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HAS-Haiti Hospital Admission/Discharge Form
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<htmlform> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue"><b><center>Hospital Admission Form</center></b></div> <table border="1" width="800px" cellspacing="0" align="center" cellpadding="1"> <tr> <td colspan="3"> <table border="1" width="100%" valign="middle" cellspacing="0" cellpadding="1" ><tr><td><b>LAST NAME</b></td><td><b>FIRST NAME</b></td><td><b>DATE OF BIRTH</b></td><td><b>DOSSIER #</b> </td></tr> <tr> <td><span><lookup expression="patient.personName.familyName"/></span></td> <td><span><lookup expression="patient.personName.givenName"/></span></td> <td><span><lookup expression="patient.birthdate"/></span></td> <td><span><lookup expression="patient.getPatientIdentifier(1)"/></span></td> </tr> <tr><td colspan="2"><B>LOCALITY</B></td><td><B>ADDRESS</B></td><td><B>CITY</B></td></tr> <tr><td colspan="2"><lookup complexExpression=" \#set( $locality = 0 ) \#set( $locality = $personAttributes.get('Tribe') ) \#if( $locality == 0 \|\| $locality == 'no tribe name specified' ) OUT DISTRICT \#else $locality \#end "/></td> <td><lookup expression="patient.personAddress.address1"/></td> <td><lookup expression="patient.personAddress.cityVillage"/></td> </tr> <tr><td><B>PATIENT AGE</B></td><td><B>GENDER</B></td><td colspan="2"><B>PARENT (Mother)</B></td></tr> <tr><td><span> <lookup expression="patient.age"/></span></td> <td> <span><lookup expression="patient.gender" codePrefix="gender_"/></span></td> <td colspan="2"><lookup complexExpression="#foreach ( $relationship in $relationshipList ) #if( $relationship.relationshipType.bIsToA == 'Parent' ) #if( \!($relationship.personB.patientId == $patient.patientId )) #if( $relationship.personB.gender == 'F' ) $relationship.personB.personName #end #end #end \#end "/> </td> </tr> </table> </td><td align="center" valign="middle"> <img src="http://intranet.hashaiti.org:81/image/HASlogo_circle_black_small_whitebackground.gif" /> <br /> <lookup complexExpression=" <img src="[http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=$]{patient.getPatientIdentifier(1)}"/> " /> </td> </tr> </table> <table border="1" width="800px" cellspacing="0" align="center" cellpadding="1"> <tr> <td valign="middle" style="width:220px"><br/><b>Services: </b><br/><br/></td><td style="width:256px"> <obs<script type="text/javascript"> $j(function() { getField('transfertoward.value').change(function() { if( getValue('transfertoward.value') == getValue('ward.value') ) { setValue('transfertoward.value', ''); } }); }); </script> <script type="text/javascript"> $j(function() { getField('dischargeDate.value').change(function() { if ( getValue('encounterDate.value') > getValue('dischargeDate.value')) { window.alert('Dat dichaj ou antre pa kapab avan dat admisyon an.\nThe discharge date you entered is before the admission date.') } }); }); </script> <script type="text/javascript"> <!-- Error Checking before Form Submit --> beforeSubmit.push(function() { var error = false; <!-- Clear the previous errors --> setValue('returnDate.error', ''); setValue('returnPlace.error', ''); setValue('dischargeDate.error', ''); setValue('procedureOne.error', ''); setValue('procedureTwo.error', ''); setValue('diagOne.error', ''); setValue('diagTwo.error', ''); setValue('diagThree.error', ''); setValue('diagFour.error', ''); setValue('transfertoward.error', ''); <!-- For Admission/Discharge Dates --> if ( (getValue('dischargeDate.value') != '') && (getValue('dischargeDate.value') < getValue('encounterDate.value'))) { getField('dischargeDate.error').html('Dat dichaj ou antre a pa kapab avan dat admisyon an.\nThe discharge date cannot be before the admission date.').show(); error=true; } <!-- For Return Visit Date --> if ( (getValue('returnDate.value') != '') && (getValue('dischargeDate.value') > getValue('returnDate.value'))) { getField('returnDate.error').html('Dat randevou ou antre a pa kapab avan dat dichaj la.\nThe return visit date cannot be before the discharge date.').show(); error=true; } <!-- For abandon with Follow-up Date --> if ( (getValue('abandon.value') == 'true') && (getValue('returnDate.value') != '') ) { getField('returnDate.error').html('Ou pa kapab antre dat randevou si pasyan an sove.\nYou cannot enter a return visit date if the patient left without authorization.').show(); error=true; } <!-- For Abandon with Follow-up Place --> if ( (getValue('abandon.value') == 'true') && (getValue('returnPlace.value') != '') ) { getField('returnPlace.error').html('Ou pa kapab antre ki kote yo bay pasyan an randevou si li sove.\nYou cannot enter a return visit location if the patient left without authorization.').show(); error=true; } <!