662 lines
46 KiB
PHP
Executable File
662 lines
46 KiB
PHP
Executable File
<link href="https://www.jqueryscript.net/css/jquerysctipttop.css" rel="stylesheet" type="text/css">
|
|
<link rel="stylesheet" href="<?php echo base_url(); ?>common/signature/drawing-table.css" type="text/css" media="screen" charset="utf-8" />
|
|
<script type="text/javascript" src="https://pagead2.googlesyndication.com/pagead/show_ads.js"></script>
|
|
<!-- MAIN CONTAINT START-->
|
|
<div class="col-lg-3"></div>
|
|
<div class="col-lg-12">
|
|
<ul class="nav nav-tabs" id="myTab" role="tablist">
|
|
<li class="nav-item" <?php if($hide_demographics===true){ ?> style="display:none;" <?php } ?>>
|
|
<a class="nav-link active" id="DEMOGRAPHICS-tab" data-toggle="tab" href="#DEMOGRAPHICS" role="tab" aria-controls="DEMOGRAPHICS" <?php if($hide_demographics===true){ } else { ?> aria-selected="true" <?php } ?>>
|
|
<h6 class="font-weight-bold text-uppercase ord-heading">PATIENT DEMOGRAPHICS</h6>
|
|
</a>
|
|
</li>
|
|
<li class="nav-item">
|
|
<a class="nav-link" id="Order-tab" data-toggle="tab" href="#Order" role="tab" aria-controls="Order" aria-selected="false" <?php if($hide_demographics===true){ ?> aria-selected="true" <?php } ?>>
|
|
<h6 class="font-weight-bold text-uppercase ord-heading">Order Details</h6>
|
|
</a>
|
|
</li>
|
|
</ul>
|
|
<div class="tab-content" >
|
|
<div class="tab-pane fade <?php if($hide_demographics===true){} else { ?> show active <?php } ?>" id="DEMOGRAPHICS" role="tabpanel" aria-labelledby="DEMOGRAPHICS-tab" >
|
|
<div class="form-group mt-1">
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Patient's ID"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->patient_id; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Patient's Name"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->first_name.' '.$patient->last_name; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Patient's DOB"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->dob; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Patient's Gender"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->gender; ?>" Readonly>
|
|
</div>
|
|
<?php
|
|
$p_arddress=json_decode($patient->address);
|
|
$p_address_text="";
|
|
foreach ($p_arddress as $pa) {
|
|
//echo $pa;
|
|
if(isset($pa)&& $pa!=""){ $p_address_text=$p_address_text.$pa.', ';}
|
|
}
|
|
//echo $p_address_text;
|
|
//print_r($p_arddress);
|
|
?>
|
|
<div class="col-lg-6">
|
|
<label><?php echo lang("Patient's Address"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $p_address_text; ?>" Readonly>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Patient's Phone"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->telephone; ?>" Readonly>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Level of Service"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $patient->service_name; ?>" Readonly>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Prescriber's Name"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $physician->name; ?>" Readonly>
|
|
</div>
|
|
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("NPI"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $physician->npi; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label><?php echo lang("Prescriber's Address"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $physician->address; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Prescriber's Phone"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $physician->phone; ?>" Readonly>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Prescriber's Fax"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $physician->fax; ?>" Readonly>
|
|
</div>
|
|
|
|
<?php
|
|
// if($type=='initial_assessment')
|
|
// { $ass_type="Initial Assmessment"; }
|
|
// else{ $ass_type="Re Assmessment"; }
|
|
$ass_type="Physician Order";
|
|
?>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang('Type of Document/Visit'); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $ass_type; ?>" Readonly>
|
|
</div>
|
|
<?php
|
|
