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["伊万里・有田地区 入退院支援ルールの手引き"]
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[1,"入院前に担当介護支援専門員等がいる場合"]
["①入院時の情報提供・介護支援専門員等の確認・連絡"]
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["②退院支援の必要性の検討・準備"]
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["③退院前調整"]
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["④入院期間の見込み"]
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["⑤退院支援開始の連絡(入院時状況共有・病棟内カンファレンス)"]
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["⑥退院直前調整(退院時カンファレンス・看護サマリー等の受け渡し)"]
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[2,"入院前に担当介護支援専門員等がいない場合"]
["②退院支援の必要性の検討・準備"]
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["③退院前調整"]
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["注","居宅介護支援事業所等",null,"居宅介護支援事業所・地域包括支援センター"]
[null,"介護支援専門員等",null,"介護支援専門員\n地域包括支援センター：プランナー、保健師、社会福祉士、主任介護支援専門員"]

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["伊万里・有田地区「入退院支援ルールの手引き」時系列版"]
["【介護支援専門員等が実施すること】",null,null,null,null,"【病院担当者が実施すること】"]
["入院前に担当介護支援専門員等がいる場合"]
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["利用者又はその家族に、利用者について、病院又は診療所に入院する必要が生じた場合には、当該利用者に係る介護支援専門員の氏名及び連絡先を当該病院又は診療所に伝える様求めなければならない。例えば、健康保険証やお薬手帳等に介護支援専門員の名刺を添付頂く等。"]
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["○認定区分に関わらず、全ての利用者について、入院\n　日から３日ないし７日以内を目途に可能な限り入院\n　先へ情報提供する。(情報提供の手段は問わず)　\n　※様式（１）　\n○検査入院の利用者については、原則として、情報\n　提供や入院連絡の対象としないが、必要に応じて\n　病院担当者と介護支援専門員等で相談し、情報提供\n　について決める。\n",null,null,null,null,"○入院時の聴き取りで介護支援専門員等を確認。\n○健康保険証、お薬手帳等に添付されている介護支援\n　専門員等の名刺や、介護保険被保険者証に記載され\n　ている居宅介護支援事業所等を確認し、可能限り\n　入院を連絡。\n○本人や家族等から介護サービス利用について確認\n　する。"]
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[null,null,null,null,null,"○退院支援の基準に基づき、退院支援の必要性を検討\n   する　※様式（２）\n○事業対象者・要支援認定の方についても、退院支援\n   の基準に照らし必要性等に準じて検討する。"]
["入院前に担当介護支援専門員等がいない場合"]
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["○病院担当者より支援依頼があれば、病院で患者、\n   家族等と面談し、退院後の生活への意向を確認し、\n   それに応じた各種社会資源の説明や必要に応じ\n   手続き代行等を行う。"]
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[null,null,null,null,null,"○患者・家族に介護保険制度の概略を説明し、必要に\n   応じて居宅介護支援事業所等の選択について助言\n   する。\n○患者・家族が居宅介護支援事業所等を選択された\n　場合は、当該事業所へ意向を連絡する。"]
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["○患者・家族に確認して入院期間の見込みが分から\n   ない場合は病院担当者へ問い合わせる。",null,null,null,null,"○概ねの入院期間の見込みを介護支援専門員等へ\n   伝える。"]
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["○連絡を受け、必要に応じて病院担当者へ連絡し、\n   患者・家族と面会し、病院関係者より情報収集\n   する。\n○必要に応じて、入院時病棟内カンファレンス等へ\n   参加することで、担当医も含めた意見等を確認し、\n   退院支援に必要な情報を共有する。\n○退院・退所情報記録書作成　※様式（５）　",null,null,null,null,"○退院支援基準に基づき、退院準備の日数をできる\n   限り多く残すことを考慮した上で、退院前、概ね\n　２週間前位を目途に担当介護支援専門員・地域\n　包括支援センターへ退院支援開始を連絡をする。\n　(実際の退院の長短になることや転院、施設入所と\n　なる可能性があることを踏まえた上での連絡とする)\n○入院時病棟内カンファレンス等開催の場合、介護\n　支援専門員等へも参加を呼び掛ける"]
