PRO JUSTITIA

DATA KORBAN :
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Diagnosa : ..........................................................................................
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Dokter Pemeriksa : ..........................................................................................
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Hari / Tanggal Kejadian : ..........................................................................................
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VISUM ET REPERTUM
KRONOLOGIS KERJADIAN :

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Karangnunggal, ................................................ 2017
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Petugas Jaga
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Kronologis kematian pasien KLL

Korban datang ke UGD pada jam 16.30 wib dalam keadaan ngorok, korban akibat terjatuh dari
speda motor di daerah Parungpung , Desa Parakan Honje, Kec Bantarkalong. Korban terjatuh
dalam keadaan telungkup, terdapat luka :
1. Tulang hidung retak
2. Keluaran darah dari hidung
3. Kedua belah mata bengkak kebiruan
4. Tulang gusi bagian atas sampai tulang palatum retak
Pemeriksaan vital :
TD : 90 / 60 mmHg
Pols : 98 X/ menit
Respirasi : 26 X/menit
Temp : 35,6 0c
Tindakan :
1. Pemberian Oxygen 4 lt
2. Pemberian Cairan intravena
Saran dari dokter jaga : Rujuk ke RS Tasikmalaya.
Belum sempat dirujuk pada jam 17,15 wib korban meninggal dunia didepan petugas dan
keluarga, dokter jaga mengetahui.
Data Korban :
Nama : Sdr. Gilang R
Umur : 15 tahun
Pekerjaan : Pelajar Tsanawiah Pamijahan
Alamat rumah : Kp Parungpung, Desa Pamijahan, Kec Bantarkalong
 Karangnunggal; 12 Maret 2017

Petugas Jaga

ERIK NUR ARIFIN