contrib/forms/medical_decision/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17 <?php
  18
  19    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  20
  21    if ($fres){
  22
  23      $patient = sqlFetchArray($fres);
  24
  25    }
  26
  27    $fres=sqlStatement("select * from form_medical_decision where id='".$id."'");
  28
  29    if ($fres){
  30
  31      $fdata = sqlFetchArray($fres);
  32
  33    }
  34
  35 ?>
  36
  37
  38
  39 <html>
  40
  41 <head>
  42 <?php html_header_show();?>
  43
  44 <title>Medical decision making</title>
  45
  46 <?php include("../../acog_printable_v.css"); ?>
  47
  48 </head>
  49
  50 <body>
  51
  52 <div class="srvChapter">Medical decision making</div>
  53
  54 <div style="border: solid 2px black; background-color: white;">
  55
  56 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  57
  58   <tr>
  59
  60     <td align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  61
  62       <tr align="left" valign="bottom">
  63
  64         <td width="40%" class="fibody2" id="bordR">Patient name:  <?php echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};          ?></td>
  65
  66         <td width="20%" class="fibody2" id="bordR">Birth date: <?php echo $patient{'DOB'};         ?></td>
  67
  68         <td width="20%" class="fibody2" id="bordR">ID No: <?php  echo $patient{'id'};  ?></td>
  69
  70         <td width="20%" class="fibody2">date: <?php echo date('Y-m-d'); ?></td>
  71
  72       </tr>
  73
  74     </table> </td>
  75
  76   </tr>
  77
  78   <tr>
  79
  80     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
  81
  82   </tr>
  83
  84   <tr>
  85
  86     <td align="left" valign="top">&nbsp;</td>
  87
  88   </tr>
  89
  90 </table>
  91
  92 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  93
  94   <tr align="left" valign="top">
  95
  96     <td width="29%" class="ficaption3">Tests ordered </td>
  97
  98     <td class="ficaption3">review of records </td>
  99
 100   </tr>
 101
 102   <tr align="left" valign="top">
 103
 104     <td class="fibody3"><p>
 105
 106       <?php echo (($fdata{'test_lab'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 107
 108       Laboratory</p>
 109
 110       <blockquote>
 111
 112         <p>
 113
 114           <?php echo (($fdata{'test_lab_cervical'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 115
 116           cervical cytology</p>
 117
 118         <p>
 119
 120           <?php echo (($fdata{'test_lab_hpv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 121
 122           HPV test</p>
 123
 124         <p>
 125
 126           <?php echo (($fdata{'test_lab_wet_mount'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 127
 128           wet mount</p>
 129
 130         <p>
 131
 132           <?php echo (($fdata{'test_lab_chlamydia'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 133
 134           chlamydia</p>
 135
 136         <p>
 137
 138           <?php echo (($fdata{'test_lab_gonorrhea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 139
 140           gonorrhea</p>
 141
 142         <p>
 143
 144           <?php echo (($fdata{'test_lab_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 145
 146           other <span class="ficaption2">
 147
 148           <?php echo $fdata{'test_lab_other_data'}; ?>
 149
 150           </span></p>
 151
 152         </blockquote>
 153
 154       <p>
 155
 156         <?php echo (($fdata{'test_rad'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 157
 158         Radiology / Ultrasound</p>
 159
 160       <blockquote>
 161
 162         <p>
 163
 164           <?php echo (($fdata{'test_rad_mammogram'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 165
 166           mammogram</p>
 167
 168         <p>
 169
 170           <?php echo (($fdata{'test_rad_other'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 171
 172           other <span class="ficaption2">
 173
 174           <?php echo $fdata{'test_rad_other_data'}; ?>
 175
 176           </span> </p>
 177
 178       </blockquote></td>
 179
 180     <td class="fibody3"><p>
 181
 182       <?php echo (($fdata{'previous_test_results'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 183
 184       previous test results:</p>
 185
 186       <p>
 187
 188         <?php echo $fdata{'previous_test_results_data'}; ?>
 189
 190       </p> <p>
 191
 192         <?php echo (($fdata{'test_results_discussion'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 193
 194         discussion of test results with performing physician:</p>
 195
 196       <p>
 197
 198         <?php echo $fdata{'test_results_discussion_data'}; ?>
 199
 200       </p> <p>
 201
 202         <?php echo (($fdata{'old_records_reviewed'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 203
 204         old records reviewed and summarized:</p>
 205
 206       <p>
 207
 208         <?php echo $fdata{'old_records_reviewed_data'}; ?>
 209
 210       </p> <p>
 211
 212         <?php echo (($fdata{'history_other_source'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 213
 214         history obtained from other source:</p>
 215
 216       <p>
 217
 218         <?php echo $fdata{'history_other_source_data'}; ?>
 219
 220       </p> <p>
 221
 222         <?php echo (($fdata{'independent_review'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 223
