Banjarnegara

Nomor :
Perihal : Hasil Pemeriksaan Luar Atas ______________

PRO JUSTITIA

VISUM ET REPERTUM
No RM _____________

--------Yang bertandatangan dibawah ini, dr. Denny Susiani, dokter Unit Gawat Darurat Rumah Sakit
Umum Emanuel kec.Purwareja Klampok kab.Banjarnegara, atas nama tim menerangkan bahwa
sehubungan dengan permintaan tertulis dari KEPOLISIAN NEGARA REPUBLIK INDONESIA DAERAH
JAWA TENGAH RESOR BANJARNEGARA, No. B/3/I/2018/Lantas., yang ditandatangani oleh
…………………... pangkat …………………., NRP ……………. , pada hari ………… tanggal
………………………….. dua ribu dua puluh tiga, pukul ………….………..menit Waktu Indonesia Bagian
Barat, di Unit Gawat Darurat Rumah Sakit Umum Emanuel kec. Purwareja Klampok kab.Banjarnegara,
telah dilakukan pemeriksaan dan perawatan terhadap korban tersebut ---------------------------------------------
Nama : Mr. X----------------------------------------------------------------------------------------------
Jenis Kelamin : Laki-laki -----------------------------------------------------------------------------------------
Umur : _______tahun----------------------------------------------------------------------------------
Warga Negara : Indonesia----------------------------------------------------------------------------------------
Agama : Islam ---------------------------------------------------------------------------------------------
Alamat : Purbalingga-------------------------------------------------------------------------------------

-------------------------------------------------HASIL PEMERIKSAAN---------------------------------------------------

1. PEMERIKSAAN FISIK---------------------------------------------------------------------------------------------------------
Pemeriksaan fisik pada saat korban datang pada tanggal __________ dua ribu dua puluh tiga --------

Keadaan umum : ---------------------------------------------------------------------------------------------------------

• Kesadaran:
__________________________________________________________________________
• __________________________________________________________________________

Kepala ----------------------------------------------------------------------------------------------------------------------
• __________________________________________________________________________
• __________________________________________________________________________
• __________________________________________________________________________
• __________________________________________________________________________
• __________________________________________________________________________

Leher ------------------------------------------------------------------------------------------------------------------------
• __________________________________________________________________________
• __________________________________________________________________________

Dada : ------------------------------------------------------------------------------------------------------------------------
• __________________________________________________________________________
• __________________________________________________________________________

Perut -------------------------------------------------------------------------------------------------------------------------
• __________________________________________________________________________
 • __________________________________________________________________________

Punggung -------------------------------------------------------------------------------------------------------------------
• __________________________________________________________________________
• __________________________________________________________________________

Lengan, tangan kiri -------------------------------------------------------------------------------------------------------

• __________________________________________________________________________
• __________________________________________________________________________

Lengan, tangan kanan: --------------------------------------------------------------------------------------------------

• __________________________________________________________________________
• __________________________________________________________________________

Tungkai, kaki kiri ----------------------------------------------------------------------------------------------------------

• __________________________________________________________________________
• __________________________________________________________________________

Tungkai, kaki kanan ------------------------------------------------------------------------------------------------------

• __________________________________________________________________________
• __________________________________________________________________________

2. Tindakan/ pengobatan---------------------------------------------------------------------------------------------------------
• Di Unit Gawat Darurat pada korban dilakukan _____________________________________
__________________________________________________________________________
__________________________________________________________________________

KESIMPULAN------------------------------------------------------------------------------------------------------------------------
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

---------Demikianlah Visum Et Repertum ini saya buat dengan sesungguhnya berdasarkan keilmuan saya
dan dengan mengingat sumpah sesuai dengan Kitab Undang-Undang Hukum Acara Pidana------------------

Dokter yang memeriksa,

dr. Denny Susiani