Medical records of an Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with shrapnel wounds to his chest and buttocks and associated injuries. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.
,-,,.. ,.,,,,.,-.,, run LOCAL
REPRODUCTIO
MEDICAL RECORD PROGRESS NOTES
DATE
NOTES
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.
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER
LAST
FIRST (SSN or Other)
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
II
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle;
REGISTER NO
WARD NO.
ID No or SSIV• Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5)1999)
Jr/
Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(10',
USAPA V1.00
MEDCOM - 23641
DOD-037219
511-119 NSN 7540-00-634-4124
' MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST- DAY
MONTH-YEAR
DAY
19 HOUR
PULSE TEMP. F
(0)
(°) TEMP. C 105°
40.6 °
180
104° °40.0
103° °39.4
160 102°
a)
38.9 °
150 101°
38.3 ° rr
140 100° 37.8°
170 I I
4 •
130 •
99° :98.6°
37.2 °
cr
120 37.0°
98°
36.7 ° -0 Lt!.
110 97°
36.1 °
100 96°
•
• °35.6
•
90 95°
• °35.0
80 C •
70 :0:
•
60
50
40
RESPIRATION RECORD
BLOOD PRESSURE
0
HEIGHT:
WEIGHT --O.
0 1111111111111111111111111111111111111111
111111111 2111111111113__
MINIM
co
co
7.5
co
0
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility) REGISTER NO.
WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 23642
DOD-037220
WardiSectior
REQUESING PiiC
4A/Uc-
JT TO-TEAILSTRY RESULT FORM
LAST, FLRST, MI. (S1111ject to thc ?rivacy At of 1974)
TIME SSN/PSE.L'DO CqGT
€44.74-47s c-f
TEST RESULT I REF. RANGE
TEST I RESULT
?ER TEST Rc:S1_,T1"-
GE
I
Na I r 13E -14-6 namoIlL ALB
8GLU 73-113 rn ,:ttl
LAR PANL-L ;1-E6g I
7-22
DISC LOT #:.
3154AA7 PICCOLO CAT
8.0-10.3 rr..edl
OPER #:8DR #: 000 11:04
08/11/038Cu: 0.6-1.2 ruz/di
SERIAL Pi/ ! REFERENCE RANGE: co(5-40-
NAT 28-145 rr.rr.oli!
8PATIENT #:
ALB 4.0 3.3-5.5 G/DL
3.3-4.7 rt.-r.ril/i
85 BASIC META
U/L
ALP 88* 26-8483325AAI .
8DISC LOT #: 98-108 mrro1/1
U/L DR #: 000 CL
ALT 35 10-47.
8OPER #:
U/L tCO2
AMY 36 14-97818-33 mrr,o1:1
8- SERIAL.
U/L
AST 36 11-388.......................... (Ptcco1o)Liyerpn Plus
_.
TBIL 0.6 0.2-1.6 MG/DL au 112 73-118 MG/DL .
.
U/L MG/DL. TEST
13 5-658RESULT REF. RANGE
GGT 7 7-22.
8BUN.
7.38G/DL 8.0-10.3 MG/DL a.,13
6.4-8.1.
TP - CA++ 9•78r_ 3.3-5.5 gill
0.6-1.2 MG/DL
1.1826-84 ILI
CRE8'r
CHEM GC: OK W
INST GC: OK8NA+ 147* 128-145 WOM-
WOK LT 10-47 till
HEM 2+, LIP 0 , ICT 0 4.5 3.3-4.7
K+8.
CL- 106 98-108 MMOUL
4Y 14-97 till
MMOUL
c tCO2 24 18-33.
11-38 WI
CHEM GC: OK
INST OC: OK80.2-1.6 Cag/d
S.2 HEM 2+, LIP 0 , ICT 0
5-65 till
CI
6.4-8.1 g/.1.1
K'
T 'RESULT REF. W.'GE
:L.
128-145 mmolA
CO2
3.34.7 rm-floVi 98-103 rarao111
18-33 rr..-noLl
REPORTED NV: I DATE:
1 LAB fD NO.: 1
I
1 0
N4-23643
DOD-037221
rckard./Section:
..1
LAST, FIRST,.M1.
eroato
1-
.•.
TEST RESULT
4.8-10.8 z 10' R_BC
::. 10•
Hgb 14-18 r4:10,..f) 12-16 /c11 (i: Hct. 42-52% (M) . 37-47% (1--)
MCV I
80-94 fl•(M) 81-99 11•(1) Plt
Lymph %
Segs
MOM
Bands
Eos
Lymph Baso
Atyp
Imm
RBC
Morph
Spun 42-52% (M)liematocsit 37247°I; (F)
Sed Rate
Other
. • • ¦
TEST 'RESULT_P_EF..-RANGE
I 1 9.8-13.6 secs
17
I i
.A21T 21-34 secs
D &me:-j 20
r
Dp 10 REMARKS: REPORTED BY:
• • - - — .. • I LABORATORY
FORNI
Sub;cct to Ezc Privaci' Ad of 1974)SSNiPS
• !Urinalyses -
, ogy: 5-EST 1 F
REF. R.-LVGE I TEZT I
RESUtT REF. -iNGE
N/A
(--"-‘ 1""r i 57C-6..., RPR ?NG&
A.:;71 -NIA
I Mono Negative (lit.: I N-7-batiVr-
Nfic rob iolo-gy
13ili Negati
I
Ket J Nevive
NC 4
pascioisinUric: . -•••• •-•
.. • Blood.Ba.1c • .--.._.• •
Cell
MUST SUBMIT SF 518 WITH
0:-.Anat
EVERY UNIT REQUESTED
DI rcctlgen Negative
.4BO/R1-t I
= .Blood: Bank Unit 2
-os:switch'
(MUST, uBNut SF:518.WITH: EVERY
Qv BLOOD
ItEQLrESTED)
UNIT
i
TIPE CROSS.L.fiCif
MEDCOM - 23644
DOD-037222
RAPIPPnTmi
SERL
a ) -
Patient ID:111111
Test Name :PT
Test Result:= 15.5 sec.
Ratio = 1.3
Calculated INR = 1.47
Sample Type:citrated wh. blood
Test Date :11/08/03
Test Time :11:01
Card Lot8GYM}
Operator
RAPIDPOINI COAG ANALYZER V4.54 SERIAL #005485 11/08/03 11:04
C6)(6)
Patient ID:111111V
Test Name :APTT
Test Result:. 25.2 sec.
***RESULT OUT OF RANGE*4
Sample Type:citrated wh. blood
Test Date :11/08/03
jest Time :11:02
Card Lot Me C 6)(-6') -2-
Operator
6)(c) Y
08-11-03
1111111111810:50
Patient
Limits
UBC.
11.9 H8x10"3/uL 4.5 10.5
RBC8210"6/uL 6.00
5.4884.00
Hgb8g/dL 18.0
15.7811.0
Hct8I 60.0
49.8835.0
MCV8fl 99.9
90.8880.0
MCH8pg 31.0
28.7827.0
MCHC831.6 L 33.0 37.0
Plt8x10"3/01 150. 450.
231..
LYZ8*L X 20.5 51.1
11.1.
LY18* x10"3/uL 1.2 3.4
1.3.
