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["更新日",null,null,null,null,null,"更新者",null,"所属；",null,null,null,null,null,null,"役職；",null,null,null,null,"氏名；",null,null,null,null,null,"麻痺",null,null,null,null,null,"部位；",null,null,null,null,null,null,null,null,"用具",null,null,null,null,null,null,null,null,null,null,"男","無","国民","自宅","全麻痺","自立","不要","軽","無","薄","未","可","トイレ","下剤","座位","普通食","米飯","普通","箸","徘徊"]
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[null,"同居の家族等","№","氏名",null,null,null,"年齢",null,"続柄",null,"介護者",null,"介護への関わりの程度",null,null,null,null,"キーパーソン",null,"緊急連絡先・方法",null,null,null,null,null,"入浴",null,null,null,null,null,null,null,null,null,null,null,null,null,"夜間",null,null,null,null,null,null,null,null,null,null,null,null,null,"その他","その他",null,null,null,"不可",null,null,null,null,"その他","その他",null,null,"ミキサー","ミキサー","その他","暴力"]
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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,"服薬管理",null,null,null,null,null,null,null,null,null,null,null,null,null,"摂取具"]
["在宅療養への要望","本人",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",null,"部位；",null,null,null,null,null,null,null,"程度",null,null,null,"とろみ使用",null,null,"（程度；",null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特記；",null,null,null,null,null,null,null,null,null,null,null,null,"嚥下咀嚼",null,"障害",null,null,"（程度；",null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜ADL・褥瘡・排泄、・栄養等FREE＞　※特に、退院時や区分変更の申請が必要な時に記入して頂きたい。"]
[null,null,"終末期の居所",null,null,null,null,null,null,null,null,null,null,null,null,"事前指示の希望"]
[null,"家族","主たる発言者；"]
[]
[null,null,"終末期の居所",null,null,null,null,null,null,null,null,null,null,null,null,"事前指示の希望",null,null,null,null,null,null,null,null,null,null,"認知　　状態",null,"中核症状",null,"長谷川式",null,null,"点",null,"MMSE",null,null,"点",null,"特記；"]
["生活歴・趣味・関心事等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"周辺症状",null,null,"徘徊",null,"妄想",null,"暴言",null,"暴行",null,"介護への抵抗",null,null,null,"不潔行為",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,null,null,null,null,null,null,null,"睡眠",null,"中途覚醒",null,null,null,null,"昼夜逆転",null,null,null,null,"薬剤使用",null,null,null,null,"特記；"]
["医療","病名・既往歴","①",null,null,null,null,null,null,"発症;","年　　月　　日",null,null,null,"④",null,null,null,null,null,null,"発症;","年　　月　　日",null,null,null,"会話能力",null,"構語障害",null,null,null,null,"重度難聴",null,null,null,null,"重度視力障害",null,null,null,null,"特記；"]
[null,null,"②",null,null,null,null,null,null,"発症;","年　　月　　日",null,null,null,"⑤",null,null,null,null,null,null,"発症;","年　　月　　日",null,null,null,"＜認知・睡眠・会話FREE＞"]
[null,null,"③",null,null,null,null,null,null,"発症;","年　　月　　日",null,null,null,"⑥",null,null,null,null,null,null,"発症;","年　　月　　日"]
[null,null,"＜主治医からの病状説明を含めFREE＞",null,null,null,null,null,null,null,null,null,null,null,"感染症"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護","介護認定",null,null,null,null,null,"要介護度",null,null,null,"介護保険証番号",null,null,null,null,null,null,null,"認定年月日"]
[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,"日常生活動作評価",null,null,null,null,null,"認知の評価",null,null,null,null,"認定始期",null,null,null,null,null,"から","認定終期",null,null,null,null,null,"まで"]
[null,"特殊医療",null,null,null,null,null,"酸素療法",null,null,"喀痰吸引",null,null,"尿道カテーテル",null,null,null,"その他",null,"（",null,null,null,null,null,"）",null,"担当包括",null,null,"氏名；",null,null,null,null,null,"所属；",null,null,null,null,null,null,null,"連絡先；"]
[null,"かかりつけ医療機関",null,null,null,null,null,null,null,null,null,null,null,null,"入院医療機関",null,null,null,null,null,null,null,null,null,null,null,null,"担当ＣＭ",null,null,"氏名；",null,null,null,null,null,"所属；",null,null,null,null,null,null,null,"連絡先；"]
[null,"かかりつけ歯科医",null,null,null,null,null,null,null,null,null,null,null,null,"かかりつけ薬局",null,null,null,null,null,null,null,null,null,null,null,null,"担当ＳＷ",null,null,"氏名；",null,null,null,null,null,"所属；",null,null,null,null,null,null,null,"連絡先；"]
[null,"医療保険",null,null,null,null,null,null,null,null,null,null,null,null,"記号",null,null,null,null,null,"番号",null,null,null,null,null,"サービス利用","訪問介護",null,null,null,null,null,null,"回/週",null,"通所介護",null,null,null,null,null,"回/週",null,"訪問入浴",null,null,null,null,null,"回/週"]
["他制度","身体障害",null,null,null,null,null,null,null,null,"難病",null,null,null,null,null,null,null,"療育",null,null,null,null,null,null,null,null,"福祉用具",null,null,null,null,null,null,null,null,"移送サービス",null,null,null,null,null,"回/週",null,"配食サービス",null,null,null,null,null,"回/週"]
[null,"精神障害",null,null,null,null,null,null,null,null,"福祉医療",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,"施設入所",null,null,"無","（名称；",null,null,null,null,null,"）","期間；",null,null,null,null,null,"安心コール等",null,null,null,"（",null,null,"）"]
["薬剤情報","お薬手帳",null,null,null,null,"薬剤アレルギー",null,null,null,null,null,null,null,null,null,"禁忌薬剤",null,null,null,null,null,null,null,null,null,null,"訪問看護",null,null,null,null,null,null,"回/週",null,"訪問リハビリ",null,null,null,null,null,"回/週",null,"通所リハビリ",null,null,null,null,null,"回/週"]
[null,"訪問薬剤管理",null,null,null,null,"※お薬手帳が無い場合、または手帳が有っても内容が不十分な場合、は以下に記述する。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"指示の遵守☑を入れる",null,null,null,"服薬",null,null,null,null,null,null,"口腔ケア",null,null,null,null,null,null,null,"摂取制限"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"安静",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,null,null,null,null,"＜介護・サービス利用・その他総合的にFREE＞"]
["歯科口腔","口腔清潔",null,null,null,null,null,null,null,null,null,null,null,null,"口腔状況"]
[null,"訪問歯科診療",null,null,null,null,"※必要に応じ歯科的評価を記述する。"]