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["　保険医療機関の現況"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　　 年　　 月　　 日現在"]
["　※　直近（事前提出日の前月）の状況により作成してください。"]
["担当者名",null,null,null,null,null,null,null,null,null,null,null," ※ 連絡窓口担当者様を記載ください。"]
["所属部署/役職",null,null,null,null,null,null,null,null,null,null,null,"電話番号\n（内線番号）"]
["メールアドレス"]
[]
["１．病院の概要"]
["保険医療\n機関コード"]
["名称"]
["所在地"]
["電話番号",null,null,null,null,null,null,null,null,null,"FAX番号"]
["開設者"]
["管理者"]
["診療科目"]
[]
["診療時間"]
["備　　　　考"]
[]
[]
[]
[]
[]
["２．許可病床数"]
["一般",null,null,null,"床",null,null,null,null,null,"結核",null,null,null,"床"]
["療 　養",null,"（ 医 療 ）",null,"床",null,null,null,null,null,"精神",null,null,null,"床"]
[null,null,"（ 介 護 ）",null,"床",null,null,null,null,null,"その他",null,null,null,"床"]
["感染症",null,null,null,"床",null,null,null,null,null,"合計",null,null,null,"床"]
[]
["３．医師数等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　　 年　　 月　　 日現在（直近の保健所による立入検査の日付）"]
[null,null,null,null,"医師",null,null,null,"歯科医師",null,null,null,"看護師及び\n准看護師",null,null,null,"看護補助者"]
["現員数",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["医療法による標準数",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　※ 直近の保健所による立入検査の際に作成した現員数及び標準数を記載してください。　"]

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["４．平均入院患者数"]
["（１）一般病床の入院患者数"]
[null,null,null,null,"一般病棟入院基本料\n（　　　　　　　　　　　　）"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["合計",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　※ 入院基本料・特定入院料ごと（特定入院料については病棟ごと）に、月別の延べ入院患者数を記載してください。"]
["　　※ 様式９に係る平均入院患者数の根拠となる人数を記載してください。（（２）も同様）"]
["（２）一般病床以外の入院患者数"]
[]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["合計",null,null,null,"人",null,null,null,"人",null,null,null,"人",null,null,null,"人"]
["　　※ 入院基本料・特定入院料ごと（特定入院料については病棟ごと）に記載してください。"]

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["５．平均在院日数"]
["（１）次のうち、届け出ている入院基本料等にチェックの上、下表に当該病棟に係る在院患者"]
["延べ日数等を記入願います。なお、該当する入院基本料等が複数ある場合は、別紙にて"]
["同様に作成願います。"]
[]
[null,"□　一般病棟入院基本料（　　　　）",null,null,null,null,null,null,"□　特定機能病院入院基本料（一般病棟（　　対１））"]
[null,"□　精神病棟入院基本料（10対１）",null,null,null,null,null,null,"□　特定機能病院入院基本料（精神病棟〔15対１を除く。〕）"]
[null,"□　精神病棟入院基本料（13対１）",null,null,null,null,null,null,"□　小児入院医療管理料(□１、□２、□３及び□４に限る。)"]
[null,"□　専門病院入院基本料(　　対１)",null,null,null,null,null,null,"□　特定一般病棟入院料（１及び２）"]
[null,"□　地域包括医療病棟入院料"]
[null,null,null,null,"在院患者延べ日数",null,null,null,"新退棟患者数",null,null,null,"新入棟患者数",null,null,null,"平均在院日数"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人",null,null,null,"日"]
[]
["６．保険外併用療養費"]
["（１）特別の療養環境の提供",null,null,null,null,null,"（※消費税込みの金額を記載してください）"]
[null,null,null,null,"費用徴収を行わない　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　病床数",null,null,null,"費用徴収を行う病床数",null,null,null,"内　　訳",null,null,null,"金　額"]
["個室",null,null,null,"床",null,null,null,"床",null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
["２人室",null,null,null,"床",null,null,null,"床",null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
["３人室",null,null,null,"床",null,null,null,"床",null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
["４人室",null,null,null,"床",null,null,null,"床",null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"床",null,null,null,"円"]
["５人室以上",null,null,null,"床"]
[]
["合　計",null,null,null,"床    ",null,null,null,"床"]

