Medical Report: 28-Year_old Iraqi Male, Insurgent, Baghdad, Iraq re: Gunshot Wound to the Head; Shrapnel to Chest, Leg and Arm

Medical report on a 28 year-old Iraqi national insurgent wounded in a firefight with Coalition Forces. The medical report states that the insurgent was shot in the head and took shrapnel to the chest, arm and leg after he and another individual initiated an attack upon soldiers.

Doc_type: 
Physical (non-death)
Doc_date: 
Sunday, September 21, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

ilScction:
Fl
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Lizits
1/4.,
xi.043hL
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141K
110'bilit 4.00 £J0ig4.32 11.0 18.0
9161.
H24 12.2 35.0 60.0 Vict 38.4 1 it 80.0 99.9 N.?
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-.1. 150. 450. it 313. 20.5 51.1
7.
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2.1 1.10"3/11
a 1.:1
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Bt
baso

Lymph
LABORATORY RESULT FORM
Privacy Act of 1914)
(Subject to the
MEDCOM - 19841
DOD-033415
Ward/Section:

/fr---I REQUESTING PHYSI
LABORATORY RESULT FORM LAST, FERST„ML1111111 T. Sub-ect to the Privae . Act of 1974

SSN/PSEUDO SS
kAte--
•• —atologt).CB
Se
TEST RESULT .RANGE TEST .
RESULT REF. RANGE TEST RESULT REF. RANGE
ID= 19-09-03 Color N/A
cc RPR • Negative
16;33
./c

Patient APP N/A
Mono Negative

imits
Glu Negative
'.!Pf 7.0 x10'7'ilii1 4.5 10.5 VCtrobiologyx10'•. .00 6.00
7, Bili Negative
12.0 gld1 11.0 18.0 Source
Hct=
3•5. 0 60.
11_11) 94.0 Ket Negative
80,0 F-9.? Gram
rajc
pg 27.0 31.0 Stain
TIC 37.8 L g/di 33.0 37.0 SG 'N/A
Occ Bld Negative
Pit VP. tif
150, 450.
LIZ 29.1 51,1 Bld Negative
- H. pylori Negative
x10'3M 3.4
.10.1 .
. • Micro
• • • .
Parasites

Segs Mono
.

Prot Negative
Malaria
Bands E

Urob 0.2-1.0
O&P
Lymph Baso

Nit Negative
Other
Atyp Imm

Lea Negative
roscopic Udall
RBC

HCG Negati

Morph
Spun 42-52% (M)
• .• .
Hematocrit 37.47% (F) lood.Baglc ':
.•. -

Sed Rate
Cell
MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED

Other
Directigen Negative
ABO/Rh I ubt.i001$03 e*:. • . . 14364 Bohlt
-

(MUST SUBMIT.SFS.1.8.WITHgVERy UNIt OV-BLOOD .

TEST RESULT REF. RANGE UNIT

TYPE
CROSSMATCH
PT 9.8-13.6 secs AYIT 21-34 secs D dimer 20 ug/m1
FDP 10 ug,/m1
REMARKS:
REPORTED BY:

DATE: I LAB ID NO.:.
MEDCOM -19842
Ward/Section: •
TEST
Na
Cl
PH .
PCO2
P02
TCO2
HCO3
s02
BEecf
AnGap
Ca
BUN
GLU
Creat
Het
Hgb
138-146 mmol/L
33-49 mmol/L'
98-109 mmol/L
731-7.45
35-45 mmHg (a 41-51 mmHg (vca g13-105 mmHg (ar NM Neal 23-27 rconotil. 24-29 mmol/L (vi 22-26roasout (if 23-211 romol/L (vi
95-98%

(-2) — (+3) mmol/L 10-20 mmol/L
1.12-1.32 mmo
8-26 mg/di
70-105 mg/d1
0.7-1.5 mg/c11
38-51% PCV
12-17 g/dl
TEST RFSULT REF. R4N(
Troponin-1
Drug of Abuse
REPORTED BY:
CHEMISTRY RESULT FORM (Subject to the Privacy Act of 19/74) TIME SS N:
TEST VO. TEST RESULT 7VRANGE RANGE
3.5-5.5 g(d1
ALB MIT
PICCOLO

16:31

PICCOLO 19/09/03

19/09/03 16:31 REFERENCE RANGE: MALE
REFERENCE RNEMALE

.c ISTRY 12
PATIENT #: -• GENERAL

3204AA4

DISC LOT #:

METLYTE 8 —¦
#: 000

DISC LOT #: OPEi #: OPER AIM % DR #: 000 •••••• 1 SERIAL #: SERIAL #: 7-;
3.3-5.5 G/DL

ALB 42.9*
97* 26-84 U/L

GLU 104 73-118 MG/DL ^ 1-ALP
55* 10-47 U/L

BUN 18 7-22 V3/DL ALT

50 14-97 U/L

CRE 0.8 0.6-1.2 MG/DL AMY

(5* 11-38 U/L

CK 162 39-380 U/L AST

0.5 0.2-1.6 MG/DL

NA+ 128-145 MMOVL TBIL

7-22 MG/DL

K4 4.4 3.3-4.7 MMOVL BUN 19

8.0-10.3 MG/DL

CL-**, 98-108 MMOVL CA++ 9.2

-CHOL 182 100-200 MG/DL

tCO2 24 18-33 MMOVL

1.0 0.6-1.2 MG/DL

-CRE

-110 73-118 MG/DL

INST GC: OK CHEM GC: OK GLU

TP 7.7 6.4-8.1 (3/DL

HEM 0 , LIP 1+, ICT 0


CHEM QC: OK

11-4-• INST QC: OK

1

• HEM 0 , LIP 0 , ICT 0

A/Ct

CJ-1 (
C

DATE: LAB ID NO.:

MEDCOM -19843
DOD-033417

¦ _
r
Ward/Section:
LABORATORY RESULT FORM (Sub'ect to the Privacy Act of 1974)
LAS
D TE
Urinalysis

Coloi
Negative

Negative Negative
Negative
Negative Gram Stain Occ BId Negative

Negative

H. pylori Negative
Micro Parasites
0.2-1.0

O &
Negative

I Other
Negative
WICIOSCOpiC Urinal S1

RBC HCG Negative
Morph

Spun I 42-52% (M)
CSF . • Blood. Bask .
Hematocrit ; 3747% (F) 1
Sed Rate
Cell
MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh
.
;:-• Coagulation Studies:-. .- BloOd"Bank Unit Crossnasitck . .
-(MUST,SUBMIT SF 518 WITH , EVERY UNIT OF.OLocob.

: .

... -
-. TEST RESULT REF. RANGE UNIT -REQUESTED) : : .. '
TYPE CROSSALATCH
PT 9.8-13.6 secs
APTT j 21-34 secs
D dimer i 20 ug/ml
FDP I 10 uWoal
REMARKS:
urprIng.c.r1 UV.. 1 ... ,,,,, ----------t-._rz...z=_-------
MEDCOM -19844
DOD-033418
Ward/Section: —STING PHYSICIAN:
l. ....,,...aRy RESULT FORM
'4 (Subject to the Privacy Act of 1974)LAST, FIRST, MI. — DATE I TIME
SSN/PSEUDO SSN:

. -: ,.:, .. _ . '(i5T-• i0:0141):',chqn40'; it-c:plOyA0t0:010iii0::,:-:'...
-‘).
....a..,,, ,...:. -.-...:,.-,-,.....„,t..:
TEST RESULT REF. RANGE .TEST RESULT
REF. ?EST RESULT I REF. RANGE RANGE Na 138-146 mmobt ALB 3 -5-5,5 gicil GLU 73 -118 mg/d1 K 3.5-4.9 trunoLl: ALP 26-84 WI BUN 7-22 mg/di
Cl 98-109 mmon. ALT 10-47 u/I i CAr+ 8.0-•10.3 rugidi
pH 7.31-7.45 AMY 14-97 u/I CRE 0.6-1.2 mg/d1
PCO2 35-45 mm1-Ig (,14) AST 11-38 u/I NA-i28-145 Initial
41 -51 mmHg(en) P02 30-105 mmHg tart) TBIL 0.2-1.6 mg/di Kr 3.34.7 nundit4m.tvem TCO2 23-27 mmol/L (an) ' BUN 7-22 i)&/d1 CI: 98-108 mmol/124-29 mmon Nen) HCO3 22-76 mmoL'L (art) CA+' 8.0-10.3mg/d1 tCO2 18-33 mmoLl13-2g mrnotl (yen)
s02 95CHOL
-98% 100-200 me&
-044O)1*-0.gailil .4140..'"/I::-. BEecf (-2) — (+3) CRE 0.6-1.2 mg/dl TEST RESULT REF. RANGE
turaul/L AnGap 10-20 rumoll. GLU 73-118 mg/d1 1 A1,13 3.3-5.5 g/d1 Ca 1.12-132 mmoIlL Tp 6.4-8.1 g/dl 26-84 u/I
ALP

BUN 8-26 mg/dl iiClikil.,:Metlytp:. r•-• ALT 10-47 &I
-GLU 70-105 mg/d1 TEST RESULT REF. AMY 14-97 till
-.4,...:;•,;5•-•:....:::..
-i...,.1:::,.;. , : ;'•:•::. .",..

RANGE

Creat 0.7-1.5 medl GLU 73-118 mgid1 AST 11-38 u/1
Het 38-51% PCV BUN 7-22 mg/dl TBIL 0.2.1_6 mgitil
-

Hgb 12-17 edi CRE 0.6-1.2 mg/dl GGT 5-65 WI
*C.:iniiii -s' '-' CK 39-380 u/I (M) TP 6.4-5.1 ell
•:::-.„......L • :::.:: e:-i"::'csi
30-190 u/I (F)
TEST RESULT REF. RANGE NA 128-145 mmol/1 ••

1001 1 C.tig4 g `-... 'i.;..'•,•. :,......' .
: :.

.'1,:1•• •';',..,;::.!-..,:t..-.!'7.1'::.r..-: Troponin-1
3-34-7 namolf1 TEST RESULT REF. RANGE
Drug of _Cr 98-108 mmolii NrA, 128-145 mmol/1 Abuse tCO2 18-33 mmo1,1 K7 3.3-4.7 main
-

CL" 98-108 romo111
.
(CO2 18-33 mmoLl
_ .......
/9.0--^.-
REMARKS:
REPORTED BY: I DATE: i LAB ID NO.:
i ,2 0 .
MEDCOM - 19845
DOD-033419

Preliminary Report

3 (D. 41, CD CI SD CD a? -8 fam 0 0 0 0 0 0 0 0 3 cp. 0 co 0 0 0 7J CD C)(D CD 0
Et. -o cp"

:NSSJO#lue!led
i

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CD

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0

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:speLis pagoe4e jo Jec.unN
MEDCOM - 19846
DOD-033420
CDD

rt

MEDCOM - 19847
DOD-033421
E 6
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5 o
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CD
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MEDCOM - 19848
DOD-033422

Microbiology Request Form

a-
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0 3 2
16:3
0
Cu 12 r
cS
ai
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MEDCOM - 19849
DOD-033423

Microbiolo • Re • ort
Name: Patient ID: Ward/Rm: IV I Staphylococcus epidermidis Specimen: Source: Ward of Iso: Wound/Sterile site Status: Final Status: Collected: Attd. Phys: Final
1 S. epidermidis 121-La

MIC
Interns
Amox/K Clay (c) Drug
4/2
R
Amp/Sulbactam (c) 16/8
Ampicillin Azithromycin Cefazolin Cefepime Cefotaxime (c) Ceftriaxone (c)
Cephalothin
Chloramphenicol Ciprofloxacin Clindamycin Erythromycin Gatifloacin Gelitamicin Imipenem (c)
Levofloxacin
Linezolid
Moxifloxacin
Nitrofurantoin
Norfloxacin

Ofloxacin
Oxacillin
Penicillin
Rifampin
Syxrcid

Tetracycline
Trimeth/Sulfa
Vancomycin

S = Susceptible = Intermediate
R
= Resistance MIC = mcg/ml (mg/L)
Ir
R
8

'ErfAb
4
R
16

R
16

R
32

R
32

R
16

R
16 ",R
=1
2

R
4
R
=2
S
8
=.4

R
=2
S
4
4

R
64
=4
4
2

R
8
BLAC
2

R
2
R
8
R
=2/38
S
16
R
N/R = Not Reported = Not Tested TFG = Thymidine-dependent strain
MIC
Inter Ds

Blank = Data not available, or drug not advisable or tested .
a ,

ESBL = Extended spectrum beta-lactamase Stec = Beta-lactamase positive
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

= Inducible Bete-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactameses; potentially they may become resistant to all beta lactamdrugs.
Monitoring of patients during/after therapy is recommended. Avoid other/comblned beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.

