Medical Report: 63-Year-Old Iraqi Male Civilian re: Gunshot Wound to Chest

Medical records of an Iraqi male, 63 years-old, with a gunshot wound to his left chest. The medical records do not give any indication as to how he received his injuries or any personal information on the gentleman.

Doc_type: 
Medical
Doc_date: 
Sunday, March 30, 2003
Doc_rel_date: 
Monday, May 30, 2005
Doc_text: 

-.4R MO 03
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST. DAY
MONTH-YEAR DAT
19 HOUR •4'0' '‘••C • • • • •• " • • •). 00 • •• : • • • t.)00 • ' •
PULSE TEMP. F . TEMP. C
(0) (0) • " . . . •
40.6°

103°

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180 . 40.0°
104°
.

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170 103° . . • . . . . . . . •
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bL , 'AL SIGNS RECORD
511-112
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MEDCOM - 3870
Record specialdata only when so ordered
DOD 010349

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MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY
POST. DAY
MONTH-YEAR DAY
19 HOUR
JI to 'C 1Y^
PULSE TEMP. C
(0) (0)
40 6°

105°
180 40.0°
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PATIENT'S IDENTIFICATION (For typed or written entries give; Name—last, first, REGISTER NO. WARD NO.
middle; rank; rate; hospitalor 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
. 1983-381'528/8361
MEDCOM - 3871
I Record specialdata only when so ordered
DOD 010350

511-118. NSN 7540-00-634-4124
MEDICAL RECORD .. VITAL SIGNS RECORD
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HOSPITAL DAY
MT-, DAY Mal
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EsPIRATION RECORD
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VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511. (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 3872
DOD 010351

MEDICAL RECORD VITAL SIGNS RECORD
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MONTH-YEAR
DAY
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,b)(6)-4

MEDCOM -3873
DOD 010352

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
.. •
Mra-MillMIMIIIMEIMIMlrali POST-. DAY -
MONTH-YEAR DAY MIIWIWIIRWI:
19 HOUR AIIMIMMISSMIIIIII •'A , ' 6 ... .. • • • • •
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... . .

TEMP. F ............ • .... ... . TEMP. C

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40.6° .. ... ... .

..: ...... .. .. ... ...
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180. 104° , .....

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.. •• •• •

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170. 103° ............... .. ... • •

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100. 90. 80
70
60 50 40
RESPIRATION RECORD
1;/ 6
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vf , PATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last. first, middle; ID No. REGISTER NO WARD NO.
Record special data only when so ordered
(SSN or other): hospital or medical facility)
12X6)-4
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511. (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 3874

DOD 010353

ae
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TEST(S)
-ST(S) :b)(6).4
TESTIS) TEST(S)
ea

SPECIMEN TAKEN
' RN TAKEN U1
SPECIMEN TAKEN I SPECIMEN TAKEN
A DATE ion r.,
DATE DATE TIME Titi 0
TIME A AT.h - .1 ig3s P.M .
..70#114C• 0 •?") • v sfous3 0(001.0 vu.)
REQUESTED (X)
REQUESTED RESULTS
RESULTS HOLIES REQUESTED RESULTS
RESULTS
GLUCOSE

¦

GLUCOSEGLUCOI /6 g GLUCOSE .2.24,
S r
G209
UREA N.
UREA N.
UREA N. UREA N. .2
a 33
CREATIN CREATININE

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CREATININECREATININE
¦

URIC ACIDURIC ACIDURIC AC URIC ACID
I i 2_ SODIUM ¦
SODIUMSODIUM i• Li 3 SODIUM
iLQ Pt3
POTASSIUM
POTASSIUM -S, Co
POTASS 3. 0 POTASSIUM
• 3 ,2 I q
CHLORIDEjoy CHLORIB ,to 7 CHLORIDE 0 CHLORIDE 1 0
I
CO. ¦

CO. ¦
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24 L
PHOSPHATEPHOSPHATEPHOSPR PHOSPHATE

aa CALCIUM
¦

CALCIUM
CALCIUM CALCIUM
TOTAL

TOTAL
TOTAL • TOTAL
¦
0

PR • FIN
PROTEINPROTEIN PROTEIN
O

ALBUMINALBUMIN
ALBUMIN ALBUMIN
GLOBULIN

¦

GLOSUUN GLOBULINGLOBUU
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ALKAUNI . PHOSPHATASE
PHOSPHATASE
' PHOSPHI PHOSPHATASE ACIDACIDACID . ACID
¦

