Medical Report: 20-Year-Old Iraqi Male, Detainee, Fallujah, Iraq re: Multiple Gunshot Wounds to Legs

Medical records of a 20 year-old Iraqi male, Enemy Combatant and Enemy Prisoner of War (EPW) admitted to hospital with multiple gunshot wounds to the legs and associated injuries. The medical records do not give any indication as to how the detainee received his injuries other than a firefight in Fallujah, Iraq. The medical report does not give any personal information on the detainee.

Doc_type: 
Physical (non-death)
Doc_date: 
Saturday, November 1, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

O COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
Why was
was is person detained? ,S2 /1.00-711r-LS
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Who witnessed this person being detained or the reason for detention? dive names, contact numbers, addresses.
How was this person traveling (car, bus, on foot)?
Who was with this person?
What weapons was this person carrying?
What contraband was this person carrying?
What other weapons were seized?
What other information aid you get from .nisperson?
,2,cdaiona! I-lelpful Information:
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5. PREOPERATIVE EMOTIONAL STATUS
CALM • ANXIOUS • EXCITED.3• CRYING . ANGRY • WITHDRAWN E OTHER (Specify)
COMMENTS:
,__Lkit-v_t_ ­
p-f---Imo' r xr41-.-t.;\ .
6. NURSING PERSONNEL
ASSIGNED eeFR ..T-:777 ----RELIEF
SCRUB .SCRUB
ASSIGNED RELIEF
CIRCULATOR 11.11111111P01-
3( _ (,-. 7..„..... ___.,..CIRCULATOR

" i NT!
7. POS IOIVIZAID POTIONASI L AID3S /RSpecify) 1)4-CriAt- ' .R1 a,k,dert/ 0-1 inA3-e.ot a...A-4-0'. iH7e--
7._ 1pRkki cli
1
• SUPINE '3PRONE II KRASKE, ,3LATERAL:3. LEFT SIDE UP3RIGHT SIDE UP
.
)6A-LeSe ej2!--ip
\ .,/^
COMMENTS:
P7-(LA c -2.-
7iR13-0-a-L-Ficry,-tst
KIN PREPARATION HAIR REMOVAL YES • -PREP S anion,' (Specify)R
.
DONE BY:3q OR SIN3SIT3 B3W
METHOD:3MI DEPILATORY N RAZOR SITE:3 BY3
-Z.
,3OM: Ill CLIP
,,___iza,a .,.....7 ,
.........

COMMENTS 1/1.4_,e4C4 O3ae„,/,,-,,-,-.• COMMENTS: v•\,0 feetAA:ri iciA.
9. LOCATION OF EXTERNAL DEVICES
,.....,.,_
lia llat --_-S
... _
.
.,.
,• . Allibillialtilij...-Vrallia -
-.............--_,¦.---

-10111111404di
:47.74211Parier
LEGEND3Xellad rap = = = Tourniquet.--
-.0
‘NA-4.01, •E-7-2C = Correct I = Incorrect
-.--
r r
btadzo -3.
trtifi0-3 First Closing Final Closing .
10. COUNTS Other• • Count3_ .i..;., COUnt .SCRL1B
CIRCULATOR Sponge Yes3'-No 0..._
Needle Sharp Yes ] No C...-
Instrument3II Yes No — -.. ..1).e..,:at'..L• •7,7Z (-4R,„...-.2 , ---
..._. ___
Other3II Yes No
11. PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTRO_SURs.X.ILEVICE(S) (ESU) 10. YES3. NO -Name - Last, first, middle; Grade. Date; Hospital or Medical Facility;)
..titkrr
.Rt--0 A - 6
:w. ESU NO:3dr.t./.4-44...a,„ C7 57-}3
AVM (0(6)--q . -
13/ 4.' •
GROUND PAD: : ?AND V
67P/Ar
LOT NO:3(41.4 eaRoth54-1 '. :1.7.E.1)'NO:
.• •-,7GMOUND PAD:
•BRAND
r,....,
. LOT NO:
( tit(2-j -2. -.3.., U BIPOLAR NO:
Ail 6 YR3
1'1 A C fl nit ¦ C 40tIl A0es •-.r. ... ••••
3
-I, 179-1 (TEST), DEC 82, WHICH IS OBSOLETE. 3 USAPA V1.00
MEDCOM -23054
DOD-036630
13. PROSTHESIS, IMPLANTS3LI NO3-,.. IF YES NAME: ID NUMBER;3FACTURER
.3.
,3..-,.3 =' ,-,. 3
of -3.,,,,: 31?MEDICATIONS/ORDERSV -.:, " 3„T._3,.3,'3,3,,,,,. IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA)3 YES3`MEDICATIONS/SOLUTION DOSAGE : TIME • METHOD PREPARED BY _.. ........„.3-— , . 0 GIVEN BY

