ISiK Formularmodul Implementation Guide
Version 6.0.0-rc - ci-build

: Verlegungsbericht für Patient Herrn Thomas Müller (1234567890) - Intensivstation 0100 (Bundle) - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="BundleExampleIntensivstation"/>
  <meta>
    <profile
             value="https://gematik.de/fhir/isik/StructureDefinition/ISiKBerichtBundle"/>
  </meta>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="FILL"/>
      </coding>
    </type>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:a8f12c45-8e61-4f32-b123-456789abcdef"/>
  </identifier>
  <type value="document"/>
  <timestamp value="2025-07-21T00:00:00+02:00"/>
  <entry>
    <fullUrl value="urn:uuid:54d0804f-c770-4b61-a175-28fa1875b2a9"/>
    <resource>
      <Composition>
        <id value="54d0804f-c770-4b61-a175-28fa1875b2a9"/>
        <meta>
          <profile
                   value="https://gematik.de/fhir/isik/StructureDefinition/ISiKBerichtSubSysteme"/>
        </meta>
        <text>
          <status value="extensions"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Composition_54d0804f-c770-4b61-a175-28fa1875b2a9"> </a><h2>Verlegungsbericht für Patient Herrn Thomas Müller (1234567890) - Intensivstation 0100</h2><div><strong>Dokument-ID:</strong><span>urn:uuid:54d0804f-c770-4b61-a175-28fa1875b2a9</span><span> (urn:ietf:rfc:3986)</span></div><div><strong>Status:</strong><span>final</span></div><div><strong>Dokumenttyp:</strong><span><span>Verlegungsbericht</span><span> (http://dvmd.de/fhir/CodeSystem/kdl)</span></span></div><div><strong>Erstellt am:</strong><span>21.07.2025 00:00</span></div><div><strong>Autor:</strong><ul><li><span>Dr. Alenia Vogt</span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Fall:</strong><span>urn:uuid:88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41</span></div></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="FILL"/>
            </coding>
          </type>
          <system value="urn:ietf:rfc:3986"/>
          <value value="urn:uuid:54d0804f-c770-4b61-a175-28fa1875b2a9"/>
        </identifier>
        <status value="final"/>
        <type>
          <coding>
            <system value="http://dvmd.de/fhir/CodeSystem/kdl"/>
            <code value="AD010116"/>
            <display value="Verlegungsbericht"/>
          </coding>
        </type>
        <subject>
          <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        </subject>
        <encounter>
          <reference value="urn:uuid:88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41"/>
        </encounter>
        <date value="2025-07-21T00:00:00+02:00"/>
        <author>
          <display value="Dr. Alenia Vogt"/>
        </author>
        <title
               value="Verlegungsbericht für Patient Herrn Thomas Müller (1234567890) - Intensivstation 0100"/>
        <section>
          <title
                 value="Beatmungswerte (Unterstützungsdruck) vom 22.07.2025 - #1"/>
          <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><div><h3>Observation</h3><div><strong>Typ:</strong><span><span>Pressure support setting Ventilator</span><span> (http://loinc.org)</span></span></div><div><strong>Status:</strong><span>FINAL</span></div><div><strong>Kategorie:</strong><ul><li><span><span><span>Artificial ventilation (regime/therapy)</span><span> (http://snomed.info/sct)</span></span></span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitpunkt:</strong><span>2025-07-21T00:00:00+02:00</span></div><div><strong>Wert:</strong><span>6</span><span>cm[H2O]</span></div><div><strong>Teil von:</strong><ul><li><span>urn:uuid:61a2e9af-88f9-4ee2-a97f-c136530aadba</span></li></ul></div></div></div>
          </text>
          <entry>
            <reference value="urn:uuid:32bb8c8a-418c-4fc2-b1c7-c33f1a99a464"/>
          </entry>
        </section>
        <section>
          <title value="Patient"/>
          <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><h3>Patient</h3><div><strong>ID:</strong><span>Patient/urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Patienten-Identifikator:</strong><ul><li><span><span>MR</span>: </span><span>1234567890</span><span> (https://example.org/fhir/sid/pid)</span></li></ul></div><div><strong>Name:</strong><span> Thomas <b>MÜLLER</b></span></div><div><strong>Geschlecht:</strong><span>male</span></div><div><strong>Geburtsdatum:</strong><span>11.04.1965</span></div></div>
          </text>
          <entry>
            <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
          </entry>
        </section>
        <section>
          <title value="Encounter"/>
