Medical Report: 33-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Blast Injuries, Leg Fracture

Medical report on a 33 year-old Iraqi male detainee who was brought in to the hospital suffering from blast injuries due to an Improvised Explosive Devise (IED) he was working on that blew-up on him prematurely and gunshot wounds incurred while being taken in to custody. The detainee was then taken to Abu Ghraib prison for internment.

Doc_type: 
Physical (non-death)
Doc_date: 
Thursday, September 25, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

33 ye cr
ANESTHESIA PLAN
RE Ph=t2aagyRAL ASSESSMENT (Sedation/Aggagaba
Age 33. DAYS MOS Sex )MALE ( ) FEMALE
PROPOSED PROCEDURE:
SURGICAL SERVICE: (039 )
NPO SINCE:

MEM PREOPERATIVE
TOBACCO: PAST MEDICAL HISTOR S REVIEW ASSESSMENT
ETOH: Cardiovascular: PAST SURGICAL/ANESTHETIC
DRUGS: Sr Hypertension

Angina
CURRENT MEDICATIONS: MI
0 = ordered as premed CVA

Other
() Pulmonary System:
() Asthma
() Bronchitis/UFO

sPHYSICAL EXAMINA
() COPD BP HR R T NV;
Other

Pain Scale 0-10
Renal System: HEENT - Teeth
Acute/Chronic RF Trachea •PREMEDICATIONS: Gastrointestinal: TPLUNeck
None Yes (0 Hrs) /CC Hepatitis
Oropharnyxmg P1 IPA PO Hiatal Hernia Nares mg IV IM PO PUEVGERD CHEST:

cp...
mg IV IM PO Endocrine System:
Diabetes

CARDIAC:

LABORATORY STUDIES: Steriods
Thyroid

EXTREMITIES:

HB/HCT: Neurological:
WA: Seizures

IV Access

OTHER: Neuropathy
Ulnar Fill' ( Other
5-3 o 1 Gynecological : BACK:'

3r Pregnancy N Y
(3d. 7 Other Significant fix: N OTHER:

N

Familial HX N

OrdX 41 -(7-effScark 1144C
at' It.`i fir 3114 NPO Since Ai/ 14
OK 1,03

ANESTHETIC { ) LOCAL ) MAC f Regi (Specify):
neral: Mask Intubation
ic e v(t

INFORMED CONSENT/COUNSEUNG STATEMENT: Plan , alternatives and risks of anesthesia including death have been explained to and
discussed with the patientfiegal guardian.

The pate
to stand and agrees. Questions answered. Signed: illPilltnstPr Ni4" 00)/bi-Z--Date:
I See G3 Time: Hrs
POST-ANESTHESIA EVALUATION AND NOTE (NON ASU)
SEDATION KEY:

{ 1 NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER
1. MINIMAL (Anxiolysis) Patient responds nornudly to verbalcommands

Signed: Date: Time: Hrs 2. MODERATE (conscious sedation) Patient responds Purposefully to verbal commands alone or Patient Identification: (Ward) SCA.4.) ".. 1 accompanied by light tactile

stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA.Patient responds purposefullyfollowing repeated or painful stimulation. Airway assistance may

iimidia couc)-ei
be necessary.
4. ANESTHESIA. Patient does not respond to painful stimulation.

iiminp(b)(0-i/
MEDCOM - 20441

WAPAC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
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SURGEONS: PROCEDURE
LOCATION
OP 376 REVISED 1 Jan 99
PATIENT RECORD
MEDCOM - 20442
DOD-034016
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER
TIME OF ORDER
LIST TIME
ORDER
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ROOM NO.
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MEDCOM - 20443
DOD-034017
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.
SYSTEM IS USED WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
IF PROBLEM ORIENTED MEDICAL RECORD
PATIENT IDENTIFICATION
HOURS
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PATIENT IDENTIFICATION
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1 FAPR
M79
DA 4256
REPLACES EDITION OF 1 JU 77, WHICH MAYBE USED
MEDCOM - 20444
DOD-034018
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
PA ENT IDENTIFICA
NURSING UNIT
PATIENT
IDENTIFICATION
PATIENT IDENTIFICATION
NURSING UNIT
REP
ES EDITION OF 1 JUL 77, WHICH MAY BE USE
00)/6) -Z
MEDCOM - 20445
DOD-034019
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see
AR 40-66, the proponent agency is OTSG
SYSTEM IS USED, WRITE PROBLEM NUMBER
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
*
IN
PATIENT IDENTIFICATION COLUMN INDICATED BY ARROW BELOW.
DATE OF ORDER
Lc-27y esJ TIME OF ORDER LIST. TIME ORDER
HOURS NOTED AND
SIGN

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PATIENT IDENTIFICATION
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DATE OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT
DA

, FAr,,m79
4256 REPLACES EDITION OF
1 JUL 77, WHICH MAY BE USED.
MEDCOM - 20446
DOD-034020
,EDICAL RECORD - DOCTOR'S ORI.,..,
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing willlist the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying.
They may be signed off, as completed, in the far right column.
ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS7 • 29 ¦ 03 /7Z5 ORDER NOTED TIME & INITIALS COMPLETED TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
0 VS q 5 min X 15 min, then q 15 min until discharge.
2 Supplemental oxygen. (1)/i)-7.-
0 Morphine / Iviepeitinte- w and 1-1­mg q 3-5 min pm pain for a
max dose of / mg.
4 Zofran mg IV pm N/V q 15 min, may repeat x .
5 Metoclopramide mg IV prn N/V x 1. •
6 Droperidol mg IV prn N/V x 1.
Phenergan / 2 ' ,-mg IV pm N/V x 1.
8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
9 IVF: Ca cc/hr.
63 Discharge from recovery status when PACU discharge criteria met.
11/1-P44-S
(b)/ b) -7— i¦-•(–C-.4444/7'

PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any changes on subsequent pages.
(4)(b) - ‘/ Diagnosis:
6
. Height: Weight:
Diet: Allergies: Nursing Unit Room No. Bed No. Page No.
PACUMEIN
1 of 1
_
-
(M HO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00
(4)Z z) -z
MEDCOM - 20447

DOD-034021

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

DATE
OF ORDER TIME OF ORDER
141
03
1111
(141t) -V
4);:e-e-21
NURSING UNIT
PATIENT IDENTIFICATION
61
( 1,) 10 -1--
AN/
NURSING UNIT
BED NO!

PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
am)
Ltozb)-Y
PURSING UNIT ROOM N
FORM
1 APR 79
IA 4256
REPLACES EDITION OF 1 JUL 77, WHICH MAY
(bl/N-L
Cd CO -2_ BE
MEDCOM - 20448
DOD-034022
MEDICAL RECORD
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES

ELATIONSHIP TO SPONSOR
TIENT'S IDENTIFICATION: (For typed or written entries, give: Name • last, first, middle;ID No or SSN; Sex; Dare of Birth; Rank/Grade, Prescribed PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999)by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10) USAPA V1.00
MEDCOM - 20449
DOD-034023

CLINICAL RECORD - OC T O'S ORDERS
For use of this form, see AR 40-66D R
THE DOCTOR SHALL RECORD DATE , the prop
onent agency is OTSG
SYSTEM IS USED, WRITE PROBLEM, TIME AND
SIGN EACH SET OF ORDER IF PROBLEM
PATIENT NUMBER IN COLUMN INDICATED BY ARROW BELOW.

ID ENTIFICATION ORIENTED MEDICAL RECORD
T TIM ORDER NOTED AND SIGN
NURSING UNIT
PATIENT IDENTIFICATION
(b)lb)-z-
NURSING UNIT
lc w I 1
-
PATIENT IDENTIFICATION
eb)th -Z
CL)11.-.):-2
NURSING Lf T
'ATIENT IDENTIFICATION
IRSING UNIT
FORM 1 APR 79
4256
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 20450
DOD-034024

MEDICAL RECORD
DATE AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
NOTES
63' 03

WitAMINNIW./ ir
„KAPY
(6) 09 --z-/
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-1¦
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is
ATIONSH/P TO SPONSOR 11( SPONSOR'S NAME
1R T./SERVICE
SPONSOR'S ID NUMBER ISSN or Other)
HOSPITAL OR MEDICAL FACILITY JT'S IDENTIFICATION: (For typed or written entries, RECORDS MAINTAINED AT
ID No or SSA); Sex; Dare of Birth Rank/
Grade)

WARD NO.
111.11 k(b1-1
PROGRESS NOTES
Medical Record
Prescobec STANDARD FORM 509
(REV. 511999)
by GSA/ICMR FPMR (41CFR) 101-11.203(15/(10) USAPA v1.00
MEDCOM - 20451
DOD-034025

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
(b)1 17 ) -z-
NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
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PATIENT IDENTIFICATION
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DA 4256
, AP R^79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 20452
DOD-034026

STANDARD FORM 509 (REV. 5119991 BACK
USAPA VI .0C
MEDCOM - 20453
DOD-034027
.EDICAL RECORD - DOCTOR'S ORDERL
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing will
list the time the new orderls1 are noted and initial in the column provided. Orders completed during the shift in which they

were written do not
require recopying.
They may be signed off, as completed, in the far right column.
ORDER
ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS

TIME & INITIALS
I C te 3 09 Co POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
1111 Sup, emental oxygen.

ret3 9
orphm• / Meperidine
2_ mg IV now and Zing q 3-5 min pm pain for a
max dose of / mg.
• • . mg • pm N/V q 15 min, may repeat x

-_ . ( -D Metoclopramide /(mg IV pm N/V x 1. —6----B/vpurict mg V prn NN x 1 . Phenergan LS—mg IV prn N/V x 1. 8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
0 IVF: Lre--0 Trac/hr. Discharge from recovery status when PACU discharge criteria met.
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mor ic. ... e •-)

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PATIENT IDENTIFICATION
Complete the following information on page 1 only.
Note any
changes on subsequent pages.
AM No) 00 ) — 9
Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

PACUMIIII
I of 1
I MAR 99 PREVIOUS EDITIONS ARE OBSOLETE (h,/
MC V1.00
- }t 2) -z_
MEDCOM - 20454
DOD-034028
r,k, 11 ivr s I ct, rt.Jrc LLA,Pa-rcrrcuutiL.
I IUN
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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HOSPITAL OR MEDICAL FACILITY!!
STATUS DEPART./SERVICE!!
RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO.!!
RELATIONSHIP TO SPONSOR
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of REGISTER NO.
WARD NO.!!
Birth; Rank/Grade.)
I
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 20455
DOD-034029

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

TIME OF ORDER
LIST- TIME
ORDER
NOTED AND

HOURS SIGN
x
i„..

1011104
( 4) 1 to
NURSING UNI
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PAT1E
WE T1F !CATION
TE OF ORDER

TIME OF
,Loth ORDER
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41
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NURSING UNIT ROOM NO.
BED NO.
PATIENT
IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
5-1 HOURS
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NURSI
BED NO.
CL) 1
c9z 11 DOI
PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
Ch )1 6) -d/ Ock 0 -\ 1(1200
HOURS
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dal
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4.)C6)-2
NURSING UNIT ROOM NO.
BED NO.
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ca4Vibio4-03 0161)
1 FAW419 REPLACES EDITION OF 1 JUL 77, WHICH MAY SE USED.

DA 4256
MEDCOM — 20456
DOD-034030
.EDICAL RECORD - DOCTOR'S ORDER._ For use of this form,
see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
list the time Only one order is allowed per line. Nursing willthe new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not
require recopying.
They may be signed off, as completed, in the far right column.
ORDER NUMBER ORDER NOTED
DAT4, TIMf, & SIGNATUAE REQUIRED FOR EACH ORDER OR SET OF ORDERS COMPLETED i'D//i-7°3 TIME & INITIALS
11 I )
TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
CD

VS q 5 min X 15 min, then q 15 min until discharge.
2 Supplemental oxygen.

,116
6) Morphine / Isdei9eridine" z..-i W now and 2 mg q 3-5 min pm pain for a
max dose of /0 mg.
4 Zofran

mg IV pm N/V q 15 min, may repeat x
.
5 Metoclopramide mg IV pm N/V x 1.
6 Droperidol mg IV prn N/V x I.

0 Phenergan /L,. ung IV pm N/V x 1.
8

Benadryl 25-50mg IVP qI hr pm, itching while in PACU.
9 IVF: (a)

cc/hr.
6) Discharge from recovery status when PACU discharge criteria met.

(L)(b) -2-
j1164-.....
PATIENT IDENTIFIr.A -rinm
Complete the following information on page 1 only. Note any

4011 (6)(19)-y changes on subsequent pages.
Diagnosis:

Height: Weight: Diet:
Allergies:
Nursing Unit I Room No.
Bed No. Page No.
PACU
1 of 1
I
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE (
mc v1.00
MEDCOM - 20457

DOD-034031

r,..,
11.../INILLLA run LtJUAL r(CrrilJLJUl, I ION
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each entry)
/
4
Lc 2540'.0) 400 ge Allf¦ 41 A. ! --. Ar ,I irA._F* WA IIA 11111111A:• / ilir , _................_ W -7
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(6)/b) - L

HOSPITAL OR MEDICAL FACILITY!!
STATUS DEPART/SERVICE!!
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN/ID NO.!! RELATIONSHIP TO SPONSOR
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or
SSN; Sex: Date of REGISTER NO.
WARD NO.!!
Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97)
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 20458
DOD-034032

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

PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
LIST TIME
ORDER
NOTED AND

L9 )
HOURS
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( 6)4 )­
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(. 6 1 1 6) _
b)(..19)-
NURSING UNIT
1100m NO.
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(AV?
PATIENT
IDENTIFICATION
DATE OF ORDER TIME OF ORDER
VOCP
HOURS
ti
6L1)(6)-z_
(601 -2-
-
NURSING UNIT M NO. 6.4 ) L. )
BED NO.
q
PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
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HOURS
(461-
NURSI
G UNIT

2-
PATIENT
IDENTIFICATION
DATE OF ORDER
b
TIME OF ORDER
HOURS
NURSING
FORMDA 1 APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM -20459
DOD-034033
AUTHORIZED FOR LOCAL REPRODUCTION
'MEDICAL RECORD PROGRESS NOTES
DATE NOTES
/74? e.).. Z-51v7,--4:::''

/I c6
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RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER LAST FIRST MI (SSY or OHO •
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: /For typed of written arftiox err Nome • hut Thy. DIA*
I
REGISTER NO.
WARD ND.
10 No of SSN; Sec Date of Birth; Rank/Snide)
PROGRESS NOTES Medical Record
o co
STANDARD FORM 509 IREV. SITDINH Prescribed by omeckin FPMR HICFRI 101-112030111M
USAPA V1.00
MEDCOM - 20460
DOD-034034
rituit-AL FitlAJKL) - DUL; I UR'S ORuE. For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not
require recopying. They may be signed off, as completed, in the far right column.
ORDER NUMpEk--y--)) DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER NOTED TIME & INITIALS COMPLETED TIME & INITIALS
P°7 c)r}..._(3---. POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
2 Supplemental oxygen.
Morphine / Meperidine 3 mg IV now and "Zing q 3-5 min pm pain for a
max dose of / 5Mg.
Zofran L--(mg IV prn N/V q 15 min, may repeat x .
5 Metoclopramide mg IV prn N/V x 1.
6 Droperidol mg IV prn N/V x I.
7 Phenergan mg IV pm N/V x 1.
8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.
9 IVF: @ cc/hr.
0) Disc tatus when PACU dischar e criteria met.

