Medical Report: 18-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound to Chest and Abdomen

-L.
U_ RECORD-SUPPLEMENTAL MEDI!IATA
For use of this see AR 40-66; the proponent agency is the Office .e Surgeon General.
REPORT TITLE OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET ^IICI = QA A r 8 Mar 89
-
SHIFT ASS
TIME:)Q(-73Zc INITIALS TIME: • ' INITIALS:
PUPILS -c---,--,-. -)r-7?k2-3 PC, OZ l
t SENSORIUM -1 v-zo c Nrspay,ds---1C. Cd-,4-,,,,,,-) /1--ci- 0 ,k 7
R EXTREMITY MOVEMENT 4.-4i,r,a yv:k.4.7t.1 1_t..t)E i.,..--.b ..--ez-440 16 vies¦ c4) 41--7.44t 1-(

),._e
0 SEDATION

YrN-D 14. . A / ) ,(. if J'.ni.-‘--en, • ,-) '---c)",-------- -671.e.,,, 1,--11
r­
.'* PAIN CONTROL
u-k. 0 kic„,, 4-g,i4re-rA4-/
R RESPIRATORY PATTERN Biz, -,...*:J.e ck 4---(V -4--1-',,U ,
/ It
BREATH SOUNDS C./1.-P,56* 1 C.709 bAGA--

cLT2LKz.ka."
S
SECRETIONS & %-e...(AL
—rA. \
02 SOURCE/FLOW/SA02 7ri - () ss---- ,-) vit, &D-a
VENTILATOR SETTINGS

C CARDIAC RHYTHM 5,S. LI,,... 1--C ill z.3 sec
V CAPILLARY REFILL ..-i-,,2 .,)74 51 S z 6f7-eal. °

e),irw,IbL".. =',..eix,-/,..,.z___,„, ',--,--.,„ • c3 5-e-c_
PULSES
-. i
EDEMA O
ABDOMEN
SI, 4, A'. - # ...4 r-,z, - „ka C- -, _ :Igo
Ir‘ inimkrwom
e sonimagminow
BOWEL SOUNDS
.0-.• - _. halLie....4.2_ -I
BOWEL MOVEMENT
';. ir./..z--, ..-
NGT/OGT
TUBE FEDDINGS
DRAINS

-V\ /per vo r 2;4 )--A. S,,,rv-t }:2--,1-ec) ,4-54COLOR/CLARITY
17,Lle fet,1) o•-\--
94, --1.4 0-.'._:_,.----7,1.-- •••
-COLOR
.1,..1 ET
--b 's ti) 12:x-A i F-1e- ‘5 )rs- /7, 6) 6A-67-.
INTEGRITY
IA-Pis \QA\,,,-; /• z?-ji 4,7cLe, 6 e-cce f 3-
#1 TYPE/LOCATION/SIZE 2 c2634 Fop.e.o....c-yr-N. 14-/ t-C3 6 F9 6
DRESSING CONDITION V, q„1„s2,-,.-1— -L„) 1,5)...,,

A 0 V5
IV FLUID/RATE .62 f (ilk-?rwr, 0-,Ar [rte,
#2 TYPE/LOCATION/SIZE ­DRESSING CONDITION
IV FLUIDS/RATE

IC
DOC DAIIIMOVallill....1111111M - - - - - - - - - - — -/ .
EL) (0v 2-ICU #1 ATE
!to
PATIE
or written entries give: Name -last, first, middle_ • date; hospital or medical facility)
NAME ( (6),...1 RANK: AGE: . HISTORY/PHYSICAL . FLOW CHART
CI OTHER EXAMINATION . OTHER (Specify)
UNIT:
r1 GENDER: (rti OR EVALUATION
. DIAGNOSTIC STUDIES
STATUS: US: AD / CIV IRAQI: CIV / EPW
TREATMENT
DA FORM 4700, MAY 78 MEDCOM - 17041
USAPPC V2.00
VOIDING DOD-030630
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11111111111111111111558

1111111111:11111111111111131111111111111118

111111111110 011ed111111121111111111m.
INEEnitgininiilinuom EmloN

11111111111111111111111111111111111E11111
111111111111111 11111P111111111111!
1011111111111111
1
1
1
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1111111111111V 11111P1905111113

1)1111111121,11"1"
MEDCOM 7042
-weN

TIME 24 01 ;03 04 05 06 07 ..7 08 ,10 11 12 13 14 15
BP Arterial line

rZrMrMgaWAMillVgiWZFIIIIr 1%'' 3 i%
3
Temperature
91, 37girs 1?-19
Pulse

a'J g6 .r) Rf gq" qt qq qoqi, 10)%5 0 4/ (
Respiratory Rate

a (),,) (-)6 JS" zc -Y( -tA '1-,19 74) 1 2-6c, ()a 9n, gro KX,9s74", Thro q 3 q 5-10 1, 1/ •=1 -7 11 41 els'. 1-1 a !ski A6(4 fli KA RP RA £4 Rfi' M RA 20 ltA IA' ILA M
TIME 24 0 02 03 04 05 06 8°T 08
1 07 09 10 11 12 13 14 15 ,D5 ft)saxk lao 1)0 4,10 Idb kio 1)0 1,o 1 --P r7,0 pv.1v P13 so
ms6
)

10 tD

TOTALS
lq97';11
TOTAL

HOUR /5,10 (9/ 7
URINE
SR gr
S/A
OUTPUT
NG PH
GUIAC

EMESIS
STOOL
DRAINS
••¦•••¦¦¦=11.1,

TOTALS
MEDCOM — 17043

DOD-030632

PAGE 3 OF 4

POST-OP DAY
ACUITY LEVEL CLASSIFICATION z----
6( -1* 7.1

][ ,v9 TIME
MODE
11% ttli; :4

1.1+.)74.
Fio 2
0

TV
qY c13 1q 613 RATE
13 lti H'1 j(-0 PEEP
pH

ig ch, 9 e3 oiq
PCO 2
M 14-M PA
p0 2 B HCO3
SAT
G
BASE TIME
CLUCOSE
0

074 -P7/15 Na/K V
CVCO 2

0.0 11 0 120 1J-0 i2/9 120
Ana
BUN/Cr

rte/%I/III
WBC/PLATELET

3 Y 4 '1 L1 41`

ArArasimaim

its 10 40 HcVHgb
vvr-vs.
5E7
Y. TIME MOUTH CARE BATCH SKIN CARE T U R N TIME
FOLEY CARE TRACH CARE S U C
ROM EXERCISES WT Yesterday wi Today 0 N 0160
IV INTAKE OUTPUT Urine:
Po
TOTAL TOTAL BALANCE
MEDCOM - 17044

