portal/patient/templates/PatientListView.tpl.php

   1 <?php
   2
   3 /**
   4  * import_template.php
   5  *
   6  * @package   OpenEMR
   7  * @link      https://www.open-emr.org
   8  * @author    Jerry Padgett <sjpadgett@gmail.com>
   9  * @author    Terry Hill <teryhill@yahoo.com>
  10  * @copyright Copyright (c) 2016-2021 Jerry Padgett <sjpadgett@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14     //require_once ("./../verify_session.php");
  15     require_once("../../library/options.inc.php");
  16     $this->assign('title', xlt("Patient Portal") . " | " . xlt("Patient Data"));
  17     $this->assign('nav', 'patientdata');
  18     /*
  19      *  row keys are js underscore camelcase and follow the underscores variables used in this template
  20      *  $row['city'] or $row['postalCode'] e.t.c.. The keys do not match table columns ie postalCode here is postal_code in table.
  21      *  */
  22     $row = array();
  23 if ($this->trow) {
  24     $row = $this->trow;
  25 }
  26 $exclude = array();
  27 if ($this->exclude) {
  28     $exclude = $this->exclude;
  29 }
  30
  31     echo "<script>var register='" . attr($this->register) . "';var recid='" . attr($this->recid) . "';var webRoot='" . $GLOBALS['web_root'] . "';var cpid='" . attr($this->cpid) . "';var cuser='" . attr($this->cuser) . "';</script>";
  32
  33     $this->display('_modalFormHeader.tpl.php');
  34 ?>
  35
  36 <script>
  37     // bring in the datepicker and datetimepicker localization and setting elements
  38     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4-alternate.js.php'); ?>
  39
  40     $LAB.script("scripts/app/patientdata.js?v=<?php echo $GLOBALS['v_js_includes']; ?>").wait(function(){
  41         $(function () {
  42             page.init();
  43         });
  44         // hack for browsers or slow sessions which may respond inconsistently with document.ready-second chance at init
  45         setTimeout(function(){
  46             if (!page.isInitialized) page.init();
  47         },1000);
  48     });
  49     // profile excludes global from layouts via PatientController
  50     const exclude = <?php echo js_escape($exclude); ?>;
  51 </script>
  52 <?php if (attr($this->register)) {?>
  53 <style>
  54     .form-group .inline .dynhide {
  55         display: none;
  56     }
  57
  58     body {
  59         padding-top: 0;
  60         padding-bottom: 5px;
  61         background-color: #fff !important;
  62     }
  63 </style>
  64 <script>
  65     // Fixes iFrame in Patient Registratiion
  66     setInterval(function() {
  67         window.top.postMessage(document.body.scrollHeight, "*");
  68     }, 500);
  69 </script>
  70 <?php }?>
  71 <body>
  72 <div class="container-fluid">
  73 <script type="text/template" id="patientCollectionTemplate"></script>
  74     <!-- Could add/manage table list here -->
  75 <script type="text/template" id="patientModelTemplate"> <!-- -->
  76
  77 <div id='profileHelp' class='jumbotron jumbotron-fluid' style='display: none; width: 650px; margin: 0 auto;'>
  78 <p>
  79 <?php echo xlt('Any changes here will be reviewed by provider staff before committing to your chart. The following apply'); ?>:<br />
  80 <?php echo xlt('Change any item available and when ready click Send for review. The changes will be flagged and staff notified to review changes before committing them to chart. During the time period before changes are reviewed the Revised button will show Pending and profile data is still available for changes. When accessing profile in pending state all previous edits will appear in Blue and current chart values in Red. You may revert any edit to chart value by clicking that red item (or vica versa) but remember that when you click Send for Review then items that populate the field items are the ones that are sent. Revert Edits button changes everything back to chart values and you may make changes from there. So to recap: Items in BLUE are patient edits with items in RED being original values before any edits.'); ?>
  81 </p>
  82         <button class="btn btn-primary btn-sm" type="button" id='dismissHelp'><?php echo xlt('Dismiss'); ?></button>
  83         </div>
  84         <form onsubmit="return false;">
  85             <fieldset>
  86             <div class="form-row mb-2 pb-2">
  87             <div class="col-sm-auto px-3 form-group plist-group" id="provideridInputContainer">
  88                     <label class="plist-label" for="providerid"><?php echo xlt('Current Physician')?></label>
  89                     <div class="controls inline-inputs">
  90                         <select class="form-control" id="providerid" value="<?php echo $row['providerid'] ?>">
  91                             <?php
  92                             echo "<option value='1'>" . xlt('Administrator Assign') . "</option>";
  93                             foreach ($this->users_list as $user) {
  94                                 $user_name = text($user['fname'] . ' ' . $user['lname']);
