Medical Report: 23-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound to Arm and Chest

Ward:Section:
REQUPST1NG P.1-11SICfAN:
- •
0 A
LAST., FIRST, 1.41. ii_ ,- .i:ST.A.TY-.-
- .-...
f::-:..1'.
TEST •. _ REF. RANGE
Nra
K
Cl
pH
PCO2
PO2
TCO2
HCO3
s02
BEecf
AnCrap Ca BUN
GLU
Creat Hct Hgb
TEST
138.• 146 ramoUL
3.s--1..9:7.17-41.11.
98-109 rarzcIlL
7.31-7.45
35-45 mml-fg (tm)
41-51 nunHn (vcn) 80-105 mall-is (an) 1-444.(veat
23-27 =lel& (tn.) 24-29 mind/. (yen)
22-26 mmolii.. WO
23-28 mmol./L (vcn)
95-98%
(-2) — (+3) mrnon, 10-20 mmol,'L
1.12-1.32 ntmol/L
8-26 med1
70-105 rni,../d1.
0.7-1.5 mg/di

1 38-51% PCV
12-17 g/cit

••.;r-Kt.gt;',Cheittispry • ' :.! CK
.1.:-.:,.::;::•..-:-..:..2.::.:',-;,-...::::::-...,.. RESULT RE.F. RANGE NA.
...
Tropcn.:.-t-1
Druz et
_CI;
Abuse
tCO2
RE 'AIA_RKS:
CHEIVIISTRY RESULT FORM (Sub c-ct to thc
Privacy Act cf 19.74)
(\_3(6i). _ LA. 1 DATE i T1.1\1:...
SSI•IRSEUDO SSN:
.icc.oloY,Clii.niiitTy):2:.,.:.. .
" . ... • . ••• . • - . . — ... .. .. •
TEST
ALB
;kr p

At T .
ANIY
AsT
TB fL
Butsz
CA.".
CHOL
CRE
GLU
TP '
TEST
GLU
BUN
CRE
RETORTED BY:
DATE: 1 LAB ID NO.: i
1
,
RESULT izz,--F,
RANGE 3.5-5.5 g.M 76-84 till 10-47 uf! 14-97 u/1 !1 -38 nil 0.2-1.6 mgidl 7-22 medl 8.0-10.3mg/d1
100-200 reg/d1
0.6-1.2 mg/di

73-118 mg/d1 6.4-8.1 gidl 1.- ed,.1# .-Metliiel.,:'-..
RESDIT REF.
R..4.NGE

73-118 rned1 7-22 mg/d1 0.6-1.2,mg/d1 39-380 uflOY0 30-190 till (F) 128-145 nunoll

324.7 mr:21/1
il
98-108 rarnolll
18-33 mmolli
.
(Bic'Colo)•Te•abolie..i.?.atiC.:1.... -.:::'-..-
TEST RESET?: REF. RANGE
GLU 73-1 i 8 mvd1
BUN 7-22 mgidl
CA-- 8.0-10.3 ragidi
CRE 0.6-1.2 mg/d:

NA' 128-145 rnmol/1
ic 33.4.7 aunolil CI: 98-108 mn-,o1/1 tCO2 18-33 mrnolil
' ." - ' •
„ jt0}5X-5'..
- -0'..r,s4,12,k1.zt.I.P.:.:.:::,
TEST RESULT REF. R4NGE

ALB
3.3-5.5 Wdl
ALP 26-84 u.,1
ALT i 0-47 IA

A.vri 14-97 till
AST 11-38 u/1
TBIL rT.2-.1.6 mg/d1
GGT I 5-65 nil
-TP I 6.4-8:1. Wdl ..E.
it.C40.).-:Ele.c.ti.-015i•e;.

,
".".7.7.:.'F'::::;',.....7:::::,": •-: .-.
TEST RESULT 1 REF. RANGE

NA. 1 128-145 rnmolf1
K-3.3-4.7 mmoLii .
CI; 9S-108 rr..-.coVI
tCO2 1 -33 r7....-no:.1
MEDCOM - 23241

Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM
•,..,..ur...t %V LUG II ivas..:y ri.ct [II 17/4)
LAST, FIRST.,,M1. DATE TIME • SSN/PSEUDO SSN:

.. (He 1-f.atOl. 14.) .08C :: . - Urinalysis" -. ,. Misc. Serology-
TEST ErSSULT -E RANGE TEST RESULT REF. RANGE TEST RESULT REF. R4NGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14­18 Wdl(M) 12-16 Wdl (F) Glu Negative • 11/Berobiology ...
Hct 42-52% (m) 37-47°4 (F) Bili Negative Source
MCV 80-94 11 (M) 81-99 fi (F) Ket Negative Stain Gram
Plt 1304110 x 10i verified SG N/A . Occ Bld Negative .
Lymph % 20.5-51.1% Bld Negative •H. pylori N gative
Olernataltigy)Wlanual Differentiiil ' -: • pH N/A Micro
Parashes
Segs Mono Prot Negative Malaria '
Bands Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
"''.MicroscOpie Urifisi
, .
.,. ., . . .... , :. -. -.

RBC HCG Negative
Morph

" ,
Spun 42152% (M)
.-. CSF , Blood Bank --- •
Hematocrit 3747% (F) -' • • " , . .
.
Sed Rate

Cell
MUST SUBMIT SF 518 WITH

_ Count
EVERY UNIT REQUESTED

Other Directigen I Negative
ABO/Rh
-

, oagulation Studies:: .
' ' ::.• . • .. .-.-. .BloOd: Bank trait CroSsmatch. : --;
(MI.J.ST5UBMTT, SF.518 WITH vER.y. UNIT: OF BLOOD .: .
. . - -: , •-• 1.. .. : . .: itEtztitstirly , :: - .-. .
' :`:

TEST RESULT REF. RANGE UNIT 7'YPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21 -34 secs
'
D dirn.er 20 ug/m1
.

FDP 10 ug/tni
1
..

!,. REMARKS:
4 , _ . _ —I _ _ __ —.=---------
.r . :
MEDCOM - 23242
ct) -
Ward/Section: RLyUESTING PHYSICIXN:
CHEMISTRY SULT FORM1C)0\ —I (Subject to the Privacy Act of 19-74)
LAST, FIRST, MI. DATE 1 TIlvfE SSN/PSE 0 SSN:
-7 I-1).) 040o
.
' z-r.-.,,. Wsr4: r. :J.,:
Me..4611411:0.1i.rijii ..; - ' '',, -.. iei-410 0, ic.azaiiit.-
'::. `-.-,--(•:Ifk•-&-.-.;'..c,-. .
:•-•:',M",`- ,,P:4',.,:::-V"....!:7-',:':(-:,"•::',.: ;.-.1?

TES'T RESULT REF. RANGE TEST RESULT
REF. TEST RESULT .REF. RANGE RANGE
Na 1 3C1 138-146 mmol/L
ALB 3.5-5.5 edi GLU 73-118 mg/c11 K 3.5-4.9 mmol/L: ALP 26-84 u/1 BUN 7-22 mg/di
C1 98-109 mrtiol/L ALT 10-47 u/1 8.0-10.3 rogldl
CA++
PH 7.31-7.45 AMY 14-97 till CRE 0.6-1.2 rog,/d1
PCO2 35-45 mmHg (Irt) AST 1 1-38 u.r1 NA+ 128-145 mm01/1
41-51 riunHg (van)
PO2 20-105 mmHg (art) TBT 3.3-4.7 rnmolil
N/A Nein
TCO2 23-27 mmol/L (art) BU r 98-108 mmo1/1
24-29 mrnoliL (yea) rPICCOLO r
HCO3 22-26 mmoVL (art) CA'r18-33 mmoUi

07/11/03r04:07
23-28 mruclIL (vcn)
95-98%

¦ \_,MALE
s02 CHREF1RENCE RANGE 'r/r.1 (Pitdolto Tiii+ef, Panel'Pliii--'
PATIENTr#:r'-.-.1 0 - -%.r.:::::::!:zv::..1;;!::."., ::::;.:-'r•",,::,:r:;:.-'.::z?-.."
BEecf (-2) -(+3) T RESULT REF. RANGE

Citi BASIC METABOLICr
mrnoWL
AnCrap 10-20 mmol/L Gm DISC LOT #:r3325AA4 3.3-5.5 g/d1
OPER #:rDR #: 000

Ca 1.12-1.32 mmol/L TP 26-84 ull
S'ER I ALr

BUN 8-26 mg/d1 11111111111 10-47 u/1
i9k(2"
• GLUr92r73-118rMG/DL
GLU 70-105 med. 1 14-97 Lill
BUNr6*r7-22rMG/DL
•
GU CA++r8.5r8.0-10.3 MG/DL

Creat 0-7-1-5 med1 11-38 u/1
CREr0.8r0.6-1.2rMG/DL
Het 38-51% PCV BID 0.2-.1.6 rogid1
NA+ iff 128-145r1110/A_
Hgb 12-17 g/d1 CR1 K+rMMOVL 5-65 ult

4.5r3.3-4.7r:.-?Ar*;', tiiiis.r'''': r-.L.,r, Cl:rCL-r104r98-108rMMOVL 6.4-8.1 gic11
, ,..
'' i:-.;,--.-,;1•:.:::;.::':....ei's.r . _ ..
.... tCO2r24r18-33r!ICU_ . TEST RESULT REF. RANGE NA'r . gleciTOpeCti.. iifree;':,'' r:-:
--''''''''''.0.:::V.;...k.:. r.r'-:::.4.:.
4-INST QC' OKrCI-EM QC' OKr-
Troponin-1
" RESULT REF. RANGE

HEM 0r1rLIP 0rIrICT 0r
Drug of _CI.; 128-145 mmo1/1
Abuse
tCO2 3.3-4.7 mmoI/1

98-108 mmoVI
18-33 ramo1/1

RE MARICS:
"

.

Cli\'\12)1()(1r
REPORTED l'Y: DA1
.
1

MEDCOM - 23243

Ward/Section: LAST, FIRST, MI.
PH •
PCO2
PO2
TCO2
HCO3

s02
BEecf
Troponin-1
Drug of
Abuse
REWRKS:
FtEPORTED BY:
FR—EQUESTING PHYSICIAN:
FBEMISTRY RESULT FORM

(Subject to the Privac • Act of 1974)DATE TIME SSN/PSEUDO SSN:
138-146 mmol/L 3.5-5.5 Wdl

73-118 mg/d1 26-84 u/1
7-22 mg/d1

10-47 u/1
8.0-10.3 mg/d1
7.31-7.45

AMY 14-97 u.,1
CRE 0.6-1.2 mg/d1
35-45 mmFIg (ari)

AST 11-38 oil
128-145 mmo1/1
41 -51 mmHg (van)
80-105 tninHg (art)

TEM, 0.2-1.6 — -'-"
s, " —mow
N/A (veal
13-27 mmoVL (art)

BIN
24-29 mmol/L (von) no1/1
22-26 mmoVL (art)

8.0-10 PICCOLO
23-28 mmoVL (von)

04/11/03

95-98% 03:29
CHOL 100-201
REFERENCE RANGE:

MALE

(-2) — (+3)

CRE 0.6-1.: PATIENT #:
mmol/L

METLYTE 8

10-20 mmol/L •

73-111
DISC LOT #:

3151AA1

I.] 2-1.32 mmol/L
6.4-8.2
OPER #

y'lDR #: 000

8-26 Tog/d1 SERIAL
;0010)Aetbirtek.

miimer

,
70-105 mg/di

RESULT GLUL
96 73-118 MG/DL

RA BUNL
0.7-1.5 mg/d1 8 7-22 MG/DL
73-121

CREL

1.4* 0.6-1.2 MG/DL

38-51°,‘ PCV

Ta2o CK 2046* 39-380
U/L

12-17 g/d1 NA+L
0.6-1.: 125* 128-145 MMOVL
K+L

39-38( 4.7 3.3-4.7 MMOR
cu

CL-L

30-19( 101 98-108 MMObt
REF. RANGE 128-1, tCO2 22 18-33 MMOft
INST GC: OKL',ANGE
CHEM GC: OK
HEM 2+, LIP 0 , ICT 0

98-10
nmolfl
18-33
mo1/1
mot'l
ao1/1

DATE: LAB
MEDCOM - 23244

.

Ward/Se ion: REQ • • -
LABORATORY RESULT FORM
Sub'ect to the Privac Act of 1974
--DATE TIME
11 -rom.1••• :r
1:::)(
o D
' Urinalysis

• :. . . -• 1SC:-ro ogy '
... . . -

–Wann.4.--, • • .-
F RANGE
TEST RESULT REF. RANGE
TEST RESULT .REF. RANGE
WBC 4.8-10.8 x 10'
Color N/A

RPR Negative
RBC 4.7-6.1 x 109

App N/A

Mono Negative
Hgb 14-18 Well (M)

Glu Negative
12-16 gm,. (17) „ IYBrobiology
• .... .. .. ..
Het 42-52% (M)

Bili Negative
. Source
37-47% (F)
MCV 80-94 fl (M)

Ket Negative
Gram
81-99 fl (F)
•
Stain

Plt 130-500 x ie SG N/A
. Occ Bld Negative
verified
Lymph % 20.5-51.1%

Bid Negative
H. pylori Negative (Hematti ) Manual Differential ..,. pH N/A
Micro
Parasites
Segs Mono Prot Negative

Malaria '
Bands

Eos Urob 0.2-1.0
0 & P
Lymph Baso
Nit Negative
Other
Atyp Imm
Leuk Negative

-rosciipic.I.Jrina '
-
— ' '.
RBC

HCG Negative
Morph

,
•
-
Spun 42.52% (M)
CSF .r
-
. . Blood Bank •

Hematocrit 37:47°4 (F) • ' •
• -• . •
Sed Rate
Cell MUST SUBlY1IT SF 518 WITH .. :.• Count

EVERY UNIT REQUESTED
Other I . Directigen Negative

ABO/Rh

: : ' 1--Coagulation.Studies.: ' . ---, :-. - . -.• -:. .13100 Bank Unit CrOsSmitcli ... '. -.-.:... , .
'
•-.. -: " . ....-7..• • . ' . ' " .. --• • : MUST SUBMIT SF,518.N.VITH E'VERy UNIT OF BLOOD ; ;
,. : •.

TEST RESULT REF RANGE UNIT TYPE CROSSALITCH
PT 9.8-13.6 secsr. -
APTT 21-34 secs

.r
D dimer 20 ug/ml •
•

'

' F DP 10 nem' -
i REMARKS: 1
I REPORTED DATE: LAB ID NO.:.
'

MEDCOM - 23245

WBC 4.8-10.8 x 10'
RBC 4.7-6.1 x 109
Hgb 14-18 Wdl OA) r12-16 Wdl (F)
Het 42-52% (NI) 37-47% (F) MCV 80-94 fl (M)
81-99 fl(F)
Plt 130-500 x 103 verified Lymph % 20.5-51. I%
).MannaI Differential
Segs Mono
Bands Eos
Lymph Baso
Atyp I m m
RBC Morph
TEST
Color App Glu Bili Ket SG Bld
pH •
Prot
Urob Nit Leuk HCG
RESULT

REF. RANGE
N/A
N/A
Negative
Negative
Negative

N/A
Negative
N/A .

Negative
0.2-1.0
Negative Negative
-Negative

LABORATORY RESULT FORM
Sub'ect to the Privac Act of 1974 SS ( (a)
tn. Serology-..
TEST RESULT REF. R/INGE
RPR Negative
Mono Negative

lYficrobiology
Source

Gram Stain Oce Bld Negative
H. pylori Negative Micro Parasites Malaria
0 & P Other
roscopic Urin" .-••
Spun 42-.52% (M)

. CSF .-, • Blood.Bank ,­
Hematocrit 37-47% (F) . .r
. .
. '
Sed Rate
Cell.

MUST SUBMIT SF 518 WITH
Count

E'VERY UNTT REQUESI'ED
Other Directigen Negative 1 ABO/Rh

I
.
-Coagulation Studies, . -... --. ' . • '­
-•Bload: Bank Unit Crossmatclf ..•-.-..... (MUST,SIBMIT SF,518.WTTH EVERy UNIT OF BLOOD.
:
TEST RESULT REF. RANGE UNIT
TYPE CROSSAL4TCH
PT 9.8-13.6 sees .
APTT 2I-34 secs

.
-
D dimer 20 ug/m1
-
FDP 10 ug/ml

1 REMARKS: CO-A /k.-_
• 12 11)(11:PT"V T% 'DV.-V Ir,-.-.-....., _-_ __
MEDCOM - 23247

;sr".
.. •

LAST, FIRST..N2. --------
L.4130RA.TOR:: RESULT' FORA' .•
Subject
thc Privaci-‘tit

1 ' I TD.1F, of 1974)
t
1 SSN7PSELTDO, SSN:
R.,(ArG,S-...
4.8-10.8x10'
4.7-6.1.:: 10
14-18 13."(11c1/4.1)
12-16 d1CF) 42-52% (M) 37-47% )

1CfCV
180-9411(2Yr) 81-99 fl (F)

Plt
130-500 x10
m--ificc1
RESCZT REF. RANGE
9-S-13.6 sccs
I 21-34
1
21-
10 ugical

R F,!tt4-RKS:
I REPORTED BY:
r,r rr ^r•

•—• • •r•,_ .•r:
t.
== ... == PICCOLO ======= PICCOLO

03/11/03L

03/11/03

09:55 09:53

REFERENCE RANGE:L

REFERENCE

MALE MALE
PATIENT #: 1111116 ((ift,-

ATIENT #:

;) BASIC METAB IC

LIVER PANEL PLUS.

