Medical Report: 37-Year-Old Iraqi Male re: Gunshot Wound to Abdomen

Medical records of a 37 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wound to abdomen. 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 or pedigree information on the detainee.

Doc_type: 
Medical
Doc_date: 
Wednesday, July 30, 2003
Doc_rel_date: 
Monday, October 3, 2005
Doc_text: 

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PROGRESS NOTES
Medical Record
STANDARD FORM 509 IREV. 5/19991 Prescribed by GSAIICMR FPMR141CFRI 101-11.203(W°)
USAPA V1.00
MEDCOM 15275
-
DOD-028664
Ip (See Instructions on Back of this 4. NSN 7540.01-075-3786
LOG NUMBER
EMERGENCY CARE AND t REATMEN71 T mp)
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ARRIVAL
TIME PATI ENT
DATE
PRIVATE
MONTH YR. AMBULANCE ALLERGIE
03 /33 tD OTHER (Specify)
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DESCRIBE (1) $ubjective data (Pertinent History); (2) Objective data TIME SEEN BY PROVIDER
VITAL SIGNS
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EMERGENCY TODAY
72 HOURS ROUTINE
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CONDITION UPON RELEASE
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PATIENT'S IDENTIFICATION (Mechanical imprint) SIGNATURE OF PFrOVTDER-)Areo-ro-sT-Am.
FOR WRITTEN ENTRIES GIVE: Name - last, first, middle;
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plans)
TREATMENT STANDARD FORM 558 (Rev. 8-82)
MEDCOM - 15276
Prescribed by GSA and 1CMR
Medical Record Copy
FIRMR 141 CFR) 201-45.503
DOD-028665
510-112 NSN 7540-00-634-4123
NURSING NOTESMEDICAL RECORD
(Sign all notes) HOUR
OBSERVATIONS
DATE
A.M. P.M. Include medication and treatment when indicated
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NURSING NOTES
Medical Record MEDCOM - 15277
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

DOD-028666
NURSING NOTES
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OBSERVATIONS
Include medication and treatment when indicated
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DOD-028667

510-112
MEDICAL RECORD
NSN 7540.00-6
NURSING NOTES
DATE
(Sign all notes) OVATIONS
Include medication and
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ment when indicated
PATIENT'S IDENTIFICATION
d--ko
(For typed
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NURSING NOTES
NOTES Medical Record
MEDCOM - 15279 STANDARD FORM S10 (REV. 7-91)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
DOD-028668

NSN 7540-00-634-4
NURSING NOTES
510-112 (Sign all notes)
OBSERVATIONS
MEDICAL RECORD
Include medication and treatment when indicated
DATE

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MEDCOM - 15280
DOD-028669
NURSING NOTES
HOUR (Sign all notes)
DATE
OBSERVATIONS Include medication and treatment when indicated
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DOD-028670

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NURSING NOTESMEDICAL RECORD
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DATE
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STANDARD FORM 510 (REV. 7-91)
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MEDCOM - 1
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MEDCOM - 15283
DOD-028672
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NURSING NOTES
Medical Record
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1.

MEDCOM - 15284
DOD-028673

NSN 7540-00-634-4123
NURSING NOTES
MEDICAL RECORD
(Sign all notes)
HOUR
OBSERVATIONS
DATE
A.M. P.M. Include medication and treatment when indicated
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NURSING NOTES Medical Record
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 15285
DOD-028674

NURSING NOTES
(Sign ail notes
HOUR OBSERVATIONS AM. P.M.
DATE
Include medication and treatment when indicated
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MEDCOM - 15286
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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)(10)
USAPA V1.00

MEDCOM - 15287

DOD-028676

rl t tc1N 1o0c001VICIN f
TIME -2 SIGN• ,
--,...S. N AND MUCOUS MEMBRANES/

Skin : 'Loose/ ht / Dia•horetic / Shin / 0
Skin :•-•:
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Mucous Membranes: -Moist / • Cracked
Skin Breakdown: /None --/Location: Size:
4.,-
....____.. NEUROLOGICAL
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Loc / Alert / ' thargic / Unresponsive . GCS: •
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Extremity Movement: Full / int ed /:None ece7 -,€#Yz-f
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Pulse ( 0 • 4): _. Radials i:
-- -'Pedals
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Homan's Sign

Jugular Venous Distension (6 Edema,
Heart Sounds 5-1S-• _
Rhythm PRI:
ORS:
Vascular Catheter Central Arterial

1.1,---e '

pen. heral i Peri•heral 2 Waveforms . Site
Solution
Chest Pain
_RESR1RATORY

Chest Expansion / mmetrical-AsymmetrIcal
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Cough roducti e4 Nonproductive 1 None
Sputum: o or / Amount / Consistency / Odor
ilUIZ-C: Chest Drainage Syste Gravity:
Suction cm: Op
Air Leak o Yes

--Crepitus Character of : 5r0(64-17?-0 -14-"
Trachea / Midi; / Deviated R /.Deviated (L) Artificial Airway Size: -Type:
Position:
Breath Sounds • Anterior/Location Posterlor/Locatioit

C rackles r"--
Wheezes
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Diminished 41 •
-Absent
GASTROINTESTINAL

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c9 lith Bowel Sour, s Normal / Hyperactive I Hypoactive Otisent„..-) Dressings:
NG Tube: Clamped/Inter, Suction/Cont. Suction/Dependent Drainage NG Drainage: Color _ ,..-Character
Tube Feeding: Cay*:-Of Strength: Rate: Aspirate:
Stool: Character V.../.
Drains: .,
/GENITOURINARY

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DOD-028683
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MEDCOM - 15295

DOD-028684
511-119 NSN 7540-00-634-4124

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MEDCOM - 15296

DOD-028685
NSN 7540-00-634-4124
VITAL SIGNS RE(MEDICAL RECORD
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MEDCOM - 15297

DOD-028686
MEDICAL RECORD VITAL SIGNS RECORD ti-.
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MEDCOM - 15298

WAMMORYSIMV DOD-028687
MSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
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70
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( $ ..•:0
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RESPIRATION RECORD .
AID

UIONIMES5 l
0

• • '14

Record specialdata only when so ordered
BLOOD PRESSURE
• ZLS I 6
.

. 3 1 riiiMillilM s• if, 11.-il.D -i I . PA, V.-.A¦ firs
r, ti, . A

HEIGHT: WEIGHT ••—¦ ,..A, N vv.* c, ,...
s . '
I R-41111111MIMEM MR • .1 i CIO lb
-

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• tvi
....
4*

PATIENT'S 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)
17
VITAL SIGNS RECORDS
411114111

Medical Record
MEDCOM - 15299

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

DOD-028688

VITAL SIGNS RECORD

MEDICAL RECORD
1 1111111MIIIMII
l 11

HOSPITAL DAY WillifiMirArM
rallie", p,111EMIFIPM11111111111
?OST-TEMP. C
MONTH-YEAR
PULSE HOUR
19 40.6 °
TEMP. F 1111011
105° i16640.0 0
OMMINEMPEMMOMM

104' 39.4 °
180 SMMEMENIMMOMMM
103° 38.9 ° 0
170 INIMMINIMMINOWN
102° 38.3' cc
160 MMMINIMMIIMMWOM
ui

101" 37.8 ° 0
150 MINOMMMOMMOMM
100° 37.2 °
140 MMINOMMIONMENN 37.0 ° a)
36.7 °
C0
99°

130 no
98.6°

120 98° MMUMBMWMMEIMMagag
36.1 °
110 97° MINIMMOOMMINIMM
35.6 °
100 W MOIMMMEMMIKOMME
35.0 °
90 95° MINIMINIMMMWMOM
MMINUMMWMMOIMM
80 MMONSIMMINNMEME 70 MONOMMEMONIMM 60 MMOMMEMWMMOIMM 50 MINIMMIIMMOMMM 40 ANOWNWIIII
RESPIRATION RECORD
err

WARD NO. REGISTER NO.
or written entries give: Name—last, first, middle; ID No.
t41WICN(101s1 cgred

PATIENT'S IDE other); spiral or medical facility)
_ STANDARD FORM 51.1 (REV. 7-95) BAC
MEDCOM - 15300

DOD-028689

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY

MOM POST-DAY 1111MTME l
irralEMINAM&I MONTH-YEAR DAY raflr" it... 7" II I arg ForaillIPEWPMFMAr .0211/01fiedaral • • 1111111011111111,111MIThal
'OR14 4

-

19 HOUR
. .
PULSE TEMP F 111= . : : : : : : :

—1
W co (..) C.i.) cow co (...) c..) (.4 A A m
1
0 -1 ul o-) o) -4 V ---1 COCO CO00
b'cr, i-‘ :-.1 bk.) 'co .G.)'
COA60) 70
0 0 00 0 0 0

(Centigrade Equivalents, for Reference only)

:. • BIM .. i • •
()
(.)
105°
. .