          <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><h2>Encounter</h2><div><strong>Fallnummer:</strong><span><span>ICU-2025-001</span><span> (https://example.org/fhir/sid/encounter-id)</span></span></div><div><strong>Status:</strong><span>in-progress</span></div><div><strong>Kontaktart:</strong><span>inpatient encounter</span></div><div><strong>Typ:</strong><ul><li><span><span><span>Abteilungskontakt</span><span> (http://fhir.de/CodeSystem/Kontaktebene)</span></span></span></li></ul></div><div><strong>Abteilung:</strong><span><span>Innere Medizin</span><span> (Code: 0100)</span></span></div><div><strong>Einrichtung:</strong><span>Intensivstation - Innere Medizin</span></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitraum:</strong><span>21.07.2025 00:00</span><span> (laufend)</span></div></div>
          </text>
          <entry>
            <reference value="urn:uuid:88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41"/>
          </entry>
        </section>
        <section>
          <title value="Observation"/>
          <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><h3>Observation</h3><div><strong>Typ:</strong><span><span>85354-9</span><span> (http://loinc.org)</span></span></div><div><strong>Status:</strong><span>FINAL</span></div><div><strong>Kategorie:</strong><ul><li><span><span><span>vital-signs</span><span> (http://terminology.hl7.org/CodeSystem/observation-category)</span></span></span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitpunkt:</strong><span>2025-07-22T14:10:00+02:00</span></div><div><strong>Messwerte:</strong><table style="border-collapse: collapse; width: 100%;"><thead><tr style="background-color: #f2f2f2;"><th style="border: 1px solid #ddd; padding: 8px;">Parameter</th><th style="border: 1px solid #ddd; padding: 8px;">Wert</th><th style="border: 1px solid #ddd; padding: 8px;">Einheit</th></tr></thead><tbody><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Systolisch</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>210</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Diastolisch</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>115</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Mittlerer arterieller Druck</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>140</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr></tbody></table></div></div>
          </text>
          <entry>
            <reference value="urn:uuid:880d8c69-fc05-4e1f-8203-a8ff40007f84"/>
          </entry>
        </section>
        <section>
          <title value="Procedure"/>
          <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml"><h3>Prozedur</h3><div><strong>Typ:</strong><ul><li><span>Jet ventilation procedure (procedure)</span><span> (http://snomed.info/sct)</span></li></ul></div><div><strong>Status:</strong><span>COMPLETED</span></div><div><strong>Kategorie:</strong><span/><ul><li><span>Artificial ventilation (regime/therapy)</span><span> (http://snomed.info/sct)</span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Durchführungszeitraum:</strong><span>21.07.2025 00:00</span><span> (laufend)</span></div></div>
          </text>
          <entry>
            <reference value="urn:uuid:61a2e9af-88f9-4ee2-a97f-c136530aadba"/>
          </entry>
        </section>
      </Composition>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
    <resource>
      <Patient>
        <id value="11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        <meta>
          <profile
                   value="https://gematik.de/fhir/isik/StructureDefinition/ISiKPatient"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_11c3de2f-d461-4063-a0c2-fde122e76a79"> </a><h3>Patient</h3><div><strong>ID:</strong><span>Patient/urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Patienten-Identifikator:</strong><ul><li><span><span>MR</span>: </span><span>1234567890</span><span> (https://example.org/fhir/sid/pid)</span></li></ul></div><div><strong>Name:</strong><span> Thomas <b>MÜLLER</b></span></div><div><strong>Geschlecht:</strong><span>male</span></div><div><strong>Geburtsdatum:</strong><span>11.04.1965</span></div></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="MR"/>
            </coding>
          </type>
          <system value="https://example.org/fhir/sid/pid"/>
          <value value="1234567890"/>
        </identifier>
        <name>
          <use value="official"/>
          <family value="Müller"/>
          <given value="Thomas"/>
        </name>
        <gender value="male"/>
