Machine translation — not yet reviewed by the association. This page was translated automatically from German. It may contain errors. If in doubt, the German version applies.

Plain language instead of jargon

Medical reports & expert opinions

Understand findings. Make better sense of expert opinions.

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Medical reports & expert opinions

What medical reports really say

Here you will find typical terms from doctor's letters, findings reports, medical expert opinions, rehabilitation reports and social medicine assessments.

Briefly explained, clearly worded and arranged so that you can quickly look up what a term means.

The explanations help you to understand and place medical wording better. They do not replace a doctor's evaluation of a specific finding or individual legal advice.

Is something missing? Then send us an email at kontakt@kein-einzelfall.de. We will add to the list and let it keep growing together with you.

Together, KE!N EINZELFALL

To the typical sentences

A

Ability to undergo rehabilitation (Rehabilitationsfähigkeit): This assesses whether physical and psychological resilience allow active participation in a suitable rehabilitation measure.
Activities (Aktivitäten): This means actions and tasks a person carries out in everyday life. Social medicine assessments can look at whether and by what these activities are limited.
Activities of daily living (Aktivitäten des täglichen Lebens): These include everyday activities such as personal hygiene, dressing, eating, getting around or other tasks of daily self-care. Which areas are looked at depends on the procedure.
Additional finding (Zusatzbefund): An additional medical finding made during an examination or supplementary diagnostics.
Anaesthesia record (Narkoseprotokoll): Documentation of anaesthesia in connection with a procedure. Anaesthesia records can be part of the patient record.
Assessment (Begutachtung): An expert examines and evaluates medical or social medicine questions for a particular assignment. The scope depends on the specific question.
Assessment (Beurteilung): Here the available information, complaints and findings are placed in a medical or social medicine context.
Assessment assignment (Begutachtungsauftrag): This sets out which medical or social medicine questions an expert opinion is to answer.
Assessment of capacity (Leistungsbeurteilung): A medical or social medicine assessment of which activities and demands are possible for a person from a health point of view.
Autonomic history (Vegetative Anamnese): Information on, for example, sleep, appetite, weight, excretion or other basic bodily functions. Such information can be part of a detailed assessment.

C

Capacity (Leistungsfähigkeit): Describes which physical or psychological demands a person can cope with from a medical point of view. The social medicine assessment of the German Pension Insurance explicitly considers capacity in working life.
Capacity profile (Leistungsbild): A summarising description of the existing capacity and the health-related limitations.
Causality / causal link (Kausalität / Kausalzusammenhang): This examines whether there is a causal connection between an event or cause and a health disorder. What is required of this connection depends on the procedure.
Causality assessment (Kausalitätsgutachten): An expert opinion that examines in particular whether a certain event or influence caused a health damage or its consequences.
Clinical finding (Klinischer Befund): Results found during a medical examination.
Co-treatment (Mitbehandlung): Another doctor or other professional is also involved in the treatment.
Comorbidity (Komorbidität): One or more illnesses that exist in addition to another illness.
Concomitant illness (Begleiterkrankung): A further illness or health disorder that exists in addition to another illness.
Consistency (Konsistenz): An assessment can examine whether statements, observations and findings appear compatible with one another. A single anomaly does not on its own allow a final evaluation.
Contextual factors (Kontextfaktoren): Personal and environmental factors that can influence how an illness or disability affects everyday life and participation. Such factors are taken into account in social medicine assessments.
Course (Verlauf): This describes how complaints, illness, findings or treatment have developed over time.
Course of therapy (Therapieverlauf): Description of the treatment carried out and of how complaints and findings developed during that time.
Course of treatment (Behandlungsverlauf): This describes how complaints, illness and treatment have developed over a certain period.

D

Diagnosis (Diagnose): The medical determination of an illness or health disorder based on the information and findings gathered.
Diagnosis of exclusion (Ausschlussdiagnose): A possible illness is specifically examined to establish whether it can be ruled out as the cause of the complaints.
Differential diagnosis (Differentialdiagnose): Different illnesses or causes that could fit the complaints or findings are examined.
Discharge report / discharge letter (Entlassungsbericht / Entlassbrief): A report after inpatient treatment or rehabilitation. It can record diagnoses, findings, treatments, course, medication and recommendations. Doctor's letters typically contain such information.
Doctor's letter (Arztbrief): A doctor's letter summarises important information about treatment, for example medical history, diagnoses, findings, treatments, medication and recommendations.

