contrib/forms/medical_decision/view.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
  18
  19 <html>
  20
  21 <head>
  22 <? html_header_show();?>
  23
  24 <title>Medical decision making</title>
  25
  26 <meta http-equiv="Content-Type" content="text/html; charset=windows-1251">
  27
  28 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  29
  30 <link rel=stylesheet href="../../acog.css" type="text/css">
  31
  32 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  33
  34 <script language="JavaScript" type="text/JavaScript">
  35
  36 window.onload = initialize;
  37
  38 </script>
  39
  40 </head>
  41
  42 <body <?echo $top_bg_line;?>>
  43
  44
  45
  46 <div class="srvChapter">Medical decision making <a href="#" onMouseOver="toolTip('The <b>Medical Decision Making</b> section provides space to document minutes counseled, total encounter time, and other services needed to determine the correct level of medical decision making. <br><br><b>Amount and complexility of data reviewed</b><br>Minimal/none = 1 box, limited = 2 boxes, moderate = 3 boxes, extensive = 4+ boxes<br><br>The following items (if checked) count as 2 boxes:<li>OLD RECORDS REVIEWED AND SUMMARIZED</li><li>HISTORY OBTAINED FROM OTHER SOURCE</li><li>INDEPENDENT REVIEW OF IMAGE/SPECIMEN</li>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  47
  48 <?
  49
  50    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  51
  52    if ($fres){
  53
  54      $patient = sqlFetchArray($fres);
  55
  56    }
  57
  58    $fres=sqlStatement("select * from form_medical_decision where id=$id");
  59
  60    if ($fres){
  61
  62      $fdata = sqlFetchArray($fres);
  63
  64    }
  65
  66 ?>
  67
  68 <form action="<?echo $rootdir;?>/forms/medical_decision/save.php?mode=update&id=<? echo $id ?>" method="post" enctype="multipart/form-data" name="my_form">
  69
  70 <? include("../../acog_menu.inc"); ?>
  71
  72 <div style="border: solid 2px black; background-color: white;">
  73
  74 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  75
  76   <tr>
  77
  78     <td align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  79
  80       <tr align="left" valign="bottom" class="fibody">
  81
  82         <td width="40%" class="bordR">Patient name <br>
  83
  84           <input name="pname" type="text" class="fullin" id="pname" value="<?
  85
  86           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  87
  88           ?>"></td>
  89
  90         <td width="20%" class="bordR">birth date
  91
  92           <br>
  93
  94           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
  95
  96           echo $patient{'DOB'};
  97
  98           ?>" size="12"> </td>
  99
 100         <td width="20%" class="bordR">ID No<br>
 101
 102           <input name="md_pid" type="text" class="fullin" id="md_pid" size="12" value="<?
 103
 104           echo $patient{'id'};
 105
 106           ?>"></td>
 107
 108         <td width="20%">date<br>
 109
 110         <input name="md_date" type="text" class="fullin" id="md_date" value="<?
 111
 112         echo date('Y-m-d');
 113
 114         ?>" size="12"></td>
 115
 116       </tr>
 117
 118     </table> </td>
 119
 120   </tr>
 121
 122   <tr>
 123
 124     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
 125
 126   </tr>
 127
 128   <tr>
 129
 130     <td align="left" valign="top">&nbsp;</td>
 131
 132   </tr>
 133
 134 </table>
 135
 136 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 137
 138   <tr align="left" valign="top">
 139
 140     <td width="29%" class="ficaption3">Tests ordered </td>
 141
 142     <td class="ficaption3">review of records </td>
 143
 144   </tr>
 145
 146   <tr align="left" valign="top">
 147
 148     <td class="fibody3"><p>
 149
 150       <input name="test_lab" type="checkbox"  value="1" <? echo (($fdata{'test_lab'} == '1')?' checked ':''); ?>>
 151
 152       Laboratory</p>
 153
 154       <blockquote>
 155
 156         <p>
 157
 158           <input name="test_lab_cervical" type="checkbox"  value="1" <? echo (($fdata{'test_lab_cervical'} == '1')?' checked ':''); ?>>
 159
 160           cervical cytology</p>
 161
 162         <p>
 163
 164           <input name="test_lab_hpv" type="checkbox"  value="1" <? echo (($fdata{'test_lab_hpv'} == '1')?' checked ':''); ?>>
 165
 166           HPV test</p>
 167
 168         <p>
 169
 170           <input name="test_lab_wet_mount" type="checkbox"  value="1" <? echo (($fdata{'test_lab_wet_mount'} == '1')?' checked ':''); ?>>
 171
 172           wet mount</p>
 173
 174         <p>
 175
 176           <input name="test_lab_chlamydia" type="checkbox"  value="checkbox" <? echo (($fdata{'test_lab_chlamydia'} == 'checkbox')?' checked ':''); ?>>
 177
 178           chlamydia</p>
 179
 180         <p>
 181
 182           <input name="test_lab_gonorrhea" type="checkbox"  value="1" <? echo (($fdata{'test_lab_gonorrhea'} == '1')?' checked ':''); ?>>
 183
 184           gonorrhea</p>
 185
 186         <p>
 187
 188           <input name="test_lab_other" type="checkbox"  value="1" <? echo (($fdata{'test_lab_other'} == '1')?' checked ':''); ?>>