if($md_order->order_status!=""){
|
|
$documents_status=$md_order->order_status;
|
|
}else{
|
|
$documents_status='Processing';
|
|
}
|
|
|
|
?>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Document Status"); ?></label>
|
|
<input type="text" class="form-control" value="<?php echo $documents_status; ?>" Readonly>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="tab-pane fade <?php if($hide_demographics===true){ ?> show active <?php } ?>" id="Order" role="tabpanel" aria-labelledby="Order-tab">
|
|
<form action="<?= base_url();?>md_order/saveOrder" method="post" use="saveClinicalOrder">
|
|
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
|
<input type="hidden" class="form-control" name="patient_id" value="<?php echo $patient->id; ?>">
|
|
<input type="hidden" class="form-control" name="main_id" id="main_id" value="<?=$md_order->main_id?>">
|
|
<input type="hidden" class="form-control" name="physician_id" value="<?php echo $physician->id; ?>">
|
|
<div class="hide" style="display: none;">
|
|
<textarea name="dynamicFormData"><?php if(isset($md_order->dynamicFormData)){ echo $md_order->dynamicFormData; } ?></textarea>
|
|
<textarea name="staticdynamicFormData"><?php if(isset($md_order->staticdynamicFormData)){ echo $md_order->staticdynamicFormData; } ?></textarea>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<h5 class="font-weight-bold text-uppercase ord-heading mt-1">ICD-10</h5>
|
|
</div>
|
|
<!-- <div class="col-lg-6">
|
|
<button type="button" class="btn btn-info pull-right" use="plusbutt" onclick="add_more_icd(null);" >Add</button>
|
|
</div> -->
|
|
</div>
|
|
|
|
<div class="form-group" id="more_icd">
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<h5 class="font-weight-bold text-uppercase ord-heading col-lg-6">Medication</h5>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<button type="button" class="btn btn-info pull-right" use="plusbutt" onclick="add_medication(null);" >Add</button>
|
|
</div>
|
|
</div>
|
|
<div class="form-group" id="more_medication">
|
|
</div>
|
|
<?php if($patient->level_of_service=='4' || $patient->level_of_service=='5'){ ?>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<h5 class="font-weight-bold text-uppercase ord-heading col-lg-6">Lab Order</h5>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<button type="button" class="btn btn-info pull-right" use="plusbutt" onclick="add_LabOrder(null);" >Add</button>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label class="form-check-label" for="InfactingOrganismTypeNA">Lab Drawn</label>
|
|
<div class="form-check form-check-inline col-lg-2">
|
|
<input class="form-check-input lab_drawn_cls" name="LabDrawn" type="radio" id="labdrawyes" class="lab_drawn_cls" value="Yes" <?php if($md_order_data_object->LabDrawn=="Yes"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="labdrawyes">Yes</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-2">
|
|
<input class="form-check-input lab_drawn_cls" name="LabDrawn" type="radio" id="labdrawno" class="lab_drawn_cls" value="No" <?php if($md_order_data_object->LabDrawn=="No"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="labdrawno">No</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6" id="lab_drawn_late" style="display: none;">
|
|
<label class="form-check-label" for="labdrawndate">Drawn date</label>
|
|
<input type="date" class="form-control" name="labdrawndate" value="<?php echo $md_order_data_object->LabDrawn; ?>" >
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
|
|
<div class="form-group mt-1" id="more_LabOrder">
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-5 form-group">
|
|
<label><?php echo lang("Infacting Organism"); ?></label>
|
|
<input type="text" class="form-control" name="InfactingOrganism" value="<?= $md_order_data_object->InfactingOrganism ?>">
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-2">
|
|
<input class="form-check-input" name="InfactingOrganismType" type="radio" id="InfactingOrganismTypeNA" value="NA" <?php if($md_order_data_object->InfactingOrganismType=="NA"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="InfactingOrganismTypeNA">N/A</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-2">
