Integrierte Versorgung Diabetes (R4)
0.1.1 - ci-build

Integrierte Versorgung Diabetes (R4) - Local Development build (v0.1.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: example-iv-3

Document Details

Profile: Diab Bundle

Final Document at 2023-04-09 09:01:30+0000 by APS Generator for Anton Testpatient


Document Subject

Generated Narrative: Patient 001

Anton Testpatient Male, DoB: 1953-11-12 ( Social Security number: 0000121153)


Marital Status:Married
Other Id:Patient internal identifier/0002
Contact DetailRotenturmstraße 14 Wien 1010 AUT (home)

Document Content

Generated Narrative: Composition example-iv-3-composition

Country of Affiliation: AT

status: Final

type: Diabetes Leitdokument

date: 2023-04-09 09:01:30+0000

author: APS Generator

title: Diabetes Leitdokument

custodian: Muster-Organisation


Medikationsliste

Ramipril 5 mg 1-0-0-0, Start 15.06.2016

Metformin 500 mg 1-0-1-0, Start 09.04.2023

Allergien und Intoleranzen

Allergie gegen Benzylpenicillin-Natrium.

Gesundheitsprobleme und Risiken

Diabetes Mellitus Typ 2

Arterielle Hypertonie

Adipositas

Diabettes Mellitus Typ 2

Familienanamnese: orzeitige koronare Herzerkrankung, Diabetes mellitus

Eingriffe und Therapien

Totalersatz des linken Hüftgelenks

Implantate, medizinische Geräte und Heilbehelfe

Hüftprothese

Impfungen

Impfung gegen Diphtherie-Pertussis-Poliomyelitis-Tetanus

Diagnostische Resultate

Glucose im kapillaren Blut 1h postprandial

Hemoglobin A1c/Hemoglobin im Blut: 8.1 %

Kreatinin in Serum: 1.2 mg/dL

Vitalparameter

Körpergröße: 173 cm

Körpergewicht: 90 kg

BMI: 30.07 (high)

Blutdruck 180 / 80

Herzfrequenz 100

Vergangene Gesundheitsprobleme und Risiken

Masernerkrankung in der Kindheit.

Behandlungsplan

Angeforderte Laboruntersuchung: Status abgeschlossen

Empfohlene Ernährungsschulung bei Diabetes mellitus Typ II: Status offen

Zuweisung zu Augenuntersuchung: Status offen

Lebensstil, soziale Umstände und Verhalten

Ehemaliger Raucher, Person

Alkoholische Getränke pro Tag, 1-2 Gläser Wein/Bier

Körperliche Aktivität 2,5h/Wo


Additional Resources Included in Document


Entry 2 - fullUrl = urn:uuid:0fed5ebe-ca8f-4ad1-aba4-ddad45bd6cc8

Resource Patient:

Generated Narrative: Patient 001

Anton Testpatient Male, DoB: 1953-11-12 ( Social Security number: 0000121153)


Marital Status:Married
Other Id:Patient internal identifier/0002
Contact DetailRotenturmstraße 14 Wien 1010 AUT (home)

Entry 3 - fullUrl = urn:uuid:75db30ee-7028-486c-929a-c5126837f474

Resource Device:

Dieses Gerät erzeugt ein APS FHIR-Dokument.


Entry 4 - fullUrl = urn:uuid:75db30ee-7028-486c-929a-c5126837f473

Resource Practitioner:

Generated Narrative: Practitioner example-iv-3-practitioner-2

identifier: Uniform Resource Identifier (URI)/urn:oid:1.2.40.0.10.99.1.2.3.4

name: Hanna Hausärztin


Entry 5 - fullUrl = urn:uuid:f6266e6a-f63d-4673-b2de-3dff11e619d6

Resource Organization:

Generated Narrative: Organization example-iv-3-organization

name: Muster-Organization


Entry 6 - fullUrl = urn:uuid:acac4c94-a752-4cf5-9a6b-0d84237d5076

Resource MedicationStatement:

