Medical Report: 55-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Multiple Gunsoht Wounds

mr . REPORTING MTF .: LOCATION
ADMISSION .-...0 CODING INFORMATION
1 2 3 1/11111111111 -. i (51We or
b03)-1 Country
For use 01 this lurm• see AR 40-400; proponent agency is OTSG
I
EM)-4
3. REGISTER NUMBER NAME (Last First. Middle Initial) 4. PAY GRADE 5. SEX
10 12_
14_

9_tl 13_15 16 17
7 . AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 CliffilEgi 10. LENGTH OF SERVICE 23 24 ETS 25 26 27 28 29 0 11111MILI 11. FMP 30 = 31 BACK-GROUND 12. SOCIAL SECURITY NUMBER
32 33 34 35 36 376I6386I 39 140 141 I 421 43 44 145

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCH / CORPS ADMISSION 46
Z( 016
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION
Country Code)
1 I
1 I L6I_6I
62-63-64 69 70 71 YEAR
. NO
I —71 A-)
20. SOURCE OF ADMISSION1AUTHORFTY FOR I WARD NAME RELATIONSHIP t F EMERGENCY ADDRESSEE ADMISSION
I71 1
--. I ADDRESS OF EMERGENCY ADDRESSEE tincliftle ZIP Code)
A 4a
_ I 'e-u -5 I by3)-1 ^ I TELEPHONENUMBER OF EMERGENCY ADDRESSEE
-- ._ 23.-DATE OF DISPOSITION (YYMMDD)
73 74 75 76 77 78 79 80 81 82 83 84 85 86
6 o •,s"-•
24. CLINIC SVC • ADMITTING 25. MTF TRANSFERRED FROM 26. DA , 1019/TY1A-M-DPL
87 88 89 90 91 92 93 94 95 96 98 99 100 101 102 1/11111 A 111 Min 0 S--0L'
iir
27. LOCATION OF OCCURRENCE 28. WIT OF INITIAL ADMI • 29. DATE INITIAL ADMISSION (YYMMDD) (Battle Casualty Only)
103 104 105 106 107 es 109 110 111 112 113 114 115 116
FOR LOCAL USE
P

S P, V ,r3 43
?07--\IGLAur"_._
114\
.... mu.- -¦-.
CI
.
OC(.0
41
•¦=11 .
/ a1 • AD,. 1..-
(S 11 7e10 0
V Wt.° ,mishiai
,b)(8)-2
b)(8)-2
red)

DA FORM 2985, MAR 89 L Di I IL11.1 LA MAY )4 01,16101.1 I E
MEDCOM - 4926
DOD 12138

-
INF.., IENT TREATMENT RECORD COVER SHEE
For use of this form. see AR 40-400; the proponent agency Is OTSG
REGISTER NUMtER
2.. NAMF a
(b)(6)-4
b)(6)-4 3.6
GRADE
ADMISSION REMARKS
SEX 15.6
AGE6RACE
Lem., I H OF SVC
ETS
101L PREVIOUS ADMISSION --117 S. N6 1(b)(6)-4 3.
ORGANIZATION
14. WARD ---
TK---Eii,76p6.
-RATING,6C6
176DEPT./ 18. e1) )
STATUS6 DSG6 BRANCH/CORPS 19.
BEN UIC/Z1P
TYPE CASE
21.
SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22.
HOURS OF 23.6
CLINIC SERVICE
ADMISSION
46
NAMEiRELATIONSHIP OF EMERGENCY ADDRESSEE
25.6
TYPE DISPOSITION
266
DATE OF DISPOSITION
"RVAk-t-'
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
279. TELEPHONE NO.
28. DATE OF6
S
ADMITTING OFFICER
ADMISSION
29.6
NAME AND I nrA Tinto nr
(b)(3)-1
30.6
DATE OF INTIAL ADMISSION
.32. UNITS OF WHOLE BLOOD. COMPONENT TRANSFUSED
33.6Ei Check II ConlelLied 011 FiCr.1"3,
CAUSE OF INJURY
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
cpcn e t-kp?6sini
MtinAt, Ws-2T
42.c1-671,
35.
Total Days This Facility
ABSENT SICK DAYS6
b.?
OTHER DAYS c.6
CONY. LV/COOP CARE DAYS BED DAYS6
SUPPLEMENTAL6e .
CARE DAYS6 T6O

TTAL SICK DAYS
36. Total Days All Facilites
ABSENT SICK D4\7g---b,6
OTHER DAYS CONY. LV/COOP CARE DAYS BED DAYS Ti•6
SUPPLEMENTAL
CARE DAYS I6• TOI Ai SICK-IiiLi'S
__—6
SIGN AT UR (b)(6)-2

b)(6)-2
SIGh(
b)(6)-2
11,, MG DA FORM.:364Y-PMAY:79L.
(b)(6) -2
EDITION OF 1 AUG 7
u6APPC v1 lo
MEDCOM - 4927
DOD 12139

IENT TREATMENT RECORD COVER SHEEI.
For use of this form, see AR 40-400; the proponent agency is OTSG
RELIi... 1 cP. NUMP
b)(6)-4 (b)(6)-4

AGE RACE
L L,ION
LENGTH OF SVC 9.
E'S
t..
13
ORGANIZATION SANG
l
(b)(6)-4
RAT1NG, I
17
3 7 ix 71..6 is6
BRANCH/CORPS
USG I BEN UIC/ZIP
I
-
SOURCE OF ADN1 ISSION:AUTHORITY FOR ADMISSION
1
122. HOURS OF ADMISSION
'131f—
/11eC/
N 4 ME ¦

RELATiONSHIP OF EMERGER1-67-435FTESSEE
A .
ADnesss OF EMERGENCY ADDRESSEE
linClude iiP Code}
276. TELEPHONE NO,
I
iro kc A n,
(b)(3)-1
• ../1111.1.311,, I
yr ua 1 A
DTAC767
CISTLOPERATIONS NO SPECIAL PROCEDURES
opc,n (2- ticp Pk) &gw Le
wAittAa M
E-1

35. Total Days This Facility
-;ifisTNTga o A ys b. Oi. HER DAYS CONV. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS
36. Total Days All Facilites
ABSENT SICKDAc'S IT. OTHER DAYS C. CON¦TLV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS
T WGNA ifac?n b)(6)-2
DA FO FIN]. 36444 %NA)! :718 EDITION OF 1 AU MEDCOM - 4928

3.
GRADE ADA41:3F,IC1N LTMFY
TO
PREVIOUS
• ADMISSION
1.1 WARD
20.
TYPE CA.E
LT:1¦13 I f f.3‘7. CLINleiERVICE
I _
26.
DATE OF DISPOSITIO-174-
IS— TIN(
ADMISSION
30. DATE OF INTIAL-----
ADM/SSION 37. UNITS OF WHOLI 111.0:m , COMPONENI Cu..;
- • • • • _
I Check if
PAT
rorA;6¦ J!..e:• •
BED DAYS
DOD 12140

MEDICAL RECORD I— PROGRESS NO if
DATE
PRE OPERATIVE EVALUATION
General Diagnosis:6 ,, L)60 V4-2.-Proc. Planned:-Anesth:
_
Anesthesiologist:-Surgeon:
Anesth. Risk Classification:-1 —
Vital Signs:-J -/2—
Physical Exam Highlights:
Procedure & risks discussed with patient: -YES-(NO)-( )."...it..4-4 / 1;
Prognosi .6
( RA.9,..)2—:
) ,7?
)s
Po)
--zN40"2e .oq,
Signature
POST OPERATIVE NOTE
Pre-Operative Dx: 61‘)6c vx.6
(9c a.l:.-.4-_ '°,_k i Post-Operative Dx: S -.
Ste-re ffr 6d AA-t_____-i\j/l_­
F7C
Anesthesia:6Ci cm_ Procedure: ..., 77-
Surgeon:6p Jo 7(21' 7111 4 .V.-.1
Findings:
I ' i'lLeit'J6C)0 J,•-(.of.(‘A ‘ t,) , ,1.n4, LY .44:S./Li 4 /.4
-? c.2
fitz_141­.

4.

5.

6.
EBL: ivi ( f-,/.I/O:6 Tissue sent to lab:
Prognosis:6f9 ri tt--
t7......4 ( 4-4-L-.
Plan: (b)(6)-2
P
i•-•-•\,
i
N ra PA-c --75-Sign
(Continue on rev PATIENT'S IDENTIFICATION(Fortyped or written entries give: Name-las/ first. middle: I WARD NO. grade; rank; rate; hospital or medical. facility)
• TES
Lt
b)(6)-4 (REV. 5-.99) FR)I01 -1 1.203 (3)(10)
MEDCOM - 4929

DOD 12141

.... ,,U.,.4.1, r,.• LUUA L nt FTIOULIC HON
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
itect pZer 2 22..-,
d 4 ,.7b0 --,-czz ,-7-.-..„-A-6S&L-1 .--,-.--,..4 ,_ 1:„4:4a..4?Z-7 eil---e.
-e-'c.--44j-r'-V eil-L° ' '..°4 -43 /1-A--_¦-z--e--_,0 g --0--, .-v-'vs--1-c7--s. -2 -(66 ---1-, !
vet-
,---tJ.--'--er-tv c›-Z-Z:t..-:,
) 0 4'7adet ,•-1,-3,,,,,2,, /2;4".-4=1*.
(e..-so KA r l. i_,.-..r.t. .¦L,5›::41
•lr-ZZ.A, -:-¦ d.42-4-9-g ,,_..-
--•'€-YLX ,••¦••s'"'"1-) 6e CSir e'Ajaa‘: ((5.-^ ?C' 6— t 's s e:g.,¦ 4+ -4--,.
) ,42.7 et1.....m.--,2Z-%.¦•-• ,4..re-^L-t/4. 1 --¦-4% ,00 c.)
,,,g-a-zp_A­C"--4-t-r-Le%.,.?5tC.-e-A-tr2-v,?-..----z.?1 )..&22-v-4-1
--a-------.----:St?_--e-e-4-.,_?GJ?aZ--?
41 cScr?i?.
6 J e-i-, -.,--..e-S --e-..--,s-e
1..tj et
(b)(6)-2
RELATIONSHIP-TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER LAST-FIRST ISSN or Otherl
DEPART ./SERVICE HOSPITALORMEDICALFACILI1 RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (for typed or written entries, give: Name lest, first, middle;
REGISTER NO.­WARD NO..
ID No or SSN• Sex: Date of Birth: Rank/Grade/
PROGRESS NOTES Medical Record
STANDARD FORM 509 (ear SSP)
Prescribed by GSMCMR FPMR (41 CFR) 101-11 2CL.1(bX10)

(b)(6)-4
MEDCOM - 4930
DOD 12142

DATE
NOTES
Ci-i_.:( .243 (i-W 9e..-' 3
/G:„.c--
O l'.2-4 ,i ,,,,,--.--1 c....-,--,4_,:_,t.- , .e.,..-c-P,, /6-6,-A I kl. ., i--) o --r 6 et ,r6e,-(..0 -c----?„_._I ,,,,,g, _.6 . ,_ -, ,-......276vs J — ,
,e,„
b)(8) 2
XCZ 1
e/AV't C''44-'j 10 10.;:e /Z'6,L ).3 - ' -46‹.74."1- W.,i5V+ 5)6--) ,,,,,-,6V l- l'¦•- a ie.? /-t-X.0--, ..s4.__Ix., ,-)T
0,,s .,-.EX -,,pe--c.,,s--zc ____ „.,(_„6--(...t,
?,e,y.,, 4 C-.......a-.....¦:4 1.,,..¦et--

b)(6)-2
2 od:.%- pae03 _____./ 7 i-...0 i
("7/ 6--r'..-C-777.3.--,, ,...- ,..-g-e c„,..--,.--. ,Z--,-.5e---./,.-..

