RUMAH SAKIT

Hi. MUHAMMAD YUSUF

Jl. Lintas Sumatera No.12 Kalibalangan- Lampung Utara
Telp: (0724) 326023, Email: rs.hmy2011@gmail.com
SITU No : 503.7.2/15-04/37-LU/2011
IMB No : 503/054-04/37-LU/2011

DATA REKAM MEDIS

PRA VISUM VISUM ET REPERTUM
KORBAN HIDUP

Permintaan
Nama peminta (penyidik) :_______________________________________
NRP :_______________________________________
Pangkat/jabatan :_______________________________________
Instansi :_______________________________________
Tgl/bln/thn permintaan :_______________________________________
Jam Permintaan :_______________________________________
No.permintaan (Ver) :_______________________________________
Perihal permintaan :_______________________________________
Penjelasan :_______________________________________

Pemeriksa
Nama pemeriksa :_______________________________________
NIP/NRPTT :_______________________________________
Instalasi :_______________________________________
Tgl/bln/thn pemeriksaan :_______________________________________
Jam pemeriksaan :_______________________________________
Jenis pemeriksaan :_______________________________________

Identitas korban
Nama :_______________________________________
Jenis kelamin :_______________________________________
Umur :_______________________________________
Agama :_______________________________________
Pekerjaan :_______________________________________
Status perkawinan :_______________________________________
Alamat :_______________________________________
Korban diantar oleh :_______________________________________
Korban di temukan di :_______________________________________
Hari :_______________________________________
Tgl/bln/thn :_______________________________________
Jam :_______________________________________
Alamat pengantar :_______________________________________
(sesuai ktp/sim, dll)
No. telp dan hp :_______________________________________

Keadaan umum
Kesadaran :_______________________________________
Pernafasan :_______________________________________
Detak nadi :_______________________________________
Tekanan darah :_______________________________________
Tinggi badan :_______________________________________
Berat badan/status gizi :_______________________________________
 RUMAH SAKIT
Hi. MUHAMMAD YUSUF
Jl. Lintas Sumatera No.12 Kalibalangan- Lampung Utara
Telp: (0724) 326023, Email: rs.hmy2011@gmail.com
SITU No : 503.7.2/15-04/37-LU/2011
IMB No : 503/054-04/37-LU/2011

Benda-benda
Penutup tubuh korban :_______________________________________
_______________________________________
Alas tubuh korban :_______________________________________
_______________________________________
Pakaian korban :_______________________________________
_______________________________________
Benda di tubuh korban :_______________________________________
_______________________________________
Perhiasan korban :_______________________________________
_______________________________________
Benda sekitar tubuh korban :_______________________________________
_______________________________________

Identifikasi
Identifikasi umum :_______________________________________
_______________________________________
Identifikasi khusus :_______________________________________
_______________________________________
Pemeriksaan luar
Kepala :_______________________________________
Dahi :_______________________________________
Mata :_______________________________________
Hidung :_______________________________________
Pipi :_______________________________________
Telinga :_______________________________________
Mulut :_______________________________________
Gigi :Gigi geligi berjumlah_______________
Rahang :_______________________________________
Leher :_______________________________________
Dada :_______________________________________
Perut :_______________________________________
Alat kelamin :_______________________________________
Punggung :_______________________________________
Pinggang :_______________________________________
Panggul :_______________________________________
Bokong :_______________________________________
Dubur :_______________________________________
Anggota gerak atas :_______________________________________
Anggota gerak bawah :_______________________________________

Pemeriksaan tambahan
1. jenis pemeriksaan
Tujuan pemeriksaan
2. jenis pemeriksaan
Tujuan pemeriksaan
:_______________________________________
:_______________________________________
:_______________________________________
:_______________________________________
 RUMAH SAKIT
Hi. MUHAMMAD YUSUF
Jl. Lintas Sumatera No.12 Kalibalangan- Lampung Utara
Telp: (0724) 326023, Email: rs.hmy2011@gmail.com
SITU No : 503.7.2/15-04/37-LU/2011
IMB No : 503/054-04/37-LU/2011

Tindakan dan terapi klinis yang diberikan

1. :_______________________________________
2. :_______________________________________
3. :_______________________________________
4. :_______________________________________
5. :_______________________________________
6. :_______________________________________
7. :_______________________________________

Deskripsi Kekerasan Yang Didapat Di Tubuh Korban

1. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

5. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

6. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 RUMAH SAKIT
Hi. MUHAMMAD YUSUF
Jl. Lintas Sumatera No.12 Kalibalangan- Lampung Utara
Telp: (0724) 326023, Email: rs.hmy2011@gmail.com
SITU No : 503.7.2/15-04/37-LU/2011
IMB No : 503/054-04/37-LU/2011

7. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

8. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

9. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

10. Dijumpai________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Tambahan :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Dokter yang memeriksa

Nip

Penjelasan :
Khusus untuk pemeriksaan luka harus ditulis dalam deskripsi luka :
1. Jenis luka
2. Lokasi luka
3. Warna luka
4. Bentuk luka
5. Sifat atau karakteristik yang spesifik dari jenis luka tersebut
6. Ukuran luka
7. Jarak luka dari titik anatomi tubuh terdekat (2 titik anatomi tubuh/ordinat luka)
8. Khusus luka bakar jelaskan keluasan (prosentase) dan kedalaman (stadium)
9. Khusus luka tusuk jelaskan arah alur luka di dalam tubuh korban
10. Khusus luka tembak tentukan luka tembak masuk dan luka tembak keluar serta tuliskan
sifat atau karakteristik dari jenis luka tersebut.