contrib/forms/medical_decision/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8 ?>
   9 <?
  10    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  11    if ($fres){
  12      $patient = sqlFetchArray($fres);
  13    }
  14    $fres=sqlStatement("select * from form_medical_decision where id='".$id."'");
  15    if ($fres){
  16      $fdata = sqlFetchArray($fres);
  17    }
  18 ?>
  19
  20 <html>
  21 <head>
  22 <title>Medical decision making</title>
  23 <? include("../../acog_printable_v.css"); ?>
  24 </head>
  25 <body>
  26 <div class="srvChapter">Medical decision making</div>
  27 <div style="border: solid 2px black; background-color: white;">
  28 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  29   <tr>
  30     <td align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  31       <tr align="left" valign="bottom">
  32         <td width="40%" class="fibody2" id="bordR">Patient name:  <? echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};          ?></td>
  33         <td width="20%" class="fibody2" id="bordR">Birth date: <? echo $patient{'DOB'};         ?></td>
  34         <td width="20%" class="fibody2" id="bordR">ID No: <?  echo $patient{'id'};  ?></td>
  35         <td width="20%" class="fibody2">date: <? echo date('Y-m-d'); ?></td>
  36       </tr>
  37     </table> </td>
  38   </tr>
  39   <tr>
  40     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
  41   </tr>
  42   <tr>
  43     <td align="left" valign="top">&nbsp;</td>
  44   </tr>
  45 </table>
  46 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  47   <tr align="left" valign="top">
  48     <td width="29%" class="ficaption3">Tests ordered </td>
  49     <td class="ficaption3">review of records </td>
  50   </tr>
  51   <tr align="left" valign="top">
  52     <td class="fibody3"><p>
  53       <? echo (($fdata{'test_lab'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  54       Laboratory</p>
  55       <blockquote>
  56         <p>
  57           <? echo (($fdata{'test_lab_cervical'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  58           cervical cytology</p>
  59         <p>
  60           <? echo (($fdata{'test_lab_hpv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  61           HPV test</p>
  62         <p>
  63           <? echo (($fdata{'test_lab_wet_mount'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  64           wet mount</p>
  65         <p>
  66           <? echo (($fdata{'test_lab_chlamydia'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  67           chlamydia</p>
  68         <p>
  69           <? echo (($fdata{'test_lab_gonorrhea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  70           gonorrhea</p>
  71         <p>
  72           <? echo (($fdata{'test_lab_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  73           other <span class="ficaption2">
  74           <? echo $fdata{'test_lab_other_data'}; ?>
  75           </span></p>
  76         </blockquote>
  77       <p>
  78         <? echo (($fdata{'test_rad'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  79         Radiology / Ultrasound</p>
  80       <blockquote>
  81         <p>
  82           <? echo (($fdata{'test_rad_mammogram'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  83           mammogram</p>
  84         <p>
  85           <? echo (($fdata{'test_rad_other'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  86           other <span class="ficaption2">
  87           <? echo $fdata{'test_rad_other_data'}; ?>
  88           </span> </p>
  89       </blockquote></td>
  90     <td class="fibody3"><p>
  91       <? echo (($fdata{'previous_test_results'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  92       previous test results:</p>
  93       <p>
  94         <? echo $fdata{'previous_test_results_data'}; ?>
  95       </p> <p>
  96         <? echo (($fdata{'test_results_discussion'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  97         discussion of test results with performing physician:</p>
  98       <p>
  99         <? echo $fdata{'test_results_discussion_data'}; ?>
 100       </p> <p>
 101         <? echo (($fdata{'old_records_reviewed'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 102         old records reviewed and summarized:</p>
 103       <p>
 104         <? echo $fdata{'old_records_reviewed_data'}; ?>
 105       </p> <p>
 106         <? echo (($fdata{'history_other_source'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 107         history obtained from other source:</p>
 108       <p>
 109         <? echo $fdata{'history_other_source_data'}; ?>
 110       </p> <p>
 111         <? echo (($fdata{'independent_review'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 112         independent review of image/specimen:</p>
 113       <p>
 114         <? echo $fdata{'independent_review_data'}; ?>
 115       </p></td>
 116   </tr>
 117 </table>
 118 </div>
 119   <p align="center">&nbsp;</p>
 120   <h2 align="center">Diagnoses / Management option </h2>
 121   <div style="border: solid 2px black; background-color: white;">
 122     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 123       <tr>
 124         <td colspan="2" align="left" valign="top" class="fibody2"> <? echo (($fdata{'established_problem'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 125           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 126           <? echo (($fdata{'established_problem'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 127         New problem </td>
 128       </tr>
 129       <tr>
 130         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 131       </tr>
 132       <tr>
 133         <td colspan="2" align="left" valign="top" class="fibody5"><? echo $fdata{'assessment_and_plan'}; ?></td>
 134       </tr>
 135       <tr>
 136         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 137           <blockquote>
 138             <p>
 139             <? echo (($fdata{'md_risk'} == 'minimal')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 140             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 141             <p>
 142             <? echo (($fdata{'md_risk'} == 'low')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 143             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 144             <p>
 145               <? echo (($fdata{'md_risk'} == 'moderate')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 146             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 147             <p>
 148               <? echo (($fdata{'md_risk'} == 'high')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 149             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 150         </blockquote></td>
 151       </tr>
 152       <tr>
 153         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 154           <tr>
 155             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 156             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_smoking'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 157               smoking cessation </td>
 158             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_contraception'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 159               contraception</td>
 160             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 161             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 162           </tr>
 163           <tr>
 164             <td align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_weight'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 165               weight management </td>
 166             <td align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_safe_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 167               safe sex </td>
 168             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 169             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 170           </tr>
 171           <tr>
 172             <td align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 173               exercise</td>
 174             <td align="left" valign="baseline" nowrap class="fibody3"><? echo (($fdata{'pc_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 175               other</td>
 176             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 177             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 178           </tr>
 179         </table></td>
 180       </tr>
 181       <tr>
 182         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><? echo (($fdata{'patient_education'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 183         Patient education materials provided</td>
 184         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 185       </tr>
 186       <tr>
 187         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 188         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 189       </tr>
 190       <tr>
 191         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 192         <? echo $fdata{'minutes_counseled'}; ?></td>
 193         <td align="left" valign="top" class="ficaption2">Total encounter time:
 194         <? echo $fdata{'total_encounter_time'}; ?></td>
 195       </tr>
 196       <tr valign="bottom">
 197         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 198         <td align="left" class="ficaption2">Date: <? echo $fdata['date']; ?></td>
 199       </tr>
 200     </table>
 201   </div>
 202 </body>
 203 </html>