Medical Report: 25-Year-Old Iraqi Male, Baghdad, Iraq re: Shrapnel Wounds to Chest

Medical records of a 25 year-old Iraqi detainee suffering from shrapnel wounds to his right flank, chest and surrounding areas. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.

Doc_type: 
Medical
Doc_date: 
Monday, May 5, 2003
Doc_rel_date: 
Monday, May 30, 2005
Doc_text: 

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STANDARD FORM 600 tREV. 8-97. BACK .U.S. GPO: 2002 - 491-600/50618
MEDCOM - 3984
DOD 010463

NSN 7540-00-W4-4178 HEALTH RECORD DATE .11/77p 24 C 4.) 600-108 CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry) -P AirriE— J,rp ( 0 .0 It1-1 11-1 ) 4.r......e..... ,...,
6, b Pr u 0 : i 162 -a-.2---1› g 6 ji- A I k
i--k",---.-.49--.--
,. C, ii 0 Fl ti-rNA-, A.---2/M .../ Ae 01., 1 L.— A L..44.44,J FL/14.3. Y • . X g. 1 ari ( 1 15 J A frl v¦rb-,-4-AP.--2 .1-)(2 ‘ c-,,,, D
)(8)-2 6 ND 4_,,,
c.. -r Joe-4

OATIENT'S IDENTIFICATION (Use this space for Mechanical
RECORDS MAINTAINED
imprint)
AT: PATIENT'S NAME (Last, First, Middle initial) SEX RELATIONSHIP TO SPONSOR STATUS RANK/GRADE SPONSOR'S NAME
;13)(13)-4
ORGANIZATION DEPART./SERVICE SSN/IDENTIFICATION NO. DATE OF BIRTH
CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM SOO (REV. 5.84)Prescribed by GSA and ICMR
MEDCOM -3985
FIRMR (41 CFR) 201-45.505
DOD 010464
510-112
..,.., ,......-„,v-o..,,,-, MEDICAL RECORD NURSING NOTES
(Sign all notes)
DATE HOUR OBSERVATIONS
A.M. P. .
Include medication and treatment when indicated
10 6 63 a i Ob el-a..A.A\U 2.c4 A V1 ! I .4. ¦ * .
.1._ Moil
b)(8)-2
r °LAI.. R C pY0.-2a. . 1(V¦ZY-1 C,(b)(6)-2
il.,,.
aa I -1,1_1 Li( CP p (-
11 VL 0 3 oa J-to ' A2,5 -1---
_ On pk-elli -l''' 7-ot-t 5 1. i . 0, 6 Pie___. ill'Ve OW MPS p p s cotA(ltn,_((„,4u2_0( Nor f ay S.
b)(6)-2
Pr iss -(--1 0.0 kr, —46 ..... .---) (rJaLi tP ic e,17,-\_piL/ S Lr-:. C3fr ki„ rou&,, 04. ekow.-tu4PA thyr fr,
.. . cr(
(dil -ittc--eit-{4 t-Q_,J4-‘
(0­
(b)(6)-2 p91 V/1/0 '-' 4 ' (OGOAS k 0
Ctr--
A IL ' i C tAv . ..e 1 I ( * At& .4.4.1° Ili r1 I
tt()2j0 I '5 k i I ja C.— HIZ 9 9 (/ 5./ 1 C L -
,)(6)-2 V1/1 (e,{,—Le----riA kaittf;
(\ar' 14.,
eAd kC41f-La(r. 0 7 • t., A ,.dita• hA ' /../_ 4
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank: rate;
REGISTER NO.
WARD NO.
hospital or medical facility)
")(6)-4
NURSING NOTES Medical Record
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 3986
DOD 010465

LRMC INTRAOPEFL • DOCUMENTMEDICAL RECORD
For use of this form, see AR 40407, the pro,-.poesy is the office of The Surgeon General.

1. PATIENT T.PORTED TO OPERATING ROOM .-b)(6)-2 PATIENT ID.IFIED. R b)(6)-2
VIA , ,,,, ,/,rf7-r_.,.BY.al ERIFIED BY

/12----
3. Okit. TIME PATIENT AORIVEA IN SUITE .-4. PATIENT IN ROOM
TIME./9,53Ztigze-.NUMBER
.9-/o-&.-6
/X,-3.--...-
5. PREOPERATIVE EMOTIONAL STATUS
¦ CALM.ANXIOUS.II EXCITED.¦ CRYING • ANGRY.• WITHDRAWN.. OTHER (Specify)
COMMENTS: z 6,-.2x-, 2-&eee-e ,7 e/ z-,,,,,eee,6,a,,

6. NURSING PERSONNE
b)(6)-2
c.......15--.

ASSIGNED 4Z-ORELIEF
SCRUB SCRUB

b)(6)-2
ASSIGNED

chf.
RELIEF
CIRCULATOR

CIRCULATOR
,.,
7. POSITION AND POSITIONAL AIDS (Specify) .., Ordir."-all , ,14,0,77., "0"")-1F, 27.2,9AP-
.. Air
II SUPINE.U LITHOTOMY.• PRONE.• KRASKE.LATERAL LEFT SIDE UP.• RIGHT SIDE UP
COMMENTS:
8. SKIN PREPARATION HAIR REMOVAL .•.YES.¦ NO
PREP SOLUTION (Specify)
DONE BY:.¦ OR. ¦ NURSING UNIT SITE. BY WHOM:
METHOD:.II.DEPILATORY.¦ RAZOR SITE. BY WHOM:

• CLIP COMMENTS:
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES
...---.larest, klifil. /.... -.... 441111110. _.
WO
lIVAPP
.-N
LEGEND.X Ground Pad.- Safety Strap..- - Tournique
C - Correct.i - Incorrect ;16)-
Fort Closing.mal.hump

10.COUNTS
Other -.Count.Count.SCRUB
CIRCU Sponge.
M erillIAMIPMAIIIIIrellillIMMINWP-.
rIV
Needle Sharp.ill Yes.MMII.ilrx(3)-2
EMI!.Instrtsment.In
Yes.RIZINIIIMINIMIIIIIIM1111111111
Other.
¦ Yes nallIWAIIIIMIIMI
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICEIS) (ESU) .A2'YES.¦ NOName • Last, fiat, middle; Grade; Date; Hosptal or Medical facility,/ C3.07--4 ESU NO:..1 .41.0 -GROUND PAD:.BRAND.,O.W.4.:11111r.../ ei LOT NO: ESU NO.
GROUND PAO:.BRAND . LOT NO:
¦ BIPOLAR NO:
rt A r nrs•• r ¦ ,n • new n-.
MCEUL OP 358, 2 Mar 00 NAPA V1.00
MEDCOM - 3987
MRRC apprvl - 3 Feb 00

DOD 010466

13. PROSTHESIS, IMPLANTS.
• YES.IDAS.IF YES NAME: ID NUMBER; MANUFACTURER
14.
MEDICATIONSIORDERS IRRIGATIONIMEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES.¦ NO.g-"''.------'-MEDICATIONS/SOLUTION DOSAGE TIME METHOD
PREPARED BY GIVEN BY
WOUND IRRIGATION .,.YES.•.NO, TYPE(S):
OTHER ORDERS TIME CARRIED OUT BY
)-2
PHYSICIAN'S SIGNATURE
NYl

15. MAY IN OPERATIN.
IF YES, SITE
YES.I.

•.Ed
16. LABORATORY SPECIMENS. -SPECIMEN IS) NAME
NAME YES.¦ NO.2"..'---FROZEN SECTION IFS) NAME
NAME YES.U..NO.Er .. CULTURE IC).6/15ME
NAME
YES.¦ NO NAME NAME NAME
NAME NAME. , 18. DRESSINGIIMMOBILIZATION (Specify)

17. TUBES, DRAINSIPACKING . YES..2r......'::0

‘17d'
TYPEISIZE 1.
2. 3.
;•--V'f--" SITE
1.,,szis_a-e_ cr2. ...e../..., tdie_ez...e.AC-_-,

19. ADDITIONAL INFORMATION
The medical record (SF 539), the progress note (SF 509), the operative consent (SF 522), and the patient agree that the correct
operative site is the side.
Verified by:
Patient/guardian Surgeon Anesthesia Operating Room Nurse
20. OPERATION(S) PERFORMED • - z .-,
./.
it ,e),,c,, ,,,..„,_•e•-x__ al 60r/41---
,ce_,. ." ze4L,e,-.4-eS •
eef.-e_ee-e-,-------k---
21. PATIENT TRANSFERRED TO TIME MEM ,.'41
22. REGI.U SE.IGNA b)(8)-2 — AP ¦011 ,.GG P,
REVERSE OF Dil FO 5179-1:- EUL OP 358, 2 Mar 00.USAPA V1.00
MEDCOM - 3988 _,ARC apprvl – 3 Feb 00

DOD 010467

•'
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY " I POST-DAY ,
MONT .YEAR DAY -­
1
q ii 1.2-libITS P -- 1 Wo
;Oa HOUR ea )7 )7;'PAIRSIMIgler 70 •35 30 moo ow) tcco Goa . PULSE TEMP. F : : TEMP. C
(0) (•) '' •• •• • • •• •• •• • • • • •• •-•• • •
•-•-•• •-•• • • • • •• -• •• •• • •
105' • • 40.6'
. . . . . . . . . ..... . . . . . . . . . . . . .
" ' .• '• • . " : " ' • • • • • •' •
. . . . . •
" . . . . ' . . . . . . . . . . . ' .
180 104" •• • '
, , •• •• : ; • ; •• •• • : : •• : • ; : 40.0'

. • • . . : ::::::::::::::::::: : : : . . . . . . .......... 170 103 . . . . . : ............ ..... 39.4'
3-,
C 0
: : . , . ................. . • • • . .

a,
........ o

... " 38.9* c
160 102' •, . •
T. .. •' " ' •
4'2
: : • • • .. ....... • ..

a, 150 ...... i 38.3' cr
101' . • .............. :

6
• .. • • .. tri 140 100° ; , , ... • : • • ; 37.8'
..... . 1., ... . 1/4/ ....... . . . : : : co
.? 37.2"
130 99-a a 98.6' 111: : ........ : : : : : t : • • 6. : : : • : 37.0° w . a) 98' . ;
120 I i . ... . . 6 . . . . (7 . . . . . -;) . 36 . 7" -0
m
. ., )• ..: 4( . 0 .: ep . .: : : .. : :.
: : I: _ -. c
i N.: g • ,: ..0 : : ./.

o
110 . . . . . : . .............. : : 36.1"

,e.®.
.o
. . 100 96' . . . 45, ..... . ..... ..... . : e 35.6'
. . ... : . . • .... 90 , • 35.0°
95' . . .... .... . • ..

....... .. ...... . . " ...
........
80 • ..... . . .
• • • . . ...... ...iN . ... . . .. . .

.

. . .
. A. . A ..... • •
...
70
" " • • ' ••
. . . .
. . . . . . . . . .
. . . . ..., ........ . . . . . . . . . . . . .

•t : : : ......
50
. . . . • . ......
. . . . . . ........ : : . : : • : • : : : • : :

--•• •• --•• •• ••
40 . . . . . . ..........

RESPIRATION RECORD . t) a9(7 .1-1
10* 112 423
92 BLOOD PRESSURE ,1 3-I fl_ 3, iqts.li4 alis`13 11A ilA
. alyb qtfhty cpiWr-te co' vi Si 4,1WIS
o
0 51 p-i II f op cli I f_,-).-tta to at 115 Itti c ,
a, HEIGHT: WEIGHT ---11. If,
c
3
0
.2.,,u op .2-4, 14,9 lox ie
,. . 3101,143 / vri
To auk) Abv

..4;617'
a

YJ 1 I/ ''': I .2.A19,..5 / .--2/Nr iwirr
7f4E7 is ".

40
6.•(..L,-.,, i 1r0
- .1
.,., (...) ki 0 2,-* ouc.,
cr .1.4.1Zio 0 X-c' RATIENT'S IDENTIFICATION (For typed or wri ten 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
II:903)4
•U.S.GPO:1998-404-763/40069
MEDCOM - 3989
DOD 010468

MEDICAL RECORD E. VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR DAY 14APe Ili ¦ II ) Air
. tr1,0 ..............

