FHIR IG analytics| Package | ch.fhir.ig.ch-ems |
| Resource Type | Composition |
| Id | Composition-2b-Einsatzprotokoll-Composition.json |
| FHIR Version | R4 |
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No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "2b-Einsatzprotokoll-Composition",
"language": "de-CH",
"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 - version 3 Document NEMSIS"
},
{
"system": "http://snomed.info/sct",
"code": "371535009",
"display": "Transfer summary report (record artifact)"
}
],
"text": "Einsatzprotokoll Rettungsdienst"
},
"subject": {
"reference": "Patient/2-PatientUnbekannt"
},
"encounter": {
"reference": "Encounter/2-Einsatz"
},
"date": "2016-12-10T13:40:00.000+01:00",
"author": [
{
"extension": [
{
"url": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-ext-epr-time",
"valueDateTime": "2016-12-10T13:40:00.000+01:00"
}
],
"reference": "Practitioner/1-SaniPetraMuster"
},
{
"reference": "PractitionerRole/1-SaniPetraMuster-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>7601002156370 (SNZ)</td></tr><tr><td>augebotene Organisation</td><td>7601002156363 (Rettungsdienst Schutz & Rettung Zürich)</td></tr><tr><td>Team</td><td>Petra Muster, GLN 7601003330434, Betreuerin / Hans Transportsanitäter, GLN 7601000028105, Betreuer</td></tr><tr><td>Einsatzort</td><td>wird 8050 Zürich, Sternen Oerlikon, Schaffhauserstr. 350</td></tr><tr><td>Zielort</td><td>USZ Notfall</td></tr></tbody></table><table><tbody><tr><th>Alarm</th><th>Status DP</th><th>Status 1</th><th>Status 2</th><th>Kontakt Patient</th><th>Status 3</th><th>Status 4</th><th>Status 5</th><th>Status 6</th></tr><tr><th id=\"alarm\">12.09</th><th id=\"disposition\">12.11</th><th id=\"rollout\">12.13</th><th id=\"arrivalonscene\">12.17</th><th id=\"arrivalpatient\">12.18</th><th id=\"departurefromscene\">12.48</th><th id=\"arrivalattarget\">12.54</th><th id=\"departurefromtarget\">13.25</th><th id=\"operationalreadiness\">13.40</th></tr></tbody></table></div>"
},
"entry": [
{
"reference": "Encounter/2-Einsatz"
},
{
"reference": "Observation/2-Alarm"
},
{
"reference": "Observation/2-Disposition"
},
{
"reference": "Observation/2-Rollout"
},
{
"reference": "Observation/2-ArrivalOnScene"
},
{
"reference": "Observation/2-ArrivalPatient"
},
{
"reference": "Observation/2-DepartureFromScene"
},
{
"reference": "Observation/2-ArrivalAtTarget"
},
{
"reference": "Observation/2b-DepartureFromTarget"
},
{
"reference": "Observation/2b-OperationalReadiness"
}
]
},
{
"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\"><span>-</span></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\"><span>-</span></div>"
}
},
{
"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>Breathing: Der Patient hat eine unauffällige Spontanatmung</p><p>Cardiology: Sein Puls ist tastbar, es liegt kein Herz-Kreislaufstillstand vor; Frequenz 84/Minute, Blutdruck 170/90, gemessen am rechten Arm</p><p>Temperatur 37.2 °C, die Augen zeigen eine deutliche Anisokorie vor</p><table><tbody><tr><th>Airways</th><td id=\"airways\">Die Atemwege sind nicht verlegt</td></tr><tr><th>GCS</th><td id=\"gcs1\">Total 9 Augenöffnung bei Ansprache (3), gibt Einzelworte von sich (3), Dekortikationsstarre (3)</td></tr><tr><th>AVPU</th><td id=\"avpu\">V (=reagiert auf laute Ansprache)</td></tr></tbody></table></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": "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 id=\"diagnose1\">Stroke (I63)</td></tr></tbody></table></div>"
},
"entry": [
{
"reference": "Observation/2-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>Infusion mit 500 ml Ringer. Der Patient wird liegend in den Rettungswagen verladen.</span></div>"
}
},
{
"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\"><p>Schmerz 4</p><table><tbody><tr><th>GCS</th></tr><tr><td id=\"gcs2\">Total 10 Augenöffnung bei Ansprache (3), Konversationsfähig aber desorientiert (4), Dekortikationsstarre (3)</td></tr><tr><th>NACA</th></tr><tr><td id=\"naca\">NACA: III</td></tr><tr><th>Zustand</th></tr><tr><td id=\"statusdischarge\">der Zustand des Patienten hat sich im Verlauf des Einsatzes verbessert</td></tr></tbody></table><p>Übergabe an USZ Effekten sowie Wertsachenverzeichnis</p></div>"
},
"entry": [
{
"reference": "Observation/2-ZustandUebergabe"
},
{
"reference": "Observation/2-NACAUebergabe"
},
{
"reference": "Observation/2-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>"
}
}
]
}