interface/forms/ankleinjury/new.php

   1 <!-- Form created by Nikolai Vitsyn: 2004/02/13  -->
   2
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 formHeader("Form: ankleinjury");
   7 ?>
   8
   9 <html><head>
  10 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  11 </head>
  12
  13 <body <?echo $top_bg_line;?>
  14 topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  15 <form method=post action="<?echo $rootdir;?>/forms/ankleinjury/save.php?mode=new" name="my_form">
  16 <span class="title"><?php xl('Ankle Evaluation Form','e'); ?></span><br></br>
  17
  18 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
  19 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  20 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" style="color: #483D8B"
  21  onclick="top.restoreSession()">[<?php xl('Don\'t Save','e'); ?>]</a>
  22 <br></br>
  23
  24 <span class="text" ><?php xl('Date of Injury','e'); ?>: </span><input type="entry" name="ankle_date_of_injuary" value=""></input>
  25 <tr>
  26 <td width="120" align="right"><?php xl('Work related?','e'); ?></td>
  27 <td><input type="checkbox" name="ankle_work_related"></input></td>
  28 </tr>
  29 <br><br>
  30
  31 <span class="text"><?php xl('Foot:','e');?> </span>
  32    <td><?php xl('Left','e');?><input type="radio" name='ankle_foot' value="<?php xl('Left','e');?>"></input></td>
  33    <td><?php xl('Right','e');?><input type="radio" name='ankle_foot' value="<?php xl('Right','e');?>"></input></td>
  34 <br><br>
  35
  36 <span class="text"><?php xl('Severity of Pain','e');?>:   </span>
  37    <td>1<input type="radio" name='ankle_severity_of_pain' value="1"></input></td>
  38    <td>2<input type="radio" name='ankle_severity_of_pain' value="2"></input></td>
  39    <td>3<input type="radio" name='ankle_severity_of_pain' value="3"></input></td>
  40 <br><br>
  41
  42 <td width="140"><?php xl('Significant Swelling:','e');?></td>
  43 <td align="right"></td>
  44 <td><input type="checkbox" name="ankle_significant_swelling"></input></td>
  45 <br><br>
  46
  47 <span class="text"><?php xl('Onset of Swelling:','e');?>   </span>
  48    <td><?php xl('within minutes','e');?><input type="radio" name='ankle_onset_of_swelling' value="<?php xl('within minutes','e');?>"></input></td>
  49    <td><?php xl('within hours','e');?><input type="radio" name='ankle_onset_of_swelling' value="<?php xl('within hours','e');?>"></input></td>
  50    <br><br>
  51
  52 <span class="text" ><?php xl('How did Injury Occur?','e');?>:</span><br>
  53 <textarea name="ankle_how_did_injury_occur" rows="4" cols="67" wrap="virtual name"></textarea>
  54 <br></br>
  55
  56 <table ><th colspan="5"><?php xl('Ottawa Ankle Rules','e'); ?></th>
  57 <tr>
  58 <td><?php xl('Bone Tenderness: Medial Malleolus','e'); ?><input type="radio" name='ankle_ottawa_bone_tenderness' value="Medial malleolus"></input></td>
  59 <td><?php xl('Lateral Malleolus','e'); ?><input type="radio" name='ankle_ottawa_bone_tenderness' value="Lateral malleolus"></input></td>
  60 <td><?php xl('Base of fifth (5th) Metarsal','e'); ?><input type="radio" name='ankle_ottawa_bone_tenderness' value="Base of fifth (5th) Metarsal"></input></td>
  61 <td><?php xl('At the Navicular','e'); ?><input type="radio" name='ankle_ottawa_bone_tenderness' value="At the Navicular"></input></td>
  62 </tr>
  63 </table>
  64 <br>
  65
  66 <span class="text"><?php xl('Able to Bear Weight four (4) steps:','e'); ?></span>
  67   <td><?php xl('Yes','e'); ?><input type="radio" name='ankle_able_to_bear_weight_steps' value="<?php xl('Yes','e'); ?>"></input></td>
  68   <td><?php xl('No','e'); ?><input type="radio" name='ankle_able_to_bear_weight_steps' value="<?php xl('No','e'); ?>"></input></td>
  69 <br>
  70
  71 <table>
  72 <tr><th><?php xl('X-RAY Interpretation:','e'); ?></th> <th><?php xl('Additional X-RAY Notes:','e'); ?></th></tr>
  73 <tr>
  74   <td>
  75    <select name="ankle_x_ray_interpretation" >
  76       <option value="Normal"><?php xl('Normal','e'); ?></option>
  77       <option value="Avulsion medial malleolus"><?php xl('Avulsion medial malleolus ','e'); ?></option>
