5219 lines
419 KiB
PHP
Executable File
5219 lines
419 KiB
PHP
Executable File
<?php
|
||
|
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if($md_order->orderData!=""){
|
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$md_order_data_object=json_decode($md_order->orderData);
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}
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$medication_count=count($md_order->md_order_medication);
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// echo '<pre>'; print_r($md_order_data_object); echo '</pre>';die;
|
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$lab_order_count=count($md_order->md_order_lab_order);
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if($patient->icd_info!=""){
|
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$icd_info_object=json_decode($patient->icd_info);
|
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}
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$icd_info_count=count($icd_info_object);
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$subData['medication_count'] = $medication_count;
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$subData['lab_order_count'] = $lab_order_count;
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$subData['icd_info_count'] = $icd_info_count;
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$subData['md_order_data_object'] = $md_order_data_object;
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?>
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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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select.form-control:not([size]):not([multiple]) {
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height: calc(1.6rem + 5px) !important;
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}
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</style>
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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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<link href="https://cdnjs.cloudflare.com/ajax/libs/select2/4.0.6-rc.0/css/select2.min.css" rel="stylesheet" />
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<script src="https://cdnjs.cloudflare.com/ajax/libs/select2/4.0.6-rc.0/js/select2.min.js"></script>
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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-12">
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<h3 class="font-weight-bold"><?php echo lang('Activate Referral'); ?></h3>
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</div>
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</div>
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</div> -->
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<div class="card-header card-header-title-part card_mrgn">
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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->active_status) { ?>
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<h3 class="mar_cus"><?php echo lang('Activate Referral'); ?></h3>
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<?php }else{ ?>
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<h3 class="mar_cus"><?php echo lang('Edit 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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<?php if(!$pdata->active_status) { ?>
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<div class="col-md-12 panel-body mt-2">
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<div class="col-md-12 panel-body">
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<?php if ($pdata->progress != null) { ?>
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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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<?php } ?>
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</div>
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</div>
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<?php } ?>
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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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$tab3 = '';
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$tab4 = '';
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$tab5 = '';
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$tab6 = '';
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||
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$tabPane1 = '';
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||
$tabPane2 = '';
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||
$tabPane3 = '';
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$tabPane4 = '';
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$tabPane5 = '';
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$tabPane6 = '';
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// if(!isset($_SESSION['actPtn_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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||
// $tab6 = '';
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||
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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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||
// $tabPane6 = '';
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// }
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// if(isset($_SESSION['actPtn_stat']) && $_SESSION['actPtn_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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||
// $tab6 = '';
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||
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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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||
// $tabPane6 = '';
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||
// }
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||
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||
// if(isset($_SESSION['actPtn_stat']) && $_SESSION['actPtn_stat']=='step2'){
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||
// $tab1 = '';
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||
// $tab2 = '';
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||
// $tab3 = 'active';
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||
// $tab4 = '';
|
||
// $tab5 = '';
|
||
// $tab6 = '';
|
||
|
||
// $tabPane1 = '';
|
||
// $tabPane2 = '';
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||
// $tabPane3 = 'active in show';
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||
// $tabPane4 = '';
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||
// $tabPane5 = '';
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||
// $tabPane6 = '';
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||
// }
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||
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||
// if(isset($_SESSION['actPtn_stat']) && $_SESSION['actPtn_stat']=='step3'){
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// $tab1 = 'disabled';
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||
// $tab2 = 'disabled';
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||
// $tab3 = 'disabled';
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// $tab4 = 'active';
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||
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||
// $tabPane1 = '';
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||
// $tabPane2 = '';
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||
// $tabPane3 = '';
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// $tabPane4 = 'active in show';
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// }
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if(!isset($pdata->form_status)){
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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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if($pdata->patient_auth_stat ){
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$tab6 = '';
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||
$tab7 = '';
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}
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else{
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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}
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||
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||
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$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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$tabPane6 = '';
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$tabPane7 = '';
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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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||
$tab5 = '';
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if($pdata->patient_auth_stat ){
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$tab6 = '';
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||
$tab7 = '';
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||
}
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else{
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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}
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$tabPane1 = '';
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$tabPane2 = 'active in show';
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$tabPane3 = '';
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||
$tabPane4 = '';
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||
$tabPane5 = '';
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$tabPane6 = '';
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$tabPane7 = '';
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}
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if(isset($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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||
$tab5 = '';
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if($pdata->patient_auth_stat ){
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$tab6 = '';
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||
$tab7 = '';
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||
}
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else{
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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}
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$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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$tabPane6 = '';
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$tabPane7 = '';
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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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if($pdata->patient_auth_stat ){
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$tab6 = '';
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$tab7 = '';
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}
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else{
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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}
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$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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$tabPane6 = '';
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$tabPane7 = '';
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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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if($pdata->patient_auth_stat ){
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$tab6 = '';
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$tab7 = '';
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}
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else{
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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}
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$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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$tabPane6 = 'disabled';
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$tabPane7 = 'disabled';
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}
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if(isset($pdata->form_status) && $pdata->form_status == 5){
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = '';
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if($pdata->patient_auth_stat && $idata->payerType!='')
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{
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$tab5 = '';
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$tab6 = 'active';
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$tab7 = '';
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}
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||
else{
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$tab5 = 'active';
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$tab6 = 'disabled';
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$tab7 = 'disabled';
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||
}
|
||
|
||
|
||
$tabPane1 = '';
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$tabPane2 = '';
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$tabPane3 = '';
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$tabPane4 = '';
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if($pdata->patient_auth_stat && $idata->payerType!='')
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{
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$tabPane5 = '';
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$tabPane6 = 'active in show';
