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[null,"医療法人　久康会　平田東九州病院　緩和ケア病棟　入棟意見書"]
[null,null,null,null,null,null,null,null,"記載日","　　　　年","　　　　月","　　　　日"]
[null,"紹介元医療機関：",null,null,null,null,null,"診療科・医師名："]
[]
[null,"ふりがな",null,null,null,"性別",null,"生年月日","　　　年","　　　月","　　　日","　　　歳"]
[null,"お名前",null,null,"様"]
[null,"病名"]
[null,"♯1.",null,null,null,null,null,"診断日","年","月","日"]
[null,"♯2.",null,null,null,null,null,"診断日","年","月","日"]
[null,"♯3.",null,null,null,null,null,"診断日","年","月","日"]
[]
[null,"stage",null,null,null,null,null,"TNM分類"]
[]
[null,"詳細部位",null,null,null,null,null,"病理診断名"]
[]
[null,"発見に至った経緯"]
[]
[]
[]
[null,"診断の際に行なった検査"]
[]
[]
[]
[null,"手術・治療内容"]
[]
[]
[]
[]
[null,"身体所見",null,"　","【症状の性質・分布】",null,null,null,null,"　【重症度】"]
[null,null,null,null,null,"1，","痛み"]
[null,null,null,null,null,"2，","呼吸困難"]
[null,null,null,null,null,"3，","倦怠感"]
[null,null,null,null,null,"4，","発熱"]
[null,null,null,null,null,"5，","口渇"]
[null,null,null,null,null,"6，","咳・痰"]
[null,null,null,null,null,"7，","食欲不振"]
[null,null,null,null,null,"8，","嘔気・嘔吐"]
[null,null,null,null,null,"9，","腹部膨満感"]
[null,null,null,null,null,"10，","浮腫"]
[null,null,null,null,null,"11，","便秘"]
[null,null,null,null,null,"12，","尿閉・失禁"]
[null,null,null,null,null,"13，","その他"]
[]
[]
[]
[]
[null,"精神的所見",null,"          【重症度】",null,null,null,"紹介される経緯"]
[null,"　1，不安",null,null,null,null,null,"　　治癒を目的とした治療に反応しなくなった為"]
[null,"　2，抑うつ",null,null,null,null,null,"　　末期状態となった為"]
[null,"　3，せん妄",null,null,null,null,null,"　　本人の希望"]
[null,"　4，不眠",null,null,null,null,null,"　　家族の希望"]
[null,"　5，眠気",null,null,null,null,null,"　　その他（具体的に）"]
[null,"　6，その他"]
[]
[null,"病名・病状に説明ついて"]
[null,"　1，患者へ（いつ頃）",null,null,"平成　　　年　　　月　　　日"]
[null,"　　　　病名のみ",null,"　　　転移・再発も含めて",null,null,"　　　　予後も含めて"]
[null,"　　　　説明していない",null,null,"→理由"]
[null,"　2，家族へ（誰に）",null,null,null,null,null,"（いつ頃）",null,"平成　　　年　　　月　　　日"]
[null,"　　　　病名のみ",null,"　　　転移・再発も含めて",null,null,"　　　　予後も含めて"]
[null,"　　　　説明していない",null,null,"→理由"]
[]
[null,"臨床的予後予測"]
[null,null,"1年以上",null,"6ヶ月以上",null,"　　　5ヶ月以上",null,"　　　4ヶ月以上",null,"　　　3ヶ月以上"]
[null,null,"2ヶ月程度",null,"1ヶ月程度",null,"　　　週単位",null,"　　　日にち単位"]
[null,null,"その他"]
[]
[null,"緩和ケア病棟についての説明"]
[null,"　1，がんの積極的治療は行わないことを患者・家族に説明した。"]
[null,"　2，痛みなどの苦痛に対する治療が中心になることを説明した。"]
[null,"　3，患者は緩和ケア病棟への入棟を同意している。"]
[null,"　4，家族は緩和ケア病棟への入棟を同意している。"]
[]
[null,null,null,null,null,null,null,null,null,"平成26年5月1日　改訂"]
[null,"※地域がん登録・DPCの導入に伴い詳細な情報が必要となりました。ご協力よろしくお願いいたします。"]

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[null,null,null,null,null,null,null,null,null,null,null,"№．１"]
[null,"久康会平田東九州病院緩和ケア病棟入棟申込書"]
[null,null,null,null,null,null,null,"記載日","　　　年","　　　月","　　　日"]
[null,null,"私たち、職員は患者様が緩和ケア病棟に入院されたその時から、ご希望にそった"]
[null,null,"ケアが行えるように努めてまいりたいと思っています。"]
[null,null,"お手数ですが、現在のあなたの状況、ご希望、ご意見などを教えてください。"]
[]
[null,"次の質問にお答え下さい。選択できる質問は、当てはまるもの全てにチェックをつけてください。"]
[null,"ふりがな",null,null,null,"性別",null,"生年月日","　　　年","　　　月","　　　日","　　　歳"]
[null,"お名前",null,null,"様"]
[null,"ご住所","〒"]
[]
[null,"連絡先　　（携帯可）","①氏名：",null,null,"続柄（　　　　　　）",null,"℡"]
[null,null,"②氏名：",null,null,"続柄（　　　　　　）",null,"℡"]
[null,"現在の　　療養場所",null,null,"その他",null,null,"家族構成",null,null,null," "]
[null,null,null,null,"　（　　　　　　　　　　　　　　）"]
[null,"入院中　　の場合",null,"　　　　　年","　　　　　月","　　　　　日入院"]
[]
[null,"入院　　　施設名"]
[null,null,null,null,null,null,null,"※最も頼りにしている人はどなたですか"]
[null,"　１．痛みなどの身体的な苦痛の症状緩和について"]
[null,"　　　現在、あなたが苦痛に感じている症状（取り除いてほしい）について教えてください。"]
[]
[]
[]
[null,"　２．精神的な症状の緩和について"]
[null,"　　（スタッフがゆっくりお話をお聞きしたり、ご相談に応じたりしております。）"]
["　","　●現在あなたが感じていることはありますか。"]
[]
[]
[]
[]
[null," ●ご希望されることがありますか。"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"R4.4改定"]

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[null,null,null,null,null,"久康会平田東九州病院緩和ケア病棟入棟申込書",null,null,null,null,null,"№．２"]
[]
[]
[null,"お名前：",null,null,null,"様"]
[null,"　３．ご家族の支援について　（患者さまだけでなく、ご家族へのケアも考えています。）"]
[]
[null,null,null,null,"　　　"]
[]
[]
[]
[null,"　４．ご自宅の療養や外泊に関して何かお考えですか。"]
[]
[]
[]
[]
[null,"　５．病名、病状についてどのようにお聞きになっていますか。"]
[null,"　●病名について"]
[]
[]
[null,"　●病状について"]
[]
[]
[null,"　６．緩和ケア病棟について説明を受けていますか。"]
[]
[null,"　●どのような病棟と説明されていますか、または思われますか。"]
["　"]
[]
[null,"　７．その他、入院に際してのご希望がありましたらご記入下さい。"]
[null,"　ご本人様ご希望："]
[]
[]
[null,"　ご家族様ご希望："]
[]
[]
[]
[null,"ご記入ありがとうございました。",null,null,null,null,"記載者："]