Medical Report: 14-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound

This is the medical record of a 14 year-old Iraqi male who was shot in the left leg and took some shrapnel to the face. The medical records do not give any indication as to the circumstances of the events that gave rise to the injuries, only that he was a passenger in a truck that was fired upon by Coalition Forces. The medical report shows he suffered a fractured Femur and tib/fib fracture with injuries to his face as well. The young man was treated for several months by U.S. medical staff and was healed by their efforts.

Doc_type:

Medical

Doc_date:

Tuesday, November 18, 2003

Rec_aclu_path:

https://www.thetorturedatabase.org/node/3973

Doc_pdf_path:

Doc_rel_date:

Friday, October 14, 2005

Doc_text:

Automated Facsimile
INPATIENT TREATMENT REC01-._• --OVER SHEET
For use of this form. see AR 40-400, the proponent agency is OTSG
1. Register Nbr 2. N 3. Grade FGN Admission Remarks
4. Sex 5. Age 6. Race 13Y X 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm NO
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21. Source of Admission Direct from ER
24. Name/Relation of Emergency Addressee 27a. Address of Emergency Addressee
22. Hour Of Adm: 23. Clinic Service
06:35 AEA - ORTHOPEDICS
25. Type Disp 26. Date of Dispf TRF-OTH 2003-12-20
27b. Telephone No 28. Date This Adm: AdmittingOfficer: 2003-11-12 OLIVERIO
29. Reportin MTFargligarig -31. Selected Administrative Data Marital Status: DoB: 1990-01-01 In/Out Patient: Inpatient MOS: 30. Date 'nit Adm 2003-11-12 32. Units Blood Components
33. Cause Of Injury:
34 Diagnosis / Operations and Special Procedures: OPEN R FEMUR/Tts4L/A, FX

35. Total Days This Facility Absent SOk Days Otherbys ConLv / C op Care Days Sup ental Care Bed Days Total Sick Days
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35. Total Days This Facility Absent soDayl Othens ConLv / oop Care Days Sunnental Care Bed Days Total Sick Days
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Au o ated Facsimile - DA FORM 3647. May 79

MEDCOM - 23870

Automated Facsimile INPATIENT TREATMENT RECORL, .,OVER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade Admission Remarks FGN

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Direct from ER

25. Type Disp 26. Date of Disp24. Name/Relation of Emergency Addressee

TRF-OTH 2003-12-20 27b. Telephone No 28. Date This Adm: AdmittingOfficer:
27a. Address of Emergency Addressee 2003-11-12 OLIVERIO
32. Units Blood Components30. Date Mit Adm29. ReportingMTF 2003-11-12
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DoB: 1990-01-01

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Absent Sick Day Other Days
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MEDCOM - 23871
MEDICAL RECORD ABBREVIATED IV1EDICAL RECORD

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MEDCOM - 23873
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MEDCOM - 23875
DOD-037453

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MEDCOM - 23876
Interventions
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MEDCOM - 23877
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES' MEDICAL RECORD
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MEDCOM - 23879
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MEDCOM - 23880
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MEDCOM - 23881
DOD-037459

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MEDCOM - 23882
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STANDARD FORM 509 MEV. BI19991 RACE
USAPA V1 GI
MEDCOM - 23911
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
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ISSN or Othed
MI
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RECORDS MAINTAINED AT1 HOSPITAL OR MEDICAL FACiLITYCEPARTJSERVICE
_
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PATIENT'S IDENTIFICATION: !far typrd ar written enaies, give: Name lost first, war
ID No Of.Sex: Dote of Birth; Bank/Grade,

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PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV.
711111111111
Prescribed by GSAIICMR FPMFII4ICHO 101-11.20:
USAP.

17;.
MEDCOM -23912
DOD-037490
PROGRESS NOTESMEDICAL RECORD
DATE 1
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PATIENT'S IDENTIFICATION lFor typed or written entries give: IVame - last, first, middle; REGISTER NO. WARD NO.
grade; rank; rate; hospital or medical facility)

-=0AA.) a
PROGRESS NOTES
Medical Record
STANDARD FORM 509 IREV. 7.91) Prescribed by GSA/ICMR. FIRMA I.41
C („0\L)—
CFR) USAPPC V1.00
./.111/01/
mD- 171
a cThracIL.,0----
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MEDCOM - 23913
ta,ayv); ss can
DOD-037491

rAL,"..,r,IcEn, run LuLd.AL rserHuum i !UN
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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SPONSOR'S NAME
SPONSOR'S ID NUMBER
LAST
FIRST ISSN or Other)
MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION:
(For typed or written entries give: Name - last, firsr, middle;
REGISTER NO. WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES Medical Record
STANDARD FORM 509 (FiEv. 5/1999) Prescribed by GSA/1CMR FPMR (41CFR) 101-11.203113)(10)
USAPA VI 00
MEDCOM - 23914
-
DOD-037492

AIIIHDRIZED FOR LOCAL REPRODUCTIOFI
MEDICAL RECORD PROGRESS NOTES
DATE NOTES •
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DEPARUSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAIFfTAINED AT
PATIEWS IDENTIFICATIOPE (For typal or written enziies. give: Nome • int firsl, mak REGISTER ND.
WARD NO.
ID No or SSN; Sex; Dare of Birth; &MOW
csw
PROGRESS NOTES Medical Record
STANDARD FORM 509 MEV. 6119991 Prescribed by GSAIICMR FPMR 14ICFR) 10711.21131b1110I USAPA VISO
MEDCOM - 23915
PROGRESS NOTES
MEDICAL RECORD
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(Continue on reverse side)
PATIENT'S IDENTIFICATION IFor typed or wrirten entries give: Name - last, first, middle; REGISTER NO. WARD NO. grade; rank; rate; hospital or medical facility,
PROGRESS NOTES
Medical Record
STANDARD FORM 509 IREV. 7.91) Presclibeti by GSA/ICMR, FIRMA 141
11,1110_,A
CFRI USAPPC V1.00
MEDCOM - 23916
DOD-037494
PROGRESS NOTES

DATE
t
re 'al -fi) for amino/ben pzthle vikranny
-J-c--1--
tork------
IcrPa D...3 TIA,-hri-te6t No.k;" POSti re,perifs lif- lAii-ht uxt4 1 .
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it) VUS e..WIAL44 im174..k.L. . 9-Pi U3

. \DI_ (.(2-- 2-
,
,k
STANDARD FORM 509 !REV. 7 91) BACK USAPPC V1 00
MEDCOM - 23917
DOD-037495

Name INITIAL ASSESSMENT _A)rway !Qatent Nasal 0 Oral Intubated 0 Crich 1 ETT 4f0 Trach
C...•
C-Spin
1' CC: D BB E_J- Securedtkjear

NORM MS. COMPETENT. 0 MS A's. GCS I 5.
TENDER. 0 DISTRACTING. INJ's.

. CNS
Pr'ES VERBAL n tv1OTOR SPO:¦!T_P ALRT I ALRT (-:viND 3 CONFD
LCL P
• PAIN 2 INAPR 3 j WDR P 4 ;NRSP I I INCIVIP 2 FIX 3 j UNRSP I 1 EXT UNRSP I
1 PERLA E ABNL
2PIN DUNI DFIX =SLOW

SSN Unit
I4-eathing ont Rate Rhythm 0 Tachy Brady
0 Sporad Eyen 0 Abnl Quality D.Rei: 0 Deep 0 Labored
iAkShall Sonorous0 Weak 0 Assisted 0 0, L/min 0 Ambu 0 Vent BBS RO,CLR 0 RLS WHZ 0 ABS L 0 RLS WHZ ABS
MOI/DESCRIPTION
o Biunt -Rrenetrating 0 Burn D B last if-GS W 0 Heat 0 MVC 0 Shrapnel Chem
Fall El Stabbed Li Elect 0 Assault WITH SEE 9:s
Other EST °A
°cation
Circulation Cir-L.Spont Lj CPR
Rhythm L REG D TACH LI BRDY Pulse Stron.cl Vv'eak E Thread
BIP 0 RAD 80 D FEM 70 CTD 60 PASG E Leus ABD Both
I Vs 41 L!,a
47 “a
43 oa
Tourniquet "'" lk. 1)en
wh y
K_Other
EQUIPMENT
Weapon
-7 Sens Items

= Other
Vitals: HR Z5 B/P 90/50 RR PDX /PV ",) TEMP -C
DATE/TIME
NOTES
Pi175 n , iffirog
c-- sct2 1-0-72T671)13
. . • •
."',:
4"..1,4WWW-tycari.%
' PaiA.
r;
MEDCOM - 23918

T
0.111.11 ria: • .8.., 7 , l./ V 1 1 1-, a .........-_

PROGRESS NOTES
MEDICAL RECORD
1-....-e_mia../1
ii 6 F41-11): .--7-_ POD: '.-Y'
Admission Date: 12- (\.[-W 0 Diaonosis: (1, Tm f p Skin assessment must be done. initially and every 7 days.
Braden Evaluation Table for Details)Braden Seale Evaluation (See
(:)/ Mobility No limitationsSensory No impairment , Slightly limitedPerception Slightly limited 4 Very limitedVery. limited Completely immobileCompleted
.)•
• 4
Nutrition Excellent
Moisture Rarely moist Adequate (Eats 50%) CO SOccasionally moist Adequate (Rarely eats)Moist I Very poorConstantly moist Friction and No apparent problemActivity Walks frequently Shear Potential problemsWalks occasionally 7 Problems
Chairfast
Bedfast

Total Score:
Add the total score
k. _ . -_t Low Risk
& : a.. een 16 and it—Ftr

itrt ' s4c.,,
Between 1 ana 1 - • is-k----'
Beinw 10 Very High Risk

HIGH RISK-requires immediate Ulcer Prevention program.
Note: A Braden Scale Score of less than 15 indicates Drainaoe:
Surgical wound (s): Yes No Location: Size:
Tubes:

Pins: Appearance: Dressing change:
.
Duni wound (s): Yes No % BSA Partial Full
Location:

Size
Appearance:
Dressing change:
Pressure Ulcer (s): Yes yNo
Stage I, 11, Ill. V Circle the one that applies and describe below)
Size: 7,4_,„,... is --z_( c-r1

Location:
Granulation tissue CO Yellow slough. (6-Tunneling/6
Wound chara er: Pink_givloist_(7)Drvj
Odsrurulent discharge (1,f) Eschar e Exudates 0
Undermining
Type of dressing change: Vv'et-to- rv a Comfeel dress: _ Carrasyn-V Gel Alginate „....

VII
YP '' Date4ime MD notified
Physician notified/consulted for -wound debridement:
CNS notified/consulted for Stage il and gr • : Yes ' o
Nutrition Referral: Yes _______ No
Physical Therapy Referral: Yt.. At.. N o

_____ae_f_ CSS____
! Action taken: k-'v. firiz42-..... Date SI Time 2-0i
I 1 ' ' r F • • 6-ed . -• ,,, : , ',I'll ,•,
-7-1- IV i un Vfl
J'alient'N identific:itiv,:t (For t)Tet! or written entries ¦.:tee: 7.1:1111C-hlti%
PROGUISS NOTI-ZS
Cr:We: null:: hospital or rneilient
7;h:clic:II Record
STANDARD FORM Nig
MEDCOM - 23920
-T
•v 1..5.1._II•JJ .“...1,7-,,,,..-• ¦ • ¦.-- - -
173Mil.,1 JAW./
PROGRESS NOTES
MEDICAL RECORD
r
/ a-
Diagnosis: ' hiceitYVV.k-X HD: POD.
Ad mission Date: .r.1--1\‘ OV
Skin assessment !mist be donc initially and every 7 days.
Braden Scale Evaluation (See Braden Evaluation Table for Details)
Mobility No limitations 4
Sensory No impairment
Slightly limited 3
Perception Sli9.,litly limited 3
7 Very limited OA
Very limited
Com•letely immobile
1
Completed
4
Nutrition Excellent
Moisture Rarely moist
Adequate (Eats 50%) CD
Occasionally moist
-? Adequate (Rarely eats) 2 L.S
Moist
I
Very. poor
Constantly moist -
Activity Walks frequently Walks occasionally Chairfast C)7 i". -;" Friction and Shear No apparent problem Potential problems Problems 3 1 Ci',1
Bedfast --Total Score:f\I
A dd the :WO score
Above 20 1 ow Risk
' etween 16 and 20 Medium Ris
.etween 11 and 15 High Risk
Below 10 Very High Risk

Note: A Braden Scale Score of less than 15 indicates HIGH RISK-requires immediate Ulcer Prevention program.
Size: Drainage:Surgical ,,vound (s): Yes__ No__ Location: Pins: Appearance:
Tubes:
Dressing, change:

Partial Full
Burn wound (s): Yes No__ % BSA
SizeLocation: Appearance: Dressing change:
Pressure Ulcer (s): Yesi41 No (Circ e the one that applies and describe below)
Staae I, Size:Location: Tunn ng
1-1)-- Granulation tissu, slowah
Wounci character: PinkSois
Eschar )9 Exudates
Underrniningdor- Purulent disclerLe, Carrasyn-V Ge Alginate
Type of dressing change: Wet-to-df5Q_ Comfeel dr sing
teitime MD notifiedPhysician notified!consulted for wound. debridernent: Y CNS notified:consulted for Staae 11 and greater: Yes. Nutrition Referral: Yes No Physical Therapy R.eferrak Yes 0 No Date & Tirne RA-k 1--\ 177
Acti.,:n taken:
REGIS': ER NO. wAim
Name-last. first, middle: PROCRESS NOTES
l'atient's identification trot typed tit ,rittelt entries ive:
C;r3de: ran!:: hospital or medical facility)
Medico: Record STANDARD FORM 509
MEDCOM - 23921
Proaress Notes
Medical Record
Braden Scale Evaluation

id 5 Q3 No Lirnitations 4
Mobility
Nk.) Impairtrient
Sensor.- Sli,-ht.1%- Limited
Limite.c1 3
Perception Very Limited Very Limited Completely Imm.obile 1
1
Completely Impaired Excellent
Nutrition
Rarely Moist Adequate (Eats 50P.-0)C1)
Moisture
Occasiorially Moist Adequate. (rarely -eats) _ Moist Very Poor 1
¦.. Moist
Constantl No Apparent Problem
Friction
4
Walks Frequently Potential Problem
Activity and
3
Walks Occasionally
Problems
Shear
Chairt-ast Bedfat Total Score: JY_ Score 15 re.quires Immediate oN.v Risk
Clce_r Prevention Program.
Above 20 Med Risk
16-19
Risk
11-15 Very Hig..h Risk
Below 10
4
No Limitations
Date: Nlobility
No Impair-a-tent 3
Sli2htly LimitedSensors;
Perception SliahtlY Limited 3 Ver.,. Limited Very Limited Completely Immobile 1
Irn. paired 1 4
Excellent
Nutrition
4
Rarely Moist Adequate (Eats f09/0)
Moisture Occasionally Moist. 3 Adequate (rarely eats)
Very Poor
3
ConszahtlY No Apparent Probie.m
Friction
W2.1ks Frequentl- Potential Problem
Activity and
3
\Valks Occasionally
Problerr:s
Shear 1
Bedfast Total Score: Scor-e 15 requires Immecliate. 1.:1cer Preven7.ion Proara-.-.1
A'cove '0
P..i-zk
11-15 Ver..
10
No. F0:71 51)9
S
Patlert
MEDCOM - 23922
Progress Notes
Medical Record Wound and Skin Assessment Date and Time foqi,5/ 3 / )0C) Wound number 0 yk_S VOtrgical or Non-Su rgical noy-)—_s u ce.A)
Stage I-IV
Location 12-

n cf•-) le r\g`14- •
Shape 0\Jt Nleasurements 1 in UosId-tfn C-
Tissue Color aa
Drains and Type n cyyk-s
Drainage (amt and color) 0-1A—sc
cx-r\-Q

Dressing, Type czyk.Q Wound Cleansina y--)c)-yt—Q
Dressing Change Frequency
Additional.Info (turning, elevation of extremeties, etc.)

g
f v"\ ° Wound number
Date and Time
Surgical or Non-Surgical

Stage I-IV
Location
Measurements

Shape
Tissue Color
Drains and Type
Drainage (amt and color)
Dressing Type

Wound Cleansing
Dressing Change Frequency
Additional Info (turning, elevation of extremeties, etc.)

Wound number
Date and Time
Surgical or Non-Surgical

Stag,e
Location.
Measurements

Shape
Tissue C,olor
Drains and Type
Drainag,e (amt and color)
Dressing Type

Wound Cleansina
Dressing Change Frequency
Additional Info (aiming. elevation of extremeties. etc.)

Unit No.
Patient ID:
Standard Form 509 l•
I
Ala
MEDCOM - 23923
Progress Notes
Medical Record Wound and Skin Assessment
Wound number
Date and Tim.e.1.4-CAS.b/Ila
r Non-Suraical

Staoe I-IV
Location • • 6-"IC' cR
Nleasurements

Shape ¦„Thail_ \A
Tissue Color
Drains and I); pe
Drainag_e (arra and color)
Dressing_ Type -0

\Vound Cleansing. 3,0_0(7--
Dressing Change Freqtiency
Additional Info (turning, elevation of extremeties, etc.)

0-ks,-.9 Wound number
Date and Time o r Non-SurgicalStale I-IV
V.
Location _ tb: 0.
0
ivIeasurements
Shape ' L‘ •
Tissue Color AA') 0\ 41 A -k SO-e-)Ef

(D`
Drains and Type Drainage (amt and color) 0?-0 0.16'._ t t.0 • I_ _Atm S I A Dressing Type Q,
Wound Cleansing ;,(N 0C
Dressing.. Change Frequencv
Additional Info (turning, elevation of extremeties, etc.)

Wound number
Date and Time 1...92.,C.045 CA 9t5leb S.
2i 1 or Non-Surgical
Stage I-I'V ----6---, (-87.717-a
Location. CD_____ p Y1 sAes A-0 E.,e,_q-ske y:A_
-Measurements —

Shape r12 ,La
Tissue Color a • L. • 1.16 t . 4i IPA
Drains and Type

Draina2e (amt and color)-10AW 4C)t) SQ)(o-t__) d, Dressing_ Type---a----Wound Cleansina.6111
..,
Additional Info (turning_ elevation of extremeties, etc.)

Dressing Chanue Frequency -7-_-)=-13) Unit No.
Patient ID:
Standard Form 509
MEDCOM - 23924

Medical Record
Progress Notes Wound and Skin Assessment
Date and Time
1.9-be.o5 Occ;.Q.0 Wound number
Stage I-IV UNONckit. o as`g_ZS Surgical or 1C-rgica-l-
Location Et) YuLt2L-

Shape oh\ (nick Measurements (Ippabc,_„21Qe jiao_x
Tissue Color
s and Type .
color)... Drainage (amt and
Dressing, Type
Dressing Change Frequency

Wound Cleansing
Additional Info (Liming, elevation of extremeties, etc.)-7
cc,oxy) cionu* paddV4

-
Date and Time () CT( 51 Wound number
Stage I-IV

or Non-Surgical ej___E_
Location

Shape On
14& • • Measurements
Tissue Color p..,(1)(1 ON-Ounk-A.a`

Drains and Ty0
Drainage (amt and color) 0
Dressing, Type U—.)

r-C, 1..15
Dressing Change. Frequency eiii) Wound Cleansing

Pr 4-0 &So' CO2a1Q16:5
Additional Info (turning, elevation of extremeties, etc.)
Date and Time beg". 01.1) Wound number
Stag,e I-IV

or Non-Surgical
Location 0‘..-\-4-e2r- S(242..c4

fy\k)(-4(-0
Shape c..),(169&‘¦ Measurements
TIssue Color

bOAS? _ 51' Q
Drains and Typ f`e:-::),--ill
.
„
Drainage (arnt and color) _AA\ c-R ,, ). clrat Acapt. 4-0 day drp S5 11/t '1.31„, odjr-
Dressing, Ty-pe ¦,...5-6- ---', iliW-LAC-1,-)
Dressing Change Frequency U -.--g,...i) Wound Cleansin.g j 0 0 f_____
Additional Info (turning_ elevation of extremeties, etc.)

Patient ID:
Unit No. Standard Form 509
-
C11111111,
OM - 23925
Medical Record
Prog4ress Notes Braden Scale Evaluation
,
t -OaJr._
Sensor-N. Perception No Ii-..1p.).:rment Limited No Limir.,ror,s
Moisture Very L:mited Impaired Nlokt Occas:or—illv N.foisc Mok: Nutrition Tirniced Very Limited Completely Immobile Excellent 4 Adequate (Eats 509..6) 0
Activity Consta:-..c1N. Moist Walks Frequently Walks Occasionally Chair:list Bec11-1k: 1 4 Friction and Shear Adecivatz_- (rarely eats) 2 Very Poor No Apparent Problem 3 Potential Problz.--.m Problems 1
Above-20 LoY. Total Score.: 317_

Score 15 requires ImmediateMed
11-1) L.-Icer Prevention Program
Hicr'n Risk
Below 10
Very 1-fi,2h Risk
Sensory
No 1m-2a:rt.-nem
4
Mobility
Perception .No Limitations
Sli.ahtly Limited 3
Slig.htly Limite.d
Very Limited 3
Very Limited
Compietely Impaired I
Moisture Com. plecely Immobile 1
Nfoist -r
Nutrition
Excellent .
4
OccasicnallyIN/r.oist
3
Adequate (Eats 50%) 3
Nlois:
Adequate (rarely eats) 2
_
Constant!.. Moist
A c tivi 1 Very Poor 1
\valks Frequently
4 Friction
No Apparent Probiem 3
Waiks 0,:casionallv
3 and
Potential Problem -,
Chair:Tas:
Shear
Proble.ms
BedCas: 1
A'cove 20 Tc,tal Score: Score 15 re...:-.u:res Irnmec_:iate Lice:. Prevention Proctram Be;o..N. I()
Risk
Patfen: (1): Yo. R:a7-12:-4 !Thrni 509
\D L LP — Lik
Cll. i

MEDCOM - 23926
PLAN OF CARE FOR SKIN BREAKDOWN AND WOUND MANAGEM N
MEDICAL RECORD

PROGRESS NOAS
Admission Date: Diagnosis:tUermx-/-hiocoptAID: c::2 Pop: cV(0

,.-
Date:(„0",e02, Time0L04:DO RN Signature:
if) ( (4) -2_ Skin breakdown as evidenced by immobility, friction, shea abrasions, surgica ound, skin tear.
.
Wound typefgurTsal wound (11) Size:-"a-\\C""64:1rainaae:
Locationkt -F-,-.,
3V
Diabetic ulcer Pins: itS
Tubes: a,ance: Venous stasis ulcer Dressing change: Other Describe Burn wound (s): % BSA Partial Full 1_,I5cation: Size Appearance: . Dressing change:
.
Pressure Ulcer (s):
Stage I, II, III, IV (Circle the one that applies and describe below) uir3)(6\s„;\-c•

0._.9Se...5/eviahlasi-
Location: KiakS.-. Size:
.
Wound character: Pink Moist Dry Granulation tissue Yellow slough
Tunneling Undermining Odor Purulent discharge Eschar .)6 Exudates

Refer to SOP for Dressing Change
Instrucitons.

0 Petrolatum gauze
Please check the appropriate Select the appropriate products 0 Hibicleanse
dressing Change: used: 0

Non-adhesive dressing 0 Telpha Pad0 Wet to Dry Dressing Ali Sterile 4x4 gauze dressing 0 Carra-smart film 0 Sterile 2x2 gauze dressing -14 Sterile Q-tip applicator0 Carrasyn-V GelDressing At Sterile gloves 0 Xeroform 5 x 9.
SX Kerlix (super sponge) 0 Moisture ban-ier cream 0 Alginate Dressing 0 Gauze bandage 0.125% Dakins sol
0 pil Sterile Norrnal Saline
Betadine Swab sticks 0 Comfeel Dressing, 0 Sterile Water
'A Hydrogen Peroxide & Y2 . 0
8 x 4 Sponge gauze Sterile Normal SalineX Pin Site Care 0 Op-site
0 Tegaderrn clear dressing Select the frequency of dressing0 J-Tube Care 0 Alkare skin prep chanae: 0 Comfeel clear 0 Colostomy Care 0 Cornfeel pressure ulcer drsg „IV b.i.d. 0 Carrasyn-V Gel 0 t.i.d 0 Chest Tube Care 0 Alginate 0 Bacitracin 0 Burn Care 0 Silvadene Cream MD Signature and Date:
NOTE: Document daily wound and
CNS Signature and Date:dressing change on Progress Note or Nursing Note.
Patient's Identification (For typed or written entries give: Name-last, first, middle:
Medical Record, SF 509
Grade; rank; hospital or medical facility)
, MEDCOM - 23927
i -
DOD-037505

- MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5

SECTION I -PATIENT ASSESSMENT
DATE:

.D--5 ' 0 3 PATIENT ACUITY LEVEL : m POST-OP DAY: HOSPITAL DAY:
C.____--
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT T9AN ER IN -TELEPHONE REPORT: . ‘
Time (-3 q35 To cl-CU-.1 ---.-From ..TC M AM ATORY i CRUTCHES III WHEELCHAIR STRETCHER
bt Ct''' 1—
T Total ER/RR/PACU time Physician Anesthesia (Specify):
_
R
Procedure/Diagnosis (3 a ce/Y11J4 fi B/P )61/64 p )16• R i g'''' T 1.q.4
A. )tN LOC Neurovascular checks 71F
r .
s Dressing/cast

el(-E-i 1 1_( gQ) 5 1 Cif\ ev,t-d- 6._ ra ifTubes Ai F Intake (IV, po) (--C._ C C, Output (EBL, other) Voided II No
Yes Amount:
E Medication r- 1019.. ci rreol CI 6 -LS t-5 • -.

R
Other \ D° — --
L.---.
Report From (._
Received By
TIME:
IMIDIMMEIM
.:, BP ARTERIAL LINE al

UM
V BP CUFF 1 °. T .rigilicAlFA
TEMPERATURE

I BIM=q. . StiR
PULSE
A II' 1(0 1 I
L RESPIRATORY RATE -if'" f' 0_0
OXYGEN (Li%)
PULSE OXIMETER
S pd-xt. /ca let Li 36
-02 METHOD
G a 4, ±24 eik
N
S

NC = Nasal cannula NR = Non rebreather
FM = Face mask VM = Ventu i mask MT = Mist tent PR = Partial rebreather A = Aerosol TC = Tract) collar Oxygen Method Key:
TimE: TIME: 061
ire) 7,,,,, gba cza) 1100
to 'Skin breakdown •• prevention i66 &II)PAIN • •
p • Falls prevention protocol 1,/ 4
INTENSITY
efil
. . . . .
A ' ...• . • E . Restraint protocol
C

o A
I it :
MED ADMINISTERED (MI • Seizure precautions
RELIEF ACCEPTABLE IY/N1
V • Isolation precautions
1.e..5Cekr---0'
fYlCi•-) 4
TIME:
t E •----. ----•
FINGER STICK GLUCOSE
E YESTERDAY'S WEIG
H INSULIN (YIN) D

T
TODAY'S WEIGHT:
E
WEIGHT CHANGE:
R
'Per hospital policy.
24 HOUR PO _LV # IV #2 TOTAL IN Urine Stool TOTAL OUT
TOTALS
1 \ PATIENT IDENTIFICATION . .
b t ul j- c
DIAGNOSIS:
g np,„,[ce,m,--i-hbic, '''Pl,„._
DRG: ADMISSION DATE: LOS:
EXPECTED RELEASE:_
ko l (/)-"L.
CASE MANAGER:
PRIMARY CARE MANAGER
!SDI ATION RF.OUIRED (Specify):
KAPTIrrIKA _ "YZOOS:t
anent-sr-inn con nn c•c)r. 11"1". ¦ ••-•1 tt
DOD-037506

SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check i in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noteo' in the appropriate column.
TIME: ) 00 INITIALS: . TIME: INITIALS: TimE, 49.0.0 1 INITIALS:
k
1. NEUROLOGICAL: Alert and oriented to
'time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
2.
CARDIOVASCULAR: Pulse regular & rate
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)

3.
PULMONARY: Respirations vvithin normal

I I
rate for age group; quiet and regular.. Dep.th is
regular. No cough. No abnormal breath .
sounds.
/
4. -G.I.: Abdomen soft and non-distended.
I I
Bowel sounds active. Reports no NiV/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding. -
5.
G.U.: Reports no dysuria, retention, I I V
urgency, frequency, nocturia. Urine clear,

yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle ii.e.4 VCNc N, P kcp

I 1
.
development and mass for age. No Cy - .ei I toLE... N r\ VO-A25C
deformities. No assistive devices needed.
Normal active ROM without pain. No joint •PC/E-7----re— . -
swelling/tenderness, weakness or paresthesia. KA-,_.(cile-Lik itf, 44,13 oi
I
7. SKIN: Warm, dry, intact. Good turgor. No
0-1a.h.40 it) I I I /-3011.1c15 0
rashes, inflammation, ulcers, breaks in skin.
S\SIO (XO.VA" COS.19
No redness, blanching, irritation over bony
4 Vega-1 5' ItAn , ,r
prominences. MUCOUS membranes moist.
c (CM -1.0 .0 it-
8. PAIN: No complaints of pain/ discomfort. ri
\,('
(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.
10. IV SITE ASSESSMENT: (LEGEND: P Puffy I -Infiltrated R -Reddened OK -No swelling/redness * -Central line)
TIME: 1 C3 INITIALS: TIME: INITIALS: TIME:t99-QA INITIALS: ei'31
IV patency ,/ q 'Ci. 11:.: ri fj IV patency ,/ q hr: IV patency „/ q ''''Z--hr: ?lap
IV site care provided: 0.55-es-ccd -IV site care provided: IV site care provided: p65e.„.s,e.„..1
IV tubing changed: / IV tubing changed: IV tubing change.d:
LocAtior4 CONDITtON LOCA710 CONDITION LOCATION CONDITION IV Site #1: (45c_ IV Site #1: IV Site #1:
OK a---) SC_ c-
IV Site #2: IV Site #2: IV Site #2:
Comments:
14t 0 . Comments: Comments:
.&'` Va\_)_ r-e-Orrl
c' A
.00 5\(LsLS OCL•k--W
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 2 of 4 pages
MEDCOM - 23929
DOD-037507
SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: TIME: TIME:
COLOR ID band visible/legible
CAPILLARY REFILL A Orient to environment prn
TEMPERATURE Side rails (2/4) up
EDEMA Bed position low
SENSATION Call light within reach
MOTION
PASSIVE FLEXION Review & post lab results
PERIPHERAL PULSE Notify MD abnormal labs

A
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stool
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs) Linen change prn
Temperature: C-cool; W-warm; H-hot

Turn/reposition q211
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting •
ROM q2h if immobile
A Sensation: A-absent; N-numb; T,tingling; S-sensation (present)
Antiembolic hose
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH DINNER
TYPE: TYPE: • TYPE:
ED: )-ZUMED: PERCENT CO SUMED: •70

PERCENT CO PERCENT C(:OLERATED: HOW TOLERATED: 4Avt.) HOW TOLERATED: Ivey-0 SELF 0 ASSIST 0 COMPLETE SELF ASSIST D COMPLETE SELF ASSIST El COMPLETE 0700-(500 1500-2300 2300-0700
SELF E.] COMPLETE D SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE
ASSIST Ej TOTAL 0 ASSIST El TOTAL NI ASSIST TOTAL
c-g-Ef 0 SELF BEDREST SELF EDRE 0 SELF AMBULATE 0 ASSIST AMBULATE ASSIST (AMBU )4 ASSIST TYPE OF ACTIVITY
BSC BSC BSC efOk"
(Circle all that apply) # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT
BRP BRP BRP
CHAIR CHAIR CHAIR
TIME: INITIALW TIME: INITIALS: -rimE? POD
CONTENT: CONTENT: CONTENT:
/) W0181 5facrr
`D'ouss\\
A

di) col-a-FM') QcoLA¦
rercood--.-r porn
0 st-e-rpN pi ILS
Ch fA8 41m da
0 Patient/Family Verbalize Unclersta 1ding atient/Family Verbalizes Understanding 4datilatrik erbalizes Understanding
/ \
PATIENT IDENTIFICATION
SHIFT
6( a) ---&)
MEDCOM FORM 689-R (TESTI IMCHO) MAR 99 MEDCOM - 23930 Page 3 of 4 pages
1-0

SECTION III -INTERVENTIONS & TEACHING (Cont)
T
W I TREATMENTS

LOCATION OF WOUND
APPEARANCE
M AND
0 E
DRESSING CHANGE
000—(1 V / flit? CFI
1\00 LE ,
. / 12,56- S CD" II
LL E
2) Ps 6- s C D:r.-W/
--,,ve._2__ pit4,44-1--..Aco,:cr).74-7-,-; .vi-c?5--.' . tv...-R-f,bni,expcF.g.c.) t,
¦, ---513----
eSI La
claer..14._.{(1/acke foll¦ . _ '
SECTION IV -NOTES
irOo; w---hc --lb . u.lard iiic4 wheel I r-in s jab ron di -hen-, _r_c_r_,„ :11----cuiv_tu,___ . --)-0 ry.) 1 ofsw - CDA- No 0e-¦/1( \-\\.\o. R-i-NSDO s\y2
_ __ .. Ao
)
_L, (c..,,--L
MEDCOM FORM 6.99-R (TEST) (MCHO) MAR 99
Page 4 of 4 pages
MEDCOM - 23931
Dressing/cast Tubes
u-Intake (IV, po) Output (EBL, other) Voided II No . Yes Amount:
Lucc Meciication
Other
I Report Front Received By •
TIMEQS[Cie, /AA Wial tf....(P4
BP ARTERIAL LINE ..¦-!7 lt i) Wi-Ge)
TEMPERATURE PULSE acilPIA 25 01 LSIO I In .
RESPIRATORY RATE 9.C1) iy "..fai, ....--. 2.0
OXYGEN (L/%)
PULSE OXIMETER
02 METHOD

z
-
MEDICAL RECORD PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT DATE: , , PATIENT ACUITY LEVEL-: POST-OP DAY: ,„ ,f HOSPITAL DAY:
....
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT: Time
To F10111 II AMBULATORY II CRUTCHES III WHEELCHAIR 111 STRETCHER Total ER/RR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P P R
T ' LOC Neurovascular checks
askOxygen Method Key:
ar
TIME:
OVE) 0 o
10 4,
PAIN
INTENSITY

(2: : : A44-
A •• • • •• • •
• ")e
MED ADMINISTERED IY/N) ------------ ------1-
RELIEF ACCEPTABLE IY/N)
(N*-
4AS0
'
TIME:
FINGER STICK. GLUCOSE
INSULIN IY/N)
24 HOUR PO I V #1 IV #2 TOTAL IN Urine Stool TOTAL OUT TOTALS
PATIENT IDENTIFICATION
voJa3
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
1 ni crrinnic• A 1 i, / • 1
.„.., -- • --,-, ,.,,“..-, ,,
,,, ,,,..- ..,,,,,,,,, Liu.; moicarus patient assessment criteria have been MET.
If all the stated criteria are not met, a briefexplanation of abnormal lindings will be noted in the appropriate column.
-X.
TIME: 0 cy3 INITI 11):: 1,2,C0i INITIALS• TIME: INITIAL S:
. 1. NEUROLOGICAL: time piace and name. Alert and oriented to Responds appropriately. Tjj I 1
Communication is adequate to express needs.
, Pupils equal and reactive to light.
f
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. rd,/ _ I . ' 1 1
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusionl

3. PULMONARY:
Respirations withir. norma! rate for age group; quiet and regular. I 1
Depth is . regular.
No cough. No abnormal breath
,
sounds.
/
—
4. G.I.: Abdomen soft and non-distended.
IS fr\ 1 e ?Ca" ri
Bowel sounds active. Reports no N/V/pain PA )e / with eating and no problems chewing/ SC4f 'Perr'".261 swallowing. Denies constipation, diarrhea or .• IgYlk Si-co 1
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
V
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.
/,..
6.
MUSCULDSKELETAL: Normal muscle
11 '-',A-T-•.X•2 10 LI-e)&E .-RY. (441 .CgiLe
development and mass for age. No
i.- C--.. , - pit, Z CCM A-06LE
deformities. No assistive devices needed. cif brq 644 --le. Normal active ROM without pain. e. 4,, •
No joint J. 716 swelling!tenderness, weakness or paresthesia.
z-
cr.,. 4-d-te 5, 068-TC „v /
7. SKIN: Warn), dry, intact. Good turgor.
No I • I kio ,./..jc" 4.0 0 ,f
I.- 04,1-Nryc Ilk- -Kgr..1/11
rashes, inflammation, ulcers, breaks in skin.
\ A-I(M (Ax44,40
No redness, blanching, irritation over bony fil 7.7, A , ;',,,n 4.-.4- ,-;,., 312/'
. prominences. Muccus membranes moist. LC' . r fr.r ,-
C.-I I P . e,,,, 5. i-e5.. —wou.-40(- i-e.) to Le-
8. PAIN:
Nc complaints of pain/ discomfort. r1 C--/ ./7 , s'i.‘ /
ac-,, c., -
(See page 1 for documenting pain intensity.) 1--/ 16 C (of
ea.41v\-,
z- Eft`1562, Pk,:
i
_ j---1/0", ,`1.-ei,
9. PSYCHOSOCLAL: —
Behavior is appropriate to the situation. —
Anxiety is controlled or mild and appropriate to situation.
Interacts appropriately with others.
.,,--b6.-,2-
io. IV SITF AC.CPCCNIICArr• -----\
u .y - n rate
-e dened OK - No ¦velling/redness * • Central line)
rIME: /36
TIME: 472CD INITIALS: TIME:
INITIALS:
IV patency q hr.
IV patency ,/ q hr:
IV patency ,/ q hr: IV site care provided:
IV site care provided:
IV site care provided: IV tubing changed:
IV tubing changed: IV tubing changed:
LOCATION
CONDITION
5
LOCATION CONDITION LOCATION CONDITION
IV Site 4'1:
IV Site 4' 1:uktyalt OSC)
IV Site #1: IV Site
Ck
!V Site #2:
IV Site 4'2:
Comments:
Comments: {-t-t."4.
Comments:
(14-4/0_
pCk. ajlirr¦
Aft.'.9COM FCRN! 6,39-R (TEST) (I1,1CHOI /11AR 99 MEDCOM - 23933
Page 2 of 4 pages
DOD-037511

SECT 4 -PATIENT INTERVENTIONS & TErCHING
1--- KA
.....
TIME:
TsiTc: irg ‘,„ TIME: OZEU1621 017 =01
ID band visible/legible
COLOR
mrati i 41 it.'I
CAPILLARY REFILL Orient to environment prn
MEM
E.
Mril
Side rails (2/4) ug
Ira
U..1.11 0 11) CC
TEMPERATURE
I ell"
SENSATION Cali light within reach
5 al S )114
,
----i
w
CC0 ce) . 0 CC '
Berl postion low
EDEMA
NMI
gl
Review & post lab results
Vi El
Ail

MOTION
PASSIVE FLEXION
PERIPHERAL PULSE Notify MD abnormal labs
MUNE
LEGEND
AIME
riga
IV
Incontinent urine/stool
Color: P-pink (normal); C-cyanotic; W-pale, white Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-( 5 secs)
Linen change prn .
Temperature: C-cool; W-warm; H-hpt
Turn/reposition g2h ./17.4
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting ROM g2h if immobile
Antiembolic hose Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
MotiPn: U-unable to move; NI-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
..

