Medical Report: 24-Year-Old Iraqi Male, Baghdad, Iraq re: Blast Injuries with Shrapnel Wounds

:
LairgiCAL •,,..•.t'.`tiftriitt
fftia
,au"la
THE DOCTOR .L RECDRO.:•DATE, .T(ME'; AND SIGN-EACH SET OF ORDERS:.PRORLEM :ORIENTED MEDICA: RECORD ..:SYSTEM 1$ USED WRITE PROStaM.OyMpER i$:..CO440.1N;:g401CATED. BY ARROW BELOW:
PivrtEINITI Ppg0-4IlfkicArOC -,,,;;TteMt.•1:Dt 1ST::TAMg,•
.
..•;. oflogrt,•••.:_
•
pti500
UNIT..
: p*T.Istrt..
• •.•.•
IEatt
:0100W..• BEd A
PAZIAIT tio*Yt ot:b000t, '.:TOO OF. 011004
11141V..
.
-• 01411* : .S9t5kt.:
1-.
•
. -;?011 e301.: . •
....•....

•
41 .,,e) e,0.1A_.1
. S
1) V-­
E.
9.144 (Ng; UNIT. ROO MrINO;,:..1:).•
(f)Of.frt,
,. . ..
• •...„.
FIE:FL-AOES, E13.11:101VOF.774.f WkitCH-OsE
.MAY.
Govthvinite::43-rvo-f?"-oFT, m4.:-re:ti f.fctiAtf Ele*g.- -
MEDCOM - 17241
DOD-030830

c-S e
c2.5 . s4--12-°A-A
Kr-t_.Scr.- 3
Lc, c•-•1= so —1 scL etD

Irick-1—e-L-cst 0 f D
LAP.,-6 5 CA1 C , CA. A .s..,

11 4") C-) tr3
( U K
S-0 00
CIL
g(74 33
-
COO
t-tc)
r)
411111.¦
of sig'
$( 1...t. ce;
1....krt
.

MV 226-03 e cfr-
MEDCOM 17242
-

DOD-030831

•-CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIMEPATIENT IDENTIFICATION DATE OF ORDER TIMK OF WIDER

ORDER NOTED AND

0& f \
HOUR SIGN
IA /hi
•

NURSING UNIT ROOM NO. BED NO. ( Ci9
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
2.--?H HOURS

(1 1/
2,5-0 CIV.--61-C1-An (VSRite1_1(..
0.3
0.0 '
1-:-
ROOM NO. Li .1111111PrntOU 0 /72/0 j 2.3
NURSING UNIT BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER .
14 A‘r-03./61-5- HOURS
C
I --E__ "rz.) r-
7 c.-1- / irN.
(
NURSING UNIT
PATIENT IDENTIFICATION GATE ORDER TIME OF ORDER
NURSING UNIT ROOM NO. BED NO.
--.113 N/.
nit-_-_ F... 194a REPLACES EDITIO • F 1 JUL 77, WHICH MAY BE USED.
•
1 APR 79
10' U.S. GO' MEDCOM - 17243 710
DOD-030832
CLINICAL RZCORD • DOCTOR'S ORDERS
For use "f this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, 7 VD SIGN EACH SET OF ORDERS. IF PRO 'DRIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUI. IN COLUMN INDICATED BY ARROW BELO
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER 1ST TIME
• RDER
0(e AND
f 2.5 A21 U--)
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER 25-Au G;0)3 A-07", /v. Amid/A ,A a¦ r.,..r....¦1114••¦•• TIME OF ORDER /2442 HOURS 600' CA••¦••••••¦•••=1/1.,
NURSING UNIT ROOM NO. BED NO. li
PATIENT IDENTIFICATION DATE OF ORDER 3 CvPPP TIME OF ORDE ,720c e HO

NURSING UNIT PATIENT 1DENT IF OOM NO. n. BED NO. 2-6 19 atai kir"fir 1 DAT ' F ORDER HOURS
-!Mr1111111.3111111111111 • .Pr
NURSING UNIT ..vt° DA1 APR -19 FORM 4256 ROOM BED NO .REPLACES • • L7 OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 17244

