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Form #1 PA : source https://jsbin.com/xemipux
Raw
index.html
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width">
<title>JS Bin</title>
<style>
body {
font-size: 16px;
font-family:Candara,Calibri,Segoe,Segoe UI,Optima,Arial,sans-serif;
}
.spasi5 { height:5px; }
.spasi10 { height:10px; }
.spasi15 { height:15px; }
td.tengah {
text-align: center;
}
td.tebel {
font-weight: bold;
}
.biru {
background: #0072c6;
}
.double-bar {
border-top: 4px double #999;
padding: 10px 0;
color: #000;
}
td.kanan {
text-align: right;
}
p.solid { border-style: solid; }
</style>
</head>
<body>
<!-- HEADER -->
<table width="100%" border="0">
<tr>
<td><img src="https://surat.rsuppersahabatan.co.id/logo-text.png"</td>
<td>
<table>
<tr>
<td>Nomor PA</td>
<td>:</td>
<td>NOMOR_PA</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Laboratorium Patologi Anatomik</td>
<td rowspan="4">
<table width ="100%" border="1">
<tr>
<td>Nama</td>
<td>: Mr. XXX</td>
</tr>
<tr>
<td>RM</td>
<td>: 9898989</td>
</tr>
<tr>
<td>Tanggal Lahir/ Umur</td>
<td>: 12/12/1212 - 100thn</td>
</tr>
<tr>
<td colspan="3">(Mohon diisi atau templekan sticker)</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Jalan Persahabatan Raya No. 1 Rawamangun,</td>
</tr>
<tr>
<td>Jakarta Timur, 13230,</td>
</tr>
<tr>
<td>Telp. 999888 888777 666</td>
</tr>
</table>
<div class="spasi15"></div>
<table width="100%" border="0">
<tr>
<td>DATA DOKTER/ RS PENGIRIM</td>
<td>DATA PASIEN</td>
<tr>
<tr>
<td>
<table width ="100%" border="0">
<tr>
<td>Nama Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>RS Asal</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Telpon Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bagian/ Unit</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
<td>
<table width ="100%" border="0">
<tr>
<td>Alamat Lengkap</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bangsa/ Suku</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
</tr>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN HISTOPATOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td width="30%">Jaringan berasal dari/ Lokasi Lesi/ Tumor</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Jaringan didapat dengan cara</td>
<td>:</td>
<td>1. Operasi 2. Biopsi 3. Kuretan 4. Ekstrapasi 5. Lannya ....... </td>
</tr>
<tr>
<td width="30%">Waktu Jaringan dikeluarkan dari tubuh</td>
<td>:</td>
<td>......................(jam/ menit)</td>
</tr>
<tr>
<td width="30%">Waktu mulai dilakukan fiksasi</td>
<td>:</td>
<td>......................(jam/ menit)</td>
</tr>
<tr>
<td width="30%">Cairan Fiksasi</td>
<td>:</td>
<td>1. Formalin Buffer 10% 2. Lainnya ................ </td>
</tr>
<tr>
<td width="30%">Jumlah jaringan yang dikirim</td>
<td>:</td>
<td>.................. botol/ bungkus/ pot</td>
</tr>
</tbody>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN SITOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td width="30%">Tanggal/ Jam pengambilan bahan</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Jaringan didapat dengan cara</td>
<td>:</td>
<td>1. Operasi 2. Biopsi 3. Kuretan 4. Ekstrapasi 5. Lannya ....... </td>
</tr>
<tr>
<td width="30%">Bahan berasal dari</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Cara Pengambilan</td>
<td>:</td>
<td>TTNA/ Sikatan/ Bilasan/ TBNA/ BJH/ Aspirasi/ Imprint/ Lainnya</td>
</tr>
<tr>
<td width="30%">Jenis Fiksasi</td>
<td>:</td>
<td>1. Alkohol 96% 2. Fiksasi Kering 3. Lainnya ................ </td>
</tr>
<tr>
<td width="30%">Jenis bahan yang dikirim</td>
<td>:</td>
