Medical report on a 20 year-old Iraqi insurgent wounded in a firefight with Coalition Forces. The report states the insurgent fired upon Coalition Forces and was return fired upon. As the insurgent attempted to explode an Improvised Explosive Devise (IED) it detonarted in his face causing his injuries. The insurgent was captured, treated and arrested and interned for processing.
SITE ROCED6RE: AccomfpNEnav:; :::
RESULTS:
•1:10E1:1 1.1 RE
. ETCO2 Change
0 Oral CT Scan: . ContrastET BBS Post Int. Nasal
0 Head . Abd 0 Pelvis
Intubation Teeth . Post CXR
. Air . Contents . C-Spine . T/L Spine *hest
Gastric 0 Oral
0 Verified
0 Nasal
Tube Suction: Y N
A-Gram Site:
0 Return ccUrinary . Meatus e.. . Heme Dip: +
/a; IV ACCESS & FLUIDS
CI Supra-Public
0 Secured
. Grossly: + -
DPI 0 Opened
Chest Tube #1 . Closed L R Cell count Sent@ 0 Air 0 Blood . Pleuravac cm Autotranstuser 010/33
Chest Tube #2 12 Lead Rhythm: L R Comments . Air . Blood 0 Pleuravac cm . Autotranstuser 7 4 o.s-Aroi MEDICATION x-. MEDICATIONS OM DOSE EOMOENPOSE DOSE
1)
2)
TIME. . D-stick . SHct . D-stick SHct Chest Post ET 11111111111111.1111111.111111MAI=
CBC ()Chem g.fT/PTT Qi Chest Post CT BLOOD PRODUCTS
ETON XT&S 0 T&C x
Tox Screen *A 0 HCG
.
OTHER
.
OTHER
LAB RESULTS INTAKE & OUTPUT
INTOKE AMOUNT OUTPUT
CBC: Chem: ft? 7/,,” - (LP 2.y.‘
IVF Urine
NGT NGT
? 3. Blood EBI
Other Other
_
.
I l., , w ------
. TRAUMA TEAM ARRIVAL. . VALUABLES & CLOTHING
TITLE RES-PONOED. ARRIVED-'." u E D Phys None Found
illai*-1 ..
S Li r g eon Given to Patient Given to Family
nes th
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other; See Nursing Notes
X-Ray -.DISPOSITION RT 0 Home . Ortho 9(6)— 7—
Admitted to Report Called to
Neuro
Ulli Time Transferred
Chaplain Accompanied By
MEDCOM -21841 'etcher 0 Wheelchair
III . . —. — .. — .. — ..
DOD-035417
V A SIGNS GLPSGOW COMA SCALE
R.rnP: di;.q q. 7 GCS: , EYE OPENING REBLE RESPONSE MOTOR RESPONSE
TIME e.;165 ,-/ BP 1s914- I-1R (c RI-1Y RR $A02 F10 2 MODtMOD E -t, V ,..m T 4 -Spontaneous 3 - To Voice 5 - Oriented 4 - Confused 6 - Obeys Commands 5 - Localizes Pain
Og4 8r2-1S7 S-- 2 - To Pain 3 - lnapp Words 4 - Withdraws to Pain
oi“) 70q/ 7 1 /0(0 I - None 2 - Incomp Speech 3 - Flexion to Pain
Ol& Li ("7 /7,9 1 04' 1 -None 2 - Extension to Pain
Mb /Y//AS / A?i , v llid- / /../r ' S. 1 - None
ri5. tZ /(76? //3 TIME 'PROCEDURE PERFORMED BY.•
/ ' . Backboard Removed BY:
/ . Downgraded BY:
/ NOTES
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MEDCOM - 21842
DOD-035418
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MEDCOM - 21843
DOD-035419
-
-;AL RECORD-SUPPLEMENTAL MEC s_)ATA
is tne Otik. . he SL•geon General.
For use of .rrn, see AR 40-66; the proponent agency
REPORT TITLE
INTENSIVE 4tRE NURSING FLOW SHEET
IN PUPILS E SENSORIUM EXTREMITY MOVEMENT SEDATION PAIN CONTROL
R RESPIRATORY PATTERN F BREATH SOUNDS S SECRETIONS P 02 SOURCE/FLOW/SAO2
VENTILATOR SETTINGS
C CARDIAC RHYTHM
V CAPILLARY REFILL PULSES EDEMA
G ABDOMEN
I BOWEL SOUNDS
BOWEL MOVEMENT
NGTIOGT
TUBE FEDDINGS
DRAINS
VOIDING COLOR/CLARITY
S COLOR K INTEGRITY
I
N
•
#1 TYPE/LOCATION/SIZE AC DRESSING CONDITION C I V FLUID/RATE
E
#2 TYPE/LOCATION/SIZES
DRESSING CONDITION
si—
IV FLUIDS/RATE
Title)
IS P
SHIFT ASSESSMEN TIME: UPS"
INITIALS:
PruL
-Fo 411. -1-0 u.c.. In +
P4 Afei--1-4-4. e--Sfo ,:,70. Mode. e.x'-h-ease-F
M ee_.:_‹47rott_1`; , Able -i-b X 11 f A1SOY 4 -Cmj ?i t/ PRS
Rt..c‘ RI. l j u.1414bot-e_d a 5744cd 04R4-6.// C--r# .6°, I ck-k --E- (4P m° 0:36.01 JL5Q,A 0 /64-
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,
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OTSG APPROVED (Date)
QA Appr 8 Mar 89
INITIALS:TIME: 113a
,4
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ir...11•.......,-..... L:-...%c. 11-044 L AA._ M _AL.__ rh. _.,.. L.,-
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Ot
IENT'S !DEN N (For typed or written first, middle; grade; date: ho spiral or medical facility) NAME: give: Name – WO -AGE:E: HISTO Y/PHYSICAL El FLOW CHART
O OTHER EXAMINATION 0 OTHER (Specify)
UNIT: GENDER: OR EVALUATION
STATUS: US: AD CIV IRAQI: CIV / DIAGNOSTIC STUDIES
MEDCOM - 21844 . TREATMINT
DOD-035420
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MEDCOM - 21845
4th
_ I 1111 l• 1 I 1--I A AAAAnAnnA A A A
DOD-035421
DATA AL RECORDSUPPLEMENTAL MEP' ,ne APPROVED (Dare)
Surgeon General.
OTSG
.onn, see AR 40-65; the proponent agency is the Of QA Appr 8 Mar 89
For use of
REPORT TITLE
or •
INTENSIVE CARE NURSING FLOW SHEET
SHIFT ASSESSMENT
INITIALS:
TIME
0700
PUPILS
RESPIRATORY PATTERN
BREATH SOUNDS
SECRETIONS
02 SOURCE/FLOW/SA02
VENTILATOR SETTINGS
I
CARDIAC RHYTHM
CAPILLARY RELL
PULSES
EDEMA
ABDOMEN
BOWEL SOUNDS
BOWEL MOVEMENT
NGT/OGT
TUBE FEDDINGS
DRAINS
Nor
f
•361) •
INTEGRITY
#I TYPE/LOCATION/SIZE DRESSING CONDITION IV FLUID/RATE #2 TYPE/LOCATION/SIZE DATE DRESSING CONDITION OJ-i-CY. IV FLUIDS/RATE
to
(Signature & Title!1
.7.—
FLOW CHART 744/ ID HISTORY/PHYSICAL 7c4
(For typed or written entries give: Name —last,
rfj
(Specify)
PATIENT'S IDE FICATION AGE:
e; hospital or medical facility)
OTHER EXAMINATION POTHER
RANK:
first, middle. .
OR EVALUATION
NAME: 40 A't
/41
GENDER:
I-1 DIAGNOSTIC STUDIES
UNIT:
TREATMENT
AD / CIV MEDCOM - 21846
STATUS: US: USAPP
DOD-035422
EINIERDA 111111111111111111111111
ig111111111111111111111111311111111111111 t)'1111111111111
g11111111111111111111g1111111111111111111111111111111
31111111111111111111112111111111111111131111111111
13111111111111111111113111111111111111211111 111111
;-1111111111111111111111811111111111111110111111 1111111d
1111111111111111111101111111111111111 8111111N111111
811111111111111111111111111111111111111121111111111
1111111111111111111118111111111111111111111111111
111111111111111111111 811111111111111111111111111
IIIIIIIIIIIIIIII 211111111111111111131111111111111
111111111111111111111111 F21111111111111111111111111111111111
-0-111111111111111111111111111111 1111111111121111111111111111
4110:0110211010111111111111111111111311111111111111111
11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111k 1111111111111112111111111111111 111111111111111111111111111
1111111111111111111111111111111111111111111111111111111111111131111111111111111111111111111111111111111111111111111111111111111M11111111111111111111 11111111111111111111111111111
011111111111111111111111111111111111111111111111111111111,e11181-11111111111111311111 1111111111031111111111111 11111111111111111111111111111111111111111111111111111111
211111111111111111131111111111 1111,1311111111111111
1111111111111111111131111 11111111111331111111111111
° 111111111111311111111118111
111111111n
w mIc9m 21N
i ED
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
.