DOD-030833

CLINICAL RECORD - DOCTOR'S ORDERS
For. ,f this form, see AR 40-66, the proponent agency. In OTSG
AND SIGN EACH SET OF ORDERS. IF P M ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM N._ AR IN COLUMN INDICATED BY ARROW BE.
THE DOCTOR SHALL RECORD DATE
PATIENT IDENTIFICATION DATE OF ORDER ZL, 4-1,41, 0 TIME OF ORDER OURS LIST TIME ORDER NOTED AND SIGN
pcAg. CD A 8C7 V GG (g) Pf2etz.e 6,-1 too 70 )R P)
NURSING UNIT ROOM NO. BED NO. G 30 A44:441.40100gektet444.4.41-2
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
How totaz,isc(20,02_ o A&A4z,e-0 HOURS
NURSING UNIT ROOM NO. BED NO. , JAL gete0A) C.-A)5 /30-ettA ro A 6C, V ed.,.N sLtr.u,0 .0 1, 4
PATIENT IDENTIFICATION DATE OF ORDER TI
act.,..-4 8- e-,5c3' O3
16.
NURSING UNIT:.-ROOM ND. BED NO.
PATIENT IDENTIFICATION EPW Lk DATE OF ORDER TIME OF ORDER 2 '2- ccu24,¢a6 d3 4),97-6"-12 3e)c-c--.x/
NURSING UNIT ROOM NO. ICI) I DA ,FAO,r,g 4256 D BED NO. REPLACES EDITION L 77. WHICH MAY BE 2-6* if USED.

MEDCOM - 17245
DOD-030834
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
2.R1uNTED SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
eV-'12*
.0-7.4LA 6

-rpt,,IPP A
NURSING UNIT ROOM NO. BED NO.
lcu
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
goe
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
/quire,3 /1/ 90/
194,
NURSING UNIT ROOM NO, BED NO.
DATE
DATE OF ORDEPATIENT IDENTIFICATION
NUR IN UNIT ROOM NO. BED NO.
REPLACES EDI I. 77,
APR^79 4256
Itr U.S. G 3.710
MEDCOM - 17246
MEDICAL RECORD
LIST TIME ORDER s NOTED AND SIGN
HOURS
HOURS
DOD-030835

CLINICAL RECORD - DOCTOR'S ORDERS
For ••-1. of this form, see AR 40-66, the proponent age , OTSG

THE DOCTOR SHALL RECORD DAT SYSTEM IS USED, WRITE PROBLEM PATIENT IDENTIFICATION Alr DATE OF ORDER TIME OF ORDER 0----) .41LLG zoo 2 /4 ce, HOURS LIST TIME ORDER NOTED AND SIGN E AND SIGN EACH SET OF ORDERS. IF I EM ORIENTED MEDICAL RECORD .ER IN COLUMN INDICATED BY ARROW
42) A/C-- --7-12c-tcy /0 (.1sC
NURSING UNIT IGO ROOM NO. 2 BED NO. Char-t-CAeck tooi,c 29-74 ihtv /6/ .274 0­3

PATIENT IDENTIFICATION DATE OF ORDER .:78 4L,G cqz6,..---6 Ns c-rsc -k a c..f 4--oent,,,/- HOURS
NU SING UNIT )(D. CA-) ROOM NO. #0)
PATIENT IDENTIFICATION DATE OF ORDER TIME OF 9,11, Auz -1,45307.Ps° URS
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION 0 BED NO. C DATE OF ORDER v ¦P 116) TIME OF ORDER 21 I D HOURS
NURSING UNIT ROOM NO. . BED NO.
DA I F:PR:179 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY SE USED.

