Medical Report: 26-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound to Abdomen

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FPI. LEX.2Printed on Recycled Paper STANDARD FORM 600 (REV. 8-97) BACK
MEDCOM - 16053

DOD-029442

NSN 7540-D0-634-41762
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD 1R CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
.

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HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE AT
i)H•ti\ -- r?‘' 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; REGISTER NO. WARD NO. Date of Birth; Rank/Grade.)
lc fici----

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSAACMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 16054

DOD-029443
DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
FPI. LEX.2Printed on Recycled Paper STANDARD FORM 600 (REV. 6-97) BACK MEDCOM -16055
DOD-029444
NSN 7540-00-634-4176 AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE 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 SSW; Sex; REGISTER NO. WARD NO. Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

\o( STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 16056

DOD-029445
— t?
7540•31.015.3788
LOG NUMBERRTR •
EMERGENCY CARE
AND TREATMENTMEDICAL RECORD

RECORDS MAINTAIR•
(Patient)
ARRIVAL
PATIENT'S HOME ADDRESS OR DUTY STATION
DATE (Day, Month, Year) TIME

STREET ADDRESS
ALLER GIES YES ND
A-06 d 24'(
CITY STATE ZIP CODER TRANSPORTATION TO FACILITY
SEX AREA CODERNUMBER DUTYILOCAL PHONE PRP MILITARY STATUS ITEM YES NORNIA ITEM ADDITIONAL INSURANCE THIRD PARTY INSURANCE YES NO
0 AREA CODE CURRENT MEDICATIONS AGE HOME PHONE NUMBER FLYING STATUS MEDICAL HISTORY OBTAINED FROM INJURY OR OCCUPATIONAL ILLNESS WHEN (Date)NOITEM YES DO 2588 IN CHART NAME OF INSURANCE COMPANY EMERGENCY ROOM VISIT DATE LAST VISIT 24 HOUR RETURN n YES la NO
IS THIS AN INJURY? WHERE TETANUS
INJURYISAFETY FORMS DATE UST SHOT COMPLETED INTITIAL SERIES

.
HOW

CHIEF COMPLAINT
VITAL SIGNSCATEGORY OF TREATMENT
tz.,
TIMETIME

EMERGENT
BP plOtg--0 PULSE 1'24--URGENT
lig
RESPINITIALS
ie
TEMP 6/1".V(

NO•URGENT C
CXR PA & LAT/PORTABLE C•SPINEBHCGIURINEIBLOODIOUANTPTIPTT
CBCIDIFF ABBRURINE C&S UA MSCCICATH LS SPINEACUTE ABDOMENCHEM:
HEAD CT BLOOD C&S X ANKLE R/L
SINUS
ORDERS

MONITOR nECG PULSE OX n PATIENTS RESPONSECOMPLETED BY TIME TIME
,f,t)
GrO
PAT1ENTIDISCHARGE INSTRUCTIONSDISPOSITION QUARTERS /OFF DUTY

n
DISPOSITION HOMERnFULL DUTY n 24 HRS. n 48 HRS. n 78 HRS. C SY
RETURN TO DUTYMODIFIED DUTY UNTIL

WHEN CONDITION UPON RELEASE REFERREDRTO
ADMIT TO UNITISERVICE
110'
IMPROVEDR

UNCHANGED
.

. I have received and understand these instructions.
TIME OF RELEASEDETERIORATED

.
PATIENTS SIGNATURE

PATIENTS IDENTIFICATIONR(fat typed of mitten *alias, give: Name — last,
liar, addle,-ID no. ISSN or ethyl; hospital ormedical facility)

EMERGENCY CARE AND TREATMENT (Patient'
Medical Record
STANDARD FORM 558 (REV. 8981
Prescribed by GSAIICMR FPMR (41 CFR) 101.11.203(b)(10) USAPA V1.00
40111111

LAB ORDERS
MEDCOM - 16057

DOD-029446
NSN 7540.01.075-3788
MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor) TIME SEEN BY PROVIDER 1.0
TEST RESULTS
ABGIPULSE OX RADIOLOGY Check if read by radiologist
C.) SUP 02 PH P02 RESULTS C 47 4t4
IT& I &Li PCO2 SAT OTHER
PT DIP EKG INTERPRETATION

APTT BHCG ETON GLU MICRO
PROVIDER HISTORYIPHYSICAL
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ACTION RESID NTIMEDICAL STUDENT SIGNATURE AND STAMP

-ATMWAEMNIIMIMPS

DIAGJOSIS
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PATIENTS IDENTIFICATION (For typsd or written envies, give: Name lost, first, &Me,-or mogul facility, ID no. ISSN or ease; hospital
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 IREV. 9.96I Prescribed by GSAIICMR
FPMR 141 UFO 101.11.20300110)
USAPA V1.00

--1111111,1(110) -
MEDCOM - 16058

DOD-029447
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CONSULTATION SHEET

TO: ,c 4.14t6
REASON FOR REQUEST (Complaints and findings)
PROVISIONAL DIAGNOSIS
t
!APPROVED
PLACE OF CONSULTATION
ROUTINE
TODAY
EI BEDSIDE
ON CALL

72 HOURS 400
EMERGENCY
CONSULTATION REPORT

ECORD REVIEWED Li YES u NO
PATIENT EXAMINED
u YES u NO
TELEMEDICINE

u YES u NO
SIGNATURE AND TITLE (Continue on reverse side)
DATE
HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
DEPARTMENT/SERVICE OF PATIENT

RELATION TO SPONSOR
SPONSOR'S NAME (Last, first, middle)

SPONSOR'S ID NUMBER (SSN or Other)
PATIENT'S IDENTIFICATION (For
typed or written entries, give: Name -- last, first, middle; ID no. (SSN
or other); Sex; Date of Birth; Rank/Grade)
ER NO.2

WARD NO.
CONSULTATION SHEET
F w -Medical Record
STANDARD FORM 513 (REV. 4-9E0

Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(13)1M
USAPA V1.00
MEDCOM - 16059

DOD-029448

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY i
DAY

0 la7­

POST-
14,
:1(0‘i
DAY
HOUR

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MONTH-YEAR
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(Centigrade Equivalents, for Reference only)
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PATIENT'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)
i i. \ i! ,r6. IA / 2—
7

VITAL SIGNS RECORDS
.

Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 16060

DOD-029449

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-2 DAY MONTH-YEAR2d DAY
/ t 2) Ici

2HOUR \• 2.., • N?
(O•2'
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R -0 la?). '20 ESPIRATION RECORD BLOOD PRESSURE • '2t•2•2•2•2•2•2..... 0 02, (pr 2‘,12•2 )0 ',:i 12C2611.11101CMYP rt 6 1°4 ..11•111Z011111 it cis k • • l 70 ii I 5-1,
a).c3 c HEIGHT:2I WEIGHT —••-¦
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fil
TIENT'S IDENTIFICATION (For typed or written entries give' Name—last, fist, middle: ID No.
REGISTER NO

(SSN or other); hospital or medical facility) am. WARD NO. I Cytkie4-
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 16061

DOD-029450

PREOPERATIVE/POSTOPEltA mit NURSING DOCUMENT
FOR Use of this form. see AR 40-407: the proponent agency is The Office of the Surgeon General.
Iodine, Tape, Medication)
2. KNOWN ALLERGIC SENSITIVITIES

7_ IODINE 0 TAPE FOOD
NKDA 0 PCN 0 LATEX

1. AGE:
ake
ACTION:
IE

HEIGHT: [ ] YES (type):
3. PREVIOUS SURGERY NO

WEIGHT:

80 LCA-

PROPOSED SURGICAt PROCEDURE:
4. sz_ 0_ ej Wu
JAL 1.)

ADDITIONAL INFORMATION: (Previous surgical and medical tory) Skin Condition
5. ASAIMotrin wi72 hrs (Y) (VI
0 Diabetes (Y) ROM

Tobaccosa_ppd X12_ vrs• Body Piercing Respiratory isease sthrna., COPD) (Y) Anticoagulants (Y) (b?)'
, Implants

ETOH( t Herbal Medicines (Y) MEDS:
Hypertension (Y) .

GlasseeChtact (Y) 94)RDentures (0R
I 7. PATIENT GOALS AND EXPE D OUTCOMES I 3. OR NUR ING INTERVENTIONS
PATIENT PROBLEMS AND NEEDS

6. y Allow pt. to verbalize freely.
/ Pt. verbalizes any specific anxiety.

A. PSYCHOSOCIAL tysi Explain OR environment and answer
otential for anxiety related /if Pt. Exhibits relaxed body posture.

questions regarding surgery. to: Offer comfort measures. (e.g.. warm . I) Surgical Procedure &
blanket. touch).
Operating Room Environment

Explain all nursing procedures before2) Separation Anxiety
they are done.(Chik_r) Remain with pt. whenever possible.
V/73 ) Surgical Outcomes 2. Maintain family interface. Parents to stay with pt.

7' Pt. will be able to breathe without itt Offer to elevate head of litter or offer
B. AERATION
difficulty during immediate intraoperative /pillow.
k"Potential for respiratory I Observe pt. while awaiting surgery forphase .

dysfunction due to: `signs of distress.
h/ I) Positioning

/ Assist anesthesia during iniubation
\-r 2) Effects of Anesthesia
and extubation.

MedicallSmoking History Pt. will not exhibit signs of impairment of yl Utilize pressure preventing devices on
C. INTEGUMENT skin integrity (e.g., reddened areas). OR table and accessories.
. Potential impairment of skin

/ Check for proper positioning andintegrity due to:
support to maintain good body alignment.
\-/-1) Intraoperative Immobility in Pad pressure points.

. 2) ESU Pad Placement

7 Place ESU ground pad on non
3) Positional Aids

/compromised skin surface area.
. 4) Prosthesis A Keep prep fluids from pooling.

%-.5) Pooling of Prep Solutions

VERIFICATIONS AT IIOLDENG AREA
9. PATIENT'S IDENTIFICATION: (For typed or written entries ! ID/Allergy Band ! Dentures Removedgive: Name- last, first, middle; grade; date; hospital or medical facility)
! Contacts Removed ! NPO Since0M ! Jewelry Removed UHCGiLMP !
H & P

Body Pierce Remover ! Consent/Blood Transfusion Signed/WitnessedDated ! Surgical Site!Consent verified by Pt./Anesthesia/Surgeon ! Contact Precautions (Y) (•Y ! Family/Friend: 0'
t:5 .4x.\ V I
Previous editions are obsolete.

DA FORM 5179, JUN 91 MEDCOM - 16062
DOD-029451

6. 'PATIENT PROBLEMS .AND NEEDS:
D. --.9-RCULAiTION:"..'. RPotential: for inadequateiissue perfusion due to:
. 1) Intraoperative Mobility
%..v 2) Positioning
ER• DiscR.se

Existing —7-4) Safety Devices RHypothermia
E. NEURON1USCUL.kR CONTROL
E.1. . Potential impairment of mobility due to: I) Pain
Intraoperative Hazards R3) Prosthesis R4) Positioning RTransfer pt. to/from OR table
E.2. .Potential discomfort due to:
1) Length of Surgery R2) Positioning R3) Arthritis
F. SPECIAL SENSES
F.1. . Diminished visual perception
due to being: . ) Pre-Medicated
R2) 1.1.-0 Glasses
F.2. RPotential for decreased cornmunication due to: R1) Diminished Hearim RLanguage Barrier --k-ea..1DiC,
F.3.RPotential injury due to dentures: 1) UpperR4) Cats
R2) LowerR5) Crowns R3) Bridges
G OTHER PATIENT PROBLEMS 'NEEDS. Or continuation of above problemsmeecis.
/R/R
10. OR URSING
RVENTION

11 POSTOPERATIVE EVAL L t EL OF CONSCIOUSNESS: 0 A&O LEVEL OF ACTIVITY:RXlIoves All
12. REOPERA
(Sire and Ti

DATE: 7...14‘.\A
REVERSE OF FOR. 179, JUN 91 r. PATIENT GOALS AND EXPECTED OUTCOME
S. OR NURSING INTERVENTIONS •
4
Check for support stockings or ace
/ Pt. will exhibit signs of adequate tissue

-raps. If none, check with doctors.
perfusion (e.e.. color, warmth, pedal pulse.

