2544 lines
159 KiB
PHP
Executable File
2544 lines
159 KiB
PHP
Executable File
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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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<style type="text/css">
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.app-content .wizard > .steps > ul > li.active .step {
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background-color: #666EE8;
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border-color: #666EE8;
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color: #fff;
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}
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</style>
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<div class="app-content content">
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<section class="content-wrapper">
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<div class="row">
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<div class="col-12">
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<div class="card">
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<div class="card-header">
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<div class="row">
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<div class="col-md-12">
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<header class="panel-heading font-weight-bold">
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<?php if($pdata->form_status >=5){ ?>
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<h3 class="font-weight-bold"><?php echo lang('Edit Referral'); ?></h3>
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<?php }else{ ?>
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<h3 class="font-weight-bold"><?php echo lang('Add Referral'); ?></h3>
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<?php } ?>
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</header>
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</div>
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</div>
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</div>
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<hr class="mt-0 mb-0" />
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<div class="col-md-12 panel-body">
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<label>Completion Percentage (<span id="progress_lbl">0</span>%)</label>
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<div class="progress">
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<div class="progress-bar" id="progress_bar" role="progressbar" style="width: 0%;" aria-valuenow="0" aria-valuemin="0" aria-valuemax="100">0%</div>
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</div>
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</div>
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<div class="card-body">
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<div class="row">
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<div class="col-md-12">
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<?php
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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if($pdata->form_status >=5){
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if(!isset($_SESSION['editRef_stat'])){
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$tab1 = 'active';
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$tab2 = '';
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$tab3 = '';
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$tab4 = '';
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$tab5 = '';
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$tabPane1 = 'active in show';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane5 = '';
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$tabPane6 = '';
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}
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if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step1'){
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$tab1 = '';
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$tab2 = 'active';
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$tab3 = '';
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$tab4 = '';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = 'active in show';
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$tabPane3 = '';
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$tabPane5 = '';
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$tabPane6 = '';
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}
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if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step2'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = 'active';
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$tab4 = '';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = 'active in show';
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$tabPane4 = '';
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$tabPane5 = '';
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}
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if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = 'active';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = 'active in show';
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$tabPane5 = '';
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}
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if(isset($_SESSION['editRef_stat']) && $_SESSION['editRef_stat']=='step4'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = '';
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$tab5 = 'active';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = '';
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$tabPane5 = 'active in show';
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}
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}
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else{
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if(!isset($pdata->form_status)){
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$tab1 = 'active';
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$tab2 = 'disabled';
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$tab3 = 'disabled';
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$tab4 = 'disabled';
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$tab5 = 'disabled';
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$tabPane1 = 'active in show';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = '';
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$tabPane5 = '';
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}
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if(isset($pdata->form_status) && $pdata->form_status=='1'){
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$tab1 = '';
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$tab2 = 'active';
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$tab3 = '';
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$tab4 = '';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = 'active in show';
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$tabPane3 = '';
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$tabPane4 = '';
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$tabPane5 = '';
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}
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if(isset($pdata->form_status) && $pdata->form_status=='2'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = 'active';
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$tab4 = '';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = 'active in show';
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$tabPane4 = '';
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$tabPane5 = '';
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}
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if(isset($pdata->form_status) && $pdata->form_status=='3'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = 'active';
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$tab5 = '';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = 'active in show';
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$tabPane5 = '';
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}
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if(isset($pdata->form_status) && $pdata->form_status=='4'){
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = '';
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$tab5 = 'active';
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$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = '';
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$tabPane5 = 'active in show';
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}
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}
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?>
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<!-- widzed -->
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<div class="wizard wizard-circle">
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<div class="steps">
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<ul class="nav nav-tabs" id="myTab" role="tablist" style="border: none;">
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<li class="nav-item first current <?php echo $tab1; ?>">
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<a class="nav-link " id="home-tab" data-toggle="tab" href="#home" role="tab" aria-selected="true" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">1</span>General Information</a>
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</li>
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<li class="nav-item first current <?php echo $tab2; ?>">
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<a class="nav-link" id="service-tab" data-toggle="tab" href="#service_need" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">2</span>Service Needed</a>
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</li>
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<li class="nav-item first current <?php echo $tab3; ?>">
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<a class="nav-link" id="payer-tab" data-toggle="tab" href="#payer_need" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">3</span>Payer Information</a>
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</li>
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<li class="nav-item first current <?php echo $tab4; ?>">
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<a class="nav-link" id="patient-authorization-tab" data-toggle="tab" href="#patient_authorization" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step ">4</span><?php if($pdata->form_status>="5" && $pdata->patient_auth_stat == '0'){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>Patient authorization</a>
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</li>
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<li class="nav-item first current <?php echo $tab5; ?>">