(a)

(b)
Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=5, 8-16=1,

(c)

16=R).
Footnote (c) applies to this drug.
(d)
For streptococci refer to penicillin interpretation& For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.
For non beta-lactamase producing enterococci,
refer
to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxecin (for Gram Negative isolates) and moxifloxecin are based on FDA approved brea

For S. pneumoniae, cefotaxime andm
Name: ceftriaxone breakpoints are based on isolates from patients with meningitis. For non-meningitis infections, use 2=S, 2=1, 2=R.kpoints.

Specimen:
Patient ID: _ t...
Status:

Source: Final 19
Ward/Rm: Sterile site Collected:
Ward of Iso: -------Req. Phys: IOWPrinted 10/22/2003 5:51:52 PM
MEDCOM - 19850 Tech:
DOD-033424

Microbiology Report
Name:c— Z_
CIVc Patient ID: pa 1p
Status:c
Final

Source:c
Ward/Rm: Wound/Sterile sitecCollected:
Ward of Iso:
Attd. Phys:

1c
Staphylococcus epidermidis
2cStatus: Final
Staphylococcus epidermidis
Status: Final

1c
S. epidermidis
2c

DMIC S. epidermidis
ellsc
Interns
Amox/K Clay (c)cDrug
4/2 MIC
R Interns
Amp/Sulbactam (c)cAmox/K Clay (c)
16/8 4/2
R R
AmpicillincAmp/Sulbactam (c)
8 16/8
BLAC RAzithromycincAmpicillin
4 8
R BLAC
Cefazolinc Azithromycin
16 4
R R
CefepimecCefazolin
16 16 Cefotaxime (c)c32 R Cefepime =8 R
R R
Ceftriaxone (c)c32 Cefotaxime (c) 32
R R
CephalothincCeftriaxone (c)
16 32
R R
ChloramphenicolcCephalothin
16 16
R

Ciprofloxacinc=1 R Chloramphenicol 16
S R
ClindamycincCiprofloxacin
2 2
R I
ErythromycincClindamycin
4 2
R R
GatifloxacincErythromycin
=2 4
S R
GentamicincGatifloxacin
8 4
I R
Imipenem (c) Gentamicin
=4 8
R R
LevofloxacincImipenem (c)
=2 =4
S R
Linezolidc Levofloxacin
4 4
R

MoxifloxacincLinezolid
4 4
R
NitrofurantoincMoxifloxacin
64 4
R

NorfloxacincNitrofurantoin
=4 64
Ofloxacinc Norfloxacin

4 =4
I
Oxacillinc Ofloxacin
2 4
R R
Penicillinc Oxacillin
8 2
BLAC RRifampinc Penicillin
2 8
R BLACSynercidc Rifampin
2 2
R R
Tetracyclinec8 Synercid 2
F2 R
Trimeth/SulfacTetracycline
=2/38 S 8 R
VancomycincTrimeth/Sulfa

16 2/38
R
Vancomycin 16

S
= Susceptible
I = Intermediate Nif2 = Not Reported
R —m

= Resistance = Not Tested Blank = Data not available, or drug not advisable or tasted MIC = mcgiml (mg/L) TFG = Thymidine-dependent strain ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive R•
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB
= Inducible Beta-lactamase. Appears in place of Sensitive with species
there

known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs,py is recommended. Avoid other/combined beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)

(b)
Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(c)
Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=s, 8-16=1, 16=R). Footnote (c) applies to this drug.

For streptococci refer

(d)

to penicillin interpretations. For amoxicillin/K clavulanate or ampicillinisulbactam with enterococci, refer to the penicillin interpretation.
For non beta-lactamase producing enterocood,
refer
to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA
For S. pneumoniae, cefolaxime and ceftriaxone breakpoints are based on isolates from pas
" approved breakpoints.lis. For non-meningitis infections, use 2=S, 2=1, 2=R.
Name: .;cCIc
Specimen:Patient ID: Status:cFinalSource:c
nun: erile sitec\_ c.,_ --(-(
Collected:
Ward of Iso:
Req. Phys, Printed 10/24/2003 12:17:23 PM MEDCOM - 19851c
Tech:

DOD-033425
iology Report r \
Name:
Patient ID:
Status: Final

,k)¦.
Source: ound/Sterile site
Ward/Rm: Collected:
Ward of Iso:
Attd. Phys:

1.
Staphylococcus epidermidis
Status: Final

2.
Staphylococcus epidermidis
Status: Final

1 S. epidermidis
2 S. epidermidis
Drug
MIC
Interns Amox/K Clay (c) 4/2 R Drug MIC Interns Amox/K Clay (c) 4/2
Amp/Sulbactam (c) 16/8 R
R
Amp/Sulbactam (c)

Ampicillin BLAC 16/8 R
8
Ampicillin

Azithromycin 8 BLAC
4
R
Azithromycin 4

Cefazolin R
16
R
Cefazolin

Cefepime R 16 R
16 Cefepime
Cefotaxime (c) =8 R
32 R Cefotaxime (c)
Ceftriaxone (c) 32 R
32 R Ceftriaxone (c)
Cephalothin R 32 R
16 Cephalothin
Chloramphenicol 16 R 16 R
Chloramphenicol

Ciprofloxacin S 16 R
=1
Ciprofloxacin

Clindamycin 2 R 2 I
Clindamycin

Erythromycin 2 R
4
R Erythromycin 4
Gatifloxacin R
=2 S Gatifloxacin 4
Gentamicin R
8
I
Gentamicin 8

Imipenem (c) R
=4
R
Imipenem (c) =4

Levofloxacin R
=2 S Levofloxacin 4
Linezolid R
4
Linezolid 4Moxifloxacin 4

R
Moxifloxacin 4

Nitrofurantoin R
64 Nitrofurantoin
Norfloxacin 64
=4 Norfloxacin
Ofloxacin =4
4
I
Ofloxacin 4

Oxacillin R
2
R Oxacillin 2
Penicillin R
8
BLAC
Penicillin

Rifampin R 8 BLAC
2 Rifampin
Synercid 2 R
2
R
Synercid

Tetracycline 8 R 2 R
Tetracycline 8

Trimeth/Sulfa R
=2/38 S Trimeth/Sulfa
Vancomycin R 2/38 R
16 Vancomycin 16 R
S = Susceptible
WR = Not Reported
I = Intermediate
Blank = Data not available, or drug not advisable or testedR = Resistance
— = Not Tested ESBL = Extended spectrum beta-lactamaseTFG = Thymidine-clependent strainMIC = mcg/m1(mg/L) Blac = Bela-lactamase positive
R'
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB
= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactamdrugs.Monitoring of patients duringlafler therapy is recommended. Avoid other/combined beta-lectern drugs.
For blood and CSF Isolates, a beta-lactamase test Is recommended for Enterococcus species.
(a)

(b)

Use maximum doses of drug with an eminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, 16=R). Footnote (c) applies to this drug.
(c)

For streptococci refer to penicillin interpretations.For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.
For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

(d)
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA
For S. pneumoniae, cefotaxime
approved breakpoints.

and ceftriaxone breakpoints are based on isolates from patieyg h mgpio
gilis. For non-meningitis infections, use 2=S, 2=1, 2=R
Name: Cut Specimen;
Patient ID: Status: Final
•-•\"'\
Source: Wound Sterile site
Ward/Rm: Collected:
Ward of Iso:
Req. Phys:

Printed 10/24/2003 12:17:23 PM
MEDCOM -19852
Tech:

DOD-033426

icrobiolo.e•ort
Name:cCIV Specimen: Status:cFinal
Patient ID: 1110c(k)
Source:cWound/non-sterile body site Collected:Ward/Rm: Ward of Iso: Attd. Phys:
1cStaphylococcus xylosus
Status: Final
2c

Proteus mirabilis
Status: Final

1cS. xylosus 2cP. mirabilis
Drug
MC Interns Drugc MICc
InternsAmox/K Clay (c) 4/2

R Amox/K Clay (c)c=8/4cSAmp/Sulbactam (c) 16/8 Amp/Sulbactam (c)c=8/4cSAmpicillin 8
SLAC Ampicillinc=8cS
Azithromycin 4 R Aztreonamc=8c
S

Cefazolin 16 R Cefazolinc16c
R

Cefepime Cefepimec=8c
S

Cefotaxime (c) 32
R Cefotaxime (c)c=8cSCeftriaxone (c) 32
R
Cefotetanc=16cS
Cephalothin 16 R Cefoxitinc=8c
S

Chloram henicol =8 S Ceftazidime (a)c=8c
SiprofloxaulTr----.5 =1

S Ceftriaxone (c)c=8c
S

Clindamycin 2 R Cefuroxime (b)c=4c
S

Erythromycin 4
R Cephalothin c=8cS,Gatifloxacin
=2 S Chloramphenicolc=8cS
=4
S =1cS
Imipenem c) =4 R
ES -a Scmc=4
Leyofloxacin =2 S ESBL-b Scrnc=1Linezolid
4 Gatifloxacinc=2Moxifloxacin
=2 entri fnc=4
Nitrofurantoin 64 Imipenem (c)c=4Norfloxacin
=4 Leyofloxacinc=2Ofloxacin
=2 Meropenem (c)c=4Oxacillin
2 Moxifloxacinc=2Penicillin 8
BLAC Nitrofurantoinc64
Rifampin 2 Norfloxacinc=4Synercid
2 Pip/Tazo (d)c =16Tetracycline
=4 Piperacillin (a)c=16 Trimeth/Sulfa =2/38 Tetracyclinec=4Vancomycin
16 Ticar/K Clay (a)c=16 Tobramycinc=4 Trimeth/Sulfac=2/38
Sc = Susceptible N/R = Not Report
= Intermediate Blank = Data not available, or drug not advisable or tested
— = Not Tested
R = Resistance ESBL = Extended spectrum beta-lactamase
TFG = Thymidine-dependent strain Blec = Beta-lactamase positiveMIC = mcg/m1(mg/L)
IR*
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB
= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lectern drugs.
Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)

(b)
Use maximum doses of drug with en aminoglycoside for P. aeruginosa in patients with granulocytopenia Or serious infections. Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=l, 16=R). Footnote (c) applies to this drug.