180 104° •• . . ••. •• . ••. ••. " . . ••. ••. " . . ••. •. " . . " . . -. •. " . . " . . •.
170 103° , . , . • . . • . . -. . • . . • . . • . . • . . • . . • . . • . . • . . • . . • . . • . . • . . • . . • • . .• . • .. . • . . • . . • . . • . .
. . . . . . . . . . . . . . . . . . . . . . . . .
160 102° . . , . . •. . •. . •. . •. . •. . . . ." •. . . •. . •. . " . . •. . •. . •. . . " . . . . " . . . •. . •. . " . . . . " . -

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

1
150 101° , ,
'
. . . . . . . . . .

. . . . . . . . . . . .
140 100° • •

•-•• •• • • • • •• •• • • • • • • • •
-

' •

. . . . . -. . . . . . . . . . . . . . . .
130 99°
98.6"

: : . : : : :it, . . : • di. : ::. ::. :
•a •• • •\
120
98°
A •
. ,
inglimillsi

-

: .:II:: ::::::::: 1111111=1/1 •
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rlislow
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vir
-

-

RESPIRATION RECORD
BLOOD PRESSURE
;-,-Imi

'Record special data only when so ordered
0111511
1Mil
„,

-

mem
.-.

HEIGHT: WEIGHT 1, i
11agliiAllEraiErantittl
V~
Or
000 7111111111141
4 •,
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/
II
v-

111111 PATIENT'S IDENTIFICATION (For typed or written entries give -Name—last, first, middle; ID No. (SSN or other): hospital or medical facility) f REGISTER NO WARD NO. STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM — 15301
DOD-028690

NSN 7540-00-634-4124
VITAL SIGNS RECORD
MEDICAL RECORD
HOSPITAL DAY POST-DAY DAY
rat.irrazw-Arminisraramasvezz

'

MONTH•YEAR
i

•• MIIIIMITAIPMEI

: I.
1:

HOUR 1
rim • -
FAVI•
111113 • • • •

I
ti ..•.
19

PULSE
• • I I
• I** g
(*)
105°
40.6°; 1MI
TEMP. C
et:
•6:-•

114 •z1
C
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I:
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. . . . . . . . . . ......
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. .
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. . . .
•.

.:. :•• :

180 104°
170 103°
160 102°
. . . . .
39.4°
• •
.

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C
c. c
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. . . . . . .

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WA
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.

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150 101°
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140 . . in
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.

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2

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37°
37.0 °
130 99° ••
a
Lu

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IMIM Lisimil
98.6° •
:
:
a

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36.7°

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98.

120
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RESPIRATION RECORD iS
-ci
BLOOD PRESSURE

faii

1,7:11171/11.
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PATIENT'S IDENTIFICATION (For typed or written entries give . Name—last, first, middle; ID No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility)
IMISMIEMI

VITAL SIGNS RECORDS
Medical Record
\1A 4 „.

STANDARD FORM 511 (REV. 7-95)
7,

Prescribed by GSA/ICMR. F1RAIR (41 CFR) 201-9.202-1
a

HEIGHT: WEIGHT •••.-.00 1TAMINMOE

Millirr-
MEDCOM - 15302

DOD-028691
NSN 7540-00-634-4124
MAW:

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY MIMI
nWalea

DAY ...fagerefall ArairdMIVOIrigik,
POST-Wim.1-7--­MONTH-YEAR DAY ..nirilWrAMIIII MOM 19 HOUR lz ifARI • • • • • IM" ,MI --&Mill • • • • mipili
PULSE TEMP. F

tO) (s)
105°
••¦••¦

IIEMII :. :. .•. :• :. :. . . . . 111

• it

H H H
ill
180 104°

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

170 103°

160 02°

COtoCOLOCO COCO CO (CPcri 9)0)-4-4-4 COo0 (
1-% -1ON bo
4

...... . . . . . . . . . . . . . . . .
•• • ..... • • • • • • • • • -• •-• • ••
. . . . . . . . . . . . . . . . . . . . . . . .
.... " • " • • • • " " • " • •
. . . .

(Centigrade Equivalents, for Reference on l
Co
. . . . .

..... .
.... •
......
......
..
150 101°

i...)
0 0

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

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. . . . . . . . . . . " . . . . .
. .

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. . . .

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. .

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

140 100°

. .

. . 111 . . i . i . . :-i i

99.
130
98.6°

0 0 0

EllEMFMNIEMINErnIIMINEIEMEEMEEMI1111===21111•1111•1111:11
: : : : : : : : : : :: II •...
im
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120 98°
.:

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li

110 97°

bin
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100 96°
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. . . . . . . . •• •lin i i
pg --

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40

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1 1

RESPIRATION RE CORD (4
BLOOD PRESSURE

ir • la Ir4 EtIMaPM1 rallIMMIIIIIIII mgr.
i q mitemaimminvism
hafrolo marimmimitfami
HEIGHT:
11=1=r3ifd aisMIIIMIIMPRIN IffillInek.11111
q laffill 1111¦/4179'd EVAI. II
AWLIIIII "AIMMI=
P'"9rIld
I

Record specialdata only when so ordered
PATIENT'S IDENTIFICATION (For typed or written entries give . Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) Iii.-1¦Es.—_ REGISTER NO WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 51.1. (REV. 7-95) Prescribed by GSA/ICMR. AMR (41 CFR) 201-9.202-1

MEDCOM - 15303

DOD-028692

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR DAY q Dal A-7' eor S ril-
19 HOUR 6174c-• • 0-101) ' • 01W " ' ' ' " • •
' ' ' ' •• •• ••

PULSE TEMP. E . .
(0) (•)
105°

. . . . . . . . . . . . . . . . . . . . . . . . . .
180 104 ° . • •• •• • • • • •• • • •• •
. . . . . . . . . . . . . 170 103°
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 102° •• • • •• • • •• •
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
150 101°

. . . . . . -. . . . . . . . . . .
. . . . . . . . . . . . . . . . •. -. •• •• •-•• . . . . . . . . . . . . . . . . . . 140 100° " " " " " •• ••
. .
.
.
.

-I (JJW WW cow W W 0.) W -4•CA. rT,
(71C.TIa) 01--.1'NI-.4 00CO(000K
O 0) i '-., ON 'co io (o :1=. b 0) 7 0 0 0 0 0 0 0 00 0 o
0 0

(Centigrade Equivalents, for Reference only)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

•• " • " •• "
130 99°
. . . . . . . . .

. . . . . . . . . . . . . . .
98.6° :• • : : . . . . . . . . v. . . . . . . . . . . . . . . . . .
120

98° . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
110 97°

100 96°
90
95° ........ . . . . -

-
....
. . ........ . . ..... . . .

........ i .. .
.. .. .. . . : : ....

80
....
......
......
. . . . . .
................... .
.

.
.
.
.
.
.
.
.
.. .

... . . . . . . . . . . . .
70
. . . .

. . . . . . . . . . . . . . . . . .
50 • • . • • . • • . • • . • • . • • . •I
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
40 RESPIRATION RECORD . i . . . . 1 . . . . " " " ' " • • . . . .

'Record special data only when so ordered
BLOOD PRESSURE tos15ci /o Vat (03151
lk V) 14 Wil- II St "
TV -r VI r 1E 1'
HEIGHT: I WEIGHT —4. 1 II, R iirp 61' 71.
)24‘ len AA

PATIENT'S IDENTIFICATION (For typed or wri ten entries give -Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) (.6 REGISTER NO WARD NO. STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 15304
DOD-028693

• ;•';

• Ti . ; .
75-) i 13 3
C C4) 0 ennsitm a• CP:CZ•ii15)

i P.'. f., 1; ! 2,...1/4, 1 1 -.-1.2%t ' .,.. :
I.g)- 1 lo ' 7. , F : :': r.1.•,' ::
_ .; i

t J
- -7 PI CCOE 0 := : = : = = -:

PICCOLO
Li E F1 NC :E. HAN—

13: '‘,1E ' ..:.-•i-ii
PA 27/07/03 13 : 53
NE-NI AI : ,1 .;:, 45 1: : i :1 i :::' ( . :. 1 . CUl.. -RN. c,i1=1,-0'1.1 ) ---II I N ¦ , RE ERENCE RANGE : MALE Y 12
- ;
PATIENT H : MI
F' LOT If :

3112AA4 ,_ s.
I ..., ..“:..

