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 <?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="<?php 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 <?php 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 ?>
  59
  60 <form action="<?php echo $rootdir;?>/forms/medical_decision/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  61
  62 <?php 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="<?php
  77
  78
  79           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  80
  81           ?>"></td>
  82
  83         <td width="20%" class="bordR">birth date
  84
  85           <br>
  86
  87           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
  88
  89
  90           echo $patient{'DOB'};
  91
  92           ?>" size="12"> </td>
  93
  94         <td width="20%" class="bordR">ID No<br>
  95
  96           <input name="md_pid" type="text" class="fullin" id="md_pid" size="12" value="<?php
  97
  98
  99           echo $patient{'id'};
 100
 101           ?>"></td>
 102
 103         <td width="20%">date<br>
 104
 105         <input name="md_date" type="text" class="fullin" id="md_date" value="<?php
 106
 107
 108         echo date('Y-m-d');
 109
 110         ?>" size="12"></td>
 111
 112       </tr>
 113
 114     </table>      </td>
 115
 116   </tr>
 117
 118   <tr>
 119
 120     <td align="center" valign="middle" class="fibody2"><h2>Amount and complexility of data reviewed </h2></td>
 121
 122   </tr>
 123
 124   <tr>
 125
 126     <td align="left" valign="top">&nbsp;</td>
 127
 128   </tr>
 129
 130 </table>
 131
 132 <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 133
 134   <tr align="left" valign="top">
 135
 136     <td width="29%" class="ficaption3">Tests ordered </td>
 137
 138     <td class="ficaption3">review of records </td>
 139
 140   </tr>
 141
 142   <tr align="left" valign="top">
 143
 144     <td class="fibody3"><p>
 145
 146       <input name="test_lab" type="checkbox" id="test_lab" value="1">
 147
 148       Laboratory</p>
 149
 150       <blockquote>
 151
 152         <p>
 153
 154           <input name="test_lab_cervical" type="checkbox" id="test_lab_cervical" value="1">
 155
 156           cervical cytology</p>
 157
 158         <p>
 159
 160           <input name="test_lab_hpv" type="checkbox" id="test_lab_hpv" value="1">
 161
 162           HPV test</p>
 163
 164         <p>
 165
 166           <input name="test_lab_wet_mount" type="checkbox" id="test_lab_wet_mount" value="1">
 167
 168           wet mount</p>
 169
 170         <p>
 171
 172           <input name="test_lab_chlamydia" type="checkbox" id="test_lab_chlamydia" value="checkbox">
 173
 174           chlamydia</p>
 175
 176         <p>
 177
 178           <input name="test_lab_gonorrhea" type="checkbox" id="test_lab_gonorrhea" value="1">
 179
 180           gonorrhea</p>
 181
 182         <p>
 183
 184           <input name="test_lab_other" type="checkbox" id="test_lab_other" value="1">
 185
 186           other <span class="ficaption2">
 187
 188           <input name="test_lab_other_data" type="text" class="fullin" id="test_lab_other_data" style="width:60px">
 189
 190           </span></p>
 191
 192         </blockquote>
 193
 194       <p>
 195
 196         <input name="test_rad" type="checkbox" id="test_rad" value="1">
 197
 198         Radiology / Ultrasound</p>
 199
 200       <blockquote>
 201
 202         <p>
 203
 204           <input name="test_rad_mammogram" type="checkbox" id="test_rad_mammogram" value="1">
 205
 206           mammogram</p>
 207
 208         <p>
 209
 210           <input name="test_rad_other" type="checkbox" id="test_rad_other" value="checkbox">
 211
 212           other <span class="ficaption2">
 213
 214           <input name="test_rad_other_data" type="text" class="fullin" id="test_rad_other_data" style="width:60px">
 215
 216           </span>  </p>
 217
 218       </blockquote></td>
 219
 220     <td class="fibody3"><p>
 221
 222       <input name="previous_test_results" type="checkbox" id="previous_test_results" value="1">
 223
 224       previous test results:</p>
 225
 226       <p>
 227
 228         <input name="previous_test_results_data" type="text" class="fullin2" id="previous_test_results_data">
 229
 230       </p>      <p>
 231
 232         <input name="test_results_discussion" type="checkbox" id="test_results_discussion" value="1">
 233
 234         discussion of test results with performing physician:</p>
 235
 236       <p>
 237
 238         <input name="test_results_discussion_data" type="text" class="fullin2" id="test_results_discussion_data">
 239
 240       </p>      <p>
 241
 242         <input name="old_records_reviewed" type="checkbox" id="old_records_reviewed" value="1">
 243
 244         old records reviewed and summarized:</p>
 245
 246       <p>
 247
 248         <input name="old_records_reviewed_data" type="text" class="fullin2" id="old_records_reviewed_data">
 249
 250       </p>      <p>
 251
 252         <input name="history_other_source" type="checkbox" id="history_other_source" value="1">
 253
 254         history obtained from other source:</p>
 255
 256       <p>
 257
 258         <input name="history_other_source_data" type="text" class="fullin2" id="history_other_source_data">
 259
 260       </p>      <p>
 261
 262         <input name="independent_review" type="checkbox" id="independent_review" value="1">
 263
 264         independent review of image/specimen:</p>
 265
 266       <p>
 267
 268         <input name="independent_review_data" type="text" class="fullin2" id="independent_review_data">
 269
 270       </p></td>
 271
 272   </tr>
 273
 274 </table>
 275
 276 </div>
 277
 278   <p align="center">&nbsp;</p>
 279
