django-fobi/examples/saved_forms_in_json_format/ssi-knee-hip.json

{"name": "SSI Knee & Hip", "form_elements": [{"plugin_data": "{\"required\": true, \"initial\": \"\", \"placeholder\": \"\", \"help_text\": \"\", \"max_length\": 255, \"name\": \"surgeon\", \"label\": \"Surgeon\"}", "plugin_uid": "text", "position": 1}, {"plugin_data": "{\"required\": true, \"initial\": null, \"name\": \"hospital_number\", \"help_text\": \"\", \"max_value\": null, \"min_value\": null, \"placeholder\": \"\", \"label\": \"Hospital number\"}", "plugin_uid": "integer", "position": 2}, {"plugin_data": "{\"required\": true, \"initial\": \"\", \"placeholder\": \"\", \"help_text\": \"\", \"max_length\": 255, \"name\": \"anaesthetist\", \"label\": \"Anaesthetist\"}", "plugin_uid": "text", "position": 3}, {"plugin_data": "{\"choices\": \"Ward 1\\r\\nWard 2\\r\\nWard 3\\r\\nWard 4\\r\\nWard 5\\r\\nWard 6\", \"initial\": \"\", \"help_text\": \"Select\", \"label\": \"Ward\", \"name\": \"ward\", \"required\": true}", "plugin_uid": "select", "position": 4}, {"plugin_data": "{\"label\": \"Gender\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"gender\", \"choices\": \"Male\\r\\nFemale\"}", "plugin_uid": "radio", "position": 5}, {"plugin_data": "{\"label\": \"Age\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"age\", \"choices\": \"<50\\r\\n51-71\\r\\n71+\"}", "plugin_uid": "radio", "position": 6}, {"plugin_data": "{\"choices\": \"Osteoarthritis \\r\\nInflammatory Joint Disease\\r\\nOther\", \"initial\": \"\", \"help_text\": \"Select\", \"label\": \"Diagnosis\", \"name\": \"diagnosis\", \"required\": true}", "plugin_uid": "select", "position": 7}, {"plugin_data": "{\"label\": \"Diabetic\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"diabetic\", \"choices\": \"Yes\\r\\nNo\"}", "plugin_uid": "radio", "position": 8}, {"plugin_data": "{\"label\": \"ASA score\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"asa_score\", \"choices\": \"1\\r\\n2\\r\\n3\"}", "plugin_uid": "radio", "position": 9}, {"plugin_data": "{\"label\": \"MRSA\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"mrsa\", \"choices\": \"Yes\\r\\nNo\\r\\nPositive\"}", "plugin_uid": "radio", "position": 10}, {"plugin_data": "{\"label\": \"MSU screen pre-op\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"msu_screen_pre_op\", \"choices\": \"Yes\\r\\nNo\\r\\nPositive\"}", "plugin_uid": "radio", "position": 11}, {"plugin_data": "{\"label\": \"Was patient admitted due to SSI\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"was_patient_admitted_due_to_ssi\", \"choices\": \"Yes\\r\\nNo\"}", "plugin_uid": "radio", "position": 12}, {"plugin_data": "{\"label\": \"Has patient been on steroids >7 days prior to surgery\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"has_patient_been_on_steroids_7_days_prior_to_surgery\", \"choices\": \"Yes\\r\\nNo\"}", "plugin_uid": "radio", "position": 13}, {"plugin_data": "{\"initial\": null, \"input_formats\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"date_of_admission\", \"label\": \"Date of Admission\"}", "plugin_uid": "date", "position": 14}, {"plugin_data": "{\"initial\": null, \"input_formats\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"date_of_procedure_antibiotic_administration_date\", \"label\": \"Date of procedure/ antibiotic administration date\"}", "plugin_uid": "date", "position": 15}, {"plugin_data": "{\"initial\": null, \"input_formats\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"anaesthetic_start_time\", \"label\": \"Anaesthetic start time\"}", "plugin_uid": "datetime", "position": 16}, {"plugin_data": "{\"initial\": null, \"input_formats\": \"\", \"help_text\": \"\", \"required\": false, \"name\": \"antibiotic_administration_time\", \"label\": \"Antibiotic administration time\"}", "plugin_uid": "datetime", "position": 17}, {"plugin_data": "{\"required\": false, \"initial\": \"\", \"placeholder\": \"Type here\", \"help_text\": \"\", \"max_length\": 255, \"name\": \"antibiotic_administration_route\", \"label\": \"Antibiotic administration route\"}", "plugin_uid": "text", "position": 18}, {"plugin_data": "{\"label\": \"Time