 224         independent review of image/specimen:</p>
 225
 226       <p>
 227
 228         <?php echo $fdata{'independent_review_data'}; ?>
 229
 230       </p></td>
 231
 232   </tr>
 233
 234 </table>
 235
 236 </div>
 237
 238   <p align="center">&nbsp;</p>
 239
 240   <h2 align="center">Diagnoses / Management option </h2>
 241
 242   <div style="border: solid 2px black; background-color: white;">
 243
 244     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 245
 246       <tr>
 247
 248         <td colspan="2" align="left" valign="top" class="fibody2"> <?php echo (($fdata{'established_problem'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 249
 250           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 251
 252           <?php echo (($fdata{'established_problem'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 253
 254         New problem </td>
 255
 256       </tr>
 257
 258       <tr>
 259
 260         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 261
 262       </tr>
 263
 264       <tr>
 265
 266         <td colspan="2" align="left" valign="top" class="fibody5"><?php echo $fdata{'assessment_and_plan'}; ?></td>
 267
 268       </tr>
 269
 270       <tr>
 271
 272         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 273
 274           <blockquote>
 275
 276             <p>
 277
 278             <?php echo (($fdata{'md_risk'} == 'minimal')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 279
 280             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 281
 282             <p>
 283
 284             <?php echo (($fdata{'md_risk'} == 'low')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 285
 286             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 287
 288             <p>
 289
 290               <?php echo (($fdata{'md_risk'} == 'moderate')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 291
 292             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 293
 294             <p>
 295
 296               <?php echo (($fdata{'md_risk'} == 'high')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 297
 298             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 299
 300         </blockquote></td>
 301
 302       </tr>
 303
 304       <tr>
 305
 306         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 307
 308           <tr>
 309
 310             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 311
 312             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_smoking'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 313
 314               smoking cessation </td>
 315
 316             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_contraception'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 317
 318               contraception</td>
 319
 320             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 321
 322             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 323
 324           </tr>
 325
 326           <tr>
 327
 328             <td align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_weight'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 329
 330               weight management </td>
 331
 332             <td align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_safe_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 333
 334               safe sex </td>
 335
 336             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 337
 338             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 339
 340           </tr>
 341
 342           <tr>
 343
 344             <td align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 345
 346               exercise</td>
 347
 348             <td align="left" valign="baseline" nowrap class="fibody3"><?php echo (($fdata{'pc_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 349
 350               other</td>
 351
 352             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 353
 354             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 355
 356           </tr>
 357
 358         </table></td>
 359
 360       </tr>
 361
 362       <tr>
 363
 364         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><?php echo (($fdata{'patient_education'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 365
 366         Patient education materials provided</td>
 367
 368         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 369
 370       </tr>
 371
 372       <tr>
 373
 374         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 375
 376         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 377
 378       </tr>
 379
 380       <tr>
 381
 382         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 383
 384         <?php echo $fdata{'minutes_counseled'}; ?></td>
 385
 386         <td align="left" valign="top" class="ficaption2">Total encounter time:
 387
 388         <?php echo $fdata{'total_encounter_time'}; ?></td>
 389
 390       </tr>
 391
 392       <tr valign="bottom">
 393
 394         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 395
 396         <td align="left" class="ficaption2">Date: <?php echo $fdata['date']; ?></td>
 397
 398       </tr>
 399
 400     </table>
 401
 402   </div>
 403
 404 </body>
 405
 406 </html>