Far use al this hum see AR 4066 -the proponent agency is the Office of The Surgeon General
OTSG APPROVED (Date)
REPORT TITLE post-Anesthesia Care Unit (PACU) Flow Sheet
Anesthesia Type (Circle)): 4112P ..nal Epidural Drains Airway
Date: ,.S¦oe--1-0-3 IV -.. Ion Nerve Block Hemovac Nasal
Time In: (0 ("3 Allergies: ------OR Intake: Crystalloid 306 Colloid
. NG Oral it./‘i N./ JP ETT
Pre-op V/S: 1 16/£4 l0 I OR Output UOP /DO EBL. ('1i) Q .ifsi 19_10fivx Meds/Times: 1A4,5 ) 1. I / aso 1- # -I , t T-tube Trach .
Procedures: J Foley Other
TLS
Pre Op Meds History
'.. L.S.72
'"'
Time *"... "1 Q Pacu Intake
k.3 *N, ¦,
Time Solution Amount Site • By Infused
Sa02
iltiVIS'
Fi02
Methods 111 /44 git Ivr
240
220 X-rays: . Labs:
Post-Anesthesia Recovery score
Criteria ADM 30' D/C Codes200
Activity
AIRWAY
(2) Moves 4 Extremities
A =Ambu
(1) Moves 2 Extremities "....)--,
180 BB= Blow-by
(0) Moves 0 Extremities
M = Mask Ainvay
FT = Face
160 (2) Cough. Deep breath
Tent
g..,
(1) Dyspnea. limited breathing
V Vv v ,g RA =RoomAir
(0) Apnea
140 NC =Nasal
Blood Pressure
• Cannula
(2)
SBP =I- 20 of Pre-op
(1)
SDP =/- 20-50 of Pre-op
120 —a (0) SBP =/- 50 of Pre-op (9) .)---` V/S X = A-line BP
a 4
Consciousness
. =Cuff BP
100 (2) Fully Awake , audible
=pulse
czYingco Arousable to verbal or pain
80 A TEMP
Color
S Skin
12) Baseline color & appearance
0Oral
—
fl (1) pale, mottled, jaundiced
60 A = Azillary
(0) Cyanotic . 0
A T =Tympanic Circulation (Peds 5 Years)
R =Rectal
40
(2) radial Pulse Palpable
• (1)Axillary palpable, not radial /
LOS
(0) Carotid only reliable pulse
20 C =Cervical
TOTALS: Must be 9 or T =Thoracic greater to DIC. otherwise
L = Lumbar RR needs anesthesia approval for
D
S = Sacral
tie 3c DIC,
T ( 6 ‘ 6
ik14
Time
Patient teaching done; Wound Care Pain Management.
T. C. & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained Pain (0-10)
LOS
konfinue on reverse)
DATE . f DEPARTMENTISERVICEICLINIC
1,10_1_ PAco 2.50c--37D3
I or Sipe or wntren terms ire: Name — last,
list. middle: grade: date.• hos i acktyl • HISTORYIPHYSICAL • FLOW CHART
• OTHER EXAMINATION—N. . OT191/1,..10
/9 (0 —"$
OR EVALUATION
ID DIAGNOSTIC STUDIES
•
• TREATMENT
WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
OA FORM 4700, MAY 78
USAPIT 02.00
MEDCOM - 21848
DOD-035424
MEDICATIONS
NURSING NOTES
Allergies:
Time Pain Medication 8 Route Pai I/E By 1-10 Dnsanp 0 'Pt Wet' L1 -Q.4 'Gary\ oe SfP Imo® e hew-cvi...aoey . hlo C 6 peti VS ?en) e„,eay
t
NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
Adm 4-
I le ,. m;Arst P e) (., PK-15' etc i„...,.4.0... 4-P a c Plc. 30'
teri44 fg..4 4 P 4 ( Pl
45'
60'
90'
,
D/C tal,,,, 1,-„.., ea( Le e 8 P V--
Movement/Sensation: + =present,- =absent Ternp:C= Cool,
W =Warm Pulses: P= Palpable, D = Doppler. A= Absent
Color: C = Cyanotic,
Capillary Refill: B = Brisk, S=S uggish P= Pale, Pk= '
C-SECTIONS
Adm 15' 30' __AS.' 60' 90' D/C
Fund. Height
Lochia
Peripad#
F . ond.
I
DRESSINGS
Location Type Drainage
Time
Adm 01,4 fe. glektfier kx-(c. r... o
30. ,D -1 V • Prri411€1) h'e'r .-k 0
60'
D/C 104. W 14-14"`Ale-A, 164t (-n4 A
PACU OUTPUT
Time Source • Color/ nce Amount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
PILI TS tz. 0 D
WAMC OP 173-E
61 -
Discharge Criteria:
Date: 250d1:13 Time: /6%9 P RS: /0
BP: iloy‘l T: qs ./ HMI/ p R: Sa02: (0
Pain Level at D/C (0-10):
Intake: 0 put:
Additional Data:
Transferred To:
Report Given To:
Transferred Via: WI ney Ambulance
Transferred By:
Cleared lAW Recove
Charge Nurse Signature:
MEDCOM - 21849
DOD-035425
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
Fm use of this form. see AR 4066: the proponent agency is the Office of The Surgeon General
OTSG APPROVED /Dare/
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
2.9e4 3 Anesthesia Type (Circle)): 1 Spinal Epidural
Dale:
IV edation Nerve Block
Time In: I I 1 (.)
Allergies: wv- 9 A OR Intake: Crystalloid 660 kr2 Colloid...
Pre-op V/S: '"iv ,--//u OR Output: UOP :3- ro EBL tin ,
Procedures:
Meds/Times:
-0
1 Yom-IA,— 5/,..., ,, t'; ,--,..÷.
Pre Op Meds
0 Li\ 0 0
•-3
Time Sa02 Fi02 Methods 240
220 200 180 160 140 120
100
80 60 40 20 RR
T et
Time
Pain (0-10)
LOS
PREPAR '
PATIENT'S IDENTIFICATION floe typed list. middle; grade; date: hospital or m a ty
IN%
Histor
Time Solution lra-o
X-rays:
0.2 37,0ej la4-
Drains Airway Hemovac Nasal . NG Oral
JP ETT
T-tube Trach
Other
TLS
Pacu Intake
Amount Site Infused
"ie) 6
Labs:
Post-Anesthesia Recovery score
Criteria Acbvity
(2)
Moves 4 Extremities
(1)
Moves 2 Extremities
(0)
Moves 0 Extremities
Airway
(2)
Cough. Deep breath
(1)
Dyspnea, limited breathing
(0)
Apnea
Blood Pressure
(2)
SBP =/- 20 of Pre-op
(1)
SBP =/- 20-50 of Pre-op
(0)
SBP .1-50 of Pre-op
Consciousness
(2) Fully Awake, audible
n9
(1) Arousable to verbal or pain
Color
(2)
Baseline color & appearance
(t)
pate, mottled, jaundiced
(0)
Cyanotic
Circulation (Peds 5 Years)
(2)
radial Pulse Palpable
(1)
AxiHary palpable, not radial
(0)
Carotid only reliable pulse
TOTALS: Must be 9 or greater to D/C, otherwise needs anesthesia approval for DIC,
ADM 30'
a
Patent teaching done; Wound Ca e, Pain Management, T, C, 8 DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained
OEPARTMTIS RVICE/CLINIC
E
(
1./
es give: Name — last,
.
HISTORYIPHYSICAL
.
OTHER EXAMINATION
OR EVALUATION
\9(6)-1
. DIAGNOSTIC STUDIES
DIC Codes
AIRWAY A= Ambu BB= Blow-by M= Mask FT = Face Tent
RA =RoomAir NC = Nasal Cannula
. . VIS X = A-line BP
=Cuff BP = Pulse
TEMP S = Skin 0= Oral A = Axillary T = Tympanic R = Rectal
LOS C = Cervical T = Thoracic L =Lumbar S = Sacral
Itonlmur on revenel
DATE
eWar.d.3
. FLOW CHART
. OTHER /soar,
2(-9 6 . TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC '12.00
MEDCOM - 21850
DOD-035426
MEDICATIONS
NURSING NOTES
Allergies: Time Pain Medication & Route Pain I/E By 1-10 nnsane 1-10 Plieu syP IV
6-e a4
_ 9ez
NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
Adm 15' 30' 45' 60' 90' D/C
Movement/Sensation: + = present.- =absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D= Doppler, A = Absent Color: C = Cyanotic. Capillary Refill: B = Brisk, S= S uggish P= Pale, Pk = Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C Fund. Height
Lochia Peripacni Fund. Cond.