(c)

For streptorbr•i refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.
(d)
For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-512 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA
approved breakpoints.

For S. pneumoniae, cetotaxime end ceftriaxone breakpoints are based on isolates from patien • itis. For non-meningitis infections, use 2=5, 2=1 2=R.
Name:cCc c
Specimen:.
Status:cFinalPatient ID:

Source:cWound/non-sterile body site Collected: 4
Ward/Rm: /c\
Ward of Iso: Req. Phys:'
Printed 9/23/2003 9:01:28 AMc
MEDCOM - 19853
1111
Tech:

DOD-033427
Micr Re s ort
Name: CIV
pecimen:
Status: Final

Patient ID: 1111
Source: Wound/non-sterile body site Collected:
Ward/Rm: /
Ward of Iso:
Attd. Phys:

1 Staphylococcus xylosus
Status: Final

2
Proteus mirabilis
Status: Final

1 S. xylosus
Druq
MIC Amox/K Clay (c) 4/2 Amp/Sulbactam (c) 1618 Ampicillin 8 Azithromycin 4 Cefazolin
16 Cefepime 16 Cefotaxime (c) 32 Ceftriaxone (c) 32 Cephalothin 16 Chloramphenicol =8 Ciprofloxacin =1 Clindamycin 2 Erythromycin 4 Gatifloxacin
=2
Gentamicin

=4
Imipenem (c) =4
Levofloxacin

=2
Linezolid

4
Moxifloxacin =2
Nitrofurantoin

64
Norfloxacin

=4
Ofloxacin

=2
Oxacillin

2
Penicillin

8 Rifampin 2 Synercid 2 Tetracycline =4 Trimeth/Sulfa =2/38 Vancomycin 16
Sc= Susceptiblec
Ic= Intermediatec Rc= Resistancec MIC = mcgfinl (mg/L)
Interps
R R BLAC. R R R R R R S S R
R
S
S
R
S

Nod TeskeA S
S R BLAC R R S S R
NUR = Not Reported
—c= Not Tested TFG = Thymidine-dependent strain
2 P. mirabilis
Druq
Amox/K Clay (c)
Amp/Sulbactam (c)
Ampicillin
Aztreonam
Cefazolin
Cefepime
Cefotaxime (c)
Cefotetan
Cefoxitin
Ceftazidime (a)
Ceftriaxone (c)
Cefuroxime (b)
Cephalothin
Chloramphenicol
Ciprofloxacin
ESBL-a Scm
ESBL-b Scrn
Gatifloxacin Gentamicin Imipenem (c) Levofloxacin Meropenem (c) Moxifloxacin Nitrofurantoin Norfloxacin Pip/Tazo (d) Piperacillin (a)
Tetracycline Ticar/K Clay (a) Tobramycin Trimeth/Sulfa
MIC lnterps =8/4 S =8/4 S =8
S =8
S 16 R =8
S =8
S =16 S =8 S =8
S =8
S =4 S
=8
S =8
S =1
S =4 =1 =2
S =4 S =4
S =2 S =4 S
=2 S 64 =4 =16 S =16 S =4 S =16 S =4 S =2/38 S

Blank = Data not available, or drug not advisable or tested ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive
R'c
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL7 = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.IBc
= Inducible Beta-lactamase. Appears In place of Sensitive with species known to possess inducible beta-lactamases: potentially they may become resistant to at beta-lectern drugs.Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)

Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
(b)
Breakpoints based on parentei'

al dose. For cefuroxime axetil (P0) use (8=S, 8-16=1, 16=R). Footnote (c) applies to this drug.
(c)

For streptococci refer to penicillin interpretations. For amcoicitin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.
(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moSfloxacin are based on FDA approved breakpoints. For S. pneumoniae, cefotadme and ceftriaxone breakpoints are based on isolates from patients '
cFor non-meningitis infections. use 2=S, 2=1, 2=R .
Name: CIV
Specimen:
Status: Final
Patient ID: IR
L\
Source: Wound/non-sterile body site
Collected:
Ward/Rm: /
Ward
MEDCOM - 19854 Req. Phys:
DOD-033428
iinuils px51

01111111101111111 111111111212111111111111111111111111111111MELIIIII

Militell1111111EMEMPEINIIMEMINIMMEMEREE
LAMINEENINIENEEMMENIEBEEMEDIERIMENnell
NIESPEEMEMINEEMMINISIMPANIMMENEMENEE

IIIIIMENNIEMEMIMEIMEMEMINIMIMENEMENEEN

RIMINIMMENIMINIMMEMINIMEMEINERMEMINEW

INIKVIIIIIIMMINNEMEINIUMEIREMINIMMIIMINEMEME

EIMIEDAMINDEINEMEMINEEMENKIIMMELVERMEN

EILIMEMINEMMEERTIMINIEMI MEMERME

filENE000000E0 000 0001100 0000000
imminffetimomptimmorammE sierAilionm
ji
MEE NE 0E0.
IMPllietintilicolia
E-
Wi.
00110.000000E000, -L ev MIME
0 0000001SVA:IP00.
f10111MMIINEHE
ME0 '000E0060000E0• '.
t riBINIEIMENIEEICINI0000012ek0000'41100iMin000•EillNN00
000111­
1E00.0:31%0000 00E 0000.410611000
0005.10000E00000000 0 1 0000000000b
0M00­
I=: , 01008111000 0 01E00E0 .0011010fir

0 MEE 0000EN1000 E.
01M100iii.E40.-411000000.
• ialLEIRIMIE0
0 ra­
100000001E00.00 REIE 001001110
NEE000 i'IN-CT-10i000E0001100010$100R1
11000 00012 i100.000:01
nammornEomemmit
Mk 000.
• --s asn. ..
'FIEENIEFIBER-4 MANNIVNIELME
.11:

00011111W 100111wEirmkA.o
000:mmrn.00 1111107-10ffl
tagrEENIOSMILMMEMErdirii7.COMM
"I I.Hal.IRSIMPIIIPEr
FLI":1P2•...k• :1
1.14MIAELMV:07301gaitHEMIlii:Vtilffialifiltin9111111k1

1124 0000000EMMERIELO fielliMfil lin 7fiVIRMINiegeir
-

EMMEN PREMhdittlillilliMPLEMEMIKEINIEI*Vith:r.
611Mil 0010:911011010ERF.

400011100NBE
000.41000000 hille1000000000001M
0E00 011101L:1-01-10000.
00000:-LARRIEN
000111000M00 1
10.1000 . 00000 0001d1110
it-ZE000000M000 .. 0000 0 000EW -3- 49
000120000 ti MIME 0000 ENE •EPEE , -,,-,F.TSAAmmIMENNEEMEIF,,000000000E ENEELE000
E000009741M00 000 0000001610000
000111.90000MBEillir700 =HEE 0 iiihandiffiqll
000.000AMEI0A10000111 .1100100 NILEl
minniamommonsm!imiLas EEPA-E5
i-OEN 0000 tial00000a200000116153
000E51-6200000E00E0000EREEE 00•
EMEKr,. 000 000000MBEIMEEMMM00000
M0000E00000M0EMMEMEMEMEMMEMM
EIMMEEEMEMEEDINTERNMEMENITH000MIENFOTA0
EIMOMM00 000E0000000EM000000E000
MEE= - -00000000000000E000000000
EIEEEMEEMEEEREHNE0000110E110011EE000
1100000110.0001E.MM
EMMELINE
LIEENEEMMEEEE00.
EME00010
DOD-033429

ot.` DRUG (Unite) MEDICAL RECORD TOTALS Y/if ypr \_ . ANESTHESIA
tr 0 0 cn z IrCU ) Unc. /114,1 ) ( KO /o TOTAL URINE c6)- 47,ey
VOLAT AGENT frabf-fl % rl I % e.t. b.-4.5" MSUMAR"FLUIDS - ;
AIR L/Min CRYST2LL9ID-
TP 1120 UMin COLLOID-

02.UMIn '
19 2 MOLE DOSE DRUOS - MARK ON ORI
BLOOD-

FWITH NUMBERS &ENTER IN REMARKS
0 LINE 5m, t Wavt1 ...-aNr.d LT
co REMARKS-
a Warnsd
Dc
..J 0 Warmed Cocks &ups with numbers. events with Weis
U- a Warmed
LOSSES EST BLOOD LOSS URINE PHYS STATUS 1
WEIGHT • SYMBOLS: mon
TIME mummilianimmw /Pidade__
BODY11
: IMI

marem
BP by cuff
i =Minn ilammeilin
71=

Heart rate
IR. MLR%

m
mirammimiurrAmannrjrnarsi
Resp rate
....mr41,1111W1110111111111MEMIll
120 Mil. M INNIMMINIENNERM MEM.
SEE

BP MINIUM.
... i i i 111111111101MI Ir
(transduced)
szatermiteamenrann nanamannamannso
100 P9111111111111kgirialMIIMMI MITIlnimni
alf (i)

80 MUM Ma=
OK? rillUINIIIIIIMISIPIIIMP.
TOURNIQUET
60 DRUNSIMINIIIIVONIMAIM, MORMEREEDIJIMESME111111.111111111M1111 I i M O T ii., _MlIMI11111111 ii NUE i i 111111111REM i i M
OK for
40 EIMIUMIMMENERNMEEMSEENMESEM :.::• 0•4-•: , =ROM
PROCEDUR
ARES-X-X MI I f I i inM i ! i i i i EMI i ¦ =ME : rase-ocw pRoc.0-125 20 M MEE= ENN ME SUMMENHERE M MEN . /edelVe7IlialliMIIIIIMI MN i i PM, I i i IMIIIIMMIlfilin i i
a
PiltVgAIROMMENNUILIMMMINIENNIERNIME
7/0.7,0 :" -/).0 7 .
, • i • i •.,
ic...irawwmmmmnmmmimimmi..I
IIIW]UltMIM.r
-i raThaii441 p.IDXMMIMIMMIEIMM.
AT

0'. ssi on RECOVERY
BP/Auto C
a CO2 ton
IIIMAIMIErilialiSTIMMINIIIMIIIImmumumilml
BP l oth
CAit IFT i It I fr sc1.
1
ART line
EMIIIIMINIVW31110
eth- PC/E EGGc ONDMON:

4.1 ..1".. SA SQ
Gas analyzer RESP-402- 93
BP- c/ 2.11R-

fg
Start Room End

I *IP

rmIng bikt
,
Cony warmer 1 /56/
Mark with lettcrs.
EVENTS Ready Begin End
urpJain under REMARKS
Position.6-1
o.