MEDCOM - 23645
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 LIST TIME
TIME OF ORDER ORDER NOTED AND
fAIOV 63 // HOURS
SIGN
URSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER. TIME OF ORDER . HOURS
PATIENT IDENTIFICATION! NURSING UNIT ROOM NO. DATE OF ORDER. TIME OF ORDER . HOURS
NURSING NIT.ROOM NO..ED NO.
PATIENT IDENTIFICATION
DATE OF ORDER.TIME OF ORDER
. HOURS
776
Nu :(!ROOM NO.
/0 3 @ 0 (60
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA IFArm19 4256
MEDCOM - 23646
DOD-037224
CLINICAL RECORD - DOCTOR'S ORDERS
For
THE use of this form, see AR 40-66, the proponent agencyis
DOCTOR SHALL RECORD DATE,
OTSG
SYSTEM IS USED, WRITE PROBLEM N UMBER IN COLUMN INDICATEDTIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
.
PATIENT IDENTIFICATION
BY ARROW BELOW.
NURSING UNI
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
NURSING UNIT
REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED
MEDCOM - 23647
DOD-037225
THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407; MO. \ (_Yr. 2003 the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING ; ' 'k.i4 . i,' im: gigyarie,-INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
.,S., ..„ .cwisti
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME 4 (6 wc, ---2
.
4-1Q
k)?Pr -RC:CC
6(a5-;-. Alit " \il *-/ . I
cfra •.b;..)-, p_if.....3,\,,--T . %
b2,
RID bc,_5,km id)
au chnyi-(f1-*PvtAitee-tc-,5 77
ALLERGIES:_11.1 YES_ l' _NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: YES_MN NO
Sc-W--PeNEL__ tKvso47--r p. c--t-AE
1\1¦ P\
PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES
( 6)(0-4' USE PENCIL. CIRCLE ACTION TIMES
AM. _
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 - 23648
DOD-037226
M ')
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION )
Mo \\ yr 2003
Order Clerk
Date to Time toDate Nurse Time Done Initials
SINGLE ACTIONS
be Done be Done
Y\ftV t\c\rc-i\ ---b \CW I ( cx-NOvi---vcx\-- S)sci-_c___ (68
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• • 1 • a¦ ¦ ¦•
¦• -
Order'
FapIr
ClerW PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION Date Nurse ACTION, FREQUENCY
(
TIME/DATE COMPLETED 65 10 ON.k-__,\_,fq) AC-I': 44_ _—K..0— •WIL.-(0.9.0
... _ _..... _ ¦1
MO NM
.....
.... ....
=a ¦ ¦•• ¦ ...b .... .... ¦
ow. ¦• .... .... ..... .... .... ¦
USAPA V1.00
MEDCOM - 23649
DOD-037227
CLINICAL RECORD.I THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) .
For use of this form see AR 40-407; I m0. 1 yr. co
the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING
.
.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/.
RECURRING MEDICATIONS,.HR
DATE.NURSE.DATE DISPENSED
DOSE, FREQUENCY
CC )-
IVF—
P5 — 11111 \\/?€39 BcD 9:k
2
•
ALL ERGIEM
El YES pi0 PRIMARY DIAGNOSISt ADDITIONAL PAGES IN USE, OYES
N\ cj-NO
Ar_4=1\IEL (1Nuue)/ e
PATIENT IDENTIFICATION: PAGE NO.
DISPENSING TIMES
von
JSE PENCIL CIRCLE MED TIME S
D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
DA 1 EDITION OF 1 r--
F
CM9 4678 - -
HAUSTE D.
MEDCOM - 23650
DOD-037228
•
032_3 3 pol ; -68
T. LAS.
ly-G) ... '..1 RANK /GRADE.
p
MALE / HOMME
FEMALE/FEMME SSN/NUMERO MATRICULL.
SPECIALTY CODE ,01,11&
RELIGION/ RELIGION
L. UNIT JUNITi.4
FORCE /ELEMENT NATIONALITY / NATIONALIT,
P.IT AF/Al.TAM MOM f al
SIC/BC
I.NBI /BNC.I.DISEASE /MALADIE. PSYCH/
3. INJURY / BLESSURE .., AIRWAY /TRACHLE.
. , ... FRONT/DRY/TNT.
RACE/RARER! HEAD/TETE
WOUND / BLESSURE
NECK/BACK IRISES! BLESSURE AU COU/AU DOS BURN/ BRCILURE
AMPUTATION/AMPUTATION
STRESS /TENSiON
OTHER (Specify) 1 AUTRE (Spteller)
¦
•' 1,,,p....roki.1 (s.t...o.,. jr-4
•--:---.f.% Li•Z U4... es
.,....-7\: ) in
f
4. LEVEL OF CONSCIOUSNESS / NIVEAU DE CONSCIENCE
Xi
ALERT! ALERTE
PAIN RESPONSE / REPONSE A LA DOULEUR VERBAL RESPONSE! REPONSE VERBALE
UNRESPONSIVE, SANS REPONSE
S. PUPOULS
I TIMZ1SE.V TOURNIQUET/ GARROT I
TIME / HEURE 110/140N.ri
...._6)
VES/ OW.
7. M.DM /MORPH. 0 SE/DOSE I TIME/RUSE! L IV !IVI le;
I
MAE , KURE
ri
NO/ NON'.YES/OUI.\,...,
S. TREAT,/ ENT, OBS_
Anon's/ CURRENT 1.11 11/31:611011 I ALLERG1 (I.' ¦
TRAIL5tir ca7t110115 , PRESENTE vs.7_RainN_. IANTATTE) 1 .
NI_KA
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pet -. •1 „,. • - ,
1, .„..... -.---JO -_ • L • .
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c1 454-4
C1 1 t PA 1
ADA • . •_, i•
p• r 4. •••••••C -_
•-') S i
%,.. f VA. /1". .57c, 2 -: 10 CPT
,.. ..-2.--
16 D1SPOSMON ,_
WPM E5TURNED YDDLITY I RETOUR A L'UNITE_( kiktI)EURE
C11111D
11. PROVIDER
D Form 1380._rmira....u...................._ . — --
— ---
. .
DEC 91 el.131,04rd OD haw' L CARD
FICHE MEDICALE DE L'AVANT ETATsIDNIS
IMMO, ESH ERR atsokte.
MEDCOM - 23651
_
. REPORTING MTF 1 2 3 4 6
A
_
REGISTER NUMBER
B. DATE OF BIRTH (Y Y Y YLIMDD)
2. a2 F LOCATION_
(Slate or
Country
Code.)
NAME (Last, First, Middle inilla0
ADMISSION AND CODING INFORMATION
For use of this form. see AR 40-4D0; the proponent agency Is OTSG . _
4. PAY GRADE 5. SEX 16 17
"
l
i
7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20_ 21 22 23 24 25 26 10. LEN _ 28 2927 11. RAP . 30 31 I BACK. GROUND 12. SOCIAL SECURITY NUMBER
32 33 34 45 .