-- For status=died with Follow-up Date --> if ( (getValue('status.value') == '159') && (getValue('returnDate.value') != '') ) { getField('returnDate.error').html('Ou pa kapab antre dat randevou si pasyan an mouri.\nYou cannot enter a return visit date if the patient died.').show(); error=true; } <!-- For status=died with Follow-up Place --> if ( (getValue('status.value') == '159') && (getValue('returnPlace.value') != '') ) { getField('returnPlace.error').html('Ou pa kapab antre ki kote yo bay pasyan an randevou si li mouri.\nYou cannot enter a return visit location if the patient died.').show(); error=true; } <!-- For Abandon with Transfer --> if ( (getValue('abandon.value') == 'true') && (getValue('transfertoward.value') != '') ) { getField('transfertoward.error').html('Ou pa kapab antre nan ki wòd yo tranfere pasyan an si li sove.\nYou cannot enter a transfer ward if the patient left without authorization.').show(); error=true; } <!-- For Both Procedures the Same --> if ( ( (getValue('procedureOne.value') != '') && (getValue('procedureTwo.value') != '') ) && (getValue('procedureOne.value') == getValue('procedureTwo.value'))) { getField('procedureTwo.error').html('Ou pa kapab genyen yon menm pwosedi de (2) fwa.\nYou cannot have the same procedure twice').show(); error=true; } <!-- For Diagnosis Two Same --> if ( (getValue('diagTwo.value') != '') && ( getValue('diagTwo.value') == getValue('diagOne.value') || getValue('diagTwo.value') == getValue('diagThree.value') || getValue('diagTwo.value') == getValue('diagFour.value') ) ) { getField('diagTwo.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show(); error=true; } <!-- For Diagnosis Three Same --> if ( (getValue('diagThree.value') != '') && ( getValue('diagThree.value') == getValue('diagOne.value') || getValue('diagThree.value') == getValue('diagTwo.value') || getValue('diagThree.value') == getValue('diagFour.value') ) ) { getField('diagThree.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show(); error=true; } <!-- For Diagnosis Four Same --> if ( (getValue('diagFour.value') != '') && ( getValue('diagFour.value') == getValue('diagOne.value') || getValue('diagFour.value') == getValue('diagTwo.value') || getValue('diagFour.value') == getValue('diagThree.value') ) ) { getField('diagFour.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show(); error=true; } if (error == true) { return false; } return true; }); </script> <macros> lightgrey=#e0e0e0 lightblue=#95ADCA darkblue=#4444ff </macros> <div style="background-color: $lightblue"><b><center>Hospital Admission Form</center></b></div> <table border="1" width="800px" cellspacing="0" align="center" cellpadding="1"> <tr> <td colspan="3"> <table border="1" width="100%" valign="middle" cellspacing="0" cellpadding="1" ><tr><td><b>LAST NAME</b></td><td><b>FIRST NAME</b></td><td><b>DATE OF BIRTH</b></td><td><b>DOSSIER #</b> </td></tr> <tr> <td><span><lookup expression="patient.personName.familyName"/></span></td> <td><span><lookup expression="patient.personName.givenName"/></span></td> <td><span><lookup expression="patient.birthdate"/></span></td> <td><span><lookup expression="patient.getPatientIdentifier(1)"/></span></td> </tr> <tr><td colspan="2"><B>LOCALITY</B></td><td><B>ADDRESS</B></td><td><B>CITY</B></td></tr> <tr><td colspan="2"><lookup complexExpression=" #set( $locality = 0 ) #set( $locality = $personAttributes.get('Tribe') ) #if( $locality == 0 || $locality == 'no tribe name specified' ) OUT DISTRICT #else $locality #end "/></td> <td><lookup expression="patient.personAddress.address1"/></td> <td><lookup expression="patient.personAddress.cityVillage"/></td> </tr> <tr><td><B>PATIENT AGE</B></td><td><B>GENDER</B></td><td colspan="2"><B>PARENT (Mother)</B></td></tr> <tr><td><span> <lookup expression="patient.age"/></span></td> <td> <span><lookup expression="patient.gender" codePrefix="gender_"/></span></td> <td colspan="2"><lookup complexExpression="#foreach ( $relationship in $relationshipList ) #if( $relationship.relationshipType.bIsToA == 'Parent' ) #if( !($relationship.personB.patientId == $patient.patientId )) #if( $relationship.personB.gender == 'F' ) $relationship.personB.personName #end #end #end #end "/> </td> </tr> </table> </td><td align="center" valign="middle"> <img src="http://intranet.hashaiti.org:81/image/HASlogo_circle_black_small_whitebackground.gif" /> <br /> <lookup complexExpression=" <img src="http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=${patient.getPatientIdentifier(1)}"/> " /> </td> </tr> </table> <table border="1" width="800px" cellspacing="0" align="center" cellpadding="1"> <includeIf velocityTest="!(($patient.gender == 'F') || ($patient.gender == 'M')) || (! $patient.age)"> <tr> <td> <b><font color='darkorange' size='+2'>ERROR: Unknown gender or date of birth. Please update patient demographics before filling out this form.