672 lines
38 KiB
PHP
672 lines
38 KiB
PHP
<?php
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$sql_rsm_pulang = "SELECT * FROM t_kajianawalmedis WHERE IDXRANAP = '".$id_admission."'";
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$get_rsm_pulang = $db->query($sql_rsm_pulang);
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$found = $get_rsm_pulang->numRows();
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$dat_rp = $get_rsm_pulang->fetchAll()[0];
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$IDXF2 = ($found > 0) ? $dat_rp['IDXF2'] : null;
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?>
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<form name="kajian_awal_medis" method="post" id="kajian_awal_medis">
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<input type="hidden" name="input[IDXF2]" value="<?php echo $IDXF2;?>" />
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<input type="hidden" name="input[IDXRANAP]" id="idx_kajian" value="<?php echo $id_admission;?>" />
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<input type="hidden" name="input[NOMR]" id="nomr_kajian" value="<?php echo $nomr;?>" />
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<input type="hidden" name="input[TANGGALMASUK]" value="<?php echo $masukrs;?>" />
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<fieldset class="fieldset">
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<label class="col-form-label col-sm-12 pt-0" style="text-align:center"><h5>ASESMEN AWAL KEPERAWATAN PASIEN RAWAT IANP<br>( Dilengkapi sebelum 24 jam pertama pasien masuk ruang rawat inap )</h5></label>
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<div class="row">
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<fieldset class="form-group">
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<div class="row">
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<div class="col-sm-6">
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Riwayat Kesehatan Pasien</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Keluhan Utama :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="input[KELUHANUTAMA]" cols="60" rows="5" class="form-control required" tabindex="1" required><?=$dat_rp['KELUHANUTAMA']?></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">Riwayat Perawatan Sebelumnya :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="input[RIWAYATPERAWATAN]" cols="60" rows="5" class="form-control required" tabindex="1" required><?=$dat_rp['RIWAYATPERAWATAN']?></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Riwayat Penyakit Dalam Keluarga :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="input[RIWAYATKELUARGA]" cols="60" rows="5" class="form-control required" tabindex="1" required><?=$dat_rp['RIWAYATKELUARGA']?></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">Riwayat Alergi </label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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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">Makanan :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[ALERGIMAKANAN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['ALERGIMAKANAN']?>" tabindex="3" required>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Obat :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[ALERGIOBAT]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['ALERGIOBAT']?>" tabindex="3" required>
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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">Lain-lain :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[ALERGILAIN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['']?>" tabindex="3" required>
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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">Status Fisik </label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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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">Keadaan Umum : </label>
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<div class="col-sm-8 pt-0" style="text-align:left;">
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="baik" type="radio" value="Baik" name="input[KEADAANUMUM]">
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<label class="form-check-label" for="baik">Baik</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="sedang" type="radio" value="Sedang" name="input[KEADAANUMUM]">
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<label class="form-check-label" for="sedang">Sedang</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="kurang" type="radio" value="Kurang" name="input[KEADAANUMUM]">
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<label class="form-check-label" for="kurang">Kurang</label>
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</div>
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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">Pernafasan :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="input-group">
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<input type="text" class="form-control mask-decimal" name="input[NAFAS]" value="<?=$dat_rp['NAFAS']?>" tabindex="4" required>
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<div class="input-group-append">
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<span class="input-group-text " id="basic-addon2">x/menit</span>
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</div>
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</div>
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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">Nadi :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="input-group">
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<input type="text" class="form-control mask-decimal" name="inpur[NADI]" value="<?=$dat_rp['NADI']?>" tabindex="6" required>
