Medical Report: 21-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wounds to Pelvis

Medical record of a 21-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wounds to Pelvis. Medical conditions included, failed/damaged right kidney; large pelvic hemotoma; laceration of neck.

Doc_type: 
Medical
Doc_date: 
Thursday, May 1, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

PROGRESS NOTES
MEDICAL RECORD

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STANDARD FORM 509 (Rev. 11-77)
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Prescribed by GSA/CMR. FIRMR (41 CFR) 201-45.50 5 con-111
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DOD 12875
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MEDCOM - 5664 STANDARD FORM 509 (Rev. I 1-7 T) ProocrIbed by GSA/ICMR, FIRMR (41 CFR) 201-45.505 snn-111

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PROGRESS NOTES
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M EDCOM - 5671
DOD 1288:-:

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STANDARD FORM 600 (REV. 6-971 Preactibell by CISNICMR FIRMR (41 CFR( 201-9,202.1
MEDCOM - 5672
DOD 12884

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MEDCOM - 5673
DOD 12885

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MEDCOM - 5674
DOD 12886

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!ENT'S IDENTIFICATION iFor Typed or written entries, give: Name • kw, lire, middle: 1D No or SSN; Sex:
Date of Binh; fiank/Grede 1
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV 6-971 Proscribed by GSA/ICMR FIRMR 141 CFR} 201-9.202-1
MEDCOM - 5698
DOD 12910

AUTHORED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL -CARE
LAICAL RECORD DATE SYMPTOMS, DI; GNOSIS, TREATMENT, TREATIN ORGANIZ; T . 0 (Sit, each enfryl
drw, 21F-,1591 A/
STATUS DEPART./SERVICE RECORDS MAINTAINED AT
PITAL OR MEDICAL 'ACILITY
SSNIID NO. RELATIONSHIP TO SPONSOR
NSOR'S NAME
WARD NO
iENT'S IDENTIFICATION: (For typed or written entries, give: N first, middle: 10 No or SSAI; Sax; • REGISTER NO. Dote of Birth; Renk/Grad
)1,4-4
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV F-9/1 Prescribed p GSA/ICMR FIRMA 141 CFR) 201-9 202.1
MEDCOM - 5699
DOD 12911

AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF'MEDICAL CARE
MCA!. RECORD1
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE
STATUS DEPART./SERVICE RECORDS MAINTAINED AT
PITAL CR MEDICAL. ACILITY
NSOR'S NAME SSN/I0 NO.

RELATIONSHIP TO SPONSOR .
WARD [V. IENT'S IDENTIFICATION:
REGISTER NO
(For typed or written entries, give: Name - last, first, middle; ID AO or SSN; Sex;
Dote of Birth; Renk/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-$7)
enloCrlbed by GSA/ICMR FIRMA (41.CFR) 201-9.202.1
MEDCOM -5700
DOD 12912

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STA OARD: FORM 600 (REV. 6.9)1 BACK M EDC 0 M - 5701 usnPaJ,.,•
DOD 12913

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD. CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE_ SYMPTOMS, DIAGNOSIS TREATMENT, TREATING ORGANIZATION (Sign each entry)
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STATUS_DEPART,/SERVICE_ RECORDS MAINTAINED AT
HOSPITAL OR MEDICAL FACILITY _
RELATIONSHIP TO SPONSOR

SPONSOR'S NAME_ SSN/ID NO._
J
REGISTER NO.
(For typed or written entries, give. Name. lest, first, middle, ID No or SSN; Sex; WARD NO Dote of Birth, Rank/Grade)
PATIENT'S IDENTIFICATIONJ
CHRONOLOGICAL RECORD OF MEDICAL CARE
RedtcqI :ROOM STANDARD VoiFtweeg MENA: 6.971 PiefOrip*k*'054/9CIVIEI OMAR:: 11.1 CFI70:440241y,_
USAPA V2 00
MEDCOM - 5702
DOD 12914

AUTHORIZED FOR LOCAL REPRODUCTION :1
-
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
•1
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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STATUS_0 44PART./SERVICE RECORDS MAINTAINED AT
HOSPITAL OR MEDICAL FACILITY
RELATIONSHIP TO SPONSOR 'For typed or written entries, gore Name -last, first, middle. ID No or SSN; Sex; REGISTER NO WARD NO
SPONSOR S NAME SSN/ID NO.
PATIENT S IDENTIFICATION_
Date ol Birth, Rank/Grade I
MEDCOM - 5703
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV 6 97)
Prescribed by GSA/ICMR
FIRM R 4,,r„F40 ii4),4*gp 2 - 1_

USAPA V200
DOD 12915

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MEDCOM - 5704
USAPA v2.00
DOD 12916
AUTHOR r ED FOR LOCAL REPRODUCTION
EDICAL RECORD. CHRONGLOGIOALRECORD-,OF-mettemicARE

04WAIIKANirdizifgen.46.,

PITAL-OR MEDICAL FACILITY
NSOR'S NAME
RI, typed or written entries, give: Name - lest, first, middle; ID No or SSA ,: Sex;
'ENT JOENTIFICATION;
Date of Birth; Rank/Credo.'

CHRONOLOGICAL RECORD OF MEDICAL CARE . Mei:lice! Record STANDARD FORA 660 1REY. 6-97)
Proictlbed by EISAI1CMR FIRMR141 cm) 201 -9; 202A
MEDCOM - 5705

DOD 12917

AMOR ED fttft LOOM: REPRODUCT1014
CHRONOLOGICAL RECORD OF MEDICAL CARE
NG ORGANIZATION (Sign each entry)
PTOMS, DIAGNOSIS, TREATMENT, TREAT.
Y
(A) ;
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RECORDS MAINTAINED AlDEPART./SERVICE
STATUSPITAL OR MEDICAL FACILITY
RELATIONSHIP TO SPONSOR NSOR'S NAME SSNIID NO.•
WARP NOREGISTER NO.
IFor typed or written entlles, give: Name -last, first, middle; ID No or SSW; Sex;
IENT'S IDENTIFICATION .
Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record NM ID FORM' 600 IREV 11.971
Presq.dbed by GSA/10AR FIRM 444 CFRI 201-9102.1
MEDCOM - 5706
DOD 12918
HORID FOR LOC7L REPRODJCTK___
MED1C L CARE
CHRONOLOGICAL RECCR
RECORD
DATE
J

f
I'ITAL OR MEDICAL FACILITY
SSN/IONQ.
NSORS NAME WARC. NO.
written entie* give: Neme - loot, first, middle: 10 No or $SN; Sex: lENT'S IDENTIFICATION (Fo typed of
Dote of Birth; Rank/Otadel
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 IREV. ii-sal p,..ciibod by GSA,ICMR FIRMR 41 CFR) 70.1.9.2O2-1
MEDCOM - 5707
DOD 12919

D FOR LOCAL REPRODUCTIONAUT..
CHRONOLOGICAL RECORD,OFSEDICAL.CARE
:D1CAL RECORD
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SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Si
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MEDCOM - 5708
DOD 12920

:CHRONOLOGICAL RECORD MEDICAL CARE RECORD (Sign each entry)SYMPTOMS, DIAGNOSIS., TREATMENT, TREATING ORGANIZATION
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RELATIONSHIP TOSPONSOR .--......
NSOR'S NAME WARStNO.
(For typed or written entries, give: Name - last, first, middle; ID No or SSA); Sex;
(ENT'S IDENTIFICATION:
Dare of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE Record
STANDARD FORM' 600 (REV. 6-97 )
Rf(*.tikied by GSAIICMR
FIRMRA41 CFR) 201-9.202-1
MEDCOM -5709
DOD 12921
'• • ,J•••J AIIIHORdED FOR LOCAL REPRODUCTION
EDICAL RECORD 1 tiinoNoLtAtiomitttio004*-',0tOoMmAav
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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MEDCOM - 5710
DOD 12922

MigijMr7
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Alelarre Wif'
(C I re tligre
: PAT_ IENT'S IDENTIFICATION (For typed or written entries give. Name--last. On middle; STER NO. I WARD NO. Slide; rank; rate: hospital or midleal facility)
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77) Restyeed by GSA/ONE. FIRMR(41CFR)201-45 505
509.111
MEDCOM - 5711
DOD 12923

STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM - 5712
DOD 12924
AUTHORIZED FOR LOCAL REPRODUCTIO
PROGRESS NOTES
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b)(0)4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV 5-99)
Prescribed by GSNICMR FPMR (41 CFR) 101-11 203(1:4(101
M EDCOM - 5713
DOD 12925

rt (b)(6)-2 rS.4 C DS 11)•sc, —44-rc 1.) Z- .54
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DOD 12926

MEDCOM - 5715
DOD 12927
DATE NOTES
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MEDCOM - 5716
DOD 12928

AUTHORIZED FOR LOCAL REPRODUCT101
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME
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DEPART /SERVICE HOSPITAL OR MEDICAL FACILITY
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STANDARD FORM 509 (REV. 3.19)
Prescribed by GSAIICMR FPMR (41 CFR)101.11 203(b)(10)
MEDCOM -571 7
DOD 12929

0'
NOTES
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STANDAROFONNI 509 (Ray. 5.99) BACI
DOD 12930

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''kUTHORIZEO'FOR LOCAL REPRODUCTION
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:DATE
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DEPART./SERVICE
(WARD NO.
_ REGISTER NO.
For typed or written entnes, give: Name - last, first, middle;
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• ''''""; Sex; Date of Birth; Rank/Grade,
(b)(6)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV 5-99) Prescribed by GSNICMR FPMR (41 CFR) 101-11 203(b)(10)
a
MEDCOM - 5719
DOD 12931

MEDICAL RECORD PROGRESS NOTES
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PROGRESS NOTES
STANDARD FORM 500 (Roo. 11-77) Presca:od by GS.VIDIA.
FIRMR(41 CFR)2 0 1.4 5.5 0 5
509.1 11
M EDCOM - 5720
DOD 12932
PROGRESS NOTES
DATE

fle/a/fJZ?/(1,7i) - -JAJ (
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*U .S . GPO: 1995-397-405
M E DCOM - 5721
DOD 12933
PROGRESS NOTES I% • J,
DATE i 1 1: •• 11131.L Al
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5tA DARCY FORM 509 BACK (Rev. 11-77)
MEDCOM - 5722
DOD 12934

OdRESS.NOTES
OttAtoitE0o:
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PATIENTS IDENTIFICATION 170',6*4*vrirtikiiiritesglii''Niinie*.s flisr::.iniiidk. REGISTER NO.
PROGRESS NOTES
STANDARD FORM 500 (Rev. 11-77)
Proaibed by GSA/INA.
;b)(8)-4 FIRMR(41CFR)201-45 505
509-111

MEDCOM - 5723
DOD 12935

MEDICAL RECORD
DATEJ1
kir.4
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4,6)(8)-2
2bc (Continue on reverse side)
PATIENTS IDENTIFICATION (For typed or written entries Ow Narne—lea4_middle; REGISTER NO.
gnaw rank• rote; hospital or medical facility)

PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77) Prescribed by GUAM. FIRMR(41CFR)2 OS. 45 505
509.1 1
J
MEDCOM - 5724
.
•J

DOD 12936

DATE NOTES
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MEDCOM -5725.
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DOD 12937

II • . a
ALAHORIZED FOR LOCAL REPRODUCTIOI
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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LAST. 'FIRST.
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DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle: ID No or SSN: Sex, Date of Ebrth; Rank/Gradel REGISTER NO. WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REv 5.99)


Prescribed by GSNICMR FPMR (41 CFR) 101.11 203(b)(10)
MEDCOM - 5726
DOD 12938

PROGRESS NOTES
MEDICAL RECORD
(Continue on reverse Sit*
PATIENTS IDENTFICATION (For typed or written entries Name—las; first. REGISTER NO. rode: rank rate; hospital or medical facility)
b)(8)-4
PROGRESS NOTES
STANDARD FORM SOB (Rev. 11-77)
Prescribed by CSA/ICIAR,
FIRMR(41CFR)201.45.505
509.111
MEDCOM - 5727
DOD 12939

PROGRESS NOTES
DATE
pis I5f4., -71 . %.L.4jaP
t-c-rfrf_id. IQ 2,4p.PAK_ pie(.n x:hctO
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' STANDARD FORM 509 BACK (Rev. 11-77)
13)(6)-4
S
MEDCOM - 5728
DOD 12940

PROGRESS NOTES
DATE
JZSitheit o S 1 Or
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-..) V '`Jc vie" "-c-C/C,1-teJvlJil)v-l&A-tn. fbiiJl'
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1J.S.G.P.D.: 1966.491..248/20616
MEDCOM - 5729
DOD 12941
lb

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MEDICAL RECORD pflogREOpiNOTE4.
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(Continue on reverse Side)
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last first, saddle: REGISTER Np. WARD NO.
I
grade: rank rare; hospital or medical faeilityl

PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
(bX8)-4 Presaited by GSVICIAR.
FIRN119(41CFR)201 .45.505
509.111
•JMEDCOM - 5730

DOD 12942

PROGRESS NOTES
DATE
//, '
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AS(AA/ .,eek;
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6)(6)-2
ArnJAHU FORM 509 BACK (Rev. 1 -7 7)
* U.S. GPO: 1995-397-405
MEDCOM - 5731
DOD 12943

NOTES
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MEDCOM - 5732
DOD 12944

AUTHORIZED FOR LOCAL REPRODUCTIO.
MEDICAL RECORD I PROGRESS NOTES
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ATIENT'S IDENTIFICATION: (For typed or written entr es, give: Name - lest, first, middle; J'REGISTER NO. (0 No or SSN; Sex; Dote of Birth; FlenitIGradel
:14(13)-4
PR9GRESS`,NOTES
. .
STANDARD FORM 509 (REV 5-99)
ProtcnOedPy .GS1349MR:PMR . ,t4t_203tb4(10)
MEDCOM - 5733
DOD 12945

J
PROGRESS NOTES
DATE
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STANDARD FORM 509 BACK (Rev. 11-77)
*U.S. GPO:1995-397-405
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M EDCOM - 5734
w
DOD 12946

PROGRESS NOTES
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uo-p , P-l3(c_c_ -I-JI
i
grade Part rate: hospital Dr medical facility)
p ' r". 16DOC Lr

PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescribed by CSA/OR.
FIRMR(4 I CFR)201•45.505

509.111
MEDCOM - 5735
DOD 12947

• ,/" •

NOTES
DATE
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MEDCOM - 5736
II-• S
DOD 12948

AUTHORIZED FOR LOCAL REPRODUCTIO.
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b)(6)-4
PROGRESS. NOTES Medical Record
STANDARD FORM 509 (REV 3.99)
Prescribed by GSNICSAR FPMR (41 CFR) wl.lf 203(b)(10)
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MEDCOM - 5737
DOD 12949

096Z I, 000

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MEDCOM - 5739 %id
a
DOD 12951

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MEDICAL RECORD PROGRESS NOTES DATE NOTES
AUTHOR4TO FOR LOCAL REPRODUCT
PI 3

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RELATIONSHIP TO SPONSOR l'S 10 NUMBER
DEPART.ISERVICE (HOSPITAL OR MEDICAL FACILITY
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; 'REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES
Medical Record STANDARD FORM 509 (REV 5-99)
Prase/Irma by GSNICMR FPMR ( 41 CFR) 101-1 1.203(b)(10)
DOD 12952

STANDARD FORM 509 (REV. 5.99) top
Printed on Recycled Paper
MEDCOM - 5741
4110P
DOD 12953
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DATE
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MEDCOM - 5742
DOD 12954

996Z I. 000

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PATIENT NAME: ba6)-4
BP ARTERIAL
I UI' CUFF I rAy5:J,J•
T MAP rict.
TEMPERATtIll
PULSE
RESPIRATION
11.11,SE OXIME

PAIN (0 — 10)
• ­f7_•
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Page 2 o 1 4
MEDCOM - 5744

DOD 12956

•_b)(8)-4 MEDICAL RECORD - ICU E.
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PATIENT ASSESSMENT DATA' ' EW OF S. S
I DATE:

NEUROLOGICAL
Alert and Oriemcd to lime, place and name;
Responds appropriately; Communication is -n m JI