-.1 -......., ' 1 C 9. 11.0 '.,-.--- Q.-lg....,

•. .
, ,,,---7,-.2.-t. 10,-,.47---
92---",47,75----ir
e....„.e.?.„.,....__:e
b)(8).2
sir, ,'T
.PI LEX 0 Printed on Recycled Paper
STANDARD FORM 509 (REV. 5-99) BACK
MEDCOM - 4931
DOD 12143

PROGRESS NOTES
DATE
b)(6)-2
-4:IL AID ii, ' A4...—.A. (3-`4--1:4--6 .107../... UN
,'I'N ..1)
, / 1
Ingga-awielril • - , :AI •
ing.._• , 1 ( ) . , / r ) _La •.taL, ,. 0 6-1/L. • 41, ,9IA/ /D3 /
) b1 .r0r0-X__, P2A1A-e­-
Pri-k_d ii-y., x.,0-, 12-1167-4 U
CLOCt.44-1-
01,15,_c_a &L____?(4 ,8,-­-1664.?,,t,,g,_,,t_Lo
1.._ . 1110/ ¦b. L/ AILL¦ i ' / l1 . - tA-4914-^(S2 ca , 1_,(474.,-(9 4-l'il) c -- i /) , ia i:z, C?I' ,/)•‘..2 .,,Q, ' 0 pc.)5e—LA-'-‘.. 6'e-t/4_
p z-z-0-6)/„. ei, pz-i-(24-C
/ t- 0/L di'. azt_P /Z )0?z.,4A9_601
"---?Ace114?id/2cA/t-f-liAAZ) ,;AfdA,
27k P/A. g:
.)(6)-2 V4i0 .
: )(6)-2 —411 tiSng_
(b)(6)-4 91-248120616 STANDARD FORM 508 BACK (R•v. 11-77)

MEDCOM - 4932
DOD 12144

MEDICAL RECORD PROGRESS NOTES
DATE
or ii -

q 46-3.
/
,,,,.
,r_s_._.'2:46'.. 4eL(2,4-.06)-r-dio•
ll ?t, evx..a?Li _.?-).11
_ . , .„1"......?-....,.......0._ Lve., 4..k.k.s. u..VA-4;. ,
'-‘A'4 b)(6)-2
0A-C a Sit4,‹
ILI w O 0?
J?h(pi-3c hs) 6 +1441, o4t.4-- gkc Reot,L,r, tft,\Js 6 01132 -it6 1 itz,+-.-...5.1)(9._ 7. LA)+: ,Pil'"..1()W azo?: gooff-eAs Pr 0/f&ec-fA eL, 1 (
ft(Pt. /1-1-J vveeis ' 30 -3S kc,,11S(414d ,-,i0Z).--9,-(-(SOk-K-4./gt
fib+e(vt .i/V-1-.4 c i's— 1 kidet.,i -- j 05— 1,6,i
Fl

butA14e-Cfp ,42;44. I . S v14--s i--Em Tr_10 .)0c47..deetA. et44. 5/
',c(. y ilk aCt, 1 — e. Cl-e*- Eiti--e i
wvaiii;tel A Cir sliw- 146r 14,11., ) 1-1Z:, ' 3))(6)-2 rii)---2,66,e).i 4 P i, 4
MPII, RD
bqa,
• , (Continue on reverse side) . ITS MEM
PATIENTS IDENTIFICATION (For *pod or written entries ere. Alaroe--kror. fine, middle; REGISTER NO. ARD NO. rode: rook; row /aggro/ or medical facility)
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77) Prescribed by GSA/ICMP. FIRMA 141 CFR) 201-45.505 509-111
MEDCOM - 4933
DOD 12145

IVIECCAl_ RECORD PROGRESS NOTES
DATE
Li itY7
a-ct o
•
at)
kb)(6)-2
/142(6c 1144
(Continue on reverse side)
PATIENTS IDENTIFICATION (For typed w entree envier ere: Name—lrue grade; rank rare: hospital w medical facility) middle; REGISTER NO.­ WARD NO.
0u A I' fi 03 PROMFSS NOTFSI
STANDARD FORM S09 (Rev. 11 -77)
Prescribed I GSA/ICMR,
FIRMR (el IR) 2f­SI
S09-111

MEDCOM - 4934
DOD 12146

PROGRESS NOTES

DATE
0 9 LAA-s-
7
b)(6)-2
fi u.s.G.P.O.: 1586 - 491- 248 / 20616 STANDARDFORM 509 BACK (Rev. 11-77)
M EDCOM - 4935
DOD 12147
PROGRESS NOTES
DATE
1/ ill o Dr- i.-4--, c. t3 . C
TZA, le .--)e DCA cA e ,„,2_,A cl:t q.:), -t¦,V,
li-N:
rxi,4A6c_Lulk-
?L_, •, (VrovA Lu 4-
V, _e,r, • (9--v. 2....
—t- i fkmek --›) 6, CVAe55 • C,,,
li-12-14-U -• , °
ck A t A 1.24_,... , ? 61:1,)t-e iD______L 5)(__;,. orrOti--- cu.
C 1-19 (b)(6) 2 Jomo)-2
TAA (... QS vote
STANDARD FORM 509 BACK (Rev. 11-77)
* GS GOVERNMENT EFINTiNGOFFICE: 1995-461-275/20017
M EDCOM -4936
DOD 12148
MEDICAL RECORD PROGRESS NOTES
DATE crItc
,1 t .
;Acitz-03.
l3 A) LUC k......_..—e.._i s) „129_75y(.—
E
LAD 6----LL c/-4—e...--A-7—e..,t,
.....: t_k_ --
(.....4.-,--• ---K7',A
..---e.
(10)(6)-2
LA-..s.c.----0_,0 Crr.4_,./....____.?Pi (-)'7
0)(6)-2
(Continue on reverse side)
PATIENTS IDENTIFICATION (For Dyed or 'einem curia gm Name—kut. Psi. middle: I REGISTER NO. WARD NO. rude rank rate: hospital or metheal forilltY)
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Nmaibed b GSA/ICMR,
FPMR (II CFR) 101-11.806-8

509-1 10
MEDCOM — 4937
DOD 12149
MEDICAL RECORD PROGRESS NOTES
DATE
L)
b ii-ii,,
I ao-i. D

CO T A.1. --S,..1 L-D+e,,
u.,.--,.,4—,0

ut,-
CL/%"-^A
610---,9--‘0,-.9/2"¦.. aj C'Cl-k Crl CI.C. ;,..r e
'g' • -?c'Q-+
--V' ,:.,e,.... ¦ • • r ,... 12-X--c- .4.A/a--C. "ji
AllAirst
--1 k-) , • ,
0„,....-4
..: --±-kiq --I) , 4-,-, \./"....\---• C:
a fe e.?IP?OP?ilk 1
JP
(b)(6)-2
1.-(r iLe., US i\¦
/
o
01?8. 41 it A ...-. -.• -,
,
All ./ 11 (24-, i -• 1111
111,7
_
11.4 --r .... -.... .
a. -A . ill 4 --_,. . .. •_ % _..• • •
,.,. ...:: C _ A . ft I..
1.)., r)(6)_2
.,....... i _ -.._ , 4 i

(Continue an reverse side)
PATIENTS IDENTIFICATION (For tYped or 'Wee', ntntoo Ow Mono—toot. 1011, eladk; REGISTER NO. WARD NO.
tiled facility)

b)(6)-4
PROGRESS NOTES
STANDARD FORM 500 (Rev. 11-T7)
prescribed by GSA/ICNR.
FIFIMR (41 CFR) 201-45.505
500-111
MEDCOM - 4938
DOD 12150

MEDICAL RECORD PROGRESS NOTES
DATE
Oe 7 5 g - a S • _ __, , , %....1
4 tt -7' ...9-1-. .• 6) ) e--2.-1--1.--L./( e rn.i .,...4 st-
,
E ,..J...--.— a-3 c...-7...., 0
.il f
L.1...e c!/1, ,i,?7 c,c„,.....,„,_,._,„."
i, `4 -
.2, J........,„ 4, . ,4„--,.., -4 .4 .
.14„ 2 . ___ i i , — .. __ , a
,../ r-c-Pg... , &// L./ 41..../31 ch Ti--,..-.. .-

4-.(--A .4-__.e,1..1„(,,,,,,, z ; -.(-_,,,15;1--.bA--
,d As ht .n .
c.;A ,
A (4 c. — ivi 14), te--/ inn?4 4-4-, -J 4 .A.,2_, 1, 6-.r.,9.7.I 2_ 47-4-( -g. III-, I) -"II U.," 4/,-=-• Or --) (A.-4, 4.. e ...,-, 1,1,1....,-,c1 ,... , Gt., y?( ....----?P i (//-,A .1,1-...-g-i-,
--.Cleort. LA=. 1,4..4" 'a et. , ..., .
b)(6)-2
1 i\ert6
1 lam. T. coDi-'A.i-.J.e_sai 4A--,3 -P. M. qa.g. C 1%411A" T.,--b , Pal ut;--,- i?hini1-011?0---) (4k) --1-o?RI"-101114c-?-C.,-?C. IrtAtAdc--1. p.n.A"?doe'?1.-,A+ Taw?r'n S 'kV G7t: a-Nt Ca Cti-A6J ikif--0 PkJG P L e-. II.LA Co*.e NO- TAA-s is--4,1 P-,L
(b)(6)-2
(Continue on reverse side).
ecl kv(-___
PATIENTS IDENTIFICATION Wor typed or written entries Ow Name.-lou, piss; m/ddin REGISTER NO. I WARD NO. grade: rank roe: hospital or medical loollOy)
PROORFSS NOTF9
STANDARD FORM 509 (Rev. 11-77) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-45.505 500-111
MEDCOM - 4939
DOD 12151
PROGRESS NOTES
t*

fiamD)2036/14&,1(ca,(Akr,­
/0s062: #fE_ drom,eA----/em15?x7v,.0(_ 7i--fex 1.a(a„,,,
Lz,6ias It( MP,-o36k I got-6;,f„(=Liii( ' il6', ., =7,-.;:i. -PO 5-141 4e. 4-T,--- - iie....(1.44,1„, ,7,, 74, ,„,,,e /t2
)41 P 6(ii(Aele--e z6k#-a1171 r`- 5'acc.r.ks /5--A/504Lc- 7W, b ll-t- \fr I/6/0 aiimite# m.,./ii,_ - ye 6okwt-e4dflit iirr- A 17-2
.A.5--p_
C?F6/6\f•6Z.L. c:-6
6 (--6i,.--c,c4-Q6c,„),„,,,Q6...b,.1-z,s2.._
b)(6) 2 N--- /14
1986-491-248/20616 STANDARDFORM 509 BACK (Rev. 11 -77)
MEDCOM - 4940
DOD 12152

MEDICAL RECORD PROGRESS NOTES
i ,7;piacr3 yp__..et Le_et,i xv...(4,667„. 1?ac
lqI5 oc )%b ji-L-(---/-714104 i-4 770 14--TL2. .)14v4ttf-e8-,-21= 19 (t--1-; ka_51)6-?/2 ?14,03146 - air /1kt ?710egt,, theolss, '
°I-bi0t-1914-1" 'If .,?nnolikuc-4 i,u/t/L-- a o/trkf,b ,i„,..e J6 ifie?
Ke-C-f9(4A/140-4A1 Fe - Cs a/?— 1/14,111-?ge-C2114.444^0- o I ?Cxyrideit.ci
40 elit,24,) .2-z_ g-?eo ii47.A4 e a" /6.5 .-1/a/ c/W 7",s‘ne-,-(s/r71,
b)(6)-2
leil
rzo,?o& 461gLI?.2-----2 dae---C
r(6)-2
MPH, RD
( 7 A-M33 , 1 to?,.....-1/4.1,--a P I LT, MSC,-(13)(6)-2 • P.A„t , L. 4
143% 'Ai 4-0¦-%?eA) kA-XCL- A.-..-\?4-1-1 .
(b)(6)-2
Fmk 1.'3" N
1(b)(6)-2

4 ) 1 4/6) 's rr-4tim 1,12_,S1-t--
ib7.-¦-1
i
b}a±H
IQ 'ET A Po b......
, • , ....-...
CI.-)
J--?, -.7--.?.e.)?(1,¦_.,?al/CQ.-..),
Ne.-.1 C t) rstWatufnue opr
—Fre siCA-ev
PATIENTS IDENTIFICATION r, 7,..,„,i:rREGISTER NO.
,„,n,,,,,,,:pe,,,,,rzez7z7r. firsc rig, WAR NO.
(b)(6)-4
:b)(6)-2
509-111
MEDCOM - 4941
DOD 12153

PROGRESS NOTES
DATE
ri,.,4),8
L11 L1 0
I
lin) to '?-,_,
Ot '?
.Imo-L
-

int-T
4.._._ a)
CT-

0— 'tc. .
'b)(6)-2
/71-Az, u3a3v-
-

ftry
-I, (b)(6)-2
0 rdo
i
(b)(6)-2
AL3a9 1,2_4-Tf,W 441r 07-ItAe /j_-i- te;
'b)(6)-2
...'-'
1 .1 )1 1 7) 3
LAT4j Y07119
virfi-, -S
9 1L-0.4-S ,-7,/-yTV

.C`P
''`f •
V)-Q. N4,1 ( -)b-;(6)-2
(b)(6)-2
* U.S.O.P.O.. 1986-4 91-248 / 20616 STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM - 4942
DOD 12154
-----.-----.-..........

