Medical Report: 58-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot to Abdomen and Chest

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MEDCOM - 16641

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510-112 NSN 7540-00-634-4123
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DOD-030032

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DOD-030041

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE_

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
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ICU3

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1_
USAPA V2.00
MEDCOM - 16653

DOD-030042

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE

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

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ICU3

CHRONOLOGICAL RECORD OF MEDICAL CARE
E./4w do(0(6)
Medical Record

STANDARD FORM 600 (REV. 6 -97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1_ USAPA V2.00
MEDCOM - 16654
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DOD-030043

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
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MEDCOM - 16655 U$APA V2.00
DOD-030044

AUTHORIZED FOR LOCAL REPRODUCTION

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DATE MPTOMS,DI. NOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, &st, middle; ID No or SSN; Sex; IREGISTER NO. WARD NO. Date of Birth; Rank/Grade.)
(6)(6)-4 CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 6-971 Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 16656

DOD-030045
_ RECORD -PATIENT ACTIVITIa._ki
For use of this form, see MEOCOM Circular qv-5
[--_ SECTION 1 - PATIENT ASSESSMENT
DATE: ‘-) 0 C-I-K)_ I PATIENT ACUITY LEVEL :_ I POST-OP DAY: _ HOSPITAL DAY: ]

COMPE,ETE ONLY AT TIM'0_ISSION or PATICiliNSFEH IN - TELEPHONE REPORT:
'

Time_ Ile ._To_ From_ . AMBULATORY_. CRUTCHES _. WHEELCHAIR_0 STRETCHER Total ER/RR/PACU time_ Phys' tan_/
Anesthesia (Specify): Proced e/Diagnosis_e:›ipt 6c-IA)_of _B/P_
P_R _T _ LOC_
Nturovalr_eck.s
Dressing/cast loet. Tubes
Intake (IV. po)_ Output IEBL, other)_ Voided_. N. . Yes_Amount: _
Medication

Other
Report From -_

Received By
TIME: /70

,.
BP ARTERIAL LINE SP CUFF
i_i
1 • TEMPERATURE .
q&' ' c•) 114) PULSE
I r7 3 RESPIRATORY RATE (e." /0 t t? OXYGEN (L/%1 PULSE OXIMETER 11, ? Vi.

• r 02 METHOD
( 1( --(k

NC = Nasal cannula_NR = Non re_breat;her_FM = Face mask
_VM = Ventu i mask MT = Mist tent_PR = Partial rebXa her_A -= Aerosol_-_TC = Trach collar
Oxygen Method Key:_
• . •
1;_to.)ytllCL: • -• _1-• -I_cry •-z • • • • • • • , • • . • • .
I
(700

--AZ kW
/

TIME: TIME:
t
o

'Skin breakdown
•
prevention
PAIN

'Falls prevention protocol
INTENSITY
._. ._.
.._.

'Restraint protocol a ....._
._._._.
1-
•
MED ADMINISTERED IY/N)
RELIEF ACCEPTABLE MN!

•
Seizure precautions

•
Isolation precautions ._...__

TIME:
.O.
FINGER STICK G
--.'Zill!

E YESTERD_'_WEIGHT:
X
----qui
H.,.. INSULIN IY/N) D

TODAY'S WEIG_S WEIGHT CHANGE:
Ift..-.
R

'Per hospital policy.
24 HOUR PO IV 01 IV #2 TOTAL IN Urine Stool TOTAL • TOTALS
PATIENT IDENTIFICATION DIAGNOSIS:_
40,••
#111101_.¦
OW-it

DAG:_ ADMI SION DATE:_.7c)C:,.. f
LOS:_ EXPECTED RELEASE:
CASE MANAGER:

PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
_

ME DCOM FORM 689.-R (TEST} (MCHO) MAR c)c) PAPVICH lc Frwrinnii, ARE C3SOLETE Por,,e:'' of 4 pages MC V 1.00
MEDCOM - 16657

DOD-030046

SE .
PATIENT ASSESSMENT --
DIRECTIONS: A check I

in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brier.explanation of abnormal findings w.71 be noted in the appropriate column.
TIME: NITIAL TIME:
INITIA TIME: INITIALS:
NEUROLOGICAL: Alert and oriented to
(0(0-1 _

1. co(0-1. r1
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.

•
CARDIOVASCULAR: Pulse regular & rate

2. 1111
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 .
010 -foc i,

6&-\1110V4:61
rx
rate for age group; quiet and regular._Depth is

16 lix..) 0_, ---csa, Aik C.54)
regular. No cough. No abnormal breath \.-.__Y--I.) 0
sounds. * C I¦
maN lial -
NO b tiO CP II

_ _ at' 1li3S1
-.
4. G.I.: Abdomen soft and non-distended. --­
Bowel sounds active. Reports no NN/pain • kr414, I "It'd-
with eating and no problems chewing/
Tekit N (00 cl
+'`-e0()
swallowing._Denies constipation, diarrhea or . -_

f.,i) Loi W_ls)
rectal bleeding.

Pdo d i•-
ct P-; to i 1--ii

Jima
1
5. G.U.:_Reports no dysuria, retention,
urgency, frequency. nocturia.

_Urine clear, 11 WOid,S19 61/ ._\JO
yel ow/amber. No unusual discharge. AJOWNN-M' CagiVAl 111

/(• ri i---0,-V f
\-t:0-\-
6.
MUSCULOSKELETAL: Normal muscle
0 0e))1_''0.--.."_6 Aj
development and mass for age. No

deformities. No assistive devices needed. tivo /(ejr a.Jy-t_Q
.

Normal % IIS
active ROM without pain. No joint

11116t.' __ ._A.
swelling/tenderness, weakness or paresthesia. I.-

_01,CC (3+_ • AP
7. SKIN: Warm, dry, intact._Good turgor. No
111 OA/4 S --h) --Q-AA/3-L-,

rashes. inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
(de r

prominences. Mucous membranes moist._. -
ti rOt i. tAxi
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 . Puffy_I - Infiltrated_R - Reddened_OK - No swelling/redness_- Central line)

TIME:
000_ tCM_
_ INITIALS: — TIME:
INITIALS:
TIME:_ INITIALS:
IV patency ,/_q 5 (b)(0•1 IV patency_,,/_q_Iv:_(b (10)-2

IV patency_,./ q_hr:
IV site care provided:_

...C..5 IV site care provided: aX•p_21:1_
IV site care provided:
IV tubing changed:

IV tubing changed: IV tubing changed:
LOCATION CONDIVON LOCATION CONDITION LOCATION CONDITION
IV Site #1:_
C4(----IV Site #1: ar°' C

IV Site #1: IV Site 02:
•. i
IV Site 02:
IV Site #2:
Comments: Comments:
Comments:
MEDCOM FORM 689-R (TEST) (MOHO) MAR 99
Page 2 of 4 pages
MEDCOM - 16658

DOD-030047

..k.•TION III - PATIENT INTERVENTIONS & 1
.• SITE:_
TIME:
TIME:
inaV011111
I (OW-

• COLOR
ID band visible/legible
1(k,)( 6)
117/11
APILLARY REFILL
Orient to environment pin
.
cnQLL.w_-0 I-
TE_RATURE
-
-• EDE
SENSATION
iR
'''' MOTION
PASSIVE FLEXION
• .: PERIPHERAL PULSE

•.
LEGEND
, I Color:_P-pink (normal); C-cyanotic; W-pale, white
. Capillary Refill: 1-(0-2 secs); 2-(3.5 secs); 3-1 5 secs)
.4. 7: Temperature: C-cool; W-warm; H-hot
Side rails (214). up
Bed position low

Call light within reach
Review & post lab results

Notify MD abnormal labs It
Incontinent urine/stool
Linen change pm
Turn/reposition q2h
14. Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
ROM q2h if immobile
. .N: Sensation: A-absent; N-numb; T-tingling; S-sensation (present) ‘Ft '

Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM -Antiembolic hose Passive Flexion:_D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
- Peripheral Pulse:_0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
-!,..
BREAKFAST LUNCH
•-• T '', PERCENT C_MED: . HOW TOLERATED:
•, El SELF_El ASSIST
] BATH/ORAL CARE •
I:
TYPE OF ACTIVITY
S.
(Circle all that apply)
TIME:_ CONTENT:_ .
, 0
/4-).
DINNER
T
TYPE:_ --
PERCENT CO

_ED: PERCENT CONSUM HOW TOLERATED: HOW TOLERATED: ,_(pie
. CO_TE . SELF_. 0700-1500
. SELF_0 COMPLETE
SIST_. TOTAL
BEDREST_. SELF

C-AMBULXITI)_. ASSIST
--6--Aki4
BRP
TIMES/SHIFT
`
BRP 11-4( CHAIR INITIA ( b)(6) -2
e.:47-
atie_amity Verbalizes Understanding PATIENT IDENTIFICATION
C P Vt) IBM
(6)(6) -1

TIME:_ets)_INITIALS: 111111 TIME:
CONTENT: ,_(‘)(6) -1-CONTENT:
--WW-1 %_e9ZI -CL_ . '. \00A16131,_1 t51ttKC'b WO_"
rULQ
_
ASSIST . COM
1500-2300

.
SELF_. COMPLETE

.
4SSIST_. TOTAL

BEDREST_. SELF AMBULATE_. ASSIST BSC
/ TIMES/SHIFT
BRP
CHAIR
F_CI ASSIST ( COMPLETE
2300.0700
.
SELF_. COMPLETE

.
ASSIST_. TOTAL

BEDREST_. SELF AMBULATE_. ASSIST BSC
._/ TIMES/SHIFT
BRP_-
CHAIR

INITIALS:

Patient_mily Verbalizes Understanding . Patient/Family Verbalizes Understanding
INITIALS SIGNATURE SHIFT
(2)(L) ­2 ---..,,,
()(0-2.

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 3 of 4 pages
MEDCOM - 16659

DOD-030048

Jtt., I Il/IM III - Inf 1 ttiVtild I ILJNS & I tAcHING (Cont)
-_,.W: ml TREATMENTS
LOCATION OF WOUND APPEARANCE

DRESSING CHANGE
0
. fid" 15 . -i.---

Vat
-'fr Ctc I-0 CT t---_
iiA c

s # pk(ei C--V f---
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SECTION IV - NOTES
l -

'703 1 Of (2dAr3176-- ry /6(/
eazi.
21
9,4' idi1

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smk. _ I A. 41:11j IL.1 kik • ttat '

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.

