Medical Report: 35-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Femur Fracture; Gunshot Wound

AUTHORIZED FOR LOCAL REPRODUCTION
_
MEDICAL RECORD PROGRESS NOTES
DATE
NOTES
0 06/;-02 awg,Wcaez&/.
e,6/5-, 6//y7 /1/ T;;Icf f/f/( caze o&,4,/,--
Az 0,tek(ve6/ ,e.,.. ­

7e, /iy;6 7• Cw cr:),1147e, ‘.4,6 4,Q3 ez7naz
61 azocivii
.A4 Ai-ilo/ A/v/ - vd4z(•/- ,//(/,-7. 7
ce7,‹ 47- -- ,/./,-)(1 _,-.6.f 45 c_I-63 .0 V4Ew-Z,21,6e4A
...-.._1_

----61€A't--e
41'31A4(--4/4:LVL- Z;J.-dij • C2--ca-21 AeA22/1 ,_ d
Alr.,[... li

r 1,9(..c --C_ ' ¦ .
.46
U
-, .1,

...., ,, -_,* _ . --,
.... Alif ....._ . ..--- ,P.'', /
._... _
ill
-

06 /kr OS arrlic?
D 7t90 IA.“...) ette_W
.,
,7"u'7izzi./ - 0 -.KO
/-0 OK 4(.574-1.07-4-017J 1 Ata. I-1 , ? u cif? r/".. 62tr-k—er.)(4.7.t_ -.
RELATIONSHIP TO SPONSOR
SPONSORS NAME
MBERLAST

FIRST ISSN or pther) \
?

DEPART./SERVICE
I HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle;
I REGISTER NO.
I WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)

PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999)

Prescribed by GSA/ICMR FPMR (41CFR) 101 -11.203(0)(10)
USAPA V1.00

MEDCOM 19041
-
DOD-032615
LAST NAME 1-IRST NAME MIDDLE INITIAL ID NUMBER
DATE
NOTES
c' oc-Ft 4i.-0 - 1----C ,Ckr-.3' ¦:.: - Z - 7 - I-6
ro /'R,t. (7r;40 -2 JZ \..-2:er_44,a614
12 C -1'1-1()( FI-Y on cf--1-7. OTA- cy_--e_) ,,-7-*z. r•cif ,;-, al 7:-,; -/js-. r'7--
itiPc 5-7,n,4",5t-,-/-4:7/t/ 4,1i/ --&-7R ---r6 ,-c,,/ -Az//' e'717L-.
, --4---"Ilinta. "I 1.)11t--1,'3 21 6--o=v-s5 ma ta,„6) siLie,,witir • A„„ )1.3 i
X (Ltd_ 1-(Ait, e_aA-12-oi6 14,x, itJJ1f,r.­__:4,,,,,„.. jo.
AP.A . . •l&if/.!-MO.°.iL l
•
- • A.ad% L/Ii/.0 CL , 4,.
6617-
Ake/ I.
.lyar)(k.(t)(Al.t71/17)Zdkilor \.S51.Le--/r-)...JQ1)0A/Cc AZ-----ct MLLAAJM/ (t? .e_alift_ ' 0 -(--dam vL-12)-__ID • A '
..

ki 11) FA" _ 0 69___efr tpel_,M,,) e.,104\41-11A-WA .61A(-LAA4 litiat&

LW iL I 0 P6 A.q Al/ci-Nevbf .3
ma) 111-12/1/WLAA/rUP-eta) CG-°, P-1---P4A. i 4 /.,),1 i411 L.A._e, -ir\,-6-AlyztAA,' ' boi 1 A
ry
111-11' OQ__ att ttizIAtti_, -to 11/1,6NA--oP
AL 7, 6:71c.4-• e./ •,„;.... 1"./
12 2,1
C .10 41•41.
IVI.4_ P ' .1./1 .01i2..."--‘47 i4;C:71/4/ e-.4 R.'"
e. Ar ... , ,.
. ... o _,.._,_, , .,/,,, /1.4.., /
eV/4 A •
.t..., IL/ -._. ,st —,_ ..mr/A
. .4.f....-4__.a.1,, .d
/
At ....1;'4_...t-..
--4/"L.t-G,,V
/ _
/ '_,..j
STANDARD FORM 509 (REV. 5/1999) BACK
USAPA V1 00
MEDCOM - 19042
DOD-032616
MEDICAL RECORD
UTHORLZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
DATE
r7Ocld 1'
'IONSHIP TO SPONSOR
"'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first.
/D No or SSN,-
111111L
Sex; Dare of Birth,- Rank/Grades
( -PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 511999)
Prescribed by GSA/ICMR FPMR
14 1CFR) 101-7 1 .203(b/I 7 01
USAPA V1.00
MEDCOM - 19043
DOD-032617

.._ ...._....._ ._.. ._........_..._......._ ,.._,..

MEDICAL RECORD PROGRESS NOTES
I
DATE NOTES
• I .i. i 0 1 1 A ' ' a I A I 0 !'Il AI A. if, C._ prA..140.B. _ 4,_ lo

a It a 4,./lai
I A of
A
if 4_ i I _I 1 . 1 &.• ..,V zy__ -_._0•0_• ._
I. _ ' I/._••
/I. ... 114..r , 4 ¦L_./.,41P_0/' /_.04/ /Al. ,_
/_. d_it_• 4 4 tii,__Ai._1
_A i _ _
.4 ISA a_i_J IA 1th: I . f tri
. lir_
I or
.
W....0-AIF _v ',a1 _ /4_ A _ , dr G'41? /4.
`L`Lr/., r1 0 1 0 it 0 a, ___,4 _J_IIAI /¦/ , i Oil .//_ d 2 IIJAW _ _ • I Asil, tho_ it 11,/ G Hi_0 0_/_AI / ! Ad_04 _ _/ /_1/A/_ 041-6di • 00 .0 09f-(-irrr ./ A. A b ( c),_ 2
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER LAST FIRST (SSN or Other)
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle;
I I
REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(1
USAPA V1.00
MEDCOM - 19044
DOD-032618
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
PROGRESS NOTES
DATE
NOTES
0,606-7-Z"
35-
6S
1-)7
biliz-,-fra L.0 c
7-7
de.A.-y1
EaktA (lizgeo -74PA,-v-t-edc-'1/ ¦-

' Pt
c;
C4A-4..b1.02-4
p,-rk
t„,7„1,) de,,,zza /A-JLL_02
--,,,,t,g f (6,./1" s --zo,„,7 )3i p U
) .
Rn -, h
/.6ir''‘-i c,-f___________.
(C-6 -2--
ELATIONSHIP TO SPONSOR
SPONSOR'S NAME
SPONSOR'S ID NUMBER
LAST
I FIRST
(SSN or Other)
MI
EPART./SERVICE
HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
I1

TIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle;
REGISTER NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade) I WARD NO.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA v1.00
MEDCOM - 19045
DOD-032619
NSN 7540-01-075-3786
LOG NUMBER
EMERGENCY CARE MEDICAL RECORD AND TREATMENT
RECORDS MAINT .
(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DrE ID .ey, Month, IV TIME
CITY F7 PA STATE ZIP CODE 111 (:)---1 TRArRe)AION TO FACILITY (
. .
SE , DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY I SURANCE
AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO
PRP ADDITIONAL INS CE
E M FLYING STATUS DD 2568 IN CHART
AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
ITEM YES N n YES n NO
IS THIS AN INJURY?
WHERE TETANUS ALLERGIES/ INJURY/SAFETY FORMS DATE LAST HOT COMPLETED INTITIAL SERIES
HOW YES • NO
.N1 CHIEF COMPLAINT es (V 6..
b.")
,s
CATEGORY OF TREATMENT VITAL SIGNS TIME TIME / 1..,0
III EMERGENT BP
I -Ji-J15 lli3 63
PULSE
t
allt•G ENT
INITIALS \-_7((i) -7-RESP
/ Z
TEMP
10/ • U
. NON URGENT 1
WT
LAB ORDERS,
3C8C/DIFF ABG PT/PTT BHCG/URINE/BLO D/OUANT CXR PA & LAT/PORTABLE C-SPINE
URINE C&S UA MSCC/CATH CHEM:
BLOOD C&S X
(ri'S
X-RA Y
O RDERS

ACUTE ABDOMEN LS SPINE
SINUS
l'.
HEAD CT
ANKLE R/L
ORDERS
PULSE OX MONITOR . ECG .
TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE
CV X 0 11-4 A¦4-11--
i

DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONSn HOME n FULL DUTY n 24 HRS. n 48 HRS. n 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE Opp. TO WHEN
REFERRED IMPROVED UNCHANGED
0

TIME OF RELEASE I have received and understand these instructions.
DETERIORATED PATIENT'S SIGNATURE
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other/; hospital or medical facility!
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 inv. 9-96)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 19046
DOD-032620

NSN 7540-01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor) TIME SEEN BY PROVIDER
TEST RESULTS
WBC ABG/PULSE OX RADIOLOGY Check if read by radiologist .

U. H/H PLT U 4 2 Cl) SUP 02 PCO2 PH SAT P02 OTHER RESULTS
PT DIP EKG INTERPRETATION
APTT BHCG ETOH .GLU 4 MICRO

PROVIDER HISTORY/PHYSICAL
CONSULT WITH TIME ACTION R ES I ENT/MEDICAL STUDENT SIGNATURE AND STAMP
DIAGNOSIS 1. PROVIDER SIGNATURE AND STAMP
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; ID no. (SSN or other); hospital or medical facility) w OU EMERGENCY CARE AND TREATMENT (Doctor) Medical Record STANDARD FORM 558 IREV. 9 -96) Prescribed by GSA/ICMR FPMR 141 CFR) 101.11.2030311101 USAPA V1.00
MEDCOM - 19047
DOD-032621

NSN 7540-00-634-4123
MEDICAL RECORD NURSING NOTES
(Sign all notes)
DATE HOUR
OBSERVATIONS Include medication and treatment when indicated
A.M. P.M.
2/95 /e2 '777 7 /171 11/251 7-7z5le /,L e(?)-77,1/07.er Ks 0%._ 019
/f"7"0
ezW
¦ e'Z
}r2/,Aez-S
3T' /2548
r1/72t _5?7,92 e -9/9y
5.
e. -
a)/es .:tap 2 97% 0A)
r7-1-7-/4,
-7Pg
A) ,F­
o—Cv " c?C'e-e.
v-se 0/5/5"-
We 4313/.
,11V T
77 .47-41e-e7-4' -le
ze41 7_5 Z::.6%,..5 e C /7.30

/1/7
570,21c. efZ,e'
120/2y-cv,e,-.57
/._s& ossis--\olu)­
rL. j2;(-Zeo_s_s .e3‹: a. ­
_50
c Z4'
0-5-Ac
,y)
3620,-c
y
. e//e./.41e--19 ..5"z7ec- Ce:e eZ .
/r/
C._
e
/.art
-5' .7-e-i .'7"e""'"
0,7
PATIENT'S IDENTIFICATION ..z?;eir:WAWOCIMTI-Feverse6.07--e--
(For typed or written entries give: Name—last, first, middle; grade; rank; rate;
hospital or medical' facility) REGISTER NO.
NURSING NOTES
(
Medical Record
MEDCOM - 19048 STANDARD FORM 510 (REV.
C A 7 -91)
Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1
DOD-032622
NURSING NOTES
(Sign all notes)
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated "Z/C_ • 1,21'iAle--9a2ce o/e/n-
A.M. P.M.
9'30
4
'U.S. Government Printing Office: 1995 — 387-722/20011 STANDARD FORM 510 (REV. 7-91) BACK
MEDCOM - 19049
DOD-032623
•

REOPERATIVE/POSTOPER,-....VE NURSING DOCUMENT
-v4amEor eoR
FOR Use alibis form. see AR 40-107: the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication)
AGE: NKDA C PCN

0 LATEX E: IODINE 0 TAPE •E FOOD
ACTION:
HEIGHT:
10.PREVIOUS SURGERY ) YES "(type): -
WEIGHT: (12

11. PROPOSED SURGICCAIL PROCEDURE:
--b Fe-WIAA-T-1 Mt. t,
3. ADDI ONAL INFORMATION: (Previous surgical and medical history) Skin Condition an, -Tobacco pd X vrs. Body Piercing Diabetes (Y)//5/ ROM 4,
5 y ASA:Mot:Lin wi72 hrs (Y)ETOH Implantifp(f ¦' S. L. btiArRespiratory Disease (Asthma'COPD) (Y)1r9 Anticoagulants (Y) (0)
Glasses! ontact (Y) Dentures
4. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL Potential for anxiety related to: t.7.,1) Surgical Procedure & Operating Room Environment 2) Separation Anxiety
(Child) s---7 3) Surgical Outcomes
B. TION Potential for respiratory dysfunction due to: ) Positioning
Effects of Aps.thesia V.-1) Medic ,Sinokin History
C. INTE IENT Potential impairment of skin integrity due to: 1.'" I) Intraoperative immobility \-." 2) ESU Pad Placement v7--3) Positional Aids
W-4) Prosthesis v," 5) Pooling of Prep Solutions
9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
k,$)—

Ef) 111.11
DA FORM 5179, JUN 91
Pre.
MEDCOM - 19050

Hypertension (Y) cm? Herbal Medicines (Y) (N) MEDS: 01°1-1
7. PATIENT GOALS AND EXPECTED OUTCOMES
Pt. verbalizes any specific anxiety. /J Pt. Exhibits relaxed body posture.
' Pt. will be able to breathe without /difficulty during immediate intraoperative phase .
Pt. will not exhibit signs of impairment of /skin integrity (e.g., reddened areas).
S. OR NURSING INTERVENTIONS
.e/ Allow pi to verbalize freely. .
/ Explain OR environment and answer
questions regarding surgery.
Offer comfort measures. (e.g.. warm

blanket. touch). Explain all nursing procedures before they are done.
7
Remain with pt. whenever possible.
Maintain family interface. Parents to
stay with pt.

1 Offer to elevate head of litter or offer
pillow.
Observe pt. whiie awaiting surger.. for
sums of distress.
,I Assist anesthesia during nitubation
and extubation.

Utilize pressure preventing devices on OR table and accessories. Check for proper positioning and
support to maintain good body alignment.
pr Pad pressure points.
y Place ESU ground pad on non

compromised skin surface area.
Keep prep fluids from pooling.

VERIFICATIONS AT HOLD ENG AREA: ! ID/Allergy Band ! Dentures Removed ! H & P
! Contacts Removed ! NPO Since ! Jewelry Removed ! U1-ICG/IMP ! Body Pierce Rernmed ! Consent/Blood Transfusion Signed/Witnessed:Dated ! Surgical Site/Consent verified by
PL./Anesthesia/Surgeon ! Contact Precautir (Y) 4.6) ! Family/Friend:
I:SAP V; 9

DOD-032624

6. PATIENT PROBLEMS AND NEEDS -
.17/.c

Poten41 for itiadequate tissue per\ftirion due to: 1) Intraoperative Mobility72) Positionin.
3) Existing. Disease . 4) Safety Deice' . 5) Hypothermia
E. NEUROMUSCULAR CONT\yt

E.1. Potential impairment of mobility due to:
¦./" 1) Pain '\,r 2) Intraonerative Hazards
3) Prosthesis \v-4) • Positioning

5) T sfer pt. to'from OR table
E.2. Potential discomfort due to:
I) Length of Surgery

\„.72) Positioning 3) Arthritis
F. S\FE/IAL SENSES

F.1. Duninished visual perception
due to b ing:
I) Pre-Medicated 2) W .0 Glasses

F.2._\ZPotential for decreased communication due to 1) Diminished Hearing \./. 2) Language Barrier 4\i-aWc_
F.3. Potential iniury due to dentures:
1) Upper 4) Coos 2) Lower 5) Crowns 3) Bridges
G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.
. PATIENT GOALS AND EXPECTED OUTCONIL
It Pt. will exhibit siims of adequate tissue perfusion (e.c.. color, warmth. pedal pulse.
Pt. will be transferred to OR table without di iculty. Pt. will not experience unnecessary physical discomfort.
Pt. will be made aware of surroundings
prior to anesthesia Induction. .5/ Pt. will be transferred safely to OR table. y Pt. will be able to understand instructions. 5/ Minimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or conunuauon of above goats and
outcomes.

8. OR NURSING INTERVENTIONS rnCheCk for stDovoci v2or
wraps. If none, check with doctor.
d Check that safety straps are
correctly applied.
/' Offer pillow for under knees.

Check that rings and all body
niercin° lirN been removed

Have sufficient people available f
V
transfer.

Insure proper body alignment.
Allow patient to lie in position of
comfort while waiting for surgery.
,

Offer support (i.e.. pillows. bath
towels. etc.) for positioning.

„el Introduce self. Keep pt. informeC where he. she is and what is happerur.
„re Inform ot. in which direction to n and assist if necessary. )2( Speak clearly and slowly. / Address pt frcrr. ty Validate pt.'s understandtng of v; c mmunication.
'Verify removai of dentures
OTHER NURSING INTERVENTIONS
Or continuation of above interventions

10. 0

NS OMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
b 6/,) - 6 II SW465 DATE
11. POSTOPERATIVE EVALUATION: SKIN INTEGRITY: Bovie Pad Site: Y\ Clean and Dry L Red 0 I\1/A DRESSING DRY & LEVEL OF CONSCIOUSNESS: 0 A&O Drowsy Sleepy . Intubated V(N)
. . LEVEL OF ACTIVITY: L%Moves All Extremities Moves Upper Extremities EATH1NC EASY
. Transferred to liner with roller due to spinal
12. PREOP (Signature an PREPARED BY 13. POSTOPERA BY (Signature and Titl
DATE: 11%p -.) REVERSE OF FO M 5179, JUN 91 TIME: 21) DATE: t I cep_3MEDCOM - 19051 TIME:
USAPA VUi

DOD-032625

MEDICAL RECORD.
I_

1. PATIENT TRANSPORTED TO OPERATING ROOM
VIA.Lt 14-e,- BY.0-TL-S"
3. DATE. TIME PATIENT ARRIVED IN SUITE
I D s-c-9 °I I L c) (--k-s

INTRAOPER;.:B.AJMENT
For use of this form• see AR 40-66, the proponent agency is the office of The Surgeon General.
2. PATIENT IDENTIFIED, RE. OCEDURE VERIFIED BY.5p e....,. ( Lt_.- 1
4. PATIENT IN ROOM
TIME.

1 ? t 0 1+7t__.NUMBER.t

5. PREOPERATIVE EMOTIONAL STATUS
CALM.ANXIOUS.
¦ ¦ EXCITED.¦ CRYING.IIII ANGRY.• WITHDRAWN.III OTHER (Specify)
COMMENT
ASSIGNED SCRUB ( (o.." q—
ASSIGNED CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)

•

6. NURSING PERSONNEL
RELIEF
SCRUB
RELIEF CIRCULATOR

SUP NE.111 LITHOTOMY.¦ PRONE.¦ KRASKE.LATERAL.
COMMEN.:
HAIR REMOVAL.¦_YES.NO DONE BY:.¦_OR. METHOD:.•.
DEPILAT RY.
¦_ CLIP

COMMENTS:
9. LOCATION OF EXTERNAL DEVICES
111.NURSING UNIT
¦ RAZOR

LEGEND.
X Ground Pad.- Safety Strap.- -- Tourniquet
C - Correct.I - Incorrect. First Closing Final Closing10. COUNTS
Other** Count Count
Needle Sharp.es_¦ No ?
Instrument Nc_cite . Yes.. No Z. Z ./..
Other.'2‘.4,...42 ‘_¦ Yes.III No 1

11. PATIENT I.TIFICATION (For typed or written entries give:Name -Last, first, middle; Grade; Date; Hospital or Meeffeal Facibtrl
LOG#
6 Ct - ---

SSAN#.i
0
i.1-4-gio l.
,_y -Q­

,P IA)
NAME:
b

III LEFT SIDE UP.¦ RIGHT SIDE UP

8. SKIN PREPARATION
VD ( C.1,.--C-

PREP SOLUTION a ecifyl 15 -9z ,. i 1,ek....7)
SITE:.1,. BY WHOM:.5 OC....
SITE ILL,6.

BY WHOM: Dr
COMMENTS:
—
b c-e_,, ---C_
SCRU
CI

12. ELECTROSURGERY DEVICE(S) (ESU) . YES.
¦ NO ESU NO:.
P.,-tr GROUND PAD:.BRAND LOT NO: MI ESU NO: GROUND PAD:.BRAND
•

LOT NO:
¦ BIPOLAR NO:

De r ARRA c770-1 nrT 07_ _—
USAPA V1.01

DOD-032626
1.3. rnuaintaio, innrum b_Y._leAgaND_IF YES NAME ID NUMBER; MAN.if,
i_

-e4,40--AN -tt e._0-4' .1,..)0 • illt ._ is°
1\)S/J
o'T

. ramatumf.ileatmagammonsamo MEDICATIONS/ORDERS_
•nenatidAMMOdeltmagn:410.?.50.U011M:iaii
ii_IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) . YES.I.NO !MEDICATIONS/SOLUTION
DOSAGE TIME METHOD PREPARED BY GIVEN BY

MOUND IRRIGATION . YES.
J NO, TYPE(S):

ii 1
43THER ORDERS
TIME CARRIED OUT BY ..!.
!PHYSICIAN'S SIGNATURE
LSI.- 2.
15. X-RAY IN OPERATING ROOM.
IF YES, SITE
YES.U.NO_•

16. -_ LABORATORY SPECIMENS
SPECIMEN IS) NAME

NAME
YES.I.NO.•
FROZEN SECTION IFS) .NAME

NAME
YES.•_NO.•
CULTURE (C) NAME
YES.•_NO.• NAME

4

NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION /Specify)
n, c, itp,_ce 11,--a_ z,-14,-. L-L,---r-
17. TUBES, DRAINSIPACKING. YES.U.NO.•
TYPEISIZE 1 2. 3. E

tl eA,ilose L l. kr_cwt.:- ik-flt A-'-`- (-'''''Y 12-1'
SITE
2. 3.
lit (-t_

19. ADDITIONAL INFORMATION I
. A-5 _a 'Bov,:...6
L

44-4 ix• ..i. 04.4_,v-e,-* , 1
MkA‘ljit-4-4-\
aA-gt SL e -I--

&A—L. -6 ,........e...,. ,

LOG # N / Ft ° MLS SSAN# ,---141 &-, EL1) ;4.
CA.IF /.FYC ML5 CA.-ob E.-, / 7 1 i 147LS

NAME: o k..„ r / ,si 6'
20. OPERATIONIS) PERFORMED
I 4- -I) 'k G_tA)_-4-ilL LC
--1 )644,--•_)9 1.44-C-t/v'e-+-41-4°_(-4_CCA'41.4A1---P?C

21. PATIENT TRANSFERRED TO_U. \ - ' TIME
.s-_ METHOD
22. REGISTERED NURSE SIGNATURE -
..-.0 C--
I

REVERSE OF BA FORM 5179.1, OCT 87
MEDCOM - 19053 USAPA1111.01
DOD-032627

INTRAOPERATIVE DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROO M , , N
2. PATIET IENTIFIE rPROCEDURE
D D '
VIA LviAtVr-BY 4so,htstjAn4 ra, VERIFIED BY ii__T—
t (-c_ R_

3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
V 12.,t-D•• • I 51-1() TIME I SLI 0 NUMBER2 -5

5. PREOPERATIVE EMOTIONAL STATUS
X CALM NI ANXIOUS • EXCITED • CRYING-• ANGRY II WITHDRAWN • • OTHER (Specify)
COMMENTS: Allergies:

1J l 0 ---ii-rY) Q
6. NURSING PERSONNEL
ASSIGNED

RELIEF
SCRUB

Jt
SCRUB \CD (Ct. , 7_,

ASSIGNED C_ PT RELIEF
CIRCULATOR CIRCULATOR

1 ur

7. POSITION AND POSITIONAL AIDS (Specify) Ph stkpl,tAL.
on petditd 0 e__
-1...k:)k..r.,._ EX SUPINE • LITHOTOMY • PRONE is KRASKE LATERAL: • LEFT SIDE UP . RIGHT SIDE UP
COMMENTS:
• SKIN PREPARATION
I

HAIR REMOVAL N_YES • NO . (--_ PREP SOLUTION (Specify) lL....,
84(. iltsw

blatCI_AA-k.....s..._
DONE BY: a OR

•
NURSING UNIT SITE: L8-et 023 BY WHOM: icr
METHOD: . DEPILATORY kJ RAZOR SITE: Pik* (11 BY WHOM: cp jui

•
CLIP l-c-&-C--COMMENTS: IW or C.A,..-.. note_d COMMENTS:0i) Lf...-4/1..0 r ,,,Alkli 1