ORGANIZATION (Active Duty Only) . 13. MARITAL STATUS _ 46 _ HOUR OF _ BRANCH / CORPS ADMISSION
14. FLYING STATUS _ 15. BENEFICIARY CATEGORY _ 18. LP CODE OF RESIDENCE
47 48 49 53 54 55 57 .59 60 61
6362 17. UNIT LOCATION (Stale or. Country Code) 64 65 66 67 68 69 70 19. TRAUMA 71 PREY ADMISSION YEAR 'NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR _ WARD _ _ ADMISSION 72_ •_ __ • NAME AND LOCATION OF MEDICAL TREATMENT FACILITY NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADDRESS OF EMERGENCY ADDRESSEE (Include 7.1P Code TELEPHONE NUMBER OF EMERGENCY ADDRESSEE •
21. TYPE OF DISPOSITION 22. MTV TRANSFERRED TO
73 74. 75 76 77 78 79 80
24, CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM
89 90 • 91 92 93 94 95 96 97 98
27, LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION
(Sallie Casually Only)
107_108 109 110 111 112 113 114
FOR LOCAL USE
23. DATE OF DISPOSMON (YYYYMMOD) 81 82 83 84 85 86 87 88
QO Z. 1 (
( .
28. DATE THIS ADMISSION (YYYYMMDD) 100 101 •102 103 104 105 108
2 0 5 O cc/
29. DATE INITIAL AD
LOSS ON (Y Y Y YM.MDD)
115 116 1 117 118 119 1 126• 121' 1 .122
1
. WI/
ADMITTING OFFICER (Signature, as required) SIGNATURE OF ADMITTING CLERK
_
DA FORM 2985, MAR 2000 EDITION OF MAR a9 IS OBSOLETE_
USAPA V1.00
MEDCOM -23652
DOD-037230
1. Reporting MTF (.)(2._)2&TF Locati_.,
Admission alga boding Information
IZ
rvi ubC VI U115101111, see HK 4U-400; the proponent agency is OTSG
3. Register Number ame (Last, First, MI) 0)(6) — 4-( 4. Pay Grade 5. Sex
MONCOO -
FGN
M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity
Religion
UMW 27Y
X 9
10. Length of Service ETS 11. FMP 12. Social Security Nyrrp.suf
99 Warsa(b)) 7. i
C
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
10:35
i.
14.
Flying Status 15. Beneficiary Category
16. Zip Code of Residence: K78-PRISONER OF WAR/INTERNEES
17.
Unit Location 18. MOS
19. Trauma
Prey. Admission DIS
NO
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER ICW1 Address of Emergency Addressee
Name and Location of Medical Treatment Facility: Telephone Number of Emergency Addressee IIIIIIIIIIIINk(lrVll Provided
21. Type of Disposition 22. MTF Transferred To
23. Date of Disposition (YYYYMMDD)
TRF-OTH
2003-11-11
24. Clinic Svc - Admitting 25. MTF Transferred From
26. Date this Admission (YYYYMMDD)
-
2003-11-08
27. Location of Occurrence 28. MTF of Initial Admission
29. Date of Initial Admission 2003-11-08
[--
1 FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: SHRAP INJURY L CHEST
Procedure Narrative(s):
Cause of Injury Narrative:
1---Admitting Officer (Signature, as required)
Si natur of Admittin C rk
W — Z-
Automated Facsimile - DA FORM
MEDCOM - 23653
DOD-037231
• •. ivicivt mck,l)111_,-:1;LoVtli SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade
Admission Remarks FGN
4. Se(
6. Race 7. Religion
M
11. FMP 12. SS 13. Organization
20
15. FlyStatus
17. Dept / Ben K78-PRISONER OF WAR/INTER
21. Source of Admission
Direct from ER
24. Name/Relation of Emergency Addressee
27a. Address of Emergency Addressee
29. Reportin MTF
31. Selected Administrative Data Marital Status: Z In/Out Patient: Inpatient
I
33.
Cause Of Injury:
34.
Diagnosis / Operations and Special Procedures: INTRATHORACIC SHRAPNEL
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days
35. Total Days This Facility
ConLv / Coop Care Days
Signature
Automated
22. Hour Of Adm:
10:35
25. Type Disp TRF-OTH
27b. Telephone No
( 1°) 012)—
Supplemental Care
10. PrevAdm NO
14. Ward ICW1
uic ZIP 20. Type Case
DIS
23. Clinic Service AAA - INTERNAL MEDICINE
26. Date of Disp 2003-11-11
28. Date This Adm:
AdmittingOfficer: 2003-11-08 ( 0(60) —rp¦
30. Date !nit Adm 32. Units Blood Components
2003-11-08
Bed Days I Total Sick Days
Bed Da s Total Sick Days
)
(I
MED 0 -23654
DOD-037232
1. ADMISSION DATE (YYYYMMDD)
ABBREVIATED MEDICAL RECORD
2. CHIEF COMPLAINT, PERTINENT HISTORY, AND PERTINENT SYSTEM REVIEW
(- 0 4-4=,--A---4— SA-0.-810"9-4
27 j17 4 .-1, ./..„..ik x 3 Q_. -r`--62-r -.L„,_,-../1 -' di ,4---0 'T i‘ "--AYak-44 l'-C.-ee arti_e.,.C6. •.rP r7SCE.ISI"---eil-e--0 4-..ro-/i-. ,
¦.
3. PHYSICAL EXAO/IINATION (Including pertinent positives and negatives) .
--1
/ -f:
1-.— 1 33/ g Y. 1-1-ez -?z---a/ -2-7' 7-- ? :7-` C°
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_Ct1,--If-P-7 ,-- Q-1
L'—'1‘. •.LA......6 ,--- •.cri-P r, r-2.,.A y\ / ,
4. IMPRESSION (Enter admission note with plan on progress notes)
64Q-M-
,-
5. ADMITTING OFF
a. SIG.
C‘.K) b. DATE SIGNED (YYYYMMDD1
— 2-
6.
DISCHARGE NOTE (Brief hospital course, diagnoses, procedures, condition on discharge, pertinent
7.
DISCHARGE DATE (YYYYMMDD)
discharge information (including medications, diet, activity limitations, follow-up instructions).)
i.
8. DISCHARGING OFFICER
a. NAME (Last, First, Middle Initial) b. GRADE
e. TITLE d. SIGNATURE
9. PATIENT IDENTIFICATION (For typed or written entries: Name (last, first, middle), grade, 10. OUTPATIENT/HEALTH RECORDSSN, dare of birth, hospital or medical facility, ward number,
and register number)
MAINTAINED AT:
11. COPY PLACED IN OUTPATIENT
RECORD (X when done).