PROCEDURES and CPT Codes o. /s:"??.gsgtANkSTHETIC TECHNIQUES:CI..scribe Nock technique undo, Remarks
aZAN_AGEMENT:
PATIENT IDENTIFICATION-owl or .71Iten onfrhoss AIRIAMintubetion.lute, blade. technique, comments
Medics/ loc/My
gee() 4=-7"

SURGEONS:
PROCEDURE 67/9 LOCATION

AN.TI
DATE
mos,t
-C3 PAGE y OF

WAMC OP 376 REVISED 1 Jan 99
PATIENT RECORD.
MEDCOM - 19856
DOD-033430

Cl)

DRU (Unite) DICAL RECORD •,
ANESTHESIA TOTALS.'q • .; '
I PIM MINIM l';;Iiimmmintimmaimimmi..........__

AIMIllEnnlmmommnsammommill RP4W11
. lira

IrMIMMINP141W2Z.---.... ....mmummuml
IVA ZIIIIIIIMI .a.; i.
:i.• ..•
..lirrAumi
z IIVREMMIEMEIII 00 :
I-111r1111ePA.i 1• i.:.. :
z •

IMINIIIIMIPA. :.: ..•.
LU
0) 4-

VOLAT
kliMIIIMII IMIOMMAVIIIIIMIllmmommummiumum
AGENT : ..: ..FLUIDS S
c.) 111811111111111M11.MARY
4

I-CRYSTALLOID
LU AIR UMin .... ...
.....
Imim
mirmwrimiumweammtimummimummumnimi
LU .
SINGLE DOSE MOS - MARK ON
WITH NUMBERS &ENTER IN REMARKS

co LINE a Warmsd
c REMAR
0 Wanro•
L
Cod. the, oSh nmbor oma
EMEIVrailititil=3
LL : i •
....". 78r:Pd
l

LOSSES tiV;hec C(.XL") I
iIrTriwniaminimmlimmammiumn
siii 4 Foe t c 6 -(=MI MEEZ= cd,
1/04Z1111 " um

mizam Sy MBpLS: essenness
i
.
BP by cuff 220 MIUMIIMELIMI • •
180 WEE=
200
V • • •
• ii.
A EMEMI '

WI Ti ••
Heart rate
160 IMMENNIUMMIMBSEEMENNEKKUMEMINKappl!
i i 1111011illaMIMMINIUMMIIII 1
Resp rate 140 OYAIIMOSESSMEMOMMILMENIENIMIIMEMBM
ICAIPmunonavAmunialEMIHNI
IMI•1111

120 ESTAMMIWARNMENNEIMENSEMIMMESURIMM
BP IMPIWITAIMINIFISMIMI 171111MIllw,
(transduced) rawnrarrat
100 agn EMMEN '
i i-.
'1471MINI =MIN gm mu i i
T KUNI.,i:i,ai4::::::iMME.
80 NEVIIEN.non IIIMMIEN 4,,
TOURNIQUET mialumummusinowimmuuntion i i IIIIII
60 116,186$112NREENIKS2mmostalAUSBNIMEMENNIEM
Tr.

T — /I/ IWAISitr/IFINZW11111111111111=1.
OK for
PROCE

pataanannsownsonnwasmauswas
40
I r IHM1 .44.01. 2, T6 lie)
AllES- X-X m mummumm i•
PR000-0 20 EffeERNMERNEMENNEMERUMENNEMENMERSEI tic-.id
i
ass Imo.i umimmummi
i

INESINUMMLIKSZKEZEURROMMEMIPAREMEEMENIE
• •-• .gminiminnmiumnimffailimilmomims
prmlum171E1011 FAIIIV
pEcovERy AT

11:11U161111.
BP/Auto C t. ET CO2 (off. •
,.I P 1 oth ¦'•1"
ART line lirrN.1231111i 6v

ilLaianr:Wia
112MMITtITM11111141111111VIIMIIIIIfflart1IIMINIIIImmommimmoiuml
1,11MTITMOGIMMENETTIIIIMINInmummummummummimmum.
, I g N-M Block T/4 11111EMIIIIIIIIMETO i

l l
IIIIIMINIIRIEMm
'41.II.•1111011111immoiammummiaminimml
........._

II
1 nning blkt 1
mi..,...._____________
11111=11111.11MIMIIMMEENNIMMMINIMINIIMIIIM
IMIIIMIMIIMIMIIIMIMMIMMIIII.11.111.111..111111111.1
..; I Cony wanner 1111
.lh Mffeu A •Ymbol.•
erp,Wn ands REMARKS Position

••¦• EVENTS
a.

PROCEDURES and CP • as Zot
AN t5THETIC TECHNIQUES:D.3"m bkek ti"ehnig4"
under Riwneri"

•Nt
S.6). 10

PATIENT Ogyym ON_ Typed cr *Mon onoios: frehnkuo
.Norm Crods,Rafe,
Mode& !way Lx • 414a1

mg,
44'11.0

SURGEONS:
LOCATION DATE
2Z5 0
PAGE.OF

WAMC OP 376 REVISED 1 Jan 99
PATIENT RECORD.
2 F
MEDCOM - 19857
DOD-033431
,A)
DRUG.
(Unite) MEDICAL RECORD
ANESTHESIA TOTALS

2 g .
o a a z.
0 V 2 /7--etili-5-c) (y\
Z /

TOTAL URINE
I)
) ka i r-. g.

L__L c
z
u,
LI g E 2 .VOLAT
(7, t'vnFik del.f5i-,.2\ V- •
.AGENT FLUIDS - SUMMARY
C.) R t g . % e.t.
CRYSTALLOID-

I-' F.' 11.NR.LJMIn
ui
N20.IJMin .

I- COLLOID-
U) .02.57
UMin.
w
Z SINOLE DOSE DRUGS — MARK ON ORIIL
BLOOD--

4 WITH NUMBERS &ENTER IN RDAARKS '-
LINE sir Warmed
ci 42t5r5 tee( REMARK
Wamsd
5
0 Wormd Code dugs wRh numbers, ..Xs with Mews
I
VVannid qqa.,:y1c4 egt /15
LOSSES EST BLOOD LOSS
URINE-
PHYS STATUS

/

TIME slez
1 I) 3 4 5 E i e-S--
SYMBOLS: (Irre
BODY WEIGHT
al OMMEMIKIIMMEEN
BP by cuff 220 111111111111 : i •IIIMMIIIINI fr MIII / 5220 "a i/Sr V m : otstm W2 F
200 ISMENNOXIMENNERNESS::V:::t.ii , ;MILINEMann A 180 EMEMENISMKONEEME:s.::i:: EMEMM
'77OM1M7MMTROMMYW
iiii i IM111111011 i : MI
Heart rate i ! 1111111MIIM
160 SIMMISITIMIESEEM
• 17 KNAIMMINIERI
miumnitinIVAILIIMIlii rillrlliMa'al
Resp rate 140
MIIMIIIMINI i i IIMI•IMIMIN i i i i Mani
120 folfglIERSIIMIIIMENNIEME
BP 0rATTOM = i
iiATA NMI
(transduced)
wilmmtwassammens.::::.:F12 . .iti:::::Enu
100 sa. ilimmannsu
lliimi T 80 llsaM rainni=
OK?-.N INPIIIIIIIIILIIIIIIMMIIIIHNIII NMI
TOURNIQUET Mil NEB
VittiVIVESSUSIENNEMMENINSUE
4°4

T—/ - oftrivayminnumumum• i i nil i i am .EffilEffillEnn
i i man

OK or
40 11111111SMINISNMENZEINKENIMMENNNISIBINESIARNEMIES
PROCEDURE?
Eliiii ii
AMES-X-X ii i i i i MIN i i 1 i_ MIIIIMIII
pRoco-0

20 SKENEMERESEREEMENESSM ENNSKU KEE
1111111 i i i i 1 i mas
T,513c)
cL.c
• I II I
k f
.
0 n ssIst n RECOVERY AT ' 151011
Auto C ET CO2 torr iry MEM BP f Oth ART line
cmirmui
Steth-PCIE
Gas anal zer

EMINEN

N-M Block 114
'1,r^-",r.7.1)"c -;",•.,:-
Ut

Ing blkt
Cony wanner /000
Mani with lotters 6 symbols,

EVEN TS
orphan under REAURICS
PosIdon
, •

PROCEDURES and CPT Codes gS-6) g0 AlflisTHET1C TECHNIQUES: D."..q.
6i tachni"under "mad"
f-em LofJi Ocif
tra rQ7
AJRVVAY INVIAGEMENT:
PATIENT IDENTIFICATION — Typed or written onfriss: Nemo. GnociseRale. Intubelion nu,* Ws,*. a 5YQme-2 Mocileal zrioivoOreG'mflpeiVf-Tiqu;c4- 7-
(t)-0,7,

SURGE02::
PROCEDURE LOCATION GYN. I

AN T rreil DATE 7/2 ffr'3
PAGE / OF /

WAMC OP 376 REVISED
1. Jan 99

PATIENT RECORD.
MEDCOM - 19858
DOD-033432

(Unite)
ANESTHESIA TOTALS
VOLAT
AGENT i4 el.
AIR 1/Min
N20 L/Mln
02 L/Mln

SINOLE DOSE DRUGS - MARK ON ORIL WITH NUMBERS CENTER IN REMARKS
Warrred
LOSSES EST BLOOD LOSS
SYMBOLS:
B. WEIGHT
KG
BP by cuff
LB
V
A
Heart rate

Resp rate
BP transduced)
T
TOURNIQUET
oK kir PROCE / AMES- X-X
PROC-0-0
BP/Auto C
T CO2 torr 0th ART line Steth- PC/E Gas anal zer
-M Block T/4
Ing blkt
Corn/ wanner
I c
i.I.I.
TI:E.il.i!.ii
Mg TMEIREMMLIM.
MIMI.MINIIIMI1111.111 ! : ..: : 1:1
SMRWM::::igNMERAMMMILI5 ggs:::':,',:]-'ME
MI IH,
NMEHM4666RWM::::i.i.:.i.:::11
a111E
MI MI i i.
MIMMIMMII
I
MAIMAKMMIMMMOOMMIMM MINIM MIIIIIIIIMIMI11111111111111 MI
140 affSMMMEMMIMMMIMSIM MIMIMMINUNIIIIIIIMM i I i i 111111111111
TANIMUNE AINKM1MMMMIIIMI
120 IUMMIIIIPII MIIMIMI
EntadaringtESAMMINEEMMIEMREMIN
100 rumbingomin Num i i i.i min i
80 ESEMPENIIIMMBENI. IMMIM
MlallIaLIMIMIIIIIII II ISM' MI
kriMIMIMMIIMEMI.
60 IIIMMIUMMO
LAMTAMIIIELLAIIRIII i i MEI i i i i MI.
UI

40 ffilMillii7ANNEEMMMMEMUNIMMi M.i MI.IMIIII MI
MMENEMEMMMMMMM
MI262M111110 MILIFINIIMERIRDI
....
IESI

IIMM/FAI.•
CIIIHE 0 i 44111* ,
ONDMoN:
REsr-
DP

AL URINE
P--vasvc. 1
F UIDS -SM AY
CRYSTALLOID-

COLLOID-.
REMAR S-

Cods dugs wNh numbers. everts witklefttfcrt
cit -rali I 4ik----;a -("104,404,1T2)(AL,4,1
,

:irtcAZ
o9/0 -ivAArci Ltd —Pd
,r4 .&tel.(
jf

Mar* rib Maws4 symbols. EVENTS
Ready Benin End

...plain under REWIRKS Position
1.11)"-'".9 PROCEDURES and CPT C±js 0910 1036 Al.THET1C TECHNIQUES: 00"db* block technic'," end" Ramada 6 4
... 7.

PATIENT IDENT1F1CAT1 or written ontios:
Norris. GrodWRofo.
Meclleer feellNy
PROCEDURE
LOCATION
DATE

WAMC OP 376 REVISED 1 Jan 99
PATIENT RECORD
MEDCOM - 19859
DOD-033433
LINE site.El Warmed 2.,..0,cgcA.c0 Warmed
. Warmed
u.
. Warmed EST BLOOD LOSS
LOSSES
UR NE -
P S STATUS
TIME +
1 4 5 E SYMBOLS:
BO.WEIGHT:
220 la) BP by cuff
97-LB "Y 200 HEMATOCRIT:
A 180
-‘"----Heart rate
160 ?dITIAL. DATA: •
Resp rate 140
BP-
13`/11 120 HR-co
BR (transduced) 100
±
EQUIP
T
OK?-Y N
. TOURNIQUET 60
PATIENT RECHECK T. —x/ 40
OK for
PROCEDURE?