P.:, A•0 •
19 HOUR •1', 0) • .
PULSE TEMP. F :
TEMP. C
(0) ( °) . •
......
105°
40.6 °

.......

....
-
180 104° 40.0°
....
.. . .
........
........
....... •

....
170
103°
-5­
39.4°
,
c
0 a) 160 102°
38.9° c :12. ..........
a)
............... • 4... 150 101° Ir
38.3 ° Ir
" •• "
. • . . . . •• . . . . . .
••-
" " •• •• •• " •• "
. .
. . . .

ui
..
140 100°
, , " 37.8 °
....
c
. . . . . ........ . . . . To-

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

130
99 ° . . . . . . . . . . . . . ...... . . . . . 37.2° 98.6° a
. . . . . . . . •. . . . . •• •• •. . . 37.0° Li,
120 98° 36.7
36.7°
•• •• •• ii)
•• •• •. •• •• c
110 97°
36.1 ° a) . . . .
. . . . . •• . . . . . .
• . .
100 96° ..
. . 35.6°
• • ...... • • ••
. .
" • ' • • ..... " "
•• •• •• . • ..... • • . .
.
90
35.0°
. .
. .
. .
l• • •
. .
80 •'

. . . . .
....
. .
. . . .
.
. .
. .
. . . . . .
70
......
. . •• •• . .
.. ••
. . . . . . . . •• •• ...... ..." 60
. . . .
• • ...... . . .. .
. .
• • " ..... " .
. . . .
. . ...... . .
50
. . . . .

" •
. .
. .
40
..... . . . ..
RESPIRATION RECORD
i v I LIM
'Record special data only when so ordered
BLOOD PRESSURE
‘51( i
P-rzi P-i.ao Ivy
• ..
4 &Wt.
1 POC3
HEIGHT: I WEIGHT ........
9_19 4,1
r Kott
dak,
4-6-4')
d ill- / k0 rivi' 0 .5(6

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
;b)(8)-4 STANDARD FORM 511 (REV. 7-95) BACK
'U.S. Govemment Printing OM= 1995 • 609.628

MEDCOM - 3990
DOD 010469

MEDICAL; [RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
' 0_

44:4

MONTH-YEAR DAY /
4/ APR
,,2-,1,
4
r •
MrifrAEM NIZIX2200iirm
. .
EIL,2

19 HOUR Eartnir=

1:1

PULSE TEMP. F : : : : : :
. .
(0)
(*) .
.
05°

co
co co CO WW CO Co CO CO4, 41
al 01 cr) a) -4 -4-.I CO CO CO 0 CO in i-. '-.1 °iv Co Co it).
0 .A. 6a
0 0 0 0 0
0 0 0 0
-
(Centigrade Equivalents, for Reference only)

.
. . • •...•. •• . . . .
. . . . . . . . . . . . .
. . . .
• • •. . . ..... 5 . . . . . .
104°
..., -
180
. . . . . .

• • •• . : " . 7 •-. :
" • • •• . . ,5. ...
. . . .
170 )3° •• •
. . .
. . . . .
.
..

. .1
. . . . . .
•• •• -• ••

. .
" " ••
. . .
. . . .
. .
160 )2°
150
101°
•.
" ' •
. . . . . "
. . . ' •
. .
. .
. . . . . •. • . ••
. . .
. ' . • . . . . . . . . . . . . . . . . : . • • .
140 130 120 100° 99° 98.6° 98° 1 . . • 11111Zkv. ... ..•• . . • • • • • • • e: 11161MOINIIMELIFAInemere• PI -4 MI . . . •
. .
. .
110 97° • • ......
. . . . . . . .

. .
On ••
100
96°
-• -• • • • •
...1

•• q •
. . . . . .
. .
" "
' ••
..• . .

.. ..

...... . .. .. ......
90 950
'ion ' •
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. •
.
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do
.. .. ..
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70

. . •• "

" ' •
• . •
.
. . II • • . . . . . .
60
. .
. . . . . .
..

•• . . . . . .
.
. .
. .
. .
50 ' " •• "
.. . . . . . . . . . . . . ,• •• -• . . . . . . . .
.....
-
. . , IA •• 140. gimp
RESPIRATION RECORD
IMMEip..1 ENle) I 11IND.
teli
mum%
Record special data only when so ordered
BLOOD PRESSURE
'Tlo
1111 VII
=EN
MPH

MI

HEIGHT: WEIGHT --OP
-' t s6;1111
illro zrq 2 2 17

-

ii 0 P . •

„Av.
T - r ?SD -I
/
-ttl i• ' el*" d
NS
,
Zoo

`0 75

'ATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) b)(6)-4 REGISTER NO STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 3991
DOD 010470

511-119
NSN 7540-00-634-4124
M EDICAL RECORD
VITAL SIGNS RECORD
HOSPITAL DAY
DOS
POST­
MONTH-YEAR
‹7365' PULSE
(0)
180 170 160 150 140 130
120 110 100 90 80 70 60 50 40
RESPIRATION RECORD -o
BLOOD
C
a HEIGHT:
C
.
0

C rolt
a.
o rus
0
a
cc Po /
PAlrENT 'S IDENTIF
,b)(8)-4
b)(6)-4
1-7
140A4A
HOUR c.,9 ci 0-0 204 oxoceoboiero tece, ORD IWO 1900 366$7 get)
TEMP. C
...... •
40.6°
...... •
40.0° 39.4° 38.9° 38.3°
• 37.8°
•i¦
37.2°
37.0°
4111111012111E­a__
36.7°
: :
:

36.1 °
y y.: yi
C 35.6 °
0 -0 .0. .0
...
35.0° .13
. .
.....
: :
....
.....
.....
A
.4
ISO
1 1 0 4 1f2 III 104 top 110 Idsc lit /o7Lg to 401 Cct sl q9 57 oo sr.
WEIGHT ¦••¦• 00A FE0 -2. 1 93 'TN soz_ j9c,
apt P°1--a-cr=q4,c)
44 430 0 I3oo
ftv) 2P-00 2..•
..•••¦•••¦•¦•••
kw-CC Joa
N (For typed or written entries give: Name—last, first, middle; ID No.
REGISTER NO
WARD NO.
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 512. (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 3992
DOD 010471
(Centigrade Equivalents, for Reference only)
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY MONTH-YEAR DAY 4 A ' MUMNM egiMi 0 Ni-MIs''* 19 HOUR •0 I 06-p _ sil 111111EAURMIIIIIMIEU 1111a11117E1 PULSE TEMP. F ''''''
TEMP. C
(0) (*)
105° 40.6° ''
'' • • •• •• •• • • • • •• •• •• • • • •
180 104° ' •' " ' • " " • 40.0°
170 103° • 39.4 ° -5", o
cv 160 102° .... . 38.9° c o
. . . . . . . . ...... . . . . . .
. . . ..... . . . . . . . . 92
. . . . . . . . . . . . . . . .
a)
150 101° .......... . . . . . . . . . . . . . . . . . . 38.3° cr . . . . . . . . . . . .
140 100° ' ' 37.8° (/)
•C'
0) . TO . . . . . .
130 99° 37.2°
• 111111011,1111131MIIMENEM111=111111•21111111FMNIEN ci
. . 37.0 .
98.6°
Lu
.W.iEMENIIIIRELFAIIII
120 98° , . . . =min 36.7° -o
co tio
-.7,

.)
110 97°
. . .. 36.1°
(...)
.
.
•• • • •• :
100 96°

35.6 °
A • • .. . •
El :. .
isci
35.0°
111 : i : i : . •
:
90 95°
.

........

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.. .
. .
. .

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. .........0: : :

. . . .
.
I.
80
.......... •.

. . • . . . . . . .
. . . . . . . . . .

. . .
70 60

: .
: .• .....
11111
..........

•. . •
50
. . . .
.......... . . . . . 40 •• -•
..........

. . . . .
,,,,,,, HIE / Ipa,
.
RESPIRATION RECORD •
(....
/ I
BLOOD PRESSURE 9
'Record special data only when so ordered
irrigaill..kal i 1,1
ir? -S DAIWA,I /2,3 S7 4s1 ME 0 ILT I I IS115-8-MEM
41REadr mrirgampim.
c

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HEIGHT: WEIGHT --0.
11111 111111111.111KIIIIMMIMIIIMI 0
111/11111P91./.111F 0 , 1'1.4= 17 R . DRi 0
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1 ,e --IV 01,. to

80
P0 aob
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gar)
3ATIENT•S IDENTIFICATION (For typed or written entries give: Name-,---last, first, middle: ID No. REGISTER NO WARD NO.
(SSN or other): hospital or medical facility)
33)(6)-4 STANDARD FORM 51.1 (REV. 7-95) BACK

MEDCOM - 3993
DOD 010472
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY Z 5 Ariko3
: ' All,
26 /4"' - • la .A -22'
...; '

OMMIEIMIMI
AllirtintraMMI 1
19
HOUR • •
PULSE 1 I:

TEMP. C
40.6°
40.0°
(0)
(*)
105°
.: :

: : •: : :
. • . • . • . . . . . • •• . . . . . . . .
. • . • ••
180 104°
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. . . . . .
.
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. . .
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. .
...
. . . . . .
170 103°
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: :
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102° 38.9°
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. .. . .
. .
;12
. . . . . . .
.

.. . . .
. . . . . .
. . . . .
412
. . . . ..
a,
38.3° Ix
. . . . . . ..
150
101°
....
. . ' . •. •. .• . " . •. . ' . " . •. •.
....
. . . . . .
140 100°
37.8°.LIC co
2
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m
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'
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-
•"
.
. . . .
. . . .
.
.
. 90 ••
95°

. .
. . —
a • •
. . . . .
. .
•• 1'
i .

80
. . . . .
• .•..•
r .....•
••.•.
1..:
..••

.•.•.


70 60
h

a•-•'-' •
...
...... . . . .
..
. . . .
......
.
.... . . ..
.
olo . •
. . . .
......
40
. .
• • n•
RESPIRATION RECORD I
0 ' 1 b
=Hz=
.
:4301 ,.1
, . • -07
Fir ITLIFEBIMMEM
I!!
BLOOD PRESSURE/hey
Record special data only when so ordered
WS

MIARRIZIELAIII
kv inuarssrim
WI 1111MIMIN MI

SIC
Ell

7o
HEIGHT: WEIGHT —1).
MEM
arillingliMiengnallEM
kit 7. en 3z-
..,. .z.-4-.14" /U._
050
.,
SW OnIZ VOC -roe oco 00
2s0 675 CM-•
,r, ,,,e. t000
CS d-e4t,--(-
a
vrinc silo ob
AT IENT'S IDENTIFICATION (For typed or written entries give' Name–last, first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO. WARD NO.
b)(6)-4 ! r ;$¦ .4.
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 3994

DOD 010473

511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-MONTH-YEAR htAy Ag 2-00 DAY DAY HOUR 01 "ty o3 ila, f• • Xi co. non 0,;(, n-.4,1 10 ? 114 63"4703 0'3 I-I Ai • 1•110516 • '• 5 4/5, too Mer• • zi • • • • • • •

—I
CO C¦J COCOCO(.,J CO ID CO CD 4=. .0. rn
1 01(3) CS) ¦1-4--4COCO(D00K
06);-...-4 ON) 0) 6.) CD :1=. b 6 70
0 0 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
PULSE TEMP. F :
(0) (*) 105° : • • • • • • • • • • • • • • " • • • • • • " • • • • • • " • "
• • • • • • • • • • • • • • • • • • • • - • • • • • • •
• • • • • • • • • • • • • • • • • • • • • • • • • • • •
. . . . . . . . . . . . . . , . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
180 104° . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .
• • • • • • • • • • • • • • • • • • • • • • • • • •
170 103° • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • - • • • •
" • • " • • • " • " " " " ' • • • " • •
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
160 102° . . . . . . . . . . . . . . . . . . . . . . . . . . . .
- • . • • • . . . . . .
150 101° . . . . . . . • . • • • • • • • • • . • •
. . . . . . . . . . . • • • • •• • • • • • • • •
• • • • • • • • • • • • . . . . . . . . . . . . . .
140 100° • . • . • . • . • . • . • . • . • . • . • . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
• • • • • • • • • • • • • • • • • • • • • • • • • • • •
130 99° •AP • " " • • " " " • 4
120 98° : : t': : •. •. •. •. •. •.

