Medical Report: 30-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Multiple Gunshot Wounds to Chest, Groin and Legs (Death)

Medical records of a 30 year-old Iraqi male admitted to hospital with gunshot wound to chest, groin, torso and associated injuries as a result of a firefight with coalition forces. The Iraqi was firing a Rocket Propelled Grenade Launcher (RPG) at a Coalition helicopter, and was return fired upon. He suffered wounds to his chest, legs and groin. He was brought in to an Army hospital on November 7, 2003 and received medical treatment for his injuries. On November 18, 2003 he expired from his injuries. No autopsy report or Death Certificate included in this medical record.

Doc_type: 
Physical (non-death)
Doc_date: 
Tuesday, November 18, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

Translation Bates page Medcom 23328: Name is:
WIROMNI

Number:

Ward/Sect:0ns

1 RE ciLTES TING Esi-IYSICIAN: ' CITEMISTRYRESULTFOIZNI
(Subject to Clic Privacy Azt of 19-i41

I DATE TLME SSNRSELTDO SCN:
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:EST R_ESUT T R_EF.
RESUIT1 kEFRANGE

-------PICCOLO

mo;oi.l. „LLB I 73-113 mgid1
11/07/03 12:74 AM

rranoi..1. I ALP
REFERENCE RAN MALE I 7-22 Ing/d1 rr..31/L ALT PATIENT #: \,-I 8.0-10.3 AMY LIVER PANEL PLUS? C9--)
I 0.6-1.2 in&Id! 1:gifigtar0 AS — DISC LOT #:
3154AA7

hi-fsz (yen) I 12g -i43 ,r.;no1/1
OPER #:1111111

DR #: 000

Og ¦ an) TEM,
SERIAL #i 3.i-4.7 ran-..01/1 ca. (Jr* BUN
)1QP
on. (vco) W I 98-108 mmo1/1 DIAL.Wt) ALB 3.3-5.5
CA"-3.1* G/DL

A/L (vcro 18-33 mm01/1
13-3 m9/dL ALP 72 26-84 U/L
CERA,
fAgsdL ALT 88* 10-17 u/LBUN CRE AMY 78 14-97 u/L
145 mmol/L

Na REFRAAk7E
AST 131* 11-38 U/L

4.0 mmol/L .I31/L CH.JJ
TBIL 0.7 0.2-1.6 MG/DL i 3.3-5.5 0.1 el ii0 mmol/L Tp
GGT 9 5-65 U/L 1 26-84 ur,

mmolst_

Tcoa TP 5.9* 6.4-8.1 G/DL

1 10-47 12/1
mmol/L

RnGap
31 %PCV TEST INST OC: OK I 14-97 WI

dt CHEM OC: OK

Hct__

HEM 1+, LIP 0 , ICT 0

I 1 / L

CILU
1 1-38
, *via Hci B LIN

algh2
ph

CRE
5-65 Wt

'7":!'"174

i00.7 mmH9
-prna CK
6.4-3.1. g/d1
mmoi/L
Nr:03
lE

-15 mmol/L
BFpcf
Sample Type_:

I .CL-
01:30

07NOV03 I 128-145 mrno1/1
1CO2
3.3-4.7 girno14

Physician:

98-103 mmoLl
tco, 13-33 rnmoill

REPORTED BY: ,
I DATE: L.AB rD NO.:
MEDCOM - 23380
DOD-036957

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RAPIDPOINT COAG ANALYZER V4.54
SERIAL 4005485 11/07/03 01:34 1,8:/1111N.

48 wow
07-/i-03

Patient 10:1111 4iC) (Or') N 01:31 E Test Name :PT lie Patient
,,
Limits

Test Result:., 20.4 sec. 23.5 H x1043/4 4.5 10.5
' ROC 3.45 L x10A6/aL 4.00 641
***RESUL1 OUT
OF RANGE***

1 list 9.5 L ME 11.0- 18.0
Ratio . 1.7 1kt 30.6 L ILIn 88.8
Calculated INR = 2.30 fl. 35.0 60.0
Irll 744
90.0

Sample Type:oitrated wh. blood 47/C P9L99.9 Fi-4
R 30.9L shtL27.0 31.0L-
Test Date :11/0003 _ PI t 2210. /..___
-

ty Test Time :01:32 , , ------1 LYZ 29.6 * Z1/043AL AO 37.0
150. 450.
Card Lot :1

20.5 51.1

LY8 7.0 *H 1101/eL 1.2 34
Operator

si

H -,--(1--

Bank

s( RAPIDPOINT COAG ANALIZER V4.54

SERIAL 4005485 11/01/03
01:37 ) -JIT SF 51S WITH EVERY UA1T REQUESTED
----Patient ID: 01111110V1i)-(1

A

Test Name :APTT

f-- ' :
Test Result:, 50.6 sec. •131c)XIB•gb.k
Pros:switch' • -
: : • :

1 T SUSNi/T SY 51s 'writ
***RESULT DDT OF RANGE***
u.N-rr j31,0,OD

-
Q._._r__ •
Sample Type:citrated wh. blood RE E.ES.Tk,D) •
rr . -_ •-••
r
Test Date :11/07/03 TYPE
cAO,s,S.,' ("11

Test Time :01:34
Card Lot

:10020'
Operator :

1111111! \ , l,

L) \.9 "
! RE? TALR:LTS: • I
Rjr',.-,TORTF.D BY:
1-DATE: ,
I LA11 rD NO.:
EMERGENCY RELEASE OF BLOOD COMPONENTS
.
SECTION I REQUISITION
-
c MPONENTS REQUESTED (Check One)
THE FOLLOWING TESTS HAVE NOT BEEN PERFORMED:
RED BLOOD CELLS (Crossmatch not performed)
ALANINE AMINOTRANSFERASE RETROVIRUS TESTS CYTOMEGALOVIRUS TEST SYPHILIS SEROLOGY TEST
OTHER (Specify)
HEPATITIS TESTS
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THESE BLOOD PRODUCTS FOR TRANSFUSION WITH
ETE TESTING. I UNDERSTAND THE INCREASED RISk TO THE-PATIENT AND ACCEPT RESPONSIBILITY FOR THE ADMI TFtANSFUSION.
DATEPHYSICIAN'S SIGNATURE

4) .- / \ 1- IV1V C)
ISSUE/TRANSFUSION DATA
-
TFtANSFUSION NUMBER RECIPIENT NSP
ABO/Rh
Ot AT

1ST VERIFIER UNIT NUMBER , ABOrRh
op

IDENTIIICAT,I9N VERIFICATION
The transfusionist (1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate Vat the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must
sign the form in the "2d Verifier" block.
1-)2 V.(31'
PRE-TRANSFUSION,
P LSE: 69 , B/ .
P: c? k,.7(6 7/- 411 I/
N (NAME- LA , FIR.DT; SN) '
in ,1 Lb( (1) 1
ature) IN TS
Cn}4'
0

_
' 11,40V D3

Cat,;1
,
.
'

2D VERIFIER DATE/TIME DATE/TIME AMOUNT GIVEN REACTION YES/NC
(Signature) STARTED COMPLETED
-i'')i
I (ANOI In t-) / MN ii.,)°1 ) 01 _? C; 1 IA_ l'i
, . (30 01.36) IIA-N.)

TRANSFUSION REACTION
If reation is SUSPECTED -IMMEDIATELY:
1.
Discontnue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Pi ocedures.

4.
DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank.

Descnalion
L j URTICARIA CHILL FEVER PAIN
OTHER
OTHER DIFFICULTIES (EQUIPMENT, CLOTS. ETC.)
0 YES (SPECIFY)
I b lift

WARD DAT,g
k./ )i\n/L)-,
One copy is placed in the medical records. Onecopy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.

MEDCOM - 23382
DOD-036959
EMERGENCY RELEASE OF BLOOD COMPONENTS

17 _)
,n,

(.
Li 05
IDENTIFICATION VERIFICATION
The transfusionist (1st Verifier) must examine the
blood bag label, tag and emergency release form to
ensure that it matches th..) patient's name or trauma
number on his/her ID bracelet. He/She must sign the
emergency release form in the "1st Verifier" block
above to indicate that the correct patient identification
was made and to document who started the
transfusion. The SECOND individual (2d Verifier) must
confirm that positive identification of the patient and the
blood unit was made by the transfusionist and must
sign the form in the "2d Verifier" block.

PRE-TRANSFUSION
Vto, L,
f-P PULSE:

k PV
ONIAME- LAST, F RST; SSN)
-

Api 11 _ ji
u1)
SECTION I REQUISITION
-
MPONENTS REQUESTED (Check One)
)1k
THE FOLLOWING TESTS HAVE NOT BEEN PERFORMED:
' RED BLOOD CELLS (Crossmatch not performed)
ALANINIE AMINOTRANSFERASE RETROVIRUS TESTS GYTOMEGALOVIRUS TEST SYPHILIS SEROLOGY TEST
THER (Specify)

HEPATITIS TESTS
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THES .BLOOD PRODUCTS FOR TRANSFUS. '
TE TESTING. I UN-DERSTAND THE INCREASED RISK. TO THE PATIENT AND ACCEPT RESPONSIBILITY FOR. IS TRANSFUSION.
DATEPHYSICIAN'S SIGNATURE

b ( cc.,- i_
1.),) N ov CD"

......
-ISS.NSFUSION DATA
TS ABO/Rh TRANSFUSION NUMBER RECIPIENT INS 1
AT

OM. --z-7,07vaj
\-., Lit‘
1ST VERIFIER 20 VERIFIEFi DATE/TIME DATE/TIME
UNIT NUMBER ABO/Rh AMOUNT GIVEN REACTION YES/NG
(Signature) (Signature)! STARTED , COMPLVED 7
,
.--

0.1
K)i., K.)
TRANSFUSION REACTION
If reation is SUSPECTED -IMMEDIATELY:
1.
Discontnue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

4.
DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank.

Descnepon
11 URTICARIA CHILL FEVER PAIN OTHER
OTHER DIFFICULTIES (EQUIPMENT. CLOTS. ETC.)
0 YES (SPECIFY) ___b_b5L,__\51__________
R OF PERSON NOTIN
/ (.._....