DOD-030633

M ,L RECORD-SUPPLEMENTAL MEDICIATA
For use of this . ., see AR 40-&6; the proponent agency is the Office Surgeon General.
c.acn114
I
OTSG APPROVED (Date)REPORT TITLE

INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
SHIFT ASSESS

TIME: Cbc,01(7) INITIALS: TIME f0 INITIAL
• N PUPILS .Siertry) p2.es.1_,14 , ruacts,7 --)10;„ .3 ",7,,-, errm SENSORIUM ri-)rn irn 0 rvis -1---e-AlcareS n-e-Fac --kg ow /.70,-yroya ryis-
R EXTREMITY MOVEMENT & A , II ... _ 1 ti at_ e 5.IA•-o ." e e/a: . S EDATION ...„
Co P-Orn af-fn _ TO ce.4.-F-iv..4150,1 Ni ?p //1 dry r r PAIN CONTROL +-pcfc ff;e4 ci1/47C, pc..iii Cal-V1 _2( ---0( c 0 It d-pere'e;vet' 4 -/ion ft­
or ilaiii 4/

RESPIRATORY PATTERN 1212..g i ytf,A 0, (-44,tal) riles-Fri. s-e. RAO
BREATH SOUNDS

(7114 --f-hoAAltivvii-eka,r-iiiia7/-
SECRETIONS
02 SOURCE/FLOW/SA02 _.--
VENTILATOR SETTINGS ---

C CARDIAC RHYTHM se -6 a) -ec ;Ty 4-ig_I
Cap rY 11 5A -A9 eceyb/y lid Ige.

V CAPILLARY REFILL
-(. -3-, +. Pt;..tS011 in a11 -tlo- 5 P Ca/4 Plii/G 3.s,w.c,PULSES raflial -i-N hqui ()din ,. 0 d it #.4 V -il a / ,,, ,.. 4 EDEMA
bfri +3 -+99 40,1;-,--,-,2.-:
G ABDOMEN
f-,QS-1,-) nom-order Sari"-/loci i -r7e'r*.
I BOWEL SOUNDS
0 lir‘ ail 14 CivardifAiTtS + A al/ 4t 74ia...is
BOWEL MOVEMENT
0 od-ed - /Iota
NGT/OGT
TUBE FEDDINGS
DRAINS

C VOIDING
Ikrie10, I -t -Girbfri 4. /
U COLOR/CLARITY
S COLOR
X44 01:41opt -arm, OrArrn 14 .s1.4 !I gx-1);Arg3 v -1,--Ar-,,,,
K INTEGRITY
¦ .. • ti. t. BIM -.c.*II i Q/G1..-4
I
N
A #1 TYPE/LOCATION/SIZE
-k-i \ v-1 e j i

th leg . LI• sI•I'I-I 4,,,iiimiri'r.d 4-
C DRESSING CONDITION pil.,t -,4ies i.,..yeI I.I
•

C IV FLUID/RATE
/---/aq A ,g 1,-1/e/

S #2 TYPE/LOCATION/SIZE
S
DRESSING CONDITION
S
IV FLUIDS/RATE
.._ (conti.augai ,GRED B Y (Signature & Title) ARTMENTISERVICE/CLINIC
ICU #1 ,

PATIENT'S IDENTIFICATION (For typed or written entries give. Name —last,
firs t, middle; gr de; date; hospital r medical facility)

. HISTORY/PHYSICAL . FLOW CHART

NAME: RANK: AGE:
. OTHER EXAMINATION . OTHER !Specify)
UNIT: GENDER: OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

STATUS: US: AD / CIV IRAQI: CIV EPW
DA FORM 4700, MAY 78
MEDCOM - 17045
USAPPC V2.00

DOD-030634
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„,
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CD

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.
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Ili' r
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111111 III g 111
1 -91111111111 1111111 vz

Ili 1111112111
. gill 111111111g '

MN IMO gill
INN 111111g

1111 III gll
Ball 13111551_8

HIM 111111
11111112
I 11

1 I 11E11
11E118
MN

11111111111111111111
1 11 MIME ?
ill 111211
1113111N111
-1 1111 ;,

III INN"
1 E1111 1111111113

III EMI
MINI 111111111 8 0

111111111111111110 -ti

VI 74111

III MIEN
NM 11111111/ I 10 II MYNAS
1111 1111111 II II% 2E11 '3113111112

1 1E111 1111111111

111 Id41111
I 6311 111111g

fill III tgil
11111111

MIMI IMMO II 1 111
1121111

1111 INN 11 I 1111
111111111

III 111.121 11M1 I 111
a

111111111

1111111 111.131101411 II gll
111111

MI MINA IIIIIIII all
I 1111 MIAMI O

III 11112 a
I Ell 111111

III 11111111M1
I T-111 111111153

III 1111
1111111

Ink LIMI I 111
III
NI EU __".._ i i'VAID MILO

MEDCOM - 17046

PAGE 1 OF 4
MED/CAL RECORD—SUPPLEMENTAL MEDICAL. DATA
For use of this form, see AA 441-66; the proponent agency is the Office of The Surgeon Genera&
Rapowrnms
INTENSIVE CARE NURSING FLOWSHEET (L. ---------4AArLpr Mar OTSG APPROVED (Date)
s
TIME 0 lob ',gnats TIALS
PUPILS
SENSORIUM •

RESPIRATORY PATTERN

S. BREATH SOUNDS SECRETIONS
.1; COLOR INTEGRITY
LOCATION CONDITION
ABDOMEN
BOWEL SOUNDS

• NI
URINE:

eigkr.kr 142161
COLOR/CLARITY

etroaKiN3 vig A/eu (Gut Jeti
CARDIAC RHYTHM

FIR -.
BP-13%1

. •

/'((^.,-1. •
•eegr(
QnQ

:C.
• (matinee* ICP. huracransal Press•re VA • Fractional
F,o2 - F racuon of IftWed 02 PCO2 • Pressure of Arsenal CO2 SAT • Saturation PEEP.
Penitove End E Ipratoey Pressure R401 • I racheostorny
(Continue on reverse)
DEPARTMENT/SERVICE/CUNIC
DATE e (
or written e

grade: date: hnspita s give: Name—Last. jv,t,
vr medical facility)
. HISTORY/PHYSICAL . FLOW CHART
0 OTHER EXAMINATION
. OTHER (Specify.)
OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

MEDCOM - 17047

TNA FORM A "f A A
DOD-030636

PAGE I OF 4
MEDICAL RECORD—SUFILEMENTAL MEDICAL DATA
For use OS this corm, see AR 40-66; the proponent agency is the Office of The Surgeon General.