ANES- X-X
20
PROC- @ID
TIME-\'43,Q
VT-ml
23 gr.
6.-. c, 4-ea b., rm//sr

6 et1
a P rr 14:X4 liigDIC AL RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG
TOTALS TOTAL EBL NC ap ,--,
2 -5
CY-,.A 'Th

N2-5 -7-0D __--¦ TOTAL URINE
/e( .

Z.0 Z-D Z.p t.5
• FLUIDS - SUMMARY CRYSTALL.-
COLLOID-,25--

—2_-2_,
BLOOD-

(.9
REMARKS Lie_ 100 '," -7-N-0
--, Code drugs with numbers, events with tethers
o coO r-sel (
30C- Y ,-. .esS, 1 e 02 , '
-S-,-,a)Cs'Cibi-,

.ILI-7.h s-c3oc_ )COc_._.3.1°
i-A1 Apccx,y4c.
111111111101111111.1111111=111 ' 11111111111111M es: ,,-)
1111•11111111111111=MMEN111111111M . ,.( iir,".v---i.-1c..„1.r y-keint
--N ‹...\ 0-e_x-.
-.rs, \
ID
Ve-h-,,,Otleel

•-\-1.) !YU-) 1K CA0152 t re-eb k
' ve...1-,
ma 6 `
,
,

Ak
WIlm.h
""=Ziv2iNIIIIIIIIIMMENII
7WrAWIII 1111111•=1111111111111 =MINI=
500 310
ISO
1--f - breaths/min
\ Z
\Z
l
l
\ to
Z
W
Peak Int pres / PEEP —
E - SIpon). A(ssist), Clonl 5

ERY AT

4P/Auto Cuff LEY'CO2 (torr)
CU.Specify)
BP/oth 142 (Fre .or To) N,.,/(%) \00 100 OTHER 41_,_0
ART line p02.
/

Steth- PC/ES 14ECt CONDITION:
T,R, :Slt.
Gas analyzer .' TEMP-site
RESP- Z'2" Sp02-4i.2.7
BP. F').11/43-1R---7 6
ANESTI SIA I PROCEDURE TIMES
ca Start Room End
us

l

N-M Bloc .(T/4)
Warming blkt
•1 1330 133 1 9S_.c.
Cony warmer 0 Ready Begin End
Mark with letters & symbols, EVENTS__„,c_c.,-,1.-L.
___________--7 .
explain tinder REMARKSmPositionm"1-.)--1 l.!
) ibc. 131-E-:, 146° 15C7
PROCEDURES and CPT Codes:.
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
--5-7,-c) 'cZ__Ac - C eyr,f- , clIc.)( \,-ec:xcl....5mCALM k
PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, m
AIRWAY MANAGEM NT: lntubarion route, blade, technique, cormpeots_____ , 1,rA A .¦-1.1.COMedical facility
m -,Cy- N j-),-,a ..) C7 7-.U Z CAt-S-ile-4m l
SUFt.•
PROCEDURE.1 LOCATION-
e).1---DATE:
/ cAlL)11 m
PAGE.1.OF i
c

NESTHESIA PROVIDER USAPA V1.00
MEDCOM - 19860
DOD-033434

MOI
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG
to (Units)
CC TOTALS
) TOTAL EBL
CC
0 4.012
) •
0 Lc..

tit°
m

) 140
TOTAL URINE ) (t^tr-t) Uo VOLAT 'TPA % del
/.5---
AGENT
0 % FLUIDS -SUMMARY
LU AIR L/Min
N20 L/Min

ral 6,o CRYSTALLOID-s,­
02 L/Min CO
(7.
SINGLE DOSE DRUGS-MARK ON GRID .4, —c
WITH NUMBERS & ENTER IN REMARKS
BLOOD-

LINE site LA.
cn . Warmed 10`1° 1'
0
. Warmed REMARKS
. Warmed
Code drugs with numbers,
events with loiters

. Warmed
.
EST BLOOD LOSS
LOSSES Cl2­
211_ Atiy-6/L
URINE
PHY STATUS

TIME
1 3 4 5 E
BODY WEIGHT: SYMBOLS:
220
BP by cuff
a 200 11t.L LA-0 V //
HEMATOCRIT: Hegh4/44a,_
A 180
Heart rate
160
INITIAL. DATA:.•
0A)o-ke Ctc

BP-. Resp rate 140
Ccfs-17120 MEW
HR-BR
(transduced) 100 11111911,1111,2101,11/ k)
EQUIP CHECK J.. 80 034/
=MEM
OK?-
TOURNIQUET 60
PATIENT RECHECK

—4'
OK for
PROCEDURE?

ANES- X-X 20
TIME. PROC-8_0
40 ime
VT ml

f - breaths/min
14,
Peek inf pres / PEEP
MODE - S(pon), A(ssist), C(on)
BP/Auto Cuff ET CO2 (torr)

RECOVERY AT I to

O

BP/oth
F102 (Frac or %) ART line Sp02 ( % ) ICU Specify)
la?
Steth• PC/ES OTHER
ECG A
Gas analyzer a CONDITION
TEMP-site
N-M Block (T/4)
RESP-.Sp02- 451,
BP-.HR. 13
ANESTHESIA / PROCEDURE TIMES

Warmin blkt Start Room End
z

Cony warmer
101.%

Mark with letters & symbols,
EVENTS_,
explain under REMARKS.Positionm"" 0 Ready Begin End
PROCEDURES and CPT Codes: O 100S— )4' R-/051(
-----ANESTHETIC TECHNIQUES:
‘A)C4" 0 (AA

Describe block technique under Remarks
PATIENT IDENTIFICATION: .11-
Typed or written entries: Namem
Grade/Rate,m
AIRWAY MANAGEMENT:
NAGEMENT:

Medical facilitym Intubation route, blade, technique, comments Ic(V'fle 3---
mUPOW 101,14.-"I 1101ALA 3 ,
&WC C&-.)4:7-vS a-) i --io-L_G- -s--"c 1.1¦0
SURGED PROCEDURE LOCATION:W".4- —)---DATE
ANESTHETISTS: lkpj
DA FORM 7389, FEB 1998 PAGE
-ANESTHESIA PROVIDER
MEDCOM - 19861
DOD-033435
PROPOSED PROCEDURE:
„.:1214&s i,e4
SURGICAL SERVICE: NPO SINCE:
18 al!.A Album
HABITS:
TOBACCO:
ETOH:
DRUGS: —

CURRENT MEDICATIONS: 0 = ordered as premed
( )
( )
( )
( )
( )
( )

PREMEDICATIONS:
None Yes (@.
Hrs) ICC mg IV IM PO mg IV IM PO mg IV IM PO
LABORATORY STUDIES:
1-1B/HCT:
U/A:
OTHER:
R

PREOPEATIVE
PAST MEDICAL H 1STORY/SYSTEMS REVIEW
Cardiovascular:
Hypertension
Angina

.Y
MI
CVA
Other

Pulmonary System:
Asthma
Bronchitis/URI.

N Y
COPD
Other
Renal System:

Acute/Chronic RF.
Y
Gastrointestinal:
Hepatitis
Hiatal Hernia
PUD/GERD

Endocrine System:
Diabetes
Steriods

Y
Thyroid
Neurological:
Seizures
Neuropathy
Other

Gynecological : Pregnancy.
N Y
Other Significant Hx:
N
N Y
Familial HX
N Y
ANESTHETIC PLAN: { } LOCAL { } MAC.
{ } Regional (Specify):
INFORMED CONS
/CO
discu
-7) sical State 10 3 4 5 E t_git_B HT: Gi?
IN.
ALLERGIES:

ASSESSMENT PAST SURGICAL/ANESTHETIC
PHYSI.
EXAMINATIONBP.
HR
Pain cele 0-10
HEENT-Teeth

Trachea
eimJ/Neck Oropharnyx Nares
IV Access:
Ulnar Filling:

BACK:
OTHER:
NPO Since
neral: M

al guardian..vy\pr
The atientA gal g
Sign s. Questi ns answer
POST-ANESTHESIA EVALUATION ND NOTE (NON ASU) Date: Time:. v Hrs

e patien ELING STATEMENT: Plans alternatives and risks of anesthesia including death have been explained to and
) NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER
SEDATION KEY:

Signed:.
Date:
Time:
Patient Identification: (Ward)
(Cit -
-1 C(A):/,
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
1. MINIMAL (Anxiolysis) Patient
responds normally to verbal commands
2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or accompanied by light tactile
stimulation. Airway assistance is not necessary.

3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistancemay
be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation.
ANESTHESIA RECORD. Previous edition is.obsolete
'U.S. GPO: 2001-629-183/40002

MEDCOM - 19862
DOD-033436

-L Civ (
14SN 7540-01-145-7254
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasouad/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED
1)1 ( PREGNANT
K YES
NO TELEPHoNE/PAGE NO.
fl

OATE REQUESTED. REASON(S)•FOR REQUEST (ComplaInt.s..arsd findings)
SPEC I F
067

Fes.,cRio
DATE OF EXAMINATION
(Month, day. year)
DATE OF TRANSCRIPTION (Month, day. year)RADIOLOGIC REPORT
eut, 12L/0
1111111) (r )09)
PATIENT'S IDENTIFICATION
(For typed or written entries glue:Name — last. first, middle, Medical Facility)
. LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
RADIOLOGIC CONSULTATION STANDARD FORM 519-8 4-83)
REDUESTMEPORT
Prescribed by GSA/ICMR

• —
MEDICAL RECORD FPMR (41 CFR) 101-11.806-8
MEDCOM - 19863
DOD-033437

NW( 7540-01-195-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
EXAMINATION(S) REQUESTED
(RadiologY/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
AGE SEX SS 73 iff C WARD REGISTER NO.
PREGNANT
YES ;a. NO TELEPHONE/PAGE NO.
SPECIFIC R EASON(S) FOR REQUEST (Complaints and findings) DATE REQUESTED.

