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[null,"　　　　　心不全フォローアップシート　　1/2　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　心不全フォローアップシート　　2/2　"]
[]
[null,"主治医：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"▶ 心不全入院歴",null,null,null,null,null,null,null,null,null,null,null,null,null,"【申し送り事項（毎回の記載は必須ではありません）】\n療養指導の内容、セルフモニタリング状況、患者理解度、行動変容には至っていないが、現在行っている取り組みについて。食事や生活の制限など療養生活で負担に感じていること等、聴き取りを行った内容。\nまた、就業・家庭環境、趣味・嗜好の状況等、直接は心不全に関連しないと思うことでも構いませんので、自由にご記載ください。"]
[null,"ID／患者名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,"　　年　　月　　日　"]
[null,"薬局名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〜",null,"　月　　日"]
[null,"フォローアップに関する患者同意：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"▶ 入院時:　　　",null,null,null,null,"kg","退院時:",null,null,null,null,"kg"]
[]
[null,"心不全フォローアップの結果を以下の通り報告いたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"202　年　　月　　日"]
[null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","担当者:"]
[]
[]
[]
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[null,"直近2週間の聴き取り内容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"／",null,null,null,null,"／",null,null,null,null,"／"]
[null,"▶ 薬を飲み忘れることはありますか？"]
[]
[null,"▶ 毎日の血圧・脈拍・体重測定を行っていますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"202　年　　月　　日"]
[null,"▶ 体重",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"kg",null,null,null,null,"kg",null,null,null,null,"kg"]
[null,"▶ 毎日の浮腫の確認を行っていますか？"]
[null,"▶ 労作時の息切れはありませんか？"]
[null,"▶ 就寝時の呼吸苦や、苦しくて横になれないこと"]
[null,"    はありませんか？"]
[null,"▶ 心不全増悪時の受診の目安を知っていますか？"]
[null,"     （1週間での２kgの体重増加、浮腫の悪化、"]
[null,"　　　　     息切れの悪化、 夜間呼吸困難の出現など）"]
[null,"▶ 塩分の摂りすぎに注意していますか？"]
[null,"（汁物は1日1杯までにしているか。麺類では汁を残すように",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"202　年　　月　　日"]
[null,"   しているか。漬物を控えているか。外食や加工食品を控えて"]
[null,"   いるか等の確認）"]
[null,"▶ 食欲の低下はありませんか？"]
[null,"（高齢者の場合、低栄養によるフレイル・サルコペニアの進行に注意)　"]
[null,"▶ 日常生活で過労しないよう注意していますか？"]
[null,"▶ 禁煙はできていますか？"]
[null,"▶ 節酒はできていますか  (日本酒1合、ビール500mLまで）"]
[null,"担当者"]
[]
[null,"服薬指導/電話フォロー時に記入いただき、当院薬剤部まで返信をお願いします（2枚目記載は任意です）\n滋賀医科大学医学部附属病院　薬剤部 　FAX：077-548-2569",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"服薬指導/電話フォロー時に記入いただき、当院薬剤部まで返信をお願いします（2枚目記載は任意です）\n滋賀医科大学医学部附属病院　薬剤部 　FAX：077-548-2569"]