Medical Report: 20-Year-Old Iraqi Male, Civilian, Baghdad, Iraq re: Skull Fracture and Scalp Injury

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I - PATIENT ASSESSMENT DATE: i (--,', a_0 PATIENT ACUITY LEVEL : POST-OP DAY: HOSPITAL
TIE
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Time o From I AMBULATORY ll CRUTCHES . WHEELCHAIR II_STRETCHER Total ER/RR/PACU time
Rf
1
7
1--ect_LL LuR-_
• Anesthesia (Specify):
sician
B/P P R 1%
Procedure/Diagnosis
R
E
F
S.'
..N.
.X.
T "
Tubes
• -rovascular checks
LOC
Dressing/cast Voided ---L Nom Yes Amount:

Intake (IV, po) Output (EBL, other)

Medication
•
Other Report From
Received By
TIME: OL C() lab a _oit w Otibb
BP ARTERIAL LINE
MIMI

BP CUFF V", LIM 17 1 .01 i nit
TEMPERATURE
'IS •0

MERPAMENIcig,
PULSE

(09 6 7& 19 rij
RESPIRATORY RATE , f

I
OXYGEN (L/%)

./--
PULSE OXIMETER ' 00

• rt,
q•'1, WY.
02 METHOD e..A 0
Ak A
4'

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
z ._
I

TIME: CAM /400 TIME: :.Vi„r7 1601%,, 10 •• ••• *Skin breakdown —• prevention 1*///•=i WI PAIN ••
' Falls prevention protocol
p
INTENSITY • • • •
E

• • . • 'Restraint protocol o •v.• ef " •• •• c
MED ADMINISTERED (Y/NI ! 'Seizure precautions
RELIEF ACCEPTABLE IY/N) it,411,

_A *Isolation precautions
N

TIME: ?nob .-_•
a EE
'0.
i
FINGER STICK GLUCOSE

E YESTERDAY'S WEIGHT: NO
) A

, _:
T
...Of •
H.
D

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 C IV DIA GNO 31 IS APC) pah -aIT') SI__jiAL_0140_ oition -Monta....

\ DRG: ADMISSION DATE: ig &,p1- 0-
111101111b ( (4 \\ - 1-LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.1)0
MEDCOM - 19441
DOD-033015
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check .
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.
_ ---- -b ( Le.) - Z -
TIME:R INITIALS: TIME:R
b od

INITIALS
E:R INIT
i1 --
1. NEUROLOGICAL: Alert and oriented to
R 0 CIO HA 1 12_clJe.s no
time place and name. Responds appropriately. !

11/A
Communication is adequate to express needs.
Znq 161 -
Pupils equal and reactive to light.

(
2. CARDIOVASCULAR: Pulse regular & rate
v(
E7
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
[Vv
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 IV
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,
I'R'
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle I 1-ika(cciA, C. I I 6 en ev-a /, -2. I , r . 0
development and mass for age. No •.
deformities. No assistive devices needed. 0-• . t,., jeciii.., 2S 5
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

7.
SKIN: Warm, dry, intact. Good turgor. o I 1 'J,„.--ik ,, -/a __P c*gi¦ INe 0 ). _p

No --
*id i i 4 _ 4o aiik
rashes, inflammation, ulcers, breaks in skin. oma
1 '" j I/ se.-'s u ";-)Q :e 5L43-0.,4.204..t Stzz-Ok5 No redness, blanching, irritation over bony 111\ • t ) S `SI S L-C-7‘''' r -"' I
• LAkt--adf 0 -CA
prominences. Mucous membranes moist. ir¦-c-C ctidr\ /VD V.; ; --, T-ec i, 0 Li

8. PAIN: No complaints of pain/ discomfort. at
V
1 1 r0 /./il EV
(See page 1 for documenting pain intensity.)
/U 10

, --r-d-f-0 16 5 0,
9. PSYCHOSOCIAL: Behavior is appropriate I
V g7to the situation. Anxiety is controlled or mild [=1
..\ 44.1
and appropriate to situation. Interacts appropriately with others.
kt? 1 .... ,2
10. IV SITE ASSESSMENT: (LEGEND: P - Puffy
I - Infiltrated R - Reddened OK - No swelling/redness * - Central line) )---_,-... TIME: 010 INITIALS: _ iZ2() INITIALS: (9(.31)
TIME: INITIALS: illIl
IV patency . q hr: re7CCI 4 IV patency . q hr: IV patency s/ q hr:
IV site care provided:

p i IV site care provided: IV site care provided:
IV tubing changed: IV tubing changed: IV tubing changed:

LOCATIONRCONDITION
LOCATIONRCONDITION
LOCATIONRCONDITION
IV Site #1: IV Site #1: IV Site #1:
D
IV Site #2: IV Site #2: IV Site //V
0
Comments: W
DiCCA. !n 12).F.A Comments: Comments:
MEDCOM FORM 689-R (TESTI (MCHO/ MAR 99 Page 2 of 4 pages
MEDCOM - 19442
DOD-033016

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: ii ETIME: TIME: {W ( r . _
COLOR ID band visible/legible
III1
IIIIM

Orient to environment prn
CAPILLARY REFILL
TEMPERATURE
Side rails (2/4) up
A
-
_mmi

IMPIPME

Bed position low
EDEMA
u
fl—-0 =LucC
Call light within reach
Review & post lab results
Notify MD abnormal labs
Incontinent urine/stool
Linen change prn
AI
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
zwoo C.)=7 *CD
¦

MUM'

SENSATION
MOTION

EN

PASSIVE FLEXION
=PM

PERIPHERAL PULSE GEND
Color: P-pink (normal); C-cyan. c; W-pale, white Capillary Refill: 1-10-2 secs -(3-5 secs); 3-15 secs)
Temperature: C-cool; warm; H-hot
Edema: 0-None; 1 • Id; 2-moderate; 3-severe; 4-pitting
Sensation: A-a• ent; N-numb; T-tingling; S-sensation (present)
Motion: U-. able to move; M-move-no pain; P-move-pain; R-full ROM
Passiv exion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Per. : eral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH DINNER TYPE: TYPE: TYPE:
aitA (LOA_
(-1K PERCENT CONN S-6 (Sta PERCENT C fJSUMED: 15, PERCENT CONSUMED: HOW TOLERATED: Lj_a_ HOW TOLERATED: pu.ell HOW TOLERATED: SELF . ASSIST . COMPLETE X SELF . ASSIST . COMPLETE . SELF . ASSIST . COMPLETE 0700-1500 1500-2300 2300-0700 ASELF . COMPLETE (Er SELF . COMPLETE . SELF . COMPLETE BATH/ORAL CARE
. ASSIST . TOTAL . ASSIST . TOTAL . ASSIST . TOTAL
BE RFS SELF BEDREST . S5LF BEDREST . SELF 317-17r-tf:
LAT . ASSIST c-Af1--471-0--ASSIST AMBULATE . ASSIST TYPE OF ACTIVITY
BSC BSC BSC
(Circle all that apply) # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT/---13F-17-\" ..) BRP BRP CHAIR ,c1::FIT) CHAIR
TIME: G/g) INITIALS -_,2 INITIAL TIME: INITIALS:
TIME: /6 6:7­CONTENT: CONTENT: . CONTENT:
An 0-1-CA,-,
cl.ii'\ et CCl2–e_.
I (06,460-,a 2. c-frth . 1-/ ...
..,,, • . , ..F I
atient Family Verbalizes Understanding . Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding
PATE TIFICATION
INITIALS_, 1.__SIGNATURE SHIFT
(_.
, :) \ .) --_A /4-A) CI V le_ .(---7/-_,,, ---,_ qii,u-mLD _a_
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99E Page 3 of 4 pages
MEDCOM - 19443
DOD-033017
SECTION III - INTERVENTIONS & TEACHING (Cont)
T
1Ar.. I M LOCATION OF WOUND APPEARANCE TREATMENTS AND
0 E DRESSING CHANGE

U ,--• :51.,;),/,;,/e. ,',- , -7 1....(_-_,/
, 1 i
A

E.

SECTION IV - NOTES
4 ,.
:. .
.-., .--

MEDCOM FORM 689-R (TEST) !WHO) MAR 99 E
Page 4 of 4 pages
MEDCOM - 19444
DOD-033018
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I - PATIENT ASSESSMENT DATE: 0 3
PATIENT ACUITY LEVEL .:-
1POST-OP DAY: in
HOSPITAL DAY: //
COMPLETE
NLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT: To From
Tim I AMBULATORY II CRUTCHES . WHEELCHAIR II
STRETCHER
Total ER/RR/PACU ti Procedure/Diagnosis
B/P P R
T:
Physician
Anesthesia (Specify):
(
T
' ..
LOC
Dressing/cast
Intake (IV, po)
Medication
Other
Report From
TIME: BP ARTERIAL LINE BP CUFF TEMPERATURE PULSE RESPIRATORY RATE OXYGEN (L/%) PULSE OXIMETER
Oz METHOD
Oxygen Method Key:
TIME:
PAIN
INTENSITY
o
MED ADMINISTERED (YIN) RELIEF ACCEPTABLE (WM
TIME: FINGER STICK GLUCOSE INSULIN IY/NI
Neurovascular checks ubes Output (EBL, other) ' ed
U No II Yes Amount:
Received By
'26CD -

¦ 0
MI

roo loi
60
a •%.'

IIIIIIMI 6 IN
1111111EMIN 7 = ..." Ciq )0° IMM,1
Inli LIM
NC = Nasal cannula NR = Non rebreather FM = Face mask
VM = Ventu i mask MT = Mist tent PR = Partial rebreather A = Aerosol
TC = Trach collar

MEINIMFIP 20 '
•
TIME: it (IV
• Skin breakdown
.•••. .••. -. • •" • • ' prevention A/71 korl.
. . . . . •. . • . . . .
• •• • • •• • -•• • " •
Falls prevention protocol
p '
'Restraint protocol

1.11111111.1 '• ': ': *: CE
4 rj 1 -.Seizure precautions
Nth_
A 'Isolation precautions
/VA atA
E
E YESTERDAY'S WEIGHT:

D
TODAY'S WEIGHT:
Zu.w I zci) I
a.•tt—zR
01—
H
T
Q.
E
WEIGHT CHANGE:
R
• Per hospital policy.
24 HOUR PO IV #1 IV #2 TOTAL IN Urine

Stool TOTAL OUT
TOTALS PATIENT IDENTIFICATION
DIAGN8SI'W of ,_ ,_, 1_b._ 1 o_
0 111_P_I.L4 ta_1
1
ADMISS eN DATE:
DRG: r ig ,Seri-c..) -?-1
111b 9_.
°-' - u\ LOS:
EXPECTED RELEASE:
( (12" PRIMARY CARE MANAGER: ISOLATION REQUIRED (Spec] y : MEDCOM FORM 689­
CASE MANAGER:
R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages Mc v .00
MEDCOM - 19445
DOD-033019
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check . 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. t ( Co - Z._

TIME: ID INITIALS: IME INITIALS
ff 30
TIME:C
--7 INITIAL
C ,
1. NEUROLOGICAL: Alert and oriented to
j b m/4 01;6°` f CCl
DOW 11 0-11-
'
time place and name. Responds appropriately.
dcfr'1/, Spe./e/tc, \o, ,­
-
Communication is adequate to express needs. 1.--... 1^ eSCI--
(4fLajt-• &-6-'‘L .
Pupils equal and reactive to light. \,„--c-v-e c--
,,t,y.- /,',--A -
. t .
2. CARDIOVASCULAR: Pulse regular & rate
D' A.........----

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 L\1,---
I Vr 1111
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 .'1/‘::///e ,e9, ,,,Aif, Cg----
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, I
FO'-----
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6. MUSCULOSKELETAL: Normal muscle
I vl-U-)44cb -5-I yr I I
development and mass for age. No 1
oj2.D4.)pir11_12-i ce-S-¦ 46 ¦ 1
de formities. No assistive devices needed. " —
Normal active ROM without pain. No joint eq-NUckaalca v_ k

`si,-,c,s.(
swelling/tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact. Good turgor. No I
3lecCULD (1_ a‘,,A,5.1z) I „A., ,:9.,, LI .,/, scatc,
rashes, inflammation, ulcers, breaks in skin. -tl
/ l ke+CA- --kp Slin_Qp
No redness, blanching, irritation over bony 4 -ie. 4, iec ),, a
-5i \,----r, % . 1 Cxe--
prominences. Mucous membranes moist. 6 Anac.,„.„
8. PAIN: No complaints of pain/ discomfort.
1--"---
(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate I j...—
El
to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
.04
10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated Fi - Reddened OK - No swelling/redness * - Central line) _• "
TIME: INITIALS: TIME: 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: jOr IV tubing changed: IV tubing changed:
i sCii.irON CONDITION LO CONDITION N CONDITION
ON LOCAT
IV Site #1: IV Site #1: IV Site #1: ../e
IV Site #2: fj IV Site #2:
) IV Site #2:
i
N.
r-
Comments:
Comments: Comment
...)
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 2 of 4 pages
MEDCOM - 19446
DOD-033020
SECTION III - PATIENT INTERVENTIONS & TEACHING SITE: TIME: TIME:
/0/10 /q3C)
COLOR
ID band visible/legible
CAPILLARY REFILL Orient to environment prn
TEMPERATURE
Side rails (2/4) up
EDEMA Bed position low
(.1) u-w -0 I—2 wcc
I -•.0omz
SENSATION
Call light within reach
MOTION PASSIVE FLEXION Review & post lab results PERIPHERAL PULSE Notify MD abnormal labs L D Color:
P-pink (normal); C-cyanotic -pale, white Incontinent urine/stool
Capillary Refill: 1-(0-2 secs); 2--5 secs); 3-(5 secs)
Temperature: C-cool; W-.rm; H-hot
Edema: 0-None; 1-mi :, 2-moderate; 3-severe; 4-pitting
Sensation: A-abs' t; N-numb; T-tingling; S-sensation (present) Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
Motion: U-u le to move; M-move-no pain; P-move-pain; R-full ROM
Passive F ion: D-dorsal flexion pain; P-plantar flexion. pain; 0-no pain
Perip.-ral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH
DINNER
—
TYPE: j-A9---1..k_o_..._ TYPE: S1._,..„2 ..}-c_k_ TYPE: ..i-,----c... PERCENT CONSUMED: PERCENT CONSUMED:
PERCENT ONSUMED: 2_,­HOW TOLERATED: bio i HOW TOLERATED: (. ,,i._eLA HOW TOLERATED: [ELF . ASSIST . COMPLETE Ra_SH_F . ASSIST . COMPLETE . SELF . ASSIST (1=1 COMPLETE 0700-1500 1500-2300 2300-0700
. SELF . COMPLETE . SELF . COMPLETE XSELF . COMPLETE
BATH/ORAL CARE
114-1TS§IST . TOTAL Ci.14:SSIST . TOTAL 1171 ASSIST . TOTAL
D BEDREST . SELF BEDREST . SELF BEDREST __SELF
L S TYPE OF ACTIVITY (Circle all that apply) B BRP LAT . ASSIST it TIMES/SHIFT cik 1M.1L.AT ) B' BRP ErASSI ST ""---:_AMBULA I e.) BSC BRP if TIMES/SHIFT . ASSIST il TIMES/SHIFT
CHAIR CHAIR CHAIR
TIME: /5/3/7 INITIALS TIME: INITIALS: TIME: INITIALS:
CONTENT: CONTENT: CONTENT:
T Zr, ri UP Cc-, ','-' .._
E

..11,
H
N
G

.
atient amily Verbalizes Understanding . Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding
PATIENT ID NTIFICATION
INITIALSb u_-/ SIGNATURE SHIFT
ztAt. :-2 y Iv
MEDCOM FORM 689-R (TEST) IMCHO) MAR 99 Page 3 of 4 pages
MEDCOM - 19447
DOD-033021
SECTION III INTERVENTIONS & TEACHING (Cont)
W 0 U T I M E LOCATION OF WOUND it .30 5 al i0 f . -­? Th (C(It APPEARANCE .5 7‘Agi k 5' 1 1 /1 71c(L. 71 , /VP , / 1 /l1C-€C,/, ( Oil, p}'NSlPae CA TREATMENTS AND , DRESSING CHANGE c..8)-(1 t _
R
SECTION IV - NOTES
A39j211/,-' 4 gi--•=4"--YE-kr / ,.0,,-/ 24 c IdLA-e-m9,1, 4-9f . /14 70 l ' AfR/ .."
"b ( C-k) ;q

,,,
i......
t
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 4 of 4 pages
MEDCOM - 19448
DOD-033022
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: '2.-05V se oc..)

