AP/Chart Review

AP/Chart Review
[textarea name="variable_1" default=""]
___________________________________________________________
Immunizations:
MMR: [checkbox name="variable_1" value="vaccine x 2|hx of pos titers|not required|not provided|titers today|other"]
Varicella: [checkbox name="variable_2" value="vaccine x 2|hx of pos titer|not required|not provided|titer today|other"]
Hep B: [checkbox name="variable_3" value="vaccine x 3|hx of pos titer|declination signed|not required|not provided|administered today|titer today|other"]
Tdap: [checkbox name="variable_4" value="UTD|last immunization >10 years|not provided|administered today|other"]
Flu: [checkbox name="variable_5" value="UTD|not provided|not required with start date between 4/30 and 09/26|administered today|other"]

COVID: [checkbox name="variable_6" value="Moderna x 2|Pfizer x 2|J&J x 1|not provided|plus booster|other"]
TB: [checkbox name="variable_7" value="Neg IGRA w/i 90 doh|TST x 2, most current w/i 90 doh|IGRA today|not provided|hx of pos TST or IGRA|Neg CXR provided|TB SA negative|not required|other"]
___________________________________________________________
Arch Baseline Questionnaire: [checkbox name="variable_9" value="clear|added to annual surveillance|working with large animals, Q-fever required|not required|not provided|other"]
Respiratory Baseline Questionnaire: [checkbox name="variable_10" value="clear|not clear|not required|not provided|other"]
[text name="variable_1" default="comments"]
___________________________________________________________
Recommended: [textarea name="variable_11" default=" "]
Needs: [textarea name="variable_18" default=" "]
OHS clearance: [checkbox name="variable_19" value="clear|pending|clear for badge"]
AP/Chart Review

___________________________________________________________
Immunizations:
MMR:
Varicella:
Hep B:
Tdap:
Flu:

COVID:
TB:
___________________________________________________________
Arch Baseline Questionnaire:
Respiratory Baseline Questionnaire:

___________________________________________________________
Recommended:
Needs:
OHS clearance:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.71, 14 form elements, 22 boilerplate words, 1 text boxes, 3 text areas, 10 checkboxes, 63 total clicks
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