Medical Report: 43-Year-Old Iraqi Male, Detainee, Abu Ghraib Prison, Baghdad, Iraq re: Gunshot Wound to Legs and Flank

Medical records of a 43 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wound to the legs and flank with associated injuries. The medical records state the detainee received his injuries in a shootout with the 134th AR. The report does not state 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: 
Thursday, October 30, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

1.
Reporting MTF 4

2.
MTi _ . zat

I Z Admission Coding Information

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3. Register Number Name (Last, First, MI) 4. Pay Grade i 5. Sex
V) .f"Gf ;i M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity i; Religion
l
X 9
MUSLIM
10. Length of Service ETS, 11. FMP 12. Social Security Number
,
Mk \0 \k (1:‘' ''' Li
Organitation (Active Duty Only)
13. Marital Status
Hour of Admission Branch / Corps: Z
19:30
14.
Flying Status

15.
Beneficiary Category

16.
Zip Code of Residence:
NO

K78-PRISONER OF WAR/INTERNEES
17.
Unit Location

18.
MOS

19. Trauma
Prey. Admission
BC NO
20. Source of Admission Ward: Name / Relationship of Emergency' Addressee
Direct from ER
ICU1 Address of Emergency Addressee
Name and Location of Medical Treatment Facility: Telephone Number of Emergency Addressee
0580 -28th CSH -Iraq; No Install Provided

21.
Type of Disposition

22.
MTF Transferred To

23.
Date of Disposition (YYYYMMDD)
EXPIRED

2003-10-30 .:
24.
Clinic Svc -Admitting

25.
MTF Transferred From

26.
Date this Admission (YYYYMMDD)
AAJ -NEUROLOGY '

2003-10-30
27.
Location of Occurrence

28.
MTF of Initial Admission

29.
Date of Initial Admission
IZ

2003-10-30
FOR LOCAL USE ---
Type Patient (Inpatient / Outpatient): Inpatient

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Admission Diagnosis Narrative: GSW TO HEAD OPEN SKULL-FX.
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Procedure Narrative(s): NONE.
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Cause of Injury Narrative: SHOOTOUT WITH 134TH,A -
F';'(-4:---T
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1..),I,,
Admitting Officer (Signatu .
Signature of Admitting Clerk
Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 22452
Automated Facsimile ATIENT TREATMENT RECORUtJER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
._,.....A FGN
'`TF;gister Nbr i 2. Name , '', 3. Grade Admission Remarks
4. Sex 5. Age 6. Race 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdnn M 43Y X MUSLIM NO
14. Ward
99

11. FMP 12. SS ' 13. Organization
15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Cas
N/A K78-PRISONER OF WAR/INTER BC

23. Clinic Service
21. Source of Admission 22. Hour Of Adm:
19:30 AEA - ORTHOPEDICSCarded for Record Only (CRO)
24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp
TRF-OTH 2003-11-03

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: Admittin fficer:
2003-10-30

6 (C"
30. Date !nit Adm 32. Units Blood Components29. Re.ortin.MTF
i ' \
2003-10-30
000. 1
31. Selected Administrative Data
Marital Status: Z DoB: 1960-01-07
In/Out Patient: Inpatient MOS:
33.
Cause Of Injury: SHOOTOUT WITH 134TH AR

34.
Diagnosis / Operations and Special Procedures:

GSW TO R FLANK WITH ILIAC FX
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.
i
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
(---­
0 ,
0 C.) 0 ...)
35. Total Days This Facility Absent Sick Days Other Days Conlv / Co Days Supplemental Care Bed Days Total Sick Days
(..) (-,3
Signature of Attend'ng Medical Signature of PAD or Medical Records Officer

._______
1 MA
;,' \
Automated Facsimile - DA FORM 3647, May 79 -(Lc.) -MEDCOM - 22453
/ AO_

COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
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YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
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Date of Report: (D/MN) Time of Report: / 0 / 6 (?10(--3 hrs
° d—toniietted ict gt . . . . Given Name— :Fitt Hair Color: Scars/Tattoos/Deformities: Hai Color: Scars/Tattoos/Deformities.
br
Eye-Color: b ,\) Weight: lb Height: Eye-Color: Weight: fb Height:
Address: Address:
Place of Birth:

ra-Place of Birth: Phonek: Sex: Phone#:
Ethn/Tribe/ Sex: EthniTribe/
Sect: Mobile Sect: DOB D/M/Y: Mobile

M DOB. D/MN:
RegularRegular
1 1 7/;/67('
Passport 1-1Dr. license Other (specify) I I Passport Dr. license Other (specify)
Document #: bug, intjetaPepon&Lnyo.,
Document #:
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Photo Taken of Suspect with Weapon/Contraband: Yes/ No
Property/Contraband I I Weapon !Color/Caliber !Receipt Provided to Owner: Yes/ No
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM

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How was this person traveling (car, bus, on foot)?
Who was with this person?
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What other weapons were seized?
What other informa'ion did you get from this person?
Additional Helpful Information:
MEDCOM - 22455
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (P:11111 dot, of .Imiefion)
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PHYSICAL EXAMINATION
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PROGRESS Enter date of ditcAarpr and find, dioynorwl
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SIGNAT U RE
DATE , IDENTIFICATION /40 ORGANIZATION OCtO 3 2100
d or tertrtert enr•1e• lire 1V•rne lase. first,
REGISTER NO. WARD 140.
grade: dare; hospital or medocal lac lity)
ABBREWATED MEDICAL RECORD
Standard Form 509
GENERAL SERVICES ADMINISTRATION AND
INTERAGENCY QOMMITTEE ON MEDICAL
RECORDS
FIRMR 141 CFR) 201-45.505 OCTOBER 1975 539-106
MEDCOM - 22456
DOD-036032

Transfer Sununary — Patien11111110
43 yo Iraqi EPW sustained GSW to right flank on 30 October 2003. History of bladder
stone removal in the past, otherwise no pertinent medical history, no allergies.
On presentation to ER, had a 2x2 cm entrance wound over the right iliac crest, and able
to palpate fragments of the iliac wing through the wound. Also had a right footdrop,
decreased sensation in the foot and lower leg. Rectal exam was WNL.
Radiographs revealed a comminuted fracture of the right iliac crest, but a stable pelvis.
There was a bullet fragment lodged within the body of L-5.
Neurology consult was obtained. Absent DTR's on right, 0-1 motor on right, and
decreased sensation on right only, with intact bulbocavernosus reflex and peroneal
sensation. Impression was of a lumbar plexus injury.
CT scan obtained which shows iliac crest fracture, and fragment in canal of L-5. Abdomen without pathology. Neurosurgery consult — no indication for removal of fragment, and concurred with diagnosis of lumbar plexus injury.
Hospital Course — Patient talcen to OR on 30 Oct 03, had I+D of right iliac crest, vvith irrigation with 6 liters, and wound packed loosely. Taken back to OR on 1 November, had wound irrigated. Very loose 2x4 segment of iliac crest excised, and wound closed in
layers over a penrose drain.
Plan: Remove pemose drain in 48 hours. Dry dressing changes. Ambulate as tolerated. Currently on Ancef 1 gram Q 8 hours and Gentamycin 400 mg q day.
MEDCOM - 22457
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS
MEDICAL RECORD I
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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/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
MEDCOM - 22458
DOD-036034

• kME ID NUMBER
DATE NOTES
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MEDCOM - 22459
MIDDLE INITIAL ID NUMBER
FIRST NAME
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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
Medical Record
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MEDCOM - 22461
DOD-036037

NSN 7540-01-075-3786
LOG NUMBER TREATMENT FACILITY
EMERGENCY CARE
MEDICAL RECORD AND TREATMENT

RECORDS MAINTAINED AT
(Patient)
ARRIVAL UTE (Day, Moptb. Year) TIM:i. 9."-0
PATIENT' HOME ADDRESS OR DUTY STATION
STREET ADDRESS
VU:\) 1-, Jo acry3.
''' STATE ZIP CODE TRANSPORTATION TO FACILITY
CITY
• ARY STATUS THIRD PARTY INSURANCESEX DUTY/LOCAL PHONE
• ITEM YES NO N/A YES prmAREA CODE NUMBER
PRP . L.: • 1
M
AGi HOM r • FLYING STATUS AEI
MEDI -• -Y OBTAINED FROM NAME OF INSURANCE COMPANYAREA C• • •• BER
f.....
INJURY OR OCCUPATIONAL ILLNE* EMERGENC OOM VISIT
CURRENT MEDICATIONS
..
•, .
WHEN,Patel DATE LAST VISIT 4 HOUR RETURN
. ITEM : ' ...'';;YES 'NO
... n ygs . n .tio

IS THIS AN INJURY? . --WHERE. ; . . , .. TETANUS
INJURY/SAFETY FORMS DATE L T SHOT k/KAPLETED INTMAL SERIES .
ALLERGIES
HOW III YES III NO
1
CHIEF COMPLAINT

VITAL SIGNS TIME TIME(Vo
—.....--... -. ...-......._ ..

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PULSE
/9C6
RGENT
INITIALS RESP
TEMFA"'"-

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VVT .
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ABG 1 PT/PTT BHCG/URINE/BLOOD/QUANT CXR PA & LAT/PORTABLE
CHEM: 0 c ks
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CBC/DIFF
SEI3C11:10
AVEVX

ACUTE ABDOMEN LS SPINEURINE C&S A MSCC/CATH
SINUS HEAD CT
ANKLE R/L BLOOD C&S X
ORDERS
____ _.. . .

MONITOR ECG
-I
I TIME / ‘''' ORDERS COMPLETED BY TIME PATIENT'S RESPONSE
2, OW 10'0
fentaP1511
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DISPO ITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
n H ME n FULL DUTY n 24 HRS. n 48 HRS. n 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN
REFERRED OP.
IMPROVED UNCHANGED
TIME OF RELEASE I have received and understand these instructio s.

DETERIORATED PATIENT'S SIGNATURE
.
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last,
first, middle; ID no. ISSN or other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9 -96) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.2030:M101 USAPA V1.00
MEDCOM - 22462
DOD-036038

NSN 7540-01-075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENTMEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
Check if read by
ABG/PULSE OX RADIOLOGY
radiologist
H/H SUP 02 PH PO2 RESULTS
co
PLT PCO2 SAT OTHER
PT DIP EKG INTERPRETATION
APTT BHCG ETOH .GLU MICRO

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PROVIDER SIGNATURE AND STAMP
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PATIENT'S IDENTIFICATION (For typed or written entries, give: Name --last, first, middle; ID no. ISSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9 -96)
Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203(b)(10) USAPA V1.00
MEDCOM - 22463
DOD-036039
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of :his form, see AR 40-66: the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSIT:VITIES (e.g., Iodine, Tape, Medication):
1. AGE:
iunA-e
HEIGHT:
3. PREVIOUS SURGERY [ NO YES (type):
WEIGHT: ("0 e-7
4.
PRQPOSED 00A OCEDURE:

5.
ADDITIONAL INFORMATION: Last l'O: Eviedical Implants: Medications: 7 "*.t

Jewelry removed: no Family waiting: ye.
6. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL
7 Potential for anxiety
related to traumatic injury;
language barrier: rani ily

separation; surgical environment
B. AER ON
Potential for respiratory dysfunction due to
sedation; positioning; iniury
C. INTEGUMENT
.
Potential impairment of gkin integuity due to bovie pad: position: fluid shill
9. PATIENT'S IDENTIFICATION
7. PATIENT GOALS AND EXPECTED OUTCOMES
.____.0-- Pt. verbalizes any specific anxiety.
-6-- Pt. exhibits relaxed body posture.
o ,PT. will be able to breathe without
difficulty during immediate intra-
operative phase.

o PT. will not exhibit signs of impair-

ent of skin integrity (e.g., reddened
areas.

8. OR NURSING INTERVENTIONS
__Q---Allow pt. to verbalize
freely. .

___P---
Explain OR environment and answer questions regarding surgery.
o Offer comfort measures, (e.g., warm blanket, touch) ra.- Explain all nursing
/procedures before they are done. o— Remain with pt. whenever 'Possible.
c:
,..L_Maintaia.f.anailyjn.terfaQe 6/
,,..e-Offer to elevate head of litter or offer pillow. .,.„0--Observe pt. while awaiting suizgery for signs of distress
---.6 Assist anesthesia during
intubation and extubation

-
.."-b Utilize pressure preventing devices on OR table and A:ocessories.
/ o Check for proper positioning and support to maintain good body alignment.
7,-----o-Pad pressure points.
Place ESU ground pad on „--4-on compromised skin surface area.
o Keep prep fluids from7'pooling.
(For typed or written entries
give: Name- last, first, middle; grade: date: hospital or medical facility)
DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01
MEDCOM 22464
-
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
D. CIR ULATION ,,er-Pt. will exhibit signs of adequate 9.-Check for support stockings or ace tissue perfusion (e.g., color, warmth, ,------wraps. If none, check with doctors.
Potential for inade-
pedal pulse). P-"Check that safety straps are
quote tissue perfusion due to /correctly applied.

Offer pillow for under knees. , -------cr
anesthesia; traumatic injury;
-e7-121 e ar
'aC—Iff•Take"-TIegs fr m it-'7position; shock; previous surgery
stirnap=itl-rstavr-lE¦iiater.al-raotion-e
___,...---crtileck that rings have been removed.
' Pt. will be transferred to OR table ave sufficient peopleE. NEUROMUSCULAR
"Zithout difficulty. ,---"-catiable for transfer.
CONT5OL o . I _sure proper body
Pt. will not experience unnecessary
Potential impairment
E.1./ gnment.
physical discomfort.
o Allow patient to lie in
of Mobility due to sedation: pain;
petition of comfort while

injury
_____-----waiting for surgery.
E 2 z-' Potential discomfort o Offer support (i.e., pillows,
bathtowels, etc.) for

due,f-o injury; pain
4ositioning.
Pt. will be made aware of o Introduce self. Keep pt.
F. NEUROMUSCULAR surroundings prior to anesthesia --Informed as to where he/she is
CO7L ,--
induction. and what is happening.
Disminished visual
o Pt. will be transferred safely to Inform pt. in which
perception due to being injury; OR direction to move and assist if
necessary.

sedation: table.
Pt will be able to understand • Speak clearly and slowly.

Potential for decreased , '
F 2 o Address pt. from
/ instructions. _...----",f-­
co unictaion due to langune
----1,a-a-------side.
cr" Minimize danger of injury during
barrier; secttaion
,...0--Validate pt.'s
/intraop period.
Potential injury due to (-," understanding of verbal
F.3.
communications.
dentures. ,,,....---o--Verify removal of dentures.
G. OTHER PATIENT PROBLEMS OTHER PATIENT GOALS AND EXPECTED OTHER NURSING NEEDS. Or continuation of above OUTCOMES. Or continuation of above goals INTERVENTIONS. problems/needs. and outcomes. Or continuation of above
interventions.
.
LET D/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
. -1.., 3e9 ocro_3 DATE
POSTOPERATIV5. EVALION:
st_. a-‹
vcc a ik
12. PREOPERTIVE EVALUATION PREPARED BY 13. PREOPERTIVE EVALUATION PREPARED
DATE: TIME: 19„,:9-/6) TIME:
REVERSE OF DA FORM 5179. JUN 91
USAPA .01
MEDCOM - 22465
DOD-036041
it
INTRAOPERATIVE uuCUMENTMEDICAL RECORD
-
For use of this form, see AR 40-407, the pro(
Icy is the office of The Surgeon General.
1
1. PATIENT TRANSPORTED TO OPERATIN .3M 2. PATIENT ID
EV WED AND PROCEDURE )
VIA t„.. BY Acyl 32-7 ---7-c-d---.' VERIFIED BY /4-.4..0--•+.-)2-,---ti

3. DATE TIME PATIENT ARRIVED IN SUITE 4.. PATIENT I
ec5-ro ---5 .--2-( 3 TIME; , L2-2-15 Le).NUMBER / — .,f------,3,41
5. PREOPERATIVE EMOTIONAL STATUS
_FaCALM II AlrOUS • EXCITED. III CRYING • ANGRY WITHDRAWN
--El Plat-IER (.Sicifyl
COMMENTS: a-ere'e '. /1..-1._-.. VI' .2,..t. Et.te_...e„....)„,-ce.: ca.E., -Aye, p if

.t
, .
t_-(_.e,2_----s;-,./z-,
6. NURSING PERSONNEL
,--srf.
ASSIGNED
--RELIEF
SCRUB

' SCRUB
ASSIGNED
RELIEF
CIRCULATOR

—. ...... . .. __CIRCULATOR :NT:.
0 ITle#N AND P0,81TIQNAL,A7 (Segye , a2,,t;f:k r 01.-.• .-7.e--,e,„.,4 .e:fi_ s .---.r,-,7,7 c ..- . /.....7,..• --.-...-— e'''C...e_ ---C.... , ig _..km...., s LITH Y • PRONE . • KRASKIE ,c.i.
44..rtr . ..,,eTE .k._ 1:1 LEFT SIDE UP ,CkgrGHT SIDE UP
t___ ..c..A.,-(,,i---1 diel - • 47-r-rA.
.e_ 6.' 16 ct ...44.--. ...c__c_---,--6 ..P./
'
CJIAtr " 143''' 1elYtr,W: Us''''. )(1--.4; 4.'4-e''Li e-g 6----jr, 37( "--7 ' :''' e-7-/-e,;(---e--. ./.4e /7.,7-.7 rz-c-cA :A- ..t___.
0-3(/ // 8. SKIN PREPARATILIN Z--0, /c-,---(--e*/ /..
=IN • OP. e it

• is .tsr,iro q
s
is

-
-.4 AI
IP" ___—_,...__ ¦201011r.MairiWillirr
__..m...,_4104.46-11.11:11W--
"Wee

•-
Sponge
KATEMIE3 11111.,45111111C4M11111111111I ¦OPP­
_¦MII
Needle Sharp krg ; Yes Azi
IIK_IillIMM1111111M _i".¦f
.. /°
Instrument Ili Yes !al ___ _ WNW
Il¦ -
Other
EfillinE3 1111Pv"
1 1. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROS RGERY DEVICEISI ESUI 2 YES IIII NO ect_T-74
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
( 'f(-) 4-07," ( 6,- zi
1277­
ESU NO.
_
GROUND PAD: BRAND 41/AW7 .. z LOT NO: 65 tV 7.)0 y-
. - : .7:
A-3"..E80 NO:
.---•-'.--tR-OUND PAD: BRAND

' L i) ) -I.,
• LOT NO:
• BIPOLAR NO:
nit C/111,11/1 G i -in 4 €-."-r e•-• - --. - --- -
MEDCOM - 22466 I IS OBSOLETE. USAPA V 1 .00
'13. .PROSTHESIS, IMPLANTS YEt NO IF YES NAME: ID NUMBER, 'IACTURER
4 k.,V..f,t.4 Alz=4.64-M MEDI CAT I ON S /0 R D E RS dteatea',•;:,..,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO

_ tMEDICATIONS/SOLUTION DOSAGE TIME -METHOD
PREPARED BY N.'s-GIVEN BY
_ -t-‘t____t.
-t_ _ ..
. .,
L
MOUND IRRIGAT N YES . NO, TYPE(S): ‘o
-,
,t _

tOTHER ORDERS TIME CARRIED OUT BY
D ..g ---- — - -
_ .
4";.PHYSICIAN'S SIGNATURE
.t-t,t -.-
15. X-RAY IN OPERATIVQ0M IF YES, SITE
YES / NO

16.t : '' LABORATORY SPECIMENS
SPECIMEN (S) NAME _ _____ ____t----- ---t-NAME
YES / NO

.t_ ._
FROZEN SECTION (FS NAME NAME
YES il NO
CULTURE (C) . NAME NAME
YES / NO ,_ _ _____ _ -_ _ _
NAME NAME NAME

_
NAME NAME 18. D SING/IMMOBILIZATION (Specify)
_ -___
17. TUBES, DRAINS/PACK1NG YES NO 111
Vt
TYPE/SIZE 2. ,? 7 . I
,./6,fr-„Ai SITE . (at, 6,2 to kia:i 3. 41t
AP
19. ADDITIONAL , .Tye a-e4-716.-1-tc ..6e-ir(zA..#4
ST ,c) ..,
-CL—r-./g..,--
6,-6NAx- .C,C--0---e-t-----
20. OPERATIONI,S1 PERFORMED
1tt,t.
_t.

1:____.,77 0
_t
&J) 1t
, _.
21. PATIENT TRANSFERRED,TO p O-Ctt TII.E.7.7. i 6 ism (4.........„,

,
MEDCOM - 22467
RFV
USAPA V1.00
•tINTRAOPERATIVL .JOCUMENT
MEDICAL RECORD
• For use of this form, see AR.40-407, the pro/ Igenc the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATII .)M 2., PATIENT DENT, (IECOI-u.) R VIEWED AND PROCEDURE VIA Li tter BY PkiNe_st1_is-ia VERIFIED BY I LT
3. DATE TIME PATIENT ARRIVED IN SUITE 4.. PATIENT IN ROOM TIME/ 09 i NUMBER ,a --#t5
1 1\) 00 c)--
5. PREOPERATIVE EMOTIONAL STATUS
0 CALM 111 ANXIOUS • EXCITED. • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)
COMMENTS: _.....
V-Vt 0)0 „.
6. NURSING PERSONNEL
ASSIGNED PFc._ 9 1 r) -.-7..:,-,_____. --—RELIEF
SCRUB

SCRUB
ASSIGNED Li , RELIEF
CIRCULATOR _ .._,.. .. . —,..C.IRCULATOR
INT.;,

7. POSITION Aril? POSITIONAL AIDS (Specify) Pt. &&keie,..-cit‘ pcide . .:,:,.. . . )1,tVII :5,),..ppb Old 19 kie.sn lo;A3 - Ax.,1%.1) roll
4:-*:(Vii9 ' "-"6
G pci‘ma. MN) bitkwt_t_u\ ProN &AN& kW .
MI SUPINE • LITHOTOMY PRONE . • KRASKE'', • LATERAL: DE UP 114 RIGHT SIDE UP
.. . COMMENTS: khow4 ,,.v\,&‘_tvv‘A., tsoc.vi ?_..t.iv.,‘Im.suw.t...:1,7,4k.ta,L. wit
8. SKIN PREPARATION
HAIR REMOVAL [4 N "—PREP •SOLUTION (Specify) attaCitv-o-/ • '
DONE BY: • OR • NURSING UNIT SITE: BY WHOM: i LI

YES
IAA e .
SITE: BY WHOM:METHOD: • DEPILATORY • RAZOR .. ....
• CLIP
COMMENTS: 147k _________. . C'OlAfENTS:

9. LOCATION OF EXTERNAL DEVICES
•.. . .r,-,-i:: 0 ..
44\0
--- '--
-4114.1111.1111"6.1111111%
, ,
"- , .1t -t-.!a•-.0111-- -
.t-._---..-t
-,_:_;-‘,-;-.-::.-,•:.-7:--:-7----7"--,=-411111-iimilwiNgiiim.--T1111-00--
--rWanith.
• • --- -t-..,101717.'",..-
,- -
,...6•'-'t_,-,,,,
/;"-- t,''?:;,"%=,
.9,1'.1.;''t?RIO V) .•
LEGVND X I.--Safety Strap = ---- =-Toumiquet--t Prtf lksvilm_l. 'ICC-C = Correct I = Incorrect I VT First Closing-Final Closing .
10. COUNTS Other*" Count ._ .i%;,, Ctiiint SCRUB CIRCULATOR
Sponge Yes o .., ¦ Needle Sharp al Yes • No WMIIIIIPPAEMIIPAIIIUIIVSIT 141111111=1 Instrument 0 Yes VI vo r IpPir. -- - -. 1:...iVi -:ili.7, i •
_
Other 0 Yes El vo
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) • YES NO Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
• ESU NO: GROUND PAD: BRAND
..,--
LOT NO:
, _.
.-z._.--
1:3,ESU NO:
-
--:"' ---r%ROUND PAD: BRAND
1,) \ . ...,„.
LOT NO:• •BIPOLAR NO:
-
.
t t
DA FORM 5179-1, OCT 87 REPLACES DS H IS OBSOLFT=, USAPA V1.00
MEDCOM - 22468
DOD-036044
13. PROSTHESIS, IMPLANTS E 'ES NO IF YES NAME: ID NUMBER;, 7ACTURER
.
11-4q gt
.0 4 'MEDICATIONS/ORDERS:,
.
IRRIGATION/MEDICATIONS GIV EN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO FIMEDICATIONS/SOLUTION DOSAGE . TIME
METHOD PREPARED BY GIVEN BY
MOUND IRRIGATION YES El NO, TYPE(S):
0 .9 °A, Ma_ 61_ s
THER ORDERS TIME CARRIED OUT BY
IPHYSICIAN'S SI NATURE
s`.
•,:ra
15. X-RAY IN OPERATING ROOM IF- YES , SITE.
YES D NO
16. :.'41LABORATORY SPECIMENS SPECIMEN (S) NAME NAME YES NO [gi
FROZEN SECTION (FS) NAME NAME YES El NO CULTURE (C) NAME NAME YES D NO El _L.-NAME NAME
NAME '
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES NO TYPE/SIZE -1.34„ 2.
SITE
C) ttio
9. ADDITIONAL INFORMATION
1A.)C

-, tor
,
41%
INAk1
4
20.
OPERATION(S) PERFORMED

21.
PATIENT TRANSFERRED TO TIME See_ METHOD

PACk,\ ?;g0C " tfe-r "
22. REGISTERED NURSE SIGNATURE
MEDCOM - 22469
DFI/FP.CL nr n rnpm g 70_ /1/.7 R7
USAPA V1.00
511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RtCORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY 19 HOUR oi Ir 5 i3A., • • 2-0 ;.2,.../ _. • •te•d• • • • • - •

PULSE TEMP. F
. .

.
. . . . . .

. . . . . . . . .
(0) (*)
. • •• ••

A--• •

. . . .
Nuo00UOJeje8 101'slualemnbjapeilluao)
o,„
0 000 0 0
a:co o c.ct 6 ;,1 'c'o 010t, °.,—, (c)
c::
2tc; c; cri ad co t...: r-..1.-: 6 cc; Ili to
wTr 44-co cn co ol coolol co co cn
1-.
.
. . . .
. . . . . . . . . . . . .
. . . .
105° •• •• .. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
. .
. . . .
. . . . .
104° AS
180
. . . . . . . . .
. . . . . . . . .
.
.
.
. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . • • • • . . . . . . . . . . . . . . . .
170 103° . . . . . . . . . . . . . .
. . . . . . ...... . . . . . . . . . . . . . .
. . . . . . ...... . . . . . . . . . . . . . .
. . . . . . . . . . . .
• • •• "

160 102°
. . . . .. . . . . . . . . . . . .
. . . . . . . . . . . . . .
. . . . ... . . . . . . . . . .
. . . . .. . . . . . . . . . .
.. . . . . . . . . . .
. .
. .
. .
• • • •••I
150 101° •• •. •. . . .. . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .
. .
140 100° •• •• •• ••
.t. .t. .t. . . . .t.
.t. .t. .t. .t. .t
....
.t41,t:
.t. .t. .t. .t..t. .t. .t. .t. .t.
.t.
.t.
.t.
..
.t. .t..t.
.t.
130 99° , , I)t: ,„. : :t:
98.6° .t. . ¦.1t: .•t: :t: :t•. .".

••. .
.t•
.t:t: :t:
:
i/t:
120 98° • , •• . . . . .
I: : : : : : : : : : : : : : . .
. . . . . . . . . . . . . . . .
. .
110 97°
. •
. •• •• •• •• ••
.
. . 100 96° . .... ..: . .


"
• . . . . . . . . . . . . . . . . . .
90 95° • . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . .
80 . gr . • • . . tit. . .t. . . .t. . . .t. .t. . . .t. . . .t. . . .t. . . .t. . .
. R : : : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
70 . • . . . . . . . . . . . . . . . . . . . . . . .

. .
.
. . . . . . .
. . . . . . . . . . . .
,
. . .
60 " . . • . • . • . • . .. . . . . . . . . . . . . . .
. . . . . . • • . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . .
50 • • • . . • • " • . . .. .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40 " • • " • • - • .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESPIRATION RECORD

pawl=osum"Apomopmoodspio3e8
BLOOD PRESSURE
IVI W13/)( 1:5$' 14i. t2-1113
"r-lAt ­
73
1
198.it( irr 1002
ir .114
HEIGHT: WEIGHT ........* il A

k
cilii 44%,c117.
-
1 v...1,24
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)
N
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22470
DOD-036046

Ward!Se.,:tiLnj\jv —1—F.—
EQUEST1Nt3 PHYSICIA.N:
' I
CH ENI1STRY RESULT FORINI (Subjc-ct to Ihc Privacy Act of 19.74)
LAST, FLRST,
1 L\f:-.: SS/
N:
, 2-C)2--
TEST RESULT REF. RANG.E
Na 138-146 mmotiL
PICCOLO -------

3.549 rr.mt)lit. 30/10/03K
20:14

-=-=.-== PICCOLO K

98-109 mmoVL REFERENCEliiiiiii MALL
20:15

30/10/03K

PATIENT #:

7.31-7.45
PH MALE
REFERENCE RANGE:K

•, ,METtYTE 8
PCO2 35-45mmF1g(trt) PATIENT #:
4 1 -5 rr_mHz (veal 3151AA4

DISC LOT #:K

12

PO2 80-105 mml-Ig (an) GENERAL CHEMISKOPER #: DR #: 000
N/A. (veul DISC LOT : 3?51-1,16M­TCO2 23-27 mmol/L (ail) SERIAL #: 000010069/

I
#: 000
24-29 mmol/L (yen) OPER #
HCO3 22-26 mmoVL (sr0 SERIAL #:)„,AW0000100684

13-28 mmout. (vcn) GLU 199* 73-118 MG/DL
s02 95-98% BUN 10 7-22 MG/DL

ALB 3.8 3.3-5.5 G/DL
BEecf (-2) — (+3) KU/L CRE 1.3* 0.6-1.2 MG/DL

ALP 62 2.0-84K

affrol/L KCK 441* 39-380 U/L
U/L

ALT 25 10-47K

.A.nCrap 10-20 mmol/L KNA+ 127* 128-145 MMOVL
U/L

AMY 37 14-97K

Ca 1.1 2-1.32 mmol/L KK+ 3.9 3.3-4.7 MMOVL
U/L

AST 40* 11-38K

CL-103 98-108 MMOM

BUN 8-26 mg/d1 TBIL 0.6 0.2-1.6 MG/DL
KtCO2 PPK18-33 MMOM.
MG/DL

BUN 10 7-22K

GLU 70-105 mz/c11
CA++ 9.0 8.0-10.3 MG/DL

KINST QC: OKK

CHEM QC: OK

CHOL 100-200 MG/DL

Creat a7-L5 mecll KHEM 0 , LIP 1+, ICT 0
CRE 1.3* 0.6-1.2 MG/DL

38-51% PCV
GLU 199* 73-118 MG/DL

K

list] 12.-17Wd! TP 6.7KG/DL
6.4-8.1K

CHEM QC: OK

INST QC: OKK

TEST RESUIT REF. RANGE
HEM 0 , LIP 0 , ICT 0

Troponin-I
Drug of Abuse tt
1 18-33 rr.raeLl
RELARKS:
REPORTED BY:
I DATE: LAB ID NO.:
MEDCOM - 22471
.1"N'ardiSection:
271',Qt.r...:::;;.:
LAB ORA-T.
Rzsuur FORM
Sub;et-; to Cie
D.¦ TE of 1974)
TL\ 1F,
SS N: , -7—.•••s•
L.3Q0C-stO
"
1
-
...•
•. . -
IVA
RPR
.1,:; 10"
NY-A.
Mono '
14-18 r,"(11 ck-f)
Negative
12-16 1/411 11.)
42-52% 0.0
•.Bili Ncznire
1 37-17% SourceI 80-94 (M')
Ncgaivc
81-99 fl (F) Crram Stain
130-:500 x le v=i fled Occ Bld I
Neviive
20.5-51.1%
Neptive
H. pylori
Parasi-tes
Mono
Maliria
RBC
Morph
Spui
1-iematocrit
Cell
C,ount
Other

Directigen
Neg--th c
ABO/Rh
6.21,, uLition
•. • • .B1p6c1:R.Ink Unit crossm'atch" -:
'
(NITJST,SUB&HT. Sr..518 WITH EVERY UrsiTT OF BLOOD
-RE liESTED
-ST . -
T REF. R.-UsIGE
UN/T.
7-2" PE.
CROSS.:1..4.TCH
9.8-13.6 secs
2 1 -34
' I ;:;1
F DP 10 t:sica!
P. :NLARK.S :
PORTED BY:
DATE: ,
AB ID. NO.:.
MEDCOM - 22472
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
iii Ent4, 01.0gli::iiiki:.'1:1:::;:ii:iii:49....14f.01?
TOTALS 't:AL
AP-t2 -II pi-oacia.
Dm ( r--ky
4: Es--,7,° s....c. (vet--.in--4 ,....6., 5"--
a ,T, m 2 0­
fev,.livii__ 10— g 1.7k L7 F. -•i , .r.1.4!xiNF
..11 2
Vi h"-. li
„,byze (
1... E in 4 7.5---
Z --... i- I-
to 1.0) k-tr) .. PVItilf"--— it.,/ ,t,
Q: 2, D g ::ivoti:kr ..k a.-21% del r ,/ /I -172-i -t..„t,-t—
— / '‘,'
4: D - 0 ....'':: ..I.W MA:VW
.AGENV
% e.t.
43: VI-u , -• -- -... CRYSTA,110pr,
FY: -,2,t'-AIRtL/Min
i,gl Z a... A4- ''
:Z: ° (I) N20tL/Min
1,,:,: u COLLOID-:cu. 02 L/Min
us.
z SINGLE DOSE DRUGS-MARK ON GRID BLOOD-cr WITH NUMBERS 1.. ENTER IN REMARKS
'•:::: CO
N.A.t::::::::::::::::MER::::
. :... I+t

a ).:-.7tID Warmed ''-' — -- — ,-
.P. k Code drugs with numbers, :.i El Warmed
eve with Miners
.:;:::::
:4! ID Warmed
::::::::':':;a':''''':, EST BLOOD LOSS /t/75. -itke.z.,
:ttigSgti:
::,::tg:i:*:,::):::: URINE -,,Z7A/o/Oe Ao9c._--

-Ok ....... '.* e yo it)--- .2.e.0 i • .rs-- .2y49 re- .ro.r : .0(1.44140 .2...0,

4,•.TIMEt
1 2 muu .. ...:::::::::::::::::::::::,,, 049 /
,,/,,,diii /7169itt i
:MPAYNV.EB310f:]:: ,::::::i0:.Agq:ii 220 KG BP by cuff iixtedAv"-(iiI°
200
LB
V . .t..il t4064'IL
OtIgNIMPAPIT.1:::::: A ioo /'' 3 j4scpcbe,---/K-
Heart rate .
160
::::::i.r.g9A.4:::PATA* • '',A3tAl
Rasp rate 14
BP-39 7, f
tO(tedit
• t/t 120 ....rte.l.e -)
HR- 77 BR a
'transducer') 100 IIIIIIIINIMBRIVAgellyalaMMI .6.,14/tt-)
iii;:g0.(41KHP.I.(;:-+ BO id,e9
RIMIiiiiii , ,)
OK7-tYtN
TOURNIQUET 60 ' A muti-&-r/e-e):f47.100,-;:fgoiE.9:Ki T -/1/
40 7-49 feeev-e7
Off for PROCEDURE?
AWES-X-X 20 PROC-e_o 4,, /Ai
TIME-t.
'
OP'
VT - ml
fr a ',"
:" ,
I -breaths/min /0ti 1 it 1 Peak int pres / PEEP 2-2 9-
?,t::::,::: „MODE -Slpon). A( slat). Clon) (q/ .
Ago .........

