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["香川県　在宅緩和ケア　地域連携パス"]
["*　このパスは診療情報提供書の添付資料としてご利用ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記載日",null,"　平成　 　 　年　 　 　月　  　　日　　"]
["ﾌﾘｶﾞﾅ",null,null,null,null,null,null,null,"性別",null,"年齢",null,null,"生年月日"]
["氏名",null,null,null,null,null,null,"様","男・女",null,null,null,"歳"]
[]
["身長",null,null,null,"cm","体重",null,null,null,"kg","血液型",null,null,"　不明　・　A　・　B　・　AB　・　O　",null,null,null,null,null,null,"Rh因子",null,null," Rh (  +  ・  -  ) "]
["感染症；",null,"無　・　有　",null,"（",null,null,null,null,null,"）","アレルギー；　",null,null,"無　・　有　",null,null,"　　（　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,"）"]
["自宅住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[]
["家族構成",null,null,null,null,null,null,null,null,"緊急連絡先①　　　　　　　　　　　　　　　　　　",null,null,"氏名　",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"緊急連絡先②　　　　　　　　　　　　　　　　　",null,null,"氏名　　",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"キーパーソン　  　                        　　　",null,null,"氏名     ",null,null,null,null,"続柄　",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"主介護者　　　　　　　　　　　　　　　　続柄　　　　　",null,null,"氏名",null,null,null,null,"続柄　"]
[null,null,null,null,null,null,null,null,null,"主介護者の健康状態　　　　",null,null,null,null,"　良　・　不良　",null,null,"　　（　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,null,null,"家族に関するコメント："]
[]
[]
["介護保険情報",null,null,null,"認定済 ・未申請・区分変更中・新規申請中・非該当",null,null,null,null,null,null,null,null,null,"介護認定",null,null,"要支援 1 ・ 2　 要介護 1　・ 2　・ 3　・ 4 　・5 "]
[null,null,null,null,"  認定日",null,"平成　   　年　   　月 　  　日　",null,null,null,null,null,null,null,"有効期間",null,null,"平成  　年  　月  　日",null,null,null,"～"," 平成    　年    　月    　日"]
["その他の障害認定（身体障害者手帳、特定疾患など）"]
["緊急入院先",null,null,null,"　未定　・　有　",null,null,null,"　（","紹介病院：",null,null,null,null,null,null,null,null,null,"担当者",null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"　（","紹介病院以外の病院：",null,null,null,null,null,null,null,null,null,"担当者",null,null,null,null,null,"）"]
["心肺蘇生処置拒否\n（DNAR）の確認",null,null,null,"DNARの確認　　　　　",null,null," 未確認　・　確認済　",null,null,null,null,null,"DNAR同意者名あるいは続柄　"]
[null,null,null,null,"確認時期　　　　　　年　　　月　　　日　　",null,"　平成 　　　年　    　月　   　日　",null,null,null,null,null,"頃"]
["代理意思決定者",null,null,null," 未確認　・　確認済　",null,null,null,"　　（　　　　　　　　　　　　　　　　　　　　続柄　　　　　　　　　　　　）","氏名",null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,null,"）"]
["疾患情報",null,null,null,"主病名",null,null,null,null,null,null,"苦痛症状の\n原因病巣",null,null,null,null,null,null,null,"その他の\n転移巣"]
[]
[]
[null,null,null,null,"手術日",null,null,null,null,null,null,"術　式"]
[null,null,null,null,"現病歴\n（治療歴）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"今後起こりうる\n症状・病態"]
[]
[null,null,null,null,"既往歴"]
[]
["病状説明と認識",null,null,null,"本人への\n説明内容"]
[]
[]
[null,null,null,null,"本人の認識",null,null,null,"病状を理解し予後まで理解している　・　原発と転移部位は知っているが予後は理解していない       　 病名（がんであること）は知っている　・　未告知あるいは理解できない状態　・　未確認　"]
[]
[null,null,null,null,"家族への\n説明内容　　　　　　",null,null,"誰に"]
[]
[]
[]
