2641 lines
149 KiB
PHP
Executable File
2641 lines
149 KiB
PHP
Executable File
<section id="main-content">
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<div class="content-body">
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<section id="main-content">
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<section class="wrapper site-min-height">
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<!-- page start-->
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<section class="row col-md-12">
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<div class="panel-body col-md-12">
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<div class="card">
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<div class="card-header">
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<h3 class="font-weight-bold"> <?php
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echo lang('Add Patient');
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?></h3>
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</div>
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<div class="card-content">
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<div class="card-body">
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<form role="form" action="initial_assessment/saveAssessment" method="post" enctype="multipart/form-data" name="newGenInfo" onsubmit="return validateForm1()">
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<hr class="my-4">
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<h3 class="font-weight-bold">Patient Visit Record</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Date'); ?></label>
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: <?php echo $data->date; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('day'); ?></label>
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: <?php echo $data->day; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Time in'); ?></label>
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: <?php echo $data->timeIn; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Time out'); ?></label>
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: <?php echo $data->timeOut; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Patients Name'); ?></label>
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: <?php echo $data->patientName; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Date of Birth'); ?></label>
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: <?php echo $data->dob; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Diagnosis'); ?></label>
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: <?php echo $data->diagnosis; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Allergy'); ?></label>
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: <?php echo $data->allergy; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('MD'); ?></label>
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: <?php echo $data->md_name; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Id Confirmed'); ?></label>
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: <?php echo $data->id_confirmed; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Reason'); ?></label>
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: <?php echo $data->Reason; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Type of therapy'); ?></label>
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: <?php echo $data->type_of_therapy; ?>
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</div>
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<div class="col-lg-4" id="typeAccValInp">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Visit activity'); ?></label>
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: <?php echo $data->visit_activity; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Types Of Device Access'); ?></label>
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: <?php echo $data->types_of_device_access; ?>
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</div>
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<div class="col-lg-4" id="deviceAccessTypeDiv">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Access Assessment'); ?></label>
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: <?php echo $data->accessAssessment; ?>
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</div>
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<div class="col-lg-4" id="accessAssessmentDiv">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Action'); ?></label>
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: <?php echo $data->action; ?>
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> <?php echo $data->action_value; ?>
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</div>
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<div class="col-lg-4" id="actionDiv">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" ><?php echo lang('Pump bettery charge'); ?></label>
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: <?php echo $data->pump_bettery_change; ?>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" ><?php echo lang('Pump Res Volume'); ?></label>
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: <?php echo $data->pump_res_volume; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Pump Rate'); ?></label>
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: <?php echo $data->pump_rate; ?>
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> <?php echo $data->pumpRateValue; ?>
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</div>
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<div class="col-lg-4" id="pumpRateDiv">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" ><?php echo lang('Bolus'); ?></label>
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: <?php echo $data->bolus; ?>
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</div>
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<div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('KVO'); ?></label>
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: <?php echo $data->KVO; ?>
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</div>
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<div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('Taper'); ?></label>
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: <?php echo $data->taper; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" ><?php echo lang('Program Verified With'); ?></label>
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: <?php echo $data->program_verified_with; ?>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">PHYSICAL ASSESSMENT</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('VITAL SIGNS'); ?></label>
