contrib/forms/medical_decision/new.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 <html>
  11 <head>
  12 <title>Medical decision making</title>
  13 <meta http-equiv="Content-Type" content="text/html; charset=windows-1251">
  14 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  15 <link rel=stylesheet href="../../acog.css" type="text/css">
  16 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  17 <script language="JavaScript" type="text/JavaScript">
  18 window.onload = initialize;
  19 </script>
  20 </head>
  21 <body <?echo $top_bg_line;?>>
  22
  23 <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>
  24 <?
  25    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  26    if ($fres){
  27      $patient = sqlFetchArray($fres);
  28    }
  29 ?>
  30 <form action="<?echo $rootdir;?>/forms/medical_decision/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  31 <? include("../../acog_menu.inc"); ?>
  32 <div style="border: solid 2px black; background-color: white;">
  33 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  34   <tr>
  35     <td align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  36       <tr align="left" valign="bottom" class="fibody">
  37         <td width="40%" class="bordR">Patient name <br>
  38           <input name="pname" type="text" class="fullin" id="pname" value="<?
  39           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  40           ?>"></td>
  41         <td width="20%" class="bordR">birth date
  42           <br>
  43           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
  44           echo $patient{'DOB'};
  45           ?>" size="12"> </td>
  46         <td width="20%" class="bordR">ID No<br>
  47           <input name="md_pid" type="text" class="fullin" id="md_pid" size="12" value="<?
  48           echo $patient{'id'};
  49           ?>"></td>
  50         <td width="20%">date<br>
  51         <input name="md_date" type="text" class="fullin" id="md_date" value="<?
  52         echo date('Y-m-d');
  53         ?>" size="12"></td>
  54       </tr>
  55     </table>      </td>
  56   </tr>
  57   <tr>
  58     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
  59   </tr>
  60   <tr>
  61     <td align="left" valign="top">&nbsp;</td>
  62   </tr>
  63 </table>
  64 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  65   <tr align="left" valign="top">
  66     <td width="29%" class="ficaption3">Tests ordered </td>
  67     <td class="ficaption3">review of records </td>
  68   </tr>
  69   <tr align="left" valign="top">
  70     <td class="fibody3"><p>
  71       <input name="test_lab" type="checkbox" id="test_lab" value="1">
  72       Laboratory</p>
  73       <blockquote>
  74         <p>
  75           <input name="test_lab_cervical" type="checkbox" id="test_lab_cervical" value="1">
  76           cervical cytology</p>
  77         <p>
  78           <input name="test_lab_hpv" type="checkbox" id="test_lab_hpv" value="1">
  79           HPV test</p>
  80         <p>
  81           <input name="test_lab_wet_mount" type="checkbox" id="test_lab_wet_mount" value="1">
  82           wet mount</p>
  83         <p>
  84           <input name="test_lab_chlamydia" type="checkbox" id="test_lab_chlamydia" value="checkbox">
  85           chlamydia</p>
  86         <p>
  87           <input name="test_lab_gonorrhea" type="checkbox" id="test_lab_gonorrhea" value="1">
  88           gonorrhea</p>
  89         <p>
  90           <input name="test_lab_other" type="checkbox" id="test_lab_other" value="1">
  91           other <span class="ficaption2">
  92           <input name="test_lab_other_data" type="text" class="fullin" id="test_lab_other_data" style="width:60px">
  93           </span></p>
  94         </blockquote>
  95       <p>
  96         <input name="test_rad" type="checkbox" id="test_rad" value="1">
  97         Radiology / Ultrasound</p>
  98       <blockquote>
  99         <p>
 100           <input name="test_rad_mammogram" type="checkbox" id="test_rad_mammogram" value="1">
 101           mammogram</p>
 102         <p>
 103           <input name="test_rad_other" type="checkbox" id="test_rad_other" value="checkbox">
 104           other <span class="ficaption2">
 105           <input name="test_rad_other_data" type="text" class="fullin" id="test_rad_other_data" style="width:60px">
 106           </span>  </p>
 107       </blockquote></td>
 108     <td class="fibody3"><p>
 109       <input name="previous_test_results" type="checkbox" id="previous_test_results" value="1">
 110       previous test results:</p>
 111       <p>
 112         <input name="previous_test_results_data" type="text" class="fullin2" id="previous_test_results_data">
 113       </p>      <p>
 114         <input name="test_results_discussion" type="checkbox" id="test_results_discussion" value="1">
 115         discussion of test results with performing physician:</p>
 116       <p>
 117         <input name="test_results_discussion_data" type="text" class="fullin2" id="test_results_discussion_data">
 118       </p>      <p>
 119         <input name="old_records_reviewed" type="checkbox" id="old_records_reviewed" value="1">
 120         old records reviewed and summarized:</p>
 121       <p>
 122         <input name="old_records_reviewed_data" type="text" class="fullin2" id="old_records_reviewed_data">
 123       </p>      <p>
 124         <input name="history_other_source" type="checkbox" id="history_other_source" value="1">
 125         history obtained from other source:</p>
