b.

Kode
<?php
<div class="ui-dialog" style="width:100%;margin- right:5px;height:auto;float:lef
t;" id="panel_main">
<div style="position: relative;" class="ui-dialog-container">
<div class="ui-dialog-titlebar"><?php echo $title;?></div>
<div class="ui-dialog-content" id="dialogContent">
<div id="admission_message" style="display:none"></div>
<form method="POST" name="frmPendaftaran" id="frmPendaftaran"
action="<?php echo site_url('admission/indoor/process_form');?>">
<input type="hidden" name="is_new" id="is_new" value="yes" />
<table cellpadding="0" cellspacing="0" border="0"
class="tblInput" style="width:100%;">
<tr>
<td style="width:150px;font-size:18px;"><?php echo
$this->lang->line('label_date');?></td>
<td><input type="text" class="date-pick" name="visit_date" id="visit_date" style
="font-size:18px;" maxlength="10" value="<?=date('d/m/Y')?>" size="10" onkeyup="
autoSlashTanggal(this, event)" onkeypress="focusNext('family_folder', 'visit_dat
e', this, event)"
/><i>dd/mm/yyyy</i></td>
<td>

<!-- <a href="javascript:void(0)"> -->
<div id="before" style="cursor:pointer;float:left"><img src="<?php echo base_url
()?>webroot/media/images/arrow_left_blue.png" border="0" title="Nomor RM sebelum
nya" alt="Nomor RM sebelumnya" /></div>
<div id="after"
style="cursor:pointer;float:left;"><img src="<?php echo base_url()?>webroot/medi
a/images/arrow_right_blue.png" border="0" title="Nomor RM sesudahnya" alt="Nomor
RM sesudahnya" /></div>
<div id="show_panel_search" style="cursor:pointer;"><img src="<?php echo base_ur
l()?>webroot/media/images/search_folder.png" border="0" title="Find (Ctrl+F)" al
t="Find (Ctrl+F)" /></div>
<!-- </a> -->
</tr>
<tr>

</td>
<td style="font-size:18px;"><?php echo $this-
>lang->line('label_mr_number');?></td>
<td>
<table cellpadding="0" cellspacing="0" border="0">
<tr>
<td>
<input type="text" name="family_folder" id="family_folder"
value="" size="9" maxlength="9" onkeypress="focusNext('patient_id',
'visit_date', this, event)" style="text-align:right;font-size:18px;font- weight:
bold" title="Family Folder" />/
</td>
<td>
<input type="text" name="patient_id" id="patient_id"
value="" size="8" maxlength="8"
onkeypress="focusNext('family_relationship_code', 'family_folder', this, event)"
style="text-align:right;font-size:18px;font-weight:bold" title="Patient ID" onc
hange="fillFamilyRelationshipId();" />/
</td>
<td>
<input type="text" name="family_relationship_id" id="family_relationship_id" val
ue="" size="2" maxlength="2" onkeypress="focusNext('family_relationship_code', '
patient_id', this, event);" title="Family Relationships Code" style="text-align:
right;font-size:18px;font- weight:bold" readonly="readonly" class="readonly2" />
<!--<input type="text" name="family_relationship_id"
id="family_relationship_id" value="" size="2" maxlength="2" onkeypress="focusNex
t('name', 'patient_id', this, event);" title="Family Relationships Code" style="
text-align:right;font-size:18px;font-weight:bold" />-
->
</td>
</tr>
<tr>
style:italic">Family Folder</span></td>
style:italic">ID Pasien</span></td>

<td><span style="font-size:10px;font-
<td><span style="font-size:10px;font-
<td><span style="font-size:10px;font-
style:italic">Kode Hubungan Keluarga</span></td>
</tr>
</table>
</td>
</tr>
<tr>

<td></td>
<td><?php echo $this->lang-
>line('label_family_relationship');?></td>
<td>
<select name="family_relationship_code"
id="family_relationship_code" style="width:200px" onkeypress="focusNext('nik',
'patient_id', this, event)" onchange="fillFamilyRelationshipId();">
<option value="">--- <?php echo $this-
>lang->line('form_change');?> ---</option>

<?php
for($i=0;$i<sizeof($combo_relationship);$i++) :?>
<option value="<?php echo
$combo_relationship[$i]['id']?>"><?php echo
$combo_relationship[$i]['name']?></option>
</tr>