DRESSINGS Loc.a lion Type Drainage
Time
Adm
30' 60' D/C
PACU OUTPUT
Time Source Color/Appearance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
kiltOv1nv-/-72;L6,
Discharge Criteria:
Date;Dfde-" Time: // 1-1' PARS: i9
%ay
Bp: T: HR: 1-) RR: Sa02:
Pain Level at D/C 10-101:
Intake: Output:
Additional Data:
Transferred To: '2_
Report Given To: 7
Transferred Via: W/C Gurney Ambulance
19 (1)-2 1,6)
1. Reporting MTF 0580 . • F ocati IZ Admission al iu. Coding Information For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number . N e (Last 4. Pay Grade 5. Sex
FGN M
6. Dob (YYYYMMD f, A 7. Age at A mission . 8. Race 9. Ethnicity Religion
X 9
10. Length of Service ETS 11. FMP -12. Social Security Number
99
13. Marital Status I Hour of Admission Branch / Corps:
Organization (Active Duty Only)
01:15
16. Zip Code of Residence:15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES Prey. Admission 14. Flying Status 19. Trauma
18. MOS BC 17. Unit Location NO
Name / Relationship of Emergency AddresseeWard:20. Source of Admission of Emergency Addressee
Direct from ER Telephone Number of Emergency Addressee
of Medical Treatment Facility: 0580 Name an Locatio Iraq; No Install Provided 23. Date of Disposition (YYYYMMDD)22. MTF Transferred To21. Type of Disposition 2003-11-04
TRF-OTH 26. Date this Admission (YYYYMMDD)25. MTF Transferred From24. Clinic Svc - Admitting 2003-10-21
ABA - GENERAL SURGERY 29. Date of Initial Admission28. MTF of Initial Admission
27. Location of Occurrence 2003-10-21
FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: BRACHIAL ARTERY INJURY
Procedure Narrative(s):
Cause of Injury Narrative: GSW
Admitting Officer (Sign ignature of Admitting Clerk
. - _J="e_;.• 4;41/15""
MEDCOM - 218
DOD-035428
ADMISSION AND CODING INFORMATION
(the proponent agency Is OTSG
1. REPORTING MTF
Slate of
For use of thIs form, see AR 40-400;
misimusiogi
5. SEX
11111111111111111
NAME Pa, First Middle Inman
A 1111111111
3. REGISTER NUMBER
11:11111111131131121131
9 RELIGION
9. ETHNIC
7. AGE AT ADMISSION
o 111111111001 7 q
BACK•
6. DATE OF BIRTH 0"8"1"I' M M GROUND
1311131119111111:3141311111113111
19
16111111111111111
e-
ITh
10. LENGTH OF SERVICE
ef)
1111E11 El=
NM
HOUR OF
ADMISSION
oRGANVATION (Active Dui). OnlY) •
ill. MOS
131111311:111611:111311111611
111111111111111111111111111111111 RELATIONSHIP OF EMERGENCY ADDRESSEE
NAME/
WARD
(Include ZIP Co*
ADDRESS OF EMERGENCY ADDRESSEE
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
NAMEAND LOCATION OF MEDICAL TREATMENT' FACILITY
(YYYYMMD D)
23. DATE OF DISPOSMON
TO
MTF TRANSFERRED
22.
vvvuosomumeurs
21. TYPE OF DISFOSTDON
112101111111311310 or 0
25. DATE THIS ADMISSION (Y YYYMMD D)
25. MTF TRANSFERRED FROM
.113
113113
C1131121
101011111113117113 Iwo
IMMO
111111111111111111111
ADmissioN
21. MTF OF
12®®1113®r
FOR LOCAL USE
SIGNATURE OF ADMITTING CLERK
AohuTTING OFFICER (SIgnatwe. es required)
MEDCOM - 21853 US/PA V1 .00
DOD-035429
INPATIENT TREATMENT RECORD COVER SHEET
Automated Facsimile
For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade Admission Remarks
1. Register Nbr . Na FGN
10. PrevAdm
8. LnthOfSvc 1 9. ETS6. Race 7. Religion4. Sex 5. Ag
M 1 Z L NO 1 20
14. Ward13. Organization11. FMP 12. S N ICW1
19. UIC / ZIP 20. Type Cas:-18. BranchCorPs17. Dept / Ben15. FlyStatus
BC
K78-PRISONER OF WAR/INTER
23. Clinic Service22. Hour Of Adm:21. Source of Admission
ABA - GENERAL SURGERY Direct from ER 01:35
25. Type Disp 26. Date of Disp24. Name/Relation of Emergency Addressee
TRF-OTH 2003-10-23 Admit ngOfficer:
28. Date This Adm:27b. Telephone No27a. Address of Emergency Addressee 2003-10-22 32. Units Blood Components30. Date lnit Adm
\7
29. Report'
2003-10-22
(7) -2,_
0580 -
31. Selected Administrative Data DoB: 1983-01-01 Q-1-
Marital Status: MOS:
In/Out Patient: Inpatient
33.
Cause Of Injury:
34.
Diagnosis / Operations and Special Procedures: MULTI SHRAPNEL WNDS --
\
-------___
,---
., ,_...
r-;
\
\ . (--.., ',
,, , -•
, , A
35. Total Days This Facility Total Sick Daysop Care Days Supplemen I Care B . lays
Absent Sick Days Other Days ConLv / C) ___O __
C.) 0
35. Total Days This Facility
Absent Sick Days Other Days Co v / Coop Care Days Supplemental Care Bed Days Tota ck Days
Sign r 0 Signature of PAD or Medica ecords Officer
MA C..),....
MEDCOM - 21854 .
Automated Facsimile - DA FORM 3647, May 79
DOD-035430
MEDICAL RECORD OiBBREVIATED MEDICAL RECORD PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON AD SION (Enter date of admission)
A- 0 6)-10 C.•-•
1(14390 Gt ‘i.. CL5C-.
2
PHYSICAL EXAMINATION
(AO (?) CT /
T,-/CD
PROGRESS (Enter date of discharge and final diagnosis)
SIGNA TURE 0 ORGANIZATION
PATIENT'S IDENTIFICATION (h a. typed or irratea entries give Name last, first. ae: hospital or medical facility) REGISTER NO. WARD NO ,
ABBREVIATED MEDICAL RECORD Standard Form 539
MEDCOM - 21855 GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRM (41 CFR) 20145.505 OCTOBER 1975 USAPPC V1.00
DOD-035431
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NO
MEDICAL RECORD
NOTES
DATE WilialliSINIEWAINF
A.00 0 MAVIr12... 411,
rarrimmirars "
, • ,.
1
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f
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am-in.
mi 0 gra 15 ,
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X LA) 1 ( ( a i,-Y)-7A-c.7 'II
ii
raixo
_ • .2_ 3 ex orstramr. ,. . _ .,
ir
SPONSOR'S ID NUMBER
RELATIONSHIP TO SPONSOR SPON• OR'S NA
(SSN or Other)
, , , I
I i in
LAST
HOSPITAL OR MEDICAL FACI ITY RECORDS MAINTAINED AT
DEPART./SERVICE
WARD NO.
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middl: REGISTER NO.
ID No or SSN• Sex; Date of Birth; Ran/Grade)
PROGRESS NOTES
MEM ( I ,_, _.
.17
STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11203(b)(10)
USAPA V1.00
MEDCOM - 21856
DOD-035432
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZAtioN pign eacn entry;
DATE a /5 3 , Z7--7 3
1c
ier vilqi5
/O -,2(-6 i q-
i /.3/
, VI)
BP il''
Nr , ob b e j, rao
Nr
P % 4,...,
P: 8g P ' q5 ty-, (I, P O -/c ' NA', fox: F' 0 1,
If
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r P....ft-
di , / 9
C-
all 0 L. C 4 ' .
I
5 e/e- viee(
AC-6-Pp e - ( i .a0 -e-3 r; Li 162 {:t ?re-. (.--ei,v5 -(:‘,..d,_
J. Ki &Jr ff2-4 , ' ,n—) --bi Or—) -6 re p-c
ekka-4-1 ki 01.41-i M 41) Ltff-i• Cbje3
L i q a ( 411 / 4) 4 L ;A-ae,-eat.„
Lie - - i e - .11-4 10 .0 'I-4 C Vra_. L.r'ca-
-
,6/14-4/691,./ t..), r/p/b L.3C.'s-1
0 Pis-hyi else) 6, F -e 2_
P1
7;2-451/Z7;2-4
STATUS DEPART./SERVICE RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACIUTY
SSN/ID NO. RELATIONSHIP TO SPONSOR
SPONSOR'S NAME IWARD NO.
PATIENT'S IDENTIFICATION: We( typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; REGISTER NO.
Date of Birth; Rank/Grade.)
