312 lines
8.7 KiB
HTML
312 lines
8.7 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, .border-table td, .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: 0.1234rem;
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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="logo-1.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="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="position: relative;">
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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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Protokol Terapi
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</h1>
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<p style="
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margin: 0;
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text-align: center;
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">Layanan Kedokteran Fisik dan Rehabilitasi
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</p>
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<div style="padding-inline: 0.5rem;text-align: center;border: 1px solid black;position: absolute;right: 0;top: 0;">
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Terapi Ke <br><br>
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{{ .Repalcable }}
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</div>
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</div>
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<table class="border-table" style="margin-top: 2rem;">
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<tr>
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<td style="width: 7rem;">
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No RM
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Nama Pasien
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Tanggal Lahir
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Diagnosa
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Permintaan Terapi
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Frekuensi Terapi
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</td>
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<td style="padding-left: 0.5rem;">
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2 x Per Minggu      
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Evaluasi: 1 Bulan
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</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Target Terapi
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Waktu Mencapai Target
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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</table>
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<table class="border-table" style="margin-top: 1rem;">
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<tr>
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<th style="width: 2rem;">
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NO
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</th>
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<th>
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Tanggal
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</th>
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<th>
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Dokter
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</th>
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<th>
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Fisioterapi
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</th>
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<th>
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Terapi Wicara
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</th>
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<th>
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Okupansi Terapi
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</th>
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<th>
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Ortotik Prostetik
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</th>
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<th>
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PSM
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</th>
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<th>
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TTD Pasien
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</th>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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1
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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2
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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3
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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4
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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5
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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6
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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7
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="height: 3rem;text-align: center;">
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8
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</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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</table>
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<table class="border-table" style="margin-top: 1rem;">
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<tr>
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<td style="height: 2rem;width: 7rem;">
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Evaluasi
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td style="width: 7rem;">
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Rencana Selanjutnya
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</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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</table>
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<table style="margin-top: 2rem;">
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<tr>
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<td></td>
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<td style="width: 15rem;">
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Malang,<br>
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Cap dan TTD Dr. SpKFR
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</td>
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</tr>
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<tr><td style="height: 6rem;"></td></tr>
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<tr>
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<td></td>
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<td style="height: 10rem;width: 15rem;">
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(........................................................)
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</td>
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</tr>
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</table>
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<div style="height: 3rem;"></div>
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</body>
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</html> |