{"id":300,"date":"2021-06-21T12:01:49","date_gmt":"2021-06-21T11:01:49","guid":{"rendered":"https:\/\/mes-formulaires.cpamcentre.fr\/?page_id=300"},"modified":"2021-06-23T14:17:29","modified_gmt":"2021-06-23T13:17:29","slug":"formulaire-eligibilite-prado","status":"publish","type":"page","link":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/formulaire-eligibilite-prado\/","title":{"rendered":"Formulaire d\u2019\u00e9ligibilit\u00e9 au retour \u00e0 domicile (PRADO)"},"content":{"rendered":"\n<p>Afin de faciliter nos \u00e9changes, nous vous invitons \u00e0 compl\u00e9ter les formulaires ci-dessous en fonction du type de retour \u00e0 domicile choisi et en indiquant les informations relatives au patient.<\/p>\n\n\n\n<div class=\"wp-block-group has-background\" style=\"background-color:#eaffcd\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p class=\"has-text-align-center\"><strong>El\u00e9ments \u00e0 prendre en compte avant la d\u00e9cision d\u2019orientation du patient<\/strong><\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-1 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<p><strong>Crit\u00e8res m\u00e9dicaux :<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Pas de dialyse r\u00e9nale<\/li><li>Pas de traitement chirurgical \u00e0 court terme<\/li><li>Pas d\u2019alt\u00e9ration significative des fonctions sup\u00e9rieures<\/li><li>Pas de transplantation cardiaque en attente<\/li><li>Pas de n\u00e9cessit\u00e9 de transfert vers un SSR<\/li><li>Pas de soins palliatifs<\/li><\/ul>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<p><strong>Crit\u00e8res d&rsquo;autonomie<\/strong><strong>&nbsp;:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Capacit\u00e9 \u00e0 se lever, se coucher, ou s\u2019asseoir seul<\/li><li>Capacit\u00e9 \u00e0 comprendre les consignes (absence de trouble du comportement)<\/li><li>Capacit\u00e9 \u00e0 marcher seul dans son logement (absence de besoin d\u2019une tierce personne)<\/li><li>Pas de n\u00e9cessit\u00e9 de transfert vers une institution sp\u00e9cialis\u00e9e (EHPAD)<\/li><\/ul>\n<\/div>\n<\/div>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n<div id=\"accordion-1\" class=\"accordion no-js\"><br \/>\n\n\t\t\t\t\t<h2 role=\"button\" id=\"accordion-1-t1\" class=\"accordion-title js-accordion-controller\" aria-controls=\"accordion-1-c1\" aria-expanded=\"false\" tabindex=\"0\">\n\t\t\t\tPRADO Chirurgie\t\t\t<\/h2>\n\t\t\n\t\t<div id=\"accordion-1-c1\" class=\"accordion-content\" aria-hidden=\"true\">\n\t\t\t<br \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f302-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"302\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/300#wpcf7-f302-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"302\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f302-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>1. Identification de l'\u00e9tablissement\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom de l'\u00e9tablissement<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ServiceEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ServiceEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin prescripteur<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMedecin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMedecin\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Email de contact<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"MailEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>2. Identification du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Pr\u00e9nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrenomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"PrenomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date de naissance<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateNaissP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateNaissP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Num\u00e9ro de chambre<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NumChambreP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NumChambreP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date d'entr\u00e9e dans le service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateEntreeP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateEntreeP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Date de sortie pr\u00e9vue<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateSortieP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateSortieP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>3. \u00c9valuation des soins m\u00e9dicaux et suivi du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Pr\u00e9cisez ci-dessous les soins n\u00e9cessaires pour la sortie d\u2019hospitalisation (rendez-vous \u00e0 organiser, le cas \u00e9ch\u00e9ant, par le conseiller de l\u2019Assurance Maladie).