{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["様式3","様式3　記入例","プルダウン"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":3,"comments":2,"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":"様式3","index":0,"n_rows":50,"n_cols":36,"rows_kept":50,"cut":false,"hidden":false,"merged":[[39,0,39,35],[40,0,42,35],[43,0,43,35],[44,0,48,35],[50,0,50,35],[49,24,49,35],[35,19,35,21],[35,22,35,34],[26,0,26,35],[27,0,27,2],[27,3,27,5],[27,6,27,17],[27,18,27,21],[27,22,27,35],[28,0,28,35],[29,0,29,3],[30,0,30,3],[31,0,31,3],[32,0,32,35],[35,14,35,17],[24,5,24,12],[21,18,22,20],[20,8,20,9],[20,13,20,15],[20,18,20,20],[20,10,20,12],[18,23,18,24],[18,25,18,34],[17,25,17,27],[19,0,19,3],[19,16,19,17],[19,27,19,29],[17,0,18,3],[17,5,17,6],[17,8,17,9],[17,18,18,21],[18,4,18,17],[17,29,17,30],[11,0,13,35],[14,0,14,35],[15,0,16,3],[15,4,15,5],[15,6,15,17],[15,18,16,21],[15,22,16,35],[16,4,16,17],[9,0,10,4],[9,5,10,17],[9,18,9,22],[9,23,9,35],[10,18,10,22],[10,23,10,35],[6,23,6,35],[7,0,8,4],[7,5,8,17],[7,18,7,22],[7,23,7,35],[8,18,8,22],[8,23,8,35],[5,0,6,4],[5,5,6,17],[5,18,5,22],[5,23,5,35],[6,18,6,22],[1,0,1,35],[2,4,2,13],[2,14,2,15],[4,0,4,17],[4,18,4,35],[20,26,20,35],[21,29,22,35],[21,21,22,27],[36,0,38,1],[36,2,38,35],[23,5,23,12],[23,18,25,20],[23,21,25,35],[25,5,25,6],[25,7,25,16],[21,28,22,28],[20,0,20,3],[20,23,20,25],[21,5,21,12],[21,0,25,3],[22,5,22,12]]}
[]
["主治医意見書依頼票"]
["●作成日　：　　　"]
[]
["◇宛　先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"◆発信元"]
["医療機関名",null,null,null,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,null,null,null,null,null,null,null,"住所"]
["住所",null,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,"ＦＡＸ"]
["医師",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-mail"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名"]
["日頃より、先生方にはお世話になっております。下記の対象者につきまして、主治医の意見書のご記入をお願い致します。\nお忙しいところ恐縮ですが、宜しくお願い致します。"]
[]
[]
["\u009d利用者情報"]
["氏名",null,null,null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ"]
[]
["住所",null,null,null,"〒",null,null,"－",null,null,null,null,null,null,null,null,null,null,"生活状況",null,null,null,null,"独居",null,"子と同居 （",null,null,null,"）名",null,null,"高齢夫婦"]
[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,"）"]
["生年月日",null,null,null,null,"明治",null,null,"大正",null,null,"昭和",null,null,"平成",null,null,null,"年",null,"月",null,"日","（",null,"）","歳","性別",null,null,null,"男","・",null,"女"]
["介護度",null,null,null,null,"申請中(",null,null,"更新・",null,"変更)",null,null,"要支援（",null,null,null,"）","要介護（",null,null,null,"）","被保険者番号"]
["利用中の\nサービス\n（プルダウンから入力・その他は直接入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）",null,"有効期間",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,null,null,null,null,"（",null,"）",null,"他科\n受診の\n状況"]
[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,"）"]
["\u009d\u009d\u009d\u009d情報提供"]
["自立度",null,null,"障害高齢者\n（ﾌﾟﾙﾀﾞｳﾝﾘｽﾄより\n入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"認知症高齢者\n（ﾌﾟﾙﾀﾞｳﾝﾘｽﾄより\n入力）"]
["\u009d中核症状"]
["短期記憶",null,null,null,null,"問題無",null,null,null,null,"問題有"]
["意思決定",null,null,null,null,"自立",null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,"見守りが必要",null,null,null,null,null,null,null,null,null,"判断できない"]
["伝達能力",null,null,null,null,"伝えられる",null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,"具体的要求に限られる",null,null,null,null,null,null,null,null,null,"伝えられない"]
