Medical Report: 25-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wounds to Face, Pelvis and Hand

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litl;UKLI -ANESTHESIA
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1 AIRWAY MANAGEMENT)/n
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11

SURGEON
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/-1 , 1.1 2 Seal 0•3 CPVitkr 1 PAGE '' /CF
DA FORM 7:1Rci PPR 1 acia ..—
NIL LiCi(J117
DOD-032015

MEDICAL RECORD - ANESTHESIA
For u
.tis form, see AR 40-66; the proponent agencN, OTSG
ci) cc) DRUG f:(:Q.'.66).: : :
cq. o _..i TOTALS I': TOTAL

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LOSSES :.
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explain nodes REMARKS Positron ) cr
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ci., ANESTHETIC TECHNIQUESPROCEDURES and CPT Codes:
Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or mitt el r s. Nam e rade/Rate, -
AIRWAY MANAGEM
bat n I. e
e, ech ,que, commentS
, y
SURGEONS:
PROCEDURE•.-----
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LOCATION:
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DATE:
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DA FORM 7389, FEB 1998 RAF nrnnii _ 1 RA -- -Ay* t
-
P'ATIB[ S MEDIC
E RD USAPA V1.00
DOD-032016

MEDICAL RECORD - ANESTHESIA
Fr
I this form, see AR 40-66; The proponent agen
± OTSG
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TOTALS \if/if 5
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.
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( 32)
% del
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:AGENT::
% e.t.
AIR L/Min
N20

DIS
02 L/Min -P_
SINGLE DOSE DRUGS-MARK ON GRID .
WITH NUMBERS & ENTER IN REMARKS

BLOOD-
LINE site
.
Warmed
(0, ac

. Warmed nEma

.
Warmed
OWarmed
EST BLOOD LOSS

URINE -
:iPtiY.4:017 AT.V.4. ::::;.

TIME
SYMBOL
BODY vs/mHui, 220
BP by cult
200

V
A 180
Heart rate
160
tN (DATA; •

Resp rate
BP-
BR
(transducer')

EctutP.;:pHEG.K, 80
DV-
TOURNIQUET 60
pAt,IEkr: geHgcks
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PROCED

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TIME-PROC. e_0 I

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Peak int pres / PEEP

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Reedy End
Position ("J
PROCEDURES and CPT Codes: 0. C)E4
ANESTHE

TIC TECHNIQUES:
Describe block technique under Remarks /
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rare,
AIRWAY MANAGEMENT:
Medical facility Intubanon route, blade, technique, comments
PROCEDURE LOCATION: (-)-e DATE:
A
DA FORM 7389, FEB 1998 PAGE OF
EDICAL RECORD USAPA V1.00
MEDCOM - 18443
DOD-032017

. ii LI
•1 • I I Age "9 DAYS MOS YRS
Sex (.)--MALE ) FEMALE ASA Physical State 1 20) 4 51r
PROPOSED PROCEDURE:
SURGICAL SERVICE: •)-WT: KG/LB HT: c) ' I .
NPO ALLERGIES: /O(C i -JR—

HABITS; PREOPERATIVE
TOBACCO: f)
PAST MEDICAL HISTORY/SYSTEMS REVIEW ASSESSMENT
""Z ETOH:
Cardiovascular:
PAST SURGICAL/ANESTHETIC
DRUGS:
Hypertension
• AnginaCURRENT MEDICATIONS:
MI N Y ( )= ordered as premed
CVA
N Y Other N I Y
()
Pulmonary System:
() Y
Asthma
()
Bronchitis/URI PHYSICAL EXAMINATION
() () () PREMEDICATIONS: COPD Other Renal System: Acute/Chronic RF Gastrointestinal: N9 T Y U2V3Z1tS) (e),r3-• BP HR . Pain Scale 0-10 HEENT - Teeth Trachea R T _
None Yes (0 Hrs) /CC mg IV IM PO mg IV IM PO mg IV IM PO Hepatitis Hiatal Hernia PUD/GERD Endocrine System: N N N Y Y C kj,51-61-Q, !LW CHEST: TMJ/Neck Oropharn Nares
LABORATORY STUDIES: Diabetes Steriods N N Y Y CARDIAC:
HB/HCT: WA: OTHER: Thyroid Neurological: Seizures Neuropathy Other N N N N Y Y Y Y EXTREMITIES: IV Access: Ulnar Filling:
zo Gynecological : Pregnancy N Y BACK:
3, 0 101 rt , iq7 Other Significant Hx: N Y OTHER:
N Y
p3.7 39• Familial HX ()--S(• N fr-E14:_a_Qp NPO Since

ANESTHETIC PLAN: { } LOCAL ( ) MAC
( } Regional (Specify): ( I-General: Mask Intubation
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternativ
discu ‘ and risks of anesthesia including death have.been explained to and

Trit
he pa ent/legal guardian. t-i-t1) 17
The pa -‘
agrees. Questions ans
CAL
Signed - • e.
-a-Date: 7-- :..74.---'62„
Time: C-3 &C-)
Hrs POST-ANE THESIA EVALUATION AND N •
ASU)
SEDATION KEY:
) NO APPARENT ANESTHETIC COMPLICATIONS { ) OTHER
1. MINIMAL (Anxiolysis) Patient
responds normally to verbal commands
Signed:
Date: Time:
Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or Patient Identiftication: (Ward) accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient re4otnis purposefully following' repeated or painful sti rrn= Airway assistance may
be
rY. -ok_ 4. ANESTHESIA. Patient does not respond to painful stimulation.
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS MEDCOM - 18444
Previous edition is obsole e
DOD-032018
. la al
• 11.761. 1.16,, •
Age-DAYS MOS
Sex MALE f)FEMALE--
PROPOSED PROCEDURE: ASA Physical State 1 2 4 5 E
1-g-0.12 I1 E06-1-co-u-t 2 Ac,-21-1*
SURGICAL SERVICE: e oiutF WT: KG/LB HT: IN.
NPO SINCE:

ALLERGIES: AW4(.1-
HABITS:

PREOPERATIVE
TOBACCO: PAST MEDICAL HISTORY/SYSTEMS REVIEW ASSESSMENTETOH: Cardiovascular: PAST SURGICAL/ANESTHETICDRUGS: Hypertension
CY 1Y FAITce, ii2 0 6' LL ,}
Angina
col-op Ad,4,,.?,
A c4..s., ..zspo 5
CURRENT MEDICATIONS: MI
I x P LAPiLez7t,1 '
( ) = ordered as premed
CVA
Other

0
Pulmonary System:
( ) Asthma N Y ra-L C014 go
Bronchitis/URI Kr_ Y I
( ) T) E.c IAD 'Flo I-3 • COPD N Y ty PHYSICAL EXAMINATION
() t BP 4 1 HR 7 T

Other R _
0 CE-16,6E;,26- Pain Scale 0-10
Renal System:
,t-m / ir;EN,3/44._
T-f_go oi_ PA,.1 HEENT - Teeth
Acute/Chronic RF N Y /0
PREMEDICATIONS: Trachea

Gastrointestinal:
None Yes (0 Hrs) /CC TMJ/Neck
Hepatitis N Y mg IV IM PO Hiatal Hernia N Y Orophamyz mg NIM PO PUD/GEFID N Y Nares CHEST:
mg IV IM PO Endocrine System: C-r Pt Diabetes
N Y
LABORATORY STUDIES: CARDIAC:
Steriods
N Y
•
Thyroid N Y
HB/HCT: EXTREMITIES:

Neurological:
U/A:
Seizures
N Y
OTHER: IV Access:
Neuropathy N Y Ulnar Filling:
Other
N Y Gynecological :
BACK:
Pregnancy N Y
14/0 toi-= ,1 Z Other Significant Hz:

OTHER:NY
`t.
139
NY
CiZeO• b 3
Familial HX
N Y
i C14.
62 Z
NPO Since
ANESTHETIC PLAN: { } LOCAL { } MAC et/
{ Regional (Specify):
(+`} general: Mask Intubation
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia
discussed with the patientfiegal guardian.i, including death have been explained to and

The patient legal u
rstand and agrees. Questions answered. Signed: I , 4
Date: 011()E/1 63
Time: .X 5-.5-
firs POST-ANESTHESIA EVALUATION AND NOTE (NON1ASU) { NO APPARENT ANESTHETIC COMPLICATIONS { OTHER
SEDATION KEY:
1. MINIMAL (Anxiolysis) Patient responds normally to verbal commands
Signed: Date: Time:
Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or
Patient Identification: (Ward)
/C accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful
elm \oL AM%
stimulation. Airway assistance may be necessary.
4. ANESTHESIA. Patient does not respond to pairdul stimulation.
Previous edition is obsolete WAMC Form 2300 (Revised) 15 Mar 01 itICXC-DOS MEDCOM -18445
DOD-032019

vc...z.,--1-1,4"---•
518-124 NSN 1540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red S'OCRI Co
REQUESTING •H
Products we requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA TYPE ANO SCREEN
E
Li
DIAG PLATELETS (Poo, of units) )23r L,R OSSMATCII
LJ CRYOPRECIPITATE (Pool of units)
DATE REQUESTED I have collected a blond specimen on the below
a Rh IMMUNE GLOBULIN S
named patient. verified the name and ID No. of the DATE AND HOU IRED oat. ent and verified the specimen tube label to lie OTHER iSpecify) correct.
VOI. OW REQUESTED (If applicable) • KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNA
REACTION fSpecif)
ME
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhiG TREATMENT? DATE GIVEN: IRE°
I ICMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO TRANSFUSION NO
TEST INTERPRETATION . PREVIOUS RECORD CHECK ANTIBODY SCREEN CROSSMATCH
1_1 RECORD
Dqc54,5 PATIENT NO i) -11.
.NA C o e('
DONOR CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ
ABO ABO
6
REMARKS:
Rh Rh

oS pos
SECTION III - RECORD OF TRANSFUSION
PRETRANSFUSION DATA POST•TRATI"
".;Ski ()TED AND ISSUED BY (Signdlui --rsitMOUNI GI "N TIME/DAIL 1NIPLETF --ANT ERRUFTED
ML off-03
TEMPERATURE PULSE!
BLOOD PRESSURE
AT (Hour/ IS C.) ON (Date) 2: ONE ID SUSPECTED

IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
have eLaitimeo the Blood Component containe: Label and this form and • find all
1. Discontinue transfusion. treat shock it p¦ fiscal!. keop intravenous line 01t1
int crinetior. identifying the container with the intended recipient matches item by item. 2. Notify Physiran and riansfusion Set VICI,

•ecipl'ent is the same person named on this Blood Component Transfusion Font, And 3. Follow Transfusion React on Procedural. on :ne °anent Identification tag
4. Do NOT distort, unit. Return Blood Bog. Filter Set. caici I.V. solutions to the Blood Bank.
1st VCRIFIE11 (Signature)
DESCRIPTION OF REACTION
liRliCARtA
CHILL • FEVER L PAIN
[3 OTHER (Specify)
OT R DIFFICULTIES (Equipment. clots. etc.!
NO LLII YES (Specify)
TE S I PULSE (C)
DATE OF TRANSFUSION TIME START
Cleir1141
C-4 °--;
PATIENT IDENTIFICATIOT --USE EMBOSSER (For typed or wntten entnes give: Name -•L rate: hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM SIH (Rev. 9-92)
Prqscnben Ey (ISA/It:MR. FIRMA (41 CFRi 201-9.2112-1

MEDCOM - 18446 Medical Record Copy
DOD-032020
NS/4 7 540.01-155-7294
591-3(
RADIO
• A1C CONSULTATION REQUEST/F SRT
( Radiology/Mx
3d/eine/Ultrasound/Computed Tomography
EXAMINATIONS (S) rations )
UESTE...;
AGE SEX SSN ...-
(Sponsor)
WARD/CN
REGISTER NO
I...c,t..4
_ .-r.
FILM NO.
PREGNANT YES . NO
REQUESTED
TELEPHONE/PAGE NO.
DAIE_IRE(OlUgSlieD
SPECIFIC REASON(S) FOR REQUEST
(Camp/aims and findings) t-
DATE OF EXAMINATION ( Month, day, year)
DATE OF REPORT
( Month, day, year)
TE TRANSCRIPTION ( Month, day, year)
1
RADIOLOGIC REPORT
PkV, TENT'S
IDENTIFICATION (For typed or written entries give :
Num,: - luvr, first, middle, Medical Facility) LOCATION
LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC
SIGNATURE
RADIOLOGIC CONSULTATION
STANDARD FORM 519-B is
REQUEST/REPORT -sal
1—Prescribed by GSAJICIVIR
MEDICAL RECORD
FPMR (41 CFR) 101-11.806-8
MEDCOM - 18447
DOD-032021

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD 1 CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each entry)
\I
0 . 51.-..?v8,2,T AN-7, ,•;, ) .-N1,...) /L.:. ,, ,Ltiri. • 10,• lar--: 5-,.1-
T P )44 4-t6. ,\Z 4 ev.4-11- 2.45) e, c; 7 c.4 c4 iss 0
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nc
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tP (-,436i:1"--01, 1.1111c_c4
cs„...\. etNc....,;t
5u. ... - 6+•.-Vj ''
'404
..,... .
HOSPITAL OR MEDICAL FACILITY STATUS DEPARTJSERV ICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle,
-ID No or SSN; Sex; Data
REGISTER NO
of Birth; Rank/Grade.) NO. WARD NO.
I
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97)
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 18448
DOD-032022

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

HOURS
C'19 c3
SP PNI
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
c urs ‘1 ,1-(5)(4 i1314
PATIENT IDENTIFICATION
TIME OF ORDER

HOURS
NURSING UNIT
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER TIME OF ORDER
HOURS
(-\ ,
NURSING UNIT ROOM NO, 8ED NO.
z FORM 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED
1 APR 79
U.S. GO' MEDCOM - 18449
DOD-032023

CLINICAL RECORD - DOCTOR'S ORDERS
For -if this form, see AR 40-66, the proponent agenc•• OTSG
THE DOCTOR SHALL RECORD DATE

AND SIGN EACH SET OF ORDERS. IF PI
IA ORIENTED MEDICAL RECORDSYSTEM IS USED, WR/TE PROBLEM A
.R IN COLUMN INDICATED BY ARROW BE,
PATIENT IDENTIFICATION

DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
oe HOURS SIGN
-CT 7L' e S-cv 11-1c 1 /7 4 ck.A.-rLstr? e_
NURSING UNIT ROOM NO.
BED NO.
3--ak.44-L

PATIENT IDENTIFICATION
DATE OF ORDER
NURSING UNIT ROOM NO.
BED NO,
a,t-41/
PATIENT IDENTIFICATION

ATE OF ORDER
TIME OF ORDER OSI S
HOURS
NURSING UNIT ROOM NO.
BED NO.
U:4 1 PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
Q 2-
FORM
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

DA 4256
1
MEDCOM - 18450
DOD-032024

MEDICAL RECORD
PROGRESS NOTES
DATE
c&Atc,
Cr) (71,0ci
suc. ensu-Th
(Do
(1)
—C2
• . PATIENT'S IDENTIFICATION lFor typed or written entries give: Name • last, first, middle; _ ---grade; rank; rate, hos Mal or medical facility) . . _ •-. -Continue on reverse side) REGISTER NO. •
PROGRESS NOTES
IVIR dicar Record .4,
MEDCOM - 18451 _77 -SfATIE11 14Ofr.(51i4,1-SOS '-. Preicribad by GSA/10414. FIRMA 141 CFR) _ USAPPC V1.00

DOD-032025

bve_s (vo-hc_cn
CLINICAL RECORD - DOCTOR'S ORDERS the proponent agenc,• - OTSG
of this form, see AR 40-66,
For
M ORIENTED MEDICAL RECORD
AND SIGN EACH SET OF ORDERS. IF PI THE DOCTOR SHALL RECORD DATE
.R/IN-,COLUMN INDICATED BY ARROW BE... SYSTEM IS USED, WRITE PROBLEM h
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA ,FLAFr7 9 4256
MEDCOM - 18452
DOD-032026
MEDICAL RECORD
PROGRESS NOTES
DATE
pi-;W-6
CA)S Fi.7/b-t) 5 -rpr. y4.) I:444w f' -s 0z_ s r /6t) 07/o/24 is076//z2e,
(-04_ L (03 Y?
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Continue on reverse ,^•
:°;,, I lir iDENTIFICAT2O7 17?adical N iFoi typed or written entries give: Name - last, first. middle: . rade' rank; rate; hasp ra .9r -7 facility) ._ WARD NO. '
..• • • . . . Record
- • -MEDCOM - 18453 15rescnbed by OSA/1CMR. FIRMR (41 • • USAPPC V1.00

DOD-032027

CLINICAL RECORD - DOCTOR'S ORDERS
For of this form. see AR 40-66. the proponent agenc.• "- OTSG

THE DOCTOR SHALL RECORD DATE
AND SIGN EACH SET OF ORDERS. IF
P M
ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM I cR IN COLUMN INDICATED BY ARROW BE.
PATIENT ATIONIDENTIFIC DATE OF ORDER TIME OF ORDER HOURS LIST TI ME ORDER NOTED AND SIGN
c9- v LiCX)c-c c tt.4)„4,s
NURSING UNIT ROOM-NO. 8ED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER o TIME OF ORDER HOURS
IJIU „ NA. C)
NURSING WNIT OOM NO. I. Of PATIENT IDENTIFIC TION BED NO. i 3 /--71-6•4 • C DATE OF ORDER CC:,),/ riff) TIME OF OR s6f ,,rierzzczoLu-74. HOURS \0(

NURSING UNIT
ROOM NO. 8ED NO.
V I
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
6\I
NURSING, UNIT
ROOM NO.
BED NO. 1.v..
DA REPLACES EDITION OF t JUL 77. WHICH MAY
,FAOPFIRM79 4256 BE USED.
MEDCOM - 18454

