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  1. <form action=""
  2. method="post"
  3. name="vm.medication"
  4. id="vm.medication"
  5. viewtype="dataentry"
  6. fhform=""
  7. class="text-left medication-form"
  8. autocomplete="off"
  9. novalidate="true"
  10. reset-directive="formData"
  11. submit-valid>
  12. <!-- Row 1: No known, Name, Specify, Strength -->
  13. <div class="row">
  14. <element-container ng-if="!vm.hasHistory && !vm.hasMedicationRecords"
  15. el="vm.medication.noknown"
  16. class="medium-4 columns">
  17. <element change="vm.updateNoKnown"
  18. tpl="toggle"
  19. label="No Known"
  20. model="noknown"
  21. form-data="vm.formData"></element>
  22. </element-container>
  23. </div>
  24. <div class="row">
  25. <div field-container=""
  26. class="medium-4 columns"
  27. ng-class="{'error':vm.medication.name.$isInvalid}"
  28. ng-if="(!vm.cfgMedicationList || vm.cfgMedicationList.length == 0 || vm.mode != 'edit')">
  29. <label ng-class="{ 'required': !vm.formData.noknown }">
  30. <span class="formlabel">Name</span>
  31. <input name="name"
  32. type="text"
  33. field
  34. ng-required="!vm.formData.noknown"
  35. ng-model="vm.formData.name"
  36. fh-disabled="{{vm.noEditable || vm.formData.noknown}}" />
  37. <validation-message for="name"></validation-message>
  38. </label>
  39. </div>
  40. <element-container ng-if="vm.cfgMedicationList && vm.cfgMedicationList.length !== 0 && vm.mode == 'edit'"
  41. el="vm.medication.name"
  42. class="medium-4 columns">
  43. <element tpl="select"
  44. custom-order="vm.customOrder"
  45. label="Name"
  46. select-options="vm.cfgMedicationList"
  47. model="name"
  48. form-data="vm.formData"
  49. fh-disabled="vm.noDrxRecord"
  50. req="!vm.formData.noknown"></element>
  51. </element-container>
  52. <div class="medium-4 columns"
  53. ng-if="vm.formData.name == 'Other' && vm.cfgMedicationList.length !== 0"
  54. ng-class="{'error':vm.medication.n.$isInvalid}"
  55. field-container="">
  56. <label ng-class="{ 'required': !vm.formData.noknown }">
  57. <span class="formlabel">Specify</span>
  58. <input name="specify"
  59. type="text"
  60. field
  61. ng-required="!vm.formData.noknown"
  62. ng-model="vm.formData.specify"
  63. fh-disabled="{{vm.noEditable || vm.formData.noknown}}" />
  64. <validation-message for="specify"></validation-message>
  65. </label>
  66. </div>
  67. <div class="medium-4 columns"
  68. field-container=""
  69. ng-class="{'error':vm.medication.n.$isInvalid}">
  70. <label ng-class="{ 'required': (vm.formData.strengthUnit || vm.requiredStrengthUnit) && !vm.formData.noknown }">
  71. <span class="formlabel">Strength</span>
  72. <div class="medication-form-row">
  73. <input name="strengthQuantity"
  74. class="medium-3 small-2 inline-column strength-quantity columns"
  75. type="text"
  76. field
  77. ng-pattern="/^[0-9 \&\(\)\%\^\#\+\.\-\/]{0,10}$/"
  78. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  79. ng-required="(vm.formData.strengthUnit || vm.requiredStrengthUnit) && !vm.formData.noknown"
  80. ng-model="vm.formData.strength" />
  81. <input name="strengthUnit"
  82. class="medium-8 strength-unit small-9 inline-column column"
  83. type="text"
  84. field
  85. placeholder="Unit"