_
MEDCOM - 23655
L
DD FORM 977n ADD loact tct-21
USAPA V1.00
DOD-037233
AUTHORIZED FOR LOCAL REPRODUCTIOI
MEDICAL RECORD I PROGRESS NOTES
DATE NOTES
0 0 \ 1 153 ----A ss L)V1A_R__C) Ce4-1r. _.__ 6;` ,/-e i a_ itis G r--, .,-(5) 444 EMT
I Ltap yc_e u.)1(\_e,--Q-c_(N_0_,, n .)_MX ,s1,-Lir-e-e fm e_ \, .,D Ou y___s to tTee r locx_c-L vick--t Q_A/Ac, _s . F c& r, p c_ d ra_ u3 N. (re _„-,.31..--k 5 at loPd ... ¦ 070 Pr) (P.A. Ve-vvt is, 0 p 6 Ur 1 i----1-
re, -k_ tAz2__C-5-c e\ -S C ' / r Po z_ ?eozo •
12-14
S 6 itin -le__ 14 22 a A c__+-1,.A., ES e__,z/i-k_c} iiL,s JJ PC. P U fl c._ 1,e__@ 12_,c--r-c_./ if_i---pecf €.4-d-(e---sus 6 iccog 1 t--/e-c-77-7r., ,,_. w; I 1 (93\--Li 4) /y•t,..9, 1
v)(7f3 1)--t-A--e-)x3 s5 c--v 7.-la g A __-
2-1 0 25
,i,.1---,e --elr-c_-k-, e5 c----)D r ai --ar -rtc) .1 Wok A . \Ac --(--
'--C-.\..,kr e_e_.c. 1,--Da c \_ --ki,e_y-Nke_ir-Cly---nvArN A_ \fv(-)‘.kr\,
tY\¦ ,11 hr-SIN Cl n -c-,A----e_ t \-ex---Ot1 \ g-es -t-'2, 1
C_Li V\ v--‘Q Po rx)E_--i--0 2)12_. s C.LNvmpi i on_S ) 7IV et_b., po)1--N-1--rfry-c--r--rk,iTh--v. i_., )i Di'\,3 •
i X-0 A.C, ' 4 IV/P62 /, )-A 'e? d. ,-7,tx-Z--, ,e4 1---,----4,e---/
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER LAST (SSN or Other)
FIRST MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; I REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10
USAPA V1.0K
MEDCOM - 23656
DOD-037234
WU- 2
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
,/,-.7r P ,Zi.-.--Z, .
P/P0 ------- friY" 1( ,z---,-;-=,-/T ..t.F,J-417. -0,y„..,.
q W0v .40 ---1 -k-D )6 VS3 s , V x s- o •
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ARIMIIMIAMII k/s/0 .. OVN b_ 1 • OO tp---
2_,s-cLe___MMIlli 0 • f--• , -2__.\/ al, i e-4-a ?QcwNc__.e. I_ *---, 1) \t-,,e.-1) 41 -e_.
C a --(-- YDS- -C6 ' s CA'
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¦.i.e..
0._.. .-.. _,.i.-I' • . '.e -
,, _ -....r? 1 ...'_••¦• 1 c51 .-,-,Z4 ,,,e,2¦6
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diar VS . Ls C--- R-0 to S -.411,.tub.•
.
CI Nb l r 0.
, • 0.like ..II.I..lib, il¦.•.•.alb.0 *.Ak-. •..It a..., LAIllfik.¦ • oft. f\.la_ flb is.' . MA ti.
SA'Ne.S.W -.-c.
b b C INA, Ak WM!... 140 A % ke.0 r. i ft, Y\.r.14 ik lb.l Ca..sty A/61/ 0* /Ott #14(4,m-,1 24,-1-- / /pt. 6-'0600, & A oe) v 5, 5..(/c
...47,-(-471.-,.% „4,44"-----‘"--,.1 „a-4 - A - e - , "4-34----04 ,esz-, "------ -d e ., Aor''r'
xie:de,=-ted 0 4 5 e,,,
MEDCOM - 23657
/,
-.A4n4,04 „. L--
/.
oc2 8
,
STANDARD FORM 509 (REV. 5/7999) BAC:
USAPA V1 .0
DOD-037235
HU 1 nuniz.tii run LIJUAL hitPHODUCTIOI
MEDICAL RECORD
PROGRESS NOTES
DATE
NOTES
uovo,e/ri,f (,e,,,,,,t),,%_w}_e_,_ _A Axif iri-i .A
.,,,,,-, 1/47
4/1 ft'. 9 ASA (
i
,,, Q/D3o , -,1‘,
A,e„, z9 4d.i; ==,-e
1///Z ' •&' A ic P/c .J ,- ee-
Pi v,z, --77g 047, 4t/t, 70(g)_
A. !
,
,
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER LAST
FIRST (SSN or Other)
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle;
REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical_Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR)
101-11.203(b)110)
USAPA V1.00
MEDCOM - 23658
DOD-037236
AUTHORIZED FOR LOCAL REPRODUC
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
plc, ,,,,„,__ ,......_.,...:__
e5 F.36 ere,(J ,i-/ E-c_47 „---ac; cc,scf---0
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.
-
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER
LAST
FIRST (SSN or Other)
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION:
(For ty
ed or written entries, give: Name - last, first, middle;
REGISTER NO.
WARD NO.
ID No r SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/199
Prescribed
by GSA/ICMR FPN1R141CFR) 101-11.203(b)(1 USAPA vl.:
MEDCOM - 23659
DOD-037237
SKIN AND WOUND ASSESSMENT
PROGRESS NOTESMEDICAL RECORD
- HD: `-f POD:
D a gn o s is:
Admission Date:
Braden Scale Evaluation- (See Braden Evaluation Table for Details
Mobility No limitations CD Sensory No impairment (2.1)
Slightly limited 3
Perception Slightly limited 3
Very limitedVery limited
1
Completely immobile
Completed 4
Nutrition Excellent
Moisture Rarely moist
Adequate (Eats 50%) C;)
Occasionally moist
Adequate (Rarely eat4 2
Moist
Very poor , I
Constantly moist I
Friction and No apparent problem CD
Activity Walks frequently Shear Potential problems
Walks occasionally 3
Problems 1
Chairfast
Bedfast
Total Score 22
Add the total score
Low Risk
Between 16 and 20
Above 20 Medium Risk
Between 11 and 15 High Risk
Very High Risk
Below 10
Note: A Braden Scale Score of less than or equal to 15 indicates HIGH RISK —Requires immediate Ulcer prevention program.
/1,1 Drainage:
No Location: )54-6x Size:
Surgical wound (s):
Tubes: Appearance: CaU 0Dressing change:
Pressure Ulcer (s): Yes •
Stage 1, II, Ill, [V (Circlet e one that applies and describe below)
Size:
Location:
Moist Dry Granulation tissue Yellow sloughWound character: Pint
Eschar Exudates
Odor Purulent discharge Comfeel dressing Carrasyn V-Gel AlginateType of dressing change: Wet-to-dr/ No
Physician notified consulted for wound debridement: Yes
No
I CNS notified/consulted for Stage II and greater: Yes Nutrition Referral: Yes
No No
Physical Therapy Refermi: Yes
Date Time:
Ac:ion Taken:
WARD NO.
REGISTER NO.
Patient's :densification( For ryped or written entries give: Name-last. first. middle: PROGRESS NOTES
(,trade: rank: hospital or medical facilithv)
Medical Record STANDARD FORM 509
r.
1 / NOI / 0'3)
(As -se-55,D
MEDCOM - 23660
DOD-037238
S
NSN 7540.01-075-3786 LOG NUMBER
EMERGENCY CARE
MEDICAL RECORD AND TREATMENT
RECORDS MAINTAIrlill.W.1
(Patient)
1
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADORESS DATE (Day, o4(h,p1.0 TIM)0 LK
CITY STATE ZIP CODE TRANSPORTATION TO FACILITY
SEX DUTYILOCAL PHONE MILITARY STATUS THIRD PA NSURANCE AREA CODE NUMBER ITEM Y NO NIA IT YES NO PRP ADDITIONAL INSURA AGE HOME PHONE FLYING STATUS DO 2568 IN CHA AREA CODE NUMBER MEDICAL HISTORY OBTA 0 FROM NAME OF INSURANCE COMPANY
_...-•
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL I EMERGENCY ROOM VISIT
WHEN Ore) DATE LAST VISIT 24 HOUR RETURN
ITEM YES 0 n YES n NO ' IS THIS AN INJURY?