One copy is placed in the medical records. One copy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE OTSG APPROVED (Daie)
TRAUMA FLOWSHEET QI Appr 11 Jun 97
The proponent is Dept of Surgery
EMS' REPORT.' -ARRIVAL STATUS .
TIME: ETA: UNIT: .....--------TIME eire 0 iv x ,.
0 0, i'D 1 /min 0 C-Spine Immob MED COM: Y N Meds: • KN 0 None 0 Yes: Allergies: iL.4LiKN 0 None 0 Yes: Tetanus: ,W.14C-N 0 Current Last Meal/Fluid Intake . hrs
-LMP; ... 0 .
PRIMARY SURVEY
-. '
.-.
..

AIRWAY ' '. , BRETHING ; ; CIRDULATIOW:-.
. , , . .. . ,. . . . ,
mural Patient ail N f ored 0 Unlabored 0 Absent PULSE: esent CI Absent SKIN: 0 Warn Aefjool 0 Hot
ow
0 ETT 0 TRACHW6Adidline 0 Deviated L R BLEEDING: 0 Pink „)!Ce_a_le 0 Cyanotic 0
?!Ckecretions CHEST SYMMETRY: tifiS L a R HEART TONES: 0 Clear Muffled ' y 0 Moist 0 Diaphoretid :
, :

SECONDARY, SURVEY
.,

DISABILITY HE.AD. HEART -ABDOMEN '
'
. -

GCS: PUPILS:XEqual 0 Fixe React 0 Dilated L R RHYTHM: tliefLegular 0 0 Rigid 0 Non-Tender
TM: *Clear 0 Blood l'`.."-j5‘',S Lk— L R PULSES: Xentral 0 Peripheral 0 Tender:
FELvis M
NECK LUNGS
t C-Spine Tenderness: Y N BREATH SOUNDS:CI Bilat 0 Equal 0 Clear 0 Stable Unstable CI
SPHINCTER TONE:

0 WNL Pain @ 14A-4 ii--1"--..Decreased L E Absent L R Blood at meatus/vagina: y N.
• None E N WheezesLL R Crackles L R Hem.; -Prostate: 0 WNL 0 Abnl
JVD:

.USE.DIAGRAM'TCY:DOCUMENT INJURIES AND. PAIIV , -VASCULAR ASSESSMENT •
(AB)rasion
aft
(AMPlutation
NJ
(AV)ulsion
e he-SA

Battle's Signs
.--+-(A

IBL)eeding
Ql-tS k/L)
(Blum exc

C
IDIeformity
(E)cchymosis
(alS )
(F)oreign Body
'MI In\ ei,( I
(H)ematoma
(LAC)eration

%NI ou
(P)uncture (W)ound (Pain) (S)eatbelt (S)ign (S)tab (W)ound • (GSW) Gun Shot Wound ID(.0 -2-
--L.0 .
Palpabie D Dopler

RN PHYSICIAN
ontinue on reverse)

- PREPARE BY (SigL .6 (k.\\J--L DEPARTMENT DATE
r ,_._ (j ..
PATIENTS IDE FICAT or type or waren entries give: Name-last, first,
middle; grade;Le; hospital or medical facduy)

• HISTORY/PHYSICAL • FLOW CHART
ER j11111111 i • OTHER EXAMINATION • OTHER (Specify) OR EVALUATION
cb ( (I2) - ki

El DIAGNOSTIC STUDIES
• TREATMENT
REQUIREMENT OF PRIVACY ACT OF 1974 IS COVERED BY DD FORM 2005.
D A 1 Fey"; a 47 0 0 /LITE. EAMC OP 503, 1 Dec 98
MEDCOM - 23384
DOD-036961

PROCEDPRE: SIZE .

ral CO2 Change
CT Scan: 0 Contrast
0 Nasal BS Post Int
0'&
Intubation 0 Head Abd pelv.
Teeth 0 Post CXR
Gastric 0 Air 0 Contents C-Spine 01:11.-Spirie 0 Chest
CI Verified

0 Oral
0 Nasal
Tube

Suction: Y N
Urinary 0 Return A-Gram Site:
CI Heme Dip: + -

IV ACCESS & FLUIDS

.0 Secured
0 Grossly: + -I count
DPL ent@ EM11111111131MIE1111 Chest ood

rintlimmoluirmouromi
01-Pleuravac cm
Tube #1

Autotransf user

111111111.
Chest CI Air CI Blood
Fleuravac cm MEDICAT IONS

Tube #2
Q Autotransfuser
Dos ;11
Rhythm: Comments
12 Lead
'AEG SITE
TIME %01.
13°2 Q2 S°.t
-RAYS
TIME

0 D-stick 0 SHct 0 Chest Post ET
0 Chest Post CT
BLOOD PRODUCTS
0 1 0
C-Spine
0 OTHER
INN
LAB RESULTS,
CBC:

INTAKE
Blood
Other Other
TOTAL TOTAL
TRAUMA TEAM ARRIVAL. 'VALUABLES & CLOTHING
-,.RESRONDED... ED Phys Surgeon
Given to Patient
Anes th
Given to Family
Inventoried and Released to Patient
Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
X-Ray

DISPOSITCON
RT
0 Home CI
Ortho

Admitted to
Neuro Report Called to

Chaplain Time Transferred
i By
VITAL SIGNS
GLA OW COMA SCALE
Rectal Temp:
GCS:
ittet. itEsiON$E
-MOTOR RESPONSE
ME BP HR
RHy RR SAO Fl02 MODE E - V
4 - S ontaneous 5 - Oriented
6 - Me Commands
@ 0 1 Ig
ice
n 3 - To Voice
4 - Confused
5 - Localizes Pain
0)-5
-
2 - To Pain 3 - lnapp Words 4 - Withdraws to Pain
IVEVIM
1 None
2 - lncomp Speech
3 - Flexion to Pain I - None
2 - Extension to Pain 1-- None
1111111111116

'PERFORMED BY:
MOM IMIIIIIIIIIIIII
Backboard Removed
0 Downgraded
MIMilL1111111111111
itarargrain mono
NOTES
MEDCOM - 23386
DOD-036963
GLP OW COMA SCALE
Rectal Temp:
GCS:
.-!:„.1A9TOFCRESP.ONSE

TIME
FZR SAO2 F102 MODE
4 - Spontaneous 5 - Oriented 6 -Obeys Commands
@ \Q)/1

111.111111VIE
3 • To Voice 4 - Contused 5 - Localizes Pain
c
o EIM1111111111111111.
2 - To Pain 3 - Inapp Words 4 - Withdraws to Pain
1 - None 2 - Income Speech 3 - Flexion to Pain
)(D
1 - Nona 2 - Extension to Pain

_AILLIIIIIIM/11
1-- None
PERFORMED BY:
VireiranteallINTIVES
0 Backboard Removed 0 Downgraded
BY:

Jal&-wilowitorrat BY:
NOTES
.2 '•"-DEI REST- I-LC(3C -hi.20
-;-
v e(5-, a 0
MEDCOM - 23386
DOD-036964
1. Reporting MTF VO-N.--2. MTE _ ca...
Admission ai id Coding Information
IZ
For use of this form, see AR 40-400; the proponent agency is OTSG
r-IIIIIIIIIIIII
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
_
FGN M
1-D l'a)--1
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
,
X 9
10. Length of Service ETS 11. FMP 12. Social Security Number
_ 99 _
.
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
00:55
14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS 19. Trauma Prey. Admission
BC NO

20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER Address of Emergency Addressee Telephone Number of Emergency Addressee
Name and Location of Medical Treatme -cility:
)7 ( 7) — 2'
21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
EXPIRED 2003-11-07

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

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-07

FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW LOWER BACK

Procedure Narrative(s):
Cause of Injury Narrative:
rb4)-2
Admitting Officer (Signature, as required) Signature of Admitting Clerk
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 23387
11¦1111•¦¦•••¦•=111.11
ister Nbr For use of this forrn, see AR 40-400, the proponent aye! v-3. Grade FGN
8. LnthOfSvc 9. ETS 10. PrevAdm

I. FMP 12. SSN 1t. Organiz4ion
((•-‘)

18. BranchCorps
17. Dept / Ben K78-PRISONER OF WAR/INTER 15. FlyStatus 22. Hour Of Adm:21. Source of Admission 01:00Direct from ER 25. Type Disp24. Name/Relation of Emergency Addressee
TRF-OTH 27b. Telephone No27a. Address of Emergency Addressee
29. e rtingMTF
b
31. Selected Administrative Data Marital Status:
DoB:
In/Out Patient: Inpatient

MOS:
33; Cause Of Injury:
34. Diagnosis !Operations and Special Procedures:
S/P GSW L GROIN R LEG

19. UIC / ZIP 20. Type Case DIS
234'. Clinic Service # AGG - FP ORTHOPEDICS
26. Date of Disp 2003-11-18 28. Date This Adm: —r Admittin Officer:
2003-11-07
30. Date Ira Adm 32. Units Blood Components
2003-11-07

NO
14. Ward ICW 1
Admission Remarks
35. Total Days This Facility
Total Sick Days
ConLv / Coop Care Days Supplemental Care Bed Days
Absent Sick Days Other Days
35. Total Days This Facility
Total Sick Days
ConLv / Coop Care Days Supplemental Care Bed Days
Absent Sick Days I Other Days
11/42)
C) 0
Signatu
Signature of Attending Medical
.
Automated Facsimile - DA FO
;
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
FIELDS MUST 6E. FILLED 1.N, IF A..PPLICABLE, UPON APPREHENSION
I
!Offense against Civifian(s) [che.ck one] If "Other"-then describe:
( 1;,,,,,(1.P.C. 2-421 I Ia.:glory or ..-rousarrra..o.king 0.F.C..-::::.F. .
i ISoL-ca....on of Forr::co--1:.or..;----ros!,•.:.:!ion r,i.F" C. .39-i.'" I IF_orz'..:_---1:Co--r.rn,:r.icrarir-7; "inta.acs 0.P.C.. 4:3i::)
Raptilrhionc,...--.4..SeaLai .4..ssats....3...c.'s (I.P.C. 393-93, 4'32) 117.1eft (1.P.C.. 4:19;.