'OUND IRRIGATION3-.51 YES3. NO, TYPEIS): 01 1 c_R ;',OT ER ORDERS .: 17/..MMI.Amm jads....,...,tt;M',k­isjr.lifroMMINITZAREguk. F,Af , TIME i _ -CARRIED OUT BY
PHYSICIAN'S SIGNATURE i.
15. X-RAY IN OPERATING ROOM3 NOYES • 16.3 SPECIMEN (S) YES .3NO NAME3 FROZEN SECTION IFS) NO . NAME3 YES3• IF YES, SITE :3.3;); '3'"! LABORATORY3PECIMENS ,._., ..3.. ________3--11-:::"L------. -- --1;:-3--.:3I NAME -NAME -
CULTURE IC) NAME NAME

YES3•3NO III ---- -3-NAME NAME
NAME
NAME NAME3
.-3-18. DRESSING/IMMOBILIZATION (Specify) ,R.R...R-......._
17.3TUBES, DRAINS/PACKING3YES3NO •
z...71---/-;2
TYPE/SIZE 1.3i ii P 2 . .
14.4throg t-642-4----/
SITE .
.
;,
.13kA-4/-e-t3.
19. ADDI IONAL INFORMATION ,3,,3 •
)3 ('-hie-&;' - ''-•
.0,

20. OPERATIONIS) PERFORMED3 •
.
t .
X7...'hi -----e--6-it,-017 .:. -;, i-tj7-­;::/0--tt--k-el.

21. PATIENT TRANSTm9 TO
3 TIME METH3•
// 61
22. REGIS
'- C11777 Al°
REVERSER (b)(=) --/- M -23055 USAPA V1.00
DOD-036631

..a1-119
NSN 7540-00--
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-7DAY
MONTH-YEAR DAY I NO4
d52-ifd‘i 3 C.N4o
19 HOUR I •7• 1 .
: -" 4 Z31 ' 1 MINIM

n— )41
PULSE7TEMP. F ,7'''
.7: •

'7(0)7I . )105°
.
:.7:. Et Illallidnnr# al let•
iv
--•00• 49.

.0.0CO0: 4i1
.0. .0. .0. . . .0
.
1807104° •• •• •• • • •0
• .0.
• • " • • " .7.
.7. .7. .7. .7. " .7.
. .7. . . .7. .7. .7.
.7.
. .7. . .7. .7. .7. .7. .7. •
.
1707103° .7. •• 7" .7
. .7. . .7. ••.7••. •.7•. •.7•. •.7••. .
•.
. .7. .
•• •• • • •• •• .7.
. .7. . .7. .7. .7. .7. .7.
1607102° "
. .7. . .•7.• •.7.• .•7.• .•7.• .•7• --
. .7
. .
.7. .7. .7. .7. .7.
. .7. .7. .7.
1507101°
.7. .
.7. .
•• •• .7. .
• " • .7. .7. .
1407100°
. . .7.7. .7.
• • • %
7• • •

MINA 1.-
130799°
11131112•1•111
RIM
AIIIIIIIIIIIIIW.AEICMPW*.
¦3
.
:7
in
go

98.6°
nairpreamibig
3 lam 0: of

11,41111111.1. • :7:
.:.

:
120798°
MN
..

.:v.:• ::
iio0
1 hi :0
97. : I: 11! Is :• 10: 0:: Ng
.
1
::

:

illi

100796°
in • IMIKW
INF • :. i i0: i
i IMF i mini
90795°

•7.1. •• • 1
.7. . .7. . NMI :lit: :: :7:: 0In
80 lin
IIME
1
.:. Inimori :: .:.
i :In
: INN" in

:: .:-

.
.:.7..
.

