@php
$data = [];
$data['keterangan'] = $periksa->keterangan;
if (!empty($komponens)) {
foreach ($komponens as $rows) {
$key = trim($rows->komponen);
if (!empty($key)) {
if ($key == 'keterangan') {
$data['keterangan'] .= $rows->isidata;
} else {
$data[$key] = $rows->isidata;
}
}
}
}
@endphp
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Barcode NIK |
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Barcode TBC.05 |
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 !!}) |
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PENANGGULANGAN TBC NASIONAL |
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TBC.05 |
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INDONESIA 2020/EDISI 3 |
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FORMULIR PERMOHONAN PEMERIKSAAN BAKTERIOLOGIS TBC |
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Nama Fasyankes |
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{!! $periksa->nmrs !!} |
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Nama Dokter Pengirim |
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{!! $periksa->klinisi !!} |
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Kode Fasyankes |
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{!! $periksa->ruangan_id !!} |
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No. Rekam Medis |
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{!! $periksa->noregister !!} |
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Nama Terduga |
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{!! $periksa->nmpasien !!} |
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No. Telp. Pasien |
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{!! $periksa->tlppasien !!} |
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No. Induk Kependudukan |
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{{$nik}} |
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No. BPJS |
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{{$bpjs}} |
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Jenis Kelamin |
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@if ($periksa->jkpasien == 'L')
√
@else
@endif
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Laki - Laki |
@if ($periksa->jkpasien != 'L')
√
@else
@endif
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Perempuan |
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Umur |
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{!! $periksa->usia !!} |
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Alamat Lengkap |
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{!! $periksa->alamatpasien !!} |
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Kabupaten / Kota |
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{!! $periksa->getPasien->kota ?? '-' !!} |
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Jenis Terduga / Pasien TBC |
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Provinsi |
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{!! $periksa->getPasien->keterangan ?? '-' !!} |
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@if (isset($data['inlineCheckbox1']) && $data['inlineCheckbox1'] != '')
√
@else
@endif
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TBC SO |
@if (isset($data['inlineCheckbox2']) && $data['inlineCheckbox2'] != '')
√
@else
@endif
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TBC RO |
@if (isset($data['inlineCheckbox3']) && $data['inlineCheckbox3'] != '')
√
@else
@endif
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Anak |
@if (isset($data['inlineCheckbox4']) && $data['inlineCheckbox4'] != '')
√
@else
@endif
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HIV |
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@if (isset($data['inlineCheckbox5']) && $data['inlineCheckbox5'] != '')
√
@else
@endif
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DM |
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No. Identitas Sediaan |
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Lama Riwayat Pengobatan Terduga / Pasien TBC |
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{{$data['id_noidsediaan'] ?? ''}} |
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@php
if (isset($data['id_lamariwayatpengobatantb']) && $data['id_lamariwayatpengobatantb'] == 'Riwayat Pengobatan < 5 tahun'){
$rw1 = ' ';
$rw2 = '√';
} else {
$rw2 = ' ';
$rw1 = '√';
}
echo $rw1;
@endphp
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Riwayat Pengobatan >=5 tahun |
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Tanggal pengambilan contoh uji |
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{{ $data['id_tanggalpengambilancontohuji'] ?? ''}} |
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{!! $rw2 !!} |
Riwayat Pengobatan < 5tahun |
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Tanggal pengiriman contoh uji |
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{{ $data['id_tanggalpengirimancontohuji'] ?? ''}} |
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Tanda tangan pengambilan contoh uji |
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Alasan Pemeriksaan : |
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@php
if (isset($data['id_alasanpemeriksaan']) && $data['id_alasanpemeriksaan'] == 'Diagnosis TBS'){
$d2 = ' ';
$d1 = '√';
$d3 = ' ';
} else if (isset($data['id_alasanpemeriksaan']) && $data['id_alasanpemeriksaan'] == 'Diagnosis Baseline TBC'){
$d1 = ' ';
$d2 = '√';
$d3 = ' ';
} else {
$d1 = ' ';
$d3 = '√';
$d2 = ' ';
}
echo $d1;
@endphp
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Diagnosis TBC |
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{!! $d2 !!} |