  86. style="width: 100%;float: none;margin-left: 10px;display: inline-block;"
  87. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  88. ng-required="(vm.formData.strength || vm.requiredStrengthUnit) && !vm.formData.noknown"
  89. ng-model="vm.formData.strengthUnit" />
  90. </div>
  91. <validation-message for="strengthQuantity"
  92. pattern="Invalid strength, please enter numeric measures only"></validation-message>
  93. <validation-message for="strengthUnit"></validation-message>
  94. </label>
  95. </div>
  96. </div>
  97. <!-- Row 2: Start date, start time, selfadministering -->
  98. <div class="row">
  99. <div class="medium-4 columns"
  100. ng-class="{'error':vm.formData.startDate.$isInvalid}"
  101. field-container="">
  102. <label class="required">
  103. <span class="formlabel">Start Date</span>
  104. <input name="startDate"
  105. type="date"
  106. ng-required="!vm.formData.noknown"
  107. ng-model="vm.formData.startDate"
  108. fh-max="vm.maxStartDate"
  109. fh-disabled="{{vm.noDrxRecord || vm.formData.noknown}}"
  110. placeholder="MM/DD/YYYY"
  111. ng-change="vm.updateMinEndDate()"
  112. field />
  113. <validation-message for="startDate"
  114. fhmax="Medication Start date cannot be more than 30 days in the future"></validation-message>
  115. </label>
  116. </div>
  117. <div class="medium-4 columns"
  118. ng-class="{'error':vm.formData.startTime.$isInvalid}"
  119. field-container="">
  120. <label>
  121. <span class="formlabel">Start Time</span>
  122. <input name="startTime"
  123. type="time"
  124. field
  125. ng-model="vm.formData.startTime"
  126. fh-disabled="{{vm.formData.noknown}}"
  127. placeholder="HH:MM AM/PM" />
  128. <validation-message for="startTime"></validation-message>
  129. </label>
  130. </div>
  131. <element-container ng-if="vm.displaySelfAdministering"
  132. el="vm.medication.selfadministering"
  133. class="medium-2 columns">
  134. <element tpl="toggle"
  135. label="Self-Administering"
  136. model="selfadministering"
  137. form-data="vm.formData"
  138. fh-disabled="vm.formData.noknown"></element>
  139. </element-container>
  140.  
  141. </div>
  142. <div class="row">
  143. <div class="medium-4 columns"
  144. ng-class="{'error':vm.formData.endDate.$isInvalid}"
  145. field-container="">
  146. <label>
  147. <span class="formlabel">End Date</span>
  148. <input name="endDate"
  149. type="date"
  150. field
  151. ng-model="vm.formData.endDate"
  152. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  153. placeholder="MM/DD/YYYY"
  154. fh-min="vm.minEndDate" />
  155. <validation-message for="endDate"
  156. fhmin="{{ 'Date must be on or after ' + (vm.minEndDate | fhdate) }}"></validation-message>
  157. </label>
  158. </div>
  159. <div ng-if="vm.isOnPrescriptFields('endtime') && vm.formData.endDate"
  160. class="medium-4 columns"
  161. ng-class="{'error':vm.formData.endTime.$isInvalid}"
  162. field-container="">
  163. <label>
  164. <span class="formlabel">End Time</span>
  165. <input name="endTime"
  166. type="time"
  167. field
  168. ng-model="vm.formData.endTime"
  169. fh-disabled="{{vm.formData.noknown || !vm.formData.endDate}}"
  170. placeholder="HH:MM AM/PM" />
  171. <validation-message for="endTime"></validation-message>
  172. </label>
  173. </div>
  174.  
