{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["峡南地域入院時情報提供書（1）","峡南地域入院時情報提供書（2）","峡南地域入院時情報提供書（3）"],"not_rendered":{"charts":0,"images":7,"macros":1,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"峡南地域入院時情報提供書（1）","index":0,"n_rows":47,"n_cols":29,"rows_kept":47,"cut":false,"hidden":false,"merged":[[5,1,5,11],[5,14,5,25],[6,4,6,11],[6,18,6,25],[6,14,6,17],[17,18,17,20],[16,6,16,14],[15,18,16,19],[12,0,12,25],[13,1,14,4],[13,5,13,6],[13,12,13,13],[13,17,13,18],[14,5,14,6],[15,20,16,20],[17,5,17,6],[17,8,17,9],[7,4,7,11],[7,18,7,25],[8,14,8,15],[23,28,23,36],[24,1,24,4],[24,9,24,10],[24,11,24,13],[18,8,18,24],[19,1,21,4],[19,6,19,7],[19,11,19,12],[19,14,19,15],[20,5,20,14],[21,6,21,8],[21,14,21,16],[17,1,18,4],[18,5,18,7],[28,28,28,38],[29,7,29,8],[30,1,30,4],[30,5,30,8],[25,20,25,24],[27,0,27,25],[28,1,29,4],[28,8,28,10],[28,12,28,13],[28,15,28,16],[28,17,28,24],[25,1,25,4],[25,6,25,7],[25,9,25,10],[25,12,25,13],[8,16,8,17],[8,12,8,13],[9,16,9,17],[13,14,13,15],[17,14,17,15],[17,11,17,12],[15,15,16,17],[38,1,39,4],[38,6,38,25],[39,5,39,25],[41,0,41,25],[34,1,34,4],[34,5,34,25],[35,1,35,4],[35,5,35,25],[36,1,37,4],[36,6,36,25],[37,5,37,25],[31,1,31,4],[33,0,33,25],[31,5,31,8],[22,1,22,4],[22,24,22,25],[23,1,23,4],[23,23,23,25],[25,15,25,16],[25,18,25,19],[46,0,46,25],[60,0,60,25],[14,12,14,13],[13,7,13,11],[14,7,14,11],[42,1,43,4],[42,5,42,25],[43,6,43,11],[43,13,43,14],[43,15,43,24],[15,21,16,22],[15,23,16,23],[15,24,16,25],[15,1,16,4],[15,6,15,7],[15,9,15,11]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,"峡南地域入院時情報提供書（1）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日：","R",null,"年",null,"月　",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入院日：","R",null,"年",null,"月　",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"情報提供日：","R",null,"年",null,"月　",null,"日",null,null,"　　　　　　　　"]
[]
[null,"＜医療機関＞　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,"＜居宅介護支援事業所＞　　　　　　"]
[null,"医療機関名：",null,null,null,null,null,null,null,null,null,null,null,null,"事業所名："]
[null,"ご担当者名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ケアマネジャー氏名："]
[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,null,null,null,null,null,null,null,null,null,"FAX：",null,null,"-",null,"-"]
[null,"利用者(患者)／家族の同意に基づき、利用者情報(身体・生活機能など)の情報を提供します。是非ご活用下さい。"]
[]
["１．利用者(患者)基本情報について"]
[null,"患者氏名",null,null,null,"（ﾌﾘｶﾞﾅ）　　　",null,null,null,null,null,null,"年齢",null,null,null,"　才","性別",null,"  ","男　 ",null," 女"]
[null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,"  ","明","  ","大","  ","昭",null,"年",null,"月 ",null,"日"]
[null,"住所",null,null,null,"〒",null,null,"―",null,null,null,null,null,null,"電話番号",null,null,null,null,"―",null,null,"―"]
[]
[null,"住環境\n　※可能ならば、\n「写真」などを添付",null,null,null," 住居の種類(",null,null,"戸建て",null,null,"集合住宅",null,null,"階建て.",null,"居室",null,"階．エレベーター(",null,null,null,"有",null,"無","）"]