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: <?php echo $data->vital_signs; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Vital Signs Measurements'); ?></label>
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: <?php echo $data->vital_signs_measurment; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('CARDIOVASCULAR'); ?></label>
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: <?php echo $data->cardiovascular; ?>
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</div>
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<div class="col-lg-4" id="CvacRhythm" style="display: none;">
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<label for="exampleInputEmail1" ><?php echo lang('Rhythm'); ?></label>
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: <?php echo $data->cardiovascular_rhythm; ?>
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</div>
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<!-- <div class="col-lg-4" id="cvacEdema" style="display: none;">
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<label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
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: <?php echo $data->cardiovascular_rhythm; ?>
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</div> -->
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
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: <?php echo $data->cardiovacularNotes; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('RESPIRATORY'); ?></label>
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: <?php echo $data->RESPIRATORY; ?>
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</div>
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<div class="col-lg-4" id="respBreathSound" style="display: none;">
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<label for="exampleInputEmail1" ><?php echo lang('Breath Sounds'); ?></label>
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: <?php echo $data->respiratory_value; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
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: <?php echo $data->respiratory_notes; ?>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">FOODS/FLUIDS</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Diet'); ?></label>
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: <?php echo $data->foods; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Fluid'); ?></label>
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: <?php echo $data->fluid; ?>
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</div>
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<div class="col-lg-3">
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</div>
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<div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('Fluid Intake'); ?></label>
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: <?php echo $data->fluid_intake; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Weight Amount'); ?></label>
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: <?php echo $data->weight; ?>
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</div>
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<!-- <div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
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: <?php echo $data->weight; ?>
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</div> -->
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<div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
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<div class="form-check">
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: <?php echo $data->fl_comments; ?>
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</div>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">ENDOCRINE</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
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<div class="col-lg-3">
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<label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label>
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<div class="form-check">
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: <?php echo $data->endoCrine; ?>
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</div>
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</div>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Diabetes'); ?></label>
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: <?php echo $data->diabetes; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
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<div class="form-check">
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: <?php echo $data->bs_comments; ?>
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</div>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">ACTIVITY/REST</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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: <?php echo $data->activity_rest; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Musculosketal'); ?></label>
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: <?php echo $data->musculosketal; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Activity'); ?></label>
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<div class="form-check">
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: <?php echo $data->mus_activity; ?>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
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<div class="form-check form-check-inline">
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<label class="form-check-label" for="inlineCheckbox2">Encouraged PROM exercises to extremeties</label>
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: <?php echo $data->encourage_p_rom_exa_extrimist; ?>
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</div>
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</div>
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<div class="col-lg-4">
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: <?php echo $data->ambulatory; ?>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Dependent'); ?></label>
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<div class="form-check form-check-inline">
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: <?php echo $data->dependent; ?>
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</div>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('wheelChair'); ?></label>
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: <?php echo $data->wheelChair; ?>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
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<div class="form-check">
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: <?php echo $data->arComment; ?>