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<div class="input-group-append">
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<span class="input-group-text " id="basic-addon2">x/menit</span>
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</div>
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</div>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Status Psikologis Sosial</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Kondisi :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[KONDISI]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['KONDISI']?>" placeholder="(Tenang, Cemas, Takut, Marah, Sedih, dll)" tabindex="3" required>
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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">Sistem Pendukung :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[SISTEMPENDUKUNG]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['SISTEMPENDUKUNG']?>" placeholder="(Suami, Istri, Anak, Saudara, Tidak ada, dll)" tabindex="3" required>
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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">Ekonomi</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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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;">Masalah terkait biaya perawatan di rumah sakit :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="" type="radio" value="1" name="input[EKONOMI]">
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<label class="form-check-label" for="">Ditanggung (Asuransi, dll)</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="" type="radio" value="0" name="input[EKONOMI]">
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<label class="form-check-label" for="">Tidak Ditanggung (Biaya Sendiri)</label>
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</div>
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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">Spiritual</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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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;">Keyakinan yang di anut :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MENOLAKTRANSFUSI]">
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Menolak dilakukan tranfusi darah
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MENOLAKPULANG]">
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Menolak pulang di hari tertentu
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MENOLAKPELAYANAN]">
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Menolak dilayani petugas lawan jenis kelamin
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MENOLAKIMUNISASI]">
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Menolak diberikan imunisasi pada anaknya
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MEMILIHALTERNATIF]">
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Menolak dirawat oleh petugas medis dan mencari pengobatan alternative
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[MENOLAKMAKANAN]">
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Tidak memakan suatu jenis makanan tertentu (Daging Sapi, Ikan bersisik, dll)
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<label class="form-check-label">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[BAYISUNAT]">
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Pada bayi baru lahir perempuan minta di sunat karena suatu kepercayaan
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</label>
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</div>
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<br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="" type="checkbox" value="0" name="input[LAINLAIN]">
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<label class="form-check-label">
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<input type="text" name="input[KEYAKINANLAIN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['KEYAKINANLAIN']?>" placeholder="Lainnya.." tabindex="3">
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</label>
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</div>
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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">Skrining Nyeri</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<hr>
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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">Skala Nyeri :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[SKALANYERI]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['SKALANYERI']?>" placeholder="Gunakan Skala NRS dan WBS" tabindex="3" required>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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Bila ada nyeri, lakukan asesmen lebih lanjut
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">P (Provokes)/Provokasi :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[PROVOKES]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['PROVOKES']?>" tabindex="3" required>
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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">R (Regio)/Lokasi :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="input[REGIO]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['REGIO']?>" tabindex="3" required>
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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">T (Time)/Waktu :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="hilang_timbul" type="radio" value="1" name="input[FREKUENSINYERI]">
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<label class="form-check-label" for="hilang_timbul">Hilang Timbul</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="terus_menerus" type="radio" value="2" name="input[FREKUENSINYERI]">
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<label class="form-check-label" for="terus_menerus">Terus Menerus</label>