|
|
<input class="form-check-input" name="InfactingOrganismType" type="radio" id="InfactingOrganismTypeNotDone" value="CultureNotDone" <?php if($md_order_data_object->InfactingOrganismType=="CultureNotDone"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="InfactingOrganismTypeNotDone">Culture Not Done</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-2">
|
|
<input class="form-check-input" name="InfactingOrganismType" type="radio" id="InfactingOrganismTypePending" value="CulturePending" <?php if($md_order_data_object->InfactingOrganismType=="CulturePending"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="InfactingOrganismTypePending">Culture Pending</label>
|
|
</div>
|
|
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6 form-group">
|
|
<label><?php echo lang("Fax results to prescriber and corma at & 516 396 8849"); ?></label>
|
|
<input type="text" class="form-control" name="FaxResultToPrescriber" value="<?php echo $md_order_data_object->FaxResultToPrescriber; ?>">
|
|
</div>
|
|
<div class="col-lg-3 form-group">
|
|
<label><?php echo lang("Access Device"); ?></label>
|
|
<input type="text" class="form-control" name="AccessDevice" value="<?php echo $md_order_data_object->AccessDevice; ?>">
|
|
</div>
|
|
<div class="col-lg-3 form-group">
|
|
<label><?php echo lang("Peripheral Line"); ?></label>
|
|
<input type="text" class="form-control" name="PeripheralLine" value="<?php echo $md_order_data_object->PeripheralLine; ?>">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<table width="100%">
|
|
<tr>
|
|
<td><label>Flush Volume (ml's)</label></td>
|
|
<td><label>0.9 % Saline</label></td>
|
|
<td><label>Heparine 10 units/ml</label></td>
|
|
<td><label>Heparine 100 units/ml</label></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>Before Dose :</label></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BeforeDose][saline]" value="<?php echo $md_order_data_object->FlushVolume->BeforeDose->saline; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BeforeDose][Heparine10Unit]" value="<?php echo $md_order_data_object->FlushVolume->BeforeDose->Heparine10Unit; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BeforeDose][Heparine100Unit]" value="<?php echo $md_order_data_object->FlushVolume->BeforeDose->Heparine100Unit; ?>"></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>Between Doses :</label></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BetweenDose][saline]" value="<?php echo $md_order_data_object->FlushVolume->BetweenDose->saline; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BetweenDose][Heparine10Unit]" value="<?php echo $md_order_data_object->FlushVolume->BetweenDose->Heparine10Unit; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[BetweenDose][Heparine100Unit]" value="<?php echo $md_order_data_object->FlushVolume->BetweenDose->Heparine100Unit; ?>"></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>After Dose :</label></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[AfterDose][saline]" value="<?php echo $md_order_data_object->FlushVolume->AfterDose->saline; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[AfterDose][Heparine10Unit]" value="<?php echo $md_order_data_object->FlushVolume->AfterDose->Heparine10Unit; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[AfterDose][Heparine100Unit]" value="<?php echo $md_order_data_object->FlushVolume->AfterDose->Heparine100Unit; ?>"></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>Other :</label></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[Other][saline]" value="<?php echo $md_order_data_object->FlushVolume->Other->saline; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[Other][Heparine10Unit]" value="<?php echo $md_order_data_object->FlushVolume->Other->Heparine10Unit; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[Other][Heparine100Unit]" value="<?php echo $md_order_data_object->FlushVolume->Other->Heparine100Unit; ?>"></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>QSOD through :</label></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[QSOD][saline]" value="<?php echo $md_order_data_object->FlushVolume->QSOD->saline; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[QSOD][Heparine10Unit]" value="<?php echo $md_order_data_object->FlushVolume->QSOD->Heparine10Unit; ?>"></td>