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||
$tabPane7 = '';
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}
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else{
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$tabPane5 = 'active in show';
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$tabPane6 = '';
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$tabPane7 = '';
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||
}
|
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}
|
||
|
||
if(isset($pdata->form_status) && $pdata->form_status == 6){
|
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$tab1 = '';
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$tab2 = '';
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$tab3 = '';
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$tab4 = '';
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$tab5 = '';
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if($pdata->patient_auth_stat && $idata->payerType!='')
|
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{
|
||
$tab6 = '';
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$tab7 = 'active';
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}
|
||
else{
|
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$tab6 = 'disabled';
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||
$tab7 = 'disabled';
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||
}
|
||
|
||
|
||
$tabPane1 = '';
|
||
$tabPane2 = '';
|
||
$tabPane3 = '';
|
||
$tabPane4 = '';
|
||
$tabPane5 = '';
|
||
$tabPane6 = '';
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||
$tabPane7 = 'active in show';
|
||
}
|
||
|
||
$tabStat = json_decode($pdata->from_tab_status);
|
||
$tabStatPctg = json_decode($pdata->from_tab_status_pctg);
|
||
|
||
|
||
|
||
?>
|
||
|
||
<ul class="nav nav-tabs nav-linetriangle no-hover-bg" id="myTab" role="tablist" style="border-bottom-color: #1e9ef1;; margin-bottom: 20px; border-radius: 0px;">
|
||
<li class="nav-item <?php echo $tab1; ?>">
|
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<a class="nav-link <?php echo $tab1; ?>" id="base-tab31" data-toggle="tab" href="#tab31" role="tab" aria-selected="true"><?php if( (int)$tabStatPctg->form1 < 20) { ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>General Information</a>
|
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</li>
|
||
|
||
<li class="nav-item <?php echo $tab2; ?>">
|
||
<a class="nav-link <?php echo $tab2; ?>" id="base-tab36" data-toggle="tab" href="#tab36" role="tab" aria-selected="false"><?php if (!in_array('2', $tabStat)){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>Patient Authorization & Consents</a>
|
||
</li>
|
||
|
||
<li class="nav-item <?php echo $tab3; ?>">
|
||
<a class="nav-link <?php echo $tab3; ?>" id="base-tab33" data-toggle="tab" href="#tab33" role="tab" aria-selected="false"><?php if (!in_array('3', $tabStat)){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>Service Needed</a>
|
||
</li>
|
||
|
||
<li class="nav-item <?php echo $tab4; ?>">
|
||
<a class="nav-link <?php echo $tab4; ?>" id="base-tab34" data-toggle="tab" href="#tab34" role="tab" aria-selected="false"><?php if (!in_array('4', $tabStat)){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>Payer Information</a>
|
||
</li>
|
||
|
||
<li class="nav-item <?php echo $tab5; ?>">
|
||
<a class="nav-link <?php echo $tab5; ?>" id="base-tab32" data-toggle="tab" href="#tab32" role="tab" aria-selected="false"><?php if (!in_array('5', $tabStat)){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?>Medical Information</a>
|
||
</li>
|
||
|
||
<li class="nav-item <?php echo $tab6; ?>">
|
||
<a class="nav-link <?php echo $tab6; ?>" id="base-tab37" data-toggle="tab" href="#tab37" role="tab" aria-selected="false"><?php if(!$pdata->patient_auth_stat || $idata->payerType==''){ ?> <i class="la la-expeditedssl" style="color: gray;"></i> <?php }else{ ?> <?php if (!in_array('6', $tabStat)){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?> <?php } ?>Insurance authorization</a>
|
||
</li>
|
||
<?php if(!$pdata->active_status) { ?>
|
||
<li class="nav-item <?php echo $tab7; ?>">
|
||
<a class="nav-link <?php echo $tab7; ?>" id="base-tab35" data-toggle="tab" href="#tab35" role="tab" aria-selected="false"><?php if(!$pdata->patient_auth_stat || $idata->payerType==''){ ?> <i class="la la-expeditedssl" style="color: gray;"></i> <?php }else{ ?> <?php if (!$pdata->active_status){ ?> <i class="la la-exclamation-circle" style="color: orange;"></i> <?php } ?> <?php } ?>Activate</a>
|
||
</li>
|
||
<?php } ?>
|
||
</ul>
|
||
|
||
|
||
|
||
<div class="tab-content px-1 pt-1">
|
||
|
||
<div role="tabpanel" class="tab-pane <?php echo $tabPane1; ?>" id="tab31" aria-expanded="true" aria-labelledby="base-tab31" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" name="newGenInfo" action="<?php echo base_url(); ?>referral/editReferal?pid=<?=$_GET['pid']?>" method="post" enctype="multipart/form-data" onsubmit="return validateForm1()">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="form_status" value="1">
|
||
<input type="hidden" name="tabPgs" value="10">
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<div class="form-group">
|
||
<label for="firstName3">
|
||
<?php echo lang('Referral Source'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<select class="form-control required" id="ref_info" name="pt_refrance_type" readonly="true" required="">
|
||
<option value="New Patient">New Patient</option>
|
||
<option value="Reffered by Patient">Reffered by Patient</option>
|
||
<option value="Reffered by Vendor">Reffered by Vendor</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-6" id="ref_by_ptn" style="display: none;">
|
||
<div class="form-group">
|
||
<label for="lastName3">
|
||
<?php echo lang('Patient Id'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control required" id="ref_pt_id" name="pt_refrance_value" value="<?php echo $pdata->reference_id; ?>" readonly="true" required="">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-6" id="ref_by_vendor" style="display: none;">
|
||
<div class="form-group">
|
||
<label for="lastName3">
|
||
<?php echo lang('Vendor'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<select class="form-control required" id="ref_vnd_id" name="vend_refrance_value" readonly="true" required="">
|
||
<option value="" selected>Choose...</option>
|
||
<?php foreach ($vendorList as $value) { ?>
|
||
<option <?php echo ($pdata->reference_id == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->vedor_name; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<script type="text/javascript">
|
||
$(function(){
|
||
$("#ref_info").change(function(){
|
||
var selVal = $(this).val();
|
||
if(selVal == 'Reffered by Patient')
|
||
{
|
||
$("#ref_by_ptn").attr("required", "true");
|
||
$("#ref_by_vendor").removeAttr('required');
|
||
|
||
$("#ref_by_ptn").show();
|
||
$("#ref_by_vendor").hide();
|
||
}
|
||
else if(selVal == 'Reffered by Vendor'){
|
||
|
||
$("#ref_by_vendor").attr("required", "true");
|
||
$("#ref_by_ptn").removeAttr('required');
|
||
|
||
$("#ref_by_ptn").hide();
|
||
$("#ref_by_vendor").show();
|
||
}
|
||
else{
|
||
|
||
$("#ref_by_vendor").removeAttr('required');
|
||
$("#ref_by_ptn").removeAttr('required');
|
||
|
||
$("#ref_by_ptn").hide();
|
||
$("#ref_by_vendor").hide();
|
||
}
|
||
})
|
||
var refInfo = "<?php echo $pdata->reference_information; ?>";
|
||
// $("#id_100 select").val("val2");
|
||
$('#ref_info').val(refInfo).trigger('change');
|
||
});
|
||
|
||
</script>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Referral Recieve Date'); ?></label>
|
||
<input type="date" class="form-control" name="referal_recive_date" id="referalRecDate" value="<?php echo $pdata->referral_date; ?>" required="">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Referral Type'); ?></label>
|
||
<select class="form-control" name="referal_type" id="inputGroupSelect01">
|
||
<option value="" selected >Choose...</option>
|
||
<option <?php echo ($pdata->referral_type == 'New')?'selected':'' ; ?> value="New">New</option>
|
||
<option <?php echo ($pdata->referral_type == 'Restart')?'selected':'' ; ?> value="Restart" disabled>Restart</option>
|
||
</select>
|
||
</div>
|
||
<!-- <div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Referal Address'); ?></label>
|
||
<input type="text" class="form-control" name="referal_address" id="exampleInputEmail1">
|
||
</div> -->
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Referral Mode of Contact'); ?></label>
|
||
<select class="form-control" name="referal_contact" id="inputGroupSelect01">
|
||
<option value="" selected>Choose...</option>
|
||
<option <?php echo ($pdata->referral_contact == 'Address')?'selected':'' ; ?> value="Address">Address</option>
|
||
<option <?php echo ($pdata->referral_contact == 'Email')?'selected':'' ; ?> value="Email">Email</option>
|
||
<option <?php echo ($pdata->referral_contact == 'Fax')?'selected':'' ; ?> value="Fax">Fax</option>
|
||
<option <?php echo ($pdata->referral_contact == 'Phone')?'selected':'' ; ?> value="Phone">Phone</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-md-6">
|
||
<label for="firstName3">
|
||
<?php echo lang('Level of Service needed'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<select class="form-control required" name="level_service" id="level_service">
|
||
<option value="" selected>Choose...</option>
|
||
<?php foreach ($lvlService as $value) { ?>
|
||
<option <?php echo ($pdata->level_of_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="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('First name'); ?><span class="danger">*</span></label>
|
||
<input type="text" class="form-control" name="fname"
|
||
value="<?php echo $pdata->first_name; ?>" required="">
|
||
<!-- value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('name');
|
||
}
|
||
if (!empty($nurse->name)) {
|
||
echo $nurse->name;
|
||
}
|
||
?>'> -->
|
||
</div>
|
||
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Last name'); ?><span class="danger">*</span></label>
|
||
<input type="text" class="form-control" name="lname"
|
||
value="<?php echo $pdata->last_name; ?>" required="">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('email'); ?></label>
|
||
<label for="exampleInputEmail1" class="pull-right"><?php echo lang('Do not have'); ?> <input type="checkbox" name="donothave" id="donothave"></label>
|
||
<input type="email" class="form-control" name="email" id="refEmailId" value="<?php echo $pdata->patient_email; ?>" placeholder="">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Date of Birth'); ?></label>
|
||
<input type="date" class="form-control" name="dob" value="<?php echo $pdata->dob; ?>" id='ptdob' required>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" ><?php echo lang('Gender'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">
|
||
Male
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Female">
|
||
Female
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Others" value="Others" <?php echo ($pdata->gender == 'Others')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Others">
|
||
Others
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<?php $dbData = explode(',', $pdata->primary_language); ?>
|
||
<div class="col-lg-6">
|
||
<label class="required"><?php echo lang('Language Preferances'); ?></label>
|
||
<select class="form-control" name="pnalguage[]" id="pnalguage" multiple>
|
||
<option value="" disabled="">Choose...</option>
|
||
<?php foreach ($langs as $value) { ?>
|
||
<option <?php echo (in_array($value->id, $dbData))? '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-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Telephone'); ?></label>
|
||
<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="">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Telephone 2'); ?></label>
|
||
<input type="text" class="form-control onlyNumber" onkeyup="USformatPhoneNumber(this.value,this)" minlength="10" maxlength="10" name="cellphone" value='<?php echo $pdata->cellphone; ?>' placeholder="">
|
||
</div>
|
||
<!-- <div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Cell phone'); ?></label>
|
||
<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="">
|
||
</div> -->
|
||
</div>
|
||
</div>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Social Security Number # (enter last 4 digit)'); ?><span class="danger">*</span></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">XXX - XX -</span>
|
||
</div>
|
||
<input type="text" class="form-control onlyNumber" name="socsec" value="<?php echo $pdata->soc_sec_no; ?>" minlength="4" maxlength="4" required="">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Marital Status'); ?></label>
|
||
<select class="form-control" name="merital_stat" id="inputGroupSelect01" name="pnalguage" required>
|
||
<option selected disabled>Choose...</option>
|
||
<option <?php echo ($pdata->marital_stat == 'Married')?'selected':'' ; ?> value="Married">Married</option>
|
||
<option <?php echo ($pdata->marital_stat == 'Unmarried')?'selected':'' ; ?> value="Unmarried">Unmarried</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
$HtFI = explode(',', $pdata->height);
|
||
$Htf = $HtFI[0];
|
||
$Hti = $HtFI[1];
|
||
?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
|
||
<div class="col-lg-6">
|
||
<label for="firstName3"><?php echo lang('Height (Feet/Inch)'); ?></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">Feet</span>
|
||
</div>
|
||
<select class="form-control" name="height" data-error="Please enter a valid height.">
|
||
<option value="" selected disabled>Select</option>
|
||
<?php for($i=1;$i<10;$i++){ ?>
|
||
<option value="<?php echo $i; ?>" <?php if($Htf==$i) echo 'selected'; ?>><?php echo $i; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">inch</span>
|
||
</div>
|
||
<select class="form-control" name="heightInch" required data-error="Please enter a valid height.">
