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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（別添１）"]
["実績報告（令和　6年　7月　1日 ～ 令和　7年　6月　30日）",null,null,null,null,null,null,null,null,null,null,null,null," コード番号"]
[]
[null,"保険医療機関名：",null,null,null,null,null,null,null,null,"届出受理年月日："]
[]
[null,null,null,null,null,null,null,null,null,null,"先進医療の費用(届出時)："]
[null,null,null,null,null,null,null,null,null,null,null,null,"(うち、人件費",null,")"]
[null,"先進医療名：",null,null,null,null,null,null,null,null,"総 件 数：",{"$f":"COUNTA(INDIRECT(\"B14:B\"&MAX($A:$A)+13))","v":0}]
[]
["番号","診　 断 　名","年 齢\n(歳)","性 別","初　回\n実施日\n(年月日)","入院\n期間\n(日)","実施\n回数\n(回)","転 帰","保険者負担","被保険者負担","先進医療\n費用(円)",null,"総 合 計\n(①＋②＋③＋④)\n(円)","評価結果"]
[null,null,null,null,null,null,null,null,"保険外併用\n療養費分①\n(円)","保険外併用療養費分に係る一部負担金②\n(円)"]
[]
[null,null,null,null,null,null,null,null,null,null,"患者負担③","その他④"]
[{"$f":"ROW()-13","v":1},null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(I14:L14)","v":0},null,null,null,"有効"]
[2,null,null,null,null,null,null,null,null,null,null,null,0,null,null,null,"無効"]
[3,null,null,null,null,null,null,null,null,null,null,null,0,null,null,null,"不明"]
[4,null,null,null,null,null,null,null,null,null,null,null,0]
[5,null,null,null,null,null,null,null,null,null,null,null,0]
[6,null,null,null,null,null,null,null,null,null,null,null,0]
[7,null,null,null,null,null,null,null,null,null,null,null,0]
[8,null,null,null,null,null,null,null,null,null,null,null,0]
[9,null,null,null,null,null,null,null,null,null,null,null,0]
[10,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(I23:L23)","v":0}]
[null,null,null,null,null,null,null,"合　計",{"$f":"SUM(INDIRECT(\"I14:I\"&ROW()-1))","v":0},{"$f":"SUM(INDIRECT(\"J14:J\"&ROW()-1))","v":0},{"$f":"SUM(INDIRECT(\"K14:K\"&ROW()-1))","v":0},{"$f":"SUM(INDIRECT(\"L14:L\"&ROW()-1))","v":0},{"$f":"SUM(INDIRECT(\"M14:M\"&ROW()-1))","v":0}]
[]
["保険外併用療養費分の合計(①+②)",null,{"$f":"I24+J24","v":0},null,null,"患者1人当たりの平均保険外併用療養費分((①+②)/総件数)",null,null,null,null,{"$f":"IF(L8=0,0,C26/L8)","v":0},null,"患者１人当たりの平均入院期間",null,{"$f":"IF(L8=0,0,SUM(INDIRECT(\"F14:F\"&MAX($A:$A)+13))/L8)","v":0}]
[]
["先進医療費用(患者負担)の合計(③)",null,{"$f":"K24","v":0},null,null,"患者1人当たりの平均先進医療費用(患者負担)(③/総件数)",null,null,null,null,{"$f":"IF(L8=0,0,K24/L8)","v":0},null,"患者１人当たりの平均実施回数",null,{"$f":"IF(L8=0,0,SUM(INDIRECT(\"G14:G\"&MAX($A:$A)+13))/L8)","v":0}]
[]
["先進医療費用(その他)の合計(④)",null,{"$f":"L24","v":0},null,null,"患者1人当たりの平均先進医療費用(その他)(④/総件数)",null,null,null,null,{"$f":"IF(L8=0,0,L24/L8)","v":0}]
[]
["上記に係る総合計(①+②+③+④)",null,{"$f":"M24","v":0},null,null,"患者1人当たり平均総合計((①+②+③+④)/総件数)",null,null,null,null,{"$f":"IF(L8=0,0,M24/L8)","v":0},null,"《実施責任医師記入欄》"]
[null,null,null,null,null,null,null,null,null,null,null,null,"所属"]
["※ 実績が０件の場合、1年間の実施件数が0件だった理由（様式第1号(別添4)）を提出すること。"]
[null,null,null,null,null,null,null,null,null,null,null,null,"署名"]
["<特記事項>(コメントがあればこちらに記入して下さい)"]