PATIENT ACUITY LEVEL :. POST-OP DAY: \,‘ HOSPITAL DAY: t .Z. Co ' , •LETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT:
Time

• From M AMBULATORY 11 CRUTCHES INRWHEELCHAIR II STRETCHER Total ER/RR/PACU time
Physician
Anesthesia (Specify):
Procedure/Diagnosis c,

B/P P • R T
N LOC

Neurovascular checks
S Tui

Dressing/cast
F , Intake (IV, po)

Output (EBL, other) Voide
I No I Yes Amount:
E Medication
R

Other ----......................„
Report From
Received By -... TIME:
. BP ARTERIAL LINE
V: BP CUFF
TEMPERATURE

e
T'
. PULSE
L RESPIRATORY RATE
OXYGEN IL/%)
PULSE OXIMETER
02 METHOD

G .

N
S _ .

NC = Nasal cannula NR = Non rebreather
Oxygen Method Key: FM = Face mask" VM = Venturi mask
MT = Mist tent PR = Partial rebreather A = Aerosol

TC = Trach collar TIME: (;7()))
TIME:
'Skin •reakdown
: s preve ion
PAIN
5 p *Falls preven n protocol

p INTENSITY •• • • ••
" " "

" '• • E
A . Restraint protocol
' I

MED ADMINISTERED (Y/NI ill I 'Seizure precautions ,
N --R-R-R•R-— --R-__—
RELIEF ACCEPTABLE (YIN) A
*Isolation precautions
L-,-
TIME:
E R
0 . R,
•
• FINGER STICK GL • • • E
E YESTERDAY'S WEIG /-
H INSULIN IY/NI

T
D
TODAY'S WEIGHT:
S
E-
WEIGHT CHANGE:
R •Per hospital policy. 24 HOUR PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
TOTALS
PATIENT IDENTIFICATION DIAGNOSIS fl(C) .\4:1-1:;‘,1
s\c,AA:Gi, c ep k 81.V.Cta ‘'..r/frA I
ADMISSION DATE:
toisesea-z,
LOS:
EXPECTED RELEASE:

} 1111111 b c6 - '.-1 DRG:
CASE MANAGER:
PRIMARY CARE MANAGER:140,0Na° rre ( C

-
Ct — OI
Q._ r--.._
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages =vim
MEDCOM - 19449
DOD-033023
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check . 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.
6 ( c,. \-7-
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.

(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: INITIALS: IV patency V q hr:
_
IV site care provided:

IV tubing changed:
LOCATI *RCONDITION
IV Site #1:
IV Site #2: v
Comments:
TIME: 0q 00RINITIALS: TIME:R INITIALS:
TIME:R INITIALS:
rw-(5,,-0,2., V‘Ok-
Sp.ea..21--e,....i...--;(-,..
-,A5
/A J....4,..-c--e...1

Ej,-I
I
L-t' I
I
2 ---ri
EI---I I
n t9C0-a_.-C-) I I
CL..,--4---c;....-e-
-----I-Y -..-t...4.---)./
1-9---- I I
111,-/- I I
R'------ ri
Puffy I - Infiltrated R - Reddened
TIME: INITIALS:
IV patency V q hr:
IV site care provided:
IV tubing changed:

I
I
n
I I
.
I
I
I
I
OK - No swelling/redness TIME: IV patency V q IV site care provided: IV tubing changed:
,i
-Central tne) - -
i-.
..-f
INITIALS: hr:
IV Site #1: IV Site #2: LOCATIONRCONDITION IV Site #1: IV Site 112: LOCATIONRCONDITION
Comments: Comments:

MEDCOM FORM 689-R (TEST) (MCHO) MAR Page 2 of 4 pages
so
MEDCOM - 19450
DOD-033024

.._ SECTION HI - PATIENT INTERVENTIONS & TEACHING
SITE: TIME: TIME: te:,w
COLOR
ID band visible/legible
CAPILLARY REFILL
Orient to environment prn
TEMPERATURE Side rails (2/4) up
EDEMA Bed position low
7o D .c 0:Do c ,rn 2-I
(/)
UJ -0 I— = LuCC
SENSATION
Call light within reach
{
MOTION , PASSIVE FLEXION Review & post lab results PERIPHERAL PULSE Notify MD abnormal labs
EGEND
Color: P-pink (normal); C-cyan c;
W-pale, white Incontinent urine/stool
Capillary Refill: 1-(0-2 secs)• -(3-5 secs): 3-(5 secs)
Temperature: C-cool; W arm; H-hot
Edema: 0-None; 1-n : d; 2-moderate; 3-severe; 4-pitting
Sensation: A-ab -nt; N-numb; T-tingling; S-sensation (present) Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
Motion: U-u le to move; M-move-no pain; P-move-pain; R-full ROM
Passive Fl ion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Periph- al Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; -
D-doppler, P-palpable

BREAKFAST LUNCH DINNER TYPE: TYPE: TYPE: PERCENT CONS MED: 95-`r... PERCENT CONSUMED: PERCENT CONSUMED: HOW TOLERATED: t.,......(...--C-1 HOW TOLERATED: HOW TOLERATED: SELF . ASSIST . COMPLETE . SELF . ASSIST . COMPLETE . SELF . ASSIST . COMPLETE 0700-1500 1500-2300 2300-0700
. SELF . COMPLETE . SELF . COMPLETE . SELF . COMPLETE
BATH/ORAL CARE
ip
ASSIST . TOTAL . ASSIST . TOTAL . ASSIST . TOTAL
BEDREST . SELF BEDREST . SELF BEDREST . SELF i&P . ASSIST AMBULATE . ASSIST AMBULATE . ASSIST
TYPE OF ACTIVITY
BSC BSC BSC
:Circle all that apply) 11 TIMES/SHIFT 11 TIMES/SHIFT 11 TIMES/SHIFT
BRP BRP BRP CHAIR CHAIR CHAIR
TIME: INITIALS: TIME: INITIALS: TIME: INITIALS:
CONTENT: CONTENT: CONTENT: .4
--•^4
. Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding
0 --I •I— —Z0
PATIENT IDENTIFICATION
INITIALS SIGNATURE/ -2._ SHIFT
(-1?-
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 3 of 4 pages
MEDCOM - 19451
DOD-033025

SECTION III - INTERVENTIONS & TEACHING (Cont)
T TREATMENTS
0 M E LOCATION OF WOUND APPEARANCE AND DRESSING CHANGE
U
N
R
SECTION IV - NOTES
1 10 0 -"10+ V_--co_ti2„

MEDCOM FORM 689-R (TESTI IMCHOI MAR 99E
Page 4 of 4 pages
MEDCOM - 19452
Lx-i¦-Nr
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form. see AR 40-66: the proponent agency is The Office of the Surgeon General.
1. AGE: Z O ' S 2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
LcAc„.
HEIGHT:
3. PREVIOUS SURGERY [ ] NO [ ] YES (type):
WEIGHT:

(TIAR/L,
4.
PROPOSED SURGICAL PROCEDURE:

5.
ADDITIONAL INFORMATION: Last PO:

Medical I-Ix: st.t. +-e Implants: 2 Medications: 2 Jewelry removed . ye /no Family waiting: yes/
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMV 8. OR NURSING INTERVENTIONS
eeAllowpt. to verbalize
A. PSYCHOSOCIAL
Pt. verbalizes any specific anxiety. ---Potential for anxiety Explain OR environment
-
d answer questions
Pt. exhibits relaxed body posture.
related to traumatic injury; r garding surgery.
language barrier; faiiii ¦ o

Offer comfort measures, ton ; surgical environment ( .g., warm blanket, touch) Explain all nursing incedures before they are dpne.I Remain with pt. whenever possible.
o Maintain family interface.
B. AERATION 2:1---PT. will be able to breathe without c Offer to elevate head of
Potential for difficulty during immediate intra-I tter or offer pillow.
operative phase. c
respiratory dysfunction due to Observe pt. while awaiting surgery for signs of distress
sedation; positioning; injury c Assist anesthesia during intubation and extubation
AffPT. will not exhibit signs of impair-
C. INTEGUMENT Utilize pressure preventing
ment of skin integrity (e.g., reddened evices on OR table and
.------
areas.
Potential impairment ccessories. Check for proper
of skin integuity due to Bovie ositioning and support to
pad; position; fluid shill
aintain good body alignment. Pad pressure points.
Place ESU ground pad on on compromised skin surface rea.
Keep prep fluids fromooling.
9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91R Previoius editions are obsolete. USAPA V1.01
MEDCOM - 19453
DOD-033027

6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
-7----Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury; position; shock; previous surgery
E. NEUROMUSCULAR
CONTROL

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

F.1. ..,---Disminished visual
perception due to being injury;
sedation;
F 2 Potential
Potential for decreased communictaion due to Iiirn4iinge barrier; sedation
F.3. Potential injury due to
dentures.

G. OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
,-Er Pt. will exhibit signs of adequate
tissue perfusion (e.g., color, warmth,
pedal pulse).
• Pt. will be transferred to OR table ithout difficulty.
Pt. will not experience unnecessary hysical discomfort.
Pt. will be made aware of
urroundings prior to anesthesia
i duction.
Pt. will be transferred safely to
R
able.
Pt. will be able to understand
nstructions.

Minimize danger of injury during intraop period.
OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS
o Check for support stockings or ace wraps. If none, check with doctors.
heck that safety straps are
correctly applied.

o Offer pillow for under knees.

o Place and take down legs from
stirrups with slow bilateral motion.

Check that rings have been
removed.

•
Have sufficient peoplevailable for transfer. Insure proper body ignment. Allow patient to lie in osition of comfort while aiting for surgery. Offer support (i.e., pillows, athtowels, etc.) for positioning.
Introduce self. Keep pt. formed as to where he/she is nd what is happening. Inform pt. in which 'rection to move and assist if
n cessary. Speak clearly and slowly. Address pt. from
4-(6/A-0-"l" side.
6 Validate pt.'s understanding of verbal communications.
o Verify removal of dentures.
OTHER NURSING
INTERVENTIONS.
Or continuation of above
interventions.

10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.

____111111111111111111r1 4) i $ P.­
'.(r-Cj5 DATE
11. POSTOPERATIVE EVALUATION:'--
sin-QA\AATh
\
12. PREOPERTIVE (Signature and Title) 13. PREOPERTIVE EVA BY (Signature and Title) Of\--Vil•-)
DATE: ig 9, 7..;1-13- TIME: 7-01-0 DATE: Lg TIME:
REVERSE OF DA FORM 5179, JUN 91 MEDCOM - 19454 USAPA V1.01

DOD-033028
INTRAOPERATIVE DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM • 2. PATIENT IDENTIFIED, RE
PROCEDURE
VIA k A ti-1P,( BY k"..0A_12, CL ¦ 0 VERIFIED BY C-12 t b c-c) -2--

3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
3 zo s-c) TIME Z_ 0 ,g73 NUMBER 1 y-a-.....k..._...., 0,„ -1

5. PREOPERATIVE EMOTIONAL STATUS
cg CALM II ANXIOUS • EXCITED . CRYING • ANGRY • WITHDRAWN
• OTHER (Specify) COMMENTS: Allergies: --v-v'k „ko,,___ .
•
6. NURSING PERSONNEL
ASSIGNED RELIEF
SCRUB

SCRUB
(-(Cc) -L
CK? I
ASSIGNED
RELIEF
CIRCULATOR CIRCULATOR
•
7. POSITION AND POSITIONAL AIDS (Specify)
. SUPINE 111‘ LITHOTOMY • PRO • KRASKE LATERAL: 111 LEFT SIDE UP [ , ...0..tFtrT SIDE UPvi-y 0 "n ccy.j, 6 CM' \ C51 4.0—0,..)(i U1/40s/Y 1 ...r L... A.,-Iv.,-Cs_ 1 cA aiSlAtlaS
, _ -v¦
a 0,----, ` irp„ ?,.., d1/4.0A--kcA
....,­
COMMENTS: "e VD 00,1r cr.-.," e-tow-- ei
lis-^i-‘A,.....)....3a,,_ - . 6 -t-0----",¦ A-.e.t.0-,
%...._ t
r,,,,r,f.
&I-1,z -,,c,\
8. SKIN PREPARATION
( -
Ca 7
HAIR REMOVAL rYES is NO
PREP SOLUTIO (Specify) V•e•ACNt 13r2A-C.,_ DONE BY: 112 OR g NURSING UNIT ie : ("kl---SITE:Ca-k . 1- 1-°--Ic-IL BY WHOM . IIMIll
WHOM:
4,,nck.u_
METHOD: 0 DEPILATORY igl RAZOR SITE: BY WHOM:
BY
• CLIP
•
COMMENTS: ,no Vv:: CA v-c,,,A.-.. --T.A.0 -c4 COMMENTS: \Thu yOrfek , . C,.--5.,::.."..\
' ..,-1-kei
9. LOCATION OF EXTERNAL DEVICES
LEGEND X Ground Pa -- Safety Stra === Tourniquet -\.-( c"-L
C = Correct I = Incorrect —3:,.;66,r2 '

First Closing Final Closing
10. COUNTS Other -Count Count SCRU: c 1
Sponge Ki Yes • No
C c
Needle Sharp 0 Yes II No C. G Instrument . Yes al No k 11.
A
MA-
: Is..dEl;" UP, 1\-
Other ¦ Yes • No "
I
11. PATIENT IDENTIFICATION (For yped or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) 171 YES . NOName - Last, first, middle; Grade: Date; Hospital or Medical Facility;)
4 l
1f GROUND PAD: RAND ' A/ b.d 1/4/ JMA•A VOX-Vat LOT NO: b.2°1-lo --U ---63
RI_ ESU NO: VQA.kkl k. O` -0\f.S.„ -.Z..
• ESU NO:
-b ( LQ - L-
GROUND PAD: BRAND
LOT NO: IR BIPOLAR NO: VC...A Ve- 'y ta•-kr. -'4-0--r-CiZ -7
_
REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA v1.01
MEDCOM — 19455
DOD-033029
X] °
13. PROSTHESIS, IMPLANTS YES . NO IF YES NAME: ID NUMBER: MANUFACTURER
0x.cw...;,,o_ilt.LiC4?... c)1C'4ii.v

.ei .-?, 0
. 4" .\0 V‘4."`"'". al . 2_00z x 3 --4 x
?4,Nr(sile-Ak-CRS 02.," 4-(75,-

11-k,,,,1w02vr8 i . 2- 0 SR )( 19 rillt-o`,4-4-a I . 49.cck x 1
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM NOT BY ANESTHESIA) YES lyi NO • ::MEDICATIONS/SOLUTION DOSAGE TIME METHOD
PREPARED BY GIVEN BY ii:: \ 10 (-,a 0 cc›,:\A.{ E I:10c, WC isc.c -.1-: i 0 1— • 7A-Wv0Thrn17iv¦ SVC 0 tA. ' GtM! :1-_ to TC_i c-c)1/4...4
-
:'WOUND IRRIGATION YES II NO, TYPE(S): 4 , ° -ar IV Nc\ cc
OTHER ORDERS
TIME CARRIED OUT BY i;,ec,...kAA
'1(0
231.A/Nr6I 7....1 . l
-
biCe -7_
;r H Y S I C I A N ' S SIGNATURE
,..................................................... ..... ....................... . .. .. .......................................................................................................... .. .................................. ,....................... ,

15. X-RAY IN OPERATING ROOM IF YES, SITE
YES NO W

¦R
16. LABORATORY SPECIMENS SPECIMEN (S) NAME NAME YES •_NO IQ
FROZEN SECTION (FS) NAME NAME YES • NO M CULTURE (C) NAME NAME YES / NO El NAME NAME NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES NO • 4-TYPE/SIZE 1. 10 t-In‘,--v , 2. 3.
[N, K
(A ,)(
rIveA.,.."
SITE 1. 2. 3.
co/-e,
VoAti Pi Hoa -­
19. ADDITIONAL INFORMATION
WCP-
Surgniis: Anesthesia: Anesthesia Type: be,,s1--.-0,31.,

SO I50—3;:13S
Bovie Pad site intact pre-op . ; post-op Bovie Settings: Coag/Cut : Tourniquet Site intact pre-op : post-op Tourniquet Time: Up Down 71,-RA
20. OPERATION(S) PERFORMED kr0,..,...„• (7) (5.7a. ().1 GIJH
(4,r T c---(
t.
21. PATIENT TRANSFERRED TO t_ \ TIME -3212-METHOD
1" (AA_ --1 L CT SC.AAV\9.)v ) --b/k);_gil
Cv\-
22. E I RE C 471-1, MEDCOM - 19456
E
RFVF
USAPA VI.01
/
DOD-033030
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY -
MONTH-YEAR . p DAY a_ '')-2-... •

rilmwriurin • • mimeo a
D
7

i E
-R1MR
I.
..s.:.,-...7.--
,*
•

HOUR
-

i : 115R11.41
•
0•011

Oivzi
PULSE P o . . II . :
TEM. F pr
(0)
TEMP. c.R
.

