Medical Report: 25-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Fractured Jaw

ATIENT TREATMENT RECORL. ..,._ .6R SHEET
Automated Facsimile MrFor use of this form, see AR 40-400, the proponent agency is OTSG ___—_r....,----,....,1
Admission Remarks
1
\ 3. Grade
1 1 FGN 11
—__:1

11. Register Nbr
L &IL,
10. PrevAdm

8. LnthOfSvc 1 9. ETS 1
\-11111L—
NO; 1 5. Age
1 I 1 '
14. Sex 25Y 14. Ward
M
ICW 1

t "-
111. MOP
99 20. Type Cail

17. Dept/Ben DIS
15. FlyStatus
K78-PRISONER OF WAR/INTER -
23. Clinic Service ABF - ORAL SURGERY

1------
; 21. Source of Admission
; Direct from ER 26. Date of Disp
I-- — 2003-11-09

24. Name/Relation of Emergency Addressee
____ AdmittingOfficer: 27b. Telephone No 28. Date This Adm:
2003-11-07
_
27a. Address of Emergency Addressee 32. Units Blood Components
30. Date Ira Adm
._-_____—_—____

;
2003-11-07
12 ReportingMTF

1.___
I
DoB:
ioritatl pStatitust:.

131 . Selected Administrative Data
\ MI aMOS:Inpatient
i 33. Cause Of Injury:
1I
34. Diagnosis / Operations and Special Procedures:
1

S/P CLOSEDREDUCTION OF MANDIBLE FX
1(/' o ?
9-5'

\ Total Sick Days

35. Total Days This Facility \ ConLv Coop Care Days \ Supplemental Care Bed Days-
Absent Sick Days \ Other Days

_

Total Sick Days
135. Total Days This Facility

ConLv / Coop Care Days Supplemental Care Bed Days
I Absent Sick Days 110ther Days
0

0 t 1.1111111011 icer
edical Officer _________
MEDCOM -12'3351

MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)
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ABBREVIATED MEDICAL RECORD
Standard Form 539
GENERAL SERVICES ADMINISTRATION ANO INTERAGENCY COMMITTEE ON MEDICAL RECOFIDS FIRMR (41 CFRI 20145.505 OCTOBER 1975 USAPPC V1.00
MEDCOM - 23A2
DOD-036928

AU MAULED I-LM LOCAL REPRODUCTIOP
• MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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LAST FIRST MI
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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.2030DH-10
USAPA V1.00
1111.1!!
MEDCOM - 23353

DOD-036929

7` I

MIDDLE INITIAL ID NUMBERFIRST NAMELAST NAME
NOTES
DATE
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STANDAFiD FORM 509 IREV. 5/19991BAC
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTESDATE
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LAST FIRST MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: IFor typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)

PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0 , USAPA V1.0C
-

411111"
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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DOD-036932

nu nunn.cu run Luuni.nr.

MEDIoAL RECORD PROGRESS NOTES
DATE NOTES
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LAST FIRST MI
EPART.ISERVIC E HOSPITAL OR MEDICAL FACILffY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: For typed or written entdes, give: Name last, list, middle,'
I
REGISTER NO.
WARD NO.

ID No or SSN; Sex; Date al Birth; Rank/Sradel
PROGRESS NOTES
Medical Record

repib
STANDARD FORM 509 (REV. sings) Prescribed by GSAI1CMR FPMR 141CFR) 101.11.2030M RI

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USAPA V1.00
MEDCOM - 23357

DOD-036933

510-112 NSN 7540-00-63-
NURShvG NOTES
MEDICAL RECORD
(Sign all notes)
HOUR
OBSERVATIONS
DATE

A.A.I. P.M. Include medication and treatment when indicated
A ¦ C....--r-,e. .?.. 111-4.11¦00

, .1......V D P C_,
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(Continue on reverse side)

pATIENT's loovrinc,vrioN (For typed or written entries give: Name—last. first. middle: grade: rank: rate: REGISTER NO. I WARD NO. hospital or mediCal faCilify)
NURSING NOTES Medical Record
STANDAR° FORM 5,0 'RP, 7-0"
MEDCOM - 23358

DOD-036934

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT

MEDICAL RECORD
FOR Use this form. See AR 40407: the Proponent agency is The Office of the Surgeon General.
-'reabki jevAi Lk/ ).reiv.

1. AGE 25" 2. KNOWN AXNKDA REACTION: LLERGIC S0 PCN 0 LATEX ENSITIVITIES ( IODINE e.g.. lodin, Ta 0 TAPE 0 FOOD pe, Medication)
HEIGHT:
VVEIGHT: I?0 ics 3. PREVIOUS SURGERY ] NO ES (type): 64A-,74-

4. PROPOSED SURGICAL,PROCEDURE:
1W,..k...0W6Q 4X
5. ADDITIQNAL I RMATION: (Previous surgical
and medical history) Skin Condition ir‘
t1-4—Tobacco 171_ APpd vrs Body Piercin

Diabetes (Y)....;)
ROM 1 COSA/Motrin W 72hrgyte
ETOH (-1/

Implants etpiratory Diseaesthma COPD) (Y) nticoagulants (Y)
Glasses/Contact (Y) (0)

Dentures Hypertension (Y) Herbal Medicines ( (7) MEDS:
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
A. PSYCHOSOCIAL
Allow pt. to verbalize freely.

potential for anxiety related Pt. verbalizes any specific anxiety. xplain Or environment and answer
to: Pt. Exhibits relaxed body posture.
estio regarding surgery. Ci 5 7

1) Surgical Procedure&
. Offer comfort measures. (e.g. warrn dZS5I
Operating Room Environment
anket. touch).
2) Separation Anxiety
xplain all nursing procedures before

(Child)
t ey are • •ne. q 5 possi 8 Le_

3) Surgical Outcomes -emain with pt. INhenever possible.
O. Maintain family interface. Parents to stay with pt.

