3368 lines
266 KiB
PHP
Executable File
3368 lines
266 KiB
PHP
Executable File
sidebar end-->
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<!--main content start-->
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<style type="text/css">
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.required:after {
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content:"*";
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color:red;
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}
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</style>
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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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<!-- <header class="panel-heading">
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<?php
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if (!empty($nurse->id))
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echo lang('Edit Patient');
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else
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echo lang('New Assessment');
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?>
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</header> -->
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<!-- <div class="panel-body col-md-7">
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<div class="adv-table editable-table ">
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<div class="clearfix">
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<div class="col-lg-12">
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<section class="panel">
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<div class="panel-body">
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<div class="col-lg-12">
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</div>
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<input type="hidden" name="id" value='<?php
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if (!empty($nurse->id)) {
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echo $nurse->id;
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}
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?>'>
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<button type="submit" name="submit" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</form>
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</div>
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</section>
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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="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('New Assessment');
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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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<div class="col-lg-3"></div>
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<div class="col-md-12">
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<form role="form" action="initial_assessment/saveAssessment?id=<?php echo $_GET['id']; ?>" method="post" enctype="multipart/form-data" name="newGenInfo" onsubmit="return validateForm1()">
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<div class="accordion" id="accordionExample">
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<!-- patient visit record start -->
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<div class="card">
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<div class="card-header" id="headingOne">
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<h2 class="mb-0">
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<button class="btn btn-link" type="button" data-toggle="collapse" data-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
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<h3 class="font-weight-bold">Patient Visit Record</h3>
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</button>
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</h2>
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</div>
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<div id="collapseOne" class="collapse show" aria-labelledby="headingOne" data-parent="#accordionExample">
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<div class="card-body">
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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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<input required type="date" class="form-control futDateNonAccept" name="pvrDate" value="<?php echo set_value('fname'); ?>">
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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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<select class="form-control" name="pvrDay" id="pvrDay" required>
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<option value="" selected>Choose...</option>
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<option value="Monday">Monday</option>
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<option value="Tuesday">Tuesday</option>
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<option value="Wednessday">Wednesday</option>
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<option value="Thursday">Thursday</option>
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<option value="Friday">Friday</option>
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<option value="Saturday">Saturday</option>
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<option value="Sunday">Sunday</option>
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</select>
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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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<input type="time" class="form-control" name="pvrTimeIn" required>
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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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<input type="time" class="form-control" name="pvrTimeOut" required>
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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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<input type="text" class="form-control" name="patientName" required value="<?php echo set_value('fname'); ?>">
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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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<input type="date" class="form-control futDateNonAccept" required name="dob" id="ptdob">
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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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<input type="text" class="form-control" required name="pvrDiagnosis" value="<?php echo set_value('fname'); ?>">