DOD-032028

MEDICAL RECORD I PROGRESS NOTES
DATE
5 i-,/-i --
4f3 4-1. 4-,..-t-k..4I04/7.s0-7
4-0 t, ht4 o -Z 0 ( a: Y.-
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(Continue on reverse side)
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name • last, first, middle;
REGISTER NO.
WARD NO
grade; rank; rare; hospital or medical faciliryl
PROGRESS NOTES
41,
Medical Record
STANDARD FORM 509 IREV. 7.911
Presclibecl by GSA/ICMR. FIRMR 141 CFR)
MEDCOM - 18455
USAPPC V1.00
DOD-032029
i.c6.
c\b .
CLINICAL RECORD - DOCTOR'S ORDERS For ••
,f this form, see AR 40-66, the proponent agenc‘- rifSG
THE DOCTOR SHALL RECORD DATE
AND SIGN EACH SET OF ORDERS. IF Pt
A
SYSTEM IS USED, WRITE PROBLEM N. ORIENTED MEDICAL RECORD
..R IN COLUMN INDICATED BY ARROW BEL
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME
ORDER
NOTED AND
SIGN

NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
P{CDO.+, •Jr* — i/ 119-493 pg-r) la61-1
NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDER
ER
HOURS
W cb tf
ry-fn
c)6
0, ¦Mi A_ .¦•
NURSING UNIT
ROOM NO. BED NO.
PATIENT IDENTIFICATION TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAT BE USED.
DA 4256
I FAOP ARM79
MEDCOM - 18456
DOD-032030

CLINICAL RECUrtu
rUl Yoe ¦••••
s
see AR 40-407;
The oro or
a.aene is the Office of The uraeon G lAfo.V6rYr. 2003
IMIZAL PROPER CO UMN FOLLOWING EACH COMPLE770N
1IG ACTIONS, ,ENCY, TIME
C.Ve 621W (Am
-Ob. 4r/A77; 6/11/4c9 o5-
- -) arni &Alt sol / d 6
ADDITIONAL PAGES IN USE:
ePRk.-6,r476';(0 AAA-J70A,, At8 elucuite D YES CD NO
rviam Loccuidi /or god irvcio
PAGE NO.
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 DA FORM 4677, 1 OCT 78 EDITION OF T DEC 77 MAY BE USED.
USAPA V1.00
MEDCOM - 18457
DOD-032031

erif , by
THERAREUMGZOCUMENTAT1ON CARE PLAN
nitialLng
(NON-MEDIC4770N) MoPOrder Clerk Yr 2003
Date Nurse SINGLE ACTIONS Data to Time to be Done Time Done Initials
be Done
a 5
71.
fig 3
TV 7 o
AO, i-12 7 1/2 GL
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Order/
Clerk/
Expir PRN
Nurse PROPER COLUMN POLLOWLVG COMPLE770N
Date ACTION. FREQUENCY
TIMEJDATE COMPLETED
MEDCOM - 18458
DOD-032032
—P16k

¦oq-/
THERAPEUTIC DOCUMENTATION CA E PLAN (NON-MEDICATION)
CLINICAL RECORD
For use of this form. see R 40-407; the =rent aaency is the Office of The Suraeon General . yr. 2003
VEUFY BY INITIALING
PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE CLERK/ RECURRING ACTIONS, NUR E FREQUENCY, TIME -0(o0n Nadvii)S — - - -filo kepaevOat c butai4 IN HR DATE COMPLETED
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ALLERGIES: u YES
ADDITIONAL PAGES IN USE:
J77.117Mts,fro 42 doily( hAp -7/10
Ei YES p NO
(:4 ektumohivildh 057A/1 Open Gy151726n)vfit/
PAGE NO•
PATIENT IDENTIFICATION:
ACTION TIMES
1111111
USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
al 5 Ott) L4
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78.. JSED.
USAPA V1.00
MEDCOM - 18459
DOD-032033
Verit , by THERAPEUTIC DOCUMENTATION CARE PLAN InitialIng
(NON-MEDICATION) Mo.Yr 2003
Order Clerk
Date to Time to
Date Nurse c_e_ --------L_ SINGLE ACTIONS Time Done Initials
be Done be Done
, , p 1-, --an froc-eu cpiici—
1 Sett
t
_....... _
. .
Order! ExPirData Clerk/ Nurse PRN ACTION, FREQUENCY INnific. PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED
'
• .

USAPA V1.00
MEDCOM - 18460
DOD-032034

THERAPEUTIC DOCUIVIENTATION CARE PLAN (NON-MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407; ' . Yr. 2003 the or000nem aoencv is the Office of The Sumeon General.

INHZAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY IN1T7ALINO '. .4:07-1E-:k.-.. :-.. 1,i4-PAL.V40.1-4124-;:
HR DATE COMPLETED
ORDER

CLERK! RECURRING ACTIONS,
DATE

NURSE FREQUENCY, TIME
o,

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ALLERGIES: C=I YES - NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
ED YES II NO -
/ 460A PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
V­1:0
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
DA FORM 4677, 1 OCT 78 MEDCOM - 18461 USAPA V1-00
DOD-032035

ERAPEUTIC DOCUMENTATION CARE PLA (MEDICATIONS)
For use of this form, see AR 40-407: Mo. r. 03
I
CLINICAL RECORD
the Proponent aaenc is the Office of The Surgeon r-neral.
INITIAL PROPER COLO N FOLLOWING EACH ADMINISTRATION
VERIFY BY INITIALING
DATE DISPENSED
HR
ECURRING MEDICATIONS.
ORDER CLERK/
DOSE. FREQUENCY
NURSEDATE
ION L rkAii 5Diy A ifiB OS"
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(tp
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ADDITIONAL PAGES IN USE:
O PRIMARY DIAGNOSIS:
ALLERGIES: l YES
/Ch./344'6 /alb swv_ of NO
VhtiroOtOforvb-Ejj YES 0
PAGE NO.
/Oki/AA 1,10`1 oidsho* (IA.)
riadth 600(PlOtt
DISPENSING TIMES
PATIENT IDENTIFICATION:
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
USAPA v I .00
crwrInm ncr- 77 wn I ac 1 1SED UNTIL EXHAUSTED.
DA FORM 4678, 1 FEB 79
MEDCOM - 18462
DOD-032036

Verify byInitialing THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr_ 0.3
Order Date Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Time Given Initials
'
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((1,\ — 2. TO) •
INITIAL PROPER COLUMN FOLLOWING ADMINIS7RATION
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MEDCOM - 18463
DOD-032037
ks)

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; ivio.fp Yr. 03
th-9 lrgocoent agency is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADMIMS7RA77ON
VERIFY BY INTFLIIING -::_. ::;:: . ,
::::5';
HR DATE DISPENSED
ORDER CLERK! RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

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ADDITIONAL PAGES IN USE:
• YES 1111 NO PRIMARVDIAGNIJOSI*:
ALLERGIES:
CjWC.th(69(1•D hP713 -aliP 0 A :r1oicicand b-6 0 YES MI NO -_X\ V oftweio CL.C4it c-Foi 9 4.31-1Z1 hi.rri"." PAGE NO. PATIENT IDENTIFICATION:
61 PENS1NG TIMES
USE PENCIL. CIRCLE TIMES D 7 8 9 10 11 12 13 14

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N 23 24 01 02 03 04 05 06
— • -- •••' • — "SED UNTIL EXHAUSTED. USAPA vl.
DA FORM 4678, 1 FEB 79
MEDCOM - 18464
DOD-032038
THERAPEUTIC DOCUMENTATION CARE PLAN
Verify by Mo. 5ff Yr. 03
(MEDICATIONS)
Initialing Date to Time to Time Given Initials Order I Clerk/ SINGLE ORDER, PRE-OPERATIVES be Given be Given
Date Nurse
TION
OrdeV PRN ExP' I NUM! MEDICATION, DOSE, FREQUENCY
Date v4-
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USAPA V1.00
MEDCOM - 18465
DOD-032039

. ZNITIAL SHIFT ASSESSMENT - -- . --- -- -!Time: .nitals: ... `Time:t t _ Initals:
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LI DIAGNOST;C STUDIES
STATUS: US: AD OV IRAQI EPW
Li 172..I.ATmENT
DA FORM 4700, MAY 78 .PC
MEDCOM - 18466

DOD-032040

_ . ___ INITIAL - - ASSESIENT

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OR EVALUATION
UNIT: pal) u-sA GENDER:n/-0 o,
0 DIAGNOSTIC STUDIES
STATUS: US: AD CTV IRAQI -E?W
TREATME•IT
DA FORM 4700, MAY 78
MEDCOM - 18467

DOD-032041

-
--IVtCLJJML Kti-orwurt-LtmtNTAL MEDICAL DATA
-
For Lse .cf this tc.-7r.. see AR 40-65, :he . -T. 1)a •Stirciti•or'IGe4 a'.
P,0pent--4,7-r7--ir--is•OE -Officeof ( • • OTSG- APPROVED ;a.;:a)
...--.- .
R=PORT
Q.-\ Appr S Mar S9
INTENSIVErARE NURSING PLOW- SHEET -INITIAL SHIFT .ASSESSMENT -.. -----. —
: I Time: Ini tals: -TiT-11:1 11/0 • .:Inital . . _ - ,0 vv.., .f.trix.... T
E Pupils 1.4_Qrt--\ - raw, . (rows
-,
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_... ..,.. ---
..-.-
R LL,OC / GCS --:---- [mCy--1_. vy) .1cbi‘-cf,i-r6y-F-7-4 -. , 4r er-JuSont,
I leo c.c:,))Droct, ) kity‘-acA .9.41,1.9° L-1)-Pc

o
C tcar.i.-iiac Rhythm A\A).›.... .:._L=S_CLANLeo_aa ) t'N) 2"-. PR.

