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["　　情　報　連　携　シ　ー　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,"No.1"]
[]
["送付先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発信元",null,null,"記入日",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
["【医療機関・サービス事業所】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【事業者】"]
[]
["【担当者】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【担当者】"]
["【連絡先】ＴＥＬ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【連絡先】ＴＥＬ："]
["【連絡先】ＦＡＸ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【連絡先】ＦＡＸ："]
[]
["氏　名",null,null,null,null,null,null,null,null,null,null,"様","性 別",null,null,"男","生年月日",null,null,null,"大正",null,null,"昭和",null,null,"平成",null,null,"令和"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,"歳"]
["住　所"]
["緊　急\n連絡先",null,null,"氏　　名",null,null,null,null,null,null,null,null,"続　柄",null,null,null,"ＴＥＬ",null,null,"自宅："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"携帯："]
["収　入",null,null,null,null,"障害年金",null,null,null,"老齢年金",null,null,null,"その他",null,null,null,null,null,null,"（年金月額：　　　　　　　　　　　　）"]
["かかりつけ医",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現病歴\n既往歴"]
["　　〃　　歯科"]
["介 護\n認 定",null,null,null,"支１",null,null,"支２",null,null,"介１",null,null,"介２",null,null,"介３",null,null,"介4",null,null,"介５"]
[null,null,null,null,"有効期限：",null,null,null,null,null,null,null,"年",null,null,"月末まで"]
["持病の\n状　況",null,null,"服薬状況",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助",null,null,"介助内容："]
[null,null,null,"褥　瘡",null,null,null,null,"無",null,null,"有","部位・処置等："]
[null,null,null,"寝　具",null,null,null,null,"布団",null,null,"ベット 【柵：",null,null,null,null,"無",null,"有","（",null,null,"点）】",null,null,null,"特殊マット"]
["ＡＤＬ",null,null,"移　動",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助",null,null,null,"介助内容："]
[null,null,null,null,null,null,null,null,"独歩",null,null,"杖",null,"歩行器",null,null,"車椅子"]
[null,null,null,"移　乗",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助"]
[null,null,null,"食　事",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助"]
[null,null,null,"食形態",null,null,null,null,"普通",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,"口腔清潔",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助",null,null,null,"介助内容："]
[null,null,null,"義　歯",null,null,null,null,"なし",null,null,"あり",null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,"排　泄",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助",null,null,null,"介助内容："]
[null,null,null,"排泄方法",null,null,null,null,"トイレ",null,null,"Ｐトイレ",null,null,null,"おむつ",null,null,null,"カテーテル等",null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,"入　浴",null,null,null,null,"自立",null,null,"見守り",null,null,"要介助",null,null,"清拭",null,"介助内容："]
[null,null,null,"入浴場所",null,null,null,null,"自宅風呂",null,null,null,"通所",null,null,"訪問入浴",null,null,null,"最終入浴：",null,null,null,null,null,"月",null,null,"日"]
[null,null,null,"衣類着脱",null,null,null,null,"自立",null,null,"見守り",null,null,null,"要介助",null,null,null,"介助内容："]
[null,null,null,"睡眠状況",null,null,null,null,"良眠",null,null,"問題有",null,null,null,"不明",null,null,null,"問題点："]
["物忘れ等症状"]
["家 族 構 成",null,null,null,null,null,null,null,null,"介　護　協　力　者",null,null,null,null,null,null,null,null,null,null,null,null,null,"介護力・介護状況"]
[null,null,null,null,null,null,null,null,null,"氏　　名",null,null,null,"生年月日",null,null,null,"続柄",null,"健康状態"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"良",null,"不良"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"良",null,"不良"]
["キーパーソン：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"良",null,"不良"]
["サービス\n利用状況"]
[]
[]
["備　考",null,null,null,"介護に関する本人・家族の意向、生活機能が入院前より低下した場合に生じると予想される問題点、退院に際しての留意点等"]