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.
.
•
.,.. -
...____.... ..,..,.,..,_.
MEDCOM FORM 689-R (TEST) MICHoi mn. n"

DOD-030049
ar

r -

MEDICAL RECORD - PATIENT ACTIVMES.FLOINSHEET For use of thie; form,
See MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: (2FP-rx-----t 005 !PATIENT ACUITY LEVEL :R
_POST-OP DAY:

HOSPITAL DAY:

` COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Time _

7o_
From _

0 AMBULATORY • .
CRUTCHES

Total ER/RR/PACU time_ . WHEELCHAt
ikTCHER
Physician

An _
Procedure/Diagnosis • ccr y):
LOC

P Neurovascular checks
Dressing/cast _
Tubes

Intake (IV, po)
_
Output (EBL, other)

E Voided
Medication . No_.
Yes Amount: Othe
Report From
Received By
TIME:

BP ARTERIAL LINE
BP CUFF
TEMPERATURE
PULSE
RESPIRATORY RATE
OXYGEN (LI%)

PULSE OX1METER
02 METHOD

Oxygen Method Key;_NC = Nasal cannula
NR = Non rebreather

FM .• Face maskMT = Mist tent
PR = Partial rebitather

A = Aerosol
•
TIME:

TIME: 'Skin breakdown PAIN prevention INTENSITY
'Falls prevention protocol
'Restraint protocol
MED ADMINISTERED IY/NI C

• Seizure precautions
RELIEF ACCEPTABLE IT/NI

'Isolation precautions
TIME:
FINGER STICK GLUCOSE E

INSULIN IT/NI YESTERDAY'S WEIGHT:
TODAY'S WEIGHT: S WEIGHT CHANGE:
'Per hospital
L
24 HOUR
IV #1 IV #2
TOTALS 'TOTAL IN
Urine I

TOTAL OUT 'PATIENT IDENTIFICATION
DiAGN•'71.F.:

1 DRG: i
ADMISSION' DATE: EXr'ECTED Ii LEA:
( ¦, )(6) -
CAST. MANAGER:
i

1 PRIMARY CARE MAr:ACEli :__ MEDCOM - 16661
.

)ufrFEDI::,,;: q
DOD-030050
1
4
o

11,
SECTION II -PATIENT ASSESSME NT ..__ ...... _. -.
DIRECTIONS: A check I

in the small box indicates patient assessment critefa have been MET."
f all the stated
cri eria are not met, a brief
explanation of abnormal findings will be noted in the appropriate column.
1.
NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.
2.
CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. _Depth is
regular. No cough. No abnormal breath
sounds.
_

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

S._
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 pa n. 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 I for documenting pain intensity.)
9.
PSYCHOSOCIAL: Behavior is appropriateto the situation. Anxiety is controlled or mild and appropriate to situation._Interacts appropriately with others.

10.
IV SITE ASSESSMENT:

_(LEGEND: P - Puffy_1 - Infiltrated_R -Reddened
,
TIME: 0 WO_riy0
INITIALS: AIL_ IV patency i_q a hr:_
tarAi
IV site care provided:_
cts5e5a-egi
IV tubing changed:
LOCATION IV Site #1:_I—_r-4 CONDITION 0 K
IV Site #2: l

Comments:_
HC-
TIME: low INITIAL
TIME:
INITIALS:
TIME:
INITIALS:
Nr_ (6)(6 • Z
rq----- .
¦
.--6-44-iiI Luck u TFe A -r) .
. 051' Cirri Pibe)_i
PaS51r1 a ktvi

ci & cti-,
01. 8S a dive ')I ti. 'V y 9. + c. Ru GI c.." clear \I elk 0 '-m cltr-can Cy •
0 In ccryii en t-e hmes • .
. 6-O era 11 Rd II
,
tilf aine3 S , /144k5
C, curis-r---. . i
r•
. Centra i 41actomi Act 1 .
utim4) ,ttur ns -to
guE oyvan-q ev ci
519 J1-a g0V J
111/..--I
Ef----
-,z TIME: INITIALS: IV patency_I_q_hr: IV site care provided: IV tubing changed:
.
r
.
III
.

_OK - No swelling/redness *_• Central line)
TIME:
_ INITIALS: IV potency_I_q_hr: IV site care provided: IV tubing changed:

IV IV Site #1: Site #2: Comments: LOCATION CONOITION IV Site #1: IV Site #2: Comments: LOCATION CONDITION
MEDCOM - 16662
DOD-030051

SECTION Ill - PATIENT INTERVENTIONS & TEACHING
TIME: I,
SITE:_ TIME: 0.10

ID band visible/legible
I" IBM

Orient to environment pm f _IME
Side rails (2/4) up
cl) u. -0 F-LIJ CC
COLOR
CAPILLARY REFILL i
4. TEMPERATURE k.)3
'

Bed position low
'. EDEMA II

Call light within reach
SENSATION
_--•
MOTION ,_i

Review & post lab results
PASSIVE FLEXION
.

Notify MD abnormal labs
PERIPHERAL PULSE
•
LEGEND
._.

Incontinent urine/stool 1,)(6)-2
Linen change prn
13)(0-2

Tum/reposition q2h 6 0-Z.
ROM q2h if immobile
ma

Antiembolic hose
MEM=
"._'l Color: P-pink (normal); C-cyanotio; W-pale, white
C.
•.--7, Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-1 5 secs)
;tj;
c..,: Temperature; C-cool; W-warm; H-hot
IV Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
..
Sensation: A-absent; N-numb; T-tingling; S-sensation (Present)
A":
,J3). Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
it-i.-; 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
DINNERBREAKFAST LUNCH

TYPE: TYPE: TYPE:
PERCENT CONSUM_: PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED: -,_r

SELF_. ASSIST . COMPLETE . SELF . ASSIST . COMPLETE . SELF_. ASSIST . COMPLETE
0700-1500 1500-2300 2300-0700
0 SELF_. COMPLETE . SELF_. COMPLETE . SELF_. COMPLETE BATH/ORAL CARE pcASSIST_
. TOTAL . 4SSIST_. TOTAL . ASSIST_. TOTAL
BEDREST_. SELF BEDREST_. SELF
ULA_IS?: ASSIST AMBULATE_. ASSIST AMBULATE_ . ASSIST TYPE OF ACTIVITY BEDREST_. SELF BSC BSC
(Circle all that apply) # TIMES/SHIFT ff TIMES/SHIFT ._0 TIMES/SHIFT
BRP BRP BRP_. L-1):1/4.._. CHAIR CHAIR
TIME:_ INITIALS:TIME:_ INITIALS: TIME:_ INITIALS: CONTENT:CONTENT: CONTENT:
. . .
Patient/Family Verbalizes Understanding

. Patient/Family Verbalizes Understanding . Patient/Family Verbalizes Understanding .
PATIENT IDENTIFICATION SHIFT
INITIAL S SIGNATURE
(10)00) -z_
RAI1-%/-.,-NR A 4 nnnn
•-• .1 .4 ,, aroc

DOD-030052
•• •:1 4

• • 4
SECTION IiiINTERVENTIONS
.7.

--. • .-• •-•...• •••.... ,.......”1 • • ... -T
TREATMENTS
. M APPEARANCE

LOCATION OF WOUND

. E
DRESSING CHANGE

U '
. .,
E
.
SECTION IV - NOTES

•
1000 .' CeneVCCL\ At)0 WOUYA hct rink__

.

(cow cti+i on -Pt -s.Cu_. on. •
Or curnceiumcst w.c)c,nt\c1 . Sict _ --v-iii stk_ +0 riltoldkr of i,v'r\t-K
iN nY1-el.VA3\e vy)-

(irn In a -e in 0 k--ee; Oirr-s_r; r-t d c-4,-)_CU 0 Urv-/ 1 JIARA-Th
-1, -•

A • mu fi;Jte. 4.114, 741 (6)(6)-2 A U fa f AO f ¦, • it.JIA0
le Q Earc 4,.1 ti. 1-!-D 0 an ri Si I V a Cfrn e gioaQ if -td

• .e. 0 • 4 • ' . ala-we /14 0 i is pm - ip
461 n0 A. IIA i _A i

/4-X 4 0 kx re5i3-1,-,«.. Cud/ co4 k rna-r7 ¦
AzAly
..

)
-
I

-I--
MEDCOM -16664 -... •
___ _
DOD-030053

SKIN AND WOUND ASSESSMENT
MEDICAL RECORD PROGRESS NOTES

Diagnosis:/r _ POD:
Skin assessment must be done initially and every 7 days.

Braden Scale Evaluation (See Braden Evaluation Table for Details)
Sensory No impairment 4 4 Mobility No limitations 4
4

'Perception Slightly limited 3 Slightly limited 3 Very limited Very limited 2 2 Completely immobile 1 Completed
Moisture Rarely moist Nutrition Excellent 4 4' Adequate (Eats 50%) 3 Occasionally moist Adequate (Rarely eats) 2
3
Moist Very poor 2 Constantly moist

Activity Walks frequently Friction and No apparent problem 3 3 4 Shear Potential problems 2 Walks occasionally Problems 3 3 Chairfast 2 Bedfast
. -

4d4.1kolfir score Total
Above 29 low Risk
and _Medturn Tusk
4441,5_high

Below 10_Very High Risk Notel ABraiien Scale Score •;iflessthaii.I5 indidates HIGH RISK-requires immediate Ulcer Prevention Pftigiurn..
Surgical wound (s): Yes 1/lo Location: Size:_ Drainage: 3 ''3-1:2L-r Tubes:_ Pins:_Appearance: _ Dressing change: _
Burn wound (s): Yes Y No % BSA_ Partial _Full_ Location: 4 1 or ver Clit-rh _Size_ Appearance: _ Dressing change: 4,11-)
Pressure Ulcer (s): Yes _No
Stage I, II, III, IV (Circle the one that applies and describe below)
Location:_ Size: _
Wound character: Pink_Moist X Dry_Granulation tissue _Yellow slough X _Tunneling_

Undermining_Odor_Purulent discharge_Eschar_Exudates _ Type of dressing change: Wet-to-dry -x' Comfeel dressing _Carrasyn-V Gel _Alginate_
Physician notified/consulted for wound debridement: Yes)4 No _Date/time MD notified _
CNS notified/consulted for Stage II and greater: Yes _No_
Nutrition Referral: Yes _No_
Physical Therapy Referral: Yes )( _No_
Action taken: _ Date & Time_

REGISTI WARD NO.
MEDCOM - 16665

Patient's identification (For typed or written entries give: Is, 11151, MILIU1C3
olDesr. cce Ninv-rve
DOD-030054
I PREOPERATIVE/POSTOPEW"`IE NURSING DOCUMENT
MEDICAL RECORD

For use of this form, see AR 40.66: the propone is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
1._AGE:
HEIGHT:

3. PREVIOUS SURGERY [ ]_NO_[X] YES (type): t
WEIGHT: et..._?
4. PROPOSED SURGICALPROCEDURE:
DcAnn"-Aw4,-L Q^2C82_

5. ADDITIONAL INFORMATION: Last 1'0: Medical IIx: H.+ Implants:"_Medications: ut^0.A-
Jewelry removed: yes/no Family waitiint: yes
1\i 1/41)1

6. PATIENT PROBLEMS AND NEEDS 7 PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
• t. to verbalize
A. PSYCHOSOCIAL Pt. verbalizes any specific anxiety. reeirl" p
Explain OR environment

--- Potential for anxiety . nd answer questions

Pt. exhibits relaxed body posture. _
related to_traumatic injury; egarding surgery.
language barrier; -kmi-i-ly Offer comfort measures,
.g., warm blanket, touch)

scrirmirrar; siinticii I env ironment

_ Explain all nursing rocedures before they are one.
Remain with pt. whenever ossible. Maintain family interface.

