Prescription formThe prescription form consists of a sheet with a front and a back side. The patient delivers the form to the therapist. The form is later part of the therapist's invoice. On the front end, the prescription is made by the doctor. The therapist's billing later). On the back the patient must confirm the receipt of the treatment achievement per treatment date with the therapist. In the case of a "prescription outside the regular case", the patient's health insurance company must also enter the confirmation on this page (unless the health insurance company waives the approval reservation). The following numbers refer to the marked areas of the prescription form.
(1) Patient data, health insurance, physician no., prescription date:
Information about the patient and the insurance can usually be taken from the insured person's chip card. In addition, the establishment no., the doctor's number and the date of issue of the prescription. All data are usually already printed on the form by simple practice EDP systems.
(2) prescription as a rule:
A
Initial prescription Is when it is the first occupational therapy prescription for a patient for a specific diagnosis. After an initial prescription, each additional prescription applies to treatment of the same diagnosis of a patient as Follow-up prescription. Note: It is possible that in the course of treatment, even if the diagnosis remains the same, the leading symptomatology and thus the therapeutic goal as well as the choice of remedies may change. However, this does not result in a new rule case. A follow-up prescription in the same case is therefore also present if the leading symptoms or the choice of remedies changes for the same diagnosis. Recurrences or new phases of illness can (only) trigger a new regular case with a new initial prescription after a treatment-free period of more than 12 weeks.
Indication: There are conceivable cases in which the same patient, due to
of several independent diagnoses In each case remedies may be received. Each diagnosis can establish a separate prescription here. The prescription must then be based on each diagnosis separate prescription forms take place. This is also necessary if additional (due to a corresponding diagnosis) measures of the physical therapy or the Voice, speech and language therapy should be prescribed. For the prescription of these measures deviating forms are to be used.
(3) Group therapy:
According to the remedy guidelines, some remedies can be used both as a
Single- as well as Group therapy be prescribed. If group dynamic effects are desired in a treatment, the physician can prescribe group therapy, also in the sense of the economic efficiency principle, unless individual therapy is required for medical reasons.
(4) Prescriptions outside the regular case:
The doctor can
deviating from the specifications of the remedies catalog prescribe further follow-up prescriptions if the therapeutic objective cannot be achieved with the prescribed quantity in the normal case. For such a prescription "outside the regular case" (especially longer-term prescriptions), the doctor must make a medical justification with a prognostic assessment indicate. These prescriptions, which require justification, must be submitted (by the patient/insured or a person authorized by the patient/insured) to the responsible health insurance company for approval before therapy can be continued (unless the health insurance company has waived the requirement for approval).
(5) Beginning of the therapy:
If the prescribing physician does not enter a date here, the therapy must be started within a certain period of time
14 days start after the prescription is issued. The physician may determine a shorter or longer period of time. In this case he enters the desired date here. Medical or organizational reasons may be decisive for specifying the start of treatment (z.B. Many holidays in the 14-day period).
(6) Home visit:
The doctor can determine that the therapy at the patient's place of residence as a
Home visit is carried out. This is only permissible if the patient is unable to see the therapist for medical reasons, or if the patient is unable to see the therapist for medical reasons. If there are compelling medical reasons.
(7) Therapy report:
The physician can specify here whether he would like to receive a therapy report from the therapist after completion of the treatment series. If yes, this is to be indicated here by marking with a cross.
(8) Prescription amount:
The physician is guided by the requirements of the therapeutic products catalog when specifying the number of treatments per prescription. Depending on the severity of the illness as well as the type of prescription (initial, follow-up prescription), this amount may vary. In the case of prescriptions "outside the regular case", the doctor must determine the prescription quantity as well as the frequency recommendation himself. This then determines the interval of the medical check-up, which should be a maximum of 12 weeks.
