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. 9/2/16 9/2/16 -
  2. 8/10/17 8/10/17 -
  3. 8/10/17 8/10/17 -
  4. 9/5/17 9/5/17 -
  5. 9/5/17 9/5/17 -
Copyright Holder

Kassenärztlicher Bundesverband

Uploaded on

August 10, 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
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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)
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