B. AERA-10 ...,./.61"-P-1;vill be able to breath without
Offer to elevate head of litter or offer otential for respiratory
difficulty during immediate intraoperative
.dtviaction due to:
phase.

bserve pt. VVhile awaiting surgery forPositioning gns of distress.
to"' 2) Effects of Anesthesia
siit anesthesia during intubatior3) Medical/Smoking Histoiy and extubation.

C. INTE9dMENT
........fr--''

PL will exhibit signs of impairment of
ze pressure preventing devicesPotential Impairment of Skin skin integrity (e.g., reddened areas).

OR table and accessories.
Intielvity due to:
eck for proper positioning and

1) Inligggeraygiwgbikty port to maintain good body alignment.*ZVI • -men
'pressure points.
3) Positional Aids
. Place ESU ground pad on nonProsthesis mpromised skin surface area.

5) ll'ooling of Prgp Solutions pre fluids form pooling.
PATIENT'S IDENTIFICATION: ( For typed or written entries
VERIFICATIONST HOLDING AREA:
).4

!: Name-last, first, middle; grade, data; hospital or medical facility)
! ID/Aller y Band

! Dentures Removed /1/(g_.441111 6-0" CAA.) ! H & P Contacts Removed f NPO inceivtiV ! Jewelry Removed
! Body Pierce Removed viA

- I Consent/Blood Transfusio9 Signed/Witnessed/Dated /1"'"
! Surgical Site/Consent verifiNDy
Pt./Anesthesia/Surgeon _ y ! Contact precautions ( (N ! Family/Friend:-,"
RM 5179, JUN 91
Previous editions are obsolete.
USAPA VI.0

8. OR NURSING INTERVENTIONS

7. PATIENT GOALS AND EXPECTED OUTCOMES
0 Check foe support stocking or ace

6. PATIENT PROBLEMS AND NEEDS
warps. if one, check with doctors.

gRCULATION . Pt. will exhibit signs of adequate tissue
D.
eck that safety straps are

Potential for inadequate tissue perfusion (e.g. color, warmth. pedal pulse.
skorrec_V-applied.

pqrfusion due to:
tt---6ffer pillow for under knees.

1) Intraoperative Mobility
1.— 0 Place and take down legs from
1;""

2) Positioning slow bilateral motion.
stirrups
3) Existin Disease

heck that rings and all bodyE4) aste-td2-0-1-Cga.
piercing has been removed.
5) H
will be transferred to OR table without 0--l-tgroient people available for

E. NEUROMUSCULAR
ifficultly. transfer.

CONTROL/
I be not experience unnecessary 4 sufe-proper body alignment.

E.I. IG/Potential Impairment of
• I atient to lie in position of

physical discomfort. •
1(rd u e to:
aiting for surgery.
omfort wh'
Pain

er support (i,e..pillows. Bath 2)
,11 Go

Intro operative Hazzards owel. etc) for positioning.
3 rosthesis
4) Positioning
table

sfer
t-/"Potential Discomfort Due to:

1,1.,ength of Surgery
Positioning
3) Arthritis

ntroduce self. keep pt informed as to
pt. will be made aware of surroundings

F. SRed- Where he. she is and what is happening.
,1—eenses
rior to an thesia induction.

Diminished visual perception orm pt. in which direction to movecio
F.I. A
will be transferred safely to OR table.
dup t,o,etrrg: nd assist if necessary.

will be able to understand instructions. e5,1pre-medicated

1) k-olearly and sIgnily.
nimize danger of injury during intraop S
_ side.

W 0 GIASSES Address pt. from'eA
____.:—.."---Potential for Decreased eriod. Idate pt.'s understanding of verbal
Communication due to: ommunication.
1) Diminished Hearin

0 Verify removal of dentures.
r_...,
.2) LangL

. .
Dentures:
4) caps
1) U2per_
5) Crowns2) Lower
3) Brk

_Ign OTHER NURSING INTERVENTIONS OTHER PATIENT GOALS AND EXPECTED OR continuation of above interventions.
G. OTHER PATIENT PROBLEMS NEEDS
OR Continuation of Above problems/needs. OUTCOMES. Or continuation of above goals and
outcomes.

k_t k\-
..."¦•••••

OMPLETE D/ADDITIONAL tNTRAOPERATIVE INTERVENTIONS NOTED.
TE
120...\ DRY
DRESSING /8,A1
D Red eeN/A
d Site: 0 Clean and Dry
SKIN INTEGRITY: Boyle P (Y) (N)

