demos

CAUTION: This page needs to be reviewed and categorized.
[text name="AGE" default="AGE"] [checkbox name="GENDER" value="MALE|FEMALE"] LIVES WITH:[select name="LIVARR" value="SPOUSE|CHILD|BROTHER|SISTER|FRIEND|OTHER-"][conditional field="LIVARR" condition="(LIVARR).is('OTHER-')"] [text default="***"][/conditional]
HOMEBOUND STATUS:[select name="hbstatus" value="HOMEBOUND|NON-HOMEBOUND"]
PRIMARY INSURANCE:[select name="INSURANCE_TYPE" value="PDGM MEDICARE|MANAGED MEDICARE|MEDICAID|MANAGED MEDICAID|COMMERCIAL INSURANCE"]

SOC DATE:[date name="SOCDATE" default="today"] | END OF CERT:[text name="ENDOFCERT" default="ADD 60 DAYS"]
REFERRAL SOURCE: [select name="REFSOURCEHOSP" value="TOLEDO HOSPITAL|BAY PARK HOSPITAL|WILDWOOD ORTHOPEDIC|FLOWER HOSPITAL|ST VINCENT HOSPITAL|ST ANNE HOSPITAL|ST CHARLES HOSPITAL|MERCY PERRYSBURG HOSPITAL|ST LUKE HOSPITAL|PHYSICIAN OFFICE REFERRAL|WOUND CARE CLINIC REFERRAL|OTHER"][conditional field="REFSOURCEHOSP" condition="(REFSOURCEHOSP).is('OTHER-')"]
[text name="OTHERREF" default="***"]
[/conditional]
PROVIDER(S):[text name="FOLLOWINGPROVIDER" default="ENTER"]
PRIMARY DX:[select name="COMMONDX" value="SELECT|HYPERTENSION|ATRIAL FIBRILLATION|HEART FAILURE|DIABETES|COPD|UTI|CELLULITIS|SEPSIS|RT KNEE REPLACEMENT|LT KNEE REPLACEMENT|RT HIP REPLACEMENT|LT HIP REPLACEMENT|PNEUMONIA|INFLUENZA|COVID 19|NEW OSTOMY|NEW UROSTOMY|FOLEY CATHETER MAINTANCE|PLURAL DRAINAGE|LYMPHEDEMA|NEW G TUBE|TRACHEOSTOMY|CANCER|WOUND CARE|OTHER-"]
[conditional field="COMMONDX" condition="(COMMONDX).is('OTHER-')"] [textarea name="OTHERREF" default="*** OTHER ***"]
[/conditional][conditional field="COMMONDX" condition="(COMMONDX).is('HEART_FAILURE')||(COMMONDX).is('COPD')"] 
INTERESTED IN TELEHEALTH? - [checkbox name="TELEHEALTH" value="YES|NO"][/conditional][conditional field="COMMONDX" condition="(COMMONDX).is('HEART_FAILURE')||(COMMONDX).is('COPD')||(COMMONDX).is('CANCER')"] INTERESTED IN PALLATIVE CARE? - [checkbox name="TELEHEALTH" value="YES|NO"]
[/conditional][conditional field="COMMONDX" condition="(COMMONDX).is('DIABETES')"][checkbox name="DIABETES" value=" -ON ORAL MEDS ONLY| -INSULIN DEPENDENT"][/conditional]
SIG PMH:
[textarea name="PMHX" default="OTHER DIAGNOSIS INFO, REASON FOR ADMIT"]
DME:
[checkbox name="ADUSE" value="CANE|WALKER|MANUAL WHEELCHAIR|MOTORIZED WHEELCHAIR|MECHANICAL LIFT|SUPPLEMENTAL OXYGEN|TUB CHAIR|BEDSIDE COMMODE|GLUCOMETER|SCALE|LIFE ALERT"]
[conditional field="ADUSE" condition="(ADUSE).is('SUPPLEMENTAL OXYGEN')"] SUPPLIER:[text name="O2SUPPLIER" default="OXYGEN SUPPLY COMPANY"][/conditional][conditional field="ADUSE" condition="(ADUSE).is('GLUCOMETER')"] TYPE:[checkbox name="GLUTYPE" value="STANDARD GLUCOMETER|CONTINOUS GLUCOSE MONITOR"][/conditional]
DISCIPLINES ORDERED:
[checkbox name="SKILLED_SERVICE" value="SKILLED NURSING|PHYSICAL THERAPY|OCCUPATIONAL THERAPY|MEDICAL SOCIAL WORKER"]

SKILLED NURSING REFERRED FOR: 
[checkbox name="SNVTYPE" value="PHYSICAL ASSESSMENT|MEDICATION EDUCATION|MEDICATION MANAGEMENT|DIET EDUCATION|FALL PREVENTION EDUCATION|HOME OXYGEN EDUCATION|DISEASE PROCESS EDUCATION"][conditional field="SNVTYPE" condition="(SNVTYPE).is('CATHETER_MAINTANCE')"][select name="CATHTYPE" value="FOLEY|SUPRAPUBIC"][/conditional][checkbox name="SNVTYPE" value="CATHETER MAINTANCE|WOUND CARE|IV MEDICATION TEACHING|PICC LINE|LAB DRAW|G TUBE EDUCATION|OSTOMY EDUCATION"]
[conditional field="SNVTYPE" condition="(SNVTYPE).is('WOUND_CARE')"]
SOC WOUND CARE ORDER:
[textarea name="WOUNDCAREVISIT" style="italics" default="ENTER WOUND CARE ORDER"]-[select name="WCTOL" value="PATIENT WILLING AND ABLE TO LEARN WOUND CARE.|FAMILY, FRIEND, AND/OR CAREGIVER WILLING AND ABLE TO LEARN WOUND CARE.|WOUND CARE MAY ONLY BE PROVIDED BY NURSE"][checkbox name="WCCYESNO" value="PATIENT GOING TO WOUND CARE CLINIC|PATIENT IS NOT GOING TO WOUND CARE CLINIC"][/conditional]
LIVES WITH:
HOMEBOUND STATUS:
PRIMARY INSURANCE:

SOC DATE: | END OF CERT:
REFERRAL SOURCE:
PROVIDER(S):
PRIMARY DX:

SIG PMH:

DME:


DISCIPLINES ORDERED:


SKILLED NURSING REFERRED FOR:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 37 form elements, 26 boilerplate words, 6 text boxes, 3 text areas, 1 dates, 10 checkboxes, 7 drop downs, 10 conditionals, 58 total clicks
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