["\u009d周辺症状"]
[null,"無",null,null,null,"有"]
[null,"幻視・幻聴",null,null,null,null,"妄想",null,null,null,"昼夜逆転",null,null,null,"暴言",null,null,null,null,"暴行",null,null,null,"介護への抵抗",null,null,null,null,null,null,"徘徊"]
[null,"火の不始末",null,null,null,null,"不潔行為",null,null,null,"異食行動",null,null,null,"性的問題行動",null,null,null,null,"その他　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["周辺症状の詳細"]
[]
[]
["\u009d栄養や食事の状態"]
[]
[]
[]
["\u009dその他特記事項"]
[]
[]
[]
[]
[]
["※出来上がりましたら、◆発信元までご連絡をお願いします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"佐世保市在宅医療･介護連携事業　多職種連携専門部会"]

{"sheet":"様式3　記入例","index":1,"n_rows":51,"n_cols":36,"rows_kept":51,"cut":false,"hidden":false,"merged":[[22,39,23,39],[21,21,22,27],[21,29,22,35],[1,0,1,35],[2,4,2,13],[2,14,2,15],[4,0,4,17],[4,18,4,35],[5,0,6,4],[5,5,6,17],[5,18,5,22],[6,18,6,22],[5,23,5,35],[6,23,6,35],[7,0,8,4],[7,5,8,17],[7,18,7,22],[8,18,8,22],[7,23,7,35],[8,23,8,35],[9,0,10,4],[9,5,10,17],[9,18,9,22],[10,18,10,22],[9,23,9,35],[10,23,10,35],[11,0,13,35],[14,0,14,35],[15,0,16,3],[15,4,15,5],[15,6,15,17],[15,18,16,21],[15,22,16,35],[16,4,16,17],[17,0,18,3],[17,18,18,21],[19,0,19,3],[17,5,17,6],[17,8,17,9],[18,4,18,17],[19,16,19,17],[43,0,43,35],[44,0,48,35],[50,0,50,35],[18,23,18,24],[18,25,18,34],[39,0,39,35],[31,0,31,3],[32,0,32,35],[28,0,28,35],[29,0,29,3],[30,0,30,3],[26,0,26,35],[27,6,27,17],[27,0,27,2],[20,0,20,3],[27,3,27,5],[17,22,17,23],[35,19,35,21],[35,22,35,34],[27,18,27,21],[27,22,27,35],[21,28,22,28],[17,25,17,26],[19,27,19,29],[20,18,20,19],[20,23,20,25],[21,0,25,3],[21,5,21,12],[21,18,22,20],[20,13,20,14],[36,0,38,1],[36,2,38,35],[22,5,22,12],[23,5,23,12],[23,18,25,20],[23,21,25,35],[24,5,24,12],[25,5,25,6],[25,7,25,16]]}
[]
["主治医意見書依頼票"]
["●作成日　：　　　",null,null,null,"2019-05-01"]
[]
["◇宛　先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"◆発信元"]
["医療機関名",null,null,null,null,"○○〇〇医院",null,null,null,null,null,null,null,null,null,null,null,null,"事業所名",null,null,null,null,"　〇〇居宅介護支援事業所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,null,null,null,"佐世保市〇〇町〇〇－〇〇"]
["住所",null,null,null,null,"佐世保市〇〇町〇〇－〇",null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,null,null,"0956－〇〇－〇〇〇〇"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,null,null,null,"0956－〇〇－〇〇〇〇"]
["医師",null,null,null,null,"九十九　島雄　先生　御机下",null,null,null,null,null,null,null,null,null,null,null,null,"E-mail",null,null,null,null,"takeko@xxx.xxx.com"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,"弓張　岳子"]
["　日頃より、先生方にはお世話になっております。下記の対象者につきまして、主治医の意見書のご記入をお願い致します。\n　お忙しいところ恐縮ですが、宜しくお願い致します。"]
[]
[]
["■利用者情報"]
["氏名",null,null,null,"ふりがな",null,"さいかい　はしぞう",null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,null,"0956－〇〇－〇〇〇〇"]
[null,null,null,null,"西海　橋蔵"]
["住所",null,null,null,"〒","×××",null,"－","×××",null,null,null,null,null,null,null,null,null,"生活状況",null,null,null,"　独居",null,null,"子と同居",null,"（",4,"）","名",null,"高齢夫婦"]
[null,null,null,null,"佐世保市〇〇町〇〇－〇",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,"）"]
["生年月日",null,null,null,null,"明治",null,null,"大正",null,null,"昭和",null,null,"平成",null,11,null,"年",11,"月",11,"日","（",82,"）","歳","性別",null,null,null,"男",null,null,"女"]
