Page Comparison

This page has been mostly superseded by the Form the Form Bank, which includes versions of OpenMRS of OpenMRS forms that can be imported using the Metadata the Metadata Sharing Module.
In order to use the sample forms listed on this page, you need to make sure that all concepts referred to in the form are in your concept dictionary, and this is usually not the case. We're leaving this page here since some people may find it useful to see actual production form definitions.

<htmlform>
&nbsp;&nbsp;&nbsp; <macros>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; lightgrey=#e0e0e0
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; lightblue=#95ADCA
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; darkblue=#4444ff
&nbsp;&nbsp;&nbsp; </macros>
&nbsp;
<div style="background-color: $lightblue"><b><center>Hospital Admission Form</center></b></div>
&nbsp;
<table border="1" width="800px"&nbsp; cellspacing="0" align="center" cellpadding="1">
<tr>
<td colspan="3">
<table border="1" width="100%"&nbsp; 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' )
&nbsp;&nbsp;&nbsp; OUT DISTRICT
\#else
&nbsp;&nbsp;&nbsp; $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>&nbsp;&nbsp; <span><lookup expression="patient.gender" codePrefix="gender_"/></span></td>
<td colspan="2"><lookup complexExpression="#foreach ( $relationship in $relationshipList )
&nbsp;&nbsp;&nbsp; #if( $relationship.relationshipType.bIsToA == 'Parent' )
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #if( \!($relationship.personB.patientId == $patient.patientId ))
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #if( $relationship.personB.gender == 'F' )
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; $relationship.personB.personName
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #end
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #end
&nbsp;&nbsp;&nbsp; #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"&nbsp; />
<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') != '') &amp;&amp; (getValue('dischargeDate.value') &lt; 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') != '') &amp;&amp; (getValue('dischargeDate.value') &gt; 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') &amp;&amp; (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') &amp;&amp; (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') &amp;&amp; (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') &amp;&amp; (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') &amp;&amp; (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') != '') &amp;&amp; (getValue('procedureTwo.value') != '') ) &amp;&amp; (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') != '') &amp;&amp;
        ( 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') != '') &amp;&amp;
        ( 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') != '') &amp;&amp;
        ( 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="
&#60;img src=&#34;http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=${patient.getPatientIdentifier(1)}&#34;/&#62;
" />

</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" />&nbsp; </td><td><b> Lieu </b>(Place)<br/><obs conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic" /></td>
</tr>

<tr>
<td&nbsp; 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>&nbsp;&nbsp;&nbsp; &nbsp;
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;
</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>