REPoRT TITLE OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET
A Appy 81Vlar 89
TIME 0.760
PUPILS SENSORIUM
.•

. i,;,,: : •
.- RESPIRATORY PATTER N

S.' BREATH SOUNDS
Di'
I.::: SECRETIONS
frf;

COLOR
INTEGRITY
LOCATION CONDITION
ABDOMEN BOWEL SOUNDS

3
URINE:

COLOR/CLARITY
CARDIAC RHYTHM

••:
•
Ev
A...
0
••ff• •,.'
•
e: grade: date: hospi

DA , r4700
,2778
PeeTLL

A$ 0Ie
rytnye by% e ,. 4 i 0 A I I ad- _ 1)
C

Rk_ Qs
SPQz • lit%
a ML.i.viirlIneei EA -irk

r.r}^ po rt

prnriLit.l.tv Cotizi k 55 r CTA (h) fi te6es i.auzere()
AJoi-ww..1Ipn to _Op.A1 Wow ...A .6 AA, 8ttrst "7"-(49. I
Gt.rely-te., 670?
rr

4 Also 9 csd Ree../1„
• .
cry'
—

NOnenu 441,,e
Cites y eJI r.,
vier

etkvi4,4
Cr - CseatImne F,02 - Fracuonol Isnpred 02 sc03 • Eir..Irtort.ine
derfACS
-
/CD -intracraniat Presyme PCO? -Pressure of Armful& CO2 E P Poutore End EnUratOry PreSSure
C
DEPARTMENT/SERVICE/CLINIC
Jly
--""
(gtT • I 'Nn IAL
Pertik., Pt-
t
n.1

CA) 1,..,"-L9k
x ASt,
,
LA • PreCtiorud SA1 • Uniurotgn IRACri • I racheOstorny
(Continue on reoerse)
DATE

/7 S.V1,.3

medlar, tentreit)sgtue(3);ariie—Last. first.
Y)I
.
HISTORY/PHYSICAL . FLOW CHART

.
OTHER EXAMINATION

. OTHER (Specify) OR EVALUATION
O DIAGNOSTIC STUDIES
. TREATMENT
MEDCOM - 17048 WAMC OP 375 (Redesignated)

DOD-030637
PAGE 21
DATE
S 03 ox /e HOSPITAL DAY TIME O6
07

8P Arterial Line
BP Cuff

s

iU 5r Ifiriffi llIIIIMEIESWEIILIMM
Temperature
Pulse

It 113 t t 0Y 1 •
Respiratory Rate
is Z5 ah ;17 ,04 05 al d,-7 2( 17% Nrb Wen 4117,,
HRA AigA
w44-
TIME

oG 02 0? /0 iz a 8° T tti is 7
6o

_56 50 So 50 50 I50 50 50 SG g g Yz SO /Co foo 100 la foo MO /00 IOC tc0 100
TOTALS
410

1104.1A
TOT AL
URINE

NG
GulAt
EMESIS
STOOL •

DRAINS
TOTALS
•rr
MEDCOM - 17049

DOD-030638
POST.O. DAY 2 5 O t.) ô L Cr, 0 AGM aye( tlASSIRCATION PAGE 3O
AV rtr 16-7 17 ? TO 14 3 P A in. j-r, Ac" 2.‘f 0( Ds. , 77 IX fl 534-41 ANA-witer '7 MODE F, TV RATE PEEP PH
A PCO2
Po2
B HCO3
SAT
G BASE

8°T ANWIPAMil

IMPAINIMIPSIMIM
KIPAPILMI/M11111

HcVHgb

PAPP" KINIELPSEPA
TIME
MOUTH CARE
BATH
SKIN CARE
FOLEY CARE
TRACH CARE

V
ROM EXERCISES
24•18,0 Trir45 :*:
E
U
R
N
S
U
C
0 NURSVS SGNATURE .:.

Dt/TIALS
PAGE 1 OF 4

MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General REPORT TITLE
n3 4.)
OTSG APPROVED (Date)

rtirTK:Ns.lyE rcAFLE raiRsiNAkt 8bei
`owSHELT-N! I
QA Appr 8 Mar 89 IN1IASSESS-MEN 4MOMPgmaMMW

TIME INITIAL INITIAL',
INIT IALS
RESPIRATORY PATTERN
BREATH SOUNDS
SECRETIONS
COLOR
INTEGRITY
CATTIgNIr
CONDITION

ABDOMEN
BOWEL SOUNDS
URINE:
COLOR/CLARITY

CARDIAC RHYTHM

PtiON Cr - Creatinine
ICP - intracranial Pressure WA • Fractional E102 - Fraction of inspired 02
PCO? -Pressure of Arterial CO2 SA1 - Satuiation

HCO3 • Bicarbonate PEEP -Positive End Expiratory Pressure 'MACH - Tracheostomy
(Continue on reverse)

PREPA DEPARTMENT/SERVICE/CUNIC DATE 1,,0-1552T3
PATIENT'S Ir NTIP A V entries give: Name—last, •st,

middle; grade; date; hospita or medical facility)
.
HISTORY/PHYSICAL O FLOW CHART

.
OTHER EXAMINATION

. OTHER (Specify)
OR EVALUATION

111111k46}J1
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA , IF¦PAIYM78 4700
MEDCOM - 17051 EDDAC Flag OP 375, 1 Apr 90 (HSXC—NU)

Proponent: Dept of Nurs
DOD-030640

DATE py
HOSPITAL DAV
TIME

mars= to )/ UMICJILIMIIISMIEMEN
BP Arterial Line

11111111111111111MOMMIN 11111.P11.11111111 MI=
BP Cuff
IIIIKINIZAMIVMMEIIMIRENIEMIMMOW
Temperature

MEI 9'),. NM Mai 1.011111111111=11111 Ill
Pulse

EIREEBNIVEIMBIIIIIIMITZL63 toirlayAil) Ma
Respiratory Rate
111111MINMEMIN EEMEN ..WMIIIMINEIMININIIIMMINISEIMMILIDEI ELIENIGLICIMIDAND1