4' Check that safety straps are
correctly applied.

/ Offer pillow for under knees.
/ Place and take down legs from stirrups with slow bilateral motion. ,FS • Check that rings and all body
piercing has been removed
Pt. will be transferred to OR table without
difficulty. /o Have sufficient people available for
transfer.

fd Pt. will not experience unnecessary
physical discomfort. le Insure proper body alignment.
ja^ Allow patient to lie in position of
comfort while waiting for surgery.
/5 Offer support (i.e.. pillows. bath
towels. etc.) for positioning.

Pt. will be made aware of sun .oundings

A A Introduce self. Keep pt. informed as to
prior to anesthesia induction.

where he. she is and what is happening.
A Pt. will be transferred safely to OR table.

Inform pt. in which direcnon to move
Pt. will be able to understand instructions.
and assist if necessary.
/ Minimize danger of injury during intraop

/ Speak clearly and slowly.
period.

/ Address p: f7C.Tr. e I 14¦11,(Tid:!.
/ Validate pt.'; understanciin• of verbal communication. I Verify removal of dentures.
OTHER PATIENT GOALS AND EXPECTED OTHER NURSING INTERVENTIONS
OUTCOMES. Or continuation of above goals and Or continuation of above interventions
outcomes.

D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
Lic) terni -7-03 DATE
SKIN INTEGRITY: Bovie Pad Site:Rcan and Dry Red 0 NiA

RSSING DRY & INTACT: Z)owsyR:2 SleepyR. Intubated (N)
ExtremitiesR2 Moves Upper Extremities • EATHING EASY:
(N)
. Transferred to liner with roller due to spinal
PREPARED BY

13. POSTOPERATIVETVALUATION PREPARED BY (Signature and Title)
DATE: endvj 03 TIME: 11.6
USA PA Vi.'!
MEDCOM - 16063

DOD-029452

INTRAOPEFR)CUMENTMEDICAL RECORD

For use of this form, see AR 40-66, the prof2. ogenc,:• is the office of The Surgeon General.
1 PATIE T TRANSPORTED TO OPERATING R • OM 2. PATIENT I DENTIFIED, REC•2-2L2• AND PROCEDURE
% ,2.2.\2ri,

VIA204.4,/.'2.42BY2/ Alga t 0162,Lit.:4 j -4, ,, %,; • •/ 1-1C v., ,,-t. , -L._
3. DAT2 TIME PATIE T RIVED IN SUIT 4. PAT1EpN ROOM
•

72.2. 0 TIME I2 NU
5. PREOPERATIVE EMOTIONAL STATUS

41 fa CALM2. ANXIOUS2• EXCITED2• CRYING2• ANGRY2II WITHDRAWN2. OTHER (Specify)
COMMENTS:2Allergies: A1101)
6. NURSING PERSONNEL

ASSIGNED RELIEF
S —T

SCRUB SCRUB
1c).. ( - 2.--

ASSIGNED cre RELIEF oos_,6„,
CIRCULATOR CIRCULATOR

COI

7. POSITION AND POSITION
Ni. SUPINE2
. LITHOTOMY2• PRONE211 KRASKE2LATERAL:2• LEFT SIDE UP2• RIGHT SIDE UP
az

COMMENTS: eo2
,-,Ma'"A./yt,4ai/yLej2'
A.41_2

hik-
8. SKIN P EPARATION2

\to ((.6 -'2_
HAIR REMOVAL2112YES2Ng, NO PREP SOLUT2N S eci ),.12all\ DONE BY:2¦2OR2. NURSING UNIT SITE: 1±. (ACP , BY WHOM: (-TC 111111 METHOD:2. DEPILATORY2. RAZOR SITE: hit.2I or.BY WHOM:
¦2CLIP " COMMENTS: COMMENTS:20-e.2
a00 1 -ndtad

9. LOCATION OF EXTERNAL DEVICES
fcbinii 0 beYg . -icrAitI .5 & r A45,0 1114 IP I mINtes

I.
I.
13-1.1111

LEGEND2X Ground Pad - Safety Strap === Tourniquet
C = Correct2I = Incorrect2 i2\
i2, )
11,
t411..kiorsutn iosing ionuani posing (r,-10. COUNTS

SCRUB2( 2 '1--CIRCULAT Sponge2ISZ Yes . No t.../ Needle Sharp2grA Yes . No -

EratiffimmommouL____ tif

Instrument2. Yes217;1 No Other2MI Yes 40 No
11. PATIENT IDENTIFICATION (For typed orwwritten entries give:
12. ELECTROSURGERY DEVICE(S) (ESU) .$ YES2. NO
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
U ESU NO:2,/.1 A2__, , 0 1 - • .2/ 4,;. 1 11b (.11-0 GROUND PAD: 41 " • ND t* Laiarat. 2 LOT NO: 0,89 4& 1
.
ESU NO:

GROUND PAD: BRAND LOT NO:

.
BIPOLAR NO:

Ci-,Lk:OD czaA.q1)
2

-1, REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V1.01
MEDCOM - 16064

DOD-029453
13. PROSTHESIS, IMPLANTS
. YES cgr NO
IF YES NAME: ID NUMBER; MANUFACTURER
.. ..2. .. .___ . __ _ ____,...-.,—..

-:. -- ------:,.,.....::,:.:::‘,,,:::::‘:;=,:w::::::ok::::,::s.:$::::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::WM:Eiii:iiiiK:::Mii
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES . NO IQ
WEDICATIONS/SOLUTION
:.. DOSAGE TIME METHOD PREPARED BY GIVEN BY
MOUND IRRIGATION Cg YES . NO, TYPE(S):
0. ',Z AG. CI
:41, •

,OTHER ORDERS
TIME CARRIED OUT BY
PHYSICIAN'S SIGNATURE
., .
. - — .
•
.. .,

15. X-RAY IN OPERATING ROOM .--...-.... ..—.
IF YE SITE

YES K2NO .
16. 10.bniV4. e- eu.ryl_-
LABORA roRY SPECIMENS •
SPECIMEN (S) NAME

NAME

YES . NO Ex
FROZEN SECTION (FS) NAME
NAME

YES . NO
CULTURE (C) NAME NAME
YES • NO
NAME
NAME NAME

NAME
NAME 18. DRESSING/IMMOBILIZATION (Specify)

gs,m, kay , (Ai') sly2 i v0 1 4(2
17. TUBES, DRAINS/PACKING YE-3
NO iii5 TYPE/SIZE 1. 2.
3.

S/Q" PeAmi SITE 1. 0 66 2.
3.

19. ADDITIONAL INFORMATION
WC Surgeons: 103 e Anesthesia: 01111.044 Anesth sia Type: aET/T
. 1 Bovie Pad site intact pre-op
... post-op(-1." Bovie Settings: Coag/Cut 3t)?3D

Tourniquet Site intact pre-op : post-oLP,— Tourniquet Time: Up,....aDa2---. Sec A (6
20. OPERATION(S) PERFORMED
\,.-2•
¦,,-26 Y Z
21. PATIENT TRANSFERRED TO .--"
TIME
METHOD
•-¦ (7[4 -D
Via .. LT' LI A I
MEDCOM - 16065 —

VERS OF DA FORM a ii -
USAPA V1.01

DOD-029454
' bath TWee - .f,;:;.4t .: INTRAOPERi,Rd DOCUMENT
,
441 T
'

:-Sfg, . 4:'-!..cR-,::137.0.6940:::".) For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.
'R4RE '!'-...R11!R• -CiP'ITEIATOTIPERATING ROOMR.
2. PATIENT IDR

.R.R, e4' t! Ritie,'•-•R, '.5 '%:.'R- ED AND PROCEDURE
%.,Rt.R...k.• R. By• : •Ra...4%-LO
VERIFIED BY :3... DATE.'.R
ARRIVED
PATIENT ARRI ED IN SUITE

4. PATIEN3 IN -
0 °Rg OLIO

_R TIMER0 00 NUMBER

5. PREOPERATIVE EMOTIONAL STATUS
CALM U ANXIOUS • EXCITEDR• CRYINGR• ANGRYR
• WITHDRAWN

OTHER (Specify) COMMSRS:
.\.) (-)`)

6. NURSING PERSONNEL
Sp 0

ASSIGNED
RELIEF

SCRUB
SCRUB
eirillir (../ Co 6-7-

ASSIGNED
RELIEF
CIRCULATOR

CIRCULATOR

7. POSITION ANDROSITIONALIDR(Specif/
op,2cyy ,a+. ik ,) ct am Wycl)3 C.-4TO .?
-)2
UPINERLITHOTO RfR
PRONE • KRASKE LATERAL:

. RLEFT SIDE UPR111 RIGHT SIDE UP
COMMENTS:
8. SKIN PREPARATION HAIR REMOVAL • YES NO -
PREP SRN (Specify)
DONE BY:

. OR . NURSING UNIT

SITE:R6 0 RBY WHOM:
METHOD: 11 DEPILATORY ¦ RAZOR SITE:R

BY WHOM:
. CLIP IR

( (-t) -COMMENTS:
COMMENTS:R2 R-ie?D(C.4.1

9. LOCATION OF EXTERNAL DE ICES
•
.• -1 L —

Ili-R-

4111411111 k
LEGEND 4(i Ground PadRiR--R-fety StrapR=

= = Tourniquet C = CorrectRI = Incorrect First Closing Final Closing

10. COUNTS
Other• • Count Count
SCRUB
CIRCULATOR

SpongeR Yes No Needle SharpRU Yes No InstrumentRYes No OtherR• Yes No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU)RU YESR• NO
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
ESU NO: \A-d* if R..., k-i\\N BRAND j(../ &ANA_ it-72r--
GROUND PAD: LOT NO:±13 Ct
;R
Aj (-A )
¦ ESU NO:
GROUND PAD: BRAND LOT NO:
• BIPOLAR NO:

. DA FORM 5179-1, OCT 87 REPLACES 0,,
o. i I oz, vvniCH IS OBSOLETE. USAPA V1.01
DOD-029455

13. PROSTHESIS,.IMPLANTS • YES iNO IF YES NAME: ID NUMBER; NUFACTURER
,2.

14. ..-.7?;,;,04e7 ,400440*-,7'140M1 MEDICATIONS/ORDERS:41M ,4' ,ff2---,-2r4-7", _2.
4e, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES I NO V MEDICATIONS. SOLUTION DOSAGE
41V41:

TIME METHOD PREPARED BY GIVEN BY
WOUND IRRIGATION \i YES • NO, TYPE(S): Y C6 t OTHER ORDERS
TIME CARRIED OUT BY
PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING OM

IF YES, SITE
YES E NO

16.