( b) (6 ) - 7-
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note anychanges on subsequent pages.
Diagnosis:
41111111111 (4)(61) ­
1 e.
Height: Weight: Diet: Allergies: Nursing Unit Room No. Bed No. Page No.PACU
1 of 1
n A r. e% ....... . ...,.. .. - ... .- -.._ - {TEST)_
-OHM -
-
0) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V1. 00
(b)C-2-) -z
MEDCOM - 20461
DOD-034035
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
sir DATE OF ORDER
talTIME
OF ORDER
LIST TIME ,,,.? 9 e,_. .-ca , //..2/ ORDER NOTED AND
HOURS
SIGN
(10(0/ -V
"/
6)L
LC-1..,1 "7 Z/4.
J
4) /24r-a4-it+
NURSING UNIT
ROOM NO.
2221 C1), 17
BED NO.
121
IA/ '9
t)46Z- 1ZS 22iLV ,I-Cr/P iY6L1J
PATIENT IDENTIFICATION
i.45017*
DATE OF ORDER
TIME OF OR •
Et9)1(V) -2-
NURSING UNIT
ROOM NO.
BED NO.
1
PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
3/ 6
HOURS
I
W1CIIII 40511 c iAIM* FF
1.1411=111111
NURSING UNIT
ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER

TIM OF O
HOURS
NURSING UNIT
ROOM NO.
BED NO.
DA, F4256
ArRM79 REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED
MEDCOM - 20462
DOD-034036
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES

.226z.
IJ
. i 4(3

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or Other)
LAST FIRST MI
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: For typed at written swiss, give Name - ks& first, male; REGISTER NO. WARD NO. . MN° s ISM; Ser Date of Birth; fiankarirlel
PROGRESS NOTES
Medical Record
STANDARD FORM 509 IREY. 51999) Presabed by GSAIICMR FPMR CFR) 101-11.2D3IbIll
USAPA VIA°
MEDCOM - 20463
DOD-034037
MIDDLE INITIAL ID NUMBER
LAST NAME FIRST NAME
NOTES
DATE
069119)--z_
STANDARD FORM 509 REV. ENDEVIBACK
USAPA V1.00
MEDCOM - 20464
DOD-034038
CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG THE DOCTOR SHALL RECORD
DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME
ORDER NOTED •ND
iar J94.5' (956---6:2C-a3HOURS SIG
cmto- 9 0
A

NURSING UNIT
ROOM NO.
BED NO.
00)/(7)
PATIENT IDENTIFICATION
A,T-etcF ORDER
IME OF ORDER
(10)l() 11
HOURS
cb)
N RSING UNIT ROOM NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
( L)1 19-z-(.6)/0)--z_ (10)-
NURSING UNIT ROOM NO.
BED NO.
tD1-°101 60
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
1 17) 22)
HOURS
NURSING UNIT
F
REPL S EDITION OF 1 JUL 77, WHICH
1 APR 79 MAY 8E USED.
MEDCOM -20465
DOD-034039

MEDICAL RECORD - DOCTOR'S ORDEb.
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying.
They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
z., a_v0-5 i \i-cro
POST ANESTHESIA ORDERS (circled Items)
1
VS q 5 min X 15 min, then q 15 min until discharge.
0 Supplemental oxygen. eVP3 SCOL (__ C1,51-3

cs/
(----D (Morphi / Meperidine 2mg IV now and Zing q 3-5 min prn pain for a max dose of 10 mg.
/c. Zofran mg IV pm N/V q 15 min, may repeat x . C,
Metoclopramide Omg IV pm N/V x 1.
Droperidol mg IV pm N/V x 1.
)7_ Phenergan mg IV pm N/V x 1.
0 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
IVF: LK._ .0) 11(0 cc/hr.

ip
11, Discharge from recovery status when PACU discharge criteria met.
CI4-(') lb) - 7--
Ogitb)-
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any changes on subsequent pages.
40
(imb)-9
Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Un Room No.

Bed No. Page No.
PACU,
1 of 1
-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00
/We 2) -z
MEDCOM - 20466
DOD-034040
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR

SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
LIST TIME
ORDER
NOTED AND

HOURS
SIGN
1\[(11060 0 b)Co
(1)1121-z_
NURSING UNIT ROOM NO.
-
(6)(b)z_
PATIENT IDENTIFICAT
Clee6 )-
Lk1(41-1.-
. NURSING UNIT
77 Pitt
DATE OF ORDER
HOURS
(
11, 6
NURSI UN LT
ROOM NO.
PA ENT IDENTIFICATION
TIME • ORDER
61,46)-1'
(L')(6)-1--
HOURS
NURSING UNIT
ROOM NO.
I BED NO.

0,04r4-
1FAOPARM79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
MEDCOM - 20467
DOD-034041

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 10ENTIF IC AT ION
DATE OF ORDER
TIME OF ORDER LIST TIM E ORDER NOTED AND
HOURS
7)6
SIGN
6 gSb22Y 715 02tv/c:.ey,r
-
Z 6.16)5 e,Pi o)-7 2.,526--P .
NURSING UNIT cri.ib L,A6?2) -evo•AL) ,);7 .LY, PZ,e,cr" 2,4/6-4Lzx 14,12zX vai/0
(b101-1-
PATIENT IDENTIFIC DATE OF ORDER TIME OF ORD
POLiAl -Of /
(L)119
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIF I CATION
DATE OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
PATIENT IDENTIFICAT ION
DATE OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
REPLACES EDITION OF 1
1 FAOPR
M79 JUL 77, WHICH MAY BE USED.
DA 4256
MEDCOM - 20468
DOD-034042

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
PROGRESS NOTES

aso,
4),3
)-2_)53s.
c-,A6v6e-w
rie.),i )6762,zzw U.iv
RELATIONSHIP TO SPONSOR SPc SOR'S NAME NUMBER
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY
'ATIENTS IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle;
ID No or SSIV• Sex; Date of Birth; Rank/Grade) REGISTER NO.

WARD NO.
(421 ) PROGRESS NOTES
Medical Record
fir0
STANDARD
FORM 509 (REV. 5/199)
Prescribed by GSA/ICMR PMR
141CF R) 101-1 1.203(b)1190)
USAPA V1.00
MEDCOM - 20469
DOD-034043

,EDICAL RECORD - DOCTOR'S ORDER_
Foruse of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new orderls) are noted and initial in the column provided. Orders completed during the shift in which they
were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER
ORDER NOTED COMPLETED NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
0 VS q 5 min X 15 min, then q 15 min until discharge. 010 Supplemental oxygen. (10) 4-1" (t )a )--1.
MVP Morphine / Meperidine 3 mg IV now and 2-mg q 3-5 min pm pain for a t,Imp-
max dose of / mg.
41 Zofran I/ mg IV pm N/V q 15 min, may repeat x .

(...)
5 Metoclopramide mg IV pm N/V x 1.
6 Droperidol mg IV prn N/V x 1.
7 Phenergan mg IV prn N/V x 1.
8 Benadryl 25-5Gmg IVP ql hr pm, itching while in PACU.
9 IVF: 0 cc/hr.
0 Disc status when PACU discharge criteria met.
iplk)4.— (b)tb)--z-
c(2)o0)-7—
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any changes on subsequent pages.
Diagnosis:
Ci° ) lb )-1/ 4..
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

PACIIIIIII.
1 of I
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00
)( ) -2-.
MEDCOM - 20470
DOD-034044
.EDICAL RECORD - DOCTOR'S ORDElts.
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER NOTED TIME & INITIALS COMPLETED TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
Supplemental oxygen. ,76x v 91 ktnne / Meperidine s_mg IV now and ) 7(-7 ng q 3-5 min prn pain for a
max dose of /6 mg.
I Zofran Nmg* IV prn . , .
5 Metoclopramide /(,) mg IV prn N/V x 1.
prn /V x 1.
1.x
_
8 Benartryl 25-50m IVP 1 hr ngqpljLgmAcrt while in P .
9 IVF: L-i.0 7-)' cc/hr.
10 Dis discharge criteria met.
cia4L(2) - 7--

PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any changes on subsequent pages.
Diagnosis:
0 (4)16) -

Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

PACUMM
1 of 1
-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V 1.00
(WO-) - z
MEDCOM - 20471
DOD-034045
,EDICAL RECORD - DOCTOR'S ORDER._
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded.
Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER
ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge.
0/.. Supplemental oxygen.

).
Morphine / Meperidine 2—mg IV now and -2--mg q 3-5 min pm pain for a max dose of II mg. 4 Zofran mg IV pm N/V q 15 min, may repeat x
(7 4 .
5 Metoclopramide mg IV pm N/V x 1.
6 Droperidol mg IV pm N/V x 1.
7 Phenergan mg IV prn N/V x 1.
8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.
9 IVF: @ cc/hr.

Disc' ery status when PACU discharge criteria met.
C
C 6)(0'7'
(0')—Z `
PATIENT IDENTIFICATION
Complete the following information on page 1 on y. Note any Diaanngoes
iso:n subsequent pages.
ch09)1/9 ) — 9 9
.1.
.
Height: Weight: Diet: -41M
Allergies:
Nursing Unit Room No. Bed No. Page No.

PACUIIIIIIIII 1 of I
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC V1.00
MEDCOM - 20472
DOD-034046
/ i: :-.-__Y‘)P T1
CLINICAL RECORD 1¦,. 1
THERAPEUTIC DOuumENTATMI
VERT . CARE PLAN
For use of this form. see AR 40-407:
• I II
,4M ;'A;-T#-IS .n U • ffi e f (NON-MENCAT/0/9
ORDER Mo.
CLERK/ INTIZ4L PROPER COLUMN FO Yr. 2003
DATE RECURRING ACTIONS,
NURSE FA
Q! COMPLETION
FREQUENCY, TIME
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PATIENT IDENTIFICATION: Open 0 + 0, mu rh -c ampA. &di IIV/Z

6i 1 0 NO PAGE NO:
)(
(6 6) -4/ ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11
12 13
14 15 E 16 17 18 19
20 21
22 23DA FORM 4677, 1 OCT 78 N 24 01 02 03 05
EDITION OF 1 DEC 77 MAY BE USED. 04 06 07
USAPA V1 AO
MEDCOM - 20473
DOD-034047
THERAPEUTIC DOCUMENTATION CARE PLAN
Verity by
Mo CID9 Yr 2003
Initialing (NON -MED/CATTON)
Date to Time to
order Clerk Time Done Initials
SINGLE ACTIONS
be Done be Done
Date Nurse
65
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Order/ PRN
Clerk/
Expir Nurse ACTION, FREQUENCY T1MEIDATE COMPLETED /
Date
MEDCOM - 20474
USAPA V1.00
DOD-034048

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN
For use of this form, see AR 40-407; (NON-MED1CA7701V)
VERIFY BY INITIALING • •h -

f
r nn I. MV Yr.
INTILIL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS.
DATE
NURSE DATE COMPLETED
FREQUENCY. TIME
(6,)1 )-Z.
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NO
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Pen as
3-
PATIENT IDENTIFICATION: GE NO:
ACTION TIMES USE PENCIL.
CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78
EDITION OF 1 DEC 77 MAY BE USED.
USAPA V1.00
MEDCOM - 20475
DOD-034049
0e4 evu

THERAPEUTIC DOCUMENTATION CARE ( NON-MEDICATION )
CLINICAL RECORD
the proponent agency Is the Office of The Surgeon General. Mo.\k .Yr. .2003
VERIFY BY IN777ALING SEMZEIM 116,,, .„, ,'• 4,

4''
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTION, HR DATE COMPLETED
DATE NURSE FREQUENCY, TIME rINEEM

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PATIENT IDENTIFICATION:

ACTION TIMES
101 (W(b ) -V 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
USAPA V1.00
MEDCOM - 20476
DOD-034050
CLINICAL RECORD I i IltliArtU I IC DOCUMENTATION CARE PLAN • VIEDICATIONS)
For use of this form, see AR 40-407; the proponent agenc is the Office of The Surgeon General. Mo.K6 Y r. 1"
VERIFY BY INITIALING ,'-?,--.44F-ft_.AtW;Q: 1--%=- ''-INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ HR
RECURRING MEDICATIONS, DATE DISPENSED
DATE NURSE

DOSE, FREQUENCY
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Ili....
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MI ..‘"S—A-1111111 IIII
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ALLERGIES: I I YES El NO
PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
YES VilOt
IIII ll NO
irriui+ ctarc-cthM c
6111 I
T„ .—..........– ___ PAGE NO