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<a class="nav-link " id="mdorder-tab" data-toggle="tab" href="#mdorder" role="tab" aria-selected="true" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">5</span>Clinical Info</a>
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</li>
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</ul>
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</div>
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</div>
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<!-- widzed -->
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<!-- basic_info tab -->
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<div class="tab-content" id="myTabContent">
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<div class="tab-pane fade <?php echo $tabPane1; ?>" id="home" role="tabpanel" aria-labelledby="home-tab">
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<form role="form" action="editReferal?pid=<?php echo $_GET['pid']; ?>" method="post" enctype="multipart/form-data" name="newGenInfo" onsubmit="return validateForm1()">
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
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<div class="form-group">
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<input type="hidden" name="form_status" value="1">
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<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>0) echo 'Edit'; else echo 'Add'; ?>">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Referral Source'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="ref_info" name="pt_refrance_type">
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<option value="New Patient">New Patient</option>
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<option value="Reffered by Patient">Reffered by Patient</option>
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<option value="Reffered by Vendor">Reffered by Vendor</option>
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</select>
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</div>
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</div>
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<div class="col-md-6" id="ref_by_ptn" style="display: none;">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Referral Patient Id'); ?>
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<span class="danger">*</span>
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</label>
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<!-- <input type="text" class="form-control required" id="ref_pt_id" name="pt_refrance_value" value="<?php echo $pdata->reference_id; ?>"> -->
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<select class="form-control required" id="ref_pt_id" name="pt_refrance_value">
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<option value="" selected>Choose...</option>
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<?php foreach ($patientList as $value) { ?>
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<option <?php echo ($pdata->reference_id == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->first_name." ".$value->last_name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="col-md-6" id="ref_by_vendor" style="display: none;">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Vendor'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="ref_vnd_id" name="vend_refrance_value">
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<option value="" selected>Choose...</option>
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<?php foreach ($vendorList as $value) { ?>
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<option <?php echo ($pdata->reference_id == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->vedor_name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<script type="text/javascript">
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$(function(){
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$("#ref_info").change(function(){
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var selVal = $(this).val();
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if(selVal == 'Reffered by Patient')
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{
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$("#ref_by_ptn").show();
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$("#ref_by_vendor").hide();
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}
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else if(selVal == 'Reffered by Vendor'){
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$("#ref_by_ptn").hide();
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$("#ref_by_vendor").show();
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}
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else{
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$("#ref_by_ptn").hide();
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$("#ref_by_vendor").hide();
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}
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})
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var refInfo = "<?php echo $pdata->reference_information; ?>";
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// $("#id_100 select").val("val2");
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$('#ref_info').val(refInfo).trigger('change');
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});
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</script>
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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('Referral Mode of Contact'); ?></label>
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<select class="form-control" name="referal_contact" id="inputGroupSelect01">
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<option value="" selected>Choose...</option>
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<option <?php echo ($pdata->referral_contact == 'Address')?'selected':'' ; ?> value="Address">Address</option>
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<option <?php echo ($pdata->referral_contact == 'Email')?'selected':'' ; ?> value="Email">Email</option>
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<option <?php echo ($pdata->referral_contact == 'Fax')?'selected':'' ; ?> value="Fax">Fax</option>
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<option <?php echo ($pdata->referral_contact == 'Phone')?'selected':'' ; ?> value="Phone">Phone</option>
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</select>
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</div>
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<div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referral Type'); ?></label>
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<select class="form-control" name="referal_type" id="inputGroupSelect01">
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<option value="" selected >Choose...</option>
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<option <?php echo ($pdata->referral_type == 'New')?'selected':'' ; ?> value="New">New</option>
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<option <?php echo ($pdata->referral_type == 'Restart')?'selected':'' ; ?> value="Restart">Restart</option>
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</select>
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</div>
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<!-- <div class="col-lg-6">
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<label for="exampleInputEmail1"><?php echo lang('Referal Address'); ?></label>
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<input type="text" class="form-control" name="referal_address" id="exampleInputEmail1">
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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('Referral Recive Date'); ?></label>
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<input type="date" class="form-control" name="referal_recive_date" id="referalRecDate" value="<?php echo $pdata->referral_date; ?>" required="">
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</div>
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</div>
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</div>
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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('First name'); ?></label>
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<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" 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('Last name'); ?></label>
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<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" 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('email'); ?></label>
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<input type="email" class="form-control" name="email" id="exampleInputEmail1" value="<?php echo $pdata->patient_email; ?>" placeholder="" 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('Date of Birth'); ?></label>
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<input type="date" class="form-control" name="dob" value="<?php echo $pdata->dob; ?>" id='ptdob' 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('Telephone'); ?></label>
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<input type="text" class="form-control onlyNumber" onkeyup="USformatPhoneNumber(this.value,this)" minlength="10" maxlength="10" name="telephone" value='<?php echo $pdata->telephone; ?>' placeholder="" 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('Cell phone'); ?></label>
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<input type="text" class="form-control onlyNumber" onkeyup="USformatPhoneNumber(this.value,this)" minlength="10" maxlength="10" name="cellphone" value='<?php echo $pdata->cellphone; ?>' placeholder="" required="">
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</div>
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</div>
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</div>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Gender'); ?></label>
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<div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> required>
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<label class="form-check-label" for="Male">
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Male
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</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?> required>
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<label class="form-check-label" for="Female">
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Female
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</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="gender" id="Others" value="Others" <?php echo ($pdata->gender == 'Others')?'checked':'' ; ?> required>
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<label class="form-check-label" for="Others">
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Others
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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 class="col-lg-6">
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<label for="exampleInputEmail1" class="required"><?php echo lang('Language Preferances'); ?></label>
