Medical Report; 20-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wound to Pelvis and Thigh

DOD-034817

0-' Z
I--o
P

'

f;i
oar3N I2 lelol so VO CO ZO 1,0 00 CZ ZZ oz I61. 81. lelol LI, 91, 171. ZI, , 1801LO 90 .Ln dln
TOT60
iz
1 leloi
I so zo oo

CZ zzILz 1 0 Z1 61 . 91. Ll. 91, ct. Z 1.1. POT 60 11FILO I90
w
Y
F MEDCOM -21241
I I I I n
2-1F-1!4-1(')1
dVI
ource
ZOI
24PL
Z0e
-..
K....,..„.

so vo
I

cq
1 /el
kz 6 1 Z6 dIN3.
1 c°/

'

c4
r_f4ir

soI do

A

Ice
I coI zo I 1.0'

I czIzz ZIoz 61. 81. Lt. 91,
I 00
51. t'1. 14 101..60I 80707 90

dER
01111-N
VITALS

-
P.­
-N
..., ..,)
[
MEL
riECORD-SUPPLEMENTAL
• on General
ee AN 4V-00; 'we plupulm....y.,,,,, ... --••.---
For use of finis k. ­
OTSG APPROVED (Date) REPORT TITLE QA Appr 8 Mar 89 INTENSIVE CARE NURSING
FLOW SHEET
, .',
TIME 0700.INITIALS

'S. PUPILS . ,,..--a.PeReiA-.2_
-' ' `"'• -.,':=:
ITIFTASSESSMIRNT
' • :...-.:.. — '''. .::...:;-;I::•-•: ,;I: III.I''i., .. . ..
SENSORIUM
'-' EXTREMITY MOVEMENT SEDATION PAIN CONTROL
:%'. ' ! RESPIRATORY PATTERN
,, ,
BREATH SOUNDS ,. SECRETIONS 02 SOURCE/FLOW/SA02 '. VENTILATOR SETTINGS
trl
gCARDIAC RHYTHM
...„.
CAPILLARY REFILL
PULSES
, EDEMA

iABDOMEN
Ah,, .
k4 BOWEL SOUNDS ',,., BOWEL MOVEMENT
' ''' NGT/OGT TUBE FEDDINGS DRAINS
, VOIDING
" COLOR/CLARITY

0 COLOR INTEGRITY
..:i.
#1 TYPE/LOCATION/SIZE DRESSING CONDITION IV FLUID/RATE
#2 TYPE/LOCATION/SIZE DRESSING CONDITION
IV FLUIDS/RATE
,,
PREPARED BY (Signature & Title)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last,
first, middle; NAME: rade; date; hospital or medical facility) b(6)-4 RANK: AGE:
UNIT: pct.) GENDER:
STATUS: US: AD / CIV IRAQI: CIV /

MEDCOM - 21242
DA FORM 4700. MAY 78
Ala te 3. UU1
pu.r (17„/ 1,(40.e„,,,,,,,.,e icy
0111041/242_11.A•CciA,
Pa.Ay .awlsolled.1r 4f.004
ge.-zi ...Vez- - 1.6 0.", 7e4
Lout Sk..,0,-i,s -CM-()
,0"..setre/fop.

xd, - RA
av-Ven.,
ye - iZ/ A,- 154/17
(1.000,7/Ary Re .,c/P-.4: Osei -14"­
1 Te7-7)4,aaa-t Pacer
4 Edi ;eg Loiver Pg-l-rp.viees
3,0-R41-.Iv.", `-ender.Ai.doi-e-.41
3000...L.Sh:pvds -7 geqc_lt," trY
010 --er.e,vf.
0/.167
,er 74 4.c. -eeri"-j,,7
arcc,--.,hvg

Wi io.er,-..;01
C/o, y. IA.-.iirt,,,,.0.4.
11.10.1044.1., r-.RQCe
/0,p s ki., brew ketro,....w
le...Ci - k.v,.,*..FY Coevw1
IV i:v LeFF.fwv.d.r+-g,st.An. oc , /4„..-4:E4s-4..car ill a.Al 0 5A
,.) 44., rftecit.0.1, ;Ng. ii-red, (..,..
-
41.1vc...:A., (4).wrisl-.'ir, ilwevr Ice
Zeazeb..4,.cued

DEPARTMENT/
ICU #1,
.
.
.
.
TIME / /00 INITIALS:
PeuzuR.3nin4.rt sk-

fti:crs 3, m6ve3 i ndcnfiy
r
trAe.Fendoehli
14-50qi.ler.-0C-405
giZe
G11 -ci
46
eaA 7' 1570
N.t A
,
0E40 sr, vist./
-
43.5.e...e X
1' 2 S (1.-
16.

et,F1 -9 ,i.i tiem-terldev-
C)
MA
1.)-2..
kJ F1'
.`.rant- Yir,NADVae.-.
FAN 1-7) qravrhi
Cie:*1 jeltock) i

NDryvvai 6.1.-Race.
D rs) It: L.L.E Car
PI V (0 i„Orict "(8) FA
CM-atiC.
Ne, a t.ZEr.-1 ° p+L
Paine/ () gaatat
OM.
(Coreirkm on oa o c 1 _._....._
I oa-
b(2 -
HISTORY/PHYSICAL . FLOW CHART
. OTHER (Specify)
OTHER EXAMINATION
OR EVALUATION
DIAGNOSTIC STUDIES
TREATMENT
DOD-034818