...
mum

ME
. . .
70
.:.7: :

60
EMI ::7:: .7:• I ::
.7. .7. . .7.
50
:: ::7:: ::7:: ..
.
.1

. .
.
40
RESPIRATION RECORD 0
I ••

No
111111111,1

MN

'Record special data only when so ordered
BLOOD PRESSURE
AIWIMMIMIRM grargiAEMEMIN.FW/M2
I 1"). : [131§1 li=
• IMI 11111111n ill1 I
1=1, 120MI
7 -rz' 17-ER
HEIGHT: .3
WEIGHT —10.. )Q
Io3riA
1 ' 1 73w, (ta @A dallalgrifill
t I (PA el
II gut
. coy)0
CRO
V 116
DATIENT'S IDENTIFICATION r'typed or wri ten entriRgive -Name—last, first, middle; ID No. ( SN or other); hospital o medical facility) REGISTER NO
VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-,
MEDCOM - 23056
DOD-036632

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-3 DAY
MONTH-YEAR %0VIDelZ DAY 4 t5 Vti/q
19 20tf.c HOUR 2.3• n -,,,, 90 ic: • -.R• q .R. .R. .R. .
...---
PULSE TEMP. F I .3. :3: :3: .3: .
.3. .3. . : :R:
. .R. . TEMP. C
(0) (.) 4
. .7. .7. .7.
.7. .
105°
.7. .7.7
. .7. .7. . .7. . .7. .7. .7. .7. .
. .7. .7. . . .7. .7.
180 104°
.7. .7. .7. .7. .7. .7. .7. . . .7
. .7. .7. .7. .7
. . . . .7. . .7. .7. .7.
.7. . . .7. .7. . . .
. .7.
170 103°
'3" " • • • " • " " •

'
160 102°
. .3. .3. . .3. .3. . . .3
. .3. .. . . . .3. .3.
: . .3. .3. .3. .3. . .
.3. .3. . .
. .3. 150 101°
.3. . . . . .3
.
140 100
130 99° o.
98.6°
120
98° . . . . . .3. .3. .3. . .
. . . . .
.3. .3. .3. . . .3. .3. . .
. . .3.
110
97°
. .3. .3. .3
. . . .3. .3. . . . . .3.
. . .
100
96° . .3. ,3. . .3. .3. .3
. . . .3. .3. . . . . . . .3. . . . . .3.
. .3.
. . . . . .3.
90
95°
.3. .3. .
. 80
. . . .3. . .3. .3. .3. . .
.3. .3. . . . . .3. . .3. . . .3. .3. .3.
70 "
. . .
• " • .3. .3. . . . . .3. 60
. .3. .3. .3. . . .3. . .
. . 3
.
.3. .3. 50
• • •-• • •
40

i• k •3• • • l•3• •• •• •• • • •• " • • • • " RESPIRATION RECORD i(
1
. .
W W W W CC
cn
cn cn cn -
O 0 i--b —.1 b
0 0 . 0 c
-(Centigrade Ec
ra Record special data only when so orderer
BLOOD PRESSURE
t10%li; r215S--1 3 ..//f' 7? li
-1-Ict qUi 'IV' ,,CI HEIGHT:3WEIGHT II—Yip. ......_
9 71 025A ciCL7Ilia 9T4 0s54 A4 'wise toy
11-41 k.
(For typed or wri ten entries give: Name—last, fret, middle; ID No.
REGISTER NO
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 23057
DOD-036633
‘C'arcliSc-ction:j 3
I •'.1.icrk.1::;::,"•• I LABORATORY n_1_,suLT FOR?fl L
LAST, Fa.ST,M.I.
Sub;ccr to t:ic3t •
or (974
SSN: .
.__..•.__•
TEST RESULT REF. RANGE iTZST ..RESC.11 T RE RANGE

WBC3
r 4.5-10.5 x 10'7 N/A.
RBC3 RPR
•3
10'
Ni.k
I7
a Mono
14-13 EAU (.1/4.4) N'czativc
12-1 ,57(T)
.Nag•at.j..m .
SC
Lymph %

BI
p
Mono
PitiPrit lf3LPjt
7„ 23
-10'3/ilL3
4.5 10.53•ipscopiCTTriiia
BC 314 L ;10'61td.3
4.00 6.„N
RBC :At
952L q'di_3
11.0 1.0
Morph Hct3
:9,0 L3
.7:,5.0 60.0
TV 92.33
tL3
N•.0 ?9.9

