contrib/forms/medical_decision/new.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 ?>
  59
  60 <form action="<?echo $rootdir;?>/forms/medical_decision/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  61
  62 <? include("../../acog_menu.inc"); ?>
  63
  64 <div style="border: solid 2px black; background-color: white;">
  65
  66 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  67
  68   <tr>
  69
  70     <td align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  71
  72       <tr align="left" valign="bottom" class="fibody">
  73
  74         <td width="40%" class="bordR">Patient name <br>
  75
  76           <input name="pname" type="text" class="fullin" id="pname" value="<?
  77
  78           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  79
  80           ?>"></td>
  81
  82         <td width="20%" class="bordR">birth date
  83
  84           <br>
  85
  86           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
  87
  88           echo $patient{'DOB'};
  89
  90           ?>" size="12"> </td>
  91
  92         <td width="20%" class="bordR">ID No<br>
  93
  94           <input name="md_pid" type="text" class="fullin" id="md_pid" size="12" value="<?
  95
  96           echo $patient{'id'};
  97
  98           ?>"></td>
  99
 100         <td width="20%">date<br>
 101
 102         <input name="md_date" type="text" class="fullin" id="md_date" value="<?
 103
 104         echo date('Y-m-d');
 105
 106         ?>" size="12"></td>
 107
 108       </tr>
 109
 110     </table>      </td>
 111
 112   </tr>
 113
 114   <tr>
 115
 116     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
 117
 118   </tr>
 119
 120   <tr>
 121
 122     <td align="left" valign="top">&nbsp;</td>
 123
 124   </tr>
 125
 126 </table>
 127
 128 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 129
 130   <tr align="left" valign="top">
 131
 132     <td width="29%" class="ficaption3">Tests ordered </td>
 133
 134     <td class="ficaption3">review of records </td>
 135
 136   </tr>
 137
 138   <tr align="left" valign="top">
 139
 140     <td class="fibody3"><p>
 141
 142       <input name="test_lab" type="checkbox" id="test_lab" value="1">
 143
 144       Laboratory</p>
 145
 146       <blockquote>
 147
 148         <p>
 149
 150           <input name="test_lab_cervical" type="checkbox" id="test_lab_cervical" value="1">
 151
 152           cervical cytology</p>
 153
 154         <p>
 155
 156           <input name="test_lab_hpv" type="checkbox" id="test_lab_hpv" value="1">
 157
 158           HPV test</p>
 159
 160         <p>
 161
 162           <input name="test_lab_wet_mount" type="checkbox" id="test_lab_wet_mount" value="1">
 163
 164           wet mount</p>
 165
 166         <p>
 167
 168           <input name="test_lab_chlamydia" type="checkbox" id="test_lab_chlamydia" value="checkbox">
 169
 170           chlamydia</p>
 171
 172         <p>
 173
 174           <input name="test_lab_gonorrhea" type="checkbox" id="test_lab_gonorrhea" value="1">
 175
 176           gonorrhea</p>
 177
 178         <p>
 179
 180           <input name="test_lab_other" type="checkbox" id="test_lab_other" value="1">
 181
 182           other <span class="ficaption2">
 183
 184           <input name="test_lab_other_data" type="text" class="fullin" id="test_lab_other_data" style="width:60px">
 185
 186           </span></p>
 187
 188         </blockquote>
 189
 190       <p>
 191
 192         <input name="test_rad" type="checkbox" id="test_rad" value="1">
 193
 194         Radiology / Ultrasound</p>
 195
 196       <blockquote>
 197
 198         <p>
 199
 200           <input name="test_rad_mammogram" type="checkbox" id="test_rad_mammogram" value="1">
 201
 202           mammogram</p>
 203
 204         <p>
 205
 206           <input name="test_rad_other" type="checkbox" id="test_rad_other" value="checkbox">
 207
 208           other <span class="ficaption2">
 209
 210           <input name="test_rad_other_data" type="text" class="fullin" id="test_rad_other_data" style="width:60px">
 211
 212           </span>  </p>
 213
 214       </blockquote></td>
 215
 216     <td class="fibody3"><p>
 217
 218       <input name="previous_test_results" type="checkbox" id="previous_test_results" value="1">
 219
 220       previous test results:</p>
 221
 222       <p>
 223
 224         <input name="previous_test_results_data" type="text" class="fullin2" id="previous_test_results_data">
 225
 226       </p>      <p>
 227
 228         <input name="test_results_discussion" type="checkbox" id="test_results_discussion" value="1">
 229
 230         discussion of test results with performing physician:</p>
 231
 232       <p>
 233
 234         <input name="test_results_discussion_data" type="text" class="fullin2" id="test_results_discussion_data">
 235
 236       </p>      <p>
 237
 238         <input name="old_records_reviewed" type="checkbox" id="old_records_reviewed" value="1">
 239
 240         old records reviewed and summarized:</p>
 241
 242       <p>
 243
 244         <input name="old_records_reviewed_data" type="text" class="fullin2" id="old_records_reviewed_data">
 245
 246       </p>      <p>
 247
 248         <input name="history_other_source" type="checkbox" id="history_other_source" value="1">
 249
 250         history obtained from other source:</p>
 251
 252       <p>
 253
 254         <input name="history_other_source_data" type="text" class="fullin2" id="history_other_source_data">
 255
 256       </p>      <p>
 257
 258         <input name="independent_review" type="checkbox" id="independent_review" value="1">
 259