1-,' T r -71 t
9. LOCATION OF EXTERNAL DEVICES

"_41 heiThibuffitz://1-sfireatar -
..
lar

- rirlitz¦reef 1

r_i.
LEGEND X GOPPI - Safety liirt === Tourniquet t!..L1 ---Prte in rbAt ; SPc- ecti'QS C = Correct I = Incor ect
-
I .'1IN.IWclik,.1/4i
First Closing Final Closing

10.. COUNTS
Other° Count Count SCRUB \----- (_ CAA - 7-CIRCULATOR ).--'----Sponge i',4,1 Yes • No
• ( 2 A

Illkll¦—
Needle Sharp 0 Yes N No

migammg lir
Instrument Yes r. No
IN irAimmwg—'
Pr

Other III Yes 0 No
11. PATIENT IDENTIFICATION (For yped or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) ei YES II NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
N ESU NO: VL 1101-Ct 40 GROUND PAD:
BRAND VL iZaii NO-T'ive.
1___ LA, - q LOT NO: (0893(0 2o6S-03
R LO ,,

• ESU NO: GROUND PAD: BRAND
LOT NO: NI BIPOLAR NO:
MEDCOM - 19054

DOD-032628
13. PROSTHESIS. IMP fl mn
•.,.,

MANUFACTURER '1101{14W\EX_ r-Z. )( 502:3 — .5 — 1 SO A-1 4920-2-q0 x LILoad_ 2s-i cz \ 5b ics--ce -iL) xz
I -1-Cl2-0 -2-020 x_ .z. 14 • ,,,,.:„•,,,,,,,:•„::::.:iii.:i.:,:..,.::.::•,.:;;,:,:,:,:,•:,•::i:,•:,,::::
...:.:::•:i::::::::,,,:::•:,,:i.:,:mEDIcArrioNsioRDERs:::::0::::::::::::::::.:::::::::::::::::::::::,:4::::::::::::::::::::::::::::::::::::::g:::]:i.::.,::_:?,;.,:::::i::;.,:i:Mii.:im;i,'.,:i!gaz5,:,,,:i*:::::„:::::::::-. IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
YES:' 0 NO
MEDICATIONS/SOLUTION DOSAGE TIME
MET .0D
PREPARED BY
GIVEN BY

WOUND IRRIGATION
Xi YES J NO, TYPE(S):
OTHER ORDERS
TIME
CARRIED OUT BY :.:.
•
1

PHYSICIANS SIGNATURE
CPT-

15. X-RAY IN OPERATING . .. •• .................................................„..............:

F YES, SITE
YES N
NO •

16. LABORATORY SPECIMENS SPECIMEN (S) . NAME
NAME
YES • NO X
FROZEN SECTION (FS) NAME
NAME
YES
Eli NO Li CULTURE (C) YES
NO ril

iiiWAIIIIIIIIIIIIIIIr

NAME
irlIllIllrAIIIIIIIIIII NAME . ,
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TYPE/SIZE TUBES, DRAINS/PACKING 1.3k 0 petkrosiz_ 2. YES ,:i 3. NO • F Kos-LA:_x
SITE 19. 0 , . le........4, ADDITIONAL INFORMATI •, 2 3. t4Cg
Surgeons: VI Anesthesia: MiLS Anesthesia Type: GEM

Boyle Pad site intact pre-op
'V : post-op
Boyle Settings: Coag/Cut 3t)hp
Tourniquet Site intact pre-op t-op i 45746— , Tourniquet Time: Up D
VD ( L6 - 7

DA-s9 1 4 .-hail&..
20. n 1.'
OPERATION(S) PERFORMED .T. Nct
rs,, _---rely\ tkr-•-)m,
c_foirl "• -•k 4---
-4,

1. PATIENT TRANSFERRED TO
TIME s

METHOD drPkr I
bk i'SS°1

___LL 'Heir C-- 02_
'ERSE OF DA FORM 5179-1, OCT 87
USAPA V 1 .01
MEDCOM - 19055

DOD-032629
INTRAOPERATIVE DOCUMENTMEDICAL RECORD
For use is form, see AR 40,-66, the proponent agenq is the office of The Surge,
1. PATI NT TRANSPORTED TO OPERATING R 2. PATIENT IDENTIFIED, RE VIEWED AND PRL.
VIA BY itetad ED BY frIAL)
IENT IN ROOM

TIME (23Z NUMBER 2— t
. CALM . ANXIOUS . EXCITED . CRYING . ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS: Allergies:

6. NURSING PERSONNEL
ASSIGNED

..C. C. RELIEF / --3 6 -5-
SCRUB

SCRUB \D ( ,k_.,) -2._
ASSIGNED

A-J RELIEF
CIRCULATOR I CIRCULATOR

. POSITION AND POSITIONAL AIDS (Specify)
"1°1-SUPINE . LITHOTOMY . PRONE
. KRASKE LATERAL: .
LEFT SIDE UP . RIGHT SIDE UP
COMMENTS:

8. SKIN PREPARATION
HAIR REMOVAL /2'1[10
. YES PREP SOLUTION (Specify)
cr.....1)
DONE BY: . OR . NURSING UNIT SITE: A4-11._ BY WHOM: fror .)

METHOD: . DEPILATORY . RAZOR SITE: Ritaf BY WHOM:
. CLIP CP7-COMMENTS: COMMENTS: 4)6 '0
Irk" d IC sar.:\-; h ( ^^ -
9. LOCATION OF EXTERNAL DEVICES
\\\c\ — r7(2-­

ct`' -``-
45
LEGEND X Ground Pad -- Safety Strap === Tourniquet

cc_Y-
C = Correct I = Incorrect
First Closing F inal Closing

10. COUNTS Other-Count Count SCRUB
CIRCULATOR
Sponge Yes I—I No
111111"
Needle Sharp [Yes . No Instrument . Yes tr, No

La*" IMIIIMPWAM
Other . Yes ,P1 No

11. PATIENT IDENTIFICATION (For yped or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) t YES . NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
Fa 162 5y _5

ESU NO:
GROUND PAD: BRAND 1./0•1 lc
LOT NO: 4,9 2 d 4
. ESU NO: GROUND PAD: BRAND
LOT NO: • ri BIPOLAR NO:
MEDCOM - 19056

DOD-032630

13. PROSTHESIS, IMPLANTS 1:1 YES - 0 IF YES NAME: ID NUMBER; MANUFACTURER
:14. MEDICATIONS/ORDERS:1
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YESLI NO
MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

.WOUND IRRIGATION YES El NO, TYPE(S): p
•OTHER ORDERS TIME CARRIED OUT BY
:PHYSICIAN'S SI
15.
X-RAY IN OP IF YES, SITE
YES Li NO

16.
LABORATORY SPECIMENS SPECIMEN (S) NAME NAME YES El NO.( FROZEN SECTION (FS) NAME NAME YES 11] NO ,12/ CULTURE (C) NAME NAME YES El NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES El NO ,e1 t¦ A eD c(-7c8' fcci—fc'r TYPE/SIZE 1. 2. 3.
Lç

• • ceLc-e k-
SITE 1. 2. 3.
19. ADDITIONAL INFORMATION WC
Surgeons: Anesthesia: AA .) nesthesia Type: 6
-

Bovie Pad site intact pre-op vr; post-op Bovie Settings: Coag/Cut
36 /3 0
Tourniquet Site intact pre-op AM: post-op Tourniquet Time: Up Al 4-Down
20.
OPERATION(S) PERFORMED

4, D CDk ( j. 4 z.-R- o--(--

21.
PATIENT TRANSFERRED TO TIME METHOD t°4 i 3 ,P5 L

22.

fvt 11-71/

REVERSE OF DA FORM 5179-1, s') — • //
MEDCOM - 19057

DOD-032631

MEDICAL RECORD_ INTRAOPERA_)OCUMENT
For use of this form, see AR 40-407, the propc
1. PATIE i-TRANSPORTED TO OPERATING ROOM
' 2. PATIENT I

VIA
BY ct,x". VERIFIED BY
3. DATE
TIME PATIENT ARRIVED IN SUITE
4. PATIENT I

Y. 0 C1-0 3

lg. CALM . ANXIOUS
COMMENTS:
i.

‘11-44 11'074 .-e-A.O'CA-Aak,
ASSIGNED 3SG
SCRUB
ASSIGNED CPI
CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
1 SUPINE . LITHOTOMY COMMENTS:
HAIR REMOVAL . YES NO
DONE BY: . OR
METHOD: • DEPILATORY
. CLIP
COMMENTS:

9. LOCATION OF EXTERNAL DEVICES
r.
•
-; I
r•
•

LEGEND
TIME 0445-
5. PREOPERATIVE EMOTIONAL STATUS
. EXCITED . CRYING

. ANGRY
-- - •
keR...4e/
6. NURSING PERSONNEL
g1 j RELIEF
SCRUB
C-6 ---
c06, 6 RELIEF

CIRCULATOR
. PRONE .

KRASKE LATERAL:
8. SKIN PREPARATION

agency is the office of The Surgeon General.
REVI
OCEDURE
o.."7--

NUMBER 1—/
Cl )

. WITHDRAWN
. OTHER (Specify)
. LEFT SIDE UP .
RIGHT SIDE UP
. NURSING UNIT • RAZOR PREP SOLUTION (Specify SITE: SITE: COMMENTS: BY WHOM: BY WHOM:
Ale — - ...
...--

X Ground Pad -- Safety Strap = = = Tourniquet
C = Correct I = Incorrect

First Closing Final Closing

10. COUNTS
Other • Count Count
SCRUB
CIRCULATOR

Sponge • Yes No
Needle Sharp Li Yes No
Instrument . Yes No
Other

O Yes No

11. PATIENT IDENTIFICATIO
(For typed or written entries give:
12. ELECTROSURGERY DEVICE(S) (ESU)
Name - Last, first, middle; Grade;
Date; Hospital or Medical Facility;) fl YES N
) • ESU NO: GROUND PAD: BRAND LOT NO:
(et)
\.., . ESU NO:

GROUND PAD: BRAND LOT NO:
• BIPOLAR NO:
"?-0_e jra j
MEDCOM 19058
-

DA FORM N177 _1_nr-r 32 -7_r.,.,..--- -____ _ ___
-

(TEST). DEC 82, WHICH IS OBSOLETE.
USAPA V1.00

DOD-032632

13. PROSTHESIS, IMPLANTS . YES NO
IF YES NAME: ID NUMBER; MANUFACTURER
MEDICATIONS/ORDERS
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

YES 111 NO
;IMEDICATIONS/SOLUTION DOSAGE TIME
METHOD PREPARED BY GIVEN BY
:WOUND IRRIGATION YES
. tg NO, TYPEIS):
:OTHER ORDERS TIME CARRIED OUT BY
PHYSICIAN'S
15. X-RAY
IF YES, SITE
YES .

16. LABORATORY SPECIMENS SPECIMEN (SI NAME
NAME YES . NO
FROZEN SECTION (FS) NAME
NAME
YES . NO
CULTURE (C) NAME NAME
YES . NO
NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES . NO
Cao-14-PLA
TYPE/SIZE 1. 111-AA
2. 3.
SITE 1.
2. 3.
19.
ADDITIONAL INFORMATION

20.
OPERATION(S) PERFORMED

21.
PATIENT TRANSFERRED TO

TIME METHOD
a vo
( u)
0 S7 (90

22. REG
r.

REVERSE FDA FORM 5179-1, OCT e •
USAPA V1.00
MEDCOM - 19059

DOD-032633
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
HOURS TOTAL HOURS
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM DATE
I To COVERED
HOURS
I D1AI
INTAKE
ORAL

INTRAVENOUS
1(X TIME TYPE AMOUNT ACCUM TOTAL 120 AMOUNTTIME STARTED ICOD -VCC 1000 TYPE (htclude Medications) N C iCO rtiastO KC0 1,crc AMOUNT RECD TIME COMPL ACCUM TOTAL
TIME IRRIGATIONS (N/G, Bladder, etc.) TYPE AMOUNT ACCUMULATIVE TOTAL
BLOOD/BLOOD DERIVATIVES

TIME STARTED PRODUCT (i.e. B!, Alb, P. cells etc.) TIME COMPL AMOUNT ACCUM TOTAL TIME OTHER INTAKE TYPE AMOUNT ACCUMULATIVE TOTAL
DD FORM 792, JAN 74 (EG) GRAND TOTAL INTAKE EDITION OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94

MEDCOM -19060

DOD-032634

OUTPUT
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

i-it() es

Phi lie

60 , ; n„,„
.. 1,-.

. , •40 - 0 400
OW3 000 IIMI
0 /1 1,111-_eilow 60
c670 •o
PM '40 •
P0 r
WMMirdill 0. 0 AM 1(100
1_0 MIMII I Aka ti 6W
• 1))
CHEST ' -
i c;::`,.:(2),

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 11 oz) .
HALF PINT MILK

240 120
2,,

LARGE SOUP BOWL
) CI 240
SMALL FRUIT CUP 160
LARGE WATER GLASS 240 COFFEE MUG
180 PLASTIC OR PAPER

JUICE CONTAINER 180
DD FORM 792 .IAM 7A
Page 2
MEDCOM - 19061

DOD-032635
NSN 7540-00-634-41
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
.4

POST-DAY MONTH-YEAR Mo DAY
11WIPIMINUMWMAWAIIMMIEFERMIIIMMII
19

HOUR

-_•

N1111111111120,9Mall
I0 : : ilillffl : :
ll•119t11
Ion

- - 11111011111111111711111711111111
PULSE
(0)
TEMP. F
(*)
105°
51)•0 :
. 1

: :

. ,

—I
01 6 c 6
--.1 --.I -.I 00CO (0 0 0E Oin i-. .--4 ON bo 4) b..p. b 6:0
0 0 0 0 0 0
0 0 0 0 0 0
o
(Centigrade Equivalents, for Reference only)
IIR
. 0
•:

0 :::::

: :

.

-

.

. ep :.: :.: ._::::::
._•

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

....

...........

180 104°
170 103°
. . . .

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

•

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

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

limo

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

. . ..
. . .. .. : : : :
,

160 102° ..... . .
...... . . . . . .
...... . .
. .
150 101° : , •
. .

: : : : :

. .

140 100°

:1

.*

130 99° ...... , , . •v
98.6° f
. . .
NI ......

• . .....CI' .
.....E.: ::
120 98°

...

I

..: :: ::

1 ..

::

:

.

...

mum:

MEI

110 97°
Ir
.... 1

: :
100 96° IMP •
•

... 0 . . '.......
•

. ... . ...... . .
,,,,
90 95° ll .

1I .....
.
i
•
. .

• • tie •
I
. .. .......

.
•
.....

.

. . .

: : : ......
• •:
.
80

1 •
. ...
. . .
. . .
. . .
. • •
i

__[NJ: .. .._.. m
• --mai

_.... Il .. I
:

_
:
I
In III
70

60

.. A .: .: ::

.

:....

...

F

. .

..........

..... .

50

_
40
"A fill i • ill 1_•

RESPIRATION RECORD
111 0
Record special data only when so ordered
BLOOD PRESSURE

IriN EMMUZINIFIER15.11 A 177i11111
'i51111
4117111111014111

paid=
11111111111

HEIGHT:_WEIGHT •••••-.
ME0 J..1 NMI
MTN/=BMI ORM4 7
wi• 10
WEN

PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility)
/ ( 1
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 19062
DOD-032636

MEDICAL RECORD
V I If' L ..mards..1 I-1 Cl.A../17LJ HOSPITAL DAY POST-DAY
MONTH-YEAR DAY , -•
• -.rod 1-4 .., ek. • it . • i ESTINMATAItflai4a II19
HOUR nil

1.11 PY-34 IIIIIMMITalillIl

PULSE TEMP. F / '
TEMP. C
(0).

(*) 11 . . ..... . . . . • . ****** • • •_
•
......
105°
40.6°

. .
.

180

104° • •• ••
40.0 °
. ..
.

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

. . .

•• . •• -
170 103° , : .. ... . . . . --

........ . . . . 39.4 ° -

. .
c
. • •
o

. . . . . . .
160 102°

. . .

..... -• ... . . .
.
. .
. .

150 101° •
-.4a
-.1 bi..) i:o 6.:
0 00 0
(Centigrade Equivalents, for R
W w W WC) co u:
cn 0-1 c.” cp -..1 --4

. . . . . .
.

. . . . . . .
. ' •• .
. . -. .
.

•
• •• . . ••
140 100' ••• •
-• .
.

• . . .... . : . .
130 99°
EIMIIIRIMENUM
98.6°

mgmin
III I I
'
.
. • .11
._. -
.

11 ......
iv
._.
.

II
120

98° ou . . i i :.
. .
:.
..
.
I
110
97°
.

.
.
.

,,
. ._. ._. .
..... . .
i—
:i

100
. ._
. .__.

.:3)
¦c.
.

.

._. .

O
96°

90._
95.

I IH I ::

¦•••
11

80
•
AM

. ._. ._. . ._. . . ._
.

. . . ._
.
._. ...... . . . .

. .

.

_
.. .
II

.:. _.:. m

70 " '
60

_

50 • • . .... ...... • . • . " . .
. . . . . . . .
. . . . . . . . . .....
40 . • . . . • . • . • . • . • . - . ... . .
. . .
RESPIRATION RECORD III MT APMI II AM • I I 0 MEd il 1 7 1 WM 1E01R I 0 ( raM111111=1'7inillORMILIMI'1 gP IMEMPAMEMIIMI 11111MMIEll

02k) ¦
IIII

li I I UN I S 1 uusi I II­
ICATION (For typed or written entries give: Name—last, first, middle; ID No.
REGISTER NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 19063
DOD-032637
NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY

AMOWAVA1 En M.
•
..

MONTH-YEAR DAY AWEIRUKOMM,,.. 0 IfilliMEAMMINM
a• . VW . . . . . \ z)ter) . . . .
19 HOUR , I • • /7 I
rah

PULSE TEMP. F •. : .. : •. . . •. •. •. : : . : .. . : : : I ."
(0) I . . :. .. . .
105°

DP

I

Joe • " • • • ' • " • • • •' • • •' 1 ' • •
180
. .
. .
. .
170 103°

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 102° " " • • " " " • • • • • • " " • • " •
. . . . . . . . . . . . . . . . . . . . . . . . •• -• •• •• • • • • •• • • • • •• •• ••
. . . . . . . . . . . . . . . . . . . . . . . .
150 101°
• • • ....
140 100°

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . .
• tio •
•

•• •• •• •• • " • • • •
130 99°

. . . . . . . . . . .
"sdir

98.6° : • . .

. . . .
N/ • • •
120 98° "-
110 97°
. . ‘,./
.
9
0
ntigrad
..
....
•-
"

. . . . . .
. .
.

._. . ._• ._. . . miiimume ._.
._. ._.
0
100_960 ••

. ._. • : ._. ._.T.
IF. . . . . . . .....
• ' ' •
90 95°
. . . . . .....
. . . . . .....
. . . . . .....
. . . . . .....
....
80
. .

• • " " ....
I • • • •

. . . . . . . .....
. . . . . . . .
•
...
. .
70
H•• ••
.: : :
•
1: A : :
.. : . . ........

/
\
•
60
......
\ •
•

A:
. . . .
•
. . . . . . .
•• •-•• • •
50
......

. . . . . . . . . . . . . . ......
. . . . . . . . . . . . . . ......
: : ii : (1. . : : : : 6: : .
..... .... :
40
:1
6
toei.
•

RESPIRATION RECORD
IR A2....

LI1I aliallillr agrallIMMIral1

MAIIIMEMINA
BLOOD PRESSURE

Record specialdata only when so ordered
r.'., Ai q '16.
C4 Cal x'11 iiil II ,-
HEIGHT: WEIGHT -.....41. • • • 4 FM si !!
g WO !IFa C aellICIMMEAMI CAI% ! m ,
9-h '

02-A0 P
eil%
.1
I

iti 1.
. .

PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, frst, middle; ID No. (SSN or other); hospital or medical facility) —.....ma REGISTER NO . WARD NO.
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 19064

DOD-032638

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
0 SifeCV 1 0-Cr 03
MONTH-YEAR
DAY • ,C.C-.-1?"" "110 c d3 410C, 4'.a.:r/53 loS 17eao3
19 HOUR

• !foe Oloo rle • • OVAS riar#5 • .
1 . 1 • • d
PULSE TEMP. F .
. . ...... ''' "
(0) (•) 1 ••
" ...
..... .
. . . .
105°

• • . . .4
. . .. . .. ..

.....
. 4-. .
r.
180 104°
•
._• ._. " • •
._. ._.
. . . .
.
._. .
" •
.......

: :_: .._

.......

170 103°
..
..
. . . .
.
.
. .
• -
160 102°
.
............

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

•
. . . . . .
. . .
.
. .
• -• -• .

150 101° . • • . . • . . • . . ' . -. . • . -. . . . . ...... . . • • . . • • .......... • • . . . . •. . : . . . : .
140 100° ... .. .. : .. : •• . •. •. . .

i

_
......

• IIIIMINEIMPE.11E111MIONNW11111 ¦=1111MIEZINIZIEMINIIIENIE!'
;_aliiiIIIMISLIIIIIIMI
: : :
.•
. . . .
:
:

........

.

•. . ........

130 99°
"
•. •.
i

. . .
IONIEWAIL
..--_

RI; iiriip I r
: HMI

98.6'
120
98°
V
•
. •
110
97°
•
.

100 .• •• . ._• ••
96°

.1 vim •
. ._. ._ -
. • •
.

._. ._
._.
._. . .

. .

.

90
95°
80
. . .
.
•
w
cn0
c
MI
-
¦
.....
.
. ..
.
..
.....
. . .
. .
. : I : .
...
sle..
•
• • -

. ._
. ._. .
._. ._. .
: : : : : .
1161 ........................

. .
•

.....
._. ._._._
:
. . .
60
.
•
._. ._. ._. ._.

. ._.

.

.

.

._._.
_A :
.

50 : :_: ........ :_: : •.

_
-••
. . .
........ .. .
......
40 : : ••

........

: : : : : •
._. ._.
•
/ P ••

RESPIRATION RECORD
,3 ti ill
tis (er BMW
.,.: -P ITI/EFFA pijammi
k.,, rIMPIMIINIZIMIT511111 Tit raligiii
t-i9 Me
riliIMERWIRM

• '.. triggiiirEM)
O ',-62-En= q-11.0

•INIMMINCRV,Ammtalit(Yr% ... A 411111.1111011111111111 Utl
11 IrlY I J lUtIN I II­
ICAI ION (For typed or written entries give: Name—last, first, middle; ID No.
REGISTER NO

(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 19065
DOD-032639
Ward/Section:
LABORATORY RESULT FORM
.
Sub'ect to the Privac Act of 1974 TIME.SSN/PSE
) CBC

TEST
REF. RANGE TEST
Color
APP
Negative Negative
1VfiCrobiology
Occ Bld Negative
Negative.H. pylori Negative
Micro Parasites
Negative.Malaria
0.2-1.0.

O& P
Lymph

Negative.

Other
Atyp

Negative.

IVIiCioscOOic
RBC
Morph

Spun
Hematocrit

Cell Count
Directigeo
Coagulation 'Studies
REF. RANGE
9.8-1.3.6 secs
21-34 secs
D dimer 20 ug/m1
10 ug/m1
REMARKS:
LAB ro. NO.:.

MEDCOM - 19066
Ward/Section: LAST, FIRST, MI.
TEST RESULT
Na
K
Cl
pH
PCO2
P02
TCO2
HCO3
.
s02
BEecf
AnGap
Ca
BUN
GLU
Creat
Hct
Hgb

TEST RESULT
Troponin-t
Drug of
Abuse

REMARKS:
REPORTED BY:

REQUESTING PHYSICIAN: DATE TIME Le?YPitatii0.
-4." •••'.
..„ •

REF. RANGE TEST
138-146 turnoUL ALB
3.549 rnmoUL' ALP
98-109 matol/L ALT
7.31-7.45 AMY
3545 mmHg (i111)4I-31 mmHg (vea) AST
110-105 mmHg (art) TBIL
1.1/1 (veal
23-27 mad& (art) 24-29 ramottL (yea) BUN
22-26 mmoVL (art) 23-28 mruot& (vet) CA".
95-98% CHOL
(-2) — (+3) CRE

nm101/1,

.
10-20 mmol/L GLU 1.12-1.32 mataL I TP 8-26 mg/d1
70-105 mg/dt

0.7-1.5 rnedl GLU 38-51% PCV BUN 12-17 Writ CRE
CK

REF. RANGE NA*
_CU
tCO2
Clik,MISTRY RESULT FORM (Sub'cet to the Privacy Act of 1974) 11 SSN/PSEUDO ESN:

TEST GE
.
- - -
11/09/03 13:07

- --PICCOLO .

MALE

REFERENCE.

