urouturfu.ascx

医疗决策支持系统

        Reviewed with Radiologist<img src="../../Images/shim.gif" border="0" width="12" height="1"> 
        <input type="checkbox" name="Digitized">
        Digitized<br>
        </span> <table align="center" border="0" width="650" cellpadding="2" cellspacing="0">
          <tr> 
            <td width="100" align="center" valign="middle" class="FormInsideTableTopLeftCell">Date</td>
            <td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Study</td>
            <td width="150" align="center" valign="middle" class="FormInsideTableTopCell">Results</td>
            <td width="300" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
          </tr>
          <tr> 
            <td height="32" class="FormInsideTableLeftCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="32" class="FormInsideTableLeftCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="32" class="FormInsideTableLeftCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="32" class="FormInsideTableLeftCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="32" class="FormInsideTableLeftCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <!---<tr  >
						<td height="18">&nbsp;</td>
						<td>&nbsp;</td>
						<td>&nbsp;</td>
						<td>&nbsp;</td>
					</tr>--->
        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Cytology</span><span> 
        <img src="../../Images/shim.gif" border="0" width="30" height="1"> 
        <input type="checkbox" name="Films Reviewed2">
        Reviewed with Pathologist</span><br> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="100" align="center" class="FormInsideTableTopLeftCell">Date</td>
            <td width="150" align="center" class="FormInsideTableTopCell">Source</td>
            <td width="250" align="center" class="FormInsideTableTopCell">Results</td>
            <td width="150" align="center" class="FormInsideTableTopCell">Data Source </td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Procedures: 
        Biopsies / Cystoscopies</span><span><img src="../../Images/shim.gif" border="0" width="30" height="1"> 
        <input type="checkbox" name="Films Reviewed22">
        Reviewed with Pathologist</span><br> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="100" align="center" class="FormInsideTableTopLeftCell">Date</td>
            <td width="150" align="center" class="FormInsideTableTopCell">Procedure</td>
            <td width="400" align="center" class="FormInsideTableTopCell">Results</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" align="center" class="FormInsideTableRegCell">Cystoscopy</td>
            <td height="12" class="FormInsideTableRegCell"><span> 
              <input type="checkbox" name="office consult2" value="yes">
              Not Done</span></td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td height="25" class="FormInsideTableLeftCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
            <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
        </table></td>    </tr>
    <tr > 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU13<img src="../../Images/shim.gif" border="0" width="45" height="1">U17<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="1">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">5</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">13</span></td>
    </tr>
  </table>
</div>
<div align="center" style="page-break-before: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">*U17*</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 Upper Tract Urothelial 
                Follow-Up Patient</span></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 height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Review 
        of Systems</span>&nbsp;&nbsp;&nbsp;<span class="smallGrayText">Clinician 
        Performing Review: 
        <input type="checkbox" name="NP22" value="Yes">
        NP / PA&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Fellow22" value="Yes">
        Fellow&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Attending22" value="Yes">
        Attending</span> <br> <table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
          <!-- <tr class="eFormInnerTableRow">
						<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
						<td colspan="1" align="left" valign="top"></td>
					</tr> -->
          <tr> 
            <td align="center" class="FormInsideTableTopCell"><strong>System</strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Symptom</strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Not<br>
              Present</strong></td>