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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroILVEndo.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroILVEndo" TargetSchema="http://schemas.microsoft.com/intellisense/ie5" %>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="center" id="LastPageInForm" runat="server" style="page-break-after: always;">
<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">*U35*</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> <br>
<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 Intralesional Injection</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 %>
</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"><img src="../../images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span></td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="15">Verification:</span>
Patient Identity has been confirmed and agreement of planned procedure
with patient ensured.<br> <img src="../../images/shim.gif" border="0" width="315" height="20">
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Yes </td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="15">Site
Marking :</span> The procedure site/side has been marked and the
marking is in concordance with the consent and patient.<br><img src="../../images/shim.gif" border="0" width="295" height="20">
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
N/A</td>
</tr>
<tr >
<td class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<tr>
<td width="100" align="left" valign="middle" class="FormInnerRowRightBorder"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="1">Vital Signs</span></td>
<td width="275" height="22" align="left" valign="middle" class="FormInnerRowRightBorder"><img src="../../images/shim.gif" border="0" width="4" height="0">Starting BP:</td>
<td width="275" height="22" align="left" valign="middle" class="FormInnerRowRightBorder"><img src="../../images/shim.gif" border="0" width="4" height="0">Completion BP:</td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="2">
<tr>
<td width="20" valign="middle"> <input type="checkbox" name="No24322">
</td>
<td width="630" valign="middle">Post instructions reviewed. Fact Cards
"Instructions Following Your Intralesional Verapamil Injection" provided to patient.</td>
</tr>
<tr>
<td colspan="2"><span class="smallGrayText">Lidocaine and Verapamil injections given by Dr._____________________________________. Patient tolerated procedure well. No active bleeding or bruising noted. Area wrapped in 2x2 gauze and 1 inch Coban. Patient instructed to leave dressing on for 1-2 hours or if he experiences difficulty urinating.</span></td>
</tr>
<tr>
<td width="70"><span class="blackBoldText">Signature:</span></td>
<td><span class="blackBoldText">___________________________________________________________________</span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow" valign="top" height="20"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="1">Allergies</span>
<input type="checkbox" name="NKA" value="NKA">
NKA <asp:Repeater ID="allergies" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "Allergen") %>
(
<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>
)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater> </td>
</tr>
<tr>
<td height="30" valign="middle" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="15">Local
Anesthesia</span><img src="../../images/shim.gif" border="0" width="30" height="8">
<input type="checkbox" name="No224">
None<img src="../../images/shim.gif" border="0" width="30" height="1"> <input type="checkbox" name="No2222">
1% Lidocaine 10ml<img src="../../images/shim.gif" border="0" width="30" height="1"># of injections <input type="checkbox" name="No2230">1 or <input type="checkbox" name="No2231">2</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td colspan="6" valign="middle" class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="1">Procedure</span></td>
</tr>
<tr>
<td width="20" height="30" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No2432"></td>
<td width="230" align="center" valign="middle" class="FormInsideTableRegCell">Intralesional Verapamil Injection # ________</td>
<td width="100" align="center" valign="middle" class="FormInsideTableRegCell">Verapamil Dose</td>
<td width="100" valign="middle" class="FormInsideTableLeftCell"> </td>
<td width="100" align="center" valign="middle" class="FormInnerRowBottomBorder">Saline Volume</td>
<td width="100" valign="middle" class="FormInsideTableLeftCell"> </td>
</tr>
<!--<tr>
<td align="left" colspan="6" height="30" class="FormInsideTableRegCell"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="1">Injections administered by Dr. Mulhall</span><img src="../../images/shim.gif" border="0" width="30" height="1">Initials:______________</td>
</tr>-->
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Exam</span> <span class="smallGrayText">Clinician Performing Review:
<input type="checkbox" name="Fellow2" value="Yes">
Fellow
<input type="checkbox" name="Attending2" value="Yes">
Attending</span> <br>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="50%" align="center" class="FormInsideTableTopCell"><strong>Penis</strong></td>
<td width="50%" align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
</tr>
<tr>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/sexFuncDiagram1.gif" width="278" height="188" vspace="2"></td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Disposition</span><img src="../../images/shim.gif" border="0" width="10" height="1">
<input name="diagnosisNew34" type="checkbox" id="diagnosisNew34">
Discharge Home <input name="diagnosisNew33" type="checkbox" id="diagnosisNew33">
Transfer to UCC <input name="diagnosisNew32" type="checkbox" id="diagnosisNew32">
Other (Specify): ____________________________ </td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="325" height="22" class="FormInnerRowRightBorder">Procedure Code: (54200) Intralesional Verapamil Injection</td>
<td width="325" rowspan="2">Copy to: <input name="fellow222" type="checkbox" id="fellow223">
referring M.D.: ________________________<br> <img src="../../images/shim.gif" border="0" width="50" height="1">
<input name="fellow2222" type="checkbox" id="fellow2222">
other: _______________________________</td>
</tr>
<tr>
<td height="22" class="FormInnerRowRightBorder">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>
</tr>
</table></td>
</tr>
<tr bgcolor="#000000">
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">Signatures</span><br></td>
<td> </td>
</tr>
<tr class="FormOuterTableRow">
<td width="100"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="6" height="1">Fellow:</span></td>
<td><span class="blackBoldText">_____________________________________________________________</span></td>
</tr>
<!--<tr>
<td class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="6" height="1">NP / PA: </span></td>
<td class="FormInnerRowBottomBorder"><span class="blackBoldText">_____________________________________________________________</span></td>
</tr>-->
<tr>
<td colspan="2" valign="bottom"><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.</td>
</tr>
<tr>
<td><span class="blackBoldText">MD / Attending:</span></td>
<td><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="1" height="20">_____________________________________________________________</span></td>
</tr>
<tr>
<td colspan="2" align="center"><span class="blackBoldTextSmall">**Please verify that the service date is printed on each page**</span></td>
</tr>
</table>
</td>
</tr>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU31<img src="../../images/shim.gif" border="0" width="45" height="1">U35<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">31</span></td>
</tr>
</table>
</div>
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