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["【診療情報提供書】"]
[null,"施設名："]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,null,"性別",null,null,"（",null,null,null,"）"]
["氏名",null,null,null,null,null,null,null,null,null,null,"生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"年","  ","月",null,"日  （",null,"歳）"]
["住所"]
[]
["病名",null,null,null,null,null,null,null,null,"既往歴"]
[]
[]
[]
["治療経過",null,null,null,null,null,null,null,null,null,null,"身体所見"]
[]
[]
[]
[]
[]
[]
[]
[]
["処方内容",null,null,null,null,null,null,null,null,null,null,"胸部ＸＰ所見"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"ＥＣＧ所見"]
[]
["検査所見"]
["WBC",null,null,"GOT",null,null,null,"BUN",null,null,null,"TP",null,null,null,null,"HBｓ抗原"]
["RBC",null,null,"GPT",null,null,null,"Cr",null,null,null,"Alb",null,null,null,null,"HCV抗体"]
["Hb",null,null,"LDH",null,null,null,"Na",null,null,null,"CRP",null,null,null,null,"TPHA"]
["Ht",null,null,"γ-GTP",null,null,null,"K",null,null,null,"血糖",null,null,null,null,"MRSA"]
["PLT",null,null,"T-Bil",null,null,null,"Cｌ",null,null,null,"HbA1c"]
[]
["尿検査（","蛋白",null,null,"糖",null,null,"潜血",null,null,"）"]
["上記のとおり診断",null,null,null,null,null,null,null,"医療機関名"]
[null,"年",null,"月",null,"日",null,null,"所　 在　　地"]
[null,null,null,null,null,null,null,null,"医　師 氏　名",null,null,null,null,null,null,null,null,null,"印"]