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["村上記念病院　医療福祉相談室　宛て"]
[null,"□診療情報提供書　□薬剤情報と併せて　※直通FAX（０８９７）５６－２３３７　　へ送信してください"]
[null,"いただきました情報をもとに、入院判定会を行います"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"転院申込患者情報"]
[]
["紹介元医療機関",null,null,null,null,null,null,null,null,null,null,"病院",null,null,null,null,"科",null,"主治医",null,null,null,null,null,null,null,null,"先生"]
[]
["相談担当者　　　　　　　　　　　　様　　TEL　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,"様　TEL ",null,null,null,null,null,null,null,null,null,"貴院の転院希望日",null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"マクロを有効にすると\n選択項目はクリックで○がつきます。"]
["ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,"M･T･S･H",null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年齢",null,null,null,null,null,null,null,null,null,"歳"]
["住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL"]
["ｷｰﾊﾟｰｿﾝ",null,null,null,null,null,"　氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,null,null,null,null,null,null,null,"TEL"]
["病名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症・受傷・手術年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"身長：",null,null,null,null,null,"ｃｍ"]
["既往歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"体重：",null,null,null,null,null,"ｋｇ"]
["感染症",null,null,null,null,null,"　無",null,"・","HBV（ ",null,"+  ・ － ）",null,null,"HCV（ ",null,"+  ・ － ）",null,null,"MRSA（ ",null,null,"＋　部位",null,null,null,null,null,null,null,"－ ）  その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["現在の状態（該当のところに○印をしてください）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"経過・備考"]
["　寝返り",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"何かにつか\nまればできる",null,null,null,null,"できない",null,null,null,null,"\n※配慮が必要な事項がございましたら、記入ください"]
["　起き上がり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"できない"]
["　座位保持",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"支えがあれば\nできる",null,null,null,null,"できない"]
["　移乗",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"見守り・\n一部介助",null,null,null,null,"できない"]
["　移動方法",null,null,null,"　（ 独歩 ",null,null,"・ 杖 ・ ",null,"歩行器 ・ ",null,null,"車椅子 ・ ",null,null,"ﾘｸﾗｲﾆﾝｸﾞ車椅子　）",null,null,null,null,null,null,null,null,null,"介助なし",null,null,null,null,null,"見守り",null,null,null,null,"要介助\n（搬送を含む）"]
["　口腔清潔　",null,null,null,null,null,null,null,null,null,null,null,null,"◆義歯",null,null,"（ 有 ・ 無 ）　",null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"できない"]
["　食事摂取",null,null,null,null,"◆摂取量（主食：",null,null,null,null,null,null,null,"割、副食：",null,null,null,null,null,"割  /  ",null,"経管栄養）",null,null,null,"介助なし",null,null,null,null,null,"一部介助",null,null,null,null,"全介助"]
["　衣服の着脱",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介助なし",null,null,null,null,null,"一部介助",null,null,null,null,"全介助"]
["　他者への意思の伝達",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"できる",null,null,null,null,null,"できる時と\nできない時がある",null,null,null,null,"できない"]
["　診療・療養上の指示が通じる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,"いいえ"]
["　危険行動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ない",null,null,null,null,null,"ある"]
["排尿",null,null,null,null,null,"　ﾄｲﾚ ",null,"・ ｵﾑﾂ",null," ・ ｶﾃｰﾃﾙ",null,null,"・ 導尿",null," ・ 人工膀胱　",null,null,null,"【尿意】",null,null,"有　・　無",null,null,"排便",null,null,null,null,null,"　ﾄｲﾚ ",null,"・ ｵﾑﾂ",null,"・ 人工肛門",null,null,null,null,"　 　【便意】  ",null,null,null,"有　・　無"]
["褥瘡",null,null,null,null,null,"　有　",null,"（部位",null,null,null,null,null,null,null,null,null,null,null,null,"：　程度",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）　・　",null,"無"]
["意識状態",null,null,null,null,null,"　明瞭 ・",null,null,"不明瞭",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"リハビリ",null,null,null,null,null,"　PT ",null,"・ OT",null,"・  ST",null,"・  無"]
["夜間の様子",null,null,null,null,null,"　良眠 ・ ",null,null,"不眠傾向 ・",null,null,null,"眠剤服用 ・ ",null,null,null,"大声を出す ",null,null,null,"・ いびき ",null,null,"・ 徘徊 ・",null,null,"他","（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["認知症",null,null,null,null,null,"  有　・　無",null,null,null,null,null,null,null,"*HDS-R",null,null,null,null,null,null,"/30点",null,null,null,"身体抑制",null,null,null,null,null," 有（",null,"ｾﾝｻｰﾏｯﾄ・ ",null,null,"抑制着 ",null,"・ 車椅子ﾍﾞﾙﾄ ",null,null,null,"・4点柵 ・ ",null,null,null,null,"） / 無",null,null,"必要があれば○を移動させて使って下さい。"]
["発熱",null,null,null,null,null,"  有（原因",null,null,null,null,null,null,null,null,null,null,null,"） ・ 無",null,null,null,null,null,null,"難聴",null,null,null,null,null," 有　・　無",null,null,null,null,null,null,"◆補聴器",null,null,null,"有","（右　・　左）",null,null,null,"/ 無"]
["装着・使用\n医療機器",null,null,null,null,null,"　酸素吸入（　　　　　",null,null,null,null,null,null,null,"ℓ/分）　",null,"・　気管カニューレ　",null,null,null,null,null,"・　ミニトラック　",null,null,null,null,"・　人工呼吸器（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,"　吸引器（頻度",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）・中心静脈栄養",null,null,null,null,null,"・末梢・",null,null,"ｴｱﾏｯﾄ・",null,null,"その他（ ",null,null,"                                    ",null,null,null,null,null,null,null,null,null,null,null," )"]
["希望の病室",null,null,null,null,null,"　個室  ",null,null,"・  ２人部屋  ",null,null,null,"・  ４人部屋",null,null,null,null,null,null,null,null,null,null,null,"リハビリ後の\n退院希望先",null,null,null,null,null,"　自宅　・　",null,null,"家族宅・",null,null,"施設・",null,"　病院　・（",null,null,null,null,null,null,null,null," )"]
["経済的問題",null,null,null,null,null,"　無　・　有",null,null,null,"（健康保険がない/医療費支払い等に不安がある）"]
["その他\n特記事項"]
[]
["保険情報",null,null,null,null,null,"　保険者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　記号番号",null,null,null,null,null,null,null,null,null,null,null,null,"本人　・　家族",null,null,null,null,null,"負担",null,null,null,null,null,"割"]
[null,null,null,null,null,null,"　公費等　負担者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　受給者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　限度額認定"]
[null,null,null,null,null,null,"　生保　・　労災　・　自賠責（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　）"]
[null,null,null,null,null,null,"　介護保険　",null,null,null,null,"(","自立",null,null,"要支援",null,null,"１　・　",null,2,null,"要介護",null,null,"１　・",null,"２　・",null,"３　・",null,"４　・　",null,"５ ",null,"申請中",null,null,null,"不明",null,null,"認定無 ）"]