Collaborative Clinical Chart Review Tool

COLLABORATIVE CHART REVIEW TOOL
[text default="chart #" name="variable_1"] <-- Visit Identifier
[date name="variable_2"] <-- Visit Date
[text name="variable_3"] <-- Visit Provider
[text name="variable_4"] <-- Reviewer
[date name="variable_5"] <-- Review Date
[text name="variable_6"] <-- 1. Patient age
[select name="variable_7" value="yes|no|uncertain|not applicable"] <-- 2. Do you have suggestions for other/additional history?[conditional field="variable_7" condition="(variable_7).is('yes')||(variable_7).is('uncertain')"] 
COMMENT: [text name="variable_8"][/conditional]
[select name="variable_9" value="yes|no|uncertain|not applicable"] <-- 3. Do you have suggestions for other/additional exam?[conditional field="variable_9" condition="(variable_9).is('yes')||(variable_9).is('uncertain')"] 
COMMENT: [text name="variable_10"][/conditional]
[select name="variable_11" value="yes|no|uncertain|not applicable"] <-- 4. Do you have suggestions for other/additional diagnoses?[conditional field="variable_11" condition="(variable_11).is('yes')||(variable_11).is('uncertain')"]
COMMENT: [text name="variable_12"][/conditional]
[select name="variable_13" value="yes|no|uncertain|not applicable"] <-- 5. Do you have suggestions for other/additional treatment?[conditional field="variable_13" condition="(variable_13).is('yes')||(variable_13).is('uncertain')"]
COMMENT: [text name="variable_14"][/conditional]
[select name="variable_15" value="yes|no|uncertain|not applicable"] <-- 6. Do you have any general suggestions or feedback?[conditional field="variable_15" condition="(variable_15).is('yes')||(variable_15).is('uncertain')"]
COMMENT: [text name="variable_16"][/conditional]