diff --git a/assets/docs/screening-form-a.html b/assets/docs/screening-form-a.html new file mode 100644 index 00000000..4f34b876 --- /dev/null +++ b/assets/docs/screening-form-a.html @@ -0,0 +1,167 @@ + + +
+ + + + + + +| No. RM | +: | +{{ .MedicalRecord }} | +
| Nama | +: | +{{ .Name }} | +
| Tanggal Lahir | +: | +{{ .BirthDate }} | +
| + ☑ {{ . }} + | +
| + |
| + {{ .Assessment }} + | +
| + ☑ {{ . }} + | +
| + |
| + {{ .Planning }} + | +
| + |
+ {{ .Date }} + |
+
| + | + ({{ .Employee_Name }}) + | +
| No. RM | +: | +{{ .MedicalRecord }} | +
| Nama | +: | +{{ .Name }} | +
| Tanggal Lahir | +: | +{{ .BirthDate }} | +
| NO | +Tanggal/jam | ++ Implementasi, Monitoring, Fasilitasi, koordinasi, komunikasi dan kolaborasi, + advokasi, hasil pelayanan, Terminasi + | +MPP | +
|---|---|---|---|
| {{ .Number }} | +{{ .Date }} | + ++ {{ .Value }} + | + ++ {{ .Employee_Name }} + | +
+
+ |
+
+
+ PEMERINTAH PROVINSI JAWA TIMUR
+
+
+ RUMAH SAKIT UMUM DAERAH Dr. SAIFUL ANWAR
+
+
+ TERAKREDITASI KARS VERSI 2012 TINGKAT PARIPURNA
+
+
+ Jl. Jaksa Agung Suprapto No. 2 MALANG 65111
+
+ Telp. (0341) 362101, Fax. (0341) 362110
+ Email: rsu-drsaifulanwar@jatimprov.go.id
+ Website: www.rsudsaifulanwar.jatimprov.go.id
+ |
+
+
+ |
+
Layanan Kedokteran Fisik dan Rehabilitasi +
+| + No RM + | +{{ .Repalcable }} | +
| + Nama Pasien + | +{{ .Repalcable }} | +
| + Tanggal Lahir + | +{{ .Repalcable }} | +
| + Diagnosa + | +{{ .Repalcable }} | +
| + Permintaan Terapi + | +{{ .Repalcable }} | +
| + Frekuensi Terapi + | ++ 2 x Per Minggu + Evaluasi: 1 Bulan + | +
| + Target Terapi + | +{{ .Repalcable }} | +
| + Waktu Mencapai Target + | +{{ .Repalcable }} | +
| + NO + | ++ Tanggal + | ++ Dokter + | ++ Fisioterapi + | ++ Terapi Wicara + | ++ Okupansi Terapi + | ++ Ortotik Prostetik + | ++ PSM + | ++ TTD Pasien + | +
|---|---|---|---|---|---|---|---|---|
| + 1 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 2 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 3 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 4 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 5 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 6 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 7 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + 8 + | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +{{ .Repalcable }} | +
| + Evaluasi + | +{{ .Repalcable }} | +
| + Rencana Selanjutnya + | +{{ .Repalcable }} | +
| + |
+ Malang, + Cap dan TTD Dr. SpKFR + |
+
| + | + (........................................................) + | +
+
+ |
+
+
+ PEMERINTAH PROVINSI JAWA TIMUR
+
+
+ RUMAH SAKIT UMUM DAERAH Dr. SAIFUL ANWAR
+
+
+ TERAKREDITASI KARS VERSI 2012 TINGKAT PARIPURNA
+
+
+ Jl. Jaksa Agung Suprapto No. 2 MALANG 65111
+
+ Telp. (0341) 362101, Fax. (0341) 362110
+ Email: rsu-drsaifulanwar@jatimprov.go.id
+ Website: www.rsudsaifulanwar.jatimprov.go.id
+ |
+
| + No RM: + | +{{ .Repalcable }} | +
| + Nama Pasien + | +{{ .Repalcable }} | +
| + Diagnosa + | +{{ .Repalcable }} | +
| + Permintaan Terapi + | +{{ .Repalcable }} | +
| + PELAKSANAAN PROGRAM + | ++ Tanggal + | ++ TTD + | +||
|---|---|---|---|---|
| + PASIEN + | ++ DOKTER + | ++ TERAPIS + | +||
| 1. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 2. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 3. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 4. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 5. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 6. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 7. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 8. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 9. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 10. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 11. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 12. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 13. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 14. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 15. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 16. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 17. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 18. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 19. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| 20. {{ .Repalcable }} | +{{ .Repalcable }} | + | ||
| + |
+ Tempat & Tanggal + Cap dan TTD Dr. SpKFR + |
+
| + | + (.................................................) + | +
+
+ |
+
+
+ PEMERINTAH PROVINSI JAWA TIMUR
+
+
+ RUMAH SAKIT UMUM DAERAH Dr. SAIFUL ANWAR
+
+
+ TERAKREDITASI KARS VERSI 2012 TINGKAT PARIPURNA
+
+
+ Jl. Jaksa Agung Suprapto No. 2 MALANG 65111
+
+ Telp. (0341) 362101, Fax. (0341) 362110
+ Email: rsu-drsaifulanwar@jatimprov.go.id
+ Website: www.rsudsaifulanwar.jatimprov.go.id
+ |
+
| I. Identitas Pasien | +No. RM | +: | +{{ .Repalcable }} | +
| + Nama Pasien + | +: | +{{ .Repalcable }} | +
| + Tanggal Lahir + | +: | +{{ .Repalcable }} |
| + Aalamat + | +: | +{{ .Repalcable }} |
| + Telp / HP + | +: | +{{ .Repalcable }} |
| + Hubungan dengan Tertanggung + | +: | ++ ☑ Suami / Istri + + ▢ Anak + | +
| II. Diisi oleh Dokter SpKFR | +
| + Tanggal Pelayanan + | +: | +{{ .Repalcable }} |
| + Anamnesa + | +: | +{{ .Repalcable }} |
| + Pemeriksaan Fisik dan Uji Fungsi + | +: | +{{ .Repalcable }} |
| + Diagnosis Medis (ICD-10) + | +: | +{{ .Repalcable }} |
| + Diagnosis Fungsi (ICD-10) + | +: | +{{ .Repalcable }} |
| + Pemeriksaan Penunjang + | +: | +{{ .Repalcable }} |
| + Tata Laksana KFR (ICD 9 CM) + | +: | +{{ .Repalcable }} |
| + Anjuran + | +: | +{{ .Repalcable }} |
| + Evaluasi + | +: | +{{ .Repalcable }} |
| + Suspek Penyakit Akibat Kerja + | +: | +
+ ☑ Ya ( {{ .Repalcable }} )
+
+ + ▢ Tidak + |
+
| + TTD Pasien + | +
+ Tempat & Tanggal + Cap dan TTD Dr. SpKFR + |
+
| + (........................................................) + | ++ (........................................................) + | +