DATE OF TRANSCRIPTION
(Month, day, year)

PATIENT'S IDENTIFICATION
Name — last, first, middle, Medical Facility)
(For tyPed or written entries give:
LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
RADIOLOGIC CONSULTATION REQUEST/REPORT • STANDARD FORM 519-B (8-83)
Prescribed by GSA/ICMR -- • •

MEDCOM - 19864
FPMR (41 CFR) 101-11.806-8

DOD-033438

t CLINICAL RECORD -
DoeTo'

SYSTEM -or use of this form, see AR 40-6C. the urot,
IS
THE DOCTOR SHAI L RECORD DATr. -TIME AND sIGN EACH SET OF ORDERS.
..ATIENT ,

rSG

IDENT
USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED f3Y ARROW BELOW.
IFICATION IC PROS ,
EM ONIf.:NTED MED:CA L DATE OF OFIDER
11 '.....r" • .
TiNIF OF ORCIER

, ¦110 •
o'3'‘ckW 6)'
"ectx,_14%.coleoc
-N URSING _ fC60-- 6111111
-,6‘)isw
OOM NO
_c

_4(70 ltdsgi - - -c-
PATIENT IDENTIFICATION
OF ORDER
T•mE by-zo
OF ORDER
_.
HOURS

STIVr-UNirm
.7ROOM NO— • • BED NO
TIENT
T I [CATION

ORDE
TimE
Of- DROR
_

;.;
ROOM NO.
. p_1-))mhi_49.0 4o
ke/
7ATIE NT ./

;Dr N-TIF ICA T,ON
e)e,oc

4i'?c
DATE OF
ALI
ORDER

a2417,c
.c4Oc
/vp

_s-i6y).-pelip- pgpir d›,,,A, Ammer
-1,/‘.7(4sy cA-42v-
NURSI
UNIT
I ROOM NO
I BF D

MEDCOM - 19865

DOD-033439

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
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
1
11
11L.

rAlff

2-41
curs
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 19866
DOD-033440
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
NURSING UNIT
BED NO.
MEW
g
ia
PATIENT IDENTIFICATION
NURSINGU
1
2IT
PATIENT IDENTIFICATION
DATE OF ORDERN
TIME OF
NURSING UNIT
36/"I
PATIENT I NTI CATION
NURSING
UNIT
BED NO.
DA 1 FACPR
M
4256
79 REPLACES EDIT'
OF 7 JUL 77, WHICH MAY BE USED.
MEDCOM - 19867
DOD-033441

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

SYSTEM IS USED, WRITE PROB DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
LEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION

NURSING UNIT
CES EDITION OF 1
JUL 77, WHICH MAYBE USED.
MEDCOM - 19868
DOD-033442
CLINICAL RECORD - DOCTORS ORDERS
THE DOCIS For use of this form, see AR 40-66, the proponent agency is OTSG
R SHAL SYSTEM ORD DATE, TIME AND COLUMN
TO USE
D,.WRITEREC PROBLEM NUMBER IN
SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
INDICATED
PATIENT IDENTIFICATION , BY ARROW BELOW.
N
L
PATIENT IDENTIFICATION
)
NURSIN
PATIENNTIFICATION
PATIENT IDENTIFICATION
A,.Nit'

6h,
IURSING UNIT
1 APR" 79
4256
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 19869
DOD-033443
N
CLIICANL
RECORD
For use of this fo - DOCTOR'S ORDERS
rm, see AR
THE DOCIS
TO US
R A 40-66, the proponent agency is OTSG
SHLL REC PROBLEM
SYSTEM ORD DATE, UMBER IN
ED, WRITE TIME ANNSIGNNEACH
N
SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD
COLUMN INDICATED
PATIENT IDENTIFICATIONN BY ARROW BELOW.
ORDER

LIST TI E
HOURS NOTED AND

SIVZ SIGN IMMIWAI111/
4111111
...ARfflimPURNM,
A WA IIRIPM.N.raMISMIPrd,'AI I I I I I I I I I I I Ms
almscruipw
PATIENT IDENTIFICATION
1111.11111PIMMANS2AELP
DATE 0
ER #F

*V
NURSING UNIT
lovosammuninemai
_

iviroap wpm- -app,-
-TE OF^gqp^R

NURSING UNIT
PATIENT IDENTIFICATION
A ir 1111111
NURSING UNIT
Allow

11111. M"
11

REPLACES
EDITION OF 1
JUL
77, WHICH MAY-BE USED.

MEDCOM - 19870
DOD-033444
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 Tim E ORDER NOTED AND
HOURS241 /c SIGN

is•
.n1 a

.c/i6 /22)-c 6 11/.
rzs /
NURSING UNIT BED NO.
PATIENT IDENTIFICATION
DATE OF ORDERN
TIME OF ORDER N HOURS

NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDERN
TIME OF ORDER N HOURS
NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDERN
TIME OF ORDER N HOURS

NURSING UNIT
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1 FACPR
M4256
79
MEDCOM -19871
DOD-033445
.EDICAL RECORD - DOCTOR'S ORDE.
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.list the time
Only one order is allowed per line. Nursing willthe new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not
require recopying.
They may be signed off, as completed, in the far right column.
ORDER
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER NOTED COMPLETED
TIME & INITIALS TIME & INITIALS

POST ANESTHESIA ORDERS (circled Items)
0 VS q 5 min X 15 min, then q 15 min until discharge.

2 Supplemental oxygen. J., z,--..:.-,.9 r,,,c_77 ii 2:5--7;_i
',`"‘" l‘ t" rt -)
3 1
Morphine / MofyreFFEe ,2,_ mellow and
mg q 3-5 min pm pain for a max dose of ,c) mg. I • •
_ - • . .
5

Metoclopramide Jo mg IV pm N/V x 1.
7 Phenergan mg IV pm N/V x 1.
• e-1.11 ti 1 11/P •1 o el
. • : . --' • •
9 IVF:

0 cc/hr. /af rf,t vz-?,-ait 7, ritev,--,iy 7-Ko ?(Y),,,,/
10 Disc status when PACU discharge criteria met. co .otpA, •
m 4 j r IvAi 14
lo ce_) - 2— •
PATIENT IDENTIFICATION Complete the following information on page 1 only. changes on subsequent pages. Note any
. illig (- ( 1\ Diagnosis: Height: Weight: Diet:
Allergies:
MFrinnivi rnanA a 0 0 15 i-rre•-r. la.,-...... ...— -- Nursing U ' -b. '''' PACU, Room No. PREVIOUS EDITIONS ARE OBSOLETE Bed No. Page No. I 1 of 1 MC V1.00

MEDCOM - 19872

DOD-033446

£DICAL RECORD - DOCTOR'S ORI..
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER
NUMBER
DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER NOTED COMPLETED TIME & INITIALS
TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
2 Supplemental oxygen.
3 Morphine / Meperidine

mg IV now and mg q 3-5 min prn pain for a
max dose of mg.
Zofran mg IV pm N/V q 15 min, may repeat x
O .
5 Metoclopramide mg IV prn N/V
x 1.
6 Droperidol mg IV prn N/V x I.
7 Phenergan

mg IV pm N/V x I.
8

Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
IVF:
cc/hr.
„9. Discharge from recovery sta
harge criteria met.
PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any changes on subsequent pages.
Diagnosis:

4
Height:
Weight:

Diet: Allergies: Nursing Unit
I Room No.
Bed No. Page No.
PAC 1 of 1
I

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00

MEDCOM - 19873

DOD-033447

_DICAL RECORD - DOCTOR'S 1
) R,

For use of this form,
see MEDCOM Circt

lar 40-5 DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders rem:list the time rded. Only one order is allowed per line. Nursing will
the new order(s) are noted and initial in the column provided. Orders comp)require recopying. eted during the shift in which they were written do not
They may be signed off, as completed, in the far right column.
ORDER
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET 0 ORDERS ORDER NOTED COMPLETED
TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
1 VS q 5 min X 15 min, then q 15 min until discharge.
7 Supplemental oxygen.
3 ,LifoTIEieli Meperidine max dose of f4,, mg. mg IV now and 3 mg q 3-5 min prr pain for a
4 Zofran mg IV prn N/V q 15 min, may repeat x .
5 Metoclopramide mg IV pm N/V x I.
Droperidol mg IV prn N/V x I.
7 Phenergan mg IV prn N/V x 1.
8 Benadryl 25-50mg IV? ql hr pm, itching while in PACU.
9 IVF: cc/hr.
10 Discharge from recovery status when PACU discharge criteria met.

PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any
changes on subsequent pages.

osis:

Weight: Diet:
Room No. I Bed No. Page No.
1 of 1

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00

MEDCOM - 19874
DOD-033448

CLINICAL RECORD Mo. Yr. 2003
VRI1f YBYJNF114LJWG
RECURRING ACTIONS,
FREQUENCY. TIME

kb, fiLtil'A
7111119111E11111
UNE N,1111111111111111111
....111111111111
MINIZZL

ADDITIONAL PAGES IN USE:

'ALLERGIES: ED YES D NO PRIMARY DIAGNOSIS:
E;(3P___N\S YES El NO tNtP sip.-q5Nr\c\2_. 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 OM - 19875 USED. USAPA V1.00

DOD-033449

(L-e-) - 2 I`C-IN

Verit y' by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(NON-MEDICATION) Mo.I (75.Yr 2003
Order Clerk
Date to Time to
SINGLE ACTIONS
Date Nurse Time Done Initials
be Done be Done
r7
cl--

IA0 -p orAN\
I-1
CUT" TD o2 71-brOn)Clc D\NI I c...)
1-7 i.) Pro 1 25
0 CEC i")-C1-8 1 r
IS

vyz- ct-se\Je--.1)-.c---)fs2k-'S t
°Q-CP
f9r)
geocr P41-4/rf r•iteZ
CCT" CS
,e)
:0C6T-
le-.tor AIT &-; 0.3 -,,(:— 115.Pitt
'/O/PCI-•
VC)
Pe ea-
etC"
03 1C,.ii0 (13 004--C -c v).'
$Y
...

• ..
. .


Order/ ,
Expir Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION •, Date Nurse ACTION, FREQUENCY
TINE/DATE COMPLETED02 ji-EC V..Qa.-.57tn -92.i.
A.0.5-W
.(NZSLIS CAM 12.Nkna
T .
. ' ..•

.
'

_.._.
USAPA V1.00
MEDCOM - 19876
DOD-033450

w`)
THERAPEUTIC DOCUMENTATION CARE PLAN ( N.
CLINICAL RECORD -MEDICATION)
For use of this forrn, see AR 40-407; the proponent agency Is the Office of The Surgeon General. Ma.Oyr. 2003
VERIF7BY INITIALING
h, n -.." ' % .4 -,,x4.-4, 4,;:wwlim INITIAL PROPER COLUMN FO .
WING EACH COMPLETION

ORDER CLERK/ RECURRING ACTION, HR DATE COMP. ETED
DATE FREQUENCY, TIME
RIMINFAMFAMIREMINIMPIel EMIL - fro-wrme
ri,'
Ign
VA

r -.11 15 .N-AX11-(f11) ffil
116"11111.411111:

I 120-91 1111111a1"'
.
rikojil pi
I ev i,\N_NIL—
Issgm11:11.1111¦Fi

n ,6-•vmezine, 6. -erv,
r.agil • , ixsN
61i-. wit illEN =MIR

IgliglilM• allb...rad aummennium
1 .
MN —.11WA/4 Gliv_ A -f-c).tIVIV MrPpN•-r-19 NIIMISEEZIEMINMEM . UMW
.1
.N.

ALLERGIES:.El YES 0 PRIMARY DIAGNOSIS:.
ADDITIONAL PAGES IN USE: .YES.IIII NO

NI K-PA • -0( ( -674-tivAPAN
PAGE NO: PATIENT IDENTIFICATION:.
P w 'W r Fry
ACTION TIMESUSE PENCIL. CIRCLE ACTION TIMES D 8N
9N10N11N12N13 14N15 EN16N17 18N19N20 21 22 23
s_.9
NN24 01 02 03N04 05 06 07
DA FORM ILA77 4 nni-70 EDITION np i me. 77 UlAV me n lep.
USAPA V1.00

MEDCOM - 19877
DOD-033451
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION) Me.Yr .2003
order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Date rse be Done be Done
9-C;gs-S -CDQ'S OCC\e/C ---ilIl 1647 / t--4 (c), ( :‘rcr3. ..,LC14-7
_
NVD p r\N
_ 1. _
1 -e 1,-
4i
:{1

.-.....N...
t 4 — — — — — — — _ — — — — — — — — — — — — — — — — Order/
m.......

Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Explr
Date Nurse ACTION, FREQUENCY
TIME/DATE COMPLETED
Om ••= Me wimp ¦¦¦ ¦¦ ms ¦¦• . .
g_

.. ... ... ".' ... ...
..N..
..= ...N... ..N... ... ¦
¦

.¦• ¦ ... ...
USAPA V1.00
MEDCOM - 19878
DOD-033452

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON MEDICATION)
For use of this form, see AR 40-407;the proponent agency Is the Office of The Surgeon General. Mo. Yr. 2003
VERIFY BY IIVITL4L1NG
0.0, C.77'
- - • -INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ HR
RECURRING ACTION, DATE COMPLETED
DATEN
NOISE FREQUENCY, TIME
Plc-1
141
.
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ALLERGIES: 1=1 YES I:=1 NO I PRI.N
Y DIAGNO IS: ADDITIONAL PAGES IN USE: AYES 117] NO
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PAGE NO NPATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
11111117,Lu
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 19879

DOD-033453

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION) Mo yrN2003
order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
,..
Z /Q110 WC-tu.r vf Cc-he -c-P-7-74s-do-
_
Orded Clerk/ Nurse
meter — — _ — —
— — — — — — — — — — — — — — — —
— — — — — — — — — — — — — — — — — — — — — — — —
INITIAL PROPER COLUMN FOLLOWING COMPLETION
PRN
ACTION, FREQUENCY
TIME/DATE COMPLETED
USAPA V1.00
MEDCOM - 19880
DOD-033454

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN
For use of this form.N(MEDICATIONS)
the pro SOO AR 40-40;
nem a my hi the Office
VERIFY BY INITIALING of The Surgeon General. Mo..
Yr. INITIAL
PROPER

COLUMN
ORDER CLERK/ FOLLOWING EACH ADMINISTRATION
N RECURRING MEDICATIONS, 1112DATE
NURSE DATE DISPENSED
DOSE, FREQUENCY
111M11111111111111111111111 1111111111111
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OB MIIIIIIIMM111111111111111111111111
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PR
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PATIENT IDENTIFICATION: PAGE NO.
DISPENSING TIMES ikallatcNCum Et, ) . L..E
-D 7 8N
11111111 1-DL:
9 10 11 12 13 14
E 15 16 17 18 19 20 21 22 N 23 24 01 02
03 04

EDITION OF
DA I FPCM9 4678. 05 06
1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 19881
DOD-033455

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo.. Yr
Order Clerk/ Date to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
G

t _ 0 D(c h) EY
C.3' —f— j
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN
ExpIr
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date - LI. -
I fte' h'.(P6c73 )710 .
Q Yr-or e=1,--(--2 rt)
------0
. 1
'U.S. GPO: 1998-454-110/95216

MEDCOM - 19882
DOD-033456
\

(MEDICATIONS)
THERAPEUTIC DOCUMENTATION CARE PLAN Mo. I Yr.
For use of this form, see AR 40-407: the pro nem a ncy Is the Office of The Surgeon General.
CLINICAL RECORD
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION VERIFY BY INITIALING DATE DISPENSED RECURRING MEDICATIONS, ORDER
CLERK/
DOSE, FREQUENCY D IFS iq to MEWS MEEZIMISIE
NURSEDATE
IV : LR e 12 5,chr Heptocic
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ADDITIONAL PAGES IN USEt
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DISPENSING TIMES
PATtENT IDENTIFICATIONt
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
4111111bm-
N 23 24 01 02 03 04 05 06
—"• "' ''"rs UNTIL EXHAUSTED.
EDITI
MEDCOM - 19883
1 FEB 79FORM 4678
DOD-033457

Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) o..1 CP yrrp.
Order Date Clerk/ Nurse SINGLE ORDEit, PRE-OPERATIVES .-, Dote to be Given be Timeme to Given Time Given Initials
CN /(Af - C cSoLt
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Order/
Clerk/N PRN
Expir
NurseNMEDICATION, DOSE, FREQUENCY
Date
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MEDCOM - 19884
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
-I
rut,
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TIME/DATE DISPENSED
09: icc FrA.:7-67 iTc,6006,2c_a00 14,4 -...
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'U.S. GPO: 1996454-110/95218

DOD-033458
bw -2 \

.. elNeUTIC DOCUMENTATION CARE PLA. ZDICATIONS)
For use of this form, see AR 40-407; MO. . 0 I' 03
CLINICAL RECORD
the proponent agenc is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
: , -_ ,,=,,,,,s .;;MIVWAW
VERIFY BY INITIALING ali-4A-1
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCYNDziocz, mom LZ-13 41 it,
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r... ozuut ADDITIONAL PAGES IN USE:ALLERGIES: IN YES NO ARY DIAGNOSIS:
®YES NO

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PAGE NO.

PATIENT IDENTIFICATION: DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11N12 13 14
(1.
Il k( G\.
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E 15 16 17 18 19 2021 22
.

_ .-
N 23 24 01 02 03 04 05 06
N
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.
DA FORM 4678, 1 FEB 79
MEDCOM - 19885
DOD-033459
Verify by THER. .iiiC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) 7Mo.

Order Clerk/
Date to Trne toSINGLE ORDER, PRE-OPERATIVES
Date Nurse Time GivenNInitials
be Given be Given
(-Pc-
al-T43
Order/ Expir Date -"A Clerk!. PRN Nurse MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION DISPENSED
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USAPA Vl.

MEDCOM - 19886
DOD-033460
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
for use of this form, see AR 40.66; the proteant agency is the Office of The Surgeon General.
REPORT TITLE OTSG APPROVED Ow
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: gig() .Anesthesia Type (Circle)): Cera }Spinal Epidural Drains Airwa
er Time In: .d 1(.065N IV Sedation Nerve Block Hemovac
Nas I

Allergies: .NKDA .OR Intake: Crystalloid 460 .Colloid . NG Pre-op V/S: 1144 Ct a OR Output: UOP — .EBL P6 c JP at Procedures: NLtaag(rty i A-.Meds/Times: 5c, Femt" . 4
T-tu .

) Trach
F. ey

Other
Pre Op Meds HistorV LS

Time
Pacu Intake
Sa02 Time Solution Amount Site •

rile 697 By Infused
Fi02
Methods tlf
240
220
X-rays: Labs:.
Post-Anesthesia Recovery score
200 Criteria ADM 30'

DIC Codes
Activity

(2) Moves 4 Extremities AIRWAY
180 (1) Moves 2 Extremities A = Ambu

I
(0) Moves 0 Extremities BB = Blow-by
M = Mask
Airway

160 (2) Cough. Deep breath FT= Face
(1) Dyspnea, Smiled breathing ).._ Tent )
140 V (0) Apnea RA = RoomAir
V
NC ne Nasal
Blood Pressure

(2) SBP =/- 20 of Pre-op Cannula
120

(1) SBP 4-20-50 of Pre-op
("A

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

100
" =CNBP A ,. = Pulse
(2) Fully Awake, aucible

crYinD
80 • o • (1) Arousable b verbal or pain 9-, a
TEMP

Color A (2) Baseline color IS appearance e)..‘ S =Skin
60
(1)
pale, mottled, jaundiced 0 = Oral

(0)
Cyanotic -0 A = Axillary T =Tympanic

40 Circulation (Reds 5 Years)
R = Rectal
(2) radial Pulse Palpable

(1) Axillary palpable, not radial
20 (0) Carotid only reliable pulse LOS

-C = Cervical
TOTALS: Must be 9 or
T = Thoracic
greater to DIC. otherwise

RR
L = Lumbar
needs anesthesia approval for
6:1

T D/C, S = Sacral
3e9
Time
Paten
Pain (0-10)
T, C. & DB,. Incentive Spirometer, Comfort Measures
LOS

Safety: SR up X 2, Falls Precautions. Privacy Maintained
n.annnue an reverie!

PREPARED BY ISignarure & Wel
DEPARTMENT/SERVICE/CLINIC
DATE

PATIENT'S IDENTIFICATION (Foe typed as rosette,, entries give:
Name — last, lint, middle; pade; date; hospital oe medical leafy)
.
HISTORY/PHYSICAL . FLOW CHART

.
4THER EXAMINATION

. OTHER opre.w OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78.WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)N
Previous edition is obsolete min vzoo

MEDCOM - 19887
DOD-033461
MEDICATIONS
NURSING NOTES

Allergies:
)

Time Pain Medication 8 Route Pain I/E By
1-10 lInsace 1-10 411012tlyd .nil -6 1e. #969t0
Q. WS • t atiAke Mutivorla
NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm 15' 0' 45' L b4 Ltrul-ett Lea I i ,,,,,;(...4 L.Elet-iL t t -k- U./1 Uk IA 5 8 -16 1,,k) "-i (,'J pIC-p ic., eV ,
60'
90'
D/C txpx{.. t I -k Lok . j i--) -PI/-

Movement/Sensation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: 8= Brisk, S = Sluggish NP = Pale, Pk = Pink
C-SECTIONSN ...--
Adm 15' 30' 45' 60' D/C Fund. Height Lochia Peripad# FuN. Cond.
DRESSINGS Time Location Type Drainage
Adm IL13g uPtxt Ace

44/ r
30'.Iu3S-I EXt-lk i f
so. cl / D/C 1 7 o g Lty.e.4-1 eke kzu,,,ci . 4,V,
PACU OUTPUT
NTime Source • Color/AppearanceNAmount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run? 11P) g NEe
9/.
Discharge Criteria:
Date:.Time:.

PARS:

HR: c1 el.RR: i to Sa02: 95 Pain Level at D/C (0-10): 0 Intake:Nb .Output: (:-.) Additional Data:
AJb

Transferred To: ICv¦J Report Given To: Transferred Via:
Gurney Ambulance

Transferred By:
Cleared IAW Reco ry Room
Charge Nurse Signature:

WAMC OP 173-E
MEDCOM - 19888
DOD-033462
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
Far use of this term. see AR 40-66: the proponent agency is the Office of The Surgeon General .
.
.
REPORT TITLE OTSG APPROVED Mater
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: 2/./43
.Anesthesia Type (Circ e)): General Spinal pidural 5 .14 Drains Airway
Time In: P-t Z
IV Sedation Ne Block
Nasal

Allergies: . OR Intake: Crystalloid olloid Pre-op V/S: 'fi sip .OR Output: UOP EBL Oral
ETT

Procedures: -1--(i) tv-.Meds/Times:
T-tu
ch
Foley
Oth

Pre Op Meds. History
TLS
Time NE 2.0 s---zt90 t

Pacu Intake 9135r,3 zY7 ) Time.Solution.Amount.Site • ; By
Sa02 .
Infused Fi02 .M 3 /C__
Methods
M
240
220 .
X-rays:
Labs:

Post-Anesthesia Recover _score
200

Criteria ADM.30'.
D/C.Codes

Activity
(2) Moves 4 Extremities AIRWAY
180

(1) Moves 2 Extremities A = Ambu
(0) Moves 0 Extremities
BB =Blow-by Airway M = Mask160
(2) Cough, Deep breath FT= Face
(1) Dyspnea. limited breathing Tent 140 RA = RoomAir
(0) Apnea
v

"V Blood Pressure NC = Nasal
(2)
SOP =1- 20 of Pre-op Cannula

(1)
SBP =/- 20-50 of Pre-op

120
2_

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

100 Consciousness
(2) Fully Awake, audible =Cult BP eying = Pulse
80 (1) Atousable to verbal or pain 2_ TEMP
Color
S= Skin
60

(2)
Baseline color & appearance

(1)
pale, mottled, jaundiced 0= Oral

(0)
Cyanotic A = Axillary

T =Tympanic

40 Circulation (Peds 5 Years)
R = Rectal

(2)
radial Pulse Palpable

NN..\\N

(1)
Axillary palpable, not radial

20 (0) Carotid only reliable pulse LOS
C =Cervical

TOTALS: Must be 9 or greater to DIC, otherwise
19
T w Thoracic
L = Lumbar
T 7 61 DIC, i0 . 0 S = Sacral

RR Z1 needs anesthesia approval (or
Time Patten teaching done: Wound Ca e. Pain Management,
Pain (0-10) T. C. & DB.. Incentive Spirometer, Comfort Measures
LOS
Safety: SR up X 2. Falls Precautions. Privacy Maintained
&WIMP on feVenel

PREPARED B
DEPARTMENTISERVICE1CLINIC
y
ditATE
47
2

PATIENT'S IDENTIFICATION !for typed or wri 1 3
Name —last
lest, grade: date: hospital or medical la
.
HISTORYIPHYSICAL.

