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[]
[" リハビリテーション情報提供書"]
[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,"紹介元："]
["紹介先：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,null,null,null,null,null,"所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"敬称"]
[null,null,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,"御中"]
["作成日：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
["リハ担当：",null,null,"理学療法士",null,null,null,null,null,null,null,null,null,null,null,"作業療法士",null,null,null,null,null,null,null,null,null,null,null,"言語聴覚士"]
[]
["入院日：",null,null,null,null,null,null,null,null,null,"退院日：",null,null,null,null,null,null,null,null,null,"リハ開始日：",null,null,null,null,null,null,null,null,null,"起算日："]
["ﾌﾘｶﾞﾅ:",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"生年月日：",null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(T11=\"\",\"\",IF(D6=\"\",\"\",DATEDIF(T11,D6,\"Y\")))","v":""},null,"歳",null,"性別："]
["患者氏名："]
["診断名：",null,null,null,null,null,null,null,null,null,null,null,null,null,"発症日：",null,null,null,null,null,null,null,"既往歴："]
["経過："]
[]
[]
["リスク管理\nその他コメント："]
[]
[]
["■","介護度・生活状況"]
["入院前介護度：",null,null,null,null,null,null,null,"入院前の様子：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護度",null,null,null,"ADL",null,null,"要介助リスト"]
["退院時介護度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし",null,null,null,"自立",null,null,"最大"]
["■退院時の状況、今後必要と考えられるサービスとその理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請中",null,null,null,"見守り",null,null,"中等"]
["本人の要望：",null,null,null,null,null,null,null,null,null,null,null,null,null,"家族の要望：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分変更中",null,null,null,"要介助",null,null,"軽"]
["家屋改修提案：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"改修箇所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要支援　1",null,null,null,null,null,null,"見守り"]
["福祉用具選定：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"種別：",null,null,null,null,null,null,null,null,null,null,null,null,"事業所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要支援　2",null,null,null,null,null,null,"接触支持"]
["補装具処方：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"種別：",null,null,null,null,null,null,null,null,null,null,null,null,"事業所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　1"]
[null,null,"通所介護",null,null,"通所リハ",null,null,"訪問看護",null,null,null,"訪問リハ",null,null,"訪問介護",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,"要介護　2"]
["　理由・コメント：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　3"]
["■退院時の心身機能・構造",null,null,null,null,null,null,"※未評価の場合はチェックなし",null,null,null,null,null,null,null,null,null,null,null,null,null,"■活動（基本動作・「している」ADL）",null,null,null,null,null,null,null,null,"※要介助：協力あり、全介助：協力なし",null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　4"]
["項目",null,null,null,null,null,"現在の状況",null,null,null,null,null,null,null,"将来の見込み（",null,null,null,6,")カ月","項目",null,null,null,null,"現在の状況　※非実施行為はチェックなし",null,null,null,null,null,null,null,"将来の見込み（",null,null,null,6,")カ月",null,null,null,null,null,"要介護　5"]
[null,null,null,null,null,null,"なし",null,"軽度",null,"中等度",null,"重度",null,"向上",null,"維持",null,"低下",null,null,null,null,null,null,"自立",null,"要介助\n※右欄：介助量",null,null,"全介助",null,null,"向上",null,"維持",null,"低下"]
["ｺﾐｭﾆｹｰｼｮﾝ障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寝返り"]
[null,null,"失語症",null,null,"構音障害",null,null,null,"難聴",null,null,"その他：",null,null,null,null,null,null,null,"起き上がり"]
["見当識障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"座位保持"]
["認知症（BPSD）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"立ち上がり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"運動感覚",null,null,null,"移動"]
[null,"・　HDS-R（",null,null,null,null,"点）",null,null,"・　MMSE (",null,null,null,null,"点）",null,null,null,null,null,"立位保持",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右側",null,null,null,"独歩"]
["精神障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移乗（Bed⇔いす）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左側",null,null,null,"杖"]
["高次脳機障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移動：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"両側",null,null,null,"歩行器"]
["運動麻痺：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"階段昇降",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"車いす"]
["感覚障害：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事"]
["筋力低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"更衣"]
["関節可動域制限",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主食",null,null,null,"副食",null,null,null,"食思",null,"職種",null,null,"活動IADL"]