[null,null,null,null,"家族の認識",null,null,null,"病状を理解し予後まで理解している　・　理解が不十分な面がある　・　未確認　"]
[null,null,null,null,"主治医が予測する予後",null,null,null,null,null," 1か月以内　・　1～3か月　・　4～6か月　・　半年以上 "]
["悪い情報の説明",null,null,null,"本人の意思",null,null,null,"聞きたい　・　聞きたくない　・　わからない　・　未確認　"]
[null,null,null,null,"家族の意思",null,null,null,"本人に説明してほしい　・　本人には聞かせたくない　・　わからない　・　未確認　"]
["病状悪化時の対応",null,null,null,"本人の意思",null,null,"病院に入院したい　・緩和ケア病棟に入院したい　・在宅療養を続けたい　・わからない　・未確認　"]
[null,null,null,null,"家族の意思",null,null,"病院に入院させたい 　　 ・　　  緩和ケア病棟に入院させたい 　 ・　　  在宅療養を続けさせたい  　　　　　 　　　　　　　　　　わからない 　 ・　  未確認  　"]
[]
[]
["服薬情報",null,null,null,"麻薬の使用",null,null,"無　・　有　",null,null,null,"薬剤名；                                                        　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,"  1日量　　　　　　　㎎　　　　"]
[null,null,null,null,null,null,null,null,null,null,null,"レスキュー薬名；　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,"　1回量　　　　　　　",null,null,"㎎"]
[null,null,null,null,null,null,null,null,null,null,null,"レスキューの1日回数",null,null,null,null,null,null,null,"　0 ～ 2 回　・　3 ～ 6 回　・　7 回以上　　"]
[null,null,null,null,"薬剤情報",null,null," 無 ・ 有 ",null,null,null,"（薬剤情報提供書やおくすり手帳などのコピーを添付してください　）"]
[null,null,null,null,"上記がない場合\n処方薬記載"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"服薬管理　　",null,null,null," 自己管理できる　・　家族が管理する　・　不安がある（頻回に医療者のチェックが必要）　"]
[null,null,null,null,"薬剤コメント"]
[]
["医療処置",null,null,null,"輸　液　　　　　　　　",null,null,"不要・要",null,null,null,null,"　cc、","頻度：",null,"毎日・隔日・時々",null,null,null,"　輸液剤名　　　　　　　　　　",null,null,null,null,null,"）"]
[null,null,null,null,"CVﾎﾟｰﾄ・CVﾙｰﾄ　　　",null,null,"無・有",null,null,"（部位　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,"PEG・経鼻ﾁｭｰﾌﾞ　　　",null,null,"無・有"]
[null,null,null,null,"ストマ　　　　　　　　　　",null,null,"無・有"]
[null,null,null,null,"尿ﾊﾞﾙｰﾝ・腎ろう　　",null,null,"無・有",null,null,null,"サイズ　　　　　　　",null,null,"　Fr",null,"　最終交換日　　　",null,null," 　　　　　　年　     　月　    　日"]
[null,null,null,null,"在宅酸素療法　　　　",null,null,"不要・要",null,null,"（",null,null,null,"ﾘｯﾄﾙ　）"]
[null,null,null,null,"気管ｶﾆｭｰﾚ　　　　　　",null,null,"無・有",null,null,"ﾒｰｶｰ",null,null,"製品名：　　　　　 　　　",null,null,null,"サイズ： 　",null,null,"Fr 最終交換日",null,null,"　　　　年     月     日",null,null,null,null,null,"　"]
[null,null,null,null,"ｲﾝｽﾘﾝ注射　　　　　　",null,null,"不要・要",null,null,"（薬剤名・投与量　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,"褥　瘡　　　　　　　　　",null,null,"無・有",null,null,"（部位　　　　　　　",null,null,null,null,"処置内容　",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,"処置コメント（交換が必要な医療材料はメーカー名、製品名、サイズ、交換頻度、最終交換日を記入してください）"]
[]
[]
["認知・精神状態",null,null,null,"認知症",null,null," 無　・　有　",null,null,null," 軽度 ・ 中等度 ・ 重度　"]
[null,null,null,null,"せん妄",null,null," 無　・　有　",null,null,null," 軽度 ・ 中等度 ・ 重度　"]
[null,null,null,null,"夜間睡眠",null,null," 良　・　不良　",null,null,null,"睡眠導入剤の使用",null,null,null,null,"無・有",null,"( 常用・ 時々 ）",null,null,"(薬品名：",null,null,null,"）"]
[null,null,null,null,"認知・精神\n　　コメント"]
[]
[null,null,null,null," 入院中　・　在宅　",null,null,null,null,"　での状況",null,null,null,null,"療養上の留意点"]