-
I 'kilo:for Ci.P-..i_'. 4.05';

I 1C-estrucn of P:3E:or:Iv C..P.'C. 477)
I I Azgrovated Assauy.)....ks..sx.. Vv:-..r! ;r!er-t To Ki!I ;:.P.0 4,10) i Ic.,t,a;:jour, a Pleoc High,...3:,-.1.1ace (.1.F-' C 437)
I l!.,iairn:r4 (i.F.C.,'. 412),

I IDiszOorging Fire_urn: Explcsi.,a in C.ityrTc,rniViitaga (C.P.C.1. 495". ' Sirr.pSO Assau; ci.P.C. 415)
I f Riot or Sr'each of Peace :J.P.0 49.5(3,”
I .r...k.fnarcg (1..P,:::. 42 ;) I 01, her-.

ify\lOffense ac.jainst Coalition Forces [check one] If "Other" then describe:
. t ift-ii-.
1 I vicz-zfc..-; 0 ;:c ,.:.1.evi

...
I. I 7:spass on Miiibri In: a!la:ion or Facrliry .
I I 1:-,`;a1 e 3'5: .' -..on, -r—; Pt-toto;ra..oh.ing:Sor.,e-i'l.:-.G Uiiry tns;:alaor. or Facir:7„.

."'-''sion of .`2`i...:.
I Assaz.J:L'Altazk on Cc-zit'c,..-...Foroas-

... , : . .. .. L labstrlictilg. P. arlurrtanza a' P.Uitary, Mission
..
I ,IT-,.'e4 cf..ccai;;;..s.., Frce Pp--parti
: - j jCatt-,ef -.
Apprehendinalinit: • -I•Lccati.on:.Grid: .
• •Cate of Incident: (DM.,1tY} -.: :...1.7.rne efincident:,' .:. .., . • Date of Report: (D/ftil/Y) Time of Report:
. -: :,.41r,;1..:," ta.,::::,.-:/:--/ ,-,‘.

.. '''' (17. .I I.' 3 i 4:2: . ' '.. . rs' /
. . ... . Detained-g-. :Key Connected Person: : Victim -IV/itnest
7 .. ' : -'' ....... -: ..-,c2 .-00.:ihisto:c_.?:/.00''. :. ''....'" '' .
h / hrs
...
Last Name: ID:. 62' 7t LasZ Name::".
First Nan-le:

'
i-iarr Color: ScarsiTanocs/Deformiries: Ha:r Color: Scars/Tat-toos/Deformities

Given Nar.rie: First Narne: - ' Given-Name:
Eye-Color: Vieight: lb ' h:: Eye-Color 1,,,ie:gnt: lb ii-leigh.: in
Acdress: Accress:
Place of Birth.

Place of Sii-th:
==thniTri'-,e/ Sex. 'Phonet-i. Ethrfinbe! S-ex: F-hor:e.t.:-

Sect' E:'.,(. I i Mc:-.1ie Sec.'• I :',1 DO6 DAVY: L_ jlk,lobile I IF 1 IReg,i., Regular
IF
Passport D'' license l

Other (specify) Passpor• • Dr. iicanse Other (specify) Document #: Doc.-.ument ;7:: -. TcZal Number of Perscns Invotved • !Os.: names/identrfying info cn.reliecse undeF"Ade;tiona 'Helpful information"}i
. . .
Vehicle InfoiTnatic,n . • Vehicle Number ' ' Vehicle(s Owner: '
t.A.akel !Color: IVIN::
t,lodel• i "rya?: ,Plate No.: NtImber of Peopie iR Vehicle:
Year: IName.s of T---.eoc:e irt Vehic!e:
C:4-;trabandAA/e.ap-ons in. Vehicle:

[ 1Proper.y./C!:‘,-,.;:.at;37rj Weac.cr: 1:----no:c Take.-c f Suspect ..v.::-. Weepcn/Co7i:ratz.,r.d. Yes! :o
-yoe I .‘...c.-..'el if.--c'.3',.Ca:ite c2.e'a! :;-. 1:11,.; 7.r n-... 'Make I P.e:ei p: Frc....v:dec.4, '..o ..-;..,:ne..r ''F:st `:c 0:.^.er 2,etai:s 1.:V^.ere T.:curl::
1.3w^er-Nanti, cf AssIV.:r.-u ;nterr...--re.er: Emai:, Ph.cne, cr Con:act 17;fc.
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COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON AF'PREHENSION
Offthrise againSt.Civilian(S).[check oriel .ff--Other.-,then d.escribe.:. .
..
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.,. .. • •
-. . . --• : •
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. . . ... • •, . • -• . :,•• •• • .• .: . •. • -•
I .-• kgrayated AssaLit/Assau?:I.N.'.h. Went To Kill (1.0%C. 4.10): .

Ct-st.-..ictin a Fte_qic Highvoy:F.lace (1.P..C. 48.7) .
. .... .
.. . . ---. • ' • , •-•
iCisc.r.:a;g1ng Fits*.a..-rnt Explosive in Cttyacwo/Vi9a.:ja (LP:C.: 495)
1 :......1i.laimirr,;(1.P.C.i. 412): •: I :.... ..... .. .-• -••• . • -•.•-:.• • "
.Iii-r..pa-A.ssau:1 (I.P.C: 415) • 1 •

[Riot or 6ieach'of Peace (I.P.C. 49.5(1.1)) :-: ' : ' -
1 .. .. .., ..,..: :•
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Place of Birth: Place of Birth:
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Dr. license Other (specify) Passpor` .1 'Dr. license 1 10ther (specify)
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Document #:

Document #: --..!TOEal:NOMber Of Pers.c..ns-lhVotyed.''.'-:.:::' (liSt:riarnestidentrfying in fccOn' reiecse%under "AdO:tionak Helpful:Informtion!') • • • • ----
VehiCle:frifoiation • • ' ::Vehiele.Nurnheis•.::.'. . :Vehicle(s Owner-;:.:::
• Niake..::' H-Color: .. ' ' • VIN:..:::).,:-•-t.lotleri Type.:: . Plafe No.:
Number' of Peooi.e. in Vehicle:
`leae-... -. -...:.--.' Nanies Of Pecofe inVehicle:
Cohtraband`ANeapons inVehiCle:-.
1Phcto Taken of Suspect with ,,A/eapcn/Contratand. Yes! No

[ Propery/Contraband 'Weapon
Type: 1 Model-IColor/Caiiter•
Yes/ No

S=rial No : _Quantity' Make. !Receipt Prcv:ced to Owner.
'Owner.

Other Details. 1%/N/here Found
Email, Phone, or Contact Info..

Name. cf Asss-tir.-g Interpreter:
• eqtr.-1-.2...scleies Nartrze Si,:z.er.ising C--'`zer s !iarr.a
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(P:ir.t1: Last, Firs: .4,: .
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Er7:2:: -Ema il: .
r'.aze: '

Sl^na-tw=: (. Si^5atura:
Lin:I Pho. Uri:: Pl-ione:
MEDCOM -23390
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM

Wh.y was this person detaine
4Vho witnessed this person being detained or the reason for detention? Give names, contact numbers, addresses.
Hot,v was this person traveling (car, bus, on foot)?
4iVho was with this person?
What weapons was this person carrying? /4),I,
A 4-
What contraband was this person carrying?
What other weapons were seized?
What other information did you get from :nis person?
Ir.fcrma!ion:
MEDICAL RECORD 1 ABBREVIATED MEDICAL RECORD

AorAISSioN Ear,' .1”1, of
PERT 'NEN HISTOR Y. CHIEF COMPLAINT. AND CONDITION ON
676'.111.r1111-d.(.5".147
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NI/N I cA/')
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date: horp,t I or mrefic•I tr.cdiry)
-
ABBREVIATED MEDICAL RECORD
Staaanrct For-= 3.39
GENE.AL SERVICES AC:PAINIS-74AT:ON ANO :::7F.P AGENCY COMMITTEE CP4 ME:.:1C-SL
CC7OFER 1075 5.39-106
MEDCOM - 23392
DOD-036970

.
IVICUILAL nct-.unu U1-1110INIULUtill;AL litt:UKU Ul-IVItUlUIAL
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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SPONSOR'S NAME SSN/ID NO.
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UNIT
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MEDCOM 23393
-
DOD-036971

AUTHORIZED FOR Loum.
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-CHRONOLOGICAL RECORD OF IVIEOICAL CARE
(Sign each entry)
SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION

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MEDCOM -23395
DOD-036973

-

MEDICAL RECORD PROGRESS NOTES
I
DATE NOTES
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Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101- VI .203(b)11 0)
USAPA V1.00
MEDCOM - 23397
DOD-036975

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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MEDCOM - 23398
USAPA V1.0(
DOD-036976
FIRST NAME !MIDDLE INITIAL ID NUMBER
LAST NAME
NOTES
DATE
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MEDCOM - 23400
DOD-036978

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MEDCOM - 23412
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07-11-03 SOUrCe
01:40
Itict
Patient Gram
Limits Stair
I liBC 20.8 H 110"3/uL 4.5 10.5 Occ B Id Negative

RBC 4.43 x10'6/91 4.00 6.00 " ra5
Hgb 12.8 9/cil. Bld Negative

11.0 1&O H. pylori Ncp.aveHct 40.5 Z 35.0 60.0
.
rev 91.3 ft Micro
80.0 59.9
lel 29.0 pg 27.0 31.0 Pares
WIC 3L7 L g/tIL Prot. Negative

33.0 37.0 Malaria
Plt 329. 110'3/IL 150. 450.
LYZ Z Urob 0.2-LO
20.5 51.1 0 & P
neej
1.2 3.4 Nit Negative
Other
)(lel
Lcuk Negative
17P-sc .T.Irtn
HCG Nt..&44-vc
Morph
RAPIOHINT COAG ANALYZER V4.54 lood.Bank
•. . .
•.SERIAL 4005485 11/07/03 01:46

. '
MTJST SUBINITT SF 518 WITH
Patient ID:

EVERY UNIT REQUESTED
: Test Name 11111,1_ en Negative
ABO/Rh
Test Result::: 13,6 sec.
: Ratio = 1.1

.131*1.1341flailaitcro'ssiaatch..
_
Calculated INR = 1.19

ITIST,s.UBMIT Sf,518.WITH,EyERy trN.r.r or. BLOOD
Sample Type:citrated wh. blood

REQLrESTED) :• •
Test Date :11/07/03 UNIT
TYPE
CROS.E AL4TCH
•Tal Time :01:45

C.11-(1 Lot

Operator

-
kAPiWOINT COAG ANALYZER V4
SERIAL 4005485 11/07/03

/ :49

.

