Form SEP

nama terang pasien
<div class="col-md-3">

<div class="box box-widget widget-user-2">

<div class="widget-user-header bg-aqua-active">
<div class="widget-user-image">
<img class="img-circle" src="/VClaim/image/male.png"
alt="User Avatar" id="imgMale" style="display: none;">
<img class="img-circle" src="/VClaim/image/female.png"
alt="User Avatar" id="imgFemale">
</div>
<h4 class="widget-user-username" id="lblnama">ISTIARI</h4>
<p class="widget-user-desc" id="lblnoka">0001926763751</p>
<input type="hidden" id="txtkelamin" value="P">
<input type="hidden" id="txtkdstatuspst" value="">
</div>






<div class="box-body">
<div class="nav-tabs-custom">
<ul class="nav nav-tabs">
<li class="active"><a title="Profile Peserta"
href="#tab_1" data-toggle="tab"><span class="fa fa-user"></span></a></li>
<li><a href="#tab_2" title="COB" data-
toggle="tab"><span class="fa fa-building"></span></a></li>
<li><a href="#tab_3" title="Histori" data-
toggle="tab" id="tabHistori"><span class="fa fa-list"></span></a></li>
</ul>
<div class="tab-content">
<div class="tab-pane active" id="tab_1">
<ul class="list-group list-group-unbordered">
<li class="list-group-item">
<span class="fa fa-sort-numeric-
asc"></span> <a title="NIK" class="pull-right-container"
id="lblnik">6402025407670001</a>
</li>
<span class="fa fa-credit-card"></span>
<a title="No.Kartu Bapel JKK" class="pull-right-container"
id="lblnokartubapel"></a>
</li>
<span class="fa fa-calendar"></span> <a
title="Tanggal Lahir" class="pull-right-container" id="lbltgllahir">1967-07-14</a>
</li>
<span class="fa fa-user"></span> <a
title="PISA" class="pull-right-container" id="lblpisa">Istri</a>
</li>
<span class="fa fa-hospital-o"></span>
<a title="Hak Kelas Rawat" class="pull-right-container" id="lblhakkelas">Kelas
3</a>
<input type="hidden" id="txtpisa"
value="3">
<input type="hidden" id="txtkdklspst"
value="3">
</li>
<span class="fa fa-stethoscope"></span>
<a title="Faskes Tingkat 1" class="pull-right-container" id="lblfktp">13211901 -
BARENG</a>
<input type="hidden" id="txtppkasalpst"
value="13211901">
</li>
<span class="fa fa-calendar"></span>
<a title="TMT dan TAT Peserta" class="pull-right-container" id="lbltmt_tat">2016-
09-01 s.d 2050-01-01</a>
<input id="txttmtpst" type="hidden"
value="2016-09-01">
</li>
<span class="fa fa-calendar"></span>
<a title="Jenis Peserta" class="pull-right-container" id="lblpeserta">MANDIRI</a>
<input type="hidden" id="txtjnspst"
value="14">
</li>
</ul>
</div>

<div class="tab-pane" id="tab_2">
<ul class="list-group list-group-unbordered">
<span class="fa fa-sort-numeric-
asc"></span> <a title="No. Asuransi" class="pull-right-container"
id="lblnoasu"></a>
<input type="hidden" id="txtkdasu"
value="">
</li>
<span class="fa fa-windows"></span> <a
title="Nama Asuransi" class="pull-right-container" id="lblnmasu"></a>
</li>
<span class="fa fa-calendar"></span> <a
title="TMT dan TAT Asuransi" class="pull-right-container" id="lbltmt_tatasu">null
s.d null</a>
<input type="hidden" id="txttmtasu"
value="">
<input type="hidden" id="txttatasu"
value="">
</li>
<span class="fa fa-bank"></span> <a
title="Nama Badan Usaha" class="pull-right-container" id="lblnamabu"></a>
<input type="hidden" id="txtkdbu"
value="">
</li>
</ul>
</div>
<div class="tab-pane" id="tab_3">
<div id="divHistori" class="list-group">
</div>
<div>
<button type="button" id="btnHistori"
class="btn btn-xs btn-default btn-block"><span class="fa fa-cubes"></span>
Histori</button>
</div>
</div>
</div>

</div>
<div id="divriwayatKK" style="display: none;">
<button type="button" id="btnRiwayatKK" class="btn btn-
danger btn-block"><span class="fa fa-th-list"></span> Pasien Memiliki Riwayat
KLL/KK/PAK <br><i>(klik lihat data)</i></button>
</div>
</div>

