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["事業所　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
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["医療機関　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,"        御中",null,null,"（記入日）   令和　　　　年　　　月　　　日　"]
[]
["在宅での生活状況及び介護状況について、下記のとおりご連絡いたします。"]
["入院時のケアやリハビリテーション、退院調整に利用していただければ幸いです。今後の退院に向け、情報協力やご指導等頂けると助かります。"]
["よろしくお願いいたします。なお情報については、本人及びご家族の同意に基づき作成されています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有","知的"]
["フリガナ",null,null,null,null,null,null,"男","生年",null," M・T・S・H　 　　　　             年　　　　月　　　   日",null,null,null,null,"　　　　　歳",null,null,null,"無","精神"]
["対象者",null,null,null,null,null,null,"女","月日",null,null,null,null,null,null,null,null,null,null,null,"身体"]
["住　所",null,null,null,null,null,null,null,null,null,"自宅電話"]
["緊急",null,null,"1.氏名　　　　　　　　　　　　　　　　　  　　　　　（続柄　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,"電話"]
["連絡先",null,null,"2.氏名　　　　　　　　　　　　　　　　　　　      　（続柄　　　　　　　　　　　　　　　     　）",null,null,null,null,null,null,"電話"]
["介護度",null,null,"申請中　・　要支援（　　）　・　要介護（　　）",null,null,null,"障害手帳　　 ",null,null,null,null,"内服薬"]
["有効期間",null,null," R.　　年　　　月　　　日　～　　　年　　　月　　　日",null,null,null,"生活保護　（受給）　　　",null,null,null,null,"管理方法",null,null,null,null,null,null,null,null,null,"薬情書の添付"]
["既","年・月・日",null,null,null,"病　　名",null,"　　　病　院　名　　　　　（担当医）",null,null,null,null,"　〈家系図〉",null,null,null,null,null,null,null,null,null,"お薬手帳の写し"]
["往",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"添付"]
["症"]
["・"]
["現"]
["病"]
["歴"]
["更衣",null,null,null,null,"　　 　（　　　　　　　　　　　　　　　　）",null,"入院に至る経緯："]
["移動",null,null,null,null,"　（　杖　・歩行器　・車イス　　）"]
["排泄",null,null,null,"　　　　（　　杖　・歩行器　・車イス　　）　　　　　","　　   （ポータブルトイレ　・　紙パンツ）",null,null,null,null,null,null,"　キーパーソン：",null,null,null,null,null,null,"自立",null,null,"自立"]
["入浴",null,null,null,"　　　　（　　杖　・歩行器　・車イス　　）　　　　　　　　　）","　　　（　自宅　・デイ　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,"見守り",null,null,"本人へ手渡し"]
["最終排便日：　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"一部介助",null,null,"お薬カレンダー"]
["最終入浴日：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"全介助",null,null,"その他"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自歯",null,null,"普通"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総義歯",null,"普通","粗キザミ","要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"部分義歯",null,"軟飯","キザミ","不要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"上義歯",null,"全粥","ミキサー"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下義歯",null,"ミキサー","ソフト食"]
["利用中の",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゼリー食"]
["サービス"]
["食事",null,null,"（主食）　",null,null,null,"水分（粘度：　　　）",null,"アレルギー　無",null,null,"歯の状態",null,null,"　　（　　　　　）"]
["形態",null,null,"（副食）　 　",null,null,null,"（とろみ　要・不要）",null,"有（　　　　　　　　　　　　）",null,null,"かかりつけ歯科医",null,null,null,null,null,null,null,null,"被害妄想"]
[null,null,null,"　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"感情不安定"]
["意思",null,null,"視力","支障　無　・　有（　　　　　　　　　）",null,null,"意思伝達",null,"出来る・出来ない（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,"昼夜逆転"]
["疎通",null,null,"聴力","支障　無　・　有（　　　　　　　　　）",null,null,"指示への反応",null,null,null,null,null,null,null,null,null,null,null,null,null,"暴言、暴行"]
["認知面",null,null,"無　・　有",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"徘徊"]
["退院後の希望（本人・家族）",null,null,null,null,null,"eひたカード：　登録済",null,null,null,"私の想いカード　：　　有　・　無　",null,null,null,null,null,null,null,null,null,null,"幻視"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他"]
[]
[]
[]
[]
