{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["看取りケアパス（A3）","看取りケアパス（Ａ4版）-1","看取りケアパス（Ａ4版）-2"],"not_rendered":{"charts":0,"images":15,"macros":1,"external_links":0,"defined_names":2,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"看取りケアパス（A3）","index":0,"n_rows":59,"n_cols":70,"rows_kept":59,"cut":false,"hidden":false,"merged":[[5,1,8,1],[5,3,5,16],[5,18,5,31],[5,33,5,46],[5,48,5,61],[5,63,5,76],[0,24,1,43],[2,0,8,0],[2,1,3,1],[2,2,3,16],[2,17,2,46],[2,47,2,61],[6,3,6,16],[6,18,6,31],[6,33,6,46],[6,48,6,61],[6,63,6,76],[7,3,7,16],[7,18,7,31],[7,33,7,46],[7,48,7,61],[7,63,7,76],[2,62,3,76],[3,17,3,31],[3,32,3,46],[3,47,3,61],[9,48,9,61],[9,63,9,76],[10,3,10,16],[10,18,10,31],[10,33,10,46],[10,48,10,61],[10,63,10,76],[8,3,8,16],[8,18,8,31],[8,33,8,46],[8,48,8,61],[8,63,8,76],[9,3,9,16],[9,18,9,31],[9,33,9,46],[11,3,11,16],[11,18,11,31],[11,33,11,46],[11,48,11,61],[11,63,11,76],[12,3,12,16],[12,18,12,31],[12,33,12,46],[12,48,12,61],[12,63,12,76],[13,3,13,16],[13,18,13,31],[13,33,13,46],[13,48,13,61],[13,63,13,76],[14,3,14,16],[14,18,14,31],[14,33,14,46],[14,48,14,61],[14,63,14,76],[16,63,16,76],[17,3,17,16],[17,18,17,31],[17,33,17,46],[17,48,17,61],[17,63,17,76],[15,1,20,1],[15,3,15,16],[15,18,15,31],[15,33,15,46],[15,48,15,61],[15,63,15,76],[16,3,16,16],[16,18,16,31],[16,33,16,46],[16,48,16,61],[18,3,18,16],[18,18,18,31],[18,33,18,46],[18,48,18,61],[18,62,18,76],[19,3,19,16],[19,18,19,31],[19,33,19,46],[19,48,19,61],[19,62,19,76],[20,3,20,16],[20,18,20,31],[20,33,20,46],[20,48,20,61],[20,62,20,76],[21,0,37,0],[21,1,23,1],[21,3,21,16],[21,18,21,31],[21,33,21,46],[9,0,20,0],[9,1,14,1],[24,1,32,1],[24,3,24,16],[24,48,24,61],[21,48,21,61],[21,63,21,76],[22,3,22,16],[22,18,22,31],[22,33,22,46],[22,48,22,61],[22,63,22,76],[24,63,24,76],[25,3,25,16],[25,18,25,31],[25,33,25,46],[25,48,25,61],[25,63,25,76],[23,3,23,16],[23,18,23,31],[23,33,23,46],[23,48,23,61],[23,63,23,76],[28,63,28,76],[29,3,29,16],[29,18,29,31],[29,33,29,46],[29,48,29,61],[29,63,29,76],[26,3,26,16],[26,18,26,31],[26,33,26,46],[26,48,26,61],[26,63,26,76],[27,3,27,16],[27,18,27,31],[27,33,27,46],[27,48,27,61],[27,63,27,76],[32,3,32,16],[24,18,24,31],[32,33,32,46],[32,48,32,61],[32,63,32,76],[33,1,35,1],[33,3,33,16],[33,18,33,31],[33,33,33,46],[33,48,33,61],[30,3,30,16],[30,18,30,31],[30,33,30,46],[30,48,30,61],[30,63,30,76],[31,3,31,16],[31,18,31,31],[24,33,24,46],[31,48,31,61],[31,63,31,76],[28,3,28,16],[28,18,28,31],[28,33,28,46],[28,48,28,61],[36,1,37,1],[36,3,36,16],[36,18,36,31],[36,33,36,46],[36,48,36,61],[33,63,33,76],[34,3,34,16],[34,18,34,31],[34,33,34,46],[34,48,34,61],[34,63,34,76],[36,63,36,76],[37,3,37,16],[37,18,37,31],[37,33,37,46],[37,48,37,61],[37,63,37,76],[35,3,35,16],[35,18,35,31],[35,33,35,46],[35,48,35,61],[35,63,35,76],[38,63,38,76],[39,3,39,16],[39,18,39,31],[39,33,39,46],[39,48,39,61],[39,63,39,76],[38,0,45,0],[38,1,40,1],[38,3,38,16],[38,18,38,31],[38,33,38,46],[38,48,38,61],[40,3,40,16],[40,18,40,31],[40,33,40,46],[40,48,40,61],[42,48,42,61],[42,63,42,76],[43,3,43,16],[43,18,43,31],[43,33,43,46],[43,48,43,61],[43,63,43,76],[40,63,40,76],[41,1,45,1],[41,3,41,16],[41,18,41,31],[41,33,41,46],[41,48,41,61],[41,63,41,76],[42,3,42,16],[42,18,42,31],[42,33,42,46],[44,3,44,16],[44,18,44,31],[44,33,44,46],[44,48,44,61],[44,63,44,76],[45,3,45,16],[45,18,45,31],[45,33,45,46],[45,48,45,61],[45,63,45,76],[48,63,48,76],[49,3,49,16],[49,18,49,31],[49,33,49,46],[49,48,49,61],[49,63,49,76],[46,63,46,76],[47,3,47,16],[47,18,47,31],[47,33,47,46],[47,48,47,61],[47,63,47,76],[46,3,46,16],[46,18,46,31],[46,33,46,46],[46,48,46,61],[48,3,48,16],[48,18,48,31],[48,33,48,46],[48,48,48,61],[50,3,50,16],[50,18,50,31],[50,33,50,46],[50,48,50,61],[50,63,50,76],[51,0,54,0],[51,1,51,3],[51,62,51,76],[52,1,52,3],[52,7,52,8],[46,0,50,0],[46,1,50,1],[53,1,53,3],[53,7,53,8],[53,9,53,10],[53,11,53,12],[53,13,53,14],[52,39,52,40],[52,41,52,42],[52,43,52,44],[52,45,52,46],[52,24,52,25],[52,26,52,27],[52,28,52,29],[52,30,52,31],[52,32,52,33],[52,37,52,38],[52,9,52,10],[52,11,52,12],[52,13,52,14],[52,15,52,16],[52,17,52,18],[52,22,52,23],[52,54,52,55],[52,56,52,57],[52,58,52,59],[52,60,52,61],[52,62,52,76],[52,47,52,48],[52,52,52,53],