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 
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<Composition xmlns="http://hl7.org/fhir"> <id value="1-Einsatzprotokoll"/> <meta> <profile value="http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"/> </meta> <language value="de-CH"/> <text> <status value="generated"/> <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> </text> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid"> <valueIdentifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"/> </valueIdentifier> </extension> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber"> <valueUnsignedInt value="1"/> </extension> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient"> <valueReference> <reference value="Practitioner/1-InformationRecipientSpezialarzt"/> </valueReference> </extension> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient"> <valueReference> <reference value="Organization/1-InformationRecipientUSZ"/> </valueReference> </extension> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"/> </identifier> <status value="final"/> <type> <coding> <system value="http://loinc.org"/> <code value="67796-3"/> <display value="EMS Patient Care Report"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="371535009"/> <display value="Transfer summary report"/> </coding> </type> <!-- CDA: recordTarget --> <subject> <reference value="Patient/1-PeterMuster"/> </subject> <encounter> <reference value="Encounter/1-Einsatz"/> </encounter> <date value="2016-12-10T12:05:00.000+01:00"/> <!-- CDA: author.assignedAuthor --> <author> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time"> <valueDateTime value="2016-12-10T12:13:05.000+01:00"/> </extension> <reference value="Practitioner/1-SaniPetraMuster"/> </author> <!-- CDA: author.functionCode --> <author> <reference value="PractitionerRole/1-SaniPetraMuster"/> </author> <!-- CDA: author.assignedAuthor --> <author> <extension url="http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time"> <valueDateTime value="2016-12-10T12:13:05.000+01:00"/> </extension> <reference value="Practitioner/1-NotarztHansNotarzt"/> </author> <!-- CDA: author.functionCode --> <author> <reference value="PractitionerRole/1-NotarztHansNotarzt"/> </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"/> </coding> </valueCodeableConcept> </extension> </confidentiality> <!-- CDA: legalAutenticator --> <attester> <mode value="legal"/> <time value="2016-12-10T12:13:05.000+01:00"/> <party> <reference value="Practitioner/1-SaniPetraMuster"/> </party> </attester> <!-- CDA: custodian.assignedCustodian.representedCustodian --> <!-- cdachems-dataelement-61 aufgebotene Organisation --> <custodian> <reference value="Organization/1-Rettungsdienst"/> </custodian> <!-- Section Einsatz --> <section> <title value="Einsatz"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100001"/> <display value="Einsatz"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Einsatz</th> </tr> <tr> <td>Einsatzdatum</td> <!-- cdachems-dataelement-54 --> <td>10.12.2016</td> </tr> <tr> <td>Einsatznummer</td> <!-- cdachems-dataelement-54 --> <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 <br/> Hans Beispiel, GLN 7601000028105, Betreuer </td> </tr> <tr> <td>Einsatzort</td> <td>Zürich, Waldrand (47.392115, 8.553192)</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">12.22</th> <th id="departurefromscene">12.48</th> <th id="arrivalattarget">12.54</th> <th id="departurefromtarget"/> <th id="operationalreadiness"/> </tr> </tbody> </table> </div> </text> <entry> <reference value="Encounter/1-Einsatz"/> </entry> <entry> <reference value="Observation/1-Alarm"/> </entry> <entry> <reference value="Observation/1-Disposition"/> </entry> <entry> <reference value="Observation/1-Rollout"/> </entry> <entry> <reference value="Observation/1-ArrivalOnScene"/> </entry> <entry> <reference value="Observation/1-ArrivalPatient"/> </entry> <entry> <reference value="Observation/1-DepartureFromScene"/> </entry> <entry> <reference value="Observation/1-ArrivalAtTarget"/> </entry> </section> <!-- Section Adminstrativ --> <section> <title value="Administrativ"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100003"/> <display value="Administrativ"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Person/Organsiation</th> </tr> <tr> <td>Ehefrau</td> <td>Erika Muster</td> </tr> </tbody> </table> </div> </text> </section> <!-- Section Vorbehandlung --> <section> <title value="Vorbehandlung"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100004"/> <display value="Vorbehandlung"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <span> - </span> </div> </text> </section> <!-- Section Anamnese --> <section> <title value="Anamnese"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100005"/> <display value="Anamnese"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Geschehen</th> </tr> <tr> <td id="anamnesis">Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td> </tr> </tbody> </table> <table> <tbody> <tr> <th>Symptome</th> </tr> <tr> <td id="symptom">Starke Schmerzen in der Brust und im linken Oberarm verspürt</td> </tr> </tbody> </table> <h4>Allergien</h4> <ul> <li>Baumpollen</li> <li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li> </ul> <h4>preMedication</h4> <ul> <li>Aspirin cardio 100, 1 Tbl/Tag</li> </ul> <h4>Medizinische Vorgeschichte</h4> <ul> <li>Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio</li> </ul> <h4>Weitere</h4> <ul> <li>Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen</li> <li>Peter Muster hat keine Patientenverfügung erstellt</li> <li>es sind keine anderen medizinische Probleme bekannt</li> </ul> </div> </text> <entry> <reference value="Observation/1-Anamnese"/> </entry> <entry> <reference value="Observation/1-Symptome"/> </entry> </section> <!-- Section Befund --> <section> <title value="Befund"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100006"/> <display value="Befund"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p> Blutdruck 120/80 mmHg gemessen am rechten Arm <br/> Schmerz 5 <br/> </p> <table> <tbody> <tr> <th>GCS</th> </tr> <tr> <td id="gcs1">Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25</td> </tr> </tbody> </table> </div> </text> <section> <title value="Disability"/> <!-- cdachems-dataelement-108 GCS --> <entry> <reference value="Observation/1-GCSBefund"/> </entry> </section> </section> <!-- Section Diagnosen --> <section> <title value="Diagnosen"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100007"/> <display value="Diagnosen"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Verdachtsdiagnose</th> </tr> <tr> <td id="diagnose1">akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="Observation/1-Diagnose"/> </entry> </section> <!-- Section Massnahmen --> <section> <title value="Massnahmen"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100008"/> <display value="Massnahmen"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <span> Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray </span> </div> </text> </section> <!-- Section Todesfall --> <section> <title value="Todesfall"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100009"/> <display value="Todesfall"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <span> - </span> </div> </text> </section> <!-- Section Transport --> <section> <title value="Transport"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100010"/> <display value="Transport"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <span> Fahrt mit Sondersignal ins USZ. </span> </div> </text> </section> <!-- Section Übergabe --> <section> <title value="Übergabe"/> <code> <coding> <system value="urn:oid:2.16.756.5.30.1.143.5.1"/> <code value="1100011"/> <display value="Übergabe"/> </coding> </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">15(4/5/6) um 13.03</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 Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis </p> </div> </text> <entry> <reference value="Observation/1-ZustandUebergabe"/> </entry> <entry> <reference value="Observation/1-NACAUebergabe"/> </entry> <entry> <reference value="Observation/1-GCSUebergabe"/> </entry> </section> <!-- Section Bemerkungen --> <section> <title value="Kommentar"/> <code> <coding> <system value="http://loinc.org"/> <code value="48767-8"/> <display value="Annotation comment"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <span> - </span> </div> </text> </section> </Composition>