  95                                 $id = attr($user['id']);
  96                                 echo "<option value='$id'";
  97                                 if ((int)$id === (int)$row['providerid']) {
  98                                     echo " selected";
  99                                 }
 100                                 echo ">$user_name</option>";
 101                             }
 102                             ?>
 103                         </select>
 104                         <span class="help-inline"></span>
 105                     </div>
 106             </div>
 107             <div class="col-sm-auto px-3 form-group plist-group" id="titleInputContainer">
 108                 <label class="plist-label" for="title"><?php echo xlt('Title')?></label><br />
 109                 <div class="controls inline-inputs">
 110                     <?php
 111                   # Generate drop down list for Title
 112                     echo generate_select_list('title', 'titles', $row['title'], xl('Title'), 'Unassigned', "form-control");
 113                     ?>
 114                  <span class="help-inline"></span>
 115                 </div>
 116             </div>
 117                 <div class="col-sm-auto px-3 form-group plist-group" id="fnameInputContainer">
 118                     <label class="plist-label" for="fname"><?php echo xlt('First{{Name}}')?></label>
 119                     <div class="controls inline-inputs">
 120                         <input type="text" class="form-control" id="fname" required placeholder="<?php echo xla('First Name'); ?>" value="<%= _.escape(item.get('fname') || '') %>">
 121                         <span class="help-inline"></span>
 122                     </div>
 123                 </div>
 124                 <div class="col-sm-auto px-3 form-group plist-group" id="mnameInputContainer">
 125                     <label class="plist-label" for="mname"><?php echo xlt('Middle{{Name}}')?></label>
 126                     <div class="controls inline-inputs">
 127                         <input type="text" class="form-control" id="mname" placeholder="<?php echo xla('Middle Name'); ?>" value="<%= _.escape(item.get('mname') || '') %>">
 128                         <span class="help-inline"></span>
 129                     </div>
 130                 </div>
 131                 <div class="col-sm-auto px-3 form-group plist-group" id="lnameInputContainer">
 132                     <label class="plist-label" for="lname"><?php echo xlt('Last{{Name}}')?></label>
 133                     <div class="controls inline-inputs">
 134                         <input type="text" class="form-control" id="lname" required placeholder="<?php echo xla('Last Name'); ?>" value="<%= _.escape(item.get('lname') || '') %>">
 135                         <span class="help-inline"></span>
 136                     </div>
 137                 </div>
 138                 <!--<div class="col-sm-auto px-3 form-group plist-group  dynhide hide" id="pidInputContainer">
 139                     <label class="plist-label" for="pid"><?php /*echo xlt('Pid')*/?></label>
 140                     <div class="controls inline-inputs">
 141                         <input type="text" class="form-control" id="pid" readonly placeholder="<?php /*echo xla('Pid')*/?>" value="<%= _.escape(item.get('pid') || '') %>">
 142                         <span class="help-inline"></span>
 143                     </div>
 144                 </div>-->
 145                 <div class="col-sm-auto px-3 form-group plist-group" id="pubpidInputContainer">
 146                     <label class="plist-label" for="pubpid"><?php echo xlt('Public Patient Id')?></label>
 147                     <div class="controls inline-inputs">
 148                         <input type="text" class="form-control" id="pubpid" disabled value="<%= _.escape(item.get('pubpid') || '') %>">
 149                         <span class="help-inline"></span>
 150                     </div>
 151                 </div>
 152                 <div class="col-sm-auto px-3 form-group plist-group" id="dobInputContainer">
 153                     <label class="plist-label" for="dob"><?php echo xlt('Birth Date')?></label>
 154                     <div class="controls inline-inputs">
 155                         <div class="input-group" >
 156                             <input id="dob" type="text" required class="form-control jquery-date-picker" placeholder="<?php echo xla('I know but we need it!'); ?>" value="<%= item.get('dob') %>" />
 157                         </div>
 158                         <span class="help-inline"></span>
 159                     </div>
 160                 </div>
 161                 <!--<div class="col-sm-auto px-3 form-group plist-group" id="ssInputContainer">
 162                     <label class="plist-label" for="ss"><?php /*echo xlt('SSN')*/?></label>
 163                     <div class="controls inline-inputs">
