new.php

   1 <!-- Form created by Nikolai Vitsyn: 2004/02/13  -->
   2
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 formHeader("Form: ankleinjury");
   7 ?>
   8
   9 <html><head>
  10 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  11 </head>
  12
  13 <body <?echo $top_bg_line;?>
  14 topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  15 <form method=post action="<?echo $rootdir;?>/forms/ankleinjury/save.php?mode=new" name="my_form">
  16 <span class="title">Ankle Evaluation Form</span><br></br>
  17
  18 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  19 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  20 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link" style="color: #483D8B">[Don't Save]</a>
  21 <br></br>
  22
  23 <span class="text" >Date of Injury: </span><input type="entry" name="ankle_date_of_injuary" value=""></input>
  24 <tr>
  25 <td width="120" align="right">Work related?</td>
  26 <td><input type="checkbox" name="ankle_work_related"></input></td>
  27 </tr>
  28 <br><br>
  29
  30 <span class="text">Foot: </span>
  31    <td>Left<input type="radio" name='ankle_foot' value="Left"></input></td>
  32    <td>Right<input type="radio" name='ankle_foot' value="Right"></input></td>
  33 <br><br>
  34
  35 <span class="text">Severity of Pain:   </span>
  36    <td>1<input type="radio" name='ankle_severity_of_pain' value="1"></input></td>
  37    <td>2<input type="radio" name='ankle_severity_of_pain' value="2"></input></td>
  38    <td>3<input type="radio" name='ankle_severity_of_pain' value="3"></input></td>
  39 <br><br>
  40
  41 <td width="140">Significant Swelling:</td>
  42 <td align="right"></td>
  43 <td><input type="checkbox" name="ankle_significant_swelling"></input></td>
  44 <br><br>
  45
  46 <span class="text">Onset of Swelling:   </span>
  47    <td>within minutes<input type="radio" name='ankle_onset_of_swelling' value="within minutes"></input></td>
  48    <td>within hours<input type="radio" name='ankle_onset_of_swelling' value="within hours"></input></td>
  49    <br><br>
  50
  51 <span class="text" >How did Injury Occur?:</span><br>
  52 <textarea name="ankle_how_did_injury_occur" rows="4" cols="67" wrap="virtual name"></textarea>
  53 <br></br>
  54
  55 <table ><th colspan="5">Ottawa Ankle Rules</th>
  56 <tr>
  57 <td>Bone Tenderness: Medial Malleolus<input type="radio" name='ankle_ottawa_bone_tenderness' value="Medial malleolus"></input></td>
  58 <td>Lateral Malleolus<input type="radio" name='ankle_ottawa_bone_tenderness' value="Lateral malleolus"></input></td>
  59 <td>Base of fifth (5th) Metarsal<input type="radio" name='ankle_ottawa_bone_tenderness' value="Base of fifth (5th) Metarsal"></input></td>
  60 <td>At the Navicular<input type="radio" name='ankle_ottawa_bone_tenderness' value="At the Navicular"></input></td>
  61 </tr>
  62 </table>
  63 <br>
  64
  65 <span class="text">Able to Bear Weight four (4) steps:</span>
  66   <td>Yes<input type="radio" name='ankle_able_to_bear_weight_steps' value="Yes"></input></td>
  67   <td>No<input type="radio" name='ankle_able_to_bear_weight_steps' value="No"></input></td>
  68 <br>
  69
  70 <table>
  71 <tr><th>X-RAY Interpretation:</th> <th>Additional X-RAY Notes:</th></tr>
  72 <tr>
  73   <td>
  74    <select name="ankle_x_ray_interpretation" >
  75       <option value="Normal">Normal</option>
  76       <option value="Avulsion medial malleolus">Avulsion medial malleolus </option>
  77       <option value="Avulsion lateral malleolus">Avulsion lateral malleolus</option>
  78       <option value="Fracture, Base of fifth (5th) Metatarsal">Fracture, Base of fifth (5th) Metatarsal</option>
  79       <option value="Trimalleolar">Trimalleolar</option>
  80       <option value="Fracture at the Navicula">Fracture at the Navicula</option>
  81       <option value="Fracture medial malleolus">Fracture medial malleolus</option>
  82       <option value="Fracture lateral malleolus">Fracture lateral malleolus</option>
  83       <option value="Other">Other</option>
  84       </select>
  85    </td>
  86
  87 <td rowspan=2>
  88 <textarea cols=35 rows=1 wrap=virtual name="ankle_additional_x_ray_notes" ></textarea>
  89
  90 </td>
  91
  92 </tr>
  93 </table>
  94  <script language="javascript">
  95  <!--
  96  function doCPT(select) {
  97         var numchecked = 0;
  98         for (i=0; i<document.my_form.openemr_net_cptcode.length; i++) {
  99                 if (document.my_form.openemr_net_cptcode[i].checked == true) {
 100                         numchecked++;
 101                 }
 102         }
 103         if (numchecked == 0) {
 104                 document.my_form.openemr_net_cptcode[1].checked = true;
 105         }
 106  }
 107  -->
 108  </script>
 109 <table>
 110 <tr>
 111 <th>Diagnosis:</th><th>Additional Diagnosis:</th>
 112 </tr>
 113 <tr>
 114 <td valign="top"><select name="ankle_diagnosis1" onChange="doCPT(this);">
 115       <option value="">None</option>
 116       <option value="845.00 ankle sprain NOS">845.00 ankle sprain NOS</option>
 117       <option value="845.01 Sprain Medial (Deltoid) Lig.">845.01 Sprain Medial (Deltoid) Lig.</option>
 118       <option value="845.02 Sprain, Calcaneal fibular">845.02 Sprain, Calcaneal fibular</option>