|
|
<td><input type="text" class="form-control" name="FlushVolume[QSOD][Heparine100Unit]" value="<?php echo $md_order_data_object->FlushVolume->QSOD->Heparine100Unit; ?>"></td>
|
|
</tr>
|
|
</table>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-12 form-group">
|
|
<label><?php echo lang("Additional Order/Information"); ?></label>
|
|
<textarea class="form-control" name="additionOrderInformation"><?php echo $md_order_data_object->additionOrderInformation; ?></textarea>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="form-check form-check-inline col-lg-3">
|
|
<label class="form-check-label">Administration supplies as required</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-1">
|
|
<input class="form-check-input AdministrationSupplies" name="AdministrationSupplies" type="radio" id="AdministrationSuppliesYes" value="YES" <?php if($md_order_data_object->AdministrationSupplies=="YES"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="AdministrationSuppliesYes">YES</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-1">
|
|
<input class="form-check-input AdministrationSupplies" name="AdministrationSupplies" type="radio" id="AdministrationSuppliesNO" value="NO" <?php if($md_order_data_object->AdministrationSupplies=="NO"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="AdministrationSuppliesNO">NO</label>
|
|
</div>
|
|
</div>
|
|
<div class="row" id="AdministrationSuppliesContainer">
|
|
</div>
|
|
<?php } ?>
|
|
<div class="row">
|
|
<div class="col-lg-3 form-group">
|
|
<label><?php echo lang("Order Received"); ?></label>
|
|
<input type="text" class="form-control" name="OrderReceived" value="<?php echo $md_order_data_object->OrderReceived; ?>">
|
|
</div>
|
|
<div class="col-lg-3 form-group">
|
|
<label><?php echo lang("Received From "); ?></label>
|
|
<input type="text" class="form-control" name="ReceivedFrom" value="<?php echo $md_order_data_object->ReceivedFrom; ?>" required>
|
|
</div>
|
|
<div class="col-lg-3 form-group">
|
|
<label><?php echo lang("Received Date/Time "); ?></label>
|
|
<input type="datetime-local" class="form-control" name="ReceivedOn" value="<?php echo $md_order_data_object->ReceivedOn; ?>" required>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<?php foreach ($templateArr as $t ) { ?>
|
|
<div use="dynamic_form" template-id="<?php echo $t; ?>" class="col-lg-12"></div>
|
|
<?php } ?>
|
|
|
|
</div>
|
|
<?php if($patient->level_of_service=='4' || $patient->level_of_service=='5'){ ?>
|
|
<div class="row">
|
|
<div use="static_dynamic_form" template-slug="directive_stop" class="col-lg-12">
|
|
<?php if($md_order->staticdynamicFormData==""){ ?>
|
|
<h5 class="font-weight-bold text-uppercase ord-heading">Nursing Procedure: STOP any Infusion or medication administration immediately</h5>
|
|
<p>1. If Modarate to severe symptoms occur, activate EMS system and initiate BCLS if indicated.</p>
|
|
<p>2. If applicable have caregiver call 911.</p>
|
|
<p>3. Notify the physician at phone.</p>
|
|
<p>4. Administer Medications below as needed for Acute Infusion Reaction to .</p>
|
|
<table width="100%" border="1">
|
|
<tr>
|
|
<td colspan="9"><label>ANAPHYLAXIS TREATMENT</label></td>
|
|
</tr>
|
|
<tr>
|
|
<td><label>Check</label></td>
|
|
<td><label>Drug of Treatment</label></td>
|
|
<td><label>Severity</label></td>
|
|
<td><label>Under 15kg</label></td>
|
|
<td><label>15 - 30Kg</label></td>
|
|
<td><label>Over 30Kg</label></td>
|
|
<td><label>Quantity</label></td>
|
|
<td><label>Route</label></td>
|
|