LABORATORY SPECIMENS SPECIMEN (S) NAME NAME YES . NO -FROZEN SECTION (FS) NAME
NAME YES ¦2NO 1 I CULTURE IC) NAME NAME YES . NO NAME NAME
NAME

NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES . NO F(U7 7J TYPE/SIZE ' 1. 2. .
ep.-tAy

SITE . 2. . 00Z
19.lifADDITION'iffirON
SOC64jY\ s-1 r-

k fr-oe r da-g v-G\0001 C30
asPit
. o., tg-ftreo ,200)6 dricl-t0v4 , atuc,
V,IA cfLp,_
6) Vj\i 44411

....._ /-/ cL4 rek A-/e,.. MDR_2re-A--, a u-e-4__ K-SI7-41
a-4 .4_4.-4-.1 id
20. OPERATIONS) PgRfORM
t

21. PATIENT TRANSFERRED TO f12,(.iti2/ T11¦843..-MET 0 I
' .1f P /ei
¦2•

22. REGISTERED NURSE SIGNATURE 7
•-,-,:, . -----ttritt,
REVERSE OF DA FORM 5179-1, OCT 87 .i:.01101E1 MEDCOM - 16067
•

DOD-029456
410

i-5 TT S+

1111111
I2iT3
Pt ratient
Lit

Pt Name: .

u4 *H xl0'31)IL 4.5- 10.5
5.95 1-1061ti 4.00 Figb16J-11.0 18.0
mg/dL

14rt 5-3.9
BUN.fL

_14 mg/dL

-rIeff 28.4 pg 27.0 51.0
Na.134 mmo 1 /L

ro:lie 31.0 L gAIL
.3.4 mmo 1 /L ; Pit 7(11. H 150. 450.
iyz 7%0220.5
.

, 97_ mmo 1 /L

• LI 2.5 * x103/aL
Hct .

;:PCV
Hb*.19 g/dL

vio
*via Hct

Samp 1 e Type_:

07AUGO3.

13: 04

Op er : 1111114

Physician:.

Ser# 4074.3
Ver: JAMSO46A

CLEW A93

DOD-029457

LAST, FIRS , MI.
2

CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974) TIME SSN/PSEUDO SSN:
3LU 73-118 mg/d1-----== PICCOLO =======.
3UN 7-22 mg/di
07/08/03.

12:59.

2.AL++
Na
K
PH
PCO2
P02
TCO2
HCO3
s02 BBecf
AnGap Ca BUN
GLU
Creat Hct Hgb
138-146 mrool/L
3.5-4.9 tranoUL
98-109 mmol/L
7.31-7.45
35-45 mmFlg (art)
41 -51 mmHg (Yea) 80-105 mmHg (an) N/A (vea) 23-27 mmol/L (art) 24-29 mmol/L (vat) 22-26 mmol/L (art)
23-28 mmoVL (Yen) 95-98%
(-2) — (+3) mmol/L 10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/d1
70-105 mg/d1
0.7-1.5 mg/dl
38-51% PCV
12-17 g/dl
.116iniS
REFERENCE RANGE: MALE

PATIENT #:

MOO OFZE

GENERAL CHEMISTRY 12 \I)(J

1A+
DISC LOT #:.

3142AA4

K+
OPER #: 210.

DR #: 000

SERIAL # .CL"
00001 00684

tCO2
ALB 4.5.

3.3-5.5.

(3/DL

ALP 128*.• icco
26-84.

U/L

ALT 41 10-47.
•
.U/L TEST RESULT
.AMY 43 14-97.

.U/L

.AST ALB 3.3-5.5 g/dI
29 11-38.

U/L

TBIL 0.7.ALP 26-84 u/1
0.2-1.9 MG/DL

.

BUN 12 7-PP.

MG/DL ALT 10-47 u/I
. CA++ 10.6* 8.0-10.3 MG/DLCHOL 243* 100-200 MG/DL AMY 14-97 u/1
.

. CRE 1.1.

0.6-1.2 MG/DL

GLU 133* 73AST 11-38 u/1
.-118 MG/DL

TP

9.8* 6.4-8.1.0.2-1.6 rug/d1
G/DL TBIL GGT 5-65 u/I
INST DC: OK.

CHEM OC. OK

TP

HEM 0 , LIP 0 , ICT 0

TEST
NA+
CU
tCO2
REPORTED BY:
iDATE: . LAB ID NO.:

8.0-10.3 mg/c11 0.6-1.2 mg/c11 128-145 mmo1/1
3.3 -4.7 nimolit 98-108 mmol/1
18-33 mmol/I

änIU
REF. RANGE
6.4-8.1 g/d1
RESULTZEFTffigrOk
128-145 mmol/1
_J

3.3.4.7 mmol/1
98-108 rnmal 18-33 mmol/1
TEST RESULT REF. RANGE
Troponin-1
Drug of Abuse
REMARKS:
MEDCOM - 16069

DOD-029458
Ward/Section: REQUESTING PHYSICIAN:

LABORATORY RESULT FORM
LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN:

ematOlogy) CBC : s. UrineRis . Misc. Serology:
TEST ULT REF. GE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8x 10' Color N/A RPR Negative —
RBC 4.7-6.1 x to9 App N/A Mono Negative
He) Het 14-18 wai (M) 12-16 g/d1(F) 42-52%(M) 37-47% (F) Glu Bili - Negative Negative • Source Microbiology• • 1
MCV 80-94 11 (M) 81-99 fl (F) Ket Negative Gram Stain
Plt 130:500 x 103 verified SG N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
ein; atO ) Manual Differential.: . ... pH N/A . Micro
Parasites
Segs Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative •Mip:osciipie Urinalysis•
RBC HCG Negative Morph ,
• .._ _ spun 42-52% (M) Hem atocrit 3747% (F)

Sed Rate Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh
Coagulation Studies, •R • •R.Blood: BankUnit CrOssinitcli • : (MUST,SUBMTT, .SF,518.Wri11 EVERY UNIT OF. BLOOD . •-R'• .RREQUESTED) •R
•
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/ml
FDP 10 ug/ml
REMARKS:
R

REPORTED BY: LAB ID NO.:

MEDCOM - 16070

DOD-029459

MEDICAL RECORD - ANESTHEI.
F O,
...is form, see AR 40-66; the proponent agent.. y is L.. , OTSG

ickaiar-
AIR L/Min CRYSTALL5-N20 UMin 02
L/Min '7
z SINGLE DOSE DRUGS-MARK ON GRID..
WITH NUMBERS & ENTER IN REMARKS

LINE site -2.0(ViCE Warmed
(--ft 10
El Warmed

0 Warmed Code drugs with numbers, event with lettters
CI Warmed

UR NE -IVO II ore
TIME -4
3 4 5 ER
Rot

220
BP by cuff
200

V

ATOR
A 180
rtibAt,9*ec(
Heart rate

160 cy4,r , 0,9,#cti
• nammistammammimm
Resp rate 140

BP-
•••••:.2.;2 .2:
161111.1111111ii_r114,11911

120 I CL Z
HR-BR
(transduced) 100

111
I2I2: J.= •
80

T 1111111E11!fill11111 R

OK?-N
TOURNIQUET 60

P1211221112R

*kir RE EcK T —4/
40

OK for
PROCEDURE? ,„)

ANES- x-x

20
TIME- ONS

PROC-
VT ml
f - breaths/min
Peak inf pres / PEEP

MODE S on), A ist), Clon)
01 ".7

al • P/Auto Cuff T CO2 (torr)
RECOVE
CIcc— Cr3P/oth
trillWillInall

EIMINAIMIMIZI

PACU ICU (Specify)
ART line

/pig'ammo,

OTHER
100 --"17
ECG

IMARVIINIMILINII

C9NDITION:
Wulf!

T.--g HR-
;/-*; '

RESP-i • Sp.2.• BP- if
gSTil
..
in

Start Room End a Cony warmer 03$) OT-00 0500 •
arming blkt UI
Mark with letters & symbols,
EVENTS

explain under REMARKS Ready Begin End
Position
TM'

gc. Ow
V. OS
ANESTHETIC TECHNIQUES:
Describe block technique under Remarks

PATIENT IDENTIFICATION:
Type or written entries: Name, Grade/Rate, Crirlir
AIRW1:).Y MANAGEMENT'

Intubation route, blade, technique, commentsMedical facility
0 -Cifilii4^- SLI Fg A)
SU

P. CEDURE
LOCATION. DATE:
git)

AGE F
DA FORM 7389, FEB 1998
MEDCOM -16071

S ME ICAL RECORD USAPA V1.00
DOD-029460

MEDICAL RECORD - ANESTHE;
•00 t,.
IS form, see AR 40-66; the proponent ageri,y is the 0
-1-G

2 z cms 3 TOTALS
V ,,„,)

IJJRLL
eq ) , ZS-0
Z
) 20e,
Z
00 % del Z n % e.t.
ZZ 1,9 It
L)
Z w AIR2L/Min
CRYST
0-
3
U)
N202L/Min L/Min /0 — — COLLOID­
022

SINGLE DOSE DRUGS-MARK ON GRID.., WITH NUMBERS & ENTER IN REMARKS
BLOOD-
LINE site LI Warmed
(1-1Z ItS - El Warmed u4130 t :IMAM(
E] Warmed 1:1 Warmed Code drugs with numbers, eve ith renters
EST BLOOD LOSS ,-
TIME BP by cuff V A Heart rate URINE -1 aim 11/5 B ?NT 9- 200 180 160 220 /11.. IMOMEMNEERINIENI "tra,Cv-r ti MIEMI IPS= All1111111111111171111111PREVEll111110%.111C AIME 11111 00 • 0 , 4. 6. l4.11S iL
•
BP- Resp rate 140 I
HR-2 47- BR 120 WYPAWARINIKTIMIESIIN11 111111111111
(transduced) 100 .. ,
80
OK for OK?-. TOURNIQUET litkai0004titO.k: T —/1/ WPM TAMP REMINIFIPMENNI 41/11XILIIIIISIMALtaLill1111111160 40
PROCE TIME- E. 0 ANES- X-X PRO C- 0.0 20
• ."...:.•
f- breaths/min2 VT - ml ID too W/11111Klif. MIN
Peak inf pres / PEEP lir MODE - Sfpon), AIssist), C(on)2We., c .-1 BP/Auto Cuff BP/oth ET CO2 (torr)23 3 F102 (Frac or %) ',I ART line2Sp02 (%) Steth- PC/ES ECG -2. 14111WIENIMINI l. A lob /11111inErinffliarn2Mnittiaiiii Vi 000600101 Yire PACU ICU Z____ISpecIfy) OTHER CONDITION:
N-M Block (T/4) wilr (1` t'.q i RESP-.1 1 :AN p02-... .. "..T.Rogg ..

Warming blkt cn Start Room End Cony warmer
(f. /gesi /9Sr
Mark with letters & symbols,
EVENTS_,

explain under REMARKS Ready Begin End
Position
cc ANESTHETIC TECHNIQUES:

PROCEDURES and CPT Codes:
Describe block technique under Remarks
Gem,
ihifstik/

PATIENT ID IFICATION:
Typed or written entries: Name, Grade/Rate,
AlftWAY MANAGEMENT
: lolubation route,
Medical facility WIZ C7X S;4, t{f 70 blade technique, co
corn

rtj 2,a Kr%
)r
SURGEON5: 1,k* 0 zycm,.