. . . . . . . . . .
P *
110 97°

.
.
y. . . . . . .
.. .. .. . . . . . .
,

• . 0` •i2 -• • • •• • •
90 95° 0 . . . . . . . . . . . . . . . . . . .
• • • 1. • , 0
. . . . . . . . . . . . . . . . . .
• " " • •
80
• •• •• -•
. . . . . . .
. . . . . . .

100 96°
. • • ...! • • • • • ••
4: • . ••
... • • ,.., • •. •• • •
•:. :.• :.• : :. ••• ••••

70
11
I
. .
' • • " " " • ' • "
50
. .. . . . . . . . .
• •• •• . . . . . . . . . .
. . . . . . . . . . .
. . . . . . . . . . .
RESPIRATION RECORD ee..... q 1-7 ' iz Cd
1 kLci /02 ;ay
. . . . . . . . . .

A: :As;
. . . .
:: :: :: I:
:: : •
. . . . .
60
• •• •• • • • • •• • .
BLOOD PRESSURE clp 1 II L WI II 7, 93
,•• . 1 0 to„ 61 br, sq fl
Record special data only when so ordered
64

bi 60., i;6
QAL. cIA 96 t; FA 10 a
HEIGHT: WEIGHT ...... 07 q 0 1 ), qI4 tit 901 94 (Pl. —r exp qi ii,,,, eh-y Alv iei ?1
Cir &lot,
tti.A/ 0/P 750 -40 (....s...
1--).015
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, frst, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM -3995

DOD 010474

.•."
(THIS FORM IS SUBJECT TO THE PRIVACY AC' .- AS A CLINICAL RECORD FORM, IT IS COVERED BY DD 2205}

ANESTHESIA RECORD Page 1 START t`t 'I r IN OR 1 e1 SS ANES. END DATE to MR. ,z,
OPERATION.,, s c ,„...—a-../1.7%PERFORMED: T".'''' '''''''' T.'' './1....V.-,i"% Y-.%. 1) i•-3 7 SURGEON(S) On- c.‘.., TOTS .2.01, SURG START DRESSING OR NO
PREOP.-RATIVE r 7. / :1,.X x TOTALS
WITIT.... JBE.IFIED a 0 BAND illir EUESTI ONING Pr P.tv. l' 2 .-V
T REVIEWED 0 NPO SINCE {{ RE-OP MEDICATION: ou 5-.csc.."'"'"? Cc., 1'13 4. I 3 7 4 1,o 17 +.-2 14 / 7- s' .

C3ZV) U.—I -•••0 CO
202-1— OCC V) — J V) — C3 ) caWcoa.
.,'
Pr eslhelic State: -AWAKE
CALM.. SEDATE
wlL/min % 4.-X x
k 1 if
go2 Urnin t. 4 i .1..
NITORS AND EQUIPME
tk N A•3+ N.,
/VS *a ,
WP‘b
CSNQIV-INV. B/P PNS
i .
Ill
n
; TIDAL CO2
MASS SPEC
%..h.-
.--"'"1 S d" . ""t) %M.' ) -" A.
Urine --, V.A..' -3 ....., - 'i 4 '-t -,
EBL ----_--)
) ,,,,,,i3 .___,,,,s •

1-1-,
II '4 ... , SYMBOLS
EKG
ST S -I-VI 57 . 1.--
AIRWAY
% 02 Inspired X
1g-1 .1( ,qr 5t ,11 /0 .2 1 , i ....3 1..3 I.-7
02 Saturation
ANESTHESIA
End Tidal CO',
-r 34 it 4% "
Tamperature 3‘• ').-1l. ).-.. 3, ®
OPERATION
PNS 7, 1-, V, — 'Ili V A
B/P CUFF
ARTERIAL LINE
RESSURE POINTS CHECKED / PQ5
ANESTHETIC TECHNIQUE
- PRESSURE 1
TIME T
ARTIAL
PRE-OP I 1 I I ER
UNE
200
PRESSURE
180 • PULSE
160
0
e/P SPONTANE-OUS RESP
140 . \/‘(41)/
INDUCTION
.
v • -•
Vidji 0
• INTRAVENOUS.

. RECTAL
ASSISTED
dr ' It' , / , • I I L.
RESP
60
R "
/AIRWAY MANAGEMENT
X CONTROLLED
/)r‘/YVViVIAtr
RESP
T
TOURNIQUET
T7 SIZE a . DOUBLE LUMEN
yj^^.
20
. U CUFFED, LEAKS AT CM H2O
CM
SECURED AT 2K
BREATH SOUNDS ^s' \
Tidal Volume $. 1/ 10 -14 ' Ills.
F
Resp Rale j
10, -
T
CRYSTAL-
LOID FLUID
MASK CASE I J VIA TRACHEOSTOMY NASAL CANNULA ^LLLJJJJ SIMPLE 02 MASK
Symbols for
. .LMA SIZE Remarks
B
Position
.i.
BLOOD
r,
REMARKS : Patient reevaluated. No change from preop plan / evaluation.2-, "1 . Significant changes from preop plan / evaluation.
RECOVERY
TIME IN PACU CONDITION
VASS .
9 re z).....T.--.--, 64. a_
B/ PULSE RESP 02 SAT /.0...ka, )..S ti, -- C.', c a, A
-rt 1.,-. e c i t
4 ir, vA el(
_....--
5-.J. -le -%L---1,4-4 a k 4 -4,Z ‘.., 3 r...„
REMARKS TEMP jo i I..P T 4-, is ,,..., ,..) c2-,,,,.;, ) ) -414 T.
-'1' "-I • i'l. c p..--% 7',,,.-„_ 43.ICY.54 z .I. 1- Tourniquet Time:.,,,/
REPORT TO. 1 (-1.$41.-1' 1".PARRS:.7 7-.Y.I er IN FLUIDS TOTALS PATIENTS IDENTIFICATION Crystalloid __Lc:"_._.EBL r'--) 13)(13)-4
3
13)(13)-2

Urine.""%-.3
MO. 4-.3 . 07---..-A
Gastric.,"S

Blood.b- #poslerkomiCRNA -bX3)-1
MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 29 M, MEDCOM - 3996
DOD 010475

/NAME: SURGEON: Dn. • ct.... Planned Surgery Date:
AGE WEIGHT
-I.
ANESTHESIA PREOPERATIVE EVALUATION a.
2--S 2.w1•
11'
PROPOSED, , PREOPERATIVE B /P R
84-^ P"—/)

OPERATION LL-I LI.-VITAL SIGNS:
PREVIOUS ANESTHESIA / OPERATIONS . NEGATIVE CURRENT MEDICATIONS . NONE
fat I.

111
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS . NEGATIVE ALLERGIES . NKDA
AIRWAY / TEETH / HEAD & NECK
..........

SYSTEM WN OMMENTS PERTINENT STUDY RESULTS
RESPIRATORY . Tobacco Use: o Yes Pack/Day for Years Chest X-ray Pulmonary Studies
Asthma Bronchitis COPD

.
Dyspnea Pneumonia Productive Cough
Recent cold SOB Tuberculosis

CARDIOVASCULAR . EKG Angina Arrhythmia CHF Exercise Tolerance Hypertension MI Murmur MVP Pacemaker Rheumatic fever
HEPATO/GASTROINTESTINAL LFTs
Ethanol Use : No Yes Frequency Bowel obstruction Cirrhosis Hepatitis Hiatal Hernia Jaundice N&V Reflux/Heartbum Ulcers
NEURO/MUSCULOSKELETAL
LI

Arthritis Back problems CVA/Stroke
DJD Headaches Loss of consciousness Neuromuscular disease Paralysis Paresthesia Syncope Seizures TIAs \ ,..).-vh. r....... .... -* tq1...3
Weakness
Urinalysis Thyroid FBSRENAL/ENDOCRINE
Diabetes Renal failure/Dialysls Thyroid disease Urinary retention Urinary tract infection Weight loss/gain
OTHER Hgb / HG / CBC Lyles Anemia. Bleeding tendencies Hemophilia Pregnancy Sickle cell trait Transfusion history 12 .1 "/"Z ..9)—
2‘•i •••••-•
9•CT . 4 f 3
PROBLEM LIST / DIAGNOSES

(1) •-CV (,) d-41 W
OPERATIVE MEDICATIONS ORDERED
COUNSELING STATEMENT POST ANESTHESIA VISITS
ANESTHESIA RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE, SO
Anesthesia alternatives, benefits and risks from minor to ii.
STATE)
death explained. All questions answered.
Patient / legal guardian voices understanding and gives
consent for :

Local / MAC, SAB, Epidural,.IV .•.eneral Anes.
Other:
Appropriate alternative as bficku .

NPO status explained. DATE: . .. SIGNED: TIME: eATIENrs SIGNATURE DATE
EVALUATOR(S) SIGNATURE
b)(6)-2
rv.3-5 . 4-3 . Ca-x---4-DATE /..q• 4r&05
CRNA DATE PHYSICIAN
Page 2 of 2
MEDCOM - 3997

DOD 010476

(THIS FORM IS SUBJECT TO THE PRIVACY ACT 0'" • " -AS A CLINICAL RECORD FORM, IT IS COVERED BY OD 22C
START IN OR ANES. END DATEPage ) of 1,1.101 tiIGl G
ANESTHESIA RECORD Y 3o
TOTS SURG START DRESSING
OPERATION0 aZ,A.„,„
PERFORMED: to
TO TAI

PREOPERATI
IDENTIFIED VD BAND QUESTIONING aCHART REVIEWED PO SINCE On-1
. PRE-OP MEDICATION: t_eo.IND Lw tui,5 Drug Dose Route Time A So
G U 5-1 5
E
N

I
T S
Pre-Anesthetic State: . AWAKE
5
CALM . SEDATE /APPREHENSIVE . UNRESPONSIVE N20 Umln 02 Umin ,
3
ONITORS AND EQUIPMENT
F
ES. MACHINE I .1._ & EQUIP. CHECKED
L
4
SON-INV. B/P . PNS M s 1,,s11:14'
Ltd CONT. EKG V LEAD EKG
Tx6OPH. STETH. PRECORO STETH.

0 Urine PULSE OXIMETER A 02 ANALYZER S EBLEND TIDAL CO2 MASS SPEC.
SYMBC
. TEMPERATURE WARMING BLANKET . FLUID WARMER EKG
5‹ X
AIRWAY HUMIDIFIER ,.., % 02 Inspired
ct_
ANESTH
N/GTUBE L..I JD TUBE 02 Saturation
. IV(s) O gm cis.' ci‘ ap, 1%,
End Tidal CO2
N
0
Temperature
.
ARTERIAL LINE OPERA!

