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["別紙様式１"]
[]
["理由書"]
["０．基本情報"]
[]
["保険医療機関コード"]
["保険医療機関名"]
["電話番号"]
[]
["１．基本診療料の施設基準通知の第３の１を満たさなくなった施設基準"]
[]
[null,null,null,"月平均夜勤時間数",{"$nulls":13},"１日当たり勤務する看護要員の数\nに対する看護師の比率"]
[null,null,null,"看護要員の数と入院患者の比率",{"$nulls":13},"看護職員の数に対する看護師の比率"]
[]
["２．報告の対象となった最初の月"]
[]
[null,"令和",null,null,"年",null,null,"月"]
[]
["３．新型コロナウイルス感染症患者の受入及び職員の感染等の状況"]
[]
[null,"① 特例を使用する病棟の入院料"]
[null,"② ①の病棟の看護配置区分"]
[null,"③ ①の病棟の届出病床数",{"$nulls":20},"床"]
[null,"④ ①の病棟の１日平均入院患者数\n［１か月］",{"$nulls":14},"（報告対象前月の１か月）",{"$nulls":7},"（報告対象初月の１か月）",{"$nulls":7},"小数点以下切り上げ"]
[{"$nulls":22},"人",{"$nulls":7},"人"]
[null,"⑤ ④のうち、１日平均新型コロナウイルス感染     症患者数　［１か月］",{"$nulls":14},"（報告対象前月の１か月）",{"$nulls":7},"（報告対象初月の１か月）",{"$nulls":7},"小数点以下切り上げ"]
[{"$nulls":22},"人",{"$nulls":7},"人"]
[null,"⑥　①の病棟の月平均１日当たり看護職員数\n［報告対象初月の１か月］",{"$nulls":20},"人",null,"小数点以下第２以下切り捨て"]
[null,"⑦　①の病棟の常勤換算看護職員数\n［報告対象初月の翌月の１日］",{"$nulls":20},"人",null,"小数点以下第２以下切り捨て"]
[null,"⑧ ⑦のうち、新型コロナウイルス感染症に感染し出勤できなくなった常勤換算看護職員数\n［報告対象初月の翌月の１日］",{"$nulls":20},"人",null,"小数点以下第２以下切り捨て"]
[null,"（備考）　当該病棟における新型コロナウイルスに感染した職員の出勤停止ルール等を記載"]
[]
[]
[]
[null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日",{"$nulls":4}," （法人名）",{"$nulls":4}," "]
[{"$nulls":17}," （開設者名）"]

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[]
["急性期一般入院基本料１","７対１","○"]
["急性期一般入院基本料２","10対１"]
["急性期一般入院基本料３","13対１"]
["急性期一般入院基本料４","15対１"]
["急性期一般入院基本料５","18対１"]
["急性期一般入院基本料６","20対１"]
["地域一般入院基本料","25対１"]
["療養病棟入院基本料"]
["結核病棟入院基本料"]
["精神病棟入院基本料"]
["特定機能病院（一般）"]
["特定機能病院（結核）"]
["特定機能病院（精神）"]
["専門病院入院基本料"]
["障害者施設等入院基本料"]
["特殊疾患入院医療管理料"]
["小児入院医療管理料"]
["回復期リハビリテーション病棟入院料"]
["地域包括ケア病棟入院料"]
["緩和ケア病棟入院料"]
["精神科救急急性期医療入院料"]
["精神科急性期治療病棟入院料"]
["精神科救急・合併症入院料"]
["児童・思春期精神科入院医療管理料"]
["精神科療養病棟入院料"]
["認知症治療病棟入院料"]
["特定一般病棟入院料"]
["地域移行機能強化病棟入院料"]
["特定機能病院リハビリテーション病棟入院料"]
["有床診療所入院基本料"]
["有床診療所療養病床入院基本料"]