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["(様式１－１)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"情報提供日："]
[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,"入院日：",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["入院時情報提供書"]
["医療機関　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　居宅介護支援事業所"]
[]
["医療機関名",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,"事業所名"]
["ご担当者名",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,"ｹｱﾏﾈｼﾞｬｰ名"]
[{"$f":"PHONETIC(E10)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,null,null,null,null,null,null,"FAX"]
["フリガナ"]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"性別",null,null,null,null,null,"生年月日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","（",{"$f":"ROUNDDOWN(YEARFRAC(AU10,AJ1,1),0)","v":120},null,"歳）",null,"2020-01-30"]
["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,"TEL"]
["入院歴",null,"最近の入院",null,null,null,"無",null,null,"有",null,null,"不明",null,null,"期間",null,null,null,null,"年",null,null,"月",null,null,"日","〜",null,null,null,"年",null,null,"月",null,null,"日","(",null,null,null,null,null,")病院"]
[]
[]
[null,null,"頻度",null,null,null,"頻度高い／繰り返している",null,null,null,null,null,null,null,null,null,null,null,"頻度は低いがこれまでにもある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"今回が初めて"]
[]
[]
["既往歴"]
["入院前に実施している医療処置",null,null,null,null,null,"無"]
[]
[]
[null,null,null,null,null,null,"点滴",null,null,null,"酸素療法",null,null,null,null,null,"吸痰吸引",null,null,null,null,null,"気管切開",null,null,null,null,null,"胃瘻",null,null,null,null,"経管栄養",null,null,null,null,null,"経腸栄養"]
[]
[]
[null,null,null,null,null,null,"褥瘡",null,null,null,"尿道カテーテル",null,null,null,null,null,null,null,"人工膀胱",null,null,null,null,null,"人工肛門",null,null,null,null,null,"痛みコントロール",null,null,null,null,null,null,null,null,"排便コントロール"]
[]
[]
[null,null,null,null,null,null,"自己注射（",null,null,null,null,null,null,null,null,null,null,null,null,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,"）"]
[]
[]
["かかりつけ医について",null,null,null,"医療機関",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師名"]
[null,null,null,null,"診療方法",null,null,null,null,null,"通院",null,null,null,"訪問診療",null,null,null,null,null,"往診",null,null,null,null,null,"頻度（",null,null,null,null,null,null,null,"）回／月"]
[]
[]
["お薬",null,null,null,"内服薬",null,null,null,null,null,"無",null,null,null,"有",null,null,null,"かかりつけ薬局（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,"管理",null,null,null,null,null,"自己管理",null,null,null,null,null,null,null,"他者管理",null,null,null,null,"（管理者：",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,"服薬状況",null,null,null,null,null,"処方通り服用",null,null,null,null,null,null,null,"時々飲み忘れ",null,null,null,null,null,null,null,"飲み忘れが多い",null,null,null,null,null,null,null,"服薬拒否"]
[]
[]
["介護保険",null,null,null,null,null,"介護度（",null,null,null,null,null,null,null,null,"）",null,"有効期間",null,null,null,null,null,null,"年",null,null,"月",null,null,"日 〜",null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,null,null,null,null,null,"申請中（申請日",null,null,null,null,null,null,null,"／",null,null,"）",null,null,"区分変更（区変日",null,null,null,null,null,null,null,"／",null,null,"）",null,null,"未申請",null,null,null,"割合（",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,"自立",null,null,null,"J1",null,null,"J2",null,null,"A1",null,null,"A2",null,null,"B1",null,null,"B2",null,null,"C1",null,null,"C2"]
