@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 "2b-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: 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:

title: Einsatzprotokoll Rettungsdienst

confidentiality: N

Attesters

-ModeTimeParty
*legalDec 10, 2016, 12:13:05 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:662e3c16-0aac-11e8-ba89-0ed5f89f718b" ] ] ], [ 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:b4044742-ab2c-49f6-8151-0e2be5d3f923" ] ]; 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/2-PatientUnbekannt" ] ]; fhir:Composition.encounter [ fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/2-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 "2016-12-10T12:40:00.000+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: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: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
Einsatzortwird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350
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
12.0912.1112.1312.1712.1812.4812.5413.2513.40
\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/2-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/2-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
" ] ], [ 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
" ] ], [ 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

Breathing:Der Patient hat eine unauffällige Spontanatmung

\n

Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; \n Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm

\n

Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor

\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
AirwaysDie Atemwege sind nicht verlegt
GCSTotal 9 Augenöffnung bei Ansprache (3), gibt\n Einzelworte von sich (3), Dekortikationsstarre (3)\n
AVPUV (=reagiert auf laute Ansprache)
\n
" ]; fhir:Composition.section.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Airway" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/2-AirwaysBefund" ] ] ], [ fhir:index 1; fhir:Composition.section.title [ fhir:value "Disability" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/2-GCSBefund" ] ], [ fhir:index 1; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/2-AVPUBefund" ] ] ] ], [ 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
Stroke (I63)
\n
" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/2-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 mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen. \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
Total 10 Augenöffnung bei Ansprache (3),\n Konversationsfähig aber desorientiert (4),\n Dekortikationsstarre (3)
NACA
NACA: III
Zustand
der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert
\n

Übergabe an USZ Effekten 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/2-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 . # -------------------------------------------------------------------------------------