DISPENSING TIMES
USE PENCIL.
CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01
02 03 04 05 06 DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V1.00
MEDCOM - 20477
DOD-034051
THERP- 'EUTIC DOCUMENTATION CARE PLAN
Verify by
Initialing (MEDICATIONS) Mo. 10.Yr. Oa_
Date to Time to
Order Clerk/ initials
SINGLE ORDER, PRE-OPERATIVES Time Given
be Given be Given
Date Nurse
OA-QYA-(1,)10-Z-
b)/b)-L
anrimpIC__. --N`C_42...-F 00513
fy)
b)/6)- Z
/1)
Wo7 0 geebt-k / U ,
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN
Expir
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date
1---) III -17-11-eArsil 69 (:) .1(1 4,0 Di cetTA\C \\Ci5 Aker-1

q14. cr g 5"444136III Iblit) 11" -V-
Di I V6 AtTf --• atAll * WY It 'Ica 7r7,111-r° v ',EOM
0..5 1111 1 -(1.4 .393 Dy -3
.71 -it,\(\10 i--I -;­
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.!..,..0 lignalli -,1-
qi .% TS V '"g' C
4• .
al" Al

USAPA V1.00
MEDCOM - 20478
DOD-034052
t, uu
CLINICAL RECORD I 3 ncruA rtu I iuu ivitni I ATION CARE PLAN (MEDICAL; iNS)
For use of this form, see AR 40-407; the proponent aqenc MO.
is the Office of The Surgeon General. 0 Yr. i
VERIFY BY INITIALING ,-`0g-tn.Z.,t.".:?,::-"::::.-.,‘
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED DATE NURSE DOSE, FREQUENCY 012
logb)-
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or Po 4 11111111/11Milla
'2,)117) -114 _
_____A teat& \\I 0 Kb lagraglilinlill
M:1111.111111111g iiiiiiiiiiiii L lb 10 /7 I
(41 (0-CR (-" .( - --4a,. 19 (26 b& Aminners,............ii

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1
ALLERGIES: • YES NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: .YES I. NO
cycon 0-tbca_ ,f\ro,-)60e_..-. mi: •
PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES if
+riga 00}a2)-r
USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N
23 24 01 02 03 04 05 06
DA FORM 467R I FFR 7Q
USTED.
U SAPA V1 ,00
MEDCOM - 20479
DOD-034053

THERAPEUTIC DOCUMENTATION CARE PLAN'
Verify by
Initialing (MEDICATIONS) .Yr. qa
Date to Time to
Order Clerk/
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
be Given be Given
Date Nurse
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk! PRN
Expir
Date Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
¦2c3V C:E531"*Cn VO CNat-c'N dt0
4MiliTi
-Tr IP)
Dir. ill
7).1:gfC1401.1 Ti-10\31 46 \.2_Vc106. co aiwicEitazr
ck--) Qm eta_ths3
bh-44.4,
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t ,\,,i

.1­
USAPA V1.00
MEDCOM - 20480
DOD-034054
RECORD ncrukrtu I it.; DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407;
the proponent agenc is the Office of The Surgeon General. Mo.01Yr. c5.3
VERIFY BY INITIALING
-07A-761.5.WV-5=1 ,ii;-A'.:.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE NURSE
DOSE, FREQUENCY
AS
CY\
tv xOti berz
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(b)16pz -
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rola(2_ 1 C0
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ALLERGIES: riYES NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
r--7YES
422,116 NO
a2/.4)- 74.." 5' PAGE
PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES D 7 8
9 10 11 12 13 14 E 15 16 17 18 20 22
19 21 N 23 24 01 02 04 06
03 05
DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V1.00
MEDCOM - 20481
DOD-034055
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo..II Yr. CP3
Order Clerk/ Date to T'me to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials Date Nurse
be Given be Given

Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN
Expir
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date
LI 448a../Iszp /4/171 -z .2(1111110 i y/inn—Q 660a1p. ti. 1-10115,i7
u k(,*), Itso,
R) c61/1)(-.pc43
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4 —t-
1 — i-01 (401f3 Y1:
/"." / / %— ‘
USAPA V1.00
MEDCOM - 20482
DOD-034056
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD I
For use of this form, see AR 40-407;
I
the proponent agency is the Office of The Surgeon General. Mo. Yr.
VERIFY BY INITIALING
¦•¦•¦¦10 INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
DATE NURSE ORDER CLERK/ RECURRING MEDICATIONS, DOSE, FREQUENCY HRI DATE DISPENSED

ALLERGIES-•••
n YES El N o PRIMARY DI AGNOSI
ADDITIONAL PAGES IN USES El YES ONO
PATIENT IDENTIFICATION, PAGE NO
DISPENSING TIMES
Lb) 1b) USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14 E 15 16 17 18
19 20 21
22 N 23 24 01 02
03 04 05 06 DA1FFM9 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHA
'ED.
MEDCOM - 20483
DOD-034057
L
THERAPEUTIC DOCUMENTATION CARE PLAN

Verify by Mo. Yr
(MEDICATIONS)
Initialing
Dote to Time to
Order Clerk/ Time Given Initials
SINGLE ORDER, PRE-OPERATIVES be Given be Given
Date Nurse
Order/ Expi Dote Clerk/ Nurse PRN MEDICATInN, DOSE, FREQUENCY
/ivitb)-2. AV M-A(61A an Pb 1: t •
Mil_
lh i l nit to s' 0 r. ,
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- • ""4/,'
L 0 \..c4_ cp -"O f0 ern)
.-'1C./ .‘n\ k--),_ -

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
., J Viliaff 40 114¦10461404494cirr7msl1kti 7135v a-I 3
/woo Iltv 2)3b OK 11451 if,Er 23301013°lots'
9-r" 25 '

gr
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/3.546 c2,31-z)A6 7,\‘)‘) . / . 0
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M F n(om -20484 '
*U.S. GPO: 1998-454-110/95216
DOD-034058
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this forrn, see AR 40-407;
the proponent agency is the Office of The Surgeon General. MolOyr.VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE CLERK/ NURSE RECURRING MEDICATIONS, DOSE, FREQUENCY HR DATE DISPENSED IS 19 a

04-
CW(b)-15
(01b)-)2
(4,)z6/-1__
(CA ) --2-
ALLERGIES- ED YES ONO
PRIMARY DIAGNOSIS.
TION AL PAGES IN USE:
Q-Tva\p.
ES ONO
iNv\AR.L51--pv--c\cc 5
PATIENT IDENTIFICATION: PAGE NO.
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7

8 9 10 11 12 13
14 E 1.5 16 17 18 19 20
21 22 N 23 24 01 02 03 04
05 06
F
OE F11119 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA 1 4678
MEDCOM - 20485
DOD-034059
Verify by Initialing Order Clerk/Dote Nurse THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Date toSINGLE ORDER, PRE-OPERATIVES be Given Mo. Time to be Given rYr.C75. Timeme Given Initials
(b)ib) -2 r9)1111 -1-( b)(6)- (3411111 [4-'6, a ,-Lv e--7 . I , ._, ,..,,,. at . .. _ tt. _ • ecr /Yei 1.1 Av cr4t10-z-

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Order/ PRN
Clerk/
Expir
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Dote e i
96. i 0 , A .:.
. .5tPj5 4 1 LQ(NCI bSOMC3 kr) C
• 41 ' ) i i 15a cia;
-EilI319
4
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MEDCOM - 20486

U.S. GPO:1996-454-110/95216
DOD-034060
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
I fr-
CLINICAL RECORD For use of this form see AR 40-407;
Mo. 1 t Yrs_
the proponent agency is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED DATE NURSE DOSE, FREQUENCY MIN I ¦ IIIIM I 2-tiffis iglill
Elm paw

— ws n . 95 ia S ,4 rea - ---¦ III
MEM= ••¦•-- ¦­
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ALL ERGI EW El YES Q NO PRIMARY DIAGNOSISt ADDITIONAL PAGES IN USES
10' r) CD —Ft b I ot., AYES

El NO
PAGE NO
PATIENT IDENTIFICATION:

lit Mu Itipe OM pi i 47th GvlS
DISPENSING TIMES
MI (10)((2)-1
USE PENCIL, CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA1FFOEIR3r19 4818
MEDCOM - 20487
DOD-034061
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo. I ( r
Initialing (MEDICATIONS)
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Dote Nurse be Given be Given
0-)1 b I-z:
d(bl-
onibenacir 1 TV v I nov\l ?;kt\i r II /Pi
ii 4,-,\ zorprv,ci :",0 (7...).4e,i'ir_11-4...---, ii
DC_ Ir\INC,C\S I 1-2.\-kft
1491.0-z
1\C11425111111--Invv-_,,rY1 Tz i feccoo2.-A--I- .2-rD q q-Ob rrr}
1-216)-z_ ' W12 ( d)(0-z-
z
'.1,!)(612_
Order/
Clerk/ PRN
ExpIr
Nurse MEDICATISN, DOSE, FREQUENCY
Date 'Z'acr: OR -Ty kind 6 5--G
i• •
a
zieAl1111 Ty lam 1 43 I-2 1-a105 po
i
(6 Lk G., •

Ma-1111 le sl- 0 i d Po %PIS pR_N
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Ty 1-ekui 4. 3 I --/kbs P() 011-6 # Per4
aZociari, ,
Gancd-T 1 ' y , -2- 50e9 -7 V/Pb/ _23M. ' 8Co° Psfe/11/
-'
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
. .4,/iPiptosv0, ,syctirlAkti -14,111L.,
t3 i ;01 rlutri P" 'Aiw
P. I 4`t Plio 1 :,A, a5:36 hefts-124 0120e-0770 2,N) 126:1 \(,)T-,
r. ' A -17 1 -ii '? ' sii-..+'' ..11 .11-
DV 1/41-
ii t'k
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t . , , 0000 acalt 5 ()O., I .7-•
1 viiv-n.1,2SriOtiOltif 4%14-MO
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M -2048R
'U.S. GPO: 1998-454-110/95216
DOD-034062
I /
CLINICAL RECORD THERAPEUTIC DOCUNIEutleT0Airh1Oform, -ARE
ER I:41...4Art¦1 (NON-MEDICATION) .
the proponent agency Is the Office A yERIFy BY IMTIALING Surgeon General. Ma Yr. 2003
:-;:ebobliatemo.0
INITIAL PROPER COLUMN FOLLOWING EA CH COMPLETION
ORDER CLERK/ HR
RECURRING ACTION, DATE COMPLETED
DATE NURSE
FREQUENCY, TIME
NNW
At
NI
Lial=1,1111M.

liRnIMMIIMPB111111117-
Lind
Army Ar,111.„IP""1111111k.
Mr-—
51-
r""IIRMIPMPINSWA71111r-
Loma
"MEW IA.
ALLERGIES:
J YES El NO PRIMARY DIAGNOSIS: AçIErIONAL PAGES IN USE: ES ED NO
2---
I PhENO:
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.
USAPA V1.00
MEDCOM - 20489
DOD-034063

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION) Mn.Yr .2003
Date to Time to
Order Clerk
Time Done Initials
SINGLE ACTIONS be Done be Done
Date Nurse
v, 4 i.c 7).6.chi.
fa-,V
— — — — /22,-4--"(--4-Ari2
s
ouctZ) eleE..--Q_ c7c.e\f-\c5 occ---,c3 FOIZ
oci
1,,,,,,,,,,-&tin,. i, )k out) (nil (IA f) 13Wrilt rOIN SP ca+V\ ijoa-/1400 dill'
Order/ExplrDate Clerk/ Nurse PRN ACTION, FREQUENCY INITIAL PROPER COLUMN FOLLOWING COMP1 ETION TIME/DATE COMPLETED
— — — — — — — —
_ _ _ _ _ ¦ .¦
NM ...MO MO WM OM Mil".
WI NM ¦D MM.= NM I= WO
Pm., ow wow ¦ ¦ mar ow •••¦
.... low ¦ ¦• am. IN. ¦• ••••

re mo. v... =we ¦ ¦ .... ....
4. ...
.... ¦ ¦ ¦ ¦ ..¦ ¦ ¦

USAPA V1.00
MEDCOM - 20490
DOD-034064
Time to
SINGLE ACTIONS be Done
Order Clerk
NurseDate
OCO )
INITIAL PROPER COLUMN FOLLOWING COMPLETION
MEDCOM - 20491
DOD-034065
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM
HOURS TO
HOURS
TIME COMPL
AMOUNT ACCUMULATIVE TOTAL
BLOOD/BLOOD DERIVATIVES
TIME TIME
STARTED ACCUM
AMOUNTCOMPL TOTAL
OTHER INTAKE
AMOUNT ACCUMULATIVE TOTAL
USAPPO v1.00
2_1 OCT-22cocor
_ -ccopo
(
MEDCOM - 20492
DOD-034066
2tRS DATE FF110171 C. -0
COVE
aaOCT
TWENTY-FOUR HOUR PATIENT II KE AND OUTPUT WORKSHEET TO S ­
INTAKE
INTRAVENOUS
ACCUM
AMOUNT TIME ACCUM TOTAL
TYPE
TIME AMOUNT RECD COMPL
AMOUNT (Include Medications)
TYPE TOTAL STARTEDTIME
roai r\
Nus 5W
It Levaccuin
jik1Unk3
IRRIGATIONS (N/G, Bladder, etc.)
ACCUMULATIVE
AMOUNT
TYPE TOTALTIME
BLOOD/BLOOD DERIVATIVES ACCUM OTHER INTAKE
PRODUCT (i.e. BI, TIME
TIME AMOUNT TOTAL
STARTED Alb. P. cells, etc.) COMPL ACCUMULATIVE
AMOUNT
TYPE TOTAL
TIME
GRAND TOTAL INTAKE
USAPPC V1.00
--2Z0c17
21 00
voic t,x1911'
Coco oc000
MEDCOM - 20493
DOD-034067
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM raw% RS
AL URS TORS CO E
ACCUM TIME TOTAL AMOUNTAMOUNT STARTED TIME ACCUM
COMPL TOTAL
ACCUMULATIVE TOTAL
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. BI, TIME STARTED AMOUNT ACCUM
Alb, P. cells etc.) COMPL
TOTAL OTHER INTAKE
AMOUNT
GRAND TOTAL INTAKE
DD FORM 792, JAN 74 (EG)
EDITION OF 1 SEP 54 IS OBSOLETE.
Designed using Perform Pro, WHS/D/OR, Jun 94
6)(17) -Y
)Boo
MED OM -20494
DOD-034068

\
IJU I 1-1.) I ,,i ¦ r ' , "•
_i p ea+h
F-­
URIN-
TIME AMOUNT TYPE ACCUM TOTAL
AMOUNT ACCUM TOTAL
TIME AMOUNT
ACCUM TOTAL T
....
-aDaC-, 61-riC D5-c-bmwri.