  175. <element-container ng-if="vm.isOnPrescriptFields('estimated-end-date') && vm.formData.endDate"
  176. el="vm.medication.endDateIsEstimate"
  177. class="medium-2 columns">
  178. <element fh-disabled="vm.formData.noknown || !vm.formData.endDate"
  179. tpl="toggle"
  180. label="Estimated End Date"
  181. model="endDateIsEstimate"
  182. form-data="vm.formData"></element>
  183. </element-container>
  184. </div>
  185. <p ng-if="vm.mode != 'view' && vm.mode != 'print'"
  186. style="text-align: center; margin-top: 10px; margin-bottom: 5px;">Dosage
  187. and Frequency are not required if sig is entered.</p>
  188. <div class="row">
  189. <div ng-if="!(vm.mode != 'edit' && vm.formData.sig && !vm.formData.doseUnitQuantity && !vm.formData.dosage)"
  190. class="medium-4 columns"
  191. field-container=""
  192. ng-class="{'error':vm.medication.n.$isInvalid}">
  193. <label ng-class="{'required': ((!vm.formData.dosage && !!vm.formData.doseUnitQuantity) || (!!vm.formData.dosage && !vm.formData.doseUnitQuantity) || !vm.formData.sig) && !vm.formData.noknown }">
  194. <span class="formlabel">Dosage</span>
  195. <div class="medication-form-row">
  196. <input name="doseUnitQuantity"
  197. class="medium-3 small-2 inline-column strength-quantity columns"
  198. field=""
  199. type="number"
  200. min="1"
  201. ng-min="1"
  202. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  203. ng-required="(vm.formData.dosage || !vm.formData.sig) && !vm.formData.noknown"
  204. ng-model="vm.formData.doseUnitQuantity" />
  205. <select name="dosage"
  206. field
  207. style="float: none; margin-left: 19px;"
  208. fh-blankoption="true"
  209. ng-options="o as o for o in vm.cfgdoseunitqtys"
  210. class="medium-8 strength-unit small-9 inline-column column"
  211. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  212. ng-required="(vm.formData.doseUnitQuantity || !vm.formData.sig) && !vm.formData.noknown"
  213. ng-model="vm.formData.dosage">
  214. <option value=""></option>
  215. </select>
  216. </div>
  217. <validation-message for="dosage"></validation-message>
  218. <validation-message min="Enter a number equal to or greater than 1."
  219. for="doseUnitQuantity"></validation-message>
  220. </label>
  221. </div>
  222. <div ng-if="!(vm.mode != 'edit' && vm.formData.sig && !vm.formData.frequency && !vm.formData.frequencyInterval) "
  223. class="medium-4 columns"
  224. field-container=""
  225. ng-class="{'error':vm.medication.n.$isInvalid}">
  226. <label ng-class="{'required': ((!vm.formData.frequency && !!vm.formData.frequencyInterval) || (!!vm.formData.frequency && !vm.formData.frequencyInterval) || !vm.formData.sig) && !vm.formData.noknown }">
  227. <span class="formlabel">Frequency</span>
  228. <div class="row medication-form-row"
  229. style="display: flex;flex-direction: row">
  230. <select name="frequency"
  231. field
  232. ng-if="vm.formData.frequencyInterval !== 'As Needed'"
  233. class="8 medium-8 strength-unit small-9 inline-column columns right ng-scope"
  234. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  235. ng-required="(vm.formData.frequencyInterval || !vm.formData.sig) && !vm.formData.noknown"
  236. ng-model="vm.formData.frequency">
  237. <option value=""></option>
  238. <option label="{{i}}"
  239. value="{{i}}"
  240. ng-repeat="i in vm.frequencyIntervalOptions">{{i}}</option>
  241. </select>
  242. <span ng-if="vm.formData.frequencyInterval !== 'As Needed'"
  243. style="display: inline-block;width: 70px;padding: 0 10px;vertical-align: middle;line-height: 30px;">x
  244. per</span>
  245. <select name="frequencyInterval"
  246. field=""
  247. ng-options="o as o for o in vm.frequencyIntervalConfig"
  248. class="8 medium-8 strength-unit small-9 inline-column columns right ng-scope"
