Medical Report: 24-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wound to Pelvis, Leg and Arm

INTRAOPERATIVE DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the propor; y IF the office of The Surgeon General.
.---1—:
t.
1. PATIENT TRANSPORTED TO OPERA TI F. 2. PATIENT IDENTIFIL •__ 3 REVIEWEEq AND PROCEDURE
VIAix) !{Wt BY 2.5-1-1112.c ica VERIFIED BY CFI— 4 ---z-
3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM 0?-3 5.---TIME • : CaF3S-- NUMBER
100003
5. PREOPERATIVE EMOTIONAL STATUS
. CALM III ANXIOUS U EXCITED. • CRYING . . ANGRY . WITHDRAWN (k12THER (Specify)
COMMENTS: Niult A/IA 601 Al
6. NURSING PERSONNEL
C,--r- --94
• ASSIGNED ----RELIEF
SCRUB SCRUB
t -1; .a .

ep 6
66
ASSIGNED } RELIEF
• CIRCULATOR • _ ...„ ____CIRCULATOR -
it\n'i. ..

7 POSITION AN POSIT1QNAL AIDS (Sp ecify) " - jyti -1-14:t 1,4 ,51,4 ,t'lAl2-.9,.f -a- ,7"," _,471 • .. .07‘.. Ctkrk. ez4 .• 4tifi. Al S 0 " "S ) ae6 wo , h.CM-Psee..44-re,0. frr71/6(114rdS S'...1 5*-504, ---ritem .:1/ Ala v,,,,
Aav ,151
i M/S PINE `4 ITHOTOMY . PRONE . KRASKE. •,. LATERAL' . ',"EFT SIDE UP . RIGHT ,SP

I D E
-,,ts- Aed; . ra/4
/0 14, 1 - of; Pi (1-ect ,), pq atteetBla c 4 Le etolclacs.,_ , pres.50_,,ef po,COMMENTS: ars1 ,OC a.e-5..5 ' 4-0 .A C- k ,11 1.4r-14. : C.,44/1€ A. itLi157 it- ha
1.
r -Cre c A-• B , 7 c l y 11-94, 41."-A74--//raf,x1.- AA,/ cr.-zp-id
8. SKIN PREPARATION
HAIR REMOVAL )YES IN NO "' PREP SOLUTION ISpecifyrE02-7Pey 134+10._-.
DONE BY: OR / NURSING UNIT SITE: anal. ovea , B WHOM:
METHOD: II DEPILATORY Q23AZOR by Dr SITE f kiA joy, _IB IHQA:. , ,

0 CLIP
0 . 1 a'
COMMENTS: bolo or 0.4 4 71-ws ft ei .
ii iit 4-4.171--..._--. 11 6) .. cOMMENTs:A0 .01-
-' '
- - S'61-cific% AS /2e)
9. LOCATION OF EXTERNAL kEVICES - • -- -
. .
,
‘116..-11.11111111°--
-
.7,1 -
-'ir..7.•:.-4.4
Tot 'P;4:4i1 a:)
•
: -tEGEND: , 111111oUnd Pad - - ty Strap = = - iquet• -- .e,='S7t.V --ii0,97 10(6) --1.-
= Correct I = Incorrect

10. COUNTS - ­
/' :..
Sponge M Y No
Needle Sharp es V Instrument . Yes
73.
gdd
--z
f6
First Closing Final Closing
Count . ,.., . Ccitint
SCRUB CIRCUL
.(i-A--
o .._. .. . ::..1.:,,_;:.;% . - ,
_ .
Other 0 Yes o
11. PATIENT IDENTIFICATION For ped or written entries give: 12. ELECTROSURGERY DEVICE(SI ESU) ES II NO
•
Name - Last, first, middle; Grade• Date; Hospital or Medical Facility;) _,
- SU NO: E/0530195 , ROUND PAD: BRAND
, GR k in !Lep ja Paivisisiveffice,
6(6)- Lf -
LOT NO: 700 1 / 00 5.----0 LI
, ¦ -.
Ar--
Er.E.qb NO: ---GROUND PAD: BRAND
...-
LOT NO:• BIPOLAR NO:
, REPLACES DA FORM 5179.1 ITESTI. DEC.82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 21441
DOD-035017

IF YES NAME: ID NUM' -., . URER13. PROSTHESIS, IMPLANTS L-7,7
WC)
__ _........_

*4.0,::\ , ;;.:. ;:;A:ft.V_:..:t"; . tMEDICATIONS/ORDERS rg-,i wF,V,Ii-MMtkairaaarigiick, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO X PREPARED BY GIVEN BY
DOSAGE : TIME METHOD
MEDICATIONS/SOLUTION
. .
MOUND IRRIGATION 530'ES U NO TYPEIS):. -
-?qv kkei, QS -,4-- . .
TIME CARRIED OUT BY
'OTHER ORDERS :L:;1 ..:' , i...:_i:: P
.
YPHYSICIAN'S SIGNATURE •
-IF YES, SITE
15.
X-RAY IN OPERATING. OM
. YES 0 NO •

"-_' LABORATORY SPECIMENS .

16.

._ ____ ___ __•__ -NAME
SPECIMEN (S) NAME
YES • N9 r,
NAME

FROZEN SECTION IF NAME
YES NO

•
NAME
CULTURE IC) 1 NAME
_____ _,........

YES • NO --
• NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify) .
NAME NAME • , ,)
-- '--1160- lezi 1-eX'/ 1.riesi r/14-f-Fs,

17. TUBES, DRAINS/PACKING YES r, NO 0 -
j-
TYPE/SIZE 1.1 ff 12-0-41 ro5.-Q_ 2. . .

)(er ie. K R0 11 s) i A 7 . C...•
SITE 1.(s..M4 .141 413 R 2. 3. ' --""--A-ko
ot-qn(.45,

19. ADDITIONAL INFORMATION
. . -----,:--,-5A (rah' :Dcini ilyw 3J-Iie 4-i4,-.6:el-.-47 nove4 NM
.,
Lx 5) 1-e ret-op C4).--T )9i'3 je 4 . 720\.4.1-e se J 3ii-,7/30 Blend 1
.._ . ..,
01)" (orhA ,.A-1 ) / . q14161474
i f .
20. OPERATION(S) PERFORMED
,as Fiv SeV.... ra l ciekr Q r+e-ri 09/a 'r"'1 i T-r D ,6,,,,,
-12-C.,,k ( LJ) -044,1- ,
: ,.
k
-... 4- D /owe-'-::; e.t4 -

21. PATIENT TRANSFERRED TO TIM METHOD
-
I C¦Gli, 3 1-10 - 2-10 30 I r) (4 acee
22. REGI
USAPA V7.
MEDCOM - 21442
DOD-035018
-INTRAOPERATIVE D9Cl.JMENT
MEDICAL RECORD .1, For use of this form, see AR 40-407, the proporl 1 the office of The Surgeon Geneial.
1. PATIENT TRAN PORTED TO OPERATIN 3 F. 2. PATIENT IDENTIk . .CRD REVIEWED AND PROCEDURE
VIA /C0 BY AAP cl-k2.1 VERIFIED BY
3. DATE II on-03 TIME PATIENT ARRIVED IN SUITE /Q .C) 4: PATIENT IN ROO TIME: : /d ,P....0 NUMBER /... /
5. PREOPERATIVE EMOTIONAL STATUS
. CALM ¦ ANXIOUS Ill EXCITED. . CRYING III ANGRY ¦ WITHDRAWN THER (Specify)
COMMENTSw KA. inAbai-eal -
C631/7-\
6. NURSING PERSONNEL

ASSIGNED .r-G. 7,-9- n) """ -RELIEF SCRUB
.. . SCRUB ---:
• •-
C_/01---MIS6 ‘" 1.-:: RELIEF
ASSIGNED CIRCULATOR ....... . _... ....CIRCULATOR 0.-•
•INT;:
_ . 0116?--14-.:.-itztof--cdtet.k-, ClettedZArt /h-m-.6 04e* 54
7. POSITION AND fOSITI9INIAL AID§ iSpccify1R--91,1°,1441......4 ,: 1....90 ° 'J.,- 64" ..'C'e 4 (ell .• p.c.1•004 of....-n.boqr-d.Sc C I-- co d lq-1-eiett isAl / a-- •
.e Q
SUPINE , ¦ LITHOTOMY 0 PRONE& 0 KRASKE, ..-,,.. L ER L: LEFT SID - III RIGHTAgg a ri-...ibeefrei
au , pa
06, rW la c4C.-1-055 _ • .5* t. or,. Hp) 11.1,4) gern .,o.d
)19y rell , p Jae-C(0- Or c0 ra : 464.4 "t--' 09 111 &J -61h-veae-[come t-t--look,;;9. ca.-
raz,16ce-Pi eac'et-
-e
Poi G-1-3 3 I— --e0".. i E ¦ Also ctS b6irrIp L4rt-Lia-r" I-kie Gb.44-9L-1,,topkup...)-Carrea- Plcay Al yhniaiir Plain i r. IC
8. SKIN PRE ARAf 10
'' • PREP SOLUTION (Specify) DONE BY: ¦ OR p NURSING UNIT SITE: Y WHOM: J METHOD: MI DEPILATORY RRAZOR_'
HAIR REMOVAL ')YES ¦ NO 8€.11:3V6-e...-+zcl .
SITE: '-BY WHOM:
-- •65 101.4..b
¦ CLIP COMMENTS: no ri iC,k_S-or CA" 11 0-.. E6t4iktENTS: AO POO) 1 1 . C4 9)114/CdIn s r) 0J-ed
r • • --
EXCEL DEVICE
9. LOCATION OF EX .., '. ,.. ; „....;140-1_ . :....._.„1:-..:,..-
.
.
-3 A
e •
/
-7--
LEGEND X Ground 7d -- Safety Strap = = = Tourniquet• ---;....:::::.....-6(0
C = Correct I = Incorrect