1111111MEMMISIPAIM1 ITIIIMEIZEThileM t'L4 Fa
k

mu mum

-

II I I
ffilMrS1I
EME11131;111111CIPVEM

TOTALS
EMESIS STOOL
DRAINS
TOTALS
MEDCOM - 17052

DOD-030641
*wire LEVEL CiASSITKAIION

11111111111111•11111111.111111
RITORMANWION
IIIIIIIIIIIIIIIIII
EIMDEMElivilmffeam
IMMENIVIUM
MITAIEE "-AWE=

1111111111111M111111 ¦1111111111
B HCO3

I Ri¦
SAT
ll II I

Id 1•
6 BASE
GLUCOSE

ElE1 MEM
Nummumil
BUN/Cr

FAMINIMPRI
WBC/PLATELET
MOUTH CARE
SKIN CARE FOLEY CARE
TRACH CARE
ROM EXERCISES
WITIALS
wt Yesterday
INTAKE
OUTPUT Urine:
TOTAL
TOTAL BALANCE
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA

For use of this form. see AR 90-66: the proponent agency rs the Office of The Surgeon General.
REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet
I----..„ Date:I9/15S Anesthesia Type (CircJe)GeneraL5pinal Epidural Time In:I1705I IV Sedation Nerve Block Allergies:IPCMIOR Intake: CrystalloidI500 Colloid Pre-op V/S:I1 1-14/1.9I3SIOR Output: UOPIpSIEBLIAl Procedures:II iiiIlift av AriIMeds/Times:
Pre Op Meds History
OTSG APPROVED wire/
Drains
Hemovac NG .IJP T-tube Foley TLS
Airway
Nasal Oral ETT
Trach Other
Time .
4
)0 ,
.522
:u Intake

Sa02 Time Solution AmouM Site -By
Qtr 94, 57 V Infused
to
Fi02 Methods fiN Rei yet zi_ot 240
220 X I . Labs:

• Post-Anesthesia Recoveryiscore 200 C ADM 30'I
DIC Codes
Activity

AIRWAY 180 (1) Moves 2 Extremities A = Ambu
(2 ) Moves 4 Extremities
(0) Moves 0 Extremibes BB = Blow-by M — Mask
Ainvay
160 FT =Face
(2 ) Cough. Deep breath

V (1) Dyspnea broiled breathing Tent (0 Apnea RA = RoomAir
140 NC = Nasal
Bl ood Pressure
Cannula

(2 ) SBP =/- 20 of Pre-op 120 V V v (1 SBP =I-211-50 of Pre-op
(0) SBP 4- 50 of Pre-op WS X = A-line BP
C onsciousness
(2) Fully Awalce, audible
Cuff BP
-=
/6
c6

4 king
• . (1) Arousable to verbal or pain
Pulse
=
TEMP

A Color
S =Skim

(2) Baseline color 1S appearance 60 A A A 0 =Oral
(I)
pale, mottled. jaundiced

(0)
Cyanotic A = Axillary

T a Tympanic 40
circulation (Peds 5 Years)
R a Rectal
(2) radial Pulse Palpable
(1)
Axillary palpable. not radial

LOS.
C = Cervical

(0)
Carotid only reliable pulse

20
TOTALS: Must be 9 or
T = Thoracic
greater to 0/C. otherwise

RR L = Lumbar
(00 10 13, needs anesthesia approval for T
S = Sacral
WC,
949 Time

Patient teaching done: Wound Care. Pain Management. Pain (0-10)
T. C. & DR.. Incentive Spirometer, Comfort Measures LOS
Safety: SR up X 2. Falls Precautions. Privacy Maintained

11.0firmue On muse] PREPARED BY ISipnature 8 Wel . DEPARTMENTISERVICEICLINIC
DATE •
PATIENT'S IDENTIFICATION (for typed or mitten entries give: Name —last
last, middle,. grade; date: hospital or medical laeat)l 0 HISTORYIPHYSICALI III FLOW CHART
• OTHER EXAMINATION I . OTHER arar]
VA (iL.) (01 OR EVALUATION
¦ DIAGNOSTIC STUDIES
O TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
Previous edition Is obsolete USAPPC42.00
MEDCOM - 17054

DOD-030643

MEDICATIONS Allergies: NURSING NOTES Time Pain Medication 8 Route Pain
I/E By
1-10 On ane 1-10 P-1 ovri

Pthrr) nYr. Da Sats 9E% , Art0 VS3 Mc) C/O pa is .
e pov NW) 17 i

NEUROVASCULAR
Time Site Range Sensory P Cap T

Color Of
Refill Motion
Adm CArn iirndyci +
L 3 iQ plc_
(( ll a

15 L110\ I( 4, I , ¦ 30' f( (1 Ii
LAVA " ( « , 45' 60' 90'
DIC 1--leek 6; re cl 4 4" 4 3
tA) let

Movement/Sensation: + = present,- = absent
Temp:C = Cool, W =Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= S uggish
P=Pale, Pk =Pink C-SECTIONS ____.—.---"
Adm 15 30' 45' 50*------10' DIC
Fund. Height .----------
Lochia

Peripad# ,—,/-
Fund. Co' .......--
DRESSINGS Time Location Type Drainage
L. icy r ex.c: y-/ate baKbq
Adm C Iri I
i

30' ‘..( i f %-
I__ f2 r'/' yry,
60'
DiC L Pqw._ e.-xf' y./ace lathic,4• Cjal ,
PACU OUTPUT Time Source •
Color/Appearance
Amount

CARDIAC RHYTHM
Time 11 0 -S Rhythm WS ( Symptomatic? 9i Rhythm Strip Run? G")

Discharge Criteria: Date: 9M Time:174 BP: X514/1 T:' 7. 9 HR:
Pain Level at ID/C (0-10):
Intake: t DLib ez Additional ata: Transferred To: C Report Given To:
%
PARS: /0
3
I RR: Sa02: 9`Z
l?f
Output:
Transferred Via:/C
Ambulance
Transferred By: It-
Claarari III1Af Reco ry
oom SOP 13-3
MEDCO VI -17055
Signature:

weur AD 171.P
I -

DOD-030644

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

For we al this torn, me AR 4066; the proponent agency is the Mire of The Surgeon General
USG APPROVED MareREPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet I
41.1¦11.11•1••••1¦11¦41,

--—q. ,\.q
Dale: Anesthesia Type (Circle)): General Spinal Epidural Drains Ain.ja Time In: Lc."-=I5-IV Sedation Nerve Block Hemovac Nasal Allergies: k) kiVN , OR Intake: Crystalloid Colloid NG Oral Pre-op VIS: OR Output: UOP EBL JP ETT Procedures: Meets/Times: • T-tube Trach
Foley
Other TLS

Pre Op Meds History
Hfi
c.,-
'6.
ri
4)

Time 04) e
k,
Pacu Intake
._

,
Time Solution Amount Site -By Infused

Sa02 Lam ccr, ct-wri..te et
F102
..-t--S
....t.-3-73c
Methods

240
220 X-rays: . Labs:
Post-Anesthesia Recoveryscore 200 Cr ADM 30' DIC Codes Activity
AIRWAY
(2) Moves 4 Extremities
A =Ambu
(1)
Moves 2 Extremities

(0)
Moves 0 Extremities BB= Blow-by M = Mask

180
Air

160 \../ FT = Face
(2) Cough. Deep breath
Tent
(1) Dyspnea fimited breathing

(0) Apnea • RA = RoomAir 140
NC = Nasal
Blood Pressure
Cannula
(2) of Pre-op
V V

120 (1) SDP =/- 20-50 of Pre-op
(0) SDP =A 50 of Pre-op VIS

' X =A-line BP
ti.