1
adequate to express needs; Pupils equal and
reactive to light.
C'ARDIOYASCULAR
Age appropriate Rate, Rhythm, and Pulses;
I1
Capillary refill 3 sec; No dependent' edetna.
Nailbeds and Illness membranes pink. No •
calf tenderness. Pressure monitoring

PULMONARY
Respirations within normal limits for age;
------. I
Breath sounds quiet and regular; Depth is
regular; No dyspneas No cough; Suction;
Secretions; Oxygen; Err; Trach

I
Abdomen son and lion-distended; Bowel
sun lids ;wive in all quadrants; No difficulty
I swallowing; No abdominal pain;

chewing a r
Frequency and type of stool; No diarrhea;
No constipation; Nn N/V; NG Tube
placement; Type of secretions

__.
(;.t . .
I
Vanliag; Catheters; Urine clear yellow/nmbe
No Orion, disc barge, frequency, urgency,

nun u ria
1
M USCULOSKELETAL:
Normal muscle mass and development Ion
age; No deformities; No assistive devices

needed; Normal movement and font;
Normal active R0111 without pain; No joint
swelling, tenderness, weakness, or
pa !Toth esi a

SKIN
Color; Warm; dry; intact; Turgor; No
lVotinds; lesions; rashes, inflammation,
ulcers, breaks in skin; No redness, blanching,
irritation,

Over hony prominences; Mucous
membranes moist; Wounds— location,
condition, drainage, dressing

_____...____.
i
! P.AIN
No complaints of pain/disconifort;
I Note Location; Duration; Intensity

PSYC. IlOS OC IA I,:
lle.haviot• is appropriate to the situation;
I A-m(1 D
s
Anxiety is controlled or mild and
appropriate to the situation; interacts

eoh-4 k,q3.1-414
appropriately with others .
hvems
rack IdeV
(A) IJ
04-ey •r-l-ss
Page 4 o 4
M EDCOM - 5745
DOD 12957
MbL L RECORD- ICU FLO•SHEE1

_
sjciiOrI - PATIENT. ASSESSMENT DATA PA I LEN I, NAMI.
b)(6)-4
:: : :::::. 1.;;1',,;..:,; -i(;•;..:.i:: ,, : ' '.' '.:... . ::..6
IV"..SITiAiSSiSSMOiTy..,:i':'1H.•.. -,,.....;1,,?4,NYRit,, ,.::-4p::;Zi2. n.,;,.,:::...;:::/Vil, ;.:: .i,7. .- .:'. .-9 . k,EGIN.DL.:WMJ: ,-.
-j r.StafTiFIRgSS15.1yEL: '_Tgij%fifialiAliiNiNtiIi.16TION
i.,, .E13-iiigiqiife.,iii,:i;i4. _if 5`1r _ -•:C4tEN112..AL.LINE • • ':,...;_. :-.. ;: : :::: .f . •. , .!: :::".-• :;';;;;X:••.....,-,.: , .:156:::',.._:45,$;......i'l::;-.`,....•;:;17.,N.L..-:... _•,-....,:,:_..,: ..,:. .i.... :_ :
i,ocATION LOCATION •CONDITION
IV SITE #1 IV SITE #
IV SITE #2
IV SITE # 3 -J- IV -STE #3_._.
TIME INITIALS TIME INITIALS
IV PATENCY CHECKED IV PATEI4Ci' CHECKED
IV SITE CARE PROVIDED -­ IV SITE CARE PROVIDED
Iv TUBING CHANGED IV TUBING CHANGED
COMMENTS: COMMENTS:

AM STRIP
SECTION Di- SHIFT NOTES
Page 3 of 4
MEDCOM -5746
DOD 12958
b)(6)-4
zwit ,EIV lg:
RP -CUFF
•!PVLSE RES 01.11ATEONS. PULSE OXIMETER
CVP
02 NI:E'P140•0 VENT SETTI'iGS:
• FIO2
0111441A V ---, Ventitalor TC = Traeh collar tiliyatOfieripk IS = Incentive spiromeier
130
TOTAW:
Page 1 of 4
M EDCOM - 5747

DOD 12959

..... kOION
;,POT,'W.4.4**00,0#400tt0t044 .244 10_'.
lt,.00DENtD..I -
r#.11NOtTIWED. • ':O4..*OENTVOL,10E •
.
,J
LOCATION. CONDITION. 'LOCATION CONDITION
, IVSITE # . IV SITE # 1 .
IV sme # 2 _ IV SITE # 2
IV SITE # 3 IV SITE # 3

.
TIME
TIME.INITIALS INITIALS
IV PATENCY CHEONEO . IV PATENCY CHEOMP .
IV SITE GARE PROVIDED IV SITE GALE PROVIDED
IV TUI3INOCHANGED tv TItISING CHANGED .
COMMENTS: COMMENTS: .

A M STRIP
PM STRIP
,..agea0fif-teStirt. No7n
.,..
..---zo...,....-,:.90i: 4,,,,,. .:,..cy.4:-..o9,4-44-46lPiil .-
,L______?.., . • i- -, -l:,,,,,44' if.,.,:„,
bX13)-2
) '244444,4 _LI Z 444, i•e;461 ' 4114:›4*.-4-,to Ted Q. 1_ '''W_ 4.441844ce. 44 Pe -?'r' , 0
bX6)-2
.4-15a ,.4,,,,,mee. 0. .Z:7'7 107- of a4P:444-* i iviiti (9e.e..ce
,1,2:3(3 „adi 'F.7 ,,,,,„0,‘‘,0-a..A. 4a,bil ,,Is 4a7.14elk11:0 r4.4e Gawoer-44-6 Er .1-4,o
T.
J
4-rr rar.‘4, (toPo l3ito.v6 f T el,.//d rvi? s b8 J
:003)-2l
,."--ie„,17-)op 3 -SO E c
.41/n140*st, .i.kpa 140-l
30 ?r cl04w •riv e,ce
t
Page 3 of 4
MEDCOM - 5748
DOD 12960

.no.1
••J •
pkI.A , rmaa.r.ozmiTo,c11.4 ,4IMAM7i.W7 , .PTT WA, MO'MA-
PATIENT NAME:
.
1
)(6)-2NEUROLOGICAL TIME: 0.45.50_INITIALfb 1TMEt INMALE: I Alert and Oriented to time, place and name; Responds appropriately; Communication Is A.1-tkU4 3 ,JpJ ,,4 adequate to express needs; Pupils equal and '_`-`--_?_
(2-/-1,4,--/-me.tiffrA.; tt4fr..X.L._7_R-Pi2;vyt*.re ,--4i-17404:40Sresctive lo light.
. ryk 6444,4Or AD' .. .
.1 .'.--.':44't.e.s'
CARDIOVASCULAR
Age appropriate Rate, Rhythm and P 1.1!FAL, -_._'_-_-•
Capillary refill 3'40; NO crelfinkfniiiiiidenIA: 42, ?ue-S i-j x y -,e,•:p f.,-pr-frig
Nailbeds and mucous membrane i pink. No
calf tenderness. Pressure mOiatiiii,fig ii_.

PULMONARY
Respirationa within normal Unnwforlige; ? 4.11-10-C_C7741_, z• ..?. t/ hia-t,t,
Breath sounds quiet and 11-gtil.ai,i POISlyia ,:i :,..1,7 .„:0,.eJi.4,00,,..,,,J

.4 . 4_7,, ,.. ,,ii,
regular; No dyspnein,Natongin,Suotiont -_-_' _'_"
Secretions; Oxygen; ETT; Trach

. a (9di;4 012. Joe
-4
..J...
Cl :So ,L_ .7— ,rtt.,.:?4,..g .,, gs-, -4-zi
Abdomen soft and nondlstended: Bowel ',f71_'_, ,
sounds active In ail quadrants; No difficuk ••:./ ki")+, vJ,. it..,3 *

79 /1..o.pre,&?
chewing or swallowing; No ntwitottilitalitailtr bi,12.‘ ' ‘...j.kz.,..r.-7,
Frequency and type Q f stook N0 dfiariliOnt .. '_,_'' -_'' " "-_--'''_:'''''' 77;_"7:1;:"."!'",-.7-r--• ,::_••••-.,_-•_,_-,
No constipation; No NA4 1 NG Tube_:-: ',k3 ...e 41-7 -:-: :-4Ve::": j;''.71_/./i.%: •

.J-;iv7944.4!.. ,.J...• ' '. 'J.:J•J:J. .':, J.
placement Type of secretions _
"444.-37a., .r:44.:,...,.„,:.: ..':1-'1.::•:::'',!' . '.' -
,,,,,,,,,..if.....---.?-; ,:,.,:''"-''' ,, --:::',--'
, ._...,
G.U..
_a1.4ya--7.J' ,..4.4,,94.4.4,7:, ; •
._.r i-e-4-'‘,. 2 . -7-
Voiding; Catheters; Urine clear yellowiambei /_.,
No odor, discharge, frequency, urgency,

-J-i' , RP_i-V Z.. I...).0 AI /,-..---6
nocturia

7-0V ._P ( c_
,i+ 12-7-1,44.407-/V6 a_?"4
MUSCULOSKELETAL:
Normal muscle mass and development for 46vi.4-PE T Aitt/1" ,., 4-14!.:0;, ...: ..

