Medical Report: 30-Year Old Iraqi Male, Detainee, Baghdad, Iraq re: Bi-Lateral Leg Fractures

10(3)-1
erative Plan Of Care & Nursinf
Patient Assessment For Surgery - Potential For Injury -Outcome: Patient is free from signs and symptoms of injury . Yes . No Trauma# or . mac.1 rse Patient # Diagnosis: `Ti) t Procedure: / ? d„..)
Planned Pcedure: {ic Slae• n NIA n Right rrf rt
b)(6)-2
Date: t-/ ti ,, AArrival Time: / o u Interviewer: a- 1.1 1.Age:jHT: WT:
From: Trassport Via: Patient ID: Bloo rdered: Surgical/Anesthesia Consent Verified: 0 CASREC D•Grumey 0 Trauma card /A Comments: .Procedure 0 15,U 0 Litter 0 Verbal .Yes 0 Consent 0 Consent completes dated, signed Thud 0 Ambulated 0-ehart q T/C #Units q-Erhligent case; no consenk,MD note
3 OTHER: .Wheelchair Q-emband . T/H #Units O Other 0 Other

Preop Labs (HSG, etc): Dnia/Latex Allergies: Present On Admission: Past Medical History: Cultural Needs Addressed:

Nonete"Yes NKDA .NIA .-NOne known .Yes JJ:lo

Test/Results: Allergy/Reaction:j0 Oxygen . Smoker ppd/yrs / List: .-P/ Site: #1 (9 A-. Asthma 0 ETOH #2 .HTN . CAD
.Foley .GERD 0 CBR exposure
DEndotrachial Tube .Other: Pre-Op Pain: .Arterial Line Site: Past Surgical History: Last PO In/ake: (date/time) 3 N .Drain(s) .None known Solid: j/ v /rjz,j¦-¦ -)

es Level Action Taken: (0-I 0) 0 Chest Tube(s) :4•16.s List: Liquid: LH/ a 1/ 4 jAz "
Location/type: 0 See RN Note # Lc
In Chart: m, Ski Condition: Limitations: Pers al Items:
AT&P . /es . No mad 0 NIA 0 Auditory one Disposition:
7 EKG 0 Yes . No 0 Other: IT6nguage .Visual 0 Military gear
3 OCR . Yes . No 1:1 Prosthesis 0 Glasses
D Other: . Other: 0 Dentures
0 Jewelry/wallet

0 Other Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological responses to an invasive procedure . Yes . No Mental/Emotional Status: Comfort Measures Implemented: Pre-op-Teaching Included: 311ert/Oriented 0-K1; 0 Clear, concise explanations &IVA due to patient condition J Disoriented 0 Sedated .Communicated patient concerns to other staff .Physical layout of OR 3 Anxious . . Unresponsive members .Personnel present during procedure 3 Appropriate for age .Remain with patient during induction .Environment (noise, temperature, etc.) 3 Other .Post-op expectation (PACU, drains, etc.) Potential For Im aired Skin Inte rit Related To Sur ical Procedure — Outcome: Patient is injury free . Yes 0 No Dperative Position: Positional Aids: Comments:

3-51-opine . Beach chair .Airplane 0 Axillary roll . Bean Bag

J Prone . Sitting .Arms 90 Cefficture Table 0 Gel Pad . Gel donut

3 Jackknife . Lateral L / R Armboard: 1:1-0-R" . Hand Table .Leg Holder . Pillows

Lithotomy Tucked: OLOR . Stirrups 0 Tape . Wilson Frame ] Other: 0 Other: ?SU # A DVT Prevention: Tourniquet: 'ad Site: Q) e SCD used 1;1-2Ci 0 Yes .Arm . Leg Comments: 'ad Lot # j-1 —.) Pressure: . Left . Right 0 Left ORight
;ite Clear at end of case? ID No . Yes Teds: . No 0 Yes 0 webril applied Applied by: f No, see RN note #
Bair Hugger used: 0 No algs'
3ipolar: Max Cut 4._) Coag Total Min: •
Other warming techniques:
Comments:
:6)(6)-4
USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page 1 of 2
(Rev 3/03) M EDCOM - 5246
DOD 12458

Potential For Infect' j`uteome: Appropriate Actions Taken to P lfection es . No
Vound Classificatiork, Shave Prep: Skip-Prep: Solution.. ations: I 0 II . III V 0 Shave 0 Clipper netadine Scrub EFIC-.Other:
ormal saline Area: By: 0 Hibiclens 0 Sterile water 0 Duraprep .Local
( /1
.Other: .Antibiotics
Tains/Packing: . None Dressing: Location: (MI ((-•) (t Si
'Foley FR: / 2l' 0 ABD . Cervical Collar Kling 0 Steri-strips 0 Benzoin
JP #1 Fr Location: #2 Fr Location: 0 Cohan .Immobilizer . Tape .Mastisol

Hemovac: Size Location .Bias . Drip Pad El-Prains 0 Webril .Bacitracin
Chest tube: Location .Band-Aid(s) 0 Fluffs .Sling EI-XEroforrn
Size H2 0 Pressure . .Cast OX rlix .Splint 0 Other:

Packing: typellocation:
See RN Note # for comments

Miscellaneous
mints: (initials) Xrav: Skirl,Integrity: rub: RN: Correct? 0 None 0 Other: aClear & Intact (other than incision) Sharps 0 Yes 0 No 0 N/A 0 Portable Comments: S Sponges 0 Yes . No 0 N/A DI-Ivo-Instruments 0 Yes 0 No 0 N/A
0 See RN note # for additional comments.
See RN note # for additional comments
AFF1X M MEM-RECORD
Ihrulaybirol orblbtrbulod AFFIXTOPMIEWRECORD Manulbehred or INVYOU*1 by
nplants:
/ Lot t# / Exp Date: SYNTHES° XLZI7:= j
11018ynNee Avenue
ilk O WAY771,55r
• 40 1 nol TI CANNULATED TIBIAL MIL .q._el ,(
11MM TI CANNULATED THAL NAIL
-STERILE
380MM STERILE

L/ Jj it CAT 8 485.138S 1-5 'Leo
ICH e 4499711 MP: 12/2011
mA(-1,C rcl jFIN f $113inks rAP: 12/2011
MT: Ti-6A1-Tlib
See RN note # for additional comments. MAT: TI-SAL-7NN

g¦ps.¦ga¦
Discharge from Operating Room
omilications: Transport From OR: Transfer d To: one Comments: 041-Report by:
rney w/ siderails up 0 Litter w/ safety strap in place 0 ICU 0 Anesthesiaprovider 0 RN 0 w/ Oxygen 0 Medivac
.w/ Monitor .Ward
See RN note # for additional comments .Other: 0 Other

A
argical Procedure Performed: / 1/-7 j J 16 14. , ;
N Note: (number each note to correspondMg area above)
Initial/Name Box: (please print)
P ' ry agRN Signature Relief OR RN Signature Date/Time
1JSNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page 2 of 2
MEDCOM -5247
DOD 12459
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Manufactured er OfoO.4.1 bl
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14MM TI CANNULATEO FEMORAL NAIL 400MM-STERILE CRT • 474.441S ACM 4455188 EXP: 12/2011
MAT: TI-541.7Nb 7 •
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MEDCOM -5248
DOD 12460

516-1 0 B -SI1757.0-00-634-4156
MEDICAL RECORD OPERATION REPORT
PREOPERATIVE DIAGNOSIS
—1
C—1k Fi
C t.c1ICK
SURGEON FIRST ASSISTANT SECOND ASSISTANT
1r) L, (b)(6)-2
ANESTHETIST b)(6)-2 CIRCULATING NURSE b)(6)-2 c OPERATIVE DIAGNOSES ANE THFTIC b)(6)-2 UB NURSE 11.57.; I, 1,)(6)-2 W 0)(6)-2 El Tr"-TIME OPERATION BEGAN I -1-, 3 '4 76 14CD i 1 2 ,s'TIME BEGAN: TIME ENDED: TIME OPERATION COM­P ETEO 1.) I'S 2 . g
(b)(6)-2

di SPO Nlbc(61ist -r-,Ic
c r 1-1
DRAINS (Kind and number)
MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION(
1/
OPERATION PERFORMED
• 1•
DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings. etc.) PROSTHETIC DEVICES DATE OF OPERATION
(tot no.)
(/ 1/111 —../ d 3
AFMXTOFMMENTRECORD
Manalboltred or DistrbAd q'0003
(81 SYNINES°
ilmm
II CANNULATED TIBIAL NAIL 380MM - STERILE CAT
485.138S
MCN *4499711 exP:12/2011 MAT: TS-6A1-7N6
r j1ci T (
grq.
ckt-
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AFFIX TO AkTENT RECORD
Mj..da Detributed byjDOOM
Lf L
SYNTHES . =COAT'
MIN TI CANNULATED TIBIAL NAIL =CMS • STERILE
485.138S MCN 8 4493265 EP:12/2011
MAT: TiAIA1-716
SIGNATURE OF SURGEON
PATIENT'S IDENTIFICATIONjT /38 or Lunt en en les give: ,Name kat, first, middle; Kturs rt Ft-71.u. NO. WARD NO, grade; date: hospital or medical raelitY)
(b)(6)-4
P.- 336) OPERATION REPORT

Medical Record
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*O.S. GOVURNMENT PRINTING OFFICE, 1990-255-:501 STANDARD FORM 516 (REV. 5-83) Prescribed by GSA and ICMR, FPMR 101-11.006-8
MEDCOM -5249
DOD 12461

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DATE
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C
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SIGNS OF ccmrAmmare PAIS OE SINSWE WiTIOS
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MEDCOM -5250
DOD 12462

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TIME GIVIEN:
NNMC 6320/16 (05/91)

OMER:
RECOVERY ROOM RECORD .14AvmE0 6320/16 (REV. 11.771 S/N 0105-1S-206-3281 O se
' Po
RAT P IRP R ED AGENTS AND TECHNICS OF ANESTHESIA

IQ1111) HOUR(SI t 15.30.45
TEMPS
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Level:
FLUID THERAPY

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FOR REMARKS T•TUBES. HEMOVAC I
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.
ACPA ISSPON DISCHARGE URINARY OUTPUT EFAII¦PM.
FROM MOR/SPEC. STUDY TO WARD TIME
DATE 410..3.HRS /5.45 DATE 11 0 MRS Cd
OREA1N_M. :TTLOCATIONS TOTAL 306

"-'b 4 gi-e-._se. ori
(4) it..-5"
STATUS: '
7/1r.-A-iN;
a4,01
XLe cur. S/A
u-a -..-) two e-epil-IsAMmtro-4,j• • Ary-P-7-'---7-0-REMARKS (AS NUMBERED! AND PERTINENT PATIENT PROGRESS NOTES ,ENDOTRACHEALTUBE - ORAL OR NASAL
46X6)-2
1) 10.4 fLcm M R accatpanied Ly
0 YES b YES
RC: •
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SINZ Nawo: IN_ O r
CLEAR 0 PLAST STATUS: (11t,1-• AIRWAY 0 OBSTRUCTS EASILY Pain Y ‘194 0);#48-7.47r44
.
• POST•ANESTHES1A RECOVERY SCORE .
A
(ALORETE SCORE( Able to move 4 extremities voluntarily Ott r: etart
A
or on command 2
Able to move 2 exirernitieivoluntarily • 'DON REVERSE) en on command 1. • Activity Able telraVe (inftrelnit;ft edunurily NAUSEA AND VOMITING:$'i10 0 YES 1 2 3 4 5 6 TIMES or on command
Able lo deep breathe and cough freely 2 CAUDAL. SPINAL. OR EPIDURAL BLOCK Dyspnee or limited breathing Respiration MOVEMENT PRESENT AT HRS Apneic 0 SENSATION PRESENT AT HAS
8P±20% of preancrthetic level 2 BPI20•50% of preanerthetic lewd 1 Circulation
g4
CONDITION ON TOW: COD 0 FAIR 0 POOR 0 CRITICAL
.BPI50% of preanerthelic level 0 Fully wake 2 RECOVERY: PATIENVS IDENTIFICATION: .Arousable on calling 1 C011aiOUSnen Not rerponding 0
(b)(6)-2 Pink 2
1

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uNEVEictrFut.
4,
•
TOTALS
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SIGNATURE OF RECEIVING AND . RELEASING 6)(6).2 OFFICERS
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MEDCOM - 5251
DOD 12463

-
.S 1
NAVMED 15 (BACK)
.
15 30 15 45 15 45 15 30 45 16
. TEMPS: r

misincitainungummusimmumnumen
21111111141111111111MILIM111111111111111111111111111
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FlAncnary:

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cblcr of urine: IJue to void:
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MEDCOM -5252
DOD 12464

NNMC 6320/16 (05/91)
RECDVERY ROOM RECORD
.NAVMED 6320/16 (REV. 11.77) S/N 0105-LF-206-3281

OPERATION PERFORMED AGENTS AND TECHNICS OF ANESTHESIA OXYGEN THERAPY
ROUTE UM % ON OFF
MASKHOURISI 15 30 45 15 70 45 15 30 45
TEMPS

1111011111111111111E11111111CIE1121111111E "AR III

Spinal
VENTILAT,

1111111101111111111111111111111.1211111 SIM
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IIIIIMIEF--11111111M111111111111111
EU to 180
TILER
nrnitor
160 OPERATING
an 1:74
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MIIIIIINEN113=1111E111111111111E

120 1111110111111115111=111111111111111111111-152.11
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00 1111111111111M-1111111111111111111111111111111111"jr
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EP A cuff
TUBES: 0 PUG . FOLEY
IV IN or

11111112111111111111N1111111111=11111111111310
Ram = . 40 OF AT cc/hr XV/
IV IN cC % Sat: OF AT cc/hr wrif

11112111111E11111111111111111111N111/511111
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MEM + r 11111111111DMMIE
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$
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STATUS: (STATUS:

SIA
REMARKS/AS NUMBERED) AND PERTINENT PATIENT PR RESS NOTES ENDOTRACHEALT UBE — ORAL OR NASAL
1) PLW from KR acompanied ty
:0 YES 0 NO I D YES
AIRWAY
0 CLEAR U PLAST STATUS:
AIRWAY
0 OBSTRUCTSEASILY Pain Yes/tsb Pcticn:

• POSTANESTHESIARECOVERYSCORE CV:
. IALDRETE SCORE)

Able to move 4 exuemities . voluntarily or on command Able to more 2 extremitieivolunterily (CONT'Othl REVERSE) Of on command Activity Able to move 0 extremities voluntarily NAUSEA AND V e ITING: 0 NO 0 YES -• 1 2 3 4 S 6 TIMES
or on command Able to deep breathe and cough freely 2 CAUDAL SPINAL 0 EPIDURAL BLOCK Dyspnea or limited breathing • I Respiration MO MENT PRESENT AT HRS Apneic 0 SATION PRESENT AT HRS 10220% ol preanestnetic level 2 BP±20-50% of preanerthetic level I Circulation
DITION ON TOW: 0 0000 0 FAIR . POOR 0 CRITICAL
BP±50% of preanerthetic *41
Fully awake 2 RECOVE : PATIENT'S IDENTIFICATION:
.Arousable on calling 1 Consciousness

• Not responding 0 (b)(6)-4
Pink 2

. COMPLICATED
Pale, dusky. blotchy. • iced, other 1 Color
Cyanotic 0

. UNEVENTFUL TOTALS
A
SIGP4/4U6(OF
RECEIV GAND
REL./ ASING TOW
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MEDCOM -5253
DOD 12465

NAVMED 6:320/111 (BACK)
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MEDCOM - 5254
DOD 12466
s„.
ANESTHESIA RECOR ?A (kg) -Ht (in) -j
Pmcedurc j..;b)(6)-2 Surgeon
b)(6)-2 "4.11jSjf) ,3_ j_

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•„, jSee Page
I Date
ties. Sart `It Sufi. Stan Surg..End, Ans. EndjResident/SRNA -2. of 4--One
Pagej
QS, k
Titre
10Agoo '30. as
Checklist -
Ak LIM
D a 0 Suction 0 Machine . Consent
. tt PO maw. Hain /Sew / Des .-
D Sao. 0 ECG 0 no, ¦. STP/pap. I Eitinkline 0 EtCO3 PIP CIL Iarm
. PCS ES 0 Temp CI Mass Spec D VjTEE 0 Fluid warner
Sag I Clstracwitan Air Wennjley 0 FHT D Palm Art cath
Ito / Raps / Ve anonium
iscocm.t.in'DOG/NG L/R LIM Rad I Fein L / R Neostigralne /91Vco
Position 0 Pm-sun:trawl padded CI Anna c 90'
Ephedrie/ Ned
Supine Prone Lithotomy SluingjL/ R m41P3iins,
Drawn, Used W Witn5
MS0.1 Retni/ DrawnjUjWasted • 'Mins
Enid. Lido Bitpli/ %nib
IV -jL / R Hand Wrist EM AC El

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60 / 90 /120 /130 / 140jmin - Samoans in/oared Antibiotics
Total Agent -
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100 Si 0.cojTotal overjmindtes
670
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cm 4tj/ teeth / tutees Trauina FOE / LW /Blind LMA DLT • jFr L / R ainienance i•-Smooth Cuff checkedjEyes taped /
canon ReversedjSjS Full T4 /Hud lift / Sustained tetanusjSuctionedjAwake / Deep : noF. sition - PACU I ICU SV 'VS5jAwake / sleepy Etrabated /incubated Conunents / DrUts:
‘
III Sterile Tecimique 6Stiinel / EpiduraljCaltrier out - up Mum

