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Oncology-Exit_form.html
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<htmlform> <!--
Oncology - Exit form
Author:
Builder: Jberchmas
started on Feb 21, 2013
-->
<style>
.formName {
background-color: #e0e0ff;
}
.section {
border: 1px solid #8FABC7;
text-align: left;
margin-bottom: 10px;
}
.disabled {
color: #D8D8D8;
}
.sectionHeader {
background-color: #3333cc;
color: white;
display: block;
padding: 2px;
font-weight: bold;
}
table.symptoms th {
text-align: right;
}
th.subheader {
background-color: #8FABC7;
color: white
}
.note {
color: red;
}
td {
border-color:white;
vertical-align: top;
}
table.labTable td {
color: red;
}
table.labTable
td.dateField {
text-align: right;
}
table.identifierTable td {
padding-right: 10px;
}
div.paddedTable span {
padding-right: 20px;
}
.indented {
padding-left: 20pt;
padding-right: 20pt;
}
.bigIndent {
padding-left: 40pt;
padding-right: 10pt;
}
.newpage {
color: #8FABC7;
font-weight: bold;
}
.midleCell{
border-right: 1px dashed black;
border-left: 1px dashed black;
}
table {
border-collapse: collapse;
}
.disdiv {
background-color: grey;
}
/* for centering the page */
#wrapper1{
width:1400px;
margin:0 auto;
}
#wrapper2{
width:1400px;
margin:0 auto;
border-style:solid;
border-width:medium;
}
#wrapper3{
width:1400px;
margin:0 auto;
}
</style>
<script>
$j(function() {
$j('.disdiv').find('input').attr('disabled', 'true');
});
</script> <script type="text/javascript">
if (jQuery) {
$j(document)
.ready(
function() {
if ($j.browser.msie) {
$j(":checkbox").click(function() {
$j(this).change();
});
}
$j('.disabled').find('input, textarea, button, select').attr('disabled',true);
$j(".enableDisable").each(
function() {
var group = $j(this);
function disableFn() {
group.children("#disabled").fadeTo(
250, 0.33);
group.children("#disabled").find(
":checkbox").attr(
"checked", false); //uncheck
group.children("#disabled").find(
"input[type$='text']").val(
"");
group.children("#disabled").find(
"input").attr("disabled",
true); //disable
}
function enableFn() {
group.children("#disabled").fadeTo(
250, 1);
group.children("#disabled").find(
"input").attr("disabled",
false);
}
disableFn();
$j(this).children("#trigger").find(
":checkbox:first").change(
function() {
var checked = $j(this)
.attr("checked");
if (checked == true) {
enableFn();
} else {
disableFn();
}
});
});
$j(".checkboxGroup")
.each(
function() {
var group = $j(this);
var uncheckAll = function() {
group
.find(
"input[type$='checkbox']")
.attr("checked",
false);
group
.find(
"input[type$='checkbox']")
.change();
}
var uncheckRadioAndAll = function() {
group
.find(
"#checkboxAll,#checkboxRadio")
.find(
"input[type$='checkbox']")
.attr("checked",
false);
group
.find(
"#checkboxAll,#checkboxRadio")
.find(
"input[type$='checkbox']")
.change();
}
group
.find("#checkboxAll")
.find("input")
.click(
function() {
var flip;
var checked = $j(
this)
.siblings(
":checkbox:first")
.attr(
"checked");
if ($j(this)
.attr(
"name") == $j(
this)
.parents(
"#checkboxAll:first")
.find(
":checkbox:first")
.attr(
"name")) {
checked = $j(
this)
.attr(
"checked");
flip = checked;
} else {
flip = !checked;
}
if ($j(this)
.attr(
"type") == "text")
if (flip == false)
flip = !filp; // this is so the user doesn't go to check the checkbox, then uncheck it when they hit the input.