MEDCOM - 17247
DOD-030836

CLINICAL RECORD - DOCTOR'S ORDERS For • -•••4 of this form, see AR 40-66, the proponent ace OTSG
E AND SIGN EACH SET OF ORDERS. IF . _EM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM AER IN COLUMN INDICATED BY ARROW BELAY.
THE DOCTOR SHALL RECORD DA1
LIST TIME
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION
ORDER NOTED AND
21 /NC 320 3 URS
SIGN
NURSING UNIT
(Cu-
PATtENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
ttabou
erao bJ
NURSING UNIT
C,u
PATIENT IDENTIFICATION
b(ck
NURSING UNIT ROOM NO.
FO RM REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USEO.
1 APR 79

DA 4256
MEDCOM - 17248
DOD-030837
40.,-86.0t,t „a;.-0pde-1.02, • •
r{„,,E.,•• 9C,C7t,01.71-- • 11.tAt •WAPITE PR.O.Sti.,M -74LVAttert • SiGN..EfiecH'•••SET.O.r. Gotils,f0•1,41;ittAitro. Aff Prif,),KL.t.Tyc rAxcif.11T.e1.1;'tgi'•DICAl. • .. • . CM; . • : -•
.• .
.
is .4S+1EC
. 7‘
•• •
. • .. ..• • . • ,
• • •
-,,,,..,,,„ UN tT irE-11Fe3&. ,17.:,iii5 .. itc::467 '---.„ .. , . •
. ,
"OA ttqw-f 47: • 61=k0:64. •nmE .ortrien
• . • • -A5(
7,•"-e , . .
-. ..: . .•, ••::;4;40, , pc ,cglt,
s'
, , • .. _.• :
QQ
*Few!: • 1=0142:0F•

0uk
LifeicP" .1k.,5..rztAl Lapin)-K44'1,4:114
MEDCOM - 17249
DOD-030838
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is -OTSG,

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME
DATE OF 0 DER TIME OF ORDER
HOURS NOTED AN 4-k SIGN
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
NURSING UNIT fjOOM NO. BED NO.
E OF ORDER TIME OF OFR
PATIENT IDENTIFICATION
CS/
HOURS
NURSING UNIT RO. M NO. BED NO.
ORDER TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
NURSING UNIT ROOM NO. .BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
,FAOPRRM„
MEDCOM - 17250
DOD-030839

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OFRDERc CI LCD TIME OF (5) ORDER HOURS LIST TIME ORDER NOTED AND SIGN
p9 NURSING UNIT 16q4-1 PATIENT IDENTIFICATION (_9') 1) ORDER
NURSING UNIT PATIENT IDENTIFICATION DATE OF ORDER
NURSIN PATIENT IDENTIF!CATION BED NO. E OF ORDER DER HOURS
NURSING UNIT ROOM NO. BED NO.

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1 FIPARM79
MEDCOM - 17251
DOD-030840

(
I THERAPEUTIC DOCUrnToAttiTION .CA PLAN (NON-MEDICATIO gT c/
CLINICAL RECORD is tor% me AR Yr. 2003
iMo• 6
7....-,,r,,, -,:, .=.;7 77117725 the =PROPER .
ZtF,L,taiiffia.,' FOLLOWING EACH COMPL ETION
VERIFY BY IN MAL1NG -o - .vg ..$,.-tiq ,-. .'!040
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

VS pi°
1110 111. -
L
1716 tcc ‘--r o& rQcs,-t,
il t blc-a-_ .,,,111
.4 AIL liER
1 i dr /0 ilr AV
lit, OS 11/1 4
CC", WC) 77 10i. S •
1 i
S4IP'7 09:) f0 10 4 a D C C-v

.-

rii j
1 e.,S.,S.•
() .
1.711
Itt'
1 01
11 VieT , ciear3
t J4 i
1 ..

