ID

25625

Description

Muster 63 - Verordnung spezialisierter ambulanter Palliativversorgung (SAPV) (Freigabe 01.09.2014). 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 --- Template 85 - Prescription of specialized outpatient palliative care (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. 1/4/17 1/4/17 -
  2. 1/5/17 1/5/17 -
  3. 1/28/17 1/28/17 -
  4. 9/7/17 9/7/17 -
Copyright Holder

KBV

Uploaded on

September 7, 2017

DOI

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License

Creative Commons BY-NC 3.0
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KBV Prescription of specialized outpatient palliative care Template 63

German

KBV Prescription of specialized outpatient palliative care Template 63b

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
geb. am
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
Erstversorgung
Description

primary health care

Data type

boolean

Alias
UMLS CUI [1]
C0033137
Folgeverordnung
Description

follow-up prescription

Data type

boolean

Alias
UMLS CUI [1,1]
C0033080
UMLS CUI [1,2]
C1522577
Unfall Unfallfolgen
Description

consequences of accident

Data type

boolean

Alias
UMLS CUI [1,1]
C0686907
UMLS CUI [1,2]
C0000924
vom
Description

Treatment start date

Data type

date

Alias
UMLS CUI [1]
C3173309
bis
Description

Treatment End Date

Data type

date

Alias
UMLS CUI [1]
C1531784
Verordnungsrelevante Diagnosen (ICD-10; ggf. Organmanifestation)
Description

Verordnungsrelevante Diagnosen (ICD-10; ggf. Organmanifestation)

Diagnose
Description

diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
ICD-10
Description

ICD

Data type

text

Alias
UMLS CUI [1]
C2598420
Komplexes Symptomgeschehen
Description

Komplexes Symptomgeschehen

ausgeprägte urogenitale Symptomatik
Description

urogenital symptoms

Data type

boolean

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C0042066
ausgeprägte ulzerierende/exulzerierende Wunden oder Tumore
Description

ulcers or

Data type

boolean

Alias
UMLS CUI [1,1]
C0041582
UMLS CUI [1,2]
C0043251
UMLS CUI [2,1]
C0041582
UMLS CUI [2,2]
C0027651
ausgeprägte Schmerzsymptomatik
Description

heavy pain

Data type

boolean

Alias
UMLS CUI [1]
C0458256
ausgeprägte respiratorische/kardiale Symptomatik
Description

cardiac or respiratory symptoms

Data type

boolean

Alias
UMLS CUI [1]
C0741933
UMLS CUI [2]
C0037090
ausgeprägte neurologische/psychiatrische/psychische Symptomatik
Description

neurologic, psychiatric or mental symptoms

Data type

boolean

Alias
UMLS CUI [1]
C0235031
UMLS CUI [2]
C0233401
UMLS CUI [3]
C0586405
ausgeprägte gastrointestinale Symptomatik
Description

gastrointestinal symptom

Data type

boolean

Alias
UMLS CUI [1]
C0426576
sonstiges komplexes Symptomgeschehen
Description

other symptoms

Data type

boolean

Alias
UMLS CUI [1]
C0037088
Nähere Beschreibung
Description

Nähere Beschreibung des komplexen Symptomgeschehens und des besonderen Versorgungsbedarfs zur Begründung, warum spezialisierte ambulante Palliativversorgung notwendig ist (z.B. therapierefraktäre Schmerzen, Ruhedyspnoe/Erstickungsanfälle, nicht beherrschbares Erbrechen/Durchfälle)

Data type

text

Alias
UMLS CUI [1]
C0037088
UMLS CUI [2]
C1719237
Aktuelle Medikation
Description

Aktuelle Medikation

Atkuelle Medikation
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Maßnahmen
Description

Maßnahmen

Beratung
Description

consultation

Data type

boolean

Alias
UMLS CUI [1]
C0009818
a. des behandelnden Arztes
Description

consultation of physician

Data type

boolean

Alias
UMLS CUI [1,1]
C0009818
UMLS CUI [1,2]
C1710470
b. der behandelnden Pflegekraft
Description

consultation of nurse

Data type

boolean

Alias
UMLS CUI [1,1]
C0009818
UMLS CUI [1,2]
C0028661
c. des Patienten / der Angehörigen
Description

consultation of patient or relatives

Data type

boolean

Alias
UMLS CUI [1,1]
C0009818
UMLS CUI [1,2]
C0030705
UMLS CUI [2,1]
C0009818
UMLS CUI [2,2]
C0080103
Koordination der Palliativversorgung
Description

coordination of palliative treatment

Data type

boolean

Alias
UMLS CUI [1,1]
C0001554
UMLS CUI [1,2]
C0030231
mit folgender inhaltlicher Ausrichtung (Gegenstand, Häufigkeit, evtl. Beratung für Sonstige)
Description

consultation topic

Data type

text

Alias
UMLS CUI [1,1]
C1706203
UMLS CUI [1,2]
C0009818
Additiv unterstützende Teilversorgung
Description

supportive care

Data type

boolean

Alias
UMLS CUI [1]
C0344211
Vollständige Versorgung
Description

complete care

Data type

boolean

Alias
UMLS CUI [1]
C0033137
Nähere Angaben zu den notwendigen Maßnahmen der SAPV
Description

further details for specialized outpatient palliative care

Data type

text

Alias
UMLS CUI [1]
C0030231
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Similar models