D-doppler, P-palpable BREAKFAST LUNCH
DINNER
TYPE: TYPE: TYPE:
PERCENT CO UMED: I 0 PERCENT CONSUNIED: PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED:
,,../e ii
F.SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE
0700-1500 1500-2300 2300-0700 0 SELF E7COMPLETE CJ SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE Ell ASSIST 0 TOTAL ASSIST 0 TOTAL 0 ASSIST 0 TOTAL
D
BEDREST 0 S,ELF BEDREST . 0 SELF BEDREST 0 SELF L ."-ASSIST A 1 :ULAT E_XASSIST AMBULATE 0 ASSIST
AMBULATE 121
TYPE OF ACTIVITY •
BSC lab BSC
(Circle all that apply) # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT
BRP BAP BRP itgletbs HAIR b ig'2 CHAIR
TIME: INITIAL TIME: INITIALS: TIME: INITIALS:
ity?-3,9
CONTENT: CONTENT: , CONTENT:
.
--frtiry.,(vavrvi1/47K.ruct
— P/°..ri Of Care
A —.PS(c) .6.`c
,_ 1 ,
ta, ,.. c.,„,.. ),-0 ( —caV _..efr cii,)(6--i-et"
N G
•
i tient arnily Verbalizes Understanding Patient Family Verbalizes Understanding 0 Patient/Family Verba!izes Understanding--,----'
PATIENT IDcNTIFICATION
1,(62-)-cf MEDCOM FORM 6479-R (TEST) (MOHO) MAR 99 INITIALS MEDCOM - 23934 SIGNATURE SHIFT ,..74.t.__.,_ u,,,v___ e-/-abz. 4 . Page 3 of 4 pagcs
DOD-037512

SECTION III - INTERVENTIONS & TEACHING (Cont)
LOCATION OF WOUND APPEARANCE TREATMENTS AND DRESSING CHANGE

43 1At int
fau.-al¦
SECTION IV - NOTES
MEOCOM FORM 689-R (TEST) (MOHO' 111.4R S.-19
MEDCOM - 23935
Page 4 of 4 pages
DOD-037513

MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT DATE: 0 012e.C)R PATIENT ACUITY LEVEL : I POST-OP DAY: (.1)1p 1 HOS1?ITAL DAY: g..25
.
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN Time To From 1 AMBULATORY • CRUTCHES N WHEELCHAIR II ST RET C HER
.
-TELEPHONE REPORT:
s
N
A.
R.
T
Physician Anesthesia (Specify):
B/P P R T
NeuroVascular checks Total ER/RR/PACU time
Procedure/Diagnosis
'e4t
LOC
BP ARTERIAL LINE BP CUFF
Z C/) LC.LUCL I "-
I — Z
Dressing/cast Output (EBL, other)
Received By
TIME: UM .,...pr.40 QVI..(24:)
F.
Voided
2 • z II
Yes Amount:Intake (IV, po)
'V'
....!
.
R
E
Medication Other Report From
110

I II /1/1 I 17/4
TEMPERATURE
1 1 IV
1
PULSE
16 ID/
RESPIRATORY RATE a)...., Ao .
OXYGEN (Li%)
PULSE OXIMETER I 0"::-pee*
02 METHOD ,

NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask
Oxygen Method Key:
MT = Mist tent PR = Partial rebrea her A = Aerosol TC = Trach collar
TIME: 06,147 jarC9-000
m ••
PAIN
INTENSITY
o ••

V
MED ADMINISTERED IY/N) RELIEF ACCEPTABLE IY/N)
feft pc.e.'t
TIME: FINGER STICK GLUCOSE
TIME: (vonto -Skin breakdovvn prevention
AiAl
p • Falls prevention protocol
• Restraint protocol C -----• -
*Seizure precautions A • Isolation precautions
E
E YESTERDAY'S WEIGHT:

T
H INSULIN IY/NI D TODAY'S WEIG • E WEIGHT CHANGE:
R
'Per hospital policy.
24 HOUR PO IV #1 IV #2 TOTAL IN Urine Stool '................"7Z11.4sOUT
TOTALS

PATIENT IDENTIFICATION
cv•
DIAGNOSIS: '1' LA _ -ceAlutAi
PI .., I - ... • ... L itt_I
DRG: ADMISSION DATE:
b ((Q-_¦-(4
LOS: EXPECTED RELEASE: 1.0\1\7:1) in CASE MANAGER:

ell=
PRIMARY CARE MANAGER: 67
-1 1\ l'Af1-0
. — - ----. —OUIRED (Specify):
MEDCOM -23936
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
in the small box indicates patient assessment criteria'have been MET. If all the slated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
DIRECTIONS: A check 1
b (60--/
-.1:mmizr
TIME: G INITIAL TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
2.
CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

3.
PULMONARY: Respirations withir. normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath

sounds.

4.
G.I.: Abdomen soft and non-distended.

Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
5.
G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swellingitenderness, weakness or paresthesia.

7.
SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

8.
PAIN: Nc complaints of pain/ discornfort.

(See page I lor documenting pain intensity.)
_
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

io. Iv SITE ASSESSMENT: (LEGEND: P
,fii „/ ;.,TIME: (.1(i (16/ INITIALS
IV patency ../ q hr:
_
IV site care provided:

IV tubing changed:
LOCATION CONOITION
IV Site # 1: 0 S.---.
V.L
;V Site #2:

Comments:
....___
',IF:DOOM FORM 689-R (TEST) (MOHO) MAR 99
2-
..
.../
n ,k/L,r 400ZE ('-A Ofi\ 4-c, OLE , 00e' ra clk.:r -rx. D ,
5 el, /. c 40 eiete1;61 t.,D,,,ricl5 4of@1•:/7 41® jrner.k- Ov-f-0" C`A 14.* DI) r Dr,
9;„ c: 1-e 5 ,_,, s4 :-, 84:0
*, r.:.-. :, ek,e
i-oe-tve e 4 -7-' ii,e
-' CO
, ,' "

_
dr 1.
'2(441 -1-1)
I I
..
.
I a VIM OLSfnr
(2j-'t.
ULA.4..4--0--K.
`L-16-11-601-6-AC..kz...1 RAA,,,
IODUArlift5 .4-0
LA'S-fW4--
Le-fes--D5%;c c-'04-t

r-4---,-f 0
_I—V
—
b6-0,
Puffy I -Infiltrated R -Reddened OK -No swelling/redness * -Central line) TIME: OW INITIALS: TIME: INITIALS: IV patency ,/ q hr: IV patency ,/ q hr: IV site care provided: IV site't.are provided:
LtalgleA
IV tubing changed: IV tubing clianged:
.,„,
LOCATION CONDITION 'LOCATION CONDITION
.....,
IV Site #1: IV Site #1: -,-... .
DK:-
IV Site #2: IV Site #2: Comments: Comments:
Page 2 of 4 pages
MEDCOM - 23937
DOD-037515

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE:
. rf
TIME: TIME:
646 ad3
COLOR
wil. S ID band visible/legible
161 LI kEarrigiM
CAPILLARY REFILL
Orient to environment prn
IV A MEM=
TEMPERATURE
Side rails (2/4) up
Fra
EDEMA
Bed position low
SENSATION
Call light within reach
MOTION
PASSIVE FLEXION

0
Review & post lab results
rival"
PERIPHERAL PULSE
A ge Notify MD abnormal labs
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, vvhite Incontinent urine/stool
Capillary Refill: 1-(0-2 secs); 2-(3-5-secs); 3-1 5 secs) Linen change prn
Temperature: C-cool; W-warm; H-hot Turn/reposition q211
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
A Sensation: A-absent; N-numb; T-tingling; S-sensation (present) ROM q2h if immobile Motion: U-unable to move; M-move-no pain; P-rnove-pain; R-full ROM Antiembolic hose Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
BREAKFAST LUNCH DINNER
TYPE: TYPE: TYPE:
PERCENT CONSUMED: PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED:
0 SELF 0 ASSIST 0 COMPLETE 0 SELF
0 ASSIST 0 COMPLETE C3
ASSIST 0 COMPLETE 0700-1500
1500-2300 2300-0700
BATH/ORAL CARE 0/ELF 0 COMPLETE 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
ASSIST 0 TOTAL 0 ASSIST 0 TOTAL 0 ASSIST 0 TOTAL
TYPE OF ACTIVITY (Circle all that apply) BEDREST AMBULATE BSC BRP yS.ELF D'ASSIST # TIMES/SHIFT BEDREST AMBULATE BSC BRP El SELF C3 ASSIST tt TIMES/SHIFT BEDREST AMBULATE BSC BRP SELF C3 ASSIST # TIMES/SHIFT
TIME: 0 INIT TIME: CHAIR INITIAL TIME: CHAIR INITIALS:
CONTENT: (7( c ),,G-e)- CONTENT: CO NT: ((,e)
A

fT
tie /Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding I 0 Patient/Family Verbalizes Understanding
PATIEN— ENTIFICATION
INITIALS
bt.c6 -
SHIFT
9/A-Me-110_
MEDCOM FORM 689
R (TEST) (MOHO) MAR 99
MEDCOM - 23938 Fage 3 of 4 pages
SECTION III - INTERVENTIONS & TEACHING (Cont)
T
TREATMENTS

W I
M ANp

LOCATION OF WOUND APPEARANCE
0 E , DRESSING' tHANGE
U Oflo ., Pj" 11,,,` 1-) /Pe,. tr-e.. '

'
, Pe e,frese A-i-14/-* D i's) Afz:- INS
N MO W 'Jr).4 .er ,.. I P ___&/s '
D
/------_ _
_
,
R

.
SECTION IV - NOTES
OG, f(2 . 4 w..,4 c a, --1-_7, , 4-(. 45-I E 4 1 0 c e Z f
;,-)
---i Fee / 6,5-4,1e/k 5' hii f( cc, A /,,,‘ (,-,2 4-0 .7--
b C4..\J- 2-
.

________ ___—
_
-. .... _ ......__ ___ _______ ____
MEDCOryf FORM 689.R (TESTI (MCHO) MAR 99 MEDCOM - 23939
Page 4 al 4 pages
DOD-037517
IVItUlUAL hitl;UHL) -PA rIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5

SECTION I -
PATIENT ASSESSMENT
'k
DATE: 61 Ipee Y3 PATIENT ACUITY LEVEL : 1--POST-OP DAYO-Sh HOSPITAL DAY: G)--
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-
TELEPHONE REPORT:
T R Time To Total ER/RR/PACU time Ff Gill Physician II O ilAMBULATORY c;_,L,TcHEs Anesthesia (Specify): WHEELCHAIR is STRETCHE9
A N Procedure/Diagnosis LOC BIP Neurovascular checks P R T
S Dressing/cast . Tubes
F E Intake (IV, po) M.dication - Output (EBL, other) Voided 0 No Yes Amount:
R Other .
— Report From Received By .
-. THVIE: BP ARTERIAL LINE .-10 IiO400 in I
y I_" T A BP CUFF TEMPERATURc PULSE 01- I c'4"ii . iti 65 I Zell. • Crt 40
L RESPIRATORY RATE ' I • r P_I L
OXYGEN (LI%) IV —
S PULSE OXIMETER I CIS ?if
02 METHOD 'kik' /i+
\I

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask
MT = Mist tent PR = Partial rebreather A = Aerosol
TC = Trach collar TIME: 11,efC2
I to I Titv,E:b5ft,
Skin breakdown ...prevention.
PAIN INTENSITY • Falls prevention protocol
A
• Restraint protocol
MED ADMINISTERED !YINI
• Seizure precautions
REL:EF J
CEPTACLE IY;N:
'Isolation precautions
TI ME:
FINGER ST)CK GLUCOSE ---•
YESTERDAY'S WEIGHT:
INSULIN IY:N)
TODAY'S VIEIGHT: Vv'EIGHT CHANGE:
• Per hospial pol.cy.
24 HOUR PO IV 4'1 IV #2
TOTAL IN Urine
I Stool I
TOTALS TOTAL OUT
PATIENT IDENTIFICAT ON DIAGNOSIS:* Opeiniirctrik1214).1-1,6 a4t DRG: ADMISSION DATE:
10 )uotia3
C.(
LOS:
' =CTED RELEASE:
11111r-

CASE MANAGER:
_ 1((_(--L-) ""
PRIMARY CARE MA, ...:tn.
O.UIRED
MEDCOM - 23940
DOD-037518

SECTION II • PATIENT ASSESSMENT • REVID,V OF SYSTEMS
DIRECTIONS: A check ,/
in the small box inc'icates patient assessment criteria have brii M T.explanation of abnolinal findings will be noteo' in the appropriate 11 all the .51ated criteria ate not met, a brief
COILI17111.
c:7,---____,
TIME 4. INITIALS: TIME: INITI,ILS,
/0 TIME: INITIALS:
1. NEUROLOGICAL:
Alert and oriented to r--
time place and name.

Responds appro;xiately.
Communication is adequate to express n,2eds.
.,

Pupils equal and reactive to light.
.
2. I I
CARDIOVASCULAR: Pulse regular F., rate
I-7
within range for age.
No dependent edema.
Nailbeds and mucous membranes pink.

No call
tenderness.

(See page 3 !or extrernity
perfusion/

3. .
PULMONARY: Respirations withir. norma! FT
rate for ace group; quiet and regular. 1.. '

Depth is .
regular. No cough. No abnormal breath .
sounds.

4. G.I.:
Abdomen soft and non-distended.
T7..
,
i7–'--r
—
Bowel sounds active.
Reports no NiVipz.,in
.vith eating and no problems chewing/
swallowing. . .

Denies constipation. diarrhe.a or
rectal bleeding.

5. G.U.:
Reports no clysuria, retention, 1/ I
„..___.1
urgency. frequency. nocturia. Urine clear, I I
yellow/amber. No unusual discharge.
6.
MUSCULOSKELETAL: Normal muscie.
i i ti/apin )-c) fat L Pr
development and mass fnr age. 11 ,-,1) kjayyt 16) 6 In
No c.,-To o-1,4/1a-E---,-)ssisj.
deformi*.,ies.
No assistive devices needed.
Normal active ROfv1 without pain. No joint 9,0 -i-e) ,Q0-

swe.11inctenderness, v,e,.:kne.ss or paresthesia.
7. SKIN: Warm, dry, intact..
Good turcor. No
I 1 P 1 1L,5 6_7--..)4 Fi Y 7v .____
I
rashes, irf:ammat;on, ulcers, breaks in skin. I I
¦/2-C. i.... 7--1....-tioc.-,-; t..03-Y ..6. 6
No rec'ness, blanchirm, irritation over bony
prominences.

Pv1,.;ccus membranes moist.
8. PAIN:
Nc complaints of pain/ discomfort. rin VG, Prjr.v .../0
LJ 1 1.-:
(See page
7 for decumentmg pain intensity.) l__J
-3-f., 92_24 eitvivi."

,IC2-'9--- ro'')
-
9. PSYCHOSOCIAL: -'"...--I I-T47
Behavior is a:)propriate 1
to the situation.

Anxiety is controlled or mild 1 0
and appropriate to situation.

Interacts
appropriately with others.

.
..,.-....," ,k i (SI--- t '
I
10. IV SITE ASSESSMENT: fLEGr.'N'D.`"P • Puf ry I -Infiltrated Fi -ned
Red
OK - No ,,weIlingiretness * -Central line)
Timr• g-1.,--, ...--- - - -___ _ _
• ___ : TIME: I INITIALS: TifliE:
IhNrItTIALS:
IV patenzy -./
q 5 :Ir.
____ : IV patency ,/ q hr:
1 IV paler.cY 1 g
IV site ca:e Dr.z)vided:
kl,./5/1WI IV size care provided:

I N site care pro./ided:
IV tubnz c"...anged:

IV•tubing changed: IV tubmg changed:
LOCANCN
COnDiT;on
LOCATION
CONDITION
iV Site =1: LOC:.TION CONO:TION
22,77,0 C-L frz,L. Oc__ iv silo 1:
ez..j-y4 IV Site =1:
iV Site =2: k-!v 'zit. =2: IV Site =2:
CC-r.rn er,:s: C o m en s:
Con-x...ents:
—
63_9-fi (TEST) (MCh'C').".!..-IR 99
Paci.., 2 o/ pages
MEDCOM - 23941
DOD-037519

E
U. ...; R
V
A
S
U
L A
R
D
l
E I
SITE: 7— C LOR CAPILLARY REFILL TEMPERATURE EDEMA SENSATION MOTION PASSIVE FLEXION PERIPHERAL PULSE
SECTION III - PATIENT INTERVENTIONS & TEACHING
Color: P•pink (normal); C-cyanotic; W-pale bite Capillary Refill: 1-(0-2 secs); 2-(3-5 Secs); 3-1 5 secs) Temperature: C-cool; W-warm; H-hot Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pining Sensation: A-absent; N-numb; T-tingling; S-sensation (present) Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Passive Flexion: D -dorsal flexion pain; P -plantar flexion pain; 0 -no pain Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable -.
BREAKFAST
I
LUNCH
TYPE: le .SC,)
TYPE:
Rt.,
PERCENT CONSUMED:
PERCENT CONSUMED: 3(9 HOW TOLERATED: I
TIME: IVO ,•"-Orr,
P p P
i 1
,
0
09
5
P ,i
c9
Ai
Al
LEGE
W
TIME:
S ID band visibliMegible A Orient to envirTiri
n (rt am E Sade rails (2/4) up
E
Bed position low
y Call light within reach
Review & post lab results
Notify MD abnormal labs

O Incontinent urineistool T Linen change prn
H Tu7r,ireposition q2h E ROM q2h if immobile R Anticmholic hose
....,55ci,e) 4101.C.34
-
e3
;.-13 pr
4/7
,-----r 1
al
1.-
IMIII

PP"
HOW TOLERATED: LA)-. t( HOW TOLERAT ii: 4) PO
ELF . ASSIST 0 COMPLETE I
.SELF . ASSIST . COMPLETE \ LF . ASSIST . COMPLETE
II 0700-1500 1500-2300 2300-0700
. SELF . COMPLETE .

SELF . COMPLETE LF . COMF TE
. - DINNER
TYPE:
ON

PERCENT CONS Ai ED: _as„-.
..Y=1
Q
Lu Z o zo
BATH/ORAL CARE
›;=TASSIST . TOTAL
C? ASSIST . TOTAL ASSIST . TOTAL
I
BEDREST . SELF BEDREST
. SELF „."--6E-------all , ELF
1:,, AMBULATE . ASSIST AMBULATE . ASSIST .ULATE IiII ASSIST
TYPE OF ACTIVITY
(Circle all that apply) BSC BSC BSC

# TIMES/SHIFT # TIMES/SHIFT # TIMESiSHIFT
BRP
P
BRP CH-ATFr¦
CHAIR
TIME: INITIALS: TIME:
.r?Ot-D INITIALS:
E: CZ- — INITIALS:
\ CONTENT: 4-7 co, 7--
eiriki.? CONTENT: . • , ,•• — ” :tr/.
CONTENT:
rn-e-3.
e441)./ 4-i-C_A--1-ec-4:111 • ‘4,2,
0,14-cs
S
.— OW —fr
i
1
Pailent/Family Vcrhalili!s Understanding
-, ramily Verbalizes Understanding !I__I Patient/Family Verbal i zes Understanding
.
H
q4p.
PATIENT IDENTIFICATION
INITIALS Le, --' ..1—
I SHIFT
\9( ()-) ' f
MEDCOM FORM 669-R (TEST) (MCHO; MAR
99
MEDCOM - 23942 Page 3 of 4 pages
DOD-037520
—
SECTION III -INTERVENTIONS & TEACHING (Com)
T
0 I M E LOCATION OF WOUND APPEARANCE ' TREATN1ENTS AN DRESSING CHANGE
' ., U N D ?)ifo E L ,-' tir/W:; 0 41 . , / oic, -i -.),,..„ WY-_ . , -e' ' d-Zip -C.-at_ t.t) ---LID
,
A
R
SECTiON IV -NOTES
.
.
.
?.,

*
1
. ..
-43,1?-- -
, : .,.,,
4.
¦ i
,
MEOCO,',1 FORM 659-R /TESTI (MCHO) MAR 9-9 MEDCOM - 23943
Page 4 ol 4 pages
DOD-037521

MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT DATE: / / pr c_. 03 PATIENT ACUITY LEVEL : / ij I POST-OP DAY:,30/ HOSPITAL DAY: -3/
..- -
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT: Time To From Il AMBULATORY . CRUTCHES II WHEELCHAIR III STRETCHER Total ER/RR/PACU time Physician
Anesthesia /Specify): Procedure/Diagnosis
B/P P R T . LOC
N Neurovascular checks .s.. Dressing/cast
Tubes 'F, Intake (IV, pc) Output (EBL, other) Voided 11 No III Yes Amount: E:-Medication Other
.
Report From
Received By TIME: i mo aca, ewe) .-.
.
BP ARTERIAL LINE -.
--.."
BP CUFF
I I tHIT1/(0 I I Vb
TEMPERATURE
Mel Ret( WI
P LSE
,A U I r) 114 la(
-
.:L.: RESPIRATORY RATE (96 (9-0. Le, OXYGEN (LP/0)
—4-

.-'
PULSE OXIMETER I 0 O.:-100 itbeis,
-. 02 METHOD
'-----kit KA Pk
G
Oxygen Method Key: NC , MT = = Nasal.cannula Mist tent NR = PR = Non rebreather Partial rebreather FM = Face mask A = Aerosol VM = Ventu i maskTC = Trach collar
TIME: frzAlc iqou IRO TIME: Cetgle)p
Skin breakdown
PAIN INTENSITY o • • . •• • • • • •' • • jc . • • . . • • . . • • . . • . • • • • . .• • " ;--...-. --, prevention 'Falls prevention protocol -*Restraint protocol -e+ Itivki kYtD
MED ADMINISTERED IY/N) y pp 0 ... . • Seizure precautions
RELIEF ACCEPTABLE IY/NI Y Ppt- ,, 'Isolation precautions

TIME:
atir
FINGER STICK GLUCOSE tilt
-YESTERDAY'S WEIGHT:
INSULIN IY/NI
TODAY'S WEIGHT:
. E;
-..:. WEIGHT CHANGE:
....---. R
• Per hospital policy.
24 HOUR PO IV ffi IV #2
TOTAL IN Urine Stool TOTAL OUT
TOTALS
wart„.1y.,..
PATIENT IDENTIFICATION DIAGNOSIS:
0 _el". -0 ykiu if -1-.1.10j
b( 02— Li e)(--k—
DRG:
ADMISSION ATE: )0 (kick)
03
LOS: EXPECTED RELEASE:
CASE MANAGER:
IcAgS --1
COIL PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify).
,
MEDCOM FORM 689-R (TEST) (MCHO) ^^--"^ -----Ns ARE OBSOLETE Page 1 of 4 pages
mc yi.00
MEDCOM - 23944
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check i in the small box indicates patient assessment criteria have been MET. If all the gated criteria are not met, a brief
explanation of abnormal findings will be noted if? the appropriate column.
TIM 0q5-INITIAL
1.
NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

2.
CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity

perfusion)
3. PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
4.
G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

5.
G.U.: Reports no dysuria, retention,

urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
6.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

7.
SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

8. PAIN: No complaints of pain/ discomfort. 13,- 9 t / • (See page 1 for documenting paM intensity.) ILO f C-1 rr-A-AP"-'
,
T eAto Ca Tv* \
9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT: (LEGEND: P -Puffy I -Infiltrated R -
TIME:
OSLts-
INITIALS:
IV patency ,/ q (i3 hr:

_
IV site care provided: 1.1.,Wo„.19 d

IV tubing changed:
LOCATION CONDITION
IV Site #1:earkti 1-00.. 4¢.,(L)fsr.
ne.._ IV Site #2:
.
Ily\o, ..cs-tu I A w{.1,'( F. OS .37 1940( re.,4-urn .
-16 com to &Lyme. to
).0 ex4- -V-bc -eda. c (tam -tati-E.
El•"-ILLUAlo -W-44-E 1-10-5-Kin
.
• i. i silt_ -k.) L
0 .4., 'I
•• % `a • ,..•40-1057 IS Ulitx 0,,
CAwn . 1
,.¦--".6--14--.)-1 ------
.
TIME: INITIALS: TIME: tp) p..,k--) INITIAL '
F
d
I I
. .
.
1 i
ail-p&v cia fiarpefap ile1411.-45 0-°40,____.0e-
ya-CV/Lck, pa-41)--'61-)
0 L ....igovamvetak.-, , st
.41:er ,
i . , , a
rtuyLcVal ' ' " I
-.. ..• 1 ...0 Vall. III I of%
I , III
lb
N S ek.... CZ ‘
. :
.A0-e_f 6-1
I I V
Reddened OK - No swelling/redness * -Central line)
TIME: IV patency ,/ q IV site care provided: IV tubing changed: INITIALS: hr: TIM E: (W3-0 INITIALS: IV patency ,/ q 6 hr: IV site care provided: IV tubing changed: ¦ D
IV Site #1: IV Site #2: LOC ON CONDMON LOCATION IV Site #1: CO6c_c_i____ IV Site #2: CONDMON ___cipSE
C°Comments: mments• Comments 610-001 -ef-vcn

MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 2 of 4 pages
MEDCOM - 23945
SECTION III -PATIENT INTERVENTIONS & TEACHING
e,,, {:),,

(0,6-
pp -P
T I M E:
a 6-'30
SITE:
ID band visible/tegible
COL
1',:','-::, " -:',..•:,7--„' —,....;',LuN-;;;;...;?;;,../7.,,..;;;;.:;.'j.7.-1;iiif.'.' ,14-:7;%':!'"-"' '47,', -.'-...".z..,',' i;'-,'''?:-Y.' 4.7ii.:65.-,7:: ..i ;i2Y4' 1
.%,,..,:,.
-.-..:::,....G.,:i.,....0,•;:,I_t::;".!J.;:-..)il,V::A:T...C;y,ce4i?:MPP2,f,...'',.4P,;w74,i ,c:,5 4-S. f;P;',.$..i.g.'i
1:4:' -. ' -.,-.. ifli...;',:. 111''' .",','*;'' !,; '',0A1..:r--a. tp'-;;TP,
•
'',.1...::::›..-x,ig,,' ,‘,....;a
I'..0-0:A! .1.1Cac--aka'1...11.
p

I t t i
Orient to enjironment prn
Side rails (2/4) up
Bed position low
Call light within reach
Review & post lab results
Notify MD abnormal labs
Incontinent urine/stool
Linen change prn
Turn/reposition q2h ^
CAPILLA
4) 0..) iti it•)
TEMPE
i
S
gi 1 16
S S ,.S
EDE
SENSA AA Ill
.
yv1 f Pe\
MOT 1,1 0 'X 0
PASSIVE
PERIPHER
if pe

LEGEND
Color: P-pink (normal); C-cyanntic; W-pale, white Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-(5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
ROM q2h if immobile
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Antiembolic hose
Motion: U-unable to move; M-moVe-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; -D-doppler, P-palpable
BREAKFAST LUNCH DINNER TYPE: e k Q 0,A_ TYPE: TYPE:
f..._.("e4APERCENT CONSQIMED: r"0-6, PERCENT CONSU ED: PERCENT CONS ED:": HOW TOLERAT-Miea HOW TOLERATED: HOW TOLERATED:
5eih..,
^SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE c5;t/ SELF 0 ASSIST 0 COMPLETE
., •w•
'
r.
''4.
4^-i-'47''
, T+7-1I
'T"'
.
„.
,,,
::
BATH/ORAL CARE
TYPE OF ACTIVITY (Circle all that apply)
TIME: Ch3(..0---
CONTENT:
-
0700-1500 0 SELF 0 COMPLETE ASSIST El TOTAL B 1/RF,ST 0 SELF
-,..
AMB
e s c B P CHAIR
INITIAL
— p6tArv`-- f)^0(AN-0.--01-11/"WA-4.--COLLQ. 0 cf,e\ 0.-,910.A.„*
.'
I
c;laktik. 4 - . iii •
i
.
—
-DSO Z)(.S ¦
Co E --Clcw"--awb1.46t4e_ c cArofci\..00
Patient Family Verbalizes Understanding
- • TIE ID IFICATION 6(-C\)-- ("'(
Ilir
0 ASSIST "Ecrt41N6
# TIMES/SHIFT
C ) -1-
TIME: •(
-•)C)
CONTENT: 0 SELF
54-ASSIST BED
-
1500-2300 0 COMPLETE 0 TOTAL
0 SEL ^
. ge..--
ASOP
-t-# I IMES
BRP CHAIR
INITI
1/4),c(9"
(Pcc. Mks,
.
1:111(Mr1A-A-4-iba, 4v\jo_eizA)1.--
AlthFamily Verbalizes Understanding
•
INITIALS 1.L.0,-,-(_,
HIFT
TIME:
2300-0700 0 SELF 0 COMPLETE 0 ASSIST 0 TOTAL
BEDREST 0 SELF BL_AT OSL ASSIST
..1l__g_)
BSC

# TIMES/SHIFTBRP
CHAIR INITIALS:
CONTENT:
0 Patient/Family Verbalizes Understanding
SIGNATURE SHIFT
_ e9L.-71. OD/ )11) Ot?-i a )1/4)

MEDCOM FORM 689-R (TEST) (MCHO) IVIAR 9_
Page 3 of 4 pages
SECTION III -INTERVENTIONS & TEACHING (Conti
TREATMENTS
I
LOCATION OF WOUND APPEARANCE AND
M
DRESSII1 CHANGE

E
.
. 0 tr.g.ln-t.f 14-h . alsfee.A14-CttotiAkta.•. fr SAC* a)
6 teAltailpe.c4-c: 0 e_a-(P

N @rh-g,r,4. yzeicruuwaka , q itock. v:sille a 14Y7D 'Z.: NS
, 0 . eA , r 1- c-' c 0 '
4 becAkc.1) fft_sls_c r 1,..eccao, -,
Z
.0 6 c • ' -i-Ss-v4_ &J., u.AILOAA•40a-) ZSIS
Crin-e-e.tera\
; kezto slfe ;r*ac-f, Q-1,7 eon 1,,,-614 Cr (444. (--11c_—tt iNerdik-dricreLa. w, 4itA.Wi-atitra0 40 6e 16iO4c/ -. 5,4
'
z,., ,
- SECTION IV -NOTES
4110_:=Aelaty4-CCL 40 diniaaa,--k_ pf—'c------ciO(A\co I.' . i .A. LA. /. ALL.' A / IA
IA.,CLO i\k 4' \ 44 hi)v. 4-e)_ci,a6I,s4-a rA"AkAA.Ack+i---"k\ • 4-cAvf-Yrvi.e0U-11,
1„(s...A-1—
19-i t,L0,z iviiiGpd, zz., toe, ,ee4 40 0,,,,,,wy et-
•„
A_, 1 _+_, ,_1
..,. coo—_.., z.. -.. .... It .0 AL& .40:4..._10_I_ are op
b

_ k • —.A II_l kit_.._al Adit.... • A .T0 d °_0_4F_.I..
I .r i . 1 l .. -.....__".11I_,
-
111 _ ¦ ._.$ (.............14WilMil

.,_LA1 P ir i.
I -.,' '
1.Arb_ :1, 4..TIVale • 0 : As_4• 01 IS ILL - e 4., li L_ ' 6 ' ! A lia.4._co A
-
r_.
I
(AA, C,cuksi_c(A-rruL, 4 • „II,' alKa at/ 6 -11...A. t ft
.
0_ • I_—_
9.41_14_
Ng ..* •.. ' ill 0110 —0 Is" A I ,. _ A A. „LOJM, _0 si y_A...:..„4/4L „. -0
i
IAPIPIIIMINIMMPMilar,
I
A ,t- .c.. si _11 ....1 O._ on A • 0 i0— At. AI AI la _ _aiit u._-_I _-A. •
;
0
--.631,0kni_o , '_--Pu L.0,11-0 0 • (3--Ctfl ri_.‘'ftaILL
....0-‘ SP ---.1.-tAi lik k-e. - •¦._ e‘ ' A.J.L. 1 "At Al

—
0
. I_1
A_I, .' .01-11:5).--i. PO- CA-C-Gt. kirS 1 CY I 41
. tirt -fn qD
-_1_ I I_. -I ,, A
I_ 0_
__we._i_ ,_1_'40 P_I I
-_i__le._-•_Alb ie _ A 0A,m_ _a... al._ .......: -_-_ —

._i i 1'4 _.•• 4 - . . ./ SIMINNIEWIF6.---.i / '--... . _ • AP .." A A_A._sr_, '.
Ale: _ / i" all
.
ii I f
• -..•ik. . ...L. beesr_e__ -' I A Us. AA___41 "//:_....1.1_,LAPI A_— IP. -' ) t i.. — .A., ,_-c_
1
:40 •'.. 2.11 AA 4_1_..,_.; jib Id ./9.-4 A_9 Oa A 1 . ____' • ilia V JP b((t)-6"
nnpnrnm_ 91Qt1.7
_
MEDCOM FORM 689-R (TESTI IMCHO) MAR 9.7
Page 4 of 4 pages
DOD-037525
SECTION III -INTERVENTIONS & TEACHING (Cont)
T
TREATMENTS
,

0 -Z C.) ..;:vtl Cti
LOCATION OF WOUND APPEARANCE AND DRESSIN CHANGE
4-el'A'SL' a--d,,,„ic`6 ,
atex.....,
. El
a
,,,,,a.
‘if.-'ci-)(,--(
W--e' P

-61.-.1_ jthoccii__
,,,,,,-
15 at,te pcv,de elcciAA-1, Loryt—e
avgat. Gothu,_d /via
°5-- &
c...6........_k__

'
SECTION IV -NOTES
.