; DISC LOT #:L

DISLLOT #:

AA4 3153AA7

5 OPER #:
OPER #:

#: 000 DR ' 000
SERIAL

SERIAL
.......................... .........................

r GLUL

113

73-118 MG/DL ALB 3.6 3.3-5.5 G/DL

1L
ALPL

7-22L
I CA++ 8.9 8.0-10.3 MG/DL 30 10-47L

BUN MG/DL 64 26-84 U/L

ALTL

U/L

CRE 0.9 AMYL

0.6-1.2 MG/DL 16 14-97L

NA+LU/L

ASTL

142 128-145 MMOI/L 43* 11-38L

K+LU/L

5.3* 3.3-4.7 MMOPL. TBIL 0.7 0.2-1.6 MG/DL

CL-L

GGTL

104 98-108 MMOtL 21 5-65L

U/L

tCO2 24 18-33LTPL

6.5 6.4-8.1L

MM._ G/DL
INST OC: OKL

INST OC: OKL

CHEM OC: OK CHEM OC: OK

HEM 0 , LIP 0 , ICT 0 HEM 1+, LIP 0 , ICT 0

MEDCOM - 23248

Ward:Section:
I
TEST
Na
C1 pH PCO2
PO2
TCO2
HCO3
s02
BEecf
A.nGap
Ca
BUN
GLU
Creat
Hct
Hgb
,,AST
Trop.orin-1
Druz of Abuse
RESULT REF. RANGE
13S-146 mmo4/L
3.5-d S trano1/1.
98-109 mrnotiL
7.31-7.45
35-45 mmfig (Let)
41-51 mmHg (I, tn) 80-105 mml-ig (ar() N/A. Neu) 23-27 rnmoVi. (arr) 24 -29 mrnol/L (vcn)
22-26 mmoVL (nrt) 23-28 mruoVL (vcn)
95-98% (-2) - (+3)
nu-noWL 10-20 mmol/L 1.12-1.32 mrnol/L.

I
8-26 med1
70-105 mg/dt
0.7-1.5 mg/di 38-51% PCV 12-17 g/d1
RES' T ;T. RANGE
•
R.E:‘,LARKS:
REPORTED BY:

REQUESTING P1.-i-1"4ICIAN
TEST RES

_ALB
ALP
T

ANIY
.A_ST TBIL BUN
CA"-CHOL CRE
GLU TP
k".c6loYiAt elfrte..8„.

TEST RESUL2* .REF. R.A2sIGE
GLU 73-118 rog/d1 BUN 7-22 mg/dt CRE 0.6-1.2smed1 CK 39-380 u/1 (M)
30-190 u/1 (F) 124-145 airnotil
32-4.7 mmoIll
98-108 ramo1/1
DATE: LAB ID NO.:
MEDCOM -23249

2-

CHEMISTRY RESULT FORM
1

LNTE (Sub.c-ct to th e Privacy Act of 1974) SINIRS-F..1.TDO SSN:
.REF.
iirLAIGE 3.5-5.5 glea 26-84 ufl 10-17 u/1 14-97 u/1 11-38 all
0.2-1.6 mectl 7-22 inedl 8.0-1 0.3medl 100-200 meal
0.6-1.2 cried'
73-118 medl 6.4-8.1 edl
TEST RESULT
GLU BUN
CRE
Nt-:
CL"
tCO2
PitealoPtai're

•t
REF. R4.NGE
73-118 ing'dt

7-22 Eng/d1 8.0-10.3 rag/d1 0.6-1.2 medi
1'28-145 zirr,o1/1 • •,.'1
17,r•
3.3-4.7 =ma 98-108 mmo1/1 18-33 mrool/1

TEST RESLii T REF. R. - 4NG E
ALB 3.3-5.5 g/d1
ALP 26-84 ul
ALT 10-47 IA
Amy 14-97 &I
AST 1-3 8 u/1
TBIL 0.2:1.6 algid
GGT 5-65 u./1
-T? "1 01
glectrolite;
-
• .
TEST RES-01-2-7.P. RANGE
NA' 128-145 rnmo1/1
3.3-4.7 crunolci

9S-108 rr--aoLl tCO2 18-33 mmoLl

•

STANDARD FORM 545 (REV 10-711/11
545-108

LABORATORY REP(
•
. TESTIS)
. S\P
. ,PECImEN TAKEN

I.. DATErr

nmErA.m. -412
.. 5A10/03 Z7L/00 P'M• Z 0

i-STRT EC8+

51
,RESULTSr
REOUESTEDr
RBC COUNT

IX) o

-o Pt : eat \O(C1
HEmOGLOISIN
\ \

Pt Name:

HEmATOCRIT
-*
M C V

0." Z
MCH 1.; a GluL
c 89 mg/dL
z
malC

BUML

mg/dL

WBC COUNT

IMmATuRE HaL137 mmol/L
5

NEUTRO-

BANDS .f%.6 mmol/L
;7: NEUTROSEGS 07 Sr: Cl L104 mmol/L
LYMPHS

3g
TCO2L

2s mMol/L

Hc1210W 113) 00018
(OSINOPHILS

BASOPHRS 0 AnGapL
co I= mmol/L
MONOCYTES

HctL

23 %Pcv
PLAHIETS

S.1. 1110d31:1ALIO1VUO8V1 HOV.LIV01 C1311ddV
YO—'0N CIO
Hb*L

8 g/dL

*via Hrt
PH ­
7.351

RIK
SED. RATE PLATELET
COUNT
RETICULOCYTE
COUNT

PCO2L

45.7 mmHg

CLOTTNG TIME

BLEEDING HCO3L
TNAE 2R mmol/L
0
P CONTROL 8Eecf L

mmol/L

1 PAINNT
c

CONTROL t Sample Type_:
0
r"

PATIENT z
o - % ACTIVITy OSNOV03L
0 -0 04:Sn
RATIO OD r3-...0

2, s,,,, 7 c)
. co
-o a n m

SICKLING TEST _, 0 je Oper:
E. E A
'0r—.
70
D WI

LE PREP —trz
-71.r7.7;r—I
C2rzr

‘,„ Physician:
7

N.--:r'6' -L
2:7.

HEMATOLOGYL

549-107 :5- 0 g 000c
STANDARD FORM 549 IRev. 7-78) n rl 0 , cA
PRESCRIBED BY GSA/10818 -o­
r" 0 n.
ct
FIRINFI MI-CFR) 20S-45.505
Ir

.1r.1 . I PHYSICIAN COPY
ALIGN ALL LABORATORY REPOR1

INSTRUCTIONS: This form may be used to display laboratory -cports as a flow sheet to be read as a progressive table. If so, a separate shcet should beused for each type of report form. When assorted report forms are mountedon the display sheet, both test names and results should always be visUe.
ENTER IN SPACE BELOW: PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE

epvill111.
i) L6-1
-mlow
Ser#
Ver:

MOUNTED ON STRIPS 1 THROUGH 7
MOUNTED ON STRIPS 1, 3, 5, AND 7 CHEMISTRY I ISE 546) • PARASITOLOGY (SF 552)
. _
IM/AUNOHEMATOLOGY (SF 556)
O CHEMISTRY. II (SF 5A7)
ASSORTED FORMS
El CHEMISTRY III (SF 54B)

• OTHER (Spocay)
• HEMATOLOGY. 15F 549)
MOUNTED ON STRIPS I, A, AND 7
MICROBIOLOGY I /SF 3531URINALYSIS (SF 550)
MICROBIOLOGY II (SF 554)
SEROLOGY (SF 3511

0
MISCELLANEOUS (SF 557)
D SPINAL FLUID (SF 5.55) ASSORTED FORMS

LABORATORY REPORT--
Prescribed by GSA/ICMR-DISPLAY
FIRM (41 CFR1 201-45, 505

trU:S. GOVERNMENT PRINTING OFF/CE,

1 290 2 6 7 -1 2 6
MEDCOM - 23250
DOD-036827
06-11-3
(34:7,
Patieri­
2.: x10'3/di. 4.5
;DC L 4.00L

11.0A6SuL 6.0C

3.LglefL 18.f,

L 11.0L
:i;:t 1.2 L 35.6L

X 60.0
01,1 SM 97.9
2G.1 pg 27.0L

31.0
ME 31.6 L gidL 37,C

310L
Pit 177. x10',3/6! 450.
DI 21.; a.5L

51.:
L9 1,g 1.2L

yl2r=3/4i 3.4

• Y.,
,t
gt4-1"-AA/1"-4"-'
(,u)
1111111

09:5:
Patient

Lilits
Z1: 2:, 2 'd

VeiL 11.0 18,

35. C; ' '

30.c,

-fL

t10': 2-8.: 27,(Y 31.0
31,8 qddl. 0 1;7r,.,
'2fk x10'7,/,IL 15v. 4w,

7,1 44. Z :Y....5 5i.:
1, X10'3AL

04-11-e:
0311-
Patient

4.5 10.5

4k)63,1f_.L

1.1.0?

11.0 1M

G'9.9

27.b 31.0
= 1.LL

33,0 37.0

15e:. 45,
-eL4

c.

¦ JaJ
:.2

.
RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 11/03/03 09:56
Patient ID: WO
Test Name :PT
Test Result:= 14.5 sec.
Ratio = 1.2
Calculated INR = 1.32
Sample Type:citrated wh, blood
Test Date :11/03/03

Test Time :1019116e\

Card Lot .L
)--\
OperatorL

:

i,APIDPOINT COAG ANALYZER V4.54 ';ii-J,IAL #005485 11/03/03 10:00
Patient ID: Test Name :APTT Test Result:. 42.8 sec. Samplt.Type:citrated wh blood Test Date :11/03/nn
MEDCOM 23251
-

OPERATION REQUEST AND WORKSH
For use of this­
see AR 40-407; the proponent agency is the Office Di
3eneral SECTION A -
REQUEST FOR SURGERY
1. PATIENT'
MI) (Print)
2.
STATUS

3.
AGE 4. RELI-

5. REGISTER NO 6. SSN
(with Family Member
)066 /6/7 GION
Prefix)
7. PREOPERATI E DIAGNOad
/24 Z5
e, 8. NURSING UNIT (fmm
(0 to Zi6 ‘2,-07e„," e „,6,‘_.
9. OPERA ION P OPOSED
i /D %cid
10. REQUESTING SERVICE
4, 0
,,,,----- .
11. ATE OF SUR ERY
7 /
12. TIME R VASE N// /7,4-2‘ /714-(//ti,2 61°0--ft,r
13.
SCHEDULE P ORITY (check one) /

14.
BLOOD REQUIRED ,52EMERGENCY (Unit)

CD SEMI-EMERGENCY
3 NO 3
ROUNTINE
17. ASSISTANT(S)
1
18. POSITION OF PNT 1/,
21. ANESTHETIST(S)
F-1.7.-f ii1::1-,_: 4rii.' •::-7 -I .., N D
23. SPECIAL INSTRUCTIONS AND REMARKS
•• • •_r
-r• • • •
'• •.^-,
24. RE -
S CTI­
OPERATION­HEET
25.
OPERATING

26.
TIME OR CASE NO

27. SEPTIC
ROOM NO 28. FLUIDS (other than blood)
29. BLOOD ADMINISTERED
30. SURGEON
31.
ASS STANTISJ

32.
ANESTHETIST(S)

33. ANESTHESIA
• -M TIME (Began andEnded)
34.
AGENT TECHNIQUE
INDUCTION 37. AIRWAY 39. SPECIAL PROCEDURES
ANESTHETIC
(Anesthesia)
35.
AGENT TECHNIQUE-±
PRIMARY -38:-RELAXANTS
ANESTHETIC • e.;•j-1.'.'s INTIMATION
OTHER
36.
AGENT TECHNIQUE;
SECONDARY , ¦r•
.-....-•
ANESTHETIC 7
40.
NURSING TIME (Began

41.
SCRUBBED PERSON(S)

and Ended)
42. CIRCULATING PERSONIS)
43.
OPERATION DATE

44.
OPERATION TIME

I
45.
DRAINS

46.
SPONGE COUNT

(Began and Ended)
47. LABORATORY SPECIMEN
::) ¦ ‘: WC)
48.
OPERATIVE DIAGNOSIS

49.
OPERATIONS(S) PERFORMED

Fl EPISODES OF SURGERY
50.
COMPLICATIONS

51.
DICTATOR'S NAME, SERVICE & PHONE EXT

(Continue on reverse, if more space Ls regliir"rd)
I
RECORDED IN REGISTER
(Initials)
DA FORM 4107, MAR 82
EDITION OF 1 :JUN 73 MAY BE USED.
USAPPC V1.00
MEDCOM -23253
DOD-036829

NSN 7540-00-634-4165
MEDICAL RECORD REQUEST FOR ADMINISTRATION OF ANESTHESIA AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES
A. IDENTIFICATION
1. OPERATION OR PROCEDURE
0('
B. STATEMENT F REQUEST
1. The nature and purpose of the operation or procedure, possible altemative . - ti eatment, the risks involved, and the possibility of
complications have been full ex lamed to me. I acknowledge that no guarantees have been made to me concerning the results of the operation or
i
procedur . I und tand th n re of the operation or proc ure to be
0 ( on of operation or pr
et
h.A-0 C.,
vhich is to be performed by or under the direction of Dr.
(2-
2. I request the performance of the above-named operation
re
and of such additional operations or procedures as are found to be
or procedure.
necessary or desirable, in the judgment of the professional staff of the below-named medical facility, during the course of the above-named operation
2. I request the administration of such anesthesia as rtifiyibee- siderei:krAceS:pary-or advisable in the judgment of the professional staff of the
below-named medical facility.
.6)
4. Exceptions to surgery or anesthesia, if any, are:
(If "none", so state)
5. 4
I request the disposal by authorities of the below-named medical facility of any tissues or parts which it may be necessary to remove.
6.
I understanil that photographs and moviei rnay be taien of this operation, and that they may be viewed by various personnel undergoing training to the following conditions:
or indoctrination at this or other facilities. I consent to the taking of such pictUreg:'and observation of the operation by authorized personnel, subject
a.
The name of the patient and his/her family is not used to identify said pictures.
b.
Said pictures be used only for purposes of medical/dental study or research.
• -•
(Cross oat an
arts above' which are not a ..ro•riatel
c. SIGNATURES
(Appropnate items in Parts A and B must be completed before sr nit,
COUNSELING PHYSICIAN/DENTIST: I have counseled this patient as to
expected results, as described above. 'sks involved, and
_ .r• .
nseling Physician/Dentist)
2. PATIENT: I understand the nature of the proposed P?ocedure(s), attendia risics involved, and expected results, as described above, and hereby
request such procedure(s) be performed.
/Signature of VVitness, excluding members of operating team) (Signature of Patient) (Date and Time)
3. SPONSOR OR GUARDIAN: (When patient is a minor or unable to give conSent)
sPensor/guardian of
risks involved, and expected results, as described above, and hereby request Stich procedure(s) be performed.

understand the nature of the proposed procedure(s), attendant
(Si9nature of Witness, excluding members of
operating team). . (Siglynure of Sponsor/Legal Guardian)
•, , .
Mate and Time)
PATIENT'S IDENTIFICATION
/For typed or written entries give: Name - last, first, middle; grade;
rank; rate; hospital or medical facility);

REQUEST FOR ADMINISTRATION OF ANESTHESIA AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES
Medical Record
STANDARD FORM 522 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR 141 CFR)
USAPPC V2.00
MEDCOM -23254
•-.
MEDICAL RECORD - ANESTHESIA
-ze of this form, see AR 40-66; the proponem ag ­
the OTSG
t'tt (It
0...¦ TOTALS
ir CC 0

• 0 -
U
2

I-
L112
2

51+0 4'cc
I—
AI to -1.0
• 0 0
D )70
0-K

AIR L/Min
z
Us a.
au) N20 L/Min

02 L/Min
z SINGLE DOSE DRUGS-MARK ON GRID
4 WITH NUMBERS & ENTER IN REMARKS BLOriz_

LJNE site
ID Warmed
MENKeil
Code drugs with numbers, events with lentess
Warmed
EST BLOOD LOSS
URINE -

TIME
PY.INTIOR. 220
BP by cuff
200
V
AMATK
180
A
Hean rate
•
Resp rateBP-
BR
ffransduced)

IRCH
OK7-Y N

TOURNIQUET
PATIgIqifFIEOfkK. T
OK for
PROCEDURE)

ANES- X-X
PROC-

TIME-
1111Plo=011111011
f breaths/mIn
Peak inf pres / PEEP

1$7/11gtelIMMETAIEDIMMIEVAIN
ODE - SI onL CIon)
warammoraorAwmireisrai
BP/Auto Cuff CO2 (torn
Iii/IMIIIMIIF171/32/1UMIEM/FEMPIIII 1071
BP/oth PACU ICU-Specify)
1071112121.2710131MIVIIIIMI 5121E1£11117131
ART line
IMIIPMP2:21 rzila
111
CONDITION:
EMS72/11MARAIEMIIMMIMINEVAIMIIME17/1
111111MVISP7 prriarairmarairamnu
REM'.-Sp02-BP-HA-
M .. .-.
w Start Room End
itt
4
Conv warmer
MU:SFA
Mark with letters IL SyMbniS, EVENTS 1212111=11121explain under REMARICS.Position
MIMEO
PROCE URES and CPT Codes: HETIC TECHNIQU :
Describe bloc technique under Remarks
SUCAZI...,c-C-Alije— .1.
-164TOI
e:c/ te2
P TIENT ID NTIFICATION: Typed or written entries: Name, Grade/Rare,
AIRWAY MANAGEMENT: ln bat
/4
e4n route, Wage, technique, corn ems
Medical facility
'E--'44' V 7
URGE •
PROCEDURE 7:7-freAr.,_
04,­
LOCATION:
DATE: &NA) 0 -S PAGE OF
2._
DA FORM 7389, FEB 1998
-PATIENT'S MEDICAL RECORD-usAPAvf.00
MEDCOM -23255
MEDICAL RECORD - ANESTHESIA
se of this form, see AR 40-66; the proponent ap
the OTSG
18 0_,
TOTALS
z
IC: cc 0
0 0 —
I
Ow
ti '142
(
)—oz
„,11. • Z
—
con .2
— ( )
D Z z
OD 0 % del
7 ).•