B. AERATION_ .,..c:KIDT. will be able to breathe without o_Offer to elevate head of
.---"'Potential for difficulty during immediate intra-litter or offer pillow.
operative phase. o_

Observe pt. while awaitingrespiratory dysfunction due to surgery for signs of distress

sedation; positioning; injury
Assist anesthesia during
intubation and extubation

,-a-14. will not exhibit signs of impair-'_Utilize pressure preventingC. INTEGUMENT ment of skin integrity (e.g., reddened evices on OR table and

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

areas. ccessories.
Potential impairment Check for proper
of skin integuity due to_bovie •

ositioning and support to
pad; position; fluid shill aintain good body alignment.
Pad pressure points.

Place ESU ground pad on on compromised skin surface rea.
Keep prep fluids from ooling.
9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
( 0(6) -if
_

DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01
MEDCOM 16666
-

DOD-030055

6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
-------Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury; posit ion; shock; previous surgery
E. NEUROMUSCULAR
CONTROL

E.1. ----Potential impairment
of mobility due to sedation; pain; injury
----Potential discomfort
E 2
due to injury; pain
F. NEUROMUSCULAR
CONTE
Disminished visual

F.1.
perception due to being injury;
sedation;

.,—
Potential for decreased communictaion due to lanLwage.
F 2
... ..
barrier; sedal ion -iral,
F.3. Potential injury due to
dentures.

G. OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs,
7. PATIENT GOALS AND EXPECTED OUTCOMES
Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse).
o Pt. will be transferred to OR table ithout difficulty.
Pt. will not experience unnecessary hysical discomfort.
Pt. will be made aware of urroundings prior to anesthesia i duction. Pt. will be transferred safely to R able. Pt. will be able to understand instructions. Minimize danger of injury during intraop period.
OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS
o Check for support stockings or ace wraps._If none, check with doctors.
,e-Theck that safety straps are correctly applied.
o_Offer pillow for under knees.
e own e
,eCheck that rings have been removed.
o Have sufficient people
vailable for transfer.
0 Insure proper body
a ignment.
0 Allow patient to lie in

p sition of comfort while
iting for surgery.

o Offer support (i.e., pillows, b thtowels, etc.) for positioning.
Introduce self. Keep pt. i formed as to where he/she is nd what is happening. Inform pt. in which rection to move and assist if
cessary. Speak clearly and slowly. Addresss pt. from
side. 0 Validate pt.'s understanding of verbal communications.
o Verify removal of dentures.
OTHER NURSING
INTERVENTIONS.
Or continuation of above
interventions.

10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED
6)(4. -
eFt \pc
DATE

11. POSTOPERATIVE EVALUATION:
e ok •^Nec-0
(
rc\.V :ASN''
c,

12. PREOPERTIVE EVALUATION PREPARED BY 13. PREOPERTIVE EVALUATION PREPARED
(Signature and Title) BY (Signature and Title)

Off I PllitU
C.Frlfd
_
07) (6)-

-
DATE:;o k7e, TIME: DATE: 0 1. 3 TIME:2 `,r

( .3
MEDCOM - 16667

REVERSE OF DA ORM 5179, JUN 91
' USAPA V1.01

DOD-030056

Co

MEDICAL RECORD
5-7

1. AGE:
HEIGHT: WEIGHT: 3S" tic

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
For use of this form, see AR 40-66: the proponent agency is The Office of the Surgeon General.
2.
KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication): _

3.
PREVIOUS SURGERY [ XL_ NO YES (type):

4. PROPOSED SURGICAL PROCEDURE:
/liffr. 2 g
-E-14-17­

5. ADDITIONAL INFORMATION: Last PO: Medical Hx: Implants: Medications: 0"
.lewelry removed: yes/no Family waiting: ye
tupo sync,. fict.euv-sv—
6. PATIENT PROBLEMS AND NEEDS
A. PS' CHOSOCIAL
Li Potential for anxiety
related to traumatic injury;
language barrier; fru II ity
sPrnf-ntinn• surgical environment

B. AERATION
V Potential for
respiratory dysfunction due to

sedation; positioning; injury
(94usit-2-4, : 2 FL(
I_ v
7. PATIENT GOALS AND EXPEC14D OUTCOMES
Pt. verbalizes any specific anxiety.
Pt. exhibits relaxed body posture.
PT. will be able to breathe without difficulty during immediate intra-operative phase.
_o--PT. will not exhibit signs of impair-
C. INTEGUMENT
J ment of skin integrity (e.g., reddened areas.
Potential impairment
of skin integuity due to bovie
pad; position; fluid shift

9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle: grade: date: hospital or medical facility)

-tar
b )(6)-
8. OR NURSING INTERVENTIONS
• Allow pt. to verbalize
reely.
Explain OR environment

.;nd answer questions
egarding surgery.

r_Offer comfort measures,
e.g., warm blanket, touch)

•
Explain all nursing

•
rocedures before they are
•one.

Remain with pt. whenever ossible.

•
Maintain family interface.

Offer to elevate head of fitter or offer pillow. Observe pt. while awaiting urgery for signs of distress
Assist anesthesia during i tubation and extubation
Utilize pressure preventing evices on OR table and ccessories.
Check for proper
ositioning and support to
aintain good body alignment. Pad pressure points.
Place ESU ground pad on on compromised skin surface ea.

o Keep prep fluids fromp oling.
DA FORM 5179, JUN 91 Previoius editions are obsolete USAPA V1.01
MEDCOM - 16668

DOD-030057

6. PATIENT PROBLEMS AND NEEDS
D. C1R ULATION
Potential for inade­quate tissue perfusion due to anesthesia; traumatic injury;
position; shock;,,p r-gery
E. NEUROMUSCULAR
CONTROL

E.1. .. Potential impairment
of mobility due to sedation; pain; injury
E 2 /Potential discomfort
due to injury; pain
F. NEUROMUSCULAR
CONTROL

F.1. tirbisminished visual
perception due to being injury; sedation;
F 2 Potential for decreased communictaion due to language barrier; sedation
vo, knci-kti
F.3. Potential injury due to
dentures. c-/

G. OTHER PATIENT PROBLEMS
NEEDS. Or continuation of above problems/needs.
10.
7.
PATIENT GOALS AND EXPECTED OUTCOMES
„331-Pt. will exhibit signs of adequate
tissue perfusion (e.g., color, warmth,
pedal pulse).
Pt. will be transferred to OR table fithout difficulty. Pt. will not experience unnecessary hysical discomfort.
Pt. will be made aware of
urroundings prior to anesthesia
nduction.
Pt. will be transferred safely to
R
able.
Pt. will be able to understand
nstructions.

Minimize danger of injury during
intraop period.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals -and-outcomes.
8. OR NURSING INTERVENTIONS
o Check for support stockings or ace wraps. If none, check/ith doctors.

—0--e-heck that safety straps are correctly applied.
o Offer pillow for under knees.

o Place and take down legs from stirrups with slow bilateral motion.

,..ert-heck that rings have been removed.
Have sufficient peoplevailable for transfer. Insure proper bodylignment.
ia
Allow patient to lie in sition of comfort while iting for surgery.
Offer support (i.e., pillows,
athtowels, etc.) for
positioning.

Introduce self. Keep pt. nformed as to where he/she is nd what is happening. Inform pt. in which irection to move and assist if
ecessary. Speak clearly and slowly. Addre s pt. from
side.
6 Validate pt.'s
understanding of verbal
communications.

o Verify removal of dentures.

OTHER NURSING INTERVENTIONS. -Or continuation of above interventions.
OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
6)(6) -7_

itc at-t OE _
DATE

11. POSTOPERATIVE EVALUATION:
6t¦i\k„ C;k: c,
)1-s 01
Vxtzt.
12. PREOPERTIVE (Signature and Title) DATE: /6­1/63 ME: 0:0( 070P D BY 44t,T 11"-) 13. PREOPERTIVE EVALUATION PREPARED BY (Signature and Title)_ CA)111511] (6)(k3)- 7-DATE: !calks 63 TIME: 10..0
REVERSE OF DA FORM 5179, JUN 91

USAPA V1.01
MEDCOM - 16669

DOD-030058
4g,_ '

-it:01:1-:tPREOPiRATIVEROSTOPE,-trivE NURSING DOCUMENT
FOR Use of this form. see AR 40-407: the pmponent-aecncy is The Office of the Surgeon General.
2. ,KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication) NKDA_C PCN_0 LATEX_E.: IODINE_C TAPE_FOOD
. AGE: 0-1-5
REACTION:

HEIGHT: _
3. PREVIOUS SURGERY_[ ] NO ),e1 YES (type):
WEIGHT:
ee i++f

4. PROPOSED SURGICAL PROCEDURE:
eino444itd-toP 3hictbl-c- /0 &icon/ AL- /0" %at) Cha
mat history) Skin Condition _ADDITIONAL INFORMATION: (Previous surgical and_
5.
ROM _AS.AiMoctin w:72 hrs (Y) (N)
_ etes (Y) (N)_

Tobacco_ppd X vrs. Body Piercing
Respiratory Disease (Astfuna:COPD) (Y) (N) Anticoagulants (Y) (N)Implants
ETOH _
Hypertension (Y) (N) Herbal Medicines (Y) (N) MEDS:
Dentures

Glasses/Contact (Y) (NI _
S. OR NURSING INTERVENTIONS
7. PATIENT GOALS AND EXPECTED OUTCOMES

6. PATIENT PROBLEMS AND NEEDS
Allow pt. to verbalize freely.

A. PSYCHOSOCIAL e" Pt. verbalizes any specific anxiety.
c„--Explain OR environment and answer
/ Potential for anxiety related Exhibits relaxed body posture.
questions regarding surgery.
to:
e'Offer comfort measures._warm _I) Surgical Procedure &
blanket. touch).
Operating Room Environment 2--Explain all nursing procedures before
2) -S?—nazat.ieti-rIcrecieLY-
they are done.
C b)((,) - z
..e-Remain with pt. whenever possible.
3S Surgical Outcomes
,c/Nlaintain family interface. Parents to stay with pt.

541. will be able to breathe without _;,...--Offer to elevate head of litter or .:.:1C7
B. .AERATION

difficulty during immediate intraoperative pillow.
/Potential fcr respiratory

phase . -..r—Observe pt. while awaiting surgery for.
c:sfunction due to:
signs of distress.

_1) Positioning
-

.:---5-1,ssist anesthesia durtne intubation

_2) Effects of Anesthesia
and exrubation.

Medical'Smoking History

will not exhibit siens of impairment of
pressure preveating devices on
C. INTEgUMENT
skin inteerity (e.g., reddened areas).
OR table and accessories.
/Potential impairment of skin
/c..--Check for proper positioning andintegrity due to: support to maintain good body alignment.

_1) Intraooerative Immobility
.,a/Pad pressure points.