01--D? ia4 : um ,c i El EE RH. : I y FE
C T LR0
L /iDR /1: 000
SERI AL It : _ DISC DR H: 50A0A04
' . N .

. -_-SERIAL H : 10101111.
., „1.
u 2 . ?* --3. . ,7.J-c -4.--36 28-84
C/EL i;
NA+ 133 128-145 MMOVL
21 10-47 u/L

. Mifi.iii.AMY K+ 3.4 3.3-4.7 MOM_
::35
14-97
U/L.

CL-104 98-108 MMOVL
11 38

I ____N
W V__-_I
t CO2 21 18-33 MMOVL
) . 9
0.2-.1 .b MG/D1..

BUN 9 _ :1
7-22

,:1 I NST GC: K._ ,1 O CHEM DC: OK
___,.1
CA t i 7.7* 8.0-10.3 M
MIG:3/1r1

1-EM 0 , LIP 0 , ICT 0
CHU_ 130
•- - , ,• 100-200 MG/DL
-
;• _
CRE 1.0
0.6-1.2 MG/DL
GLU 101

i 73-118
, a.'..5 ::.,:.1, MO/DL

• ,
TP '1.9*
6.4-8.1
8/11_ -

I BR
I NSF
OC: OK CHEM OC: (-fr.
HEM 0

LAP 0
ICI 0
hi:12;04 1a
1
ri
aik

MEDCOM - 15305

DOD-028694

T
SSN
6 ( 33
A Esc. Seg
I

XL ;L. r REF TEST I ;1.1
i 1.•zi•-; ...:.:. ,.(: ; ,_c„,.;
RPR

•111111 -_. „ ....,. li
1

ID: 27-07-03 ; ,' , .--,P rNi.'s ',.1 poluill.) I I i\lc : IA;
. I ii I
f' 113 -, I--I
1401 ir II
. • Patient Limits-f 1[
8.8 . 3 NefLtaii , :.

NBC 110A3/ti. 4.51 10.5 111:
RIC 3.72 L 11Cr,6/uL 4.00' 6.00 ,--

I
, ,. .. •

Hgb 10.8 L 9/d.11'4 - 18.0 Nc.:.:....th.-
i i'-'m I ­
lit 34.01. Z
310 '60.0-
t1CV 91.4

1 -
ft 80.0- 99.9
.:',E.i N:.-`._

la 29.1 P9 27. 0 31.0 I
WIC 31.91 g/dL 33.0 37.0 .

,
Pit 172. ti.. i ‘le.......iti... 1' H. p)..h.-.1:

z10"3/mL 150. 450.
LYZ 7.1 *L Z

LYN 20:5 . 51.1 1.7H 11.../,. ¦
0.6 +I x10‘3/td. 1.2 3.4 M
I

' • Pailislic't;
-P-Nt.tgaii.,.:
h M.:dal-id
i
L
Ba St 1 Negat;.:

.. .. ..._ ce:Iii;A:.
."%iiers)tic;roat: ....Iiihr.swit,':i;I:-.
t h
4

CSF 61o4sti ink
: .
t
. . . . -
:411i.JS 'EVIEIZY

1 i i it',C1 i'4`.N1 !i i -1\1:..-,2.• • k C , ._:.) ¦..)r is...
.._ A.L-'-. . I i
.,.
( Iint;..-b1 Sta635

B1o4:9d Bank Unit Crossr.nateh
(Nufsa St -MIT SF 5U ‘VIII-1 'EVERY UNIT Of BLOOL ).
REQUESTED')

P.'PE
4

_ - sCr1+ 5..AN '11P
MEDCOM - 15306
.0 --- (C_a

MEDCOM - 15307

DOD-028696

Ward/Su:601i:

C -IA
, • , • •
••• (1,STAT): • • . ...

TEST RES U1,7' RE fi. RANGE
a 138-146 uunon. 3.5-4.9 omat 913 -109 moa..¦ Iii.
PH
PCO2 -T 35-45 mmHg (a()
51 ,143411-14 t ¦ auHp, kart) Ni\ (vLti:i
22-27 ,,u1101/1.- (la) 24-29
TCO2
Cr.!) [ 22-26 moinVI, (art) 23-28 ;t1¦ 11111....(vco)
:302
I3Eca (-2; (-..3)

AnCiap 10-20 frtn .
. _ Ca .12- i.:12 1JunoWL,
BUN 1i-20 .14,1,if
OLU ;41­
0,c 11.
.real 1).7- i.5 7oRita
Het 3a-51"/.. PCV
12-1Y ¦.1(11
. . • - •

Mas. Ceixiry •• ' rim RESULT I REF. RA..A/CE
"Iropnin-i
Drug of
A tins::

•-••.,---¦ • - --- • --•
_
11.1?.ivYAR KS:
T1NG PHYSICIAN:
t Li)
TEST RESULT
ALE
ALP
ALT
AMY
AST

TBIL
GLu
BUN [OLE
_.......

CK
NA

CL
Way
DATE:
Mu.140-5

L:21?„SULT FORM: Subject to the Privacy Act of 1074) ATE T JE
SSI\UPS1.36-13-6
O4cO

12:7 '-(Piccolo) Metabolic Pa'net'
RLF TF
RANGE

3.5-5.5 Gi
PICCOLO .

26-84 SI BC
04:11

28/07/03.

10-47 all
Ci
MALE

.
1-1.1-ERETCE RANcL

14-97 Rh

I ei f
PATIENT #:.

11-38 u/1

1\i' METLYTE 8 0.2-1•6 nigidL DISC LOT #:.
3152AA4
OPER #:111111DR #: 000

7-22 713gkii C.1
SERIAL #: MOW

8.0-10.3111g/di t
100 -2G0 tag/d)

GLU.

172* 73-118 MG/DL
0.6-1.2 utgidl BUN.MG/DL

7 7-22.
CRE.0.6-1.2 MG/DL

1.0.

73-1i 8 mghil

A. CK.U/L
1111* 39-380.

4-8,1 g/cli A
NA+.

133.

128-145 MMOt'L A K+.
3.9.

3.3-4.7 MMOM..
CL—.

103 98-108 MMOVL

R.EF.

tCO2 23 18-33.

MMOVL

73-118 414g/dl

INST OC: OK.

CHEM OC: OK

7-22 rag/nil

HEM 0 , LIP 0 , ICT 0

0.6-1.2 mg/di G
39-3.30 :A OA) T
30-190 till 11
128-145 crunolll

)11,1101/1
98-108 auuulll
18-33 utinc.)1/1
MEDCOM — 15308

DOD-028697

L
1.,/kitoR.A.T5R.Y RESULT FORM :1 (soit...0 to the Privacy Act of I
Occ 13k!
EX 3.76 L x10"6/Hl. 4.00 6.00

TIME SSNIPSELIDO SAN:
OfernatoUogy C Urinalysis . Misc. Serology -
rac. NUI.7' I REF reAavoi, 4.8.10.810; Cu! , ,, TEST RESULT I ,:EF, RANG.E .. _ NiA TEST RESULT RPR 1 REF. k/iNG.,:,-i Neptivc. . 1
x 104 App Mono 1 Neg-1iive s
BAIIIIIIP1413 :29-07-03 04:15 Bili .1\14,g:dive Source Microbiology .
WBC 11.7 H x1043/u1 Patient Limits 4.5 10.5 K et Negative 'Niz1 Gram Stain

ll9b 11.0 L 9/d1 11.0 19.ft 1.11d Negative
11. pylori
Hct • 34.6 L I 35.0 60.0

t1CV 92.0 & pia Micro
:.1 .0 99.9
POI 29.2 Pg 27.0 31.0 Parasites

WC 31.71 g/d.

33:0 37.0 Prot MalariaPlt 199.
1101/a1 150. 450.

LTX 9.3 *1 Z tlrob

213 51.1 . 0 P14
1.1 * x10'341
1.2 3.4
Ni! Negative

Other Leek Mier oseopic Urinalysis
2-52 '!.. (A•/

CST Blood Bank

CCU

MUST SUBMIT Sr' 518 W1'111
(': aunt I

EVERY UNIT REQUESTED
ABO/Rh
Coagulat4on Siutlies

• Blood Bank Unit Crossmatch
(MUST SUBMIT SF 518.WITH EVERY UNIT OF BLOOD REQUESTED)
L.SY RESULT PE'•'. RANGE (.INTI
TYPE CRO.Sr,1AL4
--- — — — • ..• •. , • ,....,...–•_

P7i-34 tags t-
FDP
J.
REMARKS:

1
5 DATII: Liklit, ID NO.:
(1)
MEDCOM - 15309

AN: LABORATORY RESULT FORM
Ward/Section: REQUES
P. Sub ect to the Privacy Act of 1974 )
,_, -

DATE TIME , SSN/PSEUDO SSN:
LAST, FIRST, MI.7.,
t.._P 7 -act OGSK.)