WHERE TETANUS
/Cell
ALLERGIES INJURYISAFETY FORMS
DATE LAST SHOT COWL 0 INTITIAL SERIES HOW
YES NO
tjY\i"-
)(is%
CHIEF COMPLAINT
CATEGORY OF TREATMENT VITAL SIGNS
TIME TIME
I t )43
. EMERGENT
BP
‘4,-,,,..7pULSE 1 .;))
VURGENT I ..•`',# RESP
(-
,4,..,
TEMP
t
. NON-URGENT WT
1....., CBCIDIFF AB 1 TIPTT BHCG/URINE/BL000/DUANT CXR PA & LATIPORTABLE
'
C-SPINE
Sli3080eve
URINE C&S UA MSCCIC TH K... CHEM: ) D... c
BLOOD C&S X
7z- c
—1-1130H0 I
AVII• X I
ACUTE ABDOMEN LS SPINE
SINUS HEAD CT
ANKLE RIL
ORDERS
PULSE OX nMONITOR n ECG
TIME ORDERS I BY I COMPLETED BY PATIENT'S RESPONSE
c.. "1-2A—cx N .. 35-
I u 6.1-) I u _)\9_
-1— cc--
.0 POSITION
DISPOSITION LIUARTERS rT PATIENTIOISCHARGE INSTRUCTIONS HOME FULL DUTY n 24 HRS. n 48 HRS. n 78 HAS. MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNITISERVICE
TO WHEN
REFERRED IMPROVED UNCHA NGED
DETERIORATED TIME OF RELEASE I have received and understand these instructions.
PATIENT'S SIGNATURE PATIENT'S IDENTIFICATION (For typed Of written entries Ore: Name lest lirsr, m4id/e /0 no. (SSN ar orhed, hospital or masa! facility/
EMERGENCY CARE AND TREATMENT (Patient)
6)(6)
Medical Record
STANDARD FORM 558 IREV. 9.961
Prescribed by GSAACMF1
FPMR 141 CFR) 101-11.2030111101
MIR
USAPA V1.00
MEDCOM - 23661
DOD-037239
NSN 7540.01-075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC .5 • k HIH Ai. PLT SUP 02 PCO2 SAT PH ABGIPULSE OX PO2 OTHER RADIOLOGY RESULTS CL "Jr-° S CL64— Check it read by radiologist 0
PT DIP EKG INTERPRETATION
APTT BHCG ETOH GLU MICRO
PROVIDER HISTORYIPHYSICAL
v; (1_ fpNtoc2,00...)\,bciall.0--ui
1
c\c-T\70.Q.a
tx-o_A au_.
rk.a k9V
1Q A
cu Lo c_
cd,
Ai, a-- clacf (go
0,-(Vr
cr7+ TSS
GLA--
• CL-fINO E
CONSULT WITH TIME ACTION
RESID NTIMEDICAL STUDENT SIGNATURE AND STAMP
PROVIDER SIGNATURE AND STAMP 111111$ DIAGNOSIS co
11"ral
Co
G —
O
Name lest, first, Toddle:
ID no. ISSN or other'• hospital or medical facility'
PATIENT'S IDENTIFICATION For toed or Millen enlres,
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record STANDARD FORM 558 !REV. 9.961
Presaked by GSAI1CMR
(OW
FPMR 141 CFR) 101-11.2133041101 USAPA V1.00
MEDCOM -23662
DOD-037240
• 511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR DAY
c' I 104.)(4b -3
19
PULSE TEMP. F . . . . . . . . . . . . . . . . . . . . . . . . . . .
(0) (•) . . • . ' . • . ' . " . . • . • . • . ' . " . . " . . ' . • . ' . • . ' . • . ' . • .
105°
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
180 104° . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .
170 103° • " • • • • • • " • • • • ' " " • • " • " •
160 150 102° 101° " • • --. . • • • • . . • -• • " • • • . • • • • • • . • • -. . • • " • " • -. . • • • " • • • • . . • • " • -. • • • • . • • • • -• . . • • " • • . • • • • . • • • • . • • • -. • • • • . • • • • . • • • • . • • • • . • • • -. • • • • . • • • • . • • • • . • •
140
: .". •. : . : . . : •. . . •. . : . . . •. . : •. . " •
130 120 99° 98.6° 980 •. . •.*.• . N . • . . • " • " .. . . .. . • . - . . • . . • . . • . . • . . • . . • : . • : . • : . • • . • • . - • . • • . • • . - . •
110 97° . . . . . . . . . . . . . . . . . . . .
100 96° :0: . • . . • . • . • . • . . • . . • . . • . . • . . • . . • . . • . . • . . . . . • . . • . . • . . • . . • . . • . . • . .
90 80 95° • . . •. . : : . •. . • . : . . • • ..oliv• . , . . . . . • . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
60 :: . . . . . . . . . . . . . . . . . . . . . .
50 • • • • • • • • • • • • • • • • " • • " • • • • • • • • • • • • • • " • • • • • • • • • • • • • • • • • • • •
40 RESPIRATION RECORD " • • 1211 • • " ' • • • • • ' • • " " r • " " • • " • • • • • • • • • • • • • • " • • • • • - • •
. , ta co to t.0LJ CO CO CO (+
I t.n ul cr, 0)-.4-4 •-.1 COCO(1
b in i-, L.1b i.) in 4) (0 :g
00 0 0 0 0 0
i
'Record special data only when so ordered
BLOOD PRESSURE
/Pi , „ \\41,9% P
0) 91si-i 4,1?:4 i. TV q .5
V 94+-1 ./44i-4 .'
HEIGHT: I WEIGHT —1¦•
Cr4e6*/
RA.•
fill I ic ‘T-470
pii5 e Se
PATIENT'S IDENTIFICATION (For typed or written entries give . Name—last, frst, middle; ID No. (SSN or other); hospital or medical facility) Anift ax‘" REGISTER NO WARD NO. VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23663
DOD-037241
I I
SPECIMEN/LAB RPT. NO
'OTOLOGY
(-z) gmagpc')""
URGENCY PATIENT STATUS
. BED
. ROUTINE DAMB
let
OUTPATIENT ec TODAY 0
. NP . DOM iao
. PRE-OP SPECIMEN SOURCE
. VEIN
Enter in above space STAT . . CAP
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE .
REQUES ING PHYSICIAN'S SIGNATURE OTHER (Specify)
REPORTED BY
a.
r\
c0 (6)-2-C DATE
LAB. ID. NO.
REMARKS 1.111111e " A-47 lic:),S
TECH 15
0
z =. -• rl ci 6
irO Z-t. 2 .r. g .;
11111111111111111111111111111111
WBC DIFF
c.-z 'c AND 8 Li0 0 D CELL M0RP! 11111111111111111 mu
2 & E
5 . ' IN II
.
ID:11111 a)(6) -
08-11-03
WB
14:07 Patient Limits
NBC 8.6 x10"1/uL 4.5W110.5RBC 5.80
x10'6/1:I 4.00 6.00
Hgb 16.2 g/dL 11.0 18.0
Ha 50.7 Z
M.0 60.0
IV 87.3 ft
00.0 99.9
MR 27.9
P9 27.0 31.0
IOC 31.9 L gAIL 33.0 37.0
Pit 243.
z10"3/u1 150. 450.
LY): 23.5 X
20.5 51.1
LW! 2.0
x1003/u1 1.2 3.4
MEDCOM -23664
6)- 2- . . .•
...
