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["紹介状 [診療情報提供書]",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,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[]
[]
["(大腿骨近位部骨折地域連携パス用)"]
[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,"紹介元医療機関名及び所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※改行は　「Altキー　＋　Enterキー」"]
["北播磨総合医療センター"]
[]
[]
[]
[]
["整形外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科",null,null,"担当医",null,null,null,null,null,null,null,null,null,null,null,null,"先生"]
[]
[]
[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,"担当医師名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[]
["予約希望日",null,null,null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(","水",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,"電話番号：",null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")",null,null,null,null,null,null,null,"-"]
[]
["毎週水曜日午後のみ"]
[null,null,null,null,null,null,null,"上記どちらかの時間でお選びください。\nご都合の悪い場合は時間をご記入ください(午後)。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"時頃",null,null,"ＦＡＸ番号：",null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")",null,null,null,null,null,null,null,"-"]
[]
[]
[]
["フ リ ガ ナ",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,"旧姓",null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,null,null,"生　年　月　日"]
[]
["患者氏名",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,"受診歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 明治",null,null,null,null,null," 大正",null,null,null,null,null," 昭和",null,null,null,null,null," 平成",null,null,null,null,null,"　令和"]
[]
[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,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,"歳"]
[]
["住所",null,null,null,null,"〒",null,null,null,null,null,null,"-"]
[]
[]
[]
[]
[]
["自宅",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,"連絡先",null,null,null,null,null,"(",null,null,null,null,null,null,")",null,null,null,null,null,null,"-"]
[]
["主保険",null,null,"保険者番号",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,"併用保険",null,null,"負担者番号"]
[]
[]
[]
[null,null,null,"記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受給者番号"]
[]
[]
[]
["来院方法",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,"その他特記事項",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,")"]
[]
[]
["概要"]
[]
[]
[]
[]
[]
["紹介目的",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,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,")","職業",null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
[]
["患者さんの都合により当医療センターと直接予約日を変更することについて　　",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不承諾並びにどちらにもチェックがない場合は従来どおり紹介元を通しての変更をお願いします。"]
[]
[]
["（直接予約日変更時も下記予約受付時間での対応となります）"]
[]
["主訴または病名･症状",null,null,null,null,null,null,null,"大腿骨近位部骨折",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"既往歴および家族歴"]
[]
[]
[]
[]
[]
[]
["①現病歴　②現症　③検査所見　④治療経過　⑤現在の処方　⑥その他",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,null,null,null,null,null,null,null,null,null,null,"※改行は　「Altキー　＋　Enterキー」"]
[]
[]
[null,"北播磨大腿骨近位部骨折地域連携パス使用の患者様です。\n維持期評価時の受診を貴院にて希望されておりますので、お願いいたします。"]
[]
[]
[]
[null,"回復期リハビリ病棟を",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,"日",null,"に退院されます。なお、当院での経過は下記のとおりです。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["患者に関する留意事項、薬剤アレルギー、嗜好"]
[]
[]
[]
[]
[]
[]
[]
["添付資料",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,"(",null,null,")"]
[]
[]
["北播磨総合医療センター 〒675-1392 兵庫県小野市市場町926-250 代表TEL 0794-88-8800"]
[]
["地域医療連携室   FAX番号（0794)62-9911"]
[]
[null,null,"予約受付時間：　平　日　9:00～18:30     土曜日　9:00～11:30"]

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