(--) Patient ID: Test Name PIP ' Test Result:. 32.8 sec. LAB ID. NO.:
Type:citrated wh. blood
feEt Date :11/07/03
fet Time :01:41

id Lot
Opel

MEDCOM - 23413
_ . • ' Kt.:QUI:I, l 'NO rtl- .:•:"1...,IA;N:N.. 1...w...mmitiki tin i .M.C.31_11,1 rtntlY1
! Ward/See . :
J. — t--( 't to the Privacy Act of 1974)
IP
L___ ---__ „,-,
1 DATE TIME
' f..ASt , EMST,.N1-1 ___, .... __Ii.(2/1/0 ° . _
_
--.• (lierna . CBC , ..-• .Vrina ysis . .... . . .
RESULT REF. RANGE TE.ST RIESUL7' REF. RANGE TEST RE.SU.LT REF. R.17crG.E
TEST
i N/A Negative
4.3-10.3 x 10' Color' RPR.
Ni.rEC RBC 4.7-6.1 x 109---, App WA MORO . 7.4egativc
_
--7----:.• 14-13 gicli (11,1) Glu. . • Negative. . . . MiCrobiology
.H.gb
12-16 gidI (F)
Het 42-52% (M) Bili Negative Source 37-47% (F) • 30-9=1 tl (1.4) Ket Negative Grarn .
MeV
81-99 fl (17) Stain ,
-130-500 N 1 0' ; SG -N/A . Occ Bld Negatiw
Plt
verified
Nectarine
Lymph % 20.5-51.1% Bld Negati ve H.. pylori
-• (lientatelogyMtilual Differential . pH N/A . N.' icro . . . •.
Parasites
I .---Mono Prot Negative Malaria
Segs 1
_J

Urob . 0.2-1.0 0 & PBands . Eos
Nit Ncgatil,•e Other
Ly mph Baso
Atyp Inun Leuk Negative -11ficit.osccipic Krini sia " •
....„ --EGG Negative
RBC
..
D; U.INI t:OAG ANALYZER V1 .!)-1 •
AL 400S485 11/10/03 04:46

..7

•.. CSF -.. . .Blood Ba.nk •:.
Pati ent IO: .;._ •

st Name. 1110111-- -.---..

--,..

!ell i MUST SUBMIT SF 518 WITH -
st Result:= 19.3 sec.

:ount EVERY UNIT REQUESTED
*RESULT OUT OF RANGE***
.
: • inctigen ' 1 Negative ABOdth
Lt i 0 ..,..ir
i I.

____J_____ 1 •

tii-i-E14-84-1444-341M

itm)le Type:citrated wh, blood s .: -. Blood' Bank Unit Cros.sroatch. . .. . 1 . (MUSTSUBMIT SF 518.WITH EVERY UNIT OF-131,00D . .
:st Date :11/10/03 .: ,. .
'. .. ---..- RE,. QUESTED) , •• --.-• • -
:st Time :04:45

NUT TITE CROSSM-ITCII
ird Lot
perator
___---. \06d1.-

. 2
,, \\)-I 'fil; IOPOINT COAG ANALYZER V4.54 . ,'
1AL #005485 11/10/03 04:49 _..,,-/

'
; "lent ID: `_ i . 1 1 e;., t iiditIE :APIT .-• • ist Result:z 50.9 sec. •- ,-**RESOLT OW OF RANGE***

mmplelype:bitrated wh. blood FE: LAB ED NO.:.
fest Date :11/10/03


fest Time :04:47

•.
,'.7irri Ht.

\\\\---

MEDCOM -23414

TOTAL HOURS FROM __HOURS COVERED
HouRs
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET
ACCUMTIMEAMOUNTTYPE TOTAL
RECD COMPLAMOUNT
(Include Medications)
AMOUNT
(N/G, Bladder, etc.)
IRRIGATIONS
ACCUMULATIVE
AMOUNT
TOTAL
BLOOD/BLOOD DERIVATIVES
OTHER INTAKE
ACCUM
TIME
TIME AMOUNT TOTAL ACCUMULATIVE
COMPlp
AMOUNT
STARTED TOTAL
TIME
GRAND TOTAL INTAKE
USAPPC V1.00

ouTpu-N6
All11116
(Lta-A
MEDCOM - 23415
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
1. AGE:
3c)
HEIGHT:
NO [ ] YES. (type):
3. PREVIOUS SURGERY [ ]
WEIGHT:
L.)-/L-K
4. R,, OPOSEDVRGICAL PROCEDURE: PAW.po1/4--TA.-b-kr-k; Zriat
07?8 . g.--T4-0 1-1 -e--3/2(601-1-A)
5.
ADDITIONAL INFORMATION: Last- PO: Medical I-Ix: ,51(/ Implants: /25" Medications:Ac Jewelry removed: yes/C)Family waiting: yes

6.
PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NUFkSIN.G INTERVENTIONS

o Allow pt. to verbalizeA. P YCHOSOCIAL 64---Pt. verbalizes any specific anxiety. freely.
o Explain OR environmentPotentiaLfor an e y and answer questions
t--P-4-. exhibits relaxed body posture.
r ted to -matic injur regarding surgery.
;
language bar . r;., arndy,_...... ___,..\ Offer comfort measures, (e.g., warm blanket, touch)
separ, ribn; suQ.E.11 environment ,
Explain all nursing
‘.._______-_____-----
—.
p dures before they are
done.
6-Rernain with pt. whenever
possible.

o Maintain family interface.
. ' -•TION PT. will be able to breathe without o Offer to elevate head of difficu y during immediate intra-tte or offer pillow.
Potential for operative phase. o bserve pt. while awaiting
spirat dysfunction e to surgery for signs cif distress
'datio • Nasitioning; if
"r•---Assist anesthesia during intubation and extubation
-
. will not exhibit signs of impair-o Utilize pressure preventing
C. INT GUMENT
ent of skin integrity (e.g., reddened devices on OR table and areas. accessories.
Potential impairment t9(__c_heck for proper
¦ integuity due to offt) inl; I. lion; fluid shill maintain good body alignment.
o _ positioning and support to
o Frad pressure points.
ir.:......,place ESU ground pad on non Compromised skin surface area.
--e'.Keep prep fluids from pooling.
9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01
MEDCOM - 23416
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOIVIES 8. OR NURSING INTERVENTIONS
D. CIR ULATION t. will exhibit signs of adequate o
Check for support stockings or ace tissue perfusion (e.g., color, warmth, ps. If none, check with doctors.
Potential for inade-
pedal pulse). ,2rCheck that safety straps are
quate tissu a-Pfuc.,•ie-n--du to ./ correctly applied.
anesthesia, racimatic injury-o Offer pillow for under knees.

o Place and take down legs from stirrups with slow bilateral motion.
position; stir-Ric, previc us surgery
o ck that rings have been
•emoved.
,-cc...._Pt. will be transferred to OR table -In Have sufficient people
E. NEUROMUSCULAR
..
without. difficulty. av 'table for transfer.
CO
sure ro er bod
6Qt..,_will not experience unnecessary
Potential i • -ment
E.1. alignment. P P Y
tap physical discomfort.
q ility due to edit • ''13.„,..Allow patient to lie in ---'
position of comfort while
in ,
waiting for-surgery.
Iv .
E.2. Asp- • -ntiaThdiscomfort ffer support (i.e., pillows,
due 'miry; pain bathtowe , etc.) for
positioning.

o Pt. will be made aware of o Introduce self. Keep pt.
.F. NEUROMUSCULAR surroundings prior to anesthesia informed as to where he/she isCONTROL
induc-tion. and what is happening.
Disminished visual ----
F.1. , --o Pt. will be transferred safely . o Inform pt. in which
perception due to being injur • OR direction to move and assist if seclation; table. necessary.
--''
o Pt. will be able,ld understand o Speak clearly and slo .
Potential for •ecreased
F.2
instructions. 7 o Address pt. fro
communictaion due • language ..-----
barrier; sedation o Minimizerfdanger of injury during .-----gide.
intraop riod. o Validate pt.'s

F.3. Potential/ jury due to understanding of verbal
dentures.

communications. i o Verify removal of dentures.
G. OTHER PATIENT PROBLEMS OTHER PATIENT GOALS AND EXPECTED OTHER NURSING
NEEDS. Or continuatio above OUTCOMES. Or continuation of above goals INTERVENTIONS.
problems/needs. and outcomes.

Or continuation of above interventions.
(""
10. OR NURSING INTERVENTIONS COMPLETED/ADDIT1ONAL 1NTEROPERATIVE INTERVENTIONS Ncri-Fn
DATE
11. POSTOPERATIVE EVALUATION:
r-hD er-x-7C-s

12--7 197-
r
PREPAREIY
13. PREOPERTIVE EVALUATION PREPARED le)
n/N— 17 -11 (-1-) TIME: -2-2-43-TE: 7/00003
TIME.• 0 -jz 4 C3'
REVER OF DA FORM 5179, JUN 91
USAPA V1.01
I-INTRAOPERATIv- r)OCUMENT '
MEDICAL RECORD 1
• For use of this form, see AR 40-407, the propc 'icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATINL, .4 , 2. PATIENT IDE -
W D AND PROCEDURE VIA ...._0_,Ztaie-2,.BY CLA-4....0.-tke/0..204, VERIFIED B
i iird 3._DATE TIME PATIENT ARRIVED IN SUITE 4.. PATIENT OM YNO VOS
no5 NUMBER 1 -1
TIME (1--)
5. PREOPERATIVE EMOTIONAL STATUS
lyl_CALM 11 ANXIOUS • EXCITED II CRYING 11 ANGRY WITHDRAWN • OTHER (Specify)
COMMENTS:
.
p4 P,04-, s_o_Agid,A, .442-e-a-Ke/1 i--' -