 164                         <input type="text" class="form-control" id="ss" title="###-##-####" placeholder="<?php /*echo xla('Social Security(Optional)'); */?>" value="<%= _.escape(item.get('ss') || '') %>">
 165                         <span class="help-inline"></span>
 166                     </div>
 167                 </div>-->
 168                 <div class="col-sm-auto px-3 form-group plist-group" id="sexInputContainer">
 169                     <label class="plist-label" for="sex"><?php echo xlt('Gender')?></label><br />
 170                     <div class="controls inline-inputs">
 171                         <?php
 172                       # Generate drop down list for Sex
 173                         echo generate_select_list('sex', 'sex', $row['sex'], xl('Sex'), 'Unassigned');
 174                         ?>
 175                      <span class="help-inline"></span>
 176                     </div>
 177                 </div>
 178                 <!--<div class="col-sm-auto px-3 form-group plist-group" id="pharmacyIdInputContainer">
 179                     <label class="plist-label" for="pharmacyId"><?php echo xlt('Pharmacy Id')?></label>
 180                     <div class="controls inline-inputs">
 181                         <input type="text" class="form-control" id="pharmacyId" placeholder="<?php echo xla('Pharmacy Id'); ?>" value="<%= _.escape(item.get('pharmacyId') || '') %>">
 182                         <span class="help-inline"></span>
 183                     </div>
 184                 </div>-->
 185                 <div class="col-sm-auto px-3 form-group plist-group" id="statusInputContainer">
 186                     <label class="plist-label" for="status"><?php echo xlt('Marital Status')?></label><br />
 187                     <div class="controls inline-inputs">
 188                     <?php
 189                   # Generate drop down list for Marital Status
 190                     echo generate_select_list('status', 'marital', $row['status'], xl('Marital Status'), 'Unassigned', "form-control");
 191                     ?>
 192                     <span class="help-inline"></span>
 193                     </div>
 194                 </div>
 195                 <div class="col-sm-auto px-3 form-group plist-group" id="streetInputContainer">
 196                     <label class="plist-label" for="street"><?php echo xlt('Street')?></label>
 197                     <div class="controls inline-inputs">
 198                         <input type="text" class="form-control" id="street" required placeholder="<?php echo xla('Street'); ?>" value="<%= _.escape(item.get('street') || '') %>"/>
 199                         <span class="help-inline"></span>
 200                     </div>
 201                 </div>
 202             <div class="col-sm-auto px-3 form-group plist-group" id="cityInputContainer">
 203                     <label class="plist-label" for="city"><?php echo xlt('City')?></label>
 204                     <div class="controls inline-inputs">
 205                         <input type="text" class="form-control" id="city" required placeholder="<?php echo xla('City'); ?>" value="<%= _.escape(item.get('city') || '') %>">
 206                         <span class="help-inline"></span>
 207                     </div>
 208                 </div>
 209             <div class="col-sm-auto px-3 form-group plist-group" id="stateInputContainer">
 210                 <label class="plist-label" for="state"><?php echo xlt('State')?></label><br />
 211                 <div class="controls inline-inputs">
 212                     <?php
 213                   # Generate drop down list for State
 214                     echo generate_select_list('state', 'state', $row['state'], xl('State'), 'Unassigned', "form-control");
 215                     ?>
 216                  <span class="help-inline"></span>
 217                 </div>
 218             </div>
 219                 <div class="col-sm-auto px-3 form-group plist-group" id="postalCodeInputContainer">
 220                     <label class="plist-label" for="postalCode"><?php echo xlt('Postal Code')?></label>
 221                     <div class="controls inline-inputs">
 222                         <input type="text" class="form-control" id="postalCode" placeholder="<?php echo xla('Postal Code'); ?>" value="<%= _.escape(item.get('postalCode') || '') %>">
 223                         <span class="help-inline"></span>
 224                     </div>
 225                 </div>
 226                 <div class="col-sm-auto px-3 form-group plist-group" id="countyInputContainer">
 227                     <label class="plist-label" for="county"><?php echo xlt('County')?></label>
 228                     <div class="controls inline-inputs">
 229                         <input type="text" class="form-control" id="county" placeholder="<?php echo xla('County'); ?>" value="<%= _.escape(item.get('county') || '') %>">
 230                         <span class="help-inline"></span>
 231                     </div>