OPERATIVE EVALUATION : eepy Intubated THING EASY:
A&O 0 Drowsy
LEVEL OF CONSCIOUSNE

0 Moves Upper Extremities
EXTREMITIES

VES ALL . ; - ; . e" G-tnene SLR.
LEVEL OF ACTIVITY: D Transferred to PREPARED
•.'!i • "
pREPARED BY

vioes (114--cri A •
INTRAOPERATIVE ' "UMENTMEDICAL RECORD

. . For use of this form, see AR.40-407, the 3onent s the office of The Surgeon General.
. PATIENT :ANSP•RTED T. JPERATING hi_ .;,. 2. PATIENT IDENTIF ED AND PROCEDURE
, !II' a

IA ,..-4..,_,, . i _ .-. 0_ 4. BY-AIN.Lativ9\ G%- VERIFIED BY
. DATE /00.‘ 1,-IPIP ,rTIME PATIENT ARRIVED IN SUITE 4.. PATIENT INb100 TIME: NUMBER
6 Ivm 7 75-(/(2 /5 2- - - 6
5. PREOPERATIVE EMOTIONAL STATUS
g CALM ANX IOUS EXCITED. IN CRYING ANGRY IIII WITHDRAWN 11 OTHER (Specify)
COMMENTS: A) if;,A, ._ ...‘_-_ ...........

6. NURSING PERSONNEL

P C „W-D
ASSIGNED ''''' —RELIEF
SCRUB . .SCRUB
. . .

ASSIGNED RELIEF
CPT 6 6..

CIRCULATOR . ....... . —,CIRCULATOR INT;-
. .

7. POSITION AND POSMONAL AIDS (Specify)Pf . c;r,A• •o.Ke_cl 1-0 ad , -Pea An ..OCS,9-11f1,--01. Ar/rtS Ittekd-1--sia.o.s -.----sRe-efs /.4-c()--e r-1,1'ec-5 tvr,if ory-04.1,114-ow-e 3,--idf2.61 -/-0.0e.is (A066..-- 42eis..jg SUPINE . LITHOTOMY 11 PRONE . ... KRASKE ' LATERAL: III LEFT SIDE UP / RIGHT SIDE UP.
ce--4--vq-OtANyck,$)d ....1.)¦ --ts.,.,-‘,,-.„-„5.„‘„,;k,,,-","". 0...././ i..;.."."..2.A.: COMMENTS:
8. SKIN PREPARATION HAIR REMOVAL • YES N . ''--PREP SOLUJI(11 (Sp7ify) kbe.„Ce4s
DONE BY: • OR • NURSING UNIT SITE:01044Th JOK,/ ei,..11 0,-6, BY WHOM: UAW., METHOD: Ill DEPILATORY III RAZOR. • ' SITE:i7tej--i-N "." -,BY WHOM: 0711111111
• CLIP . _ ______,_. _eiliki_. Y i c ill,x._ (9..1i, canclk-e
i.1 .

COMMENTS: ________-__ ...COMMENTS: Ay jvc04 ),..t. -F.Se, /l47)0v7 S /7 dee/
9. LOCATION OF EXTERNAL DEVICES
— — '7::- i::
. 41111101S
H
411 -
-: -- ,-;---
--'114da°-
drill
Yif
IT lAli:27,4V ..
........14;,-.2&

#.474. .--Airkedr.-
111.Fidr,101------7 ig!.!,r,
..

111114Slir 4 .0.¦ ,
LEGEND X Ground Pad --Safety Strap = = = Toumiquet-.•.-ppep c = Correct I = I correct .
v't1 First Closi t Final Closing
10. COUNTS _--, "est I Count . :. • Cetint -SCRUB CIRCU . TOR
rimmiormins
Sponge ii Yes
lailli.Win

Needle Sharp -F11 Yes EnramINMI.
— .,,,

Instrument 1.112.97101111=Willi,_ :::.:VIO.Z:' . ')ther EIRMAIIEUP2111WAIIMMI . -- _
1. PATIENT IDENTIFICATI •N For ped or w tten entrie give: 12. 'ELECTROSURGERY DEVICE(S) (ESU) YES SWNO me - Last, first, middle; Grade • Date; Hospital or Medical Facility;)
III ESU NO:

tit.VCSLIA
GROUND PAD: BRAND
.
...,_,......

i .., _ LOT NO:
----z-/ -_

• , .... -: Er.Egl NO:
..._

4o -o-.7'--..7:GFI-OUND PAD: BRAND
. ....,,,...
LOT NO: . BIPOLAR NO:
(a. i CV .1--

5172-1,16CT 87 . REPLACES DA FORM 5179-1 (TEST), DEC.82, W.HICH IS OBSOLETE.. USAPA V1.00
.1.0°
..LIFACTUF
IF YES NAME: ID NUM

LANTS )
13. PR
ott2/ -1--

D ..rY1,5 5 _s'
IPMEDICATIONS/ORDERS YES NO

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT.BY ANESTHESIA) METHOD PR
DOSAGE .