PATIENT #:
•

BASIC METABOLIC.DISC LOT #: 3145AA4 OPER AIM i DR #: 000 SERI AL
GLU.73-118 MG/DL

101
10 7-22 MG/DL

BUN.

CA++ 8.3 8.0-10.3 MG/DL
CRE 10 0.8-1.2 MG/DL
NA+ 136 128-145 MMOVL

DATE: LAB ID NO.:

RESULT REF. RANGE
3.5-5.5 et 26-84 u/1 • 10-47 u/I
.14-97 u/I 11-38 u4 0.2-1.6 mg/di 7-22 rug/d1
8.0-10.3mWdl 100-200 mutd1
0.6-1.2 mg/d1

73.118m dl

6.441 ed

.

K+.4.2 3.3-4.7 MMOVL
RESULT REF. RANGE CL-.95* 98-108 MMOVL tCO2 24 18-33.MMOVL
73-118 mg/d1 7-22 mg/dl INST QC: OK.CHEM QC: 0 1-EMO , LIP 0 , ICT 0
0.6-1.2 mg/dl
39-380 (M)
30-190 (F)
128-145 mmol/1
334.7 mol/1
98-108 mmo1/1
18-33 nunolit

MEDCOM - 19067
(7SU) 4-0 U.j)

ANESTHESIA PLAN OF RE PRtrflOCEDIJRAL AWSSMENT (Seciatioggagosbnia) _5 rn4-e4.
Age DAYS MOS
PROPOSED PROCEDURE:
SURGICAL SERVICE
NPO SINCE:

HARM TOBACCO ETOH:. DRUGS:.
CURRENT MEDICATIONS:
0 = ordered as premed
()
0
0 0 ()
() .

PREMEDICATIONS:
None Yes (it.Hrs) /CC mg IV IM PO mg IV IM PO
.mg NIM PO

LABORATORY STUDIES: I
1 3° 5't a

HB/HCT: ./(ha WA: . OTHER:
Sex (t,f MALE ( ) FEMALE

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
Cardiovascular: Hypertehsion 1141-‘' Y . Angina Y MI Y CVA N Y Other
Pulmonary System: Asthma.N Y Bronchitis/URI N Y
COPD. N Y
Other. N Y
Renal System:

Acute/Chronic RF
Gastrointestinal:./ Hepatitis.N Hiatal Hernia.N PUD/GERD.N Y
Endocrine System: Diabetes.N Y Steriods.N Y Thyroid
Neurological: Seizures.i N Y Neuropathy.; N Y Other.N Y
Gynecological : Pregnancy.N Y Other Significant Hx: N Y .
Familial HX
(6);I: .

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

INFORMED CONS.NSEUNG STATEMENT: Plans a.
ASA Physi State 1 6 3 4 5
WT:_K_HT: _IN.
ALLER IES: 1‘4-0Pt
ASSESSMENT
PAST SURGICAL/ANESTHETIC
PHYSICAL_EXAMINATION
B 6 HR
Pain Scale 0-10
HEENT - Teeth

Trachea TMJ/Neck gl-Irk-Orophamyx r
Nares .
CHEST: esc-iIC1­
13,
CARDIAC:
EXTREMITIES:
IV Access: Al 4i-1Y
Ulnar Filling:
BACK:
OTHER: .
NPO Since 10
{14-ireral:.Intubation
aalcdrc
isks of anesthesia including death have been explained to and

discussed with. I guardian.
/OA
-Th
/I gal gua

nd a.rees. Questions answered.
Sig
Date: __I( y-Os-7-
lime: _/YZ.firs

POST-ANESTHESIA EVALUATION AND NOTE (NON SU) { NO APPARENT ANESTHETIC COMPLICATIONS { OTHER
(A)
- 2-

Patient Identification: (Ward)
(k)

WAIIC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
MEDCOM - 19068
PATIFNT RFIrtARrl ftrIPY
SEDATION KEY:
1.
MINIMAL (Anxiolysis) Patient responds normally to verbal commands

2.
MODERATE (conscious sedation)

Patient responds purposefully to
verbal commands alone or
accompanied by light tactile
stimulation. Airway assistance is not
necessary.

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

4.
ANESTHESIA. Patient does not respond to painful stimulation.

Previous edition is obsolete
* U.S. GPO: 2002-729-283
DOD-032642
cuall-Q,
MEDICAL RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG .[)RI•JG:]::1::;::*:.::::':•::::i1PflOY TOTALS :, :::*.041(;p:s..:...,
VIII 17111MIIIWINII IIIIMIANIIIIPZI NMI
• ( hi... ) Ilip J, 0 I c/j
• NO ( i_1.1 -.'-Z) '.::f .. :t4:.
iigii4*

Mg/ 1 ='r. I 0 MI MNIIMI11111
1•11111111M • V.OtAt.:: Mallg.Ifli 11111011/11/1171/MUMIM111 ..UHDS . SUM MARY
-
. lvi

._:AOEN:77.:. ' e.t. LLOID-_,
AIR_L.Mii j 1. --- a
sDrda ::(3NItsiiikraDvati.3141s: 1:1;
CONTINUOUS/REPEATEDDRUGS SPEC IFY UNITS MG/MCG/ML,"I° = CONSTANT INFUSION

N •_L/Min COLLOID-
11111111/111=E11111// IRA MIEl11111M1MIa INIIPM11
SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
WITH NU.ERS & ENTER IN REMARKS MIIIIIIIIII LINE sibtgi_p , armed_c1.--_C., 0 Warmed 0 Warmed fkm_, A, A .._...._. Code drugs with numbers, events with !enters
El Warmed EST BLOOD LOSS 1...2 -.._/ C. .

,,i, URINE -

"" ..._.._.:„. piaC.11-i C.,11C.-k-
1 minim_::, Pmi,
•

iIjocirvvEloN: -.).::: ..,..,M19.:qi.t 220 alffi i/e-2 Ptsz-1i0 661E
G BP by cuff

200 ' V rytAc+5 001.
HEMATOCRIT : :
A 180
iirrOt-V-1-1.L.)/t
Heart rate 160
01.1441',i0A:1*:

.:
:: • /1()C21/7-ALAle5 Resp rate 140
BP-115P gc
1 7 3 0 - "

_/ 120 -A :. -.5 Ach.nd•_+4
BR

HR -AIIIMPr
grAVArIVAMMIMIEMEN11111111111MiligrAl LI
(transduced) 100

MI15211/4111111wriliMilIFAINEFAVAIIM1111

IMPOPIPEirfriiiiiava!
.CK: + uNiiii1111 INErszspmmt.mirgiig_AAAMIDAM4•1¦21, (ila -/„
11111111.1.11=111
OK?.. MEN
elm

TOURNIQUET 60 V )
4

PfitTIONT:-.7ktiiP/( T --If 1
1Win1111/111110101111111111111111111=WARPPIIKIMIE
OK for . rAit_Ejram am rativarmoroirgran UrAIRTA111111111 C_-/_-1
PROCEDURE ,syr ANES- X-X somm111111111111111111111111k11111/110131111111111111/11GWIAMIIIIIIIII 2 111111111101=111111M11•11111111 NININIIIIIIMMINIIIIIIIIIIIIIIIIIIIIM ¦
TIME-_
•

PR"-el° IIIMMINIMOMME '_1.1.11 MIME re VT - ml

minvawrorarsnuaminal
f - breaths/min to
Peak ml pros / PEEP

IIIIMI a0 KINN ' ill
MODE - SC • .n1, Alssis0. Cion) al/ArdivArsuraraiwomunimicirA
• .110 Cuff ipr-CO2 Ito,,) 0_N_ff_MIBMIIMIIIIIIVIC0111
o

111BP/oth I_ 02 (Frac or %) 1111n1NMI 111M Mil NMI - ail 1101 Wall
IART line_11 p02_(96) Mill /a.) WA IllrrArril VD_tO_CO
• Steth- PC/ES E

ralliriallMillr&ANSIMPHIPIIMMIRIE
P.:_III P-site

MIMEtVilreiCAIMEMIrli
P sillaMI

If a ._Block IT/4/ IINNirjAiffilIMIIIIVIMW/117111•10111

I_I IIIIIIIMIIIM11111111111111111_11111/
,

I armin_blkt A ,i I. ak_
47/71
. a

.::iie: .:NOW:4_/
ICU.Specify) :
OTHER.I.--Ar ' CONDITION:
RESP¦ac Sp02.?/CA BP-.HR. /0._.a
00.4.g.mgwmpqf_: ..
Room E
Cony warmer
Ig

Begin End
PROC

Nrym writ, letters lb sw Mots, EVENTS__„..
explarn under REMARKS Position 0 i i 90
133

/4
life
Cee I e,66 J

PROCEDU ES and CPT Codes:_ ANES TIC TECHNIQUES:
Describe block technique under Remark.E:r4-14 ),,c,NA

. - i\-,‘:_c't4 I y (-C)_ •43ccILlettirs L. - tly60 .C151-4.7C.:e,
PA TIENT IDENTIFICATION: Typed or written bntries: Nair*, Grade/Ra e,
AIRWAY MANAGEty1EN'15;:3;Frtarlon route, b atilet c o Es

hnique, cmm cal tsciil t 41-W-1) D 1 -, --i-, 61z__!_eAs,_c_. elfxece ,LIs-
e.o..,,--k--
i
PROCEDURE‘...v LOCATION: m.

D 1_(.) -1
DATE: 1
I MEDCOM - 19069 PAGE
DOD-032643
r1)404-k2 C-Cryki2o)UQ,LA-ei.(1 u
(ix-cAY

4A-11S MIcM

tL

76 del
e.t.

LINE see I
0 Warmed
EST BLOOD LOSS URINE —

TIME

4 5 E
SYMBOLS:
BP by cuff 200
V
A
180
Heart rate 160
•
Resp rate 140
120
BP (transduced)
100
1.
TOURNIQUET

T —/

OK for
PROCEDURE?—
ARES— X-X

pnoc0-0

_ L_-Peak int ores I PEEP MODE— Si n) Aissist) Clon1 BP/Auto C_
T CO2 torr P/oth
2 Ifrac or •M ART line 2_• Stet). PGE Gas analyzer
ing blkt
PROCEDURES and CPT Codes
MEDICAL RECORD_ ANESTHESIA
.b L7
-

z0c-) 7D
TOTALS
b;-
i°¦
Lancu.sammanc....
CRYSTALLOID— Coo
.CCA.LOID—
BCOOD—
Code &lisp with niorberg, events with letters6....t426

MIIMIN=E=EIMNIMEMEINEININNE
Mani= MBEMM.ESE,
MUMM,_=1B =MEMIMMEMMum

MIME=

Et=NMS=Wal.=MENNE=MIM EUMENEINEWINEN,UMEWBEEMSNEENNEUINEMO

1111/0111ELIMIN
MA: • IMEMMMKNME,

NEM IllOtWaw.
IIIMIlak

SWIDIWWWW92 4ZEMENHONAMEMEMEN=E"

'VAMP ' v

NCIZZIWOR MMSMEMENNEMBIUNIMEMENIN
MOM

nmsonsamosaw.mralannommtnumEMEIMMI
IMINEMEWAIWZMNal_
NMI

PMENICCAMSZOMEMENEME=HEIMMMEM
UNFAIMINNIIM INNWNW_
MWM

MEREMMONEUNI=IMENNEEMENNE=EMMINE
ailiurfAimmak
7

PATIENT IDENTIFICATION— Typed or waten entries: Mime, Medical Away
1111110
,7
EMMA
k)ilAMC OP 376 REVISED
REE VERY AT QV.
(Specify) OTHER_

. ZO
or-tie
PROCEDURE LOCATION
DATEiy
PAGE / OF /
L Jan 99
MEDCOM - 19070
"U.S. GPO: 2002-729-180/40137
DOD-032644

MEDICAL RECORD aim
a s • ANESTHESIA TC TALS 4::
wmiestmENAmirmu
0 0 z
g 1-.1 t.
.1 .
.% e t
4:4',!:" • 4 ..
. A ;.1.
AIR i/Min

C RY STALLOID— H20/ I/Min C •
02 1111111111111.1(; LOID—
....11

SINGLE DOSE DRUGS - MARK CPI ORI(i.
WITH NUMBERS SEMTER IN REM MKS

IL0 00_

LINEltr
0 Illanned

L./IC
Ibtlertied O Viserred -Erilarreect Code cl-egs with numbers. events with Setters
EST BLOOD L.

•
1 ttiMP""kl TIME i• • ci776.calie
MOW
sy m Nitfr61
220 •'!
co)

BP by cuff A“a . ot.

MI1111111
200

gx1RETK?" V MEE_111
.;:„;;;::;;;,
"•?!!AI-;f::
A

180 s, -/e4.4) 1-4.;dd Ert,
M11111
Heart rale

160 y 1413(5, hit(
CC

• 1111M11.11111111111111111111
Resp rale 140
1111111711111111

11111011111111 UVRII

120 11; BP um NM fiew.Asei
(transduced)

100 INVI,M):111PgrilliMM111111/73:1111111M111111111
1 muffintmaa .
r"wai

T nimrenamilimumunarm z-tr. err: iere,,,t
80 awn
K? --
mo,kft+.4.

TOURNIQUET minlamumatinziz;sameliummi
T 60 i

lrriP111111,1111
111111111111MLUMINIIII

ANES— XX
PRoc-0-525 20 1E1E11

:ow

r.4
— breatti stmli _

•
MODE— S • on
ssilLS ion

mi ...___
1111

BPIAuto Cu
1. ET CD2 (tor-1110111 Y AT
jsz2 0th

'PM?'

r. • F; c) 2 • rp (610: ICU (Specify)
_ ART fine
E" • 2 ms
1;74 Steth-PC/E
ECG E
; r Ae
anal er EMP-ii -aa -N gni RC
_

I NM Block (-17.1•1_
RI: SI.-

Sp02-%If q -HR-
-

11111101111110immommi
ularrning bikt 11.

V
Room.

Cony warmer Enc
-,-/th letters a symbols, Ev N Ts //0
under REMARKS

• Rea 1 Be in
_ End

••::i1:)U RES and CPT Codes
-

44are Cr !au Es:Describe block technique under 12C1LZfl,Li
ter4-4L_CH
x

IIENT IDENTIFICATION -Tyr.ed or iritten entries: Nerne, GrederRee.
EM NT: Mtubetton route bleae, tecique. come,

Akefiettl I way hn
PR N::ED VIRE LO :ATIO N
A • •
railrI
, 1 d
ORD_NES714ESiit
r
P 376 REVISED PA t 0F7
MEDCOM - 19071
_
Jan 99
DOD-032645

/4-_)/4 ;I-1 /t Cl )17 3 /6 ilk ›P -?-P‘ il54:F1-)
Z9-4 —c-tee. to-74
MEDICAL RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG
DRUG.(Units) TOTALS TOTAL EBL
rr1

ig i_'•
0 o -' z-Fi2-0 0 . ( lb° top 3CY0
cc cc 0
0 00-ett•Lo 4 a°
ou) Lioac ( At tA'k
0 2 R l/f."--SE-4 ( z.-6"--/....,,,,...--TOTAL URINE

Z i- (._7 z ,..-..
4 ,152,_ ,f--L...1 00;45-13
u) a- .'z -_,

fA f T 7 4 -

1-," tr, 4 —S0-
Z CO 20 •

Lu Ec4-OA I r^( I
(9 0 D 0z VOLAT.Folekopi. der 2-'0 )6 -FLUIDS - SUMMARY

Q
D*C-I AGENT.% e.t.

° Z )L- ii CRYSTALLOID-
1.: F 0.
AIR.L/Min

w z t . -Zert)
Ow

S N20.L/Min COLLOID-,
I-(-)
cn 02.L/Min
uz
z SINGLE DOSE DRUGS-MARK ON GRID BLOOD
WITH NUMBERS & ENTER IN REMARKS I -,

vi LINE Si-. III Warmed
REMARKS

f:I Mil.i I.EI Warmed
I Code drugs with numbers,
...i I=I Warmed events wilt terriers

LL
. Warmed .,.....
r 0 IN
EST BLOOD LOSS

LOSSES
URINE - 0 /2-04't -Oz.-MOW.
PHYS STATUS
TIME *_rev_
0 0'6/Air

1P3 4 5 E
SYMBOLS:
220

BODY WEIGHT: ,
I —1-• TT •
Tr-z pUrPO 511

, I
KG

BP by cuff I I ,
(9 / LB

200 Kt -e2471 /6 V
HEMATOCRIT: ,.elOg 73 aL-
180 '
A

Heart rate • .
160
INITIAL DATA: • l er
,., I

Resp rate 140 I
BP-
11 6 ./ 51) 120 ••

•

BR
(transduced) 100 •• •.• • '
41 C4(

HR -
,
"
-L

EQUIP CHECK 80
4.4 •
T

OK?- 0 N 60 • e 11_1 —L L II _._J_
TOURNIQUET • I
.
PATIENT RECHECK T -,q` -, r . —1..---1-— - ---

,---,--, -r— I—I-.
40

OK for
PROCEDURE? 4

T---r--
ANES- X-X
41 Li I 20
PROC- 0_0

TIME-VT -ml
iN.SiatI OD .--f
-breaths/min

CP il 4
ur Peak inf pres / PEEP
.----...V

MODE - S(pon), A(ssist), Clon) :0/ -CV-t. --' 50
RECOVERY AT low /Auto Cuff T CO2 (torr)
5.-2--1 (111'
PACU.ICU.Sped, y1

U2, BP/oth 02 (Frac or %) 15 , -o___„_u_ ART line p02.(%) OTHER
=0 - 10'0.WO.I 1,¦) .
0 Steth- PC/ES I CG 1_1-• CONDITION:.,...A
Pr-Sit-/ ‘01._ (__.
P... .

tar Gas analyzer I.P-site q(
0 RESP-I (-.Sp02-00
0 M Block (T/4)

Y y okr ft_

. BP-.HR- f f

L/1 ANESTHESIA /PROCEDURE
CC TIMES

0 I-wStart.End
ra.Room.

Z
0 Warming blkt
‘A Cr*

1 riErtL

2 Cony warmer
o Ready.Begin End

Mark with letters & symbols, EVENTS_, oexplain under REMARKS Position
-
Ff. NA= 4

PROCEDURES and CPT Codes:.
ANESTHETIC TECHNIQUES: Describe block technique under Remarks cfpi

PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments 'RSI c btx/Medical facility p-ti A.V.. 1: vreW
-
a--r6 E IT h Z3 Lip

4 1 04 in —20.5(") 4*,A` .-37? SURGEONS:
PROCEDURE a. LOCATION:.l -I V3 ( G(.'.- Z.--
DATE:
ANES 'I act 03
-4 crr tx.-PAGE.t OF
_ ____ -COPY 2 - ANESTHESIA PROVIDER USAP A V I.00
I/
DOD-032646

Doctor's Orders—Post-OP 126th OP 4256
Nurse Complete Dr.'s Select DATE: TIME:
. RI, Er R/ 1. Admit to: . OR [PACU . ICW . Patient Holding2. Diagnosis .re' .,00'? --ee--t"---,-3. Condition: Critical Guarded stable . VSI SI4. Allergies: SF 558 -- -5. Vitals: Unit SOP . Notify Dr. for SBP or DBP ..or - , HR or RR or or Tem. 6. Activities: -2.: ed Rest, . BRP, . 00B ASAP w/ assist,Sit up and dangle when stable .Other:7. NRSG:
a. Propaq monitor w/ Pulse-ox
b. 02 to maintain SAT's above 94%
. c,-Mainsaig*tzgraettings at MODE= Vt=
PEEP= FIO2= Bfeinforce or .Change dressing for bleed-through X1 then notify Dr.e. -.1*in!;Ferrs,
c. Stietifewitaig
. d.-ielirtere.1+29-seal-or . Suction at

¦ . 8. Diet:

. NPO 21!""i': . fluids as tolerated W.T4 91ther: a
9. IV: '
DNS or [SLR TRA/Zi-Te/hr 0,1,:h I - 1 ,"
III DEXTRAN or . Hespan X 500 cc bolus titrated then cc/hrAlbumin 100cc X TRA cc/hr
.
When tolerating PO fluids, complete current fluid then SL.

.
10. ilLercrn: . T&S or .T&C

11 units
. Transfuse units .PRBCs or .Whole Blood
11. Medications:
li

. a. Iskanlyekt=300Eng IV Q12hrs X J e
• . Ceftriaxone 750 mg IV
b -Glintiatnyein-690ffig IV
.
j f OPEN G 2 million Units IV

c.
Cefazolin 1 gram IV ,

Alit k- & eedi.A2..„,t___ ittd...5....e t -tio bit.%

d. Phenergan 12-25mg Titrate giv BM Q4hrs PRN nausea/vomiting
.

g.
Droperidol ling .IV .IM X 1 PRN Nausea/Vomiting

h.
MSO4 1-3mg Titrate (TIM . 1M QlOrnin PRN Pain

i.
Robinul 0.1mg IV X 1

J.
75fam346-ms DIV or DIM or .6.25mg/hr infusion

k.
Tetanus Immune Globulin --17-----0 melel-EgPi--343rng-ergR44Cung_.

m.
Maintain sedation/ iaral sis w/ Rocuronium and MSO4 PER SOP

12. LABS:
11

a. iSTAT .Glucose
.ABG .BMP .CMP

13. Additional:
c,..-)

Vz
-

yr---

Signature: lc, « , -06#
pr IvAni6; . . 1 pi--CAW&.IOJANO3
MEDCOM - 19073
8_t 6YI-1
DOD-032647

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 IDEN TIEICATION

DATE OF ORDER
) / ORDER NOTED AND
T ME OF ORDER LIST TIME
HOURS SIGN
,,7:44A
uLa

NURSING UNIT ROOM NO.
BED NO.
hi 4-4
F PATIENT IDENT)
I !CATION
DATE OF ORDER
TIME OF ORDER
HOURS
WI

NURSING UNIT ROOM NO.
BED NO.

PATIENT IDENTI
DATE OF ORDER
TIME OF ORDER
HOURS

NURSING UNIT ROAM NO.
BED NO.

I Ce.-) PATIENT IDENTIF I CATIION
DATE OF ORDER
TIME OF ORDER
HOURS

N NIT ROOM NO.
BED NO.

FORM REPLACES EDITION OF 1 JUL 77, WHICH MAY
4256

1 APR 79 BE USED.
str U.S. Ga MEDCOM - 19074 710
DOD-032648

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_LIST TIME
TIME OF ORDER
ORDER NOTED AND

lip
SIGN
r Zir-1-''3 RS q

41 C__1.0 I
-......---1-_
ob •
,..,

j' r4 •
......
ip 6'` .9l...._%..---_V-1 `"
_1 -r-0--,---r-ey k-Ark 1^2--

NURSING UNIT_ROOM NO. BED NO._ .."
1 (1.-C') I
PATIENT IDENTIFICATION

DATE OF ORDER_TIME OF ORDER
HOURS
\O_(1)
(1-telfr ..

k
(6, C1/270

(15 et'''.

?4(t-Zr

NURSING UNIT ROOM NO.

BED NO.
Rig f la ' i---(5 \
PATIENT IDENTIFICATION DATE OF ORDER_TIME OF ORDER
HOURS
-_-Are°a el
0
Lizi-r--

NURSING UNIT ROOM NO. BED NO.
er4s---AD y .,-Ykey,--u "i .?—" ar"fr

PATIENT IDENTIFICATION DATE OF ORDER_TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.

BED NO.
-__
FORM 4256

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
APR 79

it L

-478-200

MEDCOM - 19075

1.2 v. ) )
DOD-032649

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
EN IFICATION

\o(Li. \ LA DATE OF ORDER LIST TIME
TIME OF ORDER ORDER NOTED AND
-HOURS
SIGN

c)-) t/6 / TA s0Few_ t , e)/ 4c,,,._
...."'
Ade. 4 Zi-474 ---­

V -,'-' / 7.7 s is'
NURSING UNT \I ROOM NONO.
s_....4
NO.
Le_ 9 arooy 1&-70-4 ,ori:15

PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER

L., _,elzti14-1proURS
Soy /-3
,,,

p, I 2 .1— 1.3 t V ? C 6.4,2)-( SO S a Wild f/1 ze• , A ' I 9/P - g X 6 Air • 4E1 .
NURSING UNIT
ROOM NO.
BE• NO.
(Ve_ r 0 tr r .
2, ail
Tail

/ C (77.4.C-G 6 1/14L4-1— Z-C

PATIENT IDENTIFICATION
DATE OF ORDER
pfr"-x,190 6-e„
ca....6e a,-14..„ts . 4.-1 cc)
mpPPP­
„,__
_.,....