0 FLOW CHART

.
OTHER EXAMINATION.

. OTHER ArAw/r/
OR EVALUATION

. DIAGNOSTIC STUDIES
b(
O TREATMENT .

DA FORM 4700, MAY 78.WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) .
Pre4ious edition is obsolete USAPPC V7.O0

MEDCOM -19889
DOD-033463
All.gies: MEDICATIONS NURSING NOTES
Time . ',pain Medication & Route Pain I/E By
140 Dosane 1-10

NEUROVASCULAR Time Site Range Sensory P Of Motion
Adm
arammemmiorim
15. PIM 4— pill
30'
xmi pii
45.
ri
60'
9 0.
CMIAIIIIN111111.1111111ral
Cap T Color
Refill
• (-- -

,H
IPA..sw
• I ,
Movement/Sensation: + =present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D =Doppler, A =Absent Color: C = Cyanotic, Capillary Refill: 6= Brisk, S.= S uggish NP= Pale, Pk = Pink
C-SECTIONS
--­Aadr-----L,T 30' 45' Fund. Height , •---_______.... 60' 90' D/C
Lochia
Peripad/1 ---...........,
Fund. Cond. --.

111111111
AIMN.1111
_
apamra...-
PACU OUTPUT Time Sobrce lor/A earance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
dJ C:)

WAMC OP 173-E
Ct z -Pc-q

(
Discharge Criteria:

Date:9.22• 0 3 Time: " tNPARS: 1 D
BP: la2AcT: Ci8 HR: 013 FIR: 2 2_ Sa02:
Pain Level at D/C (01 0):
Intake: I Output: , r") CL
Additional Data:
Transferred To:

Report Given To: S
Transferred Via: W/C nce
Transferred By: —
Cleared IAW Recovery
Charge Nurse Signature: I tVi1/410
MEDCOM - 19890
DOD-033464

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 40.66: the proponent agency is the Office of the Surgeon General.
. .
OTSG APPROVED OWREPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: .ot c/.as 3. Anesthesia Type (Circle)) Gei Drains Airway
CTeia pinal Epidural Time In: /.IV Sedation Nerve Block Hemova Nasal
5. Allergies: .i'V kr OR Intake: Crystalloid 40c) Colloid . NG
Oral

Preop V/S: .ft a.OR Output: UOP ESL .trini
Pr 4.-Procedures: Z-t-Ogp Finn $ rCiMeds/Times: t)e-rA (sat.)"e...n srb 0"C-tube
ach Foley

Other
Pre Op MIs History TLS

Time ho 0 A
Pacu I take
....
Sa02 TQM Lizr i co Time Solution Amount Site By.
Infused
FiO2 to'

Methods
240
.

220 X-rays: Labs:
Post-Anesthesia Recovery score
. .
200 Criteria ADM.30' D/C.Codes
1-
Activity AIRWAY
(2) Moves 4 Extremities
180 (1) Moves 2 Extremities A = Ambu

(0) Moves 0 Extremities BB= Blow-by M - Mask
Airway

160 9FT= Face
(2)
Cough, Deep breath

(1)
Dyspnea, foiled breathing Tent

(0)
Apnea , RA =RoomAir

140 NC = Nasal
Blood Pressure

V
Cri Cannula
(2) SBP =/- 20 of Pre-op

120 (1) SBP =1- 20-50 of Pre-op
• • • (0) SBP -4-50 of Pre-op 2 a-V/S

V
a
X = A-line BP
Consciousness

100 • ' =Cuff BP
(2) Fully Awake, audible = Pulse
aYinG
(1) Arousable to verbal or pain

80
TEMP
Color

A S = Skin
V (2) Elaserne color & appearance
0=Oral

60 (1) pale, mottled, jaundiced
(0) Cyanotic A = Axillary
T =Tympanic 40
Circulation (Peds 5 Years)
R =Rectal
(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial

LOS
(0) Carotid only reliable pulse

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

RR L = Lumbar
2( 15 needs anesthesia approval for
D/C.

S =Sacral

T /6
Time
Patien teaching done; Wound Ca e, Pain Management,
Pain (0-10) T. C. & DB,. Incentive Spirometer, Comfort Measures
LOS

Safety: SR up X 2. Falls Precautions. Privacy Maintained
it.ontorue on Nome/

DEPARTMENT/SERVICEICLINIC DATE
PK,U sep 03
PATIE written entries give:. Name -last: That, middle; grade: da , .al being)
.
HISTORYIPHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER /spar/ OR EVALUATION

7
44/

. DIAGNOSTIC STUDIES
TREATMENT .
.

DA FORM WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN).
FORM 4700, MAY 78 Previous edition Is obsolete
USAP?C V2.00

MEDCOM -19891
DOD-033465

MEDICATIONS
NURSING NOTES

Allergies:
Time Pain Medication & Route Pain I/E By1-in Dnsanp 1-10
NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm fit, lim:1-•4 4 J 1/0 PIL
15'
30'
45' •
60'
90'
D/C

Movement/Sensation: + = present.- = absent Temp:C = Cool, W = Warm Pulses: Ps= Palpable, D =Doppler, A= Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, Sim S uggish.P= Pale, Pk =
C-SECTIONS
Adm 15' 30' 4p-------rO' -90' D/C Fund. •Height
. .-Lochia
Peripad#
Fund. Cond.
-,/. DRESSINGS Location Type Draiqage
Time
Adm le tel leeA le4(
0:4(1 3V
60'
PACU OUTPUT
...Time Source Color/Appearan Amount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
Nse_
1 5 6 °
/3 P5
\i .Oor

1U°­
S/P
c,a6.. 2(7

sir4.1.4.4.1/4, JGY 4, to goar/-e; /ties&
Discharge Criteria:
'7
Date•.2(iSr#3 Time://a--J,_ PARS: /0
BP:.• T: S1 ).HR:/6RR: /
Pain Level at D/C 10-101:
Intake:.2.01,.tAre.— .Output:
Additional Data:.
Transferred To:.CA,
Report Given To:.1 cr
Transferred Via: WIC.Gurney Ambulance
Transferred By: .SC
Cleared IAW Recovery Ro.3
Charge Nurse Signature:
WAMC OP 173-E
MEDCOM - 19892
DOD-033466

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 OTSG APPROVED Mate/
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: Anesthesia Type (Circle)): eneral pinal Epidural Drains
AirwayTime In: IV S.ton .Block
Hemovac Nasal Allergies: OR Intake: Crystalloid WC).Colloid .
nu 19ntl` NG Oral Pre-op V/S: OR Output: UOP. EBL . ..JP
ETT

Procedures: Meds/Times:.
FQ.• I T-tube
Trach 01i• 51/14-, Foley
Other Pre Op Meds HistorV TLS
io lo
Time
:o
Pacu Intake
Sa02 4 4P,.9 Time Solution Amount ite fused F102 cL Methods (AO
240
220 X-rays: Labs:
Post-Anesthesia Recovery score
..
200 Criteria ADM.30'.

DIC.Codes
Activity

AIRWAY 180 (1) Moves 2 Extremities A = Ambu
(2) Moves 4 Extremities
I

(0) Moves 0 Extremities BB = Blow-by
M= Mask
Airway

160 FT= Face
(2) Cough, Deep breath

(1) Dyspnea. bridled breathing Tent
(0) Apnea RA= RoomAir140 V.
V
NC =Nasal
Blood Pressure
Cannula

(2) SBP =I-20 of Pre-op
120 (1) SBP =4-20-50 of Pre-op

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

100
A 4 =Cuff BP
(2) Fully Awake, audible
= Pulse
Ming
(1) Arousable to verbal or pain
7
TEMP

80 A.A
Color
1
S = Skin

(2) Baseline color d appearance 60 (1) pale, mottled. jaundiced 0 =Oral
(0) Cyanotic A= Axillary
T =Tympanic 40
Circulation (Peds 5 Years)
R = Rectal

(2)
radial Pulse Palpable

(1)
Axillary palpable, not radial

(0)
Carotid only reliable pulse LOS

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

RR L = Lumbar
1c 20 needs anesthesia approval for /0D/C, S = Sacral
T
lo

Time Patient teaching done: Wound Care. 17P in Management,
Pain (0-10)
T, C, & DB.. Incentive Spirometer, Comfort Measures
LOS

Safety SR up X 2, Falls Precautions. Privacy Maintained
aominue On InvetsPJ
DEPARTM TBERVICEJCLINIC

I DATE
PC
26, Scro_

or written entries give: Name — last.
nal or medical leafy)

.
HISTORYIPHYSICAL

.
OTHER EXAMINATION . OTHER OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78.WAMC OP 173-E, (Revised) I Apr 01 (MCXC-DN).
Previous edition is obsolete waft 112.00

MEDCOM - 19893
DOD-033467
MEDICATIONS
Allergies:
Time Pain Medication & Route Pain i/E By
1-10 linsane 1-10

NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Mm %M. tem ; i
15'
30'
45' 60. a­( l im , • AA 40 — 4 k-
9..
D/C.1171IVA 1 0 . I IC--

Movement/Sensation: + =present,-= absent Temp:C= Cool, W= Warrn Pulses: P= Palpable, D = Doppler, A= Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S=S uggish.P = Pale, Pk =Pink
C-SECTIONS
a.
Adm 15* 30' 45' LifairriD/C
Fund. Height
.-----------Lochia
...--"'"------'
Perlpad#
.-F-und-.2O-nd.
DRESSINGS Location Type Drainage
Time Adm IgIZEIIIIIIIIMMIZZ eAMIIII
-ar-Wa7 r.PP 4-IIMICREMIIIIIIIIrea I I I I I
601. D/C Vriv6ff gf..Ax---
PACU OUTPUT
Time Source • Color/Appearance mount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
io MS
WAMC OP 1T3-E
NURSING NOTES

PrAh/1-46) rD PAW 02 00. Sf rJ ?,7,
11K

04-c-erriii to allit9
/Sit.re) LT
Discharge Criteria:
Date: aoSe6Ti e: /0SS— PARS: / 0

n BP: /SCA# T: Tz6HR:21 RR: Sa02: Pain Level at D/C (0-10):
Intake: SOcc. Output: 0-
Additional Data:
Transferred To: GU"
Report Given To:
Transferred Via: W/C y Ambulance
Transferred By:
Cleared IAW Recove
Charge Nurse Signat

Doc_nid: 
3942
Doc_type_num: 
77