Medical Report: 36-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wounds to Chest, Groin and Torso

Medical records of a 36 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wound to chest, groin, torso and associated injuries. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.

Doc_type: 
Physical (non-death)
Doc_date: 
Friday, November 7, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

THERAPEUTIC DOCUMENTATION CARE LAN ( NON -MEDICATION )
CLINICAL RECORD
For use of this form, see AR 4R07: the proponent agency Is the Office of The SRgoon General. Ma 1 t yr:R2003
VERIFY BY INITIAIJNG
aNiMMAig*I% *' , ,40* INITIAL PROP.
COLUMN FOLLOWING EACH COMPLETION

ORDER CLERK! fRRECURRING ACTION, HR DATE COMPLETED
DATE NURSE FREQUENCY, TIME

iiiiiip


r. " .- - --0111 i 07-C\C\I di:R\(1C1 2" sCiS • -
op i-c) lov\ec 1e-z1,

ALLERGIES:1IM YES MN NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
-slp?asw Q.up‘sc— / 1 1-CIC3 MI YES111/ NO PAGE NO'
PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES li -1
D 81
9 10 11112113 14115 E116117 18 19120 21 22123 N124 01 02 03104 05 06107

mpnrcun _ 78441
mr,a-r."•• *,..0 • ...mi.,. •• ¦••,./ ro1e,r-r%
el. ¦ ••• 1,4
DOD-037019
THEfrAPEUTIC DOCUMENTATIO CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form,1AR 40-407;
the proponent agency Is the Office f The Surgeon General.
VERIFY BY INITIALING INITIAL OPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISP ENSE D
DATE NURSE ' DOSE, FREQUENCY

ORDER CLERK/ RECURRING MEDICATIONS,
7 13 15 kc7
=1_0.

-
Zvi
Ion

i\J (-4 I fl d RIdEMINILIMIMEr K
Val t(4 ,-) Pc-3
"tg°
Tie/r-t ND%

Nov m-,5 5 ringlara
Wan
ALLERGIES1 YES El NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: YES Q NO
PAGE NO

PATIENT IDENTIFICATION:
DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES D 7 819 10111112113114

111111111bit!

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.
DA 1 FAFIr/9 4678
MEDCOM -23442
DOD-037020
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo. Yr.
Order Date Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to be Given be Time to Given Time Given Initials

R/VD LO -e-l--------

Order/ Clerk/R PRN
Expir
NurseRMEDICATInN, DOSE, FREQUENCY
Date
lilliDe illRI
• Cl7biR523Rli 01-OA ° et,,,.R.Ntr-•iLtilitrk .
7ivot,-e.-rCCDCe41---.,1On

7\--k-k/ 1 l.
‘`' 017 1°3°
Ucl ° pn,1\3?,

-

5--------.)
_prtAJ 101cdpr) A Sb :,-,ky 0 (e 9-Pi"' f-) nel utS-e___
gen 12 1 '?c) 20 V 0 (Q H-P-4---i krtu'lq .nt,..._.
INItosef po .y 0.pi-,.1-....
11.
7
14tJa 1- ix) • lord Or-

x-54rally*:,
160 atAl
Q 4

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
-TIME/DATE DISPENSED

Adv v.,2) 61464-eti 14 ''' ittxt-plow ( trill atis* 1 psi 0 ' 0.4,
2")-3 3 !goo Vi3o 36 ' )0,4visS Zt3r) 06Lit 11 1414 12° . I -' a ,ec, -;
---(1.4" ! r
... _

M Nmsiii-,

--iWTW
04,r 1S511,K csuv
,
'U.S. GPO: 1998-454-110/95216

MEDCOM - 23443
DOD-037021
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-88; the proponent agency is the Office of The Surgvn General. REPORT TITLE TRAUMA FLOWSHEET OTSG APPROVED (Date)
The proponent is Dept of Surgery
QI Appr 11 Jun 97

TIM?
IV x . 02 R1 /min . C-Spine Immob

Meds:?. UKN?None?. Yes:
Allergies: . UKN one . Yes:
Tetanus: ji( UKN . Current Last Meal/Fluid Intake hrs
LMPI,
M c
PRIMARY SURVEY
AIRWAY-:
• •?. ".... CIRCULATION
(1Z4atural Patient 0 . Labored 'Jnlabored . Absent PULSE: 0 Present . Absent SKIN: yl(Warn . Cool . Hot
ETT TRACHEA: 9tidline . Deviated 0a BLEEDING: Pink . Pale . Cyanotic .
. Secretions CHEST SYMMETRY: 0a = HEART TONES: . Clear . Muffled Dry . Moist . Diaphoretic

SECONDARY SURVEY
DISABILITY
. AHEART
ABDOMEN

GCS: E PUPILSXLEqual a Fixed
. React . Dilated a RHYTHM: ,...ellegular .?
per-Soft . Rigid

. Non-Tender V TM:10-Clear . Blood
a
PULSES:?. Central?. Peripheral . Tender:
• ..

M NECK
LUNGS

PELVIS .. • C-Spine Tenderness:
SPHINCTER TONE: CI BREATH SOUNDO:Nat ;ig:Equal . Clear . Stable . Unstable 0
Ceis.U21. Pain @?
Decreased Absent
a a Blood at meatus/vagina:

. None JVD: Wheezes Crackles
CI a a Heme + / -Prostate: . WNL . Abnl
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN VASCULAR ASSESSMENT

IAB)rasion (AMPlutation (AVlulsion
Battle's Signs (BL)eeding
sO, 0
(B)urn 4.1 (D)eformity (E)cchymosis (F)oreign Body 0-0ematoma
0 1144

(LAC)eration (P)uncture (W)ound (Pain) (S)eatbeIt (S)ign (S)tab (W)ound (GSW) Gun Shot Wound
D Dopler

RN
PREPARED BY (Signature Continue on reverse
DEPARTMENT DATE
PATIENTS IDENTIFICATION (For typed or written entries give: Name--last, first,
middle; grade; date; hospital or medical facility)
.
HISTORY/PHYSICAL

. FLOW CHART
.
OTHER EXAMINATION

. OTHER (Specify)
OR EVALUATION
. DIAGNOSTIC STUDIES
t-7 TREATMENT

MEDCOM - 23444

DA ,1117A A
.

DOD-037022
VITAL SIGNS

Rectal Temp:
-1

tQc.. , (0 ‘ke cc, GCS: TIME BP1
HR RHY Ri#R
a0 l FIO 10:6E:

c-`)SL?
co 1 `&
C:)%0. `1Cl

1\J )'•RCO/

01\ \ 141 AP-03-11

vgx 103/
ocV,
1,20/,2 )27 NVa.
.,7
GLASGOW COMA SCALE
EBLE RESPONSE
CO- Spontaneous Oriented Obeys Commands

3 - To Voice 4 - Confused 5 - Localizes Pain

2- To Pain
3 - Inapp Words 4 - Withdraws to Pain

1 - None 2 - Incomp Speech 3 - Flexion to Pain

-None

2 - Extension to Pain 1 - None
OC,EDURI

PERFORMEIZBr'
0 Backboard Removed BY:
0 Downgraded
BY:
NOTES

.ABIEr
4041.1_0'-; .
Al

MEDCOM - 23445
DOD-037023

TDiIE 'PROCEDURE .,,DIEE ,,SITE. RESULTS
. .
0 Oral . ETCO2 Change
ET
0 Nasal . BBS Post Int Intubation Teeth 0 Post CXR 0 AirR0 Contents
Gastric . Oral
0 Verified
. Nasal
Tube Suction: YRN A Return (57,0 LI cc
Urinary
{Meatus
a Heme Dip: + -
n, . Supra-Public

) aop
• Secured CI Grossly: +?-
L
DPL LI Opened

ii&--D-—
Cell count
CI Closed

Sent@
Chest Tube #1 L R 0 Air 0 Blood 0 PleuravacRcm 0 Autotranstuser
Chest Tube #2 L R. .„ • 0 Air . Blood 0 PleuravacRcm 0 Autotransfuser
12 Lead Rhythm:R Comments

a siT 1 lCoi: 'RQ2zit111cch

2) -
LABS X-RAYS

,,,..

a
. D-stick R0 SHctRME Chest Initial
_r
-

. D-stickR0 SHctR, 0 Chest Post ET -\... CBCRCZhemREl=1‹topTT . Chest Post CT
. ETOH KtiS1"45C&C x1\, ali. C -Spine

,,,\
4....7
0 Tox Screen nal Pelvis 1 4JAR0 HCG
Mlle \
r , A „;5,,,

-COTNERRi) \. () 1.•RiN\ lA.,

TRAUMA TEAM AF, RIVAL
7IyLEA mESI11046ED 'f'4K W
E D Phys
S urgeon
.nesth
X-Ray
RT
Ortho
Neuro
Chaplain
-MEDCOM
.

.?.?.
_ COOOPMED RY
,i ROCEDUREz, , '-RN
-..-...,.
-
CT Scan Xtontrast C)CIA
1,7.ReadRgAbdRVelvis
0 C-SpineR. T/L Spine tl(hest

0
A-Gram Site:

IV ACCESS & FLUIDS

TIME l?GA •i. I¦1!,
) N
Y N
Y N

MEDICATIONS
'

,,..iyiecile4I1Olt . DOSE f-,RTE TIIN1DOSE 4
Ew -,,
0

a.
..R

1...... , 11
AMMINEEINE

11,715M7MMINIIIII
MEM

BLOOD PRODUCTS
nirifil

VALUABLES & CLOTHING
..,eM

F ,I
N'.
''''
None Found
Given to Patient .., Given to Family
Inventoried and Released to Patient Trust FundINCOD See DA Form 3696
Other: See Nursing Notes
DISPOSITION

0 Home .
Admitted to \!) (?- Z....
Report Called to
Time Transferred

td By

23446
— ....?.?.?.

DOD-037024
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
lot use 01 this form. see AR 40.66: the proponent agency is the Office of the Surgeon General.
REPORT TITLER
Post-Anesthesia Care Unit (PACU) Flow Sheet

Date:R—1 PO %) Anesthesia Type (Circle)): RSpinal Epidural Time In:R(").3 C55 IV Sedation Nerve Block Allergies:R13 E—DP1ROR Intake: CrystalloidR2300RColloid....R•
Pre-op V/S:120All1°MR,—1OR Output: UOP1EBL 50
Procedures: .a.rt:1612Arreol 0 (PrahMeds/Times: ficen±)cfezt2. R6 t • Pt-Lad fax.2.44417'onire i6Wr
OTSG APPROVED aid
Drains Airway Hemovac Nasal
• NG Oral JP
T-tube Trach of Other

turtiN Fi02 lig

WHEERIVAS
411111
4

Methods
33%vli

240
220 • X-rays:1 . Labs:
Post-Anesthesia Recovery, score

• 200 Criteria ADM 30' D/C Codes
Activity
AIRWAY

(2) Moves 4 Extremities
A= Ambu

(1) Moves 2 Extremities
180
(0) Moves 0 Extremities BB= Blow-by
M =Mask Airway
160 FT = Face
(2) Cough, Deep breath Tent
crc

(1) Dyspnea. limited breathing
' RA =RoomAlr
(0) Apnea
V
v ir
PhO

140
V NC= Nasal
V

Blood Pressure
Cannula

V (2) SBP =/- 20 of Pre-op
V
F0­

120 (1) SBP 4-29-50 of Pre-op
V

V/S V v X =A-line BP
(0) SBP =/- 50 of Pre-op
Consaousness
100 * . =Cuff BP
01M

lly Awake audible
(2) Fu

Pre Op Meds History TLS
ci
..0 .....
.0
°

E

Time
Pacu Intake
E
.1
El ig co gni
1.
r
..
.

Tin Solution Amount Site • By 'Infuted
Sa02
•¦¦•¦•••¦•••
Pulse

=
dying
.