4, 605€55 PROCEDURE
ofaik )01_ ct)- 2
LOCATION: ANEST
2

DA FORM 7389, FEB 1998 R -2. A A. GE j OF/ MED YR• 1 COPY 1 - PA E 2
(CAL RECORD USAPA V1.00
DOD-029461

PRIMMURAL ASSESSMENT (Sedation/Anesthesia)

Age AYS MOS
Sex (+MALE ( ) FEMALE

PROPOSED PROCEDU
SURGICAL SERVICE
NPO SINCE: OROO ern

HABITS;
PREOPERATIVE

TOBACCO:
PAST MEDICAL HISTORY/SYSTEMS REVIEW

ETON: 'ASSESSMENT
Cardio

DRUGS: PAST SURGICAL/ANESTHETIC
Hypertebsion
Angina

CURRENT MEDICATIONS:
MI

( ) a.- ordered as premed 5'
CVA
Other
Pulmonary System:
Asthma
() Bronchitis/UR1

()
COPD PHYSICAL EXAMINATION
( ) Other BPRTig RRT (zr
()

Renal System: PainRle 0-10 HEENT - Teeth
Acute/Chronic RF

PREMEDICATIONS:
Gastrointestinal: Trachea

None Yes (0R
Hrs) /CC

Flepatitis TPAUNeck Mon, • 7it03
rng IV IM PO

Hiatal Hernia oroPharnyx_1%.271
mg IV MI PO EE Nave;

PUD/GERD 140,
Mg It/ 111A PO CHT: r-r-
Endocrine System: fav
CPT" Xi, (

Diabetes T C
LABORATORY STUDIES: CARINAR
Steriods

11 AL re la it:6
Thyroid

HWHCT:
Neurological: EXTREMITIES:

WA:
Seizures

OTHER:
L. Neuropathy IV Access: 1 V".cx"..3 Other Ulnar Filling: R Gynecological :
Pregnancy
[OS 3.9 Ao Other Significant Hx:

OTHER: R

1,31' t't 3
Familial HX
NPO Since

ANESTHETIC PLAN: ( ) LOCAL (} MAC R
{ Regional (Specify):
General:

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
discussed with the patientilegal guardian.
(

The
d dR
Questiot arts

Sig
rime: j(i

Firs
SEDATION KEY:

1.
MINIMAL (Anxiolysis) Patient responds normally to verbal commands

2.
MODERATE (conscious sedation)

Patient responds purposefully to verbal commands alone or
Patient Identification: (Ward)
accompanied by light tactile stimulation. Airway assistance is not
necessary.

a. DEEP SEDATION/ANALGESIA.Patient responds purposefullyfollowing repeated or painful stimulation. Airway assistance maybe necessary.
4. ANESTHESIA. Patient does not respond totinfulstimulation.
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS MEDCOM - 16073 re.N I PrtUORD COPY Previous edition is obsolete * U.S. GPO: 2002-729-283
DOD-029462

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 -2 11-5-7c / 3 19 S HOURS
NOTED AND SIGN

NURSING UN
PATIENT
IDENTIFICATION
DATE OF ORDER

TIME:e ORD

NURSING UNIT ROOM NO.
PATIENT
N IFICATION
ORDER

TIME OF ORDER
HOURS

NURSING UNIT
ROOM NO.
BED NO.
/2)x19)-- b ',pier

PATIENT IDENTIFICATION
DATE OF ORDER

TIME, OF ORDER
N - Lt. z-fi
)„)
P. )42/4 2s2._.¦
• ar", 7 6-22.,Dr\ NAg f)i.ke "/"52.6Y62p,13,2vz
442. 404-2ACJ.

03g
NURSINGbUNI ROOM NO. ,t6 ZI)2 1/VAA /).)
717 252

e2N 2

aLr\i32cc is
4e,06. -fr7 )29,0)th77 tfr

FORM /4 de) AVZ

DA 4256 14--
1 APR 79 TION OF 1 JUL 77, WHICH MAY BE USED.
El MEDCOM - 16074

DOD-029463

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
4r DATE OF ORDER

TIME OF ORDER .LIST TIME ORDER03-1/2 —
NOTED ANDHOURS SIGN
RSIN BED NO.
PATIENT IDENTIFICATION !' L'SV \171:1 (DATE OF4FrEV 6tizr 2 kiti141\1 HOURS
NURSING UNIT BED NO.
PATIENT IDENTIFICATION /14VZS HOURS
NURSING UNIT 7( ROOM NO. ION OF ORDER HOURS

0363
NURSING UNIT ROOM NO. a 1°A BED NO. 05-
FORM 1 APR 79 4256 REPLACES EDITION OF 1 IIUL 77. WHIC
D MEDCOM - 16075 10

DOD-029464
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
HOURS

few b7) P1 fp
SIGN
1--/

NURSING UNIT
ROOM NO.

PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF'O
7 Ves -/1)"..
HOURS
?-1.01..A e)ahl
Y 4
)/-1 A
i"Z

NURSING UNIT
ROOM NO.
BED NO.
(-6

PATIENT IDENTIFICATION
DA
TIME OF 0
HOURS

NURSING UNIT ROOM NO. A
BED NO.

TENT IDENTIFICATION
E OF ORDER
TIME OF ORDER
HOURS

03g
NURSING UNIT
ROOM NO.
BED NO.
1 JUL 77, WHICH MAY BE USED.

DA= FORM 4256
APR 79
MEDCOM - 16076 10

DOD-029465

TUrb eon iron n
i g ii-n/AU EIJI 14 UMUllfitill I

7 CLINICAL 11LUUKU For use Al ILIAIUARE-SOB AR 413407; PLAN (NON-MEDICATION) ,
of this }01111;699I the proponent arcs is the Office of The SUMP General.R

/ VER1FY BY INITIALING nektgarnigninagennallen 1 M°. Yr '
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER CLERK! RECURRING ACTIONS, HR DATE COMPLETED
DATE NURSE

FREQUENCY, TIME

/ ¦ ¦

7 8 n to 1911111MHEIVIOIN
1 603 I wr
....1
Ali

ormum........................1111111

d 4 a iwimiLMiewilliffenlEg-__ir
1
Eitsm
ar,71.1 113

‘1 6
r\CIE—)% (ip P .14 Sekrq-1On RI:f'

Mk 111111111111111111111MMEIMMEINIMIINIJ 111 Jr
74Vals
IF

tOtlit
.
a. OIL '''

tp e AlI S
111111111116 MN

1 o` r all2,2ts__ mg. IIMPpw4111.
• 1° SEISM ,11111
mammilA"-r--- -Airs:
,.. 0 II amino am

iimesie
ALLERGIES: I I YESRI I NO PRIMARY DIAGNOSIS:
, ADDITIONAL PAGES IN USE: IRLYES I I NO
G511/0 /13 cf-Q! 0 v lip lirP"
PAGE NO:PATIENT IDENTIFICATION:

ACTION .... TIMES USE PENCIL. CIRCLE ACTION TIMES _IAIIIr9 ( (k) 1
D 8 9 10 11R12R13R14R15
ER16R17R18 19R20R21R22R23
NR24R01R02 03R04R05R06R07)A FORM 4R77 I run-7RR
MAY BE USED.
USAPA V1.00
MEDCOM - 16077

DOD-029466
¦
0( cQ \,)-2 4\

THERAPEUTIC DOCUMENTATION CARE PLAN

Verity by 1Mo Yr
(NON-MEDICATION)

Initialing
Data to Tone to Time Done Initial:

Order Clerk SINGLE ACTIONS be Done be Done
Date Nurse

7A/60y /7/j ell _
'WC „LC I.-2
frO
.if •

. ,
,-41 516--
-,a‘ ' INV 1

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..-

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.
.
)
.4'
•
4 I
INITIAL PROPER COLUMN FOLLOWING COMPLETION

Order! PRN
Clerk!
TIME/DATE COMPLETEDEx* Nurse ACTION, FREQUENCY

Date
USAPA V1.00
MEDCOM - 16078

DOD-029467

L— THERAPEUTIC DOCUMENTATION CARE PLAN
CLINICAL RECORD (MEDICATIONS)

Toru e of this fon% see AR 40407: the proponent .oyencv is the Office of The Swoon General. mo. Y Y.
VERIFY BY INITIALING
gaNSMOMENNEMONW INITIAL PROPER

COLUMN FOLLOWING EACH ADMINIS7ItA770N
ORDER CLERK] RECURRING MEDICATIONS, HR DATE DISPENSED
DATE ' E DOSE, FREQUENCY

¦

73 NI DPIME111111SENI1F1J 1 et LO
LTNMFAIZTZEEI
....o.cE i

Er-1111111•
co irapym1=1_,ir iiZin
.„,,w,,,Tamial NI

IINIMPIIIIIIIIIMIS 111111111 .lissolfil NIP
7/4ao; A. c.e2T 6 m .C1//13 effiv5 Lg -AA
a JIM
LA liormoiastior mall
lia---t, a / 1(1..-.. 1.110.1
_
1111/11

............... 4

ALLERGIES: .YESR. NOIPRIMARY DIAGNOSIS:
ADDMONAL PAGES IN USE:
5 ttiRI el 4-e fi 0 4 ,- ,/P2* . ect YES I I NO
PAGE NO.
PATIENT IDENTIFICATION:

DISPENSING TIMES

44)-1/NL b(ce) - (-1

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
DA FORM 4678. 1 FEB 79
USAPA V1.00
MEDCOM - 16079

DOD-029468
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

CLINICAL RECORD
For u e of this form, see AR 40.407; . the,proponent Rem is the Office of The Suwon General. R

IMo. Y r.
FY BY IN NG 4IRMR:reannniNS :i.age: IMTIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

ORDER CLERK! MEDICATIONS, HRR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

7/Pgos3 . $0 r 2-6 7) ..1-vo

1 111 ' nit
u,,,,,,,,,a,, •f-,
J -WIMP • HPPW0M! ‘.0-' .......c.... .1.2, M. ''..%

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id primiirra
il t117 laia

1111 irliorminiimurt
.I Ai 1 1. - -MENNE1111110111141111117R EPSm.,
11111.1k. *a. In,....-,..r._—., k-1.,....irL-..b111WWItig"17111 11 "9 -bOrMiaN• .
1117 ft '' 11--
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I 11.11
ALLERGIES: IRI YES M NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
J . QYESREll N 0

PAGE NO.
PATIENT IDENTIFICATION:

DISPENSING TIMES

/ USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14
\ r_,V1/43--)
PR /

./

E 15 16 17 18 19 20 21 22
It
N 23 24 01 02 03 04 05 06
n Emma 10,13 q rrn -4n
77 WILL B E USED UNTIL EXHAUSTED.
LEAPA 71.00
MEDCOM - 16080

DOD-029469

OD
01°
. MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this farm, see AR 40.66: the proponent agency is the Office of The Surgeon General.

2 OTSG APPROVED Ware
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet

DP¦
--r°b(t C CO Date: I t) Vift..k.G\ Anesthesia Type (Circle)): General Spinal Epidural
Drains Airwa Time In: - kien in 1 n IV Sedation Nerve Block Hemo _ Nas 1 ILC t Allergies: Y AilOn-OR Intake: Crystalloid °-/A5?) At. Colloid N Pre-op V/S: 1b3iuro 90 OR Output UOP CQ EBL
J

Procedures: i I I) I J Medsrnmes: VYJI410 T ube
T ch 0-57) r)ttil 1 6 615011 oley Cher
Pre Op Meds Histor TLS
Time

Pacu Intake
Sa02 Time Solution Amount,bite

gip qu By Infused
F102
Methods
240
220 .5 X-rays: . Labs:
PostAnesthesia Recovery score 200 Criteria ADM 30' D/C Codes Activity
AIRWAY 180 (1) Moves 2 Extremities =Ambu
(2)
Moves 4 Extremities

(0)
Moves 0 Extremities B = Blow-by M = Mask

Airway

160 FT = Face
(2)
Cough, Deep breath

(1)
Dyspnea. timited breathing Tent

(0)
Apnea RA =RoomAir

140 NC = Nasal
Blood Pressure
Cannula

(2) SBP =/- 20 of Pre-op
120 (1) SBP =/- 20-5D of Pre-op

(0) SBP 50 of Pre-op V/S X = A-line BP
Consciousness

100 = Cuff BP
(2) Fully Awake, audible = Pulse
ung
(1) Arousgkble to verbal or plain

80 TEMP
Color
S = Skin
(2) &amine calor & appearance

60 0 =Oral
(1) pale, mottled, jaundiced

(0) Cyanotic A =Axillary
T =Tympanic40
Circulation (Peds 5 Years)
R =Rectal
(2)
radial Pulse Palpable

(1)
AxAtary palpable, not radial

(0)
Carotid only ratable pulse

LOS

20
C = Cervical
TOTALS: Must be 9 or
T = Thoracic
greater to D/C, otherwise

RR L = Lumbar
needs anesthesia approval for
S = Sacral
r„z, D/C.