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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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<input type="text" class="form-control" required name="pvrAllergy">
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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 Name'); ?></label>
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<input type="text" class="form-control" required name="pvrMd" value="<?php echo set_value('fname'); ?>">
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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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<div class="form-check">
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<input class="form-check-input" type="radio" name="ID_confirmed" id="radio" value="option1" checked>
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<label class="form-check-label" for="YES">
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YES
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="ID_confirmed" id="radio" value="option2">
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<label class="form-check-label" for="NO">
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NO
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</label>
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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-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('MD Contact Info'); ?></label>
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<input type="text" class="form-control" required name="pvrMdcntInfo" value="<?php echo set_value('fname'); ?>">
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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('Reason'); ?></label>
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<select class="form-control" name="pvrReason" id="inputGroupSelect01" required>
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<option selected value="Scheduled">Scheduled</option>
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<option value="Call">Call</option>
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</select>
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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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<select class="form-control" name="therapy_type" id="therapy_type" required>
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<option selected>Choose...</option>
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<?php foreach ($therapyType as $value) { ?>
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<option value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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<option selected value="Other type therapy">Other type therapy</option>
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<option value="Type of therapy drugs">Type of therapy drugs</option>
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<option value="Type of therapy cycle">Type of therapy cycle</option>
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<option value="Type of therapy formula">Type of therapy formula</option>
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<option value="Reason For Visit">Reason For Visit</option>
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</select>
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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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<select class="form-control" name="pvrVisitActivity" id="pvrVisitActivity">
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<option value="Administration">Administration</option>
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<option value="Assessment">Assessment</option>
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<option value="Skilled Assessment">Skilled Assessment</option>
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<option value="Access Related">Access Related</option>
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<option value="Catheter Care">Catheter Care</option>
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<option value="Cassette Change">Cassette Change</option>
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<option value="Catheter Declotting">Catheter Declotting</option>
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<option value="Clinical Change">Clinical Change</option>
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<option value="Delivery/Pick-Up Only">Delivery/Pick-Up Only</option>
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<option value="Delivery of Supplies">Delivery of Supplies</option>
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<option value="Delivery of Equipment">Delivery of Equipment</option>
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<option value="Delivery of Medications">Delivery of Medications</option>
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<option value="Discharge Visit">Discharge Visit</option>
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<option value="Dressing Change">Dressing Change</option>
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<option value="Initial Patient Assessment">Initial Patient Assessment</option>
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<option value="Implanted Pump Refill">Implanted Pump Refill</option>
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<option value="Lab Draw">Lab Draw</option>
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<option value="Medication Adminstration">Medication Adminstration</option>
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<option value="Midline Insertion">Midline Insertion</option>
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<option value="Order Change">Order Change</option>
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<option value="Orientation/Training Visit">Orientation/Training Visit</option>
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<option value="Port Access Insertion">Port Access Insertion</option>
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<option value="PICC Insertion">PICC Insertion</option>
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<option value="PIV Insertion">PIV Insertion</option>
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<option value="Patient Training (IV Related)">Patient Training (IV Related)</option>
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<option value="Patient Training (Non-IV Related)">Patient Training (Non-IV Related)</option>
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<option value="Pump Problem">Pump Problem</option>
