FHIR IG analytics| Package | ch.fhir.ig.ch-ems |
| Resource Type | Composition |
| Id | Composition-1-Einsatzprotokoll-Composition.json |
| FHIR Version | R4 |
No resources found
No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "1-Einsatzprotokoll-Composition",
"language": "de-CH",
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:658ab5ea-1f63-11e6-b6ba-3e1d05defe78"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "67796-3",
"display": "EMS patient care report - version 3 Document NEMSIS"
},
{
"system": "http://snomed.info/sct",
"code": "371535009",
"display": "Transfer summary report (record artifact)"
}
],
"text": "Einsatzprotokoll Rettungsdienst"
},
"subject": {
"reference": "Patient/1-ThomasMueller"
},
"encounter": {
"reference": "Encounter/1-Einsatz"
},
"date": "2016-12-10T13:05:00.000+01:00",
"author": [
{
"extension": [
{
"url": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime": "2016-12-10T13:13:05.000+01:00"
}
],
"reference": "Practitioner/1-SaniPetraMuster"
},
{
"reference": "PractitionerRole/1-SaniPetraMuster-PR"
},
{
"extension": [
{
"url": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime": "2016-12-10T13:13:05.000+01:00"
}
],
"reference": "Practitioner/1-NotarztPierreUrgentiste"
},
{
"reference": "PractitionerRole/1-NotarztPierreUrgentiste-PR"
}
],
"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 (qualifier value)"
}
],
"text": "Normal"
}
}
]
},
"attester": [
{
"mode": "legal",
"time": "2016-12-10T13:13:05.000+01:00",
"party": {
"reference": "Practitioner/1-SaniPetraMuster"
}
}
],
"custodian": {
"reference": "Organization/1-Rettungsdienst"
},
"section": [
{
"title": "Einsatz",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100001",
"display": "intervention"
}
],
"text": "Einsatz"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Einsatz</th></tr><tr><td>Einsatzdatum:</td><td>10.12.2016</td></tr><tr><td>Einsatznummer:</td><td>S12345678</td></tr><tr><td>Aufbietende Organisation:</td><td>SNZ (GLN 7601002156370)</td></tr><tr><td>Aufgebotene Organisation:</td><td>Rettungsdienst Schutz und Rettung Zürich (GLN 7601002156363)</td></tr><tr><td>Teammitglieder:</td><td>Petra Muster (Rettungssanitäterin), Hans Transportsanitäter (Transportsanitäter), Pierre Urgentiste (Notarzt)</td></tr><tr><td>Einsatzort:</td><td>Zürich, Waldrand (47.392115, 8.553192)</td></tr><tr><td>Zielort:</td><td>Universitätsspital Zürich, Notfall</td></tr></tbody></table><table><tbody><tr><th>Alarmierungszeit:</th><th>Dispositionszeit:</th><th>Ausrückzeit:</th><th>Ankunftszeit am Einsatzort:</th><th>Ankunftszeit beim Patienten:</th><th>Abfahrtszeit vom Einsatzort:</th><th>Ankunftszeit am Zielort:</th></tr><tr><th>12:09</th><th>12:11</th><th>12:13</th><th>12:17</th><th>12:22</th><th>12:48</th><th>12:54</th></tr></tbody></table></div>"
},
"entry": [
{
"reference": "Encounter/1-Einsatz"
},
{
"reference": "Observation/1-Alarm"
},
{
"reference": "Observation/1-Disposition"
},
{
"reference": "Observation/1-Rollout"
},
{
"reference": "Observation/1-ArrivalOnScene"
},
{
"reference": "Observation/1-ArrivalPatient"
},
{
"reference": "Observation/1-DepartureFromScene"
},
{
"reference": "Observation/1-ArrivalAtTarget"
},
{
"reference": "Procedure/1-Transport"
},
{
"reference": "Location/1-Rettungswagen"
}
]
},
{
"title": "Administrativ",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100003",
"display": "administrative"
}
],
"text": "Administrativ"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Beteiligte Person</th></tr><tr><td>Ehefrau:</td><td>Erika Müller</td></tr></tbody></table></div>"
}
},
{
"title": "Vorbehandlung",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100004",
"display": "pretreatment"
}
],
"text": "Vorbehandlung"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title": "Anamnese",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100005",
"display": "anamnesis"
}
],