7
RAI. . .....A0 WO r(
.
ALLERGIES: MI YES iil NO PRIMARY DIAGNOSIS: yen% ( . c...., ADDITIONAL PAGES IN USE: C3 YES 111. No
451P ,i,s40419rIt 1 .00unD5 'L.)-) I a-
V-X\ 014
PAGE NO:
WA-X- Vaal() . PATIENT ;IDENTIFICATION:
ACTION TIMES
, E US PENCIL. CIRCLE ACTION TIMES
. Ilk e-19 -V\r f D E 8 9 10 16 17 18 11 12 13 14 15 19'20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 onmnu no % nor r UAW RF USED. MEDCOM - 17252 USAPA VI MO

DOD-030841

,.....,
Verit y y
by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialcrig
(NON-MEDICATION) Mo0Yr 2003
Order Clerk
Date to Time to
SINGLE ACTIONS
Date Nurse be Dons be Done Time Done Initials
4sbyykv_i_ .tc.t.e2._ sitz top fro
_ ary\o‘.s_c_tock.Q:,,s_, Ill y.temiovod.) i,et. _itik rAlratk. .0t2_ ,. Te,nt .c.--i--7 -irl 1,t-.Ka-teod3,6
,

..,
•
, .
Order/ clerk/
PRN INITIAL PROPER COLUMN FOLLOWMG COMPLETIONExOrDate Nurse ACTION, FREQUENCY
TINIFJDATE COMPLETED
. .
I 1
. _ ^"'"*"*" USAPA V1.00
MEDCOM - 17253
DOD-030842
THERAPEUTIC DOCUMENTATION CARE PLAN (NONMEDICATION)
-
CLINICAL RECORD For use of this form, see AR 40-407;
Mo. Inr. 2003
- • • • • I - It h . OA •f
VERIFY BY INT17.4UNG Mragilagt IN I7AL PROPER COLUMN FOLLOWING EACH COMPLETION
-.
DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY. TIME

ria.IREl05E 07 Wrannigmcom
F-1 ZI,
IIIMMIMM1111111111111111119
rom-MIELMUIIMILI
1100 1:
iiitramEms1011111rm

Isumidccx\so, ,„ Immominimum-
row-rnv.i ra ram 111 Pia
wii----rotwasmillIEW

mar Assmommiiniall
Effille'Regrir .MENU EMMA

AIMMENIMININEEM
IMINEMEIMIIIMINEMEEM UMW— P• • EINEENTEMINGEU
Lags_ 0
7m1EIMMINIIIMramonrimmomple
211111111=1111111=1.111111111 ¦¦¦¦¦¦¦¦E10¦¦¦
¦¦¦¦¦¦111111111 ¦¦¦¦¦¦

¦¦¦ 111¦¦¦1111¦¦¦¦¦
¦¦11111¦¦111111¦¦1111111 ¦
¦¦¦1111111 ¦¦¦¦¦¦¦11 ¦
1111111111¦¦¦1111¦¦¦¦1111111
111111¦1111¦¦1111¦¦¦¦1111
PRIMARY DIAGNOSIS: ADDMONAL PAGES IN USE:
17.3 YES = NO
)cLilt-f i -x(t:3hw__Yry\sacs_Ay-)
PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
( Le)
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
onmmu rim I nsr• 77 "say as USED. USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM -17254
DOD-030843
-\\

Verity by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initiakng
(NON-MEDICATION)
der Clark
Time to
SINGLE ACTIONS
te Nuns Time Darts Initials
be Dons
ASO
PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION ACTION. FREQUENCY
TIME/DATE COMPLETED
USAPA V1.00
MEDCOM - 17255
DOD-030844
4/0/110V,
CLINICAL RECORD I THERAPEUTIC DOCUM ENTATION CARE PLAN (NONMEDICA77019
For use of this form, see AR 40-407: -
TMo. Yr. 2003
1ri1!„...twiae¦Tt !ty37 is the Office of The Suraeon General.
INMAL PROPER COLUMN FOLLOWING EACH COMPLEI7ON
VERIFY RY INITIALING0
DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

vs 63' 9 Fktse. 0)6 ism
P= urtrdpnvi

fig
i9r)ust leo
ca­
crfall

F nor
tknithd cg
ADDITIONAL PAGES IN USE:ALLERGIES: El YES N PRIMARY DIAGNOSIS:
YES E3 NO PAGE NO: PATIENT IDENTIFICATION:
u\
ACTION TIMES

