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@@ -2,53 +2,53 @@
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<a start show><i class="fas fa-edit"></i></a>
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<form url="/api/client/putRmReasons" class="mcp-theme-1">
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<input type="hidden" name="uid" value="{{$patient->uid}}">
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- <div class="bg-light p-3 mb-2">
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 1</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-code data-target="input[name=rmReasonIcd1Description]" name="rmReasonIcd1" value="{{ $patient->rm_reason_icd1 }}" />
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- </div>
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 1 Description</label>
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- <input id="" type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd1Description" value="{{ $patient->rm_reason_icd1description }}">
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- </div>
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- </div>
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-
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- <div class="bg-light p-3 mb-2">
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 2</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd2" data-target="input[name=rmReasonIcd2Description]" value="{{ $patient->rm_reason_icd2 }}" />
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- </div>
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 2 Description</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd2Description" value="{{ $patient->rm_reason_icd2description }}">
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- </div>
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- </div>
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-
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- <div class="bg-light p-3 mb-2">
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 3</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd3" data-target="input[name=rmReasonIcd3Description]" value="{{ $patient->rm_reason_icd3 }}" />
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- </div>
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 3 Description</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd3Description" value="{{ $patient->rm_reason_icd3description }}">
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- </div>
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- </div>
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- <div class="bg-light p-3 mb-2">
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 4</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd4" data-target="input[name=rmReasonIcd4Description]" value="{{ $patient->rm_reason_icd4 }}" />
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- </div>
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Icd 4 Description</label>
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- <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd4Description" value="{{ $patient->rm_reason_icd4description }}">
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- </div>
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+ <div>
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+ <table class="table table-sm table-bordered">
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+ <thead class="bg-light">
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+ <tr>
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+ <th class="border-bottom-0">ICD</th>
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+ <th class="border-bottom-0">Description</th>
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+ </tr>
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+ </thead>
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+ <tbody>
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+ <tr>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-code data-target="input[name=rmReasonIcd1Description]" name="rmReasonIcd1" value="{{ $patient->rm_reason_icd1 }}" placeholder="ICD 1" />
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+ </td>
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+ <td>
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+ <input id="" type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd1Description" value="{{ $patient->rm_reason_icd1description }}">
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+ </td>
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+ </tr>
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+ <tr>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd2" data-target="input[name=rmReasonIcd2Description]" value="{{ $patient->rm_reason_icd2 }}" placeholder="ICD 2" />
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+ </td>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd2Description" value="{{ $patient->rm_reason_icd2description }}">
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+ </td>
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+ </tr>
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+ <tr>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd3" data-target="input[name=rmReasonIcd3Description]" value="{{ $patient->rm_reason_icd3 }}" placeholder="ICD 3" />
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+ </td>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd3Description" value="{{ $patient->rm_reason_icd3description }}">
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+ </td>
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+ </tr>
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+ <tr>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-code name="rmReasonIcd4" data-target="input[name=rmReasonIcd4Description]" value="{{ $patient->rm_reason_icd4 }}" placeholder="ICD 4" />
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+ </td>
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+ <td>
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+ <input type="text" class="form-control form-control-sm" icd-autocomplete-description name="rmReasonIcd4Description" value="{{ $patient->rm_reason_icd4description }}">
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+ </td>
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+ </tr>
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+ </tbody>
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+ </table>
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</div>
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- <div class="bg-light p-3 mb-2">
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- <div class="mb-2">
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- <label class="text-sm mb-1 text-secondary">RM Reason Memo</label>
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- <input type="text" class="form-control form-control-sm" name="rmReasonMemo" value="{{ $patient->rm_reason_memo }}">
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- </div>
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+ <div class="mb-2">
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+ <label class="font-weight-bold mb-1">RM Reason Memo:</label>
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+ <input type="text" class="form-control form-control-sm" name="rmReasonMemo" value="{{ $patient->rm_reason_memo }}">
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</div>
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<div>
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<button submit class="btn btn-sm btn-primary mr-1">Submit</button>
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