1 rThal-11%/.2¦01i • faFt5:0;¦.: 1 (b)(6)-2
DATE
nk\sk.QA---22-1.0­
E-q\Alas .ck._\-----/5. ..
a ?
a--ai
P
ei-71 ,r.4
1' iIi/ pe,L9.c_?1--" L e?)?cli; )----4 r 0)(6)-2
OA-PRO)
3 ,
AM J.__ '­
;-AL" A-4 AA­
. 2 ..s if-, , LIINIM441.4riL
i
1 " l
D A ., 111 -.i--414—c
62—.7 —461
A _
.4 !t--. .1.:-... 'A A I ' ,. 4, . /
.... -_,C.-Al _.¦
I .-No-_-¦ I-.-f
I I
b)(6)-2
(.4P-^ P T
..,,,v
PT I
TEHNICI 4 '.
676)-2 1
2f go ET NO ?• -P4, - sezel 4;1 Pm.?PT 7-cd. f(?,-j 47 1 Li N ?sq-0-36,14/1.4, -(-P-• -t-ct...,46 1.k4eek co Gr?:)k-(1‘4.---S clePrIDX_ 30 Tf e-6
cG-A ,c_ t6cale ,A-
OAQ LowN cLer V.---+ + IruziAtaS 19) 1 (2.-0v1 2u.9 k CI -s-e— tist-e. ( ( .1),:ek u.i-cl,(6I lAis
)(6)-2
ajrcsr P---161. A- Ad\ . 105z.
R6)-2
+AA cr., 4
af %/A4" u PA Kl‘"\I
(Continue on reverie side)
PATIENTS IDENTIFICATION
(For npd or irritrem entries (ire Name—lar. first middle:
REGISTER NO. ­I WARD NO.
park. rank: raw Juniata
or medical frociligy)
I
(b)(6)-4
PROGRESS NOTES
STANDARD FORM 509 (Rev, 1I-1/) Pram:Med by GSAACMR, FIRMR (41 CFR) 201-45.505 509-111
MEDCOM -4943
DOD 12155

PROGRESS NOTES
DATE
74_App 63 P.7, No*-M cp_e_., ,VA i'‘Ifti. 40s-co-LA-vti "TvA-ID ik4e-.) s—t ?-f-On Cr 0---cit-t--s 1-MA-13 . '.., jr-u c.,Ati es. 4. ct,.... 1, IA.4-r... a-, ititut 514-,k -k) 5-?n -i-haviv" i 01,--3-3/ciALI — --, ,,/...1-p.tiquil Li il
,b)(6)-2 CAD Al-40. -1-'r OA" P+ N LN 3 ANC (4
li 01 Q. T, Nerk-c
M r 0,4 +0 Svc ik. 11. ) .c LA-6.4,1,1 5-1-kiv 4....R. ciwkS 4--n . (?.-4 ...\3a Ais, 0,....b,Ac,, E cc Pi 15 1,, T._ s tw-e Arc4-rvN co-) . t„),1 ( e.0,4 -4 4,-2 P-4.-SI-; A ' 4,,
b)(6)-2 C (
-------ss----____, ,•----s------.___y-------.. • I 4, I
' T 1 ai--111Pa n3 S i)7. Nip.-TL4. ?--1-,.4 -j'H .('-` ' ,4 2---N,,;„ twItvz,t-k i
tiagjU - N„Ailk
, 1 , 00 b)(6)-2 , 0 i
' ' • I (13)(6)-2 A-Agma Ai
i (b)(6)-2
p":" 2etof
b)(6)-2
1-LI HP463 /VI d( 4/144)-(41 r1 F11) / 6(140 l() i e'r RAJ- ' ztis 4 I I otr4Odi 1., a 5 3 nik e 4 0 3 16049'5 0(4' gj 4 la' 14Ikd f r,g6 ,144 Vr
-
A-IP( )-1--011c1.-riAter27114isC frecc._ *20 --ipeovinietvd a °-.Ei--• re,./ 7: chictuce 4 714,50,-06,„ . poc.k4. 9.
13)(6)-2
. e)947) cP-ti .-- 3.3 s. kt";
(b)(6)-2
MPH, RD LT, MSC, 1())(6)-2
U.S.G.P.O.: 1988-49t-248/20616 STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM - 4944
DOD 12156

MEDICAL RECORD PROGRESS NOTES
DATE
l H: C)

Drae

\n$1)
$ ,
_;. .
,1.1
4eA cz-C-')'-iCiACC-$
W 4 j}'""-/!S .u.,ko6iiik.64, j
46. 0 2 ab • 0 Q 6,..,2, 4­II­CU! '
.. _­L. ... /NMI5 . . kr \ iti A)
., , • "r ..' Alt. AL ) .._7 4 , m ,K,c- 0,14

(b)(6)-2
(b)(6)-2
1 69-b ----D?'In-Ott---c;L--
.P.4 ?ce.L1/4.,,----A----?cA .?S
S?(ilkarl?L-,--?LAA
1(b)(6)-2
sca?Ul_.--..?
(Continue on reverse
PATIENTS IDENTIFICATION (For typed or mitten trunks give: Narno—los4 first. middle: grade: rank: rate: Manta or ',Wk./ foodityi
PROGRESS NOTES
STANDARD FORM 509 (Rev. 1147)
Prescribed by OSAJIDAR,
PIN (41 DR) 101-11.506-5

509-110
MEDCOM -4945
DOD 12157

PROGRESS NOTES
a 1PFg.03 Mex&..4 4)04-r(4.61;11 T f`(2
) koio .Paratv s?tic. -740e." 5 7e,kr— 41e. 6-e61-kle45/-e-44404 cla
0 ad-Rx; key ta-r-.?442b"6)-2
Lails-prz-. --NeA 444J/ 6-8-, q/36-

os -)s 1;b1/7d s:6--Li-q,c-(, .)4Ip ?O!‘,44-4-ka 4V ,?/, 64-1/4.b i I/0 71/14 Pv(-/:, sr,t4c
19 / 14-r­/7 140_6 3 , 4.c o 04:14‘24-ti eolti-rmile evvz Lx2 sz Pb -I- °ger .Pe_ S (Air crIA f I . al c-.ii)7(1431 9114-1-
-2
.
.
.
17
LT, Am, usNR(b)(6)-2 4 177i63
_. ...- .._.....,-0 A Ao i -
;4,11)
P1---; J:411 - / I, _. A! 4.
,....__--
b)(6)-2
x{/9-3 0 3 4416;44;{ AU
/
6810
4.14.C4-6 keit* 4,kto-4 kcet.i.---t--Pim) .
Its(' ,..„ L....;,,t..„-.., (b)(6)-2
WO & OPOCC?, 0 /i+?e,
P; ser-k4,?as?it-ife x?-.42-zs= .

STANDARD FORM 509 BACK (Rev. 11-77)
U.B. GOVERNMENT PRINTING OFFICE: 1985-461-275/20017
M EDCOM -4946
DOD 12158
MEDICAL RECORD PROGRESS NOTES
DATE
7 btli'tic— .

)
Nia Dk.---.

loq---
i_J--4q-j?,......,....._

.?
C¦Q71)Ci- ' elli.V1.
SIS 675--
ei—f...,
J__-.LA-A-1J C'e1/1/4-4 60 6A4*(4/C4 '`-(b)(6)-2
....,......----•••
1.011.4:5
(Continue on reverse side )
PATIENTS IDENTIFICATION (For typed or wines envies tira' Nome—Ian fl, mask' REGISTER NO. 'soda' rank: mu hospital or medfroifaciliol WARD NO.
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Pro abed tr, MA/ICHR, MIR (41 CFR) 101-11.806-8 509-1 10
MEDCOM - 4947
DOD 12159
PROGRESS NOTES
DATE
9 I-.A Io -Nar r ZA-sl., v OM.
kl rE)
.t.4_
7
G..64', 01/4kAA+" A6v--st-1u-,c3(, cs
el1„ wu-,,,4; pe ,,_ , a
,-6‘......)„,„
• A 4.p,„ cwt._ 1 tpi =t Dc.), ()L5:7\k,, I ,
— 1 V L. X-e./VILD 6 b •
_ll 111..61Me.2.4
1
i
I
a LP k.."2-tok) I ' ' IP
a,. ,,,, . ,
_A ,„:,„..,,.. bre:
1"
i I
6) . A A 4)911•1" 1Ut.41 17 b - 1/1 kr("-P'^vV,•,-...--. A) El) 2J-1-) Y•NA., (14‘ S IMO .5 triS 5— )n CLD ( Z:AJZ. artA\nr\-10 Oh Iv-
./ •••• CthA..P. . a
(b)(6)-2
I
-1 V
tis
STANDARD FORM 509 BACK (Rev. 11-77)
U.S. GOVERNMENT PRINTING OFFICE: isas-461-275 /20017
MEDCOM - 4948
DOD 12160

MEDICAL RECORD PROGRESS NOTES
DATE
D 'as
) (J.
a ..
Vilirdill % ik .

-...3. 4-...-.--.A ' Ih. AO IL-¦ -'44
'b)(6)-2 (b)(6)-2
(b)(6)-2
4 4b-z, cil
,,,
741
—-
c . k . '..-,. , ,.. o E:.-,
• • • . r*, ,
1: ' • ' .' , -
5116 IRA ---ab t-at-OC,_, ciovsv-0-__ Q.,-)
•
,..
'1 . , I 6 •
IIP
s. CIDArelfZI °
# • flb,
..A.A. III, . ,.. , ^..: \ .: -i. :...
L .......
k)8 4/: ' ' Ti; . RLLin A
(b)(6)-2
(Continue on wets° side)
PATIENT'S IDENTIFICATION (Par typed or written entries sive: Name—lad, lien middle I REGISTER NO. WARD NO. grade• nemk rete; heaping, or medical fadltryl
(b)(6)-4 PROGRESS NOTES
STANDARDFORM 509 (Rev. 11-77)
Presobel le GSA/ICNR,
RPM (41 CFR) 101-11.806-8
SC40-110

MEDCOM -4949
DOD 12161
PROGRESS NOTES
DATE
2.1 b 5 ‘6 Ka 0 t PAS 04/4 ctll'A J 4te/y Cbil U4.74C­4,7kAj
A • It .-Udt".­874-b)(6)-2 .­filb gr 4!-01.±.4­• 21116. K-ISG u5mil___
- 24103 4„„JZ.MAL I
4- _ _?...W" •Art cz -cr./?( /A?Li,6-_,,,,,___Li -4 .. , 7 ,,,-,, 4?,_ , 4 1 ...t. A 6,..r. . . ,...4.....-If 76.1..t L., 'in .. S 1...,-- 4-1 4-,v tz,....._?Lc.) o fill, 4,4,01.4k, r-isc 1....?
iq._ '9)(6)-2

STANDARDFORM 509 BACK (Rev. 11-77)
* VEI GOVERNMENT PRINTINGOFFICE 1985-461-275/20017
MEDCOM - 4950
DOD 12162

PROGRESS NOTES
DATE
¦ i 1 1? S D3 D r17)v-- zi() t¦ap
,-, -..., It .. 411
, .. dotjW, ---e, , gr­(‘ 0./)^%A.)­' _ ,._. A.Ae.41.4s-t,--) ¦413 C" : , • -rilAck/V (IA vv-ritil_. • A­lik­try i • ...L..._... _.1.
p)(6)-2
LT6_Akt-\)

1(b)(6)-4 P 11.• ICIPR x03 nt STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM -4951
DOD 12163

MEDICAL RECORD PROGRESS NOTES
DATE
e„.isiz .$3 rt. We 1 i-(00 ?-,-I-szu, -41-¦ !s • -i-. (.12;c6•10S ti .' ip .)c ( ( 7-3 pet,
`
dov-,,,,—..: P-T..szsvoi ?-71---, Lici.-fd .6047-?e m Cr.•
!?.4?
,,
Poet 'i)1-' 4-te. ek) ii4As 1, 1 6LE:6re i v-,--s
(b)(6)-2
63J4-.-PTI 6)0 ef.,,c(P),,,ci,
•i-.1 \ (^---Q"N-ar-----:1--t?2-- C-N----1
1n c)

..?:
A-P
(b)(6)-2
1' .
-
P.,-....
a....;L (b)(6)-2
H_AQ C..)---. ±_q.3:::A
1
CL,..l.A6C On ' X N...r.;71 Vt•Lk .
.`
¦
...
I: ¦ i ..- _ A es . _ _ AM 1 -1
LI— 5 i--)..,-,___, W-iervi_,C--D
-5(A-)
1‘) tr,A. :5 4, t.--11,-c%`.fte
(b)(6)-2
(Continue on Fever.
‘JUZU
PATIENT,Sz IDENTIFICAT1ON (For typed or ¦zitten eztirice:give.;„ 1leTr
,,iValfirs& middfr
b)(6)-4
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
MAR (41 ) 101-11.806-8 509-110
M EDCOM - 4952
DOD 12164

PROGRESS NOTES
DATE
0 1 ictn-Q3 1)--71 NOTE
0 ' I i i
-. - igt,„
• . , u , -j4i,
,...t. • -...1.4 • ...
b)(6)-2
AL ki¦A:L.A_ .TO
2.b)(6)-2 -
INg',7
2A eitel3 -Ci). --T tAivg

