PRACTICAL GUIDE

LONGITUDINAL BLOCK
WRITING CLINICAL FORENSIC REPORT, POSTMORTEM
EXAMINATION REPORT AND DEATH CERTIFICATION

Contributors :

dr. Beta Ahlam Gizela, DFM, Sp.FM Subsp. FK (K)

dr. Kanina Sista, Sp.FM, M.Sc

dr.Dewanto Yusuf Priyambodo, M.Sc, Sp.FM

FORENSIC AND MEDICOLEGAL SCIENCE DEPARTEMENT

2023
 WRITING CLINICAL FORENSIC REPORT, POSTMORTEM EXAMINATION REPORT,
AND DEATH CERTIFICATION

INTRODUCTION

A. Visum et Repertum
Visum et Repertum is a written report that a doctor produces after examining forensic evidence,
which could be a corpse, patient, or a part of a human body. The investigator or police make a
written request for the report. Visum et Repertum comes in several types, including:
1. Clinical forensic visum et repertum
2. Post mortem examination visum et repertum
3. Psychiatry visum et repertum.

The process for writing Visum et Repertum is outlined below:

1. Introduction: The report is written by Pro Justitia, indicating that the Visum et Repertum is
created for the judiciary.
2. Preamble: It includes the identities of the investigator, examining doctor, patient, and the
time of the examination.
3. Reporting: It provides detailed and comprehensive results of the objective examination of
forensic evidence. The examination encompasses the entire body, including clothing and
property, and supporting examinations are conducted. The writing must use proper and
correct Indonesian language (EYD). Each sentence in the paragraph should be followed by a
line to eliminate empty lines.
4. Conclusion: The subjective conclusions of the doctor/team on the examination results are
presented. The conclusion of the Visum et Repertum of the corpse contains the identity,
identified abnormalities, and estimated time of death. Meanwhile, the clinical Visum et
Repertum includes the identity, identified abnormalities, and medical consequences for the
identified abnormalities.
5. Closing sentence: A statement affirming the truthfulness of the Visum et Repertum made in
consideration of the oath of office.
Finally, the examining doctor signs the Visum et Repertum along with their clear name and
the place and time of the examination

B. Death certificate
A death certificate is an administrative document that certifies someone's death. For individuals
who die due to illness or old age, a doctor who treated the patient should issue the death
certificate. If a person dies without any prior medical examination, the doctor must conduct an
examination to determine whether there are indications of an unnatural death, such as homicide,
suicide, or accident. If injuries are found indicating an unnatural death, the doctor must report it
to the police as an unnatural death to conduct a forensic examination of the body.
The cause of death refers to the disease or trauma that leads to physiological changes in the body
and can be identified using the International Code of Diseases (ICD). The cause of death is listed
sequentially as a, b, c, and so on, with each cause leading to the subsequent one. For instance,
cause a is a consequence of cause b, which in turn is caused by disease d. If there are other disease
conditions present but not directly related to the cause of death, these conditions should be
listed under section II
PRACTICAL WORK

Learning objectives - Understand kinds of medical report

- Practising how to write medical report for litigation process in clinical
forensic case, suspicicous death case, and death registration
Relation to the SKDI No Expected Competency Level of Expected Competency
(Indonesia Medical 105 Prosedur medikolegal 4A
Doctor Competencies) 106 Pembuatan visum et repertum 4A
107 Pembuatan surat keterangan medis 4A
108 Penerbitan sertifikat kematian 4A
Responsible staff(s) Dept. of Forensic Medicine and Medicolegal
Method(s) - Writing medical report for litigation process in clinical forensic case
- Writing medical report for litigation process in suspicious death case
- Writing medical report for death registration
- Feedback for students
Content - The rules on documenting medical reports
- The rules on disclosing medical confidentiality in medical reports
- Practical skills required to be able to write medical report for
litigation process in clinical forensic cases
- Practical skills required to be able to write medical report for
litigation process in suspicious death cases
- Practical skills required to be able to write medical report for death
registrations
- Instruction for writing sessions
Prerequisite - The Therapeutic Transaction (Block 1.5)
- Informed Consent (Block 1.6)
- Medical Confidentiality (Blok 1.6)
- Dealing with Patients Associated with law cases (Block 2.3)
- Practical Session 2: Writing medical record and medical report (Block
1.7)
Continuation - Case study 3 : Understanding medicolegal procedure (case study)
(Block 2.4)
Pre-session - Read through the lesson plan
- Students will be given several patient scenarios. Read and choose the
scenario
- Each students are required to write 3 individual report:
 medical report for litigation process in clinical forensic case
 medical report for litigation process in suspicious death case
 medical report for death registration
During the session Allocated Activities Source persons
time
10 - Opening and brief instruction for Facilitators
minutes the practical session
110 - Students presenting their Facilitators ask 3-4
minutes individual reports (5 students to present
minutes/students) clinical forensic case,
- Feedbacks from others (3 3-4 students to
minutes/presentation) present suspicious
- Feedbacks from facilitator (2 death case, 3-4
minutes/presentation) students to present
death registration.
Post-session - The individual reports (3 reports/student) are to be submitted within
1 week after the practical session is conducted.
Ethical consideration - Picture, name and address should be kept confidential in accordance
with ethic and law
- The Gamel team will be responsible to protect of all information
uploaded by the students
Assessment Presentation 30%, reports 50%, feedback 20%
Reading and references - Arfianti et al. 2021. Materi Penunjang Ilmu Kedokteran Forensik dan
Medikolegal Jilid 1. Yogyakarta : Gadjah Mada University Press.
- Priyambodo et al. 2021. Materi Penunjang Ilmu Kedokteran Forensik
dan Medikolegal Jilid 2. Yogyakarta : Gadjah Mada University Press.
Attachments - Student handout
- Clinical forensic and suspicious death cases
 Case for attachment