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MEDCOM - 5255
DOD 12467

ANESTIIF-51 RECOR Vt k -1°It5Ht in -
Pmeedure( (--J.Lit ) 6)(6)-2 Surgeon boy,
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1125 1513 1 535
Timej
t3/3jstj\ 7.-41Qj.%j31.7js..1j1300jS '30j'1C.,jI LI !_10 o, 1 t/ji 1 1. i 1 I 1 % \ Checklist • Wil. um 7-7-2 7i 2 2. '2. "2. 2. -2.. ..121:r.; erguction .1;110% chinejrrEonsent •••15-NPO rt va. Ha Sevn /Des sr ..„.1 ... .-1 . ri ., .-1 Monitors -
. 'A . 'A . . L. .1
-1:31;0, -15106 -BTO; -8-NIBP 1.2)cm -7-S1P 6,I Etomidate -Ertico, 0 PCS / ES GMs -Erflp.1;1-remp
ZOO
. Mass Spec . Verbalj. TEE . Fluid warner
ua Cistracurium 1 C 0
12Ki Warm ,..ragleyj0 FHT . Pulm Art nth
ROI Raps ecZ
.1:1CVP LI/SC/Fern L/Rj00G/NG L/R • • C 0 0 A-Line Rad / Fem L / R tieostigwie /Glyet,
Position - -ItYfressure points paddedjF11ts c 90°
Ephedrine / Neo
lirgiin-P PronejlithotomyjSittingjLateral L/ R Midazolam
1-.....0¦•••
Drawn__ UsedjWastedjWhits
ms0d Rani /Siii

2,50 )_S 0 1 0
usesXno used i I 51-Nvested ¦ o %vie. 1\ --•.-
Eige. tidal Burin / RoplY
1V-j,11..Mj_Gart.) R C.-) Wrist FM ACjEl
. Tourniquetj nunfig Times 11____ 1
60 /90 / 120/ 130 / 140 /150jmin - Surteons informed . MdibiOttet
_ Tout Agent -
NS 2.0 0 Vico I'Loci.-e. t.Total Mg -
10D - )100'
• taro
1 bti-tr Total overjminutes EBL V
f Tb......0 Total •
• = Pulse
180 : •
0 t-. Mu Rap.
0 =Sport. Rasp. IN
s Velttaillarj160 160
X MAP
._ . A/V=N1BP 140 140 •
-
_L / T =A.Line ‘• V v Y VNI/
1= Intubats
Do
i,1311/ V •
E = &tame
-• 1.1 se Nit rrill / ICUjSOO ICO s -
----
IP -SO
SO 1
6. • a r e ow,aft,•• tRj-60 +A
a ia0, •
. 'N :omps •j+ / -j4°
ECG G 2.-SR 5 R-a It 52 .(Z-5 2-S2 .st"Fil, Or / Sk / Ax Temp -^"5 Jr Si% -,..36 . 36 . Cs . . 2. --8,i,s -I L. 5 16 _5 1 4, 34,1, . •
%FA i .0
. a .. 3 . 3 . . s I •3 .3 . 3 , 3
% sic). 1 cs v I on I tip loo lb° Lou lb° (bO (6o i t:so

act), .A. s A 35
3c1 "1, L. 3 iz, 3. I 31 -3 "7 Irl
."1-111C .1 1 li. '-‘( IA

ON cis.)
lv .,1 -rts 1, 4 Cg u c.4 -74 ° c 4 . v 7171
PIP (aoH2O) Naz c-
VA . 2. 44 '2.4 1-2- t.
Rey. Rate ri ) '2..
' 13 13 ‘`I I I.4
iduclion onito n n
ififia="ir . 4=1IrjInhalation CC::) Cricoid Pressure Rapid Sequence Mask ventilation easy intubation -view CAw/o v.iff Styletj
et/ MiljGradejTube SizejTO Attempts 1c-:a Nasal L / R N'
Tube tapedj@jte,g, teeth staresjTrauma Y rip FOB / LW / Blind LMA DLTjFr L/R taintenance
yes tape / tubed
xtubation
Dee nit:sashimi / ICU ltat Comments / Drugs:
ft:oRegional
.
Smile Technique . Spinal / Epidural . Catheter out - tip intact

.
Disposable kit . Touhy I Whitacre / Quincke . Level

ati 1rat 1.1..otifl,..ttnw b)(6)-4 . Bat-Wine prep x 3 . Needle gouge bjy,
Local MOM-. Sitting .
mien lingers Technique
.
Bite U CVP manually transduced

.
Miempts LOR to Air / NS

. Cordis 9.5 18.5 Fr

.
Rareuhnsia + / Blocks o SLIC .

.
Hems 4-/ -cme Stun .

. 2 1 3 • lumen
MA . CSF + -
.
Trans.ertertial

. Test dose 161
.
Dual a-di,

j=1 CSF e
MEDCOM - 5256
DOD 12468

NNW 61=79 fDis-110)
Pre / Pt:Kt-anesthetic Summary
PC,3MA:teal:Inn AgejWeightjHeight ASA Status Allergies
(kg)j(n)
-11-,101 t-P .10jrit.14 (2) 2 3 4 5th r-no
Chernistriel
licmatolory Urinalysis / HCG
NPO- /'"•4 H / H -
Teeth - I )OCC Platelets •
Airway - Mat IIj/ IV WBCs -
PROM, 3 FBjFB HM Resairatory
a CNS / Skeletal Olha
Cough: iv: Seizure: Hepatic:Sputum;
CAD: CVk.j Renal; Asthma:
MI; LOC: 0:
)
COPD: CHF:jNeuro: p Endo: Recent URI:
VHD: Muscle:j— Herne:
TB:
Arrythmias: Skeletal: Exerdse Tolerance:
&OH: 7
3
Long Exam: Cardiac Exalt':
j
tr

Tobacco: .
ECP1IL
CXR:
Previt.us Anestheti cs: Current Medications: Preineclication:
Family Hz: 15
IIMOMIDI=Maggstra -• Vitals Pre-op DOS parol: 0'00 •
•csw s S BP 341/6g Reviewed / pal10t,e4mined, • .
bit004.1400dlscussed.With patient

HR: 7
pt q400).ni .1111Mi/.060':
Resp: 'au./ patehti,:60:114M undets4m4s and acCepts:titks Terim: 'after. j• -clen!j•-• SOlids
FHR Pun 6,v‘.A
sicnature • Date 8t ,tline
jSt jDate
bb)(6)-2)(6)-2 v _S b)(6)-2 II- t./.$
(b)(6)-2 Ij°
Pmient identification
Post-operative note
kh)(6)-4
0 No apparent anesthetic complications
SignaturejDate
MEDCOM - 5257
DOD 12469

MCMC 63201279 (Dec-1K9

: Pre / Post-anesthetic Sunlit
Proposed Operationj Age LjWeightjHeight I ASA SlantsjAllergies
s/7-j(kg)j(inr
3 4 5 EIT) FeillprtiAj /VOA
Chemistriris liematoloev Urinalvsis/HCG
NPO — 17-.; 1\1 A H/H- 6,47111,1
Teeth Platelets -
11.,1) 11 / til I IV WBCs -
FROM.jFB O.jFB HM
Res.piratory a CNS / Skeletal Da=
Cough: HTN: Seizure: Hepati\s, CVA: Renal:
Sputum: CAD:
Asthma: Ml: LOC:

61: COPE): CHF: Neuro: Endo: Recent URI: VHD: Muscle: z Hcmc:
TB:j, Arrythmias:. Skeletal: Exercise Tolerance:
EtOH: Lug Exam:
T A Calfiettni: Tobacco:
ECG:

CXR:
PrevkAis Anesthetics: Current Medications: Premedication:
, 19-/ A.l¦ 14% .i--11.
1
Family Hz:
Chart Reviewed / patient examined 0 Risks / benefits/ options diicussed with patient
TlinANr t)( HR:
0 Patient questions answered Resp: parein! guardian understands and accepts risks liq jclears jsolids
Temp: 'Tule` .
Platt
FHR:
Staff MD / CRNA sienanne Date & TimeEvaluator S gnature
;b)(6)-2

^lt 4l03
Patient identification Post-operative note
;b)(6)-4

402
MEDCOM - 5258
DOD 12470

j
b)(6)-2
ANESTHESIA RECOR .441;1,j -1270 Ht (in) -
oh.dc.v.m al • •g. es MO A-
Or
b)(6)-2 Surgeon
( b)(6)-2
OR tt
Dnc See Page
Rua -4/2,EadjResident/SRNA j

OnePagejof
131— spa
Timej
(.1(jVT'
CC,/
CI, LA1
Cheeldol l

NIM11151E 110M MEI Mann Ina"
action
achier OrConscat $NPO

410=1111111111111MINSEMEIF7-11. IiiIRCIPMERSECIPS "3
uvie Halo / .arr 17
/ WM Mg IMENIVAP„ ' „..
S10i ECG. jg.Hor
•
STP Mei/ Etixiddi mitisj
laPc.$ / ES aP e,RAP temp

111=1"1.

Sue/ 4e,c 1:1 ¦400jTEE . Flisid Air Warm XrcijoijNI., Art cath
ito / Rape Ve
1
¦ OAPj Rj
DOG/NG 'L/R alai MI
IIII F.4.,
WIS
.111d
(Ilan' -PFes;ustpopts padded . Arms 90*

uthoi*Y sitting Lateral. L/ R
' . 1,1S0d Rim* /SU
IMINj Il tecr'Otigied ef 4-103
IRS71.1:Matt Wasted .wit„,
ESA& LW /RR*/ 4.01* 7:.1.2 iliaMINI / R Hada:Oast Pm AC Li
RM 11 /330/ I /j
urc itsjoifonecd
-• Tof1 Artnbtonea

A MUM
NS M .mi I w,,4 mrain Imiliginr
n =i• .111ip. = vim rim 'n:ijaz
over ird Cs
ESL, RO .
pati IIIIIII MM. 11111111 . j
Total
• " EMI EMI Mill WIEN NUM MIMI 40*
o
11111111111111111111MIIIIIIIIIINE111111111111111111111•11111111111111111111111
11111111111111111111111111111111111 MIN EMI MEIN MIMI
leo
160 1111111111111111 110111111111111111111111111111111111111111111
x m/up
A/v..1,0P . 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111121111 ..•
bX6)-2
11T 'A-1ic
1111111111111111.1111111111 MIMI 1111®11111 WEE
inigito0 20 111111VAI rwill111111111111111111111111111MENHIMIINIMPIENIIMI .

.11111111111111Kill irlIMICIACEIZIEMINWA a/i1111211 NINE HIEN
MINIKAW FAS1 011111111111111114111111111111111111111111111 D°
1111111111111M111111111111111111111111111111111111111111111111111111NRIN MUM

;A'jilOU. •
111 N11111.111EINES11010111111MMEINICEMPNWES1111111M
altalitallit EMS 111 MEIN NAM
11111111r Via SINN
ELI NMI MO NAM MEW MEW NW IMO

1111L11111111111117.0 MINN um 111M111151
IMMINFAI WAIII MAIj 40,
%/Ng .1.0r161/.4tg
VAR FEMS1 ERR EMIIVIDA Vitra
WM Fa IFISAUE30rit 1 Et Mel %IV! EMI .F. M1 %WA
SreA PAAIIIVW I Ill I it a 'A Milllirgri gramMa Irlig
° INES1111E-Irer.V KVA kr.:51a ULM Ut.

IMAM Will.nom was mis re 7L. of (14- l'et&
TV rfiZtilirAill DWI rAmmag LWAP, meza !vi( 4t*:e /o/s--
PSP rettH2O).
rairmiliPrii: UM BMW IW4'al MEM WadMXEWE OM IP:MIME
duct i on -
n fY Iriukrinnlrladbo
OW Ad**
tubanan -
Grade view Tube 0,4 2 .AttOtIPti. Nautii1:-.1 R .¦v./ Sty env Yr4iuni Y Fog .t;ii..1431irid *4. vitt , ft !L. I R. uintenanc
lobe
Aubation
FAN TV•ReadfIft /.Su;iali;edt4tantia I. Deep. kit4ow
/ ICU :.Aretotttlj
acleei*ieeteOatve

(skcpy Extubated/intubated. , .j/Oink .
Epiellita3jP CeritIne Out • iipieux, 114601.1y./Witituere / Quincke 0.lsVel .
nient Identification b)(6)-4 • *400 Q .Oeiale &ate EIR'1441.44.1!raan o S*Ilna L'/ R. R / t. P, Scididiit. T*4090.-
CY.F,)1)*Oubieransiiced. .0 c.oris* 9S /
P 13 I/3R ko Air I NS
+ /
BloCks 0SLIC
+ /Neel .unN ' .-2, /j• kiruin
CSF 4-I -
atrint.itterial. •
El Tem dm a Q
pCSFj1).irt
MEDCOM - 5259
DOD 12471

.
j
ANESTHESIA RECOR Wt k
4
.
....wt) Cal Neu 1 (4vtv me
Arrs. Sun
v
14 I t 4 / 31

.
T A
I ft D
0, LIM

AWCAMENOil

tow. Bak, Lso Se . /Des
mminov iamwdate
Sus /Cistrannium
RI) /Rape / Ve caronium Lidocake Nenstipaine /Gben Epheckke / Nen Mideralam MSQ,?Read / So / fentanyt Epid. Larks / Bunn/ Reply
• NS / LR U/0 ESL
• = Pulse
Ido
. 0 .SponL Rasp.
0 = tnsm. Req. • 0 4 VertabiOfj160 X =MAP
AN . nue 140 1 / 1-- A-Line 1 ot Inaubate
E c Ululate
PACU / ICU 100 Pulse -
BPj-jto
Tempi; -RR -Sa0, -
40
Corps-+ / ECG Es/Np /Or/Ski
Ir. 14%
scoff
4
ill
.j•
V411
.
'
NS\
I /0 S"..
44^ PIP wat-1,0)
. 00
00 Z./ 3
E.

.
Itesp.Rm.A.1_, ra/
Induction - Monitors On
Preoxygenated SmoothjInhalation / IV Intubation • Mac / Mil Gra • ______ viejube Sizej
Attempts Tube taped @ ern 0 qpe 1 BethjgjTrauma Y I N
Maintena Cuff checked Eyes tape• lobed
Exfoliation - Smooth Reversed SV VSS
Disposition - PACU / ICU SV VSS Awake / sleepy
Patient Identification
(b)(6)-4

—
.70jHt in -
• -••• „ler I I
L.
.
. Ej
1.
.
Massj CI Air Wj 0 CVP U/j

.
A-Line Rad PosIdon - 0 Pleas Supine Prone IA

See Pay,e One
of.3
—
. Consentj. NP •
BO, . NIBP L arm PNS . PIP ¦ Term
TEE . El " wanner
FM ¦ ' Im An cath
¦ OG I NG L / It
dj. Amu 90*
Sitting Lateral L/ R
DrawnjUsedjWastedjWillis DrawnjUsedjand jitns IV -Cmj Wrist FA. AC EJ
. TourniquetjIrtmkig Tj1jI 60/90/120/1j min - umeons informed . Antibio Total Agent-mg -
over mi tea @
.
'
-
-_
Csieoid PressurejRapid Sequence Oral /yj / Cuff / LW /Blind LMA a
d lift / Sustained tetanusjSuctioned Extubated / innibated
!Lee Revlon*
Ifo
IOo

GO
•
.
•

Mask ventilation easy Y / N Stylet YINjBil BS I Eta), x 3 / CIN DLT Fr L / R
Awake / Dee Cotruneau /Drops:
n s-n,, Tedwalue 0 Spinal / Epidural ha Citketer out - lip irliaCi
.
Disposable kit . Terahy / Whitacre / Quincke . Level

.
Betadine prep x . Neer* page

.
Local infiltration . Salim 0 Site L / R . Lateral R / L

.
Attempts 0 LC* to Air / NS

. Paresthesia + / -
Blocks
0 Ilsee
0 Nerve Stint inn
. CSF + / -
. Trana•anerial
0 Test dose 8
. Dual curl
J:J COP 0 Oda
Lines
.
Seldinger Technique

.
CVP rrunullly transduced

.
Gordis 9.5 I 8.5 Fr

. sue " 0 2 13 • lumen
M EDCOM - 5260
DOD 12472

j

ANESTHESIA RECOR Wt (kg) -Ht (in) - . ies -
(b)(6)-2
Surge° b)(6)-2
10
b)(6)-2
( &id; RI( OR N
Pr'.F;-lnOtia, ....
Sec Page
i t 4103
.14 ARS. Sian In Room Slog StVl Sorg. End Me . • nUSFWA
One
Pagej
I Inc
%LIM ..._
heddist -_. P.-.2— "Z.-FAIMPall • * . Suction . Machine . Consent 0 NPO
---1 — i
°-r!VAI. IIM ..*1 e•i'' IRE 21
.•
i''''' Hahn/ . 401;:l 0 • . So ljrs" .t—i ECGj0 Fi0.j0 NIBP Li'arm
*MIR= WM IEWWAWM13111111E1E•111 m
. EtCO3j0 PCS / ES . PNSj. PIP g Temp
STP / Prop. / Etomidate IIII . Mass S.j. Verbalj. TEE . d warmerSun /Cistramarium .
. Air Warm 1 Foley . FUT • ' Im An cadi Ro/ Rapa/ Ve (uranium
. CVP U/SC Fern L/R . 0G/NG L/R
Eldon:me . Aline Rad / L / R
Neostipoure /Glmo

PosItion - 0 Pressure paddedj0 Arms 90' Epliedrie/ Neo SupinejPronejy SittingjLateraljL/ R
DrawnjUjledjWitns
m90."ilterni/ S ttle„,,t5'