7—
IIMJIIMER=EMI6'1O
1Ilt I
Date:
0405 0.
VITALS 06 0708091011121314151617 IM 1819202111012300010203
U)
O
1A-LinePIMgalNO1ifflUMERMIEMNIZIMINSIMAIMMISMILSIMIWAIPI• NBP'rial MIMIEgl •
0
TEMPIMII KU •
Ce)
O

N
0
O

O
O

N

N
N
N
O

N
0')•
1%.
id
co 0
co

N

O

O

O g
o]
O

N

O

co
.01
O

cn
..., 0 I 0_
I—:' .E a.
q
fal 101•0 MI1O r• RIM rza
do /MIN0ENIKIIIEM• MIMI3iMIKIM V MES a0 VAIMINIMIIMMItiIto UAW
HR , at, EMI isc EN 1;i MilESIMMIIIVALI11/1=, IIIN 4­
RRMIMIVIMMI95. EPagalIM
Rs"
(zr
N-

0-*
Sa02
csi 0
03 uj CL CL es 0
•:t z 1— z tx co ii:
Fi
INIELIMMI lffilearallillig3

111114-1ci4
MI

M

Source
O2 d0
4.4 u-
3
co
I

IM

n
\

li
'AIZAPJ
U
M\-cf
Nis,
3 rt

g.4 In0Mall tAMI 'AIIIMISIIINNICHEIMIU•
•
MR_
¦:M•
M •
M._ •
¦-•

¦
MI N
M al
Wst
I
M
r
Tot;

u
0
0

O
0405
INTAKE06 07 08 09 1011121314151617Total18192021222300010203
-MIIIMWM 1 4:31
ntrigliallMnirall tr) El /-rc MNt26125MIMI 12611M 125
5
SJ
CO NIN
e•-•
ggt
N

V.
P•4
O
O

O

Co
O
ti

O N

CD
O

IVF1ZgingIVPB 6o
O

i

(

50
50

NGT
Ili
41...
0
0
MI6000FM%50 CB 500MEM00 0
talIIIMMINIMMIPPSIMMINillEMIS/2/%1A

• Total18190212223000102030405Tot;
TPUT 06 07 08 09 1011121314IMI 16 1 7
eJ

0
0

H
m
air a
FMpm FMasz?A
MIMIPIPMMIPIPIMPISM1
AETRURIMINfl

MLUIEWIMIFITILVIVAlltalliffILWAIIRP
11111.111111111111U1111111111111111111111111111111111111

URINE,-/MIMPiTIUMAIMENL
NGT
STOOL, El DRAINIlil IN ‘:41 110
PEW
111
MIME
III
MEDCOM - 21243
DOD-034819
11111111 Tota l IPAMPI raPriPMEMUMEanillIPMMIPMINMEIIIMILPOIMMETanralli
MMI-

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 08MAR8
INTENSIVE CARE NURSING FLOW SHEET
N
E

U
R
0
C A R D
I
A
C
R
E S
P
S
K
I
N
I
V

G
I

G
U
Pupils
Sensorium
LOC/GCS
Meds --, Cardiac Rhythm PRI: / QRS: Pulse Strength Cap Refil / WD Edema Chest Pain • Respiratory Pattern Breath Sounds Secretions Cough
Color
Integrity
Backside
Access Devices Location Condition
Abdomen Bowel sounds Stoma/Ostomy
Device Color /Clarity
PREPARED BY (Signarure & Title

INITIAL SHIFT ASSESSMENT

Time: 6 70-0 Initals:111. V-I—
A it 6 x
P. A r R-Yieq.1 t.IciVervcArt, cjio in15 COVVirnes 4T
filSn,i (24 7- V p 1 l `
}(Q-. j 6P 12/A
t
(4 ' i R/54, -c'-i-ri k 4
• f -— -4 V
,SI ;rt ti4 E 4.e.,,,K,

0 619,4- pro,'
T z _ 02e
6?0a -95Z RA
— c TA t'
0 (See-re.-l-rDNI 3 a eou. cik

ThIC.P.NrtiVe_. aphrtrws.r.4,-.r-10 x q 16
-
,,,--Ze..c-e
g Lert OZ( F DresSP,...,/' OM-
6ferAkdr-T-4”-)
t / 4-t ) i j ,A,,z,:bay Iva _
/as clo, aust,eN wet,
N c.• .s/S r,C ;,...)Cc.,4-it., Al -ir4 Orc....11-1PJ

60c 4--rvens3- +e,„,,ie.f-' ts) 43).3 -
cit.14-eNCIRZA E.L . -An., mood-Arc

C9:40 vvvy
f26 S4-0-14.14.
roi e_ii -4-b ei r-c....ri i ii
i c.4k -11.9,11 0 ..,.r u. r a ..)P, -a

,
Time: V C.-D Initals: "11lij!i—2.-
.
—7rd-7-0 7 3
P27/1006 ,5 / coNe 67771-,7445 derpeeti-/l/eq / M4
_y/5C51_
az, re-r;/_‘-.3 sec. a
,-5*•P` aele,77
eXesi— f./K7