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PHOSPHI PHOSPHATASE )SGOT ¦LDH SGOT SGOT
LDHLDH LDH CPK ¦

CPK
BILIRUBIN BIURUBIN

CPK CPK BILIRUBIN
O u II
BTILIRTuA:L N

ruieTuALBIIN
BIURUBIR BILIRUBIN

(TOTAL) ' (TOTAL)
¦
DIRECT 1111 IDIRECTI • meal (DIRECT) CHOLESTEROLCHOLESTEROLCHOLEST CHOLESTEROL TRIGLYCEBDE 5 C CITRIGLYCERIDESTRIGLYCE. TRIGLYCERIDES

0

AMYLASE rn
¦

AMYLASEAMYLASE AMYLASE
Q
LIPASELIPASELIPASE UPASE PROFILE (Specify);PROFILE (SI PROFILE (SpieeiFY) PROFILE (Specify) ,

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CHEM STRY I CHEMISTRY I CHE
STANDARD FORM 546 IR. BM!
STANDARD FORM 5A6IRM 4111
STANDARD FORM 546 STANDARD FORM 546 IR. th7T1
PRESCRIBED BY GSA ICMR
PRESCRIBED BY GSA PRESCRIBED BY GSA ICMF PRESCRIBED BY GSA ICMR
FIRMR (41 CFR) 201-45.505
(41 CFR)101-45r. FI1MR (41 CFRI01-41505
FI1MR (41 CFR)101-, FIIMR
PATIENT'S MED. RECORD
. 11 I SPECIMEN/LAB. RPT. NO.
I I

(b)(13)-4
CHEM I

URGENCY PATIENT STATUS o eg BED §
0 AMB RROUTINE

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0 PRE-OP

SPECIMEN SOURCE STAT 0 0 BLOOD R.
0 OTHER (Specify) t
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
LAB. ID. NO.

Enter in above space DV 76)(6)-2 ID DATE REQUESTING PHYSICIAN'S SIGNATURE 17)(8U"
1:P3)-2
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MEDCOM -3875
DOD 010354
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print) Products are requested.)
"b)(13)-2

21. RED BLOOD CELLS
r

. TYPE AND SCREEN. FRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE PROCEDURE
. PLATELETS (Pool of units) . CROSSMATCH
-... illW.-T7 77,4L) w144
. CRYOPRECIPITATE (Pool of units) DATE REQUESTED
I.have.collected.a blood.specimen.on the below Rh IMMUNE GLOBULIN 31 Aar 03 named patient, verified the name and ID No. of the patient and verified the specimen tube label to be
DATE AND HOUR REQUIRED
correct.

. OTHER (Specify)
'3 j Mar 03 0800
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER REACTION (Specify)
.-15-40 ML
IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
REMARKS:
RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH . RECORD.NO RECORD
PATIENT NO. SIGNATURE OF PERSON PERFORMING TEST
L/43(0'11,0
NA
DONOR RECIPIENT CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED. DATE 31 r 63 ABO ABO REMARKS:
Rh
Rh ? OS
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTEDINSPE
b)(6).2
II 50 ML IQ 3-- 03 /3//,-N
REACTION TEMPERATURE PULSE.BLOOD_P7SSURE
. SUSPECTED

AT (Hour) f 0-7 5-0 I ON (Dal‘ •44 o3 NONE -g
IDENTIRCATION If reaction 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 on this Blood Component Transfusion Form and 3. Follow 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 (Sign9t),(6)_,2 DESCRIPTION OF REACTION

. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
ur
b)(6).22 ninrn
OTHER DIFFICULTIES (Equipment, clots, etc.) • FRE-TRAN4rfil NO ON YES (Speci6r) (.1 /mg cAtkei? SIGNATURE OF PERSON NOTING ABOVE
TEMP. I PULSE V l BP
b)(6).2

DATE OF, TRANpFUSION TIME STARTED
C3 / 3 /073 9 05'
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; graci., . WARD rate; hospita or medical facility)
.1.6 1)
,b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM 3876 Medical Record Copy
-
DOD 010355

