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

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: 2b Einsatzprotokoll - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="2b-Einsatzprotokoll-Composition"/>
  <language value="de-CH"/>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:b4044742-ab2c-49f6-8151-0e2be5d3f923"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="67796-3"/>
      <display value="EMS patient care report - version 3 Document NEMSIS"/>
    </coding>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="371535009"/>
      <display value="Transfer summary report (record artifact)"/>
    </coding>
    <text value="Einsatzprotokoll Rettungsdienst"/>
  </type>
  <subject>🔗 
    <reference value="Patient/2-PatientUnbekannt"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/2-Einsatz"/>
  </encounter>
  <date value="2016-12-10T13:40:00.000+01:00"/>
  <author>🔗 
    <extension
               url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time">
      <valueDateTime value="2016-12-10T13:40:00.000+01:00"/>
    </extension>
    <reference value="Practitioner/1-SaniPetraMuster"/>
  </author>
  <author>🔗 
    <reference value="PractitionerRole/1-SaniPetraMuster-PR"/>
  </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 (qualifier value)"/>
        </coding>
        <text value="Normal"/>
      </valueCodeableConcept>
    </extension>
  </confidentiality>
  <attester>
    <mode value="legal"/>
    <time value="2016-12-10T13:13:05.000+01:00"/>
    <party>🔗 
      <reference value="Practitioner/1-SaniPetraMuster"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/1-Rettungsdienst"/>
  </custodian>
  <section>
    <title value="Einsatz"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100001"/>
        <display value="intervention"/>
      </coding>
      <text value="Einsatz"/>
    </code>
    <text>
      <status value="generated"/>
      <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 &amp; 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">13.25</th><th id="operationalreadiness">13.40</th></tr></tbody></table></div>
    </text>
    <entry>🔗 
      <reference value="Encounter/2-Einsatz"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-Alarm"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-Disposition"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-Rollout"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-ArrivalOnScene"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-ArrivalPatient"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-DepartureFromScene"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-ArrivalAtTarget"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2b-DepartureFromTarget"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2b-OperationalReadiness"/>
    </entry>
  </section>
  <section>
    <title value="Administrativ"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100003"/>
        <display value="administrative"/>
      </coding>
      <text value="Administrativ"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Vorbehandlung"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100004"/>
        <display value="pretreatment"/>
      </coding>
      <text value="Vorbehandlung"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Anamnese"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100005"/>
        <display value="anamnesis"/>
      </coding>
      <text value="Anamnese"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Befund"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100006"/>
        <display value="findings"/>
      </coding>
      <text value="Befund"/>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
    <section>
      <title value="Airway"/>
      <entry>🔗 
        <reference value="Observation/2-AirwaysBefund"/>
      </entry>
    </section>
    <section>
      <title value="Disability"/>
      <entry>🔗 
        <reference value="Observation/2-GCSBefund"/>
      </entry>
      <entry>🔗 
        <reference value="Observation/2-AVPUBefund"/>
      </entry>
    </section>
  </section>
  <section>
    <title value="Diagnosen"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100007"/>
        <display value="diagnosis"/>
      </coding>
      <text value="Diagnosen"/>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
    <entry>🔗 
      <reference value="Observation/2-Diagnose"/>
    </entry>
  </section>
  <section>
    <title value="Massnahmen"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100008"/>
        <display value="measures"/>
      </coding>
      <text value="Massnahmen"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen.</span></div>
    </text>
  </section>
  <section>
    <title value="Todesfall"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100009"/>
        <display value="death"/>
      </coding>
      <text value="Todesfall"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
  <section>
    <title value="Transport"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100010"/>
        <display value="transport"/>
      </coding>
      <text value="Transport"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>Fahrt mit Sondersignal ins USZ.</span></div>
    </text>
  </section>
  <section>
    <title value="Übergabe"/>
    <code>
      <coding>
        <system value="http://fhir.ch/ig/ch-ems/CodeSystem/IVR"/>
        <code value="1100011"/>
        <display value="handover"/>
      </coding>
      <text value="Übergabe"/>
    </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">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>
    </text>
    <entry>🔗 
      <reference value="Observation/2-ZustandUebergabe"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-NACAUebergabe"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/2-GCSUebergabe"/>
    </entry>
    <entry>🔗 
      <reference value="Practitioner/1-InformationRecipientSpitalarzt"/>
    </entry>
    <entry>🔗 
      <reference value="Organization/1-InformationRecipientUSZ"/>
    </entry>
  </section>
  <section>
    <title value="Kommentar"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48767-8"/>
        <display value="Annotation comment [Interpretation] Narrative"/>
      </coding>
      <text value="Kommentar"/>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><span>-</span></div>
    </text>
  </section>
</Composition>