6. NURSING PERSONNEL
_ _ .
ASSIGNED 6 Pd_ 4 t DT- -;---:---- """ -'RELIEF
SCRUB

SCRUB
I° f----d
6/ lb, \/
1 , &LI, )
ASSIGNED UT-., a- k--, RELIEF
CIRCULATOR
__CIRCULATOR
Iff
iN1 .,
(D(0-6 ..
7. POSITION AND P051,TIONAL A rf, (Specify) got_ fij,l_q.a::.-d, , . a_.4-ii,t_di,c-
. - Itz 0 1,-0-1,4- ai--/-ca.,_7--Zo-r-)
J-Ate.4.1)-ei-bi • V._-) lovy -40.4-% tr—Cfik-F b_... 4=7
/C1-14--ele&6( •
Et SUPINE • LITHOTOMY • PROti---/ 11 KRASKE. LATERAL: • LEFT SIDE UP 11 RIGHT SIDE UP . .
COMMENTS:
„4, 0._454.44-1 trrt-e d-_ 1)1. _ ____ _..
8. SKIN PREPARATION
. _ HAIR REMOVAL @ YEs • NO '''',-r. PREP UTION (Specify) , DONE BY: 41 OR 111 NU G NI SITE: BY HOM:e ifi--METHOD: •
.
DEPILATORY Z4 RAZOFI SITE ii,('Irgei.,.hp BY WHOM:epT-
11 CLIP -
,
COMMENTS:
1-1,0 0 Lit EA GA 0_,Gt_to --yoz,,k4---• ._ COMMENTS: in„.0 p_o--0..._ % pAg40 rke-ie GC-.
9. LOCATION OF EXTERNAL DEVICES
...,,... ..
. ,• 8.- p., . _ :at -
_ ----¦-amilimiii..--
.11,-App-__
-
. ,. "..:
LEGEND X Ground Pad --Safety Strap = = = Tourniquet.-.,.---. -
. -
C ,= Correct I = Incorrect
gt%;fieliir? Fciorsutnct losing FciontainItCiosing

10. COUNTS
SCRUB
CIRCULATOR
6 (cel`J--
Sponge Yes • o
Needle Sharp jj Yes a c_ mi.

-Ge&
Instrument • Yes
U :` a

IF .._._ ...____
Other • Yes • o
11. PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) IESU) p:i YES • NOName -Last, first, middle; Grade- Date; Hospital or Medical Facility;)
Lii i-_GA_
6-0 A-6 S-c'
, .• ‘
• 0 ESU NO: V #
cs2) ,
*L
GROUND PAD: BRAND V i ' / ' 1M 6. 7,.5-ti-
\?( LOT NO: 7*-5 ' c-00S---01 :1' 1:174:0 NO:
-.-
--'GROUND PAD: BRAND
LOT NO:
• BIPOLAR NO:
um. a _''') - t .,
rt A cf-H,RA r 4 -in . es An-r •-,-. --- --_ -
1 9-1 (TESTI, DEC.82, W.HICH IS OBSOLETE. USAPA V1.00
13. PROSTHESIS, IMPLANTS ,L. YE ] NO IF YES NAME: ID NUMBE' JFACTURER
LoAPV3 of ____ _._ _
trill Set 1
el.
TiA IdAIL;Nb sef tiik-o-aArt S : - _ . . toci4403 Psciti- al
3t,
10 x330 mr.-1.
3i
,
V 4. :::',;: r,i, ..;:,,,,,i,:k*0 M E D I C AT IONS /0 R D E RS nna,_.: ''' . .,.
-,..' ,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO •
'MEDICATIONS/SOLUTION DOSAGE TIME • METHOD PREPARED BY GIVEN BY
C.
. -... -•-
-- ' '
_. . •. ,
-MOUND IRRIGATION El. YES • NO, TYPE(S):
o,q 7, o A e L___. „
'421THER ORDERS :, . TIME CARRIED OUT BY :
; -----

_ . _
..PHYSICIAN'S SIGNATURE
; . : ,
15.
X-RAY IN OPERATING ROOM I PeY , ITE YES tij NO • 0--' lej

16.
-' ' :''_' LA9PRATORY SY:E

' CIMENS
, , . . .,
SPECIMEN (S) NAME - -- ----- ---- -NAME
, . YES • NO 11 FROZEN SECTION (FS) NAME ' NAME YES NO
CULTURE (CI NAME NAME YES • NO - -----NAME NAME NAME
NAME NAME 7 -. 18. DRESSING/IMMOBILIZ TION (Specify) _ ...._.
-- -- - ----- a ;to i,t3
17. TUBES, DRAINS/PACKING YES K NO •
, 4
TYPE/SIZE 1. I 01.4.. i,v._. 2. .U49 -1,1-cLi. iti
_ arte_ W h ale) 1 •1 '
SITE 1. k 2. 3. . .....-_-_ Si rbi- in 0-0 eir--6 i le Cyr) '
19. ADDITIONAL INFORMATION
C 1/1 VLF-011 . :-2i:I.:,i.,..-
.1),r.
6 C6.6, LI_ , . _. .. . 0,-4--9----' _
c lorgillip r-iJ Ce,izt q
20. OPERATION(S) PERFORMED
, ,
Titi./1.0...a.L.A1. ___.-
4 D Grirr.,01.iir o—K-m-et:;- - - .
..
21. PATIENT TRANSFERRED WI TIME METHOD
1.-ett. rA 0...tx.... ripe -i2:tizzA)
22. REGISTERED NURSE SIGNATURE
11111111111111111Prr I hiLb ( a -1--
USAPA V1.00

REVER 00- DA FORM 5179-1, OCT 87
MEDCOM - 23419

INTRAOPERAT-OCUMENT( (4-7_
.

MEDICAL RECORD
For use of this form, see AFi 40-407, the propi cy is *he office of The Surgeon General.
1. PATENT TRANSPORTED TO OPERATINA;..-.1 . ..._ 2. PATIENT IDENTIFIEL, *Alil¦l ) P CEDURE $ VIA 1A--110-1---BY ./1.1-7 VERIFIED BY e--ir f '''-1
3. DATE, , TIME PATIENT ARRIVED IN SUITE 4.. PATIENT IN ROOM
1 AO/ 0 0,1---9---3 TIME-: C-0-gS NUMBER C- /
5. PREOPERATIVE EMOTIONAL STATUS
CALM e5ri_DCIOUS EXCITED. III CRYING 4 • ANGRY • WITHDRAWN • OTHER (Specify)
'.C_Cri"--t-^zr---.4./ Cl.t.k.--LC-e____ eig Air--
COMMENTS: fe-f--771'
N r . .,-- , 7 r?,
6.__NURSING PERSONNEL
..: .
ASSIGNED 561--_.. """ -RELIEF
SCRUB .SCRUB

5.9 _.
___.--
ASSIGNED RELIEF
11--11/41 ,
CIRCULATOR ej. , .. _CIRCULATOR
iNT ; .
7. VION AZD POSIT! NAL AIDS (Specify)...c..,.k,;..-7.. tt - -. .
fA. „......,-1-.Pte.-)--7.-,0"--
NrSgiPINE • LITHO,TOMY ,,, PRONE • KRA. KE, , TERAL: 0 LEFT SIDE UP D.RIGHTJIDE UP hTIAA._ f nr"--- r-VAA ‘ -r-cP.-- A.-/ Si••,. • _, s,,..r ,:tA„,,-, J.,...„.) ./t--*--2----
COMMENTS:
-. .--..........

8. SKIN PREPARATION bht.)----
HAIR REMOVAL E • NO "-PREPRLUT,ION (Spe IFC iirl DONE BY: OR • RSING UNIT SITE:\F-,) (51.BY WHOM: 6, METHOD: II DEPILA ORY, AZOR SITE 44- -""."7 BY WHOM:kit)
CLIP )...64-.L--1'4"(L1.-/
_-1_,.._
,.._...,_.
COMMENTS: C,..-t_A-f (rl Af--CA,a-r ,,,,,.1---.A.. bdtvibitm-s: c(5 petn9-e----1 y r4--'
9. LOCATION F EXTERNAL DEVICES
...,,-.
'
_ .-..:„ _._

t. ..,';' '-1 ----.';---..
___:aiRigairarta
-1•1 _, :sa-Th
"
,• _
_
. -,,,-7„,------,.....
j---­
1.42/19"--Ager~
, . Now-
.
LEGEND X Gro d Pad --Safety rap -= = = Tou iquet.....---1:::::1
‘7 (11--t--
C = Correct I = Incorrect
First Closing Final Closing -
10. COUNTS Other• • Count .. rg..; Count •SCRUB / .4 CIRCULATOR Sponge Pt Yes r
.11/1 am
Needle Sharp "El o
_ iilliff ¦•••••""----111111MUIPIP...-
Instrument mil Yes ,1---
-' 1.11PPPI.-
Other • Yes , o
P Mir
11. PATIENT IDENTIFICATI 61-(For typed or written entries give: .LTROSURGERY DEVICEIS) ESUI ll YES NO Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
r&E,& -it-- O. edY1A, I
in V
ESU NO:
GROUND PAD: BRAND PL
_ .1 d - ,.&AI—
LOT/NO. -11/0211
. -,..,.-?_
: m .4.4 NO: V t -; r .
_ ..__
---.GRoUND PAD: RAND LOT NO: 4 '5 7 CG Z-lx,9.70f MI BIPOLAR NO:
\Au)..-1)( ..: E2A4A--6-G-4--7 6)-4
REPLACES DA FORM 5179-1 (TEST), DEC 82. WHICH IS OBSOLETE. USAPA V1.00
13. PROSTHESIS, IMPLANTS F YE N IF YES NAME: ID NUMBE FACTURER
. .._______ ,
.,1,::, , K•, MEDICATIONS/ORDERS ,
14, V
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • N': ¦
,
'MEDICATIONS/SOLUTION . DOSAGE TIME METHOD PREPARED BY IVEN BY
t
.,; _ , _ _
, .
-.
.-
?NOUN IRRIGg2L YES NO, TYPE(S):
1PTHER ORDERS TIME CARRIED OUT BY
_______-_ ... .
.
PHYSICIAN'S SIGNATURE
, b ( a . ,
15.
X-RAY IN OPERATI IF YES, SITE
YES • NO i

16.
- ` LABORATORY SPECIMENS

, . ,
SPECIMEN (S) NAME - ------ ------ -----NAME
YES • NOV-
FROZEN SECTION (FSV NAME NAME
YES N NO/u
CULTURE (C) V NAME NAME
YES • NO --------
NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (S.ecify).
12_,
. __.-----6-42-OL/V•.-
c___________
1 7. TUBES, DRAINS/PACKING YES NO • of , ..0
TYPE/SIZE