[53,60,53,61],[53,62,53,76],[53,47,53,48],[53,52,53,53],[53,54,53,55],[53,56,53,57],[53,58,53,59],[53,45,53,46],[53,30,53,31],[53,32,53,33],[53,37,53,38],[53,39,53,40],[53,41,53,42],[53,43,53,44],[53,15,53,16],[53,17,53,18],[53,22,53,23],[53,24,53,25],[53,26,53,27],[53,28,53,29],[55,0,57,1],[55,3,55,16],[55,18,55,31],[55,33,55,46],[55,48,55,61],[54,39,54,40],[54,41,54,42],[54,43,54,44],[54,45,54,46],[54,47,54,48],[54,52,54,53],[54,24,54,25],[54,26,54,27],[54,28,54,29],[54,30,54,31],[54,32,54,33],[54,37,54,38],[54,1,54,3],[54,7,54,8],[54,9,54,10],[54,11,54,12],[54,13,54,14],[54,15,54,16],[54,17,54,18],[55,63,55,76],[56,3,56,16],[56,18,56,31],[56,33,56,46],[56,48,56,61],[56,63,56,76],[54,54,54,55],[54,56,54,57],[54,58,54,59],[54,60,54,61],[54,62,54,76],[54,22,54,23],[61,18,61,31],[61,33,61,46],[61,48,61,61],[61,63,61,76],[62,18,62,31],[62,33,62,46],[62,48,62,61],[62,62,62,76],[57,3,57,16],[57,18,57,31],[57,33,57,46],[57,48,57,61],[57,63,57,76],[60,18,60,31],[60,33,60,46],[60,48,60,61],[60,63,60,76],[66,62,66,76],[63,18,63,31],[63,33,63,46],[63,48,63,61],[63,62,63,76],[64,18,64,31],[64,33,64,46],[64,48,64,61],[64,62,64,76],[0,1,0,14],[69,17,69,31],[69,32,69,46],[69,47,69,61],[69,62,69,76],[70,17,70,31],[70,32,70,46],[70,47,70,61],[70,62,70,76],[67,18,67,31],[67,33,67,46],[67,48,67,61],[67,62,67,76],[68,17,68,31],[68,32,68,46],[68,47,68,61],[68,62,68,76],[65,18,65,31],[65,33,65,46],[65,48,65,61],[65,62,65,76],[66,18,66,31],[66,33,66,46],[66,48,66,61]]}
["　名前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,null,null,null,"看取りケアパス"]
[]
[null,"時期","入所時",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア準備期",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,"看取り期",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り後"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"前半：概ね1年～6ヶ月前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"後半：概ね3ヶ月前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"概ね2～3週間前"]
[null,"期間","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～"]
[null,"各時期の\n目標",null,"療養生活への期待や希望の把握",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"終末期の判断",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書の実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"安らかな看取りをサポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り時の手続き"]
[null,null,null,"生活歴・健康歴の把握",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者・家族と面談し病状を説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者・家族が望む暮らしの実現",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族・友人等、介護職の看取りをサポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"遺族・介護者に対する看取り後のケア"]
[null,null,null,"事前ケアプランの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書の立案や作成"]
[null,null,null,"ACPの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
[null,"本人",null,"療養生活への期待や希望、不安を述べる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病状説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"今ここで実現したい暮らしの実現",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"安らかで、尊厳保持された状態で過ごせる"]
[null,null,null,"施設の説明を受ける際に医療の対応について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア（医療処置・ケア）の説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"緩和ケアを受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族･友人･介護者の見守りの下過ごし、"]
[null,null,null,"説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに意向を",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの見直し",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別れを遂げる"]
[null,null,null,"可能であればACPを作成する",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"述べる"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画所や看取りケアプランに同意する"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
[null,"家族",null,"家族の立場から療養生活に対する希望や",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病状説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"今ここで実現したい看取りケアの実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"心残りなく最期の看取りができる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望によりエンゼルケアへの参加"]
[null,null,null,"不安を述べる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア（医療処置・ケア）の説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの見直し",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"悲しみの表出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要時、グリーフケアを受ける"]