NURSING UNIT ROOM NO. BED NO. '4 _

velsorir
AnW\_P.
r „,

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
I. HOURS
f) i
V

tt /C 7:1Vike---

( 0 I1449
_rile_

• RSING UN arpli Wife NO.
\.3 41. 411 0
•'

rt A_- - -_ L ef• C. PI -r-11.1). 2 REPLACES EDITION
JIJL 77, Vit IC MAY BE USED.

1 APR 79
U.S.0
.3-710
MEDCOM - 19076
DOD-032650

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 LIST TIME
TIME OF ORDER
ORDER NOTED AND
HOURS SIGN
lc/

NURSING UNIT PATIENT IDENTIFICATION :• .1:
NURSING UNIT PATIENT IDENTIFICATION -
NURSING UNIT PATIENT IDENTIFICATION •

NURSING UNIT
REPLACES EDITION OF 1 L 77, WHICH —WAY BE USED.

DA 4256
1 FAOPR
M79
it U.S.
-10
MEDCOM - 19077

EL] ..„.
DOD-032651

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 T TIME 0 ER NOTED •ND
HOURS_
SIGN
NURSING UNIT ROOM NO.

BED NO.
PATIENT IDENTIFICATION

NUBS NG UNIT ROOM NO.
PATIENT IDENTIFICATI
NURSING UNIT ROOM NO.
C
VAiui

PATIENT IDENTIFICATION

NURSING UNIT
FAOPRRM79

REPLACES EDITION_77, WHICH MAY E U D.

DA 4256
MEDCOM - 19078
DOD-032652

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
_ HOURS NOTED
SIGNAND

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER_ TIME OF ORDE _ HOURS

NURSING UNIT
PATIENT IDENT F !CATION
DATE OF ORDER_ TIME OF ORDER 6c6 _
HOURS

NURSING UNIT

PATIENT IDENTIFICATION DATE OF ORDER_ TIME OF ORDER _ HOURS
NURSING UNIT ROOM NO.

BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

DA 4256

1 FAOPR
M 9
MEDCOM - 19079
DOD-032653

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.
t LIST TIME
ORDER
NOTED AND

PATIENT IDENTIFICATION DATE OF ORDER. TIME OF ORDER
HOURS

07 °` ea ia/Q IL 4) T(cox-. ,_

0 I / ,
Jr,_,

,,- 3,, - (cwt _, /4,0L/ . z_„._„v_,_A, 4 t,
.
Ar _di --
Iii Ilt I ea4c4/

NURSING UNIT ROOM NO. BED NO. Ur
0 -2.-
___.¦

PATIENT IDENTIFICATION DATE OF ORDER
_HOURS

NURSING UNIT ROOM NO. BED NO.
1

PATIENT IDENTIFICATION "" DATE OF ORDER. TIME OF ORDER
HOURS
1.4• . 4

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER. TIME OF ORDER
.HOURS

NURSING UNIT ROOM NO. BED NO.
•

REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED.
4256
DA 1FAOPRFIM79
MEDCOM - 19080
DOD-032654

\7
\\

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407;
1
tia7.2.. is the Office of The Suroeon General. IMO

VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED

ORDER CLERK! RECURRING ACTIONS,
DATE.NURSE FREQUENCY, TIME

•MMILIZITINI EISNER

lusEr wcc 31111•111•1111111111111111111•111

1111111111¦0 ._L_P2CMOI111111•111N 111111111111111111111111111111111
Mir' ITMEIEWNIEE 111111111111111111111111111MIR

_..411111111111•11111111111111111111M 1111111111•1111M1M11 Lify.A111101111.1111.1112111111111E11111•111 1,01M11111111111111111MIDIE1111111 MEMILIA. MUMMOMMIIMMEMM

trAinr-momprimmin ummommommum

WAMOMMEMMOMMP AMMEMEMINIMMEM
:NM ANIMMIIMMMMMMINIMM
EMIL/

MUMEMMENAMEMEMMEMMEMEMMEMME
r"'"--111fildiliraMOMMWKm-1 dor..IbQO PR•4 1111111111111111 Li ---JE111111111111.
111EMIZINI

Li .
119Kt. ArAME 0111111111221
Iron:

d (.,

1B1111111111111

ALLERGIES: NO PRIMARY DIAGNOSIS:
DITIONAL PAGES IN USE: E3 YES El NO •

PAGE NO: .
PATIENT IDENTIFICATION:

ACTION TIMES
c\,
USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15

:t-111•111111

E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
crirnrike AC 4 net-. n IIIANe OE t'SED.

DA FORM 4677, 1 OCT 78 USAPAV1A0 MEDCOM - 19081
Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initial ng
(NON-MEDICATION) Yr 2003

Order_Clerk
Date to Time to

SINGLE ACTIONS
Date_Nurse Time Done_Initials
be Done be Done
aL 4 A

/ SVeLLA

Ar wow
0/^

at Ea a'
It* PA---r rauti-GAJ

rouiS 1.

1/6 P-6/¦AC9k4\ge,

•
It -TC, d* a OiCILL 9-60LeL.
P(ancee,(ip or) (1 oal-
AJ

Flo • i._ ra, 01 t_s_ if I ;46.4 • n1CPP n, Nic (V) Orm,
119
5121:721 41-

AP/iA--r0 Cil,41.4 I r R
I

Order/ Clerk/ PRN
Expir INITIAL PROPER COMO! FOLLOWING COMPLETION Date Nurse ACTION, FREQUENCY
TIME/DATE COMPLETED
USAPA V1.00
MEDCOM -19082
DOD-032656

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICA770N) 7
CLINICAL RECORD For use of this form. see AR 40-407; .
MO. `1 , Yr. 2003
the orpiment eaen._ is the Office of The Surgeon General. .

vE/t/FTBY INTIAUNG
,47..f, .. ..,.,.,r,,,.1?..,;-;;;;I4114,fte...P.S:' INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLE
COMPLETED

ORDER . CLERK/ RECURRING ACTIONS,
-
DATE NURSE FREQUENCY, TIME

1101 15MOIr ROPM_MEIN llign)

13&_p-111111-m?R I0 chow_ gib e
ct, Vast. 1
1111 • 1111111 MI al

Hop -PC.0 t Ai ar ol 1 e.,
--±
0

III
_

4. in core RI E//2_ gli
/

ifil e_ R2IDZMnkiP6
..._,/
-1 eCh I t (P anNe. fIctur125
open --rt) ct.62__.

. . .

' (1 6Cti5 h•I Maki
•.
_ .
•

_ .
•

ALLERGIES:.MI YES yb PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
• nip'°1-"D

fi
'YES./111 NO QGLO -Wii ,Sh ex--)C.
CO

PAGE NO:
PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D_8_9_10 11_12 13 14 15

. b.( u) - (-A
E_16 17 18 19 20 21 22 23
N_24 01 02 03 04 05 06 07
Fnmnha nc 1 nsr 77 may as USED..
USAPA V1.00
MEDCOM - 19083
DOD-032657
••••••¦

Veril f by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing

(NON-MEDICATION) Mo Ct9 Yr 2003

Order Clerk
Date to Time to

SINGLE ACTIONS
Dal Nurse Time Done Initials
i be Done

_III
V

: .

•.
. .

Order/
PRN

Expir LV1TIAL PROPER COLUMN FOLLOWING COMPLETION
Date ACTION, FREQUENCY TIME/DATE COMPLETED
. .
.

..._
Itul

USAPA vi.00
MEDCOM - 19084
DOD-032658

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon General. MO/ Yr. 2003
VERIFY BY INITIALING iNg , L , Attagglet-ard , INITIAL PROPER COLUMN FOLLOWING EACH COM LETION
HR_ DATE COMPLETED

ORDER CLERK/ RECURRING ACTION'
DATE NURSE FREQUENCY, TIME

PAM" a -. Fli

t'SIL_____WERIErIMEITIN• Ulf
a_1--um-0.s / yiect) 11 pi 1111
...._
..
um ..1.1.1111I

. PP , •_oar
4See - -DO
1

0 , — I ) I 8
-
Ilimm........,

ie.-5y - -- -C 0 to r -
- -: ...

"i y..ilar Minall
&I'LL ID e _ To
ir
-

- - -- - - -' 2 5-i-eAi IL tt .24. . Plait e •

ctur___t-K -c ottit
4110 •
leYk--11-7) a,t4
( rew-ace

ALLERGIES: IM YES 0 PRIMARY

cci/
ADDITIONAL PAGES IN USE:
fr.
-YES IIII NO

PAGE NO*PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

411111 C0 (-(6 -_
D_8 9_
10 11_12_13 14_15 E_16_17 18 19_20_21_22_23 N_24 01 02 03_04 05 06_07

_ _ MEDCOM - 19085
I was.. 1, inns vac LIOttJ..
USAPA V1.00
DOD-032659

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION) ma Y r 2003
Order Date to Time to
Clerk
Time Done Initials

SINGLE ACTIONS
Date Nurse be Done be Done _ _ _
.

60 it_si L , D • 14 0 ' • Aok ODD( .0 0 6pf2ctr) O2_ , I i pi. rAaltil:t . la I -r .
i ,4cl..12.-Q

a 4nis
Ws
. -

:2-(C_ T%c.--0 teV\i Carry
Order/ Expl r Date Clerk/ Nurse PRN ACTION, FREQUENCY INITIAL PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED
. ,
USAPA V1.00
MEDCOM - 19086
DOD-032660

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; 1
MS-Yr. CJ-f
the or000nent aoenc‘• is the Office of The Suroeon General.

VERIFY BY INITIALING --=,._ .-',, _ INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS,
DATE -NURSE DOSE. FREQUENCY

11 1Z (514 15 1(,
. .0 a 1 91 it 14@ leocc o(h 1 a X
0. . i R") IS
P¦

isep Lovena. st. 10 RIb 1--cA,2-r-/2-) 21
•

_ it 11.„ ... ...e.
ws lawI. 111/

PD ?)1 D. Ai
ma

t‘ K.4-2,0i -ce-ta rr 05 NB(?) oc_ye Ito _
Ili/

c)1 -( . ..

16 - - 6,,,,,,...6 taf-,

_
io..-,,-

I
14-)

72( __ I 7-6,e-e_ I I 0 h I Cr
,pr
a
WA

EE

EMI
tl
-

1

611 I t L tiNfte n 4 1 PO
&

ALLERGIES: YES_Epic, NI-1-)1\ PRIMARY DIAGNOSIS: LO 0 W P l'''') ADDITIONAL PAGES IN USE:A YES_-NO PAGE NO _
PATIENT IDENTIFICATION:_ DISPENSING TIMES
, USE PENCIL. CIRCLE MED'TIMES..
Allill. D 7 8 9 10.11 12 13.14
P ( U) .-q. E.15 16 17' 18 19 20‘1-2,1. 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._ • USA PA VI .00
MEDCOM - 19087
DOD-032661

Verify by THERAtcUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) —1Mo.L Yr. (153
Order.Clerk/ Date.Nursevitt SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Time Given IrriSala
aPof
•

Date Order/Expir Clerk/ PRN MEDICATION, DOSE. FREQUENCY V INITIAL PROPER COLUMN FOLLOWING ADMLVIS7RATION TIME/DATE DISPENSED •
At _A Ai 4A
eira 624- -.po •
• 01'
•
-‘\ P-cia,o6eA---i--r Po 1"1-1- , JameAW_
fil) 6r.\S-
0!
Po '4)4 Pr-N DI,
11.
USAPA V1.00
MEDCOM - 19088
DOD-032662

Pi\\

r Th._.PEUTIC DOCUMENTATION CARE PLAN. ,MEDICATIONS)
CLINICAL RECORD MOV

For use of this form, see AR 40-407; Yr. q53 the proponent agency is the Office of The Surgeon General.
I INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY INITIALING

HR DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

ar..... -'3,D a
•,4014--I 3

y.., 3oc a;L N‘c) .., 1 , ma • „,„ 0\62 maimr --nim
( ,--aD. astaiDA IC)
3?cp.3 --CIO)c--P -7 c3(

c.2
V¦

_ cm._

-c_CD.ztY3 - - 11014-N\k"etn )\-6 •
)=-3(
1-c(2 --pig LC6-0\ -:\-cs-y 1\i C\B° Cc
A

• 2Z r-ill
f.206 -410 L--zi 1 cbc.61i) p.-141\1 )(0 i PP'1g
4

ALLERGIES: I I YES il NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
NI YES I I NO

D.P. =.\/\1 y \ /.1) .
PAGE NO.

PATIENT IDENTIFICATION: \
DISPENSING TIMES_
USE PENCIL. CIRCLE MED TIMES
11.111/_
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. USAPA V1.00

DA FORM 4678, 1 FEB 79
MEDCOM - 19089
DOD-032663

THERAr,JTIC DOCUMENTATION CARE PLAN
Verify by
Mo. Ci5 ii Yr.l:Z3____
(MEDICATIONS)

Initialing
Date to Tme to

Order Clerk/ Time Given_Initials
SINGLE ORDER, PRE-OPERATIVES
be Given be Given

Date Nurse
1'
A
Z.
INITIAL PROPER COLUMN FOLLOWING ADMINThiRATION

Order/ Clerk! PRN
E
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
D aPt ler
la ,\10,..0 a c

G`1'

vo •__ poi I
,.. : .1

r aCCC-e-t \ \ ---t-V PO °C: AP Val 512 Eget . i 7samaip,-0 ,
\\.zfil,3
\to,_•_. i ¦ ' r_. ¦
4.
M _UMS_laWIMErj11"11111114111W1 rr'. "won
, '

Il) _!IIIIIIIII1T kencl (c:5,2-xne:D/c'f--

EiliP55M1 III III
• sp° II
mop,"
¦

o 3 N, sio- id
•.._„,......,,
IN,

J LS4rIP
Pet.' `0 Cr 1.'4 'J Q ii 4 gp 1 3
I
USAPA V1.00
MEDCOM - 19090
DOD-032664

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this him see AR 40.66: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED Wale)

.REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
Anesthesia Type (Circle)).eirlr4 'nal Epidural Drains Airway IV Sedation Nerve Block Hemovac Nasal
Date: .9 ill .
Time In: .I-150.

Allergies: i¦W A .OR Intake: Crystalloid 15DO O ' .Colloid . NG Oral
Pre-op V/S: 5 .qI5 OR Output: UOP EBL Mr ^-1 JP ETT
7'.

Procedures: .y:, +c, left Gra, Meds/Times: bice P le rn 1545 . T-tube Trach
s)

Foley Other . TLS
Pre Op Meds History
Time_ Pacu Intake
!-b
._
Time Solution Amount Site • By Infused
Sa02
IVEP 11Ae-.1../1 .fin)
Fi02
Methods
240
_
-rays: Labs:

220
Post-Anesthesia Recovery score

Criteria ADM 30' DIC Codes200
Activity
AIRWAY
(2) Moves 4 Extremities
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, *meted breathing
RA = RoomAir
(0) Apnea

140 NC—Nasal
Blood Pressure
Cannula
(2)
SBP 20 of Pre-op

(1)
SBP 20-50 of Pre-op

120
V/S
(0) SBP =I- 50 of Pre-op
X =A-line BP
Consciousness
' =Cuff BP
100
(2) Putty Awake, audible
= Pulse
wiring
(1) Arousable to verbal or pain

80 TEMP
Color
S =Skin
(2) Baselne color 6 appearance
0 =Oral

60 (1) pale, mottled. jaundiced
A = Axillary
(0) Cyanotic
T =Tympanic Circulation (Peds 5 Years)
R = Rectal
40
(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 tt, I needs anesthesia approval for
S = Sacral
D
D/C,
T

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

Time
Safety: SR up X 2. Falls Precautions. Privacy Maintained
LOS
(bonnnue on inverse)
DEFARTMENTISERVICEICUNIC DATE
l^l (_.k) -2
/123 1) 1 5-0(20-3

PA Name —last
first, middle:grade; date' hospital or medical fealty)
.
HISTORYIPHYSICAL. . FLOW CHART

.
OTHER EXAMINATION.. OTHER amayt OR EVALUATION

DIAGNOSTIC STUDIES
.
. TREATMENT
.

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)_ Previous edition is obsolete
DA FORM 4700, MAY 78
USAfft 52.00
MEDCOM - 19091
DOD-032665
MEDICATIONS

Allergies: Time Pain 1-10 Medication 8 Docsae Route Pain 1-10 l/E • By
MOO — 1)-1,111P/(01 1D-CD U --- —

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refit Motion
Adm et,. _ i_ Pit.
-I. 1'5 C Lil
I.-4— ).'5 PK 30' Rle5 4-t-r w Pk
45'
60'

90'

D/C_AL,,, -i--4-p a 1---Pk
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' -----g D/C
Fund. Height
Lochia
Peripad#_,------

.--Fafroond.
DRESSINGS Location Type DrainageTime
Adm P4C, IFQ1-1, Y....,,, 1 e M k t•-)
30' •ty t y v t..y ie..). I Ai, wtti,,,,
60'
D/C e`i-elvOL k.....two bekicAJ

PACU OUTPUT

Time Source Color/Appearance Amount
CARDIAC RHYTHM
Time • Rhythm tomatic?Stomatic? Rhythm Strip Run?
185b iC %/

WAMC OP 173-E
NURSING NOTES
Re cetue r,( Praryi atz, (p96/0 . PLO-N-1 I 0 L. 1-A4 StLfi leio. Tani' t riff ?POO .? gAic ciS90 eA. ,-)13bc/rr\cirn Afeiy, Sitopiv
Discharge Criteria:
Daterto ei3 Time: IY PARS:/ 0
BP:). T:_HR:$6, RR: / Sa02:q/
Pain Level at D/C (0-10):
Intake:_ Output: Additional Data:_
Transferred To: OA)
Report Given To:
Transferred Via: WIC itter Ambulance

_Transferred By:_ci Cleared IAW Recovery R Charge Nurse Signatur
MEDCOM - 19092
DOD-032666

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this lore. 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: _ Anesthesia Type (Circ.I_ pinal Epidural Drains..Airway Time In: _/ 4)0 I edation Nerve Block Hemovac. Nasal Allergies: A.A,C1Y1 _OR Intake: Crystalloid lc: _Colloid NG Oral
. Pre-op V/S: f 0 (I (1 -1 i t 4 .OR Output UOP . EBL .( -5--
0 JP ETT
.
T-tube

Procedures:. Meds/Times: Trach
.

Le Foley
Other

Pre Op Meds . Histor TLS
Time. If

..4-_ Pacu Intake
C
Time Solution Amount Site By Infused
Sa02
Fi02
Methods
240

220 X-rays: Labs:
Post-Anesthesia Recovery score
Criteria ADM 30' D/C Codes200
Activity
AIRWAY
(2) Moves 4 Extremities
A =Ambu
(1) Moves 2 Extremities
Z
180 BB = Blow-by
M — Mask Airway
(0) Moves 0 Extremities FT = Face
160
(2)
Cough, Deep breath

Tent
(1)
Dyspnea. limited breathing

1 7_
RA = RoomAir

140 NC = Nasal
Blood Pressure

(0)
Apnea

Cannula
(2)
SBP =1- 20 of Pre-op

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

120

V Y. y v V/S
(0) SBP 50 of Pre-op
X — A-line BP Consciousness
= Cuff BP
100 v
(2) Fully Awake, audible
= Pulse

• crying
1
(1) Arousable to verbal or pain

80 TEMP
Color
S = Skin
(2) Baseline color & appearance
0=Oral

60 (1) pale. mottled, jaundiced
A = Axillary
(0) Cyanotic

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

(1)
Axillary palpable. not radial

(0)
Carotid only reliable pulse

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

. L = Lumbar
RR at) IL- needs anesthesia approval for S = Sacral
D/C,
T
\

Time Patient teaching done: Wound Care. Pain Management.
Pain (0-10) T, C. &.ncenti.• .Comfort Measures
LOS Safetyitpr_Falls_Precautio s. 'ye Maintained

n mum On reverse

PREPA DEPART_RVICEICUNIC DATE
17( 7X--c 1 ‘i 1 447 D—17
_

PA TIFICATION /for typed or witty, eat Name —fast.
%st, middle; made; date; hospital or medical !Joky)

.
HISTORYIPHYSICAL .0 FLOW CHART

.
OTHER EXAMINATION .. OTHER opae 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 42.00
MEDCOM - 19093
DOD-032667

Allergies: A-, MEDICATIONS NURSING NOTES
Time Pain Medication & Route Pain_I/E
1-10 Dnsane 1-10
tit in— I XiCt- (5 LA (),

Time Adm 15' 30' 45' Site gr Lk_ NEUROVASCULAR Range Of Motion Sensory P ,---4-p Cap Refill L'' T L..- Color 1,--Ar`- 1'11/0 5040-a) , v-. S, sh), 9 c \_ -1.1 ( 1-* — HA)
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' Fund. Height D/C ' u 06-7p 1 ce4k-,
Lochia
Peiipad#
Fund. Cond.
Time Adm
30' // Location DRESSINGS Type --("'''.4-- Drainage z A \\
60'
D/C

Time PACU OUTPUT ._Source_• Color/Appearance Amount
Time CARDIAC RHYTHM Rhythm • Symptomatic? Rhythm Strip Run?

1_
Dischare Criteria:
V L()
Date:9 9/ 4r-t-,e PARS:
BP: loci 4,-k. Sa02: 9S-
Pain Level a_-10):
.- l ¦-••
Intake:_x ill) Output:
Additional Data:_
Transferred To:_ \
Report Given To:
Transferred Via: W Ambulance
Transferred By:
Cleared IAW Recovery Room SOP B-3
Charge Nurse Signature:_ "" 7
WAMC OP 173-E
MEDCOM - 19094
DOD-032668
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 Ware)
.

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

Anesthesia Type (Circle)): j = Spinal Epidural
Date: C.-5 .
Hemo asal
IV Sedation Nerve Block
Time In: .

. OR Intake: Crystalloid ICC) Colloid .
Allergies: -­
JP . ETT
EEC

Pre-op V/S: ‘e" cif) OR Output: UOP.
'_ if . t-W_P¦11 T-tube Trach

Meds/Times: _ Foley Other Procedures: _ , .
n• On pk-i
Pre Op megs . Histor TLS

Time Pacu Intake
Tune.Solution.Amount.Site -.By.Infused
Sa02
CC) MEM
Fi02
Methods
240
.
X-rays: Labs:

220
Post-Anesthesia Recovery score

_

ADM_30'_D/C Codes 200
Criteria
Activity
AIRWAY
(2) Moves 4 Extremities
A = Ambu
(1) Moves 2 Extremities

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

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

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

120 VIS
(0) SBP =1- 50 of Pre-op

V _ X = A-line BP Consciousness = Cuff BP 100 (2) Fully Awake, audible
= Pulse
crYing

• (1) Arousable to verbal or pain
TEMP

80
Color S = Skin
A (2) Baseline color & appearance

0 =Oral
_A
(1) pale, mottled. jaundiced

60 A = Axillary
(0) Cyanotic

T =Tympanic Circulation (Peds 5 Years) R = Rectal 40 (2) radial Pulse Palpable
(1) Axillary palpable, not radial
LOS
(0) Carotid only reliable pulse
C = Cervical

20 TOTALS: Must be 9 or T =Thoracic greater to D/C. othemise
L = Lumbar
needs anesthesia approval for

RR S = Sacral
DIC.

T
Patient teaching done; Wound Care. Pain Management.
Time T. C. & DB,. Incentive Spirometer, Comfort Measures

Pain (0-10)
Safety: SR up X 2, Falls Precautions. Privacy Maintained

LOS
ILon fume on mein)
•
DEPARTmp"I ERVICEJCLINIC DA1 PREPARED BY
e., K____
e_7

PATIE. tries give: Name —last,
lest, middle; grade; date; hospital or medical laatyl . HISTORYIPHYSICAL OFLOW CHART
. OTHER EXAMINATION . OTHER [Spear/ OR EVALUATION

1111111b (LA)-
.
DIAGNOSTIC STUDIES

.
TREATMENT

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)_ Previous editlbn is obsolete
OA FORM 4700, MAY 78
tiSAPPC52 00
MEDCOM - 19095
DOD-032669

Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication & ain_I/E I By
1-10 Dosace 1-10

NEUROVASCULA ?
Time Site Range Sensory • Cap T Color
Of Refill
Motion

Adm
15'
30'
45'
60'
90'7

.-Dfo

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' • 60' 90' DIC

Fund. Height
Lochia
Peripad# r2 \
Fun_nd.

