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["入退院共通連携シート(医療機関→在宅・施設）",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,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様式２－②"]
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["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,null,null,null,null,null,null,null,null,null,null,null,null,"性別",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,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,"年齢"]
["入院期間",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,null,null,null,null,null,null,null,null,"介護保険",null,null,null,null,null,null,null,null,null,"　　　　"]
["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,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,"要支援",null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,"要介護"]
[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,null,null,null,null,null,null,null,null,null,null,"身長",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"cm",null,null,null,null,null,null,null,null,null,null,"体重",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"kg"]
["入院中の経過"]
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["家族構成",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,"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,"(本人)病気の捉え方と在宅療養に関する意向"]
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[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,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,"コミュニケーション：",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,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,null,null,null,null,null,null,null,null,null,null,null,"ツール：",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,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,"(家族)病気の捉え方と在宅療養に関する意向"]
[]
[]
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["キーパーソン："]
["連絡先：",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,"感染症：",null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　　　　　　　　）"]
["入院中の状況",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"在宅療養上の留意事項"]
["栄養",null,null,null,null,null,null,null,null,"食事",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,null,null,null,null,null,null,null,null,null,null,null,"食事内容：",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,"食形態",null,null,null,null,null,"主食：",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,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,"Kcal",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"g"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"副食：",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,null,null,null,null,null,"禁止食品："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"とろみ：",null,null,null,null,null,null,null,"　　",null,null,null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,"方法",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,null,null,null,null,null,null,null,null,null,null,null,"経管栄養の内容等："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"嚥下：",null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"咀嚼：",null,null,null,null,null,null,"　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 栄養状態："]
["排泄",null,null,null,null,null,null,null,null,"排尿",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,null,null,null,null,null,null,null,null,null,null,null,"カテーテル：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,"導尿：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"時間毎"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"サイズ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｆｒ",null,null,null,null,"最終交換日："]
[null,null,null,null,null,null,null,null,null,"排便",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,null,null,null,null,null,null,null,null,null,null,null,"排便状況：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回/１日",null,null,null,null,null,null,"排便コントロール：",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,"失禁",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,null,null,null,null,null,null,null,null,null,null,null," 便秘薬使用状況："]
[null,null,null,null,null,null,null,null,null,"方法",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,null,null,null,null,null,null,null,null,null,null,null,"オムツ・リハビリパンツ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　"]
["入浴",null,null,null,null,null,null,null,null,"清潔",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,null,null,null,null,null,null,null,null,null,null,null," 入浴の制限：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　"]
[null,null,null,null,null,null,null,null,null,"方法",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,null,null,null,null,null,null,null,null,null,null,null,"体温：（",null,null,null,null,null,null,null,null,null,null,null,"度）以上中止",null,null,null,null,null,null,null,null,null,null,null,null,null,"血圧：（",null,null,null,null,null,null,null,null,null,null,null,null,"mmHg）以上中止"]
["移動",null,null,null,null,null,null,null,null,"方法",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,null,null,null,null,null,null,null,null,null,null,null,"リハビリの内容："]
