@prefix fhir: . @prefix loinc: . @prefix owl: . @prefix rdfs: . @prefix sct: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:Composition; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "1b-Einsatzprotokoll"]; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"; fhir:index 0; fhir:link ] ]; fhir:Resource.language [ fhir:value "de-CH"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir: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:

title: Einsatzprotokoll Rettungsdienst

confidentiality: N

Attesters

-ModeTimeParty
*legalDec 10, 2016, 12:40:00 PMGenerated Summary: id: 1-SaniPetraMuster; id: 7601003330434; Petra Muster

custodian: Generated Summary: id: 1-Rettungsdienst; id: 7601002156363; name: Rettungsdienst Schutz und Rettung Zürich

" ]; 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 "2"^^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:link ; 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:link ; 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:b5e2bd3b-f670-4b0c-a62d-38303baac826" ] ]; 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:link ; fhir:Reference.reference [ fhir:value "Patient/1-PeterMuster" ] ]; fhir:Composition.encounter [ fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ] ]; fhir:Composition.date [ fhir:value "2016-12-10T12:40:00.000+01:00"^^xsd:dateTime]; fhir:Composition.author [ fhir:index 0; fhir:link ; 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:link ; fhir:Reference.reference [ fhir:value "PractitionerRole/1-SaniPetraMuster" ] ], [ fhir:index 2; fhir:link ; 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:link ; 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 "2016-12-10T12:40:00.000+01:00"^^xsd:dateTime ]; fhir:Composition.attester.party [ fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/1-SaniPetraMuster" ] ] ]; fhir:Composition.custodian [ fhir:link ; 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 "
\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
Einsatz
Einsatzdatum10.12.2016
EinsatznummerS12345678
aufbietende Organisation7601002156370 (SNZ)
augebotene Organisation7601002156363 (Rettungsdienst Schutz & Rettung Zürich)
TeamPetra Muster, GLN 7601003330434, Betreuerin \n
\n Hans Beispiel, GLN 7601000028105, Betreuer \n
EinsatzortZürich, Waldrand (47.392115, 8.553192)
ZielortUSZ Notfall
\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
AlarmStatus DPStatus 1Status 2Kontakt PatientStatus 3Status 4Status 5Status 6
12.0912.1112.1312.1712.2212.4812.5413.2513.40
\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/1-Einsatz" ] ], [ fhir:index 1; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-Alarm" ] ], [ fhir:index 2; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-Disposition" ] ], [ fhir:index 3; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-Rollout" ] ], [ fhir:index 4; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalOnScene" ] ], [ fhir:index 5; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalPatient" ] ], [ fhir:index 6; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-DepartureFromScene" ] ], [ fhir:index 7; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-ArrivalAtTarget" ] ], [ fhir:index 8; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1b-DepartureFromTarget" ] ], [ fhir:index 9; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1b-OperationalReadiness" ] ] ], [ 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 "
\n \n \n \n \n \n \n \n \n \n \n
Person/Organsiation
EhefrauErika Muster
\n
" ] ], [ 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 "
\n - \n
" ] ], [ 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 "
\n \n \n \n \n \n \n \n \n \n
Geschehen
Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.
\n \n \n \n \n \n \n \n \n \n
Symptome
Starke Schmerzen in der Brust und im linken Oberarm verspürt
\n

Allergien

\n
    \n
  • Baumpollen
  • \n
  • bekannte Unverträglichkeitsreaktion auf einzelne Medikamente
  • \n
\n

preMedication

\n
    \n
  • Aspirin cardio 100, 1 Tbl/Tag
  • \n
\n

Medizinische Vorgeschichte

\n
    \n
  • Herzvorfall vor 4 Jahren, behandelt im Triemli, seit dem Aspirin cardio
  • \n
\n

Weitere

\n
    \n
  • Seit dem Frühstück um ca.08:00 Uhr hat er nichts mehr gegessen
  • \n
  • Peter Muster hat keine Patientenverfügung erstellt
  • \n
  • es sind keine anderen medizinische Probleme bekannt
  • \n
\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-Anamnese" ] ], [ fhir:index 1; fhir:link ; 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 "
\n

Blutdruck 120/80 mmHg gemessen am rechten Arm \n
\n Schmerz 5 \n
\n

\n \n \n \n \n \n \n \n \n \n
GCS
Total 15 (Augenöffnung spontan 4/ verbale Antwort orientiert 5/ morot. Reaktion befolgt Antweisungen 6) um 12:25
\n
" ]; fhir:Composition.section.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Disability" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; 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 "
\n \n \n \n \n \n \n \n \n \n
Verdachtsdiagnose
akuten transmuralen Myokardinfarkts der Vorderwand, ACS/STEMI VW
\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; 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 "
\n Infusion gelegt und verabreichen ihm um 12:30 eine erste Dosis von 2 Hüben Nitrolingual-Spray \n
" ] ], [ 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 "
\n - \n
" ] ], [ 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 "
\n Fahrt mit Sondersignal ins USZ. \n
" ] ], [ 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 "
\n

Schmerz 4

\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
GCS
15(4/5/6) um 13.03
NACA
NACA: III
Zustand
der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert
\n

Übergabe an USZ Wertsachenbeutel mit Portemonaie, Handy, Uhr, Schlüssel, Bargel sowie Wertsachenverzeichnis

\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-ZustandUebergabe" ] ], [ fhir:index 1; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/1-NACAUebergabe" ] ], [ fhir:index 2; fhir:link ; 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 "
\n - \n
" ] ] . # - ontology header ------------------------------------------------------------ a owl:Ontology; owl:imports fhir:fhir.ttl . # -------------------------------------------------------------------------------------