) 0 s :R: "i
105°
0
11

6
40.6 °
. . . .
. . . . . . . . . . . . . . . . .
180 104°
. . . . 40.0 °
. . . . . . . . . . . . . . . . . . . . . .
.
. . . .
170 103° S.,'
39.4 ° • • •• •• • • •• •• •--• • •
. . . .
•• •• o
. . . . . . . . . . . . .
. . . . . . . . .
. .
._. ._. ._. . ._. ._. ._. ._. ._._._. a)
._. ._.
160 102° o
. . . . . . . . . . . . . . 38.9 ° c
._. ._. ._. ._. ._. ._. ._.
E'
._. ._. ._. ._. ._. ._. ._. . :_: -)
150 101° car'
38.3 °
asimmnimil
p::_:: ::_
:: :it ,,
•:.
u
140 100°
37.8° 4--
: ... : .... :1 .:. : , lik r -E, . :: c
.To
130 99° n 98.6° ...... ............... 'I,o-
4 3i.0:_a.
120 98° a)
36.7 ° -0
e
to
E'
110 97°
............ .... ...... 36.1° a)

(..)
....
............

100 96°
35.6°
90 95°
35.0°
80
...... ......
....
70
60
50

. . . .
40
RESPIRATION RECORD
IRecord special data only when so ordered
BLOOD PRESSURE
HEIGHT: WEIGHT —¦
PATIENTS IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) 6111111 , REGISTER NO V= o, 1...7 VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICSAR, FIRM (41 CFR) 201-9.202-1
MEDCOM - 19457
DOD-033031

MEDICAL RECORD
VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR p DAY
28 Cf
19 .I HOUR -I .
• 0
•
PULSE TEMP. F . / :

(0)
(*) 105° : ,
. . . .
180 104
....
40.6°
. . . .
. . . .
. . . .
. . . .
. . . .
40.0°
170 160 103° 102 39.4° 38.9° 5.­, E D • a)o c
150 140 130 120 98° 101° 100° 99° • -A * " " " e • • . • . " . . • . • . • . • . • . • . • . • . • . • . • . • . • . • . 38.3 ° 37.8 ° 37.2° 37.0 ° 36.7° Cc' 84.-En' ...... c a) To o-Li, a)-o
110 100 97° 96° . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1 ° 35.6° no C" 0.)c..)
90 95° 35.0° •
80
60 . . . . . . . • • • • • • • • • • • - • • • - - •
50
40
RESPIRATION RECORD 9 0 ,_0., BLOOD PRESSURE
0 2 ca).c 3 , 0C HEIGHT: . I WEIGHT --10.
IUCD 23 5 5OO.VI
0 w cc 0 'ATIENT'S IDENTIFICATION (For typed or wri ten entries give -Name—last, first, middle; ID No.(SSN or other); hospital or medical facility) REGISTER NO WA.e.wit c 1./2._
c t,v) 411111‘ . STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 19458

DOD-033032

Enter in above space
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE REPORTED BY
MD
TECHREMARK

REQU 111111111111. I
C. 00,
CJI\jtif
l 1
M(SC
URGENCY )UTINE TODAY . 0 PRE-OP STAT .

"12"-1
Dtia)
SPECIMEN/LAB RPT. NO.
PATIENT STATUS
0 BED
.AMB
OUTPATIENT . .. DOM
NP
SPECIMEN SOURCE (Specify)
LAB ID NO.
s,
PATIENT'S MED. RECORD
DATE I TIME A.M
P. M
ausgnoaa
RESULTS
HEMATOLOGY
U GENCY RO UTINE TODAY .
. PRE-OP
•
STAT .

Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE REQUEST' REPORTED BY MD DATE
TECH REMARKS
A /

;7" A O U U
0 = c 0 0

0 0 ILO
0 0 0 O
2m i t. 2 m f EL 22
B O U 0

0 B
WBC DO AND BLOOD CELL MORPH
sv

SPECIMEN/LAB RPT NO.
0 PATIENT STATUS 1g0
. BED . AMB 2
..,
OUTPATIENT .
0 NP 0 DOM E
SPECIMEN SOURCE ,lis I • • •
. VEIN a
111 CAP f
s—
. OTHER (Specify)
a.
LAB. ID. NO.
0
•
OI
0
0

STANDARD FORM 545 (REV 10-75)
LABORATORY REPORT DISPLAY
Pt Name: .
Na •.
A40 mmol/L

i --STAT G3+

K 3.4 mmol/L

Pt: gig /
TCO2 26 mmol/L

Pt Name: iCa 1.18 mmol/L
Hct 30 %PCV
TCO2 28 mmol/L Hb* 10 g/dL

*via Hct

At 37C
pH 7.51:2 At 37C
PCO2 pH 7.461

33.5 mmHg.
P02 187 mmHg PCO2.

34.7 mmHg

HCO3 27 mmol/L P02 191 mmHg
BEecf 4 mmol/L HCO3 25 mmol/L
s02* 100 % BEecf 1 mmol/L

*calculated 502* 100 %
*calculated
Sample Type_:

At Patient Temp

205E13 03 04:31 PH 7.453
°per:1111mm
PCO2.

35.6 mmHg
.

b( 2-N P02 - 194 mmHg
Physician:
patient Temp: 99.6F

Ser#

102 : 414

Ver:
S mple Type_: ART

95EPO3.

18:01

N

0 C:) 0 aper:
ALIGN ALL LABORATORY REPORTS ALONG THIS BASE LINE Physician:
FORMS DISPlAYED ON THIS
IHRITHellnlig: This form :may be used to disc,:ay lab-ratori -epoi-ts as a

MOUNTED ON STRIPS 1 THROUGH '
flow sheet to be read as a progressive table. If so, a separate sheet should be Ser#
used for each type of report form. When assorted report forms are mounted

• CHEMISTRY I (SF 546)
on the display sheet, both test names and results should always be visible. Ver:
• CHEMISTRY II ISE 547)ENTER IN SPACE BELOW: PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
0 CHEMISTRY III (SF 548)
I Ills ..,pc"y,

•
HEMATOLOGY (SF 549) MOUNTED ON STRIPS 1, 4, AND 7

•
MICROBIOLOGY I (SF 553) n

n
URINALYSIS (SF 550) MICROBIOLOGY II (SF 554) LI SEROLOGY (SF 5511 0 MISCELLANEOUS (SF 557)
. SPINAL FLUID (SF 555) O ASSORTED FORMS
LABORATORY REPORT Prescribed by GSA/ICMR DISPLAY
FIRMR 141 CFR1 201 -45, 505
U.S. GOVERNMENT PRINTING OFFICE 1990 2 6 7 -1 2 6
MEDCOM - 19460
DOD-033034

PICCOLO 04:36
22/ 1.n/03 MALE
FUARLNCL RA PICCOLO ft: 19//o3
PAIIEN1 04:12
BASIC METABOLIC RLFEHENur. RANGE:
LOIliligrju3145AA1 PATIENT A: MALE
DISC ill" 4-,(,(,)-
DR if: 000
MEILYIE 8

OPER4:
SEP 11\L TWIN 11111111111 DISC LOT #:
h41 3111AA4

OPER #: 0'

MG/DL. DR #:3
73-118

122* SERIAL Ali3
(ID
MG/DL
6* 7-22

BUN
8.0-10.3 MG/DL
rA++ 8.0 GLU 182* 73-112
MG/DL

0.6-1.2
0.9 BUN
CRC 14 MG/DL
MMUt

-145
128 CRE
NA+ 137 0.8 7
0f1.2

MMGM_

-4. 7
3.6 3.3 CK
K+ 392* 39-380
MMOVL
98-108

101 NA+ 136
CL- 128-145 MM:
MMOVL

23 18-33 Ki
tCO2 4.1 3.3-4.7 MMOVL
CL-113*

98-108 MMOVL

CHEM OC: OK
INST OC: UK tCO2 20
18-33 MMOPL

HEM 0 , LIP 0 ,ICI 0
INST QC: OK

CHEM OC: OK

HEM 0 , LIP 0 , ICT 0

(--) 7C Z CD 0 03 Cr)

M Z CD r- II
C/) Ci + C c.)11) + CD II
CD

C
- -•
(-) co— c) OD
IN) c) CL) -Is OD
-.A .** 34.

co' ki OD — (A)
r
;
-o C)
CD C.) -• C c= CO OD -F-CO OD C
CO c)

CO - -Is II I-1
-'Jul II II II
C)
cD
7C
MEDCOM - 19461

SPECIMEN/LAB RPT. NO.
MISC
URGENCY
.
ROUTINE TODAY .

.
PREOP STAT .

Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
REO REPORTED BY MD DATE c9c-)
TECH
REMARKS

C:

I I
CHEM I
URGENCY
. ROUTINE

dev 11111

TODAY .
. PRE-OP

3-eo

STAT .
PATIENT STATUS
.
BED . AMB OUTPATIENT .

.
DOOM

NP SPECIMEN SOURCE (Specify)
LAB ID NO.
SPECIMEN/LAB. RPT. NO.
PATIENT STATUS
. BED CI AMB
17. OUTPATIENT .
. DOM 2 .
DNP
SPECIMEN SOURCE
. BLOOD
¦
¦
¦
PHYSICIAN'SCOP
MEDCOM — 19462
SPECIMEN/LAB RPT., NO
HEMATOLOGY
URGENCY PATIENT STATUS
. BED . AMB . ROUTINE
OUTPATIENT . TODAY . . NP_DOOM
SPECIMEN SOURCE
.
PRE-OP

.
VEIN . CAP STAT .

. OTHER (Specify)

Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
IAN'S SIGNATURE REPORTED BY_ MD

SPECIMEN/LAB RPT. NO
HEMATOLOGY
URGENCY PATIENT STATUS tag 0
. BED AMB 4.)
cJt
. ROUTINE OUTPATIENT .
TODAY . . NP . DOM 2; SPECIMEN SOURCE ,n
. .PRE-OP
(
. VEIN El CAP STAT . 1_1
1-1
OTHER (Specify)

Enter nn above space_PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE G PHYSICIAN'S SIGNATURE REPORTED BY MO DATE LAB. ID. NO.
A 00-

TECH
(_ REMARK
0 7
2 2
o:

2 a 2 2 g 0
0

0 0
0 0 2 s ca
0 0
O 2 e. 22 ae C O 2
2 2
WBC DIFF AND BLOOD CELL MORPH
2 AU AIU
PHYSICIAN COPY
MEDCOM - 19463

/ RAPLOPO

COAG ANALYER V4.54
SERIAL

485 09/21/03 04:23 AM

Patient 1111/

( u

Test t, :PI
Test

it: 12.4 sec.
44;R• MI RANGE CHECKL044*

Ratio .0
Calcul it INR = 1.03
SampleTe:oitrated h. Liood

lest

:09/21/03
Test T

:04:21 AM
Card h

:010301
Opel 0 t( :gin 6 (

NAPIOPOLN WAG ANALYZER V4.54
SENTA1

09/21/03 04:21) AM.

Patient fl

HN4

fest Ndl, :APil
Test ReHil

30.3 sec.

E 4fRPAL NU! RANGE 110ii ,,Or4E
ample

Hit] :09/21/03
lest fime :64:23 AM
Card Lot
Operator

MEDCOM - 19464

i—STAT G3+

Pt: 111111
Pt Name:

TCO2 21 mmol/L
At 37C
pH 7.317
PCO2 39.5 mmHg
PO2 180 mmHg
HCO3 Z0 mmol/L
BEecf mmol/L
502* 100

*calculated

Sample Type_:
195E1)03 04:08
0per:1110

Physician:
Ser#

Ve r:
P TREND 09/21/03

Sp02 SYS / DIA - MEAN RR

9 . 91 / 54 68 25

93 112 / 72 87 20
OFF 98 / 65 78 18
OFF 108 / 65 82 24

10:01.106 97 105 / 63 82 22

09:00.78 97 104 / 61 74 OFF

08:00.90 97 104 / 60 75 OFF

07:00.79 98 116 / 1Q OFF
ADULT

;--7RO 7-pcaL
VT±. -

SERA
I
• RAP'''' • 09/20/0 -04:5.
ANALY'"

Pal 1E10 ID:
lest Name :PI
lest Resull:= 'ILI sec.
***RESULT NOT RANGE CHECKED***

Ratio = 1,0
Calculated'1 INR = 0.99
Sample Type:citrated wh. blood
Test Date ;09/20/03
Test flffle :04;55 AM
Card. Lot : :010301

Operator a_
: 1111111111

RAPIDPOiNI WAG ANALYIER V4.54JR144111111 owywoJ (6;00 AR
Patient ID: lest Name :API1 lest Resrilt:
24.0 sec.
***RESULT NO1 RANGE CHEK.0***
Sample 1 ,/pe:citraled oh. blood
lest Darr :09/20/03
Test Time :04:57 AM
TAW lot

:1002U
Opel a lo, : 11111111

RPIDPoj5T fLLG ANALYZER V4,54
AR LA1
09/19/03 04:15 AM
Pat
(
Test Name :PT
lest Re

14.1 sec. ***RES .1 NOT RANGE CHECKED*** Rat.i -= 1.2
Cd elated INN = 1.26 le Type:citrated wh. blo0d sI Date :09/19/03 I ...if lime
:04:13 AM
C -rd Lot :010301
0 -erator 1111111111

NAP It 'OiNf WAG ANALYZER V4.54 SERIAL 4JO5485 09/19/03 04:16 Al'!
Patient I

Test Name
Test Result:= 39.0 sec.

***RI501J NOT RANGE CHECKED***
Sample Type:eitrated wh. blood
Test bate :09/19/03
Test Time :04:15 AM
Card Lot

:100208
Operator

,b (
MEDCOM -19465
DOD-033039

CINEN TAKEN
I I SPECIMEN/LAB RPT. C49.
-D1C¢\) '
HEMATOLOGY
URGENCY PATIENT STATUS 0
1:3 BED . . AMB g
7,1Sj ROUTINE OUTPATIENT ED TODAY . oNp 1:1 DOM ci

a hem

- ept
SPECI4AEN SOURCE r
. PRE-OP
KVEIN '
(r)
. CAP ..:

STAT . aOTHER (Specify) a-Enter in above space, PATIENT IDENTIFICATION-TREATING FACIUTY-WARD NO.-DATE

REQUESTING PHYSICIAN'S SIGNATURE REPORTED BY MD DATE LAB. ID. NO.
ZZ eto3
TECH
REMARKS

afern 1-7
z

kb.
0 0
0 0U0

0 4:giu
2 U

WBC DIFF AND BLOOD CELL MORPH
0

ID:111111
17-0-03

70-09-G3 NB

04:14
04156

Patient
Patiert

Limits
Limits Ifif 10.1 x10',­
;AL 4.5 10.5

WBC 8.0 x10'341' 4.5 10.5

RIC 3.98 L ;10'6/IL 4.00 3.00
1,2C 3:89 L x10'/uL 4.00 6.00

Hgb 11.8 g/dL 11.0 18.0
Hgb 11,4 AL 11.0 18.0 Hct 35.77

35.0 60.0

Hct 34.7 L 17MD 89.77

35.0 60.0 fL7

80.0 99.9

MCV 89.17

TL7

80.0 99.9 IICH 29.57

pg7

27.0 31.0nal 29.4 pg 27.0 31.0 ncHc 32.9 L g/dL7
33.0 37.0

MCHE 33,0733.0 37.0

gidL7Plt 202.7

x10'3/.IL 150. 450. Pit 175.7LYZ 12.7 *L r7
x10'31ilL 150. 450.

20.5 51.1

La 17.3 L720,5 51.1 LY# 1.37

x10'.3iuL73.4

1.27

LY47x10'3AL7

1.471.2 3.4

MEDCOM - 19466
WarcVSection:

ritEQUESTINO PHYSICIAN:
CHEMISTRY RESULT FORM
(Sub'ect to the Privacy Act of 1974)
LAST, FIRST, MI.

