Layout-Editor

Krankenkasse bzw. Kostenträger

Name, Vorname

geb. am

Kostenträgerke

Versicherten-Nr.

Status

Betriebsstätte

Arzt-Nr.

Datum

Diagnose 1

ICD 1

Ursa

Diagnose 2

ICD 2

Ursa

Diagnose 3

ICD 3

Ursa

Diagnose 4

ICD 4

Ursa

Diagnose 5

ICD 5

Ursa

Diagnose 6

ICD 6

Ursa

II.A Anamnese – Zeile 1 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

II.A Anamnese – Zeile 2 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

II.A Anamnese – Zeile 3 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

II.B Schädigungen/Befunde – Zeile 1 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

II.B Schädigungen/Befunde – Zeile 2 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

TUG s

Chair

Handk

Handk

DEMMI

Tinet

MMST

GDS 1

Uhren

Schme

Ergom

FEV1

VK %

NYHA

II.D Interventionen – Zeile 1 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

II.D Interventionen – Zeile 2 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Hilfsmittel welche