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" : "2-Einsatzprotokoll-Composition",
"language" : "de-CH",
"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 - version 3 Document NEMSIS"
},
{
"system" : "http://snomed.info/sct",
"code" : "371535009",
"display" : "Transfer summary report (record artifact)"
}
],
"text" : "Einsatzprotokoll Rettungsdienst"
},
"subject" : {
🔗 "reference" : "Patient/2-PatientUnbekannt"
},
"encounter" : {
🔗 "reference" : "Encounter/2-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"
}
],
"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>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 Transportsanitäter, 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\">-</th><th id=\"operationalreadiness\">-</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"
}
]
},
{
"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\"><span>-</span></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\"><span>-</span></div>"
}
},
{
"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>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" : "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 id=\"diagnose1\">Stroke (I63)</td></tr></tbody></table></div>"
},
"entry" : [
{
🔗 "reference" : "Observation/2-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>Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen.</span></div>"
}
},
{
"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\"><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"
},
{
🔗 "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>"
}
}
]
}