["食事摂取","食事",null,"自立・見守り・一部介助・全介助・経管栄養・輸液",null,null,null,null,null,null,null,null,null,null,"食事内容：",null,null,"　一般食　・　特別食　",null,null,null,"　　（　　　　　　　",null,null,null,"）"]
[null,"形態",null," 主食　（",null,"　常食　・　粥　・　ミキサー　・　なし",null,null,null,null,null,null,null,"）",null,null,null,null,null,null,"Kcal",null,null,null,"g"]
[null,null,null," 副食　（",null,"普通・ソフト食・刻み・ペースト・なし",null,null,null,null,null,null,null,"）","禁止食品"]
[null,null,null," とろみ",null," 無　・　有　",null,null,"（　",null,null,null,null," )","経管栄養剤名・量"]
[null,null,null,"嚥下",null," 良　・　不良　"]
["排泄","排尿",null,"自立・　見守り・一部介助・全介助・　おむつ・　カテーテル",null,null,null,null,null,null,null,null,null,null,"最終排便日",null,null,"      月　　　日　"]
[null,"排便",null,"自立　・　見守り　・一部介助　・全介助　・　おむつ　",null,null,null,null,null,null,null,null,null,null,"排便状況（",null,null,null,"日/1回）",null,"排便ｺﾝﾄﾛｰﾙ　　",null,null,"不要・要"]
[null,"失禁",null,"　無　・　有　",null,null,"（　",null,null,null,null,null,null,"　)","便秘薬使用状況："]
["入浴","洗身",null,"自立・見守り・一部介助・全介助・行っていない　",null,null,null,null,null,null,null,null,null,null,"入浴の制限　：",null,null,null,"　無　・　有　"]
[null,"方法",null,"一般浴　・　シャワー浴　・機械浴　・清拭　　",null,null,null,null,null,null,null,null,null,null,"体温",null,null,"度以上中止",null,null,"血圧",null,null,null,"mmHg以上中止"]
["移動","歩行",null,"自立　・　見守り　・一部介助　・全介助　　",null,null,null,null,null,null,null,null,null,null,"運動制限：",null,null,null,null,"　無　・　有　"]
[null,"移乗",null,"自立　・　見守り　・一部介助　・全介助　　",null,null,null,null,null,null,null,null,null,null,"住宅改修の必要性等：",null,null,null,null,"　無　・　有　",null,"（",null,null,null,"）"]
[null,"方法",null,"独歩　・　杖　・老人車　・歩行器　・　車いす　・その他　"]
["口腔清潔",null,null,"自立　・　見守り　・一部介助　・全介助　　",null,null,null,null,null,null,null,null,null,null,"　義歯",null,"　無　・　有　"]
["その他\n療養上の\n留意事項"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,"情報提供\n医療機関名",null,null,null,null,null,null,null,null,"所　属",null,null,null,null,null,"医師氏名"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"所　属",null,null,null,null,null,"看護師氏名"]

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["香川県　在宅緩和ケア　地域連携パス"]
["*　このパスは診療情報提供書の添付資料としてご利用ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記載日",null,"平成　　　　　　　年　　　　月　　　　日"]
["ﾌﾘｶﾞﾅ",null,null,null,null,null,null,null,"性別",null,"年齢",null,null,"生年月日",null,null,"大正\n昭和\n平成"]
["氏名",null,null,null,null,null,null,"様","男・女",null,null,null,"歳",null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[]
["身長",null,null,null,"cm","体重",null,null,null,"kg","血液型",null,null,"　不明・ A　・B　・AB　・O　　　　Rh（　＋　・　ー　）"]
["感染症； 無　・　有　　（　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,"アレルギー；　無　・　有　　　（　　　　　　　　　　　　　　　　　　　　　　　）"]
["自宅住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[]
["家族構成",null,null,null,null,null,null,null,null,"緊急連絡先①　　　　　　　　　　　　　　　　　　　",null,null,"氏名　",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"緊急連絡先②　　　　　　　　　　　　　　　　　　",null,null,"氏名　　",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"キーパーソン　 　                       ",null,null,"氏名    ",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"主介護者  　　　　　　　　　　　　　　　　　　　　",null,null,"氏名　",null,null,null,null,"続柄",null,null,"携帯"]