\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin traitant (rendez-vous sous 7 jours) :&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMG\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMG\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Soins infirmiers<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span> : J+&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"soinsIDE\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"soinsIDE\" \/><\/span>&nbsp;&nbsp;apr\u00e8s la sortie\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Soins de masso-kin\u00e9sith\u00e9rapie : J+&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"soinsMK\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"soinsMK\" \/><\/span>&nbsp;&nbsp;apr\u00e8s la sortie <span class=\"wpcf7-form-control-wrap\" data-name=\"LieuMK\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"LieuMK\" value=\"A domicile\" \/><span class=\"wpcf7-list-item-label\">A domicile<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"LieuMK\" value=\"Au cabinet\" \/><span class=\"wpcf7-list-item-label\">Au cabinet<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>&nbsp;<br \/>\nPatient \u00e9ligible<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"aideVie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"aideVie\" value=\"Sans aide \u00e0 la vie\" \/><span class=\"wpcf7-list-item-label\">Sans aide \u00e0 la vie<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"aideVie\" value=\"Avec aide \u00e0 la vie (aide m\u00e9nag\u00e8re et\/ou portage de repas)\" \/><span class=\"wpcf7-list-item-label\">Avec aide \u00e0 la vie (aide m\u00e9nag\u00e8re et\/ou portage de repas)<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><b>Merci de saisir le code affich\u00e9 ci-dessous pour valider votre envoi : <\/b><br \/>\n<input type=\"hidden\" name=\"_wpcf7_captcha_challenge_captcha-170\" value=\"4255261223\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-captcha-170\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/mes-formulaires.cpamcentre.fr\/wp-content\/uploads\/wpcf7_captcha\/4255261223.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"captcha-170\"><input size=\"4\" maxlength=\"4\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"captcha-170\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><i>L'envoi de ce formulaire vaut signature.<\/i>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"29\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<br \/>\n\t\t<\/div>\n\n\t\t<\/p>\n<p>\n\t\t\t\t\t<h2 role=\"button\" id=\"accordion-1-t2\" class=\"accordion-title js-accordion-controller\" aria-controls=\"accordion-1-c2\" aria-expanded=\"false\" tabindex=\"0\">\n\t\t\t\tPRADO Personnes \u00e2g\u00e9es\t\t\t<\/h2>\n\t\t\n\t\t<div id=\"accordion-1-c2\" class=\"accordion-content\" aria-hidden=\"true\">\n\t\t\t<br \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f311-o2\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"311\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/300#wpcf7-f311-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"311\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f311-o2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>1. Identification de l'\u00e9tablissement\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom de l'\u00e9tablissement<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ServiceEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ServiceEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin prescripteur<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMedecin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMedecin\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Email de contact<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"MailEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>2. Identification du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Pr\u00e9nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrenomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"PrenomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date de naissance<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateNaissP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateNaissP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Num\u00e9ro de chambre<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NumChambreP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NumChambreP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date d'entr\u00e9e dans le service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateEntreeP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateEntreeP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Date de sortie pr\u00e9vue<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateSortieP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateSortieP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>3. \u00c9valuation des soins m\u00e9dicaux et suivi du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Pr\u00e9cisez ci-dessous les soins n\u00e9cessaires pour la sortie d\u2019hospitalisation (rendez-vous \u00e0 organiser, le cas \u00e9ch\u00e9ant, par le conseiller de l\u2019Assurance Maladie).\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin traitant (rendez-vous sous 7 jours) :&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMG\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMG\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Score GIR<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"scroreGIR\"><input size=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"scroreGIR\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"BSI\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"BSI[]\" value=\"Bilan de soins infirmiers\" \/><span class=\"wpcf7-list-item-label\">Bilan de soins infirmiers<\/span><\/span><\/span><\/span> : sous <span class=\"wpcf7-form-control-wrap\" data-name=\"JourBSI\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"JourBSI\" \/><\/span> jours\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SoinsMK\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"SoinsMK[]\" value=\"Soins