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Diagnosis Baseline TBC |
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Jenis Pemeriksaan |
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Lokasi Anatomi |
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{!! $d3 !!} |
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Akhir Pengobatan |
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@php
if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'Mikroskopis'){
$j1 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'TCM MTB Rif (Xpert)'){
$j2 = '√';
$j1 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'TCM XDR (Xpert)'){
$j3 = '√';
$j2 = ' ';
$j1 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'TCM MTB Rif (Truenat)'){
$j4 = '√';
$j2 = ' ';
$j3 = ' ';
$j1 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'TCM MTB Rif INH (BDMAX)'){
$j5 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j1 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'PCR Open System'){
$j6 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j1 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'LPA lini 1'){
$j7 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j1 = ' ';
$j8 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'LPA lini 2'){
$j8 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j1 = ' ';
$j9 = ' ';
$j10 = ' ';
} else if (isset($data['id_jenispemeriksaantb']) && $data['id_jenispemeriksaantb'] == 'Biakan'){
$j9 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j1 = ' ';
$j10 = ' ';
} else {
$j10 = '√';
$j2 = ' ';
$j3 = ' ';
$j4 = ' ';
$j5 = ' ';
$j6 = ' ';
$j7 = ' ';
$j8 = ' ';
$j9 = ' ';
$j1 = ' ';
}
if (isset($data['tekslokasianatomi']) && $data['tekslokasianatomi'] != ''){
$p2 = '√';
$p1 = ' ';
} else {
$p1 = '√';
$p2 = ' ';
}
@endphp
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{!! $j1 !!} |
Mikroskopis |
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{!! $p1 !!} |
Paru |
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Pemantauan kemajuan pengobatan (Follow up) |
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{!! $j2 !!} |
TCM MTB Rif (Xpert) |
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{!! $p2 !!} |
Ekstraparu |
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Bulan ke : |
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{!! $data['id_bulankemajuantbfollow'] ?? '' !!} |
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{!! $j3 !!} |
TCM CDR (Xpert) |
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Lokasi : |
{!! $data['id_ekstraparu'] ?? '' !!} |
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Pemeriksaan ulang ke- : |
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{!! $j4 !!} |
TCM MTB Rif (Truenant) |
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Bulan ke : |
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{!! $data['id_bulanpemeriksaanulang'] ?? '' !!} |
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{!! $j5 !!} |
TCM (MTB (Rif INH (BDMAX) |
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Pemeriksaan setelah selesai pengobatan : |
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{!! $j6 !!} |
PCR Open System |
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Bulan ke : |
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{!! $data['id_bulanpemeriksaansetelahselesai'] ?? '' !!} |
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{!! $j7 !!} |
LPA lini 1 |
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No. Reg. TBC/TBC RO Fasyankes |
: |
{!! $data['id_noregfasyankes'] ?? '' !!} |
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{!! $j8 !!} |
LPA lini 2 |
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No. Reg. TBC/TBC RO Kota |
: |
{!! $data['id_noregkota'] ?? '' !!} |
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{!! $j9 !!} |
Biakan |
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{!! $j10 !!} |
Paket standar uji kepekaan |
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Secara visual dahak tampak (berilah tanda V pada kotak) |
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Contoh Uji |
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Nanah lendir |
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Bercak darah |
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Air Liur |
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@if (isset($data['id_contohuji']) && $data['id_contohuji'] == 'Dahak')
√
@else
@endif
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Dahak |
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Sewaktu / Pagi |
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@if (isset($data['inlineCheckbox6']) && $data['inlineCheckbox6'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox7']) && $data['inlineCheckbox7'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox8']) && $data['inlineCheckbox8'] != '')
√
@else
@endif
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@if (isset($data['id_contohuji']) && $data['id_contohuji'] != 'Dahak')
√
@else
@endif
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Lainnya : {!! $data['id_contohujilainnya'] ?? '' !!} |
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Sewaktu / Pagi |
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@if (isset($data['inlineCheckbox9']) && $data['inlineCheckbox9'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox10']) && $data['inlineCheckbox10'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox11']) && $data['inlineCheckbox11'] != '')
√
@else
@endif
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* Lingkari yang sesuai |