DRESSINGS

Location Drainage
Time Typ I
Er

Adm MEillitale i 1--
.....--.El

30'
60'
0/C

PACU OUTPUT Time j_Arneurrt----13icharge Criteria:
Source Color/Appeara ce
Date:/ Dtr_Time: C815— PARS: 9
-19096

BP: 531 66 T:951 HR: Ck3 RR:(7 Sa02:/CO
Pain L vel at D/C 10-10):
Intake:. Output:.
Additional Data: .
CARDIAC RHYTHM Transferred To:.
Time t7 C Rh thm Symptomatic? .,...--­ Rhythm Stri• Run? 4-f-------- Report Given To: Transferred Via: Ambulance
Transferred By:
Cleared IAW Recovery R
hA r--sr\R A •se Signature:la

WAMC OP 173-E -
DOD-032670

1. DATE AND TIME OF CAPTURE 2. NO.
A

U cl3 a-ff
4.. DATE OF El
•
8. CAPTURING7. UNIT OF EMS 11. PHYSICAL CON-12. WEAPONS, EQUIP­10. CIRCUMSTANCES OF DITION OF EPW MENT, DOCUMENTSCAPTURE

DD FORM 2745, MAY 98_REPLACES DA FORM 5976, JAN 91,
USABLE UNTIL EXHAUSTED.

DD FORM 2745, MAY 98_ REPLACES DA FORM 5976, JAN 91, USABLE UNTIL EXHAUSTED.
DD FORM 2745, MAY 98 REPLACES DA FORM 5978, JAN 91, USABLE UNTIL EXHAUSTED
MEDCOM - 19097

xi t F LuCATION
1 ._REPORTING MTF ADMISSION ANI) CODING INFORMATION
(State or

8 Country For-use of this form, see AR 40-400; the proponent agency is OTSG Code.)
1 2
HE B 7

A =Z--
4._PAY GRADE 5._SEX

NAME (Last, First, Middle Initial)
3._REGISTER NUMBER 16 17 18
9 10 12 13 -
EN Emu b L (-1z
pi-J it4
1
ACE 9._ETHNIC RELIGION
AGE AT ADMI_w •

6 . DATE OF BIRTH (YYYYMMDD) 7._
27-28 29 ---.30 -31 BACK--GROUND

.--7 -y PlaSt4141
19 20 21 22 23 24 25 26
12._SOCIAL SECURITY NUMBER

10._LENGTH OF SERVICE ETS 11._FMP
37 38 39 40 41 42 43 44 .

35 3632 33 34

.:.

ORGANIZATION (Active Duty Only) • 13. MARITAL STATUS HOUR OF BRANCH I CORPS_k_. C (Z_-Li
ADMISSION
46

Me
16._ZIP CODE OF RESIDENCE15._BENE&ICIARY CATEGORY14._FLYING STATUS

53 54 55 56_1 57 58 59 60 6147 48 49 50 51 52

19. TRAUMA PREY. ADMISSION

17._UNIT LOCATION (State or 18._MOS
Country Code)

YEAR

62 63 64 65 66 67 68 69 70 71
I_NO
.,. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD

ADMISSION
72

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEENAME

\D (7-"_--1-0
23._DATE OF DISPOSITION lYYMMDDIRANSFERRED TO •

21. SP
75 76 77 78 79 80 81 82 83 84 85 8673 74
0 3 I 0 (...-..,-, rc.;
,...5"

25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDDI24._CLINIC SVC - ADMITTING
I

89 91 9596 97 98 99 100 101 102
87 88 90 1 92 93 94
A 4 A I 0 3 0 9 / /
DATE INITIAL ADMISSION (Y YMMDD)27. LOCATION OF OCCURRENCE 28._MTF OF INITIAL ADMISSION 29._

(Battle Casualty Only)
111 112 113 114 115 116

1031 04 105
rc

FOR LOCAL USE
-
Ci\DX: I_G`Cti) (ii_/ E
-1 \ / V._.) ( (1)
/g
.
SIGNATURE OF ADADMITTING OFFICER (Signet

.

r. A
MEDCOM - 19098
DOD-032672
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40400; the proponent agency is OTSG
ADMISSION REMARKS
GRADE
2. NA
REGISTER NUMB R
Ll
J -
(
VS
LENGTH OF SVC
4. SEX
14 WARD
ORGANIZATION
20. TYPE CASE
1R CIZIP
DEPT./
IN iGi15. FLYING
BEN
050
STATUS
1\;
23. CLINIC SERVICE
22 HOURS OF

SOURCE OF A DMISSIONIAUTHORITY FOR ADMISSION ADMISSION2
1
?-vv.AAC-A,..NP-VA-0
ocuasi-\

f)iftr,t CEe-) 25.
GATE OF DISPOSITION
26.
TYPE DISPOSITION
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
24
t
ADMITTING OFFICER
DATE OF THIS
28.
27b. TELEPHONE NO.
ADMISSION
ADDRESS OF EMERGENCY ADDRESSEE (Includ• ZIP Code!
27a.
OD
32. UNITS OF WHOLE BLO
30. GATE OF INTIAL
COMPONENT TRANSFUSED
ADMISSION
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
29
31 SEL
-
Check if Continued en Reverts
DIAGNOSESIOPERATIONS ANO SPECIAL PROCEDURES
34
TOTAL SICK DAYS
BED DAYS
SUPPLEMENTAL
CONY. LVICOOP
OTHER OATS

ABSENT SICK DAYS CARE OATS
CARE OAYS
S
36. Total Days All Facilites
TOTAL SICK DAYS
BED DAYS
SUPPLEMENTAL
CONY. IWCOCIP
b. OTHER OATS

ABSENT SICK OATS CARE DAYS
CAPE OATS
CP • S
L FECCROS OFFICER
SIGNATURE OF PA OOP ME81C
)•¦ In
MEDCOM - 19099 IA
E017103 OF I AUG 75 IS OF1OLETE
110 cnone 1C0
DOD-032673

PATIENT'S .CLEARANCE RECORD
Far use of this form. we AR 40-2; the proponent agency is OTSG
DATE OF DISCHARGE TIME OF DISCHARGE

K-_( CC) -(11 1 9 i 03 SIGNATURE OF WARD OFFICER /0?)°
PATIENT'S IDENTIFICATION ACTIVITY CLEARANCE (The final activity with which the patient must clear will be the disposition office.) Mlatery INITIALS' _ Noninittery 1._Patient's Trust Fund 1._Patient's Trust Fund 2._Medical Services Account Officer 2. Medical Services Account Officer 3. Clothing and Baggage 3._Clothing and Baggage 4._Medical Holding Unit 4._Postal Service a._Supply 5. _Change of Address b._Pay Sectidn 6._Other (Specify) c._Service Records 7. d._Insurance and Allotments 8. 5._Postal Service 9. G._Change of Address 10. 7._Other /Specify) 11. 8. 12. 9. 13. REMARKS 6 ( (_.._ — INITIALS' 7h
._. DATE SIG_ ADMINISTRATOR '0 ( ul_ -2 • INITIALS OF PERSON AUTHORIZING CLEARANCE REPLACES DA FORM 8-258, 1 DEC 59, WHICH WILL BE USED_ USAPPC V1.00
MEDCOM - 19100
DOD-032674

tS_ '3I
ABBREVIATED MEDICAL RECORD
MED CAL RECORD

PERTINENT HISTO Y, CHIEF COMPLAINT, AND C DITION ON AD ISSIO (En er date o admission icm ci.t..may 0700)
+V 7 f'8Y
CLUir

prExAg7, 0 20 (Q)pr.1 cL2--13S t- r" 361 7 tf4,44_, u
rAL PRIIRESS ),/r-4-Ntsc dischtu rtrSl fi 3,7 l diiersis) t 30 1 1 a °-1 (4 I u /A / 03z 5 4

IDENTI ATION NO. ORGANIZATION
DATESIGNAT fast, REGISTER NO WARD NO .

(For typed or written entries give Name la fir
middle; grade; dale; hospital or medical

PATIENT'S IDENTIFICATION
PATIENT'S
i:141111111L( (-)L
ABBREVIATED MEDICAL RECORD
Standard Form 539
GENERAL SERVICES ADMINISTRATION AND

1111111.111. INTERAGENCY COMMITTEE ON MEDICAL RECORDS
E
FIRMA !41 CFR) 201.45 505 OCTOBER IBM
USAPPC VI 00
MEDCOM - 19101
DOD-032675

_
AUTHORIZED FOR LOCAL REPRODUCHON
PROGRESS NOTESMEDICAL RECORD

NOTES

DATE
MIL,..714111111L:

it 10 al...._..
.

I_If.
11...._ AltaArtx.-
C7-

0 _ I ,
. 1,„

o_/ e-(v.i 7—
A., o 0 o r3—
- -.4._..

7/_i_
( 3 0 0 A_—_A x -_,A....... r
8 .;,.I is.e le_ • ._Iffehl
)_—

C-X 12 6_kyr -_w a c_ t f-1 -I ,
1 • • , 1 / L,z.,„:,!.. .....4.2 . ,4&,... ..td....:..-.•_.4111.eada..
1 Rip
A yr
I_iP I'

' . /APP 00 , " ._,_,
^-n V

111.._41 ¦ lli 1 --_
,.c ,-,_(z -UJ L3_1.0..i...:e.,
• AI_Iiiiromfmmrd ,

i . 3 f-'4_
• . i ..
... i /6 —Kt,-- • / ID 3 cy,
A
I f

• 1,4 IL4—,_._6, G, T--,,,,,c,.4.,,_ A 1 .cr A- s'e - 6 0 11 • A.;...: C (
1

¦_. arf /_i_
....IAA,._ERVAWIVINIIMPS.e....-L---.L2... 11—.1ar..4 Au.__11 ¦ 'MIRY
I 1......., _" 411higlai _

II: 1 ir 1 Al Aiii...._4... INIF
1./alL 4.4.4.644110—.../M1- , RELATIONSHIP TO • 1 NSOR SPON OR'S NAME
SPO.. • 'S ID UMBER v Maw Oat
LAST.FIRST MI
I

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, paw Name -lash Nat, mak REGISTER NO. WARD NO. ID No Of SSAt SEX; Date of Bide Rank/rsredel
PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. RIIRGIA Prescribed by GSAHCMR FPMR HICFRI 101.112031b11101
USAPA
MEDCOM - 19102
DOD-032676

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE. NOTES
k.
OW lignri I v
opwirte fil%. .,....../......d.,-. _ , , • ( 2_,
/
itt b 1-II C__
sommir 4
C.).-) - 2

. .
1.
MEDCOM - 19103 em. A am 'tonmom curt ,..... mro.nnal, mu/ USAPA VI le runm aim tncr. al em urnrn

DOD-032677

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

— • . 1%14'0 t-a r--1/7 iA- e c! V la-14247 vo e,, 7 / n.) () y. y I til (_1_ 662.A.,,_
i 0 0365 1-77-/-e/rt,-6/c ,9,--7".- -, z..e ‘:/ fixe"--k-3/i rt/)-7-71 s 0 1 2 c7cta2).. f?.?----c, 5rnal1. -2 Ili c L. h r-e,97 ,t,c / tvforz.t4i el -/---D klk 0 )-e A /6/-,17 g (i-'4
`I L 0,7 / (e/ 'el..-d 1,77 ,"77--e Cf--:" "71 (I r-71)-1--?
.4.----

00$30 /a4 ,s ...1.7 de. i_ / /1... ; c-c---f---tL -A b A
, r
egel'e----,•

; 74 a4e. a 019-7 • ix--P-2-1-?rq" ) /­
k,k-

..
, , ei/,--ii A 72 n --C •
I
,e-l'(_d Ai '#'
p

6f_ A
9/ 62 /.2-/' -/--,---ce e_y° 1- c 7--cc 0() a
?"61.4._ / /7 /-2 ,:

.)' 97
,

400 0 p 74 ,4 e L t
C7-_S-,-.1.,,,-) 101-1-1446c-ed ,
,

4-5 //z/3 ' '.
-If.715.---c-i---1--Aik _"L ,_.:'---)---j.4_ ....-A_A ..._,_.,„,
I hif

A. ,. Jo?
PA6).
rag'id-2)

e72.01n-/ 7e., /7-7 ,t/A-27 .... 0/zos-a 9 -2, /e--77-2 C z., &fr-L-2._„, f /... oi
Az.t....c, -

HOSPITAL OR MEDICAL FACILITY
_1../ STATUS_, DEPART./SER ir S M •,
SPONSOR'S NAME
SSN/ID NO. RELATIONSHIP TO SPONSOR

PATIENTS IDENTIFICATION:
(For typed or written entries, give: Name - lest, first, middle; ID No or SSN; Sex; REGISTER NO.
WARD NO.
Date of Birth; Rank/Grade.l
CHRONOLOGICAL RECORD OF MEDICAL CARE
-k-k
111111t
Medical Record
STANDARD FORM 600 (REv. 6-97)Prescribed by GSA/IC/AR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 19104
DOD-032678
-
I IltA 1 INu unupw.

SYMPTOMS, DIAGNOSIS, TREATMt.N I,,
DATE
,
--21-7-Y-Le

(-r/a yr-, pi-z d 4 a c‘_:_
0/1,,..5--/;o - = . ' il2 Ci-c2-e --;/ pa ze-i/T-f' AN pt ip ita-CI La_ta
-c-c 11-2;g U00 re, r, (e_of,t2
/4 6747 ` ) /p -/- a (,--I I-1 i sc ----i
-7 It/ All( /Pi leie ce. i 0-

c.,eiltlw mA4.-1 frl .alz6.4 A-c-, /vn p J A, -g /1-744,e__ , , _AR _..... -•
-
.
64-44-44 11.2,-6-zi
•
.
•
.
.
,
*U.S. WV:1998-432-786/75236
MEDCOM - 19105
DOD-032679
AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS USABLE
CHRONOLOGICAL RECORD OF MEDICAL CARE

MEDICAL RECORD
I

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
1-- [ve) L.; J:k i tr\ 4 re 14(r) ,-\ 11A,-...c. --k2

e-,..-p el 2, 5-) Ill 15 os-t-o a, ple4e.-
L.-0,—v-a1/4.-.1"---z 4. C.1/1.t I.4. vuLPt I.{ ceti ( c..o P.-1-e ( '' P (___,
ti t-,i1 ,.( CU.__

,,.tet-1.....,9 C6 C C r ,. k, a./— +7,-
11...1 ‘ c'e

q („„.0,-.4-
fw. 11-` 0 )c. put t?p L.

0 P VW Akc \ e.P r5r 12.2-/-4) it,... rykr-v1 11°67 (1?-lb
NI v-,-) A
,

Ar,-E. , ck circ I 1,t &•• a t ---1--
Cr). C3? 13 f

fr

a_ ..- a -re v( I •4.,...-,) \,,,,,,....1. ,..........„rt, Co . alit,p2,e)
(21t-'(
tv\_

f
, k v---t.\_ fir gk--C -4, -te. kA-IK 0 Pry 1r-erg-ult. e e..,\ 4...-1:Nrk V'-^
ce I r 1 11.9 (1—(N-2 7 k.A.4 ,--(
1L

LA(9\
mr ,
(.1,-0....k,_? ') -Dr-,/ ----v--3‘.--,9 c‘... G¦i-,-,...._,
k cP k 04../1. le-
TV c1-1, 1111111WIT .\cJcz-2--

DEPART./SERVICE RECORDS MAINTAINED AT SPONSOR'S NAME SSN/10 NO. RELATIONSHIP TO SPONSOR
HOSPITAL OR MEDICAL FACILITY STATUS
REGISTER NO. WARD NO.

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
Date of 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
MEDCOM - 19106
DOD-032680
_
%.,,.,..,,,,.,.-,-.. -_,.. ,.„.•
1 ncIA 1 upiu_

SYMPTOMS, DIAGNOSIS, i KLA I NItINI i ,
DATE _
3 ci 0

iivka -0-toleT5---ri--11-ff)
rt-----: (a )2o8.0 q7,3

0)
1--ti G
cie-a -Le (3 s

1
/44--Ji=zi-e

Coo ,. ----d is , AA I, n 4, i- L-,-
1--)4,,,Iz,,e _,--plA,
5 q ;
,
A- Cr a) 3 — 7
)

I t° "t 13 11 1 s—
3.3
-
biL,

El. LA 4
c.„„4Nitiititt.:,-/E.1:z_
, PlISL-T_L__
rte1 ..-.-.. e• as -. s D A f`V
MEDCOM - 19107
DOD-032681
AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS USABLE
CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE •

igsra7o3 Sua_bEZi,
0-1 So _ Lip Lc10 Cell _ PIA_DF TresprOV IStA efyloive.... Devi . (...., shrelvvnzl
Ir'vv.-c11 1-1) 12-410. ab a efteiALN 11 i 0 t"0 Lk-La • i -e-,P4­-do Fa-i
tz.v,o, . l&0 certs,...0.. ( sos - tqo erk-i-qu- IrlJ u../­12S -6 2.° SAAnkcul .
e_.•/-0.-.EA 01-. . : eN -e a c ' .,„vt- 61.p) s env t.. 04. b-41" X (eTX
S,0-2... cwt. CV. A.?V\ c exat ' rv)I vtAse-c¦ k-ai--tivIck v..4,11
. 5k39 11'-13 0 t-e.. IS% .
Lo cc...A.%.,....,0 L., in- à,..2.-t- ?k,ra..k7; cr" '42... ;0.e...61 5 'a...u....svv.,,,... '2 cin
c..y.A-0,,..N.c.c.. V.4-7 C7 LAA-4_•R... Y c-rv‘ % r \c-e-f ;or.A- () A iy..e.
F-eke...L p\ cas.,6 . Dee...c-­--, .. s' 9.,,,,,..c,, (V' Y 2- •
16.) .* PA.A.u. \-- 11_ aloclertfv• Il r\.C.I. k_W c.c.) v\ok •r...145Lk1­0.
9 \- ' .5 \iS.S``Ct 10V2-_(.91r k"-cOrelS oryrL--

V .. 1-. c ovive,V,•.or It-0 c....--0¦A `gyp ss ¦ . skp.... 9-Ac a .c
cei rMc r1/4.t.. b...

HOSPITAL OR MEDICAL FACIUTY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
c
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR

IREGISTER NO. WARD NO.

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Raiford
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
k
MEDCOM - 19108
DOD-032682

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
16 07 00
_ .

cL...
daiar

LI--c-f-cf aft3 c___ ,.. i z. 6 Zoe (3-cn( z
6._ c.
A-/--L4
tr7t)
Iv oc
's....„

,
_ .....

I •
(? b (c.k___ -2 N
1-f- fa u i a "ii-----
, , , r( v 1
tik) (3 C i 3 rtb ict.)— (zr p
ag, 3. 0 C4, LT t? ce„,,,„,,( ri— ft-LT 6? A 4.-P3-,

g

HOSPITAL OR MEDICAL FACILITY ST_DEPART. SERVICE_
/ MAINTAINED AT

SPONSOR'S NAME
SSN/ID NO. RELATIONSHIP TO

PATENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or Wilt Sex; IREGISTER NO. WARD NO. Dare of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. G-97)Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 19109
DOD-032683
wry" caw. crru yr

SYMPTOMS, DIAGNOSIS, TREATMENT, I MLA I IN( urit3 ANIL" I KAN
DATE_
1 00

Air
CA— 0 , U Nik 4-;¦ '---- 3 -e

i ra rfforpo-
FA wArjAA

N w 1 a rai1 m
.¦ iiii 0637a
irailligi
4. ca

_.4...01 . i I
-

. iv ti, 51t- 3. a A ez.,t
ki a tAmc_ cl. , 1 L
_
--\-
•
_
(REV. 6-97) BACr_
U.S. GPO: 199S-432-786/75236
MEDCOM - 19110
DOD-032684
k(_ 2-)
NSN 7540-01 075.3786
I LOG NUMBER TRE

EMERGENCY CARE. i ' MEDICAL RECORD AND TREATMENT
RECORDS MAINTAINED AT
(Patient'

PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE (Oa , Month, Year TIME
•
CITY STATE ZIP CODE TRANSPOR ATION TO FACILITY
Mk/XI/ A-C_J
SEX DUTYILOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
AREA CODE NUMBER ITEM Y r NIA ITEM YES NO
PRP ADDITIONAL INSURANCE
AGELil 0 AREA CODE HO BER ONE FLYING STATUS MEDIC • TORY OBTAINED FROM DO 2568 IN CHART NAME OF . - • 'ANCE COMPANY

0
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS_, EMERGENCY ROOM VISIT W ate// I DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO i n NO

IS THIS AN INJURY? WHERE TANUS s.
ALLERGIES -INJURYISAFETY FO DATE LAST SH COMPLETED INTITIAL SERIES
. ..

HOW YES NO
CHIEF COMPLAI
4' I11OP ClUirpt
errEGOR Y OF TREATMENT VITAL SIGNS
TIME.

j E 2 MEWL NVi 10_41M or., ma.m. i ii(7, '-/0 0
. EMERGENT
CffiriginillMirtii I °
O& i . t
CMIIIMIMPNIIIIM7AIMINEIBM z;C.' 1--/Cf
. URGENT ,1.-IN
CEMEAMM-0 P..1 1 5/
—PMEMIIME - . 'I 041

l EIMMI13.
. NON-URGENT ail_..:
MEWS ../ ANNarAMMWtiftl ----4
2 CBCIOIFF MI PTIPTT

PIABG BHCG/URINEIBLOOD/LWANT CXR PA & LATIPORTABLE C-SPINE
StI30t10 9V1
URINE C&S UA MSCCICATH

1111. Et11:1/.710.1
ACUTE ABDOMEN LS SPINE
X. RAY
ORDERS

X_- 1:1¦1111.13
HEA1 CT
0 BLOOD C_
11111111PS

1111111 11111111
SINUS
_.- .107:171,.. °
NIOZiNTIMIN.71-47 er

I

ORDERS

SE OX ONITOR ECG
AME ORDERS BY i COAPLETED BY TIME PATIENT'S RESPON E

IrdWITIMPSWVINIBINIIIL___ EIMATP 4' SriffrifLIMIL-711AVAMMEM ¦11,
Wilfflffffl.L. LIEMBETNIIIIIIIMMINIIIIIEMPIrr ,, •
remzurioramm. sy - mir.r.:vimmi
4., -_vim. 0...; ( a 2 -
DISPOSITION DISPOSITION DUARTERS /OFF DUTY PATIENTIDISCHARGE INSTRUCTIONS n HOME.n FULL DUTY n 24 HRS..ri 48 HRS..n 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNITISERVICE IMPROVED . UNCHANGED
.
TIME OF RELEASE. DETERIORATED
PATIENT'S IDENTIFICATION (fa typed or written entries, give: Name - lest, first, middle- Jll
Also !SSN or °the)* hospital or medical lanky
Ay( uv

+_.
REFERRED 00. TO WHEN
I have received and understand these instructions.
PATIENT'S SIGNATURE
EMERGENCY CARE AND TREATMENT (Patient) •
Medical Record
STANDARD FORM 558 IREV. 9.961
Prescaed by GSAIICMR
FINFI (41 CFR' 101.11.2030:41101
USAPA VI.00

MEDCOM -19111
DOD-032685

NSN 7540-01.075-3706 TIME SEEN BY PROVIDER

EMERGENCY CARE AND TREATMENT
MEDICAL RECORD (Doctor!

TEST RESULTS

Check if read by
WB 6\ ABGIPULSE OX RADIOLOGY radiologist

P02 RESULTS_kl —rm Qv_
SUP 02

CO C3 "k) o PH cyr: r
C3
OTHER
PLT

e)
DIP EKG INTERP EyTION cp,u),

PCO2 SAT

[Iv PT
MICRO
GLU
BHCG ETONAPTT

?.511

PROVIDER HISTORYIPHYSICAL
irt:b cttArnittivitte

1/9VZIf'k C_
' 7"c

a "2,/,. IA-ed 4-f 614-e_e
•"`"? )7Y-2-."— ./2' et)
r .07
6Pf,5-cc7'1"Ccf2 /.c". ` (1/.

MAst, G,Isc 1
-crei C 0 N..x.
a
ocy t`c;--4

ft-t0 tn —1;ttAJJ / t\k‘L_
e °"14-f-
IBJ _
kN ,-1 lk"*"
f—Phrs1 — ,—,ALL
kUAe o -•-••=1\ sAQ -4--1
/1•11‘1.

CONSULT WITH TIME ACTION RESIDE DENT SIGNATURE AND STAMP
AND STA P
DIAGNOSIS \
44.1-1..4k 4... 0140.3 lave ,A0
O
PATIENTS IDENTIFICATION (For typed or wfifieriantriea give: Name lest, firer, midee: ID no. ISSN or Wed; hospital or medical leaky)
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9.061
Prescaed by GSAACMR
FPMR 141 CFR/ W./ 1.2031141101
USAPA 01.00

MEDCOM - 19112
DOD-032686
.