(1) Arousable to verbal or pain
a 6 •
A

80 A ii
• A A A
TEMP
S = Skin
Color

121 Baseline color & appearance
0 =Oral
A

(1) pale. mottled. jaundiced
A
A = Axilla

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

(1)
Axillary palpable, not radial

LOS1-

I
(0) Carotid only reliable pulse
20
C = Cervical TOTALS: Must be 9 or
T -Thoracic greater to D/C. otherwise
L = Lumbar

RR needs anesthesia approval for

HINNBIllpffliqfflInallin
s=sacral

T 77, mc.
Time Patten teaching done; Wound Ca e. Pain Management,
Pain (0-10) T. C. 8 DB.. Incentive Spirometer, Comfort Measures
LOS Safely: SR up X 2, Falls Precautions. Privacy Maintained

on ewe ao reverse

DEPARTMENTISERVICKUNIC DATE
b(0-

GT11 0 -7 pov c)
Mitten entnes give: Name — last. lest, middle; grade; date; hospital or medical tackle
.
HISTORY/PHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER ormari

OR EVALUATION

.
DIAGNOSTIC STUDIES

ikt) -
111111
. TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
MARC 62.00
MEDCOM - 23447

DOD-037025
MEDICATIONS

NURSING NOTES
Allergies: Time Pain Medication & Route Pain I/E By
1.10 Dosane 1-10 OS&D -oau6, o ctufu9;19
• .1 -1
•1'
12et 01?C-ict/ i t km ,(31 q i 5 p-\-R
drituku3vi2
(11690INA-0 MCA/

NEUROVASCULAR
Time Site Range Sensory P Cap T C
Of Refill

LI lb -?brao.A1,1A fin yv olooce_a
Motion

Adm .cto r?tkipin
. 2

36.......,

15; A_op. ccuak d
0'
45'
du-bp pket +c) -75% . P-€

60' p 90' tin ek c 12- L 0z.. Th-AA . anza
D o2' rk¦...oz. n.1
Movement/Sensation: + = present,- = absent Temp:C = C• • W =Warm Pulses: P = Palpable, D =Doppler, A= A Tkr) bo% Color: C= Cyanotic, Capillary Refill: B= Brisk, S= Sluggish 1P= Pale, Pk = Pink
0ukf ?pf c­
32Apoiteive, -b v9/006-0

.;1CTIONS Adm 15' 30' 45' 60' 90' D/C t-r) / ID titc-h . S 11-v\pov; f\S Fund. Height
firrike (A)
Lochia
P1d#
SS

und. Cond.
DRESSINGS
Time Location Type Drainage

Adm k_OIVV in kl.A6-1) 25/ °
.1/1,

30' kiodicra;r1 t ti,oPaboittn he,;11A
1.

60' KDOCUT0`^ tc 70_1(11R_ [Chi
PACU OUTPUT

Time Source Color/Appearance Amount Discharge Criteria:
Dater-1 /00‘) Time:RPARS:
Bp:135/77 T:RHR: 92... RR: i ZRSaO2: qv,
Pain Level at D/C (0-10):

Intake: kDC0 Output: ZOO Additional Data:R CARDIAC RHYTHM
Transferred To: let's,/ 2_
Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To:
1) Lib° Transferred Via: W. Ambulance
Transferred By:
Cleared IAW Recove
Charge Nurse Signatu

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this term. see AR 40.66; the proponent agency is the Office of The Suntan General.
OTSG APPROVED /Due)REPORT TITLE?

Post-Anesthesia Care Unit (PACU) Flow Sheet

Date:?t1)00;? Anesthesia Type (Circle)at)• pinal Epidural Drains Airway
Time In:?i?Ns? Iv?• - lon Nerve Block Hemovac Nasal
Allergies:?NOVI .OR Intake: Crystalloid 9,(N)0?Colloid. ... • NG Oral
Pre-op V/S: lq.1/u2-?101.OR Output: UOP?350 EBL?SO CE) ETT
Procedures:?1 1,4?nal:11'1-1g?Meds/Times: 500.-1 Pit.-1-?• T-tube Tra
1C15h ou..4'?le-1-1-?lel?. We:L/03A?3vni IC :cajt,tin 4.-levee Foley her
Pre Op Meds Time 4 .--.... ,.-, -, to -- cl -.... ,•-3' --. Histor Pacu Intake TLS
Sa02 19 e g ,... ,f). .. Tin Solution Amount ile • By Infused
Fi02
Methods IA Ars tirok Itly
240

220 X-rays:? . Labs:
Post-Anesthesia Recovery_score

Criteria ADM 30• D/C Codes200
Activit
AIRWAY

(2) Moves 4 Exlremities
A =Ambu

(1)
Moves 2 Extremities

(0)
Moves 0 Extremities BB = Blow-by

180
M. Mask
Ainvay
FT = Face160

(2) Cough, Deep breath
Tent

(1) DY 1tinkled breathing
(0) Apnea RA= RoomAir 140
V NC = Nasal VI Blood Pressine
Cannula
V

\/ (2) SOP =/- 20 of Pre-op 120 (1) SBP =/- 20-50 of Pre-op
V/S •
(0) SE ?=/- 5Ciof Pre-op
X = A-line BP Consciousness
100 ' =Cuff BP
• (2) Fully Awake. audible
..¦¦......'
¦¦¦
.....
crYilvg

(1) Alousable to verbal or pain
80 e\ A
= Pulse
TEMP

60 A I\ A Color 12) Baseline color A appearance (1) pale, mottled, jaundiced (0) Cyanotic S = Skin 0 = Oral A = Axillary
T =Tympanic
40 Circulation (Pads 5 Years) (2) radial Pulse Palpable R = Rectal
20 (1) Naar/ palpable. not radial (0) Carotid only reliable pulse LOS C = Cervical
TOTALS: Must be 9 or T = Thoracic
RR T l' ialit lb greater to D/C. otherwise needs anesthesia approval for D/C, L =Lumbar S= Sacral
Time Patient teaching done; Wound Care. Pain Management,
Pain (0-10) T. C, & DB.. Incentive Spirometer, Comfort Measures
LOS _____ Safety' SR up X 2, Falls Precautions. Privacy Maintained
Ilonnnue on reverse)
DEPARTMENTISERVICEICLINIC DATE
bL(/ -/ PA CU 0? Nov 03

PAT Or yp.or WI7 Name.—last, first. middle: grade: date; hospital or medkal teary!
HISTORYIPHYSICAL? • FLOW CHART
.
. OTHER EXAMINATION?¦ OTHER amde OR EVALUATION
DIAGNOSTIC STUDIES
.

0 ?J ?(j1?

5 TREATMENT ??
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) I Apr 01 (MCXC-ON) Previous edition is obtolete
irSAPPC 67.00
MEDCOM - 23449
DOD-037027
MEDICATIONS

NURSING NOTES
Allergies:
Time Pain Medication 8 Route Pain I/E
1-10 Dnsane 1-10 recevele.

(Ye. 5/.itAk

12-2.D an A-46614 1U
+VI?e ,roi•r, . k-4 Vz 99

.g3tP aon oiti_ak ft/
010 poi n.er\c3 AkSO4 ka-3ce r94--
l!-4L t nv) K61)/1 l)
NEUROVASCULAR

Time Site Range Sensory P Cap T Color
01 Refill
Motion
Adm 15' 12.1 er, e( —t--P —I---.1 (-1 y2 13 \/`-) Vi p v., ft c-
30' --k. --k P 6 v./ pIC_
45' ...
60'
90'
D/CRMrR-1- -V f 105 W W

movemenuseaation: + = present.-= absent Temp:C = Cool, W=VVarrn Pulses: P= Palpable, D =Doppler, A =Absent Color: C= Cyanotic, Capillary Refill: B =Brisk, S = S uggishR
P= Pale, Pk = Pink
C-SECTIONS Adm 15' 45'

30" 90' D/C Fund. Height
Lochia
---------' Peripad#
Fuotleelrid.
DRESSINGS Time Location Type Drainage
I , +.

Adm1r -4 1 k_ • D
30'1At AMU= illillinlillIIII
il1

D/C
, I 111 '4 '

60' Mill
PACU OUTPUT Time Source Color1earance Amount
CARDIAC RHYTHM Time Rhythm
Symptomatic? Rhythm Strip Run?
N se_ O

WAMC OP 173-E
Discharge Criteria:
Date: cgt,sev Time: rd-t-RD PARS:1
BP:131 -70kT:i(Yllf 11R: C 'c) RR: I Sa02: Pain Level at DIC (0-10): -­Intake:1
Output: Additional Data:1 Transferred To:1C Report Given To: Transferred Via: W Transferred By: Cleared IAW Recov1oom Charge Nurse Signature:
MEDCOM - 23450
."ram.mme./Imya.¦8•4••¦•¦

DOD-037028
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet
7

Date: 15 iq k`f 0.5 Anesthesia Type (Circle)) {gene Spinal Epidural LI-{_A, Time In:11.)
1V-Sedation Nerve Block Allergies: OR Intake: Crystalloid Colloid Pre-op V/S: Immo OR Output: UOP E
Procedures: Meds/Times:
Imviip um ,
Pre Op Meds Histor
,C)
Time Sa02 F102 Methods 240 220 200 180 160 140 120 100 80 •
60
40 20
ci
RR Nit
T

Time
Pain 0-10
LOS

119
lien entries give:. , m • de: grade: date; hospital or medical leafy)
Pacu Intake

Time1Solu on1A cunt Site By _
X-rays:
Criteria Activity
(2)
Moves 4 Extremities Moves 2 Extremities

(0)
Moves 0 Extremities

Airway

(2)
Cough, Deep breath

fiamintAramr— "sr ,
Labs: Post-Anesthesia Recovery score
ADM130'

(1)Dyspnea. limited breathing
(0) Apnea
Blood Pressure
(2)
SBP =1- 20 of Pre-op

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

(0) SBP =1-50 of Pre-op
Consciousness
(2)
Fully Awake, audible

crying

(1)
Arousable to verbal or pain

Color
(2) Baseline color & appearance
(1)
pale, mottled, jaundiced

(0)
Cyanotic

Circulation (Peds 5 Years)

(2)
radial Pulse Palpable

(1)
Axillary palpable, not radial

(0)
Carotid only reliable pulse

TOTALS: Must be 9 or
greater to DIC. otherwise
needs anesthesia approval for
0/C.

Patient teaching done; Wound Care, Pain Management,
T. C. & DEL. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained
DEPARENTISERVICE/CLINIC

Name —last,
.
HISTORYIPHTSICAL

.
OTHER EXAMINATION OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

Drains/ Airway Hem9,/ac Nasal pG. JP-T-t Trach Foley
Other TLS
DIC Codes
AIRWAY A = Ambu BB = Blow-by M — Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula
VIS

X = A-line BP = Cuff BP = Pulse
TEMP S = Skin 0= Oral A =Axillary T =Tympanic R =Rectal
LOS C = Cervical T = Thoracic L = Lumbar S = Sacral
1L0nrirtUe an MOW)
DATE
. FLOW CHART
. OTHER /Away/

2
Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication & Route P.' PIE By
1-10 Onsaae 1-10

z

NEUROVASCULAR

Time Site Range Sensory P Cap T Color
Of Refill
Adm 15' -Motion wr riumilwas 21111.MNIIIIIIr
30'
45'
60'
90'
D/C

Movement/Sensation: + =present,- = absent Temp:C = Cool, W =Warm Pulses: P = Palpable, D= Doppler, A = Absent Color: C= Cyanotic, Capillary Refill: B= Brisk, S=S uggish 1P= Pale, Pk = Pink
C-SECTIONS1 _...-------.

Adm 15' 30' 45' 90' D/C Fund. Height Lochia
Fund.1d.
DRESSINGS
-1L•1. tion Drainage

Time Rr.
I,1
I1 ,,_
.

Adm
r

30' 60'
PACU OUTPUT

Time Source Color/A earance mount
,_...- CARDIAC RHYTHM
Thile Rh thm S mptomatic? Rh thm Strip Run?
;DID

MEDCOM

WAMC OP 173-E
Discharge prq Date:(--,7u PARS: BP: it-4T: `it RR: /1Sa02:ioa Pain Le er it D C 10-101: Intake:1 Output Additional Data:1 Transferred To: (,l) Report Given To. Transferred Transferred By: Cleared IAW Rec Signatur
-

23452
DOD-037030

)
Reporting MTF 2. MTF Location Admission and ..04D-Aing Information
; Register Number 4 IL Name (Last, First, MI) For use of this form, see AK 4U-4uu; me proponent agency is u i ou 4. Pay Grade 5. Sex

F GN M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
1968-06-01 35Y X
_ ... 9 .? .
[10. Length of Service ETS 11. FMP 12. Social Security Number
- Li
L . . ..
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
01:00
14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS
20. Source of Admission? . Ward:
Direct from ER ICW 1
N . .ie and Location of Medical Treatment Facility: ?1 b (1 t
21. Type of Disposition? 22. MTF Transferred To
TRF-OTH

24. Clinic Svc - Admitting 25. MTF Transferred From GG - FP ORTHOPEDICS
27. Location of Occurrence 28. MTF of Initial Admission
FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: S/P GSW L GROIN R LEG
Procedure Narrative(s):
Cause of Injury Narrative:
19. Trauma Prey. Admission
DIS NO

-

Name / Relationship of Emergency Addressee?
Address of Emergency Addressee
Telephone Number of Emergency Addressee
23. Date of Disposition (YYYYMMDD)
2003-11-18

26. Date this Admission (YYYYMMDD)
2003-11-07

29. Date of Initial Admission
2003-11-07

g7V, 1---se, 5' is4
0
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MEDCOM - 23453
DOD-037031
rt."LJC11
5.1SEX

