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[null,"医療・介護多職種の連携ツールメニュー"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"←「基本情報入力フォーム」入力により下記のかっこ内の共通内容が各シートに転記されます。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"　（対象者氏名・ふりがな・性別・生年月日・FAX送信元情報）"]
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[null,"シート選択ボタン",null,null,null,null,null,null,null,null,null,null,null,null,"入力済みチェック欄（確認必要シート）"]
[null,"（クリックすると選択シートに移動します）",null,null,null,null,null,null,null,null,null,null,null,null,"※□をダブルクリックするとチェックがつきます"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(O15=\"\",\"←入力済み及び確認が必要な場合にはチェック\",\"（様式１－３）シートをご確認ください。\")","v":"←入力済み及び確認が必要な場合にはチェック"}]
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["様式１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["多 職 種 連 携 シ ー ト"]
[]
[]
[]
[]
["送信元",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受信先"]
[]
[]
[]
["医療機関・事業所名：",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,"医療機関・事業所名："]
[]
[]
["担当者名：",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,"担当者名："]
[]
[]
["Ｔ Ｅ Ｌ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｔ Ｅ Ｌ ："]
[]
[]
["Ｆ Ａ Ｘ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｆ Ａ Ｘ ："]
[]
[]
["E-mail  ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail  ："]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"< 本票送付の目的 >",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"< 返信希望の有無 >"]
[]
[]
[null,null," 至急",null,null,null,null,null,null,null,null," 報告",null,null,null,null,null," 連絡",null,null,null,null,null," 相談",null,null,null,null,null," 返信",null,null,null,null,null,null,null,null,null,null,null," 返信願います",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 返信不要です"]
[]
[]
[]
["送付枚数",null,null,null,null,null,null,null,null,null,null," 様式１",null,null,null,null,null,null,null,null,null,null,null," 様式２",null,null,null,null,null,null,null,null," 様式３",null,null,null,null,null,null,null,null," 様式４",null,null,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,null,null,null,"（本紙）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"送付枚数は",null,null,null,null,null,null,null,{"$f":"IF(OR(K36=\"✓\",W36=\"✓\",AF36=\"✓\",AO36=\"✓\",AX36=\"✓\"),COUNTIF(K36:AX36,\"✓\"),\"\")","v":""},null,null,"枚です。（本紙を含む）"]
[]
[]
["下記の方を担当しています。下記事項についてご指示・ご確認をお願いします。"]
[]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO45=\"\",\"\",\"明治\"&AU46&\"年\")","v":""}]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU49=\"\",\"\",DATEDIF(DATE(AU49,BA46,BG46),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO47=\"\",\"\",\"大正\"&AU46&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO49=\"\",\"\",\"昭和\"&AU46&\"年\")","v":""},{"$f":"IF(AO45=\"✓\",TEXT(AT45&\"1月1日\",\"yyyy\"),IF(AO47=\"✓\",TEXT(AT47&\"1月1日\",\"yyyy\"),IF(AO49=\"✓\",TEXT(AT49&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
[]
["〈 担当者への連絡・照会事項 〉"]
["照会目的",null,null,null,null,null,null,null,null,null,null,null,"新規・更新・区分変更後のケアプラン作成時の意見について"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"利用者の医療・看護・介護・症状の医学的意見・指示について"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"サービス担当者会議における意見について"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"福祉用具貸与（購入）について、医師からの医学的意見について"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"医療系サービスを導入するにあたり、主治医の意見・相談など"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"利用者の下記状況についての相談・報告"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"担当ケアマネジャーになった挨拶"]
[]
[]
[null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["〈 相談内容等 〉",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続きは別紙（様式４）へ"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["〈 返信方法 〉"]
[null,null,null,"当連携シートで回答します。"]
[]
[]
[null,null,null,"直接会って話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に",null,null,null,null,null,"来院（来所）希望"]
[]
[]
[null,null,null,"電話で話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に電話を",null,null,null,null,null,null,null,null,"ください",null,null,null,null,null,null,null,null,null,null,null,"します"]
[]
[]
["< 連絡・照会に対するコメント >",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,"特に意見はありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記のとおりです。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記載日：令和",null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[null,null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「安芸いかの会」作成"]