.,::::, LISP/Auto Cuff T CO2 (torr)
37
PACUtFCUtSpecify)
4.12, BP/oth 2 (Frac or %)
E ART line Pt1%1 OTHER0 Sloth. PC/ES CG 57c CONDRION:
6.
:w Vaas analyzer TEMP-site
RESP• e2tSp02-C?C)N-M Block (T/41
RPt77 HR-
CC C11::,:::*.f.::::;i::::::::;:::::,.:.i,:,:,:.i::::::!: 0 fatStart Room End
w
Z
0 Warming blkt Z
.2/30 ''?; /7"--3:Zr---
al Cony warmer 04 . u Ready Begin End
Mark with letterS 8, SyMberS. EVENTS_,
ci
explain under REMARKS Position -
'122.32...2 2 yA -:43,,
®
PROCEDURES and CPT Codes: f ANESTHETIC TECHNIQUES: Describe block technique under Remarks
11461-erel 0 - A 6 lull° k ,,,,-e4/... E.71,,,,-io
PATIENT IDENTIFICATION: Typed o, written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation routejalade, _technique, commencs Medical facility
':-.' ; '42 -- Ill # 6 10 1:­. r,We C '.... # 14.- - c- i r PROCEDURE .4.
I, tt LOCATION:tA-' DATE:tA .
-7D Cei?‘ (0 3 _
PAGE /tOF
L./B. ruruvi /trtt:1 1UUI:f 1 - PATIENT'S MEDICAL RECORD USAPA V1.00
M E DC OM - 22473

DOD-036049

MEDICAL RECORD - ANESTHESIA
•t
For use of this form, see AR 40-66; the proponent agency is the OTSG
vi..1):-..::::::::::
v is- Ivo TOTALS .17Alii:
10.0.00:i.
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BLOOD-
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NOISNNI INV1SNOOm .1.
SINGLE DOSE DRUGS-MARK ON GRID...
INITH NUMBERS & ENTER IN REMARKS
LINE Sil8 & Mo.,t0 Warmed 1,IDD I-la
CI Warmed 0 Warmed 0 Warmed
•*:::::''i*]:i:'::,i'''::i::: EST BLOOD LOSS
:0$44.0:
::.;;:::;::::::::::i:::::::i::: URINE -tI OtriTi:$.114:0.k:ii TimE mkst5ri
1 2 3 4 5tE :::::,,;:,::::,,.:::::::::::::::,:;:;:: :1301)WWEIPKEK:Att?:0!: 220 KG BP by cuff
200
LB
V i::::t.I.W4979,PIIP.Ii: A 180
tHeart rate
160 -:::114.P*4:IP-i.V.r4:*:: • Resp rate 140
BP-Oil)t/12) 120 BR
HR-
(transduced) 100 (\\
ao
:;::littalki:OKOK:::: 42
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OK for PROCEDURE? ANES-X-X 20
PROC-0_0
TIME-t. VT • ml I • breaths/min Peak inf pres / PEEP MODE -Slpon). Alssist), Clon) I BP/Auto Cuff AT CO2 (torr) BP/oth iFio2 (Frac or WO
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Code drugs with numbers,
events with lettters
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arICUt
OTHER r
STIO
ART line V,Sp02tI%) INt'0)6tICCtio0 Steth- PC/ES V ECG Sli V.-t!YZtla Gas analyzer /TEMP-site ht.,t-•‘.7
N-M Block (T/4)
owl
. ,#. . ,
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CONDITION:f-t°N. Si::
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a:::::::::::::::::::::::::::::::::::::::::::::::::::::::::
a g
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¦.M7'' k k AV°
Ready Begin End
f -V "37
Warming blkt Cony warmer
Mark with letters & sw Mots, E\ T ¦iTS....„0.eiA Luc,
explain under REMARKS Position
PROCEDURES and CPT Codes:
,--, i
1: .i 0 (12) 14 I e PATItCATION: Typed or written entries.* Name, Grade/Rate,
Medical facility 'Pi-.
L.\ iu 1
" LA
K.Arl.' t
DA FORM 7389, FEB 1998
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
ot. C T A-
AIRWAY MANAGEMENT: Mtubation route, blade, technique, comments
.- -. •
0 iSil VV1A-(. . . it (1,,,J.A.. -1-v. '2,-,
SURt
't-
ANESTHt•t
MEDCOM -22474
\ PROCEDURE A _ / LOCATION:t"0-`
/trt
'tit'''' t DATE:
, k. ,,..)( / 1.10 t.i ¦ :3
PAGEt/tOF /
t

ATIENT'S MEDICAL RECORD USAPA V1.00
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECOliDt CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
•;(9 Od, d
ingt 4 I ___-.
go V3 A.-..t46(..)., , , 65cd (4--
,

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ot. r - e4,04...,
V
Aiik
1014'3

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:tl F or typed or written entries, give: Name - kst first, middle; 10 No or SSN; Sex,. Date 0113111h; Rank/Gradal
REGISTER NO.
WARD NO.
, _
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600t(REV. 6-97) Prescribed by 6SNICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 22475
DOD-036051

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry(
DATE
31) ce-)- O IFISSIIMPIP
. AIIM
/tr
"2, ,Jaj / Ir , ,. MardIEW/ 0 ' &WM"
4 a...._ I.A.Mar-t_ '11 ig , MIMI MIIIIIPAIW IhilIMPILtw
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CZS e-- I2L
-
STANDARD FORM 600 IREV. 6-971 BACK
USAPA V2.00
MEDCOM - 22476
\
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARFIOW BELOW.
Lisr TimE ORDER NOTED AND /
PA NT1FICAT DATE F ORDER,tTIME OF ORDER
' HOURS
/SIGN
';')/3
1
NURSING UNITtR OM NO.tED NO.
pA NTIFICA
NURSING UNIT ROOM NO.tBED NO.
0
PAT NTtTIFICATION F R R

NURSING UNIT
PAtT1FICATION
NURSING UNIT
ek
DA IFA0M26 re--. ITIoN oF JU 7. WHICH BE
MEDCOM - 22477

DOD-036053

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 IDENTiF !CATION
DATE OF ORDER TIME OF ORDER LisT TimE ORDER NOTED AND
HOURS
322.2J-3-
SIGN
,2%/1P thj —z 5
NURSING UNIT Room No.
PATIENT IDENTIFICATION F ORDER TIME OF ORDER
3/ ex.:163
9 tHOURS
NURSING UNIT ROOM NO.tNO.
PATIENT IDENTIFICATION DATE OF ORDERtTIME OF ORDE
NURSING U ITI ROOM NO. h-200W4,,, )-2).. 1-2.4
C5b-D 2--
PATIENT IDENTIFICATION (PST/ATE OF oRoERt TimE oF 0
t HOURS

NURSING UNIT ROOM NO. BED No.
DA ,FAcgm,. 4256 REPLACES E0iTiON OF 1 JUL 77, wHicH MAY BE USED.
MEDCOM -22478

THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MEDICATION) , i‘riiJ
CLINICAL RECORD For use of this form, see AR 4,0-407;
/t . r Yr. 2003
the pro • • nent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING :A4t3'.** AO; 4,44,W......, Ats,ti, 41 INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED
HR

ORDER CLERK/ RECURRING ACTION,
DATE NUR FREQUENCY, TIME

go• P '3 y 5--‘ 7
i 60-5 .i.4 v-2-, -f--hd i'-)

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0 (0 ° -3 1 C OCAW I illat/7")C,0 re5i— ti. ill
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Mt • ato Act1111111L-_./
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I
ALLERGIES: Ill YES MI NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
INE YEStIN NO
,

2,7 IC
ilU IC 0 i , 9sc,..i tz, 12- I It' q ( PAGE NO.
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
A D 8t
9 10 11t12t13 14t15
/ 1 Et16t17 18 19t20t21 22t23
\ tr) jt '',.)t
Nt24t01t02 03t04 05 06 07
0 F 1 DEC 77 M.AY BE USED. USAPA V1.00
DA FORM 4677, 1 OCT 78
MEDCOM - 22479
DOD-036055

, Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION ) Mo OCA— yr 2003
order Clerk Date to Time to
SINGLE ACTIONS be Done be Done

Time Done Initials Date Nurse
Rea_ 0040-
30(5-1" A-) o--2/-1-.)?) (/-Jk4
EAci-+ 5Th. f-P (n, -41 0 'c-5 3/D (xi-601E-V64 1 /1 ri 1.(76i--) 5-177 ()I e )16(4 cct T--— ',co-./t.,/,.0 --0 viirti /Of —r- ..,-(1/-'wv 3.'-ocr eva,
i • ,....., 4/
— A-ilo I.0..-
jiff, 1
A ,_i ...4,01/
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lorg-40-1";7144 Cliad----- ' W'It'''. tra0
tr--,---4 „,,,,..„,
1, D16 • irY0
.
ba-a.
IW 0Trarwha r -to
Orded INITIAL PROPER COLUMN FOLLOWING COMPI ETION
Clerk/ PRN
Expir
Date Nurse ACTION, FREQUENCY T1ME/DATE COMPLETED

USAPA V1.00
MEDCOM - 22480
/16,u)- L

7-14ERAPEUTIC DOCLutniNtZ1a2N 1(mED/CAT/ONS)
CLINICAL RECORD / Mo. Yr.
thetproponent agency Is the Office of The Surgeon General.
VERIFY BY INI77ALING . INITIALIPROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR itDATE DISPENSED
DATE NURSE DOSE, FRAQUENCY

.5i '3/titg "5 31 co--111111171 a itt-P-P kro I _
L.
3 I CLe — ---C.:(\ e.k,.,f Cos-2)/3D Po
66°

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taA} C'tM-2-4 6
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oi d9 ow.. ..... e._ I Ili 0.t01 ¦ ¦ /C6 Ali
6/ -0t7s 'IT /`tS. -) . .:-.t:,
. _ 7. rim
40-1/ -).-./ xi ‘ 4
I

¦
IALL ERGIE EI yEstErrio PRIMARY DIAGNOSIS;
ADDITIONAL. PAGES IN USE: El Y EStEl N0
ij IC3)11-
G-L5\-.) t2)0 Pb1-1(ct' a il i 1 4. c
PAGE NOt PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL, CIRCLE MED TIMES
Dt7 8 9t
10t11t12t13t14
lair-;tt.tk Et15t16t17t18t19t20t21t22
\0(()tit "'t23t24t01t02t03t04t05t06
MEDC,OM - 22481
-t
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
,

DOD-036057

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
. Mo.. Y r
Initialing (MEDICA TIONS)
Dote to Time to . SINGLE ORDER, PRE-OPERATIVES Tune Given InitialsOrder Clark/
be Given be GivenDote Nurse
1,iN.,t,---¦i--,
Clerk/ Nurse Order/ Explr Dote Agc-1-.1p- ,t P RN WEDICATION, DOSE, FREQUENCY Dt_i____I -2?.2 V 9 INITIAL .ROPER COLUMN FOLLOWING ADMINISTRATION IME/DATE DISPENSED m
0 (9---(-1 kt r 191,, r., .911-
-NAV 5e de rf._ f C1,, 1,—) ¦ , Per- C-C ert — — 1 1 _. _ P I , .9
p‘o 041 .--)c-' eiy,) c---ti,---) 0.1 4.. ra • y-_-_-, ex

U.S. GPO: 1998-454-110t95216
MEDCOM -22482
DOD-036058
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
for use of this fonn. see AR 4096: the proponent agency is Ihe Office ol The Suigeon General.
OTSG APPROVED WatelREPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: -510 ao/e21.3 Anesthesia Type (Circle)): General Spinal Epidural Drains Aln,vay Time In: 4.3...Z7/1 IV Sedation Nerve Block Hemovac Nasal Allergies: OR Intake: Crystalloid Z&F___ Colloid NG Pre-op V/S: /-50-??.7' OR Output: UOP k...) EBL "04v • JP ETT Procedures: Ze,g‘ri4„(2_,_Meds/Times: •feir-4,-, (,),-Ova,-,
T-tube Trach
Other Pre Op Meds Histor TLS
Time Sa02 Fi02 Methods 240 }ten 1 MI 'rY)601 19 I int2 1 ow/Imps WA Time Solution Pacu Intake Amount Site • • !I ..1 40.,_cini By Infused A'a
220 X-rays: Labs:
200 Criteria Post-Anesthesia Recovemscore ADM t 30't D/C t Codes

Activity (2) Moves 4 Extremities AIRWAY
180 (1) Moves 2 Extremities A =Ambu
(0) Moves 0 Edremilies BB Blow-by
160 140 120 V V Ainvay (2) Cough. Deep breath (1) Dyspnea, limited breathing (0) Apnea Blood Pressure (2) SBP =/- 20 of Pre-op (1) SSP =/- 20-50 of Pre-op (0) SBP =/- 50 of Pre-op z_ z M . Mask FT = Face Tent RA = RoomAir NC - Nasal Cannula V/S
X =A-line BP
1 00 80 • Consciousness (2) Fully Awake. audible aYing (1) Atousable to veibal or pain 2_ = Cuf f BP Rdse TEMP
60 Color (2)Baseline color appearance (1) pale, mottled, jaundiced (0) Cyanotic S = Skin 0 = Oral A = Axillary
40 20 RR Circulation (Peds 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carofid onfy reliable pulse TOTALS: Must be 9 or greater to D/C, otherwise needs anesthesia approval (or D/C, /./ 10 T =Tympanic R =Rectal LOS C =Cervical T = Thoracic 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
ILonhnue on reread

&fen entries give: Name —last de: date: hospital or medkal fachiyi
HISTOMPHYSICAL 0FLOW CHART
0 OTHER EXAMINATION 0 OTHER/swat./ OR EVALUATION
111111111111

0 DIAGNOSTIC STUDIES
\
TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPTC V2.00
MEDCOM -22483
DOD-036059
MEDICATIONS
Allergies:
Time Pain Medication Route Pain I/E By
1-1 0 Dosane 1 -10

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Re Motion
Adm
15' .-----.-----'---.....--

30'
45'
60'
),Of'6,/d
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 uggishtP = Pale, Pk = Pink

C-SECT1ONS
.---".-— Adm 15' 30' 45' ......6V--------9-F D/C Fund. Height
. —/------
Lochia

Peripad#
Fund. Cong,..------
DRESSINGS
Time Location Type Drainage

Adm 111.,i) /,-.t274/
rfizi
30' leil,,;o ll.r( Jer.rizi
60' /t. it
/4-, ."-,4
D/Ct.04'2

el ft
rifb%!
PACU OUTPUT
Time Source • Color/Ap earance Amount

CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
,2374

WAMC OP 173-E
NURSING NOTES
2-325;'492/7--lier?/7.
il/;7.---14,7.
/o/f72 42.7
-
e0'.,1)/ .0=7,,Z,vere ,-/-' ,PjA=7// /44,,Siety, °.2-141., L4
.e7/7ropne-/ 2t1/Y1-/eSne 2 1 .
"
,%zi p4;le-..
Discharge Criteria:
Date:3/e,2,11- Time:tPARS:
BP: 1/.0.-7T:tHR:R3 RR: 2:2— Sa02:4,0
Pain Level at D/C (0-10): (,2r
Intake:. 240 tOutput:

2f0
Additional Data:t
Transferred To:
Report Given To:
Transferred Via: W/C -44.1.1.wo• Gurney Ambulance

Transferred By:
Cleared IAW Recove
Charge Nurse Signature

MEDCOM - 22484
/. Reporting MTF 2_M_Tt___,..a.
AdMiSSIvi I . _1 Coding Information
iz \i,„ ,,?For use of this form, see AR 40-400; the proponent agency is OTSG Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
FGN M
111111.1111111. '
6. DoB (YYYYMMDD) 7. Age at Admission 1 8. Race 9. Ethnicity Religion
1960-01-07 43Y X 9 MUSLIM

10. Length of Service ETS 11. FMP 12. Social Security Number ;
49-

.(D b t (,„(i. .,) -(4
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
Z 19:30

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

17. Unit Location 18. MOS 19. Trauma Prey. Adm ssion
BC NO
r
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Carded for R d Only (CRO) Address of Emergency Addressee
--.
Telephone Number of Emergency Addressee
Name and Location of Medical Treatment Facility:
0580 Iraq; No Install Provided
2'1. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-OTH 1,9,. 2003-11-03 .

24. Clinic Svc -Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
AEA -ORTHOPEDICS 2003-10-30\ \i,
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
IZ 2003-10-30 _ --—
-----'. FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient , Admission Diagnosis Narrative: GSW TO R FLANK WITH ILIA —1.76--bt 1(,:v•------kn
______&--I q Cp el
Procedure Narrative(s):
5

-
Pi
CS\ co &
% ........-----\-
Cause of Injury Narrative: SHOOTOUT W 134TH AR
.—_________—
_
__ ______.
Admitting Officer (Signature, as required Signature of Admitting Clerk
Automated Facsimile - DA FORM 2985, MAR 2000
mEDcom - 22485
DOD-036061

. _
.
Automated Facsimile IrvrATIENT TREATMENT RECORD ‘Cc., SHEET
ror use of this form, see AR 40-400, the proponent agency is OTSG
1. Re 3. Grade FGN Admission Remarks 1
5. Age 34Y 6. Race 7. Religion MUSLIM 8. LnthOfSvc 10. PrevAdm NO
11.FMP 14. Ward ICU2
15. FlyStatus N/A 17. Dept / Ben K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case BC

21. Source of Admission 22. Hour Of Adm: 23. Clinic Service
Direct from ER 19:30
24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp
TRF-A 2004-01-29

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: Admittin Officer: ,iiiiiii ..,. i
2003-10-30 ; / ,0 ' ir -; -- -17.-i (s_
29. ReportingMTF 30. Date !nit Adm 32. Units Blood Components
2003-10-30
31. Selected Administrative Data
Marital Status: DoB: 1969-07-11
In/Out Patient: Inpatient MOS:
33. Cause Of Injury: SHOOTOUT WITH 134TH AR
34. Diagnosis / Operations and Special Procedures:
GSW TO BACK

\
35. Total Days This Facility (t.9 -Absent Sick Days Other Days / Coop Care-Days Supplemental`Care Bed Days Total Sick Days
q/
a ql
35. Total Days This Fpcility Absent Sick Days Other Da onLv / Coop Care Days Supplemental Calle Bed Days Total Sick Days
9
Autom
DCOM - 22486
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
' DATE
NOTES t2,6411101-1- e °S-1-0. 00J-artaltreek-P i9 19c70../4,2 Ar3.
%. 17,51C. oict-ls-ict- -
,co-ecajc,_,./.4 -0-48 :-;-4-----e—
Cl'"1-nt• die . 0'1A51."."-Ekt..1-1,t_t'Sat*. Si•CC--C -t0.-&-C'YJ--.. Oka. i.,:.--v,-6-t01 /j-ww-_-ft_ 0.-.---a_e,--61-bu-ec.--i.4.1c-A--Fi 00 . Sik"--1---.,--'-.1--.Ed-.1-1--d--:"--1-6,..,t--_ ck-v_ .,c-e,,_. _1,-, r.-..,-,-vc . -1.-4,-if
,----,c_ ,4---,i7-,.5 0-1,,,,i,.--c--- 4-c.,--t 6." ,fr,...,,,, i---7--.0 4 tc: v -4(3-61,5 CC,I ..-C----'-e.("6..,..CS ...Y01.463-...
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...- _ 1V1"' Ck.
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&Letvice-)-- - V4 , Sir' ,--4'b.(,(I-Ce I— .ti4--t, k9 4-51-1x-?...,,J-- iv‘.-!nkvb , .Y.CS -.A-d47 • 02 --5-c-i" q cr -/- ,c7.5-026-e
Go..);;,-ad-k-rd, 6.04,...- 1.701,--1-_, tfr-u-,..--e ,
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME
SPONSOR'S ID NUMBER LAST FIRST ASSN or Other)
MI
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
.
PATIENT'S IDENTIFICATION: fFor typed or written entries give: Name - last, first, middle;
I REGISTER NO.
I WARD NO.
l0 No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMF1141CFR) 101-11.203113)(10)
USAPA V1.00
MEDCOM - 22487
DOD-036063

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
. DATE `),Ci.J1 a;),..\in 0 ,9,3) . NOTES br) , (,lidi%i ;(' Ci...11'1.,', ; r A (-; P i UP 92e— .7c -, 76 Lea_ : fibil. (2 . (1F.,,:%,-,-,,ck ftkol JA-T1-tq Cki) , -)'''. . F,.“) x-3 , -P.t--.)(1 -t--, o pck,r, . V 11) E) . t -. In 0 --, -rf¦L\ .i A CiA c 1. ' " • i -1-t‘,.', A Q_ "(i_5,N,c(-_-,,,-_,,,,-,a-7, • c\N-C,..C.-\---1; -3V--. Q.i3ci"\)c'c. yr. \ Q..._ , \O., \\ 00 rv‘r\ se.N u 0_ --IC. -1-no6 -0(7. . 'ilk'. -,,, '.. . •. .p..
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STANDARD FORM 509 f REV. 5/1999) BACK
USAPA VI
MEDCOM - 22488
'
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 Ap.ROW BELOW.

PATIENT IDENTIFICATION
-TIME OF ORDER LIST TIME ORDER
11-top NOTED AND HOURS
SIGN
.
1111MIEMEMINEWOrerf
IIIIIIIIIIIIIIIITIMIIIV
IIIIIt
‘..1
NURSING UNIT ROOM NO. BED NO.
Irl.°—tWelniiteral-t
PATIENT IDENTIFIcATION
hiptainiwommemm
io 1 .,_ od -IIIPjiliff-&
DER .4 r • 7 a ri 7. : ' '
e)coo a, :-.
HOURS
INNIIIIMMINNINIIMNI
in MENIN I
NURSING UNIT. ROOM NO.
mra
PM
PATIENT IDENTIFICATION
DATE OF ORDER
. .131
-' rilEMEIMi gh•
.-pEE 0 la cs., 1,_ 0 t J__ -l .-•sc I- -k "-
.A."-
MIMI '
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
BED NO.
A FORM REPLACES EDITION OF 1 JUL 77, WHICH
4256
1 APR 79
tr U.S. GOVERNMENT PRINTING OFFICE: 2002-488-04i
"USE ctALL Pf-ItNT F
_ tMEDCOM - 22489 N PAPEEPEQUIFF"
DOD-036065

"'CLINICAL RECORD - DOCTOR'S ORDERS 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 MEDIdAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY AP.ROW BELOW.
LIST TIME ORDER NOTED AND —
PATIENT IDENTIFI DATE OF ORDERtTIME OF ORDER
clJe-21-4/0
SIGN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER
t HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER . HoURS
NURSINa UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDERt ; TIME OF ORDER t HOURS

NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED-
FORM
DA 4256
1 APR 79
_ _ _ u_S_GOVERNMENT PRINTING OFFICE: 2002-488-04i _ _ _ _ _ _
"USE BALL POtt4T PEN-P. RESS FI44MLY I NO CARBON PAPER REouiR-EID" MEDCOM - 22490
DOD-036066
1. Reporting MTF 2. MTF Lo, ,_
Admission an. iding Information
For use of this forrn, see AR 40-400: the proponent agency is OTSG
111111111111P4 IZ
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
, FGN M

o ;,i't.4
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
1969-07-11 34Y X 9 MUSLIM

6.
.. -'
10. Length of Service ETS 11. FMP 12. Social Security Number
99

1p6-q
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
19:30
14. Flying Status 15. Beneficiary Category 16. Zip Code 4Residence:
N/A K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS 19. Trauma Prey. Admission
BC NO
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Direct from ER ICU2
Telephone Number of Emergency AddresseeName and Location of Medical Treatment Facility:
0580 -28th CSH -Iraq; No Install Provided
21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-A 2004-01-29

24. Clinic Svc -Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
-
2003-10-30
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
IZ 2003-10-30
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW TO BACK

Procedure Narrative(s):
Cause of Injury Narrative: SHOOTOUT WITH 134TH AR
Admitting Officer (Signature, as required)
,"?
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 22491
Automated Facsimile
fIENT TREATMENT RECORD C., . ER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
1. Re.ister Nbr 2. Name
3. Grade
Admission Remarks /V) ICI) -FGN
4. Sex 5. Age 6. Race ,'''7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm t • M 36Y X MUSLIM
NO
11. FMP 12. SSN ---13. Organization 14. Ward
.
ICU1
15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case
N/A K78-PRISONER OF WAR/INTER BC

21.
Source of Admission

22.
Hour Of Adm: 23. Clinic Service Aff--101-4-1.6.1-
Direct from ER 23:11 AAJ ---tytEinIR&L-eGY

24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp HOME
2003-11-10 27a. Address of Emergency Addressee
27b. Telephone No 28. Date This Adm: Admittin Offic r 2003-10-30
e 19--;
:
29. Repoli. Va-f---
30. Date !nit Adm 32. Units Blood Components
0580 -Iraq 2003-10-30
31. Selected Administrative Data . Marital Status: Z DoB:
1967-10-10
In/Out Patient: Inpatient MOS:

33.
Cause Of Injury:

34.
Diagnosis / Operations and Special Procedures:

35.
Total Days This Facility Absent Sick Days Other Days

OPEN DEPRESSED SKULL FX
ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
0 0 0 /0 / 0

35. Total Days This Facility
(-V If. & ) -2-
Absent Sick Days Other Days ConLv / Coop Care Days Supple Total Sick Days

0 /0
s.
mFncom _ 724SO
mated Facsimile - DA FORM 3647, May 79
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Enter date of admission) 1-"Dj. 0,4,041/-.1A4-49-r""Q (--c,,,44
wtrA,0
110.0.
_44.;
ci ,n,14,14/. Fr-0,0W
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r.X(1E¦ PIrtt.t.--
PROGRESS (Enter dap, of discharge and final diagnosis)
5-fre-eP
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,1;)
ATIENT'S IDENTIFICATION ain• typed or wallet, eirtrieS give Name last,. rst. middle.- grade: date; hospital or medical fad to) REGISTER NO. WARD NO.
MEDCOM - 22493 ABBREVIATED MEDICAL RECORD Standard Form 539 GENERAL SERVICES AOMINISTRA TION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR14I CFRI 20145.505 OCTOBER 1975 OSAPPC VI CO
DOD-036069

•t
Auma Flow Sheet
Time of Arrival Chief Complaint 4,0 (.4 OU4s Name/Rank Time of C/C:tLOC Dur tiontft't
'
Unit Transported by: Ground Amb Military Vehicle SSN: Medications 4/0A/6-
DOB AGE:14D SEXA_
Location of Unit: AyA Allergies: Pbe-4
Airway Pete 0 Obstructed Intubated 0 Tube size MEDICATIONS/PROCEDURES DONE IN THE FIELD
Spine : obilized Cleared . Time: 9-0 4'0 Breathing: ormal 0 labored 0 shallow 0 assisted O absent 0 trach deviation
A1 o/06
Circulation: IV;s on Am)al 4-L Pulses: Upper 93wer '10 Carotid e. Slcin: Pitool 2"Dry 0 Diaphoretic 0 pale 0 flushed O mottled cyanotic Chest : Breath Sounds : Clear ei
MEDS/FLUIDS TIME INIT MEDS/FLUIDS TIME INIT
Decreased 0 R 0 L Absent LOROL Wheezing °ROL Rales OROL Ronchi L
/00 0c-
Moves upper Extremities te'Ves 0 No Sensation OY ON Moves Lower Extremities:Vces 0 No Sensation OY DN /14
Thsfre-.
PROCEDURES C Collar JBackboard 0 NG/OG FR Foley FR CT 704( FR OL R 0 Rectal Tone +
22.6"
. ,
02 irDevice % ) L
Radiology. ;Time 2.0 ( 0 XRAYS: C;A 0-6-6-'to Foxito.-tt;:tt; p.0 rq..‹.
.
''e&
t;-4 1)-
OTHER • ' Time 144 7445- '24 2-f IC ;06) it Co 1,2tt.g-
KrOilitOr 71kb-BP
" ::" -:–
1.3dh,, .f.q247
'41411113 67 l'iPAt 13Ver k'its tIsc
70
eAbration — 'CISW GleighOt WO'uhd
AP • Amputation ' 1.1'-ifernatorne
AV • Avulsion La Laceration 7-
B • Bum LS -Sutured

SA02 No% 0, gog, wot )oo 106% 1%. a15
C • Contusion P • Pain 10a 1q1
GCS /s"
DP • Deureased P11130t8W • Stab Wound
E • EachymosIs S • Scar

NOTES
Fracture Closed SP • Splint
FO -Fracture Open T -Tenderness

I/0 e lich, /4, /slagVAC A.-
IV—IV Lines SR- Shrapnel
rmAple chrarniLoPvas' Cosizima pt,k-aL. /
t), ive_A 1.6frics-x xv cre.reti t4/04,Nais
(Pigh-is (e) -A-Ch sayr-,ndon..,9 bleee41 1(5- 4 ) 0&49-1. e_kg.
Iqrd /ee-. 4-2 tit,/ iii ii) .4-e. t-a6s 1--, proce5g . 0,,,f,,I,
A-64, 44.1161:. flo-cei . pfess;hj- ,/,..e.,/ ,,, ,....04,--is .
cr--;; -/y-ansrfri.k0 4 xe sc,i4. , — rt2 6)CdtAdia 4 iii.0•4/--S(1 7 '77,/„,. c), e 211-,'e. /VC -0 Cyftd(-4)-t .540.‘14.. fl41°.
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fro c--r; fe-ro Tecate) dx Alkm _()' t.' r-,,
u C . Prepa4.40,1 eciac
CON'T NOTES ON REVERSE STE
MEDCOM - 22494
VO;72
, a
GLASCOW COMA SCALE
1. Eye Opening:
Spontaneous 4
To Voice 3
To Pain 2
None 1
2. Verbal Response
Oriented 5
Confused 4
Inappropriate Words 3
Incomprehensible Words 2
3. Motor Response
Obeys Commands 6
Purposeful Movement 5
Withdraws (Pain) 4
Flexion (Pain) 3
Extension (Pain) 2

None GCS ON ARRIVAL t S.-
44.0 At." .. / ........ '

.
.
„. ,
..!.
GLASCOW COMA SCALE (PEDIATRIC)
1. Eye Opening Spontaneous
1
Speech Pain 2 None

2. Best Verbal Oriented, Smiles, Cries 5
4
Confused Inapprop/inapprop cry 3 Incomprehensible/grunts 2 No response 1
3. Best Motor 6): ;--- "...k Spontaneous Localizes Pain 5 Withdraws to Pain 4 Decorticate (Flexion) Decerebrate (Extension)
32
None 1 GCS ON ARRIVAL ,
.2-__
40 , ./IIf / 2.2._.
NOTES (CON'T)
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iti
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MEDCOM - 22495
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD • PROGRESS NOTES
DATE NOTES