 126       <p>
 127         <input name="history_other_source_data" type="text" class="fullin2" id="history_other_source_data">
 128       </p>      <p>
 129         <input name="independent_review" type="checkbox" id="independent_review" value="1">
 130         independent review of image/specimen:</p>
 131       <p>
 132         <input name="independent_review_data" type="text" class="fullin2" id="independent_review_data">
 133       </p></td>
 134   </tr>
 135 </table>
 136 </div>
 137   <p align="center">&nbsp;</p>
 138   <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>
 139   <div style="border: solid 2px black; background-color: white;">
 140     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 141       <tr>
 142         <td colspan="2" align="left" valign="top" class="fibody2">          <input name="established_problem" type="radio" value="1">
 143           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 144           <input name="established_problem" type="radio" value="0">
 145         New problem </td>
 146       </tr>
 147       <tr>
 148         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 149       </tr>
 150       <tr>
 151         <td colspan="2" align="left" valign="top" class="fibody2"><textarea name="assessment_and_plan" rows="7" wrap="PHYSICAL" class="fullin2" id="assessment_and_plan"></textarea></td>
 152       </tr>
 153       <tr>
 154         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 155           <blockquote>
 156             <p>
 157             <input name="md_risk" type="radio" value="minimal">
 158             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 159             <p>
 160             <input name="md_risk" type="radio" value="low">
 161             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 162             <p>
 163               <input name="md_risk" type="radio" value="moderate">
 164             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 165             <p>
 166               <input name="md_risk" type="radio" value="high">
 167             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 168         </blockquote></td>
 169       </tr>
 170       <tr>
 171         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 172           <tr>
 173             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 174             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_smoking" type="checkbox" id="pc_smoking" value="1">
 175               smoking cessation </td>
 176             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_contraception" type="checkbox" id="pc_contraception" value="1">
 177               contraception</td>
 178             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 179             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 180           </tr>
 181           <tr>
 182             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_weight" type="checkbox" id="pc_weight" value="1">
 183               weight management </td>
 184             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_safe_sex" type="checkbox" id="pc_safe_sex" value="1">
 185               safe sex </td>
 186             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 187             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 188           </tr>
 189           <tr>
 190             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_exercise" type="checkbox" id="pc_exercise" value="1">
 191               exercise</td>
 192             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_other" type="checkbox" id="pc_other" value="1">
 193               other</td>
 194             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 195             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 196           </tr>
 197         </table></td>
 198       </tr>
 199       <tr>
 200         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><input name="patient_education" type="checkbox" id="patient_education" value="1">
 201         Patient education materials provided</td>
 202         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 203       </tr>
 204       <tr>
 205         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 206         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 207       </tr>
 208       <tr>
 209         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 210         <input name="minutes_counseled" type="text" class="fullin" id="minutes_counseled" style="width:60px"></td>
 211         <td align="left" valign="top" class="ficaption2">Total encounter time:
 212         <input name="total_encounter_time" type="text" class="fullin" id="total_encounter_time" style="width:60px"></td>
 213       </tr>
 214       <tr valign="bottom">
 215         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 216         <td align="left" class="ficaption2">Date:
 217         <input name="md_date" type="text" class="fullin" id="md_date" style="width:80px" value="<?
 218         echo date('Y-m-d');
 219         ?>"></td>
 220       </tr>
 221     </table>
 222   </div>
 223   <table width="100%" border="0">
 224     <tr>
 225       <td align="left"> <a href="javascript:document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 226       <td align="right"> <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link_submit">[Don't Save]</a> </td>
 227     </tr>
 228   </table>
 229 </form>
 230 <?php
 231 formFooter();
 232 ?>
 233 </body>
 234 </html>