|
||
<option value="" selected disabled>Select</option>
|
||
<?php for($i=0;$i<12;$i++){ ?>
|
||
<option value="<?php echo $i; ?>" <?php if($Hti==$i) echo 'selected'; ?>><?php echo $i; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Weight'); ?></label>
|
||
<input type="text" class="form-control onlyNumber" name="weight" id="exampleInputEmail1" value=<?php echo $pdata->weight; ?>>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<?php
|
||
$pAdata = json_decode($pdata->address);
|
||
?>
|
||
|
||
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="lang1">
|
||
<input type="hidden" name="long1" id="long1">
|
||
<input type="text" class="form-control" name="address1" id="address1" value="<?php echo $pAdata->address; ?>" required="">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment1" id="exampleInputEmail1" value="<?php echo $pAdata->Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity1" id="city1" value="<?php echo $pAdata->City; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState1" id="state1" value="<?php echo $pAdata->State; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty1" id="county1" value="<?php echo $pAdata->County; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode1" id="zipcode1" value="<?php echo $pAdata->Zipcode; ?>" required="">
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader1" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn1" value="1" onclick="check_parmanent_address(this);"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<?php
|
||
$pAltAdata = json_decode($pdata->alt_address);
|
||
?>
|
||
|
||
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Alternating Billing Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<input type="hidden" name="lang2" id="lang2">
|
||
<input type="hidden" name="long2" id="long2">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="alt_address" id="address2" value="<?php echo $pAltAdata->address; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="altApartment" id="exampleInputEmail1" value="<?php echo $pAltAdata->Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AltCity" id="city2" value="<?php echo $pAltAdata->City; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="altState" id="state2" value="<?php echo $pAltAdata->State; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="altCounty" id="county2" value="<?php echo $pAltAdata->County; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="altZipcode" id="zipcode2" value="<?php echo $pAltAdata->Zipcode; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_alternative_address_loader2" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_alternative_address_btn2" value="2" onclick="check_parmanent_address(this);"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('Direction'); ?></label>
|
||
<textarea class="form-control" name="direction" id="exampleInputEmail1" ><?php echo $pdata->direction; ?></textarea>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-12 form-group row mt-1" >
|
||
<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
|
||
</form>
|
||
</div>
|
||
<!-- patient agreement -->
|
||
<div role="tabpanel" class="tab-pane <?php echo $tabPane2; ?>" id="tab36" aria-expanded="true" aria-labelledby="base-tab36" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>referral/editReferal?pid=<?php echo $_GET['pid']; ?>" method="post" enctype="multipart/form-data" name="patientAgreementFrom" onsubmit="return validateForm4()" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="form_status" value="2">
|
||
<input type="hidden" name="tabPgs" value="10">
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>2) echo 'Edit'; else echo 'Add'; ?>">
|
||
<!-- <hr class="my-2"> -->
|
||
<h4 class="font-weight-bold">Advance Directive</h4>
|
||
<hr class="my-2">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Advance Directive'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="advanceDirective" id="Advance_yes" value="YES" <?php echo ($idata->AdvDirective == 'YES')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Advance_yes">
|
||
YES
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="advanceDirective" id="Advance_no" value="NO" <?php echo ($idata->AdvDirective == 'NO')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Advance_no">
|
||
NO
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('IF YES'); ?></label>
|
||
<select class="form-control" name="advanceDirectiveIfyes" id="advanceDirectiveIfyes">
|
||
<option value="" selected>Choose...</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "Do not Resuticate") echo 'selected'; ?> value="Do not Resuticate">Do not Resuticate</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "Living Will") echo 'selected'; ?> value="Living Will">Living Will</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "Health Care Proxy") echo 'selected'; ?> value="Health Care Proxy">Health Care Proxy</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "New York Health Care Proxy") echo 'selected'; ?> value="New York Health Care Proxy">New York Health Care Proxy</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "Other") echo 'selected'; ?> value="Other">Other</option>
|
||
<option <?php if($idata->AdvDirectiveIfYes == "File Upload") echo 'selected'; ?> value="file-upload" disabled>File Upload</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Date Recived'); ?></label>
|
||
<input type="date" class="form-control" name="advDateREcived" id="advDateREcived" placeholder="" value="<?php echo $idata->AdvDirectiveDateRecived; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6" id="advUploadFIle" style="display: none;">
|
||
<label for="exampleInputEmail1"><?php echo lang('Upload file'); ?></label>
|
||
<input type="file" class="form-control" name="advUploadFIle" placeholder="">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('DNR'); ?></label>
|
||
<input type="text" class="form-control" name="advDNR" id="advDNR" value="<?php echo $idata->advDnr; ?>" placeholder="" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Date Effective'); ?></label>
|
||
<input type="date" class="form-control" name="advDateEffective" id="advDateEffective" value="<?php echo $idata->AdvDirectiveDateRecived; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Physician'); ?></label>
|
||
<input type="text" class="form-control" name="advDateREcived" id="advDateREcived" value="<?php echo $idata->AdvDirectiveEffective; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- advance directive -->
|
||
<hr class="my-2">
|
||
<h4 class="font-weight-bold">Emergency contact</h4>
|
||
<hr class="my-2">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('First Name'); ?></label>
|
||
<input type="text" class="form-control" name="emgNamefname" id="exampleInputEmail1" value="<?php echo $idata->emgContactFirstName; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Last Name'); ?></label>
|
||
<input type="text" class="form-control" name="emgNamelname" id="exampleInputEmail1" value="<?php echo $idata->emgContactLastName; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Relationship to the Patient'); ?></label>
|
||
<!-- <input type="text" class="form-control" name="emgRelationtoPt" id="exampleInputEmail1" value="<?php echo $idata->emgContactRelation; ?>"> -->
|
||
<select class="form-control" name="emgRelationtoPt" >
|
||
<option value="" disabled>Choose...</option>
|
||
<?php foreach ($relationList as $value) { ?>
|
||
<option <?php echo ($idata->emgContactRelation == $value->name)?'selected':'' ; ?> value="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<?php $iAdata = json_decode($idata->emgContactAddress); ?>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<!-- <input type="hidden" name="lang2" id="lang2">
|
||
<input type="hidden" name="long2" id="long2"> -->
|
||
<input type="text" class="form-control" name="address3" id="address3" value="<?php echo $iAdata->address; ?>" required="">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment3" id="AddrApartment3" value="<?php echo $iAdata->Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity3" id="city3" value="<?php echo $iAdata->City; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState3" id="state3" value="<?php echo $iAdata->State; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty3" id="county3" value="<?php echo $iAdata->County; ?>" required="" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode3" id="zipcode3" value="<?php echo $iAdata->Zipcode; ?>" required="">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader3" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn3" value="3" onclick="check_parmanent_address(this);"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</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" class="form-control form-control onlyNumber" onkeyup="USformatPhoneNumber(this.value,this)" name="emgTelephone" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Other Number'); ?></label>
|
||
<input type="text" class="form-control form-control onlyNumber" onkeyup="USformatPhoneNumber(this.value,this)" name="emgOtrNumber" id="exampleInputEmail1" value="<?php echo $idata->emgContactOteNo; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Email'); ?></label>
|
||
<input type="text" class="form-control" name="emgEmail" id="exampleInputEmail1" value="<?php echo $idata->emgContactEmail; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Lives with Patient'); ?></label>
|
||
<!-- <input type="text" class="form-control" name="emglivesWithPatient" id="exampleInputEmail1" value="<?php echo $idata->emgContactLiveswithPatient; ?>"> -->
|
||
|
||
<div class="col-lg-6">
|
||
<!-- <label for="exampleInputEmail1"><?php echo lang('Access to home'); ?></label> -->
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="emglivesWithPatient" id="Lives_yes" value="YES" <?php echo ($idata->emgContactLiveswithPatient == 'YES')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Lives_yes">
|
||
YES
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="emglivesWithPatient" id="Lives_no" value="NO" <?php echo ($idata->emgContactLiveswithPatient == 'NO')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Lives_no">
|
||
NO
|
||
</label>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<!-- <label for="exampleInputEmail1"><?php echo lang('Access to home'); ?></label> -->
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="emgAccessTohome" id="Have_keys" value="Have keys" <?php echo ($idata->emgContactAccessToHome == 'Have keys')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Have_keys">
|
||
Have keys
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="emgAccessTohome" id="Access_to_home" value="Access to home" <?php echo ($idata->emgContactAccessToHome == 'Access to home')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Access_to_home">
|
||
Access to home
|
||
</label>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
<!-- emergency contact -->
|
||
|
||
<hr class="my-2">
|
||
<div class="form-group pull-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Same as general'); ?>
|
||
<input type="checkbox" name="" id="designateSame">
|
||
</label>
|
||
</div>
|
||
|
||
<h4 class="font-weight-bold">Designate Other</h4>
|
||
<hr class="my-2">
|
||
<script type="text/javascript">
|
||
$("#designateSame").click(function(){
|
||
|
||
if($('#designateSame').prop('checked')){
|
||
document.forms["patientAgreementFrom"]["dg_fname"].value = document.forms["newGenInfo"]["fname"].value;
|
||
document.forms["patientAgreementFrom"]["dg_lname"].value = document.forms["newGenInfo"]["lname"].value;
|
||
document.forms["patientAgreementFrom"]["dg_telephone"].value = document.forms["newGenInfo"]["telephone"].value;
|
||
document.forms["patientAgreementFrom"]["dg_cell"].value = document.forms["newGenInfo"]["cellphone"].value;
|
||
}else{
|
||
document.forms["patientAgreementFrom"]["dg_fname"].value = "";
|
||
document.forms["patientAgreementFrom"]["dg_lname"].value = "";
|
||
document.forms["patientAgreementFrom"]["dg_telephone"].value = "";
|
||
document.forms["patientAgreementFrom"]["dg_cell"].value = "";
|
||
}
|
||
|
||
});
|
||
</script>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<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('Other Telephone'); ?></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="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Email'); ?></label>
|
||
<input type="email" class="form-control" name="dg_email" value='<?php echo $pdata->designate_email; ?>'>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-12 mb-2">
|
||
<a class="badge badge-primary btn-sm badge_new_btn pull-right" target="_blank" href="<?=base_url()?>referral/patientAgreementForm?pid=<?=$pdata->id?>" style="padding: 5px 5px 7px !important;"> <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 class="required" for="patient_agreement_Document_Verified"><?php echo lang('Document Verified'); ?></label>
|
||
<input type="checkbox" name="patient_agreement_Document_Verified" class="form-group" id="patient_agreement_Document_Verified" value="Verified" <?php echo ($pdata->patient_auth_stat == '1')?'checked' : ''; ?>>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class=" col-md-12" id="msgActivation">
|
||
</div>
|
||
</div>
|
||
<?php foreach ($PAGDdocs as $trd){ ?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<a target="_blank" href="<?=base_url()?><?=$trd->path?><?=$trd->file_name?>">
|
||
<img src="<?=base_url()?>uploads/attachment.png" class="img-thumbnail" style="height: 30px;">
|
||
</a><?=$trd->originalfilename?>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
|
||
<!-- <input type="text" class="form-control" name="otherDoc_remarks" value="<?=$trd->remarks?>"> -->
|
||
<p class="form-control"> <?=$trd->remarks?> </p>
|
||
</div>
|
||
<div class="col-lg-2">
|
||