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</div>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">PAIN</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-2">
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<!-- <label for="exampleInputEmail1" ><?php echo lang('ACTIVITY/REST'); ?></label> -->
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<div class="form-check form-check-inline">
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<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
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: <?php echo $data->pain; ?>
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</div>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1" ><?php echo lang('Pain level assessed'); ?></label>
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: <?php echo $data->pain_level_assessed; ?>
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</div>
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<div class="col-lg-2">
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<label for="exampleInputEmail1" ><?php echo lang('type'); ?></label>
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<div class="form-check">
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: <?php echo $data->pla_type; ?>
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</div>
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</div>
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<div class="col-lg-2">
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<label for="exampleInputEmail1" ><?php echo lang('Quality'); ?></label>
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<div class="form-check">
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: <?php echo $data->pla_quality; ?>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Relief From'); ?></label>
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<div class="form-check form-check-inline">
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: <?php echo $data->relief_from; ?>
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</div>
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</div>
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</div>
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</div>
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<hr class="my-4">
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<h3 class="font-weight-bold">SKIN</h3>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('skin'); ?></label>
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<div class="form-check form-check-inline">
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: <?php echo $data->skin; ?>
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</div>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Describe'); ?></label>
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<div class="form-check form-check-inline">
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: <?php echo $data->sk_describe; ?>
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</div>
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</div>
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Bruises Location'); ?></label>
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<div class="form-check form-check-inline">
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: <?php echo $data->bruises_location; ?>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-4">
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<label for="exampleInputEmail1" ><?php echo lang('Surgical Site'); ?></label>
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: <?php echo $data->surgikal_site; ?>
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</div>
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|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound'); ?></label>
|
|
: <?php echo $data->wound; ?>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
: <?php echo $data->woundcomment; ?>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">CIRCULATION</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Chest Pain'); ?></label>
|
|
: <?php echo $data->circulation; ?>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
|
|
: <?php echo $data->edema; ?>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Location'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
: <?php echo $data->edema_location; ?>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-2">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label> -->
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Peripheral Capillary Refill'); ?></label>
|
|
: <?php echo $data->peripheral_capilary_refil; ?>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Circulation Status'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
: <?php echo $data->circulation_status; ?>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
: <?php echo $data->circulationStat_comment; ?>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">VENTILATION</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="ventilationDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator Type'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="ventilatorType" id="">
|
|
<option value="vent 1">vent 1</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Breath Sounds'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="BreathSounds" id="">
|
|
<option value="Rales">Rales</option>
|
|
<option value="Diminished">Diminished</option>
|
|
<option value="Rhonchi">Rhonchi</option>
|
|
<option value="Wheezing">Wheezing</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('SOB'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
At Rest
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
On Exertion
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
Cough
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
Productive
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="ventilator_sob" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
Dry
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Color'); ?></label>
|
|
<select class="form-control" name="ventilatorColor" id="">
|
|
<option value="Red">Red</option>
|
|
<option value="grren">grren</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator Settings'); ?></label>
|
|
<input type="text" class='form-control' name='ventilatorSetting' id=''>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator Mode'); ?></label>
|
|
<select class="form-control" name="ventilatorMode" id="">
|
|
<option value="SIMV">SIMV</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator TV'); ?></label>
|
|
<textarea class='form-control' name='ventilatorTv' id=''></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator Pressure'); ?></label>
|
|
<select class="form-control" name="ventilatorPressure" id="">
|
|