KBV Prescription of specialized outpatient palliative care Template 63b

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
geb. am
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])
primary health care
Item
Erstversorgung
boolean
C0033137 (UMLS CUI [1])
follow-up prescription
Item
Folgeverordnung
boolean
C0033080 (UMLS CUI [1,1])
C1522577 (UMLS CUI [1,2])
consequences of accident
Item
Unfall Unfallfolgen
boolean
C0686907 (UMLS CUI [1,1])
C0000924 (UMLS CUI [1,2])
Treatment start date
Item
vom
date
C3173309 (UMLS CUI [1])
Treatment End Date
Item
bis
date
C1531784 (UMLS CUI [1])
Item Group
Verordnungsrelevante Diagnosen (ICD-10; ggf. Organmanifestation)
diagnosis
Item
Diagnose
text
C0011900 (UMLS CUI [1])
ICD
Item
ICD-10
text
C2598420 (UMLS CUI [1])
Item Group
Komplexes Symptomgeschehen
urogenital symptoms
Item
ausgeprägte urogenitale Symptomatik
boolean
C1457887 (UMLS CUI [1,1])
C0042066 (UMLS CUI [1,2])
ulcers or
Item
ausgeprägte ulzerierende/exulzerierende Wunden oder Tumore
boolean
C0041582 (UMLS CUI [1,1])
C0043251 (UMLS CUI [1,2])
C0041582 (UMLS CUI [2,1])
C0027651 (UMLS CUI [2,2])
heavy pain
Item
ausgeprägte Schmerzsymptomatik
boolean
C0458256 (UMLS CUI [1])
cardiac or respiratory symptoms
Item
ausgeprägte respiratorische/kardiale Symptomatik
boolean
C0741933 (UMLS CUI [1])
C0037090 (UMLS CUI [2])
neurologic, psychiatric or mental symptoms
Item
ausgeprägte neurologische/psychiatrische/psychische Symptomatik
boolean
C0235031 (UMLS CUI [1])
C0233401 (UMLS CUI [2])
C0586405 (UMLS CUI [3])
gastrointestinal symptom
Item
ausgeprägte gastrointestinale Symptomatik
boolean
C0426576 (UMLS CUI [1])
other symptoms
Item
sonstiges komplexes Symptomgeschehen
boolean
C0037088 (UMLS CUI [1])
detailed description of symptoms and special need of care
Item
Nähere Beschreibung
text
C0037088 (UMLS CUI [1])
C1719237 (UMLS CUI [2])
Item Group
Aktuelle Medikation
Medication
Item
Atkuelle Medikation
text
C0013227 (UMLS CUI [1])
Item Group
Maßnahmen
consultation
Item
Beratung
boolean
C0009818 (UMLS CUI [1])
consultation of physician
Item
a. des behandelnden Arztes
boolean
C0009818 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])
consultation of nurse
Item
b. der behandelnden Pflegekraft
boolean
C0009818 (UMLS CUI [1,1])
C0028661 (UMLS CUI [1,2])
consultation of patient or relatives
Item
c. des Patienten / der Angehörigen
boolean
C0009818 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C0009818 (UMLS CUI [2,1])
C0080103 (UMLS CUI [2,2])
coordination of palliative treatment
Item
Koordination der Palliativversorgung
boolean
C0001554 (UMLS CUI [1,1])
C0030231 (UMLS CUI [1,2])
consultation topic
Item
mit folgender inhaltlicher Ausrichtung (Gegenstand, Häufigkeit, evtl. Beratung für Sonstige)
text
C1706203 (UMLS CUI [1,1])
C0009818 (UMLS CUI [1,2])
supportive care
Item
Additiv unterstützende Teilversorgung
boolean
C0344211 (UMLS CUI [1])
complete care
Item
Vollständige Versorgung
boolean
C0033137 (UMLS CUI [1])
further details for specialized outpatient palliative care
Item
Nähere Angaben zu den notwendigen Maßnahmen der SAPV
text
C0030231 (UMLS CUI [1])
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