Medical Report: 25-Year-Old Iraqi Male, Baghdad, Iraq re: Infection; Secondary to Stab Wound to Chest

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

HE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDiCAL
YSTEM IS
USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOw. ti E :7)
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DATE OF '

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DATE F ORDER
TME OF
ORDER ..N1
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URSING UNIT - , , A 4A. . • .. 415
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ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF OFi0ER
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URSING UiNIT ROOM NO. I BE ) NO.
f?
MEDCOM - 14041
DOD-027593
DOCTOR SHALL RECORD DA rE, TIME AND SIGN EACH SET OF ORDERS.II
PRO E1Lf M
ORIENTED MEDICAL RECORC
TEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW
!ENT
IDENTIFICATION
DATE OF ORDER
I
11ME OF ORDER LIST ORD NOT El:
HOU RS
SIC
ROOM NO1SING UNIT 'IENT IDENTIFICATION BED NO.
RSING UNIT ROOM NO. TIENT,IDENTIF !CATION:• BED NO. . . • DATE OF ORDER co ,.."— HOURS

!RS:NG UNIT ROOM NO _ _ .... BED NO.
TIENT iDENT!FICATION dyyks DATE OF OBOE r -V:0 OF OROn cy7 0.ict MO\ HOW-IS
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MEDCOM - 14042
DOD-027594

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

rHE 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 TDATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
ORDE NOTED
HOURS
02000
(2_14 0.$ SIGr
c8c
4fib r ACC_
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTI 10 3n- E2--co; C7/5350 MINSIMIWIL HOURS • .0111P
NURSING UNIT ROOM NO. I C w2, PATIENT IDENTIFICATION BED NO. DATE OF ORDER 13CiAl v.0 TIME RD CCM OURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE • ORDER j 3 G3 Ur /Use._ /6t fr,49--- - „,(-- HOURS

NURSING UNIT ROOM NO. BED NO.
REPL ON OF 1 Jul 77, WHICH MAY U ED.
DA 4256
1 For:479
MEDCOM - 14043
DOD-027595

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

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST T ORDE
! / 6) --T-) HOURS NOTED SIGt
11010 `\0' ' LJ ik.400 r At aftir____
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATEE F RDER TI E RDER
Ho HOURS
rn
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1
GP 1A11-4 7 L-c_ c P LA.) Z 4 -e_____
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NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER 1\0 6 )-- HOURS
NURSING UNIT ROOM NO. DA 1FAcapr79 4256 BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MEDCOM - 14044 MAYBE USED.
DOD-027596

THERAPEUTIC Docum-Axerl5nrur (NON-MEDICATIO1V) T
,,, i
CLINICAL RECORD
Maf LI 't -rr. 2 0 03
,:i: erl:, 4:tiev.:44„1.7iii alitr4i1S7 is the Office of The Summon G
VERIFY BY INITIALING PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS.
DATE NURS FREQUENCY. TIME
q 10 1 12 i I q 15 Ai) 7. 'yr 6 Ys
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ALLERGIES: NM YES - NO PRIMARY DIAGN25SIS: • ADDITIONAL PAGES IN USE:
1111 YES NI NO

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PAGE NO'
PATIENT IDENTIFICATION:
ACTION TIMES
C a) 117-OW/ cA9 ''‘'\ USE PENCIL. CIRCLE ACTION TIMES
D 89 10 11 12 13 14 15
1-14 /0 ¦ E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA VI .00
MEDCOM - 14045
DOD-027597
Verit f by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initiaitng

(NON-MEDICATION) Mo Yr 2003
Order Clerk
Date SINGLE ACTIONS

Date to Time to
Nurse
Time Done Initials
be Done be DOM
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PRN
AMA PROPER COLUMNFOLLOWING COMPLEVON
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
•
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'
USAPA v1.00
MEDCOM - 14046
DOD-027598
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICA270N) .
....„
1,
CLINICAL RECORD For use of this form, see AR 40-407; _____9por anent aaen. is the Office of MO. sgstfrYT. 2003
the The Suraeon General.
VERIFY BY INMALING 740: ,,,-zzlm:;.4;A:: --m INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

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ALLERGIES: ON YES a NO PRIMARY DIAGNOSIS: • ADDITIONAL PAGES IN USE:
IN YES = NO

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PATIENT IDENTIFICATION:
ACTION TIMES
\\J)/\-\
USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
-
4( (/S 0 n_-/--t E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 14047
DOD-027599
Veril f by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(NON-MEDICATION Mo w Yr 2003 .
Order Clerk
SING LE ACTIONS

