PEMERINTAH KABUPATEN PULAU MOROTAI

DINAS KESEHATAN DAN KELUARGA BERENCANA

PUSKESMAS SANGOWO
Jl. Hi. Idris No 1, Kode Pos 97771
MOROTAI TIMUR email : puskesmassangowo@gmail.com

PRO JUSTITIA
VISUM ET
REPERTUM
No. : ....... ........ ....... / Tahun 2023

Berdasarkan surat permintaan dari Kepolisian Resort Pulau Morotai, yang ditandatangani
oleh …………………… nama: ............................................., NRP : ... ..... ...... ...... .. pa ngkat: .... ...... ......
..... ...... ..... .., ja batan : .... ...... ..... ...... ... no mor sura t : ... .... .... .... ... .... .... ., tanggal surat : ...
.... .... ... .... .... .... ... .... .... .... .. Tentang Permintaan Visum Et Repertum dengan identitas sebagai
berikut :
Nama :
Jenis Kelamin :
Umur :
Pekerjaan :
Alamat :

maka Tim Kedokteran Forensik dan Medikolegal Fakultas Kedokteran Uni- versitas Gadjah
Mada Yogyakarta yang terdiri dari dokter: ............................ beserta staf dari Bagian Ilmu
Kedokteran Forensik dan Medikolegal Fakulta s Ke do kt eran U nive rs itas Gad ja h Ma
da Yog ya ka rta/ In stalas i Kedokteran Forensik RSUP UGM Dr. Sardjito pada hari :
...................., tanggal
.. .. .. .. .. .. .. .. .. .. .. .. mu la i pu ku l .. .. .. .. .. .. .. .. .. .. . sa mp ai p uk
ul .. .. .. .. .. .. .. .. .. .. . m elak uk an b on gk ar m ak
am d i .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
pemeriksaan luar dan dalam serta identifikasi di ruang otopsi RSUP
UGM D r. S ard j it o, t er ha da p alma rh um /a lm ar
hu ma h Na ma : . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. b in
/b in ti . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . Umur : ......... tahun
Jenis Kelamin : ...............Agama : ............................. Alam at
: . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
. .. .. .. .. .. .. .
.......................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a ki ba t pe ri st iw
a .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
.. .. .. .. .. .
.......................................................................
...............................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Visum
. . . . . Et
. . .Repertum
. . . . . . . .
. . . . . . 1. .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hasil pemeriksaan itu
ialah sebagai berikut:

Keadaan makam : Puntukan makam almarhum/almarhumah*), terletak di makam :

......................................................................... Desa :
............................................................................... Kelurahan : ...............................................
Kecamatan : ................................................................. Kabupaten :
............................................. Provinsi :
Batas-batas
makam :
- Timur :
.....................................................................................................................................................
- Barat :
......................................................................................................................................................
- Utara :
.....................................................................................................................................................
- Selatan
: .................................................................................................................................................

Visum Et Repertum  2

 Pa da pembongkaran sedalam __ _ __ __ _ __ _ __ da pa t di li ha t a danya __ _ __ __ _ __ _
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
Bungkus jenazah diangkat, diletakkan di atas _______________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ unt uk p emer i ksa a n s
ela n jutn ya uk ura n li a ng m a ka m ; _ _ _ _ _ _ _ _ _ _ _ _ _ x _ _ _ _ _ _ _ _ _ _ _ _ x _ _
_______________ cm

I I . PEMERIKSAAN TEMPAT KEJADIAN PERKARA:

1. Keadaan korban sudah meninggal / masih hidup : _____________________________________________
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
2. Keadaan sekitar korban : ________________________________________________________________________
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
3. Pengambilan barang bukti untuk pemeriksaan lebih lanjut : __________________________________
_______________________________________________________________________________________________________ _
4. Korban dikirim : _________________________________________________________________________________ _
_______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _

III. PEMERIKSAAN LUAR :

1. Keadaan jenazah : Je na za h ta k be rla b el t erle ta k di a ta s; _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ di b
ungk us dengan__________ Bungkus dibuka, jenazah dalam keadaan telanjang /
memakai (diceritakan semua yang melekat pada si korban) :
_______________________________

