LAPORAN MEDIS KECELAKAAN

ACCIDENT MEDICAL REPORT

SITE NAME / NAMA SITE: PT. MAKMUR SEJAHTERA WISESA

NAMA UMUR PERUSAHAAN

Name Age Company
Doni Setiawan Mahardika 23 PT. INDOMARINE

SITE DEPARTEMEN JABATAN NO. KARYAWAN

Site Department Position Badge No.
PT. MSW N/A HELPER N/A

TANGGAL KEJADIAN JAM LOKASI KEJADIAN

Date of Accident Time Place of Accident
27 JULY 2019 20:30 WITA AREA TURBIN

PENGKAJIAN / PEMERIKSAAN
Medical Assessment
(Containing brief of chronology of the incident and trauma mechanism etc.)

Korban mengatakan, ketika korban mengambil Filter di dalam air yang bercampur bahan kimia, ternyata
sarung tangan yang digunakan korban berlubang tanpa sepengetahuan korban, dan air yang bercampur
dengan bahan kimia tersebut terkena pergelangan tangan korban

DIAGNOSA
Diagnosis
( Describe it in the “general” terms and use Bahasa Indonesia e.g. “patah tulang paha kiri tertutup” etc)

Burn Scald ( Luka Bakar Derajat 1)

PENGOBATAN
Treatment
(Medical treatment required to the patient)

-Membersihkan Luka Dengan Air mengalir

-Observasi Tanda-tanda vital BP: 120/80 mmHg, Temp: 36’ C, Pulse: 80 bpm, RR: 20x/M
- Mengolesi luka dengan Salp Luka Bakar ( Burnazin )
- Paracetamol 3x1 (4 tab)

REKOMENDASI MEDIS
Medical Recommendation
KETERANGAN
(Containing the medical recommendation including medical restrictions Remarks
and planning and referral if required.) PLEASE DO NOT STATE ANY (Could be for time of treatment, etc.)
SAFETY RELATED TERMS SUCH AS LTI, RWDI, ETC.

Work Related Korban kembali ke Rumah, karen Shift sudah

berakhir

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Dibuat oleh
Nama: Reza Wahyu Pebrianoor
Name:
Tanda Tangan
Signature
Reza
Prepared by
ID No. 6781 Tanggal/Date 27 Juli 2019

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 EXPOSURE INJURY AREA

Location Injury

NOTE:

C* = Closed Fracture
O* = Open Fracture
F = Foreign Body
L = Laceration
A = Abrasion
E = Ecchymosed (Bruising)

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