1 ,
• •1-1-,,,,,n • el,- • s•-¦ • et
MEDCON1 FORM 689-R (TEST) (INCHOI MAR 99
Page 4 of 4 pages
SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: CpL6 TIME: .1,-,i2c
. TIME:
;1:e7)4-
COLOR
-¦-, 0 ID band visible/legible (s,
.-VI(
CAPILLARY REFILL i
Orient to environment prn ..
i .. "' .1•
TEMPERATURE
kti 1.0 Side rails (2/4) up
:E': .-.
EDEMA
C.---) 0 ' Bed position low
----I
-_.,-SENSATION
-. Call light within reach
5
MOTION
i-' --, M
PASSIVE FLEXION C) 0 1'1,1" Review & post lab results PERIPHERAL PULSE ,:.
Notify MD abnormal labs
l'"A' P ap ,4A-1-.;
r,.2-(4, , ,
tx • Ft:

LEGEND
4,1
.,:S.,•.i
..eezw
pet Color: P-pink (normal); C-cyanotic; W-pale, white .,14.54 Incontinent urine/stool ..,4_, (
ICJ:
..--,t Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-( 5 secs) ig¦ •
' ' Linen change prn ,
Temperature: C-cool; W-warm; H-hot
Turn/reposition q2h

. e)..
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
f•,,,..4 di•
ROM q2h if immobile-;* Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
,..e:s!
'
.-, Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Antiembolic hose
----1.-----
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; "4,:,,It .
;)-;!,'.,
D-doppler, P-palpable
..-3, '' BREAKFAST LUNCH DINNER
TYPE: ZLS.,

TYPE: i2Li..t TYPE:
Iv ,,,
„ v:. PERCENT CONSUMED: 7c.1:.;, PERCENT CONSUMED: '-c ' -PERCENT C
) e:E.. UMED: 561)1.1. HOW TOLERATED: j6,,i. LE,
HOW TOLERATED:
1 c_ ,c., Li. HOW TOLERATED: w-uuiyr., SELF O ASSIST 0 COMPLETE I:5;VSELF 0 ASSIST 0 COMPLETE ELF 0 ASSIST 0 COMPLETE
0700-1500 1500-2300
2300-0700 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE 0 COMPLETE gASSIST 0 TOTAL Pa' ASSIST
0 TOTAL 0 ASSIST O TOTAL BEL.1a,EST 0 SELF ES-T---' 0 SELF
B 0 SELF
,...--Al1.4Eit: D ASSIST eAr3ULATE----0 ASSIST 111140SIST
4 TYPE OF ACTIVITY
( i:C§C
(Circle all that apply) BSC
# TIMES/SHIFT # TIMES/SHIFT
BRP BRP C ASSISVITIMES/SHIFT
BRP
( __-.C.R"--CHAJ:5
CHAIR : -'"' TIME: j(f.,1-3(1) INITIALS: TIME:
c9-WO INITIALS: TIME:
INITIALS:
CONTENT: ) ,

, CONTENT: CONTENT:
l'/P.'-1 '-'," •-,L ri-)-4.:. i.:. N..,,,__ --,--) ,
-:cr.
—,..,, v ,---,--.)s4f.:,-,r-—'--VC1.---(e.;^ .(A/A-401
.i-;E:
.,..._..
';i1V
.._ . ' Ds---A. .------„_ ...,
. :_.-:.);37-f
X::: G2,-1--
.1 ainbct,666. c.
b
!: . tOCUP kt/t)
. ( ' /
i n e
' IMPatient/Family Verbalizes Understanding
mily Verbalizes Understandi g' 0 Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION
INITIALS SIGNATURE SHIFT
,r4/ ,
C diall
b(__QA) -(1\
MEDCOM - 23949
..-____ _____ ___ _
. -T1 imckini MAR .9.9
DOD-037527
SECTION II -PATIENT ASSESSMENT
-REVIEW OF SYSTEMS
DIRECTIONS: A check I M the small box indicates patient assessment criteria have bee ET If all the stated criteria are not met, a briefexplanation of abnormal findings will be noted in the appropriate column. ....
TIME: IC5D TIME:dta.) INITIAL 1ME: t INITIALS:
INITIALS•
1.
NEUROLOGICAL: Alert and oriented to
F F -I I
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate
vi
1 1
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity

perfusion)
3. PULMONARY: Respirations within normal
j/I
I Lii-
rate for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
,
sounds.
4.
G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
svvallowing. Denies constipation, diarrhea or

•
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle
••.:-.1.,r..L.,4.1fR c.z. 19-Av•-•49 C-...,
development and mass for age. No
deformities. No assistive devices needed. OA fji.r tin-t. s r u.aLkice,-, .
Normal active ROM without pain. No joint -1-1) itiope.,c- 0.,

1-z44t. K 42.
svvelling/tenderness, weakness or paresthesia.
01-5
7. SKIN: Warm, dry, intact. Good turgor. No
ri1/2...-n-i -,---;:"'S/.,:, -1-- c 5 itt".... c2ruk.r614.01
rashes, inflammation, ulcers, breaks in skin.
1--0).gt I Ce.4.¦71) OsC-, C-C¦far V C...e . ,.,
No redness, blanching, irritation over bony ipt-,14-e•-elS
4-1-14
prominences. Mucous membranes moist. t..)f----1 X (Y2 )
Z,6
8. PAIN: No complaints of pain/ discomfort.
Ar.(::cf, 2-1.ht: 7.--pe.A-(.42-ca ott""
(See page 1 for documenting pain intensity.)
-1441Alq, /LA--pa....4.--
.
9. PSYCHOSOCIAL: Behavior is appropriate 71---
L
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others. D ( C-t-— 7-

10. IV SITE ASSESSMENT: (LEGEND P Puffy I -Infiltrated
R -Redde K -No swelling/redness * -Central line/ TIME:
r..)-50 TIME: 9.45C0
INITIA
INITIALS:
TIME: INITIALS:
IV patency ,,/ q __ hr: IV patency ,/ q S hr:
IV patency j q hr:
IV site care provided:

____.
FLuic,./s.i) IV site care provided:
IV site care provided:
IV tubing changed:

IV tubing changed:
IV tubing changed: LOCATION
CONDITION
LOCATION
CONDITION LOCATION CONDITION
IV Site #1:
-'-‘' )1°
6... /c c1/43 r C,I IV Site #1: 0 SC, Ok IV Site #1:
IV Site #2: IV Site #2:
IV Site #2: Comments:
Comments: Comments:
MEDCOM FORM 689-R ITEST) (WHO) MAR 99
Page 2 of 4 pages
MEDCOM - 23950
DOD-037528

MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
SECTION I -PATIENT ASSESSIV1ENT
DATE:

1 D...-0eL; • 0;:i I PATIENT ACUITY LEVEL : -}L, POST-OP DAY: -‘ h ' 34--
HOtPITAL DAY: COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER.IN -
TELEPHONE REPORT: Time To From I AMBULATORY III CRUTCHES 111 WHEELCHAIR ll STRETCHEFi .T Total ER/RR/PACU time Physician
Anesthesia (Specify):
R
. . Procedure/Diagnosis
B/P P R T
A
N LOC

Neurovascular checks
.s Dressing/cast Tubes
,:. F. Intake (IV, po) Output (EBL, other) Voided 111 No

ll Yes Amount: Medication Other . Report From
Received By
TIME: (1) 260 01.00 '
BP ARTERIAL LINE
BP CUFF

it0/75
(CX2Ai, 0/i Tr
TEMPERATURE
47,6 ir. %3
PULSE .
0, lia6
-PC°
RESPIRATORY RATE /8 2.0

OXYGEN (Li%)
//,.,
PULSE OXIMETER

(0) VI° 100
02 METHOD
ll'ill ki-
NC = Nasal cannula NR = Non rebreather FM = Face mask VM = i
Oxygen Method Key: Ventu mask , MT = Mist tent PR = Partial rebreather A = Aerosol TC =
Trach collar TIME:
1206 W Kyr
TIME:
• Skin breakdown , I , ._•Z_
prevention . Gib kto
PAIN • •• •• •• •• •• ••

5 • Falls prevention protocol
INTENSITY
• Restraint protocol
MED ADMINISTERED IY/N) 1
• Seizure precautions
.??
-RELIEF ACCEPTABLE IY/N)
-
y' (4--,.:)7t., • Isolation precautions
-:L.:
t TIME: FINGER STICK GLUCOSE
XrArtf-,E-YESTERDAY'S WEIGHT: _____..--------------
H INSULIN IY/NI
..—¦--. TODAY'S WEI -E
,----------WEIGHT C ANGE: ....-------
, •Per hospital policy.
-,
24 HOUR PO IV #1 IV #2
TOTAL IN Urine Stool
TOTAL OUT
TOTALS
PATIENT IDENTIFICAT ON
,--- -
1c. (,(,) DIAGNOSIS:
.1Z/Y).14.,0„.17/1.4-14---& ; -&:-P-V
r
DRG:
ADMISSION DATE: if-Akilr D3 EXPECTED RELEASE:
Clifilki LOS:
CASE MANAGER:
PRIMARY CARE MANAGE ..

' - • Ls\---L-
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) r MEDCOM - 23951
NS ARE OBSOLETE Page 1 of 4 pages mcvi.00
MEDICAL FIECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
HOSPITAL DAY:33
POST-OP DAY.39/? I
1
PATIENT ACUITY LEVEL :
1
DATE: 1"51)eco3 . COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
STRETCHERWHEELCHAIR0 CRUTCHES ElAMBULATORY
From El 0
To
Time
Anesthesia (Specify):
PhysicianTotal ER/RR/PACU time
P
B/P
Procedure/Diagnosis

Neurovascular checks
A
LOC
Tubes
Dressing/cast 0 Yes Amount:

Voided No
Output IEBL, other)
Intake (IV, pol
Medication
Other

Received By
Report From
TIME: 17f,0 20 CA
BP ARTERIAL LINE

4){( PI /.42
BP CUFF
TEMPERATURE
PULSE /e/_q7
RESPIRATORY RATE /eti /V 4(
OXYGEN (LI%)
PULSE OXIMETER

kin iotkc
44 PA
02 METHOD
VM = Venturi maskFM = Face m.ask
NR = Non rebreather
NC = Nasal cannula TC = Trach collar
A = Aerosol
PR = Partial rebreather
Oxygen Method Key: MT = Mist tent
TIME:

TIM E: *24 20 'Skin breakdown 10 prevention
'Falls prevention protocol
PAIN
INTENSITY 'Restraint protocol

•Seizure precautions
MED ADMINISTERED IY/N)
-Isolation precautions

A
RELIEF ACCEPTABLE IY/N)
TIME:
YESTERDAY'S WEIGHT:
FINGER STICK GLUCOSE
TODAY'S WEIGHT:
INSULIN IY/N)
WEIGHT CHANGE:
'Per hospital policy. TOTAL OUT
St ool
Urine
1TOTAL IN
IV #1 IV #2
24 HOUR I PO
TOTALS

CFI/NO
PATIENT IDENTIFICATION DIAGNOSIS:
ADMISSION DATE: t(a)J0k10-3
DRG:
CA V
EXPECTED RELEASE:
LOS:
CASE MANAGER:

0.0)/(-1
PRIMARY CARE MANAGER: ISOLATION REQUIRED (Speedy):
mcvi.00
Page 1 of 4 payes
MEDCOM -23952 'IONS ARE OBSOLETE
—
nricr-IPM/1 FnRM 689-R (TESTI (MCHG,
— '\--) ¦
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1 in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
TIME: INITIALS: TIME: 2-0 INITI TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
I I
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate I
I
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)

3. PULMONARY: Respirations within normal
E./
rate for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
sounds.
4. G.I.: Abdomen soft and non-distended.
I I I"/
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
•
swallowing. Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,

yellow/amber. No unusual discharge.
6. MUSCULOSKELETAL: Normal muscle
ri I
development and mass for age. No
deformities. No assistive devices needed.
EX t--i(x la 41.-i.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact. Good turgor. No
iik4 v i NO/e 10/0=Jiid. ri
rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
prominences. Mucous membranes moist. d L g

-1-0
8. PAIN: No complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.)
fefedee'r p r)1
.,
9. PSYCHOSOCIAL: Behavior is appropriate
V
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

10. IV SITE ASSESSMENT: (LEGEND: P -Puffy I -Infiltrated R -Reddened
-No swelling/redness * -Central line/
TIME: INITIALS: TIME: INITIALS:
24.019
TIME: INITIALS:
IV patency ,/ q _ hr: IV patency ,/ q hr: IV patency V q hr:

_
IV site care provided: IV site care provided: V e IV site care provided:
IV tubing changed: IV tubing changed: IV tubing changed:
LOCATION CONDITION •/ LOCAllON CONDMON
LOCATION CONDITION
IV Site #1:
IV Site #1: -6'i '19 4 4/1"17 Ok., IV Site #1:
03116 a teL via-4IV Site #2: IV Site #2: IV Site #2:
Comments: Comments: Comments:
MEOCOM FORM 689-R (TESTI IMCHO) MAR 99 Page 2 of 4 pages
MEDCOM - 23953
DOD-037531

SECTION III - PATIENT INTERVENTIONS & TEACHING
: SITE:
TIME:
TIME:
. .
.
;,-,.-
I -: :.-...:-Cf? ...$'..,11-',-.4.1...:h.. .....,;:?,1,: I.1;‘'.'*fgtvi.':::*45in.040641-441:4zw.,4Y
. 4',;;'.4.V."1, ,,v..!,13t,,,,.... „,..,.,,„,
COLOR
CAPILLARY REFILL
TEMPERATURE
EDEMA
ID band visibleAlegible
..-
Orient to enviionment prn
Side rails (2/4) up
Bed position low
SENSATION
Call light within reach
MOTION '
PASSIVE FLEXION
PERIPHERAL PULSE
Review & post lab results
Notify MD abnormal labs
Incontinent urine/stool
Linen change prn '
Turn/reposition q2h .
ROM q2h if immobile
Antiembolic hose
.',-A,
LEGEND P-pink (normal); C-cyanotic; W-pale, white
,
(
l Color:
Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-( 5 secs)
: Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
'!
Sensation:
A-absent; N-numb; T-tingling; S-sensation (present) Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
'
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse:
.
0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
,
BREAKFAST
LUNCH
DINNER
TYPE: !____.. TYPE:
TYPE:
-7
PERCENTIC6NSUMED:
W PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: b./7,v/ HOW TOLERATED:

HOW TOLERATED:
0/SELF D ASSIST 0 COMPLETE dSELF 0 ASSIST 0 COMPLETE El SELF 0 ASSIST

0 COMPLETE 0700-1500 1500-2300
- 2300-0700 /.1Z SELF 0 COMPLETE 0 SELF El COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE -:-;?. El ASSIST 0 TOTAL 0 ASSIST 0 TOTAL 0 ASSIST 0 TOTAL
BEDREST 0 SELF BEDREST
0 SELF BEDREST 11i SELF
-94.4B150:=P• J,Zg-AS SI ST AMBULATE
TYPE OF ACTIVITY D ASSIST AMBULATE 0 ASSIST
BSC BSC
(Circle all that apply) BSC
# TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT
BRP BRP BRP
CHAIR
CHAIR
CHAIR
9
TIME: INITIALS:
TIME: INITIALS:
.. TIME: INITIALS: CONTENT:
CONTENT: CONTENT:
..
. .,-"'
.:,
-.:
..i
. ..
,_,_; El Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION
INITIALS
SIGNATURE SHIFT
!
'..
MEDCOM 23954
.........____ _ _ __ _ __ -

-ITF_STI /MI714171.P 99.
Poe.. rlf n me. .0
DOD-037532

DATE:
HOSPITAL DAY:
ait
I

,...
MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEOCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT mixt- J.-..) PATIENT ACUITY LEVEL : thoo lir_ POST-OP DAY: r-2)1 9
1—cc z u.
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT: '
Time To From 111 AMBULATORY . CRUTCHES II WHEELCHAIR 111 STRETCHER Total ER/RR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P P R T LOC Neurovascular checks
Dressing/cast Tubes
Intake (IV, po) Output (EBL, other) Voided . No . Yes Amount:
Medication
Other
Report From Received By .

—ci —z I
TIME:
) a 6 0 wo
BP ARTERIAL LINE BP CUFF i g Iii,4 Pi76.8 TEMPERATURE
4 1.e Tr
PULSE
I I I 113
RESPIRATORY RATE
),.1)f,,,,I...3
OXYGEN (Li%)
--Pr— -----
PULSE OXIMETER 100-d q9Z 02 METHOD 4-A_RA
NC = Nasal cannulaOxygen Method Key: , MT = Mist tent
TIME: 972,5-Igo ape:6
. . . . . . . .
PAIN -•• •• •• •• INTENSITY •-•• •• ••
MED ADMINISTERED (Y/ 4/ RELIEF ACCEPTABLE re/
if
16
TIME:
,
-
NR = Non rebreather FM = Face mask VM = Ventu i mask PR = Partial rebreather A = Aerosol TC = Trach collar
TIME:
OW p330
'Skin breakdown
•• . . . . . .
prevention WW1 Alj
. . . . . . . .
•• •• -• ••
• Falls prevention protocol 04 051\
•-•• •• ••
•• •• •• . .
•
Restraint protocol

•
Seizure precautions 'Isolation precautions

FINGER STICK GLUCOSE
YESTERDAY'S WEIGHT:
T
H INSULIN IY/NI
TODAY'S WEIGHT:
E
WEIGHT CHANGE:
R
• Per hospital policy.
24 HOUR PO IV #1 IV #2 TOTAL IN Urine Stool

TOTAL OUT
TOTALS PATIENT IDENTIFICATION
DIAGNOSIS: e nriN ...Q)* , xr‘s1460;&_-P4 • ..e.k...c DAG: ADMIS ON DATE:
1,51,..)(-Ai 03
LOS: EXPECTED RELfASE,:
1111 b(1,-A-,\-(}k
CASE MANAGER:
1 (... ) ''-7,,
PRIMARY CARE MANAGER ISOLATION REQUIRED (Spec/
MEDCOM FORM 689-R (TEST) (MCHO) MEDCOM -23955 INS ARE OBSOLETE Page 1 of 4 pages M C V1.00
DOD-037533

SECTION II -PATIENT ASSESSMENT
-REVIEW OF SYSTEMS
DIRECTIONS: A check. I
. in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a briefexplanation of abnormal findings will be noted in the appropriate colum
TIME: 0711.--INITIA TIME: 1 S -30 INITIA
ME: INITIALS:
1.
NEUROLOGICAL: Alert and oriented to
V
time place and name.
Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate
,/
within range for age. No dependent edema.
—
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusionI

3.
PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is
regular.

No cough. No abnormal breath
sounds.

,
4.
G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
swallowing.

Denies constipation, diarrhea or
rectal bleeding.

•
5. G.U.: Reports no dysuria, retention,
V I I (2-6-G 0-4t) i/VI.A41,Lt.
urgency, frequency, nocturia..Urine clear,
-/-0 VCI4-4 IOW--
yellow/amber. No unusual discharge.
+-CibOGC-C1 1 Lain, P, invphic
MUSCULOSKELETAL: Normal muscle
--P¦7 )-ovi_.
6. @tE
development and mass for age. No qx-C6c.-.0„, __
deformities.
No assistive devices needed. 4 ii 0 h; /,' -} , A.,,A..1. 1 e 5 41 12.-ur"-. toCE)4-4te-e--
Normal active ROM without pain. No joint

,z Pvc-i/cif c •-• -kit/ 4, rillartAf2ikejD 'D
swelling/tenderness, weakness or paresthesia.
%Jo ik,,NY22.*
7. SKIN: Warm, dry, intact. Good turgor.
No 4.,,,,' e vvv.„/) )00 i 1 01A.A...e.LOEV8
rashes, inflammation, ulcers, breaks in skin. 'p.,,1--.7toc-/J4-, 0 4, A L...V --70
a • .
, A , v, ,,,,ic(
No redness, blanching, irritation over bony
I
prominences. Mucous membranes moist. C'q,Vovi er crdi , OD AA)/
442 411 9 tA ¦y 1, , r, A ,;4e -14,.(0c, i'i'
8. PAIN:
No complaints of pain/ discomfort.
(See page 1
for documenting pain intensity.)
4..e....„___f_ 1
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild r
and appropriate to situation.
Interacts
appropriately with others.

10. IV SITE ASSESsnAFN-r• ;I Encron. 0.M.D...¦_._•.....-
-e ened OK - No swelling/redness * - Central line)
TIME: 0 -72A-
INITIALS: TIME: 0E54C
INITIALS:
IME: INITIALS:
IV patency ,/ q
hr:
IV patency ,/ q hr:
IV patency ,/ q hr:
IV site care provided:

IV site care provided:
IV site care provided:
IV tubing changed:

IV tubing changed: IV tubing changed:
LOCATION CONDMON
LOCATION
CONDMON LOCATION
IV Site #1: CONDMON
.(:_ IV Site #1: Ci...--y.... CA__
0/. CNAL IV Site #1:
IV Site #2: IV Site #2: IV Site #2:
Comments: Comments: Comments:
MEDCOM FORM 689-R (TESTI (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 23956
00-2-AA\

SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE:
TIME:
rgii...5-E2,--,
0 TIME: 25-f
.
_ COLOR ID band visibly/legible (
.,i, ?
CAPILLARY REFILL
1 Orient to environment prn 1:'.i"-=.1 TEMPERATURE \I\J Side rails (2/4) up
IV
:E":
I:..,a: ;:vtfiV..";r; t I X1Ftl'4.j'X,1,971:1A:=3
A
' EDEMA
Bed position low
95 ' SENSATION 5 Call light within reach -
, MOTION
:, frk VA
PASSIVE FLEXION ,/---0
Review & post lab results
Notify MD abnormal labs
PERIPHERAL PULSE
'-ie a.f)
0

LEGEND
Color: P-pink (normal); C-cyanetic; W-pale, white
Incontinent urine/stool
••---f, Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-(5 secs)
.
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
,,;

Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
(9-4
iff.5 Motion: U-unable to move; M-move-no
pain; P-move-pain; R-full ROM
V:'.2 Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; •
.__,. D-doppler, P-palpable

_i.;irrv
BREAKFAST
LUNCH
DINNER
TYPE:

TYP
PERCENT C SUMED: /2,.-0C/(

bY TYPE:
PERCENT 0 UMED:
PERCENT CONS ED:
Olt
HOmW/TOLERATED:vv-R HOW TOLERATED:
HOW TOLERATED: 444 fa SELF
ASSIST 0 COMPLETE ($...SELF 0 ASSIST El COMPLETE
SELF 0 ASSIST 0 COMPLETE 0700-1500 1500-2300
2300-0700 El ,SLF 0 COMPLETE 0 SELF 0 COMPLETE El SELF
0 COMPLETE ..
BATH/ORAL CARE
."ASSIST 0 TOTAL
ASSIST 0 TOTAL 0 ASSIST El TOTAL BEDREST El ULF BEDR T 0 SELF
BEDREST 0 SELF
111ASSIST
cASSIST AMBULATE 0 ASSISTTYPE OF ACTIVITY
BS
(Circle all that apply) BSC BSC
# TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT
BRP
BRP
CHAIR
TIME: 0 7-2, 5-INITIAL11111 TIME: vp):21,

INITIALS-TIME:
INITIALS: CONTENT:,,
ep;.: CONTENT:
Akt;_? CONTENT:
V a-IN
,P Cot:N .1.e_
(-)rXCL) Nr•,-IcbCrirn
t 7.
,f? atient amily Verbalizes Understanding 174 amily Verbalizes Understanding El Patient/Family Verbalizes Understanding
PATIENT I NTIFICATION
LDW
MEDCOM — 23957
!Girl-Ws/1RA EllORN 4.00 0 PTCC7-1 IARI,lant RNA 0 00
0 0 /7 A
7,r, • • 4
. ":4%2t.q.);."..Ittatt4
-2w
SECTION III -INTERVENTIONS & TEACHING (Cont)
LOCATION OF WOUND APPEARANCE , TREATMENTS AND DRESSIdpiCHANGE

.
.4,..„.gi, 0-ic,„_,e IA ,), A five e/-kvt; 9d e. I- 4,- c.:1 (., (D, e„/
0,?..)-Yhili-1 touVia.ic-
Act)
603_01,t_zt.„A„,_01
f`rNve_ ct-Cca )
.
VC.PN.J-a1Jal)
ilecle, 9 ,7,,t,,,/.4: //, Lv.--.7 0 .1)5 3 ..A
c71,A 5 1‘.04-71 41, 51., e-ril 0 1 Z_1.
i't+
ki), tozstr.6 -k "' ,
.. -t. . . IA lk.--? .TC)ilkt.t. rft,•• ,.... ..
• e _..f ' .110A ..........10

.,.. co. k-7:: • iv__--c, a ..
or. ... ' .., .-},RQQ.(2
g, -0 .1-Cri-Q 7,
1.
-11 -Q. all-0-/241..
_
.
r3 -t-,_A. /anew) 11!...:. -a "-_2...-a.,2 W.L.AD
SECTION IV -NOTES% 4 I .4
&'lz-cri— ' A-c,,,,,AL'_ .,A--- ,,,ict---1- -_r.-,. , ,, ,,c,,, 5- 71-/ G..- (‘
1
, \
--i-1,-Le 6 z 6-' 1` — k-/5 0-Fr tyP ieci. i-t,' A cor012,.. i, Ai. -,,/-
.
MEDCOM - 23958
MEDCOM FORM 689-R (TEST) IMCHOI MAR
Page 4 of 4 pages
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5

SECTION I - PATIENT ASSESSMENT
HOSPITAL DAY:POST-OP DAY: a
PATIENT ACUITY LEVEL :
0
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

\ K)ec____. .
DATE:
STRETCHEFI0 CRUTCHES 0 WHEELCHAIR El
AMBULATORY
EI
From
To
Physician

Time Anesthesia (Specify):
T
Total ER/RR/PACU time R
P
B/P
Procedure/Diagnosis

Neurovascular checks
LOC

Tubes
Dressing/cast No D

Yes Amount:
Voided
Output (EBL, other)
Intake (IV, po)
Medication
Other

Received By
Report From

Vie°
TIME:
BP ARTERIAL LINE

11111
ffilk7B111611
BP CUFF
TEMPERATURE
PULSE
A
RESPIRATORY RATE &
OXYGEN (LP/o)
frA
PULSE OXIMETER
MOM
02 METHOD
IMILa
MIN
VM = Venturi rnaskFM = Face maskNR = Non rebreather TC = Trach collarNC = Nasal cannula A = Aerosol
PR = Partial rebreather
Oxygen Method Key: MT -= Mist tent
TIME:

0,160
TIME: kin breakdown
hico n-co
evention
10
vention protocol
PAIN
INTENSITY 'Restraint p tocol

• Falls
A
'Seizure precaut
MED ADMINISTERED IY/N)
A • Isolation precaution
RELIEF ACCEPTABLE IY/N)
TIME: YESTERDAY'S WEIGHT:
FINGER STICK GLU •
TODAY'S WEIGHT:
_4_
INSULIN IY/N)
WEIGHT CHANGE:
'Per hospital policy. TOT OUT
Stool
1/ I
TOTAL IN Urine
PO IV # 1 I V #2
24 HOUR
TOTALS

51 p c,r,e.„1--9„-T, -1--t tc-C-X e5C-G.x(ELG
PATIENT IDENTIFICATION DIAGNOSIS:
ADMISSION DATE: \

DRG: EXPECTED RELEASE:
LOS:
CASE MANAGER:
PRIMARY CARE MANAGE
ISOLATION REQUIRED (Specify):

mcvi.00
Page 1 of 4 pages
MEDCOM - 23959 TIONS ARE OBSOLETE
cr1011/1 RR5:1-R ITEST) (MCHG,
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1
in the small box indicates patient assessment criter'a have been MET. If all the stated criteria are not met, a briefexplanation of abnormal findings will be noted in the appropriate column.
64Y
TIME: INMALS:
IME:
1 530 INITIALS/OP: I
INITIALS:
1.
NEUROLOGICAL: Alert and oriented to
time place and name.

Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate ....""
kil
within range for age. No dependent edema. I I
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)

.
3. PULMONARY: Respirations within normal
I Vr
rate .for age group; quiet and regular.
Depth is
regular. No cough. No abnormal breath .
sounds.

4. G.I.:
Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
swallowing. .

Denies constipation, diarrhea or
rectal bleeding.

5. G.U.: Reports no dysuria, retention, 1 1 (2 t--s tal,v5 reA/ 6 f,-. 5-fcc.--iec ku2_ has [—I
urgency, frequency, nocturia. Urine clear, lAvitifa. I-i 'an d-i'-F6\c/At„,.4 voice&u 1----1
yellow/amber. No unusual discharge. IgK-o- ,es StSU0-6

1-,
_ 7.??, Li j / 'Ice I ii lie'/
6. MUSCULOSKELETAL:
Normal muscle
I
1 6-A-•X.,;( e /1 -V re--0)11 CDLe
development and mass for age. No
V../ g0,1.-L,, p..,1-
deformities. No assistive devices needed.
a iv; via /-,-5 ,--0,-afkif - c'-f° jLjtxtatk,

CPLA-v-c,-
Normal active ROM without pain. No joint -0 qv
swelling/tenderness, weakness

or paresthesia.
7. SKIN: Warm, dry, intact.
Good turgor. No I.A.Vr ;4'1 -to e,--e10-: itaus,-,71-oQ_2--).--
rashes, inflammation, ulcers, breaks in skin.
P4- jle.) ,Oi 51-4 / 11,04 N -L --i.s3-4N
No redness, blanching, irritation over bony
k_..11Na cA Q_, ")1,-3 we_CLO
prominences. Mucous membranes moist.
8. PAIN:
No complaints of pain/ discomfort.
67 Cie
(See page 1 for documenting pain intensity.) eAl Ei
„c"-.2-----6D--6-1
9. PSYCHOSOCIAL:
Behavior is appropriate
to the situation.

Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

10. IV SITE ASSESSMENT:
(LEGEND: P -Puffy I -Infiltrated R -Reddened
OK -No swelling/redness * -Central line)
TIME:

INITIALS:V 6260 TIME: I S ?5C) INITIALS: INITIALS:
IV patency IME:
,./ q 4/ hr: IV patency
j q S hr: IV patency ,/ q hr:
IV site care provided:

IV site care provided:
IV site care provided:
IV tubing changed:

IV tubing changed:
IV tubing changed: LOCATION
CONDITION
LOCATION
CONDITION
IV Site #1: LOCATION CONDMON
CO C-; e.:._ eac a k
, -IV Site #1: (j,
C1.--Cyr__ IV Site #1:
IV Site #2: IV Site #2:
IV Site #2: Comments:
Comments: Comments:
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 23960
DOD-037538

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: e 6 6--: iirit)
!
TIME: fao TIME:
COLOR CAPILLARY REFILL I e 1 ID band visibiellegible' 4:_.Orient to environment prn
TEMPERATURE V/ LO Side rails (2/4) up
EDEMA SENSATION MOTION --P-i 1 5 P Bed position low Call light within reach
PASSIVE FLEXION i..-----'' Di, Review & post lab results
PERIPHERAL PULSE 7- Notify MD abnormal labs
LEGEND
t( Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stool

Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs) Linen change prn '
Temperature: C-cool; W-warm; H-hot Turn/reposition q2hEdema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
z
(
.,4a,„ p
gi
/01
11111

)
-
I
„. I
Sensation:
A-absent; N-numb; T-tingling; S-sensation (present) U-unable to move; M-move-no pain; -P-move-pain; R-full ROM
.
ROM q2h if immobile
Antiembolic hose
40i
t fi 11
Motion:
Passive Flexion:
D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse:
0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
-,-i.
BREAKFAST
LUNCH
DINNER
TYPE:
TYPE:
TYPE:
PERCENT C NSUMED: /07/
PERCENT CONSUMED:
(c.;_e_ PERCENTIJMED: 5eiN
HOW TOLERATED: //th/7./ HOW TOLERATED: ev,e, e--K
.

HOW TOLERATED:
vacs&
SELF 0 ASSIST o COMPLETE SELF D ASSIST 0 COMPLETE SELF 0 ASSIST 0 COMPLETE
0700-1500 1500-2300
2300-0700 . 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE 0 SELF
, -BATH/ORAL CARE re? El COMPLETE
•jr.;•«;,. ASSIST El TOTAL \:12!) ASSIST 0 TOTAL e3. ASSIST 0 TOTAL
a
t,0. -atta 0 SELF BEDREST El SELF BEDREST 0 SELF ,V1 j2/ ASSIST .t-fOrgILATI) (KZASSIST
TYPE OF ACTIVITY 414211101 11:' ASSIST
'iS (Circle all that apply) BSC BSC
BSC
# TIMES/SHIFT # TIMES/SHIFT
r-. BRP # TIMES/SHIFT
BRP
BRPr.: CHAIR HAlft) .
.... _ -Cg;1)
TIME:60-INITIALS TIME: I%---0 INITIALS: TIME:
INITIALS:
IX CONTENT: CONTENT7--...-
.
66-CONTENT:
.
,-P/Ort oC9 ?" (40 4/-C-0-12S bc:„.. 4:::„...,-.

. pc,....L,..._ c--1-4.0._ficup...._2)9...,ri....0...
..
.. \-3--ol, 1::::.

— -2_,,,c5-s-c-,,
,..,.
.,,,i,..or
.
,
,...
/
,r1 Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
0 Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION
,
INITIALS
SIGNATURE
SHIFT
.
NrD itj, --Li
.1 -
clop
.. Al il I
1.111ralinna
MEDCOM - 23961 l *
..______ _____ _ _ .____. ____
SECTION III - INTERVE _ __ .__ ._....__ ,_...,
z4 ,: c.) ,:-.5.tifccf4,412i-
TREATMENTS
LOCATION OF WOUND
APPEARANCE
AND 7r) , DRESSINIG CHANGE op (ai -y.-.1.) -r-A%
, (19 .7.5.4 .firry .,vaket_e'f,--_.7. 4-,th,
.3./chrl--arta I nag P ,' -Ai -e• tz-/- 0 n fli itc;_46'
' LUC r
‘ 0 ¦ a CI-
i /./14c-, ; , '3" A .6feco.45k (4‘),'.79 6: t 'CO II 0 ((I, Q.S-5". 2
9 ilry ,
.
de_ -....z, „,.. -
ip*, ,., 0 . , VIVii di 9U,:a. • a . a t)._.-s.i.. b ca 4.-.. _
,.... F.
A
. T
F.& ra-A/It-iqVg. , I * ito, asso. as ' gm P 'L6k..krk-S2- L,V.A14-+ Ni \ rtil; ._., . a.
i . ' • 9. (Lc . . eras PS_
5-U"-L'.6)
•
?'(-A-N-eb --Iro ureck- zi•45( vo,,,,,,,,c, OS o rk fx-I....ca.-t--.It'W•CA Z4-----A%4_
_ faeXsz_Cli N-6 SECTION IV - NOTES
.1 . Ci , ,:
. 7 -a
A LW

M_ . /Pio?//' _-Ait
"KA*_ '
hirAmpriAd 47_ ilw.___-
r ;401rif ¦ _ _ .._ . 4 _ , _
/ ' 0 b tri 7liAlga I VA MIWFAVA 1 .
1111,4W7.
i_,.., 40°AN
i(rJo / 4 A4. ' 5
/cos4o's
--46./2-. 3-77-tf, )(5)55-5:91i-A,--r--v flAY")
. .. b cc-2
MEDCOM 23962
MEDCOM FORM 689-R (TEST) IMCHOI MAR 9.Y Page 4 of 4 [laces

r-.•Afc• CC'T
rt.uvvorli_ 1
-PATIEN I AC; I IVI I It
MEDICAL RECORD
For use of this form, see MEDCOM Circular 40-5
PATIENT ASSESSMENT
SECTION I -
HOSPITAL DAY:
aq•--I POST-OP DAY: ,ii
lk;) Vet., 1)--)) I PATIENT ACUITY LEVEL : DATE:
.,
-TELEPHONE REPORT:COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
II II CRUTCHES I WHEELCHAIR II STRETCHER
AMBULATORY
From
Time To
Anesthesia (Specify):

Physician
T Total ER/RR/PACU time
R B/P

P R T
Procedure/Diagnosis
A Neuro.vascular checks
LOC

N
Tubes
s Dressing/cast

Yes Amount:Voided 0 No 111Output (EBL, other)
F Intake (IV, pol
E Medication Other
-
Report From
TIME: tab 7-4-9Geiy '
BP ARTERIAL LINE
V BP CUFF TEMPERATURE PULSE L RESPIRATORY RATE OXYGEN (Li%) S PULSE OXIMETER 02 METHOD
G
N
S
Oxygen Method Key:
TIME:
PAIN INTENSITY
A
/ lib* tettiri ty1
q,PI 'if/ I?
(I / Itc( II I /el ) te 1 (
VI to& tal
Pj VA Ppt-
NC = Nasal cannula .. MT = Mist tent
_W.2.2.2.1_1Y:ektsaa0
50
. '
o ' MED ADMINISTERED IY/NI iq ../i/ p 1/44 RELIEF ACCEPTABLE IY/N) V ik 4/.4 PA 4
?-121C/ AC.(0+
TIME: I (Ix)
T FINGER STICK GLUCOSE
H INSULIN IY/NI
E
R
PO IV #1 IV #2

24 HOUR
TOTALS
Pilk
PATIENT IDENTIFICAT ON
b i, tu, \ ---(-,
MEDCOM FORM 689-R (TESTI (MCHC
MEDCOM -23963 -IONS ARE OBSOLETE
Received By
.
NR = Non rebreather PR = Partial rebreather FM = Face mask A = Aerosol VM = Venturi mask TC = Trach collar
TIME: (CCO MD
• • • • • Skin breakdown
prevention
. 'Falls prevention protocol
• Restraint protocol
C • Seizure precautions t:.) U.)... i. 4
A • Isolation precautions

E E YESTERDAY'S WEIGHT: D TODAY'S WEIGHT: WEIGHT CHANGE:
• Per hospital policy. TOTAL OUT
Stool
TOTAL IN Urine
fi I_ -1 ,
DIAGNOSIS: SW fziejy•N Lo "JAI\ /Tim et4,5( ,,,...„,a)
..—,1, %---,,,,....,
DRG: MDMISSION DATE: 101-?..-10V VD LOS:
EXPECTED! RE\LEASE:
( Lili -1--
CASE MANAGER:
PRIMARY CARE MANAGE
ISOLATION REQUIRED (Sp .