______________________________________________________________________________________ _
______________________________________________________________________________________ _
2. Sikap jenazah : terlentang/tengkurap, dengan muka menghadap ke ; ____________; di
meja otopsi/ lengan kanan atas terhadap bawah membentuk sudut; ___________; di
tempat kejadian dengan tangan kanan ______________, lengan kiri atas terhadap
peristiwa lengan bawah membentuk sudut; _________ dengan tangan kiri; ______ tungkai
ka nan; ___ ___ ___ tungkai kiri ; _ ___ __ ___ ___ __ (tela pak tangan menghada p)
3. Kaku jenazah : Tak / terdapat pada persendian ____________________________________________________
sukar/mudah digerakkan ____________________________________________________________
4. Bercak jenazah : tak / terdapat pada ; ________________________________________________________________
(lebam) hilang/tak hilang pada penekanan, warna
5. Pembusukan : Ada / tidak
jenazah
6. Ukuran jenazah : Pa nja ng : _ _ _ _ _ _ c m, bera t : _ _ _ _ _ _ _ _ _ _ kg
Bayi : Lingkaran kepala : - Fronto occipitale ; ___________ cm
- mento occipitale ; ___________ cm
- lingkar dada ; ___________ cm
- panggul ; ___________ cm
7. Kepala
a. Rambut : Wa rna _ _ _ _ _ _ _ _ _ _ _ _ _ ta k / beruba n, pa nja ng; _ _ _ _ _ _ _ _ _ _ c m
mudah / sukar dicabut, dalam keadaan ____________________________________________

Visum Et Repertum  3

b. Bagian yang tertutup rambut
- Terdapat adanya luka, ukuran ______________________________________________________
- di Bagian ____________________________________________________________________________ _
- Ha e moto m uk ura n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ di ba g i a n
______________________________________________________________________________________ _
- ret a k t ula n g uk ura n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ di ba gi a n
______________________________________________________________________________________ _

c. Dahi : Terdapat adanya ____________________________________________________________________

______________________________________________________________________________________ _ luka
_________________________________________________________________________________ _
haematom ___________________________________________________________________________
Retak tulang _________________________________________________________________________

d. Mata kanan : Menutup/membuka : ________________________________________________________

Rambut mata : ________________________________________________________
Kelopak mata bagian luar : ________________________________________________________
bagian dalam : ________________________________________________________
warna kemerahan/pucat : ________________________________________________________
Sekitar mata / warna : ________________________________________________________
Pada perabaan teraba : ________________________________________________________
retak tulang ___________________________________________
________________________________________________________
Cornea mata : ________________________________________________________
Sclera warna : ________________________________________________________
Pupil ukuran : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ mm ___________________________
Bola mata tampak : ________________________________________________________ dan
pada perabaan : ________________________________________________________

Mata kiri Menutup/membuka : ________________________________________________________

Rambut mata : ________________________________________________________
Kelopak mata bagian luar : ________________________________________________________
bagian dalam : ________________________________________________________
warna kemerahan/pucat : ________________________________________________________
Sekitar mata / warna : ________________________________________________________
Pada perabaan teraba : ________________________________________________________
retak tulang ___________________________________________
________________________________________________________
Cornea mata : ________________________________________________________
Sclera warna : ________________________________________________________
Pupil ukuran : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ mm ___________________________
Bola mata tampak : ________________________________________________________ dan
pada perabaan : ________________________________________________________

e. HIDUNG : Dari kedua lubang tak / keluar cairan ______________________________________________

______________________________________________________________________________________ _
______________________________________________________________________________________ _ te
rda p a t a da ny a lu ka _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ ha ema t oom _____________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ret a k t ula n g ___________________________
__________________________

Visum Et Repertum  4

 f. MULUT : Da la m kea da an terbuka/ tertutup _ _ _ __ _ _ _ __ _ _ __ c m, denga n gi gi
__________
_____________ kelihatan. Dari lubang mulut keluar cairan ______________________
______________________________________________________________________________________ _
Bibir atas terdapat adanya luka ____________________________________________________
______________________________________________________________________________________ _
ha ema t om ____________________________________________
___________
______________________________________________________________________________________ _ B i b
ir bawah ___________________________________________
_ _ _ _ _ _ _ _ _ _ _ Lidah tergigit dalam keadaan tak / menjulur keluar, terdapat
adanya luka-luka
______________________________________________________________________________________ _
______________________________________________________________________________________ _
haematom ___________________________________________________________________________
Dalam mulut ________________________________________________________________________ _
dengan gigi-gigi _____________________________________________________________________
______________________________________________________________________________________ _

g. DAGU : Terdapat adanya rambut ___________________________________________________________

______________________________________________________________________________________ _
haematom ___________________________________________________________________________
retak tulang ________________________________________________________________________ _
______________________________________________________________________________________ _

h. PIPI : Terdapat adanya luka _______________________________________________________________

______________________________________________________________________________________ _
haematom ___________________________________________________________________________
retak tulang ________________________________________________________________________ _

i TELINGA : Daun telinga _________________________________________________________________________

______________________________________________________________________________________ _
retak tulang ________________________________________________________________________ _