I I
9 10 11 I 12 13 I 14 r
16R17R
/ •

6. DATE OF BIRTH (Y Y Y YMMD D)
7. AGE AT ADMISSIONR8. RACE 9. ETHNICR
RELIGION
19R20 21R22R23R24R27R

25 26R28 29 30
31 BACK­GROUND

10.
LENGTH OF SERVICERETS

11. FIMP

12.
SOCIAL SECURITY NUMBER
32 34

MEND 40 enzuramamm
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS •
HOUR OF
BRANCH / CORPS ADMISSION .
46 I

14.
FLYING STATUSR

15. BENEFICIARY CATEGORY

16.
ZIP CODE OF RESIDENCE
47R48 ' I • 49 50

ENO 5.3 154 I 55 I 56R
57R58 I 59 60
61

17. UNIT LOCATION (State or.18. MOS
19. TRAUMA
PREY. ADMISSION
62R63.

R Country Code)
64 65 66 67R68 69 70 71 YEAR NO
20. SOURCE OF ADMISSION/ AUTHORITY FORR
WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
1 ADMISSION

72R
ADDRESS OF EMERGENCY ADDRESSEE

(Include ZIP Code)


NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO
23. DATE OF DISPOSITION (Y YMMDD)
_ • - -•?••_ -•
EN11111311121011311

24... CLINIC SVC -ADMITTING
25. MTF TRANSFERRED FROMR
26. DATE THIS ADMISSION (Y Y MAID D)
87 90 91 " 92R93R94R95R96

97R98R
99 100 .101 102

27.
LOCATION OF OCCURRENCE

28. MTF OF INITIAL ADMISSION

29.
DATE INITIAL.ADMISSION • (YYMMDD)103 104

(Battle Casualty Only)
OR LOCAL USE
DMITTING OFFICER (Sign ure, as required)
SIGNATURE OF ADMITTING CLERK
703

A FORM 2985, MAR 89
EDITION OF MAY 79"IS OBSOLETE
USAPPCV1.00

r-t-ttiol c"-)
1

MEDCOM - 23454
DOD-037032
0
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM

0

YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
Ofense against CiviIin(s) [check one] Ff "Other" then de&cribo

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Date of Report: (D/M/Y)?Time of Report: hrs/?/?
Place of Birth:
Ethnaribe/ Sex: Sect:
J weapon Photo Taken of Suspect with Weapon/Contraband: Yes/ No
riProperty/Contraband
Color/Caliber

Type: [Model:
Receipt Provided to Owner: Yes/ No

Serial No.: Quantity: Make:
Owner

Other Details:?\o, -1rWhere Found:
DOD-037033
Automated Facsimile
I. ATIENT TREATMENT RECORD-- ,vCR SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr ' 2. Name 3. Grade
Admission Remarks
FGN

4. Sex 5. Age 6. Race 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
M 24Y X
11. FMP 12. SSN 3. Organization
6 ( (-L\ - (4

15. FlyStatus 17. Dept / Ben 18. BranchCorps
K78-PRISONER OF WAR/INTER

21. Source of Admission 22. Hour Of Adm: Direct from ER 03:00
24. Name/Relation of Emergency Addressee 25. Type Disp
TRF-OTH 27a. Address of Emergency Addressee 27b. Telephone No
29. Re ( 't_ - Z
31. Selected Administrative Data
Marital Status: DoB: 1979-01-01 In/Out Patient: Inpatient MOS:
33.
Cause Of Injury:

34.
Diagnosis / Operations and-Special-Procedures:_

_____.. ----.........,,,,,N

S/P VD R IF DPC OPEN MC FX VD BL LE
„,-

/2 -OD V.1 ..___L., / of 9 1
01-616., 6,2F.
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8)6
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35. Total Days This Facility._ Absent Sick bays Other Days
0
35. Total Days This Facility
/
,'6/'
.

ConLv / Coop Care Days Supplemental Care
0
Lt-7

Absent?'ck Days Other Days?ConLv / Coop Ca?a s Supplemental'Care
. ¦• ..4
Signature of Atte i
Automated Facsimile - DA FORM 3647, May 79 MEDCOM -NO

14. Ward ICW1
19. UIC / ZIP 20. Type Cas. DIS
23. Clinic Service AEA - ORTHOPEDICS
26. Date of Disp 2003-11-13
28. Date This Adm: . in Officer: 2003-11-08
\Th M -1-
30. Date Ink Adm 32. Units Blood Com onents
P 2003-11-08
2 / _S--, / 0 qIci. i
E9 9 1
g-3.Sy 9
g ca. s--
I
Bed Days Total Sick Days
6.I 0 .
Bed Days?Total Sick Days
. .

DOD-037034
ABBREVIATED MEDICAL RECORD
MEDICAL RECORD
.. ,ionJ

ft, •bitc.
-PERTINENT HISTORY. CHIEF CONFLAINT. ANO CONDITION ON }OMISSION (
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PirlYSICAL EXAMINATION
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ABBRE'HATED MEDICAL RECORD
Standard. For= 339
AND OE .RAL SER'/;CES?
:NTEPAGENCY DC,mmITTES ON A_-LICA(.
F.E,,CSDS
DF--1) CC:C.3,7A I375

MEDCOM - 23457
DOD-037035
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; I REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES

2-- Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10
USAPA V1.00
MEDCOM - 23458
DOD-037036
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
.1'
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COM - 23459
DOD-037037
b10 -7
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AUTHORIZED FOR LOCAL REPRODUCTIOt
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; .I REGISTER NO. _D NO.
WAR
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(b)(10 USAPA V1.00
111111V-

MEI - 23460

DOD-037038

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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DCOM -23461
DOD-037039
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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Medical Record

STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101 -11.203(b)(10
USAPA V1.0C
MEDCOM - 23462
gilli
DOD-037040

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES •
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PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999: Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)110:
USAPA V1.00
MEDCOM - 23463

DOD-037041

AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
1,
(1\110-0 03 wif\c) o .f o-c-6

P,,,1‘),, -ht,
wit-h

D B•L--E ?
_ AN ...A-ika_ OW

t ,-2-,c-4094.g ,...1_, ON„------A6 (4)c --z_.ft--v(
-----riftr-1Cbt&---"Q1

PI -{v--( PLA,12_ ._ t-t-?Cars.
Iv AP (.i.ite tir_ Aisci,f,t.i„,,ze,,_ ci_ To _.-.2-X6),
HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE
RECORDS MAINTAINED AT

SPONSOR'S NAME
SN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; REGISTER NO. WARD NO.
I
Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 6001REv. 8-971 Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1

MEDCOM - 23464
DOD-037042
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD

FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
1. AGE Z9 . NKDA RPCN 5 REACTION: . LATEX . IODINE . TAPE 0 FOOD
HEIGHT:
WEIGHT: 3. PREVIOUS SURGERY y NO [ YES (type):

4.
PROPOSED SURGICAL PROCEDURE: 14-r) kowsol

5.
ADDITIONAL INFORMATION: (Previous surgical and medical story) Skin Condition zetiwci,'\ 1-1- lAicrs^"^c-A

Tobacco ppd X_vrs Body Piersirgi Diabetes (Y) ( ROM 41 EMve`^^,N5ASA/Motrin W 72hrs (Y)(j ETOH ?Implants ?Respiratory Disease (ASthma COPD) (Y) lel Anticoagulants (Y) Glasses/Contact (Y) (N)?Dentures ?Hypertension (Y) 11?Herbal Medicines (Y N) ?MEDS:
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
A. PSYCHOSOCIAL . Allow pt. to verbalize freely. Pt. verbalizes any specific anxiety.
--- potential for anxiety related .?Explain Or environment and answer Pt. Exhibits relaxed body posture.
to: estions regarding surgery.
..----?1) Surgical Procedure& . Offer comfort measures. (e.g. warm Operating Room Environment anket. touch).
2) Separation Anxiety ! .?Explain all nursing procedures before
-‘ , ..t..-------,

(Cy)!
t ey are done.

q)?. i?I(3) Surgical Outcomes – .;. ‘ ,..A.--0.82 ,....."4-v-..e,v . Remain with pt. VVherrver possible.
0. Maintainifarnily interfAe. Parents to
stay with pt.

_.-0—Pt. will be able to breath without
B. AERATION .?Offer to elevate head of litter or offer
----- Potential for respiratory difficulty during immediate intraoperative illow. dysfunction due to: . Observe pt. While awaiting surgery for
....-- phase.

1)?Positioning •gns of distress.
,"--- 2)?Effects of Anesthesia .?Assist anesthesia during intubatior 3) Medical/Smoking_History d extubation. 1.
-,/
C. INTEGUMENT 9-Pt. will exhibit signs of impairment of .?Utilize pressure preventing devices skin integrity (e.g., reddened areas).
Potential Impairment of Skin OR table and accessories. Integrity due to: .?Check for proper positioning and
----?1)?IntraoperativeL-nrnotility upped to maintain good body alignment.
----. 2) ESU Pad Placement .?Pad pressure points.
3) Positional Aids .?Place ESU ground pad on non
4) ProstheSiS mpromised skin surface area.
----"-5) Pooling_gf Prep Solutions Keep prep fluids form pooling.
9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
Ina C-57)
?MEDCOM -23465
DA FORM 5179. JUN 91 F I CVIUUJ CUILIOI i aic UUJIJIGIC.
VERIFICATIONS AT HOLDING AREA:
ID/Allergy

ID/y Band?../ Dentures Rertil6ved
H&P ! Contacts moved
NPO Since I Jewel Removed
-E4-1.GGM14172, ! Bo Pierce Removed

Consent/Blood Transfusion Signed/Witnessed/Dated Surgical Site/Consent verified by Pt./Anesthesia/Surgeon Contact precautions (Y)piK . Family/Friend: ps'..
USAPA v1.0

DOD-037043
6. PATIENT PROBLEMS AND NEEDS
Potential for inadequate tissue perfusion due to:
Intraoperative Mobility 2) Positioning • 45)) 5HaypthfeotyDeremvi
aCes
E. NEUROMUSCULAR CONTROL Potential Impairment of
Mobility due to: 1) Pain 2) Intra operative Hazzards
4) Positioning ---"" 5) Transfer pt. To/form OR table
E.2. --- Potential Discomfort Due to: 1) Length of Surgery 2) Positioning 3) Arthritis
F. Special Senses
F.I. Diminished visual perception due to being:
1) pre-medicated W 0 GLASSES
F.2. -----Potential for Decreased
Communication due to: 1) Diminished Hearing 2) Language Barrier
F.3. Potential Injury due to
Dentures:
1) Upper 4) Caps
2) Lower 5) Crowns
3) Bridges

G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
will exhibit signs of adequate tissue ----perfusion (e.g. color, warmth. pedal pulse.
CI pt. will be transferred to OR table without
gifficultly.

0 pt. will be not experience unnecessary physical discomfort.
I
pt. will be made aware of surroundings p for to anesthesia induction. pt. will be transferred safely to OR table. pt. will be able to understand instructions. Minimize danger of injury during intraop
riod.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS O Check foe support stocking or ace warps. if none, check with doctors. --45—Cfieck that safety straps are
correctly applied.
O Offer pillow for under knees.
O Place and take down legs from

stirrups with slow bilateral motion. r0' Check that rings and all body piercing has been removed.
01 Have sufficient people available for
trtmsfer.
0 Insure proper body alignment.
q Allow patient to lie in position of

comfort while waiting for surgery. Offer support (i,e..pillows. Bath t wel. etc) for positioning.
01 Introduce self. keep pt informed as to
ere he. she is and what is happening. 01 Inform pt. in which direction to move aid assist if necessary.
Speak clearly and slowl . Address pt. from side. Validate pt.'s understanding of verbal ommunication. O Verify removal of dentures.
OTHER NURSING INTERVENTIONS
OR continuation of above Interventions.

10. OR NURSING INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
tt-t\J DATE
SKIN INTEGRITY: Bovie Pad Site: 12r Clean and Dry . Red . N/A DRESSING DRY & INTACT: ,%
11. POSTOPERATIVE EVALUA
LEVEL OF CONSCIOUSNESS: . A&O L Drowsy . Sleepy 1:1 intubated (N)
EATHING EASY:

EXTREMITIES . Moves Upper Extremities
LEVEL OF ACTIVITY: lg MOVES ALL
6

. Transferred to Litter With roller due to spinal
12. PREOPERATIVE EV PREPARED BY 13. PREOPERATIVE EVAL (Signature and Tirr--) 7?c)A, cAn-iitiks,?BY (Signature and Title)
, i k.,.- 2., DATE: aV,\1613 TIME: 0 DATE: g \\JCV1/47 TIME: 09 1-(-5
REVERS OF FORM 5179, JUN 91
USAPA VI.0

MEDCOM - 23466
DOD-037044
INTRAOPERATIvE nOCUMENT
MEDICAL RECORD?f
For use of this form, see AR 40-407, the prof,?;icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAT 1?iM 2. PATIENT IDENTII? AND PROCEDURE
VIA?' . Y By 1..\--C.A" VERIFIED BY CAVT? ) -..?-
•.. (?