140 -9 ria:IrIRMI AnInAl arnnan rip RAFfIlrAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 21857
DOD-035433
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD 1 PROGRESS NOTES
DATE 2-1r----t-- --- -`J NOTES )07,
¦
r
Aim .i...._
1
_46.1•11.11114111MirriI
silit'Vst-
0
r / ,
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,_.......
ow eif)a 49 03 C._ 1,f),---,..,. 0 )34„,_,_
r \9 6 -Z
Ily/1 w' Oil araillEr A
0
InEra -1111111 - Z_
AI
MIllaW4W17
Iffifir,-MIAMY'I- (9 .. A .111raffiff -
I ali.
111111111E1.111111111111M
SPONSOR'S ID NUMBER
SPONSOR'S NAME
RELATIONSHIP TO SPONSOR (SSN or Other)
MIFIRSTLAST RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITYDEPART.ISERVICE
WARD NO.
REGISTER NO.
(For typed or written entries, give: Name - last, first, middle;
PATIENT'S IDENTIFICATION:
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/19991 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.2031b)(10) USAPA V1.00
MEDCOM 21858
-
DOD-035434
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
Ognetc..)S&
Pc Mao Alt AA f?-e( r-s-ciAJ, nsc, Is -4-6aS7v),Ctlx Poi riS cc-/ h c R z)p-r4,--7-en ban 0 1,1 Jelr kt,tzha) 424 pa/002 )c\ 4v) 66
Ina-6' ea • (±-(1 Of:Or 670 po mO C195 roryt ) . M 00.-n-to TO L,CLQ le.(La 4-1_,A, I.A0
U
IA.. sk_A h
f °A. AN NAILA_AILd-eet
CA It r ) rrt ),--0 Li AA.-v. rt7tt,--v1-O k
ert lc,q ^1M zr /0,3
1300-03g °goo ooex ER d---‘4/-Li-ee ef-) 4rn
4 d DA °,4/-.
red ,7,,,at ./.07,, 1D
/-s m fivA4
1.1,z/0-?
Ay.hpiz-A 11111.147
, e 4-‘
vt414.2,W e-pv5
SPONSOR'S ID NUMBERRELATIONSHIP TO SPONSOR SPONSOR'S NAME
LW or OMNI
FIRST
RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACIUTYDEPARTJSERYICE IREGISTER NO. WARD NO.
PATIENT'S IDENTIFICATION /Fos typal or mitten macs, give: Name -Arlt; hist, middle:
ID No w &TN; Set' Dote of Birth; lionkStadol
PROGRESS NOTES Medical Record
11111 q0-1-1
STANDARD FORM 509 (REV. 5119001 Piescribid by GSAGCMR FPMR MI CFR) 10141203(b)110)
USAPA 111.00
MEDCOM - 21859
DOD-035435
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.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):1. AGE:
HEIGHT: 3. PREVIOUS SURGERY [ 1 NO [ ] YES (type):
WEIGHT:
4.
PROPOSED SURGICAL PROCEDURE:
5.
ADDITIONAL INFORMATION: Last PO: • Medical IIx: Medications: Jewelry removed: yes/no Family waiting: yes/un
6.
PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
t' Allow pt. to verbalize
A. PSYCHOSOCIAL b Pt. verbalizes any specific anxiety. reely. Explain OR environment
,V Potential for anxiety nd answer questions
o Pt. exhibits relaxed body posture.
egarding surgery.
related to traumatic injury; Offer comfort measures, .
language harrier; family
e.g., warm blanket, touch)
separation; surgical environment
Explain all nursing orocedures before they are .one.
o Remain with pt. whenever
iossible.
. Maintain family interface.
PT. will be able to breathe without ± Offer to elevate head of
B. AERATION
ifficulty during immediate intra-tter or offer pillow.
Potential for
K perative phase. r Observe pt. while awaiting
respiratory dysfunction due to
urgery for signs of distresssedation; positionine; injury
Assist anesthesia during tubation and extubation
PT. will not exhibit signs of impair-Utilize pressure preventingC. INTEGUMENT
ent of skin integrity (e.g., reddened devices on OR table and areas. ccessories.
Xn Pote tial impairment
Check for proper of skin integuity due to bovie ositioning and support to I' ad : position: Iluid shill maintain good body alignment.
po Pad pressure points.
Place ESU ground pad on on compromised skin surface rea.
Keep prep fluids from °cling.
9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first, middle: grade: date: hospital or medical facility)
USAPA VI 01
Previoius editions are obsolete.
DA FORM 5179, JUN 91
MEDCOM 21860
-
DOD-035436
6. PATIENT PROBLEMS AND NEEDS
D CI CULATION
Potential for inade -
quate tissue perfusion due to
anesthesia; traumatic injury:
position: shock; previous surety
E. NEUROMUSCULAR
CONVOL
El . .4,,_,_Potential impairment
of mobility due to sedation: pain; injury
Potential discomfort
E.2.
due to injury; p:lio
F. NEUROMUSCULAR
CONTIL
Disminished visual
F.1.
percdption due to being injury:
sedation;
F -) Potential for decreased
X
communictaion due to language harrier; 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
Pt. will exhibit signs of adequate tssue 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 nduction. Pt. will be transferred safely to R able. Pt. will be able to understand nstructions. Minimize danger of injury during ntraop period.
.
OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS
0 Check for suppok stockings or ace wraps. If none, check with doctors. 113 Check that safety straps are correctly applied.
li Offer pillow for under knees.
0 Place and take down legs from stirrups with slow bilateral motion.
fri Check that rings have been
removed.
Have sufficient people vailable for transfer. Insure proper body ignment. Allow patient to lie in sition of comfort while aiting for surgery. Offer support (i.e., pillows, thtowels, etc.) for ositioning.
Introduce self. Keep pt. i formed as to where he/she is nd what is happening.
Inform pt. in which irection to move and assist if ecessary.
Speak clearly and slowly. Address pt. from
side.
Validate pt.'s
derstanding of verbal
communications.
o Verify removal of dentures.
OTHER NURSING
INTERVENTIONS.
Or continuation of above
•
interventions.
.in no All locinin INITP',/N.ITICINIC rrlhAPI p -rpnranni -rioniAt INTEROPERATIVE INTERVENTIONS NOTED.
DATE
11. POSTOPERATIVE EVALUATION:
BY 13 OPERTIVE EVALUATION PREPARED BY Title)
12. PREOPERTIVE EVALUATION PREPARED
(Signator Title)
CPT/1W
CPT /hp,
DATE: zzoc 03
E 03/0
031(0 MEDCOM - 21861
USAPA Vi .01
REVERSE OF DA FORM 5179, JUN 91
DOD-035437
"
L., ,
IIV I II/WF 4.1l/-• I I V • ,,..../. , L!\ A
MEDICAL RECORD For use of this form, see AR 40-407, the propon' jency is f . ' ffice of The Surgeon General.
2. PATIENT IP -• ORD REVIEWED AN PROCEDURE
PATIENT TRANSPORTED TO OPERATING k ..dOM . _ i _
1. • BY tri=k-KaneSrneS-I CCI VERIFIED BY e ff 411)
VIA Idler
TIME PATIENT ARRIVED IN SUITE 4.
3. DATE
NUMBER
2rL Cf 03 D2-30
5. PREOPERATIVE EMOTIONAL STATUS
• EXCITED. II CRYING II ANGRY • WITHDRAWN • OTHER (Specify)
cg CALM II ANXIOUS
t
COMMENTS:
1(,)---1_.
140.--1,.._
6. NURSING PERSONNEL
' -RELIEF
I: ASSIGNED
SCRUBSCRUB
RELIEF
ASSIGNED
._ .. _. . .. __CIRCULATOR
CIRCULATOR iNT • •
7. POSITION AND POSITIONAL AIDS (Specify) -..... ... -:..—..,
N SUPINE • LITHOTOMY • PRONE • KRASKE -LATERAL: U LEFT SIDE UP • RIGHT SIDE UP
COMMENTS:
rropor bccl aliminerrf n-in,),-rrlaina---..,
8. SKIN PREPARATION N NO ' • PREP SOLUTION (Specify) baDdi ne. SCr
HAIR REMOVAL I YES
• NURSING UNIT SITE: 14. &I') BY WHOM
DONE BY: • OR
BY WHOM:
METHOD: • DEPILATORY ¦ RAZOR SITE:
• CLIP -____-_—_____ -ailLiN-TS: NID piinti Of fkliCIS
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES ,.....; . .
_ . ..
I. • Ati--_- -
I-..t . - .
-
IP Taleffigi)-
\ k......S. 17
X Ground Pad -- Safety Strap = = = Tourniquet— --•,,------
LEGEND
C = Correct I = Incorrect Tn;r-fi al -
First Closing Final Closing
10. COUNTS Other"• Count .. •:. Count .SCRUB '14 IRCULATOR
Sponge "2 __IEINIIMMPAI
Needle Sharp TA Y es IMIE11/41110111111111111111MIE II.