<hr></hr> Erè: Pasyan an pa gen sèks li oubyen dat nesans li antre nan sistèm nan, tanpri ajoute enfòmasyon sa yo avan ou ranpli fòm nan.</font></b> </td> </tr> </includeIf> <excludeIf velocityTest="!(($patient.gender == 'F') || ($patient.gender == 'M')) || (! $patient.age)"> <tr> <td valign="middle" style="width:220px"><br/><b>Services: </b><br/><br/> </td><td style="width:256px"> <includeIf velocityTest="$patient.gender == 'F' "> <obs id="ward" conceptId="1827" required="true" answerConceptIds="1691,2037,3036,6206,2034,2036,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBGYN,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" /> </includeIf> <includeIf velocityTest="$patient.gender == 'M' "> <obs id="ward" conceptId="1827" required="true" answerConceptIds="1691,2037,3036,6206,2034,3036,2036,1542,2035,1692,6196,6194" answerLabels="ADULT. ISOLATION,ADULT. SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL. MEDICINE,MALNUTRITION,OBGYN,OBSERVATION,PEDIATRIC. GENERAL,PEDITRIC. ISOLATION,PEDIATRIC. NEONATAL,PEDIATRIC. SURGERY" /> </includeIf> </td><td ></td> </tr> <tr><td><b>Durée de l'hospitalisation:</b><br/>(Duration of Hospitalization)</td><td><b>Du</b> (From)<encounterDate id="encounterDate" default="today" disallowMultipleEncountersOnDate="warn" /></td><td><b>Au</b> (To)<obs id="dischargeDate" conceptId="1829" /><> </td></tr> <tr ><td valign="top"><b>Diagnostics(s)<br/></b>(Diagnosis)</td><td colspan="3" > <obs valign="top"><b>Diagnostics(s)<br/></b>(Diagnosis)</td><td colspan="3" > <obs id="diagOne" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="1" size="80" /><br/> <obs id="diagTwo" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="2" size="80"/><br/> <obs id="diagThree" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="13" size="80" /><br/> <obs id="diagFour" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="24" size="80"/><br/> <obs /> </td></tr> <tr><td valign="top"><b>Traitement ou Procédure</b><br/>(Treatment or Procedure)</td> <td colspan="3"><obs id="procedureOne" conceptId="60426193" answerClasses="DiagnosisProcedure" style="autocomplete" labelText="31" size="80" /><br/> <obs id="procedureTwo" conceptId="60426193" answerClasses="DiagnosisProcedure" style="autocomplete" labelText="42" size="80" /><br/> </td></tr> <tr><td valign="top"><b>Traitement><b>Transféré ouà Procédure<</b><br/>(TreatmentTranferred or Procedureto)</td> <tdtd><td colspan="3"><obs conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="1" size="80"/><br/> <br/> <obs conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="2" size="80"/><br/> <obs conceptId="2630" size="80" labelText="Non-Coded"/>2"> <includeIf velocityTest="$patient.gender == 'F' "> <obs id="transfertoward" conceptId="1285" answerConceptIds="1691,2037,3036,6206,2034,2036,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBGYN,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" /> </includeIf> <includeIf velocityTest="$patient.gender == 'M' "> <obs id="transfertoward" conceptId="1285" answerConceptIds="1691,2037,3036,6206,2034,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" /> </includeIf> </td></tr> <tr><td valign="top"><b>Transféré><b>Condition à <L'éxeat</b><br/>(TranferredStatus at toDischarge)</td><td colspan="23"><obs id="status" conceptId="12852044" style="radio"/></td></tr> <tr><td valign="top"><b>Condition><b>Patir àsans L'éxeat<Autorisation</b><br/>(StatusLeft atwithout DischargeAuthorization)</td><td colspan="3"><obs id="abandon" conceptId="20446505" style="radiocheckbox" /></td></tr> <tr><td><b>Rendez vous:</b><br/>(Return Visit)</td><td><b>Date de Rendez-vous</b><br/><obs id="returnDate" conceptId="5096" allowFutureDates="true" /> </td><td><b> Lieu </b>(Place)<br/><obs conceptId="5096" allowFutureDates="true" /> </td><td><b> Lieu </b>(Place)<br/><obs conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic" /></td> </tr> <tr> <td colspan="4" align="center"> <b>Lieu</b> (Location) <encounterLocation default="15" order="15" type="hidden" /> <b>Nom du Medecin</b> (Doctor Name)<encounterProvider role="Provider"/> <submit /> </td> </tr> </table> id="returnPlace" conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic,Autre" /></td> </tr> <tr> <td colspan="4" align="center"> <b>Lieu</b> (Location) <encounterLocation default="15" order="15" type="hidden" /> <b>Nom du Medecin</b> (Doctor Name)<encounterProvider role="Hospital Provider"/> <submit submitClass="submitButton"/> </td> </tr> </excludeIf> </table> <script type="text/javascript"> $j(function() { $j('.submitButton').click(function(event) { if ( getValue('dischargedate.value') ) { if (!(getValue('status.value'))) { window.alert("Please select the discharge status."); event.preventDefault(); } } }); }); </script> </htmlform> |