5o si) 1.-5 ,2S 6.•1. I-6 Drawnj Was• d j• iens
Raid. Lido / Reply/ Ropiv
IV •jajL / RjHandj• Mt PM AC EJlik-ntl1117111111 LE7I7MVESI 0T -• t______mmHg Times IjI EMI 60/90/j0/130 /140/ ISO min-jinformed
1 r low.!1, 1 I P iii i l"9l I14jl I I 0 I • P I.. p reps iia pr mpArlm-
g=1 6-" . nal i''' 'i lja il wa iiI i I I I411I, .i a.. i ii Antibiotics
,40z,m, Eramg=I}=calm :--.420 11111.
Total Agent-iro gil•v-• i .ilsiiI " •¦••¦••¦ NW.Vrotal Mg
tNS Aki'KPIIrll=•i n iI i1lr IIMEIhin N1rigWel
-
t40 /P., 0 4 .; / Test over minutes EBL
Total @
YE
• = Pube
" . 0 =Sporn. Reap. IN 0(6)-4
IS ild Um f
4
O. Venulator IN 160 al 5 'in i Aet4-ed x =MAP
0 /ll IC)
.
A/V=NIBP 140 140
(b)(6)-2
1/TnA4.2be
/ \A
I. Incubate

mown'¦nrammminammumwmfinmoymming, Ilg
E = Eembaio
1111WAVIPKA FA illifilallYAM¦111111W/1 HIECENFAVA"VI " • -1-• 1 "---1-`14-
IDO MIMI¦III 11111.1111 ¦EN /2,zs-_, c ri,2/ c& u nil,
PACU / ICUj IBD
III rgAMITES ill¦111 1.¦ ••
Pulse -
BP - " MI¦WEEP..2.1:11iiiii III • a conie ore-
Temp -

1_11112111111¦I . I
'ZIII
RR - MENEM • IVA Illt•MINE¦
SaD, -
IIIIIIMPIME1411111ENIIIIIIMININ ¦wainwazdamaktal
comps.j.
1101111111111 IIMIMEO¦GPM III¦ III¦II .
..tl :alWWI 54 Es I NP /C'r IS" / " 1-' 4 ' riarA MOE1' I 51.5 MEMWW1 WW1 birAill M¦ tila! • ..
ECG .;- MIMI10711 LIMNWWI 101¦1 WAN
swkIltatlripzil!Erslrall q 11F11¦111E4/11M;IIIMMIKill •
. .
%5a°
MIMILSel era q ILIIIIMMEIG011111M1 armLL1• II
cox FAN V.FAI ViNilKMMIIMIMaUMMIIICLIII
RIJIIIIIM7 Ited1J.711n wasreaimam.aim

TM Lizaimin UPAILMIIIMMILI:11111 WMU27107.111M11 •
PIP (emthOl
NMMil
Resp. Rate IM'AIPTAIIIFE111 21 IA IMIIIIIMII MIIIIWA¦
Induction - Monitors On PreintygenatedjSmoothjInhala " IVjCricoid PressurejRapi Mask ventilation easy Y / N
Intubation.jM Grade jview Tube SizejA Oral / Nasal L / Rjw/ Cuff Stylet Y / Nj•jBS / EtCO, x 3 I CRN taped @ m@ lips / teeth / mitesjT uma Y / Nj / Blind LMA LT jFrj/ R Maintenance Smooth Cuff the Eyes taped / lube
Eambation -Smooth Reversed V VSS Full T4 / Head lift / Sustained tetanus Suctioned Awake / Deep
Disposiuon -PACU / ICU jtelt R cul. Reginal Comments Drugs: .
SV VSS Awake / sleepy Extubated / incubated
. Sterile Technique . Sphul / Epidural . Catheter out - tip enact
Disposable kit . Touky Whitacre / Quincke . Level Patient Identification
.
Bmadine prep n 3 . Needk guagc Lines

.
Local infiltration . Sitting

(b)(6)-4
. Seldinger Technique
0 site jL / R . Lateral R L
. CVP manually sransduced
. Attempts j . LOR in Au/ NS . Conks 9.5 / 5.5 Fr
. Paresthesia /
Blocks . SUC .
. HEM /
.
Nerve Slim mA

. 2 13 - bunco
. CSF + / -
.
Tianennerial '

0 Test dose 0
.
Dual cuff' CSF 9 stirl

¦
RAFnr.nm -c9A1
DOD 12473

if& /
TIME G
NNMC 6320/16 (05/91) 011-IER:

RECOVERY ROOM RECORD .NAVMED 6320/15 (REV. 11.771 SIN 0105.4F-206-32BI GlerriertA LCrn4
OPERATION PERFORMED AGFNTS min TH•PINICS OF ANESTHESIA OXYGE NTHE RAPT
13)(6)-2
ROUTE LAA OFF
oral i'ai(
HOURIS1 15 • ,0 15 45 2 15 45 MASK tDL
TSAR
TEMPS:

11111111111111111111MINIUMUM MI
Spinal
VENTILAT.
220 1111111111111111111111111111111111M11111
Level:
FLUID THERAPY

1111111111111EME11111E111111110:111
EEC to !BO TYPE BLOOD LINE OTHER
AlevdL
nrnitorj111111111111M111116111111111 + 111M1111 OPERATING
160 • st-
.
ROOM
IMO-1 - 11111E1M11111111111111
RECOVERY RhYthnjROOM •
140 ME ; IIIIIIIIETUUMIIIIIIIINEWIN
TOTAL
120 IIIIMIIIMMINEMENRINIUMES
ip 4-art 1°3 BLOOD LOSS IN OR: ,9a) CC
11.611111111011- 111E1111111111111111111¦1111
BO WARD PREOP BP / mmHg
V IP A cuff TUBES: 0 PUG 0 FOLEY
IIIIIIMMEMILLIERIMEMENIZIE _ j dgyp
cc Ram = • 40
HIUMUNIMMi IN "5_1
111111111110111 'r. I NIUMInt' lp AT u7A oeA,r AGAT •
1111111111MINEZIONEMEINIIIMIE
OF AT
% Sat:
RATE
FRIMININIERNELVIUMERIME V IN
ADS.4INC IN
NUMBERS I I

FOR REMARKS I.!
l i
.
' ADMISSION DISCHARGE URINARY OUTPUT,
PPCU
FROM NOR/SPEC. STUDY TO WARD 5
TIME -
cd
DATE 41 13104 Ian-DATE MRS' Oa,
TOTAL

DRESSINGS: LOCATI &. NCO
SP, GR

STATUS STA
S/A

REMARKS /AS NUMBERED) AND PERTINENT PATIENT PROGRESS NOTES
ENDOTRACHEAL TUBE - ORAL OR NASAL .b)(6)-2
1) .PEW fran MR amatpanied,j
OYES NO 0 YES NO
1W: As 2.
AIRWAY ARMIN scars
A6les-•-fD r(5.perwt tail
dEr‘EAR. O. PLAST STATUS:
AIRWAY
O OBSTRUCTS EASILY Pain YejPeal:

• POSTANESTIIESIA RECOVERY SCORE 01: (re% ,
A 0
IALDRETE SCORE1
OU en st Is X 2 war ,darV-ets
.
Able to move extremities voluntarily
or on command 2 Able to more 2 extremiiieivolumarily ICONT •ON REVERSE/ ow on command 1..Activity
Able to move 0 extremities volumarily NAUSEA AND VOMITING: 0 NO 0 YES • 1 2 3 4 5 6 TIMES
or on convnand Able to deep breathe and cough freely 2 CAU DURAL BLOCK Drronea or limited breathing . I Respiration MOVEMENT PRESENT HAS Apneic 0 SENSATION PRESENT AT FIRS
BPI20% of preenesthetic keel 2 .
BP420.50% of preanerthelle keel I Circulation

CONDITION ON T .00D 0 FAIR 0 POOR 0 CRITICAL
3
.101.50% of preanettbetie keel 0•

Fully wake. 2 RECOVERY: PATIE DENT IF !CATION:
.Prrousable Oil calling 1 Consciousness
:Is)(61-4

z_
Not responding 0
0 COMPLICATED

Pink 2
Pale, dusky, blotchy, laundie4d. other 1 Color
Gyanmk o

NEVEitrFUL TOTALS
,(1:4(6)-2
SIGNATURE OF
RECEIVING AND

. RELEASING TOW .bX6)-2
OFFICERS

MEDCOM - 5262
DOD 12474

NAVMED toxvIelertio
MOURI:4j15j30j45j 15j30j•5j 16 15 46 16
TEMPS:
MILTMENIIIIIIIIIIIM1111111112111=1UMMIIII

SPirk ' •

mobinunualnammonwanamminiarain

Level:
BG Ftritha 150

MICIUMUIUMIIIIKIINCIEMENE1111170111111:1

160 ElkillingE111111111111111111MIIIIIIMI=11
140 EP T art 120 W A cuff

V twanumummoolognommunnimusErsoffi
FWD = .

musanimmurnammunanummissusin

% Sat:
MERIIINE11.1.111111111111111111111111118MMICI

RESP. RATE NUMBERS 1 FOR REMARKS I '1 I, ! I L _t_L , I II I I 1 n 1 L I.11 1.1 1.1- I. T :.I.i.It• II -I I r I I _II 7
• MEDICATIONS
TIME DRUG
MEM - ROUTEIMMIMIIIIIIWO.. MN b 6 2)17- iniiir RSE

iiK0711161=11111111111111111111¦111111MMIIIIIIIIIIIIMMIN cm b)( 6)-2
IMEZMITAINII t v,..42 b)(6)-2
111.15t
• Iffif.M711"F..e.A.M.1111.111111.111111WRIA.Millgrallii"61-2
11111=M 2601 MEINAIII b (6 2 °Santr . • INIIMiatiMMINFAris )(6)-2
RE MARKr:4NUAIHEREDI AND PERTINENT TIENT PROGRESS NOTES (CON
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MMI •1
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Pain:
y"z.,
• Pulnrrentr,
(.5 . siat walk
CV: I 5
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• GI: GU: Ebley V. •
4411 •. --11°. • s • Ocacr: 'if.eT, Etta •Yr.-413.)
°Dior of urine: De to 'void: Instrirticna/Intervelticre in MU:
bX6)-2b)(6)-2
Report called to: ,
b)(6)-2
'IDAlad to:
•: 1991... 501-10120625
MEDCOM -5263
DOD 12475

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
P STINTs PHYSICIAN (Print!
..EQu Er
SECTION I -REQUISITION b)(6)-2
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY i f Red Blood Cell
Products are requested.)
RED BLOOD CELLS

1=1 TYPE AND SCREENFRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE PROCEDURE
PLATELETS (Pool of 1units) CROSSMATCH
CRYOPRECIPITATE(Pool of 1units)
DATE RENUESTED
I have collected a blood specimen on the below
. Rh IMMUNE GLOBULIN 1— kP cHEO named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED
patient and verified the specimen tube label to be OTHER (Specify) 1
correct.
CIrnI ATI inr (IC I/
VOLUME REQUESTED(If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION ILIC
REACTION (Specify)
\ WV-ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY CP
RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTERPRETATION PREVIO RECORD CHECK:
(b)(6)-4 RECORD NO RECORD

(b)(6)-4 ANTIBODY SCREEN.I CROSSMATCH
.
PF CIC:h1/1TIlor nF oroc.ruu OrlareleonAski, TCCT (b)(6)-2
e&up
DONOR RECIPIENT
. CROSSMATCH NOT REQUIREDFOR THE COMPONENT REQUESTED
.y//-)1:(3
ABO ABC REMARKS:
0
/4/3
Rh Rh
Pas
itote1: BP/1/-45-3
SECTION III - RECORD OF TRANSFUSION
PRE TRANSFUSION DATA POST-TRANSFUSION DATA
INSPFCTPD AND ISSIIFD RV Icianaturpl AMOUNT GIVEN TIME/DATE COMPLETE I7FM
(b)(6)-2
ML
c

REACT! TEMPERATUP;c PULSE RESS AT (Ho ON (Date) 42122k ( r.
ONE .SUSPECTED
CENT! TION If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present. keep Intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag, Filter Set and I.V. solutions to the Blood Bank.

tfronir.u-n isCin,
DESCRIPTION OF REACTION
',3)(6)-2
. URTICARA . CHILL . FEVER . PAIN
7r1ISR (Spec'fy)
(b)(6)-2
Lecorer.
U5/V OTH DIFFICULTIES (Equipment, clots, etc.) , I NO . YES (Specify)
SIGNATIIPP nF PPPSnAl AICTIMP. Aprwr (b)(6)-2
TEMP. tl 9 • I PULSE
DATE OF TRANSFUSION TIME STAR1Eb
PSCLQ-)6
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle: grade; rank; I SEX I WARD
rate: hospital or medical facility)

5-RAD
(b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD RRA 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy
MEDCOM - 5264
DOD 12476

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONIEf\fT REQUESTED (Check one) 1ZRED BLOOD CELLS SECTION I - REQUISITION I TYPE CF REQUEST (Check ONLY if Red Blood Cell Products are requested.) REQUESTING PHYSICIAN (Print) kb)(6)-2
I=1 FRESH FROZEN PLASMA 0 TYPE AND SCREEN OR CIPERAIIIVE PROCEDURE
El PLATELETS (Pool of 1units) CROSSMATCH
CRYOPRECIRTATE (Pool of I=1 Rh IMMUNE GLOBULIN I=1 OTHER (Specify) 1 VOLUME REQUESTED (If applicable) units) ML DATE REQUESrDATE AND HO R R.E9 KNOWN ANTIB DY FOR AT REACTION (Specify) N/TRANSFUSION I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct. SIGNATURE CF VERIFIER
REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY CF: DATE VIFS-11-j y/
RhIG TREATMENT? DATE GIVEN; -----DISEASE OF NEWBORN? HEML1MC TIME VERIFIED
SECTION II PRE-TRANSFUSION TESTING
b)(6)-4 CROSSMATCH TEST INTERPRETATION ANTIBODY SCREEN PREVI RECORD CHECK: RECORD NO RECORD

PATIENT NO. SIGNATIIRF OF PFRSON PFRFORMINK TFq'r (b)(6)-2
\Pb
RECIPIENT
CROSSMATCH NOT REQUIREDFCR THE COMPONENT REQUESTED •
ABO ABO REMARKS:

Rh Rh 1.90....c
"A_ -3
tbe yer! /7 /1­
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSF A
INSPECTE0.414D-LSSUX) BY (Signature) AMIUNT TIME/DATE NTERRUPTED
(b)(6)-2

UAL ML )3 aLn 5TION TE E TURE PULSE BLOOD PR SSU E AT (Hour)
ONE [II SUSPECTED
IDENTIFICATION If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

DESCRIPTION OF REACTION
rb)(6)-2
. URTICARIA . CHILL 1=1 FEVER I=1 PAIN
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
PRE-TR SFUSION NO . YES (Specify)

ionvpr rIF DCDCrINI toriurrns. nnnur
TEMP. Lig #5 PULSE 90.I Bpi
'b)(6)-2
D TE F TRANSFUSION TIME STARTED

1.01),-
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, irst, 1111U le, grace; rank;
rate; hospita or medical facility)
p)(6)-4
a
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribedby GSMCW1R, FIRMR (41 CR 201-9.202-1

Medical Record Copy
MEDCOM -5265
DOD 12477

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY filled Blood Cell Products are requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA

TYPE AND SCREEN
CROSSMATCH
.
PLATELETS (Pool of1units)

.
CRYOPRECIPITATE (Pool of1units)

DATE REQUESTED
Rh IMMUNE GLOBULIN .. OTHER (Specify) VOLUME REQUESTED (If applicable)
REMARKS:
NCFI
UNIT NO. b)(6)-4
TT
(b)(6)-4
PATIENT NO. DONOR RECIPIENT ABO Rh ?G•5 Rh ?Qs
./ -'").-
DATE AND HOU QUIRED

,e'1-c ;-
/,
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)1 ML
IF PATIENT IS FEMALE. IS THERE HISTORY OF: j
RhIG TREATMENT? DATE GIVEN: HEMOLYTIC DISEASE OF NEWBORN?
SECTION II -PRE-TRANSFUSIONTESTING
Nri .
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
E
Co
1
(b)(6)-2
I REOUESTING PHYSICIAN (Print) b)(6)-2
DiAtNOSiS OR ERATIVE PROCEDURE
L ' i.1? '--(-----
-I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
SIGNATURE OF VERIFIER
(b)(6)-2
DAVIERIFIED
...7„,..-./.......;__

....../.0.:
TIME VERIFIED
0i00
PREVIOUS RECORD CHECK:
111 RECORDjNO RECORD
,I,k111.1. 1 ru-nnn Ill,Nr1111,1• 1-11,1,1.
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED I DATE At.05 REMARKS:
14? ZO3
SECTION III - RECORD d F TRANSFUSION
PRE.J.RANSP1J10 si DATA
(b)(6)-2

NrRour)1OM -1 I ON (Date)
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information Identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.
1st VERIFIER (Signature) b)(6)-2
(b)(6)-2
2nd VERIFIER (Signature)
(b)(6)-2 LCDR/USN
ANESTHESIA
PRE-TRANSI-USION V
3 & 401
TEMP. PULSE Pd7
TIME STARTED
DAVARM /W:tr-
POST-TRANSFUSIONDATA AMOUNT GIVEN TIME/D TE COMPLETED/INTERRUPTED
a?-5-40 ML 4/17/ 44/03 REACTION TEMPERATURE 1 PULSE BLOOD PRESSURE NONE . SUSPECTED
317/ ( & S ia.(55 If reaction Is suspected-IMMEDIATELY:
1 Discontinue transfusion. treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service. a Follow Transfusion Reaction Procedures.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
. OTHER (Specify)
011-IER DIFFICULTIES (Equipment, clots, etc.)
1
MjYES (Specify) (b)(6)-2 Cir'AIATi ion fIF DFPC/1N nicifirsin eoreic
(b)(6)-2
PATIENT IDENTIFICATION-)SE EMBOSSER (For typed or written entries give: Name-Last &St, Mioaie, grace, rang, ratp• hnsnital or medical r=¦-ita+ ,\ (b)(6)-4
(b)(6)-4
MEDCOM -5266
LCDR/USN 2 ANESTHESIA
VOL,. WARD
BLOOD CR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARDFCRIN 518 IRV. 9-92)
Prescribed by GSA/ICA411, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy
DOD 12478

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED(Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell RFOlIFSTING PHYSICIAN (Print)
Products are requested.)