E

Earning capacity (Erwerbsfähigkeit): A social law term referring to the extent to which a person can still do gainful work under the relevant legal requirements.
Epicrisis / summarising assessment (Epikrise / epikritische Beurteilung): A summarising medical evaluation of the course of illness and treatment and of the findings.
Established finding (Befundtatsache): A medical fact established during an examination or from documents.
Examination finding (Untersuchungsbefund): The result of a medical examination.
Examination result (Untersuchungsergebnis): The results found during an examination.
Expert assessor (Gutachter / Gutachterin): An expert who has been commissioned with a medical or social medicine assessment.
Expert opinion (Gutachten): A professional assessment of a specific question. It regularly contains an evaluation of the available information and findings and a comprehensible medical or social medicine assessment.
Expert opinion assignment (Gutachtenauftrag): The question the expert assessor is to answer. The specific assignment is decisive for the content of an expert opinion.
Expert statement (Gutachtliche Stellungnahme): A professional assessment of a specific question. Scope and content depend on the assignment.
External finding (Fremdbefund): A finding made by another treating or examining body.

F

File basis (Aktenlage): An assessment is made on the basis of the existing documents. Whether a personal examination is also needed depends on the assignment and the procedure.
File review (Aktenstudium): Existing medical and other documents relevant to the question are read and evaluated.
Finality assessment (Finalitätsgutachten): A final perspective focuses mainly on the current state of health and its effects. Whether this term is used in a specific procedure depends on the area of assessment.
Finding (Befund): A finding describes a result of a medical examination or observation, for example a physical examination, imaging, laboratory test or mental status examination.
Findings report (Befundbericht): A medical report summarising the findings and other relevant information.
Fitness for work (Arbeitsfähigkeit): This assesses whether a person can currently do their specific job despite an illness. Fitness for work is not the same as earning capacity or reduced earning capacity.
Follow-up check (Verlaufskontrolle): A later examination or assessment that checks for changes in the course of illness or treatment.
Follow-up examination (Nachuntersuchung): A further examination at a later date to assess further development.
Functional finding (Funktionsbefund): A description of specific functional abilities or limitations.
Functional impairment (Funktionsbeeinträchtigung): A limitation of physical, psychological or mental functions.
Functioning (Funktionsfähigkeit): Describes which physical, psychological or mental functions and activities are possible for a person.

G

General condition (Allgemeinzustand): This describes a person's overall physical impression. The exact meaning follows from the medical context.

H

Health disorder (Gesundheitsstörung): An umbrella term for an impairment of physical or mental health.
History from third parties (Fremdanamnese): Information on the medical history or situation that comes from sources other than the examined person, for example relatives or documents.

I

ICD code (ICD-Code): A coded label for diagnoses under the International Classification of Diseases. The code alone does not automatically say how severe an illness is in the individual case.
Impaired participation (Teilhabebeeinträchtigung): A health-related limitation of participation in one or more areas of life.
Impairment (Schädigung): In social medicine contexts, this can refer to impairments of body functions or body structures.
Impairment of abilities (Fähigkeitsstörung / Fähigkeitsbeeinträchtigung): A limitation in certain abilities or actions, for example concentration, mobility or resilience.
Incapacity for work (Arbeitsunfähigkeit): Because of an illness, a person currently cannot do their most recent job, or only at the risk of getting worse. Incapacity for work does not automatically mean that no gainful work will ever be possible again.
Incidental finding (Nebenbefund): An additional finding made during an examination that was not necessarily the original reason for it.
Indication (Indikation): The medical reason for carrying out a particular examination, treatment or measure.
Interaction (Wechselwirkung): Different illnesses, complaints, medicines or other factors influence one another.

L

Limitation (Einschränkung): This describes that a physical, psychological or mental ability is not present or only to a limited extent.

