CH EMS (R4)
1.9.0 - Standard for Trial Use
CH EMS (R4)
1.9.0 - Standard for Trial Use
This page is part of the CH EMS (R4) (v1.9.0: STU) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
Source view
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Composition; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "1-Einsatzprotokoll"]; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"; fhir:index 0; fhir:link <http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition> ] ]; fhir:Resource.language [ fhir:value "de-CH"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"de-CH\" lang=\"de-CH\"><p><b>Generated Narrative</b></p><p><b>id</b>: 1-Einsatzprotokoll</p><p><b>meta</b>: </p><p><b>language</b>: de-CH</p><p><b>identifier</b>: id: urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://loinc.org 67796-3}, {http://snomed.info/sct 371535009}\">EMS Patient Care Report</span></p><p><b>encounter</b>: <a href=\"Encounter-1-Einsatz.html\">Generated Summary: id: 1-Einsatz; id: S12345678; status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode EMER}\">emergency</span>; period: 2016-12-10 --> (ongoing)</a></p><p><b>date</b>: Dec 10, 2016, 12:05:00 PM</p><p><b>author</b>: </p><ul><li><a href=\"Practitioner-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster </a></li><li><a href=\"PractitionerRole-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; <span title=\"Codes: {http://snomed.info/sct 133932002}\">Caregiver</span></a></li><li><a href=\"Practitioner-1-NotarztHansNotarzt.html\">Generated Summary: id: 1-NotarztHansNotarzt; id: 7601000028105; Hans Notarzt </a></li><li><a href=\"PractitionerRole-1-NotarztHansNotarzt.html\">Generated Summary: id: 1-NotarztHansNotarzt; <span title=\"Codes: {http://snomed.info/sct 309343006}\">Physician</span></a></li></ul><p><b>title</b>: Einsatzprotokoll Rettungsdienst</p><p><b>confidentiality</b>: N</p><h3>Attesters</h3><table class=\"grid\"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>Dec 10, 2016, 12:13:05 PM</td><td><a href=\"Practitioner-1-SaniPetraMuster.html\">Generated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster </a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-1-Rettungsdienst.html\">Generated Summary: id: 1-Rettungsdienst; id: 7601002156363; name: Rettungsdienst Schutz und Rettung Zürich</a></p></div>" ]; fhir:DomainResource.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid" ]; fhir:Extension.valueIdentifier [ fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ]; fhir:Identifier.value [ fhir:value "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78" ] ] ], [ fhir:index 1; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber" ]; fhir:Extension.valueUnsignedInt [ fhir:value "1"^^xsd:nonNegativeInteger ] ], [ fhir:index 2; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient" ]; fhir:Extension.valueReference [ fhir:Reference.reference [ fhir:value "Practitioner/1-InformationRecipientSpezialarzt" ] ] ], [ fhir:index 3; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient" ]; fhir:Extension.valueReference [ fhir:Reference.reference [ fhir:value "Organization/1-InformationRecipientUSZ" ] ] ]; fhir:Composition.identifier [ fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ]; fhir:Identifier.value [ fhir:value "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78" ] ]; fhir:Composition.status [ fhir:value "final"]; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:67796-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "67796-3" ]; fhir:Coding.display [ fhir:value "EMS Patient Care Report" ] ], [ fhir:index 1; a sct:371535009; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "371535009" ]; fhir:Coding.display [ fhir:value "Transfer summary report" ] ] ]; fhir:Composition.subject [ fhir:Reference.reference [ fhir:value "Patient/1-PeterMuster" ] ]; fhir:Composition.encounter [ fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ] ]; fhir:Composition.date [ fhir:value "2016-12-10T12:05:00.000+01:00"^^xsd:dateTime]; fhir:Composition.author [ fhir:index 0; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time" ]; fhir:Extension.valueDateTime [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ] ]; fhir:Reference.reference [ fhir:value "Practitioner/1-SaniPetraMuster" ] ], [ fhir:index 1; fhir:Reference.reference [ fhir:value "PractitionerRole/1-SaniPetraMuster" ] ], [ fhir:index 2; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time" ]; fhir:Extension.valueDateTime [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ] ]; fhir:Reference.reference [ fhir:value "Practitioner/1-NotarztHansNotarzt" ] ], [ fhir:index 3; fhir:Reference.reference [ fhir:value "PractitionerRole/1-NotarztHansNotarzt" ] ]; fhir:Composition.title [ fhir:value "Einsatzprotokoll Rettungsdienst"]; fhir:Composition.confidentiality [ fhir:value "N"; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode" ]; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; a sct:17621005; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "17621005" ]; fhir:Coding.display [ fhir:value "Normal" ] ] ] ] ]; fhir:Composition.attester [ fhir:index 0; fhir:Composition.attester.mode [ fhir:value "legal" ]; fhir:Composition.attester.time [ fhir:value "2016-12-10T12:13:05.000+01:00"^^xsd:dateTime ]; fhir:Composition.attester.party [ fhir:Reference.reference [ fhir:value "Practitioner/1-SaniPetraMuster" ] ] ]; fhir:Composition.custodian [ fhir:Reference.reference [ fhir:value "Organization/1-Rettungsdienst" ] ]; fhir:Composition.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Einsatz" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100001" ]; fhir:Coding.display [ fhir:value "Einsatz" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tbody>\n <tr>\n <th>Einsatz</th>\n </tr>\n <tr>\n <td>Einsatzdatum</td>\n <!-- cdachems-dataelement-54 -->\n <td>10.12.2016</td>\n </tr>\n <tr>\n <td>Einsatznummer</td>\n <!-- cdachems-dataelement-54 -->\n <td>S12345678</td>\n </tr>\n <tr>\n <td>aufbietende Organisation</td>\n <td>7601002156370 (SNZ)</td>\n </tr>\n <tr>\n <td>augebotene Organisation</td>\n <td>7601002156363 (Rettungsdienst Schutz & Rettung Zürich)</td>\n </tr>\n <tr>\n <td>Team</td>\n <td>Petra Muster, GLN 7601003330434, Betreuerin \n <br/>\n Hans Beispiel, GLN 7601000028105, Betreuer \n </td>\n </tr>\n <tr>\n <td>Einsatzort</td>\n <td>Zürich, Waldrand (47.392115, 8.553192)</td>\n </tr>\n <tr>\n <td>Zielort</td>\n <td>USZ Notfall</td>\n </tr>\n </tbody>\n </table>\n <table>\n <tbody>\n <tr>\n <th>Alarm</th>\n <th>Status DP</th>\n <th>Status 1</th>\n <th>Status 2</th>\n <th>Kontakt Patient</th>\n <th>Status 3</th>\n <th>Status 4</th>\n <th>Status 5</th>\n <th>Status 6</th>\n </tr>\n <tr>\n <th id=\"alarm\">12.09</th>\n <th id=\"disposition\">12.11</th>\n <th id=\"rollout\">12.13</th>\n <th id=\"arrivalonscene\">12.17</th>\n <th id=\"arrivalpatient\">12.22</th>\n <th id=\"departurefromscene\">12.48</th>\n <th id=\"arrivalattarget\">12.54</th>\n <th id=\"departurefromtarget\"/>\n <th id=\"operationalreadiness\"/>\n </tr>\n </tbody>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ] ], [ fhir:index 1; fhir:Reference.reference [ fhir:value "Observation/1-Alarm" ] ], [ fhir:index 2; fhir:Reference.reference [ fhir:value "Observation/1-Disposition" ] ], [ fhir:index 3; fhir:Reference.reference [ fhir:value "Observation/1-Rollout" ] ], [ fhir:index 4; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalOnScene" ] ], [ fhir:index 5; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalPatient" ] ], [ fhir:index 6; fhir:Reference.reference [ fhir:value "Observation/1-DepartureFromScene" ] ], [ fhir:index 7; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalAtTarget" ] ] ], [ fhir:index 1; fhir:Composition.section.title [ fhir:value "Administrativ" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100003" ]; fhir:Coding.display [ fhir:value "Administrativ" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tbody>\n <tr>\n <th>Person/Organsiation</th>\n </tr>\n <tr>\n <td>Ehefrau</td>\n <td>Erika Muster</td>\n </tr>\n </tbody>\n </table>\n </div>" ] ], [ fhir:index 2; fhir:Composition.section.title [ fhir:value "Vorbehandlung" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100004" ]; fhir:Coding.display [ fhir:value "Vorbehandlung" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>" ] ], [ fhir:index 3; fhir:Composition.section.title [ fhir:value "Anamnese" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100005" ]; fhir:Coding.display [ fhir:value "Anamnese" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tbody>\n <tr>\n <th>Geschehen</th>\n </tr>\n <tr>\n <td