Generated Narrative: Composition 5c3cddfe-bbe6-463f-b76c-3d45bc7998fb Language: de-CH Profile: CH IPS Composition identifier: <a href="http://terminology.hl7.org/5.5.0/NamingSystem-uri.html" title="As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt This oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid: Note that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR. This OID may also be used in CD.codeSystem.">Uniform Resource Identifier (URI)/urn:uuid:fe724e67-ac59-4933-b997-2770cc506f3b status: Final type: Patient summary Document date: 2024-05-03 09:30:00+0200 author: Martina Meier @ Spital title: Patient Summary for IPS Switerland confidentiality: normal Attesters - Mode Party * Legal Martina Meier custodian: Spital RelatesTos - Code Target[x] * Replaces <a href="http://terminology.hl7.org/5.5.0/NamingSystem-uri.html" title="As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt This oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid: Note that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR. This OID may also be used in CD.codeSystem.">Uniform Resource Identifier (URI)/urn:uuid:22f9773e-1a6b-4561-8642-849f15b43b02 Events - Code Period * care provision 2024-01-11 10:00:00+0100 --> 2024-05-03 09:30:00+0200
Metformin Atorvastatin Clopidogrel Aspirin
Allergies and adverse reactions Document
Keine bekannten Allergien
Diabetes mellitus Typ 2 Bluthochdruck Koronare Herzkrankheit Herzinfarkt (26.04.2024)
Stent (27.09.2022) aufgrund koronarer Herzkrankheit Stent (26.04.2024) aufgrund Herzinfarkt
DiTePe-Impfung (15.09.2017)
Körpergewicht: 65 kg Körpergrösse: 170 cm
Ehemalige Raucherin
Generated Narrative: Patient 8383926c-ece1-4384-94bc-b4250b4cb71b Profile: CH IPS Patient Monika Wegmüller Female, DoB: 1943-05-15 ( Medical record number: 987654321) Contact Detail Wiesenstr. 12 Zürich 8003 CH
Generated Narrative: Practitioner 4d4e3587-42eb-4921-8c87-8bbf89b7eb4b Profile: CH IPS Practitioner identifier: GLN/7601000234438 name: Martina Meier
Generated Narrative: PractitionerRole 869a4dd9-3a4a-4838-ad1e-42453d341147 Profile: CH IPS PractitionerRole practitioner: Bundle: identifier = UUID:fe724e67-ac59-4933-b997-2770cc506f3b; type = document; timestamp = 2024-05-03 09:30:00+0200 organization: Bundle: identifier = UUID:fe724e67-ac59-4933-b997-2770cc506f3b; type = document; timestamp = 2024-05-03 09:30:00+0200
Generated Narrative: Organization a27376ce-fa12-458d-a2dc-f90e63de126b Profile: CH IPS Organization identifier: GLN/7601000234438 name: Spital address: Spitalstrasse 2 Zürich 8005 CH
Generated Narrative: MedicationStatement 88ee1ffb-26d0-49a2-95e4-6212261805a6 Profile: CH IPS MedicationStatement status: Active medication: Medication METFORMIN Axapharm Filmtabl 500 mg (Blister 50 Stk) subject: Monika Wegmüller effective: 2020-03-03 --> (ongoing) reasonCode: Diabetes dosage patientInstruction: Unzerkaut während oder nach den Mahlzeiten mit ausreichend Flüssigkeit einnehmen timing: Morning, Evening, Once route: zum Einnehmen DoseAndRates - Dose[x] * 1 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') Generated Narrative: Medication #Metformin Profile: CH IPS Medication code: METFORMIN Axapharm Filmtabl 500 mg form: Tablette amount: 50 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)')/1 Package - unit of product usage (qualifier value) (Details: SNOMED CT code1681000175101 = 'Package - unit of product usage')
METFORMIN Axapharm Filmtabl 500 mg (Blister 50 Stk)
Package - unit of product usage (qualifier value)
Unzerkaut während oder nach den Mahlzeiten mit ausreichend Flüssigkeit einnehmen