["疼痛",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入浴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"米飯",null,null,null,"常食",null,null,null,"あり",null,"ST",null,null,"未評価"]
["摂食嚥下障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄動作",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"芋",null,null,null,"軟菜キザミ",null,null,null,"なし",null,"PT/OT",null,null,"可能"]
["食事形態・量",null,null,null,null,null,"主：",null,null,null,"副：",null,null,null,"食思：",null,null,null,null,null,"排尿コントロール",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アチビー",null,null,null,"超キザミ",null,null,null,"ムラ",null,"PT",null,null,"要介助"]
[null,null,null,null,null,null,"水分：",null,"トロミ",null,null,"なし",null,"あり",null,null,null,null,null,null,"排便コントロール",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ミキサー",null,null,null,"ミキサー",null,null,null,null,null,"OT",null,null,"困難"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゼリー状",null,null,null,"ミキサーとろみ"]
["コメント：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ソフト食",null,null,null,"キザミとろみ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※将来の見込みは、リハビリテーションを継続した場合の評価となる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"パン",null,null,null,"ゼリー状"]
["■心身機能面の詳細、基本動作・ADL自立の阻害因子など　　※その他特記事項含む",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ソフト食"]
[]
[]
[]
[]
["■活動（IADL）",null,null,null,"※　リストより選択　　コメントは右欄へ記載 "]
["項目",null,null,null,"将来の見込み",null,null,null,null,null,null,null,null,"項目",null,null,null,"将来の見込み",null,null,null,null,null,null,null,null,"項目",null,null,null,"将来の見込み"]
["食事の用意・片づけ",null,null,null,null,null,null,null,null,null,null,null,null,"掃除・洗濯",null,null,null,null,null,null,null,null,null,null,null,null,"買い物、外出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊フリー記載スペースは、記載内容にて適宜高さ調整すると良いと思います。"]
["服薬管理",null,null,null,null,null,null,null,null,null,null,null,null,"金銭管理",null,null,null,null,null,null,null,null,null,null,null,null,"IT活用　スマホ操作等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊リスト入力は施設によって項目の追加変更が可能です。"]
["■予後予測について（心身機能、活動・参加レベルの今後の見通しおよび家族・キーパーソンの状況、活動）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※退院時点の評価（退院後は在宅主治医、在宅担当セラピストと要継続検討）"]
[]
[]
[]
["【退院時の心身機能・構造・活動(基本動作・「している」ADL)・活動(IADL)】"]
["～補足記載欄～"]

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[]
[" リハビリテーション情報提供書"]
[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,"紹介元："]
["紹介先：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,null,null,null,null,null,"所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"敬称"]
[null,null,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,"御中"]
["作成日：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
["リハ担当：",null,null,"理学療法士",null,null,null,null,null,null,null,null,null,null,null,"作業療法士",null,null,null,null,null,null,null,null,null,null,null,"言語聴覚士"]
[]
["入院日：",null,null,null,null,null,null,null,null,null,"退院日：",null,null,null,null,null,null,null,null,null,"リハ開始日：",null,null,null,null,null,null,null,null,null,"起算日："]
["ﾌﾘｶﾞﾅ:",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"生年月日：",null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(T11=\"\",\"\",IF(D6=\"\",\"\",DATEDIF(T11,D6,\"Y\")))","v":""},null,"歳",null,"性別："]
["患者氏名："]
["診断名：",null,null,null,null,null,null,null,null,null,null,null,null,null,"発症日：",null,null,null,null,null,null,null,"既往歴："]
["経過："]
[]
[]
["リスク管理\nその他コメント："]
[]
[]
["■","介護度・生活状況"]
["入院前介護度：",null,null,null,null,null,null,null,"入院前の様子：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護度",null,null,null,"ADL",null,null,"要介助リスト"]
["退院時介護度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なし",null,null,null,"自立",null,null,"最大"]
["■退院時の状況、今後必要と考えられるサービスとその理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請中",null,null,null,"見守り",null,null,"中等"]
["本人の要望：",null,null,null,null,null,null,null,null,null,null,null,null,null,"家族の要望：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分変更中",null,null,null,"要介助",null,null,"軽"]
["家屋改修提案：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"改修箇所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要支援　1",null,null,null,null,null,null,"見守り"]
["福祉用具選定：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"種別：",null,null,null,null,null,null,null,null,null,null,null,null,"事業所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要支援　2",null,null,null,null,null,null,"接触支持"]
["補装具処方：",null,null,null,null,"あり",null,null,"なし",null,null,"要検討",null,null,"種別：",null,null,null,null,null,null,null,null,null,null,null,null,"事業所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　1"]