-

Misc. Sero1ogy .
(Hematology C C t ci.) ` Urinalysis

REF. RANGE
TEST RESULT V F. RANGE TEST RESULT REF. RANGE TEST RESULT
N/A Negative
4.8-10.8 x 10' Color RPR
, WBC
. _

Negative
N/A Mono Ne
RBC App
29-07-03 Glu Negative WrobiolOgy

ligla ill' vim
07:20 Patient Negative Source
BiliHet

Limits
wec 9.1 i1.01/01_ 4.5 10.5 Ket Negative Gram
MCI RE 3.87 L 11.0"6/aL 4.00 6.00

Stain
140Hct 11.3 9/ii 11.0 18.0
NegativeN/A OCC B Id

Pit M.2 Z 35.0 60.0 SG
to 91.0 fl. 80.0 99.9

BId Negative H. pylori. Negative
Lym l'Ell 29. 3 Pg 27.0 31.0
MX 32.2 I 9/cIL 33.0 37.0

N/A Micro
(r • Pit 194. x1.)"3/uL 150. 450. PH
La 7,7 *i_ z Parasites
20,5 51.1
l_Yil 0.7 *L x10".3/tiL 1.2 3.4 Prot Negative Malaria

Sep.
0.2-1.0

Urob 0 & PBan
Negative Other
NitLyn

Leuk Negative :.MicroscOpi Urinalysis'
Atyp In-im
Negative
HCGRBC

Morph •
Spun 42-52% (M) CSF , Blood Bank
3747% (F)

1-lematocrit
MUST SUBMIT SF 518 WITH
Sed Rate Cell
Count EVERY UNIT REQUESTED
1

Directigen Negative ABO/Rh
Other
Coagulation Studies :- -Blood. Bank Unit Crossmatch (MUST SUBMIT. SF:518.NOTII EVERY UNIT. OF BLOOD .: .-' -. • " • : :_r..: REQUESTED) • : .. -
UNIT TYPE CROSSMATCHTEST RESULT REF. RANGE
4.8-13.6 secs

PT
21-34 secs

APTT
20 ug/ml

D dimer
..
10 ug/mlF DP

REMARKS: ti
amNid-niii1 il t AB ID NO.:.
REPORTED BY:
D$1r-a) tv
MEDCOM -15310

DOD-028699
Ward/Section: REQuESTING PHYSICIAN:
-`13EMISTRY RESULT FORM
Suliect to the Privacy Act of 1974)
-7/Piccoln) C nuts
TEST RESULT I REF. .12.4M

.7.7.==z==
PICCOLO =2:22 = 2

-.

29/07/03.PICCOLO :======

07:35

-29/07/03.

130 REF ERENCF RANG

07:31

PATIENT #: _E - REFERENCE RANI—.

i-STAT 6+ 1-31 friAlMALE
, yr
-PATIENT #:

GENERAL CHEMISTRY 12

Pt: alr DISC LOT #:.ELECTROLYTE
3142A

Pt Name: DISC LOT #:.

OPER AIM DR #:

3135AA4

0oo 7

SERIAL #: limmor OPER #: 11111, D.
: 000

SERIAL #:

........

Glu...................

132 mg/dL -
ALB...........................

2.8* 3.3-5.5.

BUN _ _______ Mg/dL ALP (3/DL NA .#.
46 128-145

26-84.MMOVL

Na.U/L K+

135 mmol/L ALT 44.3.5

10-47.3.3-4.7

U/L EL_ MMOPL

.3.3 mmol/L A4 AMY 32 14-97 99 98-108 MMOP/L
U/L

Cl .AST tCO2 26

27.18-33 NMOL

102 mmol/L ma 11-38.
U/L

FBIL 0.5.

Hct.:PCV 0.2-1.6 MG/DL

u BUN INST QC: OK.

Mb*.#.• 7-22.CHEM QC: OK

11 g/d. MG/DL

CA++ 8.4.HEM 1+, LIP 0.

*via Hct ed 8.0-10.3 MG/DL ICT 0

CHOL 141.

100-200 MG/DL

Wd CRE 0.7.

Sample Time_: 0.6-1.2 MG/DL

CV GLU

138* 73-118 MG/DL

TP

29JUL03.5.9* 6.4-8.1.

07:50 G/DL
Oper: 7210 INST QC: OK

CHEM QC: OK

WJ1 1+, LIP 0 , ICT 0

Physician:
Ser# 111111,

ver: JRNSO46A

CLEW 1:153

MEDCOM - 15311

DOD-028700
\

Al-d/Seclina; REQUEST
LABORATORY RESULT FORM
71--__)
-C-¦­
-

(Subject to the Privacy Act of 1974)1A ST, FIRST„MI. TIME SSN/PSEUDO SSN:
/ ‘k.„,., k ' s_ , 1, e_ (Hematology) CBC ra sis osc -, Misc. Serology
/ TEST RESULT REF. RANGE TEST 'LT RE . RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 N. 10' Color 4) N/A -- RPR Negative
RBC Hgb Hot 4.7-6.1 x 109 di (M)14-18 12-16 gi g/ dl (F) 42-52% (M) 37-47% (F) App Glu Bili A, Lr t ,)f A' 6y N/A Negative Negative Mono Source Negative Mierobiology
MCV Pit Lymph % 80-94 11(M) 81-99 11 (F) 130-500x 10' verified 20.5-51.1% Ket SG Bid AA) hi5'-.ti Negative N/A Negative Gram Stain Occ Bid H. pylori Negative Negative
• (Hematology) Manual Differential pH C fc N/A Micro Parasites
Segs Bands Mono Eos Prot Urob A/L) Negative 0.2­1.0 Malaria 0 & P
Lymph Baso 1 Nit 0i 2., 4l; Negative Other
Atyp Imm Leuk Negative •.MicroscopiC Urinalysis'
RBC , HCG Negative
Morph

Spun 42-52% (M)
CSF ..

• Blood Bank
Hematocrit 37-47% (F) Sed Rate
Cell

MUST SUBMIT SF 518 WITH
Count

EVERY UNIT REQUESTED Other I Directigen 1. Negative
ABO/Rh Coagulation' Studies ..
. - Blood: Bank Unit Croisotatch
1

(MUST.SUBMIT SF 518.WITH.EVERY UNIT OF. BLOOD -. ' . : REQUESTED) -'• -.-' ' •
TEST RESULT REF. RANGE UNIT
TYPE CROSSAI4TC1-1
PT 9.8-13.6 secs APTT 21-34 secs D dimer 20 ug/ml
FDP 10 ug/m1 REMARKS:
U REPORTED BY: DATE:
LAB ID NO.:.
MEDCOM - 15312

DOD-028701
Ward/Section: REQUESTING LABORATORY RESULT FORM I 00 (Subject to the Privacy Act of 1974) LAST, FIRST,M1. 1ME SSN/PSEUDO SSN:
(Henn . i ) CB ' . _Urinalysis Misc. Serology ,
TEST I RESU - . RANGE TEST RESULT REF. RANGE TEST RESULT REF RANGE
FT RB( • Color App N/A N/A RPR Mono Negative Negative
I-Ig1 Hc1 IDIIII YR X-07-03 04 07 Patient Gill Bili Negative Negative Source Microbiology . 1
M( rs, ' ill T.,. "-"J Limits a 8.2 x104 3/sL 4.5 10.5RAC 3.14 L itI0A6AL 4.00 6.00HO 9.1 L i/4L 11.0 18.0Pct 22.7 L Z 35.0 60.0 n n re 99.991 .4 ft nu 29.1 pg Z lIlLIE 31.8 1 sidL 33.0 37.0..3/tu. 150. 4519.LYZ 11.3 44_ X 20.5 51 .1L'l 0.9 *L x10"3/uL 1.2 3.4 Ket SG Bld pH Prot ( Negative N/A Negative N/A Negative Gram Stain Occ Bld , H. pylori ! Micro Parasites Malaria Negative Negative i
B Urob 0.2-1.0 0 & P
; Nit Negative Other

Atyp Imm j Leuk Negative Uláalysis
Negative

RBC HCG Morph
1 !
!

