{% extends '../template.html' %}
{% block title %}Tambah Rekam Medis{% endblock %}
{% block subcontent %}
		{% if session.flash.error != "" %}
			{{ session.flash.error | safe }}
		{% endif %}
	
		<h2>Tambah Rekam Medis</h2>
		<form method="post">
			<table class="data" cellpadding="0" cellspacing="0" border="0">
				<tr>
					<td>No. RekMed</td>
					<td><input type="text" name="no_rekmed" value="{{ id }}"/></td>
				</tr>
				<tr>
					<td>Poli</td>
					<td>
						<select name="id_poli">
							<option value="1" {% if data.id_poli == '1' %}selected="true"{% endif %}>Umum</option>
							<option value="2" {% if data.id_poli == '2' %}selected="true"{% endif %}>Gigi</option>
							<option value="3" {% if data.id_poli == '3' %}selected="true"{% endif %}>KIA</option>
						</select>
					</td>
				</tr>
				<tr>
					<td>Tanggal</td>
					<td><input type="text" name="tgl" value="{{ data.tgl }}"/>dd-mm-yyyy</td>
				</tr>
				<tr>
					<td>Keluhan</td>
					<td><textarea name="keluhan" style="width:250px;" >{{ data.keluhan }}</textarea></td>
				</tr>
				<tr>
					<td>Diagnosis</td>
					<td><input type="text" name="diagnosis" value="{{ data.diagnosis }}"/></td>
				</tr>
				<tr>
					<td>ICD X</td>
					<td><input type="text" name="icd" value="{{ data.icd }}"/></td>
				</tr>
				<tr>
					<td>Terapi</td>
					<td><textarea name="terapi" style="width:250px;" >{{ data.terapi }}</textarea></td>
				</tr>
			</table>
			<br/><input type="submit" class="med_btn" value="Simpan" /> <a href="{% nav admin_rekmed %}/{{id}}">Batal</a>
		</form>
{% endblock %}