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["様式１－２（歯科医師用）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["多 職 種 連 携 シ ー ト"]
[]
[]
[]
[]
["送信元",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受信先"]
[]
[]
[]
["医療機関・事業所名：",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,"医療機関・事業所名："]
[]
[]
["担当者名：",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,"担当者名："]
[]
[]
["Ｔ Ｅ Ｌ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｔ Ｅ Ｌ ："]
[]
[]
["Ｆ Ａ Ｘ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｆ Ａ Ｘ ："]
[]
[]
["E-mail  ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail  ："]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"< 本票送付の目的 >",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"< 返信希望の有無 >"]
[]
[]
[null,null," 至急",null,null,null,null,null,null,null,null," 報告",null,null,null,null,null," 連絡",null,null,null,null,null," 相談",null,null,null,null,null," 返信",null,null,null,null,null,null,null,null,null,null,null," 返信願います",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 返信不要です"]
[]
[]
[]
["送付枚数",null,null,null,null,null,null,null,null,null,null," 様式１－２",null,null,null,null,null,null,null,null,null,null,null," 様式２",null,null,null,null,null,null,null,null," 様式３",null,null,null,null,null,null,null,null," 様式４",null,null,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,null,null,null,"（本紙）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"送付枚数は",null,null,null,null,null,null,null,{"$f":"IF(OR(K36=\"✓\",W36=\"✓\",AF36=\"✓\",AO36=\"✓\",AX36=\"✓\"),COUNTIF(K36:AX36,\"✓\"),\"\")","v":""},null,null,"枚です。（本紙を含む）"]
[]
[]
["下記の方を担当しています。下記事項についてご指示・ご確認をお願いします。"]
[]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO45=\"\",\"\",\"明治\"&AU46&\"年\")","v":""}]
["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,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU49=\"\",\"\",DATEDIF(DATE(AU49,BA46,BG46),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO47=\"\",\"\",\"大正\"&AU46&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO49=\"\",\"\",\"昭和\"&AU46&\"年\")","v":""},{"$f":"IF(AO45=\"✓\",TEXT(AT45&\"1月1日\",\"yyyy\"),IF(AO47=\"✓\",TEXT(AT47&\"1月1日\",\"yyyy\"),IF(AO49=\"✓\",TEXT(AT49&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
[]
["〈 歯科診療状況 〉"]
["かかりつけ歯科医の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有（医院名：",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,"）"]
[]
[]
["過去の訪問歯科診療利用状況",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有（医院名：",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,"）"]
[]
[]
[]
["〈 連絡・照会事項 〉"]
["照会目的",null,null,null,null,null,null,null,null,null,null,null,"入れ歯の状態",null,null,null,null,null,null,null,null,null,null,null,"⇒",null,null,null,null,null,"痛み",null,null,null,null,null,null,null,null,"破損",null,null,null,null,null,null,null,null,"作成",null,null,null,null,null,null,null,null,"調子が悪い"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"歯の状態",null,null,null,null,null,null,null,null,null,null,null,"⇒",null,null,null,null,null,"痛い",null,null,null,null,null,null,null,null,"虫歯",null,null,null,null,null,null,null,null,"とれた",null,null,null,null,null,null,null,null,null,null,null,"ぐらぐらする"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"歯ぐきの状態",null,null,null,null,null,null,null,null,null,null,null,"⇒",null,null,null,null,null,"痛い",null,null,null,null,null,null,null,null,"出血",null,null,null,null,null,null,null,null,"腫れている"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"口腔ケアの状態",null,null,null,null,null,null,null,null,null,null,null,"⇒",null,null,null,null,null,"口臭",null,null,null,null,null,null,null,null,"清掃"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"口腔機能の状態",null,null,null,null,null,null,null,null,null,null,null,"⇒",null,null,null,null,null,"咀嚼機能",null,null,null,null,null,null,null,null,null,null,null,"摂食嚥下機能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発音機能"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"担当ケアマネジャーになった挨拶"]
[]
[]
[null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["可能な姿勢",null,null,null,null,null,null,null,null,null,null,null,"椅子に座る",null,null,null,null,null,null,null,null,null,null,null,"車椅子に座る",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ベッド等を起こした状態",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寝たままの状態"]
[]
[]
["栄養摂取法",null,null,null,null,null,null,null,null,null,null,null,"経口",null,null,null,null,null,null,null,null,null,null,null,"経管"]
