urouturfu.ascx

医疗决策支持系统

        <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"><table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="10%" rowspan="2" align="left" valign="top" class="FormInnerRowRightBorder"><span class="blackBoldText">Vital 
              Signs</span></td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp:</td>
          </tr>
          <tr> 
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">KPS:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Height:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Weight:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BSA:</td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Exam</span>&nbsp;&nbsp;&nbsp;<span class="smallGrayText">Clinician 
        Performing Exam: 
        <input type="checkbox" name="NP2" value="Yes">
        NP / PA&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Fellow2" value="Yes">
        Fellow&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Attending2" value="Yes">
        Attending</span> <br> 
        <table align="center" border="0" width="650" cellpadding="1" cellspacing="0">
          <tr> 
            <td align="center" class="FormInsideTableTopLeftCell"><strong>System</strong></td>
            <td colspan="2" align="center" class="FormInsideTableTopCell"><strong>Normal 
              Symptoms </strong><strong></strong></td>
            <td width="30" align="center" class="FormInsideTableTopCell"><strong>Abnormal</strong></td>
            <td width="30" align="center" class="FormInsideTableTopCell"><strong>Attnd<br>
              Performed</strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">Gen</td>
            <td align="left" class="FormInsideTableRegCell">Well Developed / Well 
              Nourished </td>
            <td width="30" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td width="30" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td width="30" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td width="300" rowspan="3" align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr class="eFormInnerTableRow"> 
            <td align="left" class="FormInsideTableRegCell">No Acute Distress</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr class="eFormInnerTableRow"> 
            <td align="left" class="FormInsideTableRegCell">Alert and Oriented</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">Eyes&nbsp;</td>
            <td align="left" class="FormInsideTableRegCell">No scleral icterus</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td rowspan="3" align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInnerRowBottomBorder"> EOMI</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr> 
            <td align="left" class="FormInnerRowBottomBorder"> PERRL</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">ENT&nbsp;</td>
            <td align="left" class="FormInsideTableRegCell">Mucous Membranes Moist</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableLeftCell">Head 
              &amp; Neck</td>
            <td align="left" class="FormInnerRowBottomBorder">Neck Supple and 
              Mobile</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td rowspan="2" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInnerRowBottomBorder">Carotid Bruits</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">Nodes</td>
            <td align="left" class="FormInsideTableRegCell"> Cervical</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td rowspan="3" align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr class="eFormInnerTableRow"> 
            <td align="left" class="FormInsideTableRegCell"> Supraclavicular</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr class="eFormInnerTableRow"> 
            <td align="left" class="FormInsideTableRegCell">Axillary</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">Resp.</td>
            <td align="left" class="FormInsideTableRegCell">Clear to Percusion<br>
              and Auscultation</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">C/V</td>
            <td align="left" class="FormInsideTableRegCell"> No Edema</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" heig