142 lines
7.7 KiB
PHP
142 lines
7.7 KiB
PHP
<form action="<?php echo $editFormAction; ?>" method="post" name="form1" id="form1">
|
|
<div class="row">
|
|
<div class="col-md-6">
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Nomor MR</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="hidden" name="nomr" id="nomr" class="form-control text" value="<?php echo $row_rse['a_nomr'];?>" />
|
|
<?php echo $row_rse['a_nomr'];?>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Masuk Rumah Sakit</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="text" name="masukrs" id="tgl_masuk" readonly="readonly" class="form-control text" value="<?php echo htmlentities($row_rse['masukrs'], ENT_COMPAT, 'utf-8'); ?>"/>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Nama Ruang / Tempat Tidur</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="hidden" name="namaruang" value="<?php echo $row_rse['nama']; ?>" />
|
|
<input type="hidden" name="RUANG" value="<?php echo $row_rse['noruang']; ?>" />
|
|
<?php echo $row_rse['nama'];?> / <?php echo $row_rse['nott'];?>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Menu Makanan</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="text" name="menu_diet" id="menu_diet">
|
|
<input type="hidden" name="idx_diet" value="">
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Keterangan</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<select name="KETERANGAN" class="form-control text">
|
|
<option value=""> -Pilih- </option>
|
|
<?php
|
|
$qryket = $db->query("SELECT * FROM m_keteranganmakanan");
|
|
foreach($qryket->fetchAll() as $listket) {
|
|
?>
|
|
<option value="<?php echo $listket['id_keteranganmakanan'];?>" <?php if($listket['id_keteranganmakanan']==$row_rse['KETERANGAN']) echo "selected=selected"; ?>><?php echo $listket['nama_keteranganmakanan'];?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Keterangan Tambahan</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<textarea name="KETERANGANTAMBAHAN" class="form-control text" cols="50" rows="6"><?php echo $row_rse['KETERANGANTAMBAHAN'];?></textarea>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
</div>
|
|
<div class="col-md-6">
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Nama Pasien</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<?php echo $row_rse['nama'];?>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Dokter Pengirim</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<?php
|
|
$dktr = getNamaDokter($row_rse['dokterpengirim']);
|
|
echo $dktr['NAMADOKTER'];
|
|
?>
|
|
<input type="hidden" class="form-control form-control-sm text" name="dokterpengirim" value="<?php echo htmlentities($row_rse['dokterpengirim'], ENT_COMPAT, 'utf-8'); ?>" size="32" />
|
|
<input type="hidden" name="kirimdari" value="<?php echo htmlentities($row_rse['kirimdari'], ENT_COMPAT, 'utf-8'); ?>"/>
|
|
<input type="hidden" name="noruang_asal" value="<?php echo htmlentities($row_rse['noruang'], ENT_COMPAT, 'utf-8'); ?>"/>
|
|
<input type="hidden" name="nott_asal" value="<?php echo htmlentities($row_rse['nott'], ENT_COMPAT, 'utf-8'); ?>"/>
|
|
<input type="hidden" name="kd_rujuk" value="<?php echo htmlentities($row_rse['kd_rujuk'], ENT_COMPAT, 'utf-8'); ?>"/>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">DIIT (Shift)</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="radio" name="SHIFT" value="1" <?php if($row_rse['SHIFT']=="1")echo "Checked";?> /> Pagi
|
|
<input type="radio" name="SHIFT" value="2" <?php if($row_rse['SHIFT']=="2")echo "Checked";?>/> Siang
|
|
<input type="radio" name="SHIFT" value="3" <?php if($row_rse['SHIFT']=="3")echo "Checked";?>/> Sore
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Snack</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<input type="radio" name="SNACK" value="1" <?php if($row_rse['SNACK']=="1")echo "Checked";?> /> Pagi
|
|
<input type="radio" name="SNACK" value="2" <?php if($row_rse['SNACK']=="2")echo "Checked";?>/> Sore</span>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left">Jenis Makanan</label>
|
|
<div class="col-sm-8" style="text-align:left">
|
|
<select name="JENISMAKANAN" class="form-control text">
|
|
<option value=""> -Pilih- </option>
|
|
<?php
|
|
$qryjns = $db->query("SELECT * FROM m_jenismakanan");
|
|
foreach($qryjns->fetchAll() as $listype) {
|
|
?>
|
|
<option value="<?php echo $listype['id_jenismakanan'];?>" <?php if($listype['id_jenismakanan']==$row_rse['JENISMAKANAN']) echo "selected=selected"; ?>><?php echo $listype['nama_jenismakanan'];?></option>
|
|
<?php } ?>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
<fieldset class="form-group">
|
|
<div class="row">
|
|
<label class="col-form-label col-sm-4 pt-0" style="text-align:left"> </label>
|
|
<div class="col-sm-4" style="text-align:left">
|
|
|
|
<input type="submit" class="btn btn-primary" value="Simpan">
|
|
<!-- <input type="submit" name="Submit" value="Simpan" class="btn btn-primary text" onclick="newsubmitform (document.getElementById('form1'),'valid_save_dpmp',validatetask); return false;"/> -->
|
|
<input class="btn btn-secondary" name="kembali" type="button" value="Kembali" onclick=window.location.href='?link=129x' />
|
|
|
|
<input type="hidden" name="DPMP_add" value="form1" />
|
|
<input type="hidden" name="id_admission" value="<?php echo $row_rse['id_admission']; ?>" />
|
|
<input type="hidden" name="IDX" value="<?php echo $row_rse['IDX']; ?>" />
|
|
</div>
|
|
</div>
|
|
</fieldset>
|
|
</div>
|
|
</div>
|
|
</form>
|