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["【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："]
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["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："]
["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,"申請中",null,"（申請日　　/　　）"]
[null,null,null,null,"有効期限：",null,null,null,null,null,null,null,"年",null,null,"月末まで"]
["日常生活自立度",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：　（　　　）"]
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[null,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："]
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[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"]
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["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、ACP、\n経済面等"]

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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"]
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["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,"〇",null,"年","〇",null,"月","〇",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】"]
[null,null,"Ａ病院　や　Ｂ介護事業所名　など",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"南知多　浜美"]
["【担当者】",null,null,null,"〇〇〇〇",null,null,null,null,null,null,null,null,null,null,null,"【担当者】",null,null,null,"△△△△"]
["【連絡先】ＴＥＬ：",null,null,null,null,null,"〇△-〇△〇△",null,null,null,null,null,null,null,null,null,"【連絡先】ＴＥＬ：",null,null,null,null,null,"〇×-〇×〇×"]
["【連絡先】ＦＡＸ：",null,null,null,null,null,"〇△-△〇△〇",null,null,null,null,null,null,null,null,null,"【連絡先】ＦＡＸ：",null,null,null,null,null,"〇×-×〇×〇"]
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["住　所",null,null,"南知多町〇〇　または　美浜町〇〇"]
["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,"南知多　浜男",null,null,null,null,null,null,null,null,"夫",null,null,null,null,null,null,"携帯："]
["かかりつけ医",null,null,null,null,"B医院",null,null,null,null,null,null,null,null,null,null,"現病歴\n既往歴",null,null,"糖尿病、高血圧：Ｂ医院\n脳梗塞（右麻痺）：Ａ医院"]
["　　〃　　歯科",null,null,null,null,"Ｃ歯科クリニック"]
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[null,null,null,null,"有効期限：",null,null,null,"令和",null,8,null,"年",12,null,"月末まで"]
["日常生活自立度",null,null,null,null,null,null,"障害高齢者の日常生活自立度：　（　B2　）",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：　（　Ⅱ　）"]
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[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","（",2,null,"点）】",null,null,null,"特殊マット",null,null,null,"介助バーあり"]
[null,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,"車椅子自走、自宅内４点杖"]
[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"]
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[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,"転倒のリスクが高い"]
[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,"排便時拭く介助が必要"]
[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,"〇",null,"月","〇",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",null,null,null,null,null,null,"なし"]
["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,"主介護者は心疾患有り。"]
[null,null,null,null,null,null,null,null,null,"南知多　浜男",null,null,null,"1945-04-01",null,null,null,"夫",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,"夫",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",null,null,null,"B医院　　　　　　通所リハ（月・水・金利用）\nD福祉用具事業所　福祉用具（ベッド・ベッド付属品・車椅子・杖）"]
[]
[]
["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、ACP、\n経済面等"]
[null,null,null,null,"入院前は杖を補助に玄関段差は見守り可能であった。主介護者が心疾患を有する高齢の夫であるため、ADL低下し介護量が増加する場合、サービス変更が必要となる。\n本人の思いとして、最期は病院ではなく、在宅でむかえたい希望がある。\n世帯収入としては、老齢年金がある。"]