 232                 </div>
 233                 <div class="col-sm-auto px-3 form-group plist-group" id="countryCodeInputContainer">
 234                     <label class="plist-label" for="countryCode"><?php echo xlt('Country Code')?></label>
 235                     <div class="controls inline-inputs">
 236                         <input type="text" class="form-control" id="countryCode" placeholder="<?php echo xla('Country Code'); ?>" value="<%= _.escape(item.get('countryCode') || '') %>">
 237                         <span class="help-inline"></span>
 238                     </div>
 239                 </div>
 240                 <div class="col-sm-auto px-3 form-group plist-group" id="phoneHomeInputContainer">
 241                     <label class="plist-label" for="phoneHome"><?php echo xlt('Home Phone')?></label>
 242                     <div class="controls inline-inputs">
 243                         <input type="text" class="form-control" id="phoneHome" placeholder="<?php echo xla('Phone Home'); ?>" value="<%= _.escape(item.get('phoneHome') || '') %>">
 244                         <span class="help-inline"></span>
 245                     </div>
 246                 </div>
 247                 <div class="col-sm-auto px-3 form-group plist-group" id="phoneBizInputContainer">
 248                     <label class="plist-label" for="phoneBiz"><?php echo xlt('Business Phone')?></label>
 249                     <div class="controls inline-inputs">
 250                         <input type="text" class="form-control" id="phoneBiz" placeholder="<?php echo xla('Phone Biz'); ?>" value="<%= _.escape(item.get('phoneBiz') || '') %>">
 251                         <span class="help-inline"></span>
 252                     </div>
 253                 </div>
 254                 <div class="col-sm-auto px-3 form-group plist-group" id="phoneCellInputContainer">
 255                     <label class="plist-label" for="phoneCell"><?php echo xlt('Cell Phone')?></label>
 256                     <div class="controls inline-inputs">
 257                         <input type="text" class="form-control" id="phoneCell" placeholder="<?php echo xla('Phone Cell'); ?>" value="<%= _.escape(item.get('phoneCell') || '') %>">
 258                         <span class="help-inline"></span>
 259                     </div>
 260                 </div>
 261                 <div class="col-sm-auto px-3 form-group plist-group" id="phoneContactInputContainer">
 262                     <label class="plist-label" for="phoneContact"><?php echo xlt('Contact or Notify Phone')?></label>
 263                     <div class="controls inline-inputs">
 264                         <input type="text" class="form-control" id="phoneContact" placeholder="<?php echo xla('Phone Contact'); ?>" value="<%= _.escape(item.get('phoneContact') || '') %>">
 265                         <span class="help-inline"></span>
 266                     </div>
 267                 </div>
 268                 <div class="col-sm-auto px-3 form-group plist-group" id="contactRelationshipInputContainer">
 269                     <label class="plist-label" for="contactRelationship"><?php echo xlt('Contact Relationship')?></label>
 270                     <div class="controls inline-inputs">
 271                         <input type="text" class="form-control" id="contactRelationship" placeholder="<?php echo xla('Contact Relationship'); ?>" value="<%= _.escape(item.get('contactRelationship') || '') %>">
 272                         <span class="help-inline"></span>
 273                     </div>
 274                 </div>
 275                 <div class="col-sm-auto px-3 form-group plist-group" id="dateInputContainer">
 276                     <label class="plist-label" for="date"><?php echo xlt('Date')?></label>
 277                     <div class="controls inline-inputs">
 278                         <div class="input-group">
 279                             <input disabled id="date" type="text" class="form-control jquery-date-time-picker" value="<%= item.get('date') %>" />
 280                         </div>
 281                         <span class="help-inline"></span>
 282                     </div>
 283                 </div><!-- -->
 284                 <div class="col-sm-auto px-3 form-group plist-group dynhide" id="refProvideridInputContainer">
 285                     <label class="plist-label" for="refProviderid"><?php echo xlt('Referral Provider')?></label>
 286                     <div class="controls inline-inputs">
 287                         <select  disabled class="form-control" id="refProviderid"  value="<?php echo $row['refProviderid'] ?>">
 288                             <?php
 289                             echo "<option value=''>" . xlt('Unassigned') . "</option>";
 290                             foreach ($this->users_list as $user) {
 291                                 $user_name = text($user['fname'] . ' ' . $user['lname']);
 292                                 $id = attr($user['id']);
