79 lines
4.6 KiB
PHP
79 lines
4.6 KiB
PHP
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<form action="ranap/save_rencana_awalmedis.php" name="rencana_awalmedis" method="post" id="rencana_awalmedis">
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<input type="hidden" name="id_admission" value="<?php echo $id_admission;?>" />
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<input type="hidden" name="nomr" value="<?php echo $nomr;?>" />
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<input type="hidden" name="noruang" value="<?php echo $noruang;?>" />
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<fieldset class="fieldset">
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<label class="col-form-label col-sm-12 pt-0" style="text-align:center"><h5>RENCANA AWAL MEDIS<br>Rencana yang akan dilakukan untuk masing-masing masalah<br>(meliputi rencana untuk diagnosa, penatalaksaaan dan edukasi)<br></h5></label>
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<div class="row">
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<fieldset class="form-group">
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<div class="row">
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<div class="col-sm-6">
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Tanggal</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="tanggal" cols="60" rows="5" class="form-control text" value="<?php echo date("d/m/Y"); ?>" readonly>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Target Waktu</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="target_waktu" class="form-control text" tabindex="1">
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Rencana Pemeriksaan Diagnostik</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="rencana_diagnostik" cols="60" rows="5" class="form-control text" tabindex="3"></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Rencana Monitoring</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="rencana_monitoring" cols="60" rows="5" class="form-control text" tabindex="5"></textarea>
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</div>
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</div>
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</div>
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<div class="col-sm-6">
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Diagnosis dan Masalah Kesehatan</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="diagnosis" cols="60" rows="5" class="form-control text" tabindex="2"></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Rencana Terapi</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="rencana_terapi" cols="60" rows="5" class="form-control text" tabindex="4"></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Rencana Edukasi</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="rencana_edukasi" cols="60" rows="5" class="form-control text" tabindex="6"></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right"></label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="submit" name="Submit" value="Simpan" class="btn btn-primary text" onclick="newsubmitform (document.getElementById('rencana_awalmedis'),'ranap/save_rencana_awalmedis.php','valid_rencana_awalmedis',validatetask); return false;"/>
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</div>
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</div>
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</div>
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</div>
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</fieldset>
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</div>
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</fieldset>
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<div id="valid_rencana_awalmedis" >
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<?php include("save_rencana_awalmedis.php"); ?>
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</div>
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</form>
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