. . . .
age; No deformities; No assistive dcviccs
4,.., 0,,,,r714 pri•-o,-/_712_0 lc,:A44.. ,1: 2.0.4, :i
needed; Normal movement end tone;
Normal active ROM without pain; No joint 4,A4.4.64S f..-_QQ-4.,
swelling, tenderness, weakness, or
pa resthesia

SKIN f.:1- lc, -0_rt _4.-1;D
Color: warm; dry; intact; Turgor; No

54 61ZAL a t c:t..n3 i3-4--C ,t La_ 67
Wounds; lesions; rashes, inflaminsitto4
ulcers, breaks in skin; No redness, otophing; 4643,-4 ‘1.74,5 (3,.z' 0
irritation, pver bony prominences kiltOU3 A.4, c

xts 0_G .(.4c 0 7.-v..-0.ac7 La kJ
membranes moist; Wounds- Iiiiiiiiiin.
condition, drainage, dreuirg 17-7e-t-4.-1- -S R2A-fr.ay_,60.4ere4100...4-Atm
k2N 5.41,,.empel AA/ oc),..*e. i ?re
A,'J•J,• "'J-'J•-'J•1.........,W..,-oi.e...1:4:::

1_ PA:k.i. tfi.) ".:c2.4.-,:ird/YM;::#:! .
No complaints of Pilniclisanntorti ,• i
Note Locatitiiivrintitklit; Intensity -r--19 p 6.444€

LiA:c,iad„Jp et
,)2 Pt-.1740, ir--7-15.6.141-4k, 4-i4vi cif-0_
PSYCHOSOCIAL: C. °/144'r''''-&.;
• •;.,_•.-
Behavior is appropriate to the situation; . vAt-i Li • ? ii • ' ' ;44i;:/;,:, :c;1,7i,:t6_ ' T. -
Anxiety is controlled or mild and
appropriate to the situation; Interact's _, ir,dizna,„4,97-4 ._,•-_._ad7ii,f„t- : it.4--ri*.7•ArS_._';_._: ,.•
appropriately with others

-LA.A6a• .
Page 4 of 4
MEDCOM -5749
DOD 12961

MEDICAL RECORD - ICU FLU SHEET SECTION I - PATIENT ASSESSKENT DATA -
PA•l'IENTi NAME:
DATE:
.__..`DIME: :FI .D
HP-ARTERIAL LINE, •;. - ' ••

I. flP C 0 frE_ II. ..
'... _..
MAP .'

A
TEMPERATURE • ••
PULSE
S
RESPIRATiONS•
J
I-;
PULSE oxivirrER
I 6
CVL'
S
PAIN (0 10)..
. ,
( VG N
02 METHOD
V ENTSETTWa..
M.()I)E
RATE
Pli:111P
. PS :
Respiratory Treatmejits
J.

I

24 HOUR I & 0:_TOTAL IN _
TOTAL OUT

TIME:
000 ja211) 0100 O13() 69 0
4+146
600
I.
PO
TOTALS
ID 0 12.4,
URINE_• ()
ji? t5 .5
_1-1) QS° 0

e,pAyuci.)-3 0
betsoic-v4J
STOOL
T()T ALS

I_t
Page 2 ofti

MEDCOM - 5750
DOD 12962

4 ,
11,-118
MEDtCAL RECORD
It+

HOSPITAL:DAY
• ,-••
POST-J DAY :••
19 PULSE TEMP. C
(0) J•J40.6' 180J104 ° 40.0 ° 170J103 ° 39.4" 160J102 ° 38.9° 150J101 ° 38.3•
140J100° 37.8° J .......
130 99 ° 37.2" J 98.6 ° • ... v 37.0"
• • v, v • • y
120 98° 36.7"
• •_...... • •J....._• 110 97 ° 36.3."
100J96 ° 35.6"
: Q 43 :
F 0:
90J95" 35.0'
a
80
•A •
70 : A
60

50
40

4
RESPIRATION RECORD
I I
L
0 BLOOD PRESSURE Ps 13 1 trla
s 'EA 111 ty,
4 4, qk
0
1101" Wi I-9 I
.
HEIGHT: WEICHT
3 jt 37 IYLt1 YUJ WI 0(6
0
VRk
IR% f
Ca
CC
co
0
)TIENT'S IDENTIFICATION (For typed or wri ten entries gilw Name—last, (rst, middle; ID No. (SSN or_REGISTER NO WARD NO.
other);hospital or medical facility)

VITAL SIGNS RECORDS Medical Record
STANDARD FORM SU (REV. 7-95)
Prescribed by GSMCMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 5751
(Centigrade Equivalents, for Reference only)
DOD 12963

OATE
TcO0174_ HMAS_ -
HOURSTO —
PATitNTINTAiE AND OUTPUT WORIbliEiti74 ._. TWENTY -FOUR 1-iOUR 114TAKE
INTRAVENOU S
ACCUM
AMOUNT i TIME_
I TOTAL
—TYPE
I RECO COMPL
ORAL
TIME (Include ltierlicatinns)
AMOUNT
ACCUM
J
STARTED
i AMOUNT TOTAL_ / 3_
rePEJ
1-
1 I ME
'3-6
e:CL.)_ ;
(NIG. Bladder, etc.)
IRRIGATIONS
ik-6
AMOUNT OTAL
IME_
t--
BLOOD/BLOOD DERIVATIVES OTHER INTAKE
.
---_—_—_—_—__ --r, ACCUMULATIVE ; 'ME , AMOUNT ' ACCUM AMOUNT ;_TOTAL
PRODUCT (1.e. 13-77 TOT2k1-
TIME ; cm/ ; COMPL 1_ __ TYPE.
/I /b. I'. cells,
STARTED_
¦
i_
, •
———
GRAND TOTAL INTAKE USAPPC V 1 CO

MEDCOM - 5752
DOD 12964

URINE CINITPUN TIMEJAMOUNT I ACCUIKTOTAL ' TIMEJAMOUNT ACCUM TOTAL AMOUNT b Jc TYPEJLTJ . ACC UM TOTAL 5 —
1_

-
1 1-
-

-4-
(.4,10rek or-L'e._ -*Herr
rimE_
AMO JNT ; EMESIS
ACCUM TOTALJTIMEJ
AMOUNT ACCUM TOTAL
TIME AMOUNTJ
L,J/6 TYPE ACCUM TOTAL
6213(tft'S
COLORJ
I CHARACTER
AMOUNT ACCUM TOTAL
2.2-0 iz) —fa.T.,64C-R-ettrpOT-
TIME
.LiL7c
ACCUM TOTAL
NT--1—
_
REMARKS
GRAND TOTAL OUTPUT
.
.
err,/ !Ted rir

PA TIEN T'S IONTIFICA TIC* • _ _ _
/, (IWO l
tpilo/ Uno-ies give: •Van, lart,12r.n.
1.1/1,141 II fiteliql.)
INTAKE EQUIVALENTS
(Serving levels ce I
MEDICINE GLASS
.90 . 30 SMALL FRUIT CUP
HALF PINT MILK .......

..... 120 240 COFFEE CUP ..... 180 LARGE SOUP BOWLJ
240 LARGE COFFEE MUG
LARGE WATER
GLASS ... 240 PLAS TIC OR PAPER
.... 180
792, JAN 74 JUICE CONTAINER ...J
180
EUMCN OF 1
1 JUL 72 WHICH MAY BE USEO.

