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[]
["多剤投薬患者　減薬提案書(保険薬局)"]
[]
["作成日:　　　　 年　　　月　　　日"]
["1. 患者情報"]
["病院ID",null,null,null,"薬局ID"]
[]
["患者名",null,null,null,"薬剤師"]
[]
["診療科",null,null,null,"医師"]
[]
["その他\n医療機関"]
[]
["2.調整希望薬剤、希望者、理由"]
["薬剤名"]
[]
["希望者"]
["理由"]
[]
["その他\n報告事項"]
["医師との協議結果"]
[]
["薬剤名"]
[]
["希望者"]
["理由"]
[]
["その他\n報告事項"]
["医師との協議結果"]
[]
["薬剤名"]
[]
["希望者"]
["理由"]
[]
["その他\n報告事項"]
["医師との協議結果"]
["*トレーシングレポートに添付して送信してください。"]
["*4剤以上の場合は報告書をもう一枚作成してください。"]
[]
[]
["和歌山労災病院 薬剤部JP（2018.4）"]