145 lines
7.5 KiB
PHP
145 lines
7.5 KiB
PHP
<?php
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include "header.php";
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?>
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<form id="input" action="model/action_input.php" method="POST" enctype="multipart/form-data">
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<?php date_default_timezone_set('Asia/Jakarta'); //Menyesuaikan waktu dengan tempat kita tinggal
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?>
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<div class="modal-dialog.center">
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<div class="container-fluid">
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<div class="modal-content">
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<div class="alert alert-success" style="text-align: center;">
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<h4>Laporan Perawat UGD <?= $nama_login ?></h4>
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</div>
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<div class="container">
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<div class="row" style="margin-top: 10pt;">
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<div class="col-md-5" style="margin-bottom: 5pt;">
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<select id="perawat_ppa" name="perawat_ppa" class="form-control form-control-sm" placeholder="nama perawat " size="1">
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<option selected>Pilih perawat...</option>
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<?php
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include "model/koneksi.php";
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$sql = " SELECT nama_perawat FROM tb_perawat ORDER BY nama_perawat ASC";
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$prwsql = (mysqli_query($open, $sql));
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while ($ppa = mysqli_fetch_array($prwsql)) {
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$prwppa = stripslashes($ppa['nama_perawat']);
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?>
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<option value="<?= $prwppa; ?>"><?= $prwppa; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-5" style="margin-bottom: 5pt;">
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<input type="text" class="form-control form-control-sm" id="colFormLabelSm" placeholder="nomer rekam medis" name="register">
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</div>
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</div>
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<td><input hidden="hidden" type="" name="tanggal" value="<?php echo date('Y-m-d H:i:s '); ?>"></td>
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<div class="row mb-3">
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<div class="col-md-5" style="margin-bottom: 5pt;">
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<input type="text" class="form-control form-control-sm" id="colFormLabelSm" placeholder="nama pasien" name="nama">
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-3" style="margin-bottom: 5pt;">
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<input type="text" class="form-control form-control-sm" id="colFormLabelSm" placeholder="umur" name="umur">
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-5" style="margin-bottom: 5pt;">
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<input type="text" class="form-control form-control-sm" id="colFormLabelSm" placeholder="alamat tinggal" name="alamat">
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<select class="form-select" id="jenis_kelamin" name="jenis_kelamin">
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<option value="" selected>Jenis Kelamin</option>
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<option value="Laki-laki">Laki-laki</option>
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<option value="Perempuan">Perempuan</option>
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</select>
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<select class="form-select" id="triage" name="triage">
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<option value="" selected>triage</option>
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<option value="P1"> P1</option>
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<option value="P2">P2</option>
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<option value="P3">P3</option>
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<option value="P0">P0</option>
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</select>
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</div>
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<input type="number" name="nik" list="nik" class="form-control form-control-sm" placeholder="No. Bed">
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<!-- <datalist class="form-select" id="file">
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<option value="" selected>skrining</option>
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<option value="BUKAN KETIGANYA"> BUKAN KETIGANYA</option>
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<option value="SUSPEK">SUSPEK</option>
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<option value="PROBABLE">PROBABLE</option>
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<option value="KONFIRM">KONFIRM</option>
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</datalist> -->
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<select class="form-select" id="kedatangan" name="kedatangan">
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<option value="" selected>kedatangan</option>
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<option value="DS"> DS</option>
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<option value="Rujukan">Rujukan</option>
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<option value="Terlantar">Terlantar</option>
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<option value="Pindahan">Pindahan</option>
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</select>
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</div>
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</div>
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<div class="row mb-3">
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<select name="smf" class="form-select" id="smf" size="1">
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<option value="" selected>SMF</option>
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<option value="IPD">IPD </option>
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<option value="IKA">IKA </option>
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<option value="NEURO">NEURO </option>
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<option value="PARU">PARU </option>
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<option value="ANESTESI">ANESTESI </option>
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<option value="KARDIO">KARDIO </option>
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<option value="BEDAH">BEDAH </option>
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<option value="ORTHO">ORTHO </option>
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<option value="UROLOGI">UROLOGI </option>
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<option value="THT">THT </option>
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<option value="MATA">MATA </option>
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<option value="KULIT">KULIT </option>
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<option value="EM">EM </option>
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<option value="OBG">OBG </option>
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<option value="JIWA">JIWA </option>
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</select>
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</div>
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</div>
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<div class="modal-footer" align="left">
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<div class="row mb-3">
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<div class="col-md-2" style="margin-bottom: 5pt;">
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<input type="submit" name="submit" value="Simpan" class="btn btn-primary">
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<input type="reset" name="reset" value="batal" class="btn btn-secondary">
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</form>
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