 119       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal">825.35 Fracture, Base of fifth (5th) Metatarsal</option>
 120       <option value="825.32 Fracture, of Navicular (ankle)">825.32 Fracture, of Navicular (ankle)</option>
 121       <option value="824.2 Fracture, lateral malleolus, closed">824.2 Fracture, lateral malleolus, closed</option>
 122       <option value="824.0 Fracture, medial malleolus, closed">824.0 Fracture, medial malleolus, closed</option>
 123       <option value="824.6 Fracture, Trimalleolar, closed">824.6 Fracture, Trimalleolar, closed</option>
 124       <option value="Add ICD Code">Add ICD Code</option>
 125     </select>
 126
 127 </td>
 128 <td rowspan="4">
 129 <textarea cols=30 rows=2 wrap=virtual name="ankle_additional_diagnisis" ></textarea>
 130 <br><br>
 131 <table>
 132 <tr>
 133         <td width="10"></td>
 134         <td>CPT Codes</td>
 135         <td></td>
 136 </tr>
 137 <tr>
 138         <td></td>
 139         <td colspan="2">
 140                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value="">none<br>
 141                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value="99212 Established - Uncomplicated">99212 Established - Uncomplicated<br>
 142                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value="99213 Established - Low Complexity">99213 Established - Low Complexity<br>
 143         </td>
 144 </tr>
 145 </table>
 146
 147 </td>
 148
 149 <tr>
 150 <td>
 151   <select name="ankle_diagnosis2" onChange="doCPT(this);">
 152       <option value="">None</option>
 153       <option value="845.00 ankle sprain NOS">845.00 ankle sprain NOS</option>
 154       <option value="845.01 Sprain Medial (Deltoid) Lig.">845.01 Sprain Medial (Deltoid) Lig.</option>
 155       <option value="845.02 Sprain, Calcaneal fibular">845.02 Sprain, Calcaneal fibular</option>
 156       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal">825.35 Fracture, Base of fifth (5th) Metatarsal</option>
 157       <option value="825.32 Fracture, of Navicular (ankle)">825.32 Fracture, of Navicular (ankle)</option>
 158       <option value="824.2 Fracture, lateral malleolus, closed">824.2 Fracture, lateral malleolus, closed</option>
 159       <option value="824.0 Fracture, medial malleolus, closed">824.0 Fracture, medial malleolus, closed</option>
 160       <option value="824.6 Fracture, Trimalleolar, closed">824.6 Fracture, Trimalleolar, closed</option>
 161       <option value="Add ICD Code">Add ICD Code</option>
 162     </select>
 163    </td></tr>
 164 <td>
 165    <select name="ankle_diagnosis3" onChange="doCPT(this);">
 166       <option value="">None</option>
 167       <option value="845.00 ankle sprain NOS">845.00 ankle sprain NOS</option>
 168       <option value="845.01 Sprain Medial (Deltoid) Lig.">845.01 Sprain Medial (Deltoid) Lig.</option>
 169       <option value="845.02 Sprain, Calcaneal fibular">845.02 Sprain, Calcaneal fibular</option>
 170       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal">825.35 Fracture, Base of fifth (5th) Metatarsal</option>
 171       <option value="825.32 Fracture, of Navicular (ankle)">825.32 Fracture, of Navicular (ankle)</option>
 172       <option value="824.2 Fracture, lateral malleolus, closed">824.2 Fracture, lateral malleolus, closed</option>
 173       <option value="824.0 Fracture, medial malleolus, closed">824.0 Fracture, medial malleolus, closed</option>
 174       <option value="824.6 Fracture, Trimalleolar, closed">824.6 Fracture, Trimalleolar, closed</option>
 175       <option value="Add ICD Code">Add ICD Code</option>
 176    </select>
 177    </td>
 178 </tr>
 179 <td>
 180    <select name="ankle_diagnosis4" onChange="doCPT(this);">
 181       <option value="">None</option>
 182       <option value="845.00 ankle sprain NOS">845.00 ankle sprain NOS</option>
 183       <option value="845.01 Sprain Medial (Deltoid) Lig.">845.01 Sprain Medial (Deltoid) Lig.</option>
 184       <option value="845.02 Sprain, Calcaneal fibular">845.02 Sprain, Calcaneal fibular</option>
 185       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal">825.35 Fracture, Base of fifth (5th) Metatarsal</option>
 186       <option value="825.32 Fracture, of Navicular (ankle)">825.32 Fracture, of Navicular (ankle)</option>
 187       <option value="824.2 Fracture, lateral malleolus, closed">824.2 Fracture, lateral malleolus, closed</option>
 188       <option value="824.0 Fracture, medial malleolus, closed">824.0 Fracture, medial malleolus, closed</option>
 189       <option value="824.6 Fracture, Trimalleolar, closed">824.6 Fracture, Trimalleolar, closed</option>
 190 <option value="Add ICD Code">Add ICD Code</option>
 191 </select>
 192 </td>
 193 </tr>
 194 </table>
 195
 196 <table><tr><th>Plan:</th><tr>
 197 <tr><td>
 198 <textarea name="ankle_plan" rows="7" cols="67"
 199 wrap="virtual name">1.Rest
 200 2. Ice for two days
 201 3. Compression, leave the dressing in place unless the foot develops numbness or pale color
 202 4. Elevate the foot and leg
 203 </textarea>
 204 </td>
 205 </tr>
 206 </table>
 207
 208 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 209 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link" style="color: #483D8B">[Don't Save]</a>
 210 </form>
 211 <?php
 212 formFooter();
 213 ?>