[null,null,null,"施設の説明を受ける際に医療の対応について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに希望を",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,"付き添いの検討",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加"]
[null,null,null,"説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"述べる"]
[null,null,null,"可能であればACPの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに同意する"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
["介護関係職の支援","施設長\n介護管理者",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の終末期説明に同席",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの総括",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの総括",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族と看取り後の対応相談"]
[null,null,null,"重要事項、看取りの説明と本人・家族の",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りに向けたACP同意書確認",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,"看取り後の対応について家族と相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜・告別式参列"]
[null,null,null,"意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"役割分担の整理",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加"]
[null,"介護職員",null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書の説明と同意確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ケアに対する本人・家族の反応観察",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態の観察、看護への報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"エンゼルケア実施"]
[null,null,null,"入所時カンファレンス参加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態の観察、看護職への報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態の観察、看護職への報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜・告別式参列"]
[null,null,null,"計画書等立案と実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの評価"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等の企画・運営"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"活動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寄せ書き写真アルバムを渡す等"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"活動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"活動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りの病床の環境調整"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師・看護職との連携方法確立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"療養環境の調整",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"本人・家族の不安の傾聴・心理的サポート"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"療養環境の調整"]
[]
[null,"生活相談員",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の家族面談に同席",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族連絡・相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の病状説明に参加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族と看取り後の対応相談"]
[null,null,null,"重要事項看取りの説明と本人・家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りに向けたACP同意書確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書のモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り後の対応について家族と相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜・告別式参列"]
[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,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,null,"追想会等への参加"]
[null,"栄養士・\n調理師等",null,"状態と嗜好に応じた食事の提供",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事、水分摂取量の把握",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事、水分摂取量の把握",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,"看取りケアの評価"]
[null,null,null,"栄養ケア計画書等の作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態と嗜好に応じた食事の提供",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態と嗜好に応じた食事の提供",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,"追想会等への参加"]
["医学・医療の支援","医師",null,"診察",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"終末期の判断",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"オンコール指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への病状説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死亡確認、死亡診断書の作成"]
[null,null,null,"医学的治療計画の処方、指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族面談：終末期の告知、ACPについての説明",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,"オンコール指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への説明"]
[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,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,null,"看取りケアの評価"]