[]
[]
["〈 相談内容等 〉",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"かかりつけ訪問歯科医がいないため困っています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続きは別紙（様式４）へ"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["〈 返信方法 〉"]
[null,null,null,"当連携シートで回答します。"]
[]
[]
[null,null,null,"直接会って話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に",null,null,null,null,null,"来院（来所）希望"]
[]
[]
[null,null,null,"電話で話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に電話を",null,null,null,null,null,null,null,null,"ください",null,null,null,null,null,null,null,null,null,null,null,"します"]
[]
[]
["< 連絡・照会に対するコメント >",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,"特に意見はありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記のとおりです。"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記載日：令和",null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[null,null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「安芸いかの会」作成"]

{"sheet":"（様式１－３）多職種連携（薬剤師用）","index":3,"n_rows":121,"n_cols":71,"rows_kept":121,"cut":false,"hidden":false,"merged":[[120,54,122,72],[0,0,1,19],[76,0,78,8],[76,12,78,21],[76,24,78,33],[52,12,54,34],[109,0,117,72],[118,43,119,53],[118,54,119,56],[118,57,119,59],[118,60,119,62],[118,63,119,65],[118,66,119,68],[118,69,119,72],[103,40,105,44],[103,45,105,51],[103,54,105,63],[103,66,105,72],[106,0,108,23],[106,27,108,43],[106,51,108,72],[100,40,102,44],[103,3,105,20],[103,21,105,23],[103,24,105,26],[103,27,105,29],[103,30,105,32],[103,33,105,37],[103,38,105,39],[52,38,54,51],[120,3,122,53],[82,0,94,72],[96,0,96,72],[97,3,99,23],[100,3,102,20],[100,21,102,23],[100,24,102,26],[100,27,102,29],[100,30,102,32],[100,33,102,37],[100,38,102,39],[100,45,102,47],[100,51,102,72],[67,12,69,72],[70,12,72,72],[73,12,75,18],[73,19,75,69],[73,70,75,72],[79,0,81,11],[79,15,81,72],[46,41,46,44],[48,35,48,37],[48,41,48,44],[51,0,51,72],[52,0,75,8],[55,12,57,72],[58,12,60,72],[61,12,63,72],[64,12,66,72],[45,55,47,57],[45,58,47,60],[45,61,47,63],[45,64,47,66],[45,67,47,69],[45,70,47,72],[52,53,54,63],[52,65,54,72],[40,0,42,72],[43,0,44,8],[43,9,44,31],[44,35,44,37],[44,41,44,44],[45,0,49,8],[45,9,49,31],[45,46,47,48],[45,49,47,51],[45,52,47,54],[34,57,36,69],[34,70,36,72],[37,10,39,17],[37,46,39,53],[37,54,39,56],[37,57,39,72],[34,0,39,8],[34,11,36,20],[34,23,36,29],[34,32,36,38],[34,41,36,47],[34,50,36,56],[27,9,29,36],[27,37,29,72],[30,2,32,8],[30,11,32,15],[30,17,32,21],[30,23,32,27],[30,29,32,33],[30,41,32,56],[30,59,32,72],[20,0,22,8],[20,9,22,36],[20,37,22,45],[20,46,22,72],[23,0,25,8],[23,9,25,36],[23,37,25,45],[23,46,25,72],[14,0,16,8],[14,9,16,36],[14,37,16,45],[14,46,16,72],[17,0,19,8],[17,9,19,36],[17,37,19,45],[17,46,19,72],[0,66,1,68],[0,69,1,72],[2,0,6,72],[7,0,10,36],[7,37,10,72],[11,0,13,14],[11,15,13,36],[11,37,13,51],[11,52,13,72],[0,48,1,53],[0,54,1,56],[0,57,1,59],[0,60,1,62],[0,63,1,65]]}
["様式１－３（薬剤師用）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["多 職 種 連 携 シ ー ト"]
[]
[]
[]
[]
["送信元",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受信先"]
[]
[]
[]
["医療機関・事業所名：",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,"医療機関・事業所名："]
[]
[]
["担当者名：",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,"担当者名："]
[]
[]
["Ｔ Ｅ Ｌ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｔ Ｅ Ｌ ："]
[]
[]
["Ｆ Ａ Ｘ ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｆ Ａ Ｘ ："]
[]
[]
["E-mail  ：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail  ："]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"< 本票送付の目的 >",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"< 返信希望の有無 >"]
[]
[]
[null,null," 至急",null,null,null,null,null,null,null,null," 報告",null,null,null,null,null," 連絡",null,null,null,null,null," 相談",null,null,null,null,null," 返信",null,null,null,null,null,null,null,null,null,null,null," 返信願います",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 返信不要です"]
[]
[]
[]
["送付枚数",null,null,null,null,null,null,null,null,null,null," 様式１－３",null,null,null,null,null,null,null,null,null,null,null," 様式２",null,null,null,null,null,null,null,null," 様式３",null,null,null,null,null,null,null,null," 様式４",null,null,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,null,null,null,"（本紙）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"送付枚数は",null,null,null,null,null,null,null,{"$f":"IF(OR(K36=\"✓\",W36=\"✓\",AF36=\"✓\",AO36=\"✓\",AX36=\"✓\"),COUNTIF(K36:AX36,\"✓\"),\"\")","v":""},null,null,"枚です。（本紙を含む）"]