1. tGF..4, R,r6i 2. W. iLfj-r.„( . ion
,4 ?( :1--
I ,- ,(2
SITE 1ValkEfit).(.G.0.14,,,,....._ 3. , r
2.
,..,,,, ..
_v-71,-/-A-er.•
19. ADDITIONAL INFORMATIDN ' ,i .
i40.4..),
S \J T141/4-‘-tra---A--
. . -, .....-.--:-_
0-1
il_si
_ „g_e__,;„., 0_,4----,J---

N.A.:.c_ ,P...-4A._. ei-0--,...„./
ov-rzyy.A....„-r ,
/

20. OPERATION(S) PEliFORMED --
_
ft
1 (7))/(4/-di,p i _ T r E.2_ 0.:,../-(e_ 2 (5_01 ( g-e#-A___.
, c„,,,_ 44.._,L.e.,4_ 6.e._,sD-C..-_,,,

21. PATIENT TRANSFERRED TO kadt T I Mb 0 MEJE-21L)D114,1_
NURSE SIGNATUA7-bq N. _ _ —
(_ C.c._ ) — Z_

4) L
REVERSE OF DL5179-1, OCT 87 USAPA V1.00
MEDCOM - 23421
INTRAOPERATICUMENT
MEDICAL RECORD
,
For use of this form, see AR 40-407, thig_proix( cy-is-th ice of The Surgeon General.
1. PATIENT RANSPORTED TO OPERAT...-3,;.....PA-TIENT IDENTFIELJ, ..r_,: D D PROCERURE
r
VIA L 1 1- BY CPT-.-----VERIFIED BY / 1 6,1-, 1.
b Y ) -Z
3. DATE., TIME PATIENT ARRIVED N SUITE 4.. PATIENT IN ROOM I S NOV- Q3 0 , 2 —/ TIME. , up--7.NUMBER 2 — t
5. PREOPERATIVE EMOTIONAL STATUS
...27CALM • ANXIOUS • EXCITED. • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)
COMMENTS: _ _...._.
6. NURSING PER.S.ONNEL
.
•: ....
ASSIGNED L_c*Q1 -----RELIEF
SCRUB .SCRUB

\--,
ASSIGNED Al RELIEF
CIRCULATOR -.... —_C.IEtCULATOR
ANT; .
7. POSITION AND POSITIONAL AIDS (Specify) ...-
..‘...',:Vi-.,
g4JPINE II LITHOTOMY • PRONE • KRASKE.' LATERAL: LEFT SIDE UP RIGHT SIDE UP
COMMENTS: . ,'
8. SKIN PREPARATION HAIR REMOVAL
• YES \-Er:.10 ''., -PREP SOLUTION (Specify).
CAA:ctrii--v-
S-C iscu'Lls i-ffit-e4(CAr's.
DONE BY: 1111 OR 111 NURSING UNIT SITE: R.:•c- 2--91.-, BY WHOM:ftlitzi '
METHOD: • DEPILATORY • RAZOR . SITE ,..... BY WHOM: .
• CLIP ..._—____ ...._ COMMENTS: ________.--.. ...COMMENTS: A.i \
/i)0 c.) ‘ 1 liAl cif-_3'e LLA.---t airs_
9. LOCATION OF EXTERNAL DEVICES /3 e4o,A*..4 °Lin t_eA.
': 4.. • •
_-, --
.

..
i.-1.1 :Lit• -
• _
_- —e"mli¦-•411Riaimasi6NP--
AllraimirrewAlog,-
-
i 4,-:.=-.--
LEGEND
X Ground Pad -Safety Strap = = = Tourniquet----...--.:.-(
C = Correct I = Incorrect
First Closing Final Closing

10. COUNTS
Other** Count ...ki... Cc:hint
.SCRUB
CIRCULATOR
Sponge B Yes
iii
-E1111M1111r
Needle Sharp Yes •

=mi 11.1111111. —11MTE16., -
Instrument Yes
••1....._ ......m11111111111 -...iiiiiiIMIPP. '
10""" ,MIL
-Aaikii
.
Other 0 Yes a 0
ii. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) IESU) YES Ea‘Name -Last, first, midAlle; Grade; Date; Hospital or Medical Facility;)
i I-)
ESU NO:
-Algiffiala .
.._.._ __.
. ,GROUND PAD: BRAND
----:--,-,: • LOT NO: ;.E17,40-NO:
b 1_(6 - L\ „ . .._ ..
---7-GROUND PAD: BRAND
....,,
LOT NO:
• BIPOLAR NO:
r% A i'll'IIIII • -.yrs • oN ...-1- ••¦ •••
— , 1 9-1 (TEST), DEC.82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 23422
13. PROSTHESIS, IMPLANTS YF INO IF YES NAME: ID NUMBET -ACTURER
_____.
: :-.-
. 4-.4, . , ..„ , -:gk'S M ED I C AT I ON S /0 RD E RS .P.K ., 'i., IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO • :MEDICATIONS/SOLUTION DOSAGE . TIME METHOD PREPARED BY GIVEN BY
_
...-
. , _ _
. , .
-
-
MOUND IRRIGATION i2"YES NO, TYPE(S): Ajt - .
iI
;,OTHER ORDERS TIME CARRIED OUT BY
i,t.; .
-•
-
'PHYSICIAN'S SIGNATURE
, , __ ,, _ „ -_ . „„_„.„ __ .. ---, , .,,
......
15.
X-RAY IN OPERATINVM . IF YES, SITE
YES / NO -

16.
- ' : LABORATORY SPECIMENS
SPECIMEN (S) NO 6,2JAME -- -- --- ---NAME

YES - . ---2 -. -
FROZEN SECTION (FSL„),AME NAME
YES -NO
CULTURE (C) NO 17r.„.,.-KIAME NAME
YES •
NAME NAME NAME

NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
. __
17..TUBES, DRAINS/PACKING YES 111 N 0 LEr-* PI t k-*f---- 5
TYPE/SIZE 1. 2. ' -'-"
[C-Q-r-fi K
SITE 1. 2. 3.
19. ADDITIONAL INFORMATION
---CkV•9 -(1-01A 1,.Ov"
.. r ,.,..if,

a/Ae_S s, C131— __ , _ _ , _
\ . -
LE .'-
20. OPERATION(S) PERRNMED
-

b fiC d2/-t -e--32 . _ _„. _ _ ..___

21. PATi5NT TRANSFERRED TO TIME METHOD
LA..
-
1010.-Z._ I )44E4
22. REGI
A/Vi-J itikr
________ L
OHML- , USAPA V1.00
MEDCOM - 23423
DOD-037001

-
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONT DAY
.
r 6 il
HOUR • • • . _z . .7_. p... ... ... ... ... ... ... ...
. . .
PULSE TEMP. F • . . 3—: ' 0 ' 4 • •• • • •-

op) (*)
. 0:L.5 . . . . . . . . -
105° . . ;...... 4:9 ..

.
.

0

. . .

40.6°
.•

. . . . . . . .
i .:--i-. .•.:. . . . . . . .
-.

. . .

. . . .
180
. .
. .
104°
•• •• . : •• • •
40.0°
....... ,

170 103°
...... . . . . . 39.4° 5-, • • •• • •• c0
. . . . . .
'

. . . . . . .
a)
0
160 102°
38.9° c 92
a)

......... .. .

•. . . . . . -. . . -
.
.
. .
a)
150 101° . , . .
.
38.3°
,
Ix
,
. . . . . . . .
...........

.. .......
. . . . . . . . . . . -
8
. . . . . . . .
vi
...-•
140 100° •,
•.. •• •• • •
..
,
37.8° c
.. . .
.

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4.•• •• . •• . •
. •• . •• . . •• . •• •• •• •• •• •• •• ••
To
. . . . . . . .
.
=
cr
. w
130 99°
37.2°
98.6° )........ . . •. . ¦ .• . • •• -• •• •• •

37.0°
.
120 a)
98° ..... . .. .. .

.: ..v. ..
, .
...
... 4.: .. .. .. .. .. .. .. .. .. ..• 36.7° -D
. ... . . .
e
.... ta
. . .
. .
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110 c
97° \?: . . .
.. . . . . .
. . . . . . . . . . . . . . 36.1° a)
. . . .
. . . . .
. . . . . .
• • • 0 0 " •
100
96° , '.. , • . . , , . , . . . .
• •• , .35.6°
. . . .
90 95° . . . .

1. o
. . . . . . . . . . . . . . 35.0° . . . 1
. . . . . . . . . . . . . .
80
. . . .
-• --

70 . .
.. .. .
.. .
.. .
. . . . . . . . . . . .
1 . .
. . . . . . .
. . . . . .
• 1 • • • A '
60
...
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50 •
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.
... . .
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. . . . . . .
... . . . . ' " . .•.• ' • " " ' • ' •
40 •
..... #0. r . . . . . .
. .
. . . . . . . . RESPIRATION RECORD
— '15 6: , ir
DeJapioospawn Apoeiepte!oadspiooat{
BLOOD PRESSURE
03(rEl 41 flyq r(11 9
gi.1 JCP'11 114/1 81
HEIGHT: WEIGHT —4.
9ffo
07 —MAO Prx ft eAt
I !
!

,ATIENT'S IDENTIFICATION (For typed or written entries give* Name—last, first, middle; ID No.
REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 23424
DOD-037002
511-119 NSN 7
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY
1:74--tjAil Fs 1 • 10
:-

1:).0
1111
II

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NIMINIIIMINMI
Mil

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19 Eft3
C.)
HOUR
'°'

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czco's4
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—: :
PULSE TEMP. F
ir. . a.0E6

r;i0141•Pit
witt -: :

(0) (.)
i

105°
.

. .
•. •. " . .

!

180 104°
. .•

. . . .
" " • " • ••
. . . . . . . .
. .
1 . . . . . . . . . . . . . . .
. .
170 103°
. .

. . . . . .

. . . . . .

. . . . . .

. . . . . . . . . .

160 -102° 150 101°
"
i.. .. :. : :. :. .
ppm :. :. .. .. .. ..

100°
140
j41
.. .
IS

.... MrA

1111.AIMILAZWWINIMIZI111114•311113111IME
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130
99°
98.6'
120 98°
INIMMEME

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k• • •
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1 :: hi ::11:. Mil11
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110 97°
:

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im : : 111..

