{% extends 'dashboard_screen/base.html' %} {% block content %}

New Order Entry Form

{% if Step == 0 %}
{% else %} {% endif %} {% csrf_token %} {% if Patient %} {% else %} {% endif %} {% if Entry %} {% endif %}

Patient Information

{% if Step == 0 %} {% if Patient %}

Update Patient

{% else %}

Adding New Patient

{% endif %}
Client Name / Client Code(*)
Patient External ID:
First Name: (*)
Last Name: (*)
DOB: mm/dd/yy (*)
Address:
Address 2:
SSN:(*)
Phone:
City:
Zip Code:
State:
Gender:(*)
Ethnicity:

Enter payor information

Responsible Party (if different from patient)

Relationship To Patient:

{% endif %}

Select Exams

{% if Step == 1 %}
Collection Date:(*)
Attending Physician Name (*)

You can select Multiple Exams.

{% endif %}

Test Information

{% if Step == 2 %}

Order Info

{% if Entry.test_in_entry.all %} {% for case in Entry.test_in_entry.all %}

{{ case.exam_name }}

{{ case.exam_casetype.case_type_name }}

{{ case.cpt_name }}

{% endfor %} {% endif %}
{% if CaseTypes_in %} {% for case in CaseTypes_in %} {% if case.case_type_id == 1 %}

Enter clinical information for {{ case.case_type_name }}

Specimen Type:

Specimen Source:

Please select menstrual status.

Date of last menstrual period:(*)
Date of previous biopsy:
Date of previous pap smear: (*)
Prior abnormal report:

Present complaint or physical findings(select all that apply):

Others
{% endif %} {% if case.case_type_id == 2 %}

Enter clinical information for {{ case.case_type_name }}

Specimen Source (*):
Clinical information:
Gross description:
{% endif %} {% if case.case_type_id == 3 %}

Enter clinical information for {{ case.case_type_name }}

Specimen Source:

{% endif %} {% if case.case_type_id == 4 %}

Enter clinical information for {{ case.case_type_name }}

Clinical information:
{% if Entry.test_in_entry.all %} {% for exam in Entry.test_in_entry.all %} {% if case.case_type_name == exam.exam_casetype.case_type_name %} {% for i in exam.get_cut_range %}
Part #: {{ forloop.counter }} - Specimen Source (*):
Part #: {{ forloop.counter }} - Gross description (*):
{% endfor %} {% endif %} {% endfor %} {% endif %}
{% endif %} {% endfor %} {% endif %}
{% endif %}

Confirmation

{% if Step == 3 %}

LAB ID: {{ Entry.created_date |date:"Ymd" }}-{{ Entry.entry_id }}

{% if Entry.test_in_entry.all %}

Patient: {{ Entry.patient.full_name }}

Patient ID: {{ Entry.patient.patient_id}}

Create Date: {{ Entry.created_date |date:"m/d/Y" }}

Client: {{ Entry.patient.patient_client.get_full_name }}

Physicians Name: {{ Entry.physician_name }}

Collection Date: {{ Entry.collection_date |date:"m/d/Y" }}

Age: {% if Entry.patient.age %}{{ Entry.patient.age }}{% else %}{{ Entry.patient.how_old }}{% endif %}

DOB:{{ Entry.patient.dob |date:"m/d/Y" }}

Gender: {{ Entry.patient.show_gender_name }}

{% if Entry.initial_info == 0 %}Waiting for Confirmation {% else %} Confirmed {% endif %}
{% endif %}
{% for case in Entry.test_in_entry.all %}
Exam Name: {{ case.exam_name }}
{{ case.exam_casetype.case_type_name }}

Accession Number: {% for access in Entry.accession_number.all %} {% if case.exam_id == access.exam_in.exam_id %}{{ access.accession_number }} {% endif %}{% endfor %}