USE PENCIL. CIRCLE ACTION TIMES

-111111 ›P
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
EDIT1f1111 OF 1 DEC 77 MAY BE USED. USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM - 17256
DOD-030845
Verit f by
THERAPEUTIC DOCUMENTATION CARE PLAN
Inttialmg
(NON-MEDIG4770N)
Mo .Yr 2003 Order Clerk Date Nurse SINGLE ACT/ONS Date to Time to
Time Done Initials
be Done be Done
154.411k\ L s L)
Order/
Clerk/ • PRN

Exult INITIAL PROPER COLUMN FOLLOWING COMPLETION
Nurse
Date ACTION, FREQUENCY
TIMFJDATE COMPLETED
USAPA V1.00
MEDCOM - 17257
DOD-030846

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) -
CLINICAL RECORD For use of this form. see AR 40-407;
TIfo. yr. 2003
the or onent asencv is the Office of The Surgeon General VERHY BY IA777ALJNG 44E0.724ZAV1434Z INMAL PROPER COLUMN FOLLOA7NG EACH C LE770N
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME v7i3t1
legh I? ,
-4,3 a a e J. air 07
—6 ,e4A150.¦ ll
/
006 -6--eita,z4..
air71-z.4.)E12,4, /6 /
31\ 7) .tc,aaPi 4P6
3'A is3 111111 - /8

ALLERGIES: YES 0NO PRIMARY DIAGNOSIS:
61/P 'A
PATIENT IDENTIFICATION:
( &)
ADDITIONAL PAGES IN USE: EYES (Z] NO
PAGE NO:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9. 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
LJI

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. Lealli'A V1 AO
MEDCOM - 17258

DOD-030847

Verif y by THERAPEUTIC DOCUMENTATION CARE PLAN WON-MEDIC4770N) Mo.yr 2003
Order Ciark
Date to Trne to
SINGLE ACTIONS
Date Time Done Initials
be Done be Done
egoo Ade
x
, 4, d-w, •
•
4
LI
Order!
PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION Daw Nurse ACTION, FREQUENCY
WM
TIMEJDATE COMPLETED
. •
1
USAPA V1.00
MEDCOM - 17259
DOD-030848
c)6 2— \

EP LAPIN ..*611oNi 1**04
MGM Er MENEM
Mi
raina

Oleo witvi

Mr laigra
Kall MEIN

mar-IMO!
r"IIIMMEIN
I IMENEME
ENIEN
14115111 MINEEMEN
ESTIMEN
Er leIPMEEN
t MEM
ME NI
Eimer _MEE
r
BEAU
RINS 41 MEM
tinEMENIE
ERIENE
UWA IOU ta
INEMINIMENE

MENEMEN
MEDCOM - 17260

DOD-030849

PR#11114MPII00.

DOD-030850

\9 -
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; Mo..Y r. the or000nent aciencv is the Office of The Surgeon General.
, -,.; !,, -. iz-;.-.....,,.,.,,, INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY IIVITIALING .
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE. FREQUENCY

ZC ?-77 -22, rig 30 3( I R
210 41,11111 5.-,,f Pcard:„ 04-Ae
,.., i1 cipt2.4. Ar3 t 5 0
,t0iiiioc. 5-./74‘ 7A,.(1.,ie G. -
/ /0
21/9.03 -/71 0,/cto...e—. /°0 a 6 g /
:1-
-..-
..45,4a2, laS a c9014( 1 e_, --in-ri tbio
ig
_
aw 06
dza,tA-0
1 e g'
ALLERGIES: MI YES 1.11 NO PRIMARY DIAGNOSIS: ADDITIONA L PAGES IN USE:
K, 01-, '5 I /1 0 4. L-aiv.cal:te_, /5­c r g YES PAGE NO. 111/ NO 2
PATIENT IDENTIFICATION: DISPENSING TIMES

