Anda di halaman 1dari 2

UPTD PUSKESMAS DTP KARANGNUNGGAL

UNIT GAWAT DARURAT


Jln. Raya Karangnunggal No. 12 Tlp ( 0265 ) 580 113

PRO JUSTITIA

DATA KORBAN :
Nama : Nn. Sri Rahayu
Umur : 16 thn L/P
Alamat : Kp : Bojong Rt / Rw : 03 / 04
: Desa / Kelurahan : Ciawi
Kecamatan : Karangnunggal
Kabupaten / Kota : Tasikmalaya
Pekerjaan : Pelajar SMP N IV Cikapinis
Diagnosa : ..........................................................................................
..........................................
Dokter Pemeriksa : Dr. H. Jaka H
Hari / Tanggal Kejadian : Minggu tgl 04 Januari 2015

Dislokasi /
Fractur
scavula
dextra

Luka lecet
pada
tangan seb
kanan
Luka lecet
pada betis
dan punggung
kaki seb
kanan

KRONOLOGIS KERJADIAN :

............................................................................................... ..........................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
C
................................................................................................................................................
Catatan : Data korban diisi Form.
..............................................................................................................................................
dengan detail .
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
..................................................................
................................................................................................................................................
Karangnunggal, 04 - 01 - 2015
..................................................................
................................................................................................................................................
Petugas Jaga
..................................................................
................................................................................................................................................
( ..Tatang, HS...)
..................................................................