de masso-kin\u00e9sith\u00e9rapie\" \/><span class=\"wpcf7-list-item-label\">Soins de masso-kin\u00e9sith\u00e9rapie<\/span><\/span><\/span><\/span> : sous <span class=\"wpcf7-form-control-wrap\" data-name=\"JourMK\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"JourMK\" \/><\/span> jours\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ConsultG\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ConsultG[]\" value=\"Consultation(s) g\u00e9riatrique(s) (pr\u00e9ciser lesquelles)\" \/><span class=\"wpcf7-list-item-label\">Consultation(s) g\u00e9riatrique(s) (pr\u00e9ciser lesquelles)<\/span><\/span><\/span><\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"DetailsCG\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"DetailsCG\" \/><\/span> sous <span class=\"wpcf7-form-control-wrap\" data-name=\"JourCG\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"JourCG\" \/><\/span> jours\n\t\t\t<\/p>\n\t\t\t<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Si dans l\u2019\u00e9tablissement, pr\u00e9ciser : <span class=\"wpcf7-form-control-wrap\" data-name=\"SiEtab01\"><input size=\"20\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"ex. : Dr MARTIN\" value=\"\" type=\"text\" name=\"SiEtab01\" \/><\/span> le <span class=\"wpcf7-form-control-wrap\" data-name=\"dateEtab01\"><input size=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateEtab01\" \/><\/span> \u00e0 <span class=\"wpcf7-form-control-wrap\" data-name=\"HeureEtab01\"><input size=\"4\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"HH:mm\" value=\"\" type=\"text\" name=\"HeureEtab01\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ConsultS\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ConsultS[]\" value=\"Consultation(s) sp\u00e9cialis\u00e9e(s) (pr\u00e9ciser lesquelles)\" \/><span class=\"wpcf7-list-item-label\">Consultation(s) sp\u00e9cialis\u00e9e(s) (pr\u00e9ciser lesquelles)<\/span><\/span><\/span><\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"DetailsCS\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"DetailsCS\" \/><\/span> sous <span class=\"wpcf7-form-control-wrap\" data-name=\"JourCS\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"JourCS\" \/><\/span> jours\n\t\t\t<\/p>\n\t\t\t<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Si dans l\u2019\u00e9tablissement, pr\u00e9ciser : <span class=\"wpcf7-form-control-wrap\" data-name=\"SiEtab02\"><input size=\"20\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"ex. : Dr MARTIN\" value=\"\" type=\"text\" name=\"SiEtab02\" \/><\/span> le <span class=\"wpcf7-form-control-wrap\" data-name=\"dateEtab02\"><input size=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateEtab02\" \/><\/span> \u00e0 <span class=\"wpcf7-form-control-wrap\" data-name=\"HeureEtab02\"><input size=\"4\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"HH:mm\" value=\"\" type=\"text\" name=\"HeureEtab02\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Si dans l\u2019\u00e9tablissement, pr\u00e9ciser : <span class=\"wpcf7-form-control-wrap\" data-name=\"SiEtab03\"><input size=\"20\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"ex. : Dr MARTIN\" value=\"\" type=\"text\" name=\"SiEtab03\" \/><\/span> le <span class=\"wpcf7-form-control-wrap\" data-name=\"dateEtab03\"><input size=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateEtab03\" \/><\/span> \u00e0 <span class=\"wpcf7-form-control-wrap\" data-name=\"HeureEtab03\"><input size=\"4\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"HH:mm\" value=\"\" type=\"text\" name=\"HeureEtab03\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ConsultPS\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ConsultPS[]\" value=\"Autres professionnels de sant\u00e9 (pr\u00e9ciser)\" \/><span class=\"wpcf7-list-item-label\">Autres professionnels de sant\u00e9 (pr\u00e9ciser)<\/span><\/span><\/span><\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"DetailsPS\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"DetailsPS\" \/><\/span> sous <span class=\"wpcf7-form-control-wrap\" data-name=\"JourPS\"><input size=\"3\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"JourPS\" \/><\/span> jours\n\t\t\t<\/p>\n\t\t\t<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Si dans l\u2019\u00e9tablissement, pr\u00e9ciser : <span class=\"wpcf7-form-control-wrap\" data-name=\"SiEtab04\"><input size=\"20\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"ex. : Dr MARTIN\" value=\"\" type=\"text\" name=\"SiEtab04\" \/><\/span> le <span class=\"wpcf7-form-control-wrap\" data-name=\"dateEtab04\"><input size=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateEtab04\" \/><\/span> \u00e0 <span class=\"wpcf7-form-control-wrap\" data-name=\"HeureEtab04\"><input size=\"4\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"HH:mm\" value=\"\" type=\"text\" name=\"HeureEtab04\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<h5> Evaluation des besoins sociaux\n\t\t\t<\/h5>\n\t\t\t<p>Une \u00e9valuation sociale sera syst\u00e9matiquement propos\u00e9e avec l\u2019accord du patient. Cocher les besoins \u00e0 organiser avec le service social de l\u2019\u00e9tablissement de sant\u00e9 et les services sociaux en ville :\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"besoinsSociaux01\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"besoinsSociaux01[]\" value=\"Aide-m\u00e9nag\u00e8re et\/ou portage de repas\" \/><span