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