171 lines
10 KiB
PHP
171 lines
10 KiB
PHP
@extends('layouts.app')
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@push('styles')
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<link href="https://cdn.jsdelivr.net/npm/select2@4.1.0-rc.0/dist/css/select2.min.css" rel="stylesheet" />
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<style>
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.select2-container--default .select2-selection--single {
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height: 38px !important;
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}
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</style>
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@endpush
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@section('content-header')
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<div class="content-header">
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<div class="container-fluid">
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<div class="row mb-2">
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<div class="col-sm-6">
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<h1 class="m-0">Edit Registrasi Pasien</h1>
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</div>
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<div class="col-sm-6">
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<ol class="breadcrumb float-sm-right">
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<li class="breadcrumb-item"><a href="#">Home</a></li>
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<li class="breadcrumb-item active">Edit Registrasi Pasien</li>
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</ol>
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</div>
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</div>
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</div>
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</div>
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@endsection
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@section('main-content')
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<div class="row">
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<div class="col-12">
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<div class="card card-primary">
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<div class="card-header">
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<h3 class="card-title">Form Edit Registrasi Pasien</h3>
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</div>
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<form action="{{ route('patient-registration.update', $registration->id) }}" method="POST">
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@csrf
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@method('PUT')
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<div class="card-body">
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<div class="row">
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<!-- Left Column -->
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<div class="col-md-6">
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<div class="form-group">
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<label>Tanggal Registrasi <strong class="text-danger">*</strong></label>
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<input name="registration_date" type="date" class="form-control"
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value="{{ old('registration_date', $registration->registration_date) }}" required>
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@error('registration_date')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Pasien <strong class="text-danger">*</strong></label>
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<select name="patient_id" class="form-control select2" required>
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<option value="">-- Pilih Pasien --</option>
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@foreach ($patients as $patient)
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<option value="{{ $patient->id }}"
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{{ old('patient_id', $registration->patient_id) == $patient->id ? 'selected' : '' }}>
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{{ $patient->first_name }} {{ $patient->last_name }}
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</option>
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@endforeach
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</select>
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@error('patient_id')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Asuransi <strong class="text-danger">*</strong></label>
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<select name="insurance_id" class="form-control" required>
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<option value="">-- Pilih Asuransi --</option>
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@foreach ($insurances as $insurance)
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<option value="{{ $insurance->id }}"
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{{ old('insurance_id', $registration->insurance_id) == $insurance->id ? 'selected' : '' }}>
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{{ $insurance->name }}
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</option>
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@endforeach
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</select>
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@error('insurance_id')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>No. Asuransi <strong class="text-danger">*</strong></label>
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<input name="insurance_number" type="number" class="form-control"
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value="{{ old('insurance_number', $registration->insurance_number) }}" required>
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@error('insurance_number')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Ruangan Layanan <strong class="text-danger">*</strong></label>
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<select name="service_room_id" class="form-control" required>
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<option value="">-- Pilih Ruangan --</option>
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@foreach ($serviceRooms as $serviceRoom)
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<option value="{{ $serviceRoom->id }}"
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{{ old('service_room_id', $registration->service_room_id) == $serviceRoom->id ? 'selected' : '' }}>
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{{ $serviceRoom->name }}
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</option>
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@endforeach
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</select>
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@error('service_room_id')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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</div>
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<!-- Right Column -->
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<div class="col-md-6">
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<div class="form-group">
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<label>Nama Penanggung Jawab <strong class="text-danger">*</strong></label>
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<input name="responsible_person_name" type="text" class="form-control"
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value="{{ old('responsible_person_name', $registration->responsible_person_name) }}"
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required>
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@error('responsible_person_name')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>No. HP Penanggung Jawab <strong class="text-danger">*</strong></label>
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<input name="responsible_person_phone" type="text" class="form-control"
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value="{{ old('responsible_person_phone', $registration->responsible_person_phone) }}"
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required>
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@error('responsible_person_phone')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Email Penanggung Jawab <strong class="text-danger">*</strong></label>
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<input name="responsible_email" type="email" class="form-control"
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value="{{ old('responsible_email', $registration->responsible_email) }}" required>
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@error('responsible_email')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Hubungan dengan Pasien <strong class="text-danger">*</strong></label>
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<input name="responsible_person_relationship" type="text" class="form-control"
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value="{{ old('responsible_person_relationship', $registration->responsible_person_relationship) }}"
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required>
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@error('responsible_person_relationship')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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<div class="form-group">
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<label>Alamat Penanggung Jawab <strong class="text-danger">*</strong></label>
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<textarea name="responsible_person_address" class="form-control" rows="3" required>{{ old('responsible_person_address', $registration->responsible_person_address) }}</textarea>
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@error('responsible_person_address')
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<small style="color: red;">{{ $message }}</small>
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@enderror
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</div>
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</div>
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</div>
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</div>
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<div class="card-footer">
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<button type="button" class="btn btn-primary" onclick="history.back()">Kembali</button>
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<button type="submit" class="btn btn-success">Update</button>
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</div>
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</form>
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</div>
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</div>
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</div>
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@endsection
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@push('scripts')
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<script src="https://cdn.jsdelivr.net/npm/select2@4.1.0-rc.0/dist/js/select2.min.js"></script>
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<script>
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$(document).ready(function() {
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$('.select2').select2({
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placeholder: "-- Pilih Pasien --",
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allowClear: true,
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width: '100%',
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});
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});
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</script>
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@endpush
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