Z-11 4.M % e.t. AIR L/Min CRYSTALLOID-
ut zgf r
z N20 L/Min
COLLOID­
02 1— L/Min "7-
-z SINGLE DOSE DRUGS-MARK ON GRID.4.
:4 WITH NUMBERS & ENTER IN REMARKS BLOOD-

El Warmed
El Warmed
•Z.
;c;.)
Warmed Code drugs with numbers, 20,atz with !enters
LI Warmed
EST BLOOD LOSS

URINE
TIME 4¦17/5.----fr 4.00
1 2 3 4 5 E :43.0 YONPEGHT: igt9A,g-g-e40
-220 ­KG

BP by cuff
LB V r,e614W
sj:1411AT0PRITv:i:
A 180 ,
.ce(
Heart rate
160
• leeerfr-7 Resp rate
BP- 140
120
1--4
HR-BR
itransduced) 100 4- 4. 41:
*
BO-• 1 i"-•1 k
Y N • •
TOURNIQUET 60_ •
WIEN11::RWICK
40 ,
OK for
PROCEDURE?
ANES-X-X
20
TIME-

PROC-0,0
VT - ml
7/0 7 )47
f - breaths/min f
Peak inf pres / PEEP 24/

ODE - Sfpon). A(ssist), elm)-CV i(tf
VellAuto Cuff CO2 ftorr)­
3i WY I
-
BP/oth f_102 (Frac or %)
761. PACU ICU Specify)
ART line vSta02 (%I
OTHER ­
st th- PC/ES ECG
CONDITION:

" 3
Gas analyzer LtiE;AP -sIte 3f,
N-M Block (1/41 RESP--SpO2-BP--HR-
:E: Start Room End
o: Warming blkt
IConv warmer 4
Mark with letters & symbols.
EVENTS_,
C.) Ready Begin End
explain under REMARKS.
Position --
0
0
cCPROCEDURES and CPT Codes:
a.
ANESTHETIC TECHNIQUES:
Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT:
lntubation route, blade, technique, commentsMedical facility
61c.t-1-(
SURGEONS:
PROCEDURE
LOCATION:
b lL6 —1
, DATE:
,/f/04/ '69
r1111111V
,. PAGE OF 2_
DA FORM 7389, FEB 1998
COPY 1 -
PATIENT'S MEDICAL RECORD
USA PA VI .D0
`'?
/°/a.
MEDCOM - 23256
DOD-036832

AgedV DAYS MOS YRS
PROPOSED PROCEDURE:
SURGICAL SERVICE:
NPO SINCE:

HAM'S:
TOBACCO:
ETOH:
DRUGS:

CURRENT MEDICATIONS:
() = ordered as premed

( )
( )

PREMEDICATIONS:
None Yes (0-

Hrs) /CC mg IV IM PO mg IV IM PO mg IV IM PO
LABORATORY STUDIES.
HB/HCT: U/A: OTHER:
sex 0 N.____,___.7,LmLasaammu
A FEmALE
PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
Cardiovascular:
Hypenension
Angina
MI
CVA

Other
Pulmonary System:
Asthma
Bronchitis/URI

COPD
Other
ttenal System:

Acute/Chronic RF M11
GastroInte_stinal:
Hepatitis
Hiatal Hernia
PUD/GERD

Endocrine System:
Diabetes
Steriods
Thyroid

Neurological:
Seizures
Neuropathy
Other

Gynec log; I :
Pre­
cy­
N Y
Other Si­
scant Hx:
NY NY
Familial HX
NY
ANESTHETIC PLAN: { } LOCAL { } MAC
-
} Regional (Specify):
m.n sinr
-
ASA Physi State 1 2 3 4 50,VVT:­
KG/LB HT:­
IN.
ALLERGIES: 4,
ASSESSMENT PAST SURGICAL/ANESTHETIC
PHYSICAL EXAMINATION BP­
HR­
R-T Pain Scale 0-10 HEENT - Teeth Trachea TMJ/Neck Orophamyx Nares CHEST:
CARDIAC:
EXTREMITIES:
IV Access:
Ulnar Filling:

BACK:
OTHER:
NPO Since
),(fGeneral: Mask Intubation
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have
discussed with the patient/legal guardian.
been explained to and
The patienVlegal guardian sebms to understand and agrees. Questions answered.
Signed:
_ -­
Date:
Time:
POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) } NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER
Signed:­Date: ­Time:-
Hrs
Patient Identification: (Ward)
WAMC Form 2.300 (Revised) 15 Mar 01 MCXC-DOS
ANESTHESIA RECORD
..
,.
,
Hrs
SEDATION KEY:
1.
MINIMAL (Anxiolysis) Patient
responds normatiy to verbal
commands

2.
MODERATE (conscious sedation)
Patient responds purposefully to
verbal commands alone or

accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully 'following repeated or painful
stimulation. Airway assistance.may
be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation.
Previous edition is obsolete
•u.s. GPO: 2001-629-183/40002
MEDCOM - 23257
p.7r
.0.
CL1141CALI RECORD - DOCTOR'S oRr -se of this form, see AR 40-66, the proponent ; OTSG
-
THE DOCTOR SHALL RECORD­
, TIME AND SIGN EACH SET OF ORDERS. IF .....,BLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF °RIDE­
TIME OF ORDER-Ot..9,i)) LIST TIME ORDER
/0011/ /3 7q-
NOTED AND
raMeAffir. GN z ?a /'
NURSIN,AJNIT
ROOM NO.­BED NO.
PATI1ENT
IDENTIFICATION
c_f-
NURSING UNIT
BED No.
PATIENT IDENTIFICATION
DATE 0 ORDER
TIME OF ORDER
rb HOURS
(
g •
41'ed/
NURSING UNIT ROOM NO. BED NO,
PATIENT IDENTIFICATION
E OF ORDER­
T E OF OR
-HOURS
at 67 ;4- 4-A tar c C AT-t 104; -7,
NURSING UNIT
BED NO.
REPLACES EDITION OF I JUL 77, WHICH MAY BE
DA 4256
, FA7:479
MEDCOM - 23259
DOD-036834

(4-,\,..)-7r°-) r' (r ,
CLINICAL RECORD - DOCTOR'S ORr c\.re
of this form, see AR 40-66, the proponent a 3 OTSG

THE 00CTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF r-,,OBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIF !CATION
TIME OF ORDER LIST TI
ORDE NOTED
HOURS SIGN
NURSING UNIT
ROOM NO.
BED NO.
I CU I
PATIENT IDENTIFICATION
CLAA.
NURSING UNIT ROOM NO. BED NO.
bif\
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
DA IFA0pRi,m79 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE

MEDCOM - 23260
DOD-036835

CLINICAL RECORD - DOCTOR'S oRr
r
Fi ..)f this form, see AR 40-66, the proponent a ¦ OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF t-,,,./BLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFiCATION
DATE OF ORDER
T I ME F 0 j$2.E.F1 LIST TIME ORDER
'7A0r
NOTED AND
. 3r.?rHOURS
iiit.
IV.. g r0r. fa --,75(,, SIGN
.c.,/,,,,.........r,_

44
,
-"---./
IP
-..''.-
NURSING UNIT ROOM NO.
BED NO. _
;.-,f_(...G S— -4-
PATIENT IDENTIFICATION DATE OF ORDER fl •F ORDER
HOURS
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
T E OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF • RDER
TIME OF ORDER
OURS
NURSING UNIT ROOM NO.
-BED NO. . , \
.... .... -.
---.
r
REPLACES DITION OF 1 JUL 77.
WHICH MAY BE USED.
1FA°PFIRM7 9
MEDCOM - 23262
DOD-036836

NICAL RECORD - DOCTOR'S ORDERS: For use or this form, see AR 40-66, the proponent agency it.
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD S1STEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE­
0 DER
TIME OF
onDER LIST TIME ORDER NOTED AND
-3) -SIGN
(.1L? HOURS
NIJR.ING uNIT
ROOM NO.
PA IENT IDENTIFICATION
'¦ (.9)-`'1/4'
\c7
NURSING UNIT
PATIENT IDENTIFICAT
DATE OF OF1042.611-.4-9
\10 (-(0.-)—(L\
-NURSiNG/uNiT
I-
RooM NO.
BED NO.
,;-' Cid --)
V In play o
PATIEN IDENTIFICATION
NURSING UNIT
ROOM NO.
C1-°/ eN(34073 C51)
, FA°, e3tr:501TioN oF
q56v-
67111111111111
MEDCOM - 2
LINICAL RECORD - DOCTOR'S ORM? FOI
f this form, see AR 40-66, the proponent agen ¦-SG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PFiObLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
____.
PATiENT IDENTIFICATION NO.J1-) DATE OF ORDER ft u eic TIME OF ORDER g S-4( 7 H OU R S LIST TIME ORDER NOTED AND SIGN
NUR S I N G U
PATI T IDENTiF1CATioN DATE F ORDER TIME OF ORDER
22
HOURS
!,2
NURSING UNIT
PATIENT IDENTIF u)--Lk DATE OF ORDE/ei 1Posi-.12A./ TIME OF ORDER /I(PM kce,,Q HOURS GY.4)7
1-1/4,4_
rSING UNIT
PATIENT IDENTIFICATI DA E OF ORDER Ti
Icku: - eivaL) a 0 3c.t.)
NURSING UNIT
nik • kA25i_D Z

MEDCOM -23264
DOD-036838

"C-UVUW\
bk6-
THEFtA. _JTIC DOCUMENTATION CARE PLAN ( -MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407;
the proponent agency is the Office of The Surgeon General. MO. 1 I Yr. 2003
VERIFY BY IMTIAL1NG .' ,— ' ,
emegeomporyo
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER-CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME-

FEIMIRIE111111 el
Iry-in.' • _-_,.../
rz

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N-ov .ar u
0111 ils
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A . 1\-kattu 14 $40 (u--)rveaut 0 A
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SYVNICCir 5 rre s
cirn‘hvvOIAAGA /Lila_ N50! 4,timeir Scfier 07 DO'S 06 ior
.
ALLERGIES: PRIAAARY DIAGNOSIS:
II. YES NO • -.
ADDITIONAL PAGES IN USE:
MI YES-MI NO
6glif AO Y./(1-rhkirn
PAGE NO:
PATIENT IDENTIFICATION:

• 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
b Li) -N-24 01 02 03 04 05 06 07 _. _____ _____-_ _ __ _­
USAPA V1.00
MEDCOM - 23265
)c, E Lfi -P.c—\
THERi, _JTIC DOCUMENTATION CARE PLAN ,--MEDICATION)
CLINICAL RECORD • For use of this form. see AR 40-407; the proponent agency Is the Office of The Surgeon General. Mo. 1 \-Yr. 2003
VERIFY BY IMTIALIIVG A''''.- Miagging.4. ,,,4, z*
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTION, HR DATE COMPLETED
DATE NURSE FREQUENCY, TIME

WrillfillIMIT1531210narl
II di Al•
WO .. .
k .10. AP_ Ltu-, e. et 1: 4-x•rez...." to a
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.
ALLERGIES:-1.1 YES IMI NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: MN YES-IIM NO
3 (A) .i(-)rb./ 5c ro-})/1 6r
1
1-1 /-6-31') PAGE NO. PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8-
9-10-11-12-13 14-15
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MEDCOM - 23272
DOD-036846

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MEDCOM - 23274
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MEDCOM - 23276
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MEDCOM - 23278

DOD-036852

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
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MEDCOM - 23279
DOD-036854
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
For use of this form. see AR 40-407; the proponent aoenc is the Office of The Surgeon General.
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E 15 16 17 18 19 20 21 22
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DA FORM-4678, 1 FEB 79 ED...—.. . EXHAUSTED.
„ USAPA V1.00
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 Ynea
VERIFY BY INITIALING IMTIAL PROPER COLUMN FOLLOIWNG EACH ADMINISTRA770N
HR­
ORDER CLERK/ RECURRING MEDICATIONS, DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

1'6 I 1,4241-Sbr-ut 210:5,6
ni-Vr'conn la_ n9 Mirla
to Uwe Ng, ri
It IL 1 ill ,•,:kst-Witt DAIL
IP°111 1:1M
M1111111.11111Mr11-
1. 4h4 , 94, ept
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MINIMIIN
ttilEvani
1 1 • L. Allanial A
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P.A•1111Ma -Eltaantaulimm11111.1
f I I —.21M7'
11111
:IA #.1? urn•NI SOA, .olutais.•4 ApAs-warairma

CD 'A 6data
(ID iCL')r
ALLERGIES: n YES NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
E] YES NO
PAGE NO. PATIENT IDENTIFICATION:
(N) u); nod)r4oln
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
-280
DA FORM-4678, 1 FEB 79 ED...-.. . — „ -.ITIL EXHAUSTED. USAPA VI.00
DOD-036856

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo..II Yr. 71:3_
Order Date 47.--- Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES VCLt f . U)VVI­i rj i fr61-p A/tk.­XL Date to be Given 22_0X Tme to be Given Time Given ‘ Initials diN
27-
\ .
\r . ,

,...)

,. /
\ \ \ .
e: C3 if (.r.,,-,-c'
, r;r
br62,_ s
Order/
Clerk/-PRN IIVITIAL PROPER COLUMA FOLLOWING ADMINISTRA770N
Expir
Nurse-MEDICATION, DOSE, FREDUENDY--
Date -TIME/DATE DISPENSED
2_240.26 119
2,1*
133 3 1600 1850 No .9.2it we do va,/, z 2
2. it ifr-7;-
i'r
0 Os-CD°
o/
, -z,--C-Iniyai ITTr-Irk. TAW 21%.0
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CY'S_ 10 ,V19 000 reLL-"re pain 0 _ _
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ornr•
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•,..71 ..itir-. IF-=-1--C V, -14-i 1
r17rCOgie-+r1-2- PC, t)
(c. -r
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USAPA V1.00
MEDCOM - 23281
DOD-036857
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
, For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED !Date, REPORT TITLE
QA APPR OSMARSINTENSIVE CAR.E NURSLNG FLOW SHEET
N E Pupils
U Sensorium
R LOC / GCS

0
C Cardiac Rhythm A PRI: /rQRS: R Pulse Strength D Cap Refil / JVD
I Edema
A Chest Pain
C

Respiratory Pattern
R
Breath Sounds
E
Secretions
s
Cough
P
S Color
K Integrity
I Backside

N
----t
Access Devices
I Location
v Condition

Abdomen
G Bowel Sounds
I Stoma/Ostomy

Device
G ­
Color / Clarity
U
INITIAL S . N • SSESSMENT
Time: Inital -rTime: Lnitals: otr -Z" _A:REZA
11KWERIENIAL I 1 1­
111/11 1 44 o /t 3 ft r-iZ-k A7
00 i .9 N.IMIrDWIF i ''r-rA ..fl't.'.- A A.#.At
1 0 'dr.6.Q.6114 ( A. JA (l'e 49A0.V e¦ fi(CO
NE, 1 1,',.))
---5' I gl Pe 1/46
D ulgo 4-1) cal atAntilie4 _ e _ p_ a s e _____ A, /ik 1-i '
—rac z ,_? scc_. oaf-r.e. II
¦ efw-1- rairl VO-C,er) e.A 6(5 ax ,-,,,,,fictiki,-
II.A...-i-•
r
itaimprJ ,­01115.140107/1WE­
.Q je
C 1 4 8 ,1 0_1-
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o ProciachuP CPS
L__L.rill Ir
,ILL frdi., 1r•r_Alf re-r
PREPARED BY (Signature & 77r/e/ DEgARTmENT/sERvicucuNic
ITIMIETIOATICA, a-it r- i ). it_ . —' ,k. _ t rn_ 1 akt ilies4_c_16./J. ALI, -4. ' a AA ¦ ,' ,A,
relminimitalt ran, C._ likk I-2_, c',0_5-c_.NM_--elL1-0-44., _
Pia i A.siniffliff.
r.i i
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IMOMMAIMPli r4, i r-dir
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114$11E/YANr q LO-__ 41C .,,t / k-/UMW/r _ _r. _, ,t0,.r
/ •r' /*_4_,/r/a 1.1.a
i
..------.---Irpnrewe nn rewarc
ICU3,
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, first, middle; grade; date; hospital or medical facility)
•
HISTORY/PHYSICAL

•
OTHER EXAMINATION OR EVALUATION

E] DIAGNOSTIC STUDIES
• TREATMENT
DA FORM 4700, MAY 78
MEDCOM -23282
_r__ __ _

Ekinvez
El FLOW CHART Ej OTHER (specify/
USAPPC V2.00
DOD-036858
z
z
G) -a -n
2 ,c2 —4 co
-a
cp
11111111g EMILE '11111
111111R5411111111MIN
111111111 c°3 INF MEM
1111111111111 *MEI
111111 111111 -AIRE
1111111111111111

11111118111111 III
1111111E11111 III
111111181111 I III
1111111121111 I III
1111111111111 1 III
1111111121111 I III
nownsomon

UNMENN I 111

MUMEINU I 11111 .e0
NUM= I MI

MUMENO ONO

MOUE= NUM

MUMENO ONO

NOUICUM NUN cK3
MOUUNN NEN

MUNUMN

MOUUNO NUM

EMENUMENU NUN

11 NOW= UM

0101WIWIT

OUTPUT
VO i ID URINE PeS I tc3riACIA..._, NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
-101) pan 9 -NO)fdreA '1461-t LI II

CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME
COLOR CHAFtACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
GRAND TOTAL OUTPUT
REMARKS
piiii:Gtuk \If oc,00 — dr, CC)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, nziddle; grade; date; hospitalor medical facility)
INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (/ oz) .. 30 HALF PINT MILK
240 SMALL FRUIT CUP 120 LARGE SOUP BOWL
240 COFFEE COP 160 LARGE WATER GLASS . .. 240
VD('-e-c(
LARGE COFFEE MUG . . . .180 PIASTIC OR PAPER JUICE CONTAINER
180
.
EDITION OF 1 SEP 54 IS OBSOLETE. REPLACES DA FORM 3630ITEMP) USAPPC V1.00
1 JUL 72 WHICH MAY BE USED.
MEDCOM - 23284
DOD-036860

LSou
--v----.....
OUTPUT
URINE 110461R.6AC.T4410:11M4-ahe TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
eg. an ,IZCO
0 Vb ' .(i)aCter 9a0
1r
.tat, ca_ „COI ID .00 et-' A
0-.r 410
, is _
ribb -760
CHEST
EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT
TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHAFtACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
GFtAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (./ oz) .. 30 HALF PINT MILK
240 SMALL FRUIT CUP 120 LARGE SOUP BOWL 240 COFFEE CUP
160 LARGE WATER GLASS ... 240 LARGE COFFEE MUG .. ..180 PLASTIC OR PAPER
MED
JUICE CONTAINER
180
b ((-(--\)-4
rm-% 0111T)R11 -inn-i A Ina ,II
1 EP 54 IS OBSOLETE. REPLACES DA FORM 3630(TEMPI
USAPPC V1.00
1 JUL 72 WHICH MAY BE USED.
MEDCOM - 23285
DOD-036861

OUTPUT
“)..,..t.-.
4-777-1
URINE f¦iiiliefilIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT , ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
OSCZI
0SCO I 30 0 14 2_0 /000
ir-Z, 0--¦ c 0
- ._ 0---1)
CHEST
EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME
COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT TIME AMOUNT 'TYPE ACCUM TOTAL
GRAND TOTAL OUTPUT
/ 30 0
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; date; hospital or medical facility)
INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS a oz) . .r30 HALF PINT MILK 240 SMALL FRUIT CUP 120 LARGE SOUP BOWL 240lag COFFEE CUP . r160 LARGE WATER GLASS .. . 240 LARGE COFFEE MUG ISO PLASTIC OR PAPER
l ir
\
\)-- JUICE CONTAINER
s-k_ 180
me, resn.n. •••• et •••-• . . s ¦• .
EDITION OF 1 SEP 54 IS OBSOLETE. REPLACES DA FORM 3630ITEMP)
USAPPC Y1.00
1 JUL 72 WHICH MAY BE USED.
MEDCOM - 23286
DOD-036862
OUTPUT
Ir
URINE
-44"446*S-T446*redal
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
D844C 45 C- 250CC-
MOIrl5C1 c10 ilco (p5cc e¦ irn 110x-c o .... 11'.. ...mitt/ r 2,6-•c-c33cc_. )4-25cc,
24..Dt 0 C Y 0
OW abISCC, CA) 1,,5—a (-
.
,
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

STOOLS
TIME COLOR CHAFtACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
, TIME AMOUNT TYPE ACCUM TOTAL

GRAND TOTAL OUTPUT
REMARKS
15-N- \101 ci re,,5dual \i•r
2_5 nov oS ac -0(0
PATIENT'S IDENTIFICATION (For typed or written eraries give: Name -last, first, middle; grade; date; hospitalor medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (/ oz) . .r30rHALF PINT MILK r240 SMALL FRUIT CUP r120rLARGE SOUP BOWL r240 COFFEE CUP r
160rLARGE WATER GLASS ... 240 LARGE COFFEE MUG .. . .180rPLASTIC OR PAPER
JUICE CONTAINER r180
4111W

L-e-
.rb - Lk

nn rnrann 70'3 IA RI -IA. -------- - ----
1 JUL 72 WHICH MAY BE USED. . REPLACES DA FORM 3630(TEMP1r USAPPC V1.00
MEDCOM - 23287
DOD-036863

.c(ch NioNci ) ,‘/
OUTPUTr
URINE -r- voo ,..440keetterem-REsicica 1 v .
V d-.
TIME AMOUNT TYPE ACCUM TOTALTIMErAMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL
o0 Cc_
;1 Bell 5-`5D o cc, III At..0.
JO 0•r
. it.o 01) IIIIIIIIIIIIIIZW:4-ePM 0 .
1 el Miln.-1 09 DM i-A.-._
•
L \ 1FIFMR7714 Ti aMEM u ... • cc 0 ta o if!q. CII) A 1 2,3bC 11K1 \'ZiciZee_
/A • ,,,,,---•----,
1(CCO 5.1) e 0 S7N5cc
A -9.-.),
Gt.-it 264?
o
-eresT
444w#(1 Irl putt)
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
Ma) 2C0 I-12.0 +\) (Ai11 200 CC IY-C ap ‘trMCC 19 0 NOCC ,MACe 240 CC IM 1)1) - 4 *OW) (.2440C1
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
NU 17run sof*
GRAND TOTAL OUTPUT
REMARKS
9_-NOV( C tO — ta_59)
.
\I \CO5e-60 r636\UM \/11rV cac v6cil,
PATIENT'S IDENTIFICATION (For typed or written entries give: Narne - last, first, middle;
grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)

MEDICINE GLASS (7 oz). .r30rHALF PINT MILK r240
SMALL FRUIT CUP r120rLARGE SOUP BOWL r240
COFFEE CUP r160rLARGE WATER GLASS .. . 240
411.11 (D ) —' LARGE COFFEE MUG . . . .180rPLASTIC OR PAPER JUICE CONTAINER r180
-
r
DD FORM 792, JAN 74 EDITION OF 1 SEP 54 IS OBSOLETE. REPLACES DA FORM 3630(TEMP) USAPPC V1.00 1 JUL 72 WHICH MAY BE USED.
MEDCOM - 23288
OUTPUT
URINE NACOCACTRIC .....Tvir
? Aigil
is / ti V la j TIME AMOUNT ACCUM TOTAL / de 0-& 2C( (6 TIME M AMOUNT /11 ACCUM TOTAL _ TIME JP& n AMOUNT 1000 La TYPE ACCUM TOTAL loop
YAT(la) irio9cc 1-700cc 16202) /07) 1-valup,_ ile-0
I, OD • C...1) I c V 1A._.e.,--‹ G.,.. A w mir.... .
64011 eat , Iff,c) _I S-0 1114.42......" 1„.4,G,
/04/14/ 400 /&D 4 -,,t) /CV
/419 ..../67,4, .444. /00
je e__ MO are s /.Ce,
/019 t2‘7-- ' /145i. 4 I 67'
‘/g0 .1&731:¦' /3.,
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL

GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Nanze - last, first, middle;
grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
iiipt MEDICINE GLASS a oz) ..r30rHALF PINT MILK r240
SMALL FRUIT CUP r120rLARGE SOUP BOWL r240
COFFEE CUP r160rLARGE WATER GLASS .. . 240
LARGE COFFEE MUG . . . .180rPLASTIC OR PAPER
JUICE CONTAINER r180

EDITION OF 1 SEP 54 IS OBSOLETE. REPLACES DA FORM 3630(TEMP) USAPPC VI:001 JUL 72 WHICH MAY BE USED.
MEDCOM - 23289
DOD-036865

-
cD c I IrI r-
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CJ1 UT

MEDCOM -23290
¦-i
,,D ‘ LP TcZTvtl. HOURS DATE
FROM a-4° HOURS TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET REDr/2-F/J.OVO,
Tora -0 t" HOURS
INTAKE
INTRAVENOUS
ORAL
TYPE AMOUNT TIME ACCUM
ACCUM TIME
TYPE AMOUNT AMOUNT
TIME TOTAL STARTED (Include Medications) RECD COMPL TOTAL
FOC .0t..' COO i t 5-.C,. g s 5-1 e
/761° //1-C
IRRIGATIONS (N/G, Bladder, etc.)
ACCUMULATIVE
TIME TYPE AMOUNT
TOTAL
TIME STARTED BLOOD/BLOOD DERIVATIVES PRODUCT (i.e. BI, Alb, P. cells, etc.) TIME COMPL AMOUNT ACCUM TOTAL TIME OTHER INTAKE TYPE AMOUNT ACCUMULATIVE TOTAL
GRAND TOTAL INTAKE USAPPC V1.00

MEDCOM - 23291
OUTPUT
URINE
NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
ACCUM TOTAL
(6/,0 ic4 ° i Fe 0
CHEST
EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT
ACCUM TOTAL TIME AMOUNT
TYPE
ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYF'E ACCUM TOTAL

GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -hist. first, nziddle; grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (/ oz) .. 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
DD FORM 792_ .1Ani 7d
M 3630ITEMP)
1 JUL 72 WHICH MAY BE USED. . USAPPC V1.00
MEDCOM - 23292
DOD-036868
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 Pate)REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
SHIFT ASSESS .MENT .-'.. '...]'','' -..`-
''''. --_-:
TIME: Moo INITIALS:11111 TIME: INITIALS: N PUPILS PERRI_.zEt PC/OZL4 Z.e_n, E SENSORIUM ,rx '3 .4V-C, k' 3
.,. ,
U EXTREMITY MOVEMENT , 'resr.r.._..,,r,;,r3--r0 ••/'r'4.-,r-.-.. .__ _. ' • :AMIE
R
P9111,7111
PAIN CONTROL AI .• P ',I „ Ulfor,,,,....."W,-.AW,

• SEDATION 111•111M1=.111111111111.11111111111.11,11M—t. -:­
c. ,,
r e.,
RESPIRATORY PATTERN -2.'z_ SPOZ.-Q Z-0, ii. ‘-A--
c...1cncl, ic.)›
BREATH SOUNDS Ne. ;rCiifa 4 'arn..0.-{s/.. 0 ie.-L/2 r... ,
(
,
SECRETIONS i ,r_ -'.7L 0-v'¦.r/r'r. 4 02 SOURCE/FLOW/SA02 IN' ..APr. /IMMO
/MitMr VENTILATOR SETTINGS Ove.".4. 0-r4 edS,rc - , Y.15.,,
.

¦rA..••.¦¦• ....,
CARDIAC RHYTHM fig- 99r.5?--lz CAPILLARY REFILL S. a See
3 5‘i-- 91°-eii if
PULSES X
14...L. =
EDEMA -•r. .r. -0'r"-- -r, .
.
ABDOMEN riliMMI9311.111111111.1111.1-r. .'. - -IFIAM•0410WAIPIWPW10111
'i----rT ir.1......:7- :7--
BOWEL SOUNDS

BOWEL MOVEMENT
NGT/OGT TUBE FEDDINGS
DRAINS
G VOIDING
COLOR/CLAR1TY
S COLOR
1 INTEGRITY I N
el S/31 11-A7,-. 11-01,11.1
OA/GT/06r ,--,4,10'r/ ve X 9--Ar_ re -.1.--... /AP
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.
DRESSING CONDITION ce,r3.-.3"r• AO-acc 1-/
IV FLUID/RATE Nit I--o 6 .4L-42 TYPE/LOCATION/S1ZE A-e-r.r„r— 111111MillION
iccu w cnc.)
/I I TYPE/LOCATION/SIZE a Tr b._ -15' A./r• icct AO rr__,. A
:
:
Dr:4. iContinue on reverse)
. _ ___
PREFARED BY (Signature & Title) N / RVIrE/CLINIC
6r--c_
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; date; hospital or medical facility)
HISTORY/PHYSICAL El FLOW CHART
NAME: RANK: AGE:
OTHER EXAMINATION OTHER (Specify)
UNIT: GENDER: OR EVALUATION
DIAGNOSTIC STUDIES
STATUS: US: AD / CIV IRAQI: CIV / EPW
TREATMENT

1

DA FORM 4700, MAY 78
USAPPC V2.00
MEDCOM -23293

'atients Nam-
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co ("'
0
0

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c73
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CO 2
cn
MEDCOM - 23294
MEL-RECORD-SUPPLEMENTAL MEDICX
For use of this fon.rAR 40-66; the proponent agency is the Office of T... ,rgeon General.•
OTSG APPROVED (Date)
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET v QA Appr 8 Mar 89
-r.-
,-,-..-,-_
::-1-4,El."'-;t1',.:_V'P' -_A- S
TIME: 0700rINITIALS: TIME: 20:90.INITIA
ti-PUPILS PERL-Z+ + Ps-,,..,--hz---2 -1-,
--SENSORIUM Atox 3 Si-e,
' EXTREMITY MOVEMENT

1-.49 e-a. 7-7.-
SEDATION

525. ,SPein 4-Coy., 9 se-da),bir;
PAIN CONTROL
V ....¦ eh irn ; PK a Il 4 Ct. Perror.e4-pe.•• NSOVrProreeef-1.2//. . ‘//71-
3.-.-d
, 2 ' 7 ' 'rSRE PIR_ATORY PATTERN a s
47e-A.-VeZ ,_7% oi1.47
tql, -r
P41 BREATH SOUNDS Lu.1 c,„...4. -(1TA-a) cl A L '1‘.'rSECRETIONS
or Sfacrelles
02 SOURCE/FLOW/SA02 P-1-row N'4-1,..", Atr. Aookn 1/r--
, VENTILATOR SETTINGS Ovevg „kJ-0

_10-kt.,gruroprevii.ei-nre e ellA elk whe•I diP•r great•vs redf,/416/e eq0C,A
CARDIAC RHYTIEvI NE-.RP--V-Ae; 9
. CAPILLARY REFILL

lIc.p:fir..cif P..pcn--'.5.:3:Cee -43-3See:
' PULSES

plitAps-r.s4.-mrss X._4.. p-ertpi-e,4, 74-7, ,v/se_s-x (1 (-x7.—
EDEMA
0 erievvie,rn.rn4t4
.

' ;
--...4 ABDOMEN
.P4.11,r4-e4witir Crorn IA k),AAto A.Ninki cirdeJA• / .01 e- 7`-ezIder--
-BOWEL SOUNDS
Er.. A.,,e/ sew .ucts -rkleare....0cve %LI ,ecre ?4'ire__' BOWEL MOVEMENT
Ca 13.01.
NGT/OGT 0 nv.-r/oco-r
..
,• TUBE FEDDINGS 0 -n.1" 5erthsg
0
•_ DRAINS
P c r4 cr. akrs priraCP-717,rje,r0/-111-ii R,,,, ,
r;rVOIDING
r: 1rir1"X
i,rCOLOR/CLARITY

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PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last,
first, middle; grade; date; hospital or medical facility)

HISTORY/PHYSICAL 0 FLOW CHART
NAME: RANK: AGE:
OTHER EXAMINATION ID OTHER /specify/
UNIT:r GENDER: OR EVALUATION

DIAGNOSTIC STUDIES
STATUS: US: AD / CIVrIRAQI: CIV / EPW
TREATMENT
DA FORM 4700, MAY 78
r
USAPPC V2.00
MEDCOM - 23295
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MEDCOM -23296
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
INTENSIVE CARE NURSING FLOW SHEET it) t Appr 8 Mar 89
:: :
SHIFT ASSESS NT TIME: /5-?0 INITIAL TIME: /130-INITIA dip N PUPILS rEiefti_ 0+4 1),,,,,-.-4. z-i-E SENSORIUM Loviabto_ 4c A.csecs At" vtra-ies -I6 /14_:(14/ ,S/i.:7704U
EXTREMITY MOVEMENT iverwe. p rese„,4 ' V 54
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PAIN CONTROL MSon . Vcdrwvi....fercorw4-
RESPIRATORY PATTERN EZ-- 14 SPD-7--Mr) % eussr21-vi& P& - / '--./i5r wz 9,0s,0,-4 BREATH SOUNDS wan,-re..1,7rea,Art.k..- • iirsorrrder witeethoi (S) et;e4rSe e001G,'"-4M`` -
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SECRETIONS 29....cerse-4-car4s 06-Ere (e7i.odef
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—
VENTILATOR SETTINGS di vie...4-1112.4.--sr

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CARDIAC RHYTHM kg-51( gp IZSitan _5,nv.5 *7%-,-,
CAPILLARY REFILL -4P-3s.cg. 3 61-..e
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ABDOMEN BOWEL SOUNDS BOWEL MOVEMENT NGT/OGT TUBE FEDDINGS DRAINS tSrrei-­Vic,4.5/p Eu lutooacAic­vi 0­-R 14'1 1:2( NoT, cG-r 95 7419 o Pe,/­s col'clrett...-s Ccp
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PATIENT'S IDENTIFICATION lFor typed or written entries give: Name—last, first, middle; grade; date; hospi al qAmedical facility)
O HISTORY/PHYSICAL 0 FLOW CHART
NAME: RANK: AGE:
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-E OTHER EXAMINATION 0 OTHER (specify) UNIT: GENDER: OR EVALUATION
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DA FORM 4700, MAY 78
USAPPC V2.00
MEDCOM - 23297
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MEDICAL RECORD-SUPPLENIENTAL MEDICAL DATA
For use of this form. see AR 40-68; the peoponent agency is the Office of The Surgeon General. 0 OTSG APPROVED Pate)
REPORT TITLE
TRAUMA FLOWSHEET QI Appr 11 Jun 97
The proponent is Dept of Surgery
ARRIVAL STATUS
EMS REPORT
UNIT: TIME 041.40 0 IV x k kr_02 1 /min 0 EherrIntrilf
TIME: ETA:
Meds: sktUKN 0 None 0 Yes:

MED COM:
Allergies: '0-None 0 Yes:
Tetanus: ACUKN Current Last Meal/Fluid Intake hrs

D
-a'