SEP 54 14 08SOLETE, REPLACE-4 OA FORM 3449(TEMP)
USAPPC v op
MEDCOM - 5753
DOD 12965
996Z
179/9 - INOOCIMAI
(dwIDettt aemva tanyi.aaki aloft) slot
'o3sn ae Aviv s-fotHm
LONNINO0 3Ohlr d§s rir
N3dVd Jo Nottiaa
OLLSV-IN• • • ssno Ninthi 091 ' ' ' • Drill 39dd00 9Daibl
. OPZ • • 1M09
Ok? anos 3DerjJ
drio 33.id03
""" 3111by OZ1 • • • ' .1110 .unaJ 'MINSOC /1 S51,10 3N10103iN
(.3.3 S)A,ra)
!A.:as)
S.I.N3lvtonta
.J .J
. 351v.J.N)
WV/ •
infIVA . l
Yal-InG, l r,d4
-__
,---­
1n 0 1 _
0l. ciNvno
i
cy/
. L
----0
-7--hJ 1 ivi01 Ilinoov
¦
t Ced12 I
1Nnovvv l
3W11J t
-12(2-1,9d-1110-1V-2N-1-0 .i .-J
J -----).__
ivlo.1 vvnoov I INnontr 1 61310VNYH3 I
(
6
nJo-G 1 ----
1,001'ileje
:ft/.1.01 vu.now
oJ
3iviiJ vvnov
-e.-76):, •
OUTPt/T NE (lilts f-tymq.URINE TIME_I AMOUNT_ACCUM TOTAL TIME AMOUNT ACCUM TOTAL
0i8_LifsocLk goo
_jr -613 I 23-0 I /CD 51) 22 !IED I /2-00
!4ç
I
!
-f
i
1 _
scow 031c, _ALEy-e,Hest.,
TIME_AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL
()% SI%
Z6 JO 0 .3 C) --0.-66 •/e) sc; a
j2 KV TIME.I.COLOR CHARACTER AMOUNT ACCUM TOTAL 1
ill cc
400 kBLOp_(l_
JD NL1_ 0

.466 3 )-1-1---
1 dp,
REMARKS
•PATIENTS IDENTIFICATION, (Fcrt;;;; orivI./urn entries grltre: Name first, middle:
grade.' dine: hospital dr medical facifirp)
1,900-4

;NASOGASTRIC.
;.,,.. ,, ,, .
-...,..._._.
TIME AMOUNT TYPE ACCUM TOTAL
Om iOc Liu., [37. I C E--_ " . if
01430 3tc, 13
,,99-ur, ,;1/2-1) 61.,
-Sc., p:ERimlEMESIS
TIME AMOUNT _ TYPE_ ACCUM TOTAL
. 0
@O LIW_0(23(.. )
'
/Jt1-6 / ZO. t a-3 o o

70 413:r_t_,
.v•o0 41,4,
r 40
::: 3' 'pi) Lp../ OTHER OUTPUT
TIME AMOUNT TYPE.I ACCUM TOTAL
--1

--giF=ISV1 —
3 qg 4 C 40G2—e0tr i
frAct) I /lb J
d As'

GRAND TOTAL OUTPUT
...._.............. .... ..._
TM( EQUIVALENTS (Serving (eve is cc.)
NEDICNE GLASS (/ l.. 30 HALF PINT MILK 240 SMALL FRUIT CUP 120 URGE SOUP BOWL .. 240 COFFEE CUP 180 URGE WATER GLASS . 740 LARGE COFFEE M UG.. 180 PLASTIC OR PAPER
JUICE CONTAINER 180
OD FORM 792, JAN 74 EDITION OF 1 SEP 54 IS OISSOLETE. REPLACES CIA FORM 383017EMP.1
1 JUL 72 WHICH MAY SE USED.
MEDCOM - 5755
DOD 12967

60:_/5-70. ••7.c..f.7. 1
4V­
.b,cf-ti;iii.eam_. r570 sof. • 6t)JI p-7
wLgOlovje. 1,2—&--11 1D (I_U
,J 4J
1J ,_
.J
1
KO
i
)
IRRIGATIONS (NIG, Bladder. eic.)

------).— ACCtiMUUTTivi'
TIME TYPE AMOUNT TOTAL
—J— ........_
I
Jr_

_ J1 J 1
t----_.J... —
I
7
7J.
1
—4— _i •
4-1
1
t.
BLOODIOLOOD DERIVATIVES
--i --- --- -- -- - - —

TIMEJPRODUCT (i.e. Bl, TIME
COMPL fAMOUNT
JTOTAL
ARTED .1/b, P. cells an) —r—J
ACCUMULATIVE
AMOUNT
TIME TYPE TOTAL
FJ
GRAND TOTAL INTAKE
USAPPC Nit .00
.J, MEDCOM - 5756
DOD 12968

..
' ACC uM_
TOTAL_•
---11--IME AMOUNT ACCUM TOTAL TIME AMOUNT l'YPE _ oT
riA.,EJi AMOUNT j ACCUM TOTAL
i
X:00 5- (Dec_ id:a-
r+f0 °_.,af&S-1 _.3547 1`05.-3 -0 ; Cc.,:,.
0 `61)•DJcf00 Y10_
.n.5-() izz
i
..q.-._J0IJ
r,tS. -.
")• Ft- .
,foe..) s ac3 1 Icitcloc,01k.l.Cig— g_35--
_•__J_JJr-1-)6J11-±,), -...5--------,1
• I--
i
_J..._
i-
_ _J..
t t
4,4C-8-T-‹oee._Piwic IOLC
.__
,. ---; ACCUM TOTAL
ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
TIME 1 AMOUNT 1..
060° 30
1
/J1 / otos, OM ._.5 43,5 )0.3 a 6 0
-.J
.. OW. -• inot
E
13Z 40 /- 3 -5.
I-
0/ Li 2, Lc) - 5--r."--
I ,AtrIJ 1 0 U ..l.
¦ STOOLS_kr-) gu61.12...„ j300 -96 S-L.,roSCLAAI,' lt 5
...
CHARACTER AMOUNT ACCUM TOTAL EIT-11ER-ethrPUT Fo LgitTIME COLOR
TIME AMOUNT TYPE ALUM TOTAL
kio 6cri-s,-• iiti4n-f, . " ?c
' )0o 3 Sve, A . 10 (4.). ,„ - . 0 0 Lo .6 taxi 1' 15 I __
GRAND TOTAL OUTPUT
. _._
REMARKS

PATIENT'S IDENTIFICATION (For lypedar v,lUa, entries give: Name - last, first, middle: INTAKE EQUIVALENTS (Serving levels cc Igrade. date: hospital or medical facility)
bi(e+4 NEC4CME GLASS a_.. 30 HALF PINT MILK 240
SMALL FRUIT CUP 120 LARGE SOUP BOWL .. 240 COFFEE CUP 180 LARGE WATER GLASS... 240 LARGE COFFEE MUG. • • • 180 PLASTIC OR PAPER
JUICE CONTAINER . . . . 180
uspePCC.1 7.co
EOrM4 OF I IEP 5415 clot-METE f?EPLAC.0 OA FORM 3630(TEMP)_
DD FORM 792 JAN 74
1 JUL 72 WHICH MAY BE USED.
MEDCOM -5757
DOD 12969


. ' .
DATE
TOTAL lierLAS.1
HOURS! HOURS FROM _J
T-OUR HOUR PATIENT INTAKE.AND•OUTPUTWORKSkET TOJ

— ---------
INTAKE
INTRAVENOUS
ORAL -1JACCUMJ
TIMEJ TYPE TOTALJ
STARTEDJ
TIME 'J
/0 0
.000_01.0Jcw, 47,0_
TIME
•• 4;,40
— 4- -
BLOOD/BLOODbERIVi.:*(,,Kk Y '
..:d!,'. '.--,..•VP
-------.--.—.----. J.i40.01 - •

1 TIME •''
TIME ' PRODUCT (i.e. 131.
i COMPL
.1 I 1), P. cells, eic 1 . . --''' ,'?;,,
STARTEDJ
-1..: 'ili',
¦ ,' .' .3•e"P.
,
-1-

I
I,-

i
1
ACCUM
AMOUNT 11MEJ
—TYPE
TOTAL
RECO COMPLJ
(Include Medications)
--_.J•
170 LL 64. LO
L.F.,
IRRIGATIONS (NIG, Bludder. etc.)
ACCUMU
TYPEJ AMOUNT TOTAL
USAPPC V1.00

MEDCOM - 5758
DOD 12970

••• 1 re I I 1•4•I-v./1 t. V
OUTPUT
--------- IF

...... -.• •.-.•.•.•• •.•.-
ME Ji . AMOUNT 1 ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE i ACCUM TOTAL •• . j
,15-01 '1-5— kir.
.
01- ! lbOecl /C) 0,c 006 1 .1--,Jqtw• /o /06 1st, _ei rid IT)
___
-.....................