[]
[]
[]
[]
["送付先：みどりの風　南知多病院の場合記載して下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"No.2"]
[]
["患者氏名："]
[]
["障害者\n手　帳",null,null,null,null,"有",null,null,"無",null,null,"申請中",null,null,null,null,null,null,"感染症",null,null,"ＨＢＳ",null,null,"【",null,"有",null,"無",null,"不明】"]
[null,null,null,null,"【",null,"精神",null,null,"身体",null,null,"療育",null,null,null,"級】",null,null,null,null,"ＨＣＶ",null,null,"【",null,"有",null,"無",null,"不明】"]
[null,null,null,null,"有効期限：",null,null,null,null,null,null,"年",null,null,"月末",null,null,null,null,null,null,"梅　毒",null,null,"【",null,"有",null,"無",null,"不明】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"疥　癬",null,null,"【",null,"有",null,"無",null,"不明】"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＭＲＳＡ",null,null,"【",null,"有",null,"無",null,"不明】"]
["住　宅",null,null,null,null,"一戸建て【",null,null,null,null,null,"階建】",null,null,"集合住宅",null,null,null,null,"階【エレベーター：",null,null,null,null,null,null,"有",null,null,"無】"]
["家族関係\n意　向\n問題点\n",null,null,null,"家族の受入：",null,null,null,null,"良",null,null,"不良"]
[]
[]
[]
[]
["生 活 歴"]
[]
[]
["経　過\n\n現　状\n\n問題行為\n",null,null,null,null,"暴力",null," 暴言",null,null,"幻聴",null,"幻覚",null," 妄想",null,null,"抑うつ",null,null,"不安",null,"徘徊",null,null,"せん妄",null,null,"独語",null,"失見当"]
[null,null,null,null,null,"不潔行為",null,null,null,"睡眠障害",null,null,null,"介護抵抗",null,null,null,"盗癖 ",null,null,"収集癖　",null,"　 異食",null,null,"性的問題行動"]
[null,null,null,null,"【",null,"長谷川式",null,null,null,"ＭＭＳＥ",null,null,"（",null,null,"点）",null,null,"実施日：",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[]
["日中の\n過ごし方"]
[]
[]
["対　応\n接し方"]
[]
[]
["障害高齢者の日常生活自立度",null,null,null,null,null,null,null,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,"Ⅰ",null,null,"Ⅱa",null,null,"Ⅱb",null,null,"Ⅲa",null,null,"Ⅲb",null,null,"Ⅳ",null,null,"Ｍ"]
["服薬状況\n\n医療情報",null,null,null,"眠前薬",null,null,null,null,"無",null,"有（服用時間：",null,null,null,null,null,null,"時",null,null,"分頃）",null,"睡眠時間：",null,null,null,null,"時間"]
[null,null,null,null,"薬の管理",null,null,null,null,"自己管理",null,null,null,"家族管理",null,null,null,"病院・施設管理",null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,"予防接種",null,null,null,"インフル",null,null,null,null,"未",null,"済","肺炎球菌",null,null,null,null,"未",null,"済(",null,null,null,null,"年",null,null,"月)"]
[null,null,null,null,"不眠時",null,null,null,null,"無",null,"有【使用頻度：",null,null,null,null,null,null,"回／",null,null,null,"Ｗ程度】薬剤名："]
[null,null,null,null,"不穏時",null,null,null,null,"無",null,"有【使用頻度：",null,null,null,null,null,null,"回／",null,null,null,"Ｗ程度】薬剤名："]
[null,null,null,null,"便秘時",null,null,null,null,"無",null,"有【（",null,null,null,"）日便秘時（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）使用】"]
[null,null,null,null,"アレルギー",null,null,null,null,null,"無",null,"有　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,"排泄",null,"日　中",null,null,null,null,"トイレ",null,null,null,"ポータブルトイレ",null,null,null,null,null,null,"リハビリパンツ",null,null,null,null,null,"おむつ"]
[null,null,null,null,null,null,"夜　間",null,null,null,null,"トイレ",null,null,null,"ポータブルトイレ",null,null,null,null,null,null,"リハビリパンツ",null,null,null,null,null,"おむつ"]
[null,null,null,null,null,null,"尿　意",null,null,null,null,"有",null,null,"無",null,null,"バルン",null,null,null,"不明【失禁：",null,null,null,null,"有",null,null,"無】"]
[null,null,null,null,null,null,"便　意",null,null,null,null,"有",null,null,"無",null,null,"ストマ",null,null,null,"不明【最終排便：",null,null,null,null,null,null,"月",null,null,"日】"]
[null,null,null,null,"難聴",null,null,"無",null,null,"有","【",null,"右",null,"左","】","（対応方法：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["備　考"]
[]
[]
[null,"※分かる範囲で記入して下さい。不明なところは記入していただかなくてもかまいません。"]