Time
Patient teaching done; Wound Care, Pain Management, Pain (0-10) T, C, & DB.. Incentive Spirometer, Comfort Measures LOS
Safety: SR up X 2, Falls Precautions. Privacy Maintained

'Lento-am Oa reverse
PATIENT'S IDENTIF
—last

first middle; grade; date; hospital or medical batty!
.
HISTORY/PHYSICAL I FLOW CHART

.
OTHER EXAMINATION OTHER row*/ OR EVALUATION

.
DIAGNOSTIC STUDIES

ENAf
EI TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPPC
MEDCOM - 16081

DOD-029470

MEDICATIONS
NURSI G NOTES

Allergies: Time Pain Medication & Route Pain I/E By1-10 llonace 1-10
(r.!

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
Adm
(L t -1--4+ T, + Y7

15' a -1--bp 1 b 30'
'7 7171-".1 4--

45' i
60'
90'
D/C

Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D =Doppler. A = Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, S= Sluggish P= Pale, Pk =Pink C-SECTIONS Adm 15' 30' 45' 60' 90' D/C Fund. Height Lochia Peripad# Fund. Cond.
DRESSINGS
Time

Location Type Drainage

Adm /
30'
60'
DIC

PACU OUTPUT
Time Source Color/Appearance
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?

Discharge riteria:
Date:RTi PARS:
BP: RR: 2 Sa02
Pam a io '0 -10
Intake:R 0 put:

Additional D. a: 4141/40W"" Transferred o: ----/V411.2;141.r R4 I Pr :A9 Report Given To:

Transferred Via: umeRAmbulance Transferred By: Cleared IAW Re Charge Nurse gnat
WAMC OP 173-E
MEDCOM - 16082

DOD-029471

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 40.66; the proponent agency is the Office of The Surgeon General
.

REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet

OTSG APPROVED Ward
Date:
Anesthesia Type (Circle)):R

Time In: General pinal Epidural
Drains

Allergies: IVColloid on Nerve Block Airway
OR Intake: Crystalloid -14 CVC Hemovac NasalPre-op WS:
OR Output: UOP NG

EBL /111. 1 ^ Oral
Procedures:
ae. Medsfrimes: _2(c 3M0(4 y . JP
ETT
Ped. rrite' d T-tube
Trach
Ner-)/A Foley
Other
TLSTime

Sa02 Pacu Intake
F102 SolutionRAmountRite •

TimeRn e
1 I

Methods
240
220
X-rays:

Labs:

200 Post-Anesthesia Recov
score
R
Criteria
ADM
30'
DIC

Activity Codes 180 (2) Moves 4 Extremities
AIRWAY
(1)
Moves 2 Extremities

A= Arnbu

(0)
Moves 0 Extremities BB = Blow-by

160
Airway
M = Mask
(2) Cough. Deep breath
FT= Face
(1) Dysprop-a. abed breathing

140 Tent
(0) Apnea

RA = RoomAir Blood Presstrre
NC = Nasal
(2) SDP =1- 20 of Pre-op
Cannula
(1)
SBP =1- 20-50 of Pre-op

(0)
SBP =I- 50 of Preop

V/S
Consciousness
X =A-line BP
(2) Fully Awake, audible

=Cuff BP ng
= Pulse
(1) Arousable to verbal or pain
1

Color TEMP
(2) Baser* colors appearance S = Skin pale, mottled, jaundiced
0 = Oral
(0) Cyanotic

A = Axillary
40
Circulation (Peds 5 Years) T = Tympanic
(2)
radial Pulse Palpable R = Rectal

(1)
Axillary palpable, not radial

20
(0) Carotid only reliable pulse

LOS
TOTALS: Must be 9 or C = Cervical
RR

greater to DIC, otherwise T= Thoracic needs anesthesia approval for
T L = Lumbar
D/C,

S= SacralTime
Pain (0-10) Patient teaching done; Wound Ca e Pal
Managem
LOS T, C, & DB,. Incentive Spirometer, Comfort Measurese nt,

Safety: SR up X 2, Falls Precautions. Privacy Maintained

PREPARED BY Sigoature
DU
Lon mue on reveael
DEPARTMDITISERVIC MC
DATE
(

PATIENT'S IDENTIFI TION (Fort
Name —last,

first, middle; Fade: data• hospital or medical laarityl
.
HISTORYIPHYSICAL

. FLOW CHART
.
OTHER EXAMINATION

. OTHER ap;civOR EVALUATION
\,0
. DIAGNOSTIC STUDIES
13 TREATMENT

DA FORM 4700, MAY 78
WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-0141) PrOliious edition is obsolete USAPPC vice
MEDCOM - 16083

DOD-029472

MEDICATIONS

Allergies: Time Pain 1-10 Medication & D052ne Route PV rS9// ill 5 ' c„, Tv c Pain 1-10 3 I/E ee, B NURSING NOTES (Vvr.-s, mf48, -t-c) kt t-G,r1 ozz,(7 -ISS c,c10A,Irke-retoury, alp
nt 4)214... )?3
t -1),eti e
NEUROVASCULAR p
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Mm
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, Capillary Refill: B= Brisk, S = Sluggish P= Pale, Pk =Pink
C-SECTIONS

Adm 15 30' 45 60' 90' D/C Fund. 'Height
Lochia
Peripad#
Fund. Cond.
DRESSINGS Time Location Type Drainage

Mm kaij21grMlV!E1rLMllIkJ'-
_,30' I I 1, l vi
60' I, k-1
k P i
t t.

DIC t, 1-vl
PACU OUTPUT

Time Source Color/Appearance Amount Discharge Criteria• Date: 70t.t. upe: ') PARS: BP: JL V T:41)2?-. HR: RR: Sa02: g Pain Level at D/C 10-10): 3 Intake: Output: Additional Data:
CARDIAC RHYTHM
Transferred To: Time Rhrhm Sym atic? Rhythm Strip Run? Report Given To:

c)...6,00 s e.s. Transferred Via: Transferred By: Cleared IAW Recovery Room Charge Nurse Signature: WAMC OP 173-E
MEDCOM - 16084 VD. 2_
DOD-029473

2. SERIAL NO. -
1. DATE AND TIME OF CAPTURE
/1"77° ' 0073210 A
.77.314 o
4. DATE OF BIRTH
I -I.-75
\ ni 6. SERVICE NO.
\0 L c..t.) -pt

8. CAPTURING UNIT
7. UNIT OF EPW
A-11y,1 44 .4--P
9.
LOCATION OF CAPTURE (Grid coordinates) V--1 '(1. X V?)

10.
CIRCUM-11. F1-IYSICAL 12. WEAPONS _

EQUIPMENT, DOCU-
STANCES OF CAPTURE CONDITION OF EPW
le, I . .4... c.7)1..tr, .....7.44,0 i_ MENTS
G
,',x,..4.1
4...,
1-4"")V.t14,4' (4/3M1
MEDCOM - 16085

DOD-029474

1 . REPORTING MTF 2. MTF LOCATION
ADMISSION AND CODING 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 ( IM ( tiara Code.)
3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
9 10 11 101111111111,11R1 _____ /L. ' I . mi: 4.(a ... Lil 16 17 ___....-_,..... Eho 18 lal
6. DATE OF BIRTH (1' YYYMMDD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-
01 a ri M -­r- GROUND D ),-) Y.---
10. LENGTH OF SERVICE ETS 1. FMP 12. SOCIAL SECURITY NUMBER

37 rillirgliMirElymprimprol
32 33 34 35 36
q

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF ADMISSION _
10
46

14. FLYING STATUS 16. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
53 54 55 56 57 58 59 60 6147 1 48 149 50 51 52
19. TRAUMA PREY. ADMISSION17. UNIT LOCATION (State or 18. MOS

Country Code)

62 63 64 65 66 67 68 69 70 71 YEAR
NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

20. SOURCE OF ADMISSION! AUTHORITY FOR WARD ADMISSION 0t
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)72 \D ( '7, — 2_ ) cidadka
01_
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
00

21. 'TYPE OF DISPOSITION . MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMOD)
75 76 77 78 79 80 81 82 83 84 85 8673 74

0 6 ( t3
CD

26. DATE THIS ADMISSION (YYMMDD)24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM

87 88 89 I_ 90 i 91 92 93 94 95 96 97 98 99 100 101 102
A .F A P- 0 3 (75a0 9-
LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYMMDD) -----(Battle Casualty Only)
27.
103 104 105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE

a,c40cD 1,2_ DX'.
411 I
,00010"--¦11011 I ..,

0, 7 q 627
..)X \2¦(' 02.

S2531

E 7S-0
gY 0 .2Fs' Rq I I .R73 g
8. • ct ci i 2)
qic
. , • ,. 14-

ADMITTING OFFICER (Signature, as re.
4 A - 0 I

r ¦
. -r.. A • .. -
.
MEDCOM - 16086

DOD-029475
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40400; the proponent agency is OTSG
4. REGISTER NUMBER Qo 10Zo6 S 5. AGE 8. RACE 2. 7. NAME Out first MI) tpvr, T_O,Pteo E_ew9.RELIGION 8. LENGTH OF SVC ETS 3. GRADE StO 10. PREVIOUS4..eADMISSION ADMISSION REMARKS

•¦•\))QALM 14. WARD
13. ORGANIZATION
12. SSN

11. FMP
JC(A.Q
20. TYPE CASE
18. UICIZIP
18. BRANCHICORPS

15. FLYING
• BEN

STATUS DSO
(A)/4
23. CLINIC SERVICE

Ai 7e 22, HOURS OF
SOURCE OF ADMISSIONIAUTHORITY FOR ADMISSION ADMISSION
/s/C
28. DATE OF DISPOSITION

Ir0 C t2Xyl ^Cs 25. TYPE DISPOSITION
NAMEIRELATIONSHIP 0 EMERGENCY ADDRESSEE
24.
v/c 7-0 CAMP it/ Se, .2,003

ADMITTING OFFICER
28. DATED HIS
2 TELEPHONE NO.

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Cods) t ,., ADMISSION
27t
.......¦•••¦¦¦¦••¦

4(.26

32. UNITS OF WHOLE BLOOD)
30. DATE OF INTIAL

COMPONENT TRANSFUSED
ATMENT FACILITY ADMISSION

2 . NAM
-

31. ED ADMINISTRATIVE DATA
1:11 Check if Conliroad on Navas
33. CAUSE OF INJURY
DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES
34.
S/P ex ‘1,k-

35. Total Days This Facility
f. TOTAL SICK DAYS
SUPPLEMENTAL
c. CONY. LVICDOP

a. ABSENT SICK DAYS b. OTHER DAYS CARE DAIS
CARE DAYS

37
C

C I

36. Total Days All Facilites
1.2TOTAL SICK DAYS
a. BED DAYS
d. SUPPLEMENTAL
c. CONY. LVICOOP
b. OTHER DAYS

a. ABSENT SICK DAYS CARE DAYS
DAYS 37
0

SIG ATURE OF ATTENDING MEDICAL OFFICER
(GAM M A
DA FORM 3647, MAY 79
MED

DOD-029476

MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION ( Enter Olt of Wm if iON
2
V -2(S
9 ' 1,t7

, rip i Piv 1 01 ef))- 29-v--ir. / ii-,/3 )o,:f7 F4k2 7rr`9
X. )2)4 PHYSICAL EXAMINATION A AVX L-43:71 2-Lzr J p P
PROGRESS I Entn dart of discharge and final diagnosis)

40W
SIGNATU DATER IDENTIFICATION NO. ORGANS ZAT ION
71—A— 17

PATI NTI typed or written entries dire Name lase. first, REGISTER NO. WARD NO. middy*: grade; date: hospital or medical lac lity)
ABBREVIATED MEDICAL RECORD Stamford Form 589

vol II I II I 1.