MEDICAL RECORD
COMPONENT REQUESTED (Check one)
k RED BLOOD CELLS

.
FRESH FROZEN PLASMA

.
PLATELETS (Pool of units)

.
CRYOPRECIPITATE (Pool of units)

.
Rh IMMUNE GLOBULIN

. OTHER (Specify)
VOLUME REQUESTED (lf applicable) 45-0
ML
REMARKS:
UNIT NO. Li. (:) ito s TRANSFUSION NO.
PATIENT NO.
DONOR RECIPIENT
ABO ABO
0
Rh Rh
L9-5
PRE-TRANSFUSION DATA INSPECTEn ANn I qiirn RV rCirrnnti,rnl
b)(6)-2
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
. TYPE AND SCREEN
CROSSMATCH
....

DATE REQUESTED
31 mar 03
DATE AND HOUR REQUIRED
31 Mar 03
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
NA
REQUESTING PHYSICIAN (Print)
.13)(6)-2
br

DIAGNOSIS OR OPERATIVE PROCEDURE

/0 ift, T7 r)o ;r).14-‘..„. . W
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 VERIFIER
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:

. RECORD 111 NO RECORD SIGNATURE OF PERSON PERFORMING TEST
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE
31 Aar a

REMARKS:
SECTION III - RECORD OF TRANSFUSION
AT (Hour) ON (Date) .31 il l, 03
IDENTIFICATION
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. 1st VERIFIER (Sigraturpi
b)(6)-2
1-Ht-IKANS ilibAON
TEMP. 77
1
DATE OF TRANIFUS
g
'71W3Pt
PULSE Oa, BP 12 TIME STARTED,./
11:05 10 15)/3
AMOUNT GIVEN ML REACTION (,NONE . 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 OF REACTION

. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
.
OTHER DIFFICULTIES (Equipment, clots, etc.) NO.. YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
.131161-2

0-6-r
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grado,--, . rate; hospital or medical facility)
,b)(13)-4
MEDCOM - 3877
POST-TRANSFUSION DATA TIME/DATE COMP 'EYED/INTERRUPTED
0 313 / 0 7 /2.-02to
TEMPERATURE PULSE.BLOO7PRESSURE
t9.6 112 43 /sir
MAS WARD —L
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9,202-1

Medical Record Copy
DOD 010356

NSN 7540-00-634-4159518-124
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)
.13)(6)-2

Products are requested.)
x RED BLOOD CELLS
0

. TYPE AND SCREEN
FRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE PROCEDURE
. CROSSMATCH
.
PLATELETS (Pool of units)

_...
.
CRYOPRECIPITATE (Pool of units)

DATE REQUESTED
I.have collected.a blood specimen.on the.below named patient, verified the name and ID No. of the
. Rh IMMUNE GLOBULIN 1 A-pr 'f) 3
patient and verified the specimen tube label to be
DATE AND HOUR REQUIRED
correct.

. OTHER (Specify) 6 t lc
1 Apr 03
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER REACTION (Specify)
4 6-0 ML
IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
REMARKS:
RhIG TREATMENT? DATE GIVEN: TIME VERIFIED HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH . RECORD.p• NO ECORD
I gr`li 3 (.3

UNIT NO. TRANSFUSION NO. TEST INTERPRETATION
PATIENT NO. SIGNATURE OF PERSON PERFOR MING TEST
N
DONOR RECIPIENT CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED . DATE.
t A?, 63 ABO ABO
REMARKS:
Rh.Rh
?4'
SECTION III - RECORD OF TRANSFUSION
POST-TRANSFUSION DATAPRE-TRANSFUSION DATA

,b)(6)-2
T /INTERRUPTED
AMOUNT GIVEN TIME/DATElitZED
INSPEC ML
2oz5 ("-PC 03 013S
REACTION TEMPERATURE PULSE BLOOD PRESSURE NONE . SUSPECTED
AT (Hour), 0/ /5 ON (Date) Ar 0 3 C1 -2 15 ‘0 161/40 IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open. information identifying the container with the Intended recipient matches item by item.
I have examined the Blood Component container label and this form and I find all
2. Notify Physician and Transfusion Service. The recipient is the same person named on this Blood Component Transfusion Form and
3.
Follow Transfusion Reaction Procedures.