Instrument Yes
•
Yes NICIWAIIIMIONIIIIIIIIAINI
Other I. Yes 0 0 /
PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) ESU) I YES • NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
11. M ESU NO: Fbre_p 40 MEW-. 0 36
GROUND PAD: BRAND
Va ei_ • et
LOT NO: 001
ler 12(6)-1
07..E0 NO:
.-_..
--G BRAND
-.ROUND PAD:
......
LOT NO:
20 GiO 071
IN BIPOLAR NO:
USAPA V1.00
REPLACES DA FORM 5179-1 (TEST), DEC 82. WI-HCH IS OBSOLETE.
DA FORM 5179-1, OCT 87
MEDCOM -21862
DOD-035438
0 NO IF YES NAME: ID Num8E1i; il.11-AL: I UlitII
13. PROSTHESIS, IMPLANTS . YES
(-,
,_ '-',:-4.44,4ti'MEDICATIONS/ORDERS F:,_, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO TIME METHOD PREPARED BY GIVEN BY
:MEDICATIONS/SOLUTION DOSAGE'-
. --
f
(WOUND IRRIGATION IV YES • NO, TYPE(S):
0,q °10 NIS
TIME CARRIED OUT BY '`.
OTHER ORDERS
None
___................
•
':-'PHYSICIAN'S SIGNATURE
IF YES, SITE
15. X-RAY IN OPERATING ROOM
r. ,
YES • NO ]
' f .--' LABORATORY SPECIMENS
. ,
SPECIMEN (S) NAME j
YES • NO RI
16.
_ .
NAMEFROZEN SECTION (FS) NAME
YES • NO il
NAME
CULTURE (C) NAME
YES • NO 1Z
___ , ---NAME
NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
--- ----FiLi— fh
17. TUBES, DRAINS/PACKING YES gj NO •
TYPE/SIZE 1 ,) 2. .
Werii It.
416 Perficce-
SITE 1. 2.
el- . arrn 3.
19. ADDIT ONAL INFORMATIONli„. -
. .,...
31,11!
_. .
AY9 rerno-ted - (I.)] pf . -h) PitiC
20. OPERATION(S) PERFORMED
1. t.2)L p Jo rail on of-e-I• kern 14 cv-d -
.c6.-1_
TIME METHOD
PACK 631(° -Li t-fei/
21.
PATIENT TRANSFERRED TO
22.
RE GNA RE
0 Pi I AN ...___ ...._
USAPA V1.00
DOD-035439
NSN 7540-00-634-4124
VITAL SIGNS RECORDMEDICAL RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR DAY CC 23
am'
. • I/ AVM HOUR REIM1111 ' • ------• • • • • ' • •
7.1
,
C3C
nk-r
(+3CaC.) w wwCOco 0) co -o. -1s. rn
71 01 0) a—1 -1•-.1co 0)co o o K O 0) i..6 :-., bi.) Co 0)co .t. bCo X
0 0 0 0 0 0 0 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
1: ..... : • • • : •
PULSE TEMP. I:
(0) (.)105°
"
' • ' • •" •' • • ••
t
......
•.
.
.....
1111 . • • • • • •• • • . ..
..... • • ..............
104° • . . . •• . .
180
...... . . ........ . . . . . a
.
; ..... • -
.
. .......
170 103°° . . . . . . . . . . . . ........
. . . .• . . .•.• . . . •. ........
. . . . . .
...... . .
. . . .
. . 160 102° A
I
• • • -• • -....... •-• • • • ••
...... • • • • • • • -• .............
........ . .
. . . . . .
150 101°
11 :. . . . . . . . . . . .
.....
....
140 100° mu . . . . . . . . . . .......
.....
..............
. . .... . .
.
....
.
..... : : : .......
•
130 99° If.
ml NOMEN
EifIMIIIIINEMINENEMENSSISSIIIIIINNEMSIIIISNENININISI
FM : : . " • • : :: ....... : ..... 120 98°
98. '' I
...... • .... • • ........ " ' •
.... " "........ . .
.... . . .
1111 . • • • • • • • • ...... . • •
110
. . • .....
..
970 1 ......
.......
...... : :
100 96°
I . III :.
90
....
80 95° ¦ .:. lit ..... " . • " . • . • • .......... • • • " : •• ....... ...... ....... " ...... .
70
60 121 :. :. • " . . •. ." •. . " . . ...... ........... • • • • • • . .
50 40 . . . . M ............... : : : . ................... .................. ... ' • • • • . .
RESPIRATION RECORD .
Record specialdata only when so ordered
I
BLOOD PRESSURE
MIZE
-2412111
MEM
HEIGHT: WEIGHT --No Man
PATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, frst, middle; ID No. REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 21864
DOD-035440
‘..ESULT of 19741 Ir
em.co to-.0 •
TEST RESULT I REF. RANGE
N'A
Moro Nrcgadvc Ne-gati re
. hfi.crob
Bill Negative
Negative
Nregat.ive
SG I /,0)-5 NIA Negative
H. pylori N/A .
Micro Parasites Neg./1 ,m
Malaria
0.2-1.0
O&P
Nepri Ye
Ncgmtive
ras•ciipk Uric i • • .. ,• HCG tvc
Spun
RAPIOPOIN1 COAG ANALYZER V4.54
1-ieraatocrit
SERIAL 10/22/03 01:43
Sed Rate
MUST SUBMIT SF 518 WITH
Patient ID:
141 EVERY UNTT REQUESTED
Test Name :PT
cgutve
I ABO/Rh
Test Result:= 13,3 .;pec.
ctagu Ratio = 1.1
Fd.Bahk"Unit Crossmatch'
Calculated INR , 1.15
_ . F:
518.Wrlig EVERY UNTT OF BLOOD
Sample Type:citrated ugh. blood
!. :REQUESTED)
RISE. Test Date :10/22/03
TYPE j CROSS. 1,t4TCH
Test Time :01:40 Card Lot (71.' Operator
:2"TT
RAPIONOallThALYZER '/4.54
F I SERIAL 12/03 01:47
1:
11111— 40 1
RE MARKS:
Patient ID
Test Nam e :APTT
REPORTED 13}
Test Result:= 39.1 ec. D NO.: . Sample Type:citrat d uth. blood Test Date :10/22/ 3 Test Time :01:44 Card Lot Operator
MEDCOM - 21865
DOD-035441
bto-Lk
LA -1-
CETENI.IST Y RESULT FORM.
LAST, LST, Nf7. I
(Sub .e-zt tot c Priva:v
DA TE.6 cfic?4) icbOlo eta
Ic-Patiet
•-•
TEST !RESULT
R_4:VGE
138-146
ALB
3.5-5.5 gld.:
GLU
73-11 rvdt
3.5-4.9 rrark51/L'
7-22 ciEidl
98-109 rarzo1/1.. 1710-1 BUN pH CA— 8.0-10.3 ra glcil
7.31-7.45 1.:1
-1=== PICC 0
0.6-1.2 al gd:
PCO2 35-45mmfigol 22/10/03 CRE
02:
41 -51 minfirz (vez
REFERENCE R 128.145 r•.rr.ol./1
P02 iS 0- 1 OS mmHg (ar
N/A (veul PATIENT #:
TCO2 23-27 mmcl/L.
GENERAL CHEMISTRY
24-29 n-irnoLL c
HCO3 22-26 mmoL/L (Ir DISC LOT #:44-1.,
23-28 nvuoUL (vc
OPER ill
s02 95-98%
SERIAL #:
BEecf (-2)— (43)
nun on
ALB 4.4.
3.3-5.5 G/DL
10-20 mmol/L
ALP 118* 26-84.
U/L
1.12-1.32 mmol
ALT.
23 10-47.
U/L
8-26 mg/dI AMY.
63 14-97.
U/L
AST.
33 11-38.
U/L
70-105 medl
TBIL 0.6.
0.2-1.6 MG/DL
BUN 11.
7-22.
0.7-1.5 mg/dl MG/DL
CA++ 9.1.
8.0-10.3 MG/DL
38-51% PCV
CHOL 131.
100-200 MG/DL
12-17 g/d1 CRE
0.9.
0.6-1.2 MG/DL
GLU 103 73
118 MG/DL
TP 7.7.
6.4-8.1.
(3/DL
REF. RANG)
INST QC: OK.