M

Medical certificate (Attest): A doctor's certificate on a particular medical fact or question. A certificate is usually shorter and less comprehensive than a findings report or an expert opinion.
Medical history (Anamnese): This is the history of an illness. It can include current complaints, previous illnesses, treatments, medication and psychological and social factors. Patient records regularly contain information on the medical history.
Medical Service – MD (Medizinischer Dienst): In cases provided for by law, the Medical Service supports the statutory health and long-term care insurance funds with medical and social medicine assessments and statements.
Medication (Medikation): The medicines that have been prescribed or are being taken.
Mental status / psychopathological findings (Psychischer Befund / psychopathologischer Befund): A structured description of the current mental state, for example with regard to mood, thinking, perception, orientation and drive.

N

Need for rehabilitation (Rehabilitationsbedürftigkeit): The social medicine assessment examines whether, because of health impairments, a rehabilitation benefit is necessary to maintain or improve participation or capacity. It is a separate criterion.
Need for treatment (Behandlungsbedürftigkeit): This describes whether treatment is necessary from a medical point of view. Which treatment makes sense depends on the specific illness and situation.
Negative capacity profile / limitations (Negatives Leistungsbild / Leistungseinschränkungen): Describes activities, demands or working conditions that are not possible, or only to a limited extent, from a health point of view.
Notification of findings (Befundmitteilung): A short notice about the result of an examination.

O

Objectifiable finding (Objektivierbarer Befund): A finding that can be established or documented in a comprehensible way using medical examination methods. If complaints cannot be objectified, this does not automatically mean that they do not exist.
Own statements (Eigenangaben): Information that the examined person gives about their complaints, limitations and life situation.

P

Participation (Teilhabe): This means a person being involved in different areas of life, for example work, social relationships or social life.
Pathological (Pathologisch): Medical term for a finding that is diseased or deviates from the medical norm. What the deviation means must be assessed in context.
Patient record (Patientenakte): Essential information on treatment is documented here, for example medical history, diagnoses, examinations, findings, therapies, medication, doctor's letters and, where applicable, surgical reports.
Permanent diagnosis (Dauerdiagnose): A diagnosis that is recorded as relevant over a longer period. This alone does not show how severe the illness currently is.
Plausibility (Plausibilität): This assesses whether statements, findings and medical connections appear comprehensible.
Positive capacity profile (Positives Leistungsbild / positives Leistungsvermögen): Describes which activities and demands are still possible from a health point of view.
Pre-existing condition (Vorerkrankung): An illness that already existed before the event or period currently being considered.
Previous expert opinion (Vorgutachten): An expert opinion prepared earlier that can be taken into account as a document in a later assessment.
Previous finding (Vorbefund): A finding made earlier that can be taken into account in the current assessment or compared with new findings.
Primary damage (Primärschaden): In causality assessments, this can refer to damage to health caused directly by a particular event or influence. The exact use depends on the area of law.
Prognosis (Prognose): A professional assessment of how an illness, functional impairment or capacity is likely to develop. It is an estimate, not a certain prediction.

Q

Qualitative working capacity (Qualitatives Leistungsvermögen): Describes which kinds of activities, demands and working conditions are still possible or limited from a health point of view. Rehabilitation reports explicitly assess qualitative capacity.
Quantitative working capacity (Quantitatives Leistungsvermögen): Describes the amount of time for which an activity can be carried out from a social medicine point of view. In the pension insurance this is assessed, among other things, for the most recent job and the general labour market.

R

Recommendation (Empfehlung): A professional assessment of which further examination, treatment, rehabilitation or support might make sense. A medical recommendation is not automatically a legal decision on benefits.
Reduced earning capacity (Erwerbsminderung): A legal term used mainly in the statutory pension insurance. Whether there is reduced earning capacity in the legal sense is decided by the responsible pension insurance provider on the basis of the legal requirements and the medical assessment.
Rehabilitation goal (Rehabilitationsziel): The goal a rehabilitation measure is meant to achieve, for example improved participation or working capacity.
Rehabilitation need (Rehabilitationsbedarf): This examines whether rehabilitation benefits may be necessary.
Rehabilitation potential (Rehabilitationspotential): This can describe existing possibilities and resources that can be used or improved through rehabilitation. The term is used in connection with the rehabilitation prognosis.
Rehabilitation prognosis (Rehabilitationsprognose): A medically founded assessment of whether the goals of the rehabilitation are likely to be achieved.
Remission (Remission): Signs of illness or complaints have clearly decreased or are temporarily no longer present. Remission does not automatically mean a permanent cure.
Reserve capacity (Reservekapazität): A social medicine term that can describe whether there are still health or functional possibilities that can be used through treatment or rehabilitation.
Resilience (Belastbarkeit): This describes which physical or psychological demands a person can cope with.
Response to therapy (Therapieansprechen): This describes whether and how a treatment has had an effect.