  249. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  250. ng-required="(vm.formData.frequency || !vm.formData.sig) && !vm.formData.noknown"
  251. ng-model="vm.formData.frequencyInterval">
  252. <option value=""></option>
  253. </select>
  254. </div>
  255. <validation-message ng-if="vm.formData.frequencyInterval !== 'As Needed'"
  256. for="frequency"></validation-message>
  257. <validation-message for="frequencyInterval"></validation-message>
  258. </label>
  259. </div>
  260. <div class="medium-4 columns"
  261. field-container="">
  262. <label ng-class="{'required': vm.requiredSig }">
  263. <span class="formlabel">SIG</span>
  264. <input name="sig"
  265. type="text"
  266. field=""
  267. ng-required="vm.requiredSig && !vm.formData.noknown"
  268. ng-model="vm.formData.sig"
  269. fh-disabled="{{vm.noEditable || vm.formData.noknown}}" />
  270. <validation-message for="sig"></validation-message>
  271. </label>
  272. </div>
  273. </div>
  274. <div class="row">
  275. <div class="large-12 medium-12 columns"
  276. field-container="">
  277. <label ng-class="{ 'required': vm.requiredInstructions }">
  278. <span class="formlabel">Instructions</span>
  279. <textarea name="specialInstructions"
  280. type="text"
  281. field=""
  282. ng-required="vm.requiredInstructions && !vm.formData.noknown"
  283. ng-model="vm.formData.specialInstructions"
  284. fh-disabled="{{vm.formData.noknown}}"></textarea>
  285. <validation-message for="specialInstructions"></validation-message>
  286. </label>
  287. </div>
  288. </div>
  289. <div class="row">
  290. <div ng-if="vm.isOnPrescriptFields('clock-times')"
  291. class="medium-4 columns"
  292. ng-class="{'error':vm.formData['clock-times'].$isInvalid}"
  293. field-container="">
  294. <label ng-class="{'required': vm.requiredScheduledTimes }">
  295. <span class="formlabel">Scheduled Times <span ng-if="vm.mode !== 'view'">(Press Tab to add multiple)</span></span>
  296. <ui-select name="clockTimes"
  297. field
  298. multiple
  299. tagging
  300. tagging-label="false"
  301. type="time"
  302. ng-model="vm.formData.clockTimes"
  303. theme="bootstrap"
  304. sortable="true"
  305. close-on-select="false">
  306. <ui-select-match placeholder="hh:mm (AM|PM)">{{$item | timeFormat}}</ui-select-match>
  307. <ui-select-choices position="down"
  308. repeat="date in [] | filter: {name: $select.search}">
  309. {{date}}
  310. </ui-select-choices>
  311. </ui-select>
  312. <validation-message for="clock-times"></validation-message>
  313. </label>
  314. </div>
  315. <div class="medium-4 columns"
  316. ng-class="{'error':vm.formData.details.$isInvalid}">
  317. <label class="no-search"
  318. ng-class="{'required':vm.formData.details.$required}">
  319. <span class="formlabel">Medication Details</span>
  320. <ui-select field
  321. multiple
  322. class="multiple-select-wrapper"
  323. ng-disabled="vm.noEditable || vm.formData.noknown"
  324. ng-model="vm.formData.details"
  325. theme="bootstrap"
  326. sortable="true"
  327. close-on-select="false">
  328. <ui-select-match>{{$item}}</ui-select-match>
  329. <ui-select-choices position="down"
  330. repeat="item in vm.medicationDetetailsConf">
  331. {{item}}
  332. </ui-select-choices>
  333. </ui-select>
  334. <validation-message for="details"></validation-message>
  335. </label>
  336. </div>
  337.  
  338. <element-container ng-if="vm.isOnPrescriptFields('medsroute')"
  339. el="vm.medication.medsroute"
  340. class="medium-4 columns">
  341. <element fh-blankoption="true"
  342. fh-disabled="vm.noEditable || vm.formData.noknown"
  343. tpl="select"
  344. label="Route"
  345. select-options="vm.routeOptions"
  346. model="medsroute"
  347. form-data="vm.formData"
  348. req="!vm.formData.noknown && vm.requiredRoute">
  349. </element>
  350. </element-container>
  351. </div>
  352. <div class="row">
  353.  
  354.  
