urodynamics.ascx

医疗决策支持系统

					<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
					<td valign="middle" align="left" class="FormInsideTableRegCell">Detrusor Underactivity</td>
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					<td valign="middle" align="left" class="FormInsideTableRegCell">Small Capacity Bladder</td>
					<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
					<td valign="middle" align="left" class="FormInsideTableRegCell">Large Capacity Bladder</td>
					<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
					<td valign="middle" align="left" class="FormInsideTableRegCell">Filling Defect</td>
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					<td  colspan="3"valign="middle" align="left" class="FormInsideTableRegCell">Vesicoureteral Reflex<img src="../../Images/shim.gif" border="0" width="20" height="1">Grade ____Left&nbsp;____Right</td>
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					<td valign="middle" align="left" class="FormInsideTableRegCell">Trabeculations</td>
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					<td valign="middle" align="left" class="FormInsideTableRegCell">Bladder stones</td>
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					<td valign="middle" align="left" colspan="7">Other:</td>
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            <td colspan="3" class="blackBoldText">Impression &amp; Plan</td>
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            <td width="43%" align="center" class="FormInsideTableTopCell"><strong>Diagnoses / Problem List</strong></td>
            <td width="4%" align="center" class="FormInsideTableTopCell"><strong>New</strong></td>
            <td width="43%" align="center" class="FormInsideTableTopCell"><strong>Plan 
              &amp; Referrals</strong></td>
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            <td height="30" valign="top" class="FormInsideTableRegCell">1.</td>
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              <input name="diagnosisNew1" type="checkbox" id="diagnosisNew1"></td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
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            <td height="30" valign="top" class="FormInsideTableRegCell">2.</td>
            <td align="center" valign="middle" class="FormInsideTableRegCell"><input name="diagnosisNew2" type="checkbox" id="diagnosisNew2"></td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
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            <td height="30" valign="top" class="FormInsideTableRegCell">3.</td>
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              <input name="diagnosisNew3" type="checkbox" id="diagnosisNew3"></td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
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            <td height="30" valign="top" class="FormInnerRowRightBorder">4.</td>
            <td align="center" valign="middle" class="FormInnerRowRightBorder"> 
              <input name="diagnosisNew3" type="checkbox" id="diagnosisNew3"></td>
            <td>&nbsp;</td>
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            <td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Disposition</span><br> 
              <input name="diagnosisNew34" type="checkbox" id="diagnosisNew34">
              Discharge Home&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input name="diagnosisNew33" type="checkbox" id="diagnosisNew33">
              Transfer to UCC&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input name="diagnosisNew32" type="checkbox" id="diagnosisNew32">
              Other (Specify): ____________________________ </td>
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                  <td width="100" height="18">Prescriptions:</td>
                  <td width="80" align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
                  <td>Refill &nbsp;&nbsp;or &nbsp;&nbsp;New</td>
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                  <td height="18" colspan="3">Rx: __________________________________________________________</td>
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                  <td height="18" colspan="3">Rx: __________________________________________________________</td>
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                  <td height="18">Chemo Orders:</td>
                  <td align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
                  <td>____________________________________</td>
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            <td width="200" align="center"> <span>Protocol #: ________</span><br>
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                  <td>Considered:</td>
                  <td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
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                  <td>Consent Obtained:</td>
                  <td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
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                  <td>Registered:</td>
                  <td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
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			<input type="checkbox" name="50% of Time22">&#8805; 50% of attending time was spent in counseling<br>
			<img src="../../Images/shim.gif" border="0" width="1" height="20">If so, mark total attending time in minutes &amp; describe on right:<br> 
            <img src="../../Images/shim.gif" border="0" width="30" height="12">
			<input type="checkbox" name="15-24 (3)2">15-24 (3) &nbsp;&nbsp;&nbsp;&nbsp;
			<input type="checkbox" name="25-39 (4)2">25-39 (4) &nbsp;&nbsp;&nbsp;&nbsp;
			<input type="checkbox" name="40+ (5)2">40+ (5)</td>
            <td width="325" valign="top"><img src="../../Images/shim.gif" border="0" width="1" height="11">Describe Counseling or Dictate Note:</td>
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            <td width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Circle if Dictated:<img src="../../Images/shim.gif" border="0" width="30" height="1">Fellow/ Resident<img src="../../Images/shim.gif" border="0" width="30" height="1">Attending</td>
			<td width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Copy to:&nbsp;&nbsp;&nbsp;
			<input name="fellow222" type="checkbox" id="fellow223">referring M.D.: ________________________<br />
			<img src="../../Images/shim.gif" border="0" width="56" height="1"><input name="fellow2222" type="checkbox" id="fellow2222">other: _______________________________</td>
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            <td><span class="blackBoldText">Signatures</span><br></td>
            <td colspan="2">&nbsp;</td>
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            <td width="100"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Fellow: 
              </span></td>
            <td width="350"><span class="blackBoldText">________________________________________________</span></td>
            <td width="200">&nbsp;<!--<span class="blackBoldText">Date:____/____/____ </span>--> 
            </td>
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            <td><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">NP / PA: </span></td>
            <td><span class="blackBoldText">________________________________________________</span></td>
            <td><span class="blackBoldText">&nbsp;<!--Date:____/____/____</span>--></td>
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            <td colspan="3">
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                  <td><table width="642" border="0" cellspacing="0" cellpadding="4">
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                        <td><span class="blackBoldText"> 
                          <input name="fellow" type="checkbox" id="fellow">
                          </span>I personally performed or was physically present during the <strong>key portions</strong> of the procedure today. <br> <span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="20">MD 
                          / Attending: ________________________________________________ 
                          <img src="../../Images/shim.gif" border="0" width="24" height="1">&nbsp;<!--Date:____/____/____--></span> 
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      <td height="14" align="center" valign="bottom" class="blackBoldText">GU35<img src="../../Images/shim.gif" border="0" width="45" height="1">U40<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/06<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page 
        <span id="PageNumber">2</span> of <span id="TotalPages">2</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">35</span></td>
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