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[null,"診療情報提供書　(がん治療連携指導に伴う報告)"]
[]
[null,"年　　月　　日"]
[null,null,"広島大学病院"]
[null,null,"担当医",null,"先生"]
[null,null,"(FAX：082-257-1720　がん治療センター)"]
[{"$nulls":5},"医師名：",null,null,"㊞　　"]
[{"$nulls":6},"※医師名欄は，署名もしくは記名押印"]
[]
[null,null,"患者氏名"]
[null,null,"生年月日"]
[null,null,"患者住所"]
[null,null,"電話番号"]
[null,null,"＜","広島大学病院ID",null,"EMR,ESD施行日：",{"$nulls":3},"＞"]
[]
[null,null,"傷病名　　　　胃癌EMR,ＥＳＤ後（Ⅰ期）"]
[null,null,"紹介目的　　(胃癌EMR,ＥＳＤ後Ⅰ期　地域連携パスの適用) 　治療後　　　年　　ヶ月の報告"]
[null,null,"受診日・検査日　　　　　　",null,null,"年　　　　月　　　　日"]
[null,null,"症状経過・検査結果および治療経過　"]
[null,null,"血液・画像検査","貧血（Hb）",null,"□あり　□なし","自覚症状","体　　重","       Kg"]
[{"$nulls":3},"炎症所見（WBCなど）",null,"□あり　□なし",null,"腹　　痛","□あり　□なし"]
[{"$nulls":3},"肝機能異常（GOT・GPTなど）",null,"□あり　□なし",null,"腹部膨満","□あり　□なし"]
[{"$nulls":3},"腎機能異常（Crなど）",null,"□あり　□なし",null,"下　　痢","□あり　□なし"]
[{"$nulls":3},"腫瘍マーカー異常（CEA・CA19-9）",null,"□あり　□なし",null,"吐き気・嘔吐","□あり　□なし"]
[{"$nulls":3},"画像検査異常(CT/US/胸部Ｘ線) ",null,"□あり　□なし",null,"全身倦怠感","□あり　□なし"]
[{"$nulls":3},"*上部消化管内視鏡所見",null,"　年後□あり　□なし",null,"めまい","□あり　□なし"]
[null,null,"治療","抗潰瘍薬内服（ESD後2〜3ヶ月）",null,"□あり　□なし",null,"冷や汗","□あり　□なし"]
[{"$nulls":3},"H.pylori　除菌療法",null,"□あり　□なし","指導","食事指導","□あり　□なし"]
[{"$nulls":7},"生活指導","□あり　□なし"]
[null,null,"   有害事象の発生なく、診療計画に沿い定期的な受診、検査が行えたのでご報告いたします。"]
[null,null,"   *内視鏡所見用紙のコピーを忘れずに添付下さい。"]
[null,"現在の処方"]
[null,"添付資料",null,null,"□検査データ　　□　　　　　　　　　　□"]
[null,null,"備　　考　\nバリアンス・有害事象の発生時は、速やかに担当医、患者支援センターへ直接連絡して受診予約を依頼して下さい。\n尚、その際も診療情報提供書を用いてご連絡ください。\n広島大学病院　TEL 082-257-5465 （消化器内科外来）\n　　　　　　　　　　FAX 082-257-1720 （がん治療センター）"]