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["※お願い　退院時期が決まり次第、ご連絡をくだされば幸いです。"]

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["事業所　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
[]
[]
[]
["医療機関　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,"        御中",null,null,"（記入日）   令和　　　　年　　　月　　　日　"]
[]
["在宅での生活状況及び介護状況について、下記のとおりご連絡いたします。"]
["入院時のケアやリハビリテーション、退院調整に利用していただければ幸いです。今後の退院に向け、情報協力やご指導等頂けると助かります。"]
["よろしくお願いいたします。なお情報については、本人及びご家族の同意に基づき作成されています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有","知的"]
["フリガナ",null,null,null,null,null,null,"男","生年",null," M・T・S・H　 　　　　             年　　　　月　　　   日",null,null,null,null,"　　　　　歳",null,null,null,"無","精神"]
["対象者",null,null,null,null,null,null,"女","月日",null,null,null,null,null,null,null,null,null,null,null,"身体"]
["住　所",null,null,null,null,null,null,null,null,null,"自宅電話"]
["緊急",null,null,"1.氏名　　　　　　　　　　　　　　　　　  　　　　　（続柄　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,"電話"]
["連絡先",null,null,"2.氏名　　　　　　　　　　　　　　　　　　　      　（続柄　　　　　　　　　　　　　　　     　）",null,null,null,null,null,null,"電話"]
["介護度",null,null,"申請中　・　要支援（　　）　・　要介護（　　）",null,null,null,"障害手帳　　 ",null,null,null,null,"内服薬"]
["有効期間",null,null," R.　　年　　　月　　　日　～　　　年　　　月　　　日",null,null,null,"生活保護　（受給）　　　",null,null,null,null,"管理方法",null,null,null,null,null,null,null,null,null,"薬情書の添付"]
["既","年・月・日",null,null,null,"病　　名",null,"　　　病　院　名　　　　　（担当医）",null,null,null,null,"　〈家系図〉",null,null,null,null,null,null,null,null,null,"お薬手帳の写し"]
["往",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"添付"]
["症"]
["・"]
["現"]
["病"]
["歴"]
["更衣",null,null,null,null,"　　 　（　　　　　　　　　　　　　　　　）",null,"入院に至る経緯："]
["移動",null,null,null,null,"　（　杖　・歩行器　・車イス　　）"]
["排泄",null,null,null,"　　　　（　　杖　・歩行器　・車イス　　）　　　　　","　　   （ポータブルトイレ　・　紙パンツ）",null,null,null,null,null,null,"　キーパーソン：",null,null,null,null,null,null,"自立",null,null,"自立"]
["入浴",null,null,null,"　　　　（　　杖　・歩行器　・車イス　　）　　　　　　　　　）","　　　（　自宅　・デイ　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,"見守り",null,null,"本人へ手渡し"]
["最終排便日：　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"一部介助",null,null,"お薬カレンダー"]
["最終入浴日：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"全介助",null,null,"その他"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自歯",null,null,"普通"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総義歯",null,"普通","粗キザミ","要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"部分義歯",null,"軟飯","キザミ","不要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"上義歯",null,"全粥","ミキサー"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下義歯",null,"ミキサー","ソフト食"]
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["サービス"]
["食事",null,null,"（主食）　",null,null,null,"水分（粘度：　　　）",null,"アレルギー　無",null,null,"歯の状態",null,null,"　　（　　　　　）"]
["形態",null,null,"（副食）　 　",null,null,null,"（とろみ　要・不要）",null,"有（　　　　　　　　　　　　）",null,null,"かかりつけ歯科医",null,null,null,null,null,null,null,null,"被害妄想"]
[null,null,null,"　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"感情不安定"]
["意思",null,null,"視力","支障　無　・　有（　　　　　　　　　）",null,null,"意思伝達",null,"出来る・出来ない（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,"昼夜逆転"]
["疎通",null,null,"聴力","支障　無　・　有（　　　　　　　　　）",null,null,"指示への反応",null,null,null,null,null,null,null,null,null,null,null,null,null,"暴言、暴行"]
["認知面",null,null,"無　・　有",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"徘徊"]
["退院後の希望（本人・家族）",null,null,null,null,null,"eひたカード：　登録済",null,null,null,"私の想いカード　：　　有　・　無　",null,null,null,null,null,null,null,null,null,null,"幻視"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他"]
[]
[]
[]
[]
[]
["※お願い　退院時期が決まり次第、ご連絡をくだされば幸いです。"]