contrib/forms/medical_decision/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
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   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 <?php 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 <?php
  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=<?php echo $id ?>" method="post" enctype="multipart/form-data" name="my_form">
  69
  70 <?php 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="<?php
  85
  86
  87           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  88
  89           ?>"></td>
  90
  91         <td width="20%" class="bordR">birth date
  92
  93           <br>
  94
  95           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
  96
  97
  98           echo $patient{'DOB'};
  99
 100           ?>" size="12"> </td>
 101
 102         <td width="20%" class="bordR">ID No<br>
 103
 104           <input name="md_pid" type="text" class="fullin" id="md_pid" size="12" value="<?php
 105
 106
 107           echo $patient{'id'};
 108
 109           ?>"></td>
 110
 111         <td width="20%">date<br>
 112
 113         <input name="md_date" type="text" class="fullin" id="md_date" value="<?php
 114
 115
 116         echo date('Y-m-d');
 117
 118         ?>" size="12"></td>
 119
 120       </tr>
 121
 122     </table> </td>
 123
 124   </tr>
 125
 126   <tr>
 127
 128     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
 129
 130   </tr>
 131
 132   <tr>
 133
 134     <td align="left" valign="top">&nbsp;</td>
 135
 136   </tr>
 137
 138 </table>
 139
 140 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 141
 142   <tr align="left" valign="top">
 143
 144     <td width="29%" class="ficaption3">Tests ordered </td>
 145
 146     <td class="ficaption3">review of records </td>
 147
 148   </tr>
 149
 150   <tr align="left" valign="top">
 151
 152     <td class="fibody3"><p>
 153
 154       <input name="test_lab" type="checkbox"  value="1" <?php echo (($fdata{'test_lab'} == '1')?' checked ':''); ?>>
 155
 156       Laboratory</p>
 157
 158       <blockquote>
 159
 160         <p>
 161
 162           <input name="test_lab_cervical" type="checkbox"  value="1" <?php echo (($fdata{'test_lab_cervical'} == '1')?' checked ':''); ?>>
 163
 164           cervical cytology</p>
 165
 166         <p>
 167
 168           <input name="test_lab_hpv" type="checkbox"  value="1" <?php echo (($fdata{'test_lab_hpv'} == '1')?' checked ':''); ?>>
 169
 170           HPV test</p>
 171
 172         <p>
 173
 174           <input name="test_lab_wet_mount" type="checkbox"  value="1" <?php echo (($fdata{'test_lab_wet_mount'} == '1')?' checked ':''); ?>>
 175
 176           wet mount</p>
 177
 178         <p>
 179
 180           <input name="test_lab_chlamydia" type="checkbox"  value="checkbox" <?php echo (($fdata{'test_lab_chlamydia'} == 'checkbox')?' checked ':''); ?>>
 181
 182           chlamydia</p>
 183
 184         <p>
 185
 186           <input name="test_lab_gonorrhea" type="checkbox"  value="1" <?php echo (($fdata{'test_lab_gonorrhea'} == '1')?' checked ':''); ?>>
 187
 188           gonorrhea</p>
 189
 190         <p>
 191
 192           <input name="test_lab_other" type="checkbox"  value="1" <?php echo (($fdata{'test_lab_other'} == '1')?' checked ':''); ?>>
 193
 194           other <span class="ficaption2">
 195
 196           <input name="test_lab_other_data" type="text" class="fullin"  style="width:60px" value="<?php echo $fdata{'test_lab_other_data'}; ?>">
 197
 198           </span></p>
 199
 200         </blockquote>
 201
 202       <p>
 203
 204         <input name="test_rad" type="checkbox"  value="1" <?php echo (($fdata{'test_rad'} == '1')?' checked ':''); ?>>
 205
 206         Radiology / Ultrasound</p>
 207
 208       <blockquote>
 209
 210         <p>
 211
 212           <input name="test_rad_mammogram" type="checkbox"  value="1" <?php echo (($fdata{'test_rad_mammogram'} == '1')?' checked ':''); ?>>
 213
 214           mammogram</p>
 215
 216         <p>
 217
 218           <input name="test_rad_other" type="checkbox"  value="checkbox" <?php echo (($fdata{'test_rad_other'} == 'checkbox')?' checked ':''); ?>>
 219
 220           other <span class="ficaption2">
 221
 222           <input name="test_rad_other_data" type="text" class="fullin"  style="width:60px" value="<?php echo $fdata{'test_rad_other_data'}; ?>">
 223
 224           </span> </p>
 225
 226       </blockquote></td>
 227
 228     <td class="fibody3"><p>