A zizz.:/9Rs: tS-2_gpt:1-q-cP-qtQ6 `i----‘uL 0-67)4Z-Ftf.
-R Pulse Strength ak u?_..lik ---" - -PZ-i_Viaa...../(tte&-kfn4L7-/ D Cap Refit 4 jv D _ . 1—:Z_SEEC-1,41_ e/Krire.ON -.1.YX— "
I Edema
A Chest Pain

C-I'
C . • .
R Rfspy_ a to ry Pattern VA-1- l'-1-2 -12Nrim70.f,lig-icti,,A ,,[4b.,,A -1-,,,,k 1.14_.._.___.______
I',eath Sounds 17)E:FD ,

E secretions it:').D‘Q .C. kf--. t'- t,30¦.•k:_-j - C2f-ire'y--1 oL.:0
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---N \1/4-ViCkt_ -. rS4 I. prxXi_fccz_li:(ir's
P E:rp -1AnVil-li a4 JA.,;a-41r,e. .
...,_ -1( ok-on

Color
R Integrity LI-C--)11 k-P I Irs(1.'61-t-n-t fri)-), 04-Kul ni
I Backside k rOCACt\ v\)0t.unelS 0), rr-01,-e-I-h 5144., '-1---."

-6
N uyyntx--./-nD\1,\-3(\ I ion G)Vi-e-Access Devices r-C--)t .t_ k_ % c,\
',---,
I Location i'c---
V Condihon E.Pc-DIPti... -¦212,C__\ 6.74)1V3

,
PA (:)(:Q r..-L

Abdomen
S 1)-T. PD.. _ /--L' 5.:"...21 Sounds___ _ jrt !A_ _.¦..,LQ0( it2 [:c S X ti I Storn3/05tomy
1 _ :
-r
'
r, De. ie ItAt7A_L'A.1-9 )1()LC_P 2-19i o-b I Fo Lot
r-olor / Cl?ritv C Li 1,i ---... l CO -1-0T) c.L. li . (evirriateitaA)
- -I •
_
... ..
_ __„ A
DEPARTMENT2SERViCE:CLINIC.
t:I,-287-1 Com:oat Suppe:7 Hospi:al
,
FATiENT'S ID_.
rmc'd.,q; grecle; eater hosp1 cr raedicz.l n HISTDP.Y:P'riYSICAL 0 FLOW CHART
RANK: AC-F:
.'5?4,5,
-706) - OTHER EXAMIN'ATiON 0
OR EVALUATiON
UNIT: GENDER: 11A..ck.
q 0:AGNOSTIC STUDIES
STATUS: US: AD I -' EPW IRAQI
TREA7.tIENT
. DA -FORM -4,700, MAY 78 ..
•
MEDCOM - 18468 — -
DOD-032042
MEDICAL RECORD-SUPPLEMEish -ALMEDIC4L. , R 40-55; -1!•.,e p,oPOnent 2,..,?.."Ce -is te-.v! The Sue"Ge e 3.
FoT use .cf this !c7.-r.. see
OTSG APPROVED to..,:a; RPPORT TITLE -----kAppr-S Mar 89 INTENSIVE CARE NURSING FLOW SHEET •'
-
INITIAL SSESSMENT -
inle:. 4.;;.)6__Initais:
i _ Time:07QX-) Irdtals
•
riyiA—
E Pupils - --- — pu.91: - ---.
Ifik,-•-i...
riTanTiTril.111111LAMINfaas.MtlaAlle
....„....„._ .______-.
---1_,L1Serisoritifit -- — -lb ;:' ' wog - 1.1. _ . _
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-
GCS --- ---- l.D..A.X.-file -
-R LOC/GCS----vp/vrt .11-e_LP....V1k iMIT
0 I ..._:_wun -rr \ "i "-ct-
----1
C Cardiac RhY thn) ---Z ST._ OrCi. va.--ou,c) #_,/ • 4.1-7_ 1(_, ea) : A PRL / QRS: . -• 1
tkA-
- R Purse Strength-2 -_+.: „...-tg:_,: c:..Z.2,,s_2_,--!--1"&c,.u..k:untki.. -.5--3 G-3 Cap Re.fil /. JVD ___ !-ISNJ 0 .. . • -,._ .cel____2-0
p
I Edema.. -• .. 0" _. ik.e •
s
A Chest Pain
_...

-,..C. .
R 4PsPirat°1-Y Pat tern E 2) 1 (4 -ii PoffilPLI#0.1.--91.
E 'L oa il SDUI1Ci5 (tik.V.a VIA_ biciaXa__ 0-15)-'
p*on.utA,i,h, p1,14 E,Solliq ")-tp,,11.-:... .

5 -=:.._e_c.r_c-L. 2'.-t. .. _ ._ . ..._.
P co,-igh alAka.-bUirlDC1.1'er‘Al eo_ita,i-t-civ I opents-,
aticY1 I

,-cD64,ii,1-104 ; 1,10
NJorm Gil
5 Color , OVori_-_.. 'WIWI.: ___,,iiitti2L-4-
K integrity ib .,o al/lib/AD ciclAra -A zif-,,,,,gs--
I Backside Qp-G'4 nilowv_ 11-6o 'vile, ,-!i2 1--: , 1(p pc
irou+haitkr&. eArc_th-oilyi elect

N it 6rri ' ta
Access Devices 1 •te 1-- ix ,-;, 4-- N--t; adeoi-IV
I Location Ili-L1 th-FALL631-1r Ott: ptiko-.
V Condon I/rIblei• (75 qs_vlOcclior) Os-,.,_"•11--Jr7r--)-(c(_-_-1-1/1

,
.,-.-,--k,,_plas-1 i-Nr¦ ,--%;rne",( 3/ ,..e_II.i.o__L-Ok-___
Abdomen 1 )33-1_41 _ _
G Bo,..-ei Sounds i 4ctei. 4 rvn , .rA6-i-A,c, _45./..x_i______._ _

,
1---------. - -- - .--.- ------ ------ - — ___ -
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_
I.&IPA.
E,,..i: _ .._-
UARTiENTSEPViCICLINK;
P.P:EPAP.ED BY I.Sicr:a.-:.'re & 77:te)

ICU :ft., 28. -Fri Cc:Inbar_ Sur:pon Hof.pial
Name -les:,
FAT:P.NT'S IDENTIFICATION 'Foe' typee or oiri,t1en en:ries
0 PLOW CART
HETOP.(:PHYSICAL.0 OTHER E_XMINATION.
mfeele: grade; eve; hospi:p1 cr
0 OTHER OR EVALUATION
GENDER: p/1UNIT:
DiAGNOST;C STUDIES
STATUS: US: AD / CIV IRAQ EPW
El TREATMENT

_
DA F 0 C-1 4700TMAY 78 _„
-—
MEDCOM - 18469
DOD-032043

tVItUIL;AL iitl:01-1U-SUFFLtMENTAL MEDICAL DATA . • . • r_ see AR 43-65; .t!'e-pFsponent–ese,cy -is-tIse Office crf The-S ugeon.Ge.--e-.3'.-7—
..For use .c! tis fc:1­
0TS 13 APPROVED REPORT TITLE
QA Appr S Mar S9INTENSIVE CARE NURSING FLOW SHEET
.....iiiiimigarialtaingni
NI i Time: 0101) Inital, -t . _ . .
FillMNIM. ___ - -
- , .. : • .Vbtr.._ ,
' 4••__4•ilic -,-ii,y.,
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diF
77:21r-27; • t _7777
urn -.-1711,1119111Mr• -C-7 ' 47 fiff1MR1211S2.'-li¦r : .'" 1:,,..J14 ZE________
1Sensori
R LOC / GCS -----t3 ffitki il igtt,q0/04 04/. .irtaxgz..-csii

o ! ,-., I, kg e 5b c s arcliac Rhythm 1-----In, - 110 sp.), . . A !PRI:.. i - QRS: i 51 e ctivipitAak, tot: • 1.4--se-f a
_.
-7.—_-
R Pulse Strength
D Cap Refil / JVD '51‘. ' z 3-Pc4: -.11a44144 • S_C --kill 3Set-
-
I Ed ern a (riCAIL-i-• sitd (1 • , -1 • a. A Chest Pain TY. 11; V 4 C _ • .e.4.,..t.,4 rr.se.,04' 1. er !Respiratory Pattern 0.1' tt.Seattr 4(4a6i 018 3i
R r--------—
: 8i-ea th Sounds - C L4iI....ii ___ - •• 4‘.,7'.__bil414 ).__..c6n-a.74a___,a.-4_ ,eoses-__ _
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.17.-ecretions j SPCI ra_c.-o-cil . 4zik
603 le
S Color Tome n . Ni•OhTtal pl • O-
K integrity . isitici 5i 1 hitifj. ' OulOcir (=W) -SGIAlArdr 'V 4-4 OE At4i7 r 1 he

..,_ _
I Backside tif sad 14 iiict.s;ci, 1r gr. 1 A(2-,0 7
N . . Access Devices I 1(411 PIV .4t & po6i4 /firket I 13 . • are-4 ig' e .
I Location V Condition fiAlta A,k (Jib&) '1-1\ a_C_J-n -keAtt_n• ' ---1
Oiki
11
Abdonlen 4itt_4.--_MIVI. £ Ait9%61:431104i)

