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  1. <htmlform>
  2.  
  3.  
  4.  
  5. <macros>
  6. paperFormId = (Fill this in)
  7. headerColor =#009d8e
  8. fontOnHeaderColor = white
  9. </macros>
  10.  
  11. <style>
  12. .section {
  13. border: 1px solid $headerColor;
  14. padding: 2px;
  15. text-align: left;
  16. margin-bottom: 1em;
  17. }
  18. .sectionHeader {
  19. background-color: $headerColor;
  20. color: $fontOnHeaderColor;
  21. display: block;
  22. padding: 2px;
  23. font-weight: bold;
  24. }
  25. table.baseline-aligned td {
  26. vertical-align: baseline;
  27. }
  28. </style>
  29.  
  30. <style type="text/css">
  31. #who-when-where {
  32. margin-bottom: 6px;
  33. border-bottom: 1px solid #ccc;
  34. }
  35.  
  36. #who-when-where p {
  37. display: inline-block;
  38. padding-right: 20px;
  39. }
  40.  
  41. #where > input[type=text] {
  42. display: inline-block;
  43. }
  44.  
  45. .field-error {
  46. color: #ff6666;
  47. font-size: 1.1em;
  48. display: block;
  49. }
  50.  
  51.  
  52. #data-collection {
  53. display: inline-block;
  54. width: 58%;
  55. vertical-align: top;
  56. }
  57.  
  58. #encounter-diagnoses-target {
  59. display: inline-block;
  60. width: 40%;
  61. vertical-align: top;
  62. }
  63.  
  64. #encounter-diagnoses-app {
  65. margin-bottom: 20px;
  66. }
  67.  
  68. </style>
  69.  
  70.  
  71. <h1>Clinical Notes </h1>
  72.  
  73. <div id="who-when-where">
  74. <p id="who">
  75. <label>Doctor</label>
  76. <span><encounterProvider default="currentUser" required="true" /></span>
  77. </p>
  78. <p id="when">
  79. <label><uimessage code="coreapps.patientDashBoard.location"/></label>
  80. <span><encounterLocation default="SessionAttribute:emrContext.sessionLocationId"/></span>
  81. </p>
  82. <p id="where">
  83. <label><uimessage code="coreapps.patientDashBoard.date"/></label>
  84. <span><encounterDate id="encounterDate" default="now" /></span></p>
  85. <p></p> <section headerLabel="1. History Taking">
  86. <table cellpadding="15">
  87. <tr>
  88. <td style="width:50%;"><label for="hpc"><h4>1: Presenting complaint:</h4></label>
  89. <obs conceptId="166493" labelText="" rows="6" cols="20"/></td>
  90. <td style="width:50%;"><label for="hpc"><h4>2: History of presenting complaint:</h4></label>
  91. <obs conceptId="166494" labelText="" rows="6" cols="20"/></td>
  92. </tr>
  93.  
  94.  
  95. <tr>
  96. <td><label for="hpc"><h4>3: Past Medical History:</h4></label>
  97. <obs conceptId="166495" rows="6" cols="20"/></td>
  98. <td><label for="hpc"><h4>4: Drug History:</h4></label>
  99. <obs conceptId="166496" labelText="" rows="6" cols="20"/></td>
  100. </tr>
  101.  
  102.  
  103. <tr>
  104. <td><label for="hpc"><h4>5: Family History:</h4></label>
  105. <obs conceptId="166497" labelText="" rows="6" cols="20"/></td>
  106. <td><label for="hpc"><h4>6: Social History:</h4></label>
  107. <obs conceptId="166498" labelText="" rows="6" cols="20"/></td>
  108. </tr>
  109.  
  110. <tr>
  111. <td><label for="hpc"><h4>7: Review Of Systems:</h4></label>
  112.  
  113. <obs conceptId="166499" rows="6" style="textarea" cols="20" /></td>
  114.  
  115.  
  116. <td><label for="hpc"><h4>8: Summary Of History:</h4></label>
  117. <obs conceptId="166500" labelText="" rows="6" cols="20" placeholder="Write a summary of your clinical history. This may help other clinicians to make quicker assessment if this patient is reviewed later."/></td>
  118. </tr>
  119. </table>
  120. </section>
  121.  
