Care documentation in Germany is not a description of what happened. It is a structured assessment that has to justify every measure taken, and since 2019 it has followed one national format: the Strukturierte Informationssammlung, or SIS. Every provider working under the framework agreement set out in section 75 of the eleventh social code uses it.
For a newcomer, the SIS is also the most useful language exercise in the sector. Learn to write it and you have learned the vocabulary of the whole job, because the form forces you to name exactly what a person can and cannot do without help.
Why the Old Format Changed
Before the SIS, every provider used its own care planning form, and the result was a folder of documents that were rarely read. The reform replaced them with a single structure that starts with the person rather than with the diagnosis.
| Older documentation | SIS equivalent |
|---|---|
| Pflegeplanung built on standard problems | Themenfeld one to six |
| Catalogue care plans | An individual assessment in your own words |
| Measures listed per activity | Maßnahmenplanung after each field |
| Risk forms kept separately | Risikomatrix attached to the assessment |
The decisive change of principle is that the assessment comes first and the measures follow from it, rather than a template being adapted to a person.
The Six Themenfelder
The form has six fields, always in the same order, and each one is answered in prose before any measure is written.
| Field | German name |
|---|---|
| 1 | Kommunikation und kognitive Fähigkeiten |
| 2 | Mobilität und Bewegungsfähigkeit |
| 3 | Krankheitsbezogene Anforderungen und Belastungen |
| 4 | Selbstversorgung |
| 5 | Leben in sozialen Beziehungen |
| 6 | Wohnen und Häuslichkeit |
Each field has room for the person's own statement, your assessment as the nurse, and the resulting measures. The form is deliberately long, because a short answer is treated as an unanswered one.
Writing the Assessment, Not the Diagnosis
The style expected in a SIS entry is specific, personal and in the third person. A diagnosis is not an assessment.
| Weak entry | Strong entry |
|---|---|
| "Patient ist mobil" | "Frau K. geht mit dem Rollator kurze Strecken selbstständig." |
| "isst schlecht" | "Herr B. isst etwa die Hälfte der Portion und lehnt Fleisch ab." |
| "ist verwirrt" | "Frau S. weiß abends nicht, wo sie sich befindet." |
| "braucht Hilfe" | "Beim Anziehen übernimmt Herr M. die Oberkörperpflege selbst." |
The pattern is always the same: how much, with which aid, and whether the person does it themselves. Rehearsing those three parts out loud is a better way to learn German for documentation work than reading a word list.
The Risikomatrix
Attached to the assessment is a risk matrix listing the standard risks. Each one is marked as present or absent, and any risk that is present requires a measure.
| German term | English meaning |
|---|---|
| die Risikomatrix | risk matrix |
| die Sturzgefahr | risk of falling |
| das Dekubitusrisiko | pressure-sore risk |
| der Ernährungszustand | nutritional state |
| die Inkontinenz | incontinence |
| die Wundversorgung | wound care |
| der Schmerz | pain |
| die freiheitsentziehende Maßnahme | restraint |
That last item is the one with legal weight. A freiheitsentziehende Maßnahme such as a bed rail requires informed consent or a court order, and it must be documented as such, with the reason and the review date.
Handover and Evaluation
The SIS is evaluated on a fixed cycle, and the date of the next evaluation is part of the record. Die Evaluation is the review and die Aktualisierung the update when something changes.
The spoken handover compresses the same material into a few sentences: what changed, which risk has risen, which measure is new. Learning to turn a written assessment into that summary is the skill that makes a shift handover work. If you want to learn German for a care role, the SIS form is a better course text than most textbooks, because every sentence you can write on it is a sentence you will use on the floor.
The Evaluation Cycle
| German term | English meaning |
|---|---|
| die Evaluation | the scheduled review |
| die Aktualisierung | the update after a change |
| die Pflegevisite | the record review with a supervisor |
| die Fallbesprechung | the case discussion |
| die Bezugspflege | named-nurse case responsibility |
| die Qualitätssicherung | quality assurance |
The review is not a formality. If the assessment no longer matches the person, every measure built on it is wrong, and an inspector reading the file will say so in plain German.
Most providers run a Pflegevisite, in which a supervisor reads a sample of records in the presence of the nurse who wrote them. Being able to explain your own entry out loud and without notes is the standard the sector works to.
Six Sentences Worth Getting Right
| Purpose | German sentence |
|---|---|
| documenting a change | "Der Zustand hat sich seit gestern verschlechtert." |
| recording a refusal | "Frau K. lehnt die Körperpflege heute ab." |
| recording an action | "Herr B. wurde um 14 Uhr umgelagert." |
| recording a measurement | "Blutdruck 130 zu 80, Puls 72." |
| recording a handover | "Übergabe an den Spätdienst erfolgt." |
| recording a risk | "Sturzgefahr besteht weiterhin." |
German documentation avoids adjectives and prefers numbers, times and completed actions. "Frau K. lehnt die Körperpflege heute ab" is a complete and defensible entry, while "Frau K. ist schwierig" is neither, and it is the sentence that gets a file criticised.
Practising that conversion from a vague observation to a specific one is the whole job, and it is the exercise a provider is most likely to set at interview.
The bars show the order in which the six fields are completed, not a score; each field is assessed in prose.
Where This Gets You Hired
Documentation is the part of German care where foreign-trained staff are most often held back, and it is also the easiest skill to demonstrate in an interview. Providers routinely set a short written exercise alongside the conversation.
A candidate who can turn "Herr M. isst schlecht" into a specific, measurable sentence is a candidate who can carry a Bezugspflege case load. Practising that transformation, in German, is a better use of an hour than memorising further vocabulary lists.
The SIS is the language of German care work. Learn German with the six Themenfelder and the Maßnahmenplanung built into the course.
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