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY ,COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975R
539-106
MEDCOM - 16088

DOD-029477
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MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
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MEDCOM - 16089

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DOD-029478
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MEDCOM - 16090

DOD-029479
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600-108
NSN 7540-00-634-4176
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MEDCOM - 16091

DOD-029480

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'U.S. Government Printing Office: 1996. 404-763/40001
STANDARD FORM 600 BACK (REV. 5.84)
MEDCOM - 16092

DOD-029481
DATE CLINICAL RECORD P.M.RA.M HOUR OBSERVATIONS Include medication and treatment when indicated NURSING NOTES (Segn all notes)
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PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first. middle; grade; date; hospital or medical jaciliti) Continue on reverse side I REGISTER NO I WARD NO. NURSING NOTES Standard Form 520 General Services Administration and Interagency Compittee on Medical RecordsFPMR 101-1 1:806-8—October 1975 510-109
MEDCOM - 16093
DOD-029482

DATE HOUR A.M. P.M. 21 UP NURSING NOTES ( Sign all notes) OBSERVATIONS Include medication and treatment when indicated
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MEDCOM - 16094

DOD-029483

NSN 7540-00-634-4176
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HEALTH RECORD i:2?
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MEDCOM - 16095 FIRMR (41 CFR) 201-45.505
DOD-029484
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MEDCOM - 16096

DOD-029485

800-108
NSN 7540-00-634-4176
CHRONOLOGICAL RECORD OF MEDICAL CARE

HEALTH RECORD
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MEDCOM - 16097 FIRMA (41 CFR) 201-45.505
DOD-029486

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MEDCOM - 16098

DOD-029487
R

NSN 7140-00434-4176
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD

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Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM -16099

DOD-029488

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DOD-029489

NSN 7540-00-634-4176R
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DOD-029490
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DOD-029491
NSN 7540-00-634-4176R
AUTHORIZED FOR LOCAL REPRODUCTION
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DOD-029493

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DOD-029494
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STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 C.;`•R) 201-9.202-1
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DOD-029501

I5N 7540-00-634-4176
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STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 16113

DOD-029502
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DOD-029503
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AUTHORIZED FOR LOCAL REPRODUCTION
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STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMA (41 CFR) 201-9.202-1
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DOD-029504
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MEDCOM - 16116

DOD-029505
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NSN 7540-00-634-4176
AUTHORIZED FOR LOCAL REPRODUCTION
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 16117

DOD-029506
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DOD-029507

AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM - 16119

DOD-029508
AUTHORIZED FOR LOCAL REPRODUCTION
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PROGRESS NOTES`MEDICAL RECORD

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MEDCOM - 16120

DOD-029509
558-104 7540-01-075-3788 .....m.¦...
LOG NUMBER

EMERGENCY CARE
MEDICAL RECORD AND TREATMENT

RECORDS MAIN
(Patient)
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ARRIVAL
STREET ADDRESS DATE (Da . Month,Year) TIME
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MODIFIED DUTY UNTIL RETURN TO DUTY
N UPON RELEASE ADMIT TO UNIT/SERVICE WHEN
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PROVED . UNCHANGED
TIME OF RELEASE

RIORATED I have received and understand these instruct ions.
PATIENT'S SIGNATURE

(For typed or written entries, give: Name - last,
first, middle; ID no. ISSN or other); hospital or
medical facility)

PATIENTS IDENTIFICATION
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record

STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.203(b)(10)

MEDCOM - 16121

LABORDERS
DOD-029510

TIME SEEttBY PROVIDER
EMERGENCY CARE AND TREATMENTMEDICAL RECORD

(Doctor)
TEST RESULTS

WBC Check if road by c]ABG/PULSE OX RADIOLOGY
radiologist SUP 02 PH P02 RESULTS
4

es
U

PLT PCO2 SAT OTHER DIP EKG INTERPRETATION APTT BHCG
ETOH GLU MICRO PROVIDER HISTORY/PHYSICAL
3()I\ • IA L1/4.,0 -2—co Psd _Sukso\y, .
7(__Q 04) i&.st/010

CONSULT WITH TIME ACTION RESIDENT/MEDICAL STUDENT SIGN
tiL PROVIDER SIGNATURE AND
DIAGNOSIS
0 0
PATIENT'S IDENTIFICATION (For typed or written entries. give: Name — last, first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record STANDARD FORM 558 (REV. 9­96)Prescribed by OSA/ICMR FPMR (41 CFR) 101-11.203(1 . 110i

MEDCOM - 16122

DOD-029511

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CONSULTATION SHEET REQUEST

TO:
DATE OF REQUEST
REASON FOR REQUEST (Complaints and findings)
tA.,,-24-1-1-7Wzgr__ t

PROVISIONAL DIAGNOSIS
tjlelA/
DOCTOR'S SIGNATURE
APPROVED

PLACE OF CONSULTATION ROUTINE2. TODAYID BEDSIDE2ON CALL 72 HOURS2EMERGENCY

WWI2C4
CONSULTATION REPORT

RECORD RENEWED
YES 11 NO
PATIENT EXAMINED

Li YES UNO TELEMEDICINE YES NO
U U

4')
(Continue on reverse side)

SIGNATURE AND TITLE DATE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT DEPARTMENT/SERVICE OF PATIE T
RELATION TO SPONSOR
SPONSOR'S NAME (Last, first, middle)

SPONSOR'S ID NUMBE R ISSN or Other)
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. (SSN
REGISTER NO.

WARD NO.
or other); Sex; Date of Birth; Rank/Grade)

CONSULTATION SHEET
Medical Record

STANDARD FORM 513 (REV. 4-98)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.2031131(101

USAPA V1.00
MEDCOM - 16123

DOD-029512
FOR Use of this form. sec AR 40-407: the proponent agency is The Office of the Surgeon General.
34

I. AGE: HEIGHT: WEIGHT:
WAi(yVAK)

4. PROPOSED SURGICAL PROCED
L

KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication)
NKDA 0 PCN 0 LATEX 2 IODINE 0 TAPE FOOD
REACTION:
3. PREVIOUS SURGERY [ NO [ I YES (type):

ADDITIONAL INFORMATION: (Previous surgical and medical 'story) Skin Condition
5.
Tobacco pd X vrs. Body Piercing 75 Diabetes (Y) ROM AS.A/Nlorrin w:72 hrs (Y)

ETO .1 b . Implants Glasses. ontact (Y) Dentures ii
6. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL ,--Potential for anxiety related to: 1) Surgical Procedure 8: Operating Room Environment 2) Separation Anxiety
(Child) LV 3) Surgical Outcomes
B. AERATION
\V.-Potential for respiratory
dysfunction due to:
\.7 1) Positioning

N, 2) Effects of Anesthesia MedicallSmoking History

C. INTEGUMENT ‘./ Potential impairment of skin
integrity due to: 1) Intraoperative Immobility 2) ESU Pad Placement 3) Positional Aids 4) Prosthesis
\./-5) Pooling of Prep Solutions • Respiratory Disease (Asthma, COPD) (Y) (14) Anticoagulants (Y) Hypertension (Y) (N Herbal Medicines (Y) MEDS:

7. PATIENT GOALS AND EXPECTED OUTCOMES
5e/ Pt. verbalizes any specific anxiety. / Pt. Exhibits relaxed body posture.
is Pt. will be able to breathe without
difficulty during immediate intraoperative
phase .

5/ Pt. will not exhibit signs of impairment of skin integrity (e.g., reddened areas).

9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
1111111.
\rD

S. OR NURSING INTERV&NTIONS / Allow pt. to verbalize freely. 7 Explain OR environment and answer questions regarding surgery. / Offer comfort measures. warm blanket. touch). / Explain all nursing procedures before they are done. / Remain with pt. whenever possible.
c, Maintain family interface. Parents to stay with pt.
Offer to elevate head of litter or offer pillow. / Observe pt. while awaiting surgery for signs of distress. Assist anesthesia during intubation and extubation.
7 Utilize pressure preventing devices on
OR table and accessories.
7 Check for proper positioning and
support to maintain good body alignment.

/6 Pad pressure points. p Place ESU ground pad on non compromised skin surface area. ia Keep prep fluids from pooling.
VERIFICATIONS AT HOLDLNG AREA: ID/Allergy Band ! Dentures Removed
H & P ! Contacts Removed
NPO Since ! Jewelry Removed
UHCG/LMP ! Body Pierce Removed

Consent/Blood Transfusion Si gne cl/WitnessedDated Surgical Site/Consent verified by Pt../AnesthesiaiSurgeon Contact Precautions (Y) . Family/Friend: 9,
DA FORM 5179, JUN 91 Previous editions are obsolete. OAP. % V I 9 MEDCOM - 16124
DOD-029513

6. PATIENT PROBLEMS.AND NEEDS
CIRCULATION: •

s."--Rotentii: for iitadequate tissue perfusion due to:
1.7 l) Intraoperative Mobility
V 2) Positioning

3) Existing Disease
V 4) Safety Devices
v 5) Hypothermia

E. NEUROMUSCULAR CONTROL
E.1. V Potential impairment of mobility due to: V 1) Pain V' 2) Intraoperative Hazards
R3) Prosthesis
V 4) Positioning
1,5) Transfer pt. to/from OR table

E.2. 1.,/ Potential discomfort due to:
‘77—Length of Surgery
2) Positioning
lz) Arthritis

F. SPECIAL SENSES
F.1. . Diminished visual perception due to being: RPre-Medicated
2) \V O Glasses
F.2. t..." Potential for decreased
communication due to:

1) Diminished Hearing ----V2) Language Barrier - -h(Q.3.01c­
F.3.RPotential injury due to dentures: R1) UpperR4) Caps R2) Lower R5) Crowns R3) Bridges
G OTHER PATIENT PROBLEMS NEEDS.
Or continuation of above problems/needs.

PATIENT GOALS AND EXPECTED OUTCOMES
f Pt. will exhibit siens of adequate tissue perfusion (e.g.. color, warmth, pedal pulse.
7 Pt. will be transferred to OR table without
difficulty.
is Pt. will not experience unnecessary
physical discomfort.

5/ Pt. will be made aware of su:Toundings
prior to anesthesia inductior..
5/ Pt. will be-tzansferred safely to OR table.
5/ Pt. will be able to understand instructions.

Minimize danger of injury during intraop period.
OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.

... OR NURSING INTERVENTIONS
2e--Gheck for support stockings or ace
wraps. If none, check with doctors. / Check that safety straps are correctly applied. / Offer pillow for under knees.
o Place and take down legs from
stirrups with slow bilateral motion.
9/ Check that rings and all body

/piercing has been removed
9/ Have sufficient people available for
/transfer.

Insure proper body alignment. "y Allow patient to lie in position of /comfort while waiting for surgery.
9/ Offer support (i.e.. pillows. bath
/towels. etc.) for positioning.
/ Introduce self. Keep pt. informed as to where he. she is and what is happening. / Inform pt. in which direction to move and assist if necessary. / Speak clearly and slowly. / Address pt fro^: -CABiti/
/r? Validate pt.'s understanding of verbal /communication. Vent.): removal of dentures.
OTHER NURSING INTERVENTIONS
Or continuation of move interventions

10.OR N D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
AN scS"
DATE

11. POSTOPERATIVE EVALUATION: SKIN INTEGRITY: Bovie Pad Site: Clean and Dry LEVEL OF CONSCIOUSNESS: . A&O (Drowsy R7.: SleepyR. Intubated
LEVEL OF ACTIVITY:R. Moves All ExtremitiesRMoves Upper Extremities . 0 Transferred to liner with roller due to spinal
12. PREOPERAT N PREPARED BY 13. POSTOPERATIV, (Signature and Title)
BY (Signature and Title) \r1L 0) -DATE: 7 .1\,,,, x603 TIME: 7k)
353R DATE­

C Red 0 NiA Aii,FSSING DRY & INTACT: cioAx,v, ( N(Ai N:
o TH I G EASY:

eirsT";)(
y0A6 05 TIME:

REVERSE OF FOR: 179. JUN 91
USAPA
MEDCOM - 16125

DOD-029514

—Rcotittiti k _

ii:.4 R .- 1,Ria;'.-:. 4 ;f.,,. ,R""' ' ., R-4;c:z.: '. INTRAOR3A1.RDOCUMENT
:‘• AR:,,,-.R4 ,... -wwilr 1;',,-RFor use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.