A. Clinical forensic case

Write visum et repertum in clinical forensic case with following cases :
Case 1

No. :
MEDICAL RECORD
Date of Visit : December 10, 2022 Time : 08.00
Doctor’s name : (use your own information)
Patient name John Doe
Date of birth February 23, 2009
Gender Male
Address Mlati, Sleman
Anamnesis Pain in neck after being strangled by his senior. Dizziness, nausea, vomitus and
shortness of breath were denied.
Past medical history -
Family history -
Vitals BP : 110/85 mmHg
HR : 90 bpm
RR : 20 bpm
Temp : 37⁰C
Physical Examination Head : Normal
Neck : bruise with a diameter of one centimeter
Thorax : Normal
Abdomen : Normal
Extremity : Normal

Laboratory test and -

other supporting
test
Diagnosis Bruise in neck due to blunt trauma
Treatment and Paracetamol 500mg/8 hours (pain)
management plan
Case 2

No. :
MEDICAL RECORD
Date of Visit : February 10, 2023 Time : 08.00
Doctor’s name : (use your own information)
Patient name Ms. Jane Doe
Date of birth February 24, 1983
Gender Female
Address Mlati, Sleman
Anamnesis Pain in right eye and cheeks after being hit by a friend. At the time of the
incident the patient was conscious and no sign of dizziness, nausea and
vomiting.

Past medical history -

Family history -
Vitals BP : 120/80 mmHg
HR : 89 bpm
RR : 20 bpm
Temp : 37,3⁰C
Physical Examination Head : conjunctival oedema OD. vulnus excoriatum 4 cm x 3 cm in cheeks.
Neck : Normal
Thorax : Normal
Abdomen : Normal
Extremity : Normal

Laboratory test and CT Scan : periorbital soft tissue swelling

other supporting
test
Case 3

No. :
MEDICAL RECORD
Date of Visit : February 24, 2023 Time : 08.00
Doctor’s name : (use your own information)
Patient name John Doe
Date of birth March 12, 1977
Gender Male
Address Wonosari, Klaten
Anamnesis Pain in the right foot after traffic accident

Past medical history -

Family history -
Vitals BP : 110/80 mmHg
HR : 95 bpm
RR : 20 bpm
Temp : 37,4⁰C
Physical Examination Head : Normal
Neck : Normal
Thorax : Normal
Abdomen : Normal
Extremity : 2 vulnus excoriatum with a diameter of one centimeter each

Laboratory test and -

other supporting
test
Diagnosis Vulnus excoriatum pedis dextra

Treatment and Paracetamol 500mg / 8 hour

management plan
Case 4

No. :
MEDICAL RECORD
Date of Visit : March 10, 2023 Time : 12.00
Doctor’s name : (use your own information)
Patient name Jane Doe
Date of birth December 19, 1982
Gender Female
Address Wonosari, Klaten
Anamnesis Pain in the right forearm after falling while working in the attic

Past medical history -

Family history -
Vitals BP : 140/90 mmHg
HR : 120 bpm
RR : 24 bpm
Temp : 37,5⁰C
Physical Examination Head : Normal
Neck : Normal
Thorax : Normal
Abdomen : Normal
Extremity : swelling (+) redness (+) deformity (+)
Laboratory test and
other supporting
test

Diagnosis Fracture ulna dextra

Treatment and open reduction, internal fixation (ORIF)

management plan
B. Postmortem examination report
Write suspicious death visum et repertum with following cases :
Case 1