31.8 L 3/113•••
Spun
Pit 198,3
Hematocrit x.10 43/.11 150.- co,3
• .•••3
LYZ 16.03Z3• _Biood.B-arik ._ii3
20.5 51.1
11 44_13iL31,2 '1UST SUBN1Tr SF 518 VERY tJNT I.(21.FESTED
DircctgL
LBC:vPk
¦
asguL2ti•on Stn
.111964. -4.13
u ti -Crus.scriateb . -3
-3.;•
OfT.IS±,5 (.41M11".SF,518.VITEr EVERY UNTE OF BLPO


TEST • :• :REI UF_STED •
RES ULT REF R.-INGE
PT
9.5-13.6 3C
APrr 2 1 -3 4
0 crL.7e:
I REMARKS: PEP-ORTED BY:3
DATE: ,3
LAB NO.: .
MEDCOM -23058
DOD-036634

Wart-1'S cztion3
LAST, FLRST,
TEST RES ULT
Na
CI
PH
PCO2
P02

"TCO2 HCO3 s023
BEecf
AnGap
.

C

3
BUN 3
GLU
Creat Hct

REQLFES
" CH411,STRY.R8SULT FORA'

Sub .cct to the Privacy At of 104)
DATE3TIME3
/PSEUDO SSN:, -
1 00'.)
—3•3. .
kco1o).1q.etabolic".rall'et
REF. RANGE TEST . : -RESULT
138-14o =WI_
3.5-4.9 arr./1.2
98-109 airool/L
7.31-7.45
35-45 mtrilfg ( -t 41-51 rruni­
{lEic.Lit
80-105 mmHg (art) NJ,A. (yeul 23-27 rrunal/L (kg)
24-29 mrnal/L Nal 22-26 mmol/L (4 rr;
23-25 rrim7our_ (NT7!'
95-98%
(-2) - (+3) rtll-nolit 10-20 mmol/L L12-I.32 mato!
8-26 rag/d1
70-105 mg/di
0.7-1.5 mg/d1 38-51% PCV
Hgb j 12-17 g/d1
TEST RESULT REF. RANG
Drug of
Abuse
RE : ,LA.R.KS:
..... == PICCOLO0 1/11/03 REFERENCE RANGE:
PATIENT #: 1111

BASIC METABOLIC

DISC LOT #: OPER #: 111 SERIAL
....... I!BUN .., 7-22 mg/d1
18:06 !CA' 8.0-10.3 rued!
NIALE CRE 0.6-L2 mg/cit
A' .128-145 rrirr.a1/1 -

.......................... ' .

GLU.

121*' 73-118 MG/DL Fi.ce!3i0Y.T:241*.ieFite_1141
BUN.

9 7-22.

MG/DL I

nirtv.,1/1
3325M4

DR #: 000 CL" 98-108 mir,o1/1 tC0
18-33 . mrrlo1/1
CA++ 7.7* 8.0-10.3 MG/OL

CRE3
0.7
0.6-1.2 MG/DL

NA+.

140 128-145 MOM_ i
K+ 5.2* 3.3-4.7 MOM_ [
CL- 102 98-108 MOW IL.
tCO2 25 18-33 MMOVL

R1T.-TEST IT
RANGE
7 1 118 mg/111
TEST RESULT I REF. R. -INGE
ALB 3.3-5.5 g/d1
ALP 26-84 wT ALT 10 -47 ul
AMY 14-97 uil
INST QC: OK.

CHEM Q(: OK I AST 11-38 u/17s .
HEM 0 , LIP 0 , ICT 0.

L
L TBIL 0_271.6 rag/d1 GGT I 5-65 u/1
TP
S-108 rarao1.1 18-33 rr..--ao:1
1:-

REPORTED BY:
DATE:3
LAB ID NO.:
MEDCOM 23059
-
DOD-036635

A Ji b 7,19 / 1-43. p/o//az 7
I/ t HI( 4, 414 P-Xj.
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG

PRIJOEM::::::::::::::::1040: TOTALS :;:totM(:EEL fewill/ slic--10 I
m0) /00 ) ttil*OR(iiie
I7I
(71
1

ri9:01.Ari: 4_,„4-0 4del I 2 b5- ..,.. . LIIDEWSLIM,MAI*
AGENT % et. ;CRYSTALLOID-AIR L/Min N20 L/Min COLLOID-
t 1111
02 L/Min
37
SINGLE DOSE DRUGS-MARK ON GRID.., BLOOD -
CONTINUOUS/REPEATEDDRUGS SPECIFY UNITS -MG/MCG/ML, = CONSTANTINFUSION
WITH NUMBERS 8 ENTER IN REMARKS
4!'"1
-di LINE site n Warmed
-
0 Warmed F 4.---- - ----_ _...
I-. -5ce7----------- Code ddrugs with numbers,
events with Miners
Warmed
0
EST BLOOD LOSS
t¦ 0:00:::: ....DE/Giee
URINE -
J . , op--,`,,,,m.
14$ T)( -A1744::::: TIME0
/ '4 ./--j-0 //e- /*---
1 3 4 57E :: / /gae c.-Aire_ 3i
... ..• •• • • • .. „SYMBOLS; :
3f.1041:0.]:::sti::::::::::::::::::.::::: 220 _72-1A-644417_
popr.r.
/07&-).0BP by cuff

