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    From Visum KTA

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    Warsito
    This 3 page document is a medical examination report from a doctor at the Blambangan Umpu Community Health Center regarding a case. It provides identifying information about the victim such as name, age, gender, religion and address. It then describes the reported circumstances of the incident and findings from the physical examination. The doctor concludes it was an examination of a male/female child.

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    From Visum KTA

    Uploaded by

    Warsito
    11 views2 pages
    This 3 page document is a medical examination report from a doctor at the Blambangan Umpu Community Health Center regarding a case. It provides identifying information about the victim such as name, age, gender, religion and address. It then describes the reported circumstances of the incident and findings from the physical examination. The doctor concludes it was an examination of a male/female child.

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    This 3 page document is a medical examination report from a doctor at the Blambangan Umpu Community Health Center regarding a case. It provides identifying information about the victim such as name, age, gender, religion and address. It then describes the reported circumstances of the incident and findings from the physical examination. The doctor concludes it was an examination of a male/female child.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    11 views2 pages

    From Visum KTA

    Uploaded by

    Warsito
    This 3 page document is a medical examination report from a doctor at the Blambangan Umpu Community Health Center regarding a case. It provides identifying information about the victim such as name, age, gender, religion and address. It then describes the reported circumstances of the incident and findings from the physical examination. The doctor concludes it was an examination of a male/female child.

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    of 2

    :445/……/VER-PPT-KSA/……/20…..

    Halam 1 dar 3 halaman

    KASUS 001

    UPT PUSKESMAS BLAMBANGAN UMPU


    Nomor : 445/……/VER-PPT-KSA/……/20…..
    Lampira
    : -
    n
    Perihal : Hasil Pemeriksaan Visum et Repertum
    a/n : ………………………………..

    PRO JUSTITIA

    Blambangan Umpu,……,……………………………

    VISUM ET REPERTUM

    Saya yang bertanda tangan dibawah ini ……………,dokter di UPT Puskesmas Blambangan
    Umpu,berdasarkan atas permintaan tertulis dari Resort Kepolisian ……………………,dengan
    Nomor ………………………………………………………………tertanggal…………Juni …………..dua
    ribu dua puluh tiga mengenai permintaan Visum et Repertum tersebut diatas,maka dengan ini
    menerangkan bahwa pada tanggal…........juni dua ribu dua puluh tiga pukul Sembilan titik
    dua puluh lima menit (contoh) Waktu Indonesia bagian Barat,bertempat Unit Gawat
    Darurat UPT Puskesmas Blambangan Umpu …………………telah melakukan pemeriksaan
    atas korban yang menurut surat permintaan visum tersebut adalah :

    Nama : …………………………………………………….
    Umur : …………………………………………………….
    Jenis Kelamin : …………………………………………………….
    Warga Negara : …………………………………………………….
    Agama : …………………………………………………….
    Alamat : …………………………………………………….

    RIWAYAT KEJADIAN ……………………………………………………………………………………………


    Pada hari…………………………..tanggal …………………..dua ribu dua puluh tiga pukul dua
    belaas titik dua puluh emapt waktu Indonesia bagian Barat bertempat
    ………………………………..korban mengaku telah…………………………………………………………
    Lanjut sesuai dengan keterangan korban

    HASIL PEMERIKSAAN …………………………………………………………………………………………


    Hasil Pemeriksaan Umum…………………………………................................................................
    :445/……/VER-PPT-KSA/……/20…..
    Halam 2 dar 2 halaman

    PadaPemeriksaan
    Fisik…………………………………………………………………………………………………………………...

    KESIMPULAN……………………………………………………………………………………………………
    Telah dilakukan Pemeriksaan pada seorang anak Perempuan/Laki-laki

    Dokter Pemriksa diatas

    …………………………………

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