3. DATE? TIME PATIENT ?IN SUITE 4; PATIENT IN ROOM?
-1K '1‘' sr,X) n 7 TIME• ; 0 g 4-0? NUMBER -2
5. PREOPERATIVE EMOTIONAL STATUS
a CALM?U ANXIOUS ?EXCITED. II CRYING . ANGRY U WITHDRAWN?U OTHER (Specify)
COMMENTS:?ia (-01")`"VVI7 VC\62-CX" _.?...
6. NURSING PERSONNEL
ASSIGNED ._-)c;;C, ---------""` "RELIEF
SCRUB ..?.SCRUB

ASSIGNED RELIEF
C TT 1111.11111N

CIRCULATOR . —....CIRCULATOR
11‘.i .-f. •

7. POSITION AND POSITIONAL AIDS (Specify) -•.,-
..-,..

IN SUPINE U LITHOTOMY ,?. PRONE U KRASKE LATERAL: • LEFT SIDE UP?• RIGHT SIDE UP ....)/-Ace.A4n.e.2.A.nA . ,...,:AAckAAA.-A,7nA...ztki
,=-(3,,r \-.2-0 -''"

COMMENTS: 4-=..
8. SKIN PREPARATION
HAIR REMOVAL?0?YES II NO ' PREP SOLUTION (Specify) C"...1CA-c",,-'--t— ICS•P-Ac\-- s1sk DONE BY:?0.?OR • NURSING UNIT SITEcgCs.,-,‘,...N.? BY WHOM: METHOD:?I/?DEPILATORY 0 RAZOR SITE: b‘?LE.1BY WHOM:
• CLIP

..... COMMENTS: — --?. COMMENTS:"1,...(7,' y TN( 9/,,,,1/4„,1/4 /1 ,
l

9. LOCATION OF EXTERNAL DEVICES
se.,"0...,V 1r611 ki,&& '
. kil..
".""

.7.-N.,.., 1--.::-Nrts f • • .., _ . . Al'1.... ¦
I . -
-.MIMMINA.-4111/1-1111Mal -. TilI IraffP
-1.

.... -.--. ..../
...
0‘ik. 0 \ r

LEGEND?X Ground Pa - Safety Strap?= = = Tourniquet --. :• -2
C = Correct?I = Incorrect?

( (--c.?-2 First Closing Final Closing
10. COUNTS Other•' Count?. !, Count • E.
__ CIRCULATOR Sponge?0 Yes Vo ..
..,;-----Needle Sharp?[2 Yes o ......--"" ,----..-. .. ..-.....
. Instrument?. Yes M o :, I. .;. -1 -,". T -. Other?NI Yes kNI Vo
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) • YES?. 2:1 NOName - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
471) kg ESU NO:?VC\ ‘kelic.:Ar" -t L3Nr u)... Lk() GROUND PAD: BRAND VL V...;,/-A. ,,\ l'IQVII`rtil-
, LOT NO ?
..; -.4"?4 . 5 .g."7 4 x.)--s" -i ..0.4ESU NO:
Q \ik\'iC,3 4' (2-11 '
---GROUND PAD: BRAND -..-.
'?
LOT NO:

• BIPOLAR NO:
-1, LACES DA

MEDCOM -23467 -I IS OBSOLETE. USAPA V1.00
DOD-037045
13. PROSTHESIS, IMPLANTS?• YE._?' NO?IF YES NAME: ID NUMBER;?^OTURER
'MEDICATIONS/ORDERSM0? IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)? :MEDICATIONS/SOLUTION DOSAGE . TIME' METHOD
_.,
MOUND IRRIGATION?4 YES?. NO, TYPE(S):
.

OTHER ORDERS r'k,A_CD,.__Q_.
PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING ROOM? YES II NO
cg

16.? SPECIMEN (S)
YES?•?NO E
FROZEN SECTION (FS)
YES?¦ NO r4
CULTURE (C)
YES?¦ NO
NAME

NAME NAME? NAME NAME NAME NAME
17.?TUBES, DRAINS/PACKING?
TYPE/SIZE 2.
120S
SITE if-, 2.
.R) \ACT.A.Aek,

19. ADDITIONAL INFOR?
,...„
_?— --
. --?IF YES, SITE :LABORATORY SPECIMENS
,?..--?,?..,.

.?NAME NAME
-_____ __ _?___. _ ...__
NAME
..?:,., '1'
YES •?NO

PREPARED BY GIVEN BY

TIME?-CARRIED OUT BY
'
YES?al?NO • ..?_?. 3. 18. DRESSING/IMMOBILIZATION (Specify) be_co V._9-i•AX
3.?,_?.,„,,_____ Y....1./NAX?i¦ r.)../v ¦All, C2;t'i‘o1.‘ikk 'gi 4.

s/\/\( — CY\ .. ((): '.(..._
:, ..

. . _ .... ,_
itlkil.gki2Vi O¦ .
20. OPERATION(S) PERFORMED
1

-
_-L--1 T 1e c.,,,,t-A_Q?L E
21. PATIENT TRANSFERRED TO T I M E ' ¦2.2._ METHOD I OA UAL%) A7 Cfb '1-' . it-33 Uti-Z.J.V
22. RE (STERE? 1 ‘?\.I?MEDCOM - 23468
DOD-037046
. INTRAOPERATIVE. D" ''':UWIENT
MEDICAL RECORD1
For use of this form, see AR 40-407, the? -?
the office of The Surgeon General.

1. P TIENT TRANSPORTED TO OPERATIr ‘. 2. PATIENT?
WED AND PROCEDURE VIAS? BY -VERIFIED BY?
CPT.Ar,J 6 ( e., -2
3. DATE? TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN R Nov 03 ,-, TIME (103 MBER
5. PREOPERATIVE EMOTIONAL STATUS
ri CALM MI ANXIOUS?. EXCITED U CRYING . ANGRY?. WITHDRAWN?. OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL?•
.

ASSIGNED -- --RELIEF
Spc?

SCRUB SCRUB
...-- i.i

ASSIGNED RELIEF .
CPT
CIRCULATOR .___.?_ _?.. __CIRCULATOR .

7. POSITION AND POSITIONAL AIDS (Specify) ...-
5 SUPINE LITHOTOMY II PRONE?LATERAL:?
• U KRASKE . LEFT SIDE UP?. RIGHT SIDE UP
COMMENTS: prbp _
Q, yDtthi a-Liriltitt moi nicv-114:_..__-_-.
8. SKIN PREPARATION HAIR REMOVAL . YES?mi NO PREP SOLUTION (Specify) 8 ttacti vg_..c.coi
DONE BY: U OR U NURSING UNIT SITE:Il-t-,aryy) BY WHOM:
METHOD: DEPILATORY IN RAZOR SITE -

. BY WHOM: II CLIP
COMMENTS: _ COMaENTS: 1\10 in of ftuids (?---Z-
9. LOCATION OF EXTERNAL DEVICES Pot/
-•

'
.1*
-

— --"simml.""4113.01111m11111W-
-

1-1716P-.?....?.:?,
a?4.
.0-?!,

LEGEND?X Ground Pad?-- Safety Strap?= = = Tourniquet...-. -----
,i,.:.?1(2, )

C = Correct?I = Incorrect?C? 1
-BILI:-W"?
l
First Closing Final Closing

10. COUNTS
Other• • Count?, • Count

SCRUB
CIRCULATOR

Sponge Yes
Needle Sharp f Yes
Instrument D Yes
Other?. Yes
0 0 0I0 7' 7 7 7
.
7

...,•1)1 ?f .?'?........._--------

-c---:"-
11. PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTROSURGERY DEVICEIS) (ESU)?YES?. NOName - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
,

i2 ESU NO: FDIC Z.- 4-D?IZSe?ID 5,..3i_OAS 4614b k0 ( Q.) - ' 11 GROUND PAD: BRAND Va )(to (GEM LOT NO: 93 53
. ZE6U NO: -• 'GROUND PAD: BRAND
LOT NO: III BIPOLAR NO:
11111111114.0 -'7j1
DA FOHivi1
, OCT 87 REPLACES DA MEDCOM -23469 I IS OBSOLETE. USAPA V1.00
DOD-037047
13. PROSTHESIS, IMPLANTS 1' ] NO IF YES NAME: ID NUMBER JFACTURER
, J-z.:7;A:,_ ,•,::::,..:;PMEDICATIONS/ORDERSi IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY. ANESTHESIA) YES • NO 7:1, MEDICATIONS/SOLUTION DOSAGE TIME -METHOD PREPARED BY GIVEN BY
, •, . .... — —.
-•
WOUND IRRIGATION 2 YES • NO, TYPE(S):.

0.990 r¦)S.
'OTHER ORDERS
TIME CARRIED OUT BY
TDr JZ
_?
-

PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING RO IF YES, SITE

YES • NO

16.
s' -= LABORATORY SPECIMENS

.._ , .,

SPECIMEN (5) NAME — ------ — NAME
:

YES / NO gi
FROZEN SECTION (FS) NAME NAME
YES NO MI

CULTURE (C) NAME NAME
YE5 ¦ NO N ___ ._1..1-1- -----
NAME NAME
NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
- -----../ 1 15 6 Le V-e r Arm
17. TUBES, DRAINS/PACKING YES NO g
TYPE/SIZE 1. 2. -' -. NA AS "
Vel‘
)e,j(11 y,?
VtdilA

SITE 1. 2. 3. art( )
• 10.4114 Pkrlde-r spiA.A-1

19. ADDITIONAL INFORMATION NC.-Lw i
Suri . AYULS4d1 • cef\)A._Alks,s:fh. i ! 6-evu_val.brn.ii-
20. OPEFIATIOtO(S) PERFORMED
T:1.-i) id closLat 0+-al- hand 1,,)(5-Lvad,
_
-

z. Clert_vi_ recly e ig;o, Lcuer eA
t+. 1-ogiAA-d5

21. PATIENT TRANSFERRED 0 TIME METHOD
PA- -tk, 1201 V-micirLer-
ATURE, frti

MEDCOM - 23470
VT/ .

DOD-037048
i .)11-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
I POST-?DAY
MONTH-YEAR WiI.?DAY irfallInfill11111 3111 .m ..13E1 HOUR ; • - PrIMII" •• MIP.1211-41111111Will -1-PULSE?TEM P. F 3.?• 0 : :1:1:1: -.1: :1:1.1. .1. .1. .1.
fillitm.
.?.

(0)1c.) P1-•. 3?• :?•?•?• • -?•?:?-• .?.
105° .44?

.?. .?. .?. .?.. .?. .?
. .?. .?. .?.
.?. .?. .?. .?. .?. .?
. .?. .?. .?.
.?. .?. .?. .?.?, .?. .?
. .?. .?. .?.
•' 180?104° .?. .?. .?. .?. .?. .?. .?
. .?. .?. .?.
•• • .?• .?. .?. .?. .?. .?. .?
. .?. .?. .?.
170?103° .?. .?. .?. .?. .?
. .?. .?. .?.
•-
.?.

.?. " " - '?" • " • "
.?. .?. .?. .?.
160?102° ...?
••.
.?. .?. .?. .?. .?. .?. .?
. .?. .?. .?. '?• •.?.• .•?•. •.?.• •.?•. •.?-. •.?
-. •.?•. •.?-. •.?•.
150 101° • .?. .?. .?. .?. .?. .?
. .?. .?. .?.
.?• •-•• •-•• •• •?
-•• •• •.
.?. .?. .?. .?. .?. .?. .?
. .?. .?. .?.
-?• •• -?-•- •• •?
-•• •• ••
140?100° •• . .?
. •• .?. .?. .?i
.?. .?. ..

130 99°
98.6 MM.

drikignigir. i
:::::::::

120?98°° ... ••
gai1:. 111 : : in ....
l
.... 1
110?97° if 1 ....... 100?96°
1111 bililli ...........

90?95°
1111? ..1.?. • .?....... 80 :: III I ::. .•:• :II.: ::.
I.:: 11111
:•?...........?

70 1 En .:.?:: I ilalliligLi ..?.......
. . .R
.
.?. .?.

50 .?. .?. . .?.?..... . .?.
:: .. .•
60 : : : : 111 :R
:
.?. .?. .?.?.. ..