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<option value="Routine Visit">Routine Visit</option>
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<option value="Subcutaneous Access Insertion">Subcutaneous Access Insertion</option>
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<option value="Supervisory Visit">Supervisory Visit</option>
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<option value="Teaching">Teaching</option>
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<option value="Wound Care">Wound Care</option>
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</select>
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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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<select type="text" class="form-control" name="PVRtypesOfDeviceAccess" id="deviceAccessType">
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<option selected>Choose...</option>
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<option value="Enteral Type">Enteral Type</option>
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<option value="PICC Exposed Length">PICC Exposed Length</option>
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<option value="Number Of Lumens">Number Of Lumens</option>
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</select>
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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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<select class="form-control" name="accessAssessmentDD" id="accessAssessmentDD">
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<option selected value="">please select an option</option>
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<option value="Comments">Comments</option>
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<option value="CARE DID NOT OCCUR">CARE DID NOT OCCUR</option>
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<option value="NON-BILLABLE VISIT">NON-BILLABLE VISIT</option>
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</select>
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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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<select class="form-control" name="action" id="action">
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<option value="N/A">N/A</option>
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<option value="Injection Cap Device Change">Injection Cap Device Change</option>
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<option value="Dressing Change">Dressing Change</option>
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<option value="Blood Return">Blood Return</option>
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<option value="Flushed With 0.9% Nacl">Flushed With 0.9% Nacl</option>
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<option value="Flushed With Heparin">Flushed With Heparin</option>
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<option value="Huber Device Type">Huber Device Type</option>
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<option value="Huber Device Accessed">Huber Device Accessed</option>
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<option value="Huber Device Deaccessed">Huber Device Deaccessed</option>
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<option value="Huber Device Flushed without Reistance">Huber Device Flushed without Reistance</option>
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<option value="Access Type">Access Type</option>
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<option value="Access To Vein">Access To Vein</option>
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<option value="Device Name">Device Name</option>
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<option value="Device Size">Device Size</option>
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<option value="Lab Work Obtained">Lab Work Obtained</option>
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<option value="Peripheral Site">Peripheral Site</option>
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<option value="Via Central Line">Via Central Line</option>
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<option value="Lab Sheet Tracking Sticker">Lab Sheet Tracking Sticker</option>
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<option value="Subcutaneous Site Change">Subcutaneous Site Change</option>
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<option value="Subcutaneous Location">Subcutaneous Location</option>
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<option value="Subcutaneous Name">Subcutaneous Name</option>
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<option value="Subcutaneous Site">Subcutaneous Site</option>
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<option value="Pump Function">Pump Function</option>
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<option value="Pump Function Model Number">Pump Function Model Number</option>
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</select>
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</div>
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<div class="col-lg-8" 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 Battery charge'); ?></label>
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<input type="number" class="form-control" name="pumpBetteryCharge" value="<?php echo set_value('fname'); ?>">
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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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<input type="number" class="form-control" name="pumpRexVolume">
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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 Infusion Volume'); ?></label>
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<input type="text" class="form-control" name="pumpInfusionVolume" id="pumpInfusionVolume">
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</div>
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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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<select class="form-control" name="pumpRate" id="pumpRate">
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<option value="Mg">Mg</option>
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<option value="ml">ml</option>
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<option value="times per hour">times per hour</option>
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<option value="times daily">times daily</option>
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</select>