• Consdousness
100 ' = Cuff BP
•
(2) Fully Awake, audible
= Pulse

clYinfi
ti (1) ;Unusable to verbal or pain

80
TEMP

1N 11 color
S-Skin
(2) Baseline *sear A appearance
0= Oral

60 (1) pale, mottled, jaundiced
A 11 A = Axillary
(0) Cyanotic
T = Tympanic Circulation (Peds 5 Years)

40 R= Rectal
(2)
radial Pulse Palpable

(1)
Axillary palpable, not radial

LOS
(0) Carotid only reliable pulse
20
C = Cervical TOTALS: Must be 9 or
T = Thoracic
greater to 0/C. otherwise
L = Lumbar

RR 2. 321, ,,K3=1 •U needs anesthesia approval for
S = Sacral

0/C,
T

Time ¦ln;--112c. 040 Patient teaching done: Wound Care, Pain Management.
Pain (0-10) L! A-•--.7r11 alb T, C, & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained

!Continue On reveliii7

PREPARED BY/ DEPARTMENTISERVICEICLINIC DATE
pA 9 19`

PAM or typed or written entries give: Name —last, first, middle; grade: date: hospital or medical fadityl
.
HISTORYIPHYSICAL ORM CHART

.
OTHER EXAMINATION . OTHER dowirt OR EVALUATION

.
DIAGNOSTIC STUDIES

TREATMENT
.

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPVC 01.00
MEDCOM - 17056

DOD-030645
Allergies: f' Time Pain 1-10
(K)o ,--it-
¦ kko -7711-mo
"-v-A

kk 'Ace 0tA ‘1t0 • .._
-TON,,,... Site
.•
.•

Adm
15
30'
45'
60'
90'
D/C

MEDICATIONS

. Medication & Route Pain I/E ByDrmarie
1-10
Q. ,,,,cp,t1\ • \./ -Y-t
c.,
Q , st--t-4:r v 0M-c'k\'

2,ritle(z,,,„ / ...\/ -) 71---
;14--%.cloez,c-'ve.-k‹34 -6Pc„4,--ss\NaLA
NEUROVASCULAR Range Sensory P Cap T Color Of
Refill
Motion

`--...,,,

Movement/Sensation: + = present.- = absent Temp:C =
W - Warm Pulses: P= Palpable, 0 = Doppler, A = Absent Color: C = Cyanotic.
Capillary Refill: B = Brisk, S = Sluggish
P.= Pale, Pk =Pink C-SECTIONS Adm 15' 30' 45' 60'
90' D/S_.„

Fund. Height Lochia Petipad# Fund. Cond.
Time
Adm
30' ./ D/C
Time
WAMC OP 173-E
DRESSINGS Location Type

¦ ....-44.d' ...I-. Cki-. . ...-\NA.", a ,
NIMMII
I
PACU OUTPUT

Source Color/Appearance c\f‘.4
CARDIAC RHYTHM
_
Drainage
.4.

a NM
Amount
k,?,nrc

R-4.111n1 Symptomatic? Rhythm Strip Run?
MEDCO
NURSING NOTES
p-61-ti•-k.

t5( t' risre PR,
l.cock.ct
t
-
c

t4.
rcqsk C cl r-kc--9 ?..cz.(0,4‘ N c5eck-6,-,LLQ3 Pat (0,147,,1w1)
.
;) 1s, 5, '1-Z. (4--k-,c4Loi0
q-mti..-c42Ackc-IrZ21 (ao
- 4
4:1:. .1..¦_JM
ce-aS rE) s,
Discharge Criteria:
Date:ct kms( Time: I Z \ C
PARS: BP: L HR: q'7 RR: 8 Pain Level at DIC (0-10): Intake:
Output: CC Additional Data: Transferred To: Report Given To. Transferred Via: Transferred By: Cleared JAW Recovery
M -17057 t Signature:

DOD-030646

PAGE 1 OF

MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 4D-66, the proponent agency is the Office of The Surgeon General REPORT TITLE
OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89

NI IAL':SH .FTASSESSMOM:

TIME INITIALS
115
PUPILS
Pe7z,2/-P-5m
SENSORIUM
6-7444.a
31W/Fie Co
moves itic-10
ee.rf-X L

!!irl¦ ••
RESPIRATORY PATTERN

l'14€ Ree. 9770
BREATH SOUNDS

-)444€ eA-4-elezet, erackle5 dear StiCh
... SECRETIONS
-.44

es_teutufki.)/24A+ gmyvt Track
o -tvS 5 Mel. Trackz
COLOR ,PLea-'14644,6 If* A-40-c.i. ¦
Worma
INTEGRITY

W711.1_72ltartsi
such-on NI/4c_. nbck

6717,i1/144-D
wc,k-Act- .fb rzsit, , •

.*• LOCATION
dot--As
CONDITION

4-L.9-se . / ca
• vs
Dg1 tf S 1 201=e1

a 5a 3
ABDOMEN
• *:] BOWEL SOUNDS .