_..
k..., /4./4 pc , 1,1144. X f Ac:74 .,.."._.-k 1 5, tom alOstomy.. _ PEO Igt •ii.4 igt3et 3 r 3x _. 11(2---' T P 'C_1. .L.4. . Yrt.:_._..4 . _ _______
I
G De% ice --14 /(7 . 1 64-if -tb Color / Clarilw . • . 4 c1,04 -41,e,t1.01A) (A ntli__
U
DATE -
DEP,ARTMENTISERVICE2CLINIC
IOU I, 28TH Combat Supper Hospi:a1 to sa 03
writrea entries •,..:”ve: PlernLz nospr:p. r:..q facillryl STOP.V:PI-IN'SICAL
PA;
0 FLOW CI-4A7
NAME: . •RANK:
..• Li OTHER EXAMINATION Li OTHER OR EVALUATION
GENDER: • -. •.
UNIT:
:
O;ACRIOSTIC STUDIES
STATUS: US: AD CIV IRAQI: CIV EPW
DAT" 0:F--IM 4700, MAY 7S .
MEDCOM - 18470
DOD-032044
1. REPORTING MTF
z. ,OCATION
ADMISSION ,-...J t,ODING INFORMATION
1 2 3 4 5 6 7 8 (State or
Country

::,...,:-:•;.. For use of this form, see AR 40-400; the proponent agency is OTSG
A Code.)
0
3. RE ISTER NUMBS
AME (Last. First Middle Initial)
4. PAY GRACIE 5. SEX 9 10 11 12 13 14 15
W
16 17 ‘, 18

A P APO" v (L6-4
. 6. DATE OF BIRTH (YYYYMMDD) 7.
AGE AT ADMISSION 8. 9. RELIGION
RACE ETHNIC
19 20 I 21 1 22 I 23 24 25 2 27 28 29 30
31 BACK-GROUND)
--1-(6 C-) 6 A_ C y )(
10.
LENGTH OF SERVICE ETS

11. FMP
12.
SOCIAL S URITY NUMBER
32 33 34

35 36 37
ORGANIZATION (Ac ive Duty Only) 13. MARITAL STATUS
: 4' ' ¦ -ADMISSION
-46
14.
FLYING STATUS

15. BENEFICIARY CATEGORY
16.
ZIP CODE OF RESIDENCE
47

48 49 50 51 52 53 54 55 56 57 58 59 60 61

,e_ 7
17. UNIT LOCATION (State or 18. MOS
19. TRAUMA
PREV ADMISSION
62 163 64

Country Code)
65 66 67 68 69 70 71 YEAR
-r
i
[ I N °
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION

72j
ADDRESS OF EMERGENCY ADDRESSEE

(Include ZIP Code)
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
22. MTF TRANSFERRED TO
23. DATE OF DISPOSITION (YYMMDD)
1
73 7,, I
75 . 76 . 77 . 78 .. 79 80 82 v
4 --,--- 81 83 -.. 84 85 . 86 -
24.
CLINIC SVC - ADMITTING

25. MTF TRANSFERRED FROM
26.
DATE THIS ADMISSION (YYMMOD)
87 88 89 90

91 92 93 94 95 96 97
98 99 100 101 102
27. LOCATION OF OCCURRENCE .
28. •MTF OF INITIAL. ADMISSION
-. _ 29. DATE INITIAL ADMISS ON (YYMMDD)
(Battle. Casualty 'Only)
103 104 105 106 107 108 109 110 .
111 112 113 114 115 116
---F0.OCAL USE
DX 0,2 , .,5-2k3 0 g900 MO 7.--80 (31 ?.?..-3cz. 41-2 / 4.s---0
1,_,5 . / ( V5s0 5-7673
V-55/ 93/9 02'25,2

7 HI, 63 8.6,2f
g73 9, / /
12-1,
73 q -
-
--,F.9 "
pA2 76 7
ADMITTING OFFICER-(Signature.as required)
SIGNATURE OF ADMITTING CLERK
..---------
..
DA FORAn 98 5. MA 12 RQ '
-- • - -
EDITIO N OF MAY 79 IS OBSOLETE
USAPPC V1.00
MEDCOM - 18471
DOD-032045

J CODING INFORMATION
¦•e., LOCATION
ADMISSION
1. REPORTING LITE
8 (State or
see AR 40-400; the proponent agency is OTSG
2 Country For use of this form,
Code.)

4. PAY GRADE 5. SEX
NAME 'Last,. Fast. Middle Initial)
3. REGISTER NUMBER 10 10
a 1111111.11=11 q
RELIGION
9. ETHNIC.
7. AGE AT ADMISSION 8. RACE
(YYYYMMOD)
S. DATE OF BIRTH
30 Ell BACK­
GROUND

MO 23
20
12. SOCIAL SECURITY NUMBER
ETS. 11. RAP.•
10. LENGTH OF SERVICE.
• EllinEarlirrunirmali0
11:1113
HOUR OF BRANCH I CORPS.0-4
13. MARITAL STATUS
ORGANIZATION (Active Duty Only)
ADMISSION
46 0-(5'
16. ZIP CODE OF RESIDENCE
16. BENEFICIARY CATEGORY14. FLYING STATUS
59 60
•

IMIESECIEIEREI
50
48 49
11311113
lc 1
PREY. ADMISSION
19. TRAUMA
17. UNIT LOCATION (State or 18. MOS
Country Code)

111 NO
EllE11111131:11 YEAR
11111111111.1111111111M111
NAME/RELATIONSHIP OF EM RGENCY ADDRESSEEWARD
20. SOURCE OF ADMISSION/ AUTHORITY FOR
ADMISSION

(include DP Code)
ADDRESS OF EMERGENCY ADDRESSEE
72
CY ADDRESSEE CATION OF MEDICAL T TELEPHONE NUMBER OF EMER E
6-2 z
23. DATE OF DISPOSITION IY YMMDD) 22. MTF TRANSFERRED TO
21. TYPE OF DISPOSITION
80 81

74 ElE110113131

IIIIMISIENEI
11111111111111111111 co Q
26. DATE THIS ADMISSION (Y YMMDDJ
25. MTF TRANSFERRED FROM24. CUNIC SVC • ADMITTING
100 101 102
1131111111311, 1111131 EZIECIEI
011E3113111

III MEM= PI
(YYMMOD1
29. DATE INITIAL ADMISSION28. MTF OF INITIAL ADMISSION
27. LOCATION Of OCCURRENCE
(Battle Casualty Only)
110
11111111111111113MEMI
105 106 107 108 109
103 104
1111111111111111111111111
11111111111•1111111111
FOR LOCAL USE
IA, cc u1/4,
67-5 tA)
7-
-
CLERK
SI
AD
PIA C
MEDCOM - 18472
DOD-032046
INPATIENT TREATMENT RECORD COVER SHEET ...70,.For use of this form, see AR 40.490; the proponent agency is OTS6
4) 3. GRADE ADMISSION REMARKS
REGISTER NUMBER

NAME (10$1, Rut, PAH
1k
OAK ."- EPW _FPI.)
10. PREVIEWS
AGE RACE 1. RELIGION 8. .
DMISSION
_ NOA
/11 1 ,tis
g /
14. WARD
13. ORGANIZATION1 FMP 12. SSN
pred i
20. TYPE CASE
18. BRANCH/CORPS le ICIZIP
15 FLYING 18. STATUS ON BEN
b ( Ut)
22. HOURS OF 23. CLINIC SERVICE
21 SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION .
ADMISSION
Di r f_CI" {-row .r_-.2 t $00
26. DATE OF DISPOSITION
25. TYPE DISPOSITION
24 . NAMEIRELATIONSINP IIF EMERGENCY ADDRESSEE
.
C, o carte 2 seR.HIS 03
ADMITTING OFHCER
21b . TELEPHONENO. 20 BATE IS
27,. ACIIPS‘Fl/MERGENCY ADDRESSEE (Include ZIP Cede) ADMISSION
.20,F O
VAIK Q
Uotig 30. DATE OPINTIAL 32. UNITS OF WHOLE 610001
NAME AND LOCATION OF MEDICAL TREATMENT COMPONENT TRANSFUSED
29. ADMISSION
10 / --t, ) -Z--
31.
Check it Cominund on Reverse
33. CAUSE OF INJURY

In Pio( CsI6 le.. ACC 14". /11-
34. DIAGNOSES/OPERATIONS AO SPECIAL PROCEDURES
• "7?o,o1 910,0
DX; ft/ o LT/ Co A) ru s / atif ci /MAAS-494s '73 • 1I q1z, t-,¦
.0
eiaas 1 ,..,
e? 1 9. D.
35. Total Days This Facility e. ABSENT SICK DAIS b OTHER DAYS c. CONY. LWCOOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e..BED DAYS I..TOTAL SICK DAYS
36. Total Days All Facilites e. ABSENT SICK DAYS b SIGNATURE OF ATTENDING MED no. OTHER DAYS c. CONY. LYICOOP CARE DAYS.IlD' t i , • ',It • d..SUPPLEMENTAL.CARE OATS A nA A..8E9 DAYS I..TOTAL SICK DAYS toVt6 7-USAPPC V1.10
DOD-032047

PATIENT'S .CLEARANCE RECORD
\c) ( ct,.., .-- c_-- (
For uoo of this form, sae AR 40-2; the ProPonsra 4124rocY .1 , OTSG
TIME OF DISHARGEDATE OF DISCHARGE
lila
OSSZPO3 SIGNATU.
CER :-..-...
•
/1„
PATIENT'S IDENTIRCATION ACTIVITY CLEARANC
(The final activity with which the patient must dear will be the cftposition office.)
INITIALS' tAilftry
Noo-nillsesyINITIALS' _ 1..Patient's Trust Fund 1..Patient's Trust Fund Medical Services Account Officer
2.
Medical Services Account Officer2..3..Clothing and Baggage3. Clothing and Baggage 4..Postal Service 4..Medical Holding Unit 5. .Change of Address*
a..Supply
.