Generated Narrative: MedicationStatement 6f369210-adb1-4f11-893d-9977e34932de Profile: CH IPS MedicationStatement status: Active medication: Medication EZETIMIB Atorvast Mepha Filmtabl 10mg/40mg (Blister 30 Stk) subject: Monika Wegmüller effective: 2024-05-03 --> (ongoing) reasonCode: Hypercholesterinämie dosage sequence: 1 patientInstruction: Kann unabhängig von den Mahlzeiten eingenommen werden timing: Morning, Once route: zum Einnehmen DoseAndRates - Dose[x] * 0.5 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') dosage sequence: 2 timing: Evening, Once DoseAndRates - Dose[x] * 1 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') Generated Narrative: Medication #Atorvastatin Profile: CH IPS Medication code: EZETIMIB Atorvast Mepha Filmtabl 10mg/40mg form: Filmtablette amount: 30 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)')/1 Package - unit of product usage (qualifier value) (Details: SNOMED CT code1681000175101 = 'Package - unit of product usage')
EZETIMIB Atorvast Mepha Filmtabl 10mg/40mg (Blister 30 Stk)
EZETIMIB Atorvast Mepha Filmtabl 10mg/40mg
Kann unabhängig von den Mahlzeiten eingenommen werden
Generated Narrative: MedicationStatement e463547f-7414-47cb-b97f-04a81e1ab7d8 Profile: CH IPS MedicationStatement status: Active medication: Medication CLOPIDOGREL axapharm Filmtabl 75 mg (Blister 28 Stk) subject: Monika Wegmüller effective: 2024-05-03 --> (ongoing) reasonCode: Blutgerinnungshemmer dosage patientInstruction: Die Filmtablette soll mit etwas Wasser - unzerkaut und ohne sie zu lutschen - während oder unabhängig von den Mahlzeiten eingenommen werden. Es wird aber empfohlen, sie immer zum selben Zeitpunkt einzunehmen. timing: Morning, Once route: zum Einnehmen DoseAndRates - Dose[x] * 1 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') Generated Narrative: Medication #Clopidogrel Profile: CH IPS Medication code: CLOPIDOGREL axapharm Filmtabl 75 mg form: Filmtablette amount: 28 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)')/1 Package - unit of product usage (qualifier value) (Details: SNOMED CT code1681000175101 = 'Package - unit of product usage')
CLOPIDOGREL axapharm Filmtabl 75 mg (Blister 28 Stk)
Die Filmtablette soll mit etwas Wasser - unzerkaut und ohne sie zu lutschen - während oder unabhängig von den Mahlzeiten eingenommen werden. Es wird aber empfohlen, sie immer zum selben Zeitpunkt einzunehmen.
Generated Narrative: MedicationStatement f27b9345-6ba6-4fd6-83ab-6db6c2acd981 Profile: CH IPS MedicationStatement status: Active medication: Medication ASPIRIN CARDIO Filmtabl 100 mg (Blister 28 Stk) subject: Monika Wegmüller effective: 2024-05-03 --> (ongoing) reasonCode: Herzinfarktprophylaxe dosage patientInstruction: Tabletten mit etwas Flüssigkeit mindestens eine halbe Stunde vor der Mahlzeit einnehmen timing: Morning, Once route: zum Einnehmen DoseAndRates - Dose[x] * 1 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)') Generated Narrative: Medication #Aspirin Profile: CH IPS Medication code: ASPIRIN CARDIO Filmtabl 100 mg form: Filmtablette amount: 28 Tablet (unit of presentation) (Details: SNOMED CT code732936001 = 'Tablet (unit of presentation)')/1 Package - unit of product usage (qualifier value) (Details: SNOMED CT code1681000175101 = 'Package - unit of product usage')
ASPIRIN CARDIO Filmtabl 100 mg (Blister 28 Stk)
Tabletten mit etwas Flüssigkeit mindestens eine halbe Stunde vor der Mahlzeit einnehmen
Generated Narrative: AllergyIntolerance 27da84cc-526a-4098-afb5-f08c7836d893 Profile: CH IPS AllergyIntolerance clinicalStatus: Active verificationStatus: Confirmed code: No known allergy (situation) patient: Monika Wegmüller recordedDate: 2024-04-26 recorder: Martina Meier @ Spital