Spun 42-52%(M) CSF Blood Bank . 37-47% (F)
¦ Hematocrit
Sed Rate Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rb I
Coagulation Studies , Blood. Bank Unit Crossmatch (MUST SUBMIT, SF.5.18.NYITI4EyERY UNIT OF BLOOD . "
TEST RESULT REF. RANGE UNIT TYPE CROSSIII4TCH
9.8-13.6 secs

PT
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/m1
REM:
k, 41

DATE: LAB ID NO.:
MEDCOM - 15313 r 41314440. ( %sr —w-: 91.0 %of
DOD-028702
f,
Ward/Section:
REQUESTING PHYSIC

HEMISTRY RESULT FORM
LAST, FIRST, M. Soliect to the Privacy Act of 1974)
SSN/PSEIIDO SSN:

14fv.
TEST RESULT

REF RANGE TEST

1218-146mmoM.

ALB

GI ALP 26-84 till
El.

i—STAT 6+

tkLT

------- PICCOLO .10-47 u/I C,
04:07.pt:
30/07/03.kMY 14-97 u/I C].
REFERENCE RANGE:.kST 11-38 u./1

r MALE .Pt Name:

N
bt,ct')

PATIENT #:.

TBE. 0.2-1.6 mg/dl
K
GENERAL CHEMISTRY 12

Glu

7-22 ingicll 118 m9/di
3204AA4 31-114
DISC LOT #:.

BUN.

OPER #:.DR #: 000 8.0-103n:1g/di t( Sm9/dL
136 mmol/L

SERIAL.100-200 mg/(11 Na.
114111111.11-;110L K
3.3 mmol/L

ACE

,.0.6-1.2mWdl

ALB.(3/DL .

2.2* 3.3-5.5.el.

101 mmoi/L
ALP.U/L ILU Md.

43 26-84.73-118 mg/c11

27 %PCV

ALT.U/L P

53* 10-47.6.44.10.

Nb*.

gidL
AMY.U/L.

39 14-97.

_ ett
*via Hct

AST.U/L .

39* 11-38.

0.2-1.6 MG/DL TEST RESULT.

MIL 0.6.REF.

-

Sample Type
RANGE

BUN •+4 MG/DL

7-22.

73-118 rng/d1

8.0-10.3 MG/DL .

CA++ 8.1.30JUL03.

04:06

UN 7-22 mg/ill

CHOL 120 100-200 MG/DL .
CRE 1.2.
0.6-1.2 regicll OPer: 13

0.6-1.2 MG/DL RE

GLU 125* 73-118 MG/DL
30-190 till (F) Physician:

TP.G/DL A+

5.1* 6.4-8.1.

128-145 rruno1/1
3er# 1111111,

CHEM OC: OK

INST OC: OK.

3.347 mmol/I
Ver: JRM504G41

1-EMO , LIP 0 , ICT 0

CLEW 14,3

L-98-108 mato1/1
:02 18-33 mmol/I

CI: 98-108 canal
(CO2 18-33 mmol/1
REPORTED BY:
LAB ID NO.:

io(o) -

NIP&1CJ 1i t
MEDCOM - 15314

DOD-028703

Ward/Section: REQUESTIN

LABORATORY RESULT FORM
C A b (1/.,‘) (Subject to the Privacy Act of 1974)
LAST, FIRST, Ml.

TIME SNP
%9( =
3/ L03
CBC
TEST RESULT

REF. RANGE TEST RESULT REF. RANGE TEST
WBC 4.8-10.8 x 10' Color N/A RPR Negative
p (, 1 -2 o_ N/A Mono Negativ
Glu 1\-1-€5 Negative Aricrobiology
:Y• 31 -0--03 08;05 Bili Negative Source
UBC SBC Hgb :t 6.7 2.90 L "e.6 1 27.0 L ;110'3/ii x10'6./uL gldL Patiertt Likts 4.5 10.5 4.00 6.00 11.0 18.0 35.0 60.0 SG Bid , v i s Negative 'N/A Negative Gram Stain Oce Bid H. pylori Negative Negative
rev 53.1 fL trri 29.5 pg41C 31.7 L glutPit 19(2. L72 10.2 *L X DI 1 7 *I_ 1. 10A3ltiL 80.0 99.9 27.0 31.0 33.0 37.0 151. 450. 20.5 51.1 1,2 3.4 pH Prot Urob e_S N/A Negative 0.2-1.0 Micro Parasites Malaria 0 &
Nit 10 45 Negative Other
Leuk Negative !wok Urinalysis
RBC Morph HCG Negative

Spun 42-52% (M)
CS!

Hematocrit 3747% (F) Blood. Bask Sed Rate
Cell

MUST SUBMIT SF 518 WITH
Count

EVERY UNIT REQUESTED
Directigen Negative

ABO/Rh I lation Studito,
Mood Bank Unit Crosamatch .(MUST SUBMIT . SF 518.WYJII.EYERY UNIT BLOOD
ItEQuEsres9 , . .
TEST RESULT REF. RANGE UNIT
TYPE CROSSMATCH

PT 9.8-13.6 sees APTT 21-34 secs D dimer .c20 ug/m1
FDP 10 ug/m1
REMARKS:
Lc —

REPORTED BY DATE:
LAB NO.:.
MEDCOM - 15315

DOD-028704

Ward/Section: -1.. kC.Go REQUESTING PH SICIAN:.-, Ick ct) - LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FIR D TE T ¦ E SSN/PSEUDO SSN:
ematology) CBC btti) ' 14 i, di¦ • Urinalysis Misc. Serology
TEST RESULT RANGE TEST RESULT REF. TEST RESULT REF. RANGE
WI RE 1: .7y -ci --, - `' ic::-, :­=1 ­0: Color App _ei(). c /4,,,..„. N/A N/A RPR Mono Negative Negative
1-12 Ptient LiDits ' i Glu 4- Negative Microbiology
..3 -,q ,/..11 { _ ?9 1If' r Bill Negative Source
M Ni L) ? 1' 9/.4L i.­..-t _ ¦ ;.3') g1.9 ii... '11­-, 211 P2 l -.: H; 1 Pit 4i33. ,i :.1:.)'::: , r: 1;3.2 ,,, i_l' LY4 1.4 -n's :410'3,;:IL II cl , p r -.5.J :.0,0 S., 27.0 3!.0 37.0.0 :.5.. : 4F:0, --­.-51.1 1,7 Ket SG Bld pH '`'1' 1,' (•1:05-'tv 's 6. a Negative N/A Negative N/A Gram Stain Occ Bid H. pylori Micro Parasites .Negative Negative i.
S i Prot /„..ke.4_ Negative Malaria '
II Urob 7k?._.5 0.2-1.0 0 & P
Lymph bast) Nit /1... 1 Negative Other
Atyp ImM Leuk Negative Microscopic Uriin sis
RBC Morph ACG Negative i

Spun 4252% (M) j CSF , Blood.Bank
-
3747% (F)

Hernatocrit f
Sed Rate Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Directigen Negative ABO/Rh
Other
Coagulition Studies . Blood Bank Unit Crossmatch (MUST SUBMIT SF.518.*ITH EVERY UNIT OF BLOOD REQUESTED)
UNIT TYPE CROSSILL4TCH
TEST RESULT REF. RANGE
9.8-13.6 sees

PT
21-34 sees •
APTT
20 ug/m1

D dimer
1 0 ug/mi

F DP
REMARKS:
REPORTED BY: mis DATE) ......71,51 LAB ID NO.:
MEDCOM -15316

DOD-028705
Ward/Seglioir. REQUESTAISSallYSICIAN: LABORATORY RESULT FORM Subject to -the Privacy Act of 1974
LAST, FIRST, MI. , DATE TIME SSN/PSEIJDO SSN:
(Au(-7P 04 .3 4.-
: . alegoatoloeqBc, : urinalysis .misc Serology
TEST RESULT I REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC i 4.8-10.8 x 10 Color N/A RPR Negative --.
4.7-6.1 x l 09 App N/A Mono Negative
Glu Negative Microbiology
But Negative Source
Ret Negative Gram
Stain
SG N/A Occ Bld Negative
[ -.:; --;'" ' --: • :': Bld Negative H. pylori Negative
PH N/A Micro
Parasites
Prot Negative Malaria
Urob 0.2-1.0 0 & P
Nit Negative Other

Leuk Negative - .MicToscople Urinalysis
itttC HCG -Negative Morph

Spun 422%( CSF ' . Blood Bank
37-47% (F)