[null,null,null,null,null," 特記事項（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"入院時の\n要介護度",null,null,null,null,"要支援（",null,null,"）",null,"要介護（",null,null,"）有効期間：",null,null,null,"年",null,"月 ",null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"～",null,null,"年",null,"月 ",null,"日"]
[null,null,null,null,null,null,"申請中（申請日",null,null,null,"/",null,"）",null,"区分変更（申請日",null,null,null,"/",null,"）",null,"未申請"]
[null,"障害高齢者の\n日常生活自立度",null,null,null,"                ","自立",null,"J１",null,"J２",null,"A１",null,"A２",null,"B１",null," B２ ",null,"C１ ",null,"C２",null,"医師の判断"]
[null,"認知症高齢者の\n日常生活自立度",null,null,null,"                ","自立",null,"Ⅰ",null,"Ⅱa",null,"Ⅱb",null,"Ⅲa ",null,"Ⅲb ",null,"Ⅳ  ",null,"　M",null,null,"ケアマネジャーの判断"]
[null,"介護保険の\n自己負担割合",null,null,null,"　",null,"割",null,"不明",null,"障害など認定",null,null,"　","なし　",null,"あり（",null,"身体",null,"精神",null,"知的","）"]
[null,"年金などの種類",null,null,null,null,"国民年金",null,null,"厚生年金",null,null,"障害年金",null,null,"生活保護　",null,null,"その他（",null,null,null,null,null,null,"）"]
[]
["２．家族構成／連絡先について"]
[null,"世帯構成",null,null,null,null,"独居",null,"高齢者世帯",null,null,null,"子と同居 ",null,null,"その他（",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"＊",null,"日中独居"]
[null,"主介護者氏名",null,null,null,null,null,null,null,"（続柄　　",null,"・",null,"才）",null,"同居",null,"別居",null,null,"TEL",null,"―",null,"―"]
[null,"キーパーソン",null,null,null,null,null,null,null,"（続柄　　",null,"・",null,"才）","TEL",null,"―",null,"―",null,"TEL",null,"―",null,"―"]
[]
["３．本人／家族の意向について"]
[null,"本人の趣味・興味・関心領域等"]
[null,"本人の生活歴"]
[null,"入院前の本人の\n生活に対する\n意向",null,null,null,null,"同封の居宅サービス計画（１）参照"]
[]
[null,"入院前の家族の\n生活に対する\n意向",null,null,null,null,"同封の居宅サービス計画（１）参照"]
[]
[]
["４．入院前の介護サービスの利用状況について"]
[null,"入院前の介護\nサービスの\n利用状況",null,null,null,"同封の書類をご確認ください。\n"]
[null,null,null,null,null,null,"居宅サービス計画書1.2.3表",null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"＊＝診療報酬　退院支援加算１．２「退院困難な患者の要因」に関連"]
[]
["峡南地域在宅医療・介護連携検討会"]

{"sheet":"峡南地域入院時情報提供書（2）","index":1,"n_rows":35,"n_cols":30,"rows_kept":35,"cut":false,"hidden":false,"merged":[[29,16,29,18],[29,20,29,21],[29,23,29,25],[30,6,30,7],[30,8,30,12],[30,19,30,20],[31,16,31,17],[31,18,31,19],[31,20,31,22],[31,6,31,7],[31,8,31,12],[24,7,24,12],[24,13,24,16],[24,17,24,19],[24,20,24,24],[24,1,24,2],[13,1,14,4],[14,6,14,7],[14,8,14,23],[19,17,19,24],[15,1,15,4],[15,5,15,25],[10,1,12,4],[11,6,11,10],[12,6,12,10],[7,6,7,7],[8,6,8,21],[9,6,9,9],[9,11,9,13],[9,14,9,17],[9,18,9,19],[10,6,10,10],[4,29,4,36],[4,1,5,4],[4,8,4,9],[4,11,4,15],[4,17,4,18],[4,21,4,22],[5,6,5,7],[5,8,5,21],[34,1,34,25],[20,1,20,9],[17,0,17,25],[18,1,18,9],[19,1,19,9],[30,1,31,5],[30,13,31,15],[28,0,28,23],[29,1,29,5],[29,6,29,12],[29,13,29,15],[26,1,26,5],[26,6,26,25],[25,1,25,2],[22,0,22,23],[24,4,24,5],[23,12,23,15],[23,1,23,2],[23,7,23,10],[23,20,23,21],[23,22,23,24],[2,0,2,25],[3,1,3,4],[3,5,3,25],[9,1,9,4],[6,1,8,4],[6,6,6,7],[9,22,9,23],[9,20,9,21]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,"峡南地域入院時情報提供書（2）"]