.
CENTRAL LINE T PNS

V
. SWAN-GANZ 0
A
. FOLEY INSERTED: . O.R. . FLOOR R
BlP CU
. EYE CARE S
PRESSI
. PRESSURE POINTS CHECKED / PADDED .. T.. TIME
ARTER
ANESTHETIC TECHNIQUE PRE-OP LINE
200 PRESS!
VALUES
. GENERAL . LOCAL/MAC

0 REGIONAL . NERVE BLOCK 180
PULS
160
V C
SPONT,
B/P Vvoictri
QUS RI
140
INDUCTION T
A

. PREOXYGENATION . INHALATION 120
L
. RAPID SEQUENCE . INTRAMUSCULAR
P
ASSIS" 100 RES
. INTRAVENOUS . RECTAL
S
R 80 /N.
AIRWAY MANAGEMENT
N
CONTRC
A
. INTUBATION . ORAL . NASAL S 60 RES DIRECT VISION A BLIND . AWAKE
SAT T
FIBER OPTIC STYLET USED 40
H
. ATTEMPTS a — .0 BLADE ETT SIZE A DOUBLE LUMEN
TOURNI ,
20
STRAIGHT . RAE . ANODE
H / H
.
CUFFED ML AIR INJECTED 5 .5

.
UNCUFFED. LEAKS AT CM H2O

F

R Tidal Volume
ETT SECURED AT CM
E Resp Rate CRYS1
BREATH SOUNDS
1.010 Fl
S Peak Pressure
AIRWAY . ORAL A NASAL .NATURAL
P
MASK CASE VIA TRACHEOSTOMY
NASAL CANNULA . SIMPLE 02 MASK Symbols for
LMA SIZE Remarks

B
0
BLOC
Position
REMARKS : . Patient reevaluated. No change from p cop plan / evaluation.
RECOVERY
. Significant changes from preop plan / evaluation. TIME IN PACU CONDITION
11) sLetof
B/P UI,SE 02 SAT
P1 Cl 6N .
TEMP

REMARKS
Tourniquet Time:
REPORT TO: PARRS:

b)(6)-2 PATIENTS IDENTIFICATION
IN FLUIDS TOTALS OUT
1b)(6)-4
Crystalloid EBL
Urine I -t-fN1Q,
Gastric
Blood

3ICIAN I CRNA
MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 2!
MEDCOM - 3998
DOD 010477

ANESTHESIA RECORD
OPERATION
PERFORmED Rk/r4 fe,.1
PREOPERATIVE
DENTIFIED . ID IiIVOUESTIQNING
.
CHART REVIEWED PO SINCE pia,

.
PRE•OP MEDICATION: Drug Dose Rout* Time

Pr e.AnesUletic Slats: . AWAKE
. SEDATE PPREHENSIVE UNRESPONSIVE
.
MONITORS AND EQUIPMENT
S. MACHINE I — I EOUIP. CHECKED
.INV. 13/P PNS CONT. EKG V LEAD EKG E PH. STETH. PRECORD STETH.
ULSE OXIMETER 02 ANALYZER ENO TIDAL CO2 MASS SPEC.
. TEMPERATURE WARMING BLANKET . FLUID WARMER AIRWAY HUMIDIFIER N / O TU 0 /G TUBE Iv(s) 14t-c_
ARTERIAL LINE CENTRAL LINE EXAN•GANZ /LEY INSERTED: .R. . FLOOR
0. E_XX—CARE
•PRESSURE POINTS CHECKED I PADDED
..
. 0 ESTHETIC TECHNIQUE
LSd GENERAL • . LOCAL /MAC
. REGIONAL . NERVE BLOCK
INDUCTION
.
PREOXYGENATION . INHALATION

.
0 SEQUENCE . INTRAMUSCULAR

r
NTRAVENOUS . RECTAL
Et
AIRWAY MANAGEMENT
. INTUBATION ORAL. 9 NASAL
H
DIRECT VISION BLIND AWAKE FIBER OPTIC STYLET USED . ATTEMPTS a — . BLADE
QQ ETT SIZE 9 DOUBLE LUMEN
STRAIGHT—RAE

. . ANODE CUFFED ML AIR INJECTED
. UNCUFFED, LEAKS AT CM H2O ETT SECURED AT CM BREATH SOUNDS AIRWAY . ORAL NASAL .NATURAL MASK CASE VI TRACHEOSTOMY NASAL CANNULA MPLE 02 MASK LMA SIZE
RECOVERY
TIME IN PACU CO •ITION
02_
B/P PULSE 02 SAT
)/.) ill 2— 55
TEMPREMARKS
5)(6)-2
REPORT TO:/Lr PARRS:
IN FLUIDS TOTALS OUT
Crystalloid , eft, EBL
Urine
Gastric
Blood

A
N
T

F
L

S

N

T

0
R
S

T

A
N
S

R E S P
(THIS FORM IS SUBJECT TO THE PRIVACY ACT 0 • ,S A CLINICAL RECORD FORM, IT IS COVERED BY DO 22C .stART ANES. ENO
Page of
03
b7 30 017°4 i) 619 0,TE
SI IRCiF TOTS SURG START DRESSING
'5)(6)-2
OR NO
r-
77-4 7'1 3 D? 5 g
TOTAI
6710
72-e Art 5
7rIf)1 '.3
P0 100
Urine
EBL STUB(
EKG
X
*A 02 Inspired
ANESTH
02 Saturation
O

Temperature
OPERA1
PNS
V A 5/P CL PRESS ,
_L .T
TIME
ARTER LINE
PRE-OP
200 PRESS'
VALUES •
180
PULE
160
SPONT. B/P QUO R
140
("1
/I 120
ASSIS 100 RES
80
CONTR1 RE:
5? Vo
SAT 40
TOURN
20
H / H
F

Tidal Volume Reap Rate CRYS
L0i0 1 Peek Pressure
Symbols for
Remarks
Position at.
111
REMARKS : . Pallent reevaluated. No change from mop plan / evaluation.
. Significant changes from prop plan / e aluation.

Tourniquet Time:
PATIENTS IDENTIFICATION
5)(8)-2
;5)(8)-4
PHYSICIAN / CRNA
MEDCOM - 3999
An •rtn nn ID risCSOP apprznvFn. 9$1 MAN NH I rows I vt 4
DOD 010478

(THIS FORM IS SUBJECT TO THE PRIVACY ACT 0/ S A CLINICAL RECORD FORM, IT IS COVERED BY DD 22C ANc... START IN OR ANES. EC)
ANESTHESIA RECORD , . Page I of 1 DAT
/10 0 13A s— ,./y/ am. 4,-..e . 3 OPERATION 1•{ SURG EON(S)
Q.)7h-ts.i, -707,‘„), „w TOTS SURD START DRESSING OR NO
-St /44'6164-C -5 AIN ..Treki 4
P E RFORMED:
/4?-57 /907 PREOPERATIVE TOTAI
E IDENTIFIED M ID BAND °QUESTIONING :/t1.79/.4.,/ /v../ . 5-. . /4* (2 CHART REVIEWED 0 NPO SINCE tv:•(:// ng A , ,
•3 '
. PRE-OP MEDICATION: 14.14nm /dye 010 A9.3-CA-0 -,IGga.
Drug Dose Route Time
. _
M.SO4 /i.
0UI Z ,n ILJ7— '0 U) —0LC to
0
0
1 (r.
I
+ rq.
r

Pre.Anesthelic Slate: . AWAKE ria CALM SEDATE
.
APPREHENSIVE 0 UNRESPONSIVE
F0,0-4 (4‘:--
.
N20 Umin 02 Umin
i ibis )-y— 5.--•5— K
MONITORS AND EQUIPMENT
M ANE S. MACHINE II _ d EQUIP. CHECKED pppIII NON-INV. B/P PNS ypJCONT.EKG V LEAD EKG
IAL^IjJlIESOPH.STETH. PRECORD STETH.
PULSE OXIMETER 02 ANALYZ ER
END TIDAL CO2 MASS SPEC.
_,. ­
-PI S ... a — ?ft 0
.
'Urine
EBL
SYMBC WARMING BLANKET 0 FLUID WARMER EKG
0 TEMPERATURE
..51— 6•1-s r -1-fi r 5 i
AIRWAY HUMIDIFIER % 02 Inspired QA ›.41 1 •.1. f -2/ ,Z' e...1 X N I G TUBE .... 0 0 /G TUBE ANESTH
02 Saturation
71 IV(s) .oZO ), -)ju20 44,74V . qg c't3 4, g ty 9Y 0 End Tidal CO2
El
Temperature
ARTERIAL LINE
CENTRAL LINE
SWAN.GANZ
OPERA '
PNS
V
A
era ci.
D FOLEY INSERTED:
0 O.R. 0 FLOOR
. EYE CARE
PRESS
. PRESSURE POINTS CHECKED / PAD
..1.
..
Le. o Igoe . _lc • i c., 30 30 . Avo T
ZH
I —
O 0
.
TIME
ARTEP
'
ANESTHETIC TECHNIQUE PRE -OP 200 LINE VALUES
PRESS'
. GENERAL 5KOCAL I MAC 0 REGIONAL .0 NERVE BL 160ao •
.
PULS
113 k. 8-160
V C
'1_, 4v ./,61 t.( 1 d i SPONT,
B/P
140 N. 1....:,,..11N OUSRI
INDUCTION
•1

0 PREOXYGENATION
o RAPID SEQUENCE
8 Li
120 (I/
.
INHALATION

.
INTRAMUSCULAR

P
0 INTRAVENOUS . RECTAL ASSES'
100 RES
*AA
er4 A
A) 44
80
R
AIRWAY MANAGEMENT .
0 INTUBATION
ORAL 8 NASAL
-CONTRC
RES
5 a ,
A
60
DIRECT VISION BLIND . AWAKE
'
SAT
FIBER OPTIC STYLET USED
40
. ATTEMPTS 1 -. BLADE T
ETT SIZE AB DOU LE LUMEN
TOuRNi
20
STRAIGHT . RAE 0 ANODE
H / H
CUFFED ML AIR INJECTED
F
UNCUFFED. LEAKS AT CM H2O
.
.
VRoaltueme .
Tidal Volume
I K ILI III IL
EB TTSTCUOENDS
REAEHSRIJOATCM
AIRWAY . ORAL NASAL ?NATURAL
mASK CASE VIA TRA ?NATURAL
I+1 CRYS'
1 18 i ILI It. 1
LOlOF
Pressure
SY S Y / Y /V ..I•/ ',./V
NASAL CANNULA SIMPLE 02 MASK SymbPoeleakfoPr
LMA SIZE Romano

E
610Position
) R147.
0-1
REMARKS : . Pollen! reevaluated. No change from p sop plan / evaluation.
RECOVERY
. Significant changes from preop plan/evaluation.
TIME IN PACU •
CONDITION
B/P PULSE RESP, 02 SAT /..73/7yj 13 i, 1/ 9
TEMPREMARKS
9:
Tourniquet Time:
REPORT TO: PARRS: PATIENTS IDENTIFICATION
IN •FLUIDS TOTALS OUT
6)(8)-2 lb)(8)-4
Crystalloid: 160 EBL I B -3
Urine
Ga stric /114- r/9

•••--
Blood
1 MEDCOM - 4000
DOD 010479

SURGEON:NAME: ANESTHESIA PREOPERATIVE EVALUATION PROPOSED OPERATION PREVIOUS ANESTHESIA! OPERATIONS 0 NEGATIVE PREOPERATIVE VITAL SIGNS: CURRENT MEDICATIONS 0 NONE AGE I B /P P Planned Surgery Date: M I HEIGHT I WEIGHT F R
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS 0 NEGATIVE ALLERGIES KDA
AIRWAY I TEETH HEADS NECK

ND I

SYSTEM
COMMENTS
RESPIRATORY
PERTINENT STUDY RESULTS
Tobacco Use: . NO
Yes
Asthma
Pack/Day for
Bronchitis COPE)
Years
Chest X-ray
Pulmonary Studies
Dyson's° Recent cold Pneumonia SOB Productive Cough Tuberculosis
CARDIOVASCULAR

.
Angina Arrhythmia CHF . EKG
Exercise Tolerance Hypertension MI
Murmur MVP Pacemaker
Rheumatic lever
HE
Bowel obstruciion Hiatal Hernia Cirrhosis Jaundice Hepatitis N&V . Ethanol Use : . No Yes Frequency LFTs
Reflux/Heartburn Ulcers
NE URO/MUSCULOSKELETAL • . .
Arthritis Back problems CVA/Siroke
DJD Headaches Loss of consciousness
Neuromuscular disease Paralysis Paresthesia
Syncope Seizures TIM
weakness
RE NAL/ENDOCRINE .
Diabetes Urinary retention Repel failure/Dialysis Urinary tract Infection Thyroid di Weight lose/gain Urinalysis Thyroid . FBS
OTHER
Anemia Pregnancy Bleeding tendencies Sickle cell trait Hemophilia Transfusion history Hgb / Hcl / CBC Lyles