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
........ --

For use of this form, see MEDCOM Circular 40-5 SECTION
ON I - PATIENT ASSESSMENT PATIENT ACUITY LEVEL :
--I POST-OP DAY:__ -HOSPITAL
I

DATE: f) k-6 COMPLETE ONLY AT TIME OF ADMISSION-OR PATIENTTRANSFER -IN -
--- - ------'--------------
TELEPHONE.REPORT•
I AMBULATORY_• CRUTCHE S.--., LJ .V4;iiiICI-iii1L:Irk(ritritiCA0-
Time N S-5— To 1.-Z- _ From

f-C31 -
. ._..._... _ Anesthesia (Specify):

Total ER/RR/PACU time 11-41--"7 Physician
V

Procedure/Diagnosis /AO/ ic.c... Citoz/ 11T-) B/P (I (91 - P 9,6 . R 20 T 7— LOC 010105c • /OD 6--c, 1 \LA Neurovascular checks g2t, "-
./ ' Dressing /cast Cit 2.--A0-1..? ,../-r,---d, Tubes , g)—?
.

,.. -— --(V.)
4 34

Z :'-•FrtiH711 10r-06';v.:
ISI-No II Yes Amount:

Intake (IV, po . Output (EBL, other) Voided Medication
.

0;he'r .5/1) --e....b-1._4(05,1/4"."-.+ Lc' 6 QC-, 2 -tv-,..- 5
_

... . -
• C Cmc -:

Report From 91-12( (_-(_— 2_ Received By tr TIME: i 0 NOD
:4,-,

-BP ARTERIAL LINE.
BP CUFF (M/6 4 " % ill (RR ' TEMPERATURE
g,5 Q''-'1 cap
PULSE
6 sr boa -
RESPIRATORY RATE ) 3 tir f t9
OXYGEN (1/%)
PULSE OXIMETER 9c76

?p cuR
02 METHOD
'.A (A-

Oxygen Method Key: NC = Nasal cannula MT = Mist tent t\ P = Non rebreather = Partial rebreather FM = Face mask A = Aerosol VM = Venturi mask TC = Trach collar
TIME: I/sod Z4bdI9 PAIN INTENSITY 10 o • . . f.) . MED ADMINISTERED MN) TIME: • Skin breakdown prevention • Falls prevention protocol 'Restraint protocol • Seizure precautions )5c p 'LA-MIA-
RELIEF ACCEPTABLE IY/N . • Isolation precautions
(\1601 -1^^­)

TIME: PO
FINGER STICK GLUCOSE 44-
INSULIN IY/N)
zIwGICl) I
YESTERDAY'S WEIGHT: _______4
TODAY'S WEIGHT:
WEIGHT CHANGE: Per hospital policy.
TOTAL OUT
PO IV #1 IV #224 HOUR

TOTALS PATIENT IDENTIFICATION .. \ DIAGNOSIS: ir./ k
Ar
),D( .{-,) ' I
DRG: ADMISSION DATE: TS— Shy- 43
\
LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):

.
ARE OBSOLETE Page 1 of 4 pages MC vi.00

MEDCOM FORM 689-R (TEST) (MCHO)
MEDCOM -19113
DOD-032687

SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
criteria are not mac a brief
have been MET. If all the stated

in the small box indicates patient assessment criteria
DIRECTIONS: A check .
. .. _ _. . _.

explanation of abnormal findings will be noted in the appropriate column. b C .,LJ -2
NEUROLOGICAL: Alert and oriented to
1.
Responds appropriately.
Communication is adequate to express needS. -
Pupils equal and reactive to light.

time place and name.
_....

CARDIOVASCULAR: Pulse regular & rate
2.
within range for age .

: No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity
. .

perfusion) .
._.-.. . •
3.. PULMONARY: Respirations within normal
'rate far age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
sounds.
. 4_.
) •
Abdomen soft and non-distendh.

4: G.I.
,..._

BOwel sounds active: Reporti no NN/pain
.

......
with eating and no problernS chewing/
swallowing. Denies constipation, diarrhea or
-.,. rectal bleeding.
G.U.: Reports no dysuria. retention, urgency, frequency, nocturia.
5.
Urine clear,

yellow/amber. No unusual discharge.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities.
6.
No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
No

7. SKIN: Warm, dry, intact. Good turgor.
rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
prominences. Mucous membranes moist.
PAIN: No complaints of pain/ discomfort.
8.
(See page 1 for documenting pain intensity.)
PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
9.
(LEGEND: P10. IV SITE ASSESSMENT:

INITIALS:TIME: J.500

IV patency ._q 5" hr: i
IV site care provided: asyess,4
IV tubing changed:
LOCATION.CONDITION

IV Site #1: 'A-C._ - OK___
IV Site #2:
' Comments: L2( cCli
:
1

INITIALSf. ----
INITIALS: TIME:.
INITI TIME: a330_

TIME:..
.... . .__ __ _

r a
.
rct,
. I. • c....y-, "C., -
,
-free „..,,..,
- \• ¦
, t' %TV ‘ t cx—C-c--;32.-

k\f-A lac_ )-1, k . N
'Vt..k..._...3-yo eye, vi 1-

-i° -r, c_t_........N k...S.-l-Len_.-, .

' a.-ck_AA
LA...N.,----v-.-(2

\teq_0 u--) \S rsit-P ,
C.,%----1 T. .
&S Z.5 0/-)--4...-"aPt- '')_ ° ft)

po-A-reN
a5-STS+—
-Fa WO?

g ‘ .
U11)( i 4/(4 es) k to iv-e-1) . 1 a_r___
eu nctlx¦re c1. 8-e_

lac ,
•
10 -( (.( pc---rv-.

l•-k 0 1--k g1-(7,r e:5---1-',/...
PI .
OK - No swelling/redness * - Central line)

Puffy I - Infiltrated R - Reddened INITIALS: -- -
INITIALS: (4-1'%-.) TIME: hr: IV patency ._q hr:

TIME: DD-30
IV patency . q S.
IV site care provided:

IV site care provided: cty..) e35e CA
IV tubing changed:

IV tubing changed:
LOCATION.CONDITIONCONDITION• LOCATION.
0,e..--IV Site #1: •

IV Site #1: A•icy.._
IV Site #2: CC) licyc.... Oke-

IV Site #2:

Comments: Lie_c;) 1 00 c q(AA "fp Comments: 0" ' O --i• t--
)
. _ f _
age o page

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
MEDCOM - 19114
DOD-032688

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: III TIME: 15.a.).pa,A--)
COLOR AriA /¦-iPt-
CAPILLARY REFILL
i- TEMPERATURE
EDEMA •
SENSATION
R : ,.D .:-.,.--, MOTION PASSIVE FLEXION PERIPHERAL PULSE I _...., sb1
' LEGEND

Color: P-pink (normal); C-cyanotic; W-pale, white
0
; Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs) U Temperature: C-cool; W-warm; H-hot L Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
A-
Sensation: A-absent; N-numb; T-tin g; S-sensation (present) Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
R
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
BREAKFAST LUNCH
TYPE:
PERCENT CONSUMED:
HOW TOLERATE •

. SELF . ASSIST

Lu LU_C.) -z a
•
I

BATH/ORAL CARE
TYPE OF ACTIVITY (Circle all that apply)
TIME: CONTENT:
TYPE:
PERCENT CONS •.
HOW T ATED:

. COMPLETE SELF . ASSIST .
0700-1500
.
SELF . COM TE

.
ASSIST OTAL

BEDREST . SELF AMB ATE . ASSIST
BRP # TIMES/SHIFT
R
CHAIR

INITIALS: TIME: CONTENT:
. SELF
54ASSIST . TOTAL
BEDREST . SELF ..iiiggagg31'7 KASSIST
BSC BRP CHAIR
INITIALS: TIME:
.s. : ID band visible/legible
4 ; Orient to environment pm
;.F. . Side rails (2/4) up Bed position low Call light within reach
. 4' " Review & post lab results Notify MD abnormal labs
Incontinent urine/stool Linen change prn
T
H Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose

DINNER TYPE: 0 ..__. PERCENT CONSUMED: HOW TOLERATED:
COMPLETE . SELF . ASSIST
. COMPLETE
1500-2300
. COMPLETE
# TIMES/SHIFT
2300-0700
.
SELF . COMPLETE

K.
ASSIST . TOTAL

BEDREST . SELF BUTA-_14 ASSIST
Tr)
-C BRP CHAIR
TIME: as .._.)
CONTENT:
F g7r3d)
4412 P i.) /Y3 /j
Ali/A—'1691-
,cp, oij
Tif
, IN
PIA NPY
)
\I)
# TIMES/SHIFT
INITIAL'''.
per ,-"crovvLa_
—
--1-143_,..,N.,
rsz_„_:„.,_e_li3 o-63._-v ,
— f.An c_cro-n_o ss,_ ?o 41-•-•"-A-

0 Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION
SIG E
INITIALS 16( cAN3 -Z SHIFT

nI-) (ca. —
J 7 v-
MEDCOM
DOD-032689

-2w

TREATMENTS LOCATION OF WOW APPEARANCE AND DRESSING CHANGE
C)( /°. 0 (.-c Oa_ Oc--T,-R .ei;( e
' ..'' 'UM-VI Pan')/(-__
.
1,iire/i 10 .c K(ded Socteeri 66(f74
N
.
,..
,
SECTION IV - NOTES

-1-K.GU-07) -7--1,74-e,7 (hr-khockv) ccii.r ' . 1* S.''U -i-c) ie. A-e -c-c_x• iivricogi 9A-c 1AL , 1.5--' f-czo1 '4\,-; c troy--•-a' • ..),(--__() -19,V -5 4-Et .' ¦ -U.4 ccvd-• io )01--)'1---161
jEC.)3 ;.12-fm_ Id.F,(172 -(Jig
4_,IY6:..pc-c. A SI . A.- ' -1 0 k")(5--1NN-, A-0 CA. k ,--igi- ®L ' -'‘‘OC'Q -c., AX,--, --A\C"NA-Nciicl-t . tR)Q-A. cr...9.-k-k k -it.3---0 C.13-1.... --A-0DX' -.M \ _dC-.:N\
W(S0 -2 N\

MEDCOM FORM 689-11 (TEST) (M .. , MAR 99 Pagel4 of 4 pages
MEDCOM - 19116
DOD-032690

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I - PATIENT ASSESSMENT I POST-OP DAY: HOSPITAL DAY:
DATE: 1C2 Gep 05 I PATIENT ACUITY LEVEL :_r, COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER .IN
- TELEPHONE REPORT:_T -

. ,J7... Z..-
'.cei. .. . • 5 —14' 'ct 4,1' , • co ozcn C. Q. .I cp cc
II CRUTCH.Ell. WHEELCHAIR.II.STRETCHER
• I AMBULATORY.

Time_ To_ From_ • nesthesia (Specify):
Total ER/RR/PACU time _Physician_ Procedure/Diagnosis B/P_ P_ R_ T Neurovascular checks
LOC Tubes
Dressing/cast II Yes_Amount:
Intake (IV, po)_ Output (EBL,_other) Voided_ 111 No Medication Ot Report From
Received By TIME: to-4, )09 2.0„, DV) BP ARTERIAL LINE .....----...-*".
4
LIr:1-.1...,1 Ilya Mk,
BP CUFF TEMPERATURE
9 7 1 17 1 Q33
PULSE
1.j 47 3 RESPIRATORY RATE

i (., /6 /co, i
r,...----,....,..---
OXYGEN (L/%)

/./ PULSE OXIMETER qc 76 Cl g, ic 02 METHOD fi---Q ic/t 6 A
VM = Ventu i mask
Oxygen Method Key: MT = Mist tent_PR = Partial rebreather_A = Aerosol_ TC = Trach collar

TIME: 161007ov, 32-TIME: to • • • Skin breakdown
NC = Nasal cannula_NR = Non rebreather_FM = Face mask_
._.
PAIN
INTENSITY
o
MED ADMINISTERED (Y/NI ik)
.
cor .wc.) ---Jzuiwo
prevention
•
Falls prevention protocol

_

•
Restraint protocol

•
Seizure precautions_.--4,0

•
Isolation precautions

1.-'.0

YESTERDAY'S WEIGHT: N7
TODAY'S WEIGHT:_(4,40
RELIEF ACCEPTABLE (YIN)
44-
k"--)Pi
FINGER STICK GLUCOSE
TIME:
!(c at)
J
INSULIN (Y/N1
WEIGHT CHANGE:
'Per hospital policy.
TOTAL OUT

PO IV #1 IV #2 TOTAL IN Urine Stool
T
24 HOUR
TOTALS

PATIENT IDENTIFICATION C( \) b((x_ - z_ DIAGNOSIS:_I___.,,re_..„,-----( a-c-DRG:_ ADMISSION DATE:_ic Se_19 o3 LOS:._ EXPECTED RELEASE: CASE MANAGER: MEDCOM - 19117_ ARE MANAGER: 'I IC/ll nm/)Lent.)
DOD-032691

SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check

. in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
,--, IVC.J C_-
E:_INITIALS: TIME:
INITIALS E1,2,3O_INITIAL

1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately. LJ

LTJ

Communication is adequate to express needs.
Pupils equal and reactive to light.
-¦,, -

2. CARDIOVASCULAR: Pulse regular & rate .1E
within range for age. No dependent edema. UUU
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion]

•

3.
PULMONARY: Respirations within normal I
rate for age group; quiet and regular. Depth is iii:__--.I V LL JJ
regular. No cough. No abnormal breath
sounds.

4.
G.I.: Abdomen soft and non-distended.

CA 990". t• %.-1010 Tre
-) (4,4 0 s 4 ()Q.. Z..

Bowel sounds active. Reports no NN/pain j \-L-t. ,..AS1-3613rk-AYN6
with eating and no problems chewing/ drs ' Saifp Ao 'ZO ,t-C swallowing. Denies constipation, diarrhea or 1--rOLZA/01-b4-: CiArei G' Z . c2,..Q.3pCidtk.
/..-1-NC-4`_l.,55—S\D rectal bleeding.
gee

5. G.U.: Reports no dysuria, retention,
0.,&/ piC.

urgency, frequency, nocturia._Urine clear, [0/ 4y-0\ pic_
yellow/amber. No unusual discharge.

NrcskaAJN• -b 'ITO us...N./v..0,S)-
6. MUSCULOSKELETAL: Normal muscle

_-------F1
development and mass for age. No

12(
deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

7. SKIN: Warm, dry, intact. Good turgor. N—o---"El
rashes, inflammation, ulcers, breaks in skin. A Ruclk tiv-e--N \ L)q
No redness, blanching, irritation over bony t Gt-C_)1./_1N8 C D r____

pk.)c,c-s-vcc...--;-_,
) 0

prominences. Mucous membranes moist.
CD \

8. PAIN: No complaints of pain/ discomfort. If]
(See page 1 for documenting pain intensity.) El --. Pi_•
9. PSYCHOSOCIAL: Behavior is appropriat i
to the situation. Anxiety is controlled or mild

gi
and appropriate . to situation._Interacts appropriately with others.
10. IV SITE ASSESSMENT:_LEND: P - Puffy_I - Infiltrated_R - Reddened OK - No swelling/redness • - Central line)

TIME:_tISV_INITIAL . TIME: /6er)_INITIALS: _TIME: .(9.9-?-,C) INITIALS: AM
IV patency ._q_hr:
IV patency V_q ahr:_-110

IV patency V q_hr:
IV site care provided:_

""-C IV site care provided:_a, 3e55-4_01
IV site care provided:
IV tubing changed:

IV tubing changed:

IV tubing changed: LOCATION_
CONDITION
LOCATION_CONDITION
LOCATION_CONDITION
ro r4,--i tx....,

IV Site #1:_ IV Site #1:_
6. ,..DE_CIV___ IV Site #1: IV Site #2:
IV Site #2: IV Site #2:

Comments: Comments: Likrr& +5 A7) Comments:_
a_cce

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 19118
DOD-032692

SECTION III - PATIE NT INT ERVENTIONS CHING
SITE:_ TIME: I Ps TIME: COLOR ni AL ID band visible/legible

CAPILLARY REFILL

Orient to environment prn TEMPERATURE
Side rails (2/4) up EDEMA
Bed position low
SENSATION
Call light within reach
MOTION
PASSIVE FLEXION
O
Review & post lab results
PERIPHERAL PULSE

Notify MD abnormal labs LEGEN D
Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stoolCapillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-(5 secs) Linen change pm
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting Turn/reposition q2h
Sensation: A-absent; N-numb; T-tingling; S-sensation (present) ROM q2h if immobile
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM

Antiembolic hose
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable

BREAKFAST
LUNCH

D. DINNER
TYPE:
TYPE: C
TYPE:
PERCENT CONSUMED: PERCENT CONSUMED:

I pszt,
E PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED:
. SELF . ASSIST . COMPLETE
SELF 0 ASSIST
. COMPLETE . SELF
. ASSIST . COMPLETE

0700-1500 1500-2300 2300-0700
,721, SELF

0 COMPLETE
BATH/ORAL CARE . SELF . COMPLETE . SELF_. COMPLETE
. ASSIST

Et TOTAL aASSIST . TOTAL
0, ASSIST_0 TOTAL BEDREST
.p3 SELF BEDREST . SELF
BEDRE El SELF
AMBULATE . ASSIST rT

TYPE OF ACTIVITY UL¦ 'i" it7ASSIST
.,ASSIST

S BSC
(Circle all that apply) BSC
# TIMES/SHIFT BSC
BRP # TIMES/SHIFTBRP $ TIMES/SHIFT
BRP
CHAIR
CHAIR

CHAIR
TIME:_ INITIALS:

TIME: 110Q)_INITIALS:
TIME: ?-3:, INITIALS CONTENT: CONTENT:

CONTENT:
("ib

cr aft
Ci)b-A—iNTh (\Or \O-PirlOTIC-PW)L3--
cdc„

A a,v^r‘V) ..) C^SS^ airap-Lan1/43zsl. T.
C TZ1 /z EA-/C-154.4— PP 'r
H
t
CGLQ._3( .ef\Ct.Dai-31-katiA

N
G
. Patient/Family Verbalizes Understanding
. Patient/Family Verbalizes Understanding0.46-at-S.
1 /Family Verbalizes Understanding

PATIENT IDENTIFICATION INITI S b(,,6 — '2-
SIGNATURE_ SHIFT
-
\11111 \-_) ((...6
aMk) E
MEDCOM - 19119
on) 91?-6&
DOD-032693

.TION III - INTERVENTIONS & TEACHING Ma.
..!..' T

TREATMENTS Of I LOCATION OF WOUND APPEARANCE AND DRESSING CHANGE
E

:••6¦); 4
'1,t
111° 42 4'L--C1SAs CrkreS etA I L
(9 E C. GS Dir;
Z (fa v 1 ¦---1.

:f:
SECTION IV - NOTES

dfr-c2-04..-C-1,-•( 67.------taA-•
6/ / ''''-6./.¦•a1.... V_1

-.
' c_
Id--_ a..-,....r.-- 5„4... -tit . , --t-_ 411,Oryo_..a-... -'6..r......",--C-.. ....
.-"A •

IV . P'''‘.1'-4L-1 C91---.--
II

• - a___A e a . & .JI_a '_& • . •_'_111 ... • ip._-_• •111.-
1 -_-
% lb k._ , 2.1.% Call•le_I_
• -•— at

•g M_:.-11_. illi a ¦ e. • a Ilk
IIII

I a__ a _• ...._•_ its_-kik a._ 1 ir..a• ....aa II
C.)_"•(.1.-:--)Nl-N ,... trz,-/-1

-tut PrO.
M.FOCOM FORM 689-8 (TEST) , MAR n^
t Page 4 of 4 pages
MEDCOM - 19120
DOD-032694

•w•L_LAll,/-1I.. nCloU111-) -
rkk I ItN I AU I IVI I ItS FLOWSHEET For use of this form, see MEDCOM Circular 40-5

-_SECTION I - PATIENT ASSESSMENT
DATE: 1 -1 se O3

PATIENT ACUITY LEVEL :_
rt
POST­OP DAY: 0 HOSPITAL DAY: 3
.-.:q COMPLETE NLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT:

tif •
STRETCHER
Total ER/RR/PACU time

5...Eb Physician Anesthesia (Specify):
13 ;
Procedure/Diagnosis

IN
K, Neurovascular checks
Dressing/cast

_`

Tubes

4
F II No U Yes Amount:

Medication —^
t
...:li
_ Received By

.:„.,.., vr
..., TIME: 6f-k() Oro 12.1.1) core), A
.. _
-•t;. BP ARTERIAL LINE -.----

------"

IL r:
BP CUFF

I 1'5100—,-1 .4A,99 "41,4 01 (ii
TEMPERATURE

iqs-°H. 6 !! .0
177
PULSE

11 ._.-qc q-Li
RESPIRATORY RATE
1 g 7,----

tk0 /9 1 (.0
OXYGEN (U%) ,...-.
/--'''
PULSE OXIMETER

4-6 -----Cliti, ?6 qt,,
02 METHOD

1-4-A" Rik
NC = Nasal cannula_
Oxygen Method Key: NR = Non rebreather_FM = Face mask VM = Venturi mask
MT = Mist tent_
PR = Partial rebrea her_
A = Aerosol

TC = Trach collar TIME: 060 02FiC,A). ._.: 10 • • TIME: Ntsa-/ OD 2;t3? • • Skin breakdown
._.

PAIN s prevention kitac 4-folA.
INTENSITY • • , • Falls prevention protocol
•

o • • .‘ • • • Restraint protocol C
MED ADMINISTERED 1Y/NI
.

KJ IQ • Seizure precautions

.
RELIEF ACCEPTABLE IY/NI MA
NA
•Isolation precautions

.___ .____
TIME:

. ..-I--
MOD I403

-10
. FINGER STICK GLUCOSE

,ft
_.. _._ 0 A A.I
E YESTERDAY'S

H INSULIN IWMI :
V
D
TODAY'S WEIGHT:

E
------,,....,„
S WEIGHT CHANGE:_

R
,._.
Per hospital policy.

24 HOUR PO •
I._AL IN U 1 •
atop(— TOT-At•OUT

PATIENT IDENTIFICAT ON DIAGNOSIS:_
1 a , I A

b ( c.,_ - 'A 0 .. --
Ci_ DRG:_
ADMISSION DATE:_IS--LOS:_
EXPECTED RELEASE: PA C C
"A•‘GER:
MEDCOM 19121
- • . ..............ARE MANAGER.

DOD-032695

Z_.
SECTION H - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check . in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a briel

explanation of abnormal findings will be noted in the appropriate column.
1.
NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2.
CARDIOVASCULAR: Pulse regular & rate

within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity
perfusion/

3.
PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
sounds.

4.
G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain C-3 cpy__Az?
with eating and no problems chewing/

swallowing. Denies constipation, diarrhea or
rectal bleeding.

5.
G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle
development and mass for age. No
deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

7.
SKIN: Warm. dry, intact. Good turgor. No
rashes, inflammation, ulcers, breaks in skin. VOQ
No redness, blanching, irritation over bony

f.m.o-WcAir

prominences. Mucous membranes moist.
-C1,60-Q_71 1 ei% c-c› t

B. PAIN: No complaints of pain/ discomfort.
e.../to 6 111 c_fo

/See page 1 for documenting pain intensity.) .
pc,A, -iv (Qi/ 0,..N\GS1
pLAA.12.4t.4/19—
cprOav-ks).-k,:-,5N-D

9.
PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

10.
IV SITE ASSESSMENT:

(LEGEND: P Puffy_
I - Infiltrated_
R - Reddened
OK - No swelling/redness • - Central line)

TI INITIALS:
TIM INITIALS: TIME:_
IV pat- cy ,/ q_hr: INITIALS:
IV pat cy ,,/ q_hr:

IV patency ,/ q
_hr: IV site car •rovided:

IV site care • ovided: IV site care provided:IV tubing change IV tubing chap. d:
IV tubing changed:TION_CONDITION
CATION CONDITION

IV Site #1: LOCATION CONDITION
IV Site #1: IV SiteIV Site #2: `Iv Site #2:
IV Site #2: Comments:
Comments:
Comments:

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 19122
DOD-032696

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: TIME:
CAPILLAR ID band visible/legible Orient to environment pm
EDEMA SENSATION MOTION Bed position low Call light within reach
PASSIVE FLEXION Review & post lab results
Notify MD abnormal labs

TYPE:
QC)_INITIALS:
CONTENT:
Qc-Q-C2

. Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION
)r)
-2- SIGNATURE SHIFT

C¦
MEDCOM - 19123

DOD-032697

SECTION HI - INTERVENTIONS & TEACHING , -at) LOCATION OF WOUND TREATMENTS
APPEARANCE AND
DRESSING CHANGE
ftv
k.) LJ
Dr-SY
ccuresThy-e9/
Q
()5 Col
SECTION IV - NOTES
L44+0 (fie ti
Mv60A-te L
A
Vere.Joi..4-/lagerjl
(I...La Ili e.
La-eCt

Yo 6.1 4-1) be., rtki...,,t,te,
so • Aq..
.11h_&_
,Dta_f•c\-¦_,—Ji— •

ceS C--_t—rx.A.:ry_UJ a-0 ( eiL
MEOCOM FORM 689-R (TEST) MO. , MAR 9Q
Page 4 of 4 pages
MEDCOM - 19124 •
DOD-032698

mpnirel Dcrtnorl itt-t-_r...-r••
MEDICAL stg-a..viAla - I-OA I ICIII I ACTIVITIES
PAT WI I ICJ rLAJWSVItt I For use of this form, see MEDCOM Circular 40-5
• SECTION I - PATIENT ASSESSMENT DATE: k is-Solo c5).)_
PATIENT ACUITY LEVEL :. POST-OP DAY:. HOSPITAL DAY:
4

"- COMPLETE OALY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:.
Time. To. . i Total ER/RR/PACU time. '?,-- Procedure/Diagnosisi. LOC .... From. Physician. - I AMBULATORY I CRUTCHES ri Anest.• pecify): B/' P.Neurovascular checks R. I STRETCHER T
Dressing/cast Tubes
4: 5-Fit Intake (IV, pol Output (EBL, other). Voided II No.El Y es Amoun t:

Medication i).• Other
rt From
Received By
fl.:

. [. TIME:
1 L-41:S\.
..• „,,,D /. aria 'A, i 0 , A O'X't5
'! BP ARTERIAL LINE
-:

V BP CUFF
A5 .....„.

