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{"sheet":"診療情報提供書","index":0,"n_rows":65,"n_cols":24,"rows_kept":65,"cut":false,"hidden":false,"merged":[[0,0,0,23],[38,0,40,0],[38,1,40,23],[31,0,34,0],[31,1,34,2],[27,3,30,23],[27,0,30,0],[27,1,30,2],[1,0,2,23],[3,1,3,2],[5,2,5,10],[19,0,24,1],[25,0,26,1],[5,19,5,20],[6,0,10,1],[11,0,15,1],[43,27,43,29],[44,0,47,0],[44,1,47,2],[51,1,53,23],[7,13,10,23],[7,2,7,12],[9,2,10,12],[31,6,34,23],[44,3,47,4],[44,5,47,23],[35,1,37,23],[41,1,43,23],[19,2,21,23],[22,2,24,23],[25,2,26,23],[16,2,18,23],[54,0,56,0],[56,2,56,23],[61,0,62,3],[61,13,62,15],[61,22,62,22],[58,1,58,2],[59,0,60,3],[59,15,60,16],[55,2,55,23],[16,0,18,1],[5,0,5,1],[5,11,5,12],[5,13,5,17],[11,2,15,23],[51,0,53,0],[35,0,37,0],[41,0,43,0],[31,3,34,5],[48,0,50,0],[48,1,50,23]]}
["第２号様式"]
["診療情報提供書"]
[]
[null,"　　（提出先）",null,"川崎市長　"]
[]
["氏　名",null,null,null,null,null,null,null,null,null,null,"生年月日",null,"年　　月　　日",null,null,null,null,"年　齢","歳",null,"性　別","男","女"]
["診断名",null,"主診断名",null,null,null,null,null,null,null,null,null,null,"既往歴（入院・手術・骨折等主なもの）"]
[]
[null,null,"合併症"]
[]
[]
["経　過"]
[]
[]
[]
[]
["処方内容\n※別紙（処方箋写し）添付可"]
[]
[]
["発作",null,"発作時の状況"]
[]
[]
[null,null,"発作時の対処"]
[]
[]
["アレルギー\n（薬・食事）"]
[]
["気管\n切開","□　なし　□　あり",null,"気切部の状態やカニューレ抜去時の対応等"]
[]
[]
[]
["人工\n呼吸器","□　なし　□　あり",null,"使用状況",null,null,"24時間　　夜間のみ"]
[]
[]
[]
["酸素"]
[]
[]
["吸引"]
[]
[]
["吸入"]
[]
[]
["経管\n栄養","□ 経鼻　　□ 胃瘻　　□ 腸瘻",null,"チューブ\nタイプ\nサイズ・その他"]
[]
[]
[]
["その他の処置","（例）中心静脈栄養、腹膜透析等"]
[]
[]
["急変時の対応等"]
[]
[]
["対象\n要件","以下に該当する状態であると認める。（いずれか該当する□に必ずチェック）"]
[null,"□","高度な医療的ケア（人工呼吸器による常時管理や頻回な吸引、中心静脈栄養、腹膜透析）が必要である"]
[null,"□","上記以外の児童（１８歳未満の方及び１８歳の達する日以降の最初の３月３１日までの間にある方）であり、医療機関での一時的な療養が必要である"]
[]
[null,"（記入日）",null,"　　　　　年　　　月　　　日"]
["医療機関住所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電　話："]
[]
["施　 設　 名：",null,null,null,null,null,null,null,null,null,null,null,null,"医師氏名："]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（自署の場合は押印不要）"]
[null,"※65歳未満の場合、医療的ケアの判定スコアを添付してください"]