I LABORATORY RESULT FORM .-(Sub'cct to the Privacj. Act of 1974)
___,.
i L.'s.f ', t
! /.AC r(.b) (G)-i
I
T' ) t6-5-D I
i .
1.11:-iailysis ' ...• ' .. . .::•
. . . . . . ,..Niis-c.. ro ov: •• . . •• 1 .
.
.iNG,r.:: -. 72S.T .
I RESULT I REF. RANGE'
TEST RESULT REF. RANGE
08-11-03! ''Dior i e /4..a_. N/A J RPR
11:03 1-77.-i; (
"NIA
Patient ¦ 1"--11 1-4_ I Mon o Negative
Limits
& j I Negative-
8.1 x1043/u1 4.5 10.5 Gig lyric rob iology
& 5.66
110"6/uL 4.00 6.00 Bill .
/1313 15.6 g/r1 Negative Source
11.0 18.0
I
LL
e.---a-rfrz
MCV
35. 0 60. 0 Ket Negative
IV 87.2 fL Gram
.
80.0 999 ,. /1.
ICH 27.6
pg Stain
27.0 31.0 ; ,-,
PIE IOC 31.6 LI V& N/A
. 33.0 37.0 1 -`,"f /. 0 2 5' Ock: Bid NegativePlt 315.
"- x10"3/aL 150. 450. DidLymph %
in 26.8 Z Negative
20.5 51.1 Are H. pylori • Negative
ale
tayfll 2.2 x1043/aL 1.2 3.4 ' pH N/A
. • - -. Micro
‘.. 0 Parasites
Se -
Mono
Prat. Negative
61 C) Malaria
Bands
Eos
Urob 0.2-1.0
O&P
Lymph Baso
V
Nit Negative
e Other
Atyp
I mm
Lcuk Negstivc
pasciipk Urini
RBC
HCG N...gstivc
Morph
Spun 42-52% (14)
Hematocrit 37247/. (F) • Blood Bank •
Scd Rate
Cell
MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED
Other
Directigen Negative
ABO/Rh
I
oaguLitioii "Stti "e;::
BloOdltank Unit Croisntitch . • -(MUSTS UBMIT SF 518. WITH EVERY urirr O r BLOOD . •
tit trEsTED)
TEST
RESULT REF. RANGE
UNIT TYPE
C ROSS A-L-iTC 11 .
PT 91-13.6 sc
I ADTI-21-34 secs
h dimer i -20 uzja-ll ,rF DP I I 10 Lg/m1
I REMARKS:
I REPORTED BY: LAB ID NO.: .
MEDCOM - 23665
DOD-037243
I
I _
vianvs01 -
fltSTG -' ' \ ----C67 ---,
CHEMISTRY RESULT FORM (Subject to the Privaci.‘ Act of 1974)
.
LAST, FIRST, Mi.
ATE ' TLME
1-7 Nov
t t 0'1
--,i
.iSTA
-44.10.9 . 1 .i4 „ 7.,.k. . ..
(1cLuIuj jv&tLd uulIcPJael.::.; '.-..2
TEST
11.,-3.--1z-4-42
RESULT REF_ RANGE, -7-------PfF.
TEST RESULT 1 -REF. RANGE RANGE
Na 138-146 rnmo4/L
ALB
3 .5-5. 5 Val GLU 1 73-118 ma.kfl
K 3.549 mmol/I ' '
' BUN I I 7..221.13EVCI 98-1G9 erool/
PH 7.31.-7.45 -=.=-=,==8-
PICCOLO88
08/11/03811:27
PCO2 35-45 mmHg (
PICCOLO
41.51.-Ez(v,8von/LE8
REFERENCE RANGE:8
PO2 0n/11/038
' 11:1K AM
ACI-K15"14" PATIENT #1111111`J88
14/ANe0 "D' -
REF ERENCE. FZANGE :
TCO2 23-27mmouL(.8
LIVER PANEL PLUS
CO asiliNE
24-29 =non (,. PATIENT8
#:
DISC LOT #:8
3154AA7
HCO3 22-26 mmoVL (a
METLY1E 8
23-2S mruot/L (v OPER ft: IN8
DR #:8
DISC LOLL8
s02 95-98%8000 3151AA1
SERIAL #:8
OPER #:111,8
DR #: 000
BEeef (-2) — (+3)
mmon SERIAL #:8
ALB83.3-5.5811111111111,
4.58(3/DL
ArtGap 10-20 mmol/L
ALP 105*8
U/L
26-848Ca 1.12-1.32 mrno ALT 60*8
U/L GLU8114 73-1188
MG/DL
10-478
BUN8MG/DL
8 7-228
52 14-978
BUN 8-26 rag/d1 AMY8U/L
CRE80.8-1.28
1.4*8MG/DL
AST8U/L8
37 11-388
CK8
39-3808
2338U/L
GLU wmosmot TBIL8
0.2-1.68
0.6 MG/DL
NA+8130 128-1458
GGT 388
U/L MOUE
5-658
Creat K+8
4.5 3.3-4.78
MOM._
117-4-5mWdl TP 6.4-8.18
8.9*8
G/DL
CL-8MMOtt
103 98-1088
Hcc 38,-51% PCV
tr)::,8MMOL
21 18-338
OK8OK
.8HEM 0 ,8
,8
Hob 12-17 gicli 1NST OC:8CHEM OC:8
LIP 0 ICT 0
INS1 GC: OK8
CHEM OC: OK.
HEM 0 ,8ICI 0
LIP 1+,8
TEST RESULT REF. RANGE
Troponin-1
Drug of Abuse
REMARKS:
REPORTED BY: r---
DATE: LAB ID NO.:
MEDCOM - 23666
DOD-037244
F:.ALT.)IOLOGIC CONSULTATION REQU:_--ST7R=POR.T
•Cf.-_-C2.•-•ELTE
CT 51-
PACç
i
AEC-t-:F.S7E3 3Y (...n.7;
I
5: ..7.-",A7u•-. -.......- "..:E.::'-
-.-S• 70 =••
ckc, sl-siNk_tcq
• -:.7E OF EX.--,•-•-•:.',A7iON ', -1:.,..:::.:7. ;••cr...--.1 I 0A7 OF AE.?"3;¦ 7 ('4.-, :-, ..--..y. 7 "•-). DA 7 E
0F 7 A...NS C r.... I •=-7 IC •N O., c''': ..-..., . e•---7.• . .1- c--:
COclC
•
f
.01r
Oz)(a) -2
S 7:2
7,2 • -
r••• 2: -•
09)()1
, •
Nig
• 1-•-e C • • .
•": E - 2 -; 7
,v=2 ,,r¦
MEDCOM - 23667
DOD-037245
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
ti.,01/1:5-_
/ L.--.1 NOTED ANDHOURS
SIGN
1
0)(C) 4 -/-_L-a, ,/,!. d',1..0
¦9_, ./''''_6.:1-04---1-4,3„,.... c-e--,-..se #•14
co,42, (-01., -.cs-f--",.(12
e'.
vq-A-Q--4S-ex--
ft .
N c O -2.__4,1 -k---4---.-I--iii..., ..),_.._..
NU RSING UNIT ROOM NO. BED NO.
PO.ci (Sr-f t
PATIENT IDENTIFICATION /
DATE OF ORDER_ TIME OF ORDER
HOURS
71--
4,1„,,int_e_41 / Pli
.0...1 .