Date to Time to
Date Nurse Time Done Initials
be Done be Done
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ACTION. FREQUENCY TIME/DATE COMPLETED
"""--"*" USAPA V1.00
MEDCOM - 14048
DOD-027600
THERAPEUTIC DOCUMENTATION
CLINICAL RECORD CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407; the ornoonent aisency is the Office of The Surgeon General.
MOTIVLY F.
9'3
VERIFY BY INITIALING ',.=, ..-.:.;:k:.:`4;:,, '' INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
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ADDITIONAL PAGES IN USE:
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PAGE NO
PATIENT IDENTIFICATION:
DISPENSING TIMES &(40 It— C9).A USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14
LEI /0 07

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 EXHAUSTED. USAPA V1.00
MEDCOM - 14049
DOD-027601

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN
03
Initialing (MEDICATIONS) Mo..Yr.
Order Clerit/ Date to lime to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
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Expir .
Date " MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
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USAPA V1.00
MEDCOM - 14050
DOD-027602
1 . REPORTING MTF 1 2 3 4
A 1
l
3. REGISTER NUMBER 9 10 11 12
-. MTF LOCATION
5 6 .. 7 8 ... (State or Country Code.)
NAME (Last, First, Middle Initial!
14 15
/­27 P 3

6. DATE OF BIRTH (YYYYMMDDI 7. AGE AT MISSION 19 20 21 22 23 24 25 26 27 28 29
10. LENGTH OF SERVICE ETS 11. MAP 32 33 34 35 36
N) PC
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS 46
14. FLYING STATUS 15. BENEFICIARY CATEGORY 47 48 49 50 51 52
...MEI
17. UNIT LOCATION (State or 18. MOS
Country Code)
62 63 64 65 66 67 68 69 70
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
ADMISSION

72
EDICAL TREATMENT FACILITY
ADMISSION MND CODING INFORMATION
For use of this form, see AR 40-400; the proponent agency is OTSG
4. PAY GRADE 5. SEX
16 17 18 '.\A
8. RACE 9. ETHNIC RELIGION
30 31 BACK­GROUND

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12. SOCIAL SECURITY NUMBER 37 38 39 40 41 42 43 44 45
HOUR OF BRANCH / CORPS ADMISSION
b( -Ii
16. ZIP CODE OF RESIDENCE 53 54 55 56 57 58 59 60 61
19. TRAUMA PREY. ADMISSION
71

YEAR
NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADDRESS OF EMERGENCY ADDRESSEE /Include ZIP Code)
_

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 73 74
6
24. CLINIC SVC -ADMITTING 87 88 89 90
h
27. LOCATION OF OCCURRENCE
--- • ---• -(Battle Casualty Only)
103 104
FOR LOCAL USE
Vx°0 kie d 1 1.) urv?
c).2¦-__
-
22. TF TRANSFERRED TO

75 76 77 78 79 I 80
25. MTF TRANSFERRED FROM 91 92 93 94 95 96
28. MTF OF INITIAL ADMISSION 105 106 107 108
23. DATE OF DISPOSITION lY Y M M D Dl 81 82 83 84 85 . 86
k5 1-/ 5-
G
26. DATE THIS ADMISSION (V VMMO 01 97 98 99 1 100 101 102
29. DATE INITIAL ADMISSION ---(I' YM M Obi-112,6 114 115 116
eros
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SIGNATURE OF ADMITTING,CL_ERK........-

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Nomptoppw.. 7.mm"1"7'
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MEDCOM - 14051
DOD-027603
ATIENT TREATMENT RECORD COVEN -EF
For use of this form, see AR 40-400; the proponent agency is OTSG
3 . GRADE ADMISSION REMARKS
11. FMP REGISTE t(L/ 12. SSN . NAME (Las rst. ref OA) RELIGION 8. H OF SVC 9. ETS VI.1V6 (l q u\-,v LAM K 13. 01TIZION CI..-../ \A9 10. PREVIOUSn6ADMISSION 14. WARD
20. TYPE CASE

18. BRANCH/CORPS 19. UIC/ZIP
7. DEPT./
15. FLYING
BEN
DSG -11
STATUS
14:(1114
R1:ie
23. CLINIC SERVICE
(1/6
22. HOURS OF
21. SOURCE OF ADMISSION/AUTHORITYFFOR ADMISSION ADMISSION
A
(-CC
Ic
26.DATE OF DISPOSITION
;tr
25. TYPE DISPOSITION
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
r3es
ADMITTING OFFICER
28. DATE OF THIS
27b. TELEPHONE NO.
ADMISSION
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
32. UNITS OF WHOLE BLOOD/
30. DATE OF INTIAL
COMPONENT TRANSFUSED
ADMISSION
29. N
b 3 es O
31. SELECTED ADMINISTRATIVE DATA
7
Check if Continued on Reverse
33.
CAUSE OF INJURY

34.

DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
(0:, -1_s riCec
,
3tt
35. a. OTHER DAYS Total Days This Facility ABSENT SICK DAYS c. CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS BED DAYS I (4 f. TOTAAL SICK DAYS t(
36. ac SIGN Total Days All Facilites ABSENT SICK DAYS b. OTHER DAY R c. CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL CAR DAYS e. BED DAYS CORDS OFFICER f. TOTAL SICK DAYS (
DA MEDCOM - 14052 ION Or. USAPPC V1.10

DOD-027604

ABBREVIATED MEDICAL RECORD
MEDICAL RECORD
(Enter dale of admission)
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION
EA)Ikpf fuLAJL__ LA-43-c frvitAAA
s,e_q
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PHYSICAL EXAMINATION
PROGRESS (Enter date of discharge and final diagnosis)
a, ,
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ION NO.
en entries give Name Iasi. first, e; hospiu I or medical ftwilay) REGISTER NO. WARD NO.
ABBREVIATED MEDICAL RECORD Standard Form 539
MEDCOM - 14053 GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR 141 CFR} 201.45.505 OCTOBER 1 05 USAPPC V1.00

DOD-027605

NSN 7540-01-075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
ti
WBC H/H PLT SUP 02 PCO2 ABG/PULSE OX PH SAT P02 OTHER TEST RESULTS RESULTS RADIOLOGY Check if read by radiologist .
PT DIP EKG INTERPRETATION
APTT BHCG ETOH GLU MICRO
PROVIDER HISTORY/PHYSICAL

Ite
CONSULT WITH TIME ACTION RESIDENT/MEDICAL STUDENT MP
PROVIDER SIGNATURE
DIAGNOSIS
C,
CAL :AM 0
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9-96)

D
Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.20311400) USAPA V1.00
MEDCOM - 14054
DOD-027606
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
NOTES
DATE
4A-a?AdA
Diq avver— r sii-v4-
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SPONSOR'S ID NUMBER
RELATIONSHIP TO SPONSOR
ISSN or Orner;
MI
RECORDS MAINTAINED AT
HOSPITAL OR MEDICAL FACILITY
DEPART./SERVICE
WARD NO
REGISTER NO
(For typed or written entries, give: Name - last. first, m,adle:
'.4TIENT'S IDENTIFICATION:
-rn; Rank/Grade;10 No or SSN: Sex: Date of Ba
PROGRESS NOTES
Medical Record STANDARD FORM 509 (REV
5.'1999) Prescribed by GSA/ICMR FPMR 141CFR 101-11 2030D/110)
MEDCOM -14055
DOD-027607

AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE
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DEPART./SERVICE RECORDS MAINTAINED AT
STATUS
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SSN/ID NO. RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
REGISTER NO. WARD NO.
I
(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
PATIENT'S IDENTIFICATION:
Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
\c2,-"\\ Medical Record
STANDARD FORM 600 (REV. 6-97)
Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 14056

DOD-027608

AUTHOR ED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD
SYMPTOMS, DIAGNOSIS, TREATMENT, THEA I INC, UmUikNizA I ivril town ed(41 untryl
DATE
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(For typed or written entrees, give: Name - last, first, middle; ID No or SSN; Sex:
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 IREV. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 14057
DOD-027609
AUTHOR ED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 14058
DOD-027610
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

DATE
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PATIENTS IDENTIFICATION:
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 IREV. 6-97) Prescribed by GSA/ICMR FIRMA (41 CFR) 201-9.202-1
MEDCOM - 14059
DOD-027611
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE MEDICAL RECORD SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) DATE
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
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STANDARD FORM 600 (REV. 6-971 Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 14060
DOD-027612

AUTHORIZED FOR LOCAL REPR(
PROGRESS NOTES
DICAL RECORD
NOTES
DATE
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(x)(10 GaAA"--ck-j -w-c,
SPONSOR'S ID NUA DNSHIP TO SPONSOR (SSN or Other)
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PROGRESS NOTES
Medical Record
STANDARD FORM 509 (RE Prescribed by GSA/ICMR FPMR (41CFR) 101-11
MEDCOM - 14061
DOD-027613