YAI ir?
_4Zr­
rt.
URINE:
COLOR/CLARITY

CARDIAC RHYTHM

5 Io 0 Pa
itt4t.t.e..‘
f( 3 5.tc.

Cr -Creatinine
ICP • Intracranial Pressure VA • Fractional F 102- Fraction or inspired 02
PCO2 : Pressure or Arterial CO2 SA1 • Satuiation HCO3- Bicarbonate
PEEP • Positive End Expiratory Pressure 1RACH • I racheostorny
(Continue on reverse)
DEPARTMENT/SERVICE/CLINIC DATE ti? S. P° 3

inert entries
entries give: Name—lost, first, nti r, gra ; date; hospita or medical facility)
. HISTORY/PHYSICAL 111 FLOW CHART
111 OTHER EXAMINATION . OTHER (Specify) OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA ? TARA. 4700
uEDDAC FBg OP 375, 1 Apr 90 (HSXC-NU)

Proponent: Dept of Nurs ME DCOM - 17058
DOD-030647
EYESO PEN
PAGE 4 OP 4
EUROLOG1CAL ASSESSMENT;';

.:••• • • • • • • HOURS p 7 LEGEND
94( bi to I i
WON IANIOuSLY C Closed by swelling
TO SPEECH 3
10 PAIN 2

NO EVE OPENING

T TrachiEndu
°HIEN I EDQu S Slurring
CONFUSED

D Dysphasia
vEHBALIZES 3

a.
¦--`" R Receptive
vOCALIZES

E Expressive
NO VOCAL itA TION I
OBEYS
COMMANDS
LOCALIZE S PAIN

mon.
PtEXION
wiTHDFLAWAL

• OZ
23. ABNORMAL
EI ESION

EX lENSiON
10 PAIN
NO MOTOR
RI SPONSE

NORMAL POWER

R Right
MILD WEAKNESS
L Left

M . SEVERE WEAKNESS

S.
ABNORMAL FLEXION

Record ABNORMAL EXTENSION separately if
bl NO RESPONSE
there is a

difference between the
NORMAL POWER

two sides. MILD WEAKNESS
E :
SEVERE WEAKNESS
ABNORMAL FLEXION
ABNORMAL EXTENSION

MINIM II MEM
NO RESPONSE

. a Brisk SIZE
RIGHT. REACTION . Slow
^ No Response
SIZE
LEFT
REACTION
ill

•2 •6 7 mm
PUPIL SCALE • 3 • 4
• Intact
ICP •

. Abnormal
CEREBRAL PERFUSION
PRESSURE
................................. ::.VASCULAR :ASSE55M LEGEND
HOURS

R . 4. Normal

WINIEMPINPOIAWAVA
. Weak

FORROWARAWANNINVIA
Absent
D Doppler

VANNINPRIVAINUNNONNON
R Right

APRIVAINKIEMPIPANNIONIN
L left

11111MON111
MEDCOM - 17059

DOD-030648

NL RECORD-SUPPLEMENTAL MEDI IATA
For use of this see AR 40-66; the proponent agency is the Office . .e Surgeon General.
REPORT TITLE OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET A Appr 8 Mar 89
• SHIFT ASSES ITIME: 0700 INITIAL TIME: /930 INkTIA
•N PUPILS Pe/PY-t..-4 iOer^c4
SENSORIUM A ,

U, Akel -0 ,./ ..,
EXTREMITY MOVEMENT A - --/
R I. ,env • d e
SEDATION .0'
• _f__, :, • ., ,d.....t., , *i--: ... •, 14,50 d•t -1 . . 4,
PAIN CONTROL / i

c.4A.-"• -"if° itisc3 j-//-601//f A.
R RESPIRATORY PATTERN ,g , i_i-nn. I 11441 e, . ge.542--on/a, dared
.E BREATH SOUNDS 4

' .04/ ' 1 _j if. .-S _±,Ljts2s/14-
S SECRETIONS ,

.., . -,..a _
P
02 SOURCE/FLOW/SAO2 i ap-74.1_ .z., _ tf / #
e, a, Y r. 1/1a.vte/ CO//may,
Afor

VENTILATOR SETTINGS / lir 01
si a 444 . , -
i

C CARDIAC RHYTHM
Se_ L0 AT s/J - ST
V
CAPILLARY REFILL
L 3 As-e-4
C 3see-

PULSES 4-3 Lvt, AP 9 20
it-P4 71-3 a// ext-rem I 17 es

EDEMA
JO

G ABDOMEN
lit ( A-)0--nnil,Lgaz ' n 017 disknete,‘
1 BOWEL SOUNDS
....

BOWEL MOVEMENT _L ,,,- ,„-,0 , ape d„7-,,n,,
NGT/OGT
" 6arI4 A: • ,,,,,_0 --'1
j U. 7,1d

TUBE FEDDJNGS
DRAINS
TF DA,*_:,)-t4 )( CI 7.`ii. (7nzrv-it i . TA dra....pis x If to la/I saehew JP aleti,frtigrom L30,0,,,,i Vezz.-6, ink.4---,-..“/otix.0 la,e to et. n It Salt/ e2
C VOIDING F.,,,,._ - . -,
_ . 'le eA,M .t., n;1-

U COLOR/CLARITY
Creeet.A 6-0-tra, dear--76,o14%
$ COLOR ,L;b244-4-‘.._Q lc, /Carr-t. /Vori4,0,/ {
-oto

INTEGRITY
,
,__:.,.... r S ......_ ___-_ ___, JI4 ., C,

1 K Pho ,t.4.74,4_,-Ile ge%4 •r14-6.4-,0e 6rs, to twe,L. a" Ae.Wisdk,
P 6e).5 ,Z/ , 6--) At I

A II I TYPE/LOCATION/SIZE
P 1 V.....; rig A/ g it.,-,7-
C DRESSING CONDITION
9,1 5 5 .9-, ,,gize..6; 0-VS Orif/ li•kelf)C IV FLUID/RATE
V5 7z_ A_Ac.',( -74'4 itC (g/MkeZkt 7JS-t, A/Cra? )¦Vsf , e,/ 43i0
#2 TYPE/LOCATION/SIZE
DRESSING CONDITION

S
IV FLUIDS/RATE
'Confine on rovorso)
—.—..--.-__...__ _
b

1,110 ICU #i, 20 56190 3
PATIENT'S I
d or written entries give: Name -last,
fir•i, middle; grade; da

I or medical facility)
NAME: . HISTORY/PHYSICAL . FLOW CHART
000 RANK: AGE:
(1')(C.)-1

. OTHER EXAMINATION . OTHER (Speedy)

UNIT:
GENDER: OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

STATUS: US: AD / CIV IRAQI: CIV / EPW
DA FORM 4700, MAY 78
MEDCOM - 17060 uSAPPC V2 00

DOD-030649

O z O m 0 -1 0 0 z co z (n0 CD Cr) X1 I M m E -0 z its
rn CO
rf O 0) ist O
O "4 • —1? .1•. •
O
co
Tz; O
4=•