40 , .
11

1 i1
• 31111111111

SPIRATioN RECORD
BLOOD PRESSURE AILIMINIMEADIAMIIIIIIMRIA

123/a1111111g111111= UM km.
im • -ilre ,ai
17'1
¦Mill 4ill

HEIGHT:RWEIGHT .-110.
MI

bt1A t VI; -UP) Pt!' • MO 'MI§ :MIME' v,ex.J
...• • z, ., -ft) ctlaok
°Pil '
-
--elo '' all) 11 &Mr
Fq6f

3 IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)
ICS1 1

VITAL SIGNS RECORDS
Medical Record

STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 23471
DOD-037049
—i
CO to CO (.041O.) CO CA)(.43C.a) A AM
CII 01 a) a) —,1 --.1H CO03cp00E
0in H H 0)v bo .03(0:A a) 70
.0 0 0 0 00 0b0
0
(Centigrade Equivalents, for Refere nce only)

,%.....
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
D' G1(Units)1 TOTALS1TOTAL EBL
'ANESTHETICAGENTS AND DRUGS
to LINE si e 0 Warmed REMARK
2 immir CI Warmed V* •19ff -----•.------.----tgt.))-Code dm s with numbers,
. Warmed events wiqlenleris ,. 30111 a
cttel
. Warmed
EST BLOOD LOSS

LOSSES ,„-t t"./.1"\)r '
U• E -ri 1 Vtle-4-1

'Aji 1 S STAT t.K 09ce is" Cie(
TIME :,0 UM
wo A-_--, ,,c.....,, •
Fe
• DIZIEF
WEIGM SYMBOLS: 220 ,
trc,...„, -CV
/7 ‘0 B BP by cuff 200 1 • I . ,) 1.,` d OG ../ tt-y0 V
HEMAT MN ¦ I I I I I (1 06 i 16 (
180 : : : : .
A '
'

11/1/X4111 Heart rate 160 Eggs S f / sir (
: : : : . . .
INITI • L A A: • cdti aw-52_
CT
IIIII ¦ . ¦

BP-Resp rate 140 IIIII , , , ' IIIIIIII :
W (.6.L4'120 maritilMersMM ,
nAixamPISIMMETAFA

MiNtwq ' ' ' 0/1 11 at/A— in= Itran:dRucec0 100 ' litillii "6 zr-2,6--- Y-
ain . . = ,
' ' ' # ME ,
-L NNE .

EQUIP ECK 80 EwAvAl , , 6 _C1,6-Lit-r-52-1 c
T

OK?-60 =NINO UWE MEM
N TOURNIQUET k..1.--6Lt& O
. si L-4
EVA OM Mg ' . MEI

PATIENT RECHECK T-X-
.U.f . Mill
40 , , d... r
OK for 4
1 1 f I I I ¦ I ,
PROCEDU --
ANES- X-X 20 090 Ifif C-Xd
PROC- 8_0 MIME ' ' IEEE

TIME-ipYtt
EMI OMNI 111111•Mii / it/ S0.' t
VT-ml
r 1 PLOMMI .1L9It
Lk- ,H

z f - breaths/min wmieim ...• ir.
ut Peak inf pres / PEEP A. MIMI_ s-i-d At--1
MODE - St on). Issist). C(on) 11/111 ;NM
=HMV
to_ ,T CO2 (torr)

14- BP/Auto Cuff r„ rep. 32-
lairtir ICU Spacily1
102 (Frac or %) —la fall

' P/oth ,_ II , 1r wf:
ART line ESpO2 1%) IF illw 1 Pi g 'r ". Nip
Steth- PC/ES F; ECG 4V WiltWil t CONDITION: 50-71"."

ur C Gas analyzer TEMP-site RESP. a
SpO 9 iii
CI I
C./g N-M Block (T/4) KIM I Opp Tr e HR
Q
I Al ilk ANEST A / PRO EDU'E
CO
TIMES

CC
I

0
1-CA Start Room End
Z Zuj -
0 Warming Witt 1
y ag9
Cony warmer
t Ready Begin End
Me k with letters & SYmbols. EVENTS_, 0 •••••
explan under REMARKS Position - 0.---1 ----41T-66 ------) a.cc . 6 1 eb
PROCEDURE and CPT Codes: ANESTHETIC TECH IQUES: Describe block technique under Re narks .6-9 wock5 ,PATIENT ID TIFICA ION: Type/ or written entries: Name, Grade/Rate, • i NAGEMENTA Intubation route,h1We, technique omOenus_ vopic liMedical facility 1 AWAY 47
CLA? c, L.C3clAe ;At' 4 A ...p`. E.. Ea............K. or - dr
U.. PROCEDURE /7 / a
LOCATION: C" DATE:9' ya) 0 3
AN •
‘c.(uk-S - 1-\1/4
PAGE J OF /
1—

9, FEB 1998 COPY 3 -ANESTHESIA DEPARTMENT r USAPA V I.00
MEDCOM -23472
DOD-037050
i1

wanR(\iRlogil r'l
F.am („( i) sp.
s`

1 a TOTAL URINE C-C ( • AI
.
I MI VOLAT % del lagliMillig FLUIDS . SUMMARY AGENT % e.t. CRYS Imo DI -
.

AIR L/Min ale N20 L/Min COLL ID-02 L/Min /111IIMMEIMMII
SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
WITH NUMBERS 6 ENTER IN REMARKS
CONTINUOUS/REPEATEDDRUGS SPECIFY UNITS -MG/MCG/ML, "I" = CONSTANT INFUSION
ANESTHESIA PLAN OF CARE PREPROCEDURAL ASSESSMENT (Sedation/Anesthsial
Age _&515AYS MCZ44: Sex ( ) MALE ( ) FEMALE
ASA Physical StatR2 3 4 E PROPOSED PROCEDURE: 1 1 WT: RKG/LB . R SURGICAL SERVICE: 1
ALLERGIES: R

NPO SINCE: 1
HABITS:
PREOP ATIVE TOBACCO: PAST MEDICAL HISTORY1EMS REVIEW ASSESSMENT ETOH: Cardiovascular: FAST SURGICAIJANESTHEI1C DRUGS: Hypertension1N Y 1
Angina1N Y 1
CURRENT MEDICATIONS: MI1 N Y
( ) = ordered as premed CVA1N Y

Other1N Y
() Pulmonary Syst

( ) Asthma1N Y 1
() Bronchitis/URI1N Y PHYSICAL EXAMINATION
() COPD1N Y BP _ HR _ R T_
() Other1N Y

Pain Scale 0-10
( ) Renal System:

HEENT - Teeth 1
• Acute/Chronic F N Y

Trachea ,4---212-0.---
PREMEDICATIONS: Gastrointestinal:

TMJ/NeckNone Yes (@ 1Hrs) /CC Hepatitis1N Y Oropharnyx1mg IV IM PO Hiatal Hernia1N Y

1mg IV IM PO PUD/GERD1N Y
CHEST: oV/4---1mg IV IM PO Endocrine System:
Diabetes1N Y

CARDIAC: LABORATORY STUDIES: Steriods
Thyroid

EXTREMITIES:
HB/HCT: 1 Neurological:

U/A: 1 Seizures
IV Access: 1
OTHER: 1 Neuropathy1N Y

Ulnar Filling: 1 Other1N Y
Gynecological :

BACK: 1 Pregnancy1N Y Other Significant Hx:
OTHER: 1
N Y N Y Familial HX1N
NPO Since 1

ANESTHETIC PLA { ) MAC1{ Regional (Specify):
‘ral: Mask Intubation

INF
SELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
disc egal guprdi7.

Th _-z_
s to un erstand and agrees. Questions answered.
Si • Date: '--1/YbV)er 3 . Time: 63.3/....-Pa Hrs
POST-A1 AND NOTE (NON ASU)
SEDATION KEY: { ) NO APPARENT ANESTHETIC COMPLICATIONS { OTHER
1. MINIMAL (Anxiolysis)Patient responds normally to verbal commands

Signed: 1 Date: 1Time:1Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or
accompanied by light tactile stimulation. Airway assistance is not necessary.
Patient Identification: (Ward) 3. DEEP SEDATION/ANALGESIA.
.ttiaria.(c,S1
Patient responds purposefully
following repeated or painful
stimulation. Airway assistance may
be necessary.
4. ANESTHESIA. Patient does not respond to painful stimulation.

WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
Previous edition is obsolete PATIENT RECORD COPY •U.S. GPO: 2001-62948300002
MEDCOM -23473
DOD-037051

•- •

R.LDIOLOGIC CONSULTATION REO.
ESYREPORT
Yg •,.. P. iC

RE C:IS -.-C,.
K52f¦—. jfi KO'

YEiS
:=-7:c..t...:Zsrzo ay •,
i cd \t& I
• 7.

7.
Lf YO.1-1 1c45I AAç
OF .10,N 0...7E OF ;-1.=_?-o.;:(Hart:,. ezy. ' ­
.3 .... 7 .:.
L 1 OF 1-A.=..NS:....P.l. • i 0 :4

(11 0.... '..-, . L.--;.. -... ;

1

A ,..:rO L OG f C
t
1 •
7... 0
7 A:41% • c - -

C FA; :a:•...- - •
MEDCOM - 23475
DOD-037053
REOLIEST:". •
CITEI‘ILSTRY REULTF0RI
(Stzeto the ?rivacy Azt of 1374) IL\ tE
SSN/PS
SSN: )7_)
8?
TEST
RESULT REF RANGE
TEST I RESULT

o4.1 ALB I GUI 73-11S rr:•.'.:11 LI; BUN 7-22 mi.-ft!
i-STAT

CA.-8.0-10.3 rnEiiii

PICCOLO
pow' 08/11/03 CU 0.6-1.2 rid[

03:51 (art) • REFERENCE Ra MALE \IA
AE:

Pt Name: veal -, 128-145 mrr.o1/1
PATIENT II:

)2C/2 -E.4
3.3-4•7 runoli1

LIVER PANEL PLUS

Clu 111 mg/dL (Nca) DISC LOT #: 9S-108 mmol[
(let)

(W) 3154AA7 711-
BUN 10 mg/dL OPER AIMS DR #: 000 CO2

(vca) 18-33 thrnoLl
Na 138 mmol/L SERIAL #:k4Q)=U000100491

1. R4.0 mmol/L
Cl 10g. mmol/L ALB 4.4 3.3-5.5 G/DL TEST RESULT REF. RANGE
L ALP 85* 26-84 U/L I
TCU 22 mmol/L LB
ALT 94* 10-17 U/L

ioIIL

AnGap 10 mmol/L LP
AMY 59 11-97 U/L
Hct 43 AST 55* 11-38 U/L LT
Hb* 15 q/dL ••: TBIL 0.9 0.2-1.6 MG/DL

GOT 33 5-65 U/L NtY 14-97 ull
*via Hct

TP 8.0 6.4-8.1 G/DL

pH 7.329

iT 1-38 uil

PCO2

50.7 mmHg

CHEM OC: OK [IL 0.271.6 ogld

INST OC: OK

HCO3 27 mmol/L

HEM 0 , LIP 1+, ICT 0 31-I 5-65 till
BEect 1 mmol/L

6. .1 0.1

Sample Type_:

08NOV03

05:53

EST
RESULT REF. RANGE

O per:IIIIIII
j-1

Physician:

3.3-4.7 trunoLii

Ser# 42015

9S-105 rrsaoLl

Ver: JAN304R
CLEW R93

1:3-33

R_EPORTED BY:
DATE:?I LAB ID SO.:
MEDCOM - 23476
DOD-037054

F.Vard: ?•?-
'ScN:ticic. -i

--\ -AT (C.e) --t- LABORATORY RESULT FORM
I .-
i LAST, FIRST, MI. Sub;cct to tic Eciv:.•c ¦,• Act of [9741?
? ?---t: 1 rivc?i,
I

SS2,:iPSEET-577----------'''
1 .,,\.
A53 03 1 S?

L )11=. ti(a--1
‹).. ric../ ----?-?.. .
rooms
11­

I? Z:S:-.7 Rib: R4 VGE .

TEST' ( RESULT 1 REF RANGE
N/A
RPF.?I?I M.S.-1.1i rc Nioao I I Nicabut Ne-3-3:ire

H I ?Microb io-1 az), -
RAPIDPOINT COAG ANALYZER V4.54 SERIA1 41.105485 11/08/0j 04:09 Pi Patient ID: 1411111 1„: lest Name Tet)i Result.= 15.2 sec. Ratio == 1.2 ? -4-1 1 I Nklp vc I NVA I-leg:at -lye. NJA NcIpth-c. Gram Stain CkzcBld H. pylori Micro I S ou;cc nv_tivc 4vc
St Calculated INR = 1.43 Si4.mple type:citrated wh. loud Negative Parasites Malaria
Bi TeA Date :11/08/03 fet Time :114:08 02-L 0 O&P
L3 At Card Lot Operator :080201 I Ncgati Yr, (1Ik ,e

RI RAP1DPOINT COAG ANALYZER V4.54

M SERIAL 4005485 11/08/03 04:14

Patient ID:

(Cz-

Sp?Test Name ',"
„ C

Fie Test Result:. 31.5 sec. 1.13Ank Se.?Sample Type:citrated wh. blood Test Date :11/08/03 SF 518 WITH
n411111110OB-11-03
Test Time :04:10 III)? aQ
Or` 04:06
Card Lot :100208 Patient Operator IR Limits
UK 19.1 H x1083/uLR
4.5 10.5 0:11JSTSURRX 5.37Rx10*6/td. 4.00 6.00
Hgb 14.6 g/d1.R
11.0 18.0 05. BLOOD •

Ha 45.7 ZR
TEST I RESULT j REF. RANGE 35.0 60.0
U?v7T.MD/ 811 ftR
80.0 99.9RROSSAL-f TCH

' 9.E-13.6 3CC3 .ICH 27.2RpgR27.0 31.0 ME 320 I. g/dLR33.0 37.0Plt 202.R
1 21-34 110"3/uL 150. 450.LYX 11.7 *I. ZR
20.5 51.1

LY11R2.2 * 110"3/uLR1.2 3.4
rE"
f P_EPOR.TED BY:
I DATE: LAB ID NO.: .