<a href="<?=base_url()?>referral/documentDelete?fid=<?=$trd->id?>&redirect=referral/editReferal?pid=<?=$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 <?php echo ($pdata->patient_auth_stat != '1')?'disabled' : ''; ?>" <?php echo ($pdata->patient_auth_stat != '1')?'disabled' : ''; ?>><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<!-- patient agreement -->
|
||
|
||
<div class="tab-pane <?php echo $tabPane3; ?>" id="tab33" aria-labelledby="base-tab33" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>referral/editReferal?pid=<?php echo $_GET['pid']; ?>" method="post" enctype="multipart/form-data">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<div class="form-group">
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<input type="hidden" name="form_status" value="3">
|
||
<input type="hidden" name="tabPgs" value="20">
|
||
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>3) echo 'Edit'; else echo 'Add'; ?>">
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Level of care needed'); ?></label>
|
||
<select class="form-control" name="level_care" id="inputGroupSelect01">
|
||
<option >Choose...</option>
|
||
<option <?php echo ($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('Service Activity/Therapy Needed'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<!-- <?php var_dump($serviceActivityTherapy); ?> -->
|
||
<select class="form-control required" name="service_activity" id="service_activity" required="">
|
||
<option value="" selected>Choose...</option>
|
||
<option value="Lab Draw">Lab Draw</option>
|
||
<?php foreach ($serviceActivityTherapy as $datas) { ?>
|
||
<?php $saTypeVal = ($pdata->service_type_required=='Service')? $pdata->service_ids : $pdata->therapy_ids ; ?>
|
||
<option <?php echo ($pdata->service_type_required.'~'.$saTypeVal == $datas['value'])?'selected':'' ; ?> value="<?=$datas['value']?>"><?=$datas['name']?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php $dbData = explode(',', $pdata->type_access); // var_dump($dbData); ?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<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="type_access" multiple>
|
||
<option value="" disabled>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 class="col-lg-6">
|
||
<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>
|
||
|
||
<!-- <hr class="my-1">
|
||
<h4 class="font-weight-bold">Medication</h4>
|
||
<hr class="my-1"> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Name'); ?></label>
|
||
<select class="form-control" name="medication_name" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Frequency'); ?></label>
|
||
<select class="form-control" name="medication_frequency" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Route'); ?></label>
|
||
<select class="form-control" name="medication_route" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
<script type="text/javascript">
|
||
$("#service_activity").change(function(){
|
||
if ($(this).val() == 'Lab Draw')
|
||
{
|
||
$("#forLabDraw").show();
|
||
}
|
||
else
|
||
{
|
||
$("#forLabDraw").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div id="forLabDraw" style="display: none;">
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Lab Company</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Lab Company'); ?></label>
|
||
<select class="form-control" name="lab_company" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
<option value="">LabCorp</option>
|
||
<option value="">Quest</option>
|
||
<option value="">Other</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Type of Labs Required'); ?></label>
|
||
<select class="form-control" name="Type_lab_required" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
<option value="">Quest</option>
|
||
<option value="">Other</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Lab Frequency</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Intervals'); ?></label>
|
||
<select class="form-control" name="Intervals" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
<option value="Intervals are Daily">Intervals are Daily</option>
|
||
<option value="Weekly">Weekly</option>
|
||
<option value="Once a Week">Once a Week</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Day'); ?></label>
|
||
<select class="form-control" name="Day" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Time'); ?></label>
|
||
<select class="form-control" name="Time" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</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 $pdata->formula; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Flush With (Water)'); ?></label>
|
||
<select class="form-control" name="flush_with" id="inputGroupSelect01">
|
||
<option value="" selected>Choose...</option>
|
||
<?php for($i = 10; $i<=240; $i++) { ?>
|
||
<option <?php echo ($pdata->flush_with == $i)?'selected':'' ; ?> value="<?=$i?>"><?php echo $i; ?> ML</option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Flush Frequency'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check form-check-inline">
|
||
<input class="form-check-input" <?php echo ($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('Daily Intake Requirment'); ?></label>
|
||
<input type="text" class="form-control" name="daily_intake_requirment" value="<?php echo $pdata->daily_intake_requirment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Fluide Restrictions'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="fluid_restriction" id="fluid_restriction_yes" value="YES" <?php echo ($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>
|
||
|
||
<!-- lab draw div -->
|
||
</div>
|
||
<!-- lab draw 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>
|
||
|
||
|
||
<div class="tab-pane <?php echo $tabPane4; ?>" id="tab34" aria-labelledby="base-tab34" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>referral/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 $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="form_status" value="4">
|
||
<input type="hidden" name="tabPgs" value="20">
|
||
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>4) echo 'Edit'; else echo 'Add'; ?>">
|
||
<!-- <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 $pdata->payerType; ?>"> -->
|
||
<select class="form-control" name="payerType" id="payer_type_1" required="">
|
||
<option value="" selected disabled="">Choose...</option>
|
||
<?php foreach ($payerType as $value) { ?>
|
||
<option <?php echo ($pdata->payerType == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->name; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-2">
|
||
<div class="form-group">
|
||
<div class="row" id="pmodeRow" style="display: none;">
|
||
<div class="col-md-3 pmodes" id="CreditDebit">
|
||
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="CreditorDebitCard" value="Credit or Debit Card">
|
||
<label class="form-check-label" for="CreditorDebitCard">
|
||
Credit or Debit Card
|
||
</label>
|
||
</div>
|
||
<div class="col-md-3 pmodes" id="etf">
|
||
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="EFT" value="EFT">
|
||
<label class="form-check-label" for="EFT">
|
||
EFT
|
||
</label>
|
||
</div>
|
||
<div class="col-md-3 pmodes" id="monthlyInvoice">
|
||
<input class="form-check form-check-inline paymodes" type="radio" name="paymentModes" id="MonthlyInvoice" value="Monthly Invoice">
|
||
<label class="form-check-label" for="MonthlyInvoice">
|
||
Monthly Invoice
|
||
</label>
|
||
</div>
|
||
<div class="col-md-3 pmodes" id="InsuranceInformation">
|
||
<input class="form-check form-check-inline paymodes" type="radio" style="display:none;" name="paymentModes" id="InsuranceInformationradio" value="Insurance Information">
|
||
<label class="form-check-label" for="InsuranceInformation">
|
||
Insurance Information
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<span id="insInfoSection" class="paymodesSh" style="display: none;">
|
||
<hr class="my-2">
|
||
<h4 class="font-weight-bold">Insurance Information</h4>
|
||
<hr class="my-2">
|
||
<div class="form-group">
|
||
|
||
<div class="row" style="display: <?php echo ($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" notRequired="TRUE">
|
||
<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" >Madicaid(MCOs)</option>
|
||
<option value="Private" >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>
|
||
<?php foreach ($insuranceCompanyList as $value) { ?>
|
||
<option <?php echo ($pdata->reference_id == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>"><?php echo $value->vedor_name; ?></option>
|
||
<?php } ?>
|
||
</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>
|
||
</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>
|
||
|
||
|
||
<!-- md info -->
|
||
<div role="tabpanel" class="tab-pane <?php echo $tabPane5; ?>" id="tab32" aria-expanded="true" aria-labelledby="base-tab32" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="editReferal?pid=<?php echo $_GET['pid']; ?>" 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 $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="form_status" value="5">
|
||
<input type="hidden" name="tabPgs" value="10">
|
||
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>4) echo 'Edit'; else echo 'Add'; ?>">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Primary Care Physician/MD Info (NPI)'); ?><span class="danger">*</span></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">
|
||
NPI
|
||
<!-- <span id="npiNoValidating" style="display: none"><i class="la la-hourglass-start" style="color: blue;"></i></span>
|
||
<span id="npiValid" style="display: none"><i class="la la-check" style="color: green;"></i></span>
|
||
<span id="npiinValid" style="display: none"><i class="la la-close" style="color: red;"></i></span> -->
|
||
</span>
|
||
</div>
|
||
<input type="text" class="form-control" name="primaryCarePhyMdInfo" id="phymdNPI" value="<?php echo $pdata->primaryCarePhyMdNpi; ?>" minlength="10" maxlength="10" required>
|
||
<div class="input-group-append" id="npivalidateTab" style="display: none;">
|
||
<span class="input-group-text" >
|
||
<span id="npiNoValidating" style="display: none"><i class="la la-hourglass-start" style="color: blue;"></i></span>
|
||
<span id="npiValid" style="display: none"><i class="la la-check" style="color: green;">Valid</i></span>
|
||
<span id="npiinValid" style="display: none"><i class="la la-close" style="color: red;">Invalid</i></span>
|
||
</span>
|
||
</div>
|
||
</div>
|
||
<input type="hidden" name="npivalidate" id="npivalidate" value="<?php if($pdata->primaryCarePhyMdNpi!=""){echo "valid";} ?>">
|
||
</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 $pdata->diagnosis; ?>">
|
||
</div> -->
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="col-md-12 form-group row mt-1">
|
||
<button type="submit" name="submit" value="mdOrders_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</form>
|
||
<?php if($pdata->primaryCarePhyMdNpi!=""){ ?>
|
||
<?php $this->load->view('md_order/OrderInsideView',$subData); ?>
|
||
<?php $this->load->view('md_order/InsideFooterScript',$subData); ?>
|
||
<?php } ?>
|
||
</div>
|
||
<!-- md info -->
|
||
|
||
<!-- insurance authotization -->
|
||
<div role="tabpanel" class="tab-pane <?php echo $tabPane6; ?>" id="tab37" aria-expanded="true" aria-labelledby="base-tab37" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>referral/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 $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="fromType" value="activeRef">
|
||
<input type="hidden" name="pid" value="<?=$pid?>">
|
||
<input type="hidden" name="form_status" value="6">
|
||
<input type="hidden" name="tabPgs" value="20">
|
||
<input type="hidden" name="form_mode" value="<?php if($pdata->form_status>4) echo 'Edit'; else echo 'Add'; ?>">
|
||
<!-- <?php var_dump($insCompanyDetails); ?> -->
|
||
|
||
|
||
<div class="row">
|
||
<div class="col-12">
|
||
<!-- <div class="card">
|
||
<hr class="mt-0 mb-0" />
|
||
</div> -->
|
||
|
||
|
||
<div class="card-body">
|
||
<?php if($idata->paymentModes == 'Insurance Information'){ ?>
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Fax No.'); ?></label>
|
||
<input type="text" class="form-control" name="InsfaxNo" value="<?php echo $insCompanyDetails->fax_no; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Web Addrress'); ?></label>
|
||
<input type="text" class="form-control" name="InsWebAdd" value="<?php echo $insCompanyDetails->web_address; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('EIN No'); ?></label>
|
||
<input type="text" class="form-control" name="InsEin" value="<?php echo $insCompanyDetails->ein_no; ?>" minlength="9" maxlength="9">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-6">
|
||
<label for="firstName3" class="required"><?php echo lang('Contract Period'); ?></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">Start</span>
|
||
</div>
|
||
<input type="date" class="form-control" name="InsContractStart" value="<?php echo $idata->InsContractStart; ?>" required>
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">End</span>
|
||
</div>
|
||
<input type="date" class="form-control" name="InsContractEnd" value="<?php echo $idata->InsContractEnd; ?>" required>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Location'); ?></label>
|
||
<input type="text" class="form-control" name="InsLocation" value="<?php echo $idata->InsEin; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Notes'); ?></label>
|
||
<textarea class="form-control" name="InsNotes"><?php echo $idata->InsEin; ?></textarea>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<label for="firstName3">
|
||
<?php echo lang('Skilled Nursing Care'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
|
||
<select class="form-control" name="skilled_nursing_care" id="skilled_nursing_care" required="">
|
||
<option value="" selected>Choose...</option>
|
||
<?php foreach ($skillNursingCare as $value) { ?>
|
||
<option <?php echo ($idata->skilled_nursing_care == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>" attr_name="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