/q/` Z5 — 3 0 6407 i790 diicer
p-i,e vm,--/- C
-Zr" Ae)740 y'a
-
.
&S, M:2-
P.Z.V0wrisi - //p46_,
,C7-F /142/7 KZ(iSki.-9e.c::Z
ilOrp70 ,.e7i KG,
0
le.-49/
d-a- r-/te i..---
DEPARTMENT/SERVICE/CLINIC
ICU3,
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, -2.) first, middle; grade; date; hospital or medical facility)
.
HISTORY/PHYSICAL

O OTHER EXAMINATION OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

Irnntinne on nnnw-Rel
DATE GC1-03
. FLOW CHART
. OTHER (Specify,
DA FORM 4700, MAY 78
USAPPC V2.00
MEDCOM - 21244
DOD-034820
IM=MM

I-

I-

U) U)
U)
O

O

C)
•zr
CD
O
C4) C4)

O
ce)
O
O
O
NN
N
O
O
O
•r"
O
O
O

0
O

O

O

O

ce)
NN
N N
N g p I'kkAD N N

N N NN
O
O O
N
N N 1
0) 01
CO
CD CO
CO

O 0
I-
ti

ti 9,
Co
0 CD
O
111
AL

•cr
Ce) ce) kf, 0
ti N""
N
N N
O

O O
CT)
O cT-
CO 03 CO
O O ra O
ti ti

O O
CD c.0 ¦..g, cD

t
O +z— ctg O
I-
CO
M
Co
—I a) IL u j —J ../
0 0_ c.) 411 .
c 170 6— Zire
— —, O. M 8 na' I-8
est
7. CO al Lt CZ cv — 0 MEDCOM - 21245 O ._ 0 I—
Z I-- = cc u) it u) 2 a. z cn o
illit
DOD-034821

rA_ RECORD-SUPPLEMENTAL ME.

surgeon General.
For use of this t, .. see AR 40-66; the proponent agency is the Office oi
OTSG APPROVED (Date)
REPORT TITLE QA Appr 8 Mar 89 INTENSIVE CARE NURSING FLOW SHEET
REFT ASSESSME INITIALS:
TIME:INITIALS:
PUPILS SENSORIUM EXTREMITY MOVEMENT SEDATION
° prm j),"
PAIN CONTROL in y
SP012 q7t1 fim RA
RESPIRATORY PATTERN
/qr.
BREATH SOUNDS SECRETIONS ciserredivivs-02 SOURCE/FLOW/SA02 9' 0-1. VENTILATOR SETTINGS
CARDIAC RHYTHM 141Z-tZl CAPILLARY REFILL PULSES
EDEMA
ABDOMEN Soc+ BOWEL SOUNDS BOWEL MOVEMENT NGT/OGT TUBE FEDDINGS DRAINS
VOIDING COLOR/CLARITY
COLOR INTEGRITY
#1 TYPE/LOCATION/SIZE DRESSING CONDITION IV FLUID/RATE
#2 TYPE/LOCATION/SIZE DRESSING CONDITION
Ironticon, nn rein,rcxq
IV FLUIDS/RATE DATE
DEPARTMENT/SERVICE/CLINIC
PREPARED BY (Signature & Title)
ICU #1
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, FLOW CHART
first, middle; NAME: date; hospital or medical facility) t.,\ RANK: AGE: .. HISTORY/PHYSICAL
. OTHER EXAMINATION . OTHER (Specify)
UNIT: GENDER: OR EVALUATION
. DIAGNOSTIC STUDIES
STATUS: US: AD / CIV IRAQI: CIV / EPW
. TREATMENT
MEDCOM - 21246
DA FORM 4700, MAY 78

DOD-034822

O
I-

LO O O
O O
0.3 O O
N O N O
O O
O O O O
Cy)N CI" N
N N N N
N N
O N O N
CY) O
T-
00 CO
lE
6' t—
ti ti e- ti
CO CO CD T
U)
01 CV)
N 2 '3-Cr* N e- N
O O 0
O O CO O O O
03O CO O CO O
1••• 0 4 ti O
-.v
is co r ao (3- 00 C.4 cl cG e
Ci) -J 0 z
0
cc a. z O

MEDCOM - 21247
DOD-034823
Automated Facsimile APATIENT TREATMENT RECORt- -,OVER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
-%.,---, •
3. Grade FZ:Frn-ission Remarks 1. ter Nbr Nam FGN
14. Sex M 5. Age 23Y , i 6. Race X 17. Religion i ISLAMIC 8. LnthOfSvc 9. ETS 10. PrevAdm NO
11. FMP 1 13. Organization - 14. Ward tCW1
99
15. FlyStatus 17. Dept / Ben -K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case BC
22. Hour Of Adm: 23. Clinic Service

21. Source of Admission
AEA - ORTHOPEDICS17:43Direct from ER 25. Type Disp 26. Date of Disp
24. Name/Relation of Emergency Addressee TRF-C-ICU 2003-10-15
27b. Telephone No 28. Date This Adm: mitt ngOfficer:
r
27a. Address of Emergency Addressee 2003-10-06 12U') -1--'
32.0 Blood Components30. Date nit Adm
29. ortin m beo ;2_ 2003-10-06
31. Selected Administrative Data Marital Status:
DoB: 141) In/Out Patient: Inpatient MOS:
33.
Cause Of Injury:

34.
Diagnosis / Operations and Special Proced ires: WI g -) ) ) \

T4--"-A-44A--
L FEMUR FX W/ EX FIX,
' Plq ‘
9

ig.\ 9,09
ii2)V
35. Total Days This Facility
• ental Care Total Sick Days
Absent Sick Days ' Other Days ConLv / Coop Care Days I Suppl -Bed Days 0 1 0
1 0 J 5) 5
35. Total Days This Facility
1 Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care 1 Bed Days . -ick Days
C.-)
04.)) 1 . q q
ds Officeri Signat re of Attendin icer 11,3 1•1,2/-'
-
-
DCOM - 21248
Automated Facsimile - DA FORM 3647, May 79
DOD-034824

ABBREVIATED MEDICAL RECORD
MEDICAL RECORD
(Enter date of admission)
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION
Y614'z­m-0 5-

104,0A °Le.,4n,11
ctak. Y/frptitil4si
PHYSICAL EXAMINATION
PI GG. /¦.:1-
C4511-
A-02 7 21-0'

f
`fL-.7
cx.S
a
61-6-51 f-bor
,
PROGRESS (Enter dote 4discharge(gt al firm! diagnosis)
1C
Pr---olS S \rtl)Lft FiL (73 (
6)
0 NA-......._A i

REGISTER NO. WARD NO.
I
PATIENT'S IDENTIFICATION (For typed or whiten entries give Name last. first.
middle; grade: date; hospital or medical facility)
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS MLR 141 CFR) 201.45.505 OCTOBER 1575
USAPPC V I BO
MEDCOM - 21249
DOD-034825

AUTHORIZED FOR LOCAL REPRODUCTION
OF MEDICAL CARE CHRONOLOGICAL RECORD (Sign each ent
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
MEDICAL RECORD
HGT:
AGEASA:1i9. 3 4 5 E
SEX: .
A
ALLERGIES: 1..3
:

DICATIONS
CURRENT
PROPOSED SURGICAL PROCEDU :

Mallampat6. 3 4
CARDIAC.
DISCUSSION OF RISKS AND BENEFITS:
ANESTHESIA PROVIDER.
ex, sae first, middle; ID Mo or ssN;SPO Name - last,
give:
(For typed or written entries, CHRONOLOGICAL RECORD OF MEDICAL Medical Record
PATIENT'S IDENTIFICATION: of Birth; Rank/Grade.) VAI) -97) STANDARD FORM 600 (REV. 6
usAPi
Prescribed by GSNICMR FIRMR (41 CFR) 201-9.2021
MEDCOM - 21250
DOD-034826

AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD I
I KEA I NU VFW/ANIL" 1 RAI fotgr/ udGII Cultyl
SYMPTOMS, DIAGNOSIS, TREATMENT, --DATE
•
.
, ..
-A ._ i .m....._....k.. '¦
¦maill¦ 101 . vb

muntraturameas .
veriet.
A„ , - (otcoA
i
__: ie.... . miLa...a.-4
46 eS'
i. LIQ A A
al III 4. Dia.

mirwimmigarawro
yr 1
glinlatelit
14Mign1111-¦.. Oitio...A.111111
1110INIII ¦ II 6 Ari4 46L 11, % 14 Eib
iiiii.i
dM119.4) 40¦ 1 .... pc niM11s , ..,„11„1,Ilb
It
nr\C_ 19 0-z--
,
STATUS DEPART./SERVICE RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITY
.
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR ,
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of REGISTER NO. WARD NO.
Birth; RanWGrade.)
_ Int AA

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR
USAPA V2.00
FIRMR (41 CFR) 201-9.202-1
1;4 4-a1 10 L MEDCOM - 21251
rs I
DOD-034827
AUTHORIZED FOR LOCAL REPRODUCTION
‘4011-1-PROGRESS NOTES
MEDICAL RECORD 1
NOTESDATE
1/43,_ V2/1— vl•
0 A -to Cuki-A=1_ \JSS ir
Go
0C-IiiN
3 • Ro /ID __.1--V CD 140,CIV"
2' ril A a -12-- io s oz?'
.AS1 • l'.. S1/2_ 1K) S • ---,4-. P /N -t" ---kr\ V • as. 14... " • , ¦ CE iro1 •
It\
\ aCe_ O'Y-\
-el•CX-LC \ 1 J.10 ada. S A IP ... IlL ¦
C.) 1/111 / 1 -.4-• r
.4,7--L..
, \ . LS
A C S
• CI a l'A & x ' b\k•

IIM, -
4 ....) k S-Z--e..S-.1,-. "±(D MOW
Will 6S
•... -'-3 sec_ A. a_ 5-es
2 5-k-ra' ow, , ce__ SSS • 6 --C r • 0 oma-, •111.__ .
"
...
. IAil 0 V 4 ._ a, . da _ , ., ..,,,
c ... #
-...
1
.
_ill Al Ar A/Fr —
-...111
_... _...c........._ _.......__ -Al di

di, ,
rte—AV
/MI ... -an. -
, / /
-/ -
0-e c.../ ,... ¦r / f
/
C:1-
.....-SPON 9' MBER
OR SPONSOR'S NAMERELATIONSHIP TO SPO
(SSN
MI
FIRST
LAST RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITYDEPART./SERVICE
—
WARD NO.
REGISTER NO.
PATIENT'S IDENTIFICATION: (For typed or written entries give: Name - last, first, middle;
ID No or SSN; Sex; Date of Birth; Ra /Grade/
PROGRESS NOTES
-11
Medical Record
STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00