Generated Narrative: Condition 506b9fef-be0a-4398-bb7e-7d14c311912f Profile: CH IPS Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Moderate (severity modifier) (qualifier value) code: Diabetes mellitus type 2 (disorder) subject: Monika Wegmüller
Moderate (severity modifier) (qualifier value)
Generated Narrative: Condition 8a79d459-0d2f-460b-87fd-a7de12d49871 Profile: CH IPS Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Moderate (severity modifier) (qualifier value) code: Hypertensive disorder, systemic arterial (disorder) subject: Monika Wegmüller
Hypertensive disorder, systemic arterial (disorder)
Generated Narrative: Condition 2c67cf62-d712-44c7-aedb-b5582bc707f1 Profile: CH IPS Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Moderate (severity modifier) (qualifier value) code: Coronary arteriosclerosis (disorder) subject: Monika Wegmüller
Generated Narrative: Condition 12d8debe-5e03-465d-83f3-17675be9db4a Profile: CH IPS Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Severe (severity modifier) (qualifier value) code: Myocardial infarction (disorder) subject: Monika Wegmüller onset: 2024-04-26 recordedDate: 2024-04-26 recorder: Martina Meier @ Spital asserter: Martina Meier @ Spital
Severe (severity modifier) (qualifier value)
Generated Narrative: Procedure ad3ec07d-1814-4faf-86fd-1a8ebeecb5fe Profile: Procedure (IPS) status: Completed code: Placement of stent in coronary artery (procedure) subject: Monika Wegmüller performed: 2022-09-27 reasonCode: Koronare Herzkrankheit reasonReference: Koronare Herzkrankheit
Placement of stent in coronary artery (procedure)
Generated Narrative: Procedure d646c888-7af0-4439-8aae-9fd490054583 Profile: Procedure (IPS) status: Completed code: Placement of stent in coronary artery (procedure) subject: Monika Wegmüller performed: 2024-04-26 recorder: Martina Meier @ Spital asserter: Martina Meier @ Spital Performers - Actor * Martina Meier @ Spital reasonCode: Herzinfarkt (26.04.2024) reasonReference: Herzinfarkt (26.04.2024)
Generated Narrative: Immunization 19efd704-3461-4120-b3cf-a76ae046e150 Profile: CH IPS Immunization status: Completed vaccineCode: Boostrix patient: Monika Wegmüller occurrence: 2017-09-15 09:12:56+0200 recorded: 2017-09-15 09:12:56+0200 lotNumber: 12-34244 route: Intramuscular use protocolApplied targetDisease: Diphtheria caused by Corynebacterium diphtheriae (disorder), Tetanus (disorder), Pertussis (disorder) doseNumber: 1
Vaccine product containing only Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae antigens (medicinal product)
Diphtheria caused by Corynebacterium diphtheriae (disorder)
Generated Narrative: Observation db5ef7b0-e946-4260-a604-128b8887a41b Profile: Observation Body Weight Profile status: Final category: Vital Signs code: Body weight subject: Monika Wegmüller effective: 2024-04-27 14:05:00+0200 performer: Spital value: 65 kilogram (Details: UCUM codekg = 'kg')
Generated Narrative: Observation 07b2e450-a62e-4734-98bf-51462f008e0f Profile: Observation Body Height Profile status: Final category: Vital Signs code: Body height subject: Monika Wegmüller effective: 2024-04-27 14:05:00+0200 performer: Spital value: 170 centimeter (Details: UCUM codecm = 'cm')
Generated Narrative: Observation 93fe0d81-a547-494e-941c-113506108b76 Profile: Observation - SH: tobacco use status: Final code: Tobacco smoking status subject: Monika Wegmüller effective: 2024-04-26 performer: Spital value: Former smoker