<option value="High">High</option>
|
|
<option value="Low">Low</option>
|
|
</select>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator BR'); ?></label>
|
|
<input type="text" class="form-control" name="ventilatorBR" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Ventilator Oxygen Mesured In L/Min '); ?></label>
|
|
<input type="text" class='form-control' name='ventilatorOxygenMeasure' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Inspiratory Time'); ?></label>
|
|
<select class="form-control" name="ventilatorInspiratoryTime" id="">
|
|
<?php for ($i=1; $i < 60 ; $i++) { ?>
|
|
<option selected value="<?=$i?>"><?=$i?> Sec</option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Oximeter Frequency'); ?></label>
|
|
<textarea class="form-control" name="OximeterFrequency" id=""></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Oximeter Paramteres'); ?></label>
|
|
<textarea class='form-control' name='oximeterParameter' id=''></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Other'); ?></label>
|
|
<textarea class='form-control' name='ventilatorOtherNote' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class="form-control" name="ventilatorComments" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">TRACHEOTOMY CARE</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Tracheotomy Care Required'); ?></label>
|
|
<select class="form-control" name="TracheotomyCareRequired" id="">
|
|
<option value="High">High</option>
|
|
<option value="Low">Low</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">MD Orders</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MdOrderNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Excoriation'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachExcoriation" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachExcoriation" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MDTrachExcoriationNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Drainage'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachDrainage" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachDrainage" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MDTrachDrainageNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Redness At Trach Site'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MDredNessAtTrachSiteNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Inner Cannula Changed'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MDTrachInnerCannulaChangedMdOrderNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Connector Size'); ?></label>
|
|
<input type="text" class="form-control" name="MDtrachConnectorSize" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Connector Length'); ?></label>
|
|
<input type="text" class="form-control" name="MDtrachConnectorLength" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDtrachSuction" id="radio" value="option1" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDtrachSuctions" id="radio" value="option2">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MDTrachSuctionnotes" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction Type'); ?></label>
|
|
<select class="form-control" name="MDtrachSuctionType" id="">
|
|
<option value="Oral">Oral</option>
|
|
<option value="Nasal">Nasal</option>
|
|
<option value="Tracheal">Tracheal</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction Catheter Kit'); ?></label>
|
|
<input type="text" class="form-control" name="MDtrachSuctionCatherKit" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suciton Catheter Kit Size'); ?></label>
|
|
<input type="text" class="form-control" name="MDtrachCAthertarKitSize">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="CateterKitNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">GASTROINTESTINAL</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('GASTROINTESTINAL'); ?></label>
|
|
<select class="form-control" name="GASTROINTESTINAL" id="">
|
|
<option value="Bowel Sound Audible">Bowel Sound Audible</option>
|
|
<option value="Nausea">Nausea</option>
|
|
<option value="Vomiting">Vomiting</option>
|
|
<option value="Diarrhea">Diarrhea</option>
|
|
<option value="Anorexia">Anorexia</option>
|
|
<option value="Dysphagia">Dysphagia</option>
|
|
<option value="Thrust">Thrust</option>
|
|
<option value="Stomatits">Stomatits</option>
|
|
<option value="Constipation">Constipation</option>
|
|
<option value="Abd Soft/Nontender">Abd Soft/Nontender</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Date of Last Bowel Movement'); ?></label>
|
|
<input type="date" class="form-control" name="DateLastBowelMovement">
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class="form-control" name="DateLastBowelMovementComment"></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">GENITOURINARY</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('GENITOURINARY'); ?></label>
|
|
<select class="form-control" name="GENITOURINARY" id="">
|
|
<option value="Burning">Burning</option>
|
|
<option value="Hematuria">Hematuria</option>
|
|
<option value="Odor">Odor</option>
|
|
<option value="Urgency">Urgency</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Color'); ?></label>
|
|
<select class="form-control" name="GENITOURINARYColor" id="">
|
|
<option value="red">red</option>
|
|
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Cathertar'); ?></label>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Indwelling" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Indwelling
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Staight Catheter">
|
|
<label class="form-check-label" for="NO">
|
|
Staight Catheter
|
|
</label>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="GENITOURINARYNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">HYGINENE</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="HYGINENEnoDeficit" type="checkbox" id="inlineCheckbox3" value="After Feed">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('HYGINENE'); ?></label>
|
|
<select class="form-control" name="HYGINENE" id="">
|
|
<option value="Adequate">Adequate</option>
|
|
<option value="Inadequate">Inadequate</option>
|
|
<option value="Self Care">Self Care</option>
|
|
<option value="Needs Assistance">Needs Assistance</option>
|
|
</select>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">INTEGUMENTARY</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('INTEGUMENTARY'); ?></label>
|
|
<select class="form-control" name="INTEGUMENTARY" id="">
|
|
<option value="Color">Color</option>
|
|
<option value="Temperature">Temperature</option>
|
|
<option value="Turgor">Turgor</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Color Vairables'); ?></label>
|
|
<select class="form-control" name="INTEGUMENTARYColorVairables" id="">
|
|
<option value="Pink">Pink</option>
|
|
<option value="Pale">Pale</option>
|
|