I?si.
6-ert/U• u)-4,iaill IiIAL ilA6P?Latlf-d2A--4
i
.?101 ,..?IA ?1 / ,?I /
a?.,...e. ice `.4-4-.6.L.wil. I 1...1/ 1 -'
&-.144.4‘‘ ' (dad, 6t P7: lab " ROCA
b)(6) 2
PT TECITI
-PIA tY5 ‘9 P. f--Gr.rit-
(‘-....,• )
91/ be, I 11 FA-}".1) gi / t/tot-4 &14?-fiN.. 1 4,07-. i-e÷/c.i i Army/41
Ar
at ?Gv•-.45 lAiteli

,
Ift,,a co",k‘e4 laa„,,,,,,,,z 49 0 c4 ,....9..Q,,
ReL eAwk T • 41) tm:Y.tik- co, 5-4' WI) Pi.effi ush.cwl i-ekui-vto-,
. i
Tel [-D, 4-c, kl-cat.bl-, u;v-ti--Q -,e.....ae-eil at vi6 in
(b)(6)-2
RFAX.C, U gke.-.
-
U.S. GOVERNMENT PRINTING OFFICE:1985-461-275 /20017 STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM - 4953
DOD 12165

7T:!"4.'
MEDICAL RECORD PROGRESS NOTES
tdc ( Aicptr c.65)7 .,5. fit) i
,.8.fta0y3
---/fre 3 Ateak, 4-/b_g —Re
frect,krztd-4 Lthece,ti 0' 0(-tlf-A)ef keft.a.r , lAtas.,crp3-02r b90 8106 5j//2-6 , 4 /9-/)2( - 148 6/1-/E1-4/- reccw14444,dorte2r/r r, s. O ,i z- 6,I,t,
-i--0 P. i Ache .5,,,v_ xeovvvppeizi
W`i Pt-fra44-3 (4.ivr-41/7,-t
4450 rO4,-,, 'Ph0.61-vukktve ?4462me-PO ivizikke, £i2 o ?3 -5-46-k&s ,
eLA-e.
.
t))(6)-2 2
apt.,/J,
3; 6;b---sicri.(
b)(6)-
.2P1 PA 0.3 ;).---r Woree-
' S L ,P . a ;
T-1-7,..e.o........_ . ,

. I .__¦¦. MI
I I?/
?PA--,-,.._51 '
:b)(6)-2
•_......ft,a: _ . .1....A1 A
.worma
,u6
FrbTAHNI
RR
lei NI63 0 fe._,Titti (b)(6)-4

5 Jr Rir,z r, R 4--4-4-,-s ,........._ es. ' ,_,,,,, • L , + - i-Lz k 4

(6)-2 )---
L... e . z*.-\4„.7 4.,.4-s-A-...,.-4 L.53-4.
L
S r--01/1/4 7- c N,-..
cf-A-3--e_
de-Air,.
c.N.--, ij\n-S-+N SA-
init.W.4
gat I G41.49 :
1._ C-,Lrr-i, -L
(Continue reverse st
PATIENT'S IDENTIFICATION War Wed or ,ffitte. ,nuies Sim Ara.•-last first midair' 0 WARD NO.Pak /ma; rote-haspical or medical facility)
(b)(6)-4
PROGRESS NOTES STANDARD FORM AtIA Mow 11-771 Prescribed by GSA/ICMR,
FIRIAR (41 CFR) 201-45.505
gm,. 4
MEDCOM - 4954
DOD 12166

PROGRESS NOTES
DATE
11 '46 ( 41. em,+., ?e, b i
A
f ..6h-y.6 .
(b)(6)-2
3o4P 62123 Ii"-: T. Norgr P-1-4-z_z„_ iL. --4-11--'Pt-1-, Pil.,,./-:-.---e 6rD .45kett4 . !114,-,44 , P._._,,t • . ...., , A', .0/, b)( -2 I C4 F.. ---T.,. (b)(6) 2 La-
b)(6)-2 VII IlirliAll
-
I M —1 6.3 t f-rtk-66f t"
b)(6) 2
1134\0 ri \ vt...
(b)(6)-2
r ?.
(3)(6)-2
;#.1-, ,.
tl N'A r• ' ' of
abiLl WO t. fT susi'64-) 44-Wal-fe-P ito?+ iv,,,A ( L ?z
`1:6Y-k.-ct-P?• .ett, f),,-, CO {t o cle.int„, st4k.t-ei. co,--(--, PT (b)(6)-2Q,0 14(44C (PAO
T. --P c)--
/ i14444/0 3 M eCecti iticAl- A1;6,1 yl)(F7­
, 100 s ; ee-r+rzut,La(44.0(-- _ .ea t-( cJI. pt„,e_a.s `i 4-s-/
0.. Occi-Aec kie6Litct-r-, z,6 5 1 i2/111Y ti *1;110- i , 6,H.2e . (;,

Me‘ /.6191/41/ ,I) — re-tot;vvite,AriogGy --E.6,ill ic,c-e0 rta6s0c041 , (Olo.-4,14-e-gr( 11.-6 )(4 ' " ' - e- i - t 6.-cA'fit-ItZt -etA eeiv-rtuz ¦
-
from4kL.— /6)4 iPtA)i--
b)(6)-2 44 ea ik-49
U.S.G.P.0 ?' STANDARD FORM 509 BACK (Rev. 11-77)
986 _491-248/20616
(b)(6)-2
MPH, RP
LT, MSC, USNR (b)(6)-2
MEDCOM - 4955
DOD 12167
MEDICAL RECORD PROGRESS NOTES
(b)(6)-2 6
DATE 6I.
rg T.-A6‘2,4-----04d tal*,,,,c)c, 206e-, e...A-(-k.6.--L1s ic_A.,-1_
1 it paaCk Attila lerlAAA-12-A .II ..letjAati Li2-41/:41•4 ' ' ' l'is
ZZAZO-"'"a'jt-'44 &4 7;e, PT6) N 4a_s_A__1,2,ta.
(
(b)(6)-2
,(b)(6)-2
c
031-1,4va3 P -T. re 7-7epro
4C1-- ev A uufai, sitA-Lfd. ® / /,-A ' A 11. 2.-.. • Li ..14.
! fI I 1 •-•_.. / — 1411 / / 1 _-_! A . _ ...!. -_-_ _ /„ ¦ , , 4?.
fLit -,..i......7
f b)(6)-2

:i0u.vire•itravilli
IV
b)(6)-2
(Continue on remise side)
PATIENT'S IDENTIFICATION (For sypri or miaow auger Aro. Name—lms, Au, ',Oak I REGISTER NO, WARD NO. pale nsatk; Anc &Vial or mmtiartfadligl
•)(6)-4
PROGRESS NOTES
STANDARD FORM 509 Divy. 11-77) Pre/Axioms by GS/MMR. FIRMR (41 CFR) 201-45.505 599-111
MEDCOM - 4956
DOD 12168

MEDICAL RECORD PROGRESS NOTES
DATE
11776°7 6S
g9,61)?t \1S?) 074o/i
[D, q00) 20, v-te,?IN-rg. 4 tg'0k3/ 5:6 if;3'9Ivi47?d4:5 7e-6 • lop ik,6za, spi6k ekp&? 7,7--irc6-4--F. )6/407fro) f.la?­
.,-is.?zek fi- le.evid?-tr .fIY'
(b)(6)-2 /4,
7ide6f2eiti3 tV cr iso,z ?8,3 /6, 5, 7 - PT Af?Se?..,( -6 stuc y ?.
7-4,c c 23; e) les f -0 fi $e•-a1 dolt ra Akdei, 7?,(fees /Me • 4...zet. .r .s./..;- ,74. ;6„_/164-r., . Pr 6/0 y„....4.,4,( vtctr.?fre, se(i—?,-7'
b)(6)-2
(6 . a /5-51z,-4.1 zoker 7%r/ .e-i,/,L,•?4,.('
. el_P '# .', "GiK ,i:-V?
(b)(6)-2
ce...e.4
).//"---
eLee cam^ /#(.4" ,-11/3-,,,,t,
egeto .17-. ree,,,,,.." Attar ?Oer.e.( -,?pe„ t., /rie,...4? e„he ,r,„-z..,
b)(6)-2
• _ ,
51r4gf 03 /5, ) - of I CV c'?4 T
- , A(z--70 .
.
b)(6)-2
t, of /0 Ft tik ., ),./ i/?.71-1?4 ?1?PA, ei 1 C-$72,—)
C I r . 44, k?Luc
,_, cp)?1?4.-. 4of

-
I I
.._ .., . "(
b)(6)-2
?0(4., {-, 5-4A. 11(Alnixt
A(6)-2
•Vb 1 .54 ---iil Sat , tinuevO1; rev stele) _ ¦-PATIENT'S IDE
IFICATION (For typed or written wrist' ve: Name—lar; first middle: REGISTEF7 NO.
grade' rank me: hospiral or modiedfocniO4

:b)(6)-4 PROGRESS NOTES
STANDARD FORA1508 (Rev. 11-77) Presaged IN GSAMPAR. FIRMR(41CFR)201.45.505 508;111
MEDCOM - 4957
DOD 12169

PROGRESS NOTES
C-12b/54)—
6 V-e —r tfa
es
64° .A.t6.ak --1-35 Se . IF ' 0.41.1
s?
-
-
h).a (v .cg?r / AL. . j" -ft' t" , rfi-e-?m)(-ri0( (eo,-61-,vt h(241--i -a-. W S 04y o U.S?lz:376s?/?(7-313 a--if te-/e05/ 4W iii 0.-'( . nal s
b)(6)-2
.
Xiti /it/41 ..
0/0 ,t lee ;4 e‘.4e/( -4,p ' off tGrvr, / r-r:f ffJ-
1(b)(6)-2

11?f /fr
i 4.?',(-(?,f(f teL"k?
T-tt', C?);4:0 Z ltez
,..j....Als.
b)(6)-2 (b)(6)-2 -• - •
---Fp ' itf,yee, -' 7_ .1-90 (-00/0041),..c 41-cj?LX-e...?1.-?Gs irL)--c-t,e-c Cly,. g .i / 6-WI?u-(--ei?klbLA--v(?.-e , PIL?/iu (4-(2,i
162/141 Ol 7gDia ruse, ' -6z LA-1916(g - a,-611
.C0 64L. ,
:b)(6)-2
7— ?'
....(3/ ...._,
C.-?Cal fries?cC "/ k-
STANDARD FORM 509 BACK (Rev. 11-n)
*U . S GPO: 1995-397-405
MEDCOM - 4958
DOD 12170
NSN 7540-00-634-4176 600-108
HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

cf..-= 1ae43 49/ 2e...4-,
a.
c.....„.....zre...as
02, z-....--."--.-Q-...,.........„‘L."Cja3 ,,......9.,--i• /1"4-1 41.4 -../4."4"ZZ:r.,...., .1..4i*
...^.'-alZ ...-6......49-Gy '-.."..."1- vt...41/ /2,-...s42 ._. ___Cif -i -... -yr1-‘,.....(0 / .C.,-,.=t...Z, ,e_...,_.._.,„....r, ;-­
2.....C.-10, 4-4L--6a___________ .__________________
b)(6)-2
c...,.. .9-a_e.44-0)
PATIENT'S IDENTI FICATION (Use this space forMechanicalImprint) M A INTAINED
M AT:
PATIENT'S NAME (Last. First, Middle Initial) SEX
RELATIONSHIP TO SPONSOR STATUS RANK/GRADE
SPONSOR'S NAME ORGANIZATION
DEPART./SERVICE SSN/IDENTIFICATION NO. DATE OF BIRTH
MEDCOM -4959 1 :'RA=r1IPAI f•A Or Nn ARDELISNA-11130 (Rev Pre by GSA and ICMV FIRMS 141 CFRs 201-45.506
DOD 12171

CLINICAL RECORD NURSING NOTES
(Sign all notes)
HOUR 1
DATE OBSERVATIONS
A.M.-P.M.
Include medication and treatment when indicated
(to
??sy,yar?
AAJAA0
D
9 74-4 46 4-,,Dzi/. 4A /6,(4, /01a 7_ /C47144 So.a. icz'
.b)(6)-2
(b) 6)-2
u,13
4L
b)(6)-2
\1:4)?0(60\(
2441
IC
Ascoul?eeeleA
;,)(6)-2
.13)(6)-2
1
.16I
Continue on reverse side
PATIENT'S IDENTIFICATION­
(For typed or written entries give: Name—last, first,
middle• P REGISTER NO.­
ude; date; botpital or medical facility) `WARD NO
'. 13)(6)-4
NURSING NOTES
Standard Form SIO
General Services Administration and
Interagency Committeeon Medical Records