IUWE

"wegeog000rl
PAGE 1 OF 4

MEC - RECORD-SUPPLEMENTAL MEDICAL Dr. -
For use of this form s 40-66; the proponent agency is The Office of T Leon General REPORT TITLE
OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET (0-2. QA Appr 8Mar 89
goommon3.5 PUPLIS -• TIME lettliet efreN) gail . .. AVVIIET40.0301ERTW tei .atk / 9C,c) [ INall-I INTILIIIIII-/ itk—,e4t NOM? ,.. . ,,,, g 1. I .,,,, INTILAS ow!
SENSOR IUM az0-146. a492,-0, ki e,,,,, ..,I. e'er: Mgt" f Pfe
',Fii i e -)i.ziege, eAiltie-up* . flej./Z7 . bcov /1, i-Aaw-dixe.4".....-4 ///4".(eA.,11-;:
:rt..,::E.:::: W: RESPIRATION PATTERN BREATH SOUNDS ,Ziefog dtp 56/5 . _i-ifl .1,- ,f_eamf..,./ 2/..e..c :::- pc( 1*-4, //' et' 4/ 1,47,i,,' c 7-A ( 4
;:r w ;.7=I:.? SECRETIONS 4-i-eked; 0 L / 62 ,--4.t 0 7S--9 7.- '•/2i e.-/ A7,oe-n !,4, 4 /1-ei", 4,,r. 'i #7 -A1-4 ,(e//vc
1:5; NC:i - 4;1- )141{-4A AeLeace ,
1.: COLOR INTEGRITY P P 4 , 4,-72„,...4 a) .tie Ili I:, kJ/A Wei 1,4, 61-6-4 11-1774,42 l ZC-ol 46/ .f/iiiwae i eb.r-vsi tri-461,i
1--e--4/2444-1.4f....tz /-.0f-G, cAd-e. g-r•ffl .2Iz cf;;:te-G¦ft, a-eta"-
LOCATION 0 a--)T---kit., rOPlit,
CONDITioN b -4 --r-? A- -4,-. 6 6 p r n e e eXlivi,.. Jr
...ry r bs-s - g 2.),k itii,Ay 'b PI: v4 -,f /5 6 ,2,--
-;;0 xi oi yie,yey,54,.
•u) , Nisar rdide.,
r­1.4.- 4-e—eit-4244,i,
ABDOMEN BOWEL SOUNDS X ok,e14...-radi.. 6 5 . dei-Texi ruAt ,-.4..e.A.4.4.4.-4 2 ,V,6( S,9Ai ,77/4Y, oclem7 Z­. 5- 0/ . /Ve1‘....#7 /9 -, Nry PL./ u-fr.z c?

URINE
1-7detZ;11= gr,7S-t--De". .0,./tecej, COLOR/CLARITY
A./Le-A-42/ e-144 pJ:7.., tz, it //it?

40 CARDIACRHYTHM /1/... -ST 71e,--:4 10 5 5, ,2. --1-: e ei gt, 5:9 wok
4:,I-, 110 5. ii&r• i' f,1 els f 4 01;eAdt
Cr •- CreatinIneI
ICP • Intracranial PressureI S/A • FractionalFr O -Fraction of inspired 02I PCO ,- PRESSURE OF ARTRIAL CO,I
LEGEND SAI • saturationF., Or BicarbonateI PEEP - Positive ens Expiratory Pressure ITRACH -Tracheostomy
ME (Continue on reverse)
PREPARED BY (Signature & Title)
DEPARTMENT/SERVICE/CINC DATE

PATIENTS INDICATIONS (For typed or written entries give: Name—Last, F rst,
middle; grade; date; hospital or medical facility) • HISTORY/PHYSICALI• FLOW CHART

. OTHER EMIN¦ OTHER (Specify)

XATIONATION &) ((:)) -1 OR EVALUA
V k)
. DIGNOSTIC STUDIES

¦ TRETMENT

UA WAMC OP 375 (Redesignated)
IMO 78
M 4700
1 APR 90 (HSXC - NU)

Proponent Dept of Nurs
MEDCOM - 17062

DOD-030651
PAGE 1 OF 4

ME . RECORD-SUPPLEMENTAL MEDICAL 1111
For use of this form . 40.66; the proponent agency is The Office of 4. geon General
REPORT TITLE

OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET QA Appr 8Mar 89
ammagga WON* ,gognreggititrACisS.t.MAssessmEWEEP-00.4-PPREMARkiiW:flbglgantRIP:0:';.:;:!:m..,-,
INTILAS

TIME . 1 I INTILAs iNTIL
18 115-j

PUPLIS
P aKL
'.

SENSORIUM
r4 k73h.i-151 ;cerikiLed -.
Moti I Iiii-hia_Ni • RespDAsNe. -+ aktaso....1018 -4?) Voice 4---4-04.ck s-ffm IL if. e

RESPIRATION PATTERN
ikct R44Z

4:::.i BREATH SOUNDS
P1 :;:,: %-)C_Ti4 -Hil-ectjimm-t-
:k SECRETIONS
: 41 11C- k Yff, &V -fi-om -1-i-iici

* F
311: ie V 41-0 CA 44 8j
..::: .

-11
its: I 045"a*s 0, 9a -I? % 0,4 --:—.
E,' COLOR
:?j /4-f-/K

-::../C, INTEGRITY
spi-e-S5r¦Jorc C.111/Z

IH.
.
'-` LOCATION tibiti (9 C.-, fsh-e.5,..1
CONDITION elnfli 0 ALIri c'14-jAefid e,IRA
K- P e 1. v t NI4),5 16 g. C..
i Xi(c/ ¢.4)1.11) 4-ffkrwa5

ABDOMEN
BOWEL SOUNDS
:.,.
: URINE
\107(0,J1 tli-Yellow fli^f AP.

COLOR/CLARITY

MR -FilYe V it) 3 I-- mil. ?4-Y
;.:

Fki 041P. (tit l'I.te PO IL ti4'

CARDIACRHYTHM
11/41MZ si a R - lea 8P /8'?/5.?