["介護度",null,null,null,null,"申請中(",null,null,null,"・",null,null,null,null,null,"（",null,"）","要介護",null,"（",1,"）","被保険者番号",null,null,1,"×","×","×","×","×","×","×","×","×"]
["利用中の\nサービス\n（プルダウンから入力・その他は直接入力）",null,null,null,null,"通所介護(デイサービス)",null,null,null,null,null,null,null,"週","（",1,"）","回","有効期間",null,null,"令和○年○月○日",null,null,null,null,null,null,"～","令和○年○月○日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）",null,"他科\n受診の\n状況",null,null,"・○○整形外科（○○医師）週1回　　　　　　\n・○○○○歯科（○○医師）2週1回"]
[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,"）"]
["■情報提供"]
["自立度",null,null,"障害高齢者\n（ﾌﾟﾙﾀﾞｳﾝから\n選択）",null,null,"Ｂ１．屋内での生活は何らかの介助を要し、日中もベッド上での生活が主体であるが、座位を保つ。車いすに移乗し、食事、排泄はベッドから離れて行う ",null,null,null,null,null,null,null,null,null,null,null,"認知症高齢者\n（ﾌﾟﾙﾀﾞｳﾝから\n選択）",null,null,null,"Ⅰ．何らかの認知症を有するが、日常生活は家庭内および社会的にほぼ自立している状態"]
["■中核症状"]
["短期記憶",null,null,null,null,"問題無",null,null,null,null,"問題有"]
["意思決定",null,null,null,null,"自立",null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,"見守りが必要",null,null,null,null,null,null,null,null,null,"判断できない"]
["伝達能力",null,null,null,null,"伝えられる",null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,"具体的要求に限られる",null,null,null,null,null,null,null,null,null,"伝えられない"]
["■周辺症状"]
[null,"無",null,null,null,"有"]
[null,"幻視・幻聴",null,null,null,null,"妄想",null,null,null,"昼夜逆転",null,null,null,"暴言",null,null,null,null,"暴行",null,null,null,"介護への抵抗",null,null,null,null,null,null,"徘徊"]
[null,"火の不始末",null,null,null,null,"不潔行為",null,null,null,"異食行動",null,null,null,"性的問題行動",null,null,null,null,"その他　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["周辺症状の詳細"]
[]
[]
["■栄養や食事の状態"]
["毎日３食摂取されており、栄養面は特に問題なし。現在、義歯の調整のため歯科受診中です。"]
[]
[]
["■その他特記事項"]
["最近歩行や外出する機会も減り、両膝の疼痛を訴え自宅でも横になって過ごすことが増えたとのご相談がありました。話しかけても無気力なことが多く、素っ気ない返答をする傾向があります。"]
[]
[]
[]
[]
["※出来上がりましたら、◆発信元までご連絡をお願いします。"]
["                                                              佐世保市在宅医療･介護連携事業　多職種連携専門部会"]

{"sheet":"プルダウン","index":2,"n_rows":24,"n_cols":6,"rows_kept":24,"cut":false,"hidden":true,"merged":[]}
[]
[null,"利用中のサービス",null,"自立度",null,"認知症高齢者自立度"]
[]
[null,"訪問看護",null,"自立",null,"自立"]
[null,"訪問介護(ヘルパー派遣）",null,"Ｊ１．何らかの障害を有するが、日常生活はほぼ自立しており独力で外出する。交通機関等を利用して外出する",null,"Ⅰ．何らかの認知症を有するが、日常生活は家庭内および社会的にほぼ自立している状態"]
[null,"訪問リハビリ",null,"Ｊ２．何らかの障害を有するが、日常生活はほぼ自立しており独力で外出する。隣近所へなら外出する",null,"Ⅱa．日常生活に支障をきたすような症状・行動や意思疎通の困難さが家庭外で見られるが、誰かが注意していれば自立できる状態"]
[null,"訪問入浴サービス",null,"Ａ１．屋内での生活は概ね自立しているが、介助なしには外出しない。介助により外出し、日中はほとんどベッドから離れて生活する",null,"Ⅱb．日常生活に支障をきたすような症状・行動や意思疎通の困難さが家庭内で見られても、誰かが注意していれば自立できる状態"]
[null,"通所介護(デイサービス)",null,"Ａ２．屋内での生活は概ね自立しているが、介助なしには外出しない。外出の頻度が少なく、日中も寝たり起きたりの生活をしている",null,"Ⅲa．日常生活に支障をきたすような症状・行動や意思疎通の困難さが日中を中心に見られ、介護を必要とする状態"]
[null,"通所リハビリテーション(デイケア)",null,"Ｂ１．屋内での生活は何らかの介助を要し、日中もベッド上での生活が主体であるが、座位を保つ。車いすに移乗し、食事、排泄はベッドから離れて行う ",null,"Ⅲb．日常生活に支障をきたすような症状・行動や意思疎通の困難さが夜間を中心に見られ、介護を必要とする状態"]
[null,"短期入所生活介護(ショートステイ)",null,"Ｂ２．屋内での生活は何らかの介助を要し、日中もベッド上での生活が主体であるが、座位を保つ。介助により車いすに移乗する",null,"Ⅳ．日常生活に支障をきたすような症状・行動や意思疎通の困難さが頻繁に見られ、常に介護を必要とする状態"]
[null,"短期入所療養介護(ショートステイ)",null,"Ｃ１．１日中ベッド上で過ごし、排泄、食事、着替において介助を要する。自力で寝返りをうつ ",null,"Ｍ．著しい精神症状や問題行動あるいは重篤な身体疾患が見られ、専門医療を必要とする状態"]
[null,"福祉用具の貸与",null,"Ｃ２．１日中ベッド上で過ごし、排泄、食事、着替において介助を要する。自力では寝返りもうてない"]
[null,"福祉用具の購入"]
[null,"住宅改修"]
[null,"施設入所中"]
[null,"配食サービス"]
[]
[]
[null,"週"]
[null,"月"]
[]
[]
[null,"日"]
[null,"回"]