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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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<input type="text" class="form-control" name="pvrBolus">
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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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<input type="time" class="form-control" name="pvrKVO">
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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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<div class="form-check">
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<input class="form-check-input" type="radio" name="pvrTaper" id="radio" value="UP" checked>
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<label class="form-check-label" for="YES">
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UP
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="pvrTaper" id="radio" value="DOWN">
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<label class="form-check-label" for="NO">
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DOWN
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</label>
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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-6">
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<label for="exampleInputEmail1" ><?php echo lang('Program Verified With'); ?></label>
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<input type="text" class="form-control" name="Program_Verified_With">
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</div>
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</div>
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</div>
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|
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</div>
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</div>
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</div>
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<!-- patient visit record end -->
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<!-- patient PHYSICAL ASSESSMENT start -->
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<div class="card">
|
|
<div class="card-header" id="headingTwo">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
|
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<h3 class="font-weight-bold">PHYSICAL ASSESSMENT</h3>
|
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</button>
|
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</h2>
|
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</div>
|
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<div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
|
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<div class="card-body">
|
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<div class="form-group">
|
|
<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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<select class="form-control" name="phyAssVitalSign" id="phyAssVitalSign">
|
|
<option value="Temperature">Temperature</option>
|
|
<option value="Pulse">Pulse</option>
|
|
<option value="Blood Pressure">Blood Pressure</option>
|
|
<option value="SpO2">SpO2</option>
|
|
<option value="Respiration">Respiration</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Vital Signs Measurements'); ?></label>
|
|
<textarea class='form-control' name='vital_Sign_measurement' id=''></textarea>
|
|
</div>
|
|
</div>
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</div>
|
|
|
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<div class="form-group">
|
|
<div class="row">
|
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<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('CARDIOVASCULAR'); ?></label>
|
|
<select class="form-control" name="cardiovascular" id="cardiovascular"> <option value="" selected>Choose...</option>
|
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<option value="Rhythm">Rhythm</option>
|
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<option value="Edema">Edema</option>
|
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</select>
|
|
</div>
|
|
<div class="col-lg-4" id="CvacRhythm" style="display: none;">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Rhythm'); ?></label>
|
|
<select class="form-control" name="CvacRhythm" id="">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="Regular">Regular</option>
|
|
<option value="Irregular">Irregular</option>
|
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</select>
|
|
</div>
|
|
<div class="col-lg-4" id="cvacEdema" style="display: none;">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
|
|
<select class="form-control" name="cvacEdema" id="">
|
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<option value="Absent">Absent</option>
|
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<option value="Present">Present</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="cvacNotes" id="cvacNotes"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('RESPIRATORY'); ?></label>
|
|
<select class="form-control" name="respiratory" id="respiratory">
|
|
<option value="Within Normal Limits (WNL)">Within Normal Limits (WNL)</option>
|
|
<option value="Breath Sounds">Breath Sounds</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4" id="respBreathSound" style="display: none;">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Breath Sounds'); ?></label>
|
|
<select class="form-control" name="respBreathSound" id="">
|
|
<option value="Diminished">Diminished</option>
|
|
<option value="Rales">Rales</option>
|
|
<option value="Wheeze">Wheeze</option>
|
|
<option value="SOB At Rest">SOB At Rest</option>
|
|
<option value="SOB on Exertion">SOB on Exertion</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="respNotes" id="respNotes"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<!-- patient PHYSICAL ASSESSMENT end -->
|
|
|
|
<!-- patient FOODS/FLUIDS start -->
|
|
<div class="card">
|
|
<div class="card-header" id="headingThree">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">
|
|
<h3 class="font-weight-bold">FOODS/FLUIDS</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseThree" class="collapse" aria-labelledby="headingThree" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Food'); ?></label>
|
|
<select class="form-control" name="foodDiet" id="foodDiet">
|
|
<option selected value="Regular">Regular</option>
|
|
<option value="No Deficit">No Deficit</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="dietType" id="radio" value="Compliant" checked>
|
|
<label class="form-check-label" for="Compliant">
|
|
Compliant
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="dietType" id="radio" value="Non Compliant">
|
|
<label class="form-check-label" for="Non Compliant">
