This application guides you through completion of an admission form for the University Medical Center. It is specifically designed to accurately reproduce the hospital's paper form, thereby easing the transition to a computer-based system.
The form is relatively simple to complete. Press Enter to move from field to field, filling in the information as requested. To access the Insurance Information form, click the area indicated at the bottom of the form.
Since very few of the advanced ObjectVision features are used in this application, it demonstrates how a professional-looking application can be designed with limited knowledge of ObjectVision.
Click here to close
Physician
Enter the name of the patient's physician.
This field uses a grey background color for
emphasis.
Type of Admission
INPATIENT: For patients who will be admitted
for an overnight stay, and/or will be using a
bed in one of the recuperation wards.
OUTPATIENT: For procedures which can be
completed and the patient released on the
same day.
MATERNITY: For delivery of a baby or for
inpatient treatment of pre-delivery
complications in pregnancy.
This field uses the Object Vision
"Radio Button" type.
Inpatient
Outpatient
Maternity
Date of Admission
Enter the date which the patient is entering
the hospital. The date shown can be over-
written by typing in a new value.
This field uses an ObjectVision Event Tree
to automatically provide this value.
33534
Prior Patient
If the patient has a chart on file in the
medical records files or archives, click Yes,
otherwise click No. If Yes is chosen, the
cursor will proceed to ask for the name under
which the patient was admitted. If No, then
the cursor will automatically jump to Birthplace.
The logic for this action is stored in the
Value Tree of the "Admitted under what
name" field.
Admitted under what name
If the patient has a chart on file in the
medical records files or archives enter the
name under which the patient was admitted.
The cursor will automatically jump to this field
and proceed to Birthplace if the Prior Patient
field is set to "No".
The logic for this action is stored in this field's
Value Tree.
Birthplace
Enter the patient's place of birth.
00/00/00
Maternity
Date of last Menstrual Period
If "Maternity" is checked in the Type of Admission field, the cursor will automatically proceed to this field for entry. Enter the date of the patient's last menstrual period.
If "Maternity" is not checked, then this field will be skipped.
A simple ObjectVision Value Tree is used to create this effect.
No Blanks allowed here
Patient Name
Enter the name of the patient in the format:
Last Name, First Name, Middle Initial
Enter M or F.
Social Security #
Enter the patient's Social Security Number.
This uses an Object Vision "Picture" field to
automatically format the input.
365.25
Based on the current system date and the
date entered as the patient's birthdate, the
patient's age is automatically calculated.
This field is calculated using an ObjectVision
Value Tree and built-in @ functions.
Birthdate
Enter the patient's date of birth.
Enter the race of the patient, choosing from
a selection list that will automatically appear.
Caucasian
Black
Hispanic
Native Amer.
Asian
Complete Mailing Address
Within the space provided, enter the patient's
mailing address as fully as possible.
Patient's Home Telephone Number
Enter the patient's home telephone number.
This uses an Object Vision "Picture" field to
automatically format the input.
Marital Status
Select Married or Single by clicking the mouse
one the circle next to the appropriate choice.
Married
Single
Patient's Employer
Enter the name of the patient's employer.
Patient's Occupation
Enter the patient's occupation.
Patient's Work Phone Number
Enter the patient's work telephone number.
This uses an Object Vision "Picture" field to
automatically format the input.
Responsible Party Name
Enter the name of the person who is
responsible for paying the patient's bill.
This field uses a grey background color for
visual emphasis.
Responsible Party's Social Security Number
Enter the Social Security Number of the person
responsible for paying this bill.
This uses an Object Vision "Picture" field to
automatically format the input.
Relationship to Patient
From the selection list, choose the
appropriate relationship of the responsible
party to the patient.
Parent
Legal Guardian
Spouse
Son/Daughter
Other
Responsible Party's Address
As completely as possible, enter the address
of the preson listed as the responsible party.
Responsible Party's Home Phone Number
Enter the home telephone number of the
person who is responsible for paying the
patient's bill.
This uses an Object Vision "Picture" field to
automatically format the input.
Alternate Person to Notify In Case of Emergency
In case of emergrncy, another person (other
than the resposible party) should be named so
that proper notification and contacts can be
made for authorization of treatment.
Alternate Contact's Phone Number
Enter the telephone number of the alternate
person to contact in case of emergency.
This uses an Object Vision "Picture" field to
automatically format the input.
Responsible Party's Work Phone Number
Enter the home telephone number of the
person who is responsible for paying the
patient's bill.
This uses an Object Vision "Picture" field to
automatically format the input.
Alternate's Relationship to Patient
From the selection list, choose the appropriate
relationship to the patient of the person named
as the alternate contact.
Parent
Legal Guardian
Spouse
Son/Daughter
Other
Primary Health Insurance Co.
Enter the name of the primary insurer for this
patient.
Subscribers Name
Enter the name of the person under whom the
insurance coverage is provided.
Group/Policy #
Enter the identifying number for the applicable
insurance policy.
Social Security Number, Primary Insured
Enter the Social Security Number of the person
named as the Primary Insured.
This uses an Object Vision "Picture" field to
automatically format the input.
Print
Clicking this button will print the current form
and all its data. Note that ObjectVision does
not print the buttons themselves.
Hospital Admissions (
Primary Health Insurance Co.
Clear
Clicking on the 'Clear' button will remove all
current data from the form.
Primary Insurance Mailing Address
Enter the mailing/billing address of the primary
insurer.
Primary Insurance Company's Phone Number
Enter the telephone number of the primary
insurer of this patient.
This uses an Object Vision "Picture" field to
automatically format the input.
Secondary Health Insurance Co.
Enter the name of the primary insurer for this
patient.
Secondary Subscribers Name
Enter the name of the person under whom the
seconsdary insurance coverage is provided.
Secondary Group/Policy #
Enter the identifying number for the applicable
secondary insurance policy.
Social Security Number, Secondary Insured
Enter the Social Security Number of the person
named as the Secondary Insured.
This uses an Object Vision "Picture" field to
automatically format the input.
Secondary Insurance Mailing Address
Enter the mailing/billing address of the primary
insurer.
Secondary Insurance Company's Phone Number
Enter the telephone number of the secondary
insurer of this patient.
This uses an Object Vision "Picture" field to
automatically format the input.
Employer for Secondary Insurance
Enter the name of the employer under whom
the secondary insurance is provided.
Secondary Employer's Phone Number
Enter the telephone number of the employer
providing the secondary insurance of this patient.
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