131 lines
3.0 KiB
HTML
131 lines
3.0 KiB
HTML
<html>
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<head>
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<meta charset="UTF-8" />
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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: 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="margin-top: 1rem;">
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<tr>
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<td style="width: 9rem;">
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Tanggal Terbit
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td>
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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>{{ .Repalcable }}</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>{{ .Repalcable }}</td>
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</tr>
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<tr>
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<td>
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Tanggal Lahir
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</td>
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<td class="data-colon">: </td>
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<td>{{ .Repalcable }}</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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FORM A
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</h1>
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<section>
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<h4 class="section-title">Kajian Awal Medis:</i></h4>
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<table style="margin-top: 0.3rem;">
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<tr>
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<td>
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☑ Kasus Dengan Penyakit Kronis, Katastropik (memerlukan Pembiayaan Tinggi), Terminal
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</td>
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</tr>
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<tr>
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<td>
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▢ Status Fungsional Rendah, Kebutuhan Bantuan ADL(Activity Daily Living) Yang Tinggi
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</td>
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</tr>
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</table>
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</section>
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<section>
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<h4 class="section-title">ASSESMEN:</h4>
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<table style="margin-top: 0.3rem;">
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</table>
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</section>
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<section>
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<h4 class="section-title">IDENTIFIKASI MASALAH:</h4>
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<table style="margin-top: 0.3rem;">
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</table>
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</section>
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<section>
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<h4 class="section-title">PERENCANAAN:</h4>
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<table style="margin-top: 0.3rem;">
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</table>
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</section>
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<table style="margin-top: 3rem;">
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<tr>
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<td></td>
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<td style="text-align: center;width: 15rem;">
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2025-10-08 16:06:22
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</td>
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</tr>
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<tr>
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<td></td>
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<td style="text-align: center;height: 10rem;width: 15rem;">
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GATOT SUBROTO,AMd.Kep
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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> |