  122.  
  123.  
  124. <section headerLabel="2. Physical Examination">
  125. <table cellpadding="15">
  126.  
  127. <tr>
  128. <td style="width:50%;"><label for="hpc"><h4>1:General Examination:</h4></label>
  129. <obs conceptId="166501" labelText="" rows="6" cols="20"/></td>
  130.  
  131. <td style="width:50%;"><label for="hpc"><h4>2:Chest:</h4></label>
  132. <obs conceptId="166502" labelText="" rows="6" cols="20"/></td>
  133. </tr>
  134.  
  135.  
  136. <tr>
  137. <td><label for="hpc"><h4>3:Cardiovascular System</h4></label>
  138. <obs conceptId="166503" rows="6" cols="20" defaultValue="Pulse: 80/min regular |
  139. BP: 130/80 mmHg |
  140. Heart Sounds: 1, 2 + |
  141. JVP: ↑ |
  142. Apex: 5LICS "/>
  143. </td>
  144.  
  145.  
  146.  
  147. <td><label for="hpc"><h4>4:Abdomen</h4></label>
  148. <obs conceptId="166504" labelText="" rows="6" cols="20" defaultValue="Full|
  149. Non-tender |
  150. No palpable organomegaly|
  151. Bowel sounds are normal|
  152. "/></td>
  153. </tr>
  154.  
  155.  
  156. <tr>
  157. <td><label for="hpc"><h4>5: Genitourinary System</h4></label>
  158. <obs conceptId="166505" labelText="" rows="6" cols="20"/></td>
  159.  
  160. <td><label for="hpc"><h4>6:Musculoskeletal System</h4></label>
  161. <obs conceptId="166506" labelText="" rows="6" cols="20"/></td>
  162. </tr>
  163.  
  164.  
  165. </table>
  166.  
  167. New table
  168.  
  169.  
  170. <table>
  171. <tr>
  172. <td style="text-align: left; vertical-align: top;">
  173. <h4>Cranial Nerves</h4>
  174. <table>
  175. <tbody>
  176. <tr>
  177. <td><obs conceptId="166541" labelText="" rows="6" cols="20"/></td>
  178. </tr>
  179. </tbody>
  180. </table>
  181. </td>
  182. <td style="text-align: left; vertical-align: top;"><br />
  183. <table>
  184. <tbody>
  185. <tr>
  186. <td>
  187. <h4>Glasgow Coma Scale:</h4>
  188. </td>
  189. <td><obs conceptId="166528" defaultValue="/15" /></td>
  190. </tr>
  191. </tbody>
  192. </table>
  193. <table>
  194. <tbody>
  195. <tr>
  196. <td style="background-color: #f6f5f5;"></td>
  197. <th>Eyes</th>
  198. <th>Verbal</th>
  199. <th>Motor</th>
  200. </tr>
  201. <tr>
  202. <td style="background-color: #f6f5f5;">6</td>
  203. <td style="background-color: #dfe0df;"></td>
  204. <td></td>
  205. <td>Obeys</td>
  206. </tr>
  207. <tr>
  208. <td style="background-color: #f6f5f5;">5</td>
  209. <td style="background-color: #dfe0df;"></td>
  210. <td>Orientated</td>
  211. <td>Localises</td>
  212. </tr>
  213. <tr>
  214. <td style="background-color: #f6f5f5;">4</td>
  215. <td>Spontaneous</td>
  216. <td>Confused</td>
  217. <td>Withdraws</td>
  218. </tr>
  219. <tr>
  220. <td style="background-color: #f6f5f5;">3</td>
  221. <td>Speech</td>
  222. <td>Words</td>
  223. <td>Abnormal flexion</td>
  224. </tr>
  225. <tr>
  226. <td style="background-color: #f6f5f5;">2</td>
  227. <td>Pain</td>
  228. <td>Groans</td>
  229. <td>Exrension</td>
  230. </tr>
  231. <tr>
  232. <td style="background-color: #f6f5f5;">1</td>
  233. <td>Nil</td>
  234. <td>Nil</td>
  235. <td>Nil</td>
  236. </tr>
  237. </tbody>
  238. </table>
  239. </td>
  240. </tr>
  241. <tr>
  242. <td style="text-align: left; vertical-align: top;">