of IV AB's administration\", \"initial\": \"\", \"help_text\": \"\", \"required\": true, \"name\": \"time_of_iv_abs_administration\", \"choices\": \"Within 1 hour prior to incision\\r\\nAt surgical incision time\\r\\nNot documented\\r\\nAnaesthetic end time\"}", "plugin_uid": "select", "position": 19}, {"plugin_data": "{\"label\": \"Type of antibiotic\", \"initial\": \"\", \"help_text\": \"\", \"required\": false, \"name\": \"type_of_antibiotic\", \"choices\": \"Zinacef\\r\\nVancomycin\\r\\nOther\\r\\nAntibiotic allergy\"}", "plugin_uid": "select", "position": 20}, {"plugin_data": "{\"choices\": \"Stopped within 24\\u00b0 of anaesthesia end time\\r\\nStopped within 48\\u00b0 of anaesthesia end time\\r\\n> 48\\u00b0\\r\\n> ?\\r\\nUTI?\\r\\nRTI?\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Length of time IV AB's continued\", \"name\": \"length_of_time_iv_abs_continued\", \"required\": true}", "plugin_uid": "select", "position": 21}, {"plugin_data": "{\"choices\": \"<4 (or=??)\\r\\n>4\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Number of doses\", \"name\": \"number_of_doses\", \"required\": false}", "plugin_uid": "radio", "position": 22}, {"plugin_data": "{\"choices\": \"</= 24 hours\\r\\n</= 48 hours\\r\\n</= 72 hours\\r\\n> 72 hours\\r\\nRemoval not documented\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"IV cannula removal\", \"name\": \"iv_cannula_removal\", \"required\": false}", "plugin_uid": "select", "position": 23}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Catheterised intra op\", \"name\": \"catheterised_intra_op\", \"required\": false}", "plugin_uid": "radio", "position": 24}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Was pt catheterised within 24\\u00b0 post operatively\", \"name\": \"was_pt_catheterised_within_24_post_operatively\", \"required\": false}", "plugin_uid": "radio", "position": 25}, {"plugin_data": "{\"choices\": \"General\\r\\nRegional\\r\\nBoth\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Type of anaesthetic\", \"name\": \"type_of_anaesthetic\", \"required\": false}", "plugin_uid": "radio", "position": 26}, {"plugin_data": "{\"choices\": \"Pre admission warfare\\r\\nLow molecular heparin - Innohep or cleaner\\r\\nWarfarin\\r\\nOral factor  - Xarelto\\r\\nNu-Seals aspirin\\r\\n?? Reason, cells alva get,  timeout, blood transfusion??\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"VTE prophylaxis\", \"name\": \"vte_prophylaxis\", \"required\": false}", "plugin_uid": "select_multiple", "position": 27}, {"plugin_data": "{\"choices\": \"Intrathecal morphine\\r\\nFemoral block\\r\\nPCA\\r\\nIM/PO\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Post op pain management\", \"name\": \"post_op_pain_management\", \"required\": false}", "plugin_uid": "select", "position": 28}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"VTE prophylaxis started within 24 hours of surgery\", \"name\": \"vte_prophylaxis_started_within_24_hours_of_surgery\", \"required\": false}", "plugin_uid": "radio", "position": 29}, {"plugin_data": "{\"choices\": \"<500\\r\\n500-750\\r\\n750+\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Blood loss\", \"name\": \"blood_loss\", \"required\": false}", "plugin_uid": "select", "position": 30}, {"plugin_data": "{\"choices\": \"Op-site 10 X 30\\r\\nMepore 10 X 30\\r\\nJubilee\\r\\nOther\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Type of primary dressing\", \"name\": \"type_of_primary_dressing\", \"required\": false}", "plugin_uid": "select", "position": 31}, {"plugin_data": "{\"choices\": \"1\\r\\n2\\r\\n3\\r\\n4\\r\\n5\\r\\n6+\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Number of dressing changes\", \"name\": \"number_of_dressing_changes\", \"required\": false}", "plugin_uid": "radio", "position": 32}, {"plugin_data": "{\"choices\": \"Clean\\r\\nClean contaminated\\r\\nContaminated\\r\\nDirty or infected\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Wound class\", \"name\": \"wound_class\", \"required\": false}", "plugin_uid": "select", "position": 33}, {"plugin_data": "{\"choices\": \"Yes (if