[null,"看護職員\n訪問看護師",null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"緩和ケアの実施とモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態観察と介護職への指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死亡診断書の管理"]
[null,null,null,"医師への状態報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の家族面談に同席",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師への状態報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"夜間緊急時オンコール対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"エンゼルケア実施"]
[null,null,null,"重要事項看取りの説明と本人・家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書立案",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"夜間・急変時等オンコール対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清等の直接ケアを介護職と実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの評価"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　医療面の対応、夜間・急変時の対応策を立案",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への説明・心理的サポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への説明・心理的サポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護との連携方法確立"]
["ケアマネジメント","ケアマネジャー",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランのモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者・家族を訪問",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの評価"]
[null,null,null,"重要事項看取りの説明と本人・家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族との面談",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要時遺族に対するグリーフケア"]
[null,null,null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアカンファレンスの開催",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"（生活支援の専門機関へつなげる）"]
[null,null,null,"入所時カンファレンスの開催",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの作成",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加やお悔やみ訪問等"]
[null,null,null,"ケアプラン作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの説明と同意確認"]
["状態確認\nシート\n記載欄",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒"]
[null,"R年月日",null,null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,"R年月日",null,null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,"R年月日",null,null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
["その他\n自由記入欄"]
[]
[]
["出処：「令和4年度鹿児島県グループホーム連絡協議会佐々木炎氏研修資料を参考」",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※加算の算定については各事業所や担当者が随時確認する",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　　年　　月　第　1版"]

{"sheet":"看取りケアパス（Ａ4版）-1","index":1,"n_rows":60,"n_cols":32,"rows_kept":60,"cut":false,"hidden":false,"merged":[[0,0,0,31],[52,2,52,3],[52,17,52,18],[53,4,53,5],[54,4,54,5],[55,4,55,5],[53,19,53,20],[54,19,54,20],[55,19,55,20],[22,18,22,31],[54,2,54,3],[53,17,53,18],[53,22,53,23],[53,24,53,25],[53,26,53,27],[53,28,53,29],[53,30,53,31],[51,3,51,16],[51,18,51,31],[53,11,53,12],[53,13,53,14],[53,15,53,16],[46,18,46,31],[52,4,52,6],[52,19,52,21],[54,17,54,18],[54,22,54,23],[54,24,54,25],[54,26,54,27],[54,28,54,29],[54,30,54,31],[54,7,54,8],[54,9,54,10],[54,11,54,12],[54,13,54,14],[54,15,54,16],[56,0,58,1],[56,3,56,16],[56,18,56,31],[57,3,57,16],[57,18,57,31],[58,3,58,16],[58,18,58,31],[55,17,55,18],[55,22,55,23],[55,24,55,25],[55,26,55,27],[55,28,55,29],[55,30,55,31],[55,2,55,3],[55,7,55,8],[55,9,55,10],[55,11,55,12],[55,13,55,14],[55,15,55,16],[52,0,55,0],[53,1,55,1],[53,2,53,3],[53,7,53,8],[53,9,53,10],[47,0,51,0],[47,1,51,1],[47,3,47,16],[47,18,47,31],[48,18,48,31],[49,3,49,16],[49,18,49,31],[50,3,50,16],[50,18,50,31],[39,0,46,0],[39,1,40,1],[39,3,39,16],[39,18,39,31],[40,3,40,16],[40,18,40,31],[42,1,46,1],[42,3,42,16],[42,18,42,31],[43,3,43,16],[43,18,43,31],[44,3,44,16],[44,18,44,31],[45,18,45,31],[46,3,46,16],[33,18,33,31],[34,1,35,1],[34,3,34,16],[34,18,34,31],[35,3,35,16],[35,18,35,31],[26,1,33,1],[37,1,38,1],[37,3,37,16],[37,18,37,31],[38,3,38,16],[38,18,38,31],[23,0,38,0],[23,1,25,1],[23,3,23,16],[23,18,23,31],[24,3,24,16],[10,0,22,0],[29,3,29,16],[29,18,29,31],[30,3,30,16],[30,18,30,31],[31,3,31,16],[31,18,31,31],[24,18,24,31],[25,3,25,16],[25,18,25,31],[26,3,26,16],[26,18,26,31],[27,3,27,16],[27,18,27,31],[28,3,28,16],[28,18,28,31],[32,3,32,16],[32,18,32,31],[33,3,33,16],[15,3,15,16],[15,18,15,31],[16,1,22,1],[16,3,16,16],[16,18,16,31],[17,3,17,16],[17,18,17,31],[18,3,18,16],[18,18,18,31],[19,3,19,16],[10,1,15,1],[19,18,19,31],[20,3,20,16],[20,18,20,31],[21,18,21,31],[22,3,22,16],[12,3,12,16],[12,18,12,31],[13,3,13,16],[13,18,13,31],[14,3,14,16],[14,18,14,31],[3,0,9,0],[3,1,4,1],[3,2,4,16],[3,17,3,31],[4,17,4,31],[6,1,9,1],[6,3,6,16],[6,18,6,31],[7,3,7,16],[7,18,7,31],[1,27,1,31],[1,1,1,5],[8,3,8,16],[8,18,8,31],[9,3,9,16],[9,18,9,31],[10,3,10,16],[10,18,10,31],[11,3,11,16],[11,18,11,31]]}
