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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{
"resourceType" : "Composition",
"id" : "2b-Einsatzprotokoll",
"meta" : {
"profile" : [
"http://fhir.ch/ig/ch-ems/StructureDefinition/ch-ems-composition"
]
},
"language" : "de-CH",
"text" : {
"status" : "generated",
"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>: 2b-Einsatzprotokoll</p><p><b>meta</b>: </p><p><b>language</b>: de-CH</p><p><b>identifier</b>: id: urn:uuid:b4044742-ab2c-49f6-8151-0e2be5d3f923</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-2-Einsatz.html\">Generated Summary: id: 2-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, 12:40:00 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></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>"
},
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-setid",
"valueIdentifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:662e3c16-0aac-11e8-ba89-0ed5f89f718b"
}
},
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-versionnumber",
"valueUnsignedInt" : 2
},
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient",
"valueReference" : {
"reference" : "Practitioner/1-InformationRecipientSpezialarzt"
}
},
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-informationrecipient",
"valueReference" : {
"reference" : "Organization/1-InformationRecipientUSZ"
}
}
],
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:b4044742-ab2c-49f6-8151-0e2be5d3f923"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "67796-3",
"display" : "EMS Patient Care Report"
},
{
"system" : "http://snomed.info/sct",
"code" : "371535009",
"display" : "Transfer summary report"
}
]
},
"subject" : {
"reference" : "Patient/2-PatientUnbekannt"
},
"encounter" : {
"reference" : "Encounter/2-Einsatz"
},
"date" : "2016-12-10T12:40:00.000+01:00",
"author" : [
{
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime" : "2016-12-10T12:40:00.000+01:00"
}
],
"reference" : "Practitioner/1-SaniPetraMuster"
},
{
"reference" : "PractitionerRole/1-SaniPetraMuster"
}
],
"title" : "Einsatzprotokoll Rettungsdienst",
"confidentiality" : "N",
"_confidentiality" : {
"extension" : [
{
"url" : "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-confidentialitycode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "17621005",
"display" : "Normal"
}
]
}
}
]
},
"attester" : [
{
"mode" : "legal",
"time" : "2016-12-10T12:13:05.000+01:00",
"party" : {
"reference" : "Practitioner/1-SaniPetraMuster"
}
}
],
"custodian" : {
"reference" : "Organization/1-Rettungsdienst"
},
"section" : [
{
"title" : "Einsatz",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100001",
"display" : "Einsatz"
}
]
},
"text" : {
"status" : "generated",
"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>wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350</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\">12.18</th>\n <th id=\"departurefromscene\">12.48</th>\n <th id=\"arrivalattarget\">12.54</th>\n <th id=\"departurefromtarget\">13.25</th>\n <th id=\"operationalreadiness\">13.40</th>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Encounter/2-Einsatz"
},
{
"reference" : "Observation/1-Alarm"
},
{
"reference" : "Observation/1-Disposition"
},
{
"reference" : "Observation/1-Rollout"
},
{
"reference" : "Observation/1-ArrivalOnScene"
},
{
"reference" : "Observation/2-ArrivalPatient"
},
{
"reference" : "Observation/1-DepartureFromScene"
},
{
"reference" : "Observation/1-ArrivalAtTarget"
},
{
"reference" : "Observation/1b-DepartureFromTarget"
},
{
"reference" : "Observation/1b-OperationalReadiness"
}
]
},
{
"title" : "Administrativ",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100003",
"display" : "Administrativ"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>"
}
},
{
"title" : "Vorbehandlung",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100004",
"display" : "Vorbehandlung"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>"
}
},
{
"title" : "Anamnese",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100005",
"display" : "Anamnese"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>"
}
},
{
"title" : "Befund",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100006",
"display" : "Befund"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Breathing:Der Patient hat eine unauffällige Spontanatmung</p>\n <p>Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; \n Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm</p>\n <p>Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor</p>\n <table>\n <tbody>\n <tr>\n <th>Airways</th>\n <td id=\"airways\">Die Atemwege sind nicht verlegt</td>\n </tr>\n <tr>\n <th>GCS</th>\n <td id=\"gcs1\">Total 9 Augenöffnung bei Ansprache (3), gibt\n Einzelworte von sich (3), Dekortikationsstarre (3)\n </td>\n </tr>\n <tr>\n <th>AVPU</th>\n <td id=\"avpu\">V (=reagiert auf laute Ansprache)</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"section" : [
{
"title" : "Airway",
"entry" : [
{
"reference" : "Observation/2-AirwaysBefund"
}
]
},
{
"title" : "Disability",
"entry" : [
{
"reference" : "Observation/2-GCSBefund"
},
{
"reference" : "Observation/2-AVPUBefund"
}
]
}
]
},
{
"title" : "Diagnosen",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100007",
"display" : "Diagnosen"
}
]
},
"text" : {
"status" : "generated",
"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\">Stroke (I63)</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Observation/2-Diagnose"
}
]
},
{
"title" : "Massnahmen",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100008",
"display" : "Massnahmen"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen. </span>\n </div>"
}
},
{
"title" : "Todesfall",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100009",
"display" : "Todesfall"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>"
}
},
{
"title" : "Transport",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100010",
"display" : "Transport"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> Fahrt mit Sondersignal ins USZ. </span>\n </div>"
}
},
{
"title" : "Übergabe",
"code" : {
"coding" : [
{
"system" : "urn:oid:2.16.756.5.30.1.143.5.1",
"code" : "1100011",
"display" : "Übergabe"
}
]
},
"text" : {
"status" : "generated",
"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\">Total 10 Augenöffnung bei Ansprache (3),\n\t\t\t\t\t\t\t\t\t\tKonversationsfähig aber desorientiert (4),\n\t\t\t\t\t\t\t\t\t\tDekortikationsstarre (3)</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 Effekten sowie Wertsachenverzeichnis </p>\n </div>"
},
"entry" : [
{
"reference" : "Observation/1-ZustandUebergabe"
},
{
"reference" : "Observation/1-NACAUebergabe"
},
{
"reference" : "Observation/2-GCSUebergabe"
}
]
},
{
"title" : "Kommentar",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48767-8",
"display" : "Annotation comment"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <span> - </span>\n </div>"
}
}
]
}