FPMR
101-11 .806-8—October 1975
MEDCOM - 4960

DOD 12172

,.12
NSN 7540-00-634-4123
NURSING NOTES
MEDICAL RECORD
all notes HOUR
OBSERVATIONS
DATE
A.M. P.M. Include medication and treatment when indicated
(b)(6)-206t) 5 VD M -)49 4 A'57K) Nr 57". .. VED "E.1 ___("4612:_____-b)(6)-2
(b)(6)-2
-
PF-. 2-DR. . 0 RD F.12- .?
(b)(6)-2
Leq '- ¦ _0)(6)-2
7101") 01.0 ro I 5-retE-1)?,.1--.,-i A-N\ AIQKET: 1-2 FS De—
I
(Continue on reverse side) PATIENTS IDENTIFICATION For typed or written entries give: Name—last first, middle; grade; rank; rate; REGISTER NO. WARD NO.
hospital or medical facility)
NURSING NOTES Medical Record
STANDARD FORM 510 (REV. 7-91.1Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1
MEDCOM - 4961
10)(6)-2
DOD 12173
CLINICAL RECORD Nunn, flogs
T HOUR OBSERVATIONS
DATE
A.M. 1-P.M. Incled, medication end treatment when indicahtd
0 AN-5 °Ctip TA-.-2.-ItGi2...t 5Voi) -,,,r,,--PACA), Alb y 3 ,USS ts StZ (Mb
a L ti C. . tiLLLA.La c-kst-cAzs & C4-v3e-n Li-E 61/4,--A yt 4.1 .c.,:cr we_QS a s SA,A.?amll
cd;' ,40?c-ts...o.,.).-?k?,12-A-. .-1)-ki-tc.a.,..6?cea 1?
TetAA..,..) A-C -4 A-Ii4.3,_ , b)(63-2 t v-e__
t" CAm-ALA.,v-t_ to tryL.4-,A,Itis-N.,
Vriit) 4K
_?ism_ Pt-6 k K _
1 to
Oral- Wzaio t?lit,i10(lilk . Jr dAaii-Y.- i ailli--d 1 . 74 ' 4 4 __,I 41: .../ 1 . r__-A,_-Lib Ai ILI g-1.1,1 ' 0
liMrd - ai-t-- gi-E (.1k--?tkarliat. 10.-E- !aim. it Imitik,
D i / 4...i_ I ..k.
•. ILA Ai. ...._ Li i _ 4., _ ' 0.' .1.L I. le
(_Le 7. a.0 1,th a p t0 f-tilk etAkd cd LP.?- c NT_ 1 Lb 7-LA Wm, lb c t o- IA 4. i t, enitveniti-t a y At-ilD e-3-4-11 E, (btlid Pim?¦ (&v-t. itiFfe. '?
' 4 .3-lb: S -hAjagak__LL4U11,11gLESAlei&______
b)(6)-2
Obliktiti dlitAlatail ) (A 114,\I'Ut _ 414 iffp CIPIA... 'Ai , 013C (ss.t.,,,,__SP e ,„,„?0 a..-t co . ICA b )( S .?'..0mg?
"Y1
•q
-., • t...L5
„.„„f„,„__A-.m ,........k......t,

.6.2.-Cfils-t...
e7g.t'''''
CONfiNNO ON /IOW. side PATIENT'S IDENTIFICATION­(12„,, ,0,4 on ,,,iiii. ,„Din dint: None_hua, p)t, (b)(6)-4 ¦acdity) REGISTER NO. WARD NO.
NURSING NOTES Standard Form 510 ."Te,rib"'InEt-510-110 •

MEDCOM - 4962
DOD 12174

NURSIN6 NOTES
(Sign all notes)
ISA OR I NOUN OBSERVATIONS
I A.M. P.M.. Include medication and treatment when indicated

fkeabl P-10 6 3119 T 0'01E TO CAS RFC— . C.751A) 111E0 Pt LTIAI D LE) r-50 ourrocys,D F-E-rnogAL NE_Cic F-Ow-TIA-F FtRi2--Ftl,Snt.1 \(S r)u=q),S pFALS_, v 15 rA 133)89
1: 1lbI.1 4-.SP= . 5 ,sPnr 43_,Ss (AP P..E.FILL ,--fR-Es
onNE TI) 6D MEDI fkl. 1i41 Ft riL), LE, ORQTRyjAS Kle, mnpPHi Jc. P\DmiNMEE.P...'FQ THIant)(711-Iv
'b)(6)-2

$8.3. 0P01 1987-18 -247/60056 NURSING NOTES
Staiudard Form MA
MEDCOM - 4963
DOD 12175
DATE (Si it all notes)
OLSERVATIONS

include medication and treatment when indicated
leo
ik • • ID
Ahlett
OCric.
II R59, JR, ffAy LUT b)(6)-2
euL
•
i
ifUL,
b)(6)-2
15 63
1/1
b)(6)-2
4,1,4
ire I., fi id. LA 4' L.$

111111vimiuM
'A
h ki a!
imc 3. 4AJ LI
Agn Li'-. 1 A
Ski V

111.
Alt Alta-VI 4ts­
.
b) (6)-2
MEDCOM - 4964
NOTES
DOD 12176

NURSING NOTES
CLINICAL RECORD
(Sign all notes)
1101.112
ONSEIVATIONS
DATE
A.M. P .M Include rniteficetion and treohylent when inelicer.d (b)(6) 2
loan?Ne 5561 a-Ar pa„.t. /146_--.
coPF-Tr(eri op -(3,c_t 1,446, ¦J`Jk I I Merkr-for SA-1-10 smitt.(tvrA t a5-c% 15,30 Istasaf6.6,1 iV¦Vec( 6J+ {:x,k Staihici crir2C 7-4 car-4-0 ' -6 NI-dr\ t 4-or O÷Lb TEc bee,15d poai--CI f Sell r¦-(-1C)A ew DeFsskiAmc clvarvirc .l 4e,
?
gs c i
Ser?741 o e,7c./ a evi-(-7.0.goicito?t- Pre557 579—
A114)"5
Aftpre Cl dcS D•Fet-0 Arcw-af te"-‘ FS CO Pehr/t
b)(6)-2
itte U v t4firtie.5be5g1
71-0/a .
wyk au; ry614,444e.iAnai e keeri nit ml cg A1);y,
,
I I. i I Al,
.11 4AI a a
)(6)-2
PAte,/am, vook AWL, . RUH-NW )LJ) Ate mer .,MAA alccadt­
le 414-ae.e-!
"?.
(3)(6)-2
A--tttit.m.Vect
bx6)-2
ff1/66 s? ?74) LI/ /kW
ekhuv at het4 et_mta 0-10' 4.(Ve .?
g..16/A/Q, 0(6)-2
1.24pOS 63410 k&A/17691 e4/( G CO5?dexp.",2 111 A4.1-ue ?H ?Igo cn Lf--74,. f CI? 1..1a41126-0 eln?1-26 0.140w3C-Eyri1.L
?otgeOL .02-2i.aoklA
. A441:4-, 412-Itrn& r)(*01 4..1,-P ace zonal° 6 aff411?(A 1 nuc ixt(o
,t3)(6)-2
Eel AIL.
Coatings on reverse utile
IDENTIFICATION
(Por typed or wine,: entries sire: Noose—last, first, •
REGISTER NO
WARD NO.
middle; grade; dale; hospital or medical facility)
NURSING NOTES
(b)(6)-4
Standard Penn 310
Prescribed GSA/ICMR
MIR (41 CFR) 201-45.505
OCTOBER 1975
510-115

MEDCOM - 4965
DOD 12177

NURSING NOTES
(Sign all notes)
HOURDATE O!SERVATIONS
P.M..
Include medication and treatment when indicated
fec
r

A4 .11./....i/agr An_
A.AEL
2.0- -77i6
0
kN-o
4111•••-••••¦•
•,
v 4
t. /4tAer
b)(6)-2
.#
1—• C-
el •
IA •
Emiligm• aS a • L • ••'
Allp&o. AL
• AP, • • _CD • i
..
hi. •
•
• tit _is-•a.
b)(6)-2
kiwi.° ANL .1D t11/ J-cht 2_4
WA
A As
.•91 A
.
b)(6)-2
b)(6)-2
ITAK20.3
4 .Q.ed. bQ • 41-­
• ci eNe b)(6)-2
•„Ital
• Ae i3;riknuLd_ •• ad-5
Li id .1 1
IL it/.
¦••¦•¦
L
i l l
NW LLL S
ft
I A / }
L.
•I b)(6)-2
PRINTING OF
verse
MEDCOM - 4966
DOD 12178

NURSING NOTES
CLNICAL RCM
( Sign all notes)
HOUR OBSERVATIONS
llt.A.
A.M. P.M. Include medication and treatment when indicated
itir_416-• 61 i teVA i a AND?AIL-.•?•? e_ As.6a , _2_,I cof trn z) asdritinte-Aer:Prl. P-1-, fThO ,—I-ernp. 10i .t-1 and V 15-(,/q0 af I c4f_t_._ vfa) liDIQL —1)i-1-11,3 draGgoilt9
al. a _ c ---p4, S. .. -.. .. i ---1-0 L-j
4-1-v 1 M—A , ci re.) 01 inpc-A-1611 . . \I --h) (
ilie • 1 at 11....f _ .— l',.__h• _A 1 _lc.. ._ ,
,b)(6)-2
Odi ox-yrrfinwe,____?rrbni-hs-y .?-1).
1 itifP) COW Pe aCC)111-red ift ,I /hp --lemp. looYr), 0-)1 I r1 (b)(6)-2
CerfthillQs 1±Er
1tlApi(e6 C155 1--(t.U0.404ej 4/6h -' notolii:askd ,7125,7?(p zjfe15.)1 Ieuf.. 1.: /60. 9.
b)(6) 2

kic.et Cualtricil lito-ri dtA v.
C4*-
qe,Pf9.23 2,0)0 Fz91-6`i 1-45 D/c_?E.uoouza:61.7j_?507-?7z9?b-ILIAJic--
HUI D9?n/0 ,_S/S?of?f`-1-.7)7?if-Gt.) 6"e2/1110C:4 :b)(6)-2 1,1 lii 64211 1-//1 iie.../ /13 /110r OCT
r(P.fiAt4) 23 /5-PI Fl FoLO c..ATH pLAc_i--
D?k.v.9?Dific,001",?v64 15Y1!/„...L
(b)(6)-2
Theli1/4)1°•1/4 ' 30.P c-c. burnAL ovr?0, -

LOA* . ry?0!• . ,it i a 4 : 0 a' a
.
'
I
' , 11111 we -...A• Ft
a/o 1110(Wn. \Ice ,6-119.610--P-1-?i' P • rii3Oi
41. 1
Lr
_ _ _• 1 ¦ ; ° •A AA di
.V II IP NE
'' (b)(6)-2 ,
..A.N i (b)(6)-2
In kel.\-$) OW 11 COY\ CY' f• "" __.,,,,, ,,,, ..,. os;de?".S.%).e.

TP/IIW,
PATIENT'S IDENTIFICATION (For typed or written „wrier give : Na in 6.1 a i g , first,
i REGISTER N..-
middle; grade; date; hospital or medical facility) ?.
• • s
(b)(6)-4
NURSING NOTES
Standard Form 510
General Services Administration and Interagency Committee on Medical RecordsFPMR 101-11.805-8—October 1975 510-109
MEDCOM - 4967
DOD 12179

CLINICAL RCM NUTIWINOM
-
HOUR OBSERVATIONS
LI"
A.M.-P.M. Include medicolion and treatment when indicated
le,t6:; eee levrIM 0.?..•,___As "Ap.' '-11P 1: .-•
/Le_-. b 1he,.. as.-•­
Other IR, AVIV-le, --4:)l _ii inn-lex-Li-rirwn CLL
V-YLO610 `6.-1e . in 11..?tral-loc.4-. ---0-h5o CID I i & /A. 'a • lip Ai..6• ..,6LIr.At2.,00U1tc2 row 0 Alta-_ Arn-0. a sAtioat -G 4.t _ 0 .,
1111
IN,...1r. el% 1_ ,' . It. • ... zee i r.0..4
afl -hay) pll Imo. tDil Ccn-f-ii)LP -i-o n-rni4c3Q-
1 (b)(6)-2
b)(6)-2
' f 1-1): 21,z7-LLexwit-id.1. le...1/,4-A-eieePs t..) A5...... ...4-6-Si, b 2,z .7 -n--..ry 4.-.e..,-k ,.......),,-?._]

1q141430oto PE,0,1A.noer-.1?an-40 . ­
l,e?ep. Q., ,iiiii (b)(6)-2
b)(6)-2
.4-"""*.
/73914117 geZ ac?-/44gier/ e.,:h,
,c-nx&r .lc)?
I' ilz.t... A_ G' igioro ..eir.4 •_.' 0 ^?_ ---. !_CA4
II

0-ArnpiQLn-I-O 4hte hroc_d_ -Pb.han
_iie)linb
II/P _41. 4 • ta •--s! _AAP b./ 0 _AIR •
1-0 CD un rey- -4-hi • h elly 1_ 1_ aiN nn cs-) p2rx,e) ill
-
•, 0 A if • , LI C -7 . 0111 COO-Lin( -1-0
-. )
b)(6)-2
11! I •• -°°1".04) 0._s . IP I./. '.0.1. el 11 _1-....! 'Jo?dt' 0.. 0 410
_____(b)(6)-2
1
b)(6)-2
.....-.6:-.--............--.