100 96°
90 95°
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RESPIRATION RECORD 6
pomp°osuaqm Apomoplepads'mom I
..,

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

STANDARD FORM 311 (REV. 7-95)
(ct
Prescribed by GSA/ICMR, r1RMR (41 CFR) 201-9.202-1
MEDCOM - 23425
DOD-037003
ANESTESIA PLAN OF CARE PREPASSENRAL ASSESSMENT (Sedation/A=1=W
Age3.12 DAYS MOS YRS
PROPOSED PROCEDURE: SURGICAL SERVICE
NPO SINCE: L/17.,91)
TOBACCO:
ETOH:
DRUGS:

CURRENT MEDICATIONS: ( ) = ordered as premed
( )
0
0
PREIAEDICATIONS:
None Yes (0 Its) /CC mg IV DA PO mg W IM PO mg W DA PO
LABORATORY STUDIES:
HI3/11CT: U/A: OTHER:
PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
Cardiovascular:
Hypertension
Angina
MI
CVA
Other
Puktionary System:
Asthma
Bronchitis/URI
COPD
Other
Renal System:
Acute/Chronic R Y
Gastrointestinal:
Hepatitis
Hiatal Hernia
PUDIGERD
Endocrine System:
Diabetes
Steriods
Thyroid
Neurological:
Seizures
Neuropathy
Other
ncy N Y
nificant Hx:
N Y
N Y
Familial HX N Y

Sex ( ) MALE ( ) FEMALE
ASA Physical State 1 2 3 4 5 E WT: FfT: IN. ALLERGI 4/e4-
ASSESSMENT PAST SURGICAL/ANESTHETIC
/49 PHYSICAL EXAMINATION BP HRAQ R I_ Pain le 0-10 3 HEENT - Teeth —74/—W-e-v:4-/
Trachea — 2-TIAJ/Neck Orophannyx Nares
CHEST: e
CARDIAC: /t/Cif
EXIREMMES:
IV Access:
Ulnar Filling:

BACK:
OTHER:
NPO Since /YPC4f)
ANESTHETIC PLAN: { LOCAL { MAC { ) Regional (Specify): )(General: Mask Intubation
INFORMED CONSENT/COUNSEIJNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and discussed with the patientfiegal guardian. 4010CCA--1--The . Questions anwered. Signed: ' Date: 0-0°./493 TiMe: Hts
POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) SEDATION KEY:
} NO APPARENT ANESTHETIC COMPUCATIONS { OTHER
1. MINIMAL (Anxiolysis) Patient
responds normally to verbal
commands
Date: Time: Hrs 2. MODERATE (conscious sedadon)
Patient responds purposefully to
verbal commincts al0M) or
Patient Identification: (Ward) accompanied by light tactile stimulation. Airway assistance is not
necessary.
3. DEEP SEDATION/ANALGESUL
Patient responds purposefully
following repeated or painful

stimulation. Airway assistance may be necessary.
4. ANESTHESIA. Patient does not
respond to painful stimulation.

V/1111111,-
WAMC Fonn 2300 (Revised) 15 Mar 01 MCXC-DOS Previous edition is obsolete
MEDCOM - 23426
*U.S. GPO: 2002-729-283
MEDICAL RECORD -ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG (Units) TOTALS TOTAL EBL
ireA/ 4/17/ /C4 41* ,0 • &?-0 ) •'.3---iD
Zetire4,,trOrrlant i TOTAL URINE
( ) ( ) 5.—c..,0 ( )
VOLAT -FLUIDS -SUMMARY
rrrAirre.wo del -AGENT % e.t. • CRYSTALLOID-AIR L/Min '2. yeeo
N20 L/Min COLLOID-02 2._ L/Min
BLOOD-
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
IspntiaCINV SIN3911 3113I-11.S3NV I saunAI
NOISrldNIINV1SNOD= .1. "11/1/0011/DVI -sliNnA3103cIS son8a031¦13d3U/SflOrINII.NOD
LIN site 0 Warmed —.es REMARKSrotanarm 0 Warmed
le"ideffilliiiiih-. Code drugs with numbers,
•A ,
events with !enters
rem= 0 Warmed ...-----Eif4„.. mit= /E] Warmed IIIIM=E /15 1:4C Al
EST BLOOD LOSS
LOSSES
..",../644C.4)
UR NE -
PHYS STATUS
TIME • . j))/eitieu/ / ke)1 2 3 4 5 E . . At SYMBOLS:
Altchlet ief'n V
BODY WEIGHT: 220 i , i
i__..,__. .

KG BP by cult i ZA-444-6-4440/
LB 200 . . i
'
v ' # 6 (se —
HEMATOCRIT:
i so ' , , ,
A
. ,__
" : / S.fro c....Abr-._ Z.:
Heart rate , .
160 Nu: ", ,
INITIAL DATA: • .
Resp rate 140 . . , , . . , , , , alpAded4/t„BP-/ /,,
MI AIM , . . .
_PP C 12° MIIIIE111MIE . , . . ' &Aiwa( tfPgfi
MSEMIKVAI ¦ , .
.
BR Aft C 14 ()Al id t h 4
Itransduced) 100 . . . . ,

MIIIINTARV EMMEN
7-q o J._ . . Irrati'MW1121r.AVANK/41 . , IMO
EQUIP CHECK
T 8° MMUimmirtiaiNEWA sow . ieir ,i ,,,,
01O-Y N 60 NMI Moor EN
TOURNIQUET , 4.--L,
PATIENT RECHECK T —4`. T—T—
IlleiMMIII , i 1
i ¦ c."4.ev4.4) /
40 , ,
OX for • , piaMPIra ___rn .

PROCEDURE? ANES-X-X IIIIINIIIIIIIN
PROC-0_125 20 IMMEMEINE111 , ¦ =MI : , . , , ¦ . sex.A6474if,
TIME- , , . ¦ , , /
IIMPUDIMa:-ANIBEEM
7-0 te eeiv,"
lan
It II-
VT -ml
ilFraiTa 7 0 " .
1IJ.N3A S3180SS333V/SIJOIINOIN I
f -breaths/min ...
Peak in( pres / PEEP
DE - S( on), A sist), CIon) MI A

RECOVERY AT rBP/Auto Cull CO2 Itorr) MI 3 2-_ir_t
PACU iCu Specify)
IBP/oth F 2 (Frac or %) 4/ ayLfr7 0 6 IART line r (oh, _A___OTHER
9,6 ' Do.. 5---
Ste -PC/ES CG CONDITION:a
' A l'i
as analyzer TEMP-site
RESP-Sp02-
IN-M Block (7/4) BP./1_7/57 HR 73
-
ARES HESIA / PROCEDURE TIMES 1 e) Start Room End
I Warming blkt I .1 tr 0.72 0,3S7C-
Cony warmer
o Ready Begin End
with letters & symbols,. 0
EVENTS---0- 1.....7 &
erg's'', under REMARKS.PasitiOn
Me k
411,
03
ci-Oaf
PROCEDURES and CPT Codes: A---ir-A henel-gfde ANESTH TIC TECHNIQUES: Describe block technique under Remarks
6044 5 . &C 9 14,f'.4reiCI ifipkii-eA/C4ido
PATIENT IDENTIFICATION: Typed or written entrie.Name, Grade/Rate,
fAIRV/AY MANAGEMENT: lntubation route, blade, technique, comments Medical facility
fl7t0. -----,3.ft,er
SURGEONS: PROCEDURE "04 LOCATION: 1-.--DATE:
-WCA ' (1 gr--- \---0 /16,C93__
i
PAGE / OF /
A FORM 7389, FEB 1998 ANESTHESIA DEPARTMENT USAPA V1.00 MEDCOM - 23427
DOD-037005

MEDICAL RECORD -ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
TOTALS TOTAL EBL
DRUG (Units)
U) En LI 0 _I
1
a D2 z . (1/__ .111
a a'.. AfL
cc c c - cp av,L
( mg) :1
a .ca.
TOTAL URINE
a ,?..R iv-( /1,6 )
z 1- 0 z ,
(IV-wal i
N*I 11 21.-tn a- . Z ( )
37i Z --. 1— I— ( )
I— et U) 4
uj (/) 2 U)
FLUIDS -SUMMARY
CI DDz VOLAT • LAZIMIFM
4 0 0 IP % del
F1-44-41iiiAiiliMil
D- u AGENT % e.t. CRYS2AigS
0 Z LI- J
P I:: L)t- AIR L/Min
uj Z ti •
COLLOID-
x 0 co N20 L/Min IN
i . -U elIi..'
u) 02 L/Min "WC IMIII/1110. IrMIIIIFIN
1 I BLOOD-
LAI SINGLE DOSE DRUGS-MARK ON GRID
re,-„ g
41LCO r.olle
WITH NUMBERS & EN ER IN REMARKS '`".
.1
tn NAT& WAgr Awrifai wipm./te.tRY R.E„M7rrY A• KS
LINE site armed
Code drugs with numbers,
CI I] Warmed
e.ts.WI lettters, ...; 11) Warmed
5
of ?,,---ploi
El Warmed
EST BLOOD LOSS
LossEs 6cti, 76 Oe
UR NE -
PHYS STATUS TIME 110'. 30 C7 09 I 0/39 /Doc , /cx10 f 94" / Alf2141.2;7
„,3 4 5 E