(9) Remedies according to the catalog:
The permissible remedies result from the leading symptomatology and/or. The resulting treatment goal. The catalog of remedies provides for an order of priority in the selection of remedies for the indication-related treatment of patients, which – on the basis of years of practical experience – distinguishes between priority (most likely/most frequent), optional (alternative) and supplementary remedies. The treatment described in the catalog section under
[A] listed priority remedies should be applied in the first place. If several remedies are possible as alternatives, these are designated in the catalog as [A1], [A2], [A3]. The physician may of one select from these for regulation. If the implementation of the priority remedy is not possible for reasons lying in the person of the patient, the following may be used as alternatives of a the optional remedy [B] prescribed. In addition to [A] or [B] may, in order to improve the efficiency of the therapy, a complementary remedy [C] be enacted. The simultaneous prescription of a priority remedy is not permitted [A] and an optional remedy [B]. The designation of the remedies on the prescription form can be tendered or shortened. The abbreviation does not have to comply with any formal requirement. However, it must be clear. A list of all prescribable remedies for occupational therapy can be found in our remedies catalog in Section IV "Remedies for Occupational Therapy".
(10) Therapy frequency (number per week):
The prescribing physician gives here a recommendation for the number of therapy units per week. If this frequency recommendation cannot be met, z.B. For reasons that lie with the patient, the therapist can change the frequency after consultation with the physician and document this on the reverse side of the prescription (see item 20). The indication key of the catalog of remedies is 3 characters long. If the diagnosis group results in. The indication code has no reference to the ICD. Example: A case is assigned to the diagnosis group "spinal disorders. The indication code is "SB1″. The indication code does not replace the illustration of diagnosis and leading symptoms in the form. (Note: The indication codes in the area of physical therapy can be one character longer).
(12) Diagnosis and leading symptoms, findings:
The indication for the prescription of remedies is always derived from the diagnosis plus the accompanying
Leading symptomatology (ability disorder). The leading symptomatology and the associated therapeutic goal are the decisive criteria for the selection of the remedy to be prescribed. In order for the therapist to begin therapy as seamlessly and efficiently as possible, the diagnosis, leading symptomatology, and information about other relevant findings/companion diseases should be indicated on the prescription form.
(13) Specifics:
If the patient has been diagnosed by the physician with neurological/psychiatric, pediatric or orthopedic specialties that may be relevant for the therapist, these should be noted here by the physician.
(14) Specification of therapeutic goals:
If the therapy goals in a specific individual case do not clearly emerge from the diagnosis and leading symptomatology of the remedy catalog, the physician can explain these goals in more detail here. Here the already mentioned indication of the medical reason takes place. The prognostic assessment for "prescriptions outside the regular case" (see point 4). If there is not enough space on the form, the justification can be provided in writing without any formalities on an additional sheet or. Be continued. In the medical justification, the physician should be guided by the established need for therapy, the ability to provide therapy, and the therapy prognosis, taking into account the intended therapy goals. Here the textual extent is not given.
(16) IK number, co-payment, remedy item number, billing:
The information in the upper right-hand corner of the form is not to be completed by the physician, but by the health care provider as part of the billing process for the therapy service rendered.
(17) Contractor's stamp, signature:
The name, address and signature of the prescribing physician must be indicated at the bottom right of the form.
(18) Approval of the health insurance fund:
Prescriptions outside the regular case must be submitted (by the patient/insured or a person authorized by him/her) to the health insurance company for approval before the treatment is continued. After presentation of the prescription, the therapy can be continued. The health insurance company will cover the cost of the remedy regardless of the outcome of the decision on the request for authorization, but no longer than the receipt of a decision rejecting the authorization. There is no reclaiming of costs for services already provided.
Notice: The health insurance company can waive the submission of "prescriptions outside the regular case", which corresponds to a blanket approval. In recent years, various health insurance companies have often proceeded in this way.
(form at the bottom of the page)
(19) Acknowledgement of receipt:
In this section of the form, the patient must acknowledge receipt of therapy services per treatment by signing the form.
(20) Information on the performance of the therapy:
At the bottom left of the form, the therapist can enter information on the course of therapy. Here it is to be indicated if the prescription defaults to the therapy frequency or group treatment in agreement with the physician were changed. In addition, any discontinuation of treatment must be noted.
Notice: This reverse side is not transmitted to the prescribing physician. The entire form is part of the therapist's invoice.