432 lines
10 KiB
HTML
432 lines
10 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="
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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>{{ .Repalcable }}</td>
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<td style="width: 7rem;">
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Kelas
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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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NIK
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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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<td>
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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>{{ .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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<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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .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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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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .Repalcable }}</td>
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</tr>
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</table>
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<table class="border-table" style="margin-top: 0.7rem;">
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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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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .Repalcable }}</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>{{ .Repalcable }}</td>
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</tr>
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</table>
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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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<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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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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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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Keluhan Utama
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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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<h4 class="section-title">Konsultasi</i></h4>
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<table class="border-table" style="margin-top: 0.4rem;">
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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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Konsultasi
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</th>
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<th>
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Jawaban Konsultasi
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</th>
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</tr>
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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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<tr>
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<td>
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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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</tr>
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</table>
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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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Replace
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</td>
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</tr>
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</table>
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<h4 class="section-title" style="margin-top: 3rem;">Obat yang diberikan</i></h4>
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<table class="border-table" style="margin-top: 0.4rem;">
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<tr>
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<th>
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Terapi (Farmakologi & Non Farmakologi) Selawa Perawatan
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</th>
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<th>
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Terapi (Farmakologi & Non Farmakologi) Selawa Pulang
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</th>
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</tr>
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<tr>
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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>{{ .Repalcable }}</td>
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<td>{{ .Repalcable }}</td>
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</tr>
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<tr>
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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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<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">
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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>{{ .Repalcable }}</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> |