WiD:CTS
..._
......_
_ ...
... ___.
. , — ..___. .... _ EMESIS
CHEST ACCUM TOTAL
TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
TIME AMOUNT ACCUM TOTAL
STOOLS OTHER OUTPUTCHARACTER AMOUNT ACCUM TOTALTIME COLOR TIME AMOUNT TYPE ACCUM TOTAL
. _ __......
---GRAND TOTAL OUTPUT
REMARKS
(For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility). INTAKE EQUIVALENTS (Serving levels cc)

PATIENT'S IDENTIFICATION
MEDICINE GLASS 11 az) . 30 HALF PINT MILK 240
(WI& ) - -
240 SMALL FRUIT CUP 160 LARGE WATER GLASS 240 COFFEE MUG 180 PLASTIC OR PAPER
JUICE CONTAINER
AIM 120 LARGE SOUP BOWL
180
Page 2
DD FORM 792, JAN 74
MEDCOM - 20495 ‘_ JD_
DOD-034069
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
FROM CA.
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET velU3iLIA TOTS DATE
TO CLODURS
°Cr
INTAKE
ORAL
INTRAVENOUS
TIME TYPE AMOUNT ACCUM TOTAL TIME STARTED AMOUNT TYPE (Include Medications) AMOUNT RECD TIME COMPL ACCUM TOTAL

IRRIGATIONS (N/G, Bladder, etc.)
TIME
TYPE ACCUMULATIVE
AMOUNT
TOTAL
BLOOD/BLOOD DERIVATIVES
TIME STARTED PRODUCT (i.e. BI, Alb, P. cells etc.) TIME COMPL AMOUNT ACCUM TOTAL . OTHER INTAKE
TIME TYPE AMOUNT ACCUMULATIVE TOTAL
GRAND TOTAL INTAKE
DD FORM 792, JAN 74 (EG) EDITION OF 1 SEP 54 IS OBSOLETE.
Designed using Perform Pro, WHS/DIOR, Jun 94
(6)(b 1-11
COM - 20496
DOD-034070

OUTPUT
IIMIII_M 0
Gi p C a-1-h . 7...E.skrimwm
URINE TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL -TIME AMOUNT TYPE ACCUM TOTAL co
O
TICE 20E . 919OCC - --I5a-brry 1 scc,
0 _or io_x__
rrc tnIs-, i--ur_c .
.0,50 ? x„ voo ID i2e4_, 10) 2. xi_ void tobcct .....
02DD x i NibtCf-tth-t0 --6:D .2e)D Lgoe
CHEST • '" ---_.._ EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT TIME AMOUNT TYPE ACCUM TOTAL
GRAND TOTAL OUTPUT
REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, ..
first, middle; grade; date; hospital or medical facility).26.--71... INTAKE EQUIVALENTS (Serving levels cc)

M EDICINE GLASS 11 oz) . 30 HALF PINT MILK 240 —C6CO 7 120 LARGE SOUP BOWL 240 SMALL FRUIT CUP 160 LARGE WATER GLASS ... 240

41111W .
COFFEE MUG 180 PLASTIC OR PAPER
0:72t&i-
JUICE CONTAINER 180
DD FORM 792, JAN 74 Page 2 MEDCOM - 20497
-
2
DOD-034071

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET INTAKE FROM TO HOURS HOURS TOTAL HOURS COVERED PATE
AMOUNT ACCUM TOTAL TIME STARTED AMOUNT AMOUNT RECD INTRAVENOUS TIME COMPL ACCUM TOTAL

AMOUNT
BLOOD/BLOOD DERIVATIVES
TIME STARTED TIME COMPL AMOUNT ACCUM TOTAL OTHER INTAKE
AMOUNT
GRAND TOTAL INTAKE
DD FORM 792, JAN4EG)
EDITION OF 1 SEP 54 IS OBSOLETE.
Designed using Perform Pro, WHS/DIOR, Jun 94
MEDCOM - 20498

DOD-034072
OUTPUT
URINE Va C
----'
TYPE ACC " .e
TAL TIME AMOUNT ACCUM TOT -TIME UNT
TIME AMOUNT ACC .
1125 5„,a5 5 . - P-HS-ice-jfe.en)lorn , IOCC
-gZ00400014­25 '
.._
...
_...
CHEST . .- -._ _ _ . _. _ .. EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
..... - _ ..
GRAND TOTAL OUTPUT
REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility)... ,.. INTAKE EQUIVALENTS (Serving levels cc)

"Ms COIW-11 C MEDI INE GLASS Cl oz) . 30 120
SMALL FRUIT CUP 160
COFFEE MUG 180

HALF PINT MILK 240
LARGE SOUP BOWL 240
LARGE WATER GLASS 240
PLASTIC OR PAPER
JUICE CONTAINER 180

DD FORM 792, JAN 74
MEDCOM - 20499
DOD-034073
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM TO HOURS HOURS TOTAL HOURS COVERED DATE
INTAKE
ORAL INTRAVENOUS

TIME TYPE ACCUM TIME
AMOUNT TYPE
AMOUNT AMOUNT TIME
TOTAL STARTED ACCUM
(Include Medications)
RECD COMPL TOTAL
-8947— ..3-; 5tx .C„ x3 eon 'cock.
,
20s ,h '.-.0c.,
a ?Id 14 N
' .1-.. . too i tiObt.t. Le....4
• ,`,.1
/00 C,C,
C) E 1 3: -a -.fir
ft-51)1 a "Z20039-rh di)
(0
NM friz_n
Art)17--ko
0 alp t-t7 r)

IRRIGATIONS (N/G, Bladder, etc.)
TIME
TYPE ACCUMULATIVE
AMOUNT
TOTAL
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. BI, TIME

ACCUM
STARTED AM , P. cells, etc.) COMPL AMOUNT
TOTAL OTHER INTAKE TIME
TYPE ACCUMULATIVE
AMOUNT TOTAL
GRAND TOTAL INTAKE
USAPPC V1.00
iss(ab b- iv 2.2NOCT-03 6r6007­
MEDCOM - 20500
DOD-034074
TOTAL HOURS DATE
FROM _ _HOURS
COVERED
KE AND OUTPUT WORKSHEET
TWENTY-FOUR HOUR PATIENT II
TO HOURS IffiggigE. (C)Lpt ?„.„....--x Y^ INTRAVENOUS
4*Ittla.. 'a,•Fa--,I
AMOUNT TIME ACCUM
ACCUM TIME TYPE
AMOUNT
TIME TYPE AMOUNT TOTAL STARTED (Include Medications) RECD COMPL TOTAL
1930 f)5Z C-Lea-1/.\„ZO—Illi.Y¦e_ I to el i too darKv2,LiamPar.Q Roo 20
TIME IRRIGATIONS TYPE (N/G, Bladder, etc.) AMOUNT ACCUMULATIVE TOTAL
BLOOD/BLOOD DERIVATIVES

TIME STARTED PRODUCT (i.e. BI, Alb, P. cells, etc.) TIME COMPL AMOUNT ACCUM TOTAL TIME OTHER INTAKE TYPE AMOUNT ACCUMULATIVE TOTAL
GRAND TOTAL INTAKE
USAPPC V1.00
44011 Ntio)­11 --P-40cT
0(000
MEDCOM - 20501
DOD-034075

TWENTY-FOUR HOUR PATIENT IN I AKE AND OUTPUT WORKSHEET FROM .,OURS TOTAL HOURS DATE
COVERED
TO
HOURS
INTAKE
"-Htillifigaira4G.66Ec
"
TIME
TIME
AMOUNT AMOUNT TIME
STARTED ACCUM
(Include Medications).
RECD COMPL TOTAL
9 firOMEN1111priltra¦ TYPE
_
NtbV - 3
11 cx--)cr,

IRRIGATIONS
(N/G, Bladder, etc.)
TIME
TYPE ACCUMULATIVE
AMOUNT TOTAL
BLOOD/BLOOD DERIVATIVES
TIME
PRODUCT (i.e. BI, TIME
ACCUM
STARTED Alb, P. cells, etc.) COMPL AMOUNT
TOTAL OTHER INTAKE TIME
TYPE
ACCUMULATIVE TOTAL AMOUNT
GRAND TOTAL INTAKE
USAPPC V1.00
MEDCOM - 20502
DOD-034076
OUTPUT
URINE )(n
ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT 11''''seTYPE ACCUM TOTAL
0t a I
M5CE/ 10 15CC brown i F) cc. o
mnEgra
0600 -e'-
?ki• k ,
gilt/Laid
6 c
4,-
c`,1
Gaon 13-14) ico 1 9,00c
o 4W ,-,:30D
)034 esOD -1. (-_-2)C
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

STOOLS .
TIME COLOR
CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
GRAND TOTAL OUTPUT REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle;
grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (J oz). . 30 HALF PINT MILK
240
(Otb) - LI SMALL FRUIT CUP 120 LARGE SOUP BOWL 240
IT COFFEE CUP
160 LARGE WATER GLASS . . . 240
4 IN
LARGE COFFEE MUG . . . .180 PLASTIC OR PAPER JUICE CONTAINER 180
DD FORM 7(39 IA1\1 7e
• EDITION OF - --- 54 IS ____
. REPLACES DA FORM 3630ITEMP)1 JUL 72 WHICH MAY BE USED. USAPPC Vim
MEDCOM - 20503
DOD-034077
TOTAL Fe) DATE
FROM ..4956 URS
I
COVR
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET
TO C , _ ael): RS I 9(0ccr
INTAKE
INTRAVENOUS
ORAL
TYPE AMOUNT TIME ACCUM
ACCUM TIME
AMOUNT TOTAL
TIME TYPE AMOUNT TOTAL STARTED (Include Medications) RECD COMPL
WO 1-k2-0 500 (40c-c

TIME IRRIGATIONS TYPE (N/G, Bladder, etc.) AMOUNT ACCUMULATIVE TOTAL
TIME STARTED BLOOD/BLOOD DERIVATIVES PRODUCT (i.e. BI, Alb. P. cells. etc.) TIME COMPL AMOUNT ACCUM TOTAL TIME GRAND TOTAL INTAKE OTHER INTAKE TYPE AMOUNT ACCUMULATIVE TOTAL

MEDCOM - 20504
DOD-034078
OUTPUT Mal ii1111.111111TellEar-
URI ,. IIII UR MILW ; . • -
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM OTAL TIME AMOUNT TYPE ACCUM TOTAL

_. .
. _
' -
_.__.
CHEST — '"' EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
.... .— -
GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility).. . ,._
INTAKE EQUIVALENTS (Serving levels cc)
tio)09) .If MEDICINE GLASS (1 oz) . 30 HALF PINT MILK
240 120 LARGE SOUP BOWL
240
* SMALL FRUIT CUP 160 LARGE WATER GLASS ... 240
COFFEE MUG 180 PLASTIC OR PAPER JUICE CONTAINER 180
5oa Lou-P5i1r)

MEDCOM - 20505
DOD-034079
HIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
FRO WI IS TO L H..)1/QC DATE
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET
T OURS
)
INTAKE
ORAL INTRAVENOUS (Csti.)Synirc—
TIME TYPE AMOUNT ACCUM TOTAL TIME STARTED AMOUNT TYPE (Include Medications) AMOUNT RECD TIM COMPL ACCUM TOTAL

._....
IRRIGATIONS (N/G, Bladder, etc.)
...
ACCUMULATIVETIME TYPE AMOUNT TOTAL
. _.. _._.
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. Bl, TIME ACCUM

AMOUNT OTHER INTAKE
STARTED Alb, P. cells etc.) COMPL TOTAL
ACCUMULATIVETIME TYPE AMOUNT TOTAL
GRAND TOTAL INTAKE
DD FORM 792, JAN 74 (EG) EDIT ON OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94
(10) Lb)
15 OCr
--co)
MEDCOM - 20506
DOD-034080
THERAPEUTIC DOCUMENTATION CARE PLAN
Verity by
( NON-MEDICATION ) Mn.)1.Yr .2003
Initialing
Date to Time to
order Clerk Time Done Initials
SINGLE ACTIONS be Done be Done
Date Nurse
kov .. t I (C--i-CDOC e-Xl V\1 C%a0C\k? 111111 -Wen -7 CP-if (_P:_,)()kaACAS2---VCRS • 11111VOICV\I Op \1\8?_.--, /S . ( 14W -,
- - - -- - - -- - - -- - - -
- - - -- - —
- - - -- - - -
- - - -- - - -

INITIAL PROPER COLUMN FOLLOWING COMPLETION
Order/
Clerk/ PRN
Explr
Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
Date
„xi*
(6)110)-'---A-4911111 Roti-force.oVsep-Q,
USAPA V1.00
MEDCOM - 20507
DOD-034081

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 4066; the proponent agency is the Office of The Surgeon General.
REPORT TITLE
USG APPROVED Warm
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date:
Anesthesia Type (Circle)): Gene Spinal Epidural Drains Airway
Time In:
I ation Nerve Block
Hemovac
Allergies: Nasal
OR Intake: Crystalloid 0 D Colloid 0( Oral
Pre-op V/S: OR Output: UOP NG
EBL '
. JP
ETT
Procedures:
tSr. Ii'/7 le (15 Meds/Times: )i PAT, • 0 T-tube
Trach Foley
Other
Pre Op Med Histor TLS
Time
Pacu Intake
Sa02
Time Solution Amount Site
By Infused F102 IC/la
L 42r cc.
/0
Methods
240
220
X-rays:
Labs:
Post-Anesthesia Recove score
200
Criteria ADM
30' D/C Codes
Activity
(2) Moves 4 Extremities AIRWAY
180

