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["紹介状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（診療情報提供書・\n　 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,"令和",null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[]
[]
[]
["北播磨総合医療センター",null,null,null,null,null,null,null,null,null,null,null,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」"]
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["整形外科　　担当医　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,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,"印"]
[]
[]
["受\n診\n希\n望\n日",null,null,"第１",null,null,null,null,null,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日",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,"-"]
[]
[]
[null,null,null,"第２",null,null,null,null,null,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,null,null,")",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,"-"]
[]
[]
[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,null,null,null,null,null,null,null,null,null,null,null,"申込担当者："]
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["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,null,null,null,null,null,"受診歴",null,null,null,null,"性別",null,null,null,null,null,"患者さん予約待ち状況"]
[]
["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,null,null,null,null,null,null,null,"有",null,null,null,null,"男",null,null,null,null,null,"貴医療機関にて外来待機中"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"貴医療機関に入院中"]
[null,null,null,null,null,null,null,null,null,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,null,null,null,"女"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"帰宅され、貴医療機関より連絡待ち"]
[]
["旧　　姓",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※お分かりでしたらご記入お願いします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,"）"]
[]
["生年月日",null,null,null,null,null,null,null,"明治",null,null,null,null,null,null,"大正",null,null,null,null,null,null,"昭和",null,null,null,null,null,null,"平成",null,null,null,null,null,null,"令和",null,null,null,null,null,"患者さん来院方法"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,"日",null,null,null,null,null,null,null,"歳",null,null,null,null,null,"独歩",null,null,null,null,null,null,null,"車イス",null,null,null,null,null,null,null,null,"ストレッチャー"]
[]
[]
["住　　所",null,null,null,null,null,"〒",null,null,"-"]
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[]
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[]
["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,null,"連絡先",null,null,null,null,null,"(",null,null,null,null,null,null,")",null,null,null,null,null,null,"-"]
[]
["紹介目的",null,null,null,null,null,"大腿骨近位部骨折地域連携パス",null,null,null,null,null,null,null,null,null,null,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\n（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）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"承諾する",null,null,null,null,null,null,null,"不承諾",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、紹介元を通しての変更をお願いします。"]
[]
[]
["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"]
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[]
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[]
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["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。"]
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[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,null,"月",null,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。"]
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["患者に関する留意事項、薬剤アレルギー、嗜好"]
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[null,null,"添付資料"]
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["※ FAX予約受付時間（月～金　9:00～18:30　土　9:00～11:30　（祝祭日・年末年始は除く））　（FAX受信は24時間可能です）"]
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["北播磨総合医療センター地域医療連携室　  FAX：0794-62-9911　TEL：0794-88-8800㈹"]
[]
[]
[]
["2024-04-01"]