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DEPART./SERVICE HOSPITAL MEDICAL FACILITY _. ________.-----.RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: !For typed or written entries, give: Name -last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Gradel
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STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00

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MEDCOM - 22496
DOD-036072

AUTHORIZED FOR LOCAL REPRODUCTION
'MEDICAL RECORD PROGRESS NOTES
DATE NOTES
.
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-ID No et SSW; Sec Date of Sint listkieterkl
PROGRESS NOTES
Medical Record
STANDARD FORM 509 MEV. 5,191301 Prescribed try GSAIICMR FPMF1141CFRI 101-11.203(b)110)
USAPA V1.00
MEDCOM 22497
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AUTHORIZED FOR LOCAL REPRODUCTION
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203(b)(10)
USAPA V1.00

MEDCOM - 22498
DOD-036074

AUTHORIZED FOR LOCAL REPFIODUCTION
MEDICAL RECORD PROGRESS I%
• r
DATE NOTES x i Ota,.." i2. \Ld
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STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00
MEDCOM 22499
-
DOD-036075

LAST NAME ME MID' ---' 1 ID NUMBER
DATE NOTES
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AUTHORIZED FOR LOCAL REPHODUCTIOP
MEDICAL RECORD PROGRESS NOTES
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RECORDS MAINTAINED AT PATIENT'S IDENTIFICATION: 'For typed or written entries, give: Name - last, first, middle; REGISTER NO.
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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)
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MEDCOM - 22501
DOD-036077

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MEDCOM - 22502

AUTHORIZED FOR LOCAL REPRODUCTIO
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MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO.
ID No or SSN,- Sex; Date of Birth; Rank/Grade)
.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/199;
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1(
USAPA V1.04
MEDCOM - 22503
DOD-036079

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD Or wiEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
///9A 7
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SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:ttfot typed or mitten entlies, give: Name • last hist, middle:ID No or SSN; Sex,* Date of Birth; Rank/GradeJ
REGISTER NO. I WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600t(REV. 6-97) Prescribed by GSAI1CMR F1RMR (41 CFR) 201-9.202-1
USAPA V2.00
MEDCOM - 22504
DOD-036080

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE -144€3ceeep,
,4464-22/.0-4
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L A ST J FIRST MI

(SSIV or Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999)

Prescribe0 by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
111111)
IJSAPA V1.00
'D
MEDCOM - 22505
DOD-036081

SI_11\r A.ND VVOUi¦ D
- -- -------_ NIEDICAL RECORD .';'ROGRES-S Nc_)TES • .100-MPTRit" 1-1-4Yr cga:SW \ Admission Date: --.5.aol 9'4--(54 eiC, Diagnosis: 0,.,CA^L.re;., : , t..,. POD:
..
Skin assess7nznt niust be done initially. and every 7 days. -
Braden Seale Evalua.tion (See Braden Evaluatiwz Table for Details)
Sensory No impairment NIobility No limitations
Perception Slightly limited Very limited Completed I i - Slightly limited Very limited Completely immobile 3 / 1 I
Moisture Rarely moist C..) 4 Nutrition Excellent "
Occasionally moist Moist 3 -,L Adequate (Eats 50%) Adequate (Rarely eats) 3 2 1 :
Constantly moist Very poor 1

.7.,
Activity Walks frequently Friction and No apparent problem (....___..b Walks occasionally 3 Li Shear Potential problems / 6 Chairfast / Problems I
-S
Bedfast
Add the total score.
Total Score:
Above 20 Low Risk Between 16 and 20 Medium Risk ' Between i 1 arid 15 High Risk Below 10 Very High Risk Note: A Braden Scale Score of less than 15 indicates HIGH RISK-requires immediate Ulcer Prevention program.
Surgical wound (s): Yes)4.,,No Locati °go:inkk \ Size: Drainage: s)-,
. C/7e..... IQ) 0...)(n.
---,..
Tubes: -.E=)--Pins: "e9---Appearance: s--e_.8 csrf\
laclys i SoVoc
-Dressing change: .."'=".-7.
Bum wound (s): Yes % BSA Partial Full
.
Location: Size
Appearance:
Dressinz change:

Pressure Ulcer (s): Yes No
,, Stage I, II, III, IV (Circle the one that applies and describe below) i• Location: Size: Wound character: Pink Moist Dry Granulation tissue Yellow slough Tunnelina
.
Undermining Odor Purulent discharge Eschar Exudates Type of dressing change: Wet-to-drv Comfeel dressing Carrasyn-V Gel Al.,inaze
.
Physician notified/consulted for ‘,vound debridement: Yes No ?I Dateltime MD notified CNS notitied/consulted for Stage II and greater: Yes N Nutrition Referral: Yes No/4 Physical Therapy Referral: Yes No -Ct Action taken: Da.te 3.: Time n ....;:x.1 on,
REG:STER NO. WARD NO.
Patient's :deat:rvtina (For typti ur written entries give: Name-!ast. first, middle: Gruae: ;:ospi:al or medical facility; PROGRESS NOTES
Medical Record STANDARD FOR:',1 509
,
MEDCOM - 2 506
MEDICAL RECORD
-
PATIENT ACTIVITIES FLOWSFIEET
For use of this form, see MEDCOM Circular 40-5 SECTION I
-PATIENT ASSESSMENT
'
DATE:
0 .---///c7 V 62.3 PATIENT ACUITY LEVEL :-21-.
POST-OP DAY: HOSPITAL DAY:
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT:
Time 13.5-3---To _.--C./..-,-/-From C-64./ / II
AMBULATORY 111
II WHEELCHAIR I.
CRUTCHES STRETCHER
I— EC ctZ(/) ti- 141 CC I — I— c:t —I (/) — 0 Z C/) ELct—Z 0 I— ILuEC
1
Total ER/RR/PACU time Physician
Anesthesia (Specify): Procedure/Diagnosis 5—A.ec, e/ C'''''''9A/16- 6 44 J V'ekte'e.-B/P
P R T
cn'
LOC Neurovascular clycks Oressing/cast Tubes /-.4.
.
Intake (IV, po) 12514/..--.Z9/./• Output (EBL, other) Voided
le No a-Yes Amount: Medication
Other d-P raKeeP •', co•e_ii-/'-e--/ 4 .1/1 ,I-..-4-, /e c
„_ ___
Report From
___—.------19 ( IL ..:/
-----Z----LRec-eived BY
TIME: 40r) BP ARTERIAL LINE BP CUFF 131/ TEMPERATURE
e(
PULSE
ti RESPIRATORY RATE I () OXYGEN (L/%1 PULSE OXIMETER 02 METHOD
1
..
NC = Nasal cannula NR = Non rebreather FM = Face mask
Oxygen Method Key: VM = Ventu i mask
MT = Mist tent PR = Partial rebrea her A = Aerosol
TC = Trach collar TIME: A-0C 0,NO 0110 TIME: j91,9 eisio . . ••
'Skin breakdovvn
prevention if /41:44
. . . . . .
u)a.ILI 0 —ct --I ZLLIek-U 0(f)
. .
. .
PAIN •• •• "
INTENSITY
. . . . .
. . .
'Falls prevention protocol
'Restraint protocol
'Seizure precau (iOns
• Isolation precautions
_
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:*
. .
.
•'
.
o
1-.
MED ADMINISTERED IY;t0 A/4
RELIEF ACCEPTABLE IY/N)
/Air ph
TIME: .
4
FINGER STICK GLUCOSE
__ _ ..____ _ _ ._ A
INSULIN IWNI
-If
.
WEIGHT CHANGE:
'Per hospital policy.
24 HOUR PO IV #1 IV 7..•2 TOTAL IN Urine Stool TOTAL OUT TOTALS
PATIENT IDENTIFICATION
DIAGNOSIS:
DRG: ADMISSION DATE:

milt..,

LOS: EXPECTED RELEASE:
' CASE MANAGER:
PRIMARY CARE MANAGER:
REQUIRED (Specify):
MEDCOM - 22507
DOD-036083

'4
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
in the small box indicates patient assessment criteria nave been MET. If all rhe stated criterif are not met, a brief explanation of abnormal findings will be noted in the appropriate column. .
DIRECTIONS: A check 1
1. NEUROLOGICAL: Alert and oriented to _time place and name. Responds appropriately.
"Communication is adequate to express needs.
Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate
within range for age. No dependent edema. Nai!beds and mucous membranes pink. No calf
(See page 3 for extremity
tenderness.
perfusion)
3. PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath
sourds.
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V!pain
with eating and no problems chewing/
svvallov:ing. Denies constipation, diarrhea or
rectal bieeding.
5.
G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle
development and mass for age. No

deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling!tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact. Good turgor. No
rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
prominences. Mucous membranes moist.
8. PAIN: No complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.)
3. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

_
10. IV SITE ASSESSMENT: (L • P TIME: /6770
ellTIALS:
IV patency 1 q hr:

IV site care provided:
IV tubing changed:
LOCATION CONDITION
IV Site gl: 79,4--/f._ ,e.
IV Site #2:
Comments:
-
— --- -
TIME:6.790 INITIAL TIME: INITIALS: T IME :QS 1,0 INITIA
T L7
u..„—.-----
% _\,0 et .
E /7 10 Ira./ I .1., r
cleo-k\a',ADa, , .

,
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Li G en e/-ar /,‘"e e
ItI LJ InsIAT"Wras8
.-eak, es-5 u.9e-c*Aszei.5

f-7 ,..43-ed2- 5-.4. P .,, 1 1 cti.cl-sovykt5
.toc.4-0...\ NO )0Q-.
— 5-1-"V te. 5 740 Occ.,;(; 71-
olii2-1NA10 0-3' f.'

F-4.../ II
.
I I
1
Puf fy I -Infiltrated R -Reddened OK -No swellinglredness * -Central lit -
TIME: INITIALS: TIME: gbala____ INITIALS: IV patency V q hr: IV patency V q y hr: 4..) IV site care provided: IV site care provided: .1\_, L_____
IV tubing changed: IV tubing changed:
LOCATION CONDITION LOCATION
CONDITION
IV Site #1:
IV Site #1: laR2612.001./A OIL,
IV Site #2:

IV Sitc #2:

Comments:
_ Comments: ____________---___... _ _ nApnrnm _ 99c11R
MEOCOM FORM 659-R (TEST) (MOHO) MAR 99
Page 2 of 4 pages
DOD-036084
f \
11:(2,0
SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE:
TIME:
COLOR CAPILL FILL
. TEMPERATURE
E
EDEMA
U
SENSATION
R
MOTION
0
PASSIVE FLEXION
V
PERIPHERAL PULSE
A
S
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white •
C
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs)
U
Temperature: C-cool; W-warm; H-hot
L Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
A Sensation: A-absent; N-numb; T-tingling; S-sensation (present) R Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler. P-palpable
BREAKFAST LUNCH TYPE: TYPE:
,---
----"------.....-
1
PERCENT CONSUME PERCENT CONSUM-EIT:
E
HOW TOLERAT : HOW TOL TED:
T
E SELF El ASSIST 0 COMPLETE •I SELF ¦ • SSIST El
TIME: 490
,___ -•
s .ID band visible/legible I -Illr'"....., A orient to environment prn i 11 + •• i. Side rails (2/4) up
E
Bed position low
T
Call light within reach
Review & post lab results
Notify MD abnormal labs

Incontinent urine/stool
0
T Linen change prn

H Turn/reposition q2h
E ROM q2h if immobile
R

Antiembolic hose
DINNER
./.------TYPE: PERCENT CONSUMED: HOW TOLERATED:
COMPLETE E SELF CI ASSIST EJ COMPLETE
0700-1500 1500-2300
2300-0700 0 SELF P • MPLETE 0 SELF 0 COMPLETE E SELF CJ COMPLETE
BATH/ORAL CARE Ef ASSIST Ff4 TOTAL ZASSIST 0 TOTAL El ASSIST 0 TOTAL
D BEDREST 0 SELF BEDREST CI SELF-BEDREST C] SELF
L
AMB ATE 0 ASSIST •=2W—IBT-C-A-T-C--..,. BULAT ASSIST
_1 g---"SIST
TYPE OF ACTIVITY
B . BSC B
(Circle all that apply) # TIMES/SHIFT # TIMES.'SHIFT # TIMES/SHIFTBRP BRP BRP ' "
CHAIR W) -1-CHAIR CHAIR ,''AU -- (-
TIME: / 190 INITIA TIME: INITIALS: TIME:419") ‘ c) INITIALS
CONTENT: - -CONTENT: CONTENT:
T E ----P/ai c'9---. C a c'e_, A C H
I . N
ADamily Verbalizes Understanding . Patient/Family Verbalizes Understanding 0 Paiient/Farnily Verbalizes Understanding
••¦•¦•• _
PATIENT le NTIFICATION INITIALS SHIFT
z.--..._._ _
6-WM
, , -,. 5
,,,._ •
, ;
r,..,
RAI—Mo.-St-1R A nntrArs
MEOCOM FORM 689-R trEST) (MOHO) MAR 99
Page 3 of 4 pages
DOD-036085

OnZ f2 C.) .:S CCw
1
SECTION III -INTERVENTIONS & TEACHING (Cont)
T
TREATMENTS
I t
LOCATION OF WOUND APPEARANCE AND •
M
DRESSING CHANGE
E
..__ _____
,
.

SECTION IV -NOTES , . 1

16 M Gr tliAr. k., .1--, //A-Pg, (.121 ,f;i 'IN / -/
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RACI-V'CIRA
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MEDCOM FORM 6S9-R ITRSTI Imruni MAC, 00
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
n For use of this form, see MEDCOM Circular 40-5
SECTI -

I
DATE:
LOSIC. 05
I PATIENT ACUITY LEVEL : rycs.
I POST-OP DAY:
HOSPITAL DAY: COMPLETE ONLY AT TIME OF ADN1ISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT:
Time To From II
AMBULATORY il CRUTCHES 111 WHEELCHAIR 111 STRETCHER
T Total ER/RR/PACU time
-ail
R Anesthesia (Specify):
Procedure/Diagnosis BiP
A P R T
N LOC
‘ .vascular checks
s Dressing/cast •

Tubes
.
F Intake (IV, po) Output (EBL, other) Voided II Yes
Amount:
E Medication R
Other
Report From Received By
TIME: icick. ea
4.4_*10 • (0
BP ARTERIAL LINE
11111
V BP CUFF 44120I Z6 7,‘ 'it,
q„„c.,„,,A,
gcc,4 ft:77
TEMPERATURE *Alb a 4 1.63.
T
PULSE
A 0 :ILI 66 ft/L RESPIRATORY RATE Ito l(k• /0 if, OXYGEN (Li%) S
PULSE OXIMETER
91-Q6 7r,)
02 METHOD
1 Pk qA ,-
G N S
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi maskMT = fv1ist tent PR = Partial rebreather A = Aerosol TC = Trach collar
I CO0-LLI - Z uJ L1-1 0 C/)
TIME:
OV6Ite)
TIME:
4
• Skin breakdovvn
•• •• -t-•-•
. . . . •. • • • .

' •
prevention
.

tl)
PAIN •• •• •
• " ••

'Falls prevention protocol
• Restraint protocol
. Seizure precautions
.1solation precautions INTENSITY
•• •-•• ••

0- -Z 0 I--LuCC
0
4)5e/
, _
1
. .

iC •
-44

" " ' •

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MED ADMINISTERED IWNI p1/4,
iv A
RELIEF ACCEPTABLE IY/N)
________ . _ .__ ...
IME:
FINGER STICK GLUCOSE
YESTERDAY WEIGHT:
..._

INSULIN IWNI
TODAY'S W HT: WEIGHT CHANG .
. PP, hosptil pobcy.
24 HOUR PO IV ttl IV #2
TOTAL IN Urine
Stool TOTAL OUT
TOTALS PATIENT IDENTIFICATION
DIAGNOSIS: S____oailei____,________1_20/1._0, ia.._.-
f
_ _, ._. --
impDRG: ADMISSION DATE:
EXPECTED RELEASE:
\ Alt LOS:
N" -
CASE MANAGER:
It 14 j PRIMARY CARE MANAGER:
icni ATInNI mcn, 'loci-, ,c..__,..,.•
MEDCOM - 22511
mmnrinn AR€1.1:1 ITFCT1
RA A C1C1 oppwuli IC FrliTinNIC ARP PTP Pace 1 of 4 pages f AC V 1 .00
DOD-036087
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check ,/ in the small box indicates patient assessment criteria explanation 01 abnormal findings will be noted in the appropriate column.
1. NEUROLOGICAL: Alert and oriented to time placP and name. Responds appropriately. 'Communication iS adequate to express needs.
• Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate
within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 lor extremity
perfusion)
3. PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
4.
G.I.: Abdomen soft and non-distended.
Bovvel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallovi,ing. Denies constipation, diarrhea or
rectal bieeding.

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

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

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

8.
PAIN: No complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild

and appropriate to situation. Interacts
appropriately vvith others.

10. IV SITE ASSESSMENT:
(LEGEND: P
TIME:
b VI s n INITIALS:
IV patency V q ._D hr:

IV site care provided: _____Jazygo____
IV tubing changed:
IV site A.,: IV Site #2: Comments:
_
rATIONt
CONDITION
12_ _Fil 0 Dc`I2, •---i la64....
____O (M______
Ti.6(oLis-
INITIALS:
0' ')'
L20,-.1/-471)2-
1,?ovil..i....crl.."
I %....K
have been MET. If all the stated criteria are not met, a brief
1
I cirx' -)

E: INITIAL. TIME: INITIALS:
UNIU1.0 /5 1.01U1-'
1-0/
i
'Lie--
I -rity.ef",a,. 40 vii.;16 Lj Al 0 ,
cpablikd I I
I 4
0 •Rrnic, 'd di-f-fic--b '-/'
n 54511:, Le s !sutures iO Pfr2hia 1 i ° be-
Inta.1--fd el rkt ri-k-s32,
Lil,./
.DatittkQo et strepio t° I eractS 0 1 60
7
tat...IQ) (•-t i
..C4-70ik....i
I .4' i
.
I I
Puffy I -Infiltrated R -Reddened OK -No swellingfredness -Central line)
TIME: INITIALS: TIME:
1901.)
INITIALS:
IV patency V q _ 2 hr: IV patency V q hr:
IV site care provided: jasLW___ IV site care provided:
IV tubing changed: IV tubing changed:

LOCATION CONDITION
LOCATION CONDITION
IV Site #1: orn IV Site #1:
a_
IV Site #2:
IV Site #2: Comments:
Da3C, 20V Comments: .
e-Le ) a5c_ci iv(
It larr,...,••¦ • I l•el, A IN
MEDOOM FORM 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
DOD-036088
\r) Lzt,
SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE: TIME: TIME

COLOR
CAPILL • " REFILL
(/)(% w -0 I— wcc
.ID band visible/legible
Orient to env_jionment prn
I
Z CC 0 (f) CC —11.1I—I CI—Icr, f— U.1 C.) — Z (.7
TEMPERAT 'E Side rails 12/4) up
EDEMA Bed position low
SENSATION
Call light within reach
.
MOTION PASSIVE FLEXION Review & post lab results PERIPHERAL PULSE
Notify MD abnormal labs LEGEND Cotor: P-pink (normal); C-cyanotic; W-pale, white
Incontinent urine/stool
Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-( 5 secs)
Temperature: C-cool; W-warn-i; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full -OM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-vveak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiernbolic hose
BREAKFAST
I LUNCH DINNER TYPE:
V--a--S---I TYPE: TYPE: PERCENT CONSUMED: j„..(364 I PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED:
1/00-‘2,--e
1,19ELF 0 ASSIST 0 COMPLETE I 0 SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE 0700-1500 1500-2300
2300-0700 INSELF D COMPLETE 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE
ASSIST

0 TOTAL 0 ASSIST 0 TOTAL E ASSIST 0 TOTAL
BED' 0 SELF BEDREST 0 SELF BEDREST 0 SELF' AMBULAT 0 ASSIST AMBULATE 0 ASSIST AMBULATE 0 ASSIST
TYPE OF ACTIVITY
(Circle all that apply) BSC BSC

BSC
# TIMES/SHIFT /I TIMES/SHIFT # TIMES/SHIFT
BRP BRP BRP CHAIR CHAIR CHAIR
TIME: INITIALS:IM
CPI( g----TIME: INITIALS: TIME: INITIALS:
CONTENT:
CONTENT: CONTENT:
fi_a
_,,..,_ ,r. e_a,, .. ,
e.„,,Le oed........ ,,,,....,..„

atier29 amily Verbalizes Understanding I 0 Patient:Family Verbalizes Unders,tand,ing El Patient!Family Verbalizes Understanding
PATIENT IDENTIFICATION Cit v. lip INITIALS - ......... t,, --)i (..) (-SIGNATURE , SHIFT -&ta2-l___
____ _ _ :0 kii) "11' • ORM 689-R (TEST) (MCHO) MAR 99 nAcrIrsrinn _ __ onai..) Page 3 of 4 pages
DOD-036089

SECTION III -INTERVENTIONS & TEACHING (Cont)
T
W 0 I M E LOCATION OF WOUND APPEARANCE TREATMENTS ANG) DRESSING CHANGE
; U N D 4006 1 TfOrk-Ft1 L 1-01b cc.,iiik, 6 0.4e, pC't"1-4—,,,,_.2,,- Asse--,
C
A
R
E
.
SECTION IV -NOTES

f ,
.
-
MEDCOM - 22514
MEDCOM FORM 689-R ITEST) (MCHO) MAR 99
Page 4 of 4 pages
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5
SECTION -
-• . —._.....,....,..miErdi I
.
DATE: 1 NOV a 6 PATIENT ACUITY LEVEL •
I POST-OP DAY: HOSPITAL DAY:
COMPLETE ONLY AT TIME OF ADNIISSION OR PATIENT TRANSFER IN

-TELEPHONE
REPORT:
Time To

From II AMBULATORY II
CRUTCHES 111 WHEELCHAIR I. STRETCHER
T Total ER/RR/PACU time Physician
R Anesthesia (Specify):

Procedure/Diagnosis
A BiP P R TN LOC
Ncurovascular checks s Dressing/cast
Tu e
F Intake (IV, po) Output (EBL, other)
Voided MI.
, II Yes Amount:E Medication
R
Other
Report From Received By
TIME: 000 9.-storgirry
BP ARTERIAL LINE .....‹.....„,...""--

— 1— —Z
—Z 0 F— wCC
BP CUFF
GI tic 67 0 qiibq
• . „
TEMPERATURE
7 0 -f_15 r/f
PULSE
qt) tt:n
16_ ‘C, it--P, 't"
RESPIRATORY RATE
OXYGEN (Li%)
PULSE OXIMETER idl,
02 METHOD

NC
Oxygen Method Key: MT
TIME: ar to •
PAIN
croi
C2N.A-

= Nasal cannula NR = = Nlist tent PR =
ft-O3/5,0=qdtkr) •• •• -• ••
•• -• •• ••
•• -• •• "
Non rebreather Partial rebreather
• • "
" ••

FM = Face mask VM = Venturi mai; /./ , ,A = Aerosol TC = Trach collar ,41),
TIME:
I/ 1• )i.,13,(
'Skin breakdown prevention Le
'Falls prevention protocol
CL 11.1 C.) —c:t Z LU LI,t(1)
INTENSITY •• • • •• •• •• •• . . . •
• Restraint protocol
' Seizure precautions
.1solation precautions
-
YESTER ' WEIGHT:
TODAY'S WEI WEIGHT CHANGE:
.
o
A I
X
MED ADMINISTERED MN)
kir— orv

....._
... ..
IV
/174--Am
____ ______. ..._____
RELIEF ACCEPTABLE iY/N)
TIME:
,
EJNOF0 STICX GLUCOSE
_
INSULIN IWNI
,
. 24 HOUR TOTALS PO IV #1 PATIENT IDENTIFICATION C., IV 42 • Prir hoSPilal PolICY• TOTAL IN Urine Stool I 1 DIAGNOSIS: ,,._____N\nglik_icilicic DRG: ADMISSION DATE: TOTAL OUT ei(OQ-,
' CNN() ../A\I0 JU . LOS: CASE MANAGER: . EXPECTED RELEASE:
PRIMARY CARE MANAGER:

Icr" ^T''''N REQUIRED (Specify):
r¦APnrnm _ 99MR nnPnr-ruln cnonn acra o
ftrt 17, csn DOCl/inl IC CrlITIrlAIC A qg
rincru TP Paa0 / 0/ 4 Oages MC V1.00
ikkj\
SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1 in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief
1

explanation of abnormal lindings vrill be noted in the appropriate column. .
.
TIME,
INITIA TIME: INITIAL TIME: INITIALS — —
1. NEUROLOGICAL: Alert and oriented to
vy VV. kink_
garfracie
time place and name. Responds appropriately.
Communication is adequate to express needs.
bel.-i\h"
"'Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate 1‘...„-r
21/ gfl
within range for age. No dependent edema.
Nai!beds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity

perfusion)
3. PULMONARY: Respirations vvithin normal ILy--
D//
rate for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath

sounds.
4. G.I.: Abdomen soft and non-distended.
I D//
Bowel sounds active, Reports no N/V!pain
with eating and no problems chewing/

swallowing. Denies constipation, diarrhea or
rectal bleeding.

..--,
5. G.U.: Reports no dysuria, retention.
VI k- ) ley ,tc. e-ef-tr 4/ de
urgency. frequency, nocturia. Urine clear,
yeliow/amber. No unusual discharge. 6-raid 1-1-1

6. MUSCULOSKELETAL: Normal muscle
T'. R/i/ V
development and mass for age. No
deformities. No assistive devices needed. Normal active ROM without pain. No joint
swelling!tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact. Good turgor. No [ I Sikhocky /gap/es-0 _474.5 Jo rxedfAlor.
rashes, inflammation, ulcers, breaks in skin. NCO-95 tk
No redness, blanching, irritation over bony -h. -oyt-1-wr._ a--0 be 5.,./a°.f ',1---i,41 . SuAukars aditttk
prominences. Mucous membranes moist.

S", 0 .1/,'50v..e./aten, +-;) 014-0 IdaQ-.
PAIN: No complaints of pain/ discomfort. Lk­
8. 1 \4/1
(See page 7 for documenting pam intensity.)
9.
PSYCHOSOCIAL:
Behavior is appropriate [Th.'''.
to the situation. Anxiety is controlled or mild -..i/i .and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT: ILEGEND-:- P -Puffy I -Infiltrated R -Redden
-No swelling:redness * -Central TIME:
(-263— INITIALS:
TIME: INITIALS
/c3/57 TIME:DU:2D INITIALS:
IV patency 1 q hr:
IV patency ,/ q e lir: ,/ hr:
IV patency q 2
IV site care provided:

Arszao IV site care provided: IV site care provide& ° AA.tAAt0X no,/-.411 EC* 11 V tubing changed:
IV tubing changed: IV tubing chan. if
6)CATION CONDITION
IP
LOCATION CONDITION . •tA CONDITION I V S i 1 C # 1 : Flpy . nk.
IV Site #1: ea
IV Site Ill•
" till
IV Site P2: IV Site #2:
IV Site #2:
3.
COMMCII1S: :„....1-13ic --C....• 9....acc,L.
Comments:
— Comments:
a) \
-e-I °S-C-L.- --
—_--.. ___._
MEDCOA1 FORM 68.9-R (TEST) IMCH0). MAR 99
Page 2 of 4 pages
DOD-036092
SECTION III -PATIENT INTERVENTIONS & TEACHING SITE: TIME: TIME: ;Pt 411fr,,,,_ COLOR .ID band visibleilegible
I
Orient to environment prn
L
____ . _. . ______
111111.
w-0 I-ui
CAPI ARY REFILL
Z CC 0 WO D CC - LLI I-
TEMP• ATURE
EDE
SENSATIO
Side rails (2/4) up
MUNN

Bed position low
Call light within reach
.
MOTION
PASSIVE FLEXION

Review & post lab results
.......

PERIPHERAL PULSE
Notify MD abnormal labs
11‘11 .
EINI
Color: P-pink (normal); C-cyanotic; W-p e, white
Incontinent urine/stool
IIM 1111

Capillary Refill: 1-10-2 secs); 2-13-5 secs); 5 secs)
Temperature: C-cool; W-warrn; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-'fling
Sensation: A-absent; N-numb; T-tingling; S-sensatioi resent) Linen change prn
Turn/reposition q2h
IMMO
ROM q2h if immobile
1 1 11
Motion: U-unable to move; M-move-no pain; P-move-pa • R-full ROM Antiembolic hose 111M1 Passive Flexion: D-dorsal flexion pain; P-plantar flexion paii • 0-no pain
1 -
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-b nding; D-doppler, P-palpable
BREAKFAST
LUNCH
DINNER TYPE:
TYPE:
TYPE: PERCENT CONSU
PERCENT CONSUMED:
PERCENT CONSUMED: HOW TOLERATED:
HOW TOLERATED:
HOW TOLERATED:
ELF 0

IAJLW
0 COMPLETE El SELF 0 ASSIST 0 COMPLETE El SELF El ASSIST 0 COMPLETE
ASSIST
1

0700-1500 1500-2300
2300-0700
;Q:3SELF 0 COMPLETE ETZSELF D COMPLETE E SELF El COMPLETE
BATH/ORAL CARE
El ASSIST 0 TOTAL 0 ASSIST 0 TOTAL

0 ASSIST 0 TaTAt_e.
D
BEDFfE El SELF ,, BEDREST . C7 ;ELF BEDREST 0 SELF
L
B A 0 ASSIST ?Nes•48.61 11rASSIST AMBULATE 0 ASSIST
TYPE OF ACTIVITY
ICircle all that apply) BSC

BSC BSC# TIMES/SHIFT . # TIMES/SHIFT # TIMES/SHIFT
BRP BRP BRP CHAIR
CHAIR
CHAIR
TIME: 5-5.— INITIALS. TIME: 5----3 INITIAL
TIME• INITIAL
CONTENT:
CONTENT• CONTENT: •
- •
T . Cf17___L R__ Assic-r 4,----oi ce...-1„--(MU Aol coolacuLu, (6
E ______
1\ _.(a_CrQd
A C ' 9Cian (56 eirtjH I N G
1 ,
/
atient
Indy Verbalizes Understabding 0 Pacient•Family Verbalizes Understanding 0 patienuFamily Verbalizes Understanding P TIENT IDENTIFICATION INITIALS SIGNATURE SHIFT
Wifin,
..
li
. . . . •••Z
f%\ gr-'-

_
erl . Ir ' CM
:5
It ¦11-1-1,,,NR •t/1,1,.. ,
-R (TEST) (MCHO) MAR 99 Page 3 of 4 pages
DOD-036093

.. SECTION III -INTERVENTIONS & TEACHING (Com)
OM Z00Ccw
t-—2w
TREATMEVT5 LOCATION OF WOUND APPEARANCE AND ' ' DRESSING CHANGE
_
I
0 00171-co 4pbe. 0-a,, , ai -itSiesS
Tale • an 4:90Pn =. Cleafted.--c; ,._},,
I1/4-)S
Nel afft-t-.e.)i ,.
f-tt--
.
SECTION IV -NOTES
1t_,, bT1/ ,t.1t / ,t
M.0 ../, .371/
/ Itejitio
___DLict .._z_ahl erped-i_. (04,-L,..__f_-7)-t.0---t.;_,
keedzits . ege.g4taa c..., (ucs-
-
,„ ( _ ' 4
/5---e/ t n1A-4 A"( "4- ''' te"--1 "9-e-'7-i -e-1 ;1'1 R--i" c5 ......•:,-fflorm.logliglannig ..e-
f
1"1 0.”-.‘,16V-, .„„1-,
.--0° ).
10169.) -L---.
______ __ . __ _ _ _ __._____.. __
_
-• ------- - -- ------------7=----- --
.
MEDCOM - 22518
w-nrnm rnam F.QQ_L? /TCCTI Inic•uni /IX A 1.1 e ¦
WILL/IL/AL titL:OHL) -
PATIENT ACTIVITIES FLOWSHEET
For use of:this form, see MEDCOM Circular 40-5
.
SECTION I -PATIENT ASSESSMENT
DATE:
NW 05 PATIENT ACUITY LEVEL : 7777 (.,
POST-OP DAY:
HOSPITAL DAY:
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT:
Time
To
II AmeuLATony
From
_
II CRUTCHES ll
WHE
Fli STRETCHER
1-- CC Z u.Li.1CC I -
s
N
A
R
T
Total ER/RR/PACU time
Procedure/Diagnosis
LOC
Dressing/cast
Physician
Anesthes.. .. cify):
BiP
P R T
Neurovascular checks
Tubes
,
_..-----67—r
itput (EBL, other)
F
Intake (IV, po)
Voided
II No 1111 Yes Amount:
V
.
E
Medication
-----------"----
Other eport From
Received By
BP ARTERIAL LTE E:
INIM19)524:192
,/---°11,...f°
Lil/65-1 yi
BP CUFF
TEMPERATURE
qq/6 eiV
PULSE
n tit 7/
RESPIRATORY RATE Ice
li /4;!.
OXYGEN (L/%) ........----:„.¦ —/

T
ql

III1 (it.. r....„,
4„ 7 4
(

1) Z(/)
PULSE OXIMETER 02 METHOD
,./..'
NC = Nasal cannula NR
= Non rebreather FM
Oxygen Method Key:
= Face mask
VM = Ventu i mask
MT = Mist tent PR = Partia rebrea her A = Aerosol TC = Trach collar
I

.
TIME: nryc, lab
TIME: n7Y__.?
to •• • let
. . . . *Skin breakdown
. .
. . prevention
' • •• WA
PAIN INTENSITY p 'Falls prevention protocol '
r

MED ADMINISTERED IY/NI iv
4.-..) • Seizure precautions
RELIEF ACCEPTABLE re/N)
y p (A.
.---*Isolation precautions
0-
_
"
•• •. E
.Restraint protocol
4/2_

)9(._' ' •
o
-Z

I
H E S
WEIGHT CHANGE:
R
'Per hospitril policy.
24 HOUR PO IV V IV #2
TOTAL IN Urine Stool ....'
-
N
TIME:
E
FINGER STICK GLUCOSE
__ E
YESTERDAY'S WEIGHT:
INSULIN (YIN)
D
TODAY'S WEIGHT:
_.------------.
TOTAL OUT
TOTALS PATIENT IDENTIFICATION
.
CI V \ i,,,ti DIAGNOSIS: DRG: LOS: CASE MANAGER: ItAl , I a ai A c ADMISSION DATE: EXPECTED RELEASE: Li II Ilk . .1 If 0 lafi
PRIMARY CARE MANAGER:
rutPrIc•niln prIonn con rp r-rcc—r$ II', RR I% vs MEDCOM - 22519 EQUIRED (Specify):
DOD-036095

SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS.. A check i in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
1.
TIME:Crn-C) INITIALS: TIME: INITIALS:
TIME: lei ge) thwriALIIIIII
1. NEUROLOGICAL: Alert and oriented to
I 1 tPdt/M5L-te 77.2 M.5.5. I I I I 1?-a,V.t2y(k. cva
time. place and name. Responds appropriately. c:,,p 4-Afierrl 04--b 11Ej.
. Communication is adequate to express needs. .13.v (.7,1,0 1-- MeAZ 1 We. . -95t1 (151\1 er Pupils equal and reactive to light. ei--- 15 A tkAnzi
lekray-ck6¦ 0--
42.1...5 J'045/ 0 %.-
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion) . Fl kir
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds. • I I
4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding. I
5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge. I I I fi
6. MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist. 5 cill LP L.AL.-r_.--5)1)0i-4..5 ),u-rA,-r---C ,c, 5 (.-PA-fbl'no,1-- n SN-ct.c. Nc Cr CYA-0--Q- 1 C1OQ, \ (IV

8. PAIN: No complaints of pain/ discomfort. ...---o G70 lb p4-¦ ii,"
(See page 1 for documenting pain intensity.) 1-1 'Z's Q_I 0 Pair

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

10. IV SITE ASSESSMENT: (LEGEND: P Puffy I -Infiltrated R Reddened
OK -No swelling/redness * -Central line) TIME:
INITIALS:
TIME: INITIALS: TIME:
INITIALS:
IV patency ,/ q hr:
_ IV patency ,/ q hr: IV patency ,/ q hr:
IV site care provided:

IV site care provided: IV site care provided:
IV tubing changed:

IV tubing changed: IV tubing changed:
LOCAT CONDITION
LOCAT N CONDITION
LOCATIO CONDITION
IV Site #1:
IV Site #1: IV Site #1: IV Site #2:
IV Site #2: IV Site #2:
Comments: Commen Comments:
..--..
MEDCOM FORM 689-R (TEST) IMCHO) MAR 99 Page 2 of 4 pages
DOD-036096
SECTION III -PATIENT INTERVENTIONS & TEACHING
_
SITE: TIME: ,t-7,_cn . TIME: aice)
ii
ID band visible/legible
1

Orient to environment prn e j)
Side rails (2/4) up
COLOR
r
(/)Li.LI.1 I-›-tItf-tW CC
CAPILLARY REFILL
i
jtI
ZtCC 0 CC 0t CC 0--I I -Z
1.1
11111

TEMPERATURE
LA)
11111

EDEMA -61-
SENSATION
5
MOTION
F---
Bed position low
-
Call light within reach
Review & post lab results
PASSIVE FLEXION
--0" 1
,...---f-----
„....„/".