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

on the patient identification tag. DESCRIPTION OF REACTION
. URTICARIA 111 CHILL . FEVER . PAIN
. OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.) NO.. YES (Specify)
SIG ATURE OF PERSON NOTING ABOVE
DATE OF TRANSFUSION. TIME STARTED b)(13).2
I CA?C. 0 \ 3 \
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, SEX WARD rate; hospital or medical facility) a- LA
\ iltalsz_

;b)(13)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

Medical Record Copy
MEDCOM - 3878
DOD 010357

MEDICAL RECORD
COMPONENT REQUESTED (Check one) Kt. RED BLOOD CELLS
.
FRESH FROZEN PLASMA

.
PLATELETS (Pool of units)

.
CRYOPRECIPITATE (Pool of units)

.
Rh IMMUNE GLOBULIN

. OTHER (Specify)
VOLUME REQUESTED (If applicable) Lig°
REMARKS:
ML
UNIT NO. TRANSFUSION NO. PATIENT NO.
DONOR RECIPIENT
ABO 0 ABO
Rh ?°' Rh

PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)
AT (Hour) ON (Date) IDENTIFICATION
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
.
TYPE AND SCREEN

.
CROSSMATCH ....

DATE REQUESTED
I Apr 03
DATE AND HOUR REQUIRED
I Ar 05 I `-i 15-
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH

NA NA
REQUESTING PHYSICIAN (Print)
4(6)-2
"Of DIAGNOSIS OR OPERATIVE PROCEDURE

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 VERIFIER
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:

. RECORD WNO RECORD SIGNATURE OF PERSON PERFORMING TEST
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE /1-pr
REMARKS:
SECTION III - RECORD OF TRANSFUSION
AMOUNT GIVEN 0.
ML

POST TRANSFUSION DATA TIME/DATE COMPLETED/INTERRUPTED
leCr).T MPERATURE.PULSE BLOOD PRESSURE
(O@

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.
1st VERIFIE.ature)
2nd
(6)-2
PRE-TRANL..
TEMP. 9 $ BP
DATE OF TRANSFUSION TIME STARTED
ApC O3 f7 DO

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, rate: hospital or medical facility)
;b)(6)-4
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 OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
. OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.) NO.. YES (.343eci6,)
)(6)-2
MEDCOM - 3879
WARD ^ c. 0 1
OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy
DOD 010358

124
NSN 7540-00-634-4159
AEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)
Products are requested.) 1,96)-2

zi RED BLOOD CELLS
Or

FRESH FROZEN PLASMA TYPE AND SCREEN DIAGNOSIS OR OPERATIVE PROCEDURE
PLATELETS (Pool of units) CROSSMATCH
_...

CRYOPRECIPITATE (Pool of units) DATE REQUESTEp
I.have collected.a blood specimen.on the.below Rh IMMUNE GLOBULIN I Apr 0A 3 named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to be
OTHER (Specify) correct.
1 i i /C / A- ( 03
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATIO /TRANSFUSION SIGNATURE OF VERIFIER
REACTION (Specify)

t1 S-0 ML

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED.
- RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH

El RECORD.D410 RECORD
07 T4 ^'^ PATIENT NO. SIGNATURE OF PERSON PERFOR MING TEST
N 4 M A
DONOR RECIPIENT CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE
Ayr 453 ABO ABO REMARKS:
Rh Rh
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST TRANSFUSION DATA
b)(6)-2
INSPECTE AMOUNT GIVEN TIME/DATE.COMPLETED/INTERRUPTED
ML

4 ,5t)
REACTION TEMPERATURE PULSE BLOOD PRESSURE AT (Hour) I ybejs-.I ON (Date) / A.-pr 03
El-NEWIE El SUSPECTED /0
470/77

IDENTIFICATION If reaction 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 on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.