[]
[]
["下記の方を担当しています。下記事項についてご指示・ご確認をお願いします。"]
[]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO45=\"\",\"\",\"明治\"&AU46&\"年\")","v":""}]
["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,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU49=\"\",\"\",DATEDIF(DATE(AU49,BA46,BG46),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO47=\"\",\"\",\"大正\"&AU46&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO49=\"\",\"\",\"昭和\"&AU46&\"年\")","v":""},{"$f":"IF(AO45=\"✓\",TEXT(AT45&\"1月1日\",\"yyyy\"),IF(AO47=\"✓\",TEXT(AT47&\"1月1日\",\"yyyy\"),IF(AO49=\"✓\",TEXT(AT49&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
[]
["〈 連絡・照会事項 〉"]
["照会目的",null,null,null,null,null,null,null,null,null,null,null,"薬の飲み忘れ・飲み間違いがある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"服薬カレンダー希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"一包化希望　（",null,null,null,null,null,null,null,null,null,null,null,"日付希望）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"薬の量・回数を自分で調整している"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"薬についての理解が得られにくく、服薬拒否もある"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"服薬困難・嚥下困難がある"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"薬剤による副作用が疑われる所見がある"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"処方薬について、患者（介護者）の要望がある"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"処方薬についての薬局（薬剤師）からの提案"]
[]
[]
[null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["栄養摂取法",null,null,null,null,null,null,null,null,null,null,null,"経口",null,null,null,null,null,null,null,null,null,null,null,"経管"]
[]
[]
["〈 相談内容等 〉",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続きは別紙（様式４）へ"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["〈 返信方法 〉"]
[null,null,null,"当連携シートで回答します。"]
[]
[]
[null,null,null,"直接会って話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に",null,null,null,null,null,"来院（来所）希望"]
[]
[]
[null,null,null,"電話で話をします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,null,"～",null,null,null,null,null,null,"に電話を",null,null,null,null,null,null,null,null,"ください",null,null,null,null,null,null,null,null,null,null,null,"します"]
[]
[]
["< 連絡・照会に対するコメント >",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,"特に意見はありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下記のとおりです。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記載日：令和",null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[null,null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「安芸いかの会」作成"]

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["様式２",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,"多職種情報提供シート"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"事業所名：",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,"ＴＥＬ："]
[]
[null,null,null,null,null,null,null,null,null,null,"担当者名：",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,"ＦＡＸ："]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO12=\"\",\"\",\"明治\"&AU13&\"年\")","v":""}]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU16=\"\",\"\",DATEDIF(DATE(AU16,BA13,BG13),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO14=\"\",\"\",\"大正\"&AU13&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO16=\"\",\"\",\"昭和\"&AU13&\"年\")","v":""},{"$f":"IF(AO12=\"✓\",TEXT(AT12&\"1月1日\",\"yyyy\"),IF(AO14=\"✓\",TEXT(AT14&\"1月1日\",\"yyyy\"),IF(AO16=\"✓\",TEXT(AT16&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
["住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族構成図"]
[]
[]
["電話",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"駐車場"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,"無"]
[]
["被保番",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険者"]
[]
[]
["負担割合",null,null,null,null,null,null,null,null,null,null,"１割",null,null,null,null,null,null,null,null,"２割",null,null,null,null,null,null,null,null,"３割",null,null,null,null,null,null,null,null,"給付制限有"]
[]
[]
["介護度",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"障害自立度",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"認知症自立度"]
[]
[]
[null,null,"申請中",null,null,null,null,null,null,null,null,null,null,"要介護１",null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,"Ｂ１",null,null,null,null,null,null,"自立",null,null,null,null,null,"Ⅲa"]
[]