<td><label>Note</label></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="checkbox" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="checkbox" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="checkbox" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td rowspan="6"><input type="checkbox" class="form-control"></td>
|
|
<td colspan="8"><label>Other Medications or O2</label></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td rowspan="5"><label>Medicate to Severe</label></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
<tr>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
<td><input type="text" class="form-control" ></td>
|
|
</tr>
|
|
|
|
</table>
|
|
<p>5. If reaction subsides, resume infusion at one half previous rate and increase gradully to a rate no greater than previous rate</p>
|
|
<p>6. If reaction does not subside</p>
|
|
<p>a. Continus to follow BCLS.</p>
|
|
<p>b. Contract Prescriber for additional medical management .</p>
|
|
<p>c. Remain with patient until EMS arrives.</p>
|
|
<div class="row">
|
|
<div class="col-lg-12 form-group">
|
|
<label>Refill</label>
|
|
<input type="text" class="form-control" name="Refill">
|
|
</div>
|
|
<div class="col-lg-12 form-group">
|
|
<label>Additional Order Information</label>
|
|
<input type="text" class="form-control" name="AdditionalOrderInformation">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="form-check form-check-inline col-lg-12">
|
|
<label class="form-check-label">For medicare patient in the Home Setting only. Administration supplies as required</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-1">
|
|
<input class="form-check-input AdministrationSupplies" name="AdministrationSuppliesHomeSetting" type="radio" id="AdministrationSuppliesHomeSettingYES" value="YES" >
|
|
<label class="form-check-label" for="AdministrationSuppliesHomeSettingYES">YES</label>
|
|
</div>
|
|
<div class="form-check form-check-inline col-lg-1">
|
|
<input class="form-check-input AdministrationSupplies" name="AdministrationSuppliesHomeSetting" type="radio" id="AdministrationSuppliesHomeSettingNO" value="NO" >
|
|
<label class="form-check-label" for="AdministrationSuppliesHomeSettingNO">NO</label>
|
|
</div>
|
|
</div>
|
|
<div class="row" id="AdministrationSuppliesContainerHomeSetting">
|
|
</div>
|
|
<?php }else{ ?>
|
|
<?php echo $md_order->staticdynamicFormData; ?>
|
|
<?php } ?>
|
|
</div>
|
|
</div>
|
|
<?php } ?>
|
|
<div class="row">
|
|
<div class="form-check form-check-inline col-lg-12">
|
|
<input class="form-check-input" name="Acceptence" type="checkbox" id="Acceptence" value="accepted" <?php //if($md_order->Acceptence=="accepted"){ echo "Checked"; }?>>
|
|
<label class="form-check-label" for="Acceptence"><p>I, the ordering prescriber for the medication, have no financial relationship with the WeCuro Inc that would prohibit the provision of the therapy. I hereby certify that the above infusion and services are medically necessary and are authorised by me. The Patient is under my care and is in the need of the services listed.</p></label>
|
|
</div>
|
|
</div>
|
|
|
|
<?php if($view_for=='Physician'){ ?>
|
|
<div class="row">
|
|
<input type="hidden" name="phy_signature" id="signature_field" value="<?php echo $md_order_data_object->phy_signature; ?>">
|
|
<div class="col-lg-6 form-group">
|
|
<label>Signature</label>
|
|
<?php if($md_order_data_object->phy_signature!=""){ ?>
|
|
<img class="form-control" width="200" height="200" src="<?php echo $md_order_data_object->phy_signature; ?>" />
|
|
<label>Approved By : <?php echo $md_order_data_object->submitted_by; ?> On : <?php echo $md_order_data_object->submitted_on; ?></label>
|
|
<?php }else{ ?>
|
|
<canvas class="form-control" id="signature" width="400" height="200" ></canvas>
|
|
<label>Entered By : <?php echo $md_order_data_object->submitted_by; ?> On : <?php echo $md_order_data_object->submitted_on; ?></label>
|
|
<?php } ?>
|
|
</div>
|
|
<div class="col-lg-6 form-group">
|
|
<label>Order Date</label>
|
|
<input type="datetime-local" class="form-control" name="OrderDateTime" value="<?php echo $md_order_data_object->OrderDateTime; ?>" required>
|
|
|
|
</div>
|