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["○サービス担当者会議開催について、病院担当者と\n　開催の有無や日程等の連絡調整\n○看護サマリー等の受け渡しの確認",null,null,null,null,"○退院時カンファレンス開催について、介護支援\n　専門員等と開催有無や日程等の連絡調整\n○看護サマリー等準備"]

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["様式一覧"]
["様式番号","様式","説明"]
["（１）","入院時情報提供書","入院にあたり介護支援専門員等から病院へ書面で情報提供\nする際に使用。\n順次伊万里・有田地区統一様式として運用を予定"]
["（２）","退院支援に用いる基準","病院側が退院支援を開始する判断の目安として提示"]
["（３）","診療報酬・介護報酬一覧","平成３０年度診療報酬・介護保険報酬改定に準じた入退院\n支援に係る報酬一覧"]
["（４）","介護保険担当窓口","伊万里市、有田町の相談窓口"]
["（５）","退院・退所情報記録書","退院後の生活支援を進める上で、介護支援専門員等が医療\n機関より情報収集し、その内容を記録する様式。\n順次伊万里・有田地区統一様式として運用を予定"]
["（６）","退院支援チェックリスト","退院支援が円滑に進む様に進捗状況の把握に活用"]
["（７）","退院調整窓口一覧","※現在調整中"]

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["入院時情報提供書",null,null,null,null,null,null,null,null,null,null,null,null,null,"【",null,null,null,null,null,null,null,null,null,null,"  】"]
[null,null,null,null,null,null,null,null,null,null,null,"（地域包括支援センター・居宅介護支援事業所　⇒　病院・診療所）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"作成日：平成",null,null,null,null,null,"年",null,"月",null,"日"]
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["医療機関名等",null,null,null,null,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,"御中",null,null,null,"事業所　　　所在地"]
["入院時の情報提供について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者"]
["◎",null,"月",null,"日に入院（予定）の下記の方に関する情報を",null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,null,"-",null,null,"-"]
[null,"提供させて頂きます。",null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX",null,null,null,null,"-",null,null,"-"]
["◎","退院に向け、情報提供やご指導等頂けると助かります。　今後ともよろしくお願い申し上げます。"]
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["※　利用者の情報は、利用者本人及び家族の同意に基づき提供しています。"]
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[null,"本書類は、居宅介護支援事業所が加算を算定する為に必要な公的な文書です。"]
[null,"受領確認の署名捺印にご協力お願い致します。"]
[null,"なお、転院となられる場合には、恐れ入りますが、転院先への情報提供、並びに、当居宅への連絡"]
[null,"にもご協力賜ります様、重ねてお願い申し上げます。"]
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[null,"本日提供した書類",null,null,null,null,null,null,null,null,null,"様","の基本情報及びＡＤＬ等情報",null,null,null,null,null,null,null,"計",null,null,"枚"]
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[null,"上記以外の追加資料",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
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[null,"こちらの書類は、以下の加算算定に関連しています　（※居宅介護支援費のみ）"]
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[null,null,null,null,null,null,null,"（200単位）",null,null,"入院された際、ケアマネが入院先に必要な情報提供を行った場合に算定します。　（入院日から３日以内の情報提供）"]
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[null,null,null,null,null,null,null,"（100単位）",null,null,"入院された際、ケアマネが入院先に必要な情報提供を行った場合に算定します。　（入院日 から７日以内の情報提供）"]
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[null,"資料を受け取りました。"]