Continue on reverse side
PKTTE N7 • S I-WI Ft CA TIO N­
(For typed or written entries give: Name—lost, first, REGISTER NO. WARD NO. middle; grade; date; hospital or medical facility)?.
6
b)(6)-4 ---
NURSING NOTES Standard Form 510 General Services Adm In istre then and
Interagency-Fil-0 Committee Medial I
IViirs
510-109
MEDCOM - 4969
DOD 12181

CLINICAL RECORD
OBSERVATIONS
Include medication and treatment when indicated
-
b)(6)-2
JA:1218111! b)(6)-2
b)(6)-2
b)(6)-2
(wc-

b)(6)-2
b)(6)-2
...c ( 4 -4„ s-?s 71----- ) (6) -2
3 c PATIENT'S IDENTIFICATION I rit -- C.­.r.6e.ntim oleo.

(b)(6)-4 (Far typed or written entries give; Name—last, first,middle; grade; date:?,6jacuay) • • rly (b)(6)-2 y CLD / —1-2"ARD NO.
NURSING NOTES Standard Form 510 General Services Administration andInteragency Committee on Medical RecordsFPMR 101-11.811(',-B.-October 1975510-109

MEDCOM - 4970
DOD 12182

HOUR . I A.M. 1 P.M..
4- zu (:,z. lag)
7103 46-
\,..s.\t's icsz..
2...V rts T2.-D­
act ilfic
;b)(6)-4
---t5-1
ri:
..-
N 1TE
(Sign all notes)
OBSERVATIONS
Include medication and treatment when indicated

r SAktirt Well . AvALAik-fl vlo _ W 1 h. CA4% )-eLE.S.6v.3)-ti inueoAd--rt-.me6$D A,,,,,i;( -6._ %EL:6Elae ,1_ . yfkai?.c:).613.4_ Cc e..1-r.A4- 'co Lt=wek ec-v-4.A...cAn6APCr o'lle.4.3 ylt) toictiii k.
b)(6)-2
a.Prie-'-
ILI 47 ' ....0 G' . / el / Zir eatv/l ele?`rii.,'i?,
//.r_r,• tfe.:-.-ft/elicA) 7azzoJ . .,re..,--.7., „oseto
te4 "4

11'147' '.
bed Lee, he-e?2 • k;?eli-fir AIS?et, /7 -, ;.•
(b)(6)-2 --...c.
/42;17/C641,71t 7 277e72 ,4;t i ra;r/t/c
.,,
vy ete,k-,,,,,Lc?\-41 kwk.‘zgi \A-142_ \ aei-k t I` A-uk tiA-VA, -&\.-.FN t.vo eAt, ri,
;, t VAr.54-;••-x.kr; ':-• tAV•q_• • Ce)-141.1v;\ -. r›,--c, -se.:4¦ ••ri

k (‘,_:-.„ t Ake
frey.NA-..rk_ck (is/ 1-D.° pt) s\- CSP. @-‘1,‘..:6,\- S-Ls sv,-)PQ.-.s: ' ) ." \-A-Jr-'fs& 04,
. ?6.4.
6
SAW, .. A.2?{1sb)C t.. q A?t-ko?- o st?
N--,p,-,-kt,?Pc.d .?.7-)?Wr?Wnts....,,i 7. 3.1.8-tat—S.` ¦ le' Piv...we_ Vez 1:-. V.

-1...1._ ivt.k.ck WA^ l'nwe-V-1/4.k-t-...., i-A.C.-¦ w.A...t
l.00..iwN/L tvlip \ ‘q.... ce". - k\ k...e. '
kiaDAA+,.,23_,--U.AV%-••• V. rt.S.S=1 (e".N/FIA.-. \I-"¦.D.Fin OA— IN" 640-0i-
b)(6)-2 °•-•.Ar.1.--CAS"."-i‘ V-I\V
he.. epf 4-..o, P-T IS€) ) 19-1-57"&4_6 i?els.er-, rl-c. z./..m pt-di I
br `' .1-P- Cb l.Si...24.-re,r: C3 ; Al li 0 F. -/Ai! h. ,lil 7:1/•71 G's-n.L. :e2, IA4.41 ,b)(6)-2
ce ror.s?drizArtzk e y ...7 n-e. c.ch? r D TA'" /-..-:::Z/32 ',I...1'C
.,eg 1.(ja-i1?4-(.., ', e di.,,,,.,7?,i 07-......,......e ?..e
b)(6)-2
1 r?'-' 4.-e/?fes./?r??./)2-19/74-..,14 tri
¦ ---7

* U . S . GOVERNMENT PRINTING OFFICE = 1983 0 921-526 (9201) NURSING NOTES
standard Form 610 (Reverse)
MEDCOM - 4971
DOD 12183

r-..
CLINICAL RECORD NURSING NOTES
HOUR
DATE OBSERVATIONS
A.M. P-M.
Include medication and treatment when indicated
AIM 016 1SS no cli6(.41) ylcA edi?Ii A, 11?bgA?Arc ?p6n,i,A?S_) 5e
11 ) Zit( 6s-)xcl IA ( Let,. j ?/1 15421. . wcuadib_p_____0._,AA6OR 3tiov iheitpi..64q-.6to?0);?ini,,,.;,,„_?..k.,,) 43 au 0 , L
b)(6)-2
1.4
I • 6,zie (.4.OrPr?Vi)) Pani-yymr,+.,--3 0 N't, 03 41)3V1 ft:6t.,,,e_ 7_ 4 ii, ii4.44 ...„:„.„,y,:c,
b)(6)-2
,1,4-11• 4) 'di 40)141iq, -7 kl1;714
CaNC.
) 36 409 QS 3 0 .*e OSS
/1d 4,54-4,0 nr5t 4?,?
In & 4 PA Pi ii---5. 5?,,fI .1 I?ula-
n'
•-....-.i;-_-,­
I rt ' 1. ' • 114
di *lad
Vitt 11,14-. ria
•
) A'. • . '' u -6 !...„,_ ,
CI ft I i • • ..5 kit . ....., Iv, ,,,--u. qv...I-TA/v-6 A 61.v,­
'In-1,0kajbj,„2-4.„. Con veal i-t.
G.044,..fir ptc, m_.-ra_A?..?-
W ‘?exuthA.L....tk
I r?'•?1 . -.?xv34:44n. vie, . cun (Dx6)-2
F
01 may a.?f. Wes At i.t5,3 ty'Vettits ritki OW-5.5, IA
..i .s c....,-.Z.sve...:, nry&we---.-S ..__
,-kny, "law., eta...1 1); led tkitXil , ne.ixiO,c3
.• • , , . f , • C., 16 env . b)(6)-2
• 1.1IL . IIII • !!. . . . .. ' • al • j . v e.9% k i ,
ri) 0.6...rA. C),- rt- % liv1 V\73 a 01,-tratude)
t...... A X. ___ • taz, ... „. —

(b)(6)_2
4 Z IA.
ginIE. Oil f., A ,
-
. • &-x-ys ruarri .S S 2 lay..-00,4 No/ p I 14;14 I . fiSaiV
Continue on reverse side
PATIENT'S IDENTIFICATION
(For Typed or written entries give: Name—last, first ,
REGISTER NO.
middle; grade; date; holpital or medical larilitY) I WARD NO.
A
NURSING NOTES Standard Form 510 General Services Administration and Interagency Committee on Medical Records FPMR 101-11.806-8—October 1975 510-109
MEDCOM - 4972
DOD 12184

NURSING NOTES
(Sign all notes)
OBSERVATIONS
DATE HOUR
A.M. PM. Include medication and treatment when indicated I HAY.;
p lry,1. .4r2 0 ytsrn r. noi)i1,L5 ol?fi 44, gt.i
.;2 iS;.- 4-1) A rfiA ; (lei,: " r lei 1 fi. .. , . 1, . 6_ _. ... _ • / 6 r •
I
(b)(6)-2 _Mdarlir-& n a (JAI et rnt 47, rrwr, i fer -kl.. , 05e..)
EP hi Y 03 . 736o -4 . Z " '
`,/, , Ay, z`,-•-) (^40,21‘.2,,L-,0914 4‘
tp ' 'b)(6)-2 5'd * P457 CPA/ "/C
a ,
A fi / ,d,' ' .1,
/ • flf, (Arkicv. x 41, RLL 4 ell ita n Ltd E StAiXeor fra
I IV As C. t 6-p. trj CO r01•' -teik(r.t. *41 cfrl l; (.., ; ll ()cm 3-cin "......-nj 401 D 31142 5 3 2hcb aebit.osej CeLtAe,t2., i e • g • s - 6) /- -/''-‘10 A?
-E.4-
r„ A riege,-frzet.,,,,,,-, GO. I( eemZ4......e
mer4ZA
to:444;2... •(b)(6)-2 1/46 C.:2¦14-0
i
79.e: PilraA ' -X40 a -•
• aca) _ _ • v a ,,,,,,,e,- 7,14:41n-7-4,..----,-2.0 sb)(6)-2 ‘Y14P ki5 /1
LI

1 U.S. GOVERNMENT PRINTING OFFICE : 1983 0 - 421-526 (9201) NURSING NOTES
Standard Form 610
[Reverse)
MEDCOM - 4973
DOD 12185
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST.­MONTH-YEAR DAY DAY ,.1 Arr. MIL IMUFP4ItigEMIRfir .. 0 iv, 1 blip 4 1110.4
19 NOUN .­. .­. .­• i alline, ,aillW . ,:. •••e3s 111=2/1
PULSE­TEMP. F • • • •
• • • • '
105° • '' • • •
' ' ' • • • ' • ' • " • ' " • ' " • • "
180 104° • • ' • • • . • . . . . . . • •• • " • • • . • • •
170 103° • . . • . . ' . . • . • ' . . • •. • . . . . • . . ' . • ' . . • . . • . ' • • . ." •. . . . . . • -. . . • • . . . • • . . . • • . . • • . . • . • • . . .
160 • • I.
. . • ' ' , ' . • •• .
ISO 101° • • • ' • * • • • ' • ' • • • • . . . • . '
" . . ' . •. ' • •• " . . ' •• . " . . . . . . . . • • • •
HO­ 100° • • • • • '
130 99° 98.6 • ' •• -• • • •• 9 • • • • • • ' • • • • • •• • • • • • •
120 98° •
. • • • . • . • . . . • . • • • • • . . . . . . .
• • • • • ' -' • • • • • • • • • • • • • • • • •
110 . •
-
.
100 96 " . . • • • • . . ••
90 95 . . . •• 0: : , . 0. . •
• . 0 • • •
• " • ' . , .
.0. . • . . . . . . . • . . . • . . . . • . . . : . . . : . : : • . ' • • .
• • • • • • • • • • • • , . , . .
70 • • • ' • - -
. • . • . • ' . •. ' . •. •. •. " . . " • . • . • . • • • ' •
60 . • • • . . • • • • . • • • . • . . ' ' " . . • • " . • • • • ' . • ' • •
50 • • • • • • • • • •
. • . •
• • • • •
40 RESPIRATION RECORD 4 -I " q­• I­•-. ji.­• • •Li - " i • ' • , .. k. e . . .. . . . . . . .

a 1 l p p -4.
93
(Cen tigrade Equivalents, for Refer
!! Record special data only when so ordered
,3 Ain= 79,3
I T.filp 1130 1313/70 ...
'I ' XiaWife
BLOOD PRESSURE , P.
to
HEIGHT:-WEIGHT-P
CV it --"AlpiV
14.5• (, 75 iso 51.6-
./D'?
kc0
_._.._._ . _.._
Of typed or 54,1 ten entries give. ama—lest, first. REGISTER NO. -WARD NO. middle; rank; rate; hospital or medical facility)
VITAL SIGNS RECORD
STANDARD FORM 511 (REV. 9-79) Prescribed by GSA and Interagency Committee on Medical Records FPMR (41 CFR) 101-11.806-8
MEDCOM - 4974
DOD 12186
MEDICAL RECORD VITAL SIGNS RECORD

MAMAS DAT
POST. mdurtIo-yLAM DAY 1 CAT 1
11 mum • • • • • • • • •
_..,1 Sr ; 1 DIM (0)­(0) I 0 -­.­•­. 0 :­• Ci .­• .­.­' • • . , • •••• . • • • .­. • • • ' • • .­. • • • ' .­. • • .­. .­. • • .­. • • .­. .­. .­. .­. .­•
180 104 • . . .­. , . .­• . . .­. • ,. • .
.
.
.­. . . " .­. . . • ' .­. . . .­• . . . .
170 103 . . . . . . . . . . . . .
160 150 102° 101° . • . , • . . . . . . . . . . . . • . • . . • . . • . . . . . • . • . .
140 1004 . . •• • " • . ' . . . . . . . . . . . . . , . , .
6 t 130 120 110 99° 98.6° W 97° , , , • , 8.• . . . . .11 ,,, . i V V V . . . . . . . . . . . . . • • .­• . . . . . . . . . . . • . . . . . . . .
100 9P . • . • . • . • . . . . . . . . . . . .
90 80 95° . : . • . . • • . • . . . , . . . • . . • . • • , . . . . • . . . . . . • . .
70
60 : : : : : : : : : : : , . . . ., . . . . • , . . .
RATION 50 40 1. mono­i • • . . . . . . • • . • r... ot... /J1.._r.­I iff t f • • .­. • • . • . . • . . . . . , . .­. • . • • . . . . . . • . . ., . • . . . . . . . . . . . . . . . . . .