|
</div>
|
|
<?php }else{ ?>
|
|
<div class="row">
|
|
<input type="hidden" name="submit_signature" id="signature_field" value="<?php echo $md_order_data_object->submit_signature; ?>">
|
|
<div class="col-lg-6 form-group">
|
|
<label>Signature</label>
|
|
<?php if($md_order_data_object->submit_signature!=""){ ?>
|
|
<img class="form-control" width="200" height="200" src="<?php echo $md_order_data_object->submit_signature; ?>" />
|
|
<label>Entered By : <?php echo $md_order_data_object->submitted_by; ?> On : <?php echo $md_order_data_object->submitted_on; ?></label>
|
|
<?php }else if($md_order_data_object->phy_signature!=""){ ?>
|
|
<img class="form-control" width="200" height="200" src="<?php echo $md_order_data_object->phy_signature; ?>" />
|
|
<label>Approved By : <?php echo $md_order_data_object->submitted_by; ?> On : <?php echo $md_order_data_object->submitted_on; ?></label>
|
|
<?php }else{?>
|
|
<canvas class="form-control" id="signature" width="400" height="200" ></canvas>
|
|
<?php } ?>
|
|
</div>
|
|
<div class="col-lg-6 form-group">
|
|
<label>Order Date</label>
|
|
<input type="datetime-local" class="form-control" name="OrderDateTime" value="<?php echo $md_order_data_object->OrderDateTime; ?>" required>
|
|
|
|
</div>
|
|
</div>
|
|
<?php } ?>
|
|
<?php if(!isset($md_order_data_object->phy_signature)){ ?>
|
|
<div class="form-group mt-1">
|
|
<button type="submit" name="submit" id="orderSubmit" class="btn btn-info" disabled><?php echo lang('Submit'); ?></button>
|
|
</div>
|
|
<?php } ?>
|
|
|
|
|
|
</form>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<!-- MAIN CONTAINT END-->
|
|
<div use="add_container" style="display:none;">
|
|
<datalist id="medications">
|
|
<?php echo $medicationOption; ?>
|
|
</datalist>
|
|
<div class="form-group" use="medication-form">
|
|
<div class="row" use="medication-dtl">
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Name"); ?></label>
|
|
<input type="text" list="medications" name="MedicationName[]" dname="MedicationName" class="form-control" value="" required>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Dose"); ?></label>
|
|
<input type="text" name="Dose[]" dname="Dose" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label><?php echo lang("Frequency"); ?></label>
|
|
<input type="text" name="Frequency[]" dname="Frequency" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-5">
|
|
<label><?php echo lang("Method of Admin"); ?></label>
|
|
<input type="text" name="Method_of_Admin[]" dname="Method_of_Admin" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label><?php echo lang("Diluent"); ?></label>
|
|
<input type="text" name="Diluent[]" dname="Diluent" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label><?php echo lang("Route"); ?></label>
|
|
<input type="text" name="Route[]" dname="Route" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label><?php echo lang("Duration of Infusion"); ?></label>
|
|
<input type="text" name="Duratio_of_Infusion[]" dname="Duratio_of_Infusion" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-1 ">
|
|
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Start Date/Time"); ?></label>
|
|
<input type="datetime-local" name="Start_Date_Time[]" dname="Start_Date_Time" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("End Date/Time"); ?></label>
|
|
<input type="datetime-local" name="End_Date_Time[]" dname="End_Date_Time" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Dispense"); ?></label>
|
|
<input type="text" name="Dispense[]" dname="Dispense" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label><?php echo lang("Refills"); ?></label>
|
|
<input type="text" name="Refills[]" dname="Refills" class="form-control" value="">
|
|
</div>
|
|
<div class="col-lg-1 ">
|
|
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" class="img-thumbnail mt-2 minusbutt" style="height: 50px; cursor: pointer;">
|
|
</div>
|
|
<div class="col-lg-12">
|
|
<hr/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group" use="lab0rder-form">
|
|
<div class="row" use="lab0rder-dtl">