Generated Narrative: MedicationStatement example-iv-3-medication-summary-1

status: Active

medication: RAMIPRIL 1A TBL 5MG

subject: Anton Testpatient

effective: 2016-11-02 11:00:00+0000 --> (ongoing)

dosage

sequence: 1

text: S:0-0-0-2 / FR

timing: Night, Once

route: Oraler Verabreichungsweg

DoseAndRates

-Dose[x]
*2 Tablet (Details: elga-medikationmengenart code{TAB} = '{TAB}')

Entry 7 - fullUrl = urn:uuid:acac4c94-a752-4cf5-9a6b-0d84237d5011

Resource MedicationStatement:

Generated Narrative: MedicationStatement example-iv-3-medication-summary-2

status: Active

medication: METFORMIN HEX FTBL 500MG

subject: Anton Testpatient

effective: 2023-03-17 08:01:30+0100 --> (ongoing)

dosage

sequence: 1

text: S:0-0-0-2 / FR

timing: Night, Once

route: Oraler Verabreichungsweg

DoseAndRates

-Dose[x]
*2 Tablet (Details: elga-medikationmengenart code{TAB} = '{TAB}')

Entry 8 - fullUrl = urn:uuid:768eb9cb-00f3-4ab1-bfc2-ff835cb3b89b

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance example-iv-3-allergy-1

clinicalStatus: Active

code: Benzylpenicillin-Natrium

patient: Anton Testpatient

asserter: Dr. Hausärztin


Entry 9 - fullUrl = urn:uuid:9d1c0b74-20c1-4603-a95a-71e6a1dc8fde

Resource Condition:

Generated Narrative: Condition example-iv-3-problem-1

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Arterielle Hypertonie

subject: Anton Testpatient

recordedDate: 2016-11-01 11:00:00+0000

asserter: Dr. Hanna Hausärztin


Entry 10 - fullUrl = urn:uuid:8d3a18fb-3610-4bfb-9aa4-1169cc6dd2dd

Resource Condition:

Generated Narrative: Condition example-iv-3-problem-2

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Adipositas

subject: Anton Testpatient

recordedDate: 2022-12-01 14:00:00+0000

asserter: Dr. Hanna Hausärztin


Entry 11 - fullUrl = urn:uuid:a3a9be59-ec61-4cab-92a9-9cbab6aec437

Resource Condition:

Generated Narrative: Condition example-iv-3-problem-3

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Diabetes Mellitus Typ 2

subject: Anton Testpatient

recordedDate: 2023-03-15 08:00:00+0000

asserter: Dr. Hanna Hausärztin


Entry 12 - fullUrl = urn:uuid:e66d8ac1-a124-4e94-be22-969c9b117ce5

Resource Condition:

Generated Narrative: Condition example-iv-3-problem-4

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Familienanamnese: vorzeitige koronare Herzkrankheit

subject: Anton Testpatient

recordedDate: 2022-12-01 14:00:00+0000

asserter: Dr. Hanna Hausärztin


Entry 13 - fullUrl = urn:uuid:e66d8ac1-a124-4e94-be22-969c9b117ce6

Resource Condition:

Generated Narrative: Condition example-iv-3-problem-5

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Diabetes mellitus in der Familienanamnese

subject: Anton Testpatient

recordedDate: 2022-12-01 14:00:00+0000

asserter: Dr. Hanna Hausärztin


Entry 14 - fullUrl = urn:uuid:75c46c35-8f4e-4232-b026-5672c60d076a

Resource Procedure:

Generated Narrative: Procedure example-iv-3-procedure-history-1

status: Completed

code: Totalersatz des linken Hüftgelenks

subject: Anton Testpatient

performed: 2010

FocalDevices

-Manipulated
*Hüftprothese

Entry 15 - fullUrl = urn:uuid:490dab5c-271e-4736-8a6b-5f6f089d0a11

Resource DeviceUseStatement:

Generated Narrative: DeviceUseStatement example-iv-3-medical-deviceUse-Hueftprothese

status: Active

subject: Anton Testpatient

timing: 2020 --> (ongoing)

device: Verwendetes Gerät: Hüftprothese

bodySite: Gesamtes linkes Hüftgelenk


Entry 16 - fullUrl = urn:uuid:490dab5c-271e-4736-8a6b-5f6f089d0a22

Resource Device:

Generated Narrative: Device example-iv-3-medical-device-Hueftprothese

Profile: AT APS Device

DeviceNames

-NameType
*Hüftprotheseother

type: Hüftprothese

Versions

-Value
*123456

patient: Anton Testpatient


Entry 17 - fullUrl = urn:uuid:590dab5c-271e-4736-8a6b-d04fd2a04607

Resource Immunization:

Generated Narrative: Immunization example-iv-3-Immunization-1

status: Completed

vaccineCode: Diphtherie-Pertussis-Poliomyelitis-Tetanus

patient: Anton Testpatient

occurrence: 2025-01-08 14:31:30+0000

route: Intramuskulär

Performers

-Actor
*Dr. Hanna Hausärztin

protocolApplied

targetDisease: Diphtheria, Pertussis, Poliomyelitis, Tetanus

doseNumber: 1


Entry 18 - fullUrl = urn:uuid:725bcf71-22e6-473b-a879-49a4b63cd654

Resource Observation:

Generated Narrative: Observation example-iv-3-diagnostic-result-1

status: Final

category: Laboratory

code: Glucose im kapillaren Blut 1h postprandial

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 250 mg/dL (Details: UCUM codemg/dL = 'mg/dL')

specimen: example-iv-3-diagnostic-specimen-1


Entry 19 - fullUrl = urn:uuid:aeff2319-2cc2-4fba-9541-7a4de3d20f91

Resource Observation:

Generated Narrative: Observation example-iv-3-diagnostic-result-2

status: Final

category: Laboratory

code: Hemoglobin A1c/Hemoglobin.total in Blood

subject: Bundle: identifier = http://system-to-be-defined.com#63fef90a-be11-4ddf-aece-d77da15c4f20; type = document; timestamp = 2025-03-15 14:01:30+0000

effective: 2023-03-16 09:30:00+0100

performer: Amadeus Spital - Labor

value: 8.1 % (Details: UCUM code% = '%')

specimen: example-iv-3-diagnostic-specimen-1


Entry 20 - fullUrl = urn:uuid:d16dce15-bc5a-48a5-910e-6ac039785a2a

Resource Observation:

Generated Narrative: Observation example-iv-3-diagnostic-result-2

status: Final

category: Laboratory

code: Kreatinin in Serum

subject: Bundle: identifier = http://system-to-be-defined.com#63fef90a-be11-4ddf-aece-d77da15c4f20; type = document; timestamp = 2025-03-15 14:01:30+0000

effective: 2023-03-16 09:30:00+0100

performer: Amadeus Spital - Labor

value: 1.2 mg/dL (Details: UCUM codemg/dL = 'mg/dL')

specimen: example-iv-3-diagnostic-specimen-1


Entry 21 - fullUrl = urn:uuid:82f802a7-56a9-49b4-a675-95da08f0d7a6

Resource Organization:

Generated Narrative: Organization example-iv-3-diagnostic-result-performer-1

identifier: Uniform Resource Identifier (URI)/urn:oid:1.2.40.0.34.99.4613

name: Amadeus Spital - Labor

telecom: +43.1.3453446.0, fax: +43.1.3453446.4674, info@amadeusspital.at, https://www.amadeusspital.at

address: Währinger Gürtel 18-20 Wien 1090 AUT


Entry 22 - fullUrl = urn:uuid:e3567418-073e-4fd7-af4e-5fd7ee4785f7

Resource Specimen:

Generated Narrative: Specimen example-iv-3-diagnostic-specimen-1

status: Unavailable

type: Blutprobe

subject: Anton Testpatient


Entry 23 - fullUrl = urn:uuid:74c5e186-d765-4c93-a624-c9b0746e8142

Resource Observation:

Generated Narrative: Observation example-iv-3-vital-sign-1

status: Final

category: Vital Signs

code: Körpergröße

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 173 cm (Details: UCUM codecm = 'cm')


Entry 24 - fullUrl = urn:uuid:428259da-e0f7-4780-b1e3-c177515edd37

Resource Observation:

Generated Narrative: Observation example-iv-3-vital-sign-2

status: Final

category: Vital Signs

code: Körpergewicht

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 90 kg (Details: UCUM codekg = 'kg')


Entry 25 - fullUrl = urn:uuid:daf9c15d-14d4-429c-b658-6842fdff67d8

Resource Observation:

Generated Narrative: Observation example-iv-3-vital-sign-3

status: Final

category: Vital Signs

code: Body Mass Index (BMI) [Verhältnis]

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 30.07 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')

interpretation: High


Entry 26 - fullUrl = urn:uuid:8248cc70-65a2-4d37-ae14-a3ef2abf8f32

Resource Observation:

Generated Narrative: Observation example-iv-3-vital-sign-4

status: Final

category: Vital Signs

code: Blood pressure panel with all children optional

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

component

code: Systolischer Blutdruck

value: 180 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolischer Blutdruck

value: 80 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')


Entry 27 - fullUrl = urn:uuid:4d3f7ac4-fd0a-49af-a56b-303a2dbe67d1

Resource Observation:

Generated Narrative: Observation example-iv-3-vital-sign-5

status: Final

category: Vital Signs

code: Herzfrequenz

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 100 /min (Details: UCUM code/min = '/min')


Entry 28 - fullUrl = urn:uuid:82301518-66ca-4b4c-821d-087adf643cc4

Resource Condition:

Generated Narrative: Condition example-iv-3-illness-history-1

clinicalStatus: Resolved

verificationStatus: Confirmed

category: Problem List Item

code: Zustand nach Masern

subject: Anton Testpatient


Entry 29 - fullUrl = urn:uuid:39cd75da-2456-46a9-a703-89d8b65ae631

Resource CarePlan:

Ausstehende Laboruntersuchung


Entry 30 - fullUrl = urn:uuid:39cd75da-2456-46a9-a703-89d8b65ae63b

Resource CarePlan:

Ausstehende Ernährungsschulung bei Diabetes mellitus Typ II


Entry 31 - fullUrl = urn:uuid:39cd75da-2456-46a9-a703-89d8b65ae222

Resource CarePlan:

Ausstehende Untersuchung der diabetischen Netzhaut


Entry 32 - fullUrl = urn:uuid:d0a5bbf1-6d01-4d44-bac5-05f12c98411e

Resource Observation:

Generated Narrative: Observation example-iv-3-social-history-1

status: Final

code: Raucherstatus

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: Ehemalig rauchende Person


Entry 33 - fullUrl = urn:uuid:d0a5bbf1-6d01-4d44-bac5-05f12c984112

Resource Observation:

Generated Narrative: Observation example-iv-3-social-history-2

status: Final

code: Alkoholische Getränke pro Tag, 1-2 Gläser Wein/Bier

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: 2 Gläser pro Tag (Details: UCUM code/d = '/d')


Entry 34 - fullUrl = urn:uuid:9add5c32-1ded-43d6-b163-c3fe13f94984

Resource Observation:

Generated Narrative: Observation example-iv-3-social-history-3

status: Final

code: Körperliche Aktivität

subject: Anton Testpatient

effective: 2023-03-15 08:00:00+0000

performer: Dr. Hanna Hausärztin

value: >2.5 h (Details: UCUM codeh = 'h')/1 wk (Details: UCUM codewk = 'wk')