':Rt. ¦ E ' --'fi 13 POPTEC4TOYOPERATING ROOM •R. 2. PATIENT IDENTIFIER ED AND PROCEDURE
.R
v. •RiTii R...z..:1.7.: 'RBY RA VI•e5S-A-. -ValTa-VERIFIED BYRWI R (4)
TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM

8:' DATR
--i2,k_b (Th 1. Li DS TIMERI 4 O S--RNUMBERR2
5. PREOPERATIVE EMOTIONAL STATUS

[ysz CALM III ANXIOUSR¦ EXCITEDRI CRYINGR¦ ANGRYR¦ WITHDRAWNR• OTHER (Specify)
COMMENTS:
NaN

6. NURSING PERSONNEL

ASSIGNED -1-C_ RELIEF
SCRUB SCRUB
ASSIGNED RELIEF

(A7111111111110

CIRCULATOR CIRCULATOR
I AM, ( EMI' g Itt-410)

7. POSITION AND POSITIONALRpeci y
[X1 SUPINER• LITHOTOMYR¦ PRONERI:: KRASKERLATERAL:R. LEFT SIDE UPR• RIGHT SIDE UP
rf•N -4^-• V7OCAi CL51 `5.'Lew."-2-‘,.•R4•A'N'O•A VA ciK:.4.41.) A ev‘mA.0 (9.k it Si, wow, eko° VARr....04044.041
COMMENTS: 0-vyI, oc,„..tric) 1 exj-kl) vi-3,c4Anda C X -1 " t -''' 41°.-ekokk. °1 i2r vs.-, ch. ov*-cp-ev-qv-e.,e/t2i) 1 col,..0-aKey, .4- ca4".altikl
0­
( lc2- 2. 8.RKIN PREPARATION --0 -
HAIR REMOVALR4 YESR• NO Dr-PREP SOLUTION (Specify) 312.­
4CacLa4..)-- /

DONE BY:RP ORR . NRIT SITE: Le. -t Lac 2BY WHO
METHOD:R•RDEPILATORYRIX RAZOR SITE:R BY WHOR.
¦ CLIPRLe_ft -l-tUV\
I

COMMENTS: db Ik•,k_S cor cut2 COMMENTS: ‘4•Ar \r) eft.Avg Gy 5k...6 s ft".0-tok.
vlo•Usi /a.,

9. LOCATION OF EXTERNAL DEVICES
22 c Ovrt.0.. \R
.21.11111-
•- i 12 ark.... ,, Rome. 111: —
,.....-2---"
.•2
.•2 Tilirjr.--
/

LEGENDRX G.Pad III- Safety Strap = = = Tourniquet (t\ltPt)
C = CorrectRI = Incorrect
First Closing Final Closing

\i,RLt).-

10. COUNTS Other• • Count Count SCRUBRCIRCULATORR\10Rt--
SpongeR Yes . No
Needle SharpRNrYes U No
InstrumentR• YesRNo

rl
N/1 ViA

OtherRII/ Yes No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) ESRCg] NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;) qty{1-t04
ESU NO: #3

GROUND PAD:RBRAND VL Rem Futtik)61.1)Cir LOT NO:R701p2.r-i:, zed-t-II

if 111111.
t
• ESU NO:
GROUND PAD:R438AND
ut i '
tr

I LAT NO:R A BIPOLAR NO:
USAPA V1.01
DA FORM 5179-1, OCT 87 REPLACES IICH IS OBSOLETE.
DOD-029515
13. PROSTHESIS, IMPLANTS pg YES . NO IF YES NAME: ID NUMBER; MANUFACTURER
5018--(2 - 1 gO x 4-2itcvto —1-0 10 X if-2 -1-toftwitin M
its110 -2-1 10 X li-Covo.,,ttv-. Rozks X 22 Lot ft 0 (sal 363
It otz0 -2,-07.4 x 2
.,..2-,-.m. , .,.- gr;.--4044.

14. - ,f,-.,' _.2,2
MED I CATIO NS/ORDERS*1040 tagSkrIrar4V2
,!

'' 11,,.krit :,..?; -''r,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES II -,NO a
MEDICATIONS. SOLUTION DOSAGE TIME

WOUND IRRIGATION . M YES • NO, TYPE(S): ! D .9 % "CA - Q • • T
OTHER ORDERS
PHYSICIAN'S SIGNATURE ...._
15. X-RAY IN OPERATING ROOM IF YES, SITE
YES I NO
16. SPECIMEN (SI YES . NO X FROZEN SECTION IFS) YES • NO M
CULTURE (C) YES . NO NAME
NAME
. C - -Nm k....124-t
LABORATORY SPECIMENS
NAME
NAME "
NAME
NAME
NAME

17. TUBES. DRAINS/PACKING TYPE/SIZE ' 1. SITE 1. 19. ADDITIONAL INFORMATION StaleOn . bt. loN.:..AA.ktse,at CP-c- 2. 2. YES . 3. 3. NO Zi .
20. OPERATIONIS) PERFORMED ex-1-\X
21. PATIENT TRANSFERRED TO 22 NURSE SIGN 1 ( AA 2 TIM .A938e‘ T

METHOD PREPARED BY GIVEN BY-

fi

TIME CARRIED OUT BY
NAME NAME NAME NAME

18. DRESSING/IMMOBILIZATION (Specify) ...-ii.„,lr,
/h if
n- c......,,v0v

-iI2t 5-1')9 1:q¦-. atect
METHOD ; .-tc,
Lattr
..... ..... 'ii.r" -. ',
,- - . ':i 5 5-,-e.,i' 2t 54;74‘031,.;• ',.-2'5 , -2 .2. 525... ;U$APA'yi:01.',

DOD-029516

INTRAOPERATIVE DOCUMENT

For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.
MEDICAL RECORD

AND PROCEDURE
RECORD REVIEWED
2. PATIENT IDENTIFIE
ROOM1. PATIENT TRANSPORTED TO OPERATING

VERIFIED BY C4BY tS°\.

VIA Ukk-1042
4. PATIENT IN ROOM
TIME PATIENT ARRIVED IN SUITE NUMBER

3. DATE
TIME21-440
13See 65 PREOPERATIVE EMOTIONAL STATUS

5.

OTHER (Specify)
.
. WITHDRAWN
.
ANGRY

.
CRYING

. EXCITED
. ANXIOUS
En CALM

COMMENTS: Allergies:
I¦W 6. NURSING PERSONNEL
RELIEF
ASSIGNED SCRUB •
SCRUB

RELIEF
ASSIGNED CIRCULATOR
CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
. RIGHT SIDE UP
. LEFT SIDE UP
LATERAL:
. KRASKE
. PRONE
. LITHOTOMY

El SUPINE
uay.mrvuzint 1~AI:211mA_ •

0(19 c

COMMENTS1N1W
SKIN PREPARATION PREP SOLUTION (Specify) Vj Pk--
. YES y:1 NO BY WHOM:

HAIR REMOVAL
SITE:
. NURSING UNIT

DONE BY: . OR BY WHOM:
SITE:
. RAZOR. DEPILATORYMETHOD: . CLIP

COMMENTS:
COMMENTS:

9. LOCATION OF EXTERNAL DEVICES
Pt
IVN === Tourniquet
— Safety.)2
X Ground Pad

LEGEND2
GO Correct I = Incorrect First Closing Final Closing CIRCULATOR
Count SCRUB
CountOther•*

10. COUNTS
. Yes N

Sponge
. Yes al No

Needle Sharp
. Yes 13ZI No

Instrument
. Yes2No . YES N
Other 12. ELECTROSURGERY DEVICE(S) (ESU)
(For typed or written entries give:

11. PATIENT IDENTIFICATIO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility)
.
ESU NO: GROUND PAD:

.
ESU NO:

BRAND LOT NO:

1-=
BRAND LOT NO:
GROUND PAD:
. BIPOLAR NO:

UMPAW
REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE.
1, OCT'87
-

nA FORM 5179
MEDCOM - 16128

DOD-029517
13. PROSTHESIS, IMPLANTS • YES [9k NO IF YES NAME: ID NUMBER; MANUFACTURER
A

14.:.;Maii!.1::!ii1: i
;,1:Sliii.;!;::iiineg!;ii:iNiN;i1;:gi!::!•;e1::i;:ainga iRMEDICATIONS/ORDERS:NE:::::::::;:::1::::::NO:::: .

:
:::ji:::::;:n:::::::::::;:;::::::::::iii!;i:::::::::::::::;:p.Oi.i.;:10:M.:::: :::PAi'iii IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO !`MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY KIVEN BY
. r
.t
'::
rOUND IRRIGATION III YES NO, TYPE(S):
T ,OTHER ORDERS ' ,k x . TIME CARRIED OUT BY
.
0

::-l:::PHYSICIAN'S SIGNAT RE
,....... ... .

,..,

15.
X-RAY IN OPERATING ROOM IF YES, SITE
YES ¦ NO 0§,\

16.
LABORATORY SPECIMENS

SPECIMEN (S) NAME NAME
YES • NO el
FROZEN SECTION (FS) NAME NAME
YES • • NO 1rd
CULTURE (C) NAME NAME YES ¦ NO A NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
Stt
LY Li
,niLtIL

17. TUBES, DRAINS/PACKING YES U NO X TYPE/SIZE 1. 2. 3. 6 I
Ca.%-t

SITE 1. 2. 3.
19. ADDITIONAL INFORMATION 1. % WC .-q-Surgeons: Anesthesia: Anesthesia Type:2c,..-e--I--K
Bovie Pad site intact pre-op t-op Bovie 1:.)/(
, piN-op Settings: Coag/Cut2
Tourniquet Site intact pre-op
Tourniquet Time: Up Do n

----Vict cs.,‘ c.Acx"Pi-,s61 6'5. .AA..Or201.

20.
OPERATION(S) PERFORMED

21.
PATIENT TRANSFERRED TO TIME RL. METHOD

V±D). -‘3Ps. ,._M 01 kA
2 i

iWEOMA2 mpnrnm _ 1'11
1 R1 21 I

7 USAPA VI.01
REVER
DOD-029518
•

511-119 NSN 7540-(.,
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-2 DAY MONTH-YEAR2' DAY Cb
•
•

0)2 9 y2PULSE2 HOUR TEMP. F / I'2' CI24 /\• .
(0)2 )
105°

•
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.....
....

1802 10 ° ,2, ,2..
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•,

co co c.,.) co co w r.,,, u.) cv co 4
01 P.'a) cr) -.1-A-.4 COCO(0 C b a) i-. :-.1ONim (A) 4;1 :1=. C
o 0 o 0 o o
°
°°°
(Centigrade Equivalents, for Reference only)
......
. .....
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•
....
•

.2.

1702 103°
....
'2. .. ..... ' • '
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.
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• . ,2. .2..2.
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....... ... .