[]
["５．今後の在宅生活の展望について（ケアマネジャーとしての意見）"]
[null,"在宅生活に\n必要な要件"]
[null,"退院後の世帯状況",null,null,null,null,"独居",null,"高齢世帯",null,null,"子と同居（家族構成員数",null,null,null,null,null,"名　）",null,"＊",null,"日中独居　"]
[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,"世帯に対する配慮",null,null,null,null,"不要"]
[null,null,null,null,null,null,"必要"]
[null,null,null,null,null,"（　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"退院後の主介護者",null,null,null,null,"本シート２に同じ",null,null,null,null,"左記以外（氏名",null,null,null,null,null,null,"・　続柄",null,null,null,"・ 　年齢",null,null,"才）"]
[null,"介護力*",null,null,null,"","介護力が見込める      (",null,null,null,null,null,"十分",null,"一部","）"]
[null,null,null,null,null,null,"介護力は見込めない　"]
[null,null,null,null,null,null,"家族や支援者はいない"]
[null,"家族や同居者等による虐待の疑い*",null,null,null,null,"なし"]
[null,null,null,null,null,null,"あり（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"特記事項"]
[]
["６．カンファレンス等について（ケアマネジャーからの希望）"]
[null,"「院内の多職種カンファレンス」への参加",null,null,null,null,null,null,null,null,null,"希望あり"]
[null,"「退院前カンファレンス」への参加",null,null,null,null,null,null,null,null,null,"希望あり",null,"・具体的な要望（",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"「退院前訪問指導」を実施する場合の同行",null,null,null,null,null,null,null,null,null,"希望あり"]
[]
["７．お薬について　　　※必要に応じて、「お薬手帳（コピー）」を添付"]
[null,"内服薬",null,""," なし　",null,"あり（",null,null,null,null,"）","居宅療養管理指導",null,null,null,"　"," なし　",null," あり","（職種：",null,null,null,null,"）"]
[null,"薬剤管理",null,"　　　　　　　　　","自己管理",null,null,"他者による管理　（管理者：",null,null,null,null,null,null,null,null,null,"　・管理方法：",null,null,null,null,null,null,null,"）"]
[null,"服薬状況",null,"　","処方通り服用",null,null,null,"時々飲み忘れ",null,null,null,"飲み忘れが多い、処方が守られていない",null,null,null,null,null,null,null,null,"服薬拒否"]
[null,"お薬に関する特記事項"]
[]
["８．かかりつけ医について"]
[null,"かかりつけ医機関名",null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,null,null,null,"―",null,null,"―"]
[null,"医師名",null,null,null,null,"（ﾌﾘｶﾞﾅ）　",null,null,null,null,null,null,"診察方法\n・頻度",null,null,"　","通院",null,"訪問診療"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・頻度＝（",null,null,null,"）回　／　月 ",null,null,null,null,null,null,null,null,"　　　　　　　　　"]
[null,"*＝診療報酬　退院支援加算１．２「退院困難な患者の要因」に関連"]
[]
[null,"峡南地域在宅医療・介護連携検討会"]

{"sheet":"峡南地域入院時情報提供書（3）","index":2,"n_rows":48,"n_cols":27,"rows_kept":48,"cut":false,"hidden":false,"merged":[[22,21,22,25],[3,20,3,24],[47,1,47,25],[18,5,18,25],[46,14,46,23],[21,3,21,4],[21,14,21,16],[22,3,22,4],[22,14,22,16],[23,3,23,4],[17,1,18,4],[17,5,17,7],[14,14,14,17],[5,13,5,15],[13,14,13,17],[6,13,6,15],[20,1,20,4],[20,12,20,14],[10,1,12,1],[10,2,10,4],[11,2,11,4],[12,2,12,4],[12,10,12,11],[11,20,11,25],[2,0,2,23],[3,1,3,4],[3,13,3,15],[4,1,9,1],[4,2,4,4],[6,2,6,4],[4,13,4,15],[5,2,5,4],[7,2,7,4