1066/ TEMPERATURE.
b. .rakianiallia ipe •0
¦ •

-...--z PULSE
q 9 2. ,-- Alp
RESPIRATORY RATE :;5; ./6, I 6 •
i OXYGEN (U%)1 ,----PULSE OXIMETER
q 71
02 METHOD

N.
Oxygen Method Key:.NC = Nasal cannula.NR = Non rebreather.FM = Face mask.MT = Mist tent.VM = Venturi maskPR = Partial rebreather.A = Aerosol.
TC = Trach collar TIME: /40b.DQ io •. _ r TIME: °TIM 14(fri 0/0)
. ..
• Skin breakdown.
' •

PAIN. . •. t.prevention 11110 /144 OA.
• •.. . INTENSITY ,.•Falls prevention protcTco-T .
. . . " . . . --I v A A .•. : : . • Restraint protocol r/A
-I
MED ADMINISTERED IY/NI

N • Seizure precautions
• ., RELIEF ACCEPTABLE IY/N) "A
A)
, •Isolation precaut ns io
Al A
1
__ _.. _ ._ ......
TIME: o

T E - -_- - --_-
FINGER STICK GLUCOSE

0 _... ._. _.. ...__ E
YESTERDAY'S WEIGHT:.

H_ /N 4-.1A
INSULIN IYI
D_
TODAY'S WEIGHT:.

E ti/3
WEIGHT CHANGE: T\14

R -,-----_
'Per hospital policy.

24 HOUR I PO_IV J1 1 IV 02
TOTAL IN Urine.

TOTALS_ Stool. TOTAL OUT
PATIENT IDENTIFICATION
DIAGNOSIS: A _

°LAIN. DRG:.
b((-0 -Li ADMISSION DATE: r--D.C.P1 LOS:.
EXPECTED RELEASE:
CASF MANAGER:
MEDCOM - 19125_
1E MANAGER:_ \—( (i\-I
DOD-032699

SECTION II -PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check . in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a bri
explanation of abnormal findings will be noted in the appropriate column.
TIME: 0
TIME:
VCrO INMALS:
1.

NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

2. CARDIOVASCULAR: Pulse regular & rate
\F1 LV

within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity

perfusion)

3. PULMONARY: Respirations within normal
171

rate for age group; quiet and regular. Depth is
0./
regular. No cough. No abnormal breath
sounds.

4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain . fT 6Xic 0¦1"1/45---bo i„ca,v,,„
with eating and no problems chewing/ 0-f-t-eaa s t,s,
swallowing. Denies constipation, diarrhea or

oc. Ai1D
dlw .
rectal bleeding.
F
5.
G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.

MUSCULOSKELETAL: Normal muscle
development and mass for age. No

deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

7. SKIN: Warm, dry, intact. Good turgor. No .SEI rashes, inflammation, ulcers, breaks in skin.
. ( .1a,K,)

No redness, blanching, irritation over bony
prominences. Mucous membranes moist. tAapi&ra -ds coT-

8. PAIN: No complaints of pain/ discomfort.
g IJi t. 4 j Pr-4,0
n
(See page 1 for documenting pain intensity.)
sIp iri IL4 is/C4-
. 511c- (-)
t.,%.

9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild Liv
rg
and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT:

(LEGEND: P - Puffy_I - Infiltrated_R - Reddened OK - No swelling/redness * - Central line)TIME: 1 1.6% INITIALS:
TIME: I le)D_INITIALS: 41111 TI_

IV patency_q_hr: INITIALS:
IV patency . q_hr:
IV pa ncy q_

IV site care provided: . hr:
IV site care provided:
IV site ca provided:
IV tubing changed:
IV tubing changed:
IV tubing cha ed:

LOCATION.CONDITION .
LOCATION
CONDITION .

IV Site /I: LOCATION CONDITION
IV Site /1:
IV Site /1:
IV Site /2:
IV Site /2:

IV Site /2:
6)Pts .`k...""43 Comments: Sl

Comments: ."-eNr--
Comments:

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 19126

DOD-032700

SECTION III - PATIENT INTERVENTIONS & TEACHING
TIME: *NI
r'
TIME: IJP, tiCoCOLOR ID band visible/legible
CAPILLARY REFILL
Orient to environment pm
TEMPERATURE
Side rails (2/4) up
EDEMA
0
Bed position low
SENSATION Call light within reach
mo-rionCtit io.,
PASSIVE FLEXION Review & post lab results Fct,PERIPHERAL PULSE
¦tt
Notify MD abnormal labs

LE • D
hx

Color: P-pink (normal); C-cyanotic• -pale, white
Incontinent urine/stoolCapillary Refill: 1-(0-2 secs); 2- -5 secs); 3-( 5 secs)

U. Temperature: C-cool; W- rm; H-hot Linen change pm
L. Edema: 0-None; 1-rn• -; 2-moderate; 3-severe; 4-pitting Tum/reposition q2h
Sensation: A-ab t; N-numb; T-tingling; S-sensation (present) ROM q2h if immobile R.. Motion: U-u le to move; M-move-no pain; P-move-pain; R-full ROM
.
Anbembolic hose

Passive F xion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain Perip. ral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; 0-doppler, P-palpable
BREAKFAST LUNCH

D. DINNER
TYPE: TYPE:_ rs, TYPE:_P-e,
PERCENT CONSUMED: `7,.‘ PERCENT CONSUMED: CrI)

E PERCENT CONSUMED: 131,
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED:
04_
(V) SELF . ASSIST .
COMPLETE
.
SELF 0 ASSIST 0 COMPLETE
QI SELF . ASSIST . COMPLETE

0700-1500
1500-2300
2300-0700
L -SELF
I

A D; TYPE OF ACTIVITY (Circle all that apply) BATH/ORAL CARE BEDREST AMBULATE BSC BRP CHAIR . ASSIST ab COMPLETE BEDREST AlngfIXTE BSC BRP CHAIR 0 SELF . TOTAL_. ASSIST SELF . ASSIST I TIMES/SHIFT . COMPLETE . TOTAL . SELF . ASSIST I TIMES/SHIFT \Ig SELF ASSIST . COMPLETE . TOTAL AMBULATE_ .„ffiELF SSIST BSC BRP CHAIR / TIMES/SHIFT
E TIME:_ INITIALS: CONTENT: Czi•-••M_CO, 7t/-1 /4.. A_ s Er4F TIME: (tin).INITIALS: CONTENT: -staP TIME:_ CONTENT: INITIALS:
A
C H p C-4 .LO C. (3 0.- c ,3 _ ta•0
N
G

. Patient/Family Verbalizes Understanding
_ XPeritigr...
4/Family Verbalizes Understanding

PATIENT IDENTIFICATION . Patient/Family Verbalizes Understanding INITIALS
SIGNATURE SHIFT

Civ
fc(-27
MEDCOM - 19127
e-y-NonCr r-1 41-5
DOD-032701

_CTION III - INTERVENTIONS & TEACHING (Cott., LOCATION OF WOUND TREATMENTS
APPEARANCE
AND DRESSING CHANGE
-,s cA DI1 ez s r,.c peeCa ,..3b
s
c o„-ec.-e4
655
SECTION IV - NOTES
607_,1
• Os
b(69---fts-

MEDCOM FORM 689-R (TEST) (MC.. , MAR 00
MEDCOM - 19128 Page 4 of 4 pages
DOD-032702

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
COMPLET
AT TIME.OR ADMISSION­

_ POST-OP DL
Time OR -PATIENT ­
To 5 I
TRANSFER -IN - TELEPHONE REPOR
77-77
Total ER/RR/PACU time
0 AMBULATORY.
7-M-13U-1AT OR Y

^_ Physician .-Cr CiiUTC1:167.
:Procedure/Diagnosis El iiiiiii.oiiiiR".--0 ...kiii-td-iiii
Anesthesia

LOC. /Specify): .. _
B/P
Diessing/cast P
Neurovascular checks

;Intake (IV, pot.

Tubes 11/lediCation _ .
Other " .

11111111111111111111111111111111111
;INGER STICK GLUCOSE
111111111ftra 019111111111111111111111111111111111
119111111111111116111111111111111111111111111111111111111 11111111111111111
YESTERDAY'S W Hi: TODAY'S WEIGH : 1.11111111111111111111111111111111
WEIGHT CHANGE:

111721111177111111111111111•11m¦_'Per hospital policy.
TIENT IDENTIFICATION
DIAGNOSIS:

CA'v 1111S
DRG: ._t LOS: ADMISSION DATE:
si—CD
EXPECTED RELEASE:
CASE MANAGER: PRIMARY CARE MANAGER: MEDCOM - 19129_—
?cify):

)COM FORM 689-R (TEST) (MCHni nee „
DOD-032703
aoosre.. -_•-.. -

SECTION II -PA I ItN I 1.¦
have been MET. If all the stated criteria are not met; a brief

in the small box indicates patient assessment criteria
.

DIRECTIONS: A check
explanation of abnormal findings will be noted in the appropriate column b(
_TIME:
INITIALS:
TIME:
INITIALS:

TIME:_
NEUROLOGICAL: Alert and oriented to
1.
time place and name. Responds appropriately.

Communication is adequate to express needir:-Pupils equal and reactive to light.
CARDIOVASCULAR: Pulse regular & rate
2.
within range for age: No dependent edeMa. Nailbeds and mucous membranes pink. No calf
(See page 3 for extremity?

tenderness.
.

perfusion)
PULMONARY: Respirations within normal
3. group; quiet and regular. Depth is
rate for age regular:. No cough. No abnormal breath
sounds.
4: G.I.: Abdomen soft and non-distended. BoWe-I SoUndi active. RePorts . no NN/pain witlie'ating and no problenii chewing/
Swallowing: Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria. retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
MUSCULOSKELETAL: Normal muscle
6.
development and mass for age. No
deformities. No assistive devices needed.

Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.

SYk

SKIN: Warm, dry, intact. Good turgor. No
7.
rashes, inflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony
prominences. Mucous membranes moist.

PAIN: No complaints of pain/ discomfort.
8.
(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others. 10. IVIV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated TIME: INITIALS: TIME: IV pat cy .V q hr: IV patency . q IV site care provided: R - Reddened INITIALS: hr: OK - No swelling/redness * - Central line) TIME: INITIALS:-IV patency . q hr: IV site care provided:

IV site ca provided:
IV tubing changed:IV tubing changed:

IV tubing ch. .ed: LOCATION_CONDITION LOCATION_
CONDITION LOCATION_
CONDITION
IV Site #1:IV Site #1:

IV Site #1: IV Site #2:IV Site #2:
IV Site #2: Comments:
Comments:
Comments:
Page 2 of 4 pages

MEDCOM FORM 689-R (TEST) (MCI-10) MitR.99
MEDCOM - 19130
DOD-032704

SECTION III - PATIENT INTERVENTIONS & TEACHIN
-SITE:_TIME: ...iij &
TIME:
1111111.kut!.OR
.g$ ID band visible/legible

./. 4 MIESEIMIIIIMM
Orient to environment pm
_

t-111.1110=M1411
Side rails (2/4) up
•
EDEMA_`NI NM
Bed position low
SENSATION
110

• Call light within reach
,--_MOTION En
`(.. , PASSIVE FLEXION

. i IIMMI Review & post lab results
• PERIPHERAL PULSE
NW
Notify MD abnormal labs
LEGEND

Color: P-pink (normal); C-cyanotic; W-pale, white
Incontinent urine/stool
Capillary Refill: 1-(O-2 secs); 2-(3-5 secs); 3-( 5 secs)
U Linen change pm

Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting Tum/reposition q2h

A:, Sensation: A-absent; N-numb; T-tingling; S-sensation (present) ROM q2h if immobile
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

R. Antiembolic hose
• D-doppler, P-palpable
BREAKFAST
LUNCH
DINNERTYPE: TYPE: TYPE:

I.
PERCENT CONSU D:
PERCENT CONSUMED: PERCENT CONSUMED:

E.
HOW TOLERATED: HOW TOLERATED:

HOW TOLERATED: F . ASSIST .
COMPLETE
. SELF . ASSIST 0 COMPLETE
. SELF . ASSIST . COMPLETE

0700-1500 1500-2300 2300-0700
F . COMPLETE . SELF_
BATH/ORAL CARE 0 COMPLETE . SELF_. COMPLETE ASSIST
.
TOTAL . ASSIST . TOTAL

. ASSIST 0 TOTAL
.
SELF BEDREST

. SELF BEDREST . SELF
AMBULATE

TYPE OF ACTIVITY . ASSIST AMBULATE . ASSIST
AMBULATE . ASSIST (Circle all that apply) BSC
I/ TIMES/SHIFT BSC
BRP TIMES/SHIFT BRPBRP I TIMES/SHIFT
CHAIR
CHAIR

CHAIR
TIME: \i/v()/ ).INITIALS: 111111 TIME:

INITIALS: TIME:

INITIALS:
CONTENT:_

CONTENT: CONTENT:
Dsa-

E
_ pa th

A
C
H &se:
N
ient/F,Iamily Verbalizes Understanding
.
Patient/Family Verbalizes Understanding
. Patient/Family Verbalizes Understanding

PATIENT IDENTIFICATION
0( (is -e SIGNATURE_ SHIFT
MEDCOM - 19131
DOD-032705

SECTION Itl - INTERVENTIONS & TEACHING (Cont)
M E LOCATION OF WOUND APPEARANCE Sr& viv)v-,62 tiv-tze TREATMENTS AND DRESSING CHANGE 'D3 KA

SECTION IV - NOTES
/frtx,_ek
M.5000M FORM 689-R (TEST) (MCI.
MEDCOM - 19132
Page 4 of 4 pages
DOD-032706

511-119
NSN 7540-00-634-4124

M EDICAL RECORD
VITAL SIGNS RECORD

HOSPITAL DAY
DAYPOST-
H-YEAR p 1.MONT DAY ct
0.2,5a3 HOUR 3-p •
PULSE (0) TEMP. F(.) ...... .. .. •:
105°
......
......
180 104° ......
170 103°
......
......
......
160 102°
......
......
......
150 101° ......
......
......
140 100° .....
......
......
130 99° •
98.6° 120 98° . r. • ...... ...... ..... • •
......
110 97°
100 96°
......
......
......
90 95° ......
80
......
......
......
70 ......
......
60 ......
50
......
......
40 ......

TEMP. C
40.6 ° 40.0° 39.4 ° 38.9° 38.3 °
37.8 °
37.2° 37.0°
36.7 °
36.1 °
35.6 ° °35.0
oa)
8
-cT3 5
o-
w -o
ai
m

RESPIRATION RECORD
-o BLOOD PRESSURE
a

-o
0
c

a HEIGHT: I WEIGHT --O.
.c
0
0
U
0
O
a

cc PATIEN 'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, middle; ID No
REGISTER NO
(SSN or other); hospital or medical facility)

C - VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, EIRMR (41 CFR) 201-9.202-1
MEDCOM - 19133

DOD-032707

•

Ward/Se:.)14......r REQUES I G.t.-LABORATORY RESULT FORM
LAST, FIRST,.MI. A= ( uz
...e Mate_4; ._ BC -.
RESULT . RANGE
109--03
:, 08 :51
Patient
Limits

4.5.10.5
17.i. AC.19.4 H.x10'3/uL.--7.-:BC 5.18 x10"6/t 4.00 6.00
1:4:Hgb 15.1 g/dL 11.0 18.0
60.0 -
;.•;; ..lict.47.4.X.35.0.
: MCV.91.5.ft.80.0.99.9
.="mai.29,1.pg.27.0.31.0

33.0 37.0
ef. .t1CHC 31.8L 910E
aC.P1t 205. x109/uL 150. 450.
4 -
51.1
:•,,'.:XYX 9.4 *L 2 20.5
",:-LY# 1.8 * 110"3/uL 1.2 3.4 Segs Mono
Bands Eos
Lymph Baso
Atyp Imm
RBC Morph
Spun 42
-
52%
04) Hem atocrit 3747% (F)
Sed Rate
Other
c!"..800131 !Oldie*
...
• .. -
TEST RESULT REF. RANGE
9.8-13.6 secs
PT 21-34 secs
AM
D dimer 20 ug/ml
FDP 10 ug/ml
REMARKS:
REPORTED BY:.-
Le i i
SuFect to the Privac - Act of 1974 ... •
-VII - -.:......
• - Unna is • ...:.• _Mise, Serology.•
RESULT RANGE TEST RESULT REF. BINGE
Color ,..:,,elimc, , N/A RPR Negative
App y ..1. y I N/A Mono Negative
Gin Negative - Wkrobiology

.. BEN Negative Source
-•
c-'
Ket Negative Gram -
/.46--
Stain SG /0.30. NA OCC Bid Negative
Bld 1-ra. L.Negative H. pylon Negative
,
pH N/A Micro CI 0 Parasites Prot Negative Malaria • /-1‘ Urob 0.2-1.0 0 & P
0..1--
Nit Negative Other/140-
Leuk ryes Negative :: MicroscopicU,rinalY6ls'
. -.
-
Negative
HCG 1(1.4c -o -3 c2tz,,I,,,,,e--4-1 . Cli 001 -.-,9-.7
(...ips.-.c -f
" • ••.• Blood.Bank.-
-• -.•...-•.••
Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Directigen Negative.j ABO/Rh
.
• - -.IPtitIllank.11nit. -Oroasistatch' :
.....
. (MOST SUBMIT SF 318.W1711 EVERY UNIT OE' BLOOD . '
. .• • .•._..•.......•
I'. : ;-.7 " -. • • , .: :- REQUESTED) !---: : .-• -' :-'• ,
UNIT TYPE CROSSALAITCH
...

DATE: LAB ID NO.: •.•. -5-'1 f--_, -••
: -
MEDCOM - 19134

Flit+
HySIC
C.a.AVIISTRY RESULT FORM
LAST, FIRST, MI. t4-
138-146 mmol/L
mmoVL•
98-109 mmol/L
7.31-7.45
35-45 mmHg (art) 41-51 nurila 110-105 mmHg (art) WA roil 2347 mmol/L (art)
24.29 nand& (rut)
22-26 mmol/L (art)23-21 mmol/L (veil 95-98%
(-2) - (+3) nuno//L 10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/d1
70-105 mg/di
0.7-1.5 mg/di
3E-51% PCV
12-17 g/d1
RERAANGE
REMARKS:,
bL (L)-
REPORTED BY: Sub'ect to the Privac Act of 1974
.
SSN/PSE
TEST RESULT
73-118 mg/11
PICCOLO ==7,T-zz-

15/09/03.za

08:48

REFERENCE Ri.

A li

_= PICCOLO ======:

PATIENT #: A-MALE 15/09/03.

D1u6-4

08:48

GENERAL CHEMIS1RY 12 REF ERE .

RA.

MALE

DISC LOT #:.PATIENT #:

3142AA4

OPER #:.METLYTE 8

DR #: 000

SERIAL # kuy-L. , DISC LOT #:.

3141AA4

OPER #:11111.

DR #: 000

7
ALB 3.3 3.3-5.5 G/DL SERIAL #44.u)-
ALP 49 26-84 U/L ........................

ALT.

83* 10-47.

U/L GLU 129* 73-118 MG/DL

AMY.E BUN.

98* 14-97.16 7

U/L 22.

MG/DL

AST.F CRE.­
77* 11

-38.

U/L 1 .2 0.6-1.2 MG/DL

TBIL 1.5.CK.

0.2-1.6 MG/DL 120 39-380.

U/L

BUN.NA+.

15 7-22.130.

MG/DL 128-145 MMOVL

CA++ 8.7.K+.

8.0-10.3 MG/DL 3.7 3.3-4.7 MMOVL

CHOL 179.CL-.

100-200 MG/LX.-104.

98-1080,E

CRE 1.2.

0.6-1.2 MG/DL tCO2 26 18-330,

GLU 137* 73­
118 MG/DL
TP 7.0.
G/ DL

6.4-8.1.INST GC: OK.

CHEM QC: OK

• HEM 0 , LIP 1+, ICT 0

INST QC: OK.

CHEM QC: OK
HEM 0 , LIP 0 , ICT 0

DATE:
LAB ID NO.:

9 —e 4=7 3
MEDCOM 19135
-
DOD-032709

REQUESTING PHYSICAN: LABORATORY RESULT FORM
Ward/Section: 1 _
(Subject to the Privacy Act,of 1974)
DATE TIME SSN/PEEUDO SSN:
Liiii01047 -
*M:

rur--tREP: RANGE
15-09-03 WE 18131 Patient
Limits
URC 16.2 H_x10"3/mL_4.5_10.5
RPC 5.09_Y.10"6/ 1E_4.00_6.00
Hgb 15.1_g/d1._11.0_18.0
Hct 46.8_35.0_60.0

91.9 fL 80.0 99.9
ITH 29.6

P9 27.0 31.0
HCHC 32.2L_gidL 33.0 37.0
Plt 207. x10"3/¢L 150. 450.
Lyz 10.4 *L z 20.5
Ly# 1 7 * x10A3/uL 51.1

1.2 3.4
Segs Mono
Bands Eos
Lymph Baso
A ty p Imm
RBC Morph
Spun
42-52%(M)Hem atocrit 37-47%(F)
Set Rate
Other
TEST RESULT REP: RANGE
PT 9.8-13.6 secs
APTT 21-34 SESS
D dimer 20 ug/ml
10 ug hnl
FDP
REMARKS: .
REPORTED BY:.all
nunl
TEST RESULT
Color
App
1
Bili
Ket
SG
Bld
pH

Prot Urob
Nit Leuk HCG
Cell Count
Directigen
UNIT

DATE:

goe
REF. RANGE TEST RESULT REF: RANGE
..
N/A Rl'R Negative
..

N/A Mono Negative
Negative
Negative_Source
Gram
Negative
Stain . Osl/A
Occ Bld Negative
.
Negative II. pylori Negative
.
N/A Micro

Parasites
Negative_Malaria
_
0.2-1.0 0 & 1'

Negative_Other
_
Negative
AfifitkittOteNforAtIl
Negative
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Negative_ABO/Rh
TYPE CROSSMATCH
LAB ID NO.:
MEDCOM -19136

DOD-032710

WaILSzt;13 ... RE
LAST, FIRST,
Una i wgyj
TEST RESULT 1REE RANGE
16-09-03I : 10: 04:59
1
Patient
Limits WBC 12.6 H x10"3/ut 4.5 10.5 RBC 4.86 xl0A6/ut 4.00 6.00 Hgb 14.1 g/dL 11.0 18.0
Hct 44.4
Z 35.0 60.0 I1CV 91.4
ft 80.0 99.9
27.0 31.0
11C8 29.1 fig.MDC 31.9 L g/dL 33.0 37.0 Pit 200. x10"3/uL 150. 450.
IA 15.5 *L X
20.5 51.1
LI 1.9 * x10"3/uL 1.2 3•4
Segs Mono

Bands Los
.

Lymph Ba so
.
A ty p Imm
RBC
Morph

Spun
42-52%(M)
Hematocrit 37-47%(F)

Set Rate
Other
TEST RESULT REF RANGE
PT 9.8-13.6 secs
APTT 21-34 SESS
D dimer 20 ug/ml
FDP 10 ug mu
REMARKS:
Ccc PV-C+ REPORTED BY:. LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)
TIME SSN/PEEUDO SSN:
PATE
D5-00 Urrnalysls 441$00r.:774''
TEST RESULT REF. RANGE TEST RESULT REF: RANGE
Color N/A . RPR Negative
.
App N/A Mono Negative

Glu Negative
Microbtoogy
Bili Negative. Source
Ket Negative Gram
Stain
.