Page 1 of 4 pages MC V 1.00
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1
in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
.
TIME• INITIALS:
=5LAS•
INITIALS:-110111E: I.
INITIALS:
1. NEUROLOGICAL: Alert and oriented to
1-7
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate ---7.---
I I
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)
3.

PULMONARY: Respirations withirl normal 1.7 rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath
.
sounds.
4. G.I.: Abdomen soft and non-distended.
l-1
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
_ - 7 r\--0
'\' (LIswallowing. Denies constipation, diarrhea or
rectal bleeding.
_ ,
— • • -'
. .
eports no dysuna, retention, t..,7 urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
tt(Let'LL-1-3 it)
6. MUSCULOSKELETAL: Normal muscle fan 40 Aide FL/0 R-rr\aD
I I
development and mass for age. No -V NZArr4\ -toV5Z
z' ext,
deformities. No assistive devices needed.
fe-cM. 40 vm"..
Normal active ROM without pain. No joint
cuyyt_93--rwa. CJa_QA
swelling/tenderness, weakness or paresthesia.
RrI1-10 e),C
(3-",uc
SKIN: Warm, dry, intact. Good turgor. No
7. vanAdio g-E tV,0(6t-e Au
rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
A-0 wzDtxpAzo._-
prominences. Mucous membranes moist.
trnwywnut)
8. PAIN: No complaints of pain/ discomfort.
(See page 1 for documentMg pain intensity.) f'
elo
A'-'1°15
9.
PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R -Reddened
OK - No swelling/redness * - Central line)
TIME: IOW IV patency INITIALS: q S. hr: TIME: It (..) IV patency q INITIALS hr: TIME: IV patency V q INITIALS: hr:
IV site care provided: IV site care provided: IV site care provided:
IV tubing changed: IV tubing changed: IV tubing changed:
IV Site #1:Cektial LOCATION I OSZ., CONDITION IV Site #1: LOCATION (i;YOC CONDMON IV Site #1: LOCATION CONDITION
IV Site #2: IV Site #2: IV Site #2:
Comments: IA Ltri Comments: Al-e-3-4.0 6 Comments:

MEDOOM FORM 689-R (TESTI IMCHOI MAR 99 Page 2 of 4 pages
MEDCOM - 23964
6U-L
SECTION III - PATIENT INTERVENTIONS & TEACHING
I
SITE:
TIME: (c./DO rs-30 TI • "
COLOR
e ,
CO e•;!tt
••• Fr-
•• •-••:-; ••••••7' :-.c".,m•C. ,-.:"!.1:!;0::
/ii'-;71.:'.")";•7•••n'''..if,-,,,,•
-
ID band visjbJe/legibJe
Orient to environment prn
Side rails (2/4) up
CAPILLARY REFILL
I
TEMPERATURE
V.) U.)
EDEMA
Bed position low
Call light within reach
Review & post lab results
Notify MD abnormal labs
Incontinent urine/stool
j
Linen change prn '
Turn/reposition q2h
0

-
• .•• • •
SENSATION
S 5
MOTION
VA9210..oide. 91 u -Pf IA-
PASSIVE FLEXION to& MA
et------.
OP af

PERIPHERAL PULSE LEGEND Color: P-pink (normal); C-cyancitic; W-pale, white
•
,
!
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-(5 secs)
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting

,
-

Temperature: C-cool; W-warm; H-hot
ROM q2h if immobile
Sensation: A-absent; N-numb; T-tingling; S-sensation (present) Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Antiembolic hose Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
BREAKFAST LUNCH
DINNER
TYPE:
• • ¦ 0/4 0_L---TYPE: 1 0," i 0 TYPE:
' _Old A. i.e: 1
PERCENT CONS I EI:e71.(6 PERCENT CO 4 UMED:
---."
PERCENT CONS • ED: a
HOW TOLERATED:
HOW TOLERATED: HOW TOLERATED: AA9c32_0
7.4 SELF 0 ASSIST 0 COMPLETE SELF D ASSIST
0 COMPLETE SELF El ASSIST 0 COMPLETE 0700-1.500 1500-2300
2300-0700
•
0 SELF D COMPLETE 0 SELF D COMPLETE 0 SELF
COMPLETE
BATH/ORAL CARE L7
. .
y(ASSIST D TOTAL V ASSIST 0 TOTAL D ASSIST El TOTAL
la:z
tr;4,.. ' BED.B.E.S.T XSELF •
BEDR I 34 SELF
-.7U
.. AmB t_ATE 0 ASSIST
C_2_D
TYPE OF ACTIVITY 41313P liCE/WW ASS ST
BSc -6 Vat,
.,,,,:iti (Circle all that apply) BS "CD
# TIM S/SHIFT ; .
-p,:s - # TIMES/S IFT
BR"
, CH9 VT, 43,
TIME: A Ap INITIALS: TIME: k%bc2) INITIALS:

TIME: INITIALS: ...„. ,,: OC NTENT: ciyi CONTENT: s
ONTENT:
JO; —
.
kILY-
,...,1b. ti..`
—rtt)1\1 ,r-N .
..
-4V-CV)/X)&44/. f' Own _ a 0.:,.• • 4-7?)-...._ --V-
. -
1.-),,
.
...
CA.P(NLAI A--)C5 .-,,. .
A7t)
Patien Family Verbalizes Understanding amily Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
P TIE ID TIFICATION
INITIALS
(L,\)--- Z.,
SIGNATURE SHIFT
AIM
(.,,A1-0
E ( (9_-(4
MEDCOM - 23965

..______ __ __ _
SECTION III -INTERVENTIONS & TEACHING (Cont)
T
TREATMENTS cL m LOCATION OF WOUND APPEARANCE AND DRESSINIG CHANGE
E
•
' cp ocakVu,_bik iCNICICMOCAL a -.% 4 ' 11,
, v .
til,v4 ,, vi. is
(41 63.1 9 e . • • • ' %, ni.11 4 . 111

4. . . •• 0
I 11it,
1UVIII_
' AO_. el
.. Z \OL-Z2-3‘C& C-C"43 to_6 -I 6, : CA-•fr
$ ilk ,ez,_ il • _ mai -

.....mt,..„.__
. 'a4 iii c:::, s sli. , 40,4 4,, 0-0--
t
.
aN
‘-'2_,Y-)S it% .._a...-,,,...._. At .. • ._ _ . . A r0.-1-)..-
Vi , ¦
.1 ''''
%a 0 rt-j2' .7k7k_ C;(;/-2. k.) `-6IC- --6)( 9r1)-4ThrN
II°
'?'A.1,
SECTION IV -NOTES
,
.
,
.
rornormA _ 91CIRA
MEDCOM FORM 689-R (TESTI (MCHOI MAR
Page 4 of 4 pages
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
SECTION I -PATIENT ASSESSMENT

VI De...,.C_C)----) PATIENT ACUITY LEVEL : -b' POST-OP DAY:86112_ HOSPITAL DAY: -Y/
'
DATE:
I

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REP• "T: Time To From
AMBULATORY Pall CRUTCHES WHEELCHAIR . STRETCHER
111 III
Total ER/RR/PACU time Physician Anesthesia /Specify); Procedure/Diagnosis B/P P R T LOC eurovascular checks Dressing/cast
Tubes Intake (IV, po) Output lEBL, other) Voided ill No III Yes Amount: Medication
Other
.
Report From Received By
TIME: CHEC---frati
BP ARTERIAL LINE ,----17 BP CUFF
lithi
I
TEMPERATURE
gl PULSE -
1(53
RESPIRATORY RATE
1•6"
OXYGEN (L/%1 ..-------PULSE OXIMETER Cil 02 METHOD
ie-4-1-
NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar
-
TIME: TIME:
VI ID lir•t) 07 •••32o
• Skin breakdown
-• , Ill
prevention (
PAIN •• •
'Falls prevention protocol -
INTENSITY
•Restraint protocol
0 :. :. 3.5 :. : : : : : : : : : : : :
10
• Seizure precautions
MED ADMINISTERED IY/N)
RELIEF ACCEPTABLE IY/N1
• Isolation precautions
.\\ 0:-)
I— CCe:(Zci)u: CC' 2c)1— wccI
TIME:
z' w,u,
YESTERDAY'S WEIGHT:
FINGER STICK GLUCOSE INSULIN IY/N)
TODAY'S WEIGHT:
1
1 IV
WEIGHT CHANGE: 'Per hospital policy. PO IV #1 IV #2 TOTAL IN Urine Stool
24 HOUR
TOTAL OUT
TOTALS
PATIENT IDENTIFICATION DIAGNOSIS: DRG: 61? tr-v, ,to mmui.)14-1,67_c,. -9( '1(3,(P)COL ADMISSI N DATE: ,.,x1,...30v
CIIIINIP b t Lt.') - LI LOS: EXPECTE• RELEASE-.—,-1./CASE MANAGER: PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MEDCOM -23967 DNS ARE OBSOLETE Page 1 of 4 pages MC V1.00
DOD-037545

-Pc

SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1 in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief
explanation of abnormal findings will be noted in the appropriate column.
TIME: Oci 15 INITIALS TIME: 1.3(..D INMA IME: ' INITIALS:
1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. 21 INfi I I
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate
I I
within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity
perfusion)
3. PULMONARY: Respirations within normal rate .for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
sounds.
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint syv e I li n g/t e nd ern e ss, weakness or paresthesia.

7.
SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

8.
PAIN: No complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.)
9.
PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild

and appropriate to situation. Interacts
appropriately with others.

10.
IV SITE ASSESSMENT: P

TIME: a..1t5
INITIAL
IV patency ,/ q hr:

IV site care provided:
IV tubing changed:
LOCATION CONDITION
IV Site #1:
br.,
0,L
IV Site #2:
Comments: ti-L.....
,
'
114 lig I
EV it rztrivLAT
Mock& 4.A.
h cg,fitittx,
ik.cat(ey- ano piwifuttv (PLA--C.OA_12._
Ck.SS15+ '
l(Ohl+Ira
eca. qltutl-rib
-P...K -Ftx
I.4 (ID-1.---glAiliatit. 1
it( , -.
valn .
-1-0-40
r
.
...),11.4cii 0 iirlk COd*--le-e-a-Walaen 1 hIltic.Q-I—acca2 LUL/
0 P-Y
k„,A.s2.._12_ fe_,‘ U 1 ,,J
P7

I -InfiltratedPuffy -R Reddened OK -No swelling/redness * -Central line)
TIME: 15 3z) INITIALS: IME: INITIALS:
IV patency ,/ q ft, hr: IV patency ,/ q hr:
IV site care provided: IV site care provided:
IV tubing changed: IV tubing changed:

LOCATION CONDMON LOCATION CONDMON
IV Site #1: ICA...,C.i...., _o___. IV Site #1: IV Site #2:
IV Site #2: Comments: 14(1.....,,
Comments:
MEDCOM FORM 689-R (TEST) (WHO) MAR 99 Page 2 of 4 pages
MEDCOM - 23968
DOD-037546
SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE:
,J..i*
TIME: i‘f,
1:-.

TIME:
I

ID band visible/legible Orient to environment prn
....t,.;6:c..
x,
COLOR
.

e
i
/

CAPILLARY REFILL
.

,u....,,i,'LLI:.-,.', 1...-.
,' ,:-.',--!'t4.,;. ;' I :-.4 ,::`?„:,
Side rails 12/4) up
Bed position low
Call light within reach
Review & post lab results
.:., TEMPERATURE k.)1 GO
.
EDEMA
S t5
..;•., , SENSATION
.
P ?
P

MOTION
,-
PASSIVE FLEXION
ili:'!". PERIPHERAL PULSE (9` Notify MD abnormal labs
• -ii ci, ,
LEGEND
:i
‘.
•• ;
-7,` Color:
:
7,e.r?..,,:
P-pink (normal); C-cyano'tic; W-pale, white Incontinent urine/stool
Linen change prn, Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-1 5 secs)
Temperature: C-cool; W-warm; H-hot
. Turn/reposition q2h
,-' Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
ROM q2h if immobile

Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
, Motion: Antiembolic hose

U-unable to move; M-move-no pain; P-move-pain; R-full ROM
'' Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
) p Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

j;
D-doppler, P-palpable
1
Witt
-f,a-,,,
BREAKFAST LUNCH
DINNER
TYPE: TYPE:

TYPE:
(Lif-
. . EP RCENT CONSU : I PERCENT CO UMED: PERCENT CON MED: ra-670 HOW TOLERATED: HOW TOLERATED: HOW TOLERATED: 'KW_ SELF 0 ASSIST 0 COMPLETE 0 SELF D ASSIST 0 COMPLETE Yij. SELF D ASSIST 0 COMPLETE i 114.0r 0700-1500 1500-2300
ar
2300-0700 0 COMPLETE El SELF O COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE
,:f. XASSIST O TOTAL cZ.. ASSIST El TOTAL 4‹. ASSIST 0 TOTAL

BEDREST 0 SELF BEDREST ID SELF BEDREST 0 SELF' , -AMBLEdwir_./153.12:T:=, ULAT C.T.SSSIST cc—AMBULATE -2.)
tcceASSIST
! TYPE OF ACTIVITY (Circle all that apply) BSC # TIMES/SHIFT BSC # TIMES/SHIFT BSC 11 TIMES/SHIFTBRP BRP
BRP CHAIR CHAIR
CHAIR y z-', T I M E: 1121 WallrElf— INITIALS:MM
1 TIME: INITIALS:
it,i'
Ida
,6 CONTENT:

CONTENT:
...A _ 1 -/--'---
, l'i" cOf aSS IS+ CDT_L..4,
-i.
Li\CIA.CLA\-0-t)--ANI•SlA/k
•'
.
-
-. '':'.
;6.,s. O Patient/Family Verbalizes Understanding
atient amily Verbalizes Understanding 0 Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION INITIALS kD (...(2. — 7...• SIGNATURE SHIFT
(CR L\
.I 0 No
AIMS
111-6L) k)
_MEDCOM - 23969
fiRcrwrinm Cl1011.4 .e00 /7-COTI fAR,IJI-11 IIMA OD
SECTION III - INTERVENTIONS & TEACHING (Cont)
I TREATMENTS
M LOCATION OF WOUND APPEARANCE AND
E DRESSIrAG CHANGE
.

6 1 0 in=
,,,, . Leo
-
•
-I. d `;1)_US6- 4
: .
._._. .:-_--‘00..%.s.j, 41 .. az_ 41. Willtiara....4 "Ili V U1/4)÷- to -^A
4
1 VD-L7-ticC Wc_ /NOLL/A_ (1.0 .• ilr ,---% %ez
t dt,—„, • •
-

4NT: N.
--t*.'CL gel -'W.A..-A_
,. • 111.. (/ , . it
...
Or. C•11-0--/Is-e__A--c-
i I (:)...) Al __ ..... (oi , ' (j\l'--j
--....-,,,,.... ....
...7,e
471111 ----Ck -Ist-ell'"- CS-L-±.-a C-bt.
Ei.
LA) CC*-13-4-
'r,-..g .
SECTION IV - NOTES .
•
,
,1
MEDCOM - 23970
MEDCOM FORM 689-R (TEST) (MCHO) MAR
Page 4 of 4 pages
MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT DATE: V:ibe_C____ C5I'D PATIENT ACUITY LEVEL : —tic POST-OP DAY: 31 13 0 PITAL DAY: s COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT:
111
IN AMBULATORY II CRUTCHES Ill WHEELCHAIR STRETCHER
Time To From
Total ER/RR/PACU time Physician

Anesthesia (Specify):
CCZ LI- LIJ CC u) ' 0 LLJ CC
I I. ,ct z
Procedure/Diagnosis B/P P R T LOC
Neurovascular checks
Tubes Intake f1V, pc)) Output IEBL, other) Voided IIIII No . Yes Amount: Medication
Other Dressing/cast
.
Report From Received By TIME: ale ,c)e.)0 eIL(00 ' BP ARTERIAL LINE
0 4 ,a34.5 i iyx
BP CUFF TEMPERATURE
ells-IV 77
PULSE
la lit jo7 • RESPIRATORY RATE o ulc, RD OXYGEN (Li%) -0-PULSE OX1METER 06 /00 n 02 METHOD
-1 A 1V
NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar
-
TIME: ono
cv-v-AP 2oco
TIME:
• Skin breakdown• •• •• prevention
. . . . . . . k
PAIN •• •• ••
• Falls prevention protocol
o., —.4, Z' „ Lu ' '
INTENSITY
:
. .

`Restraint protocol
•
Seizure precautions

•
Isolation precautions

YESTERDAY'S WEIGHT:
i
o
MED ADMINISTERED IY/NO
. NA
RELIEF ACCEPTABLE MN)
TIME:
FINGER STICK GLUCOSE
INSULIN IY/NI TODAY'S WEIGHT:
..---'-------
WEIGHT CHANG
'Per hospital policy.
24 HOUR PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
TOTALS
PATIENT IDENTIFICATION
DIAGNOSIS: • ,t,,, ammo „ __ V .
., . • "1-1A. '" —1111.-•,._
DRG: ADMISSION DATE:
I .-N.):::31
LOS: EXPECTED REIIEASE _
C___ ell,
CASE MANAGER: b (..
imilio_
b tb„,.5 - 4
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) DNS ARE OBSOLETE Page 1 of 4 pages MC V1.00
MEDCOM -23971
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1 in the small box indicates patient assessment criteria have been MET. If all the sta ed criteria are not met, a briefexplanation of abnormal findings will be noted in the appropriate column.
TIME:ogc-' INITIAL
TIMEgO INITIALS: ME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
LT/ +7
time place and name. Responds appropriately. ...se
Communication is adequate to express needs.

®_C b j c)11'
Pupils equal and reactive to light. ._
2. CARDIOVASCULAR: Pulse regular & rate
I l'ir
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)

3. PULMONARY: Respirations withio normal
IL,„1-----
[:1. I
rate .for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath ,
sounds. .

4. G.I.: Abdomen soft and non-distended.
g.
I I
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/

e,.....
swallowing. Denies constipation, diarrhea or
rectal bleeding. .

P\--k \
5. G.U.: Reports no dysuria, retention,
I 1•1/ F
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.
6. MUSCULOSKELETAL: Normal muscle ‘1_, a.o..,1 TO_1,11-i.... 'Yr'
Able —6 uttikee'
development and mass for age. No
)(2-EY Ft i
deformities.
No assistive devices needed. --
40 4112-
Normal active ROM without pain. No joint 4....y.,--ay„,e5 -4-D g-tb
swelling/tenderness, weakness or paresthesia.

t lk+15( Ci"
7. SKIN: Warm, dry, intact. Good turgor. No ni ki.,11100.- LiXx.,,v0
tOCUra.2 -10 _ . ,
rashes, inflammation, ulcers, breaks in skin. 5 er1.5 7-c---,-, 2./-F._ 6
12_1.E. 140..).,44i Wre.)i-L
_...,
No redness, blanching, irritation over bony
c6i, c,0 s(2. CV-440/KD rotti_ s_ua /110.9tkpte
,
prominences. Mucous membranes moist.
\uc--,444--r ;In_ -r", a-t--
gt.c.-_
8. PAIN: No complaints of pain/ discomfort. e""k" P140,-, TO .
-:-.-pe4-exce-f
(See page 1 for documenting pain intensity.) I i
fzyr po-----
ii '
9.
PSYCHOSOCIAL: Behavior is appropriate —
to the situation. Anxiety is controlled or mild

and appropriate to situation. Interacts
appropriately with others.

10.
IV SITE ASSESSMENT: (LEGEND: P Puffy I -Infiltrated R -Reddened

-o swelling/redness * -Central line) TIME: cr1 30 INITIALS: IME: grXX) INITIAL TIME:
INITIALS:
IV patency ,/ q 5 hr: IV patency
_____ j q C hr: IV patency
____ j q hr:
IV site care provided:

FL.E, R IV site care provided: / MAIMII IV site care provided:
L... . -
IV tubing changed: I
IV tubing changed: IV tubing changed:
LOCATION CONDITION
OCATION
CRNIDITION LOCATION CONDITION
IV Site #1: IV Site #1:
Ruf. 4. ,,s7_, (20 C C 0 C.. IV Site #1: IV Site #2:
IV Site #2: IV Site #2:
Comments:
Comments: Comments:
3L

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99_
Page 2 of 4 pages
MEDCOM - 23972
DOD-037550
PATIENT INTERVENTIONS & TEACHING
-
RLE-
SECTION III
1.

TI ME: 0--no ODD
TIME: -73c.
SITE:
_
1
_'' ,..,' . _.'..:.1.„7,:-. • • -.7.4_,,:. -....: ' •',-.:i' , .,:,..3 -':1,1.',",;:.•T%,,,:,:•,t,,,,'::,,.,:', .!:?,-,:r.j...,;;;',417:-',7'.',`7.•':, ::: "ria,.-Nr.:77.-a
•L'o -:,• ••'::-::•,•;¦ ::.Z:'' Ur',M"...: Ct•4 0; : r) -,:r:. cr,, (i).!. C.) , .a. ' r, ;,,I:i,.CIC.1 :, CC':,:i4p.,,,i_il.C.4,,I,
-,e. • ..';'"V.-'.'.' ,..' -,...:. iV.---"H. • ',:i'',,,..,..',,P,,..,,, , ....-..., i;iv...='04''..''...1%::#,,r''.:, 4.k. ;;':P.,f`..,..'.-..,,..,:.,. .,' :i',',,'.,''P'. .rna,. ..:. C.)
"

-AS--111 -1-"" '01 tr. " -Ce
, : r4.
P T

ID band visib)e/legible
Orient to environment prn
COLOR
—

CAPILLARY REFILL
1,0

Side rails (2/4) up
TEMPERATURE Lk.%
'

Bed position low
EDEMA
S S

Call light within reach
/
SENSATION
MOTION
reivai) IA -C:9-' 0
Review & post lab results
PASSIVE FLEXION
PERIPHERAL PULSE Notify MD abnormal labs
D---
LEGEND
Color: P-pink (normal); C-cyancitic; W-pale, white Incontinent urine/stool Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-1 5 secs) Linen change prn ' .
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
Turn/reposition q2h
ROM q2h if immobile
4-
Antiembolic hose
BREAKFAST LUNCH DINNER TYPE: P.Z.,, TYPE: (24.4 TYPE: PLc, PERCENT C(ASUMED: 7 5,— PERCENT CONSUM : i 61-6•°::-PERCENT CONSUMED: 707,1
K ‘,
HOW TOLERATED: ,..1.20 t,.-r,G•;) HOW TOLERATED HOW TOLERATED: t/tAe_X--‹
F. SELF El ASSIST 0 COMPLETE • SELF D ASSIST 0 COMPLETE 01/S.ELF 0 ASSIST 0 COMPLETE
0700-150 1500-2300 2300-0700 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE 0 ASSIST 0 TOTAL fAnSSIST 0 TOTAL ?gPASSIST 0 TOTAL
BEDREST 0 SELF BEDREST El SELF B_EpJa.,E_S._1-__ 0 SELF 0 ASSIST CAMBULgrIZ, 0 ASSIST :L L. tcayai_e_p
-.1ASSIST
TYPE OF ACTIVITY
.-- BSC -- BSC "7-
(Circle all that apply) # TIMES/SHIFT (--0-0-gefiMES/SHIFT # TIMES/SHIFT
BRP BRP BRP
CHAIR CHAIR CHAIR
TIME: C.,Pc..-INITIALS:Mr TIME: ,:::/CCO INITIALeir TIME: INITIALS:
CONTENT: /IL -6 tA je4Lec,,z it_2_,,CONTENT: CONTENT:
t9mi3c, airf,--rt 0 . tell*Lia;k) —C1 Lti3-Qkei
11' fro' r/._ (-405
0 Patient/Family Verbalizes Understanding Patien /Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION ' INITIALS SIG RE SHIFT
cap \, ,, \ (,, ) -t\ PC/ 0

i /
MEDCOM - 23973 ,..._.)k ,.
SECTION III -INTERVENTIONS & TEACHING (Cont)
TREATMENTS
"W,
I
LOCATION OF WOUND APPEARANCE
AND
,
DRESSINt CHANGE
. Sif
.)
(,-IP11" fifill-lt 4 Lival -1_,.44,, 4,-tth-Jo iii--Ap -,,te-kil.A') Jks .5_141--Ard AIMell r
0 I j Ls
. ,,.., j___. ' w i 1-11, li j)c .
-Ices
1,0 far tgh--Ft40pm:flecks. pilic,piktk, flan ci,..4.A-N-R___
tosicIto*(4.)--o DxILL
-
r t le6 oreh. tA-6144-64.)
y
PtKk'
*
.....:
bELQ. '-' SECTION IV -NOTES 055,c,
,r
Xf...r.4,53 1.7- A-obvt., 4-1,5,L3.,12-'ro C/u/t. ii-94--Or_75/) /)5,£. Pii 47-- y
.
'il i !.
nApnefun _
"Y1C17A
_
FORM 689-R (TESTI /MOHO) MAR 9.-
Page 4 of 4 pages
MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT DATE: lei DEccG PATIENT ACUITY LEVEL : 40--POST-OP DAY:*pl HWITAL DAY: 37 COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -
TELEPHONE REPORT:
Time To From NI AMBULATORY . CRUTCHES . WHEELCHAIR II STRETCHER Total ER/RR/PACU time Physician Anesthesia (Specify):
R
Procedure/Diagnosis
B/P P R T
A
.N LOC
Neurovascular checks
.S Dressing/cast Tubes

.F, Intake (IV, po) Output (EBL, other) Voided 111 No 111 Yes Amount:
Medication

Other .
Report From
Received By .
TIME: gov )60 141)(9 .
BP ARTERIAL LINE -, -i

.
!sic( ti-Ai %%mt.
BP CUFF
TEMPERATURE
11-11-Rt / i•
PULSE I .
1K ih'
RESPIRATORY RATE 910 I _
OXYGEN (Li%)
----ft—
PULSE OXIMETER % Mr cri
02 METHOD

A- RN
t----
.
.
NC = Nasal cannula NR ---- Non rebreather
Oxygen Method Key: FM = Face mask VM = Ventu i mask , MT = Mist tent PR = Partial rebreather A Aerosol =
= TC Trach collar TIME. ti
)D0 TIME: f•-2.-0 Da-
,. .• • • . • • •• •• •• 'Skin breakdown 1)6.-)," •• " • ••
" • prevention
•' ' • •• " ' • •'
PAIN •• •• •• •• •• ••
• Falls prevention protocol
. INTENSITY •• . • Restraint protocol ,
o X' ' • ' • " •• ••
.
MED ADMINISTERED CY/NI
\I • Seizure precautions 1
RELIEF ACCEPTABLE IY/NI
• Isolation precautions
itec4
TIME: (2C,0 -1)(2)
T FINGER STICK GLUCOSE .0+" 4j
..E YESTERDAY'S WEIGHT:
Ei INSULIN tY/NI

D
TODAY'S WEIGHT:
E
WEIGHT CHANGE: ,
R
• Per hospital policy.
24 HOUR PO Al IV #2

TOTAL IN Urine Stool
TOTAL OUT
TOTALS
—
PATIENT IDENTIFICATION
i
\ DIAGNOSIS:
Or 1../ ..,.. . -P, '0 1 : ' ,
n . -\ , ., I.A., 1 ., .,/ .0. , i DRG: AD ISSION +ATE: r P.C.!-
, A barb
L....t1/ LOS:
EXPECTED RELEASE: CASE MANAGER:
4 6-,)....,
PRIMARY CARE MANAGER:
_____011.1
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MEDCOM -23975
)NS ARE OBSOLETE Page 1 of 4 pages mcvtoo
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check I in the small box indicates patient assessment criteria have been mEr. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
1.
NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

2.
CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nal!beds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

3.
PULMONARY: Respirations within normal rate .for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

4.
G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

5.
G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

7.
SKIN: Warm; dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

B. PAIN: No complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.)
9.
PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

10.
IV SITE ASSESSMENT: (LEGEND: P TIME: 1 1.-60 INITIALS: IV patency ,./ q .3.' hr:

IV site care provided: mcct...5 At;
IV tubing changed:

LOCATION CONDITION
IV Site #1:
• 6.1 s. 61. cix-
IV Site #2:
Comments:
i ri.,C6 INITIALS TIME: INITIALS./ TIME: t INITIALS:
TIME:
,DD. SM. p`Vt% ri
F I 1
I/I/. I—
.
.
,bLUI) - (2-fv \\
%../.
I—
I—t I I
n fle -e, 1....12-P-a-,‘..
'-(ZryirW._ feCrfl -VOC)
Rik-

k-f•4.02_. ) po-la if Ravv¦ Nk IZOTY‘-
-0 Pal\ io CcuAke c9-1')4--11^--K-.4-1
2-- ip '6ici"-ct-ic
-pli1PA.-c, ' 40

---eOrYtf("I)
111.1-VW 40 TAZI . I

Walt/A-44 --1-bita /
+ S . , , Si.4--6CG--ei i
( ecc, Az or\ c I 0 , ,/ " cbt, l
• , ;1.4 11-iliP
-
P C.:(a eCCAA--pi-ux-i-A-11:
4‘,;
1
VA---"`"
‘,/(
11-'7
Puffy I -Infiltrated R -Reddened OK No swelling/redness * -Central line)
TIM E: ‘1,011.5 INITIALS: TIME: INITIALS: IV patency j q 5 hr: IV patency I q hr:
IV site care provided: L IV site care provided:
IV tubing changed: IV tubing changed:
CATION CONDITION LOCATION CONDMON
IV Site #1: IV Site #1:
D V
IV Site #2: IV Site #2:
Comments: g I/ Comments:
Page 2 of 4 pages
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
MEDCOM - 23976
DOD-037554

-2_

SECTION III - PATIENT INTERVENTIONS & ,, SITE: 0...9_,p-TIME: q,c0 .I.
TIME: (-70c, „An °
,.,_
COLOR
e s ., , ID band visible/legible ‘
CAPILLARY REFILL
1 .,..
*.. Orient to environment prn
1
TEMPERATURE ::.F.... . -r .
Lo U-) .,,.., Side rails (2/4) up EDEMA
Bed position lovv
Oc., Pro
SENSATION
.__ i Call light within reach
7
.
- -
MOTION a va..(1(4,4EL uk.I p ulfitt:
4--PASSIVE FLEXION :.,
tit A-ter , Review & post lab results
.. PERIPHERAL PULSE

'1P Notify MD abnormal labs
,,, , 0 n -0„abiz4_ccapoe

LEGEND
ill% . Color: P-pink (normal); C-cyanatic; W-pale, white
12
Incontinent urine/stool
.:,, Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-(5 secs)

Linen change prn " ,,,:=, Temperature: C-cool; W-warm; H-hot
T "
Turn/reposition q2h, Edema: ..
0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
11 Sensation: 4 ROM q2h if immobile

A-absent; N-numb; T-tingling; S-sensation (present) ,.....„
:,-; Motion:

. U-unable to move; M-move-no pain; P-move-pain; R-full ROM Antiembolic hose
_ , Passive Flexion: ..,

D-dorsal flexion pain; P-plantar flexion pain; 0-no pain •
Peripheral Pulse:

0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable ',.,
4-.N
ii,..,i BREAKFAST
LUNCH
DINNER
TYPE:

TYPE:
e......Q.0,4_
1-..J
. TYPE:
...;; PERCENT CONS MED: )0 PERCENT CONICMED: PERCENT CONSU ED: -)
-HOW TOLERATED:LL, HOW TOLERATED: HOW TOLERATED:
LA--e-'2-e
SELF 0 ASSIST 0 COMPLETE
XSELF 0 ASSIST 0 COMPLETE
rELF 0 ASSIST 0 COMPLETE
t.b.:
0700-1500
. 1500-2300
2300-0700 7)k,SELF 0 COMPLETE
BATH/ORAL CARE X1ELF 0 COMPLETE 0 SELF 0 COMPLETE 7::. El ASSIST 0 TOTAL 0 ASSIST 0 TOTAL El ASSIST 0 TOTAL
BEDREST 0 SELF REST 0 SELF BEDRE 0 SELF
' ,---71" Bl1I_A . _ SSIST A^A13Ill.
"g—_
TYPE OF ACTIVITY 4---n , E2:-IFSSIST C,,AIMULARP ,k:ikSSIST
B C.V.&
(Circle all that apply) BSC-i--44-4--
# TIMES/SHIFT # TIMES/SHIFT BSC
--e":64-ej:2111,11ES/SHIFT
1
CE31--7
./4E?‘2-"S
L_CI-1 i.fij
__-_,4
-,-.-

t:4:: TIME: t'') cc) INITIALS."' TIME: ?itren.?
INITIALS
AR•TIME: INITIALS:
,.,_.
‘t-' CONTENT:

—cciiT\CENT7" b6 -.2---
_ CONTENT:
-— V - ili\-, 4_,E.,,Siot. 0,p*.Q__

n-C-0.--ck..61011/"Lf-Vd-— 1_4_02S)k.1-
.
. I " A _
14.,83.1..e.
_,, .-- CAA/ CfC&C_Cti-C, Z1-- (A-X4CeA
.. 1 19.4-15-s\--e---Q--4 C4.0.4-valot,tc,c
i
: pry\ ,, 4e, gi .
vi,,(._
.,
• Patien /Family Verbalizes Understanding atien amily Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
ATIE TIFICATION
INITIALS 1.,-.:, a L SIGNATURE SHIFT
-k-L (1.) -q
ail-L.?
11111 ,_-, x A)
nnFnc.nm _ 91(177
ry-srm, ,f7r1_ ••••••• Nes I NI,_"Iry
DOD-037555

SECTION III -INTERVENTIONS & TEACHING (Cont) W . -, . . .‘ :?Ii:S";?.. 11'...; :4:0 T I M E LOCATION OF WOUND APPEARANCE I___ t)Ar\--iv,icf i'Vcr_ a tetr.4,,t t. cue...iv...ter Vccd.63 tCrixit:1 Oltaar\rtIf , -S 1r 4 inrecirarl,tutu -cg-Lavv1/4,(0-i-c-d1 a_ • - c It - , • ' --L. ti — v-c 0 . 6/1-• caNiicuilste 3 rea &A/c a (4-tarnclet-"k0€ -f 4r,../z_.01 2„., n: —7- S • i 4 • c • ic,;--,f-CIA.f.4.;,-Cf R-63 SccuM-0(-41.4 3e."..oslcuelav4"oc.s -PC(..i-ck_.. MI SECTION IV - NOTES 1C-4* , -e4--r\cu-e.ck _() _s-r-r-c_ on L.V., . . . TREATMENTS AND , DRESSINt CHANGE -''''.11 ';. a p 1A.ca.A0 A.L.:A - -,f• .4 4 41.1710"--. / / ' ' "" '-7--
.
'
;
.