•...•• ifl•-,tinn • rt 896)-2
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION URTICARIA.El CHILL.El FEVER.El PAIN
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRANSFUS El YES (Specify)

3
TEMP. I PULSE./ 0 (Q.I B 75 SIGNATURE OF PERSON NOTING ABOVE
DATE OF T ANSFUSION. TIME STARTED.,

. /.---
b)(6)-2

PATIENT I NTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, f rst, ddle; grade; rank;
al facility)

698)-4
..4/ -rat, it
. C .--(-NENT TRANSFUSION
BLOOD OR BLO COMPOMedical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMFL F1RMR (41 CFR) 201-9.202-1

MEDCOM 3880 Medical Record Copy
-
DOD 010359

MSN 754040-634-1.122
509-113
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:b)(6)-2 PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; .-ate;
REGISTER NO.

hospital or medical facility)
:b)(6)-4 rrw.Aant_oo 1W I 1.....1
Medical Record
STANDARD FORM 509 (REV. 7-91)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 3881
DOD 010360

PROGRESS NOTES
DATE
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MEDCOM - 3882
DOD 010361
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
1)
LIST TIME ORDER )3)(8)-4 NOTED AND SIGN
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS

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HOURS

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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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APR 79

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MEDCOM - 3883
DOD 010362

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION :b)(6)-4 DATE OF ORDER TIME OF ORDER 07 HOURS LIST TIME ORDER NOTED AND SIGN
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHIC
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MEDCOM - 3884
DOD 010363

CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION ;6)(6)-4 DATE g OP ORDER TIME OF ORDER 00__3 (52 46,.xe AotA-.ar­-;&evyi a, ;,,,dtz HOURS LIST TIME ORDER NOTED AND SIGN A b)(6)-2
NURSING UNIT ROOM NO. BED NO. 6)(6)-4
PATIENT IDENTIFICATION DATE OF ORDER I 4r1 2003 (6 20 HOURS

NURSING UNIT ROOM NO. BED NO.
PATIENT' IDENTIFICATION DATE OF ORDER
N G-
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION OATE OF ORDER 03APX03 TIME OF ORDER rYto `r 4 r) HOURS
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MEDCOM - 3885
DOD 010364

THERAPEUTIC DOCUMENTATION CARE PLAN (11f2D/CATiONS)
CLINICAL RECORD For use of this form see AR 40-407; M*1144
o.,,bmyr.03._
the proponent agency is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

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EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
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MEDCOM - 3886
DOD 010365
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Initialing (MEDICATIONS) 1Mo. Yr
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MEDCOM - 3887
DOD 010366

PEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORDn-For use of this form, se* AR 40-407;
THERA Mo. fitobtYr. 0

the proponent agency Uthe Office of The Surgeon General.
VERIFY BY INITIALING , : INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

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DA1 FFOEV9 4678 EDITION OF 1 DEC 77 WIL,L,BE USED UNTIL EXH AUST ED.
MEDCOM - 3888

DOD 010367

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Initialing (MEDICATIONS) Mo. Yr
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE•OPERATIVES Time Given Initials
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DOD 010368

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THERAPEUTIC DOCUMENTATION CARE PLAN
CLINICAL RECORD For use of this forrn, see AR 40.407; Mor.Y-/ Yr. o 3
the proponent agency Is the Office of The Surgeon General.
'
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR I DATE DISPENSED DATE NURSE DOSE, FREQUENCY
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So

ALLERGIES YES El NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: ES Q NO
PAGE NO

PATIENT IDENTIFICATION:
DISPENSING TIMES

(b)(6)-4
USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
DA 1 F
OEFIN9 4678 EDITION OF 1 DEC 77 WILL BE USED UMEDCOM - 3890 N NTIL EXHAUSTED. 23 24 01 02 03 04 05 06

DOD 010369

,TICAL RECORD - SIJPLE??ffiNTAL N 1L UA tA
tr use of this form, see AR 40-66; t. .ccent agency is the Office of the Surgeon Ge.
EPORT TITLE OTSG APROVED (r)age)
TRAUMA FLOWSHEET

. INITIAL. ASSESSMENT •
II IC: Arrival Time:
Ilergies: Last Meal:
hief Complaint:
vIH:
reatments PTA:
ITAL SIGNS: BP: A3 P: )03
/4‘7
SKIN
El WARM SOFT
CI NO .
A.rN DYES .N° . .DRY . DISTENDED