CHEM QC: OK
HEM 1+, LIP 1+, ICT 0
Drug of
Abuse
12 8-145mmo1/1
RE NLA.RK S:
REPORTED BY:
DAT:
LAB ID NO.:
MEDCOM - 21866
DOD-035442
MEDICAL RECORD - ANESTHESIA
\\X___O 0
For use of this form, see AR 40-66; the proponent agency is the OTSG
I `t
LU STHETICAGEN TSANDDRUGS
TOTALS TOTAL EBL
DRUG}(Units)
P(loi --1)1""}A-14-15°
(}
-5,-(... ( P--il) I1P_ /JO -----LC.--ar—,-
s-, TOTAL URINE
ktja""t'aAt 1-4;`-AZ(v\
I})
(})
I})
VOLAT c'-‘16",--1)6 del I -----1.---FLUIDS • SUMMARY AGENT % e.t. CRYSTALlg,Dc
A0 AIR}L/Min
COLLOID-
N20}L/Min
02}L/Min 73*- --
BL001:;-*"....\...........s
CONTINUOUS/REPEATEDDRU GS SPECIFY UNITS -MG/MCG/ML, "I" =CONSTANT INFUSION
SINGLE
--le-
WITH NUMBERS
LINE site 1-14,.1.-Med . -T, ai REMARKS •••¦-
Code drugs with numbers, events with Millers
.
Warmed
.
Warmed
EST BLOOD LOSS
LOSSES E'ri---1.—. 5:4_9.....(r..s •--.) e URINE ---CO z)/1-' ( .. dv....+2-
PHYS STATUS
TIME sii¦,T--,--0 01,d"
1}345}E e- ,3-1. _ (t .t
-I-- -I--_1_1_ q Y'
SYMBOLS:
BODY WEIGHT: :• .CLALt--
220 . --, -' .
!
_ ,_ _,___
KG BP by cuff
, LB 200 : ,}. C,4-. etL1-Jati 7--V
,
HEMATIOCRIT: r.....g......vu,--10 riz`Z.A.1.-
180 ,
A ' ) ,.kI Litt, D Heart rate . ,}, . ¦ . 1-t.) Pli-rc-t— ,/'1
160 . I I I
.
INITIAL DATA: • •
. Stv-t--.. Resp rate 140 -7--} , .
.
BP-04.`)/1-1._
120 :
/
BR
HR-}-4;4.e_
(transduced) 100
,___,-_-.,---TI_ , --I I I I , I
EQUIP}CK BO } . ,
* -• '}e' ,—,— —,--,— --,—,-OK?-}Y}N 1.-.if -1 .L ' I_
TOURNIQUET GO ¦
' *
. -7 -1-1 -PATIENT}ECI4ECK T ---/f _(___ ..___ _¦_. , _1_ -1-._J-1-_1_1-
7-' 40
OK for '
, -I-PROCEDURE? 'N ANES- X-X i___ 1_ I- t---L--i---.-1-1--: .
20 "--i ----
.
PROC- ®_(;)
m-- :TIME
[MONITORS/ACCESSORIES I VENTILI
VT - ml
100 f51'
f - breaths/min 10 I D}' ,ac:
Peak int pres / PEEP @5 a)
MODE - SIpon), A(ssist), Cion) 31/1-1C-t) C_V-i,W
r9I RECOVERY AT
BP/Auto Cuff ET CO2 Itorr) 3 3 3 a ,‹-c,
--{NACU cU}Specify) BP/oth F102 (Frac or %) . -4-1 •. :1-I ..-4-1
OTHER
ART line Sp02}(%) ti.7° (a° (00 Steth- PC/ES ECG Sit cif-Se"( CONDITION: tz,49.-
Gas analyzer TEMP-siteift-N RESP-i‘ Sp02-
5'1-f+
`
N-M Block (T/4) BP-0/ '3CGC-ANESTH IA t PROCEDURE TIMES
in Start Room End
w C-7 30 .233i .-}."/_,.)
Warming blkt .ft
Com/ warmer 0 Ready Begin End Ma k with letters & symbols, EVENTS_ }A 0 explain under REMARKS Position -
Et. oa35-
eatic--0-3(N
',•--1,„
n",
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
/...„-- r, p 1000RcA, 2 uk 4 ,A.,,,-.s. it1-A..) C.3"-Lni GA-PATIENT IDENTIFICATION:}Typed or written entries: N c, Grade/Rate, AIRWAY MANAGEMENT: Intubation route, blade, technique, comments Medical facility ,,r-vg.e.r_cx--u-
t) €3- -eir 1.)4c'i elS11 ,4:1 11114,4,-.. .3P-8.6
1 Ci-- -4)--ii,A Li-) ./-14.1-0--, c.—
c.
ONS: PROCEDUREcny LOCATION:
WO '-'l
DATEA.--V ..., ,,e 'l Oc 16-5
PAGE}(}OF
}
DA FORM 7389, FEB 1998 MEDCOM - 2TauCOPY 2 - ANESTHESIA PROVIDER USAPA V1.00
DOD-035443
csr
-
otSN TS40-01-165—TV4
RADIOLOGIC CONSULTATION REQUESTIREPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
WR/ INIC REGISTER NO.
AGE SEX SSN (Sponsor).
REQUESTED}
EXAMINATION(S)
\\1\
PREGNANT
FILM NO.
n YES D NO
TELEPHONE/PAGE iv
DATE REQUESTED
(Complaints and findings)
;PECIFIC REASON(S) FOR REQUEST DATE OF TRANSCRIPTION (Month, day. year)
DATE OF REPORT (Month, day, year).
,ATE OF EXAMINATION (Month, day. year)
ADIOLOGIC REPORT
LOCATION OF MEDICAL Rt_COROS
sTIENT'S IDENTIFICATION (For typed or la • ten entries give:.
last, first, middle. Medical Facility)
,me —
LOCATION OF RADIOL•GIC FACILITY
SIGNATURE
STANDARD FORM 519
Prescribed lay GSALC" I
--IC CONSULTATION
FPMR (41CFR)101-11
MEDCOM - 21868}IEST/REPORT
• — AO IOLOG Y
DOD-035444
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
NOTED AND
HOURS SIGN
19 )
intratili¦-¦li./gams'--.--'}
------47-.f ---t:---lkj
EMI.
.. .,
)S
NURSING UNIT ROOM NO. BED NO.
/
PATIENT.IDENTIFICATION OA E OF ORDER TIME OF ORO 10 ---1 /.V L...g_ c,-,, --HOURS
a • AT' }, / /1/-/0/3 xi . ---k-
-0303 OPt.-
.11'
..
& ¦,
. Pa r 1(67 -2-
NURSING UNIT RO/ :EC) NO. / ,
PATIENT IDENTIFICATI• I E 6)6(0 CV"'
HOURS
...... ,
mrimmopp„...._
,........
lirirmr) ............„..
42
NURSING UNIT ROOM NO. BED NO.
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.
D 4256
FORM
, APR 79
MEDCOM - 21869
DOD-035445
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
PATIENT IDENTIFICATION DATE OF ORDER}TIME OF ORDER}•
ORDER NOTED AND
1--0 C....-1— a-1? _.L______} HOURS SIGN
Mfyl,--./ -3,7,__,..... ri,....." „...........
j,L-Li
Allro(k) -9
""a---
-7--2-CI.
411.CRS'
UNIT ROOM NO. BED NO.
12 (0 -- 2.--
PATIENT IDENTIFICATION DATE OF ORDER}TIME OF ORDER } HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER}TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
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
1 FACIP FIRM79
MEDCOM - 21870
DOD-035446
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
CLINICAL RECO For use of this fo.. see AR 40-407;
Mo..Yr. 2003
the ornera apencv is the.0 'cc.of The Surgeon General.
VERIF Y BY INI77ALING 7i , .7. , 7:ii ,1 I MParliii lli.;: -PROPER COLUMN FOLLOWING EACH COMPLETION
HR} DATE COMPLETED
ORDER CLER / RECURRING ACTIONS,
DATE FREQUENCY, TIME
IN
N. ,,, A}ten -le -.PC 1..
1111111
,_ Pa inai • ••
.
,
O.,
_
0,6,111
-
-.ocir) \tcs.Q .in i,.
(-1, ..if
MI NO PRIMARY DIAGNOSIS:.• ADDITIONAL PAGES IN USE: 11111 YES.I. NO ALLERGIES:.MN YES
A •
i iYul-fropv G 6 (10
PAGE NO'
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
0.
)-1.
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
}
EDITION OF 1 DEC 77 MAY BE USED.} USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM - 21871
DOD-035447
Verity by Initiating THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo . Yr 2003 1
Order.Clerk Date.Nurse SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
00)0c4-
CO ncl
Order/
Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Date Nurse ACTION, FREQUENCY
TIME/DATE COMPLETED
""*"'"' USAPA V1.00
MEDCOM - 21872
DOD-035448
}
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; Mo..Yr.the proponent agent}is the Office of The Surgeon General.
VERIFY BY INITIALING . .INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
•
-—v L V ett -lace] hlr
,et 11
ALLERGIES-}J YES}Q No PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: AYES}1::] NO
PAGE NO. }
PATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CI RCL E MED TIMES
illip 1)10 -}
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
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA 1FF7719 4678
MEDCOM - 21873
DOD-035449
Verify by t} THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo.. Yr
Order Clerk/ Data to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date be Given be Given PC)1\11-In An(L .).jYYN.V '? ?)-A I AOC--t ' .(3 C1) PN C
Order/ Expir Dote Clerk/ PRN MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED
ilrf.
