtTarget"
},
{
🔗 "reference" : "Observation/2b-DepartureFromTarget"
},
{
🔗 "reference" : "Observation/2b-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\"><span>-</span></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\"><span>-</span></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\"><p>Breathing: Der Patient hat eine unauffällige Spontanatmung</p><p>Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm</p><p>Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor</p><table><tbody><tr><th>Airways</th><td id=\"airways\">Die Atemwege sind nicht verlegt</td></tr><tr><th>GCS</th><td id=\"gcs1\">Total 9 Augenöffnung bei Ansprache (3), gibt Einzelworte von sich (3), Dekortikationsstarre (3)</td></tr><tr><th>AVPU</th><td id=\"avpu\">V (=reagiert auf laute Ansprache)</td></tr></tbody></table></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\"><table><tbody><tr><th>Verdachtsdiagnose</th></tr><tr><td id=\"diagnose1\">Stroke (I63)</td></tr></tbody></table></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\"><span>Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen.</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\">Total 10 Augenöffnung bei Ansprache (3), Konversationsfähig aber desorientiert (4), Dekortikationsstarre (3)</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 Effekten sowie Wertsachenverzeichnis</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/2-ZustandUebergabe"
},
{
🔗 "reference" : "Observation/2-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\"><span>-</span></div>"
}
}
]
}