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PRIMARY SURVEY
CIRCULATION .
BRE:MING
AlFtWAY" •
PULSE: esent 0 Absent SKIN: KWarn CI Cool 0 Hot
Labored 0 Unlabored CI Absent
\;,...7eatural Patient
BLEEDING: er.rti liteink 0 Pale 0 Cyanotic 0
TRACHEA: 0 Midline 0 Deviated Isitwor
(3) 13 HEART TONES: XCiear 0 Muffled A'Dry CI Moist 0 Diaphoretic
CHEST SYMMETRY:
0 Seaetions
SECONDARY SURVEY
FIEAD
PUPitt;iir-Eouai Foced 0 React 0 Dilated a RHYTHM: iKegular 0 0 Soft Rigid 0 Non-Tender
GCS: E
13
PULSES: 0 Central 0 Peripheral Sender:

TM-Clear CI Blood
tcY
PELVIS-
NECK. ; too,iGs,
Uns-table
SPHINCTER TONE:

BREATH SOUNDS:4_13ilat "(Equal 0 Clear 0 Stable Thu-`1
C-Spine Tenderness:
Blood at meatus/vagina: 13
Pain @ Decreased a Absent 13
AWNL Wheezes Crackles a Herne+ - Prostate: CI WNL Abnl
0 None
JVD:
VASCULAR ASSESSMENT
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN
(AB)rasion
CAMPlutation
(AVlulsion

Battle's Signs
(BLIeeding
(B)urn
(Dleformity
(E)cchymosis
(F)oreign Body
(H)ematoma
(LACIeration
(P)uncture (W)ound
(Pain)
(S)eatbelt (Slign

(S)tab (W)ound (GSW) Gun Shot Wound + + Strong + Palpable D Dopler
4.fir
PHYSICIA
Lt on reverse
PREPARED BY (Si
/CC)\ (LY
PATIEN E Fl rst, O HISTORY/PHYSICAL El FLOW CHART
middle; grade; date; hospital or me cal facility)
O OTHER EXAMINATION OTHER (Specify) OR EVALUATION
.
!AGNOSTIC STUDIES
O TREATMENT
REc' ```-'e ^"''CRED BY DO FORM 2CO5.
EAMC OP 503, 1 Dec 98
DA 1 FaRYM78 4700 MEDCOM -23299r;CLETE.
......
V..L. SIGNS
GLASGOVV COMA SCALE
.ial Temp: GCS: 1c :::,-. EYE OPENING'.
, YREBLE FIE1:!ON'EE
,-,-. •:':iloitiFiilESP,ONSE',,,
.• ,-,-..-..
liME . BP, . FIR :gfri, RR . SAIDi FIO MODE
4 -Spontaneous 5 -Oriented 6 -Obeys Commands
DIV) illiq 6( AS IS 100(a 3 -To Voice 4 -Confused 5 -Localizes Pain
:VAC') l';i /7:4 —1 I. / / / / NS r g t.civ 4 2 -To Pain 1 -None . .:::-.T.i,nn 3 -Inapp Words 4 -Withdraws to Pain 2 -Incomp Speech 3 -Flexion to Pain 1 -None 2 -Extension to Pain 1 -None pfpnicxclu,13,k, -,0:03.04,00,40,y;
/ 0 Backboard Removed BY:
/ 4---E1 Downgraded B.Y:
/ NOTES
/
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MEDCOM - 23300
DOD-036876
e, PR teoliai size srit ' y ^Reath:Ts' --. TIME-PROCEDURE ACCOMPANED BY RETURN 0 Oral 0 ETCO2 Change
CT Scan: 0 Contrast 0 Nasal 0 BBS Post Int
lntubation Teeth 0 Post CXR
ET
0 Head 0 Abd 0 Pelvis 0 Air • ' ontents Q C-Spine 0 T/L . • Chest
Gastric
0 Oral
0 V led
0 Nasal 0

Tube :uction: Y N
cc . Gram Site:
0 Return
Urinary
0 Meatus
CI Herne Dip: + -
0 Supra-Public IV ACCESS & FLUIDS 0 Secured v-,-..
' "-z-i-'?:
LA1iit'SOPr
0 Grossly: +r-, r2=r,r. '
DPL Cl Opened
Cell count MIME N grAMMIll0 Clo
Sent@ .
Y N
13 Air 0 Blood
Chest
0 Pleurayac cm Y N

L R
Tube # 0 Autotransfuser
Y N
0 Air 0 Blood
est MEDICATIONS

0 Pleuravac cm
L R — . . :„.:
Tube #2
0 Autotransfuser EDICAT,-. .. E DOSEra-oose , . s
Rhythm: Comments
12 Lead
T---e,-4.4,1 L CCElligi 7 -Ta-,..k.A.„ 3131M i 4.u i -Q__,,
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LABS X-RAYS

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UD-stick 0 SHct leChest Initial
D-stick SHct 0 Chest Post ET
*CBC • P.:them latT/PTT 0 Chest Post CT BLOOD PRODUCTS
0 ETOH T&S x C-Spine

TOx Screen )(Pelvis
efril(UAr0 HCG 0
0 OTHER
IVF Urine NGT NGT Blood EB1 Other Other
TOTAL TOTAL TRAUMA TEAM ARRIVAL VALUABLES & CLOTHING
.
-7, - n.,
. .-,.r.-k., -1,i?..A.
.,
',..,:i ,•-' $ .
.., .
D Phys It-1--LQ-ce---. None Found
urgeon
Given to Patient .nesth 1.— Given to Family . Inventoried and Released t6 Patient Trust FundfNCOD See DA Form 3696
Other: See Nursing Notes
X-Ray
DISPOSITION
RT
I 0 Home . C)r' Ortho
Admitted to
Neuro Report Called to
Time Transferredr-r

Chaplain ---
Acco panied By MEDCOM -23301
tretcher 0 Wheelchair i ra A e new A rl C Dranest,Ne.....•-rt v..-ri .....
DOD-036877
6 (.(2--q
REUG1ON / RELIGION
pc...„.
a. UNIT /UNITE NATIONAUTY / NATIONALITE
FORCE / ELEMENT .
An' ARA I-N/M IRAIDI CPW

MC'N
BC/BC

I-Nal /13NC I DISEASE / MALAD1E I-I PSYCH / PSYCH
AIRWAY I TPACHEE'3. INJURY /BLESSURE
HEAD /TETE Y WOUND/ BLESSURE
NECKMACK MULMY I BLESSURE AU COUMU DOS BURN / BROLURE AMPUTATION / AMPUTATION
FRONT / DEVAtiT BACK / ARIVERE
/
STRESS / TENSION
OTHER (Sp.d FYI / puTRE (5p4ofied
CIr 6 .1 ) .4.4: 0 side.ebri.J
C.79.41 '''
Atkic,-te.
s P3t-PAA,,-4J-,e.,/
A 1 Pa. di if
I. LEVEL OF CONSZIOUSNESS 1 NIV EAU OE CONSCIENCE PAM RESPONSE/ REPONSE A IA DOULEUR
Xi ALERT / ALERTE
yERBAL RESPONSE / REPONSE VERBALE uNRE SPONSIVE ; SANS REPONSE
I TIME HOURE r----1 NO/NON in yes,ou,
S. PULSE/ POULS , TIME / HEURE S. TOURNIQUET / GARROT
•,
V / n/ TimE / HELIsfs
NO/ NON ril YES / OU1 los , t...)-43r70 D eti5 i . TREATMENT / OBSERVATIONS / CURRENT MED ON/ALLERGIES /NBC LAN11DOTO TRATEMENT / OBSERVATIONS / PRESENT1 MEDICATION / ALLERGIES /ANTIDOTES
T. MORPHINE / MORPHINE .. ' DOSE / DOSE I TIME / MEURE 10b1e
PR55Ore. cli'e5Str),3 41) 5rc;ill,r, i
exts+ vx.,..n..1 VS7 014(cilei )

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TIME/ HEURE
DISPOWION
EVACUATED /EVACUE
DECEASED/ DECEDE
11. PROVIDER/ UNIT / Of FICIER MEDICALE/UNITE DATE/OATE (YYMMDCO
2617 4.1 g r A , DO Forra 1380, rna fonn replaces previousedltions . U.S. FIELD MEDICAL RD
DEC 91 of DO Form 1380.nd DO form.FICHE MEDICALE DE L'AVANT ETATS-UNIS 1360(7E5n whkh are *to:4M
MEDCOM - 23302
k2 t
1. Reporting MTF 2. MTF L,__ Admission -, id Coding Information
IZ For use of this form, see AR 40-400; the proponent agency is OTSG
__.
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
MUM FGN M

6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
X 9

10. Length of Service ETS 11. FMP 12. Social Security Number
99 r-Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
09:38
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 ICU1 Address of Emergency Addressee
Telephone Number of Emergency Addressee
Name and Location of Medical Treatment Facility:
0580 -28th CSH -Iraq; No Install Provided

21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-OTH 2003-12-09

24. Clinic Svc -Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
ABA -GENERAL SURGERY

2003-11-03
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-03

FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW ABD/SCRTUM/GROIN

Procedure Narrative(s):
Cause of Injury Narrative:
54. a ,)
Admitting Officer (Signature, as required)
Automated Facsimile - DA FOr
MEDCOM - 23303
, PAY GFtADE
9 11 . SEX
10 12
15 MEI CI
. DATE OF BIRTH
(Y Y YYM MD D) INN NI
. AGE AT ADMISSION
ETHNIC RELIGION
El 2° El1E1E310111111ECIENE112
BACK­GROUND
111111111111111111111111.1111111111111
10. LENGTH OFiERVICE
11.
FMP

12.
SOCIAL SECUR1Ty NUMBER

DEMI ETS
1111E111E1 . 40
11:111112111211:111C1
ORGANIZATION
(Active Duly Only)
13. MARITAL STATUS
HOUR OF
'BRANCH / CORPS 46 ADMIISION
14. FLYING STATUS
15. BENEFICIARY CATEGORY IS. ZIP CODE OF RESIDENCE
47 50 co
1111ZIEUZIEME:11:11
6°
CI
17.
UNIT LOCATICiN (State or 11111111111111111111111111111111111

18.
MOS

Country Ccrde) 19. TRAUMA
62 PREV. ADMISSION
1:111311011:111130E11111
YEAR
NO
20.
SOURCE OF ADMISSION/ AUTHORITY FOR
-1
WARD
i ADMISSION NAME/RELATIONSHIP OF EMERGENCy ADDRESSEE
72

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
22.
MTF TRANSFERRED TO

23.
DATE OF DISPOSMON

'73.-(YYMMDD)
-80 -
112111E1116111311131
_ _ _ _ _•
24. -
CUNIC SVC - ADMIT1ING 25.
MTF TRANSFERRED FROM 26. DATE 17-1IS ADMISSION
90 (Y Y MMD DJ
11311:1110EICICKI clam

1111111111111111
11111111111111111111111 illammisam
27. LOCATION OF OCCURRENCE 28. MTF OF INMAL ADMISSION
(Battle Casualty OW 29.
1 03 104 DATE INMAL ADMISSION
(YYMMDD)
.105 106 107
108 109 110
1111111:1111112111011113
FOR LOCAL USE
'
Co (
co a ,ce
ADMITTING OFFICER
(Signature, as required)
SIGNATURE OF ADIVIITTING CLERK
DA FORM 2985, MAR 89
EDMON OF tvIAY 79 IS OBSOLETE
USAPPCV1.W
MEDCOM -23304
MEDCOM - 23305
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
• t Civillants)T-heck'oney,ff,X)
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.. .. . ...... ...
.
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. . ...•r•r•r• •
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Date of Report: (D/MN)
Time of Report:
hrs .etairkee: ....
MOOr:
'a$ arn -
........

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.
•• :
01':6)ori*
.................. ... .. . :••"" .

Hair Color.
Scars os/Deformities: Hair Color: Scars/Tattoos/Deformities:
\)
Eye-Color: Weight:rlb 'Height:rin Eye-ColOr: Weight:r
lb Height: in
Address:.
Address:
Place of Birth: .

Place of Birth:
Ethn/Tribe/ Sex: Phone#:

Ethn/Tribe/ Sex: Phone#:
Sect'
DOB D/M/Y: I Mobile Sect:
Ir1 DOB D/M/Y: MobileIrI Regular
IrI Regular FlPassport IrI Dr. license IrI Other (specify) Passport Dr. license Other (specify) Document #:
Document #:
1/etude,:r.. ... ....
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.............................................................

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4
......... . s•r

........... ......... ...... ....r

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IrI FlWeapon

Property/Contraband
Photo Taken of Suspect with Weapon/Contraband: Yes/ No
Type: I Model: Color/Caliber:
Serial No.: 'Quantity:r

'Make: Receipt Provided to Owner: Yes/ No
Other Details:
'Where Found:
Owner:
. ... . C rita ct OfP .:;'S "
•-• ......... ... .. .

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0011;
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•nit Date: ...........

MEDCOM -23306
1. Reporting MTF ''' -2. MTF
IZ Admiss'i. ariu-Coding Information
-
For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number MOW Name (Last, First, MI) 4. Pay Grade FGN 5. Sex M
6. DoB (YYYYMMDD) glialf 7. Age at Admission 30Y 8. Race X 9. Ethnicity 9 Religion i
10. Length of Service ETS 11. FMP 12. Social Security Number
20
Organization (Active Duty Only) 13. Marital Status 6-I1rHour of Admissioni —Li Branch / Corps:
23:25

14.
Flying Status

15.
Beneficiary Categqry

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 ofEmergency Addressee
r. Telephone Number of Emergency Addressee
Name ar• , • cilityoca) ____r.....
,r21. Type of Disposition ,!
22.
MTF Transferred To

23.
Date of Disposition (YYYYMMDD)

TRF-OTH 2003-11-04
24.
Clinic Svc -Admitting

25. MTF Transferred From
26.
Date this Admission (YYYYMMDD) AAA -INTERNAL MEDICINE

2003-11-03
27.
Location of Occurrenc,e

28.
MTF of Initial Admission

29.
Date of Initial Admission

2003-11-0,3-- _„----„r„e„.--
----.......:2.,.......::,,

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FOR LOCAL USE
/r
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Type Patient (Inpatient / Outpatient): Inpatientr /r \r, ,,,_
Admission Diagnosis Narrative: MULT CONTUSIONS r 7
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C22..4,-.1.0_.0._rCkSia*--S•r,
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Procedure Narrative(s): 1r
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Cause of Injury Narrative: .
\\...._______
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..„---+"–S-ignature o AdmittinrClerk
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DOD-036883
Automated Facsimiler
aNI-ATIENT TREATMENT RECOrto COv-R SHEET
r
For use of this form, see AR 40-400, the proponent agency is OTSG
-
2. N-Ir-3. Grade Admission Remarks
(4-r-Ci FGN

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Source of Admission

22.
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23:25
24. Name/Relation of Emergency Addressee 25. Type Disp
TRF-OTH 27a. Address of Emergency Addressee
27b. Telephone No
29. Re ortingMTF
‘› ( 7') ---L--
31. Selected Administrative Data Marital Status:r In/Out Patient:rInpatientr
33. Cause Of Injury:
_-
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-______.---
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34. Diagnosis / Operations 'and Special Procedures: r
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MULT CONTUSIONS
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••,----• I
.
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Automated Facsimile - DA FORM 3647, NO
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19. UIC / ZIP 20. Type Cas DIS
23. Clinic Service AAA -INTERNAL MEDICINE
26. Date of Disp 2003-11-04
28. Date This Adm: Admittin Officer: 2003-11-03
.
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30. Date Mit Adm 32. Units Blood Components 2003-11-03
. ---
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Bed Days
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. ­
----4v1---
579 . z, .7 ___-------- .._--
Total Sick Days
i
ick Days
AUTHORIZED FOR LOCAL REPRODUCTIC
'MEDICAL RECORD I- PROGRESS NOTES
DATE NOTES
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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
gal
STANDARD FORM 509 (REV. 5/199 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 USAPA
MEDCOM -233
DOD-036885
MEDICAL RECORD
DATE
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STANDARD FORM ROO 6IE9. 6-97)Pruning) by GSA9CIAR FIRM 141 CFR) 201-92024-USAPA
MEDCOM - 23310
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MEDCOM - 23311
NSN 7540-01.075.3786
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EMERGENCY CARE MEDICAL RECORD-AND TREATMENT
RECORDS MAINTAINEOTRAE TATMENT
(Patient)
PATIENT'S HOME A LITY STATION ,r ARRIVAL
.
STREET ADDRESS DATE (Day, Month, rear) IT.r(.5)
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SEX • DUTY/LO HONE MILITARY ST RTY INSURAN AREA CODE NUM ITEM YES NO NIA ITEM S NO PRP ADDITIONAL INSURANCE
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AG.-7 HOME PHONE FLYING STATUS DO 2568 IN CHART
AREA C NUMBER MEDICAL H RY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICA 10 S INJURY OR OCCUPATIONAL ILLNESS EMERGEN ROOM VISIT
' WHEN fDate DATE LAST VISIT 4 HOUR FIETURN '

ITEM YES NO
n YES n NO
\10ri'N ‘ ( ) IS THIS AN INJURY? WHERE TETANUS
ALLERGIES DATE LAST SHO COMPLETED INTITIAL SERIES

INJURYISAFETY FORMS
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CATEGORY OF TREATMENT VITAL SIGNS
TIME TIME .2....5 b o 0 9 f
EMERGENT
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ORDERS PU SE OX J ) -0 ir n MONITOR n
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DISPOSITION DISPOSITION QUARTERS IOFF DUTY PATIENTIDISCHARGE INSTRUCTIONS
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•
MODIFIE DUTY UNTIL RETURN TO OLITY
CONDIT! N UPON RELEASE ADMIT TO UNITISERVICE REFERRED op. TO WHEN
IMPROVED UNCHANGED
DETERIORATED TIME OF RELEASE I have received and understand these instructions.
.---""--) PATIENT'S SIGNATURE
PATIENT'S IDENTIFICATION the typed or written entriee, give: Name -last,
firer, trials; ILI na ISSN or Wert hasaim/ or
medical leedityl
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9.961
Presclibed by GSAIICMR
FPMR 141 CFR) 101-11203(bRIOI
USAPA VI.00
-
MEDCOM - 23312
DOD-036888

NSN 7540-01.075.3786 TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENTMEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
ABGIPULSE OX RADIOLOGY Check if read by radiologisi
H/H UP 02 PH PO2 RESULTS
-7 7,421 -
PLT PCO2 SAT OTHER --- 4?"`'
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PROVIDER HISTORY/PHYSICAL
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PATIENT'S IDENTIFICATION For typed or written entries, give: Name last, first, mte'd4" ID no. (SSN °theft hospital re merical Maly!
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 IREV. 9-961
Prescrked by GSARCM))
FPMR 141 CFR) 101.11.2030)/1101
USAPA V1.00
MEDCOM - 23313
DOD-036889

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, WFIITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER-TIME OF ORDER LIST TIME
•-• . ORDER

,i.4.1 I.) Oc.). _5----NOTED AND
HOURS SIGN
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NURSING UNIT ROOM NO.
BED NO. A-4/ : 1:. .7._,-..r.v. / I 71."--4--Cerc..1-11"--„,..,.. 0 ..-7,0 p.• -,,,,--4_,",
ffro-i r nr-Eroo /N.) d--e--6,1--•?,:`.
PATIENT IDENTIFICATION DATE OF ORDER­TIME OF ORDER
1 .
HOURS
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PATIENT IDENTIFICATION DATE OF ORDER-TIME OF ORD ,
.-__
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NURSING UNIT ROOM NO. BED. NO.
PATIENT IDENTIFICATION DATE OF ORDER-TIME. OF ORDER
._
HOURS
____.
NURSING-NIT ROOM NO. B.ED NO. .
-REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA IFAr,m79 4256
MEDCOM - 23314
DOD-036890
_
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-r DAY
MONTH-YEAR DAY 1‘,Iii--) '
19
HOUR 1412_ --b --: -.• •• •• -.• • • • • ..• •• I,
-
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PULSE TEMP. F . .. . ..../ : . . . . . . . . . . . . .
. -• • TEMP. C
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130
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120 " --r• • " . . 36.7° -o
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100 96°
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RESPIRATION RECORD
-
BLOOD PRESSURE 12'1
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'ATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, 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, F1RMR (41 CFR) .201-9.202-1

MEDCOM - 23315
DOD-036891
.