200 • • 3 Atedett.13.1
L B
V
144r400qp(V,:5 •
A 180 , , . .4196eJCIC-e—, 1
Heart rate 160
A ................. •

Resp rate 140
0B F. -
. 4k I(/ ScdRe 14 '1
9 120
111
BR ieAte, etZilit 44
HR- 111MillIgvArilirraMIIIMMIGifrOMIIIIIIIIIII ,
(transduced) 100
423 IPINIVAIIIIMILAM219211111.1111P • 7-5-te Ctri7
211=11111EIVAIIIIIIIIC'
paviketiggrA:::;: : + BO
.
OK?-0Y0N
0:0.*Oit:............... T --/l/

TOURNIQUET 60
111
40
OK for ALIMATIOMMVIFIGME1111111111111111EdiM111111111M111
.
PROCEDURE?
ANES- X-X 20
PROC- e_t25 1111111E11111111111 ME
TIME-1 VT - ml
WIram.PRI 6 0 , so
f - breaths/min
• WEENEAR211.1allall in
Peak inf pies / PEEP
a
MODE - Slponl. AIssisO, Clon) c-5 5
Li/ NM
TAPP*0***
LAIP/Auto Cuff VET CO2 Itorr) 3 -3-lig C033
PACU0ICU0Specify)
BP/oth Fl • 2 (Frac or %) F41M1111114111111131111E11
ART line Sp0-20(%) 490 , ITEMIEMIMMIMAIMIIIMIANNI OTHER
CONDITION:

Steth- PC/ES VCG INTA s 1 ri imarmaranwammi
as analyzer TEMP-site
RESP-20 5902-/era
N-M Block (1/4)
BP./7f "A-97
in Start Room End
ioz
Warming blkt
409R/ ciAte i'Dy.g
Cony warmer
u Ready Begin End
Mark with letters & symbols.REVENTS I
INIOISIITORSIAQ C
0
erowe under REMARKSRPosition
CED9r7 F57,7 JOA
d)PROCEDURES and CPT C des: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
id 0
PATIENT IDENT(FICA ION: Typ d or written entries: Name, Grade/Rare, AIRWA
MANAGEMENT: In ubation route, bla technique, comments Medical Facility
Li.) J I7aa73.)( ? SUR
•A PROCEDURE
CO(0 --2
' -'1. LOCATION: DATE: ( 0 as) -41 ANEST i
02 a 03
MEDCOM -237 PAGE / OF
461/7---
11 7
DOD-036636

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 ORDER3 TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
SIGN
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
( 60
NURSING UNIT ROOM NO.
PATIENT IDENTIFICA fII
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION E' OF ORDER3 TIME OF OR
(6)(0 -1/
NURSING UNIT
DAtFORM1 APR 794256 MEDCOM - 23061
DOD-036637

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 ORDER7TIME OF ORDER LIST TIME
ORDER

NOTED AND
Ci-O7HOURS
rlD\r03
SIGN
a HL IV.
.
( ro (-) _K
)7V o Yr
r il
J ul
NURSING UNIT ROOM NO.7BE -70.
a. _7
A.fi--* 1 .
,....,
PATIENT IDENTIFICATION 6 DAT ORDER TIME OF ORDER
E 1) (:)-RHOURS
JO
itila-
.
IIIOIIJIIIMIIIPIKIWP

AIIIIIIIIIIIIIIIIIII
• -....•747
111W
Air-
/NU SING UNIT
'41711r3-11 ----11111111111LMI 7
FA
PATIENT 10ENTIFICATIO DATE OF ORDER7TIME OF ORDER
Co INID\J957I 95. Ofi
HOURS
0 13 ¦ D drs7b,Is --tc, a LE
4(D bu -V-‘7_V).7NTD):=1-
co(6) -q Wrap C, i-ierikK7,
(.(3)(4)li -

