Admission.html

<htmlform formUuid="fc803dd8-aa3c-4de9-bd87-64ea7c947ae4" formName="Admissions" formEncounterType="d02513f0-8b7a-4040-9dbf-7a1eb62cc271" formVersion="1.0">
    <style>
        .background {
        background-color: #888;
        }
        table.hospt {
            border-collapse: collapse;
            background-color: #000;
        }
        table.hospt > tbody > tr > td, table.hospt > tbody > tr > th {
            border: 0;
            vertical-align: baseline;
            padding: 2px;
            text-align: left;
            background-color: #F3F9FF;
        }
    </style>
    <script type="text/javascript">
        jq(function () {
            jq('input[type="checkbox"]').on('change', function() {
                jq(this).siblings('input[type="checkbox"]').prop('checked', false);
            });
        });

    </script>
    <h2>Hospitalization Form for BKKH</h2>
<div class="background">
    <div>
        <table class="hospt">
            <tbody>
                <tr>
                    <td>Admission Date<encounterDate id="encounterDate" default="now" disallowMultipleEncountersOnDate="block"/></td>
                    <td>Discharge Date<obs conceptId="1641" allowTime="false" defaultDatetime="now"/></td>
                </tr>
            </tbody>
        </table>
    </div>
    <div>
        <table class="hospt">
            <tbody>
                <tr>
                    <td>
                        <uimessage code="coreapps.patientDashBoard.provider"/>
                        <encounterProvider default="currentUser" required="true"  />
                    </td>
                    <td>
                        <uimessage code="coreapps.patientDashBoard.location"/>
                        <encounterLocation default="24"/>
                    </td>
                </tr>
            </tbody>
        </table>
    </div>

    <br />
    <div>
        <repeat>
            <template>
                <table class="hospt">
                    <tbody>
                        <tr>
                            <td>
                                Diagnosis: <obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Diagnosis" style="autocomplete" />
                            </td>
                            <td>
                                <obs conceptId="159946AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159943AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Primary" style="checkbox" />
                                <obs conceptId="159946AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159944AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Secondary" style="checkbox" />

                            </td>
                        </tr>
                    </tbody>
                </table>
            </template>
            <render n="1" concept="Diagnosis"/>
            <render n="2" concept="Diagnosis"/>
            <render n="3" concept="Diagnosis"/>
        </repeat>
    </div>

    <div>
        <table class="hospt">
            <tbody>
                <tr>
                    <td>
                        <p>
                            <label><uimessage code="coreapps.consult.freeTextComments"/></label>
                            <obs conceptId="CIEL:162169" style="textarea" rows="5"/>
                        </p>
                    </td>
                </tr>
            </tbody>
        </table>
    </div>


</div>
    <ifMode mode="VIEW" include="false">
        <div id="buttons">
            <submit submitClass="confirm right" submitCode="general.save"/>
            <button type="button" class="cancel"><uimessage code="general.cancel"/></button>
        </div>
    </ifMode>

</htmlform>