["看取りケアパス "]
["名前　",null,null,null,null,null,"様",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"No.1"]
[]
[null,"時期","入所時",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア準備期"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"前半：概ね1年～6ヶ月前"]
[null,"期間","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日"]
[null,"各時期の\n目標",null,"療養生活への期待や希望の把握",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"終末期の判断"]
[null,null,null,"生活歴・健康歴の把握",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者・家族と面談し病状を説明"]
[null,null,null,"事前ケアプランの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書の立案や作成"]
[null,null,null,"ACPの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
["本人\n家族","本人",null,"療養生活への期待や希望、不安を述べる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病状説明を受ける"]
[null,null,null,"施設の説明を受ける際医療の対応について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア(医療処置･ケア)の説明を受ける"]
[null,null,null,"説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに"]
[null,null,null,"可能であればACPを作成する",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"意向を述べる"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画所や看取りケアプランに同意する"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
[null,"家族",null,"家族の立場から療養生活に対する希望や",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病状説明を受ける"]
[null,null,null,"不安を述べる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケア(医療処置･ケア)の説明を受ける"]
[null,null,null,"施設の説明を受ける際医療の対応について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに"]
[null,null,null,"説明を受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望を述べる"]
[null,null,null,"可能であればACPの作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書や看取りケアプランに同意する"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ACPの作成または見直し"]
[]
["介護関係職\nの支援","施設長\n介護管理者",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の終末期説明に同席"]
[null,null,null,"重要事項･看取りの説明と本人･家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りに向けたACP同意書確認"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"役割分担の整理"]
[null,"介護職員",null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書の説明と同意確認"]
[null,null,null,"入所時カンファレンス参加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態の観察、看護職への報告"]
[null,null,null,"計画書等立案と実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"活動"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師・看護職との連携方法確立"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"療養環境の調整"]
[null,"生活相談員",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の家族面談に同席"]
[null,null,null,"重要事項･看取りの説明と本人･家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りに向けたACP同意書確認"]
[]
[null,"栄養士・\n調理師等",null,"状態と嗜好に応じた食事の提供",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事、水分摂取量の把握"]
[null,null,null,"栄養ケア計画書等の作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態と嗜好に応じた食事の提供"]
["医学・医療\nの支援","医師",null,"診察",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"終末期の判断"]
[null,null,null,"医学的治療計画の処方、指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族面談:終末期の告知、ACPの説明"]
[]
[null,"看護職員\n訪問看護師",null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アセスメント"]
[null,null,null,"医師への状態報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の家族面談に同席"]
[null,null,null,"重要事項･看取りの説明と本人･家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り介護計画書立案"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療面の対応、夜間･急変時の対応策を立案"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護との連携方法確立"]
["ケア\nマネジメント","ケアマネジャー",null,"入所に際して契約書説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アセスメント"]
[null,null,null,"重要事項看取りの説明と本人･家族の意思確認",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族との面談"]
[null,null,null,"アセスメント",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアカンファレンスの開催"]
[null,null,null,"入所時カンファレンスの開催",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの作成"]
[null,null,null,"ケアプラン作成",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの説明と同意確認"]