(b)(6)-2
RED BLOOD CELLS

• TYPE AND SCREEN
FRESH FROZEN PLASMA UIHUNUJIJ IJII UV.IA I I Vt 1-.111-1l,tULIlit
¦
)g-CROSSMATCH —.•
. PLATELETS (Pool of1units)
?.Z------
CRYOPRECIPITATE (Pool of .units)
. DATE REQUESTED
I have collected.a.blood specimen on the below
named patient, verified the name and ID No. of the
Rh IMMUNE GLOBULIN
'
. patient and verified the specimen tube label to be
DATE AND HOUR RE.D
correct.
. OTHER (Specify)
....'fr.'.JO).—7

c.r.AIATI Inc nr VICOtricn
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY DRMATION/TRANSFUSION
(b)(6)-2
REACTION (Specify)
ML
IF PATIENT IS FEMALE. IS THERE HISTORY OF: DATE VrRIEIED .
REMARKS:
RhIG TREATMENT? DATE GIVEN:
Aor;103
TIME VERIFIED . ' HEMOLYTIC DISEASE OF NEWBORN?
SECTION I1 -PRE-TRANSFUSION TESTING
UNIT NO. TRA x S 1 ¦ I TEST INTERPRETATION PREVIOUS RECORD CHFrw .
b)(6)-4

ANTIBODY SCREEN CROSSMATCH RECORD NO RECORD
.
(b)(6)-4 CI,KIATI Inc /IC nrnento rIFIICIVIKAIKI, TrIXT A.,
PATIN
CO r
E
IV
DONOR RECIPIENT
I--CROSSMATCH NUT REQUIRED FOR THE COMPONENT REQUESTED if (I DATE / - 1 of -U3
MO ABO REMARKS:
A A.-6
Rh r?:;/5 Rh 20.5
C_4ept144 A?P-03
SECTION III RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION De¦TA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
INSPECTED AND ISSUED BY (Signature)
(b)(6)-2
ML /Z ZS-_q/(i//03 REAC 0. TEMPERATUREXINONE . SUSPECTED 3,7
AT (Hour)1t d 71ON (Date)140'Cli'L. .F;U. .BLOOD PRE 2k IDENTIFICATION reaction Is suspected—IMMEDIAirLA
41141
iz 7
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open.

information identifying the container with the intended recipient matches item by Item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to the Blood Bank.

1st VERIFIER (Signature) DESCRIPTION OF REACTION

(b)(6)-2 . URTICARIA . CHILL . FEVER . PAIN (h)(6)-2
LTS5
. OTHER (Specify)
2nd VERIFIER (Signature)

(b)(6)-2 LCDR/LiSN
ANESTHESIA

ER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRAN FU ION, NO. . YES (Specify) (b)(6)-2
46
SIGNATURE OF PERSON NOTIbIG ABOVE
TEMP. PULSE I BP 11 1
1k'.
(b)(6)-2
DATE QF TRANSFUS1ONI. Tlyly 7213TED LCDR/IJSN
ANESTHESIA
Ofi
PATIENT ICENTIFICATIO 1%4 DOSSER (For typed or wrinen entries give: Name—Last
rate: hospital cr medical facility)

(b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record smsuso Fcmi 518 (REV. 9-92) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1
Medical Record Copy
MEDCOM -5267
DOD 12479

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orders)
DATE AND TIME
DOCTOR'S NURSE'S
RX DRUG ORDERS
SIGNATURE SIGNATURE
START STOP
j Jb)(6)j2
Ij7 ctrerqmFlei)
Ob.b
b)(6)-2
4(Dc( ¦ 1A,
, RVj4 AI . ., _
A li(T-CD P A__.A . • „ UV/LC
b)(6)-2
•. MOOS ikj• . ijoA k . A4 wiLi., i
646, 2oy, Di op o?4;chtkA:-. -_i: _
Lisqv,u3 ortPJ
0 31,4m, •AbX6)-2
IN 2 6) c\--14,6 C_ A .,--(3--.qt-k-,.I
b)(6)-2
(b)(6)-2
t O CAS
• / b)(6)-2
• ••
(Continue on reverse side) PATIENT ' S IDENTIFICATION (For typed or written enlries give: Name - last, first. middle; grade; rank; rate; hospital or medical facility) REGISTER NO. WARD NO.
b)(6)-4 DOCTOR'S ORDERS
STANDARD FORM 608 (Rev. 1045) Prescribed by GSA and ICMR FPMR 101-11. 806-8 608110
MEDCOM - 5268

DOD 12480

=73
DOCTOR'S ORDERSMEDICAL RECORD
(Sign all'orders)
DATE AND TIME
DOCTOWS NURSE'S SIGNATUE SIGNOURE
START STOP " DRUG ORDERS R
. (6)-2
I 1
2.1, 0 . . 4 b)(6)-2
..
011 . .
nzi s.iinismaim
% ¦b)(6)-2
IIII. S-A) t(-
b)(6Y2
WeS(b)(6)-2

ram enammismarfimmarignm
b)(6)-2
VI

miumlimmram
Illmit
III 6b)(6)-2
IMMO
MitiMIth-111:AILM.1111911

p/IPMirr*6)-2
b)(6)-2
23 A • 3 011 1111
A.,t,.I ....,.L. ¦ •
s
=I b)(6)-2 suaku. i b)(6)-2 hiihh...Ell
hilalMilerra.0 • ' '
4 k t 34M6 ,40 b)(6)-2
AI IIIMION
l
ag animimumenimim lin...R..„ ILIIIIIIIIIII¦
1111 111i._ awn
IM1111111¦11¦111111111111111111111• ¦

111¦111111111¦¦111111M
111=111111111111¦11¦1111111111

111111111M111111111M1111¦1
tinue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Njlast, first, middle; grade; rank; rate; hospital or medical facility)
(b)(6)-4
STANDARD PORN INS OW. 10451 Pilmer6m1 by GSA ard ICUS
FIR MR (41 CFR) 201-45.505 508-111
tr U.S. GPO: I0IS
-201.710/10076
MEDCOM - 5269
DOD 12481

508-112 7540-01-044-5515
DOCTOR'S ORDERS
MEDICAL RECORD

INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S NURSE'S
DRUGORDERS
START STOP Rx SIGNATURE SIGNATURE
(b)(6)-2.
4 26)03 2.4(30 `Jt DR_ (b)(6)-2 / 0.3&
...
0 g\(-)C.
2
a_URANk, A I Qc)
(b)(6)-2
..')(
(b 6)-2
3.61 t.dldAL
-
(b)(6)-2
.... tr d Ja ,.............j5-2,0j4 l---4"

VI I! ..-F
&11% b)(6)-2 -...t SiT7' _... "?....--
r)_(.6)-2
S.c.........14. aza)-711.74,-...... a...-(L..-

(b)(6)-2 —
) \._.../..--(b)(6)-2
(b)(6)-2
. oa 0 i,
(b)(6)-2
0 Poi/DO.Yt) ata V,,tidttitk
(b)(6)-2
(2; i 4-1ctlAnv, it, ecri) (b)(6)-2
/at \ (/'(A -
(b)(6)-2

(b)(6) 2 A)(°103 b' e4' 5
ChnAt rofv,.:,-0 (con.e on reverse side) .e../ 1
ANO. PATIENTS IDENTIFICATION (For typed or written entries give: Name—last first, REGISTER NO.V1Pg
—INIC
(b)(6)-4 middle; grade; rank; rate; hospitalor medical facility)
DOCTOR'S ORDERS
11.41..112.......1

STANDARD FORM 508 (Rev. 3-94)
Prescribed by GSA/ICMR, FIRMR (41 CFR] 201-9.202-1

MEDCOM -5270
DOD 12482
rative Plan Of Care & Nursin
Patieni AsseSiment For Sur er - Potential For In'ur - Outcome: Patient is free fr and s ptoms of injury es ONo
frau ma# or
?atient # Diagnosis: Planned Procedure:

b)(6)-2
Side: . N/ Right . Left Date/1 ..,-,7Arrival Time Interviewer: Age: T; WT: Tr sport Via: Patient ID: Blood Ordered: Su cal/Anesthesia Consent Verified:
:Trom: Comments: 0 Procedure
CASREC ,eGumey 0 Trauma card 0 N/A
0 Litter herbal .Consent ibX6)-2 nsent complete, dated, signed

.T/C #Units `2---0.Emergent case; no consent, MD note
a Ward .Ambulated ?Chart I OTHER: 0 Wheelchair FIA-rmband Li T/H #Units 0 Other
Other at-w ?reap Labs (H 0, etc): DruB/Latex Allergies: Present On Admission: Pasj.Medical History: Cultural Needs Addressed: ] None 0 A .N/A one known .Yes KNo rest/Resul llergy/Reaction: .Oxygen . Smoker ppd/yrs / List: j 121.-Kr Site: #1 r6co C-(A . Asthma 0 ETOH #2 .HTN . CAD %a-Foley 0 GERD . CBR exposure
.Endotrachial Tube 0 Other: 're-Op Pain: 0 Arterial Line Site: Past Surgical History: Last PO Intake: (datdtime) 2 No t30 Nble. 4o aces 0 Drain(s) 0 None known Solid: -s
aAIfig1111 A Liquid:
SP.
] Yes Level (0-10) 0 Chest Tube(s) Nef es
fiction Taken: List: ms's
Jocation/type: 0 See RN Note #
En Chart: Skin Condition:

Limitations: Personal Items: I H&P &Yes 0 No .Intact . A . Auditory mwlone Disposition: J EKG 0 Yes Ei-o FlOther: guage 0 Visual 0 Military gear I CXR 0 Yes 'El-*Slo obility 0 Prosthesis .Glasses I Other: 0 Other: 0 Dentures
0 Jewelry/wallet 0 Other
Potential For Anxiety — Outcome: Patent demonstrates knowledge ofpsychological responses to an invasive procedure': Yes . No Mental/Emotional Status: j omfort Measures Implemented: Pre-op Teaching Included: 3 Alert/Oriented /Calm 0 Clear, concise explanations . UkA due to patient condition 3 Disoriented. 0 Sedated Communicated patient concerns to other staff 01?) ysical layout of OR Anxious .Unresponsive members sonnel present during procedure Appropriate for age Remain with patient during induction nvironment (noise, temperature, etc.) 3 Other st-op expectation (PACU, drains, etc.)
Potential For Impaired Skin Integrity Related To Surgical Procedure Outcome: Patient is injury free 0 Yes 0 No Operative Position: Positional Aids: Comments: Supine 0 Beach chair . Ai 0 Axill•roll . Bean Bag Prone . Sitting firms 90/1 .Gel donut 3 Jackknife . Lateral L / R Annboardi. L 0 R 0 Hand Table .Pillows 3 Lithotomy Tooke . Stirrups CI Wilson Frame 3 Other: . Other: ESU # AM. DVT Prevent' . Tourniquet: Pad Sit AIKIKTIMF SCD used 0 No . Yes IJ Ann . Leg Comments: Pad Lot • -res • Right .Left .Right Site Clear at end o case? . No 0 Yes Teds: . No . Yes .webril appli Applied by: If No, see RN note # Bair Hugger used: . No Bipolar: Total Min:
Max Cut Coag Other warming techniques: I' j4. j
. Comments:
b)(6)-4
USNS COMFORT (T­AH 20) PenOperative Plan Of Care & Nursing Note Page 1 of 2 (Rev 3/03)
M EDCOM - 5271

DOD 12483

Potential For Infec' 'tcome: Appropriate Actions Taken to v,fectiores . No
Hound Classification: Shave Prep: Prep: Solutions/r ions:
er
¦•••&
31 y 0 III 0 IV .Shave . Clip Betadine Scrub ormal sai. 0 Other:
Area: By: .Hibiclens 0 Sterile water
0 Duraprep . Local
.Other: .Antibiotics
/rains/Packing: None Dressing: Location: 0 ABD 0 Cervi Collar ¦ Kling .Steri-strips 0 Benzoin
Foley FR:
Location: 0 Ace D Coban Immobilizer .Tape 0 Mastisol

I JP #1 Fr
I Hemov ze Location .Bias 0 Drip Pad Mains .Webril 0 Bacitracin
0 Band-Aid(s) 0 Fluffs .Sling eroform
Size H2O Pressure: 0 Cast .Kerlix 0 Splint .Other:

I Chest to e: Location
:ounts: Xray: kjn Integrity:
;b)(6)-2
0 None 0 Other: Clear & Intact (other than incision)
omments:
Sha 46es 0 No 0 N/A 0 Portable
Sponges iteYes 0 No 0 N/A 1F(C-Arm
Instruments 0 Yes 0 No 0 N/A

0 See RN note # f o r additional comments.
See RN note #Afor additional comments nplants: em I Lot # I Exp Date:
See RN note # for additional comments.
Dischar • e from 0 eratin Room !omnlications:j Transport From OR: Transferred To: }'one Comments: mey w/ siderails up ACU Report by: t(tuitter w/ safety strap in place 0 ICU Knesthesia provider 0 RN
. w/ Oxygen 0 Medivac
D w/ Monitor 0 Ward
See RN note # for additionaltent .Other: 0 Other

)
orgical Procedure Performed: / / e
AFFIXTOMENTRECORD Membolone Etsvitulad by
N Note: (number each note to corresponding area above)
) ti SYNDIES .8"%t",7:7:.
14MM TI CANNULATED MORAL
j MIL 400MM-5TERILE

j cat r 474,4418 j inn e 4455188 DPI 12/2011
MAT: Ti-MAI.TNN
Initial/Name Box: (please print)
,,(,..3.-0-3 ,//fete Relief OR RN Signature Datc/Time USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page-2 c'f9r
DOCTOR'S ORDERS
MEDICAL RECORD

INSTRUCTIONS: Place torm on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S NURSES
DRUGORDERS
SIGNATURE SIGNATURESTART STOP Rx
D...,

(b)(6)-2 ik. (b)(6)-2

..
14/.1)0 /lit,
V° re

4,3q f }J Li Li-.
1 4-4. S 84,,, b)(6)-2
le. 4LS o---et e. ICA .
b)(6)-2 a
¦
...:i1„'Eng•jlalerldr-Wnr
M1 Aar. 1 -b)(6)-2 c I 2Io 3 A ._„ ...
1 a "
111
mlimil
si
, ria .
b)(6)-2 b)(6)-2

IN,
I, 6)
' ).b It

0' a s.
( (b)(6)-2
......./".....\--/'''''....''s•-¦•''....\.___.,

4 IA MI J., ,. ._ - .. .. 4
= ,. .i D ZZ (2) b)(6)-1
(b)(6)-2
jeth

,........--. -v

itnia 14050 ..) M1 i--TA a Po a tpk\L ( )(6)-2 ¦1....._ 2) Y‘e_ Slt 32-5 ttlier--.0.CQ bAN .t-N.-
(6)(6)-2
V 10
(b)(6)-2

1 74C6 0 in OuminAiris
p. on sine
PATIENT'S IDENTIFICATION (For typed or written entries give: Name--/asl,first, REGISTER NO. WARD NO. middle; grade; rank; rate; hospital or medical facility)
DOCTOR'S ORDERS
1(b)(6)-4

Medical Record
STANDARD FORM 508 (Rev. 3-84)
Prescribed by GSAIICMR. FIRMR (41 CFR) 201-9.202-1

Q MEDCOM - 5273
DOD 12485

508-112 7540-01-044-5515
DOCTOR'S ORDERS
MEDICAL RECORD
INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S NURSES
DRUG ORDERS SIGNATURE SIGNATURESTART STOP Rx
.....(b)(6)-2
2---2-zz, (........f e._.6.....•_i_L_ _ (...„,-47 ..,.e2_,._.
; . /A.-. ci •
-
(b)(6)-2 (b)(6)-2
LtrYir
(b)(6)-2
(b)(6)-2
(b)(6)-2 ten' Ill C.\.5 N.IL "r-Al.g ) '110 UL) ,
.
''
V -.,5-4- ' ' 2Vraffi'MY-.. - • -7 --4`4.47 b)p-Z—' i.' -4,r_ZA
ritatT"t''
v
-...._------b)(6)-2
t so aA) 0g I° Lk1ale c i .A.: -Li , N-1—¦----------,-----¦---------
4' 2-, 0 4.6„,;(1,14 -.),
b)(6)-2 b)(6)-2
i Q.vii¦ • . ¦.Cr I,
--. V•I 6' _____---....„
N CA.,..e,---1-1-4,-,--O .
¦ i (Dc). 1 o 41-2.11-03.„::::,(b)(6)-2
(b)(6)-2

(DD`
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, REGISTER NO. WARD NO. middle; grade; rank; rate; hospital or medical facility)
I
(b)(6)-4
DOCTOR'S ORDERS
Medical Record
STANDARD FORM 508 (Rev. 3-94)
Prescribedby GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 5274
DOD 12486

DOCTOR'S ORDERS
(Sign; all ordrrs)
EDICAL RECORD
DOCTOR'S SIGNATURE NURSES SIGNATURE
TIME DRUG ORDERS
STOP RX
STOP
(hi),(2.
b)(6)-2
b)(6).