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<select class="form-control" id="inputGroupSelect01" name="pnalguage" required="">
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<option value="" selected>Choose...</option>
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<?php foreach ($langs as $value) { ?>
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<option <?php echo ($pdata->primary_language == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>" attr_name="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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</div>
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<div class="form-group pull-right">
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<label for="exampleInputEmail1"><?php echo lang('Same as above'); ?>
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<input type="checkbox" class="form-control " name="" id="designateSame">
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</label>
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</div>
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<h4 class="font-weight-bold">Designate Information</h4>
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<hr class="my-2">
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<script type="text/javascript">
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$("#designateSame").click(function(){
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if($('#designateSame').prop('checked')){
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document.forms["newGenInfo"]["dg_fname"].value = document.forms["newGenInfo"]["fname"].value;
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document.forms["newGenInfo"]["dg_lname"].value = document.forms["newGenInfo"]["lname"].value;
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document.forms["newGenInfo"]["dg_telephone"].value = document.forms["newGenInfo"]["telephone"].value;
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document.forms["newGenInfo"]["dg_cell"].value = document.forms["newGenInfo"]["cellphone"].value;
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}else{
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document.forms["newGenInfo"]["dg_fname"].value = "";
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document.forms["newGenInfo"]["dg_lname"].value = "";
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document.forms["newGenInfo"]["dg_telephone"].value = "";
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document.forms["newGenInfo"]["dg_cell"].value = "";
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}
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});
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</script>
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<div class="form-group">
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<div class="row">
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<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('First name'); ?></label>
|
|
<input type="text" class="form-control" name="dg_fname" value='<?php echo $pdata->designate_first_name; ?>'>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Last name'); ?></label>
|
|
<input type="text" class="form-control" name="dg_lname" value='<?php echo $pdata->designate_last_name; ?>' placeholder="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Telephone'); ?></label>
|
|
<input type="text" onkeyup="USformatPhoneNumber(this.value,this)" minlength="10" maxlength="10" class="form-control onlyNumber" name="dg_telephone" value='<?php echo $pdata->designate_telephone; ?>'>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Cell Phone'); ?></label>
|
|
<input type="text" onkeyup="USformatPhoneNumber(this.value,this)" minlength="10" maxlength="10" class="form-control onlyNumber" name="dg_cell" value='<?php echo $pdata->designate_cell; ?>'>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-md-12 form-group">
|
|
<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
|
|
<!-- services tab -->
|
|
<div class="tab-pane fade <?php echo $tabPane2; ?>" id="service_need" role="tabpanel" aria-labelledby="service-tab">
|
|
<form role="form" action="editReferal?pid=<?php echo $_GET['pid']; ?>&phase2=complete" method="post" name="referalFrom" onsubmit="return validateForm3()" enctype="multipart/form-data">
|
|
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
|
<div class="form-group">
|
|
<input type="hidden" name="form_status" value="2">
|
|
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>2) echo 'Edit'; else echo 'Add'; ?>">
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Level of care needed'); ?></label>
|
|
<select class="form-control" name="level_care" id="inputGroupSelect01">
|
|
<option >Choose...</option>
|
|
<option <?php echo ($pdata->level_of_care == '1')?'selected':'' ; ?> value="1">1 High</option>
|
|
<option <?php echo ($pdata->level_of_care == '2')?'selected':'' ; ?> value="2">2</option>
|
|
<option <?php echo ($pdata->level_of_care == '3')?'selected':'' ; ?> value="3">3</option>
|
|
<option <?php echo ($pdata->level_of_care == '4')?'selected':'' ; ?> value="4">4</option>
|
|
<option <?php echo ($pdata->level_of_care == '5')?'selected':'' ; ?> value="5">5 Low</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<label for="firstName3">
|
|
<?php echo lang('Level of Service needed'); ?>
|
|
<span class="danger">*</span>
|
|
</label>
|
|
<select class="form-control required" name="level_service" id="level_service" required="">
|
|
<option value="" selected>Choose...</option>
|
|
<?php foreach ($lvlService as $value) { ?>
|
|
<option <?php echo ($pdata->level_service == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>" attr_name="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<label for="exampleInputEmail1"><?php echo lang('Corresponding Requirements'); ?></label>
|
|
<input type="text" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-md-12 form-group">
|
|
<button type="submit" name="submit" value="services" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
<!-- services tab -->
|
|
|
|
<!-- payer tab -->
|
|
<div class="tab-pane fade <?php echo $tabPane3; ?>" id="payer_need" role="tabpanel" aria-labelledby="payer-tab">
|
|
<form role="form" action="<?php echo base_url(); ?>patient/editReferal?pid=<?php echo $_GET['pid']; ?>" method="post" enctype="multipart/form-data" name="newInsuranceFrom" onsubmit="return validateForm4()" >
|
|
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
|
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Payer Type</h4>
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Payer Type'); ?></label>
|
|
<!-- <input type="text" class="form-control" name="payerType" value="<?php echo $pdata->payerType; ?>"> -->
|
|
<select class="form-control" name="payerType" id="inputGroupSelect01" required="">
|
|
<option value="" selected disabled="">Choose...</option>
|
|
<?php foreach ($payerType as $value) { ?>
|
|
<option <?php echo ($pdata->payerType == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-md-3">
|
|
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="CreditorDebitCard" value="Credit or Debit Card">
|
|
<label class="form-check-label" for="CreditorDebitCard">
|
|
Credit or Debit Card
|
|
</label>
|
|
</div>
|
|
<div class="col-md-3">
|
|
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="EFT" value="EFT">
|
|
<label class="form-check-label" for="EFT">
|
|
EFT
|
|
</label>
|
|
</div>
|
|
<div class="col-md-3">
|
|
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="MonthlyInvoice" value="Monthly Invoice">
|
|
<label class="form-check-label" for="MonthlyInvoice">
|
|
Monthly Invoice
|
|
</label>
|
|
</div>
|
|
<div class="col-md-3">
|
|
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="InsuranceInformation" value="Insurance Information">
|
|
<label class="form-check-label" for="InsuranceInformation">
|
|
Insurance Information
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<span id="insInfoSection" class="paymodesSh" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Insurance Information</h4>
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
|
|
<div class="row" style="display: <?php echo ($pdata->reference_information == 'Reffered by Vendor')? 'block' : 'none'; ?>;">
|
|
<div class="col-lg-3">
|
|
<input class="form-check-input" type="checkbox" name="RefertoVendorDocument" id="RefertoVendorDocument" value="Refer to Vendor Document">
|
|
<label class="form-check-label" for="RefertoVendorDocument">
|
|
Refer to Vendor Document
|
|
</label>
|
|
</div>
|
|
<hr>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" class="required"><?php echo lang('Insurance Type'); ?></label>
|
|
<select class="form-control" name="insurance_type" id="insurance_type">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="Madicaid" <?php echo ($idata->insurance_type == 'Madicaid')?'selected':'' ; ?>>Madicaid(MCOs)</option>
|
|
<option value="Private" <?php echo ($idata->insurance_type == 'Private')?'selected':'' ; ?>>Private(PPOs)</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" class="required"><?php echo lang('Insurance Plan'); ?></label>
|
|
<select class="form-control" name="insurance_plan" id="insurance_plan">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="A" <?php echo ($idata->insurance_plan == 'A')?'selected':'' ; ?>>company A</option>
|
|
<option value="B" <?php echo ($idata->insurance_plan == 'B')?'selected':'' ; ?>>company B</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
<span id="medicaidInfoSection" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Medicaid information</h4>
|
|
<hr class="my-2">
|
|
<!-- <p class="lead"> Please fill all the emergency contact</p> -->
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Medicaid ID'); ?></label>
|
|
<input type="text" class="form-control" name="MedicaidId" id="exampleInputEmail1" value="<?php echo $idata->medicaid_id; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Medicaid adult'); ?></label>
|
|
<input type="text" class="form-control" name="medicaidAdult" id="exampleInputEmail1" value="<?php echo $idata->medicaid_adult; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Medicaid Pediatric'); ?></label>
|
|
<input type="text" class="form-control" name="MedicaidPediriatic" id="exampleInputEmail1" value="<?php echo $idata->medicaid_pedriatic; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Primary or Secondary'); ?></label>
|
|
<select class="form-control" name="primarySeconday" id="primarySeconday">
|
|
<option value="" selected>Choose...</option>
|
|
<option value="Primary">Primary</option>
|
|
<option value="Secondary">Secondary</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-check form-check-inline">
|
|
<!-- <label for="exampleInputEmail1"><?php echo lang('Wage Priority'); ?></label> -->
|
|
<input type="checkbox" class="form-check-input" name="WagePriority" id="exampleInputEmail1">
|
|
<label class="form-check-label" for="YES">
|
|
Wage Priority
|
|
</label>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</span>
|
|
<span id="pvtInsInfoSection" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Private Insurance</h4>
|
|
<hr class="my-2">
|
|