PROBLEM LIST I DIAGNOSES
ASA PREOPERATIVE MEDICATIONS ORDERED
I 2 3 4 5
E
COUNSELING STATEMENT POST ANESTHESIA VISITS
Anesthesia alternatives, benefits and risks from minor to ANESTHESIA RECOVERY COMPLICATED BY THE
FOLLOWING PROBLEMS: (IF NONE. SO
death STATE)
explained. All questions answered. Patient / legal guardian voices understanding and gives
.
.
consent for;
Local / MAC, SAB, Epidural, IVR, General Anes. Other: • Appropriate alternative as backup. NPO status explained.
DATE:
SIGNED:
TIME:
PATIENTS SIGNATURE DATE
EVALUATORS) SIGNATURE
b)(8)-2 en
:RNA _
/00-"CW/Li..0-DATE.p8.,104 03
'HYSICIAN DATE
MEDCOM - 4001
DOD 010480
I
'
'00AVO.EcoRRImpft, . MEDICAL
For' JgrtmaseAF.L.
!efficaaI TW
-• •. . • • •
• P OSW MEC fl E RECOlkw.rx' -7 • ; OTSG, getatPvv-ig . ...... „.. ii/L2 '. rroceaure: 'b)(13)-2
"....,,....
ASA Grade (l . ..V„): . *,Physician:, '!.• ,...
Anesthesia Provider I. ' Pre-Op Vitals: T= P= R= BP=
/ ' Sa02=
ANESTHESIA.. General Spinal Epidural Allerg a.
INTAKE: OR / PACU OUTPUT: OR! PACU
Sedation . Local Nerve Block:
Latex allergy: N / Y Crystalloids /
Urine /Intrathecal vr/ narcotic: time:
.. MedicaUllirth Hx: ___ _ Blood Prod
Other: . / EBL / -
Colloids / Drains /Complications: Irrigations / Emesis /

REVERSALS: Narcotic: No;' Yes time: ,.
Other / Other /
Muscle Relaxant No / Yes time: Tourniquet time:
VITAL SIGNS
IOOST 'MEM.VEO,RECINErf SCORE FAIN ASSESSMENT
Time BP T P R IgHER
Sa02 02 Act
Rasp Circ LOC Skin Total - 0-10 Clual/ Dern WV' Nurse kilt
-, Local
Level action
AIDS— ni‘i/ ?Jr' %, ,ao
-Ti-luti
21)t-i Ki2 — 3, A 9s q'ai
. a .a a I .;/_ ct ;Await
,o7k3o.itu N; a ,--1 51 0, kiRla *ir\ çJ
6/6
....—
1.20)1
..1.1-i
.

_
VITAILGNS. I
Activity (Act) . RESPIRATIONS. (Rasp) ,. , CIRCULATION (OM
BP =.blood pressure LEVEL OF CONSCIOUSNESS (LOC) SKIN
2 = Moves 4 extremities 2 =Cough/deep breath 2 = 20% +/- PRE-OP BP 2 r- Fully awake-- .
P = pulse, • 1 = Moves 2 extremities .1 = Dyspnea, ainvay x. . -2 = Pink
1 * 20% - BO% +/-1 = Verbally aroused
R = respirations , 1 • Pale. dusky
0 = Moves 0 extremities 0 = Apnea
T - temperature ax = axillary.. 0 = 50% +/-0= Unresponsive 0 = Cyanotic
. .... .
No nystagmus w/ ketamineSa02 = oxygen saturation
a
,kidentiVe Spin*
. .s cough/deem breath HOB * elevate head . . . P 6 • rso ,
.
. .
*-
-seelfloio-walkwarrn kilanketlu till = heat tarn
Ica chit% • H /0/BleiM OIlna • '• f** thorn bipvi.by Othde:
Quality Codes:
AH = Aching BN burning CO = ciimPlaints of pain CR = slushing DL = dull • IR = Irritable PE = painfiXoPressiOn PR = pressure RT = restless SI•I = sharp
= stamping .
SP splinting ST = stabbing TN = throbbing UD = unable to describe Other.
.
F.4.404 ,..FdkrodusWa tfrcl N4:rietit
Sci."(thoulderRedc 000 441.30.P OfidtiOen Uwlim
herld uP174ar. alttramit:
44.4I: •

-MEDICATIONS RECEIVED IN PACU
TIME ' PROBLEM/COI/PLAINT A -MED DOSFJROUTE-INIT • REASSESSMENT/RESPONSE.
TIME
For analgesic inclirde Quality. Intensity..
• For analgesic include Quality. Intensity .
(0-10), and Location (0 --.- 10). and Location

PREPARED BY ISignetwe & 7711,1 1Contime en rows,/
DEPARTMENT/SERVICE/CLINIC
DATE PATIENTS IDENTIFICATION (for typed or mitten
entries give:
Name "-last,
lkst. middk; grade; dam: ho
n HISTORY/PHYSICAL J FLOW CHART E OTHER EXAMINATION
OTHER es.i.ao
OR EVALUATION DIAGNOSTIC STUDIES 71 TREATMENT
DA FORM 4700, MAY 78
MCEUL OP 45(Rev), 19 Sep 01
Page 1 of 2
MEDCOM - 4002 apprvl — 02 Aug . 01
DOD 010481
RN ASSESSJIENT

ADMISSION ASSESSMENT
TIME: ,v7 I 1..) 5 DISCHARGE . JESSMENT
TIME:
Alrway:aatentl assisted / thin Int /jaw thrust / sniff position
Airway: patent / unassisted / chin lift / jaw thrust / sniff position
RESP
Artificial aims nasal / oral / endotracheal I other.
Artificial airway: N/A I nasal / oral / endotracheal / other.
Respirations. unlabored / spontaneous / ofijer:
Respirations: clear / unlabored / spontaneous / other
Oxygen by: simple mask / nasalzanula / BB / RA / other. t•-.1177 -..
Oxygen by: simple mask / nasal canula / BB / RA / other.
Monitor sinus rhythm
eftRR b lelh o&er. Monitor sinus rhythm / RRR by path I other
Peripheral puls
o er Peripheral pulses: palpable / other.
Capilla refill: tcs@FTF-1.1nra 'then ff
Capillary refill: 3 seconds /other
Skin-Ii beds / other.

Skin: worm / dry / pink nail beds / other.
LOC: A d P U Oriented x 3/ other.

LOC: AV P U Oriented x 3/ other:
NEURO
Movementgrasps & plantar-dorsiflexion strong and equal: Yes N/A Movement grasps & plantar-dorsiflexion strong and equal: Yes No/ N/A
Sensation: denies nueas and ting ng
nibn / No / Sensation: denies numbness and tingling: Yes / No / N/A
Other. P4-
rfliA etr Other.
Abdomen: tit) non-distended / other:

Abdomen: soft 1 non-distended / other.
GI/GU
Foley catheter. Yes / No Urine ()yellow / other.
Foley catheter. Yes / No Urine dear yellow / other.
Other: '
Other
Affe plate perative / other.

•Patient informed of present condition: Yes / No
PSYCHO-
Language: English of er. Interpreter„presentS) N 1 NA
SOCIAL Family updated on patient condition:, Yes /.No
`Special Needs': N/A / identified:
Other.
Other.
None: Gauge: 1L-1. Location: (E.„) PL — None:

Gauge: Location:
Condition: patent! no•redness/ no edema -Other:.... -
Condition: .patenti no. redness / no edema.- Other: .-
SOlution:
Rate: J Fi Solution:
Rate: Mount Mma
None:
* None: Type:
DSO Location: • ,. .1 ..M..11/ME;FMN901111MM, Location:

IX
Gond *; -MTE:Ta'.. Other .2. -CAIra

Condition: dean / dry! Intact OtherDrain-41 .M emovaat Jackson Pratt / Other. 'Mains: N/A / Hemovic / Jackson Pratt ! Other.Dralnrig lc/ serosanguenous / bloody:Mem' —' •• • .3-••
-Drainage: none I sercrusrserosanguenous 1 bloody I Oher:'• • • • ••Measures taken: s poked Safety measures taken: side rails up /bed straps on / bed locked
SAFETY
Pedia • es / crib sides padded x 4
Pediatric: staff/parent at bedside at all times / crib sides padded x 4Other.
Patent at bedside to comhxLchild;-.Yet-i-Ple-----:•• •
Parent at bedside to comfort child: Yes / No
PEDS
luzni
fdRy4gafgesu-ArestkizrrtiVA
•• Humidified Oxygen: Yes /No / N/A IV on armboard: Yes / No / N/A
OTHER
b)(6)-2
RN Signatur
RN Signature:
PATIENT TEACHING IN PACU (circle all that apply)
Dademonstrated
.
Level of InvOlvement I/inviteUsed
Pulmonary Toileting: WIT
Importance of / Cough-deep breathing exercises / incentive spirometer / ABD splinting /
Other. D / V
Wound Card: ice compress / heat application / extremity elevation / signs of uompartmental syndrome / DI V
Other • - •

. • -•• •
.
. . ._
Pain management Medications: type, dose, route, indications, side effects / positioning / activity restrictions / D / Vpm .Rx requests on ward I Other:
Surgeons and Anesthesia post-op orders
a Iv
Pediatric: safety: padded sides. IV armboard / monitoring equipment/ staff-parent at BS at all times /
D /V
pediatric post-op agitation vs pain / Other.
Spinal anesthesia: use nursing assistance first time 00B, avoid pressure points while numb / Fundal massage /
D / Vlochla and pad count / Other.
Post cardiac cath: signs of bleeding / apply pressure over site when coughing, sneezing, or vomiting / D / V
lie flat with leg straight / use of sandbag / Other.
MISC: Elevate HOB / avoid eye strain / wire cutter worn around neck / Oral intake restrictions

D / V
Other
ftlt sesirom¦ hr. •ol.mrts.ei
SCHARGENOTE: This patient meets criteria for discharge from -the PACU or has been cleared by the anesthesia provider indicated on MCEUL OP 501:
lesthesia Record.
Nursing Care Plans remain open: #
toad 'called •to:• Lr • Via: • At
• .. ..;•:•f4:,•-
wri*•­• •.• :,,V 1 ,• 44• •
•j_APIT'
.?"S,'/,i • e
MEDCOM -4003

DOD 010482

STANDARD FORM 545 (rev. 10-75) 545-108
LABORATORY REPORT DISPLAY
TESTIS)
SPECl/
DATE b)(6)-2
DATE,/
-7 e RESULTS REQUESTED .41111¦• •
RESULTS
GLUCOSE

SODIUM
cs)
POTASSIUM
CHLORIDE O
rn

0
-4
PHOSPHATE
Je

TOTAL 2 I
v
PROTEIN
0
b)(8)-2 Z
GLOBUUN
m2
N N 9n
PHOSPHATASE
U.)
ri
O 9, 4
A
IL RUBIN TOTA
u.
CHOLESTEROL
O

RT
O

O

z

rn
LP

—4
z

1R
CHEMISTRY I
RD FORM 5,16
ST"
PRESCRIBED BY GSA ICMR PFIEs 4C1 FIR (41:FR) E1-451505
a
FIIMR ' M
REPORTS ALONG THIS BASE LINE
(Check one)
ALIGN ALL LABORATORY
FORMS DISPLAYED ON THIS SHEET ARE
AND 7MOUNTED ON STRIPS I, 3, 5
MOUNTED ON STRIPS 1 THROUGH 7
This form may be used to display laboratoiv reports as a PARASITOLOGY (SF 552) INSTRUCTIONS: O
CHEMISTRY I (SF 546)
flow sheet to be read as a progressive table. If so, a separate sheet should be
O IMMUNOHEMATOLOGY (SF 556)
used for each type of report form. When assorted report forms are mounted on
the display sheet, both test names and results should always be visible. CHEMISTRY II (SF 547) O
ASSORTED FORMS
O O
ENTER IN SPACE BELOW: PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE 0 OTHER (Specify)
CHEMISTRY III (SF 548) O
MOUNTED ON STRIPS 1, 4, AND 7
0
HEMATOLOGY (SF 549) O MICROBIOLOGY I (SF 553) O URINALYSIS (SF 550) MICROBIOLOGY II (SF 554) O
0
MISCELLANEOUS (SF 557)
SEROLOGY (SF 551)O
0
ASSORTED FORMS
SPINAL FLUID (SF 555) O
LABORATORY REPORT
PRESCRIBE BY GSNICMR
DISPLAY
FIRMR (41-CFR) 201-45,505
U.S. GOVERNMENT PRINTING OFFICE PROa 1752-2001/2002 rt
MEDCOM - 4004
DOD 010483

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 MEDICKL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

LIST TIMEDATE OF -ORDER TIME OF OFIDPIPATIENT IDENTIFICATION
ORDER lir( -.) NNOTED ANt
?' IC/b."3 nouns SIGN
1 Admit Patient to ICU
Diagnosis:.