N.
fro KV First Closing Final Closing '
10. COUNTS fa•kim• Count ..!1-4 , .: Count SCRUB CIRCULA
Sponge rf; es \lo . ,.. (;--Needle Sharp in'Yes II Vo Instrument . Yes 1st) No Other •_ Yes . o No •
11. PATIENT IDENTIFICATION (For typed or written entries give: --,--ri. ELECTROSURGERY DEVICEIS) (ESUI YES . . NO
,,.1
Name - Last, first, middle; Grade; Date; Hbspital or, Medical Facility;)
3as ,..
- ) ESU NO: gm tos-GROUND PAD: BRAND I/alley /44 Blylvs),A-rt-R6P1 .-
,--.-:-,7--: LOT NO WOll /Roc :7 s--oti ......41r , j ---
. :111..ESU NO:

, illir tp _If . ...

-- --.d)IDUND PAD: BRAND
:..... -
LOT NO:
. BIPOLAR NO:
•

USAPA V1.00 -
DA FORM 5179-1, OCT 87 • REPLACES DA FORM 5179-1 (TEST). DEC.82, WHICH IS OBSOLETE.
MEDCOM -21443

DOD-035019

1111 , NO YES NAME: ID NUMB! N_ . TURER
13. PROSTHESIS, IMPLANTS
. .

,.:4,4,., ,,;,,4„-t.yw..4.ji.,,Ig:::_±-,r MEDI CATION S/ORDERS;'. ';f, ...,:.75,,aw:; ii, 474,r rif, G;;; ;,,,,A.iit.Z0)-40t: IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM INOT BY ANESTHESIA) YES • NO DOSAGE.. TIME METHOD PREPARED BY _ GIVEN BY
`MEDICATIONS/SOLUTION
.
_

.WOUND IRRIGATION Nal'ES MI NO, TYPE(S):
:1
0, 4? % /V 41ek -6)-&,.
TIME CARRIED OUT BY

,OTHER ORDERS
..- ---. -

; ' • -¦
'PHYSICIAN'S SIGNATURE
IF YES, SITE

15. X-RAY IN OPERATING ROOM
Lt
¦ NO igl YES
' :•:- LABORATOR'i' SPECIMENS

16.
_ _ _ • ________ - --NAME

SPECIMEN IS) NAME
YES ¦ NO '
----t2 -"
.
NAME

FROZEN SECTION IF)S NAME
YES ¦ NO n
iSSL...Q.

C ..,,z, NAMECO -HAl2...di 1.A.,M4710( -1-51..15-1;412_ eixj NAMCO ISLAIleir4 4
,., YES Ci NAME
NAME

NA'
18. DRESSING/IMMOBILIZATIONApecify)
NAME NAME
-- --- ----43 P ""K.OAVA ("711-AWS 46D 117°10(
I

17. TUBES, DRAINS/PACKING . YES ..,_ • .. NO ' Ke...-le \a 12011,S) I k---t-p--,z_
TYPE/SIZE • 1. 2.
1/41li7)- VLet+ie-7e i-- A.) 114aiS4--karle)e R-01 1/-

3.

SITE. 1. 2. . -. --"':-----)46 . 1)941-)1k_ frva_e_
19. ADDITIONAL INFORMATION
. ; ,
\0/6)-7-
WO----WE ' 14) --t- .

rd CPT OKA) /9-
1.4 -{--124,A. h•-• Dr ---' s--1/21Cili . rye") e 0- ' -

-Boviv___ __---frh',,\.. : 3036-enda_- -56\A -*}-C'9 !/ P05179P -
e_; pe'e:--op 7.- (‘ -fr.
--f---4/5-
. . -.
,.

.-
Dft -51r)cl pre tiOtAS/ 1 ntAiOL-1-d CA .OIS AO4T-45---

7611.1

20. OPERATION 7D
.
LALDOodd

-ri-D C-3T-. . _
"7....c.....4-1) 0 -V 4azo tioelz c_)0 km&

TIME E

21. PATIENT TRANSFERRED TO M THQD _
/C14 1 6 ° /C-1.4 i3,2d-
22.
.

' USAPA V1.
MEDCOM - 21444

DOD-035020
-INTRAOPERATI DOCUMENT
MEDICAL RECORD For use of thi orm, see AR 40-407, the pair cy is the office of The Surgeon General.
. ,

2. PATIENT IDENTIK ‘• • • • WED AND PROCEDURE1. PAT NT T•AN P D TO O•tRATIlyG I VERIFIED BY C °J
' 0 BY
.11

VIA Ai 1 ,
E 4. PATIENT IN OOM

TIME PATIE 6 TIME: : / NUMBER /---3
3. DATE
i g -0C TC) (6 6
5. PREOPERATIVE EMOTIONAL STATUS

. CRYING • ANGRY • WITHDRAWN In OTHER (Specify)• EXCITED .
El CALM . ANXIOUS
COMMENTS: A3KID

, 6. NURSING PERSONNEL -.
VO--.._ ---. ----- "RELIEF

Tec- . ..,
ASSIGNED
. . SCRUB
SCRUB
q0--1-,-
.

66,c----- . .
ASSIGNED o,p7-- RELIEF AI --z5--r— E
_L....CIRCULATOR
CIRCULATOR ..._. .....
' i NT, •

,

7. POSITION ANDAND PO,SITIOML AIDS ISpecify' _ • P7-1^5 1(4-. 1" 1;,--et Cir ",-.1 S . -e)4 'tomir,' 11 ,•ei /01 • ee.,Allrea -.0 -6 atie5, -€C...4/*•
JO 1044.-A rry? ba grat c ••L-01/941. )-D-N_ 4r1,1 Lea 10 ic(e
UL THOTOMY, ¦ PRO E .. 0 KTIASKE . ; .-. „LATERAI) LEFT IDE UP , a RIGHT SID .1413 I), --C-l V b'l AXI I a ':*--4"/ I 1 l. 1 ,...„csz , •13-!O Id..e be- -twee.", a ervt$ gp ,-,.,..,..
SUPIN

ren i,, ,. -p, 1 tangykth,tiee-, lot.O.es /—
COgMENTS: 01^A ra Ivr-, , • C. ro 5 5 -t-reet 1, -ci-P , I. .
AA G.. t Q'S ¦--0,Y * ft-P0 70cly 1 („9-frI eL-,02--A--1---.ektaiklierr,"-e a -1---,A, co.,..71-
8. SKIN PREPARATION
HAIR REMOVAL . YES o , •PREP SOLUTION (Spepifyle—TIC(6e41-

• NURSING UNIT SITE: 1.1-Ab 1GS °---C4 (27-.) BY WHOM: .ei
- DONE BY: • OR
METHOD: . DEPILATORY . RAZOR SITE . z... 1-14,, k 4-ettildlei BY WHOM:

• CLIP ... ___............ _

r /.. .., TS: r7
COMMENTS: /2(J pai

COMMENTS: l •rtr, d--P S C ICA-110AS 4 0
- -•

9: LOCATION OF EXTERNAL • EVICES

-;•--- ":',':: I:: 6)--2-
•

vie t.oi - ---.
..- i 004.1.4¦7-.4rfw,1*-1,11101g111111ftswit; it-_
. 4AtigrtrIFFIIIMIPMII.

