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["（別紙様式18）"]
[]
["特 別 訪 問 看 護 指 示 書"]
["在宅患者訪問点滴注射指示書"]
[]
["※該当する指示書を〇で囲むこと"]
[]
["特別看護指示期間　（令和　　　年　　　月　　　日　～　　　年　　　月　　　日）"]
["点滴注射指示期間　（令和　　　年　　　月　　　日　～　　　年　　　月　　　日）"]
[" 患者氏名",null,null,null,null,null," 生年月日　明・大・昭・平・令　　　　　年　　　月　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,"　（　　　　　 歳）"]
[]
[" 病状・主訴"]
[]
[]
[]
[]
[]
[]
[" 一時的に訪問看護が頻回に必要な理由"]
[]
[]
[]
[]
[]
[]
[" 留意事項及び指示事項（注：点滴注射薬の相互作用・副作用についての留意点があれば記載してください。）"]
[]
[]
[]
[]
[]
[]
[]
[" 点滴注射指示内容（投与薬剤・投与量・投与方法等）"]
[]
[]
[]
[]
[]
[]
[" 緊急時の連絡先等"]
[]
[]
[]
[]
[" 上記のとおり、指示いたします。"]
[]
[null,null,null,null,null,null,null,null,null,null,"  令和　　　　年　　　　月　　　　日"]
[]
[null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,"電　　　　話"]
[null,null,null,null,null,null,"F   　A  　 X"]
[null,null,null,null,null,null,"医 師 氏 名",null,null,null,null,null,null,null,null,"印"]
[]
["つかだファミリークリニック訪問看護ステーション　　殿"]

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