<td>1. Dengan fiksasi alkohol 96% 2. Cairan Pleura/ Pericard/ Asites 3. Dengan Fiksasi Kering 4. Lainnya ................</td>
</tr>
</tbody>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tebel" colspan="3">GINEKOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td colspan="2">1. Pra-menopause</td>
<td>2. Menopause/ Pasca-menopause</td>
</tr>
<tr>
<td width="30%">Kontrasepsi</td>
<td width="1%">:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Tanggal Haid Terakhir</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Status ginekologi</td>
<td>:</td>
<td>......................</td>
</tr>
</tbody>
</table>
<div class="spasi10"></div>
<div class="double-bar"></div>
<table width="100%" border="0">
<tr>
<td class="tebel" width="20%">DIAGNOSA KLINIK</td>
<td width="2%">:</td>
<td>...................</td>
</tr>
<tr>
<td colspan="3">KETERNANGAN KLINIK (Hasil Pemeriksaan Bronskoskopi/ Radiologi/ Pemeriksaan lainnya)
</tr>
<tr>
<td colspan="3">(Rincian Gambar)</td>
</tr>
<tr>
<td rowspan="3"></td>
<td class="kanan" colspan="2">Jakarta, Tgl: .../ ..../ .....</td>
</tr>
<tr>
<td height="100"></td>
</tr>
<tr>
<td class="kanan" colspan="2">Tanda Tangan dan Nama Jelas Dokter Pengirim</td>
</tr>
<tr>
<td colspan="3">
<p class="solid">
Cara Fiksashistopatologi: <br />
Jaringan harus segera direndam dalam cairan fiksasi formalin buffer 10% selambat-lambatnya 30 menit setelah jaringan dikeluarkan dari tubuh. <br />
Cara fiksasisitologi: <br />
- Sediaan apusan apda kaca benda harus segera direndam dalam cairan alkohol 96% minimal 30 menit untuk pewarnaan papanicolaou. <br />
- Cairan tubuh (pleura, asites, pericard, cairan otak) harus segera dikirim ke Lab. PA, bila ada penundaan harus disimpan dalam lemari es pada suhu 2-8 derajat celcius, maksimal 3 hari.
</p>
</td>
</tr>
</table>
<script id="jsbin-source-html" type="text/html">
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width">
<title>JS Bin</title>
<style>
body {
font-size: 16px;
font-family:Candara,Calibri,Segoe,Segoe UI,Optima,Arial,sans-serif;
}
.spasi5 { height:5px; }
.spasi10 { height:10px; }
.spasi15 { height:15px; }
td.tengah {
text-align: center;
}
td.tebel {
font-weight: bold;
}
.biru {
background: #0072c6;
}
.double-bar {
border-top: 4px double #999;
padding: 10px 0;
color: #000;
}
td.kanan {
text-align: right;
}
p.solid { border-style: solid; }
</style>
</head>
<body>
<\!-- HEADER -->
<table width="100%" border="0">
<tr>
<td><img src="https://surat.rsuppersahabatan.co.id/logo-text.png"</td>
<td>
<table>
<tr>
<td>Nomor PA</td>
<td>:</td>
<td>NOMOR_PA</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Laboratorium Patologi Anatomik</td>
<td rowspan="4">
<table width ="100%" border="1">
<tr>
<td>Nama</td>
<td>: Mr. XXX</td>
</tr>
<tr>
<td>RM</td>
<td>: 9898989</td>
</tr>
<tr>
<td>Tanggal Lahir/ Umur</td>
<td>: 12/12/1212 - 100thn</td>
</tr>
<tr>
<td colspan="3">(Mohon diisi atau templekan sticker)</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Jalan Persahabatan Raya No. 1 Rawamangun,</td>
</tr>
<tr>
<td>Jakarta Timur, 13230,</td>
</tr>
<tr>
<td>Telp. 999888 888777 666</td>
</tr>
</table>
<div class="spasi15"></div>
<table width="100%" border="0">
<tr>
<td>DATA DOKTER/ RS PENGIRIM</td>
<td>DATA PASIEN</td>
<tr>
<tr>
<td>
<table width ="100%" border="0">
<tr>
<td>Nama Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>RS Asal</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Telpon Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bagian/ Unit</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
<td>
<table width ="100%" border="0">
<tr>