..1"76P1117FP-
..1144.14¦NNN
'4111111144111111\
Ili
LEGEND X round Pad fety Strap = = = ourniquet•••••-•::::'.--10 (6) — 1
•
. ..... .
C = Correct I = Incorrect
First Closing Final Closing
Yil

10. COUNTS Count . i ,F.. CoLlnt SCRUB CIRCUL
Sponge Oh, Yes ¦ 0 C., C?•• • .. Cr PPC G,0111.11.
Needle Sharp L. a N o C. ‘,..„._..,...
Instrument 01 Yes • .. 7-',..4.1.,,1.77. 7 ( c

(._./
Other

. Yes 1103EIMMINIPM1111 •

11. PATIENT IDENTIFICATION (For typed or wri ten entries give: . 12. 'ELECTROSURGERY DEVICEIS) ESUI ItgYES • NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility.: 1..

ESU NO: 'i t 1 05-305
INIEElairefffESWINEVAII
GROUND PAD: BRAND

.---.— -LOT NO: 7 4. ti - 405— —6(1 • Er-0s 1-J NO:
..
.....7.-GliOUND PAD: BRAND

6 4) -If

LOT NO:
• BIPOLAR NO:
USAPA V1.00
DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179-1(7E5T), DEC.82, WHICH IS OBSOLETE. MEDCOM - 21445

DOD-035021

IF YES NAME: ID NUME M AC RER
13. PROSTHESIS, IMPLANTS .`
:,.1 -,::••,`-:4-t,:;144' MEDICATIONS/ORDERS :4•,;-.4„d:.-;.,i t-„,i4,:f4.4S,4i141 -?:=4g2414.71. YES . NO
IRRIGATION'""EDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) DOSAGE -.. TIME • METHOD PREPARED BY /... GIVEN BY
MEDICATIONSISOLUTION
-

, ,......... .

11
1WOUND IRRIGATION 1/4-PES • NO TYpE(S):

iO-Cee ri)Cke-r4__-' 05 -
TIME CARRIED OUT BY

OTHER ORDERS
1
.__..---- -...... ..._
. . • ,,,

''PHYSICIA '
F YES, SITE

15. X-RA -, 7.7
-::::) -•.:.
. NO .
YES
-:"-!.I,. RY SPECIMENS

16.
„...,, .
._ •_•__:_._ .-.---- -NAME

SPECIMEN (S) NAME
YES • NO f-'-,: .
FROZEN SECTION (F 1 NAME NAME

YES . NOW,
NAME

CULTURE (C)
YES .:10 NO ¦ L. IA)A:,t: '1
NAME

NAME 1 , ME
•

. _ 15. DRESSING/IMMOBILIZATION (Specify)
NAME NAME

_ .0,9°€ Pilate 1(nrie
.. _ . _ il g 0, - --Kock 6411./ ) ­
17. TUBES, DRAINS/PACKING YES El-NO . - -rii/EffS t (r/Opela/' 1 I k'/A+ L'e
I

TYPE/SIZE l AP-1-4-) CV)1QS TT!)--7,, CtA•le-r *-6 y__
t ti toqi tk
SITE .tfbe. 4 - ic-111) Ap-t.-

19. ADDITIONAL INFOR
r,,•_L?:,
71.4 1.9-12.0-1\ S-- _ .
_ ._,.... , ..
0
_ slid-

.

ny..R-5Ansol-ae,11---rida.
yr.AA e ,,....0.,,,,,,;_s c,/5 0 ote,,it :.L -race s. „_1 c_._ p ile --ole C.29-1_ . -.10_ Cif--7.-7—,

rc64 °r --" _...,.
,
.
20. OPERATION(S) PERFORMED fv_ i ,
--c (0-5 U r..°-"t rxert.c..---1 / )1 q L-f-JCA-4 kid chhS CP/4( 2•--,

(0 -7---
21. PATIENT TRANSFER D TO /I, IA TIME . METHOD

I k--1-'13 -c-t. crin 1 c,14,.6-ed.
USAPA V1.00
MEDCOM - 21446

DOD-035022

INTRAOPERAT1 ' ''c.. )CUMENT MEDICAL RECORD • . , , For use of this form, see AR 40-407, the propd, r mcy is the office of The Surgeon General.
2., PATIENT IDENTIM. ... .ORD REVIEWED AND PRIDGEDURE
PATIENT TRANSPORTED TO OPERATING R
VERIFIED BY C,c7\---66)' 1--

1.
VIA C\,r\-t..-/ BY -C Sn 0,-TIME PATIENT "RIVED IN SUITE
4.-PATIENT IN ROOM

3. DATE TIME• : .10 NUMBERS
I.: OkiVaS
5. PREOPERATIVE EMOTIONAL STATUS

IR ANGRY I. WITHDRAWN • OTHER (Specify)N CALM . ANXIOUS • EXCITED . . IN CRYING
COMMENTS:
6. NURSING PERSONNEL
, .. ' RELIEF. :,.., :-.
ASSIGNED ? C.:
+_IIIIIIIIIII7iL____.____
. .SCRUB
SCRUB

-1..,--. • A _
RELIEF
ASSIGNED (r
---,CIRCULATOR

CIRCULATOR --- -• -

7. POSITION AND POSITIONAL AIDS (Specify) _ -
gl LEFT SIDE UP • RIGHT SIDE UP .
M SUPINE . LITHOTOMY_ IN PRONE . KRASKE--_ LATERAL:

\a‘e.,o,......,_ I.. t•••• a-e.-ak.-1 cu-acita
t pv,i-e_rA-‘.=. 0 '1"-• ¦-•--(Lid¦- 1
Q-4-'itE) c,s_^`' .,...p ,,,_ ojN, Ir-;. 'ejLev ...) .

•----¦.-A----- 1 Pr's.", \ -,,,, %,--..5 ‘'0.-"*.
COMMENTS: Nrtre-X- i..-°"-.. % sz...x ,...
e 5v\- cWtiv-e_v\ 'N-A sat,1/4/7,-ftevvx-t-c1/4.„As_s4A0Act ot
. -
8. MN PREPARATION.

HAIR REMOVAL • YES ER NO • -PREP SOLUTION (Specify) goa--#0,. k cit Q-
-A--pc.,.4e.

-- DONE BY: MI OR • NURSING UNIT SITED iria,..A• BY WHOM
. • .. SITE: fr?'"--"e '''''cr`"---(A ) BY WHOM:

METHOD: . DEPILATORY . RAZOR.
. CLIP ... . • .• • .

• ... .... t
.. ....... f COMMENTS: ...... _______ ..COMMENTS: -1110 IV ccfs.A..,-, bites,, a's 'NA-0'k • at:.
- • -,--N •9. LOCATION OF EXTERNAL DEVICES

C3^-^s--4..13%,
.
=
.
1-L • _
• •Iffs-a0,

A
• tirt,
X Ground Pad -- Safety Strap = = = Tourniquet....-;.-•-
LEGEND
C = Correct I = Incorrect ',...7"..e.,:,...CL:t .
Tr..-first Closing Final Closing

10. COUNTS Other• • Count . •1 ,.. CoUnt SCRUB CIRCULATOR
Sponge Yes • No C _
Needle Sharp Yes U No G --
.. • ,..7.:,;:,2V.:7;s• - . _........-------

Instrument . Yes RI Vo . -
Other . Yes It No

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) M YES . U NO -
LOP 4 5-1 LA-Jr t.tg.
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

\Pair-1 61r TO-V...0--Q.
_ ..._ : W-. ESU NO: .• ItO
(01 ..
ill

GROUND PAD: BRAND VI--4 -1:-....-- ft.14.1194.
--.,:.--t.-:-,•-• . LOT NO: 1-11)0 I t 7-1e-S -(•1' 0
,.,.-
c ErESU NO:
Okik`. 0 . .
••----CROUND PAD: BRAND

-...,
LOT NO:
--ig A-1 /•.- C_
. BIPOLAR NO: -
REPLACES DA FORM 5179-1 'TEST). DEC 82, WHICH IS OBSOLETE.

DA FORM 5179-1, OCT 87
MEDCOM - 21447

DOD-035023
NO IF YES NAME: ID NUMB! NUFAC S URER
13. PROSTHESIS, IMPLANTS . YES
1 :,;104:MEDICATIONS/ORDERSVow .—..-..„........,......____ m„. GIVEN IN OPERATING ROOM INOT BY. ANESTHESIA)..... 'MEDICATIONS/SOLUTION DOSAGE:-TIME . METHOD ..—_— . YE PREPARED BY 40 GIVEN BY
_ ,.. .....

