The PTV 3 report: structure and sections

As of October 2026 · about 6 minutes to read

Anyone who applies for long-term therapy under statutory health insurance usually writes a report to the Gutachter, the independent expert reviewer who assesses the application on behalf of the insurer. The structure follows the guidance notes to the PTV 3 form, the official report form under the German psychotherapy agreement. This article explains the structure and what matters in each section.

When a report is required

Since the structural reform of outpatient psychotherapy in April 2017, short-term therapy (Kurzzeittherapie, KZT) is divided into two blocks of up to twelve sessions each and is in principle possible without an expert review. For long-term therapy (Langzeittherapie, LZT), by contrast, the Psychotherapie-Richtlinie provides for the Gutachter procedure as the rule. A report is therefore typically written in three situations:

• Initial report (Erstbericht) – when you apply for long-term therapy directly after the probatory sessions (Probatorik);
• Conversion report (Umwandlungsbericht) – when ongoing short-term therapy is to be converted into long-term therapy;
• Continuation report (Fortführungsbericht) – when approved long-term therapy is to be extended beyond its quota.

The report goes to the Gutachter in pseudonymised form: instead of the name, it carries a Chiffre (case code) made up of the first letter of the family name and the six-digit date of birth. It is forwarded via the health insurer in a sealed envelope (PTV 8).

The six sections at a glance

The guidance notes divide the initial report into six sections. The same structure applies to a conversion, supplemented by the course of the short-term therapy so far. The continuation report has its own, shorter structure that builds on the initial report.

1. Relevant sociodemographic data

Age, living situation, occupation and work situation – but only as far as they matter for understanding the illness and the treatment. A short paragraph is usually enough. Avoid identifying details such as employer or place of residence.

2. Symptoms and mental state findings

Here you describe the complaints the patient presents with and the mental state findings at the time of the examination. It helps to keep the two apart: first the subjective picture in the person’s own words, then the findings in professional language. Test results, for example total scores on standardised questionnaires, belong here with date and instrument. A value without a date cannot later be shown as a course over time.

3. Somatic findings and consultation report

Before psychotherapy begins, a physician must examine whether physical causes contribute to the symptoms; the result is documented in the consultation report (Konsiliarbericht). In the report you summarise its result and name relevant medication.

4. Life history, history of the illness and disorder model

The most extensive part. It contains the treatment-relevant information on life history and on the history of the illness, and – depending on the approach – the functional analysis (Bedingungsmodell, behavioural therapy) or the psychodynamic hypothesis (psychodynamic and analytical psychotherapy). Gutachter look at whether symptoms, biography and model fit together coherently. A life history that merely lists events without relating them to the disorder model is a common weakness.

In a conversion, the course so far also belongs here: what was worked on in the short-term therapy, what changes occurred, where limitations persist? Concrete, dated observations carry more weight than general assessments.

5. Diagnosis at the time of application

The diagnosis according to ICD-10-GM (the German modification of the ICD-10) with the degree of diagnostic certainty. It should follow comprehensibly from sections 2 and 4. If the diagnosis has changed since the start of treatment, explain this briefly.

6. Treatment plan and prognosis

Therapy goals, planned methods, frequency and the number of sessions applied for, and a reasoned prognosis. Goals are easiest to check when they are concrete and observable (“a contribution in the team meeting twice a week” rather than “more self-confidence”). The prognosis is your professional assessment; it should rest on factors that appear in the report, such as motivation, changes so far or a chronic course.

Language and length

The report is addressed to an expert reader who knows the case only from this text. Technical terms are therefore appropriate, but abbreviations should be introduced. Write in the past tense when describing the history and the course so far, and in the present tense when describing the current findings. Indirect speech (“she reported that she avoids …”) makes clear what is the patient’s statement and what is your own observation.

Brevity is a strength. Gutachter read many reports; a report that presents the essentials in a clear order is easier to review than one that reproduces every detail of the probatory sessions. Check the current guidance notes for any length requirements.

Common weaknesses

• Claims without evidence: “The distress has decreased significantly” – what shows this? A measured value or a concrete observation from a session makes the statement verifiable.
• Contradictions between sections: The symptoms in section 2 do not fit the diagnosis in section 5, or the goals take up problems that were not described before.
• Too much biography, too little model: Life events without a connection to the current disorder.
• Unspecific goals: Goals that cannot be checked also make the later continuation report harder.
• Boilerplate: Wording that would fit any case says little about this one.

Keeping statements traceable

A good report does not start at the desk on the weekend before the deadline; it starts with your ongoing documentation. Three habits help:

1. Document with dates. Every session note with a date, every questionnaire with the time of assessment. This lets you show a course instead of asserting it.
2. Record verbatim statements. Key sentences from the patient (“Everyone notices that I blush”) make cognitions and fears vivid.
3. Separate observation from evaluation. First note what happened (exposure carried out, tension from 70 to 35), then your assessment.

If you document this way, you can point to the place in the file behind every sentence as you write. This is exactly the principle the Application Copilot (German: Antrags-Copilot) implements technically: it arranges your own records into the structure of the PTV 3, shows the source on every sentence and flags sentences without a source as “Not sourced” (German: “Nicht belegt”). You write and take responsibility for the report yourself. Our sample report on a fictional case shows what this looks like.

In brief

• The PTV 3 report has six sections: sociodemographics, symptoms and findings, somatic findings, life history with disorder model, diagnosis, treatment plan with prognosis.
• In a conversion, the course of the short-term therapy is added.
• Coherence between the sections counts for more than length.
• Dated, concrete documentation makes statements verifiable.