yes, number of doses)\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Innapropriate administration of perfalgan\", \"name\": \"innapropriate_administration_of_perfalgan\", \"required\": false}", "plugin_uid": "radio", "position": 34}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Day 5 SSI nursing documentation completed\", \"name\": \"day_5_ssi_nursing_documentation_completed\", \"required\": false}", "plugin_uid": "radio", "position": 35}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"D/C SSI nursing documentation completed\", \"name\": \"dc_ssi_nursing_documentation_completed\", \"required\": false}", "plugin_uid": "radio", "position": 36}, {"plugin_data": "{\"choices\": \"<= 5 days\\r\\n6-10 days\\r\\n11-15 days\\r\\n16+ days\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Length of stay\", \"name\": \"length_of_stay\", \"required\": false}", "plugin_uid": "select", "position": 37}, {"plugin_data": "{\"initial\": \"\", \"help_text\": \"\", \"label\": \"Comment?\", \"required\": false, \"name\": \"comment\", \"placeholder\": \"\", \"max_length\": 255}", "plugin_uid": "text", "position": 38}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Has patient developed an SSI\", \"name\": \"has_patient_developed_an_ssi\", \"required\": false}", "plugin_uid": "radio", "position": 39}, {"plugin_data": "{\"choices\": \"Superficial incisional\\r\\nDeep incisional\\r\\nOrgan space\\r\\n\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Type of SSI\", \"name\": \"type_of_ssi\", \"required\": false}", "plugin_uid": "select", "position": 40}, {"plugin_data": "{\"choices\": \"Joint of Bursa\\r\\nOsteomyelitis\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Site of organ / space infection\", \"name\": \"site_of_organ_space_infection\", \"required\": false}", "plugin_uid": "select", "position": 41}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Returned to theatre for drainage of abscess/ washout\", \"name\": \"returned_to_theatre_for_drainage_of_abscess_washout\", \"required\": false}", "plugin_uid": "radio", "position": 42}, {"plugin_data": "{\"choices\": \"During hospital stay\\r\\nOn readmission\\r\\nPost discharge\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"When was surgical site infection detected\", \"name\": \"when_was_surgical_site_infection_detected\", \"required\": false}", "plugin_uid": "select", "position": 43}, {"plugin_data": "{\"choices\": \"Home\\r\\nRelative\\r\\nNursing home\\r\\nOther\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Discharged to\", \"name\": \"discharged_to\", \"required\": false}", "plugin_uid": "select", "position": 44}, {"plugin_data": "{\"text\": \"Blood cultures\"}", "plugin_uid": "content_text", "position": 45}, {"plugin_data": "{\"initial\": null, \"input_formats\": \"\", \"label\": \"Date sent\", \"name\": \"date_sent\", \"help_text\": \"\", \"required\": false}", "plugin_uid": "date", "position": 46}, {"plugin_data": "{\"choices\": \"Yes\\r\\nNo\", \"initial\": \"\", \"help_text\": \"\", \"label\": \"Contaminated specimen\", \"name\": \"contaminated_specimen\", \"required\": false}", "plugin_uid": "radio", "position": 47}, {"plugin_data": "{\"initial\": \"\", \"help_text\": \"\", \"label\": \"Growth\", \"required\": false, \"name\": \"growth\", \"placeholder\": \"\", \"max_length\": 255}", "plugin_uid": "text", "position": 48}, {"plugin_data": "{\"initial\": \"\", \"help_text\": \"\", \"label\": \"Sensitivity\", \"required\": false, \"name\": \"sensitivity\", \"placeholder\": \"\", \"max_length\": 255}", "plugin_uid": "text", "position": 49}], "action": "", "is_public": false, "is_cloneable": false, "slug": "ssi-knee-hip", "position": null, "form_handlers": [{"plugin_data": null, "plugin_uid": "db_store"}, {"plugin_data": "{\"subject\": \"SSI Knee & Hip form\", \"body\": \"SSI Knee & Hip form submitted\", \"from_name\": \"Someone\", \"to_name\": \"Someone\", \"from_email\": \"foreverchild.to@gmail.com\", \"to_email\": [\"foreverchild.to@gmail.com\"]}", "plugin_uid": "mail"}], "success_page_title": "Form submitted successfully", "success_page_message": ""}