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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