WEE SSN/PSEUPO SSN:
r /0-.2/Le r,_____ *
I
‘, ...ei, --.--641:,:ebe-ii,litistgko.,..,,::..t... ?,...:

f,..._ „....„...,,,
....!.r.:*(4.:;.:',-.-:?:-
TEST RESULT REF RANGE TEST RESULT REF TEST
RESULT REF. RANGE
RANGE

ALB 3.5-5.5 g/d1 GLU 73-118 mWdl
ALP 26-84 u/1
BUN 7-22 mg/d1
. ¦ ALT 10-47 u/1
; ANN c.A4+ 8.0-10.3 mg/d1
Pt a F! e

AMY 14-97 u4
CRE 0.6-12 rog/dI AST 11-38 u/I
NA+ 128-145 m rooV1
i :3 IA DI 0 I •
TBIL 02-1.6 mg/di
BUN 7-22 mg/dl
CL 911-108 mmol4
CA++ 8.0-10.3mWdl
tCO2 18-33 mmolA
CHOL 100-200 mg/d1 - " ‘,"-'z':,:rpo kak
p •
Wet
-• •
::te .'• '

CRE 0.6-12 rag/d/
TEST RESULT REF. RANGE
GLU 73-118 mg/c11
ALB 3.3-5.5 gldt, TP 6.4-8.1 g/d1
ALP 26-84 un
gc9.16 . ALT 10-47 u/I
¦=:;•.,
.
' '';,',:• -•‘/.2 •••¦¦'

TEST RESULT REF. AMY 14-97 u4 RANGE
GLU 73-H8 mg/di AST 11 -38 till
BUN 7-22 mg/dl TBIL 0.2-1.6 mg/di CRE 0.6-1.2 mg/d1 GGT 5-65 01 aiculat ci CK 39-380 till (M)
TP p/d130-190 u/I (F)
NA+ 128-145 mmo1/1
K4 33-4.7 mol/1
TEST RESULT REF. RANGE
CL 98-108 mmo1/1 NA' 128-145 aunolA
tCO2 18-33 mmola K4 33-4.7 mmol/1
Pat ent T4Ylp ff7. Of.-;
F cic3

CL 98-108 ouno1/1
S vip :I+ tCO2 18-33 mmolA
REMARKS:
REPORTED BY:

DATE: LAB ID NO.:
MEDCOM -19467

TING PHYSICIAN:
CHEMISTRY RESULT FORM

(Subject to the Privacy Act of 1974) DATE TIME SSN/P,SE. SSN:
/5)
jeCipto
TEST • RESULT REF. RANGE

ALB 3.5-5.5 'dl GLU 73418m#d
P7. Name: 7

P
C

.77= L:

MM OI/L PICCOLO L 7 : 27 PICCOLO
MMOisL 18/09/03 19:33 18/09/03 19:33
REFERENCE Rai MALE ,1; 7 PLEIRE111 RANCE; MALE
PATIENT #: PAILLNT
LIVER PANEL. PLUS MEILYIE 8
DISC LOT #: 31228A4 DISC LOT #: 3111AM

OPER # DR #:7OPER #:

0
*Y18 1-1Ct SERIAL SERIAL #:

11111111111

37C

ALB 4.37G/DL • 138* 73-1187MG/DL

3.3-5.57GLU7
MG/DL

(5726-U/L BUN726* 7-227

ALP 847

A

27.4 mmHg CRE7MG/DL

7ALT 26 10-477
U/L 0.9 0.6-1.27
.-U/L

P02________473 mmhg AMY 48 U/L 511* 39-3807
MMOVL

14-977
CK7

43*7U/L NA+713J 128-1457
-10 r,4,moi/L 0.2-1.6-MG/DL 4.1 MMOVL

71; mmol/L AST 11-387

TBIL 1.37K+73.3-4.77

7

MMOVL

U/L 106 98-1087
20 MMOVL

GGT 9 5-657
CL-7

TP ­

7.976.48.17I3/DL tG02718-337

Ti

0-EM OC: OK

INST OC: OK7OK OK.7

CHEM OC: INST OC
P...t lent Tefrip;:c HEM 1+, LIP 0 , ICT 0 Gt HEM 0 , LIP 0 , ILI 0
TF

pr:n2 7

NiAdcr

5

Pn27

m7H9.
P8ti@7It tremp 3470

FTn?7 Ni

Sampie TypE.,)

2L=2' 1

_:;SEF'{ 7

O per-,'
11011

/ tCi

OS

DATE: LAB ID NO.:
Se
MEDCOM - 19468

DOD-033042

Ward/Section - REQ
LAST DATE
TIME 3 Ji
"
emato

TEST RESU RANGE TEST SULT RANGE
WBC Color N/A
18-0-03
WB

RBC 19238 N/A
APP
(1--rvz.

PatientHgb Limits Glu Negative
WK.. Axe_ 6--
17 7 -416 ­
'3hJi_ 4.5 10.5
Het RBC 5.37 x10'6/uL 4.00 6.00 Bill Negative
MCV HO 15.r, Hct 47.6 rE1) 98.6 gldL X 11.0 18.0 35.0 60.0 80.0 5'9.9 Ket la Negative
Plt Lymph % . 29.0 pg 27.0 31.0 MX 32.7 L gidL 33.0 37.0 NI 282,7x10-3AL 150. 450. Yz 6.F: 44 3 20.5 51.1 SG Bld ), 0 3 0 Tra C-e 'N/A Negative
tol LY# 0.9 k x10-1 3/:11. 1.2 _. 4 pH ,o N/A
Segs Mono Prot Negative
Bands • Eos Urob 0.2-1.0
Lymph Baso Nit /t-•. Negative
Atyp Imm Leuk /t/e &. Negative
RBC
Morph

Patient ID:
Spun 42-52% (M) Hematocrit 3747% (F) Test Name :PT . Test Result:: 15.1 seG.
Sed Rate ***RESULT NOT RANGE CHECKED**.* Ratio = 1.2
Other

Calculated
Sample Type:citrated wh. blood

Coagulation Studies
Test Date :09/18/03
Test Time :08:23 PM
Card Lot7

:010301

TEST RESULT REF. RANGE
Operator

9.&-13.6 secs

(rr
APTT/ 21-34 sees RAPIDPOINT COAG ANALYZER V4,54 SERIAL.. 09/18/03 08:28 PM
`traimer 20 ug/ml Patient ID: gill FDP 10 ug/m1 Test Name :APTT Test Result:= 27.9 sec.
REMARKS:
***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood
REPORTED BY:
Test Date :09/18/03

LABORATORY RESULT FORM I (Subject to the Privacy Act of 1974) S SSTI•
ro :
TEST RESULT REF. RANGE
RPR Negative
Mono Negative

Microbiology
Source
Grain Stain Occ Bld Negative
H. pylori Negative
Micro Parasites Malaria
O&P
Other
oscopicthiia
Aa:+es-+ -10-15
R he S ro
vS c' cif
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
ABO/Rh
OitCrOOinitclf • TE EVERY UNIT O• BLOOD ESTE.Dy •
DE CROSSAMTCH
MEDCOM - 19469

DOD-033043

Ward/Section: C LAST, FIRST,M1.0
TEST RESULT
Na
K
CI
pH
PCO2
P02
TCO2
HCO3
SO2
BEecf
AnGap
Ca
BUN
GLU
Creat
Het
Hgb
TEST RESULT

Tropoin-1
Drug of
Abuse
REMARKS:
REPORTED BY:

REQUEST] PHYSICAN:
CHEMISTRY RESULT,,KORM

REF RANGE TEST
138-146 mmol/d1, ALB
3.5-4.9 mmol/L ALP
98-109 mmoUL ALT
7.31-7:45 AMY

35-45 mmHg (art) AST
41-51 mmHg (ven)

80-105 mmHg (art) TBII.
N/A (Yen) 23-27 mmol/L (art)
24-29 mmol/L (ven) 22-26 million, (art) 23-28 mmo1/1, (art)
95-98% (-2) - (+3) mmoUL 10-20 mmoUL 1.12-1.32 mmol/L 8-26 mg/d1
70-105 mg/d1
0.7-1.5 rng/dI
38-51% PCV
12-17 g/t11
REF. RANGE
-

2
GL
BU
CR1
RESULT EE NGE
3.5- .5 g/dI 26-8 WI
10-4 u/I 14-97 u/I
11-38
=-
- PICCOLO -
= = -- —

04 'il 4 26/ 09/03 MALE
REFERENCE RANGE

•
( PATIENT # MTLYTE
vL,) 3152M4
DISC LOT # :

1 DR # : 000
OPER #

111111111/
SERI AL

...... , .....
.........7.3-

118 MG/DL r
117

GLU MG/DL
9 7-22
BUN

0.9-1.2 MG/DL
1.1 c
CRE U/L
43 19-380

Cf: L
4€011.3l328-145 MMOVL
NA+ -

3.8 3.3-4.7 MMOL
CK K+ MMOUL
89* 98-108
CL-

NA+ MMOVL
tCO2 21 18-33

CHEM GC: OK
K+
I NST GC: OK

ICT 0
HEM 0 , LIP A +

CL­1CO2
DATE
(Subject to the Privacy Act of' 4)
TEST RESULT RE4 RANGE
GLU 73-118 mg/t11
BUN 7-22 mg/dl
CA + 8.0-10.3 mg/d1
CRE 0.6-1.2 mg/d1
NA 128-145 nunoUtll
le 3.3-4.7 mmoUl
CL 98-108 trimo1/1
tCO2 18-33 mtnoUl

fri0002j4kOtr##OURE0
EST'
T
RESULT REF RANGE
3.3-5.5 g/d1 26-84 u/I 10-47 u/I
14-97 IA
11-38 u/1
0.2-1.6 mg/dl 5-65 u/I 6.4-8.1 Will
EIectrolyt
RESULT REF. RANGE
128-145 mmol/I
3.3-4.7 mmol/1
98-108 nutio1/1
18-33 mmidll
MEDCOM - 19470
DOD-033044

Ward/Section: REQUESTING PHYSICAN:
CHEMISTRY RESULT FORM
TEST

ALB
ALP
ALT AMY AST TBIL
BUN + +
CA CHOL
CRE
GLU
TP
TEST
GLU BUN CRE
CK
NA+ K+
CL-1CO2
DATE:
DATE TIME
Jc5910.c1,4901t,
RESULT .REF. RANGE
3.5-5.5 g/d1 26-84 u/I 10-47 u/I
14-97 u/I 11-38 u/1 0.2-1.6 mg/d1 7-22 Ing/d1
8.0-10.3 mg/d1 100-200 mg/di 0.6-1.2 mg/di
73-118 mg/d1
6.4-8.1 Wdl
RESULT .REF. RANGE
73-118 mg/dl
7-22 mg/dl 0.6-1.2 mg/t11 39-380 /1 (M)
30-190 /I (F) 128-145 mmo1/1
3.3-4.7 InmoUl
98-108 mmo1/1
18-33 mmo1/1

LAB ID NO.:
(Subject to the Privacy Act o•1974) SSN/PEEUDO SSN:
PICCOLO ===---

09/28/037

07:57 AM

REFERENCE RAM7

MALE

PATIENT #:7

(4Y-af

METLYTE 8
DISC LOT #:

3152AA4

OPER #:

0, DR #: 000
SERIAL #.

1111111111
GLU7

109 73

-118. MG/DL

BUN7

10 7-227

MG/DL

CRE7

0.97

0.6-1.2 MG/DL
CK7

26* 39-3807

U/L

NA+7

118* 128-145 MMOVL
K+7

4.2 3.3-4.7 MOM_
L-7

92* 98-108 WOK.
tCO2 20 18-337

MMOL

INST OC: OK7

CHEM OC: OK
HEM 0 , LIP 0 , ICT 0

CL-98-108 mmo1/1
1CO2 18-33 mmo1/1
Na
K
pH
PCO2
PO2
TCO2
HCO3
SO2
BEccf
AnGap
Ca
BUN
GLU
Creat
Het
Hgb
TEST

Tropoin-1
Drug of
Abuse
LAST, FIRST,MI.

TEST RESULT REF RANGE
138-146 nnnoUJL
3.5-4.9 tnmoUL
98-109 mmoUL
7.31-7.45
35-45 mmHg (art)
41-51 mmHg (yen) 80-105 mmHg (art) N/A (Yen)
23-27 mmol/L (art) 24-29 mmoUL (yen) 22-26 mmol/L (art) 23-28 mmoUL (art)
95-98% (-2) - (+3) mmo1/1_,
10-20 mmoUL 1.12-1.32 mmoUL 8-26 Ing/d1
70-105 mg/di
0.7-1.5 mg/t11 38-51% PCV 12-17 g/d1

RESULT REF. RANGE
REMARKS: REPORTED BY:
MEDCOM - 19471
DOD-033045

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
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\ LOCATION: DI
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GE OF C T'S MEDICAL RECORD USAI1A V1.00
MEDCOM - 19472
DOD-033046

ANESTHESIA PLAN OF CARE Pri=0:10CEDIJRAL ASSESSMENT (Sedatiogaggiabesial
Age 7 DAYS MOS YRS
PROPOSED PROCEDURE:
SURGICAL SERVICE:
NPO SINCE:

HABITS: TOBACCO: ETON: DRUGS:
CURRENT MEDICATIONS: 0 = ordered as premed
• ft

mirmspiar et
Tar
PREMEDICATIONS:
None Yes (0 Hrs) /CC

mg IV IM PO mg IV IM PO mg IV IM PO
LABORATORY STUDIES:
HB/HCT: U/A: OTHER:
Sex (MALE ( ) FEMALE
my

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
Cardiovascular:
Hypertension N Y
Angina N Y
MI N Y
CVA N Y
Other N Y
Pulmonary System:
Asthma N Y
Bronchitis/URI N Y
COPD N Y
Other N Y
Renal System:

Acute/Chronic RF N
Gastrointestinal: Hepatitis Metal Hernia PUD/GERD Endocrine System: Diabetes Steriods Thyroid Neurological: Seizures Neuropathy Other
Gynecological : Pregnancy Other Significant Hx:
Familial HX
N Y N Y N Y
N Y N Y N Y
N Y N Y N Y
N Y
N N N

ANESTHETIC PLAN: { 1 LOCAL { 1 MAC { ) Regional (Specify):
ASAInfsio-eAate 2 3 4 5 E WT: 70 Kok": HT: IN. ALLERGIES:
ASSESSMENT PAST SURGICALJANESTHETIC
„„, PHYSICAL EXAMINATION
BP HR A1 R z4 T
Pain 0-i 0
HEENT - Teeth
Trachea
TMJ/Neck
Oropharnyx
Nareser2=2=
CHEST:
CARDIAC: tau'
rue_ 2
EXTREMITIES:
IV Access;
Ulnar Filling:
BACK:
OTHER:
NPO Since
f-ro—eneral: M ntubation

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
discussed with the patient/legal 9uardian. cc_ ) The . Questions ans Sig
rd4
(11‘
ESIA EVALUATION NON ASU) ARENT ANESTHETIC COMPLICATIONS { } OTHER
Patient Identification: (Ward)
A

111b p(Lt)
lime: 20 73 Hrs
SEDATION KEY:
1.
MINIMAL (Anxiolysis) Patient responds normally to verbal commands

2.
MODERATE (conscious sedation)

Patient responds purposefully to verbal commands alone or accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA.
Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.
4. ANESTHESIA. Patient does not respond to painful , stimulation.