_2) ESU Pad Placement Place ESU ground pad on non _3) Positional Aids
compromised skin surface area.
_4)_P1ubtlii...1_(19 )(0- z
..o.—Keep prep fluids from pooling.
_5) Pooling,_rev Solutions
RIFICATIONS HOLD ENG AREA:

9. PATIENT'S IDENTIFICATION: (For typed or written entries /Allergy Band ensures Removed
give: Name- last, first, middle; grade; date; hospital or medical facility) /Allergy
(k, )(L)

&P ontacts Removed Since pill, welry Removed ody Pierce Rernmedcb^ ( onsent.Sloirransfusion
-
ed/Wimessed:Dated
urgical Site/Consent verified by ../AnesthesiaiSurgeon Contact Precautions (Y) & Family/Friend: /41C
_ p r_MEDCOM2 1 6670_
DA FORM 5179, JUN 91

DOD-030059
6. PATIENT PROBLEMS AND NEEDS .

D. CI_ULATION.-:-:'
_Potential for inadequate tissue perfusion due to:_
• 1) Intraoperative Mobility 2) Positioning 3) Existing Disease 4) Safety Devices 5) Hypothermia

E. NEUROMUSCULAR CONTRO,I,
E.I._/ Potential impairment of mobility due to:
1) Pain _2) Intraoperative Hazards _3).-frcrsTris-ir
_(6)(0 -Z _4) Positioning _5) Transfer pt. to/from OR table
E.2._Potential discomfort due to :
I ) Leneth of Sureer• _2) Positioning _3) Arthritis
F. SPECJAI_ SENSES
F.I. _/ Dtrninished visual perception due to being:
Z-1-) Pre-Medicated _2) \V 0 Glasses
F.2._Potential for decreased communication due to:
1) Diminished Hearin , • _2) Laneuage Barrier
F.3._Potent:al injury d_to dentures:_
(6)(=)-2-

_1) Ulmer_4) Cans 2) Lo_5) Crowns ridees
G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problemsineeds.
PATIENT GOALS AND EXPECTED OUTCOMES
(0(0-2
.efit. will exhibit signs of adequate tissue
perfusion (e.g.. color, warmth, pedal pulse.

(W0-2
9.--Pt. will be transferred to OR table without difficulty.
t. will not experience unnecessary
physical discomfort.

_1;r-1%. will be made aware of sun -ounciines
• prior to anesthesia inductior.. . will be transferred safeiy to OR table. will be able to understand instructions.
o.yinimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above zoo's and
outcomes.
R NURSING INTERVENTIONS
r ace f none, check with doctors. Check that safety straps are ectly applied. 1, fer pillow for under knees. —P-6C-e-aftti-te-Ite-elowii4et3.43FBfill S Li_
ttateral motion
-Check that rings and all body
niercino ha' been removed

aye sufficient people available for transfer. ,e---insure proper body alignment. ..5„).-Allow patient to lie M position of comfort while waiting for surgery. _o_jaffer support (i.e.. pillows. bath towels. etc.) for positioning.
_c.-1-no-oduce self. Keep pt. informed as to where he. she is and what is happening. -e--inform pt. in which direction to move and assist if necessary. `r. _clearly and slowly. z Address ptcm _ata_. c
`7"-­
c'aiidate pt.'s understanzin c.1-verbal 2mmunication. Verify removal of•dennires.
OTHER NURSING INTERVENTIONS Or continuation of above interventions

10.
LETE D/A DDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
(iI.L.) -2.
DATE
/7 74 0
-3

11. POSTOPERATIVE E ALUATION: SKIN INTEGRITY: Bovie Pad Site: Clean and Dry
C Red_N/A DRESSING DRY E.: INTACT:

LEVEL OF CONSCIOU
SS: . A&O . Drowsy Sleepy_&Intubated LEVEL OF ACTIVITY: yes All Extr REATHING EASY
r-Moves Upper Extremities_
(Y) (N) k)/ik

ed_liner with roller due to spinal_
12. PREOPERATIVE 13. POSTOPERATIV
(Signature and Title)
BY (Signature and Title)

DATE'VI / 03 TIME: erJ_MEDCOM - 16671 (Z) TIME: (3(9 1-r (6)(0 2
REVERSE OF FORM 5179, JUN 91
DOD-030060
PREOPERATIVE/POSTOPE' VE NURSING DOCUMENT
MEDICAL RECORD

FOR Use this form. See AR 4D.407: the Proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
1. AGE . NKDA_. PCN_. LATEX_. 10DINE . TAPE . FOOD
REACTION:
HEIGHT:

3. PREVIOUS SURGERY_] NO_[t.]" ES (type):
WEIGHT:

4. PROPOSED SURGICAL PROCEDURE:
a-s7-5-7,-

5.
ADDITIONAL INFORMATION: (Previous surgical and medical history) Skin Condition _ Tobacco ye-s ppd X_vrs Body Piercing Diabetes (Y) (N)_ROM _ASA/Motrin W 72hrs (Y) (N) ETOH Implants Respiratory Disease (Asthma COPD) (Y) (N) Anticoagulants (Y) (N) Glasses/Contact (Y)4U Dentures N Hypertension (Y) (N)_Herbal Medicines_(Y) (N)_MEDS:

6.
PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS

A. PSYCHOSOCIAL
.O-Allow pt. to verbalize freely.
Pt. verbalizes any specific anxiety.
_potential for anxiety related

O. Explain Or environment and answer to: Pt. Exhibits relaxed body posture.
questions regarding surgery.
. 1) Surgical Procedure&

a.Offer comfort measures. (e.g. warm Operating Room Environment blanket. touch). 2) Separation Anxiety
0-. Explain all nursing procedures before(cni15)
they are done.
3) Surgical Outcomes
-OKRemain with pt. Whenever possible.
0. Maintain family interface. Parents to
stay with pt.
~-0-Pt. will be able to breath without

B. AERATION -12 Offer to elevate head of litter or offer
Potential for respiratory difficulty during immediate intraoperative pillow. dysfunction due to: .ef."--Observe pt. While awaiting surgery for
phase.

1) Positioning signs of distress.
2) Effects of Arieghtsia

sist anesthesia during intubatior
—7-3) Medical/Smoking History and extubation.

C. INTEGUMENT ll5Pt. will exhibit signs of impairment of -07--Utilize pressure preventing devices skin integrity (e.g., reddened areas).
_Potential Impairment of Skin on OR table and accessories.
Integrity due to: Check for proper positioning and
_1) Intraoperative ImmeDility

support to maintain good body alignment. L.--/ 2) ESU Pad Placement Pad pressure points. _3) Positional Aids
ve Place ESU ground pad on non
_4) PEQ51b5515 compromised skin surface area.
_5) Pooling of Prep Solutions

J2( Keep prep fluids form pooling.

9. PATIENT'S IDENTIFICATION: ( For typed or written entries VERIFICATIONS AT HOLDING AREA: give: Name-last, first, middle; grade, data; hospital or medical facility) ! ID/Allergy Band
_! Dentures Removed
! H&P ! Contacts Removed ! NPO Since_! Jewelry Removed
! UHCG/LMP_I Body Pierce Removed
(6)(6)_1
Consent/Blood Transfusion

• Signed/Witnessed/Dated
! Surgical Site/Consent verified by \)(2)Z-Pt./Anesthesia/Surgeon
_
! Contact precautions (Y) (N)
/ Ail CAS" (17.3

! Family/Friend: _
111111116_

IDA FORM 5179, JUN 91_ Previous editions are obsolete. USAPA v1.0
MEDCOM - 16672

DOD-030061

6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION Potential for inadequate tissue
perfusion due to: _1) Intraoperative Mobility V 2) Positioning
_3) Existing Disease 4) Safety Devices 5) Hypothermia
E. NEUROMUSCULAR CONTROL,
E.I. _1------.Potential Impairment of
Mobility due to:
i.../1) Pain
2) Intra operative Hazzards 3) prosthesis
—7-4) 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. _LVDiminished visual perception
due to being; 1) pre-medicated
_2),,AN 0 GLASSES
F.2._Potential for Decreased
Communication due to:
_)) Diminished Hearing (--r* 2 Language Barrier
F.3. Potential Injury due to
Dentures:
1) Upper 4) Caps
2) Lower 5) Crowns

3) Bridges
G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
will exhibit signs of adequate tissue perfusion (e.g. color, warmth. pedal pulse.
, Crypt. will be transferred to OR table without
0 pt. will be not experience unnecessary
physical discomfort.
be made aware of surroundings
prior to anesthesia induction.
pt. will be transferred safely to OR table.
will be able to understand instructions.
g....--Minimize danger of injury during intraop
period.
OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and
outcomes.

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

..,0-/Have sufficient people available for
transfer.
-Cri Insure proper body alignment.
Allow patient to lie in position of

comfort while waiting for surgery.
&"Offer support (fe..pillows. Bath
towel. etc) for positioning.
,-(:(Introduce self. keep pt informed as to where he. she is and what is happening. .....0.--fnform 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. Ilittr Verify removal of dentures.
OTHER NURSING INTERVENTIONS
OR continuation of above Interventions.

10. OR NURSING INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
_

_

(0(6) -1 \jf
Al(V‘ C) ')DATE
11. POSTOPERATIVE EVALUATK)N.) SKIN INTEGRITY: Bovie Pad Site: 9a Clean and Dry . Red . N/A RESSING DRY & INTACT: LEVEL OF CONSCIOUSNESS:11115-. Drowsy_ . Sleepy_. Intubated (N)
A&O
BREATHING EASY:

MOVES ALL EXTREMITIES CI Moves Upper Extremities ((y)/(N)
LEVEL OF ACTIVITY: rri-­
. Transferred to Litter With roller due to spinal

12. PREOPERATIVE EVALUATION PREPARED BY_13. PREOPERATIVE EVALUATION PREPARED
15o 4.) (6)(6) -MEDCOM - 16673
nr gro'll,L c47n PI 110

DOD-030062

INTRAL,r'ERI DOCUMENT
MEDICAL RECOR_

For use of this form, see AR 40-66, the props.. agency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM .. 2. PATIENT I_
PROCEDURE VIA_1 1k BY NIakit(-6\ 0\ VERIFIED BY_
4/e •

3. DATE_ TIME PATIENT ARRIVED IN SUITE 4. PATIENT_oorvi
(b)(0- 2-

6 4-7:5 01-4- 5 TIME_14-g_NUMBER — i
5. PREOPERATIVE EMOTIONAL STATUS

0 CALM_. ANXIOUS_11 EXCITED_. CRYING_. ANGRY_. WITHDRAWN_. OTHER (Specify)
COMMENTS:_Allergies: ,,,-,LoAa,
6. NURSING PERSONNEL
ASSIGNED RELIEF
. OM
SCRUB SCRUB
(1)(L)-2
ASSIGNED
RELIEF CIRCULATOR
eidjill114111 CIRCULATOR
64(...) - 2-