["状態確認\nシート\n記載欄","項目",null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒"]
[null,"確認日\nR　　年","/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
["その他\n自由記入欄"]
[]
[]
["出処：「令和4年度鹿児島県グループホーム連絡協議会佐々木炎氏研修資料を参考」"]

{"sheet":"看取りケアパス（Ａ4版）-2","index":2,"n_rows":60,"n_cols":39,"rows_kept":60,"cut":false,"hidden":false,"merged":[[71,2,71,15],[72,1,72,15],[73,1,73,15],[74,1,74,15],[53,3,53,4],[54,3,54,4],[55,3,55,4],[65,2,65,15],[66,2,66,15],[67,2,67,15],[68,2,68,15],[69,2,69,15],[70,2,70,15],[58,32,58,42],[64,2,64,15],[55,23,55,24],[55,25,55,26],[55,27,55,28],[55,29,55,30],[55,31,55,42],[53,18,53,19],[54,18,54,19],[55,18,55,19],[57,17,57,30],[53,23,53,24],[53,25,53,26],[53,27,53,28],[53,29,53,30],[56,0,58,0],[56,2,56,15],[56,17,56,30],[56,32,56,42],[57,2,57,15],[54,29,54,30],[54,31,54,42],[55,1,55,2],[55,6,55,7],[55,8,55,9],[55,10,55,11],[55,12,55,13],[55,14,55,15],[55,16,55,17],[55,21,55,22],[54,14,54,15],[54,16,54,17],[54,21,54,22],[54,23,54,24],[54,25,54,26],[54,27,54,28],[57,32,57,42],[58,2,58,15],[58,17,58,30],[52,0,55,0],[52,31,52,42],[53,1,53,2],[53,6,53,7],[53,8,53,9],[53,10,53,11],[53,12,53,13],[53,14,53,15],[53,16,53,17],[53,21,53,22],[45,32,45,42],[46,17,46,30],[46,32,46,42],[53,31,53,42],[54,1,54,2],[54,6,54,7],[54,8,54,9],[54,10,54,11],[54,12,54,13],[47,0,51,0],[47,2,47,15],[47,17,47,30],[47,32,47,42],[48,2,48,15],[48,17,48,30],[48,32,48,42],[42,0,46,0],[42,17,42,30],[42,32,42,42],[43,17,43,30],[43,32,43,42],[44,2,44,15],[44,17,44,30],[44,32,44,42],[45,2,45,15],[45,17,45,30],[49,17,49,30],[49,32,49,42],[50,2,50,15],[50,17,50,30],[50,32,50,42],[51,17,51,30],[51,32,51,42],[39,0,41,0],[39,2,39,15],[39,17,39,30],[39,32,39,42],[40,17,40,30],[40,32,40,42],[41,17,41,30],[41,32,41,42],[37,0,38,0],[37,2,37,15],[37,17,37,30],[37,32,37,42],[38,2,38,15],[38,17,38,30],[38,32,38,42],[34,0,36,0],[34,2,34,15],[34,17,34,30],[34,32,34,42],[35,2,35,15],[35,17,35,30],[35,32,35,42],[36,17,36,30],[36,32,36,42],[25,0,33,0],[25,17,25,30],[25,32,25,42],[26,17,26,30],[26,32,26,42],[27,17,27,30],[27,32,27,42],[28,17,28,30],[31,2,31,15],[31,17,31,30],[31,32,31,42],[32,32,32,42],[33,17,33,30],[33,32,33,42],[28,32,28,42],[29,17,29,30],[29,32,29,42],[30,2,30,15],[30,17,30,30],[30,32,30,42],[22,0,24,0],[22,2,22,15],[22,17,22,30],[22,32,22,42],[23,2,23,15],[23,17,23,30],[23,32,23,42],[16,0,21,0],[24,17,24,30],[24,32,24,42],[18,32,18,42],[19,2,19,15],[19,17,19,30],[19,31,19,42],[20,2,20,15],[20,17,20,30],[20,31,20,42],[16,17,16,30],[16,32,16,42],[17,2,17,15],[17,17,17,30],[17,32,17,42],[18,2,18,15],[18,17,18,30],[21,2,21,15],[21,17,21,30],[21,31,21,42],[13,2,13,15],[13,17,13,30],[13,32,13,42],[14,2,14,15],[14,17,14,30],[14,32,14,42],[10,0,15,0],[10,2,10,15],[10,17,10,30],[10,32,10,42],[11,2,11,15],[11,17,11,30],[11,32,11,42],[12,2,12,15],[12,17,12,30],[12,32,12,42],[15,17,15,30],[15,32,15,42],[6,0,8,0],[6,2,6,15],[6,17,6,30],[6,32,6,42],[7,2,7,15],[7,17,7,30],[7,32,7,42],[8,2,8,15],[8,17,8,30],[1,38,1,42],[1,27,1,31],[1,1,1,9],[3,0,4,0],[3,1,3,15],[3,16,3,30],[3,31,4,42],[4,1,4,15],[4,16,4,30]]}
["看取りケアパス "]
["名前　",null,null,null,null,null,null,null,null,null,"様",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,"No.2"]
[]
["時期","看取りケア準備期",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り期",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り後"]
[null,"後半：概ね3ヶ月前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"概ね2～3週間前"]
["期間","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～","R",null,"年",null,"月",null,"日","R",null,"年",null,"月",null,"日","～"]
["各時期の目標",null,"看取り介護計画書の実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"安らかな看取りをサポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り時の手続き"]
[null,null,"患者･家族が望む暮らしの実現",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族･友人等、介護職の看取りをサポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"遺族･介護者に対する看取り後"]
[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,null,"のケア"]
[]
["本人",null,"今ここで実現したい暮らしの実現",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"安らかで尊厳保持された状態で過ごせる"]
[null,null,"緩和ケアを受ける",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族･友人･介護者の見守りの下で過ごし"]
[null,null,"ACPの見直し",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別れを遂げる"]