</td>

<?php endfor;?>
</select>

</table>

<tr>
</tr>

<td colspan="3"><hr /></td>
<div style="float:left;width:50%">
<table cellpadding="0" cellspacing="0" border="0" class="tblInput">
<tr>
<td style="width:200px">NIK/No. RM Lama</td>
<td><input type="text" name="nik" id="nik"
value="" size="20" maxlength="16" onkeypress="focusNext('name',
'family_relationship_code', this, event)" /></td>
</tr>
<?php if($this->config->item('use_last_name') == true) :?>
<tr>
<td><?php echo $this->lang-
>line('label_first_name');?></td>
<td>
<input type="text" name="name" id="name" value=""
size="30" onkeypress="focusNext('last_name', 'family_relationship_id', this,
event)" />
&nbsp;<?php echo $this->lang->line('label_last_name');?>
<input type="text" name="last_name" id="last_name"
value="" size="30" onkeypress="focusNext('parent_name', 'name', this, event)" />
</td>
</tr>
<tr>
>line('label_parent');?></td>

<td><?php echo $this->lang-
<td><input type="text" name="parent_name"
id="parent_name" value="" size="30" onkeypress="focusNext('birth_place',
'last_name', this, event)" /></td>
</tr>
<?php else:?>
<tr>
>line('label_name');?></td>

<td><?php echo $this->lang-
<td>
<input type="text" name="name" id="name" value=""
size="30" onkeypress="focusNext('parent_name', 'nik', this, event)" />
</td>
</tr>
<tr>
>line('label_parent');?></td>

<td><?php echo $this->lang-
<td><input type="text" name="parent_name"
id="parent_name" value="" size="30" onkeypress="focusNext('birth_place', 'name',
this, event)" /></td>
</tr>
<?php endif;?>
<tr>

<td><?php echo $this->lang-
>line('label_place_date_of_birth');?></td>
<td>
<input type="text" name="birth_place"
id="birth_place" value="" size="10" onkeypress="focusNext('birth_date',
'parent_name', this, event)" />,
<input type="text" name="birth_date"
id="birth_date" value="" size="10" maxlength="10"
onkeyup="autoSlashTanggal(this, event)" onkeypress="focusNext('age_year',
'birth_place', this, event)" /><i>dd/mm/yyyy</i>
</td>
</tr>
<tr>
>line('label_age');?></td>

<td><?php echo $this->lang-
<td><input type="text" class="age" name="age_year"
id="age_year" value="" size="1" onkeypress="focusNext('age_month', 'birth_date',
this, event)" />th
<input type="text" class="age" name="age_month"
id="age_month" value="" size="1" onkeypress="focusNext('age_day', 'age_year', th
is, event)" />bl
<input type="text" class="age" name="age_day"
id="age_day" value="" size="1" onkeypress="focusNext('sex', 'age_month', this,
event)" />hr </td>
</tr>
<tr>
>line('label_sex');?></td>

<td><?php echo $this->lang-
<td>
<select name="sex" id="sex"
style="width:100px;" onkeypress="focusNext('address', 'age_day', this, event)">
<option value="Laki-laki">Laki-
laki</option>
value="Perempuan">Perempuan</option>
</td>
</tr>
<tr>

<option
</select>
>line('label_address');?></td>

<td><?php echo $this->lang-
<td><input type="text" name="address" id="address"
value="" size="40" onkeypress="focusNext('district_id', 'sex', this, event)"
/></td>
</tr>
<tr>

<td><?php echo $this->lang-
>line('label_district');?></td>
<td>

<select name="district_id" id="district_id"
style="width:200px" onchange="get_sub_district(this.value);"
onkeypress="focusNext('sub_district_id', 'address', this, event)" >
<option value="">--- <?php echo $this->lang-
>line('form_change');?> ---</option>

<?php
for($i=0;$i<sizeof($combo_district);$i++) :?>
<?php if($combo_district[$i]['id'] ==
$profile['district_id']) $sel='selected'; else $sel='';?>
<option value="<?php echo
$combo_district[$i]['id']?>" <?php echo $sel;?>><?php echo
$combo_district[$i]['name']?></option>
<?php endfor;?>
<option value="add">--- <?php echo
$this->lang->line('form_add_district');?> ---</option>
</select>
</tr>
<tr>

</td>
<td><?php echo $this->lang-
>line('label_sub_district');?></td>
<td>

<select name="sub_district_id"
id="sub_district_id" style="width:200px" onchange="get_village(this.value);"
onkeypress="focusNext('village_id', 'district_id', this, event)" >
<option value="">--- <?php echo $this-
>lang->line('form_change');?> ---</option>

<option value="add">--- <?php echo
$this->lang->line('form_add_sub_district');?> ---</option>
</select>
</tr>
<tr>
>line('label_village');?></td>