|
||
<div class="col-md-6">
|
||
<label for="firstName3">
|
||
<?php echo lang('HCPCS/CPT CODES'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<select class="form-control" name="HCPCS_codes" id="HCPCS_codes" required="">
|
||
<option value="" selected>Choose...</option>
|
||
<?php foreach ($HCPCSCodes as $value) { ?>
|
||
<option <?php echo ($idata->HCPCS_codes == $value->id)?'selected':'' ; ?> value="<?php echo $value->id; ?>" attr_name="<?php echo $value->name; ?>"><?php echo $value->name; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class=" col-md-12">
|
||
<label for="ins_agreement_doc_Verified" class="required"><?php echo lang('Insurance Document Verified'); ?></label>
|
||
<input type="checkbox" name="ins_agreement_doc_Verified" class="form-group" id="ins_agreement_doc_Verified" value="Verified" <?php echo ($pdata->insurance_auth_stat == '1')?'checked' : ''; ?>>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class=" col-md-12" id="InsMsgActivation">
|
||
</div>
|
||
</div>
|
||
<?php foreach ($INSDdocs as $trd){ ?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<a target="_blank" href="<?=base_url()?><?=$trd->path?><?=$trd->file_name?>">
|
||
<img src="<?=base_url()?>uploads/attachment.png" class="img-thumbnail" style="height: 30px;">
|
||
</a><?=$trd->originalfilename?>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
|
||
<input type="text" class="form-control" name="otherDoc_remarks" value="<?=$trd->remarks?>">
|
||
</div>
|
||
<div class="col-lg-2">
|
||
<a href="<?=base_url()?>referral/documentDelete?fid=<?=$trd->id?>&redirect=referral/activatePatient?pid=<?=$pdata->id?>" class="badge badge-pill badge-danger white">Delete</a>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php } ?>
|
||
<div class="row">
|
||
<div class=" col-md-12" id="insVerifiedDocument">
|
||
</div>
|
||
</div>
|
||
<?php } else { ?>
|
||
<div class="row">
|
||
<div class=" col-md-12">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Varification not mandetory (please check to skip)'); ?></label>
|
||
<input type="checkbox" name="ins_agreement_doc_Verified" class="form-group" id="ins_agreement_doc_Verified" value="Verified" <?php echo ($pdata->insurance_auth_stat == '1')?'checked' : ''; ?>>
|
||
</div>
|
||
</div>
|
||
<?php } ?>
|
||
<div class="row">
|
||
<div class="col-md-12 form-group mt-1">
|
||
<button type="submit" name="submit" value="insAgreement" id="insAgreementBtn" class="btn btn-info <?php echo ($pdata->patient_auth_stat != '1')?'disabled' : ''; ?>" <?php echo ($pdata->insurance_auth_stat != '1')?'disabled' : ''; ?>><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<!-- insurance authotization -->
|
||
|
||
|
||
<div class="tab-pane <?php echo $tabPane7; ?>" id="tab35" aria-labelledby="base-tab35" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<!-- activation frame -->
|
||
<div class="row">
|
||
<div class="col-12">
|
||
<!-- <div class="card">
|
||
<hr class="mt-0 mb-0" />
|
||
</div> -->
|
||
<div class="card-body">
|
||
<div class="row">
|
||
<div class=" col-md-12">
|
||
<label for="check_acElgb" class="required"><?php echo lang('Activate referral'); ?></label>
|
||
<input type="checkbox" name="activation" class="form-group" id="check_acElgb" value="<?=$pid?>">
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class=" col-md-12" id="msgActivationCtra">
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-12 form-group">
|
||
<a href="activateReferral?pid=<?php echo $_GET['pid']; ?>&activate=true" id="activatePatient" value="services" class="btn btn-info disabled pull-left"><?php echo lang('Activate'); ?></a>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
<!-- activation frame -->
|
||
</div>
|
||
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</section>
|
||
</div>
|
||
<div use="insuranceDocuploadContaner" style="display: none;">
|
||
<div class="eachinsuranceDocupload" action="<?php echo base_url(); ?>referral/documentsSave" enctype="multipart/form-data" use="insuranceDocuploadForm">
|
||
<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="<?php echo "insDoc" ; ?>[]">
|
||
</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 "insDoc" ; ?>_remarks[]">
|
||
</div>
|
||
|
||
<div class="form-group col-md-2">
|
||
<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="lessinsAgreementDocument(this);" class="img-thumbnail" style="height:30px; margin-top: 20px; cursor: pointer;" >
|
||
<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="insAgreementDocument(null);" class="img-thumbnail" style="height:30px;margin-top: 20px; cursor: pointer;">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div use="agreementDocuploadContaner" style="display: none;">
|
||
<div class="eachagreementDocupload" action="<?php echo base_url(); ?>referral/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="<?php echo "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="<?php echo "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: 20px; cursor: pointer;" >
|
||
<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="patientAgreementDocument(null);" class="img-thumbnail" style="height:30px;margin-top: 20px; cursor: pointer;">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div use="otherUploadFormContainer" style="display: none;">
|
||
<div class="eachTrachDoc" action="<?php echo base_url(); ?>referral/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: 20px;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: 20px;cursor: pointer;" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<script type="text/javascript">
|
||
$(function(){
|
||
|
||
$("#payer_type_1").change(function(){
|
||
$ptype = $(this).val();
|
||
$("#pmodeRow").show();
|
||
$(".paymodesSh").hide();
|
||
$(".pmodes").hide();
|
||
$(".paymodes").attr('checked', false);
|
||
|
||
if ($ptype == '1') {
|
||
$("#CreditDebit").show();
|
||
$("#etf").show();
|
||
$("#monthlyInvoice").show();
|
||
}
|
||
else if ($ptype == '2' || $ptype == '3' || $ptype == '4') {
|
||
$("#InsuranceInformation").show();
|
||
$("#insInfoSection").show();
|
||
$("#InsuranceInformationradio").attr('checked', true);
|
||
setRequiredFields($("#insCommonInfoSection"));
|
||
}
|
||
if ($ptype == '5') {
|
||
$("#etf").show();
|
||
$("#monthlyInvoice").show();
|
||
}
|
||
});
|
||
|
||
var payerType = "<?php echo $idata->payerType; ?>";
|
||
var paymode = "<?php echo $idata->paymentModes; ?>";
|
||
|
||
if(payerType!='' && paymode != '')
|
||
{
|
||
$('#payer_type_1').val(payerType).trigger('change');
|
||
// $("input[name=payerType][value='" + payerType + "']").attr('selected', 'selected').trigger('change');
|
||
$("input[name=paymentModes][value='" + paymode + "']").attr('checked', 'checked').trigger('click');
|
||
|
||
if (paymode == 'Insurance Information')
|
||
{
|
||
var insType = "<?php echo $idata->insurance_type; ?>";
|
||
$('#insurance_type').val(insType).trigger('change');
|
||
}
|
||
}
|
||
|
||
$("#donothave").click(function(){
|
||
|
||
if($('#donothave').prop('checked'))
|
||
{
|
||
$("#refEmailId"). prop('disabled', true);
|
||
}else
|
||
{
|
||
$("#refEmailId"). prop('disabled', false);
|
||
}
|
||
});
|
||
|
||
$(".paymodes").click(function(){
|
||
var paymodes = $(this).val();
|
||
$(".paymodesSh").hide();
|
||
if(paymodes == 'Insurance Information')
|
||
{
|
||
$("#insInfoSection").show();
|
||
setRequiredFields($("#insInfoSection"));
|
||
}
|
||
if(paymodes == 'Credit or Debit Card')
|
||
{
|
||
$("#CreditDebitPayOpt").show();
|
||
setRequiredFields($("#CreditDebitPayOpt"));
|
||
}
|
||
if(paymodes == 'EFT')
|
||
{
|
||
$("#ETFPayOpt").show();
|
||
setRequiredFields($("#ETFPayOpt"));
|
||
}
|
||
if(paymodes == 'Monthly Invoice')
|
||
{
|
||
$("#monthlyInvoicePayOpt").show();
|
||
setRequiredFields($("#monthlyInvoicePayOpt"));
|
||
}
|
||
});
|
||
|
||
function setRequiredFields(targetspan)
|
||
{
|
||
$("#insInfoSection").find("input, select, textarea").removeAttr("required");
|
||
$("#CreditDebitPayOpt").find("input, select, textarea").removeAttr("required");
|
||
$("#ETFPayOpt").find("input, select, textarea").removeAttr("required");
|
||
$("#monthlyInvoicePayOpt").find("input, select, textarea").removeAttr("required");
|
||
|
||
$.each($(targetspan).find("input, select, textarea"), function(){
|
||
if($(this).attr("notRequired")=="TRUE")
|
||
{
|
||
// do nothinh
|
||
}
|
||
else
|
||
{
|
||
$(this).attr("required","required");
|
||
}
|
||
|
||
});
|
||
}
|
||
|
||
$('#pnalguage').select2();
|
||
$('#type_access').select2();
|
||
})
|
||
|
||
</script>
|
||
|
||
|
||
<script type="text/javascript">
|
||
// --insurance Docs---------------------------------------------------
|
||
insAgreementDocument(null);
|
||
|
||
function insAgreementDocument(data){
|
||
var appenddata = $("div[use=insuranceDocuploadContaner]").find("div[use=insuranceDocuploadForm]").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: 30px;">'
|
||
//+'<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: 30px;">';
|
||
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
||
}
|
||
}
|
||
|
||
|
||
$('#insVerifiedDocument').append(appenddata);
|
||
$('#insVerifiedDocument').find("img[use=plusbutt]").hide();
|
||
$('#insVerifiedDocument').find("img[use=plusbutt]").last().show();
|
||
$('#insVerifiedDocument').find("img[use=minusbutt]").last().show();
|
||
if($('#insVerifiedDocument').find("img[use=minusbutt]").length<=1)
|
||
{
|
||
$('#insVerifiedDocument').find("img[use=minusbutt]").first().hide();
|
||
}
|
||
}
|
||
function lessinsAgreementDocument(obj){
|
||
console.log(obj);
|
||
//alert()
|
||
var form = $(obj).parent().closest(".eachinsuranceDocupload");
|
||
// ajax
|
||
$(form).remove();
|
||
$('#insVerifiedDocument').find("img[use=plusbutt]").hide();
|
||
$('#insVerifiedDocument').find("img[use=plusbutt]").last().show();
|
||
$('#insVerifiedDocument').find("img[use=minusbutt]").last().show();
|
||
if($('#insVerifiedDocument').find("img[use=minusbutt]").length<=1)
|
||
{
|
||
$('#insVerifiedDocument').find("img[use=minusbutt]").first().hide();
|
||
}
|
||
}
|
||
|
||
// --agreement Docs---------------------------------------------------
|
||
|
||
patientAgreementDocument(null);
|
||
|
||
function patientAgreementDocument(data){
|
||
var appenddata = $("div[use=agreementDocuploadContaner]").find("div[use=agreementDocuploadForm]").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: 30px;">'
|
||
//+'<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: 30px;">';
|
||
$(appenddata).find("span[use=uploadContainer]").append(img_data);
|
||
}
|
||
}
|
||
|
||
|
||
$('#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();
|
||
}
|
||
}
|
||
|
||
// --trach Docs---------------------------------------------------
|
||
|
||
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: 30px;">'
|
||
//+'<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: 30px;">';
|
||
$(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();
|
||
}
|
||
}
|
||
|
||
</script>
|
||
|
||
|
||
<script type="text/javascript">
|
||
|
||
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>
|
||
|
||
<script type="text/javascript">
|
||
$(function(){
|
||
|
||
$("#RefertoVendorDocument").click(function(){
|
||
|
||
if($('#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('referral/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) {
|
||
|
||
var resp = JSON.parse(data);
|
||
|
||
// alert(data);
|
||
if (resp.status == '0') {
|
||
$("#msgActivationCtra").html(resp.msg);
|
||
$("#activatePatient").addClass('disabled');
|
||
}
|
||
if (resp.status == '1') {
|
||
$("#msgActivationCtra").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"> /* 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
|
||
|
||
$('#ptdob').attr('max',maxDate);
|
||
|
||
});
|
||
|
||
|
||
$(".onlyNumber").keypress(function(evt){
|
||
var charCode = (evt.which) ? evt.which : evt.keyCode;
|
||
if (charCode > 31 && (charCode < 48 || charCode > 57))
|
||
return false;
|
||
return true;
|
||
})
|
||
|
||
</script>
|
||
|
||
<script type="text/javascript">
|
||
function USformatPhoneNumber(phoneNumberString,_this) {
|
||
var cleaned = ('' + phoneNumberString).replace(/\D/g, '')
|
||
var match = cleaned.match(/^(1|)?(\d{3})(\d{3})(\d{4})$/)
|
||
if (match) {
|
||
var intlCode = (match[1] ? '+1 ' : '')
|
||
var fres = [intlCode, '(', match[2], ') ', match[3], '-', match[4]].join('')
|
||
_this.value = fres;
|
||
}
|
||
return null
|
||
}
|
||
</script>
|
||
|
||
<script type="text/javascript">
|
||
|
||
function load_progress(){
|
||
$.ajax({
|
||
url:'<?php echo base_url(); ?>referral/load_progress?id=<?php echo $_GET['pid']; ?>',
|
||
type :'GET',
|
||
success:function(data){
|
||
console.log(data);
|
||
if(data>99){ data=100; }
|
||
$('#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);
|
||
|
||
$('.nav-item').click(function(event){
|
||
if ($(this).hasClass('disabled')) {
|
||
return false;
|
||
}else{
|
||
$(".nav-item").removeClass("active");
|
||
$(this).addClass("active");
|
||
}
|
||
});
|
||
|
||
// $('.nav-item').click(function(event){
|
||
|
||
// $(".nav-item").removeClass("active");
|
||
// $(this).addClass("active");
|
||
// });
|
||
|
||
|
||
$("#patient_agreement_Document_Verified").click(function(){
|
||
|
||
if($('#patient_agreement_Document_Verified').prop('checked')){
|
||
$("#patientAgreementBtn").removeClass("disabled");
|
||
$("#patientAgreementBtn"). prop('disabled', false);
|
||
}
|
||
else{
|
||
$("#patientAgreementBtn").addClass("disabled");
|
||
$("#patientAgreementBtn"). prop('disabled', true);
|
||
}
|
||
|
||
});
|
||
|
||
$("#ins_agreement_doc_Verified").click(function(){
|
||
|
||
if($('#ins_agreement_doc_Verified').prop('checked')){
|
||
$("#insAgreementBtn").removeClass("disabled");
|
||
$('#insAgreementBtn').prop('disabled',false);
|
||
}
|
||
else{
|
||
$("#insAgreementBtn").addClass("disabled");
|
||
$('#insAgreementBtn').prop('disabled',true);
|