  78       <option value="Avulsion lateral malleolus"><?php xl('Avulsion lateral malleolus','e'); ?></option>
  79       <option value="Fracture, Base of fifth (5th) Metatarsal"><?php xl('Fracture, Base of fifth (5th) Metatarsal','e'); ?></option>
  80       <option value="Trimalleolar"><?php xl('Trimalleolar','e'); ?></option>
  81       <option value="Fracture at the Navicula"><?php xl('Fracture at the Navicula','e'); ?></option>
  82       <option value="Fracture medial malleolus"><?php xl('Fracture medial malleolus','e'); ?></option>
  83       <option value="Fracture lateral malleolus"><?php xl('Fracture lateral malleolus','e'); ?></option>
  84       <option value="Other"><?php xl('Other','e'); ?></option>
  85       </select>
  86    </td>
  87
  88 <td rowspan=2>
  89 <textarea cols=35 rows=1 wrap=virtual name="ankle_additional_x_ray_notes" ></textarea>
  90
  91 </td>
  92
  93 </tr>
  94 </table>
  95  <script language="javascript">
  96  <!--
  97  function doCPT(select) {
  98         var numchecked = 0;
  99         for (i=0; i<document.my_form.openemr_net_cptcode.length; i++) {
 100                 if (document.my_form.openemr_net_cptcode[i].checked == true) {
 101                         numchecked++;
 102                 }
 103         }
 104         if (numchecked == 0) {
 105                 document.my_form.openemr_net_cptcode[1].checked = true;
 106         }
 107  }
 108  -->
 109  </script>
 110 <table>
 111 <tr>
 112 <th><?php xl('Diagnosis:','e');?></th><th><?php xl('Additional Diagnosis:','e');?></th>
 113 </tr>
 114 <tr>
 115 <td valign="top"><select name="ankle_diagnosis1" onChange="doCPT(this);">
 116       <option value=""><?php xl('None','e');?></option>
 117       <option value="845.00 ankle sprain NOS"><?php xl('845.00 ankle sprain NOS','e');?></option>
 118       <option value="845.01 Sprain Medial (Deltoid) Lig."><?php xl('845.01 Sprain Medial (Deltoid) Lig.','e');?></option>
 119       <option value="845.02 Sprain, Calcaneal fibular"><?php xl('845.02 Sprain, Calcaneal fibular','e');?></option>
 120       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal"><?php xl('825.35 Fracture, Base of fifth (5th) Metatarsal','e');?></option>
 121       <option value="825.32 Fracture, of Navicular (ankle)"><?php xl('825.32 Fracture, of Navicular (ankle)','e');?></option>
 122       <option value="824.2 Fracture, lateral malleolus, closed"><?php xl('824.2 Fracture, lateral malleolus, closed','e');?></option>
 123       <option value="824.0 Fracture, medial malleolus, closed"><?php xl('824.0 Fracture, medial malleolus, closed','e');?></option>
 124       <option value="824.6 Fracture, Trimalleolar, closed"><?php xl('824.6 Fracture, Trimalleolar, closed','e');?></option>
 125       <option value="Add ICD Code"><?php xl('Add ICD Code','e');?></option>
 126     </select>
 127
 128 </td>
 129 <td rowspan="4">
 130 <textarea cols=30 rows=2 wrap=virtual name="ankle_additional_diagnisis" ></textarea>
 131 <br><br>
 132 <table>
 133 <tr>
 134         <td width="10"></td>
 135         <td><?php xl('CPT Codes','e');?></td>
 136         <td></td>
 137 </tr>
 138 <tr>
 139         <td></td>
 140         <td colspan="2">
 141                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value=""><?php xl('none','e');?><br>
 142                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value="99212 Established - Uncomplicated"><?php xl('99212 Established - Uncomplicated','e');?><br>
 143                 &nbsp;&nbsp;&nbsp;<input type="radio" name="openemr_net_cptcode" value="99213 Established - Low Complexity"><?php xl('99213 Established - Low Complexity','e');?><br>
 144         </td>
 145 </tr>
 146 </table>
 147
 148 </td>
 149
 150 <tr>
 151 <td>
 152   <select name="ankle_diagnosis2" onChange="doCPT(this);">
 153       <option value=""><?php xl('None','e') ;?></option>
 154       <option value="845.00 ankle sprain NOS"><?php xl('845.00 ankle sprain NOS','e') ;?></option>
 155       <option value="845.01 Sprain Medial (Deltoid) Lig."><?php xl('845.01 Sprain Medial (Deltoid) Lig.','e') ;?></option>