3B . YES Q NO . PALE El 'TENDER
UNG SOUNDS

.
DUSKY BOWEL SOUNDS R L . MOIST CD YES . NO ] . CLEAR GUIAC TEST ] . WHEEZES . POS 0 NEG

.
DECREASED
D . ABSENT

X7REMETIES1
DISTAL PULSES
JRTX2OLTX2

'MOVES EXTREME-TIES
X4
NO EDEMA

I NO DEFORMITIES
XCEPTIO NS TO
.BONTE'' SPLINTS: • ARAMETERS: REA TMEN
2: LPM ORAL AIRWAY TT # 1,5.4 NASAL AIRWAY 1ONITOR 0 Y ON EKGE3Y . N IG TUBE # OLEY: # DPL . POS 'HEST TUBE ER CM H2o
EL
REPARED BY (Signature & Title)
ATTENT'S IDENTIFICATION (For typed or written itries give: Name - last; first; middle; grade; date: 9spiial or medical '
5A ;1132M .17fin. MAY -tie
. I IMMEDIATE . . DELAYED . 0 MINIMAL
Sex: M F Age: Wt.
Tetanus Status: UM Unknown
Medications:
RR: 1;0 .9) TEMP:
sA02:qc‘

PERRL YES mm L.
.. NO R mm GLASCOW SCORE:
dW
2 6 3* 40 59 6 a® 96
• 7

GN
1. EYE OPENING 2. VERBAL RESPONSE 3. MOTOR RESPONSE
Spontaneous-4 Oriented - 5 Obedient • 6 Confused -4 Purposeful -5
To Voice - 3
Witharawai -4
Inappropriate - 3

To Pain • • -2
Flexion -3
• Incomprehensible- 2

-None -1 Extension •2
None 1
None

A • kixasicn AP . Arran= AV • Ayttarn B • Burn C Coma=
D Mammy E • &ammo OF . Open Fracas CF • Closed Fracute G • GSW. ilSitasi L • hearten FW • Pirettre Wound S • Stab Ward
0 . Over
(23 NEG
FRONT

BACK

Continue at reverse)
DEPARTMENT/SERVICE/CLINIC DATE 399th CSH
.
HISTORY/PHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER (Specify)
OR EVALUATION

0 DIAGNOSTIC STUDIES
OTREATmENT
MEDCOM - 3891
DOD 010370

..._:.,—...n.
n1+1./..GPO/.
.1°"" 118-678
ACUATION TAG — FICHE D'gVACUATION DE PATIE .a this tag to patient — Attacher cette fiche au patient)
PATI .
FROM (Medical treatment facility)
OR (Installation de vehement medical) l

b)(3)-1
"'NAME ( Last— first—nuddle !natal) A. ////
NOM (Nom de (amine—premier preno14—initiale deuxiem prenom)

en

4
)(6)-4
i 4,4„....&
Eqyay OF PERSONNEL (Service or employer and
V,lGt NUIVICILII n NKRIATING/G E
NUMERO MATRICULE GRADE

tionality) CATEGORIE DE PERSONNEL (Service ou employeur et
nationalite)
DIAGNOSIS
DIAGNOSTIC

'DISEASE i3ATTLECPSUALV INJURY
CLASS—CLASSE
MALADIE BLESSE AU =VAT BLESSURE
1A 2A
la 2B
CABIN OR COMPARTMENT NO. BUNK NUMBER

1C
NO. CABINE OU COMPARTIMENT NUME(110
3 4

COUCHETTE

VSI
TAS GRAY. MAL.

BAGGAGE TAG NUMBERS)
m Yes No NUMgROS ETIQUETTES BAGAGE
= Oui Non

SHIP/AC (Number/type) NAVIRE/AVION (Matricule/type)
DESTINATION
DESTINATION
TREATMENT RECOMMENDED EN ROUTE (If no treatment is required a notation to this effect is made)
EMENT RECOMMANDE EN ROUTE (Indiquer si (actin traitement n'est necessaire)
TR
SI GNA .b)(6)-2 DATE
DATESIGNA

kJ Lit
)
REGIM NUM/1AL Htuunnu arc,...in wen.riPtion)

RE,GUL
SHIP'S RECORD OFFICE TAB — FICHE POUR ARCHIVES TRANSPORTS
—...—...., -—....—..