MEDCOM 23978
MEDCOM FORM 689-R (TESTI (WHO/ MAR 99
Page 4 of 4 pages
MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I -PATIENT ASSESSMENT .
DAT E: "DO rjecti PATIENT ACUITY LEVEL : -. POST-OP DAYT-51 IS" HOSPITAL DAYe-10 COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT: ' C Time To From 111 AMBULATORY I. CRUTCHES i WHEELCHAIR . STRETCHER
1—cc elzcnu-Lu m
Total ER/RR/PACU time Physician Anesthesia (Specify):
Procedure/Diagnosis B/P P R T
LOC Neurovascular checks
Dressing/cast Intake (IV, pol Output (EBL, other) Tubes Voided . No II Yes Amount:
Medication
Other Report From . Received By

TIME: le9.0b . . ,:,
BP ARTERIAL LINE „.,..-----
BP CUFF ifNI
TEMPERATURE .B 71
PULSE t k5 -
RESPIRATORY RATE i (--1
OXYGEN (Lick) /------
PULSE OXIMETER Ct q
02 METHOD .---------
Oxygen Method Key: NC .. MT = = Nasal cannula Mist tent NR PR = = Non rebreather Partial rebreather FM = Face mask A = Aerosol VM = Ventu i mask TC = Trach collar
TIME: cri0 TIME: 0-710
'Skin breakdown

cr cn— cn waI
PAIN
s . . . . . . . . . . . . . . . .
INTENSITY
MED ADMINISTERED (Y/N) 11./ RELIEF ACCEPTABLE (Y/N1
1
...---------
TIME:
FINGER STICK GLUCOSE
,¦"--"'------'..-.'—
INSULIN (Y/NI
CO 0:-',W ,C) Z 1-11 LU :
prevention
•
Falls prevention protocol

•
Restraint protocol

•
Seizure precautions

• Isolation precautions
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:
...----....-...."--1
WEIGHT CHANGE: 'Per hospital policy. '
24 HOUR TOTALS PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
PATIENT IDENTIFICATION DIAGNOSIS: DAG: , ../Sir opeR1:44,Gtx 14h-ific -PK. ADMISSION DATE: 12.kuu3
k. (1 - q LOS: EXPECTED RELEASE: ‘(-( C.t--2_CASE MANAGER: PRIMARY CARE MANAGER:01111111111•111111

ISOLATION REQUIRED (Spec, VI:
•
MEDCOM FORM 689-R (TEST) (MCHO: MEDCOM -23979 ONS ARE OBSOLETE Page 1 of 4 pages MC V1.00
SECTION II -PATIENT ASSESSMENT
-REVIEW OF SYSTEMS
DIRECTIONS: A check 1
in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
TIME: ,-1.72C) INITIALS.
TIME: INITIALS: TIME: INITIALS:
1---1

1. NEUROLOGICAL: Alert and oriented to . t
I I I 1
time place and name. Responds appropriately.
Communication is adequate to express needs. \D((eY Z_

Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate X'
I I I I
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion)

3. PULMONARY: Respirations within normal
I I
rate .for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath

'
sounds.
4. G.I.: Abdomen soft and non-distended.
KI, I 1 I 1 ¦
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding. .

_ _ .. _
. .
eports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6. MUSCULOSKELETAL: Normal muscle Q.) •f---0-1 z:—.(4)4L. KCO-
development and mass for age. No

3.1.4n6
deformities. No assistive devices needed.
L-0
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

7. SKIN: Warm, dry, intact. Good turgor. No cA,(L.5 Pr),
[-I
rashes, inflammation, ulcers, breaks in skin. rS Fin
No redness, blanching, irritation over bony
prominences. Mucous membranes moist.

8. PAIN: No complaints of pain/ discomfort.
-71 Lt/..T/A----
(See page I for documenting pain intensity.) y 5, R 1,..)4-
(1.41•••0 L./47,w0

L.Li_ C.-7‘14-7 '11—‘"""
5 t/P-i..5
9.
PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

10. IV SITE ASSESSMENT: (LE D. P Puffy I - Infiltrated R - Reddened OK - No swelling/redness - Central line)
TIME: Dc-4-10
INITIALS: TIME:
INITIALS:
TIME: INITIALS:
IV patency q hr: IV patency q hr:
IV patency q hr:
IV site care provided:

fr..1.4.S.mr,42 IV site care provided:
IV site care provided:
IV tubing changed:

IV tubing changed: IV tubing changed:
LOCATION CONDITION
LOCATION
CONDMON
LOCATION CONDITION
IV Site #1: IV Site #1:
IV Site #1: IV Site #2:
IV Site #2: IV Site #2:
Comments: as k3,-cr) Comments: Comments:
MEDCOM FORM 689-R (TEST) IMCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 23980
DOD-037558

1,1, ,g'" A'''. ; .' e '' AZ-'(r..P'Lli:';',1'-' '''''4';':'' .2', "";14'‘I-ZS-tiii•3Y!..;:,...i I
,'.. '-'".¦"? -4"
¦:: -,` ' t .. ',Z LU .M ,CC ,-.0..• 'ea., ctvki3Oli.a,.D-..-1 :, ct -CC.--,,,-,rt2.tv-. 1. , 4#inn-i?r
SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE: TIME: (7) i -r.:. TIME: 71c.- /
COLOR P - ID band visiblp/legible
CAPILLARY REFILL i ."':- ' Orient to environment prn
TEMPERATURE l't.../ '''- " Side rails (2/4) up
EDEMA SENSATION C.) 5 :1 --r: „.,,,Tar.:,i Bed position low Call light within reach
MOTION P . 44i
PASSIVE FLEXION 0 Review & post lab results
PERIPHERAL PULSE Notify MD abnormal labs

LEGEND
Color: P-pink (normal); C-cyanolic; W-pale, white
Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-(5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH
Ll',,,,,,I' il„..ild,'1;:.1i'4''iii:.i.:fi 'Itli.;'.,,f,:in:Vg::. '*.f,K,4,,,,!2,:.•a ;.' ?Vrq.,--:.,k ... 4-1 L? ..2').11*ILTA,1!,k
Incontinent urine/stool
Linen change prn '
.
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
1

DINNER
TYPE: p.....-, PERCENT CONSUMED: (idg HOW TOLERATED: L_Lii.-(--`--L=X-SELF 0 ASSIST El COMPLETE TYPE: PERCENT CONSUMED: HOW TOLERATED: 0 SELF 0 ASSIST 0 COMPLETE TYPE: PERCENT CONSUMED: HOW TOLERATED: D SELF 0 ASSIST 0 COMPLETE
0700-1500 1500-2300 2300-0700

q SELF COMPLETE 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
''' BATH/ORAL CARE
l:j ASSIST TOTAL 0 ASSIST 0 TOTAL 0 ASSIST 0 TOTAL
.:4;' -:: 411:71',Tr:,,,P..v ,. ,,, %,e-'' -,,,,A.-.: ;#fic TYPE OF ACTIVITY (Circle all that apply) BEDREST 0 SELF 0=10 0 ASSIST BSC # TIMES/SHIFTBRP CHAIR (1-)--TIME: cf)/(-5-INITIALS: TIME: CONTENT: A . l'E" LIN.,10..12.--no 1-1 coi,3 Tc-1-I 0 J'I cA):;uiLL. t.T".1/1/ Alec.hLS CONTENT: BEDREST AMBULATE BSC BRP CHAIR INITIALS: . 0 SELF 0 ASSIST # TIMES/SHIFT BEDREST 0 SELF AMBULATE 0 ASSIST BSC # TIMES/SHIFTBRP CHAIR I: TIME: INITIALS: CONTENT: ,
, . . ,..e'

! Latient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding El Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION
INITIALS SIGNATURE SHIFT
Stir 9 rui/ti6 __)
r
MEDCOM - 23981

INTRAOPERATR L—UMENT
MEDICAL RECORD
For use of this forrn, see AR a0 -66, the proponent agency is the office of The Surgeon General.
PrI.T:=NT TRANSPORTED TO OPERATING ROOM "). PATIENT IDENTIFIED D PROCE, URE
..z_-. BY VERIFIED BY
/
. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
TIME IF ( ¢th -2, NUNIBER

5. PREOPERATIVE EMOTIONAL STATUS
— CA OA -ANXIOUS 7 EXCITED E CRYING ANGRY L! WITHDF,AWN --1-OTHER (Specify)
;___,
1....:q-.ENTS.
r •

6. NURSING PERSONNEL
::,5SiGNED
RELIEF
5,1'..=%LjEz SCRUB

-1--
I
-
A:SIGED RELIEF
2/9.--
:.=-2',..;LL,-:-C,'R
CIRC.:ULATOR
,
. PC:E,IT:CN AND POSITIONAL AIDS ISpecify)
.
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SUPiNE _ LITHOTOMY . PRONE i---, KRASKE . LA EAAL: ; : LE7T SiD'E UP • -RIGHT SIDE UP
2 e2‘,-"4.7(.-;k
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,

-2 r)-`,2-='-"/
8 SKIN PREPARATION
;_i; 7L'.,,-.4.C..VAL .___ yEs .' NO

I PREP SOLUTION l.S.Decif://
eirz.-
1,,C. N E E ., .1
OR 7---NURSING UNIT ! SITE: S"V/II-I0 -
_
_
r':ETHC-7:'• ___ C,'EPILATORY _ RAZOR ' SITE: -13`!",1-.,: OM:

_ CLAP
•
i
T:i. . . :-S-¦ ,:TS i0.
! COMMENTS:
'.;.:.C..7:0r-:),= EXTERNAL DEVICES

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--Safety Str = = = Tourniquet
b ( 02) - Q--
C = Correct I = Incorrect
I First Closing I

1 _:•.1.- NTE Final Closing I
Other" I Cour,: ' Count
:7— I SCRUB -CIRCULATOR
_
)..;:.::e- Yes ; . No
I
_ 44'
2.ec•ie Sharp dimmiism 1-..
Yes I : No Ai
d111111111r4INERNIMM
s7rume.r.! Yes i No
_ s,
•r.-ar yes o
I . R.LTENT IDENTIFICAT N (For ryped or written enrries give: 12.
i.,-..-!. - Las:, ELECTROSURGERY DEVICEIS) (E-SU) 1 YES 1---i NO
hiS i. .71..C.'012;
Grade; Dare; Hospiral or Medical Facilirwi
I ESU NO: 6:7
f/:4 ' .L.,Th
GROUND PAD: BRAND ,.-.70.2--\ LOT NO: /5747i -1, /*-2/f
-
ESU NO: GFiOUND PAD: -BRAND LOT NO:
) 4. I .el ...1 _I
MEDCOM - 23982

-
Disbibuted by
Stryker®
1-towrnedioa

2-7 /
OSTEONICS
Full Dose

12-A/
Cat. No. 6107-0-001
iF,:P;GATIONWEDICATIONS GIVEN Control No. MEK003 kNESTHESIAI YES LI NO
D1CAT IC:MS METHOD PREPARED EY r=1Vc!--1

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. =E 71.

' -
--.
-,!.: LABORATORY SPEr_'IMENS
S'-'.1:::::E'. 3 ',:Ar,IE NA• ME
-.E
FF-,CD.E!...a:EDT : • L.-::=-ME. NAM,:

.,_
...
_
D'.....,..T_•=E-D! ;'.•:.-!3!.,1.: NAM:
.
,
-,- .
YES —__ .- .
.
NAi.,:::: - NAME
,.:.:.,.',E '4,--',ME. 1S. DRESSING ft.lbilOBILIZATIO.N :Spec,ty)
-7 -_E-E-7 -_-:--:-:::S :•ACKING YEF, NO i p iig,5,-) tecg,
TY:--E. 5. ::-.:. -2. 3 1 /'/-ifi• fii-p---.,
s,-E , 2 3 . afiei---
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.
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ST di2j ii4
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1,
,
20. OPERAT;D:ii(S.! PEF-FORN1ED ,
. _
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,
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21 PATIENT TRANSFERRED TO I TIME METHOD
1 I h\:),9',-
/Z7-"e/-----22 REGISTERED NURSE SIGNATU ,E
7. . -4:„.9„/
. - - -
REvERSE OF DA FORM 5779-7, ^,77- .
MEDCOM - 23983
•

1 —1 _ , ,
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MEDCOM - 23984
DOD-037562
• MEDICAL RECORD
-; ANESTHESIA
TOTALS
2 .
CI 0 r.
.• C °
• E
z tc-cs.:17.

a.-t S-6 0 c.
•-
• 0
•- • 7, • -
• u
12,
AIR • L/Min
z_c, 0 0 ,
• ‘3 0 -suaJc-COLLOID-02 L/Min 5 _c-1) c
smoLt-ouit 'Pasouc om
•f/ .'fr BLOOD—
milt NUMBERS LENTERDI REMARKS
WO,. 3 -EL'
P6.47 e cr_&c ;77
c.) / ci4 :"±-5
LIMIE sou cv
0 Warm" (-axe iv
570.2.
.A-cufa Mined •); Code 61-1,5p ,with_Groatsg L with fetters
EST BLOOD LOSS 4.0 0f k-fce.fie-1,
wors 0 LT
URINE —
kfrY) Ai,
a.° 3D Z.15) Ker;;—
fl 13P
SYMBOLS:

02 iee A
220 dr To Z1
BP by cuff -&71111111111
200 /IA 0 V s-T-- /(7-6-4- 6-4')
CD 72
A mamma= ifilmotwmi
Heart rate -r-Lt-6-
- 0
160
• 180 milummumwmgarae
Resp rate 140 •
120 _ .s Le. BP 0 6 -e
mansducecn
100
NMI v.
/K7-80 , cel

TouRNtauET
VPIDKIDIONECK:
GO
stimmlas'..semegtag- smazzedismom
.. T
For I
2C.CEDURn 40 6-

AN ES- X -X
20 (Le p 4,9
C
PROC-0 - 0
I b
( 1
Z Z.
RECOVERY AT
=Iran caml
, CO2 toff o2-5 4431 (spec rryl
ART line
11M11101111 (.9'2 tol 0 -6
I CD 0 ¦ .C2 a OTHER
SI eth- PC/E a 0'3_j
Birm
cobiornom:
MEMPA9.1!=lrefaml
1111:1Er=Thil G.) ,-,
REM.-
1111111111111. Sp02- ( d
sr ° ICe2 HR- tt(?
MOIL'
Mammy
bikt
En
Cony %warmer
w•th_
0o301 00 yVio..._ioc,1
.Y*.hod.
EVENTS A,mtkm Ready
t7SP
Begin I End
OC ED U RF_S 9,7`'P,/ 0
-thi PT Codes
6uS0 J058 OZ?1(..5—
AA L.sTnETtc TECHNKIUES:
block tioc/Voque Le-tlar Renwti
Femur ‘ c.t.1 T. t 6' E-7--,7f6. a a
t c
p '711
MEDI IDENTIFICATION
—
Typed ar *wean orrsa: Abram Grosoyeadat
AIRWAY PEADAGEDIEM T: hIMaaoriaaaiL
Idedlart lediry
.
, • C
2f -7¦• e-
• C €.1"`.fcr—cs
s Q.)," suRGEo
PROCEDURE LOCATION R.-11 4:)a-A OATE
r a it/v..1-0,3
RECORD - ANEST14181A
P 376 PAGE F
MEDCOM - 23985 REVISED PATIVUT DCThon. .I. Jan 9 9
DOD-037563
. , .
PROCEDURE SIZE-
eEsuurs
'
0 Oral ETCO2 Change 0 Nasal BBS Post Int
ET
Intubation
Teeth 0 Post CXR Gastric
0 Air 0 Contents
0 Oral 0 Verified0 Nasal
Tube
Suction: Y N Urinary 0 Return cc
ja.mali-us
Heme Dip: + -
-ro Supra-Public
CI Secured DPL
0 Grossly: + -
0 Opened Cell count
CI Closed
Sent@ Chest 0 Air 0 Blood Pleuravac cm
Tube #1
Autotransfuser Chest 0 Air Blood 0 Pleuravac cm
Tube #2
Autotransfuser
12 Lead Rhythm: Comments
ABG SITE- .
%o2 PH BE PCO2 o set HCO3 1) 2)
D-stick 0 SHct
0 Chest Initial D-stick 0 SHct
CI Chest Post ET r9-Ct. • Cllrern PT/PTT
0 Chest Post CT ETOH ;LAS 0 T&C x
C-Spine
0 Tox Screen
0 Pelvis &lir 0 HCG 0 OTHER
CBC:
TRAUMA TEAM ARRIVAL
'TFTLE

NAME (Print)
:-.PADED RESPONDED OWED'
ED Phy Surgeon Anesth
X-Ray
RT
.4 •
Ortho
Neuro
Chaplain

-PROCEDURE -•
'ACCOMPANEDRY .
RETURN: .
CT Scan: 0 Contrast
0 Head 0 Abd 0 Pelvis
C-Spine 0 T/L Spine 0 Chest

0
A-Gram Site:
TIME GA. 01¦Iii.S0P1'
APirE9P-.
Hre-
Y N
Y N
Y N

• MEDICATION TIME. DOSE
'110.1E- DOSE
START. TYPE UNIT*
AMT UP
INTAKE & OUTPUT
IVF
Urine NGT
NGT Blood Other
Other
TOTAL TOTAL
VALUABLES & CLOTHING
Nona Found Given to Patient Given to Family
Inventoried and Released to Patient
Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
DISPOSITION
CI Home 0 Admitted to Report Called to Time Transferred
MEDCOM -23986
Via. 0 St tcher Whppl
DOD-037564

-finciarnimp: GLASGOW COMA SCALE
TIME BP
O-
GCS: FIR RHY RR SA02 F102 MODE
EV M T
MEM
11111111111
MEN
MEM
11111111111
MINIM NENE
MEE
MEE
MEE
MEM
MEE
MEE
MEE
MEE
MEM
MEE
MEE
MEE
MIN
MEE
111111111111111
MEM
111111111111111
MEE
EYE OPENING : 13E60 RESPON6E MOTORRESPONSE..
4 -S ontaneous
5 - Oriented
3 -To Voice 4 - Confused
2 - To Pain 3 - Inapp Words
1 - None
2 !Incomp Speech 1 - None
' TIME.
PROCEDURE • 0 Backboard Removed 0 Downgraded
NOTES
6 -Obeys Commands 5 - Localizes Pain 4 - Withdraws to Pain 3 - Flexion to Pain 2 - Extension to Pain 1 - None
MEDCOM - 23987
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-88; the proponent agency is the Office of The Surgeon General.
REPORT TITLE OTSG APPROVED (Date)
TRAUMA FLOWSHEET
01 Appr 11 Jun 97
The proponent is Dept of Surgery
ARRIVAL STATUS TIME: -nmE6-7 (A0 02 1 /min C-Spine Immob MED COM: Meds: UKN • 'one 0 Yes:
Allergies: 0 UKN (9,11;ne 0 Yes:
Tetanus: 0 UKN 0 Current Last Meal/Fluid Intake hrs
LMP:_,2),01, 0
' PRIMARY SURVEY
..•
AIRWAY EIRETH G CIRCULATION

till‘r.iral Patient CI Labored. Unlabored 0 Absent PULSE: D-4--ent Absent SKIN: LP0‘.r: Cool 0 Hot
ETT TRACHEA: CI Midline ra Deviated BLEEDING: 0 Pink 0,-F‘ 0 Cyanotic CI
13 0 Secretions CHEST SYMMETRY: 13 = HEART TONES: lear 0 Muffled 0 Dry CI Moist 0 Diaphoretic
SECONDARY SURVEY..
DISABILITY HEAD HEART ABDOMEN
GCS: PUPILS: 0-6e1 0 Fixed a-flitact 0 Dilated 13 RHYTHM: Ll-Re-6ular 0 (*loft CI Rigid 0 Non-Tender
TM: Clear 0 Blood 13 PULSES: 0 Central CI Peripheral 0 Tender:
NECK LUNGS PELVIS
C-Spine Tenderness: ErBREATH SOUNDS:C:1--Bilar6LE‘al aflear Stable 0 Unstable CI
SPHIN5,TER TONE: 0"-WNL Pain @ Decreased Absent a Blood at meatus/vagina:
CI None JVD: ElFrWheezes Crackles a Heme + / - Prostate: 0 WNL Abnl

USE'DIAGRAK TO DOCUMENT INJURIES AND PAIN' VASCULAR ASSESSMENT
(AB)rasion (AMPlutation (AV)ulsion
Battle's Signs IBLIeeding (Blum IDIeformity (E)cchymosis (Floreign Body (1-1)ematoma (LAC)eration Illuncture (VV)ound [Pain) (Sleatbelt (Slign (Sltab (Wlound (GSW) Gun Shot Wound
+ Palpable D Dopler
Coniinue on reverse
DATE
) ,\-)A.)(-13
entries give: Nante—last, first,
El HISTORY/PHYS1CAL D FLOW CHART
OTHER EXAMINATION El OTHER (Specify) OR EVALUATION
El DIAGNOSTIC STUDIES
TREATMENT
DA 1 WARY% 4700 REOUIF MEDCOM - 23988 D ay DD FORM 2005.
rmcveuu cue eurt EAMC OP 503, 1 Dec 98
DOD-037566

RECORD—SUPPLEMENTAL. M t;. DATA
For uu.- .,r this form. !MI AR a0-66: the proponent agency la Ow Oftioa of The Summon Gametal.
REPORT TITLE
I
OTSG APPROVED Mom
POST•ANESTHESIA CARE UNIT (PAM)) FLOW SHEET
DATE • 1 2 inshry GT--;
rim ni. .e) 2 5-6-

:
CX
fi6A,
FRE-o. vs: izVlo,ip ftz5-Me. INTAKE
TIME SOLUTION
ADM 52,-6 1_4
X -RAYS OONE:
TUE D2.50 03Dt
at'C3?
a36 33V1 03/00374-C •-ilPtc/ 4,pm-rectal
F.0 2 '3(-3L
31-3(.-• 2.61 Rif kg-
0 2 SATAA, /ay /
AD 166
.
A30 loo go ico /or; /AI flob
J°0
TEar %. 77.
lb/ 911)
f o BR try Curl V mew Ras
240
220
, .11011/1,o,
1110
120
100
v
•sa
.10
33
a
RES, 2 Z5-22-20 t 7,1 21

LOS
* LOS Levret Sammons. -PREPARED ERY (Signature& Mkt
eAtlearsmewriFicAnota-fFor typed.or written entries -giver Natne--last, first.
middle; grade; date: horpitai or medical facility)
(
0 ¦ 0( vnkq
TYPE AKESTNISIA: t
ivE SAB EPICURI
sun IY..sED.
cs! mug: crotluzda; calaid f

al6,
CR OUTPUT: Wine Outmt 5°° cc E3.
OUTPUT
Ant. Morns TIME
SOURCE COLOR ART
LABS DRAWN: •
SCOPE.
. 30 •
IN
ACTIVITY SCCEE Min
CUT fRnoomonsea: - 0 Vermin's amoomni
SIRPL. Mar: strette. toore.0 2
SOW MIL ee SUDIXWt 101•NN
Mower O Onoa_ms more sae
Nona n

names "16' ...3••sfa ogee No. ammo Dios
ianinenome.
-0 Arenas@ GIN •••11, Npormill INI1UNINVI
4C)renoron .4e., -SP 33.1e
a•smana. 'owe
Aoub

1
31, 20 - SON ore- mmanneer Saw . —-2— OR SOM• meo-onesmons saw
Imam
0 Canto an" mow* Pus* FaNactur MANY NON as FINN Pw net ...al 2 Rolm on Ds Mit mos at nest
MaNNNINNI 0 Asmara NM. cla
Tor O. .11:16.ee
2 TaroSa F

(Continue on rivers:et
DEPARTMENT/SERVICE/CLINIC
I PATE.
2.0
.
HISTORY/PHYSICA•

. PLOW CHART
.
OTHER EXAMINATION

. OTHER /Specify)
OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA I Pafri7I I 4700 MEDCOM 23989
-
lEDDAC FBg 011 _173 (Revised)_____
INITIAL ASSESSMENT: 066EZ -1A10003V1
LEVEL Cr CONSCIOUSNESS: alert Res 'v[ ve mal Endotracheal T racheostomy AlFtWAY OXYGEN Hudson 61;0 acts Oxygen NiSt Nasal Cannula Roca Air Jackson-Prat N/O
MEDICATIONS SIGNATURE:

ALLERGIES; -
wuR5E5 NOTES
.o. "-receiswellfarc S
SS pc-Al-e-1cf ire /74_,,x.. Pf 0317-Aiso L
P+,.

C.4.4.4-1,-vA . t.vv.•••4-4"-.
e..(17
277395!

Pcgc___,.

DRESSINGS -
_DRAINAGE
e

CBI INIFIRmATIDN
TIME
URINE UAL
URGNE 01,1"„
PACU FLUID TOTALS
can't/tut= IN UR* -Oirnkr •
COLLOID IN
NG TUBE
'".frbAiiiiikEtadvAc
TOTAL INTAKE
DISCHARGE CRITERIA Time: trate:
REACT Score:
VS:., R.

BP HR
Clearacraccording to

wARD 2-D SOP C-2
Charge Nurse Signature!' .g
56Dgi A-AP-Cr

WArt-NtA 9 2.C)C4T\
1. Reporting MTF 2. M-11- IZ .on Admissiol. .,id Coding Information For use of this form. see AR 40-400: the proponent agency is OTSG
3. Register Number Nam Last First MI 4. Pay Grade 5. Sex
b(62_) —Ck FGN
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Relrgion
1990-01-01 13Y X 9

10. Length of Service ETS 11. FMP 12. Social Security Number
99 C-Q-\2)
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
06:35
14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
NO K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS
20. Source of Admission Ward:
Direct from ER ICW1
Name and Location of Medical Treatment Facility: ,
21. Type of Disposition 22. MTF Transferred To TRF-OTH
24. Clinic Svc - Admitting 25. MTF Transferred From AEA - ORTHOPEDICS
27. Location of Occurrence 28. MTF of Initial Admission
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: OPEN R FEMUR/TIBULA FX

Procedure Narrative(s):
Cause of Injury Narrative:
19. Trauma Prey. Admission
DIS NO Name / F,Zelationship of Emergency Addressee
4
Address of Emergency Addressee Telephone Number of Emergency Addressee
23. Date of Disposition (YYYYMMDD) 2003-12-20
26. Date this Admission (YYYYMMDD) 2003-11-12
29. Date of Initial Admission
2003-11-12

0 ) 0
'
•
ni
01 I P
;.,;;
-`:"I"
in Officer (Signature. as required) ture of Admittin Clerk 1Th CCL\
Automated FacsirrfITC: DA-FORM 2985. MAR 2000 MEDCOM - 23991
MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon
General.
1. AGE:13 2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
--1Ak

HEIGHT:
3. PREVIOUS SURGERY ] NO
[X] YES (type):
WEIGHT:
e K
4. PROPOSED SURGICAL PROCEDURE:
'74 -sr) ok Wo-IA"-Nriks
5. ADDITIONAL INFORMATION: Last 1)0:11N
Medical 1.1x 04-k-cA-"ek'
Implants: t..3C t"‹ M ed 'cations: Szt
Jewelry removed: yes Family waiting: yes/0
6. PATIENT PROBLEMS AND NEEDS •
A. PSYCHOSOCIAL .... Potential for anxiety
related to traumatic injury; language barrier; family separation; surgical environment
-
ii
B. AERATION
..--"'
Potential for
respiratory dysfunction due to

sedation; positioning; injury
C. INTEGUMENT
-------Potential impairment of skin integuity due to bovie pad; position; fluid shift
'
.
„ --............_______ _

7.
PATIENT GOALS AND EXPECTED OUTCOMES
Pt. verbalizes any specific anxiety.
Pt. exhibits relaxed body posture.
.
.., .. •
/...-0,,ii-A c..-"? , bo.A.etn en( --21- v -N,r, -vv,,. •
.
t PT. will not exhibit signs of impair-ment of skin integrity (e.g., reddened areas.
8. OR NURSING INTERVENTIONS
Allow pt. to verbalizereely. Explain OR environment nd answer questions egarding surgery. Offer comfort measures, e.g., warm blanket, touch) Explain all nursing rocedures before they are one. Remain with pt. whenever ossible.
o Maintain family interface.
Offer to elevate head of tter or offer pillow. Observe pt. while awaiting urgery for signs of distress Assist anesthesia duringi tubation and extubation
Utilize pressure preventing evices on OR table and
• ccessories. Check for proper
sitioning and support to aintain good body alignment.
o Pad pressure points.
Place ESU ground pad on On compromised skin surfacere6. Keep prep fluids from
pooling.
.
(For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
aminr
,
DA FORM 5179, JUN 91
Previoius editions are obsolete.
USAPA V1 01
MEDCOM - 23992
6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury;
4terct ; previous surgery position;
E. NEUROMUSCULAR
CONTROL

E.1. Potential impairment
of mobility due to sedation; pain; injury
E 2 Potential discomfort
due to injury; pain
F. NEUROMUSCULAR
CONTROL

F.1. Disminished visual
perception due to being injury; sedation;
F 2 ./ Potential for decreased
communictaion due to languatte
barrier; sedation A Tvw
F.3. Potential injury due to-
dentures. IAA

G. OTHER PATIENT PROBLEMS
NEEDS. Or continuation of above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
t Pt. will be transferred to OR table
vithout difficulty.
I, Pt. will not experience unnecessary
physical discomfort.

Pt. will be made aware of urroundings prior to anesthesia . duction. Pt. will be transferred safely to R able. Pt. will be able to understand structions.
Minimize danger of injury during intraop period.
OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
o Check for support stockings or ace
wraps. If none, cl-Ock with doctors.

hdck that safe6t straps are
correctly applied.

o Offer pillow for under knees.
O Place and take down legs from
stirrups with slow bilateral motion.

heck that rings have been
removed.

Have sufficient people
vailable for transfer.
Insure proper body
lignment.
Allow patient to lie in
osition of comfort while
aiting for sui-gery. .

Offer support (i.e., pillows,
bathtowels, etc.) for
positioning.

Introduce self. Keep pt.
nformed as to where. he/she is
nd what is happening.
Inform pt. in which
irection to move and assist if

ecessary.
Speak clearly and slowly.
Address pt. from

--A---:14,e.v-side.
,a Validate pt.'s - cx.G V=49i bit understanding of verbal q communications.
o Verify removal of dentures. is..AA
OTHER NURSING
INTERVENTIONS.
Or continuation of above
interventions.

10. OR NURSING INTERVENTIONS COMPLETED/ADD TIONAL INTEROPERATIVE INTERVENTIONS NOTED.
CSIIT tirt3 b Way o?, DATE
11. POSTOPERATIV N:
74\jks cjaacx",,¦
DV-jcx ok

e"
rc::47,
POST
12. PREOPERTIVE ). A ARED BY
• A 13. --laR-EOPERTIVE EVALUATION PREPA D
(Signature and Title)
GV-1-BY (Signature and Title
CAVA- \-4-Q
DATE: TIME:
w tat 4s DATE: \---1\i,6.16:70 TIME: )-.)((s) -
-2-
REVERSE OF DA FORM 5179, JUN 91
USAPA V1.01
MEDCOM - 23993
IN I RAOPERATI
MEDICAL RECORD DOCUMENT
1 For use of this form, see AR 40-407, the 5to.'
tgenty is -0:.ef office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATIN(
. ROOM . 2. PATIENT IDEINT ¦
-1ECORD EVIEWED AND PROCEDURE
VIA 1,..t-V+,/
BY ihtTA-1,\e5,‘0,-, VERIFIED BY (_ VI
=.(C.Q__- (
3. DATE
TIME PATIENT ARRIVED IN SUITE 4.- PATIENT IN ROOM
i?-) NOV 0 3 /
TIME : 0 cO 4-' NUMBER ...
5. PREOPERATIVE EMOTIONAL STATUS
3 CALM II ANXIOUS EXCITED. . CRYING

ANGRY . WITHDRAWN
OTHER (Specify) COMMENTS: ."
I,
.
-
6. NURSING PERSONNEL
: ASSIGNED
•" —"RELIEF
SCRUB
. SCRUB b ( CL -
ASSIGNED
(----Vis RELIEF
CIRCULATOR
. .. ____CIRCULATOR :NT; •
7. POSITION AND POSITIONAL AIDS (Specify)
---=.- -
.
jg SUPINE • LITHOTOMY [:I PRONE 1111 KRASKE,.--. LATERAL: LEFT SIDE UP RIGHT SIDE PP, _I
C..0\r‘re.k.A 1-,C..)CE, 4•--A-A.--tV "^..",-.* .-,1 -.1.r.......-2.3.--....ke-A,_ i GA."( %."....C. CY\ . 0...........,.. 1, t c,,p,0-1

¦-•%,!.... :vr,...c..A (2).,
COMMENTS:
.
0.A- kt5 n,,,,---9 v-P- , f-611•No-^ -----•-1-1-'44-11 -44.......evr.)„,...c--,..1 -r r...,......--,2_ •&Cv‘../ 91,e......

_ . . — ..._ .
8. SKIN PREPARATION
HAIR REMOVAL II YES 2f NO

• ' PREP SOLUTION (Specify)
2.")-eA-CX.SC1Adj(1-1 B-Q-Acx- Prz...-Zv,k
DONE BY: OR III NURSING UNIT SITE (cl..12.0A,
BY WHOM:METHOD: DEPILATORY MI RAZOR SITE.L.
L.4,,,,,,,,,,, Lel
BY WHOM:
CLIP
_
_
• . .•,-.• .
COMMENTS: _______ _____. . -1----C...:-._'', _--71. I
. COMMENTS: --'1..A.k.i Vii:(.1vv\
9. LOCATION OF EXTERNAL DEVICES (X StAA" 5 -4.A.6kt. CN,
_
_
.

1.
-1 • t 11/
1 • . _ / ¦ 41:11:7; ---.1.1.111 1111.; 1111M.-
-
. 1111111,
-N Villip l
zij rars„ c,....,,4.0...
LEGEND 5
X Ground Pali-- Safety Strap = = = Tourniguet•• • --------i,
':,
C = Correct I = Incorrect "_r_.-.......;,tic First Closing Final Closing
10. COUNTS
Other • • Count :,:. , Cciunt
SCRU
.. CIR U
Sponge Eq Yes No
-C 6( 6.c.)
Needle Sharp g Yes No _. , ,
-.........-•
Instrument III Yes No -- ---

...:'.,i.itTI - .
Other ..
Yes No
..--'-e----------_.------
11. PATIENT IDENTIFICATION (For typed or written entries give:
Name -12. ELECTROSURGERY DEVICE(S) (ESU) A YES . NO
Last, first, middle; Grade; Date; Hospital or Medical Facllity,1
30 (so
?=,((..,Y- q
41 El ESU NO: VCA‘112.41(Nt T vv-1-2_ 4-0 VA:131053V,
GROUND PAD:
I8RAND VI.-- RJZ-11/‘ FfAiklet_ 1 _r_
......
,.--......
.-: . LOT NO: 1-0 3-1-I X) .1"--- OS.
1.' kW 1;?, ( 2--) — --(-
:'07.ESU NO: •••• --dFibUND PAD:
BRAND
LOT NO: BIPOLAR NO:
,., .. ,
DA FORM F i 7R-1 nr_T 52 "7

r-,rtl A r,, Is I% •¦¦•¦ ••¦ •• .....-..- - ---_ _ _
ficrl-M,CO 1.11.4 runnel bl
(TEST). DEC 82, WHICH IS OBSOLETE.
USAPA VI .0o
• .. _____ MEDCOM - 23994
13. PROSTHESIS, IMPLANTS .
1 . ' L.,Ivi c : i u NuMI:StH ; MAI . TUBER
. __ . . _ __ i
_f
14 •
'f,2,:4•1.:?zr -:--4 'f, '" .,,,7f, .'f
-'' 2`.'MEDICATIONS/ORDERS ‘--
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) -
YES . NO',MEDICATIONS/SOLUTION DOSAGE
TIME"
METHOD PREPARED BY GIVEN BY
. -
.. __ , .-,_.._ _
!
WOUND IRRIGATION ill YES . NO, TYPE(S):
•,' a. Ct Cl/C.-, 1\)0 .-C—(2._
( QS)
-
-OTHER ORDERS
TIME

CARRIED OUT BY-A-x-GTht"...k.,
/ _ .., ......... .