 293                                 echo "<option value='$id'";
 294                                 if ((int)$id === (int)$row['refProviderid']) {
 295                                     echo " selected";
 296                                 }
 297                                 echo ">$user_name</option>";
 298                             }
 299                             ?>
 300                         </select>
 301                         <span class="help-inline"></span>
 302                     </div>
 303                 </div>
 304                 <div class="col-sm-auto px-3 form-group plist-group" id="emailInputContainer">
 305                     <label class="plist-label" for="email"><?php echo xlt('Email')?></label>
 306                     <div class="controls inline-inputs">
 307                         <input type="email" class="form-control" id="email" required placeholder="<?php echo xla('Email'); ?>" value="<%= _.escape(item.get('email') || '') %>">
 308                         <span class="help-inline"></span>
 309                     </div>
 310                 </div>
 311                 <div class="col-sm-auto px-3 form-group plist-group dynhide" id="emailDirectInputContainer">
 312                     <label class="plist-label" for="emailDirect"><?php echo xlt('Email Direct')?></label>
 313                     <div class="controls inline-inputs">
 314                         <input type="text" class="form-control" id="emailDirect" placeholder="<?php echo xla('Direct Email'); ?>" value="<%= _.escape(item.get('emailDirect') || '') %>">
 315                         <span class="help-inline"></span>
 316                     </div>
 317                 </div>
 318                 <div class="col-sm-auto px-3 form-group plist-group" id="languageInputContainer">
 319                     <label class="plist-label" for="language"><?php echo xlt('Preferred Language')?></label>
 320                     <div class="controls inline-inputs">
 321                         <input type="text" class="form-control" id="language" placeholder="<?php echo xla('Language'); ?>" value="<%= _.escape(item.get('language') || '') %>">
 322                         <span class="help-inline"></span>
 323                     </div>
 324                 </div>
 325             <div class="col-sm-auto px-3 form-group plist-group" id="raceInputContainer">
 326                 <label class="plist-label" for="race"><?php echo xlt('Race')?></label><br />
 327                 <div class="controls inline-inputs">
 328                     <?php
 329                   # Generate drop down list for Race
 330                     echo generate_select_list('race', 'race', $row[ 'race'], xl('Race'), 'Unassigned', "form-control");
 331                     ?>
 332                 <span class="help-inline"></span>
 333                 </div>
 334            </div>
 335            <div class="col-sm-auto px-3 form-group plist-group" id="ethnicityInputContainer">
 336                     <label class="plist-label" for="ethnicity"><?php echo xlt('Ethnicity')?></label><br />
 337                     <div class="controls inline-inputs">
 338                         <?php
 339                       # Generate drop down list for Ethnicity
 340                         echo generate_select_list('ethnicity', 'ethnicity', $row['ethnicity'], xl('Ethnicity'), 'Unassigned', "form-control");
 341                         ?>
 342                     <span class="help-inline"></span>
 343                     </div>
 344             </div>
 345             <div class="col-sm-auto px-3 form-group plist-group" id="religionInputContainer">
 346                 <label class="plist-label" for="religion"><?php echo xlt('Religion')?></label><br />
 347                 <div class="controls inline-inputs">
 348                     <?php
 349                   # Generate drop down list for Religion
 350                     echo generate_select_list('religion', 'religious_affiliation', $row['religion'], xl('Religion'), 'Unassigned', "form-control");
 351                     ?>
 352                  <span class="help-inline"></span>
 353                 </div>
 354             </div>
 355             <div class="col-sm-auto px-3 form-group plist-group dynhide" id="familySizeInputContainer">
 356                     <label class="plist-label" for="familySize"><?php echo xlt('Family Size')?></label>
 357                     <div class="controls inline-inputs">
 358                         <input type="text" class="form-control" id="familySize" placeholder="<?php echo xla('Family Size'); ?>" value="<%= _.escape(item.get('familySize') || '') %>">
 359                         <span class="help-inline"></span>
 360                     </div>
 361                 </div>
 362                 <!--<div class="col-sm-auto px-3 form-group plist-group" id="referralSourceInputContainer">
 363                     <label class="plist-label" for="referralSource"><?php /*echo xlt('How Referred')*/?></label><br />