I

MEDCOM 23477
-

DOD-037055

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
co crt DRUG1(Units) TOTALS TOTAL EBL
7 n 2 z
0 ° S ,17)
CI 2 2 r, ( TOTAL URINE

Z 1- 0 __ zikree0,,,, /,,,?
ifj 2 i__ . PI____

0) CI-1• Z I • - • w co
Z --.1-1--1
uj 43 2 CO
.c..-(-2( (r)16 VOLA? f7941/C_ % del F, ,2 .y1 1 --4_ FLUIDS -SUMMARY 0 R EL.AGENT % e 1.
• (-11)
CRYSJ.SLLOID 17-1:: (-) !--AIR L/Min
uj Z It! .
F 0,.• N20?L/Min COLLOID-
1_. ti
co 02 —:3 L/Min —7—

.
Z SINGLE DOSE DRUGS-MARK ON GRID.,s, iiiOlic- -- WITH NUMBERS & ENTER IN REMARKS
LINE site? . Warmed
cn REMARKS
El Warmed 5 ID Warmed -events with lettlers
0 XL 1Code drugs with numbers,
1 --2 .90. —
. Warmed

(9 7;764)
0-?EST BLOOD LOSS
—i—r,

LOSSES
UR NE -PH a STATUS TIME 1,145 E SYMBOLS:BoSY WEIGHT: KG LB V BP by cuff -lialve- /5-----3.r.s---.-.. 220 . 200 ,?. , I---L--1 .?, —, • t ------— . -1-1-,?. " • ; a 2"th...4k) c ,/,.65re u, ,r9,41 --.4c.a¦ 7 Z4PC)0 (.4114/-1.2-6At D,dc)/1/9-41 /6"6/k) ,Ifve, /five- /"°7
HEMATOCRIT: A 180 i-- ' 01i-/14//1"1-
INITIAL DATA: Heart rate • 160 1?1 ¦ 1 . ( 400.6.1eve 47-f
BP- Resp rate 140 ; , , 171r9igew-e--)Cer‹. Po.i';
120 (transduced) 100 EQUIP CHECK 80 ?-1TOURNIQUET 60 BR I. T _2(2_ , 57 R­2031,e OK?Y1N _ ' — • ,1----' , „ ,?. .?, ' , -, .r.,2 bireii*p • A/e /I , Cad Xit,,r4 . __,_ -70 /a,e0Ar,27,
PATIENT RECHECK OK for T —/-r" 40 ? — TT I / At _L 1-- -1--1---1 --L -1-___ --• • --,—,---"

PROCEDURE?
ANES- X-X t _...t_._ i?. ' i

20 --" , , ,?, ,a
PROC-8_0TIME-

or
.
VT-ml

I-
f - breaths/min _ZY?0

Z tu Peak int pros I PEEP IL
/MODE - SIpon).?ssist), Clon) S-V
RECOVERY AT BP/Auto Cuff E?CO2 (torr)
PACU ICU Specify] LE2 BPloth F?(Frac or %) ..?dr
,,,,?• •

CE ART line S?2?1%) OTHER
r0) th- PC/ES CG 5 CONDITION: 5'714 e
0 IrKa / 0.__ ,L.'
ur `G as analyzer TEMP-site
(..) RESP-7 Sp02- 74, 9.
r.)
N-M Block (114) BP-f HR-77
ANEST ESIA / PROCEDURE CC TIMES 0 PROCEDURE
In
i- to?Start Room End
'Li

2
o Warming blkt .1 /19,9/ /0 /2c( Cony warmer
e
.
Ready Begin End
Mark with letters a symows. EVENTS__...6 0 0expla n under REMARKS.Position.-.
o,- // 2 3 //,7 / 05,1 PROCEDURES and CPT Codes:
ANEST ETIC TECHNIQUES: Describe block technique under Re narks
17 .72) /fit/tit CI— C ZOcare °.? i "1j f"
4

e/. C i /1/1 /4PATIENT IDENTIFICATION:?Typed or written entries: game, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments Medical facility -# 9 .Z/)/W
PROCEDURE
(11)."'-'
LOCATION:?C....ilf
t -''

DATE:?A. A9 ?63
.127/..../11._

PAGE /?OF .-.... ----. -- --_ ____
COPY 3 -ANESTHESIA DEPARTMENT USAPA VI.00
MEDCO?
DOD-037056

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 MEDIFAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER LIST TIM ORDER NOTED AND
HOURS
SIGN
-

Acti,..4 44. Icta L
.

c Dx- (R) r,4" I4itlitL
(fir
-3`

1A-1--(s- G2 9°
NURSING UNIT ROOM NO. BED NO.
411--?cf.) at\c,-147 - tvb b. I Apift-eD
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
imp - Lg..0 /00c .HOURS
CI)

ro N O - a., c....J( A.6 CYC
r -7Ti.I U.1"144-J--) ,.._ 10 . 0./121^1

NURSING UNIT ROOM NO. BED NO.
c9 _
PATIENT IDENTIFIC ATION DATE OF ORDER
0—. 0 Nt.¦ Cc
4.) Apt, tto oc1D-ki4 NAN) (29 Dy--RT-a-b G (PRmeFx IdD a. LE
NURSING UNIT ROOM NO. B D NO. () vcvv,IN —c? tb x3 Al\--Po-) — -7t gx., A
PATIENT IDENTIFIC Act- qa-io-DATE OF ORDER1 TIME OF ORDER
O _ Lfzc, PLTU HOURS

da6-A)
4-aL4r-ke-e-

-Av..ip.,,,1V Qt °
(t) (9+0`) P(4-.)
ts--iv avp

NURSING UNI BE• NO.
(ti)
9 /202

RE ACES EDITION OF 'I JUL 77. WHICH MAY BE USED.
DA 4256
, FAOPP M79

MEDCOM -23479
t A J

DOD-037057
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 MTCAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER1TIME OF ORDER

• i1
LIST TIME
Ct 1000 C801
doRAi/lb — MA}
il 0, c OR li, AM
0.cc.€P .
vi

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
u) ri

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
NURSING UNIT RO•
PATIENT IDENTIFICATION
C)

op.E.

&
# 'i.. 0
• 0
. ,- .A.

\ \
BED N s
fli
-1,..,1

A6
AG
ATM
0

ORDER NOTED AND[ 1 501HOUR'S`.
SIGN
de
/0v 03

loposste0-11-.IVF t.gco (o ull.„
r

\--D ._(-k-AlRi .AAA-i .-.A.... • •.d.L
LUM.X34,0)
DATE O1 •1OF as1• ER
IR 16D
1HOURS

W1tft2 -V31
101

ALS, Kk?Po) Iz_i-) I_ • _ .5-15 D1 r ( IP-09k, kYt-Px
ANA— b,.. a I V OF x3
mS0,1 r -Tr Ka ty Q i° 1 P R P Ats.kilui eiv.t..zr .0, Q ° AZAJ
Z.5-,61W1RA,* ,f.Pr— ‘50 0 PO (0 V—V461,/

DATE OF ORDER1TIME OF ORDER 1 c1 ...
D,,,?d.,,,c6 &R,.•. i • 6 _
sa
x3i-L_ a.sit,

C e) 4-&5711:
?I) 6
DO (5- Ar.14k- 1 ki Lula,

OF ORDER1TIME OF ORDER
HOURS

-1-ilork i,Rit u...eR
-(610-4-•--PRasiP.
i ..1 '
bkiA,Y-1--

• ...• r '•etif 0

NURSING U ,d, •
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
D 4256
FORM

I APR 79
MEDCOM - 23480
DOD-037058
THERAPEUTIC DOCUMENTATIONtARE PLAN ( NON -MEDICATION)
CLINICAL RECORD For use of this form. see AR 40-407;
2003
theRproponent agency Is the Office Of The Surgeon General. MO. (RYr.1
VERIFY BY INITIALING ag**Otaetrin4M*tr.., ''' g INITIAL PROPER COLUMN FOLLOWING EACIt COMPLETION
ORDER DATE NIDi CLERK/ NURSE RECURRING ACTION, FREQUENCY, TIN \/1-VA_ q4-9 ‘3 HR I 0 ilf01 DATE COMPLETED 061I I V a n-F.,
4V-szn . III
. . _ •\-­c--,.S\C-¦1B-- Aill
4)3 --­011pc_t ems-_ _ 'c2k , (.0\1 c.- -aes-­Jai Illi -11111 ir f --3 4° _

-

0(1 -dpirp, dA,+. .
- --A at. LL mt-Lckc-
j

'RoirrA 01111r-An q 4--Q YN-)
101' _

cl)
iiirn 9
sb -

1 -. -Sioc iz\e¦,0-cn
.

F__-
93 _ \„_,.,\\,), .

s„

¦
.1Li I' Ii C dsL.F.
!in4- ScD PM01,
-141,
/

ALLERGIES: )0,YES MI NO PRJMARY DIAGNOSIS:1-pcC. ADDITIONAL PAGES IN USE:
s(p. VD ;" CD¦._,N) t-(V____ N. YES1MI NO
' PCNI
VD "BL_ LF_. PAGE NO' 1 PATIENT IDENTIFICATION: ACTION TIMES
MI6 L6 ' 4q1
USE PENCIL. CIRCLE ACTION TIMES D 8 91
10111112113 14115 E116117 18119120 21122123 N124 01 02 03 04 05 06 07

MEDCOM - 23481
•••¦ OhRam.. N... • • ¦¦•• • "IPR 11.4.• ••• •• Cu. I gun ur 1 UCL. s I Mar nt USED.
USAPA V1.00
DOD-037059
Verity by itHERAPEUTIC DOCUMENTATION CARE PLAN Initialing z ( NON-MEDICATION) Mo.Yr .2903
7

Order
Clerk Date to Time to
Date Nurse SINGLE ACTIONS be Done be Done . , Time Done Initials
• i . m Lc) \c_.\k; \ - cie__1--vc) -Dr-\Ni\f-¦&._, ma( \
Te, \

(Ps N PO-cc c \ -ko o-_ IrDi -/ /0/9/) r---hrliu --Inoi c79-10
1/(A/0 a, OA A 0 , .\-\- 47c3 -P\C_SD --=) \CAN) 1 - CCrd 72'8e-i0
Ordxped
Clerk/ '` PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Elr
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
— — — — — —

— — — — — — —
— — — — — — — — .

USAPA V1.00

MEDCOM - 23482
DOD-037060

r1:D a_‘) - a \
,/a
/ THERAPEUTIC DOCUMENTATION

CLINICAL RECORD,/ For use of this form see AR 40-407; q.4.:a the proponent agency is th e
TIINITIAL
VERIFY EllyIVI ALING N
. _

HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

OF1DER CLERK!/ RECURRING MEDICATIONS,
$ 01
I

Wart1 2 ---C:= R\ Ticbcd \--1--• -ok__.\\] 0.. .., Ni.O\.
r
-
fum:RAIM

ARAs. --:-.-Ar.
\ Nir MI
16k-
.F. /py ES10 NO PRIMARY DIAGNOSIS:
F:
ONAL. PAGES IN USE:

? V1-
., ..-. c(,.-.3 .
mc -(7._ ES El NOR
r)C—.N--/

\1 VI) ?3,_ (E
I

K—q71 RN--3 cce PAGE NO
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 819 10 11 12 13 14
E 15 16 17 18 19 20 21 22
23 24 01 02 03

MEDCOM - 23483 04 05 06
DOD-037061

THERAPEUTIC DOCUMENTATIUN LAKC Mo. 1)\
Verify by
(MEDICATIONS)
Dote to Time to Time Given Initials be Given

)rder Clerk/ SINGLE ORDER, PRE•OPERATIVES be Given Date Nurse
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
PRN
TIME/DATE DISPENSED
MEDICATION, DOSE, FREQUENCY
\\(Lf`cn \\I c\bc)
U.S. GPO: 1998-454-110/95216

MEDCOM - 23484
DOD-037062
¦1111•11•111•R ¦
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; Mo. Il Yr.
the proponent agency is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
$ Id I 0
I -l
.