Hematocrit •
-' Sed Rate Cell . MUST SUBMIT SF. 518 WITH
Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh .•
'Coagulation Studies -I Blood Bank Unit Crossmatch (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD REQUESTED) TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 sees :
APTT
21-34 secs D dimer 20 ug/ml FEW 10 ug/m1 REMARKS:

REPORTED BY: DATE: LAB ip NO.:
MEDCOM - 15317

DOD-028706

Ward/Section: REQUESTING PHY SICIAN: LABORATORY RESULT FORMYC;._) 9--(Subject to the Privacy Act of 1974) LAST, FIRST Mt DATE TIME SSN/PSEUDO SSN: VA ii, - Ll
''-7 A 4A 64a)
(Hemitology) _Uri aalysig Misc. Serology
TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10 Color N/A RPR Negative
RBC 4. i-6.1 x 10) App N/A Mono Negative
HE Glu Negative Microbiology
Hc Bili Negative Source
M ' .'i-L; Ket Negative Gram 1
, Stain
._-_, __

PI .,..,_ SG N/A Occ Bld Negative
.f: ,

Bld Negative H. pylori Negative .7.,(.. 60,..
rg -, pH N/A Micro
Parasites

S. -- -; Prot Negative Malaria f s
1., --: _

B Urob 0.2-1.0 0 & P
L 1 Nit Negative Other
At,, Leuk Negative Microscopic Urinalysis
RBC HCG Negative Morph
Spun 42-52% (M) CSF • Blood Bank
37:47% (F)

Hematocrit
Sed Rate Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
Coagulation Studies Blood. Bank Unit CrosSinatch (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . . REQUESTED)
TEST RESULT REF. RANGE UNIT TYPE CROSSAL4TCII
PT 9.8-13.6 secs
APTT 21-34 secs
D diner 20 ug/m1
F DP 10 ug/mi
REMARKS:
REPORTED BY: DATE: LAB ID NO.: ' AIIIIIIL
MEDCOM - 15318

DOD-028707
Ward/Section: N: LABORATORY RESULT FORM ,0 (..(4 -0 Sub'ect to the Privacy Act of 1974) LAST, FIR 1 SSN/PSEUDO SST:
,7
ko C. 4

eatern 4 CBC :. •--1-410-tilYlis -. Misc.. Serology. .
TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC ' 4.8-10.8 x 10 .? Color N/A RPR Negative RBC 4.7-6.1 x 10 App ti N/A Mono Negative 7
14-18 g/d1 (NT) Negative • , Microbiology12-16 g/d1 (I') -1-3
42-52% (M) Bi li Negative Source
_ .
37-47% (F)

MCV 80-94.11 (M) Ket Negatiw Gram . 81-99 fl (F)
Stain
Plt 130400 x 103 SG NIA Occi3rd Negative. i
verified
Lymph % 20.5-51.1% Bld el Negative H pylori Negative

(Hematol y) Manual Differential pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria '

n...cj
Bands Eos Urob 0 0.2-1.0 0 & P

Lymph Baso Nit Negative Other
P. S
Atyp 1mm Leuk Neg:ative -• . MkrosroPiC Urtaii

....: .... ... .... _ .
1 RBC HCG Negative . c5.x, ..,...., _ y t
I
Morph , 0 -0 t.v, t..
i J-Vo• c

Spun 42-52% (M) CSF - -- - • . .Blood.Bank •
.....,.. .
Hematocrit

37..47° (F)

Sed Rate Cell MUST SUBMIT SF 518 WITH
Count EVERY UNIT REQUESTED

Other Directigen Negative ABO/Rh
Coagulation Studies. Blood. Bank Unit Crossmatch-• (MUST,SUBMIT SF. 518 . WITH EVERY uNITor.sooD.:
... ,

- -. . . . .,. RE • tESTED) .-TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCII
9.8-13.6 secs
PT
APTT 21 -34 secs
D dimer 20 ug/ml
FDP 10 ug/m1
REMARKS:

u 2_ .
REPORTED BY: DATE: LAB U) NO.:
/ ,,,

MEDCOM -15319

DOD-028708
519-301
NSN 7540-01-165-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AG' Sig SSN (Sponsor) WARD/CLINIC REGISTER NO. FILM NO. P4EGNANT
6 t - YES LI NO
TELEPHONE/PAGE NO.
DATE E •T
SPECIFIC REASON(S) FOR REQUES (Comp dints and find ga)
DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC REPORT
PATIENT'S IDENTIFICATION (For typed or written entries give: LOCATION OF MEDICAL RECORDS Name — last, first, middle, Medical Facility)
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE

I TATZON STANDARD FORM 51g.P • - -•
MEDCOM - 15320 Prescribed by r2. "
•— nnot

DOD-028709

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 I. 4-bilLio O 3 TIME OF' ORDER /6'',9,_5-..- HOUR, S LIST TIME NOTED AND SIGN ORDERA ..._
lir ' 1 )0111W V„tali. I • i..2... % _AIL illell.11111MEIMIOrtFAillik ..1_2&.;_
I A iii, 11 . MAII 1.. . -NIA, Al ... (i) 1.....gr
NUFISIN 11TWAIII I'"" ,F-.'•NA NO. • NO.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF OR ER
2,1 3.

'\ (16 3 )13'71
HOURS
livii 2,---)o N--:,v Tr, p4k,

1. -I
7b0 01 rx,'". 2_0 to
21,,,,,,41t e c!
di
.7
NURSING UNIT ROOM NO. BED NO.

PATIENT IDENTIFICATION DATE OF ORDER E OF ORDER
HOURS
j p,,,......4-N ,-4--4.D Sil
ti,a.,_

6/14--—1,0 , ki. ", 1, v 14 I-4 , c_. A.11...
... ,..

u.v ,i. as Ajr-SiJilo ..cv/1-617---
0.1 c ,,,,(0.._ I ,..5 )._ t.v...„._ Tv\ 4...).__ A
NURSING UNIT ROOM NO. BED NO.
a r--

--To ./.-1-1 qe_A-k --------
PATIENT IDENTIFICATION DATE OF ORDER TIME OF
2-2 f....ii_
AA ..4""i

iiii P CAC-HOURS
*

1 t a\ -•
NURSING UNIT ROOM NO. D N •
C). .1

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 1 FAVRM79 4256
MEDCOM - 15321

DOD-028710
_ . .

- :.,..: ; ¦ ) ; i li.: r, III .....::.1 / 1..r.. 0 `—‘ 0--t9 gs0 c rk e J c_7"—¦
45
.....-. ¦ I r -- LS I.• ; • L -!-­-0=
i /V5 E10¦11)4,1 "%AAP 4-17 derv_v4,

M DCO
\Nr
Y IG---r

DOD-028711

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 ORDER63 NOTED AND
HOURS
SIGN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER 2544,461 TIME 0 ORDER a 35 HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION OATE OF ORDER )11/1,4 cd TIME OF ORDER c(3 HOURS -d/4-
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION ; DATE OF ORDER 3 LtS1 TIME OF ORDER HO S

NURSING UNIT ROOM NO. BED NO.

REPLACES EDITION OF 1 J11.410144PHiCH MAY BE USED.
DA 4256

1 FAOPARM79 '
MEDCOM - 15323

DOD-028712

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

,lz,2\ 1 i . NURSING UNIT i ',ROOM NO. i PATIENT IDENTIFICATION i BED NO. I 3 645-V HOURS ORDER NOTED AND SIGN ( ,A PI ift./MbAA2-­-' -4 06 7 r6 i, .......ig. . L) A ---r A. A Illik. -... -11111111pk AL Ariff*Wal.Fir. A 04) --La.:. - Asa•¦• 1 DATE OF ORDER ) itl CI TIME OF O ?rc-.) HOURS 6 ? 411 0 ) 6-- p-k--UC.: Ac t lit.„
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NURSING UNIT ROOM NO. BED NO. , •
PATIENT IDENTIFICATION 4 DATE OF ORDER Azj, JVL d TIME OF ORDER .7-- HOURS ow.
t) (..-N4i,"..._.-- , _40C A C r • , rci' c ( R.) -2.
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE 0231:1DE R TIME OF DER HOURS -'44% 5_, ' - ' ;`,...
i
/
NURSING UNIT ROOM NO. BED N . 4. s

REPLACES EDITION OF 1 J SL 77, WHICH MAY BE USED.
DA 4256

1 FAOPR
M79
MEDCOM - 15324

DOD-028713

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.

I.
PATIENT IDENTIFICATION

DATE OF ORDER TIME OF ORDER LIST . I • ORDER Cj L.% 1 6-.2-6-2--) NOTED AND
HOURS
SIGN
KIIIIIIIIIWII"
NE
(01 I
Ilhommor--
NURSING UNIT ROOM NO. BED NO.