. tids Fir
I
Record omelet data only when so ordered

i
BLOOD PRESSURE
MORD-FRIUGHT
-
PATIENT'S IDENTIFICATION [For typed or written entries 'live: Name—last. first, GISTER NO. WARD NO.
mirloile • rank; rate; hospital or medical facility)
1(1)1(6)-4 t
VITAL SIGNS RECORD
STANDARD FORM 511 (REV. 9-79)
Prescribed by GSA/1CMR
WIMP (41 CFR) 201-45.505
511-113 /
MEDCOM -4975

DOD 12187

516-109 NSN 7540-00-634-4156 MEDICAL RECORD OR!) OPERATION REPORT PREOPERATIVE DIAGNOSIS
,r-Aor4?•m.Ad,0
SURGEON FIRST ASSISTANT SECOND ASSISTAN
b)(6)-2
ANESTHETISIb)(6)-2 AN b)(6)-2 TIME BEGAN:`O J Q TIME ENDED:
r•ica,i a ATuktr, no le, (b)(6)-2 b)(6)-2 Scnimmumec ., b)(6)-2 TIME OPERATION BEGAN TIME OPERATION COM­PLETED
OPERATIVEDIAGN SES C

DRAINS (land and nunber) SPONG COUNT VERIFIED
I

MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION
OPERATION PERFORMED
c,3 , /)/Z8R4 _41-LAA (1:Ai7"-RA I Gq76Ff6N4A---HTi•-)G
uutiQ r-u-f?i LL?113
DESCRIPTION OF OPERATION (Type(s) of:a/tun used, gross findings, etc.) -I BRPSTHETIC DEVICES DATE OF/OEFrION (LOT no.)?
Pre-Operative Nsg-sessment :­
V 41
Dentures:-Y-Implants: -49 ­
/
Allergies: -A K4 --) .Foleyinsertedby: 6d2f NPO: (T\ N?
SafFif §tElf31?41/4.94
Intra Operative Nsg Assessment Anesthesia: 41 Prep: Bovie Equip 1/ : -Irrigation: -.4/'S Bovie Pad #: Medications:-la
/Blood
Operative EBL: ­
Post Operative
/*-7 Afrvt.Z.0 Wound Class: ­DSC: .
U/O: ie.-y:1,1,7-Zee/ A 0, D.-A.4—T'
Fluids: 7 .0 0 iri 1/4?")
b)(6)-2
Counts:
b)(6)-2
SIGNAT DATE
b)(6)-2
(OA____N•c--1_ 2 „ROY
PATIENT REGISTER/1.D. NO. WARD NO. •
(b)(6)-4
OPERATION REPORT Medical Record
r43

STANDARD FORM 516 (FIEv S-83)
by GSA/ICMRMEDCOM-4976 FIRMR (41 CFR) 201-46.505
DOD 12188

C er'401)C LAPID-t4Aa/3 c4..
SU--'01\1 ;b)(6)-2
A
A IV ESTH E.1 . 131

b)(6)-2 ----'-g-e-AJA400 ET-r-
1;.11. • !•:,•,1
Seln it".,
01' .• • - • ; ,q-11151•4 1.
160.V6.)-2
61051-2
„ 1.7.:111.11171
•
OPERATIVE DI A.C,T1U3ES ( .1... (751—
SA-4
•
(fle,L w1 „,.,,,th
— -
/0
MPiEPlALRVfDf.0
ii•;: 7
' M
d
O PERATIONEFRF!:DIWED
7)-­=
0
ti,ce.AA LJ (
.31 ch -,D
I.7•C'SC F: I PT I r-¦
= /9,06, u4//ug
-iv) sem
LL-v--(:) yr& te-oa-
Cie-IOr \ er

C2\ * tn,a-G--Qc ( ,-2-) ¦b
e-e r-N CCD-42.

9,b,cv„.4)6ptrr-6iL_Ap4A--c46rt--,E+6o1/4_,6 LAA--r \-1, A) 2-?46c6ctc \io 12..41
\ /
Loc.. -) C:)(2. L'""
\I I
1.-A-A2D
(b)(6)-4
M EDCOM -4977

DOD 12189

6-10r;
SURGEON :b)(6)-2
AN:s?irrt.. r.)
! 0 FL( CI Rd '")70.10571-46‘1 I 14. 071
••A
IA Mt
!••¦ ;• • 1 i • IV -FiT5(47....! -?..
b)(6)-2
I.! •
-1-/pro I_36
OPERATIVE DIAGI-10:3ES
" • . ••• 1:
tz.,‘
t-f-b)(6)-2
Are¦J k f'
MATERIAL_ FOSVVAR DE LA DO RA i -6LXAM:61'1 f)i !
A.r
oPERATiorst PER I'0 MEC)
o P._
1ki-,64-1-
wrti"D
6ffE -7tiFr151`1"-F5 •=75 FJ':ifOr'r('r-Ypefg..,. gr' findinka,

•
•'P E R AT ION
51101t"65 bit
alritliS L-G- F-g-AG-
.1
PIA"-e 140° t
ite (.24u o tf 2)
"X EA y• u oe: 3c1-.0
bL ,20s_
b)(6)-2
C 4 tDr"., --(4 e.-(?1 ( vet?)(
;
C1.e,a0 re etuL9-4 e*-Co, r
-
C fLit (V-1 yyth-2 , kle, 146' .b..1-1-s 6, 1 cliffieQ
-
C CV A6
Solov gRi 4-A-A .tt.henu
USC?
dgcti
cvA1/4)cAy-t46 /0" Dfvve-1 c
0AAA i r tAAAA rei

b)(6)-4
•
MEDCOM - 4978

DOD 12190

SV1 7110-00-614-4156
MEDICAL RECORD
OPERATION REPOlif
PREOPERATIVE DIAGNOSI S
SCfri-TI SAitte" (ArzA44-?-Th1‘64-cktp-
SURGEON (b)(6)-2 FIRST ASSISTO,NT SECOND ASSISI-p.p.
kJ
I
ANESTHETIpi ANEST6TIC
TIME BEGAN: /Z,
CCD • TIME ENtr2.
CIRCULATING NURSE SCRUB NURSF

TIME OPERATION BEGAN TIME OP6ATAICOM•
/
c 42g_p)(6)-2 (b)(6) 2 PLETEOve
141/A

OPERA"._,.. L.....-r,..,to
wES
DRAINS (Kind aolnyber) TSPONn1 COUNT VERIFIED
1:i)(6)-2
MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION
kb)(6)-2 I
out
OPERATION PERFORMED
Tift(9 64- + CALF CaliVAID
DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.) PROSTHETIC DEVICES6
1DA/TOF__O'ERATION
(Lot no.)?( A.,
1
:b)(6)-2 /C11
Ei/g. WI t XJ6
fl ;(r7.:(112_ s_rx_.4_, (E.e10 4-,k0-4 442
4.L16L_ C,494.
rwrcli -vv,z. k
A) t 0 c vv.t co c .y 4 mAA,as.c cierGit. LI) aar^-s2
,
e-+14
S-tiv )w6) 6\\.e. k-)st.r,Q
9).DaVP` nf-ey),TL ckP
k) ,6ft2-4,4 7 Lx1:5A-4 -2e_ Ce-N

SG o ecr-N
kTE/
s ' n"." "" c kb)(6)-2 ririt(t‘j 4j3
,b)(6 )-2 o
1/140
PAY-rENT'S 11BENTIFICATION (Pos typed or written en trigfctroilYtaylle -last, first, middle; REGISTER/I.D. NO. WARD NO.
b)(6)-4
OPERATION REPORT Medical Record
o. S. GOVERNMENT PRINTING ONVICE, 1990-259-301
STANDARD FORM 516 (REV. 5.83)
Prescribed by GSR and 1CMR, FPMR 101-11.806-8

MEDCOM - 4979
DOD 12191

SN 753. 0.00-634-4156
-
MEDICAL RECORD OPERATION REPORT
PREOPERATIVE DIAGNOSI
FIRST ASSIST,17 DtVUNU Abblb IAN I
ANESTHETIST0)(6)_2 ANE THETIC
TIME BEGAN: 0 er­
Le,of___ . 2;
TIME ENDED:
Inec
A "MI Mr nu !nee
SCR B ""6 PLETED el
CIRCU [D.(6)_2 b)(6)-2 TIME OPERATION BEGAN TIME OPERATION-
LT I` I 08'47-
I I
OPERATIVE DIAGNOSES
9vk
tp)(6)-2
DRAINS (Kind and number}
IFIED
MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION
OPERATION PERFORMED
ok44,-g- ei,o4AAA, g -44 ,410 (64
DESCRIPTION OF OPERATION (Type(s) ofsuture used, gross findings, etc.) PROSTHETIC DEVICES DATEF 07 AT ION
(Lot no.)

Ltm,L,1

Lth'P
cL4 E 7 -x 4 "c: Le vial434 . 60 sh. 9 vvc4e-±,L-6,-L, 11\4-64 ann-A Ofif
Vtr-.0-40
Ck-DCAIJ b1/05-t-e -Th CaA-CYA C boc d-4
r
(b)(6)-2 DATE
A/2-C /``'' 5
? !tries glue: Name - last, first, middle; I REGISTER/1.0, NO. . WARD NO.
grade rclate; hospital or medical facility)
.," 1,7
r)(6)„,
OPERATION REPORT Medical Record
GM/UWE:NT
PRINTING oryTcE: Pn0-'259,01

STANDARD FOrliVI 516 (REV. 1-83)MEDCOM -4980 Prescribed by (;5r, r.rld ICMN, FPMR
101-11.606-a
DOD 12192
ee"-
NNMC 4.120/279 (Dec-00)
Proposal Operation Pre / Pon-anesthetic Summary
Age Weight Height ASA Status
Allergies (kg) (to) a-L., -A 3 4 5 a AM kiff
Che iehj^
Ileniawkgx
Coaes Urinatysis / HCG NPO —
H H
PT -
I
Teeth —
Platelets -
INR -WBCs -Airway — MP I / 11 / ID / IV
PTT -FROM,-Ms V.-FB HM
.E.EVintin
CNS / Skeletal
Cough:
HTN:\
Sputum: Hepatils
CAD: \
CVA:
GI:ME:
COPD LOC:
Endo:CHF:
Recent URI. Neuro: Heme:VHD:
TB: Muscle:
Arrythmias:
Skeletal/
Exercise Tolerance:
Lung Exam p
EtOH: Cardi
CXR: ECG:
Tobacco:
Preyivas Anesthetics:
Medications:

II „‘
Family Hz:
MDrphi)9,e,
-uxugarj2Lagacara •
Mulls Pre-op DOS

Pay of $ureery­
. BP;
63-5W khart Reviewed / patient examined •
HR: O Risks / benefits/ options diicussed with patient

4 / al 3
..Padent Miestions answered.
Resp:
Patient ccp
rarent / guardian understands and accepts risks
iotb)(6)-2
Temp: liq.,­
clears, -solids •rq,eriorcti Peck RR: Plan:
{44
gu-i+ock
Evaluator Signature Staff MD / CRNA sienanne
Date & Time
(b)(6)-2
b)(6) 2
LCDR/UStiARESIHESIA
Patient identification
Post-operative note
(b)(6)-4
No apparent anesthetic complications
hIlS1-, b)(6)-2
1(b)(3)-1
r-r unit

4/3 1-001-{
rg_SA ES
MEDCOM - 4981
DOD 12193

Height
ASA Stains
(in)
Allergies ,? 4 5 E-
i0
/ iv
FB HM
14Y0-4guitze
t
ivrtort kevicwel tb efi tpNi ntexa.IMPN •
ai4
ent qifemstwig* d4cus,ted. "
WPatient
. Ans*#iid: pati
P#44ta
•
pw a .
/04044.utidekstaPds and
lig.,
actePit
Plas1; clears,
Olicts
b)(6)-2
entitication Po etativ
(b)(6 )-4 no e
No apparent anesthetic complications
Signature MEDCOM - 4982
DOD 12194
PRE—RNESUIETIC EURLURT1ON
Date of Surgery 4m los
Zedun
Age Wt-g lb .11PQ after MN Last PO
cillf etn:
641101-inAr M) F Ht
-C
c..c Prosthetics:
Surgeon (b)(6)-2 ASA 1 2 3 4 5 E-Airway: Malampoti 1 2 3 4
LABS Neck ROM! Allergies: sli I(D Environme
UHCG Pos Neg N/A UA: Normal Abnormal N/A
120/77... Pulmonary 1 Cardiovascular Other Systems
BP:127_4_ P: -‘e&-
No problems CI No problems . No problems . Tobacco COPD HTN Skeletal .ETOH 6S‘P-14
Asthma MI Anemia
LURE ETA NOM 7 Bleeding
TB Chest Pain
Heart Sounds: RRR Irreg Liver
Murmur
URI CHF
TESTS: CXR N/A

