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["在宅医療資源及び在宅医療の提供等に関する調査（訪問看護事業所用）"]
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[]
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["【調査にあたってのお願い】"]

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[1,"【基本情報等について】"]
[]
["1－①",null,"事業所名称等についてご記入ください。"]
[]
[null,null,"回答者名"]
[]
[]
[null,null,"事業所名称",null,null,null,null,"（ふりがな）"]
[null,null,null,null,null,null,null,"法人名"]
[]
[null,null,null,null,null,null,null,"（ふりがな）"]
[null,null,null,null,null,null,null,"事業所名"]
[]
[null,null,"所在地",null,null,null,null,"（〒",null,null,null,"－",null,null,"）",null,null,null,null,"区"]
[]
[null,null,"連絡先",null,null,null,null,"代　表",null,null,null,null,null,"電話",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,"ホームページURL"]
[]
[null,null,"外国語対応\n（対応可能な言語に○を記入）",null,null,null,null,null,null,null,null,null,"英",null,null,"中国",null,null,"韓国",null,null,"その他",null,null,"（その他の言語を記載）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　",null,null,null,null,"　）"]
[]
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["1－②",null,"営業（相談対応）時間等についてご記入ください。"]
[]
[null,null,"営業時間",null,null,null,null,"曜日",null,"月",null,null,"火",null,null,"水",null,null,"木",null,null,"金",null,null,"土",null,null,"日"]
[]
[null,null,null,null,null,null,null,"午前",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～"]
[null,null,null,null,null,null,null,null,null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,"午後",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～"]
[null,null,null,null,null,null,null,null,null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,"祝日・盆・年末年始等の対応"]
[]
[]
["1－③",null,"訪問地域についてご記入ください。"]
[]
[null,null,null,null,null,null,"門司区",null,null,"小倉北区",null,null,"小倉南区",null,null,"若松区",null,null,"八幡東区",null,null,"八幡西区",null,null,"戸畑区"]
[]
[null,null,"○を記入",null,"全域"]
[]
[null,null,null,null,"一部"]
[]
[]
["1－④",null,"スタッフの配置状況をご記入ください。"]
[]
[null,null,"職種",null,null,null,null,null,null,null,null,"人数",null,null,null,null,"左記のうち介護支援専門員を兼務している人数"]
[]
[null,null,"理学療法士"]
[]
[null,null,"作業療法士"]
[]
[null,null,"言語聴覚士"]
[]
[null,null,"保健師"]
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[null,null,"助産師"]
[]
[null,null,"看護師"]
[]
[null,null,"准看護師"]
[]
[null,null,"事務員"]
[]
[null,null,"介護支援専門員"]
[]
[null,null,"その他："]
[]
[null,null,"計",null,null,null,null,null,null,null,null,{"$f":"IF(AND(L58=\"\",L60=\"\",L62=\"\",L64=\"\",L52=\"\",L54=\"\",L56=\"\",L66=\"\",L68=\"\",L70=\"\"),\"\",SUM(L52:P71))","v":""},null,null,null,null,{"$f":"IF(AND(Q58=\"\",Q60=\"\",Q62=\"\",Q64=\"\",Q52=\"\",Q54=\"\",Q56=\"\",Q66=\"\",Q70=\"\"),\"\",SUM(Q52:Y71))","v":""}]
[]
[]
[2,"【施設情報について】"]
["2－①",null,"各種届出状況等について、あてはまるものに○をご記入ください。"]
[]
[null,null,"項目",null,null,null,null,null,null,null,null,null,null,null,"届出あり",null,null,null,null,null,null,null,"今後届出予定有り"]
[]
[null,null,"機能強化型訪問看護管理療養費",null,null,null,null,null,null,null,null,null,null,null,"療養費１"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"療養費２"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"療養費３"]
[]
[null,null,"サービス提供体制強化加算"]
[]
[null,null,"２４時間対応体制"]
[]
[null,null,"精神科訪問看護"]
[]
[]
[]
["2－②",null,"上記の設問２-①で「24時間対応体制」に「届出なし」の場合は、実際の対応状況についてご記入ください。"]
[]
[]
[null,null,"対応体制"]
[]
[]
[]
[]
[]
["2－③",null,"居宅介護支援事業所併設の有無についてご記入ください。"]
[]
[null,null,null,null,null,null,null,"○を記入",null,null,null,"事業所名"]
[]
[null,null,"併設有り"]
[]
[null,null,"併設無し"]
[]
[]
[3,"【在宅医療情報について】"]
["3－①",null,"対応可能な医療処置について、可能なものに○をご記入ください。"]
[]
[null,null,"医療処置",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"可",null,null,"要相談",null,null,"不可"]
[]
[null,null,"膀胱留置カテーテル"]
[]
[null,null,"在宅酸素療法（ＨＯＴ）"]
[]
[null,null,"気管カニューレの管理"]
[]
[null,null,"腹膜透析"]
[]
[null,null,"点滴・静脈注射"]
[]
[null,null,"麻薬を用いた疼痛管理"]
[]
[null,null,"経管栄養（胃ろうを含む）の管理"]
[]
[null,null,"在宅中心静脈栄養の管理（ＩＶＨ）"]
[]
[null,null,"在宅中心静脈栄養の管理（ポート）"]
[]
[null,null,"腎ろう・膀胱ろう"]
[]
[null,null,"人工呼吸療法（レスピレーター、ベンチレター）"]
[]
[null,null,"在宅自己腹膜灌流（ＣＡＰＤ）"]
[]
[null,null,"人工肛門（ストマ）・人工膀胱"]
[]
[null,null,"吸引"]
[]
[]
["3－②",null,"小児患者の受け入れの有無等について〇をご記入ください。"]
[null,null,"小児患者の受け入れ",null,null,null,null,null,null,null,null,null,"○を記入",null,null,null,null,null,null,null,null,null,null,null,"対応できる年齢"]
[]
[null,null,"可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"歳以上"]
[]
[null,null,"不可"]
[]
[]
[]
[4,"【その他】"]
["4－①",null,"今後の事業規模の展開についてあてはまるものに○をご記入ください。"]
[]
[null,null,"事業規模の展開",null,null,null,null,null,null,null,null,null,null,"○を記入"]
[]
[null,null,"拡充"]
[]
[null,null,"現状維持"]
[]
[null,null,"縮小"]
[]
[]
[]
["4－②",null,"貴事業所の特徴や特に力を入れている取り組みなどございましたらご記入ください。"]
[]
[]
[]
[]
[]
[]
[]
["4－③",null,"貴事業所が行っている訪問看護業務以外の取り組み（教育、研修会、実習など）をご記入ください。"]
[]
[null,null,"訪問看護業務以外の取り組み"]
[]
[]
[]
[]
[]
[]
[]
[null,null,"全ての情報を非公表にする。  "]
[]
[]
[null,null,"☆ご協力ありがとうございました。"]