ME DCOM - 21252
DOD-034828

I
FIRST NAME
LAST NAME
NOTES

DATE
• up - -A
t if vQ No 0
n • o 4 t
a
m
VD-41)/ OUL btAl_ r I
rOTP1 i L' CA-P 0
: _ ()I-D -L-6frikket
•' • 'i. „I 4, .
Kral ,i, # x •I A 1: 4 ATV\
)(
A 1 0 a _ i rIAA ()Ake W1AD
P i t X -C tteA -11) LUE 0 /. . O&E .
l'IY2Lt
1 -. Aatit. 611-AA : kce- ( ' .
41 ri i 1 0 .1/t: w Rive. 1 . ' , (-(A) -o
k-f& o D 1:x i/como/

I ww1-7)1 '•
6a (s/t_cK pa I/ wergasz:lorarrimai¦rar.--avvrrine...;.1

is 6
7)4,0_12 ,
¦ VIAA h CIA uktkusiA -
fee I 6 II -.on l 4•-a ..._I-,& 170I ° di I
I
1 ---
ii A 0
-1 __ , i '\-D 1
¦
Lt . .i.
• ...........-

A/ ,..._.x, • 2.)•%1., I IL ...11r:
.„__. ' i ­
... -. • 1
4 -• _ ,_k-l_ , .
...o.
0 e (%--) -
r 1 r
... .-41....AA...¦ _ ¦
¦11 •
.¦ A -/¦-¦-_AMP q_krw--,-___3. -, (
ELL -1--
1¦111¦41111
0 A 6W/I b Lik / an
I atkt A gf KUD
i., COP 0
,ralvteAA G , ti ' I i 'flAitSteLL Gooks i-i-ci L.Le ex e:
Qi eV
-1,u Cbilf' VUTa-g , --IV / i I

C Sni cult-5ao .-v
_._ dveD [4\ (./ LUCA lx-e_ v -GoNirlD1(Pia --f & 4.11
-.„-Amnft. pnREA_Arma.......rigammim

MEDCOM - 21253
DOD-034829
A. DATE MEDICAL RECORD • (1-/&{ yr 5L4 ga. PROGRESS NOTES v.5 urt-,d 4-0 cuf d /(100 Pte 14-
e• • o 6 9 •
ELay.../ 1 NO 4 °O Z.) ei • h
)1- rtl 't r'" 1 T­6Jet. 0 rea ),zir Mir A

WARD NO.
(Continue on reverse side)
REGISTER NO.
Nome—last. first. middle:
give:
or written entries medical focally) PROGRESS NOTES PARENT'S ,DENT¦ FicKnoN7n, typed k; rote: hospital or
grade: ran
STANDARD FORM 509 (Rev. IS-77) ?Mated IN GSA/OR ,
WO 101-11•36-
MIR (II 509-11 0
MEDCOM - 21254
DOD-034830
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/
DATE
efA, Co
It)
41° af
q__75 L
RECORDS MAINTAINED ATDEPART./SERVICE
STATUSHOSPITAL OR MEDICAL FACILITY RELATIONSHIP TO SPONSORSSN/ID NO.
SPONSOR'S NAME WARD NO.
IREGISTER NO.
(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
PATIENTS IDENTIFICATION:
Date of Birth; Artnk/Grade.) i ()) ........k.f.
•

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 1REV. 6-97)
Proscribed by GSA/ICMR FIRMR 141 CFRI 201-9.202-1
MEDCOM - 21255
DOD-034831
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD NOTES
DATE yin P ry

sisx, vo -calm (IL GP
0-AA/UtUl) 01 A itchu).

toci
Or1N,
oinfuji) A aA/V ¦ Watiaktri&

2/1 C-b Utuk,
f
41 Lit
G
AG
_
La _ Al oki,A
_
AA
•ha, t . l AL it 0 416 .11 /
tO
"Al
ALIA e a 4_41
• LA
t l
.
0,1 jo

PA 401 4 Ova
oeu-a_ pie

ob5o
\WI'S
SPONSOR'S ID NUME
ISSN or Other)
RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
DEPART ./SERVICE
iddle; (For typed or written entries, give: Name - last, first, m
((3) 1
PROGRESS NOTES
f Birth; Rank/Grade) \to
PATIENT'S IDENTIFICATION: ID No or SSN; Sex; Data of
Medical Record
(RE
STANDARD FORM 509
Prescribed by GSAIICMR FPMR 141 CFR) 101-11
56
DOD-034832

MIDDLE INITIAL ID NUMBER
S ANDARD FORM 509
(REV. 5/1999) BACK
USAPA V1.00
MEDCOM - 21257
DOD-034833
AUTHORIZED FOR MAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
NOTES
SPONSEIFII ID NUMBER
(MX or Merl •
RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
DEPARTJSERYICE WARD NO.
PATIENTS IDENTIFICATION: (For typed or written entries, give: Na • 114 Via mid*:
lionlAnde1
. No or SSt Sec Date of PROGRESS NOTES
Medical Record STANDARD FORM 509 IREV. 611E
05)—y
Pmsaibed by GSANCIAR FPMR 141CFRI 101-11.2 03iM USAPA V
DOD-034834