WEDICATIONS/SOLUTION
14-44--÷,0

o
X YES NO; TYPEIS):MOUND IRRIGATION
,I V'.f.4 to
— ---CARRIED OUT Ed I
TIME el;

t
PTHER ORDERS
t . ,-4-:
F ....._
,
IF YES, SITE
""=.LABORATORY PECIMENS

1 u.
SPECIMEN (S) NAME . NAME

. . _ _

YES • N 0 /iiif
......
_ . NAME

FROZEN SECTION (FS) NAME
. ..
• SYP

YES NO
NAME CULTURE (C) NAME

YES • NO 911 . .. , .
NAMENAMENAME

. -
-18 DRESSING/IMMOBILIZATION (Specify) NAME NAME -

— ---

17. TUBES, DRAINS/PACKING YES ill NO ilf_ .
TYPE/SIZE 1. 2.

.
3.

2.
SITE 1.
19. ADDITIONAL INFORMATIO
LOC-
ity.2A1ANI-)g\W

G-en ic-1\
DR- S-1

20. OPERATION(S) PERFORMED
ejoiced ricpaohtte:,, 4,1 goys Gji(e5
-roc-44, 4_30:
/ usa.,PA v

NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS
HOSPITAL DAY POST-DAY MONTH-YEAR
DAY t) Nal 77 1
19 HOUR

k4q) ) • ' °P-h" • . . . . . . ......
J . . . Z . . . . .
PULSE TEMP. F . . . . .
....2-• •1 ,• a
•• •• • • •. . .

(0) (.) : TEMP. C
. e • -u- /....• • " • •
-

105° • • il t• .-•7 •• •• •••• .•• .
". (...-
. . . . . •• •• 40.6°
. . .
•. •. . . . .
. . . .

180 104° . • • " " ••
.... . . . . " ••
40.0°
. . . .
. . . .
. . .
. . . . .
. . .
.
. . . . . .
170 103°
....

160 102° 150 101° 140 100° 130 99° 98.6° '120 98° 110 97° 100 96° 90 95° 80 70 60 50 40 . . . . . . . . . . . . . ..... • . • . . . . • . . • • . . .......... ..... . . • . . . • •. . . . . . • • " • • . . • . . . . . . . . .. ..... . . • . . . . ••
• . . . . . . • . . . . . . • • ..... . ..... . •
. . . . . . . . • . ... . . 6 4 . . ¦''. . • . . . . .. . . ..... . . ...... . . . . . . . . . . . . • . . . . . . • • • • . . • • • • . . • • .• • . • . . . . . . . . . . . . . . . • • . • • • • . " ., , . . . . . . . . . . . .. .
• • . . . • ... " .. . • • . . . . • • . • • . . . . . . • . . . . . • • . . • • • • • • . . • • ... • • . ) . . 1 . . : . 0 .. • . . . . . . . . . .. . . . . . . . . .
... . . . . . . . • • . . . . . . . . . . . . . • ...... ..... 0 .... ..... . . . . . . . . . . . . . . . ..... ...... . . . . . . . . . . . . . . . . . • • . . . . • . • . . . . . RESPIRATION .., RECORD .1 . IV .. 2. . f . , . S' 0 ; I :12 w 13 8 . . ca) -.-. . Do..0 To .(16;au) 76' a cc ,ATIENT'S BLOOD PRESSURE /3 14 P/5110741 li ' r 5 gin cirpl,-;.0HEIGHT: WEIGHT ..-••••• 1 ria RA iqtr,,,,i. . • crz..,z. "?‘.4VA. fflii--./V67,) IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) . . . . . . . . . . • . •. . . . . . . . . . . . . . . • . . . ... . . . . . . . . . • . . . . . . . . . . . . • . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . • . . . . •. . . . • . . . . . . . . . . . . • . . . . . . • • . . • . . . . . . . . . . . . • . . . . • . . . . . . . . . . . . . . • ... . . . . . . . • . . . • . . . . . • • . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . • • . . . . . . •. . • •
. • . . . . . • . • • • . . . . . . . • . . . . . . . . . • . . • • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • ... .. . . . . . . . . ... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REGISTER NO . . . . . . . . . . • . . • . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.4° . . . . . . . . . . . . . . . . . . 38.9° . . . • . . . . . . . . . . . . . . . . . . . 38.3° . . . . . . . . . . . . . . . . . . 37.8° 37.2° 37.0° 36.7° 36.1° 35.6° 35.0° • • . . • •. . • •. . ...... ..... . ...... .. . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . ... . . . . . . . . ... . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , WARD NO. S's, c o a)o c 2a) a)cc 8 ai ca.) 71)-. g1.1.1 i to v.: ca)c.)
VITAL SIGNS RECORDS
Medical Pecord
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 23363

DOD-036939

Q,c4iik40---) 00, ....3 .11.Q.-MEDICAL RECORD -ANESTHESIA
1(,:., o use ip .41i) form, see AR 40-66; the proponent agency is the OTSG Alq Fr
1)0^

DR 1 • ' f )
writerhimrou
Dortmemlii
t

TOTALS TOTAL EBL
i
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(Units)
1 00 —
100
-,

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TOTAL URINE
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MA 11 2% I I I I I I IPA
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.