[]
[]
["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,"自立",null,null,null,"Ⅰ",null,null,"Ⅱa",null,null,"Ⅱb",null,null,"Ⅲa",null,null,"Ⅲb",null,null,"Ⅳ",null,null,"M",null,"BPSD",null,null,null,"無",null,null,"有"]
[]
[]
["上記 日常生活自立度の判断",null,null,null,null,null,null,null,null,null,null,null,null,"主治医",null,null,null,null,"ケアマネジャー"]
[]
[]
["障害認定",null,null,null,null,null,"無",null,null,"有",null,"（",null,"身体",null,null,"精神",null,null,"知的",null,"）","障害手帳",null,null,null,null,null,"無",null,null,"有",null,"（",null,"申請中",null,null,null,null,"／",null,null,"）"]
[]
[]
["家族状況",null,null,null,null,null,"独居",null,null,null,"高齢者のみ（",null,null,null,null,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,"日中独居"]
[]
[]
["家族との関係"]
["介護者",null,null,null,"主介護者氏名",null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）","関係（",null,null,null,null,null,"）",null,null,"同居",null,null,null,"別居",null,null,"TEL"]
[]
[]
[null,null,null,null,"キーパーソン氏名",null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）","関係（",null,null,null,null,null,"）",null,null,"同居",null,null,null,"別居",null,null,"TEL"]
[]
[]
["意向",null,null,null,"本人入院前の意向"]
[null,null,null,null,"家族入院前の意向",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同居の有無",null,null,null,null,null,null,"同居",null,null,null,"別居"]
[]
[]
["退院後",null,null,null,null,null,"在宅",null,null,null,"施設",null,null,null,"不明",null,null,null,"主介護者氏名（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["入院前サービス利用",null,null,null,null,null,"デイサービス",null,null,null,null,null,null,null,"デイケア",null,null,null,null,null,"ホームヘルパー",null,null,null,null,null,null,null,"訪問入浴",null,null,null,null,null,"ショートステイ",null,null,null,null,null,null,null,"住宅改修"]
[]
[]
[null,null,null,null,null,null,"訪問リハビリ",null,null,null,null,null,null,null,"訪問看護",null,null,null,null,null,"福祉用具レンタル",null,null,null,null,null,null,null,"福祉用具購入",null,null,null,null,null,null,"居宅療養管理指導"]
[]
[]
[null,null,null,null,null,null,"インフォーマルサービス（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,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１－２)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（氏名：",null,null,null,{"$f":"IF(E10=\"\",\"\",E10)","v":""},null,null,null,null,null,"）様"]
["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,"備　考"]
["動作",null,"寝返り",null,null,null,null,null,null,"できる",null,null,null,null,"つかまれば可",null,null,null,null,null,null,"できない"]
[]
[]
[null,null,"起き上がり",null,null,null,null,null,null,"できる",null,null,null,null,"つかまれば可",null,null,null,null,null,null,"できない"]
[]
[]
[null,null,"座位保持",null,null,null,null,null,null,"できる",null,null,null,null,"支えれば可",null,null,null,null,null,null,"できない"]
[]
[]
[null,null,"移乗",null,null,null,null,null,null,"自立",null,null,null,null,"見守り",null,null,null,null,null,null,"一部介助",null,null,null,null,null,"全介助"]
[]
[]
[null,null,"歩行",null,null,null,null,null,null,"できる",null,null,null,null,"つかまれば可",null,null,null,null,null,null,"できない"]
[]
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[null,null,"補助具",null,null,null,null,null,null,"杖",null,null,null,null,"歩行器",null,null,null,null,"車椅子",null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["栄養",null,"栄養摂取",null,null,null,null,null,null,"経口",null,null,null,null,"経管栄養",null,null,null,null,null,"水とろみ",null,null,null,null,null,"無",null,null,"有"]