PERIPHERAL PULSE -2--
Notify MD abnormal labs
LEGEND Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Incontinent urine/stool
Linen change prn
Turn/reposition q2h
ROM g2h if immobile
Antiembolic hose
1

Passive Flexion: Peripheral Pulse: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
BREAKFAST TYPE: PERCENT CONSUMED: HOW TOLERATED: c.-.) y/v/i61 LUNCH TYPE: PERCENT CONSUMED: HOW TOLERATED: DINNER TYPE: '1/4`)? PERCENT CONSU HOW TOLERATED:

Op SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST El COMPLETE El SELF El ASSIST 0 COMPLETE 0700-1500 1500-2300 2300-0700 0 SELF 0 COMPLETE D SELF 0 COMPLETE __AK1/4 SELF 0 COMPLETE
BATH/ORAL CARE q ASSIST 0 TOTAL El ASSIST El TOTAL . 0 ASSIST 0 TOTAL
BE --) S El SELF BEDREST 0 SELF BEDREST NI SELF E D ASSIST AMBULATE El ASSIST AMBULATE 0 ASSIST
TYPE OF ACTIVITY
:7,32m.C. BSC BSC
(Circle all that apply) # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFTBRP BRP '..1AIR CHAIR CHAIR
TIME: r)-2-30 INITIALS: .. TIME: INITIALS: TIME: INITIALS:
• CONTENT: 14)F0k)Y1 Sr,O3FrO 1-44 eONTENT: CONTENT: cA-u- Fr) k ,Iii--5(5 7-k"t'CC--
ID Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes UnderStanding 0 Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION '',.
INITIALS Not id ) - '1, SIGNATURE SHIFT
U\si
ropnennA _ 9",c',1
MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 3 of 4 pages
DOD-036097
IVICLAUFAL litCUKU -
PAIIENT ACTIVITIES FLOWSHEET
[ For use of this form, see MEDCOM Circular 40-5
SECTION I -PATIENT ASSESSMENT DATE: ‘
C\ 00-v cr., 7.-n-
PATIENT ACUITY LEVEL POST-OP DAY: K") HOSPITAL DAYI. 0 • ,...,,,.:.,
.. i •
ETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT: Time From Ill AMBULATORY II
CLTCHES
i WHEELCHAIR
II
STRETCHER
T Total ER/RR/PACU time Anesthesia (Specify):
R
AN Procedure/Diagnosis LOC BiP Neurs• . ular checks P
s Dressing/cast Tubes
F E Intake (IV, po) l¦Aedication Output (EBL, other) Voided ll o Yes Amount:
R Other t '
Report From . Received By
TIME: Nei' , eb5c. p fb
BP ARTERIAL LINE .4111111 ,e."-

-
oz I
BP CUFF
12, IV 7
TEMPERATURE
-a k ce,
PULSE
WI fg g'T
l
RESPIRATORY RATE
& VO
OXYGEN (Li%) .......,..----,....--PULSE OXIMETER
/ 99,0
02 METHOD
RA R4-
NC = Nasal cannula NR
L
A
T
.-.
= Non rebreather
FM
Oxygen Method Key:
= Face mask
VM = Venturi mask
MT = Mist tent PR =
Partial rebreather
A = Aerosol
TC = Trach collar
ItCatLUt—t
A t
TIME: Jew
TIME:
'Skin akdown
rotocol
p
s
_prevent
• Falls prevention
PAIN
s
. .
INTENSITY
•• •-•• •• •• •• . • . •
. . . • •• •• ••
-Z

• Restraint protocol
o
I
i
b 4,
'Isolation precautions
MED ADMINISTERED IY/NI
_.. ... .__
.. RELIEF ACCEPTABLE (Y/N)
'Seizure precautions
E
N
A
I •
TIME:
FINGER STICK GLUCOSE
UJtCi)
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:
WEIGHT CHANGE:

INSULIN IY/N) •
Lu
,
24 HOUR TOTALS PO IV #1 IV #2 TOTAL IN 'Per hospit-il policy. _ Urine Stool TOTAL OUT
PATIENT IDENTIFICATION
DIAGNOSIS: D p::,::4,, LOS: .:%. ADIS'AtON DATE: EXPE6TED RELEASE: ,.. 0 go 41 -016,
rviFnrnnn pnpum gRCLO . \ /rt/Ir'Uni t L CASE MANAGER: PRIMARY CARE MANAGER: —' ' -'-'. -1EOUIRED (Specify):mpnrnm _ 9999 1111 A r, nn ir•
S

DOD-036098

il -
SECTION II -PATIENT ASSESSIVIENT -REVIEW OF SYSTEMS
DIRECTIONS: A check i in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
I
TIME: 1 2/2-1) INITIALS: TIME: Pp' c"--INITIALS INITIALS:
IME:
1. NEUROLOGICAL: Alert and oriented to
I I 6/0/44 III'-' I
time place and name. Responds appropriately. 4 , .._._ ,_
l'" "1""0 610-14 M., INV.e.A..i

, Communication is adequate to express needs.
' Pupils equal and reactive to light. IrtA-..V

70(21-Ucl et-1-'N 1
2. CARDIOVASCULAR: Pulse regular & rate [4."'"
I—(' I I
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 for extremity

.
perfusion;
3. PULMONARY: Respirations within normal
rate for age group; quiet and regular. Depth is

regular. No cough. No abnormal breath
sounds.
4. G.I.: Abdon-ien soft and non-distended.
['. Er--I I
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
g----
urgency, frequency, nocturia. Urine clear,
.
yellow/amber. No unusual discharge.
6. MUSCULOSKELETAL: Normal muscle

pc/ 1 1
development and mass for age. No
deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.
7. SKIN: Warm, dry, intact.
Good turgor. No I 154-1-0.1-& 1/fArA0V&A I-1 e-,14c..--e f jc-,
rashes, inflammation, ulcers, breaks in skin.
Sk-41,f 4¦, ¦-rt,t-o.c, .0,161-{,e1.4),--5'c.s.11/00 I I
No redness, blanching, irritation over bony
fp 5i5x 0 (- zi,cy
prominences. Mucous membranes moist. 1‘,1 4, c i-
8. PAIN: No complaints of pain/ discomfort. HV
(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate
I I

to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

10. IV SITE ASSESSMENT: (LEGEND: P -Puffy
I -Infiltrated R -Reddened OK -No swelling/redness * -Central line)
TIME: INITIALS:
TIME: INITIALS: TIME:
INITIALS:
IV patency ,/ q hr:

____ IV patency / q hr: IV patency ,/ q hr:
IV site care provided:

IV site care provided: IV site care provided:
IV tubing changed:

e
IV tubing cha : IV tubing changed:
LOC ON CONDITION LOCATION yNDITION LOCATION CONDITION
IV Site #1:
IV Site #1: IV Site #1:
h, /
IV Site #2:
IV Site #2: iv site #2:
L
Comments: Comments: Comments:
_
MEDCON1FORN1 689-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
DOD-036099

SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE: TIME:
TIME: _.__A i
COLOR
cf)u—W1— — It0 UJ CC
ID band visibleilegible
_
1.1
CAPILLARY REFILL
Orient to environment prn

__.
Side rails 12/4) up

Vat
ZUJ O CC 0 o
1111

TEMPERATURE
EDEMA
SENSATION
MOTION
PASSIVE FLEXION
PERIPHERAL PULSE
EGEND
Color: P-pink (normal); C-cya, tic; W-pale, white
Capillary Refill: 1-10-2 sec ; 2-(3-5 secs); 3-( 5 secs)
=IL..

...-r
(-".
,/'
ft
Bed position low
Call light within reach
Review & post lab results
Notify MD abnormal labs
Incontinent urine/stool
Linen change pm
Temperature; C-cool; -warm; H-hot
Edema: 0-None; 1-ild; 2-moderate; 3-severe; 4-pitting
IMA_

Turn/reposition q2h
ROM q2h if immobile
--1111111
An tiembolic hose
Or
cc
Sensation: A-ae.ent; N-numb; T-tingling; S-sensation (present)
Motion: U-u ble to move; M-move-no pain; P-rnove-pain; R-full ROM
Passive Fl ion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-vveak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH
DINNER
TYPE: TYPE: TYPE:
%61
PERCENT CONSUMED: PERCENT CONSUMED: PERCENT CONSUi E :
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED: [ALF E ASSIST 0 COMPLETE E SELF 0 ASSIST 0 COMPLETE 0 ASSIST El
Q-'tELF COMPLETE 0700-1500 1500-2300 2300-0700 ELF 0 COMPLETE El SELF 0 COMPLETE Q4-ELF 0 COMPLETE
BATH/ORAL CARE
ASSIST 0 TOTAL E ASSIST CI TOTAL E ASSIST 0 TOTAL
BEDREST ELF BEDREST 0 SELF I: le: El-t-E-LF
— w I—I

AMBULATE ASSIST AMBULATE E ASSIST AMB . P..-CI ASSIST
TYPE OF ACTIVITY
BSC BSC :
(Circle all that apply) # TIMES/SHIFT
# TIMES/SHIFT # TIMES/SHIFT
BRP BRP BRP
m t
CHAIR CHAIR
_J

I

TIME: V......) INITI TIME: /745----INITIALS• E: INITIALS:
CONTENT: CONTENT: /7/ CONTENT:
-"--/-7/1.
.4){1r(2)-.jc t) 4/410 0 Pc .,--..c.„
-woAAA ,,,,,,,, ...._
-i c, fi.e.,,„..,..v.,,,, )
4 ,
\,, t u)---z_
Patient/Family Verbalizes Understanding Q7-rTe7.1)Family Verbalizes Understanding ' ----- -balizes Understanding
a1

,
1—• Z
PATIENT IDENTIFICATION
C-3 V dpl
.
SHIFT

t1...
r r_7".4._____
.-g-:
V)1-(/ ) 4
RAPnrnnn _ 00g0/1
MEDCOM FORM 689-R (TEST) (MCHOI MAR 99
Page 3 of 4 pages
DOD-036100
SECTION III -INTERVENTIONS & TEACHING (Cont)
T W i
LOCATION OF WOUND
M 0 E
U
N _
D
C A R E
APPEARANCE
.
SECTION IV -NOTES
__/t et //-5---,LA L.-10,4.r —1,--p. /-e.e.--71-Arze 5 ,s,.. ... I 'est o r— air S c
I i'112:¦_1_1,14 ..1.7,%.4../_/__ _14/,'/I_ co .".Z I/1 g--C._ Z-. re, / (35,_,Vor,
fr"..1
TREATMiNTS tia0k, AND• DRESSING CHANGE
,
a I-,
1;-)11-1)--1,--
.
_ -- --- —
_ ___
MEDCOM -22525

MEDICAL RECORD -PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 SECTION I
-PATIENT ASSESSMENT DATE: / 0 /t/e2 v 0 3 PATIENT ACUITY LEVEL :.., ____77E' POST-OP DAY: / / HOSPITAL DAY:
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT:
To From 111
Time AMBULATORY 111 CRUTCH .11:
WHEELCHAIR II STRETCHER
T Total ER/RR/PACU time Physician
R • -st iesia (Specify):
Procedure/Diagnosis

.4./p
A. P R
TLOC '
N Neurovascular checks
s Dressing/cast

Tubes
F Intake (IV, po/

Output (EBL, other)
Voided II No II Yes Amount:
E Medication
R

.t- -
Report From
Received By •
TIME: :-_,15-3ci jvc)

BP ARTERIAL LINE
i '154
. V BP CUFF
TEMPERATURE
1 .'r
T
PULSE
A 6C L RESPIRATORY RATE VI,
OXYGEN (Li%)
S
PULSE OXIMETER 95
i

02 METHOD
a'
G
N S
NC = Nasal cannula NR
Oxygen Method Key: = Non rebreather FM = Face mask VM = Venturi maskMT = Mist tent PR = Partia rebrea her A = Aerosol TC = Trach collar
I
coa.wo—--IzLuwacn
TIME: a-7,,,--It,th
TIME: (905
to •• ••
•• 'Skin breakdown
•• ' •
. .
' •
.
prevention.
. . .
.
PAIN
"
• Falls prevention protocol
,
,
0--Z
INTENSITY
. .
. .
o *v• " MED ADMINISTERED (Y/N) 7,..v,..
RELIEF ACCEPTABLE (Y/N) /),
'Restraint protocol
'Seizure precautions
'Isolation precautions
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:
TIME:
FINGER STICK GLUCOSE
T
H INSULIN IY/N)
E
R 24 HOUR TOTALS PO . IV #1 IV #2 TOTAL IN WEIGHT CHANGE: 'Per hospit-il policy. Urine Stool TOTAL OUT
PATIENT IDENTIFICAT ON Itr, DIAGNOSIS: DRG: LOS: tiz4 c,,, cil.r ,4 ADMISSION DATE: EXPECTED RELEASE: . Leal 4 Atet 3a r)c,7--03'
CASE MANAGER:
PRIMARY CARE MANAGER:
MEDCOM - 22526 EQUIRED (Specify):

SECTION II -PATIENT ASSESSMENT -REVIEW OF SYSTEMS
DIRECTIONS: A check 1 if) the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief
explanation of abnorrnal lino'ings will be noted in the appropriate column.
TimEtp-i lc"-INITIALS: IME: INITIALS: TIME:
"0,,.
1. NEUROLOGICAL: Alert and oriented to I iir „„tir-vi..42.9-Atty I time place and name. Responds appropriately. cat.5por-fr. Lit. 4-0 5 173.0tr.. ., i Communication is adequate to express needs. 0 pc5 cony/lux fc.-451. A II
1 yl ;47,
li/
Pupils equal and reactive to light. t7-f/L.t. fiPr--40 5t6.4.411..5 t,
2. CARDIOVASCULAR: Pulse regular & rate
Li
within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf
tenderness. (See page 3 tor extremity
perfusion).

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

4.
G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.

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

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

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

8.
PAIN: No complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.)
9.
PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

10.
IV SITE ASSESSMENT: (LEGEND: P

TIME: INITIALS: IV patency ,/ q hr:
_
IV site care provided:
IV tubing changed:
LOCATION CONDITION
IV Site #1:
IV Site #2:
1 it
Comments: -

7/
i

I I
I
I 5C144-17 (-4-4-5 F 5701415 1-1 artp-,vvi../)i rs/0 cPP4A-1"4-wit. 55...f.., ALA_
p''P-7" Diu/f.-4 I I
Puffy I -Infiltrated R -Reddened
TIME: INITIALS:
IV patency 1 q hr:
IV site care provided:
IV tubing changed:

I I
I I
OK -No swelling/redness *
TIME: IV patency ,/ q IV site care provided: IV tubing changed:
I,
INITIALS:
-Central line)
INITIALS: hr:
LOCATION CONDITION LOCATION CONDITION
IV Site #1: IV Site #1:
IV Site #2: IV Site #2: .
Comments: Comments: '

MEDCOM - 22527
MEDCOM FORM 689-R ITEST) IMCHOI MAR 99 Page 2 of 4 pages
DOD-036103

-2-
SECTION III -PATIENT INTERVENTIONS & TEACHING
SITE: TIME:
0-/c0 TIME: -7 ric,
ID band visible/legible
COLOR
P
cou_w1—-0 F- = wCC
CAPILLARY REFILL
Orient to environment prn
(

zuin cr o coc_) n --1 cr t-w ox-zo
0-w I °--
_
TEMPERATURE
Side rails (2/4) up
Bed position low
Call light within reach
EDEMA
-P-'

1.-

SENSATION _S
MOTION
R
,..c-4...
PASSIVE FLEXION Review & post lab results ___.-------PERIPHERAL PULSE 2.- -Notify MD abncumal labs LEGEND
.,
Color:
P-pink (normal); C-cyanotie; W-pale, white
Incontinent urintstool "eh ,-
Linen change prn
Capillary Refill: 1-40-2 secs); 2-(3-5 secs); 3-( 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-mocierate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion:
U-unable to move; M-move-no pain; P-rnove-pain; R-full ROM Turn/reposition q2h
ROM q2h if immobile
Antiernbolic hose
/-1

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

BREAKFAST LUNCH DINNER TYPE: 4_6_1.. TYPE: TYPE: PERCENT CONSUMED: a-5--z PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED:44f Czo , HOW TOLERATED: HOW TOLERATED: SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE 0 SELF 0 ASSIST 0 COMPLETE 0700-1500 1500-2300 2300-0700 19/I SELF 0 COMPLETE 0 SELF 0 COMPLETE 0 SELF 0 COMPLETE
BATH/ORAL CARE In ASSIST 0 TOTAL 0 ASSIST 0 TOTAL 0 ASSIST 0 TOTAL
BEDREST 0 SELF BEDREST 0 SELF BEDREST 0 SELF _C.:Alas A--E__-0 ASSIST AMBULATE 0 ASSIST AMBULATE 0 ASSIST
rJr7--7_-­
TYPE OF ACTIVITY (Circle all that apply) BSC # TIMES/SHIFT BSC # TIMES/SHIFT BSC # TIMES/SHIFTBRP 8RP BRP CHAIR Li 4. 1-CHAIR CHAIR TIME: 0710.INITIALS: TIME: INITIALS: TIME: INITIALS: CONTENT: Puss OK 7-6.-/)/4"/ CONTENT: CONTENT:
01-5-2-1-STAFF 11.91111A, PPV0-
'C-c'''. (7-ro9 0^0,-7-692

/1,144);
tt. Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding 0 Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION )r) / Li .) .. irlfti • ill-r,/,/,. A MEDCOM FORM 689-R (TEST) IMCI-10) MAR 99 INITIALS _ _ _... _ P4 -,I ,117,1 (I ...,..-.._ _ -k) 11,), „ GNATURE .c..---Paa Page 3 of 4 pages „ SHIFT
DOD-036104

W 0 U N T I M E LOCATION OF WOUND SECTION III -INTERVENTIONS & TEACHING (Cont) APPEARANCE TREATMgNTS t, AND' DRESSING CHANGE
A R . ,
SECTION IV -NOTES IcAxt4,03 /33C 1:27- eye d 7-cp J--le-t-tr4 c- -7-,,C.: II--All' 1-144-1 ...... -1 ) 0 ..4; r g--A, .1 ...., (s9.4, i.— .u?s....i.,A. — 7724.4,.52,9-2_.___ A-146 e-627ex'--_s_.,9--)5_____AlMi L., Y .(94-,-. —c.) -.6
. ) LI

.
.
MEDCOM 22529
-
DOD-036105

MEDICAL RECORD
1. AGE Lip
HEIGHT:
WEIGHT:

PREOPERATIVE/POSTOPERAT1VE NURSING DOCUMENT
FOR Use this form. See AR 40407: the Proponent agency Is The Office of the Surgeon General.
.2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) ICRKDA D PCN 0 LATEX 0 IODINE 0 TAPE 0 FOOD REACTION:
3. PREVIOUS SURGERY ] NO NI:YES (type):[
LIQ
4. PROPOSED SURGICAL PliOCEDUR,E: A
CreA¦ e(cfk CITA" VNI-aabffSQ1
/10) T))k ?(A)
5. ADDITLONAL INFORMATION: (Previous surgical and medical history) Skin Cond. ' Tobacco ppd X_vrs Body Piercing 4 Diabetes (Y) ROM y , ASA/Motrin W 72hrs (Y) (0)
ETON 0 Implants
Glasses/Contact (Y),--9 Dentures

6. PATIENT PROBLEMS AND NEEDS
A. PS. OSOCIAL
potential for anxiety related
to:
1) Surgical Procedure&

Ope ating Room Environment 2)Separation Anxiety f Child) 3) Surgical Outcomes
B. ON
Potential for respiratoni
dy function due to:
J.) Positioning
(2) Effects of Anesthesia 3) Medical/Smoking Histm
C. INTE UMENT Potential Impairment of Skin Integn ue to: 1.) lntraoperative ImmobilRy /As
2) ESU Pad Placement 3) Positional Aids 4) Prosthe
5) Pooling_of Prepolutions
0 Respiratoi-y Disease (Asthma COPD) (Y) Anticoagulants (Y) ( (e-", Hypertension (Y) 07 Herbal Medicines Y)/(151 MEDS: 0
7. PATIENT GOALS AND EXPECTED OUTCOMES
tX.Pt. verbalizes any specific anxiety. EK---P-L Exhibits relaxed body posture.
lek...,pt. will be able to breath without difficulty during immediate intraoperative phase.
Pt. will exhibit signs of impairment of
skin integrity (e.g.. reddened areas).

9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
MEDCOM 22530nA MRM 517A JUN 91 Premus eanions are oesoiete.
8. OR NURSING INTERVENTIONS
cd;lv.:-.O.Ilow.pt. to verbalize freely.
O. Explain Or environment and answer questions regarding surgery. comfort measures. (e.g. warm blanket. touch). all nursing procedures before
they are done.
...C4..,Zemain with pt. VVhenever possible.

O. Maintain family interface. Parents to
stay with pt.

O. Offer to elevate head of litter or offer
pillow.
Er's-Observe pt. VVhile awaiting surgery for
signs of distress.

15.Assist anesthesia during intubatior
and extubation.

Utilize pressure preventing devices
on OR le and accessories.

•te--Cbeck for proper positioning and
support to maintain good body alignment.
-Tr-.--Pad pressure points.
ESU ground pad on non

compromised skin surface area. c=...‹...Keep prep fluids form pooling.
VERIFICATIONS AT HOLDING AREA:
! ID/Allergy Band ! Dentures Removed ! H & P ! Contacts Removed ! NPO Since ! Jewelry Removed
! UHCG/LMP I Body Pierce Removed
I Consent/Blood Transfusion
SIgned/VVitnessed/Dated
! Surgical Site/Consent verified by

Pt./Anesthesia/Surgeon
! Contact precautions (Y) (N)
! Family/Friend:

USAPA vI.o
6. PATIE T PROBLEMS AND NEEDS
D. RCULATION
Potential for inadequate tissue

perfus' due to:
1) Intraoperative Mobility

2) Positioning
3) Existing Disease 4) Safety Devices
5) Hypothermia
E. NEUROMUSCULAR
CONT

E.I. Potential Impairment of
Mobility due to:

(----1) Pain
2) Infra operative Hazzards
3) prosthesis
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
2) W 0 GLASSES
F.2. Potential for Decrease
Communication due to: 1) Diminished Hear'
2) Language Ba4ier _..,--•
F.3. Potentia fijury-dtie 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
''`Eir,---P--Lwill exhibit signs of adequate tissue perfusion (e.g. color, warmth. pedal pulse.
tEr—pt. will be transferred to OR table without diffi ultly. 'II-be not experience unnecessary physical discomfort.
o pt. will be made aware of surroundings prior to anesthesia induction.

o pt. will be transferred safely to OR table.

o pt. will be able to understand instructions.

o Minimiz-e-danferof inju during intraop

. pertod.
z., --"-----
c''' -
,,.--.. .0tHER PATIENT GOALS AND EXPECTED ,.., ' OUTCOMES. Or contuatiga-efaboverrats-and outcomes.,,,--------
„..,..........,............

8. OR NURSING INTERVENTIONS 0 Check foe support stocking or ace warps. if none, check with doctors. 0,--eheck that safety straps are correctly applied. 0 Offer pillow for under knees. 0 Place and take down legs from stirrups with slow bilateral motion.
9Y--ebeck that rings and all body
piercing has been removed.

cp­...--Hav_e sufficient people available for transfer.
•zetrisure proper body alignment. C6:410-W"patient tO lie in pOSitiOn Of comfort while waiting for surgery.
CIOTier support (i,e..pillows. Bath towel. etc) for positioning.
0 Introduce self. keep pt informed as to
where he. she is and what is happening. 0 Inform pt. in which direction to move and assist if necessary.
Speak clearly and slowly.
0 Address pt. from side. 0 Validate pt.'s understanding of verbal communication.
0 Verify removal of dentures.
OTHER NURSING INTERVENTIONS OR continuation of above Interventions.
__________.--.—....„)
\ .0. /a......_ ill li. '''
10. 0 OMPLETE D/ADIXT-IONAL INTRAOPERATIVE INTERVENTIONS NOTED.
‘319 C)=1- 0-2 DATE
SKIN INTEGRITY: Bovie Pad Site: EYClean and Dry LEVEL OF CONSCIOUSNESS: 0 A&O 114
11. P OP A ALUATION :
, owsy D Sleepy D Intubated LEVEL OF ACTIVITY: -if-MOVES ALL EXTREMITIES D Moves Upper Extremities D Transferred to Litter VVith roller due to spinai
12. PREOPERATIVEiiiiiiiiEPARED BY 13. PREOPE
(Signature and Titlq) BY (Signatur
DATE: 067'63 IME: XcD DATE:3( „LT 6
REVERS OF FORM 5179, JUN 91

Red 0 N/A DRESSING DRY & INTACT: ,;
fi)(N)
BREATHING EASY:
'tiS) (N)
PREPARED
e-nk J
TI
USAPA VI.0
MEDCOM -22531
.-.J4
• •INTRAOPERATr- r)OCUMENT
'
, .
MEDICAL RECORD ,Pq
.r use of this form, see AR 40-407, the propii !it( .'he office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPL.iATING '1-ItiOM 2.- PATIENT IDENT 4 _.= ND PROCEDURE
VIA BY a-/Le-4, VERIFIED BY
_at t (14 1
3. DATE TIME PATIENT ARRIVED I UITE 4.. PATIENT IN RO • v
.
3( 0 Cro 3t 5C-TIME.. .: . --58 NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
II CALM VLANXIOUS EXCITED, 111 CRYING ANGRY WITHDRAWN NI OTHER (Specify)
COMMENTS:
.
. ; •
6. NURSING PERSONNEL
•,
ASSIGNED - -"RELIEF

g.
SCRUB .S.CRUB
ASSIGNED (Yr RELIEF
CIRCULATOR . .. , --,_CIRCULATOR
) ilCI.;:

7. POSITION AND POSITIONAL AIDS (
... .-"! i -
1g.4.SUPINE / LITHOTOMY II PRONE.. .111 KRASKE -• LATE L: LEFT SIDE UP III RIGHT SIDE UP
0 Lae) -.,--N pc,..c,Q6t4,. c_,.. 02 --1-.- ,f iz_ E-er.,,--..._-.J2.;),/eu..cOLA_; c.).--
COMMENTS: RE : -
det.¦.,i71 ,Ct-e'-i¦ riN 1 -4 13 • (,,:qta...k..,i,;-:',_ c
Al.Q.C.-
8. SKIN PREPARATION
e..
:-... girl. -- ---
H A I R REMOVAL • YES 11 NO 1 PREP SOLUTION (Specify) ,ft -DONE BY: OR / NURSING UNIT SITE: 6w-dale"( '-i fa, BY WHOM: METHOD: DEPILATORY V RAZOFl - ' SITE: - SkatP4-4---BY WHOM:
crCLIP , 1-el. (kit,
COMMENTS: D/*\.(C-Vc —_.--TCOMI4NTS: -Ca-p_qp, P
0 ..
9. LOCATION OF EXTERNAL DEVICES
1c)D ' - -- ..:,.i::
1.0Lii d er
rof I
.. CP}
INIIIIIIIII¦w:11E-ire
-- I • 1
I • v. -t-¦¦ . ...t-••••1111111NEgysimpo..-
-
• T 1 llCaggii -
..,.. •t. ,
(S4'.
9/.

6
D6 /ISI
' ifr
LEGEND . X Ground Pad -- SafetNi Strap = =.= Tourniquet.-----•
C = Correct 1 = Incorrect
/..‘.-CK First Closing. Final Closing

10. COUNTS Ot er • Count k.. Cdunt -SCRUB
..„.... :_. CIRCU , Sponge
s AEI .-/ NM= IllErr
Needle Sharp Yes _IElmil .
'WV
Instrument
I. Yes NIEIMPPAWAIIIIMIMIIIIIMEMPI. ......1111111
p¦ ---
Other / Yes r," .
1 1 . PATIENT IDENTIFICATION For typed or written entries give: 12. ELECTROSURGERY DEVICEIS) IESU) Ei3YES /
. NO
Name -Last, first, middle; Grade• Date; Hospital or Medical Facility;)
51) /S-1)
Ri), t 04.3 _s
jga ESU NO: GROUND PAD: BRAND Wtt-fle-vb
-' .... . • LOT NO:
•-•'-'---?a II . 4 I,
---• 1:17,E‘.111 NO:
.
kg :
- --7-GFI-OUND PAD: BRAND
, . --.: ._-•
.2(..: LOT NO: BIPOLAR NO: ,e-rc c......,,,A._.... -:3 1-)
_ _ _ _ __ _ _ _ __t_
REPLACES DA FORM 5179-1 (TEST). DEC 82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 22532
DOD-036108
13. PROSTHESIS, IMPLANTS EF. c..,14)..._ IF YES NAME: ID NI: .ER„UFAC RER
._________
. ,.
.
, Zi'MEDICATIONS/ORDERS; , :4-
•:i=.4C -•Y4i4 ' .,, .ir.s,,,,
, • ..;--,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO •
I
MEDICATIONS/SOLUTION DOSAGE . . TIME' METHOD P
BY GIVEN BY
0.C.:.-,:. .._, 1 .kt.: _. Lii in-ivi Nr _
_
1,_!____Lifb
i
MOUND IRRIGATION YES NO; TYPE(S):
; „.)1 ,' , 1,0
? 0'N, Aii4 Ci / Y ' V
.... ,
!OTHER ORDERS TIME CARRIED OUT BY
i
,i
4 _ ,..... __
-
I, •,
r THYSICIAN'S SIGNATURE
q
, . ,.. . ,
, ,.. .
..
15. X-RAY IN OPERATINgOOM IF YES, SITE
.-; . .,1),., ''
YES • NO
16. ' ' ' '''-' LABORATORY SPECIMENS
...
, ..,,,
SPECIMEN (S) NAME _. _ .......__ _____ --------- • NAME

-• ,
YES • NO
-
FROZEN SECTION (FS) NAME NAME
YES / NO
CULTURE (C) NAME NAME
YES 1111 NO ___. _ ----- ---

NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES /yr NO IN }6aciCr--- ) gye) 1
TYPE/SIZE 1. 2. .