<option value="Gray">Gray</option>
|
|
<option value="Jaundice">Jaundice</option>
|
|
<option value="Other Describe">Other Describe</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Temperature Variables'); ?></label>
|
|
<select class="form-control" name="INTEGUMENTARYTemperatureVariables" id="">
|
|
<option value="Warm">Warm</option>
|
|
<option value="Dry">Dry</option>
|
|
<option value="Cool">Cool</option>
|
|
<option value="Diaphoretic">Diaphoretic</option>
|
|
<option value="Other Describe">Other Describe</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Turgor Variables'); ?></label>
|
|
<select class="form-control" name="INTEGUMENTARYTurgorVariables" id="">
|
|
<option value="Good">Good</option>
|
|
<option value="Fair">Fair</option>
|
|
<option value="Poor">Poor</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="INTEGUMENTARYNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">NERUOLOGICAL</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-2">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="NERUOLOGICALnoDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Status'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Disoriented">
|
|
<label class="form-check-label" for="inlineCheckbox2">Disoriented</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Memory Intact">
|
|
<label class="form-check-label" for="inlineCheckbox2">Memory Intact</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Headache">
|
|
<label class="form-check-label" for="inlineCheckbox2">Headache</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Confused">
|
|
<label class="form-check-label" for="inlineCheckbox2">Confused</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="neuroStatus" type="checkbox" id="inlineCheckbox3" value="Forgetful">
|
|
<label class="form-check-label" for="inlineCheckbox2">Forgetful</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Activity'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Ad Lib">
|
|
<label class="form-check-label" for="inlineCheckbox2">Ad Lib</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Up with Assistance">
|
|
<label class="form-check-label" for="inlineCheckbox2">Up with Assistance</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Bedrest">
|
|
<label class="form-check-label" for="inlineCheckbox2">Bedrest</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="NERUOLOGICALactivity" type="checkbox" id="inlineCheckbox3" value="Equipment">
|
|
<label class="form-check-label" for="inlineCheckbox2">Equipment</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="NEUROLOGICALnotes" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">PSYCHOLOGICAL / EMOTIONAL REACTION</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-2">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ENDOCRINE'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="phycholEmotionalNodeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Social Support System'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Adequate">
|
|
<label class="form-check-label" for="inlineCheckbox2">Adequate</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Calm">
|
|
<label class="form-check-label" for="inlineCheckbox2">Calm</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Anxious">
|
|
<label class="form-check-label" for="inlineCheckbox2">Anxious</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="phycholEmotionalSocialSupportSystem" type="checkbox" id="inlineCheckbox3" value="Depressed">
|
|
<label class="form-check-label" for="inlineCheckbox2">Depressed</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Copes Effectively with Therapy'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="phyEmocopesEffWithTherapy" id="radio" value="YE" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="phyEmocopesEffWithTherapy" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Copes Effectively with Disease'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="phyEmocopesEffWithDieases" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="phyEmocopesEffWithDieases" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="NEUROLOGICALnotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">SKILLS - KNOWLEDGE ASSESSMENT</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Include Family'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="skillKnowIncludeFamily" type="checkbox" id="inlineCheckbox3" value="Inc">
|
|
<label class="form-check-label" for="inlineCheckbox2">Include Family</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('TEACHING'); ?></label>
|
|
<select class="form-control" name="skillKnowIncludeTeaching" id="">
|
|
<option value="Ciompliant">Ciompliant</option>
|
|
<option value="Non Compliant">Non Compliant</option>
|
|
<option value="Reinforce Fall & Accident Prevention">Reinforce Fall & Accident Prevention</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="skillKnowIncludeTeachingnotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('LEARNING'); ?></label>
|
|
<select class="form-control" name="skillKnowIncludeLearning" id="">
|
|
<option value="Ciompliant">Ciompliant</option>
|
|
<option value="Non Compliant">Non Compliant</option>
|
|
<option value="Reinforce Fall & Accident Prevention">Reinforce Fall & Accident Prevention</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="skillKnowIncludeLearningNotes" id=""></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">RESPONSE TO THERAPY</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Adverse Medication Side Effects'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="adverseMedicationSideEffects" id="radio" value="Denied" checked>
|
|
<label class="form-check-label" for="Denied">
|
|
Denied
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="adverseMedicationSideEffects" id="radio" value="Confirmed">
|
|
<label class="form-check-label" for="Confirmed">
|
|
Confirmed
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Complain with Medication Thearpy'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PatientComplainwithMedicationThearpy" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PatientComplainwithMedicationThearpy" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="RESPONSETOTHERAPYnotes" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
|
|
<input type="text" class="form-control" name="respTotherapyCaregiver" value="">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Copes Effectively, with Therapy or Disease process'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CopesEffectivelywithTherapyorDiseaseprocess" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CopesEffectivelywithTherapyorDiseaseprocess" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">MEDICATION</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Medication Changes'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MedicationChanges" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MedicationChanges" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Review Medication Profile Include Otc'); ?></label>