[null,null,"通所介護",null,null,"通所リハ",null,null,"訪問看護",null,null,null,"訪問リハ",null,null,"訪問介護",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,"要介護　2"]
["　理由・コメント：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　3"]
["■退院時の心身機能・構造",null,null,null,null,null,null,"※未評価の場合はチェックなし",null,null,null,null,null,null,null,null,null,null,null,null,null,"■活動（基本動作・「している」ADL）",null,null,null,null,null,null,null,null,"※要介助：協力あり、全介助：協力なし",null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護　4"]
["項目",null,null,null,null,null,"現在の状況",null,null,null,null,null,null,null,"将来の見込み（",null,null,null,null,")カ月","項目",null,null,null,null,"現在の状況　※非実施行為はチェックなし",null,null,null,null,null,null,null,"将来の見込み（",null,null,null,null,")カ月",null,null,null,null,null,"要介護　5"]
[null,null,null,null,null,null,"なし",null,"軽度",null,"中等度",null,"重度",null,"向上",null,"維持",null,"低下",null,null,null,null,null,null,"自立",null,"要介助\n※右欄：介助量",null,null,"全介助",null,null,"向上",null,"維持",null,"低下"]
["ｺﾐｭﾆｹｰｼｮﾝ障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寝返り"]
[null,null,"失語症",null,null,"構音障害",null,null,null,"難聴",null,null,"その他：",null,null,null,null,null,null,null,"起き上がり"]
["見当識障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"座位保持"]
["認知症（BPSD）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"立ち上がり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"運動感覚",null,null,null,"移動"]
[null,"・　HDS-R（",null,null,null,null,"点）",null,null,"・　MMSE (",null,null,null,null,"点）",null,null,null,null,null,"立位保持",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右側",null,null,null,"独歩"]
["精神障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移乗（Bed⇔いす）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左側",null,null,null,"杖"]
["高次脳機障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移動：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"両側",null,null,null,"歩行器"]
["運動麻痺：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"階段昇降",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"車いす"]
["感覚障害：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事"]
["筋力低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"更衣"]
["関節可動域制限",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主食",null,null,null,"副食",null,null,null,"食思",null,"職種",null,null,"活動IADL"]
["疼痛",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入浴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"米飯",null,null,null,"常食",null,null,null,"あり",null,"ST",null,null,"未評価"]
["摂食嚥下障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄動作",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"芋",null,null,null,"軟菜キザミ",null,null,null,"なし",null,"PT/OT",null,null,"可能"]
["食事形態・量",null,null,null,null,null,"主：",null,null,null,"副：",null,null,null,"食思：",null,null,null,null,null,"排尿コントロール",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アチビー",null,null,null,"超キザミ",null,null,null,"ムラ",null,"PT",null,null,"要介助"]
[null,null,null,null,null,null,"水分：",null,"トロミ",null,null,"なし",null,"あり",null,null,null,null,null,null,"排便コントロール",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ミキサー",null,null,null,"ミキサー",null,null,null,null,null,"OT",null,null,"困難"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゼリー状",null,null,null,"ミキサーとろみ"]
["コメント：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ソフト食",null,null,null,"キザミとろみ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※将来の見込みは、リハビリテーションを継続した場合の評価となる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"パン",null,null,null,"ゼリー状"]
["■心身機能面の詳細、基本動作・ADL自立の阻害因子など　　※その他特記事項含む",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ソフト食"]
[]
[]
[]
[]
["■活動（IADL）",null,null,null,"※　リストより選択　　コメントは右欄へ記載 "]
["項目",null,null,null,"将来の見込み",null,null,null,null,null,null,null,null,"項目",null,null,null,"将来の見込み",null,null,null,null,null,null,null,null,"項目",null,null,null,"将来の見込み"]
["食事の用意・片づけ",null,null,null,null,null,null,null,null,null,null,null,null,"掃除・洗濯",null,null,null,null,null,null,null,null,null,null,null,null,"買い物、外出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊フリー記載スペースは、記載内容にて適宜高さ調整すると良いと思います。"]
["服薬管理",null,null,null,null,null,null,null,null,null,null,null,null,"金銭管理",null,null,null,null,null,null,null,null,null,null,null,null,"IT活用　スマホ操作等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊リスト入力は施設によって項目の追加変更が可能です。"]
["■予後予測について（心身機能、活動・参加レベルの今後の見通しおよび家族・キーパーソンの状況、活動）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※退院時点の評価（退院後は在宅主治医、在宅担当セラピストと要継続検討）"]
[]
[]
[]
["【退院時の心身機能・構造・活動(基本動作・「している」ADL)・活動(IADL)】"]
["～補足記載欄～"]