[null,"受領日",null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,"受取者",null,null,null,null,null,null,null,null,"印"]

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["退院支援に用いる基準"]
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["基準１","入院前に担当介護支援専門員等がいる場合"]
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[null,"下記の判断ができれば、担当介護支援専門員等に退院支援開始の連絡を行う。"]
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["※判断する前に医師から退院指示が出た場合はすみやかに介護支援専門員等へ連絡"]
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["基準２","入院前に担当介護支援専門員等がいない場合"]
[null,"(介護保険の認定を受けていない、または介護支援専門員等が決まっていない場合)"]
[null,"⇒下記のいずれかに該当し、主治医もしくは担当医が病状安定と判断した場合、\n   患者の居住地の市町役場に介護保険申請等の相談に出向くことを勧める　※様式（４）"]
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["４０歳～６４歳(第２号被保険者)の場合は、下記の疾病が介護保険申請の条件となります。"]
["①","がん末期",null,null,null,"⑨","脊柱管狭窄症"]
["②","関節リウマチ",null,null,null,"⑩","早老症"]
["③","筋委縮性側索硬化症",null,null,null,"⑪","多系統萎縮症"]
["④","後縦靭帯骨化症",null,null,null,"⑫","糖尿病性神経障害"]
["⑤","骨折を伴う骨粗鬆症",null,null,null,null,"糖尿病性腎症及び糖尿病性網膜症"]
["⑥","初老期における認知症",null,null,null,"⑬","脳血管疾患"]
["⑦","進行性核上性麻痺",null,null,null,"⑭","閉塞性動脈硬化症"]
[null,"大脳皮質基底核変性症及びパーキンソン病",null,null,null,"⑮","慢性閉塞性肺疾患"]
["⑧","脊髄小脳変性症",null,null,null,"⑯","両側の膝関節又は股関節に著しい"]
[null,null,null,null,null,null,"変形を伴う変形性関節症"]

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["入退院時の連携に関わる主な診療報酬・介護報酬一覧\n(注：加算の要件など詳細については、国の関連通知をご確認ください)"]
[]
[null,"介護報酬\n(居宅介護支援事業所側)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療報酬\n(医療機関側)"]
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["〈居宅介護支援基準〉",null,null,null,null,null,null,null,null,null,null,null,"入院",null,null,"入退院支援加算"]
["居宅介護支援の提供に際し、あらかじめ、利用者又はその家族に、利用者について、病院又は診療所に入院する必要が生じた場合には、当該利用者に係る介護支援専門員の氏名及び連絡先を当該病院又は診療所に伝える様求めなければならない。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入院早期より退院困難者を抽出し、適切な退院先に、適切な時期に退院できるよう退院支援計画の立案及び退院した場合に算定"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,"６００点　又は１２００点　(退院時１回)"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,null,"１９０点　又は　６３５点　(退院時１回)"]
[]
["入院時情報連携加算",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院困難な要因"]
["利用者入院にあたり、入院医療機関に対して、利用者の心身の状況や生活環境等の当該利用者に係る必要な情報を提供した場合に、利用者一人につき１月に１回を限度として所定単位数を加算。\n(提供方法は問わない)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ア","悪性腫瘍、認知症又は誤嚥性配線等の急性呼吸器感染症のいずれか",null,null,null,null,"キ","排泄に介助を要する"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ク","同居の有無に関わらず、\n必要な介護又は養育を\n十分に提供できる状況に\nない"]
[]
["(Ⅰ)",null,"入院してから３日以内　２００単位",null,null,null,null,null,null,null,null,null,null,null,null,"イ","緊急入院"]
["(Ⅱ)",null,"入院してから７日以内　100単位",null,null,null,null,null,null,null,null,null,null,null,null,"ウ","要介護認定が未申請",null,null,null,null,"ケ","退院後に医療処置(胃瘻等の経管栄養法を含む)が必要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"エ","虐待を受けている又はその疑い"]