|
|
<input type="text" class="form-control" name="ReviewMedicationProfileIncludeOtc">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('New Meds'); ?></label>
|
|
<input type="text" class="form-control" name="medicationNewMeds">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Changes & Effects Reviewed with'); ?></label>
|
|
<input type="text" class="form-control" name="ChangesEffectsReviewedwith ">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
|
|
<input type="text" class="form-control" name="medicationCaregiver">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Use Of Pump'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="medicationUseOfPump" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="medicationUseOfPump" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Prepour Medications By'); ?></label>
|
|
<input type="text" class="form-control" name="PrepourMedicationsBy">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Job Title'); ?></label>
|
|
<select class="form-control" name="medicationJobTitle" id="">
|
|
<option value="HHA">HHA</option>
|
|
<option value="PCA">PCA</option>
|
|
<option value="RN">RN</option>
|
|
<option value="LPN">LPN</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Independent In Medication Administration'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PatientIndependentInMedicationAdministration" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PatientIndependentInMedicationAdministration" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('LOT#'); ?></label>
|
|
<input type="text" class="form-control" name="MEDICATIONlot">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Expiration Date'); ?></label>
|
|
<input type="date" class="form-control" name="MEDICATIONexpirationDate">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">EQUIPMENT</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('EQUIPMENT'); ?></label>
|
|
<select class="form-control" name="equipment" id="">
|
|
<option value="Hospital Bed">Hospital Bed</option>
|
|
<option value="Hoyer Lift">Hoyer Lift</option>
|
|
<option value="Motorized Wheel Chair">Motorized Wheel Chair</option>
|
|
<option value="Gloves">Gloves</option>
|
|
<option value="Bed Pan">Bed Pan</option>
|
|
<option value="Other">Other</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Enviornmental Safety'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipmentEnvSafty" id="radio" value="Waste Disposal" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Waste Disposal
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipmentEnvSafty" id="radio" value="Maintain Clear Pathway">
|
|
<label class="form-check-label" for="NO">
|
|
Maintain Clear Pathway
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Safety Concerns'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipSafetyConcerns" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipSafetyConcerns" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('WOUND CARE'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipWondscare" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Sterile
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="equipWondscare" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
Clean
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">MD Orders</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('MD Orders'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersNotes" id=""></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Date'); ?></label>
|
|
<input type="date" class="form-control" name="MDOrdersWounddate" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Type'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundType" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Site Location'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersSiteLocation" id=""></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Description'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersWoundDesc" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Measurement'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersWoundMeasurment" id=""></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Lenghts'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control" name="MDOrdersWoundLength" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Width'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control" name="MDOrdersWoundWidth" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Diameter'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control" name="MDOrdersWoundDiameter" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Undermining'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control" name="MDOrdersWoundUndermining" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Undermining @ Clock Position'); ?></label>
|
|
<input type="time" class="form-control" name="MDOrdersWoundClockPosition" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Cleanse With'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="radio" value="Normal Saline" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Normal Saline
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="radio" value="0.125% Dakins Solution">
|
|
<label class="form-check-label" for="NO">
|
|
0.125% Dakins Solution
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Applications'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="Algisite-M" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Algisite-M
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="4X4 Sterile Gauze">
|
|
<label class="form-check-label" for="NO">
|
|
4X4 Sterile Gauze
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="radio" value="Santyl Ointment">
|
|
<label class="form-check-label" for="NO">
|
|
Santyl Ointment
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Applied Other'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersAppliedOther" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Covered With'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="4X4 Sterile Gauze" checked>
|
|
<label class="form-check-label" for="YES">
|
|
4X4 Sterile Gauze
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="ExuDry">
|
|
<label class="form-check-label" for="NO">
|
|
ExuDry
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="Derlix">
|
|
<label class="form-check-label" for="NO">
|
|
Derlix
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="radio" value="Combine/ABDPad">
|
|
<label class="form-check-label" for="NO">
|
|
Combine/ABDPad
|
|
</label>
|
|
</div>
|
|