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lifg/DOIN/DIN -siiNnAd133dS sonua03 1V3d311/9110fINIINO0
NOISIUNI INVISNO3= .1.
, . . L.,....

VOLAT
MC-91/M111
FLUIDS -SUMMARY

% del I, 0 *MEM I ' 11111MBILIT
_
% e.t.
CRYSTALLrbo
AGENT
AIR L/min
COLLOID-
N20 L/Min

02 L/Min /0 -7 '-'2 '7.----2-- Z.-1-/ i °
B 00D-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
IMMIaltarffir 'r4 Warmed
• Warmed
R MARKS

iffrillriallill
SCO' Code drugs with numbers,
.
en ith lettters
El Warmed
t2,

1=1 Warmed i
IN 1 . /
EST BLOOD LOSS
'

LOSSES
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i
'•-• 0 Cr( '

PH S STATUS
TIME . P '
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SYMBOLS:
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. , . , , , .
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MEIN111111=1•111=11111•1111 , , INIMINE1111111
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Heart rate
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INITIAL DATA: •
. 11 1 11 1 fi.„ Vc

111111EM111111111111/111=1 , , terAiginiaa ,

140 isionwriwinsmpropamium. . . ,
Resp rate

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OK?-N TOURNIQUET 60 . , .
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PATIENT RECHECK T -.„T" 1011-'-'- .-___
40

OK for
PROCEDURE? NES-X-X ...1 EMilli-'—r-'
' ' '

2° MIME ' '
MIIIIMIIIIIMIIIINIIIIIIMMINI1111111111
PROC-0_0
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TIME-
.

VT -ml daCilli 0 el a
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MODE - SO on), Alssist). Cion) RECOVERY AT %BP/Auto Cuff 0 ET CO2 (torrf
1111 33
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PP/oth 2 02 (Frac or % an. 1 TIFIRMISR1,,a_LI__ A Mai
ER

IART line I p02 (%) Willid11 ffn2117:11 ic.X...) 0 MA 611LIZIEFOIMIIIIMIIIIIMIONII
ONDITION: ow
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Gas analyzer EMP-site e In a pi •
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Mark with letters & symbols, EVENTSexplarn under REMARKS Position fraNIMKW-11I ". A a_-1.-. M-4. (51. 111/111 165°11EM-
PROCEDURES and CPT Codes: , fl ANESTHETIC TECHNIQUES: Mribe block technique under Remarks
A,),oI

Itt-i-C-i• PATIENT I N FICATION: Typed or writ entries: Name, Grade/Rate, AIRWAY MANrA,..E4NT-ntub don route, Wade, tech ique, comment*. 7 s--
/21•432“1- _A SCEL. IC_ .4— . C,-)oi A_ .: -.1.o6 0 SoS

Medical facility V X.
\VI- 1
su •o
:o PROCEDURE z ( z LOCATION:
*'o
er-i-Ci 4--So DAT s
6 0
L Ll' -1--
k
PA GE OF
NM
PYA- T USA PA V1.00

DA FORM 7389, FEB 1998
ANESTFIFSIA PLAN OF ARE PRF UORAL ASSESSMENT (Sedation/. Ihesial
Age 2..5 DAYS MOS Yr Sex (-'6-VIALE ( FEMAL
PROPOSED PROCEDURE: al (WA 4 SURGICAL SERVICE:
1ALLERGIES:

NPO SINCE:
HABITS: TOBACCO:
-2C120
ETOH:
DRUGS:

CURRENT MEDICATIONS: ( )= ordered as premed
PFiEMEDICATIONS:
None Yes (4it Hrs) /CC mg P/ IM PO mg IV IM PO mg IV IM PO
LABORATORY STUDIES:
U/A: OTHER: PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
Cardiovascular:
Hypertension Angina N Y I y
MI
CVA
Other
Pulmonary System-
Asthma N Y
Bronchitis/URI N Y
COPD N Y
Other
Renal System:
Actrte/Chronic R N Y
Gastrointestinal:
Hepatitis
Hiatal Hernia N Y
PUD/GERD N Y
Endocrine System:
Diabetes ?sr' Y
Steriods N Y
Thyroid N Y
Neurological:

Seizures /fiN Y
Neuropathy N Y
Other N Y
Gynecological : Pregnancy /3)/I-Other Significant Hx:
N Y

N Y Familial HX
ASSESSMENT
PAST SURGICAUANESTHETIC

HYSICAL EXAMINATION
BP OM RoSalk 99-
Pain ale 0-10 HEENT - Teeth . Trachea 41"4-,4 0A--0
TMJ/Neck reor,
Orophamyx yki Nares CHEST: T-011./-3
FO
CARDIAC:
EXTREMITIES:
ni Access:
Ulnar Filling:
BACK:
OTHER:
NPO Since /5 ISO t.cfJO

ANESTHETIC PLAN: { } LOCAL ( } MAC ) Regional (Specify): (C).-M-Ileral: Mask ubation
• aa A I AI: 11141 rid
INFORMED CONS /COUNSEL11# STATEMENT: Plans, attematives and risks IF anesth ia including death have been explained to and qf
discussed with the patient/legal uardian.
—1.—

The pa rstand and ag ees. Questions answer.
iff-) Pc

Sig ikfigke: co 00 Time: jcZ_ Hrs
(NON ASU) SEDATION KEY: ANESTHETIC COMPLICATIONS { OTHER
1.
MINIMAL (Anxiolysis) Patient responds normally to verbal commands

2.
MODERATE (conscious sedation)

Patient responds purposefully to verbal commands alone or accompanied by light tactile

Patient Identification: (Ward)
stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following rePeated or painful stimulation. Ainvay assistance may be necessary.

allirta)
4. ANESTHESIA. Patient does not respond to painful stimulation.

