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

Medical records of an 18 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wounds to his chest and abdomen with associated injuries. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.

Doc_type: 
Medical
Doc_date: 
Monday, August 18, 2003
Doc_rel_date: 
Monday, October 3, 2005
Doc_text: 

-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

.'* 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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11111111111111111111111111111111111E11111
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1011111111111111
1
1
1
C) .3°-1111111111191
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
i3c,..0
„,
,,,,,z , -T, " TT;
CD

,
.
.4.

Ili' r
:ma 21111 1 MEMIEI i

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 ()

Doc_nid: 
3928
Doc_type_num: 
72