|
|
Non Compliant
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Fluid'); ?></label>
|
|
<select class="form-control" name="fluidDiet" id="fluidDiet">
|
|
<option selected value="Regular">Regular</option>
|
|
<option value="No Deficit">No Deficit</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="fluidType" id="radio" value="Compliant" checked>
|
|
<label class="form-check-label" for="Compliant">
|
|
Compliant
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="fluidType" id="radio" value="Non Compliant">
|
|
<label class="form-check-label" for="Non Compliant">
|
|
Non Compliant
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Fluid Intake'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="fluidIntake" id="radio" value="Adequate" checked>
|
|
<label class="form-check-label" for="Compliant">
|
|
Adequate
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="fluidIntake" id="radio" value="Inadequate">
|
|
<label class="form-check-label" for="Non Compliant">
|
|
Inadequate
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Weight Amount'); ?></label>
|
|
<select class="form-control" name="WeightAmount" id="WeightAmount">
|
|
<?php for ($i=1; $i < 500 ; $i++) { ?>
|
|
<option selected value="<?=$i?>"><?=$i?> LBS</option>
|
|
<?php } ?>
|
|
<!-- <option selected value="Regular">Regular</option> -->
|
|
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Type'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="WeightGainType" id="radio" value="Compliant" checked>
|
|
<label class="form-check-label" for="Compliant">
|
|
Gain
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="WeightGainType" id="radio" value="Non Compliant">
|
|
<label class="form-check-label" for="Non Compliant">
|
|
Loss
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<div class="form-check">
|
|
<textarea class='form-control' name="WeightComments"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<!-- patient FOODS/FLUIDS end -->
|
|
|
|
<!-- patient ENDOCRINE starts -->
|
|
<div class="card">
|
|
<div class="card-header" id="headingFour">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapsefour" aria-expanded="false" aria-controls="collapsefour">
|
|
<h3 class="font-weight-bold">ENDOCRINE</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
|
|
<div id="collapsefour" class="collapse" aria-labelledby="headingOne" data-parent="#accordionExample" aria-expanded="false" >
|
|
<div class="card-body">
|
|
<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="ENDOCRINE" 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('Diabetes'); ?></label>
|
|
<input type="text" class='form-control' name='Diabetes' id=''>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Blood Sugar(MG/dl)'); ?></label>
|
|
<input type="number" class='form-control' name='bloodSugarMeasure' id=''>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<div class="form-check">
|
|
<textarea class='form-control' name="DiabetesComments"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingFive">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFive" aria-expanded="false" aria-controls="collapseFive">
|
|
<h3 class="font-weight-bold">ACTIVITY/REST</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseFive" class="collapse" aria-labelledby="headingFive" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ACTIVITY/REST'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="ENDOCRINE" 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('Musculosketal'); ?></label>
|
|
<input type="text" class='form-control' name='Musculosketal' id=''>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Activity'); ?></label>
|
|
<div class="form-check">
|
|
<textarea class='form-control' name="MusculosketalActivity"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="ARprom" type="checkbox" id="promExercises" value="After Feed">
|
|
<label class="form-check-label" for="inlineCheckbox2">Encouraged PROM exercises to extremeties</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="ambulatoryAr" type="radio" id="promExercises" value="After Feed">
|
|
<label class="form-check-label" for="inlineCheckbox2">Ambulatory</label>
|
|
</div>
|
|
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang(''); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="ambulatoryAr" type="radio" id="promExercises" value="After Feed">
|
|
<label class="form-check-label" for="inlineCheckbox2">Non Ambulatory</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Dependent'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="DependentAR" type="text" id="inlineCheckbox3" value="">
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('wheelChair'); ?></label>
|
|
<input type="text" class='form-control' name='wheelChairAR' id=''>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<div class="form-check">
|
|
<textarea class='form-control' name="CommentsAR"></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingSix">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSix" aria-expanded="false" aria-controls="collapseSix">
|
|
<h3 class="font-weight-bold">PAIN</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseSix" class="collapse" aria-labelledby="headingSix" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-5">
|
|
<img width="300" src="https://www.disabled-world.com/pics/1/pain-scale-chart-3.gif">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-2">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('ACTIVITY/REST'); ?></label> -->
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painDeflict" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Pain level assessed'); ?></label>
|
|
<select class="form-control" name="painLevelAssessed" id="">
|
|
<option value="0">0 No pain</option>
|
|
<option value="1">1</option>
|
|
<option value="2">2</option>
|
|
<option value="3">3</option>
|
|
<option value="4">4</option>
|
|
<option value="5">5</option>
|
|
<option value="6">6</option>
|
|
<option value="7">7</option>
|
|
<option value="8">8</option>
|
|
<option value="9">9</option>
|
|
<option value="10">10 Sever pain</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('type'); ?></label>
|
|
<div class="form-check">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Accute">
|
|
<label class="form-check-label" for="typePainAccute">Accute</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Constant">
|
|
<label class="form-check-label" for="typePainConstant">Constant</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painType" type="radio" id="inlineCheckbox3" value="Sporatic">
|
|
<label class="form-check-label" for="typePainSporatic">Sporatic</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Quality'); ?></label>
|
|
<div class="form-check">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="After Feed">
|
|