WAMC Form 2300 (Revised) 15 Mar 01 MCXCDOS Previous edition is obsolete
ANESTHESIA SERVICE RECORD 'US. GPO: 2001-629483/40002
•
MEDCOM - 23365

L -1/41\ L.)C\VL S-73 (k,N.c...;,-i7C.C:.
CLINICAL RECORD - DOCTOR'S ORDERS
Ck

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.
1ST TIME DER

PATIENT IDENTIFICATION DAT OF ORDER TIME OF ORDER
NURSING UNIT ROOM NO.
I t
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
ow°
.c)% NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
DA ,FLR.^479 4256
1¦)011 0 3 ‘52_, HOURS AND
BED NO.
tP C2) HOURS
BED NO, DATE OF ORDER CD3 TIME OF 0 HOURS 4-t)
TE OF ORDER TIME OF ORDER HOURS

BED NO. 67/
REPLA DITI 77:7CH MAt:Y,M,.OF 1 JUL ‘,V VC) ViV1 f°"4"/",
iAM-141-1P1 NO V 0 cs 1V Lrfetelf6W

MEDCOM - 23366

DOD-036942

...EDICAL RECORD -DOCTOR'S ORDERS
t
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
100003 I --/ .0 POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharee.

1:3:
Supplemental oxygen. '' So_O-z.. C—CtS - '70 r, 2a

3 Morphine / Meperidine nig IV now and nig q 3-5 min pm pain for a
p \
ma_x dose of mg.
l''t_ 67-e...)--Z­

4. Zofrantl ming IVI pm N/V q:5 inin,xmay-repein-*---.--
/11 i I? 3`u
.1-731-..

X Droperidol mg IV prn N/V x 1.
' 41..7
-.,...„--Phenergan mg IV prn N/V x 1.

t 7 3
-

____" Benadryl 25-50mg IVP ql hr prn,-itching while in PACU. 9 IVF: (4)-17K-Occ/hr.
.c__ t____Je-----
,
:1'7 3 t

Discharge from recovery status when PACU discharge criteria met.
-......
-,
. . 6ltiL)-L

PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any changes on subsequent pages.
Diagnosis:
Height: Weight: Diet:
111118
Allergies:

6 ( q.,, -1
g
Nursing Unit Room No. Bed No. Page No.
— — 28th CSH 1 of I
MEDCOM 23367
-
.

DCOM FORM RRR-R irtnrum nitAD 00 DDC%/1(11 C1,11-1111•In rtr
DOD-036943

-12v-1
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 IGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
ROOM NO.
NURSING UNIT
PATIENT IDENTIFICATION
ROOM NO.
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT ROOm NO.
PATIENT IDENTIFICATION
1ROOM NO.
NURSiNG UNIT
DA 4256

1 Fo"
APR 79
LiST TimE
TIME OF ORDER
OATE OF ORDER ORDER NOTED AND
6)____\a5y
1 \/ 0'3 SIGN

• 0
111 c.. _ .. If ___— -_ .... .. is.:_. __
iII11-1 "i`liblIL ......¦ - ....... 4 A iii

-___.!
Aka" ...,.. if __-_.¦,c-_­
INIII
, 3-vey___,,,--i--.0_,Ljr--ArSLSLIN. . (5-6
.
_c›,....)..)&,-
-
TiME OF ORDE
0 • •
DAT:t4
-I Z3C_,
I/

BED NO.
TIME OF ORDERDATE OF ORDER
HOURS
BED NO.
TIME OF ORDEFI
DATE OF ORDER HOURS
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23368

DOD-036944

_
-MEDICATION )

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON
For use of this form, see AR 40-407; MO.oYr. 2003

CLINICAL RECORD
the proponent agency Is the Office of The Surgeon General.
INITL4L PR 0 PER COLUMN FOLLOWING EACH COMPLETION

VERIFY BY INITIALING .;'W,A ' .c, Airr0 WV:SRW:4"5'' T.:0
DATE COMPLETED
CLERK/ RECURRING ACTION,

HR

ORDER
DATE NURSE FREQUENCY, TIME S'
ii. , V---// 4--..._,,_ z; 4_ I
lit —.0ii iftl' s -i Feriffi,r1 VIIMM

111111""-IMMINIIMINIIIIr '1111111211M11111111111
NI MIMI
IL JI
.