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r ' —r
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Calculated 11AR ­
Sample lype:citrated oh. blood
r
lest Date 111/031(13r(.1).,.7.,_
lest. lime •73..46
C,ard Lotr
Operato I'

RAVIDIAIIIA1 COPAG Nt\INE1 LER \i4.t.',4
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b (t.., - 0,
li)t.'leht 10:000
1 est Mite ..0.11
Test Result ..---- 11.9 sec .
***RESDLI DUI QV RMICIE-4-**
Sample lype..citrated oh. blood

-fest Date :11/0'3103
lest lime :23 .. 48 r\i\E:Id
Lot :100203r10:‘A-
Card
com 23316
-
Doerator
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REF ,
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RESDIT
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3.5
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PICCOLO

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Fr:11L

98-BC7F-,1-
03/11/03 23:51 ; 77-7' rz:Vd!
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i 7.31
REFERENCE RANGE: 04.-r
MAL ;.ra
[-P-C.02
L.TI
35--1 PAT TENT #:
I 41 -51 I 0.6-1.774:7c.71
PO2 LIVER PANEL LUS ?till
80-1C
I Ni.-1.( DISC LOT #:

TCO2 3153AA7 .6 mg/d1
23-27
OPER #:

24-29 DR #: 000 3.3-4.7 rrtm431/1
HCO3
22-26 SERfAL vdf
23-28

s02
95-98
ALB 4.5 3.3-5.5 G/DL ======= PICCOLO =======

3mide.1
(-2) — ALP 82 26-84 03/11/03L
U/L 23:51

riLmo1.1 REFERENCE
AnGap ALT 62* 10-47 U/L mVcil
10-20 MALE
PATIENT #:

AMY 43 14-97

U/L mgal
METLYTE 8

AST 217* 11-38 U/L

g'.(11 DISC LOT #:L
8 -'76 ru. TBIL 2.4* 0.2-1.6 mo/pL 3151AA4
OPER #:L

GGT 11 5-65 U4L . mi.pR #: 00D

70-105 .17k)
WWI TP 7.5 G/QL SERIALc„-(.41111111111/.
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CreaC P. ........... ), ..............

-

'GE GLULL
Fict INST QC: OKL,eed 104 1173-118 MG/DL
CHEM GC: dK

38-51% BUNL
HEM 2+, LIP 0-, ICT 0 if 28* t?-22L

Hg-b itt CRELMG/DL .
12-17 gA 1.5* 10.6-1.2 MG/DL .
CKL

.s. 139-380L

".: y U/L .
( (N-f) NA+ 126* 028-145 MOM_
REF. R.. : (F) K+L
5.3* 113.3-4.7 MMO&L - .

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Drug of i,
INST QC:•00 CHEM QC: OK.

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iIrRE :NL-U-CKS:
REPORTED BY:
I DATE:
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1
MEDCOM - 23317
.
THERAPEUTIC DOCUNIENTAThIOIN CARE PLAN (NON-MEDICATION)
CLINICAL RECORD 40.-4,-;
the proponent agency Is the OgrCesgthRe S -g°e7on General. Mo..Yr. 2003
,..?::: kg*,.X;''W-'
VERIFY BY IIVITIALING -,?,--''.. INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
,
HR DATE COMPLETED
ORDER CLERK/ RECURRiNG ACTION,
DATE NU FREQUENCY, TIME
3
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ALLERGIES: ME YES aStN0 PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
Mil YES., MI NO
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. PAGE NO.-••
PATIENT IDENTIFICATION: .

"
ACTION TIMES
I,-­
...._ _­
USEPENCIL. CIRCLE ACTION TIMES D 8 9-
10 11-12-13 14-15
•rE-16-17 18 19-20-21 22-23 6-,( 6-0-r
N-24 01 02 03-04 05 06 07 _____ _ ,
MA BE USED.
ORM 4677, 1 OCT 78 -USAPA V1.00.
MEDCOM -23318
DOD-036894
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN initiaiing (NON-MEDICATION mo ir 2003
)
Order
Cleric
Date to Time to
Date Nurse SINGLE ACTIONS Time Done Initials
be Done be Done
4
411!vvii 00'4rI
A-Nam : (VW/ i 1 ir (44 4144
,
- - -AthitiLtD VW CaAtip
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_ _ _ _ .
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Order/
Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Date Nurse ACTION, FREQUENCY

TIME/DATE COMPLETED
— — — — _ _
:
_ _ _ _ _ _ _ _ .
— — — — — — — —
_ _ _ _ _ _ _ _ '-
—
_ _ _ _ _ _

—
_ _ _ _ _

mFrumm 91110 USAPA V1.00
CLINICAL RECORD 1.— THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)For use of this form, see AR 40-407; the proponent agency is the Office of The Surgeon General. Mo..Yr.
VERIFY BY INITIALING . INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRA770N
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED

DATE NURSE DOSE, FREQUENCY
JI es 30414 ?.-P 0
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¦ ADDITIONAL. PAGES
IN USE:
0 YES 0 NO
kW& UM/
Orgn 14/051U
.

PAGE NO
ATIENT IDENTIFIcATinki.
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES D 7 8-9 10-11-12-13-14
111111L(,
E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
45)

EDITION OF 1 DEC 77 WILL SE USED UNTIL EXHAUSTED.
'AiFFI'm 4678
MEDCOM - 23320
DOD-036896

THERAPEUTIC DOCUMENTATION CARE PLAN
MEDICATIONS)
Nlerayby
Time to I nl t I al s
Date to Time Given
be Given SINGLE ORDER. PRE-OPERATIVES
bo Given
Clerk/
Date Nu se

Order
MI
11111111111111
11111111111111
IIIII-UMW

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IS-11111111111111111
NI-1111111111111
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MN---2 AAL

111-11111111M111
NML

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ADMINISTRA77ON
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INITIAL PROPER
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P RN '.:LTIME/DATE DISPENSED
Order/
.-Clerk/­exPli.Nurse MEDICATION. DOSE, FREQUENCY­
. sP.A-11C).-E11111111111111111111111111111111
Date CC-"/'­
1111111111111111111111111111
111111
1111111111111111111111111•111111111111
11111111111111111111111111111111111
1111111111111111111111111111111111111111
MMITIMMOMMOMMO

MINIMMINIMMO
MOM WOMEOMINIM
WOMMOMMEMMEMOM
111111111111111111111111111111111111111111111M111111111
GPO:.199B-464-110/95216,
MEDCOM - 23321
NW_

t)
COALITION PROViSIONAL AUTHORITY FORCES APPREHENSION FORM
0
`raELLO'N FIELDS i¦AUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION Offense against Ckiiiian(s) [check one] tf -Other then describe:
3,-2) Seti•-•-ation ctr (I.P.C. 399) Ra. pe/IndecentirScxttair(1:.P.C. 393:98; 402)r"
.
.1
.
Murder 4C:7T; .
Aggravated Assat.A.,-,.-ti:.-trv•rth went To Kill (t.P.C. 410)
Maitr2rsg 12)_ -

Simp Assault (I.P.C: 415)
ki"cfnappel• g 421) •

al:TgfOry Of }-iousolara....-J.':tng 428)
Ex2ortk:,-1/Corrtrourcatirvg Tnreats (LP.C. 430)
1 Theft (I.P,C. 43972" .
:r•
Destritc:tiort of Property (I.P.C. 477)r•

. Oestnictmg a Plettlic tiigh.v.arrPlace C 487) Dischargin9 firo.afrn/ Explos:r.4 in CityrrowniVillage 495) Riot or Breach e Peace (I.P.0 495(3)): &hot:
00ffense.against CoalitiOn_Forces (chek One] If "Other then describe:
Vitaion of CUrfevir
Illegal Possession et 44/capon.

rI
AssauttAtbacic on CoaZtiort Forces
I ,, .r
I
IrI Theft of Caalkio.-1:Force Pr:O9arti-:
:Apprehending Unit:
:Date of InCident (C)/N1/Y)

:---,/.:"..t./03to. • • / •••••:•:
Time of Incident:::,
:
-7:": Eietaine e:#
Last Name:
First.Narne:
Hair Color:

13
Eye-Color: ;,./1
Address:
Place of Birth:

Ethn/Tribe/ Sex
Sect-

Passport
Document #-.
:Giy.en Name:
rtattoos/Deformi

Weight: lb Heigh:: in
Phone#: DOB D/M/Y: Mobile Regular
-7 ntu./73
Dr. license Other (specify)
1.-',IJOtisi:::Ndrnbe(of:Rersons..1:nVoNed:::. .. ... r
VehicleinfOri-rtatiori::: • ::Vehible hlumber
IVIake. Color: VIN:
MOdei: • Plate No.:
Narhes-Of Peopie in Vehicle:

;-,ContrabandAA/eaodns in Vehicle: :
Trespass on Military Ir.stallation or Facility Photogr-aphing,'.8urVeitErt Milry...InstartatiOn.or
ObstraellnaPerforrnance or MilitariMis-st9t1'..
r1
otiva4 . . .
•'I t_ocation:Gricif
Date of Report: (D/M/Y)_ Time of Report:
' aas:
hrs
•Key Obnnected Person! : Witness : Last Narne:: •
.First Name: • :Giver-I.:Name:" Hair Color: Scars/Tattoos/Deformities:
Eye-Color: Weight: lb 1--leight: in
Address:
Place of Birth:
Ethn/Tribe/ Sex: Phone#:
Sect: DOB D/M/Y: Mobile
Regular
Passport • Dr. license Other (specify')
Document #

reYerse'Undet'AdOttionak:Helpftglnforrnatiohl-
• Vehicle(s): :.; -Owner;
[Number of People:in Vehicle:
Property/Contraband Weapon Photo Taken of Suspect ..v:th Vv'e-ipon/Oortraband. Yes/ No Type: Model Color/Caliber.
r
Serial No -Quantity: Make Receic,: Provided to Owner: Yes/ No
Other Details: Where Found Owr,er.
Name terpreter: Ema:I, Phone, cr Contact Info,

Detai Si:;.•-ervising Ce5GRI. Uen-m.
(Print?. (Print1:
Last, Ficst Last;-First Mi.
Sionature:
Ema:;: • tt.L
I la:t Phor-e: r.)ate:_ tJn;t• Phore Date:
MEDCOM -23322

COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
0
Why Wa S. this person detained? CL.taz d Ca Srci-kc
Who witnessed this person being- delained or the reason for detention? Give names, contact numbers, addresses.
How 1,vas this person traveling (car, bus, on foot)?
Who was with this person?
What weapons was this person carrying?
What contraband was this person carrying?
¦
f
VVhat other weapons were seized?
../
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What ot!ier information did you get from this person.?
-Yd e_Q.vsock
COLd
Additional Helpful Information:
1
MEDCOM - 23323
Automated Facsimile
INF- -1 IENT TREATMENT RECORD GOV._ _ SHEET _____---Foruse-of-ttrisfofm,seAAR 40-400, the proponent agency is OTSG
1. Re i terr .
-Namer 3. Grader
Admission Remarks :rFGN
-Li r:_
.r
r
4. Sex 5. Age ; 6. Race 7. Religion 8. LnthOfSvc 1 9. ETSr10. PrevAdm 1I
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15. FlyStatusri 17. Dept / Ben
18. BranchCorpsr19. UIC / ZIPr20. Type Case j K78-PRISONER OF WAR/INTER
DIS r__L__
¦ 21. Source of Admissionr
I 22. Hour Of Adm:r23. Clinic Service
Direct from ERr

08:25rAEA - ORTHOPEDICS
_ _
-
24. Name/Relation of Emergency Addresseer
25. Type Dispr26. Date of Dispr •. TRF-OTHr
2003-11-06
27a. Address of Emergency Addressee

27b. Telephone No 28. Date This Adm: Admitting0fficer: 2003-11-04
30. Date !nit Adm 32. Units Blood Components 2003-11-04
131. Selected Administrative Data
: Marital Status:r DoB: 11101111 In/Out Patient: Inpatientr
MOS:
•
33.
Cause Of Injury:

34.
Diagnosis / Operations and Special Procedures:

_
gl, P
BULLET L FOREARM
4:-. 11/, a
24,p2(
.
35. Total Days This Facility Absent Sick Days Other Daysr
ConLv / Coop Care Days 'Supplemental Care Bed Days Total Sick Days
35. Total Days This Facility
, 1 1
Absent Sick Days ; Other Days rConLv / Coop Care Days !Supplemental Care
1 Bed Days I Total Sick Days
..,i/D(C..Q.) -Z__
..
Signature of Attending Medical Offi e r
/ Signature of PAD or Medea ecords Officer
MEDCOM - 23324
/1/r'41

4111111111MMEDICAL TRANSFER REQUEST FORM

DATE OF REQUEST: Oa°

REQUESTOR:A11111111111,41160p1

C.c.- -(4
COMPOUND:
PRIORITY : A50)
LITTER/AMBULATORY (CIRCLE)
DESCRIPTION F INJURIES:

ISN #: _1111111111L1--1

-e_eAr77.,d
X- At We
NUMBER F.- MEgigg tRSONNEL ACCOMPANYING:
DATE OF TRANSFER:
TIME OF TRANSFER:
DESTINATION:
POC AT DESTINATION:L(Lo._\
ANTICIPATED LENGTH OF TRANSFER: /14//4

EQUIPMENT REQUESTS:

-poTE,:.COORDINATION IS ALSO REQUIRED THROUGH
'VEmtioNailwi, FOR A TRIP TICKET.

.