' USE PENCIL. CIRCLE MED TIMES
o.. -L,\
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

crImcm r1F 1 fist^. » wa1 es USED UNTIL EXHAUSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79
MEDCOM - 17262
DOD-030851
Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Ma.Yr. 03
Order Date Clerk! tireari -SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Tens Given Initials
1449 A Am -r.z ...._,.. L . 1 .0,/e e 6 i 4k 7 do e
264_ oi 4110

ISii

-

-)(4011t_. 20eL )( I

„Los -iTaivis--kk.4.e 1 WA* 0 (42‘-ouex- r

*Au tr,
23/4,44-*
_J.
..Zitia__

fOq58'

04 -KG( tf 0 AO ) I ET4 y3
Mt
INITIAL ITOPER COLUMN FOLLOWING ADMINIS7RATION
°rd.° . Clerk/ . -. - -. PRN _
Emir
. tiaras MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date
PR Aisk33 Tif-114 / OM (Y) 0/ a pv)P4Au.-10 L
• • , . . •
•

USAPA V1.00
MEDCOM -17263
DOD-030852

oL)
CARE L4, N (MEDICATIONS)
7THERAPEUTIC DOCUMENTATI O N it _1420
CLINICAL RECORD Mo. Ob Yr. 0
the
VERIFY BY I.VITIALING 9r9n9'7?' '2"1 -c iINITIALPROPER COLUMN EOLLOWINC EACH ADMINISTRATION
.
'
HR -DATE DISPENSED ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY 3
V lis MEE= ZEI Elr'3IIIIII z -c-k----e-r-zr-t-z_ Tarr IIIIIII ¦
in 11111111•EMIEMPIPINEIMI
te(a4\14-2-e)kce., /2s-trrA amommill 1.2141111Swicaligiltiam
Va....,.r//1191111
7,7M,,
_
. gee 4 , 0 len 5 FAM ..ei irnryw,A.,m1INN
tv. mr-4--ligium. 1 rig it.....rd
is iszrarta zeizai

a, rammilla
I aA -/AA.-A r o / 0 +.5-C C-SEE 111
4.5' e c._ Al S , 6 ° /La AWIPIIIII
iii. .,.......2•Aglim"ILTINEFalraN
--ig Mil -11M111111 111111111

I) 4, ,us + .24) ei.6
MEM= 75 6c, (IL A/ FAIN - - AlaILIPMESEMMI
1111111
Silitili
•
MI .IV Z4
IINFINIBIMNEESE 4111M11111111
IP,"111111111111111•11111111 11116firsid \=. MI 1
II ...
EMI linr-
, 3 :37-5-
.
' E mut i Aill
wiiiiiii AMU
1111r1 ismarams..,
ammaimug
31011LAil 0 .-2-5- I
-

OC
9.)‹

01111111 ¦1111m
irmil¦
P . a .

ILM QiiiMI illiiilini ilk
171Mmi...... MINg./.11111111
iyAd1111111SEEM
FrMil ,J11._....4,... 0
4... lr0 ")."
b 1 d

FIELC.Al

ALLERGIES YE '' 11/ NO PRIMARY DIAGNOSIS. _±, DITIONAL PAGES IN 1=kAgt. '-di-A C-0V al YES 1111 NO
t PATIENT IDENTIFICATION
Mg P A 549 EA,p..ty (Aie 7 •),.1 x.
PAGE NO
M 4 1... P' -41-"-• rt /et_ DISPENSING TIMES
fPal I ^ ( ct - u I 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
DA FORM 4678, 1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00,

MEDCOM -17264
DOD-030853
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mn. Yr. 719D3
Order . Clark/ Date to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initiate
Date Nurse be Given be Given A., 0-1....,_
vt..ki—r.
., / c'..._
1. .....
oive 1 iSbe4 NS 00' 2Y etlitir kw 0S3t,.OS-IL t--—., ---­
tit.:
2-3L.s,!
P — •
1.0(c-LS
A*4T4

ke' A
:44
413
07/0

10e0
...--..,

..

iaair-"-f.