 156       <option value="845.02 Sprain, Calcaneal fibular"><?php xl('845.02 Sprain, Calcaneal fibular','e') ;?></option>
 157       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal"><?php xl('825.35 Fracture, Base of fifth (5th) Metatarsal','e') ;?></option>
 158       <option value="825.32 Fracture, of Navicular (ankle)"><?php xl('825.32 Fracture, of Navicular (ankle)','e') ;?></option>
 159       <option value="824.2 Fracture, lateral malleolus, closed"><?php xl('824.2 Fracture, lateral malleolus, closed','e') ;?></option>
 160       <option value="824.0 Fracture, medial malleolus, closed"><?php xl('824.0 Fracture, medial malleolus, closed','e') ;?></option>
 161       <option value="824.6 Fracture, Trimalleolar, closed"><?php xl('824.6 Fracture, Trimalleolar, closed','e') ;?></option>
 162       <option value="Add ICD Code"><?php xl('Add ICD Code','e') ;?></option>
 163     </select>
 164    </td></tr>
 165 <td>
 166    <select name="ankle_diagnosis3" onChange="doCPT(this);">
 167       <option value=""><?php xl('None','e') ;?></option>
 168       <option value="845.00 ankle sprain NOS"><?php xl('845.00 ankle sprain NOS','e') ;?></option>
 169       <option value="845.01 Sprain Medial (Deltoid) Lig."><?php xl('845.01 Sprain Medial (Deltoid) Lig.','e') ;?></option>
 170       <option value="845.02 Sprain, Calcaneal fibular"><?php xl('845.02 Sprain, Calcaneal fibular','e') ;?></option>
 171       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal"><?php xl('825.35 Fracture, Base of fifth (5th) Metatarsal','e') ;?></option>
 172       <option value="825.32 Fracture, of Navicular (ankle)"><?php xl('825.32 Fracture, of Navicular (ankle)','e') ;?></option>
 173       <option value="824.2 Fracture, lateral malleolus, closed"><?php xl('824.2 Fracture, lateral malleolus, closed','e') ;?></option>
 174       <option value="824.0 Fracture, medial malleolus, closed"><?php xl('824.0 Fracture, medial malleolus, closed','e') ;?></option>
 175       <option value="824.6 Fracture, Trimalleolar, closed"><?php xl('824.6 Fracture, Trimalleolar, closed','e') ;?></option>
 176       <option value="Add ICD Code"><?php xl('Add ICD Code','e') ;?></option>
 177    </select>
 178    </td>
 179 </tr>
 180 <td>
 181    <select name="ankle_diagnosis4" onChange="doCPT(this);">
 182       <option value=""><?php xl('None','e') ;?></option>
 183       <option value="845.00 ankle sprain NOS"><?php xl('845.00 ankle sprain NOS','e') ;?></option>
 184       <option value="845.01 Sprain Medial (Deltoid) Lig."><?php xl('845.01 Sprain Medial (Deltoid) Lig.','e') ;?></option>
 185       <option value="845.02 Sprain, Calcaneal fibular"><?php xl('845.02 Sprain, Calcaneal fibular','e') ;?></option>
 186       <option value="825.35 Fracture, Base of fifth (5th) Metatarsal"><?php xl('825.35 Fracture, Base of fifth (5th) Metatarsal','e') ;?></option>
 187       <option value="825.32 Fracture, of Navicular (ankle)"><?php xl('825.32 Fracture, of Navicular (ankle)','e') ;?></option>
 188       <option value="824.2 Fracture, lateral malleolus, closed"><?php xl('824.2 Fracture, lateral malleolus, closed','e') ;?></option>
 189       <option value="824.0 Fracture, medial malleolus, closed"><?php xl('824.0 Fracture, medial malleolus, closed','e') ;?></option>
 190       <option value="824.6 Fracture, Trimalleolar, closed"><?php xl('824.6 Fracture, Trimalleolar, closed','e') ;?></option>
 191 <option value="Add ICD Code"><?php xl('Add ICD Code','e') ;?></option>
 192 </select>
 193 </td>
 194 </tr>
 195 </table>
 196
 197 <table><tr><th><?php xl('Plan:','e'); ?></th><tr>
 198 <tr><td>
 199 <textarea name="ankle_plan" rows="7" cols="67"
 200 wrap="virtual name"><?php xl('1.Rest
 201 2. Ice for two days
 202 3. Compression, leave the dressing in place unless the foot develops numbness or pale color
 203 4. Elevate the foot and leg','e');?>
 204 </textarea>
 205 </td>
 206 </tr>
 207 </table>
 208
 209 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 210 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" style="color: #483D8B"
 211  onclick="top.restoreSession()">[<?php xl('Don\'t Save','e');?>]</a>
 212 </form>
 213 <?php
 214 formFooter();
 215 ?>