<!-- <p class="lead"> Please fill all the emergency contact</p> -->
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Insurance Plan ID or Policy Number'); ?></label>
|
|
<input type="text" class="form-control" name="privatePolicyNumber" id="privatePolicyNumber" value="<?php echo $idata->Pvt_Ins_PlanId_Policy_no; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Claim Number'); ?></label>
|
|
<input type="text" class="form-control" name="Private_claim_number" id="Private_claim_number" value="<?php echo $idata->claim_no; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</span>
|
|
</span>
|
|
|
|
<span id="CreditDebitPayOpt" class="paymodesSh" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Credit or Debit Card</h4>
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Credit Card Info'); ?></label>
|
|
<input type="text" class="form-control" name="CreditCardInfo" id="exampleInputEmail1" value="<?php echo $idata->CreditCardInfo; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('CC Number'); ?></label>
|
|
<input type="text" class="form-control" name="ccNumber" id="exampleInputEmail1" value="<?php echo $idata->ccNumber; ?>">
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Expiration'); ?></label>
|
|
<input type="text" class="form-control" name="ccExpiration" id="exampleInputEmail1" value="<?php echo $idata->ccExpiration; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('CVV'); ?></label>
|
|
<input type="text" class="form-control" name="ccCvv" id="exampleInputEmail1" value="<?php echo $idata->ccCvv; ?>">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Zipcode'); ?></label>
|
|
<input type="text" class="form-control" name="ccZipcode" id="exampleInputEmail1" value="<?php echo $idata->ccZipcode; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</span>
|
|
|
|
<span id="ETFPayOpt" class="paymodesSh" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">EFT</h4>
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Bank Account'); ?></label>
|
|
<input type="text" class="form-control" name="bankAccount" id="exampleInputEmail1" value="<?php echo $idata->bankAccount; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('name'); ?></label>
|
|
<input type="text" class="form-control" name="bankName" id="exampleInputEmail1" value="<?php echo $idata->bankName; ?>">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Number'); ?></label>
|
|
<input type="text" class="form-control" name="bankNumber" id="exampleInputEmail1" value="<?php echo $idata->bankNumber; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Routing Number'); ?></label>
|
|
<input type="text" class="form-control" name="RoutingNumber" id="exampleInputEmail1" value="<?php echo $idata->RoutingNumber; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</span>
|
|
|
|
<span id="monthlyInvoicePayOpt" class="paymodesSh" style="display: none;">
|
|
<hr class="my-2">
|
|
<h4 class="font-weight-bold">Monthly Invoice</h4>
|
|
<hr class="my-2">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Monthly Invoice'); ?></label>
|
|
<input type="text" class="form-control" name="Monthly Invoice" id="exampleInputEmail1" value="<?php echo $idata->Monthly_Invoice; ?>">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</span>
|
|
|
|
<button type="submit" name="submit" value="insInfo" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</form>
|
|
</div>
|
|
<!-- payer tab -->
|
|
|
|
<!-- patient agreement -->
|
|
<div class="tab-pane fade <?php echo $tabPane4; ?>" id="patient_authorization" role="tabpanel" aria-labelledby="patient-authorization-tab">
|
|
<form role="form" action="<?php echo base_url(); ?>patient/editReferal?pid=<?php echo $_GET['pid']; ?>" method="post" enctype="multipart/form-data" name="newInsuranceFrom" onsubmit="return validateForm4()" >
|
|
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
|
<div class="row">
|
|
<div class="col-12">
|
|
<a class="badge badge-primary btn-sm badge_new_btn pull-right" target="_blank" href="<?=base_url()?>patient/patientAgreementForm?pid=<?=$pdata->id?>"> <i class="la la-link"></i><?=lang('Download patient agreement form')?></a>;
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-12">
|
|
<div class="card">
|
|
<hr class="mt-0 mb-0" />
|
|
</div>
|
|
<div class="card-body">
|
|
<div class="row">
|
|
<div class=" col-md-12">
|
|
<label for="exampleInputEmail1" class="required"><?php echo lang('Document Verified'); ?></label>
|
|
<input type="checkbox" name="patient_agreement_Document_Verified" class="form-group" id="patient_agreement_Document_Verified" value="Verified">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class=" col-md-12" id="msgActivation">
|
|
</div>
|
|
</div>
|
|
<?php foreach ($PAGDdocs as $trd){ ?>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<a target="_blank" href="<?=base_url()?><?=$trd->path?><?=$trd->file_name?>">
|
|
<img src="<?=base_url()?>uploads/attachment.png" class="img-thumbnail" style="height: 50px;">
|
|
</a><?=$trd->originalfilename?>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
|
|
<input type="text" class="form-control" name="otherDoc_remarks" value="<?=$trd->remarks?>">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<a href="<?=base_url()?>patient/documentDelete?fid=<?=$trd->id?>&redirect=patient/editReferal?pid=<?=$pdata->id?>" class="badge badge-pill badge-danger white">Delete</a>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<?php } ?>
|
|
<div class="row">
|
|
<div class=" col-md-12" id="agreementVerifiedDocument">
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-md-12 form-group">
|
|
<button type="submit" name="submit" value="patientAgreement" id="patientAgreementBtn" class="btn btn-info disabled" disabled="true"><?php echo lang('submit'); ?></button>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
<!-- patient agreement -->
|
|
|
|
<!-- mdorder tab -->
|
|
<div class="tab-pane fade <?php echo $tabPane5; ?>" id="mdorder" role="tabpanel" aria-labelledby="mdorder-tab">
|
|
<form role="form" action="editReferal?pid=<?php echo $_GET['pid']; ?>&phase2=complete" method="post" name="referalFrom" onsubmit="return validateForm3()" enctype="multipart/form-data">
|
|
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
|
|
|
<!-- <div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label>
|
|
<textarea class="form-control" name="MdOrderNotes" id=""><?=$mddata->md_orders_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div> -->
|
|
<div id="rnlnp" style="display: <?php echo($pdata->level_service== $rnId || $pdata->level_service== $lnpId)?'block' :'none' ; ?>">
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Primary Care Physician/MD Info'); ?></label>
|
|
<input type="text" class="form-control" name="primaryCarePhyMdInfo" value="<?php echo $pdata->primaryCarePhyMdInfo; ?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1"><?php echo lang('Diagnosis'); ?></label>
|
|
<input type="text" class="form-control" name="diagnosis" value="<?php echo $pdata->diagnosis; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('New order'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->new_order == 'YES')?'checked':'' ; ?> type="radio" name="new_order" id="radio" value="YES" checked>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->new_order == 'NO')?'checked':'' ; ?> type="radio" name="new_order" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<?php $dbData = explode(',', $pdata->service_activity);
|
|
// var_dump($dbData);
|
|
?>
|
|
<div class="col-md-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Service Activity needed'); ?></label>
|
|
<select class="form-control" name="service_activity[]" id="inputGroupSelect01" multiple>
|
|
<option value="">Choose...</option>
|
|
<?php
|
|
foreach ($serviceActivity as $value)
|
|
{
|
|
?>
|
|
<option <?php echo (in_array($value->id, $dbData))? 'selected' : '' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<?php $dbData = explode(',', $pdata->therapy_type); ?>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Therapy type'); ?></label>
|
|
<select class="form-control" name="therapy_type[]" id="inputGroupSelect01" multiple>
|
|
<option value="">Choose...</option>
|
|
<?php foreach ($therapyType as $value) { ?>
|
|
<option <?php echo (in_array($value->id, $dbData))? 'selected' : '' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<?php $dbData = explode(',', $pdata->type_access);
|
|
// var_dump($dbData);
|
|
?>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Type Of access'); ?></label>
|
|
<select class="form-control" name="type_access[]" id="inputGroupSelect01" multiple>
|
|
<option value="">Choose...</option>
|
|
<?php foreach ($accessType as $value) { ?>
|
|
<option <?php echo (in_array($value->id, $dbData))? 'selected' : '' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Patient seen by MD'); ?></label>
|
|
<input type="date" class="form-control" name="patient_seen_by_MD" value="<?php echo $pdata->patient_seen_by_MD; ?>">
|
|
</div>
|
|
</div>
|
|
|
|
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Current Lab Work'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" <?php echo ($pdata->new_order == 'YES')?'checked':'' ; ?> name="current_lab_work" id="radio" value="YES">
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" <?php echo ($pdata->new_order == 'NO')?'checked':'' ; ?> name="current_lab_work" id="radio" value="NO">
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Lab Order'); ?></label>
|
|
<input type="text" class="form-control" name="lab_order" value="<?php echo $pdata->lab_order; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Additional Lab Orders'); ?></label>
|
|
<input type="text" class="form-control" name="additional_lab_order" value="<?php echo $pdata->additional_lab_order; ?>" placeholder="">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Lab Frequency'); ?></label>
|
|
<select class="form-control" name="lab_frequency" id="inputGroupSelect01">
|
|
<option <?php echo ($pdata->lab_frequency == 'Weekly')?'selected':'' ; ?> value="Weekly">Weekly</option>
|
|
<option <?php echo ($pdata->lab_frequency == 'Every 2 weeks')?'selected':'' ; ?> value="Every 2 weeks">Every 2 weeks</option>
|
|
<option <?php echo ($pdata->lab_frequency == 'Every other week')?'selected':'' ; ?> value="Every other week">Every other week</option>
|
|
<option <?php echo ($pdata->lab_frequency == 'Every 6 months')?'selected':'' ; ?> value="Every 6 months">Every 6 months</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Other Lab Frequency'); ?></label>
|
|
<input type="text" class="form-control" name="other_lab_frequency" value="<?php echo $pdata->other_lab_frequency; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Tube'); ?></label>
|
|
<select class="form-control" name="tube_type" id="inputGroupSelect01">
|
|
<option value="" selected>Choose...</option>
|
|
<?php foreach ($tubes as $value) { ?>
|
|
<option <?php echo ($pdata->tube_type == $value->name)?'selected':'' ; ?> value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Formula'); ?></label>
|
|
<input type="text" class="form-control" name="formula"
|
|
value="<?php echo $pdata->formula; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Schedule'); ?></label>
|
|
<input type="text" class="form-control" name="schedule" value="<?php echo $pdata->schedule; ?>">