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD

RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
DEPART ./SERV I CE
(For typed or written entries, give: Name - last, first, middle;
PATIENT'S IDENTIFICATION: ID No or SSN; Sex; Date of Birth; ff k. Grade) PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/19! 03H
Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203AUSAP V I
259

DOD-034835

MIUDLE INITIAL ID NUMBER
DATE NOTES
7 iLpt.s PAI-(r6--))6)-2..
8 oc...4,,3 its s, ,,,,-.4-c ...xc... 4, 10 T-0-c Coo , V3 3 , LA k.)..-...A-it-) .t, t rttr A.-4-4":: j

itig‘ rv..crc-rN.,%N.) . _F-56' C K CWR-S sc-vrk.v...r c_ c,(. t r cp (,,,,.. a J, , c,c_..r____ L ca,tct,zy c_ .
41.-v \ _ 4--)C eb k L.I.xot AAs c.) , k_
IA AV 6-64-LeY1/4 LI e--"1-"ci //1"ci/lAciC -- "?/1-1--/ •
‘3,,ci-era27_3St) )55zAA.A.A. Cer.f.e_C-. Rs3-vs 5 ) ,CA7 4-e -..e s It()LArt7 1" , -c-c-s--7-m,40,,,;. (rk ,;:-
1) 01 AI
J)
r, ,,,,,,,,„ IT c5 3 ...)-,-,..._ 7 ---AASr 4 4.4.....„-s+2_,-.4 .m, -. .-7-P) ,i,s3 .4,9 V 1.-CA)T_ intit-,T)',,,,t9 1A.rrfrff i ( c ,11.5 11-L ?p 1 1,,, c•,,e 0_,,r- 4.. ,,c-F-e-*--eA i,j- ; FTE
fizr C G v... 5
P _rt,a,..-/C ,,,.a,....... . , 0 , • 4 . __

k,
,tae i er...i. e ) (50 r _.ji-c... .42) $ ikik-, 1.0-4‘t i,,Y--_,-/ig-s-,),.. \ i C.A9-1,-..* ." ,f0.-+..„.%. r -_,-,... . ...
"-2-(-1,-Y-.7 11--fte
/q" c-t(2
OVZ, 3 t

a-Q.1,-s-71/ ' 5 l(Lbc•i-c_ '2-19/P / alla
--r-r. 9 5- (o / 6 7115-e :i 2--) .5-i-5g -Z , , A , 0-2)-15 12a-e-1A1--! tiOC.6-3 As 5 t.euv•-C cam_ c,-t, -Pr-' Co ( ,)K , 5„_.., 6 4 A., ttc.,4-4_ oi-acAr-
1-„, Tr-k••• ¦eve .. C/o per,;,.. 5 ., ve-fr. re4-e..._ch_v ..e...t..4--(,.....Li-
totr..!„,..t_. r ) d-c)m-k_ yaigg,t, Coto kr. //e- 0 t.reN...1 --.A- s i (...._ t fo_ce-1 rxr.) s. k.irl ; 44-04ALX.P.

it0 ft-3 c4A-. k_ A, cc, K.oll'Inve— Vek iltn.av-t_ter; --"------.___... ¦-¦.--------eV*
umb
V10 40?4%) 2-° IS 4,s ...14 CA---c (;) I q-ce-t-, ; At. ki-S5/ .-Ail) X 3/ c--e( Lei Z.-2SA--er ;8152 400
r.,,,.. p"..rs ,LE--c 2- . • , ; L . u . s-., • 0 ,,, , ,.::.
.ILIP
4 ¦ --• .. • i...-__.. cLa r_t ' • _ IsL.. • ft.-_ Co a
. +1. l•-e--P-1.,.., i-0,1 • - --
STANDARD FORM 509 (REV. 5/1999) BACK USAPA V1.00
MEDCOM - 21260
DOD-034836
MIDDLE INITIAL ID NUMBER
_AST NAME
(REV. 5/1999)E
STANDARD FORM 509
SAP)
MEDCOM - 21261
DOD-034837
NSN 7540-01-075. 3786
TREA
EMERGENCY CARE RECORDS MAINTAINED AT
AND TREATMENT
MEDICAL RECORD (Patient)

ARRIVAL
TIME
PATIENT'S HOME ADDRESS OR DUTY STATION
:STREET ADORE TRANSPORTATION TO FACILITY
e.IVOC THIRD PARTY INSURANCE
\
CITY ND
11
W111111111111:12213
DUTYILOCAL PHONE
111231011011
ADDITIONAL INSURANCE
SEX VIM
AREA CODE DO 2566 IN CHART
`NM
NAME OF INSURANCE COMPANY HOME PHON
MEDICAL HISTORY OBTAINED FROM
AGE
EMERGENCY ROOM VISIT
AREA CODE INJURY OR OCCUPATIONAL ILLNESS 24 HOUR RETURN '
DATE LAST VISIT YES NO
CURRENT MEDICATIONS
NO •
Na
TETANUS --COMPLETED INTITIAL ETESDATE LAST SHOT
NO0 YES -0
INJURYISAFETY FORMS 1112IS II I
ALLERGIES