,

taze

.
.. /col, A),61
_ i.
se-a-e.. .- . ., ,s.4304,1_
• , F
a
if 71v tL. P5 eo 7l ir . i i‘e.'
Order/ l . i PRN INITIAL PROPER COLUMN FOLLO NG ADMINISTRAWN
.
FIKOir Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date 1.
........

C...
- - - - -
. t
,
.
-
_ _ _ _ _ .
. ,-.
_ .....-.
-....

. ,.. .
1
USAPA V1,00
MEDCOM - 17265
DOD-030854
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD ITFor use of this form, see AR 40-407; MO. Derr. 0
the proponent alert 1. • 1 : . • '.: •,:.•• , ., •
VERIFY BY INITIALING , - % ',' -r -• INITIAL PROPER COLUMN FOLLOWING E4 alADMINISTRATION
'' '' DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

FErmENI -24anzamonEs 3
,...1
..
I A 4 -• d ,.--A-• a e SI
gii MI : Is . _4- 3 11/ 1 II 111111111111111 /1 illil 4--.0 4. y . i
, 11
. 0 0 e

/ q . Tip .121.111111/7-11
iissailati
11 __MMENNIIMINII WUd'
Agrapai
110111 E
Nwapw-itgm A_,..iviEBItinireliMminiiminiiil EOM
_. Mill 1.. 112Z
10111 C 12._. - P.-1. MI¦isrmisimui radweermir.7.1.2 07 /Eros ,a sr a
=num I II m/swgIII 171:1EMEWP
lEiNial GGA
4511111 E511121.11;61.111L11111111
NI-Alsoussabsligh.G....Km.:17I -11E1­
: A .
.
rfige ILI . _ .1111111 3
6 6 624
ilinwri 111/11..mmmirg 4iFill'iMMAYA
.
20 Panawir, ANN MEM
OrPtr---mpaimmignore.........g

gnon
-3ffilogiiii
gilmegromcgr, a 4. ..r.
11111216adilffillVallilitillifillt AU iil 4E71 Orinrimml i .W MIFEKIIME111.11 11111rnmall 11,111111MI
ow ..06 EN. _3
,. niErsumw t• Animism'
ADDITIONAL PAGES IN USE:ALLERGIES: [1] YES MI NO PRIMARY DIAGNOSIS:
• YES MI NO
K get A /1 -1 c 6(
Al SIP fig. 44P (I-1 9 -P / AGE NO.
PATIENT IDENTIFICATION:

®l"` A-.9...wrn i a DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES ..-
D 7 8 9 10 11 12 13 14 ,

E rw o
E 15 16 .17 18 19 20 21 22 12 (CO - 9
N 23 24 01 02 03 04 05 06
USAPA VI .0
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA FORM 4678, 1 FEB 79
ri6
. I a MEDCOM -17266
DOD-030855

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Yr. o
• Order Date to Time to
SINGLE ORDER, PRE-OPERAT1VES Time Given oInitiate
Date-• Nurse. be Given be Given
n.yre,T1e, 11-
050 0
-
PaD
(
ay oF36
C
30
#66 4 Al S
PC; 72--
Ord Clerk! . . -INITIAL PROPER COLUMN FOLLO oADMINISTRATION Expir
Date Nurse -MEDICATION, DOSE, FREQUENCY TIMEIDATE DISPENSED
•
USAPA V1.00
MEDCOM - 17267
DOD-030856
Le_ 7 A\
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40,407:
h. • - • i 'oft; •f T • -r.
VERIFY BY IMTIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
DATE DISPENSED
ORDER CLERK! RECURRING MEDICATIONS.
DATE NURSE DOSE. FREQUENCY

lartEMEIKIM momErwri
mai giro
ria ¦,-0,ViS ra jtl
ILMINESIEWOolai
lar ---- 411111261111111L,kad
I xls.
10 P2