(V-----R -
. .P.-S=D \ CACCA-`c ' 14--\\/ I #
1 .
4\ ker \ "C)\ . (--) V\ i(D\ \ I •

Cra -1111111Acce_V -‘--91N cf-3-lb
kt-
_,--.1")
\dr

ALLERGIES-I t.y E sRQNo PRIMARY DIAGNOSIS: ADRTION AL PAGES IN USE:
p vc_.(P \-- ic)(=r\ ,f,pc._ -i. YES p NO
-/PC-Tot-.6't-/(-7.-\V-1 P V -1) F.3.-- ( F PAGE NO 1i
PATIENT IDENTIFICATION:
DISPENSING TIMES

k USE PENCIL. CIRCLE MED TIMES D 71
819110111112113114
11111P)--
E115116117118119120121122 N123124101102103104105106

I11
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA 1 FFOE'r;i9 4678
MEDCOM - 23485
DOD-037063
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) 1 Mo. )1r93-3
Order Date Clerk/ Nurse SINGLE ORDER, P, PRE-OPERATIVES Date to be Given be Time to Given Time Given Initials
D I
AiI ._ 2 A. .# ELL /1/P 4-4p/b(5&e //A/

,
7-
/
Order/ Expir gel Date \EY Clerk/ Nurse /1PRN MEDICATION, DOSE, FREQUENCY r Co° INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED
Asti
rv3zsors\\! 960 %_
1_
T-ro c,esN c bp, 1 5

U.S. GPO: 1998-454-110/95216

MEDCOM - 23486
DOD-037064
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this Ione see OR 40.66; the proponent agency is the Office of The Surgeon General
OT55 APPR9VEO fibre
REPORT TITLE?

Post-Anesthesia Care Unit (PACU) Flow Sheet?
' •

Date:?T t¦1 sf) i 03? Anesthesia Type (Circle)) pinal Epidural Drains Time In:?QQHS? IV Sedation Nerve Block Hemovac •al Allergies:?t Cd.OR Intake: Crystalloid?400?Colloid NG • ral
Pre-op V/S: lat-417 it?1 IS?OR Output: UOP? EBL?MI r'-I JP ETT Procedures:?(40'6?\P.SC Meds/Times:?I,,,, ArceF-?, ,,c,, rnr .ce,,,,f-T-tube Trach
Li 21-)Pfat'-• Foley Other
Pre Op Meds History, TL
Time ‘1,2 2 I§ .Z.
Pacu In tak?

. ). .. . :4 ' -. ; —. Tim Solution Amount Site •?By used
Sa02 it Ti
?rft trn
Fi02 MN
Methods RA& tik p_A eFt

240
220 X-ray ? . Labs:
Post-Anesthesia Recovery_score
30'

Criteria DM . Codes Activity
200 ADM
AIRWAY

(2)
Moves 4 Extremities A= Ambu

(t)
Moves 2 Extremities

180
(0) Mo 10 Extremities BB = Blow -by M = Mask
Airway
FT =Face

160
(2) Cough, Deep breath Tent_
(I) Dyspnea. limited breathing
I OA n. Room
(0) Apnea
140 NC = Naiir" Blood Pressure
Cannula

(2)
SBP =I- 20 of Pre-op

(1)
SEI P =/- 20-50 of Pre-op

120 V, iV
V/S X?:. 'ne BP

"V V.‘„, (0)SBP 4-50 of Pre-op
.

Consciousness
drianlil¦

100 '4
(2) Fully Awake. audible
= Pulse
trying

(1) Arousable to verbal or pain
80 • • • TEMP
Color

• • S = Skin
(2) Basehne color & appearance
t3eralc

60 (1) pale, mottled, jaundiced
(0) Cyanotic
A INA,\ A T = Tympanic Circulation (Peds 5 Years)
R = Rectal40

(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 N II II (0 needs anesthesia approval for
S = Sacral
ID/C.

T
0
,

Time Patient teaching done; Wound Care. Pain Management. ?I
Pain (0-10) T. C. 8 DB,. Incentive Spirometer. Comfort Measures
LO Safely: SR up X 2, Falls Precautions. Privacy Maintained
i aonrinue on revenel
ib

0?TMENTISERVICEICLINIC DATE ?•(e) -.-
P 03
ACU

PATI pe or written entries give: Name.-last.
first, middle: grade; date: hospital or medical facility)

¦ IIISTORYIPHYSICAL ? 9 FLOW CHART
In OTHER EXAMINATION?• OTHER tsprarr OR EVALUATION
jD ( (:,) ' ,
. DIAGNOSTIC STUDIES
• TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 ( MCXC-DN) Previous edition is obsolete USAPPC 02.00
MEDCOM - 23487
DOD-037065

MEDICATIONS

Allergies: NURSING NOTES Time Pain Medication & Route Pa I/E?13y 1-10 Dnsane
1-10 received 'Pon, OR s/{) 1-'4)
( 13)456 harti • "4 SpOz PA Klo rib tA2ir-1

WAMC OP 173-E
eA, (V) C/O
Discharge Criteria:
Date:gNOVI5S Time: 103 a PARS: 9
BP: lupt590 T: 47 • I HR: r71 RR:1Sa02:

Pain Level at D/C (0-10): —
Intake:1

Output:

Additional Data: A.)0).%-/C Transferred To:
_
IC t/L1

Report Given To: Transferred Via: W/C Ambulance
Transferred By:
Cleared IAW Recov
Charge Nurse Signature:

7? Time Site
Adm 61615 15'
P(09 30'
iNe5r 45' 60' 90' D/C s (e5,
NEUROVASCULAR
Range Sensory P
Of
Motion
-I- -I- P
.--t -t P
4 't p

e 4-ri
Cap Refill T Color
fl) Y3 6 C. C C VI f'
0 C

Movement/Sensation: + = present,- =absent Temp:C = Cool,
W. Warm Pulses: P= Palpable, D= Doppler, A = Absent
Color: C -= Cyanotic, Capillary Refill: B= Brisk, S=S uggish ?
P= Pale, Pk = Pink C-SECTIONS Adm 15' 30'
45' 60' ......913:—,—D7C---

Fund. Height Lochia
Peripad# Fund. Con __.---..,..,_?
Time
Location Adm 0955 a le3,S 30' 6 fe3 c 60'
f3 irr\ s
DRESSINGS
Type Drainage
iCevles,- rv¦.1^
veytekc I.", h•-¦
, IceAr lex ta.1 i...)

Time PACU OUTPUT Source • Color/Agpaance Amount
Time OC4.5 5 CARDIAC RHYTHM Rhythm Symptomatic? NS's o Rhythm Strip Run? cp

MEDCOM - 23488
DOD-037066
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this lana, see AR 4066: the proponent agency is the Office of The Surgeon General.
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet

l b ki 0-4 CL3?Anesthesia Type (Circle)): General Spinal Epidural Time In: 114, (..--.)?
Date:
IV Sedation Nerve Block Alleigies: %--)V---6\ ?OR Intake: Crystalloid .'Z," ?Colloid ? Pre-op V/S: 111 57?)03 0 Output: UOP ? EIBL 5-0‘.1— Procedures: j+ IN ?Meds/Times: 1 --rl-rar)L, j '
IP. xti 1-ttS -(:).-
Pre Op Meds istor
5, a
Time Sa02
Fi02
Methods 240
220
200
180
160
140
120
100
80
60
40
20
RR
T
Time
Pain (0-10)
LOS
Or ed w written entries give: list middle: grade: date: hospital ar medical tank)

Time Solution
I? 00
X-rays:
Drains Hemo c
rP
-tube Foley TLS
Pacu Intake
Amount Site By
1:koilf6
Labs:
Post-Anesthesia Recovery score

Criteria
Activity
(2) Moves 4 Extremities
Moves 2 Extremities

(0) Moves 0 Extremities
Airway
(2)
Cough. Deep breath

(1)
Dyspnea. fimited breathing

(0)
Apnea

Blood Pressure
(2)
SOP. =4-20 of Pre-op

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

(0)
SBP =I-50 of Pre-op

Consaousness
(2) Fully Awake, audible crying
(1) Arousable to verbal or pain
Color
(2) Baseline color & appearance
(1)
pale, mottled, jaundiced

(0)
Cyanotic

Circulation (Peds 5 Years)
(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial

(0)
Carotid only reliable pulse

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for
DIC.
ADM 30'
z,
2_)
ID

Patten teaching done; Wound Ca e. Pain Management.
T. C, 8 DB,. Incentive Spirometer. Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained
DEPARTMENTISERVICEICLINIC
iltaL

Name -last.
.
HISTOLPHYSICAL

.
OTHEipAMINATION OR EVALUATION

O DIAGNOSTIC STUDIES
. TREATMENT
OTSG APPROVED !Dater
rl
lb

Airway Nasal C_Ota1 ETT Trach Other
Infused
-z_sn
Codes

AIRWAY
A= Ambu
BB = Blow-by
M - Mask
FT= Face
Tent
RA = RoomAir
NC = Nasal
Cannula

VIS

X= A-line BP ,
=Cuff BP
= Pulse

TEMP S.= Skin 0= Oral A = Axillary T = Tympanic R =RectalR.1
LOS
C = Cervical
T = Thoracic
L = Lumbar
S = Sacral

Montrone on reverse!
DATE
FLOW CHART
.
. OTHER aNa,./

DA FORM 4700, MAY 78RWAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC 52.60
MEDCOM - 23489
DOD-037067

MEDICATIONS

Allergies:
Time Pain Medication & Route By
1-10 Onsaae

V

NEUROVASCULAR

Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm?(i)a ilit 15' g LI. LIDP1 reiyiut_ -I--- f . 6 —B ki b\I Pig12 le--
30'
45'
60'
90'
DIC

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

Adm (6 tiZri,--V L/ rit -:-.7:=)-
c..­

30• E.?LL, "Z-k t
60' DIC
NURSING NOTES
k.kStrvAq /1(6-mu
Lsfp I -I- (6 -hard_ a-) X_ b;/ eftAtc.?ic-41vAti t
LI)--L

-)/4?ZX Z Lv /i )-)-PAJ JOTirvite,Yft "Lriki.rikou 4\(?trr(ae5f-. i V
bitA{)1AHLI/iy) ?-h). Orli
ILL(

et.
PACU OUTPUT
Time Source?Colerfl‘earance Amount

CARDIAC RHYTHM Time Rhythm Symptomatic? Rhythm Strip Run?
1 .Z.DO Ste _, c:L='-. c=:=,-
Discharge Criteria:
Date: loy.la-1( Time: /1PARS: jo
Bp: IDbiy1tl' , RR: a/.Sa02:q5—

„ T: 9HR: Pain Le er at D/C 10-101: Intake:.21 ) 1Output: --,-C---;) Additional Data: Transferred To: (‘ I Report Given To: Transferred Via:
Gurney Ambulance

Transferred By: b 10- t
Cleared lAW Rec
0
.e Signature:

-234901
WAMC OP 173.E
DOD-037068

RESULTS ;- fiOCEDURE ACOOMPANEC,
PROCEDURE :SIZE rrE
O ETCO2 Change

. Oral CT Scan:?. ContrastET
.
Nasal . BBS Post Int

.
Head?. Abd?. Pelvis Teeth

Intubation . Post CXR
. Air . Contents . C-Spine . T/L Spine . Chest
Gastric
.
Oral

. Verified?
.
Nasal

Tube Suction: Y N
? A-Gram Site:

. Return CC
Urinary
. Meatus . Herne Dip: + -
IV ACCESS & FLUIDS
. Supra-Public
0 Secured
AMT
. Grossly: + ­DPL . Opened

Cell count
. Closed
Sent@
. Air . Blood
Chest
. Pleuravac?cm
L R

Tube #1
.
Autotransf user

.
Air . Blood

Chest
MEDICATIODJS
. Pleuravac?cm
L R

Tube #2
. Autotransf user MEDICATION DOSE TIME DOSE R PQSE Rhythm: Comments
12 Lead

? AMMO =AIM M
sO IC
/5
PM ABS:
?

.
D-stick 0 SHct . Chest Initial
?

.
D-stick . SHct . Chest Post ET

SBC • ,4:1 Chem ji(PT/PTT . Chest Post CT BLOOD PRODUCTS
Mt*

.
ETOH . T&S O T&G.-x . C-Spine

.
Tox Screen . Pelvis

UA . HCG

.
OTHER

.
OTHER

INTAKE & OUTPUT
INTAKE OUNT U Amovto-

CBC: Chem:
IVF Urine

c..)4,./0
NGT NGT
2e2
Blood EBL

5, /
Other Other P7/z7 /s-, 1/31 ; TOTAL TOTAL
TRAUMA TEAM AF-RIVAL VALUABLES & CLOTHING ,—,E,t,,
1404 ,?.
LE Eiikiiiiimi '
E D Phys None Found
S urgeon Given to Patient
Given to Family

nesth
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes

X-Ray DISPOSITION
RT . Home .