class=\"wpcf7-list-item-label\">Aide-m\u00e9nag\u00e8re et\/ou portage de repas<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"besoinsSociaux02\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"besoinsSociaux02[]\" value=\"Besoin d\u2019am\u00e9nagement du domicile\" \/><span class=\"wpcf7-list-item-label\">Besoin d\u2019am\u00e9nagement du domicile<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"besoinsSociaux03\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"besoinsSociaux03[]\" value=\"Mise en place d\u2019aides sociales ou financi\u00e8res\" \/><span class=\"wpcf7-list-item-label\">Mise en place d\u2019aides sociales ou financi\u00e8res<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><b>Merci de saisir le code affich\u00e9 ci-dessous pour valider votre envoi : <\/b><br \/>\n<input type=\"hidden\" name=\"_wpcf7_captcha_challenge_captcha-170\" value=\"616806272\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-captcha-170\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/mes-formulaires.cpamcentre.fr\/wp-content\/uploads\/wpcf7_captcha\/616806272.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"captcha-170\"><input size=\"4\" maxlength=\"4\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"captcha-170\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><i>L'envoi de ce formulaire vaut signature.<\/i>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"_wpcf7_ak_js\" value=\"84\"\/><script>document.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<br \/>\n\t\t<\/div>\n\n\t\t<\/p>\n<p>\n\t\t\t\t\t<h2 role=\"button\" id=\"accordion-1-t3\" class=\"accordion-title js-accordion-controller\" aria-controls=\"accordion-1-c3\" aria-expanded=\"false\" tabindex=\"0\">\n\t\t\t\tPRADO Pathologie chroniques\t\t\t<\/h2>\n\t\t\n\t\t<div id=\"accordion-1-c3\" class=\"accordion-content\" aria-hidden=\"true\">\n\t\t\t<br \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f309-o3\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"309\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/300#wpcf7-f309-o3\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"309\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f309-o3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>1. Identification de l'\u00e9tablissement\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom de l'\u00e9tablissement<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ServiceEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ServiceEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin prescripteur<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMedecin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMedecin\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Email de contact<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailEtab\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"MailEtab\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>2. Identification du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Pr\u00e9nom<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrenomP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"PrenomP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date de naissance<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateNaissP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateNaissP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Num\u00e9ro de chambre<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NumChambreP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NumChambreP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date d'entr\u00e9e dans le service<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateEntreeP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateEntreeP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Date de sortie pr\u00e9vue<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateSortieP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateSortieP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>3. \u00c9valuation des soins m\u00e9dicaux et suivi du patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Pr\u00e9cisez ci-dessous les soins n\u00e9cessaires pour la sortie d\u2019hospitalisation (rendez-vous \u00e0 organiser, le cas \u00e9ch\u00e9ant, par le conseiller de l\u2019Assurance Maladie).\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du m\u00e9decin traitant (rendez-vous sous 7 jours) :&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMG\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomMG\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h5>Rendez-vous dans les 2 mois apr\u00e8s la sortie :\n\t\t\t<\/h5>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><strong>> Avec le pneumologue :<\/strong>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><br \/>\nStade : <span class=\"wpcf7-form-control-wrap\" data-name=\"stadeP\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stadeP\" value=\"GOLD I\" \/><span class=\"wpcf7-list-item-label\">GOLD I<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stadeP\" value=\"GOLD II\" \/><span class=\"wpcf7-list-item-label\">GOLD II<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stadeP\" value=\"GOLD III\" \/><span class=\"wpcf7-list-item-label\">GOLD III<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stadeP\" value=\"GOLD IV\" \/><span class=\"wpcf7-list-item-label\">GOLD IV<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p>Lieu : <span class=\"wpcf7-form-control-wrap\" data-name=\"LieuP\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"LieuP\" value=\"En