form_status >=5){ ?>
Completion Percentage (
0
%)
0%
form_status >=5){ if(!isset($_SESSION['editRef_stat'])){ $tab1 = 'active'; $tab2 = ''; $tab3 = ''; $tab4 = ''; $tab5 = ''; $tabPane1 = 'active in show'; $tabPane2 = ''; $tabPane3 = ''; $tabPane5 = ''; $tabPane6 = ''; } if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step1'){ $tab1 = ''; $tab2 = 'active'; $tab3 = ''; $tab4 = ''; $tab5 = ''; $tabPane1 = ''; $tabPane2 = 'active in show'; $tabPane3 = ''; $tabPane5 = ''; $tabPane6 = ''; } if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step2'){ $tab1 = ''; $tab2 = ''; $tab3 = 'active'; $tab4 = ''; $tab5 = ''; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = 'active in show'; $tabPane4 = ''; $tabPane5 = ''; } if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step'){ $tab1 = ''; $tab2 = ''; $tab3 = ''; $tab4 = 'active'; $tab5 = ''; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = ''; $tabPane4 = 'active in show'; $tabPane5 = ''; } if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step4'){ $tab1 = ''; $tab2 = ''; $tab3 = ''; $tab4 = ''; $tab5 = 'active'; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = ''; $tabPane4 = ''; $tabPane5 = 'active in show'; } } else{ if(!isset($pdata->form_status)){ $tab1 = 'active'; $tab2 = 'disabled'; $tab3 = 'disabled'; $tab4 = 'disabled'; $tab5 = 'disabled'; $tabPane1 = 'active in show'; $tabPane2 = ''; $tabPane3 = ''; $tabPane4 = ''; $tabPane5 = ''; } if(isset($pdata->form_status) && $pdata->form_status=='1'){ $tab1 = ''; $tab2 = 'active'; $tab3 = ''; $tab4 = ''; $tab5 = ''; $tabPane1 = ''; $tabPane2 = 'active in show'; $tabPane3 = ''; $tabPane4 = ''; $tabPane5 = ''; } if(isset($pdata->form_status) && $pdata->form_status=='2'){ $tab1 = ''; $tab2 = ''; $tab3 = 'active'; $tab4 = ''; $tab5 = ''; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = 'active in show'; $tabPane4 = ''; $tabPane5 = ''; } if(isset($pdata->form_status) && $pdata->form_status=='3'){ $tab1 = ''; $tab2 = ''; $tab3 = ''; $tab4 = 'active'; $tab5 = ''; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = ''; $tabPane4 = 'active in show'; $tabPane5 = ''; } if(isset($pdata->form_status) && $pdata->form_status=='4'){ $tab1 = ''; $tab2 = ''; $tab3 = ''; $tab4 = ''; $tab5 = 'active'; $tabPane1 = ''; $tabPane2 = ''; $tabPane3 = ''; $tabPane4 = ''; $tabPane5 = 'active in show'; } } ?>
1
General Information
2
Service Needed
3
Payer Information
4
form_status>="5" && $pdata->patient_auth_stat == '0'){ ?>
Patient authorization
5
Clinical Info
*
New Patient
Reffered by Patient
Reffered by Vendor
*
Choose...
reference_id == $value->id)?'selected':'' ; ?> value="id; ?>">first_name." ".$value->last_name; ?>
*
Choose...
reference_id == $value->id)?'selected':'' ; ?> value="id; ?>">vedor_name; ?>
Choose...
referral_contact == 'Address')?'selected':'' ; ?> value="Address">Address
referral_contact == 'Email')?'selected':'' ; ?> value="Email">Email
referral_contact == 'Fax')?'selected':'' ; ?> value="Fax">Fax
referral_contact == 'Phone')?'selected':'' ; ?> value="Phone">Phone
Choose...
referral_type == 'New')?'selected':'' ; ?> value="New">New
referral_type == 'Restart')?'selected':'' ; ?> value="Restart">Restart
gender == 'Male')?'checked':'' ; ?> required>
Male
gender == 'Female')?'checked':'' ; ?> required>
Female
gender == 'Others')?'checked':'' ; ?> required>
Others
Choose...
primary_language == $value->id)?'selected':'' ; ?> value="id; ?>" attr_name="name; ?>">name; ?>
Designate Information
Choose...
level_of_care == '1')?'selected':'' ; ?> value="1">1 High
level_of_care == '2')?'selected':'' ; ?> value="2">2
level_of_care == '3')?'selected':'' ; ?> value="3">3
level_of_care == '4')?'selected':'' ; ?> value="4">4
level_of_care == '5')?'selected':'' ; ?> value="5">5 Low
*
Choose...
level_service == $value->id)?'selected':'' ; ?> value="id; ?>" attr_name="name; ?>">name; ?>
Payer Type
Choose...
payerType == $value->id)?'selected':'' ; ?> value="id; ?>">name; ?>
Credit or Debit Card
EFT
Monthly Invoice
Insurance Information
Insurance Information
Refer to Vendor Document
Choose...
insurance_type == 'Madicaid')?'selected':'' ; ?>>Madicaid(MCOs)
insurance_type == 'Private')?'selected':'' ; ?>>Private(PPOs)
Choose...
insurance_plan == 'A')?'selected':'' ; ?>>company A
insurance_plan == 'B')?'selected':'' ; ?>>company B
Medicaid information
Choose...