WAIAC Form 2300 (Revised) 15 Mar 01 MCXC-DOS Previous edition is obsolete
MEDCOM - 19473
*U.S. GPO: 2002-729883
PATIENT RECORD COPY
DOD-033047

MEDICAL RECORD
COMPONENT REQUESTED (Check one) 4... RED BLOOD CELLS
.
FRESH FROZEN PLASMA

.
PLATELETS (Pool of.units)

.
CRYOPRECIPITATE (Pool of.units)

.
Rh IMMUNE GLOBULIN

.
OTHER (Specify) VOLUME REQUESTED (lf applicable)

REMARKS:
UNIT NO
DONOR
ABO
C

Rh
ML
•

TRANSFUSION NO. PATIENT NO. III RECIPIENT ABO 0 Rh
INSPECTED AND ISSUED BY (Signature)
(Hour) ON (Date)
a

IDENTIFICATION
NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION ! -REQUISITION

TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
. TYPE AND SCREEN
Vls CROSSMATCH
DATE REQUESTED 4,
/ SS -CP 0 DATE AND HO R REQUIRED
llte

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Speci
(Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE•TRANSFUSION TESTING
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
Corvfx

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED REMARKS:
40} SeP6

SECTION III - RECORD OF TRANSFUSION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.
R (Signature)

TEMP. PULSE
DATE OF TR TIME STARTED
03
PATIENT IDENTIFICA N—USE EMBOSSER (For typed or written entries give: Name—Last,
rate; hospital or medical facility)

REQUESTING PHYSICIAN (Print)
".:
PERATIVE PROCEDURE
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
SIGNATURE OF VERIFIER
In
DATE VERIFIED
itS 5-fia 4
TIME VERIFIED
/S 2.0
PREVIOUS RECORD CHECK:
RECORD
TIME/DATE
1-1F-

REACTION TEMPER ONE . SUSPECTED
If reaction is suspected—IMMEDIATELY: . NO RECORD
PERFORMING TEST
NTERRUPTp,
2,3 0
SE BLOOD PREURE
7_.-1o27 3

1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION

. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)

R DIFFICULTIES (Equipment, clots, etc.)
NO . YES (Specify)

BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 19474
Medical Record Copy
DOD-033048

519-301

NSN 7540-01-185-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AGE SEX SSN (Sponsor) WARD/CLINIC REGISTER NO.
FILM NO. • 'REGNANT
n YES 1111 NO

REQUESTED BY (Print) TELEPHONE/PAGE NO.
SIGNATURE OF REQUESTOR DATE REQUESTED.
V 5 SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
e-e_d
ito

DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC REPORT
/0-f rt4zcr,
7

er6_
LD

4,e 4-1(
1:­

tv;1 Ci&,2-gt
PATIENT'S IDENTIFICATION (For typed or written entries glue: LOCATION OF MEDICAL RECORDS
Name — last, first, middle, Medical Facility)
LOCATION OF RADIOLOGIC FACILITY
11111 -•.
SIGNATURE

zrrioN STANDARD FORM 519-8 (8 -83)
MEDCOM - 19475 Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8
7 -tin.iNectr94i4
DOD-033049
• (7 C.3 rvl
DOD-033050

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED 4EDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF, ORDER TIME OF ORDER LIST TIME •
•
ORDER ED ANDHOURS

0 i e g/ A .q e c-— NOTSIGN
. ?-14 e1, ..A s
dird

/4, •
k-Dl cc k) -q
4RIETIMPio• Z.' INIMMINW
. drAVM. de.4se_ WA dcdif,Z~ I A
ni,0 e. F IMINFJPIM
NURSING UNIT ROOM NO. BED NO.
roM-6-25s -: WIFININERIMa
MI IMMIETWAMI,
70-4;-

PATIENT IDENTIFICATION
DAT OF ORD TIME TwF 0 DER
H0111

II A I t i..
FAMBILMIIIIA
mramirrammem¦
thirmarmw

im e
c

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION RDER
9/iS 'Y. HO RS
11 kek4,44'Ir SI _dr-Ta
¦tzy ., c, p Pd-
1 ,..7__

No A,.
1,-.Ira01 ,s,,, F..
/ •(.b Le) -
P41 Ir/e°

NURSING UNIT ROOM NO. BED NO. • ....
a i,. , .
,,,..._..

Qb¦
..-4A "fflraffinFA
PATIENT IDENTIFICATION .-. DATE OF ORDER TIME OF ORDER
°_. c.
r/ ,—,c.4—..-.H
V I -2-r I.4 i'1•11MEM111111
ria 70,1
IMIWINNE -PM

•
I

NURSING UNIT ROOM NO.
BED NO. .
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1 F4256
AOPR
M„
MEDCOM - 19477
DOD-033051

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED P4EDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME
ORDER
NOTED AND

PATIENT IDENTIFICATION DATE OF ORDER
HOURS
IhY/ 03
SIGN

NURSING UNIT ROOM NO. PATIENT 10ENT FICATION BED NO.
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. DATE OF ORDER ME OF ORDER HOURS rir
PATIENT IDENTIFICATION N NURSING UNIT ROOM NO. BED NO. OF • RDER .2) TIME OF ORDER HOURS

NURSING UNIT ROOM NO.
REPLACES EDITION OF 1 JUL 77. H MAY BE USED.
\ DA 1=9 4256
MEDCOM - 19478
DOD-033052

CLINICAL RECORD - DOCTOR'S ORDERS
Fpr . of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE,'TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
.LIST TIMETIME OF ORDERPATIENT IDENTIFICATION DATE OF ORDER

ORDER NOTED AND

94V/0 3 HOURS
SIGN

NURSING UNIT
44)
PATIENT ID ENTIFICATIOK
HOURS

NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED HOURS
NURSING NIT ROOM NO. PATIENT IDENTIFICATION
BED NO.

FORM REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
D-A--z 2
r's 1 APR 79
tr U.S. GC MEDCOM - 19479 .710
fl ' )
.
(t )
DOD-033053

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME
ORDER •

.

,z NOTED AND
17 y
HOURS SIGN
OA! .diZti,as.;,
lr
Al ,
w

NURSING UNIT ROOM 0. BED NO.
1/44

PATIENT IDENTIFICAT N DATE OF ORDER TIME OF ORDER
OCC30 51 4V5-23
HOURS

Owe.- Gar; icc,,-(--; oh : Acivanc•e ctle4-
as -k-o‘e,roAcot1111111 \JD br gi.35(Pcj4ed-g
a'

NURSING UNIT ROOM NO. BED NO.
q2e • illi.. -.
'i i A I ig• r, . . ...._ P • illiM1E" , lib eArx.., ..... •
PATIENT IDENTIFIC • DATE p OR TI • •y • • I
b ( c_e. --L-_ 9,/?, 60.Op-,.
HOURS

CL !ye_ .. 4 4 PrD ........,
4.-

...e,14..-1.4.2._.5/,.f9,-.A i • si
-
li!
Ae 14

:k a iffi¦ -
L •

NURSING UNIT ROOM NO. BED NO. ',)
(c.,.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
f.

t
4• NURSING UNIT ROOM NO. BED NO.
\
FORM

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED
4256
1 AP? 79

o U.S. GOVE MEDCOM - 19480 .9
DOD-033054

THERAPEUTIC DOCUF12155Athlall.CAFIE PLAN (NON-MEDICATIO1V)"
CLINICAL RECORD Mo..Yr. 2003
.-Y,...V,Z.1,:i.: f:Ii ...s,:. ,r11.-
INITIAL PROM? COLUMN FOLLOWING EACH COMPLETION

VEIUFY BY INMAUNG
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

a -
IliCll
\)gl
-
_

I NY() I rill
" k •
um./

64111111111PARMANIM1 e _____Jrilfil.
MI

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...4MINIIII
-t

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tvik 1 -tv.goo Izt- io 1 'MIN
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"dal ti 0 1.-0' 0 Viva = li iwio
.

11011111111
117 $.° •
PAI ..4
, 17C CArl 'Fr 1 I M -1

10411 II ION II
.. r Alowarnmemirand "Eirlid=IMIC.a.,0
.:... FAIL.__IRA' ,c) 41-4 d-oscr-)0.-d V01-1,f Pt,'-e. F ii Ifi — 1
t
ADDITIONAL PAGES IN USE:

ALLERGIES: MN YES. MN NO PRIMARY DIAGNOSIS: •
IN YES INO NO

5(c2 z-u-r„..c ifg
PAGE NO'
PATIENT IDENTIFICATION:

ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
, D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
I .._._ .....

EDITION OF 1 DEC 77 MAY BE USED.
DA FORM 4677, 1 OCT 78
MEDCOM - 19481
DOD-033055

Verit y by
THERAPEUTIC DOCUMENTATION CARE PLAN ,
lnitaahng
(NON-MEDICATION) Mo.Yr 2003
Order Clerk
Date to Time to

SINGLE ACTIONS
Date Nurse Time Done Mltiala
be Done be Done

taluvv-k
1)v,
0 ez,--1
(pf-)7 VD
4-J

Order!
Clerk/

Expir PRN LVTTIAL PROPEi COLUMN FOLLOWDIG COMPLETION
Nurse

Date ACTION, FREQUENCY
TIME/DATE COMPLETED
ti
USAPA V1.00
MEDCOM - 19482

DOD-033056

-f\

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION ) C4
CLINICAL RECORD For use of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon General. MO..1.Yr..2003
VERIFY BY INITIALING „,. ......................................................................... INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME

t 2--3

NEINIRIOLTIE121 W
2/ SF,/#3"' .' C, is.z ° ,---
'
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V.. e.Jg'. 6 1-6-1.V4..1
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II

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211-lliP-Atimcaye 1.)-ie_k as-kr-lei-city' gior." 100,k_ G. Or A.
I
IC6

ALLERGIES: MI YES F7741(0 PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
,.-i / i /

w.eg.,,v./ 5-4,, / i F/k- Z.--ppl,,-„,r me,,470„,,,,, =YES - NO
xro/f

c•-PAGE NO -
vmernei/110,1
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15

( 67_S - (4
glib
E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM - 19483
DOD-033057

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing • (NON-MEDICATION) Mo. Yr.2003
)

Order
Clerk Date to Time to

Date Nurse SINGLE ACTIONS Time Done Initials
be Done be Done
-

215607 is re-G „_cler [0 ..6- LI/ — 5 4,1/e-215E d.,) .1-
7
trW Fd (.2(.--c, 1.,frz2
A.
N
— — — —
,
— — — —
— — — —

Order/
Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expi r
Nurse ACTION, FREQUENCY
Date TIME/DATE COMPLETED — — — — _ _ _ _ •
— — — — — — — — — — — — — — — —
MEDCOM - 19484 USAPA V1.00
DOD-033058
-2 7L­

1 THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407;
Mo..Y T.

the oroc agency, is the Office of The Surgeon General. -
VERIFY BY INITIALING 'Ii;:^E;,; .., INITIAL PROPER COLUMN FOLLOWING EACH ADMINIS7RA7ION
HR I DATE DISPENSED ORDER CLERK! RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
j•Gtx.dt.v-i 10 "1 fki
IC\
^^

t7

2-(
1
•

GINAv
iimq0-55-c2)0( 06
113GS) tr-.w all c /
_ 160 iti)r Ili

0$51) - , „,...4 RD AnfOiLr -kg a_41 n Ssej$4,;9) pc IR A Ilitair • 4--. . di ._ .
As ill- Ps"^-1 1 tr vin $ r 111
. tg,
•
ALLERGIES: III YES MI NO PRIMARY DIAGNOSIS: 5/12 EtiCke c() ED IA— ADDITIONAL PAGES IN USE:NI YES MO NO PAGE NO
PATIENT IDENTIFICATION: DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
10 b (()--L' D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06

DA FORM 4678, 1 FEB 79 crwrinni nr 1 ncr 77 WII I RC I mpo UNTIL EXHAUSTED. USAPA V1.00
MEDCOM - 19485
DOD-033059

Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(MEDICATIONS) Mo..Yr.
Order Clerk/
Date SINGLE ORDER, PRE-OPERATIVES Time to

Date toNurse Time Given Initials
be Given be Given
•

- .
Orderi Date
. Clerk/ Nurse r&Sir • MEDICATION, PRN DOSE, FREQUENCY MSS 4d VI-I,N . (2 ' .,.._„ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED

•
USAPA V1.00
MEDCOM - 19486

DOD-033060
Cs2

/THERAPEUTIC DOCelZt.¦,17-4,10-12i\sieFAIAN (MEDICATIONS) mo. ti, .yo
CLINICAL RECORD
/ Ihe proponent agency is the Office of The Surge n General.

VERIFY Ll ? IN I T I /I L I N G .i:::;:liM m i*ia:* ;:; I N EI I A L P R 0 P E If C L UA, I N 1.'0 LL 0 IV I N G E. A C I-I /I I. ..)A1 I N I ST It A T ION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

.2/ 22 __r i ,i, , ,
5

V' ,' Pc OW 7204-/
u JOKSIIP%Oi
.-
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—

2 i SeA 3 WO /‘eP [ vr,, ,i-e 06 I 4/ 2-Asp 5 .2.17
. 1 IIMUr.71.waAi¦M=M I Nor

L5-E-6,1110 ,p,1„„1,‘,,.300,.®o.45 an
t _ . . )/0 -* • NS 0) Jo ,, c / er f— / r---libb
111111Arar-

-4 7
ALLERGIES: I 1 YES ---f-NO PRIMARY DIPANOSIS: ADDITIONAL PAGES IN USE:
57/10A1,!ei-o. 7 s--1,-, // C--,t-- 2-.5"/:" ,-.11. h/e.,.., cii,,,ii M. YES MI NO
41 d fr

64,2. C LA.A. kr/N. PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14

C Illir V-( (5- - `A
E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V1.00
MEDCOM - 19487
DOD-033061

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo.

(1 ----Yal

Order Clerk) Date to Time to
SINGLE ORDER, PRE -OPERATIVES Time Given . Initials
Date Nurse be Given be Given
t
Order! Clerk! PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
EDxaPte' r Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED

114c.f

0 ,45\-et-as dIze,e4-2.46Elele
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14°.f-YN-10 p,,, ., (c.)- e,.,k,\
•,
,
USAPA Vi .00
MEDCOM - 19488
DOD-033062
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 OTSG APPROVED (Dote) INTENSIVE CARE NURSING FLOW SHEET • QA Appr 8 Mar 89
FTAS5ESSME I

)NI1IAI. INITIALS MO MIS
TIME

I
P4i1 PUPILS

A-r--k- 2 n..^0,
SENSORIUM 4
RESPIRATORY PATTERN
BREATH SOUNDS kkeid-14,44.,
SECRETIONS

f
r../-• 97-16D %.

C OL 9R
INTEGRITY

0-0/ 4,4 Cil-siteri
LOCATION
0 .4e_
-
CONDITION
E

D 1 1L .( 2—Ufr—C-t.1{30CL.r.
ABDOMEN
•
BOWEL SOUNDS

!gIci)
fr

URINE: _
COLOR/CLARITY •

CARDIAC RHYTHM /-21"-r_26
.

1 f
2e4t1 OS

SM- Fractional tio2 -fraction of Inspired 02 PCO2 -Pressure of Arterial CO2
Cr - Creatinine ICP Intracranial Pressure
SAl - Saturation HCO3 • Bicarbonate 1RACH Iracheostomy
PEEP - Positive End Expiratory Pressure
(Continue on reverse) lure & Title) DEPARTMENT/SERVICE/CLINIC I DATE
9koil 2/ Se, 0,3
riven entries give: Name—lost, fi -st, le; grade; date; hospita or medical facility) O HISTORY/PHYSICAL 0 FLOW CHART
O OTHER EXAMINATION 0 OTHER (Specify) OR EVALUATION
•
DIAGNOSTIC STUDIES

•
TREATMENT

Dik FMCP/M78 4700 - 1 MEDDAC FBg OP 375, 1 Apr 90 ( HSXC-NU
Proponent: Dept of Nurs MEDCOM - 19489
DOD-033063

OAT PAGE 2 OF 4
EZ/ ,a D
5)" HOSPITAL DAY
TIME at G -7
BP Arterial line

BP Cuff tta-4.4 1 1 `fq
Temperature
..

"1?7
Pulse
90
ZZ

q 7
TIME
Dp4-s7L -).„)‹.

Jo
TOTALS

HOUR
TOTAL
URINE
TP
SIA
ourPur
NG pH
GuLac
EME1IS
STOOL

DRAINS
TOTALS
IY

7q
/04 75-7f# 96 ¶7(,

ZZ 27-214 tq -q7.bei qg gs" 4/)-.(z4--/10 lam'
8° T 8° T
ftrd ja
iia
/00
//
MEDCOM - 19490
DOD-033064
PAGE 3 OF 4

POST-OP DAY
ACUITY MEL CLASSIFICATION

_111111111111111
1111111•111111•0111111111111
B HCO3
SAT
G BASE

II.I I 111
GLUCOSE

111111111111111111111111•1111
12111111MMILIMULTIMILI
1112/4.1111281111112111
BUN/Cr

PR PENNI MOM PA
WBC/PLATE LET

12121611121111161/M1
SIMMIRMIIIMAILS
MOUTH CARE
SKIN CARE
FOLEY CARE

TRACH CARE
ROM EXERCISES

OUTPUT
Urine:
TOTAL
TOTAL
BALANCE
..

HOURS 9
SPON LANE OUSL Y
1 0 LO SPEE0-1 . 3
1.11 10 PAIN . 2
1.1.¦ NO In OPENING

ORIENIED

A CONFUSED
'z
3
EL
NW v OCAt S 2
NO VOCAt I2A DON 1

S.
ONLY%
COMMANDS
OCALIZES PAIN
0,7,1 I-i XION WIT NORAWAL
00
ABNORMAL t-El Ex ION
un"'
Ex TENSION
10 PAIN
NO MOTOR
ID
NI SPONSE

NORMAL POWER MILO WEAKNESS SEVERE WEAKNESS ABNORMAL FLEX ION ABNORMAL EXTENSION NO RESPONSE
NORMAL POWER
V
MILD WEAKNESS
E:.