Thr CO (Ert a1,0 44
' In fa °
6 (L) ---/__
'U.S. GPO: 199e-454-110/95216
MEDCOM - 21874
DOD-035450
}
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
the proponent agency is the 011ice al the See peon General
MSG APPROVED Matti
AR 40.66;
Fat use of this tam. yes
Post-Anesthesia Care Unit (PACU) Flow Sheet
REPORT TITLE
Drains Anesthesia Type (Circle)): General Spinal Epidural Hemovac a 0 IV Sedation Nerve Block NG
Colloid
OR Intake: Crystalloid
Time In: _C2,.....2D.--JP
0
EBL T -tube
Allergies:
OR Output: UOP Pre-op V/S: 1 • 0 Meds/Times: Foley
Procedures: IA) TLS
— ..- ME a I .
d Swami it ir nu
Pre 0• M eo
imis
Infused
Time Solution Amount ECM By
motazinassanumin NEMIMINIMINIIMI
SaO2 MMOMMIN
EME111111111111111111111111111111111 }IMIIMI
FIO2} UR IMINKINIMMINNi
1132111111E0M11111111111111111111111111 111111110111111.1111111111
13} 11 11111111111110.1 11111.1111110.111111.111
240 1111111111111111111111111111111
Lab
1111111111111111111111111111111 1.111111 1.11111
11111111111 Postecove scoreic
111111111111111111111111111111111 -Anesthesia R s:
220 11 30 Codes
ADM
AIRWAY
111111111111111111 Adivily
200 111111111111111111A = Ambu
(2)
Moves 4 Extremities BB= Blow
-by
(1)
Moves 2 Extremibes
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
= Mask
(0) Moves 0 Extremities
111111111111111111111111111111111
FT = Face
180 111111111111111111111111
Airway
11111111118111111111111111111
(2) Cough, Deep breath Tent
lnlaaIIIIIIIIIIIIIIIIIIIIMMI tinkled breathing , RA =RoomAir
160 (1) Dyspnea
NC = Nasal
11111111111111111111111111111111111111 (0) Apnea
111111111
Cannula
Blood Pressure 4-20 of Pre-OP
140 1118111,111111111011111111111111111118
(2) SBP
11111111111MINII1111111118111111111111111111
(1) 5BP =/- 20-50 of Pre-op VIS
X -- A-line BP
(0)5OP =1- 50 of Pre-op
120 IIIIIIIIINIIIIIIIINIIIIIIIIIIIIIIIII
=Cuff BP
15111111111111111111111
Consciousness
-- Pulse
1111111111111111111111111 (2) Fully Awake, audible
100 11111111111111111111111111111111111111 crying
1111111111111111111111111 (7) Arousable to verbal or pain TEMP
11111111111111111111011
S =Skin
1111111111111111111111111111111111 Color
0=Oral
80
,2 , Bas eune c h,,, & appearance
A = Axillary
11111111111111;112101f111111111111111111111111111111 }( 1 ) Pale . monied. iaundice d
T =TVITIparliC
11111iii111111111M111111111111
60 B = Rectal
1111111111111111111111111M1111111111111111111 (0) Cyanotic Weds 5 Years)
Circulation
radial Pulse Palpable LOS
11111111111111111111111111111111111
40 ( 1 ) AkillarY Palpable , not radial C= Cervical
reliable Pulse
111111111111111111111111111111111111111111111 (2)(0) Carotid only
KIN
T =Thoracic
IIIMMIMMIIMIHMIIIIIIIall Must be 9 or
L = Lumbar
TOTALS': DIG. otherwise
20 ¦IIIIIIIIIIII greater to
S = Sacral
II_IIIIIIIIIIIIIIIIIIIII needs anesthesia approval for
OULU}11111111111111111111111111111
Pill
E130111 DIC.
It10111110
naaement.
M111111111111111111111111111111
Patient leachin done: Wound Care. P•
IIIIIINII IIIIIIMIIIIIIIIIIMIIII.N DEL. Incentive S iromeler, Comfort Measures
Time
n up On reverie
IIIIIIIIIIIIIIIIIIIIUIIIIIIIIMIII T. C. &
111111111111111111111111111111111111111 Salet : SR u X 2. Falls Precautions. Privac Maintained
Pain 0-10 IEIII
DATE cia o TO 3
LOS
DEPARTpNTISERVICEICU NIC
PREPARED BY (Si;n2
A-(}
L 7,9 Name — last,
es give: . FLOW CHART
O HISTORYIPHYSICALPATIENT'S 10ENTIF
, NFU 11,
middle: grade: dal . OTHER ram.aly,
b(0 —i . OTHER EXAMINATION
OR EVALUATION
DIAGNOSTIC STUDIES
.
46)
TREATMENT
Previous edition is obsolete (MCXC-USA
DN) }V2.00
WAMC OP 173-E, (Revised) 1 Apr 01
OA FORM 4700, MAY 78
MEDCOM - 21875
DOD-035451
MEDICATIONS
Allergies: Time Pain Medication & Route Pain I/E By 1-10 Do Floe 1 -10
NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm .15' "Up., tau( ---TREIIIIPIRMINILWIEZ 6 6 pu ill Lily L Lyn)
36 :64MIFIEE11.1=11111111 EA/ 14.) ,QL
45'
60'
90'
D/C I 1. 4wag -"\-- t 6 LL., N..1-Lk4.,
W = Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Retill: B = Brisk, S = S uggish P = Pale, Pk = Pink C-SECTIONS Adm 15' 30' 45' 60' 9 • D/C Fund. Height Lochia Peripad# F • ,. ' ond.
DRESSINGS
Location Type Drainage
Time
Adm 03.20
er-Lbc6400 30, 03c0 `G1 G ourt 60'
D/C o$ 36" fZe it t )c Gait C4
NURSING NOTES
Rece.ineof .--PfovA e)R U(cf
C)J R +Al 05.5 4L.,1 (---3
/4-e 006cdX4 sib Lt4alzbe-Q S4oNILM, V C9e. GU 5 400 FA 0 "I.s f eL.k. fe4z4L 3 — 1-4-Q : NSn L.(LTA L ' s -t).ev,
RC,(/IL pv e s 3 a55 -1--0 a() otryc ttA:VRC.:47 5Kail ky CGIG-L c,ti GI/ L—
cAn 5 35,— PT 5-1-ci 2 5
PACU OUTPUT
Time
L source:t Color/Appearance Arnow?'
03a (3 It I.) A tv-k , klectryclimAj 3.00 0-4-
CARDIAC RHYTHM Time Rhythm Symptomatic , Rhythm Strip Run')
03a0 Risk
A xs-
Discharge Criteria: Date:OC---0/3Time: oq 3 BP:t.irk: T:q7 HR:& Pain Level at D/C (0-101:3 Intake: gs Additional Data: Transferred To:.iCk/ Report Given To: Transferred Via: W Transferred By: Cleared IAW Recovery Charge Nurse Signature
PARS: of RR: /6.Sa02cte
Output: SPC_.)
Ambulance
WAMC OP 173-E
MEDCOM - 21876
DOD-035452
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
TRAUMA FLOWSHEET QI Appr 11 Jun 97
The proponent is Dept of Surgery
. 02 1/min . s-Spine Immob
D
TIME: ETA: ), TIMOVN5 . IV x
Meds:
. UKN lkNone . Yes:MED COM: Allergies: 0 UKN None 0 Yes:
NN\c-kLyc.t
Tetanus: 0 UKN . Current Last Meal/Fluid Intake hrs
LMP: 0
CIRCULATION
PULSE: )(Present . Absent SKIN: yWarn . Cool . . Hot
IN12,r Patient
BLEEDING: XI Pink . Pale . Cyanotic 0
0
. ETT . a a
HEART TONES: . Clear . Muffled Dry . Moist . Diaphoretic
. Secretions
SECONDARY SURVEY
ABDOMEN:
Soft . Rigid . Non-Tender GCS: E
PUPILS: X Equal . Fixed . React . Dilated a a RHYTHM: Regular .
TM: . Clear . Blood PULSES: 0 Central . Peripheral . Tender:
a
PELVIS
LUNGS .
NECK
Clear . Unstable
C-Spine Tenderness: BREATH SOUNDSX Bilat Equal KStable .
