Platz für Kliniklogo
| |Psychosozialer Protokollbogen (Kurzversion) |
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|Platz für | |
|Kliniklogo | |
| |Platz für Klinikkopfzeile |
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|Patient: | |
| |Blatt:____ |
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|Platz für Patientenaufkleber |Zuständige/r PSD-Betreuer/in |
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|Diagnose: |Diagnosedatum: |
|Psychosoziale Belastungsgruppe: |Psychosoziale Diagnose ICD-10: |
1. Status des Patienten Stationär/ Ambulant/ Teilstationär/ Verstorben
2. Kontaktperson: Patient/ Angehöriger/ Klinikmitarbeiter/ Umfeld
3. Kontaktart: angesichtlich/ telefonisch/ schriftlich
|Datum |1. |2. |3. |Inhalt |OPS |Zeit |Signatur |
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|1. Status des Patienten Stationär/ Ambulant/ Teilstationär/ Verstorben |
|2. Kontaktperson: Patient/ Angehöriger/ Klinikmitarbeiter/ Umfeld |
|3. Kontaktart: angesichtlich/ telefonisch/ schriftlich |
|Datum |1. |2. |3. |Inhalt |OPS |Zeit |Signatur |
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