-
6..Other (Specify)
b..Pay Section
.

7.
c..Service Records
a.
Insurance and Allotments
5..Postal Service s.

d..i...
6..Change of Address
7..Other (Specify)
12. 0(Li) ''.-Z—.
8.

9.
0(0 ., I,. 13.
REMARKS

i -2
DATE
S
' INITIALS OF PERSON AUTHORIZING CLEARAN

USAPPC V1.00
11•111111111111111*.. 1 DEC 59, WHICH WILL BE 1 ,"
.
DA FORM 4029, MAR 73
MEDCOM - 18474
p
DOD-032048

-MEDICAL RECORD ABBREVIATED MEDICAL RECORD
I
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Ener dine of admission)
PHYSICAL EXAMINATION
PROGRESS (Enter date of discharge and final diagnosis)
SIGNATURE OF PHYSICIAN . DATE . IDENTIFICATION NO..ORGANIZATION
PATIENT'S IDENTIFICATION (For typed or written entries give Name last, first. middle; grade; date; hospial or medical facility) REGISTER NO.. WARD NO.
ABBREVIATED MEDICAL RECORD
Standard Form 539
GENERAL SERVICES ADMINISTRATION AND
INTERAGENCY COFAM1TTEE ON MEDICAL RECORDS
FIRMR 141 CFRI 201-45.505
OCTOBER 1975
USAPPC VT.00

MEDCOM
MEDCOM - 18475
AUTHORIZED FOR LOCAL REPRODUCTION
•
NSOR
EPA
RECORDS MAINTANED
flE
JIPN: (For Typed or wrirren erirrieS, give: Naive - lest, ffrsr;ri7irldle;
ID No or SSN: Sex: Dare of Birth; Rank/Grade,

',.•:,•pfitibt:is.S,1407F55•.:::i.:....,:...iiie‘dic2;100410‘.: ,
. • ::.1
. -• ,.:.•. :: '.--.7' :!.•.
.
tva
, •
.4 509 . iREV. 5n99. 9) Prescr, e , ..•.•"FPMFI 141 C FR) 1 .2A7v)( .10) ...,
:9 TA.-144,7¦.F14iS.:0:6R11
b d by GSA/ICIAR 01-1 ...01 3Alb1 00
; .. . .
-.-•.:*.":::i•:' ,.::'•.:' , :-..,.,^,;;....•• ,;:,,. .:.. ......r.,, i .. .. , . :,.:..... ; ...
. , .
MEDCOM - 18476
DOD-032050

AUTHORIZED FOR LOCAL REPRODUCTION
..„..MEDICAL RECORD.----
CHRONOLOGICAL RECORD OF NIEDICAL .CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each sentry)
SEP 0 2 200:._ . ¦
or.•.N.....k... ... 1
--).- -7.
JAAILA 411 -.4 -
r --
0 )5 8 )
b:NaPALAMI A*.illiakfti.
A..ja,.,. ..
•..-e/..i.ha...,..e......_efiararAll

' '.
.
-"--/.A /.i.•.d , ,.,.. .,._.
Adar .., —
/Pr' In -."'" Pr '• r-i¦ r.• - -.,.I
A
,....rimir
lob

rigr r
f
b. 1.....01L.x.
1
ciLLib
ir
1_,--
(CD '
-e./45:-*¦-
,
i
.,4 AKIN --j• -r.-... ..._ 3 -cra
.,--CtV--. 119 UtS ----1.--
--r-N.A.'s\
. i.
...
.I../..„ ...._....4. 0' • 4'. Mk
44.0...
i.
A,
A/
di' /, 6-6,-)---( P"."'".4.Apir
11L-alrAl Al.
10111¦,.
..„„,..
iffoi._ es
HOSPITAL OR MEDICAL FACILITY STATUS. DEPART./SERVICE
b
SPONSOR'S NAME SSN/I0 NO. RELATIONSHIP TO SPONSOR.TO j
PATIENT'S IDENTIFICATION:.
(For typed or written entries, give. Name - last, first, middle; ID No or SSN; Sex;
REGISTER NO.
WARD NO.
Date of Birth; Rank/Gfacle\)
1 - \ ..I ,. . --' 1 ht-N1 i • Vo. 1 1
HRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
CoB 109th ASMB
MEDCOM - 18477

MAP IRAQ
DOD-032051
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each entry)
Lz —ks-N, PL-cd\
s.
STANDARD FORM 600 (REV. 6.97) BACK
USAPA V2.00
MEDCOM - 18478
DOD-032052

NSN 7540-01-05.3786
LOG NUMBER TREATMENT FACILITY
EMERGENCY CARE MEDICAL RECORD AND TREATMENT ..
RECORDS MAINTAINED AT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY ON ARRIVAL
DATE IDay,_Monthr Year) TI
STREET ADDRESS STATE ZIP CODE TRANSPOR ATION TO FACILITYCITY
DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
SEX , ITEM YES NO N/A ITEM YES NO
/v. AREA CODE NUMBER
PRP 1..., ADDITIONAL INSURANCE
HOME PHONE FLYING STATUS /„...---DD 2568 IN CHART 2-
AGE .-i AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
",lind JILZ., 1Z/2•7/ .67..a-,
CURRENT MEDICATIONS INJURY OR OCC ATIONAL ILLNE S EMERGENC ROO VISIT

• WHEN (Date) DATE LAST VISIT 24 HOUR RETUR V _....¦-
ITEM YES NO
n YES NO
i / ,a_j_cleir/l/W-4--• IS THIS AN INJURY? 1/7 yVHERE TETANUS ALLERGIES
INJURYISAFETY FORMS L----DATE LAST SHOT COMPLETED INTITIAL SERIES HOW II YES . NO
r
CHIEF COMPLAINT

NT VITAL SIGNS
TIME TIME ?...
II EMERGENT ///le
BP 7a
/17y'y ire}
i -10,0 PULSE U RGENT INITIALS RESP
... 0 /41-TEMP •
1 ,
• NON URGENT
WT .
L9A.-:
X-F
MA_ORDERRSS
ILAB ORDERS'
gs.-A CXR PA & LAT/PORTABLE C-SPINECBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT
UA MSCCICATH X CHEM: .2_2,
ACUTE ABDOMEN LS SPINE
URINE C&S T
. .. .
SINUS HEAD CT
ANKLE R/L t
BLOOD C& X
ORDERS
MONITOR ECG IME ORDERS BY COMP TIME PATIENT'S RESPONSE
7
1 PULSE OX n / 0
aa To( 0,5-cc X jr 17u /s c7 :/ c2e
/5.020 re PA r r/. 1,14 15' oCe-/5"..2p

1010) -2-
DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
n HOME n FULL DUTY n 24 HAS. n 48 HRS. F-1 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN
REFERRED 11111. 0 IMPROVED 0 UNCHANGED TIME OF RELEASE I have received and understand these instruction S.
DETERIORATED
PATIENT'S SIGNATURE

PATIEN T'S IDENTIFICATION (For typed or written entries, give: Name — last,
first, middle; ID no. ISSN or other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9-961 Prescribed by GSAIICMR FPMR (41 CFR) 101.11.2031b)110) USAPA V1.00

"1111111117,111
MEDCOM - 18479
DOD-032053

NSN 7540-01-075.3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENTMEDICAL RECORD
(Doctor)
TEST RESULTS .
WBC
Check if read by .
ABG/PULSE OX RADIOLOGY radiologist
to H/H U SUP 02 PH P02 RESULTS/
PLT PCO2 SAT OTHER .AP
)4
PT DIP
EKG INTERPRETATION

cYr-
APTT BHCG.ETOH.GLU MICRO
PROVIDER HISTORY/PHYWAL
cc/4z--, 3 4f-j,
• "'CA-4—

56 r ag/
0 /444,""fir Ed"

42- /a/ A- &AdeA_
/Yo tA/A /V4225 .e
telt° di'Yt VZ/WP 'h ref /0 Fatr 17
71/e /Y 'riptiA-
--/((zilt
• 77)7L
Caa_
CONSULT WITH TIME ACTION RESI DENT/MEDICAL STUDENT SIGNATURE AND STAMP
.
PROV MP
DIAGNOSIS
0
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle;
ID no. ($SN or other); hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSAIICMR FPMR 141 CFR) 101-11.2031b)(10) USAPA V1.00
MEDCOM - 18480
DOD-032054
' 511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
r)..
.1-•••
POST-DAY
MONTH-YEAR DAY 7.4C•P Ob Carr:Jet:a
19 HOUR 1 • • ..... .. • • " • -1.•

PULSE TEMP. F •

.. • .

