ID

19983

Description

Muster 26 - Verordnung Soziotherapie gemäß § 37a SGB V(Freigabe 01.09.2014). Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php --- Template 26 - Social Therapy Prescription (Released 09-01-2014). Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

Link

www.kbv.de

Keywords

Versions (4)
  1. 2/1/17 2/1/17 -
  2. 2/2/17 2/2/17 -
  3. 8/16/17 8/16/17 -
  4. 9/7/17 9/7/17 -
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February 2, 2017

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Creative Commons BY-NC 3.0
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KBV Social Therapy Prescription Template 26

German

KBV Social Therapy Prescription Template 26

1 forms  
Briefkopf
Description

Briefkopf

Name der Krankenversicherung
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1]
C0021682
Nachname
Description

Patient surname

Data type

text

Alias
UMLS CUI [1]
C0421448
Patientenname
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Adresse des Patienten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Patient Geburtsdatum
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451
Kostenträgerkennung
Description

Insurance ID

Data type

integer

Alias
UMLS CUI [1]
C1547687
Versichertennummer
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1]
C1549712
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1]
C0449438
Betriebsstättennummer
Description

Facility number

Data type

integer

Alias
UMLS CUI [1]
C1549700
Arzt- Nr.
Description

Physician ID number

Data type

integer

Alias
UMLS CUI [1]
C1548646
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Erkrankung
Description

Erkrankung

Diagnose (ICD-10)
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Schweregrad (lt. GAF-SKALA)
Description

diagnosis severity

Data type

text

Alias
UMLS CUI [1]
C0561904
Die Erkrankung besteht seit
Description

diagnosis date

Data type

date

Alias
UMLS CUI [1]
C2316983
Art und Ausprägung der Fähigkeitsstörungen
Description

impairment manifestation

Data type

text

Alias
UMLS CUI [1,1]
C1280464
UMLS CUI [1,2]
C0684336
Art und Dauer der stationären Aufenthalte wegen dieser Erkrankung in den vergangenen 10 Jahren
Description

type and duration of hospitalization in the past 10 years

Data type

text

Alias
UMLS CUI [1]
C0023303
Anschrift und Telefonnummer des Versicherten
Description

Anschrift und Telefonnummer des Versicherten

Straße
Description

street

Data type

text

Alias
UMLS CUI [1]
C1301826
PLZ
Description

postal code

Data type

text

Alias
UMLS CUI [1]
C1514254
Ort
Description

city

Data type

text

Alias
UMLS CUI [1]
C2316883
Telefonnummer
Description

telephone number

Data type

integer

Alias
UMLS CUI [1]
C1515258
Gesetzlicher Betreuer
Description

Gesetzlicher Betreuer

Wurde ein gesetzlicher Betreuer bestellt?
Description

legal guardian

Data type

boolean

Alias
UMLS CUI [1]
C0023226
Wenn ja, für welche Angelegenheiten?
Description

legal guardian justification

Data type

text

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C0566251
Name, Anschrift und Telefonnummer des Betreuers,
Description

Name, Anschrift und Telefonnummer des Betreuers,

Name
Description

Legal Guardian name

Data type

text

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C0027365
Staße
Description

Legal Guardian street

Data type

text

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C1301826
PLZ
Description

Legal Guardian postal code

Data type

text

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C1514254
Ort
Description

Legal Guardian city

Data type

text

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C2316883
Telefonnummer
Description

Legal Guardian telephone number

Data type

integer

Alias
UMLS CUI [1,1]
C0023226
UMLS CUI [1,2]
C1515258
Name, Anschrift und Telefonnummer des nächsten Angehörigen
Description

Name, Anschrift und Telefonnummer des nächsten Angehörigen

Name
Description

relative name

Data type

text

Alias
UMLS CUI [1,1]
C0080103
UMLS CUI [1,2]
C0027365
Straße
Description

relative street

Data type

text

Alias
UMLS CUI [1,1]
C0080103
UMLS CUI [1,2]
C1301826
PLZ
Description

relative postal code

Data type

text

Alias
UMLS CUI [1,1]
C0080103
UMLS CUI [1,2]
C1514254
Ort
Description

relative city

Data type

text

Alias
UMLS CUI [1,1]
C0080103
UMLS CUI [1,2]
C2316883
Telefonnummer
Description

relative telephone number

Data type

integer

Alias
UMLS CUI [1,1]
C0080103
UMLS CUI [1,2]
C1515258
Umgebung
Description

Umgebung

Wohnform (z.B. alleinstehend in eigener Wohnung; Familie/Eltern; in Einrichtung)
Description

type of living

Data type

text

Alias
UMLS CUI [1]
C0337645
Voraussichtliche Anzahl der Therapieeinheiten
Description

planned therapy units

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1301732
UMLS CUI [1,3]
C0449788
Beantragte Anzahl der Therapieeinheiten
Description

requested therapy units

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0449788
Voraussichtliche Dauer der Therapie
Description

planned treatment duration

Data type

text

Alias
UMLS CUI [1]
C0444921
Bereits durchgeführte Leistungen
Description

sercvices performed

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0884358
UMLS CUI [1,3]
C0449788
Prognose
Description

Prognose

Prognose
Description

prognosis

Data type

text

Alias
UMLS CUI [1]
C0033325
Krankenhausbehandlung
Description

inpatient treatment

Data type

integer

Alias
UMLS CUI [1,1]
C0021562
UMLS CUI [1,2]
C0087111
Begründung
Description

Der soziotherapeutische Betreuungsplan ist beigefügt

Data type

text

Alias
UMLS CUI [1,1]
C0021562
UMLS CUI [1,2]
C0087111
UMLS CUI [1,3]
C0566251
Unterschrift
Description