(6)-2
b)(6)-2
0(6)-2 (6)-2 az.
0 3 pil-z
erse .side)
1..CniintAc P11,A
ATION (For typed or written entries gt 'AT
middle; grade; rank; rate; hospital or medical facility) DOCTOR'S ORDERS
STANDARD FORM 500 (Rev. 10-15)
b)(6)-2 Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 50E-112
MEDCOM - 5275
DOD 72487

DOCTOR'S ORDERS
MEDICAL RECORD (Sign all orders)
DRUGORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE

(Continue on reverse side)
wrIA\10.
REGISTER NO.
I 1
PATIENTS IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)
DOCTOR'S ORDERS
0(6)-4
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 508-112
MEDCOM 5276
-
DOD 12488

DOCTOR'S ORDERS
(Sign all orders)
MEDICAL RECORD
NURSE'S SIGNATURE
DATE AND TIME
b)(6)-2
START
b)(6) -2
b)(6)-2
b)(6) -2
b)(6)-2
I DS b)(6)-2
b)(6)-2
MOM
01"
UMW
_va_i',41.
4I
t`
AMP',
ketaillin
¦
001111
lirISWSMI"1"MjpWA i
WAFTIFILILF-4L1.111111115
b)(6)-2
nin. ri
I b)(6) 2
WPM. 04¦40 ing. b)(6),At
4WRINI.
olt7011
Immi"r4_ 41
WARD
(For typed or wrier
b)(6)-2
JEEP
PATI NT'S IDENTIFICATION
mid •le; grade; tank; rate; hospital or medical facility)
b)(6)-4
f0 3
FIRMA (4 1 50S-112
3 Q
MEDCOM - 5277
DOD 12489

DOCTOR'S ORDERSMEDICAL RECORD
(Sign all orders)
DATE AND TIME
DOCTOR S. NURSES Rx SIGNATURE SIGNATURE
DRUG ORDERS
START STOP
1 S4Pte03 15 9 30.0 0 e1(fpwtejr eitt4Ard-ciskicl
b)(6)-2(b)(6)-2 4.40
MEa A' XQ y--6-.5 0 ..«. ..f?fr.(35, ' ,.e,o, ¦ _
..
1 SA 13 I 6-6I 1 .t
(6)-2
,et:t
1111 0.
b)(6)-2
c-4).
_,O____e_r_j_cl,J--va-vic5 Lp4t_L-In
C 4701)
ft

b)(6)-2 b)(6)-2
,I / OM U. 0 E )4 5" b)(6)-2
... I¦
ellfil.io yuce;469-1 .th
(A) ..
•.\.,
0 ..13.1 q.5.4 il
b)(6)-2
''''............-...."-------._

b)(6)-2
— Nyman 1111Pr-5 ipc
2.-CiOrC.
- i
(b)(6)-2 (b)(6)-2

1 • d. U . a _
t1°----r-.
fir.,
11,1gri aif
IIMIMAI.11 .p-Millnil
b)(6)-2
II

1r.b)(6)-2
MI 11-MIMII
11111111. -.

i • ei
611611111A1.
(Continue on reverse side)
PATIE 'S IDENTIFICATION (For typed or written entries give: Name - last, first, REGISTER NO. WARD NO. middle; grade; rank; rate; hospital or medical facility)
j1)(6)-4
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75)
Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-505 508-112
MEDCOM - 5278
DOD 12490

DOCTOR'S ORDERS (oRTHOPED7.

.IT/POST OP)

MEDICAL RECORD

(Sign all orda
DATE AND TIME DOCTOR'S.

NURSE'S

DRUG ORDERS

START.SIGNATURE.
SIGNATURE

STOP

jM(6)-2 b)(6)-2
ADMIT TO: ORTHO STAFF: .
1
Dx:4rho Ifq . Pe44 A7,00c4,2, ,41f Aer4 /AK CONDIIION: STABLE
ALLERGIES: 14/,e.LADAk-
VITAL SIGNS: Q. 1 hr X 4 •THRU Q 4 hr X 2411r THEN
Q 8 lir
NURSING:

-

N/V CHECKS W/ VITALS

-I &O's q 8 hr x 48 hrs

Foley to gravity (remove 6 A.M. on .

6..

-drain to self.suction

-Remove wound dressing and replace w/ sterile
dressing on POD #2

7 Diet: Clears, advance as tolerated— --.
Activity: 'Ona t-1, Gto-kc-

8.
is
•
LABS: CHEM 7, CBC in AM; )CBC q AM POD # 2 & 3_1.

10. IV: D5LRa0100cc/hr 141
•••¦•••••¦
MEM:

hr x 48 At-
-Ancef ig IV.

- h
-Lovenox 30mg SQ BID
11. -MSO4 LO,mg IM or IV q 4hr :prn pain significant-
-Phenergan 25 mg IM or I1014 hr prn .

-Percocet 1 - 2 tabs po q.3 hr prn pain moderate .

-Tylenol 650 mg po q 4 hrpin .
-MOM 30cc no qH4 hr prn
-Benadryl 25mgpo'q 4 hr prn .

-Surfak 240mg po bid prn ii
Other Meds:.immommilf

9_, .
Tbtivcpc,tc.4,1-1 1 9-0 0-7 (J
12.

Call Ortho tech for casts, splints, traction

13.

equipment or cast bivalving .

.

X-rays: 011/41

14. (1-1"417 C;D) Po-c_t_AL
units PRBC if HCT less than

Transfuse.

units
Type and Screen for.

15. Type and Hold for .

' units

bX6)-2
b)(6)-2
---/ al il+;D ll afiLv_ekcide
...A.-L.7
PArIENT'S IDENTIFICATION

6)(6)-4
if(65 iS0
d
b)(6.)-2
ftr (?,?1(
MEDCOM -5279 C
DOD 12491

DATE AND TIME START STOP Rx DOCTOR' BORDERS (ORTHOPEDICS ADMIT/POST .../P) (Sign all orders) Doctor's Signature Nurse's Signature
• t ,_. Pin care - % strength H202 q 8 hr to all exposed
• 3_ L15 gins :­, "DressingDressing changes
¦..
Traction - pin care to exposed pins

•

bx6)-2
Misc:
-'---

afat.-c--) C6)L E.Lslii,a6 ,:) 6,-,_a_
19.

..
•

it 5)-2
If N / V changes occur, call Charge Nurse / Ward

i

20. Medical Officer to assess and bivalve cast if

I present
1 If UOP 30 cc/hr, bolus 500 cc NS and assess

.

Call Ward Medical Officer if no
[ - ' improvement.

21:7 . results...

'
i'• Oxygen:

22.

Physical Therapy:.r
23.

I ,
I=X6N

4.

,

lw NI
\..).

Ifi 1511.

1 SCO

A

(b)(6)-2
(PErsicIAN-stsasuRE) ''y
iC 63 en^
op_15
PATIENT'S IDENTIFICATION
(b)(6)-4
MEDCOM - 5280
.-•
DOD 12492

506-U1
DOCTOR'S OF,,--RSMEDICAL RECORD I
'1(Sign all orders)
DATE AND TIME
DOCTOR'S. NURSE'S

RX DRUG•RDERS
START I STOP '

SIGNATURE.SIGNATURE
ANES I HES1A PACU ORDERS
I I

b)(6)-2
IP'
mit to
Allergies:
Vital signs per PACU Protocol.

b)(6)-2
4. 1 02: FM Ca; 10LYM, % Blowby,NI NP (a ,) / t- -LPM.:
•'' -L.
/
Ij¦-•••• -
.
IVF: at _____/:Th( )Whr
1 —
-N On ward: 02 @ 2-3 LPM via NC: .
YES 1\10)
/ k.Pain medication:
,.....1.)r I
Ketorolac mg IV xl dose (adults 30 mg max; peds Isider 0.2-01 mg/kg).1 ._._. MSO4 1=-." R mg IV q--(LyIlin pm; max dose Z)mg _G...1 i
Fentanyl 025ncg IV q ._.5 min pm; max dose /1,0 mcg i e;
A .
b)(6)-2
Percocet tabe( p.o. with sip of water
I
e /_,....2, „ me -1-0Aagdvu-i-toil .4
Other: P it , orA, .. , ' a.4.'-- '.I Ver 11
8. Antiemetics: 0Ondansetron Li 1mg IVP, may repeat x 1 in 15 min (0 . 1 mg/kg: max 4 mg) ',
" Metoclopramide It) mg IV xl (0.15 mg/kgmax 11) mg)
a'. 1 II • • -• • . -..„. ...• •
• e . -! . .„. .
1141-r.available before administration.
Mi
Other _
9. Clear liquids as tolerated: 411/0 NO
4111) Notify Anesthesia (pager (b)(3)-1 ;Dr airway issue , pain, nausea/vomiti 1 :. not responsive to above orders or other patient piloblems/concerns per PACU protocol.
40
vi 3/2002) (OVER)
(Continue on reverse side] (b)(6) 2
PATIENT'S !DENT! !CATION (For type1written entries give: Name-lest. first. REGISTER NO.
nnielriln• morin •1r,In• hernia I 'It
(b)(6)-4
DOCTOR'
1:77.7,17-CTWAT
Medical Record
STANDARD CORM 508 I Rev. 3-04)
Prescribed by GSA ICMR FIRMR 141 OFR} 201-9.202-1

MEDCOM - 5281
DOD 12493

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orders) DATE AND TIME.1 DOCTOR'S NURSES
OPUG ORDERS
START.STOP.RX SIGNATURE SIGNATURE
fix 1 I
AIN ES 1 HES1A I'M- U * 9 I .
Alibl¦.
llischarge patient om PACU per protoco : Wile 0
I
1-2:- when ep urairspinal patipnts meet discharge criteria per PACU protodol, discharge to ward. On war • bedrest pending ttill recovery of sensory and /
1 c
1 I
.•• motor tUridtion;)rgress to ambulation with ass stance.
1
SR PACU KEEP FA 1)1EINTS ONLY'
1
-
13. Release patient from anesthesia care to KEEP st tus when patient meet sianesthesia discharge criteria: YES NO •
.
14. Notify anesthesia (1506) for airway management and: (circle if applicable)
a.
Pain management

b.
Fluid management

. .
I C. Other
.
i
15. ! TOW patient to ward in a.m. if patient meets disbharge criteria:
i YES NO
,•
(b)(6)-2
¦..
; ! Signature Beeper
(b)(6)-2 b)(6)-2
LCDR/USH
am i rmi

1
,
ir WM
WArArro—A"A
..'
1' "
STANDARD FORM 5O (Rev 3-941 BACK
MEDCOM - 5282
DOD 12494
DOCTOR'S ORDERS
MEDICAL RECORD (Sign all atlas)

DATE AND TIME
DOCTR'S
DRUG ORDERS SIGNATURE

SIGNATURE
FOC
START STOP

(b)(6)-2
(o al(
6
1 535
..-lJ L c t__ J3C M 51,1 -_______-
1-•
..
\
-\\\
.\\\
\\*.\
\\*\
. \\N
-•
•—
. , .
fContrrrue on reverse it e
REGISTER NO.. WARD NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first,
middle; grade; tank; rate; hospital or medical facility)
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (45 CFR) 201-45-505 500-112
MEDCOM - 5283
nnn 124AS
DOCTOR'S ORDERSMEDICAL RECORD
(Sign all orders)
DATE AND TIME
DOCTOR'S IjNURSE'S RX SIGNATURE SIGNATURE
DRUG ORDERSj I
START STOP
. 1 4-Lin, 3 (b)(6)-2 (b)(6)-2
5 (s-o1(cap QAmb 1
1V.o Dr . -I '''s 0),(6).2
f CZ (1. ?,54—kv--tAs— IliP
(b)(6)-2

¦pA--4:tud5) ifi8 .ra--Lte--
-.._
--(b)(6)-2
. 3 A 2_
G1 l 15. (P Wce.1
C._46 e_cleift5 -16 itif ff,

j
144 LeiA/ A r'-i? `2-----...-----
c(e.i.4 t-?
D.Aszc4 7- 6,
eA,--(,,-,14-g Dik.e.g.( -14 fr*CLIZA
b)(6)-2
b)(6)-2
p(
cev 4
i(b)(6)-2
(b) 6)-2
AL1 ‹._
E../ (b)(6)-2 -------------
.)‘. /k rg
CO51-)Caf2 .ti C-5110.-00 ., /10-- 1- 2G
i
(b)(6)-2 /X/ VI-XL 1,e3in.-a/ 0
. (b)(6)-2
. in`h---v-,
N( c3 e -,--9,Li°1cA,,,,,i--- 00---"-; Q-eL1
"e) /
03 6
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, I REGISTER NO. WED NO.
middle; grade; rank; rate; hospital or medical facility) 3 1)
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev.10-75) Prescribed by GSA and ICMR FIRMR (41 CFR1201-45-505 50B-112
M EDCOM - 5284
DOD 12496
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
START STOP RX DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE

;13)(6)-2 b)(6)-2
b)(6)-2
o$ 7—S-C01/NCI
6 /.,fel
(b)(6)-2 (b)(6)-2
Wir-4-C-0-54411
6)-2
lq's°
1 4P /oo e 44_4 irip
.1
b)(6)-2
b)(6)-2 b)(6)-2
(2/00'403 /P50
b)(6)-2
b)(6)-2
0 20
"rife) / 5
b)(6)-2
3 05
b)(6)-2
(Continue on reretue side)
PAT NT's IDENT (CATION (For typed or written era CSC, b)(6)-2 WARD NO.
/,
middle; grade; rank; rate; a ay)
b)(6)-2
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-5D5
505-112
MEDCOM - 5285
DOD 12497
.

DOCTOR'S ORDERS (ORTHOPED MIT/POST OP)

MEDICAL RECORD

•.1. (Sign all ordc
j
1„.
DATE AND TIME DOCTOR'S NURSE'S
DRUG ORDERS
STARTjSTOP SIGNATURE 017491111mp____
b)(6)2
aA.Ar O. IADMIT TO: ORTHO STAFF:
1.
1X6)-
2. DX : .5h:3 /

A/ /2­
,b)(6)-2 ( . — .b)(6)-2
3. CONDITION: STABLE

1-1
4. ALLERGIES:

VITAL SIGNS: Q1 hr X 4 THRU Q 4 hr X 24 .hr.THEN

,

0 8 hr

NURSING:

-N/V CHECKS W/ VITALS

-I & O's q 8 hr x 48 hrs

-Foley to gravity Cremeve-6--A-41-,-en .

-drain- -to—se-11 —suction_

-Remove wound dressing and replace w/ sterile

dressing on POD #2
Diet: Clears, advance as tolerated

Activity;
• (t):c'F

'6X6)-2
•
9 LABS:.

CHEM 7, CBC in AM: CBC q AM POD # 2 & #3 .

10. IV: D5LR@lOOcc/hr .LI MEDS:
-Ancef lg IV q'S hr x 48 hr =,„.
Gentamicin 80 mg IV q 8 hr x 48 hr OP-

-

-Lovenox 30mg SQ BID

11. - MSO4.
mg IM or IV q 4#r prn pain significant
-Phenergan 25 mg IM or IV;ci 4 hr prn .

-Percocet 1 -2 tabs po q 3 hr prn pain moderate,
-Tylenol 650 mg po q 4 hr prn ,.

- MOM 30cc po q 4 hr prn

-Benadryl 25mg!po'q 4 hr prn. .

Surfak 240mg po bid prn
Other Meds:

12.

Call Ortho tech for casts, splints, traction

13.

equipment or cast bivalving
X-rays:

14. -11-^) L,t1-7
Transfuse ' units PRB1C if HCT less than
15. Type and Hold for.

units
Type and Screen for.

units

b)(6)-2
aq-eade. (414 [o)
ZS)
ATCbntinue on reveragZalittil)j
PATIENT'S IDENTIFICATION

,bX6)-4
N(6)-4
MEDCOM - 5286
DOD 12498

.p0)-2
DATE AND TINE Doctor' Nurs
DOCTOR. ,RDERS (ORTHOPEDICS ADMIT/POS'.. /.
¦.START STOP (sign all orders). Signature Signa. .
Pin care - % strength H202 q e hr to all exposed
pins_

'

'.Dressing changes

Traction -pin care to exposed pins

Mis c:
19.

If R / V.changes.occur, call Charge Nurse / Ward

20.
Medical Officer to assess and bivalve cast if
.

.present lf tRIP,130 cc/hr, bolUs 500 cc NS and assess b)(6)-2
21.
results.' Call Ward Medical Officer if no
improvement.
Oxygen:

Physical Therapy:

(b)(6)-2 qiu )03-. 24 50 ,b)(6)-2 ( PHY SI CI (b)(6)-2
PATIENT' S IDENTIFICATION
(b)(6)-4

MEDCOM - 5287
DOD 12499

DOCTOR'S OR 3

EDICAL RECORD 1
(Sign all order
DATE AND TIME
DOCTORS NURSE'S
/. DRUG ORDERS
SIGNATURE SIGNATURE
START I STOP
ANESTHESIA YALU ORDERS
Admit to PACU.
tilICI pv3; it 1---. u r
1
LA , til 0 3
Vital signs per PACU protocol. . , 02: 'fM (allOLPM, % Blowby, NP ()ALPM.; IVF: LS,-at \--7.--u cc/ r
b)(6)-2
On ward: 02 @ 2-3 LPM via NC: YES WO
Pain medication: 1.-.
i •
1 .....
7:7
Ketorolac mg IV xl dose (adults 30 mg max; iieds cinsider 0.2-0.4 mg/kg) a-- -t--I
C MSO) '2- ' 5 mg IV q -5 min pm; max dose1-7--0—mg %
I 490 mcg r)(6)-2
Fentanylc"a mcg IV q57-0 min pm; Max dclse
/
b)(6)-2
Percocet / - ,_tab(s) p.o. with sip of water ilkiP 7/ 2, Other: Antiemetics: \ Ondansetro• •jmg IVP, may repeat xi in 15 min (0:1 mg/kg; max 4 mg)
..2,..... .. etoclosr, " 0 mg IV xl (0. IS mg/kg; max I D mg) Droperidol mg IV x I dos,- (4).°1 mg/kg; --t-in 011ili in-;,) r`1,-- t h.r'c 6.1e1;%. E C available before administration.
• Other
b)(6)-2
--,.I
1 Clear liquids as tolerated: E NO , • 1 . Notify AnesthesiE (b)(3)-1 i for airway issuel, pain, nausea/vomiti I not responsive to above orders or other patient piloblems/concerns
b)(6)-2
I
rn
per PACU protocol. i 0
,
b)(6)-2
(rev; 3/2002) (OVER)
'b)(6)-2
.A1
./MIIIA. ANL—
9ATIENT'S I DENTIFItATIO , (For typed or written entr as give: RE ST.NO. ARD NO. mieifilm• nrmrita• rank -rale1hospital .. , .__
(b)(6)-4
DOCTOR'S ORDERS Medical Record
STA)404RO FORM 508 !Rev.
(b)(6)-4
Presc:18ed Cy )354-1CAIR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 5288
DOD 12500

DOCTOR'S ORDERS MEDICAL RECORD . (Sign all orders)
• DOCTOR'S NURSE'S
DATE AND TIME I
RX 1 DRUG ORDERS
SIGNATURE SIGNATURE
START , S • ID
II 11.
siI ` IjI
( 0 INN&