R kA A: Dc3117.9-6-,e, .,v, 0-":".LAN 1-"Icrood
Allergieq..

NKDA/

JO!

1.,10$.,.

9
'4 •.
..I.Rhr/q.
shift

-.

NURSING UNIT ROOM NO. BED NO. 9
... ..

Illrin . •.
.

.

) aiTeE Ri C7i1 / /.1 'I 11.1 a Is I I b
soft-! r..1 par.

PATIENT IDENTIFICATION OF FORDER IME OF OFIRFR
Vj)‘it"J A• 4A ;LA
HOURS
41 Activity: AD LI;.BR with BSC/
Strict B.

NWB R or L LE
30 des
41 :::: 304 .

410) Norsinr7 Immid NG to LIS/ LCS
Chem 7/ H/H/ PT/PTT/

NURSING UNIT ROOM NO. BED O.
CBC qAM/.hrs/ 8 hrs/ BID

EKG q AM
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
1 ¦IIZ%
HOURS

13 PCXRAY . AM/o0D

To run @ 1
4 Ancef 1 GM IV Q 8 hrs.4t. 1L/F IA.PiX4./ -P/L...
Gentamycin.IV Q.

4 IVF NS/ LR/ D5NS/ D51/2NS.cc/hr.

In
Ira 1.../ tA-.... ..---/
Cefoxitin 2gm IV q8hrs.

NURSING UNIT ROOM NO. BE NO.
i ' 02 titrate to keep SPO2 511;/. .
•19 Versed gtt 1-10mg/hr IV titrate to

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
Illamse Scale of
2 1 Fentanyl Rtt start at 50mcg/hr titrate
for adequate pain control. MAX DOSE of
21 Vecuronium !mcg/kg/min
I MSO42 - 21.

2 MG IV q/-1/HR PRN Pain

NURSING UNIT ROOM NO. BE NO.
• Phenergan 12.5-25mg IV q 4-6hrs PRN N/V
24 MOM 30cc PRN Gastric upset

D
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

, APR 79 4256
MEDCOM - 4005

DOD 010484

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

THE DOCTOR SHALL RECORD DATE, TIME AND N EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICI
SYSTEM IS USED, WRITE PROBLEM NUMBER IN

. L RECORDUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TI ORDEI p 1:1 NOTED
HOURS SIGN
25 NS/ LR bolus X liters
26 Neuro checks q lhr/ 2hr/ 4hr/ 6hr/ q shit
27
Vascular checks q lhr/ 2hr/ 4hr/ 6hr/ q
ft
0›,--6.)// A g
S-Tel
1 F-1 i:4-4-ceo V ir7
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF OR
(6).2
NURSING UNIT ROOM NO. BED NO.
PATI ENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
,FAwA„
MEDCOM - 4006
DOD 010485

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
IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
SYSTEM
LIST TIME PATIENT IDENTIF ICATION ORDER
DATE OF ORDER' TIME OF ORDER NOTED AND
:13)(6)-4
HOURS
SIGN
L. • 6k79-
NURSING UNIT ROOM NO. BED NO.
PATIENT IGENTIF !CATION . L DATE OF ORDER TIME OF ORDER HOURS
1e(C9c-r/4,—

NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. 4 r1M-p 5K9 DATE OF ORDE C--% c-1,-02.4A X1' ( -Z• 4/.62/ TIME ORDER . c,..)1€
6_, 17f4i--/I (-) ve e"s b)(6)-2 HOURS
7
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS

b)(6)-2
NURSING UNIT ROOM. NO. BED NO.
REPLACES E DITION OF 1 JUL 77, WHICH MAY
DA 4256
,FAOPPM19
-pM/ElikIMENT1M.INTING`::,0*FICE:' V99E1,499.924
MEDCOM - 4007
DOD 010486

ativitAL RECORD. DOCTOR'S ORDERS
For use of `orm, see AR 40-66, the proponent agency isC
THE DOCTOR SHALL RECORD DATE, TIM ¦
SIGN EACH SET OF ORDERS. IF PRO131. ¦ ANTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBEh COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE ORDER TIME ORDER LIST TIME
OF OF
ORDER NOTED AND
0-MID HOURS
b)(6)-4 1Wg/e4.) SIGN
• , )(13)-2
I. Li.." ". an
"..
a
-h ...1,4 N(e)-2 Ilenullit.i.
41116.
... .
vi'
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
VU e,„ a 1-.7 le, a3 Yy-y.../3 49 p
Amb,.-.." hi—, P ,v',
b)(6)-2
iwv,oN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
-.NM.
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE
ORDE TIME OF ORDER
HOURS
NURSING UNIT ROOldNO.
BED NO.
-_ _ --REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
,74:19

* U.S. GOVERNMENT PRINTING OFFICE: 1994-363•710
• "..)
"USE•BALL POINT.PENPRESS.EIRMLY-1,NaCARBOWPAPER,REOUIRED9!
MEDCOM - 4008
DOD 010487

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 TIME ORDER NOTED AND
'b)(8)-4 1-5' kr 03 tie LC HOURS SIGN
O
i .1%. c 4-0 VAA-( --—r
kwo-r4 1 sI? 14.4
CD' .DY 1 OnAoui,.‘,.. s' S toG-G--VI 1-0-Q-1 • k (a° — CD ituLif;.ts t t-) Ktodi
NURSING UNIT ROOM NO. BED NO.
(5 •... ...A i
• .. lir Sit ¦ -r
PATIENT IDENTIFICATION
DATE OF ORDER i TIME OF ORDER
HOURS
111.:"'
'1 .17‘.& 1 Dc LA e (so' k..,-A
/14-ta 4 (J_ .. . 0 8•
11
tVISO¦i. q-,..) iv Q Z` Pied ?
Pkw----r., Is-s-..) j ©Z f -c...

(0 rk.As;,..3 . .,L,1 4, iran. Ty
O
NURSING UNIT ROOM NO. BED NO.
We* 614,43,1...) 40-,. 0.....1C. a •;
O k- 4:-1
7 oto vulit-4 gr.A. 01.4.14.&17
s
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
I-4.--
4.1 HOURS
5,)(8)-4 0 11 4 oz, .' / L 1712,p1 oz so-t3 91? 1 ,„„4_,., ft, k, io 0-1., -7 3
bX8)-2
NURSING U NIT
ROOM NO. BED NO.
4 1 m,_9. Internal 114Pdirinp
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
1G-Ape (I)-(P& ICOURS 0 \ hAgtek Z -4 ----,./ pp..) 4,..ss.,L, a
b)(8)-4 . ekce34 S pg.,1 (AAAssi„: it
b)(8)-2
4'
O
VI' CO elteli '. ?0
0 -. # (8)-2
g;b D(c arf-= ,,AA,•¦ 4r..-••¦• kill474 Pi
( my -
0 Neo 7 AA.J 4suzy-4-A
,b)(6)-2
NURSING UNIT ROOM NO. BED NO. 1016F2-------.\ •
..,.., ;tet_
\
i."&i'41 T.— . ......
FORM REPLA,
:H MAY BE USED.
APR 79 MEDCOM - 4009
DOD 010488

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

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. ,."
LIST I I NI t
DATE OF ORDER TIME OF 0QDER NOTED AND PATIENT IDENTIFICATION ORDER
al 0
HOURS
i -113( 0-3 SIGN
30 rn9. 8. Fir 5 PR /4 A/-
6)(6)-4 RP..S I 15­
/
cS,, Le....e_To • # 1 Dy, , b)(6)-2
b)(6)-2
Ni:•
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sr.
NURSING UNIT ROOM NO. BED NO. V
f. •
4-ir
e 2/V24¦-/1/4-).
TIME OF ORDER
DATE OF ORDER
PATIENT IDENTIFICATION 065K HOURS
Li l\__
le
PtAlVY k f-) .CCI
'6)(6)4
_ PA' L..!.: . .. A a
NAII t0') 6 , . V4b Erikr -
st. ii,
..t. • ,
. -`` ,, Am . , •••• -• --1
.... • , . • A -
NURSING UNIT ROOM NO. BED NO. ••
'LP • C.A116 ' • 0 19' A
k ...k...1 id:
_ccAl 4-1 i
r7
A .A/
d" IIP • 10),..k1—_-11-'.
PATIENT IDENTIFICATION
HOURS
te et tio @, krok kk:li
'6)(6)-4
1
CA/am& •5‘kit4
6,b.
Ikki.c6 kvaRS-n SO 1/4.e) NURSING UNIT ROOM NO. BED NO. j
•ID •
Ifeb
e, a -1' . ( \r1.1)1/4/01.1ZaA k2,6 —25 vitoc R'N CII: imti4 %AP VICliAtil4 PATIENT IDENTIFICATION
DATE OF °ROE TIME OF DER
HOURS
1
Zaszkov4k PG -tit) Irb VO 61.tkt, rv¦ ( -z)v(` i, . I p.
'6M4 3a.).1 k--cAt ots-ta 841-0. D I C, .
ill bp
I. .
•)(6)-2 --.IIV__ IMAI •
NURSING UNIT ROOM NO. BED NO.
44-
3--- Vut. - (
USED.
1 FAOPFIRM79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE
DA 4256
MEDCOM - 4010
II 4 GM/PPNINIFNT PRINTING CIPPICF• 1 ARR-41 .1A-5174
L
DOD 010489

THE DOCTOR SHALL RECORD
SYSTEM IS USED, WRITE PROS

PATIENT IDENTIFICATION
:b)(6)-4
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD LEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
DATE Of ORDER TIME OF ORDkR LI T TI • ORDER 1 (6 /Ap r (-27 0 r3 NOTED AND
HOURS 1121111ffil SIGN
imomi Gr‘..,e.
wrmslimprd wair
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1
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2,1N1111711111
BED NO. b)(6)-2
bX6)-2
NIMMIELM011011
111111110111ErS=11
DATE OF ORDER
TIME OF ORDER
,t 20
b)(6)-2 fib b)(6)-2
DATE OF ORDER TIME OF ORDER
HOURS
b)(6)-2 b)(6)-2 b)(8)-2
1/ A •D
b)(6)-2
:211
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DATE OF ORDER TIME OF ORDER
B PI?
HOURS
FAIMIEWILMAI
b)(6)-2 16111"rAIIIWO 2
?(6}2C C 431.11.111F
Ig INF
NURSING UNIT ROOM NO.
FOR
M
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 APR 79
MEDCOM - 4011
DOD 010490
CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIMETIME OF ORDERPATIENT IDENTIFIC ATION DATE OF ORDER
ORDER NOTED AND
0 HOURS SIGN
el peg 0573
bX13)-2
'bX6)-4
Ve/Serf 3,y wer
'b)(13)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
b)(8)-4 HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
HOURS
:3)(8)-4
NURSING UNIT ROOM NO. BED NO.
M REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
„ 4256
DA , FOR
MEDCOM - 4012
DOD 010491
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 TIME ORDER
(b)(6).4
NOTED AND
HOURS SIGN
;6)(6)-2
/a3 Appi assz,„ g II —le pm #pi °,
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ICJ 3

PATIENT IDENTIFICATION TIME OF ORDER
D5:El 7); 1/C3
HOURS
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1) Pg A b 04,444._e.4 1
2

6)(6)-2
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,b)(6)-2
NURSING UNIT ROOM NO. BED NO.
'PiffO3 o7cb
bX6)-2
ICU 3 110 -ge4 Rtv--rt" elbty
PATIENT IDENTIFICATION
at,
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(b)(6)-4
b)(6}2
V
NURSING UNIT OOM NO. PATIENT IDENTIFICATION ED NO. Io 3 -7"p --Le if ccoctpDATE OF ORDER -77 fiegre,8(8,2 TIME OF OF
:6)(6)-4 .717.
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NURSING UNIT ROOM NO. BED NO.
oi
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256

1 FAOPFing
MEDCOM - 4013
DOD 010492

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 LIST TIME ORDER NOTED AND
0 63*VOS0 SIGN
HO URS
(b)(6)-4
-e-a"? /iv/ 7 Lt-i/DeD.
b)(6)-2
•a 1/00.1:-,V,,,
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NURSING UNIT ROOM NO. BED NO.
1X 2 170
PATIENT IDENTIFICATION DATE OF ORO R TIME OF ORDER
HOURS
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:b)(6)-4
NURSING UNIT ROOM NO. BED NO.
bX6)-2
•Z Z AprA 03 (7),•()57)
*ed )--5mc DP -PM Evil'or '65 cbtaSso AI
PATIENT IDENTIFICATION DATE OF ORD
TI E OF ORDER
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/ WAY/
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NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION b)(6)-2o'7c DATE OF ORDER 09/0 TIME DrORDER 03
U(94 z_/TS) eA / 3150 —Po X HOURS
b)(6)-2 V. 0

NURSING UNIT ROOM NO. BED NO.
REPLA^" • " " `•''-•"7.H MAY BE USED.
DA 4256
1FAr;1'479
MEDCOM - 4014
DOD 010493

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
TIM LIST TIME ORDER NOTED AND
;b)(6)-4 DA0/31Z 0.3 E/Y/RV R HOURS
6)731 SIGN
7( 1 14‘7C.,
/e6-5-,e(ts, 7/41/71
?/o/
NURSING UNIT ROOM NO.
BED NO
5) i&Le XeS./Ohzec/
6 hai bo /uo r
PATIENT IDENTIFICATION
DATE OF °Rd
TIME OF ORDER
HOURS
, 4ff
NURSING UNIT ROOM NO.
BED NO.
cordig,dififfiralinglfir
PATIENT IDENTIFICATION
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NURSING UNIT ROOM NO. BED NO.
11111111 1 b
PATIENT IDENTIFICATION
DATE OF ORDER
TIME 0
b)(8) 2 b)(8}2 /7(0
1.1
NURSING UNIT ROOM NO. BED NO. b)(8)-2
REPLACFS rnrrima no I III "
MAY BE USED.
DA 4256
1 FArRM79
MEDCOM - 4015
DOD 010494
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 LIST TIME
TIME OF ORDER ORDER
NOTED AND
HOURS
10 AMISS
(6)(6)-4
(b: tr-ia)c es4
b)( )-2
(etwe
'A. V108/
Q
b 6 2
NURSING UNIT ROOM NO. BED NO.
kAz
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
3()
HOURS
:13)(6)-4
Be/t..riou
6)(6).2
Pe
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NURSING UNIT ROOM NO. BED NO
bXe)-2
ao,„2 4
-.••••••"77­
14-tz.....¦
PATIENT IDENTIFICATION DATE OF ORDER TIME ‘ cps. EA
-zoo 3
/22)
:b)(6 )-4
ra.
:6)(6)-2
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
.b)( 6)-4
DAtt 07.) -7`
HOURS
ie._ tiersect
Cifkre-KA-e. triaritALA. 0,1.J ribte_c_i—h"
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6)(6).2
6)0)-2
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
.6)(6)-2
dtv,bte, c h cK' 4" wz 0/10
'4 )
M
REPLACES EDIT N OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 PR 79
MEDCOM - 4016
DOD 010495

CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is.OTSG
RECORD
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME
DATE OF ORDER TIME' OF ORDER
ATION
ORDER NOTED AND HOURS
SIGN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFI CATION DATE OF ORDER
NURSING UNIT ROOM NO. Cj-R,K, CATIONPATIENT IDENTIFI BED NO. rrio. DATE OF 0 Dell b)(13)-2 I 'me OF ORDER URS 12 53C/
z
NURSING UNIT PATIENT IDENTIFI ROOM Ny. A'T ION BED NO. DATE OF ORDER TIME OF ORDER HOURS

NURSING UNIT ROOM NO. = D NO.
FORM REPLACES EDITION OF 1 JUL 77. WHICH MvAY -id USED.
DA 4256
1 APR „ '
MEDCOM - 4017
DOD 010496


CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. LIST TIME
PATIENT IDENTIFICATION DATE OF ORDER IME OF ORDER .J
i il Li HOURS ORDE
NOTED AND
SIGN 1
/ ThloalratZ41' 65-. Ai/
341
,b)(6)-4
6 ib 4ke t le
A .
b)(6)-2
NURSING UNIT ROOM NO. BEp NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
( i) 0 4)--
0 3 )1.1 Lk., u3
_
HOURS
ro gy.j. 6..e.o.. ery.. o‘ttivict,_,
...... )(6)-2
NURSING UNITNURSING ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO. •
¦
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
1
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1 APR 79FORM 4256
MEDCOM - 4018
DOD 010497


CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is ursq.
THE
DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTE SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. D MEDICAL RECORD
PATIENT IDENTIFICATION DATE OF ORDER
.
D,ROER LI SI TIME
ORD E R
Olintc NOTED AND
b)(6)4 HOURS
SIGN
_ •Oritry e Maxicei‘f
"
• fikl• AIL
NURSING UNIT ROOM NO. BED NO, b)(8).2
b)(8)­2
e
PATIENT IDENTIFICATION • • °ADE TIME OF ODDER

HOURS
:b)(6)-4
NURSING UNIT
ROOM NO. BED NO.
ICATION TE OF ORDER
TIME OF ORDER
:bX6)-4
HOURS
NURSING UNIT
ROOM NO.
BED NO.
'ATIENT IDENTIFICATION
DATE OF ORDER
TIME of O:ROE.R
HOURS
.13)(8)-4
NURSING UNIT
ROOM NO.
BED NO
DA IFA?pr79 456 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
U.S GOVERNMENT PRINTINGDFFICE: 1994-, 383.710
MEDCOM - 4019
DOD 010498

MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded.
ORDER NOTED COMPLETEDORDER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
NUMBER TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS' ..1) OXYGEN: ,1 litres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air. :2.) IVF: N --s @ 71"--cc/hr, bolus cc x 1 0 MORPHINE: o? mg IV q 5-10 minutes PRN pain. MAX dose of PO mg
,4) DEMEROL: -Zs:-mg IV q 5-10 minutes PRN pain. MAX dose of ..s-omg
5 . Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
/e 10 mg IV PRN nausea X 1
8 Release from "PACU" when Aldrete score is or greater
Call Anesthesia for any questions or concerns
7417"7 OCIS-rl- / . /2•A(V AW,s7-7 A.C../Aud1-34-c_., -
(b)(6)-2
SIGNE ,i,fir 0-c,,, --2 -

PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any changes on subsequent pages.
Diagnosis:
11)(13)-4
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

MEDCOM FORM 688-R (TEST) (MCHO) M A" """` ARE OBSOLETE MC V1.00
MEDCOM - 4020
DOD 010499

MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial In the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS • TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS. . • p)(6)-2 —
1 OXYGEN: 1....." litres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air.
0 (VP: P1 5 0 1 -2.,5- cc/hr, bolus 7,0 cc x 1
0) MORPHINE: 3 mg IV q 5-10 minutes PRN pain. MAX dose of1,3 mg
3 DEMEROL: kr1.5./ mg IV q 5-10 minutes PRN pain. MAX dose of 51) mg
5 ZpirliKg: Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 D_RDPERZUL: 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
7 RffatATNI: Give 10 mg IV PRN nausea X 1
/1)I Release from "PACU" when Aldrete score is Call Anesthesia for any questions or concerns or greater
13)(6)-2
\-*J/
SIGNE

PATIENT IDENTIFICATION
Complete the following information on page 1 on y. Note any changes on subsequent pages.
Diagnosis:
1)(6)-4
Height: Weight: Diet:
Allergies:
-Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) MA"' :OBSOLETE MC V1.00
MEDCOM - 4021
DOD 010500
,,/ERAPEUTIC DOCUMEFNTATflOh Alf CAREAPRL4g7(NOiv-MEDICATION)
' CLINICAL RECORD
the immanent aa ncv is the Office of The Surgeon General. . 1-
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETEDORDER CLERK! RECURRING ACTIONS, DATE NURSE FREQUENCY, TIME
10 11
I% /lir a ....,x6), - -JO AFA cs - - \Vital signs q hr / q 2hr q6h4 q8hr / q shift Cardiac Respiratory Monitoring 07 /:b)(6)-2 19 )(6)-2 07 / 19 "8)-2 •
Id (OA CZ — Diet: NPO /41(sul;)/ Soft / Clear 07 7
1 0 4tA06 Liquid b.-AND-N. a.kooir..A. Activity: Ad Lib / with BSC / NWB R or L LE 19 "")-2 / ,--07 19-:.b)(42 .
P elr 5 HOB up 30 Degrees 07 / 19 3))(6)-2
ID Ar Nursi CDB / NG to LIS / LCS 07 19 / )(6)-2
Labs: Chem 7 / H&H / PT/PTT / 04
CBC q AM / 4 hrs / 8 hrs / BID 08
12
16
20
24
EKG q AM / QOD 06
PCXRAY q AM / QOD 06
Neuro checks q lhr / 2 hr / 4 hr / 6 hr / 07
q shift 19
Vascular checks nq lhr / 2 hr / 4 hr / 07
ALLERGIES: - -b)(6)-2 M YES 6 hr / q shift 19 Dee SSM A 9 cl. W 220 76­7---s-)(AA no It in nMO I I NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE M YES Is NO
PATIENT IDENTIFICATION: :b)(6)-4 PAGE NO: ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
0 8 9 10 11 12 13 14 15.
E 16 17 18 19 20 21 22 23
Treatment Facility: b. ")-1 N 24 01 02 03 04 05 06 07 USAPA V1.00
MEDCOM - 4022
DOD 010501

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (NON-MEDICATION) Mo Yr

Order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
Admit Patient to ICU
Diagnosis: cg.)-,By.n ..... cecit6,6,,,„,4_ r, . IOU r'
ODU
)
Condition. Serious / Critical

Allergies: NKDA
Order? INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk? PRN
bulk Date Nurse ACTION, FREQUENCY TIMEIDATE COMPLETED
. —
USAPA 111.0D
MEDCOM - 4023
DOD 010502

r".. THERAPEUTIC DOCUMENTAON CAREPLAN lingeleffign/S)
ION
CLINICAL RECORD For useof this see AR 40-407;
Mo. 'Y Yr. 03
the proponent egencx Is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE P8 APi2(33 NURSE x )- DOSE, FREQUENCY vs Per r01./..kw., Call HO to-7 1g i s 28I 21 -se ,b)(6)-2 2- ci 5-- 6 1 1 4 I I
c0 -,-Jurr.. (OI 23
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.73
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ef,c off To') 13
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J

ALL ERGI EM El y Es El No PRIMARY DIAGNOSIS%
ADDITIONAL PAGES IN USE: 0 YES 0 NO
Sick() cfrckAt±‘
'S%14% ••
r...., 1; pApg NO
PATIENT 'DEN TI FICATIOWII • •

..L.•.” 6.— " •
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s!..1/4,: r ' C .' • •11t;4 CIO:: fr; . . '
• I
:., Nxi. •.. -' :b)(6)-4
. USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA 1 FFO49 4678
EIr
MEDCOM - 4024
DOD 010503

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo. 0 Yr 61
Initialing (MEDICATIONS)
Date to Time to SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Order Cleric/ be Given be GivenDote Nurse
b)(6)-2 gaft pe pito ‘cA t o (b)(6)-2
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IWITIAL PRDPeR L 4OLUMN FOLLOWING ADMINISTRATION
Order/.
' C lerk/ PRN
EspIr
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date
• . ..,
,...
.;^.
'U.S. GPO: 1996454-11W95216
MEDCOM -4025
DOD 010504

TITHERAPEUTIC DOCUMENTATION CARE PLAN al/ED/CATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; Mo. Yr.
the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING I INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

I •F WO VI taanniNEFAM
INNIIMIMILialRI
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ALLERGIES- E] YES PRIMARY DIAGNOSISt
E'NO ADDITIONAL PAGES IN USES 0 YES E:1 NO © FIRNK tdauticIS PAGE NO PATIENT !DENT FICATIONs • bX3)-1
•)(6)-4
DISPENSING TIMES
b)(6}4
I USE PENCIL. CI RCL E MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA 1 FEBr79 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. I
MEDCOM - 4026

DOD 010505

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo. Yr
Initialing (MEDICATIONS)
Order Dote Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to bo Given Time to be Given Time Given
(b)(8)-2
PPR arLyi:A- ft, lc u 1:),v 0Fian LJoli-44 7Mcri 05 ys5-
Coviefkuen Sate , , 1 learn_ 0(7
Falfy OP1 1,19g v/ire o I 76z) 105610/11 1 -4J
NI ( R M 'kJ Q,7 P4 2 7 A (2,v to RI coo rJ
j -12_ mi_oli,irk To 30 “, )1 I nint,3 AP to Na Li 3.00

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Order/ Clerk/ PRN
Espir
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Dote
U.S. GPO: 1996-454-110/95216
MEDCOM - 4027
DOD 010506

0 ra
-.
Th cnAPEUTIC DOCUMEFEATJOiNfoelsigE APRVIVI9N IV OPIONWRiff)
CLINICAL RECORD Mo. Yyr. rig
ncv is the Office of The Swam General.
,,,....,...)12,R9soriip
agatIMEMICEMMiMISOM INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INITIALING
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS, I
DATE NURSE FREQUENCY, TIME

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MEDCOM - 4028
DOD 010507

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DOD 010508
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407;
the proponent agency is the Office of The Surgeon General.