id=\"anamnesis\">Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td>\n </tr>\n </tbody>\n </table>\n <table>\n <tbody>\n <tr>\n <th>Symptome</th>\n </tr>\n <tr>\n <td id=\"symptom\">Starke Schmerzen in der Brust und im linken Oberarm verspürt</td>\n </tr>\n </tbody>\n </table>\n <h4>Allergien</h4>\n <ul>\n <li>Baumpollen</li>\n <li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li>\n </ul>\n <h4>preMedication</h4>\n <ul>\n <li>Aspirin cardio 100, 1 Tbl/Tag</li>\n </ul>\n <h4>Medizinische Vorgeschichte</h4>\n <ul>\n <li>Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio</li>\n </ul>\n <h4>Weitere</h4>\n <ul>\n <li>Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen</li>\n <li>Peter Muster hat keine Patientenverfügung erstellt</li>\n <li>es sind keine anderen medizinische Probleme bekannt</li>\n </ul>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/1-Anamnese" ] ], [ fhir:index 1; fhir:Reference.reference [ fhir:value "Observation/1-Symptome" ] ] ], [ fhir:index 4; fhir:Composition.section.title [ fhir:value "Befund" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100006" ]; fhir:Coding.display [ fhir:value "Befund" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p> Blutdruck 120/80 mmHg gemessen am rechten Arm \n <br/>\n Schmerz 5 \n <br/>\n </p>\n <table>\n <tbody>\n <tr>\n <th>GCS</th>\n </tr>\n <tr>\n <td id=\"gcs1\">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25</td>\n </tr>\n </tbody>\n </table>\n </div>" ]; fhir:Composition.section.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Disability" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/1-GCSBefund" ] ] ] ], [ fhir:index 5; fhir:Composition.section.title [ fhir:value "Diagnosen" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100007" ]; fhir:Coding.display [ fhir:value "Diagnosen" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tbody>\n <tr>\n <th>Verdachtsdiagnose</th>\n </tr>\n <tr>\n <td id=\"diagnose1\">akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW</td>\n </tr>\n </tbody>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/1-Diagnose" ] ] ], [ fhir:index 6; fhir:Composition.section.title [ fhir:value "Massnahmen" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100008" ]; fhir:Coding.display [ fhir:value "Massnahmen" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray </span>\n </div>" ] ], [ fhir:index 7; fhir:Composition.section.title [ fhir:value "Todesfall" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100009" ]; fhir:Coding.display [ fhir:value "Todesfall" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>" ] ], [ fhir:index 8; fhir:Composition.section.title [ fhir:value "Transport" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100010" ]; fhir:Coding.display [ fhir:value "Transport" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> Fahrt mit Sondersignal ins USZ. </span>\n </div>" ] ], [ fhir:index 9; fhir:Composition.section.title [ fhir:value "Übergabe" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "urn:oid:2.16.756.5.30.1.143.5.1" ]; fhir:Coding.code [ fhir:value "1100011" ]; fhir:Coding.display [ fhir:value "Übergabe" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Schmerz 4</p>\n <table>\n <tbody>\n <tr>\n <th>GCS</th>\n </tr>\n <tr>\n <td id=\"gcs2\">15(4/5/6) um 13.03</td>\n </tr>\n <tr>\n <th>NACA</th>\n </tr>\n <tr>\n <td id=\"naca\">NACA: III</td>\n </tr>\n <tr>\n <th>Zustand</th>\n </tr>\n <tr>\n <td id=\"statusdischarge\">der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert</td>\n </tr>\n </tbody>\n </table>\n <p> Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis </p>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/1-ZustandUebergabe" ] ], [ fhir:index 1; fhir:Reference.reference [ fhir:value "Observation/1-NACAUebergabe" ] ], [ fhir:index 2; fhir:Reference.reference [ fhir:value "Observation/1-GCSUebergabe" ] ] ], [ fhir:index 10; fhir:Composition.section.title [ fhir:value "Kommentar" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:48767-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "48767-8" ]; fhir:Coding.display [ fhir:value "Annotation comment" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>" ] ]. # - ontology header ------------------------------------------------------------ a owl:Ontology; owl:imports fhir:fhir.ttl.