[null,null,"区変中",null,null,null,null,null,null,null,null,null,null,"要介護２",null,null,null,null,null,null,null,null,null,"Ｊ１",null,null,null,null,null,null,null,"Ｂ２",null,null,null,null,null,null,"Ⅰ",null,null,null,null,null,"Ⅲb"]
[]
[null,null,"総合事業",null,null,null,null,null,null,null,null,null,null,"要介護３",null,null,null,null,null,null,null,null,null,"Ｊ２",null,null,null,null,null,null,null,"Ｃ１",null,null,null,null,null,null,"Ⅱa",null,null,null,null,null,"Ⅳ"]
[]
[null,null,"要支援１",null,null,null,null,null,null,null,null,null,null,"要介護４",null,null,null,null,null,null,null,null,null,"Ａ１",null,null,null,null,null,null,null,"Ｃ２",null,null,null,null,null,null,"Ⅱb",null,null,null,null,null,"Ｍ"]
[]
[null,null,"要支援２",null,null,null,null,null,null,null,null,null,null,"要介護５",null,null,null,null,null,null,null,null,null,"Ａ２",null,null,null,null,null,{"$f":"IF(OR(W33=\"✓\",W35=\"✓\",W37=\"✓\",W39=\"✓\",W41=\"✓\",AD33=\"✓\",AD35=\"✓\",AD37=\"✓\",AD39=\"✓\"),IF(OR(W33=\"✓\",W35=\"✓\"),\"自立\",IF(W37=\"✓\",\"杖歩行\",IF(OR(W39=\"✓\",W41=\"✓\"),\"介助歩行\",IF(OR(AD33=\"✓\",AD35=\"✓\"),\"車いす\",IF(OR(AD37=\"✓\",AD39=\"✓\"),\"寝たきり\",\"\"))))))","v":false}]
[]
["緊急時\n連絡先",null,null,null,null,null,null,null,null,"氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"続 柄",null,null,null,null,null,"住　所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[]
[null,null,null,null,null,null,null,null,null,"①"]
[]
[null,null,null,null,null,null,null,null,null,"②"]
[]
["住環境"]
[null,null,null,null,null,null,null,null,null,null,null,"持家",null,null,null,null,null,"賃貸",null,null,null,null,null,"戸建（",null,null,null,null,null,null,null,null,"階建）",null,null,null,null,null,"集合住宅（",null,null,null,null,null,null,null,null,null,null,null,"階）",null,null,null,"エレベーター",null,null,null,null,null,null,null,null,null,"有",null,null,null,"無"]
[]
["保険等\n情報"]
[null,null,null,null,null,null,null,null,null,null,null,"国保",null,null,null,null,null,null,null,"社保",null,null,null,null,null,null,"後期高齢",null,null,null,null,null,null,null,null,"原爆",null,null,null,null,null,null,null,null,"重度医療",null,null,null,null,null,null,null,null,null,null,null,"特定疾患",null,null,null,null,null,null,null,null,null,null,null,"生保"]
[]
[null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["手帳"]
[null,null,null,null,null,null,null,null,null,null,null,"身障（",null,null,null,null,null,null,null,null,"級）",null,null,null,null,null,"療育（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,"精神（",null,null,null,null,null,null,null,null,"級）"]
[]
["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,"医療機関・診療科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主治医",null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[]
[]
[]
[]
["介護保険等サービス利用状況"]
[]
[]
[null,null,"訪問介護（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"訪問入浴（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"短期入所（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,"訪問看護（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"通所介護（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"福祉用具貸与（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,"訪問リハ（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"通所リハ（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"小規模多機能（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"不明"]
[]
["ADL",null,null,null,null,null,null,null,null,"自立",null,null,"見ま\nもり",null,null,"一部\n介助",null,null,"全\n介助",null,null,"要支援者は必要事項のみ記入"]
["移動方法"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"車いす",null,null,null,null,null,null,null,null,"杖使用",null,null,null,null,null,null,null,null,"歩行器使用",null,null,null,null,null,null,null,null,null,null,null,"装具・補装具使用"]
[]
["口腔清潔"]
[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,"有",null,null,null,null,null,"無（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["食事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事形態（",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["入浴"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自宅（浴室）",null,null,null,null,null,null,null,null,null,null,null,"訪問入浴",null,null,null,null,null,null,null,null,"通所系",null,null,null,null,null,null,null,null,"清拭のみ（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["排泄"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"場所：",null,null,null,null,null,null,"トイレ",null,null,null,null,null,null,null,null,"ポータブル",null,null,null,null,null,null,null,null,null,null,null,"尿器",null,null,null,null,null,"オムツ（",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,null,null,null,null,"視覚障害（",null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,"聴力障害（",null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,"言語障害（",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,null,null,null,null,null,null,null,null,null,"残薬：",null,null,null,null,null,null,"無",null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["療養上の問題"]