uncheckAll();
$j(this)
.parents(
"#checkboxAll:first")
.find(
":checkbox")
.attr(
"checked",
flip);
$j(this)
.parents(
"#checkboxAll:first")
.find(
":checkbox")
.change();
});
group
.find("#checkboxRadio")
.find(
"input[type$='checkbox']")
.click(
function() {
uncheckAll();
$j(this)
.siblings(
"input[type$='checkbox']")
.attr(
"checked",
false);
$j(this)
.attr(
"checked",
true);
$j(this)
.change();
});
group
.find(
"#checkboxCheckbox")
.click(
function() {
uncheckRadioAndAll();
});
});
});
}
</script>
<div id="wrapper1">
<section>
<table border="0" cellspacing="0" cellpadding="6" width="100%">
<tr>
<td><b> IMB ID: <lookup class="value"
expression="patientIdentifiers.get("IMB ID")" /> </b></td>
<td></td>
</tr>
<tr>
<td>Last name / Nom: <lookup class="value"
expression="patient.personName.familyName" /></td>
<td>First name / Prénom: <lookup class="value"
expression="patient.personName.givenName" /></td>
</tr>
<tr>
<td><img src="/openmrs/images/emr_hands.gif" align="left"
height="75" width="56"></img>
<h2>
Inshuti Mu Buzima <br /> PIH Rwanda
</h2></td>
<td><strong> Oncology Program / Programme d'oncologie <br />
Exit Form</strong> <br /></td>
</tr>
<tr align="left">
<td>Clinique / Clinic: <encounterLocation
default="Butaro Hospital" />
</td>
<td></td>
</tr>
</table>
</section>
</div>
<br/>
<div id="wrapper2">
<table border="1" cellspacing="0" cellpadding="6" width="100%">
<tr>
<td style="border-bottom-style:solid; border-width:1px; border-color:black;">EMR</td>
<td style="border-bottom-style:solid; border-width:1px; border-color:black;" colspan="3">EXIT FROM PROGRAM</td>
</tr>
<tr >
<td style="border-bottom-style:dashed; border-right-style:dashed; border-width:1px; border-color:black;"></td>
<td style="border-bottom-style:dashed; border-right-style:dashed; border-width:1px; border-color:black;"><b>Date of exit</b>:</td>
<td style="border-bottom-style:dashed; border-width:1px; border-color:black;" colspan="2"><encounterDate id="encounterDate" default="today" /></td>
</tr>
<tr >
<td></td>
<td class="midleCell"><b>Reason for exit</b>:</td>
<td class="disabled" colspan="2"><br/><input type="checkbox" name="" value="">Biopsy
negative for cancer</input><br /> <input type="checkbox" name="" value="">Not
cancer (no biopsy)</input><br /> <input type="checkbox" name="" value="">Declined
further care</input><br /> <input type="checkbox" name="" value="">Lost
to follow-up </input>
</td>
</tr>
<tr>
<td style="border-right-style:dashed; border-width:1px; border-color:black;"></td>
<td class="midleCell"></td>
<td colspan="2"><br />
</td>
</tr>
<tr >
<td style="border-top-style:dashed; border-width:1px; border-color:white;"></td>
<td class="midleCell"></td>
<td colspan="2"><b>Referred out for:</b><br /> <span class="disabled"><input
type="checkbox" name="" value="">Curative cancer care</input><br />
<input type="checkbox" name="" value="">Palliative systemic
therapy</input><br /> <input type="checkbox" name="" value="">Palliation-only
care</input></span>
</td>
</tr>
<tr>
<td style="border-right-style:dashed; border-width:1px; border-color:black;"></td>
<td class="midleCell"></td>
<td colspan="2"><br />
</td>
</tr>
<tr>
<td style="border-top-style:dashed; border-width:1px; border-color:white;"></td>
<td class="midleCell"></td>
<td colspan="2"><b>Death:</b>                  <obs
conceptId="4ecbbed3-3a37-493a-975a-80142923f60d" labelText="Unexpected" value="true" style="checkbox" />              <obs conceptId="964828b9-cb72-4dbb-bc4c-487753e25570"
answerConceptId="3cd6f600-26fe-102b-80cb-0017a47871b2"
answerLabel="Prior to curative treatment initiation" /> <br /> <span class="disabled"><input type="checkbox" name="" value="">
Cancer-related </input><br /> <input type="checkbox" name="" value="">
Non-cancer-related </input><br /> <input type="checkbox" name="" value="">
Unknown reason </input></span></td>
</tr>
<tr>
<td></td>
<td class="midleCell"></td>
<td colspan="2" class="checkboxGroup"><b>              Location:</b><br />
<span
style="float: right; display: inline-block; margin-right: 750px;"
id="checkboxRadio"> <obs
conceptId="7d3a9892-1674-4943-adc5-414a8076319e"
answerConceptId="682754d6-cff2-4f2e-90a3-ea3b1e7fa230"
answerLabel="While admitted at Butaro" /><br /> <obs
conceptId="7d3a9892-1674-4943-adc5-414a8076319e"
answerConceptId="3cda8388-26fe-102b-80cb-0017a47871b2"
answerLabel="While admitted at Rwinkwavu" /><br /> <obs
conceptId="7d3a9892-1674-4943-adc5-414a8076319e"
answerConceptId="21fce379-01e4-4baf-a683-116e4c4e2c4b"
answerLabel="While admitted at OTHER facility" /><br /> <obs
conceptId="7d3a9892-1674-4943-adc5-414a8076319e"
answerConceptId="b38fccb6-7ddf-4087-a56f-18eadfcd60e2"
answerLabel="At home or other outpatient setting" /><br /> <obs
conceptId="7d3a9892-1674-4943-adc5-414a8076319e"
answerConceptId="3cee7fb4-26fe-102b-80cb-0017a47871b2"
answerLabel="Other location: " /> <obs
conceptId="8fd332f2-d936-4943-9248-08ac0bc9169a" /> </span></td>
</tr>
<tr >
<td style="border-right-style:dashed; border-width:1px; border-color:black;"></td>
<td style="border-top-style:dashed; border-width:1px; border-color:black;" colspan="3"><b>Notes:</b><br />
<br />
<br />
<br />
<br />
<br />
</td>
</tr>
</table>
</div><br/>
<div id="wrapper3">
<table border="0" cellspacing="0" cellpadding="6" width="100%">
<tr>
<td></td>
<td align="right">Form filled by:<encounterProvider id="encounterProvider"
role="Oncology Provider" />
</td>
</tr>
</table>
</div>
<br/>
                 <submit />
</htmlform>