CH EMS (R4)
2.1.0-ci-build - ci-build
CH EMS (R4)
2.1.0-ci-build - 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 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
{
"resourceType" : "Composition",
"id" : "1-Einsatzprotokoll-Composition",
"language" : "de-CH",
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "67796-3",
"display" : "EMS patient care report - version 3 Document NEMSIS"
},
{
"system" : "http://snomed.info/sct",
"code" : "371535009",
"display" : "Transfer summary report (record artifact)"
}
],
"text" : "Einsatzprotokoll Rettungsdienst"
},
"subject" : {
🔗 "reference" : "Patient/1-ThomasMueller"
},
"encounter" : {
🔗 "reference" : "Encounter/1-Einsatz"
},
"date" : "2016-12-10T13:05:00.000+01:00",
"author" : [
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T13:13:05.000+01:00"
}
],
"reference" : "Practitioner/1-SaniPetraMuster"
},
{
🔗 "reference" : "PractitionerRole/1-SaniPetraMuster-PR"
},
{
🔗 "extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T13:13:05.000+01:00"
}
],
"reference" : "Practitioner/1-NotarztPierreUrgentiste"
},
{
🔗 "reference" : "PractitionerRole/1-NotarztPierreUrgentiste-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 (qualifier value)"
}
],
"text" : "Normal"
}
}
]
},
"attester" : [
{
"mode" : "legal",
"time" : "2016-12-10T13:13:05.000+01:00",
"party" : {
🔗 "reference" : "Practitioner/1-SaniPetraMuster"
}
}
],
"custodian" : {
🔗 "reference" : "Organization/1-Rettungsdienst"
},
"section" : [
{
"title" : "Einsatz",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100001",
"display" : "intervention"
}
],
"text" : "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>SNZ (GLN 7601002156370)</td></tr><tr><td>Aufgebotene Organisation:</td><td>Rettungsdienst Schutz und Rettung Zürich (GLN 7601002156363)</td></tr><tr><td>Teammitglieder:</td><td>Petra Muster (Rettungssanitäterin), Hans Transportsanitäter (Transportsanitäter), Pierre Urgentiste (Notarzt)</td></tr><tr><td>Einsatzort:</td><td>Zürich, Waldrand (47.392115, 8.553192)</td></tr><tr><td>Zielort:</td><td>Universitätsspital Zürich, Notfall</td></tr></tbody></table><table><tbody><tr><th>Alarmierungszeit:</th><th>Dispositionszeit:</th><th>Ausrückzeit:</th><th>Ankunftszeit am Einsatzort:</th><th>Ankunftszeit beim Patienten:</th><th>Abfahrtszeit vom Einsatzort:</th><th>Ankunftszeit am Zielort:</th></tr><tr><th>12:09</th><th>12:11</th><th>12:13</th><th>12:17</th><th>12:22</th><th>12:48</th><th>12:54</th></tr></tbody></table></div>"
},
"entry" : [
{
🔗 "reference" : "Encounter/1-Einsatz"
},
{
🔗 "reference" : "Observation/1-Alarm"
},
{
🔗 "reference" : "Observation/1-Disposition"
},
{
🔗 "reference" : "Observation/1-Rollout"
},
{
🔗 "reference" : "Observation/1-ArrivalOnScene"
},
{
🔗 "reference" : "Observation/1-ArrivalPatient"
},
{
🔗 "reference" : "Observation/1-DepartureFromScene"
},
{
🔗 "reference" : "Observation/1-ArrivalAtTarget"
},
{
🔗 "reference" : "Procedure/1-Transport"
},
{
🔗 "reference" : "Location/1-Rettungswagen"
}
]
},
{
"title" : "Administrativ",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100003",
"display" : "administrative"
}
],
"text" : "Administrativ"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Beteiligte Person</th></tr><tr><td>Ehefrau:</td><td>Erika Müller</td></tr></tbody></table></div>"
}
},
{
"title" : "Vorbehandlung",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100004",
"display" : "pretreatment"
}
],
"text" : "Vorbehandlung"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Anamnese",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100005",
"display" : "anamnesis"
}
],
