ID

24634

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 -
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 1

German

KBV Certificate of work disability Template 1a

4 forms  
Briefkopf
Description

Briefkopf

Name der Krankenversicherung
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1]
C0021682 (Health Insurance)
Nachname
Description

Patient surname

Data type

text

Alias
UMLS CUI [1]
C0421448 (Patient surname)
SNOMED
184096005
Patientenname
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487 (Patient name)
SNOMED
371484003
Adresse des Patienten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449 (Patient address)
SNOMED
184097001
Patient Geburtsdatum
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451 (Patient date of birth)
SNOMED
184099003
LOINC
LP57552-9
Kostenträgerkennung
Description

Insurance ID

Data type

integer

Alias
UMLS CUI [1]
C1547687 (Insurance company ID codes)
Versichertennummer
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1]
C1549712 (Patient's Medicare number)
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1]
C0449438 (Status)
SNOMED
263490005
LOINC
LP73412-6
Betriebsstättennummer
Description

Facility number

Data type

integer

Alias
UMLS CUI [1]
C1549700 (Facility ID)
Arzt- Nr.
Description

Physician ID number

Data type

integer

Alias
UMLS CUI [1]
C1548646 (Unique physician ID no.)
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008 (Date in time)
SNOMED
410671006
Arbeitsunfähigkeitsbescheinigung
Description

Sick leave certificate

Data type

integer

Alias
UMLS CUI [1,1]
C0242807 (Sick Leave)
UMLS CUI [1,2]
C0260844 (Issue of medical certificate)
Arbeitsunfall, Arbeitsunfallfolgen,Berufskrankheit
Description

Working accident, sequelae of working accident,occupational disease

Data type

boolean

Alias
UMLS CUI [1]
C0277721 (Worker in work-related accident)
UMLS CUI [2,1]
C0745339 (work related injuries)
UMLS CUI [2,2]
C0243088 (sequelae aspects)
UMLS CUI [3]
C0028797 (Occupational Diseases)
SNOMED
115966001
Dem Durchgangsarzt zugewiesen
Description

Referred to accident and emergency doctor

Data type

boolean

Alias
UMLS CUI [1,1]
C0586803 (Emergency department physician)
SNOMED
309294001
UMLS CUI [1,2]
C0034927 (Patient referral)
SNOMED
440377005
LOINC
LA27930-9
Arbeitsunfähig seit
Description

Start date of sick leave

Data type

date

Alias
UMLS CUI [1,1]
C0242807 (Sick Leave)
UMLS CUI [1,2]
C0808070 (Start Date)
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 (End date)
SNOMED
454551000124105
LOINC
MTHU008302
UMLS CUI [1,2]
C1517001 (Expected (qualifier))
UMLS CUI [1,3]
C0242807 (Sick Leave)
Festgestellt am
Description

Date of diagnosis

Data type

date

Alias
UMLS CUI [1]
C2316983 (Date of diagnosis)
SNOMED
432213005
LOINC
LP114957-6
Vertragsarztstempel und Unterschrift
Description

Physician Stamp and signature

Data type

text

Alias
UMLS CUI [1]
C1519316 (Signature)
LOINC
LP248948-4
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 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
ICD-10 Code
Description

ICD-10

Data type

text

Alias
UMLS CUI [1,1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
ICD-10 Code
Description

ICD-10

Data type

text

Alias
UMLS CUI [1,1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
ICD-10 Code
Description

ICD-10

Data type

text

Alias
UMLS CUI [1,1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
ICD-10 Code
Description

ICD-10

Data type

text

Alias
UMLS CUI [1,1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
ICD-10 Code
Description

ICD-10

Data type

text

Alias
UMLS CUI [1,1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
UMLS CUI [1,2]
C0870733 (International Classification of Diseases)
LOINC
LP57597-4
Diagnose: Freitext
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900 (Diagnosis)
SNOMED
439401001
LOINC
LP30831-9
Sonstiger Unfall, Unfallfolgen
Description

Other accident, sequelae of accident

Data type

boolean

Alias
UMLS CUI [1]
C0029484 (Other accidents)
UMLS CUI [2,1]
C0243088 (sequelae aspects)
UMLS CUI [2,2]
C0000924 (Accidents)
LOINC
MTHU021177
Versorgungsleiden
Description

War-injuries, vaccination damage

Data type

boolean

Alias
UMLS CUI [1,1]
C4042938 (War-Related Injuries)
UMLS CUI [1,2]
C2609236 (Vaccination related complications)
Es wird die Einleitung folgender besonderer Maßnahmen für erforderlich gehalten
Description

Special treatments and procedures

Data type

integer

Alias
UMLS CUI [1]
C1719237 (Special treatments and procedures)
LOINC
MTHU021217
Es wird die Einleitung besonderer Maßnahmen für erforderlich gehalten: Sonstige
Description

Special treatments and procedures

Data type

text

Alias
UMLS CUI [1]
C1719237 (Special treatments and procedures)
LOINC
MTHU021217
Im Krankengeldfall
Description

Sickness benefit

Data type

integer

Alias
UMLS CUI [1]
C0438920 (Sickness benefit)
SNOMED
160979005
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Similar models

KBV Certificate of work disability Template 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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