7, POSITION AND POSITIONAL AIDS (Specify)
IXSUPINE_U LITHOTOMY_• PRONE_• KRASKe LATERAL:_II LEFT SIDE UP_. RIGHT SIDE UP

Vo ok-.2c 0--t,:...6-1." tio-t...t,‘ r ^A.\ ....v. k c..,..;. ,,0A,_kkk_e-cA_--%-,t S h.,-_
9,,, to-----okrt---A \ 0,-", vs-, r\,
.(-Ak-?•-k
, °t-9. 2)

COMMENTS: Ml"e
"'"'"‘ '6'0 ° Prl P c`-'"k" c"'"'-‘°° " ---"k5 I r s, h im- c-lc hrt.ci¦ 61, 4r----%-to-1. t 0.4.s rin.01(A.,
1, (0 - 2._8. SKIN PREPARATION HAIR REMOVAL_IX YES_NO "irr -_ IP.
PREP SOLUTION (Specify) la.Q_A--c_\ Sa 11-0....
DONE BY:_N' OR_ . NURSING UNIT (6)(t)-2 SITE:1¦11_1-e_JO Nal 'rt..;_BY WHOM:
METHOD:_•_

DEPILATORY_RAZOR SITE:_1 V_ BY WHOM: 41117)."
. CLIP A c‘ COMMENTS: dk.A.ts- ,i.....-.. 04.S
_E.(_u-..N-h_"-,-04%-t.CA COMMENTS:A-iva-vart...,_
(iv-fA,....., ti ‘ c --,43-ka.0\.,

9. LOCATION OF EXTERNAL DEVICES
,• S.
-r i eglignillilloot a
•alf
T.GEND_X Ground Pad 126lrl_-- Safety Strap4svl _=== Tourniquet PA

C = Correct_I = Incorrect
UNTS -­..... sicri-Z Other" First Closing Count Final Closing Count SCRUB CIRCULATOR
U Yes • No C C. 0 Tharp_Xi Yes •No C C C it 2 Yes . No C. C., C... . Yes 0 No i\J A MA M A NT IDENTIFICATION (For yped or written entries give: f, first, middle,-Grade; Date; Hospital or Medical Facility;) 11111k_(b)( (D) " z Ina (b)(0-1-(6)(6) -2 MEM_( \:.)( 6 ) -1 ( b)(i_- ik\J p, Up 12. ELECTROSURGERY DEVICE(S) (ESU)_M YES_IN NO .
3+,* WO • 00)(0 -LI El ESU NO:_VL adv CQ -a_ 4 Lie GROUND PAD:_BRAND_V L iLL-,-.•--, IC:1 I_. 1/¦4-Sialirt ..11*3O' 3‘ LOT NO:_(It 13 62 oi 5-01, . ESU NO:
GROUND PAD:_BRAND
LOT NO:
¦ BIPOLAR NO:

d El

MEDCOM - 16674

-1, OCT 87 REPLACES DA . IS OBSOLETE. USAPA V1.01
DOD-030063

ROSTHESIS, IMPLANTS . YES El NO IF YES NAME: ID NUMBER; MANUFACTURER
SIORDERS
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES . NO
DICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

OUND IRRIGATION oD YES . NO, TYPE(S):
Ck

tVt, IQC:"-
D.Ci°i
:;OTHER ORDERS TIME CARRIED OUT BY
:5-)kR__

PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING ROOM IF YES, SITE
YES . NO Ki

LABORATORY SPECIMENS
SPECIMEN (S) NAME NAME
YES . NO .
FROZEN SECTION (FS) NAME NAME
YES . NO .
CULTURE (C) NAME NAME
YES . NO 0
NAME NAME NAME

16.
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
•'M D
4-X g

17. TUBES, DRAINS/PACKING YES . NO
TYPE/SIZE 2. 3.

SITE 1. 2. 3.
19. ADDITIONAL INFORMATION
C6 AO-2.

wc-rm c -
Surgrahsfunwim Anesthesia:6Mb Anesthesia Type: Ca/u.s.mza,
ow.
(6)((0)- 7-
c_0(o-

3o 36-
Bovie Pod site intact pre-op NJ ; post-op Bovie Settings: Coag/Cut

20. OPERATION(S) PERFORMED
Exq kcs( eNtto-( ,, 4s3-130,-
,z.."1/tAD of Ccf(Al
C5113v¦A-0-

21.
PATIENT TRANSFERRED TO TIME S. METHOD CAA, ckzr

22.
EGISTERED NURSE SIGNATURE

USAPA V1.01

REVERSE ,87
(1,)( 6)- MEDCOM - 16675

DOD-030064

1NTRAOPER/ DOCUMENTMEDICAL RECORD
0 A)-1For use of this form, see AR 40-66, the prop,. _.gency is the off/_Surgeon General.
1. PAT ENT TRANSPORTED TO OPERATI_ROOM 6 2. PATIENT ID_
PROCEDURE
VIA_( .4 ./.4ej._ VERIFIED BY

BY ile4 1 eolq 0 _ _ e/77,4_
3. DATE_ TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN_OM_
(b) (6) -7-; ,
/1_y 03 173 0 TIME_/7,3°_ NUMBER_/ '1.-'

l

5. PREOPERATIVE EMOTIONAL STATUS_
. CALM_. ANXIOUS_• EXCITED_. CRYING_. ANGRY_. WITHDRAWN_. OTHER (Specify)
COMMENTS:_A Ilergies:1,{k10,16( t Ai) 0240,1,4e.. -pt_ calQinkL,9
P (-- tni..L12' -f))-1,--(ILA-ndi..1. 10KA-A-_(WO " 2-
6. NURSING PERSONNEL
ASSIGNED

SPC 11111111 Ori RELIEF PC-- I C130 -tri
SCRUB
SCRUB

O(to) -1 (_
C I
O( )(-(=) -.2"
(6)(0'1
ASSIGNED RELIEF i SZND ^ iii)

ePT an 4)

ill_
CIRCULATOR

CIRCULATOR 1._
( b) (Ls) - Z. e
I Li 19 1 D -CiAA
7. POSITION AND POSITION4 AIDS (Specify) cri
Skirt' -it) X. 11-10 1e. OK tea (Iv a ),gne {-01,-.guicsyccO
ococtue. , jouv—x- undo, .K0
carou 6,-, --?Qocco arfrie boa (e 24 "I' 0
0_ SUPINE_. . -LITHOTOMY_. PRONE_

II KRASKE_LATERAL:_D LEFT SIDE UP_. RIGHT SIDE UP •
COMMENTS: 1,. ) orms masAm\.c., ipoi_
4WANCAt ratJAMCIMOt
8. SHIN PREPARATION

HAIR REMOVAL_L YES_E0
PREP SOLUTION (Specify) 4161ciax..3
DONE BY:_•_OR_ . NURSING UNIT SITE: 194,0di„crylt-Q-1"..-_BY WHOM: cp+a
METHOD:_._DEPILATORY_Fl RAZOR SITE:_ BY WHOM:_

(6)(. 1° " 7-

. CLIP -*5ee., 1:b 9 COMMENTS:
COMMENTS: qa pod 1.„...2./.4.)
9. LOCATION OF EXTERNAL DEVICES
ato P
s V-s

I. -1,,,,,c1
. ik
•ME. ...-
.444i
ilP
(
1 )01- 2-----------------c-3c) u" .
i 't
. cd ,.. ,
(._b (6) t

LEGEND_X1_111ri_d Pad_- _S rap -===floumiquet0X6) -2 (6)(6)- 2-(b) ( (0) -
C = Correct_I -= Incorrect_

1_OM_
SIM
f n .41.0 First Closing Final_osing

10. COUNTS Count
Count

SCRUB CIRCULATOR Sponge_El Yes . No C C-
C-Needle Sharp_Yes . No C
C... ('
V\1

Instrument_Yes . No (.... C-C-Nt Other • Yes No
C-C...•

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. LECTROSURGERY DEVICE(S) (ES_YES_• NO_t)/Name - Last, fir e; Grade; Date; Hospital or Medical Facility;)
3-0 2P IX) V4. ESU NO:_V4-1-11-t-J0 -4* 4 GROUND PAD:_ND Valk 0...b
( OW - 1(

LOT NO: 1.2)(0_HP e3CO5--G.3
• ESU NO: GROUND PAD:_BRAND
LOT NO:
. BIPOLAR NO:
mprirrinn _ 1 kR7k

- - - - - — - '-- " - -- - -
-i , REPLACES DA . _ IS OBSOLETE. USAPA V1.01
DOD-030065
13. PROSTHESIS, IMPLANTS_. YES_NO_IF YES NAME: ID NUMBER; MANUFACTURER
4. .•:::::A:,1!: :::anfigni:::::ffing;:5:0NOW::::§Mafigi:i:iii MEDICATIONS/ORDERS:!.:iE::!::;;;;::!.: .,:]!::9::%!: ;.,:::::::!.:!:459E:!;;!:M:!1 :1:Miia::;ig:Ni::iii;i:ig:::':N:]:.IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)_YES ._NO
4

JVIEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY
.WOUND IRRIGATION_% YES III NO, TYPE(S):
,15

,OTHER ORDERS TIME CARRIED OUT BY ..
THYSICIA_
( b)(6) ' 1.-

15. X-RAY IN OPE ROOM_ IF YES, SITE
YES ¦ NO A,

16._ LABORATORY SPECIMENS
SPECIMEN (S) I NAME NAME
YES ¦ NO K

FROZEN SECTION (FS) NAME NAME YES ._NO CULTURE (0) NAME NAME YES ¦ NO gill NAME NAME NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
Aifili 141
17._TUBES, DRAINS/PACKING_YES v l NO ¦
TYPE/SIZE 1...pa 2. Lt-cl
I blAti-V )(. 316 Fr: efriat,„:0.(ftl , tr--'jSITE 1..C.44%.“.41) 0 .11-.-2._N 3._ -
Jc Av.,..v,w, ,

blac4-4-8 0,1) 4-Mettc_-0-1--e.AIIA --to cit(-ocww-wk
19. ADDITIONAL INFORMATION WC ga---SuSi l-a io_
• Anesthesia:Me 6)(6) Anesthesia Type: 614,r‘s_ka.....Q....
(6 )(3) -1-MS - -1 ()(b)
(00°) -i

Bovie Pad site intact pre-op VI_; post-op ‘, _Bovie Settings: Coag/Cut do/30 Tourniquet Site intact pre-op : post-op ii./pav"
bi\- snei --t-wi-k-,.&ed) '

20. OPERATION(S) PERFORMED
. ranTIAA'd-_Itt-f-CAk-S iMA.CJ-L ON--
21.PATIE,NT TRANSFERRED TO TIME_kj METHOD
ATURE

. j1.t
..A.Ak3 / i RSE OF DA FORM 5179-1, OCT 87 , (WO.) - Z-IJSAPA V1.01
( b)( (-) -2-
( 6)( 6) -Z MEDCOM - 16677

DOD-030066

INTRAOPERP DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-66, the props 4ency is the office of The Surgeon General
1. PATIENT TRANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE
VIA_(--,kt\-e--4-_ BYA--r,e. -Aevelck I 6R 11%.,,,,,se VERIFIED BY 6 FT_
CO(6) "1-