://45. 11--1 .4(/ _. Ati---)z)
, vvii
Ikku ),,..) Qck,,,i-,,, -11141
?eo,—
i , I

v\-. '1kb ir
1

.1\
11111t--1111
. 11.-1 '')
1 -

IMPIIIMIOIIILI ,, 1 rio
P 103
G"-:rt V'.cu.L.Wer .Gt., N0
..D --
e C-. \ +1 Pt 5
: I( 1?—)TS D(C—A--D

¦ c, ¦ ickl-t
ADDITIONAL PAGES IN USE:

ALLERGIES: MI YES , NO PRIMARY DIAGNOSIS: 0 F--
r c MI YES MI I N o
5 .1" C-- 10911s (Mr-arlik
1 r
PAGE NO'

k.,_%__. 0 6' Z.- 4 - GLeo, e - -
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19''20 21 22 23
N 24 01 02 03 04 05 06 07
____...................._ •••••• ••••./flii, • Ic•rm USAPA V1-00

DA FORM 4677, 1 OCT 78
MEDCOM - 23369

DOD-036945
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing ( NON-MEDICATION) mo A----1")-1-1 Yr .2003

order Clerk Date to Time to
Time Done Initials
SINGLE ACTIONS
be Done be DoneDate Nurse

. . I V
/ /G /V1/11--(--'11: --2 4 t( te.-) — I (-21 Nip) % i 1?—..5
4 -"M":"Y
i/ 07
((,' Wil /)) /-'41( 6e A ,""-(" C-
i ki

/4--„,d:d7-„ p a -A
t LP 1:). (1, --\-ft) NCLA -* --a-Z-.) 1--I 11 to — li‘ 3C)
Th(f CD_° -"?._ ' fkn\
- —
_ - _ _

- - -—

Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerkf

Explr PRN
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED – – – – – _ – –
– _ _ _ _ _ _ _ – – – – — –
– – – – – – – – — — — –
– – ... ,,, ..
... ... .. ..
... ... .. ... ..

..• ¦ ¦ ¦.. ¦• ... ... mm
MEDCOM -23370

DOD-036946
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
For use of this for _,
m see AR 40-407;the proponent ency is the Office of The Surgeon General. Mo. 1 / Yr.

VERIFY BY INITIALING .
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

, in -1 1 9
/ -i ee---ci cr) ' -,. Li i ,, / _ -2 An'
-/-:IP . i Arri, , r 7 i -.ow -
—

IF--niqoez2.11.,o
— -:3:1\1 i 141– --Zi- \I -Mei\ e--
DI C (:;---lherl eh nci cc_
( rrh-vb e 4e
, -. ..
it ,_
0 5
11.1 -

- -... \1 Q S ko 1
x. 0

6( (-E„..----2___ 1\--"\\
.

ALL ERGI EU p YES patIO pRImARY D Ar3NOSI..
ADDITIONAL. PAGES IN USE:5 n--1 rl d k b(e _)(.-0 YES 10 NO / -
,r65,_,d) Ireckuic-rto-,, 04- ex k,4,,,,,p

4).4)12. ‘---4:-,k/Z "/; --,L. PAGE NO
/7rZPATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES
NM
D 7 8 9 10 11 12 13 14

L.( (.12- —L4
c , c az ,, •., .... __
RS IY 20 .4 21 22

N 23 24 01 02 03 04 05 06
A 1 FEB 79 4678 EDITION OF 1 DEC 77 WILL BE usBn lam,

F"M EXHAUSTED.
MEDCOM - 23371

DOD-036947

THERAPEUTIC DOCUMENTATION CARE PLAN 71/1/
.0
(MEDICATIONS)
Time to Time Given Initials
be GivenSINGLE ORDER, PRE-OPERATIVES

owe /L cL120e Delver
/Y
COLUMN FOLLOWING ADMINISTRATIONINITIAL PROPER

w
PRN TIME/DATE DISPENSED

Order Clerk/
met e MEDICATInN, DOSE, FREQUENCY
E3rcar
Do
••••••,....,
-1 org cb 1 3o ti‘i
......
0
MEI
U.S. GPO: 1998-454-110/95216

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this torn see AR 40.66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED Ward
REPOFIT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet
/ i JO L /-.,3 Anesthesia Type (Circle pinal Epidural Drains Ai rvray Time In: / -11 c-' IV ation Nerve Block Hemovac Nasal Allergies: OR Intake: Crystalloid .11:5N-N) Colloid NG Oral Pre-op V/S: t3h t4-1,4 . OR Output: UOP EBL JP ETF Date:
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Procedures: Meds/Times: 2 rt 4, L/ L-R-4.-5,3 T-tube Trach
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Other
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Pre Op Keds History
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Time f`-' Ki Cil '''.
Pacu Intake
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Time Solution Amount Site • By Infused
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Methods ?.. re. 0,4,3 ao Ap 0)) 240