[null,null,null,null,null,null,null,null,null,"主介護者の健康状態　　　　良　・　不良　（　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,"家族に関するコメント；"]
[]
[]
["介護保険情報",null,null,null," 認定済・未申請・区分変更中・新規申請中・非該当",null,null,null,null,null,null,null,null,null,"介護認定",null,null,"　要支援１　2　 要介護　1　　2　　3　　4　　5"]
[null,null,null,null," 認定日",null,"平成　　　年　　　　月　　　　日",null,null,null,null,null,"有効期間",null,"平成　　　年　　　月　　　日　～　平成　　　年　　　月　　　日"]
["その他の障害認定（身体障害者手帳、特定疾患など）"]
["緊急入院先",null,null,null,"未定　・　有",null,null,null,"（紹介病院：　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,"担当者　　　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"（紹介元以外の病院：　　　　　　　　　　　　　　　  ",null,null,null,null,null,null,null,null,"担当者　　　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,"）"]
["心肺蘇生処置拒否\n（DNAR）の確認",null,null,null,"DNARの確認　　　　　",null,null,"未確認　・　確認済",null,null,null,null,null,"DNAR同意者名あるいは続柄　"]
[null,null,null,null,"確認時期　　　　　　年　　　月　　　日　　",null,null,null,null,null,null,null,"頃"]
["代理意思決定者",null,null,null,"　未確認　・　確認済 　　（氏名　　　　　　　　　　　　　　　　　続柄　　　　　　　　　　　　　　　）"]
["疾患情報",null,null,null,"主病名",null,null,null,null,null,null,"苦痛症状の\n原因病巣",null,null,null,null,null,null,null,"その他の\n転移巣"]
[]
[]
[null,null,null,null,"手術日",null,"　　　　年　　　月　　　 日",null,null,null,null,"術　式"]
[null,null,null,null,"現病歴\n（治療歴）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"今後起こりうる\n症状・病態"]
[]
[null,null,null,null,"既往歴"]
[]
["病状説明と認識",null,null,null,"本人への\n説明内容"]
[]
[]
[null,null,null,null,"本人の認識",null,null,"病状を理解し予後まで理解している　・　原発と転移部位は知っているが予後は理解していない　　\n病名（がんであること）は知っている　・　　未告知あるいは理解できない状態　・　未確認"]
[]
[null,null,null,null,"家族への\n説明内容　　　　　　",null,null,"誰に",null,"　　　　　　　　　"]
[]
[]
[]
[null,null,null,null,"家族の認識",null,null,"　病状を理解し予後まで理解している　・　理解が不十分な面がある　・　未確認"]
[null,null,null,null,"主治医が予測する予後",null,null,null,null,"　１か月以内　・　１～3か月　・　4～6か月　・　半年以上"]
["悪い情報の説明",null,null,null,"本人の意思",null,null,"　聞きたい　・　聞きたくない　・　わからない　・　未確認"]
[null,null,null,null,"家族の意思",null,null,"本人に説明してほしい　・　本人には聞かせたくない　・　わからない　・　未確認"]
["病状悪化時の対応",null,null,null,"本人の意思",null,null,"病院に入院したい　・緩和ケア病棟に入院したい　・在宅療養を続けたい　・わからない　・未確認"]
[null,null,null,null,"家族の意思",null,null,"病院に入院させたい　・緩和ケア病棟に入院させたい　・在宅療養を続けさせたい　\n　わからない　・　未確認"]
[]
[]
["服薬情報",null,null,null,"麻薬の使用",null,null,"　無　・　有　　薬剤名；　　　　　　　　　　　　　　　　　　　　　　　　 　1日量　　　　　　ｍｇ　\n　　　　　　　　　レスキュー薬名：　　　　　　　　　　　　　　　　　　　　1回量　　　　　　ｍｇ　　　　　　　　　　　　　　　　　　　　　　　　　　　　\n　　　　　　　　　レスキューの1日回数：　0～2回　・　3～6回　・　7回以上"]
[]
[]
[null,null,null,null,"薬剤情報",null,null,"　無　・　有　（薬剤情報提供書やおくすり手帳などのコピーを添付してください　）"]
[null,null,null,null,"上記がない場合\n処方薬記載"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"服薬管理　　",null,null,"　自己管理できる　・　家族が管理する　・　不安がある（頻回に医療者のチェックが必要）"]
[null,null,null,null,"薬剤コメント"]
[]
["医療処置",null,null,null,"輸　液　　　　　　　　",null,null,"　不要　・　要",null,null,"　（　　　　　　　cc、　頻度：　",null,null,null,null,"毎日・隔日・時々　　",null,null,null,"　輸液剤名　　　　　　　　　　　）"]
[null,null,null,null,"CVﾎﾟｰﾄ・CVﾙｰﾄ　　　",null,null,"　　無　・　有　　",null,null,"（部位　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,"PEG・経鼻ﾁｭｰﾌﾞ　　　",null,null,"無　・　有"]