BarCode Number: {% for access in Entry.accession_number.all %} {% if case.exam_id == access.exam_in.exam_id %}{{ access.barcode }} {% endif %}{% endfor %}

CPT Code: {{ case.cpt_name }}

{% for access in Entry.accession_number.all %} {% if case.exam_id == access.exam_in.exam_id %} {{ access.barcode }} {% endif %} {% endfor %}
{% if case.exam_casetype.case_type_id == 1 %}

Specimen Source: {% if Entry.GYN_Cervix == 1 %} Cervix {% endif %} {% if Entry.GYN_Vaginal == 1 %} Vaginal {% endif %} {% if Entry.GYN_Endocervix == 1 %} Endocervix {% endif %} {% if Entry.GYN_None == 1 %} None given {% endif %}

Menstrual Status: {% if Entry.GYN_mestrual == 'Regular' %} Regular{% endif %} {% if Entry.GYN_mestrual == 'Irregular' %} Irregular{% endif %} {% if Entry.GYN_mestrual == 'Post-menopausal' %} Post-menopausal{% endif %} {% if Entry.GYN_mestrual == 'Pregnant' %} Pregnant{% endif %} {% if Entry.GYN_mestrual == 'Post-partum' %} Post-partum{% endif %}

{% if Entry.GYN_last_menstrual_period %}

Date of last menstrual period: {{ Entry.GYN_last_menstrual_period }}

{% endif %} {% if Entry.GYN_previous_biopsy %}

Date of previous biopsy: {{ Entry.GYN_previous_biopsy }}

{% endif %} {% if Entry.GYN_pap_smear %}

Date of previous pap smear: {{ Entry.GYN_pap_smear }}

{% endif %} {% if Entry.GYN_abnormal_report %}

Prior abnormal report: {{ Entry.GYN_abnormal_report }}

{% endif %}

Present complaint or physical findings:

{% if Entry.GYN_routine == 1 %} Routine {% endif %} {% if Entry.GYN_vaginitis == 1 %} Vaginitis {% endif %} {% if Entry.GYN_cervicitis == 1 %} Cervicitis {% endif %} {% if Entry.GYN_condyloma == 1 %} HPV {% endif %} {% if Entry.GYN_herpes == 1 %} Possible Herpes {% endif %} {% if Entry.GYN_clinically_suspicious == 1 %} Clinically suspicious {% endif %} {% if Entry.GYN_abnormal_bleeding == 1 %} Abnormal Bleeding {% endif %} {% if Entry.GYN_cervical_lesion == 1 %} Cervical Lesion {% endif %} {% if Entry.GYN_menopausal_syndrome == 1 %} Menopausal Syndrome {% endif %} {% if Entry.GYN_bleeds_on_contact == 1 %} Bleeds on Contact {% endif %} {% if Entry.GYN_infection == 1 %} Infection {% endif %} {% if Entry.GYN_iud == 1 %} IUD {% endif %} {% if Entry.GYN_discharge == 1 %} Discharge {% endif %} 
{% if Entry.GYN_hysterectomy == 1 %} Hysterectomy {% endif %} 
{% if Entry.GYN_hysterectomy == 1 %} 
 

{% if Entry.GYN_discharge_info == 'Partial' %} Partial {% endif %} 
 {% if Entry.GYN_discharge_info == 'Total' %} Total {% endif %} {% endif %}


{% if Entry.GYN_hysterectomy_description %}Others: {{ Entry.GYN_hysterectomy_description }}{% endif %}

{% endif %} {% if case.exam_casetype.case_type_id == 2 %}

Specimen Source: {% if Entry.Non_GYN_specimen_source %} {% for source in no_gyn_specimen_sources %}
{% if source.id == Entry.Non_GYN_specimen_source %} {{ source.name }} {% endif %}{% endfor %}{% endif %}

