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[]
["診療情報提供書"]
["（乳がん術後地域連携クリニカルパス）"]
["　　年　　　月　　　日"]
["広島大学病院"]
[]
["　　　担当医　　　　　先生"]
["（FAX：082-257-1720　がん治療センター）　　　"]
[{"$nulls":5},"　　"]
[]
[{"$nulls":5},"医師名：",{"$nulls":3},"　　　　　　㊞"]
[]
[{"$nulls":5},"※医師名欄は，署名もしくは記名押印"]
[]
["患者氏名",{"$nulls":6},"　性別　"]
[{"$nulls":7},"　生年月日　　　　　"]
[{"$nulls":3},"　（広島大学病院ID　　　　　　　　　　　　　　　　　　　　）"]
["住所"]
["電話番号"]
[]
["傷病名　　",null,"乳がん術後（地域連携パス）　　手術日",null,null,"　　　　　年　　　月　　　日"]
["受診日　　　　　",null,"　年　　　　月　　　　日　　",null,"　　（術後　　　　　　年　　　　ヶ月後）"]
["紹介目的",null,"共同診療計画に沿った診療"]
["既往歴"]
["症状経過・検査結果および治療経過"]
[{"$nulls":4},"コメント"]
["問診","術後疼痛",null,"無　・　有",null,"検査","血液検査",null,null,"実施　・　未実施"]
[null,"ＴＡＭ","更年期症状","無　・　有",null,null,"腫瘍\nマーカー","ＣＥＡ",null,"実施　・　未実施"]
[null,null,"帯下の変化","無　・　有",{"$nulls":3},"ＣＡ１５－３",null,"実施　・　未実施"]
[null,"ＡＩ剤","更年期症状","無　・　有",null,null,"画像検査","マンモグラフィー",null,"実施　・　未実施"]
[null,null,"関節痛・こわばり","無　・　有",{"$nulls":3},"乳房エコー",null,"実施　・　未実施"]
["視触診","局所・リンパ節",null,"無　・　有",{"$nulls":3},"ＣＴ",null,"実施　・　未実施"]
[null,"患肢：リンパ浮腫・炎症",null,"無　・　有",{"$nulls":3},"ＭＲＩ",null,"実施　・　未実施"]
["投薬","ホルモン剤処方",null,"無　・　有"]
[null,"内服状況確認",null,"無　・　有"]
[null,"併用薬チェック",null,"無　・　有"]
["コメント"]
[]
[]
[]
["有害事象の発生なく、診療計画に沿い定期的な受診、検査が行えたので報告します。"]
["施行検査",null,null,"　□血液検査   　　      □乳房エコー　　　　　□腫瘍マーカー       "]
[{"$nulls":3},"　□マンモグラフィー        　  "]
["添付資料",null,null,"　□検査データ　　　　　 □その他（　    　　　　　　　　       　　　　）　"]
["現在の処方"]