Other Renal SOB/DOE
ECG N/A .
Neurological GI: GERD HM PUD No problems I=1 ArrhythmiaStress test
Seizure Thyroid: Hyper Cl CVA Exercise Tol: Good Fair Hypo .
Echo
Poor Diabetes: NIDDM H/A IDDM PFT OtherOther
Other
Family Ifistory: None Medications
.
Prior Anesthettstproblems: rI1MP
mat Guor
Preop Diagnosis \/\/ elAkiike CE Premed: None -PO Versed mg
S Zantac Region Inhaler
b)(6) 2
Evaluator Signath
DOS: Plan reviewed. Changes since preop: None 1:1 rim.. (4 /L /03 --71Me Jo'
Provider-Proceed 0 Cancel Cl Primary Plan‘* SAB MAC CLE ISB AXB Bier
PostOp Assessment via: Pt interview .
Alternate PI ..: ­Chart review 0 Anesthesia related complications reported: None Cl plan reviewed with patient/guardian who Entry nude in Progress Notes 0 communicates understanding of the plan induding I risks, benefits, and options. All questions answered.
Evaluator Signature
I
. Risks discussed Include but are not limited to death,
Date -Time -stroke, NI H/A, aspiration, dental damage.

(b)(6)-4 SF 517 (BALA)
nni-crig•Ad,
(ill
MEDCOM - 4983
DOD 12195

MAC 6120/219 (Dec-la)
Pre / POSteanathetice Summary
Proposed Operation
Age Weigh;-Height ASA Status Allergies
(kg)-(in)
so 5 E-

-Tc.amatris 1c 1a" tkoi
Coags Urinalysis /HCC Nth-g,_s •
PT­\os_• •600 Teeth
Platelets INR
a_vs_ • ,21
Airway - MP I ``C J/ m / IV
WBCs PTT FROM,-FB NNI
Rogow
a
Cough:
Sputurn-Seizure: H(patic:
CAD:

Asthma: CVA:
COM:1i-111/1,hNE: )1(J1tt. le44-10t, ado. tcrx

(73142
CHF: it
Recent URI-c-—( IL Neuro:
A
Muscle: Heme:
TB:-L.:I" 2441044.4 VHD: (
Arrythrnias: Skeletal: Exercise Tolerance: Lung Exam; EOM Carulac Exarn:
trk
(La. (Z.
CXR:-ECG: Tobaccr0
•
hewZ..11s Anesthetics:
Current. Medications:
Premedication:
INN)b04 .'")- Lc)
Fat-„x l
imulnmaliagniara
3!itaa
1 F11:tf UI ban pa00ii
Lfl6LLD • .0170440004 i.opOill*,00400:*ittirpit*.nt-
CAA) kosp;

0*.*:*4444)140#44**d.s accepts risks
.
I*); .4i14 Itr°?1 °41E'
?e
Patient iclentir cation ,b)(6)-4 Post-onei'ative note
(b)(6)-4
0 No apparent anesthetic complications
Signature -MEDCOM - 4984 Date

DOD 12196

MEDICAL RECORD
COMPONENT REQUESTED (Check one)?
%RED BLOOD CELLS
FRESH FROZEN PLASMA EI PLATELETS (Pool of units)?111 CRYOPRECIPI TATE (Pool of units)
Rh IMMUNE GLOBULIN
111 OTHER (Specify)

VOLUME REQUESTED (Ifapplicable)
LSO
REMARKS:
UNIT NO. :b)(6) -4
DONOR
ABO
Rh
gas

ML
TRANSFUSION NO.
PAT
RECIPIENT ABO
Rh
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood REQUESTING PHYSICIAN (Print)
Cell Products ore requested.)
111
TYPE AND SCREEN
C -1/ CROSSMATCH
DATE REQUESTED
8 pr 0 6
DATE AND HOUR REQUIRED
Oc-j‘.(X, .Cal
KNOWN ANTIBODY FORMAT N/TRANSFU­SION REACTION (SPeeliY)
IF PATIENT IS FEMALE. IS THERE HISTORY
i0F: RhIG TREATMENT?DATE GI V, HEMOLYTIC DISEASE OF NEWBOR
SECTION II -PRE-TRANSFUSION TESTING TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
-12.S
6C VLA—e
CROSSMATCH NOT REQUIRED FOR THE CIM" ENT REQUESTED DAT 2
REMARKS:
/74tor
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFU/ON DATA INSPECTEn ANin tal(i IF r] (b)(6)-2
AT (Hour)6 (Date)
IDENTIFICATI N"
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.
let
b)(6)-2
2
(b)(6)-2
C-

PRE-TRAN
TEMP.6 BP
2,-?
DAT F SFUSION TIrAE STARTED
PA6NT •ENTIFIC6ON -USE EMBOSSER (Fo typed or written entries give:NAME - Last, first, middle; rank/rate; hospital number and name of facility.)
;t3)(6)-4
(b)(6)-2
DIAGNOSIS OROPERATIVE PROCEDURE
R.--IA,. ?G Sia
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to
be correct. SIGNATURE OF VERir IER
S Or DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:Ell RECORD6 NO R
SIGNATURE OF PERSON PER FO b)(6)-2
— ^"^"6
b)(6)-2
AMOUNT GIVEN
REACTION
POST-TRANSFUSION DATA 'TIME DATE COMPLETED INTERRUPTED
• di.
•
¦¦¦=i11..... IRWIN/MI
6
NE SUSPECTED

If reaction is suspected — IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to
the Blood Bank.

DESCRIPTION
URTICARIA 0 CHILL60 FEVER rl PAIN
riOTHER
DIFFICULTIES (Eq ipment, clots, etc.)
0?iljES (Specify)
b)(6)-2
SEX
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8.86) General Services Administration Interagency Committee on Medical Records FIRMA (41CFR) 201-45.505
518.122
MEDICAL RECORD COPY
MEDCOM - 4985
DOD 12197

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one) -TYPE OF REQUEST (Check ONLY if Red Blood REQUESTING PHYSICIAN (Print)
Cell Products ore requested.)

(b)(6) -2
RED BLOOD CELLS
lOr FRESH FROZEN PLASMA niannineterna nOC. -ri,ic no,r-cr, tri TYPE AND SCREEN
sql..CROSSMATCH
7 PLATELETS (Pool of units)
..6.n CRYOPRECIPITATE6al of_ units) klta) trf)6 W +C't D
DATE EQ ESTE
I6have collect6a blood specimen6••11 the below
Rh IMMUNE GLOBULIN
'6C3CD-named patient, verified the na .e 6:6r./la6No.6of IDA E AND HOUR RE UIRED
the patient and verified the 6p6i :16u•e6.bel to OTHER (Specify) / be correct.
VOLUME REQUESTED (Ilapp(1"...3, KW) NANTI BODY FORM •IIPiN/TRANSFU-SIGNATURE OF VZRI SION REACTION (Specify)
k.../
(--) ML
REMARKS: I F PATIENT IS FEMALE. Is THERE HISTORY DA6FIE°
OF:
RhIG TREATMENT? DATE GIVEN.
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBOfirA/—
SECTION II PRE-TRANSFUSION TESTING
UNIT NO. PREVIOUS-RECORD-CRECK

TEST INTERPRETATION6b)(6)-4
ANTIBODY SCREEN CROSSMATCH / NO RECORD
1
PATIENT NO. !SIGNATURE OF PERSON PERF 6 6 'b)(6)-2
p)(6)-2
DONOR RECIPIENT
I CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED icirAff LOPS
ABO
ABO REMARKS:
0 1
Rh Rh
P05 / 740R0,5
SECTION III — RECORD OF TRANSFUSION
POST-TRANSFUSION DATA RSPECTED AND AM o NT (_ I v TIME OATE r6L-(b)(6)-2 ML REACTION6 6
NE SUSPECTED
? AT (Hour) ON (Date)?
cLs
IDENTIFICATI a N' If reaction is suspected # IMMEDIATELY:
1.
Discontinua transfusion, treat shock if present, keep intravenous line open.
I have examined the Blood Component container label and this form and I

2.
Notify Physician and Transfusion Service.find all information identifying the container with the intended recipient

3 Follow Transfusion Reaction Procedures.
matches item by item. The recipient is the same Person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and IN. solutions to
Component Transfusion Form and on the patient identification tag. the STO-Ed Bank. 1st yr= p wic
DESCRIPTION
(b)(6)-2
URTICARIA ['CHILL n FEVER6PAIN
2tid-v-em6 TT-1—
n OTHER
b)(6)-2
OTH ER DIFFICULTIES (Equipment, clots, etc.)
PR YES (Specify)
1.1?
IU6T
, 2.7.1 n_
, TIV:vreivrmle7pr,e..1, .
1 11
TEMP. CI C1 ,6PULSE 1 I ._)6i -....) BP
b)(6)-2DATE OF -cRAN;FUSION6TIME STA TED
2 1526
11?/10 ? PAT NT I DENTIF I CATION - USE EMBOSSER (For typed or written entries giveN?E - Last, first. middle; rank/rate; hospital number and name of facility.)
(b)(6 ) -4
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86)General Services Administration FlnitRermaaRenizecoFmR mi 2ttoer.4o5n.sMold ical Records
btry
518-122
MEDICAL RECORD COPY M EDCOM -4986
DOD 12198

NSN 7540-00-634-41,
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE CF REQUEST (Check ONLY ifRed Blood Cell
Products are requested.)
z\ ED BLOOD CELLS
-1-Li FRESH FROZEN PLASMA Ej TYPE AND SCREEN
. PLATELETS (Pool of ?units) XCROSSMATCH
1=1 CRYOPRECIPITATE (Pool of units)
DATE I have collected a blood specimen on the below
Rh IMMUNE GLOBULIN Rmu'17 /W 63
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to be 1=1 OTHER (Specify) ?
/SAP
/ N 3
VOLUME REQUESTED(If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION S r.
REACTION (Specify)? 13)(6)-2

WriAt -ML
REMARKS: II' PATIENT IS FEMALE. IS THERE HISTORY CF: DATE VERIFIED
6
RhIG TREATMENT? DATE GIVEN: ?INJIA 7 //)
-'TIME-VERIFIED HEMOLYTIC DISEASE CF NEWBORN? t'hk:
SECTION II -PRE-TRANSFUSIONTESTING
UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK ANTIBODY SCREEN CROSSMATCH
(b)(6)-4 RECORD 1=1 NO RECORD
PATIENT NO.

SIGNATU
Corn p
DONOR RECIPIENT .
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQU
P130
REMARKS:
C)
ABO
0 Eip: 17 AP4. ac1U1 e
Rh Rh
Po.s PO3
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSIONEATA POST-TRANSFUSION DATA
Ahim-
INCPFnTCn -
AMOUNT GIVEN
TIME/DATE COMPLETED/INTERRUPTED
r
)(6) -2
' ML
APA_ 3 • -a.1.5"
. REACTION
TEMPERATURE PULSE 91/00 P9ESSURE AT (Hour) ON (Date) 4 11 1 93 NONE 1=1 SUSPECTED
57) / aO /."/
IDENTIFICATION
If Action is suspected-IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.

The recipient is the same person named an this Blood Component Transfusion Form and 3, Fdlow Transfusion Reaction Procedures.
on the patient identification tag.

4. Do NOT discard unit. Return Blood Bag. filter Set. and I.V. solutions to the Blood Bank.
1st VERIFIER (Siorature) DESCRIPTION CF REACTION
Kb)(6)-2 . URTICARIA CHILL 1=1 FEVER . PAIN
OTHER (Specify)
(b)(6)-2
1VC OTHER DIFFICULTIES (Equipment, clots, etc.J
PRE-TRANSFUSION /
. NO . YES (Specify)
TEMP. inn,9 PULSE 1 :1&12 1( 1 SIGNATBRi OF PFPS019 hlrITI
b)(6)-2

DATE OF T N FUSION TIME STARTED
5-11
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, ti , ran S X It A WARD
rate; hospital or medical facility)

c:;
x7 oq
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
S1351430113 FORA 518 KV, 9-92)
Prescribed by GSA/ICMP), FIRMR (41 CFR) 201-9.202-1
MEDCOM -4987 Medical Record Conu
DOD 12199