,14
.PHYSICIAN'S SIGNATURE
,
, _ ,
15. X-RAY IN OPERATING ROOM . ---
IF YES, SITE , ""
YES II NO ::•7:i. ,-, ,
gS,16.
-• ' LABORATORY 'SPECIMENS
SPECIMEN (S) ,_
NAME _ ___ _ _ ___ _
YES . NO E
---:: -----
FROZEN SECTION (FS) NAME i
YES . NO 12. NAME

CULTURE (C)
NAME NAME
YES • NO 2 __.
NAME

NAME NAME
NAME NAME
18. DRESSIN JMMOBILIZATkON (Specify) ---ICAC0¦¦••• L cw-k,-.. (.-tees )
17. TUBES, DRAINS/PACKING YES / NO igi . t.,...\-i
TYPE/SIZE 1.

2. .
K.,,,k¦ 4'X- I c,
irs::.
SITE 1, 2.
3.
5ic,\ 0\Ckt,11

19.ADDITIONAL INFORMATION
-
Get-A-eviNe_ArYN_ 1 UM
is
A-1AD Atm0L: .
_ . .... ... ._ . _ ..
A Tw., 0.9.-N--kt„ A, vc—Li. „kr; 0-,A.,,,,,..t.. -, crcg-
--3)A S-I1-(1% l v.. . 4-i 0-41k.ok,
b -

,
,
20. OPERATION(S) PERFORMED
. _
t F,,,,A.1-0,4 _,, ).L.-\„„cx)
21. PATIENT TRANSFERRED TO
I TIME se_e
METHOD
1 C \,13 C VACkA)
2 0.....6,*--.41mci.-UHCA/
--.^. ¦-•-i-CRPrI All 'Dec
SIGNATURE
C-Ca 1A-1\j
REVERS • DA FORM 51 9-1, OL . 7
USAPA V1.0
MEDCOM - 23995
1
IN I RAOPERAT. .--z DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the pro?'
-0,, -icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERA,:
, ROOM 2. PATIENT IDEN-
t REVIEWED AND PROCEDURE
VIA cl/k-LAA \')._ (A BY /69-11\, .t-liVe ek VERIFIED BY C_--'4'" 1

1._ ( \ -2._
3. DATE
TIME PATIENT ARRIVED IN SUITE 4.. PATIENT IN ROOM
1.S- \•..I'k) \P1-5 /
TIME ;11 2 (.:-.,
NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
CALM ANXIOUS EXCITED
CRYING III ANGRY
WITHDRAWN
OTHER (Specify)
COMMENTS:

t
,
..... ..
._
6. NURSING PERSONNEL
, _
__.':. ASSIGNED
'' " '''' "RELIEF
! SCRUB
. SCRUB -
1((_,.. -
__„•____________ ASSIGNED (..A) k .
RELIEF CI'T
CIRCULATOR lal0.12.41))
_C.IRCULATOR
iIq I . •
7. POSITION AND POSITIONAL AIDS /Specify)
•
-
El SUPINE LITHOTOMY , II PRONE II KRASKE LATERAL: LEFT SIDE UP RIGHT SIDE UP
c uy v..e._ Lk_ b „. . 0.1.7„,.....6., va„,÷,k_r.,A-.. ..\......,.... r *' 1 -4.---- 1------ S f
).....",......4.0......;,.,....,,z. (1,k_
C5-y-1 4.7., c,.. cA cA:...t...t. °vv. t....1...% 1, i...,--A.,.....sis
COMMENTS: c,-k i., ,,., n,, -', Tos.-,,3--):::-.--... 0--fr 4 -e--0:,,t,-,. _,-;.....,,,,y-CV1 -1- C-1... ¦ t-A,-,z- 1 0...
-. . -..----.1--..
8. SKIN PREPARATION
HAIR REMOVAL ffil YES 0 NO

PREP OLUTION (Specify) g•tik-Ck ScArvai 1 .SLAcx..Pr......*Ikik_k
DONE BY: MI OR
NURSING UNIT SIT (...2-6K I H t';' BY WHOM:
METHOD: Ill
DEPILATORY 11. RAZOR SITEU_, („c\AJ--k„,,, 1.,ty/ BY WHOM:III CLIP
_________. k---((2). :
c., _
COMMENTS: .
______...— ....___ _
COMMENTS: rt.° r.,(\_Akkkq 0--.(-'Ac4iv.‘ A 15 --.1/4..Athccf),..
9. LOCATION OF EXTERNAL DEVICES
0
\
_ .....:._-
.

J.
— I .1 I NP. ¦
I • — . -0 -
7..."
.
LEGEND X Ground Pad --Safety Strap = = = Tourniquet --,..-. -
C = Correct I = Incorrect
's Lit__. -"1__
First Closing Final Closing
10. COUNTS
Other" Count , Count
SCR
CIRCUL TOR
Sponge C Yes \Jo _ C Needle Sharp X Yes \lo ..
___.
Instrument Yes No .
. . 1...., ii!.,'; Other MI Yes No .----
..----""
11. PATIENT IDENTIFICATION
For typed or written entries give:
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;) 12. ELECTROSURGERY DEVICE(S) (ESU) n YES Ell NO
30130
M ESU NO: Vc•11-1100,› tc).,“—il_. ut 0 6k.RE 10&_3(.
1 SIR ' L 1* 6 — Li
GROUND PAD: BRAND 3 ivl .
LOT NO: t't k LI 5
, • ..:-.7--, -. •-•
WNW f
( Z j - -L ' . !.:b_ESU NO:
(C i\i'6\1 VI,
•---GROUND PAD: BRAND
LOT NO:
II BIPOLAR NO:
DA FORM 51751-1 nr-r R-7
-.
. WHICH IS OBSOLETE.
USAPA V1.00
MEDCOM - 23996
tr rt NAME: ID NUMBER; MA
TURER
MEDICATION S/ORDERSVMelUM444k4.0ggt:
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT..BY ANESTHESIA)
..,:eg,taitAtiggAki.--
D NO
!WOUND IRRIGATION
RI YES
19. ADDITIONAL INFOR
S 0--yi •

A--frvATINebi d.\
20. OPERATIONtS) PERFORMED ‘"\31.7\e¦-neNat
a
REVERSE DA FO
IF Y , SITE _ : -.':•:LABORATORY SPECIMEN
18. DRESSING/IMMOBILIZATION
T-CtirV7 (Specify) A D
X v--or°'61
r.s
DR
, OCT 87
—
USAPA V1.00
MEDCOM - 23997
DOD-037575

I RN 41 -074A0 70, tPh Ee Rp:
MEDICAL RECORG
For use of this form, see A c
I
1. PATIENT TRANSPORTED TO OF.
,,, ROO 2. PATIENT IDENT. VIA QtAr BY A-iti/....5 Sir tk, VERIFIED BY Cii--
3. DAt TIME PATIENT ARRIVED IN SUITE 4.• PATIENT IN ROOM
1°)/001/193 1 f 60 TIME. ./ /00
5. PREOPERATIVE EMOTIONAL STATUS
. NtiOCALM • ANXIOUS EXCITED • CRYING ANGRY
COMMENTS: AUC4
_. .
6. NURSING PERSONNEL
o /^
ASSIGNED ..."--lA....,

_ . --- "RELIEF
SCRUB .SCRUB
(.1 \ .
.
6E
ASSIGNED
RELIEF
CIRCULATOR

.._ . ..._... . __CIRCULATOR
,

iN1 :.
vE DOCUMENT
agency is the office Of The Surgeon General.
VIEWED AN PROCEDURE

" 7,...__
NUMBER /--• a
WITHDRAWN
• OTHER (Specify)
/./114,.1 Dv-u-t-(4, (---( /-12j() -1;;L:
7. ROSI,TION AN,D POSITIQNAL AIDS (Spgcify)771-aN, ---ellegj
,., ,.61At. it, Si dla.S C-10 ° ••1 CRP Se c-g-treet 40 pa -ffronbcia e !if t--- S41.11-biy Th'‘,05. t3'e-6 peviael
1,-t .__-R,--pd, ktsel 0). 42,1, do145.1) 'vast. 7-trrbi 5 exiteA 1
, g SUPINE _,D LITHOTOMY PRONE • KRASKE-• LATERAL: LEFT SIDE UP • RIGHT SIDE UP
tn. 4-0 ...3 J-eit Le-
4-1elei
.
COMMENTS:
La
" (re c-I-3odyk/rTh "pte,n--/-inain -1-474,
8. SKIN PREPARATICiN
HAIR REMOVAL • YES NO
PREP SOLUTION (Specifylae
DONE BY:
• OR • NURSING UNIT SITE: 12_L_
METHOD: II DEPILATORY • RAZOR SITE: 4i 3 /0'1,1)
• CLIP ______
.._. -,.
COMMENTS:
._______ COMMENTS:no, pooll,
0-P sdtdrOhS 4d7lel
9. LOCATION OF EXTERNAL KVICES
.
, 1.
I•- , • i .
LEGEND X Ground Pad .
10. COUNTS Sponge E Yes Needle Sharp Yes
Instrument Yes Other Yes
11. PATIENT IDENTIFICATIO
Name - Last, first, middle; Grade,- Date; Hospital or Medical Facility;)
'17 ( (31-- Lk
DA FORM 517A-1 nr-r Pt 7
„ _
-' ----Fkropx.. az, spkw : • 'fil _
' I •11)._. • -.67•10.1 A
IgeSTIO 1.0 I'P1. ir•••• -
.11.1.11.111...-1
Ak. * 411k¦ -41111"11b-;$ A:40k amirillT
'-411.464.:
•
-Safety Strap = - = Tourniquet.... ,----...-
l
C = dorrect I = Incorrect
First Closing Final ClosingOther** Count ....I,. ; Count
o
No ,..-..
No -

.. ._
No
(For typed or itten entries give:
_
b ( Ct, ) -7 ' L-
.SCRUB
-CIRCULATO
P
•. -.J.;'_;.1-71.:.,,
__ .__..
12. ELECTROSURGERY DEVICEIS) IESUI YES 21(10
ESU NO: GROUND PAD:
- -. .. 0,7.E.) NO:
, ,._
.--'GROUND PAD: MI BIPOLAR NO:
BRAND
LOT NO:

BRAND
LOT NO:

„ 0 SOLETE. USAPA V1.00
MEDCOM -23998
(
BY WHOM: CP .BY WHOM:
.,
-
13.
PROSTHESIS, IMPLANTS YES NO IF YES NAME: ID NUMBER; MA TIME R

14.
4MEDICATIONS/ORDERSL

IRRIGATION/MEDICATIONS GIV EN IN OPERATING ROOM (NOT BY ANESTHESIA) YES Ej VEDICATIONS/SOLUTION DOSAGE
TIME • METHOD PREPARED BY
;'
MOUND IRRIGATION ES NO, TYPE(S):

?a/df—
". •
-0THER ORDERS
TIME ' • CARRIED OUT BY
;:pllYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING ROOM , IF YES, SITE
YES NO

16.
LABORATORY SPECIMENS SPECIMEN (S) NAME

NAME
YES NO p
FROZEN SECTION (FS) NAME
lg NAME YES NO
CULTURE (C) NAME
YES
NO )4) NAME NAME NAME
NAME
NAME NAME 18. DRESSING/VM_OalLIZATION .(Specify)
14./ r/C4 ffs, kee(ex. /1130
17. TUBES, DRAINS/PACKING YES 111 NO
TYPE/SIZE
2. pvis, 6i-v4P ?s
SITE 1 . 2. 3.
19. ADDITIONAL INFORMATION
UJ C.- -.
veg-60 A ;

&Nes ; a C-en Lir C. 1f ie/t14
20. OPERATION(S) PERFORMED
-a-f'Sp'141-{/4 Zztveer--
21. PATIENT TRANSFERRED TO
--pncu.
TIME METHOD
'R 19q.,01 rite/
USAPA V1 .00
MEDCOM - 23999
IRN4T0R4A070,tPhrpr. VE DOCUMENT
MEDICAL RECORL
I -For use of this form, see A o Igency
the office of The Surgeon General.
1.
PATIENT TRANSPORTED TO OF _. a-, ., ROOM

2.
PATIENT IDENT.

D AND PROCEDURE
VIA TA (..A..k \CV- Cle BYATC\204e`p-k C1/4. VERIFIED BY Cc:` k

"1-) ( 6L_. --L.
3. DATE
TIME PATIENT ARRIVED IN SUITE 4.. PATIENT IN ROO
let 1\i'V\IC)5 / 03-4t)--TIME. . C:446,i--NUMBER if —/
5. PREOPERATIVE EMOTIONAL STATUS E CALM III ANXIOUS EXCITED MI CRYING ANGRY 11 WITHDRAWN Lk OTHER (Specify)
COMMENTS: jil . _.
_„..., . .......

•
.
6. NURSING PERSONNEL
r
I. ASSIGNED ,.5' PC
---- 'RELIEF
. SCRUB
SCRUB ' (. (-4.--) -
.
ASSIGNED
RELIEF
CIRCULATOR
._ _ ...... . __CIRCULATOR
• :NI • .
7. POSITION AND POSITIONAL AIDS (Specify) _.,-,_ ._. ,,,...-:._ -
-- --,--. : .
-.•
... EKSUPINE / LITHOTOMY III PRONE
:4" KRASKE. LATERAL: III
LEFT SIDE UP NI RIGHT SIDE UP
COMMENTS: 2 J; . .. -,.
,---,F4 r-c-kfcli'l ,--, rfcl- '\ .filiti4(.0(e-11fn fict--4 oei 'Aid oil-fl.---k_,91,e _ ..., ? a 1
/ 8. SKIN PREPARATION .

. ,.
HAIR REMOVAL
YES NO -' PREP SOLUTION (Specify) lie.
ir;A .f._ SC t, .A.1, (..--jii.44-fiA"--.
DONE BY: MI OR 111 NURSING UNIT SITE: Le..;f4-- kJ? BY WHOM:
METHOD: IN DEPILATORY RAZOR . SITE:1.4_ NI
I3Y WHOM:
CLIP
7._ 7—, ,_
COMMENTS:
__________. . •COMMENTS: it 1 6
/la , 1 i 04- s-c (,,,..4-1-,,,--
, , ."45 C_
9. LOCATION OF EXTERNAL DEVICES
.:;FIT-c:_.:04:64--UN
_ ..
•

... ..
I •- IA •
-
-'."1.1111111.4111.101iinF
'irieill
.
,0101¦1111rtinjpep-
.
' / :::
-. -.....: '
.
LEGEND X Ground Pad --Safety Strap = = = Tourniquet.-—.1.,..:-.7.: .... ,;
CR._
. C = Correct I = Incorrect -
First Closing Final Closing
10. COUNTS
Other" Count _. I.q., Cciunt
-SCRUB
.0 IRCULATOR
Sponge
EIERJEll . --
Needle Sharp • dl ....----,
LI ESDIEl .„, ..__.. ..
Instrument -.111111•111,/
. Yes MEI ' . . . .. _. ..._ '.:J.:,.;... ' *MA
/11. Yes MEI MiNialr
Other
PP"
11.
PATIENT IDENTIFICATION (For typed or written entries give:
12. ELECTROSURGERY DEVICE(S) (ESU)
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;) YES ET/NO
,-
... MI ESU NO:
IN= 1‘ (-'-:-) - LI
GROUND PAD: LOT NO:
-,.. _ ...._ BRAND
01.111. (73 - t- s l'In.7.E.1 NO:
.
( ci NW C.7-7 ..::
.1- --Ft. OUND PAD: BRAND LOT NO: IN BIPOLAR NO: .
DATORN1'51/4-1 nr-r 117 -
„ HICH IS OBSOLETE.
•USAPA V1.00
MEDCOM -24000

13. PROSTHESIS, IMPLANTS YES., NO IF YES NAME: ID NUMBER; MAI ' ¦ \' , -'KR
-- I--. .
l' f
-i
1 4. _,
.. . -.. 'MEDICATIONS/ORDERSkafia
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES N9
;MEDICATIONS/SOLUTION DOSAGE TIME : METHOD

PREPARED BY N GIVEN BY ..... .-. _
.‘
.
rf .
.

MOUND IRRIGATION F2 YES / NO, TYPE(S):
0 .ri CV* "M--C12.,
( W.D)
:OTHER ORDERS

TIME CARRIED OUT BY
.
.......—__

.e
iPHYSICIAN'S SIGNATURE
, .„ .,.. .
„ _
15. X-RAY IN OPERATING ROO.M
IF YES, SITE
:;
YES / NO —, , .;
16. -' ' '
'::LABORATORY SPECIMENS
. .. ... ,..,
SPECIMEN (S) NAME
-- ------- -----.:-:-:,n1---:.:-.--NAME
YES NO X

FROZEN SECTION (FS) NAME
YES II NO M. NAME
CULTURE (C) NAME

NAME
YES • NO N
NAME NAME NAME
NAME
NAME 18. DRESSING/IMMOBILIZATION (Specify) .......
- — "---i-Ulf,
17. TUBES, DRAINS/PACKING YES 111 NO cV .
TYPE/SIZE . 1. 2. . V,),AAAX fA -3

/.ttilfr -/:i
SITE 1.

2. 3. ... ... .,......._

19. ADDITIONAL INFORMATION
., :.
UN/N/
eon T IIIIIIIIIIImp
, ;.:: ,_.. ,:,,,,_::(,);:
AvmsnA.,e,sic,: :. _ ..
. _..... •
(6) - 2
.
-
-
_:-Dikci-T cv-, cLe¦.o.,,A 1 ,e1 A :'...: ---c-,'"Ve--cil.i ..
e-
,,
20. OPERATION(S) PERFORMED
,-
-----C VI- n CA/GW-..ek J a/‘_ .).--1-.1---.CJVSee'_.2-- ..;-___:. c.--k-t-.--4

1. eir,
TZ.1--`it1r"541 ( ' ct.i... -4 ..
/. 1 1.----c4.4..-c.,"...2_,,e„.
21. pATIENT TRANSFERRED TO 7
TIME.Sett METHOD
/ -
IC; i.A 4--( C._e 3 — --t— .NtI.M9-. YAW 4-e_L-k,
22.
(14 A-3 (6-N
REVERSE OE nil KORAI! R170_1 n r-r f a,
USAPA V1.00
MEDCOM - 24001
I INTRAOPERA". '70CUMENT
MEDICAL RECORD
For use o his form, see AR 40-407, the proi
ni is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAI...-2 RO i 2. PATIENT IDENTII
-' • ' WED AND PROCEDURE VIA Z__('i+_,,,w--BY V/ VERIFIED BY rilitIri
3. DATE TIME PATIEN IVED IN SUITE 4.. PATIENT IN ROOM2 / AJ,,N— 0.2_/0 cO TIME • • (C0-0 NUMBER 2_—
5. PREOPERATIVE EMOTIONAL STATUS
ItKALM ANXIOUS EXCITED. • CRYING • ANGRY / WITHDRAWN II OTHER (Specifyl
COMMENTS: .. .. : .,..
6. NURSING PERSONNEL
ASSIGNED
-- --RELIEF
SCRUB

.SCRUB (..t -2_
ASSIGNED
014-J RELIEF
CIRCULATOR
. .-_. .. .... . , __CIRCULATOR
-ifil-;.
7. POSITION AND POSITIONAL AIDS (Specify) _..,,
. .
-
. j24PINE LITHOTOMY III PRONE KRASKE-'. LATERAL: Ill

LEFT SIDE UP • RIGHT SIDE UP
,• .
COMMENTS:
Bo J-1-•.- di ,----‘-f as-N._ it' 4.--( c, r ,1/4 o a „,-,kt c—ils ‘-'*--'y le_ . 9 6‘"
8. SKIN PREPARATION HAIR REMOVAL • YES ....-E(NO
'' PREP SOLUTION (Specify)
12„_e.t....'A._,),(•• c... .. s - co-i-6 I--c-f-c---11-1ev‘__
DONE BY: • OR NURSING UNIT SITE: P1-- km --1-04.4- --A9 k,;,0 BY WHOM:(116, j
METHOD:

1111 DEPILATORY II RAZOR ..• :,_ , , . SITE: .,.. . ' ay WHOM:
• CLIP .J(.(A•-- Z-
COMMENTS:
------.. 'CONiiIENTS: N 0 i 0 0 0 ),s,„y
0 f. s cyl i471-14l.^-
9. LOCATION OF EXTERNAL DEVICES
/ (/ , ic7°..---,'...:.•:-4, .
: e‘r "1 __ ,_ -. •- r 4 _ At" . -...
.. ..
r. ---.......--....ifigium....-

-
.
AgfaVniffiArAtiallia"--.,
LEGEND X Ground Pad -Safety Strap = = = Tourniquet.--' ''' ..
(,. s,_ \--1_
, C = Correct I = Incorrect
./°-
Fjrst Closing' Final Closing
10. COUNTS
other•• Count '''• . Cciiint
SCRUB
IRCULATOR
Sponge
laMINIEI C.-:
Needle Sharp il Yes EI _.,----,'-'°-
..../1„.....-----
1111111WSA. ..¦('--
Instrument
MEM=
1111111111•111/1111115_
Other Yes ] Ell
11. PATIENT IDENTIFICATION For typed or written entries give: 12.
.ELECTROSURGERY DEVICE(S) (ESU) II YES ,-lar¦10
Name -Last, first, middle; Grade• Date; Hospital or Medical Facility:1
s: . Ell. ESU NO:
GROUND PAD: BRAND
U. jcp (Cki J--( ,...
LOT NO: , „ El.":16:1.). NO:
., • ,
- •• -:-GROUND PAD: BRAND
LOT NO:
I ( 't-"1-• "
III BIPOLAR NO:
..\ t4 PC-r3 11110111111116..
DeFfIRIVI cl7a_i nr•-r .
.-- --- --- - -
. , S OBS O LETE. USAPA V1.00
MEDCOM - 24002
13. PROSTHESIS, IMPLANTS • YF NO IF YES NAME: ID NUMBER; MA: TURER
- -. ______

r
,
:,..
.'14.
.-.MEDICATIONS/ORDERS!4,,Z4z,,,-t .q.'' IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES N9 g'-'-' :MEDICATIONS/SOLUTION DOSAGE TIME
-METHOD PREPARED BY \ GIVEN BY -
' - --
;
'-
,WOUND IRRIGATION EK'ES / NO, TYPE(S):.4 I (..
/V ,
3, _
,OTHER ORDERS TIME CARRIED OUT BY
. -
RHYSICIAN'S SIGNATURE
...„, -„....-- „.„ ,
- . .
15. X-RAY IN OPERATINiGn5100M IF YES, SITE
-:;7:
YES • NO ::-:, • % ,
16. : ''.: LABORATORY SPECIMENS
SPECIMEN (S) NAM.& -'-

_ _ __, _____ . _ NAME
.
YES • NO -Ef C ) EV? 0,,lios ,v- t-. v : ....
f-IAI q1/1 w ev"-ci . -
FROZEN SECTION (FS) AME
NAME
YES • N
CULT;Er) 0 NAME

NAME
YES , ____ __ ___ ....___
NAME NAME

NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)_ __ _ _ -_____
17. TUBES, DRAINS/PACKING YES 0' NO r-----1 I.,- \ Cf:/
_
TYPE/SIZE . 1.,r-i n 2. . "
i r el) 1-13-1-(- (te r l'1 y lef
A-I--k•-/-)
SITE 1. 2. 3.
A8 0
Ail,-t- 11-p4k
19. ADDITIONAL INFORMATION
r..e_it if (c
so_ r•,.2 c_m,\ ! - . g.-1 .! 4—

rit_.--4-.1
. f.:E,.:
.
0.--.-\R-1 ,, C ri-. --. . -_ . -_
.
--- -1...
-(
..
_ .
, A.
,
20. OPERATION(S) PERFORMED
:.:F. 4- 0 Qf' Gvavo,,,cts A---f ,.__.,,.i
/L. ___ .._.
I-, r""
21. PATIENT TRANSFERRED TO
TIME S.e. e. METHOD
PA C.-k.&__ L C-1,) -
22. 1---ir--ft /-or- I- iti-i-e,---c-,s,'‘,{0_,-41 io
R Al tki (1-ki -—2. 1 At ,--, o 3
el,
USAPA V1.00
MEDCOM - 24003
DOD-037581
NI rtrALsr--MEDICAL RECORD For use of this form, 6 AR 40-407, the propc ency i .1, office of The Surgeon General.
2. PATIENT IDENTIF, ' I D AND PROCEDURE
.1. PATIENT TRANSPORTED TO OPERAT,.. :IC, A / VERIFIED BY
VIA (--( 1- \--'2.,,^ BY //:(Af4-3 iltA_,) T 4.. PATIENT IN ROOM
TIME PATIENT
---) AI cid---F---.4f / o if 2_. TIME: • ( 0f2.__ NUMBER ,„2 -

3. DATE
5. PREOPERATIVE EMOTIONAL STATUS
• WITHDRAWN OTHER (Specify)
eZi-CALN1 ANXIOUS EXCITED. CRYING ANGRY
,
COMMENTS:
_ .. .—
6. NURSING PERSONNEL
.,....______
./kSSIGNED _S. c.--'1---"RELIEF
SCRUB

SCRUB
RELIEF
ASSIGNED
....._. _ .... . -___CIRCULATOR • - INT ; ..
CIRCULATOR
-
.
7. POSITION AND POSITIONAL AIDS (Specify)
'
III PRONE KRASKE. LATERAL: LEFT SIDE UP /RIGHT SIDE UP
4 Et/SUPINE / LITHOTOMY
,
COMMENTS: "Pre)-It'-\-Bi- S' R-i-C.:. r iv.. o'v-¦ 1 ,$)..4\,_0(.,.a.._1/, A_100.....0-c-4_ cul- co-oi 6,.... _...,_. ett,C7 6,

2---71-- CZ 0 r"--/ -- '---'—. — -.c-A e--
8. SKIN PREPARATION HAIR REMOVAL NO F'REP SOLUTION (Specify) g, 4-6.4,t,,- ,....v., 5--ce— 4-- s cl.....A-74c •
• YES
DONE BY: • OR III NURSING UNIT SITE: /-2_,-t--t_si BY WHOM:/v/A-J

METHOD: 111 DEPILATORY 1111 RAZOR • .. .... SITE:,..... BY WHOM:
(1,---1
II CLIP . ',.
COMMENTS: . ..-.------COMMENTS: kl, i f , rf\--0 4- .S.-6 1. 4,4—i -'7,

/ '
9. LOCATION OF EXTERNAL DEVICES.,
---1::-i': i /-d-ej, c..1/"%ket
411 -
_ .1
.... . .
.

..
.
. if' --
— 1.1
_
*11.1114TIZIPP— ...-. .
• HAIIPM
.
LEGEND X Ground Pad --Safety Strap = = = Tourniquet-.-•-,-..... , • k( (/ -
L_.--„, --,
, C = Correct I = Incorrect
First Closin Final Closing

10. COUNTS Other•• Count i.. CoUnt .SCRUB CIRCULATOR
Sponge gir•Yes 'D No -:•, (.--
Needle Sharp Yes 'D No ....___

I•Ng-\3 1.1
Instrument 111 Yes No ;. !..,..i.;,1• -v -
Other 0 Yes No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S1 (ESU) • YES (all
Name - Last, first, middle; Grade; Date; Hospital or Medical Facllity;)

• ESU NO:
GROUND PAD: BRAND
-. .
LOT NO:
•-. ,
.._.___:-
: ErES:I•J NO:
gv J -(4 •-•---.GFICiUND PAD: BRAND

•-....-:
LOT NO: IN BIPOLAR NO:
USAPA V1.00
DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179-1 (TESTI, DEC 82. WHICH IS OBSOLETE.
MEDCOM -24004
13. PROSTHESIS, IMPLANTS YES {NO IF YES NAME: ID NUMBER• 7# 2TURER
. _ _______
,

. i;';.'NIEDICATIONS/ORDERS-:1;,, :'° 2
-::.,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES • NO c1-7-
MEDICAT1ONS/SOLUTION DOSAGE TIME . METHOD PREPARED BY GIVEN BY
.. . , .. . _
;WOUND IRRIGATION &YES NO, TYPE(S):
r .:
,----,-. .
_
OTHER ORDERS
TIME CARRIED OUT BY
__-_-__
- -.
PHYSICIAN'S SIGNATURE
,! (.*,
. _ , , .
,
15. X-RAY IN OPERATING R OM IF YES, SITE '
YES III NO -:Ui "
-
16.
-' '.11ABORATORY SPECIMENS
SPECIMEN (S) c( NAME _ ______ _____ -NAME

YES II NO
FROZEN SECTION (FS) /NAME

YES III NO NAME
a
CULTURE (C) NAME
YES • NO • -- ---7----- --. — ._ _____ NAME
NAME
NAME NAME
NAME
NAME 18. DRESSING/IMMOBILIZATION (Specify)
_ _ _ _. -_ _
17. TUBES, DRAINS/PACKING YES 12/ NO
. . _ TT-, f+.1
TYPE/SIZE 1. 30,', rOcti,,,,,,y_t_ 2. .
. ge-r-i ; )‹.
SITE 2_2.
1 t__ h rip 3.
19. ADDITIONAL INFORMATION
‘.5- v....,--k7 Q_Gne‘: ! D v.,
. ,..... _.

. _
civ.),&5 1 /11 Po _ _
.
b(Lt, w
,:
20. OPERATION(S) PERFORMED
,
_-.C. ot-0 A-4-( ,‹_?-, 0 t-c..5.5,,,,,,,__/ . (..1_ ,..,2„.„-,., A__ i--, L.c.„,....-,,,---,

1 C Q Nk.-1-1,--0.—(
,
/„--.;.,-e._ (z.91,51,.cQ ."--• z,-.1— .
21. PATIENT TRANSFERRED TO
TIME,se_e_ METHOD
PA-C Lk_
sR-s-1-7--ci-7-L.--(-4--
22 / 11 fid 77-3 Iticv---p 3
RE .
USAPA V1.00
MEDCOM - 24005
1 ".1-7\,,i_ / IN I K-AUPLHA , E. DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-407, tha-pror
'gency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERA i .. _...R 2. PATIENT !DENT!. . . D AND PROCEDURE
VIA Z-C ‘A-4.-k-.4"' BY VERIFIED BY kt /4.t.i
3. DATE TIME PATIEN IVED IN SUITE 4.. PATIENT IN ROOM
2 6—,iki. t-,--0' 7f (:)2 2--"? TIME. i 0 g 2 7fNUMBER 2- .."-(
5. PREOPERATIVE EMOTIONAL STATUS
ki3...CALM ANXIOUS 111 EXCITED. III CRYING ANGRY WITHDRAWN
OTHER (Specify)
COMMENTS:
.
6. NURSING PERSONNEL
ASSIGNED -J' 6_1------RELIEF
SCRUB
.SCRUB
FD ( (.0.
ASSIGNED Yk firJ
RELIEF
CIRCULATOR

..—. .. -. __CIRCULATOR -iIii.:.
7. POSITION AND POSITIONAL AIDS (Specify) _..,
tIZJUPINE LITHOTOMY PRONE
KRASKE'% LATERAL: / LEFT SIDE UP RIGHT SIDE UP
.,
- . -
COMMENTS: )....j-. 11fC¦_ i'" Ws IfCV\ fpo....d...d.c.of ce.,17,6 0-441"Ykd dc-% c'-'..-1 ( ,--

_ . _ _..--._... ' .--q6 4
. 8. SKIN PREPARATION
HAIR REMOVAL 11 yEs D410

'', PREP SOLUTION (SpecifY) B c_:_.6.,,A (.,„, _r ,..: e, •
S t:: t..+,./I'r :. ki....
DONE BY: 111 OR II
NURSING UNIT SITE: 7Q,_:1--_ f .r,_,,,,BY WHOM:MS-1...j
-:.
METHOD: DEPILATORY IN RAZOR . .., .,., SITE: . / BY WHOM:

„
CLIP VD (C-?,._
COMMENTS:

_ CCiMM'ENTS: IV tot-i-q-1(Y., j?
el -I So (_‘..iJcist-r-c\
9. LOCATION OF EXTERNAL DEVICES
-.... .
N . .7.24..d Ck. re-sk
_ _ .,
.

1.
-IA
. --•••
t •
...
. i
.— .
LEGEND
X Ground Pad --. Safety Strap ---- = = Tourniquet•-• ...--...... \i'' i (-s1-- .7
C = Correct I = Incorrect
.
t
First Closing Final Closing
10. COUNTS
Other"' Count .. -i..:..;
CPUnt .SCRUB
CIRCULATOR
Sponge EfYes o ._ . Needle Sharp ErYes No
Instrument
0 Yes No L.. l';,1.:,17, Other Yes No
—
11.
PATIENT IDENTIFICATION (For typed or written entries give:

12.
1ELECTROSURGERY DEVICES/ (ESU)

YES ra NO
IVame -Last, first, middle; Grade; Date; Hospital or Medical.Facility;)
111111iya) -(4 • ESU NO:
GROUND PAD: BRAND

LOT NO:
-...z.-
, . [TEJO. NO:
_
' --GFIOUND PAD: BRAND
.b ( is' _ --L
LOT NO: N BIPOLAR NO: 21S-A) (717" VS nil 'FORM R170_1 nr•-r o ..,.-,,, .,..-- —.. --_ _ .___ ___ _
-, , S OBSOLETE. USAPA V1.00
MEDCOM - 24006

7-1 v.-es
Li T rz, NU
II- YES NAME: ID NUMBER; MA, TURER
• . _ „..__ ..,„„

, -.:,,,:
14. , ''',44,'4:.i'' rMEDICATIONS/ORDERS*;,, - '-'1=;. ,, .:
'
' , .,'
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
YES • -40—Er
*1EDICATIONS/SOLUTION DOSAGE
TIME METHOD PREPARED BY GIVEN BY
.., .___
_
:WOUND IRRIGATION OYES h
NO, TYPE(S): I P t tS_
1
=OTHER ORDERS TIME CARRIED OUT BY i-
.
-.PHYSICIAN'S SIGNATURE
,,..
— ,_ . . „
15. X-RAY IN OPERATING ROOM
IF YES, SITE
YES III NO . :;) '

16.
' ' LABORATORY SPECIMENS
SPECIMEN (S) i _ '"-" —,

NAME _____ ____.
NAME
YES • NO Ul

--. -
FROZEN SECTION (FS) , NAME

• sr NAME
YES NO
CULTURE (C)
NAME
YES NO

• e NAME .....,_ --
NAME

NAME NAME
NAME
NAME 18. DRESSING/IMMOBILIZATION (Specify/
17. TUBES, DRAINS/PACKING YES III V r(v-f-4J
NO
-f--Q ).f ile;,6/
TYPE/SIZE , 1. 2. .
li-Ce'll'•.
fi--/--Ler....ces.... .cri
SITE 1.