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["５．平均在院日数",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　別紙（平均在院日数）"]
["（２）","□　一般病棟入院基本料（　　　　）",null,null,null,null,null,null,"□　特定機能病院入院基本料（一般病棟（　　対１））"]
[null,"□　精神病棟入院基本料（10対１）",null,null,null,null,null,null,"□　特定機能病院入院基本料（精神病棟〔15対１を除く。〕）"]
[null,"□　精神病棟入院基本料（13対１）",null,null,null,null,null,null,"□　小児入院医療管理料(□１、□２、□３及び□４に限る。)"]
[null,"□　専門病院入院基本料(　　対１)",null,null,null,null,null,null,"□　特定一般病棟入院料（１及び２）"]
[null,"□　地域包括医療病棟入院料"]
[null,null,null,null,"在院患者延べ日数",null,null,null,"新退棟患者数",null,null,null,"新入棟患者数",null,null,null,"平均在院日数"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人",null,null,null,"日"]
["（３）","□　一般病棟入院基本料（　　　　）",null,null,null,null,null,null,"□　特定機能病院入院基本料（一般病棟（　　対１））"]
[null,"□　精神病棟入院基本料（10対１）",null,null,null,null,null,null,"□　特定機能病院入院基本料（精神病棟〔15対１を除く。〕）"]
[null,"□　精神病棟入院基本料（13対１）",null,null,null,null,null,null,"□　小児入院医療管理料(□１、□２、□３及び□４に限る。)"]
[null,"□　専門病院入院基本料(　　対１)",null,null,null,null,null,null,"□　特定一般病棟入院料（１及び２）"]
[null,"□　地域包括医療病棟入院料"]
[null,null,null,null,"在院患者延べ日数",null,null,null,"新退棟患者数",null,null,null,"新入棟患者数",null,null,null,"平均在院日数"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人",null,null,null,"日"]
["（４）","□　一般病棟入院基本料（　　　　）",null,null,null,null,null,null,"□　特定機能病院入院基本料（一般病棟（　　対１））"]
[null,"□　精神病棟入院基本料（10対１）",null,null,null,null,null,null,"□　特定機能病院入院基本料（精神病棟〔15対１を除く。〕）"]
[null,"□　精神病棟入院基本料（13対１）",null,null,null,null,null,null,"□　小児入院医療管理料(□１、□２、□３及び□４に限る。)"]
[null,"□　専門病院入院基本料(　　対１)",null,null,null,null,null,null,"□　特定一般病棟入院料（１及び２）"]
[null,"□　地域包括医療病棟入院料"]
[null,null,null,null,"在院患者延べ日数",null,null,null,"新退棟患者数",null,null,null,"新入棟患者数",null,null,null,"平均在院日数"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人",null,null,null,"日"]
["（５）","□　一般病棟入院基本料（　　　　）",null,null,null,null,null,null,"□　特定機能病院入院基本料（一般病棟（　　対１））"]
[null,"□　精神病棟入院基本料（10対１）",null,null,null,null,null,null,"□　特定機能病院入院基本料（精神病棟〔15対１を除く。〕）"]
[null,"□　精神病棟入院基本料（13対１）",null,null,null,null,null,null,"□　小児入院医療管理料(□１、□２、□３及び□４に限る。)"]
[null,"□　専門病院入院基本料(　　対１)",null,null,null,null,null,null,"□　特定一般病棟入院料（１及び２）"]
[null,"□　地域包括医療病棟入院料"]
[null,null,null,null,"在院患者延べ日数",null,null,null,"新退棟患者数",null,null,null,"新入棟患者数",null,null,null,"平均在院日数"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人"]
["　　　　　　年　　　　月",null,null,null,"日",null,null,null,"人",null,null,null,"人",null,null,null,"日"]