...„.4,.
/V f-¦.it.1 i----ei 4,...PL----,0 \\„. :;' y .(-6
NURSING UNIT ROOM NO._ -",..7. BED NO.
C. 6 I— C__..f t_12,_-, , S.-13
? 4y,r-ceAt--12__ 7
ri-17- ,-7 I-_tr p--.( Cap
PATIENT IDENTIFICAT •
DATE OF ORDER_
TIME OF ORDER
,
?. HOURS
r
J„4„
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PATIENT IDENTIFICATION_
DATE OF ORDER_ TIME OF OR ER
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REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 FAOPR
M79
MEDCOM - 23668
DOD-037246
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
^V
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.
PATI ENT IDENTIFICATION DATE OF ORDER LIST T I MEe
TIME OF ORDER ORDER
i /6 ,4raU .63 6 $ X_.‘ HOUR
NOTED A SIGN
) (6) 4
•-•_.r,,,
WIN. r Air
0 '
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NURSING UNI ROOM NO. :_•• o.
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PATIENT IDENTIFICATION
• TE OF ORDER TIME OF ORDER
_HOURS
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION X; BED NO. 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
,FAr, m79
MEDCOM - 23669
DOD-037247
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
CLINICAL RECORD For use of this form, see AR 40-407;
the proponent agency Is the Office of The Surgeon General. Mo. ( ( Yr. 2003 VERIFY BY IIVITIALING g.311ni
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER HR DATE COMPLETED
CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME
TO `I b zt..
roff) ---006d-: fer,)..k_rdrocd M
---# I
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ALLERGIES:..111 YES FM NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
-YES.M. NO
\A6C 1 ITVAM-OP-ACA C- 5:tiVeLeNa--
PAGE NO'
PATIENT IDENTIFICATION:
-AIIIIIIIIII 6)(6) -I. ACTION TIMES.
• USE PENCIL. CIRCLE ACTION TIMES D 8 9.
10.11.12.13 14.15 E.16.17 18.19.20.21.22.23 N.24 01 02 03 04 05 06.07
nn.re.tonw A"-1-1.A I* • •••¦¦•• ••¦ oh. MEDCOM - 23670 ...^...
USAPA V1.00
DOD-037248
(WO — 2 ..,1(
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) Mo ti.yr_2003
Order Clerk
Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse
be Done be Done
AcIroi- -i-cD -\(aM • No,165
CP 3 V3 p 11111111 ____... ce Cr \ K \ -AO Q "-RI.C/.-JL' 4Z:f. X V:r.D7' 1,6 eaAry X iox --1N)-- OD )S5 o (P r0
___ 4.. ....
Order/
Clerk/. PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Date Nurse.ACTION, FREQUENCY
TIME/DATE COMPLETEDdrib,/ NCOZ-the..-)TDIffili lIZIA-). ,c) Vox '=,F-1,
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_ _ _ _ __ __ -c9s, or ,so6
I
MEDCOM -23671
DOD-037249
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407;
the.proponent agency is the Office.of The Surgeon General.
MO. I(.Yr.q)--
VERIFY BY INITIALING .
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE CLERK/NURSE RECURRING MEDICATIONS,DOSE, FREQUENCY HR 01 0 II DATE DISPENSED
C6AJYA/0 " - K_IF_C7 \MC_2-* 2411111
EPINlej I k¦illi_ I OA. lita 1111. ill
111111 -
,
ll
ALLERGIES-YES
YES.Eti:leo PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: D Y ES 0 NO
NWP \
1 NT12P-TfiCe-ACIC.-\-41einVerv___ PAGE NO
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL, CIRCLE MED TIMES 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
.
1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23672
DOD-037250
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo.. yr
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
if
F'
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/. PRN
Explr
Date TIME/DATE DISPENSEDNurse.MEDICATION, DOSE, FREQUENCY
woroov
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Up_ 3_: °43f1-Th q. (76-3to3c
Li '111-AiNtl'
U.S. GPO: 1998-454-110/95216
MEDCOM - 23673
DOD-037251
' 1. Reporting MTF IL'-)
CIDD2. V (h) (6) — 1'.
Admission a..., Coding Information11.11 ,
For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number
-.Name (Last, First, MI)
) co --,( 4. Pay Grade 5. Sex
Cb)C-/-) — 9( FGN M
6. DoB (YYYYMMDD)
7. Age at Admission 8. Race 9. Ethnicity Religion
27Y X 9
MIN
10. Length of Service 11. FMP
ETS 12. Social Security Number 1(
20 COCO --
Organization (Active Duty Only)
13. Marital Status
Hour of Admission
Branch / Corps: Z 10:35
14. Flying Status 15. Beneficiary Category
16. Zip Code of Residence: K78-PRISONER OF WAR/INTERNEES
17. Unit Location 18. MOS
19. Trauma
Prey. Admission
DIS NO
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER
ICW1 Address of Emergency Addressee
Name and Location of Medical Treatment Facility: Telephone Number of Emergency Addressee
. rag; No Install Provided
21. Type
Type of Disposition 22. MTF Transferred To
23. Date of Disposition (YYYYMMDD)
TRF-OTH
2003-11-11
24. Clinic Svc -Admittinn MTF Transferred From
. Date this Admission (YYYYMMDD) AAA - INTERNAL MEDICINE
2003-11-08
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-08
FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: INTRATHORAC C-SHRAPNEL
--r-,-I fp g
Procedure Narrative(s): va 0
E 3
Cause of Injury Narrative:
'omated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 23674
DOD-037252
, _I/ i INP/4:11E\1T TREATMENT RECORD COVER SHL.....
For use of this form, see AR 40-400; the proponent agency is OTSG
ea0
C(6) -
3. G E ADMISSION REMARKS
REGISTER NUMBER 2
ETS 10. PREVIOUS
RACE LIGIO 8. LENGTH OF SVC 9.
4. EX 5 AGE 16. 0 SION
I .--.. ' 61¦ Nil&
14. WARD
to rOANIZ4ArTION
0 112. SSN ---
20. TY E CASE
15. FLYING 16. RATING/ 17: DEPT./ 118. BRANCH/CORPS 19. UIC:ZIP
STATUS 050 BEN
B
.,4•
....___
22. HOURS OF 23. CLINIC SERVICE
21 SOURCE OF ADMISSION:AUTHORITY FOR ADMISSION
ADMISSION
25. TYPE c SPOLITION 26. DATE OF DIS TIO
24. NAME/RELATIONSHIP OFEMERGENCY ADDRESSEE
-...-401.-..s.S ' 'Cl%\\ '' 27a. ADDRESS OF EMERGENC ADDRESSEE (Include ZIP Code/ 275. _ EPHONE NO. 28. DATE OF THIS
ADMISSION
\ -
\‘...:1\,.... 0 QC\)-
30. DATE OF INTIAL
29. A ND LOCATION OF MEDICA
ADMISSION
CO (Z) -2-
I
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATI NS AND SPECIAL PROCEO 'ES s'..
I kj ) X'
1 ...
.--..
1
.
