2b-Einsatzprotokoll
type: Composition
node role: treeRoot
resource.id:
  value: 2b-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: 2b-Einsatzprotokoll meta: language: de-CH identifier: id: urn:uuid:b4044742-ab2c-49f6-8151-0e2be5d3f923 status: final type: EMS Patient Care Report encounter: Generated Summary: id: 2-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 title: Einsatzprotokoll Rettungsdienst confidentiality: N Attesters - Mode Time Party * legal Dec 10, 2016, 12:13:05 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/2-PatientUnbekannt
  reference.reference:
    value: Patient/2-PatientUnbekannt
composition.encounter:
  link: http://fhir.ch/ig/ch-ems/Encounter/2-Einsatz
  reference.reference:
    value: Encounter/2-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: 2016-12-10T12:40:00.000+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.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: 2016-12-10T12:13:05.000+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 wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350 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 12.18 12.48 12.54 13.25 13.40
  composition.section.entry:
    index: 0
    link: http://fhir.ch/ig/ch-ems/Encounter/2-Einsatz
    reference.reference:
      value: Encounter/2-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/2-ArrivalPatient
    reference.reference:
      value: Observation/2-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
composition.section:
  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: -

value: 17621005

value: Normal

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: -

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: Breathing:Der Patient hat eine unauffällige Spontanatmung Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor Airways Die Atemwege sind nicht verlegt GCS Total 9 Augenöffnung bei Ansprache (3), gibt Einzelworte von sich (3), Dekortikationsstarre (3) AVPU V (=reagiert auf laute Ansprache)
composition.section.section:
  index: 0
  composition.section.title:
    value: Airway
  composition.section.entry:
    index: 0
    link: http://fhir.ch/ig/ch-ems/Observation/2-AirwaysBefund
    reference.reference:
      value: Observation/2-AirwaysBefund
composition.section.section:
  index: 1
  composition.section.title:
    value: Disability
  composition.section.entry:
    index: 0
    link: http://fhir.ch/ig/ch-ems/Observation/2-GCSBefund
    reference.reference:
      value: Observation/2-GCSBefund
  composition.section.entry:
    index: 1
    link: http://fhir.ch/ig/ch-ems/Observation/2-AVPUBefund
    reference.reference:
      value: Observation/2-AVPUBefund

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 Stroke (I63)
composition.section.entry:
  index: 0
  link: http://fhir.ch/ig/ch-ems/Observation/2-Diagnose
  reference.reference:
    value: Observation/2-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 mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen.

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 Total 10 Augenöffnung bei Ansprache (3), Konversationsfähig aber desorientiert (4), Dekortikationsstarre (3) NACA NACA: III Zustand der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert Übergabe an USZ Effekten 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/2-GCSUebergabe
  reference.reference:
    value: Observation/2-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: -