<label class="form-check-label" for="typePainAching">Aching</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Throbbing">
|
|
<label class="form-check-label" for="typePainThrobbing">Throbbing</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Pressure">
|
|
<label class="form-check-label" for="typePainPressure">Pressure</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Sharp">
|
|
<label class="form-check-label" for="typePainSharp">Sharp</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Burnig">
|
|
<label class="form-check-label" for="typePainBurnig">Burnig</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="painQuality" type="checkbox" id="inlineCheckbox3" value="Dull">
|
|
<label class="form-check-label" for="typePainDull">Dull</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Relief From'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="ReliefFrom" type="text" id="" value="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingSeven">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSeven" aria-expanded="false" aria-controls="collapseSeven">
|
|
<h3 class="font-weight-bold">SKIN</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseSeven" class="collapse" aria-labelledby="headingSeven" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('skin'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="skin" id="">
|
|
<option value="Warm">Warm</option>
|
|
<option value="Dry">Dry</option>
|
|
<option value="Intact">Intact</option>
|
|
<option value="Rash">Rash</option>
|
|
<option value="Puritis">Puritis</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Describe'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="skinDescribe" type="text" id="" value="">
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Bruises Location'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="skinBruisesLocation" type="text" id="" value="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Surgical Site'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Clean" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Clean
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Dry">
|
|
<label class="form-check-label" for="NO">
|
|
Dry
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Clean" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Clean
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Dry">
|
|
<label class="form-check-label" for="NO">
|
|
Dry
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class='form-control' name='skinComments' id=''></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingEight">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEight" aria-expanded="false" aria-controls="collapseEight">
|
|
<h3 class="font-weight-bold">CIRCULATION</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseEight" class="collapse" aria-labelledby="headingEight" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="circulationDecifit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Chest Pain'); ?></label>
|
|
<textarea class='form-control' name='circCheastPain' id=''></textarea>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="circEdema" 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="circEdema" 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('Location'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="circLocation" id="">
|
|
<option value="Warm">Warm</option>
|
|
<option value="Dry">Dry</option>
|
|
<option value="Intact">Intact</option>
|
|
<option value="Rash">Rash</option>
|
|
<option value="Puritis">Puritis</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Edema'); ?></label> -->
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="circEdema" id="radio" value="Pitting" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Pitting
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="circEdema" id="radio" value="Non Pitting">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</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>
|
|
<textarea class='form-control' name='peripheralCapilaryRefill' id=''></textarea>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Circulation Status'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="CirculationStatus" id="">
|
|
<option value="Good (less than 3 seconds)">Good (less than 3 seconds)</option>
|
|
<option value="Fair (3-5 seconds)">Fair (3-5 seconds)</option>
|
|
<option value="Poor (greater than 5 seconds)">Poor (greater than 5 seconds)</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class='form-control' name='Circulation_Comments' id=''></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingNine">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseNine" aria-expanded="false" aria-controls="collapseNine">
|
|
<h3 class="font-weight-bold">VENTILATION</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseNine" class="collapse" aria-labelledby="headingNine" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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">Green</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('Vent Dependent'); ?></label>
|
|
<select class="form-control" name="ventDependent" id="">
|
|
<option selected value="a">a</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class="form-control" name="ventilatorComments" id=""></textarea>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTen" aria-expanded="false" aria-controls="collapseTen">
|
|
<h3 class="font-weight-bold">TRACHEOTOMY CARE</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTen" class="collapse" aria-labelledby="headingTen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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="Change">Change</option>
|
|
<option value="Sterile">Sterile</option>
|
|
<option value="Clean">Clean</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingEleven">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEleven" aria-expanded="false" aria-controls="collapseEleven">
|
|
<h3 class="font-weight-bold">MD Orders</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseEleven" class="collapse" aria-labelledby="headingEleven" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwelve">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwelve" aria-expanded="false" aria-controls="collapseTwelve">
|
|
<h3 class="font-weight-bold">GASTROINTESTINAL</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwelve" class="collapse" aria-labelledby="headingTwelve" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="GASTROINTESTINALnoDeficit" type="checkbox" id="inlineCheckbox3" value="No Deficit">
|
|
<label class="form-check-label" for="inlineCheckbox2">No Deficit</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingThirteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseThirteen" aria-expanded="false" aria-controls="collapseThirteen">
|
|