MOUND IRRIGATION YES . NO TYPES):
°!O
TIME CARRIED OUT BY

OTHER ORDERS
hn(5-W1.-
PHYSICIAN'S SIGNATURE
sPt
IF YES, SITE

15. X-RAY IN OPERATING ROOM
YES . NO 5'
''.LABORATORY SPECIMENS

16.
NAME

SPECIMEN (SI NAME
YES . NO
NAME

FROZEN SECTION (FS) NAME
YES . NO
NAME

CULTURE (C) NAME
YES . NO Eg"
NAME

NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
NAME NAME
ysititN)e
17. TUBES, DRAINS/PACKING YES I-NO .
2. 3. ItlaD
TYPE/SIZE
te, -F lb-ekArt )12
SITE 1 .

d 2 51-4-ak. 3.
19. ADDITIONAL INFORMATION
25Z_C-1/1 11111111111 •
\_s2 ck.
,t e
—DA _CI 3c1 crY¦ s
0-11-11"&ck4A-A-a Aco ci",-"Nrc‘Ocx_k_
20. OPERATION(S) PERFOR D

TIME METHOD 3 13,t_011/4..
21. PATIENT TRANSFERRED TO
USAPA V1.00
REV
MEDCOM - 21448

DOD-035024

INTRAOPERATIVF DOCUMENT MEDICAL RECORD .
_ „ i, 1y is the office of The Surgeon General.
For use of this form, see AR 40-407, the proF
RO EDURE2. PATIENT IDENTIR

1. PATIENT TR NSPORTED TO OPt_r(ATfivi f VERIFIED BY 1 LT
VIA It iL,k. a BY -NA-11..)/StUnia
4. PATIENT IN ROOM

TIME PATIENT ARRIVED IN SUITE TIME- . P.5-00 NUMBER g.. —2
3. DATE
[5. oc 1 /

5. PREOPERATIVE EMOTIONAL STATUS EXCITED CRYING • ANGRY 1=1 WITHDRAWN II OTHER (Specify)t9:1 CALM . ANXIOUS ¦ 1¦
COMMENTS:
-
6. NURSING PERSONNEL
-. -----RELIEF
ASSIGNED SVC ';1 D-"
SCRUB
SCRUB
RELIEF
ASSIGNED
M
-._CIRCULATOR
CIRCULATOR - •—. - -----
II41 -;.

7. POSITIO AND POSIT OVAL AIDS (Spe9kf)114., 44-aw ful, t-e-q trid-D,.-11 cm l--i .aL IL, yi ed/„. For
. i

,sursc ce.,„_y- p-isiciza-w-e__ -E.--..,..vair.. 3 i.tnr--GHQ
Del ikacl.t a- - et VOA 6rbl, at -,8:r qti to
• RIGHT SIDE UP

. SUPINE I. LITHOTOMY • PRONE . --. KRASKE---• LATE AL: II LEFT SIDE UP Ott v`" CACA 05.5 cam.. 4--c., be tt*i_Dae."--ca •^-..•¦ I e cisw ,-.4-c pit I to al b e,44.40J2.1,,, 1.es5,
---pi I too..i
a

COMMENTS:
8. SKIN PREPARATION -• PREcluTioN (Specify) ifk,64­
HAIR REMOVAL ¦ YES N 1a0-44-.
teSux_LL Y WHOM: wiz.
SIT
h1p 1
• NURSING UNIT
DONE BY: • OR

SITE: ,. BY WHOM:
METHOD: II DEPILATORY • RAZOR. .. ' _ ri
_ Ste-.___ ______ .. CdiviiiiENTs: 6 p6 a i fl e. b4tori, n Ip,./
M CLIP •.- -------• i t2•
COMMENTS: Se
9. LOCATION OF EXTERNAL DEVICES
D'.
rt/

r. .. jo
At; .....
.

• . / /4.-
.

-, • Af/A.: . Ilt.

40-z.

LEGEND X Ground Pad y Strap = = = TournrqUet.- - -,-1;..1.::::...-
C = Correct I = Incorrect kA4.(st,I. _ SPC., AAA-1 Art—
kek.t.-) First Closing Final Closing

10. COUNTS .atlIer• • Count .. :-.: Critint SCRUB CIRCULATOR
Sponge Yes IIII
Needle Sharp Yes ¦ o -..

. :,''W1:•.:.; . 7 .
Instrument . Yes Mil o .-
Other Yes E gi o AIM II III IP1°, . d I 1 I II I I I I I MII 111I I I I I I I I I I ¦

•

12. ELECTROSURGERY DEVICE(S) ESU) F2 YES MI NO 367
11. PATIENT IDENTIFICATION For typed or wt., en entries give:
Name - Last, first, middle; Grade Date; Hospital or Medical Facility;) 60, •

ercZ

. 41-ESU NO: 06 io Z/7 S , . OUND PAD: BRAND
GROUND allIAJO ...._ LOT NO: (0 g its sap 9.01)C - OZ ' .: 0.7.41.1" NO:

it 1111116A )-1
-. "`GROUND PAD: BRAND
..-
LOT NO:
. BIPOLAR NO:

DA FORM 5179-1, OCT 87 REPLACES DA FORM 8178.1 (TESTI, DEC.82, WHICH IS OBSOLETE. MEDCOM -21449

DOD-035025
NO IF YES NAME: ID NUMBF .C -ER
YF

13. PROSTHESIS, IMPLANTS
"MEDICATIONS/ORDERS

.' RATING .ROOM (NOT .BY. ANESTHESIA) YES . NO
..,. .... .... —...... ..__ G IVEN
DOSAGE . TIME -

METHOD PREPARED BY GIVEN BY
MEDICATIONS/SOLUTION
-....

-
'

-

,. .
MOUND IRRIGATION iti YES • NO, TyFEIS):0
+AA-( Z 51---TIME CARRIED OUT BY40THER ORDERS
:PHYSICIAN'S SIGNATURE
: ,. ,. . ..,.........,,,„...,_ . _...... . ...,-....,,,„.

IF YES, SITE

15. X-RAY IN OPERATINGIOOM
:: ,
YES El NO

- SPECIMENS

16.
.,_.......•_ NAME

_ __.__

SPECIMEN IS) NAME
1_..

YES ¦ NO,
NAME

FROZEN SECTION IFS) NAME
YES El NO

.

CULTURE (C) NAME eavOIRL c() NAME
....._

YES -91 NO . .-
NAME
NAME
..

NAME
.

18. DRESSING/IMMOBILIZATION (Specify)
NAME NAME
r eo Li

17. TUBES, DRAINS/PACKING YES s...4 NO •

T-6 10 4t_ •`---
TYPE/SIZE 1. 2. v l ii, -- _ '1 • •

1G F,rt_
- -10 1i q VI-
SITE 2.6,7) / 3.

0114cjic
dill '
19. ADDITIONAL INFORM • ION
StirgeOR 1

'7,--,,-
.
KASI*102 a '• W\ k ..._._ .. _.....

(2(0 '
_.......;.

20. OPERATIONIS) PERFORMED
Uk.) a (c-

--.1,---4'b 1.(t-
T; E METHOD

21.
PATIENT TRANSFERRED TO i)
CiLiA #3 , -1-4 -ex c

22.
REGISTERE' IGN

USAPA V1.00

REVERSE OF DA F
MEDCOM - 21450

DOD-035026

• INTRAOPERA F DOCUMENT
, ' : The Surgeon General.
MEDICAL RECORD For use of this form, see AR 40-407. the 'cy is
1.71i

2. PATIENT - • - ' ND F2/CEDURE
1. PATIENT TRANSPORTED TO OF,iRA . '.
VERIFIED B

(l•!/ Ae
VIA BY Ill.:A 0
__
TIME PATIENT ARRIVED IN SUITE 4: PATIENT .s,

3. DATE
TIME .fil/0 NUMBER ON?".
/7 (t O3 /6/0

5. PREOPERATIVE EMOTIONAL STATUS 1/(6)--7---
. EXCITER . • CRYING • ANGRY • WITHDRAWN . OTHER (Specify)
II CALM '_ANXIOUS

COMMENTS: AC .d.,
quia.Ke. e/u

6. NURSING PERSONNEL -
rc --RELIEFASSIGNED
. SCRUB
SCRUB
6 ----2— -

RELIEF
ASSIGNED if-A"
_.—. ,..... . ....__CIRCULATOR
CIRCULATOR
•

7. POSITIO AND POSITI NAL AIDS (Specify) II ,PI I g fr • , ,/ f, d/lei lit .„( eV, Mr'
.

.... tVc . 0 a ,/,/6.4)-,-iiii4ei cii I Qie) cu ,,d/ L::‘, r ev / /....6., z ca ,
• SUPI E LITHOTOMY • PRONE _ II KRASKE -• LEFTT SIDE UP r4 ; GHT SIDE UP .
RAL: EF
-7,
I

Cop m.01.1 GL.C.4,73 .1. . tairti 4j 414.4.4-ezis. -Ar _r OMMENTS:
8. SKIN PREPARATION
NO " PREP Se UTION (Specify)
HAIR REMOVAL . YES

DONE BY: III OR U NURSING UNIT SIT eit AI ef,,.. _ eY WHOM: ,,,Arfik.
SIT • BY WHOM: _LMETHOD: III DEPILATORY • RAZOR
bk • CLIP -. •
--------...E6mn4trsITS: .6.--//0lerif Jo lul-fh, A, .14, 2
COMMENTS: ,_:-_—
9, LOCATION OF EXTERNAL DEVICES _
.....-, ,A) •‘. ....:

.-... • ,
.0 .-.., . p, th ••...)

