707 lines
20 KiB
HTML
707 lines
20 KiB
HTML
<html>
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<head>
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<meta charset="UTF-8" />
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<title>General Consent</title>
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<style>
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body {
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padding: 2rem 3rem;
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}
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table {
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width: 100%;
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border-collapse: collapse
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}
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td {
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vertical-align: top;
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}
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.border-table,
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.border-table td,
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.border-table th {
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border: 1px solid black;
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}
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.section-title {
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margin-top: 1rem;
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margin-bottom: 0rem;
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}
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.data-label {
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width: 9rem;
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}
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.data-colon {
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width: 15px; padding-left: 10px;
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}
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.description-label {
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font-size: 0.7rem;
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margin: 0;
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}
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</style>
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</head>
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<body style="font-family: Arial, sans-serif; line-height: 1.4">
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<table style="width: 100%; border-collapse: collapse">
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<tr>
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<td style="text-align: center">
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<img src="assets/docs/logo-provinsi-jawa-timur.png" alt="logo" style="height: 70px" />
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</td>
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<td style="text-align: center">
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<div style="font-size: 14px; font-weight: bold">
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PEMERINTAH PROVINSI JAWA TIMUR
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</div>
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<div style="font-size: 14px; font-weight: bold">
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RUMAH SAKIT UMUM DAERAH Dr. SAIFUL ANWAR
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</div>
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<div style="font-size: 13px">
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TERAKREDITASI KARS VERSI 2012 TINGKAT PARIPURNA
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</div>
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<div style="margin-top: 8px">
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Jl. Jaksa Agung Suprapto No. 2 MALANG 65111
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</div>
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<div>Telp. (0341) 362101, Fax. (0341) 362110</div>
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<div>Email: rsu-drsaifulanwar@jatimprov.go.id</div>
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<div>Website: www.rsudsaifulanwar.jatimprov.go.id</div>
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</td>
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<td style="text-align: center">
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<img src="assets/docs/logo-rssa.png" alt="logo" style="height: 70px" />
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</td>
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</tr>
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</table>
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<hr style="margin: 20px 0" />
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<div style="
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text-align: center;
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font-weight: bold;
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font-size: 1rem;
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">
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IDENTITAS PASIEN
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</div>
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<table style="
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width: 100%;
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margin-top: 20px;
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border-collapse: collapse;
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">
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<tr>
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<td style="width: 10rem;">
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No. RM
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</td>
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<td class="data-colon">: </td>
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<td>{{ .MedicalRecord }}</td>
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<td style="width: 7rem;">
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Ruang/Klinik
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Unit }}</td>
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</tr>
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<tr>
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<td>
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NIK
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</td>
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<td class="data-colon">: </td>
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<td>{{ .NIK }}</td>
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<td>
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Kelas
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Class }}</td>
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</tr>
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<tr>
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<td>
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Nama
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Name }}</td>
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<td>
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DPJP
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Doctor_Name }}</td>
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</tr>
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</tr>
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<td style="padding: 5px 0"></td>
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</tr>
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<tr>
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<td>
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Tempat/Tanggal Lahir
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</td>
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<td class="data-colon">: </td>
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<td>{{ .BirthPlaceDate }}</td>
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</tr>
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<tr>
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<td>
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Jenis Kelamin
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Gender }}</td>
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</tr>
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<tr>
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<td>
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No. Telepon
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Phone }}</td>
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</tr>
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</table>
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<hr style="margin: 20px 0" />
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<h1 style="
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text-align: center;
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font-weight: bold;
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font-size: 1rem;
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margin: 0;