SITE 1. ii51.44412A_ 2. 3.
19. ADDITIONAL 0 -
- CL,L0....„,L
•.") (-92i) (.-Or 1
-1,i,...:14:-/
'' CP T t
h 44\901 ^ .,.. C('..'0 ..1'4.¦t-41Z....
1n .'

-.-__ -. .-- . - -....._ .
g I
.
je---6.----) -
*
20. OPERATIONIS) PERFORMED
e I *._32._ jiLkii....,
Cra....1A__)
_ C el-A-teatli,4-(i_i i,
, \ ,
1 ,
21.
PATIENT TRAN5URRED TO ' TIME — 1MET D
/('/(..(../ 1

22.
REGISTERED NURSE SIGNATURE

1 4)-
REVERSE OF DA FORM 5179-1, OCT 87
USAPA V1.00
MEDCOM - 22533
DOD-036109

STOOL !D RAIN
1
1 I 1

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1-
.
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.
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=
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IC U I ....'.:,....
PatieiitsN a me:_ ..-%
[-VITALS 06r 08 09 • .i 13 14EIL1.16 17
INTAKE I 06 07 08 09 10 11 12 13 14 15I 16 17

irir
Source
Iririyirlyirinrirlyirr
I
MAP
06 07 08

.

.

1

I

(1

V

.
"1

Total 19 20 23 00 17.1 0203 05 Tot
q
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E2 E2 R3 R3 2 ES 2 2 ES A, E3 la R3 2 ES ca

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21
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Ca Ul GC C2
cn C12 Ul C2
ill

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19 20

cn E2 Ul C2 CO
CO Ul E2
2
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Ca CM 13 C7 CO 13
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111 CC . F. P 1...
. C7 C2 C2 C7 C2 CO en
,7 C2 ea pp co ea
. c2 bsg 73
..C7 C7 C2 02 C2 121 C2 CO CM G7
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in na AJ NJ
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'
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co
I.

N.

23
-,27 Os CNI -1.3 ....1 -.I 3
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-..1.3 1-1.
an cn G2 GI PJ 411 -a -.2 CK c2 NJ co
2 2.
N./ ci'l. I /%Il..
1.

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17 17 17 13 17 17 43 13 13 13 21 13 21 17 17 2
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CI /V -...7 -...7 ia 2. Ch Ch CI Ca Ch cn I-. Ja NJ ro 33 = N./ 1•3 F..23
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1 ---

/". 4`. 051

; ., .,.. V.y0

..
MEDCOM - 22534

I I I I I I ITIP
254¦

qs

ITRI•

VVVVVVVVVVVVVY
cm.

111111¦

DOD-036110

EYESOPE

PAGE 4 OF 4 NEUROLOGICAL ASSESSMENT HOURS 0
ZMc6-et,
LEGEND SPONTANEOUSLY 4 TO SPEECH 3 0 TO PAIN 2 NO EYE OPENING 1
ORIENTED
5
A w CONFUSED 4
al
0

VERBALIZES
3
w

W
VOCALIZES
CS 2
NO VOCALIZATION 1

OBEYS
COMMANDS
LOCALIZESPAIN 5
FLEXION

1—(0 g-
A OZ WITHDRAWAL 4
ABNORMAL
V"'W FLEXION

, (1)
3
EXTENSION 2
TO PAIN
NC RESPONSE

NORII,IAL POWER
MILD WEAKNESS '

a
R Right

SEVERE WEAKNESS L Left


ABNORMAL FLEXION
ABNORMAL EXTENSION

Record NO RESPC,NSE
Se arately if
0 6. -13
NORMAL POWER
MILO WEAKNESS
co

• SEVEREWEAKNESS
ABNORMAL FLEXION
ABNORMAL EXTENSION
NO RESPONSE

SIZE
3 3 3 3
RIGHT Brisk
REACTION t t
SIZE • Slow LEFT
33 -53
REACTION No
— Response PUPIL SCALE • 2
5 7 mm ICP
Intact
CEREBRAL PERFUSION PRESSURE
— Abnormal
1 1 I 1 3 I I 11-I 1 1 1 6
VASCULAR ASSESSMENT
HOURS b 03 OLI' Cc
of2per
+ + Normal
FAVAWAWAWMAMEWAN

Weak
iouxy
WANNEVANNEMENER

Absent
REIVRAMENNWANNWA

Doppler Right
Wan/NW
MEDCOM - 22535
v u I/ uuuul L Left
DOD-036111

-

¦••¦t
.11¦1101••=161•410.
PAGE 4 OF 4
NEUROLOGICAL ASSESSMENT
EYES OPE N
HOURS
4/3 10 11 Cs
/. ( 11 LEGEND
SPONTANEOUSLY 4
4, 4. cril-
TO SPEECH 3
C Closed 0 TO PAIN 2 by swelling
NO EYE OPENING
ORIENTED s--
w

A x cnz CONFUSED 4 T TrachrEndo 0
S Slurring u) 3
c_ vERBALIZES
j D Dysphasia
vOCALIZES
2 R Recep:ive NO VOCALIzATioN 1
E Expressive
OBEYS
COMMANDS
LOCAUZESPAIN

ow FLEXION¦-•
A z wiTHDRAwAL
ABNORMAL
wu, FLEXION

`A x
EXTENSioN
To PAN
NO RESPONSE
NORMAL POWER 11, gt. fzu
14:9“ RA-
MILD WEAKNESS R Right
Cr, SEVERE wEAKNESS
CC L Left
AeNORmAL FLExiON
B
ABNORMAL aXTENS1ON
Record
NO RESPONSE

Separately if there is a
R2t-?k. k vt.
NORMAL POWER Difference MILD WEAKNESS berween the
SEVEREWEAKNESS tow sides
ABNORMAL FLEXION
ABNORMAL ExTENSioN
NO RESPONSE
SIZE
S 3 I, 1)
RIGHT
• Brisk
REACTION
.1-
SIZE irt • Slow
LEFT I -15
REACTION f 1- 4- 4-

4-No
— Response
PUPIL SCALE
•2
• 3 4
7 mm
+ Intact
CEREBRAL PERFUSION PRESSURE
— Abnormal
ICP ill-11 III -I 1 6 I 1 1 1 -I
VASCULAR ASSESSMENT
HOuRS
07 10 r 14, vc---1 tV
V C-
MEM WAVAIWAVAVAIN 4- + N°Mial e-11111FAVrAWAVANWAVAg
We71
VAVAWAWVAWAWAVAVIA
:::
MEMANWAVAIWAVAr
Right
MEDCO - 22536
utL Left
ItI/ I / I/1/1/ I
DOD-036112

VITAL SIGNS RECORD
...___ . _ . __ CORD
HOSPITAL DAY POST-DAY
Z. 1-36 4 . -Aial cf3 , , .1 ‘Artri 63 . k
MONTH-YEAR A w DAY ‘ I
..... +

19. V.. HOUR •
7
l
.7tA0
PULSE TEMP. F •0
: Ci
: :

':

:

.

•. •

I

(0) (*)
105°

.
r,
II-
.,


. 9 .:. :: :: :: a :: :: :: :: :: . :: ::
180 104°

!
4
170 . . 103°
......
102°
..............

"

....
. .
.
160

.

150 • • ..
. . .. .
140 100 ••
Ma : : : : . : . . Mrdi14 :: :: i I ; : ". :: fin :t: :t: :t: : : 111 it:.
130 larISIMISITIONSIIIErY/WEIIIIITZSMILMEMENIIIIIIMIEMIIIM31111113•1111
9e.96: .
. .
. . : : : ...... .:. : ; : : :
120 98° 7 •. .t.
.t. . : -t......... :t:t:t: :t: .t. .
-,iii ......... :t: :t
: :t:

¦
liot97° 1 :: Hu
0 )

°CC
CY
...
.
-
.
. . . . Nr . ..........

......
100 96° immi

1
:

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

.
.

.
1E1E1 • I
:. i
: I
: ,1
: La

90

i :
:

ifilliM
::

95°

I . . . . . . .... . •.
....... . ....

i :. .: .,, :: :: :: :: *:

. .

I MI IVA -• I

MINIM :. ghli
80

: :.

:.

:

..
ME

M.IIII. . • • Ir. • • •
. . MB
70

60

. .
.
...•
.
.
.
.

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

...•
.

: : : : :

.

.

.

.

50

................ 111 ....... .
.' .' .

40

cxo,-
. .-N.Ea

r7.

c.‘‘()
IIma

RESPIRATION RECORD
CR)

gm Fil
a
cct)
c.0 70 uy.wirm. wommimml
..,.
,.-,tm ,,,.
Iwo CO
.2vl'ai . (.,
a,

o.
u)
'2

iD
.
0
ce
REGISTER NO WARD NO.
PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
IIIKIMMIS
MIMI i
-o
2
nu

-24).

FM

r
t

s

;0
MEDCOM - 22537
DOD-036113

NSN 7540-00-634-4124
511-119
VITAL SIGNS RECORDMEDICAL RECORD
HOSPITAL DAY POST-' DAY
1
MONTH-YEAR DAY
r I 0
HOUR 01. • -/). ,•2
19
6-• •
TEMP. F
If.

ecr:a.0
••t: •• ••t•• ••t••
• •. 0 • •• •
.

(Apoaouwaja8Jo; ' sluaienobjapei5pao)
c.) .
.
O:co cO 4 Co CO CO CVO ;¦• *,-I CD o 2 c:i O oi cci cO r-: 1-:r-:ai 6 Lc; Lci
11.1 Ti-cl-ol cO co co coo,CO CO.co cf)
1—.
PULSE
... ...
(0) (*)
105°
" • " " " " " " " . . . . . . . . . . . . . . . . . . . . . . .
180 104° " . . " . . •. •. •. •. " . . •. •. •. •. " . .•.• .•.• •. .• .•.• .• •. .• .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
170 103° " " " • • • • • • •• •• •• •• •• •• •• •• . . • " • " " ' • '
160 102°
• " • " • • • • " " •' " • • •'
. 150 101° •• • • •• • " • " .•.• . " . .•.• .••. .•.• .•.• . . . .
" " " " • • •' ' • •' " •' " " "
. . . . . . . . . . . . . .
140 . . . . . . . . . . . . •a .' •-•• " •• • • " " " •• " •• • " •
: : :
130 99° •• • .. .. .. .. .. : : : : : :
: .. ..
; e 0 •• •. •• : .•. . . . . . . . . . . . 120 98° . • . . •• . . •• •• •• •• •• • • •• •• •. . .
98.6° •' ;
•• " " ' " ' • ' • " " ' • ' • ' •' ••
110 97°

100 96° . . . . . . . .
. . . . . . . . . . . . . . . . . .
90 95°
. •
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . „ . . . . . . . . . . . . . . . . . . .
•• •• •• •• ' • "
. . . . . . . . . .
80
. . . . . . . . . . . . . . . . . .
" ' • •' "
. . . . . . . .

70 . . . . . . . . . . . . . . . ' . •. ' . ' . •. ' . ' . " . . " . . •. ' . •. •. ' . ' .
60 . . . . . . . . . . . . . . . . . . . . . . . . . .
. • . . . . . . . . . . . . . .
50 40 . • • . • • . • • . • . . " . • . • . • . • . . " " . • • . ' • . . • • " .. . . . " " • . . " " • • . . " " " • . . • • " • • • • . . • • " • • • . • ' • • . • • •
RESPIRATION RECORD

BLOOD PRESSURE
.
HEIGHT: I WEIGHT ..---11.
.
..
_
,.:
PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO.
paiapioosuaum Apomopiepadspioaau
WARD NO.
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 51-1 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 22538
DOD-036114

,i , „ .
Ward/Section: i-a) 1 REQUES r
-
LABORATORY RESULT FORM
(Suliect to the PrivacY Act of 1974)LAST, FIRST„Ml.
‘4 . TIME 'N -SSN/PSEUDO SSN:310c1--0(51'00
_. -,
. ---....(Herilatol,

, . .CBC:. . . • _Urinalysis .-..• ..' . ' ..,....: ,..Misca'Serolog
.
.
TEST RESULT -.-.
NGE TEST .RESULT REF. RANGE TEST RESULT REF. RANGE WBC 4.8-10.8 x 10' ' Color N/A
• RPR
R;BC 4.7-6.1 x 10' A •Nr. - -N/A

Mono
-Hgb 14-18 Wdl (M)
-• .11gCrobiology
' t6 Wdi (n , -.
• • • .-:. .. . .
1=';'------::
Hct PICCOLO a :---- --: '
Source
31/10/03
04:30
MC'
. HA- EREN(.1-._ RANGE: Gram
, MALE
• PATIENT # : 11111 V) 114 - 4.4 Stain
Plt .

ME TLYT E 8 1 Occ Bld Negative Lyrn pi SC LOT #: 3151AA=I
H. pylon Negative
OPER #: el, DR # : 000 SERIAL. # : ' ,i),.,' 0000100684 pMaricarles
.. . ,
.
' Segs, Iva ,
GL_U Malaria
31-10-03 172* ?3-118 116/DL
'‘ Wri 04:27

Barac„... .-BUN 6* 7-22 MG/ DL 0 & P
Patient
.,CRE 1.0 0.6-1.2
Limits r MG/1-4.... '
LYE11-Ot 13.0 H x10'3/111. 4.5 10.5 ' CK 429* 39-380 U/L ' ()t‘ her
RIC 4.69 x10'6/ii 4.M 6.00 NA+ 130 128

-115 MGR_
Atyp HO 13,3 gAL 11.0 18.0
K+ 4 . 4 3.3-4.7 MMOVL .; ....MitiosCoOk .1.,irina si '
H.-:t 43.1 % 35,0 60.0 •..• •• •.. .... . . , -.• : _ , trj,) 91,8 i 80.0 29.9 CL-106 98 -1 os ttiott_. ' _
RBk, 3sH.pgK
2m 27.0 31.0 tCO2 19 18--33 MMOV
Morc :TEE 30.9 L gidL 33.0 37.0
Pit 160. -410'3/id 150. 450.

INST QC: OKK

LY% 8.2 4,1. % 20.5 51.1 CHEM QC: OK
LY4 1.1 *I_ x10'3/uL .1.2 3.4 HEM 0 , LIP 0 , ICI 0

Spun
... .. Blood.Bank .-. .
. Hema
Sed R
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other ABO/Rh
-

..
::'. COagulatioll 'Studies: - ..-rnitCrcissmatcli- :1..:,.'-....: •.: . .. .. ,
....•:-- , -,.- .%. . ... .. -...• .
TA:EVERY .UNIT OF BLOOD .:
TEST .RESULT REF. RANGE .
PE CROSSM4TCH PT 9.8-1.3.6 secs .-•
APTT 21-34 secs
D dimer 20 ug/m.1
'
,.
F DP 10 ug/m1 ,
: REMARKS: ctc,
...:41A
[ REPORTED BY: DATE: LAB ID NO.:. . .
. . .
MEDCOM - 22539

Ward/Section: REQUEST
I CU
LAST, FIRST, MI. '..r
. .
' , 1: ,
.... ----'..:,....';'7;-
TEST RESULT REF. RANGE TEST
Na 138-146 mmo1/L ALB K 3.5-4.9 rnmoUL: ALP CI 98-109 mmol/L ALT
7.31-7.45 PCO2 35-45 mmHg (art) AsT
PH AMY
41-51 [mmHg (von) PO2 , 813-1a5 mmHg (1'1) TBIL
N/A (veul
TCO2 23-27 outtol/L (art) BIN 24 -29 mmol/L (von) 22-26 mmoVL (art)
HCO3 CA
23-28 mmol/L (von) 95-98%
sO2 CHOL
BEecf (-2)— (+3)
CRE
nanoi/L
AnGap 10-20 mmol/L GLU Ca 1.1 2-1.32 mmol/L TP
.
BUN 8-26 mg/di
GLU 70-105 mg/cll. TEST
Creat 0.7-1.5 mg/di
GLU Het 38-51% PCV BUN Hgb 12-17 edi CRE '',,!..-,1Kxs=5: ..lieliiiif • • ! CK
": ,:,,.-,:-,,2'..:•;.:: S..1::::-.'"...-:- '.1.;•
TEST RESULT REF. RANGE NA÷
Troponin-1 +
Drug of .C1..-Abuse tCO2
RE M.kRKS :
1.-, ) , i/g T. .t.v CHEMISTRY RESULT FORM V f 4.- .1 '''' ''''' (Subject to the Privacy Act of 1974) ATE TIME SSN/PSEUDO SSN:
3 i Der 61-'0 0
.. .. , „. —
ItC.OlOY,c,heruiS , ., k...06)..!.: . $.4.1..itilie...P.aiiet. ... .
:.:-...f'.k: ::,..,..i.cg..:;',7'..-:-,1",.."..---..::!...,:7:-...!tif.:::.
RESULT REF TEST RESULT REF. RANGE RA.NGE
3.5-5.5 g/c11 GLU 73-118 mg/di
26-84 u/1 BUN 7-22 rug/di
10-47 u/1 CA+ 8.0-10.3 ing/d1
14-97 u/1 CRE 0.6-1.2 mg/di
11-38 u/l NA' 128-145 mmoV1
0.2-1.6 mg/d1 K' 3.3-4.7 mmolil
7-22 rug/d1 CI; 98-108 mmo1/1
8.0-10.3mg/d1 18-33 mmol./1
tCO2
100-200 roWctl
Ili'c6i10)-1:_keir: Panel TitilS;;-,,,,,
-..1,..,::::;.:•-i.---,....,..,--Ist i;..,:.: ,,,:::::::77::5::, .'.±..;,;::.2'-7 ....,f 0.6-1.-mg/di TEST RESUIT REF. RANGE
73-11E mg/d1 ALB 3.3-5.5 g/dl
6.4-8.1 g/d1 ALP 26-84 till
ic.c0.0)Well e -ALT 10-47 u/1
..'":'-;:::')":..; ..,::,1' 1 -.:.:

'
RESULT REF. AMY 14-97 IA

RA NIG F
73-118 mg/di AST 11-38 u/1
7-22 mg/d1 TBIL 0.271.6 mg,/d1
0.6-1.2 mg/d1 GGT 5-65 u/t
39-380 u/l(M) TP 6.4-8.1 g/dl 30-190u/1(n
. . , . _ .
128445 Eruno1/1 --..; ietal.6.).Eleet-i-Obrte:,'.::, , . . _ ,: .
:::::.?:- —
33-4.7 mmo1/1 TEST RESULT REF. RANGE
98-108 mmo1/1 NA' 128-145 mmo1/1
18-33 mmo1/1 3.3-4.7 mmo1/1
CL- 98-108 rnmolll
' tCO2 18-33 mmo1/1
,

1t REPORTED BY: DATE:tri.A_B ID NO.:
MEDCOM - 22540

SOMA aNvsiNapv011314IV
NOISnANI INV.I.SNO0= .1. —INI/DO LNIDIA1-simnAd133dS sonlla03 .1.V3d3HIS110fINI.I.NOD
MEDICAL RE,CORD -ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
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AIR L/Min
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SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
WITH NUMBERS A ENTER IN REMARKS

LINE siteckitit2S. t&rt-iirrned r.X71s-
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Code drugs with numbers,
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LI Ready Begin End
Mark with letters & symbols, EVENTS_,
,
o
Ef. aoc.)M.LA, Di a,„
explain under REMARKS Position —"--t-4,-Nei\--"4--
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks_r_ .
Oe-\50 alj1/4.2.:C .' illrADI- bl)"°442•Atilc-'\.5%"-" ilit‘j..51 GM'
PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWAY MANAGEMENT:
Intubation route, blade, technique, comments Medical facility
/t,„t1, .6 S.0t5-t" 10 Ly_i C1-' VC-er),c7--.5 tt-\ 01.-45)___Q):1 ,---i-.4__
b I Li ,1
SURGEONS: PROCEDURE r-viria. LOCATION:ts''''''
11.10-0-01•41/}
DATE:
ei l'-
ANESTHETISTS:
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MEDCOM - 22541tellIA-F- 0'6' ' PAGEtttOF i
,,1-1•0trl 1-.1- • rr., 111-1,1, A I ner-non IC • OA 1,•• net
DOD-036117
ANESTHESIA PLAN OF ARE PREPROCEDLIRAL ASSESSMENT Meclation/Anesthesia) -
Agett4D DAYS M YR -t Sex.),ALE ( ) FEW
.__t\SA Physi ate 1 CI 4 5 PROPOSED PROCEDURE: C-ri:Ve`' 1 i t---` exickte-eLe-P-r"e415-ect. ---A A j VYT: 6 HT: t SURGICAL SERVICW're-k-1 ckeior ickeryvarit. I
ALLERGIES: NW'S:0A
NPO SINCE: t\.
HABITS:
PREOPERATIVE
TOBACCO: PAST MEDICAL HISTORY/SYSTEMS REVIEW ASSESSMENT
ETOH: Cardiovascular: PAST SURGItAIJANESTHET1C
DRUGS: Hypertension

Angina I AB--
CURRENT MEDICATIONS: MI ( ) = ordered as premed CVA Other Pulmonary System:, t Asthma
Bronchitis/URI 0
%PHYSICAL EXAMINATION
COPD
I3Pt
HR OAPtT
Other
Pain Scale 0-10 t
Renal System:
HEENT - Teeth SANG/4
Acute/Chronic Rit t
Trachea
PREMEDICATIONS: Gastrointestinal:
TMJ/Neck
None Yes (0tHrs) /CC Hepatitis
Oropharnyx
mg IV IM PO Hiatal Hernia Y t
Nares
tmg IV IM PO PUD/GERDt
CHEST:
tmg IV IM PO Endocrine System:
Diabetes

CARDIAC:
LABORATORY STUDIES: Steriods Thyroid
EXTREMITIES:
ti t
HB/HCT: Neurological:
U/A: Seizurest
IV Access:t C4—
OTHER: Neuropathy
Y Ulnar Filling: /a/k
Other
Gynecological :

BACK:
Pregnancy
g(kerre\ ato
Other Significant Hx I t
OTHER:
„er INA L. sk,
crcv MI
Familial HX Yr NPO Sincet'EC) cp.
ANESTHETIC PLAN: { LOCAL { } MAC { Regional (Specify):
t Mas Intubation
••¦¦•
a
INFORMED CONSENT/COUNSELING STAT MENT: Plans, afternatives and risks of anesth ia including der have been explained to anddiscussed with the patienVlegal guardian. '--tC1/4
4d) 111--
'The patie
tand and agrees. Questions answered. Signed: Date: tV.V/30 tTime: 2.--"S 3 Hrs
POST-At
ASU) aels" SEDATION KEY:
) NO APP RENT ANESTHETIC COMPLICATIONt{ } OTHER
e-re v-ilco1/4\ 1. MINIMAL (Anxiolysis) Patient responds normally to verbal commands
3LEs
Signed: t Date: tTime:tHrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or
Patient Identification: accompanied by light tactile
stimulation. Ainvay assistance is not
necessary.

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

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

.
WAMC Forrn 2300 (Revised)15 Mar 01 MCXC-DOS Previous edition is obsole e
ANESTHESIA RECORD *U.S. GPO: 2001-629-183/40002
_
MEDCOM - 22542
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.

LIST TIME ORDER PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
y3j/e__.•t
NOTED AND
HOURS SIGN
\ i
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NURSING Ul¦HT ROt0 N 9.
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ICU 1
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pva
PATIENT IDENTIFICATION (,
440 kfrA i
ppm.%t• 09 1 _
to- 1 ._
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NURycUNI ROOM NO. tr •
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4
PATIENT IDENTIFICATION
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NURSING UNIT ROOM NO.
ca Ne.1 o% oa-t s-
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PATIENT IDENTIFICATION
4,14 -L.,
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NURSING UNIT ROOM NO. NO.
BED ‘eAf ,,,,,- L.,
,o
REPLACES EDITION oF 1 JUL 77. wHICH MAY BE USED.
DA , ApRRI9 4256
MEDCOM - 22543
DOD-036119
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 ARROYv BELOW.
PATIENT IOENTIFICATION Ir. DATE OF/7ER/tTIME OFc.C.2.13.DER LIST TIME ORDER
4" 3/ 6 7
NOTED AND
al :' l HOURS SIGN
( e/A7:11/U-4, f&f./1.
p a 6ts./e-itzr c--.czc-,/-7-w
011!"V Ill
P -57P D., ,t,,......,?- 37c= , a e ' 1.---e-i-e._ ;,,,,,,,,,t,;_ 1-2r--)-21-4.,/me-fill 1;-e, 'J. 0 C----A-P 4 kr_
NURSING UNIT FlOOM NO. BED NO. el0 ,).:f /4)4.36) e
tC)0 ( -: //.177-4.7 )-Le...ts,,G, A-
PATIENT IDENTIFICATION DATE OF OR ERt TIME OF ORDER

HOURS
&5 /11P° -6\ 9, ‘2,,,, 0.. givist,2..6 /ce...r....._e_ Are./..../4
,s Al &....„ • YI,
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c.) 4".
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1-474-4,7".7.1: (4,141-J.....1 kj
NURSING UNIT ROOM NO. BED NO.
rilia Zia.i.f...-. 41-27P f-r
i . .1 I .. - -Itr
illgar c-6,2.-,tn..0-7_,-- 5-/t-,---t--,---- -
PATIENT IDENTIFICATION DATE OF ORDERtTIME OF ORDER
HOUFIS t
4;10.
NURSING UNIT ROOM NO. BED NO.
_t2.1rektarq-Chee.k_ q5 -"a /1-1---FI-AJ
PATIENT IDENTIFICATION OATE OF °ROEt TIME OF O'DER
7: ? 6
1073 //0 __ (t...-'1't
HOURS
4D A-64."-r--,---,---t/-6 (0.1,v.--t10.air
NURSING UN:T ROOM NO. BEO NO. Ig it,5-/,
F°RM, APR 79 4256 REPLACES EOiTION OF JUL 77, WHICH MAY BE USED.
MEDCOM - 22544

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 MEI*AL RECORD SYSTEM IS USED, VYRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIM ORDER NOTED AND
PATIENT IDENTIFIC ATiON DATE F . HOER TIME OF ORDER
1, 03 HOURS
a SIGN Aeogic
NURSING UNIT ROOM NO. BED NO.
---w-°V-7-0---A,777-5-o-57-7111111fr

PATIENT IDENTIFIC TION DATE OF ORDERt TIME OF ORDER t HOURS -
PATIENT IDENTIFIC ATiON NURSING UNIT ROOM NO. BED NO. DATE OF ORDERt TIME OF ORDER HO URS
PATIENT IDENTIFIC ATION NURSING UNIT ROOM NO. BED NO. DATE OF ORDERt . • TIME OF ORDER t HOURS

NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
F:pRRAA79
MEDCOM - 22545
DOD-036121

THERAPEUTID DOCUMENTATION CARE PLAN1( NON -MEDICATION )
CLINICAL RECORD For use of this form, see AR 40-407; I the pro nent agency Is the Office of The Surgeo General. MO. Yr. 2003
VERIFY BY INITIALING .
n't l'katk: ,Stel. ,,,-"C''' ., 7. INITL4L PROPER OLUMN FOLLOWING EACIII COMPLETION
HR DATE COMPLETED DATE NURSEt/ REQUENCY, TIME
ORDER CLERK/tRtURRING ACTION,
al 1tZ nalgirtil 1 MCI V P-----
(
MEW ClAita
(Ae-RY
3A ...d1 // IItityr IMP _ + # 4. _NM WHOMMan. I 4°
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.
.
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.
..
ALLERGIES:t/111 YES MI NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
I
1 MI YEStMill NO
1
I 1.
Arukt-R;

PAGE NO. PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8t
9 10 11t12t13 14t15 \tAkt Et16t17 18 19t20t21 22 23 Nt24 01 02 03 04 05 06 07
tMEDCOM - 22546
AWN. ..••• Ma* &Mk '
(I 77 1111AV RP I icpn
I IAA Pa Vi nn
DOD-036122
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICA770N) Mo ik.)"\J.r 2003
order Date Clerk Nurs SINGLE ACTIONS Date to be Done Time to be Done , Time Done Initials
It 9 —1)( ( 0(J°41-I Pr Cnte--ICe SVI-OU-Ath .g. L-VIL-tArCLAOLIc---(..7--)/ c /-2,8-r-Ava OW **Ill
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Order/ Explr Date PRN ACTION, FREQUENCY INITL4L PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED

,
.
.
.
. '¦
USAPA V1.00
MEDCOM - 22547

THERAPEUTIC DOCUMENTAThION CARE PLAN (NON-MEDICATION )
CLINICAL RECORD Mo. OCT"1'.r..2003
the proponent agency Is the Office of The Surgeon General.
-VERIFY BY INTIALING 7*:'., .:,,,,tamossit' , ,,,o, INITIAL PROPER COLUMN FOLLOWING EACIACOMPLETION
ORDER DATE CLERK/ NURSE RECURRING ACTION, FREQUENCY, TIME HR .3o 3 oi oz- DATE COMPLETED
31ccr VSZ of.
18
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ALLERGIES:tNI YEStMI NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: open 5k_ull Fx MN YESt/I/ NO si P Debncicmerrt sk4411 Fx EV3C_Vailbr) PAGE NO:
PATIENT IDENTIFICATION:t
,(11/4/Vrta r 1 11/66( Fral5 g Frortial L12e,)
ACTION TIMES USE F'ENCIL. CIRCLE ACTION TIMES
D 8t
'9t10t11t12t13 14t15
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MEDCOM - 22548
'Cr...yr...1 on= 4 1,C, Tir la4/1',/ oc sueertt
IIRAPA VI nn
DOD-036124
Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICA770N Mo jf)=____yr 2003
)
order Cleric Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
310a - Aamr-F lCU toer „.„....---- 0 Igo
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_ __ _
_ __ _
_ _ _ _
_ _ _ _
_ _ _ _
_ __ —

Order/ Explr Date Clerk/ Nurse _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PRN ACTION, FREQUENCY INTTIAL PROPER COLUMN FOLLOWING COMPLETIONTIMEJDATE COMPLETED . .
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USAPA V1.00
MEDCOM - 22549
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form_, see AR 40-407; Yr.
Mo.
the proponent agency is the Office of The Surgeon General.
VERIFY BY INITTALING , . INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

ORDER CLERK/ RECURRING MEDICATIONS,
31 IIII 2-111 13 If 11 Eli MIMI(C2-)
A A IL., _ 1.-_.1 -AI sw. Armili ff -1. --IIKOMME
.3 1_ DI 0 't. r ) , 6 114 A 4 . 0 W. I- ---&ailli , ..iiiii
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31 11.11 AtncE+ .-tWI* r 6
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- - - -X 4-6 . v ill iimusirAmigrd .
____ minii
2lf -IciA I /'•
,.." . i
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6( )-2 1111.1
.
ALLERGIES- El y EstI= No PRIMARY DIAGNOSIS: ADDITIONAL P AGES IN USE:
0 Y ES 0 NO

612/C41k divAkcf 4h,t11*-
PAGE NO t
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
Dt7t8t9t10t11t12t13t14

4111111111 Et15t16t17t18t19t20t21t22
\0\4t Nt23t24t01t02t03t04t05t06
EDITION OF •t" ''"'t EXHAUSTED.
DAiFFIV9 4678
MEDCOM - 22550
DOD-036126
1 - z
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) oca— 1tCLINICAL RECORD For use of this form, see AR 40-407; Mo..1 -ifYr. 1=3
the proponent agency is the Office of The Surgeon General.
VERIFY BY INITIALING , . INITIAL PROPER COLUMN POLLOTHNG EACH ADMINISTRATIOIY
HR DATE DISPENSEDORDER RECURRING MEDICATIONS,
CLERK/
NURSE

' lt7-1 ..

Of OZ-
, -
'
.

DATE
DOSE, FREQUENCY
310a- Iii D5 0 8 N5F-. 20 KC I
tQ, 125 c.cl°
310er Ance-F I rIA 1VPS 8°

31 Oc:r IIIIIIIi Di larTf-in /00 Iv]
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ALL ERGIEM l= y Es El No PRIMARY DIAcNOSI.Sa .
ADDITIONAL PAGES IN USE:
Opextt..a.tA I ItFy 0 Y ES 0 NO 4p -16-1,fi4ryievrE- sk.1211 F.,;( etraCtt
PAGE NO
PATIENT IDENTIFICATION:

NOrtaritVieral Fra964) fr-b' Ala( df?
ING TIMES
J.
USE PENCIL. CIRCLE MED TIMES ST-- UPIt
D 7 8 9 10 11 12 13 14
Et15t16t17t18t19t20t21t22 \0\..)1/4-t- t)t Nt23t24t01t02t03t0,1t05t06
t
EDITION OFt t. EXHAUSTED.
D AiTE749 4678 MEDCOM - 22551
DOD-036127

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo.. Yr
Order Clerk/ Dote to Time to SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be GIven
'
Order/ INITIAL
Clerk/ PRN
Explr
Nurse MEDICATION, DOSE, FREQUENCY
Dote
-
, 1 D
• nerlo I Gviip Preiv i
1 Pain iii-V i D /1../
I 4."-.
.......