||
}
|
||
})
|
||
|
||
$("#phymdNPI").blur(function(){
|
||
var npiCode = $(this).val();
|
||
$.ajax({
|
||
url:'<?=base_url()?>referral/getNpiData?code='+npiCode,
|
||
type :'GET',
|
||
dataType: "json",
|
||
beforeSend: function() {
|
||
$("#npiValid").hide();
|
||
$("#npiinValid").hide();
|
||
$("#npiNoValidating").show();
|
||
$("#npivalidateTab").show();
|
||
},
|
||
success:function(data){
|
||
console.log(data);
|
||
$('#phymdfName').val(data.fname);
|
||
if(data.license)
|
||
{
|
||
$("#npivalidate").val('valid');
|
||
$("#npiValid").show();
|
||
$("#npiinValid").hide();
|
||
$("#npiNoValidating").hide();
|
||
}
|
||
else
|
||
{
|
||
$("#npivalidate").val('invalid');
|
||
$("#npiValid").hide();
|
||
$("#npiinValid").show();
|
||
$("#npiNoValidating").hide();
|
||
}
|
||
}
|
||
});
|
||
})
|
||
|
||
|
||
|
||
});
|
||
|
||
</script>
|
||
|
||
<script type="text/javascript">
|
||
function check_parmanent_address(_this)
|
||
{
|
||
var idPostfix = $(_this).val();
|
||
|
||
var address1=$('#address'+idPostfix).val();
|
||
var zipcode1=$('#zipcode'+idPostfix).val();
|
||
$.ajax({
|
||
url:"referral/checkaddress",
|
||
type:"GET",
|
||
data:{address:address1,zipcode:zipcode1},
|
||
dataType: "json",
|
||
beforeSend: function() {
|
||
$("#check_parmanent_address_btn"+idPostfix).hide();
|
||
$("#check_parmanent_address_loader"+idPostfix).show();
|
||
},
|
||
success:function(data){
|
||
console.log(data);
|
||
if(data.address_info.status_code=="200"){
|
||
$('#state'+idPostfix).val(data.address_info.address.state);
|
||
$('#county'+idPostfix).val(data.address_info.address.county);
|
||
$('#city'+idPostfix).val(data.address_info.address.city);
|
||
$('#lang'+idPostfix).val(data.geo_info.latlong.Latitude);
|
||
$('#long'+idPostfix).val(data.geo_info.latlong.Longitude);
|
||
$('#contact_info_submit').prop('disabled',false);
|
||
}else{
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Address not found',
|
||
showConfirmButton: true,
|
||
});
|
||
$('#contact_info_submit').prop('disabled',true);
|
||
}
|
||
$("#check_parmanent_address_btn"+idPostfix).show();
|
||
$("#check_parmanent_address_loader"+idPostfix).hide();
|
||
}
|
||
});
|
||
}
|
||
</script>
|
||
|
||
|
||
<?php if(isset($_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 } ?>
|
||
|
||
<script type="text/javascript">
|
||
function validateForm1(){
|
||
|
||
var x = document.forms["newGenInfo"]["addrZipcode1"].value;
|
||
if (x != "") {
|
||
var y = document.forms["newGenInfo"]["state1"].value;
|
||
if (y == "") {
|
||
document.forms["newGenInfo"]["addrZipcode1"].focus();
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please check the address',
|
||
showConfirmButton: true,
|
||
});
|
||
return false;
|
||
}
|
||
}
|
||
|
||
var x = document.forms["newGenInfo"]["altZipcode"].value;
|
||
if (x != "") {
|
||
var y = document.forms["newGenInfo"]["altState"].value;
|
||
if (y == "") {
|
||
document.forms["newGenInfo"]["altZipcode"].focus();
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please check the alternate address',
|
||
showConfirmButton: true,
|
||
});
|
||
return false;
|
||
}
|
||
}
|
||
}
|
||
|
||
function validateForm4()
|
||
{
|
||
var x = document.forms["patientAgreementFrom"]["addrZipcode3"].value;
|
||
if (x != "") {
|
||
var y = document.forms["patientAgreementFrom"]["addrState3"].value;
|
||
if (y == "") {
|
||
document.forms["patientAgreementFrom"]["addrZipcode3"].focus();
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please check the emergency contact address',
|
||
showConfirmButton: true,
|
||
});
|
||
return false;
|
||
}
|
||
}
|
||
}
|
||
|
||
function validateForm3()
|
||
{
|
||
var y = $("#npivalidate").val();
|
||
if (y == 'invalid' || y == "") {
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please enter a valid NPI number',
|
||
showConfirmButton: true,
|
||
});
|
||
return false;
|
||
}
|
||
}
|
||
|
||
|
||
|
||
</script>
|
||
|
||
|
||
|
||
|
||
|
||
|
||
<!-- physical md info -->
|
||
<!-- <hr class="my-2">
|
||
<h4 class="font-weight-bold">Physican and MD information</h4>
|
||
<hr class="my-2"> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('First Name'); ?></label>
|
||
<input type="text" class="form-control" name="phymdfName" id="phymdfName" value="<?php echo $idata->PhysicanName; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="phymdlName" id="phymdlName" value="<?php echo $idata->PhysicanAddress; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Address'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdaddress" id="mdaddress1" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('city'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdcity" id="mdcity1" value="<?php echo $pdata->add_zip_code; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('state'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdstate" id="mdstate1" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdCountry" id="mdCountry1" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdContryCode" id="mdContryCode1" value="<?php echo $pdata->add_zip_code; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Postal Code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="mdpostalCode" id="mdpostalCode1" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</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" onkeypress="return isNumberKey(event)" onkeyup="formatPhoneNumber(this.value,this)" class="form-control" name="phymdTelephone" id="phymdTelephone" value="<?php echo $idata->PhysicanTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('FAX'); ?></label>
|
||
<input type="text" class="form-control" name="phymdFAX" id="phymdFAX" value="<?php echo $idata->PhysicanFax; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Email'); ?></label>
|
||
<input type="text" class="form-control" name="phymdEmail" id="phymdEmail" value="<?php echo $idata->PhysicanEmail; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Affiliation'); ?></label>
|
||
<input type="text" class="form-control" name="phymdAffiliation" id="phymdAffiliation" value="<?php echo $idata->PhysicanAffiliation; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('NPI'); ?></label>
|
||
<input type="text" class="form-control" name="phymdNPI" id="phymdNPI" value="<?php echo $idata->PhysicanNPI; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Lisence'); ?></label>
|
||
<input type="text" class="form-control" name="phymdLisence" id="phymdLisence" value="<?php echo $idata->PhysicanLisence; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="phymdPrimary" id="phymdPrimary">
|
||
<label class="form-check-label" for="phymdPrimary">Primary</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Note'); ?></label>
|
||
<input type="text" class="form-control" name="phymdnote" id="phymdnote" value="<?php echo $idata->PhysicanNote; ?>">
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
<!-- physical md info -->
|
||
|
||
<!-- diagonosis and secondary diagnosis -->
|
||
<!-- <hr class="my-2">
|
||
<h4 class="font-weight-bold">Diaganosis</h4>
|
||
<hr class="my-2"> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="firstName3"><?php echo lang('Write a ICD Name To Search'); ?></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">ICD</span>
|
||
</div>
|
||
<input type="text" class="form-control" name="diagICD" id="diagICD" placeholder="Search ICD Here">
|
||
<select class="form-control" name="diagICDopt" id="diagICDopt"></select>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('date'); ?></label>
|
||
<input type="date" class="form-control" name="diagDate" id="diagDate">
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('Description'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Vent Dependent" id="diagDesc1">
|
||
<label class="form-check-label" for="diagDesc1">Vent Dependent</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Wheelchair Bound" id="diagDesc2">
|
||
<label class="form-check-label" for="diagDesc2">Wheelchair Bound</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Total Care" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">Total Care</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Hoyer Lift" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">Hoyer Lift</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Tracheostmy" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">Tracheostmy</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="Colostomy" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">Colostomy</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="PICC" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">PICC</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagDesc[]" value="PIV" id="diagDesc3">
|
||
<label class="form-check-label" for="diagDesc3">PIV</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Historical date Diaganosis'); ?></label>
|
||
<input type="date" class="form-control" name="diagHistData" id="diagHistData" placeholder="" value="<?php echo $idata->diagonosisData; ?>">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="diagRefchkbocx" id="diagRefchkbocx">
|
||
<label class="form-check-label" for="diagRefchkbocx">Referral</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="diagAsschkbox" id="diagAsschkbox">
|
||
<label class="form-check-label" for="diagAsschkbox">Assessment</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="diagPrimarychkbox" onclick="secDigActive(this)" value="Primary">
|
||
<label class="form-check-label" for="diagPrimarychkbox">Primary</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="diagPrimarychkbox" onclick="secDigActive(this)" value="Secondary">
|
||
<label class="form-check-label" for="diagPrimarychkbox">Secondary</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
|
||
|
||
<!-- <div id="secondaryDiagonosis" style="display: none">
|
||
|
||
<hr class="my-2">
|
||
<h4 class="font-weight-bold">Secondary Diaganosis</h4>
|
||
<hr class="my-2">
|
||
<div class="form-group">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="firstName3"><?php echo lang('Write a ICD Name To Search'); ?></label>
|
||
<div class="input-group">
|
||
<div class="input-group-prepend">
|
||
<span class="input-group-text" id="">ICD</span>
|
||
</div>
|
||
<input type="text" class="form-control" name="SecdiagICD" id="SecdiagICD" placeholder="Search ICD Here">
|
||
<select class="form-control" name="SecdiagICDopt" id="SecdiagICDopt"></select>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('date'); ?></label>
|
||
<input type="date" class="form-control" name="diagSecDate" id="diagDate">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('Description'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Vent Dependent" id="diagSecdDesc1">
|
||
<label class="form-check-label" for="diagSecdDesc1">Vent Dependent</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Wheelchair Bound" id="diagSecdDesc2">
|
||
<label class="form-check-label" for="diagSecdDesc2">Wheelchair Bound</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Total Care" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">Total Care</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Hoyer Lift" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">Hoyer Lift</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Tracheostmy" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">Tracheostmy</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="Colostomy" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">Colostomy</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="PICC" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">PICC</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="checkbox" class="form-check-input" name="diagSecdDesc[]" value="PIV" id="diagSecdDesc3">
|
||
<label class="form-check-label" for="diagSecdDesc3">PIV</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Historical date Diaganosis'); ?></label>
|
||
<input type="date" class="form-control" name="diagSecdHistData" id="diagSecdHistData" placeholder="">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="diagSecdRefchkbocx" id="diagSecdRefchkbocx">
|
||
<label class="form-check-label" for="diagSecdRefchkbocx">Referral</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="diagSecdAsschkbox" id="diagSecdAsschkbox">
|
||
<label class="form-check-label" for="diagSecdAsschkbox">Assessment</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
|
||
<!-- <hr class="my-2">
|
||
<h4 class="font-weight-bold">CLINICAL INFORMATION</h4>
|
||
<hr class="my-2"> -->
|
||
|
||
<!-- <div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="firstName3"><?php echo lang('Start of Care'); ?></label>
|
||
<input type="date" class="form-control" name="mdAddrApartment1" id="mdAddrApartment1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Allergies'); ?></label>
|
||
<select class="form-control required" name="level_service" id="level_service" >
|
||
<option value="" selected>Choose...</option>
|
||
<?php foreach ($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-6">
|
||
<label for="phymdPrimary">Allergic Reaction</label>
|
||
<textarea class="form-control" name="phymdnote" id="phymdnote" value="<?php echo $idata->PhysicanNote; ?>"></textarea>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Notes'); ?></label>
|
||
<textarea class="form-control" name="phymdnote" id="phymdnote" value="<?php echo $idata->PhysicanNote; ?>"></textarea>
|
||
</div>
|
||
</div>
|
||
</div> -->
|
||
|
||
<!-- container border for HHA PCA FROM -->
|
||
<!-- <span id="HHAPCAFROM" style="display: none;">
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">HOME HEALTH CERTIFICATION AND PLAN OF CARE</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group container border">
|
||
<div class="row justify-content-md-center">
|
||
<div class="col col-lg-2 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('1. Patient’s HI Claim No.'); ?></label>
|
||
<input type="text" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