 189
 190           other <span class="ficaption2">
 191
 192           <input name="test_lab_other_data" type="text" class="fullin"  style="width:60px" value="<? echo $fdata{'test_lab_other_data'}; ?>">
 193
 194           </span></p>
 195
 196         </blockquote>
 197
 198       <p>
 199
 200         <input name="test_rad" type="checkbox"  value="1" <? echo (($fdata{'test_rad'} == '1')?' checked ':''); ?>>
 201
 202         Radiology / Ultrasound</p>
 203
 204       <blockquote>
 205
 206         <p>
 207
 208           <input name="test_rad_mammogram" type="checkbox"  value="1" <? echo (($fdata{'test_rad_mammogram'} == '1')?' checked ':''); ?>>
 209
 210           mammogram</p>
 211
 212         <p>
 213
 214           <input name="test_rad_other" type="checkbox"  value="checkbox" <? echo (($fdata{'test_rad_other'} == 'checkbox')?' checked ':''); ?>>
 215
 216           other <span class="ficaption2">
 217
 218           <input name="test_rad_other_data" type="text" class="fullin"  style="width:60px" value="<? echo $fdata{'test_rad_other_data'}; ?>">
 219
 220           </span> </p>
 221
 222       </blockquote></td>
 223
 224     <td class="fibody3"><p>
 225
 226       <input name="previous_test_results" type="checkbox"  value="1" <? echo (($fdata{'previous_test_results'} == '1')?' checked ':''); ?>>
 227
 228       previous test results:</p>
 229
 230       <p>
 231
 232         <input name="previous_test_results_data" type="text" class="fullin2"  value="<? echo $fdata{'previous_test_results_data'}; ?>">
 233
 234       </p> <p>
 235
 236         <input name="test_results_discussion" type="checkbox"  value="1" <? echo (($fdata{'test_results_discussion'} == '1')?' checked ':''); ?>>
 237
 238         discussion of test results with performing physician:</p>
 239
 240       <p>
 241
 242         <input name="test_results_discussion_data" type="text" class="fullin2"  value="<? echo $fdata{'test_results_discussion_data'}; ?>">
 243
 244       </p> <p>
 245
 246         <input name="old_records_reviewed" type="checkbox"  value="1" <? echo (($fdata{'old_records_reviewed'} == '1')?' checked ':''); ?>>
 247
 248         old records reviewed and summarized:</p>
 249
 250       <p>
 251
 252         <input name="old_records_reviewed_data" type="text" class="fullin2"  value="<? echo $fdata{'old_records_reviewed_data'}; ?>">
 253
 254       </p> <p>
 255
 256         <input name="history_other_source" type="checkbox"  value="1" <? echo (($fdata{'history_other_source'} == '1')?' checked ':''); ?>>
 257
 258         history obtained from other source:</p>
 259
 260       <p>
 261
 262         <input name="history_other_source_data" type="text" class="fullin2"  value="<? echo $fdata{'history_other_source_data'}; ?>">
 263
 264       </p> <p>
 265
 266         <input name="independent_review" type="checkbox"  value="1" <? echo (($fdata{'independent_review'} == '1')?' checked ':''); ?>>
 267
 268         independent review of image/specimen:</p>
 269
 270       <p>
 271
 272         <input name="independent_review_data" type="text" class="fullin2"  value="<? echo $fdata{'independent_review_data'}; ?>">
 273
 274       </p></td>
 275
 276   </tr>
 277
 278 </table>
 279
 280 </div>
 281
 282   <p align="center">&nbsp;</p>
 283
 284   <h2 align="center">Diagnoses / Management option <a href="#" onMouseOver="toolTip('<b>Diagnoses/management options</b><p><b>MINIMAL:</b> Minor problem; established problem, stable/improved<br><b>MULTIPLE:</b> New problem, no additional workup planned<br><b>LIMITED:</b> Established problem, worsening<br><b>EXTENSIVE:</b> New problem, additional workup planned</p>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></h2>
 285
 286   <div style="border: solid 2px black; background-color: white;">
 287
 288     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 289
 290       <tr>
 291
 292         <td colspan="2" align="left" valign="top" class="fibody2"> <input name="established_problem" type="radio" value="1" <? echo (($fdata{'established_problem'} == '1')?' checked ':''); ?>>
 293
 294           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 295
 296           <input name="established_problem" type="radio" value="0" <? echo (($fdata{'established_problem'} == '0')?' checked ':''); ?>>
 297
 298         New problem </td>
 299
 300       </tr>
 301
 302       <tr>
 303
 304         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 305
 306       </tr>
 307
 308       <tr>
 309
 310         <td colspan="2" align="left" valign="top" class="fibody2"><textarea name="assessment_and_plan" rows="7" wrap="PHYSICAL" class="fullin2" ><? echo $fdata{'assessment_and_plan'}; ?></textarea></td>
 311
 312       </tr>
 313
 314       <tr>
 315
 316         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 317
 318           <blockquote>
 319
 320             <p>
 321
 322             <input name="md_risk" type="radio" value="minimal" <? echo (($fdata{'md_risk'} == 'minimal')?' checked ':''); ?>>