I
+) i-odta.l+hda.1 ret_izs E kgs X e of 1-0.4711. #54741 etio.inn

Cr • creadronsI ICP • Intracranial PressureI
S/A • FractionalFraction inspired PCO 2 - PRESSURE OF ARTRIAL c02°2I
LEGEND F10 -of SAI - Saturation F1 0 3 - Bicarbonate
PEEP- Positive end Expiratory Pressure TRACH - Iracheostomy

*116 6 (i,),---L.
(Continue on reverse)
F4..r.to D E PA RTME NI,SeEF:y I ci../C I N C DATI/s./.0, 03

give: Name --Last, F rst,e; gra e; a • or medical facility) • HISTORY/PHYS1CAL • FLOW CHART
./64 U OTHER EXAMINATION . OTHER (Specify)C(°.) (1)L-1 OR EVALUATION
. DIGNOSTIC STUDIES

. TRETMENT
..._ _

uA FORM
WAMC OP 375 (Redesignated)

1 MAY78 4700 Proponent Dept of Nurs 1 APR 90 (HSXC - NU)
MEDCOM - 17063

DOD-030652

DATE 2/se
HOSPITAL DAY
03

TIME 24 01 0.3 04 05 06 07

610 L 701199 /40M1
BP Arterial line

111111111111111111111111111.1111111111111110111111M
BP Cuff
Temperature

yo 111111M111111111311111111MINIMMIIII7M11
Pulse
Respiratory Rate

I
Sa0 11111111NEINIiii61111
-61111

Ifiq21111111MM 47°3
RIS

POIMIK11111111111111M 1111Pil PMEIMMINI gfr /1/1-
TIME 24 01 02 03 04 05 06 07 08 09 10
8 ° T
ouTpu,
PH
allAC

DRAINS
TOTALS
PAGE 3 OF 4

POST-OP DAY ACUITY LEVEL CLASSIFICATION
17 18 19 1 20 21 2._ -23 ,Z TIME
4-5-191A1"Yteir.'0 — tit 3 — ii?-3 (ce a6, q -vg Pa, Ws% AP all, 1441 R11 RA V pH MODE F,0 2 PEEP RATE TV PCO 2 B PO 2 HCO, -t
G SAT BASE
TIME
14 17 18 19 20 21 22 23 8 ° T CLUCOSE NaIK
DO /do /d0 1 10 CVCO 2 BUN/Cr WBC/PLATELET Hct/Hgb /V z
TIME T TIME
MOUTH CARE BATCH SKIN CARE U R N 1•••••¦••
FOLEY CARE TRACH CARE S U C
ROM EXERCISES 0 N
WT Yesterday wt Today ts43GATIr
INTAKE OUTPUT
•¦ IV Urine:
Po
TOTAL TOTAL BALANCE

MEDCOM - 17065

DOD-030654

PAGE 1 OF 4

. RECORD -SUPPLEMENTAL MEDICAL D7-For use of this form . 40-66; the proponent agency is The Office of ' ¦ geon General
REPORT TITLE OTSG APPROVED (Date
INTENSIVE CARE NURSING FLOW SHEET ,------- L._(oft. [....___ QA Appr 8 Mar 89
yiontg.wgVWIHNMNi: %' ..'4: 4:aRBOWS
*V: atgrfrr''

TIME ,
PUPLIS

SENSORIUM

c
RESPIRATION PATTER N
Si; BREATH SOUNDS
SECRETIONS

:',O.:::: AFC
COLOR
INTEGRITY

LOCATION
CONDITION
,,.
‹..,:.
ABDOMEN
• ..,,,::
I BOWEL SOUNDS
W
ir

URINE
COLOR/CLARITY

,, CARDIACRHYTHM
V: 1: " .f
i
PR
PATIE
middle; grade; date; hospital or
8 PA)

DA FORM 4700
1 MAY713
Proponent Dept of Nurs

0 5177) I INTILAs ,091W
Jzz.44,-marire 4.mt.6.4.41"..., IfiaB
W.7.4,-....91..,
1207 ,/ef/
tiogie
Q

Ga-fit4-Aei
4- (t...e
•izz..4.
4...€

ttlX14 2aa-ear4 pir-rp-0-4 4.1.-", i.e„.-...x . .L.r_.....e.,
(16 a-Y-4(A-,
4- .J.-

exit,--....". 4..,z,&„
dc-14.0-si .455 7-p-ce.../.9a6.e.lett....-
1.,

a.....----..- i..-4..,Le...,
Wig la 7D 5 -5i:4AV iS
5% 5'2 deo ,t-e-credize-/v
Cr •• Creafirine FF11002: F r a conotnspired 02
LEGEND

Bicarbonate
^
I iNTILAS
:2r0
err/e ‘ f "a fikai­
ed ii4e4
71)/eR
(VA I:7 /9 1/-siieben
ivihwieki 7C7 /Z;z_eR
A4v/1-04. vvoutas
69 kii'-ii. f
ti .1-2--
,
Opkitooy e5icte
Ai Afk-ro0a,Ati vgeo.
7"Fe vo e6/11,,-
'a,-
e /14/ vri4e.
SR R2­
25
5. SZ A/ C2( f /0/0/
P
ICP - Intracrarlial Pressure S/A • Fractional PCO 2 - PRESSURE OF AR7RIAL CO2 SAI - Saturation
PEEP - Posityie and Expiratory Pressure TRACH - Iracheostomy
(Continue on reverse)
DEPARTMENT/SERVICE/CINC Dx g - ,/4-o 3
give: Name—Last, F"rst,

medical facility) ¦ HISTORY/PHYSICAL ¦ FLOW CHART
III OTHER EXAMINATION ¦ OTHER (Specify).6(-(,).-Li OR EVALUATION
¦ DIGNOSTIC STUDIES
. TRETMENT
WAMC OP 375 (Redesignated)
1 APR 90 (HSXC - NU)
MEDCOM -17066

DOD-030655
DATE PAGE 2 OF 4
•
0!1 -Y

TIME -g4— BP Arterial line
08 0, /0
/7
BP Cuff Temperature
Pulse
05
Respiratory Rate
7-3 X 35' q-1/ q 2' 9
q6
Pll n ,R14/ iR A
/6 /! / 03 04 05 06 07 IP , lle; (Li) (70 14 75 s 15 8 ° T
boo

SP gr
S/A
OUTPUT
PH
GUIAC
EMESIS
STOOL m-it".7
DRAINS 2-

`T' it
MEDCOM - 17067

DOD-030656

PAGE 3 OF 4

POST-OP Y
ACUITY LEVEL CLASSIFICATION
TIME
2:3

os MODE
8it F10 2

A B PCO 2 PO 2
14 2-t dt o1.03oq 17 18 19 20 21 /W /00 /oG /0/tv Us-22 7 23 8° CLUCOSE Na/K CYCO 2 BUN/Cr T WBC/PLATELET Hci/Hgb
CI TIME MOUTH CARE U R TIME
FOLEY CARE TRACH CARE N ROM EXERCISES fl W"24 °18Q: WT Yesterday wt Today S UC 0
INTAKE OUTPUT IV Urine: Po TOTAL TOTAL BALANCE ()