urourinfuncnp.ascx

医疗决策支持系统

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


<div id="PaperFormStart">

<div align="center">

<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">*U20*</div>
	<div  class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
	<div  class="VerticalBarCodeDate"><% =BarCodeDate %></div>
	</div>
</div>


<font style="font-size: 12px;">CONTAINS PROTECTED  HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font>
  <table width="650" border="0" cellspacing="0" cellpadding="0">
    <tr> 
      <td class="FormOuterTableTopRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="325" 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>
              Urology Urinary Function New Patient</span><br> </td>
            <td width="325" 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"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date: 
        <% =apptClinicDate %>
        <img src="../../Images/shim.gif" border="0" width="220" height="1">Physician: 
        <% =apptPhysicianName %>
        </span></td>
    </tr>
    <tr bgcolor="#FFFFFF">
      <td class="FormOuterTableRow"><table width="100%" border="0" cellpadding="1" cellspacing="0">
          <tr>
            <td colspan="2" align="left" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1" /><span class="blackBoldText">Category of Service</span></td>
          </tr>
          <tr>
            <td width="23%" valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" />&nbsp;New Patient Encounter<br />
              (CPT 99201-99205)</td>
            <td width="77%" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1" />Use for patients who have not been see by anyone in your billing group in the last 3 years <strong>AND</strong><br />
                <img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are self referred (includes those referred by friend or patient)<br />
                <img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Do not have  physician asking for your advice/opinion (see PIF sheet or PAS info)<br />
                <img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are referred solely for management and/or treatment of aspect of care<br />            </td>
          </tr>
          <tr>
            <td valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" />&nbsp;Office Consultation&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<br />
              (CPT 99241- 99245)</td>
            <td class="FormInnerRowBottomBorder"><table width="100%" cellpadding="0" cellspacing="0" border="0">
                <tr>
                  <td class="FormInnerRowBottomBorder" colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1" />Office Consultation is requested by _________________________ MD/PA/NP for my advice &amp; opinion<br />
                      <img src="../../Images/shim.gif" border="0" width="4" height="1" />regarding this patient&rsquo;s ______________________________________________________</td>
                </tr>
                <tr>
                  <td colspan="2"><table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
                      <tr >
                        <td align="left" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0" />Requesting&nbsp;M.D.:
                          <asp:Repeater ID="ReferringMD" runat=server >
                              <ItemTemplate> <%# DataBinder.Eval(Container.DataItem, "phFirstName") %> <%# DataBinder.Eval(Container.DataItem, "phLastName") %> ( <%# DataBinder.Eval(Container.DataItem, "phInstitution") %> )</ItemTemplate>
                            <SeparatorTemplate>, </SeparatorTemplate>
                          </asp:Repeater>
                            <asp:Label ID="blankReferrringMD" Runat="server"></asp:Label>                        </td>
                      </tr>
                  </table></td>
                </tr>
            </table></td>
            <!--<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Office Consultation is requested by _________________________ MD/PA/NP for my advice & opinion<br />
					<img src="../../Images/shim.gif" border="0" width="4" height="1">regarding this patient&rsquo;s ______________________________________________________</td>-->
          </tr>
          <tr>
            <td valign="top" align="center" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" />&nbsp;Established Patient Visit<br />
              (CPT 99212-99215)</td>
            <td><img src="../../Images/shim.gif" border="0" width="4" height="1" />Use for patients who<br />
                <img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are seeing you for the first time for management or treatment (Not a consult) and have been seen<br />
                <img src="../../Images/shim.gif" border="0" width="18" height="1" />by someone else in your billing group in the last 3 years<br />
                <img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are seeing you for follow-up care/visits </td>
          </tr>
      </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow" height="30" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Chief Complaint</span></td>
    </tr>
    <tr> 
      <td height="200" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">HPI</span></td>
    </tr>
    <tr> 
      <td valign="top" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
          <tr valign="top"> 
            <td height="55" class="FormInnerRowRightBorder"><span class="blackBoldText">Past 
              Medical History / Comorbidities</span> <br> <img src="../../Images/shim.gif" border="0" width="1" height="3"><br> 
              <asp:Repeater ID="comorbidities" runat=server> 
                <ItemTemplate> 
                  <%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %>
                  - <strong> 
                  <%# DataBinder.Eval(Container.DataItem, "Comorbidity") %>
                  </strong> </ItemTemplate>
                <SeparatorTemplate>;&nbsp; &nbsp; &nbsp; </SeparatorTemplate>
              </asp:Repeater> </td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td height="50" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Surgical History</span></td>
    </tr>
    <tr> 
      <td valign="top" class="FormOuterTableRow">
	  	<table width="650" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="335" valign="top" class="FormInnerRowRightBorder"> <table width="325" border="0" cellspacing="0" cellpadding="0">
                <tr> 
                  <td class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Medications</td>
                  <td height="15" colspan="2">&nbsp;</td>
                </tr>
                <tr> 
                  <td width="135" height="20" align="center" class="FormInsideTableTopCell">Agent</td>
                  <td width="95" align="center" class="FormInsideTableTopCell">Dose</td>
                  <td width="95" align="center" class="FormInsideTableTopCell">Schedule</td>
                </tr>
                <asp:Repeater ID="medications" runat=server> 
                  <ItemTemplate> 
                    <tr> 
                      <td class="FormInsideTableRegCell">&nbsp;<strong> 
                        <%# DataBinder.Eval(Container.DataItem, "Medication") %>
                        </strong></td>
                      <td class="FormInsideTableRegCell">&nbsp;<strong> 
                        <%# DataBinder.Eval(Container.DataItem, "MedDose") %>
                        <%# DataBinder.Eval(Container.DataItem, "MedUnits") %>
                        </strong></td>
                      <td class="FormInsideTableRegCell" style="font-size: 9px;">&nbsp;<strong> 
                        <%# DataBinder.Eval(Container.DataItem, "MedSchedule") %>
                        </strong></td>
                    </tr>
                  </ItemTemplate>
                </asp:Repeater>
              </table></td>
            <td width="315" valign="top"> 
				<table width="315" border="0" cellspacing="0" cellpadding="0">
                <tr> 
                  <td colspan="2" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Allergies</span>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span> 
                    <input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">NKA&nbsp;&nbsp;</span></td>
                </tr>
                <tr align="center">