1b-Einsatzprotokoll
type: Composition
node role: treeRoot
resource.id:
  value: 1b-Einsatzprotokoll
resource.meta:
  meta.profile:
    value: http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition
    index: 0
    link: http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition
resource.language:
  value: de-CH
domain resource.text:
  narrative.status:
    value: generated
  narrative.div: Generated Narrative id: 1b-Einsatzprotokoll meta: language: de-CH identifier: id: urn:uuid:b5e2bd3b-f670-4b0c-a62d-38303baac826 status: final type: EMS Patient Care Report encounter: Generated Summary: id: 1-Einsatz; id: S12345678; status: finished; emergency; period: 2016-12-10 --> (ongoing) date: Dec 10, 2016, 12:40:00 PM author: Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster Generated Summary: id: 1-SaniPetraMuster; Caregiver Generated Summary: id: 1-NotarztHansNotarzt; id: 7601000028105; Hans Notarzt Generated Summary: id: 1-NotarztHansNotarzt; Physician title: Einsatzprotokoll Rettungsdienst confidentiality: N Attesters - Mode Time Party * legal Dec 10, 2016, 12:40:00 PM Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster custodian: Generated Summary: id: 1-Rettungsdienst; id: 7601002156363; name: Rettungsdienst Schutz und Rettung Zürich
domain resource.extension:
  index: 0
  extension.url:
    value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid
  extension.value identifier:
    identifier.system:
      value: urn:ietf:rfc:3986
domain resource.extension:
  index: 1
  extension.url:
    value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber
  extension.value unsigned int:
    value: 2
domain resource.extension:
  index: 2
  extension.url:
    value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient
  extension.value reference:
    link: http://fhir.ch/ig/ch-ems/Practitioner/1-InformationRecipientSpezialarzt
    reference.reference:
      value: Practitioner/1-InformationRecipientSpezialarzt
domain resource.extension:
  index: 3
  extension.url:
    value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient
  extension.value reference:
    link: http://fhir.ch/ig/ch-ems/Organization/1-InformationRecipientUSZ
    reference.reference:
      value: Organization/1-InformationRecipientUSZ
composition.identifier:
  identifier.system:
    value: urn:ietf:rfc:3986
composition.status:
  value: final
composition.type:
  codeable concept.coding: http://loinc.org/rdf#67796-3
    index: 0
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 67796-3
    coding.display:
      value: EMS Patient Care Report
  codeable concept.coding: http://snomed.info/id/371535009
    index: 1
    coding.system:
      value: http://snomed.info/sct
    coding.code:
      value: 371535009
    coding.display:
      value: Transfer summary report
composition.subject:
  link: http://fhir.ch/ig/ch-ems/Patient/1-PeterMuster
  reference.reference:
    value: Patient/1-PeterMuster
composition.encounter:
  link: http://fhir.ch/ig/ch-ems/Encounter/1-Einsatz
  reference.reference:
    value: Encounter/1-Einsatz
composition.date:
  value: 2016-12-10T12:40:00.000+01:00
composition.author:
  index: 0
  link: http://fhir.ch/ig/ch-ems/Practitioner/1-SaniPetraMuster
  element.extension:
    index: 0
    extension.url:
      value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time
    extension.value date time:
      value: 2016-12-10T12:13:05.000+01:00
  reference.reference:
    value: Practitioner/1-SaniPetraMuster
composition.author:
  index: 1
  link: http://fhir.ch/ig/ch-ems/PractitionerRole/1-SaniPetraMuster
  reference.reference:
    value: PractitionerRole/1-SaniPetraMuster
composition.author:
  index: 2
  link: http://fhir.ch/ig/ch-ems/Practitioner/1-NotarztHansNotarzt
  element.extension:
    index: 0
    extension.url:
      value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time
    extension.value date time:
      value: 2016-12-10T12:13:05.000+01:00
  reference.reference:
    value: Practitioner/1-NotarztHansNotarzt
composition.author:
  index: 3
  link: http://fhir.ch/ig/ch-ems/PractitionerRole/1-NotarztHansNotarzt
  reference.reference:
    value: PractitionerRole/1-NotarztHansNotarzt
composition.title:
  value: Einsatzprotokoll Rettungsdienst
composition.confidentiality:
  value: N
  element.extension:
    index: 0
    extension.url:
      value: http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode
    extension.value codeable concept:
      codeable concept.coding: http://snomed.info/id/17621005
        index: 0
composition.attester:
  index: 0
  composition.attester.mode:
    value: legal
  composition.attester.time:
    value: 2016-12-10T12:40:00.000+01:00
  composition.attester.party:
    link: http://fhir.ch/ig/ch-ems/Practitioner/1-SaniPetraMuster
    reference.reference:
      value: Practitioner/1-SaniPetraMuster
composition.custodian:
  link: http://fhir.ch/ig/ch-ems/Organization/1-Rettungsdienst
  reference.reference:
    value: Organization/1-Rettungsdienst
composition.section:
  index: 0
  composition.section.title:
    value: Einsatz
  composition.section.code:
    codeable concept.coding:
      index: 0
      coding.system:
        value: urn:oid:2.16.756.5.30.1.143.5.1
      coding.code:
        value: 1100001
      coding.display:
        value: Einsatz
  composition.section.text:
    narrative.status:
      value: generated
    narrative.div: Einsatz Einsatzdatum 10.12.2016 Einsatznummer S12345678 aufbietende Organisation 7601002156370 (SNZ) augebotene Organisation 7601002156363 (Rettungsdienst Schutz & Rettung Zürich) Team Petra Muster, GLN 7601003330434, Betreuerin Hans Beispiel, GLN 7601000028105, Betreuer Einsatzort Zürich, Waldrand (47.392115, 8.553192) Zielort USZ Notfall Alarm Status DP Status 1 Status 2 Kontakt Patient Status 3 Status 4 Status 5 Status 6 12.09 12.11 12.13 12.17 12.22 12.48 12.54 13.25 13.40
  composition.section.entry:
    index: 0
    link: http://fhir.ch/ig/ch-ems/Encounter/1-Einsatz
    reference.reference:
      value: Encounter/1-Einsatz
  composition.section.entry:
    index: 1
    link: http://fhir.ch/ig/ch-ems/Observation/1-Alarm
    reference.reference:
      value: Observation/1-Alarm
  composition.section.entry:
    index: 2
    link: http://fhir.ch/ig/ch-ems/Observation/1-Disposition
    reference.reference:
      value: Observation/1-Disposition
  composition.section.entry:
    index: 3
    link: http://fhir.ch/ig/ch-ems/Observation/1-Rollout
    reference.reference:
      value: Observation/1-Rollout
  composition.section.entry:
    index: 4
    link: http://fhir.ch/ig/ch-ems/Observation/1-ArrivalOnScene
    reference.reference:
      value: Observation/1-ArrivalOnScene
  composition.section.entry:
    index: 5
    link: http://fhir.ch/ig/ch-ems/Observation/1-ArrivalPatient
    reference.reference:
      value: Observation/1-ArrivalPatient
  composition.section.entry:
    index: 6
    link: http://fhir.ch/ig/ch-ems/Observation/1-DepartureFromScene
    reference.reference:
      value: Observation/1-DepartureFromScene
  composition.section.entry:
    index: 7
    link: http://fhir.ch/ig/ch-ems/Observation/1-ArrivalAtTarget
    reference.reference:
      value: Observation/1-ArrivalAtTarget
  composition.section.entry:
    index: 8
    link: http://fhir.ch/ig/ch-ems/Observation/1b-DepartureFromTarget
    reference.reference:
      value: Observation/1b-DepartureFromTarget
  composition.section.entry:
    index: 9
    link: http://fhir.ch/ig/ch-ems/Observation/1b-OperationalReadiness
    reference.reference:
      value: Observation/1b-OperationalReadiness