<h3 class="font-weight-bold">GENITOURINARY</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseThirteen" class="collapse" aria-labelledby="headingThirteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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" onclick="ifInweldingFun(this)" 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" onclick="ifInweldingFun(this)" name="Cathertar" id="radio" value="Staight Catheter">
|
|
<label class="form-check-label" for="NO">
|
|
Staight Catheter
|
|
</label>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<script type="text/javascript">
|
|
function ifInweldingFun(_this){
|
|
var val = _this.value;
|
|
if(val == 'Indwelling')
|
|
{
|
|
document.getElementById("cathBalOrfr").style.display = "block";
|
|
|
|
}
|
|
if(val == 'Staight Catheter')
|
|
{
|
|
document.getElementById("cathBalOrfr").style.display = "none";
|
|
|
|
}
|
|
}
|
|
</script>
|
|
<div class="form-group">
|
|
<div class="row" id="cathBalOrfr" style="display: none;">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('If Indwelling'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Fr" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Fr
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="Cathertar" id="radio" value="Ballon">
|
|
<label class="form-check-label" for="NO">
|
|
Ballon
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingFourteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFourteen" aria-expanded="false" aria-controls="collapseFourteen">
|
|
<h3 class="font-weight-bold">HYGINENE</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseFourteen" class="collapse" aria-labelledby="headingFourteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" name="HYGINENEnoDeficit" 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('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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingFifteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseFifteen" aria-expanded="false" aria-controls="collapseFifteen">
|
|
<h3 class="font-weight-bold">INTEGUMENTARY</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseFifteen" class="collapse" aria-labelledby="headingFifteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingSixteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSixteen" aria-expanded="false" aria-controls="collapseSixteen">
|
|
<h3 class="font-weight-bold">NERUOLOGICAL</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseSixteen" class="collapse" aria-labelledby="headingSixteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingSeventeen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseSeventeen" aria-expanded="false" aria-controls="collapseSeventeen">
|
|
<h3 class="font-weight-bold">PSYCHOLOGICAL / EMOTIONAL REACTION</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseSeventeen" class="collapse" aria-labelledby="headingSeventeen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingEighteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseEighteen" aria-expanded="false" aria-controls="collapseEighteen">
|
|
<h3 class="font-weight-bold">SKILLS - KNOWLEDGE ASSESSMENT</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseEighteen" class="collapse" aria-labelledby="headingEighteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingNineteen">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseNineteen" aria-expanded="false" aria-controls="collapseNineteen">
|
|
<h3 class="font-weight-bold">RESPONSE TO THERAPY</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseNineteen" class="collapse" aria-labelledby="headingNineteen" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwo">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
|
|
<h3 class="font-weight-bold">MEDICATION</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwenty">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwenty" aria-expanded="false" aria-controls="collapseTwenty">
|
|
<h3 class="font-weight-bold">EQUIPMENT</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwenty" class="collapse" aria-labelledby="headingTwenty" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwentyOne">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyOne" aria-expanded="false" aria-controls="collapseTwentyOne">
|
|
<h3 class="font-weight-bold">MD Orders</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwentyOne" class="collapse" aria-labelledby="headingTwentyOne" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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 Bed Appearance'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Beefy" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Beefy
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Pink">
|
|
<label class="form-check-label" for="NO">
|
|
Pink
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Yellow">
|
|
<label class="form-check-label" for="NO">
|
|
Yellow
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="radio" value="Black">
|
|
<label class="form-check-label" for="NO">
|
|
Black
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Tunneling'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="woundTunnelling" 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="woundTunnelling" 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('Comments'); ?></label>
|
|
<textarea class='form-control' name='woundTunnelingComment' 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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwentyTwo">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyTwo" aria-expanded="false" aria-controls="collapseTwentyTwo">
|
|
<h3 class="font-weight-bold">PROGRESS TOWARDS GOALS</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwentyTwo" class="collapse" aria-labelledby="headingTwentyTwo" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwentyThree">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwentyThree" aria-expanded="false" aria-controls="collapseTwentyThree">
|
|
<h3 class="font-weight-bold">Skilled Nursing Interventions Summary/Follow-UP Plan</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwentyThree" class="collapse" aria-labelledby="headingTwentyThree" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="card">
|
|
<div class="card-header" id="headingTwo">
|
|
<h2 class="mb-0">
|
|
<button class="btn btn-link collapsed" type="button" data-toggle="collapse" data-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
|
|
<h3 class="font-weight-bold">Authorities</h3>
|
|
</button>
|
|
</h2>
|
|
</div>
|
|
<div id="collapseTwo" class="collapse" aria-labelledby="headingTwo" data-parent="#accordionExample">
|
|
<div class="card-body">
|
|
<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>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
</div>
|
|
|
|
|
|
|
|
<!-- <hr class="my-4">
|
|