Admitted to
Ortho
Report Called to
Neuro
Time Transferred

Chaplain
MEDCOM - 23491 By?

DOD-037069
VI AL SIGNS GLASGOW COMA SCALE
Temp: GCS: VREBLE RESPONSE . -:NIOTOR;RESPONSE -,'`.
TIME RR' "SA°2 FiO2 :MODE' 4 - Spont 5 - Oriented 6 - Obeys Commands
ti) 1 3(g/73 10 3 - To Vo 4 - Confused 5 -Localizes Pain
PC/13 0396 f7/06 is-z to 1) 3 I C tr-110 2 - To Pai 1 - None 3 -Inapp Words 2 - Incomp Speech 1 - None -Withdraws to Pain 3 - Flexion to Pain 2 - Extension to Pain
04­01 IP 1 - None
oq w 12014o 13.0CdijiME:: .,.,PERFORME1); EY:,
0 Backboard Removed BY:
CI Downgraded BY:
-z_
'1
fr
MOO.pi,-AR -ekLi e.c
p c:a ¦ l¦1Or
e3oLLA
----/

MEDCOM - 23492
DOD-037070
E ki !'-'U pi pi 6-- j .et_
0 75
A-An° 3

e
Ow.
vp,

MEDCOM - 23493
DOD-037071

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE

OTSG APPROVED (Date)
TRAUMA FLOWSHEET

The proponent is Dept of Surgery 01 Appr 11 Jun 97
TIME: R ETA:
0 IV x r . 02 . Vrnin . C Spine Immob

MED COM:
a Meds:?. UKN?. None?. Yes: ? Allergies: . UKN?. None?. Yes:?
Tetanus: D UKN?0 Current Last Meal/Fluid Intake ?hrs LMP:
PRIMARY SURVEY
AIRWAY

BRETHING CIRCULATION
,LEkNaturalRPatient . Labored A4 UnlaboredR. Absent PULSE:R Present . Absent SKIN: )Warn . Cool
. Hot

.
ETT TRACHEAd Midline . Deviated BLEEDING: . Pink . Pale . Cyanotic .R

.
Secretions

1
CHEST SYMMETRY: 13 ci HEART TONES: . Clear 0 Muffled Dry . Moist . Diaphoretic
SECONDARY SURVEY
"DISABILITY'
HEAD HEART ABDOMEN
GCS: ERPUPILS:REqual . Fixed . React . Dilated 13 a RHYTHM: C14115trlar . oft . Rigid allNon-Tender
TM:R. Clear . Blood a PULSES: . CentralR. Peripheral . Tender:
M NECK LUNGS . PELVIS
C-Spine Tenderness: a BREATH SOUNDS: . Bilat . Equal 0 Clear Getable . Unstable .

SPHINCTER TONE:
R
Pain @

.
WNL Decreased a Absent II a Blood at meatus/vagina:

.
None

JVD: Wheezes LI Crackles II a Herne +f -Prostate: . WNL O Abnl
USE DIAGRAM TO' DOCUMENT INJURIES AND PAIN VASCULAR ASSESSMENT

(AB)rasion
(AMP)utation
(AV)ulsion

Battle's Signs
IBLIeeding
IB)urn
ID . eformity
(E)cchymosis
(F)oreign Body
IH)ematoma
ILAC)eration
1Pluncture Mound
(Pain)
ISleatbelt (S)ign
(SItab (W)ound
IGSW) Gun Shot Wound — )2

+ + Strong + Palpable D Dopler

PHYSICIAN
(Continue on reverse)

DEPARTMENT/SER E/CLINIC DATE
ENTIFICATION (For typed or written entries give: Name--last, first,

middle; grade; date; hospital or medical facility) . HISTORY/PHYSICALR. FLOW CHART

.
OTHER EXAMINATION . OTHER (Specify)OR EVALUATION

.
DIAGNOSTIC STUDIES

411111110(1 -
. TREATMENT
D BY DD FORM 2CO5.

DA I FP ZYM7 8 4700
MEDCOM 234941_ETE. EAMC OP 503, 1 Dec 98
-

DOD-037072

,Q
1. Reporting MTF 2. MTF Loc....—•
Admission and Cod,ng Information
IZ

For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number Name (Last, First, MI) 4. Pay Grade i?5. Sex 0015197
FGN M
(_4?3\

6. DoB (YYYYMMDD) 7. Age at Admission 8. Race?9. Ethnicity Religion

1979-01-01
24Y X?9
10. Length of Service
ETS 11. FMP?12. Social Security Number 99
-?Organization (Active Duty Only)
13. Marital Status Hour. of Admission Branch / Corps:
03:00

14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS
19. Trauma Prey. Admission DIS NO
20. Source of Admission Ward:
Name / Relationship of Emergency Addressee Direct from ER ICW1 Address of Emergency Addressee
-?• cility:?i?,_ Telephone Number of Emergency Addressee
21.
Type of Disposition

22.
MTF Transferred To 23. Date of Disposition (YYYYMMDD) TRF-OTH /

2003-11-13?

24.
Clinic Svc - Admitting

25.
MTF Transferred From 26. Date this Admission (YYYYMMDD) AEA - ORTHOPEDICS

2003-11-08

27. Location of Occurrence
28. MTF of Initial Admission

29. Date of Initial Admission 2003-11-08
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: S/P VD R IF DPC OPEN MC FX VD BL LE

Procedure Narrative(s):
Cause of Injury Narrative:
k
Admitting Offi :
Automated Facsimile - DA FORM 2985, MAR 2000?
MEDCOM - 23495
DOD-037073
Automated Facsimile INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade Admission Remarks

e ister? me
FGN
10. PrevAdm

8. LnthOfSvc 9. ETS
5. Age?6. Race 7. Religion?

4. Sex?
NO M 32Y?X

14. Ward13. Organization11. FMP 12. SSN?

MOM ICW1
19. UIC i ZIP 20 Type Case

418. BranchCorps
17. Dept / Ben?'?

15. FlyStatus
BC
K78-PRISONER OF WAR/INTER 23. Clinic Service

22. Hour Of Adm:
21. Source of Admission ABA - GENERAL SURGERY
03:00

Direct from ER 25. Type Disp?26. Date of Disp
24. Name/Relation of Emergency Addressee
TRF-OTH?2003-12-17 AdmittingOfficer .
27b. Telephone No 28. Date This Adm: ?
27a. Address of Emergency Addressee 2003-11-08?
IMO (66 ?
32. Units Blood Components30. Date Mit Adm
t,

29. Re orcin MTF?
2003-11-08
01111.111.1

31. Selected Administrative Data
DoB: 1971-01-01

Marital Status:?
MOS:

In/Out Patient: Inpatient?
33.
Cause Of Injury:

Diagnosis / Operations and Special Procedures:
GSW L BUTTOCKS AND THIGHS

34.

19-6,a

1002 / t
ges-S-7

35. Total Days This Facility ?
Bed Days Total Sick Days

ConLv / Coop Care Days Supplemental Care
Absent Sick Days Other Days?
0 0 1-a
0.C.

35. Total Days This Facility
Bed Days?Total Sick Days

ConLv / Coop Care Days Suppl*ental Care ?Absent Sick Days Other Days?
avitor**:? ,o
Signature of PAD or Medical Records Officer
(
MEDCOM - 23496
Automated Facsimile - DA FORM 3647, May 79

DOD-037074

MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITI N N ADMISSION (Eair date of .1 Ini?fiott
114(1i

ilk 1.
S./?, J'e
s
r
/
Lail '9-5%14C4(

ier7r= Itl/2,1.0 Oa= /.-z
g72 /1/214 •
7117

PHYSICAL EXAMINATION
/02 /V :- /1(0/7 i r (0 ('4? (r'' ' / EA,
7 .

4/7,1{ Jd vo.46 I
k

14: i1A /:_ e ,,,eia tio,
f,ori ad,d;
dtil„724cjj

PROGRESS l „„/6„ clale(6)/i„Anr„and final
=
cf fcciki./go(
(11A va° .0-7

R
ORGANIZATIONIDENTIFICATION NO.

NIA111111111111111111 Dtkv03
'5 rdryP ii :;: te itREGISTER NO.R WARD NO.
I '5 IOENTIFiCATION (Fod. ee
E heon
.e.elvd1Z7
ABBREVIATED MEDICAL RECORD Standard Form aft
GENERAL SERVICES ADMINISTRATION AND
INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975?
539-106
/IT

MEDCOM - 23497
DOD-037075

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD

NOTESDATE

(MVO S? 0 ejcb Jed PI . °I NY\ (t b-ta_ ti o/c) . 1)7_0,12_14)/v
if• • 1 1 k i a ..1.1)4, _ iii_ti affils bpii. . F 2.' , __L :„,
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j. ' ,.77V.eh-c , • -I .4 1 4 .I4 . 4/106 .. Ai ./L'.)-td.76 '.oar.#, , ..L ,
406

./0, ,16,,L,er •.(7,.-0.-5.,-,.c (32Acz.l.„; ,,,i "e4,c, L.,./,/i2 I _Lac
IBP TREND

TIME HR/PR 3p02 SYS / DIA - MEAN I

HH: MM BPM nolig
X.RI
08:10 92 100 101

139 I -,6

08:00 103 100 145 / 24 102

07:50 91 100 141 / ?D 103

07:40 94 100 141 / 77 101

07:30 92 100 166 / 77 110 J

07:20 97 100 139 / 70 96

07:17 09 inn 1 ./

flGet,oxj
OF)L-I 3 Da• I -01 ,1 .1 tat 0,4 ,A ultDri({, • Ribttathrith.
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, Q,Fr-----
I SPONSOR'S ID NUMBER

SPONSOR'S NAME
RELATIONSHIP TO SPONSOR
(SSN or Other) • 4
IMI

HIST
LAST

, ..---- ...,---,.?• .-
DEPARTJSERVICE

HOSPITAL CR MEDICAL FACILI

••••¦••11,11¦111••••••••=..,
r
EGISTER NC. WARD NO.
NNW • lay, fen, made;
No a SU; Sex; Date of Beth; .9ank/6tede1

PATIENT'S IDENTIFICATION: (far typed Of written entries, give:
1..¦111.11
PROGRESS NOTES Medici! Record

STANDARD FORM 509 my:. 511599
Prescribed h•..• GSAIICMR FPIAR FlItER) 101.11.2231M
vw1111li

US' PA V; CO
MEDCOM -23498
DOD-037076
LAST NAME FIRST NAME 1 MIDDLE INITIAL ID NUMBER
DATE NOTES
IUNA
6. I 0--g.( /4, ‘,/_761641--7e, iri of-61.K.:-La
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MEDCOM - 23499
STANDARD FORM 50S IREV. 5119991 I3ACX
DOD-037077
AUTHORIZED FOR LOCAL REPRODUCTION
R

MEDICAL RECORD PROGRESS NOTES
DATE NOTES
ab 1 Mtn _ J A. IRLi I i la A I a' i • 115 1 113-`R )5R7 $1
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SPONSOR'S NAME

LASTR

FIRST ISSN Of'Other)
MIR

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed 01 written entries, give: Name • last, lin mahlle•
REGISTER NO.
WARD ND,
/D No ar SSM- Ser; Date of Birth; Rank/Grade)


I /. N . i
PROGRESS NOTES Medical Record

`-P-PLU 14111111 STANDARD FORM 509 IREV. 511999)
Prescribed by GSAIICMR FPMR I4ICFRI 101-11.203(bIl1al
MEDCOM - 23500
USAPA VI.00
DOD-037078
1ST NAME
FIRST NAME
MIDDLE INITIAL ID NUMBER

DATE
NOTES1

)462-&PT, _:Zel)
1-
-

Rizo i . h Le_ 0,,/).AA. e (7,6 --7.k(),P61/.
I

MEDCOM - 23501
STANDARD FORM 509 niEv. 6119091 BACK
DOD-037079
STANDARD FORM 509

(REV. 5/1999) BAC:
MEDCOM - 23502
0161 -tj
111iIk
USAPA VI

DOD-037080
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD I1 PROGRESS NOTES
DATE NOTES
Th *-0,.,,,sF,2_,/,,-,1-1-r, lad I ..,-,,,-, I( k_i i ul, -H-e-•• A--, '; 1.-0 i f ec9-----a-.1-1, 4,-,---j.A-1 V5 5, ,,-1---1
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Doc_nid: 
3969
Doc_type_num: 
77