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Flush With (Water)'); ?></label>
|
|
<select class="form-control" name="flush_with" id="inputGroupSelect01">
|
|
<option value="" selected>Choose...</option>
|
|
<?php for($i = 10; $i<=240; $i++) { ?>
|
|
<option <?php echo ($pdata->flush_with == $i)?'selected':'' ; ?> value="<?=$i?>"><?php echo $i; ?> ML</option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Daily Intake Requirment'); ?></label>
|
|
<input type="text" class="form-control" name="daily_intake_requirment" value="<?php echo $pdata->daily_intake_requirment; ?>">
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Flush Frequency'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->flush_frequency == 'Before Feed')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox1" value="Before Feed">
|
|
<label class="form-check-label" for="inlineCheckbox1">Before Feed</label>
|
|
</div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->flush_frequency == 'After Feed')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="After Feed">
|
|
<label class="form-check-label" for="inlineCheckbox2">After Feed</label>
|
|
</div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->flush_frequency == 'Before Medication')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="Before Medication">
|
|
<label class="form-check-label" for="inlineCheckbox2">Before Medication</label>
|
|
</div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" <?php echo ($pdata->flush_frequency == 'After Madication')?'checked':'' ; ?> name="flush_frequency" type="radio" id="inlineCheckbox2" value="After Madication">
|
|
<label class="form-check-label" for="inlineCheckbox2">After Madication</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Fluide Restrictions'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="fluid_restriction" id="fluid_restriction_yes" value="YES" <?php echo ($pdata->fluid_restriction == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="fluid_restriction_yes">YES</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="fluid_restriction" id="fluid_restriction_no" value="NO" <?php echo ($pdata->fluid_restriction == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="fluid_restriction_no">NO</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Fluide Restriction Amount'); ?></label>
|
|
<input type="text" class="form-control" name="fluide_restric_amount"
|
|
value="<?php echo $pdata->fluide_restric_amount ; ?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1"><?php echo lang('Fluide Restriction Frequency'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" name="fluide_restric_frequency" type="radio" id="inlineCheckbox3" value="Per day" <?php echo ($pdata->fluide_restric_frequency == 'Per day')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="inlineCheckbox2">Per day</label>
|
|
</div>
|
|
<div class="form-check form-check form-check-inline">
|
|
<input class="form-check-input" name="fluide_restric_frequency" type="radio" id="inlineCheckbox4" value="Per Hour" <?php echo ($pdata->fluide_restric_frequency == 'Per Hour')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="inlineCheckbox2">Per Hour</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Md Order Recive Date'); ?></label>
|
|
<input type="date" class="form-control" name="MdOrderReciveDate" id="" value="<?=$mddata->MdOrderReciveDate?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Excoriation?'); ?></label>
|
|
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachExcoriation" id="MDTrachExcoriationYES" value="YES" <?php echo ($mddata->trach_excoriation == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDTrachExcoriationYES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachExcoriation" id="MDTrachExcoriationNO" value="NO" <?php echo ($mddata->trach_excoriation == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDTrachExcoriationNO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label> -->
|
|
<textarea class="form-control" name="MDTrachExcoriationNotes" placeholder="<?php echo lang('Notes'); ?>"><?=$mddata->trach_excoriation_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Drainage?'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachDrainage" id="MDTrachDrainageYES" value="YES" <?php echo ($mddata->trach_drainage == 'YES')?'checked':'' ; ?> >
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachDrainage" id="MDTrachDrainageNO" value="NO" <?php echo ($mddata->trach_drainage == 'NO')?'checked':'' ; ?> >
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label> -->
|
|
<textarea class="form-control" name="MDTrachDrainageNotes" id="" placeholder="<?php echo lang('Notes'); ?>"><?=$mddata->trach_drainage_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Redness At Trach Site?'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="MDredNessAtTrachSiteYES" value="YES" <?php echo ($mddata->redness_trach_site == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="YES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDredNessAtTrachSite" id="MDredNessAtTrachSiteNO" value="NO" <?php echo ($mddata->redness_trach_site == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="NO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label> -->
|
|
<textarea class="form-control" name="MDredNessAtTrachSiteNotes" id="" placeholder="<?php echo lang('Notes'); ?>"><?=$mddata->redness_trach_site_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Inner Cannula Changed?'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="MDTrachInnerCannulaChangedYES" value="YES" <?php echo ($mddata->trach_inner_cannula_changed == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDTrachInnerCannulaChangedYES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDTrachInnerCannulaChanged" id="MDTrachInnerCannulaChangedNO" value="NO" <?php echo ($mddata->trach_inner_cannula_changed == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDTrachInnerCannulaChangedNO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label> -->
|
|
<textarea class="form-control" name="MDTrachInnerCannulaChangedMdOrderNotes" id="" placeholder="<?php echo lang('Notes'); ?>"><?=$mddata->redness_trach_site_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction?'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDtrachSuction" id="MDtrachSuctionYES" value="YES" <?php echo ($mddata->trach_suction == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDtrachSuctionYES">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDtrachSuctions" id="MDtrachSuctionsNO" value="NO" <?php echo ($mddata->trach_suction == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDtrachSuctionsNO">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Notes'); ?></label> -->
|
|
<textarea class="form-control" name="MDTrachSuctionnotes" id="" placeholder="<?php echo lang('Notes'); ?>"><?=$mddata->trach_suction_notes?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Connector Size'); ?></label>
|
|
<input type="text" class="form-control onlyNumber" name="MDtrachConnectorSize" id="" value="<?=$mddata->trach_suction_notes?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Connector Length'); ?></label>
|
|
<input type="text" class="form-control onlyNumber" name="MDtrachConnectorLength" id="" value="<?=$mddata->trach_suction_notes?>">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction Type'); ?></label>
|
|
<select class="form-control" name="MDtrachSuctionType" id="" placeholder="<?php echo lang('Notes'); ?>">
|
|
<option <?php echo ($mddata->trach_suction_type == 'Oral')?'selected':'' ; ?> value="Oral">Oral</option>
|
|
<option <?php echo ($mddata->trach_suction_type == 'Nasal')?'selected':'' ; ?> value="Nasal">Nasal</option>
|
|
<option <?php echo ($mddata->trach_suction_type == 'Tracheal')?'selected':'' ; ?> value="Tracheal">Tracheal</option>
|
|
</select>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suction Catheter Kit'); ?></label>
|
|
<input type="text" class="form-control" name="MDtrachSuctionCatherKit" id="" value="<?=$mddata->trach_suction_catheter_kit?>">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Trach Suciton Catheter Kit Size'); ?></label>
|
|
<input type="text" class="form-control onlyNumber" name="MDtrachCAthertarKitSize" value="<?=$mddata->trach_suciton_catheter_kit_size?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('comments'); ?></label> -->
|
|
<textarea class="form-control" name="mdorderComments" id="" placeholder="<?php echo lang('comments'); ?>"><?=$mddata->md_orders_comments?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<?php foreach ($TRACHdocs as $trd){ ?>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
|
|
<a target="_blank" href="<?=base_url()?><?=$trd->path?><?=$trd->file_name?>">
|
|
<img src="<?=base_url()?>uploads/attachment.png" class="img-thumbnail" style="height: 50px;">
|
|
</a><?=$trd->originalfilename?>
|
|
</div>
|
|
<div class="col-lg-4">
|
|
|
|
<input type="text" class="form-control" name="otherDoc_remarks" value="<?=$trd->remarks?>">
|
|
</div>
|
|
<div class="col-lg-2">
|
|
<a href="<?=base_url()?>patient/documentDelete?fid=<?=$trd->id?>&redirect=patient/editReferal?pid=<?=$pdata->id?>" class="badge badge-pill badge-danger white">Delete</a>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<?php } ?>
|
|
|
|
|
|
|
|
|
|
<div id="mdorder_Trach"></div>
|
|
|
|
<hr class="my-2">
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<!-- <div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('MD Orders'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersNotes" id=""></textarea>
|
|
</div> -->
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Date'); ?></label>
|
|
<input type="date" class="form-control" name="MDOrdersWounddate" value="<?=$mddata->WoundDate?>">
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Type'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundType" value="<?=$mddata->WoundType?>">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Site Location'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersSiteLocation" id=""><?=$mddata->woundSiteLocation?></textarea>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Description'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersWoundDesc" id=""><?=$mddata->WoundDescription?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-12">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Measurement'); ?></label>
|
|
<textarea class="form-control" name="MDOrdersWoundMeasurment" id=""><?=$mddata->WoundMeasurement?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Lenghts'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control onlyNumber" name="MDOrdersWoundLength" id="" value="<?=$mddata->WoundLenghts?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Width'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control onlyNumber" name="MDOrdersWoundWidth" id="" value="<?=$mddata->WoundWidth?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Diameter'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control onlyNumber" name="MDOrdersWoundDiameter" value="<?=$mddata->WoundDiameter?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Undermining'); ?></label>
|
|
<span>(In Centimeter)</span>
|
|