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Lab Company"); ?></label>
|
|
<select name="LabCompany[]" sname="LabCompany" class="form-control" required>
|
|
<option value="">Select</option>
|
|
<option value="LabCrop">LabCrop</option>
|
|
<option value="Quest">Quest</option>
|
|
<option value="Other">Other</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-3">
|
|
<label><?php echo lang("Type of Labs Required"); ?></label>
|
|
<select name="TypeOfLabsRequired[]" sname="TypeOfLabsRequired" class="form-control" >
|
|
<option value="">Select</option>
|
|
<?php echo $labOption; ?>
|
|
<!-- <optgroup label="Panels">
|
|
<option value="Basic Metabolic (Green & Gray)">Basic Metabolic (Green & Gray)</option>
|
|
<option value="Renal Function (Green & Gray)">Renal Function (Green & Gray)</option>
|
|
</optgroup> -->
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<label><?php echo lang("Lab Frequency"); ?></label>
|
|
<select name="LabFrequency[]" sname="LabFrequency" class="form-control" id="LabFrequency">
|
|
<option value="">Select</option>
|
|
<option value="Intervals">Intervals</option>
|
|
<option value="DayTime">Day&Time</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-3" jid="LabFrequencyOption">
|
|
|
|
</div>
|
|
<div class="col-lg-1 ">
|
|
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" class="img-thumbnail mt-2 minusbutt" style="height: 50px; cursor: pointer;">
|
|
</div>
|
|
<div class="col-lg-12">
|
|
<hr/>
|
|
</div>
|
|
</div>
|
|
|
|
<script type="text/javascript">
|
|
|
|
</script>
|
|
</div>
|
|
</div>
|
|
|
|
<div use="add_container_2" style="display:none;">
|
|
<div class="form-group" use="icd-form">
|
|
<div class="row" use="icd-dtl">
|
|
<div class="col-lg-8">
|
|
<div class="form-group">
|
|
<label for="firstName3"><?php echo lang('Write a ICD Name To Search'); ?></label>
|
|
<div class="input-group">
|
|
<div class="input-group-prepend">
|
|
<span class="input-group-text" id="">ICD</span>
|
|
</div>
|
|
<input type="text" class="form-control icd_search" name="ICD[]" use="icd_search" placeholder="Search ICD Here">
|
|
<select class="form-control" name="icd_info[]" use="icd_option" required>
|
|
<option value="<?php echo $icd_data->code.'`'.$icd_data->title; ?>"><?php echo $icd_data->title; ?></option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-4 ">
|
|
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutticd" class="img-thumbnail mt-2 minusbutticd" style="height: 30px; cursor: pointer;">
|
|
<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutticd" onclick="add_more_icd(null);" class="img-thumbnail mt-2" style="height: 30px; cursor: pointer;" >
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div use="roughPatch" style="display: none;"></div>
|
|
<script src="https://code.jquery.com/jquery-3.4.1.min.js" integrity="sha384-vk5WoKIaW/vJyUAd9n/wmopsmNhiy+L2Z+SBxGYnUkunIxVxAv/UtMOhba/xskxh" crossorigin="anonymous"></script>
|
|
<script src="<?php echo base_url(); ?>common/signature/drawing-table.js" type="text/javascript"></script>
|
|
<script>
|
|
try {
|
|
fetch(new Request("https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js", { method: 'HEAD', mode: 'no-cors' })).then(function(response) {
|
|
return true;
|
|
}).catch(function(e) {
|
|
var carbonScript = document.createElement("script");
|
|
carbonScript.src = "//cdn.carbonads.com/carbon.js?serve=CK7DKKQU&placement=wwwjqueryscriptnet";
|
|
carbonScript.id = "_carbonads_js";
|
|
document.getElementById("carbon-block").appendChild(carbonScript);
|
|
});
|
|
} catch (error) {
|
|
console.log(error);
|
|
}
|
|
</script>
|
|
<script type="text/javascript">
|
|
var _gaq = _gaq || [];
|
|
_gaq.push(['_setAccount', 'UA-36251023-1']);
|
|
_gaq.push(['_setDomainName', 'jqueryscript.net']);
|
|
_gaq.push(['_trackPageview']);
|
|
|
|
(function() {
|
|
var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
|
|
ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
|
|
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
|
|
})();
|
|
|
|
</script>
|