 260         independent review of image/specimen:</p>
 261
 262       <p>
 263
 264         <input name="independent_review_data" type="text" class="fullin2" id="independent_review_data">
 265
 266       </p></td>
 267
 268   </tr>
 269
 270 </table>
 271
 272 </div>
 273
 274   <p align="center">&nbsp;</p>
 275
 276   <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>
 277
 278   <div style="border: solid 2px black; background-color: white;">
 279
 280     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 281
 282       <tr>
 283
 284         <td colspan="2" align="left" valign="top" class="fibody2">          <input name="established_problem" type="radio" value="1">
 285
 286           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 287
 288           <input name="established_problem" type="radio" value="0">
 289
 290         New problem </td>
 291
 292       </tr>
 293
 294       <tr>
 295
 296         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 297
 298       </tr>
 299
 300       <tr>
 301
 302         <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>
 303
 304       </tr>
 305
 306       <tr>
 307
 308         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 309
 310           <blockquote>
 311
 312             <p>
 313
 314             <input name="md_risk" type="radio" value="minimal">
 315
 316             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 317
 318             <p>
 319
 320             <input name="md_risk" type="radio" value="low">
 321
 322             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 323
 324             <p>
 325
 326               <input name="md_risk" type="radio" value="moderate">
 327
 328             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 329
 330             <p>
 331
 332               <input name="md_risk" type="radio" value="high">
 333
 334             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 335
 336         </blockquote></td>
 337
 338       </tr>
 339
 340       <tr>
 341
 342         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 343
 344           <tr>
 345
 346             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 347
 348             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_smoking" type="checkbox" id="pc_smoking" value="1">
 349
 350               smoking cessation </td>
 351
 352             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_contraception" type="checkbox" id="pc_contraception" value="1">
 353
 354               contraception</td>
 355
 356             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 357
 358             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 359
 360           </tr>
 361
 362           <tr>
 363
 364             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_weight" type="checkbox" id="pc_weight" value="1">
 365
 366               weight management </td>
 367
 368             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_safe_sex" type="checkbox" id="pc_safe_sex" value="1">
 369
 370               safe sex </td>
 371
 372             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 373
 374             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 375
 376           </tr>
 377
 378           <tr>
 379
 380             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_exercise" type="checkbox" id="pc_exercise" value="1">
 381
 382               exercise</td>
 383
 384             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_other" type="checkbox" id="pc_other" value="1">
 385
 386               other</td>
 387
 388             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 389
 390             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 391
 392           </tr>
 393
 394         </table></td>
 395
 396       </tr>
 397
 398       <tr>
 399
 400         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><input name="patient_education" type="checkbox" id="patient_education" value="1">
 401
 402         Patient education materials provided</td>
 403
 404         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 405
 406       </tr>
 407
 408       <tr>
 409
 410         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 411
 412         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 413
 414       </tr>
 415
 416       <tr>
 417
 418         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 419
 420         <input name="minutes_counseled" type="text" class="fullin" id="minutes_counseled" style="width:60px"></td>
 421
 422         <td align="left" valign="top" class="ficaption2">Total encounter time:
 423
 424         <input name="total_encounter_time" type="text" class="fullin" id="total_encounter_time" style="width:60px"></td>
 425
 426       </tr>
 427
 428       <tr valign="bottom">
 429
 430         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 431
 432         <td align="left" class="ficaption2">Date:
 433
 434         <input name="md_date" type="text" class="fullin" id="md_date" style="width:80px" value="<?
 435
 436         echo date('Y-m-d');
 437
 438         ?>"></td>
 439
 440       </tr>
 441
 442     </table>
 443
 444   </div>
 445
 446   <table width="100%" border="0">
 447
 448     <tr>
 449
 450       <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 451
 452       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 453
 454        onclick="top.restoreSession()">[Don't Save]</a> </td>
 455
 456     </tr>
 457
 458   </table>
 459
 460 </form>
 461
 462 <?php
 463
 464 formFooter();
 465
 466 ?>
 467
 468 </body>
 469
 470 </html>