],[8,2,8,4],[9,2,9,4],[6,21,6,22],[7,13,7,17],[8,13,9,25],[15,14,15,17],[16,14,16,17],[19,12,19,14],[15,21,15,22],[10,15,10,16],[12,16,12,17],[19,19,19,25],[13,1,14,1],[13,2,13,4],[14,2,14,4],[15,1,16,1],[15,2,15,4],[16,2,16,4],[19,1,19,4],[14,12,14,13],[14,9,14,10],[14,6,14,7],[19,9,19,10],[45,1,45,4],[36,1,38,1],[38,2,38,4],[34,5,34,25],[43,5,43,25],[31,1,35,4],[35,5,35,25],[39,1,44,4],[44,5,44,25],[45,11,45,21],[41,16,41,18],[41,20,41,23],[42,6,42,8],[42,10,42,11],[42,18,42,19],[42,12,42,15],[42,20,42,24],[36,2,37,4],[40,8,40,9],[40,11,40,12],[40,14,40,15],[40,17,40,18],[40,20,40,21],[40,23,40,24],[31,26,33,33],[32,6,32,7],[32,9,32,10],[32,12,32,15],[32,17,32,19],[33,6,33,7],[33,8,33,22],[32,21,32,22],[10,6,10,7],[13,6,13,7],[13,9,13,10],[13,12,13,13],[11,16,11,19],[29,5,29,25],[16,21,16,22],[20,10,20,11],[20,20,20,25],[21,6,21,7],[21,9,21,10],[12,20,12,21],[10,17,10,18],[23,18,23,19],[23,21,23,22],[23,24,23,25],[21,1,25,2],[24,5,24,6],[25,5,25,25],[26,26,28,34],[27,6,27,7],[27,11,27,12],[27,16,27,18],[27,20,27,22],[28,6,28,7],[28,11,28,12],[28,14,28,15],[28,17,28,18],[28,19,28,24],[26,1,30,4],[30,5,30,25],[22,9,22,10],[21,12,21,13],[22,6,22,7],[23,6,23,7],[23,14,23,16],[23,9,23,10],[22,12,22,13],[23,12,23,13],[21,21,21,24],[41,8,41,10],[41,12,41,14],[36,26,37,33],[36,8,36,9],[36,10,36,17],[37,6,37,7],[37,14,37,15],[38,6,38,10],[38,12,38,17],[38,19,38,21],[36,20,36,21]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,"峡南地域入院時情報提供書（3）"]
[]
["９．身体・生活機能の状況／療養生活上の課題について"]
[null,"麻痺の状況",null,null,null,null,"なし",null,"軽度",null,"中度",null,"重度","褥瘡の有無",null,null," ","なし　",null,"あり（",null,null,null,null,null,"）"]
[null,"ADL","移　　動",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助","移動(室内)",null,null,null,"杖",null,"歩行器",null,"車いす",null,null,"その他"]
[null,null,"移　　乗",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助","移動(屋外）",null,null,null,"杖",null,"歩行器",null,"車いす",null,null,"その他"]
[null,null,"更　　衣",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助","起居動作",null,null,null,"自立",null,"見守り",null,"一部介助",null,null,"全介助"]
[null,null,"整　　容",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助","ＡＤＬに関する特記事項"]
[null,null,"入　　浴",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助"]
[null,null,"食　　事",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助"]
[null,"食事内容","食事回数",null,null,null,"回／日（朝",null,null,"時頃","・昼",null,"時頃","・夜",null,"時頃）",null,"食事制限",null,null,"あり",null,"なし",null,"不明"]
[null,null,"食事形態",null,null,"　","普通",null,"きざみ",null,"嚥下障害食",null,null,"ミキサー",null,null,"UDF等の食形態区分"]
[null,null,"摂取方法",null,null,"","経口",null,"経管栄養",null,"水分とろみ",null,null,"なし",null,"あり","水分制限",null,null,"あり（",null,null,")","なし",null,"不明"]
[null,"口腔","嚥下機能",null,null,null,"むせない",null,null,"時々むせる",null,null,"常にむせる",null,"義歯",null,null,null,null,"なし　",null,"あり（",null,"部分",null,"総）"]