  355. <element-container ng-if="vm.isOnPrescriptFields('drug_type')"
  356. el="vm.medication.drugType"
  357. class="medium-4 columns">
  358. <element fh-blankoption="true"
  359. tpl="select"
  360. req="!vm.formData.noknown && vm.requiredDrugType"
  361. fh-disabled="vm.noEditable || vm.formData.noknown"
  362. label="Drug Type"
  363. select-options="vm.drugTypeOptions"
  364. model="drugType"
  365. form-data="vm.formData"></element>
  366. </element-container>
  367.  
  368.  
  369. <element-container el="vm.medication.type"
  370. class="medium-4 columns">
  371. <element fh-blankoption="true"
  372. req="vm.requiredRxOtc"
  373. tpl="select"
  374. label="Rx/OTC"
  375. fh-disabled="vm.noEditable || vm.formData.noknown"
  376. select-options="vm.rxOTCOptions"
  377. model="type"
  378. form-data="vm.formData"></element>
  379. </element-container>
  380. </div>
  381. <div class="row">
  382. <div ng-if="vm.isOnPrescriptFields('scriptnum')"
  383. class="medium-4 columns"
  384. field-container="">
  385. <label>
  386. <span class="formlabel">Rx #</span>
  387. <input name="scriptNumber"
  388. type="text"
  389. field=""
  390. ng-model="vm.formData.scriptNumber"
  391. fh-disabled="{{vm.noDrxRecord || vm.formData.noknown}}" />
  392. <validation-message for="scriptNumber"></validation-message>
  393. </label>
  394. </div>
  395. <div ng-if="vm.isOnPrescriptFields('expirationdate')"
  396. class="medium-4 columns"
  397. ng-class="{'error':vm.formData.expirationDate.$isInvalid}"
  398. field-container="">
  399. <label ng-class="{ 'required': vm.requiredExpirationDate && !vm.formData.noknown }">
  400. <span class="formlabel">Medication Expiration Date</span>
  401. <input name="expirationDate"
  402. type="date"
  403. ng-required="vm.requiredExpirationDate && !vm.formData.noknown"
  404. ng-model="vm.formData.expirationDate"
  405. fh-disabled="{{vm.formData.noknown}}"
  406. placeholder="MM/DD/YYYY"
  407. fh-min="vm.formData.startDate"
  408. field="" />
  409. <validation-message for="expirationDate"
  410. fhmin="{{ 'Date must be on or after ' + (vm.formData.startDate | fhdate) }}"></validation-message>
  411. </label>
  412. </div>
  413. </div>
  414. <div class="row">
  415. <div class="medium-4 columns"
  416. field-container="">
  417. <label>
  418. <span class="formlabel"># Refills</span>
  419. <input name="scriptRefills"
  420. class="medium-4 small-2 columns"
  421. type="number"
  422. ng-max="999"
  423. ng-min="0"
  424. field=""
  425. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  426. ng-model="vm.formData.scriptRefills" />
  427.  
  428. <validation-message for="scriptRefills"
  429. min="Please enter a valid number (0-999)"
  430. max="Please enter a number less than 999"
  431. number="">
  432. </validation-message>
  433. </label>
  434. </div>
  435. <div class="medium-4 columns"
  436. field-container=""
  437. ng-class="{'error':vm.medication.scriptQty.$isInvalid}">
  438. <label>
  439. <span class="formlabel">Quantity</span>
  440. <input name="scriptQty"
  441. class="medium-4 small-2 columns"
  442. type="number"
  443. field
  444. fh-disabled="{{vm.noEditable || vm.formData.noknown}}"
  445. ng-model="vm.formData.scriptQty" />
  446. <validation-message for="scriptQty"></validation-message>
  447. </label>
  448. </div>
  449. </div>
  450.  
  451. <div class="row">
  452.  