SYMBOLS: ' P4v4/574,
B Y WEIGHT: 220 ,
laa
.._ 4..o
BP by cuff , • , 1. a :1-ge,e 'A,
LB 200 . .
" MN ge_
v -er Sdfahleal, Ci
i , , , '
HEMATOCRIT:
18o : ; . ,
A "
_,_,_
40 C • L ,,,,,,,,,,,„.„-
Heart rate . I Pa,
160 , , .
=MIEN w
INITIAL DATA: • BP-.'
, IMMINII ,Pg per
Resp rate 140 „ 1.0"
MEM ¦ . rrA11711r ' FW411911.11111
, 120 41F4PM°!"1
1 2- 3 K• MillillAIR AT•211112r AlIkr ERNIE
e,vi--'611.--cw, Z
HR-IIIIIIINWIVaita= , ' . ri :NE
BR x smig
ftrensducedI 100 ,.„ • 1612
P9/
1.. 111111111111111ENMEM • , , . . 11111
EQUIP CHECK 80 . • . . 11111
T
_,___¦__ . 1111111111111111
OK?- 60 M
N TOURNIQUET
' -AL • MN
PATIEN ECHECK T —./1" PI vAY MLR
40 =Mean
' NEM . dk
OK for
PROCEDURE? ANES-X-X MIN IMIIIIII PROC-8_0 20 ENE ' " ' . . 1111111
TIME-?
MilIMMI MN ' 11111111111111 ‘,.
VT -ml IFM 4111 70L.0 CASEI • fp . -tik,71 • r-f -breaths/min 0 0 10 IC, 0 0 MU
Z
w Peak int ores / PEEP 0 20 i
_L7, ._l_g_
ODE - S( on), A(ssist). C(on) L C (.. L. .
PlISCUaTaggalErAti,'
BP/Auto Cuff CO2 (mu) 3 IMI 50 ,3 0_ 2, Irra ilri IIMID/Efr.-icu Specify) w BP/oth F102 (Frac or %) 0 0 / 0 nell #. C, I . 0 h 0 4 II pit"''.
14,„1 „. THER 1-Dc,a).---e_
CC ART line Sp02 (%) 69 0 /0,0 WI / .00 ,90 a• '00
0 • COND ZIA ...119,43
tn Steth- PC/ES A IffrAlliralliMI NE. 3 E 1
CA
in Gas analyzer TEMP-site V "'ESP.' " Sp02-/DD
C.) WW1 -4° 31C1-1--3314 /Li 0 N-M Block (T/4) BP-4.94/0-- RR-/C.9.1 ANESTHESIA / PROCEDURE
CO TIMES
Ce 0 M Start Room End
I-- u,z
2
0 Warming blkt 4 °rill/S.-1F-05-/ ea2 Cony warmer 0 Ready Begin End Me k with letters & symbols, EVENTS_, ci „9......., ..„. i
explain under REMARKS.Position.-C2---A----, -K vaxs elpes / tr PROCEDURES and CPT Codes: ANESTHET TECHNIQUES: Describe block technique under Rernarks
PCs ; 1.T419.Z Groli Criza4eati". 04 PATIENT IDENTIFICATION: Typed or written entries; Name, Grade/Rate, AIRWAY MANAGEMENT: lintub lion ro te, blade, tgnioue comments.' Medical facility. *4,1 y I" m i 1 /titL6-rae-Lt"rx....,Lk 1 C 02_ ÷ a ',ff, e r f . i*-..(
r
PROCEDuRE
Mk LOCATION: /- /
11111111111‘11 --1' ( CJZ._ ---? DATE:

L(C..--- 0
ANESTH -d'keti 0-3 PAGE i OF 7
4
DA FORM 7389, FEB 1998 COPY 3 -ANESTHESIA DEPARTMENT USAPA V1.00 MEDCOM -23428
/*-1 . Lair //r)/7) ,rf•
DOD-037006

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG TOTALS TOTAL EBL
AL URINE

-
/SI/INI/S f
N3!
lc •/ ...-/ • • - FLUIDS -S CRYSTALL D- RY
*FA '
COLL• 11
2-
4/ B •OD-
u) o 5 -J 11 LINE siteatyli, 0 Warmed 0 Warmed El Warmed tiiii -.. . REMARKS Code drugs with numbers, events with letruLl
LOSSES 0 Warmed EST BLOOD LOSS UR NE - .•02-41.- e"
PHYS STATUS TIME IROI• 2 3 4 5 E I SYMBOLS: 220 200 180 160 140 .B 0 DY WEIGHT: KG LB HE ATOCRIT: BP by cuff V A Heart rate • Resp rate BR ltransduced)_I_T TOURNIQUET T —4/ ' ' ¦ !NIT L DATA:B AWE re 1 201/0,/ HR -AV 100o i En F. c lEll OK? -Y ,BO 60 PATIENT REC OK for 01‘ A A , ' i /8.00 : , •• : , , . 1 , . „ , , 3'-eV °C)/./ Z.`".
/ : , : : ,_ •___ . . .i _,_.--, . , . , •-. ___•___:__ . , : : I I / , ' . . , , . ' , • , . ' ¦ I , . , . ' , , . rj2--_..... 4 e'vljPC, _5L./ e-Di 5X--vi.--5-()(-6.11-113 gt.,-.4r / V P grfr4/1" 141/: 6 dfr-'1,2 ((..te-
PROCEDURE? TIME- ANES-X-X PROC-0_0 VT - ml 20 " , 8160 • , • , „ i , i i . i i , . , • . • , , ., . .. i i. —r-7--i i .
PZ i f -breaths/min Peak inf pres / PEEP

MODE -Stpon), Mssist), Cion) RE i OVERY AT I
kElP/Auto Cuff ET CO2 (ton) i cf)BP/oth 102 (Frac or TO PAC Specify
„, ICU
FE ART line Sp02 WO
OTHER 01 Stelh- PC/ES CG
0
-nr cm Gas analyzer TEMP-site
Cn CONDIAik: ,,,,, f
C.)
RESP- -3IP SpO
C.) N-M Block IT/41
BP-H • U) ANESTHESIA / • • OCEDURE
o tx A
TIMES
1-
mice
n • 0 Warming blkt
2 ow MIL
2 Cony warmer .1
(I criffi BeginMark with letters & SYmboiS..EVENTS End explain under REMARKS.Position o
cc
o.
PROCEZURES and CPT Codes: ANESTHETIC TECHNIQUES:
Describe block technique under Remarks
-------*-4--
PATIENT IDENTIFICATION: Typed or written entries:
Name, Grade/Rate,
AIRWAY ANAGEM
lion route, blade, technique, commentsMedical facility
1P--€/e-
ilw6.41 ...._.___

PROCEDURE
DwAcTAE:Ts„:
roNecA,./4.3
b ( c.,t -4-
PAGE Z.OF 2
nit Cf1C/11n 'T-aors ers ...-Ine,
COPY 3 - ANESTHESIA DEPARTMENT USAPA V1.00
MEDCOM - 23429
DOD-037007

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
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PAGE OF f n a FfIRIVI -7.200 CCD 1 ODD MEDCOM - 23430 Y 1 -PATIENT'S-MEDICAL RECORD USAPA VI.00
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RADIOLOGfC CONSULTATION REQUEST/REPORT
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MEDCOM - 23431
DOD-037009

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75-40-01=16S-7Z94
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RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tornography Exa-minations)
1(1
EXAMINATION(S) REQUESTED
AGE SEXISSN (Sponsor)
wAR,cLiNic REGISTER NO.
PAW
'FILM
PREGNANT
ri ri NO
R-P 4-Lat YES
TELEPHONE/PAGE N,
't5A-r-RE9uEsTED.
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SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
.1rA
DATE OF EXAMINATION (Month. day, year)
DATE OF REPORT (Month, day, year)
DATE OF TRANSCRIPTION
(Month. day. year)
-z.ADIOLOGIC REPORT
?AT IENT'S I OENTIF [CATION (bor tyPed or written entries give:Name — fart. first, middle. Medical Facility)
LOCATION OF Mt.OICAL RECORDS
LOCA ION OF- RADIOLOGIC FACILITY
MEDCOM - 23432
gif0(6e
DOD-037010

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R.ADIOLOGIC CONSULTATION REQUEST7REPOF:T
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MEDCOM - 23433
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR sHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARFIOW BELOW.
PATiENT IOENTIFIC ATION
DATE OF ORDER
TIME OF ORDER LIST Ttm ORDER
NOTED AND
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PATIENT IDENTIFIC _/
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DATE OF ORDER
TIME OF ORDER
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DATE OF ORDER
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FORM
DA 4256 ACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
1 APR 79
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MEDCOM -23434 D
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DOD-037012

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CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION LIST TIM
ORDER
NOTED AND
SIGN
NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
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HOURS
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
DATE F ORDER
TIME OF ORDER
HOURS
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NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
BED NO.
REPLAC EDITI
N OF 1 JUL 77, WHICH MAY BE
DA 4256
IFA0pRR19
MEDCOM - 23435

DOD-037013

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66. the proponent agency is OTSG
THE DOCTOR SHALL RECORD
DATE, TIME A 9,SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUM

IN COLUMN INDICATED BY ARROW BELOw.
PAT:ENT JOENTiFICATioN
OATE OF ORDER
TiME OF ORDER LIST TIME ORDER NOTED AND
e t 70
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TTIENT IDENTIFICATION
DATE F ORDER TIME OF ORDER
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REPLACES EDITION OF JUL 77. VYHICH MAY BE USED.
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MEDCOM - 23436
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66. the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION 0 TE OF ORDER LIST TIME
TIME OF ORDER ORDER NOTED AND
HOURS
Op \k"2 /I -/.n--c.) SIGN
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PATIENT IDENTIFICATION
DATE OF ORDER TIME OF ORDER
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HOURS
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TIME OF ORDER
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A FArRm79 _ __ _ REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED. ..
MEDCOM - 23437

DOD-037015

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PFIOBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICA TION NURSING UNIT IN I PATIENT IDENTIFICATION ROOM NO. ) BED NO. DATE OF ORDER TIME OF ORDER -• HOURS (2-011:‘,4, e.jut-4,Q 1L,3, wyvt5--v_ivo "-A/IAA, 1-0 LA4-siP irft•L-DATE OF ORDER TIME OF ORDER HOURS LIST TI AND(,(ta)-e ORDER N ME
NURSING UNIT ROOM NO. ED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER HOU RS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER HOURS

NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH
MAY BE USED.
DA 4256
IF:pr3m79
MEDCOM - 23438
DOD-037016
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THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)
CLINICAL RECORD
For use of this form; see AR 40-407; the proponent agency Is the Office of The Surgeon General. Ma Yr. 2003
VERIFf'BY INITIALING
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ORDER CLERK/ RECURRING ACTION, HR DATE COMPLETED
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ADDITIONAL PAGES IN USE: 11NO
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PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07
_MEDCOM: 23439_
DA FORM 4677. 1 OCT 78 JSED.
USAPA V1.00
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICA770N) mo yr 2003
Order Cleric Date to Time to SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
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USAPA V1.00
MEDCOM-23440

Doc_nid: 
3968
Doc_type_num: 
77