(1)
Moves 2 Extremities A = Ambu

(0)
Moves 0 Extremities

BB = Blow-by Airway M = Mask160
(2)
Cough, Deep breath FT = Face

(1)
Dyspnea. limited breathing Tent

(0)
Apnea

140 RA = RoomAir
NC Nasal
Blood Pressure
(2)
SBP =/- 20 of Pre-op Cannula

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

(0)
SBP 4-50 of Pre-op V/S

120 X - A-line BP
100 Consciousness
(2) Fully Awake, audible -=Cuff BP
n0 = Pulse
80 (1) Arousable to verbal or pain

TEMP
Color
S= Skin
so (1) pale. mottled, jaundiced 0 = Oral

(2) Baseirne coke d appearance
(0) Cyanotic A = Axillary
T =Tympanic
40 Circulation (Peds 5 Years)
R =Rectal
(2) radial Pulse Palpable
(1) Axillary palpable, not radial
20 (0) Carotid only reliable pulse LOS

C = Cervical
TOTALS: Must be 9 or
greater to D/C. otherwise
T = Thoracic needs anesthesia approval for L = Lumbar [VC, S = Sacral
/ 0 /0
Pa en teaching done; Wound Ca e. Pain Management,
T, C, & DB,. Incentive Spirometer, Comfort Measures
Safety: SR up X 2, Falls Precautions. Privacy Maintained
tcontsnue on reverse)
PREPARED BY 'Signature & Title)
DEPARTMENTISERVICE/CLINIC DATE
25c/05
or typed or written entries give:
Name - last,
e; Fade: date: hospital or medical faatyl

. HISTORYIPHYSICAL
.....21flOW CHART
. OTHER EXAMINATION
0 . OTHER asap./ OR EVALUATION
Who ) -V
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78
WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
Previous edition is obsolete mon02.00
MEDCOM - 20508
DOD-034082

MEDICATIONS
Allergies: Time t 1 Pain 1-1n Medication & Dnsane rri So ci. 5-•1147 Route I Pain 1-10 I/E CIAO '7- By
! 33 r /- m bOYI r" T3 /6/* 7-- tiON -1- .

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
Mm f e r.
IMI
15 P-MMIIIIIIMIIIIIMMIIIIMIN P
30' MI IIMIIMMILMWAII 45'
In -MI W IIIPIPAIIIIII ._,../11111 90' NMI MIN NM
DiC ZIIIIMMIIIIIIMITAILIMMIIIMMI Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C= Cyanotic. Capillary Rein: B= Brisk, 5= Sluggish P= Pale, Pk = Pink
C-SECTIONS Adm 15 37 45 67 9Q:.----156-
Fund. Height _..----------
Lochia ------------Peripaclit Fupricl.
....—
DRESSINGS Location Type Drainage
Time
Adm 6OCAI Le t • -f--
37 CP ir.r"( r _L.
67
D/C 69-11'N tr4 I CC-'te 4-

PACU OUTPUT
Time Source • Color/Appearance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
/41 /0

WAMC OP 173-E
NURSING NOTES
19/-001M fie) 19 "P-C__ S P igr) /3(.9121Leis. fp2s /0 010/ confirocc.J (5 d
"
(b)(6)-/-e055 (4 7 e, Z ‘-e-•r vts e fr,--1 11111111 ‘0441. I to lGe-t.,1 7400.o/f-
too, -2, LT-/ X6.LIX6)-7—
/LC
Discharge Criteria:
Date: 2G5ert_Time: /WO PARS: /0
BP:19/0 HR:G0 RR: -7 Sa02:
Pain Level at D/C (0-10):
Intake: ( OO eC z Output:
Additional Data:
Transferred To: /Gk./
Report Given To: 6)(L9 )- z
Transferred Via: W/C Gurney Ambulance
Transferred By: W119
Cleared IAW Recovery oo (10) (14-z_
Charge Nurse Signature:

MEDCOM -20509
DOD-034083

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this tom see AR 40-66: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED AndREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: k. , ,43-k. Anesthesia Type (Circle)): General Spinal Epidural Drains Airway
Time In: Allergies: t`, 1¦31.0, \\ OR Intake: Crystalloid Liv IV Sedation Nerve Block Colloid Hemovac NG Nasal Oral
Pre-op V/S: OR Output: UOP t _,,r,_ EBL I %.A.,,L7,v-.."0) JP ETT
Procedures: Meds/Times: T-tube Trach
Foley Other
Pre Op Meds History TLS

Time
11'
FW77
Pacu Intake
Sa02 Mtrzc qef F102
ktibAs A Methods 240
220
200
180
160
140
120
100 4 v,V ‘.,
80 .
60 C I
A A /% A
40
20
RR T Time Pain (0-10) LOS
PREPAR . (Al.') ---4.
PATI or P entries give: list, middle,. grade,-date: hospital or medical lacskyl
Ck0) L6) - 'lb
Time Solution Amount Site -By Infused
X-rays:
Post-Anesthesia Recoveryscore

Criteria ADM 30 D/C Codes
Activity (2) Moves 4 Extremities (1) Moves 21 AIRWAY A =Ambu
(0) Moves 0 Extremities BB = Blow-by
M = Mask
Airway (1) Dyspnea, limited breathing (0) APrlea (2) Cough, Deep breath FT = Face Tent RA = RoomAir NC =Nasal
Blood Pressure (2) SBP =/-20 of Pre-op Cannula
(1)SBP =/-20-50 of Pre-op (0) SBP =/-5 of Pre-op V/S
X = A-line BP
Consciousness (2) Fully Awake. audible Ming (1) Arousable lo verbal or pain " =Cuff BP = Pulse
TEMP
Color S=SMn
(2) Baseline color & appearance (1) pale. mottled, jaundiced (0) Cyanotic 0= Oral A = Axillary T =Tympanic
Circulation (Peds 5 Years) R = Rectal
(2) radial Pulse Palpable
4.1.).Axillarrpotpavrnanszor (0) Carotid only reliable pulse LOS C = Cervical
TOTALS: Must be 9 or T = Thoracic
greater to D/C, otherwise roneeds anesthesia approval for DC, L = Lumbar S = Sacral

Patient teaching done: Wound Care. Pain Management.
T. C. & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained
Ilonloue on awful
DEPART T1 ERVICEICUNIC DATE
C
(6 4(

Name -last,
• HISTORYIPHYSICAL . FLOW CHART
U OTHER EXAMINATION . OTHER (4..44 OR EVALUATION
III DIAGNOSTIC STUDIES

• TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPPC V2.00
MEDCOM - 20510
DOD-034084

MEDICATIONS
NURSING NOTES
Allergies Time Pain-........Medication Route Pain TIE By 1-10 f1nsa 1-10 16
ttl AA tit
I ,
'0,PA
- C/ AI_ k .4
k•-rj, 4) Qt171
cL:) ,,,,i, ._
NEUROVASCULAR
Time Site Range Sensory
Of
O.
Cap T Color
s04, ----eA4,,, &, 5,_.
Refill
Motion
Adm -4.-.-, C.,----WM 5' / b)1.6 -7,
15' 30' 45' 60' 90' D/C
Movement/Sensation: + = present,- = absent Temp:C = Cool, W= Warm Pulses: P = Palpable, D = Doppler, A= Absent Color: C= Cyanotic, Capil ry Refill: B= Brisk, S= S uggish P= Pale, Pk = Pink C-SECTIONS 15' 30' 45' 60' 90' DM Fund. Height .."----................................_
Lochia
Peripad#
*---....,...........

Fund. Cond.
— DRESSINGS -rime Location Type Drainage
Adm.
30'
------..„.................._

60'
D/C
PACU OUTPUT
Time Source • Color/Appearance Amount

CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Str p Run?

WAMC OP 173-E
vr,10,,ted-_,
.... .46, - . ¦ „ ,_____4__ A Lid _
LO (" CV \ (24% (N N4 a mac_ czb.._.., s1_,..t. • 62,2 cP/0 P\S Gvk ho
Discharge Criteria:
Criteria:
Date: t aLk Time: U PARS:

T: b HR:6c) RR: Sa02:iCa
Pain Level(at D/ 10-101: Intake: Output: C-Additional Da : Transferred T : Report Given To: S. Transferred Via: W/C y Ambulance Transferred By: („7-Cleared IAW Recovery Roo Charge Nurse Signature:
MEDCOM - 20511
DOD-034085

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 40.66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED lOnelREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: Anesthesia Type (Circle)) . General pinal Epidural, Drains Airway Time In: iR-S--I 5e ation Nerve Block 19Srt" .f./. Hemovac Nasal Allergies: f\-)1/... 0 A OR Intake: Crystalloid Colloid NG Oral
oto
Pf----Q
Pre-op VIS: rittili 8(0 OR Output UOP Ii6 QS EBL y•-•-iNIN JP
(...,,, s Err
Procedures: c-tiS-Lsr...x.-2-Meds/Times: ,) r--0,-“... b tr-,_.*-T-tube Trach :VP r c-4---1-. 77.:4--CI CI /.-;A t Foley
Other ,..v:.,,.. 0.)..,...i. TLS
Pre Op Meds History
Time $ /0
Ig1
4
Pacu Intake
, .N. ¦
Time Solution Amount Site -By
Sa02 C4Cril 1 0:1009Cd Infused
F102 ,=1- a f CAL _360 9 cN AI--go C1
FICI QC Pit gik 0 al
460 tc.vit, -oc.) S P „,,,3 ...)
Methods
/ 6 ° PUS Pl4111 "-No sele
240
220
X-rays: . Labs:
Post-Anesthesia Recovemscore
200 Criteria ADM 30' DIC Codes
Activity


AIRWAY
(2) Moves 4 Extremities
180 (1) Moves 2 Extrernilies

A =Ambu
(0) Moves ( Extremities BB= Blow-by M = Mask
Airway
160 FT =Face
(2) Cough, Deep bre.3th
Tent
(1)
Dyspnea, limited breathing

(0)
Apnea RA= RoomAir

140
NC = Nasal
Blood Pres sure
Cannula
• /X (2) SBP 4• 20 of Pre-op
, I,
120 A (1) SBP .1- 20-50 of Pre-op
.
(0) SBP =1-50 of Pre-op VIS
iS /t ft
X =A-line BP
e Consciousness
100 ' = Cuff BP
(2) Fully Awake, aucfible
a crying
o (1) Arousal le to verbal or pain
r(
r(

= Pulse
a TEMP
Color
S =Skin
SI i . (2)Baseline color a appearance
0 = Oral
60 (1) pate. monied. jaundiced
V
A = Axillary T =Tympanic
(0) Cyanotic
...• Circulation (Peds 5 Years)
40 V R = Rectal
(2)
radial Pulse Palpable

(1)
Axillary palpable, not radial

LOS
(0)
Carotid only reliable pulse

20
C = Cervical
TOTALS: Must be 9 or
T = Thoracic
greater to D/C, otherwise
L = Lumbar
RR 11 i4 ia -1 needs anesthesia approval for
S =Sacral
D/C,
T ri
?
Time Patient teaching done; Wound Care, Pain Management.
Pain (0-10) T, C. & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained

lLonlinue an fraeffel
PRE DEPARTMENTISERVICEICUNIC DATE
(io)tb) -
Pilc
PAT r r or mitten eludes give: Name —last,
first, middle: glade; date: hospital or medical lanEtyl
. HISTORYIPHYSICAL FLOW CHART
.
.
OTHER EXAMINATION . OTHER /spade OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition Is obsolete
USAPPC V2.00
MEDCOM - 20512
DOD-034086
MEDICATIONS
NURSING NOTES
L
:L.J.\\\
Allergies: Time Pain Medication & Route Pain By 1-10 Dnsane 1-10 RAT" r-,-eJL,_ lefty,:
(-Pvlbd
r ----cotto-i-

5Ap V\‘‘,4 '-^ A ,--$, g""(•°4 --yu e „..------/ t
tP__ ..r-A-0 Leco ; „‘o...c (. -1.r.trC0
16 , I 1
ti-M4 t" ()ros 0150t a_v Q r/
L 21A—i-e) , QSv =t c7"/of t„/5 re, teed 14(c„, Q rwr.5 /4/St..hi TA/P .........--f (b)(6) --z-
-ns-A-g-44 5 rc-,•+. 7, Le Y,2 pca.Q.A., PA cio • also+ (5AArt
NEUROVASCULAR
Site Range Sensory P Cap T Color

Time 5S61(..piu L6) 6-b) -1-
Of . Refill
Motion

iboo (-o-r4pL, pc,kle.67- st
Adm 610_4 LL:010-1. 1) ,_ 15' "4 CV en Q.—1 eCsk "VW.
• di C)
30' -
00
45'
60'
90'
DM
Movement/Sensation: + = present,- = absent Temp:C= Cool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, S = Sluggish P= Pale, Pk = Pink
C-SECTIONS
Adm 15' 30' 45' 60' 90' D/C
Fund. Height
Lochia
Peripad#
Fund. Cond.
DRESSINGS
Location Type Drainage