1602 102° It
....
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1502 101° . : : ••• i I,2•
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1402 100°
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1302 99°
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98.1 ° :2:2:0:
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2ESPIRATION RECORD , ip
...:4 •

EDTditri: i
I

r
ecord special data only when so ordered
BLOOD PRESSURE • -'
Mall. .
-.or. •
wriA ezi ra
mar
ILER/40

..i
..

..,..,

P., MIIIIMMTAIIIM111011111111M3111 Wile

HEIGHT: WEIGHT .t•—¦•
, 6 .1 '
`1576 -1°''' --
e
c.nito) L....

rIENT'S IDENTIFICATION (For typed or written entries give' Name—last, fist, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility)

AN .

MEDCOM - 16130 STANDA Piescrl VITAL SIGNS RECORDS Medical Record 01-9.202i 4
DOD-029519

.....

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
4

MONTH-YEAR .440r DAY I
. Re
. .
194, 6b HOUR •a •
. • MIIIIIIMIll 4 laniMr • •
I
I.

k(i
t
PULSE TEMP. F ty , l: : . g
0
....
....
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....
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105) ° .......... : :
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. . . . . .
180 104° , ,
...................

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170 °103. . . . . . '
.......

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160 °102 .
.........

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...... 150 °101 • • ......
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98.6°
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BLOOD PRESSURE
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,AllENT'S IDENTIFICATION (For typed or written entries give -• •
Name—last, first, middle; ID No. REGISTER NO

(SSN or other); hospital or medical facility)
,_ .. ,
STANDARD FORM 511 (REV. 7-95) BACK
at ;
MEDCOM - 16131
DOD-029520

511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
co

HOSPITAL DAY
13 .RI . /4-
5

POST-R DAY
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(Centigrade Equivalents, for Reference only)
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PULSER••'R-TEMP. F :0 :
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RESPIRATION RECORD
•IR• •ti,.R. .R. .R. 1..R. .R. .R.R.R.
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1: 18 761 Itfikil )16114.; 12111"
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1

A: A VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICKAR. FIRMA (41 CFR) 201'=',9
MEDCOM — 16132
•p

DOD-029521

• w v, La

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-2 DAY .." I
MONTH-YEAR DAY 19 HOUR • '''''''''''' '2• " '2• "
............

•

PULSE2TEMP. F . .2. •
. ........ • •

(4 W(•5 GO O.)CA W (.0 AAH
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RESPIRATION RECORD2
'Record special data only when so ordered
BLOOD PRESSURE2P If° 574r HEIGHT:2WEIGHT ¦••+
• `• . T• . ,

DATIENT'S IDENTIFICATION (For typed or written entries give: Name.—last, frst, middle; ID No.. (SSN or other); hospital or medical city) : REGISTER NO2 '
•

STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 16133
911°
AIN

DOD-029522
511-119 NSN 7540-00-634-4124
wR .11.—
MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY POST-DA DAY
1/41•

?Ct.vI
"N.

MONTH-YEAR
-7,
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5-1,941-
,
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HOUR PULSE TEMP. F
19
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. . . . . . . . . . . . . . . . . . 180 104° . . . . . . . . . . . .
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(Centigrade Equivalents, for Reference only)
•

170 103°
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. . .
. . . . . . . . . . . . .
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. . . . . . . .
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160 102°
150 101°
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140 100°
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130 99°
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100 96°
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RESPIRATION RECORD
evi si11I6-7/,57 cr/51
0
,

(Record special data only when so ordered
BLOOD PRESSURE taliQC
S (r14

HEIGHT:RI WEIGHT ,-410. itf (-A9 V IC efiTo
qiCEPIc,
I

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, frst, middle; ID No. REGISTER NOR . WARD NO. (SSN or other); hospital or medical facility) •
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR. FiRMR (41 CFR) 201-9.202-1

MEDCOM - 16134
•

DOD-029523
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY POST-DAY
MONTH-YEAR DAY !ill/ * lil a rifF.6ZAII _.,, it 4.111112,10 J`+ • .Iii
19 . .
HOUR IIRIMIrAnITIZEMM.1111111rraP° • • • 11111 .
•
.
.........

PULSE TEMP. F di ri .......

(0) (*) : : : : ........ I: 105°
.........

. . ...............................
180 104°
170 103° ............. .... ' ......

160 102°

.........

.
.
.
•

150 101°

.

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.
.

. . '0 • •• . .
.
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020
cc;2Lci tr
co2co .

.

140 100°
•

.

.

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.

. .

•

.

130 99°
98.6.
ElliglE!II
¦ • .
•

. . , . . . . . .

.

......

120 98° ..; .:.•

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. . ..•. :• .
.

................
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110 97°

. . .
.
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................ •
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100 96°

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....
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90 95° ill
80

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50

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.
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.

40
0
1(LA,
:

RESPIRATION RECORD
6111 1 USI

i
,Record special data only when so ordered
•BLOOD PRESSURE

MISIIIIIIINIWIVMELMIL71112100111241
7701111111a2Aktfi IrC •0 111111111111M.MI ILWALIIIIIIIILIMEM

HEIGHT: WEIGHT ••.

PIIII
.(64 ,j;

ANALM11111
4
0h.IIILTJTMININIMil

gooey • t,
• io .. CO 97A 6t30,1 cra%

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, fist, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO.
STANDARD FORM 511 (REV. 7-95) BACK
ep 1. MEDCOM - 16135
DOD-029524

•

511-119 NSN 7540-00-634-4124
NMI

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DA
MONTH-YEAR DAY i 7 WZMiiiikillAIML.14Miril '
rt •

19 HOUR 070/) A
'
•
......

PULSE TEMP. F • 6 . . . ' • TEMP. C
.
•
••
........

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

(0) (°) :
•
105°
•

40.6°
40.0°
........

........

• .
•
•
: : : :
...... •

180 104°
•

170 103°
160 102°
•

39.4° S:.
c
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38.9°
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. . .
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38.3°
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150 101°
. . . • •
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. ...
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•

140
100°
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37.8°
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:
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.
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.

130 99° 37.2°
•
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: :
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: ........ 37.0°

•
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0..

120 98
970

110
100 96°
90 95°

80 70 60
36.7° -a 2
.. • •• • • • •• •
41 • • .1.
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..
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36.1° (i)
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35.6°
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.
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50
40

I A,
'

RESPIRATION RECORD -.A,
•
.
. .• . .

. . • •

7.7 ."/
A y
4
BLOOD PRESSURE
MI
rilf
'

'Record special data only when so ordered
±4 coo • x 0
1 trg (0367r7r Jrqr/
/1-2

HEIGHT:2I WEIGHT ••¦•••¦
ILF% 17Z nzi-9420 'TOWS

PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO • WARD NO.
2
(SSN or other); hospital or medical facility)

'VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 16136
• 0 •

DOD-029525

•

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY

POST-2DAY 2,. a MONTH-YEAR
DAY2101ti
19 HOUR2•2i • • MINI= VIS •2 II • • 141

rr Ak febireVir_3!_eW1M1111111EVIMII (!.2A
311Mall • • .01 1
-
bIn : : . .

PULSE2
TEMP F2.
. .
(*)2' • • id : : : : : : f
105°2

TEMP. C
(0)2
,

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•2•

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•
40.6°

1802104°2• .2. .2.2.2. .2.2.2. .2. .2. . .—,.
.2.
1702103°
1602102° .2. : •
.2. .2.
.

Record special data only when so orderer
1502101 • .2.
.2.

1402100
.2.

.2.
130299° •2
•

98.6 2:2•
1202

98°

•
110297

1002
HI . 90295' 2•
96°2•
80 • 111
•
70

•
602

•
• •I •
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50 '

• •
• 40
.2.

RESPIRATION RECORD .,...
1 I I

COCA)CA)CA)0)CO4.0 0.
CP 51 ch c) -.I--1--4a b0 0im I-‘ :-..1 bio bp 6:
0 0 0
°
°
(Centigrade Equivalents, for R
BLOOD PRESSURE2
Air ­
; 1/..,t1° , • •141LIVRISTIMINFAI 1171P.IFACM017
'arm ;In trlyczamorna asivolimcfn
•Trami ria vill 04/ rE, whisultai

HEIGHT:2

IMMO=212.4M,1
IIII

farA €PYIPMEIIINEMMISWILWATA
le -MI
PM= qiri.

'A 1 IENIrS IDENTIFICATION (For typed or written entries give -Name—last, fist, middle; ID No.
REGISTER NO
(SSN or other); hospital or medical facility)

STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 16137

DOD-029526
•

-
alp \t1\4 07-.08-0 pow-1. 17,02 . Patimt '2Lirits
• 9.62x10'3/11i244'5 10.5fr; 4.64

13.5 . sitiL2E0 18.6
44.621235.0 60.0 00 96.0 fL2st 0
••JH229.12P.2227.0 31.0 tiSiD • 30.3 L 2/IL23,3.0 37.0 Pit 432,2x103AL 1M. 450.
yz. 20.2290.5 51.1 IT?21.9*. x10'31uL21.223.4
/
MEDCOM - 16138

CHEMISTRY RESULT FORM
Suliect to the Privac • Act of 1974
------- PICCOLO

.

RE
13:06 REFERENCE RANGE:.A+
07/08/03.

MALE.
PATIENT #:
METLYTE 8
DISC LOT #:.

3141AA4
OPER #: 210.

DR #: 000

73-118
7-22
0.6-1.2
39-380
128-145
3.3-4.7
98-108
18-33

MEDCOM - 16139

DOD-029528
MEDICAL RECORD - ANESTHE
44obre'114 [2_ of this form, see AR 40-66; the proponent .. ncy lb the OTSG
;W: 0 z flt 7 cimr. TOTALS
Z ....:. 00 Fu3 2 LLI (itc /50 (2zitfi Apt9 3-
* 0- ' Z

Et' CO
Z I-- I-
Al.2 p /IC2e 22)
4 7 Z OD 0
50 Onalf

D-o
/c/(.4

z z w — AIR
ut
N20 LI

02 L/Min SINGLE DOSE DRUGS-MARK ONGRID.*
fr/3-131-3/3/3/f

BLOOD-
WITH NUMBERS & ENTER IN REMARKS
REMARKS
Warmed
EST BLOOD LOSS

LOSSES
URINE -

.. • ....2• •
220
BP by cuff
200 V

-........

A 180
160

/silo gifr
140

BP­
6 kov; 120 (c14.7_
HR-
II .1. . • .VW2.2
.
80
. .
. ,•2"

OK? VAN
.2.2•
40

OK &AA
PRO I
TIME I2.
a
MODE - S(pon)• Aissist), C(on)
— 5 5

I,AP/Auto Cuff LZt CO2 (torr) 414 V6
392sip

441 BP/oth 1(02 (Frac or %) 40 30 o PACU ICU Specify)
ART line 14p02 (%) /CO (CO /6•0 OTHER
63. Steth- PC/ES 4G sr 3r. sr
CONDITION: Gas analyzer MP-site 4 t 34 s"2
'3V

RESP-Sp02-913'
N-M Block (T/4) 9/ 44u

BP cr./ HR-
44 As; .
to Start Room End
2
Warming blkt 2
qe/523

Cony warmer
Mark with letters & symbols, EVENT Ready Begin End explain under REMARKS Position
111/3 MO 1570

PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks x rix Fiouta. C EVA PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, bLade, technique, commend76Ve. if
Medical facility Fpotic gr4Rrt/

?.... le14) lit 0 ft/ 'PZ2c-.710+490,. b,e leerafe£P 4 VP", 4141 4 ist err 72rp-T-WM PROCEDURE Z. LOCATION: DATE: ivied, to 2.
PAGE OF/
DA FORM 7389, FEB 1998
COPY 1 - PATIENT'S MEDICAL RECORD US4'A V1.00
MEDCOM -16140

DOD-029529