 229
 230       <input name="previous_test_results" type="checkbox"  value="1" <?php echo (($fdata{'previous_test_results'} == '1')?' checked ':''); ?>>
 231
 232       previous test results:</p>
 233
 234       <p>
 235
 236         <input name="previous_test_results_data" type="text" class="fullin2"  value="<?php echo $fdata{'previous_test_results_data'}; ?>">
 237
 238       </p> <p>
 239
 240         <input name="test_results_discussion" type="checkbox"  value="1" <?php echo (($fdata{'test_results_discussion'} == '1')?' checked ':''); ?>>
 241
 242         discussion of test results with performing physician:</p>
 243
 244       <p>
 245
 246         <input name="test_results_discussion_data" type="text" class="fullin2"  value="<?php echo $fdata{'test_results_discussion_data'}; ?>">
 247
 248       </p> <p>
 249
 250         <input name="old_records_reviewed" type="checkbox"  value="1" <?php echo (($fdata{'old_records_reviewed'} == '1')?' checked ':''); ?>>
 251
 252         old records reviewed and summarized:</p>
 253
 254       <p>
 255
 256         <input name="old_records_reviewed_data" type="text" class="fullin2"  value="<?php echo $fdata{'old_records_reviewed_data'}; ?>">
 257
 258       </p> <p>
 259
 260         <input name="history_other_source" type="checkbox"  value="1" <?php echo (($fdata{'history_other_source'} == '1')?' checked ':''); ?>>
 261
 262         history obtained from other source:</p>
 263
 264       <p>
 265
 266         <input name="history_other_source_data" type="text" class="fullin2"  value="<?php echo $fdata{'history_other_source_data'}; ?>">
 267
 268       </p> <p>
 269
 270         <input name="independent_review" type="checkbox"  value="1" <?php echo (($fdata{'independent_review'} == '1')?' checked ':''); ?>>
 271
 272         independent review of image/specimen:</p>
 273
 274       <p>
 275
 276         <input name="independent_review_data" type="text" class="fullin2"  value="<?php echo $fdata{'independent_review_data'}; ?>">
 277
 278       </p></td>
 279
 280   </tr>
 281
 282 </table>
 283
 284 </div>
 285
 286   <p align="center">&nbsp;</p>
 287
 288   <h2 align="center">Diagnoses / Management option <a href="#" onMouseOver="toolTip('<b>Diagnoses/management options</b><p><b>MINIMAL:</b> Minor problem; established problem, stable/improved<br><b>MULTIPLE:</b> New problem, no additional workup planned<br><b>LIMITED:</b> Established problem, worsening<br><b>EXTENSIVE:</b> New problem, additional workup planned</p>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></h2>
 289
 290   <div style="border: solid 2px black; background-color: white;">
 291
 292     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 293
 294       <tr>
 295
 296         <td colspan="2" align="left" valign="top" class="fibody2"> <input name="established_problem" type="radio" value="1" <?php echo (($fdata{'established_problem'} == '1')?' checked ':''); ?>>
 297
 298           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 299
 300           <input name="established_problem" type="radio" value="0" <?php echo (($fdata{'established_problem'} == '0')?' checked ':''); ?>>
 301
 302         New problem </td>
 303
 304       </tr>
 305
 306       <tr>
 307
 308         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 309
 310       </tr>
 311
 312       <tr>
 313
 314         <td colspan="2" align="left" valign="top" class="fibody2"><textarea name="assessment_and_plan" rows="7" wrap="PHYSICAL" class="fullin2" ><?php echo $fdata{'assessment_and_plan'}; ?></textarea></td>
 315
 316       </tr>
 317
 318       <tr>
 319
 320         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 321
 322           <blockquote>
 323
 324             <p>
 325
 326             <input name="md_risk" type="radio" value="minimal" <?php echo (($fdata{'md_risk'} == 'minimal')?' checked ':''); ?>>
 327
 328             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 329
 330             <p>
 331
 332             <input name="md_risk" type="radio" value="low" <?php echo (($fdata{'md_risk'} == 'low')?' checked ':''); ?>>
 333
 334             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 335
 336             <p>
 337
 338               <input name="md_risk" type="radio" value="moderate" <?php echo (($fdata{'md_risk'} == 'moderate')?' checked ':''); ?>>
 339
 340             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 341
 342             <p>
 343
