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["みえ在宅医療クリニック　連携シート　　FAX番号　0595-83-4139"]
["依頼元は□にチェックをお願いいたします。"]
["依頼日",null,"月　　　　日",null,null,null,null,null,null,null,"訪問先",null,"自宅　・　施設（　　　　　　　）"]
[]
[null,null,"退院ｶﾝﾌｧ以外入院中の相談は自費3,300円"]
["　医療機関",null,null,null,null,null,null,"担当医：",null,null,"入院",null,"病院担当者："]
[null,null,null,null,null,null,null,null,null,null,"通院"]
["　ケアマネ",null,"事業所",null,"   ",null,null,null,null,null,"担当",null,null,null,null,null,null,"直近の\nｱｾｽﾒﾝﾄｼｰﾄ",null,null,"チェック\n\n\n"]
["　訪問看護",null,"事業者"]
["ﾌﾘｶﾞﾅ\n患者氏名",null,null,null,null,null,null,null,null,"様","男","ご家族連絡先",null,null,"氏名："]
[null,null,null,null,null,null,null,null,null,null,"女","続柄（",null,"）","TEL：",null,"　-",null,"　-"]
["生年月日",null,"T ・ S ・H",null,null,null,"年",null,"月",null,"日生",null,"歳"]
["住所"]
[]
["病名"]
["依頼に\n至った経緯"]
[]
[]
["※情報提供書を添付する場合は以下記入不要"]
["情報提供書",null,"  あり  :  FAX・郵送依頼済  ・  当日持参",null,null,null,null,null,null,null,"なし：記入してもらうよう依頼して下さい"]
["医療保険",null,null,"割","限度額証（　　　）　特定医療費受給者証　身障手帳　身体障害者受給者証　生保",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者"]
["医療処置",null,"CVポート",null,null,"HOT",null,null,"呼吸器",null,null,"気切",null,null,"吸痰",null,null,"褥瘡"]
[null,null,"Ba",null,null,"導尿（　　　回 / 日）",null,null,null,null,null,"コロストミー",null,null,"ウロストミー",null,null,"PTCD"]
[null,null,"インスリン（　　　　回 / 日）",null,null,null,null,null,"血糖（　　　回 / 日）",null,null,null,null,null,"膀胱瘻"]
[null,null,"胃瘻",null,null,"腸瘻",null,null,"その他（    　　　　　　　　　　　　　　　　　　　　　　　　  ）"]
["※直近のｱｾｽﾒﾝﾄｼｰﾄを添付する場合は以下記入不要"]
["介護状態\n家族背景",null,"【主介護者】　　　　　　　　　　　　　　　　　　　　　　\n【介護力】"]
[]
[]
["介護保険",null,null,"割"," 支援　 ／ 　介護　（　　　　）",null,null,null,null,"未申請　申請中（新規 ・ 変更） （　　　/　　申請・調査）"]
["持参物",null,"保険証　限度額証　介護保険証・負担割合証　特定医療費受給者証　身障手帳　身体障害者受給者証"]
[null,null,"　お薬手帳　印鑑　その他（　　　　　　　　　　）"]
["依頼時\n必要な\n書類",null,"　　連携シート　　　　               アセスメントシート                             診療情報提供書　　\n※現時点でお手元にある書類で構いませんので、一緒に添付してお送りください。\n　　　　　　　　　"]
[]
[]
[]
[]
[]
["以下クリニック記入欄"]
["１.対応可能　２.対応困難（　　　　　　）",null,null,null,null,null,null,null,null,null,null,"相談",null,null,"カンファレンス",null,null,null,"初診往診"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日","（    ）",null,null,"："]

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