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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,"様式２－①"]
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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,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,"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,"要介護度",null,null,null,null,null,null,null,null,null,"未申請 　更新中 　新規申請中 　総合事業対象　 非該当"]
["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,"１",null,null,null,"２",null,null,null,null,null,null,"要介護",null,null,null,null,null,null,null,null,null,null,"１",null,null,null,"２",null,null,null,"３",null,null,null,"４",null,null,null,"５"]
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["入院中の経過"]
[]
[]
["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,"(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,"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,"不可",null,null,null,null,null,null,null,null,"可能"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"言語",null,null,null,null,null,null,"筆談",null,null,null,null,null,null,"ジェスチャー",null,null,null,null,null,null,null,null,null,null,null,null,null,"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,"(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： なし　あり（　　　　　　　　）"]
["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,"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,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",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,"一般食",null,null,null,null,null,null,null,"特別食",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,"食形態",null,null,null,null,null,"主食（",null,null,null,null,null,null,null,"常食",null,null,null,null,null,null,null,"粥",null,null,null,null,null,null,null,"ペースト",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,"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,"普通",null,null,null,null,null,null,null,"ソフト食",null,null,null,null,null,null,null,"刻み",null,null,null,null,null,null,null,"ペースト",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,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,"方法",null,null,null,null,null,"経口",null,null,null,null,null,null,null,"経管栄養",null,null,null,null,null,null,null,"（",null,"鼻腔",null,null,null,null,null,null,"胃ろう",null,null,null,null,null,null,"腸ろう",null,null,null,null,null,null,"）",null,"輸液",null,null,null,null,null,null,"経管栄養の内容・量等："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"嚥下：",null,null,null,null,null,null,null,"良",null,null,null,null,null,"不良",null,null,null,null,null,null,null,null,null,"咀嚼状況：",null,null,null,null,null,null,null,null,null,null,null,"良",null,null,null,null,null,"不良",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,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",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,"尿道",null,null,null,null,null,null,null,"膀胱ろう",null,null,null,null,null,null,null,"腎ろう",null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
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[null,null,null,null,null,null,null,null,null,"排便",null,null,null,null,null,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",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,"不要",null,null,null,null,null,"要"]
[null,null,null,null,null,null,null,null,null,"失禁",null,null,null,null,null,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"トイレ",null,null,null,null,null,null,null,"ポータブルトイレ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"おむつ",null,null,null,null,null,null,null,"カテーテル等",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,"常時",null,null,null,null,null,null,null,"夜間のみ",null,null,null,null,null,null,null,"）"]
["入浴",null,null,null,null,null,null,null,null,"清潔",null,null,null,null,null,"自立",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",null,null,null,null,null,null,null,"行っていない",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,"なし",null,null,null,null,null,null,null,"あり"]
[null,null,null,null,null,null,null,null,null,"方法",null,null,null,null,null,"一般浴",null,null,null,null,null,null,null,"シャワー浴",null,null,null,null,null,null,null,null,null,null,null,"機械浴",null,null,null,null,null,null,null,"清拭",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,"独歩",null,null,null,null,null,"杖",null,null,null,"シルバーカー",null,null,null,null,null,null,null,null,null,null,null,"歩行器",null,null,null,null,null,null,null,"車椅子",null,null,null,null,null,null,null,"ストレッチャー",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,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助"]
[null,null,null,null,null,null,null,null,null,"移乗",null,null,null,null,null,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",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,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["夜間の\n状態",null,null,null,null,null,null,null,null,"不眠",null,null,null,null,null,"良眠",null,null,null,null,null,null,null,"不眠",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,"不眠時対応："]
[null,null,null,null,null,null,null,null,null,"睡眠薬",null,null,null,null,null,"なし",null,null,null,null,null,null,null,"ときどき",null,null,null,null,null,null,null,"常用"]
["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,"自立",null,null,null,"Ⅰ",null,null,null,"Ⅱa",null,null,null,"Ⅱb",null,null,null,"Ⅲa",null,null,null,"Ⅲb",null,null,null,"Ⅳ",null,null,null,"Ｍ",null,null,null,"認知症状：",null,null,null,null,null,null,null,null,null,"記憶障害",null,null,null,null,null,null,null,null,null,"幻覚/妄想",null,null,null,null,null,null,null,null,null,"昼夜逆転",null,null,null,null,null,null,null,null,null,"介護への抵抗"]
[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,"自立",null,null,null,"Ｊ1",null,null,"Ｊ2",null,null,"Ａ1",null,null,null,"Ａ2",null,null,null,"Ｂ1",null,null,null,"Ｂ2",null,null,null,"Ｃ1",null,null,"Ｃ2",null,null,"暴言/暴力",null,null,null,null,null,null,null,null,null,"不潔行為",null,null,null,null,null,null,null,null,null,"徘徊",null,null,null,null,null,null,null,null,null,"その他"]
[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,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["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,"p",null,null,null,null,null,null,"体圧分散マット：",null,null,null,null,null,null,null,null,null,"不要",null,null,null,null,null,"要",null,null,null,null,null,"マットの種類：",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[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,"p",null,null,null,null,null,null,"体位変換：",null,null,null,null,null,null,null,null,null,"不要",null,null,null,null,null,"要",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,"p",null,null,null,null,null,null,"リスク等："]
["口腔清潔",null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",null,null,null,null,null,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,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"なし",null,null,null,null,null,null,null,"あり",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["服薬",null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,"見守り",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",null,null,null,null,null,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,"なし",null,null,null,null,null,"あり",null,null,null,null,"（　　　　　　　　　　　　　　　　　　　　　　）"]
["医療的\n処置の\n有無",null,null,null,null,null,null,null,null,"なし",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,"可",null,null,null,null,null,"不可",null,null,null,null,null,"回数：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回）",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,null,null,"人工呼吸器"]
[null,null,null,null,null,null,null,null,null,"あり",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,"使用状況：",null,null,null,null,null,null,null,null,null,null,null,"常時",null,null,null,null,null,null,null,"夜間のみ",null,null,null,null,null,null,null,"昼のみ",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,null,null,null,null,null,"喀痰吸引",null,null,null,null,null,null,null,null,null,"（回数：　　　　回）",null,null,null,null,null,null,null,null,null,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,"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】"]