..7--( --.--.77.-- -.. • 10-)
.. -
;Wig
)
a. Tleriltig'— . . ...,..,..
4,9(0
as k el-C: P it'

LEGEND X Grou d -- S rap = = .---- Toumiquet-......L .:::.: 1, b(6)-2-.
C = Correct I = Incorrect

First Closing Final Closing
CIRCULA OR
10. COUNTS Other• • Count . i ,: .Count SCRUB

Sponge FA' Yes 'D No (7 J . , r
es 'D V o -e.K. . ‘4

Needle Sharp wi
.. !;.1,:d1Y!:T

Instrument •Yes . Vo %' •
Other • Yes . No

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. .ELECTROSURGERY DEVICE(S) (ESU) E • NO ay
Name - Last, fir ; Grade; Date; Hospital or Medical Facility;) ...596
LI
ESU NO: s . a 1 4. • GROUND PAD: BRAND VIIMUMN-RMEW-I6-4 le
10 (0 -
-

LOT NO: 1 *: R a )05 01
7a i ' ;trE.SO. NO:
,. -• .--,
•--. -GROUND PAD: BRAND
,.., ..-

LOT NO:
. BIPOLAR NO:
REPLACES DA FORM 6179-1 ITESTI. DEC 82. WHICH IS OBSOLETE.

DA FORM 5179-1, OCT 87
MEDCOM - 21451

DOD-035027
IF YES NAME: ID NUMB JFAC 1ER
13. PROSTHESIS, IMPLANTS MI _*--N°
_........--

::ReW:::: ,..4,34*Arigti.ok*AbkA.5,k,*3.:ig::th..s'esi-0! MEDICATIONS/ORDERS SIMAniiStv.:.- ninagStiltRagafg, 1.14aSi,k4
_.,

1 4
YES . N
IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT. BY. ANESTHESIA) _, METHOD PREPARED BY GIVEN BY
DOSAGE . . TIME

WIEDICATIONS/SOLUTION
_ . _...... -,...-

4
_ .... . . ,__..

. .
)
;WOUND IRRIGATION p.m NI NO TYPEIS):.
. . TIME CARRIED OUT BY
OTHER ORDERS
.

r .,.
. -. .... ..

-ipHYSICIAN'S SIGNATURE
.,' IF YES, SITE
15. X-RAY IN OPERATING OOM 77".
i.:7i ; • .•; -, '
-
YES • NO •

-
16 ' ' .""2',LABORATORY SPECIMENS
.
.
.
_ ..-----...--...__ ,,, NAME

SPECIMEN (S) NAME • . .
:-..

YES • N 0,4
NAMEFROZEN SECTION (FS) NAME

YES ¦ NO , a.
CULTURE (CI NAME 6.,.. cg, t 444 0.) NAME ,..
_,_ _._.

YES ,i0 NO •
NAMENAME NAME

18. DRESSING/IMMOBILIZATION (Specify)
NAME NAME
-- --[:-.41-41
NO

17. TUBES, DRAINS/PACKING YES g U 44(,./_ (la c. I c , aj
TYPE/SIZE 1. Kir til. raif 2. --1-dLaivi
7( l•--.
_ . .. ....-....
3.

SITE 1. 2.
19. ADDITIONAL INFORMATION Ary„..av .449
,...:
e
CUr 5evh
...
f ..'::•:?
, . . ..
.__ . _ .....,
I \
----------....\* - -
• .. :
.
20. OPERATIONS) PERFORMED

U./ YU. et-k• 4 4-it, c.,
-S-4,-L 1 -4 „....-
•

TIM METHOD lij . -[ 1,44e'l c 0 ?...
21, PATIENT TRANSFERRED TO
tC )
22. REGISTERED N
tA/117 44--

.._._..._ __

REVERSE OF DA FORM
MEDCOM - 21452

DOD-035028

INTRAOPERATIVF COCUMENT MEDICAL RECORD A....,
• For use of this form, see AR 40-407, the prop/ •icy is the office of The Surgeon General.
2. PATIENT IDENTIR = • : • : VIEWED AND PROCEDURE
1. PATIENT TRANSPORTED TO OPERA . AG ,
VERIFIED BY

VIA 1-.... ( ' 4-t.. Ely irci 41 TIME PATIENT R• •(• d: PATIENT IN,BpOM I
3. DATE
,ll
5. PREOPERATIVE EMOTIONAL STATUS ^
/ : CALM ANXIOUS in iii II

6. NURSING PERSONNEL _
V

SCRUB SCR ; 1
WAW
¦

tfr i .-35 --7 E_.62,
ASSIGNED " PIN 'S 1 -110 RELIEF
CIRCULATOR _ _.,..CIRCULATOR
•

7. POSITION AND POSITIONAL_AIDS (Specify) --. -
. SUPINE 0 LITHOTOMY 15 PRONE . : KRASKE. LATERAL -'EFT SIDE UP 5 RIGHT SIDE UP _.
Vit, . .

COMMENTS: IN f0 --fl,k- i 41 -0(.. ov--e ---opo--7 k ,..\,...,..._t_..-._ I sz.,f j. , . .i. 0.-.... , /a *.N-aka •e4
l( inv-Yv...' cz rpr.... op of rNr...1 .
8. SKIN PREPARATION
•

HAIR REMOVAL [1] YES . . , -•PREP SOLUTION Specify) i3 0.......k r,,, ' Ice.i.e (A. tz 4. S4 14.,,Ar4 DONE BY: . OR III NURSING UNIT SITE lA f (C.,_ '-BY WHOM:CfirGt b 6,, ; METH D: El DEPILATORY 5 RAZOR ' SITE: QI--"S Z=.(c-•,--c). BY WHOM: O
. CLIP - .. __-______ . _ •
.._.,
1 i

_/ ,
COMMENTS: _________ ._____. ._ CdIVIMENTS: CIC) pc20(t 11,0 cy-j-So(t...t. Da '¦t, h c:0)--c_0(

9. LOCATION OF EXT RNAL DV/ICES
, 1:_ i::
Yttit'l
1A-f f ciu.,-

,-•
:

0 1
--- .
-.. .
.--__

11111 671711/
hess,¦=10WIMINNt .OE ,4*(1,1¦41„244

116.0„
. _.........„,,...41*-­

Ammingo..-____-..¦-.........-1-4.7.4-.,_,T,ft.

,
......
:.i .. gilta4fk.s.n.
LEGEND X Grour4-06d ' - - -Strap = = = Tourniquet- —,,,,,, ,,.. r--Tr
.... C —Correct I = Incorrect

: .
Rrst Closing Final Closing

10. COUNTS Other•• Count I•:. Count .SCRUB CIRCULATOR Sponge NO .%
(..,
..

-. Instrument . Yes r"?0 .- ..., Litp•
Needle Sharp YesYe No C__ _ .......

. ._.. ..
Other II Yes , No

11. PATIENT IDENTIFICAT104 For typed or w men entries give: -12. ELECTROSURGERY DEVICE(S) ESU) erYES• NO Name - Last, first, middle; Grade -Date; Hospit I or Medical Facility;)
ESU NO: 0 162-39 S ' GROUND PPAD: BRAND 114-.- It C 4 ittJr-
4t- i -...
I ON

LOT.NO: ( u 19 LI -CA? i.3r1.)
,, ...,..-=
.... . :..-z-
17.E
:-.:Tri'NO:
-
- --..GROUND PAD; BRAND
•., •
)- - 2-
LOT-NO:
. -
• 15 BIPOLARNG:'••
0 c 4-
,,.
.. -
-A

DA FORM 5179-1, -OCT 87 ..• ',REPLACES ON FORM 5179-1 (TEST). DEC.52,WHICH IS OBSOLETE.., VSAPA V1.00 MEDCOM - 21453
DOD-035029

yNO IF YES NAME: ID NUMB\ -,TuHui13. PROSTHESIS, IMPLANTS ¦ YE;
`14 .................... 'A = 2,,,,i.f-.:.•04.;:liat-40A_044 MEDIC ATI ON S /0 RDE RS4*.PAI.1(4171;WMtakkail=aiRia:, V.,t::;i--IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM ;NOT BY_ ANESTHESIA) YES . NO
.:MEDICATIONS/SOLUTION
}WOUND IRRIGATION ter YES
1 6 U--
0 T7( GIS
,IDTHER ORDERS
PHYSICIAN'S SIGNATURE iI
15.
X-RAY IN OPERATING YES ¦ N