-
--)7-11-'-
¦1111rdaMr--:
NURSING UNIT ROO •7
./ No.pummirmiwAammmmm
I
\A#VJ (Q
I) P laNP MIT 11 Fr-T e
P IENT IDENTIFICATION
OF • • • .
1111111.1".' .F ORDER
(67
Ell /Vor(Ro(fio7HOURS
• PRAdivcc(---Rir/°6
6 0/cR/17.5z_ 'Lc:7; A4
a (C - 2RChj 66:), - 2-
NURSING UNIT ROOM NO.
BED NO.
RE P LAC J
P RR79 MEDCOM - 23062 H MAY BE USED.
A 1 FAOM 4
DOD-036638
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is OTSG3
k
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 IDENTIFICATION7 DATE7ORDER7 LIST TIM

TIME OF ORDER
, ORDER , 670,37\ )1)0
.
,
NURSING UNIT7ROOM NO.7BED NO.
PATIENT IDENTIFICATION7 DATE OF ORDER7

TIME OF ORDER HOURS
,7. *,-
4.
NURSING UNIT7ROOM NO.7BED NO.

PATIENT IDENTIFICATION7 DATE OF ORDER7TIME OF ORDER
HOURS

i.
I I7. NURSING UNIT7ROOM NO.7BED NO. Q
., ri PATIENT IDENTIFICATION7 DATE OF ORDER7TIME OF ORDER HOURS
t7
t
.7I7
NURSING UNIT7ROOM NO.7BED NO.
MEDCOM - 23063
RE P LAC
_H MAY BE USED.
DA . F.(1.12M,,, 4256
DOD-036639
THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MEDICATION) I A.,
CLINICAL RECORD For use of this form, see AR 40-407;
M e . 11iYr.
,&..t2003
the proponent agency Is the Office of The Surgeon General.
.
VERIFY BY INITIALING §4,104V-55VagiV.„M,70,114n4 ,,,. INITIAL PROPER COLUMN FOLLOWING EA C 1 COMPLETION
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTI DATE NURSE FREQUENCY, Tin I
Z Kraniaregill •
i
i
I , 17
1
--7t. MINMI PAM
TM MINN111111."1111111. ."1"111
/ 1
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MEDCOM 230647
-
DOD-036640
Veri y by0 THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing0 (NON-MEDICATION) Mo I I Yr 2003
Order Date Clerk Nurse0 SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
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USAPA Vl.DO
MEDCOM - 23065
DOD-036641
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407; Mo..( Yr. IRCLINICAL RECORD the proponent agency is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
'VERIFY BY INITIALING ,
HR DATE DISPENSED
RECURRING MEDICATIONS,
ORDER CLERK/
DATE NURSE DOSE, FREQUENCY
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ALLERGIES-El Y ES El NO PRIMARY DIAGNOSIS:
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-

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PAGE NO
PATIENT IOENTIFICATIONt

DISPENSING TIMES USE PENCIL, CIRCLE MED TIMES • D 7 8 9 10 11 12 13 14
IIIII(_1)—L(
E 15 16 17 18 19 20 21 22
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N -; 23 24 01 02 03 04 05 06
EDITION TIL EXHAUSTED.
DA 1 FFOEFIP49 4678 MEDCOM — 23066
DOD-036642
. Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo..Yr CP '3
Order Clerk/ Date to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
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MEDCOM -23067
DOD-036643

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use al this fonts see AR 90.66: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED !Carel
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Dale: L V Anesthesia Type (Circle)) Qe_n_ecal -§pinal Epidural Drains Airway Time In: In% IV Sedation Nerve Block Hemovac Allergies: i "fr‘ • OR Intake: Crystalloid 1 1 (-;•-•-Colloid
NG
Pre-op V/S: 15._.7..-OR Output: UOP E s L ilk_ Li,_ JP

ETT
Procedures: 11=1 V ¦ Meds/Times: i T-tube

Trach
tAX Is-i&
Other Pre Op Meds Histor TLS
Time
Pacu Intake Sa02 7in 0. .4-1 Tire Solution Amount Site • By Infused F102 • lb )I-CY) (a( ) Methods
240
220 X-rays: Labs:
Post-Anesthesia Recoveryscore
200 Criteria ADM 30'

D/C Codes
Activity
AIRWAY
(2) Moves 4 Extremities
180 ' Moves 2 Extremities A =Ambu