{"sheet":"（４）勤務医名簿","index":4,"n_rows":34,"n_cols":7,"rows_kept":34,"cut":false,"hidden":false,"merged":[[2,3,2,5],[3,3,3,5],[27,3,27,5],[18,3,18,5],[25,3,25,5],[21,3,21,5],[22,3,22,5],[23,3,23,5],[24,3,24,5],[20,3,20,5],[4,3,4,5],[15,3,15,5],[17,3,17,5],[16,3,16,5],[11,3,11,5],[13,3,13,5],[12,3,12,5],[14,3,14,5],[26,3,26,5],[5,3,5,5],[19,3,19,5],[6,3,6,5],[7,3,7,5],[9,3,9,5],[8,3,8,5],[10,3,10,5]]}
["７．勤務医の概要"]
["　※　記入にあたっては、下部の「記入上の注意」を確認してください。"]
["診療科目","保険医氏名","保険医登録記号番号","勤務形態",null,null,"備　考"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[null,null,null,"常勤　・ 非常勤"]
[]
["記入上の注意"]
["　１．非常勤については、備考欄に勤務日（曜日等）を記載してください。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["　２．届け出ている施設基準の専従・専任者について、その基準名と専従・専任の区分を備考欄に記載"]
["　　してください。"]
["　※　上記項目が記載されているものがあれば、既存の資料で差し支えありません。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

{"sheet":"（５）看護要員名簿","index":5,"n_rows":32,"n_cols":5,"rows_kept":32,"cut":false,"hidden":false,"merged":[[25,0,29,3]]}
["８．看護要員の概要"]
["　※　記入にあたっては、下部の「記入上の注意」を確認してください。"]
[null,"[　病棟名等　：　　　　　　　　　　　　　　　　　　]"]
["職　種","氏　　名","勤務形態","備　考"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[]
["記入上の注意"]
["　１．病棟（看護単位）・治療室ごと、職種ごとに記載してください。"]
["　２．「職種」欄には、看護師、准看護師、看護補助者の区別を記載してください。"]
["　３．「備考」欄には、看護部長、副看護部長、師長等の役職を記載してください。"]
["    また、褥瘡対策チームの看護職員、身体的拘束最小化チームの看護職員、急性期総合体制加算、産科管理加算、緩和ケア診療加算、小児緩和ケア診療加算、精神科リエゾンチーム加算、栄養サポートチーム加算、医療安全対策加算、感染対策向上加算、患者サポート体制充実加算、重症患者初期支援充実加算、報告書管理体制加算、褥瘡ハイリスク患者ケア加算、呼吸ケアチーム加算、術後疼痛管理チーム加算、入退院支援加算、精神科入退院支援加算、認知症ケア加算、排尿自立支援加算、ウイルス疾患指導料、喘息治療管理料、糖尿病合併症管理料、がん患者指導管理料、外来緩和ケア管理料、移植後患者指導管理料、糖尿病透析予防指導管理料、乳腺炎重症化予防ケア・指導料、腎代替療法指導管理料、生殖補助医療管理料、二次性骨折予防継続管理料、慢性腎臓病透析予防指導管理料、院内トリアージ実施体制加算、救急外来医学管理料、救急外来緊急検査対応加算、外来放射線照射診療料、外来腫瘍化学療法診療料、ニコチン依存症管理料、療養・就労両立支援指導料の注３に掲げる相談支援加算、心不全再入院予防継続管理料、外来排尿自立指導料、在宅経肛門的自己洗腸指導管理料、外来化学療法加算、心大血管疾患リハビリテーション料、摂食嚥下機能回復体制加算、難病患者リハビリテーション料、障害児（者）リハビリテーション料、リンパ浮腫複合的治療料、療養生活継続支援加算、児童思春期支援指導加算、救急患者精神科継続支援料、認知療法・認知行動療法、依存症集団療法、精神科ショート・ケア、精神科デイ・ケア、精神科ナイト・ケア、精神科デイ・ナイト・ケア、重度認知症患者デイ・ケア料、静脈圧迫処置、緊急穿頭血腫除去術、人工肛門・人工膀胱造設術前処置加算、麻酔管理料（Ⅱ）、ホウ素中性子捕捉療法医学管理加算、画像誘導密封小線源治療加算の専従・専任者については、その基準名と専従・専任の区分を備考欄に記載してください。\n"]
[]
[]
[null,null,null,null,"　　"]
[]
["　４．非常勤については、備考欄に勤務日（曜日等）を記載してください。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["　※　上記項目が記載されているものがあれば、既存の資料で差し支えありません。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