MEDCOM - 23325
MEDICAL RECORD I
ABBREVIATED MEDICAL RECORD
PER TINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION
( Ent. r dart 0( nwsion
1-2 j
-5/19
i orAr
)1--1.-)J a)/ Yrj
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PHYSICAL EXAM INATiON
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P ROG R ESS I Enter date a/ die/gm qv.. and finoidiornosts)
V /-2.,2.,-73— 4
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/(--./L) &=?C?"-ri
SIGN DAT E
IDENTIFICATION NO.
ORGANIZATION
el or ttttt n entrIrs give
N•121! lasr. Aram, rniddlo; grade: dare; hospital or medical lac lity) WARD NO.
REGISTER ma.
Mai
ABBREVIATED MEDICAL RECORD
atanglard Form sae
GENERAL SERVICES ADMINISTRATION ANO INTERAGENCY COMmITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106
b •
MEDCOM - 23326
DOD-036902

MEDICM. RECpRD
-4_
\DATE
921 i 0 / d
HaPITAL OR MEDICAL FACILITY SPONSOR'S NAME PATIENT'S IDENTIFICATIO
UTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MLACAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
¦ r.I
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STATUS I DEPART.ISERVICE RECORDS MAINTAINED AT I
i SSNIID NO. IrATIONSHIP TO SPONSOR
(For typed or written entries, give: Name. last, first, middle; ID No Of S X; Date o Birth; Ranklarade.1 REGISTER NO. WARD NO.
) I cp.
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record STANDARD FORM 600-(REV. 6 -97) Prescribed by GSAIICMR USAP A V2.00
FIRMR (41 CFR) 201-9.202-1
MEDCOM -23327
DOD-036903

BATES PAGE MEDCOM 23328 HAVE BEEN
WITHHELD PENDING TRANSLATION

IDA: MEDCOM

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
NOTES
DATE
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SPONSOR'S ID NUMBER
RELATIONSHIP TO SPONSOR SPONSOR'S NAME
(SSN or Other)
LAST 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 I41CFR) 101-11.203(b)(10)
USAPA V1.00
d(vJ L\
MEDCOM - 23329
DOD-036905

MIDDLE INITIAL ID NUMBER
(AST NAME FIRST NAME
NOTES
DATE
_&_11.40L,--03 /C74"---s "--( z4s.a (-2„ il",--4 ,t,11-r"P .e..,13/, 4. 7.--Y--z5e,. ,..!_..{-1--,,,,.. +;.--,
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_
STANDARD FORM 509 IREV. 5/1999) BACK
USAPA VI .00
11111110 o
MEDCOM - 23330

-t
-INTRAOPERATIVE DOCUMENT­
MEDICAL RECORD-For use of this form, see AR 40-407, the proponent ai the office of The Surgeon Gener LLL) .r-• 2.. PATIENT I D PROCEDURE
1. PATI§NT TRANSPORTED TO OPERATING fl.
VERIFIED BY
VIA J2,(4j211) BY 6../h.f. WT/ Asi•-)
TIME PATIENT ARRIVED IN SUITE 4.. PATIENT I
3. DATE
5 f4o v o 3 TIMEr0 0 NUMBERr/-/rca`
5. PREOPERATIVE EMOTIONAL STATUS
• EXCITED. • CRYING • ANGRY WITHDRAWN OTHER (Specify)1 CALM ANXIOUS
.
1
,,
COMMENTS: 4. 71--A -At 0.0.9-4-A-c-e_ ry-n
6. NURSING PERSONNEL
.r
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Sra.r.1r. -:-„,-.-.-:-----r.----:Rs Ec LR- I u

E FB
ASSIGNED
SCRUB

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RELIEF
ASSIGNED 1 b&
I --....,..C.II3CULATOR

CIRCULATOR
-INT;•

—r-iir.—e .,f,-4:4.
. •OSITyON AND POSITIONAL AIDS (Specify) etA 1.1,L., it_mxptAh_c_ik. 1-r2sel-A-eA..) tfrl•-•
• ,. ..
1 1 , "7" CLA/h-1.
• PRONE.. • KRASKE, LATERAL: E LEFT SIDE UPr• RIGHT SIDE UPir, SUPINE is LITHOTOMY
-r'
COMMENTS:
8. SKIN PREPARA,TION
oe.,*(­DONE BY: .rIN-OR • NURSING UNIT SIT OP .,ei h et-w irB WHOM: C,p-r-
SITE: BY WHOM:

HAIR REMOVAL •rYES • NO . PREP Ss UTION (Specify) 1 15E_Ylvt.-
METHOD: IIIrDEPILATORY N RAzo9 ,.,: .. . , ._r
• CLIP _... .r
.•_.. •r
•. -• •r
.. 1-4-r-r.1-____________— .67OKAIVENTS: Inn r„,....0 L., Qi fatep Amin( 9
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES
1------r.:::-i::
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7 4: ..
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LEGEND Pad = = = Toumiquetip..faa:otr,r4cp,,
C =, CopectrI = Incorrect

t PlItttiFirst Closing Final Closing •
10.COUNTS Other' Count .,_i-4:,1 Cciiint .SCRUBrCIRCULATOR
Sponge Yes N e_ J '''

Needle Sharp iYes D \T;--C._ .r..,. ,._...._ _r,....
Instrument Yes No -. :::LIT::;,1.."';-

..._.._ ..,.....__ .„..___ __.r.
Other Yes o
PATIENT IDENTIFICATION (For typed or written entries give: 12.• ELECTROSURGERY DEVICE(S) ESU) M,YES • NO

11.
Name -Last, first, middle; Grade; Date; Hospital or Medical Facllity;) 3-D
-C.A.L7" 3(...) C-0 A-6--
l&l. ESU NO: Vellateat &-
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GROUND PAD: RAND V a_12 !IAA& 1,... E-7 S '0 _...... LOT NO: 651-00/ `ZOO ce.--/ /
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IN BIPOLAR NO:
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USAPA V1.00
DA FORM 5179-1, OCT 87 REPLACES D MEDCOM - 23331r.:11 IS OBSOLETE.r
DOD-036907
13. PROSTHESIS, IMPLANTSrC-rkNorIF YES NAME: ID NUMB'r,rACTURER
Lr r . :r
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IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) rYES DOSAGE . TIME' METHOD PREPArr •• I EN B
,iiIVIEDICATIONS/SOLUTION r i...a a a--f-'r0 .r't . E -r
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MOUND IRRIGATIONr&YESr• NO, TYPE(S):
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TIME CARRIED OUT BY 1.
bTHER ORDERSf. 7
. .r• 4 / ' ,.r,r..
iHYSICIAN'S SIGNATURE
_ -,r . r,,-r,,,t.
15. X-RAY IN OPERATING ROOMr IF YES, SITE.
-r..,:i
YES ilkrNO •r Alr. '':rA-10-41
16.r -r' :"." LABORATORY SPECIMENS

r •,...
SPECIMEN (S) NAMEr ----- .---r-------NAME
YESr•rNO -
FROZEN SECTION (FS) NAME

NAME
YESr•rNO
CULTURE (C) NAME

NAME
YESr•rNO -r-----
NAME
NAME NAMEr --18. DRESSING/IMMOBILIZATION (Specify)

NAME NAME
17. TUBES, DRAINS/PACKINGrYESr•rNO r1(-
..r_ .
-
TYPE/SIZE 1. 2.
, itE/SAA-A

SITE 1. 2. 3.
19. ADDITIONAL INFORMATIONr -r.
--.:;2;k1,:....:1.;I: _ ___ . ___ ..
_
'r•
20. OPERATION(S) PERFORMED
'
.
,lies.ml. ..... ....,_ . ,
.2— II D 1..- a_k --. : 0---it-a___e

,--le}c---€'ell' 1-4 d-dg- '
.
21. PATIENT TRANSFERRED TO\ TIME MET 0,D
.1 CAI_r
\O \ ')`) it
22. REGISTEREDr
MEDCOM - 23332
1¦ ••¦ ••••• II•
511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-r DAY MONTH-YEAR NOV DAY .1-9-a,090 HOUR ! • Of+ ,.,1 • • 5 cla ittie • • - • •

" •• •• •• • • " " " •• •• " " ••
• -•• •
(Apo9D1.19J9198 JO}'slualemnb3apeAwao)
c..)r0 cr:r
0r4r°0rcc'nrecorh-rc'‘—Ir0r0
2drc;roirco cc;rN: r-: air cs; rri Lc; UJr COr COrCO CO COr CO
TEMP. F
A-0
•
PULSEr
•. . •. .
-
. .
-.
. .. .
. . .
" •" • • • •
(0)r
• " •• ' •
(*)
•• " •• •
105° . . . • •• •• • • •• •• •• •• •• •• •• •• ••
180r 1°4° " .r. " .r. " .r. . " r. •.r•. . "r
. ' .•r' . " .r. . " r. . "r
' . . 'r
. ' . 'r
. ' . 'r
.• . 'r
. ' .r. .r. .r. .r. .r. .r. .r. .r. .r. .r. .r. .r. .r. .r.
170
•
•• •• •• • --• --•-•• •• •-
160r 102°
•• •• •• •• •• •• •• " •• •• •• •
. . . . .
. . . . . . . . . . . . . . . . . . . . . . .
101° • • • • " " •• " • " • " " • • " " ••
150r . . . . . . . . . . . .
.
. . . . . . . . .
. . . . . . . . . . . . . . . .
• • •• -• • • • • •• •• • • •• •• •• •• ••
. . . . . . . . . . . . . . . . . " ' " "
140r 100° .. . .• : . : •• ••r. : •. . . ••r.". . ••r: : : ••r: .". : : : ••
99° •• • • • 98.6° . . . . . . . . . . . . . . . . . . . . . . . . . . .
130r •• • • •• •• •• •• •• •• •• •• •• •• ••
120r 98° . . . . . . .
. . . . . . . . . . . . . . . . . . . . •• • -•• •-• • •• •• •• •• •• •• •• •• .
110r 97°
•• • • •• •• • • •• •• •• •• " •• •• ••
. . . . . . . . . . . . . .
. . . . •. . . •• •. •• •. . . •. . . . .
. .

100r 96°
. . . . . . . .
. . . . . . .
. . . . . . . .
•
•"
•
. . . . . . . .

" ••
• • •I'',• • • • • " ••90r 95° . . •••r . . . . . . . .
.
80 . . • • " • . . " . -,• -, • . • • " • • • . • • " " . . • • • . • • • • • • • . • • • . • • " " . . • • • " • • • • • • • " • • • • " " • • • • " • • • . • • " • • . .
70 • • • • • • . • • • • • ••-• • • • • • • . • • • • • • • . • • • • • • • • - • • • • • • • • • • . • . • . • . •
60

. .
.
50 40
. . . .
. . . . . . . . . . . . . . . . . . .
- •
. .
o
1.
REspIRATioN RECORD
n
ILII tiv
paiewoosuoym ApoelOplepacispoom
BLOOD PRESSURE
rsg: Vi-11 It.
f93 -f97q
HEIGHT:rI WEIGHT --k= cf1.-3 c17qp cro

121A
9 7-
PATIEN 'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO. WARD NO.
(SSN or other); hospital or medical facility)
IC:_kj,!)‘
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM SI1 (REV. 7-95)
Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1

MEDCOM - 23333
DOD-036909
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is .r, .sG
DRUG (Units) TOTALS TOTAL EBL

NOISNN1 INVISNOD= .1.
"IVN/DOIN/DIN -siiNnAdI33dS
soma03 .1.V3d3H/S110IINIINO3
Isonua SIN3DV01.1.3HIS3NV
c.i.„—
V 01-SPO-i ii`-'.) 1-41_ ­k.n.,_totn,Wve.. ( in..-) ‘a° s-o 1.51)".1,—
F9ppst i...-(1,,...) 1— I .5-e, TOTAL URINE

pikurr,r( Li_ _512 ___c_v_______
( 0r) ,_____--
(r)
VOLAT % del FLUIDS -SUMMARY
AGENT % e.t. CRYST-01D-
AIR-L/Min c.3-
COLLOID-

BLOOD-
-11..
4....----. s
rREMARKS
0 Code drugs with numbers,
5 events with 1e:ire's

u.
...I *1-0 0,4:.* 1 , /4-0-4"--
L (...9_A-J-1._
UR NE -
PH S STATUS

410-0,p-10:5- 10,_,Q " -j-,,,, 4
TIM E \ . w-lp.2-R •y-4,.¦
1-3 4 5-E
_L. _i____ I__ 1 __I 1 _1_1_ 1 J___I_
SYMBOLS:
BODY WEIGHT: 220 !-, ,-, . ; :5,--11,----_,
• _L__
KG BP by cuff , . '— , .-, , ITC, c.,. Or fLurkc-.-.., ,
Cr
200 ; .
LB -.
V I ',.),»fr , cr, 1,2,
HEMATOCRIT:
180
A . .
, , .-, . ,___
, , L)1.10':"^-• '3144
Heart rate .160 ,-,
INITIAL DATA: e ' -I'm : /5- "r4,...t.e......1\*.4---,
Resp rate 140 --4-1-----...,
BP-V)43/3i
-
'1 v :
1 ,/ ,C7
.

120 , .-I Ir¦ like'llrhit'k-,.
.
HR-BR k_ , .
t 1/43-I (transducer') 100 --1----F7 ,-
, '
„ ' , ,
-I-
EQUIP C ECK 80 ----77-4 A — . '„
T -------. —,--,—
• ,
OKT--) N
TOURNIQUET 60 „ ,
, -r

PATIENT RECHECK T —/T-
_._:___I___
40 1--"-
OK for
PROCEDURE71 ANES-X-X ,-4___

20
PROC-0_0 '
TIME-(LAO
VT -ml
1-f -breaths/min D._ 1 0 ­
Z
Peak inf pres / PEEP 1.'
MODE - Slponl, AissIstl, Cif:in) ST-.5V-----5NI SV RECOVERY AT 1101.--BP/Auto Cuff ET CO2 (torr)
P-_ICU Specify) w -----. ­
En BP/otb F102 (Frac or %) -qls:-/7)-(1 CC
OTHER
0 ART line Sp02 (%) IOD if-0-(OZ) CONDITION:
to Steth- PC/ES ECG
(ft-__.5-r s S. w Gas analyzer TEMP-site RESF-ti-S 0 •
C.)
0 N -M Block (T/4) BP- l'A-sA,6HR--I/ .:(
ANEST ECIA /PRO EbURE
0)
TIMES
CC 0
0)-Start Room End
1-a
0 Warming blkt .1 irivo (001: I Ics," a Conv warmer
r, Ready Begin End Mark with letters & symbols, EVENTS_, 0 expleM under REMARKS Position - "--Sc. VDCP1 052_ (6.°
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
1-7_,t-G-..."--L aok) k.-) I a.eir-‘3,1,....P tly-041p, 114K.-PATIENT IDENTIFICA-ON: Typed or written entries: Name, Gra AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
itRaI
Medical facility c' NCZAV.,,,,...\
SURG PROCEDURk." 4_ 4C-LOCATION: ‘-ic,./ DATE: ANE THE-TISTS: -.-.-V n III Cli. * PAGE-1-OF 1 -
DA FORM 7389, FEB 1998 COPY 3 - ANESTHESIA DEPARTMENT USAPA V1.00
MEDCOM - 23334

DOD-036910

AA)
A
(\c)
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL FIECORD 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 TIMEPATIENT IDENTIFICATION DATE OF ORDER-TIME OF ORDER
ORDER NOTED AND
HOURS
e!) I V'
SIGN
9/11-)"."J­
9
42o,-1--i-T ?",e7 141-1/ i 6.), ir6 1)-1-2_ )q- ri\I 4 rid2rizt-x ,./.r/-1.)_._/,-/}/-c-.9 )-)e----r66...i2J-7
NURSING UNIT ROOM NO. BED NO.
AI 44-- •49'' )2,‘ z.L,
/ I ) PO
PATIENT IDENTIFICATION 0 DATE OF ORDER-TIME OF ORDER
le 4 74)-25 eh-C25)?* HOURS
0
.."1".?.';°2-, 2.
6..-6-./VP.--92., ,
•
.-AlF,(
—
NURSING UNIT ROOM NO. BE • NO.
TIME OF OFIDERPATIENT IDENTIFICATION DATE OF ORDER­
(q5Dr`
HOURS
-1-1445\iv5r
1 1 kW() 1F. MO " i °-. C"1C--- IV 0 g- tUY//tig211,6'24) / ic
i-/ 1­at----/--i V op AI\
,.
'VIP
A
NURSING UNIT ROOM NO. BED-.

. N-102
DAWORDER-TIME OF ORDER /RIO ­PATIENT IDENTIFICATION
HOUR
5")./--L-,/ ia.'
‘..
—4../44
.,";'"
.11111, 41e-6,r_____I .,:-. /Vr ...
/./
.A. "_'—at • ,­
,.. rallir _4711
1' Ilbar„he
FIIMMAIIIIWANLIIIMINIE
), 9 IIll•''-
¦
lib ° PVAII I I FWA I I MI I rAliggiliM14 w
ar.rjullfryfffAr a ej, Adr--_ a
NURSING UNIT RO­
A-7-.
liv401) m72. t• /-7.., AO, f5 49,-..- 4i .2,-,,,i
awn
FORM REPLACE-N OF 1 .JUL 77, WHICH MAY BE USED.
DA 425
1 APR 79
MEDCOM - 23335

DOD-036911

Xt_4,r sr=5AI
Or
-
¦•¦-¦••=Z _¦/%1IL 2,
• A°
.:.S.TANDARD.FORM 600 -MEV. 6-97) BACK
FPI. LEX. Or Printed On
°
MEDCOM - 23336
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. I 1-Yr.-2003
VERIFYIHIMTIALING *ANL " 4:11ga Ne1 liNCE INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
FIR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION, DATE NURSE FREQUENCY, TIME
tA P-S 0
(1)6
"-NE\ta).-- 011- -\16 '.0.---iii2___ 1 a
Yir - 11111 " BircV--
0..--___r,.......,,,,,,,.....
__
.c‘,4,,_
-

,,.
.WWer.1

_.
, _........„

,_,( (9__\,•\,, - 2,-----
,,r.
.
ALLERGIES: MN YES MI NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
IN YES-IIIII NO
BL_NLI-E.:37 lt'¦ )-.C--' \-1:::9---2P*C-M.
'
PAGE NO*
PATIENT IDENTIFICATION:­
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
111111 b (-"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

ON OF 1 DEC 77 MAY BE USED. USAPA V1.00
DA FOFtM 4677, 1 OCT 78
MEDCOM - 23337
DOD-036913

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICA770N ) Mo Yr 2003
Date to Time to
Order Clerk
Time Done Initials
SINGLE ACTIONS
Date Nurse be Done be Done
ci31-",
%API -1-\0(\607- -"\IC, \ C--\13 l•-U4W-- '
. .-­04--7:C13 Ofg— A7--'0 ,_.-)_ 93dt--

-4 KR) PtiQ . 'fo7) oia t, lc 5Lrov/ cool
,
r/-36 easocra_?,re\hzu actais2 OG
—uFk..:4 A
Os 3/c_AD Efv\I Lorscy -'rc=ri- Oercs "2
_
(csL-2 kA
_ _ _ —
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
EvIr Clerk/ PRN
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
_ — _ _ _ _ _ _ — — — — — _ _ _ — — — — — — —
..
M.¦ ••••¦• ¦• ¦¦
¦ ./ ¦;mx....
..•... ,........