(0) Moves 0 Extremities BB= Blow-by M =Mask
Airway
160 FT = Face
(2)
Cough. Deep breath

(1)
Dyspnea. limited breathing Tent

(0) Apnea RA =RoomAir140 NC =Nasal
Blood Pressure Cannula
(2) SBP. =/- 20 of Pre-op
120 -(1) SBP =/- 20-50 of Pre-op

(0) SBP =1- 50 of Pre-op VIS
NP/
es. X = A-line BP
Consciousness
100 V
= Cuff BP
(2) Fully Awake, audible crying
= Pulse
(1) Arousable to verbal or pain
80
TEMP
Color
S = Skin
A. (2) Baseline color & appearance
60 0 =Oral
(1)
pale, mottled, jaundiced

(0)
Cyanotic A = Axillary T =Tympanic

Circulation (Peds 5 Years)
40 A
R = Rectal
(2)
radial Pulse Palpable

(1)
AxiHary palpable, not radial. _

(0)
Carotid only reliable pulse LOS C = Cervical

20
TOTALS: Must be 9 or
T =Thdracic
greater to D/C. otherwise
RR Sal L = Lumbar

needs anesthesia approval for D/C, S = Sacral
sT
Time
Patient teaching done; Wound Care. Pain Management,
Pain (0-10)

T, C, & DB,. Incentive Spirometer, Comfort Measures
LOS

Safety: SR up X 2, Falls Precautions. Privacy Maintained
II-onlinue on reread
PREPARE ­
I:TB
OEPARTMENTISERV EICLINIC
t
I(-kk
PATIENT'S IDENTIFICATION Ifor typed or written ent7is give: Name
— last. first,.grade: ff..hospital or medical lachtyl
.
HISTORYIPHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER rsp../0 OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
Previous edition is obsolete
USAPPC V2.00
MEDCOM - 23068
DOD-036644

MEDICATIONS
NURSING NOTES
Allergies: Time Pain Medication & Pain ItE ay i-in Inane
1-10 -e-F ID I.,,Q ITIJI..iji_DY r.
._i'MI .
-
bill i.)()_61/-)PJ .umr. ) If? .._-14012,4_ DI L4Nt-,c)
..
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2
qty.---d
LL tr.)
NEUROVASCULAR
Time Site Range Sensory P Cap T Color

Of Refill
Motion

Adm :ej, ugropk_ ..-1-4 -, i, 9.1
15' u , v¦, 4
+ e2,--vJ .e'l
30'
(
45'

60'
90'
D/C

Movement/Sensation: + =present,- =absent Ternp:C = Cool,
W =Warm Pulses: P = Palpable, D =Doppler, A = Absent
Color: C = Cyanotic,
Capillary Refill: 13= Brisk. S = S uggish P= Pale, Pk = Pink

C-SECTIONS
Adm 15' 30' ....-45----60' 90' D/C
Fund. Height

---'-'''----
Lochia

.--------
Peripadi_------)

„fitingCond.
DRESSINGS
Time :-.„Location Type Drainage

rentalle-rnaraW Ai 1, 30'
Adm irairminsism a.
60' ,....-D/C
PACU OUTPUT
Time Source C ppearance Amount Discharge Criteria:
Date: ti\chi Time: 11 ( i) PARS: 6/'
BP: NI-11 T:e Z_ HR: RR: 7i9 Sa02:.(ic„
Pain Lev r at D/C (0-10):

Intake: Output Additional Data:
CARDIAC RHYTHM
Transferred To:
Time Rhythm S mplomatic? Rhythm Strip Rupl? Report Given To:

(6)-1
Transferred Via 1IN 11137,Trai
y Ambulance Transferred By: a
Cleared IAW Repk fl ACME
-cie Charge Nurse Signatu
WAMC OP 173-E
4

MEDCOM - 23069
DOD-036645

.
. REPORTING MTF

F LOCATION
ADMISSION AND CODING INFORMATION
8 (State or Country
2 3 4
For use of this form. see AR 40-400; the proponent agency Is OTSG
Code.)
A I
. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRAD k 5. SEX
(6)(c) 'or
16 17 18
DATE OF BIRTH (Y Y Y Y MMD D) 7. AGE AT ADMISSION 8. RACE B. ETHNIC RELIGION
.
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-
GROUND