[]
[]
[null,null,"形態",null,null,null,null,null,null,"普通",null,null,null,null,"きざみ",null,null,null,null,"嚥下障害食",null,null,null,null,null,null,"ミキサー"]
[]
[]
["口腔",null,"義歯",null,null,null,null,null,null,"無",null,null,null,null,"有  （",null,null,null,"部分",null,null,null,"総",null,"）"]
[]
[]
[null,null,"口腔ケア",null,null,null,null,null,null,"自立",null,null,null,null,"一部介助",null,null,null,null,null,"全介助"]
[]
[]
[null,null,"嚥下機能",null,null,null,null,null,null,"むせない",null,null,null,null,"時々むせる",null,null,null,null,null,"常にむせる"]
[]
[]
["排泄",null,"排尿",null,null,null,null,null,null,"自立",null,null,null,null,"トイレ",null,null,null,null,null,"Pトイレ",null,null,null,null,null,"オムツ",null,null,null,null,null,"その他"]
[]
[]
[null,null,"排便",null,null,null,null,null,null,"自立",null,null,null,null,"トイレ",null,null,null,null,null,"Pトイレ",null,null,null,null,null,"オムツ",null,null,null,null,null,"その他"]
[]
[]
["更衣清潔",null,"入浴",null,null,null,null,null,null,"自立",null,null,null,null,"清拭",null,null,null,null,null,"一般浴",null,null,null,null,null,"特浴",null,null,null,null,null,"訪問入浴"]
[]
[]
[null,null,"衣服着脱",null,null,null,null,null,null,"自立",null,null,null,null,"見守り",null,null,null,null,null,"一部介助",null,null,null,null,null,"全介助"]
[]
[]
["認知",null,"物忘れ",null,null,null,null,null,null,"無",null,null,null,null,"有",null,null,null,null,"本人自覚",null,null,null,null,null,null,"無",null,null,null,null,null,"有"]
[]
[]
[null,null,"問題行動",null,null,null,null,null,null,"無",null,null,null,null,"幻視幻聴",null,null,null,null,null,"興奮",null,null,null,null,null,"焦燥•不穏",null,null,null,null,null,"妄想"]
[]
[]
[null,null,null,null,null,null,null,null,null,"暴力",null,null,null,null,"暴力/攻撃性",null,null,null,null,null,"介護抵抗",null,null,null,null,null,"不眠",null,null,null,null,null,"昼夜逆転"]
[]
[]
[null,null,null,null,null,null,null,null,null,"徘徊",null,null,null,null,"危険行為",null,null,null,null,null,"不潔行為",null,null,null,null,null,"その他"]
[]
[]
["コミュニケーション",null,"意思疎通",null,null,null,null,null,null,"可",null,null,null,null,"不可",null,null,null,null,"本人自覚",null,null,null,null,null,null,"無",null,null,null,null,null,"有"]
[]
[]
[null,null,"言語障害",null,null,null,null,null,null,"無",null,null,null,null,"失語",null,null,null,null,null,"講話障害"]
[]
[]
["その他",null,"視力",null,null,null,null,null,null,"問題無",null,null,null,null,"やや困難",null,null,null,null,null,"困難",null,null,null,"眼鏡",null,null,null,null,"無",null,null,null,"有"]
[]
[]
[null,null,"聴力",null,null,null,null,null,null,"問題無",null,null,null,null,"やや困難",null,null,null,null,null,"困難",null,null,null,"補聴器",null,null,null,null,"無",null,null,null,"有"]
[]
[]
["外出",null,"外出頻度",null,null,null,null,null,null,"週2回以上",null,null,null,null,null,null,"週1回",null,null,null,null,null,null,"月2〜3回",null,null,null,null,null,null,"無"]
[]
[]
[null,null,"外出目的",null,null,null,null,null,null,"サービス利用",null,null,null,null,null,null,"通院",null,null,null,null,null,null,"趣味",null,null,null,null,null,null,"その他"]
[]
[]
["（特記事項）"]
[]
[]
[]
[]
[]
["個人情報提供について同意",null,null,null,null,null,null,null,null,null,null,"ケアプラン添付",null,null,null,null,null,null,null,"退院時連絡希望"]
[null,null,null,"有",null,null,null,null,null,null,null,"（",null,null,null,null,null,"）枚",null,null,null,"有",null,null,null,"無　（理由：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]