[]
[]
[]
["家族",null,"今ここで実現したい看取りケアの実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"心残りなく最期の看取りができる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望によりエンゼルケアへの参加"]
[null,null,"ACPの見直し",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"悲しみの表出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"必要時、グリーフケアを受ける"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"付き添いの検討",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加"]
[]
[]
[]
["施設長\n介護\n管理者",null,"看取りケアの総括",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの総括",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族と看取り後の対応相談"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り後の対応について家族と相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜･告別式参列"]
[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,null,"追想会等への参加"]
["介護職員",null,"ケアに対する本人･家族の反応観察",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態の観察、看護への報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"エンゼルケア実施"]
[null,null,"状態の観察、看護職への報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜･告別式参列"]
[null,null,"保清",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排泄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの評価"]
[null,null,"排泄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"食事",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等の企画･運営"]
[null,null,"食事",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"活動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寄書き･写真アルバムを渡す等"]
[null,null,"活動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りの病床の環境調整"]
[null,null,"療養環境の調整",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"本人・家族の不安の傾聴"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"心理的サポート"]
[]
["生活\n相談員",null,"家族連絡･相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師の病状説明に参加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族と看取り後の対応相談"]
[null,null,"看取り介護計画書のモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取り後の対応について家族と相談",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見送り、通夜･告別式参列"]
[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,null,"追想会等への参加"]
["栄養士\n調理師等",null,"食事、水分摂取量の把握",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,"看取りケアの評価"]
[null,null,"状態と嗜好に応じた食事の提供",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,"追想会等への参加"]
["医師",null,"オンコール指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への病状説明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死亡確認、死亡診断書の作成"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"オンコール指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への説明"]
[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,null,"看取りケアの評価"]
["看護職員\n訪問看護師",null,"緩和ケアの実施とモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"状態観察と介護職への指示",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死亡診断書の管理"]
[null,null,"医師への状態報告",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"夜間緊急時オンコール対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"エンゼルケア実施"]
[null,null,"夜間･急変時等オンコール対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保清等の直接ケアを介護職と実施",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアの評価"]
[null,null,"家族への説明･心理的サポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"家族への説明･心理的サポート",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"追想会等への参加"]
[]
["ケアマネジャー",null,"看取りケアプランのモニタリング",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者･家族を訪問",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看取りケアプランの評価"]
[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,null,"必要時遺族に対するグリーフケア"]
[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,null,"（生活支援の専門機関へつなげる）"]
[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,null,"追想会等への参加や"]
[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,null,"お悔やみ訪問等"]
["状態確認\nシート\n記載欄",null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒",null,null,null,"体重",null,null,"食事",null,"排泄",null,"体調",null,"皮膚",null,"覚醒"]
[null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
[null,"/",null,null,null,"kg",null,null,null,null,null,null,null,null,null,null,"/",null,null,null,"kg"]
["自由\n記入欄"]
[]
[]
["　　※加算の算定については各事業所や担当者が随時確認する",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,"令和　　年　　月　　日　第1版"]