</div>

</div>
Form Input SEP
<div class="box box-success">

<div class="box-header with-border">
<h3 class="box-title"><label class="pull-right"
style="font-size:larger" id="lblnosep">0197S0010919V000681</label> </h3>
<label class="pull-right" style="font-size:larger"
id="lbljenpel">Rawat Jalan</label>
<input type="hidden" id="txtjenpel" value="2">
</div>
<form class="form-horizontal" id="theform">
<input type="hidden" id="txtprsklaimsep" value="0">
<div class="box-body">
<div>
<label style="color:red;font-size:small">* Wajib
Diisi</label>
</div>
<div class="form-group" id="divPoli">
<label class="col-md-3 col-sm-3 col-xs-12 control-
label">Spesialis/SubSpesialis <label style="color:red;font-
size:small">*</label></label>
<div class="col-md-9 col-sm-9 col-xs-12">
<div class="input-group">
<span class="input-group-addon">
<label><input type="checkbox"
id="chkpoliesekutif" disabled=""> Eksekutif</label>
</span>
<input type="text" class="form-control ui-
autocomplete-input" id="txtnmpoli" maxlength="10" placeholder="ketik kode atau nama
Spesialis/Subspesialis min 3 karakter" autocomplete="off" disabled="">
<input type="hidden" class="form-control"
id="txtkdpoli" value="MAT">
</div>
</div>
</div>
<div id="divRujukan">
<div class="form-group">
<label class="col-md-3 col-sm-3 col-xs-12
control-label">Asal Rujukan</label>
<select class="form-control"
id="cbasalrujukan" disabled="">
<option value="1">Faskes Tingkat
1</option>
<option value="2">Faskes Tingkat
2</option>
</select>
</div>
</div>
control-label">PPK Asal Rujukan <label style="color:red;font-
autocomplete-input" id="txtppkasalrujukan" placeholder="ketik kode atau nama ppk
asal rujukan min 3 karakter" autocomplete="off" disabled="">
id="txtkdppkasalrujukan" value="13211901">
</div>
</div>
control-label"><label style="color:gray;font-size:x-small">(yyyy-mm-dd)</label>
Tgl.Rujukan</label>
<div class="input-group date">
<input type="text" class="form-control
datepicker" id="txttglrujukan" placeholder="yyyy-MM-dd" maxlength="10" disabled="">
<span class="fa fa-calendar">
</span>
</span>
</div>
</div>
</div>
control-label">No. Rujukan <label style="color:red;font-
<input type="text" class="form-control"
id="txtnorujukan" placeholder="ketik nomor rujukan" maxlength="19" disabled="">
</div>
</div>
</div>

<div id="divkontrol" style="display: block;">
control-label" id="lblkontrol">No.Surat Kontrol/SKDP <label style="color:red;font-
id="txtnosuratkontrol" placeholder="ketik nomor surat kontrol" onkeypress="return
event.charCode >= 48 && event.charCode <= 57" maxlength="6" disabled="">
<input type="hidden" id="txtidkontrol"
value="1">
<input type="hidden"
id="txtnosuratkontrollama" value="000681">
id="txtpoliasalkontrol" value="MAT">
id="txttglsepasalkontrol" value="2019-09-17">
</div>
</div>
control-label">DPJP Pemberi Surat SKDP/SPRI <label style="color:red;font-
autocomplete-input" id="txtnmdpjp" placeholder="ketik nama dokter DPJP Pemberi
Surat SKDP/SPRI" autocomplete="off" disabled="">
<input type="hidden" id="txtkddpjp"
value="14921">
</div>
</div>
</div>

<div class="clearfix"></div>

label"><label style="color:gray;font-size:x-small">(yyyy-mm-dd)</label> Tgl.
SEP</label>
datepicker" id="txttglsep" placeholder="yyyy-MM-dd" maxlength="10" disabled="">
</span>
</span>
</div>
</div>
</div>
label">No. MR <label style="color:red;font-size:small">*</label></label>
<div class="input-group">
id="txtnomr" placeholder="ketik nomor MR" maxlength="10" disabled="">
<label><input type="checkbox"
id="chkCOB" disabled=""> Peserta COB</label>
</span>
</div>
</div>
</div>
<div class="form-group" id="divkelasrawat"
style="display: none;">
label">Kelas Rawat</label>
<select class="form-control" id="cbKelas"
disabled=""><option value="3">Kelas 3</option></select>
</div>
</div>
label">Diagnosa <label style="color:red;font-size:small">*</label></label>
autocomplete-input" id="txtnmdiagnosa" maxlength="10" placeholder="ketik kode atau
nama diagnosa min 3 karakter" autocomplete="off" disabled="">
<label id="lblDxSpesialistik" style="color:
red; display: none;"></label>
id="txtkddiagnosa" value="H54.5">
</div>
</div>
label">No. Telepon <label style="color:red;font-size:small">*</label></label>
id="txtnotelp" placeholder="ketik nomor telepon yang dapat dihubungi"
onkeypress="return event.charCode >= 48 && event.charCode <= 57"
maxlength="15" disabled="">
</div>
</div>
label">Catatan</label>
<textarea class="form-control" id="txtcatatan"
rows="2" placeholder="ketik catatan apabila ada" disabled=""></textarea>
</div>
</div>