16.
SPECIMEN (S) YES ¦ NO FROZEN SECTION IFS YES ¦ NOy CULTURE (C) YES ¦ NO 1 NAME

NAME
OOM i NAME NAME NAME NAME NAME

17. TUBES, DRAINS/PACKING TYPE/SIZE 1.jI e x 2w i-cr-DOSAGE': TIME -
--- - . •-.
. NO, TYPES):.
,___ ._
. ,
-
,•, .
. •ie%
IF YES, ,SITE ... ---''-' LABORATORY SPECIMENS
- ----,-'" -: :-- , ....,, .----;,,•-----, I'„., .
-•-----•-•
. 2. _ _...,_ YES E•r ..... ..._ --',:-• NO ._ - -- -"--¦ • • . -

tam y,.. 74)--,_,-- - -• SITE 1. i it CO- 1.5 &IWO 2. wo, /I 3. LUCIA4 4/..-46 tAr41 cy'r)
19. ADDITIONAL INFORMATION
1,0073 - .,.
•-51\./¦--(' v_v)-..: 0 r ,_
.1, .4_-:.--__ ---F ,d.75. 1
ir,:e /s95 .a 50
D 14-5-1 79 pre iii, ()tits / , r In 77 . rid! 02s.,'

20. OPERATION(S) PERFORMED )
METHOD PREPARED BY GIVEN BY
TIME CARRIED OUT BY
.
NAME NAME NAME NAME

18. DRESSING/IMMOBILIZATION (Specify)
Ar/d AI c-e mcxy4--kal, e y ico 1 /5, cpabLeol) 1yi-e)6 rk
i

_--.—thbc? 71 .

e. /,-_e -ap co"-(f)05---1-.- cp C-)Dr_
44
ci orize a/
•
"CO
1- * cr

:__Og/0.51tbs,vi CAA
.0 6-IA 4-40C1 W CA-ArIC", ,:___----•-• y-
---- 4-0

19(04; 21 - PATIENT TRANSFERRED TO TIME METHOD/ ez 4/ i1 &1 ?(-"C c,./
22. R _
is7-71/
USAPA V1.00

DOD-035030
INTRAOPERATIv D( JMENT 1 MEDICAL RECORD 7..,
• • For use of this form, see AR 40-407, the prop( en..,,r is the office of The Surgeon General.
ti. PATcre0-17PelpRR 3 TO OPEF1,,iING .. • . s 2. PATIENT IDENTIF, -VIEWED AND PROCEDURE;1, VERIFIED BY CPI-
L VIA tk) It et-t-BY Alit j•Vi\-ZS I Ck TIME PATIENT ARRIVED IN SUITE 4; PATIENT IN ROOM ) 1 TIME .: 05?:(3 --903)1-NUMBER
3. DATE
•-LI 0 C.71-03 0905-
5. PREOPERATIVE EMOTIONAL STATUS
\------

m ALM • ANXIOUS • EXCITED. . CRYING • ANGRY • WITHDRAWN a OTHER (Specif
COMMENTS: ft) /4 111--
6. NURSING PERSONNEL .
'PC -. 9, i ----R EL I E F
SCRUB

• ASSIGNED
SCRUB V(.6)-1

6 6C
C/P-r. MOM
RELIEF
CIRCULATOR

ASSIGNED
.. -_. ....-__CIRCULATOR IN I r

a - •• 41 504 , -4-..., /1 0 , .1.-0 CA„f "-e P051 eal,
•

T. -PO ( TION ArkID POSIVONA AIDSApecify) Al do e, f,, /
A-4:CW MIA,j-107,,.71-5 ," --cc 4-• • Old,, p4 /idt-t./ , 4da SUPINE U LITHOTOMY El 4 _ .. KRASKE %, , L6T E,F31_; , p2 LEFT SIDE UP III RIGHT SIDE UP
140:0 et O Olf.0(•4 -,.)9-7r wk., &poi.,..e..,-,Apid (91, ,,-,.., -„,,-„,
. nk"-N. 1:)-0_ . d • -I.,cie-f ei n 100-ytk 1..e_
42 -0..eS, T=4 ( tC.I.A.3 --; l'illi.e...5 1--Cl P1 -14)1 .¦ Vel
. .. ,.

COMMENTS:
Cara el----Sc,oly 14 kr,,e„,./.. /Vid-7./4 ed 4•11,--0 t-ti/A °I'd- t
8. SKIN PREPARATION
HAIR REMOVAL..K:),/Es III NO• 0 ' PREP SOLUTIION "Spe • g.e-71--, 6.-ela

DONE BY: NOR NI NURSING U IT SITE:7:VittOCk5 i,- ji i B WHOM:
SITE00,114.. )9.betayile).) i BY T:

OMMETHOD: • DEPILATORY MIII" AZ (4
ie

. CLIP olio Pr -4432/2.401 vi-. CO lc-510) n y eL TA i c,,,_ LI
:.... ..
COMMENTS: telo h i e, ,r.e o jc -COMMENTS: ri l a "r)/(4 71)0Y)5
• - - • •---

9, LOCATION OF EXTERNAL DEVICES
.....
00) 2
...4.,*2¦70,..-

44341
-.-....1111101111111111111116r#144.4V
' 111110,----4-11rjr, &Via . ..‘ ..
i• ------- --4:-Aiu~mrp.--- -......-----
,
Alps-ipw Ir4.¦ .,,,,...,..

LEGEND r • Pad . -Strap = Moumiquet---.-,-- A:410..A¦••.:41 iir %,•(2. tole) --L-
..--= Correct I = Incorrect

ill, ' First Closing Final Closing

10. COUNTS Count . r-.-Cciunt SCRUB CIRCUI •
Sponge . Yes J Vo C' . Pe.
Needle Sharp . Yes . lo C . . ..-_: -......:-.....
:.. ,.:i;111_27.. -

Instrument MI Yes J 4
Other . Yes J o --------
11. PATIENT IDENTIFICATION (For t ped or wri en entries give: •• 12. ELECTROSURGERY DEVICE(S) ESU) YES ¦ NO
Name - Last, first, middle; Grade; Date; Hospital or l Facility;))

hz, ESU NO: ( 0 060 -._ GROUND PAD: BRAND OMR 0 PRIELMBr P1
______ .

_ LOT NO: 70 ] I g 5-04
. 7E-SU NO:
--:-:GROUND PAD: BRAND .., LOT NO:
¦ BIPOLAR NO:
USAPA V5.00
=ORM 5179-1, OCT 87 REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS ospOLETE. MEDCOM - 21455

DOD-035031
IF YES NAME: ID NUMB' UF -URER
13. PROSTHESIS, IMPLANTS [7] "i-ES NO
a s '8?--S ORDERSi:r4.: "1:1,

;. . ‘• :: ;;.-..ii.,_ ,. :,;,: .:146:3;.;:z4T-4-Ar.:4411,;;:;--.: 1-5-1,k,kp:i ,f.-^—,.-i. rc-c.-.;:o IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
YES II \ i.. , DOSAGE:-TIME'-. METHOD PREPARED BY GIVEN BY
-MEDICATIONS/SOLUTION
_ -........ _ .
. .
= :
. i
, '

I
MOUND IRRIGATION ES • NO, TYPE(S):
' CHO NoiN
TIME CARRIED OUT BY

;OTHER ORDERS
....

1 _
. .

,
.
•

,PHYSICIAN'S SIGNATURE
!; . . ,..1 • u +
IF YES, SITE

15. X-RAY IN OPERATING OM
: ,.:;
YES NO

.
-' ± LABORATORY SPECIMENS

16.
r - • ___
NAME _ _____ _ _____ -___,_.-- . NAME

SPECIMEN IS)
YES . NO
NAME

FROZEN SECTION IFS NAME
YES ¦ NO
NAMECULTURE (C) NAME

—. -._-° ___

YES • NO V
NAMENAMENAME

NAME NAME AB, DRESSING/IMMOBILIZATION (Specifyl_i rf.A A _...... . VS 6C;61,"-e-PrIU S '''‘ teLA IC-2 i-teg 1-114 -ttS -PUY/ YES siklc_.-kp-P--.
17. TUBES, DRAINS/PACKING NO ¦
TYPE/SIZE 1. 18,f\;-\01,0..q 2. t . 0130-40eks—k5 5,0,/ced it //ex ic3/,
--i-— °bp n .

SITE 1. jc,..._ 2. 3.
•

19. ADDITIONAL INFORMATION -IA
V -L_

WC-TP
...