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Malang, {{$tanggal}} |
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{{$periksa->klinisi}} |
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HASIL PEMERIKSAAN BAKTERIOLOGIS TBC |
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No. Register Lab. (sesuai Buku Register Lab TBC.04) : ..... |
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Contoh uji *) |
Tanggal Hasil Dilaporkan |
Hasil Pemeriksaan Mikroskopis (BTA/lainnya) **) |
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{!! $data['hasilpemeriksaantbbiakan_tgl'] ?? '' !!} |
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+++ |
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++ |
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+ |
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1-9 ***) |
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Neg |
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{!! $data['hasilpemeriksaantbbiakan_mikroskopispagi'] ?? '' !!} |
Pagi |
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@if (isset($data['inlineCheckbox12']) && $data['inlineCheckbox12'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox13']) && $data['inlineCheckbox13'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox14']) && $data['inlineCheckbox14'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox15']) && $data['inlineCheckbox15'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox16']) && $data['inlineCheckbox16'] != '')
√
@else
@endif
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{!! $data['hasilpemeriksaantbbiakan_mikroskopisswaktu'] ?? '' !!} |
Sewaktu / Pagi |
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@if (isset($data['inlineCheckbox17']) && $data['inlineCheckbox17'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox18']) && $data['inlineCheckbox18'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox19']) && $data['inlineCheckbox19'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox20']) && $data['inlineCheckbox20'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox21']) && $data['inlineCheckbox21'] != '')
√
@else
@endif
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No. Register Lab. (sesuai Buku Register Lab TBC.04) : ... |
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Contoh uji *) |
Tanggal Hasil Dilaporkan |
Metode Uji |
Hasil Pemeriksaan Mikroskopis (BTA/lainnya) **) |
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{!! $data['hasilpemeriksaantbbiakan_tglbiakan'] ?? '' !!} |
MGIT |
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Pos |
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Neg |
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NTM |
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KTM |
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TDL |
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{!! $data['hasilpemeriksaantbbiakan_mgitpagi'] ?? '' !!} |
Pagi |
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@if (isset($data['inlineCheckbox22']) && $data['inlineCheckbox22'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox23']) && $data['inlineCheckbox23'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox24']) && $data['inlineCheckbox24'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox25']) && $data['inlineCheckbox25'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox26']) && $data['inlineCheckbox26'] != '')
√
@else
@endif
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LJ |
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3+ |
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2+ |
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1+ |
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1-9 ***) |
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Neg |
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NTM |
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KTM |
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TDL |
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@if (isset($data['inlineCheckbox27']) && $data['inlineCheckbox27'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox28']) && $data['inlineCheckbox28'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox29']) && $data['inlineCheckbox29'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox30']) && $data['inlineCheckbox30'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox31']) && $data['inlineCheckbox31'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox32']) && $data['inlineCheckbox32'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox33']) && $data['inlineCheckbox33'] != '')
√
@else
@endif
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@if (isset($data['inlineCheckbox34']) && $data['inlineCheckbox34'] != '')
√
@else
@endif
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Mengetahui |
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Tanda tangan pemeriksa |
Dokter PJ pemeriksaan Lab |
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{!! $tandatangan !!} |
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{!! $periksa->nmexcutor !!} |
{!! $periksa->nmdokter !!} |
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*) |
Diisi sesuai dengan kode huruf sesuai identitas sediaan/waktu pengambilan dahak |
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**) |
Hasil pemeriksaan Mikroskopis, TCM dan Biakan : beri tanda rumput pada hasil pemeriksaan yang sesuai |
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****) |
Isi dengan jumlah BTA (misalnya 2 BTA, 7 BTA) / koloni yang ditemukan |
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