Time
Adm
30'
60'
WC .
PACU OUTPUT
Time Source • Color/Appearance Amount Discharge Critsria: Date:ch,Slic)°)Time: PARS: BP: tega T:rHR: ( RR: 00 Sa02: Pain Level at DIC (0-10): Intake: 43.e)-0 Output: '&00 Additional Data:
CARDIAC RHYTHM
Transferred To:
Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To: SPL 6)(b)--z. Transferred Via: W/C fitter Gu Ambulance Transferred By: S clo /Lb )-z.
Cleared lAW Recovery Room Charge Nurse Signature:
WAMC OP 173-E
MEDCOM - 20513
DOD-034087
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this torn see AR 40-66: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED WareREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: 6 f Od-I5. Anesthesia Type (Circle) Genera Spinal Epidurali _AAA Drains Airway Time In: ry Hemovac Nasal
jo3D IV align Nerve Block Allergies: NCAA OR Intake: Crystalloid 17/60re Colloid Oral Pre-op V/S:1116/Kg $? 0 OR Output: UOP '00 EBL e..co cc. VPS ETT Procedures: /141) te leci medsrrimes: ' ,,,--Gt.fr.T-tube Trach
,,) 1:. 7 JP rin-Mqe.or Other
Pre Op Meds History
Time i.e.'
Pacu Intake e elig
'', -. ¦.* V.
JO

Time Solution Amount Site -By
Sa02
Infused
'lb
119.0 te 1 so 1 v

Fi02
Methods it‘gpwi a a,
220 X-rays: . Labs:
. Post-Anesthesia Recovery score
200 Criteria ADM 30' O/C Codes
180 Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities AIRWAY A = Ambu BB = Blow-by
160 140 120 1./ v V %./V • Ainvay (2) Cough. Deep breath (1) Dyspnea, limited breathing (0) Alma Blood Pressure (2) SBP =/- 20 of Pre-op (1) SBP ­-4- 20-50 of Pre-op (0) SBP =4- 50 of Pre-op M= Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula V/S

X = A-line BP
)
Consciousness
100 •
(2) Fully Awake, audible
." =Cuff BP
= Pulse
aYing
4--
80 • sa
(1)/unuble to verbal or pain
TEMP
Color
S =Skin
(2) Baseline color & appearance
0 = Oral
(1) pale, mottled. jaundiced
A•
A = Axilla
Axillary
(0) Cyanotic
A tit
T =Tympanic
Circulation (Peds 5 Years)
40 /\
R =Rectal
(2) radial Pulse Palpable
(1)
Axillary palpable, not radial

LOS
(0)
Carotid only reliable pulse

RR to lc a° A it
C = Cervical
TOTALS: Must be 9 or
T =Thoracic
greater to D/C. otherwise
L =Lumbar
needs anesthesia approval for
S = Sacral
DIC,T ,i,c1
_
Time Patient teaching done; Wound Care, Pain Management, Pain (0-10) T. C. & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained -
/continue on metro
PREP DEPARTMENTISERVICEICUNIC DATE
(Way ) —1-

• ?AC U 74 °_S
DI 0 c-c--
PA e
of typed or minim entries givive. Name — last,
lest, middle; grade; date; hospital or medical lauNtyl
¦ HISTORYIPHYSICAL • FLOW CHART
¦ OTHER EXAMINATION . OTHER overdo
1111111 Y
d 0 6066) -
OR EVALUATION
• 0 DIAGNOSTIC STUDIES
¦ TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC V2.00

MEDCOM - 20514
DOD-034088
MEDICATIONS
NURSING NOTES
Allergies: Time Pain 1 ­10 Medication & Dncnae Route Pain 1-10 I/E By
roto Fig, ID , (b)04" L
/o lio Deine,,) ) v L (r

NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm
15'
30'
45'
60'
90'

Movement/Se ation: + =present,- = absent Temp:C = Cool, W = Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, S= S uggish P = Pale, Pk = Pini,c0„....
C-SECTIONS ---------Adm 15' 30' 60' 90' D/C Fund. Height Locitia
---.'"-----Peripad# . Cond.
DRESSINGS Location Type Drainage
Time Adm f; :e.`4 !C.( ()_,)) 0 P.)40,01.--,
30' a ei e. JFAiv-0,: . ,
60'
D/C //1-16 X ( ec 0 f)dir 4 (-1

PACU OUTPUT
Time Source • Color/Appaar.ancr---Amount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
fr; "30 A.ic P 0 P-
WAMC OP 173-E
AiLotota, ,L)1 VSS. oz
,ate cWo -pf aA,e, ,,i/p2r/ u ke v4-. :4A fr
jg. 5.W4 .t)c„
Discharge Criteria: Date: 01 Oct 03Time: Io s10 PARS: /-0 BP:/ t4' T: OR: 6 &• RR: Sa02:/O 0 Pain Level at D/C (0-10): 0 Intake: /00c G Output: Additional Data: /ve"P,-,e Transferred To: ec,0
Clo )00 )- L
Report Given To: L Transferred Via: W y Ambulance Transferred By: 0.4(.19 Cleared IAW Reco 0
(e)03)-7-
Charge Nurse Signature:
-
MEDCOM 20515
DOD-034089
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 40.66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED lDatelREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: 4 (25,3 Anesthesia Type (Circle)): General Spinal Epidural Drains Airway Time In: 0-C--IV Sedation Nerve Block ntri Hemovac Nasal
i
Allergies: 11 1 OR Intake: Crystalloid re,.." Colloid ---C--e--NG Or Pre-op V/S: OR Output: UOP. (Cr' I
talEilliEwdr. , . EBL7'X . JP Procedures: 4 111111.41 . 1 Meds/Times:ill'k-Ift T T-tube rach
\I-ZYSI..:
I
C Foley"
Other Pre Op Med ,. History TLS
Time o ,•'''
—, Pacu Intake
Sa02 Time Solution Amount Site -By

.....-ii0 Infused
Fi02 LL 141/11110BEENK 3 OV--_ _p
Methods S -. d ,„..., 4--

240 .

220 I X-rays: . Labs:
Post-AneSthesia Recovery score

200 Criteria ADM 30' D/C Codes

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

(0) Moves 0 Extremities BB= Blow-by M - Mask
Ainvay
160 FT = Face
(2)Cough, Deep breath
Tent
(1)
Dyspnea foiled breathing

(0)
Apnea RA =RoomAir

140 NC =Nasal
Blood Pressure
Cannula
(2) SBP ,--/- 20 of Pre-op
120 V 1 () SHP =/- 20-50 of Pre-op
a (0) SBP =/- 50 of Pre-op V/S

V
• 4 NI
.

X =A-line BP
a Consciousness
100
" =Cuff BP
N

N

N
• (2) Fully Awake, audible
= Pulse
TEMP
crying
(1) Arousable to verbal or pain
80 A
60 Color (2) Baseline color & appearance (1) pale, mottled, jaundiced (0) Cyanotic S = Skin 0 = Oral A = Axillary
40 Circulation (Peds 5 Years) (2) radial Pulse Palpable T =Tympanic R = Rectal
20 (1) Axillary palpable, not radial (0) Carotid only reliable pulse TO'S C =Cervical
RR T oSc TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for DIC, T = Thoracic L = Lumbar S = Sacral
Time Patient teaching done; Wound Ca e, Pain Management,
Pain (0-10) T. C, & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained
rtonrmue on reverse]
DEPARTM T SERVICEICLINIC DA i)

PATIENT'S or typ 4r written entries give: Name — last, . Inst, middle• grade: date: hospital or medical facEtyl
0 HISTORYIPHYSICAL 0 FLOW CHART
¦ OTHER EXAMINATION . OTHER tsi=art
11.02)0o )— -
OR EVALUATION , • DIAGNOSTIC STUDIES MI TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC V2.00
MEDCOM - 20516
DOD-034090
MEDICATIONS
NURSING NOTES
Allergies:
Time Pain Medication & Route Pain I/E By
1-10 nrmAcie 1-10

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
IMAM ourminin.
Adm t • 4
is

30' 45'
60'
90' iraniturammurainummir
0/C Movement/Se IP ation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D =Doppler, A= Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= S uggish P=PalPink
C-SECTIONS Adm 15' 3 45' 60' 90' D/C
Fund. Height Lochia Peripad#
F . .
DRESSINGS Location Type Drainage
'Time -Adm
ID .P ITMIZIFM
30' 0 a 60' i •
—....„..
D/C IIMER=ElA. 4 U P
PACU OUTPUT

Time Source • Color/Appeara Amount Discharge Criteria: Datelvr Tirane: I iD PARS: Ci BP: R HR:qcf3 Sa02: t_ Pain Lee at D/C (0-101: Intake: Output: Additional Data:
CARDIAC RHYTHM
Transferred To: fit`
Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To: TT

I07.5-F.:4 *-1:f.r. 01==-c Transferred Via: /C rney Ambulance Transferred By: K. Clo)(2)--z_ Cleared lAW Recovery Roo Charge Nurse Signature:
WAMC OP 173-E
MEDCOM - 20517
)4.10)-z_
DOD-034091
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 40.66; the proponent agency is the Office of The Surgeon General.
OT SG APPROVED IDatelREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: Anesthesia Type (Circle)): General Spinal Epidural . • Airwa Time In: IV Sedation Nerve Block tIlli• e e t '
4rin '--Allergies: in,/ I/ 0 A OR Intake: Crystalloid SO 4' t-4_ Colloid NG Oral
,d C) fi Vt) Pre-op WS: Wilt 9G OR Output: UOP EBL Ps",-.\tl JP ETT
Jiro r=c,..-if-
Procedures: 7/...4--0 6)( ..z.Es Meds/Times: T-e Trach Foe
Other
Pre Op Meds History TLS
a -.

Time (:", K.AI., L 4 3
...„ ..,. -... •,,, .e. Pacu Intake
Sa02 Time Solution Amount Site -By Infused

341 Ti 5r 147 Ce
F102 A 14 (IP IA itn 1r30 7.0e.PS --qc.$ c) 06 i 10 (Wtb) -2.-

Methods
240

220 X-rays: Post-Anesthesia Recovery_score
'
200 Criteria ADM 30' D/C Codes
Activity

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

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

180
Airway
160 FT = Face
Dr breath
(2) Cough, D
Tent
(1) Dyspnea , limited breathing
(0) Apnea RA - RoomAir 140
NC = Nasal
Blood Pressure
Cannula
(2) SBP .1.-2 of Pre-op
120 (1) SBP =A 20-50 of Pre-op

V/S X =A-line BP
(0) SBP =A 50 of Pre-op
I
Consciousness
100 "' = Cuff BP
6 ., 4 ..% r (2) Fully Awake. audible
= Pulse
crying
A
(1) ;Unusable to verbal or pain
80 ^
• TEMP Color
S = Skin
(2) Baseline color 8 appearance
0=Oral
60 (1) pale. mottled, jaundiced
V V A = Axillary

(0) Cyanotic
v
T =Tympanic . Ci aton (es
Circulation Pd 5 Years)
40 R =Rectal
(2) radial Pulse Palpable
(1)
Axillary palpable, not radial LOS

(0)
Carotid only reliable pulse

20
C = Cervical TOTALS: Must be 9 or
T = Thoracic
greater to DIC. otherwise
L =Lumbar
RR AA ibial needs anesthesia approval for
S = Sacral
OIC .
T
Time Patien teaching done; Wound Care, Pain Management,
Pain (0-10) T, C, & DB.. Incentive Spirometer. Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

1Connnue on reverse/
PREPARED DEPARTMENT1SERVICEICLINIC DATE
• LW t 0 )-'7--
c i 0c403
PA u
PATIENT'S IDENTIFICATIal or typed or e.. Name -last,
lig middle: grade; date: hospital or medic

¦ HISTORYIPHYSICAL ¦ FLOW CHART
ttLitillart
L'' )1_0' )" V ¦ OTHER EXAMINATION ¦ OTHER Nym;lrf
C/
OR EVALUATION
rill CO Lb) -4/ 0 DIAGNOSTIC STUDIES
'
0 TREATMENT
DA FORM 4700, MAY 78 WAMC OP 1T3-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
WNW V2.00
MEDCOM - 20518
DOD-034092
Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication Route Pain I/E By
1-10 DrAani, 1-10

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of . Refill Motion Adm 15' 30' 45' 60' 90' D/C
Movement/Sensation: + = present,- = absent Temp:C= Cool, W = Warm Pulses: P = Palpable, D = Doppler. A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= S uggish P= Pale, Pk = Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C
Fund. Height Lochia Peripadtt Fund. Cond.
DRESSINGS Location Type Drainage
Time Adm 30' 60' D/C
PACU OUTPUT
Time Source Color/Appearance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
(1) tpt 1_4—v3 c;)c,, 9e0.tiSS
OC' eactrs.—; ..31/
Discharge Cri ria:
Date: ..?e7 iime: /6( 1 PARS:
BP: clivyT: f? 3 HR: /4't RR: 1 Sa02:
Pain Le el at D/C (0-10):
Intake: a--0 O Output:

Additional Data:
Transferred To: "—Z.:X.4,J
Report Given To: (1.) 2—
Transferred Via: W/C Litter urney Ambulance
Transferred By: 5C6-66)112) z-
Cleared IAW Recovery Room -3
Charge Nurse Signature:

WAMC OP 173-E
MEDCOM - 20519
DOD-034093

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this form. see AR 4066: the proponent agency is the Office of The Surgeon General OTSG APPROVED (Date)
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: I 0 0-14*-0 3 Anesthesia Type (Circle)): Spinal Epidural Drains Airway I?b r IV Sedation Nerve Block Hemovac Nasal
Time In:
Tr^ NG Oral
Allergies: 4, " K 0 4 OR Intake: Crystalloid 6 (4._ Colloid Pre-op V/S: 6 1 OR Output: UOP EBL Qj JP ETT
/ ° II o,
T-tube Trach
Meds/Times: • Foley
Procedures:
Other
TLS
Pre Op Meds History
g L
Time Pacu Intake

Time Solution Amount Site • Infused
Sa02
L le)tb)-
F102 /,16 Ye,

Methods
240
X-rays: Labs:
220
Post-Anesthesia Recovery score

Criteria ADM 30' D/C Codes 200
Activity
AIRWAY
(2) Moves 4 Extremities
a
A= Ambu
Moves 2 Extremities
180 BB= Blow-by M = Mask
(0) Moves 0 Extremities
Airway
FT = Face
160 (2) Cough. Deep breath