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Covered with Other'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersCoverOther" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Secured With'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="Paper Tape" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Paper Tape
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="ACE Bandage">
|
|
<label class="form-check-label" for="NO">
|
|
ACE Bandage
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="radio" value="Hypafix Tape">
|
|
<label class="form-check-label" for="NO">
|
|
Hypafix Tape
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Packed Wound Bed With'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersPackkedWoundsWithBed" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Status'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Unchanged" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Unchanged
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Healing">
|
|
<label class="form-check-label" for="NO">
|
|
Healing
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Resolveds">
|
|
<label class="form-check-label" for="NO">
|
|
Resolved
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="radio" value="Deterioratings">
|
|
<label class="form-check-label" for="NO">
|
|
Deteriorating
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Granulating'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Excrotic Tissue Present'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Eschar'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundEschar" id="">
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Exudate'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundExudate" id="">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Slough'); ?></label>
|
|
<select class="form-control" name="MDorderWoundSlough" id="MDorderWoundSlough">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="Tan">Tan</option>
|
|
<option value="Grey">Grey</option>
|
|
<option value="Green">Green</option>
|
|
<option value="Yellow">Yellow</option>
|
|
<option value="White">White</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Present'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Color'); ?></label>
|
|
<select class="form-control" name="MDorderNecroticTissueColor" id="">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="Leathery">Leathery</option>
|
|
<option value="Black">Black</option>
|
|
<option value="Brown">Brown</option>
|
|
<option value="Tan">Tan</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Type'); ?></label>
|
|
<textarea class='form-control' name='MDORDERWoundDrainageType' id=''></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Rate'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Light" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Light
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Modarate">
|
|
<label class="form-check-label" for="NO">
|
|
Modarate
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="radio" value="Heavy">
|
|
<label class="form-check-label" for="NO">
|
|
Heavy
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Amount'); ?></label>
|
|
<textarea class='form-control' name='MDORDERWoundDrainageAmount' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Redness At Site'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MDOrdersWoundRednessAtSiteComment' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Odor'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MDOrdersWoundOdorComment' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Swelling'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MDOrdersWoundSwellingComment' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Pain'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MDOrdersWoundPainComment' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Independent In Wound Care'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Is Willing To Learn'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver Is Willing To Learn'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MDOrdersCaregiverIsWillingToLearnComment' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='MdOrdersLastComment' id=''></textarea>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
|
|
<input type="text" class='form-control' name='MdOrdersCaregiver' id=''>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">PROGRESS TOWARDS GOALS</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label>
|
|
<textarea class='form-control' name='ProgressTowordsGoals' id=''></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('CARE PLAN REVIEW DISCLOSURE'); ?></label>
|
|
<span>(Review HHA Care Plan and advise HHA to report any chages in conditions to nurse. In case of emergency call 911)</span>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="checkbox" name="PogToGoalCArePlanReviewDisclouser" id="radio" value="YES">
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Care Plan Details'); ?></label>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Accidents/Injury" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Accidents/Injury
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Body Mechanics and Transfer Techniques" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Body Mechanics and Transfer Techniques
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Complaints of Pain" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Complaints of Pain
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Skin Flushed and Hot" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Skin Flushed and Hot
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Nausea/Vomiting" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Nausea/Vomiting
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Nausea/Vomiting" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Developing Wound or Sore
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Skin Pale and Sweating" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Skin Pale and Sweating
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="Change in Mental Status" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Change in Mental Status
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Dizziness/Headaches
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Shortness of Breath
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Slurred Words
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalCarePlanDetails" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Diarrhea
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang("Fall Precautions"); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="High" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Mild
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="Moderate">
|
|