  453. <div field-container=""
  454. class="medium-4 columns"
  455. ng-class="{'error':vm.medication.doctor.$isInvalid}"
  456. ng-if="!vm.cfgPhysicianlistPref">
  457. <label>
  458. <span class="formlabel">Prescribing Physician</span>
  459. <input name="doctor"
  460. type="text"
  461. field
  462. ng-model="vm.formData.doctor"
  463. fh-disabled="{{vm.noEditable || vm.formData.noknown}}" />
  464. <validation-message for="name"></validation-message>
  465. </label>
  466. </div>
  467. <element-container ng-if="vm.cfgPhysicianlistPref"
  468. el="vm.medication.doctor"
  469. class="medium-4 columns">
  470. <element tpl="select"
  471. fh-disabled="vm.noEditable || vm.formData.noknown"
  472. custom-order="vm.customOrder"
  473. label="Prescribing Physician"
  474. select-options="vm.cfgPhysicianList"
  475. model="doctor"
  476. form-data="vm.formData"></element>
  477. </element-container>
  478. <div class="medium-4 columns"
  479. ng-if="vm.formData.doctor == 'Other' && vm.cfgMedicationList.length !== 0"
  480. ng-class="{'error':vm.medication.doctor.$isInvalid}"
  481. field-container="">
  482. <label>
  483. <span class="formlabel">Specify Physician</span>
  484. <input name="specifyPhysician"
  485. type="text"
  486. field
  487. ng-required="!vm.formData.noknown"
  488. ng-model="vm.formData.specifyPhysician"
  489. fh-disabled="{{vm.noEditable || vm.formData.noknown}}" />
  490. <validation-message for="specifyPhysician"></validation-message>
  491. </label>
  492. </label>
  493. </div>
  494.  
  495. <div class="medium-4 columns"
  496. ng-class="{'error':vm.medication.doctorPhone.$isInvalid}"
  497. field-container="">
  498. <label>
  499. <span class="formlabel">Phone</span>
  500. <input name="doctorPhone"
  501. type="text"
  502. field=""
  503. ng-model="vm.formData.doctorPhone"
  504. fh-disabled="{{vm.formData.noknown}}" />
  505. </label>
  506. </div>
  507. </div>
  508. <div class="row"
  509. ng-if="vm.showConsent">
  510.  
  511. <element-container el="vm.medication.consent"
  512. class="medium-4 columns">
  513. <element tpl="toggle"
  514. fh-disabled="vm.noDrxRecord"
  515. label="Consent"
  516. model="consent"
  517. form-data="vm.formData"></element>
  518. </element-container>
  519.  
  520.  
  521. <div ng-if="vm.formData.consent && vm.cfgConsentDates"
  522. class="medium-4 columns"
  523. ng-class="{'error':vm.formData.consentStartDate.$isInvalid}"
  524. field-container="">
  525. <label class="required">
  526. <span class="formlabel">Consent Start Date</span>
  527. <input name="consentEffectiveDate"
  528. type="date"
  529. ng-required="!vm.formData.noknown"
  530. ng-model="vm.formData.consentEffectiveDate"
  531. fh-disabled="{{vm.formData.noknown}}"
  532. placeholder="MM/DD/YYYY"
  533. field />
  534. <validation-message for="consentEffectiveDate"></validation-message>
  535. </label>
  536. </div>
  537. <div class="medium-4 columns"
  538. ng-if="vm.formData.consent && vm.cfgConsentDates"
  539. ng-class="{'error':vm.formData.consentExpirationDate.$isInvalid}"
  540. field-container="">
  541. <label class="required">
  542. <span class="formlabel">Consent End Date</span>
  543. <input name="consentExpirationDate"
  544. type="date"
  545. field
  546. ng-model="vm.formData.consentExpirationDate"
  547. ng-required="!vm.formData.noknown"
  548. fh-disabled="{{vm.formData.noknown}}"
  549. placeholder="MM/DD/YYYY"
  550. fh-min="vm.formData.consentEffectiveDate" />
  551. <validation-message for="consentExpirationDate"
  552. fhmin="{{ 'Date must be on or after ' + (vm.formData.consentEffectiveDate | fhdate) }}"></validation-message>
  553. </label>
  554. </div>
  555.  