<input type="text" class="form-control " name="MDOrdersWoundUndermining" value="<?=$mddata->WoundUndermining?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Undermining @ Clock Position'); ?></label>
|
|
|
|
<select class="form-control" name="MDOrdersWoundClockPosition" >
|
|
<option <?php echo ($mddata->MDOrdersWoundClockPosition == '12')?'selected':'' ; ?> value="12">12oh Clock</option>
|
|
<option <?php echo ($mddata->MDOrdersWoundClockPosition == '3')?'selected':'' ; ?> value="3">3oh Clock</option>
|
|
<option <?php echo ($mddata->MDOrdersWoundClockPosition == '6')?'selected':'' ; ?> value="6">6oh clock</option>
|
|
<option <?php echo ($mddata->MDOrdersWoundClockPosition == '9')?'selected':'' ; ?> value="9">9oh clock</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Cleanse With'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="mdOrdersWondsCleasnswith1" value="Normal Saline" <?php echo ($mddata->WoundCleanseWith == 'Normal Saline')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWondsCleasnswith1">
|
|
Normal Saline
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWondsCleasnswith" id="mdOrdersWondsCleasnswith2" value="0.125% Dakins Solution" <?php echo ($mddata->WoundCleanseWith == '0.125% Dakins Solution')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWondsCleasnswith2">
|
|
0.125% Dakins Solution
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Applications'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="mdOrdersWoundApplication1" value="Algisite-M" <?php echo ($mddata->WoundApplications == 'Algisite-M')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundApplication1">
|
|
Algisite-M
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="mdOrdersWoundApplication2" value="4X4 Sterile Gauze" <?php echo ($mddata->WoundApplications == '4X4 Sterile Gauze')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundApplication2">
|
|
4X4 Sterile Gauze
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundApplication" id="mdOrdersWoundApplication3" value="Santyl Ointment" <?php echo ($mddata->WoundApplications == 'Santyl Ointment')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundApplication3">
|
|
Santyl Ointment
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Applied Other'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersAppliedOther" value="<?=$mddata->AppliedOther?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Covered With'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="mdOrdersWoundCoverdWith1" value="4X4 Sterile Gauze" <?php echo ($mddata->WoundCoveredWith == '4X4 Sterile Gauze')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundCoverdWith1">
|
|
4X4 Sterile Gauze
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="mdOrdersWoundCoverdWith2" value="ExuDry" <?php echo ($mddata->WoundCoveredWith == 'ExuDry')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundCoverdWith2">
|
|
ExuDry
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="mdOrdersWoundCoverdWith3" value="Derlix" <?php echo ($mddata->WoundCoveredWith == 'Derlix')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundCoverdWith3">
|
|
Derlix
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundCoverdWith" id="mdOrdersWoundCoverdWith4" value="Combine/ABDPad" <?php echo ($mddata->WoundCoveredWith == 'Combine/ABDPad')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundCoverdWith4">
|
|
Combine/ABDPad
|
|
</label>
|
|
</div>
|
|
</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" value="<?=$mddata->CoveredwithOther?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Secured With'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="mdOrdersWoundSecureWith1" value="Paper Tape" <?php echo ($mddata->WoundSecuredWith == 'Paper Tape')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundSecureWith1">
|
|
Paper Tape
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="mdOrdersWoundSecureWith2" value="ACE Bandage" <?php echo ($mddata->WoundSecuredWith == 'ACE Bandage')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundSecureWith2">
|
|
ACE Bandage
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundSecureWith" id="mdOrdersWoundSecureWith3" value="Hypafix Tape" <?php echo ($mddata->WoundSecuredWith == 'Hypafix Tape')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundSecureWith3">
|
|
Hypafix Tape
|
|
</label>
|
|
</div>
|
|
</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" value="<?=$mddata->PackedWoundBedWith?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Status'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="mdOrdersWoundStatus1" value="Unchanged" <?php echo ($mddata->WoundSecuredWith == 'Unchanged')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundStatus1">
|
|
Unchanged
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="mdOrdersWoundStatus2" value="Healing" <?php echo ($mddata->WoundSecuredWith == 'Healing')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundStatus2">
|
|
Healing
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="mdOrdersWoundStatus3" value="Resolveds" <?php echo ($mddata->WoundSecuredWith == 'Resolveds')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundStatus3">
|
|
Resolved
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="mdOrdersWoundStatus" id="mdOrdersWoundStatus4" value="Deterioratings" <?php echo ($mddata->WoundSecuredWith == 'Deterioratings')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="mdOrdersWoundStatus4">
|
|
Deteriorating
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Granulating'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="MDOrdersWoundsGranulating1" value="YES" <?php echo ($mddata->WoundGranulating == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundsGranulating1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundsGranulating" id="MDOrdersWoundsGranulating2" value="NO" <?php echo ($mddata->WoundGranulating == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundsGranulating2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Excrotic Tissue Present'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="MDOrdersExcroticTissuePresent1" value="YES" <?php echo ($mddata->ExcroticTissuePresent == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersExcroticTissuePresent1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersExcroticTissuePresent" id="MDOrdersExcroticTissuePresent2" value="NO" <?php echo ($mddata->ExcroticTissuePresent == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersExcroticTissuePresent2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Eschar'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundEschar" value="<?=$mddata->WoundEschar?>">
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Exudate'); ?></label>
|
|
<input type="text" class="form-control" name="MDOrdersWoundExudate" value="<?=$mddata->WoundExudate?>">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Slough'); ?></label>
|
|
<select class="form-control" name="MDorderWoundSlough" id="MDorderWoundSlough">
|
|
<option value="" selected>Choose...</option>
|
|
<option <?php echo ($pdata->WoundSlough == 'Tan')?'selected':'' ; ?> value="Tan">Tan</option>
|
|
<option <?php echo ($pdata->WoundSlough == 'Grey')?'selected':'' ; ?> value="Grey">Grey</option>
|
|
<option <?php echo ($pdata->WoundSlough == 'Green')?'selected':'' ; ?> value="Green">Green</option>
|
|
<option <?php echo ($pdata->WoundSlough == 'Yellow')?'selected':'' ; ?> value="Yellow">Yellow</option>
|
|
<option <?php echo ($pdata->WoundSlough == 'White')?'selected':'' ; ?> value="White">White</option>
|
|
</select>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Present'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="MDOrdersNercroticTissuePresent1" value="YES" <?php echo ($mddata->NecroticTissuePresent == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersNercroticTissuePresent1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersNercroticTissuePresent" id="MDOrdersNercroticTissuePresent2" value="NO" <?php echo ($mddata->NecroticTissuePresent == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersNercroticTissuePresent2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Necrotic Tissue Color'); ?></label>
|
|
<select class="form-control" name="MDorderNecroticTissueColor" id="">
|
|
<option value="" selected>Choose...</option>
|
|
<option <?php echo ($pdata->NecroticTissueColor == 'Leathery')?'selected':'' ; ?> value="Leathery">Leathery</option>
|
|
<option <?php echo ($pdata->NecroticTissueColor == 'Black')?'selected':'' ; ?> value="Black">Black</option>
|
|
<option <?php echo ($pdata->NecroticTissueColor == 'Brown')?'selected':'' ; ?> value="Brown">Brown</option>
|
|
<option <?php echo ($pdata->NecroticTissueColor == 'Tan')?'selected':'' ; ?> value="Tan">Tan</option>
|
|
</select>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="MDOrdersWoundDrainage1" value="YES" <?php echo ($mddata->WoundDrainage == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundDrainage1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainage" id="MDOrdersWoundDrainage2" value="NO" <?php echo ($mddata->WoundDrainage == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundDrainage2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Type'); ?></label>
|
|
<input type="text" class='form-control' name='MDORDERWoundDrainageType' id='' value="<?=$mddata->WoundDrainageType?>">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Amount'); ?></label>
|
|
<textarea class='form-control' name='MDORDERWoundDrainageAmount' id=''></textarea>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Drainage Rate'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="MDOrdersWoundDrainageRate1" value="Light" <?php echo ($mddata->WoundDrainageRate == 'Light')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundDrainageRate1">
|
|
Light
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="MDOrdersWoundDrainageRate2" value="Modarate" <?php echo ($mddata->WoundDrainageRate == 'Modarate')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundDrainageRate2">
|
|
Modarate
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundDrainageRate" id="MDOrdersWoundDrainageRate3" value="Heavy" <?php echo ($mddata->WoundDrainageRate == 'Heavy')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundDrainageRate3">
|
|
Heavy
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Bed Appearance'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="woundBedapperance1" value="Beefy" <?php echo ($mddata->WoundBedAppearance == 'Beefy')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundBedapperance1">
|
|
Beefy
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="woundBedapperance2" value="Pink" <?php echo ($mddata->WoundBedAppearance == 'Pink')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundBedapperance2">
|
|
Pink
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="woundBedapperance3" value="Yellow" <?php echo ($mddata->WoundBedAppearance == 'Yellow')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundBedapperance3">
|
|
Yellow
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundBedapperance" id="woundBedapperance4" value="Black" <?php echo ($mddata->WoundBedAppearance == 'Black')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundBedapperance4">
|
|
Black
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comments'); ?></label> -->