  243. <h4>Meningeal Signs</h4>
  244. <p></p>
  245. <table>
  246. <tbody>
  247. <tr>
  248. <td><obs conceptId="166511" labelText="" rows="6" cols="20"/></td>
  249. </tr>
  250. </tbody>
  251. </table>
  252. </td>
  253. <td style="text-align: left; vertical-align: top;" rowspan="3">
  254. <p></p>
  255. <table style="margin-left: auto; margin-right: auto;">
  256. <tbody>
  257. <tr style="height: 18px;">
  258. <td style="background-color: #f6f5f5;"></td>
  259. <td style="background-color: #f6f5f5;"></td>
  260. <td style="background-color: #f6f5f5;">RIGHT</td>
  261. <td style="background-color: #f6f5f5;">LEFT</td>
  262. </tr>
  263. <tr style="height: 18px;">
  264. <td style="background-color: #f6f5f5;" rowspan="2">
  265. <h6><strong>Tone</strong></h6>
  266. </td>
  267. <td style="height: 18px;">Arm</td>
  268. <td style="height: 18px;"><obs conceptId="166516" defaultValue="Normal" /></td>
  269. <td style="height: 18px;"><obs conceptId="166529" defaultValue="Normal" /></td>
  270. </tr>
  271. <tr style="height: 18px;">
  272. <td style="height: 18px;">Leg</td>
  273. <td style="height: 18px;"><obs conceptId="166517" defaultValue="Normal" /></td>
  274. <td style="height: 18px;"><obs conceptId="166530" defaultValue="Normal" /></td>
  275. </tr>
  276. <tr style="height: 18px;">
  277. <td style="background-color: #f6f5f5;" rowspan="4">
  278. <h6><strong>Power</strong></h6>
  279. </td>
  280. <td style="height: 18px;">Proximal Arm</td>
  281. <td style="height: 18px;"><obs conceptId="166518" defaultValue="/5" /></td>
  282. <td style="height: 18px;"><obs conceptId="166531" defaultValue="/5" /></td>
  283. </tr>
  284. <tr style="height: 18px;">
  285. <td style="height: 18px;">Distal Arm</td>
  286. <td style="height: 18px;"><obs conceptId="166519" defaultValue="/5" /></td>
  287. <td style="height: 18px;"><obs conceptId="166540" defaultValue="/5" /></td>
  288. </tr>
  289. <tr style="height: 18px;">
  290. <td style="height: 18px;">Proximal Leg</td>
  291. <td style="height: 18px;"><obs conceptId="166520" defaultValue="/5" /></td>
  292. <td style="height: 18px;"><obs conceptId="166532" defaultValue="/5" /></td>
  293. </tr>
  294. <tr style="height: 18px;">
  295. <td style="height: 18px;">Distal Leg</td>
  296. <td style="height: 18px;"><obs conceptId="166521" defaultValue="/5" /></td>
  297. <td style="height: 18px;"><obs conceptId="166533" defaultValue="/5" /></td>
  298. </tr>
  299. <tr style="height: 18px;">
  300. <td style="background-color: #f6f5f5;" rowspan="6">
  301. <h6><strong>Reflexes</strong></h6>
  302. </td>
  303. <td style="height: 18px;">Biceps</td>
  304. <td style="height: 18px;"><obs conceptId="166522" defaultValue="Normal" /></td>
  305. <td style="height: 18px;"><obs conceptId="166534" defaultValue="Normal" /></td>
  306. </tr>
  307. <tr style="height: 18px;">
  308. <td style="height: 18px;">Triceps</td>
  309. <td style="height: 18px;"><obs conceptId="166523" defaultValue="Normal" /></td>
  310. <td style="height: 18px;"><obs conceptId="166535" defaultValue="Normal" /></td>
  311. </tr>
  312. <tr style="height: 19px;">
  313. <td style="height: 19px;">Supinator</td>
  314. <td style="height: 19px;"><obs conceptId="166524" defaultValue="Normal" /></td>