</td>
<td><?php echo $this->lang-
<td>
<select name="village_id" id="village_id"
style="width:200px" onchange="add_village(this.value)"
onkeypress="focusNext('education_id', 'sub_district_id', this, event)" >
<option value="">--- <?php echo $this->lang-
>line('form_change');?> ---</option>
<option value="add">--- <?php echo
$this->lang->line('form_add_village');?> ---</option>
</select>
</table>
</div>

</tr>

</td>
<div style="float:left;width:50%">
<table cellpadding="0" cellspacing="0" border="0" class="tblInput">
<tr>
<td style="width:200px;"><?php echo $this->lang-
>line('label_education');?></td>
<td>
<select name="education_id"
id="education_id" style="width:200px" onkeypress="focusNext('job_id',
'village_id', this, event)">
>lang->line('form_change');?> ---</option>

<option value="">--- <?php echo $this-
<?php
for($i=0;$i<sizeof($combo_education);$i++) :?>
<option value="<?php echo
$combo_education[$i]['id']?>"><?php echo $combo_education[$i]['name']?></option>
<?php endfor;?>
</select>
</tr>
<tr>

</td>
>line('label_job');?></td>

<td><?php echo $this->lang-
<td>
<select name="job_id" id="job_id"
style="width:200px" onkeypress="focusNext('marital_status_id', 'education_id', t
his, event)">
>lang->line('form_change');?> ---</option>
for($i=0;$i<sizeof($combo_job);$i++) :?>

<option value="">--- <?php echo $this-
<?php
<option value="<?php echo
$combo_job[$i]['id']?>"><?php echo $combo_job[$i]['name']?></option>
<?php endfor;?>
</select>
</tr>
<tr>

</td>
<td><?php echo $this->lang-
>line('label_marriedstatus');?></td>
<td>

<select name="marital_status_id"
id="marital_status_id" style="width:200px" onkeypress="focusNext('admission_type
_id', 'job_id', this, event)">
<option value="">--- <?php echo $this-
>lang->line('form_change');?> ---</option>

<?php
for($i=0;$i<sizeof($combo_marriage);$i++) :?>
<option value="<?php echo
$combo_marriage[$i]['id']?>"><?php echo $combo_marriage[$i]['name']?></option>
<?php endfor;?>
</select>
<tr>

</tr>

</td>
<td colspan="2"><hr/></td>
</tr>
<tr>

<td><?php echo $this->lang-
>line('label_admission_type');?></td>
<td>
<select name="admission_type_id"
id="admission_type_id" style="width:200px" onkeypress="focusNext('clinic_id',
'marital_status_id', this, event)">
>lang->line('form_change');?> ---</option>

<option value="">--- <?php echo $this-
<?php
for($i=0;$i<sizeof($combo_admission_type);$i++) :
if($combo_admission_type[$i]['id'] ==
5) $sel = 'selected="selected"'; else $sel='';
?>
<option value="<?php echo
$combo_admission_type[$i]['id']?>" <?php echo $sel;?>><?php echo
$combo_admission_type[$i]['name']?></option>
<?php endfor;?>
</select>
</tr>
<tr>
>line('label_clinic');?></td>

</td>
<td><?php echo $this->lang-
<td>
<select name="clinic_id" id="clinic_id"
style="width:200px" onkeypress="focusNext('payment_type_id',
'admission_type_id', this, event)">
>lang->line('form_change');?> ---</option>

<option value="">--- <?php echo $this-
<?php $k=0;
for($i=0;$i<sizeof($combo_clinic);$i++) :?>
<?php
if($i!=0 && $combo_clinic[$i]['parent_id'] !=
$combo_clinic[$i-1]['parent_id'] && $combo_clinic[$i-1]['parent_id'] != NULL) {
echo '</optgroup>';
}
if($combo_clinic[$i]['parent_id'] != NULL &&
$combo_clinic[$i]['parent_id'] != $combo_clinic[$i-1]['parent_id']) :
echo '<optgroup label="'.$combo_clinic[$i]['parent_name'].'">';
?>
<?php endif;?>
<option value="<?php echo
$combo_clinic[$i]['id']?>"><?php echo $combo_clinic[$i]['name']?></option>
<?php endfor;?>
</select>
</tr>
<tr>

</td>
<td><?php echo $this->lang-
>line('label_payment_type');?></td>
<td>

<select name="payment_type_id"
id="payment_type_id" style="width:200px" onchange="enableDisableInsurance(this)"
onkeypress="focusNext('insurance_no', 'clinic_id', this, event)">
<option value="">--- <?php echo $this-
>lang->line('form_change');?> ---</option>

<?php
for($i=0;$i<sizeof($combo_payment_type);$i++) :?>
<option value="<?php echo
$combo_payment_type[$i]['id']?>"><?php echo
$combo_payment_type[$i]['name']?></option>
</tr>
<tr>