I
.
11.G. GPO: 1998-454-110/95216
MEDCOM - 22552
DOD-036128

1. LISTNAME. FIRST MARIE / NOM ET imolai /LANK / GRADE ALE / HOMME
FEMALE I FEMME

,117 r 44 9 e ; t....1 ,.. 4 .,
SSNI NUMERO MAYIUCULE SPEOALTY COOE 1 GPM RELIGION / REUGION
......... AAHAA....'
u.........-

2. UNIT / UNITE
..
FORCE /ELEMENT

WTI AF/Atti/ CJM
BC/ BC D1SEASE /MALADIE

7. INJURY / BLESSURE
AIRWAY 1 TRACHEE
FRONT / DEVANTtBACK 0 ARRIERE HEAD / TETE
WOUNO / BLESSUKE
NECK/BAC1C IN1URy /
BLESSURE AU COWAL1 DOS
..-. 1-...

BURN / tmuLURE AMPUTATION / AMPUTATION STRESS /TENSioN , OTHER (Speedy), AUTRE (Speedier)
I,
r ItL4k-.ki)le, .
d
6 ‘s. N...i..), tz,
\...)
iNzi-24i 41,-Lel:4erla
4. LEVEL OF CONSCIOUSNESS / NIVEAU DI CONSCIENCE
LERT / ALERTF PAW RESPONSE / REPONSE A LA DOULEUR vERBAL RESPONSE / R PONSE VERBALE UNRESPONSIVE / SANS R PONSE
...../ciULS
el..V.DNO / NONtI .".7.1 EFS / Out

S. PULSE /tMAE / HEURE G. TOURNIQUET / GARROT MAE / H uRE
drig:
¦
7. MORPHINE / MORPHINE DOStOSE TIME / HEURE I.. IV / IV TIME / HEURE
L-1,1Cent1----i YES / OUI /75/ ts
9. TREATMENT / OBSERVATIONS / CURRENT MEDICATION / AU.ERGIES / NBC MNT1DOTEI
TRAITIMENT / OWERVATIONS / PRESENTE MEDICATION / ALLERGIES / ANTIDOTES

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er)
_. 1_, 11
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'‘,At c....
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10. DISPOSITION /
RETURNED TO DUTY / RETOUR A L'uNitt / MIME
DISPOSITION ` EVACUATED / EVACUE DECEASED/ 02t.t-- --/q(ei het IL DATE/DATE FYYRIMDdr
PIA& ..7isee.77' II t Fin n aarnersi rAon DEC 91t Do KHE MEDICALE DE L'AVANT ETATS-UNIS r1.0 OEM st#Adt an dada"
*U.S. GOVERNMENT PRINTING OFFICE- 2001-478-671
MEDCOM - 22553
mEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED (Date)REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89k/4-2
SHIFT-A$SESSMENT,'• . TIME: INITIALS: ' TIME:
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PULSES +Z Upper t 2_ lower

EDEMA 0

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DEPARTMENT/SERVICE/CLINIC DATE
r -
i C-17/41 j ICU #1. 28TH Combat Support Hospital '3 C 0C-7 03
,:
entries give: Name—last,
fifty)

• H1STORY/PHYSICAL II FLOW CHART
RANK: AGE:
, I
• OTHER EXAMINATION 0 OTHER (Specify)
GENDER: ---) OR EVALUATION
0 DIAGNOSTIC STUDIES
IRAQI: CIV (CP177)51,--
.
0 TREATMENT
IAAPPC V2.00
MEDCOM - 22554
DOD-036130
. M_ RECORD-SUPPLEMENTAL NI-J1 3ATA For use of thiz, see AR 40-66; the proponent agency is the Office —le Surgeon General. OTSG APPROVED (Date)
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
\) V
'' t-SHIFT ASS . _ -

IZF=1 fxG I ta,
PUPILS SENSORIUM EXTREMITY MOVEMENT SEDATION PAIN CONTROL
RESPIRATORY PATTERN BREATH SOUNDS SECRETIONS 02 SOURCE/FLOW/SA02 VENTILATOR SETTINGS
CARDIAC RHYTHM CAPILLARY REFILL PULSES EDEMA
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It: 1. (Continue on rev-rse
DEPARTMENT/SERVICE/CLINIC DATE
i(--r Af¦.i icu #1, 28TH Combat Support Hospital 3) OCr 03
PATIENT'S ID ritten entries give: Name —last, first, middle; grade; date; hospital • edical facility)
• HISTORY/PHYSICAL 0 FLOW CHART
NAIVIE: RANK: AGE:
S
. OTHER EXAMINATION / OTHER (Spec,fy)
UNIT: — GENDER: 0-7-9
OR EVALUATION
• DIAGNOSTIC STUDIES
STATUS: US: AD / CI % IRAQI: CIV EPW III TREATMENT
DA FORM 4700, MAY 7 8
USAPPC V2.00
MEDCOM - 22555
DOD-036131
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MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this forrn, see AR 40-86; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED (Date)
REPORT TITLE TRAUMA FLOWSHEEr Tbe proponent is Dept of Surgery QI Appr 11 Jun 97
EMS REPORT ARRIVAL STATUS
TIME: MED COM: ETA: UNIT: TIME Meds: .16 IV x 0 UKN 0 N 2 1 / Yes: C-A ine Immob r0/0
Allergies: UKN one 0 Yes:
Tetanus: UKN 0 Current Last Meal/Fluid Intake hrs
LMP:

PRIMARY SURVEY
CIRCULATION' -
'BR ETHING.
AIRWAY
Patient Laboreyd Unlabored 0 Absent PULSE: Present 0 Absent SKIN: 1,9-/rVarn 0 Cool Hot
-Pink 0 Pale CI Cyanotic 0
ETT CI TRACHEA: ipidline 0 Deviated 13 13 BLEEDING:
HEART TONES: leer 0 Muffled ry 0 Moist 0 Diaphoretic
CHEST SYMMETRY:
0 Secretions
SECONDARY SURVEY-
ABDOMEN
DISABILITY HEART Soft LI Rigid/Non-Tender
GCS: E PUPILS.A Equal 0 Fixed 0 React 0 Dilated a a RHYTHM: VRegular
TM: t) Clear 0 Blood a 13 PULSES: ikentral fPeripheral 0 Tender:
)5 v
PELVIS
NECK LUNGS
1 C-Spine Tenderness: BREATH SOUNDS;latilat ,laiquaLld/Clear fable 0 Unstable 0
SPHI CTER TONE: Pain @ Decreased R Absent Blood at meatus/vagina:
WNL al 13 0 None VA-ieezes
Crackles Heme + / -Prostate: 0 WNL Abnl
a
JVD:
VASCULAR ASSESSMENT
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN
(AMPlutation
(AV1u1sion
Battle's Signs IBLIeeding (B)urn (Dleformity (E)cchymosis (Floreign Body
(Hlematoma (LACleration (P)uncture (W)ound (Pain) (Sleatbelt (S)ign (S)tab Mound (GSW) Gun Shot Wound
+ + Strong + Palpable D Dopler
RN
'Continue on reverse)
DATE
PREPARED
PATIENT'S IDENTW or pe o ante--last, first.
HISTORY/PHYS1CAL FLOW CHART
middle; grade; date; hospital or medical facility)
ID OTHER EXAMINATION El OTHER (Specify) OR EVALUATION
El DIAGNOSTIC STUDIES
1=1 TREATMENT
REOUI .D BY OD FORM 2035.
DA I MAYM78 4700 MEDCOM -22557 EAMC OP 503, 1 Dec 98
LETE.
DOD-036133


.
-ACCOMPAP4EP:BYtREID
PROCEDURE, ,:stze:
,
ETCO2 Change
0 Oral 0 Contrast
ET
Y/
0 BBS Post Int 0 Abd Pelvis Teeth
U Nasal
Intubation CI Post CXR
0 Air 0 Contents 0 C-Spine T/L Spine 0 Chest

Gastric 0 Oral
CI Verified
0 Nasal

Tube Suction: Y N
A-Gram Site:
Return cc
Urinary
0 Meatus
0 Home Dip: + -
IV ACCESS & FLUIDS
0 Supra-Public '0 Secured
0 Grossly: + -
DPL 0 Opened

Cell count
0 Closed

Sent@ la Air 0 Blood
Chest
Pleuravac cm

L R
Tube #1
Autotransf user 0 Air 0 Blood
Chest
Pleuravac _cm

L R
Tube #2
Autotransf user MEDICATION TIME. DOSE RTE DOSE OE. Rhythm: Comments
12 Lead
;,TimE 62: Sat "iico3
"402
1)
2)
LABS X-RAYS
'
CI D-stick SHct Chest Initial
D-stick SHct 0 Chest Post ET
0 Chest Post CT
C -Spine AMT UP orlit
0 Pelvis
0
LAB RESULTS INTAKE & OUTPUT
INTAKE AMOUNIT'2;
CBC:
IVF Urine
NGT NGT
Blood EBL
CI
Other Other
1 0917 TOTAL TOTAL
TRAUMA TEAM ARRIVAL. VALUABLES & CLOTHING
Tat ARRIVED't "STA
ED Phy None Found
Surgeo Given to Patient
-1111M
Given to Family
Anes th
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
X-Ray DISPOSITION
RT 0 Home 0
Ortho Admitted to
Report Called to

Neuro
Time Transferred

Chaplain
Accompanied By
'etcher 0 Wheelchair MEDCOM 22.5
___ Precautions: 0 Yes 0 No
SIGNS "
• -GLASGOW COMA SCP¦ LE
"9ilmtal Temp: TIME BP HR RHY •(\, RR I SA02 F102 MODE GCS: EV MT EYE OPENING -._ BLE RESPONSE. , t, ,t
,t,t, . ' MOTOR RESPONSE,t, -S ontaneous HIP Oriented 6t• betCommands 5 -Localizes Pain
3 -lnapp Words . 4 -Withdraws to Pain
1 -None 2 -lncomp Speech 3 -Flexion to Pain
1 -None 2 -Extension to Pain
1 -None
TIME -tPIROCEDURE- ' CI Backboard Removed F'ERFORMED BY: BY:
/ / / / /// / t, I CI Downgraded BY: , , 011_21At ' IMILIIIMIWIEWMIMINON, NOTES I 41, ....s.vm.,--"Mt. MONMIIMINMPINIFIIVI" hillIMMININCIRIMBE I • • 5111/121d117,. 4YaBehlifir IIILLIMMIMPIIIILINIPRINNEMININt. '13/111/P---..trfli . -IVLt.... . -; -V t
/ / /
,
,

MEDCOM - 22559

DOD-036135

7 Sed.t_ 2003.

MEMORANDUM 70R Rear Area Operation Center, Baghdad

Subject: Patient Follow UP

'1.K

The following Iraqi civilian was seen at the 28th CSH
as a patient and is authorized I K

follow up visit(s) on
the date below:

FOLLOW UP VISIT DATE:

PATIENT NUMBER: K

f6 11-1)-#

2.K

The patient can be escorted to the 28th CSH during
regular visiting hours (1000 and 1400) after the necessary
security precautions have been performed.

'K

for this memorandum is the undersigned at

)0

//original igned//

10/6tVt

, MC
Deoutv Commander for Clinical

MEDCOM - 22560
l.MbU -zutn usH -IL
For use of this form, see AR 40-400; the proponent agency is OTSG gister Number Name (Last, First, MI) \j,\.) / 4. Pay Grade 5. Sex FGN M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 9. Ethnicity Religion
1967-10-10 36Y X 9 MUSLIM

10. Length of Service ETS 11. FMP . 12. Social Security Number
1 \ c„) t ."0„) 0'
99
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
Z 23:11

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

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

20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER ICU1 Address of Emergency Addressee
Qd---
Telephone Number of Emergency Addressee
us
Name ion of Medical Treatment Facility:
0580 -Iraq; No Install Provided
21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
HOME 2003-11-10

24. Clinic Svc -Admitting 253/ITF Transferred From 26. Date this Admission (YYYYMMDD)
A/E....4y .s....,..j. 4-2
AAJ 41C-4.11ZGL-GGY-
2003-10-30
27. Location of Occerence ft. M1F of Initial Admission 29. Date of Initial Admission
4r, -1`
1Z 2003-1 -3n

FOR LOCAL USE
PA' : 020.2_.
Type Patient (Inpatient / Outpatient): Inpatient
6,K : Fr)IP
.*
Admission Diagnosis Narrative: OPEN DEPRESSED SKULL FX fiED3 1
—7/qq-1 .
Procedure Narrative(s):
Cause of Injury Narrative:
Ad
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 22561
f
Automated Facsi
N.--,TIENT TREATMENT RECORD-..:_A!,ER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
R ister Nb . Name 3. Grade Admission RemarksSAHOLE, HAMDE FGN
4. Sex 5. Age 6. Race 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
M 32Y X

NO
11. FMP 12. SSN 13. Organization 14. Ward
-
20 -- . •
ICU2
15. FlyStatus
1/Dept / Ben I, 18. BranchCorps 19. UIC / ZIP 20. Type Case 11-ARMY ACTIVE DUTY
DIS
21.
Source of Admission

22.
Hour Of Adm: 23. Clinic Service
Direct from ER

18:00 ABA -GENERAL SURGERY
24. Name/Relation of Emergency Addressee
25. Type Disp 26. Date of Disp TRF-OTH
2003-11-04
27a. Address of Emergency Addressee

27b. Telephone No 28. Date This Adm: ' Officer: I /
--2... 2003-10-31
(2 l'u
29. Repoli, Iraq
W'-r)-- 30. Date !nit Adm 32. Units Blood Components0580 -2003-10-31
31. Selected Administrative Data
Marital Status: DoB: 1971-01-28
In/Out Patient: Inpatient MOS:
33.
Cause Of Injury: IED

34.
Diagnosis / Operations and Special Procedures:

SHRAPNEL CHEST, GSW R ARM
-)/ gq,0 1.5 I Prvc---S7,yq
e-2,q1
(40(-4,tb
3q,o4
_c(ct I .9
35. Total Days This Facility
Absent Sic Days Other Days

(1)
,ConLv / Coop Care Days Supplemenkilpre sor ed Days Tqtpl Sick Days
66 tAtt.
,
.
fei .:.
35. Total Days This Facility
Absent Sick Days Other II
ConLv / Coop are Days Cupplemental-tare Bed Days Total Sickpays
v. .
5
1--)
Signature of Attend ng Medical Officer
Az S'
. _ of PAD or Me . I Records Officer \(.1 \ 1\/ iN)
MEDCOM=62
Automated
ii
DOD-036138
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
,VRTINENT HISTORY. CHIEF' COMPLAINT. AND CONDITION ON ADMISSION ?Enter .inre of ad inirrion
3
3 ). 0--e s ip e 1
0
(^"G1/4.-4_,
-1..„01--(._ 0_9(1— i_____ tp
f
Pm, c=9
PHYSICAL EliAMINATION
P L,"( t---k_ )
‘/" G_--D spic
bLee,,A,
Wee
A,
-
rindtdiav,..)
PROGRESS I Ewer dare.
I JA-,
1‘1'.P
t v_e__
/72-/4-
P? — iv
C
fi
men ervert•• ,tats ...lama last. h•se, REG ISTER NO. WARD INC). hosp.ral r medical lAcslity)
ABBREVIATED MEDICAL RECORD Eir.a.n.Ciard FOrza 41+99
GENERAL SERVICES ADMINIETTRAT:CN AND
INTERAGENCY CCMMITTEE ON MEDICAL
FCC:DADS
FiSMR {41 CFA) 201-15.505 CC.TCBER 1975
539-106
i!:,* 4.1,,; ,,z
MEDCOM - 22563
DOD-036139

AUTHORIZED FOR LOCAL REPRODUCTION
t
'MEDICAL RECORD PROGRESS NOTES
NOTES
DATE -
b 1i)-
31034-6-23 any 146.+E0 ,/ . ot,u-d() vp4 in.4:ru , I tug/

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/DIM or SW; Sex:Bate of Beth; lienk/Gratte) 1 n I a_
PROGRESS NOTES Medical Record
STANDARD FORM 509 IRV/. 511999) nescribed by GSAIICAIR RIM 14ICFW 101-11.2030311101 uSAPA YI.00
MEDCOM - 22564
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
kA-rm Qccio),-QAD CLA 2,1, CD1\
STANDARD FORM 509 MEL 5119991 BACK
USAPA {it .00
MEDCOM - 22565
AUTHORIZED FOR LOCAL REPRODUCTION
t
MEDICAL RECORD I PROGRESS NOTES

NOTESDATE
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LAST FIRST
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/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
MEDCOM - 22566
. LAST NAMEt ----rt\JAMEt 177t,TIAL ID NUMBER
DATE NOTES
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STANDAt509 (REV. 5/1999) BACK )tUSAPA V1.00
/ LIt'--L
MEDCOM - 22567
AUTHORIZED FOR LOCAL REPR DUCTIOI
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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FIRST MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle,-REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(19
E" 40
USAPA V1.0C
MEDCOM - 22568
MEDICAL RECORD
DA E
.) .
HOSPITAL OR MEDICAL FACILIIY
SPONSOR'S NAME
PATIENTS IDENTIFICATION: AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entryl
5 , 1---) fr,,,3 c ( evi..." (-e,v1-- tfk &
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STATUS DEPARTJSERVICE RECORDS MAINTAINED AT
SSNIID NO. RELATIONSHIP TO SPONSOR
(for typed or written entries, glie: Name - last, first, middle,. ID No or SSN,- Sec Bete of Priv Rank/Grade.) REGISTER NO.
WARD NO,
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FOFIM 600 (REV. 6-97) Prescribed by GSAIICMR FIRMR 141 CFR) 201.9.202.1 IJSAPA V2.00
MEDCOM - 22569
DOD-036145

TEST RESULTS
RADIOLOGY
SUP 02 RESULTS
PCO2
DIP EKG INTERPRETATION .
BHCG MICRO
" --"""
PROVIDER HiSTORY/PHYSICAL
,tJ

I
ocx

v-\7
I
CONSULT WITH
TIME ACT101.\77 FIESIDENT/MEDICAL STUDENT SIGNATURE AND .S.TAMP . •t.t•
PFIOVIDER SIGNATURE AND STAMP
AGNOSIS
)
sl\kia)e V3C).6(k.C41.1 6 Dickts-lac,cc
0 0
TIENT'S IDE,NTIFICATION 1F-or typed Of
written entries, give: Name — last, first middle:
ID no. ISSN or other); hospital or mcoical

/ EMERGENCY CARE AND TREATME7gT /Doctor) Medical Record
)
STAT¦IDARD FOFiM 552 (REV. 9-96/P7oscribod by GSA/ICMR
FPNIR (41 CFRI 101-11.203IbI1101
MEDCOM - 22570
CT, • ,
DOD-036146
533-104
LOG NUMBER
EMERGEN-CY CAREMEDICAL RECORD
AND TREATMENT
RECORDS MAINTAINED AT A. _ j _a\ _.)
(Patie/r0 ' P C '-) C. PATIENT S HOME ADDRESS OR DUTY STATION
ARRIVAL
STREET ADDRESS
_t. .

DATE (Day, Month, Year) TIMEt
7/ 0 kta
/ 7/ c----
STATE ZIP CODE
TRANSPORTATION TO FACILITY
L,, iA-4.ti
//42,'4/.1 le
At DUTY/LOCAL PHONE
MILITARY•STATUS
THIRD PARTY INSURANCE(\i/.... AREA CODE NUMBER
TTEM
YES N/A ITEM YES NO PRP
ADDITIONAL INSURANCE
AGE HOME PHONE FLYING STATUS
DD 2068 IN CHART
AREA CODE NUMBER
3
MEDICAL HISTORY OBTAINED FROM

. .. NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS .....-,t IkltII IOW /NOtete,-.1 art•-rir,•• A. .. 2 ............ r

NI VISIT
WHEN /Date/ DATE LAST VISIT 24 HOUR RETURN
fTEM YES NO
0 YES 0 NO IS THIS AN INJURY? WHERE
TETANUS
ALLERGIES
INJURY/SAFETY FORMS
DATE LAST SHOT C.OMPLETED INMAL SERIES HOW El YEStEl
CHIEF COMPLAINT
(41 antl.
CATEGORY OF TREATMENT
TIME VITAL gIGNS TIME
EMERGENT
BP

PULSE
. I:2rURGENT
INMALS
RESP
Z_
TEMP
.0 NON-URGENT
WT
e,./cd3C/DIFF ABG

PT/Prr
I BHCG/URINE/BLOOD/GUANT
.CX11 PA & LAT/PORTABLE C-SPINEURINE C& S UA IYISCC/CATH
EM: )- cc ACUTE ABDOMEN LS SPINE
BLOOD C&S X 1.L1
0 CC 0 SINUS HEAD CT
S'C o

rC ANKLE R/L
1.¦•¦•
ORDERS
U2I
PULSE DX
r-LFMGNITORt ECG
TIME
ORDEFtS
BYtCOMPLETED BYtTIME
PATIENT'S RESPONSE
DISPOSITIONt DISPOSMCM QUARTERS /OFF OUP/
PATIENT/DISQ-IARGE INSTRUCTIONS
) HCMIE

ri FULL OUT/ ri 24 Ht..t
49 HRS. TI 79 HRS MODIFIED DUTY UNTIL
RETURN TC1 DUTY
COHOMON UPCH FIELEASE ADMIT TO UNIT/SERVICE. t
TO
WHEN
REFERRED
IMPRO`/ED UNCH
ANGED
6
DETERIORATED ITIME. OF RELEASE

have received and understand these instruct ons.
PATIENT'S SIGNATURE
PATIENT'S IDENTIFICATION /For typed of writtan entries, give: NOT° — last,fir, middle; JD no. ISSN 0 f other); hospital orrno
c
EMERGENCY CARE AND TREATMENT (Patient) Medical Record
STANDARD FORM 558 !ELEV. 9-96)Proscribed by GSA/ICMR
MEDCOM - 22571
FPMR 141 CFR) 101-11.203(b)(101
MOP
DOD-036147

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RtCORD
HOSPITAL DAY
POST-DAY MONTH-YEAR Naf DAY o -3 /4 Mk
HOUR P . 1. 2. L. 0 • FT. I • •..,,._. 0€0:z • • • • • • . •
/1.6 c'0313


. . . 0. TEMP. F •. : q: If: ' • 0.

....
(Apoamaialatj 'swalenobaapaanuao)
o: 'cc! 'b. 4 'al cc'') ;-• 'c?
' N cr;):
PULSE
(0) (6) ' 0; •• . . , ..• • 0 •
•-r-• •
105° , , tt-E4
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...
. . . . . . . . .
. . . . . . . . . .
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. . . . . . . . -
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18.0 104° , : , , .. .
. .
I....
. . . . . . . .. . . .
. . . . . . • •
. . . . . . . .
. . . . . . •• . . . . . . . .
170 103° , , .• •.
. . . .
. . . . . . . . . . . . . .
....
. .
. .
. .
....
. . . . . . . . . . . . . .
• • •• " •-" " ••
160 102d

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

150 101°
. . . . . .

. . . . . . . .
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. . . . .6 .• . . . .
. . . . . . . . . . . . . .
. . . . . . . . .1, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
140 100°
. . . . . . . . . .
. . . . .. . . . . .
..."
. . . .
.

. .
. . . .
. . . . . .
130 99° .
. .

98. 6° 1V : 111: V: : : : •. . .". a : •. : .". : •. •. •. : •. : : : : : •. . . . . . . . . . . . . . . . . . . . .
120 98° : , V. •. . .
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; • • • -
I • • •
. .
"
. .
. . . .
•' " " " •• ••
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110 97° . . . . . . . . . . . . . . . . . .
. . . . . . . .
. . . . . . . .
. . . . . . .1. . .
. . . . . . . . . .
: :
..
100 96° . . . . . . . . . .
•• " ' •
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' • "
. . . . . . . . .
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90 95°
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... • • • ...


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.
. . . . . . . .

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Iv • -
RESPIRATION RECORD '6
pomp°osimpsApoamp!spec'sp000e8
1
BLOOD PRESSURE rztfo n,E7 114* ItNo Illivi /t.s'N lkieVt I ViT, 99,_ 161 p
100.v foo-3 VT HEIGHT:tI WEIGHT cat/ ill, %My
97*q6 'Mar) V*
I

PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO WARD NO. (SSN or other): hospital or medical facility)
_....11111/111
VITAL SIGNS RECORDS
co c,k)
Medical Record
STANDARD FORM Sit (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 22572

DOD-036148

ko(
Ward/Section: REQUESTt
LAB ORA.TORY RESULT FORM SuVeer to the Privac.
Act of 1974
SSN/P U
TEST I RESULT REF. RANGE TEST RESULT REF. RANGE TEST . • ., RF_SULT I REF. RANGE .
'IA 31-10-03 23:73 Patient APP Color N/A N/A Mono RPR Negative Negative
WPC 13.2 H x10'3iiiL 4.5 10.5 Glu Negative l4.rUcrobielagy
a 4.71 x10'611.d. 14gb 13.4 g/dL Hrt 42.2i Z IV 28.6 iCHC 31.8 L g/dL Plt 440. x10'3/aL LYZ 16.51 *L 4.00 6.00 11.0 18.0 35.0 60,0 80.0 79,9 27.0 31.0-33.0 37.Q. 150: 474:: 7.0.5 51.i • Kct Bill 'N/A Negative Negative Negative H. pylori Crram Stain Occ Bld Source • . • • . Negative -Negative
Lilt 2.2* • x10"3/aL ' 3.4 N/A . Micro
Parasites
Negatise Malaria
0.2-1.0 0 & P
Ly mp h; NcEpiti Ye Other
Atyp I m ra Negative

rascOpic Urizfs RBC
'Negative Morph
Spuz 42-52% (M)
fiematocrit 3747•/. (r) .• Blocxl.Etrittk • .--.•

• • • . . . • . . • • • .
.
Sed Rate MUST SUBMTT SF 518 WITH EVERY UNIT REQLTESTED Other
Negative
ABO/Rh
-CoaguLition Stt dies:: • . , • - Blood. Baitk Unit Crosse:latch' - :
: •
.
(MUST,SUBMIT SF:5I8 WTTH EVERY
• . '• •
.

jUNrr Or BLOOD
• - • • Q UF_STED)
TEST I u-LT I REF. RANGE .UNTT . TYPE • •
CR.OS.V.L4TCF1
PT I 9.8-13.6 secs 21-3 4 s=
D di.raer I 20 I:g/tro
FDP 10 ugleil
REMARKS:
R_EPORTED BY:

DATE: LAB ID. NO.:. MEDCOM - 22573
DOD-036149
totthUeRprYivRESAUctLI; FL907RN1
4
Cl.k.,---10 ac .
L'il:b.c1C'trk
L S 71 ER-ST. NII -or ,1 D.:N.,.
LE SS N
U. '' . lilt
0 iii
— •:.-c to ' :-TEST. 1 RESULT .v . RANGE W._ Iri IMO 31-10-03 RE WB 2'0:52 Patient _ .. . .... .. . . , LimitsHg , WIC 16.9 H x10'3/ut ',. 4.5 10.5 Ho REC 4.85 x10'6/cilr 4.00 b. 00 1495 13.9 9/EIL ! 11.0 18.0 m( Htt 43.4 7. — 7 35.0 60.0 IV 89.5 ft • .80,0 ;99.9 ,,, NCH 28.7-P9 27.0 : 31. ..,.rit roc 32.1 L gift. 33.0 - .7.0 ' ,r Plt 450. H x101'34. 150. 450.-LT LY% 10.3 44_ Z : 20.5 51.1 • LYII 1.7,-;4. x10'3/aL 1.2 . 3.4 ., TEST Color APP Glu Bill Kct -SG Bld pH -.. RESULT REF RANGE N/A N/A Nes ti re Negatire Negative N/A . Negative N/A . •• •• •• • TEST RPR Mono -.. Source Gram Stain Occ Bld H. pylori Nficro .. Niisc.*Serology• . ". •• -: . • 2'.. . RESULT REF. RA WGE Negutre Negative I4EC ro b ioicrgy .• . •• • • " . _• . -Ncgattve Ncganve
Parasites
Sel,.: Prot Ncgztivc MaLaria
Bai: -...-.. Urob 0.2-1.0 0 & P
Lymph 13aso . Nit Nciptivc Other

Atyp Imm Lcuk Negative
-:. Nal-pleb:1)k tfrisiily-sis '
. . .. .
.
_ „ . .
-•. -• ; : • . RBC HCG Negzti-ve Morph
-. -
.
.
Spun 42-52% (M)
--• looci.Bank ; • -
Fieciatocrit • 3747% (F) . .. ,- -• • • • . . , . .• '
Sed Rate
r Cell MUST SUBM:IT SF 518 wrrii
_
COunt
. -EVERY UNIT REQUESTED
Other Directigen Negative
ABO/Rli I
Co.x.tguLationiSt-ndies:: -•:. -..•
••• -Blood flank Unit Crossultitch .:-. '
(MVST,SUBMIT SF 518 WITH EVERY UNrT OF BL:00D
. .. . .
-: s: . : :. REQUESTED)
TEST RESULT I REF. RANGE u-Airr
TYPE
CROSSM4TC1-1
PT 9.8-13.6 secs
A.P1 1 21-34 sec:s
.
D d ; net-I 20 I:ecni
-
F DP 1 10 uerni
RE MARK.S:
REPORTED BY:
-LAJ3 ID NO.:
'
/ A c/f17
MEDCOM - 22574
.
-
Wald/Section: REQUE TDIG
Q j.k.,9_._
LABORATORY RES.T.ILT FORM (.. Sub'ect to the Privaci• Act of 1974
LAST, FIRST, II
TDAE SSN/P Us •
. d-3 (3,
a'
. _. • .c . t9 .
.,..
.../14,1is. c:S•ero .ogy: • .
. . ". .• : -.•• • . •
TEST .RESUL r REF. RANGE TEST .-
RESULT REF. RANGE .TEST
RESULT REF. RANGE
SVI .id.

al-11-.03' Col or -N/A RPR
4 NegatiVC
03:0 t
'
RE Patient. . AP P NIA Mono Negative
Hg ,

, Limits' Glu Negative
pilq, 11..31-1 xlre3/t . .14ECrobit4crey .
-4:5 '115 . .
-T-4c .. . . . :. .
.PX, i. -34
xl0A6iiiL . 4, 00 • 6.00 Bill Negative
ggb 13.3 Source
girl_ 1 . . .
11.0 10.0 '
--ET -Kt-40.2 ' Z
35.0 , 60.0 Kct Negative
tr-.1) 2,8.6 IT . 80.0 99:0 Crram -
.
; _ TA -27.2 -pg - Stain
:-f'27;0:-,310 -- •-
Pl. Mt SG N/A
. 33.0 L 9/dL 33.0 - .37.0 . Occ Bld Negitive .
_
Plt 411.
-x10'341. 1!&i. 4-0.
.
L3. ' Negative
LYZ 20.6 * „7 Bld H. pylori Negative
20.5 51.1
—77 ;IA . 2.3
* y.10'3AL 1.2
3.4 , ,.-P N/A . Nficro
Parasites
Segs Mono Pr Neg:ative

Malaria .
Bands . E . 0.2-1.0

Urob
0 & P
Lymph Baso • Nit Negative Other
Atyp Imca Lenk Nepal ve

ros.ciip i .IIriiii
.
RBC HCG Negative

-
?A orph .
-
'

.
- •
-
Sp tin 42-52% (M)

I
F ,
Hematocrit 3 72474 (F) • : • . load:Bank ',... -.
'
•-
Sod Rate
Cell
MUST SUBMIT SF 518 WITH
C4LU1L
- E'VERY UNIT REQUESTED
-
Other Directigen Negative
ABO/Rh .
oaguLationStudies:: -- •• _. '..
• •Bloo:cl:Bailk Unit Crossmatch'
:-
(1‘.4UST SUBMIT SF 518.WITH EVERY UN
. .. . . . IT OE BLOOD . ' :. RE Q UES TED )
.
TEST .I R..r:SUZ,T I REF. R.-iNGE UNIT TYPE .C.ROSSM4TCH
PT 9.8-13.6 secs .
APTT 21-34 sc=
D diraez• 1 20 I: cr, i

F DP 10 L:g.'ail
.