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">
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RESUME MEDIS
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</h1>
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<p style="
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font-size: 0.7rem;
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margin: 0;
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text-align: center;
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"><i>Medical Discharge Summary</i></p>
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<p style="
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font-size: 0.7rem;
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margin-top: 1rem;
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"><i>(Diisi oleh Dokter Penanggung Jawab Pelayanan)</i></p>
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<table>
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<tr>
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<td class="data-label">
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Tanggal Masuk
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</td>
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<td class="data-colon">: </td>
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<td>{{ .StartedAt }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Tanggal Keluar
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</td>
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<td class="data-colon">: </td>
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<td>{{ .FinishedAt }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Diagnosis Masuk
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</td>
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<td class="data-colon">: </td>
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<td>{{ .DiagnosisIn }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Diagnosis Keluar
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</td>
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<td class="data-colon">: </td>
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<td>{{ .DiagnosisOut }}</td>
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</tr>
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</table>
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<table class="border-table" style="margin-top: 0.7rem; page-break-inside: avoid !important;">
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<thead>
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<tr>
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<th style="width: 1rem;">
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No
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</th>
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<th>
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Diagnosa
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</th>
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<th>
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Dasar Diagnosa
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</th>
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<th>
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Kode ICD-10
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</th>
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</tr>
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</thead>
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<tbody>
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{{ $dataLen := len .Diagnosis }}
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{{ if gt $dataLen 0 }}
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<!-- If we have data, show all of it -->
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{{ range $index, $diagnosis := .Diagnosis }}
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<tr>
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<td>{{ if eq $index 0 }}1{{ else if eq $index 1 }}2{{ else if eq $index 2 }}3{{ else if eq $index 3 }}4{{ else if eq $index 4 }}5{{ else }}{{ $index }}{{ end }}</td>
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<td>{{ $diagnosis.DiagnosisName }}</td>
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<td>{{ $diagnosis.Basis }}</td>
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<td>{{ $diagnosis.ICD10 }}</td>
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</tr>
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{{ end }}
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<!-- If data is less than 2, fill remaining rows -->
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{{ if eq $dataLen 1 }}
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<tr>
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<td>2</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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{{ end }}
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{{ else }}
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<!-- If no data, show 2 empty rows -->
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<tr>
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<td>1</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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<tr>
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<td>2</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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{{ end }}
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</tbody>
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</table>
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<h4 class="section-title">Kajian Awal Medis</i></h4>
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<p style="
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font-size: 0.7rem;
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margin-top: 0rem;
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margin-bottom: 0.4rem;
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"><i>(Diisi oleh Dokter Penanggung Jawab Pelayanan)</i></p>
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<table>
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<tr>
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<td class="data-label">
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Keluhan Utama
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</td>
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<td class="data-colon">: </td>
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<td>{{ .MainComplaint }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Riwayat Penyakit
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</td>
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<td class="data-colon">: </td>
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<td>{{ .MedicalHistory }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Pemeriksaan Fisik & Keadaan Umum
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</td>
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<td class="data-colon">: </td>
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<td>{{ .PhysicalExamination }}</td>
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</tr>
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</table>
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<h4 class="section-title">Pemeriksaan Penunjang</i></h4>
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<table>
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<tr>
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<td class="data-label">
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Pemeriksaan
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</td>
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<td class="data-colon">: </td>
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<td>{{ .SupportingExamination }}</td>
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</tr>
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</table>
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<table style="page-break-inside: avoid !important;"></table>
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<tr>
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<td>
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<h4 class="section-title">Tindakan Medis</i></h4>
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<table class="border-table" style="margin-top: 0.4rem;">
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<thead>
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<tr>
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<th style="width: 1rem;">
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No
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</th>
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<th>
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Tindakan
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</th>
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<th>
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Dasar Tindakan
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</th>
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<th>
