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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"報告日:",null,null,{"$f":"TODAY()","v":"2024-09-18"}]
[]
["【服薬情報提供書（トレーシングレポート）】"]
["<注意>このFAXによる情報伝達は、疑義照会ではありません。疑義照会は通常通り電話連絡にてお願いします。"]
[]
["担当医　　",null,null,null,null,null,null,null,null,"科",null,null,null,null,null,"施設名・所在地"]
[]
[null,null,null,null,null,null,null,null,null,null,"先生　御机下"]
[]
["当院患者ID :"]
["患者氏名 :",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL :",null,null,null,null,null,null,"FAX :"]
["生年月日 : ",null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,"担当薬剤師 :"]
[]
["この情報を伝える上で、患者からの同意を",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（代諾者続柄: ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["＜報告・提案内容＞該当する項目に、印☑を付けて、FAXにてご連絡ください。"]
[]
[null,null,null,null,null,null,"⇒",null,"≪理由≫",null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
[]
["≪残薬が生じた状況（介入前）≫"]
["　・薬剤名（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["　・飲み忘れやすい服用時点　（",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,"）"]
["　・管理状況　",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,"）"]
["　・調剤方法、服薬支援状況",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,"）"]
[]
["≪介入事項≫"]
["   ・指導内容"]
["   ・服薬支援   "]
["※アドヒアランス改善のための提案事項等については備考欄に記載してください。"]
[]
[" ・継続の必要性の乏しい薬剤（ポリファーマシー）⇒薬剤中止提案（薬剤名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["　  "]
["　・被疑薬（薬剤名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"、","内服開始日：",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["　・症状・訴え",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,"、","いつ頃から",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["　・検査値確認依頼（",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,"）"]
[]
["※患者は副作用の対処法（服用中止や受診目安など）について理解しているか　"]
[]
[]
[]
["備考（必要に応じて記載してください。）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２０２４年９月改訂　第２版"]