</td>

<?php endfor;?>
</select>
<td><?php echo $this->lang-
>line('label_insurance_no');?></td>
<td><input type="text" name="insurance_no"
id="insurance_no" value="" size="30" onkeypress="focusNext('fee_is_free',
'payment_type_id', this, event)" /></td>
</tr>
<tr>
>line('label_cost');?></td>

<td><?php echo $this->lang-
<td>
<input type="radio" name="fee" id="fee_is_free"
value="free" onkeypress="focusNext('pay', 'insurance_no', this, event);enableDis
ableFee(this)" onclick="enableDisableFee(this)" /><label for="fee_is_free"><?php
echo $this->lang->line('label_free');?></label>
<input type="radio" name="fee" id="fee_is_pay" value="pay" onkeypress="focusNext
('pay', 'insurance_no', this, event);enableDisableFee(this)" onclick="enableDisa
bleFee(this)" /><label for="fee_is_pay"><?php echo $this->lang-
>line('label_pay');?></label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
Rp.<input type="text" name="pay" id="pay" value=""
maxlength="8" size="20" style="text-align:right" /></td>
</tr>
</table>
</div>
<div style="clear:both"></div>
<div style="text-align:center" class="tblInput">
<input type="submit" name="Save" id="save" value="Simpan" />

value="Reset" />
</div>
</div>

<input type="reset" name="Reset" id="reset"
</form>
</div>

<div class="ui-dialog-buttonpane">
<?php echo $this->lang->line('info_ctrl_f_find');?>
</div>
</div>
<div id="search_by_name" style="display:none;z- index:2;position:absolute;backgr
ound-color:#FFFFFF;border:solid 3px
#28530b"></div>
<div id="panel_search" class="ui-dialog"
style="display:none;width:99%;height:auto;position:absolute;z-index:3;top:0;">
<div style="position: relative;" class="ui-dialog-container">
<div class="ui-dialog-titlebar">Pencarian Pasien
<a class="ui-dialog-titlebar-close" href="javascript:void(0)"
id="close_panel_search"></a>
</div>
<div class="ui-dialog-content" style="min-height:490px;">
<form method="POST" name="frmSearch" id="frmSearch"
action="<?php echo site_url('admission/search');?>">
<table cellpadding="0" cellspacing="0" border="0"
class="tblInput">

<tr>

<td style="width:150px"><?php echo $this->lang-
>line('label_keyword');?></td>

<td><input type="text" name="q" id="q" value=""
size="30" onkeypress="focusNext('search_district_id', 'search_village_id', this,
event)" /></td>
</tr>
<tr>

<td><?php echo $this->lang-
>line('label_district');?></td>
<td>

<select name="search_district_id"
id="search_district_id" style="width:200px" onchange="get_sub_district_for_searc
h(this.value)" onkeypress="focusNext('search_sub_district_id', 'q', this, event)
" >
<option value="">--- <?php echo $this->lang-
>line('form_all');?> ---</option>
<?php for($i=0;$i<sizeof($combo_district);$i++) :?>
<?php if($combo_district[$i]['id'] ==
$profile['district_id']) $sel='selected'; else $sel='';?>
<option value="<?php echo
$combo_district[$i]['id']?>" <?php echo $sel;?>><?php echo
$combo_district[$i]['name']?></option>
</tr>
<tr>

</td>

<?php endfor;?>
</select>
<td><?php echo $this->lang-
>line('label_sub_district');?></td>
<td>
<select name="search_sub_district_id" id="search_sub_district_id" style="width:2
00px" onchange="get_village_for_search(this.value);" onkeypress="focusNext('sear
ch_village_id', 'search_district_id', this, event)" >
<option value="">--- <?php echo $this->lang-
>line('form_all');?> ---</option>
</tr>
<tr>

</td>

</select>
>line('label_village');?></td>

<td><?php echo $this->lang-
<td>
<select name="search_village_id"
id="search_village_id" style="width:200px"
onkeypress="focusNext('submit_search', 'search_sub_district_id', this, event)" >
<option value="">--- <?php echo $this->lang-
>line('form_all');?> ---</option>
</tr>
<tr>

</td>

</select>
<td></td><td><div style="float:left;"><input type="submit" name="Search" id="sub
mit_search" value="Cari" /></div>
<div id="divLoadingSearch" class="divLoading"
style="display:none">Loading...</div></td>
</tr>
</table>
</form>
<div id="divSearchResult"></div>
</div>
?>

</div>
<div class="ui-dialog-buttonpane">
<?php echo $this->lang->line('label_press_esc_to_close');?>
</div>
</div>
</div>
?>