  315. <td style="height: 19px;"><obs conceptId="166536" defaultValue="Normal" /></td>
  316. </tr>
  317. <tr style="height: 18px;">
  318. <td style="height: 18px;">Knee</td>
  319. <td style="height: 18px;"><obs conceptId="166525" defaultValue="Normal" /></td>
  320. <td style="height: 18px;"><obs conceptId="166537" defaultValue="Normal" /></td>
  321. </tr>
  322. <tr style="height: 18px;">
  323. <td style="height: 18px;">Ankle</td>
  324. <td style="height: 18px;"><obs conceptId="166526" defaultValue="Normal" /></td>
  325. <td style="height: 18px;"><obs conceptId="166538" defaultValue="Normal" /></td>
  326. </tr>
  327. <tr style="height: 18px;">
  328. <td style="height: 18px;">Plantar</td>
  329. <td style="height: 18px;"><obs conceptId="166527" defaultValue="Normal" /></td>
  330. <td style="height: 18px;"><obs conceptId="166539" defaultValue="Normal" /></td>
  331. </tr>
  332. </tbody>
  333. </table>
  334. </td>
  335. </tr>
  336. <tr>
  337. <td style="text-align: left; vertical-align: top;">
  338. <h4>Cerebellar Function</h4>
  339. <p></p>
  340. <table>
  341. <tbody>
  342. <tr>
  343. <td><obs conceptId="166512" labelText="" rows="6" cols="20"/></td>
  344. </tr>
  345. </tbody>
  346. </table>
  347. </td>
  348. </tr>
  349. <tr>
  350. <td style="text-align: left; vertical-align: top;">
  351. <h4>Gait</h4>
  352. <p></p>
  353. <table>
  354. <tbody>
  355. <tr>
  356. <td><obs conceptId="166513" labelText="" rows="6" cols="20"/></td>
  357. </tr>
  358. </tbody>
  359. </table>
  360. </td>
  361. </tr>
  362. <tr>
  363. <td colspan="2">
  364. <h4>Extrapyradimal Signs</h4>
  365. <p></p>
  366. <table>
  367. <tbody>
  368. <tr>
  369. <td><obs conceptId="166514" labelText="" rows="6" cols="20"/></td>
  370. </tr>
  371. </tbody>
  372. </table>
  373. </td>
  374. </tr>
  375. <tr>
  376. <td colspan="2">
  377. <h4>Sensory Testing</h4>
  378. <p></p>
  379. <table>
  380. <tbody>
  381. <tr>
  382. <td><obs conceptId="166515" labelText="" rows="6" cols="20"/></td>
  383. </tr>
  384. </tbody>
  385. </table>
  386. </td>
  387. </tr>
  388. </table>
  389.  
  390. </section>
  391.  
  392. </div>
  393.  
  394. <section headerLabel="3. Diagnoses, Investigations and Treatment Plan">
  395.  
  396.  
  397. <div id="data-collection"><h2>1: Diagnosis</h2>
  398.  
  399. <encounterDiagnoses required="true" selectedDiagnosesTarget="#encounter-diagnoses-target" />
  400. </div>
  401.  
  402. <div id="encounter-diagnoses-target">
  403. </div>
  404.  
  405. <p>
  406. <label><h2>2: Investigations and Results</h2></label>
  407. <obs conceptId="CIEL:162169" style="textarea" rows="5"/>
  408. </p>
  409. <p></p><label for="hpc"><h2>3: Management and Plan:</h2></label>
  410. <obs conceptId="166509" labelText="" rows="6" cols="20"/>
  411. </section>
  412.  
  413.  
  414.  
  415.  
  416.  
  417.  
  418.  
  419.  
  420. <div id="buttons">
  421. <submit submitClass="confirm right" submitCode="general.save"/>
  422. <button type="button" class="cancel"><uimessage code="general.cancel"/></button>
  423. </div>
  424.  
  425.  
  426. </htmlform>
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