<link href="//netdna.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.2.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Pre-Insertion Form</legend> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_consent_signed">Consent Signed and Verified with Order</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_consent_signed-0"> <input type="radio" name="pre_insert_consent_signed" id="pre_insert_consent_signed-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_consent_signed-1"> <input type="radio" name="pre_insert_consent_signed" id="pre_insert_consent_signed-1" value="No"> No </label> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_name">Fill in your name</label> <div class="col-md-6"> <input id="pre_insert_name" name="pre_insert_name" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_family_verbal_understand">Pt/Family Verbalized Understanding</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_family_verbal_understand-0"> <input type="radio" name="pre_insert_family_verbal_understand" id="pre_insert_family_verbal_understand-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_family_verbal_understand-1"> <input type="radio" name="pre_insert_family_verbal_understand" id="pre_insert_family_verbal_understand-1" value="No"> No </label> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_family_verbal_explain">Explain</label> <div class="col-md-4"> <textarea class="form-control" id="pre_insert_family_verbal_explain" name="pre_insert_family_verbal_explain"></textarea> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="label"><h2>Time Out and Prep</h2></label> <div class="col-md-4"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_identity_verified_by_name">PT Identified Verified By</label> <div class="col-md-6"> <input id="pre_insert_identity_verified_by_name" name="pre_insert_identity_verified_by_name" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Checkboxes --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_identity_verified_by"></label> <div class="col-md-4"> <div class="checkbox"> <label for="pre_insert_identity_verified_by-0"> <input type="checkbox" name="pre_insert_identity_verified_by" id="pre_insert_identity_verified_by-0" value="Photo"> Photo </label> </div> <div class="checkbox"> <label for="pre_insert_identity_verified_by-1"> <input type="checkbox" name="pre_insert_identity_verified_by" id="pre_insert_identity_verified_by-1" value="Armband"> Armband </label> </div> <div class="checkbox"> <label for="pre_insert_identity_verified_by-2"> <input type="checkbox" name="pre_insert_identity_verified_by" id="pre_insert_identity_verified_by-2" value="Patient Response"> Patient Response </label> </div> <div class="checkbox"> <label for="pre_insert_identity_verified_by-3"> <input type="checkbox" name="pre_insert_identity_verified_by" id="pre_insert_identity_verified_by-3" value=""> Check All </label> </div> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_timeout_observed_by_name">Time-Out Observed By</label> <div class="col-md-6"> <input id="pre_insert_timeout_observed_by_name" name="pre_insert_timeout_observed_by_name" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Checkboxes --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_timeout_observed_by"></label> <div class="col-md-4"> <div class="checkbox"> <label for="pre_insert_timeout_observed_by-0"> <input type="checkbox" name="pre_insert_timeout_observed_by" id="pre_insert_timeout_observed_by-0" value="Proper Patient"> Proper Patient </label> </div> <div class="checkbox"> <label for="pre_insert_timeout_observed_by-1"> <input type="checkbox" name="pre_insert_timeout_observed_by" id="pre_insert_timeout_observed_by-1" value="Proper Order"> Proper Order </label> </div> <div class="checkbox"> <label for="pre_insert_timeout_observed_by-2"> <input type="checkbox" name="pre_insert_timeout_observed_by" id="pre_insert_timeout_observed_by-2" value="Proper Site"> Proper Site </label> </div> <div class="checkbox"> <label for="pre_insert_timeout_observed_by-3"> <input type="checkbox" name="pre_insert_timeout_observed_by" id="pre_insert_timeout_observed_by-3" value="Correct Equipment/Supplies Available"> Correct Equipment/Supplies Available </label> </div> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_patient_positioned">Patient Positioned</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_patient_positioned-0"> <input type="radio" name="pre_insert_patient_positioned" id="pre_insert_patient_positioned-0" value="Supine" checked="checked"> Supine </label> <label class="radio-inline" for="pre_insert_patient_positioned-1"> <input type="radio" name="pre_insert_patient_positioned" id="pre_insert_patient_positioned-1" value="Other"> Other </label> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_patient_positioned"></label> <div class="col-md-6"> <input id="pre_insert_patient_positioned" name="pre_insert_patient_positioned" type="text" placeholder="other" class="form-control input-md"> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_correct_prep">Correct Side/Site Prepped with Chloraprep (Allow 30 Second Dry Time)</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_correct_prep-0"> <input type="radio" name="pre_insert_correct_prep" id="pre_insert_correct_prep-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_correct_prep-1"> <input type="radio" name="pre_insert_correct_prep" id="pre_insert_correct_prep-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_cleanse_hand_alcohol">Cleanse Hand with Alcohol Gel or Wash with Antimicrobial Soap and Water for 15 Seconds</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_cleanse_hand_alcohol-0"> <input type="radio" name="pre_insert_cleanse_hand_alcohol" id="pre_insert_cleanse_hand_alcohol-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_cleanse_hand_alcohol-1"> <input type="radio" name="pre_insert_cleanse_hand_alcohol" id="pre_insert_cleanse_hand_alcohol-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_don_cap_mask_gown">Don Cap, Mask, and Sterile Gown</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_don_cap_mask_gown-0"> <input type="radio" name="pre_insert_don_cap_mask_gown" id="pre_insert_don_cap_mask_gown-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_don_cap_mask_gown-1"> <input type="radio" name="pre_insert_don_cap_mask_gown" id="pre_insert_don_cap_mask_gown-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_don_sterile_gloves">Don Sterile Gloves</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_don_sterile_gloves-0"> <input type="radio" name="pre_insert_don_sterile_gloves" id="pre_insert_don_sterile_gloves-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_don_sterile_gloves-1"> <input type="radio" name="pre_insert_don_sterile_gloves" id="pre_insert_don_sterile_gloves-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_establish_sterile_field">Establish and Maintain Sterile Field</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_establish_sterile_field-0"> <input type="radio" name="pre_insert_establish_sterile_field" id="pre_insert_establish_sterile_field-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_establish_sterile_field-1"> <input type="radio" name="pre_insert_establish_sterile_field" id="pre_insert_establish_sterile_field-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_procedure_performed_aseptically">Procedure Performed Aseptically Per Standard of Care</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_procedure_performed_aseptically-0"> <input type="radio" name="pre_insert_procedure_performed_aseptically" id="pre_insert_procedure_performed_aseptically-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_procedure_performed_aseptically-1"> <input type="radio" name="pre_insert_procedure_performed_aseptically" id="pre_insert_procedure_performed_aseptically-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_seldinger_technique">Modified Seldinger Technique</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_seldinger_technique-0"> <input type="radio" name="pre_insert_seldinger_technique" id="pre_insert_seldinger_technique-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_seldinger_technique-1"> <input type="radio" name="pre_insert_seldinger_technique" id="pre_insert_seldinger_technique-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_over_the_wire_exchange">Over the Wire Exchange Performed Per Protocol</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_over_the_wire_exchange-0"> <input type="radio" name="pre_insert_over_the_wire_exchange" id="pre_insert_over_the_wire_exchange-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_over_the_wire_exchange-1"> <input type="radio" name="pre_insert_over_the_wire_exchange" id="pre_insert_over_the_wire_exchange-1" value="No"> No </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="pre_insert_verify_placement_xray">Verify Placement w X-Ray Prior to Use if Indicated per Facility Protocol</label> <div class="col-md-4"> <label class="radio-inline" for="pre_insert_verify_placement_xray-0"> <input type="radio" name="pre_insert_verify_placement_xray" id="pre_insert_verify_placement_xray-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="pre_insert_verify_placement_xray-1"> <input type="radio" name="pre_insert_verify_placement_xray" id="pre_insert_verify_placement_xray-1" value="No"> No </label> </div> </div> </fieldset> </form>