        <birthDate value="1965-04-11"/>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41"/>
    <resource>
      <Encounter>
        <id value="88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41"/>
        <meta>
          <profile
                   value="https://gematik.de/fhir/isik/StructureDefinition/ISiKKontaktGesundheitseinrichtung"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Encounter_88bdd3e7-fbd1-42b8-bd9f-9afdf1e31d41"> </a><h2>Encounter</h2><div><strong>Fallnummer:</strong><span><span>ICU-2025-001</span><span> (https://example.org/fhir/sid/encounter-id)</span></span></div><div><strong>Status:</strong><span>in-progress</span></div><div><strong>Kontaktart:</strong><span>inpatient encounter</span></div><div><strong>Typ:</strong><ul><li><span><span><span>Abteilungskontakt</span><span> (http://fhir.de/CodeSystem/Kontaktebene)</span></span></span></li></ul></div><div><strong>Abteilung:</strong><span><span>Innere Medizin</span><span> (Code: 0100)</span></span></div><div><strong>Einrichtung:</strong><span>Intensivstation - Innere Medizin</span></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitraum:</strong><span>21.07.2025 00:00</span><span> (laufend)</span></div></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="VN"/>
            </coding>
          </type>
          <system value="https://example.org/fhir/sid/encounter-id"/>
          <value value="ICU-2025-001"/>
        </identifier>
        <status value="in-progress"/>
        <class>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="IMP"/>
          <display value="inpatient encounter"/>
        </class>
        <type>
          <coding>
            <system value="http://fhir.de/CodeSystem/Kontaktebene"/>
            <code value="abteilungskontakt"/>
            <display value="Abteilungskontakt"/>
          </coding>
        </type>
        <serviceType>
          <coding>
            <system
                    value="http://fhir.de/CodeSystem/dkgev/Fachabteilungsschluessel"/>
            <code value="0100"/>
            <display value="Innere Medizin"/>
          </coding>
        </serviceType>
        <subject>
          <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        </subject>
        <period>
          <start value="2025-07-21T00:00:00+02:00"/>
        </period>
        <serviceProvider>
          <identifier>
            <system value="https://example.org/fhir/sid/abteilungsid"/>
            <value value="ICU-001"/>
          </identifier>
          <display value="Intensivstation - Innere Medizin"/>
        </serviceProvider>
      </Encounter>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:880d8c69-fc05-4e1f-8203-a8ff40007f84"/>
    <resource>
      <Observation>
        <id value="880d8c69-fc05-4e1f-8203-a8ff40007f84"/>
        <meta>
          <profile
                   value="https://gematik.de/fhir/isik/StructureDefinition/ISiKBlutdruckSystemischArteriell"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_880d8c69-fc05-4e1f-8203-a8ff40007f84"> </a><h3>Observation</h3><div><strong>Typ:</strong><span><span>85354-9</span><span> (http://loinc.org)</span></span></div><div><strong>Status:</strong><span>FINAL</span></div><div><strong>Kategorie:</strong><ul><li><span><span><span>vital-signs</span><span> (http://terminology.hl7.org/CodeSystem/observation-category)</span></span></span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitpunkt:</strong><span>2025-07-22T14:10:00+02:00</span></div><div><strong>Messwerte:</strong><table style="border-collapse: collapse; width: 100%;"><thead><tr style="background-color: #f2f2f2;"><th style="border: 1px solid #ddd; padding: 8px;">Parameter</th><th style="border: 1px solid #ddd; padding: 8px;">Wert</th><th style="border: 1px solid #ddd; padding: 8px;">Einheit</th></tr></thead><tbody><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Systolisch</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>210</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Diastolisch</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>115</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr><tr><td style="border: 1px solid #ddd; padding: 8px;"><span><span>Mittlerer arterieller Druck</span></span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>140</span></td><td style="border: 1px solid #ddd; padding: 8px;"><span>mmHg</span></td></tr></tbody></table></div></div>
        </text>
        <status value="final"/>
        <category>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/observation-category"/>
            <code value="vital-signs"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="85354-9"/>