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220 X-rays: . Labs:
200 180 160 140 120 100 80 60 40 20 ta(‘' RR T II5 NI Igi 0 f"2-0 /gR Cfk 77 77 5.‘ To 71 g't • 0 ri-2443-tto-k. I 1'1 g 3° 16 n -N. iS-lc,-- . Post-Anesthesia Recovery score Criteria ADM 30' DfC Activity (2) Moves 4 Extremities (1) ktoves 2 Extremities (0) Moves 0 Extremities 2-I Airway (2)Cough. Deep breath (1) Dyspnea. limited breathing MAPnea 2.. -2. ).., Blood Pressure (2)SOP =/- 20 of Pre-op (1) SBP 4-20-50 of Pre-op(0)SBP=/-50 of Pre-op 9-)---, Consciousness (2) Fully Awake, audible crYing (1)Arousable to verbal or pain ( 9._ 2-, Color (2) Baseline odor a appearance (1) pale. mottled, jaundiced (0) Cyanotic 2., • Circulation (Peds 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse TOTALS: Must be 9 or greater to D/C, olhenvise needs anesthesia approval for D/C. / 1 Codes AIRWAY A =Ambu BB = Blow-by M = Mask FT = Face Tent RA = RoomAir NC ...Nasal Cannula yrs X =A-line BP " =Cuff BP . . Pulse TEMP S = Skin 0.0fal A = Axillary T =Tympanic R = Rectal LOS . . C = Cervical T = Thoracic L = Lumbar S = Sacral
Time Pain (0-10) LOS Patient teaching done; Wound Care, Pain Management. T, C, F. DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained on mue on reverse
P P DEPARTMENTISERVICEICUNIC DATE
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PATIEN first, middl ed or written mules give: r medical facility' Name - Us& HISTORYIPHYSICAL D FLOW CHART
OTHER EXAMINATION El OTHER Porarr
OR EVALUATION
[3 DIAGNOSTIC STUDIES
[3 TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USOPC117.00
MEDCOM - 23373

DOD-036949

MEDICATIONS
NURSING NOTES

Allergies: Time Pain Medication & Route Pain UE By 1-10 Dnsane 1-10
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IP

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion Adm 15' 30' 45' 60' 90' D/C
Movement/Sensation: + =present,- =absent Temp:C = Cool, W=Warm Pulses: P= Palpable, D = Doppler. A =Absent Color: C = Cyanotic, Capiltary Refill: B = Brisk, S= S uggish P = Pale, Pk =Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C Furid:14eight
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Lochla
Peripad#
Fund. Cond.

DRESSINGS Location Type Drainage
Time ----..____________.
Adm •

----___________
30'
----___________

60' ---.........,..........„_

D/C

PACU OUTPUT
Time Source Color/Appearance Amount

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? ip,,,,c-s ,s-„,,• 1-:-• ,
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WAMC OP 173-E
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Discharge Criteria:
Datellickik:1 Time: th-q- PARS: 0
BP: TA("d- RR: ) Sa02:
Pain Lette'l at D/C (0-10):
Intake: 3.• — 0 Output:
Additional Data:
Transferred To:
Report Given To:
Transferred Via: W/ Ambulance
Transferred By:
Cleared IAW Reco
Charge Nurse Signatu

1. Reporting MTF 2. MTF L--t)u.. Admission al id Coding Information
IZ For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
b kiiz/ , FGN M

6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
25Y X 9

11. FMP 12. Social Security Number

10. Length of Service ETS
99

(A
((-0--—

Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
09:05

16. Zip Code of Residence: K78-PRISONER OF WAR/INTERNEES 14. Flying Status 15. Beneficiary Category 19. Trauma Prey. Admission
17. Unit Location 18. MOS
DIS NO

Name / Relationship of Emergency Addressee20. Source of Admission Ward: Address of Emergency Addressee

Direct from ER ICW 1
Telephone Number of Emergency Addressee

Name and Location of Medical - - I. --ility:
iip (1) --1—

21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-OTH

2003-11-09
011/

24. Clinic Svc -Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD) -ABF -ORAL SURGERY
2003-11-07

28. MTF of Initial Admission 29. Date of Initial Admission 2003-11-07 27. Location of Occurrence
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: S/P CLOSEDREDUCTION OF MANDIBLE FX

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Procedure Narrative(s): • I tC\ !
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Cause of Injury Narrative:
-

Admittin • s required) Signature of Admitt'n Clerk
Automated Facsimile " IN. ATIENT TREATMENT RECORD dER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
1. ' ter Nbr 3. Grade Admission Remarks FGN
4. Sex . M 5. Age 6. Race X 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm NO ,
-1
11. FMP Wan 13. Organization 14. Ward
99 ‘9 U.t.: L'i -
. 15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case
K78-PRISONER OF WAR/INTER BC

23. Clinic Service

21. Source of Admission 22. Hour Of Adm:
00:55 ABA -GENERAL SURGERYDirect from ER

24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp EXPIRED 2003-11-07
1

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: Admittin•Officer: 2003-11-07 b( Le---11
29. ReportingMTF 30. Date !nit Adm 32. Units Blood Components 2003-11-07
1110111111111111111114 ( -1--4.--.
31. Selected Administrative Data

Marital Status: DoB:
In/Out Patient: Inpatient mbs:
33. Cause Of Injury:
.

34. Diagnosis / Operations and Special Procedures:
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35. Total Days This Facility Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
0 0 0 / /
35. Total Days This Facility

Absent Sic ther Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sic! Days
_a ____O 0 _____/ _________ _ _. .
ing Medical Officer Signature o PAD
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-A FORM 3647, May 79
MEDCOM - 23376

DOD-036952