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</div>
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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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<label class="col-form-label col-sm-8 pt-0" style="text-align:left">Catatan : Bila pasien kritis/tidak sadar/koma/ ataupun pasien tahanp terminal, gunakan skala <i>Crititcal Pain Observation Tool (CPOT)</i></label>
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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">Skrining Resiko Jatuh :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" value="1" name="input[RESIKOJATUH]">
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<label class="form-check-label">Ya</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" value="0" name="input[RESIKOJATUH]">
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<label class="form-check-label">Tidak</label>
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</div>
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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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<label class="col-form-label col-sm-8 pt-0" style="text-align:left">Catatan : Pada pasien dewasa menggunakan penilaian <i>SAKTI-J</i> dan pasien anak dengan <i>SKOP-DULL</i>.Bila Beresiko Iya pasang setiker penandah resiko jatuh warna kuning pada gelang identitas pasien</label>
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</div>
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</div>
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<!-- TENGAH -->
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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"> </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">Riwayat Penyakit Sekarang :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="input[RIWAYATPENYAKIT]" cols="60" rows="5" class="form-control text" tabindex="2" required><?=$dat_rp['RIWAYATPENYAKIT']?></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">Riwayat Pengobatan :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="input[RIWAYATPENGOBATAN]" cols="60" rows="5" class="form-control required" tabindex="1" required><?=$dat_rp['RIWAYATPENGOBATAN']?></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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</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"> </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"> </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"> </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">Reaksi :</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<input type="text" name="input[REAKSIMAKANAN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['REAKSIMAKANAN']?>" tabindex="3" required>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Reaksi :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<input type="text" name="input[REAKSIOBAT]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['REAKSIOBAT']?>" tabindex="3" required>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Reaksi :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<input type="text" name="input[REAKSILAIN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['REAKSILAIN']?>" tabindex="3" required>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"><hr></label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<hr>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Kesadaran : </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left;">
|
|
<select class="form-control" name="input['KESADARAN']">
|
|
<option value="1">Compos Mentis</option>
|
|
<option value="2">Delirium</option>
|
|
<option value="3">Somnolen</option>
|
|
<option value="4">Spoor</option>
|
|
<option value="5">Koma</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Tekanan Darah :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<div class="input-group">
|
|
<input type="text" class="form-control mask-decimal" name="input[TEKANANDARAH]" value="<?=$dat_rp['TEKANANDARAH']?>" tabindex="9">
|
|
<div class="input-group-append">
|
|
<span class="input-group-text " id="basic-addon2">mmHg</span>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Suhu Tubuh :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<div class="input-group">
|
|
<input type="text" class="form-control mask-decimal" name="input[SUHUTUBUH]" value="<?=$dat_rp['SUHUTUBUH']?>" tabindex="11">
|
|
<div class="input-group-append">
|
|
<span class="input-group-text " id="basic-addon2">°C</span>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Hubungan pasien dengan Keluarga :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="baik" type="radio" value="1" name="input[HUBUNGANKELUARGA]">
|
|
<label class="form-check-label" for="baik">Baik</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="tidak_baik" type="radio" value="0" name="input[HUBUNGANKELUARGA]">
|
|
<label class="form-check-label" for="tidak_baik">Tidak Baik</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Kegiatan Ibadah Pasien :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="aktif" type="radio" value="1" name="input[KEGIATANIBADAH]">
|
|
<label class="form-check-label" for="aktif">Aktif</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="tidak" type="radio" value="0" name="input[KEGIATANIBADAH]">
|
|
<label class="form-check-label" for="tidak">Tidak</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-12 pt-0" style="text-align:left">Catatan : Gunakan Skala <i>Numeric Rating Scale (NRS) dan Wong Backer Scale (WBS)</i></label>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right"> </label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Q (Quality)/Kualitas :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<input type="text" name="input[]" cols="60" rows="5" class="form-control text" value="" tabindex="3" required>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:right">S (Severity)/Derajat :</label>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="nyeri_ringan" type="radio" value="1" name="input[DERAJATNYERI]">