[null,null,"口腔清潔",null,null,null,"良",null,null,"不良",null,null,"著しく不良",null,"口臭",null,null,null,null,"なし　",null,"あり"]
[null,"排泄\n*","排尿",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助",null,"ポータブルトイレ",null,null,null,"　","なし　",null,"夜間　",null,null,"常時"]
[null,null,"排便",null,null,null,"自立",null,"見守り",null,"一部介助",null,"全介助",null,"オムツ／パッド",null,null,null,"　","なし　",null,"夜間　",null,null,"常時"]
[null,"食事内容・\n口腔・排泄",null,null,null,"特記事項"]
[]
[null,"睡眠の状態",null,null,null,"　　　　","良　",null,"不良（　　　　　　　　",null,null,"）","眠剤の使用",null,null,null,"なし",null,"あり"]
[null,"喫煙",null,null,null,"　　　　","無",null,"有 ",null,"本くらい／日",null,"飲酒",null,null,"　　　","無　","    ","有",null,"合くらい/日あたり"]
[null,"コミュニ\nケーション\n能力",null,"視力",null,null,"問題なし",null,null,"やや難あり",null,null,"困難",null,"眼鏡",null,null,null,"なし",null,"あり(",null,null,null,null,"）"]
[null,null,null,"聴力",null,null,"問題なし",null,null,"やや難あり",null,null,"困難",null,"補聴器",null,null,null,"なし",null,"あり"]
[null,null,null,"言語",null,null,"問題なし",null,null,"やや難あり",null,null,"困難",null,"意思疎通",null,null,null,"問題なし",null,null,"やや難あり",null,null,"困難"]
[null,null,null,null,null,"特記事項"]
[]
[null,"精神面における\n療養上の問題",null,null,null,"\n　","なし　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　"]
[null,null,null,null,null,null,"幻視・幻聴",null,null,"興奮",null,"焦燥・不穏",null,null,"妄想",null,"暴力/攻撃性",null,null,null,"介護への抵抗",null,null,null,"不眠"]
[null,null,null,null,null,null,"昼夜逆転",null,null,"徘徊",null,"危険行為",null,null,"不潔行為",null,null,"その他（",null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"問題行動に関する特記事項（具体的な問題行動と対応）　　\n"]
[]
[null,"疾患歴*",null,null,null,null,"なし"]
[null,null,null,null,null,null,"悪性腫瘍",null,null,"認知症",null,null,"急性呼吸器感染症",null,null,null,null,"脳血管障害",null,null,null,"骨折"]
[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,"特記事項"]
[]
[null,"入院歴*","最近半年間\nでの入院",null,null,"\n","なし",null,"あり （理由：",null,null,null,null,null,null,null,null,null,"）",null,"不明",null,null,null,null,null," "]
[null,null,null,null,null,null,"期間：",null,null,"年",null,"月",null,"日～　",null,null,"年",null,"月",null,"日"]
[null,null,"入院頻度",null,null,"　","頻度は高い／繰り返している",null,null,null,null,null,"頻度は低いが、これまでにもある",null,null,null,null,null,null,"今回が初めて"]
[null,"入院前に\n実施している\n医療処置*　",null,null,null,null,"なし",null,"あり "]
[null,null,null,null,null,null,"点滴",null,"酸素療法",null,null,"喀痰吸引 ",null,null,"気管切開",null,null,"胃ろう",null,null,"経鼻栄養 ",null,null,"経腸栄養"]
[null,null,null,null,null,null,"褥瘡",null,"尿道カテーテル　",null,null,null,"尿路ストーマ　　",null,null,null,"消化管ストーマ",null,null,null,"痛みコントロール"]
[null,null,null,null,null,null,"排便コントロール",null,null,null,"自己注射（",null,null,null,null,null,"）",null,"その他（",null,null,null,null,null,null,"）"]
[null,null,null,null,null,"特記事項"]
[]
[null,"感染症の有無",null,null,null,null,"不明",null,"なし",null,"あり　（",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"*＝診療報酬　退院支援加算１．２「退院困難な患者の要因」に関連"]
[null,"峡南地域在宅医療・介護連携検討会"]