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[null,null,null,null,null,null,null,null,null,null,null,"作成日","年　　　　　月　　　　　日"]
[null,"退院時カンファレンス報告書"]
[]
[]
["患者氏名(イニシャル) ：　　　　　　　・　　　　　　【＊薬剤師会提出の際は、氏名の部分を隠して送付してください。】"]
["患者年齢 ：　　　　　　歳",null,null,"性別 ：　　男　・　女　　",null,null,null,null,null,"開催日 ：　　　　　年　　　　　月　　　　　日"]
[]
["開催場所 ：　　　　　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,"開催時間 ：　　　　：　　　　～　　　　：　　　　"]
["参加者","病院主治医：　　　　　　　　　　　　　　　病棟看護師："]
["主病名"]
["基本情報",null,null,null,null,"該当薬剤",null,null,null,"発現時期",null,"発現時の状況等（検査値動向含む）"]
[null,"禁忌薬"]
[null,"アレルギー歴"]
[null,"副作用歴"]
[null,"腎機能","SCr",null,null,"mg/dL","eGFR",null,null,null,"mL/min/1.73m2","体表面積（DuBois式）",null,null,"ｍ2"]
[null,"その他必要な検査情報"]
[null,"入院中の服薬管理"]
[null,"投与経路"]
[null,"調剤方法"]
[null,"服薬状況"]
[null,"退院後の薬剤管理方法",null,null,null,null,null,null,null,null,null,"(                                                   )"]
[null,"一般用医薬品・健康食品等",null,null,null,null,null,null,null,"（　　　　　　　　　　　　　　　　　　           　　　　　　　　　　　　　　　）"]
[null,"退院時処方"]
["日常生活状況","食事"]
[null,"睡眠障害",null,null,null,null,null,null,"眠剤使用",null,null,"(                                                   )"]
[null,"排便障害",null,null,null,null,null,null,"下剤使用",null,null,"(                                                   )"]
[null,"ふらつき"]
[null,"同居",null,null,null,"(                                              )"]
[null,"サービス利用"]
[null,"生活上の問題点"]
["特記事項","※患者情報で伝達が必要と思う内容を記載すること（問題点、薬剤の評価、医師の処方意図等/入院中の薬剤の追加、減量、中止で伝えたい内容）\n　\n"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"　　薬局        　　　    店　薬剤師"]