CHIEF COMPLAINT
lY1
VITAL SIGNS
MEM
CATEGORY OF TREATMENT
TIME
EMERGENT 11111111111111

111.11111111
URGENT INITIALS
101111111111111111111
11111
C-SPINE
CXR PA & LATIPORTABLE
ION-URGENT LS SPINE
BHCGIURINEIBLOODIOUAN T a
¦ ACUTE ABDOMEN
CBCIDIFF 1111331111111231111111111 HEAD CT
›- CC
CC
k
1111013311111111 ¢
1111=1111111.111111111
BLOOD C&S X
I • ECG
ORDERS
MONITOR PATIENT'S RESPONSE
COMPLETED BY
• PULSE OX
ORDERS

TIME
PATIENTIOISCHARGE INSTRUCTIONS DISPOSITION QUARTERS loEE DUTY
DISPOSITION 78 HRS.
48 HRS.
24 HRS.
FULL DUTYHOME
RETURN TO DUTY
MODIFIED DUTY UNTIL WHEN

ADMIT TO UNITISERVICE REFERRED
CONDITION UPON RELEASE

received and understand these instructions.
UNCHANGED I have
CI IMPROVED TIME OF RELEASE
PATIENT'S SIGNATURE
CI DETERIORATED
-lase
(Fol typed or written entries, give. Name
PATIENT'S IDENTIFICATION lust. middle' 10 no. ON fr other/; hospital m
medical facility'

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 5581REV. 9-961 Plescaol by GSAIICMF1 f PIM 141 UM loi.11.2630Atio)
USAPA V1.00
MEDCOM -21262
DOD-034838

0o0 IMPLI I.00
MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor) TIME SEEN BY PROVIDER
TEST RESULTS
WBC ABGIPULSE OX RADIOLOGY Check if read by radiologist
HIH SUP 02 PH P02 RESULTS
PLT PCO2 SAT OTHER
PT DIP EKG INTERPRETATION
APTT BHCG ETCH GW MICRO
PROVIDER HISTORYIPHYSICAL 712,1-#--rt-4-11-/L-4-t d 7i" 717.4_ s/ P (Z)3 .
73° t7C eT°3 / 24 11 4-- eS-4 p7 -cq „ ---All!16-

CONSULT WITH TIME ACTION RESIDENT/ EDIC NT SIGNATURE AND STAMP
DIAGNOSIS P
PATIENT'S IDENTIFICATION For oyes or written entries, give, Name - less, fest, middle; ID no. ISSN Of oared. hospital or nese, feelkyl 111111'(') ' EMERGENCY CARE AND TREATMENT (Doctor) Medical Record STANDARD FORM 558 IREV. 9-96I Prescribed by GSAI1CMR FPMR 141 CFR; 10 1•11.21:131611101 USAPA VI.00

MEDCOM - 21263
DOD-034839
NURSING NOTES
(Sign all notes) OBSERVATIONS Include medication and treatment when indicated
MEDCOM - 21264 STANDARD FORM 510 (REV
DOD-034840

OCUMENT INTRAOPERA ;icy is the office of The Surgeon General. -66, the propos, VIEWED AND PROCEDURE
For use of this form, see AR 40 R
2. PATIENT IDENTIFIED, RECORD
MEDICAL RECORD
ROOM VERIFIED BY 2
BY
1. PATIENT TRANSPORTED TO OPE R
Oirt/f— 4. PATIENT IN ROOM
NUMBER
6
TIME PA IENT ARRIVED IN SUITE
VIA ‘...t TIME INC TIME • it/5 /1.‘c OTHER (Specify)
3. DATE
5. PREOPERATIVE EMOTIONAL STATUS
. WITHDRAWN .
06'

. ANGRY
CRYING
. EXCITED . ANXIOUS
CALM
.
COMMENTS:
.et.-12 (Pr 6. NURSING PERSONNEL
RELIEF
\AO A--
SCRUB
ASSIGNED
SCRUB

2
RELIEF CIRCULATOR2L1
ASSIGNED CIRCULATOR 0 RIGHT SIDE UP
(Specify) . LEFT SIDE UP
LATERAL: 0 KRASKE
7. POSITION AND POSITIONAL AIDS
. PRONE
0 LITHOTOMY SUPINE
•
AI
S. SKIN PREPARATION eINDWECOMMENTS:
PREP S UTION (Specify)
BY WHOM:
Lgt, 19 Li)
NO SITE: BY WHOM: NURSING UNIT
HAIR REMOVAL 0 YES •
SITE:OR
DONE BY: . RAZOR
.
DEPILATORY
METHOD: r-
COMMENTS:
CLIP
.
:
COMMENTS
-NLAN
9. LOCATION OF EXTERNAL DEVICES
M111411111111ter...
Afiri2.91:44 15V1
'411111r
• ...--
-, ....
ID -........,..-..-¦Iiiiiiiiiiiimil•IIIIIIII.....­
-
It"
_At ''s
IA Illlit-iiii•
•
=== Tourniquet
— Safety Strap
X Ground Pad CIRCULATOR
C = Correct I = Incorrect
LEGEND
19 (3 —I—
Closing Final Closing
SCRUB
First
Count Other" Count
10. COUNTS 11111111111
. No MN
0 Yes
11111111111 15
sponge . No
.4 Yes
Needle Sharp 111111111111111 0 Yes b. 11111111111 ELECTROSURGERY DEVICE(S) (ESU)
1111111111111111111
Instrument
12.
Yes .4 No 1111111111
written entries give:
Other O or typed or Facility;)
6
PATIENT IDENTIFICATI Hospital or Medical -5E1)
1/11
11. (ESU NO:
30'1
Last, first, middle; Grade; Date; BRAND
Name -
? GROUND PAD: LOT NO:
b
. ESU NO:

BRAND
GROUND PAD:N/Itit LOT NO:
5
BIPOLAR NO:
b1111111/
b¦d — .
MEDCOM - 21265
DOD-034841

,L NO IF YES NAME: ID NUMB JUI-AL; I UKtIl
13. PROSTHESIS, IMPLANTS . ;:i MEDICATIONS/ORDERS,,::„ '3 ,. g.
1 . J.:: . 4'',.Z,O,'. wa., , ;;, PT:- ' ; , :4K,, :,. -
NO V,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • METHOD PREPARED BY.
DOSAGE TIME...
MEDICATIONS/SOLUTION
p5
:WOUND IRRIGATION Ki YES . NO, TYPE(S): TIME CARRIED OUT BY;OTHER ORDERS ;,
.cti
'PHYSICIAN'S SIGNATURE
IF YES, SITE
15. X-RAY IN OPERATING ROOM
YES NO
r
LABORATORY SPECIMEN
16.
NAMESPECIMEN (S) NAME
YES . NO lyr FROZEN SECTION (FS) NAME NAME
YES . NO NAMECULTURE (C) NAME
YES . NO NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)NAME NAME
Kalor-01z-w.
17. TUBES, DRAINS/PACKING YES NO •
liki Ors'ISIV
TYPE/SIZE 1. 2.

-Ve..-i.ix
10,.. ri,ki ,-)7 Ace kA), ..e
SITE _,,, . 3.
1 ,de,Y4AA 6(4)e 0
(9 1 IN15k s
19. ADDITIONAL INFORMATION
51-kor -1,--: 13351,4,
tri.11--E" -- 153 I m ,

--51..- )a)fri_
20. OPERATION(S) PERFORMED
PI
'1-1'N,--A)N's I 1)ep".;.-k G--) Pt,.-A-- -E Eyk----t -F;x..76,--6 Ci.L- i-6-A.,r-6(6)-L.
21. PATIENT TRANSFERRED TO 1TIMeEi. Li kir.t 1 METHOD
1_31— (elk 1.--C1rErz., MEDCOM - 21266
122. REGISTERED NURSE SIGN
DOD-034842
INTRAOPERATIVF DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the propon 3cy is the office of The Surgeon General. . ,
JM 2. PATIENT IDENTIFIE LORD REVI WED AND PROCEDURE
1. PATIENT TRANSPORTED TO OPERATII' - VIA j.t„4:a).1) BY at./1.-e--4, -4.4-4.-R_A-VERIFIED BY aerr/A-A3
TIME PATIENT ARRIVED IN SUITE 4. PATIENT I TIME 045-3 NUMBER /"! ()
3. DATE
gOeT-03
5. PREOPERATIVE EMOTIONAL STAT S
cg. CALM . ANXIOUS • EXCITED U CRYING • ANG • WITHDRAWN • OTHER (Specify)
OMMENTS:
piLii:efoi,,,,_„4,,,,,..,4.,:m .... 1 („fo)...2
. .......... .

6. NUR51NGT)ERSO NE/
EL
ASSIGNED a IIIIIII4 .----.Itio-.. --"RELIEF
'SS
SCRUB

SCRUB
ASSIGNED C..;Pr i G6 RELIEF
CIRCULATOR . .__. _ ..... . __CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) --,-
g
SUPINE • LITHOTOMY • PRONE • KRASKE. LATERAL: • LEFT SIDE UP • RIGHT SIDE UP
COMMENTS:
b LC) -L
8. SKIN PREPARATION -
HAIR REMOVAL • YES NO PREP • UTION (Specify) 4e,.."-X1 r..6e.„/e-
DONE BY: • OR • NURSING UNIT SIT AOCQJ B WHOM: ejor-

METHOD: U DEPILATORY • RAZOR . 2 SITE:.s- BY WHOM:
• CLIP
--r---. COMMENTS: .. COMMENTS: 11-.0 IC2-d—i--&-+',..81 rile, A4 d
9. LOCATION OF EXTERNAL DEVICES
. _
•
• .-
-, t :OE-.-
-'°¦--**Namemmo.--.-

• -Torim---
......_..

LEGEND X Ground Pad ety Strap = = = Tourniguet-• ••-:-•:.-­
•
C•= Correct I = Incorrect
vt § V-10., I First Closing Final Closing
10. COUNTS Other•• Count .. i ,:. CoLint .SCRUB ' IRCULATOR
Sponge Yes Vo e_
Needle Sharp Yes Vo

- _
Instrument D Yes Vo _ ,. Ur.;11:1_,.:, ,
_ ..
Other U Yes Vo

11. PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTROSURGERY DEVICE('.) (ESU) • YES NO
. iil,
Name - Last, first, middle; Grad • • Hospital or Medical Facility;)
Co AG
ESU NO:
GROUND PAD:: i •A i- 7S-7) -
\I/A- _..._._
. . , LOT NO: 0 Oil -, .1-c) 0 5--Cy-.:':'..ESU NO:
NO:
... ,• . .. • •"GROUND PAD: BRAND
. r ._..
LOT NO:
r-1 nine. A [I
NO: MEDCOM - 21267
g (0 dr 0 3 I
DOD-034843