H
]
.i.

.....
i
i
1
i
6
II-J
r
-6+464-T--.:SUSS4S jp
WIN
UV)))JIC
4E 1 AMOUNT I ACCUM TOTAL I TIME AMOUNT . ACCUM TOTAL TIME AMOUNT TYPE I ACCUM TOTAL
-i— I--._._•_.._•
a i sro o IJ, 23-67-too _5-.24-0s.tx\-% .__./.60
i _
•i h_
i_ -T---
1
L__

-i--
I_1 :uJe.
••• 5.­
-1----
zoix-s L. •J
J—1' FO LEY (1.47. •
EJiJCOLOR I CHARACTER AMOUNT ACCUM TOTALJ G-T44r9R-Qial4M
TIME AMOUNT TYPE ACCUM TOTAL
5-JAmiler-vrirv2, . (925 625J
. °
a? s-ziiJ
-4-

_.._ L __.......J_...
. GRAND TOTAL OUTPUT

_J. ____.
--------- ..... --- - --;-------1,RKS
ENT'S IDENTIFICATION (For typed or written entries give: Name - kW, first, middle;
.; dole. on-pilot Or medico! fiscility)
INTAICE EQUIVALENTS (Serving levels cc)
.J.
MEDICINE GLASS (I or) 30 HALF PINT MILK J240
SMALL FRUIT: CLI....120.LARGE SOUP-BOWL . . •.240 COFFEE CUP . . ..180.LARGE WATER GLASS .. 240
LARGE COFFEE MUG 180_ PLASTIC OR PAPER • .
JUICE CONTAINERJ1E0
FORM 792, JAN 74 EQITION CF 1 SEP 54 IS OSSO.LETE, REPLACES OA FORM 3630(TEMP) USAPPC V1.00.
I JUL 72 WHICH MAY BE USED.
MEDCOM - 5759
DOD 12971

I-.v
TOTAL HOURS_DATE
! FRC HOURS.. C00EREC1 .. .
TWEN Ty-FOUR HOUR PAM . rAKE AND OUTPUT WO
0

-J
_ INTP •
ORAL
TIME
TIME TYPEJi AMOUNT TOTAL STARTED

ovooJ_
i Ho J)10
3,()::J1-h_Dl- r
ao_c2_640__ oqop : 0-2.0 1 (po 13qo
1_ Co
goo ILI.00 -70 IL,
1 , 11-01 i_aQ
.) -)--J--+-
L--­
ta,5 .6 •Sidt•-f_ 2
.1-.C-.`.-6 I. 1rPa (-k.
-1-
La-) ki i° N--)_
.
1010 1 —
! 13.A0
ePSU \.)JSk,a/kJ
IRRIGATIONS (1 11G,

• AMpk.INNI
TYPEJ
TIME 1J
+-
BLOOD/BLOOD DERIVATIVES ACCUM OTHER INTAKE
TIMEJPRODUCT (i. .. BI. i TIMEJAMOUNT
TOTAL r —J
4 Ib. P. cells. elc.) ; COMPL ACCUMUCATIVE
STAR TEDJ
AMOUNT t_
TYPE TOTAL
TIME
;J. \
)
GRAND TOTAL INTAKE
.
USAPPC Vi co
b)(6)-4
MEDCOM - 5760
DOD 12972

_
ACCUM TOTAL
'r.TYPE'
,,,,......:,.....
.J
-Aq-k1m -lp1­
.!...wf.,r„.._otiorp..N,.„,....Fory,
a_0_ _
860 igiai_
olp_0.0._1_.10...,...44..:..:0_'. ...l' il'
-±-
-_•_•
p.y.e0._..t.le • .. a-(L)_ 1
1466?.5..,0.._.,.....4(e_c3,

.._
.. ...
t.A... :: q"., 6
....41_!.1 3t.z)-
I
;_JI......-......--__J,...-
1
-4
i iJ_t 7 J1JI
-ettesT-
ACCUM TOTAL
,S v p rex?lTIME
AMOUNT
ACCUM TOTAL
AMOUNT ACCUM TOTAL ! TIME AMOUN
TIME_
po3o
(o0 (0 .0
oroo.
-
020(1
(409_ SD JID._JI 4 179
5-eAr0 3 •-_
0 I TO I
No ISO g (00 t)
OO ,
ii-tpo ic-too 1 6 5 .i. t -3-0 -), ,-6-0 S-
R-02111\i
R:eci ciE
1 AMOUNT ACC UM TOTAL
j CHARACTER_
COLOR_
T 1ME_
•1J}q_zs t425-
) TC4 . C 1. 1k_
7J1/5-0 535
roto. GC ; C13 _: Moo ..
c-r),J1 1 5-1J(A 0S 1i _,
REMARKS
eniries give: Nome • lost Jim, middle,.
-
PATIENT'S IDENTIFICATION /Fur (vpv// ii'
medical fin31/1.1.9
grade flaw.
)(6)-4
fot.._5...)1
- -6414E.42-014P4T--
I J
ACCUM TOTAL
TYPE
TIME I AMOUNT
ttlaD i0
s--
11° 10
GRAND TOTAL OUTPUT
INTAKE EQUIVALENTS(Serving levels cc i
240
HALF PINT MILK ... .J
.. 30JLARGE SOUP BOwL ..
MEDICINE GLASS fi_
240 .d
SMALL FRUIT cUP _ 120_ LARGE WATER GLASS . 240 -
180_
COFFEE CUP _
PLASTIC OR PAPER
180JJUICE GONTAJNER JLARGE COFFEE MUG . . .
180
USAPPC:
ELATIC44 OF 1 SEP 541$ OeSOLETE. REPLACES CIA FPRM 54Q(TEMP)
DO FORM 792, JAN 74 JUL 72 WHICH MAY BE USED. MEDCOM - 5761
DOD 12973
f
TWENTY-FOUg HOUR PATIENT INTAKE AND OUTPUT WOCIKeHEET IFRO" .""j143

I TO _ HOURS C.0
. •J ----•••-••
• •J
INTAKE
ORAL INTRAVENOUS
C
TIME TYPE I AMOUNT TIME' [ ACUM
AMOUF
TimE_ TYPE_ 1 AMOUNT ! ACC? STARTED (Include Medications) RECO_COMPL_TOTAL
-_
TO TAL
-1 b-7„,o
1-1 -67 3-.6#70a, Lka706c,%.e._1,50 0
613J6
.30 ; loDul tinasilii¦-I ./le:j..06. 0,000)(° C)
4z,1
, 1-/J:..
:JI (.2,)
—t IJ1--
I
—1--J1
I
1
-I-
--11—J-1-J
1--.Jr
IRRIGATIONS (VG, Bladder, 'elc.)
- -r-ACCUMULATNE
TYPE [ AMOUNT
TIMEJ TOTAL