{% if Entry.Non_GYN_clinical_info %}

Clinical information: {{ Entry.Non_GYN_clinical_info }}

{% endif %} {% if Entry.Non_GYN_gross_description %}

Gross description: {{ Entry.Non_GYN_gross_description }}

{% endif %}
{% endif %} {% if case.exam_casetype.case_type_id == 3 %}

Specimen Source: {% if Entry.MP_speciment_source == 'Vaginal' %} Vaginal swab {% endif %}
 {% if Entry.MP_speciment_source == 'Urethral' %} Urethral swab {% endif %} {% if Entry.MP_speciment_source == 'Urine' %} Urine {% endif %}
 {% if Entry.MP_speciment_source == 'Liquid-based' %} Liquid-based {% endif %} {% if Entry.MP_speciment_source == 'PAP' %} PAP {% endif %}

{% endif %} {% if case.exam_casetype.case_type_id == 4 %}
{% if Entry.SP_clinical_info %}

Clinical information: {{ Entry.SP_clinical_info }}

{% endif %} {% if Entry.test_in_entry.all %}
 {% for exam in Entry.test_in_entry.all %} {% if case.exam_casetype.case_type_name == exam.exam_casetype.case_type_name %} {% for i in exam.get_cut_range %}


Specimen Source Part #: {{ forloop.counter }}: {% if forloop.counter == 1 %}{{ Entry.SP_specimen_source_1 }}{% elif forloop.counter == 2 %}{{ Entry.SP_specimen_source_2 }}{% elif forloop.counter == 3 %}{{ Entry.SP_specimen_source_3 }}{% elif forloop.counter == 4 %}{{ Entry.SP_specimen_source_4 }}{% elif forloop.counter == 5 %}{{ Entry.SP_specimen_source_5 }}{% elif forloop.counter == 6 %}{{ Entry.SP_specimen_source_6 }}{% elif forloop.counter == 7 %}{{ Entry.SP_specimen_source_7 }}{% elif forloop.counter == 8 %}{{ Entry.SP_specimen_source_8 }}{% elif forloop.counter == 9 %}{{ Entry.SP_specimen_source_9 }}{% elif forloop.counter == 10 %}{{ Entry.SP_specimen_source_10 }}{% elif forloop.counter == 11 %}{{ Entry.SP_specimen_source_11 }}{% elif forloop.counter == 12 %}{{ Entry.SP_specimen_source_12 }}{% endif %}

Gross description Part #: {{ forloop.counter }}: {% if forloop.counter == 1 %}{{ Entry.SP_gross_description_1 }}{% elif forloop.counter == 2 %}{{ Entry.SP_gross_description_2 }}{% elif forloop.counter == 3 %}{{ Entry.SP_gross_description_3 }}{% elif forloop.counter == 4 %}{{ Entry.SP_gross_description_4 }}{% elif forloop.counter == 5 %}{{ Entry.SP_gross_description_5 }}{% elif forloop.counter == 6 %}{{ Entry.SP_gross_description_6 }}{% elif forloop.counter == 7 %}{{ Entry.SP_gross_description_7 }}{% elif forloop.counter == 8 %}{{ Entry.SP_gross_description_8 }}{% elif forloop.counter == 9 %}{{ Entry.SP_gross_description_9 }}{% elif forloop.counter == 10 %}{{ Entry.SP_gross_description_10 }}{% elif forloop.counter == 11 %}{{ Entry.SP_gross_description_11 }}{% elif forloop.counter == 12 %}{{ Entry.SP_gross_description_12 }}{% endif %}

{% endfor %} {% endif %}
 {% endfor %} 
{% endif %}
{% endif %}
{% endfor %}
{% endif %}
{{ message }}
{% if Step == 0 %}
{% endif %} {% if Step == 1 %}
{% endif %} {% if Step == 2 %}
{% endif %} {% if Step == 3 %}
{% if Entry.initial_info == 1 %} View Entry New Entry Enter Result {% else %} {% endif %}
{% endif %}
{% endblock %}