SEVERE WEAKNESS ABNORMAL FLEXION ABNORMAL EXTENSION NO RESPONSE
SIZE
RIGHT
REACTION
P.
SIZE
3
LEFT
REACTION

NEUROLOGICAL ASSESSMENT MI MIME 211rai., 71.V.F.:1=11111•111 PAGE 4 OF 4 LEGEND C Closed by swelling T Trach/Endo S Slurring D Dysphasia R Receptive E Expressive
+ + Brisk Slow No Response R Right t. Left Record separately if there is a difference between the two sides.

• 2_• 3
PUPIL SCALE •6 mm
• Intact ICP
-Abnormal
CEREBRAL PERFUSION PRESSURE
ASClitAR ASSESSME
LEGEND

HOURS
R + • Normal ViVtak
FICRIPANNISPINNINNININMON
Absent D Doppler

11151/A511151/11PAVAPPINVAITIVOI
R Right

BIPININVAPINFANOVAN/NONSPInd
Left

/NOVTAMINIBOONFA
MEDCOM 19492
DOD-033066

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

REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
1 .!,.
,.

.:* '.!SHIFT ASSESSAtlsiT! .1:--, ,-TIME: O .yo.INITIALS:./ TIME:.1.900..INITIAL . PUPILS Pei (101.SWOT) ..' P-,.at( i.difresinryq-C
!:PT ., LA-.ZC/..‘"),..-4 K.,."k ,,, SENSORIUM /-4-xi-el-e,cf,,p,....... ,3Le, iz,2,-:, 4-417rid-,...7,1 Pi-i.s.rtiliVsglif) t )4..-ID +if(' 11-) Li. 5-1-i ntiati ;ft EXTREMITY MOVEMENT kete. 72.,,,,i.0,-,._,--e4.06-,..-...2.44-4:1-1- OULSCIPL.LI •04+021/0„1+41.4.ig,N (1. n(IYI
.1,-0,12.
SEDATION :Z.. . F..,4..di.,.Amor 1._. i I la a l—t , _ ri—.e....¦".....,1 PAIN CONTROL .-r ii 04.ihv Vasa + SD (Pic- 11,vr ..41.ku1t / .
,--,.,
RESPIRATORY PATTERN it-.•.&."1-..ce.....,
1
44.,"tr,1'
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:'I A H SOUN S -. 11,, ....--,d).c-P-re-R.--i kat' ..,6.s.tin,' 4.4.-..3-.-ak_.•._•• SECRETIONS t".41-4"-er-----t.,4.--, r.:- -1-i)-1-1 ,:-.iffee....ind-, 00 03cryi1rz) nvhan.1rib9 :tsli i=ded vc-A
-.
- -.

.r, 02 SOURCE/FLOW/SAO2 66,zzkfz...1,7;.:=45:4g,-1-.ci,,t....;-5.,,,-,,,,.....A in . 1,4.I.CM.L:-0--..... 0,9- 1 067r.Mil VENTILATOR SETTINGS 7\icF6c.1 gPo F--iba 3/402.'r AL. isVartrOicri.mid-. 63 ia a meaf-AkicuAni.
-

•.( CARDIAC RHYTHM -5'...hitt-.cifir.:61'7 lfer.-i_v-, the-g040/5 - $t-.7• n)W_. CAPILLARY REFILL 4351. . (-;--:q Ow frvemP fraa4, 6-:21) 0,0.(
° PULSES A?-01 _...--e.,(6-.gbiltzu 1161-6,9(.40 CpivAa co.(4,-V--a -
EDEMA. (----,e_a21-2_0‘ -(---) ,i2 rid ittffie.z--se, 5 `

A Lz_i 4- (etz_ca,•0_0 ABDOMEN kkir °,-.-t,..,.i--e-40 ,g4f.1\,4K.,,,--el---ad.9-. ,P-PL on.a. • r)irr.-tn t-,v!s BOWEL SOUNDS r. 0.,a,l1.1 _ C.:.i0 .
- li 0,..44
(

BOWEL MOVEMENT
:‘,,,,

NGT/OGT Q CT -1-c,.t.:AP-,-,..-M-c,..,-.4-.c.
TUBE FEDDINGS

P:5-
DRAINS

0 .

VOIDING ' '57.{-.lao,.co . (").
-r.e.t.Ali. COLOR/CLARITY 21-4ad 0A:.1.,/..f Lit-i:
COLOR re)-7Arti. la.14,0c4c5)-1-k (j. ' 04.dical A.Ifici .5j.tht.t., INTEGRITY c---,..,.4.,..e14.7.i ...,, n.....„..ds.......,
aint.—d Ft rfera'frft-r4 21
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PREPARED BY DEPARTMENT/SERVICE/CLINIC
ICU #1,

or typed or written entries give: Name -last,
-?.-

first, mid e; grade; da e; hospital or medical facility)
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NAME: RANK:.AGE:
. OTHER EXAMINATION.. OTHER (Specify) UNIT: GENDER: OR EVALUATION
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STATUS: US: AD / C V.IRAQI: CIV / EPW
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DA FORM 4700, MAY 78
.
USAPPC V2.00
MEDCOM - 19493
DOD-033067

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MEDCOM - 19494

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General. OTSG APPROVED (Date)
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
INITIA SHIFT ASSESSMENT
N Time: vo is.Initals:.b -1--Time: Initals: E Pupils
_21011__IX r
__IP2rASq441141-042—
U Sensorium

10 .I .',{ _111:.ii.II si.cA
R LOC / GCS

1411.4414:61.0 . S ip-LpaAriLiLlitadiblack,_lt .
0
C Cardiac Rhythm S i - S9 . 5n us rh941,1rn•.ate.lo's .

A PRI:./.QRS: +2 0 pia pailLeib i a)1(6,--)ractitej .
R Pulse Strength piA/3e,, 02 0"): rroijA pulaa . e.eit ..i&
D Cap Refil / JVD _ -So' .

!I.• -6-Qttrann, Arad
I Edema
A Chest Pain

.

C' R Respiratory Pattern Tirifujotaid, in ,.9qtiag 0 Li-•.cz-vidy Breath Sounds 10.ThIStD.P-.• s-.,.1.
A i A

E
Secretions
fo 016WiA_
S •-itbAILh)(4. W (co% . Grottirl__---
P Cough .11-.1.6 •.ll i.._ O., , i.A '_4., /1.
OW-primal/0z, a0- -2 civil-170 • S Color .1• tvi Lt. LIC .. (A-(.ylt.) ID OD pa/aiteS.al _ K Integrity LAW •.640631 ciirtnc.k. Mod 'lb efolt Art . Backside
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A -Likut..lbwri+ Wad .Crori yam vicwe ,
Abdomen ;Y(.
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ad SI+ • 1.?-0. rittcof • 0G-ink) ft, LE.5.
I Stoma/Ostomy

I.li ' 4.1.t_••.au.y2 GS4:061:i
thisli IA f.*IAA ilv.301 dal% na.5.4
Device

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Color / Clarity CA).1A/LC-11LC .. I c c . K j h_

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(Continue on reverse) PREPARED BY (Signature & Title) DEPARTMENT/SERVICE/CLINI DATE
ICU #1, I S03.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, first, middle; grade; date; hospital or medical facility)
. HISTORY/PHYSICAL.. FLOW CHART
NAME:. Li.RANK:.AGE:
. OTHER EXAMINATION.. OTHER (Specify) UNIT: 'A*. GENDER: OR EVALUATION
. DIAGNOSTIC STUDIES
STATUS:.US: AD I CIV.IRAQI: CIV / EPW
ni TREATMENT
MEDCOM - 19495

11A CrlDhA n r-In.A V "70
DOD-033069

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MEDCOM - 19496
DOD-033070

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

QA Appr 8 Mar 89INTENSIVE CARE NURSING FLOW SHEET

z
---,,,

INITIAL SHIFT ASSESSMENT.
N Time: 066'.Initals:.1111 Time: AO Initals: IP_

16"-­
-92,4-1— -

' E Pupils e'gLt 16a,.; k--
-g-
R LOC / GCS

U Sensorium at() •.ed-t_11,,,,,t71-i.d U. ly,:, a-.--_J -114-cli-•--.----"2-41-e_ii-5 -e-----'--
4ggefi.. N__tiqraa4Z__
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C Cardiac Rhythm 14' Ali 45..5 r•-.3-LN,-..-1),,._t_p______. ..),_
FrC-A PRI:./.QRS: tc,7_, r-st,...21.,.(1-0.2,....--z._ .efr-e.ki.4 R Pulse Strength Cae •.P,-i„.e D ;Cap Refil / JVD 4 _1.:— ..NI D MON I Edema
-.-Q-Ze.2-.-----a .
A Chest Pain 6,,,,. 4-12 h co-e-e-qic,,,--
C

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,.:z.­
tAt2.--;44

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Breath Sounds Cee,f.AA ‘4i.53-.9,,,,i c_1,-,t__.-e7y, 4__.,--.A., ' - •.
1.L.L2-..),--f2 (1.4.---)-,
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S

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SV.

Device ,
d_.-

G , _
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PREP.•.& Title) DEPARTMENT/SERVICE/CLINIC ...9N DATE

co °3

-ICU ill,
yped or written entries give: Name -last,
firs ,.e,-grad ; ate; hospital or edical facility).

. HISTORY/PHYSICAL . FLOW CHART
NAME:.1 f. RANK:.AGE:
. OTHER EXAMINATION . OTHER (Specify,
UNIT: GENDER: OR EVALUATION

(11 DIAGNOSTIC STUDIES
STATUS: US: AD / CIV IRAQI: CIV / EPW
ri TREATMENT
.MEDCOM - 19497

114 PflPhil 47fIrl rol A V 7P
DOD-033071

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MEDCOM - 19498
DATE.TIME MODE RATE VOLUME 1 FIO2'PEEP! PIP
Ph
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REMARKS

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MEDCOM 19499
‘ '`
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AMERGENCY CARE AND TREATMENT Treatment Facility: BED #
/(Medica' Record) 21' CSI-I OP 01 ).IC) ARRIVAL TIME: I S.9 03 ' 21 st CSH/EMT TRANSPORTATION Ground Tactical . Air Rotati1 . ALLERGIES MEDICATIONS:
DAY MONTH YEAR
Ground Ambulance 0 Air Fixed . N YJOA-
Other .

CHIEF COMPLAINT PAIN SCALE TETANUS SEX AGE (1-10) nead_r
I URGENT ERGENT n(TIME SEEN BY PROVIDER:VITAL SIGNS NON-URGENT n
TIME 70 -1 1. • (1.4.4104,:v ej.
BP lag ZO;-
oce PULSE 119 101 cvedit qtr Lidtt-ry .
RESP LLz:544_.
10 b014.k..— V
TEMP KA, u.
t ot-o ,
%02 5 z /„r ORDERS IME PAIN U5 6'.4-0, 4-frix.• tLf
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DISPOSITION: HOME 0._DUTY
QTRS . 24 . 48 . 72
OA

\ MOD DUTY: UNTIL REFERRED TO: .
Al\r,

EMERGENCY . TODAY . 72 HRS 0 ROUTINE .
(47) p is E
ADMITTED:_ SERVICE:
s.

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PATIENTS IDENTIFICATIO PROVIDER SIGNATURE:
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NAME/RANK: (.11,e4,,Azgy,INSTRUCTIONS TO PAT ENT:
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SSN:
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DOB:
UNIT:
LOCATION:
MEDCOM - 19500
DOD-033074

,,,,_,STING PHYSICIAN AfitUKATORY RESULT FORM
Ward/Section:
\-9.1 (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
LAST, FIRST, MI.

1 etvl.W-St. 3 1 5 1 ci *S-: :$ero.
RESULT REF. RANGE

TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST
Negative4.8-10.8 x 10 3 Color N/A Mono

WBC
1 8b1
Negative4.7-6.1 x 10 App N/A RPR

RBC
14-18 g/dl (M) SG N/A tgrAHgb 1-7, 1 12-16 g/df (F) 42-52% (M) pH N/A SourceHct 534 3 37-47% (F) 80-94 f1 (M) Leu Negative GramMCV 'P 81-99 fl (F) Stain Negative
500 x 103 Negative Occ Bld
130-NitPlt 35 verified Negative
Negative

20.5-51.1% HIV
Lymph % Pro Negative Micro
ea a to itis&.

3tfferenr

Parasites Negative MalariaSegs Mono
0.2-1.0 Other
Bands Eos
Negative Serum
Lymph Baso
HCG Negative rtg.cgp e y,to
Atyp tg.
Negative

RBC
Morph

Spun 42-52% (M)
37-47% (F)

Hematocrit
MUST SUBMIT SF 518 WITH

Sed Rate
'EVERY UNIT REQUESTED

Negative.ABO/Rh
Other
Qi roSSulate

TYPE CROSSMATCHTEST RESULT REF. RANGE

9.8-13.6 secs '

PT
21-34 secs

APTT
20 ug/ml •
D dimer
10 ug/ml

FDP
REMARKS:
C.; Cheryl% -14-.
REPORTED BY:. DATE-LAB ID NO.:
lxLAMM \ -.SR/ 9 03

MEDCOM - 19501
DOD-033075

Ward/Sect on:
LAST, FIRST, MI.
Na K Cl pH
PCO2
P02
TCO2
HCO3
s02
BEecf
AnGap
Ca
BUN
GLU
Creat
Hct
Hgb
TEST RESULT
Troponin-1
Drug of
Abuse
REMARKS:
REPORTED BY:
EQUESTING PHYSICIAN: CHEMISTRY RESULT FORM
I.(Subject to the Privacy Act of 1974) DATE TIME SSN/PSEUDO SSN:
•
0 it

TEST RESULT REF. TEST RESULT REF. RANGE RANGE
138-146 mmol/L ALB 3.5-5.5 g/dl GLU 73-118 mg/dl
1
HI
3.5-4.9 mmol/L.ALP 26-84 u/1 BUN 7-22 mg/dl
2(6-

98-109 mmol/L 10-47 u/1 CA++ 8.0-10.3 mg/di
ALT
cid. qr.

7.31-7.45 14-97 u/1 CRE 0.6-1.2 mg/di
AMY
to 2-. 35-45 mmHg (art) AST 11-38 u/1 NA+ 128-145 mmol/1
41-51 mmHg (yen) 0.2-1.6 mg/di 3.3-4.7 mmol/1
80-105 mmHg (art)

TBIL K+
N/A (yen) S.R 23-27 mmol/L (art) 7-22 mg/dl 98-108 mmol/1
BUN CL-
24-29 mmol/L (yen) l00 22-26 mmol/L (art) CA++ 8.0-10.3mg/d1 tCO2 18-33 mmol/1 23-28 mmol/L (yen)
2:2-100-200 mg/di
95-98% CHOL i0t010 eke:
(-2) - (+3).CRE 0.6-1.2 mg/di.TEST RESULT REF. RANGE mmol/L 10-20 mmol/L.GLU 73-118 mg/di.ALB 3.3-5.5 g/dl
1.12-1.32 'ninon TP 6.4-8.1 g/dl.ALP 26-84 u/1
10-47 u/1

8-26 mg/dl ALT
70-105 mg/dl TEST RESULT REF..AMY 14-97 u/1 RANGE
0.7-1.5 mg/di.GLU 73-118 mg/dl.AST 11-38 u/1
0.2-1.6 mg/di38-51% PCV.BUN -7-22 mg/dl.TBIL

12-17 g/dl CRE 0.6-1.2 mg/di.GGT 5-65 u/1
CK 39-380 u/I (M) TP 6.4-8.1 g/d1 30-190 u/1 (F) 128-145 mmol/1
REF. RANGE NA+
K+ 3.3A.7 mrno1/1.TEST RESULT REF. RANGE
CL- 98-108 mmol/1 NA+ 128-145 mmol/
18-33 nuno1/1.K+ 3.3-4.7 mmol/1
tC 02
98-108 mmol/
CL-
18-33 mmol/1
tCO2

DATE: LAB ID NO.:

MEDCOM -19502
DOD-033076

Hospital EMT 1 rauma Flow Sheet
Chief Complaint 1-ka_rt) C
Time of Arrival 1'5 i5 Time of C/C: e _
_ LOC ratio
Name/Rank_
Unit (2:4v Ii n.—p Transported by Ai.i .Amb Military Vehicle Medications _
SSN:
D N

DOB.AGE:.SEX
Location of Unit: Allergies: _5lV.—)0.-Pc
MEDICATIONS/PROCEDURES DONE IN THE FIELD
Airway.ear Obstnicted jin'tibated . Tube size . Spine :.rmuobilized EY ared Time: ico aa Breathing: . Normal.ored U shallow . assisted
. absent . trach deviation C_- aiokict( vv._-,0)(3,ce 1..ria wnynbkitrainn
Circulation: IV's on Arrival .y„.32-5 1-1 ft •
YLLV1.11

Pulses: Upper.D4..ower.Carotid V DL c,pc..Skin: . Cool p-"Dry 0 Diaphoretic 0 pale . flushed U Mottled . cyanotic FANA,kes, Chest : Breath Sounds : Clear cia- 0,E MEDS/FLUIDS TIME IN TIME I Decreased . R . L Absent DROL Wheezing . R . L Rates . R . L Ronchi . R. L TV N5
ae5 CherYNq 15!`t
Moves upper Extremities0 No Sensation DY ON )
Moves Lower Extremities.0 No Sensation OY ON Tyr GI:es 151ct V 1\1 1550
PR EDURES C Collar . Backboard.NG/OG .FR Foley.FR CT.FR DLRO Rectal Tone + -vbw 11\1oo
02 frOevice Ore
Radiology: Time XRAYS: Chest C Spine
149,.
Labs: Liver Panel UA T&C Units
Time 5i5 I5 it
OTHER
Monitor EKG BP I %Li.
i 1/75
P

A - Abreiion GSW • GUnshat Wound
R e sp 10 10 Il
AP -Amputation H-Hemadoma
Ttrp,?