[null,null,null,null,null,null,null,null,null,"歩行",null,null,null,null,null,"　　　　",null,null,null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,"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,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,"運動制限：",null,null,null,null,null,null,null,null,null,"　　   ",null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
["夜間の\n状態",null,null,null,null,null,null,null,null,"不眠",null,null,null,null,null,"　　　",null,null,null,null,null,null,null,"（状態：　　　　　　　　　　　　　　　　　　　　　　　　　）",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," 不眠時対応："]
[null,null,null,null,null,null,null,null,null,"睡眠薬",null,null,null,null,null,"　　　",null,null,null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
["認知\n精神面\n＊",null,null,null,null,null,null,null,null,"認知症高齢者の日常生活自立度：",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,null,null,null,null,null,null,null,null,null,null,null,"認知症状：",null,null,null,null,null,null,null,null,null,"□",null,null,null,"記憶障害",null,null,null,null,null,null,null,null,null,"□",null,null,null,null,"幻覚/妄想",null,null,null,null,null,null,null,null,null,"□",null,null,null,"昼夜逆転"]
[null,null,null,null,null,null,null,null,null,"障害高齢者の日常生活自立度：",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□",null,null,null,"介護への抵抗",null,null,null,null,null,null,null,null,null,null,null,null,null,"□",null,null,null,null,"暴言/暴力",null,null,null,null,null,null,null,null,null,"□",null,null,null,"不潔行為"]
[null,null,null,null,null,null,null,null,null,"精神状態（疾患）：",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□",null,null,null,null,"徘 徊",null,null,null,null,null,null,null,null,"□",null,null,null,"その他（　　　　　　　　　　　　　　　　　　）"]
["褥瘡\n＊",null,null,null,null,null,null,null,null,"部位",null,null,null,null,null,null,null,"d",null,null,null,null,null,null,null,"e",null,null,null,null,null,null,null,"s",null,null,null,null,null,null,null,"i",null,null,null,null,null,null,null,"g",null,null,null,null,null,null,"n",null,null,null,null,null,null,null,"p",null,null,null,null,null,null,"体圧分散マット：",null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　",null,null,null,null,null,"マットの種類："]
[null,null,null,null,null,null,null,null,null,"部位",null,null,null,null,null,null,null,"d",null,null,null,null,null,null,null,"e",null,null,null,null,null,null,null,"s",null,null,null,null,null,null,null,"i",null,null,null,null,null,null,null,"g",null,null,null,null,null,null,"n",null,null,null,null,null,null,null,"p",null,null,null,null,null,null,"体位変換：",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,"）時間毎"]
[null,null,null,null,null,null,null,null,null,"部位",null,null,null,null,null,null,null,"d",null,null,null,null,null,null,null,"e",null,null,null,null,null,null,null,"s",null,null,null,null,null,null,null,"i",null,null,null,null,null,null,null,"g",null,null,null,null,null,null,"n",null,null,null,null,null,null,null,"p",null,null,null,null,null,null,"リスク等："]
["口腔清潔",null,null,null,null,null,null,null,null,"　  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"義歯：",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,"口腔の問題：",null,null,null,null,null,null,null,null,null,null,null,"　　　　　　",null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　　　　）"]
["服薬",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院後必要な福祉用具"]
[null,null,null,null,null,null,null,null,null,"服薬の問題：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
["医療的\n処置",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,"インスリン注射（自己注射：",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,"回数：",null,null,null,null,null,null,null,null,null,null,null,"回）",null,null,null,null,null,null,null,"□",null,null,null,"在宅酸素",null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,"□",null,null,null,"非侵襲的人工呼吸器",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（使用状況：",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,"中心静脈栄養",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□",null,null,null,"疼痛管理"]
[null,null,null,null,null,null,null,null,null,null,"□",null,null,null,"喀痰吸引",null,null,null,null,null,null,null,null,null,"（回数：",null,null,null,null,null,null,null,null,null,null,null,null,"回）",null,null,null,null,null,"□",null,null,null,"気管切開カニューレ挿入",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,"人工肛門",null,null,null,null,null,null,null,null,null,null,null,null,"□",null,null,null,"その他（　　　　　　　　　　　　）"]
["その他"]
[]
[]
[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,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,"＊　別紙判定基準参照"]
[]
["「入退院共通連携シート」の目的を説明し、情報提供について",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,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,"に同意を得ました。"]
[]
["情報提供元の医療機関名："]
["所　属："]
["記載者氏名：",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,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,"責任者氏名："]
[]
["栃木県看護協会・とちぎケアマネジャー協会・栃木県医療社会事業協会　入退院共通連携シート作成委員会Ver.1"]
["【H30年3月　安足健康福祉センター改訂版】"]