 280   <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>
 281
 282   <div style="border: solid 2px black; background-color: white;">
 283
 284     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 285
 286       <tr>
 287
 288         <td colspan="2" align="left" valign="top" class="fibody2">          <input name="established_problem" type="radio" value="1">
 289
 290           Established problem&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 291
 292           <input name="established_problem" type="radio" value="0">
 293
 294         New problem </td>
 295
 296       </tr>
 297
 298       <tr>
 299
 300         <td colspan="2" align="left" valign="top" class="ficaption2">Assessment and plan:</td>
 301
 302       </tr>
 303
 304       <tr>
 305
 306         <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>
 307
 308       </tr>
 309
 310       <tr>
 311
 312         <td colspan="2" align="left" valign="top" class="fibody2"><p>Risk of complications and/or morbidity/mortality:</p>
 313
 314           <blockquote>
 315
 316             <p>
 317
 318             <input name="md_risk" type="radio" value="minimal">
 319
 320             Minimal (EG, cold, aches and pains, over-the-counter medications)</p>
 321
 322             <p>
 323
 324             <input name="md_risk" type="radio" value="low">
 325
 326             low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors) </p>
 327
 328             <p>
 329
 330               <input name="md_risk" type="radio" value="moderate">
 331
 332             moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)</p>
 333
 334             <p>
 335
 336               <input name="md_risk" type="radio" value="high">
 337
 338             high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)  </p>
 339
 340         </blockquote></td>
 341
 342       </tr>
 343
 344       <tr>
 345
 346         <td colspan="2" align="left" valign="top" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 347
 348           <tr>
 349
 350             <td width="20%" rowspan="3" align="left" valign="top" class="ficaption3">Patient counseled about:</td>
 351
 352             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_smoking" type="checkbox" id="pc_smoking" value="1">
 353
 354               smoking cessation </td>
 355
 356             <td width="15%" align="left" valign="baseline" nowrap class="fibody3"><input name="pc_contraception" type="checkbox" id="pc_contraception" value="1">
 357
 358               contraception</td>
 359
 360             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 361
 362             <td width="15%" align="left" valign="bottom" nowrap>&nbsp;</td>
 363
 364           </tr>
 365
 366           <tr>
 367
 368             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_weight" type="checkbox" id="pc_weight" value="1">
 369
 370               weight management </td>
 371
 372             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_safe_sex" type="checkbox" id="pc_safe_sex" value="1">
 373
 374               safe sex </td>
 375
 376             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 377
 378             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 379
 380           </tr>
 381
 382           <tr>
 383
 384             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_exercise" type="checkbox" id="pc_exercise" value="1">
 385
 386               exercise</td>
 387
 388             <td align="left" valign="baseline" nowrap class="fibody3"><input name="pc_other" type="checkbox" id="pc_other" value="1">
 389
 390               other</td>
 391
 392             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 393
 394             <td align="left" valign="bottom" nowrap>&nbsp;</td>
 395
 396           </tr>
 397
 398         </table></td>
 399
 400       </tr>
 401
 402       <tr>
 403
 404         <td width="50%" align="left" valign="top" class="ficaption2" id="bordR"><input name="patient_education" type="checkbox" id="patient_education" value="1">
 405
 406         Patient education materials provided</td>
 407
 408         <td width="50%" align="left" valign="top" class="fibody2">&nbsp;</td>
 409
 410       </tr>
 411
 412       <tr>
 413
 414         <td align="left" valign="top" class="fibody2" id="bordR">&nbsp;</td>
 415
 416         <td align="left" valign="top" class="fibody2">&nbsp;</td>
 417
 418       </tr>
 419
 420       <tr>
 421
 422         <td align="left" valign="top" class="ficaption2" id="bordR">Minutes counseled:
 423
 424         <input name="minutes_counseled" type="text" class="fullin" id="minutes_counseled" style="width:60px"></td>
 425
 426         <td align="left" valign="top" class="ficaption2">Total encounter time:
 427
 428         <input name="total_encounter_time" type="text" class="fullin" id="total_encounter_time" style="width:60px"></td>
 429
 430       </tr>
 431
 432       <tr valign="bottom">
 433
 434         <td height="50" align="left" class="ficaption2" id="bordR">Signature:</td>
 435
 436         <td align="left" class="ficaption2">Date:
 437
 438         <input name="md_date" type="text" class="fullin" id="md_date" style="width:80px" value="<?php
 439
 440
 441         echo date('Y-m-d');
 442
 443         ?>"></td>
 444
 445       </tr>
 446
 447     </table>
 448
 449   </div>
 450
 451   <table width="100%" border="0">
 452
 453     <tr>
 454
 455       <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 456
 457       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 458
 459        onclick="top.restoreSession()">[Don't Save]</a> </td>
 460
 461     </tr>
 462
 463   </table>
 464
 465 </form>
 466
 467 <?php
 468
 469 formFooter();
 470
 471 ?>
 472
 473 </body>
 474
 475 </html>