Visum Korban Hidup (pl).docx

PEMERINTAH KABUPATEN LAMPUNG UTARA INSTALASI P.J / KEDOKTERAN FORENSIK DAN MEDIKOLEGAL RUMAH SAKIT UMUM DAERAH MAYJEND. HM. RYACUDU KOTABUMI Jl. JenderalSudirman No. 02 Telp. 0724-22095 KOTABUMI 34511

Kotabumi, _________________ Nomor Lampiran Ikhwal

: / / KFM/ / 2015 : : Pemeriksaan luar korban hidup An. _______________________ VISUM ET REPERTUM

PRO JUSTITIA Permintaan----------------------------------------------------------------------------------------Tanggalpermintaan;________________, No Polisi;_____________________, Perihal; PermintaanVisum et RepertumpemeriksaanluarkorbanhidupAn. ____________________________, Penyidik;___________________, Pangkat;___________________, NRP;_______________, Jabatan;________________________, Instansi;____________________________, Penjelasan;_________________________________________________, padahari_________, tanggal;_______________, sekitar jam;_______ wib, dengankondisikorban;__________________________________________________ _____ ____________________________________________________________________ _______________________________-----------------------------------------------------Pemeriksa:---------------------------------------------------------------------------------------Nama;_____________________________, NIP;______________________, Instalasi;____________________________ RSUD Mayjed. HM Ryacudukotabumi, Tanggalpemeriksaan;__________________, Jampemeriksaan;_______ wib, Korbandiantaroleh;_______________, Jenispemeriksaan;Pemeriksaan____________________________----------------------------------------------------------IdentitasKorban:----------------------------------------------------------------------------------Nama;________________________, Jeniskelamin;_____________________, Umur;______ tahun, Agama; ____________, Pekerjaan;_____________, Status perkawinan; _________________, Alamat; Jln. ___________________________________________________-------------------------PEMBERITAAN KeadaanUmum---------------------------------------------------------------------------------1 Kesadaran;_______________________________-------------------------------------2 Pernafasan;_______________________________------------------------------------3 Detaknadi;_______________________________------------------------------------4 Tekanandarah;____________________________------------------------------------5 Tinggibadan;_____________________________-------------------------------------6 Beratbadan;______________________________------------------------------------7 HariPertamaHaidTerakhir (HPHT);______________-------------------------------1

Benda-benda--------------------------------------------------------------------------------------8 Penutuptubuhkorban;________________________________---------------------9 Alas tubuhkorban;___________________________________---------------------10 Pakaiankorban;_____________________________________ ---------------------11 Benda di tubuhkorban;_______________________________ ---------------------12 Perhiasankorban;___________________________________ ----------------------13 Benda sekitartubuhkorban;___________________________ --------------------Identifikasi---------------------------------------------------------------------------------------14 Identifikasiumum ; Dijumpaiseorangkorbanhidupdikenal, jeniskelamin_______________, umur ___________, warnakulit _______________, tinggibadan_______________________, beratbadan_______________, rambutsepanjang______________, bentuk____________, warna ______________----15 Identifikasikhusus;__________________________________----------------------Pemeriksaanluar--------------------------------------------------------------------------------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 Alatkelamin;_________________________________-------------------------------29 Punggung;________________________________------------------------------------30 Pinggang;______________________________________----------------------------31 Bokong;_________________________________-------------------------------------32 Dubur;________________________________----------------------------------------33 Anggotagerakatas;_______________________--------------------------------------34 Anggotagerakbawah;__________________________-------------------------------35 HasilPameriksaanTambahan;______________________-------------------------KESIMPULAN Telahdiperiksaseorangkorbanhidupdikenal, umur__________tahun, tinggibadan__________________________, rambutsepanjang_______________, warna_________________----

jeniskelamin_________________, warnakulit_______________, tinggibadan________________, bentuk_____________,

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Dari hasilpemeriksaanluar(danpemeriksaantambahan) dapatdisimpulkan, korbandalamkondisiumum_____________, dengantandatandakekerasanberupa________________________, pada_____________________________, akibatkekerasan___________, sehinggakorbanmengalamiderajadluka____________--------------------------------------------------------------------------DemikianlahvisumetrepertuminidibuatdengansejujurjujurnyaberdasarkansumpahjabatandankeilmuanmenurutKitabUndangundangHukumAcaraPidana (KUHAP) untukdipergunakanbilamanaperlu-------------------------------------------

Dokter yang memeriksa,

Dr. ……………………………… Nip. ………………………………

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