|
|
<textarea class='form-control' name='woundTunnelingComment' id='' placeholder="Comments"><?=$mddata->woundTunnelingComment?></textarea>
|
|
</div>
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Tunneling'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundTunnelling" id="woundTunnelling1" value="Yes" <?php echo ($mddata->woundTunnelling == 'Yes')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundTunnelling1">
|
|
Yes
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="woundTunnelling" id="woundTunnelling2" value="No" <?php echo ($mddata->woundTunnelling == 'No')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="woundTunnelling2">
|
|
No
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Redness At Site'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="MDOrdersWoundRednessAtSite1" value="YES" <?php echo ($mddata->WoundRednessAtSite == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundRednessAtSite1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundRednessAtSite" id="MDOrdersWoundRednessAtSite2" value="NO" <?php echo ($mddata->WoundRednessAtSite == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundRednessAtSite2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MDOrdersWoundRednessAtSiteComment' id='' placeholder="<?php echo lang('Comment'); ?>"><?=$mddata->WoundRednessAtSite?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Odor'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="MDOrdersWoundOdor1" value="YES" <?php echo ($mddata->WoundOdor == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundOdor1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundOdor" id="MDOrdersWoundOdor2" value="NO" <?php echo ($mddata->WoundOdor == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundOdor2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MDOrdersWoundOdorComment' id='' placeholder="Comment"><?=$mddata->WoundOdorComments?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Swelling'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="MDOrdersWoundSwelling1" value="YES" <?php echo ($mddata->WoundSwelling == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundSwelling1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundSwelling" id="MDOrdersWoundSwelling2" value="NO" <?php echo ($mddata->WoundSwelling == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundSwelling2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MDOrdersWoundSwellingComment' id='' placeholder="Comment"><?=$mddata->WoundSwellingComments?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Wound Pain'); ?></label>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="MDOrdersWoundPain1" value="YES" <?php echo ($mddata->WoundPain == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundPain1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersWoundPain" id="MDOrdersWoundPain2" value="NO" <?php echo ($mddata->WoundPain == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersWoundPain2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MDOrdersWoundPainComment' id='' placeholder="Comment"><?=$mddata->WoundPainComments?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group">
|
|
<div class="row">
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Independent In Wound Care'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="MDOrdersPatientIndependentInWoundCare1" value="YES" <?php echo ($mddata->PatientIndependentInWoundCare == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersPatientIndependentInWoundCare1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIndependentInWoundCare" id="MDOrdersPatientIndependentInWoundCare2" value="NO" <?php echo ($mddata->PatientIndependentInWoundCare == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersPatientIndependentInWoundCare2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Patient Is Willing To Learn'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="MDOrdersPatientIsWillingToLearn1" value="YES" <?php echo ($mddata->PatientIsWillingToLearn == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersPatientIsWillingToLearn1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersPatientIsWillingToLearn" id="MDOrdersPatientIsWillingToLearn2" value="NO" <?php echo ($mddata->PatientIsWillingToLearn == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersPatientIsWillingToLearn2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group" style="display: none;">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver Is Willing To Learn'); ?></label>
|
|
<div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="MDOrdersCaregiverIsWillingToLearn1" value="YES" <?php echo ($mddata->CaregiverIsWillingToLearn == 'YES')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersCaregiverIsWillingToLearn1">
|
|
YES
|
|
</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" type="radio" name="MDOrdersCaregiverIsWillingToLearn" id="MDOrdersCaregiverIsWillingToLearn2" value="NO" <?php echo ($mddata->CaregiverIsWillingToLearn == 'NO')?'checked':'' ; ?>>
|
|
<label class="form-check-label" for="MDOrdersCaregiverIsWillingToLearn2">
|
|
NO
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MDOrdersCaregiverIsWillingToLearnComment' id='' placeholder="Comment"><?=$mddata->CaregiverIsWillingToLearnComment?></textarea>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group" style="display: none">
|
|
<div class="row">
|
|
<div class="col-lg-6">
|
|
<!-- <label for="exampleInputEmail1" ><?php echo lang('Comment'); ?></label> -->
|
|
<textarea class='form-control' name='MdOrdersLastComment' id='' placeholder="Comment"></textarea>
|
|
</div>
|
|
|
|
|
|
<div class="col-lg-6">
|
|
<label for="exampleInputEmail1" ><?php echo lang('Caregiver'); ?></label>
|
|
<input type="text" class='form-control' name='MdOrdersCaregiver' id=''>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<div class="col-md-12 form-group">
|
|
<button type="submit" name="submit" value="mdOrders_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
<!-- mdorder tab -->
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
<div use="agreementDocuploadContaner" style="display: none;">
|
|
<div class="eachagreementDocupload" action="<?php echo base_url(); ?>patient/documentsSave" enctype="multipart/form-data" use="agreementDocuploadForm">
|
|
<div class="row">
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Document (gif/jpg/png/jpeg/pdf)'); ?></label>
|
|
<input type="file" class="form-control" name="pagreeDoc[]">
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Remarks'); ?></label>
|
|
<input type="text" class="form-control" name="pagreeDoc_remarks[]">
|
|
</div>
|
|
<div class="form-group col-md-2">
|
|
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="lessPatientAgreementDocument(this);" class="img-thumbnail" style="height:30px; margin-top: 32px; cursor: pointer;">
|
|
<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="patientAgreementDocument(null);" class="img-thumbnail" style="height:30px;margin-top: 31px; cursor: pointer;">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- trach doc -->
|
|
<div use="otherUploadFormContainer" style="display: none;">
|
|
<div class="eachTrachDoc" action="<?php echo base_url(); ?>patient/documentsSave" enctype="multipart/form-data" use="otherUploadForm">
|
|
<div class="row">
|
|
<!-- <input type="hidden" name="id" id="patient_id" value="<?php echo $_GET['pid']; ?>">
|
|
<input type="hidden" name="doc_type" value="<?php echo "TRACH" ; ?>">
|
|
<input type="hidden" name="doc_id" value=""> -->
|
|
|
|
<div class="form-group col-md-6">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Other Documents (gif/jpg/png/jpeg/pdf)'); ?></label>
|
|
<input type="file" class="form-control" name="<?php echo "otherDoc" ; ?>[]">
|
|
</div>
|
|
<div class="form-group col-md-4">
|
|
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Remarks'); ?></label>
|
|
<input type="text" class="form-control" name="<?php echo "otherDoc" ; ?>_remarks[]">
|
|
</div>
|
|
<div class="form-group col-md-2">
|
|
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_other_documents(this);" class="img-thumbnail" style="height:30px; margin-top: 32px; cursor: pointer;">
|
|
<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_other_documents(null);" class="img-thumbnail" style="height:30px;margin-top: 31px; cursor: pointer;">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<script type="text/javascript">
|
|
|
|
// --agreement Docs---------------------------------------------------
|
|
|
|
patientAgreementDocument(null);
|
|
|
|
function patientAgreementDocument(data){
|
|
var appenddata = $("div[use=agreementDocuploadContaner]").find("div[use=agreementDocuploadForm]").clone();
|
|
|
|
|
|
|
|
// need to review
|
|
if(data!=null)
|
|
{
|
|
$.each($(appenddata).find("input"),function(){
|
|
var val = data[$(this).attr("name")];
|
|
if($(this).attr("type") != 'file')
|
|
{
|
|
$(this).val(val);
|
|
}
|
|
else
|
|
{
|
|
$(this).removeAttr('required');
|
|
$(this).parent().closest('div').find('label').removeClass('required-field');
|
|
}
|
|
});
|
|
|
|
if(data.OTR!='')
|
|
{
|
|
var img_data='<a target="_blank" href="'+data.OTR+'">'
|
|
+'<img src="uploads/attachment.png" class="img-thumbnail" style="height: 50px;">'
|
|
//+'<img src="uploads/uploaded.png" class="img-thumbnail" style="height: 50px;">'
|
|
+'</a>';
|
|
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
|
}
|
|
else
|
|
{
|
|
var img_data='<img src="uploads/attachment.png" class="img-thumbnail" style="height: 50px;">';
|
|
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
|
}
|
|
}
|
|
// need to review end
|
|
|
|
|
|
|
|
|
|
$('#agreementVerifiedDocument').append(appenddata);
|
|
|
|
|
|
$('#agreementVerifiedDocument').find("img[use=plusbutt]").hide();
|
|
$('#agreementVerifiedDocument').find("img[use=plusbutt]").last().show();
|
|
$('#agreementVerifiedDocument').find("img[use=minusbutt]").last().show();
|
|
if($('#agreementVerifiedDocument').find("img[use=minusbutt]").length<=1)
|
|
{
|
|
$('#agreementVerifiedDocument').find("img[use=minusbutt]").first().hide();
|
|
}
|
|
}
|
|
|
|
function lessPatientAgreementDocument(obj){
|
|
console.log(obj);
|
|
//alert()
|
|
var form = $(obj).parent().closest(".eachagreementDocupload");
|
|
// ajax
|
|
$(form).remove();
|
|
$('#agreementVerifiedDocument').find("img[use=plusbutt]").hide();
|
|
$('#agreementVerifiedDocument').find("img[use=plusbutt]").last().show();
|
|
$('#agreementVerifiedDocument').find("img[use=minusbutt]").last().show();
|
|
if($('#agreementVerifiedDocument').find("img[use=minusbutt]").length<=1)
|
|
{
|
|
$('#agreementVerifiedDocument').find("img[use=minusbutt]").first().hide();
|
|
}
|
|
}
|
|
|
|
add_other_documents(null);
|
|
|
|
function add_other_documents(data){
|
|
var appenddata = $("div[use=otherUploadFormContainer]").find("div[use=otherUploadForm]").clone();
|
|
|
|
if(data!=null)
|
|
{
|
|
$.each($(appenddata).find("input"),function(){
|
|
var val = data[$(this).attr("name")];
|
|
if($(this).attr("type") != 'file')
|
|
{
|
|
$(this).val(val);
|
|
}else{
|
|
$(this).removeAttr('required');
|
|
$(this).parent().closest('div').find('label').removeClass('required-field');
|
|
|
|
}
|
|
});
|
|
|
|
if(data.OTR!='')
|
|
{
|
|