[null,null,null,null,"ストマ　　　　　　　　　　",null,null,"　無　・　有　"]
[null,null,null,null,"尿ﾊﾞﾙｰﾝ・腎ろう　　",null,null,"無　・　有",null,null,null,"サイズ　　　　　　　　Fr",null,null,null,null,"　　　最終交換日　   　　　   　年　　　　月　　　　日"]
[null,null,null,null,"在宅酸素療法　　　　",null,null,"　不要　・　要　",null,null,"（　　　　　　ﾘｯﾄﾙ　）　"]
[null,null,null,null,"気管ｶﾆｭｰﾚ　　　　　　",null,null,"無　・　有",null,null,"メーカー：　　　　　製品名：　　　　サイズ：　　　Fr　最終交換日　　　年　　　月　　日　　"]
[null,null,null,null,"ｲﾝｽﾘﾝ注射　　　　　　",null,null,"不要　・　要",null,null,"（薬剤名・投与量　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,"褥　瘡　　　　　　　　　",null,null,"無　・　有",null,null,"（部位　　　　　　　処置内容　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,null,null,"処置コメント（交換が必要な医療材料はメーカー名、製品名、サイズ、交換頻度、最終交換日を記入してください）"]
[]
[]
["認知・精神状態",null,null,null,"認知症",null,null,null,"　無　・　有　",null,null,"（軽度　・　中等度　・　重度）"]
[null,null,null,null,"せん妄",null,null,null,"　無　・　有　",null,null,"（軽度　・　中等度　・　重度）"]
[null,null,null,null,"夜間睡眠",null,null,null,"良　・　不良　  （睡眠導入剤の使用　無　・　有　（常用・時々）薬品名：　　　　　　　　　　　　）"]
[null,null,null,null,"認知・精神\n　　コメント"]
[]
["入院中　・　在宅　での状況",null,null,null,null,null,null,null,null,null,null,null,null,null,"療養上の留意点"]
["食事摂取","食事",null,"　　自立・見守り・一部介助・全介助・経管栄養・輸液",null,null,null,null,null,null,null,null,null,null,"食事内容：",null,null,"一般食・特別食",null,null,null,"（　　　　　　　　　）"]
[null,"形態",null," 主食",null,"　（","常食・粥・ﾐｷｻｰ・なし",null,null,null,null,null,null,"）",null,null,null,null,null,null,"Kcal",null,null,null,"g"]
[null,null,null," 副食",null,"　（","普通・ｿﾌﾄ食・刻み・ペースト・なし",null,null,null,null,null,null,"）","禁止食品"]
[null,null,null," とろみ",null,"無・有",null,null,"（　",null,null,null,null," )","経管栄養剤名・量"]
[null,null,null,"嚥下",null,"良・不良"]
["排泄","排尿",null,"　　自立・見守り・一部介助・全介助・おむつ・カテーテル",null,null,null,null,null,null,null,null,null,null,"最終排便日",null,null,"月　　　日"]
[null,"排便",null,"　　自立・見守り・一部介助・全介助・おむつ",null,null,null,null,null,null,null,null,null,null,"排便状況",null,null,"（　　　　日/1回）",null,null,null,"排便ｺﾝﾄﾛｰﾙ　　",null,null,"不要・要"]
[null,"失禁",null,"無・有",null,null,"（　",null,null,null,null,null,null,"　)","便秘薬使用状況："]
["入浴","洗身",null,"　　自立・一部介助・全介助・行っていない",null,null,null,null,null,null,null,null,null,null,"入浴の制限　：　無　・　有　（　　　　　　　　　　　　　　　　　　　）"]
[null,"方法",null,"　　一般浴・シャワー浴・機械浴・清拭",null,null,null,null,null,null,null,null,null,null,"体温",null,null,"度以上中止",null,null,"血圧",null,"mmHg以上中止"]
["移動","歩行",null,"　　自立・見守り・一部介助・全介助",null,null,null,null,null,null,null,null,null,null,"運動制限：",null,null,null,null,"無・有"]
[null,"移乗",null,"　　自立・見守り・一部介助・全介助",null,null,null,null,null,null,null,null,null,null,"住宅改修の必要性等：",null,null,null,null,"無・有",null,"（","）"]
[null,"方法",null,"　　独歩・杖・老人車・歩行器・車椅子・その他"]
["口腔清潔",null,null,"　　自立・見守り・一部介助・全介助",null,null,null,null,null,null,null,null,null,null,"　義歯　：無・有"]
["その他\n療養上の\n留意事項"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,"情報提供\n医療機関名",null,null,null,null,null,null,null,null,"所　属",null,null,null,null,null,"医師氏名"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"所　属",null,null,null,null,null,"看護師氏名"]