 323
 324             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 325
 326             <p>
 327
 328             <input name="md_risk" type="radio" value="low" <? echo (($fdata{'md_risk'} == 'low')?' checked ':''); ?>>
 329
 330             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 331
 332             <p>
 333
 334               <input name="md_risk" type="radio" value="moderate" <? echo (($fdata{'md_risk'} == 'moderate')?' checked ':''); ?>>
 335
 336             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 337
 338             <p>
 339
 340               <input name="md_risk" type="radio" value="high" <? echo (($fdata{'md_risk'} == 'high')?' checked ':''); ?>>
 341
 342             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 343
 344         </blockquote></td>
 345
 346       </tr>
 347
 348       <tr>
 349
 350         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 351
 352           <tr>
 353
 354             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 355
 356             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_smoking" type="checkbox"  value="1" <? echo (($fdata{'pc_smoking'} == '1')?' checked ':''); ?>>
 357
 358               smoking cessation </td>
 359
 360             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_contraception" type="checkbox"  value="1" <? echo (($fdata{'pc_contraception'} == '1')?' checked ':''); ?>>
 361
 362               contraception</td>
 363
 364             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 365
 366             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 367
 368           </tr>
 369
 370           <tr>
 371
 372             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_weight" type="checkbox"  value="1" <? echo (($fdata{'pc_weight'} == '1')?' checked ':''); ?>>
 373
 374               weight management </td>
 375
 376             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_safe_sex" type="checkbox"  value="1" <? echo (($fdata{'pc_safe_sex'} == '1')?' checked ':''); ?>>
 377
 378               safe sex </td>
 379
 380             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 381
 382             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 383
 384           </tr>
 385
 386           <tr>
 387
 388             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_exercise" type="checkbox"  value="1" <? echo (($fdata{'pc_exercise'} == '1')?' checked ':''); ?>>
 389
 390               exercise</td>
 391
 392             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_other" type="checkbox"  value="1" <? echo (($fdata{'pc_other'} == '1')?' checked ':''); ?>>
 393
 394               other</td>
 395
 396             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 397
 398             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 399
 400           </tr>
 401
 402         </table></td>
 403
 404       </tr>
 405
 406       <tr>
 407
 408         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><input name="patient_education" type="checkbox"  value="1" <? echo (($fdata{'patient_education'} == '1')?' checked ':''); ?>>
 409
 410         Patient education materials provided</td>
 411
 412         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 413
 414       </tr>
 415
 416       <tr>
 417
 418         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 419
 420         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 421
 422       </tr>
 423
 424       <tr>
 425
 426         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 427
 428         <input name="minutes_counseled" type="text" class="fullin"  style="width:60px" value="<? echo $fdata{'minutes_counseled'}; ?>"></td>
 429
 430         <td align="left" valign="top" class="ficaption2">Total encounter time:
 431
 432         <input name="total_encounter_time" type="text" class="fullin"  style="width:60px" value="<? echo $fdata{'total_encounter_time'}; ?>"></td>
 433
 434       </tr>
 435
 436       <tr valign="bottom">
 437
 438         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 439
 440         <td align="left" class="ficaption2">Date:
 441
 442         <input name="md_date" type="text" class="fullin" id="md_date" style="width:80px" value="<?
 443
 444         echo date('Y-m-d');
 445
 446         ?>"></td>
 447
 448       </tr>
 449
 450     </table>
 451
 452   </div>
 453
 454 <table width="100%" border="0">
 455
 456   <tr><td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 457
 458   <td align="left" nowrap> <a href="<? echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<? echo $id; ?>&formname=<? echo $formname; ?>"
 459
 460    target="_blank" class="link_submit" onclick="top.restoreSession()">[Printable form]</a> </td>
 461
 462   <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 463
 464    onclick="top.restoreSession()">[Don't Save]</a> </td></tr>
 465
 466 </table>
 467
 468 </form>
 469
 470 <?php
 471
 472 formFooter();
 473
 474 ?>
 475
 476 </body>
 477
 478 </html>