 364                     <div class="controls inline-inputs">
 365                         <?php
 366 /*                      # Generate drop down list for Referral Source
 367                         echo generate_select_list('referralSource', 'refsource', $row['referralSource'], xl('Referral Source'), 'Unassigned', "form-control");
 368                         */?>
 369                         <span class="help-inline"></span>
 370                     </div>
 371                 </div>-->
 372                 <!--<div class="col-sm-auto px-3 form-group plist-group dynhide" id="regdateInputContainer">
 373                     <label class="plist-label" for="regdate"><?php /*echo xlt('Registration Date')*/?></label>
 374                     <div class="controls inline-inputs">
 375                         <div class="input-group">
 376                             <input disabled id="regdate" type="text" class="form-control jquery-date-picker" value="<%= item.get('regdate') %>" />
 377                         </div>
 378                         <span class="help-inline"></span>
 379                     </div>
 380                 </div>-->
 381                 <div class="col-sm-auto px-3 form-group plist-group" id="mothersnameInputContainer">
 382                     <label class="plist-label" for="mothersname"><?php echo xlt('Mothers Name')?></label>
 383                     <div class="controls inline-inputs">
 384                         <input type="text" class="form-control" id="mothersname" placeholder="<?php echo xla('Mothers Name'); ?>" value="<%= _.escape(item.get('mothersname') || '') %>">
 385                         <span class="help-inline"></span>
 386                     </div>
 387                 </div>
 388                 <div class="col-sm-auto px-3 form-group plist-group dynhide" id="guardiansnameInputContainer">
 389                     <label class="plist-label" for="guardiansname"><?php echo xlt('Guardians Name')?></label>
 390                     <div class="controls inline-inputs">
 391                         <input type="text" class="form-control" id="guardiansname" placeholder="<?php echo xla('Guardians Name'); ?>" value="<%= _.escape(item.get('guardiansname') || '') %>">
 392                         <span class="help-inline"></span>
 393                     </div>
 394                 </div>
 395                 <div class="col-sm-auto px-3 form-group plist-group" id="hipaaMailInputContainer">
 396                     <label class="plist-label" for="hipaaMail"><?php echo xlt('Allow Postal Mail')?></label>
 397                     <div class="controls inline-inputs">
 398                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaMail0" name="hipaaMail" type="radio" value="NO"<% if (item.get('hipaaMail')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 399                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaMail1" name="hipaaMail" type="radio" value="YES"<% if (item.get('hipaaMail')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 400                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaMail2" name="hipaaMail" type="radio" value=""<% if (item.get('hipaaMail')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 401                         <span class="help-inline"></span>
 402                     </div>
 403                 </div>
 404                 <div class="col-sm-auto px-3 form-group plist-group" id="hipaaVoiceInputContainer">
 405                     <label class="plist-label" for="hipaaVoice"><?php echo xlt('Allow Voice Call')?></label>
 406                     <div class="controls inline-inputs">
 407                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaVoice0" name="hipaaVoice" type="radio" value="NO"<% if (item.get('hipaaVoice')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 408                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaVoice1" name="hipaaVoice" type="radio" value="YES"<% if (item.get('hipaaVoice')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 409                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaVoice2" name="hipaaVoice" type="radio" value=""<% if (item.get('hipaaVoice')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 410                         <span class="help-inline"></span>
 411                     </div>
 412                 </div>
 413                 <div class="col-sm-auto px-3 form-group plist-group" id="hipaaNoticeInputContainer">
 414                     <label class="plist-label" for="hipaaNotice"><?php echo xlt('Allow Notice')?></label>
 415                     <div class="controls inline-inputs">
 416                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaNotice0" name="hipaaNotice" type="radio" value="NO"<% if (item.get('hipaaNotice')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 417                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaNotice1" name="hipaaNotice" type="radio" value="YES"<% if (item.get('hipaaNotice')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 418                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaNotice2" name="hipaaNotice" type="radio" value=""<% if (item.get('hipaaNotice')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 419                         <span class="help-inline"></span>
