Visum Korban Hidup (PL)
Visum Korban Hidup (PL)
Kotabumi, _________________
Nomor : / / KFM/ / 2015
Lampiran :
Ikhwal : Pemeriksaan luar korban hidup
An. _______________________
VISUM ET REPERTUM
PRO JUSTITIA
Permintaan-----------------------------------------------------------------------------------------
Tanggal permintaan;________________, No Polisi;_____________________,
Perihal; Permintaan Visum et Repertum pemeriksaan luar korban hidup An.
____________________________, Penyidik;___________________,
Pangkat;___________________, NRP;_______________,
Jabatan;________________________, Instansi;____________________________,
Penjelasan;_________________________________________________,
padahari_________, tanggal;_______________, sekitar jam;_______ wib, dengan
kondisi korban;_______________________________________________________
____________________________________________________________________
_______________________________------------------------------------------------------
Pemeriksa:----------------------------------------------------------------------------------------
Nama;_____________________________, NIP;______________________,
Instalasi;____________________________ RSUD Mayjed. HM Ryacudu kotabumi,
Tanggal pemeriksaan;__________________, Jam pemeriksaan;_______ wib,
Korban diantar oleh;_______________, Jenis pemeriksaan;
Pemeriksaan____________________________---------------------------------------------
---------------
PEMBERITAAN
Keadaan Umum----------------------------------------------------------------------------------
1 Kesadaran;_______________________________--------------------------------------
2 Pernafasan;_______________________________-------------------------------------
3 Detak nadi;_______________________________-------------------------------------
4 Tekanan darah;____________________________-------------------------------------
5 Tinggi badan;_____________________________--------------------------------------
6 Berat badan;______________________________-------------------------------------
7 Hari Pertama Haid Terakhir (HPHT);______________--------------------------------
1
Benda-benda---------------------------------------------------------------------------------------
8 Penutup tubuh korban;________________________________----------------------
9 Alas tubuh korban;___________________________________----------------------
10 Pakaian korban;_____________________________________ ----------------------
11 Benda di tubuh korban;_______________________________ ----------------------
12 Perhiasan korban;___________________________________ -----------------------
13 Benda sekitar tubuh korban;___________________________ ---------------------
Identifikasi----------------------------------------------------------------------------------------
14 Identifikasi umum ; Dijumpai seorang korban hidup dikenal, jenis
kelamin_______________, umur ___________, warna kulit _______________,
tinggi badan_______________________, berat badan_______________, rambut
sepanjang______________, bentuk____________, warna ______________-----
15 Identifikasi khusus;__________________________________-----------------------
Pemeriksaan luar---------------------------------------------------------------------------------
16 Kepala;_____________________________________________--------------------
17 Dahi;_________________________________________________------------------
18 Mata;_____________________________-----------------------------------------------
19 Hidung;_______________________________________-----------------------------
20 Pipi;________________________________--------------------------------------------
21 Telinga;________________________________----------------------------------------
22 Mulut;___________________________________-------------------------------------
23 Gigi;______________________________________________-----------------------
24 Rahang;________________________________----------------------------------------
25 Leher;_______________________________________________-------------------
26 Dada;_______________________________________________________--------
27 Perut;_____________________________________________________-----------
28 Alat kelamin;_________________________________--------------------------------
29 Punggung;________________________________-------------------------------------
30 Pinggang;______________________________________-----------------------------
31 Bokong;_________________________________--------------------------------------
32 Dubur;________________________________-----------------------------------------
33 Anggota gerak atas;_______________________---------------------------------------
34 Anggota gerak bawah;__________________________--------------------------------
35 Hasil Pameriksaan Tambahan;______________________--------------------------
KESIMPULAN
Telah diperiksa seorang korban hidup dikenal, jenis kelamin_________________,
umur__________tahun, warna kulit_______________, tinggi
badan__________________________, tinggi badan________________, rambut
sepanjang_______________, bentuk_____________, warna_________________----
2
akibat kekerasan___________, sehingga korban mengalami derajad
luka____________----------------------------------------------------------------------------
Dr.
Nip.