Primary
Secondary
Wage Priority
Private Insurance
Credit or Debit Card
EFT
Monthly Invoice
;
originalfilename?>
Delete
new_order == 'YES')?'checked':'' ; ?> type="radio" name="new_order" id="radio" value="YES" checked>
YES
new_order == 'NO')?'checked':'' ; ?> type="radio" name="new_order" id="radio" value="NO">
NO
service_activity); // var_dump($dbData); ?>
Choose...
id, $dbData))? 'selected' : '' ; ?> value="id; ?>">name; ?>
therapy_type); ?>
Choose...
id, $dbData))? 'selected' : '' ; ?> value="id; ?>">name; ?>
type_access); // var_dump($dbData); ?>
Choose...
id, $dbData))? 'selected' : '' ; ?> value="id; ?>">name; ?>
new_order == 'YES')?'checked':'' ; ?> name="current_lab_work" id="radio" value="YES">
YES
new_order == 'NO')?'checked':'' ; ?> name="current_lab_work" id="radio" value="NO">
NO
lab_frequency == 'Weekly')?'selected':'' ; ?> value="Weekly">Weekly
lab_frequency == 'Every 2 weeks')?'selected':'' ; ?> value="Every 2 weeks">Every 2 weeks
lab_frequency == 'Every other week')?'selected':'' ; ?> value="Every other week">Every other week
lab_frequency == 'Every 6 months')?'selected':'' ; ?> value="Every 6 months">Every 6 months
Choose...
tube_type == $value->name)?'selected':'' ; ?> value="name; ?>">name; ?>
Choose...
flush_with == $i)?'selected':'' ; ?> value=""> ML
flush_frequency == 'Before Feed')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox1" value="Before Feed">
Before Feed
flush_frequency == 'After Feed')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="After Feed">
After Feed
flush_frequency == 'Before Medication')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="Before Medication">
Before Medication
flush_frequency == 'After Madication')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="After Madication">
After Madication
fluid_restriction == 'YES')?'checked':'' ; ?>>
YES
fluid_restriction == 'NO')?'checked':'' ; ?>>
NO
fluide_restric_frequency == 'Per day')?'checked':'' ; ?>>
Per day
fluide_restric_frequency == 'Per Hour')?'checked':'' ; ?>>
Per Hour
trach_excoriation == 'YES')?'checked':'' ; ?>>
YES
trach_excoriation == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->trach_excoriation_notes?>
trach_drainage == 'YES')?'checked':'' ; ?> >
YES
trach_drainage == 'NO')?'checked':'' ; ?> >
NO
<?=$mddata->trach_drainage_notes?>
redness_trach_site == 'YES')?'checked':'' ; ?>>
YES
redness_trach_site == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->redness_trach_site_notes?>
trach_inner_cannula_changed == 'YES')?'checked':'' ; ?>>
YES
trach_inner_cannula_changed == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->redness_trach_site_notes?>
trach_suction == 'YES')?'checked':'' ; ?>>
YES
trach_suction == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->trach_suction_notes?>
trach_suction_type == 'Oral')?'selected':'' ; ?> value="Oral">Oral
trach_suction_type == 'Nasal')?'selected':'' ; ?> value="Nasal">Nasal
trach_suction_type == 'Tracheal')?'selected':'' ; ?> value="Tracheal">Tracheal
<?=$mddata->md_orders_comments?>
originalfilename?>
Delete
<?=$mddata->woundSiteLocation?>
<?=$mddata->WoundDescription?>
<?=$mddata->WoundMeasurement?>
(In Centimeter)
(In Centimeter)
(In Centimeter)
(In Centimeter)
MDOrdersWoundClockPosition == '12')?'selected':'' ; ?> value="12">12oh Clock
MDOrdersWoundClockPosition == '3')?'selected':'' ; ?> value="3">3oh Clock
MDOrdersWoundClockPosition == '6')?'selected':'' ; ?> value="6">6oh clock
MDOrdersWoundClockPosition == '9')?'selected':'' ; ?> value="9">9oh clock
WoundCleanseWith == 'Normal Saline')?'checked':'' ; ?>>
Normal Saline