3. DATE_ TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
2(:,_0_ I tict TIME_) 4-(4-6'_ NUMBER .5
5. PREOPERATIVE EMOTIONAL STATUS

. CALM_¦ ANXIOUS_¦ EXCITED_. CRYING_¦ ANGRY_. WITHDRAWN_Z OTHER (Specify)
i‘..,:k ...1/460,Apt pi

COMMENTS:_Allergies: --t,ek..,e1A-d _
6. NURSING PERSONNEL
ASSIGNED .i7C..._ (0(0 - 2-RELIEF
SCRUB SCRUB

ASSIGNED um ( b)(6) -Z. RELIEF G PT_
C-CP-F ( S-ZO -CIRCULATOR CIRCULATOR
( 1 )0=) -1--

7. POSITION AND POSITIONAL AIDS (Specify)
Di SUPINE_. LITHOTOMY_¦ PRONE_¦ KRASKE_LATERAL:_. LEFT SIDE UP_111 RIGHT SIDE UP
p_

..bv 0.....1,q.a5,,,,,,„v‘s,„„„or ,.,,,,,,....,-4--c...-.------e._ at, ,_kz.:=-A En.p..._,-cici_..-..-.._ rAO-N.------4t-t r--"."-•-•5 ort re-'01‘ktol
COMMENTS: r)-tnoe„,„&lk_c.._-}- Ic.s_(1...o...t... cloy,_l''')--;ciic-.-s- "--vt. Grv-€C4 ---c, 4-----a-eov,4-,o,.-n-2 19%-
8. SKIN PREPARATION

HAIR REMOVAL_. YES_MI NO PREP SOLUTION (Specify) B e--1/4 1:i. \ 3•74 eA...
DONE BY:_¦ OR_ . NURSING UNIT SITE: t`i \ Vlet-S 3t0 CIY-"n1//2._BY WHOM:_ . ( 1:)00) -1-
METHOD:_•_DEPILATORY_El RAZOR SITE:_V‘"-‘4/1_ BY WHOM:

•_CLIP

COMMENTS: COMMENTS: oo ve),...;ti ,„;: ,,,-y ,,,/,,--14 044 al
S.

9. LOCATION OF EXTERNAL DEVICES
okyr-C ON-\
...

I I i _._._....mmi.11k"smiiiii......
_ -rillirjr.--

/. .
LEGEND_X Ground Pad_-- Safety Strap _=== Tourniquet_(,)(b) -2_ (6)(0- 1
I C -?-Correct I = Incorrect 3..A.,,........it '.
First Closing Final Closing

10. COUNTS Other' Count Count
CIRCULATOR Sponge El Yes . No C C C (6)(0-1. -Needle Sharp_/12 Yes . No c C C
1W6--— "15135111111111 .... b (6 -1
_

Instrument 21 Yes ¦ No C C
‘) 6 -1 W-1-"4"-I) (.6 -1-
Other_¦ Yes .A No WA Ni A KJA NA% 1 4
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU)_Ki YES ¦ NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
K1 ESU NO:_VOt,i,‘,Q.1‘0,i0_TON-t...9-_40
111. .

GROUND PAD:_BRAND VL R.cw, VOA Int .%i/t It
(6)(0 -4 ?-0 13 il"

LOT NO:_IS-4-0(r)_. .1.--(i
. ESU NO:

GROUND PAD: BRAND
LOT NO:
¦ BIPOLAR NO:

M 5179-1, OCT 87 REPLACES DA IS OBSOLETE. SAPA V1 01
MEDCOM - 16678

DOD-030067

13. PROSTHESIS, IMPLANTS_. YES_'NO IF YES NAME: ID NUMBER; MANUFACTURER
`MEDI ATIONS/0 D
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ._NO DO
MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

;\/1/OUND IRRIGATION_XI YES_. NO, TYPE(S):
0.9
::OTHER ORDERS
TIME CARRIED OUT BY 1A.c-vQ2_
PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING ROOM_ IF YES, SITE
YES ._NO 1M

16.
LABORATORY SPECIMENS SPECIMEN (S) NAME NAME YES ._NO FROZEN SECTION (FS) NAME NAME

YES ._NO E CULTURE (C) NAME NAME
_

YES . NO NAME_ NAME NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify) OX O
17._TUBES, DRAINS/PACKING YES kl NO . TYPE/SIZE tot,.„, a 2.
t Z%-A-

SITE 1. 2. 3.
ASO CA.Crev...2-A.n._ /tbot.cmQ,k,.

19. ADDITIONAL INFORMATION
WC
(b)(6)-/

Surgeons: Anesthesia: Anesthesia Type: FA
1111111111111111116.
1 I ( -

-013(7-Bovie Pad site intact pre-op post-op . Boyle Settings: Coag/Cut Tourniquet Site intact pre-op : post-op
t-¦ IA
Srf
d S -LA oA-rt

20.
OPERATION(S) PERFORMED

Cx ThEN-_ Abs

21.
PATIENT TRANSFERRED TO TIME S-es_ METHOD

r ek-1-\-eAr
22._ RE
ce't"

REVERSE OF DA FORM 5179-1, 1CT 87 USAPA V1.01
MEDCOM - 16679
(b)E0 -

DOD-030068
'. : lig , . 7?:4 ,,k4,p4::* ,:.,, -: 7 • INTRAOPERJ,. DOCUMENT
.. '''.;.' 'iit ¦ AC::4:Mii -'..'r or use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.

v . EA,_ E f1:144 , C.ifiTEMTOPERATING ROOM -. 2. PATIENT ROAED1.(E
•;-g.,'
ier

. BY Q.--k.(2-c7 +4-12---a-4----" VERIFIED BY Uir J 3.-DA • . TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN OM (b)(0 - Z. • ep_SS ta-Lf_060 Z / 67
TIME / ,,,: NUMBER' AC .
5. PREOPERATIVE EMOTIONAL STATUS fff
14CALM • ANXIOUS . EXCITED M CRYING . ANGRY • WITHDRAWN . OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL
ASSIGNED S PC, RELIEF
SCRUB SCRUB

( )((,) -Z
ASSIGNED eiChr. RELIEF
CIRCULATOR O., (6 --2-CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
',,,SUPINE .-. LITHOTOMY II PRONE il KRASKE LATERAL: . LEFT SIDE UP . RIGHT SIDE UP
i3 u9_05,te.,\_4_,0 cfrk-, 1---),,,,_ ---1---t,-c4.,ea. t_.,,. ,

COMMENTS:
8. SKIN PREPARATION

HAIR REMOVAL . YES '.NO PREP SOLUTION (Specify) . 6e_ DONE BY: 0 OR . NURSING UNIT SITE: 6.,A.A.f•-• -it, BY WHO fC40T2/11111 METHOD: U DEPILATORY 01 RAZOR SITE: y1, BY WHOM:
COMMENTS: COMMENTS: A--0 pai 01) ve A-44C-)d P
9. LOCATION OF EXTERNAL DEVICES
1 .

— Y t a It" •••• a.
._.... --.111111 -..1.0.0.....

---".......-•

•
IP/PP-
'1411111

A

LEGEND X Ground Pad(t)W: Safety Strap = ==
tint 0...i -= Correct I = Incorrect

First Closing Final Closing

10. COUNTS
)- 1, Other" Count Count SCRUB l.0 CIRCULATOR
Sponge Yes I¦ No

a

Needle Sharp Yes U No L1
VC-
Instrument Yes . No

ko)
Other . Yes No
•

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICES) (ESU) cgl YES . NO
Name - Last• first, middle; Grade; Date; Hospital or Medical Facility;)

Lia 40
d ESU NO: v A-A GROUND PAD: B ND If
NMI (6)(0--zi P1 CO-
LOT NO: 000 —
• ESU NO:

GROUND PAD: BRAND
11111111111111111 (.‘)(7--2

LOT NO:
• BIPOLAR NO:
P t Pra G B
MEDCOM - 16680

DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179-1 ITEST). DEC 82, WHICH IS OBSOLETE. USA PA
DOD-030069
13. PROSTHESIS, IMPLANTS_. YES_p NO_
IF YES NAME: ID NUMBER; MANUFACTURER
14. ..7,:f-3..44444:: WARM MEDICATIONS/ORDERS WW-t#4411W:WaAti
-.4.;14-04$4400#400,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

_ YES • NO .
MEDICATIONS. SOLUTION
DOSAGE

TIME METHOD PREPARED BY GIVEN BY
.
,--

WOUND IRRIGATION_1... YES_. NO, TYPE(S):
,
D.
99 /,% N Ar c..-1._

OTHER ORDERS
TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE
•

04 _____ _
15. X-RAY IN OPERATINGOOM_
IF YES, SITE
YES E_NO ' ''

S,

16._
LABORATORY SPECIMENS
SPECIMEN IS) NAME
YES_ . NO ' ! NAME
FROZEN SECTION (FSI NAME
YES_. NO ! NAME
CULTURE (C) NAME

NAME

YES_. NO_ '
NAME NAME

NAME

NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
7Re,f71

17._TUBES. DRAINS/PACKING_YES_NO . Q-^ g-X 4f '
TYPE/SIZE_• 1 s- Fe - &ler; Stri Ps

2. I tor-3. , .--,-,64Itia-61-1-&-at
F:7 fAdtd -1-12)( aN -6Ser. -or 1,

SITE_1._Nee.K. 2 - 0 n cpri. 1 4-) 3. IN. „a,
-r-51---1-1)

19. ADDITIONAL INFORMATION
'1 C O 0 A-15 ,M 1^_ 001-j- •
W(_(:)- Z
(')( (z.) -2
Me 0;') 00) - Z

20. OPERATION(S)_PERFOR
AA.A.11.,e.47-u
J
(C-) ) ep

1 .
21. PATIENT TRANSFERRED TO
:".i..P

r e-o , 16
. . . V&•Aprz.eatatit : ---'T -
er -

AIMINIIIIIIIIM 0 Pr/ Aii • l..2359?Wali
te13

RE
E OF DA FORM 5179-1, OCT 87
1-01 :
(6)(0- z MEDCOM - 16681

DOD-030070
INTRAOPER/ • DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the pro'._agency is the office of The Surgeon General
1. PATIENT TRANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFIED, REC
_ PROCEDURE
VIA Ut1-24_ BY /in..tgliAcac1/4 \ M.\-\\J\VERIFIED BY_(.._,p ‘

3. DATE_ TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM_(b)(6)
3) ANto--7-7 'aV?..Acr TIME '. .-czo--_ NUMBER 2--1k

5. PREOPERATIVE EMOTIONAL STATUS
t

-_. CALM_. ANXIOUS_. EXCITED • CRYING_• ANGRY . WITHDRAWN_7 OTHER (Specify)
COMMENTS:
'-' v•kiliM:DcoNtc,