[null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有（",null,null,null,null,null,"幻視・幻聴",null,null,null,null,null,null,null,null,null,null,null,"興奮",null,null,null,null,null,"不穏",null,null,null,null,null,"妄想",null,null,null,null,null,"暴力",null,null,null,null,null,"難聴",null,null,null,null,null,"転倒歴"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"介護への抵抗",null,null,null,null,null,null,null,null,null,null,null,"昼夜逆転",null,null,null,null,null,null,null,null,null,null,null,"危険行為",null,null,null,null,null,null,null,null,null,null,null,"不潔行為",null,null,null,null,null,null,null,null,null,null,null,"意思疎通困難　）"]
[]
["夜間の状態"]
[null,null,null,null,null,null,null,null,null,null,null,"睡眠薬使用有（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,"良眠",null,null,null,null,null,null,null,null,"不眠",null,null,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,"）"]
[]
["家族との関係・\n介護力等"]
[null,null,null,null,null,null,null,null,null,null,"介護力：",null,null,null,null,null,null,null,null,"協力者がいる",null,null,null,null,null,null,null,null,null,null,null,null,"協力者がいない"]
[]
[null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「安芸いかの会」作成"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["自立",null,null,null,null,null,null,null,null,null,null,null,"杖歩行",null,null,null,null,null,null,null,null,null,null,null,"介助歩行",null,null,null,null,null,null,null,null,null,null,null,"車いす",null,null,null,null,null,null,null,null,null,null,null,"寝たきり"]

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["様式３"]
[]
["多職種連携一覧"]
[]
[]
[]
[]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO10=\"\",\"\",\"明治\"&AU11&\"年\")","v":""}]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU14=\"\",\"\",DATEDIF(DATE(AU14,BA11,BG11),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO12=\"\",\"\",\"大正\"&AU11&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO14=\"\",\"\",\"昭和\"&AU11&\"年\")","v":""},{"$f":"IF(AO10=\"✓\",TEXT(AT10&\"1月1日\",\"yyyy\"),IF(AO12=\"✓\",TEXT(AT12&\"1月1日\",\"yyyy\"),IF(AO14=\"✓\",TEXT(AT14&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,"年",null,null,null,null,null,"月 時点"]
[]
["〈 担当者への連絡・照会事項 〉"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"機関名",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,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号\nFAX番号"]
["かかりつけ医院"]
[]
["医療機関①"]
[]
["医療機関②"]
[]
["歯科医院"]
[]
["薬局①"]
[]
["薬局②"]
[]
["訪問看護①"]
[]
["訪問看護②"]
[]
["ケアマネジャー"]
[]
["介護サービス事業所①"]
[]
["介護サービス事業所②"]
[]
["介護サービス事業所③"]
[]
["地域関係者\n（民生委員等）"]
[]
[]
["〈 家族等介護者の連絡先 〉"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"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,"本人との関係",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
["緊急時の連絡先①"]
["緊急時の連絡先②"]
[]
[null,null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。"]
[]
[]
[null,null,null,"「救急医療情報キット」に入れています。"]
[]
[]
[null,null,null,"「連絡ノート」に添付しています。"]
[]
[]
["「安芸いかの会」作成"]

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["様式４",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["連絡事項・その他"]
[]
[]
[]
[]
[]
["ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,"明治",null,null,null,{"$f":"IF(AO10=\"\",\"\",\"明治\"&AU11&\"年\")","v":""}]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,{"$f":"IF(AU14=\"\",\"\",DATEDIF(DATE(AU14,BA11,BG11),TODAY(),\"Y\"))","v":""},null,null,"歳）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正",null,null,null,{"$f":"IF(AO12=\"\",\"\",\"大正\"&AU11&\"年\")","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,"昭和",null,null,null,{"$f":"IF(AO14=\"\",\"\",\"昭和\"&AU11&\"年\")","v":""},{"$f":"IF(AO10=\"✓\",TEXT(AT10&\"1月1日\",\"yyyy\"),IF(AO12=\"✓\",TEXT(AT12&\"1月1日\",\"yyyy\"),IF(AO14=\"✓\",TEXT(AT14&\"1月1日\",\"yyyy\"),\"\")))","v":""}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,"この情報を提供することについて、ご本人またはご家族から同意を頂いています。"]
[]
[]
["「安芸いかの会」作成"]

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