S

Secondary damage / consequential damage (Sekundärschaden / Folgeschaden): Damage to health that may have developed as a result of other damage to health or an event. Whether such a connection actually exists must be examined in the procedure.
Self-reported history (Eigenanamnese): Information a person gives about their own medical history, complaints and treatments.
Social history (Sozialanamnese): Information on living circumstances, work, housing, family, support and other social factors, insofar as they are relevant to the medical or social medicine assessment.
Social medicine assessment (Sozialmedizinische Begutachtung): An assessment in which health impairments are evaluated in connection with capacity, rehabilitation, participation or social law questions. The German Pension Insurance describes the assessment of capacity and need for rehabilitation, among other things, as central tasks.
Social medicine assessment of capacity (Sozialmedizinische Leistungsbeurteilung): A summarising professional assessment of which activities and demands are still possible for a person, taking their health limitations into account.
Social medicine statement (Sozialmedizinische Stellungnahme): A professional social medicine assessment of a particular question. In pension insurance assessments, a final social medicine statement is part of the process.
Somatic finding (Somatischer Befund): A finding relating to the state of physical health.
Specialist's statement (Fachärztliche Stellungnahme): A medical assessment by a specialist doctor on a particular question.
Statement (Stellungnahme): A professional assessment of a particular medical or social medicine question.
Status after … (Zustand nach … / Z. n. …): Means that a certain event, illness or treatment took place in the past, for example „Zustand nach Operation“ (status after surgery).
Subjective statements / subjective complaints (Subjektive Angaben / subjektive Beschwerden): Complaints or limitations that a person describes themselves. These statements are part of the medical assessment and can be considered together with other findings.
Summarising assessment (Zusammenfassende Beurteilung): At the end of a report or expert opinion, the most important findings, connections and professional assessments are brought together.
Supplementary diagnostics (Zusatzdiagnostik): Additional examinations that may be necessary to answer a medical or assessment question. The German Pension Insurance explicitly takes necessary supplementary diagnostics into account in the assessment process.
Surgical report (Operationsbericht): Documentation of a surgical procedure. Surgical reports are among the information that can be part of a patient record.
Suspected diagnosis (Verdachtsdiagnose): An illness is suspected on the basis of the information so far but has not yet been finally confirmed.

T

Therapy recommendation (Therapieempfehlung): A professional recommendation on which further treatment or medical measure might make sense.
Therapy success (Therapieerfolg): This describes which changes a treatment has achieved.
Treatment records (Behandlungsdokumentation): The records of diagnoses, findings, examinations, therapies, medication and the course of treatment. Such information is regularly part of the patient record.

W

Work history / occupational history (Arbeitsanamnese / Berufsanamnese): Information on previous work, the workplace and the actual physical or psychological demands of the job.
Working capacity (Leistungsvermögen): Describes which activities a person can still carry out from a health point of view, and under what conditions.

Typical sentences – in plain words

Sometimes the problem is not a single technical term but a whole sentence.

Here you will find typical wording from doctor's letters, findings reports and expert opinions – translated into plainer language. The sentences are quoted in German, the way they appear in your letter.

The plain translation is meant to help you understand a sentence better. What it means in your particular case always depends on the context. This is not legal advice.

Is a phrase missing? Then send us an email at kontakt@kein-einzelfall.de. We will add to the list and let it keep growing together with you.