2. Z___...-f-egq /--c-IA,a,^ (e_.,
19. ADDITIONAL INFORMATION (
'_,_:'

.
Sus--ry R--ev\.. 1 o r-

, -i -_ . _ . _ _ . .
GAA •: CP f
.
k---(Gt__Y" 2_ +-\\
20. OPERATION(S) PERFORMED
—71— 4-0 t-i\JRA-- iLl 0-4‘--—Ci! l-d1-.,-.,f'
‘ f CL \-4 ,Ok.--i C th..0i.A.,,, E 4 L f 1 f( ,.1ff.
)
21. PATIENT TRANSFERRED TO
TIME— METHOD
-='- C e_ ..
Plet—CAA___ ,-
, rt-----_.5-7i c/R____L:4-1-p_Ais
.22.iiiiimiminni . _ _ ._.,... _ (---_1' tti Ci/sel IfIf „p
10, , I A4V 1 if' td nv-- (11
REVERSE OF DA FORM 5179-1,
USAPA V1.00
MEDCOM - 24007
DOD-037585

1
INTRAOPERA1,11c r -CUMENTMEDICAL RECORD
i
For useof this form, see AR 40-407, the pror

. .cy is he °Ric& of The Surgeon General.
1. PATIENT TRANSPORTED TO ()PERM ....., ROOM • • , -2. PATIENT IDENTI ¦ ORO FiEVI AND PROCEDURE
VERIFIED BY
VIA L k 1-k-p)r BY v\6Alnea 1 Cr
1:((-J2 -1-
3. DATE TIME PATIENT ARRIVED IN SUITE 4.• PATIENT IN ROOM
ag \\\ 3 TIME. 12:s NUMBER 1:::) -3 #.5-
5. PREOPERATIVE EMOTIONAL STATUS
N CALM ANXIOUS / EXCITED CRYING / ANGRY III

WITHDRAWN
(OTHER (Specify)._
'COMMIT
.__ ......
0 1\)\c/ON ..
6. NURSING PERSONNEL
'r'
T ASSIGNED . .ii --"RELIEF
SCRUB

. .SCRUB
-Z--•
ASSIGNED
RELIEF
CIRCULATOR

la uo€:
. __. .. --_CIRCULATOR iiTi.;.
7. POSITION AND POSITIONAL AIDS (Specify) . —
[Xi SUPINE III LITHOTOMY PRONE . KRASKE -LATERAL: . LEFT SIDE UP RIGHT SIDE UP
COMMENTSVDT mo
c----AtzA A A ZC,-- -)JUA-t VkAa¦DA-/-ign
8. SKIN EPARATI HAIR REMOVAL / YES Ki NO -
PREP S
UTION (Specify) EC4C;)Ce.1--1:4.,1
DONE BY:
OR NURSING UNIT SITE: BY WHOM:
METHOD: III DEPILATORY II RAZOR SITE: I I,
. ... . By WHOM:
.
CLIP ... ___-_-_— ------. \cjckS" 1--
•..., ,..-, ....
COMMENTS:
--. —. . .COMMENTS: 11'\
Of BliktfT_Ar
9. LOCATION OF EXTERNAL DEVICES
. ...
, . - , , _ :it-- .,
. . •
-
• i , 0.4riivARrri eifir
7Imi- --. '
-;4. . ,
Pt N, (
LEGEND i•dv,•/` -- S ycipAv = = = Tourniquet ---.. PA_RruP 6 -7 ,
G nd Pad trap
A
,

10. COUNTS CIRCU
Sponge Ejj Yes Needle Sharp A 41; Mar
P2t Yes INICIIMIAIIIIIIVAIMEOPMIMIE
M
Instrument Yes
NEIWAIIIIIWAIIIIIIIIIIIMIIIIIINEm
Other / Yes a 0 Pr
i 1. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) ESU) Mt YES / NOName - Last, first, middle; Grade; Date; Hospital or Medical Facility:I CLA-1- SO
N ESU NO: V1--- -1-01 (-e-- 14) Co2n 3 0
,
-b ( c., -9 .. GROUND PAD: BRAND \A-- -12--EVIA PON (41/VIOL tr.
-.:.!.._;.-. •
-.-_,-
LOT NO: (0 ci 141-1 1 ;,v) zoa57-03
' ::'-n-Au.No:
;-W IMF ..
..•.--.-611-6UND PAD: BRAND
..,..-
LOT NO: 0 BIPOLAR NO:
b(_?_)- --2_
DA FORM 517A-1• , rinT P7 -,
S OLET E USAPA V1.00
MEDCOM - 24008
wr.
..... . • Iv., r e ..—A—elv, 11,11 1—,11V i ..,_
L.1 ' " II- YES NAME: ID NUMBER; 1'0AI
NU fURER
. . „.....,.......

.
MEDICATIONS/ORDERSS T,;,„' -IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
YES 111
NIEDICATIONS/SOLUTION DOSAGE TIME
: ., METHOD PREPARED BY ? klVEN BY -
. -
,t
i Z7
MOUND IRRIGATION [la YES . NI NO, TYPE(S): '
0 9 eq0 \AK\ -Q . S .._ ,
;OTHER ORDERS TIME
CARRIED OUT BY
-
..
e
.
,PRYSICIAN'S SIGNATURE
i
__ ,. „, _ , ,— . . , ,
15. X-RAY IN OPERATING OOM ,
IF YES, SITE
YES MI NO :::. -
16.
. -..' LABORATORY SPECIMENS
-.
SPECIMEN (S) NAME ... ........_ ..............

YES / NO X - -.
FROZEN SECTION (FS) . NAME
YES NO

1111 X NAME
CULTURE (C) NAME NAME
YES NO
all pi - ---
NAME NAME NAME
NAME /7 NAME
18. DRESSING/IMMOBILIZATION (Specify)
-
17. TUBES, DRAINS/PACKING _ YES
NO Ki -I- Ukt-tS
TYPE/S1ZE 2.
.
.-\)
b214aLX
SITE
1. 2. 3. .. . ....,..-- .
19. ADDITIONAL INFORM
...4
IM\ '• b-f
.4 ' ,..,-.
-,,:s.,..: . s.:-,:-- ',
iNaltkk-QX L-1- C
'
_ __ -._ --, -•
. : .....
:
..,
.
k--( .
MSY)9 he\ C_WRft ;.
20. OPERATION(S) PERFORMED
_I_
. . . .
.
.
21. PATIENT TRANSFERRED TO
TIME Sizik_ METHOD
Pi\
--)accl--LA' Tref FT 0?-
22. REGISTERED NURSE SIG
')1\.
A FORM 5179-1, 0
USAPA V1.00
MEDCOM - 24009
Intl ill,VI LW, I I --.1.-0,..../11/1L-110 1
MEDICAL RECORD
For use of this form, see AR 40-407, the prop, iency '-ie office of The Surgeon General.
PATIENT TRANSPORTED TO OPERA1 1..-R.. J M 2. PATIENT IDENTIF .ECORL/ REVIEWED AND PROCEDURE

1. VERIFIED BY 10-
VIA Li TT G..e..._ BY 4\ t-le.' c51-1.-tESi F1 b 162) -2-•
TIME PATIENT ARRIVED IN SUITE 4.. PATIENT IN ROOM TIME. : pK55-NUMBER --- I
3. DATE
,Q ce-c._ D3 /
5. PREOPERATIVE EMOTIONAATATUS '
[X] 'CALM ANXIOUS ' EXCtTED. ..-CRYING ANGRY 1. WITHDRAWN • I (Specify)
..
-COMMENTS:_. '
,
1 t
L. l
,...... 6 c-NURSING PERSONNEL
.%

.
;..
r
• ASSIGNED -""- RELitF
SCRUB SCF1UB., ,--". '

._
ASSIGNED ,f RELIER ,
CIRCULATOR .._ .. . . ____CII3CU" LATOR

• ' ' IN I. .. '. i J_
7. POSITION AND POSITIONALAIDS (Specify) ik,, S:01-05A-e..:-',Ir_\ Vactok.taf,..; -t-In.1..st. . Pi. 11 oo.5 v. u_vicksuf Licis . arms
.c_uor,s_a, ; on 'a rmAc•Or(is
fl 'f. .„fII LITHOTOMY ly4 PRO.NE -----KRASKE,-. 1:)3TERAL: • LEFT SIDE UP IN RIGHT SIDE UP

oz. --SUPINE
.f.f . f.f. f.f. .f. -.f
.
COMMENTS: .
MLA -2 -.A —sr AI ._, II i_I_, _a_1 r a A A l 1_1.-- -IVIAl:._.._'02_Gt '
IC.ANA

P. . SKIN PREPARATION
HAIR REMOVAL EC YES X' NO by--' , PREP SOLUTION ,(Specify) 13t±a cic./13,t_tct.zp
DONE BY: 1%. 'OR --,.._. la N SITE: Bl...„. BY WHOM: I tr-

... _,
III 115 IlY .. SITE: BY WHOM: MAN
METHOD: DEPILATO Y -.... -RAZOR s)
• CLIP tv\licli_3X.4W41‘. ...—... ,
COMMENTS:, 1\1;du\ c) c.xxt,v\mcf-x._.9.___.. ._66oANTs:1\10 vccul Diatuusg. tealiolo
9. LOCATION OF EXTEFiNAL DEVICES
, -..,

C7.------) -•
. 0.-16:A' ' •
fi i VOW . e4P•-' "I .-----...
1 I 6 k"k
-er- - . -Zill, ML1 1111b¦
riartiliffar_ , ..
-/ -I . IfirirkaliffrigArdrar
ArfiArIl'-gwo-0,itgwel y, A ,
Immetw
"
,._
-
-
._

0 /A
LEGEND '''.. dun '---Safety = = = Tourniquet.--v.42 •
i10%-r\ fv%.4".' i'.(--G, 5,2,1‘c.iieii .4 C = Correct = Incorrect ' 1-L-, ! ,
'::. '1 71.L1-ivi a i zo,,,.;_

First Closing Final Closing
10. COPNIV.'4.. ' -' Other' • Count .. CoUnt ' .SCRUB CIRCUL , -'
•-• r
Sponge n Yes _ Odra IMMT
yes, -JIM

Needle Sharp n •ct-AziminEvAds' Ehmikgres, 1 Instrument
0 Yes: MalWWAIIIIIENEMENSEL _--ariaii0/11111•1111=11111111__--...
%1.
Other
MIEVAIIIIMITIIIMIIIIIPPP- 1/M111111111PM11/10/
n Yes -A111111111
11. PATIENT IDENTINCATION (For typed or Written entries give: .. ELECTROSURGERY DEVICE( I (ESUI 1:11 YES s
Name - Last, fir,st,rniddle; Grade; Date; Hospital or Medical Facility;)

,
CtAi . g Q :. ESU NO: VL 1-0\itk 40 (...()A(9 36 : ,--GROUND PAD: BRAND \Il_
i___,„alailOiteagat_ 6 (.6-) --'44 ' Lor NO: tottLILI I .E7*.* 20°5- - 03 ":110-NO:
•
•"..---GROUND PAD: BRAND
..:
.
LOT NO:
(D ( / . \ -
. BIPOLAR NO:
. :... Jf
7. •
DA FORM 5179-1, OCT 87 _ RE.PLACES:DA,TOR. -1 ITES.TI, DEC 82. VIMICH IS OBSOLETE.
MEDCOM - 24010

13. PROSTHESIS, IMPLANTS eES ' NO IF YES NAME: ID NUMBER; -2TURER
. _
— ----
-
-.
, . --14. ,-. ':.,,.,..:-..-
;,:4;„,:.±.:;1;qi;..:4:6:c,. .!;:::.:V:i:,,-ii:lii',r'.:,'''"'d',"::::.'-''';':ii.tql'=.t: M E DI CAT I ON S /0 RD ERS .Rti.:4EV4A",5:406,tat#,ZAWM,Nag;4,itiM. IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM INOT BY ANESTHESIA)
YES n NO III NEDICATIONS/SOLUTION DOSAGE :
., TIME METHOD PREPARED BY f, GIVE : -3d-fataine-0 ' tAa. Sar" D.S 0 612 s., A•F‘.... I 1 -:11'.11::.-: -p-i-trA6 S.. -., t, ¦ . t...\ Owef
MAI __
2-74P
:,14`1Cti1 Oil ll pat, Stk • ;c1:2.-,--01! qtt-ivr.iya e K431(-&-1 0AN.: _
-...5,5 _1 s' I
Alien ,I, y¦ ,--1-ttk 2.5-.D, .2...-,_,, p NIF ' : ILAminesa:t 0 i 1 ---°.T. %9., ev`g, 4 ' RI S t vt-ta
. , bp a..Q taw,
.i., ,...ar AFL
:: ;ode, 2n I-_ • Jan-a -
Ur' •
:WOUND IRRIQATION 0 YES / NO, TYPE(S):
.. .,._ ,.
go(C.0.-) - P2..
0 . c\ tie 1\laCt_ - (3 -S •
. _
-OTHER ORDERS TIME CARRIED OUT BY ;..
•-(=t, -, -
•PHYSICIAN'S S
:. .
15. X-RAY IN IF YES, SITE
,:',:: '
YES • NO
. ‘
16. f . :'f.LABOR4TORY SPECIMENS
. .,. ,
SPECIMEN IS) NAME _ .._......_ ______
YES • NO [gl ,.. -' --.
FROZEN SECTION (FS) NAME

NAME
YES NO N .

'
CULTURE (C) NAME
NAME
YES • NO 111 ) . ,_ __ _____ _________.
NAME NAME

NAME
-; .
NAME NAME , :-:. 18. DRESSING/IMMOBILIZATION (Specify)
L LE.,.:
. _ _ g.LE:
X.-e...r0 -Enr-v,,,-1
17. TUBES, DRAINS/PACKING YES II NO •
_ _ _ .. clu-CES Rut(
TYPE/SIZE 1 2. ,--. .
K0.41.4
le-45-1":--Y¦ ' SITE k.tely
.
• 4.
1. CV 1/C Vtikl ACE
19. ADDITIONAL INFORMATION -
-• t'''
Sk-c8e011 '.
lb' _. ;,:,,,-¦ ;..-_;.„ ''''')i' . -'' „,,-''''
1- .:
-1\V\tq•-ttlYZS4.• li. --'''''' - -, .-...7-
.._.... _ .,., . •
-.-. t4
7-.1?-riC-- \ \
.
: :11 't -•., , . . .. . .
.. - -..1.
20. brkSnfl \ CAKi\c-t "
OPERATION(S) PERFORMED
. r-:( 0 -7:1 . Nc.b hofe Tect.A2-iv.4 twao pt c_ia,
,. . .; sTs / ...._..1 ,-.1
,
, ...,
.
21. PATIENT TRANSFERRED TO
TIME c=c,. METHOD DIN --ITg°1-Lt tte:r
22. REGISTERED NURSE SIGNATU
‘..'7 h..)
art/cpee rte n It ra-tina• r-a,,,, a_.......... a.-.

USAPA V 1 .00
y • •
MEDCOM - 24011
MEDICAL RECORD IN I RAOPERATINx )CUMENT
For use of this form, see AR 40-407, the prow'
''-tcy is,-' e office of The Surgeon General.
.
1.
PATIENT TRANSPORTED TO OPERAl.. .100M

2.
PATIENT IDENTIF. '

AND PROCEDURE
VIA L't
f BY -14\1--\:\Q Yi VERIFIED BY 1 UT 1. L, \ -)-
3. DATE
TIME PATIENT)
1FU LED IN SUITE
4.. PATIENT IN ROOM
¦\c"1/4)C__ ( _0, TIME : OCC33 NUMBER
I - i
5. PREOPERATIVE EMOTIONAL STATUS
[X] CALM . ANXIOUS EXCITED 111 CRYING ANGRY WITHDRAWN II
OTHER (Specify) COMMENTS:
,
_.....
,
\Aqi\ tA) 0 3
6. NURSING PERSONNEL
•
. ASSIGNED
Pc--c_ --cli-b --RELIEF
SCRUB
SCRUB -.) .$) -
ASSIGNED
k_T to E RELIEF
CIRCULATOR
.__,. _. .... . __CIRCULATOR iI\11 • •
7. POSITION AND POSITIONAL AIDS (Specify)
. ,
KI, SUPINE. LITHOTOMY II PRONE / KRASKE -LATERAL: LEFT SIDE UP RIGHT SIDE UP
COMMENTS:
-.
IN\Of Pi\) Bt\Wil)P6(__ \irVIN k-,C1 WVIYNit-- terV-Ya-U. r)-t-a L. trwd
-8. SKIN PREPARATION
HAIR REMOVAL

/ YES N NO ' PREP SOLUTION (Specify)
13.e.tct,c_v_kisecUL,L.1/4.0_
DONE BY: / OR II NURSING UNIT SITE: Ce) til
BY WHOM: ILT--al=
METHOD: / DEPILATORY / SITE:
RAZOR BY WHOM:
E, , 1 e `,. __ ,-7
CLIP . • _ -
-.7. .,..r., ..)
.
COMMENTS:
liv N
. tdtAtiENTs: IA \MIA,k3Ati of ctktrai)._ itAttio 0
9. LOCATION OF EXTERNAL DEVICES
......),..."-----0
' cl 6

-
.
– 1-1
t • . Alk: — ..
.
. 4(0iireily--";="14.0"1"
A' &mom_
-1,474MW l'Arwja
/ 060
/

LEGEND X Ground Pad -- S. ap plc()
= = = Tourniquet -..-•.,..VA -
I rk
tia,k : fr-c ...koreis = Correct I = Incorrect
1 vt thaid2s0AL k' (C43- '?

First Closing Final Closing
10. COUNTS
Other ' ' Count i .r Count
SCRUB
CIRCULA
Sponge
21/ EIIIIIIMMIIIIIIIIIIMINIMIr —
Needle Sharp WI
FA Yes MIEINVINIIIIVAIIIIMINIMILII JIIIIIIMI
Instrument
Yes
Yes NICIVAIIIMMIIIIIIIMmiesp-
Other D ,A¦¦
Yes In _
0
1 1.
PATIENT IDENTIFICATION For typed or written entries give:
12. .ELECTROSURGERY DEVICE(S) (ESU)
Name -Last, first, middle; Grade• Date; Hospital or Medical Facility;) YES NO
, -ci.tr: 0
i . ESU NO: V 1-- 4-1N-C-e--210 c.okkGe : r
GROUND PAD: BRAND N. fl- REm Po 4-Flesi ue. ir-... ,-.-_.--. — LOT NO: 1151 LP -4"-- q 200-5 -CID
..•07.E,0 NO: .----GR-OUND PAD: BRAND
b ( u-.S --I
LOT NO: BIPOLAR NO:
DA FORM R1714-1 nrr S:r7 n "e-s-•
!If n1 .-. a ......... -. - _ _ _ _

u 51 /9
1 (TESTI, DEC 82. WHICH IS OBSOLETE.
USAPA V1.00
MEDCOM - 24012

DOD-037590

13. PROSTHESIS, IMPLANTS YES I NO IF YES NAME: ID NUMBEE, :
.CTURER
--..._...,...
'=--2_;1,:.!;'MEDICATIONS/ORDERS_:: '' .-_. , „,,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES NO
MEDICATIONS/SOLUTION DOSAGE TIME

METHOD PREPARED BY I G ' 33CACe.)1\ Oi at LeZi.,:01-0 s-& -1 ittrA --0 TOPIC_A
MF111111111 fr
.
---,( 42)- Z.--
MOUND IRRIGATION Ki YES foj NO, TYPE ):
. CI cib \\ U -0 •S •
OTHER ORDERS
TIME CARRIED OUT BY
. .
PHYSICIAN'S SIGNATURE
.
. _ . .
.
. ..
15.
X-RAY IN OPERATING ROOM IF YES, SITE
YES • NO NI] P -I

16.
:LABORATORY SPECIMENS

_ . ,
SPECIMEN (S) NAME _ __ __ ____ _ YES • NO ki FROZEN SECTION IFS) NAME NAME YES • NO Ilj CULTURE (C) NAME
NAME YES • NO kk] ---- -----NAME NAME
NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify/ .. — 1., Lc_ 1. )(9-VD-6.-"(1. {-WS . bi..11 )t , 50C1A-1-, ACE
17. TUBES, DRAINS/PACKING YES 11 NO TYPE/SIZE 1 2. -_---, 1GIAA n
R Le ,. -kn.') t Lutils , I,&v-LI1/4-)c
SITE . .
19. ADDITIONAL INFOR 1
G.-C-1- k

Su_rOsep\A I IN-.
\,I3 C '. aM
4ytrv0v4,5 '. .1LI ,Q6a,.0 103-,
b (_(Q__- 7 -N-k\
. .s,-1., 1 Cti\ Int
20. OPERATION(S) PERFORMED
-brl 6,_ LLE
......_
— 1 Ii.
fkV_E__
fit,,-'t,1
21. PATIENT TRANSFERRED TO
, TIME see_ METHOD IA 1gC1 1.__N kk et-
22. REGISTERED NURSE SIGNAT
-,
USAPA V1.00
EDCOM - 24013
MEDICAL RECORD For use of this form, see AR 40-407, the prop( --Icy ir ' 'e office of The Surgeon General.
.
.
2. PATIENT IDENTIF. AND PROCEDURE
1. PATIENT TRANSPORTED TO OPERA1.. rtOOM . -
VERIFIED BY I a k___, ( cc') -1._

VIA t_.:k \W:Ar. BY 4\\Nesl-WA
4.. PATIENT IN ROOM
TIME PATIENTED IN SUITE
3. DATt
TIME Cn6-33 NUMBER 1 -I
‘V (Y)-1
5. PREOPERATIVE EMOTIONAL STATUS
CRYING ANGRY WITHDRAWN . OTHER (Specify/
IV CALM MI ANXIOUS EXCITED
COMMENTS:
_
NAW\ \Ai) 0
6. NURSING PERSONNEL
-St-t. - -"RELIEF
ASSIGNED N----c .SCRUB
SCRUB
\., V.(12‘)" --L

ASSIGNED 1 LT ailli blo t RELIEF
__CIRCULATOR
CIRCULATOR
ilii • .
..... _,_..,....,
7. POSITION AND POSITIONAL AIDS (Specify) KRASKE -LATERAL: LEFT SIDE UP . RIGHT SIDE UP
11 SUPINE IN LITHOTOMY 11 PRONE II .. COMMENTS:
-'
1\\M"Pf\ B.V\33.)1Ntr\\ C__ \MIN \-c.C--ViVi\r-nti-.-V1iYa-0. rYta Or\ Qd
--B. SKIN PREPARATION PREP SOLUTION (Specify) Bet.c.t,C.A,0...." CLU/
HAIR REMOVAL II YES N N
DONE BY: OR

• . NURSING UNIT SITE: I?, al BY WHOM: i cl-
- -SITE: BY WHOM:METHOD: III DEPILATORY • RAZOR
Ic. (_ l..---7.--
„
CLIP . _________ ____. -COMIVIENTS: t‘‘ pC)1)V\JAC) Of ki3ONS.Q._ it.W-io vi
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES ..
60
{ 4
....
-

...
Ai--
I • i•- vi • _
4KOMIlakffi
gNMar4Mailaffia
•
4 CWO
/
i
LEGEND X Ground Pad --P = = = Tourniquet. - -VA pc-P
= I = Incorrect '6 (..e_., - 2

tr„tia,,k: fr. ...lowa Correct
tvx-thh..tristl-Z-First Closing Final Closing
Other•• ,..

10. COUNTS Count Ccitint .SCRUB CIRCULATO
—
Sponge 1:1 Yes o
_..
Needle Sharp Yes Nlo .
Instrument El Yes \lo .__. .. :_,I;i1:,1"-

Other IM Yes \Jo
----.
11. PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) YES [ZI NO Name -Last, first, middle; Grade• Date; Hospital or Medical Facility;) c L4.-z- .• gs
• ESU NO: V L -4-orc-e_ ziO c..,,,,e, GROUND PAD: BRAND Vt.- -REV po 4.-Hesi ue_ TE-LOT NO: '7 15( Lp 'E xp zon5 -(-1..0
tr.,E0 NO:
l

•.---:GFI-OUND PAD: BRAND
.,
-c--( LOT NO: 111 BIPOLAR NO:
bcciz_
7
USAPA V1.00
REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE.
DA FORM 5179-1, OCT 87
MEDCOM - 24014
I.,. rnvo I ,1 NU
rICJIJ, IIVIrLHIV I J
nen Y tZ.: IF YES NAME: ID NUMBEE, ,CTURER
. ... _______
-
.1 . .. . _; k ZP.MEDICATIONS/ORDERSP '' -,.,,,,, tl --14-:.':,,.,,
-..!; A '
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
YES IN NO
'NIEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIV
;133c a-r-a6f¦ °int Lea.,i),W-Ds & ...):L --intri4-:---oP,---1-0P ¦ caA rAFR:
. . _....

-r
YVOUND IRRIGATION Ki YES NO, TYPE(S): •
',", 0 -11 °A Ma CA - 0 .S •
:OTHER ORDERS TIME CARRIED.OUT BY '.
. ....--_ .... _ _ ,
'pj-1YSICIAN'S SIGNATURE
' ri
.. „--" ,, _ .
..,-.-,-, ,. .
, -_ -
15. X-RAY IN OPERATING ROOM
IF YES, SITE
YES

II NO [K] . ri-::: ¦
16.
:LABORATORY SPECIMENS
• , . . ,,,. ,
SPECIMEN (S) NAME _ ____ _ _
YES II NO IV :
FROZEN SECTION (FS) NAME

NAME
YES III NO IX
CULTURE (C) NAME NAME

YES II NO iyQ ...................._
NAME

NAME NAME
NAME
NAIVIE
18. DRESSING/IMMOBILIZATION (Specify)
..._
17. TUBES, DRAINS/PACKING YES ' 1.. t_t. I. UAIDfr-Ynrn, "RtA-i4 S . tILA' X , SpULAt, tio
NO Ill
TYPE/S1ZE 1. 2. .
R Le '• -WIT Ltifts , kQx 1,,CA ,
SITE
1. 2. 3. . . . ..-,_-__ _
19. ADDITIONAL INFORMATION
GZ-i-A
Guneoll\ i bir.
v3 c ' 13t . , 3 ' ,
Mv.0\kp.Fa : 1 L
i---:
.---,.. .
....
-
.
' ( ce_) - -t
.
__ . TA S 1-19 1 vl C.V\ ay. -t il
20. OPERATION(S) PERFORMED
-Nil A. L._t__E.
- -1- v.

ikk._ E ._
-

)
21. PATIENT TRANSFERRED TO
TIME see_ METHOD
IA -Thgcl -U kke_r
22. REGISTERED NURSE SIGNAT
71 N\)- - - -- -
REVERSE OF DA FORM 5179-1, OCT
USAPA V1.00
MEDCOM - 24015
INTRAOPERI-, e )CUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the proponent
,....icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM , 2. PATIENT IDENTIFIE
IEWED,ANO PROCEDURE
VIA LI. qe.....Y-BY -k.VV2._SkV\Zc1 a VERIFIED BY 1 Cr b.C17.--ri_

3. DATE TIME PATIENT ARI7 IN SUITE 4.. PATIEV 11\14100M
1 0 1-12-0.1 TIME: 06 ) U NUMBER

i
5. PREOPERATIVE EMOTIONAL STATUS
/ CALM II ANXIOUS / EXCITED. IN CRYING ANGRY WITHDRAWN 1111 OTHER (Specify)
COMMENTS: '
1
6. NURSING PERSONNEL
ASSIGNED SPc_ ci l -fr.T.,:-- --"RELIEF
SCRUB

SCRUB
ASSIGNED 1 Cc (010 RELIEF
CIRCULATOR

....__. .. .... . __CIRCULATOR
-INT - •
7. POSITION AND POSITIONAL AIDS (Specify)
pt . I13.5--V-(Dtr\ pectoittb -(3.01.1z . % i -6* c.,.y‘ sikp porbld by brcai if-_
0: ablA3 tetAARSLIA USIS ar\d arvv\s. -
a SUPINE II LITHOTOMY / PRONE

KRASKE. -LATERAL: LEFT SIDE UP 0 RIGHT SIDE UP
.-: ::,
COMMENTS:
8. SKIN PREPARATION
HAIR REMOVAL /

YES 0 NO ' PREP SOLUTION (Specify) Ge.t.A.a-iv.k. / 13.ra_ct.¦_
DONE BY: Ill OR / NURSING UNIT SITE: IN v. BY WHOM:
METHOD: / DEPILATORY II RAzoR . - -SITE: . BY WHOM:

. . . .. \ \.„\--
CLIP
.,... ._ .... .
COMMENTS:
0 pi . .CtiMMENTS: \\*.) ‘C)i, t---
CP\
9. LOCATION OF XTERNAL DEVICES
......
k Ck 0°
.
. -,
-;.i
. .41 -- ¦
I•
ac,e-,,;-i,:.;;-.-:•-.•-=
:..--ze:i:-TAPAIrAi--:Ifil .r.v.;,--n•-;,;?.:If.',. '.;- ifi.,91.;;;;;• ¦ ¦ -•::41 -.
iteNN g Aof--`4,4switiAriansig 0,, it ouJ
lope
i'ilow r
0/-k-
LEGEND
-- Safety St = = = Tourniguet..--. i.::,- p , ,InitZal 1 SP C = Corrett I = Incorrett AI
,
its- \-t(.1 2-
First Closing Final Closing
10. COUNTS
Other•* Count .1-.:.. Ciiiint SCRUB'
CIRCULATOR
Sponge [KI Yes — \lo _ Needle Sharp ril Yes \io
_O. I ex-
Instrument El Yes --)1 \lo Other Yes js,_ \lo
11. PATIENT IDENTIFICATION (For typed or written entries give:
12. ELECTROSURGERY DEVICEISI (ESUI al YES
Name -Last, first, mio'dle; Grade; Date; Hospital or Medical Facility;) NO
N. ESU NO: Vi--.)rCe_.. 1+0 .GROUND PAD: BRAND VI_ RUA PoWr\e_Si Ye Is_
,
... ... .. LOT NO:
' -. . tr..ESU NO:
.. ......
-
• -'GROUND PAD: BRAND LOT NO: III BIPOLAR NO: .
DA FORM R 1 7c1-1 riPT S:r7
-, ,
S OBSOLETE. USAPA V1.00
MEDCOM — 24016
13. PROSTHESIS, IMPLANTS YE NO IF YES NAME: ID NUMBER; mAN ,CTURER
,i-,1
.. _______
,
' ., _.A ,-.„. , c4,..1„.7.4MMEDICATIONS/ORDERS 7.'t IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) ,, , '-k , YES • NO Li 44,
MEDICATIONS/SOLUTION DOSAGE . TIME - METHOD PREPARED BY GIVEN BY
_— . , - .
_

\
WOUND IRRIGATION
re, YES • NO, TYF'E(S): 0 - 9 clo Q C..k._ -a • :IS _
'OTHER ORDERS
TIME CARRIED OUT BY
_......-__. -
et -
TI-IYSICIAN'S SIGNATURE
6 (Q_._) -

„,_ „

.....,
, __.
15. X-RAY iN OPERATING RO IF YES, SITE
YES • NO t :-r -
'16.
' .-= LABORATORY SPECIMENS
, „,,
SPECIMEN (S) NAME
YES 0 NO
Ut \IOUPd Ce) tA16A-v(--,.--fc)
FROZEN SECTION (FS) AME . /-_-,
s NAME
YES NO [4 a vaututtuWiA . .. (6faimstin
CULTURE (C) AME NAME
YES ffj NO • . _ _____
NAME NAME NAME
NAME
NAME 18. DRESSING/IMMOBILIZATION (Specify)
17 . TUBES, DRAINS/PACKING YES Ei NO •
. _ _ . -C 1.u.qc,
TYPE/SIZE 1. 2.
YzAr k.;:x
41-10 J-P C;t1)
SITE 1. . .
(4) tiAl‘01 WOUrICI
19. ADDITIONAL INFORMATION
Sus of\ 1 bc:
.
.
ttn. _'. IL...7 ,... . .
i . __ ,, , 0 tit /1—
,
t
.
__ ,• bik Snoi iv\ C,I4e_r t ,
20. OPERATION(S) PERFORMED
_1 ,c.b R LE 1.0c3vonck,
.
• Dvt.T-M\D -A i.:1_"G: ----
21. PATIENT TRANSFERRED TO TIME METHOD
Sc_c_
P.Ato.
C¦4\135E1 - l___; tttf-
22. REGISTERED NURSE SIGNATUR
7
AM ( 6 ) ot\Q
REVERSE Or n A rEwn.f .c170 1 nr-r o-,
USAPA V1 .00
MEDCOM - 24017
DOD-037595
NSN 7540-00-634-4124
VITAL SIGNS RECORD
1.._,,,,, ,._,
,VIL-Limrnt-.
HOSPITAL DAY
llt, Ikc

)ST-ilk A DAY DAY 0- IlagraMIZIO ir
ONTH-YEAR
r -• -10 , • - .I ---a-0 -" -"
A • 2 ..... 0 I* ._.
I
.
¦11'
-. 11%
: : am:. :.
HOUR
—alp
N-^t0C:).1
(41u° aouala-108Joi. 'swalemnb3apei nua0)
0 0 0
c.)o 0 0 0 0 0 00
T-1 CO °C:)
o .1-o) cofco (N0 N-
cl: (-0 Lc) LO
N.: l•-• CO CO
O CS/ C(5 CO N:
2 ci In CO CO CO CO Cn
w.4 ,:h 0, Cc) Cc) Cc)
. 1 c
—
c. r.113
TEMP. F
(.)

105'
s
P
' 1)0 '

2. t
.. igi 0 •.
.. .. .. .. .. .. .. .. .. ..

is()
.. .. .. .. . . ..
170 . . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . . . .
. . . . . . . . .
102° " . •' • •.
PULSE
e
:..:

,. .
1
V •
(
r

(0)
0 •
.
It
. .
I
if
•
160

.... . . .. . . .
63 ;1 1 . . . .•.
. .
. .

. . . .

. .
•
.

. . .
. . .
'
101°

. .
•
" .• .
•
.
.

• " .
. . •.
-• -
.
•
.
•
'

" .• .
•
.
•
•
•.
•.• .

•.
" . :

150

nom
ER
NM•
.

•
. . .
.

. .
. .
.

100° : : •:

140

. . . . . .

OM
WO•
1

. .

. . . .

. .
130 or:
-• M=MIENICE
•: :• : go
Ft". . li :.

L,,
Ea : : : : : : puss
I: :
: :Ea
:: ::1111111.110
:

: :

. .
: :

ME [ i.
. C.)
: :

MINIMISIMIIIIMMIIIIMMIECIIIIIMMINMIEINE
NIEMMIENI .: 111/111111
ii iminiam :: :: 1 :: :: :.1
''''''''
120
98°
110
100

97°
96°
.

:: i
:: i
. ..
.:• :: III '
:: .1
.
:: ::

. . . I I
....

in :: :: um ::

90 95°
I i
11111/111111111.1P1
monisim .:. 1 ::
..

i. :"

mil

70 :: :: :: :: :: 111111111M 111011111 :: ; .
60 : .

i .. i .. .. .. .. i .. :. .. .

50 . A.

. . . . . :: :: :: :: :: ..
.‘ :: :: :: . . .
40
. . . . . . .

ill • • • •

I
-9

1 . e..1 .4
.rPIM •
• MA • •
MIMIMI
III
RESPIRATION RECORD
RINENTRA

Ortilaill ECM

BLOOD PRESSURE

gi
1:2
111111111EMMINIffall
MOM
ta1.14.
raBIESIIIZE 7.-
tn.3rAigaging
o . 101.(p
o
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c
a HEIGHT: WEIGHT =¦--III.
too "4 ICO

ilikareAMINIMINII

.
›, _AIFY1511111311EM e.,. In
12 A A 1
14_4' 4 Migillitilallallil
ci-G, MI, 121-(17 1 =VI=
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V.
v a p,ds 133
..
VA mins

-7LA \

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0. .
VA
120 0
¦a).)
cc
WARD NO.
REGISTER NO.
PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
StANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/10MR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 24018
\,13AL RECORD
VITAL SIGNS RECORD
SPITAL DAY
DAY

1.1111111011_1ralIPZIMMINM 7.2_
HOUR
DAY giorimomplim toranimotillgi
6•E TEMP. F,/,(o) ; (*) TEMP. C
105°
MEM 11111111111111
40.6°
180 104°
40.0° 170 103°
11 Ell=
39.4°
160 102°
MIN II MIEN
150 101°
• # MINE '38.9°
38.3° a)
8 140 100°
MIEN M
37.8°
130 To
11110 MEM MEM.
99°
98.6° 37.2°
liMMEMEN1111111111111211MINE RMININ•1111111•1111•11111111111 112111
120 37.0°. O
98° W
a)
36.7° -c) 97°
ISEMII 11111
1111 ;2
36.1°
c.) 100
1 10 Milli IIIIIIPMEME
35.6°
90
95° 35.0°
96° 1111110111•1111 1111•111
80
MI 111E1111
70
IMENION111 MINIM
60
50
ENE IIIMMININE
40
ME= HI NMI
RESPIRATION RECORD
BLOOD PRESSURE

ELCIENItirw 0 jilig
-P_ 11111131111101111111=111113111r1111111111111111111=
HEIGHT:

TL8n¦clAtillaWA
MOM .(LIA
0 WID ram: VI
a)
8
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility)

REGISTER NO WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK
AD( co
MEDCOM - 24019
DOD-037597
VITAL SIGNS RECORDMEDICAL RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR DAY 2_ 5 -_IMINIMENIMII-111EalliglENIMUM
IIMI ' • El I (1--• 40111121181111=1 • • Iralllailtal
19
HOUR t
.
2 6
w•zr r•-•
ZYJZ13
tCA
c.) 0 o
111

: :

PULSE TEMP. F
i 1111121116 '
:A iiii :::::::::

Ri i
if

0
180 104°
170 103° . . . . . . . . . . ...... . . . . . . • •• •.
. . . . .
......
160
" ' ' "
. . . . . .
. . . . . .
. . . . . . . . . . ...... . . . . . . . . . .
150 101°
. . . . . . . . . . . . . . II . . . . . .
......-
:•:.0:::w

. .

(0)
c0
(.0
:

(*)
105°
c;
cy; co c.6 (13
co co corn cc) co co or)
140 .-
,i,
. . . . . . .

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......
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IMPIEME111111111.11M
. •

ME:

. . . .

NO r•-• ‘—t A.0 0
99°
130 orommalsiati
98.6' : : : : imi : : 4r :
120 98° Eim : : 'Eel
: :

MEI

iio ° III : : lentil: ::
9 7
::

MEM

:in:: ::1::

:: -:. :: :: ::

1111 11111.111

mil:: :. :. :. :. : I: „I:
Eil

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10 0
90
i.

96e
In
95.. .
1 1:

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IlliENNIEME EMI"
I

I I

:: ::

80
M :: :: :: MIN :: ::
70 ill .. .. :. .. i :. :. i
60
•
. . . . . . . . . . ...... . . . . . . . . . . . .
50 _ . . . . . . . . ...... . . . . . . . . . . . .
. . . . . . . . ...... . . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . . . . ...... . . . . . . . . . . . .
40 ..
.. je . ct
RESPIRATION RECORD
Vit7r1=1113111111111 INIMIIIEL
ITEMIIIIIIII
BLOOD PRESSURE
ffiVA
paiapioosuaym Apoeleplepadsploom
Ell MIMI
Iffill 01111/1511101111111111171MMUM MI
HEIGHT: WEIGHT .-0.
. en EWER. flgeo ririi • Itirdi llEFAMIIMMErfMEM
MI=EWAUMEME/
Ibia VA
-)
trle
?
PATIENT S IDENTIFICATION (For typed or written entries give. Name—last, first, middle; ID No. REGISTER NO. WARD NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK-
MEDCOM - 24020
DOD-037598
NSN 7540-00-634-4124
.DICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR a:EC_ 02_ . ieC
DAY fikc4-.
. . . . . . . . . . . . . . .
/142.07). HOUR I. • • ' 0' ' ? •
4"
0: :
•
ti•--VZ"
_
PULSE TEMP. F
.

. . . . .
. . . . . . . . TEMP. C
.
*.ed
(0)
. . . . . . . . . . . . . . .
(.)
:
.3 . •
. . . . . . .
. . . . . . . .
. .
.
105°
40.6°
. .
.1"`
. .
. . .. . .
180 104° . . . . 40.0°
. . . . . . . . ..
170 103° . . . . .. . . . 39.4° 3:
160 102° • • . . " . . -• • . • . • - -. ' . • -. • . . -• . " . • -• . -. • • • . ' . • • .. .. .. . . . . . . . . . . . . . . . . . . . . . . . 38.9° -a o a)o c 2a)
150 a)38.3° cr
. . . . . . . . . . . . . . . . . . . . . . 8
140 100° • • • •. •. •. " . . . . . . . . . . . . . . . . . . . . cri37.8° c
130 120 99° 98° • . . . -. • . • • • • - . . . . . . . . . . . . . . 37.2° 37.0° 36.7°. a) -(T3.? o o-w a)-o

4).
z,ca..4
•--•
•• .
• . . . . . .110 97° 1 . '2
36.1°
0
c.)
.
. .
•
. . . . . . .
• . •
100 96°
. . . 35.6°
' " "
. . . .
" • ' '
. . •• .
. . . . . . . . . . . . . . . . . .
90
95°
• •• --35.0°
•
. . . . . .
' " • '
' "
. . . . . . . .
. .
• "
80
• • . . . . . . . . . . . .
' . . . . . . . . . . . .
.
.

70
60
•
• • •
t•••
". . . . .
. . . .
. . . . .
. . . . . . . . .
50
. . . . . . . • .. •• • • • -••
. . . . . . . .
. . . .
40
9. . . . . . . .
. . . . . . . .
. . . . . . . . . .
••¦ •••-..I1
75
Ii
RESPIRATION RECORD t
12,

maimasum" Apoeleplepadspiooa8 I
BLOOD PRESSURE w
Ilk lefoci
4, to.
RY( 9c1*
HEIGHT: WEIGHT --0.
I
. 0
0,c0--VcRiceelov.cnz vcrb
! •
" A A
DATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name--last, first, middle; ID No. REGISTER NO.
WARD NO.
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 51_1 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 24021
DOD-037599

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR 1III, -19 PULSE (0) DAY HOUR TEMP. F (•) 105° NZif • - 11/11 • • . . : :2: :Li:l• • radmohl. .E.,. _. .:m.ini.".g.0 • : Ak . . TEMP. C 40.6°
180 104° -. • . • . -. • . • . • . -. • . -. • . • . -. -. • . -. • . • . • . • . • . • . • . • . • . • . 40.0°
170 39.4° -5,
160 150 140 130 120 110 102° 101° 100° 99° 98° 97° . . . . . . . . . . • . . . . . . . . . . . . . . • . • . . . . . . • . • . . . . . . • . • . . . . . . • . • . . . . . . • . • . . . . . . . . . . . . " • • . . • . . . . . • . -. -. . . . . • . -. -. . . . . . . . . . . " • • . . • . . . . . . . . . . " • • . . • • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . -. . • di; . . . . . . . . -• . . • •. . • • 38.9° 38.3° 37.8° 37.2° 37.0° 36.7° 36.1° 0 • a)0 c 'I.' co a) c. .:(5 ,.4...-ca)To .a 7 cr)).1 a)-0 '2 .o.o "*E" CD C..)
100 96° . . . 35.6°
90 95° 35.0°
80
70 . . . . . . . . . . . . . . . . . . . . . . . . . .
60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50 40 • . - • . • • . - • . • -. - -. • • . • • . • • . • • . . . . .
RESPIRATION RECORD
g3) lo 6 oo) ca) BLOOD PRESSURE " HEIGHT: INEIGHT —0.
,.. c o
g
a ..F5 :8
2 a 'ATIENT'S IDENTIFICATION (For typed or wri ten entoes give' Name—last, first. middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO. , .
(
I. 1 kJ r)V

VITAL SIGNS RECORDS
(-
Medical Record

STANDARD FORM 51.1 (REV. 7-95)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

111P1't

MEDCOM - 24022
DOD-037600

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-MONTH-YEAR Vy79 19 (4,Y.: PULSE (0) 180 170 160 150 140 130 120 110 DAY . DAY t. 4 4 . r ) HOUR f I • . , .TEMP. F (*) 105° 104° 103° 102° 100° 99. 98° 97° . 0 ..40 6' ' . . . .f............... di ...............rill ...... . . ...... . . . (}: . . . . . . . . . . . . . . . . . . . . . .. -....... . ........... .. . . . . . . . . . . . . . .... . . . . . . • . . • • . . • • . . • • . . • • . . • . . . . . . ......... o 9 .. . . . .......... .. • b • ^ ;( . • • • • • • 6': • ........ . , . • • . . . . • • . . . • . . . • • •......... TEMP. C 40.6° 40.0° 39.4° 38.9° 38.3° 37.8° 37.2° 37.0° 361° 36.1° -5..-c o a.)c.3 c :12a) a., cr '..-;' v; C.a.)To ._ cr' Lu a)-o 2 na '..7,c cp0
100 96° .. .. .. 35.6°
90 95° -... . ..... 35.0°
80
70 - ....
60 .. .... • ' .... ..
50 .. . . ........ ...i',.. .
40 ..... . . .. .
RESPIRATION RECORD

¦
i
)aiapioosuawn AluoeleplePadS 111039N 1
'A I itN i 'S
BLOOD PRESSURE
HEIGHT: WEIGHT —1.•
IDENTIFICATION (For typed or wri ten entries give" Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
i CRAf.
STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 24023
DOD-037601

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
I
MONTH-YEAR rw,ta-c DAY IV ._0(c.?
19 HOUR rtze• • (-)-1-i • . . . . . .
PULSE TEMP. F . . . . . RI . . .. ..• ... •: .. ..
.
..
•.. .: •: . . . . . .
• -TEMP. C
(0) (•)
105° • • •• •1

40.6°
180 104°
40.0°
• • -" --• • • " • " • •' •• " •• " • •
170 103°
-• . . . . . . . . . . . . . . . . . . . . . . . 39.4° 5--,
. . . . . . . . . . . . . . . . . . . . . . . . 6 T . . . . . . . . . . . . . . . . . . . .
o
. . .
. . . . . . . .0
0160 102° ••
. . . . . . . . . . . . . . . . . . . . . . . . . . 38.9° c
. . . . . . . . . . .
. . . . . . . . . . . . '2 . . . a)
. . . . . . . . . . . . . . . . . . . . . . . a)
" '
150 101°
. . . 38.3° cc . . . . . . . . . . .
-..-6
ui
140 100°
. . . . . . -. . . . . . . . . . . . . . . . . . . . . 37.8°
c . . . . . 6 . . . . . . . . . . . . . . . . . . . . . . a.,
co
.?.
130 37.2° n
0-
37.0° L.0 120 a)
36.7° .0
' • ' d
al
•• •-
. . . .
..11.1)
.
-• • --• " • • • -" " •' " " •' • •
V
110
97°
36.1°
a)
0
100 96° . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.6°
90 95° 35.0°
80
70 60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
40
RESPIRATION RECORD

paiapioosuaym Aiuoeleplepadsp0008 I
BLOOD PRESSURE . HEIGHT: 1 VVEIGHT --I.
.
.
WIEN 'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO. (C-6().
c11111111k k(( - MEDCOM - 24024 VITAL SIGNS RECORDS Medical Record STANDARD FORM 51_1 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

DOD-037602

OUTPUT
URINE REMEINIMISVCC ..-0---,
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

/0 21 GAII-il ic C. 5'e-1-05"Ct ittr-e?
/Pe g)e._,
NM I ••¦• I
....Milli I
4#
'-'-
CHEST EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT TIME AMOUNT TYPE ACCUM TOTAL
..
,
. .. ..
aliAND TOTAL OUTPUT.
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; date; hospital or medical facility)
INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS 11 oz) . 30 HALF PINT MILK
240 120 LARGE SOUP BOWL
240 SMALL FRUIT CUP 160 LARGE WATER GLASS ... 240 COFFEE MUG 180 PLASTIC OR PAPER JUICE CONTAINER
180
W(12--
_ ._ ___ __ _ _ _ _
Page 2
MEDCOM - 24025
OUTPUT
_
URINE
6C ckArcaIN-) ) I ))0
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
AC OTAL
tkeco.„ b , titft Nlic i Cicc_ ild-cl' (0 (._(._ rc_ b tocv t i 1t5W 1., eL.9 ,9s--cc.
\I
d-11
1
______Zre
G.
.
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
.
TIME AMOUNT TYPE ACCUM TOTAL
'
-Q14AND TOTAL OUTPUT.
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last,
first, middle; grade; date; hospital or medical facility)f. INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS 11 oz) . 30 HALF PINT MILK
240 120 LARGE SOUP BOWL
240 SMALL FRUIT CUP 160
LARGE WATER GLASS ... 240 COFFEE MUG 180
PLASTIC OR PAPER
JUICE CONTAINER b ( (r)-180
4
nn poplin 7Q9 IAM -Ill
Page 2
MEDCOM - 24026
-

OUTPUT
URINE NASZI:132AEI+Ftit" -75-P
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
0,-,--L:c)
---/LIt- ;ZA..-.0 il-771 /./4/ -7 cf
lop-g-,900 /OCC- f_.c( /7c-C../
20°G-ow 0 cc- Oc c.
..

, 01144.1
\ICC i 9-- 6
_......
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
.
TIME AMOUNT TYPE ACCUM TOTAL
.....
, ,
.
QRAND TOTAL OUTPUT.
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last,
first, ntiddle; grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS 11 az) . 30 HALF PINT MILK
240 120 LARGE SOUP BOWL
240 SMALL FRUIT CUP 160 LARGE WATER GLASS ... 290 COFFEE MUG
180 PLASTIC OR PAPER
JUICE CONTAINER 180
(C)' ' 4i
nn munn -7a-) inni -7A
Page 2
MEDCOM - 24027
DOD-037605
1 3D( —oco

OUTPUT
URINE ALAGiee#3T-Rte-
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
24,37 6 20 o&--' -pi tl /250)

.
._..... . ...
CHEST
EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE

ACCUM TOTAL
, ; '
•.,
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
'
TIME AMOUNT TYPE ACCUM TOTAL
..
,
. .... _ ..
-dAAND TOTAL OUTPUT.
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; date; hospital or ntedical facility) INTAKE EQUIVALENTS (Serving levels cc)
. MEDICINE GLASS (1 oz) . 30 HALF PINT MILK 240
120 LARGE SOUP BOWL
C LV ON°
240 SMALL FRUIT CUP
160 LARGE WATER GLASS ... 240 COFFEE MUG 180
PLASTIC OR PAPER
)r 66 -- 4'(
JUICE CONTAINER
180
DD FORM 792. JAN 74
Page 2
MEDCOM -24028
IFT:Varlift.;cc:ia L:kBORATOR.1" RESULT 'r-OR!.I LAST, Fr cc• the ,kc-t
I.974)
SN:
6ft)
0000100684.

,:olor 1 5 I NYA ----== PICCOLO .
, 12/11/03 AM
L G I i yc REFERENCE R NGE PATIENT #: MALE
E Bili I t:c-z.ti , BASIC MEIABOLIC
-12-11-0J Pitiprit fali.; 110 AO, 0 ‘f.v gAIL ,:;/ 0 -• 2(15 51 Ixinit t,t‘• 1 Isict S C; Prot. Urob Fre_,0 or Zse,-,rivc I Nrcgatiyc -NYA I 0.2-1.0 DISC LOT #: OPER #: 777 .SERIAL #: 3325AA4 DR #: 000 ; r GLU 128* 7j--)18 MG/DLBUN.11 7-22 CA++ 7.6* CRE 0.8 .I NA+..139 ( K+.4.8* CL-.110* tCO2 22 MG/DL 8.0-10.3 MG/DL 0.6-1.2 MG/DL ' 128-145 MOM_ 3.3-4.7 'MMOVL 98-108 MMOVL 18-33 mom_ i• INST OC: OK.CHEM OC: OK
ziirc HEM 0 , LIP 0 , ICT 0
(AC-1-c(
I--.: .sp e_a:Hematocrit 37-47.0F) op. —
Scd Rate
a:;d: COunt Dircctizen , MUST SUBMIT SF 518 WITH EVERY uNrr REQUESTED

URGENCY PATIENT STATUS E1. AM B
KtROUT /NE
• OUTPATIENT El . ODAY 0 NP DOM
SPECIMEN- SOURCE VEIN 0 CAP
0..PRE-OP
STAT
OTHER (Specify)
Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.DATE RE SKINATIME_ E PO RTED BY MD DATE LAB. ID. NO.
b t/ /S/09
a— _• -
MEDCOM - 24029
DOD-037607
diSect ion: I REQUESTING PHYSICIAN: ! LABORATORY RESULT FORM
1 (Subject 1:: the Privacy Act of 197,1')
'3—
;1 1., c N-11. 1 T.', MT 1/ 3 I 0 0 SS N" PSF:. '
vatology) CBC . • Urinalysis .. Misc.
11,157. 4-SULT 'TEST RESULT R.EF RANG.E .TEST RESI:J I REF. RA ,VGE
---
Coloi RIIR 1
App NIA 10:10
_
Glu Negati ve Microbiology
Negative Z:3onrce
-i„ Kos Negative Gram
Stain
pj SCi Occ Bid Negafive
Bld Negativ::: 1-1. pylori . Nem:ice
icro
Parasites
I S Negative Maiaria

T.,-
Atyp
RBC Morph
. Spun 1 42-52% CM) CSF - Blood Bank
37-47% (F)
Hematocrit I
L Sed Rate ; Ce fl 'MUST SUBMIT SE 518 WIT1.1 C ount EVERY UNIT REQUESTED
__ , Other Directigen 1 Nev.ative ABOah i I ____ _ .._ . :--Coagulation.Studies. . - Blood Bank Unit Crossatatch. - . . , (MUSTSUBMIT SF 518 WITH EVERY UNIT OF BLOOD . • -REQUESTE'D) -TEST RESULY' i .REF. RALNGE CIATT TITE fCROS'SALITC1.1
.
P IF i 9.8-13.6 secs ! A IY IT ; 21-34 sees
D dirner : 26 .igim)
17 DP 1 Ii) wilt&
i .---,
!
i RE NI A RE:S
•
EPORT.ED DATE: LAB -ID NO.:. 0101/Cf
0
MEDCOM - 24030
c-C r-C

a
—J

. ro
(.0 0 '-
o._ _
O c_
co
7-z ro
_c CD
(-7) E co co
co
C
C
Microbiology Request Form

MEDCOM - 24031
Microbioloev Re ort 1 C_---t---c_ a
Name: Specirnen- W139 Status: Prial
Patient ID. Source: Wound/Sterile site Collected:
Ward/Rm: vvii VVard of [so-Altd. Phys•

1 Klebsiella oxytoca Status. Final
1 K. oxytoca
Drug MIC Inter_ Drug MIC Interps Amox/K Clav (c) 16/8 I Amp/Sulbactam (c) 16/8 R Ampicillin 16 R Aztreonam =8 S Cefazolin 16 ,..., R Cefepime =8 S Cefotaxime (c) 32 I Cefoietan =16 S Cefoxitin 16 I Ceftazidime (a) =8 S Ceftriaxone (c) 32 .,.-.,,I Cefuroxime (b) 16 R Cephalothin 16 R Chloramphenicol 16 R Ciprofloxacin =1 S ESBL-a Scrn 4 ESBL-b Scrn 1 Gatifloxacin =2 S Gentamicin 8 R imipenem (c) =4 S Levofloxacin =2 S Meropenem (c) =4 S Moxifloxacin =2 S ,;,. Nitrolurantoin =32 Norfloxacin =4 . PipiTazo (d) =16 S Piperacillin (a) 64 R Tetracycline ›8 R Ticar/K Clay (a) 64 I Tobramycin 8 R Trimeth/Sulfa 2/38 R
= E,s--..eobole
":4.4-t: = No: Repor:•:c: STal, -di.t.t.a •,cr a..a:toc,.e .:, 7,q,...,; -•::: .:,-:.., ¦ Sh!,,, . :‘,,,,.: . Irterr,ectate
,
t Nrint res:et:
E SHE = F•tecrtec specst..c= .:e:a- ao:.?., ase
p = Tr.71,11,:e-o.-.:A•• .:e•:: stw,A; 8:ac = 13=.,a--ar.ra:rase pos., ..

., Pes s:ance -F r,
P.-.1D = .r-.;:p•I: :moll;
= Res s:ent at..e to e....enctee sttectr,rn nera•tac:otnases
S-scec:e ESSE Conitrgsator., rests tteece.t c:iterer::ate E SBL from Wile! oe,„_
IS = P,cuc ble Beia-tac:ar,ase Appears n piace oi Sens:nye
spec:es -,,nown lc possess ,Cucoole ac:otnases potenuatly irtey cloy oe.cotne res:stant al; peta-iactam drugs Moc:::or.ng ol pauents pt.:nog/alter merapy .s recommence:* A,toto orneticornotnec• oeta-:ac:ain °rugs
For otocc ano CSF Isotates a beta-lactarnase rest :s recornmendec 'or Enierococcus spec:es
• .1. :•tat.,nt..cn clOSes of an ammogiyoos.oe P ae:...3.ntosa •rt paoects g-EMvlocylopeofa Or 5.:.:3 ¦ As .ofer.:lof
o: Free-too:n:5 baSecl parenteral :Jose Fut calutounte itset:1:p0; ,8es 3.11.5.; ,:t5=R. Footnote ft-A appnes TO
th.s nrug
sPectococct refer :o pen.c.,i:n oterpretattons For amou: ciavulanate A.";7:C.. •-:S.,:f.,aClam win .4rIelOCOC.:: !ale, to !r,,, pen,:: ¦ ; ,

F -Pc 7..:e:a-tactatcase proo,cog enterococc: ',ger :o :re :ntepretai.oc 'a: atso
potnis are caseo
NCCIS Mlf)C•S::: Jan 20G2 Soa:t:o.tac:n Oar G:ae: Plegao,e :sotatest at=o 'coulioxac.:, at cased ott FDA ,ior,,o,ic
S _ celota..^re Lettua.one oreoi.ao.r:s oaseC ,scAates •nerancil* F .sr non-mentogets :nfecuons 2=S 2=1 t2=R s
Name: Specimen• W139 Status: Final Patient ID
-Source: Wound/Sterile site Collected:
L
Ward/Rm• Ward of Is° Req. Phys.
printed 11/23/2003 9 48 35 AM Page 1 of 1 Tech:
MEDCOM -24032
EEOVZ - 1A100C131/1

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Name: pecimen: W139 Status: Final
Patient ID: Source: Wound/Sterile site Collected:
Ward/Rm: W1/ Ward of lso: Attd. Phys:
1 Klebsiella oxytoca Status: Final
1 K. oxytoca
Drug MIC Interps MIC Inter
Amox/K Clay (c) 16/8 I
Amp/Sulbactam (c) 16/8 R
Ampicillin 16 R
Aztreonam =8 S
Cefazolin 16 R
Cefepime =8 S
Cefotaxime (c) 32 I
Cefotetan =16 S
Cefoxitin 16 I
Ceftazidime (a) =8 S
Ceftriaxone (c) 32 I
Cefuroxime (b) 16 R
Cephalothin 16 R
Chloramphenicol 16 R
Ciprofloxacin =1 S
ESBL-a Scrn 4
ESBL-b Scrn 1
Gatifloxacin =2 S
Gentamicin 8 R
lmipenem (c) =4 S
Levofloxacin =2 S
Meropenem (c) =4 S
Moxifloxacin =2 S
Nitrofurantoin =32
Noilloxacin =4 •
Pip/Tazo (d) =16 S
Piperacillin (a) 64 R
Tetracycline 8 R
Ticar/K Clay (a) 64 I
Tobramycin 8 R
Trimeth/Sulfa 2/38 R

= SuSCeplible N/R = Not Reported Blank = Data not available. or drug not advisable or testedintermediate = Not Tested
ESBL = Extended spectrum beta.laclamase
= Resistance TFG = Thymidine-dependent strain Blac = Eleta-faciarnase positive
MIC = mcg/m1(mg/L)
R' = Resistant due to extended spectrum beta-lactamases (ESBL)
E8L? = Suspected ESBL. Confirmatory tests needed to differentiate ES8L from other beta-lactamases
113
= Inducible Beta-lacramase. Appears in place of Sensitive with species known to possess inducible beta-lactamases: potentially they may become resistant lo all beta-lactam drugs. Monitoring of patients during/after therapy is recommended Avoid other/combined beia-lactam drugs
For blood and CSF Isolates. a bela-lactamase lest is recommended for Enterococcus species.
(a)
Use maximum doses of drug with an aminoglycoside for P aeruginosa in patients with granulocytoperua or serious infections.
(b)
Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1. 16=R). Footnote (c) applies to this drug
(c)

For streplococci refer to penicillin interpretations For amoxicillin/K clavulanale or ampicillin/sulbaciam Nvith enterococci. refer to the penicillin interpretation.
(d)
For non beta-lactamase producing enterococci, refer to the penicillin interpretation Footnote (a) also applies to this drug

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates)
and moxifloxacin are based on FDA approved breakpointsFor S. pneumontae. cefolaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis. For non.meningtis infections. use
2=S. 2=1. 2=R
Name:
Specimen: W139
Status: Final
Patient ID: \ I
Source: Wound/Sterile site Collected: t-Ward/Rm: W1/
Ward of Iso: Req. Phys:
.raff
Printed 11/23/2003 9:48:35 AM
Page 1 of 1
Tech:
:Ca
MEDCOM 24034
-
DOD-037612

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MEDCOM - 24035
wJod ;sonbed A6olomonnAl

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MEDCOM - 24036
,••'. •
(
Microbiology Report
WININIMMINa ‘tDC2-\
Name Specimen: W174 Status: Final Patient ID Source: Wound/Stenle site Collected-
fa
VVard/R m W1/ VVard of Is° Attd. Phys:
1 K. pneumoniae 2 S. haemolyticus Drug MIC lnterps Drug 1VIC Interps Tobramycin 8
Trirneth/Sulfa 2/38
3 S. auricularis Drug MIC Inteips Drug MIC Interns Amox/K Clay (c) =4/2 Amp/Sulbactam (c) =8/4 Ampicillin 2 BLAC Azithromycin 4 Cefazolin =8 Cefepime =8 Cefotaxime (c)
=8 Ceftriaxone (c) =8 Cephalothin =8 Chloramphenicol 16 Ciprofloxacin 2 Clindamycin 2 Erythromycin 4 Gatifloxacin =2 Gentamicin
8 Imipenem (c) =4 Levofloxacin 4
Linezolid =2 Moxifloxacin =2 Nitrofurantoin 64 Norfloxacin
8 Ofloxacin 4
s-
Oxacillin 2 Penicillin 8 BLAC Rifampin 2 Synercid =1 Tetracycline
8 Trimeth/Sulfa 2/38 Vancomycin =2
NrR Nni Reo0,..7C 6;ants Lia!a -,o, avaJao.e 7•••• oo ¦ •ot atty ¦ sao•e S Susceptofe ESBL = E“er,cea soecItur, L-e:a-taztao•ase= No: Testec4,tetfoe.3ta:e
TFG Tny,t1,-;:re.3e.C,5,30er:: Bloc Beta-actamase oos.t.ye
R Res•stance
NBC = mcgimi (mg/L.
R' = Restsiant aL.e to es:ended spectrum beta-lactamases IESBL; EBL,' = Suspectea ESBL Conlirmatory tests neece0 to aferent.ate ESBL from otner oeta-lactalnases 1B = Inducible Be:a-•ac:arlase Appears m place of Sensa,e wrtn spectes Known to °assess mauc,c,e c•ra••aczamases ¦ aify oley ,ca•,• seco,,e
nc•enr L•.,:o-ac:Jtc
Mon,:ormo ,:urtno/afte• :neraoi .s 'eCOmme,cel Avc.a omeoccmcmeo oem-fac:afc
F3' z..3oa ana Csr tss wes 3 7,era.iac13,77.3.i..3 !eS, .
.izR L.,,,:•-:"•••• ,..70es ,g
7.‘ 00,7!s ras.3 7 ' 1,3Se
,O, Fot non oeta -,ac:ar."ase ;:.rocaocmg .3,71e,ocecc. •efer !t3 Ice :7,3r,C.,,,r• ir.7,3:•3012 .3: Ir•:5
Cdeai•po..-,s zasel NCCLS Mi00•512 Jan 2002 Sparflo.acm ifot Gra,- Negat,,e ¦ SC,WES a -1 -00,00.3C, a'e 5aSec on FDA acwovea oreaKoomts
S oneomonoe ze•::a.,-••:.• anti celtoaxone breakpomts are oasea on ¦ sciates f••o, 2ri

s •Io"•moo.•••,: ¦ :s ..ljet•J•ons ,se • 2.S
Name: Specimen: W174 Status: Final
kp/co
Patient ID: Source: Wound/Sterile site Collected. WardiRm: w 1! vo 0,\) Ljk Ward of Iso: Req. Phys.
Printed 12/13/2003 11.13.56 Aro Page 2 of 2 Tech: •re
MEDCOM -24037
DOD-037615
Microbiology Report
.• .

-
Name: Status: Final Patient ID: 11/111,_
Source: Wound/Sterile site Collected:
Ward/Rm: VV1/ VVard of Isol Attd. Phys:

1 Klebsiella pneumoniae Status Final
2 Staphylococcus haemolyticus Status Final
3 Staphylococcus auricularis Status Final
1 K. pneumoniae 2
S. haemolyticus
Drug MIC Interps Druq • MIC Interps
Amikacin =16

Amox/K Clay (c) 4/2
Amox/K Clay (c) =8/4

Amp/Sulbactarn (c) 16/8
Amp/Sulbactam (c) 16/8 Ampicillin

8 BLAC
Ampicillin 16 Azithromycin 4
Aztreonam

16 Cefazolin 16
Cefazolin

16 Cefepime 16
Cefepime

16 Cefotaxime (c) =8
Cefotaxime (c)

32 Ceftnaxone (c) =8
Cefotetan =16

Cephalothin 16
Cefoxitin =8

Chloramphenicol =8
Ceftazidime (a) 16

Ciprofloxacin 2
Ceftriaxone (c) 32

Clindamycin =0.5 S ,
Cefuroxime (b) 16

Erythromycin 4
Cephalothin 16

Gatifloxacin 4
Chloramphenicol 16

Gentamicin 8
Ciprofloxacin 2

Imipenem (c) 8
ESBL-a Scrn 4

Levofloxacin 4
ESBL-b Scrn 1

Linezolid =2
Gatifloxacin 4

Moxifloxacin =2
Gentamicin 8

Nitrofurantoin =32
Imipenem (c) =4

Norfloxacin 8
Levofloxacin 4

Ofloxacin 4
Meropenem (c) =4„

Oxacillin 2
Moxifloxacin 4

Penicillin 8 BLAC
Nitrofurantoin 64

Rifampin =1
Norfloxacin 8

Synercid =1
Pip/Tazo (d) =16

Tetracycline 8
Piperacillin (a) 64

Trirneth/Sulla 2/38 Tetracycline 8
Vancomycin =2 Ticar/K Clay (a) 64
B Suscepuble
= Not Reporter: Blank = Data :tor avaeaole rtr..,r; opt
= Intermechate

= Not resteo.
ESSE. = Panoel specitto- Peta-acoarre,:e• Res,stance TFC,
Thvr,orte•:sPe-Pent spa,
Blac = kA;C rncrprrnI•ingri. •
R • = Res,s:a, i•te• ;:rea.
BBL^ = • E Sat_
:a :lorerre,t: dte r_SPt. • i,;:ao,ses i8
INiponle Beta-a.:ta-ase Appears o p.a:e ol Sensarve w.ut
acta,,,se5 ::`
ve__rne oe:a•.actar,
Morktorog or pal e.r•s c:oonglalte, inerapi s recornmenceo oinerrcomo,ec

or-cr..3
For olon.r. Roc CSF is,::ates a Peia-lacarnase lest s tecominenoea tor E,terococcus spec.es
.3. Use tra..,p, Pcses ..,!n art armnoTycos,ce lot P aerpg,csa paPents rrer g•anutocytoperna •:• se.,ous ullect,orts ,b) Breakpo.nts oaseo
:at enteral Pose For ce!..roxirne axem (PO) ose (B.S. 8.16=1 t.•.3=R) Footnote • c appbes to it-os cr.rg
co For s:reotococc, •ere.• oierpretapors For amOxICOIIIK .t.:avulanate or artc:c.: ¦ ,/sulbactarn :r enterococci reler to ine pernc, • ¦ ,;e...-/eta;.pr•
la, For rton Pela•;actarnase enterococc tete, E0 :ne pento.:, :nef oretzmoo
-.3't also apt: :o :rt.s Orpg
Interpret .e preakoc.,:s ::::•;E:7: NGCLS ryt •S • 2 Jan 200:' Soar' c.rac,:l.t.-k.egaove .sorates •r.o..flo‘ac,r, Are caseo app,;rec For S p,e--tnort.ae zelotar ..st•ct cerma.one prea•po,ts 6,4: Paseo .).• .scr,ates ;7.6!
s ,,ieC;:onS -se --.7:=5 2ei -2=1.1
Name: Specimen: W174 Status. Fir-91 ..._ -7 Patient ID:
N
Source: Wound/Sterile site Collected: --' (, ¦,,, \3 , "---
firv
Ward/Rm-011 I Ward of Iso: Req. Phys ,---
Printed 12/11:2003 11 13.56 AM Page 1 of 2 Tech.
MEDCOM -24038
,------,.., ,..--
i /
Oh' q
t '-I
.______;...___ ,
a Ward; Jectton: LQICESTP.: 1 ,....,- BORA...TORY RESIJLT FORM ,\C=1-)3. I (Subject t..-.. the Privocy Act of 1974'; II . F. I i'LME. -N:
: L-i¦-•,ST, FIRST, VI. 1 1 S ' r
. i-,(c..
C.9 _______LLIVS2Y__jkPS 0e)f
_
. :fMisc. Serolou
-:f-. 04,40ag:0-f uo,akysis f,
RIEF. RANGE.
Ror PANKTE fRESULT REF. RANGE TEST I RELI.L___
.....71EST i RFSLIL 224 6,--1 ...-.....-.--f RPP, 1 1.Jeeative —
Mono I Nerpativc
Negative Microbiology
, Negative Source .
•
CL.
Ne2.ative
PI
Q(Lf.f L3 f = H. pylori 'Negative
iS
•na N/A . Micro
Parasites

1.1..
! Negative
Se: :ft '1'1. Prot Malaria
Ba; Urob . & P
Lyr Nit Negative Other
Atyp Imm Negative Wicroscopic Urina sis
Negative
REC. HCG
Morph

$pun . Li -CSF Blood Bank Fiernatocrit Sed Rate 11117ST SUBNEET SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen ABO/Rh
Coagulation Studies. .- Blood Bank Unit Cros.sinatch (MUST SUBMIT SF 518 W1TFI EVERY UNIT OF BLOOD REQUESTED) .
TEST—I RESULT 1 REF. R.4_1VGE UNIT TYPE i CROSSAL4TCH
,
D dimer 20 tigimi
F DP 10 ugimt
•
REMARKS:
.
REPORTE1) BY: ij DATE: I,A11 ID NO.:
MEDCOM - 24039

u- -

1-\\cdiSection: l' EQUEST J.,.A.BOIUTORY ii:ESU LT 1-q)R.ZA ,,;I
-
(St]; eel to the Pr ivae-y-Aid. of 197.1) il
C/tAl 1 1 ‘ ._ , , .
i_____
i 1 Ly111 . 1 s-s7-,,,§E.77--,0 .'"' -
LAST, FIRST., .1s.-11. ;
\;-11
......- t6 No\J -A._r____L..._
__.,1326
(Refloat-AM „...) CPC • -Vrinaly-sis . „Misc.. ScrolagT-
I!ii .
771.
TEST fI RESET' ..: RANGE lEST RESULT REF. RAi‘IGE TEST RE.SLi.f," REF. RAA-rG.1:.
WA R PR I .Netzutiv-,.,
----Col0 —
:NBC _ - -i App . NIA l'.viono ; Negali7e. 1
,..--.-- .
__ __ -..... rt-G iu Negative . ilyfiCrobloiagy
,
. _, Bili Neg,ative Source '
:•-•:.-,...----7.-: K.et lic-sative Gram
i
Stain
_- , 1
NIA Occ Bld ; Nz:::ative
__, SG
1
_ ,- I --
_ i
:•
Negative II. pylori Iegat-ii.-c
Bld
::..,-, , .
1:9.. :r., pH N/A Micro
– .,_._'-., , 12--:-.:1-- Parasites
•:•:-1.0'71:S.1L. _ ,
4.A. Prot Negative Malaria _ , _ , ,
Urob 0.2-1.0 0 & P
Nit Negative Other -
Leuk Negative .1%ficioscopie Urinalysis
Negative
R BC HCG Morph
Spun Hematocrit [---1 42 -.52% iM) 37--17°, (F) ,, . -. - CSF • . .fflood. Bank .. –4
Sed Rate Cell MUST SUBMIT SF 518 WITII
Count EVERY UNIT REQUESTED
Other Directigen Li ' ii Neszative ABO/Rh .
Coagulation:Studies. -- . ..-. Blood Bank Unit Croismatch - ; - 7.-. ..._. . ...T.:
. (MUST. SUBNIIT SF 518 WI-TH EVERY UNIT OF BLOOD .
. . . - . •1.- REQUESTED) , -
TEST RESULT' 1 REF RA_AIGE UNIT TYPE CROSSAL4TCH
PT iI 9.8-13.6 sec-s
AlY1-1. : 21 34 secs

D dime; : -20 tigimi
i
i
1 F DP ' i -'..i 0 uirm ,
1
L___ . .....__. _ _
REMARKS: .
_ _i
f. DATE: A P. ED NO.:. \ tA/01/0-.
MEDCOM - 24040

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Medical Report: 14-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound

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