No. :
MEDICAL RECORD

Date of Visit : March 20, 2023 Time : 10.30 AM

Doctor’s name : (use your own information)
Patient name Ms. Bright
Date of birth March 23, 2003
Gender Female
Address Mlati, Sleman
Alloanamnesis According to police information, the victim was run over by a truck while on
her way home form work. The accident started when the victim wanted to
passing (overtake) the car in front of her, but the motorbike was fell.
Past medical history -
Family history -
Physical Examination Rigor mortis : easy to move in all joints
Livor mortis : There are purplish-red livor mortis that disappear by pressing the
fingers on the back of the neck and waist.
Decomposition : -
Body length : 160 cm, body weight : 50 kg
Head : vulnus laceratum with open fractures 19 cm x5 cm x 4cm
Neck : bruise 4 cm x 2 cm
Thorax : Normal
Abdomen : Normal
Extremity : vulnus excoriatum 4 cm x 3 cm in right shoulder
Laboratory test and Blood alcohol : negative
other supporting
test

Case 2

No. :
MEDICAL RECORD

Date of Visit : March 13, 2023 Time : 01.30 AM

Doctor’s name : (use your own information)
Patient name Ms. Bright
Date of birth March 23, 2003
Gender Female
Address Mlati, Sleman
Alloanamnesis On Monday night a burning body of a female was found in the wood. According
to the police, burning body was reported to authorities around 9:45 PM
Monday night.
Past medical history -
Family history -
Physical Examination Head : hair (-) soot (+) head fracture (+), 3 rd degree burn
Neck : 3rd degree burn
Thorax : 2rd degree burn
Abdomen : Normal
Extremity : Normal
 Laboratory test and Carbon monoxide : positive
other supporting
test

Case 3

No. :
MEDICAL RECORD

Date of Visit : March 20, 2023 Time : 10.30 AM

Doctor’s name : (use your own information)
Patient name Mr. Shine
Date of birth January 23, 1992
Gender Male
Address Mlati, Sleman
Alloanamnesis According to police information, victim and another man got into a fight while
eat in angkringan. During the altercation, the suspect stabbed the victim with
a knife. Despite attempts to resuscitate him, the victim died on the scene.
According to police, the two men did not know each other beforehand.
Past medical history -
Family history -
Physical Examination Rigor mortis : easily movable in all joints
Livor mortis : There are purplish-red livor mortis that disappear by pressing the
fingers on the back of the neck and waist.
Decomposition : -
Body length : 170 cm, body weight : 60 kg
Head : Anemic (+/+)
Neck : Normal
Thorax : There were two stab wounds to the front of the chest. The upper
one was located in the left lower region of the chest, 50 cm below hair line.
The stab wound penetrated the heart, ran through the right ventricle. 350 ml
of blood was found in the chest cavity. The lower one present in the left lower
region of the chest, 60 cm below hair line, penetrated the musle of the chest.
Abdomen : Normal
Extremity : Normal
Laboratory test and Blood alcohol : negative
other supporting
test

C. Case of death registration

Writing a death registration with following cases :
Case 1
A 11-months child with history of fever since 3 weeks ago with rash in neck. One day the rash is
extends to the entire neck, chest and face. Family denied history of asthma and food allergies.
The patient’s mother admitted that their nephew who has a measles. Six days ago, patient began
to feel shortness of breath and than died with pneumonia.

Case 2
A 70-year-old female had joint pain related to osteoporosis and its complications. One day while
walking, she had an acute pain in her hip and was admitted with a pathologic fracture of left
femoral neck. Five days postoperatively she died of pulmonary embolism which originated in a
lower extrimity deep vein thrombosis.
Case 3
A 55-year-old male complained of severe headache after intercourse and died unexpectedly. An
autopsy confirmed subarachnoid hemorrhage resulting from a rupture cerebral artery
berry/saccular aneurysm. He also had a Diabetes Mellitus.

Case 4
A 60-year-old man had a hypertension for 15 years. Over the years, he developed progressive
renal failure, which ultimately required dialysis. Dialysis progressively less effective and later he
died with severe uremia and uremic encephalopathy.
 Attachment

1. Visum et Repertum for clinical forensic cases

INSTALASI GAWAT DARURAT RS MAHAPATIH GADJAH MADA

Jalan Mapahit no 01 Yogyakarta Telp 0274 101020

PRO JUSTITIA

VISUM ET REPERTUM
No. / TUM/VER/II/2023

Yang bertandatangan di bawah ini, ....................................... dokter pada rumah sakit .................,
memenuhi surat permintaan visum klinik dari kepolisian sektor ………........ dengan surat
nomor………........ tertanggal………........ atas nama………........ pangkat/jabatan………........
akibat peristiwa………........ maka dengan ini menerangkan bahwa pada tanggal………........
pukul………........ bertempat diruang ………........ rumah sakit ………........ telah melakukan
pemeriksaan korban dengan nomor rekam medis………... yang menurut surat tersebut adalah :
Nama : ...........................................................................................................................................
Umur : ...........................................................................................................................................
Jenis Kelamin: ...............................................................................................................................
Warga Negara: ...............................................................................................................................
Pekerjaan : .....................................................................................................................................
Agama : ..........................................................................................................................................
Alamat : ..........................................................................................................................................
HASIL PEMERIKSAAN :
1. Korban datang dalam keadaan..................................................................................................

