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["医師とケアマネジャーとの連絡票"]
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["●送信日　：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"●送信時間："]
["◇宛　先",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,"事業所名"]
[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,"TEL"]
[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,"E-mail"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏　名"]
["日頃より、先生方には大変お世話になっております。\n下記の件につき、先生と連絡をとりたいと思います。お忙しいところ誠に恐縮ですが、ご都合の良い連絡方法等につきまして、ご回答をお願いいたします。"]
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["※なお、今回の照会を行うこと及び先生から情報提供いただくことにつきましては、"]
[null,"ご本人、ご家族の同意を得て、ご連絡いたします。（同意日： ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,"年",null,"月",null,"日","）"]
[null,"ご本人の心身状況から同意は得ておりませんが､ご本人の為に必要がありますのでご連絡いたします。"]
["  利用者情報"]
["氏名",null,null,"ふりがな",null,null,null,null,null,null,null,null,null,null,"介護度",null,null,null,"申請中",null,"（",null,"更新・",null,"　","変更　）"]
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["住所",null,null,"〒",null,null,"-",null,null,null,null,null,null,null,null,null,null,null,"要支援",null,"（",null,"）","要介護",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,1,1]
["生年月日",null,null,null,"明治",null,"大正",null,"昭和",null,"平成",null,null,"年",null,"月",null,"日","（",null,"）","歳","性別",null,null,"男",null,"女",null,null,2,2]
["  照会目的",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,3]
[null,"新規・更新・区分変更後のケアプラン作成時の医学的意見について",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,4]
[null,"利用者の医療・看護・介護・症状の医学的意見・指示について",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,5]
[null,"サービス担当者会議における医学的意見について"]
[null,"福祉用具貸与（購入）について、医師からの医学的意見について"]
[null,"医療系サービスを導入するにあたり、主治医の意見・相談など"]
[null,"担当ケアマネジャーになったご挨拶"]
["＜相談内容＞"]
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[]
[]
[]
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["《医師からの回答》（返信）"]
["  連絡方法など"]
[null,"直接会って話をします（日時：",null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"時","頃に来院ください）"]
[null,"電話で話をします（日時：",null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"時頃に",null,null,"電話をください",null,null,null,null,"電話します",null,null,"）"]
[null,"文書で回答します",null,null,null,null,null,null,null,"FAXで回答します",null,null,null,null,null,null,"メールで回答します"]
["  サービス担当者会議について"]
["サービス担当者会議に",null,null,null,null,null,null,"出席します(希望開催場所:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,"出席しません"]
["＜その他連絡事項＞"]
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[]
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["回答日",null,"令和",null,null,"年",null,"月",null,"日","医療機関名",null,null,null,null,null,null,null,null,null,"医師名"]
["佐世保市在宅医療･介護連携事業　多職種連携専門部会"]