Tent
(1) Dyspnea. limited breathing
RA =RoomAir
(0) Apnea
140

NC =Nasal Blood Pressure
Cannula
(2)
SBP 4- 20 of Pre-op

(1)
SBP 20-50 of Pre-op

120 V/S
(0) SBP 4- 50 of Pre-op
X =A-line BP
Consciousness
-= Cuff BP100 (2) Fully Awake, audible
= Pulse
aYin9
a
(1) Arousable to verbal or pain
TEMP Color S =Skin 80
(2) Baseline color & appearance
0= Oral
(1) pale. mottied, jaundiced

60 2 A = Axillary
(0) Cyanotic
T =Tympanic
Circulation (Peds 5 Years) R= Rectal
40

(2)
radial Pulse Palpable

(I)
Axillary palpable, not radial

LOS
(0) Carotid only reliable pulse
20

C = Cervical TOTALS: Must be 9 or T = Thoracic greater to D/C. otherwise
I= Lumbar RR
needs anesthesia approval for
7 2 ID
S = Sacral
D/C.
T
Pat en teaching done; Wound Ca e. Pain Management,

Time
T, C. & DB,. Incentive Spirometer, Comfort Measures
Pain (0-10)
Safety: SR up X 2, Falls Precautions. Privacy Maintained

LOS
fLonhnue on levers?)
DATEDEPARTMENTISERVICFJCLINICPREPARED BY rsip
) Lb 1--L. q- LOQ
gwe
PATIENT'S WENT . Name —last,
list. middle; grade: date: hospital or medical laciityl . HISTORYIPHYSICAL . FLOW CHART

. OTHER EXAMINATION . OTHER ryi.arr
)Lo )16
OR EVALUATION
-t
.
DIAGNOSTIC STUDIES

.
TREATMENT

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition Is obsolete
DA FORM 4700, MAY 78
USAPPt V2.00
MEDCOM - 20520
DOD-034094

MEDICATIONS
NURSING NOTES
Allergies: Time Pain Medication & Route Pain I/E By
1.10 Dosane 1-10 1/-40 /17gh-T-c (-7)1c...) .41,14-faJ-f 1,,t 4.7 q-Okr,-. A --rt In svci 7, t, (bAbil
U4(0 „S.
/iv -7-4-0 77,..6/4 / 6c. t4
(1461'L
azo 11oL . 2 fw6 )4604 1-A
059 P.Dy, Vac 0 C ooto-L r
0726 4-c411.,_ ( 64'S- 01°4— It/
10 4..,
-
4-0
NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion Adm 15' 30' 45' 60' 90' D/C
Movement/Sensation: + =present,- = absent Temp:C= Cool,
W =Warm Pulses: P = Palpable, D =Doppler, A = Absent
Color: C = Cyanotic,
Capillary Refill: B = Brisk, S = S uggish P= Pale, Pk =Pink

C-SECT1ONS
Adm 15' 30' 45' 60' 90' D/C

Fund. Height
Lochia
Peripad#

Fund. Cond.
DRESSINGS
Location Type Drainage

Time
Adm
30'
60'

D/C
PACU OUTPUT
Time CARDIAC RHYTHM Source Color/Appearance Amount Discharge Criteria: Date: toac-43Time: P PARS: BP: /*7 T: HR: SO RR: /SG Sa02:9,7/ Pain Level at D/C (0-101: Intake: br-v ¦ Cc Output: S)o Additional Data: Transferred To: =Cc—)

Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To: (lo)110)-z
Transferred Via: W/C Gurney Ambulance
Transferred By: 02) 142 ) 2—
Cleared IAW Recovery • 111 S P B-3
Charge Nurse Signature:
WAMC OP 173-E

MEDCOM - 20521
DOD-034095

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
for use of this form. see AR 4066: the proponent agency is the Office of The Surgeon General.
REPORT TITLE OTSG APPROVED Watel
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: (5 6)
Anesthesia Type (Circle ))• Spinal Epidural
Drains Airway
Time In: I t
IV er asion Nerve Block
Hemovac Nasal
Allergies: /*DA' OR Intake: Crystalloid 400 Colloid NG
Oral
Pre-op VIS: I Lt 0 OR Output: UOP EBL. g.
ETT
• CF7
Procedures: Meds/Times: 1 tt
i VC.44 ( 5n .r4.1.--# T-tube Trach
Foley
Other
Pre Op Meds Histor TLS
Time to
Pact. Intake
Sa02 Time Solution Amount Site • By

Infused
F102
In°
1 t.)
Methods
240
220
X-rays:
Labs:
Post-Anesthesia Recovertscore
200

Criteria ADM 30'
D/C Codes
Adivity
(2) Moves 4 Extremities AIRWAY
180

(1)
Moves 2 Extremities A =Ambu

(0)
Moves 0 Extremities

BB= Blow-by
M = Mask
Airway
160
(2) Cough, Deep breath FT = Face
(1) Dyspnea, limited breathing Tent 140 RA= RoornAir
(0) Apnea
NC = Nasal
Blood Pressure
(2) SBP =1- 20 of Pre-op Cannula
120
(1)
SBP =A 20-50 of Pre-op

(0)
SBP =/- 50 of Pre-op V/S

X = A-line BP
100 Consciousness
(2) Fully Awake, audible ' =Cuff BP Ming = Pulse
Bo (1) Arousable to verbal or pain
TEMP
Color
S = Skin
(2) Basel.* color & appearance
60
(1)
pate, mottled, jaundiced 0= Oral

(0)
Cyanotic A = Axillary T = Tympanic

40, Circulation (Peds 5 Years)
R =Rectal

(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial

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

TOTALS: Must be 9 or greater to DEC, otherwise
T = Thoracic
RR 25 Ili needs anesthesia approval for L = Lumbar
WC, S = Sacral

10 b
Time
Pat en teaching done: Wound Care, Pain Management,Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures
LOS
Safety: SR up X 2, Falls Precautions. Privacy Maintained
Itonlinue on reverse,
DEPA TMENTISERVICEIGUNIC DATE
(Oa) -4
cu / So c713­
e or vmttea entries give:
Name —last, list, middle; grade; date; hospital or medical leafy!
. HISTORYIPHYSICAL . FLOW CHART
11.1 ziwkl-g
.
OTHER EXAMINATION

.
OTHER OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
Previous edition is obsolete
USAPPC V2.170
MEDCOM - 20522
DOD-034096
MEDICATIONS
Allergies: Time Pain 1-10 Medication & Dosage Route Pain 1-10 I/E By
1V3

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion Adm UM" -1i-
IMIEMIIIMEI P .
15. riffil 4 -(-irjr1/11NRIS P(cd
30' rairl te IraMEM I'
45' 60' 90'
D/C UM 4)
VIIIIIIMMIIIM1 ' G
Movement/Se sation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P. Palpable, D =Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= S uggish P= Pale, Pk .-- Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' Fund. Height
...------------'-Lochia
Petipad#
....-----------.' FUTIC
DRESSINGS Location Type Drainage
Time Adm IIS O'' VA ee..) 41:0 c/),141071 0' t
3at
,?.., ti... „..„...
60' D/C
PACU OUTPUT
Time Source • or/Appearance Amount
CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run? ti
0
NURSING NOTES
P.

A A a_A. diallfflart -Arr
f eit
Fid 0
_ MIT -MN
12)
Discharge Criteria: Date: 15000!) Time: I 211.0 PARS: /0 BP: 139/0 T: q63) HR: 5S RR: p, Sa02(0 Pain Level at D/C (0-10): 0 Intake: Output: 71 Additional Data: ,‘..4,1"4-Transferred To: PO/ Report Given To: ( tto -Transferred Via: W/C Wit. a rney Ambulance
Transferred By: L
. Cleared IAW Recovery oom SOP B-3 Charge Nurse Signature:
WAMC OP 173-E
MEDCOM - 20523
DOD-034097

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this form. are AR 40.66: the proponent agency 4 the Office of The Surgeon General.
OTSG APPROVED IDatelREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Dale: )55 0C•1153 Time In: 1(5-7 Anesthesia Type (Circle)): Spinal Epidural IV Sedation. Nerve Block Drains Hemovac Airway Nasal
Allergies: NK-)A OR Intake: Crystalloid Colloid 1460 NG Oral
Pre-op V/S: 1 ISO IS OR Output: UOP Ci EBL ( .3 JP ETT
Procedures: WO-5h but Meds/Times: 100 (1.4 ?f1) tz+r-1On T-tube Trach
Foley Other
Pre Op Meds , _IN Csi f¦pal History TLS
Time -Z.° Q.t. ...Ir.. Pacu Intake ..,-/-------
Sa02 P Cli CFI cri Time Solution Amount itel By Infused
F102
Methods 11(pl% *Rif
240
'-

220 X-rays:
. Post-Anesthesia err score
200 Criteria ADM 30' D/C Codes Activity
AIRWAY
(2) Moves 4 Eidremities 180 (i) Moves 2 Extremities A = Ambu
(0) Moves 0 E BB = Blow-by M=Mask
Airwayy
160 FT = Face
(2) Cough, Deep breath V NI (1)Dyspnea, hailed breathing Tent
(0)Apnea RA =.RoomAir
140
NC = Nasal
Blood Pressure
Cannula
(2) SBP =1- 21 of Pre-op 120 (1) SBP =/- 20-50 of Pre-op
(0) SBP =1- 50 of Pre-op V/S X - A-line BP
Consciousness
100 ' =Cuff BP
(2) Fully Awake, audible
=pulse
ang
- (1) Arousable to verbal or pain
80 A TEMP
Col or

S =Skin
(2) Baseline cd A appearance 60 0 = Oral
(1) pate, mottled. jaundiced
A = Axillary
• (0) Cyanotic
/N
fT = Tympanic
Circulation (Peds 5 Years)
40
II= Rectal
(2)
radial Pulse Palpable

(1)
AxiNary palpable, not radial

LOS
(0) Carotid only reliable pulse
20
-C = Cervical TOTALS: Must be 9 or
T = Thoracic
greater to WC, otherwise
L = Lumbar
RR ID y. V. jo needs anesthesia approval for 0/C,
S = Sacral
T
Time Pa ien teaching done: Wound Care, Pain Management,
Pain (0-10) T, C. 8 DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained
Itonhnue on rerun/
PREPA DEPARTMENTISERVICEICLINIC DATE (0(19) ' 1 0 601-66
I PATTEN S I or typed or written entries give: Name -last, Cyst, middle: grade; date; hospital Of medkal facility'
• HISTORY/PHYSICAL 0 FLOW CHART
¦ OTHER EXAMINATION . OTHER amidii WI 061)119 ) -it OR EVALUATION
al DIAGNOSTIC STUDIES
O TREATMENT
OA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPPC 52.00
MEDCOM - 20524
DOD-034098
Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication & Route Pain t/E By
1-10 fln'ane

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill
-Motion
Mm Lt --4-f3 W M., tit
t 15' 1,162 -le t r I.5 w,,,,...
30' Li 4. Si 00 12— p..4,l4 V.
45'
60'
90'
D/C u es ..4 "4" F t 1-4, 431c,

Movement/Sensation: + =present,- =absent Temp:C = Cool, W=Warm Pulses: P = Palpable, D =Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= Sluggish P= Pa= Pink
C-SECT1ON
Adm 15' .,39'--"-45' 6• 90• D/C Fund. Height Lochia
..,..------P Peripad# Fu . ond.
DRESSINGS Location Type Drainage
Time Adm l., lecl — "1411(' '1A(A-11)---f. 30' 1,..I el -71 1(..-e...1c..p Sk•-•-•KiYn-60'
-.:
D/C LIQ —\ IC e et-G.)0 tet,t.6ti",,x
PACU OUTPUT
Time Source • Color! •earance Amount

CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
(
NSYL
V5.
Discharge Cap: Date: WO. 'time:IX1.S: PARS: (13 BP: )147T: % o HR: 7•g RR: /0 Sa02:/ Pain Le el at DIC (0-10): 0 Intake: 0 Output: Additional Data: C-16,..--) Transferred To: 1C(A.2 Report Given To: b (lo)Liv ) -Transferred Via: Ambulance
Mir"' Transferred By: ,09211 Cb -L Cleared IAW Recove 00 Charge Nurse Signature:
WAMC OP 173-E
MEDCOM - 20525
DOD-034099

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For USE of this form, see AR 4066: the proponent witty is the Office of The Surgeon General.
OTSG APPROVED Ward REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
Anesthesia Type (Circle)): liGlISpinal Epidural Drains Airway
Dale: .1 r (''..T
1
IV Sedation Nerve Block Hemovac Nasal
Time In: N12.3 — Allergies: — OR Intake: Crystalloid Colloid NG Oral Pre-op VIS: li14-/ -58 (ti OR Output: UOP r-2)00,50 EBL 50 . JP EU Procedures: __.5-/-/-),Meds/Times: .?.4) re--4-Or.r;‘,-R ,i,,,,fa I2 Ye.,..,,,/ T-tube Trach &Q7 -In aji Oi t-r, 6c.)..,,,,.) • Foley Other
Pre Op Meds Histor TLS
i :z• 1.4

Time ... ... ai. .„..
AI Pacu Intake
Time Solution Amount Site • By Infused
Sa02 11 PGV
Fi02

Methods fie+ 1 pt if,A pi
240
X-rays: . Labs:220
Post-Anesthesia Recovery score
ADM 30' INC
Criteria Codes200
Acrwity
g
AIRWAY
(2) Moves 4 Extremities -..‘
ABB=.ABrniobwu -by
(1) Moves 2 Extremities
180 .
(0)
Moves 0 Extremities ot

M.
Mask Airway

FT = Face
160 (2) Cough. Deep breath
Tent
(1)
Cryspnea, limited breathing RA =RoomAlr

(0)
Apnea

140 NC...Nasal
Blood Pressure
Cannula
. V (2) SBP 4-20 of Pre-op
•.. (1) SDP =A 20-50 of Pre-op
120
Ws
(0) SBP =/-50 of Pre-op
X = A-line BP Consciousness
' =Cuff BP
100
(2) Fully Awake, audible
= Pulse
crying
(1) Arousable to verbal or pain 'I
a
80 Di TEMP
Color

S =Skin
0 •
(2) Baseline color & appearance
0 =Oral
60 A A A . (1) pale, mottled. jaundiced
A = Axillary
(0) Cyanotic •
T Tympanic /1° Circulation (Peds 5 Years)
R = Rectal
40
(2)
radial Pulse Palpable

(1)
Axillary palpable, not radial

Z LOS
(0) Carotid only reliable pulse20 C = Cervical
TOTALS: Must be 9 or
T = Thoracic greater to [VC.otherwise
L = Lumbar
ID
RR 9713 P. 10 R needs anesthesia approval for 1 D .
S = Sacral
DIC.
T
Time Patient teaching done; Wound Care, Pain Management.
Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained ..__.._.._ __ __.........