BLOOD/BLOOD DERIVATIVES
f4EJPRODUCT (i.e. RI. TIME ACCUM OTHER INTAKE

AMOUNT
COMPL TOTAL
litED( AI& P. cells, etc.)
ACCUMULATIVE
TIME TYPE AMOUNT_
TOTAL
GRAND TOTAL INTAKE
MEDCOM 5762
-
DOD 12974
.-.!..':,„J',_. . . -•J
::J.:J ',::J.J...:,,.."'
frosfricAit .10.3!r JJ.„J,, DiTh
Tru:kY,e, ' : .',': JP
TIME _ AMOUNT 1 .:AJM TOTAL TIMEJ1 AMOUNT ACCUM TOTAL TIME AMOUNT TYPEJACCUM TOTAL
SrrOr
.1, ¦
. , •—.. I'.fl, 003o 0 w-os Jci 0
•--I
1
1 11. 00. / 0
.:.: _ .........- -......• 25 •_9 2J- 5. _i_ l' -a E6V2461. ).
0 -

b000. cio sznros .v.0
•40P 60(3 ,V--a_7 bul)J14 (5Y1_(_9 a vz coqd 5-0 cicAro 6 a-ii":7 3 3 o
,-..--- .,--
( J
_......J
_ ---=r•
.,..,J. 't 1
f
... .J
.J ,

--.7---J---1-
!J
(
;J4

-4 1-cIiC3T EM -
S Q r rap i/12.1,clFOIC-1
TIMEJ! AMOUNT 1_ ACCUM TOTAL TIMEJ) AMOUNT ) ACCUM TOTAL TIME AMOUNT TYPE
ACCUM TOTAL
1
oi--11..1 . 60 ; ,
........JI

.arJ, -1
9.,..„, i
, r"J..4 --I-

.J.J,../ .
'J..,
.,....,-.
\J
1
—J
1.------
{
. . STOOLS
• RED koJt K)J
/
TIMEJCOLOR JCHARACTER AMOUNT ACCUM TOTAL ..0 Le G-THE-R—Gu-T-Purr„,41-777/
.; .

...___ TIME AMOUNTJTYPEJ..i.i ACCUM TOTAL
I5 ._(,(.75 (77,5---.
61-( figt1J:J.J. i 0& I g 3-0--R-IJcl vA,JClck.J
, • ae-C4A-'-1-
---1
-----7-
,--- ---...-"--.
GRAND TOTAL OUTPUT . .
REMARKS
..J..J_ -...J.
—J .
PATIENTS IDENTIFICATION (Pm-()Ted or mitien entries. give Name -fast. Jim, middle:
grmle ¦ kw bow, fa, or mnbral fitc1110)
INTAKE EQUIVALENTS (Serving levels cd
b)(8)-4
MEDICINE GLASS e / az/ . . JOJHALF F1NT MILK ..J.JNOJ
4
SMALL FRUIT CUP J120JLARGE SOUP BOWLJ240 jr
COFFEE CUP 1 60JLARGE WATER GLASS.. - 24j LARGE COFFEE ROG .. 160JPLASTIC OR PAPERJ? JUICE CONTANER „
DO FORM 792, JAN 74 EDITION QF 1 SEP 64 IS OSSOLETE. REPLACES OA FORM 1630(TEMP)
I JUL 72 WHICH MAY BE USED.
MEDCOM - 5763
^^

^^

DOD 12975

LAB FLOW SHE
t.-).11)J‘74' r
I •-s• ••¦¦ • I .1, Al". )
j.). 7R/ t (VW 7
Date/Time_% 2,_o21Wb 14
a, mistgAgg: .,.;,::::;gc - 4.P,:;;: (.ki.:3•,. Jq-,,ii-J:, JiJi',.4.J•
.::t-:."' •J
-!,24L!-'JNiall-6---'--74J.r=''ItgigiOJ.JSt4k WBC (4.8-10.8) Kik Jal --7-JT.1J7,-3 IJ
. RBC (4.7-6.1) 1X10 6/LIL J3 , /J'7 ,qJ2 , tJt:.3 HGB (14.0-18.0) g/D1 J7,J. (aJitJ.-9 HCT ('..%:;2; 90J'ti .3Jas; i,J2,y. L .J
..J. PLT (150-450) 1x10 3/UL J-.4 S%JZ. J177-C,JSZJ• NEUT%J . 6
taiMM011gAtelMat *VW **50 WMJOM ,..J'7"77-'ILZLj]4i-;'d iteXP
.I 0; MO: OW NOW T-,4 ''1:1?';!'' '"INA+ (137-145) rnmol/LJI VOJiti3 i h
.
K (3.6-5.0) mrnol/LJ3 J---....---. 43. 4J
CL- (97.107) mmol/LJ107JII 2JloJto
CO2 (22-31) mmol/LJ31-J32-J31J33
BUN (9-21) mg/D1JI fJI 2Ji 0J('7
GLUCOSE (76-110) mg/dLJOltJ151J11?J./,
CREAT (0.8-1.5) mg/dLJ-0 ,`IJ0, LiJc.5J0 . Y
CA (8.8-10.4) mg/dL J "7 (LI
PHOSPHORUS (2.5-4.5) mgldlJ
/ 3--URIC ACID (3.3-8.4) mg/dl PROTEIN TOTAL (6.3-8.3) g/dL ALBUMIN (3.5-5.0) g/dL AST (15-46) Lilt LDH (313-618) U/L ALK PHOS (70-250) U/L TRU (1.0-10.5) mgldL GGT (8-78) U/L CK (0-203) UIL MG (1.7-2.2) mg/dlJ
1,6
AMYLASE (30-110) UIL
_IPASE (23-300) UIL
ALT (11-66) U/L
ktralMORAMegaiO Ma NW UMW ..J, 1,f, ,-J....a1.3 :..,_,-4,,1 J,,,Qil,,,y34Jtom ix_1:.: ,„21LL,‘„,,,;:_... i 7,22,,,,n
ti
)CO2
C2
iCO3
1E
•ao2 OideA.4,,SP.6.0agitiagak 4.4414'-e VI Sciatraia VW J0A: ittO g' 14 MAC Wit* g'1r'1-1', 7,-;g1.J;J
"Sig6- , atte misi
0.:'J1
PTT (23.8-35.5) SecondsJ23 . 'J22-D /ASJz/ .1..
T (11.6-14.4) SecondsJ

Il .4iJif. (gJ11.k.Jit. ro
(RJ
IJLrc)J1 , ( '4'''b:'e1g 010.PfMiA.V.141. 'g'S*?X40: #11C.',A9 Ofithb it** WfAt5t: Watt 10** Mige.WSW,{t4:-*; W-vei.0 FROM WO itikettlikkg
MEDCOM -5764
DOD 12976


•••-•
6"" "c, '"_ jg...
f
cnifs,c,R.. SUBJECT TO THE PRIVACY_107,_
A CLINICAL RECORD FORM. lT 1S COVERED eY DD 22r. ANESTHESIA RECORD ANES. END oty,...‘141_,_-
ANES. START— IN OR_Pal( QI aoao 2_0 3 r)OPERATION SURGEON(S)_/_ TOTS_SUNG STARr DRESSING
PERI- ARMED OR NO
FFdr7C
r ( f'; ff L I 20 "CO 7.0SC.)
PREOPERATIVE
z'(-)1$-.J.12°0
IDENTIFIED ai0 5AND DOUESTIONING
T REVIEWED

. NPO SINCE
El PRE-OP MEDICATION. C1 , v9J0010JROulltJTime
Ul-I z mC
_3
NNW
P, a 'AWAKE
A..Insinchc Stele
. „.
• SEDATE
APPREHENSIVE Q UNRESPONSIVE I.' .c
H2O Li _in
, 02 IJrren
MONITORS ANO EQUIPMENT _A

I_1.-rth
re;rES MACHINE —6 EQUIP. CNECK4

gtrall1111•111411di ausratIMIELMINI
ptraiCIN•INV 5,P PNS
.1.1 11110,,
1111111111INIIITX11111111111111111M
EKG VLEAD EKG
SON-¦ STEIN

PRECORO STEM
Urine
A 0 loninaiiiimmommissiamorAmow.
ULSE OXIME TER 2 ANALYZER 'D I
EEL
ENO TIDAL CO2 MASS SPEC. 0
g-TIMPERATURE
S MEC
MINIM11110111111111111¦91111111•11M1111111.111111111111111•111111.•=1.11
0 WARMING BLANKET 0 FLUID WARMER EKG
sammarnrimmurainsaimilallIgidlnintilEfigiv-
AIRWAY HUMIDIFIER J
Yr 02 inspired