. S:
REPORTED BY:

DATE: I LAB m NO.:. •
MEDCOM - 22575
DOD-036151
Wa_td/Sectioa: 1 c tit...9._ REQUE pliQ P -
1 LABORA.TORY.RESPLT FORNI
LAST, FIRST. . ‘, I i ; ...• t ettiatulocri) :' . : ' !..):.) -tels-., I (Subject to the Prtvacii TIME esos-a • A:ct of 1974 SS-N/PSE • • SSN: ,--L7 t,,.
TEST RESULT • F. .RANGE SifFIr iiiii , ID: 4.8-10.8 x 10' 01-11-03 '1,1R 01:0q-— --. --Patient . Litits la 12.6 li x10'3/11 4.5 10.5 .REC 4.59 xl0A6/u1. 4,T 6.00 Ebb 13,5 11.0g/d1 ...-.18.0 . Itt 41.2 . Z ‘,;i 35.0 60.0 XV 89,9 t1.--, -00.0 99.9 itii 28.9: pg 27.0 41.0 -MX :32.2 L -91d1.---.--,T3.0 7, 37.0. -PIt 451. li x10'3/1 150. 450. 'Ca 20.2 *I_ I ' ' 20.5. 51..1 , ' ;:LYII 2..5 * x10'3/tti. 1.2 3.4. .. Segs MOTI. 0 TEST Co1or APP Giu Biii Ket . SG B la pH Prot RESULT - WA 1\11A Negative Negative Negative N/A Negative tst/A . Negative RPR Niono Source Crram Stain Occ Bid H. pylori Is,ficro Parasites MaLaria REF. RAh'GE Negative Negative NfiCrobiolagy . -Negative Neg;inve . _ . • . i '
Bands E Urob 0.24.0 0 & P
Lymph Baso • Nit Ne-gative Other

Atyp Imtn Lcuk Ncgsttyc
. .Nai-oscopie 13rIni
. . .
. , ... . . _ , . .
.. • . -.•-. ....
RBC
HCG Ncgzti-vc Morph
., -
.
.
. Spun 42;52% (M) Fiera atocrit 37-47% (F) -• -• " "
• • .. •-• • -' '
Sed Rate
r Cell
MUST SusNtrr SF 518 WITH
_ : Ccur.1
EVERY UNIT REQUESTED Other Dircctigcn Negative
ABO/Rh :-.CoaguLtrion -Syndics:: : , , -.•i: -'.-_. ' ::
. - .Bioad Bank Unit Crossmittelf
: - - -: .: : .
. . -• " • -- . . -.
• , -(MUST SUBMIT SF,51.8.WITH EVERY 1.TNn7 OF BL.00D •
------' -' ' • ''. .-
• •• -
TEST RESULT I REF. RANGE
UNIT Tif'E.
1.CROSS,'/L4TCH
PT 9.8-13.6 secs . • I
AP-TT 21-34 scc
D d im e 7 1 20 t:g/mi I I
I
FDP 1 10 eon!
RE ."(1.4.R.K. S :
r, i- arm -v-c- r. r) v.. - -,.

-
. O.:.
MEDCOM - 22576
Ward.,'Sdction: , 'SICIA._^,;": ' CHEAIISTRY RESULT FOR:41
, , . i 1 1,1.1.:1-5:. LIME . c'--- Sub;e-o•t to thc Privacy A.7t of 1.974) , SSN/P_SEL1/9. SSN:• ' — ._
...) ''. _ . ... - : - , ___ .. ._ -
TEST RESULT REF. RANG I' ' PICCOLO ------- K: PICCOLO
31/10/03K18:07K31/10/03K18:06

Na MALE

' RANGE:K

138-146"Ic4/1-REFERENCE RANIL:00.KREFEREK.
MALEK

K . 3.54.9mrrloVU PAT IENT # : M. (4,t,.S —L
. PATIENT #: IIIIIrkv)-LAK
..
• BASIC METABOLIC DISC LOT #:KDISC L T #:K
Cl ! 98-109=1,7my,KvK
LIVER PANEL PLUS
3153AA7

3203AA4

7.31-7.45
PH
;IF #: 000

OPER #K

OPER #:KDR #: 000K

PCO2 35-45 nrmlig (LL-C
SERIAL ' tr),000010069l

41-51 mrnHc(vcc) ' SERIALK/0000100684KK

K.KPO2 .50-10.5 mcnHg (art) N?
.
N/A (veul TCO2 23-27 mrncl/L (art) 98 73-118K
MG/DL ALBK
4.6 3.3-5.5KG/DL
G_UK2.4-29 ,..-unol/L (vcc) U/L
BUNKMG/DL 72K26-84K

12 7-22K
ALPK

HCO3 22-26 mmcVL (411) U/L
10-47K

9.4KALTK

1.3-28 mruoUL (yen) CA++K8.0-10.3 MG/DL 69*K
U/L

CREK0.6-1.2K
NA+K128-145K
AST 64*K' U/L'

s02 95-9104 0.9 MG/DL AMYK
56 14-97K

133 MMOILK11-38KK

BEecf (-2)-0%11
0.7KMG/DL

0.2-1.6K

4.2 MMUL AnGap 10-20mmoVL CL-98 MMO&L GGTK
5-65K

mmuill.. K+K3.3-4.7K
TBILK

. 48 U/L
98-108K
Ca 1.12-1.32nm:on 18-33K
7.8KG/DL
6.4781 ;K

23 TPK

tCO2KMMOVL

,
-
. BUN' 8 26 rag.id1
CHEM OC: OK;.

-INST OC: OKKINST OC: OKK
i,CHEM OC: OKKGLU 70-105 mg,(11. ,K
ICT 0KLIP 1+,K
HEM 0 LIP 1+,KHEM 1+,KICT 0

.K

Creat 0.7-1.5 mg/til .
Hct -38-51% PCV -,-----
Hgb 12-17 ecil
,,A-c,.F.4iftiiiti-Y1.•,.'
..:;:;-'7.'-.::'......:::
'...:i?::7,*-',',F.;'-''',-:".!;.-.,..':::::..Y,!:.'''' ,-;.:. ......Y.-..,.:
TES'T RESUiT RE
—F. RA.NGE
Troperin-t
Drug of Abuse
-,.
. . I I . CL-1 98-10S r:-.moV1
tCO2 I 1S -33 r.-.mo'..1
, i .
REMARKS: . .
REPORTED AY: -,;..
1 DATE: I LAB ID NO.:
i -I -
MEDCOM - 22577
I

LABORATORY RESULT FORNI (Sub;cct Zo the Frivaci- Act of t 974)
l.D$TE _1_, I ZEN at)
s
!31,CC I I \Th
1-1,
Fb
PI

Segs
Bands .
Lymph Baso
Atyp

Imm
RBC
Morph

Spun 42;52% (M)Hernatocrit 37 .4 T'A (F)
Se.:1 Rate
Other
oaauLitioix
• . s• •.-
TEST
i2ESE/Z.T REF. RANGE PT
9.3-t3.6 secs A,...DT-r I 21 -34 3= D 20 ._:glcri1
F DP 1 0 ug/m1 RE N1A_RICS : [P__EPORTED BY: -
rology•
.•
RANGE .
P_ESULT I .- •
ID
31-.IPE-03
4-1B
18:04, Patimt,
IR
26.2 1-1 X1.0 'I'ut
4.5 10.5
FM 5.14
Y10'6/Ii. 4,00 6.00
Ilab 14.9
AL
11.0 18.0
lict 46.2 Z ai.0 60.0
MU 90.0 fL W.0 97.9
-29.1 Pg.27.0 31.0 MK 32.3 L a/tIL 33.0 37.0 Flt 58. H x107.AL 150. 450. LYZ 4.6 44_ 20.5 51.1
UN , _ 1.2 * x10"3/tiL 1.2 3,4 .
Mono
REF. R.-INGE TEST
RESULT REF. .R.4,YGE
1..7olor N/A
RPR Negative N'A
Nfono Nef;ativc Giu
Bili N c-gati ye
I
Source
Ket Nc-gativc

Gram
Stain
SG N/A .

Occ Bld ] Nev../ i vc Bld ' Negative
H. pylori Ncg-pave NIA .
Micro

Parasites
Prot Negative

Malaria
Urob 0.2-1.0

0 & P
Nit Negative

Other
Leuk Negative •.

rinci3PiC
. • .
-
HCG egarrys
'.• • Blood Battik •
. •
Cep
MUST SUBMIT SF 518 WITH
Count
EVERY UNTT REQUESTED Dircctigen Negati ve
ABO/Rh .
• load:11;11.k Upit Croissaitch. :

(MUSi.,SUBNIIT Sf..518.3iVITHEvERy UNTr BL,90Li -
REQUESTED) - • • •
. •
UNIT TYPE
CROSS.b-fTCil
DATE: LAB M. NO.:.
MEDCOM - 22578
-*
)Cija AP. 11{-i
Ward/Sec.tion: RE Q UE SUNG P LABORA.TORY RESULT FORM I I Sub cct to the • •
t.../Na I, tit_K-s ,I, „Nil.
. TIME • SSN/PSE
l_,c1J)---ki --
d60e
,.....oacriLloiot,,
• _Urinslysis • .- ,' •
: • .. ., . .... • • u.Nfisc..S•ero o
-
. ...
TEST .RESULT .REF. RANGE TEST RESULT REF. R.-iNGE TEST .-
RESULT I REF. R,4NGE
Color • N/A
ID:1111111F—. 6121T-701". II' RPR
Negative —
NB
05:43
Patient APP N/A Mono Negative Limits , Gtu Negative
-..hfiCrob ial au .
411C 12.1 H xl0A3/d. 4.5 10.5 .- -
. :. . . -. .. . .• • . •
a 4.50: x10"6/tiL 4.00 6.00 Bili Negative
Source
HO
9/1_ 11.0 IS O-
RA
35.q, 60.0 ' Kct Negative
h. Crram .
XV d.. iL 80.0 94'.§ .7.
Stain
•.
rat 73.2 Pj 27:0731:0:-: :. '
SG NJA
ME 32.5 L . Occ Bld Negstive .
9/dL.33.0 37.0i
Pit 406. —110'3/uL 150; 4,50...
Bld Negati vc
lg. 20.4 A_ Z ,.. 205.51 1 H. pylori Negative . LY.4 2.'3 * xl0A341.-.- 1.2 ',:;;4 N/A .
:1 .,.• Nficro
. PH Parasites Prot Negative
Malaria

-
Urob 0.21.0
0 & P
Lymph Baso
, • Nit Negatim -Other
A typ ...
I mca Lcuk Ncgszivc
•" . N 13}S03-0 k .tir nal -
-• • • -—
.
RBC
HCG Negative
-
Morph
• .
. . .
..

S p un 42;52% (M)

F ., .-
Fiernatocrit 37-47% (F) kKx1.13-ank ;,.....-*
' • • -—••:--
.. ' --
Sect Rate
Cell
MUST SUBMIT SF 518 WITH
Cu.n.t
EVERY UNIT REQUESTED
Other Dircctigcn Negative 1 ABO/Rh

I
, onulation -.Studies.: -.:• :. ' , '. _.
. - .1310:d. Sank Unit Crossmatch. :.: - -
..
• .-• -. .. • (MUST SUBMIT SF 518.WITH EVERY UNTr OF BL:OOD
--•
: '
• ... :REQUESTED)
TEST RLS—ULT [REF. RANGE UNIT TIT E.
I.C .R 0 S S MITCH
FT I 9.8-13.6 scat . -

1
APTT 21-34 5.TCS I
D di_:-.-..e .1 20 tig/cni
1
I
F DP 0 ug/eal
REMARKS:
... R_EPORTED BY:
DATE: 1 LAB ID. NO.:
'
MEDCOM - 22579

\c-) t6--\ -
LABORATORY RESULT FORm
t RE
War-d/Sectiou:
Sub-ect to the Privacy Act of 1974
KAIN/ /
_
ATE ThME SS 1.A ST, FIRST,.M1.
• I -7 4-5. Lt )
I.i., .
FO (ID-
Urinalysis
•("Hcmat9k)& •. -:
RESULT REF RA NG.E
RESULT REF. RANGE .TEST
RESULT REF RANGE TEST
N/A RPR
& Jt_i n I i x 10' Cdioi
Il.);• (11-11-W

-, ,-"' Negative
,,,,...,.I_E Mono _
2 18:03 -
1 ,,.
Ritient 23:34 .
-Z MicrObiol
Ligits htia-it, . --!..TEC 13.6 1-1 x10'3AL 4.5 10.5 1 ilits
iource
Fa 2.42 k g10'6/11 4.00 6.00 4D: 13.6 k 1:10'3AIL 4.5 10,5
1-1L-fb 14.3 4, girl 11.0 18.0 RN -4.37 x10-'6AL 4.00 MO iram
lict 21.9 k 7. 3:3.0 ;1.0.0 4:ib . 14,3 gAL 11.0 18,0

;Min1'0 7/3 * fL 80.0 99.9 :5.0 60.0
Hzt 43.9 '.4 Neaative
30.0 ,.-T9.9 kc Bld
MI :38.9 iti 99 27.0 31,0 g-):, P.3 ft.
NC-11..; iD-5. 3 Al 91.11. 33.0 .37.0 -3:,¦ I 1'7,, 1 pg, 27.0 31.0 Negative

I. pylori
Kt 22:1. * x10'3/.1 150. 450, i'D 4: 32.2 L gidL 310 37.0
LI% 16,6-. -k % -20.5 51,1 Pit .172. g x10'311i 150. 450, ,fiero
L11,' 2.3 48 x10'.3h1. 1,7' 3,4 16.8 k '.' M.5 51.1

i rt !arasites Lit; 2.3 * -,.:10'3,11 1.2 3.4
4alaria
•, ,.„,
) & PBands Eos
\
Negative Other
Lymph Baso Nit
Negative . Microscopic Urinalysis.
Atyp Imin Leuk
Negative
HCG
RBC
Morph

Blood Bank ,
42,52% 04) CSF
Spun 37.47% (n

Hematocrit
! MUST SUBMIT SF 518 WITH

Cell
. Sed Rate
EVERY UNIT REQUESTED
Count
Negati v e
1111111111111111111
Directigen ABO/Rh
:. Blood Bank Unit Crossmatch-
;-- Coagulation Studies,
(MUST SUBMIT SF 518 WITH lEVERY UNIT OF BLOOD .-- RE I UESTED) :
-
UNIT T1TE .CROSSAL4TCH
TESI' RESULT 1 REF. RANGE
I
' I 9.8-13.6 secs

PT i ,
1
' 21-34 secs

AVIT ! . i
; 20 ug/m1
D dimer
I

1 10 ugimlF DP I
REMARKS: ,

t DATE: 1 LAB ID NO.:
REPORTED BY:
-

MEDCOM -22580

_
CLINICAL fiECORD - DOCTOR'S IA0611
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 FIECO
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICA,TED BY ARROIN BELOW. DATE OF 0iDER LtetTik,
TIME' Df ORDER
PATIENT IDENTIFICATION N 71T1
HOURS
0 ? 1 .4
(-1 c 4
I /
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDERtTIME OF ORDERPATIENT IDENTIF !CATION
Houns
Le y\)P
/.?AL
J)-1t, 1/4-C.:/
--e_
NURSING UNIT ROOM NO. BED NO.
C
DATE OF ORDERtTIME OF ORDERPATIENT I DENT IF ICAT ION t HOURS
cloc)--1}Q___,
--el—ss
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER
PATIENT IDENTIF 'CATION
3/Oc7-i-n
IBt fr•
NURSING UNIT ROOM NO. BED No.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA ,FA°,4119 4256
MEDCOM - 22581
DOD-036157

A
CLINICAL RECORD - DOCTOR'S ORDEP.S
For use of this form, see AR 40-65, the proponent ace.ncy is OTSG
THE DOCTOR SHALL RECORD DATE, TItAE AND SIGN EACH SET OF ORDERS. IF PROBLEM OPJENTED MEDICAL F.ECORD
SYcTEM L'SED, WRiTE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOw.

LIST TIME
pAriENT IDENTIF:cATIoN + DATE OF ORDER TIME OF ORDER
OROER -• - NOTED AND
HOURS
. 4; N 01/4-) ° SIGN
NURSING uNIT 7-100M NO. . BED NO.
PATIENT IDENTIFICATION DATE OF ORDER
"3' /1/e v a 5
Pilyee4.D 4- / 0,19k
heAfQ/ /10/0° rc,e'/
Ati,
NURSING UNIT ROOM! NO BED NO.
dZrNi
PATIENT IDENT.IF,CATfON F ORDER
HOURS
Di)
NUR( G tUl/t17 ;R.00M NO. BED NO.
PATIENT IDENT:FiC,...s.T..ON DATE OF ORDE
c_5(E
NUR SI NG UN IT ROOM NO.
REP. ES EDI-NON OF 1 JUL 77, "WHICH MAY BE US.
DA 425e
F°FirA
1 APR 79
MEDCOM - 22582
CLINICAL RECOP.D - DOCTOR'S ORDERS
For use of this form, see AR 40-66. the prop3nem acency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME
AND sIGN EACH SET OF
ORDERS.
IF PROBLEM ORIENTED MEDICAL RECORDSYSTEM IS USED, wRITE PROBLEM NUMBER IN COLUMN. INDICATED BY ARROW BELOw.
PATIENT IDENTIF iCATiON
+ I
DATE OF/ ORDER
TIME OF ORDER
LIST TIME
ORDER
NOTED AN'D

HOURS SIGN
-xc
V S r
6.e :
NURS I NG UNIT L_ L-(0 r
IROOM NO.
D NO.
[P I (0 Aj J3-0 a V'
PATI E NT
I DENTIFIcATI O N
DATE OF ORDER
TIME OF ORDER
Houns
)--de,,_0./
-P vtlsP
u 1'0,4 Act tc
C •/
ED ;
0
PATIENT !DENT;
DATE OF ORDER •
TIME OF ORDER
4 *


;
D NO.
EDL MEDCOM - 22583
LO'
/ THERAPEUTIC DOCUMENTATION C RE PLAN (NON -MEDICATION ) jitf
CLINICAL RECORD For use of this formes AR 40-407; ; the proponent agency Is the OffIc The Surgeon General. M Yr. 2003
ra,11 Wrt ';'!6 .: :41Witai .
VERIFY BY INITIALING .I ,400INIT.PROPER COLUMN FOLLOWING EACH COMPLETION
i
HR DATE COMPLETED
ORDER CLERIV RECURRING ACTION,
DATE NURSE FREQUENCY, TIME

I 0 I OPt
C/5/6a/CP.r. -11011110S C\ 4-°t, C% _ .
.. -
(15 #1111kDef\ CA1.--....
os. I z
dr - .
RKkg--411NO(*_DU\\----e_— -
:'
i e
rff,-
.
. _
.
.
ALLERGIES:tim YES IM NO PRIMARY DIAGNOSIS: 1t--A-_-_,) ADDITIONAL PAGES IN USE: MI YEStNE NO
PAGE NO'
pATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
\,),t Dt8, 9t10 11t12t13 14t15
E . 16t17 18 19t20 21 22t23
Nt24 01 02 03t04 05 06t07
MEDCOM - 22584

t
es7' 7 0 .t LEA Itur utc 7/ MAY BEt.
USAPA V1.00
DOD-036160

Witty by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) mo.I C15 kr 2003
Order Clerk Date to Time to Initials
SINGLE ACTIONS Time bone
Date Nurse be Done be Done
IP/
1 ILO '-t\C—\NI NC 0 ,
NOV4 _ 01 11116 Car\ce,1 Plevic:us i_1:) cidcr 0 t
01 kt. cEc a.4- 3F,(y\ Or scoo ri
(Pit .1 X t--c._. (c)(01) (b, eQ,(1 -NA. %4 ebervs Novo (,( &Li
q5t L 1 AzD ,prs)::)r \V--2._:
0-z_
1111"t-1
bV CI— --\-l_ —?\(50f)
-A / tv,5/?b--6
At...),.t'a al ..1tA
or
— •
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk/ MN
EXpir
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
• • 0 Aiie,ki MD r-4-' b fa.
(c c...ec....ram trAnia/
.
7.
,. -
USAPA V1.00

MEDCOM - 22585
THERAPEUTIC DOCUMENtTION CARE PLAN ( NON-MEDICATION)
For use o his form, see AR 40-407: the proponent agency Is e Office of The Surgeon General
CLINICAL RECO" II MO. kr: 2003
0: INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
obvp:vg, ,amtatagoat
VERIFTBY INITIALING
HR DATE COMPLETED
ORDER CLERK RECURRING ACTION,
DATE NURS FREQUENCY, TIME

1 ti / A -.
J160-1111 0/5t(g, / 6t
ii Ot-k - - VIII W4 /I 1207 4 COItr 01/4-Aij 0/9 jtq /7 Ji Otk ler A_//dO 07 1 eV q Z j i 00----An tiu al-kJ t 4_1_, bX 6/0411 it /it
31 ed-Ai u`v ', (2)QcI, rto-f-ap /
. ....
i
_
ALLERGIES:tMI YEStIMI NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
/gA dill/ )4" aodo eikte-A 11111 YES NM No
PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES

.tUSE PENCIL. CIRCLE ACTION TIMES D 8 9t
10t11 12 13 14 15 E 16 17 18 19 20 21 22 23
V
.
N 24 01 02 03 04 05 06 07
MEDCOM - 22586
I IC 13,01 \ 141
1, .0, ¦,c\
Verity by . . THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) Ain. Yr .2003
.
Order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Date e be Done be Done
010d— hiPitkj 4) /6u( - 4, 16--A .dlici v-6€,69,( ii0d-c------19.50 ,...i. , ,C.v.e a 41. „5161 ti/617 6 * )169d_ thd ir-Akk 01 ehAciee Jiou L-----1 .-• 0
_ ___ .
_ _ .
_ —
Order/
Clerk/ PRNtINITIAL PROPER COLUMN FOLLOWING COMPLETION
Explr •
Date Nurse ACTiON, FREQUENCY
T1ME/DATE COMPLETED
— — — — — -
_ _ — — — — -.
— — — — — —
— — — — — — —
Pm.. ow .... ows 1” ¦
n.. ¦ ... ... 2... ... =Es ¦
.
-
. -
.-
.... .¦ am. ..... ..¦¦ ... ..w .
... on. ... ....
--. .-- ..¦ .... .--. .... ....t....
USAPA V1.00
MEDCOM - 22587
,
THERAPEUTIC DOCUMEN ATION CARE PLAN (MEDICATIONS)
CLINICAL RECORV For use of t s form, see AR 40-407; MOglk Y r. a.5
the or000nent agency is he Office of The Surgeon General.
VERIFY BY INITIALING , i ,s .":; : .: Y- .r, INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
. I HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

JI, 1
.
.
31 Oa— 410 /,e_ /0-FdAt--u. 7
3160-- -lib rOno ( 660/19 R (kV aL/
Cscps-/6, 0 a •
hz /
ilt,
on
-

.

ALLERGIES:tIN 'as IN NO PRIMARY DIAGNgItti / „„ amonct.tA /a- ADDITIONAL PAGES IN USE: MI YES_tEll NO
PAGE NO t
PATIENT IDENTIFICATt• DISPENSING TIMES

.N\I\\
USE PENCIL. CIRCLE MED TIMES
‘Nr,\X,
'NJ Dt7t8t9t10 11t12 13 14 Et15 16t17t18 19 20 21t22 Nt23 24 01 02 03 04 05 06
MEDCOM - 22588
s-str rt .1 A f!
ot MCI, -In. primnm I1F 1 nrr 77 Vint I RF I !SFr) I INT1I FXHAUSTED.t USAPA V1.00
DOD-036164

uk)

kt i
THERAPEUTIC DOCUMENTATION C RE PLAN (MEDICATIONS) • 1( if,____.mr,
CLINICAL RECORD For use of this for_ _,40-407;
m seet
Mo.--r.¦4-1.--)
the proponent agency Is the Office ofthe Surgeon General.
VERIFY BY INITIALING .
,.INI77AL P.PER COLUMN FOLLOWING EACH ADMINISTRATTON
i I.
i".".".".".'
,HR _ DATE DISPENSED
ItORDER CLEW; RECURRING MEDICATIONS,
DATE NURSE' DOSE, FREQUENCY
.
frI
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k .01 AI — ¦ Ilk • IN
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ALLERGIES-= y Est= No PRIMARY DIAGNOSIS: ADDITIONAL P AGES IN USEI ED Y EStEl No
‘-€'...\*
PAGE NO
PATIENT IDENTI FICtTION:
DISPENSING TIMES
%
_i\,\, USE PENCIL. CIRCLE MED TINES
VtDt7t8t9t10t11t12t13' 14 Et15t16t17t18t19t20t21t22 Nt23t24t01t02t03t04t
05t06
EDITION OF 1 DEC 77 WILL FIE I n 'Huy, t. EXHAUSTED.
D A iVeir19 4678
MEDCOM - 22589
DOD-036165

...._
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) mo..i 03trt1.

Order Dote Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Time Given Initials
3"2Nr51 ( C__ V`acp\CC-Y-__ -2 NOV
.
I

.t .
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRA770N
• - -t
Clerk/
Expir
Nurse MEDICATIDN, DOSE, FREQUENCY TIME/DATE DISPENSED
Dote
0Aft4 7 Conot (=611-Yr\pa 94-1,7MO OW
1/4_9 PO
ilzlis • o ,:.,. ,
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.
.
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.
t. t
U.S. GPO: 1998-454-110/95216
MEDCOM - 22590
DOD-036166

PAGE OF 4
MEDICAL RECORD-SUPPLEMENTA MEDICAL DATA . •
For use of this form see, AR 40-66; the proponent agency i The Office of The Surgeon Gerieral
REPORT TITLE
I
OTSG APPROVED (Dare)
INTENSIVE CARE NURSING FLOW SHEET
QA Appr 8Mar 89
INITIAL S • SSESS N:T • TIME I
I
INTILAS TILAS
PUPLIS
SENSORIUM
aritn,3s
eqm.rnct_rid 5 In

fit• 454YZI .;/-).t"t'
RESPIRATION PATTERN
r LLn 166-4,6)(4
BREATH SOUNDS
exre 1\k, 4, A LS(' r
SECRETIONS
pf Conk I SPci) o AI •
A
0
COLOR
(m-N-
INTEGRITY
(),,A4Lod.51/1o)
SNA a_m+c
LOCATION
6-) a t
CONDITION
L-R_ej p- cc fLe
?5
ABDOMEN
Ain ALI
6P) ¦°)
BOWEL SOUNDS
aiort Sol -I-
C)
URINE
\I (Did
COLOR/CLARITY w;Ni9
C CARDIACRHYTHM
. A S (I, 'go` ?s, dip p Atx0.e g
0 N-PAct-ro fn.,
. 91)
Y.
A
S

Cr - CreatinIne
ICP - Intracranial Pressure
Ei 0 - Fraction of inspired 02 S/A - Fractional .
U LEGEND PCO2 - PRESSURE OF AR:FFSAL CO2
L. Fi 02 -Bicarbonate SAI - Saturation
PEEP - Positive end Expiratory Pressure
": A TRACH - Iracheostomy R-
(Continue on reverse)
PREPARED BY (Signature & Title)
I DEPARTMENT/SERVICE/C1hr-DATE
PATIENT'S INDICATIONS (For typed
I 3)0a-63
or written entries give: Name --Last, First,
middle; grade; date; hospital or medical facility)
\)\\ HISTORY/PHYSICAL El FLOW CHART
j
V pk) El OTHER EXAMINATION OR EVALUATION El OTHER (Specify)
El DIGNOSTIC STUDIES
TRETMENT
DA FORM 4700 1 MAY78 Proponent Dept of Nurs MEDCOM - 22591 WAMC OP 375 (Redesignated) 1 APR 90 (HSXC - NU)

DOD-036167

k PAGE 2 OF 4
')
DATE rr•••¦•¦¦....,
TIME Zg- 11 12 13 14 15
BP Arterial line
• .;T: 50)Axe BP Cuff Temperature Pulse Respiratory Rate ,q0( ck 1_44-11( M 109, migl% '766 . go'?".5 -7Q- 79 71 "n 7(6 R -1015-1 ItLf ALA fi-P II-0 a q6

TIME L-k . Lupo glt3 .94 2g K195 1 0 11 12 13 14 15 8°T
(22100c1
/110 1 L.).

TOTAL
375 5-bo 621950 g-75" ))% )25t
HX/g//11:0O7/ //
0 URINE
SP gr
S/A

OUTPUT
NG PH
GUIAC

EMESIS
STOOL

DRAINS
TOTALS
MEDCOM - 22592
-7. 8° T
8° T
NOMPAPAINEIVAIMPPAPATIMPAN

MEDCOM - 22593
vk..CDa.
COPLITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
0
YELLOW FIELDS MUST BE FILLED iN, IF APPLICABLE, UPON APPREHENSION
FlOffense agiriSt Ci‘iifianis) [check onel,lf -Other". then deScribe.:' •
. .
(1.P.0 3-4-0 ' , . • I IF.4.-rc,-Iori or Ficusatreaking (I.P.C. 426) : :
•.
Solir-statti4ft. of F..ort7:-4.,.%:VP:ISS1'..luhon (.1.P 3;;91 ' 1-71Extorttc,-11:2-c-trtrher.lcatir-2, Threats (I.P.C. 43.0)

I 1 . . • .. • : • ,
spe,Indexm-tt'Sexital Assaultif tr.p c. 3.93-93, 402) : (I P.'3 439) ".. •

IMareler . : . [ a: Property (I P.C. 477) • -'
F—Tiwcgiavated,AssatitIASFaCt With Intent To Kii1 (i.P.0 .41 I iCtstructing a Put-..-fic Highway:Place (I F C 437) . :
0)
:••
i,i3irrtIrtg:(1-.P.C: 412) : " Dischardir Firiarmi Explosive in Cityrrowniviiikie (I.P.C. 4'33)
I .1 ' 1 I
...
Sirrtpla Asia4.14. (I.1! 6..4 • • Riot or ii'eact-;:of Peace 495(3)) •
I :• : • .. •
Kid:naptpLng.(I.F',.C. 421) .:\ • •

I I
)71&;
.:00.11ertse:against COafitIonfo-r.Oes [check:01:1e] 1.(7.0ther...theh describe: .ie W4.'4,75/n:• i ' /1/7 _5.1-1-ric
. . . . .
Vioiaticel.ef:Ciirfey:' :: ••• .• :: :::-.. ,.. -, ---- ; ....,-::•..•: : --- .. - • . [ ... I T.rspass cri IsiltIttary Ir.stallalton cr Facrlity 3 / L./
.
Iltepi'F'ItiS:;etSsien cf Vtfeapon :-:. -' ' ' ':-: ' - '''''.:''' :-."-:-...."''.'.:,-: • :'•••' .."'•'t • . IFttotc4ezichirtgrurvaiifir.g. .?•.4iI4tir. InStittarion or Face). • ' • •','""'H:

1 .•. ---: , ---. : :• . .. . • .'.. ...: ' • : : ' . • -, -• . • . ,: ...... • ,. .
AssauklAttfc On Cctaicri Forcos" • ' -..::,...":' :- ::. , . 1:••::::•;::::.:::. - •:. ... .:-: .11 ICbstructin§,perforrndtice:Ct ft,hlit.ar'it Mission: ' • ' ' ' ..

. .. .. . .
.
f -.1 . . - , .. .... ... ..... .. ... :.: . . . . s,.. ... : :: .:.... ....:, ::::: : • '.-.
Th'eft.ci:C.diliio.r.).-..krce PrOtihi,.::ir.•'...S":'," .i."...;,i..'-:;':' .:.',.." ! ":.!:...'....:•,"..:::"'" 1.:....!g".".''''."1 '.."."-:lairkef.S.E"'!.:'''..::::,-:::-...:::.':_.S..',.:S„..;,•:.... SIS.. T............: ....,..'''.•:,' '1,''....s"....:"."....... 1:"..

.1.1rne.:of-tn.Oiden ....... ............................... Date of Report: (0/M/Y) Time of Report: hrs
.......

.
. ........ . .
ie)./ ConrieCteCI-Person: Victim:. Witness
Last Narrie'... :;Last Name: :
Eirst:Narne:-:. .1.;;;;.-F .:. Given Name.. :First Name: . Given'Narne:
Half D 01.0r: ScarsiTattoos/Deformities: Hair Color: Scars/Tattoos/Deformities:

Eye-Color: ///.1/ Weight: lb Height: Eye-Color Weight: lb Height: in
Address: Address:
Place of Birth: Place of Birth:

EthnfTribe/ Sex: Phoneg. Ethn/Tribe/ Sex: Phone#:
Sect:

Sect-DO8 D/M/Y. Mobile DOB D/tvt/Y: Mobile
F Regular Regular t
Passport Dr. license Other (specify) Passport Dr. license I Other (specify)
Document #. Document #:

',:::,•.-(lit:narriestidentrfYingjnfO'brfrecte....under".!ctddrtionpt..Hel0fUl:triformatitirry
Vehicle -.Vehicle Number: tof Vehicte(s): Owner,
Color: VIN: :- •
Model' Type:: r1Plate No.: INumber of People Vehicle.
Year: Names of People irt Vehicle'
ContrabandANeapons-in VehiCle: : . •:: •

LJProperty/Contra bend Weapon Photo Taken of Suspect ,,vith Weapon/Contraband. Yes/ No
Model ICololCaliter
S.rial No Quantity_ Make: iReceio: Frcvicied to Owner Yes/ No

Type:
'Owner.
Otner Details. 'Where Found
. Name. ef Assis.-ting Ime.rpreter: Err.ail, Phone, or Contact Info:
Sct6er's Nary. G"-ttcer's :tame
(Ft1r4): fPnr.tr

.s.' First N11 I ast,'First MI

"

MEDCOM 22594
-

DOD-036170
0 COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM 0
r\
/
Why was this person detaineq? j-i,---.7!.' .1. LI.; ,Z-t ...-'-...'...-_-7/-,,,,\_/ _;,. 1 /-/ 7-1•:!.. L.---,,L.•.:;—
_.--
7/... t . /,' ,...,_,.71._... r .... . ./ ...:-7-77,-., . -.; . ,--: .-—47' '..)'D'1: --(..-,-... I/ . --1 ;:"-,- --- ; e . c -• , ,.----,....:_-_-..,
.
/ "/— (;)
Who witnessed this person being detained or the reason for detention? Give names, contact numbers, addresses.