-11
if
--..,______. ..........-
. ........—.......... -
/
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d. S LEMENTAL i a• 0 GAYS
CARE I
36. Total Days All Facilites
a ABSENT SICK DAYS 1 b. OTHER DAY; c. CONY. LV/COOP d. SUPPLEMENTAL BED DAYS
CARE DAYS CARE DAYS
illiblii
I
;7 7-- - I_ RE 7}5FICiR
ICER •: ; 6)(6) -
`c
ADMITTING OFFICER
32 UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED
Check if Continued on Reverse
TOTAL SICK DAYS
TOTAL SICK DAYS
. m
cnrnnN r. • It SAPPC V1.10
DA FORM 3647, MAY 79
MEDCOM - 23675
DOD-037253
t
1. REPORTING MTF f 2. MTF LOCATION
ADMISSION AND CODING INFORMATION
(State or
' I 2 3 4 8
7
con
Country
For use of this form, see AR 40-400; the proponent agency is OTSG
\ -Code.)
A \ \ \
3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
Al
9 1 10 1 11 al 13 14 0 ay6)-7/ 16 17 18
6. DATE OF BIRTH IVVVYMMD0) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 RACK...3\, GROUND
'J\..\
10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER 32 33 34 -35 36 37 38 39 40 41 42 43 44 45
c Q\ ORGANIZATION (Active Duty Only 13. MARITAL STATUS HOUR OF BRANCH / CORPS ADMISSION
46 ....____
D
14.1 FLYING STATUS 15. BENEFICIARY CATEGORY .. e 16. ZIP CODE OF RESIDENCE 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61
17. UNIT LOCATION (State or 18, MOS 19. TRAUMA PREY. ADMISSION
Country Code)
YEAR y NO
-M.
NAME/REL IONS sE
62 163 64 65 66 67 68 69 70 71
M RGENCY ADDRESSEE20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
ADMISSION
72
ADDRESS OF EMEDGEKT*DDRESSEE (Include ZIP Code) ..'.......\.\\...\
0 -¦
)(4)-- 2tELEPHoNE NUMB ADD RESSEE E19 °F E . RENCY
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (VVVYMMDC)) 73 1 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88
If I
Al ..11CWILMMCi \ MI
EN
24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION /V Y Y I'MMD01
89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 XFX ')C-A 4111 iL INEanin
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IVVVYMMIDDI (Battle Casualty Only)
107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122
....
FOR LOCAL USE '
_
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;
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MEDCOM -
DOD-037254
Automated Facsimile •._ INPATIENT TREATMENT RECORD COVER 6HEET
For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade Admission Remarks1. Register N Olt( 2. Name (b)(j------17 FGN
-
i I
1 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
i 6. Racei4. Sex 5. Age
x I j NO
.
M 1
14. Ward13. OrganizationI 11. FMP 12. SSN ICU120
J6b()--""
15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case
DIS
NO K78-PRISONER OF WAR/INTER 22. Hour Of Adm: 23. Clinic Service21. Source of Admission ABA - GENERAL SURGERY
09:20
Direct from ER 25. Type Disp 26. Date of Disp24. Name/Relation of Emergency Addressee
HOME 2003-11-23 27b. Telephone No 28. Date This Adm: Admitting0fficer& )(c )_ z_
27a. Address of Emergency Addressee 2003-11-11
OEM
30. Date !nit Adm 32. Units Blood Components29. Reporting MTF
a)(2)-2- 2003-11-11
31. Selected Administrative Data
Marital Status:
DoB:
In/Out Patient: Inpatient MOS:
33.
Cause Of Injury:
34.
Diagnosis / Operations and Special Procedures:
35.
Total Days This Facility Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
GSW R CHEST/ ABDOMEN RENAL FAILURE
I 35. Total Days This Facility Total Sick Days
ConLv / Coop Care D s Supplemental Care Bed Das
I I I
, Absent Sick Days Other Do
0 I. ..
(51 ,-, ._.... . .
Signature of Attending Medical Officer
SUNDBORG
I. MEDCOM
DOD-037255
Automated Facsimile
IENT TREATMENT RECORD t,,IJ ._'BEET
For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr 2. Name
G)(c) - 3. Grade
Admission Remarks FGN t_-_(----•
4.. Sex 5. Age 6. Race 7. Religion ;
8. LnthOfSvc ; 9. ETS 10. PrevAdm
. M I
X
NO
,11. FMP 12. SSN 13. Organization 14. Ward
20 0
ICU1
15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case
NO K78-PRISONER OF WAR/INTER DIS
21.
Source of Admission
22.
Hour Of Adm: 23. Clinic Service
Direct from ER
09:20
ABA - GENERAL SURGERY
24. Name/Relation of Emergency Addressee
25. Type Disp 26. Date of Disp HOME
2003-11-23
27a. Address of Emergency Addressee
27b. Telephone No
28. Date This Adm: Admitt ng0ffice6.. „..., _ 2_
2003-11-11 MilliC-"-()
29. ReportingMTF
02)(2) - Z-30. Date lnit Adm 32. Units Blood Components 2003-11-11
31. Selected Administrative Data
Marital Status:
DoB:
In/Out Patient: Inpatient F MOS:
.I.
1
33.
Cause Of Injury:
34.
Diagnosis / Operations and Special Procedures:
GSW R CHEST/ ABDOMEN RENAL FAILURE
l \ %
. ,
1 .
)
35. Total Days This Facility
Absent Sick Days Other Days
ConLv / Coop Care Days !Supplemental Care
I
Bed Days I Total Sick Days
I
35. Total Days This Facility Absent Sick Days Other Days I
ConLv / Coop Care Days ; Supplemental Care
Bed Da s Total Sick Days
0
C, C.) 1 0 ( 11--
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Automated Facsithile - DA FORM 3647", May 79
MEDCOM - 23678
DOD-037256
MEDICAL RECORD I ABBREVIATED MEDICAL RECORD
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G.F. ,;;L;'..CEZ
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MEDCOM - 23679
DOD-037257
AUTHORIZED FOR LOCAL REPRODUCTION
.
MEDICAL RECORD PROGRESS NOTES
.
DATE NOTES
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
ASSN Ar Othtd •
FIRST
DEPARLISERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: IFot typed or wirten whits, give: Name - kst lea Diddle; REGISTER NO. WARD NO.
ID No or SSW Sex; Date of Bilk liank/6ndel
I
PROGRESS NOTES
Medical Record
STANDARD FORM 509 DIEU. 6119991 PrescrAnd by OSAIICMR FPIAR 141CFN 101-11.2031141101 USAPA V1.00
MEDCOM - 23680
DOD-037258
LAST NAME FIRST NAME. --1 MIDDLE INITIAL ID NUMBER
BATE NOTES
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USAPA VIDO
MEDCOM -23681
DOD-037259
AUTHORIZED FOR LOCAL REPRODUCTION
.
MEDICAL RECORD
PROGRESS NOTES
DATE
NOTES
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SPONSOR'S NAME
SPONSOR'S ID NUMBER LAST
FIRST ISSN or &heti •
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'S IDENTIFICATION: For typed or written gneiss, give: Nome • last, fist middle;
RESISTER NO.
ID No or SSV• Ser; age of Kr* Rank/Grade
I wrL
PROGRESS NOTES Medical Record
STANDARD FORM 509 MEV. 5119991 Ptescribed by GSAIICMR FPMR (41CFRI 101-111031b11101
USW VI CO
mot
MEDCOM - 23682
DOD-037260
LAST NAME
FIRST NAME MIDDLE INITIAL ID NUMBER
DATE
NOTES
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MEDCOM - 23697
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