Together, KE!N EINZELFALL

„Der Allgemeinzustand ist reduziert.“: In plain words: The treating or examining person describes the general physical condition as impaired. How severely and why should be clear from the rest of the report.
„Es besteht ein unauffälliger Befund.“: In plain words: No noticeable deviation was found in this examination.
„Kein pathologischer Befund.“: In plain words: No pathological finding was made in the examination described.
„Es besteht kein Anhalt für …“: In plain words: The examining person did not find sufficient signs of the illness or anomaly named.
„Es ergeben sich Hinweise auf …“: In plain words: Certain information or findings suggest that the illness or anomaly named could be present.
„Es ergeben sich keine Hinweise auf …“: In plain words: No sufficient signs of the illness or anomaly named were found in the examination.
„Ein Ausschluss ist nicht möglich.“: In plain words: On the basis of the information so far, the illness or cause named cannot be ruled out with certainty.
„Differentialdiagnostisch ist … zu berücksichtigen.“: In plain words: Besides the current assessment, another possible cause or diagnosis also comes into question and should be kept in mind.
„Die Diagnose ist gesichert.“: In plain words: The treating or assessing person considers the diagnosis confirmed on the basis of the available medical information.
„Die Diagnose kann nicht bestätigt werden.“: In plain words: In the examining person's view, the available information is not enough to confirm the diagnosis suspected so far.
„Es besteht der Verdacht auf …“: In plain words: The illness named is suspected but has not yet been finally confirmed.
„Anamnestisch berichtet die Patientin / der Patient …“: In plain words: What follows is based on what the examined person said about their medical history or complaints.
„Fremdanamnestisch wird berichtet …“: In plain words: The information does not come from the examined person but from another source.
„Die Beschwerden sind subjektiv.“: In plain words: The complaints are perceived and described by the person concerned. The term alone does not mean that the complaints do not exist.
„Die Beschwerden sind nicht objektivierbar.“: In plain words: The examination methods used could not establish a corresponding measurable or detectable finding for the complaints described. This does not automatically mean that there are no complaints.
„Die Beschwerden sind glaubhaft geschildert.“: In plain words: The examining person considers the description of the complaints comprehensible.
„Die Beschwerden lassen sich durch die Befunde nur teilweise erklären.“: In plain words: In the examining person's view, the medical findings do not fully explain all the complaints described.
„Die Befunde korrelieren mit den angegebenen Beschwerden.“: In plain words: From a medical point of view, the findings match the complaints described.
„Es besteht eine Diskrepanz zwischen Befund und Beschwerdeangaben.“: In plain words: In the examining person's view, the findings and the complaints described do not fully match.
„Die Angaben sind plausibel.“: In plain words: The statements appear comprehensible to the examining person.
„Die Angaben sind konsistent.“: In plain words: In the assessing person's view, different statements, observations and findings largely fit together.
„Die Symptomatik ist chronifiziert.“: In plain words: The complaints have existed for some time and have developed into a long-lasting illness.
„Die Beschwerden bestehen seit …“: In plain words: The complaints have been described or documented since the date stated.
„Der Befund ist unverändert.“: In plain words: Compared with an earlier examination, no significant change was found.
„Es zeigt sich eine Verschlechterung.“: In plain words: Complaints or findings have developed unfavourably compared with before.
„Es zeigt sich eine Besserung.“: In plain words: Complaints or findings have developed favourably compared with before.
„Es besteht weiterer Behandlungsbedarf.“: In plain words: From a medical point of view, further treatment is considered necessary.
„Eine weitere fachärztliche Abklärung wird empfohlen.“: In plain words: The treating or examining person recommends having the complaints or findings examined by a relevant specialist.
„Eine stationäre Behandlung wird empfohlen.“: In plain words: From a professional point of view, treatment in a clinic or another inpatient facility is recommended.
„Die Erkrankung ist derzeit nicht ausreichend stabil.“: In plain words: The state of health is currently still considered too unstable or impaired.
„Das Leistungsvermögen ist eingeschränkt.“: In plain words: From a medical or social medicine point of view, certain activities or demands can no longer be carried out without restriction.
„Die Leistungsfähigkeit ist aufgehoben.“: In plain words: In the area described, sufficient capacity is currently no longer seen.