•
isc arge pa ien rom per protoco : • • • en epi•ura spina patients me -isc arge criteria per protolo ,

•
isc arge to war.. •1 are :-- e • rest pen• ing u recovery o sensor . d

b)(6)-2
motor _tpetion; progress to am •u ation wit ass stance. FOR PACU KEEP PATIENTS ONL IIIIMIE.„
13. I Release patient from anesth -' are to KEEP st tus when patient meet
anesthesia disc e criteria: YES NO (b)(3)-1
i 14. I Notif esthesia for airway management and: (circle Ie applicable)
a. Pain management
b)(6)-2
b.
Fluid management /

c.
Other 1

15. TOW pat' t to ward in a.m. if patient meets d sbharge criteria: i Y NO
b)(6)-2
S ignatu . Beeper
!
b)(6)-2 b)(6)-2
;,,,,-
/-/-(/-0 3 0 / , -.o. 0 ic Nan
-.-
ffitti
IIMPA A I3)(6)
.Yr.,,.yen.S1 ..
/S
I b)(6)-2
-Ca
_z

b)(6)-2
(b)(6)-2
At
))(6)"
b)(6)-2
S
b)(b)-

14ce%-.
eAm lift-) 4- .
STANDARD FOSR1 505 IRttv. 3-9 41 3,
MEDCOM - 5289
DOD 12501

MEDICAL RECORD DATE AND TIME DOCTOR'S ORDERS (Sign all tiers)
START STOP RX DRUGORDERS SIGNATURE. NURSES SIGNATURE
(b)(6)-2

14(AT TA).
oa-
0 c--10 vt,t IU 46947ect—:
71A4A
fi6t, it ;4-t) /IAA-
b)(6)-2
Aocif i.t/ vk 0.Jrz,tra:t.,
644 (e, c0 II
12's b 11Air
(4.Ceo L/P7ho'7:
(b)(6)-2
(b)(6)-2
24 50
Itolos )(6)-2
-
/upo
OtreCPC_, fr1))4-644--4))6/ /5)0 zio
b)(6)-2
IVA-401 /Lt.
( )P-2
se
PATIENT'S IDENTIFICATION (For typed or written enn ast, t, WARD NO. middle; grade; rank; rate; hospital or medical facility)
(b)(6)-4
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75)
Prescribed by GSA aid ICMR FIRMR (41 CFR) 201-45-505 508-112
MEDCOM - 5290
DOD 12502

NAVMED 6550/B (RE V.4-74) S/N 01l. .16-5581 MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
I
„ter.2491 DATES
SCHEDULED DRUGS MO THjedi GIVEN
MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION
HOURS
/3
IWUMWINE:
b)(6)-2
--¦-¦amumml
•
INITIAL bX6)-2 b)(5)-2 FULL SIGNATURE & TM.E INITIAL INITIAL CODE FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
. •'
ADDRESSOGRAPH PLATE bX6)-4 IjWARD NO. Injection SteNe Code 0 = Left Buttockj® = Left Leo C) = Right Buttock 0 . Right Leg jSNGLE DOSE, C) = Left DeltoidjC) = Left AnnjPRE-CP PRN C)jRight Deltoid(DjRight Annj& VARIABLE DOSE CftDERS 0 = Abdomen SEE REVERSE

MEDCOM - 5291
DOD 12503

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-2165581
SNGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION-DOSAGE GNEN
ROUTE CF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

MEDICATION-DOSAGE
FREQUENCY
ROUTE OF ADMINISTRATION

ORDER
DATE --TA 4, Lisbiz.
Li-t )1. DATE
TIME
P jR4° P
DOSE INIT.
4 t 0, ropm, 3kA__ po DATE
TIME DOSE INIT.
6? 4-° peiJ
) 4 I ,„,,,,
, DATE
41 11
' 1,. , iii TI
T a
DOS:
INIT.
----(
it ( 1 ( 1.44 elk 2401146 DATE
1 ‘
TIME
P D 11 D 0
DOSE INIT.
4/ IS ae teva-D avi 04---00,6DATE I) 0 (06 . T RA) TIME DOSE INIT. DATE TIME DOSE INIT. DATE TIME DOSE INIT.
PRN AND VARIABLE DOSE MEDICATIONS
DOSES GIVEN
4 7.0
3c0
b)(6)-2 11 •
....------.....
I , I ¦ ./...
• )(6)-2
qk
614 xiD
b)(6)-2
\----"
4-7
MEDCOM - 5292
DOD 12504

NAVMED 6550/8 (REV. 4-74)S/N 01t, 216-5581
MEDICAL RECORD M E D ICATI 0 N ADMINISTRATION RECORD
SCHEDULED DRUGS MONT ' . al— 01063jWEE:

MEDICATION- DOSAGE- FREQUENCYORDER
ma it INEMI
HOURSROUTE OF ADMINISTRATIO N. ATE
l DTMGIMI I
ir LAMMrilCO M
0.e.
(19 CO MI03 egiriPM
nor mod

i. I 1IUAS'Ill iniliMPSIIIIPM.bX6¦_,%man1011irl %,¦.
IMIERIMMrMERMIIII* i CO MIMI MINIM
WIAdRIMINWAIMIlltillUirIMIZIKSIW----PAIMPaar
gatintk..-‘. Ij::. \)1):' 1,1 • oo VarilleffilMHIMI
hx6)_2
FA a aifir al
1 1 IT Ki rim
MEW.:

¦P m, ,,,A. b),„- -- -i 0 inivri/
ll Fr._,AmaracaI,60 101KA b)(6Y2b)(6)-2ilIMBIWIMMIIII
I1
t:) i • ...,L 0 , 4 a co 5112111M bX6)-2 jp21 ...),
MI' NW.. im
2• =FMINIMIIIMINIIMIIM
EI ..Ft:'... .__,v.., ---ts a & et...AMIREIMIMINIIIIMILIMIr
Aummamirmormimsseit
simmutesnemr­
, , ;mum wargirp
b)(6}2
....

120 Com ( s?t541:€ _MIII.1 MIMI
mmiimmloym____„..a,
t)(6}2
1 /1 Cle.pkr_ -r-(Do.ik 0 9 6-0
bX6)-2
( 3 YKD ht\ '3 o grc. 2 1 ID 10-0
a I ri)
INITIAL CODE
INITIAL jZ.SiGNATUIC1T111 INITIAL FULL SIGNATURE &TITLE INITIAL FULL SIGNATURE & TITLE
:b)(6)­2.'r D)(6}2 b)(6)-2 b)(6)-2 b)(6)-2 b)(6)-2
V b)(6)-2 )(6)-2 b)(6)-2 b X6)-2

ADDRESSOGRAPH PLATE WARD NO
Injection Site Code
0 = Left Buttock ® = Left Leg
b)(6)-4
(7)= Right Buttock 0 = Mont LegjSINGLE DOSE, PRE- OP PRN
® Left Deltoid C) = Left Arm & VAFRABLE
® Right Deltoid C) Right ArmjDOSE ORDERS
0 = Abdomenj SE REVEFLSE
MEDCOM - 5293
DOD 12505

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGEj GIVEN MEDICATION.. DOSAGE GIVEN
ROUTE OF ADMINISTRATIONj ith9 DATE 11101,1 A. I!b)(6)-2 ROUTE OF ADMINISTRATION DATE TIME INITIAL
_DLL 4.0.LA fig

PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGE
ORDER j DOSES GIVEN
FREQUENCY
DATE
ROUTE OF ADMINISTRATION
DATE

4 ) rflEx iii„kt5-ionts I VD 2(!I 'fill VII
TIME
1 6 AO., 2o,A,
(b)(6)-2
INIT.
V
1I T GQ*3 autto DATE 6)40 Piu)
TIME
DOSE

b)(6)-2
INIT.
DATE
TIME
DOSE
INIT.

. it
PATE
if taii.vvu El+-sl2 VI 113
TIME
Tip P^ en, Ise
DOSE
r
b)(6)-2
INIT.
VASEMILTIEMEIVEI
2.140 010 Imo
INSIMENTINITIMI
I
sS110/1!!!!Itilffil!Migr' 6
INIT. b)(6)-2
DATE
i-f(u 'Plotopi*us-m r
TIME
&ft, im.nok-nir
DOSE
INIT.
DATE

4(1( pa.acd.
TIME til
6230 PerJ 660 43/b ke0
DOSE
INIT.
II.II II
MEDCOM - 5294
DOD 12506

MEDICATIONADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION-DOSAGE •GIVENj II MEDICATION-DOSAGE GIVEN
ROUTE CV ADMINISTRATION DATE TIME INITIAL.II ROUTE OF ADMINISTRATION DATE TIME INITIAL

PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE MEDICATION-DOSAGE FREQUENCY ROUTE OF ADMINISTRATION DOSES GIVEN
L5kik 2-WIIF-NVPR1/4-4 L. m45 ....c...42. Mc.cri DATE TIME
C".0 irn c..P SZ.N. DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
•
INIT.
DATE
TIME
DOSE
INIT.
MEDCOM - 5295

DOD 12507

NAVM ED 6550/8 (REV. 4-74)51N.01%. [16-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES
ORDER DATE MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION HOURS • .sr . 411RA
RM._ al.ti.M le.¦ :19. 'b !IfilMil ol¦ IIMP,
'VI% rfflilkSAIPII¦11111111111jV? Vli *WORM \ OA) b)(6)-2 N..1j ffi.Wal.6.4 A.siPli¦ b)(6)-2 so XI! 4. --a910 b)(6)-2 • 1 ll WI . C
7/ 'IL .orP,s_gnffitilMil¦ kik -MI , ,mgivile IINRIPR.i.../w/Ell. Ft k/9 / YOU i A2C90 b)(6)-2

INITIAL CODE
INITIAL FULL SIGNATURE & TITLE 1111.__.„.. (FUL/SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
(b)(6)-2 (b)(6)-2

„.......\.v.1 ,„

.j.-
ADDRESSOGRAPHPLATE Injection Site Codej l.WARD NO.
b)(6) -4 C) -LeR Buttockj0j= Left Leg
. C)j= Right Buttock.C).= Right LegjSPIGLE DOSE, PRE- OP PRN
-a.vn uonvm.v -won ..gym
&VARIABLE
= Right Deltoid.C) = Right Arm
DOSE ORDERS 0 = Abdomen SEE REVERSE
MEDCOM -5296
DOD 12508

MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SECLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE CF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGE FREQUENCYj• DOSES GIVEN
ORDER
DATE
ROUTE OF ADMINISTRATION -V \ \ \mt .1k or.., c....A.AG DATE .4;13 X \\ie "1-1t.PS), TIME 1.‘: a92J'i" c-C-1?'¦ OtGN-TfN-ri 0 6 DOSE .V4 5-1.-,4A
bX6)-2
INIT.
....\A\ ".IP:Ali, . .,j• ". DATE ...1\1 \ ..)I l.S...1 I (2) . . 0 v v TIME
El t el* ,C,\AC"; OM
JjW.j• -
DOSE. kCV.1. ior'. (ot-4^ 1, -
?NM cb\rItc\cc-akIN
'b)(6}2 b)(6)-2
INIT. --V \ \ cArrepi,-- c2(...5..1/4.c, DATE 1 t...k) Nj0bl...A c. 9v.....1..::1/2 TIME DOSE INIT. .41/ \ \ PEP-Cr—c_.e-T. 1-,,a-ippc DATE 115 ,...\\5y,1 TIME ) ..$ \e/cl-f' 0..2,0
R.-) c.• PRI.)
eFewsjts..),A—..-14... DOSE g ;2

O.
bX6)-2
INIT.
-rLik.,00.1.(cfr nt„„tc.‘ DATE
\/ ` k
Pr') Cg(.4 * PR t¦\ TIME
DOSE
INIT.
.

`‘•-•\ ) \ \ poi—ICI-1 ••(*h c. c-DATE all
.
TIME `0
P() C-. .),'' Pe.1
DOSE ¦
b)(6)-2
INIT. LAil \ F-A.RFPX... D\-10 .4, '-\\\a'
DATE
VC) C1-]Kr) cl?-3%

TIME ...64)C''' DOSE 2..)y'
(b)(6)-2
MIT.
MEDCOM - 5297
DOD 12509

NAVMED 6550/8 (REV. 4-74)SIN 0105 .;-5581
M EDICAL RECORD MEDICATION ADMINISTRATION RECORD
SCHEDULED DRUGS MONTHj 49-j DATES GIVEN

MEDICATION-DOSAGE- FREQUENCY
ORDER
HOURS
ROUTE OF ADMINISTRATION
nATE
I
INITIAL CODE
INITIAL FUU SIGNATURE& TITLE INITIAL FULL SIGNATURE& TITLE INITIAL FULL SIGNATURE & TITLE
;b)(6)-2 :b)(6)-2
. .'
ADDRESSOGRAPHPLATE WARD NO.
Infection Site Code
(b)(6)-4 C) = Left Buttock C) = Left Leg
C)jRight Buttockj© = Right Leg SFIGLE DOSE,
0 = Left DeltoidjC) = Left Arm PRE- OP PRN
C) = Right DeltoidjC) = Right Arm &VARIABLE DOSE ORDERS
0 = Abdomen SEE REVERSE
MEDCOM - 5298

DOD 12510

MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGEORDER
DOSES GIVEN DATE
FREQUENCY
ROUTE OF ADMINISTRATION
c

iv p , ht.
1-1 /it jedrum 5-.DATE
TIME 1445. DOSE g.
-no prek
et(1: f eh(bleU
b)(6)-2
INIT.
DATE TIME DOSE INIT.
DATE TIME DOSE INIT.
DATE TIME DOSE INIT. DATE
TIME DOSE INIT. DATE TIME DOSE INIT. DATE TIME DOSE INIT.
MEDCOM - 5299
DOD 12511

NAVMED 655018 (REV. 4-74) SIN 010e-LF-218-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES
SCHEDULED DRUGS MONTH ILI ,9 Y.19 09105 GIVEN
MEDICATION-DOSAGE-FREOU ENCYORDER
HOURS
DATE ROUTE OF ADMINISTRATION I. Z
11 Z - I' a,j•O*1 al,.04.Mei kf -7
IREMCIIIIIIIIIIIIIIIRIIIIEMO Mina

1g5 • MRIPAL
f
-.
b
' f I
118 CI IMMEAMMOIREINITO IMMINIVA
LRINIMIIII1111111111111=1.le -.___IPIIMMI_ . chvektfo ,...6* Ir
2 AnliMIWillari o FM,
— lffil Il
1, •"
bX6)-2
Li /5" ArNMEIMIrill oti Co
imfannalli zibX6)-2
•
;
•K. bX6)-2
,
141 i 3
•
'11 I 3 C.,_b...._1r jPoj1r b

-....LOLIIMPIN.I.
Milb:::t Li
0 0 0
14 i #
•
ft„-W I, C -jSej4e
bX6)-2
LUZZ r10 -tl'-1.P'434.,. 5 PO 'T-10 (2s.
I, f
0
L.1 I i in,.Po 0
1i
.

•

7 0jPr oo
INITIAL CODE
INITIAL b)(6)-2 FULL SIGNATURE & TITLE 'bX6)-2 INITIAL FUL2.75),,NATURE & TITLE b)(6)-2e)(6)-2 ; b)(6}2 FULLMNATURE & TITLE b)(6)-2
:b)(6)-2 bX6}2 b)(6)-2 b)(6)-2
1'

ADDRESS GRAPH bX6)-4 PLATE Injection Site Code WARD NO.
CD = Left Buttock 0 = Left Leg
(g) = Right Buttock 0 = Right Leg
0 = Left Deltoid (4) = Right Deltoid (2) = Left Arm = Right Arm PRE-OP PRN &VARIABLE DOSE ORDERS

= Abdomen SEE REVERSE
MEDCOM - 5300
DOD 12512

MEDICATION ADMINISTRATION RECORD (Back) 0105-LF-216-5581
SINGLE ORDERS — PRE-OPERATIVE
MEDICATION-DOSAGE GIVEN MEDICATION-DOSAGE GIVEN
ROUTE OP ADMINISTRATION DATE TIMEjINITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
&'P 16/}111( 6617 6 el\e/i10/11 2cr/19r 51.3 _6(42.xec (4z5-&_cusirdi tt--,0 5-7zi bX6)-2 2115 b)(6)-2 &

PRN AND VARIABLE DOSE MEDICATIONS
ORDER NICIDICATKIN•DOSAGE DATE ROUTC OP ADMINISTRATION DOSES GIVEN
_LI 1 14iPeruoc -els DATE iltillit1/1 ql.Li y, 57.1 5]•/ S.. 1, 511/., 11440 1613 H113 5/4
__ .j1 '. z..-TIN-9 S.PZ3 TIME 75b ' .\‘131 5‘ crev 6 di 2 61.01t0 4 (01‘64-c9tAlti (a3tIOVZ42"1 Di'75 0114
A
DOSEj2j 2. t. 2.. 1. /,.1.2
(ALJ c'.17.-1k-1 _.
bX6)-2
INIT.
DATE .

gimpAraraltimg,
eg rt.101-11"1-10
A V.Q-V-1° TIME 051/1 1036 153(1.1`33.•V 10 's LL: 11
DOSE jo-ym , st„,, ,,,,,,, c, 5 5. . bX6)-2 INIT.
•
,
_DATE 51-2I '0 .
enk C(.1---
-.s po TIME 0
2..
?
2.
e.' S.POJ DOSE
-
b)(6)-2 •
INIT.
. PATE. ,
TIME
DOSE
INIT.

.j
..j,j.•
.. DATE -. • TIME DOSE • 4 INIT. .
• -• DATE .
. TIME .
•
• • DOSE
INIT.
DATE
TIME
DOSE
INIT.