["退院・退所加算"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"オ","医療保険未加入者又は生活困窮者",null,null,null,null,"コ","入退院を繰り返している"]
["医療機関に入院又は、介護保険施設に入所していた者が退院又は退所に当って、当該職員と面談を行い、利用者に関する必要な情報の提供を受けた上で、居宅サービス計画を作成し、居宅サービスの利用に関する調整を行った場合に入院・入所期間中につき１回を限度として加算"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"カ","入院前に比べＡＤＬが低下し、退院後の生活様式の再編が必要であること(必要と推測されること)",null,null,null,null,"サ","その他患者の状況から\n判断してアからコまでに\n準じると認められる場合"]
[]
[]
[]
[null,null,"カンファレンス参加無",null,null,null,null,"カンファレンス参加有",null,null,null,null,null,null,null,"+入院時支援加算"]
["連携１回",null,"450単位",null,null,null,null,"600単位",null,null,null,null,null,null,null,"入院予定の患者に対し、入院中に行われる治療の説明等を入院前の外来において実施"]
["連携２回",null,"600単位",null,null,null,null,"750単位"]
["連携３回",null,"-",null,null,null,null,"900単位",null,null,null,null,null,null,null,null,"２００点(退院時１回)"]
["《留意事項》\nカンファレンスについては、退院時共同指導料の※に準じた場合のみ算定可能"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護支援等連携指導料"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院後に介護サービス導入することが適当と考えられる場合。患者に対して、介護支援専門員と連携し、退院後の介護サービスについて指導"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"４００点(退院時１回)"]
[]
[]
["初回加算",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院時共同指導料"]
[]
["新規に居宅サービス計画を作成した場合に算定。但し、運営基準減算になっている場合は、初回算定できない。\n※退院・退所加算を算定する場合は、算定しない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病院の医師と在宅療養を担う医師等が共同して、退院後の在宅療養上必要な説明・指導を実施"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,1,"在宅療養支援診療所の場合",null,null,null,null,null,null,"1500点"]
["300単位",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"１以外の場合",null,null,null,null,null,null,"900点"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,null,null,null,null,null,null,null,null,"400点"]
["初回加算(介護予防支援)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※","入院中の医療機関の「保険医又は看護師等」が在宅療養に係る外部三者以上と共同して指導を行った場合に加算",null,null,null,null,null,null,null,"2000点"]
[]
["①新規作成の場合\n②要介護者が要支援認定を受けた場合"]
[]
["300単位",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院時共同指導加算"]
[]
["〈居宅介護支援基準〉",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"８００点"]
["指定居宅サービス事業者から利用者に係る情報の提供を受けたときその他必要と認めるときは、利用者の服薬状況、口腔機能その他利用者の心身又は生活状況に係る情報のうち必要と認めるものを、利用者の同意を得て主治の医師若しくは歯科医師又は薬剤師に提供するものとする。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"退院時リハビリテーション指導料"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"退院",null,null,null,"３００点"]
[]
[]
["緊急時等居宅カンファレンス加算"]
["病院又は診療所の求めにより、医療又は看護師等とともに利用者宅でカンファレンスを行い、必要に応じて介護サービスを調整"]
[]
[null,"２００単位(１月に２回)"]
[]
["ターミナルケアマネジメント加算"]
["在宅で死亡した利用者(末期の悪性腫瘍の患者に限る)に対して、死亡日及び死亡前１４日以内に２日以上、当該利用者又はその家族の同意を得て、当該利用者宅を訪問し、当該利用者の心身の状態等を記録し、主治の医師及び居宅サービス計画に位置付けた居宅サービス事業者に提供した場合に算定できる"]
[]
[]
[]
[null,"４００単位"]

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[]
[null," 介護保険担当窓口"]
[]
[null,"伊万里市　市民部　長寿社会課"]
[null,"848-8501","佐賀県伊万里市立花町1355番地1"]
