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["居宅サービス計画書（１）\n"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"初回・紹介・継続",null,null,null,"認定済 ・ 申請中"]
["利用者名",null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,"住所"]
["居宅サービス計画作成者氏名"]
["居宅介護支援事業者・事業所名及び所在地"]
["居宅サービス計画作成(変更)日",null,null,null,null,null,null,null,null,null,"初回居宅サービス計画作成日"]
["認定日",null,null,null,null,null,null,"認定の有効期間",null,null,null,null,null,null,"～"]
[]
["要介護状態区分",null,null,null,null,null,"要介護度１",null," ・","要介護度２",null," ・","要介護度３",null," ・","要介護度４",null," ・","要介護度５"]
["利用者及び家族の\n生活に対する意向"]
["介護認定審査会の\n意見及びサービス\nの種類の指定"]
["総合的な援助の\n方針"]
["生活援助中心型の\n算定理由",null,null,null," 1. 一人暮らし",null,null,"2. 家族等が障害、疾病等",null,null,null,null,"3. その他(",null,null,null,null,null,null,null,null,null,")"]
["居宅サービス計画について説明を受け、内容に同意し交付を受けました。",null,null,null,null,null,null,null,null,null,null,"同意年月日",null,"　　　年　　月　　日 署名",null,null,null,null,null,null,null,null,"印"]

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["居宅サービス計画書（２）"]
["要介護度"]
["利用者名　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,"　　",null,"　　　　　　　　　　"]
[]
["生活全般の解決すべき\n課題(ニーズ)",null,"援助目標",null,null,null,"援助内容"]
[null,null,"長期目標","期間","短期目標","期間","サービス内容",null,"※1","サービス種別",null,"※2","頻度","期間"]
[]
[]
["居宅サービス計画について説明を受け、内容に同意し交付を受けました。",null,null,null,null,"同意年月日　　　　　年　　　月　　　日　　署名　　　　　　　　　　　　　　　　　　　　　　印"]
["※１　「保険給付対象かどうかの区分」について、保険給付対象内サービスについては○印を付す。"]
["※２　「当該サービス提供を行う事業者」について記入する。"]