<div class="col col-lg-2 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('2. Start Of Care Date'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
|
||
<div class="col-md-auto border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('3. Certification Period'); ?></label>
|
||
<div class="row justify-content-md-center">
|
||
<div class="col-sm">
|
||
<label for="exampleInputEmail1"><?php echo lang('From:'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
<div class="col-sm">
|
||
<label for="exampleInputEmail1"><?php echo lang('To:'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="col col-lg-2">
|
||
<label for="exampleInputEmail1"><?php echo lang('4. Certification Period'); ?></label>
|
||
<input type="text" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">6. Patient’s Name and Address</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('First name'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="lang1">
|
||
<input type="hidden" name="long1" id="long1">
|
||
<input type="text" class="form-control" name="address" id="address3" value="<?php echo $pdata->add_house_Number_and_Street_Name; ?>" >
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity" id="city3" value="<?php echo $pdata->add_city; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState" id="state3" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode" id="zipcode3" value="<?php echo $pdata->add_zip_code; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty" id="county3" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader3" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn3" value="3" onclick="check_parmanent_address(this);"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">7. Providers Name and Address</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('First name'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="emg_lang1">
|
||
<input type="hidden" name="long1" id="emg_long1">
|
||
<input type="text" class="form-control" name="address" id="address4" value="<?php echo $pdata->add_house_Number_and_Street_Name; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity" id="city4" value="<?php echo $pdata->add_city; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState" id="state4" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode" id="zipcode4" value="<?php echo $pdata->add_zip_code; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty" id="county4" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader4" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn4" value="4" onclick="check_parmanent_address(this);"><?php echo lang('Check'); ?></button>
|
||
</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" class="form-control" name="emgTelephone" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Other Number'); ?></label>
|
||
<input type="text" class="form-control" onkeyup="USformatPhoneNumber(this.value,this)" onkeypress="return isNumberKey(event)" onkeyup="formatPhoneNumber(this.value,this)" name="emgOtrNumber" id="exampleInputEmail1" value="<?php echo $idata->emgContactOteNo; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="row ">
|
||
<div class="col-lg-8 border-right">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('8. Dob'); ?></label>
|
||
<input type="date" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('9. SEX'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">
|
||
M
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Female">
|
||
F
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Medication</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Name'); ?></label>
|
||
<select class="form-control" name="medication_Name" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Frequency'); ?></label>
|
||
<select class="form-control" name="medication_Frequency" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Route'); ?></label>
|
||
<select class="form-control" name="medication_Route" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4 border-right">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('11. ICD'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Principal Diagnosis'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Date'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4 border-right">
|
||
<div class="form-group ">
|
||
<label for="exampleInputEmail1"><?php echo lang('12. ICD'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Surgical Procedure'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1 border"><?php echo lang('Date'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-4 border-right">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('13. ICD'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Other Pertinent Diagnoses'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Date'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6 border-right">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('14. DME and Supplies'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('15. Safety Measures'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6 border-right">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('16. Nutritional Req.'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('17. Allergies'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('18.A. Functional Limitations'); ?></label>
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Amputation</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Bowel/Bladder (Incontinance)</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">
|
||
Contracture
|
||
</label>
|
||
</div>
|
||
<div class="form-check">
|
||
4: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">
|
||
Hearing
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Paralysis</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Endurance</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Ambulation</label>
|
||
</div>
|
||
<div class="form-check">
|
||
4: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Speech</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Legally Blind</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Dyspnea With Minimal Exertion</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Other (Specify)</label>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('18.B. Activities Permitted'); ?></label>
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Complete Bedrest</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Bedrest BRP</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Up As Tolerated</label>
|
||
</div>
|
||
<div class="form-check">
|
||
4: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Transfer Bed/Chair</label>
|
||
</div>
|
||
<div class="form-check">
|
||
5: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Exercises Prescribed</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Partial Weight Bearing</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Independent At Home</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Crutches</label>
|
||
</div>
|
||
<div class="form-check">
|
||
4: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Cane</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Wheelchair</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Walker</label>
|
||
</div>
|
||
<div class="form-check">
|
||
3: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">No Restrictions</label>
|
||
</div>
|
||
<div class="form-check">
|
||
4: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Other (Specify)</label>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('19. Mental Status'); ?></label>
|
||
<div class="row">
|
||
<div class="col-lg-3">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Oriented</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Comatose</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-3">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Forgetful</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Depressed</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-3">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Disoriented</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Lethargic</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-3">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Agitated</label>
|
||
</div>
|
||
<div class="form-check">
|
||
2: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Other</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('20. Prognosis'); ?></label>
|
||
<div class="row">
|
||
<div class="col-lg-2">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Poor</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-2">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Guarded</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-2">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Fair</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-2">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Good</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-lg-2">
|
||
<div>
|
||
<div class="form-check">
|
||
1: <input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Excellent</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">21. Orders for Discipline and Treatments</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Amount'); ?></label>
|
||
<input type="text" class="form-control" name="emgTelephone" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Frequency'); ?></label>
|
||
<input type="text" class="form-control" name="emgOtrNumber" id="exampleInputEmail1" value="<?php echo $idata->emgContactOteNo; ?>">
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Duration'); ?></label>
|
||
<input type="text" class="form-control" name="emgOtrNumber" id="exampleInputEmail1" value="<?php echo $idata->emgContactOteNo; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">22. Goals/Rehabilitation Potential/Discharge Plans</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<label for="exampleInputEmail1"><?php echo lang('Plans'); ?></label>
|
||
<textarea class="form-control" name="Plans" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>"></textarea>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-8 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('23. Nurse’s Signature and Date of Verbal SOC Where Applicable:'); ?></label>
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<input type="text" class="form-control" name="emgTelephone" id="exampleInputEmail1" placeholder="Signature" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<input type="date" class="form-control" name="emgTelephone" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('25. Date of HHA Received Signed POT'); ?></label>
|
||
<input type="date" class="form-control" name="emgOtrNumber" id="exampleInputEmail1" value="<?php echo $idata->emgContactOteNo; ?>">
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">24. Physician’s Name and Address</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('First name'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="lang1">
|
||
<input type="hidden" name="long1" id="long1">
|
||
<input type="text" class="form-control" name="address" id="address1" value="<?php echo $pdata->add_house_Number_and_Street_Name; ?>" >
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity" id="city1" value="<?php echo $pdata->add_city; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState" id="state1" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode" id="zipcode1" value="<?php echo $pdata->add_zip_code; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty" id="county1" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn" onclick="check_parmanent_address();"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="form-group border-top">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('26. I certify/recertify that this patient is confined to his/her home and needs
|
||
intermittent skilled nursing care, physical therapy and/or speech therapy or
|
||
continues to need occupational therapy. The patient is under my care, and I have
|
||
authorized services on this plan of care and will periodically review the plan.'); ?></label>
|
||
|
||
<div class="form-check">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Agree</label>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('27. Attending Physician’s Signature and Date Signed'); ?></label>
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<input type="text" class="form-control" name="emgTelephone" id="exampleInputEmail1" placeholder="Signature" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<input type="date" class="form-control" name="emgTelephone" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('28. Anyone who misrepresents, falsifies, or conceals essential information
|
||
required for payment of Federal funds may be subject to fine, imprisonment,
|
||
or civil penalty under applicable Federal laws.'); ?></label>
|
||
|
||
<div class="form-check">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Agree</label>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</span> -->
|
||
<!-- container border for HHA PCA FROM -->
|
||
|
||
<!-- container border for RN LPN FROM -->
|
||
<!-- <span id="HHAPCAFROM" style="display: none;">
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Prescribe Order</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group container border">
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">6. Patient’s Name and Address</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('First name'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="lang1">
|
||
<input type="hidden" name="long1" id="long1">
|
||
<input type="text" class="form-control" name="address" id="address1" value="<?php echo $pdata->add_house_Number_and_Street_Name; ?>" >