"text": "Anamnese"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Ereignis:</th></tr><tr><td>Hat sich beim Spazieren im Wald schlecht gefühlt und ist abgesessen.</td></tr></tbody></table><table><tbody><tr><th>Symptome:</th></tr><tr><td>Starke Schmerzen in der Brust und im linken Oberarm verspürt.</td></tr></tbody></table><h4>Allergien / Unverträglichkeiten:</h4><ul><li>Allergisch auf Baumpollen</li><li>bekannte Unverträglichkeitsreaktion auf einzelne Medikamente</li></ul><h4>Bestehende Medikation</h4><ul><li>Aspirin Cardio 100 (1 Tbl./Tag)</li></ul><h4>Medizinische Vorgeschichte:</h4><ul><li>Herzvorfall vor vier Jahren, der im Triemlispital in Zürich behandelt wurde</li></ul><h4>Weiteres:</h4><ul><li>Seit dem Frühstück um ca. 8 Uhr hat er nichts mehr gegessen</li><li>Thomas Müller hat keine Patientenverfügung erstellt</li><li>Es sind keine anderen medizinischen Probleme bekannt</li></ul></div>"
},
"entry": [
{
"reference": "Observation/1-Anamnese"
},
{
"reference": "Observation/1-Symptome"
},
{
"reference": "AllergyIntolerance/1-Baumpollen"
},
{
"reference": "AllergyIntolerance/1-Medikamente"
},
{
"reference": "MedicationStatement/1-AspirinCardio"
}
]
},
{
"title": "Befund",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100006",
"display": "findings"
}
],
"text": "Befund"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Zeitpunkt des Befundes: 12:25</p><table><tbody><tr><th>Blutdruck:</th><th>GCS:</th><th>Weiteres:</th></tr><tr><td>120/80 mmHg, gemessen am rechten Arm</td><td>Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)</td><td>Schmerz: 5</td></tr></tbody></table></div>"
},
"section": [
{
"title": "Circulation",
"entry": [
{
"reference": "Observation/1-Blutdruck"
}
]
},
{
"title": "Disability",
"entry": [
{
"reference": "Observation/1-GCSBefund"
}
]
}
]
},
{
"title": "Diagnosen",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100007",
"display": "diagnosis"
}
],
"text": "Diagnosen"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Verdachtsdiagnose:</th></tr><tr><td>Akuter transmuraler Myokardinfarkt der Vorderwand (ACS/STEMI VW)</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "Observation/1-Diagnose"
}
]
},
{
"title": "Massnahmen",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100008",
"display": "measures"
}
],
"text": "Massnahmen"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>Sofortige Infusion gelegt und Verabreichung einer ersten Dosis von 2 Hüben Nitrolingual-Spray um 12:30.</span></div>"
},
"entry": [
{
"reference": "MedicationAdministration/1-Infusion"
},
{
"reference": "MedicationAdministration/1-Spray"
}
]
},
{
"title": "Todesfall",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100009",
"display": "death"
}
],
"text": "Todesfall"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
},
{
"title": "Transport",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100010",
"display": "transport"
}
],
"text": "Transport"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>Fahrt mit Sondersignal ins USZ.</span></div>"
}
},
{
"title": "Übergabe",
"code": {
"coding": [
{
"system": "http://fhir.ch/ig/ch-ems/CodeSystem/IVR",
"code": "1100011",
"display": "handover"
}
],
"text": "Übergabe"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>GCS:</th><th>NACA:</th><th>Zustand:</th><th>Weiteres:</th></tr><tr><td>Total 15: Augenöffnung spontan (4), verbale Antwort orientiert (5), motorische Reaktion befolgt Antweisungen (6)</td><td>III</td><td>Zustand des Patienten hat sich im Verlaufe des Einsatzes verbessert</td><td>Schmerz: 4</td></tr></tbody></table><p>Übergabe an USZ mit Wertsachenbeutel mit Portemonnaie, Handy, Uhr, Schlüssel, Bargeld sowie Wertsachenverzeichnis.</p></div>"
},
"entry": [
{
"reference": "Observation/1-ZustandUebergabe"
},
{
"reference": "Observation/1-NACAUebergabe"
},
{
"reference": "Observation/1-GCSUebergabe"
},
{
"reference": "Practitioner/1-InformationRecipientSpitalarzt"
},
{
"reference": "Organization/1-InformationRecipientUSZ"
}
]
},
{
"title": "Kommentar",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48767-8",
"display": "Annotation comment [Interpretation] Narrative"
}
],
"text": "Kommentar"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span>-</span></div>"
}
}
]
}