inptnonlinkedadmit.ascx

医疗决策支持系统

<%@ Control Language="c#" AutoEventWireup="false" Codebehind="InptNonLinkedAdmit.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.InptNonLinkedAdmit" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">

<div id="PaperFormStart">
<div id="LastPageInForm" runat="server" align="left" >
  
<div align="center">
	<div align="right" class="VerticalBarCodeDiv">
	  <div  class="VerticalBarCodeStatement"><img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"><br/>
        <img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121" vspace="220"><br/>
        <img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"></div>
	<div  class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
	<div  class="VerticalBarCodeDocType">*U39*</div>
	<div  class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
	<div  class="VerticalBarCodeDate"></div>
	</div>
</div>

<div align="center">
<font style="font-size: 12px;">CONTAINS PROTECTED  HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font></div>
  <table width="700" border="0" cellspacing="0" cellpadding="0">
    <tr> 
      <td class="FormOuterTableTopRow"><table align="center" border="0" width="700" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="350" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
              Genitourinary / Head and Neck Service<br>
			  Attending Inpatient Admission: Non-Linked</span></td>
            <td width="350" align="center" valign="bottom"> <table  width="325" border="0" cellspacing="1" cellpadding="0" >
                <tr> 
                  <td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
                  <td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
                </tr>
                <tr> 
                  <td align="right"> 
                    <% =patientMRNLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td align="left"><strong> 
                    <% =patientMRN  %>
                    </strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
                    <% =patientDOB  %>
                  </td>
                </tr>
                <tr> 
                  <td colspan="1" align="right"> 
                    <% =patientNameLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td colspan="1" align="left"><strong> 
                    <% =patientLastName  %>, <% =patientFirstName  %> <% =patientMiddleName  %>
                    </strong></td>
                </tr>
                <tr> 
                  <td align="right" valign="top"> 
                    <% =patientAddressLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td align="left" valign="top"> 
                    <% =patientAddress1  %>
                    <% =patientAddress2  %>
                    <% =patientCity  %>
                    <% =patientState  %>
                    <% =patientPostalCode  %>
                  </td>
                </tr>
                <tr> 
                  <td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
                </tr>
                <tr> 
                  <td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient 
                    Identification</td>
                </tr>
              </table></td>
          </tr>
        </table></td>
    </tr>
    <tr>
		<td class="FormOuterTableRow">
	  		<table width="100%" border="0" cellspacing="0" cellpadding="0">
				<tr>
				  <td align="left" colspan="3" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date:</span><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText"><% =apptClinicDate %></span></td>
				</tr>
				<tr>
				  <td><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Non-Linked Admission Note</span></td>
				  <td align="right"><span class="blackBoldText">Admit Date:</span></td>
				  <td width="15%">&nbsp;<span class="blackBoldText"><% =InPatientAdmitDate  %></span></td>
				  <!--<td align="right"><span class="blackBoldText">Room #:</span></td>-->
				  <!--<td width="15%">&nbsp;<span class="blackBoldText"><% =InPatientRoomNumber  %></span></td>-->
				</tr>
			</table>
		</td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">History of Present Illness:</span>
	   <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td height="20" width="15%" valign="bottom"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span>Primary Site:</span></td>
            <td width="35%" class="FormInnerRowBottomBorder">&nbsp;</td>
            <td width="15%" valign="bottom"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span>Prior Therapy:</span></td>
            <td width="35%">&nbsp;</td>
		  </tr>
          <tr>
            <td height="20" valign="bottom"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span>Histologic Type:</span></td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
            <td colspan="2" rowspan="3" class="">&nbsp;</td>
		  </tr>
          <tr>
            <td height="20" valign="bottom"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span>Metastatic Site:</span></td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
		  </tr>
          <tr>
            <td height="2" colspan="4">&nbsp;</td>
		  </tr>
		</table>
	  </td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td height="20" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Reason for Admission \ Symptoms:</span>&nbsp;&nbsp;&nbsp;<!--<strong><% =InPatientAdmitReason  %></strong>--></td>
          </tr>
          <tr> 
            <td height="20" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td height="20" class="FormInnerRowBottomBorder" align="right" valign="bottom">&nbsp;</td>
          </tr>
        </table>
	  </td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td height="25" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Other 
              Medical Problems:</span></td>
          </tr>
          <tr> 
            <td height="25" class="FormInnerRowBottomBorder" align="right" valign="bottom">&nbsp;</td>
          </tr>
        </table>
	  </td>
    </tr>
	<tr>
	  <td class="FormOuterTableRow">
		  <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
			<tr>
				<td height="20"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0"><span><strong>&nbsp;I agree with the Past Med/Surg Hx, S&amp;P Hx, FHx as documented by the NP dated ____/____/____.</strong></span></td>
			</tr>
			<tr>
				<td height="20"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0"><span><strong>&nbsp;Review of symptoms is as documented by the NP on the Adult Initial Admission / Chemotherapy <br><img src="../../Images/shim.gif" border="0" width="20" height="1">Assessment dated  ____/____/____.&nbsp;&nbsp;The Review of Symptoms is otherwise negative.</strong></span></td>
			</tr>
		</table>
		</td>
	</tr>
	<tr> 
      <td class="FormOuterTableRow">
	  <table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="10%" rowspan="2" align="left" valign="top" class="FormInnerRowRightBorder"><span class="blackBoldText">Vital Signs</span></td>
            <td height="20" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>