.. .
ETS 11. FMP 12. SOCIAL SECURITY NUMBEh10. LENGTH OF SERVICE
35 36
32 33 34
ORGANIZATION (Active Duty Only) , . 13. MARITAL STATUS . HOUR OF .BRANCH 1 CORPS
ADMISSION

46
14. FLYING STATUS IS. BENEFICIARY CATEGORY 18. LP CODE OF RESIDENCE
47 48 49 1 50 51 52 53 54 55 f 56 57 58 59 60 61
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV ADMISSION
Country Code)

YEAR NO
62 63 64 65 66 67 6E) 69 70 71
..
NAMEJRELATIONSHIP OF EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
.ADMISSION
72 ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
.
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23..DATEOFDISPOSITION (Y YYYMMD D)
73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88
2 0 0 3
24. CUNIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 28. DATETHISADMISSION (YYYYMMDD)
89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106
IV 6 0 I
27. LOCATION OF OCCURRENCE 2B. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISS ON Y Y D
(Battle Casually Only)
107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 • 122
FOR LOCAL USE
.
ADMITTING OFFICER (Signature, as required) SIGNATURE OF ADMITTING CLERK
DA FORM 2985, MAR 2000. EDITION OF MAR 89 IS OBSOLETE . USAPA V1.00 MEDCOM - 23070
DOD-036646

1. Reporting MTF 1 0 C. 2. MTF Locatir. Admission i... . Coding Information
IZ For use of this form, see AR 40-400; the proponent agency is OTSG

C 6 .)C6-F7---4. Pay Grade 5. Sex
3. Register Numbafe --$ame (Last, First, MI)
FGN M

INN 1111111111.1 ‘.
6. DoB (YYYYMMDD) 7. Age atirmitsion 8. Race 9. Ethnicity Religion
X 9

10. Length of Service ETS 11. FMP 12. Social Security r
-r
6 gi 5 ,
99
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:

17:24
..
04
14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
N/A -K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS 19. Trauma Prey. Admission
BC NO

20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Direct from ER ICW 1
Telephone Number of Emergency Addressee

Name and Location of Medical Treatment Facility:
o Install Provided
21. Type of Disposition " " 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-OTH 2003-11-09

24. Clinic Svc - Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD) ABA - GENERAL SURGERY 2003-11-01
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-01

FOR LOCAL USE ,i
'
t
.- Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: SOFT TISSUE WOUND
Procedure Narrative(s):

Cause of Injury Narrative:
CO(C) - I.
( .) )(":4,1 — 7
Admitting Officer (Signature, as r Si nature of Admitti Cle -
DAVIS

MEDCOM - 23071
A • nn FriPhA 9ciftc nncR 7nnn
DOD-036647
Automated Facsimile ATIENT TREATMENT RECORD. JVER. SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
(1)-(6,-"1 3. Grade Admission Remarks1. Register Nbr ii 2. Name
FGN
41Sex $ 5. Age t 6. Race 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm t
NOM 42Y Z
14. Ward11. F 12. SSN (6)(C-1( 13. Organization
ICU3
MEW
15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case NO K78-PRISONER OF WAR/INTER ARMY BC
22. Hour Of Adm: 23. Clinic Service21. Source of Admission 23:37 ABD - NEUROSURGERYDirect from EI
24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of pig0\­TRF-OTH 2003-11-15
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This A . AdmittingOfficer: 2003-1-01 ARMONDA
30. Date n dm 32. Units Blood Components
29. Re.ortingMTF 2003-11-01
(k.)(2) -2-
31. Selected Administrative Data
Marital Status: DoB: VIM
In/Out Patient: Inpatient MOS:
33.
Cause Of Injury:

34.
Diagnosis / Operations and Special Procedures:

GSW HEAD
go--_ a_o , P40e, • / 46-0
i) 14 r7 Fl L1 . 3 // ?0-1-().o,-.0...2-, F.," `? q I :,-,_. Scp-/(/6.013c1
0 a _91
(1,&
35. Total Days This Facility .
Absent • • Days Oth Cont o8 Care Days Supple are ys Tott I clifDays
5 /
35. Total Days This Facility
Absent Sick Days Other Days CoConLv / op Care Days Supplemental Care 0 Bed Days Total Sic Days F-1 3
-
S Signature o AD or I Re ds Officer

R M-lf",/-111
(Gr6)-
Automated Facsimile - DA FORM 3647, May 79
DOD-036648

Doc_nid: 
3963
Doc_type_num: 
77