Riwayat sebelum peristiwa, kronologi kejadian, riwayat setelah peristiwa, riwayat perkembangan
mental.............................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

2. Pada korban ditemukan (pemeriksaan fisik)

a. .................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
b. .................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

3. Pemeriksaan mental:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.
4. Pemeriksaan penunjang :
........................................................................................................................................................
........................................................................................................................................................

5. Terhadap korban dilakukan tindakan :........................................................................................

........................................................................................................................................................

6. Korban dipulangkan/dirawat …………………………………………………………………………

KESIMPULAN :
 Identitas pasien……………………………………………………………………………………
  Penyakit atau trauma yang ditemukan…………………………………………………………
 Konsekuensi medis akibat penyakit atau trauma tersebut …………………………………..

PENUTUP :
Demikianlah visum et repertum ini dibuat dengan sebenarnya dengan menggunakan
keilmuanyang sebaik-baiknya, mengingat sumpah sesuai dengan Kitab Undang-Undang Hukum
AcaraPidana.
Yogyakarta , tgl bulan tahun Dokter pemeriksa

dr.............................................
NIP :.....................................
 2. Visum et Repertum for postmortem examination cases

INSTALASI GAWAT DARURAT RS MAHAPATIH GADJAH MADA

Jalan Mapahit no 01 Yogyakarta Telp 0274 101020

PRO JUSTITIA
VISUM ET REPERTUM
No. / TUM/VER/II/2023
Berdasarkan surat permintaan penyidik Nama: Nama penyidik NRP: nomor NRP, Pangkat: Pangkat
polisi, Jabatan : Jabatan polisi, Nomor surat: nomor surat, tanggal: tanggal surat, maka Tim Kedokteran
Forensik dibawah pimpinan nama dokter beserta staf dari Instalasi Kedokteran Forensik dan Pemulasaraan
Jenazah Rumah Sakit Umum Pusat xxxx pada hari _______, tanggal _____________, mulai pukul
_____________ Waktu Indonesia Barat sampai pukul __________ Waktu Indonesia Barat, melakukan
pemeriksaan luar dan identifikasi di ruang otopsi Rumah Sakit Umum Pusat dokter Soeradji Tirtonegoro
Klaten, terhadap almarhumah Nama : ________, Umur : ____________ Jenis kelamin : _________, Agama
: _________, Pekerjaan : _________, Kewarganegaraan : _________, Alamat : _________,. Akibat
peristiwa ____________________________________________________________

Hasil pemeriksaan itu sebagai berikut :

I PEMERIKSAAN LUAR DAN IDENTIFIKASI

1 Keadaan Jenazah :

2 Sikap jenazah di atas meja otopsi :

3 Kaku jenazah:

4 Bercak jenazah:

5 Pembusukan jenazah :

6 Ukuran jenazah :

7 Kepala

a Rambut :

b Bagian yang tertutup rambut:

c Dahi :

d Mata :

Mata kanan :

Mata kiri :

e Hidung :

f Mulut :

g Dagu :

h Pipi :

i Telinga:

8 Leher :

9 Dada :

10 Perut :
 11 Alat kelamin:

12 a Anggota atas kanan

- Lengan atas:
- Lengan bawah :
- Tangan:
b Anggota atas kiri

- Lengan atas:
- Lengan bawah :
- Tangan:

13 a Anggota bawah kanan

- Paha :
- Tungkai bawah :
- Kaki :
b Anggota bawah kiri

- Paha :
- Tungkai bawah :
- Kaki :
14 Punggung :

15 Pantat :

16 Dubur :

II Pemeriksaan penunjang :

III PEMERIKSAAN DALAM:

IV KESIMPULAN

1 identitas
2 Kelainan yang ditemukan
3 Saat kematian
V PENUTUP
Demikianlah visum et repertum ini dibuat dengan sebenarnya dengan menggunakan
keilmuanyang sebaik-baiknya, mengingat sumpah sesuai dengan Kitab Undang-Undang Hukum
AcaraPidana.
Yogyakarta , tgl bulan tahun Dokter pemeriksa

dr.............................................
NIP :.....................................
3. International form of medical certificate of cause of death
Part I Immediate cause: Approximate interval between
onset and death
A.
Due to, or as a consequence of :
B.
Due to, or as a consequence of :
C.
Due to, or as a consequence of :
D.
Part II Other significant conditions : condition contributing to death
but not resulting in the underlying cause of death in Part I