var img_data='<a target="_blank" href="'+data.OTR+'">'
|
|
+'<img src="uploads/attachment.png" class="img-thumbnail" style="height: 50px;">'
|
|
//+'<img src="uploads/uploaded.png" class="img-thumbnail" style="height: 50px;">'
|
|
+'</a>';
|
|
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
|
}else{
|
|
var img_data='<img src="uploads/attachment.png" class="img-thumbnail" style="height: 50px;">';
|
|
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
|
}
|
|
}
|
|
|
|
$(appenddata).on("submit",function(e){
|
|
e.preventDefault();
|
|
submit_upload_form(e,this);
|
|
});
|
|
|
|
$('#mdorder_Trach').append(appenddata);
|
|
$('#mdorder_Trach').find("img[use=plusbutt]").hide();
|
|
$('#mdorder_Trach').find("img[use=plusbutt]").last().show();
|
|
$('#mdorder_Trach').find("img[use=minusbutt]").last().show();
|
|
if($('#mdorder_Trach').find("img[use=minusbutt]").length<=1)
|
|
{
|
|
$('#mdorder_Trach').find("img[use=minusbutt]").first().hide();
|
|
}
|
|
}
|
|
|
|
function less_other_documents(obj){
|
|
console.log(obj);
|
|
//alert()
|
|
var form = $(obj).parent().closest(".eachTrachDoc");
|
|
// ajax
|
|
$(form).remove();
|
|
$('#mdorder_Trach').find("img[use=plusbutt]").hide();
|
|
$('#mdorder_Trach').find("img[use=plusbutt]").last().show();
|
|
$('#mdorder_Trach').find("img[use=minusbutt]").last().show();
|
|
if($('#mdorder_Trach').find("img[use=minusbutt]").length<=1)
|
|
{
|
|
$('#mdorder_Trach').find("img[use=minusbutt]").first().hide();
|
|
}
|
|
}
|
|
|
|
function submit_upload_form(e,formObject){
|
|
e.preventDefault();
|
|
//console.log('>>>>>>>>>>');
|
|
var formObj = $(formObject);
|
|
// alert($(formObject).attr("action"));
|
|
console.log(formObj);
|
|
var from_data=new FormData(formObject);
|
|
$.ajax({
|
|
url: $(formObject).attr("action"),
|
|
type : 'POST',
|
|
data : from_data,
|
|
dataType: "text",
|
|
contentType: false,
|
|
cache: false,
|
|
processData:false,
|
|
beforeSend : function(){
|
|
//$("#preview").fadeOut();
|
|
$("#err").fadeOut();
|
|
},
|
|
success : function(data){
|
|
console.log(data);
|
|
|
|
// if(data.upload=='success'){
|
|
// Swal.fire({
|
|
// position: 'center',
|
|
// icon: 'success',
|
|
// title: data.msg,
|
|
// showConfirmButton: false,
|
|
// timer: 3500
|
|
// });
|
|
|
|
// $(formObj).find("span[use=uploadContainer]").empty();
|
|
|
|
// var insert = '<a target="_blank" href="'+data.file_url+'">'
|
|
// +'<img src="uploads/attachment.png" class="img-thumbnail" style="height: 50px;">'
|
|
// //+'<img src="uploads/uploaded.png" class="img-thumbnail" style="height: 75px;">'
|
|
// +'</a>';
|
|
// $(formObj).find("span[use=uploadContainer]").append(insert);
|
|
// }
|
|
},
|
|
error : function(err){
|
|
alert("error");
|
|
}
|
|
|
|
});
|
|
}
|
|
</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
|
|
$('#ptdob').attr('max', maxDate);
|
|
$("#referalRecDate").attr('max', maxDate);
|
|
|
|
});
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
function validateForm() {
|
|
var fldval = $("#slotEditname").val();
|
|
if (fldval == "") {
|
|
$("#msg_rm").html("<div class='alert alert-danger' role='alert'> Please enter a value</div>");
|
|
return false;
|
|
}
|
|
var fldval = $("#slotEditname").val();
|
|
var currId = $('#nameId').val();
|
|
|
|
var msgs = '';
|
|
$.ajax('master_icd/duplicateCheck', {
|
|
type: 'POST', // http method
|
|
data: { val: fldval, currId: currId }, // data to submit
|
|
async: false,
|
|
success: function(data, status, xhr) {
|
|
// $('p').append('status: ' + status + ', data: ' + data);
|
|
// alert(data);
|
|
msgs = data;
|
|
|
|
},
|
|
error: function(jqXhr, textStatus, errorMessage) {
|
|
// $('p').append('Error' + errorMessage);
|
|
alert("error duc");
|
|
|
|
}
|
|
});
|
|
if (msgs == 'exist') {
|
|
$("#msg_rm").html("<div class='alert alert-danger' role='alert'> Value already exist in the list</div>");
|
|
return false;
|
|
} else {
|
|
return true;
|
|
}
|
|
|
|
}
|
|
</script>
|
|
<script type="text/javascript">
|
|
function USformatPhoneNumber(phoneNumberString,_this) {
|
|
var cleaned = ('' + phoneNumberString).replace(/\D/g, '')
|
|
var match = cleaned.match(/^(1|)?(\d{3})(\d{3})(\d{4})$/)
|
|
if (match) {
|
|
var intlCode = (match[1] ? '+1 ' : '')
|
|
var fres = [intlCode, '(', match[2], ') ', match[3], '-', match[4]].join('')
|
|
_this.value = fres;
|
|
}
|
|
return null
|
|
}
|
|
</script>
|
|
<script>
|
|
$( document ).ready(function() {
|
|
$('.nav-item').click(function(event){
|
|
if ($(this).hasClass('disabled')) {
|
|
// return false;
|
|
}
|
|
});
|
|
});
|
|
</script>
|
|
<script type="text/javascript">
|
|
$(document).ready(function(){
|
|
// Initialize Select2
|
|
$('#ref_pt_id').select2();
|
|
|
|
// Set option selected onchange
|
|
$('#user_selected').change(function()
|
|
{
|
|
var value = $(this).val();
|
|
// Set selected
|
|
$('#ref_pt_id').val(value);
|
|
$('#ref_pt_id').select2().trigger('change');
|
|
});
|
|
});
|
|
</script>
|
|
<script type="text/javascript">
|
|
function load_progress(){
|
|
$.ajax({
|
|
url:'patient/load_progress?id=<?php echo $_GET['pid']; ?>',
|
|
type :'GET',
|
|
success:function(data){
|
|
//console.log(data);
|
|
if(data>99){ data=100; }
|
|
if(data==''){ data=0; }
|
|
$('#progress_lbl').html(data);
|
|
$('#progress_bar').html(data+'%');
|
|
$('#progress_bar').attr('aria-valuenow',data);
|
|
$('#progress_bar').attr('style','width: '+data+'%;');
|
|
}
|
|
});
|
|
}
|
|
$( document ).ready(function() {
|
|
|
|
setInterval(function(){
|
|
load_progress();
|
|
}, 1000);
|
|
});
|
|
</script>
|
|
<script>
|
|
$( document ).ready(function() {
|
|
|
|
$(".onlyNumber").keypress(function(evt){
|
|
var charCode = (evt.which) ? evt.which : evt.keyCode;
|
|
if (charCode > 31 && (charCode < 48 || charCode > 57))
|
|
return false;
|
|
return true;
|
|
})
|
|
|
|
$('.nav-item').click(function(event){
|
|
if ($(this).hasClass('disabled')) {
|
|
<?php if($pdata->form_status <=5){ ?> return false; <?php } ?>
|
|
}else{
|
|
$(".nav-item").removeClass("active");
|
|
$(this).addClass("active");
|
|
}
|
|
});
|
|
|
|
});
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
$(function(){
|
|
|
|
$("#patient_agreement_Document_Verified").click(function(){
|
|
|
|
if($('#patient_agreement_Document_Verified').prop('checked')){
|
|
$("#patientAgreementBtn").removeClass("disabled");
|
|
$("#patientAgreementBtn"). prop('disabled', false);
|
|
}
|
|
else{
|
|
$("#patientAgreementBtn").addClass("disabled");
|
|
$("#patientAgreementBtn"). prop('disabled', true);
|
|
}
|
|
|
|
});
|
|
|
|
$("#RefertoVendorDocument").click(function(){
|
|
|
|
if($('#RefertoVendorDocument').prop('checked')){
|
|
$("#insurance_type"). prop('disabled', true);
|
|
$("#insurance_plan"). prop('disabled', true);
|
|
}else{
|
|
$("#insurance_type"). prop('disabled', false);
|
|
$("#insurance_plan"). prop('disabled', false);
|
|
}
|
|
|
|
});
|
|
|
|
$('#insurance_type').change(function(){
|
|
|
|
var insType = $(this).val();
|
|
if(insType == 'Madicaid')
|
|
{
|
|
document.getElementById("medicaidInfoSection").style.display = "block";
|
|
document.getElementById("pvtInsInfoSection").style.display = "none";
|
|
}
|
|
if(insType == 'Private')
|
|
{
|
|
document.getElementById("medicaidInfoSection").style.display = "none";
|
|
document.getElementById("pvtInsInfoSection").style.display = "block";
|
|
}
|
|
})
|
|
|
|
$("#check_acElgb").click(function(){
|
|
var pid = $(this).val();
|
|
|
|
if($('#check_acElgb').prop('checked')){
|
|
$.ajax('patient/activatePatientCriterial', {
|
|
type: 'POST', // http method
|
|
data: { pid: pid ,<?php echo $this->security->get_csrf_token_name(); ?>:'<?php echo $this->security->get_csrf_hash(); ?>'}, // data to submit
|
|
async: false,
|
|
success: function (data, status, xhr) {
|
|
// msgs = data;
|
|
var resp = JSON.parse(data);
|
|
if (resp.status == '0') {
|
|
$("#msgActivation").html(resp.msg);
|
|
$("#activatePatient").addClass('disabled');
|
|
}
|
|
if (resp.status == '1') {
|
|
$("#msgActivation").html(resp.msg);
|
|
$("#activatePatient").removeClass('disabled');
|
|
}
|
|
|
|
|
|
},
|
|
error: function (jqXhr, textStatus, errorMessage) {
|
|
alert("error duc");
|
|
}
|
|
});
|
|
}
|
|
else {
|
|
$("#activatePatient").removeClass('disabled');
|
|
$("#activatePatient").addClass('disabled');
|
|
}
|
|
});
|
|
});
|
|
|
|
function secDigActive(_this){
|
|
var val = $(_this).val();
|
|
if (val=='Secondary') {
|
|
$("#secondaryDiagonosis").show();
|
|
}
|
|
else{
|
|
$("#secondaryDiagonosis").hide();
|
|
}
|
|
}
|
|
|
|
|
|
$("#advanceDirectiveIfyes").change(function(){
|
|
var val = $(this).val();
|
|
if(val == 'file-upload'){
|
|
$("#advUploadFIle").show();
|
|
}
|
|
else{
|
|
$("#advUploadFIle").hide();
|
|
}
|
|
});
|
|
|
|
$(function(){
|
|
|
|
$("#level_service").change(function(){
|
|
var valu = $("#level_service option:selected"). attr("attr_name")
|
|
// var valu = $(this).("option:selected").attr("attr_name");
|
|
// var valu = $(this).val();
|
|
if(valu != 'RN' && valu != 'LPN')
|
|
$("#rnlnp").hide();
|
|
else
|
|
$("#rnlnp").show();
|
|
|
|
});
|
|
});
|
|
</script>
|
|
|
|
<script type="text/javascript">
|
|
|
|
$(function(){
|
|
$(".paymodes").click(function(){
|
|
var paymodes = $(this).val();
|
|
if(paymodes == 'Insurance Information')
|
|
{
|
|
$(".paymodesSh").hide();
|
|
$("#insInfoSection").show();
|
|
}
|
|
if(paymodes == 'Credit or Debit Card')
|
|
{
|
|
$(".paymodesSh").hide();
|
|
$("#CreditDebitPayOpt").show();
|
|
}
|
|
if(paymodes == 'EFT')
|
|
{
|
|
$(".paymodesSh").hide();
|
|
$("#ETFPayOpt").show();
|
|
}
|
|
if(paymodes == 'Monthly Invoice')
|
|
{
|
|
$(".paymodesSh").hide();
|
|
$("#monthlyInvoicePayOpt").show();
|
|
}
|
|
|
|
});
|
|
|
|
var refInfo = "<?php echo $idata->paymentModes; ?>";
|
|
// $("#id_100 select").val("val2");
|
|
$("input[name=paymentModes][value='" + refInfo + "']").attr('checked', 'checked').trigger('click');
|
|
});
|
|
|
|
function secDigActive(_this){
|
|
var val = $(_this).val();
|
|
if (val=='Secondary') {
|
|
$("#secondaryDiagonosis").show();
|
|
}
|
|
else{
|
|
$("#secondaryDiagonosis").hide();
|
|
}
|
|
}
|
|
|
|
|
|
$("#advanceDirectiveIfyes").change(function(){
|
|
var val = $(this).val();
|
|
if(val == 'file-upload'){
|
|
$("#advUploadFIle").show();
|
|
}
|
|
else{
|
|
$("#advUploadFIle").hide();
|
|
}
|
|
});
|
|
</script>
|
|
|
|
<?php if(isset($_SESSION['ref_added'])){ ?>
|
|
<script>
|
|
Swal.fire({
|
|
position: 'center',
|
|
icon: 'success',
|
|
title: 'Referal data added',
|
|
showConfirmButton: false,
|
|
timer: 3500
|
|
})
|
|
</script>
|
|
<?php } ?>
|
|
|
|
<?php if(isset($_SESSION['ref_updated'])){ ?>
|
|
<script>
|
|
Swal.fire({
|
|
position: 'center',
|
|
icon: 'success',
|
|
title: 'Referal data Updated',
|
|
showConfirmButton: false,
|
|
timer: 3500
|
|
})
|
|
</script>
|
|
<?php } ?>
|
|
|
|
<?php if(isset($_SESSION['doc_deleted'])){ ?>
|
|
<script>
|
|
Swal.fire({
|
|
position: 'center',
|
|
icon: 'success',
|
|
title: 'Document Successfuly deleted',
|
|
showConfirmButton: false,
|
|
timer: 3500
|
|
})
|
|
</script>
|
|
<?php } ?>
|
|
|
|
<?php if(isset($_SESSION['doc_deleted_fails'])){ ?>
|
|
<script>
|
|
Swal.fire({
|
|
position: 'center',
|
|
icon: 'error',
|
|
title: 'Unable to delete the document',
|
|
showConfirmButton: false,
|
|
timer: 3500
|
|
})
|
|
</script>
|
|
<?php } ?>
|