8. LEHER : Tidak ada / Terdapat jejas / bekas jeratan _________________________________________

______________________________________________________________________________________ _ luka
_________________________________________________________________________________ _
haematom ___________________________________________________________________________
retak tulang ________________________________________________________________________ _

9. DADA : Terdapat adanya luka _______________________________________________________________

______________________________________________________________________________________ _
haematom __________________________________________________________________________ _ ada
perabaan terdapat retak tulang _______________________________________________
______________________________________________________________________________________ _
pada ketukan _______________________________________________________________________ _

10. PERUT : Permuka a n _ _ _ _ _ __ _ _ _ _ __ _ _ _ _ __ _ _ _ _ ti nggi dengan permuka a n da da

_______
______________________________________________________________________________________ _
Pada daerah perut sebelah kanan / kiri bawah ____________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ terl i ha t w a r na
__________________________________________ Visum Et Repertum  5
______________________________________________________________________________________ _
 Pusat datar/menonjol _______________________________________________________________
Luka-luka ___________________________________________________________________________ _
Haematoom ________________________________________________________________________ _
Pada perabaan teraba ______________________________________________________________
Pada ketokan ________________________________________________________________________

11. Alat Kelamin : Jenis rambut laki-laki / perempuan, sudah / tidak disunat _________________________
Rambut kelami n warna ________ ___ lurus / keri ting, pa njang __ ________ _ cm
Mudah / sukar dicabut ______________________________________________________________
Pada lubang zakar __________________________________________________________________ Dari
lubang kelamin tidak / keluar _________________________________________________
______________________________________________________________________________________ _
Pada kantong pelir terlihat adanya ________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ bua h pel i r
________________________________________________________ Pada saluran liang senggama
(vagina) _____________________________________________
______________________________________________________________________________________ _
Pada pemeriksaan dalam ___________________________________________________________
______________________________________________________________________________________ _
Pada pemeriksaan dalam ___________________________________________________________
______________________________________________________________________________________ _

12. Anggota Atas : ______________________________________________________________________________________ _

Kanan : Lengan atas (luka, haematoom, retak tulang) _____________________________________
______________________________________________________________________________________ _
Lengan bawah _______________________________________________________________________
______________________________________________________________________________________ _
Tangan _______________________________________________________________________________
______________________________________________________________________________________ _ Kiri
: Lengan atas ________________________________________________________________________ _
Lengan bawah _______________________________________________________________________
Tangan _______________________________________________________________________________

13. Anggota bawah : ______________________________________________________________________________________ _

Kanan : Paha ________________________________________________________________________________ _
______________________________________________________________________________________ _
Tungkai bawah ______________________________________________________________________
______________________________________________________________________________________ _
Kaki _________________________________________________________________________________ _
______________________________________________________________________________________ _

Kiri : Paha _________________________________________________________________________________

______________________________________________________________________________________ _
Tungkai bawah ______________________________________________________________________
______________________________________________________________________________________ _
Kaki _________________________________________________________________________________ _
______________________________________________________________________________________ _
14. Punggung : Luka-luka ___________________________________________________________________________ _
______________________________________________________________________________________ _
Haematoom ________________________________________________________________________ _

Visum Et Repertum  6

 Retak tulang ________________________________________________________________________ _

15. Pantat : Luka-luka ____________________________________________________________________________

haematom ___________________________________________________________________________
retak tulang ________________________________________________________________________ _

16. Dubur : sekitar dubur ________________________________________________________________________

17. Bagian tubuh yang lain : ______________________________________________________________________________________ _

______________________________________________________________________________________ _

II I. PEMERIKSAAN DALAM _____________________________________________________________________________________ _

IV. Pemeriksaan mikroskopis: (semua organ) __________________________________________________________________

_______________________________________________________________________________ _
_______________________________________________________________________________ _
_______________________________________________________________________________ _

V. Pemeriksaan Laboratorium : _______________________________________________________________________________ _

_______________________________________________________________________________ _
_______________________________________________________________________________ _
_______________________________________________________________________________ _

VI. Pemeriksaan konsultasi lain-lain : ___________________________________________________________________________

_______________________________________________________________________________ _
_______________________________________________________________________________ _
_______________________________________________________________________________ _
_______________________________________________________________________________ _

VII. Kesimpulan : _______________________________________________________________________________ _

_______________________________________________________________________________ _
_______________________________________________________________________________ _
_______________________________________________________________________________ _

Demikian Visum et Repertum ini dibuat dengan mengingat sumpah pada

waktu menerima jabatan dan Undang-undang No.8 tahun 1981 _________
_______________________________________________________________________________ _

Tanda tangan

(do kter : ____________________

_ _ ) Nama lengkap

Visum Et Repertum  7

Visum Et Repertum  8