          </coding>
        </code>
        <subject>
          <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        </subject>
        <effectiveDateTime value="2025-07-22T14:10:00+02:00"/>
        <component>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="8480-6"/>
            </coding>
          </code>
          <valueQuantity>
            <value value="210"/>
            <unit value="mmHg"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="mm[Hg]"/>
          </valueQuantity>
        </component>
        <component>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="8462-4"/>
            </coding>
          </code>
          <valueQuantity>
            <value value="115"/>
            <unit value="mmHg"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="mm[Hg]"/>
          </valueQuantity>
        </component>
        <component>
          <code>
            <coding>
              <system value="http://loinc.org"/>
              <code value="8478-0"/>
            </coding>
          </code>
          <valueQuantity>
            <value value="140"/>
            <unit value="mmHg"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="mm[Hg]"/>
          </valueQuantity>
        </component>
      </Observation>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61a2e9af-88f9-4ee2-a97f-c136530aadba"/>
    <resource>
      <Procedure>
        <id value="61a2e9af-88f9-4ee2-a97f-c136530aadba"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Procedure_61a2e9af-88f9-4ee2-a97f-c136530aadba"> </a><h3>Prozedur</h3><div><strong>Typ:</strong><ul><li><span>Jet ventilation procedure (procedure)</span><span> (http://snomed.info/sct)</span></li></ul></div><div><strong>Status:</strong><span>COMPLETED</span></div><div><strong>Kategorie:</strong><span/><ul><li><span>Artificial ventilation (regime/therapy)</span><span> (http://snomed.info/sct)</span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Durchführungszeitraum:</strong><span>21.07.2025 00:00</span><span> (laufend)</span></div></div>
        </text>
        <status value="completed"/>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="40617009"/>
            <display value="Artificial ventilation (regime/therapy)"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="4764004"/>
            <display value="Jet ventilation procedure (procedure)"/>
          </coding>
        </code>
        <subject>
          <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        </subject>
        <performedPeriod>
          <start value="2025-07-21"/>
        </performedPeriod>
      </Procedure>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:32bb8c8a-418c-4fc2-b1c7-c33f1a99a464"/>
    <resource>
      <Observation>
        <id value="32bb8c8a-418c-4fc2-b1c7-c33f1a99a464"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_32bb8c8a-418c-4fc2-b1c7-c33f1a99a464"> </a><h3>Observation</h3><div><strong>Typ:</strong><span><span>Pressure support setting Ventilator</span><span> (http://loinc.org)</span></span></div><div><strong>Status:</strong><span>FINAL</span></div><div><strong>Kategorie:</strong><ul><li><span><span><span>Artificial ventilation (regime/therapy)</span><span> (http://snomed.info/sct)</span></span></span></li></ul></div><div><strong>Patient:</strong><span>urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79</span></div><div><strong>Zeitpunkt:</strong><span>2025-07-21T00:00:00+02:00</span></div><div><strong>Wert:</strong><span>6</span><span>cm[H2O]</span></div><div><strong>Teil von:</strong><ul><li><span>urn:uuid:61a2e9af-88f9-4ee2-a97f-c136530aadba</span></li></ul></div></div>
        </text>
        <partOf>
          <reference value="urn:uuid:61a2e9af-88f9-4ee2-a97f-c136530aadba"/>
        </partOf>
        <status value="final"/>
        <category>
          <coding>
            <system value="http://snomed.info/sct"/>
            <code value="40617009"/>
            <display value="Artificial ventilation (regime/therapy)"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="20079-0"/>
            <display value="Pressure support setting Ventilator"/>
          </coding>
        </code>
        <subject>
          <reference value="urn:uuid:11c3de2f-d461-4063-a0c2-fde122e76a79"/>
        </subject>
        <effectiveDateTime value="2025-07-21T00:00:00+02:00"/>
        <valueQuantity>
          <value value="6"/>
          <unit value="cm[H2O]"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="cm[H2O]"/>
        </valueQuantity>
      </Observation>
    </resource>
  </entry>
</Bundle>