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["入退院共通連携シート(医療機関→在宅・施設）"]
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["情報提供元の医療機関名：",{"$nulls":78},"＊　別紙判定基準参照"]
["所属："]
["記載者氏名：",{"$nulls":58},"責任者氏名："]
["　私は「入退院共通連携シート」の目的について説明を受け理解した上で利用することに同意します。"]
[{"$nulls":57},"署名（代筆）："]
[{"$nulls":22},"栃木県看護協会・とちぎケアマネジャー協会・栃木県医療社会事業協会　入退院共通連携シート作成委員会　Ver.1"]