<div class="form-group" id="divkatarak" style="display:
block;">
label">Katarak <input type="checkbox" id="chkkatarak" disabled=""></label>
<p class="text-muted well well-sm no-
shadow">Centang Katarak <i class="fa fa-check"></i>, Jika Peserta Tersebut
Mendapatkan Surat Perintah Operasi katarak</p>
</div>
</div>

label">Status Kecelakaan <label style="color:red;font-size:small">*</label></label>
<select class="form-control " id="cbstatuskll"
disabled="">
<option value="-">-- Silahkan Pilih
--</option>
<option value="0" title="Kasus bukan akibat
kecelakaan lalu lintas dan kerja">Bukan Kecelakaan</option>
<option value="1" title="Kasus KLL Tidak
Berhubungan dengan Pekerjaan">Kecelakaan LaluLintas dan Bukan Kecelakaan
Kerja</option>
<option value="2" title="1).Kasus KLL
Berhubungan dengan Pekerjaan. 2).Kasus KLL Berangkat dari Rumah menuju tempat
Kerja. 3).Kasus KLL Berangkat dari tempat Kerja menuju rumah.">Kecelakaan
LaluLintas dan Kecelakaan Kerja</option>
<option value="3" title="1).Kasus
Kecelakaan Berhubungan dengan pekerjaan. 2).Kasus terjadi di tempat kerja.Kasus
terjadi pada saat kerja.">Kecelakaan Kerja</option>
</select>
</div>
</div>
<div id="divJaminanHistori" class="text-muted well

well-sm no-shadow col-md-12 col-sm-12 col-xs-12" style="display: none;">
<input type="hidden" id="txtkasuslaka" value="0">
<input type="hidden" id="txtnosepjaminanhistori">
<input type="hidden" id="txtnosepjaminanhistori2">
<input type="hidden" id="txtkasuskejadian2">
<input type="hidden" id="txtstatusdijamin">
<p style="margin-top: 10px;" id="pketerangan"></p>
</div>
<div id="divJaminan" class="text-muted well well-sm no-
shadow" style="display: none;">
control-label">Tanggal Kejadian</label>
datepicker" id="txtTglKejadian" placeholder="yyyy-MM-dd" maxlength="10"
disabled="">
</span>
</span>
</div>
</div>
</div>
<div class="form-group ">
control-label">Lokasi Kejadian</label>
id="cbpropinsi" disabled=""><option value="">-- Silahkan Pilih Propinsi
--</option><option value="16">BALI</option><option
value="15">BANTEN</option><option value="07">BENGKULU</option><option value="13">D
I YOGYAKARTA</option><option value="10">DKI JAKARTA</option><option
value="27">GORONTALO</option><option value="05">JAMBI</option><option
value="11">JAWA BARAT</option><option value="12">JAWA TENGAH</option><option
value="14">JAWA TIMUR</option><option value="19">KALIMANTAN BARAT</option><option
value="21">KALIMANTAN SELATAN</option><option value="20">KALIMANTAN
TENGAH</option><option value="22">KALIMANTAN TIMUR</option><option
value="34">KALIMANTAN UTARA</option><option value="09">KEP. BANGKA
BELITUNG</option><option value="33">KEPULAUAN RIAU</option><option
value="08">LAMPUNG</option><option value="99">LUAR NEGERI</option><option
value="28">MALUKU</option><option value="29">MALUKU UTARA</option><option
value="01">NANGGROE ACEH DARUSSALAM</option><option value="17">NUSA TENGGARA
BARAT</option><option value="18">NUSA TENGGARA TIMUR</option><option
value="30">PAPUA</option><option value="31">PAPUA BARAT</option><option
value="04">RIAU</option><option value="32">SULAWESI BARAT</option><option
value="25">SULAWESI SELATAN</option><option value="24">SULAWESI
TENGAH</option><option value="26">SULAWESI TENGGARA</option><option
value="23">SULAWESI UTARA</option><option value="03">SUMATERA BARAT</option><option
value="06">SUMATERA SELATAN</option><option value="02">SUMATERA
UTARA</option></select>
</div>
</div>
control-label"></label>
id="cbkabupaten" disabled=""></select>
</div>
</div>
control-label"></label>
id="cbkecamatan" disabled=""></select>
</div>
</div>
control-label">Keterangan Kejadian</label>
<textarea class="form-control"
id="txtketkejadian" rows="2" placeholder="ketik keterangan kejadian"
disabled=""></textarea>
</div>
</div>
</div>

</div>
<div class="box-footer">
<div id="divSimpan" style="display: none;">
<button type="button" id="btnSimpan" class="btn
btn-success pull-left"><i class="fa fa-save"></i> Simpan</button>
</div>
<div id="divEditSEP" style="display: block;">
<button type="button" id="btnEdit" class="btn btn-
info pull-left col-md-1 col-sm-1 col-xs-12">Edit</button>
<button type="button" id="btnHapus" class="btn btn-
danger pull-left col-md-1 col-sm-1 col-xs-12">Hapus</button>
<button type="button" id="btnCetak" class="btn btn-
warning pull-left col-md-1 col-sm-1 col-xs-12">Cetak</button>
</div>
<button type="button" id="btnBatal" class="btn btn-
danger pull-right">Batal</button>
</div>
</form>
</div>

Form SEP

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Copyright:

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Form SEP

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Copyright:

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nama terang pasien

<div class="box box-widget widget-user-2">

Form Input SEP

<div class="box box-success">

<div id="divJaminanHistori" class="text-muted well

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