.U.S • CPO, 1986-605-009/46155

MEDCOM - 5301
DOD 12513

ALLERGIES:
TIM C DATE 1 LABORATORY/DIAGNOSTIC
DATE DATE
MEDICATIONS (HOURS TO OFjTESTS EXAMINATIONS/
ORD. KNEW SENT COltfir
BE GIVENI ORDERjCONSULTATIONS
Olt ID
0 / I • /t2s Al.11164, AL ) 4L..1114..*_¦¦ •1j 6 L 4- 2_
. 11E.Mrl_Welferall
'15131MINIM -. / Gid11MMMani ill P.
LI- 15-(3 Ah-42_ MO, PO 64-3 'tip
4'

A DD RESSOG RA PR
,b)(6)-4
MEDCOM - 5302
DOD 12514

PATIENT PROFILE
NAVMED 6550/12 (5-80) S/N 0105-LF-206-5560

f ; ACTIVITY DATE N./ BATH DATE DIET DATE ‘i VITAL. SIGNS FRED 4 SPECIAL NOTES
A Li.o ';',
fr./Bedrest Bed bath NPO Temp Dentures Bathroom Privileges Shower Pulse CA' 1-( Ilk) Speech impediment Up in chair 4, 1 Tub 1.1 AIII Resp h.4.131 L Language barrier
1 11,12
,.., 1,,
Ambulate Needs assistance (...) B/P r. 0 (4\12") device
Pro sthetic 0
C ommode Other Visual impairment Needs assistance r Blind Restricted to unit • Contact lenses Hospital Privileges ORAL HYGIENE DATE Glasses
NN 1/ V •&
Other Self FEEDING DATE FLUIDS Hearing defect

Needs assistance Self Forced to: Other
./CLVAA)017 St e Li Special Needs assistance Restricted to:
Gavage I & 0
CZ3x i-g •
DATE DATE DATE DATE
TREATMENTS/SPECIAL NOTES TIMES TREATMENTS/SPECIAL NOTES : TIMES
0(R D. RENEW ORD. RENEW
tE ) 0 /4-06 ftw. 12)0 D 1s bstv. ./00(k r
1 .... ),„7„
,1I1A1.,
.,1.1
kik...) td--1.1
I (0 -gtiv.;1.i, 4-, t._,64.... z;? to°-02 0t ,K,-2_0 I.r..,,,. ,,,--1.coi.,-.., ,-,_-
Cv-4-ELLLA',1 go iE) U6ki:b Th lANINA... t
kr

(11.iv c ,..1 isks.55 4vog icklt -...i.:7-spc:citty.1
•- ....1. • •¦•••
. 11 \ &7'.¦-i-t):30,6, ca. r-t—, 1..e1ivis f''''.4.."--

4 - r ¦)), /A) 6
N-= bU:).6 ')Lti (VI) /-4*--i I..1)."..t.:6(t-,,,#'
1

1 ).1 1(6.3(", IAA eij_tZ) Sbo ce., PJS
QAC A-!\

Acy:.,i..:.) LA/40 (7 .(.1 (I f , )01 0 if
1`.1 J
. „,,
0:4.1-ittiv irorjAireArtj.1TO T
r
....,,Q --t...---n r' g... -• ''' '
, ..r 6 L./1 r).—
0.1AGNosi . . AGE HEIGHT
AO OR ESSOGRAPH WEIGHT
..-PATIENT CLASSIFICATION caAAA.U.A. c)f•-c Ex)
..
. ....6
f It SIP& I IA NajiA:4 Tthi'w
pP/SPgCIAL PROCEITLI
DATE DATE if 14 SI to ) lik tiad,;Af.Pitiy-ce,14,44,v,
ON OFF
SI
FINDINGS: VSI
`,1'::**.-. •
,....1
A • IP;:•. ,„ RELIGIOUS RITES
MEDCOM - 5303
DOD 12515

ALLERGIES:
TIMEjDATEjLABORATORY/DIAGNOSTIC
DATE DATEj DATE DATE
MEDICATIONSj INCURS TOjor TESTS EXAMINATIONS/
ORD. RENEWj SENT COMP
BE GIVEN)jORDERjCONSULTATIONS
i-..
--.. —77,7;:zr..,..:.....--------7r.:-;-Flmm --m • a ---. EIMMIVILUMEMINIMPA
"VII 1-111 ME/ 11- 7`..1-1.-a,.11 jA 12) AilL11 11111
C13C cc. • 1 b.cl 1,1 anIIM111MKTPIIIM. cdc- 1 PO 1j
cogjEa.j. 7--' a-p, In
t3
I..be • .._ A 1 , 1.
MI.PT1wil
. InNAIEMMEEMMM1En1- Vali

'1Milrial. el •1
01uhetA' -1, 1et1
IEIIIIII[GI_MVL. .

IMEMIIIMELVMMIE ' '. _i IS
Ileir
4 t1 o au,L,„,i 4.6 (o) @ o a.VAPNI
MPIfflinta
..• (41' c,060.MIR",.111 ..______4212 -=1,---4 cs MUM"•.jCa- i -2.0 Mil WIMP ai-IT j'''' 'MI
WM LI j74*:--, -ju.
LI)j-j
146
.. L.....•'B1.PM In1214 Ajins
•.raMIVAIIj
4 b:z. of 12 00 „,_ ' • A
. = IM
k
f3.rriffillil 417_-J__ mmol3Z. -.
Ori Ilb P 0.u
ASO_ .._ '0 t WO Mil 4- ;... uniimmrismi e 4 h2__ MIINIEFIIEIIWTPMIIIIM 0 41 too
`­
13 • IF K 4-,-, L.. X 3 •.gwar-To MEI
4 'co
itk504 2-10nst\I ();--11 ° PA114 15R.N
A AjIj • ,b,ju 1,101-1) IF S ATt%)
,,j,-.- .-. , ii.•.WA/
4 iLl -61°Vkk. C'Si)1PO &V Pfd if fq -1-(u/not (psbou Po G Li 6 po
I A
41)4 If kert_el- 1-2-rtabo ?c, (V.` plao4 (1 ¢vtQ.im(/ 0..
d-1k-i 'PR_,,, q, )4 I lon i.
io rohokm
ADDRESSOGRAPH
b)(6) -4
MEDCOM - 5304
DOD 12516

PATIENT PROFILE
NAVMEO 6550112 (5-80) S/N 0105 -11 -206 -5560
ACTIVITY DATE BATH DATE DIET DATE VITAL SIGNS FRED SPECIAL NOTES
Bedrest Bed bath NPO Temp Dentures

:athrOOm Privileges Shower Pulse Speech Impediment in chair Language barrier
Emu Tub 1 lin 11=MI7DIEMII
a • _ Self FEEDING DATE FLUIDS Hearing defect
-
eeds assistance Self Forced to: Other
I 1 Special Needs assistance Gavage Restricted to: I & 0 (DS
DATE ORD, DATE RENEW TREATM TS/SPECIAL NOTES TIMES DATE 0 D. DATE RENEW TREATMENTS/SPECIAL NOTES TIMES
4D /1 3 i #X €A,,L..e., i;L7

rr,

Am late Needs assistance Prosthetic device Comm e Other Visual impairment Needs assi ance Blind Restricted to nit Contact lenses Ho pita! PrivIleg ORAL HYGIENE • ATE Glasses
1-4,
1\1 kJ ''//
fj....cAlve1.
,-
/.. P-1--fZ-bM PVL LE Col &A p35 4'
1.013 E.: ( aim 14.5 i, --TR I N
1...,
Lfh tO ‘,..11 , r. -.NT.
t.....)
witniii

now(
0 2._e ',.a MM.
b)(6)-2 ) -A
AGE
A DORESSOGRAPH
DIAGNOSIS
• --b)(6)-4 11. 1,-..tS OCI--kf PATIENT CLASS IC ATION
(9 OP/SPECIAL PROCEDURES DATE DATE
• ON OFF
47/1 V I tA N.\ ;..\t.. \ Ot 13-CC:tt'''' ). '..-SI
‘'N q't)C..) , \ .V ''')
FINDINGS: VSI
RELIGIOUS RITES MEDCOM -
53n5
DOD 12517

ALLERGIES:
I
TIME DATE LABORATORY/DIAGNOSTICDATE IFIDATE DATE DATE
MEDICATIONS (HOURS TO OF TESTS EXAMINATIONS/ORD. ENEW. SENT
COMP
BE GIVEN) ORDER CONSULTATIONS
Lib hk0 M 30 c.c. TO 'BID 09 - 2.1 1/1:::eild-? ,..1mrc.6 a 1._de,,,ey,„„ LOG SURFAK.r.AP P 0 CO.0900 ,a,t-kle.`Av.',LI, _-A Lqi 5 0 G. tAt_qTp ;LL 1
htags 61:t eL3L1LZ
-
`4 hci, 1.114-t¦MA 5 web P47 1 b se_Noz-z).OH- 14 -20 4 117-- 1.`600.PO -rib 06-11-ZZ 9 it-) At mp( 20rri5P 0.'D13'.).09 - 2.1
4/ 21 e.S(014 12.5 n,01) 1)0 Q 14y 090 0 4122 MV I t Trt8 PO Q A V1Olo 0 yira V14-1(.in 1 Sol XIII ay3 t b./01( lac,
PT "I rn4-to i e rt -eh,--.ASourn ..;(1/.a?c;i6
.
V.— t4 eXi/i .
l 2-!
Y1 Ikt- (00ryt. c4.1r)A/2.
t
•
..,
411c.6
WO 4 2-10 frf,01 Q 1 - q °.PRN 4 1 1 ',I 11E11TV:312N I.15- 50 re% l'O.Q b° PR N 4 114 -1\11..g0 L (0 0,4 0 0 u° ...TR N
4 liu -PEP-scoter t -ii-raS PO (Ve ?SW 4114 TIAE_NERGA si DS rof.L6 11011Vj021 °jPRO
ADORESSOGRAPH
;b)(6)-4
MEDCOM -5306
DOD 12518
PATIENT PROFILE
NAVMED 6550/12 (540) S/N 0105-LF-206-S560
ACTIVITY DATE VjOATH DATE DIET DATE */ VITAL SIGNS FRED si SPECIAL NOTES
Bedrest Bed both NPO Temp Dentures Bathroom Privileges Shower 41114 Pulse 3 .3 Speech impediment
RE.. G
'..4 Up i.chalr 4i(I4 Tub Rasp Language barrier Ambulate Needs assistance B/P Proithetle device Commode Other ti tv Visual Impairment
•its Needs assistance 11h4 Blind

Restricted to unit Contact lenses Hospital Privileges ORAL HYGIENE DATE D l .
Other Self FEEDING DATE FLUIDS Hearing d fact Needs assistance Self Forced to Other
x1•40)3 3et. 4114
Special Needs assistance Restricted to: Gevags I & 0
45
D ATA DATE DATE DATE
jNESTS/SPECIAL NOTES TIMES TREATMENTS/SPECIAL NOTES TIM ESORD. RENEW ORD. RENEW
4
W-4 b in.EsstaCT -r0
tistto% 1- CALM E-S .
-

4 R•.2.11...LE
0 Rigo -1)R. :13)(6)-2
ADDRESSOGRAPH bIAGNOSIS AGE HEIGHT WEIGHT
. (t1 YE.PAORfN L F X
PATIENT CLASSIFICATION
(b)(6) -4 6'TM -FIB FX
OP/SPECIAL PROCEDURES DATE DATE
51P NimuNG 01 TF-INUK ON OFF
MA ROD -nsIA )42- SI
FINDINGS.
VEI
RELIGIOUS
MEDCOM - 5307 RITES

DOD 12519

NAVMED 6550/8 (REV. 9-74) SIN 0.•216-5581
MEDICALRECORD MEDICATION ADMINISTRATION RECCRD A DATES
SCHEDULED DRUGS MONTH 11A( -4,9""°202) GIV N
MEDICATION- DOSAGE- FREQUENCY
0 DER
HOURS
ROUTE OF ADMINISTRATION
NiVAVAIME GgrfAl
ATE rrimm b)("2
b)(6)-2
b)(6)-2
b)(6)-2
.7 a S766 • -)0 .jMr1111
i‘The 7:2no
yh^ A Ce...x 2 0,19 Po C4160
7, I 00
2_1 r1o -0.s-5 Oq GO)

INITIAL CODE
INMAL FULL SIGNATURE & TITLE INITIAL FULL 'SIGNATURE &TTTLE INITIAL FULL SIGNATURE & 1TTLE
I
:b)(6)-2 b)(6)-2 b)(6)-2
b)(6)-2 b)(6)-2 ,b 6)-
b)(6)-2
ADDRESSOGRAPHPLATE WARD NO.
injection SiteCode
:bX6)-4
0 = Left Buttock..j0jLeft Leg
02 o Right Buttock, 0 = Right Leg SPIGLE DOSE. PRE- OP PRN
(a'=....._Left Deltoid j0 = Left Arm & VARIABLE
0 = Right DeltoidjRight Arm
Cj
DOSE ORDERS 0 = Abdomen SEE REVERSE
MEDCOM - 5308
DOD 12520

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION-,thsAGE GIVEN ROUTE OF ADMINISTRATION ROUTE OF ADMINISTRATION
DATE TIME INITIAL DATE TIME INITIAL
I •
•
ORDER DATE 1/1 MEDICATION-DOSAGE FREQUENCYROUTE OF ADMINISTRATION '?P /- Z ,t,,..7,0 e• 1 ° 7°A A).7 A I A) DATE TIME DOSE INIT. L PRN AND VARIABLE DOSE MEDICATIONS DOSES GIVEN IMMIITEVIIIIMIZEMITIEFEEMPEPARTZ q IffMEErilIMOMMEMINirS118=El 0 1,-11021AMIBM 1, Fs t in -7, ,i, ,)-- 7 2 b)(6)-2
/11 NtnAr:5 0,1 1\l/ 7-71-11?). Lt°A'1"Z. Ni DATE TI ME DOSE INIT. •
17//CI Ty /e.t, 0 1 2-0 f,,,, ' - P r)1a9 0 7qZ/\) DATE TIME DOSE INIT. 40.5 0,1 Ili tEll' j4T°12‘ IP (05-70 a (b)(6)-2
9//q 120 Li CO /1161471.-?0,c, rj7,0 (/ el1.p-k A) pile, dry i ZS' 1'7910 ' Rk) Al eo L./1z... 1 0 A c, :7:­.:v.al -LI ° ") ...rh,N).?/:1 i N Nal d ; C serial-eii DATE TIME DOSE INIT. DATE TIME DOSE INIT. DATE TIME DOSE INIT. DATE Ifil.5 Aq24. ' 11i$ 2-3{6 . 2,3 2 ...) 6)(6)-2 IP M2\ :Or 4tk Alt kV% qh15 42A-04 0)."161 VO 104). iv) 0 fo4 ooter)32-I 0 nt4 5 5 ? (b)(6)-2 ..)ktotii\ A 9`k 6-1-1 VI 74 413) 0 4 fT4 509 z3nr
TIME
DOSE
INIT.
MEDCOM - 5309

DOD 12521

NAVMED 6550/8 (REV. 4-74)SIN .--216-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD j DATES
SCHEDULED DRUGS MONTH APR) L t432.._00 3 GIVEN
MEDICATION-DOSAGE-FREQUENCY
ORDER
(IP
ROUTE OF ADMINISTRATION
ATE 22.
\iktibiA 5frrviPO "Tib
1.1OLD IF' SEDATE D
(b)(6)-2 412-1-• NVITAIN %Mfr....16,M 11 D Oh og '-''-...¦-
b)(6)-2
)
11 040 . 2100
14122— !X.-W.0( 2Orry.c0bjBin oc)00 - -4....
-...„4 b)(6)-2
.....›.... amim„..
4 2-1--NI I " --IN• ;.. PO ik D') 00 411.¦ MR.% k 422— F • • ...•jcP• lb . " • 9tro I -'11111-4* 111'" . I--g-9j
e.to - -ji0 . 1... ,a) X e.j¦ .
rice;
I NMAL CODE
INITIAL FULL SIGNATURE & Trfft INITIAL FULL SIGNATURE & TITLE INITIAL Fyly9GNATURElli TITLE
b)(6)-2 b)(6)-2 b)(6)-2 (b)(6)-2 ( )(6)-2 (b)(6)-2
l (b)(6)-2 / •oe
ail
momme...--
II
nIb76)p­Tno.POPI-1 PI ATF Injection Site Code IjWARD NO.
Left Buttock 0 Leh Leg
Right Buttockj0 = Right Leg SINGLE DOSE.
Left DeltoidjC) = left Arm PRE- OP PRN
Right Deltoidj0 = Right Arm &VARIABLE DOSE ORDERS
0 = Abdomen SEE REVERSE
MEDCOM - 5310
DOD 12522

MEDICATION ADMINISTRATION RECORD (Back) 5/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
1
MEDICATION-DOSAGE GIVENjMEDICATION-DOSAGE GIVEN
I ROUTE a: ADMINISTRATION DATE THE ITIMA. ROUTE OF ADMINISTRATION. DATE TIME INITIAL
5 ; b :b)(6)-2 1j• NIT IC N'' K I VI 0 L4 b)(6)-2 i „„Iii =Va.— , A
.
Ifj- z. "I.A.MiiiIIIIIM imi o.-
PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGE
FREQUENCY DOSES GIVEN

ORDER
DATE ROUTE OF ADMINISTRATION .
miarwairmulitgoingrt
ff-f--,
tp311 3 r. d TIME di 14 plii ig 421,55 via.
DOSE "t.-
p c-,.. r ir -Tr--21
b)(6)-2
INIT.
21

71/I L( k kJ, ella 1
DATE
eff15 V rttl TIME

a ti_1p g
DOSE
INIT.

DATE
/) it -7-(e
ISL! i
p 0 TIME
3 4,„, 1
DOSE
INIT.

lilif (Ylon?
3ncn p 0 ir‘si DATE .
TIME I-io1
DOSE
1 II A– INIT. I
DATE

•jPi ,r3 e n c tp 1 rAL 25 nig.0 TIME / .,,2i Li A,..1,oRA/
DOSE
INIT.

I 1 1 01 661 It cO, -) Q,7) c
. DATE lible Ll
.