<h3 class="font-weight-bold">SKIN</h3> -->
|
|
<!-- <div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('skin'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="skin" id="">
|
|
<option value="Warm">Warm</option>
|
|
<option value="Dry">Dry</option>
|
|
<option value="Intact">Intact</option>
|
|
<option value="Rash">Rash</option>
|
|
<option value="Puritis">Puritis</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Describe'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="skinDescribe" type="text" id="" value="">
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Bruises Location'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-control" name="skinBruisesLocation" type="text" id="" value="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Surgical Site'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Clean" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Clean
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinsurgicalsite" id="radio" value="Dry">
|
|
<label class="form-check-label" for="NO">
|
|
Dry
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound'); ?></label>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Clean" checked>
|
|
<label class="form-check-label" for="YES">
|
|
Clean
|
|
</label>
|
|
</div>
|
|
<div class="form-check">
|
|
<input class="form-check-input" type="radio" name="skinWonds" id="radio" value="Dry">
|
|
<label class="form-check-label" for="NO">
|
|
Dry
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class='form-control' name='skinComments' id=''></textarea>
|
|
</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('Peripheral Capillary Refill'); ?></label>
|
|
<textarea class='form-control' name='peripheralCapilaryRefill' id=''></textarea>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Circulation Status'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<select class="form-control" name="CirculationStatus" id="">
|
|
<option value="Good (less than 3 seconds)">Good (less than 3 seconds)</option>
|
|
<option value="Fair (3-5 seconds)">Fair (3-5 seconds)</option>
|
|
<option value="Poor (greater than 5 seconds)">Poor (greater than 5 seconds)</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label>
|
|
<textarea class='form-control' name='Circulation_Comments' 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="Change">Change</option>
|
|
<option value="Sterile">Sterile</option>
|
|
<option value="Clean">Clean</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<hr class="my-4"> -->
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</form>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</section>
|
|
<!-- page end-->
|
|
</section>
|
|
</section>
|
|
</div>
|
|
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
|
|
<script type="text/javascript"> /* future date dob not accept */
|
|
|
|
$(document).ready(function () {
|
|
// alert("dateSec");
|
|
var todaysDate = new Date(); // Gets today's date
|
|
|
|
// Max date attribute is in "YYYY-MM-DD". Need to format today's date accordingly
|
|
|
|
var year = todaysDate.getFullYear(); // YYYY
|
|
var month = ("0" + (todaysDate.getMonth() + 1)).slice(-2); // MM
|
|
var day = ("0" + todaysDate.getDate()).slice(-2); // DD
|
|
|
|
var maxDate = (year +"-"+ month +"-"+ day); // Results in "YYYY-MM-DD" for today's date
|
|
|
|
// Now to set the max date value for the calendar to be today's date
|
|
$('.futDateNonAccept').attr('max',maxDate);
|
|
|
|
});
|
|
|
|
</script>
|
|
<script type="text/javascript">
|
|
$('#respiratory').change(function(){
|
|
var respType = $(this).val();
|
|
if(respType == 'Breath Sounds')
|
|
{
|
|
document.getElementById("respBreathSound").style.display = "block";
|
|
}
|
|
else
|
|
{
|
|
document.getElementById("respBreathSound").style.display = "none";
|
|
}
|
|
})
|
|
$('#cardiovascular').change(function(){
|
|
var cvacType = $(this).val();
|
|
if(cvacType == 'Rhythm')
|
|
{
|
|
document.getElementById("CvacRhythm").style.display = "block";
|
|
document.getElementById("cvacEdema").style.display = "none";
|
|
}
|
|
if(cvacType == 'Edema')
|
|
{
|
|
document.getElementById("CvacRhythm").style.display = "none";
|
|
document.getElementById("cvacEdema").style.display = "block";
|
|
}
|
|
})
|
|
$('#therapy_type').change(function(){
|
|
var therapy_type = $(this).val();
|
|
$.ajax('initial_assessment/ajax_type_therapy', {
|
|
type: 'POST', // http method
|
|
data: { val: therapy_type }, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
// msgs = data;
|
|
$("#typeAccValInp").html(data);
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
}
|
|
});
|
|
});
|
|
$('#deviceAccessType').change(function(){
|
|
var dAccesType = $(this).val();
|
|
$.ajax('initial_assessment/ajax_type_device_access', {
|
|
type: 'POST', // http method
|
|
data: { val: dAccesType }, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
// msgs = data;
|
|
$("#deviceAccessTypeDiv").html(data);
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
}
|
|
});
|
|
});
|
|
$('#accessAssessmentDD').change(function(){
|
|
var accessAssessment = $(this).val();
|
|
$.ajax('initial_assessment/ajax_type_access_assessment', {
|
|
type: 'POST', // http method
|
|
data: { val: accessAssessment }, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
// msgs = data;
|
|
$("#accessAssessmentDiv").html(data);
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
}
|
|
});
|
|
});
|
|
$('#action').change(function(){
|
|
var accessAssessment = $(this).val();
|
|
$.ajax('initial_assessment/ajax_action_box', {
|
|
type: 'POST', // http method
|
|
data: { val: accessAssessment }, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
// msgs = data;
|
|
$("#actionDiv").html(data);
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
}
|
|
});
|
|
});
|
|
$('#pumpRate').change(function(){
|
|
var accessAssessment = $(this).val();
|
|
$.ajax('initial_assessment/ajax_pump_rate', {
|
|
type: 'POST', // http method
|
|
data: { val: accessAssessment }, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
// msgs = data;
|
|
$("#pumpRateDiv").html(data);
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
}
|
|
});
|
|
});
|
|
</script>
|
|
<script>
|
|
/*tool tip section*/
|
|
$(document).ready(function(){
|
|
$('[data-toggle="tooltip"]').tooltip();
|
|
});
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
function isNumberKey(evt){
|
|
var charCode = (evt.which) ? evt.which : evt.keyCode
|
|
if (charCode > 31 && (charCode < 48 || charCode > 57))
|
|
return false;
|
|
return true;
|
|
}
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
function isCharKey(inputtxt){
|
|
|
|
var letters = /^[A-Za-z]+$/;
|
|
if(inputtxt.value.match(letters))
|
|
{
|
|
return true;
|
|
}
|
|
else
|
|
{
|
|
// alert("message");
|
|
return false;
|
|
}
|
|
}
|
|
</script>
|
|
<!--main content end-->
|
|
<!--footer start
|