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["【FAX返信用】  FAX：098-857-0947　"]
[null,"小禄病院　地域連携室　行"]
[null,"レスパイト入院申込書"]
[]
[null,"申込日",null,null,null,null,20,null,null,null,"年",null,null,"月",null,null,"日"]
[null,"在宅主治医\n医療機関名"]
[null,"医師名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主治医より\n入院申込許可"]
[null,"【申込記入者の情報】"]
[null,"事業所名"]
[null,"担当者名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"職種"]
[null,"TEL",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
[null,"【患者情報】"]
[null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別"]
[null,"患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,"住所",null,null,null,null,"〒"]
[null,null,null,null,null,null,"沖縄県"]
[]
[null,"入院希望期間\n（14日以内）",null,null,null,null,20,null,null,null,"年",null,null,"月",null,null,"日　～",null,null,20,null,null,null,"年",null,null,"月",null,null,"日"]
[null,"主病名"]
[null,"【患者状態、医療提供等】"]
[null,null,"▼該当の項目にチェックを入れてください。"]
[null,null,null,null,"寝たきり",null,null,null,null,null,null,null,null,"喀痰吸引",null,null,null,null,null,null,null,null,"気管切開"]
[]
[null,null,null,null,"在宅酸素",null,null,null,null,null,null,null,null,"人工呼吸器",null,null,null,null,null,null,null,null,"腎瘻"]
[]
[null,null,null,null,"胃ろう",null,null,null,null,null,null,null,null,"腸ろう",null,null,null,null,null,null,null,null,"経鼻経管栄養"]
[]
[null,null,null,null,"中心静脈栄養",null,null,null,null,null,null,null,null,"麻薬使用",null,null,null,null,null,null,null,null,"ストマ"]
[]
[null,null,null,null,"褥瘡等創傷処置（",null,null,null,null,null,null,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,"▼その他の情報・連絡事項等"]
[]
[]
[]
[]
[null,"【申込時のお願い】医療・ケア継続のために下記書類についてもFAXにてお送りください。"]
[null,"　①在宅主治医からの情報提供書"]
[null,"　②訪問看護、ケアマネージャー等からの入院時情報シート"]
[null,"　③１日の具体的なケア計画（個別の注意点についての情報）"]
[null,"　※ご提供いただいた情報より判定会議にて入院を検討いたします。ご協力をお願いします。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"小禄病院"]

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["主治医より入院申込の許可","性別","生年月日"]
["有","男","M"]
["無","女","T"]
[null,null,"S"]
[null,null,"H"]
[null,null,"R"]