<label class="form-check-label" for="NO">
|
|
Moderate
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalFallPrecautions" id="radio" value="High">
|
|
<label class="form-check-label" for="NO">
|
|
High
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-8">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Weight Gain Amount'); ?></label>
|
|
<input type="text" class="form-control" name="PogToGoalweightGainAmount" value="">
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Weight Gain in days'); ?></label>
|
|
<input type="text" class="form-control" name="PogToGoalweightGainAmountIndays" value="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Temperature More Than'); ?></label>
|
|
<div>(Measured in Degrees fahrenheit)</div>
|
|
<input type="text" class='form-control' name='PogToGoalTemperatureMoreThan' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Pressure Ulser Risk'); ?></label>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Risk" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Risk
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Moderate" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Moderate
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="High" checked>
|
|
<label class="form-check-label" for="YES">
|
|
High
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="PogToGoalPressureUlserRisk" id="radio" value="Very High" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Very High
|
|
</label>
|
|
</div>
|
|
|
|
</div>
|
|
|
|
<div class="col-lg-5">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Constipation'); ?></label>
|
|
<div>No Bowel Movement after (X) days</div>
|
|
<input type="text" class='form-control' name='PogToGoalConstipation' id=''></text>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">Skilled Nursing Interventions Summary/Follow-UP Plan</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Other Current Services'); ?></label>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="OT" checked>
|
|
<label class="form-check-label" for="YES">
|
|
OT
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="PT" checked>
|
|
<label class="form-check-label" for="YES">
|
|
PT
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="ST" checked>
|
|
<label class="form-check-label" for="YES">
|
|
ST
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="LPN" checked>
|
|
<label class="form-check-label" for="YES">
|
|
LPN
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="Teacher" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Teacher
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="otherCurrentServices" id="radio" value="Other" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Other
|
|
</label>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Review Of Emergency Plan'); ?></label>
|
|
<input type="text" class='form-control' name='reviewEmergencyPlan' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Review/Update Care Plan'); ?></label>
|
|
<input type="text" class='form-control' name='reviewOrupdateCarePlan' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Fall Prevention & Home Safety'); ?></label>
|
|
<input type="text" class='form-control' name='FallPreventionAndHomeSafety' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Seizure Precautions Observed '); ?></label>
|
|
<input type="text" class='form-control' name='SeizurePrecautionsObserved' id=''>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Standard Precautions Observed'); ?></label>
|
|
<input type="text" class='form-control' name='StandardPrecautionsObserved' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Maintain Aspiration Precaution'); ?></label>
|
|
<input type="text" class='form-control' name='MaintainAspirationPrecaution' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Equipment Checked'); ?></label>
|
|
<textarea type="text" class='form-control' name='EquipmentCheckedNotes' id=''></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Supplies Inventory Checked'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="SuppliesInventoryChecked" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="SuppliesInventoryChecked" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Supplies Inventory Needed'); ?></label>
|
|
<textarea class='form-control' name='SuppliesInventoryNeededNotes' id=''></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Prepour Medication'); ?></label>
|
|
<input type="text" class='form-control' name='PrepourMedication' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Oxygen Safety'); ?></label>
|
|
<input type="text" class='form-control' name='OxygenSafety' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Supervise'); ?></label>
|
|
<span>(Caregiver Name)</span>
|
|
<input type="text" class='form-control' name='SuperviseCaregiverName' id=''>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Care Giver Title'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="RN" checked>
|
|
<label class="form-check-label" for="YES">
|
|
RN
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="HHA" checked>
|
|
<label class="form-check-label" for="YES">
|
|
HHA
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="LPN" checked>
|
|
<label class="form-check-label" for="YES">
|
|
LPN
|
|
</label>
|
|
</div>
|
|
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="CaregiverTitle" id="radio" value="PCA" checked>
|
|
<label class="form-check-label" for="YES">
|
|
PCA
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class='form-control' name='CaregiverTitleNotes' id=''></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Revisit Date'); ?></label>
|
|
<input type="date" class='form-control' name='RevisitDateFlowupPlan' id=''>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-4">
|
|
<h3 class="font-weight-bold">Authorities</h3>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('PRINT NAME'); ?></label>
|
|
<select class="form-control" name="caregiverPrintName" id="">
|
|
<option value="Hospital Bed">Hospital Bed</option>
|
|
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('TITLE'); ?></label>
|
|
<select class="form-control" name="caregiverPrintTitle" id="">
|
|
<option value="RN">RN</option>
|
|
<option value="LPN">LPN</option>
|
|
<option value="HHA">HHA</option>
|
|
<option value="PCA">PCA</option>
|
|
<option value="Other">Other</option>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('CLINICIAN SIGNATURE'); ?></label>
|
|
<input type="text" class='form-control' name='clinicalSignature' id=''>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Date'); ?></label>
|
|
<input type="date" class='form-control' name='clinicalSignatureDate' id=''>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</form>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</section>
|
|
</section>
|
|
</div>
|
|
</section>
|
|
|
|
|