value: 17621005

value: Normal

index: 1
composition.section.title:
  value: Administrativ
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100003
    coding.display:
      value: Administrativ
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Person/Organsiation Ehefrau Erika Muster

index: 2
composition.section.title:
  value: Vorbehandlung
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100004
    coding.display:
      value: Vorbehandlung
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: -

index: 3
composition.section.title:
  value: Anamnese
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100005
    coding.display:
      value: Anamnese
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Geschehen Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen. Symptome Starke Schmerzen in der Brust und im linken Oberarm verspürt Allergien Baumpollen bekannte Unverträglichkeitsreaktion auf einzelne Medikamente preMedication Aspirin cardio 100, 1 Tbl/Tag Medizinische Vorgeschichte Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio Weitere Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen Peter Muster hat keine Patientenverfügung erstellt es sind keine anderen medizinische Probleme bekannt
composition.section.entry:
  index: 0
  link: http://fhir.ch/ig/ch-ems/Observation/1-Anamnese
  reference.reference:
    value: Observation/1-Anamnese
composition.section.entry:
  index: 1
  link: http://fhir.ch/ig/ch-ems/Observation/1-Symptome
  reference.reference:
    value: Observation/1-Symptome

index: 4
composition.section.title:
  value: Befund
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100006
    coding.display:
      value: Befund
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Blutdruck 120/80 mmHg gemessen am rechten Arm Schmerz 5 GCS Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25
composition.section.section:
  index: 0
  composition.section.title:
    value: Disability
  composition.section.entry:
    index: 0
    link: http://fhir.ch/ig/ch-ems/Observation/1-GCSBefund
    reference.reference:
      value: Observation/1-GCSBefund

index: 5
composition.section.title:
  value: Diagnosen
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100007
    coding.display:
      value: Diagnosen
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Verdachtsdiagnose akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW
composition.section.entry:
  index: 0
  link: http://fhir.ch/ig/ch-ems/Observation/1-Diagnose
  reference.reference:
    value: Observation/1-Diagnose

index: 6
composition.section.title:
  value: Massnahmen
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100008
    coding.display:
      value: Massnahmen
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray

index: 7
composition.section.title:
  value: Todesfall
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100009
    coding.display:
      value: Todesfall
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: -

index: 8
composition.section.title:
  value: Transport
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100010
    coding.display:
      value: Transport
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Fahrt mit Sondersignal ins USZ.

index: 9
composition.section.title:
  value: Übergabe
composition.section.code:
  codeable concept.coding:
    index: 0
    coding.system:
      value: urn:oid:2.16.756.5.30.1.143.5.1
    coding.code:
      value: 1100011
    coding.display:
      value: Übergabe
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: Schmerz 4 GCS 15(4/5/6) um 13.03 NACA NACA: III Zustand der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis
composition.section.entry:
  index: 0
  link: http://fhir.ch/ig/ch-ems/Observation/1-ZustandUebergabe
  reference.reference:
    value: Observation/1-ZustandUebergabe
composition.section.entry:
  index: 1
  link: http://fhir.ch/ig/ch-ems/Observation/1-NACAUebergabe
  reference.reference:
    value: Observation/1-NACAUebergabe
composition.section.entry:
  index: 2
  link: http://fhir.ch/ig/ch-ems/Observation/1-GCSUebergabe
  reference.reference:
    value: Observation/1-GCSUebergabe

index: 10
composition.section.title:
  value: Kommentar
composition.section.code:
  codeable concept.coding: http://loinc.org/rdf#48767-8
    index: 0
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 48767-8
    coding.display:
      value: Annotation comment
composition.section.text:
  narrative.status:
    value: generated
  narrative.div: -