•
—4
co 0.1 (,) co (..)W C.) (r) Cs.1 COA Am
01 alCD O4--,1 CO CO4.43 00K
b o i-• :-.1 bi) i.,J io 'a bin 70
0 00 000 0 0000
0 0

(0) (9) •
•
105°
.... ..
•
•
•
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l• • • •
....
170
103° •
.. .. . .

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180 104° . .
: . .
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. . . . "
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(Centigrade Equivalents, for Reference only)
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.

160 102°

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140

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130 .
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98.5° 120 98°
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100 96°

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95° • •
110 97° •
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6
RESPIRATION RECORD f/
BLOOD PRESSURE

r,
0..4% e
y 0 ioE i-,7
l data only when so ordered
HEIGHT: I WEIGHT —fib
• 1411
'Record speciaPATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, middle; IC) No.(SSN or other); hospital or medical facility)1_)\,4140f° REGISTER NO WARD NO.
VITAL SIGNS RECORDS
Medical Record

STANDARD FORM Sil (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 18481
DOD-032055
P, tint
L. Lin
h 1
47.
tCH 321LE Pit 23. 3 51.9 t; Pg X10'3. 919 99.9 31 0 3i. e 150.

MEDCOM - 18482
.,;QUESTING P )RATORY RESULT FORM
1
Ward/Section:
,...iubject to the Privacy Act of 1974)
11110 D (")-L I:
LAST, FIRST,MI.. DATE.I TIME
TEST RESULT REF RANGE
WBC 4.8-10.8 xlb
RBC 4.7-6.1 x16 14-180/1(M)
Hgb
1246gM4n
Hct 42-52%(M) 37-47%(F) 80-94 RN!)
MCV
81-99 0(F) Plt
130-500 x10' verilleil
Lymph % 20.5-51.1%
•

Cem atolpg fferenCtti
Segs.Mono
.

Bands Eos
.

Lymph Baso
Atyp Imm
RBC Morph\
Spun
52%(M)Hem atocri -47%(F) .
Set Rate
Other
Yftk
TEST RESULT REF RANGE
PT 9.8-13.6 secs
APTT 21-34 SESS
D dimer 20 nem!
FDP 10 ug /ml
REMARKS:
REPORTED BY:
.PICCOLO
UT, RESULit REF RANGE
15:15

02/09/03.

Negative
REFERENCE RANGE: MALE.

no Negative
PATIENT #: 1111111)ck(,0-.

o-P4X440
GENERAL CHEMISTRY 12.f DISC 3204AA4 nye OPER #.
L` DR #: 000

fin SERIAL #v0-0000100676 in S • Bid Negative
B ALB 3.6 3.3-5.5 G/DL qlori Negative ALP.U/L
72 26-84.
ALT.U/L ro

28 10-47.

miles

43 14-97 U/L

AMY.

P: aria
U/L

28 11-38.
0.2-1.6 MG/DL

.AST

TBIL 0.8.P

MG/DL

22 7-22.

BUN.

N er
8.0-10.3 MG/DL

CA++ 9.4.
100-200 MG/DL

Lt CHOL 154.

tqC:P.
CRE 1.0 0.6-1.2 MG/DL

H4
GLU 107 73-118 MG/DL
TP 8.5* 6.4-8.1 G/OL

CHEM QC: OK

INST QC: OK.
HEM 1+, LIP 0.

ICT 0

Cel ST SUBMIT SF 518 WITH Cot i:RY UNIT REQUESTED
Dir /Rh
n;,!
avg-
f0,
IMPEL

'

*7Agilr

CROSSMATCH
DAlE: LAB ID NO.:
x/9

yelloki

Moe-- siotaCt.
AN_ Hazy

.A/e
Gtvcost
P4 — 6.0 1
Ailp Ate6-
prat 11 –s0 -1-
=41::
Wryw -fra(' t/rAd-.ad:-0 .4
MEDCOM - 18483
DOD-032057

Ward/Section: .STING PHYSI CAN:
CHEI,AiSTRY RESULT FORM
LAST, F1RST,MI. .
. V. .= .,
4: „,;,;;: •14,:',.,5,As-'---t,
TEST RESULT REE RANGE
138-146 mmolldLNa
K 3.5-4.9 mmol/L
98-109 nunol/L
pH 7.31-7.45
PCO2 35-45 mmHg (art) 41-51 mmHg (yen)
P02 80-105 mmHg (art)N/A (yen) 23-27 mmol/L (art)
TCO2
24-29 mmol/L (ven) 22-26 mmol/L (art)
HCO3
23.28 mmoi/L (art) SO2 95-98%
BEecf (-2) - (+3)
mmul/L
AnGap 10-20 mmol/L
Ca 1.12-1.32 mmol/L
BUN 8-26 mg/dl
GLU 70-105 mg/dl
Creat 0.7-1.5 mg/d1
Hct 38-51% !'CV
Hgb 12-17 g/d1
,, .,,,, 1111 rig ;4.-; , S
s, , :.:.i.:,,4 PM' '
"—k. ,e,.4, ,--.
TEST RESULT REF RANGE
Tropoin-1
Drug of
Abuse

REMARKS:
REPORTED BY:
DATE TIME
'.' liftik .';'," IS .,`
xi;,---,.., .,,-w-' 4,4-vrgps -,.
TEST REE RANGE
ALB 3.5-5.5 Will,
26-84 u/I
ALP ALT 10-47 u/I AMY 14-97 u/1 AST 11-38 u/1
TBIL 0.2-1.6 mg/dl BUN 7-22 mg/dl
8.0-10.3 nag/d1
CA++
CHOL 100-200 mg/d1 CRE 0.6-1.2 mg/dl
GLU 73-118 mg/t11 TP 6.4-8.1 g/dl ', ,Iete,1.0 -e4
"
TEST RESULT REF
RANGE

73-118 mg/dl
GLU BUN
7-22 Ing/d1 0.6-1.2 mg/d1
CRE CK
39-380 /1 (141) 30-190 /1(F)
NA+ 128-145 mmol/1
' 334-7 111m01/1
CL 98-108 mmol/1
tCO2 18-33 mmol/I
DATE: LAB ID NO.:

(Subject to the Privacy Act of 1974) SSN/PEEUDO SSN:
,, 41 ' e ' MIS:WV
wi-41:1M-fl' -",qi
TEST RESULT . RANGE
73-118 mg/di
GLU
7-22 mg/dl
BUN 8.0-10.3 mg/d1
CA++
0.6-1.2 mg/d1
CRE
128-145 mmol/dl
NA+
le 3.3-4.7 rnmo1/1 CL-98-108 mmolll 18-33 nunall
tCO2
Aff ittd ', II:kW Yie , ,,,
-, ,,r,*,ft,1,-m,-,,!, : -omv,: ,
1,--i;&-:,,0
TEST RESULT REE RANGE
ALB 3.3-5.5 g/dI ALP 26-84 u/li, ALT 10-47 u/I
AST 14-97 p/1
AMY 11-38 u/I TBIL 0.2-1.6 mg/d1
GGT r 5-65 u/I
----.
TP 6..1 g/dI
A,C -xg
0 t*
IR ,. .,....; :.,. l N, ,,,,
-,..-. ,.., ,,, .
TEST E RANGE
NA+ 128-145 mmol/1
• 3.3-4.7 mmol/I
CL 98-108 mmo1/1
tCO2 18-33 mmoUl
MEDCOM - 18484
DOD-032058
i -STAT EC8+

Pt: 11.11(°1
Pt Name: .

Glu.

101 AWOL
BUN.

27 m9/cIL
Na.

139 mmol/L

.3.4 mmol/L
Cl.

105 mmol/L
TCO2.

26 mmol/L
AnGap.

11 mmol/L

Hct.

48 %PCV

Hb*.

16 g/dL
*via Hct

PH.

7.501
PCO2.

32.3 mmH9
HCO3.

25 mmol/L

EtEecf.

2 mmol/L

Sample Type_:
02SEP03.

15:18

Oper:IIIIIIII
Physician: .

** PRINT CANCELLED **

MEDCOM - 18485
DOD-032059
CLINICAL RECORD DOCTOR'S- ORDERS . For tap-
of this fork, sed AIR otere.,the p!clOoright agency is CTTS6
THE. DOCTOR SRA LI. RECORD DATE,. TIME AtID. SIGN' EACH SET OF ORDERS. IF PAOELEM OF41 NTED M-Et4DAE_ R IC IS USED, WRITE PFIQatEM„ Ntime-Eiti 1N COLUMACINORTED BY ARROW BELOW-
, SYSTEM ­
•••¦••¦•••¦•••••••
•eArIttsvr IDENTfFi;cATION
Ottli„:4?,C:
gt-relM. AN
PATIENT i•DENTO, tcATioN rivne, NG UNIT RO NO RED : NO, 0A1E 0E- ORDER./0 .2th 4 IME OF octoery 5 tevidu 521: - izaz`h of s aorlif) heCi
NVA-s4 4c.4 www RATIL;Nr 10:eniTtFitAT ION eCi NO.
NiafiSING UNI T 'ROOM NO. •pATIGNT toslaTtFOZAT.toici loxo d CYK rae% DATE OF ORDER.0-0D • TIME. OP ORDER HOURS
NOiiiI47.S UNIT ROOM NO. EEO NO
REPLACES E OiTION OF 11 JUL 77. WHICH MAV BE USED.
MEDCOM - 18486

DOD-032060

r THERA • UTIC DOCUMENTATION ARE PLAN (NONMEDICATION)
-
CLINICAL RECORD For use of this form, s-= AR 40-407;
Mo. Yr. 2003
,.., ce
VERtFY BY INITIALING : ,.,.44:0,g Nf..:-P5 i PROPER COLUMN FOLLOWING EACH COMPLETION
-ftt-s--
HR DATE COMPLETEDORDER CLEM/ RECURRING ACTIONS,
/. t
DATE NURSE FREQUENCY, TIME
A -S I\

A Vsv,2_,
Com_

ca I (4bucts, (e _
•
..
..