SG N/A Occ 11Id Negative
.
Bid Negative pylori Negative
.
pH N/A Micro

Parasites
Prot Negative. Malaria
Urob 0.2-1.0 . O &P
Nit Negative. Other
Negative
Leuk . 400.4:00.ievoi#10itsimi HCG Negative
_AD ............................
Cell MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED
Directigen Negative ABO/Rh
UNIT TYPE
.YIS
DATE:° '.LAB ID NO.:
MEDCOM -19137
DOD-032711

Ward/Section: R Y SI CAN:
CHEMISTRY RESULT FORM

1.C-0•--) -a-b( C-c)-.-2.-to the Privacy Act of 1974)
I DATE TIME SSN/PEEUDO SSN:

LAST„, FIRS
\.i idcZ -L( •.
:*•, . . . .-

- • ° .W110):i114440.040::ggii01 PICCOLO - -- - . - - -
TEST RESULT REE RAJ 1 8/09/03 TEST RESULT REE RANGE
04 :57 E REF ERLNCE RANGE :
MALL di

Na 138-146 nm:.PAT CLU 73-118 mg/d1
i ENT #: -6 tc4)- (4
K 3.54.9 nom.ME ILY1E 8 BUN 7-22 mg/JI
DISC: LOT #: q.-

--\--3151AA1

CI 98-109 mm. c., 8.0-10.3 mg/d1
CA++
OPER #.

DR #:.

000

pH 7.31-7.45 0.6-1.2 mg/ill
SERIAL CRE
PCO2 35-45 mml . 128-145 mmol/d1
41-51 mml.
OLU 100
73-118 MG/DL

P02 80-105 mm ighll K+ 33-4.7 mmo1/1
N/A (yen) BUN 10 7-22.

MG/DL

23-27 rim(.CRE

T CO2 1 0.6-1.2 MO/DL Cr 98-108 mmo1/1
24-29 rome.dl
CK 112

HCO3 22-26 mum. 39-380 U/L ing/d1 (CO2 18-33 romo1/1
.23-28 mon.NA -f 132 128-145
IVOR _
SO2 95-98%.K+ 4,4 3,3_ 4.7 mmut L nighll ti .,11' gp,,16,440;,F ,40.61.:110.1:0; i''''
BEccf (-2) -(+3).CL-100 98-108 MOW /JI ----,”.PPP RANGE

Inniola,
tCO2

22 18-33 MMOilL ugh.ll -
AnGap 10-20 mm.
:-.-_-:::::::: .

Ca 1.12-1321.gidl.. PICCOLO.z.-.-. zzzzz.
I NST GC: OK -
CHEM OC: OK _
1 b/09/03

BUN 8-26 mg/ HEM 0 ,.04:57
LT 0 , ICT 1+ '
REFERENCE R•Wii.;.
MALE —
70-105 mg/d1

GLU TEST RESULT REF PATIENT #: IMIIIIIV
-(6,)- (-(
RANGE
L I VER PANEL PLUS
—

Creat 0.7-1.5 ing/d1 73-118 nighl DISC LO #:
GLU
3154M7
OPER # : _

Hct 38-51% PCV BUN 7-22 ing/d1 DR #: 000
SERIAL #: b ,.,,y

Hgb 12-17 g/dl CRE 0.6-1.2 ng/dl
........................

—

aa 1Sei'.--CK 39-3804(M.
,.z. . : ALB 3.3
30-190 /1 (F 3.3-5.5
G/DLALP

TEST RESULT REE RANGE NA+ 128-145 mir 49 26-84 U/L :'m
ALT
81* 10-47
U/L --..
3.3-4.7 mm AMY 63

Tro po in-1 14-97
U/L E
AST
58*
11-38
U/L

Drug of 98-108 mm.TBIL
CL-3.1*
0.2-1.6.

Abuse MG/DL
GOT 17
5-85
U/L I

tCO2 18-33 innu TP
6.5
6.4-8.1
G/DL .
INST OC: OK.
CHEM OC: OK 1
HEM 0 ,.0.
I
LIP ,.
ICT 1+

tCO2.I
I "------.I

REMARKS:
•.
_

REPORTED-BY: '
DATE: LAB ID NO.:
MEDCOM - 19138
LABORATORY RESULT FORM

LAST, F1RST,M1. (Subject to the Privacy Act of 1974) SSN/PEEUDO SSN:
TEST
RESULT

REE RANGE
RESULT

WI RESULT
• lomxib Color
1 7-09-03 RPR
Negative

05:01 Patient Negative
Negative
URC
9.3 * Limits
Hi x/0"3.41.
RFC
4.99 CS 10.5

x10'6411_ Negative Source
Hgb 14.5 4.00 6.00
11.0
N Hct 45.3 z 18.0
Negative

90.9 35.0 60,0 Gram
Stain
MI 29. py 80.0 99.9
OE 27.0 31.0

Occ BId Negative
32.0 1g/d1.
Pit 11.1. 33.0 37.0
Negative II. pylori
x10.43/11L
Negative
LYX 23.1 * Z 150. 450.
IA 2.2 20.5 51.1
Micro
x10"3/uL
1.2 14
Parasites
Segs PIA
Negative Malaria
Bands
0.2-1.0
Bast)
Negative Other
Let& Negative
roscop4c1V,iiti," I
RBC
Negative
Morph
Spun
42-52%(M)
Hematocrit
37-47 %(F)
Set Rate
Cell Count
Other
Directigen Negative
RESULT
9./1-13.6 secs
D dimer
I 0 ug inil
REPORTED BY:

DATE:
LAB ID NO.:
MEDCOM - 19139

DOD-032713

Ward/Section: I CU_) D.
LAE,
FIR.
.ii,-'
TEST
Na
K
pH
PCO2
P02 TCO2
HCO3
SO2
BEecf AnGap
Ca
BUN
GLU
Creat
Hct
Hgb
RESULT. -

',-( Le -q -
v
REF. RANGE
138-146 mmoUtIL
3.5-4.9 anmoUL
98-109 mmol/L
7.31-7.45
35-45 mmHg (art)
41-51 mmHg (ven) 80-105 mmllg (art) N/A (Yen)
23-27 mmol/L (art) 24-29 mmol/L (ven) 22-26 tnmol/L (art) 23-28 mmol/L (art) 95-98%
-(+3)
(-2)ol/L

mm 10-20 mmoUL 1.12-1.32 mmoUL 8-26 mg/t11
70-105 mg/d1
0.7-1.5 mg/d1
38-51% PCV
12-17 g1d1

L "„,..111.4',5.!tm ,:::.!. 'w , -.:
TEST RESULT REF RANGE
Tropoin-1
Drug of
Abuse
REMARKS: ,_ C 6C-9 LFT's
REPORTED BY:
REQUESTING PHYSICAN: CHEMISTRY RESULT FORM

3,_, ( (_, ) -2 (Subject to the Privacy Act of 1974) DATE TIME SSN/PEEUDO SSN:
11 & 051;) .itcoqq*wty., 1c010I-1+404iilie?anel -
TEST
ALB
Au
ALT
AMY
AST
TBIL
BUN
CA+
CHOL CRE
GLU
TP '_-'
TEST
GLU
BUN
CRE
CK
NA+
K+
Cc
tCO2
RESULT REF RANG E
3.5-5.5 011
26-84 u/I 10-47 u/I 14-97 u/I
11-38 u/I
11.2-1.6 ---
18-33 mmo1/1
==='': --_ s.,- ' .\
INC-
7/09/03
1 7• t 110 bL(. --L\ Nfijt13191:RY"CR.,c — -,--
, RANGE
REE KANGE
'''' .,cPLUS 31 5ANN (
P1\11CY t.. \
LIVER „ ._3.3-5.5 gill
LIVERPP"-„.e. 000_
26-84 u./1
DISC.°ill"_DR
1000)Aktb_oPEP,, m# . _1 ..r.7-t-
) . 10-47 u/1 '-'2:1::"A::;:g:`,' '::•_SERFr'L--_._• •_''_' . . C a-
RESULT .. . . . • ' ' ' 3.35 ...., 3 u/\......4-97 u/I
ALB 35.41 26-84 U/\--
7 68 u/L 38 u/I
ALP 10-47
4 7
7-i --‘ 55 1 A -9 UR--1.6 mg/dl AMY A3% 11 -38 1,46/01__
0.6- un
F81 0 :a-1 .6 on_ 39-3 IBIL 3 18 5-65 -/0\--I Will
30-1
' -e . A -1 °
128-1.GG1 6.8 ..9 ,
IP OK 3.3-1.7 at-14 °C. INGE
ICT
NS1 GC; C' p 0 1 4
LIP
98-108 i ‘-{EM 0 ' I -101/1
18-33 mn. VI
1
•

DATE: LAB ID NC

RESULT REF RANGE
73-118 mg/JI
GLU BUN 7-22 mg/dl 8.0-10.3 mg/t11
CA++
CRE 0.6-1.2 mg/dl 128-145 mmol/dI
NA+
- 3.3-4.7 mmol/1
98-108 mmo1/1
c-N_:- ---.--:-_7-
Cl

: n.c' 0

PI..

MEDCOM - 19140

Ward/Section: RE UESTING PHYSICAN: CHEMISTRY RESULT FORM
(Subject In the Privacy Act of 1974)

\LrD-
DATELTIME SSN/PEEUDO SSN:

(1.1001011!topoolpoopik,

TEST RESULT REF. RESULT REF. RANGE
18-09-03
RANGE

05:22 Patient il/dL ALB 3.5-5.5 g/d1 73-118 mg/d1
Ltd= Y10'3IuLL4.5 10.5 /L 26-84 u/1 7-22 mo/d1
ALP
RBC 521 x106/121.L4.00 6.00
MgtL15.5 9/dLL11.0 18.0 VI
Uct 47.8 35.0 60.0 -

r====== PICCOLO -------

P:
tL80.0 99.9

icy 91.8 ------. PICCOLO -------
( 18/09/03U

pi Til 29.8 P9L27.0 31.0 r05:36
05:17

18/09/03 .U

33.0 37.0 ;( REFERENCE RANGE:U
MN 32.4 L glcILLMALE
MALE

P1 Pit 211. 10WuL 150. 450. T(.REFERENCE RANGE:UPATIENT #: 1111111U
vc.-0)-

LYZ 24.0 20.5 51.1 PATIENT #: lirD(c46 -1A
LIVER PANEL PLUS

T Lq 2.2 i10.3/uLL1.2 3.4 • (
A4-LY11111NWL( BASIC METAB DISC LOT #:U

3154AA7

HCO3 22-26 mmol/L DISC LOT #: 1
OPER #111111 DR #: 0

23-28 Mrnol/L

OPER #:1111r1 DR #: 000 SERIAL

95-98%

SERIAL #:

BEccf
ALB 3.5 3.3-5.5 G/DL

GLU 94U73-118 MG/DL ALP 51

AnCap 10-20 mmoUL 26-81U
U/L

MG/DL

14 7-22U

Ca 1.12-1.32 mmol/. BUN ALT 58* 10-47U
U/L

8.0-10.3 MG/DL

CA+4 8.9U

AMY 58 14-97U

BUN 8-26 mg/d1 U/L
CRE 0.6-1.2 MG/DL

1.2UAST
26 11-38U

U/L

70-105 mg/d1 128-145 MMOI/L
NA+ 137UTBIL 3.3*

0.2-1.6 MG/DL

3.9 3.3-4.7 MMOVL

K+ GGT 20 5-65U

U/L

0.7-1.5 mg/d1 CL-103 98-108 MMOM. TP
7.4 6.4-8.1U

G/DL

tCO2 25 18-33 MMOVL

38-51 PCV
INST QC: OKU

CHEM QC: OK

12-17 g/d1
CHEM OC: OK

INST OC: OKUHEM 0U

Mg' LIP 0 , ICT 1+
2--

._k4t044-HEM 0 , LIP 0 , ICT 1+

NemmRgggmwmK::

TEST RESULT REF RANGE
Tropoin-I
Drug of Abuse
REMARKS:
_TT

REPORTED BY: DATE: LAB ID NO.:
MEDCOM -19141

RADIOLOG IC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(5) REQUESTED AGE SEX SSN (Sponsor) WARD/CLINIC REGISTER NO. FILM NO. PREGNANT
. (14 ./t IrN

CTLFA
YESLNO TELEPHON /PAGE NO.
–STOR DATE REQUESTED.
1C.T_T f-w3

SPECIFIC RE/kSON(S) FOR REQUEST (Complaints and findings)
,

I/Zf vim,. t,„euL0-ux,-tItp
• DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC REPORT
tie4 pra OrT &11°
PATIENT'S IDENTIFICATION (For typed or written entries give: LOCATION OFL-Name — last, first, middle, Medical Facility )
LOCATION OF RADIOLOGIC FACILITY

AID
SIGNATURE
RADIOLOGIC CONSULTATION STANDARD FORM 519-B (8-B3) REQUEST/REPORT
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8
3 RADIOLOGY
MEDCOM - 19142
DOD-032716

•
:,

7540--01-1 65-7294 RADIOLOGIC CONSULTATION REQUEST/REPORT
ARD/CLINIC REGISTER NO.

(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
(Sponsor) .,
AGE SEX SSN

:AMINATION(S) REQUESTED PREGNANT
L n Ci V
—
k..9-2.-1 D NO
FILM NO.L N'D YES TELEPHONE/PAGE NO.
REQUESTny (Pr•
Dc_c
DATE REQUESTED.
SIGNATURE OF REQU
(e-) 91 -
-

(Complaints and findings)
PECIFIC REASON(S) FOR REQUEST
Li-vert.
(Month, day, year)
DATE OF TRANSCRIPTION
(Month, daY, Year)

DATE OF EXAMINATION
RADIOLOGIC REPORT
0/14s, a

614L14(a

(1:\
1°1 111 — ez_
PATIENT'S IDENTIFICATION (Fo aci 'rt li yped or written entries pee: Name — last, first, middle, Medical Fty) LOCATION OF MEDICAL RECORDS LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
RADIOLOGIC CONSULTATION REQUEST/REPORT 1 — MEDICAL RECORD MEDCOM - 19143 STANDARD FORM 519-B (8-83) Prescribed by GSA/ICMR FPMR (41 CFR) 1 0 1-1 1.806-8

DOD-032717

RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AGE SEX WARD/CLIS
.40 OU3
FILM NO.

C¦X
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
1 1‘ v-e\r- a_c_.--ekroJi o‘r\
REGISTER NO.
PREGNANT
1-1 YES flNO
TELEPHONE/PAGE NO.
DATE REQUESTED.

DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOG ft REPO RT
PATIENT'S IDENTIFICATION (For typed or written entries gine: LOCATION OF MEDICAL RECORDS Name — last, first, middle, Medical Facility )
LOCATION OF RADIOLOGIC FACILITY
LI
SIGNATURE
RADIOLOGIC CONSULTATION STANDARD FORM 519-B (8-83) REQUEST/REPORT
Prescribed by GSA/ICMRFPMR (41 CFR) 101-11.806-8
1 — MEDICAL RECORD
MEDCOM - 19144
DOD-032718

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

• . i 3 0 cm) 40URS
SIGN
A
rt.dieza...1.4--
­
1171 (A)
,...
1,10-- 0D 13.tat./ 4' '

NURSING UNIT ROOM NO. BED
( t 4

PATIENT IDENTIFICATION DATE OF OR TIME OF ORDER
HOURS
i.
...___

`-) 1 V LA_ l 0 DZ C3— t,5 a
__ \_

-11A
/ /
/ .PC ' 3'
ycro I v i
T
c- t3 c. co
c,a c L / 'A.;

NURSING UNIT ROOM. D NO WV- 1 /Cele / 6
/J1
n 5 2- -6L/ VLt t-z_4

PATIENT IDENTIFICATION DAT OF ORDER TIM
, fl)
A
7(L
some
"Al _
V CF

NURSING UNIT ROOM NO. BED NO.
0 iIvamiEr4 im 1 1 1 1 FE ._ in ii
1 ,: cL. iate, , .Diral.I
"'"VAIrdi

PATIENT IDENTIFICATION • E OF ORDER TIME OF ORDER
!6 I 0?c9c). HOURS
p
1.h.. ..1
flir.
WfflairAilligairA1.11 I i I Si1 11WV
1111FAVIVIIIMFAIIIIMMIMp W
illi

NURSING UNIT ROOM NO. BED NO.
-Lr
b (L.-L

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 1 FAO4256
PR
M79
MEDCOM - 19145
DOD-032719

For tv.e of this form, see AK 4U-Wa, me proponent agency is via.,
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.
LIST TIME

Ii DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION ORDER NOTED AND
HOURS
30L
SIGN
V 4- IV A-6 `r
c- 1. F-1-5-

NURSING UNIT ROOM NO.
f,d,-;
DA E 0 ORDER TIME OF ORDER

PA TENT 'lb ENTIFICATION
\AutY-('
AJo

NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ORDER AY PATIENT IDENTIFICATION

HOURS

NURSING UNIT ROOM NO. BED NO.
DA E OF ORD R TIME OF ORDER

PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BE • NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1FAOPRIIM79
MEDCOM - 19146
DOD-032720

For use of this form, see AR 40-66, the proponent agency is U I W.,
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.
LIST TIME
DATE OF ORDER TIME OF ORDER

PATIENT IDENTIFICATION
ti ORDER NOTED AND
HOURS
240(ri SIGN

ROOM NO.NURSING UNIT P • TIEN DENTIF !CATION Art
ROOM NO.NURSING UNIT PATIENT IDENTIFICATION
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. BED NO. DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT DA 1 FAOPRRM79 ROOM NO. 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

MEDCOM - 19147
DOD-032721

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
the proponent acienc/ is the Office of The Surgeon General.

VERH:Y BY iNMALING I N 117 A 1_ P R 0 l' E I/ CO L U 114 N 1 7 0 I. L. 0 IF I N G E A C 11 A D M I N I STR A 7101V
DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS, HR DATE NURSE DOSE, FREQUENCY
/ /6 A
. l S ,ie J, ix o

aw

9-1c, , 4,1v ii.Disccihrl
l'-i5 Nip ........t... C 14 ' Tk , 1-. 13 Grn-t-Lmti Plij t\) ,
¦ k1:99.

-O. Coro S op pyo icy •
A

ALLERGIES: I J YES [ I NO PATIENT IDENTIFICATION: , C/ (1. DA FORM 4678, 1 FEB 79 PRIMARY DIAGNOSIS: 6 a•(36) 2t) / Ce /O c_ 7-7E6 ADDITIONAL PAGES IN USE: I I YES I. NO PAGE NO. DISPENSING TIMES ... __ USE PENCIL. CIRCLE MED TIMES (-\=)(uz--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. USAPA V1.00
MEDCOM - 19148
DOD-032722

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (iVIEDIC'ATIONS) Mo. Yn_

1

Order Clerk! Date to Tme to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
.
.

Order! Expir Date '11.5 —. -4: Clerk/ Nurse PRN MEDICATION, DOSE, FREQUENCY AA g-(49 I TVTV .„I 7.100 , , I INITIAL PROPER COLUMN FOLLOWING ADMINIS7 RADON TIME/DATE DISPENSED
I i glIV4
3_ L 1 .. Percoce-k 1-0p0 crat ....9
Oki' tartJ /1 fa
)
MEDCOM - 19149 USAPA V1.00
DOD-032723

2 Pc
-

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
CLINICAL RECORD For use of this form, see AR 40-407; Ma Yr_ 2003 the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING , INITIAL PROPER COLUMN FOLLOIVING EACH COMPLETION
HR DATE COMPLETED

ORDER CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME

i5 k Pw 9 45 C t-1) it--f--.. ---.2. _-------
p____)-------
(/ ,CH I
C
,

9--• 6 10 El 1111
-- - -4()1-a_k ara6c)(07 rt_.,
IIIIEIIIII

.-1- I IP ,_ Am _Ics3a ,... Nr¦Ic._,( 1 % 11,0•11111=1=1111ffir
El 1111•111=11V
a
• ,oi

-Iv 0#04•04
a 1
v J'

//
-.. , -WI

D 11W-

i L _ _ ir. L Mug 4
1111111•11 11111,11111M ---
gm,
Al

9-1L0 — -----La-0--N t ,,-5A Cfg' 00 Iti
ca. q -,_-D i. ..
-I-1 - --,_- -A b ! ..--A. -,,
• I 0..
E. r
id / ,

66 : •
._....
•

tO' ptu
K)

Z
/

;

1
1

V e SS-¦ rl ,

._ n
6-1-1

•

_.........! E.

IIMEINSF.

-1 •P ..

.
b q °

ALLERGIES: 11.1 YES all NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: NMI YES MI NO
Caeda I fillei )C(_ /
.21.7?", j
PAGE NO:

PATIENT IDENTIFICATION:
ACTION TIMES /:) \• • -, USE PENCIL. CIRCLE ACTION TIMES
C ( U 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
bCQ' - LI
EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

DA FORM 4677, 1 OCT 78
MEDCOM - 19150
DOD-032724

Verity by
Initialing
Order Clerk
Date Nurse

-1
cih
5III
9-6
.0-
CIIta I.
q-4
01-vi
4
, .
30s-
- - -—
Order/
Clerk/
Explr
Nurse
Date
J.:0_ 0
-
1“1 MO MO OS MS Imb WI
.¦ ¦•• .... ..... ..... ..¦ ..¦ ¦..
,.... ¦ ¦ .... .—.. ¦ .... ....
¦ ¦ ¦ ..¦ ¦ ¦.. ¦..

THERAPEUTIC DOCUMENTATION CARE PLAN
(NON-MEDICATION) mu_ y, 2003
SINGLE ACTIONS , pi At4A4'I 4--40 1--7- -P 60 id 0401 Date to be Done Time to be Done Time Done Initials 91S &o tic II
Ccii-DI ,ce c 0 Noo 43-vie . ,
Ce C 1 i-cs t pis i1y - i 4-AM q/69 WOO

, PO (7-0 W. /0( K- /0 -2(:17P '. (,,d ,, 6
0 -e0 TU3:- a /vol p(a u
I, yLu.,-.) ,Ale.a4 -V/6. 7-.3s
N C-'u\
...
7

-11-. JL)3 \iNd ts)c' 61C- Ca //N c C L 7--TS (2),-) - 0 ._...i-- _ WOO 3_
C . Lri% :iv. mow. ¦ 5S-.0--OL-10C) 0970
.....--

P(B-1 4: (111
I

IAA) IE.:. as rn ‘ , • i i% La,ta- 5 am GO OStO cytrt-, c Gc i z r--
-'.1-) .(-6-1,--q //cut 3 9/0. 0 c=i-
INITIAL PROPER COLUMN FOLLOWING COMPLETION
PRN

ACTION, FREQUENCY
TIME/DATE COMPLETED

Cull MO i f U 0 (vo cc .-CeA any coh_se cu-ii u-e/
*

USAPA V1.00
MEDCOM - 19151
DOD-032725

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
CLINICAL RECORD For use of this form, see AR 40-407;
Al. Yr. 2003

the proponent agency Is the Office of The Surgeon General .
VERIFY BY !NI TIALING ,--; , 'p " ''. .1-K-;,.'-."' INITIAL PROl'Elt COLUMN FOLL011'ING EACH COMPLETION
HR DATE COMPLETED

ORDER CLERK! RECURRING ACTION,
DATE NURSE FREQUENCY, TIME 2C

15 ct 21 22 23
1 k.....19 0,5
i L
IS

t`c3-,-, - 1111. -.G-,,V-,-Jc -,-, krIca_k3 D . E.--7_
N
11111-

, c-z{ko..-_. to
,,
^^ .

^_

1‘03c4D
HISS c -c-: 0,,__(-) 0 c,---2 ,4
^..

^,:

t,-
ru

lEirM rlt--, AnLP Pt) Lirk-/3 °
. - --

E tk- , (4, a__ PDP \ p(,__v4 aD ocl oLt
' J
0(8 eti
R. N 1(0
20

ALLERGIES: ME YES NE No PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
IIIII YES MI NO
t.pi- 6¦1_ ia_3': ¦ 4- C- PAGE NO*
PATIENT IDENTIFICATION:
ACTION TIMES
. _ ._ , USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
.._-- (Cc i E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

DA FORM 4677, 1 OCT 78
MEDCOM - 19152
DOD-032726

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN initraiing (NON-MEDICATION) Mo Yr 2003
Order Clerk Date to Time to SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
a
.4t '
. ,.
.,.%.

Order/ INITIAL PROPER COLUMN FOLLOI 'INC COMPLETION
Clerk/ PRN
Expir

Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
in
..0-U (nD Ct L1C)

(c)cisQco_ALL—c_ Q furs
— -- — — — --
USAPA V1.00
MEDCOM - 19153
DOD-032727