. .
6. NURSING PERSONNEL
ASSIGNED
C RELIEF
SCRUB

SCRUB
(CO -2.•
ASSIGNED (._._. "ill1111111111_
RELIEF
CIRCULATOR ( 6)((r))_._2 CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
Lg(SUPINE • LITHOTOMY _EJ PRONE • KRASKE __

LATERAL:_. L F T SIDE UP_. RIGHT SIDE UP cx-ti si,6 te..."---‘,4--.-1--,-",..c.AA,..-4ccp.......v,tek. , . \rksLe,ck.. ty\k, OCA.......,.., Cil CA/VAt t Gw w.5 oat.
eV bo

COMMENTS:_t.c.&.s ,410 y o—c.Ackto.N., c's-ry •"ff:- \c' 0 clw C-A_1 V556--‘1.-j 6-N.,_ CCfr 6VR, CA 14:a-Z5 S"./.7V 5e eNA 1- CV1/41 K/ "j-
8. SKIN PREPARATION

HAIR REMOVAL_. YES_X NO PREP SOLUTION (Specify) MNAt f3e-Ak
-
DONE BY:

_ji OR_ . NURSING UNIT SITE: A10 L'A.A-_BY WHOM:_
METHOD:_Il DEPILATORY_. RAZOR SITE: BY WHOM:

_(0(0._ L
• CLIP

COMMENTS: COMMENTS:"-vw_yGOV
3V_9k;.--.._la l '_"A.t)A.R.QA,..,

9. LOCATION OF EXTERNAL DEVICES
I 1..... ..
I
e•
.

/ .-(1)(0-1_
a )(6) -I
LEGEND_X Ground Pace_-- Safety Strap.. = = = Tourniquet

C = Correct_I = Incorrect
First Closing Final Closing

10. COUNTS Other*• Count Count
SCRUB CIRCULATOR
Sponge_le Yes . No C

C Needle Sharp_N Yes . No C.--
C-

11111 (6)
(
l.6)) --17-g=r)6()(1)-:
Instrument_. Yes_No Other_• Yes 2 No QIN ljft Me( 0N
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) 11 YES .760 Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
• II ESU NO:_Ve-A. \Vt..' 14,s-‘0 1: 45% t..$1...._1.0
Will 03)((o) -4( GROUND PAD: BRAND_V L eQ-v-. PO.,7‘V-0A ve.. 11-LOT NO:_to 8 c.G (.0_zoos-a
_1..cu--N

m ESU NO: GROUND PAD: BRAND
LOT NO:
• BIPOLAR NO:
_
_

-r . REPLACES DA F IS OBSOLETE. USAPA V1.00
MEDCOM -16682

DOD-030071

13. PROSTHESIS, IMPLANTS . YES_PS
NO_IF YES NAME: ID NUMBER; MANUFACTURER
MED ICATIONS/ORDERS
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES . NO gj
.MEDICATIONS/SOLUTION_ DOSAGE TIME_ METHOD PREPARED BY GIVEN BY

_

:WOUND IRRIGATION YES NO, TYPE(S):
0_/0
:;.:OTHER ORDERS
TIME_CARRIED OUT BY

':PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING ROOM_ YES t__.; NO 16. SPECIMEN ISI YES . NO NAME NAME NAME NAME FROZEN SECTION (FS) YES ._NO A NAME CULTURE IC) YES 0_ NO IF YES, SITE LABORATORY SPECIMENS NAME NAME NAME NAME
NAME 17._TUBES, DRAINS/PACKING TYPE/SIZE_ 1: NAME 2. YES ._NO 3. . 18. DRESSING/IMMOBILIZATION (Specify) 14 "TOTTR-•
SITE
19. ADDITIONAL INFORMATION (b)(b) -1-LAV,6)rX 1
AAAJZON-LC\ (VP I
20. OPERATION(S) PERFORMED \p (NG-NAAA NA

21. PATIENT TRANSFERRED TO
TIME SRI-MET,I10D
k.
Ut‘ljUli

22.
REVERSE
7 USAF'', V1.00
MEDCOM - 16683
(6)((.. -2

DOD-030072

J
INTRAOPERATIVE DOCUMENT
MEDICAL RECORD

For use of this form, see AR 40-66, the p -^ ,nent agency is the office of The Surgeon General.
1. PATI NT T_NS_RTE_TO OP _G RO 2. PATIENT I_ WED AND PROCEDURE
VIA VERIFIED B_
( 12)00)" 2

3. DATE_ TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
_,P03 i 9_C_)
O&S(--- ND-0 TIME_NUMBER r9// /(i
5. PREOPERATIVE EMOTIONAL STATUS

NI CALM_• ANXIOUS_• EXCITED_. CRYING_0 ANGRY_• WITHDRAWN_._THER (Sprify)
•%

COMMENTS:_Allergies: . A)V. PI 1n Lgledet--
6. NURSING PERSONNEL
ASSIGNED RELIEF
5PC___ Inn 9 1 0
SCRUB SCRUB
(10)I(‘)) -2.
216)-
&PT-ON= 6CE
ASSIGNED RELIEF
CIRCULATOR 06)(0- CIRCULATOR

7. P a S I TI 0 A D POSITIONAL AIDS (4pecify)50,1 poe-teifiele I. --. cl
K t2-ed eritee d2 Pc,a- P-1 11t-44-i'-1'415
Ai_a.,, oz......-1--1-0 saes Oa e 4.4 r" 71c, pczel €7,-11-%_0 c-ceS C S _017 - ././°5 ' 2._fir PINE_• LITHOTOMY /_• PRONE_• KRASKE LATERAL:_¦ LEFT SIDE UP_• RIGHTSIDE UP_-Si , , '-to weis L.4. *N.Ce--e-r--fri-kg0415,, COMMENTS:
Ce)r)(42C71------a5ciy 01; YlAzu-+ PIA 0-1-ct i A.p. 0 / -
8. SKIN PREPARATION

HAIR REMOVAL_¦ YES_llt) PREP SOLUTION fSpecifyieef-eVeLeA DONE BY:_•_OR_ • NURSING UNIT SITE: Oto-31-Ab Y WHOM: C•PTIIIIIIB METHOD:_•_DEPILATORY_¦ RAZOR SITE: Cc.-5IligZt. . BY WHOM:_( b)(6) - 7_.
• CLIP

)_.. COMMENTS: COMMENTS:40 pcicy /V 01 S '1, /;00_5 vt.4-4-e el
9. LOCATION OF EXTERNAL_EVICE
..4.
,.., —.ft.%

r . 011b' 11 ,41 ...
iii¦ tlE
i "AO'
47",
,...WIINIMMMINIP--

( 6)(0 - 1 .
( koc, . ,
dIIIP-AVIRM .,
LEGEND_X Gr ound Pad_fety Strap_=_-trniquet tr.*or-v4; — p re es
C = Correct_I = Incorrect
ihiketj First Closing Final Closing

10. COUNTS * *OW Count Count SCRUB 0 )(6)- 1. CIRCU_6 (6 -1 Sponge_%le es No c...-
I 10 sec_ dliN c.."7-- m, jlc.
Needle Sharp _es_¦ No C— L
)--1-
Instrument WI es • No
(_6Y6)

1 L- r
Other • Yes

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) ''ES • NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

OESU NO: : :E. Io 41;
GROUND PAD: BRAND 11,4fflellffffliteaaW
_.41111111011
-----J15-'
LOT NO: -:¦AatitV ,._ •_AP __

• ESU NO:_ GROUND PAD:_BRAND
LOT NO: ( 1DY- ('''- If
• BIPOLAR NO:

DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179.1 (TEST), DEC 82, WHICH IS OBSOLETE._ USAPA V1.01
MEDCOM - 16684

DOD-030073
13. PROSTHESIS, IMPLANTS • YES . NO IF YES NAME: ID NUMBER; MANUFACTURER
a. 01 EDICATIONS/ORDERS:::::::::::,!.:::::::::::::::::::::4:
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ._NO . :MEDICATIONS/SOLUTION DOSAGE TIME METHOD
PREPARED BY GIVEN BY
is

WOUND IRRIGATION Kt YES_• NO, TYPE(S):
61S -z' 0(1% Akt Ce/

OTHER ORDERS TIME CARRIED OUT BY ::
1PHYSICIAN'S SIGNATURE
• •_
... • •_
•_---_....------_•_ ._,_„_.,._..,_...._.
15.
X-RAY IN OPERATING ROOM IF YES, SITE
YES II NO X

16.
LABORATORY SPECIMENS

SPECIMEN (S) NAME NAME
YES III NO FROZEN SECTION (F) NAME NAME YES II NO CULTURE (C) NAME NAME YES . NO 161 NAME NAME NAME
NAME NAME 18. DRESSIN /IMMOBI ZATION (Specify)
17. ' TUBES, DRAINS/PACKING. YES 00 - NO . 4xq TYPE/SIZE 1.rs2514 Tugs 2. 3.
Tapiz SITE 14\loctolan 2. 3.
IONA

19.,ZL IN11,31(Z4AiFION
( 6)(0 - -2.

WCC _ : Dr Anesthesia: /14 111P Anesthesia Type:
D) Ger,_ Citi
grIcieS
clou.)- i

Boyle Pad site intact pre-op ; ost-op V7 Bovie Settings: Coag/Cut sots 6 0 Le4-ted •/Tourniquet Site intact pre lost-op
. pTourniquet Time: Up 3ow 1
20.OPERATION(S) PERFORMED
21.PATIENT TRANSFERRED TO TIME MET -1
153° k lel (1-W er
101.0111111111111111b7,_ MEDCOME-1111611311511/1/7//1-13
(

DOD-030074

INTRAOPERATNE DOCUMENT
MEDICAL RECORD •

For use of this form, see AR 40-407, the pror' _3ency is the office of The Surgeon General.
1. PATIENTt.iioNSO)F(I(T.IEC7). TO OPERATI I_•.)M_-2. PATIENT IDENTS_ D PROCEDURE VIA _.\i,N41\":,?1,-. A-t,,40,,ack4e,_BY AY1I-K\19\ (X_ VERIFIED BY_CV\
3. DATE_ TIME PATIENT ARRIVED IN SUITE 4.- PATIENT IN ROOM
_(lo)(20)-Z
R 36A 679 1 WO TIME -_(60()_ NUM

5. PREOPERATIVE EMOTIONAL STATUS

gi CALM • ANXIOUS • EXCITED_$ CRYING . ANGRY $ WITHDRAWN E] OTHER (Specify)
COMMENTS: .__...._.
6. NURSING PERSONNEL
ASSIGNED 0:0(0---------RELIEF
SCRUB

SCRUB
(1,)0a) - Z
ASSIGNED C-C7T RELIEF
CIRCULATOR . ....... __CIRCULATOR
i hi i. : •
..__

7. POSITION AND POSITIONAL AIDS (Specify) _.-
[g] SUPINE $ LITHOTOMY ¦ PRONE . KRASKE '.._LATERAL:

II LEFT SIDE UP_II RIGHT SIDE UP VY , )-,c)_c .--12-Artyy--, N--.-.:6(,,,_-\-,-,-----._b_....._:::_„k-c1-2;•-v.-1_01. c"." sr \-/";\ din Z-VS,CAO1/44, COMMENTS: oay 170c‘necAS 1_pls045-. .;.:56-.AJNI fa.61-‘ SlOt\).:7¦ 0,
--)6(s-N-\. 4rIs-k_ok 10 ¦,A/sV
8. SKIN PREPARATION