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Kode ICD 9-CM
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</th>
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</tr>
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</thead>
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<tbody>
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{{ $dataLen := len .MedicalActions }}
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{{ if gt $dataLen 0 }}
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<!-- If we have data, show all of it -->
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{{ range $index, $action := .MedicalActions }}
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<tr>
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<td>{{ if eq $index 0 }}1{{ else if eq $index 1 }}2{{ else if eq $index 2 }}3{{ else if eq $index 3 }}4{{ else if eq $index 4 }}5{{ else }}{{ $index }}{{ end }}</td>
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<td>{{ $action.Action }}</td>
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<td>{{ $action.Basis }}</td>
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<td>{{ $action.ICD9 }}</td>
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</tr>
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{{ end }}
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<!-- If data is less than 2, fill remaining rows -->
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{{ if eq $dataLen 1 }}
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<tr>
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<td>2</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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{{ end }}
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{{ else }}
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<!-- If no data, show 2 empty rows -->
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<tr>
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<td>1</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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<tr>
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<td>2</td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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{{ end }}
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</tbody>
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</table>
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<table style="margin: 0.7rem 0;">
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<tr>
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<td class="data-label">
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Tindakan Medis
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</td>
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<td class="data-colon">: </td>
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<td>{{ .MedicalAction }}</td>
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</tr>
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</table>
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<table style="page-break-inside: avoid !important;">
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<tr>
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<td>
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<h4 class="section-title">Konsultasi</i></h4>
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</table>
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<table class="border-table" style="margin-top: 0.4rem;">
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<thead>
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<tr>
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<th style="width: 1rem;">No</th>
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<th>Konsultasi</th>
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<th>Jawaban Konsultasi</th>
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</tr>
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</thead>
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<tbody>
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{{ $dataLen := len .Consultations }}
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{{ if gt $dataLen 0 }}
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<!-- If we have data, show all of it -->
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{{ range $index, $consultation := .Consultations }}
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<tr>
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<td>{{ if eq $index 0 }}1{{ else if eq $index 1 }}2{{ else if eq $index 2 }}3{{ else if eq $index 3 }}4{{ else if eq $index 4 }}5{{ else }}{{ $index }}{{ end }}</td>
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<td>{{ $consultation.Consultation }}</td>
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<td>{{ $consultation.ConsultationAnswer }}</td>
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</tr>
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{{ end }}
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<!-- If data is less than 2, fill remaining rows -->
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{{ if eq $dataLen 1 }}
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<tr><td>2</td><td></td><td></td></tr>
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{{ end }}
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{{ else }}
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<!-- If no data, show 2 empty rows -->
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<tr><td>1</td><td></td><td></td></tr>
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<tr><td>2</td><td></td><td></td></tr>
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{{ end }}
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</tbody>
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</table>
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</td>
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</tr>
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<h4 class="section-title">Terapi</i></h4>
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<table>
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<tr>
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<td class="data-label">
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Alergi
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</td>
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<td class="data-colon">: </td>
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<td>
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{{ .Allergy}}
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</td>
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</tr>
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</table>
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<table style="page-break-inside: avoid !important;">
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<tr>
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<td>
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<h4 class="section-title" style="margin-top: 3rem;">Obat yang diberikan</h4>
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<table class="border-table" style="margin-top: 0.4rem;">
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<thead>
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<tr>
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<th>
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Terapi (Farmakologi & Non Farmakologi) Selama Perawatan
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</th>
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<th>
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Terapi (Farmakologi & Non Farmakologi) Waktu Pulang
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</th>
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</tr>
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</thead>
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<tbody>
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{{ $dataLen := len .Medications }}
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{{ if gt $dataLen 0 }}
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<!-- If we have data, show all of it -->
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{{ range .Medications }}
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<tr>
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<td>{{ .DuringTreatment }}</td>
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<td>{{ .AtDischarge }}</td>
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</tr>
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{{ end }}
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<!-- If data is less than 2, fill remaining rows -->
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{{ if eq $dataLen 1 }}
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<tr>
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<td> </td>
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<td> </td>
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</tr>
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{{ end }}
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{{ else }}