ville\" \/><span class=\"wpcf7-list-item-label\">En ville<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"LieuP\" value=\"A l\u2019h\u00f4pital\" \/><span class=\"wpcf7-list-item-label\">A l\u2019h\u00f4pital<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p><br \/>\nMasseur-kin\u00e9sith\u00e9rapeute : <span class=\"wpcf7-form-control-wrap\" data-name=\"besoinMK\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"besoinMK\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"besoinMK\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p>Date : <span class=\"wpcf7-form-control-wrap\" data-name=\"dateP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateP\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><strong>> Avec le cardiologue :<\/strong>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><br \/>\nStade : <span class=\"wpcf7-form-control-wrap\" data-name=\"stadeC\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stadeC\" value=\"NYHA I\" \/><span class=\"wpcf7-list-item-label\">NYHA I<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stadeC\" value=\"NYHA II\" \/><span class=\"wpcf7-list-item-label\">NYHA II<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stadeC\" value=\"NYHA III\" \/><span class=\"wpcf7-list-item-label\">NYHA III<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stadeC\" value=\"NYHA IV\" \/><span class=\"wpcf7-list-item-label\">NYHA IV<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p>Lieu : <span class=\"wpcf7-form-control-wrap\" data-name=\"LieuC\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"LieuC\" value=\"En ville\" \/><span class=\"wpcf7-list-item-label\">En ville<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"LieuC\" value=\"A l\u2019h\u00f4pital\" \/><span class=\"wpcf7-list-item-label\">A l\u2019h\u00f4pital<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p><br \/>\nF.E.V.G. >= 50 <span class=\"wpcf7-form-control-wrap\" data-name=\"FEVG\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"FEVG\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"FEVG\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p>Date : <span class=\"wpcf7-form-control-wrap\" data-name=\"dateC\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"dateC\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><b>Merci de saisir le code affich\u00e9 ci-dessous pour valider votre envoi : <\/b><br \/>\n<input type=\"hidden\" name=\"_wpcf7_captcha_challenge_captcha-170\" value=\"519555985\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-captcha-170\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/mes-formulaires.cpamcentre.fr\/wp-content\/uploads\/wpcf7_captcha\/519555985.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"captcha-170\"><input size=\"4\" maxlength=\"4\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"captcha-170\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p>&nbsp;<br \/>\nPatient \u00e9ligible<span style=\"color: #ff0000; font-size:18px; font-weight:bold;\">*<\/span> : <span class=\"wpcf7-form-control-wrap\" data-name=\"aideVie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"aideVie\" value=\"Sans aide \u00e0 la vie\" \/><span class=\"wpcf7-list-item-label\">Sans aide \u00e0 la vie<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"aideVie\" value=\"Avec aide \u00e0 la vie (aide m\u00e9nag\u00e8re et\/ou portage de repas)\" \/><span class=\"wpcf7-list-item-label\">Avec aide \u00e0 la vie (aide m\u00e9nag\u00e8re et\/ou portage de repas)<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><i>L'envoi de ce formulaire vaut signature.<\/i>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_3\" name=\"_wpcf7_ak_js\" value=\"214\"\/><script>document.getElementById( \"ak_js_3\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<br \/>\n\t\t<\/div>\n\n\t\t<\/p>\n<p><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Afin de faciliter nos \u00e9changes, nous vous invitons \u00e0 compl\u00e9ter les formulaires ci-dessous en fonction du type de retour \u00e0 domicile choisi et en indiquant les informations relatives au patient. El\u00e9ments \u00e0 prendre en compte avant la d\u00e9cision d\u2019orientation du patient Crit\u00e8res m\u00e9dicaux : Pas de dialyse r\u00e9nale Pas de traitement chirurgical \u00e0 court terme Pas d\u2019alt\u00e9ration significative des fonctions sup\u00e9rieures Pas de transplantation cardiaque en attente Pas de n\u00e9cessit\u00e9 de transfert vers un SSR Pas de soins palliatifs Crit\u00e8res d&rsquo;autonomie&nbsp;: Capacit\u00e9 \u00e0 se lever, se coucher, ou s\u2019asseoir seul Capacit\u00e9 \u00e0 comprendre les consignes (absence de trouble du comportement) Capacit\u00e9 \u00e0 marcher seul dans son logement (absence de besoin d\u2019une tierce personne) Pas de n\u00e9cessit\u00e9 de transfert vers une institution sp\u00e9cialis\u00e9e (EHPAD)<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-300","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/300"}],"collection":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/comments?post=300"}],"version-history":[{"count":9,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/300\/revisions"}],"predecessor-version":[{"id":313,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/300\/revisions\/313"}],"wp:attachment":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/media?parent=300"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}