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["　　　　　　　共通診療情報提供書（伊勢地区）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"宛",null,null,null,null,null,null,null,null,"主治医名"]
[]
["氏名",null,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","（",null,null,"歳）",null,"2021-03-17"]
["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,"TEL"]
[]
["現在の病名（介護サービス提供上重要なものから順に記入してください。）"]
["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,"発症日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日（",null,null,null,null,"）"]
["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,"発症日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日（",null,null,null,null,"）"]
["③",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日（",null,null,null,null,"）"]
["④",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日（",null,null,null,null,"）"]
["⑤",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日（",null,null,null,null,"）"]
["主な\n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,"使用中薬剤"]
[]
[]
["症状\n及び\n経過"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸部X線検査（",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,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",null,null,"月",null,null,"日実施"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"コメント"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["心電図",null,null,null,null,"（",null,null,null,null,"年",null,null,"月",null,null,"日実施）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮膚疾患",null,null,null,null,"褥瘡",null,null,null,null,"疥癬"]
["（",null,null,null,"）","（",null,null,null,null,"）（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,"（",null,null,null,"）","（",null,null,null,"）","（",null,null,null,"）"]
["血液\n検査",null,null,null,null,"採血検査日時",null,null,null,null,"（",null,null,null,null,null,"年",null,null,"月",null,null,"日実施）",null,null,"（採血データ添付可）"]
[null,null,null,null,null,null,null,"RBC",null,null,null,null,null,null,null,null,"×104/μL",null,null,null,null,"T-bil",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"TP",null,null,null,null,null,null,null,null,"g/dL"]
[null,null,null,null,null,null,null,"Hb",null,null,null,null,null,null,null,null,"g/dL",null,null,null,null,"Glu",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"Alb",null,null,null,null,null,null,null,null,"g/dL"]
[null,null,null,null,null,null,null,"Hct",null,null,null,null,null,null,null,null,"%",null,null,null,null,"HbA1c",null,null,null,null,null,null,null,null,"%",null,null,null,null,"A/G"]
[null,null,null,null,null,null,null,"WBC",null,null,null,null,null,null,null,null,"/μL",null,null,null,null,"UA",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"AST(GOT)",null,null,null,null,null,null,null,null,"IU/L"]
[null,null,null,null,null,null,null,"PLT",null,null,null,null,null,null,null,null,"×104/μL",null,null,null,null,"BUN",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"ALT(GPT)",null,null,null,null,null,null,null,null,"IU/L"]
[null,null,null,null,null,null,null,"LDL-chol",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"CRE",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"γ-GTP",null,null,null,null,null,null,null,null,"IU/L"]
[null,null,null,null,null,null,null,"HDL-chol",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"Na",null,null,null,null,null,null,null,null,"mEq/L",null,null,null,null,"ALP",null,null,null,null,null,null,null,null,"IU/L"]
[null,null,null,null,null,null,null,"TG",null,null,null,null,null,null,null,null,"㎎/dL",null,null,null,null,"K",null,null,null,null,null,null,null,null,"mEq/L",null,null,null,null,"※CRP",null,null,null,null,null,null,null,null,"㎎/dL"]
[null,null,null,null,null,null,null,"LDH",null,null,null,null,null,null,null,null,"IU/L",null,null,null,null,"Cl",null,null,null,null,null,null,null,null,"mEq/L",null,null,null,null,"※血液型 （",null,null,null,null,null,"）","RH（",null,null,null,"）"]
["※　　\n感染症",null,null,null,null,null,null,"HBs抗原",null,null,null,null,null,null,null,null,null,null,null,null,null,"ワッセルマン",null,null,null,null,null,null,null,null,null,null,null,"血圧",null,null,null,"/",null,null,"身長",null,null,null,null,"㎝"]
[null,null,null,null,null,null,null,"HCV抗体",null,null,null,null,null,null,null,null,null,null,null,null,null,"MRSA",null,null,null,null,null,null,null,null,null,null,null,"㎜Hg",null,null,null,null,null,null,"体重",null,null,null,null,"kg"]
["※　　\n尿検査",null,null,null,null,"蛋白（",null,null,null,null,null,"）","糖（",null,null,null,null,null,"）","潜血（",null,null,null,null,null,"）","ウロビリノーゲン（",null,null,null,null,null,null,null,null,null,null,"）","ケトン（",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,"認知症高齢者の日常生活自立度",null,null,null,null,null,null,null,null,null,null,"BPSD（",null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,"介護度"]
["（",null,null,null,null,null,null,null,null,null,null,null,"）","（",null,null,null,null,null,null,null,null,null,"）","症状（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）","（",null,null,null,null,null,"）"]
["実施中の措置"]
["（",null,null,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,null,null,null,null,null,"）"]
["特記事項"]