-r i)1a 3 -If A) TIME PIP T?
-lain PIN DOSE 16., id 6,,
r t C ij .1 f' ,5ettifdPNIT. :b)(6)-2

DATE
TIME
DOSE
INIT.

MEDCOM - 531 1
DOD 12523

NAVMED 6550/ (REV. 4-74) SN -216-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
teic0 sjGnEENS

DAT
SCHEDULED DRUGS MONTH
MEDICATION- DOSAGE- FREQUENCY
1
ORDER
ROUTE OF ADMINISTRATION HOURS 1
i 07-D z:z. -7... --3
DATE .
b)(6)-2 kb)(6)-2
a
fluyinedactt ­
4 amte4h0,,,,1901 16 t)t.p 60 —
b)(6)-2
JLt/i. dr_40 As
)(6)-2 -
_
MIN

lig [WM _4111111MMIMINIME • IMil
(b)(6)-2
4 17 IMINIgk.IIIMMIIIIRMIC4_
MICII
14.ri 111P1MiliTIMPLIMMINE1. _ ALI. ..
)(6)-'
aj¦ .1• _...
Emsjli
IMMI
IIE 0 a •.a 4 ' MARTMIM
,112111MINMIMMINIENNIM

11
MIMS=b)(6)-2 Elf‘: • .
Mb .
b)(6)- I 1
b
iltl-b
11 cob
4 Gm.
...
_.A

cum b)(6)-2
INITIAL CODE
INITIALjj.FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE (b)(6)-2 (b)(6)-2 (b)(6)-2 b)(6)-2 (b)(6)-2 (b)(6)-2
1/1"Al
b)(6)-2 (b)(6)-2 r—la
,b)(6)-2 ,b)(6)-2
ri_41 JL Ot741.'-'
b)(6)-2 (b)(6)-2
EMI ,
b)(6)-2
4
idkVIL (b)(6 ) -2 b)(6)-2
.ir 0
ADDRESSOGRAPH PLATEj I WARD NO.
Injection Site Code b)(6)-4
CT) .. Lett BUSIOCKj(1)j= Len Leg
®.= Right Buttockj0j= Right LegjSINGLE DOSE. PRE-OP PRN
0j= Left DeltoidjC)j= Left Amij& VARIABLE
0j= Right Deltoid 0.= Right Armj
C) = Abdomen SEE REVERSE
MEDCOM - 5312
DOD 12524

MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE

MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN ROUTE OF ADMINISTRATION DATE TIMEjINITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
.
ILL"ta ()
Valit ory, 10in d Vet 1, Prb-5-m catane) ei11r co Liax sitpf Pik
M.A4 REP EAT TO ri1o12.11_ov,1
PR. eJ
NitrK loo recIP/
Ain-K 1.0 70

ORDER DATE MEDICATION-DOSAGE FREQUENCY ROUTE OF ADMINISTRATION
4 14 idtcyvkg, 11,1,.)
cPS— akk kW
046 Tie0

11211111

IN ,... e.Wllito
R i
(r) ee4,1
ill 6.
gurvk
4 tp. orLA t-)6
4 111 M31111.1.1
31) .e. Po
mrgagroom

ORMUZ
HAMM
g
4 .6
IMMEPOPIN
MffirMINI
, ....li .
PRN AND VARIABLE DOSE MEDICATIONS
DOSES GIVEN
DATE
TIME
DOSE INIT.
DATE MEM fill IDESIMIMENIERVIIMEM ..2't--
TIME WAIIMOSO 012-EMU DS,1,,1a:: ;:_ IAA.
2,°:, . or = CeuX 7
Q 4.—p lezi,..) DOSE 44114,
ail 7.-M 2 --irDOSE
b)( • )-2
INIT. DATE
TIME )1A
'b)(6)-2
INIT.
Tama
DATE igif 0/7•
TIME B
6..„ A 2._ EM 0._.e__.
.2...
--O 2_1
V
INIT. b)(6)-2
varmiummi
DATE foSITEM z355
TIME
DOSE 5reM 11111 I II ,.
SO
bX
Y
INIT.
DATE
BEINIIMMIRMIE11112,1 EPRIEMFAIMIE 4, 1124
Eliriab EiMEMPSEEIMERIMIEMEM VI • a
TIME ortmo) efE `, Ilnin er 1 mirarm
DOSE b56)-2
INIT.
,
DATE TIME DOSE INIT.
MEDCOM - 5313
DOD 12525
NAVMED 6550/8 (REV. 4-74)5/N L -216-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES
SCHEDULED DRUGS MONTH
coo3
GIVEN
MEDICATION-DOSAGE- FREQUENCY
ORDER
ROUTE OF ADMINISTRATIONj HOURS

.14- lc
ATE b)(6)-2
4 14 A NpA.x ()GOO
'&"n

• :b)(6)-2
de.
1

V
II/IEIBIIIIIIEMIMMIE!44V'ZFMEMfgv
MITIVIWIPANI*Wnier Wit-
b)(6)-2
b)(6)-2
b)(6)-2
MEM
b)(6)-2
W:41101
(b)(6)-2
1.1.6
MIIMILIMP3511111
b)(6)-2iO0 (b)(6)-2
0100 .) 1
lgc0
INITIAL CODE
INITIAL FULL SIGNATURE & TITLE FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE &TTTLE
b)(6)-2 b)(6)-2 b)(6)-2 MIME b)(6)-2 I b)(6)-2
b)(6)-2 b)(6)-2 b)(6)-2
MEINUI=.1111111
ADDRESSOGRAPH PLATE WARD NO.
Injection Site Code
0 = Left ButtockjC) = Left Leg
0 = Right Buttock © = Right Leg SPIGLE DOSE.
-9=nEtz::1---
_,,
‘....
0 = Left Deltoidj0 = Left Arm PRE- OP PRN &VARIABLE
= Right DeltoidBQ = Right Arm DOSE ORDERS
0 = Abdomen SEE REVERSE
MEDCOM - 5314
DOD 12526

SINGLE ORDERS - PRE-OPERATIVE MEDICATION ADMINISTRATIONRECORD (Back) S/N 0105-LF-216-5581
MEDICATION- DOSAGE ROUTE OF ADMINISTRATION GIVEN DATE.TIME.INITIAL MEDICATION- DOSAGE ROUTE OF ADMINISTRATION DATE GIVEN TIME INITIAL
_CDO.[N-N-xei;AN tOnK1 14\11-1et0

PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGE
FREQUENCY DOSES GIVEN

ORDER.
DATE. •
ROUTE OF ADMINISTRATION
WirgeMi4M11111 DATE
li—griliNAMMIVINIZIELIFIMINIZEI11111111111
IL: TIME
MIMMEETEMENdegiMMUM
mmamorsoloammunmero
414.
MIIPjMIN DATE 7418E2211111112/200.10;91012111111111111•11
TIME FENNEIMMEITMENIIEMIIIIII
MM DOSE EIDIMMIElla- FIE111801119111111141 ¦¦¦
b)(6) 2
MENEM INIT.
Lvtundlosn DATE
tO4 R Poi' TIME
DOSE

al
to Cito

A5C-
cP4 t).Pb
orb
MEDCOM - 5315
DOD 12527

-
(b)(6)-4
11 4111e;
..NG FLOW SHEET Date: !// /_ ct
6550/l 2/Tenip Form
Time 07 08 09 10
EIMIEMBIEDIREI 16 MI 18 19 20 ILIIIIENIEMIES 01 02 03 04 05 06 CUFF 200
11111111110111=RIMIIIIIIIMMIEMI Milli
180
11111111111111111¦ ¦¦11¦11¦11¦¦¦¦1111111111
11111111111111.111111111111111111111M1111111111111111•111111111111111111•11111111111111111111•IMINIMIIMMINI
AL 1 —I-I I
160 MIE111111111111111111011111111111111111111111111111 11
140 .111111101111111.1111.111111111111111111111111111111111111111111111•111111111111111111
*
120 11111111111111111111111110MMIIIIIIIMIMIMIREIMIIIIIIIIIME11111111111111111.1111111M1111 I
1111111111111111111111111MMININA111111111111•11111111111111111111MINIIMMINIMINIMBEINIIIIIIII 100 1111111111111M1111111111111111111•1111111=1111111111111111111111111111111111111111111111111111M1111111111111111•11111 80 11111111111101111111111111111111111111=111111111111111111111111M1111111MIMINIMIIIMMIIIIIIIIIIIIIIIN
60 11111MAIIIIIIIIIIIIMEN11111•111111111111111111111111111111111•11111111.1111111111111111111111111111111111•11111111111
INIIMIIIIIIIIIIIIMIE1111111111111111111111111111MMIIMMENIMINIIIIIIENI 1111•111h111111111
1111 111111•11111111111111111111111111111111M11111111111111111•1111111111111MIUNIIIIIIIIIIIIIIIMMIIIIII
40 IM11111•11=d10111
RR.
TEMP \

SA02 MIMI nom ismommuriammurimmumInmu =num MAP
• 02
Mode
. "
D
R

O

:ZsZ le OW
MEDCOM - 5316
iName:
NURSING FLOW SHEET Date:
MEDTFtEFAC 6550/l2/Temp Eben
Time 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 105 06
• ZSZ a •
Mee1ri
CUFF
AL
•

200 180 160
140
120
100
80
60
40
RR TEMP SAO2 MAP 02
Mode
R ft I
_i
O
E

Time 08 09 10 . 1111 13 14 - 15 en MEM 01 0203 04 05 06
FP 200 180 j 11111111111111111111111111111111111111
L
tL 160
F
, 140
• 120
HP.
100
1111111111111111111111111111111111111111111111N
1111111111111MIININNIIIIIIMINNINNINIIMINININIIIIIIINNNIIIIIIIIIIIIIIINIIMINII I NM 60 1111111111111111111•111EIMMINIMMINNIIIIIIIMIIIIIIIIMMIIIIIIIIIN 1 111111•1111111111NNE1111111111 1111111111ENNINE111101111111111111111111111111111111111MININ1111111111111111111111111111111111NIMENHINIII
40
RR
Ira
TEMP 1
SAO2 •
,
MAP'
02

Mode
ICSZle OW
MEDCOM - 5318
¦

0) C7)lf) 2 0 • 0 Lu
c3-6,, cr 0

O
) •
¦
E

z 0 413
1.•
cn cc a.
• (j-2 I--• '4
DOD 12531

4
O.•.•
O

•••¦.....¦., )1..s
9 -
O

E
C.7 0 I
0 X
0 Cl2
Ctl. CC
• t I- •
k71IgerelMl!MP-Zi,
DOD 12532

II•1Mt_klE
IHDI:4M IN3S3I1c1 • Irian° mon PZ .LNEISHIld mail 21110H Pr.LN35311c1
IHDIRM SCIOIAMIr1 Lfld.Lf10 21110H PZ S1101A3Ic1 21f1OH PZ %IMAMId

WH

•
044
ATIOd 190 co PO E0 ZO I0 OZ EZ 'ZZ I Z OZ 61 1V10.1. 8 LI 91 SI . 01 El Z1 II 01 60 80 LO
I!
!I.I
I I I_ I --I Ij.1 "_l_ • - I 1 I I 1-I
I I
I I IIjI Ij
I •j
IIsI
I I I.I I Ij
-I.....jI I . 1j
i
j
190 co £0 ZO I0 0Z EZ ZZ 1Z 61 ' SI LI 91 SI 171 EI Z 1 II 0 1 60 801 LO
I
toys
111-1
• dg
.2'
j

Nare: . .
Time 07'
200
180

L

160 .
F

140 11•11111••111111 11111=1111
•
MAI I
HR
HIM
wet b)(6)-4
,
Olt •
pmiNG 511 bate]
`11--
MEDIREEAC• i2framp Farm 16 1 18 . 19 20 21 22 23 24 01 02 03 04 05 06
111111111•1•1111111•1 ••111•111111111.10111111• MIN
111111•111111111111•11111111•11MMIEM IIMM¦ I WM
OM i 1111111111111111•011
111 IINIIIIIIIIIIIIEIIIIIIIIII

IIIIMENINEMEMEM
40
RR Mil jNM min
TEMP
-it
SAO2
MAP'
02
Mode
WR FM
P
R
rio
E

•

• r.•
111j
jum
v£9Zle CI%II
MEDCOM -5322
..1.143011d IHDEM .111c1.111011f1OH 6ZS1101A311c1 indwi unoli tzj lil IHDIHRt ItcL1110 liflOH 17Z INaSalId .1.1111•1111110H 6Z ..1143MM
wti
sz Szt1 dOCI,
1.3
190 co _ . V0 £0 tO , bZ • ZZEZ , 1Z jOZ 61 1$1.1.0.1. 81 LI 91 SI' . V I EI Z1 , 1I 01 60 sO LO -1
C191 1.)1 •• 2 (PI1
/11 8 ,HdA w
jOd 2
90 SO CO to 10 VZ EZ ZZ _ 1Z 61 • Sr _ LI 91 SI to 1 - £1 Z1 , 11 01' 60 80 LO .1¦11
.1.11(1.1110/llicINI
•EONTS

. . •
.oRtivegeonemialOPMET2=Kizzezipi*, .
SI "tv
v

G^f .y 0
-CA—.co_
f-F2 O 0 CP¦ O .73
B

1 00111-
101110:ju
II III.•IIII ¦ O
II IN III
11
1: II il III II 2

1-1-1-:9 1
-
MEM Min'
I ., rno ,1
MEDCOM - 5324
DOD 12536
INgSnd IfId1110 )1110H vz Diasua .111&¦1111110H bZ .1.1%6Salid .LHDIRM SflOTARIld
1f1aino11110H VZ SflOIAMId IfIdNI 11110H VZ SflOTAMId
KeD 1253
e Oil I41 • NEI
101 90 170 £0 ZO 10 bZ EZ ZZ I Z OZ 61 11/1.01 81 LI 91 • Si bI Et Z1 11 01 60 80 LO don P-10.3 in° -.II
90 ISO 170 EO ZO 10 EZ ZZ TZ OZ 61 IY.L01j81 LI 91 Si bi El 0 1 . 60 SO EldAI Od NI
JA11,1110/IflaNI
SO WN
h ' Q07 A / 43. .69 5 cab or! gA' hl oh -set ?It owl! .12 trA b 001 9•) g '&10 N9ISj'oalm 17;' 9), bog c /A I 70

AI aBI•101MIM1:PA
rj

,==t
r
tag.-
0
0
1,0
O
&2,
¦¦¦¦¦•¦¦¦¦•¦•¦••,¦
•
r
8
0 0 0
co
•¦• CV Go 10.et (1) 02 N1e,,,,V ise
CL — 0.
LL 1 • 1 do• c4.
A:INSW1:EM

DOD 12538

. •
FREQ. VI SIGNS
TIME
BP •
HR
RR
TEMP
SAO2.

INPUT/OUTPUT
TOTAL
IN 07 08 09 10 12 13 •j14 15 16 1 .7 18 . TOTAL-19 20 21 22 23 24 01 02 03 04 05 06 m PO 0 IVPB
O

cn

CA)
TOTAL 19 20 21 22 23 24 01 02 03 04 05
07j08j09.10.11j12j13j14j15j16j17j18
OVYj1

11 :-Nomommom mum j111119 1'

I INII mum= 1
mt_mmeimmnam:m¦I
,0
CSZ•le CI oR
PREVIOUS 24 HOUR INPUTj PREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHT PRESENT/4HOUR INPUTj PRESENT 24 HOUR OUTPUT PRESENT WEIGHTj
VI
0
0
0
0
O
N
0
0
N
j
N
N
N
N
O
N
0I
00
N
VD
of•••
•
0
0
00 9
0
0
(=00 . 0 sr; •tr N 0 0 0 CO V)

7i 1A101•181:140,4::
DOD 12540

-
TIME BP HR RR TEMP SA02. • FREI); VIjSIGNS
Notes:
INPUT/OUTPUT
1 1 g 1 rn Bo - 07 08 09 10 11 12 13 14 15 16 -17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
-cn — .,•

TOTAL
TOTAL 22 23 24 01 02 03 05 06
OUT 07 08 09 10 r 11 12 13 14 15 116 17 18 19 20 21
D• FOLEY tab 510 UOP
BM
PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHTj PRESENT.24HOUR INPUT PRESENT 24 HOUR OUTPUT, PRESENT WEIGHT
•
NURSINGjSHEET Date;
tabrIkEFAC.6550112fienp Forrn
441•41¦¦¦•¦•. 0350
Time 0 9 10 4 15 16 71 18 19 20 21 22 23 24 01 02 03 04 05 06

.L.
V
V
100 V
4
80
•1r
60
40 1' RR
TEMP MIIMMMMIIMMMMIMMOMMI Lim
MMIMMIIIIMIMMUR MIM . M MUM
1=1111MIMMI
P-11,
ENE ABM III IIIII ¦
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DOD 12544

DOD12545

FREQ. VITAL SIGNS

Notes! INPUT/OUTPUT j •
IN PO IVPB 07 . 08 '09 10 11 12 13 14 15 16 17 18j' TOTAL 19 20 21 22 23 24 01 02 . 03 04 05 06 TOTAL Cf)Lc) 2 0 C.)0
OUT FOLEY UOP 07 08 09 10 11 12 13 14 .15 16 17 18 TOTAL 19 20 21 22 23 24 0 v 01 02 100 03 04 WO 05 06 TO 1
BM

PREVIOUS 21 HOUR INPUT jPREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHT
PRESENT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT
N
0
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DOD 12546

D 1254

FREO. VITAL SIGNS

TIME zoo 009.
BP 41171... 11,9/5­0
HR 70o /02—
1p
TEMI /06),S /o/. 0
SA02 (4 1% q7
Notes.i ,
INPUT/OUTPUT
IN 07 08 09 10A11 12 13 14 15 16 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
PO
IVPB
1-k

OUT FOLE)'r UOP i.. 07 08 09 10 11. 12 13 14 .15 16 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 SDv TOT
BM

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PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHT
PRES INT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT