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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="InptLinkedAdmit.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.InptLinkedAdmit" 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">*U32*</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 Progress Note: 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 %>
</td>
<td align="left"><strong>
<% =patientMRN %>
</strong>
<% =patientDOB %>
</td>
</tr>
<tr>
<td colspan="1" align="right">
<% =patientNameLabel %>
</td>
<td colspan="1" align="left"><strong>
<% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %>
</strong></td>
</tr>
<tr>
<td align="right" valign="top">
<% =patientAddressLabel %>
</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 colspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Linked Admission Follow-up and Discharge</span></td>
<!--<td align="right"><span class="blackBoldText">Room #:</span></td>-->
<!--<td width="15%"> <span class="blackBoldText"><% =InPatientRoomNumber %></span></td>-->
</tr>
<tr>
<td align="left" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">Admission</span><img src="../../Images/shim.gif" border="0" width="50" height="1"><span><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">Follow-up</span><img src="../../Images/shim.gif" border="0" width="50" height="1"><span><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">Discharge</span></td>
<td align="right"><span class="blackBoldText">Admit Date:</span></td>
<td width="15%"> <span class="blackBoldText"><% =InPatientAdmitDate %></span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="60" valign="middle" align="left" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">The
patient was interviewed and examined by me with Dr. __________________________________________.<br>
<img src="../../Images/shim.gif" border="0" width="4" height="1">His/her
findings were confirmed or corrected and the plan reviewed. I agree with
the history, physical exam, <br>
<img src="../../Images/shim.gif" border="0" width="4" height="1">and plan
as documented in his/her note.</span></td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td height="25" class="FormInnerRowBottomBorder"> <!--<strong><% =InPatientAdmitReason %></strong>--></td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Signature</span><br>
<img src="../../Images/shim.gif" border="0" width="4" height="20"><span class="blackBoldText">Attending:<img src="../../Images/shim.gif" border="0" width="15" height="8">___________________________________________________________________</span></td>
</tr>
<tr>
<td align="center"><span class="blackBoldTextSmall">**Please verify that the service date is printed on each page**</span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="700" border="0" cellspacing="0" cellpadding="4">
<tr>
<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Discharge Day Only</span>
<br>
<br><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0"> Discussed the Care Plan with the patient and Family; and Instructed the caregivers.
<br>
<br>
<img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0"> I have supervised preparation of Discharge records, Prescriptions,
and Referral Forms. <br>
<br><img src="../../Images/shim.gif" border="0" width="4" height="1"><span><strong>Total Attending time in Minutes:</strong></span><img src="../../Images/shim.gif" border="0" width="20" height="1"><span><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0"><30 minutes</span><img src="../../Images/shim.gif" border="0" width="20" height="1"><span><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">>30 minutes</span>
</td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Signature</span><br>
<img src="../../Images/shim.gif" border="0" width="4" height="20"><span class="blackBoldText">Attending:<img src="../../Images/shim.gif" border="0" width="15" height="8">___________________________________________________________________</span>
<asp:Label id="PhysicianSignatureLabel" runat="server" Font-Bold="true" ><br/><img src="../../Images/shim.gif" border="0" width="240" height="1"></asp:Label>
</td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder" align="center"><span class="blackBoldTextSmall">**Please verify that the service date is printed on each page**</span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU28<img src="../../images/shim.gif" border="0" width="45" height="1">U32<img src="../../images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/05<img src="../../images/shim.gif" border="0" width="45" height="8"><!--rev:9/17/04--><img src="../../images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">1</span> of <span id="TotalPages">1</span><img src="../../images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">28</span></td>
</tr>
</table>
</div>
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