¦•• ¦¦¦•• ¦ ••• ¦¦
ww•••••¦¦¦••••• ¦¦••
.....• ¦• ¦¦•• ¦• ¦¦
USAPA V1.00
MEDCOM - 23338
THEA-A-PEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of thls form, see AR 40-407; MO. V Yr.M_S
the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING .I . INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
ft P.:. 4:??
ft
WA', -NI . L-V---\--JC-) nC I ei
.
Cheploc_k___N)
*,
-A Nog ikoce4 -1--.iv qz-
ti
I
1

- -- -•¦
ALLERGI ES-p y ES El NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
1::1 YES ED NO
BL.)Us-E-1— rk•---S \---12__Ei\e_Nk.
PAGE NO
PATIENT !DEN TIFICATIONt
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES
111111/
D-7-8-9-10-11-12-13­
4'
M "A 14
E-15-16-17-18-19-20-21-22 N-23-24-01-02-03-04-05-06
-
n A .F2nt. /OR EDITION OF MEDCOM - 23339r EXHAUSTED.
DOD-036915
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo..1(.r
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Glven Initials
Dots Nurse bo Given be Given
Order/-INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/-PRN
Explr
Date-Nurse-MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
-INC\----2---krcn \\IP (LA b/
(z9110\,?
. ___:_p_cf-N
_.b(
\:, (CL)--7 1"
, r
_
U.S. GPO: 1998-454-110/95216
MEDCOM - 23340

DOD-036916

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use ol this form. see AR 40.66; the proponent agency is the Office ol The Surgeon General.
OTSG APPROVED Ward
REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: G i\lo 6rAnesthesia Type (Circle))* Spinal Epidural Drains Airway Time In: 110-7r IV edation Nerve Block Hemov c Nasa Allergies: NJ if--PA OR Intake: Crystalloid 100rColloid N Or Pre-op V/S:111/0 i 0 0rOR Output: UOP EBL
-
Procedures: 4-D L.. eA laiY0rMedsTrimes: G V wzrzt 1501/tIvv,,,c, 1 6.4=5660 T ube rach Ftirt-. Ixrafef-61 oley
Other
Pre Op MedS HiSto TLS
n3 t. ,Nf N C. ---- '' Time -...-...Ns7t0Q
--. -.... ------"--Pacu Intake
-. -...... -... -..... -, --...
Sa02 Time Solution Amount Site • y Infused

q9ili%/41114
_.--------
Fi02
Methods 0 titi pp( pa D ti•
_.---------
240

220 ys. :r . Labs:
i Post-Anesthesia Recovery score .
•
200 •

Criteria ADM 30' D/C Codes
Activity
AIRWAY
(2)
Moves 4 Extremibes

A = Ambu
(1)
Moves 2 Extremities

180
(0)
Moves 0 Extremities BB = Blow-by M- Mask

Ainvay
FT = Face160
(2) Cough, Deep breath
Tent
(t ) Dyspnea. limited breathing
RA = RoomAir
(0) APnea
140 NC = Nasal
Blood Pressure
Cannula
(2) SBP =/-20 of Pre-op
vvs,../ • (1) SBP =/- 20-50 of Pre-op
V
120
V/S
(0) SBP =/-50 of Pre-op
X -A-line BP
C,onsciousness
(2) Fully Awake, audible
• • • • • • crying
...-___.,
.....,_,_..,

-=Cuff BP
= Pulse
(1) Arousable to verbal or pain
BO
TEMP
color
S= Skin
AiA NA^.
(2)13aselne cobr & appearance
/*NJ 0= Oral
(1)
pate. mottled. jaundiced

(0)
Cyanotic

A = Axillary
T =Tympanic Circulation (Peds 5 Years)
R= Rectal40
(2) radial Pulse Palpable
(1) Axillary palpable. 1101 radial
LOS
(0) Carotid only reliabie pulse
20
C =Cervical TOTALS: Must be 9 or
T = Thoracic greater to D/C, otherwise
L = Lumbar
RR Ibalob]LAm needs anesthesia approval for
S = Sacral
VI' _.4 D/C,
T
Time Patient teaching done; Wound Care. Pain Management,
Pain (0-10) T, C, & DB,. Incentive Spirometer. Comfort Measures
LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained
aonlinue on leversel
DEPARTMENTISERVICEIGUNIC OATE
b (Le,S - Z
PA CU 5 N.10\/ .
P or written mines give: Name - last,
first, middle; grade; date: hospital or medkal fatiityl
111 HISTORYIPHYSICAL III FLOW CHART
• OTHER EXAMINATION • OTHER 'sow OR EVALUATION
. 0 DIAGNOSTIC STUDIES
IIIII:.1, C. ("(--r— L\r
II TREATMENT
r
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPPC1r2 OD
MEDCOM - 23341

DOD-036917

MEDICATIONS
Allergies:
Time Pain
Medication 8.
Route in I I/E By
1 -1 0 Dnsane
1-10
i ime site Range
Sensory
Cap T Color
Of Refill
-Motion
Adm Leos. 6'64ec( 4.-
15' P ),q c pv...
L gr.,– ix ,.... A-c.,i ..4 P 6
C ?fr---
30'
Let,..--1,'A.-iVed —k-P ''13
c_ Ptc
45' Larn, ¦ C4-1;4-c4 -4-' ‘6) 45 (._ ? (e.60' L AA' lek 1 I 04/1 t I° 1. L 0 16
90'
D/C

ovement/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, P
...---
-Adm 15' 30' 45'.„-----6 90' D/CFund. Height ___,...../
Lochia
Peripad#
Fund. Con
DRESSINGS
Time Location Type

Drainage
Adm DO/ Lavm. A Ce 30'-1131 I. 0.6"-ts9
et C C..-
60.-190 1..#0, of,-6 D/C
PACU OUTPUT
Time
Source • Color/Aqiearance
mount
CARDIAC RHYTHM
Time Rhythm Symptomatic?

Rhythm Strip Run?
I (01 IS
0 c:.
NURSING NOTES
veceivecir0-, 0 e Sip D
vevti .
, LA narousablervev-b0.1 c70 n
toO, 100% RA. izo-7 P-i avn(nsoble +r) vei-ilnal no C/A pArtn c)%r
-3cy- #-rveil, in,
Discharge Criteria:
Date: SNI-01­
Time: I alrPARS: ei BP: WI-T: 9(4 .3 HR: 9Q
RR: 1 D.,-Sa02: Pain Level at D/C 10-10): — Intake:-—
Output: ----Additional Data: —
Transferred To: IClAl
Report Given To: S. C Transferred Via: W/C-urne Transferred By:---­
Cleared IAW Recove Room
-B-3 Charge Nurse Signature:
MEDCOM - 23342
DOD-036918

\\,21°71Y _ ding Information
Admission ano
2. MTF Location
•
1. Reporting MTF
1 For use of this form, see AR 40-400; the proponent agency is OTSG IZ
1111111111 — 4. Pay Grade ; 5. Sex
Na e (Last, First, MI3. Register Number
FGN ._ _ _ . ___ _ - • - --Religion
. V • . h ' 't
; 8. Race
7. Age at Admission
6. DoB (YYYYMMDD) ,
23Y 9 2._r,

411111. X
_r 12. Social Security Number I
I 11. FMP
ETS
1 a Length of Service I i
Ir99 I

_______________ _I
___________L____r
. . I ir , Branch / Corps:
1
' Hour of Admission
i 13. Marital Status , Organization (Active Duty Only) .
08:25
i
. _
•r_r. . 16. Zip Code of Residence:
15. Beneficiary Category
: 14. Flying Status K78-PRISONER OF WAR/INTERNEES Prey. Admission
19. Trauma
18. MOS17. Unit Location NODIS
.___—_____._.____
Name / Relationship of Emergency Addressee Ward:20. Source of Admission _._____ _
._.____ _
Address of Emergency Addressee I CW1
Direct from ER _____—________ -kfelephone Number of Emergency Addressee
_ _r
. _r_ _
cility:
Name and Locatio _
__._ __________ r
, _.—_—_—__ __I__
23. Date of Disposition (YYYYMMDD)
22. MTF Transferred To ,
; 21. Type of Disposition I t i;
2003-11-061 _—_________—____ .
TRF-OTH _ __—_______+
. _ I,
26. Date this Admission (YYYYMMDD)
I 25. MTF Transferred From I
24. Clinic Svc - Admitting
2003-11-04
AEA - ORTHOPEDICS Ir

--- — ----- --
i_____---- . - — --
_ —.___ __
... 29. Date of Initial Admission
1 28. MTF of Initial Admission
27. Location of Occurrence 2003-11-04
I
1__________
,
FOR LOCAL USE
D)(-
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: BULLET L FOREARM
fqq
iv.; 'Po
19(z_r.(DD 5
Procedure Narrative(s):
Cause of injury Narrative:
Signature of Admittingrlerk
Admitting Officer (Signature, as requi
MEDCOM - 23343
croann 9QR.5. MAR 200(
icril I INCH I IVICI¦1 I
tttl:UKU COVER SHEET
r use of this form, see AR 40-400, the proponent
is OTSG
' 11. Register Nbr
I
3. Grade
, Admission Remark:7
1
,
CIV
14. Sex 5. Age
7.
Religion

8.
LnthOfSvc 9. ETS

10. PrevAdm
44Y
NO
11. FM13,,,,c 12. S
13. Organization
14. Ward
15. FlyStatus
17. Dept / en
18.
BranchCorps

19.
UIC / ZIP

20. Type Casel°REIGN CIVILIAN
BC
21. Source of mission ,;!„
22.
Hour Of Adm:

23.
Clinic Service

Dire rom ER
18:00
AAA - INTERNAL MEDICINE
24. Name/Relation of Emergency Addressee
25.
Type Disp

26.
Date of Disp CRO/DOA

2003-11-04
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:
Admitting0fficer: 2003-11-04
29. Re rtin
30. Date !nit Adm
-
32. Units Blood Components 2003-11-04
31. Selected Administrative Data Marital Status:
DoB:
In/Out Patient: Inpatient

MOS:
33.
Cause Of Injury: GSW

34.
Diagnosis / Operations and Special Proced res: .04 SUCKING CHEST WND

ob/?ci
P`c wDi I
3 -77,
I

35. Total Days This Facility Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care
1
Bed Days Total Sick Days
35. Total Days This Facility Absent Sick Days Other Day ConLv / Coop Care Days
Supplemental Care Bed Days
I
Total Sick Days
Signatu \ •r
1
icer Signature of PAD or Medical Records Officer
b (4_\„)
Automat
7, May 79
b -
")
MEDCOM -23344
L RECORD-SUPPLEMENTAL MEDICAL D For use of Its ., see AR 40-65: the proponent agency is the Office of The SIIIIneral.
Ilk
OTSG APPROVED (Date)
-
REPORT TITLE TRAUMA FLOWSHEET QI Appr 11 Jun 97 The proponent is Dept of Surgery
: ARRIVAL STATUS
1 /min 0 C-Spine Immob02
TIMEA010 IV x
UKN 0 None 0 Yes:
Meds:
0 None Yes: Last Meal/Fluid Intake
Allergies: 0 UKN
hrs
0 Current
Tetanus: 0 UKN
LMP:
1?RIMARY SURVEY
CIRCOLATIOIC
,
.­
'AIRWAY •
, SKIN: 0 Warn CI Cool Hot
PULSE: 0 Present 0 Absent0 AbsentLabored 0 Unlabored
0 Natural Patient
CI Pink 0 Pale 0 Cyanotic 0
BLEEDING:
TRACHEA: CI Midline CI Deviated
ETT
CI Dry 0 Moist 0 Diaphoretic
HEART TONES: 0 Clear 0 Muffled
=
CHEST SYMMETRY:
0 Secretions
"bisA HEAD 0 Soft Rigid CI Non-Tender
RHYTHM: 0 Regular CI
PUPILS: 0 Equal ca Fixed 0 React 121 Dilated
GCS: E
CI Tender:
0 Central 0 Peripheral -TM: 0 Clear 0 Blood
PULSES:
rELyie.
LUNGS
rificx •,
Stable CI Unstable 0
BREATH SOUNDS:0 Bilat 0 Equal 0 ClearC-Spine Tendemess:
SPHINCTER TONE: Blood at meatus/vagina:
Absent Pain @
Decreased
13 GI­
VVNL Heme+) - Prostate: 0 INNL Abnl
Crackles
0 None JVD:

Wheezes
VASCULAR ASSESSMENTUSE DIAGRAN1 TO DOCUMENT 1N.JURES AND PAIN
(AB)rasion (AMP)utation IAV1u1sion
Battle's Signs (BLIeeding (B)urn (0)eformity (E)cchymosia (noreign Body (H)ematoma
(LACleration
(Pluncture (W)ound
(Pain)
(S)eatbelt (S)ign

(S)tab (W)ound
(GSW) Gun Shot Wound
+ + Strong + Palpable 1-D Dopler

RN PHYSICIAppii4-
iContinue on reverse)
DATE
DEPARTM
PREPARED BY (Signature & Die)
\—\-Q3
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, D HISTORY/PHYSICAL • FLOW CHART
middle; grade; date; hospital or medical facility)

OTHER (Specify)
• OTHER EXAMINATION D
OR EVALUATION
‘9"
DIAGNOSTIC STUDIES
\DA .611)
MIN
El TREATMENT
REQUIREMENT OF PRIVACY ACT OF 1974 IS COVERED BY DO FORM 2005. EAMC OP 503, 1 Dec 98 PREVIOUS EDMON IS OBSOLETE.
DA la% 4700
-MEDCOM - 23345
,.PROEDURg,
ETCO2 Change
Apra! CT Scan: 0 Contrast
ET
0 Nasal CI BBS Post Int
0 Head 0 Abd Pelvis
Intubation -C1 Post CXR
Teeth-0 Air 0 Contents 0 C-Spine 0 T/L Spine 0 Chest
Gastric 0 Oral
0 Verified
0 Nasal
Tube Suction: Y N
A-Gram Site:
0 Return ccUrinary
CI Meatus
Heme Dip: +
IV ACCESS & FLUIDS
Supra-Pubfic
0 Secured CI Grossly: + -
CI Opened
Cell count
0 Closed
Sent@ CI Air 0 Blood
Chest
Pleuravac cm Tube #1
0 Autotransfuser 0 Air 0 Blood
Chest
Pleuravac cm Tube #2
0 Autotransfuser
g
Rhythm: Comments
12 Lead
LABS X-RAYS
0 Chest Initial D-stick SHct CI Chest Post ET CBC • 0 Chem CI PT/PTT CI Chest Post CT BLOOD PRODU
0 ETOH 0 T&S Q T&C x 0 C-Spine
D-stick
0 Tox Screen 0 Pelvis
UA 0 HCG 0 OTHER 0 OTHER
LAB RESULTS 'TAKE & OUTPUT
Urine
Blood
Other Other
TOTAL
TRAUMA TEAM ARRIVAL VALUABLE & CLOTHING
,, 1_ , _r''''.1 _ ,r
71 '''.. trgr, "r,s-1!3" ppii-;,, ;5,.,rv ,r.r-.0%r.r°r',;...,r ,,,,r.
D Phys None Found
argeon Given to Patient
nesth Given to Family
Inventoried and Released to Patient
Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
X-Ray DISPOSITION
RT 0 Home 0
Ortho Admitted to
Neuro Report Called to ,

Time Transferred
Chaplain
Accompanied By Via: 0 Stretcher CI Wheelchair As per ACLS Precautions: 0 Yes 0 No
r
lpage 21
MEDCOM - 23346
•r
DOD-036922
NEMENEM yIrph-RIGNS. .
GLASGOW COMA SCALE
Rectal Temp:
TIME
EY VREBLE RESPONSE MOTOR RESPONSE
TIME BP / / / / FIR RHY RR A02 • FIO2 MODE E V M T 4 -Spontaneous 3 -To Voice 2 -To Pain 1 -None 5 -Oriented 4 -Confused 3 -Mary Words 2 -lncomp Speech 6 -Obeys Commands 5 -Localizes Pain 4 -Withdraws to Pain 3 -Flexion to Pain
/ 1 -None 2 -Extension to Pain
/ _ 1 -None

PROCEDURE­
-PERFORMED BY:
/
0 Backboard Removed BY:
/
0 Downgraded BY:
/ / / / / /
_. . _
/
_
/ /
•
. _
/
—
X ,L -1-1,511111""elMitil I . 8
vairg
-0. f &10
&-1 AA •
IL¦AMINLIM $
_- . c _ MENInt
.
‘14'-1 , ,a f -
IL-A-A.._,_-A •-t ). t-°-I-._-MEM i
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% IP . IL_ 1 Is tkiAllat _10 0
--n Itilel I WIRMAIMM M._lintil N.
eitraNIESILOMMILIIIME
Mallit-41 rz -----.. _'
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N-111 1..6. 11-,.
-I--1 -77

MJ.S.GOVERNMENT PRINTING OFFICE 1997-571.7000
(page 31
r
•
MEDCOM -23347
DOD-036923
1. Reporting MTF152 2. MTF z.ocati
IZ 0 I Admission andro•ing n orma io
For use of this form, see
0-400; the proponent agency is OTSG ,r3. Register Num r Name (Last, First, 4. Pay Grade 5. Sex
b (:0..) '--Li civ M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity
eligion
MN X 9

44Y
10. Length of Service ETS
11. FMP 12. Social Security Number 99
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
18:00
14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
K76-FOREIGN CIVILIAN

17. Unit Location 18. MOS 19. Trauma Prey. Adm ssion
BC NO
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER Address of Emergency Addressee
N me and Location of 'rent Facility: ) 1.... L Telephone Number of Emergency Addressee
)z) k-

21.
Type of Disposition

22. MTF Transferred To
23.
Date of Disposition (YYYYMMDD) CRO/DOA

2003-11-04
24.
Clinic Svc -Admifting

25.
MTF Transferred From 26. Date this Admission (YYYYMMDD)
AAA -INTERNAL MEDICINE

2003-11-04
27. Location of Occurrence
28. MTF of Initial Admission 29. Date of Initial Admission
,
'.. .r2003-11-04
FOR LOCAL USE /
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: SUCKING CHEST WND

Procedure Narrative(s): ii1,r
Thov-c., c-d\--ii
f
r
Cause of Injury Narrative: GSW
-miiiiiiF.
•
.
.A .J__,..• -
Signature of Admitting Clerk
Automated Facsimile - DA F M 8 , MAR 2000
MEDCOM - 23348