 420                     </div>
 421                 </div>
 422                 <div class="col-sm-auto px-3 form-group plist-group dynhide" id="hipaaMessageInputContainer">
 423                     <label class="plist-label" for="hipaaMessage"><?php echo xlt('Hipaa Message')?></label>
 424                     <div class="controls inline-inputs">
 425                         <input type="text" class="form-control" id="hipaaMessage" placeholder="<?php echo xla('Hipaa Message'); ?>" value="<%= _.escape(item.get('hipaaMessage') || '') %>">
 426                         <span class="help-inline"></span>
 427                     </div>
 428                 </div>
 429                 <div class="col-sm-auto px-3 form-group plist-group" id="hipaaAllowsmsInputContainer">
 430                     <label class="plist-label" for="hipaaAllowsms"><?php echo xlt('Allow SMS')?></label>
 431                     <div class="controls inline-inputs">
 432                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowsms0" name="hipaaAllowsms" type="radio" value="NO"<% if (item.get('hipaaAllowsms')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 433                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowsms1" name="hipaaAllowsms" type="radio" value="YES"<% if (item.get('hipaaAllowsms')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 434                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowsms2" name="hipaaAllowsms" type="radio" value=""<% if (item.get('hipaaAllowsms')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 435                         <span class="help-inline"></span>
 436                     </div>
 437                 </div>
 438                 <div class="col-sm-auto px-3 form-group plist-group" id="hipaaAllowemailInputContainer">
 439                     <label class="plist-label" for="hipaaAllowemail"><?php echo xlt('Allow Email')?></label>
 440                     <div class="controls inline-inputs">
 441                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowemail0" name="hipaaAllowemail" type="radio" value="NO"<% if (item.get('hipaaAllowemail')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 442                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowemail1" name="hipaaAllowemail" type="radio" value="YES"<% if (item.get('hipaaAllowemail')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 443                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="hipaaAllowemail2" name="hipaaAllowemail" type="radio" value=""<% if (item.get('hipaaAllowemail')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 444                         <span class="help-inline"></span>
 445                     </div>
 446                 </div>
 447                 <div class="col-sm-auto px-3 form-group plist-group" id="allowImmRegUseInputContainer">
 448                     <label class="plist-label" for="allowImmRegUse"><?php echo xlt('Allow Immunization Registry Use')?></label>
 449                     <div class="controls inline-inputs">
 450                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmRegUse0" name="allowImmRegUse" type="radio" value="NO"<% if (item.get('allowImmRegUse')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 451                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmRegUse1" name="allowImmRegUse" type="radio" value="YES"<% if (item.get('allowImmRegUse')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 452                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmRegUse2" name="allowImmRegUse" type="radio" value=""<% if (item.get('allowImmRegUse')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 453                         <span class="help-inline"></span>
 454                     </div>
 455                 </div>
 456                 <div class="col-sm-auto px-3 form-group plist-group" id="allowImmInfoShareInputContainer">
 457                     <label class="plist-label" for="allowImmInfoShare"><?php echo xlt('Allow Immunization Info Share')?></label>
 458                     <div class="controls inline-inputs">
 459                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmInfoShare0" name="allowImmInfoShare" type="radio" value="NO"<% if (item.get('allowImmInfoShare')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 460                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmInfoShare1" name="allowImmInfoShare" type="radio" value="YES"<% if (item.get('allowImmInfoShare')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 461                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowImmInfoShare2" name="allowImmInfoShare" type="radio" value=""<% if (item.get('allowImmInfoShare')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 462                         <span class="help-inline"></span>