How was this person traveling (car, bus, on foot)?
\Nho was with this person?
What weapons was this person carrying?
`74/4:— — c •
What contraband was this person carrying?
What other weapons were seized?
What other information did you get frcm this person?
Acditional 'Helpful Information•
-
MEDCOM - 22595
1. Reportin MTF :No 2. MTF Lcl. -.--4
,c. ''•... Admiss . Coding Information
- -.-1
IZ Name (Last, First, MI) ( Ct\) '
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race 1971-01-28 32Y X
10. Length of Service ETS 11. FMP
20
. ..
'
For use of this form, see AR 40-400; the proponent agency is OTSG
4. Pay Grade 5. Sex
FGN M

9. Ethnicity Religion
9

12. Social Security Number
—_
_... _
17(9
Organization (Active Du y Only) 13. Marital Status Hour of Admission Branch / Corps:
14. Flying Status 15. Beneficiary Category
All:ARMY ACTIVE DUTY
0
17. Unit Location 18. MOS
20. Source of Admission
Direct from ER Name and Location of Medical Treatmen
21. Type of Disposstion
TRF-OTH

24. Clinic Svc -Admitting ABA -GENERAL SURGERY
27. Location of Occurrence
FOR LOCAL USE Ward:
ICU2
cility: ..., . 1/ LIA
22. MTF Transferred To
25. MTF Transferred From
28. MTF of Initial Admission
18:00
16. Zip Code of Residence:
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) 2003-11-04
26. Date this Admission (YYYYMMDD) 2003-10-31
29. Date of Initial Admission
2003-10-31

Type Patient (Inpatient / Outpatient): Inpatient Admission Diagnosis Narrative: SHRAPNEL CHEST, GSW R ARM
Procedure Narrative(s):
Cause of Injury Narrative: IED
\10 Q 'I/
Admitting Officer (Signature, as requir
Signature of Admitting Clerk
/t'l.'s A P. I . —IV
Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 22596
s•
,A-ous. A out, ann.mic
4. PAY GRADE
. SEX
10t11t12t13t14
16 17
111•1111111111111
6. DATE OF BIRTH (Y Y YYM MD DJ 7. AGE AT ADMISSION
8. RACE 9. ETHNIC RELIGION
30
BACK. GROUND
El 2° EllEllEllESIDIEIDEIZIEll
10. LENGTH OF SERVICE . ETS 12. SOCIAL SECURITY NUMBER
EllESICII FMP
IMIDEll 4° 11011113111111011211
ORGANIZATION (Active Duly On4f)
13. MARITAL STATUS • •
HOUR OF 'BRANCH / CORPS
ADMISSION
46
14. FLYING STATUS 15. BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 •50

11311113111101121110111 1311
111111111111 1.1M11111 6°
111111111MMIllall11111111111
17. UNIT LOCATION (State or is. mos
19. TRAUMA
Country Code) PREV. ADMISSION
64 65
=CI I I I
66 70t71 YEAR NO

.1
20. SOURCE OF ADMISSION AUTHORITY FOR
WARD NAMEJREL471ONSHIP OF EMERGENCY ADDRESSEE
ADMISSION • •
72

ADDRESS OF EMERGENCY ADDRESSEE (Inctude ZIP Code)
NAME AND LOCATION OF MEDICAL TREA17t4ENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSMON
MTF TRANSFERRED TO
23. DATE OF DLSPOSMON (Y YM
•• -- • - • •-• • • •-
4s---
111311113111111011311 .1EMEIMENEIEMUID)
24.
• CLINIC SVC - ADMITIVG

25.
MTF TRANSFERRED FROM

26.
DATE THIS ADMISSION (Y YMMDD)
87

90
END 111111111111111313101 swum
1 00 101 •102
27. LOCATION OF OCCURRENCE 29. MTF OF INMAL ADMISSION
(Battle Casualty Only) 29. DATE INMAL.ADMISSION • (YYMMDD) .105 106 107
CIO 110
103 1111EI MEI BEIM 121 FOR LOCAL USE
ADMITTING OFFICER (Signature, as required)
i
' SIGNATURE OF ADMITTING CLERK

DA FORIVI 2985, MAR 89
EDMON OF MAY 79'16 OBSOLETE
USAPPC V1.00
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG

-
mt
GRADE ,ADMISSION REMARKS
-liAs-
4.tSEX 5. AG . . _
. 10 PFIEVICIUS
1...1:7 se:54
l'A 5 U-04-l )L-1\)11---NI Pc
II_ FMP 12.
13. ORGANIZATION
14. WARD
.
Pc 11 N -rCJID I
15. FLYING 16.
BRANCHICORPS
J8. 1.9. • - • UIC121P 20. TYPE CASE -STATUS DSG BEN .F,L._
NI Pc Ni
1\1 as--
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22. HOURS OF 23. CLINIC SERVICE
ADMISSION
.
0 k C e_ck-cum E f\r-c--- O '3 Li o A- CbA
24. NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE
25. TYPE DISPOSITION
28. DATE OF DISPOSITI N
..)••-••0 \*4
3 1 0 I NJ OV 0 (-3
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Cod./ 27b. TELEPHONE NO. 28. DATE OF THIS
ADMITTING OFFICER ADMISSION
U-0 \-2— k-A---1\-) \ 4' r?2 OCCD' E)) Dr-,
29.
30. DATE OF INTIAL 32. ADMISSION
0MPONEN:::NSFUSZED
-
Clill11111
31.
. -ip C-1)'. I
Cluck al Continued on Flamm
33.
CAUSE OF INJUFIY

34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

.
_.,,..)0.,k-Ni D S
. 0 .-. okc2..(PNE L-
_
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d. SUPPLEMENTAL s. BED DAYS
CARE DAYS

t. TOTAL SICK DAYSCARE DAYS
0 0 0 0
a 'a.
36. Total Days All Facilites
a. ABSENT SICK OAYS OTHER BAYS c.
CONY. LVICOOP SUPPLEMENTAL BED DAYS
CARE OAYS CAFtE DAYS TOTAL SICK DAYS
0
0 '---•
SIGNATURE OF ATTENDING MEDICAL OFFICER SIGNATURE OF PAO DICA REC PDS FICER
DA FORM 3647. MAY 7g R A r%tR A ,InG(10
DOD-036174
MEDICAL RECORD , ABBREVIATED MEDICAL RECORD
PERTINENT VIStORY. CHIEF COOLAINr, AND CONDITION ON ADMISSION ( Ent( r dole or 0 .1 lit l'S %On At
7,
D". S (r r),M5CLI 1/1/61/,. L''‘12C 71r
(„1.,..ifr
1.e7A4
61,0--b-t-
Ika-1°
P7(42,4L-.
PHYSI L EXAMINATION
/ 9-'9 6--tr7Z---- /a 3 /41----/4. #Q,- n2
/7--?1"
/W-6. ( r.s
C,44,.1
v1-4--1"&.--d
74-
te"-rJ..
PROGRESS (Enter date of diarhergic and final diaonm.)
,e
t21 c'1/4-2
-1--4- es graer
01)
DATE IDENTIFICATION NO. ORGANIZATIONI
31
(For typed or written entries live N•rne laai. fir•r.
REGISTER NO. W ARO NO.
Irade: dare; hospit•I or medical !acidity)
ABBREVIATED MEDICAL RECORD
Standard Forret sae
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL
RECORDS FIRMF1 (41 CFR) 201-45.505 OCTOBER 1975 539-toe
v
MEDCOM - 22599
DOD-036175

I
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS I(
_
DATE NOTES
01/0VO/f/M- g /44 0 r VS, 3 . 0'C/0 ... r ,e54/1 (1)- bI, %
A b/c ,J A gPtv--e-,--'7 , 24 ryor
b((c
,
-

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
LAST FIRST MI (SSN or Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: IFor typed A written entries, give: Name -last, first, middle,- REGISTER NO. WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES
Medicel Record
STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00

MEDCOM - 22600
DOD-036176

0 n n
. .
NSN 7140-00-464-41711
[mood-tn.
• siwn.n.n... 1 PO
MEDICAL' RECORD - - —t• CI-141610LOGICAL RECORD OF MEOICAL CARE t4
'.----ThATE SYMPTONS, DIAGNOSIS, 'TREATMENT, TREATING ORGANIZATION (Sign each entry)
.
0 — t 1° 4_411-1, ...fil

DorAir. .4A. ' _ ' A A 'AN;
IV r 4 i ,t i
Ai. a at . .4t
.1 -al A 4,4 _t
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a., 1:2'4.Sr6/11--'. ---fr-j?7, / ' I 7 aSi3 -
6C K , A,%6( /./&( .AR altCaLt A 0:4 ,_
/ °3 qi./. , 1 vtit... Ai b wif A.A a.. • ' A Aldat-f_d ., LA .
.;
li-7 4(5 1, 62,5— L
arber Q\---, ---. N \k3 / .V. . i •.: Ac ‘kAi,i . , t ,e i
Lio., A
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a ¦ 4 4 ° ttI8 Q-A,k,i('CAr
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• --)\\,Nm a III A ...... \,t
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i
( (9)r 1--HOSPITAL. OR MEDICAL FAOUTY
STARJS DEP
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: v j
IF typeti of minors dunes, give: Name - test. last, middle; ID No REGISTER NO. WARD NO.
Of SSA!: Sea;
Dat of Birth: Rankormege.l
.

CHRONOLOGICAL RECORD OF MEDICAL CARE MEDCOM - 22601 Medical Record RTANnann cnolui gAn mei/ A..071
DOD-036177

N3N 734D-00434417S
AUTHORIZED FOR LOCAL REPRtT
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE ItSYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
'
0( 11/4r8U 63 I 3 CA94-CA--tit..,
.

6 9 3-6
. 5-2- 6 eft 6fILA.) s (70 1,-J i'l-k_ '
rti 0 4..-eiA .,.) -6 ve.61,,--p-,--rid-J-4-e_
,
eec d--Pv42-) C--7 5 c....--A-v-,-1)--rw . --/-e--0 ...---.....,..4-c----
is 1----fl-za--03-1766 (4--;(---¦*-01 (Se____O-.4-.Q70 t"9-4I e le_ -74
12.ty t-z-yz)_-„,_49 A /a(-0 a----„nra . A-I23 e.-..21'-ei
it
?t: C.
.."7 c--Go..47,.afr-fjr,t ---/.71-pt16-- 4.,,....., 4,,,....,0 / h.,...kt. et,--, el "sv,a-ye..0-7-.7,--/0 c32:3Le.„ „ 41 c4,--A% .Z..('-r 'Kiri q„.__60 e_e_,__zrefid---rm, of,'„,N.___
1-4cP
._k=,((s2 -2-
HOSPITAL OR MEDICAL FACIUTY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSNAD NO.
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
(For typed or mitten entries, give: Name - Mst, first, middle; ID No or SSN; Sex; REGISTER NO. WARtO.Date of Birth; Rank/Grede.l
/) . \ _
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 8-97)
Prescribed by GSAACMR
FIRMR 141 CFR) 201-9.202-1
MEDCOM -22602
DOD-036178

511-1.19 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-MONTH-YEAR (73M-iOte, 27 DAY DAY HOUR • --'1 • • • • • • • • • • • • • • • • • • • • • • • • • ,

.t.
TEMP. F
(•)

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p.t. .t. .t. .t.
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(0)
(ApoeauaiolauJo; •swaiettinb3ape.i2puao)
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180 104°
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160 102° " •.t•.
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150 101°
1: :: :

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. .t. .t. .t. .t. .
140 100° ,t, ,t, ,t, .
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.t. .t. .t. .t. .t. .t. .t. .t. .t. .t. . .t. .t. .t.
130
981. .. .. .. .
.. .. .. .. .. .
.. .
.. .. .. .. .. .. .. .. .. .. .. .. .t. .. .. 120 98° "
" •• " •• " •• " • • " • • ••
.t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t.
.t. .t. .t. .t. .t. .t• • . .t. .t. .t. .t. .t. .t.
110 97°
.t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. .t. •-•• •• •• •• •• •• •• •• •• • • •• •• • • •• • " •
•• •• •-•• • • • •• •• •• •• •• .• • ••
100 96°

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.t. .t. .t. .t. .t. .t. . .t. .t
.t
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90 95° .t. .t.
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40
.t. .t. .t. .t. .t. .t. .t. .t. .t. .t.
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RESPI TION RECORD
pampaastiet4m Am) elep'epeespmettl I
BLOOD PRESSURE COZgi
?0
,
HEIGHT: I WEIGHT -11. /60
PATIENT'S IDENTIFICATION (For typed or written entries give' Name--last, frst, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
MEDCOM - 22603 VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR. F1RMR (41 CF-13) 201-9.202-1
DOD-036179

WIC 14.5 N x10'3/ii KM 5.24 x10'6/1iL Hgb 14,7 g/dL Hit 46.3 % fa 88.4 fL rf1.4 '28.1 p9 rat 31.8 L g/dL
Plt 438, x10'3/aL 150. 450. -LYZ 13.4 *L. Z
20.5 51.1
LYN 2.0 * x10'3AL 1,2 3.4
Segs Bands . Mono
Lymph Baso
Atyp Imm
RBC I¦Aorph

Spun Fiematocrit
Sed Rate
Other aagulatioit.Stti
TEST RESULT REF. RANGE
9.8-13.6 5c•cs
21-34 s=
r) dizle: 1
FO? 10 ug'tid P,E MARKS:
R_E PORTED B Y:
r
LABORATORY RESULT FORM
TIME ("D
F. .RANGI::.
31-19-03
19:07
Patient
Limits

4.5 10,5
4.00 6.00
11.0 18.0
35.0 60.0
00.0 • 99,9
27.0 .:31.0
53.0 37.0
F_ESULT.1 REF.
t _e_csIpx ! •
• 1 N/ARA1-110POIN 1 WAG ANALII.ER V4.!)-1
7_4
SERIAL g00548b 10/31/0j 19:10
`‘
Patient ID:11111

Test Name :PT

Test Resolt:= 14.2 sec.
i Ratio = 1.2

Calculated INR = 1.28

Sample Type:citrated wh.

blood

Test Date :10/31/03

TEST
Ct01?
Test Time :19:08K

-

Card Lot
:080201
Operat Or um
(
RA,IDPOINT COAG ANALYZER V4.5
RIAL #005485 10/31/03

16
Patient ID: NMI
Test Name :APTT
Test Result:. 24.7 sec.
***RESULT OUT OF RANGE***
Sample Type:citrated wh.

blood

Test Date :10/31/03,

t Time :19:14
CarK

tK

:030201

ccApperator
cou4t

I
(Sub¦ ect to Ctic P:ivacc;: Act of 1974) • • SSN __,•
SSN:66,3
•••....•
1-R 'ESC/LI 1 REF. R.. MG.E
I Neg:aive
I Negative ii=pabiciagy .
•.
• . • .
Negative Negative
rOPic
tood Bar* •
,,r-uo'i. DI/is:Yin SF 518 WITFI
I
EVERY UNIT REQUESTED Dircc/igen Ncg.-th v c
ABotpii
• _ . .
_Blood:Nit* Unit Crossmitch. . ("NiUST SUBNITT SF5I8.WITEE EVERY uN. Tr or BL-0()D
(TESTED
avrr
TYPE
CROSS.1:1.42-Cif
'DATE: ,
LAB ED NO.:.
MEDCOM - 22604
Ward/Sc.:60o:
LAST, F

TEST R_ES ULT
Na
pH
PCO2
PO2
TCO2
HCO3
SO2
BEeof
AnG-ap
Ca
BUN
GLU
Creat
Hct
Hgb
TEST
Trcpcnir 4
Drug of Abuse
RE ,,LA_RKS:
REPORTED EI Y:
1 RE _ I
‘4
(ii..---c-A
REF. RANGE
138-146 talmo.111_.
98-109 mrool/L
7.31-7.45
35-45 mmHg (Lci
41-51 ramHz (veal
SO-105 mmHg (art)
NIA. (veul
23-27 mmal/L (art)
24-29 auncl/L (van
22-26 mmoVL (in)
23-28 mruot/L (van
95-98%
(-2) - (+3)
rtimon
10-20 mmoliL

1.12-1.32 Imola
8-26 rag/d1
70-105 medl
0.7-1.5 roedl
38-51% PCV
N.6( a,
-' s.' - . - ,
. I CHEMISTRY RESULT FORM
I (Subject to thc Privacy Act of 1974)
. I PATE I TIME 1310.0.0'3 1 \ IA 0- NV 6i -4-i -
:::(1).4:11oME6746.4-kj:1.- 9._
TEST RES Ur. T .RE.F. .T.E ST . ..RES T... 4T I F:.
RANGE

PICCOLO K

PICCOLO K 19:08

31/10/03K
31/10/03KREFERENCEK

19:06 MALE
REFERENCE RANGE:KATIENT #:

MAL
PATIENT #:KLIVER PANELT771

6(u)-(1 BASIC METAPil DISC LOT #: 3153AA7 DISC LOT #: 3 DR #: 000 OPER #:KDR #: 000 SERIAL #: 0000100684 SERIAL Pi,' 0000100494
6

7 ALB 3.9 3.3-5.5 G/DL
K

GLU 238* 73-118 MG/DL ALP 106* 26-84 U/L

K

BUN 9 7-22 MG/DL ALT 27 10-47 U/L

K

CA++ 9.2 8.0-10.3 MG/DL AMY 46 14-97 U/L

K

CRE 1.0 , 0.6-1.2 MG/DL AST 28 11-38 U/L
NA+ 138 128-145 MMOVL TBIL 0.8K

0.2-1.6 MG/DL

K

K+ 4;8* 3.3-4.7 MMOVL GGT 24 5-65 U/L

K

CL-98-108 MMOVLKTP 8.7* 6.4-8.1 G/DL
7
tCO2 27 18-33K

VMOVL
INST QC: OKK

CHEM QC: OK
INST QC: OKKHEM 1+, LIP 0 , ICT 0

CHEM QC: OK
HEM 0 , LIP 0 ) ICT 0

— //OS-

18 -33 m.rnolfl
DATE: LAB ID NO.:
MEDCOM - 22605

I 1 1 ¦zi 4i SI I I. • 11 i 1
110 11 112 4-." :6 ia
0 11J 11f....
*U.S.' GPO: 1992-31.0-dU9/o6,1.75 '... --.
. --...:-.
_
0-01-185-7284
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Iladiology/Nuclelr Medicine/Ultrasound/Computed Tomography Examinations)
INATION(S) REQUESTED
AGE SEX SSN (Sponsor)
WARD/CL:NiC REGISTE_P,

PILGNANT
ri YES L_
TELE .F.-.Ri01\FE/P'A
9e_Avts
LiAi"E kE-diDE:51
)\J
c
-IC REASON(S) FOR REQUEST (Complaints and findings)
'N\
Q_JzgAi
OF EXAMINATION (Month, day, year)
DATE OF REPORT (Month, day, year)
DATE F TRANSCRIPTION (Month
LOGIC REPORT
cZkyk)al
) (9.
A/ki/J
11111/1
IT'S IDENTIFICATION (For typed or written entries gtca:
last, first, middle, Medical Facility) ILOCATION OF MEDICAL RECORDS
*11111111-ki,
MEDCOM - 22606
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

'THE DOCTOR SHALL RECOFID 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 OATE OF ORDERtTIME OF ORDER LIST TIME ORDER NOTE 0 AND
SIGN
S $ oc.7"e)-3.HOURS .
-Ill
3 i--.24 c,,,s-0,--...Q:c
II-4 P
1 e_fit_124 90“-- --' J---/-.46-- •
APA.,
114 V.-1-----6'--- — ----R;74-,..-A----d-,..jkl4-..

Ol,'Fi'''
‘--es_._ Ark_ /2/9-
Or* '9(
NURSING UNIT ROOM O. BED NO.tAl
ik....4
0-1)_.CA.) ra-4+fCd 47
PATIENT IDENTIFICATION DATE OF ORDEFItTIME OF
OFIDER
HOURS
fp A.A...4.,_,,-____„, __ -1,/,‘,.__7/dele v e ) /-?---e, .,,-,.
_Fir--,
.
,,,--yry f_i__.), 2_13t6tC (5--r
tee..?.Z----5— cs-tc ( ets
NURSING UNIT ROO • NO.
, S V,, uf
. rly cdo.-1,. Al
PATIENT IDENTIF ICAt DATE OF ORDE RtTIME OF ORDER
0
-V\(2--/0 etA... . . L,S--13f
ee
\,\ -4') il( j/keb-- lev-trui-- - 1-- 0--eF-/-K-C AIP"./'"
C\
NURSING UNIT ROOM NO. BED NO.
pvs_e_._,- -7- si....t„, .-v19,6 , -x ? 4-st-9
PATIENT IDENTIFICATION DATE OF ORDERtTIME OF ORDER
I ,,..
, ,
.1%
(A.frac? KO . HOURS
..-tow-NN---6btS. /IL
...ee
NURSING UNIT NO. BED
ROOM NO. l
( (t )t(.1
0/40t
00VO 10 (2 /17'7 VNI
REPLACES EDIT!
DA ,FA°p7479 4256
MEDCOM - 22607
DOD-036183

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 ORDERt TIME OF ORDER LIST TIME ORDER NOTED AND
(c.„Ny-4 g(xd Q .33t8 ?)_32,tHOURS -SIGN
-
.
T. 9(c_. _i_--v .A-fc
1
.......

....-
I.-MIK 't
,t'
..... ...a „ii
NURSING ir 0tO.
II
1, .
4, °
0t
)-,(A') rtPATIENT IDENTIFtT1ON DATE OF ORDERtTtME OF ORDER
t HOURS

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDERtTIME OF ORDER
HOUFIS
44‘,
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDERtTIME OF ORDER
t HOURS
NURSING UNIT ROOM NO.
BED NO.
FORM
REPLACES EDITION oF 1 JUL 77, WHICH MAY BE USED.
4256
, APR 79
MEDCOM - 22608
DOD-036184

THE 71' PEUTIC DOCUMENTATION C RE PLAN (NON -MEDICATION)
CLINICAL RECORD For use of this form, s e AR 40-407;
Ma Yr. 2003
the proponent agency Is the Office o The Surgeon General.
VERIFY BY IMTIALING ' , ,Z1-i' raTeMataMMin, INITL4 PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION,
DATE NURSE FREQUENCY, TIME

Id
g iiiyyt TaLs:A,6-Ltw) b_ 4 .
_
\
..,g
-----7--
W---4(4-' W-plobDco-e_ (-r

-7-1111roo-h-. co fro
it-tb -6-r,
--r. f 6-0,4
15P ,11 /5.0 4-qt15e) /
1-1-re--120 z-gb
r___g-26 Pi-LID /

10J---% A.J2gAt
ALLERGIES: ED yEs N PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
_
=YES IIIII NO
Pe_roi5
PAGE NO-
PATIENT IDENTIFICATION: ,

ACTION 'TIMES. USE PENCIL. CIRCLE ACTION TIMES
IIIII61t
Dt8t9t10t11t12t13 14t15
Et16 17 18 19 20 21 22 23
)0 (62') -(A\
Nt24 01 02 03 04 05 06 07
- ----- ---- _ _ ___ MEDCOM 22609 .___
--.- • - •-. . • ••••••• • •
USAPA V1.00
DOD-036185

, Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) Mo.-Yr .2003•
order Date 3) (5-1 73( Clerk SINGLE ACTIONS n­-tI CU) 1 tato i_e_.i Wa4 ii-od frunukcid -i b_eAra 6{-101-oct 3ic__---\-c=) epN,J. c:_,.._Th,y\9 Date to be Done 'Time to be Done Time Done _ Initials
b ( 6) - -z__
,

_.
Orded Explr Date Clerk/ Nurse ..A t . PRN ACTION, FREQUENCY . INITIAL PROPER COLUMN FOLLOWING T1ME/DATE COMPLETED COMPLETION
. .t.._ .

USAPA V1.00
MEDCOM - 22610
((s.
THERAPEUTIC DOCUMENTtION CARE PLAN (MEDICATIONS)
CL IN ICAL RECORD For use of this fotsee AR 40-407; Mo. Yr.the proponent agency Is thetice of The Surgeon General.
VERIFY BY INITIALING ,.INI.L PROPER COLUMN FOLLOWING EACH ADMINISTRATION
/
HR DATE DISPENSEDORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
o .
3
3/ Ill" NP-(-)97-Loci-w .
a, _
., ::-.
....,
III 0-nce_P411-ky, /.090. ete, • .‘
q g ° )c 3 d,zs-Jed /4

_._
/7
-
,
.

ALLERGIESm ED y Es 0 No /A)0M-' PATIENT IDENTIFICATIONt PRIMARY DIAGNOSIS% 341106iNbA/751/UkdA ADDITIONAL. PAGES IN USEt ID YES E3 NO PAGE NO DISPENSING TIMES
(Ijt-Cift USE P ENCIL. CI RCL E MED TIMES Dt7t8t9t10t11t12t13t14
Et15t16t17t18t19t20t21t22
D Ai FFc'EZ119 4678 Nt23t24t01t02t03t04t05t06 EDITION OF 1 DEC 77 WILL BE USED UNTIL ExHAusTED. MEDCOM - 22611
DOD-036187

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
PO
Initialing (MEDICATIONS) Mo.. r...-..--..)
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
93 (-6(
NAME"
'VC ) \I -7NA3')( kalV
,
i \
1'. (0- ) "2--

c_.
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRA770N
Clerk/
Expir
MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
Date
1 -7 /20 6f2,1__—. Di
Pe-vroCe f
Xt - _
le °per) tr
4
.
.
.
_......

U.S. GPO:1998-454-110/95216
MEDCOM - 22612
e-e)
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
0

YELLOW FIELDS I¦AUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION . . .
-.
17.71Offense against CiVilfaniSyjcheck th6ri "---
Or Housiebria.14ng

I I
[771Soli4.16X: cif Foi:r.a1;?-40.;..ii1Ori:(1'.P.C.
I i
. . .
I --' .
.
crtzerop6rry'0-..p.c.... 477)
Mul:416.r. 4r7r5}-.
I 1 AssaultrAssaUt To g R..Fic NigFrAray/place :(1..F.soc • :

: .. .
Maiming . ... . . ...... ?plos!ve.:in city.00wn/viiia.20
Sirr4:4e Asoztu't (IP.C::415) . :::: : -gict Or Breac4:Of POaCe (I . ...

I 1 : : • .
kcidnappi-rg (I.P.C. 421) : ,
I um*7 -
.. . ..
.
_Effftense..agaln.-st.Oa11.ticini Fcrces..(cife-ck:'.46e):::(t.:70:ther!.!,:then. d'scilbe• s /47-4.,?.eixAgi
yTh;.fga.6::. . . . . .............. . .. Trespass-lorti.MilitorY Iristallartion::.or..Facrtit;/: . . .

JA
F'bssiO:rvof . I Photogra',Ohii-sgisurveilffrig tiviiI6r)(InstltbOrt or FOcii?..y.
•: .
Assatit'Afi.Oricoaiort FoIO:o&: ...... . .
f I . ..... •:.•-• : .• •••..: .... .

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

Date of Report: (D/M/Y) Time of Report: hrs .......................... ............
::Keyconriected.Person: Victirri:-.

LaStsNaMe:
.• ":Firtf;Na;rtie: pi.en . : . Naire :Pivep:Namp:
Hair Coly2/A--ttoos/Deformities: Hair Color: Scars/Tattoos/Deformities:

/ .
Eye-Color: k/L/ Weight: lb Height: in Eye-Color: Weight: lb Height:
in
Addreis: Address:
.

Place of Birth: Place of Birth:
Sex: Phone#:
Ethn/Tribe/ EthnfTribe/ Sex: Phone4:
Sect Sect:
DOB D/M/Y: Mobile DOB D/M/Y: Mobile
Regular Regular
I I I 1
Passport Dr. license Other (specify) Passport s. Dr. license I Other (specify)
I I
Document #-• Document tt• ,•,:-JotaNtitnber..of.:PersO nSA:rtv.Olved;'.::.::,:::::-::.(.1iSt:: parneSlidentifying:lhfcr. :on.:reyer.:se::uticler.'Add rtiort at.flgltal01;•,trifOrtria tiatill Info'rriiatiOn. .... ... ..... ..........
I '.1

ablar; • :: •
-•" No .: .:: NUMber.of Peopte: VehiCle:
. Narries•Of People irtVehicie:, s.. • . . : ".
CoritrabanCivIleapons:irr:Ve'aiOle:: . . • .

Property/Contraband Weapon Photo Taken of Suspect with Weapon/Ccntraband Yes/ No
Type: Model: Color/Caliber:
Serial No : Quantity: Make: Receipt Provided to Owner Yes/ No
Other Details IWnere Found Owner:

Name of Assisting Interp,-eter: • Email Phone or Contact Info.
Datair-jng Sok:: Ges t:arna.
(Pert,:
_as( First MI. :
SionatT..ire-
Ematl:
Ortrt PI-Da te.

•1, •••••
Unit PhOne:' Date.:
MEDCOM - 22613
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
Why was this p rson detained? / i/t/ 4 ,z-/g. -7...43'S k5 /1/ 7,t, 7/1/71-'
/c.; fi/v Who A,vitnessed this person being detained or the reason for detention? Give names, contact numbers, addresses.
How was this person traveling (car, bus, on foot)?
Who was with this person?
What weapons was this person carrying?
:3712 144371,r7 (44A/
What contraband was this person carrying?
What other weapons ,.vere seized?
What other information did you get from this person?
Additignal Helpful Informa'.
)$771,1)1 /9 _Z--/-Y12/4 3.65.zz
//Oh,/ ( z.:;yt,'7.746
1—/ 7/ 2.-
MEDCOM - 22614
. .t.
.tPA a r LOCATION
.tREPORTING MTF . ADMISSION mAID CODING INFORMATION
....,
8 (State or
1 2 3 5t6 7t
Country For use of this form, see AR 40-400; the proponent agency is OTSG .
Code.)

A r IMMO -a_
.tREGISTER NUMBERt NAME (Last, First, Middle Initial) 4.tPAY GRADE 5.tSD(
16 17 ' 18

9t10t11t12t13t14
.
.t. • E OF BIRTH (YYYYMMDD) . AGE AT ADMISSION RACE 9.tETHNIC,. RELIGIONt_

.t
19 M 21 22 23 24 25 26 27-Ell 29 -30 ' 31 BAcK­
0\ GROUND (....,L....k..3y.......

LIMM, 0
' NUMBER
12.tOCIAL SECURITYt
10. LENGTH OF SERVICE ETS 11.tRAP 32 33 35 36 37 38 .t,39t;40 41 42 43 44
11,1,,K-ct (1)
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS - • -
._:." fs::,.1 Ley.
ADMISSION 46
CD11-1 0 tl Px-'
°-----N--
14.tFLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
50 51 52 53 54 55 56 57 58 59 '60 61
47 48 49
N.1 . IL, —1
PREV. ADMISSION
17.tUNIT LOCATION (State or 18.tMOS 19. TRAUMA
Country Code)
YEAR
62 63 64 65 66t67 8 6 70 71
NO_

IIIM
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

20. SOURCE OF ADMISSION/ AUTHORIrf FOR 1NARD
ADMISSION U--0\- .
72 ‘.,t. , 1

ADDRESS OF EMERGENCY ADDRESSEE (Include DP Code)
----EIC -D
I i f ,
I k.;_\-.)'e'-.,
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
NAMt:
.)¦--1 \ t.
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (Y YMMDD)
73 74 75 ' 76 77 78 79 80 81 132 83 :84 85 86
\ .. ..: r) C: 37 t 1 (.D 1
24.tLINIC VC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (yYMMDDk.
I 161 1:.
87 88 .89 90 91 92 93 94 95 96 97 98 99 102
.
-A_ cb A-'Pc
o lb k

0

1

27.tOCATION OF OCCURRENCE 28. MTF OF INITIALADMLSSION 29.tDATE INITIAL ADMISSION (YYMMOD)--
— (Battle Casualty Only)
103 104 105 106 109 110 111 112 114
107 108 113 115 116
0 rb I D 1
FOR LOCAL USE
G __\ p‘e-EL L3L-)L-00 S
---r_
87q,,
roc., : Ws- ' c
-?I'? (o,-C)
KLItoil
......_, -cr., 11
.2.1-yv.., \ ry.f.A.,rN\ : Et . CO
....) - 88: D 1
1 87 6 j
LI /13
--4,93
ADMITTING OFFICER (Signature, a SIGNATURE OF ADPAITTING CLERK
rt enrssA nrioc PIA A v./ on
MEDCOM - 22615

Doc_nid: 
3958
Doc_type_num: 
77