ALLERGIES: -YES MI NO PRIMARY DIAGNOSIS' i-ADDITIONAL PAGES IN USE: 1.
t(,r, ¦ of 4.1 YES.NI NO .
PAGE NO•
A AV, AY1 1 - • I iiIii0
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
*16±) ( (--/^..(-1. N.24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78. EDITION OF 1 DEC 77 MAY BE USED.. USAPA V1.00
MEDCOM - 18487
DOD-032061

61L, -pciA

Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(NON-MEDICATION)
M° 2003
1
Order.Clerk
Date.Nurse
...71••¦¦S
Order/
Eepir.C.lerk/
Date.Names

EfW ca(41
;

arywrylvArAdoUt I , N-rmA6-­
PRN
ACTION. FREQUENCY

SINGLE ACTIONS
.

21--ourp 1-e)
Date to Time to be Done be Done
tium/uruy4-L4
IA7714 PROPER COLUMN F
OLLG COMP
TIME/DATE COMPLETED
USAPA V1.00
MEDCOM - 18488
DOD-032062
THERAPEUTIC DOCUMENTATION
CLINICAL RECORD CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407:the orloonent men is the Office of The Suraeon General . MoCR Y r. 03
VERIFY BY INIMILING ---; INITIAL PROPER COLUMN FOLLOWING EACH ADM INISTRATION
HR
ORDER CLERK/ RECURRING MEDICATIONS, DATE DISPENSED
DATE NURSE DOSE. FREQUENCY

,-
isuiri7;-_41..ztrim
iworillilllierilii¦Immi
..,s ritli" 11--• --.''"'
-
"LamarammIIIMINIIIIIIr. '.'
ALLERGIES: • YES IIII NO PRIMARY DIAGNOSIS:. .•
ADDITIONAL PAGES IN USE: 1111 YES.MI NO
11/49Uat 0S-ffillt-S'& I MA.AcX1a) I ntO
r
PAGE NO
PATIENT IDENTIFICATION:. .,
-(-C/rni,Ltiq- COYrilL/kY VT)
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES D.7.8.
-11111FA • 9.10 11.12 13 14 E.15 16 17.18 19 20 21 22
b(Stj-
N.23 24 01 02 03 04 05 06
rs A [-Anna a a ftes.. rrn. ¦•••¦. ----.---------
UNTIL EXHAUSTED.
USAPA V7.00
MEDCOM - 18489
DOD-032063

Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing

(MEDICATIONS) Aio.EEL Yr. (2.3
Order Clerk/
Data to Tete to
SINGLE ORDER, PRE-OPERATIVES
Date Nurse Time Given Initials
be Given be Given
Order/ . Clerk/ PRN

INITIAL PROPER COLUMN FOLLOWING ADMINIS7RA77ON
Expir
ate MEDICATION, DOSE, FREQUENCY
TIME/DATE DISPENSED
USAPA V1.00
MEDCOM - 18490
DOD-032064

•
. REPORTING MTF
LOCATION
1 2

CHM 5 8 (State or ADMISSION AND CODING INFORMATION Country Code.)
For use of this form, see AR 40-400; the proponent agency is OTSG
3. REGISTER NUMBER
NAME (Last, First, Middle Initial) . PAY GRADE
. SEX
I 111113
6. DATE OF BIRTH
IYYYYMMO

MM.E
7. AGE AT ADMISSION
8. RACE
9. ETHNIC
RELIGION
20 22 23 24
25 26
BACK­
111111111111.111 a
GROUND
unitanna 28 30
10. LENGTH OF SERVICE
tal 121 inu
32 33 12. SOCIAL SECURITY NUMBER
NI 36
pallmlInglim11111111Mell 44 45
MEI
ORGANIZATION
(Active Duty On/y)
13. MARITAL STATUS
46 ADMISSION
PI
14. FLYING STATUS
15.
BENEFICIARY CATEGORY

16.
ZIP CODE OF RESIDENCE 50 51

47 48 52
Inman
17. UNIT LOCATION
(State or 18. MOS
Country Code)

63 PREY. ADMISSION
64 65 66 67 68
-il YEAR
CI 7° MI

NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD
ADMISSION NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
72
ADDRESS OF EMERGENCY ADDRESSEE
(Include ZIP Code)
C_ I
NAME AND L TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF
22. M TRANSFERRED TO,
23. DATE OF DISPOSITION
73
Y YMM00)
75 76
80
IMII1111111
24. CLINIC SVC - ADMITTING
0 Ellard 9 • WI
25. MTF TRANSFERRED FROM DATE THIS ADMISSION
IVY YYMMDD)
93 94
CCI 9° 1E11 26.
100 101
CI 96 C11111 106
1121 102 103 104 105
EMI
111111111111111111111.
27. LOCATION OF OCCURRENCE
R ralf
28. MTF OF INITIAL ADMISSION iranrain
(Battle Casualty Only)
29. DATE INITIAL ADMISSION
107 108
(Y YYYM Ar1 D 0)
109 1 10
114
11111181111
GENEEMEMICI
120
FOR LOCAL USE
1111111111111111 11111111111
UL 1 oiVI t A (3 12A-t lam
V AK .Ztio gat!.q Baa
a
ITTING OFFICER
(Signature
SIGNATUR
OF ADMITT
DA FORM 2' ,M
2000
MEDCOM - 18491
1./SAP.A V1.00
DOD-032065
• INPATIENT TREATMENT RECORD COVER SHEET
.....ee AR 41-400., the proponent agency is OTSG
Mt.I
GRACE 7 ADMISSION REMARKS
ePLO Ki 14
4. AGE 6. RA LEND OF SVC
9 .
IA Ujr,-) I, l.).. 0 ..— t•-) Pr 13 A-
t, FM? 12. -
15. FLYING 16. 1 " ,i STATUS DSG BEN
SOURCE OF AOMISSIONIALITHORITY FOR ADMISSION
10Q. --(1. -pf2,01,--k ev--t-i--
24. NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE U,A0 ''--
K130 i.)—
27.. ADDRESS Of EMERGENCY ADDRESSEE Orchids ZIP Code/
LA--/4•) \)"."'
29. d F MEDICAL TREATMENT FACILITY .
31. SELECTED ADMINISTRATIVE DATA
33.
CAUSE OF INJURY

34.
DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES

0flG0.lhZAi10M
BRANCHICOPPS 16. UICIZIP
22. HOUF1S OF ADMISSION
oboo
25. TYPE DISPOSITION
1 0
27b. TELE NO.
LA-40 K
(_
'-/,`) --1--
./
10. PREVIOUS AIDLCSI8
14. WARD
20. TYPE CASE
23. GUMC SERVICE
a./ O
26. DATE OSITION
A • IV •.Y: . I; —.i
29. DATE OF . S
ADMISSION

Da S--)9 e)'-
30 . DATE OF MAL
ADMISSION

,
ADMITTING OFFICER
32. UNITS OF WHOLE BL DOW COMPONENT TRANSFUSED
¦ Chub if Continued on flown
W; 0 1 ao.) A (1:4}.....4,4,40;_

\l I:.11PAAIEL ,.
1.,.
19{2_0“ L .LEC,, V ..
-Th.
(.,s .if. q. ,-: -02...._ ,
I. 09 0 I .
tc...:.9 r ci. citill \..43-•.t3e22-z-
.
.\
35. Total Days This Facility.
7 C-1.:;2—.
7. ABSENT SICK DAYS b. OTHER DAYS CONY. LVICOOP \d SUPPLEMENTAL BER.OAYS TOTAL SICK OATS CAIN OAYS CARE DAYS
\ 21-..-j
a 211
c) n
0
36. Total Day. All Facilites. \
o. ABSENT SICK GAYS b. OTHER DAYS c. CONY. LVICOOP ' d. SUKEMENTAL a BED DAYS I. TOTAL SICK Dos CARE OATS CARE
_.--------------"-------- .....
SIGNATURE OF ATT
SI A DUCAL RECORDS OFRC
/ME COM 18492
3131117-1OTArTS on .no t saw In to n ••••••••• • In i•
DOD-032066
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, HIEF COMPLAINT, AND CONDITION ON ADMISSION
(Enter dole of admission)
o 7--nt V-"-stt-r
1 — ZAL- S-7".
•
S"-
1.(LE-­
(c). )
_41
1-11.
PI -7S
I
pv4-I F•7 D
Pt4441 ,y • . tAA'LA-1

PH SICAL EXAMINATION
L. i-4.44•
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