AV -Avulsion Laceration
b - burn LS -Suturod
SAO2

qs-

C -Contusion P -Pain
GCS

OP • Decreased Pulse SW. Stab Wound
E • Ecohymosis 8 'Scar
NOTES

F -Fracture Closed SP -Splint
FO - Fracture Open T -Tenderness 6 1 00r,l'or\ I.ear car-)0, 1
IV--IV Lines SR- Shrapnel

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1U`):). er\ c-ecl 1771,0', pl---atvN /1 -h Piti 5/4) I-abt ou-IL.cup LA4T-11. (45(1, q4Z or? arroal. to,00/ Akthei kith"
191-7:09/c.al/51/va,v qq51104c,; 0 rite irig.)///h..Set-(aid.Lt hi -.mildly chfrwivavo )", X1445 apowle i-x61 .W—airtiatt.1-14;
Mat . a- si)141-e, Nciikal .(A).-i ptvig!-.MAO -, aritAxcif,Ak__iv \ok(„ c
CON'T NOTES ON REVERSE SIDE

\,,h,\.¦ ck„6,yv.vc:\ID.I
MEDCOM -19503
1 1_ll 73 L9-)
DOD-033077

.t . GLASCOW COMA SCALE
1.
Eye Opening: Spontaneous.4

2.
Verbal Response Oriented. 5

To Voice. 3
To Pain. 2
None. 1

Confiised . 4 Inappropriate Words.•.3 Incomprehensible Words.2
3. Motor Response

Obeys Commands.; . Purposeful Movement.5 Withdraws (Pain).4
Flexion.(Pain).'.3
Extension (Pain).2
None
GCS ON ARRIVAL

If... GLASCOW COMA SCALE (PEDIATRIC)
1. Eye Opening
Spontaneous ' '.4 Speech. 3 Pain. 2 None. 1
2. Best Verbal Oriented, Smiles, Cries.5. Confused. 4 Inapprop/inapprop cry.3 Incomprehensible/grunts .2
No response. 1
3. Best Motor
Spontaneous. 6
Localizes Pain. 5

Withdraws to Pain.4 Decorticate (Flexion) .3 Decerebrate (Extension) .2 None. 1 GCS ON ARRIVAL
. NOTES (CON'T)
.
.
t .

..
.

..,
MEDCOM - 19504

DOD-033078

_...

1..REPORTING MTF ., LOCATION
ADMISSION AND CODING INFORMATION
1 2 3 4 5 6 7 8 (State or Country
For use of this form, see AR 40-400; the proponent agency is OTSG
A 1 .0 1 :t.:.,, -17,„ -2_ Code.)
,, ---

3 ..REGISTER NUMBER NAME (Last, First, Middle Initial)
4..PAY GRADE 5..SEX

It 9.10.11.12.13.14.15
'.16 17
—

6 ..DATE OF BIRTH (VVVYMMDD) 7..AGE AT ADMISSION 8..RACE 9..ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 D 29 30 '..... 31A BACK­GROUND t...Ao 10
10..LENGTH OF SERVICE ETS 11..FMP..) 12..SOCIAL SECURITY NUMBER
32 33 34 ORGANIZATION (Active Duty Only k 35 36 ct 9 13..MARITAL STATUS 37.38.39.40.41.42.43.44.45 HOUR OF.BRANCH/ CORPS.L.k -2(.i.
1

ADMISSION
46

\\ I CI Li 5.N k
14..FLYING STATUS 15..BENEFICIARY CATEGORY 16..ZIP CODE OF RESIDENCE
47 48 49 50 51 52 53 54 55.56.57 58 59
60 61 \Z-----.1 U
17..UNIT LOCATION (State or 18..MOS 19..TRAUMA. PREY. ADMISSION
Country Code)

62 63 64 65 66 67 68 69 70 71 YEAR
.---"'
20..SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72 \..1¦,0 --
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
NAM. T FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
t --
b(2-) - k AO
21..YP. ION 22..MTF TRANSFERRED TO
73 7 4 75 76 77 78 79 80 81 82 83 84 85 86 87 88
0

24..CLINIC SVC -ADMITTING 25..MTF TRANSFERRED FROM
89 90 91 92 93 94 95 96 97 98 99 100 101 102.103 104.105.106
_A
(19 P\ ). . inraMIMIIIIIIIN
27..LOCATION OF OCCURRENCE 28..MTF OF INITIAL ADMISSION 29..DATE INITIAL ADMISSION (Y Y Y Y M M D DI
(Battle Casualty Only)

107 108 109 110 111 112 113 114 115 116
117 118 119 120 121 122

FOR LOCAL USE
...\.

---UC1-L.F-(Z-A 7-11--R,L.
CI) PR P-X,E1 ILS 5V0,,z4De 0(.610.P" q(.7(
eQ \ CI,AS2- (A-_...01--kp\--o..1--tov 8;icii((tf
egi7‘i
o. 93 cmoki , .._____/

AD. R.
Si nature, as required).jc" (3_9 ),.---1._ SIGNATURE OF ADMITTING CLERK
r, A.,r1,11)._, n r-1 r-_il A es r,_, fn •-¦ •-¦
.
US.APA V I 00
MEDCOM - 19505
DOD-033079

INPATIENT TREATMENT RECORD COVER SHEET
)For use of this form, see AR 40.400; the proponent agency is OTSG
I..REGISTER.o 2.NAM
GRADE ADMISSION REMARKS
--\,
ERA) iun

4..SEX.5.AGE.6. RACE.7.
10..PREVIOUS
P\ I

k 5 urYvk u-N ¦2---0 A N) A
RMP i2.SSN 13..ORGANIZATI 30 WARO
Q u_a
rc(_,..L

15.FLYING 16..ELATING/ 17..DEPT.) 18..BRANCHICORPS 19.UICIZIP --20..TYPE CASE STATUS OSG N
K1, A

\ . 1 00--37— SOURCE OF AOMISSIONIAUTHORITY FOR ADMISSION 22..HOURS OF 23..
CLINIC SERVICE ADMISSION
0 \.

ecA.c 01--N.k--, NN\--0-0D 'A&A-Pk
24,.NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25..TYPE DISPOSITION 26..DATE OF DISPOSITION
O. (.....\ v...
27a.ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 275..TELEPHONE NO. 28,.DATE OF THIS ADMITTING OFFICER
ADMISSION bbo (Le. — 2_

` A 1f— \ V.—• SLSt R .g3.----)
s t\-).2---or
29.NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30..DATE OF INTIAL
32..I.WHOLE 81.0001 ADMISSION COMPONENT TRANSFUSE°

31..SELECTED ADMINISTRATIVE DATA
.
Check A Conti/wad on Ramos

33.CAUSE OF INJURY
34.DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES
(;...

35. Total Days This Facility
a..ABSENT SICK OATS b..OTHER DAYS c..CONT. LVICOOP d..SUPPLEMENTAL s..BED DAYS I..TOTAL SICK OATS
CARE DAYS CARE DAYS
--
(..'..)
36. Total Days All Facilites

a..ABSENT SICK DAYS b..OTHER OATS.I c..CONY IN d..SUPPLEMENTAL s..BED DAYS 1..TOTAL SICK DAYS
CAP./S CARE OATS

.—. C.) c:.) .---) . _) r--)D
SIGNATURE OF S1GNATt;RE CF PAD OR MEDICAL RECORDS OFFICER
/ EF fii.—

;!
DA FOR., 506.
USAPPC El
.

((.-,.1.—
DOD-033080

MEDICAL RECORD I O cA5IBREVIATED MEDICAL RECORD ' PERTINENT HISTORY, CHIEF COMPLAINT, AND ONDITION ON ADMISS (Enter date of admission) 5 /0 c".-GS A ..S—o 0 ..s/s, fs-G •.,-,"4-1
F 0247 P-A-tile

PHYSICAL EXAMINATIO -
Amp
W P

AA4A,
(A, [6,vel.
),J1-(14 –.iThe
/

PROGRE (Enter date of discharge.diagnos.
.tit LLL
—

t e/ri
.4-1/P-J20

C444/44r
/Pr•-et-
\D(_

D71,65, IDENTIFICATION NO. ORGANIZATION
'S IDENTIFICATION (For typed or written entries give .first.. REGISTER NO. WARD NO.
middle; grade; date; hospital or medical.icy)

ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 USAPPC V 1.00
MEDCOM - 19507
DOD-033081
AUTHORIZED FOR LOCAL REPRODUCTION

' MEDICAL RECORD PROGRESS NOTES
42,0-

DATE I NOTES
..1--,-/0
L-bit/i . C CI S lAj fj4-‘3
-6 1/11,vy,1 Al I `0°
1 4?
CL912 a-_ i'Ll Ft
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1 tAfir.i__ ¦ 111W-0 c • -.. ..a.... Pic ILAINIfing
/.
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I.

be a,,,:e.1i-./ I
_

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1 .t.i.
....A.4 ......../A.....-.:.... -A..L .6 .6...4¦ 11.4.A.... . f./
Z.. A
1
' ( -Z--

RELATIONSHIP TO SPONSOR
a.SPONSOR'S NAME SPONSORS ID NUMBER LAST FIRST MI
ISSN it Orkel

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: /For typed or vairlen odes. give Name • kst fiat rdddle; I REGISTER NO.
WARD NO.

ID Na or SSN• Sex; Date of Bith,• lisakOifkl
PROGRESS NOTES Medical Record

o cu) -
STANDARD FORM 509 IREV. 611999) Plescribed by GSAACMR FPIAR 14ICFR) 101-11.2031b11101
USAPA V1.110
MEDCOM - 19508
DOD-033082
AUTHORIZED FDA LOCAL REPRODUCTION

MEDICAL RECORD PROGRESS NOTES
DATE NOTES
06.3 . pAxoi.A.. . -,.
iE(s-kj_cs-Ae .i_5 e42. .ifaiko_ ....i.-4 . .11 ..4:-._ .,&....,..7:,.....I Os-, is.,-_ .
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)
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1,, •

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r.•
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_.., i

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,.
wet! ,_ 0,.If A'a.— I.._ ..AI Aar 1 A.., -
Al

rAVIANWF .11.0 41 Igirar Ilk 4
slio. Is Au...0.Ar, Aracl_/
1 111. P pt1 ,
• JP a 5.5 ,,,......„....a c,,,-,.,--a-, 100 '.1 USS 8 Atalill/ALINNWAm.cwow.. +/, _..
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Vs ¦ cLv i ON CI es., ,,,,-/i-11.1 l erv.) L,, /ZI.-,A--013,1 -1,1^:"`'l
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( --°-2- - - - -.i''-'-e-p-e.---.3.R"st^-¦.-Pi -).=.fi=b3L.i
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S r.4- '-"k 1='r.e..-11.--4--.'.Ce•-s----.-1-6.,.--....e."----: 1-o-r-
1

RELATIONSHIP TO SPONSOR
SPONSORS NAME LAST FIRST MI
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT _ .
PATIENT'S IDENTIFICATION: (Fa typed of WfilitA Orlin IA..
Name . Nat Fist middle; I REGISTER NO. WARD NO.
IAIIIIIIIIIt No o 'SSA' Ser; Dote of 131r* lind/Gradel

PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. 6110091 Prescfind by GSARCMR FPMR NI CFR) 10141.203a1H101
USAPA V1.00
MEDCOM 19509
-
DOD-033083

LAST NAME
FIRST NAME
MIDDLE INITIAL ID NUMBER

DATE
NOTES

20 J.I I s.t.
i A..0.APO e) .A.Iii.1 AM
•

.,ALA.Aa___- 1 4 •/ _-_, 011..6:-. 1 i .....,...._A__
....

('C--e 0 -L_ - - .. 6 S-c-• 4,4, , 4 -1.-.. 611-1 '-'
4 -1

cil,(.2„1c.ti.:a...
1°e.tiKC / )(¦j 1'41' '')C. •-62(12 1.4.e ; (Alla e-----"(A -:•-:: -.(C:1 "4"--t CC, "Z .' -•-0 -MiZillomitrAva.i... ,4 Aitii.
.' — - -

_it, 4_.•02g
lit Alr Arff/51101BISMIkeiNina.....e.Kr_Ar f/Ji
If
r
, •
-
STANDARD FORM 509 pm. snow BACK
USAPA
MEDCOM - 19510
DOD-033084
AUTHORIZED FOR LOCAL REPRODUCT1OP

MEDICAL RECORD PROGRESS NOTES DATE NOTES
•2- f 0 o
-
.
•/

-Airikar_..(4----
.
-AL.._ . A./ '.41rAr.dilt,g I ...L.64.0„...
i Ot9 0 4111‘Lini (ArtrIA.La / k C • / .0 i AIL_Ir 4 0/4" AIIIIONSW _
0 ii:.• anffile I 4.. .1 A. •
._)(C(.-7 A-\\

RELATIONSHIP TO SPONSOR
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: Nome - last, hist, middle;
REGISTER NO.
`WARD NO.

ID No or SSN; Sex; Date of Birth; Rank/Grade!
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV 5-99)
Prescribed by GSAACMR FPMR (41 CFR) 101-11 203(b)( 1 0)

MEDCOM - 19511
DOD-033085

.
PREVIOUS EDITION IS USABLE AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL. CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
),

. 5..e0 '3.S./ - -.Ve :7.1.-re.,-r,,, • 617-).4, , L.,."., c I.2.' s- -e5---
e-,/r;l; 5G,).4-./.r--/.c/ vt• ei.1I.Ai .5'.__T_TV
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AS 43:1(21.0e..I 43--q ce 6-Stki (CSi erirrN)..0 01)1)e/irk—
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-
f : /3 1---sc-e.,"-e..vs.€4•s sty envy, . __..--¦
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__.......-.as.• J.0 ,.•.•
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'new oi., AL., ( -Lk, ir 01.,c i,, .&S Lk). 4+, )qt.
l rn-e.4 i a 1I. o. IF94-211(_
6 000k. go-A o I n.Ik.oze .An k £15-ir-StrerA fkroviLvot
f ;

M t. to 1 i t e r v cd.11.C, ir" 0,4-erfrra WO VOA eel. Cok IVO( I t ie.An •
PLA I' V\.1... fG vv% Lirr 3 CU %Ateri ce, -Cr aci-um
2 ° Stn r 1,1,4 (---".'or caw\ ut4.4--reniff vni ()tits
G-S14) 0 tin t ie\ I-
wit( icy' Cciate, 1.A.,(9-1A4-vcg i (--V 11.-Me-oc .(_ -2-
•Plavl_6VowC.-_ 6.C.St•t p I uAl a/084.
C I

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
REGISTER NO. WARD NO.

PATIENT'S IDENTIFICATION: /For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
Date of Birth• Rank/Grade.)
1.\.,I

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
-

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/1CMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 19512
DOD-033086
AUTHORIZED FOR LOCAL REPRODUCTION.

