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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（歯科診療所用）"]
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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】"]
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["1－①",null,"診療所名称等についてご記入ください。"]
[]
[null,null,"回答者名"]
[]
[]
[null,null,"（ふりがな）"]
[null,null,"法人名"]
[]
[null,null,"（ふりがな）"]
[null,null,"医院名"]
[]
[null,null,"所在地",null,null,null,null,"（〒",null,null,null,"－",null,null,"）",null,null,null,null,"区"]
[]
[null,null,"駐車場",null,null,null,null,null,null,null,"（",null,null,"台","）"]
[]
[null,null,"診療科目"]
[]
[null,null,"連絡先",null,null,null,null,"代表",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,"－"]
[]
[null,null,"ホームページURL"]
[]
[]
["1－②",null,"外来診療時間等についてご記入ください。"]
[]
[null,null,"外来診療時間",null,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,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,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,"："]
[null,null,"祝日・盆・\n年末年始等の\n診療"]
[]
[null,null,null,null,null,null,null,null,"〔記入例：祝日は午前（9:00～12：00）は診療、8/13～15と12/29～1/4は休み〕"]
[]
["1－③",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,null,null,null,null,null,null,"人数"]
[]
[null,null,"歯科医師"]
[]
[null,null,"歯科衛生士"]
[]
[null,null,"歯科技工士"]
[]
[null,null,"医師"]
[]
[null,null,"看護師"]
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[null,null,"薬剤師"]
[]
[null,null,"管理栄養士・栄養士"]
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[null,null,"医療ソーシャルワーカー、社会福祉士"]
[]
[null,null,"事務員"]
[]
[null,null,"その他："]
[]
[null,null,"計",null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AND(R45=\"\",R47=\"\",R49=\"\",R51=\"\",R53=\"\",R55=\"\",R57=\"\",R59=\"\",R61=\"\",R63=\"\"),\"\",SUM(R45:V64))","v":""}]
[]
[]
[2,"【施設情報について】"]
["2－①",null,"届出状況についてご記入ください"]
[]
[null,null,"届出・算定項目",null,null,null,null,null,null,null,null,null,null,null,null,null,"届出状況に○を記入"]
[]
[null,null,"在宅療養支援歯科診療所",null,null,null,null,null,null,null,null,null,null,null,null,null,"有り",null,null,null,null,null,null,null,"今後届出予定有り"]
[]
[]
[]
[]
["2－②",null,"各種算定状況について、過去１年間（R3.7.1～R4.6.30）で算定したことがある場合、○をご記入ください。"]
[]
[]
[null,null,"報酬別",null,"項目",null,null,null,null,null,null,null,null,null,null,null,null,null,"〇を記入"]
[]
[null,null,"診療報酬",null,"歯科訪問診療料"]
[]
[null,null,null,null,"訪問歯科衛生指導料"]
[]
[null,null,null,null,"歯科疾患在宅療養管理料"]
[]
[null,null,null,null,"在宅患者訪問口腔\nリハビリテーション指導管理料"]
[]
[null,null,"介護報酬",null,"居宅療養管理指導費（歯科医師）"]
[]
[null,null,null,null,"居宅療養管理指導費（歯科衛生士等）"]
[]
[null,null,null,null,"口腔機能維持管理加算"]
[]
[]
[]
[3,"【在宅医療情報について】"]
["3－①",null,"歯科訪問診療の実施状況についてあてはまるものに○をご記入ください。"]
[]
[null,null,"歯科訪問診療の実施状況",null,null,null,null,null,null,null,null,null,null,null,null,"○を記入"]
[]
[null,null,"実施している"]
[]
[null,null,"実施していない（今後予定あり）"]
[]
[null,null,"実施していない（今後予定なし）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["3－②",null,"歯科訪問診療先についてあてはまるものに○をご記入ください。"]
[]
[null,null,"歯科訪問診療先の限定",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○を記入",null,null,null,"内容"]
[]
[null,null,"特に限定していない"]
[]
[null,null,"特定の訪問先\nに限定している\n（複数回答可）",null,null,null,null,null,"自宅"]
[]
[null,null,null,null,null,null,null,null,"居住系施設\n（有料老人ホーム、グループホーム、サービス付き高齢者向け住宅等）"]
[]
[]
[null,null,null,null,null,null,null,null,"その他"]
[]
[]
["3－③",null,"歯科訪問診療を実施するにあたり、条件等があればご記入ください。\n　【例】：訪問可能日、訪問地区など"]
[]
[]
[]
[]
[]
[]
[]
["3－④",null,"歯科訪問診療の患者対象年齢についてご記入ください。"]
[]
[null,null,"年齢区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○を記入"]
[]
[null,null,"全年齢対象"]
[]
[null,null,"小児以外を対象"]
[]
[null,null,"小児のみを対象"]
[]
[null,null,"その他"]
[]
[]
["3－⑤",null,"歯科訪問診療体制についてご記入ください。（複数回答可）"]
[]
[null,null,"体制",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○を記入",null,null,null,null,"その他記載"]
[]
[null,null,"歯科医師のみで訪問"]
[]
[null,null,"歯科医師と歯科衛生士で訪問"]
[]
[null,null,"歯科衛生士のみで訪問"]
[]
[null,null,"歯科医師と管理栄養士・栄養士で訪問"]
[]
[null,null,"歯科医師と訪問看護ステーションで訪問"]
[]
[null,null,"かかりつけ医と歯科医師で訪問"]
[]
[null,null,"その他"]
[]
[]
[]
["3－⑥",null,"歯科訪問診療で対応可能な処置についてご記入ください。"]
[]
[null,null,"対応可能な処置",null,null,null,null,null,null,null,null,null,null,null,null,"可",null,null,"要相談",null,null,"不可"]
[]
[null,null,"診察のみ"]
[]
[null,null,"入れ歯の製作や調整"]
[]
[null,null,"冠を被せる治療やブリッジの治療"]
[]
[null,null,"虫歯の治療や歯の根の治療"]
[]
[null,null,"歯周病の治療"]
[]
[null,null,"抜歯"]
[]
[null,null,"歯や口の中、入れ歯の清掃方法の指導"]
[]
[null,null,"食べ方・飲み方の訓練（摂食嚥下リハビリテーション）"]
[]
[null,null,"その他"]
[]
[]
[]
[4,"【その他】"]
["4－①",null,"今後の歯科訪問診療への取り組みについてあてはまるものに○をご記入ください。"]
[]
[]
[null,null,"今後の取り組み",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"]
[]
[null,null,"開始について検討中"]
[]
[null,null,"取り組む予定なし"]
[]
[]
[]
["4－②",null,"貴院の特徴や、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。"]
[]
[]
[]
[]
[]
[]
[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。"]