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ID

24633

Description

Formulare für die vertragsärztliche Versorgung 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 Forms for contract medical care 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 (5)
  1. 02.09.16 02.09.16 -
  2. 10.08.17 10.08.17 -
  3. 10.08.17 10.08.17 -
  4. 05.09.17 05.09.17 -
  5. 05.09.17 05.09.17 -
Copyright Holder

Kassenärztlicher Bundesverband

Uploaded on

10. August 2017

DOI

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License

Creative Commons BY-NC 3.0
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    KBV Certificate of work disability Template 1d

    German

    Certificate of work disability Form 1a

    4 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
    Arbeitsunfähigkeitsbescheinigung
    Description

    Sick leave certificate

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0242807
    UMLS CUI [1,2]
    C0260844
    Arbeitsunfall, Arbeitsunfallfolgen,Berufskrankheit
    Description

    Working accident, sequelae of working accident,occupational disease

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0277721
    UMLS CUI [2,1]
    C0745339
    UMLS CUI [2,2]
    C0243088
    UMLS CUI [3]
    C0028797
    Dem Durchgangsarzt zugewiesen
    Description

    Referred to accident and emergency doctor

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0586803
    UMLS CUI [1,2]
    C0034927
    Arbeitsunfähig seit
    Description

    Start date of sick leave

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0242807
    UMLS CUI [1,2]
    C0808070
    Voraussichtlich arbeitsunfähig bis einschließlich oder letzter Tag der Arbeitsunfähigkeit
    Description

    Expected end date of sick leave

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0806020
    UMLS CUI [1,2]
    C1517001
    UMLS CUI [1,3]
    C0242807
    Festgestellt am
    Description

    Date of diagnosis

    Data type

    date

    Alias
    UMLS CUI [1]
    C2316983
    Vertragsarztstempel und Unterschrift
    Description

    Physician Stamp and signature

    Data type

    text

    Alias
    UMLS CUI [1]
    C1519316
    AU-begründende Diagnose(n) ICD - 10
    Description

    AU-begründende Diagnose(n) ICD - 10

    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    ICD-10 Code
    Description

    ICD-10

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0011900
    UMLS CUI [1,2]
    C0870733
    Diagnose: Freitext
    Description

    Diagnosis

    Data type

    text

    Alias
    UMLS CUI [1]
    C0011900
    Sonstiger Unfall, Unfallfolgen
    Description

    Other accident, sequelae of accident

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0029484
    UMLS CUI [2,1]
    C0243088
    UMLS CUI [2,2]
    C0000924
    Versorgungsleiden
    Description

    War-injuries, vaccination damage

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C4042938
    UMLS CUI [1,2]
    C2609236
    Es wird die Einleitung folgender besonderer Maßnahmen für erforderlich gehalten
    Description

    Special treatments and procedures

    Data type

    integer

    Alias
    UMLS CUI [1]
    C1719237
    Es wird die Einleitung besonderer Maßnahmen für erforderlich gehalten: Sonstige
    Description

    Special treatments and procedures

    Data type

    text

    Alias
    UMLS CUI [1]
    C1719237
    Im Krankengeldfall
    Description

    Sickness benefit

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0438920
    Back to the top of the page

    Similar models

    Certificate of work disability Form 1a

    4 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
    Arbeitsunfähigkeitsbescheinigung
    integer
    C0242807 (UMLS CUI [1,1])
    C0260844 (UMLS CUI [1,2])
    Sick leave certificate
    Code List
    Arbeitsunfähigkeitsbescheinigung
    CL Item
    Erstbescheinigung (1)
    CL Item
    Folgebescheinigung (2)
    Working accident, sequelae of working accident,occupational disease
    Item
    Arbeitsunfall, Arbeitsunfallfolgen,Berufskrankheit
    boolean
    C0277721 (UMLS CUI [1])
    C0745339 (UMLS CUI [2,1])
    C0243088 (UMLS CUI [2,2])
    C0028797 (UMLS CUI [3])
    Referred to accident and emergency doctor
    Item
    Dem Durchgangsarzt zugewiesen
    boolean
    C0586803 (UMLS CUI [1,1])
    C0034927 (UMLS CUI [1,2])
    Start date of sick leave
    Item
    Arbeitsunfähig seit
    date
    C0242807 (UMLS CUI [1,1])
    C0808070 (UMLS CUI [1,2])
    Expected end date of sick leave
    Item
    Voraussichtlich arbeitsunfähig bis einschließlich oder letzter Tag der Arbeitsunfähigkeit
    date
    C0806020 (UMLS CUI [1,1])
    C1517001 (UMLS CUI [1,2])
    C0242807 (UMLS CUI [1,3])
    Date of diagnosis
    Item
    Festgestellt am
    date
    C2316983 (UMLS CUI [1])
    Physician Stamp and signature
    Item
    Vertragsarztstempel und Unterschrift
    text
    C1519316 (UMLS CUI [1])
    Item Group
    AU-begründende Diagnose(n) ICD - 10
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    ICD-10
    Item
    ICD-10 Code
    text
    C0011900 (UMLS CUI [1,1])
    C0870733 (UMLS CUI [1,2])
    Diagnosis
    Item
    Diagnose: Freitext
    text
    C0011900 (UMLS CUI [1])
    Other accident, sequelae of accident
    Item
    Sonstiger Unfall, Unfallfolgen
    boolean
    C0029484 (UMLS CUI [1])
    C0243088 (UMLS CUI [2,1])
    C0000924 (UMLS CUI [2,2])
    War-injuries, vaccination damage
    Item
    Versorgungsleiden
    boolean
    C4042938 (UMLS CUI [1,1])
    C2609236 (UMLS CUI [1,2])
    Item
    Es wird die Einleitung folgender besonderer Maßnahmen für erforderlich gehalten
    integer
    C1719237 (UMLS CUI [1])
    Special treatments and procedures
    Code List
    Es wird die Einleitung folgender besonderer Maßnahmen für erforderlich gehalten
    CL Item
    Leistungen zur medizinischen Rehabilitation (1)
    CL Item
    Stufenweise Wiedereingliederung (2)
    CL Item
    Sonstige (3)
    Special treatments and procedures
    Item
    Es wird die Einleitung besonderer Maßnahmen für erforderlich gehalten: Sonstige
    text
    C1719237 (UMLS CUI [1])
    Item
    Im Krankengeldfall
    integer
    C0438920 (UMLS CUI [1])
    Sickness benefit
    Code List
    Im Krankengeldfall
    CL Item
    ab 7.AU Woche oder sonstiger Krankengeldfall (1)
    CL Item
    Endbescheinigung (2)
    Back to the top of the page 

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