 463                     </div>
 464                 </div>
 465                 <div class="col-sm-auto px-3 form-group plist-group" id="allowHealthInfoExInputContainer">
 466                     <label class="plist-label" for="allowHealthInfoEx"><?php echo xlt('Allow Health Info Exchange')?></label>
 467                     <div class="controls inline-inputs">
 468                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowHealthInfoEx0" name="allowHealthInfoEx" type="radio" value="NO"<% if (item.get('allowHealthInfoEx')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 469                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowHealthInfoEx1" name="allowHealthInfoEx" type="radio" value="YES"<% if (item.get('allowHealthInfoEx')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 470                             <label class="btn btn-secondary btn-gradient btn-sm"><input id="allowHealthInfoEx2" name="allowHealthInfoEx" type="radio" value=""<% if (item.get('allowHealthInfoEx')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 471                         <span class="help-inline"></span>
 472                     </div>
 473                 </div>
 474                 <div class="col-sm-auto px-3 form-group plist-group" id="allowPatientPortalInputContainer">
 475                     <label class="plist-label" for="allowPatientPortal"><?php echo xlt('Allow Patient Portal')?></label>
 476                     <div class="controls inline-inputs">
 477                             <label class="btn btn-secondary btn-gradient btn-sm"><input disabled id="allowPatientPortal0" name="allowPatientPortal" type="radio" value="NO"<% if (item.get('allowPatientPortal')=="NO") { %> checked="checked"<% } %>><?php echo xlt('NO'); ?></label>
 478                             <label class="btn btn-secondary btn-gradient btn-sm"><input disabled id="allowPatientPortal1" name="allowPatientPortal" type="radio" value="YES"<% if (item.get('allowPatientPortal')=="YES") { %> checked="checked"<% } %>><?php echo xlt('YES'); ?></label>
 479                             <label class="btn btn-secondary btn-gradient btn-sm"><input disabled id="allowPatientPortal2" name="allowPatientPortal" type="radio" value=""<% if (item.get('allowPatientPortal')=="") { %> checked="checked"<% } %>><?php echo xlt('Unassigned'); ?></label>
 480                         <span class="help-inline"></span>
 481                     </div>
 482                 </div>
 483                 <!--<div class="col-sm-auto px-3 form-group plist-group dynhide" id="careTeamInputContainer">
 484                     <label class="plist-label" for="careTeam"><?php /*echo xlt('Care Team')*/?></label>
 485                     <div class="controls inline-inputs">
 486                         <select disabled class="form-control" id="careTeam"
 487                             title="<?php /*echo xla('Care Team'); */?>" value="<?php /*echo $row['careTeam']; */?>">
 488                             <?php
 489 /*                            echo "<option value=''>" . xlt('Unassigned') . "</option>";
 490                             foreach ($this->users_list as $user) {
 491                                 $user_name = text($user['fname'] . ' ' . $user['lname']);
 492                                 $id = attr($user['id']);
 493                                 echo "<option value='$id'";
 494                                 if ((int)$id === (int)$row['careTeam']) {
 495                                     echo " selected";
 496                                 }
 497                                 echo ">$user_name</option>";
 498                             }
 499                             */?>
 500                         </select>
 501                         <span class="help-inline"></span>
 502                     </div>
 503                 </div>-->
 504                 <div class="col-sm-auto px-3 form-group plist-group dynhide" id="noteInputContainer">
 505                     <label class="plist-label" style="color:green" for="note"><?php echo xlt('Comments about change request')?></label>
 506                     <div class="controls inline-inputs">
 507                         <textarea class="form-control" id="note" rows="2" col="160" style='min-width:380px'><%= _.escape("To Admin: ") %></textarea>
 508                         <span class="help-inline"></span>
 509                     </div>
 510                 </div>
 511                 </div>
 512             </fieldset>
 513         </form>
 514 </script>
 515     <div id="collectionAlert"></div>
 516     <div id="modelAlert"></div>
 517     <div id="patientCollectionContainer" class="collectionContainer"></div>
 518     <div id="patientModelContainer" class="modelContainer"></div>
 519 </div> <!-- /container -->
 520 </body>
 521 </html>