5617011 : Dr _ . . _ _.
akikl ---
f)-yq), -R.12-)s I a • il 43-
-r-

Oft-51 1Y1 pl,evi. oi,trst, inii) le -s4 de, 4r,
20. OPERATION(S) PERFORMED
a\c_ d/-e55; (ef/ace_ 6106 1\ o
S G1/4.70 1.Ar1 4-14 ..
© 781../14-fett -.)
r,oci. 5 k cm.4-

womykel D-ess)ys c... Loc6A 4y.
-wr I - (,,a)v, Ad . _ 711
ZTh C-0 10,Slowly BA9_, A 6-4 01---, f
21. PATIENT TRANSFERRED TO TIME TH04 -

/C. tA /1)/.964 ° VO ME ki _4' Me7
22
"77/11-1-1-/

USAPA V1.001
Z_ MEDCOM - 21456

DOD-035032

--INTRAOPERATIvc DOCIMENT
I
MEDICAL RECORD •

For use of this form, see AR 40-407, the prop( enc he office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAI ING. . . 2. PATIENT IDE IEWED AND PROCEDURE VERIFIED BY
VIA 1..,e'.1 BY (pill On 1.)00 --Z.--
3. DATE TIME PATIE T RRIVr\IN SUITE 4. PATIENT IN 01 Ci--1-03 b 6)--7--TIME ; NUMBER).
5. PREOPERATIVE EMOTIONAL STATUS

¦ CALM Eg, ANXIOUS ¦ EXCITED, . CRYING ¦ ANGRY . WITHDRAWN ¦ OTHER (Specify)
..

COMMENTS: Li":.-F ; IVA -r-e-go ,0-1,P ,fi.l
...___..._........... ..

. :

6. NURSING PERSONNEL .
, . , ,

f'
ASSIGNED . S • .. •-F.-.7-7-----. ---RELIEF
SCRUB - ' ' . SCRUB

6 (0---z:.
ASSIGNED RELIEF
CIRCULATOR _ ._. ..._ . __CIRCULATOR

. . .. -.

7. PRSITION AND PNAIQS (SnififY..) Lo.v22- 04,/,, &in 0,6 0a, . pi tidtplegii
-Mail ...7160
.)

¦ SOPIPIE ¦ LITHOTOMY ¦ PRONE ¦ KRASKE. • LATERAL: yll LEFT SIDE UP -¦ RIGHT SIDE UP -
'
COMMENTS:

8. SKIN PREPARATION

HAIR REMOVAL ¦ YES VD NO -' PREP SOLUTION (Specify) J It ,ret,1a/pps` kcpa
DONE BY: ¦ OR ¦ NURSING UNIT SITE: If- /laid( . BY WHOM:
METHOD: ¦ DEPILATORY ¦ RAZOR, .. , , SITE: BY WHOM: .

¦ CLIP -. _ _ : ..__._ 7.--q()—___
COMMENTS: . .._.----tdividirEK-ts: to (OP) 1'3

9. LOCATION OF EXTERNAL DEVICES
•

Sail . ¦
-vt . _ :is--••••
-¦•.---......111.*-.4*401111110111111."-¦

-••¦••••••..--

• I.Illrjlr.-.
Aj 11)
LEGEND X Ground Pad -- Safety Strap = = = Tourniquet....,,.-4-1 •-• ..-

0 C = Correct I = Incorrect
.
First Closing -Final Closing -

10. COUNTS Other' • ...1%;-;Count Count SCRUB CIRCUL • •
Sponge killall IIElMIWAIIIMIIII
Needle Sharp ¦ MAIElNIMIIIIIIIIENIIIIIMININEM ¦IWA

Instrument ANIENEMink ¦1¦1111ffire
INIEW-A7AIEMEMIWAIIIMP
Other a Yes 111+ o

P"

1 1 . PATIENT IDENTIFICATI•N (For ty• -d or written entries give: 12. . CTROSURGERY DEVICE(S) ( U) . YES
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)

• D. ESU NO:
GROUND PAD: BRAND
4111111 Liti)L9
LOT NO:
¦rESt1 NO: . .----GROUND PAD: BRAND
. ,_.

LOT NO: .
. BIPOLAR NO: _
DA FORM 5179-1. OCT 87 REPLACES DA FORM 5179-1 (TEST). DEC 82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 21457

DOD-035033
—.. ,

IF YES NAME: ID NUMBE ,IU 'TUBER
13. PROSTHESIS, IMPLANTS L (E• O
-

14 .:.i:1V, . pigiNig,'.44,4Witg' MEDICATIONS/ORDERSfeft-pj.W4A.AAW„-W; :RMaigVqVea:;
.t4i:1.;:,,14:;;King,;g1.47-1.

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT.BY. ANESTHESIA) YES d No
METHOD PREPARED BY GIVEN BYDOSAGE..... TIME :
MEDICATIONS/SOLUTION
. .
.1,,
MOUND IRRIGATION YES

• NO, TY!E(S): A e/a4D A.,.(

T. Li I
. _. .

• ---TIME CARRIED OUT BY
`OTHER ORDERS
. . ,

A . .
:.-PHYSICIAN'S SIGNATURE
IF YES, SITE

15. X-RAY IN OPERATI OM
YES NO ,1
• .
' ' :-..''2:1:ABORATORY' SPECIMENS

16.
. - -1 NAME
,. .:......--...

SPECIMEN (S) NA
...„

YES ¦ , 93.:
NO .p

FROZEN SECTION IF9) A
NO tc`‘\., 0' A NAME

YES .
NAMECULTURE IC) NAM

-— -.----

YES NO .
. .
NAMENAMENAME

18. DRESSING/IMMOBILIZATION (Specify)NAME
NAME
NO D.--

17. TUBES, DRAINS/PACKINGRAINS/P C YES
TYPE/SIZE ,. , 2. 3_ P QC v3(2-z
SITE 1.

2. 3.

19. ADDITIONAL 1NFOR
_ ......_,....
li.'
\C 'CPI
LY'l
k
1 -

20. OPERATION(S) PERFORMED .
,--Li

D ippd, 6 ' •
TIM METHOD tlik:

21.
PATIENT TRANSFERRED TO INV

22.
REGISTERED NURSE SIGNATURE

i .......... ,...--,

REVERSE OF DA FORM 5179-1, OCT 87
MEDCOM - 21458

DOD-035034
INTRAOPERATIVr 9OCUMENT MEDICAL RECORD For use of this form, see AR 40-407, the groom( . y is the office of The Surgeon General.
2. PATIENT IDENTIFIE .. • ED AND PROCEDURE
1. PATI NT TRAN PORTED TO PERATIN , •.k. VERIFIED BY CP1­
VIA VO . o • 0/ 5 -BY lib 0 .a44: ¦ I TIME PATIENT ARRIVED IN SUITE 4.- PATIENT IN ROOM 1;4) .....z.
3. DATE
1 -3 0 9S-C9 TIME; -:0 r75-6) NUMBER /4---
OD-A.)0./0
5. PREOPERATIVE EMOTIONAL STATUS

U ANGRY • WITHDRAWN n OTHER (Specify) . VCALM U ANXIOUS . EXCITED. • CRYING
COMMENTS: Nk*-.-...,..... _......_.
• ,.
6, NURSING PERSONNEL
--RELIEF
ASSIGNED
.. .s.cm.,B

SCRUB
•b . --7-•:
VT 6-6-. _ RELIEF
ASSIGNED
.._-.. -..

—CIRCULATOR
CIRCULATOR
INT.; •

- J4 a. cas., ?II . . 4, ....4....., s
„. pckorm7 ;0g• ! PI, a i. t
7. POSITION AND POSITANAL AIDS (Speafy)or .cr
p/E'slbt ft..,152A r= 01,--EASehi v-E, in 4A-vm f•---ickcirg`7 Grei-, Ai ,h-ets crza.:4--.. .-"V-° .÷--" a ' L. i9-,-)PA: cA\

LATERAL: 4FT SIDEMP 0 'IGHT SIDE P .........

SUPIN LITHOTOMY 11 PRON •• K S E.-:

,p111.00 0s-t iop 64-, .o.,,, .*Op c..),Y. Aroi /1.c.k.), Hyms sa . .. •,t., i
WI 3, °Wirt b
1 -63-01 I I. , _ ‘41".2_ ,v. Tv, ; ticit..%) ).-0.--h.{...A-e12.-,"¦..... (-1 -5 ee--q--2/4"
COMMENTS:
..*-4,01a.pe_
Ca or C )71---fil'?"-1")"1.42-14AP ir t ,,./ i-.1­
8. SKIN PREPARATION.

•', 'PREP UT1ON (Specify) 6.Q...64/6-..12.647
HAIR REMOVAL • YES 1 :11 NO
SITE .3440J,s, B WHOM: C.,'
DONE BY: • OR . NURSING UNIT .
SITE: BY WHOM:

METHOD: • DEPILATORY 0 RAZOR - • . ... ..,.. .--:.t.c,15 )
) -2---

III CLIP . .. ' —-6/o7 s 64-16n.j •
-..L._-_.:!.. __ .... - -/
.... ....