<td>Alamat Lengkap</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bangsa/ Suku</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
</tr>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN HISTOPATOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td width="30%">Jaringan berasal dari/ Lokasi Lesi/ Tumor</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Jaringan didapat dengan cara</td>
<td>:</td>
<td>1. Operasi 2. Biopsi 3. Kuretan 4. Ekstrapasi 5. Lannya ....... </td>
</tr>
<tr>
<td width="30%">Waktu Jaringan dikeluarkan dari tubuh</td>
<td>:</td>
<td>......................(jam/ menit)</td>
</tr>
<tr>
<td width="30%">Waktu mulai dilakukan fiksasi</td>
<td>:</td>
<td>......................(jam/ menit)</td>
</tr>
<tr>
<td width="30%">Cairan Fiksasi</td>
<td>:</td>
<td>1. Formalin Buffer 10% 2. Lainnya ................ </td>
</tr>
<tr>
<td width="30%">Jumlah jaringan yang dikirim</td>
<td>:</td>
<td>.................. botol/ bungkus/ pot</td>
</tr>
</tbody>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN SITOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td width="30%">Tanggal/ Jam pengambilan bahan</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Jaringan didapat dengan cara</td>
<td>:</td>
<td>1. Operasi 2. Biopsi 3. Kuretan 4. Ekstrapasi 5. Lannya ....... </td>
</tr>
<tr>
<td width="30%">Bahan berasal dari</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Cara Pengambilan</td>
<td>:</td>
<td>TTNA/ Sikatan/ Bilasan/ TBNA/ BJH/ Aspirasi/ Imprint/ Lainnya</td>
</tr>
<tr>
<td width="30%">Jenis Fiksasi</td>
<td>:</td>
<td>1. Alkohol 96% 2. Fiksasi Kering 3. Lainnya ................ </td>
</tr>
<tr>
<td width="30%">Jenis bahan yang dikirim</td>
<td>:</td>
<td>1. Dengan fiksasi alkohol 96% 2. Cairan Pleura/ Pericard/ Asites 3. Dengan Fiksasi Kering 4. Lainnya ................</td>
</tr>
</tbody>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tebel" colspan="3">GINEKOLOGI</td></tr>
</thead>
<tbody>
<tr>
<td colspan="2">1. Pra-menopause</td>
<td>2. Menopause/ Pasca-menopause</td>
</tr>
<tr>
<td width="30%">Kontrasepsi</td>
<td width="1%">:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Tanggal Haid Terakhir</td>
<td>:</td>
<td>......................</td>
</tr>
<tr>
<td width="30%">Status ginekologi</td>
<td>:</td>
<td>......................</td>
</tr>
</tbody>
</table>
<div class="spasi10"></div>
<div class="double-bar"></div>
<table width="100%" border="0">
<tr>
<td class="tebel" width="20%">DIAGNOSA KLINIK</td>
<td width="2%">:</td>
<td>...................</td>
</tr>
<tr>
<td colspan="3">KETERNANGAN KLINIK (Hasil Pemeriksaan Bronskoskopi/ Radiologi/ Pemeriksaan lainnya)
</tr>
<tr>
<td colspan="3">(Rincian Gambar)</td>
</tr>
<tr>
<td rowspan="3"></td>
<td class="kanan" colspan="2">Jakarta, Tgl: .../ ..../ .....</td>
</tr>
<tr>
<td height="100"></td>
</tr>
<tr>
<td class="kanan" colspan="2">Tanda Tangan dan Nama Jelas Dokter Pengirim</td>
</tr>
<tr>
<td colspan="3">
<p class="solid">
Cara Fiksashistopatologi: <br />
Jaringan harus segera direndam dalam cairan fiksasi formalin buffer 10% selambat-lambatnya 30 menit setelah jaringan dikeluarkan dari tubuh. <br />
Cara fiksasisitologi: <br />
- Sediaan apusan apda kaca benda harus segera direndam dalam cairan alkohol 96% minimal 30 menit untuk pewarnaan papanicolaou. <br />
- Cairan tubuh (pleura, asites, pericard, cairan otak) harus segera dikirim ke Lab. PA, bila ada penundaan harus disimpan dalam lemari es pada suhu 2-8 derajat celcius, maksimal 3 hari.
</p>
</td>
</tr>
</table>
</body>
</html></script>
</body>
</html>
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