FROM (Medical treatment facility)
ORIGINE (Installation de traitement medical)

NAME (Last first—middle initial)
NOM (Nom de famille—premier prenom—initiale deurieme prenom)

SERVICE NUMBER RANK/RATING/GRADE CATEGORY OF PERSONNEL
NUMEROMATFIICULE GRADE

CATEGORIE DV PERSONNEL
•DATE In SHIPMENT
NUMEROS ETIQUETTES BAGAGES DATE DEPART

BAGGAGE TAG NUMBER(S)
ARRIVAL DATE
DESTINATION

DESTINATION DATE ARRIVEE
1AR KATION TAB — FICHE D'EMBARQUEMENT
I a

MEDCOM - 3892
DOD 010371
Trauma Resuscitation Form

SSN:
Data and lime al iniury.
Olds end time of arrival
CNef corriphint
Pm-hospital Inforasstion
Medianism of injury:
A.:COunshot wound . Stebbinp

0 Num
.
Chemical castisity

.
Other
Pmeedures below =Wel

.
Ainy: typil eke.
c1.01 Q 11 Unlil vie

40--Ped location and • A C-el-Chest bibs: locaden eke s 3 i‘
.
Splints: Type

.
Mediations:

.
Chemical caselly:

.
DeoententimMisa datalline:
Weeps OeleMme

.
Arens:

O am*
.
Ohm:

.
Other prooedures:

AMPLE history
Past Illnesses: j..TA
last mask ,jna Last Totowa: Nat. Events:
WNW seesssment
Airway
Patent Breelhkig
.
Normal

.
Symendricsi

%dem Wane
ass& sounds: Premed Oar Reareesed
heat
Releadtheedli
CORER.;
(2r-Yes ROI
0
0
0
0
0
. Yes
.
Obstructed

.
Labored

2r--Asyrnmerrical O No
Lilt
0 0
0
. No
Page 1 of 4
Midst aseasament Circulation Skinhnucous Membrane color
AT Plnk • . PM*
. Amen
Side temporsture: On-Want Skin moisture: Normal Pubes: Carodd
. Flushed
.
Alundiced

.
cyanotic

.
Not . Cool

.
pry . Moist Radial Femoral

Nonni 11;\ L R )e
R

1111100111 . . . . . 0
Walk 0 0 . . . .
Absent . . . . . .
Oissiday

Olsegow Cann Scala Wrote appropride moms):
1. EP Milininfr
Spentimemes To ries
3 Ts pais 2 Ness
1
2. debut Ortemled Conlimed
4
Inspoopriele wads 3 incomplehe words None
1
3. Motor. Obeys commands 6 Localizp to pain 5 INIMOrrals to peke Flexion Extension
2 Nona

1 Told GCS .. Pupillary response Pupil reacdon:
Wit Lilt Oridt
0 0 Constricaml
. 0 Slimaioh
.
Mad
0
Nonreacdve
0 0
te2rb so 4054111407.10

March•April 1997
15
MEDCOM - 3893

DOD 010372
Trauma Resuscitx in Form
Physical axantinatim
(years): Height (inches): Weight (kg's):Head. eyes, ears, nose, throat:
Hack:
10 VA
malt:65k., 196 " 9e , dt-c,64-+06L

Back:
IP 41\
C4rvicalghoraciciturnbar spine:
Abdomen:
Perineum and rectum:
Extremity:
Skin:
Neurologio:
Other
Diagram for escuonenting 'Nudes (Watt* kqury Me by number)
1.
laceration

2.
Abrasion

3.
Hematoma

4.
Contusion

5.
Deformity

6:
F /17-6

O.
Stab wound(s)

9.
Pain

10.
Cold injury

11.
Edema

12.
Amputation

13.
Avulsion

14.
Bum

15.
Other (Describe)

NAM ponnwamr• from J)I-ogorcall
FtH. Steno. ins Groordold u
. Multvolond rJHV, 04ctown KT.

anti Zander* Ga s Unary Scioroile Prroples ord Proclkd PtdoSolphit Js ldipinood Cronpony. 10113.1
Page 2 of 4
NAVY MEDICINE
MEDCOM - 3894
DOD 010373