 344               <input name="md_risk" type="radio" value="high" <?php echo (($fdata{'md_risk'} == 'high')?' checked ':''); ?>>
 345
 346             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 347
 348         </blockquote></td>
 349
 350       </tr>
 351
 352       <tr>
 353
 354         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 355
 356           <tr>
 357
 358             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 359
 360             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_smoking" type="checkbox"  value="1" <?php echo (($fdata{'pc_smoking'} == '1')?' checked ':''); ?>>
 361
 362               smoking cessation </td>
 363
 364             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_contraception" type="checkbox"  value="1" <?php echo (($fdata{'pc_contraception'} == '1')?' checked ':''); ?>>
 365
 366               contraception</td>
 367
 368             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 369
 370             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 371
 372           </tr>
 373
 374           <tr>
 375
 376             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_weight" type="checkbox"  value="1" <?php echo (($fdata{'pc_weight'} == '1')?' checked ':''); ?>>
 377
 378               weight management </td>
 379
 380             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_safe_sex" type="checkbox"  value="1" <?php echo (($fdata{'pc_safe_sex'} == '1')?' checked ':''); ?>>
 381
 382               safe sex </td>
 383
 384             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 385
 386             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 387
 388           </tr>
 389
 390           <tr>
 391
 392             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_exercise" type="checkbox"  value="1" <?php echo (($fdata{'pc_exercise'} == '1')?' checked ':''); ?>>
 393
 394               exercise</td>
 395
 396             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_other" type="checkbox"  value="1" <?php echo (($fdata{'pc_other'} == '1')?' checked ':''); ?>>
 397
 398               other</td>
 399
 400             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 401
 402             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 403
 404           </tr>
 405
 406         </table></td>
 407
 408       </tr>
 409
 410       <tr>
 411
 412         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><input name="patient_education" type="checkbox"  value="1" <?php echo (($fdata{'patient_education'} == '1')?' checked ':''); ?>>
 413
 414         Patient education materials provided</td>
 415
 416         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 417
 418       </tr>
 419
 420       <tr>
 421
 422         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 423
 424         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 425
 426       </tr>
 427
 428       <tr>
 429
 430         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 431
 432         <input name="minutes_counseled" type="text" class="fullin"  style="width:60px" value="<?php echo $fdata{'minutes_counseled'}; ?>"></td>
 433
 434         <td align="left" valign="top" class="ficaption2">Total encounter time:
 435
 436         <input name="total_encounter_time" type="text" class="fullin"  style="width:60px" value="<?php echo $fdata{'total_encounter_time'}; ?>"></td>
 437
 438       </tr>
 439
 440       <tr valign="bottom">
 441
 442         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 443
 444         <td align="left" class="ficaption2">Date:
 445
 446         <input name="md_date" type="text" class="fullin" id="md_date" style="width:80px" value="<?php
 447
 448
 449         echo date('Y-m-d');
 450
 451         ?>"></td>
 452
 453       </tr>
 454
 455     </table>
 456
 457   </div>
 458
 459 <table width="100%" border="0">
 460
 461   <tr><td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 462
 463   <td align="left" nowrap> <a href="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>"
 464
 465    target="_blank" class="link_submit" onclick="top.restoreSession()">[Printable form]</a> </td>
 466
 467   <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 468
 469    onclick="top.restoreSession()">[Don't Save]</a> </td></tr>
 470
 471 </table>
 472
 473 </form>
 474
 475 <?php
 476
 477 formFooter();
 478
 479 ?>
 480
 481 </body>
 482
 483 </html>