. COMMENTS:-,1c) roclie As) ta.P.504r. hO. .8 Cie/
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES or
_. . ., ..

PPP111¦07111P":"4r
. O
_a.-

-•4104-4P0
v.447:741411
aiii-or
'!611100

.

sit .,.., iiirl
411"11,11‘r.
_,......4t,
Ground . ety S trap =tumiqUet.- .0*--4 p iv
LEGEND X Ground • . • . = i.)
C Correct I = Incorrect

ge, a:t I FciorsutnCt losin....‘ . FdondaIntClosing
TOR

10. COUNTS SCRUB CIRCU
Sponge Yes No 0.- t
Needle Sharp Yes ] Vo e__ .. .,..,...._.....
!,:;.:..:;,:: _____--=----"?

Yes iVo . . _.... _ .;

Instrument
. ........ ------------.

,.....;.-..---.---

Other . Yes Vo
11. PATIENT IDENTIFICATI fFo yped or ritten entries e: 12. ELECTROSURGERY DEVICES) (ESU) • YES otrNO
Name - Last, first, middle; Grade; 0 t • Hospital or Medical Facility;)

o)
D. ESU NO:
la LI
GROUND PAD: BRAND ._.._- -
...., L. LOT NO: ":0,,E'
SU NO: ._
•-`.• .-..6Fpu ND PAD: BRAND LOT NO:
• BIPOLAR NO::
REPLACES DA FORM 5179-1 {TESTI. DEC.82, WHICH IS OBSOLETE.

DA FORM 51 OCT 87
MEDCOM - 21459

DOD-035035
IF YES NAME: ID NUMB P._-. ACTURER ,......_ .........._
13. PROSTHESIS, IMPLANTS • Y YNO
4. qt,t;_::;::::**4.V,::j , V*.4:4T-cAatilV:Vg4oviEDicATIONS/ORDERS MtiltiVAVA',4etateMa:Xe , -', -,;! .24= , ,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY. ANESTHESIA) YES • NO :!.1 MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY ' . .
.

MOUND IRRIGATION)20 YES • NO, TYpEIS):
i 0. 9 4(0 /1)4 a .-C100 4--Ce . '
'.OTHER ORDERS TIME CARRIED OUT BY ;
_.....— .
_

:PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING ROOM ,.,.; IF YES, SITE
YES • NO

16.
' ''- LABORATORY SPECIMENS
, •.,,

SPECIMEN (S) NAME -- ------ --NAME
YES • NO
FROZEN SECTION IF NAME NAME
YES NO

•

CULTURE IC) NAME NAME
¦,0
-- - . --

YES • NO ,III LL _". -
NAME NAME NAME
NAME NAME . :-,,, 18. DRESSING/IMMOBILI4TIWeavie jidec -i /
- - '-r----0, 9% 11.6 te. 111-4215j-e
17. TUBES, DRAINS/PACKING YES :82 NO ¦
pi-eb pad 5; lk 71-Zy2--r
-"

TYPE/SIZE 1.1‘fr ripl-ey 2. -I
&pin ....---
SITE 1. ‘,4 ...1 n A 2. 3. _. ...-. -

66. • .e. 0

19. ADDITIONAL INFORMATION
, . .

WC- L71-_--V-­
51„ ,ILOri --Dr- i: ,, , ,.(..;::
. _.„..,., _.
Arti AR-Si a — fly' 11) fr":7; C-e, 15 ,

-4 -- ' 1--

DA 5-v79 piv vi 014.5 f iii 1 -1)-41" 4-ei
20.
OPERATION(S) PERFORMED

.(16 Atgl5kOlA)1 0 ii ---,---19 (0-z-

21.
PATIENT TRANSFERRED TO ME MET OD

P PreAA
0 E'
CA) re

22. REGIST
OF-T-k4j---
USAPA V1.00

REVERSE OF
MEDCOM - 21460

DOD-035036
NSN 7540-1-634-4124
MEDICAL REC VITAL SI RECORD
HOSPITAL DAY 9/ Cl./.. POST-DAY
alb!
MONTH-YEAR DAY i r)I 1 0/4 / 3
.

": 0
'
•
19 HO UR o..‘• II • • it
•
• 4
•

. . . . . . . .
•
•
•

•. • •. I i • • • • •• •
.

.1

•
I.

.: :. :. :.

•
•
t :
:

—I
rn
70
0
PULSE TEMP. F
. .

.

(0) (*)
105°
•
•
•
—
(43t8
:

•
' • ••
'
:.:
. . .
. . .
bb
0 00000 0
(Centigrade Equivalents, for Reference only •
•
• I • • • •
•
104° ‘.... .
180
. . . . . . .
•
•
. .
•
• • • ... 0• a•• ¦••¦••¦
4.

. . . . . . . .
170
I • •
l• • • 7
•
. .
. .
. .
.
••a • • •
•
• 0 •
•
•
•
.
.

160 102°
1 • • • • •••
•
. . . . . .
• " "
.
• • 7
: .
. . . . .
150 101°
• •I• • •• • • •
' •
. . . .
. . .
.

.
. .
N W (-41

140 100°
. .
. .
•
..• •• • • •
.
. .
" • •I
. .
. .
' • '
•: : :
.
130 99°
. • .
•
.
.
120 98° . .
••• '
.
. .
•
110 97
°
. .
.
•
.•
•I •• • • •
. .

•

100 96°
.
. .
•
•
. . . .

90 95°
.
80 . .
.• • • • • I
. . . . .
I_••••
...
1" .•
.; .,
•
:. .:
•
. .
•
'
.
.
70
•
. I_ 1 ....:
60
• • • • • •
. .
. .
50

I. • • •
•

40 . . . . . . . . . .
RESPIRATION RECORD
•--.4
BLOOD PRESSURE 1 yt

61 a`1 Ilse ... 4110.11IIMMK..ZiELI
sip j.-7 C 1 1,, iii, V ' , •

,.., .
ycli
HEIGHT: I WEIGHT —ms

s
71191

HM9c19°I. (HA •,:p Itz
(PA
(1.'
1B10
CM )

PATIENT'S IDENTIFICATION (For typed or vat ten entries give: Name—fast, first, middle; ID No. REGISTER NO WARD NO. .-
Record special data only when so ordered

(SSN or other); hospital or medical facility)
i2(0-1-1 VITAL SIGNS RECORDS .
Medical Record
STANDARD FORM SU (REV. 7-95)
Prescribed by DSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 21461
DOD-035037

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-MONTH-YEAR CE:r DAY DAY a NANZIMFI AKAILI c2/Scz5 LI. RWAI '

WAENN4111E41141111111F1111 •- MEM .0,

0-- 0
1,4 0C/M3
PULSE
(0)
HOUR
TEMP. F

(')
105°
.1. : :

--2--• .
IEEEW
C.) 0
t12 C
:
•

1 . 4,
.
•- •-
' •
6
..

: $ 4) : : 0?
.

. ....

. .

. . . . . . . . .....

• ...... • ......
180 104°
: :
. .
: : . . . .
....

• ' ' • • • • • • • •
170 103°
. . . . . . ..

. . • •• ••
•
. . .
•
•

• . .
. .
:
. . . .
. . . . . . .
. .
. . .

. . . . .
160 102°

" ......
......
.
. . .
..........

'

...
......
.
.
150 101°
.. ...... .
. . . .
......
.....
...... ... 41:
. .
:
: :
140 100°
•

.. 4

H. . il

..
....
•
.....
........

......

: : : : " •'
. . . .
130 99°
98.6°
120
98°

.
. . . . .
... . .
. .
..
. . . .
9
ntigrad
.
1 .' •
110 97°
..
•

Li.
•

1.111111MMEN111
..1

1

..
. . . .
. .. :. .:
100 96° il

. . ..

. .

90 95°
.

1

i

4`

'•

1
80
. . .
:A •. .

II

......
50 ' ' •'
. . .
. .
. . . . . . .
" •
.

............

70
. .

•
• ... 1 ... :.
. . . .
. ..
•
. . . . .
. .. .
..•• • • •
h.. .
. . . .

:/ ..........

........

....
....,
•• .. . . . .
.. . . . .
So
40 cb 0 . g..k, . "

i. • " " *V
e
•

RESPIRATION RECORD

onvormommavrismi 7
Record special data only when so ordered
BLOOD PRESSURE
MO:.

am
f

milimirrgniurrilLIIIIMMTIM
171 111111
.

II 02
NMI
HEIGHT: WEIGHT ---•
ft/
• A111110111111r Xi'

9
.

- -.2.0M.MillM

colNitto

:-,­
.

'
gil cget)
Cet"
....._

1DATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, frst, middle; ID No. REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 21462

DOD-035038