PREPARED BY alipature a Thiel DEPARTMENTISERVICEICLINIC DATE
PATIENTS IDENTIFICATION (For typed or written entries give: Name -last,
Fist, middle; grade; date; hospital or medical laatyl

.
HISTORYIPHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER tro=dri OR EVALUATION

'iouo ll11111 0°)(6 ) -
DIAGNOSTIC STUDIES
.
TREATMENT
.
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete won WOO
MEDCOM - 20526
DOD-034100
Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication Route Pain I/E By
1-10 11 sane 1-10

NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion

Cb01-2.-
Adm
15' 30' 45' 60' 90' D/C
Movement/Sensation: + =present.- =absent Temp:C --- Cool, W =Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, S= S uggish P= Pale, Pk = Pink
C-SECTIONS
Adm 15' 30' 45' 60' 90' D/C Fund. Height Lochia Peripad#
Fund. Cond.
DRESSINGS
Location Type Drainage

Time Adm lite/4 2,0.49
11..
30'
D: t0 rAtt 60'
0
D/C
PACU OUTPUT
Time Source • Color/Appearance Amount Discharge Criteria: Date-Time: /96(6 PARS:1 0 BP: t T%5 HR: -55 RR:I Sa02:
Pain Level at D/C (0-10):
Intake: -115/ Output: /:(
Addition I Data:

CARDIAC RHYTHM
Transferred To: ((,U-3
Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To: Transferred Via: W/C Gurney Ambulance Transferred By: Cleared IAW Re Charge Nurse Signatur
WAMC OP 173-E
MEDCOM - 20527
DOD-034101

ABU GHARAIB MEDICAL TRANSFER REQUEST FORM
b) C6) -z
c71
Sq 9 eDATE altUE'03­
REQUESTOR: 09)(19) -Z_
111.1111111 (.1,g
ISN #:
COMPOUND: ern) P Da1 dt,
PRIORITY: gThi-42 LITTER674BULATOR (CIRCLE)
DATE OF TRANSFER:
TIME OF TRANSFER:
DESTINATION:
POC AT DESTINATION:
ANTICIPATED LENGTH OF TRANSFER:
EQUIPMENT REQUESTS:

NOTE: COORIDINATION IS ALSO REQUIRED THROUGH MOVEMENT CONTROL FOR A TRIP TICKET.
MEDCOM - 20528
DOD-034102
1 . REPORTING MTF 2. MTF LOCATION
ADMISSION AND CODING INFORMATION
1 2 3 4 5 6 7 8 (State or
Country

A For use of this form, see AR 40-400; theproponent agency is OTSG
Code. )
..._,
3. REGISTER NUMBER
NAME (Last, First, Middle Initial)
4. PAY GRADE 5. SEX
9 10 11 12 13 14 15
16 17 18 00)00 ) -y
6. DATE OF BIRTH (YYYYMMDD)
7. AGE AT ADMISSION 8. RACE
9. ETHNIC RELIG ON
19 20 21 22 23 24 25 26 27 28 29 30 31
BACK­
GROUND
AMIE 11111M1V01111 I) NI K
10. LENGTH OF SERVICE ETS
11. FMP
12. SOCIAL SECURITY NUMBER
32 33 34 35 36 37 38 39 40 41 42 43 44 45
6/ 9
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
HOUR OF BRANCH / CORPS (d I b)-Li ADMISSION
46
1 6) 1 0
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61

K 1 ei
17. UNIT LOCATION (State or 18. MOS
19. TRAUMA
PREY. ADMISSION
Country Code)
62 63 64 66
65 67 68 69 70 71 YEAR
NO
7
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD NAME/RELATIONSHIP OF EMERGENCYDDRESSEE
ADMISSION

72
V ADDRESS OF EMERGENCY DRIZ
(Include ZIP Code)
law(
o (Ja*/) - 2-
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
U
NK
21. TYPE OF DISPOSITION
22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYYYMMDD)
73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88
111:11
24. AriPirMill111 1 1 1
CLINIC SVC - ADMITTING
25. MTF TRANSFERRED FROM
26. DATE THIS ADMISSION (YYYYMMOD)
89 90 91 92 93 94 96
95 97
98 99 100 101 102 Dim 105 106 A MILIFil irAii irsukaingiminvan6,---1
__Atopzuoulinieurar,.._*.g.wi
27. LOCATION OF OCCURRENCE
28. MTF OF INITIAL ADMISSION DATE INITIAL ADMISSION
(Battle Casualty Only) (II V V' V M M # i
107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122
FOR LOCAL USE
1,X.; 691 I.
TkixtAA,,,_
q 5p s
DX : (10 OPEN) 0A4 Es-r °kir)
-
30.-ar i
pea-N ‘bAel of AT) .7-201-rf ).N--A;,...,,,,,
ADMITTING OFFICER (Signature, as required) (b)00) -Z_ SIGNATU (&) lb)" Z
DA FORM 2985, EDITION OF MAR :9 IS BSO
USAPA V1.00

Ob-1 Li-
MEDCOM - 20529
v91
DOD-034103

ADMIZ-SIC¦ K: FE1, ,:.F.S !Las:, Pirst, MI) ¦
• a. GRA.DE ,
I REG;..., I ER 1\1 ¦ ,n,ISE A.-1 2 . ^1,, ME 09)11+)" 4
10. PRE V10. 2:.S
RACE I T RELICII ,N 18. -•
SEX ,- — ,.....y . ADMI,,oIL,N
, , A.,/,1
IK A 1 0,054E,-. , I
. 14. WAR
4--- : 15. ORGANIZATION
I i . F' "Fs 12. SSN go Lip ). y I I /3-
2C. TYPE CASE
EFT. , 18. 3RANCH/CORPS 19. UIC/ZIP
15. L't !NG :16. z
BENDSOSTATUS.
/4 I .,A itiii4—
/ rf ; K. 7 I I kii. fl
22. HOURS OF 1,23. CLINIC SERVICEzi SOURCE OF .s.DMiSSION/AUTHORITY FOR ADMISSION
ADMISSION
0 I

ite 110 1 i1 1 gilfi
DATE OF DISPOSITION
NAME FELATIONSHIP OF EMERGENCY ADDRESSEE

25. TYPE DISPOSITION 2E.
24. (9- / 2$' // If ADMITTING OFFICER
28. DATE OF THIS
ADDRESS O. EMERGENCY ADDRESSEE (include ZIP Code) ADMISSION

27o. TELEPHONE NO.
0,1W)- Z. 6 0'3 e5 9 3-,e.
32. UNIT , WH L
30. DATE OF INTIAL
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY COMPONENT TRANSFUSED
29. ADMISSION
C
te,)(--2--) — Z.,
31. SELECTED ADMINISTRATIVE DATA
cp,_, if ,v 0v
/Ie.
1---L,,,., A 5 P/c. r 2.
...-

0
Check if Continued on Reverse
-
/
33. CAUSE CF INJURY
_ •

34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES •
b kfc 0 Pe" I ;1. --/.1---8 F4.-
.•
ExT F.I-X
0C11:11
43-'53
..,.,
.
35. Total Days This Facility
TOTAL SICK DAYS
SUPPLEMENTAL BED DAYS I I.
OTHER DAYS 17...— CONS. I VICOOP l CARE DAYS 1
a. ABSENT SICK DAYS b. i•
CARE DAYS
I q 7 i
_fr1 I , V 7
S6. Total Days All Facilites a. A BS ENT SICK DAYS i b. I I OTHER DAYS l c. 1 ,-:2 ,,.L,is _P C O R E C. ' - • Te. 1 SUPPMT.. N BED DAYS I. TOTAL SICK DAYS L/7
SIGNATURE OF A TTENDiNCi MEDICAL OF 6 °L. DA FORM 3bvT IVEMY 79 EDiTION O i SIG. 1 r.o_;s: 6 IS ,,E1SOLETE (L)10) ••• 2., USA:,.: V I .' 0

MEDCOM - 20530
DOD-034104
ABU GHRAIB MEDICAL TRANSFER REQUEST FORM

DATE OF REQUEST:ARS
REQUESTOR:LT
ISN #: V

(b)(b) -9.
th)(b)--"I
COMPOUND

PRIORITY:
LITTER

(CIRCLE)
DESCRIPTION OF INJURIES:

LLQ
46_ -4.MIffillrarfteRger
BER OF

DIM PER

O

COMPANY NG:

DATE OF TRANSFER:
TIME OF TRANSFER:
DESTINATION:

POC AT DESTINATION:

ANTICIPATED LENGTH OF TRANSFER:
EQUIPMENT REQUESTS:

NOTE: COORDINATION IS ALSO REQUIRED THROUGH

MOVEMENT CONTROL FOR A TRIP TICKET.

MEDCOM - 20531
DOD-034105

DATE SYMPTOMS DIAGNOSIS, TR TMENT, TREATING ORGANI ATION (Sign each entry)
& . , -Eq OD IMPALIIMPAMf TkM1,-.4_ 4/12
ANY • 1 ( 9 7010
1
IIMIEFLAA. Li -i
P PJFIQA L,-AlirMallitilW
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te 4
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i (__)Lb) -2_
4"
11/41
111W-
WAIF
STANDARD FORM 600 (REV. 6-97) BACK
USAPA V2.00
MEDCOM 20532
-
DOD-034106
ABBREVIATED MEDICAL RECORD
MEDICAL RECORD (Enter date of admission)
Lac
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION
Ni-y2.) ,"447
5/}0
p
NJ1D'
/
).-?
S A--
1A16-141

ivb
'kilo 40
A-0
PHYSICAL EXAMINATION
H 15-)7L11.
z —
L2s-1'1;3/ 4
rY
6-257"
l-v-PY )) 4 fiC
5
71,/77
r)"vr 1-4.
Cb)-"
,)‹.P.)-,Ce
litter date of discharge and final diagnosis)
T/ '11-3 )‘'/
PROGRESS
Gh--J4 )2D
ORGANIZATIO N
DATE WARD NO .
5677-
SIGNATURE OF
(For typed or written entries give Name last, first, piddle: grade: date; hospital or medical facility)
PATIENT'S IDENTIFICATION ABBREVIATED MEDICAL RECORD
Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS
FIRMR 141 CFR1201 45 505
OCTOBER 1975
USAPPC VI 00
MEDCOM - 20533
DOD-034107
A111110RIZETI FOR LOCAL REPRODUCTION
MEDICAL RECORD I PROGRESS NOTES DATE NOTES 1V4/ iC /dam 7/7 4/2 -',L4. ( (//a ,(_, 47&.i1 i
, ..,.a. lat!,00(
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........_...._....... -/
(Mgr ALIP
/ ArMAKIWo - -' . -• -ilie Com -
was." AWN"
.., ...-. A* .,..CILag......... 411tiv) lb 1- 2.. 111111V47r
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-A • .• A II Ma
RELATIONSHIP TO SPONSOR

SPONSOR'S NAME SPONSOR . , LAST FIRST ND
Nal or Oda!
DEPARTJSERYICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: /For typed or Irina entAkx Or Kw -Int fiat addle; REGISTER ND. WARD ND. ' ID flo et =Vats; Dots of Mt Rfinklersds1
PROGRESS NOTES Medical Record
L6) STANDARD FORM 509 1REV. 61101191 Presalbod by 13SIMCMR FPIAR 14ICFM 101-11.203114110) USAPA Y1.00
MEDCOM -20534
DOD-034108

(6)03)'1

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
aco 0101 \IAD, LociliM) 11-12RiceEsK40)
(1q3 ceotQ olcaQ, idioru2ix -ttpin

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ctIojv QUO paw cgikctio • ctirvw --17)0Le,(c r(2 daac, Liataikroda) paapotb.0.. rapcywV_Q:Q. L-t-i PAC rmuivit, \Awl s
-" -
t $ *AIM_ I Gratab---
CILLOrYtoOt
STANDARD FORM 509 unwire% BACK
USAPA V1.00
MEDCOM - 20535
DOD-034109
AUTHORIZED FOR LOCAL REPRODUCTION
' MEDICAL RECORD PROGRESS NOTES
DATE NOTES
Vlikif 4116 I ill , - . 1...! • i•AlifI b iA• .tia AP a A Wit& AV-k1
C
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KINSHIP TO SPONSOR • SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or Other, •
FIRST
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: /Trot typed or written macs, ;lc Name- last fint milt* RESISTER NO. WARD NO.
ID No re SSV; Sec Dam of Bilk lienarade!

PROGRESS NOTES Medical Record
Mit c L6)--`t
)
STANDARD FORM 5D9 IREV. 51199111 Pisa:find by SSARCLIR FPMR 141 CFR) 101.11.203091101
USAPA 111.00
MEDCOM - 20536
DOD-034110

Alla 00) it7
MIDDLE INITIAL ID NUMBER
FIRST NAME
LAST NAME
NOTES
DATE
laida
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MEDCOM - 20537
DOD-034111

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Gradei
PROGRESS NOTES eo)tb)---) Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101. 11.203(b1110)
USAPA V1.00
MEDCOM - 20538
DOD-034112

AUTHORIZED FOR LOCAL REPRODUCTION
' MEDICAL RECORD PROGRESS NOTES
DATE NOTES

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Doc_nid: 
3945
Doc_type_num: 
77