HAIR REMOVAL_MI YES_12 NO PREP SOLUTION (Specify)
&.;\ Cr \ B-14-A
-¦
DONE BY:_• OR $ NURSING UNIT SITE:_

C-..nr V•.1... BY WHOM: METHOD:_• DEPILATORY ¦ RAZOR SITE:_ BY WHOM:_(6)(‘ - 2_
. CLIP

-_•_ ,
COMMENTS: _._-__ ___...._.. COMMENTS:
rx)vot-Un L.,_, ,l(.4.,,,,_'_-tA.6te-oU
9. LOCATION OF EXTERNAL DEVICES
-. c.,-.,-,c a.
sy00040.,

LEGEND X Ground Pad - Safety Strap.. = = = Tourniquet... ---::: : (6)(0 -2-(b)(6)-2 C = Correct_I = Incorrect_1.-...-:4SPX .
:_111111.1111
First Closing Final Closing
..
Other' • Count_' • Cdunt

SCRUB CIRCULATOR
Sponge 0 Yes
Needle Sharp_ff.' Yes Instrument_III Yes Z
Other_
1/1 Yes
.
O0M
_

00(.0 - Z (V)( L)- 1
_
KH; W_: -
-, 1
P\

1 1 . PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICEIS) ESU)_jg YES_MI NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
. Jam.ESU NO:_-%''''Ate-7( cx.‘c._--A-0-1 CL. 40 ( (') -II GROUND PAD: BRAND_VL. 2..,._.—... cro)...p..Q.ki ,,-. ----....
... ,.:,30 130

LOT NO: 6 2. 2.1-S
2 MS' D'
—

1 ---CROUND PAD: BRAND LOT NO: U BIPOLAR NO:
-. -.. - - -- -_- -- --
_

-I, REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V1.00
MEDCOM -16686

DOD-030075

13.
PROSTHESIS, IMPLANTS 0 YES NO IF YES NAME: ID NUMBER; r ,ACTURER

,. ,:.,.;

14.
_ -..:?:.: „L..4,„;,::',VMEDICATIONS/ORDERS. IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA) YES •

ki
MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

:WOUND IRRIGATION 0 YES II NO, TYPE(S): 0, 1°/13 IJCs-a•
OTHER ORDERS TIME CARRIED OUT BY
......_____ . ,.

— PHYSICIAN'S SIGNATU
OMAIBI (6)(c) --7_

15. X-RAY IN OPERATING ROOM IF YES, SITE
:,
YES / NO 0,

16. -'"'LABORATORY SPECIMENS
_ , .

SPECIMEN (SI NAME - --. --.----NAME YES • NO LA " FROZEN SECTION IFS) NAME NAME YES • NO RI CULTURE (C) NAME NAME
YES ¦ NO gi _ ._.. ....
---— NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify) -- - --T-'('C,NA\S
17. TUBES, DRAINS/PACKING YES • NO •
1(1 • Ni TYPE/SIZE 2. Ar(-.5U\i`M C4y SITE 1. 2. 3. , . . __-__. cti\\ ,\.. 1 1 z 1 eLv\
19. ADDITIONAL INFORMATION ( t,)(0 - 1 (OW) -2. -
%-i\tY.2-6-1,\ NM \
^
-cil-1 CIA cc ,,,,i \ X 6 1 -5-.AXt--\e-ok., '

20. OPERATION(S) PERFORMED
0.0.,\,1/4" 6 k_k3(s----,,,,.,..".0j¦ Lk_ t, (z&V\--?..._
-1--\--

21.
PATIENT TRANSFERRED TO -LINE sgiz. ME:1+1414
CAK -N t`IW -(A

22.
1-1),),(yo

REVERSE OF7J7f701405179=71 OCT 87 USAFA V 1.00
MEDCOM - 16687

DOD-030076
INTRAOPERATIVE DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the pro/ _
tency is the office of The Surgeon General.

1. PATIENT TRA sPqRTEp TO OPERATII_JM 2. PATIENT (DENT,_. 4_REVIEWED AND PROCEDURE VIA 14..42.0., 1 i 41-e(_BY artp..;s; a__ VERIFIED BY CPT;_ (0(0-2
3. DATE_ TIME PATIENTRIVED IN SUITE 4; PATI NT IN ROOM 1 1 Se PO 3_ (5 /35 TIME• 0 9 35-_ NUMBER jia 3
5. PREOPERATIVE EMOTIONAL STATUS /
CALM_ANXIOUS_U EXCITED. • CRYING II ANGRY_. WITHDRAWN_
11 OTHER (Specify) COMMENTS: -N ot .
..:. ..........

6. NURSING PERSONNEL
ASSIGNED 000. -_ ' " -° '"RELIEF
SCRUB

.SCRUB •
beT 11.11111111 6 6
ASSIGNED
RELIEF
CIRCULATOR (_0 (to) - 7-_ _. _ .___ __CIRCULATOR
IN :ff-

.

7. POSITION AND pOSITIONAL AIDS (Spfc.
ifyl N-(..3 • PPeisigd o e, -,,M,__cfl 14-0101 ..1-Pocl,---, do ,I ,,,,i-- &A lcrie,,,,
-ex

ti-0715„..0,1- 40 Sid-Ps-go° -6-, C--4-.e.. e.:,,,,=m,-tz p,d,teat cf,./.--, 6aA s C SG4e1--/
UPINE_n LITHOTOMY_II PRONE_• KRASKE _LATERAL:

• LEFT SIDE UP_. RIGHT SIDE UP SA'rokrce) LW .-p,..,..,Leis-,.-t ,-, cte,-- ita. Is
,

COMMENTS: '.'
_irLeej-Pc'GI . . _ .:em.,-i--,/,261
II- 1,9.44 `''Le„,.
8. SKIN PREPARATION

HAIR REMOVAL rES_• NO_ ' PREP SOLUTION (Specify) h 6, cle,-7.s. DONE BY:_OR 111 NURSING UNIT SITE: f kb cto P-1-‘44.1 j-BY WHOM: METHOD:_•_DEPILATORY_F:PRAZOR 6 ._Zpf-SITECLc(-411-j.5.4..,_ BY WHOM:
IN_CLIP_( 6)(6) - L _____ Q 5 `/b__,2 jo1.3
.,.. COMMENTS: AO_5 0 ,- r . tcimrvitN-rs:40 0,,c,c, t. ,
c-u, -4-i'e..-ic 9 i-t-....7.7 .-).-s /1..v.136k-rs it cl
9. LOCATION OF EXTERNAL DEVICE -_
. ...„......

c,...__....._
...,„
....„s,,

,,,,...,,,

IA Vi#0,'0_4t4t,emer¦. _--".1.1.1"a3=1111111=11111111..-_ -
0..A -Meel\r;-ototontAIMMIPI•Lrrilr./PP-
*I Nww, 4Vo-¦Aarge-z..
.4.1 _...._., vo..-
1
I, )(b) - 1 (6)(6)--, Alfr

LEGEND_X Ground Pad_afety Strap_= = - Tourniquet.:- -.:.---- -
C = Correct_I = Incorrect

N. i•-%. th.‘ First Final Closing

10. COUNTS CountClosiCountCont -I-
.. SCRUB _ CIRCULATOR (0 )( (-Q)" -7-
Sponge_
riI Pi il A ElILO INMI! M II I I I MI 9/9 d if.
Needle Sharp_
2 OENElII,CIIIWAIIIIIIIIIIMIIIPIIII

Instrument_
¦ Yes 0:lMBIMIWAIIIIMISOMPIIIII IIM11.
Other_
• Yes
OM /41111111111111111N11111/

11. PATIENT IDENTIFICATION (For yped or w tten entries give. . ELECTROSURGERY DEVICE(S) ESU)_
W ES_. NO

Name - Last, first, middle; Grade; Date; Hospira or Medical Facility;)
Re SU NO: gq-S 1 0V9-S GROUND PAD:_BRAND_1311-6 Ac, poTv it+, SAir icrep,
:t11111111
,:
.._.

.. LOT NO _ -ei.3 S---0 3
,-.:::-

isit_i NO:
`GROUND PAD;_BRAND
( 6)((,) - Y ' LOT NO:

. BIPOLAR NO:

-1 . PLACES DA FORM 5179.1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V1.00
MEDCOM -16688

DOD-030077
13. PROSTHESIS, IMPLANTS El YES IF YES NAME: ID NUMBER;
PACTURER
....Y3_.__........._

(

1 4 _ ._..1.`:;', 'MEDICATIONS/ORDERS;;T :._-_E
...a..?_;-_kr
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA)_YES . •
MEDICATIONS/SOLUTION DOSAGE TIME METHOD

PREP G
•0

ell no re, i o , ( az. 5 oli-for-o , - i -c7 p 1 c_c, 1 C_P Or
(6)(6) -I' -----' ( 0(0 -2-

WOUND IRRIGATION_}YES • NO, TYPE(S):
ase-baCe 0,?7,0 .t_ Aja ck. 0, q% c-,-_:-/,'/X GS

OTHER ORDERS
TIME CARRIED OUT BY
-.............

PHYSICIA
«)(. b) --

15. X-RAY IN OPER
ROOM IF YES, SITE
YES ¦ NO

16._
' LABORATORY SPECIMENS
SPECIMEN (S) NAME_ _ ____ _____
YES_¦ NO
FROZEN SECTION (_) NAME

NAME

YES_¦ NO
CULTURE (CI NAME

NAME
YES_¦ NO " _____.._.. _ _
NAME NAME

NAME

NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
----- -ze ro Var., 6,-.1.--z,z._ , We-4-Ice/ 1,-. yo
17._TUBES, DRAINS/PACKING_YES_NO
.__ . r--(c4c5 --CI )004-1_
i_ f-eilZdikl

TYPE/SIZE 1.40/..41fr.i :SP 2._ i)l/lelq
/ Dlca ivl
65 17)).-r•7_b:29_,,
SITE 1.4 b do 4,-. 6-2. 3.
143e.vi ri a

19. ADDI IONAL INFORMATION
t.1 C__ cl,A.0-z
(6)00)-7-St..,,, .4.01,- -`bc--If-Ytt-5-14zsi C. -, eAtitid -3-e ir- 1
EA , f,e PAs /Le_ ,,,,,,, , ,2
Pact -l0 5 t

CA)1 CO'3W---d Blia,,ol I
20. OPERATION(S) PERFORMED
Si eN_G-r-4f+ ,-i-o,
... . /9..dO )•¦-1...0

21. PATIENT TRANSFERRED TO
TIME METHItD
......._ .. ___ ..._____. .__

-I.
USAPA V1.00
6)( CD)

DOD-030078