SPHINCTER TONE:
Absent Blood at meatus/vagina:
Pain @ Decreased a Q a a U
IIi(4VNL Wheezes Crackles Heme + atrostate: ANL . Abnl
. None
a a
VASCULAR ASSESSMENTUSE DIAGRAM TO DOCUMENT INJURIES AND PAIN '
(AB)rasion
(AMP)utation
(AV)ulsion
Battle's Signs
(BL)eeding
(Blum
(D)ef ormity
(E)cchymosis
(F)oreign Body
(H)ematoma
(LAC)eration
(P)uncture (W)ound
(Pain)
(S)eatbelt (S)ign
(Sltab (W)ound
(GSW) Gun Shot Wound
D Dopler
PHYSICIAN
RN
. Continue on reverse) DATE
PREPAREMMII
PATIENT'S IDENTIFICATION (For typed or written entries give: Name--last, first, .
1:1 HISTORY/PHYSICAL . FLOW CHART
middle; grade; date; hospital or medical facility)
.
OTHER EXAMINATION . . OTHER (Specify) OR EVALUATION
.
TREATMENT
111111111 31° 1:1 DIAGNOSTIC STUDIES
DA 1 FORM 4700 RE.MEDCOM - 21877}ERED BY DD FORM 2005. EAMC OP 503, 1 Dec 98
1-TCLVILWO cvr r it..pro to ._,G,SOLETE.
DOD-035453
}
}
SITE BY TIME PROCEDURE r¦c coat iir,N ED. BY}RET
SIZE}
. Oral . ETCO2 Change
CT Sean: 0 Contrast
ET
. Nasal . BBS Post Int 0 Heed . Abd 0 Pelvis
Intubation Teeth . Post CXR
0 Air . Contents . C-Spine 0 Tn. Spine 0 Chest
Gastric . Oral
. Verified
. Nasal
Tube Suction: Y N
A-Gram Site:
0 Return cc
Urinary -‘ S
Meatus
0 Herne Dip: + -
IV ACCESS .& FLUIDS .
. Supra-Publ
0 Secured
T.IN
. Grossly: + DPL 0 Opened
Cell count
. Closed
Sent@ 0 Air . Blood
Chest
. Fleuravac cm
L R
Tube #1
.
Autotranstuser
.
Air 0 Blood
Chest
MEDICATIONS
. Pleuravac cm
L R
Tube #2
. Autotransfuser MEDICATION --;RTE: "TIME Rhythm: Comments
12 Lead
, ABo,Olyt H BE .PCO2 PO 0z SAS HCO3
1)
2)
TIME. "2
X-RAYS
LABS
. D-stick . SHct Chest Initial
O D-stick 0 SHct . Chest Post ET
NEI
CBC Chem NiiPT/PTT Chest Post CT BLOOD PRODUCTS
0 ETOH 0 T&S VT&C x UNIT# IT IIP
O Tox Screen
UA O HCG
OTHER )t, \ TA
,Q
. OTHER
LAB RESULTS INTAKE & OUTPUT
INTAKE
011 IVF Urine NGT NGT Blood EBL Other Other
P7 2 77 L, 7 TOTAL TOTAL
CBC: Chem:
TRAUMA TEAM ARRIVAL VALUABLES & CLOTHING
TITL TA
ED Phy None Found Surgeo Given to Patient Anesth
Given to Family
Inventoried and Released to Patient
Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
X-Ray DISPOSITION
RT O Home .
Ortho Admitted to
Report Called to
Neuro
Time Transferred
Chaplain
' —ed By
MEDCOM -21878
, _ stretcher . Wheelchair
DOD-035454
Re.Temp: TIME ' \3 ) / / / / / / / . _-` VITAL SIGNS MODE GCS: EYE OPENING -GLASGOW COMA REBLE RESPONSE 4 - Spontaneous 5 - Oriented 3 - To Voice . 4 -Confused 2 - To Pain 3 - Inapp Words 1 - None 2 - Incomp Speech 1 - None TIME}'PROCEDURE U Backboard Removed U Downgraded NOTES SCALE MOTOR RESPONSE 6 - Obeys Commands 5 - Localizes Pain 4 - Withdraws to Pain 3 1- Flexion to Pain 2 - Extension to Pain 1 - None PERFORMED BY BY: BY:
/ .
/
/
/
MEDCOM - 21879
-A.
DOD-035455
VITAL StGNS --
.
N. GLASGOW COMA SCALE
Re}Temp: Cx , ,..
GCS: EYE OPENING REBLE RESPONSE MOTOR RESPONSE
....-• .
TIME BP 0 \ .krl °'. CIPA z.)\ A X ‘3‘\' / / / / / / / °I(e ci RR ',QC) 4 a SA02 °I CI \co F102 MODE 4 -Spontaneous 3 - To Voice 5 .Oriented 4 - Confused 2 - To Pain 3 - Inapp Words 1 - None 2 - Incomp Speech 1 - None TIME}PROCEDURE 0 Backboard Removed D Downgraded NOTES 6 - Obeys Commands 5 - Localizes Pain - Withdraws to Pain 3 - Flexion to Pain 2 - Extension to Pain 1 - None PERFORMED BY: BY: BY:
/
/ ,
/
r
r
/
/
/
/
/
/
/
/
/
/ . ,
MEDCOM -21880
DOD-035456
6 , t /•-
r &e_w-2
c _ / ct
OS'
MEDCOM - 21881
DOD-035457
INTREP 32-031022-001 TF 1-32 S2
14(6 )
DTG: 22 1349 OCT 03 that the two detainees taken last night
1. Haswah police informed LTC in the Mercedes were terrorists from aghdad, and that we should not release
them. NFL
ASSESSMENT: Report is consistent with the circumstances of the incident.
2. The same police officers provided information on other detainees in the past,
once they were in US custody, which was confirmed by multiple intelligence sources.
S2, TF 1-32 INF, FOB Chosin
POC: CP .army.smil.mil
\O [6)--I,
MEDCOM - 21882
DOD-035458
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
Offense against Clvilian(s) [check one] if "Other" then describe:
1}!Arson (I.P.C. 342) Burglary or Housebreaking (I.P.C. 428) I
.
Solicitation of Fornication/Prostitution (I.P.C. 399) On Extortion/Communicating Threats (I.P.C. 430)
Rape)Indecent/Sexual Assaults/Acts (I.P.C. 393-98. 402) Theft (I.P.C. 439)
Murder (I.P.C. 405) Destruction of Property (I.P.C. 477)
Aggravated Assault/Assault With Intent To Kill 1l.P.C. 410) Obstructing a Public Highway/Place (I.P.C. 487)
Maiming (I.P.C. 412) QDischarging Firearm/ Explosive In CIty/TowrVVillage (I.P.C. 495)
Simple Assault (I.P.C. 415) Riot or Breach of Peace (I.P.C. 495(3))
MI Kidnapping (I.P.C. 421) Other
Offense against Coalition Forces [check one] if "Other" then describe:
Violation of,Curfew Trespass on Military Installation or Facility
/1111illegal Possession of Weapon PhotographIng/Survellling Military Installation or Facility
FE:rAssault/Attack on Coalition Forces 1 loObstructing Performance of Military Mission
Theft of Coalition Force Property
Apprehending Unit: l Location Grid:
Date of Incident: (D/M/Y) Time of Incident: Date of Report: (D/M/Y) Time of Report: 2 I /10 /03 to / 2.330 hrs to}hrs /}/ hrs
Detainee # eiw Key Connected Person:}EVictim}Witness
Last Name:
Last Name:
First Name:} Given Name: First Name:} Given Name:
Hair Color: Scars/Tattoos/Deformities: Hair Color: Scars/Tattoos/Deformities:
Eye-Color: Weight: lb 'Height: in Eye-Color: Weight: Ib Height: in
Address:
Address:
Place of Birth.
Place of Birth.
EthnfTribe/ Sex: Phonett: Ethn/Tribe/ Sex: Phone#:
Sect:
IM DOB D/M/Y: 'Mobile Sect: I IM DOB D/M/Y: 1 'Mobile I IF I 'Regular I IF I 'Regular
I 'Passport ' IDr. license I 'Other (specify) 'Passport I IDr. license I Other (specify)
I
Document #:
Document #:
Total Number of Persons Involved
(list names/identifying info on reverse under'AdditiOnal Helpful Information") i Vehicle Information Vehicle Number of Venicle(s)
!Owner:
Make: Color: VIN:
Model:
Type: Plate No.:
'Number of People in Vehicle:
Year: Names of People in Vehicle:
Contraband/Weapons In Vehicle:
WeaponI !Property/Contraband}I Photo Taken of Suspect with Weapon/Contraband: Yes/ No
Type: 'Model:
Color/Caliber:
Serial No.:
Quantity: Wake:
Receipt Provided to Owner: Yes/ NoOther Details: {Where Found:
Owner:
Name of Assisting Interpreter:} Email, Phone, or Contact Info:
Detaining Soldiers Name Supervising Officer's Name
(Print) . 55 61
(atm: LT
La Signature:}
Z _Signature:
Email:
. Email . Unit Phone: Date: / / t Init Phn,-.9:
Date:}2,2, 1}t 0 /}03
mpnrnm -71 RR1 --
DOD-035459