{"sheet":"（６）その他従事者名簿","index":6,"n_rows":34,"n_cols":4,"rows_kept":34,"cut":false,"hidden":false,"merged":[[28,0,29,3]]}
["９．その他の医療従事者等の概要（事務職も含む）"]
["　※　記入にあたっては、下部の「記入上の注意」を確認してください。"]
["職　種","氏　　名","勤務形態","備　考"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
[null,null,"常勤　・ 非常勤"]
["記入上の注意"]
["　１．「職種」欄には、薬剤師、臨床検査技師、診療放射線技師、理学療法士、作業療法士、言語聴覚士、\n　　　管理栄養士、社会福祉士、精神保健福祉士、公認心理士、事務職等の区別を記載してください。"]
[]
["　２．非常勤については、備考欄に勤務日（曜日等）を記載してください。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
["　３．届け出ている施設基準の専従・専任者について、その基準名と専従・専任の区分を備考欄に記載"]
["　　してください。"]
["　※　上記項目が記載されているものがあれば、既存の資料で差し支えありません。　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

{"sheet":"（７）病棟構成","index":7,"n_rows":33,"n_cols":12,"rows_kept":33,"cut":false,"hidden":false,"merged":[[25,0,25,3],[25,4,25,8],[25,9,25,11],[26,0,26,11],[27,0,27,11],[24,9,24,11],[21,0,21,3],[21,4,21,8],[21,9,21,11],[22,0,22,3],[22,4,22,8],[22,9,22,11],[23,0,23,3],[23,4,23,8],[23,9,23,11],[24,0,24,3],[24,4,24,8],[19,0,19,3],[19,4,19,8],[19,9,19,11],[20,0,20,3],[20,4,20,8],[20,9,20,11],[17,0,17,3],[17,4,17,8],[17,9,17,11],[18,0,18,3],[18,4,18,8],[18,9,18,11],[15,0,15,3],[15,4,15,8],[15,9,15,11],[16,0,16,3],[16,4,16,8],[16,9,16,11],[13,0,13,3],[13,4,13,8],[13,9,13,11],[14,0,14,3],[14,4,14,8],[14,9,14,11],[11,0,11,3],[11,4,11,8],[11,9,11,11],[12,0,12,3],[12,4,12,8],[12,9,12,11],[9,0,9,3],[9,4,9,8],[9,9,9,11],[10,0,10,3],[10,4,10,8],[10,9,10,11],[7,0,7,3],[7,4,7,8],[7,9,7,11],[8,0,8,3],[8,4,8,8],[8,9,8,11],[0,10,0,11],[4,0,5,3],[4,4,5,8],[4,9,5,11],[6,0,6,3],[6,4,6,8],[6,9,6,11]]}
[]
[]
["10．病棟構成"]
[null,null,null,null,null,null,null,null,null,null,null,"（令和　　年　　月　　日現在）"]
["病棟の名称",null,null,null,"病床の種別",null,null,null,null,"病床数"]
[]
["（例）５階東病棟",null,null,null,"一般病棟入院基本料\n（急性期一般入院料１）",null,null,null,null,"46床"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["注　「病床の種別」欄には、入院基本料や特定入院料の施設基準に係る届出別に記載してください。\n　　（例：一般病棟入院基本料（急性期一般入院料１）、救命救急入院料１等）"]
[]
[]
[]
[]
[]
["　"]