I CU
PATIENT IDENTIFICATION

DATE OF ORDER TIME OF ORDER
./SU-c-J 1)
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FS

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EMMA -.TIMM
NURSING UNIT ROOM NO. BED NO.

rmAIIII.
PATIENT IDENTIFICATION DATE OF ORDER
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NURSING UNIT ROOM NO. BED NO. (. ‘ 10
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PATIENT IDENTIFICATION DAT OF ORDER a IME 0 '0 • R

jallgrfirlWAIMMIIM
Oi A .G-03 CKSLi 1 HOURS
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,..._ ,M5!Fl ,) Mffirw I rEliffirillEarAPANWIEEElirgq-QA
NURSING UNIT ROOM NO.
BED NO.

IIIVIENIMMENEP
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ArAllr
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE
1 FAOPT479
MEDCOM - 15325

DOD-028714
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 4EDICAL 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
CL0 (../ Cc3 0633 HOURS SIGN
CI
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORD TIME ORDER

))32-

61)14X°3 HOURS
6411N I. 1
L zrle.
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NURSING UNIT ROOM NO. ED NO.

Fc;
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PATIENT IDENTIFICATION DATE OF ORDER TIME pF ORDER
HOURS
_ 1)/$13A.,-hcig. dry 3)6
1

NIING UNIT ROOM NO. BED NO. Z.'i 8/0
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&ye/10,x TO YR i Li4Y
PATIENT IDENTIFICATION DATE OF ORDER TIME OF O RDE R
HOURS

1:„.,,,c

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NURSING UNIT ROOM NO. BED NO. pi
IT
-11
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1 FORM

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE US
DA 4256

MEDCOM - 15326 1:
DOD-028715

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

PATIENT IDENTIFICATION ¦ DATE OF ORDER TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
611111111111111111 /1-1--r oLi /y co SIGN
2 ti/ii (3c )4
,
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NURSING UNIT
N•r_•.b.
r:
•1
PATIENT IDENTIFICATION OF ORDER • OF ORD -

/(-0 3c.

HO

1)(e-- TV
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NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION

111MME4S IMMO 72:;1'1
A4
NURSING UNIT ROOM NO. BED NO.

,011111111.1021
PATIENT IDENTIFICATION
ID( (e) -9

wateisrimr
NURSING UNIT ROOM NO. BED NO.
(711

DA REPLACES EDITION OF 1 JUL 77. WHICHIFAOPRRN179 4256
MEDCOM - 15327

DOD-028716

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
1 S HOURS IGN
4\10

NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
ramarmr
,

ZipNOM
Mae 4vA
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
arc

NURSING UNIT REPLACES EDITIO 1 -I 77, WHICH MAY BE USED.
Dit1 APR 79FORM 4256
Sr U.S. GOV
MEDCOM - 15328 '1 0

F]
DOD-028717

Ct fl¦ROA. RECORD DOCTORS `ORDERS • :
For use of Tltis. corm, see AR- 40..:6e, The prapoi*rit agency Ts °ISO 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.
PA7.Itt.4.17.1E.*".1.471:F 1CA:110W

TIME OF ORDER:' ,-.: . LISP TIME ORDER , NOTI0 ANP
HOURS

77/0.. 1.74
PATIENT tOENTIF•I
ROOM NO. SW NO ,
HOWIS •. ,

PATIENT ItiENTuFICAriON
RATE :OF OFIDEn TIME OF WIDER ¦ •2•;, •• ilop.ct 4 • •
• : NURSIND • ... EiEr, NO.
TAEFILneE:EDI:TION• .. • , WHI C H:MAY. SE.
•..*, ..u...cayntiffvt-NI-ARiNT140. :OfPfeE 1 496,493.4324: . • • ICC It f ariiniTPFN,-.41FsnFIRN11.Y I'NO rARR ME DC OM - 15329

DOD-028718

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 67 7Y--f-c3 TIME gl, F ORDER 1 X LIST TIME ORDER NOTED AND SIG
NURSING
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
NURSING UNIT
PATIENT IDENTIFIC
NURSING UNIT ROOM NO. BED NO.
DA FORML APR 794256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
MEDCOM - 15330
DOD-028719

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 OIDER LIST TIME ORDER :i '''' ' NOTED AND
4.1 0 6 oCT-- 1 cf'--/ HOUR IQN
G b_ , _
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,,,,,,
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PA -1TENT IDENTIFICATION DATE OF 0
TIME OF ORDER

HOURS
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NURSING UNIT ROOM NO. 8E0 NO.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
11,,4
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F.
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 MAY BE USED.

DA 4256
1FA0pRRK479
MEDCOM - 15331

DOD-028720
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
CLINICAL RECORD
For use of this form, see AR 40-407;
the DIM • 0 411J - • -Mo.I Yr. 2003
VERIFY BY INITIALING
ORDER RECURRING ACTIONS, DATE COMPLETED
DATE FREQUENCY, TIME

NEMEOWAN,

rximir iFA2'ftI'fAtiIr1f/PfA1iVdJ.r! -
Old _..0111111, 4611 .3erzi 03 _ -N Ai
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ALLERGIES: 0 YES 01 NO PRIMARY DIAGNOSIS: •
AD ITIONAL PAGES IN USE: 0 YES p NO
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PAGE NO:
PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.
USAPA VI AO
MEDCOM -15332

DOD-028721
THERAPEUTIC DOCUMENTATION CARE PLAN
(NON-MEDICATION)
SINGLE ACTIONS

0?)

Clerk/ PRN Nurse ACTION, FREQUENCY TIME/DATE COMPLETED

MEDCOM - 15333

DOD-028722

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDIC.A7701V)
F4w us eed isthis f prorfnficseeeoflhe4csi4cTon General. FAio. yr. 2003

anency '
VERIFY BY INITIALING
i Hiti

14,;:ii'':-.,7;R:W4=igti,-. 744,7ifiliaiINTTIAL PROPER COLUMN . FOLLOWING E4QI COMPLETION
HR
DATE NURSE FREQUENCY, TIME 't ' 1.

ORDER CLERK/ RECURRING ACTIONS, DATE COMPLETED
OA C*--tk • --‘
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-

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ALLERGIES: MI YES = NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
1.1 YES I. NO
. _ 5/p 6sLL) 4 62,(c_L-
PAGE NO' PATIENT IDENTIFICATION:
ACTION TIMES ,
USE PENCIL CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07
— - ----- ---- - --- --
E (Ai * q

RR 1 fl51 77 MAV RE USED,
USAPA V1.00
MEDCOM - 15334

DOD-028723
Verit y by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initiating
(NON-MEDICAT1ON)

Mo Yr 2003
Order Clerk
Date to

SINGLE ACTIONS Time to
Date Nurse
Time Done Initials
be Done be Done

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Expir -IMTIAL PROM COLUMN FOLLOWING COMPLETION
ACTION FREQUDate '''"z‘k13i , FREQUENCY

—___L_____
TIME/DATE COMPLETED
.

. . . •

_ - -— • .

USAPA V1.00
MEDCOM - 15335

DOD-028724
THERAPEUTIC DOCUMENTATION CARE PLAN

CLINICAL RECORD (NON-MEDICATION)
For use of this form, see AR 40-407: them vent a encs is the Office of The Surgeon General. Mo . Al&Yr • 0
VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING
EACH COMPLETION
ORDER
ERR! RECURRING ACTIONS, DATE COMPLETED
DATE NURSE FREQUENCY, TIME

Ai I -7 I It() l I IL I13 19 trIg, 117
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ADDMONAL PAGES IN USE: I I YES I I NO
7-4 F
PAGE NO:PATIENT IDENTIFICATION: ?11-PI-

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES 8 9 10 11 12 13 14 15 E
16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78
EDITION OF 1 DEC 77 MAY BE USED.
USAPA VI 01
MEDCOM - 15336

DOD-028725

THERAPEUTIC DOCUMENT AT ION CARE PLAN
(NON-MEDIC ATION)

Verity by
Initialing

Clarkartier
NunsDate
INITIALTROPER COLUMN FOLLOWING COMPLETION
13 PRN GrdeM CWW
1111 11107111111111111

1111

11111111111111111"11111111111
1011
110
MEDCOM -15337

USAPAVI.Ot
DOD-028726

THERAPEUTIC DOCUMEIQTATION CARE PLAN (NON-MEDICATION)
'