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<!-- If no data, show 2 empty rows -->
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<tr>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> </td>
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<td> </td>
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</tr>
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{{ end }}
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</tbody>
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</table>
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</td>
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</tr>
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</table>
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<h4 class="section-title">Kondisi saat Pulang</i></h4>
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<table>
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<tr>
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<td class="data-label">Kesadaran</td>
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<td class="data-colon">: </td>
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<td>{{ .ConsciousnessLevel }}</td>
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</tr>
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<tr>
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<td class="data-label">
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Tanda Vital
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<p class="description-label"><i>Vital sign</i></p>
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</td>
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<td class="data-colon">:</td>
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</tr>
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<tr>
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<td colspan="3">
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<table>
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<tr>
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<td style="width: 50%;">
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<table cellspacing="0" cellpadding="0">
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<tr>
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<td>
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<td class="data-label" style="text-align: right;"> Tekanan Darah
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<p class="description-label"><i>Blood Pressure</i></p>
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</td>
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<td class="data-colon">: </td>
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{{ if and .BloodPressure (ne .BloodPressure "0/0") (ne .BloodPressure "") }}
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<td>{{ .BloodPressure }} mmHg</td>
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{{ else }}
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<td></td>
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{{ end }}
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<td>
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</tr>
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<tr>
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<td>
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<td class="data-label" style="text-align: right;">Suhu
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<p class="description-label"><i>Temperatur</i></p>
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</td>
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</td>
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<td class="data-colon">: </td>
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{{ if ne .BodyTemperature 0.0 }}
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<td>{{ .BodyTemperature }} C</td>
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{{ else }}
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<td></td>
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{{ end }}
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<td>
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</tr>
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<tr>
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<td>
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<td class="data-label" style="text-align: right;">Nadi
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<p class="description-label"><i>Pulse</i></p>
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</td>
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<td class="data-colon">: </td>
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{{ if ne .HeartRate 0.0 }}
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<td>{{ .HeartRate }} x/Menit</td>
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{{ else }}
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<td></td>
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{{ end }}
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</td>
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</tr>
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</table>
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</td>
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<td>
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<table cellspacing="0" cellpadding="0">
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<tr>
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<td>
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<td class="data-label" style="text-align: right;">Frekuensi Nafas
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<p class="description-label"><i>Respiratory rate</i></p>
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</td>
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</td>
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<td class="data-colon">: </td>
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{{ if ne .RespirationRate 0.0 }}
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<td>{{ .RespirationRate }} x/Menit</td>
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{{ else }}
|
|
<td></td>
|
|
{{ end }}
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<td class="data-label" style="text-align: right;">Skala Nyeri
|
|
<p class="description-label"><i>Pain Scale</i></p>
|
|
</td>
|
|
</td>
|
|
<td class="data-colon">: </td>
|
|
<td>{{ .PainScale }}</td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="data-label">Keadaan Keluar</td>
|
|
<td class="data-colon">: </td>
|
|
<td>{{ .ConditionOnDischarge }}</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="data-label">Cara Keluar
|
|
<p class="description-label"><i>Patient discharge of hospital</i></p>
|
|
</td>
|
|
<td class="data-colon">:</td>
|
|
<td>{{ .DischargeMethod }}</td>
|
|
</tr>
|
|
</table>
|
|
|
|
|
|
|
|
|
|
|
|
|
|
<table style="
|
|
margin-top: 1rem;
|
|
">
|
|
<tr>
|
|
<td>
|
|
<h4 class="description-label">INSTRUKSI UNTUK TINDAK LANJUT</h4>
|
|
<p class="description-label"><i>Follow up Consultation to</i></p>
|
|
</td>
|
|
<td class="">
|
|
<h4 class="description-label">Kontrol Ke</h4>
|
|
<p class="description-label"><i>Follow up Consultation to</i></p>
|
|
</td>
|
|
<td class="">
|
|
<table>
|
|
<tr>
|
|
<td style="width: 4rem;">Fasyankes</td>
|
|
<td class="data-colon">: </td>
|
|
<td>{{ .ControlHealthcare }}</td>
|
|
</tr>
|
|
<tr>
|
|
<td>Tanggal</td>
|
|
<td>: </td>
|
|
<td>{{ .ControlDate }}</td>
|
|
</tr>
|
|
<tr>
|
|
<td>Klinik</td>
|
|
<td>: </td>
|
|
<td>{{ .ControlUnit }}</td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
<tr><td style="height: 1rem;"></td></tr>
|
|
<tr>
|
|
<td class="">
|
|
<h4 class="description-label">Dalam keadaan darurat dapat menghubungi</h4>
|
|
<p class="description-label"><i>In case of emergencycontact</i></p>
|
|
</td>
|
|
<td class="">
|
|
<h4 class="description-label">IGD</h4>
|
|
<p class="description-label"><i>(Accident & Emergency Instalation)</i></p>
|
|
</td>
|
|
<td class="">
|
|
<table>
|
|
<tr>
|
|
<td style="width: 4rem;">Telepon
|
|
<p class="description-label"><i>Phone</i></p>
|
|
</td>
|
|
<td class="data-colon">: </td>
|
|
<td>(0341) 362101</td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
<tr><td style="height: 1rem;"></td></tr>
|
|
<tr>
|
|
<td class="">
|
|
<h4 class="description-label">EDUKASI & RENCANA TINDAK LANJUT</h4>
|
|
<p class="description-label"><i>Follow up plan (if necessary)</i></p>
|
|
</td>
|
|
<td class="">
|
|
<h4 class="description-label"></h4>
|
|
<p class="description-label"><i>(bila diperlukan)</i></p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
|
|
|
|
|
|
|
|
<table style="margin-top: 3rem;">
|
|
<tr>
|
|
<td></td>
|
|
<td style="width: 15rem;">
|
|
Malang, {{ .Date }}<br>
|
|
Dokter Penanggung Jawab Pelayanan
|
|
</td>
|
|
</tr>
|
|
<tr><td style="height: 7rem;"></td></tr>
|
|
<tr>
|
|
<td></td>
|
|
<td style="width: 15rem;">
|
|
({{ .Doctor_Name }})
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<div style="height: 3rem;"></div>
|
|
<hr style="margin: 20px 0" />
|
|
<p>*) Data dapat berubah setelah pasien pulang sesuai prosedur</p>
|
|
|
|
</body>
|
|
|
|
</html> |