Ilaill1=111111M111111ff(0
Milliriww, ioD •oMast
4104111=1/011101

_____ENT
-'7'Ar _ „ +— A °
,.‘-NE
L MINIMEMEL
lummummtaimmomnim
immummENNEEENEEN

iammeimmummummun
oee Or-1111111111111111111111111111111111
MN/ 111111111111111111111111111111111111111
0:3
111•111111111111111111111111111
Ilide¦l11111111111111 ¦11111111111
11111111111111111111111111111E111111111
111B11111111 1111111 ¦¦¦1111111111111111111=11111111

1111111111111111111111111111111MM•111
111¦11111¦111111111111111111¦11111

ALLERGIES: 11 YES PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
=I YES 0NO

N P c4NR. `4)t-rc\cDoP\I Croeou2N&..
PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES
AMIN
USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14
(i2)
E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAKSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79
MEDCOM -17268
DOD-030857
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo Yr. CII
Order Dote Clerk! Nu SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Time Given

Wan 02 pic
LISFict53 Order/Ex* Data PRNClerk/ Nurse MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADAMSMATION TIMEIDATE DISPENSED
6.iee 4150 fq0 1545 dPtb 34

USAPA V1.00
MEDCOM -17269
DOD-030858

THERAPEUTIC:'DOCUMENTATION CARE PLAN (MEDICATIONS) 4111°
_,
CLIMCAL RECORD For use athis term, see AR 40-407: T
Ito:PreikeTiNtwnv is the Office of The SurgeonGefiarel,T Mcc Y

votiFIST/y117:11.1 NG w -niAvoy
VENRINEVINinvagagss PROPER coilimAtFpLi.q.}FING EAdr.4Ditinus
DATE DISPENSED
D.RIDER Ct.gikte RECURRING MEDICATIONS; '
DATE NURSE DOSE, FREQUENCi

2
•
•
M64f/PCL603
c---r-
----r.Tcc-Lao ja ti I
FL ERG.tES:, IT YES " [7-7:1 NO :PRIMARY DIAGNOSIS: ADDITFONAL PAGES IN USE:
1:73

/fi Ex Y4-
PAGE NO PATIENTIDENT1FI.CATM
DISRENSING.Times
USE pEtqc.L:.CIRCLE IVIED WES' p-7 VI 12 13 14
1510 17 18 1.9 20 21 .22 14-23. 24 01 02 03 04 0. 06
E.

DA FORM 018,1 FEB.79 . EDITION OE ' DEC 77:Vitl. 6 SED UNTIL EXHAUSTED:T USAPA MEDCOM - 17270
DOD-030859

PXV Plas

MEDCOM - 17271

DOD-030860

I (4) - 2, Pc ¦\
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; . . Q3
the or000nent agencv is the Office of The Surgeon General.

IIVITIAL PROPER COLUMN FOLLOWING EACH ADMIWISIRATIONVERIFY BY INITIALING -o::17„ .-o-o:,;.:,t,-;Ii5.,. ; :i1=3';_goL
HR DATE DISPENSED
ORDER CLERK! RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

CI
i a ' v

n % a In a ' ' 1 (D
0, 0_, • k.,. •
. _ _ _
t. t•
.
/

•
. . .
. -. .
•
ADDITIONAL PAGES IN USE:
JELNO PRIMARgilall:
NARYALLERGIES: 1111 YES
tonuiri, O Itvi-at t. I. YES
Ell NO
PAGE NO
VA M '-'t kf3cvs\nou,k---i ( Cm eg-tcLP
t
PATIENT IDENTIFICATION: DISPENSING TIMES
.
USE PENCIL. CIRCLE MED TIMES -11111111 .19P‘i\J
D 7 8 9 10 11 12 13 14
b ( (-ft -44 E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 0506
EDITION OF 1 DEC 77 WILL BE USED N L EXHAUSTED.
DA FORM 4678, 1 FEB 79
MEDCOM - 17272
DOD-030861