L) 7, I•_.o_1.0_I._-0
J N /C TUBE 0 oic TUBE i•_
-1V7s I . 02 Saturation -s'•)(.--'• iv) cs-0 tJ(/ 12 To
0 .l00_it& 4?J' C.,'JL
/
N End Tidal CO2
yuJmay[ z-7 15J-2,1 37J3 7 .0
ARIERIAL LINE Temperature EN 1 rtAi. LINE OFCRA ,
PNS
f:-A....,,eiCNSE11.6E0 0 LOOO V
LOOK
ZE •.,r..1-4 R A
CA
5 on CI.
_V PRESSURE r raRliEggiFA88h8
POSES.
_ 0 J
J0 _ TIME Z6ej_ kJ3 0J2_1=-)13

TT-ART"

t,
H.11.111i ir_frriii_ 1
ANESTHETIC TECHNIQUE PRE-OP
VALUES
_s=G6ERAL S LOCAL /MAC
J REGIONAL NERVE BLOCK
100
2t11
_.1"
_
lif

_
I
/
f
INDUCTION
dPRE OXYGENATION a INHALATION SEOuENCE . INTRAMUSCULAR
}TN TFtAVENOLISJ. RECTAL
AIRWAY MANAGEMENT
T-
INTUBATION_
! 'RAI_NASAL 1 • 5IRECT VISIONJII BLINO AWAKE I FIREROPTIC , 2 ISLET US
P \AT
160 C
V

VONT.
140
11111111111111111111111111111111111111111111 .11111111•11111111111111111111111
L 120
A ItlE111111111RINIMP/PIP1116.swEsimariordmrs
MilasnrAdiaillElliIPE:411MINIMX4J18,12MSMIEMSEPrar IA
irt
2215
;ICS
S "Jj
N ¦11111111E46a191¦1111111111111.RIMINI.ION
5 60 COMM
REO
1111111111111111111WW:WRIMIINIGONSMININNIIVIP..
SAT
ainamenranaminsaememinumninis
40
1311

I

111111 II

, T

) -AT-TEMPTS_0 BLADE ETT SIZE_. DOUBLE LUMEN
20
STRAIGHT ;_RAE
101)001
_. ANODE
It:LIFTED J1.0 _14 AIR INJECTED /H UNCUFFED. LEAKS AT JCM H2O
R Tidal Volume
31: - y
. Crri5
In' SECURED AT
.
E Reap Rata
-BREATH SOUNDS .• 9. /1. iy_/.1. -2-J12-JI)
re ?)
AIRWAY . ORAL NASAL .NATURAL S Peak PresSure
L3.0;
"7-44
MAIN WE_VIA TRACHEOSTOMY
NASAL CANNULA_
SIMPLE 02 MASK Symbols for
LMA SIZE
Remarks
E
Position
BCC
REMARKS : .JPatten' reevaluated. No change from p lop plan / ovelualion. 0_Signdieant eh AVIS (ronlarriopilan / evaluation._ ...„7
RECOVERY
IE IN PACU cOuoirio., 7-2.vi-sj-,4:---
et4.1,:fe eV" e'y' •
1.JQ 24 to
_
PULSE 'REEF
02 SAT
4653081
MARKS TEMP '_24 37_.2+ 5_p RC C.. 114
,
LTG_ ¦;:)_ 4-0
. 4660769 651295 /
Tourniquet Time
PORT TO PARRS: CAV J-raj t7 IS " 11 -2Z
rip)(6)-2
IN_FLUIDS TOTALS OUT FPATENTS IDENTIFICATION
J 'TeXIS)-4
YstallotO• EEL J Urine J
Gastrin
K

---J
J0 0 MEDCOM - 5765J
I r (/'
DOD 12977

[THIS FORM IS SUBJECT TO THE PRIVACY _OF 197A • AS A CLINICAL RECORD FORM. IT IS COVERED BY DO 221 ANES. START IN OR ANES. END
ANESTHESIA RECORD I ,, DATE
OPERATION SURGEON'S) TOTS SURD START DRESSING
0 NO
PERFORMED
rciA,
PREOPERATIVE • ' 1
0 IDENTIF IED 0 ID BAND 0 OUESTIONING 0 CHART REVIEWED . NPO SINCE I ;72 PRE -OP MEDICATION -13_icg. ¦ In -.07-10
D/uo_0.0 ROW*.Time
-27,ff) cif
'
L
' •
P. e Anesinchc StaleJ0JAWAKE I'• CALM_ D SEDATE ::i APPREHENSIVE_D UNRESPO NSIVE --e., .. e 1
N20 Umin 1111111111111111JMIMI MEI MEI MI _.
min WE11111EMINIIIIIIIIIIIIMMIMMIIMIll MI

02_
MONITORS AND EQUIPMENT {
•-i 1
HANE s MACHINE 0 -4 EQUIP. CHECKED
NON•INV B/PJ' ' PNS_ 0 CONT EKG V LEAD EKG Li E SOPS STEIN_PRECORD STETH 8 PuLsE OXIMETER 02 ANALYZER I¦
ENO TOM. CO2 U MASS SPEC.
Eel

:roma(
TEMPERATURE
. WARMING BLANKET . FLUID WARMER
61-III
X
1.0_-15
AHEST.
Q cs'n'fvAY HumfOiFIER . 0/G TUBE IA N i G TUBE
/ VD VD
End Tidal CO2
"3 (.ARTERIAL LINE Temperalurs ¦
OPERA
4 CENTRALLINE
V
.._ SvVAN.DANZ LI F 01. EY INSERTEDJ0 OR_D FLOOR A IJ EYE CARE_ _
'up Cl
0 PRE S SURE POINTS CH 0 / PAD PAM
_L T
0
. TIME
-Arms ANESJETIC\ ECHNIQL
IN
P f I C:-.3
INN VIII
0 GENERA LOCAL I MAC
. REGioNA NERVE BLOCK •
Put :
n
C 5,,Onif . OU5 R
INDUCTION
0 PREOXYGENATIONJ. INHALATION
I
0 RAPID SEQUENCEJSCU
0 INTRAMULAR
n INT RAVENOUS 0 RECTAL lir AsStS
qJ .ES
JAIRWAY MANAGEMENT X
CON IR(
. INTUBATIONJORALJ. NASAL
RES
1111
H DIRE CT vISIONJBLIND_AWAKE
FIBER OPTIC_STYLET USED SAT KO
. ATTEMPTS . _ . eLADE
I
11 ETT SIZE J. 00L/BLE LUMEN

— fOu:r
STRAIGHT_01 RAE_0 ANODE CUFFED_MI AIR INJECTED
I
n UNCUFFED. LEAKS AT_CM H2O
Tidal Volume_• .. ' • e
0 Er TTJSECURED AT_CM
Rasp Rite Cfirs
Ei BREATH SOUNDS / •,--1 AIRWAY 0 ORAL NASAL °NATURAL Peak PfeS5Uf 0 I
,0,0;
33J3
MASK CASE VIA TRACHEOSTOMY L, NASAL CANNULA SIMPLE 02 MASK Sym ols lor
L, E
LMA SIZE RtrrIfill
oicPosition
b
i
RECOVERY REMARKS :_. Patient ',evaluates'. No chino from p cop pion 1 evaluation._C f_3-). 75JG-4--f)28 c._
• . Significant changes torn pniop plan ( evaluation.
I thiE INP CONOITION

/3 c-r-,..c%
0 \U Ld 7/-.J-hJTc_ e.t # -)--J
At-co tA;?•t-ey—,re...-AsA 4•J,J /-1
fl/P _ L PULSE, 1RESP 02 SAT o .57. Azi.
'_ix-375Q _.

CC 7 t ')-
OD
REMARKS TEMP e).-.s4- /ev,c' , 1.)3/3-2 /23, (--;cL. /vii_fir( (_.x. tot

-
• Z(9.11/our nique IJeJ
REPORT TO._ PARRS: . • .5 6, //ditid-..rc/5/--J p-d..A.ove9 60 .4" f I'lJ..

tll
-
0 ,A,,'J:).--J.-L.1)AffIENTS IDENTIFICATION
INJFLUIDS TOTALSJOLT
Dv. EBL_9-6142 • .b)(8)-, 0 .b)(81-4 Wine_/..V.1 Cowie_..._
LC
MEDCOM — 5766
_.
. .._. "
DOD 12978

Doc_nid: 
3561
Doc_type_num: 
72