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

Medical report of a 24 year-old Iraqi male detainee shot in the buttocks, pelvis arm and leg. the medical reports do not give any indication as to how the detainee incurred his injuries, but does list his treatment and progress.

Doc_type: 
Medical
Doc_date: 
Friday, October 10, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

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 WITHDRAWN (k12THER (Specify)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

Doc_nid: 
3950
Doc_type_num: 
72