Unterschrift

Datum
Description

Signature date

Data type

date

Measurement units
  • TT-MM-JJ
Alias
UMLS CUI [1]
C0807937
TT-MM-JJ
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Similar models

KBV Social Therapy Prescription Template 26

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Briefkopf
Health Insurance name
Item
Name der Krankenversicherung
text
C0021682 (UMLS CUI [1])
Patient surname
Item
Nachname
text
C0421448 (UMLS CUI [1])
Patient Name
Item
Patientenname
text
C1299487 (UMLS CUI [1])
Patient address
Item
Adresse des Patienten
text
C0421449 (UMLS CUI [1])
Patient Birth Date
Item
Patient Geburtsdatum
date
C0421451 (UMLS CUI [1])
Insurance ID
Item
Kostenträgerkennung
integer
C1547687 (UMLS CUI [1])
Insurance number
Item
Versichertennummer
integer
C1549712 (UMLS CUI [1])
Status
Item
Status
integer
C0449438 (UMLS CUI [1])
Facility number
Item
Betriebsstättennummer
integer
C1549700 (UMLS CUI [1])
Physician ID number
Item
Arzt- Nr.
integer
C1548646 (UMLS CUI [1])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Item Group
Erkrankung
Diagnosis
Item
Diagnose (ICD-10)
text
C0011900 (UMLS CUI [1])
diagnosis severity
Item
Schweregrad (lt. GAF-SKALA)
text
C0561904 (UMLS CUI [1])
diagnosis date
Item
Die Erkrankung besteht seit
date
C2316983 (UMLS CUI [1])
impairment manifestation
Item
Art und Ausprägung der Fähigkeitsstörungen
text
C1280464 (UMLS CUI [1,1])
C0684336 (UMLS CUI [1,2])
type and duration of hospitalization in the past 10 years
Item
Art und Dauer der stationären Aufenthalte wegen dieser Erkrankung in den vergangenen 10 Jahren
text
C0023303 (UMLS CUI [1])
Item Group
Anschrift und Telefonnummer des Versicherten
street
Item
Straße
text
C1301826 (UMLS CUI [1])
postal code
Item
PLZ
text
C1514254 (UMLS CUI [1])
city
Item
Ort
text
C2316883 (UMLS CUI [1])
telephone number
Item
Telefonnummer
integer
C1515258 (UMLS CUI [1])
Item Group
Gesetzlicher Betreuer
legal guardian
Item
Wurde ein gesetzlicher Betreuer bestellt?
boolean
C0023226 (UMLS CUI [1])
legal guardian justification
Item
Wenn ja, für welche Angelegenheiten?
text
C0023226 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Item Group
Name, Anschrift und Telefonnummer des Betreuers,
Legal Guardian name
Item
Name
text
C0023226 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
Legal Guardian street
Item
Staße
text
C0023226 (UMLS CUI [1,1])
C1301826 (UMLS CUI [1,2])
Legal Guardian postal code
Item
PLZ
text
C0023226 (UMLS CUI [1,1])
C1514254 (UMLS CUI [1,2])
Legal Guardian city
Item
Ort
text
C0023226 (UMLS CUI [1,1])
C2316883 (UMLS CUI [1,2])
Legal Guardian telephone number
Item
Telefonnummer
integer
C0023226 (UMLS CUI [1,1])
C1515258 (UMLS CUI [1,2])
Item Group
Name, Anschrift und Telefonnummer des nächsten Angehörigen
relative name
Item
Name
text
C0080103 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
relative street
Item
Straße
text
C0080103 (UMLS CUI [1,1])
C1301826 (UMLS CUI [1,2])
relative postal code
Item
PLZ
text
C0080103 (UMLS CUI [1,1])
C1514254 (UMLS CUI [1,2])
relative city
Item
Ort
text
C0080103 (UMLS CUI [1,1])
C2316883 (UMLS CUI [1,2])
relative telephone number
Item
Telefonnummer
integer
C0080103 (UMLS CUI [1,1])
C1515258 (UMLS CUI [1,2])
Item Group
Umgebung
type of living
Item
Wohnform (z.B. alleinstehend in eigener Wohnung; Familie/Eltern; in Einrichtung)
text
C0337645 (UMLS CUI [1])
planned therapy units
Item
Voraussichtliche Anzahl der Therapieeinheiten
integer
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
requested therapy units
Item
Beantragte Anzahl der Therapieeinheiten
integer
C0087111 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
planned treatment duration
Item
Voraussichtliche Dauer der Therapie
text
C0444921 (UMLS CUI [1])
sercvices performed
Item
Bereits durchgeführte Leistungen
text
C0087111 (UMLS CUI [1,1])
C0884358 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])
Item Group
Prognose
prognosis
Item
Prognose
text
C0033325 (UMLS CUI [1])
Item
Krankenhausbehandlung
integer
C0021562 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
inpatient treatment
Code List
Krankenhausbehandlung
CL Item
wird vermieden (1)
CL Item
wird verkürzt (2)
CL Item
ist nicht ausführbar (3)
reason for inpatient treatment
Item
Begründung
text
C0021562 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0566251 (UMLS CUI [1,3])
Item Group
Unterschrift
Signature date
Item
Datum
date
C0807937 (UMLS CUI [1])
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