|
|
<label class="form-check-label" for="nyeri_ringan">Nyeri ringan</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="nyeri_sedang" type="radio" value="2" name="input[DERAJATNYERI]">
|
|
<label class="form-check-label" for="nyeri_sedang">Nyeri sedang</label>
|
|
</div>
|
|
<div class="form-check form-check-inline">
|
|
<input class="form-check-input" id="nyeri_berat" type="radio" value="3" name="input[DERAJATNYERI]">
|
|
<label class="form-check-label" for="nyeri_berat">Nyeri berat</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="col-sm-12">
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-3 pt-0" style="text-align:right">Asesmen Kebutuhan Fungsional</label>
|
|
<div class="col-sm-9 pt-0" style="text-align:left">
|
|
<hr>
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Makan (Feeding) :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALMAKAN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALMAKAN']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tidak mampu | 1 = Butuh bantuan memotong, mengoles mentega, dll | 2 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Mandi (Bathing) :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALMANDI]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALMANDI']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tergantung orang lain | 1 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Perawatan diri (Grooming):</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALPERAWATAN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALPERAWATAN']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Membutuhkan bantuan orang lain | 1 = Mandiri dalam perawatan muka, rambut, gigi, dan bercukur
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Berpakaian (Dressing) :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALBERPAKAIAN]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALBERPAKAIAN']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tergantung orang lain | 1 = Sebagian dibantu (Misal mengancing baju) | 2 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Buang air kecil (Bladder) :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALAIRKECIL]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALAIRKECIL']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Inkontinensia atau pakai kateter dan tidak terkontrol | 1 = Kadang Inkontinensia (1x24 jam) | 2 = Kontinensia (Teratur)
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Buang air besar (Bowel) :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALAIRBESAR]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALAIRBESAR']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Inkontinensia (Tidak teratur atau perlu enema) | 1 = Kadang Inkontinensia (1x seminggu) | 2 = Kontinensia (Teratur)
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Penggunaan Toilet :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALTOILET]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALTOILET']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tergantung bantuan orang lain | 1 = Kadang Inkontensia (1x seminggu) | 2 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Transfer :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALTRANSFER]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALTRANSFER']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tidak mampu | 1 = Butuh bantuan untuk bisa duduk (2 Orang) | 2 = Bantuan kecil (1 Orang) | 3 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Mobilitas :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALMOBILITAS]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALMOBILITAS']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Immobile (Tidak mampu) | 1 = Menggunakan kursi roda | 2 = Berjalan dengan bantuan satu orang | 3 = Mandiri (Meskipun menggunakan alat bantu)
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Naik turun Tangga :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[FUNGSIONALTANGGA]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['FUNGSIONALTANGGA']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
0 = Tidak mampu | 1 = Membutuhkan bantuan (Alat bantu) | 2 = Mandiri
|
|
</div>
|
|
</div>
|
|
<div class="form-group row">
|
|
<label class="col-form-label col-sm-2 pt-0" style="text-align:right">Total Score :</label>
|
|
<div class="col-sm-2 pt-0" style="text-align:left">
|
|
<input type="text" name="input[TOTALSCORE]" cols="60" rows="5" class="form-control text" value="<?=$dat_rp['TOTALSCORE']?>" tabindex="3" required>
|
|
</div>
|
|
<div class="col-sm-8 pt-0" style="text-align:left">
|
|
Interpretasi Hasil
|
|
<br>0-4 : Ketergantungan total <br> 5-8 : Ketergantungan Berat <br> 9-11 : Ketergantungan Sedang <br> 12-19 : Ketergantungan Ringan <br> 20 : Mandiri
|
|
</div>
|
|
</div>
|
|
<hr>
|
|
<div class="form-group row">
|
|
<div class="col-sm-12 pt-0" style="text-align:center;">
|
|
<input type="button" name="Submit" id="simpankajianmedis" value="Simpan" class="btn btn-primary" tabindex="41"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
</div>
|
|
</fieldset>
|
|
</form>
|
|
<!-- <div id="valid_kajian_awal"></div> -->
|
|
<script>
|
|
$(document).ready(function(){
|
|
|
|
$.get("<?php echo _BASE_;?>ranap/save_kajian_awal.php",{get_data:true,NOMR:$("#nomr_kajian").val(),IDXRANAP:$("#idx_kajian").val()},function(data)
|
|
{
|
|
$("#valid_kajian_awal").html(data.html);
|
|
},"json");
|
|
|
|
$('#simpankajianmedis').click(function(){
|
|
$.post('<?php echo _BASE_;?>ranap/save_kajian_awal.php',$('#kajian_awal_medis').serialize()+"&save=1",function(data){
|
|
Toast.fire({title:data.message,type:data.type,onClose : function(){
|
|
window.location.reload();
|
|
}});
|
|
},"json");
|
|
});
|
|
|
|
});
|
|
</script>
|