CLINICAL RECORD Mo. 'r. b
VERIFY DY INITIAIJNO1 : INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

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USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL 13E USED UNTIL •EXHAUSTED.
DA JFEng 4678
MEDCOM - 4030
DOD 010509

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MEDCOM - 4031
DOD 010510
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLANYM.MICATIONS)
uw of thiiterni, Na AR 40407;the proponent anent is the Office pf The Surgeon General. Mo. 1
7 yr. 03
VERIFY EY INITIALING
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DA 1FFOEV9 4878
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM -4032
DOD 010511

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MEDCOM - 4033
DOD 010512

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Initialing (MEDICATIONS) 1Mo. Yr

Order Clerk/ Data to Time to SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
--.-
O rder/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
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MEDCOM - 4034
DOD 010513

CLINICAL RECORD THERAPEUTIC 'vow's" ATION QARE:11 •••‘'-MEDICATIONS)
Far UN of th rn
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llMIN
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ORDER CLERK/ RECURRING MEDICATIONS,
DATE
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MEDCOM -4035
DOD 010514
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, 568 AR 40-407; Mo.APSyr. fla.
the proponent agency Is the Office of The Surgeon General.
: INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY INITIALING
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

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1 FEB79
MEDCOM - 4036
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DOD 010515

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MEDCOM — 4037
DOD 010516
TH. EUTIC DOCUMENTATION CARE ,ON-MEDICATION)
CLINICAL RECORD For use of this form, see AR ter,
MO. 0 4 Yr. fl
h. . ... -..:n ¦, is the Office of The Suraeon General.
'VERIFY By mratuNG q.:7 47:7-4-W,11-,NTr::-F7:-1,r0174.417 INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

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scale of 19
Fentanyl gtt start at 50mcg/hr titrate for 07
adequate pain control MAX Dose of 19

Vecuronium 'mg/kg/min 07
19

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s.0 1-0 cGt.,c, ci„ f (A vizj im YES M NO
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N 24 01 02 03 04 05 06 07
Treatment Facility: )(3)-1 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 4038
DOD 010517

Verify by THE .OTIC DOCUMENTATION CARE PLAN
Initialing (NON-MEDICATION) Mo bl Yr

Order Clerk
Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
_...

Order/ Expir Date Clerk/ Nurse ,tet. :b0)-2 31.2pek_ PRN ACTION, FREQUENCY itirlphine Sulfate d-tmg IV qi-Lhr pain Phouitau-l4.5-26n4V-q-4.15 -trrs prn N/V -----, MOM 30cc PRN Gastric Upset NS I LR bolus X liters INITIAL PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED Ar-A315 to tIkr cookt _iitr, 6(61 9 I n 4,,e, Ci'V iw20 a. (b)(6)-2
P kiNuAsan )2s -23,75 2Y. Li -6 IPA) Alli1
MEDCOM - 4039 USAPA V1.00
DOD 010518

:b)(6)-4
N 3a. STATUS 3b. SERVIC 14. PRECEDENCE 5. GRADE
1 . ')
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?. SEX 11 8.WEIGHT 9. BLOOD TYPE 10. CLASSIFICATION/(1A TO 5F)--11.ACCEPTING MD 12.CITE/AUTH # 1_ MALE 'FEMALE AMBUL 174.1..ITTER 13.APPT/SURG DATE
6. FSE
14a. ORIGINATING FACILITY 15a. DESTINATION Fia:i 16.# OF ATTENDANTS
b)(3)-1
16a. MED 16b.NON-MED 14b.ORIGINATING FACILITY PHONE NUMBER 15B. DESTINATION FACILITY PHONE NUMBER 5584b)(3)..1 ,1 1. . _ DIAGNOSIS 19. CLINICAL ISSUES (Please indicate Yes or No on china! issues Explain
1 St -r ) J---i-E---I Al J /,R,7 I-C..i.le.,1 7 ,} YES comments in Section 23)
F t.n 4.44:YES NO ISSUE YES NO

-
a.
Hypertension i. Bowel Problem

b.
r Cardiac Hx j. Self-care

1. 1 'BATTLE CASUALTY (DISEASE I I NON BATTLE INJURY c. Diabetes k. Ambulatory
,),-;. PHYSICIANS ORDERS d. Respiratory I. Ambulatory Ald
2(..a. DATE 20b. TIME 20c. ALLERGIES e. Ears/Sinus m. Self-meds
f Motion Sick n. Adequate Supply of Meds

2ud. DIET IREG I3GM NA I 'CARDIAC I [DIABETIC GALS g. Vision Impaired o. Other:
RENAL Gm Prot Gm Na MagK mg PO4 h. Voiding Prob.
TUBE TYPE cc/hr, 1/2, 4, FULL STRENGTH 21. PRE-FLIGHT VITALS
PEDIATRIC: 'OTHER (Specify) 21a. DATE / TIME 21b.TEMP: 21c. PULSE 21e. BP

: AGE
TPN: Change to 010 at cc/hrmax of 21d. RESP:

cc/hr for days
TUBE FEEDING: _ at , strength at cc/hr 22. BRIEF NARRATIVE

'IV / BLOOD.2:e.
f. SPECIAL EQUIPMENT FOLEY CATH
SUCTION TRACTION ORTHO BRACES -----2--riee 1-e2--.-
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OTHER (USE 23) tikof 43 z.-.-'1"&g 77,1 ,,. (;.--, 4/1-(C---)1-1.4 /LAC 4-
INCUBATOR MONITOR
0 ,IYGEN: PERCENT or LITERS ROUTE:
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2 . ALTITUDE RESTRICTION: Yes / No feet
2i.. , 11. RECORDS TO ACCOMPANY PATIENT
OUTPATIENT RECORDS XRAYS OTHER:
INPATIES. IT RECERDS OB
NARRATIVE SUI. MAR ( DENTAL
F1, IANC., 1_

• .1EDICA.TIONS / TREATMENTS 23. ASSESSMENT / PROGRESS
DATE / TIME NOTES , ...._
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STAMP AND SIGNATURE OF ATTENDING PHYSICIAN 25. STAMP AND SIGNATURE OF FLIGHT SURGEON
A': Form 3899 (433 AES Excel version)
MEDCOM - 4040

DOD 010519

../Pt i A
.:AL RECORD • SUPLEdENTAL MED
Ir use of this form, see AR 40-66; the proponent acyls the Office of the Surgeon General
OTSG APRON/ED (Demi
EPORT TITLE
TRAUMA FLOWSHEET
. MINIMAL
E:3 DELAYED .
SMENT
INITIAL ASS
Arrival Time:
ate:
Ilcrgics:
VLF: hie omplaint:
rr_atments PTA:
TIAL SIGNS:
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. 140
RAUMAZZ.Es
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FIES . NO
UNG S UNDS R L c-AMCLEAR
H EEZES
DECREASED
ABSENT
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LTX2
MITI ES
CMS
X4 I NO EDEMA I NO DEFORMITIES
XCEtrititiS TO BOVE .... . . : ARAMETERS
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Last Meal:
BP: /17/
A BD 0 MEN
WARM ..4n SOFT
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.
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. NO
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MOIST ED YES
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C R
REP ARED BY (Signature & Title)

(For typed or written
ATIENT'S IDENTIFICATION
'tries give: Name - last; first: middle: grade: date: 7spital or medical facility)
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Sex:
Unknown
Tetanus Status: UTD
Medications:
SAO 2 :
TEMP:
RR: Z 4
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. NO R mm
PERRL trd YES GLASC•

2• 3. 40 50 6
7S
I. EYE OPENING Spontaneous-I
To Voice • 3
To Pain • 2
-None 1

2. VERBAL RESPONSE
Oriented • 5 Confused • 4 ria ppr op' i3te • 3 Incompttilensible • 2 None • 1
8 9
3. MOTOR RESPONSE
Obedient • 6
Purooserul • 5
Wiinornvr:r • 4
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FRONT
ronrirrue ar ;
r ATE
DEP ART-NENT/SER CF./CLINIC
399'h CSH

. FLOW CHART
. HISTORY/PHYSICAL OTHER (Specify)
.
0 OTHER EXAMINATION
OR EVALUATION

DIAGNOSTIC STUDS
. TREATMENT
MEDCOM - 4041
DOD 010520
1. REPORTING MTF 2. OCATION
ADMISSION AINO CODING INFORMATION
1 2 3 4 5 6 7 8 (State or
Country
Code.)

b)(3)-1 For use of this form, see AR 40-400; the proponent agency is OTSG
b)(13)-4
3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
9 10 11 12 13 14 15 16 17 18
6. DATE OF BIRTH (YYYYMMOD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 -- 30 31 BACK-
19 1 b 1 J / 5' \ GR OUND ti. iiSU 41
10. LENGTH OF SERVICE ETS 11. FMP SECURITY NUMBER12. SOCIAL
32 33 34 35 36 37 38 39 40 41 42 43 44 45
P-C)
ORGANIZATION (Active Duty Only 13. MARITAL STATUS HOUR OF BRANCH / CORPS
ADMISSION
46
0 Lo CZ
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 5.0 51 52 53 54 55 56 57 58 59 60 61

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION Country Code)
YEAR
62 63 64 65 66 67 68 69 70 71
NO
. -7N1

NAME/RELATIONSHIP F EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD ADMISSION
72
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
D u\k-e-+ -r-- LU I
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
b)(3)-1
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYYYMMOD)
73 74 ' 1.4 Orre-75 76 77 78 79 80 81 82 83 84 85 86 87 88
2-° 3 c) S-o A,
24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y V Y ' • a 0)
89 90 91 92 93 94 95 96 WICI 99 100 101 102 103 104 Ertl
iirAl..
nrgi MIfuha
PM 0 5 6Eanrllii.
Z.-C
27. LOCATION OF OCCURRENCE 28. MTF OF INIT . L ADMISSION 29. DATE INITIAL ADMISSION (YYYYMMDD) Wattle Casualty Only)
107. 108 109 110 si 112 113 114 115 116 117 118 119 120 121 122
FOR LOCAL USE
DX: e---7 15 -TA tLikit.itiMitPk.
k (
)
sys,.
NI c , q 00 '2-Oa .9r LF4{9
AnnarrTnun (IFFInc1:2 Iginnatiirs: ae rpnuidri) , SIGNATUOVVIITTING CLERK
(b)(13)-2
/ EDITION OF MAR 89 IS USAPA V1.00
MEDCOM - 4042
DOD 010521

Doc_nid: 
7030
Doc_type_num: 
72