  556. </div>
  557. <div class="row">
  558. <div class="medium-12 columns"
  559. field-container="">
  560. <label>
  561. <span class="formlabel">Reactions</span>
  562. <textarea name="reaction"
  563. type="text"
  564. field=""
  565. ng-model="vm.formData.reaction"
  566. fh-disabled="{{vm.formData.noknown}}"></textarea>
  567. </label>
  568. </div>
  569. </div>
  570. <div class="row">
  571. <div ng-if="vm.isOnPrescriptFields('purpose')"
  572. class="medium-4 columns"
  573. field-container="">
  574. <label ng-class="{'required': vm.requiredPurpose}">
  575. <span class="formlabel">Purpose</span>
  576. <input name="purpose"
  577. type="text"
  578. field
  579. ng-required="vm.requiredPurpose"
  580. ng-model="vm.formData.purpose"
  581. fh-disabled="{{vm.formData.noknown}}" />
  582. <validation-message for="purpose"></validation-message>
  583. </label>
  584. </div>
  585. <div ng-if="vm.isOnPrescriptFields('source-knowledge')"
  586. class="medium-4 columns"
  587. field-container="">
  588. <label>
  589. <span class="formlabel">Source of Knowledge</span>
  590. <input name="sourceKnowledge"
  591. type="text"
  592. field
  593. ng-model="vm.formData.sourceKnowledge"
  594. fh-disabled="{{vm.formData.noknown}}" />
  595. <validation-message for="sourceKnowledge"></validation-message>
  596. </label>
  597. </div>
  598. <div ng-if="vm.isOnPrescriptFields('rationale-change')"
  599. class="medium-4 columns"
  600. field-container="">
  601. <label>
  602. <span class="formlabel">Rationale for Change</span>
  603. <input name="rationaleChange"
  604. type="text"
  605. field
  606. ng-model="vm.formData.rationaleChange"
  607. fh-disabled="{{vm.formData.noknown}}" />
  608. <validation-message for="rationaleChange"></validation-message>
  609. </label>
  610. </div>
  611. </div>
  612. <div class="row">
  613. <div ng-if="vm.cfgPrescriptions"
  614. class="large-4 medium-4 columns"
  615. ng-class="{'error':vm.formData.renewDate.$isInvalid}"
  616. field-container="">
  617. <label>
  618. <span class="formlabel">Renewal Date</span>
  619. <input name="renewDate"
  620. type="date"
  621. field
  622. ng-model="vm.formData.renewDate"
  623. fh-disabled="{{vm.formData.noknown}}"
  624. placeholder="MM/DD/YYYY"
  625. fh-min="vm.formData.startDate" />
  626. <validation-message for="renewDate"
  627. fhmin="{{ 'Date must be on or after ' + (vm.formData.startDate | fhdate) }}"></validation-message>
  628. </label>
  629. </div>
  630. <div ng-if="vm.cfgPrescriptions"
  631. class="large-4 medium-4 columns"
  632. ng-class="{'error':vm.formData.nextVisit.$isInvalid}"
  633. field-container="">
  634. <label>
  635. <span class="formlabel">Next Meds Review Appt Date</span>
  636. <input name="nextVisit"
  637. type="date"
  638. ng-model="vm.formData.nextVisit"
  639. fh-disabled="{{vm.formData.noknown}}"
  640. placeholder="MM/DD/YYYY"
  641. field=""
  642. fh-min="vm.formData.startDate" />
  643. <validation-message for="nextVisit"
  644. fhmin="{{ 'Date must be on or after ' + (vm.formData.startDate | fhdate) }}"></validation-message>
  645. </label>
  646. </div>
  647.  
  648. <element-container ng-if="vm.isOnPrescriptFields('negation_reason_code')"
  649. el="vm.medication.negationReasonCode"
  650. class="large-4 medium-4 columns">
  651. <element tpl="select"
  652. fh-disabled="vm.noDrxRecord || !vm.formData.endDate"
  653. label="Negation Reason"
  654. select-options="vm.negationReasonOptions"
  655. model="negationReasonCode"
  656. form-data="vm.formData"></element>
  657. </element-container>
  658.  
  659. </div>
  660. <form-buttons></form-buttons>
  661. <!-- end expandable sections -->
  662. </form>
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