[null,"介護給付係",null,null,"電話","0955-23-2154","ＦＡＸ","0955-23-7844"]
[null,"高齢福祉・介護認定係",null,null,"電話","0955-23-2162","ＦＡＸ","0955-22-7844"]
[null,"伊万里市地域包括支援センター",null,null,"電話","0955-23-2155","ＦＡＸ","0955-22-7844"]
[]
[null,"有田町　健康福祉課"]
[null,"844-0027","佐賀県西松浦郡有田町南原甲664番地4\n（有田町福祉保健センター内）"]
[null,"健康福祉課　介護保険担当",null,null,"電話","0955-43-2179","ＦＡＸ","0955-43-2301"]
[null,"有田町地域包括支援センター",null,null,"電話","0955-43-2196","ＦＡＸ","0955-43-2301"]
[]
[]
[null,"医療・介護相談窓口"]
[null,"伊万里有田　在宅医療・介護連携支援センター"]
[null,"844-0027","佐賀県西松浦郡有田町二ノ瀬甲806番地\n（伊万里有田共立病院内）"]
[null,null,null,null,"電話","090-9562-2459","ＦＡＸ","0955-46-2160"]

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["退院・退所情報記録書"]
[null,null,null,null,null,null,null,"記載者",null,null,"事業所名：",null,null,null,null,null,null,null,null,null,null,null,"氏名："]
["１．基本情報・現在の状態　等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日："]
["属性","フリガナ",null,null,null,null,null,null,null,null,"性別",null,"年齢",null,null,"退院(所)時の要介護度",null,null,null,null,null,null,null,"(",null,"要区分変更",null,null,"）"]
[null,"氏名",null,null,null,null,null,null,null,"様",null,null,null,null,"歳",null,"ｻｰﾋﾞｽ事業対象者",null,null,"要支援(",null,null,")","要介護（",null,null,null,"）","申請中",null,null,"なし"]
["入院(所)概要","入院(所)先",null,null,null,null,null,null,null,null,null,null,null,null,"入院(所)日",null,null,null,null,null,null,null,null,"退院(所)予定日"]
[null,"入院原因疾患\n(入所目的等）"]
[null,"今後の医学管理",null,null,null,"医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,"方法",null,null,"　通院",null,null,null,"訪問診療"]
["①疾患と入院(所)中の状況 ","現在治療中の疾患　",null,null,null,"➀",null,null,null,null,null,"②",null,null,null,null,null,"③",null,null,null,null,null,"疾患の状況\n※左記番号記入　",null,null,null,"安　 定（",null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不安定（",null,null,null,null,"）"]
[null,"移動手段",null,null,null,"自立",null,null,"杖",null,null,"　歩行器",null,null,null,"車いす",null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"排泄方法",null,null,null,"トイレ",null,null,"Ｐトイレ",null,null,"オムツ",null,null,"カテーテル　・　パウチ（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"入浴方法",null,null,null,"自立",null,null,"シャワー浴",null,null,null,"一般浴",null,null,null,"機械浴",null,null,null,"清拭のみ",null,null,null,"　行わず"]
[null,"食事\n形態",null,null,null,"普通",null,null,"経管栄養",null,null,null,"その他(",null,null,null,null,null,null,null,null,null,null,null,")","UDF等の食形態区分"]
[null,"嚥下機能(むせ)",null,null,null,"なし",null,"時々むせる",null,null,null,"常にむせる",null,null,"義歯",null,null,"なし",null,"あり（",null,"部分",null,"総）","入院(所)中の使用：",null,null,null,null,"なし",null,"あり"]
[null,"口腔清潔",null,null,null,"　良　　　　　",null,null,"　不良",null,null,"　著しく不良",null,null,"口腔ケア",null,null,null,"　自立",null,null,"一部介助",null,null,"全介助"]
[null,"睡　眠",null,null,null,"良好　　　　　",null,"不良（",null,null,null,null,null,null,null,null,null,null,null,null,")","眠剤使用",null,null,null,null,"あり",null,null,"なし"]