CLINICAL RECORD For use ot this torm, see AR 40-407:
ilio: • YT. 2003
VERIFY BY INITIALING .7.:,,-1.-::--; qi, C:"'.'4 ' -9-M.L';:.,„.4 :PT" INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERIC/ RECURRING ACTIONS. HR DATE COMPLETED I,
DATE NU FREQUENCY, TIME

¦1M1a /7 faiq 2DISIFE2-3 WE1--) 1E :I --II
tELMSIBMIN/IIIg
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,
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USE PENCIL. CIRCLE ACTION TIMES
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D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 MEDCOM - 15338 !SW. USAPA V1.00
DOD-028727

THERAPEUTIC DOCUMENTATION PLAN (NON-MEDICATION) '
CLINICAL RECORD
Mo. yr. 2003
Vain'BY DIMALING , ,Z7r4MZ=-1NMAL PROPER COLUMN FOLLOWING EACH COMPLEHON
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS.
DATE NURSE FREQUENCY. TIME
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ALLERGIES: - YES NO PRIMARY DIAGNOSIS: . ADDITIONAL PAGES IN USE:
ill

YES MI NO
Sqrat9n6' T4 op.-•
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PATIENT IDENTIFICATION:
ACTION TIMES .
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15

Via 6(4\4) -Li

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 VI .00
DA FORM 4677, 1 OCT 78
MEDCOM - 15339

DOD-028728
---,
Verif i ,,,-

THERAPEUTIC DOCUMENTATION CARE PLAN
InitialLrez:
(NON-MEDIC4170N) )
Mo Yr 2003
Order Clark ut 1,
Date Nurse / 1)1 ' ' SINGLE ACTIONS

Oats to Time to/ TI me Dons Initials
be Done be Done
i
YAW - ,

1/4 i
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..

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i

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'
.
'

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. PRN .
Order/ clack/
Explr INITIAL PROPER COLUMN FOLLOWING COMPLETION Date ACTION. FREQUENCY
Nurse
TIME/DATE COMPLETED

•.
.

. . •
. .

. ..
.
.
_
. \,4

1

... • . USAPA V1.00
MEDCOM - 15340

DOD-028729
"\ 1,
19(oi

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. i.Yr. '2003 VERIFY BY IIVITL4LING STAINOTERNIMMUSEMOSS INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTION, DATE NURSE FREQUENCY, TIME
MitfaiiriaMi 7
MIMI' Jumpy:mm=0A ar i
INEMILIVIMMA (s.*AL m
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ALLERGIES: F-1 YES Eata PRIMA Y DIAGNOSIS: ADTIONAL PAGES IN USE: YES I=1 NO
GE NO:
1\1(-0/4-1241

PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
MEDCOM - 15341
r% A 0.41=11111• • 1.'77 A I11,"1" 70 tUlflUN OF 1 DEG 77 MAY BE USED. USAPA V1.00

DOD-028730

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (NON-MEDICATION) Mo.'

,

order
Clerk Date to Time to

Date Nurse SINGL CT1ONS Time Done Initials
be Done be Done
/L
Credd
,

PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION pate Nurse ACTION, FREQUENCY
TIME/DATE COMPLETED
'I
USAPA V1.00
MEDCOM - 15342

DOD-028731

THERAPEUTIC DOCUMENTATION CARE PLAN IMEDir27'...:VS)
CLINICAL RECORD For use ot this term. see AR 40-407:
Mo..Y r
VERIFY BY WHALING •. ..... . .,--•.
INTI7AL PROPER COLUMN FOLLO•WING EACH ADMINISMil!0:7: .---.1=
--S

ORDER.CLERK/.RECURRING MEDICATIONS,.' HR ..DATE DfSPEASED.
DA ' -.DOSE, FREQUENCY.0.,

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PAGE NO.
PATIENT IDENTIFICATION:

DISPENSING TIMES
ti)(A).

USE PENCIL. CIRCLE MED TIMES
D.7.8.9.10 11.12 —3 14 i(.• „.
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MEDCOM - 15343

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DOD-028732

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MEDCOM — 15344

DOD-028733

THERAPEUTIC DOCUMENTATION CARE PLAN ,MEDICATIONS) I
CLINICAL RECORD For use of this form, see AR 40-407;
IMo. Azir-Y or53
the or000nent acienciis the Office of The Surneon General.

VERIFY BY INITIALING .--, - - .. . ,-. _ INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
NURSE DOSE, FREQUENCY

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DISPENSING TIMES
' USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14
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N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA Vt.00
DA FORM 4678, 1 FEB 79 MEDCOM - 15345
DOD-028734
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MEDCOM - 15346

DOD-028735
THE.:APEUTIC DOCUMENTATION CARE PLAN (.f7DICATIONS)
For use of this form. see AR 40-407;
CLI ;V; NE-CORD Mo. .Yr..I
INITIAL PROPER COLUMN FOLLOWING EACH-71•1370f eetpi
ORDER.:1:1_ ERK/ DATE.NI RSE 7 RECURRING DOSE, FREQUENCY HR cz.5 fl DATE DterE115615 RY” 0 -R3c7--t90 • ROMP111 E:IE:1
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USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
:Q.EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
FAV77 1 FEB 79
MEDCOM - 15347

DOD-028736

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For u e of this tom, see AR 40-407:

MO. 8 n O3
the Proponent agency is the Office of The Surgeon General,
VERIFY BY INITIALING .inanaMEM.-::,inagnaiiMI:! INITIAL PROPER COLUMN FOLLOWING EACH AD M IN LS' I RA77 ON
HR DATE DISPENSEDORDER, CLERKI RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
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DA FORM 4678, 1 FEB 78 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA 01.00
MEDCOM - 15348

DOD-028737

, ,icriAPEUTIC DOCUMENTATION CARE PLAN (MEDICAT1ONS) 1
CLINICAL RECORD For use of this form, see AR 40-407; . the proponent agenc ¦ is the Office of The Surgeon General . 1 MO..)96Y r. .
VERIFY BY INITIALING ,, -:- -: - -:-:::]z:7;' ‘'.,-:;:i:ir;i!t`„-:;`---• : ::_; ,.=15.i-: INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY
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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
____..__.___ _

L BE USED UNTIL EXHAUSTED..
USAPA V1.00
MEDCOM - 15349

DOD-028738

THERAPLUTIC DOCUMENTATION CARE PLAN I Mol__--Yr.
Verify by. (MEDICATIONS) .
Time to

Time Given Initials
initialing. Date to
be Given be Given
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Order Clerk/
Date Nurse
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usApA Vi .00
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407:
i MI.4.--1 y r.45
the nrononent acienv, is the Office of The Surgeon Genera,
VERIFY BY INIVALING _ -_ . *:•...,.., .." _ : -;: --. IN7TIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
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DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
DA FORM 4678, 1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EX ISTED. USAPA v1.00 MEDCOM - 15351
DOD-028740
Verity by HERAPEUTIC DOCUMENTATION CARE PLAN
Initialing

(MEDICATIONS) 1Mo. CrY1 Yr. g_c__5
Order Clerk/
Date to Time to

Date Nurse SINGLE ORDER, PRE-OPERATIVES Time Given Initials
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MEDCOM - 15352

DOD-028741
Veri -THC..,.kPEUTIC DOCUMENTATION CARE PLAN
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sr MEDCOM - 15353

DOD-028742

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MEDCOM - 15354

DOD-028743

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MEDCOM - 15355

DOD-028744
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MEDCOM - 15356

DOD-028745

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MEDCOM - 15357

DOD-028746

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IVIL—ZAL 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)
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
-

INITIAL SHIFT ASSESSMENT
N. . Time:."Irtitals:
Time:.Initals:

E. Pupils
U Sensorium ,• R LOC / GCS
0:
C Cardiac Rhythm
A PRI: /.
QRS:
R Pulse Strength

D: :Cap Aefil / JVD
I !Edema

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Breath Sounds

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PREPARED sy (Signature 6 Title) —
DEPARTMENT/SER ICE/CLINIC I DATE
CU#1, 1I CbI r .'4PATIENTS IDENTIFICATION (For typed or written entries give:.Name —last,first, middle; grade; data; hospital or medical facility)
NAME: RANK: . II HISTORY/PHYSICAL • FLOW CHART
,AGE:.. . ...
UNIT:. • OTHER EXAMINATION 0OTHER ppeetto
GENDER:, OR EVALUATION

STATUS: .El DIAGNOSTIC STUDIES
US: AD / CIV.IRAQI: CIV / EPW

OTHER:
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MEDCOM - 15358

DOD-028747

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MEDCOM - 15360

DOD-028749
MEDCOM - 15361

DOD-028750

Doc_nid: 
3919
Doc_type_num: 
72