WoundCleanseWith == '0.125% Dakins Solution')?'checked':'' ; ?>>
0.125% Dakins Solution
WoundApplications == 'Algisite-M')?'checked':'' ; ?>>
Algisite-M
WoundApplications == '4X4 Sterile Gauze')?'checked':'' ; ?>>
4X4 Sterile Gauze
WoundApplications == 'Santyl Ointment')?'checked':'' ; ?>>
Santyl Ointment
WoundCoveredWith == '4X4 Sterile Gauze')?'checked':'' ; ?>>
4X4 Sterile Gauze
WoundCoveredWith == 'ExuDry')?'checked':'' ; ?>>
ExuDry
WoundCoveredWith == 'Derlix')?'checked':'' ; ?>>
Derlix
WoundCoveredWith == 'Combine/ABDPad')?'checked':'' ; ?>>
Combine/ABDPad
WoundSecuredWith == 'Paper Tape')?'checked':'' ; ?>>
Paper Tape
WoundSecuredWith == 'ACE Bandage')?'checked':'' ; ?>>
ACE Bandage
WoundSecuredWith == 'Hypafix Tape')?'checked':'' ; ?>>
Hypafix Tape
WoundSecuredWith == 'Unchanged')?'checked':'' ; ?>>
Unchanged
WoundSecuredWith == 'Healing')?'checked':'' ; ?>>
Healing
WoundSecuredWith == 'Resolveds')?'checked':'' ; ?>>
Resolved
WoundSecuredWith == 'Deterioratings')?'checked':'' ; ?>>
Deteriorating
WoundGranulating == 'YES')?'checked':'' ; ?>>
YES
WoundGranulating == 'NO')?'checked':'' ; ?>>
NO
ExcroticTissuePresent == 'YES')?'checked':'' ; ?>>
YES
ExcroticTissuePresent == 'NO')?'checked':'' ; ?>>
NO
Choose...
WoundSlough == 'Tan')?'selected':'' ; ?> value="Tan">Tan
WoundSlough == 'Grey')?'selected':'' ; ?> value="Grey">Grey
WoundSlough == 'Green')?'selected':'' ; ?> value="Green">Green
WoundSlough == 'Yellow')?'selected':'' ; ?> value="Yellow">Yellow
WoundSlough == 'White')?'selected':'' ; ?> value="White">White
NecroticTissuePresent == 'NO')?'checked':'' ; ?>>
YES
NecroticTissuePresent == 'NO')?'checked':'' ; ?>>
NO
Choose...
NecroticTissueColor == 'Leathery')?'selected':'' ; ?> value="Leathery">Leathery
NecroticTissueColor == 'Black')?'selected':'' ; ?> value="Black">Black
NecroticTissueColor == 'Brown')?'selected':'' ; ?> value="Brown">Brown
NecroticTissueColor == 'Tan')?'selected':'' ; ?> value="Tan">Tan
WoundDrainage == 'YES')?'checked':'' ; ?>>
YES
WoundDrainage == 'NO')?'checked':'' ; ?>>
NO
WoundDrainageRate == 'Light')?'checked':'' ; ?>>
Light
WoundDrainageRate == 'Modarate')?'checked':'' ; ?>>
Modarate
WoundDrainageRate == 'Heavy')?'checked':'' ; ?>>
Heavy
WoundBedAppearance == 'Beefy')?'checked':'' ; ?>>
Beefy
WoundBedAppearance == 'Pink')?'checked':'' ; ?>>
Pink
WoundBedAppearance == 'Yellow')?'checked':'' ; ?>>
Yellow
WoundBedAppearance == 'Black')?'checked':'' ; ?>>
Black
<?=$mddata->woundTunnelingComment?>
woundTunnelling == 'Yes')?'checked':'' ; ?>>
Yes
woundTunnelling == 'No')?'checked':'' ; ?>>
No
WoundRednessAtSite == 'YES')?'checked':'' ; ?>>
YES
WoundRednessAtSite == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->WoundRednessAtSite?>
WoundOdor == 'YES')?'checked':'' ; ?>>
YES
WoundOdor == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->WoundOdorComments?>
WoundSwelling == 'YES')?'checked':'' ; ?>>
YES
WoundSwelling == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->WoundSwellingComments?>
WoundPain == 'YES')?'checked':'' ; ?>>
YES
WoundPain == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->WoundPainComments?>
PatientIndependentInWoundCare == 'YES')?'checked':'' ; ?>>
YES
PatientIndependentInWoundCare == 'NO')?'checked':'' ; ?>>
NO
PatientIsWillingToLearn == 'YES')?'checked':'' ; ?>>
YES
PatientIsWillingToLearn == 'NO')?'checked':'' ; ?>>
NO
CaregiverIsWillingToLearn == 'YES')?'checked':'' ; ?>>
YES
CaregiverIsWillingToLearn == 'NO')?'checked':'' ; ?>>
NO
<?=$mddata->CaregiverIsWillingToLearnComment?>
[]">
_remarks[]">
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