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE .
SYMPTOS• JAJ?jOIflAIM(NLiflAIIN&OflANIZAIffiNJiqi1_ is
•

Os° '00.546 ,. 415,, 404 ,14 Li?.-7—/Q ).rk/I 1041 e •I730 Inew9hav_. 61' ,5 0.14.ifitto ,Tu PEA.5A Prts, cle.ss4.5.ot4 •e-4,1 4 c_-­•:--)9 10_ 1.1_ IVOerfrici /Si 0 c, 0, 1
17,30
ao . jllijllkv\..
/0,4.
HOSPITAL OR MEDICAL FACILITY 3/505 BAS SPONSOR'S NAME STATUS SSWID ND. DEPARLSERVICE RELATIONSHIP TO SPONSOR RECORDS MAINTAINED AT
SSN: PATIENT'S IDENTIFICATIOk NAME:, STANDARD FORM 000 (REV. 6-97) 1%.....nled_by CSAIICMR_ FIRMR (4) CFR) 291-9.202-1 Mal% V2.011 DOB: AGE: 1• or(f typed Of mitten wan, give: Paso • Inc. That middis; ID No or SW Su; DOI of NA; Rani/Glade).REGISTER NO. RANK:_ ._ WARD NO. CHRONOLOGICAL RECORD OF MEDICAL CARE

MEDCOM - 19513
DOD-033087

NSN 7540.01-075-3786

EMERGENCY CARE JG NUMBER TREA
MEDICAL RECORD AND TREATMENT
(Patient) RECORDS MAINTAINED A
PATIENTS HOME ADDRESS OR DUTY STATION ARRIVALImE 55
STREET ADDRESS.1,___,-- .)(V DATE /gayhippiy3
I 5 1
CITY STATE ZIP CODE TRANSPORTArr.ILITY

SEX • DUTY/LOCAL PHONE MILITARY STATUS
THIRD PARTY INSURANCE ....4A AREA CODE NUMBER ITEM YES NO NIA ITEM YES NO
PRP ADDITIONAL INSURANCE
AGE HOME PHONE FLYING STATUS 00 2568 IN CHART
6.-----

AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
WHEN are) DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO ar-----....--, n YES.n NO
IS THIS AN INJURY?
WHERE TETANUS ALLERGIES INJURYISAFETY FORMS
DATE LAST SHOT COMPLETED INTITIAL SERIES HOW
. YES.. NO
Nilib 4--

CHIEF COMPLAINT 6
CATEGORY OF TREATMENT
VITAL SIGNS TIME TIME.S
EMERGENT 1 PULSE

URGENT INITIALS --RESP to
Z_ TEMP.. NON-URGENT
WT
CBC/DIFF ABG .PTIPTT BHCG/URINEIBLOODIOUANT CXR PA & LATIPORTABLE C-SPINE URINE C&S
UA MSCCICATH c/b ACUTE ABDOMEN LS SPINE
-
•cc

BLOOD C&S X cc c) SINUS HEAD CT
rEc

ANKLE R/L
ORDERS PULSE OX n MONITOR
n ECG
n

TIME ORDERS BY
TIME PATIENT'S RESPONSE
"Coe AG?
Doz)
DISPOSIT ION DISPOSITION QUARTERS TOFF DUTY PATIENTIDISCHARGE INSTRUCTIONS
n
HO ME.n FULL DUTY n 24 HRS. nyHRS. n 78 HRS. MODIFIE DUTY UNTIL
RETURN TO DUTY

CONDITION UPON RELEASE
ADMIT TO UNITISERVICE TO WHENREFERRED
. IMPROVED . UNCHANGED
1:1 DETERIORATED TIME OF RELEASE I have received and understand these instructions.
PATIENT'S SIGNATURE
.

PATIENT' S IDENTIFICATION Lia typed re written emus% give: Name last fest. mddlr• ID na ISSN ar other)• hospital or melee/ ladityl
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record

STANDARD FORM 558 IREV. 9.961
Prescribed by GSARCMR FPMR 141 CFR) IOW 1103041101 USAPA 01.00
MEDCOM - 19514
DOD-033088
NSN 7540-01-075.3786
4.
TIME SEEN BY PROVIDER

EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS

WBC
Chock if read by

ABGIPULSE OX RADIOLOGY
radiologist

H/H
SUP 02 PH P02 RESULTS
vo

PLT
PCD2 SAT OTHER

PT
DIP
EKG INTERPRETATION

APTT
BHCG ETOH GLU MICRO
PROVIDER HISTORYIPHYSICAL
1;e-E,2

.741i-`14' Ke--eLA-r,------°.
ii-Ge -a—
S—Zawet
f s 0
71-0 67'5e-4-) .•. f://.*•••''.
401---- •

619
CONSULT WITH TIME ACTION RESIDE NTIMEDICAL STUDENT SIGNATURE AND STAMP
PROVI ER SIGNATURE AND STAMP
DIAGNOSIS
O
O
,•
PATIENT'S IDENTIFICATION For wpm Iry written envies give:Name last first. narkfim
ID no. ISSN re Mat hose nal or media flake
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 WET 9.96)
Preset bed by GSAIICMR
FPMR 141 CFR/ 101-11.2030)11M
USAPA VI GO

MEDCOM - 19515
DOD-033089

DATE HOUR A.M. P.M. NURSING NOTES Sign all notes OBSERVATIONS and treatment when indicatedInclude medication
G 19V Pi—. Ar'.
_I' - •--* ,. .../.iv.X _...0.,0.1 5. 5-¦_, iti./ ,e .../. -74' ce.127,,z-e-",-,a /
ora ,^ "t97.--e*ls;)...t­' ---- _ i.1./,‘ Ff-..." As.
/tit— .--Z4Z=Ali--—.f ,--­2-'.1•4 ;2 02p 7 -7/ .Y/-d.' /.-!z7_?_-_ --/ 7 x .(--z.4:.d ..riot, 1, ( (., _ -.
,
__112_,___/._.I/ .-./ u./ / -_4.zr____/ Z.2,-.-74----7.­--7,./-e-z.--. .../..../---1--) ( ci.) -.--e-/'Ai/

_

'U.S. Government Printing Office: 1995 - 404-763/20065
STANDARD FORM 510 (REV. 7-91) BACK
MEDCOM - 19516
DOD-033090

511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-_ DAY
MONTH-YEAR DAY ' ec 03 '
19 HOUR ...... ._. ........

._. . _. ... .
'
..... ...
........

PULSE_TEMP. I:
(0)_
(*)

. ._. • ......
1:3_: •._.
......
105
• --_•
•• •-

...
...

:_: :_: 180_ 104
. • • • • ..........................

._. ._.
._. ._.
._. ._.. ._. ._.
._. ._. ._.
..._. ._.

. . ._. ._.
._. ._.
170_ 103°
_.
• • " ._. .
Lk) CO CAI CO C.J CA) (..C.
ul 01 O0)-.4 V 3 CO
,J CC6.I-.:,1ON tic 4.) b:o
0)
0 0 0, 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only

160_ 102° . .
• • ._.
• • ._. .......... : :_•.
• • ._. ._. ._.
• • ._. ._. ._. ........

._.

150_ 101°
1

. ._. ._.

._. ._. ._. ._.
•
.'A :

140_ 100°
... .... ._. ._. ._. ._. ._.
........

._. ._. . . ._. . . . ._
......
• . ._.

98.6°
... 120_ 98°
4 ._. ._. ._. ._. ._. ........

._. ._. ._. ._. ._. ...... ._. ._. ._. ._. ._. ..........
._. ._. ._. ._. ._. ._. ._
. ........

110_ 97°

•

._. ._. ._. . . ._. .. .
• • • .....
130_ 99°
• -_•
.... ....
._.
._.
._.
• -_•

• • • • • •• •• ._. ._.
• •-• •
-_• • • ._. ._.
100_

96°
'•••• " • '

I
.. '1¦. :

. ._. ._. . .
._. ._. ._. . .
. ._•
. ._•

90_ 95°
. . . ._.
•
.

. ._. . ._. ._. ._. ._. ._. ._. ._.
.

. ._. ._. ._. ._. ._. ._. ._.
80

• -_• ._. ._. ._. ._. ._. ._. ......
• . ._.
. ._. • • • ......
. ._.
70

._. ._. ._. ._. ._. ._.
. • • ._. ._. ._. ._. ._. ._. ......

._. ._. ._. ._. ._. ._.
......

• • ......
¦ P • •
... ... ... ... ... ... ...
50 ... ... ... ... ... ... ...

1: :::

._. ._. ._. ._. ._. ._. ...... :_: ._. ._. ._. ._. ._. ._. ...... • • ._. ._. ._. ._. ._. ._. ...... • • ._. ._. ._. ._. ._. ._. .. ....
40
. ._. .....

RESPIRATION RECORD
!Record special data only when so ordered
_BLOOD E
-I.
HEIGHT: WEIGHT ¦ •p• MIII afingrann1111

PATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, frst, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS

Z=4'.1117,(a)
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 19517
DOD-033091
A

r.
DATE , I TIME REQUESTED A.M. P.M. 0 0

IL: 1111
0456

Pgient
Lint LH 6.1 A107'31uL 4.5 10.5 RBC 3.98 L '4106 1,1 4.00 6.00 Hgh 12.5 g1d1 11.0 18.0
" 35.0 60.0 ND 93.9 fi 30.0 99.= PH 31.5 H pg 27.0 31.0 11-11: 316 gldL 33.0 37.0
Pit 263. k10'3 1,11. 150. 452. La 32.5. 51.1 i0 7.0 eVIldl_ 1.2 5.4
MISCELLANEOUS
5104100110 FORM 557 11144 3-771
Preberted by GSAFION1
fIRMR dl (FRI 701-45-505

Dlil1N3011N31 1V
0
z

C o

CR
0
C
z

000
557-107 n
0

PATIENTS MED. RECORD
MEDCOM - 19518
.

Wad/Section:./r REQUEST
LA ST, FIRST„MIL
',Meant

TEST I REAULT L-1(FF R Aitrezr TEST
18-09-03
.

_WBC At111111 _ _..LJ Color
Patier;t

RBC.
APP

Limits

-.

Ilgb.UK 10.8 H n10'3/:_L_4.5 10.5 Glu
,.10.;6.:._
4.00 6.00
RIC_4.21_ 4.00
Hct.Hgb 114 gidL FT \ 11 0
Bili

_Rd 40.7_2_Q7•15.V60.0
MCV.NCV 94.9 fL_80.0 W.9 Ket
EH 31.2 H pg_27.0 31.0
_NCF 32.8 L gitiL_13.0 37.0

Plt SG
Pit 306._:410'3111 150. 450. LY? 16.4 +L X_20.5 51.1
Lymph '/o. Bid
,•_ Lig.1.8 * x10'3/[ii.1.2_3.4 weaSH.ogYi:Kanuai pinereathil ' ,:: pH
. •::.•.4-. ..:.. • . • • % • .. ..
..., .

Segs.I Mono.Prot
I
Urob
- • 1!
Nit

.

( 0-

Patient ID:41111

Leuk Negative

Test Name Frr ivc
Test Result:. 14.7 sec

HCG

***RESULT NOT RANGE piECKED*** Ratio = 1.2 Calculated INR-200,r Sample Type:citrated ,01. blood Test Date :00/18/03 Test Time :08:30 PM Card Lot.Cell
:010301 Operator :OW ) Count Dircctigen
((it

. RAPIDPOINT COAG ANALYZER V4.54
SERIAL.

09/18/03 08:34 PM

Patient ID: 795
Test Name :APTT
Test hesult:= 32.8 sec
***RESULT NOT RANGE CH ECKED***
Sample Type:citrated w h. blood
Test Date :09/18/03

7 _iT -

LABORATORY RESULT FORM

IcD(62) "2-
Sul:it-et to the Privac Act of 1974 TIME SSN/PSEUDO SSN:
X
)i)

REF. RANGE TEST RESULT REF. RANGE
5M N/A RPR ' Negative
fi r. N/A Mono. Negative
Negative • .1Y0Crobiolugy
' '• • . • '
Negative ource
Negative Gram
Stain
'N/A 0c,c Bid
Negative H. pylori
N/A . Micro
Parasites
Negative Malaria
0.2-1.0 O&P
Yfre6_ Negative Other

Negative

MUST SUB^GIIT SF 518 WITH EVERY UNIT REQUESTED Negative.I Ago/Rh
.Blood. Bank
(MUST stramtr. SF,518.WFIXI EVERY uNrr OF BLOOD . r
• •-•.REQUESTED}
UNIT TYPE CROSSA•4TCII
REMARKS:

REPORTED BY:. -7 J LAB ID NO.: MEDCOM - 19519
DOD-033093

Ward/Section: REQUESTING PHYSICIAN:
CHEMISTRY RESULT FORM I (Subject to the Privacy Act of 1974) LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN: /.
vsT 44'+ig :._''_‘: .-j -•:-:--4044 :_, "_101.k; -4tiit.,.:i.
..6,-.?:.:5;,:-. _•"`_.',',::::.•:, ..._rl.;,,.::; , i;
TEST RESULT REF. RANGE-TES. T '.ULT F. TEST RESULT REF. RANGE RANGE Na 138-146 mmol/L ALB 3.5-5.5 eidl GLU 73-118 mg/di K 3.5-4.9 mmol/L' ALP 26-84 till BUN 7-22 mg/dl —
98-109 =non
Cl
_

pH_-7.31-7A5.7. 7 - - - -, , 1: -: •._
PICCOLO.

- - • 18/09/03.,____.:_}..1r:rn,zrjcriwrjr:_20:21
PCO2 35-45 mmHg (I.20:21 _
8/0:J/ri

41-51 mmHg (va
MALL.

FEF WNCK RANGE:.

80-109 omit (a,
P02 MALL

Nhk (yen).

PATIENT #:.

\77((j6-dk— PA I I LNI.

#: TCO2 23-2.1 """O/' (u LIVER PANEL PLUS
4-29 mmo1/1. (vi. METLYIE 8
2226romamm.3122BA1 —

DISC LOT #:.

HCO3 DISC LOT #:.

3141AA4

2348irmloULN4 DR # : 000 _ opm # :.
OPER # :111111.

95-98% DR #: 000
s02
SERIAL 77----

- SFR I Ai. , -

(-2) — (+3)

BEecf .. W-9--) —
-1.'

nunol/L.G/DL
3.3-5.5.

ALB 1.1.

GLU.73-118.

AnGap 10-20 mmol/L 110 MG/DL
ALP 201*.
U/L.

26-84.

11 7-22.

— BUN.MG/DL

112-1.32 mmol.
Ca ALT U/L
22 10-47.

CRE.0.6-1.2.

0.8 MG/DL

14-97.7

8-26m01.AMY 36.
U/L.
909*.U/L

BLD4 CK.39-380.

11-38.

41*.
U/L

28-145.

AST L NA4.133 1 MMOuL

GLU 70-105 mg/d1.1.0.MG/DL
TBIL.0.2-1.6.4.9*.Nmoi/L

K+.3.3-4.7.

. \.

GOT 6 U/L ,„_

5-65.

CL-.105 98-108.

MOM_

Creat Q.7-1-5 mg/dl 7.0.
G/DL.
TP 6.4-8.1.

_. tCO2.18-33.

23 MMOLL

38-51% PCV
Het

CHEM GC: OK

12-17 g/d1.INST OC: OK.—
Hgb INST GC: OK.
CHEM OC: OK

LIP .

! HEM 0 ,.
0 , ICT 0 —

:;chemist HEM 0 , ,.

LIP 0 ICT 0

TEST T REF. RANG1
Troponin-I
t.
Drug of
9

Abuse ..._
-..-
J.
REMARKS:

REPORTED DATE: LAB ID NO.:
BY:IIIIIk ii, Sep?
MEDCOM - 19520
DOD-033094

CLINICAL RECORD DOCTOF_
DERS

For use of this form, sea AR 40-66. the °root,
_agency s C
THE
-

DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ONTE.D MED:CAL R!r.r:'.
,,SYSTEM IS USF.D, WRITE PROBLEM NUMBER IN COLUMN INDICATED

j
BY
ARROW BELOW.

PATIENT IDENTIFICATION
DATE OF -RDER
TIMF OF ORDER
i -' ' •

Z-00 0 HO LI RS -
J
f I
i' if I AS it9,°t*
NURSING UNIT ROOM NO
4 0

PATIENT IDENTIFICATION
E OF ORDER
Ilk pip,
P.
1

NURSING UNIT ROOM NO BED NO.
PATIENT IDE: NT iF icAT iON
OF ORDER
TIMS hi-0
. HOURS_!
-1
''/URSING UN!'

1900M NO. BED NO.
104TE OF_Fi D E
TIM1,.
_
NUFISING L5'!
0 N
'-
1
MEDCOM - 19521
DOD-033095

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM'IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME ORDER i NOTED AND
PATIENT IDENTIFICATION + DATE F ORDER TIME OF ORDER
0 0 V HOURS
SIGN
1
NURSING UNIT

PATIENT IDENTIFICATIO
NURSING UNIT ROOM NO. BED NO.
ajlf/
PATIENT IDENTIFICATION, ER TIME OF ORDER
700 HOURS
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1FAOpr79
MEDCOM - 19522
DOD-033096