[null,"認知・精神",null,null,null,"認知機能低下",null,null,null,null,"せん妄",null,null,"徘徊",null,null,"焦燥・不穏",null,null,null,"攻撃性",null,null,"その他(",null,null,null,null,null,null,null,null,")"]
["➁受け止め/意向","＜本人＞\n病気、障害、後遺症等\nの受け止め方",null,null,null,"本人への病名告知：",null,null,null,null,null,"あり",null,null,"なし"]
[]
[]
[null,"＜本人＞\n退院後の生活に\n関する意向"]
[]
[null,"＜家族＞\n病気、障害、後遺症等\nの受け止め方"]
[]
[null,"＜家族＞\n退院後の生活に\n関する意向"]
[]
["２．課題認識のための情報"]
["③退院後に必要な事柄","医療処置\nの内容",null,null,"なし"]
[null,null,null,null,"点滴",null,null,"酸素療法",null,null,null,"喀痰吸引",null,null,null,"気管切開",null,null,null,"胃ろう",null,null,"経鼻栄養",null,null,null,"経腸栄養",null,null,null,"褥瘡"]
[null,null,null,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,"排便コントロール",null,null,null,null,"自己注射（",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,"看護\nの視点",null,null,"なし"]
[null,null,null,null,"血圧",null,"水分制限",null,null,null,"食事制限",null,null,null,"食形態",null,null,"嚥下",null,"口腔ケア",null,null,"清潔ケア",null,null,"血糖コントロール",null,null,null,null,"排泄"]
[null,null,null,null,"皮膚状態",null,null,"睡眠",null,"認知機能・精神面",null,null,null,null,"服薬指導",null,null,"療養上の指導（食事・水分・睡眠・清潔ケア・排泄 などにおける指導）"]
[null,null,null,null,"ターミナル",null,null,"その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,"リハビリ\nの視点",null,null,"なし"]
[null,null,null,null,"本人指導",null,null,"家族指導",null,null,"関節可動域練習(ストレッチ含む)",null,null,null,null,null,null,null,"筋力増強練習",null,null,null,"バランス練習",null,null,null,"麻痺・筋緊張改善練習"]
[null,null,null,null,"起居／立位等基本動作練習",null,null,null,null,null,null,"摂食・嚥下訓練",null,null,null,null,"言語訓練",null,null,"ADL練習(歩行／入浴／トイレ動作／移乗等)"]
[null,null,null,null,"IADL練習（買い物、調理等）",null,null,null,null,null,null,null,"疼痛管理（痛みコントロール）",null,null,null,null,null,null,null,"更生装具・福祉用具等管理",null,null,null,null,null,null,null,"運動耐容能練習"]
[null,null,null,null,"地域活動支援",null,null,null,"社会参加支援",null,null,null,"就労支援",null,null,null,"その他",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,"禁忌事項",null,"（禁忌の有無）",null,null,null,null,null,"（禁忌の内容／留意点）"]
[null,null,null,null,"なし",null,null,"あり"]
["症状・病状の\n予後・予測"]
["退院に際しての日常\n生活の阻害要因\n（心身状況･環境等）",null,null,null,"例）医療機関からの見立て・意見（今後の見通し、急変の可能性や今後、どんなことが起こりうるか（合併症）、良くなっていく又はゆっくり落ちていく方向なのか　等）について、➀疾患と入院中の状況、➁本人・家族の受け止めや意向、③退院後に必要な事柄、④その他の観点から必要と思われる事項について記載する。"]
[]
["在宅復帰のために整え\nなければならない要件"]
["回目",null,"聞き取り日",null,null,null,null,"情報提供を受けた職種（氏名）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"会議出席"]
[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,"無",null,"有"]
[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,"無",null,"有"]
[3,null,null,null,null,null,null,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,"有"]
["※課題分析にあたっては、必要に応じて課題整理総括表の活用も考えられる。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"厚生労働省　様式"]