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity" id="city1" value="<?php echo $pdata->add_city; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState" id="state1" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode" id="zipcode1" value="<?php echo $pdata->add_zip_code; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty" id="county1" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn" onclick="check_parmanent_address();"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="row ">
|
||
<div class="col-lg-8 border-right">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('8. Dob'); ?></label>
|
||
<input type="date" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('9. SEX'); ?></label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">
|
||
M
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Female">
|
||
F
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container bg-light">
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Name/Dose/Frequency</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Name'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Dose'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Frequency'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<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="Plans" id="exampleInputEmail1" value="<?php echo $idata->emgContactTelephone; ?>"></textarea>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-4">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Method of Admin'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Rate Flow'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<label for="exampleInputEmail1"><?php echo lang('Diluent'); ?></label>
|
||
<input type="date" class="form-control" name="correspondingRequirment" value="<?php echo $pdata->correspondingRequirment; ?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group ">
|
||
<label for="exampleInputEmail1"><?php echo lang('Route'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Duration of Infusion'); ?></label>
|
||
<select class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group ">
|
||
<label for="exampleInputEmail1"><?php echo lang('Start Date'); ?></label>
|
||
<input type="date" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('End Date'); ?></label>
|
||
<input type="date" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group ">
|
||
<label for="exampleInputEmail1"><?php echo lang('Dispence'); ?></label>
|
||
<input type="text" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 border-right">
|
||
<label for="exampleInputEmail1"><?php echo lang('Refill'); ?></label>
|
||
<input type="text" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container bg-light">
|
||
<div class="form-group border-bottom">
|
||
<div class="row mt-2 mb-2">
|
||
<div class="col-lg-12">
|
||
|
||
<div class="pull-right">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">
|
||
N/A
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Female">
|
||
Culture Not Done
|
||
</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Female">
|
||
Culture Pending
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Lab Orders'); ?></label>
|
||
<select class="form-control" name="Time" id="inputGroupSelect01">
|
||
<option value="">Choose...</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="pull-right">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Female" value="Female" <?php echo ($pdata->gender == 'Female')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Female">
|
||
To Be Drawn
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Fax Result To'); ?></label>
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Coram At'); ?></label>
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Access Device:'); ?></label>
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Heral Line'); ?></label>
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white">
|
||
Flush Volume M/S
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">0.9% Saline</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Herapin 10 units/ml</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">Herapin 100 units/ml</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-light">
|
||
Before Dose
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-light">
|
||
Between Dose
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-light">
|
||
After Dose
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-light">
|
||
After Lab Draw
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input type="text" class="form-control" name="Time" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
|
||
<hr class="my-1">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-primary text-white">
|
||
Administration Supplies
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">A4221-maintenance of infusion catheter per week</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white">
|
||
As Required
|
||
</div>
|
||
<div class="col-lg-2">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">YES</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-2">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">NO</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">A4211 Self Administrated Injection</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">A4223-infusion not using external infusion pump</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">K0522-using external infusion pump</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white">
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
<label class="form-check-label" for="Male">A4222-Maintenane of infusion pump per cassetes or bag</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container bg-light">
|
||
<div class="form-group border-bottom border-top">
|
||
<div class="row">
|
||
<div class="col-lg-1 bg-dark text-white align-middle">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?>>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-11">
|
||
<label class="form-check-label" for="Male">I, The ordering prescribe for this medication, have no financtial relationship with WeCuro Inc that would prohibit the provision of this therapy. i hereby certify taht the above infusion and services are medically necesery and are authorized by me. The patient is under my care and is in need of the services listed.</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</span> -->
|
||
<!-- container border for RN LPN FROM -->
|
||
|
||
<!-- container border for RN LPN FROM 2nd part -->
|
||
<!-- <span id="HHAPCAFROM" style="display: none;">
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Acute Infusion Reaction prescription and Treatment Guideline.</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group container border">
|
||
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">Prescriber Name and Address</h4>
|
||
<hr class="my-1">
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('First name'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Last name'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Telephone'); ?></label>
|
||
<input type="text" class="form-control" name="fname" value="<?php echo $pdata->first_name; ?>" value="<?php echo $pdata->first_name; ?>" >
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1" class="required"><?php echo lang('Email'); ?></label>
|
||
<input type="text" class="form-control" name="lname" value="<?php echo $pdata->last_name; ?>" value="<?php echo $pdata->last_name; ?>" >
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<label for="firstName3">
|
||
<h3><?php echo lang('Address'); ?></h3>
|
||
</label>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="hidden" name="lang1" id="lang1">
|
||
<input type="hidden" name="long1" id="long1">
|
||
<input type="text" class="form-control" name="address" id="address1" value="<?php echo $pdata->add_house_Number_and_Street_Name; ?>" >
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1" value="<?php echo $pdata->add_Apartment; ?>">
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('City'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCity" id="city1" value="<?php echo $pdata->add_city; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('State'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrState" id="state1" value="<?php echo $pdata->add_state; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('Zip code'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrZipcode" id="zipcode1" value="<?php echo $pdata->add_zip_code; ?>" >
|
||
</div>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<div class="form-group">
|
||
<label for="firstName3"><?php echo lang('County'); ?>
|
||
<span class="danger">*</span>
|
||
</label>
|
||
<input type="text" class="form-control" name="addrCounty" id="county1" value="<?php echo $pdata->add_county; ?>" readonly>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="col-md-1 mt-2">
|
||
<div class="form-group">
|
||
<img src="<?php echo base_url(); ?>uploads/ajax-loader.gif" id="check_parmanent_address_loader" Style="display:none;">
|
||
<button type="button" class="btn btn-info pull-right" id="check_parmanent_address_btn" onclick="check_parmanent_address();"><?php echo lang('Check'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container bg-light">
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">ICD-10</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-6">
|
||
<div class="form-group">
|
||
<label for="exampleInputEmail1"><?php echo lang('Description'); ?></label>
|
||
<input type="text" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Code'); ?></label>
|
||
<input type="text" class="form-control" name="type_access[]" id="inputGroupSelect01">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="container bg-light">
|
||
|
||
<hr class="my-1">
|
||
<h4 class="font-weight-bold">NURSING PROCEDURE: STOP ANY INFUSION OR MEDICATION ADMINISTRARTION IMMEDIATELY</h4>
|
||
<hr class="my-1">
|
||
|
||
<div class="row">
|
||
<div class="col-lg-1 bg-dark text-white">
|
||
1:
|
||
</div>
|
||
<div class="col-lg-11">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="Male">If modarate no sever symptomps occure, activate EMS system and initiate BCLS if indicated</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-lg-1 bg-primary text-white">
|
||
2:
|
||
</div>
|
||
<div class="col-lg-11">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="Male">If applicable, have caregiver call 911</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-lg-1 bg-dark text-white">
|
||
3:
|
||
</div>
|
||
<div class="col-lg-11">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="Male">Notify the physician at phone</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<div class="col-lg-1 bg-primary text-white">
|
||
4:
|
||
</div>
|
||
<div class="col-lg-8">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="Male">Administer Medication Below as needed for acute infusion reaction to</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
Gamunex-C 10%
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row">
|
||
<hr class="my-1">
|
||
<div class="col-lg-12 text-center font-weight-bold">
|
||
ANAPHYLICS TREATMENT
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Drug or Treatment
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Epinephine mg/ml AMP (1:1000) or auto infusion</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Drug or Treatment</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Drug or Treatment</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Severity
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Moderate to Severe</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Mild</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Moderate</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Under 15Kg
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">0.01mg/kg max 0.1mg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">1.25mg/kg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">1mg/kg</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
15-30 kg
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">0.15 mg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">1.25mg/kg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Range 125-50mg Dose</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Over 30 kg
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">0.3 mg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">25mg</label>
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">50mg</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">25mg</label>
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">50mg</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Quantity
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">1</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">1</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Route
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">SO</label>
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">IM</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">PO</label>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Slow IV</label>
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Slow IM</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="container">
|
||
<div class="form-group border-bottom">
|
||
<div class="row">
|
||
<div class="col-lg-3 bg-dark text-white align-middle">
|
||
Note
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Repeat in 3-5 mins PRN</label>
|
||
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-3">
|
||
|
||
</div>
|
||
<div class="col-lg-3">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" name="gender" id="Male" value="Male" <?php echo ($pdata->gender == 'Male')?'checked':'' ; ?> >
|
||
<label class="form-check-label" for="Male">Repeat in 3-5 mins PRN</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
</div>
|
||
</div>
|
||
</span> -->
|
||
<!-- container border for RN LPN FROM 2nd part -->
|
||
|
||
|
||
|
||
<!-- <div id="rnlnp" style="display: <?php echo($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> -->
|
||
|
||
|
||
|
||
|