"text" : "Anamnese"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Ereignis:</th></tr><tr><td>Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td></tr></tbody></table><table><tbody><tr><th>Symptome:</th></tr><tr><td>Starke Schmerzen in der Brust und im linken Oberarm verspürt.</td></tr></tbody></table><h4>Allergien / Unverträglichkeiten:</h4><ul><li>Allergisch auf Baumpollen</li><li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li></ul><h4>Bestehende Medikation</h4><ul><li>Aspirin Cardio 100 (1 Tbl./Tag)</li></ul><h4>Medizinische Vorgeschichte:</h4><ul><li>Herzvorfall vor vier Jahren, der im Triemlispital in Zürich behandelt wurde</li></ul><h4>Weiteres:</h4><ul><li>Seit dem Frühstück um ca. 8 Uhr hat er nichts mehr gegessen</li><li>Thomas Müller hat keine Patientenverfügung erstellt</li><li>Es sind keine anderen medizinischen Probleme bekannt</li></ul></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-Anamnese"
},
{
🔗 "reference" : "Observation/1-Symptome"
},
{
🔗 "reference" : "AllergyIntolerance/1-Baumpollen"
},
{
🔗 "reference" : "AllergyIntolerance/1-Medikamente"
},
{
🔗 "reference" : "MedicationStatement/1-AspirinCardio"
}
]
},
{
"title" : "Befund",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100006",
"display" : "findings"
}
],
"text" : "Befund"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Zeitpunkt des Befundes: 12:25</p><table><tbody><tr><th>Blutdruck:</th><th>GCS:</th><th>Weiteres:</th></tr><tr><td>120/80 mmHg, gemessen am rechten Arm</td><td>Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)</td><td>Schmerz: 5</td></tr></tbody></table></div>"
},
"section" : [
{
"title" : "Circulation",
"entry" : [
{
🔗 "reference" : "Observation/1-Blutdruck"
}
]
},
{
"title" : "Disability",
"entry" : [
{
🔗 "reference" : "Observation/1-GCSBefund"
}
]
}
]
},
{
"title" : "Diagnosen",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100007",
"display" : "diagnosis"
}
],
"text" : "Diagnosen"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Verdachtsdiagnose:</th></tr><tr><td>Akuter transmuraler Myokardinfarkt der Vorderwand (ACS/STEMI VW)</td></tr></tbody></table></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-Diagnose"
}
]
},
{
"title" : "Massnahmen",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100008",
"display" : "measures"
}
],
"text" : "Massnahmen"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>Sofortige Infusion gelegt und Verabreichung einer ersten Dosis von 2 Hüben Nitrolingual-Spray um 12:30.</span></div>"
},
"entry" : [
{
🔗 "reference" : "MedicationAdministration/1-Infusion"
},
{
🔗 "reference" : "MedicationAdministration/1-Spray"
}
]
},
{
"title" : "Todesfall",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100009",
"display" : "death"
}
],
"text" : "Todesfall"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title" : "Transport",
"code" : {
"coding" : [
{
"system" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100010",
"display" : "transport"
}
],
"text" : "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" : "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code" : "1100011",
"display" : "handover"
}
],
"text" : "Übergabe"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>GCS:</th><th>NACA:</th><th>Zustand:</th><th>Weiteres:</th></tr><tr><td>Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)</td><td>III</td><td>Zustand des Patienten hat sich im Verlaufe des Einsatzes verbessert</td><td>Schmerz: 4</td></tr></tbody></table><p>Übergabe an USZ mit Wertsachenbeutel mit Portemonnaie, Handy, Uhr, Schlüssel, Bargeld sowie Wertsachenverzeichnis.</p></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/1-ZustandUebergabe"
},
{
🔗 "reference" : "Observation/1-NACAUebergabe"
},
{
🔗 "reference" : "Observation/1-GCSUebergabe"
},
{
🔗 "reference" : "Practitioner/1-InformationRecipientSpitalarzt"
},
{
🔗 "reference" : "Organization/1-InformationRecipientUSZ"
}
]
},
{
"title" : "Kommentar",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48767-8",
"display" : "Annotation comment [Interpretation] Narrative"
}
],
"text" : "Kommentar"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
}
]
}