„Die Leistungsfähigkeit ist teilweise erhalten.“: In plain words: Certain activities or demands are still possible, others are limited.
„Leichte Tätigkeiten sind möglich.“: In plain words: The assessing person considers certain physically less demanding activities possible in principle. Which additional limitations apply should be clear from the full capacity profile.
„Eine Tätigkeit ist sechs Stunden und mehr möglich.“: In plain words: In the social medicine assessment system concerned, it is estimated that the activity described is possible for at least six hours a day under the conditions stated.
„Das quantitative Leistungsvermögen beträgt …“: In plain words: This estimates how many hours a day an activity is possible from a health point of view.
„Qualitative Leistungseinschränkungen bestehen hinsichtlich …“: In plain words: Certain kinds of activities, demands or working conditions are limited from a health point of view.
„Es bestehen erhebliche qualitative Leistungseinschränkungen.“: In plain words: There are several or significant health limitations regarding the kind of activities or demands.
„Das positive Leistungsvermögen umfasst …“: In plain words: This describes which activities and demands are still possible from a health point of view.
„Das negative Leistungsvermögen umfasst …“: In plain words: This describes which activities or demands should be avoided or are no longer possible from a health point of view.
„Das Restleistungsvermögen beträgt …“: In plain words: This describes to what extent capacity still exists from a social medicine point of view.
„Eine Tätigkeit unter Zeitdruck ist nicht zumutbar.“: In plain words: Activities with heavy or constant time pressure are not recommended or not considered reasonable from a health point of view.
„Nachtschicht ist nicht zumutbar.“: In plain words: From a health point of view, there should be no night shift work.
„Publikumsverkehr ist nur eingeschränkt möglich.“: In plain words: Activities with regular contact with many people are considered possible only to a limited extent.
„Die Wegefähigkeit ist erhalten.“: In plain words: The assessing person considers the distances required in the relevant context manageable in principle.
„Die Prognose ist günstig.“: In plain words: The professional assessment assumes that an improvement or a favourable course seems possible or likely. A prognosis is not a guarantee.
„Die Prognose ist ungünstig.“: In plain words: The professional assessment expects a favourable development to be unlikely, or only limited possibilities for improvement.
„Die Prognose ist ungewiss.“: In plain words: It is currently not possible to reliably estimate how the illness or limitation will develop.
„Eine wesentliche Besserung ist nicht zu erwarten.“: In plain words: The assessing person does not currently expect a clear improvement in health.
„Eine Rehabilitationsbedürftigkeit besteht.“: In plain words: From a social medicine point of view, rehabilitation is considered necessary.
„Eine Rehabilitationsfähigkeit besteht.“: In plain words: From a medical point of view, the person is considered resilient enough in principle to take part in a suitable rehabilitation measure.
„Es besteht keine ausreichende Rehabilitationsprognose.“: In plain words: The assessing body does not currently expect, with sufficient probability, that the intended rehabilitation goals can be achieved.
„Aus gutachterlicher Sicht …“: In plain words: What follows is the professional evaluation of the assessing person.
„Die erhobenen Befunde sprechen für …“: In plain words: From a professional point of view, the examination results support the assessment or diagnosis named.
„Die erhobenen Befunde sprechen gegen …“: In plain words: From a professional point of view, the examination results tend not to fit the assessment or diagnosis named.
„Ein kausaler Zusammenhang ist nicht hinreichend wahrscheinlich.“: In plain words: The assessing person does not consider the necessary connection between the event and the health disorder sufficiently established by the standard that applies to the procedure.
„Ein Zusammenhang kann nicht ausgeschlossen werden.“: In plain words: A connection is possible, but this sentence alone does not assess it as proven or sufficiently likely.
„Der Zusammenhang ist wahrscheinlich.“: In plain words: From a professional point of view, there are more reasons for than against the assumed connection – what this means legally depends on the procedure.
„Der Zusammenhang ist nicht feststellbar.“: In plain words: On the basis of the available information, no sufficiently certain statement can be made about a connection.
„Ein Vollbeweis kann nicht geführt werden.“: In plain words: In the view of the assessing or deciding body, the fact to be proven cannot be established with the standard of proof required for it.

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