ANAMNESIS & VISUM ET

REPERTUM

Dewi, Rahmania Kemala

Dep. Of Forensic and Legal Medicine

Medical Faculty of Airlangga University
Dr. Soetomo Surabaya District General Hospital
 Anamnesis

Information gained by a physician by asking

specific questions, either of the patient or of other
people who know the person and can give suitable
information, obtaining information useful in
formulating a diagnosis and providing medical or
care to the patient.
Anamnesis

The medically relevant complaints reported by the patient or others

fsymptoms, in contrast with clinical signs, which are ascertained by direct
examination on the part of medical personnel.

Medical histories vary in their depth and focus.

For example, an ambulance paramedic would typically limit their history

to important details, such as name, history of presenting complaint,
allergies, etc. In contrast, a psychiatric history is frequently lengthy and
in depth, as many details about the patient's life are relevant to formulating
a management plan for a psychiatric illness.
• Identification and demographics: name, age, height, weight.
• The "chief complaint (CC)"
• History of the present illness (HPI)
• Past medical history (PMH)
• Review of systems (ROS)
• Family diseases 
• Childhood diseases
• Social history (medicine)
• Regular and acute medications (including those prescribed by doctors,
and others obtained over-the-counter or alternative medicine)
• Allergies
• Sexual history, obstetric/gynecological history
• Conclusion & closure
Visum et Repertum : written report for justice made by doctor/physician

under oath/vow for anything and everything that are seen and inspected

or found.

Visum et Repertum is substitute of an evidence, since the evidence can

not be brought directly into court of Law as it is.

The evidence is human body, as the wound may be healing at time the

court of Law occur.

Who have the right to ask for VeR :

1. Investigating officer (penyidik) : min. rank 2nd chief petty

officer (Aipda), 2nd petty officer (Bripda)

2. Judge of criminal cases (hakim pidana) : usually through

Distric Attorney/Public Prosecutor

3. Judge of civil cases (hakim perdata)

4. Judge of religion cases (hakim agama) : condition for

polygamy, divorce, widow/widower

Who have the right to make VeR :

(KUHAP 133; 1)

1. Forensic physician expert

2. Other physician or expert

Order of mien/manner to request VeR for living victim :

1. Written

2. The victim is the evidence, by mean the request has to be

given by the officer in charge with the victim to the doctor

directly

3. Can not be requested by past event

Order of mien/manner to request VeR for passed victim :

1. Written

2. The victim and the requested letter are given by the officer

in charge to the forensic directly

3. Label had to be tied on the victim (KUHAP 133; 3) by the

officer in charge
 Request form of VeR :

1. Upper right corner : to whom and address the letter for, date of regards

2. Upper left corner : address of the requested, letter number and matter of concern

3. Middle : SPVR for living victim or passed victim

4. Information of victim identity including name, age, gender, nationality, address, religion,

occupation, and others

5. Information of incident take place, date, time, and others

6. Request for medical treatment

7. Request to report investigating officer if the victim is heal, reference to other medical facilities,

escape, or passed away during treatment

8. Lower right corner : information of the investigating officer including name, rank, unit, rank

number, and address that being signed and officially stamped

9. Lower left corner : information of the letter acceptance including name, date, time, signed, and

officially stamped. This request form had to be copied into hospital archive
 PARTS OF VER :

1. PRO JUSTISIA : upper left corner

2. Pendahuluan / Preface :

a. Identity of the requested letter

b. Identity of the doctor/physician

c. Place, date, and time of examination

d. Identity of victim

e. Information from investigation officer for incident, wound, treatment,

time of death, manner of death, and others

f. Information of the victim care take or escort and time he/she arrive in

the vicinity
 Parts of VeR :

3. Pemberitaan / Report :

a. Identity of victim according the physician examination such as age, gender,

height, weight, skin tone, vital sign, consciousness, and others

b. Wound, disease, anomaly, abnormality, and others characteristic in or on each

of the victim body section

c. Treatment or medication acquired by the victim in the present medical facility

d. Results of additional examination or others expert consultation

 Parts of VeR :

4. Kesimpulan / Conclusion :

a. Living victim :

• Identity of the victim, height, weight, skin tone, vital sign, consciousness, and others

• Type of wound, disease, or other abnormality on the victim

• Cause of trauma or coercion

• Wound qualification or either severity are implied according to each or best knowledge of

the doctor/physician

b. Passed victim :

• Identity of the victim, length, weight, skin tone, and others

• Type of wound, disease, or other abnormality on the victim

• Cause of trauma or coercion

• Cause of death, mechanism of death

 Parts of VeR :

5. Closure / Penutup :

“ Demikianlah Visum et Repertum ini dibuat dengan

mengingat sumpah pada waktu menerima jabatan “ /

“ This Visum et Repertum is written accordingly into

account of incumbency oath “

With the doctor/physician name, identity number, and

signed
 TYPE OF VER :

1. VER for living victim

2. VER for passed/death victim

3. VER for crime scene

4. VER for exhumation

5. VER for psychiatric report

6. VER for other evidence

QUESTION
 Wound Qualification : for living victim

1. KUHP 352 : penganiayaan yg tidak menimbulkan penyakit atau halangan

untuk menjalankan pekerjaan jabatan atau mata pencaharian

(penganiyaan ringan / light or venial persecution)

2. KUHP 351; 1 : penganiayaan yg menimbulkan penyakit atau halangan

untuk menjalankan pekerjaan jabatan atau mata pencaharian sementara

waktu

3. KUHP 351; 2 : penganiayaan yg menimbulkan luka berat (severe wound)

 Persecution  Wound

• Luka yg tidak menimbulkan penyakit atau halangan untuk

menjalankan pekerjaan jabatan atau mata pencaharian /
Wound which not procured disease or complication or
hindrance to perform occupation incumbency or livelihood
•Luka yg menimbulkan penyakit atau halangan untuk
menjalankan pekerjaan jabatan atau mata pencaharian /
Wound which procured disease or complication or hindrance
to perform occupation incumbency or livelihood
•Luka yg tergolong luka berat / Wound which classified as
severe wound
THANK YOU