Trauma Resuscitation Form
Procedures performed by trauma terror
diedketions

Time:
Procedure:
Time:
Drug: Dosage:

S
-
I (41 4 Wr)L(

Trammil
delimurd YrMisl pesibms N fluid reresissust
rselgMlpr ane Visite WA. awl eldest

I . IV said of choke: Lactose Rasps% solute&
MAW
Qubit

N e the felesing equations)
lR
mi Blood

ml2. Total fluid requirement (Mt):
TFR • 4 ml u of (Ws) ur % burr (2' wed 3°) PRYC
ml Urine

od
TFR • (4 a X
CC FFP
all NG lute

3. Estimated fluid niquisoreat In I Irmo peat bunt mI
Ptutdtais
art dust lute

mi
(TFR/2) • oc
4.
Estimated Ord requirearem rest 16 hours post bunt Drrsr
rd Other

ml
OMNI oe
Toad

WO
Time:
OP:
crel66
Puree:
Temp:

Raw 67
GCS: I 1Nat":
re cal
ANIIIIIMANWIMIIIAMENBEWEALTAIME U111
111P¦
f/5-11 ,4-rf tANJ.4
b)(6)-2

Signi4(fir puomason fn at au *maroon Calico al Surgeons Commas!, an Trmana. Advanced
Page 4 of 4
AVY MEDI CIN E
MEDCOM - 3895
DOD 010374

REPORTING MTF .F LOCATION
ADMISSION AND CODING INFORMATION
I f2 3 8 Mote or
b)(3)-1 Count ry

For use DI this lurm, sue AR 40 -
Code) 400; proponent agency is OTSG
3. REGISTER NUMBER
b)(6)-4
4. PAY GRADE

5. SEX
111111111111111111•1111111
6)(6) • -4 16 17 18
6. DATE OF BIRTH (Y Y Y Y.M M 0 D) 7.
AGE AT ADMISSION 8.RACE 9. ETHNIC
RELIGION

20 m BACK-
19 111111111111111.1111111111111111111111 11, pli .
-GROUND '

11//11LgAirligitiarillICtINIEGIF•111111 LI iirlit4 1)54 rv)
10. LENGTH OF SE VICE 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 . 1 .
35 36
37 •

(b)(6)-4

1111
ORGANI2ATION (Active Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH / CORPS
..--------ADMSSION

I

i (._,.ti/111(%1 ''‘ 46
-1,---(61
l 3
0

14. FLYING STATUS
15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
1 47 48 49
0 —
Mini 53 54 55
.-dr 56 57 58 59 60 • 61
...m.........40.0¦1110

INIabilLararalPjlairl
17. UNIT LOCATION (State or 18. MOS
19. TRAUMA
Country Code) PREY ADMISSION
62 63
64 65 66 67 68 69 70 71 ...--."--'---1 YEAR NO
S V-I
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
11)7T-4—
ADMISSION
t
c4,,E.sEMERGENCY ADAESSEE (Include ZIP care)
NA E AND
)(3)-1
TELTI,(6).;i
21. TYPE OF DISPOSITION 7 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD)
Iri
75
D 76 77 78 79 80 81 82 intAl 83 lel 85
73 r-,,i
_
b.KS
A.._ al-l .... ' WI
Ellnri •all.ritti

24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM
• . DATE THIS ADMISSION (YYMMDD)

87 89
is El 98 n El
91 92 93 94 95 96
99 101

. Ariz FA iltarrii
. im, Lin

27. LOCATION OF OCCURRENCE
28. MTF OF INITIAL ADM SSION
29. DATE INITIAL ADMISSION (YYMMDD)

(Battle Casualty Only)
103 104
105 106 107 108 109 110 112 114
111 113 115 116

SI
FOR LOCAL USE rt
via.u.tyl --- ___:1.
11\i\ '' (a.9 -3" -7.-" 5 )9 rp6
,...-

. 4... ---"
I s i 9 ,
.

;..,.
.

b)(6)-2
6)(6)-2
ADMITTING OFFICER (Signature, as required)
6)(6)-4
04.+2; 4.... r
UFA 1— LI1YIVI O4H M AI-1 i. Q ..-- .. --
DOD 010375
. REPORTING MTF
F LOCATION
• DMISSIL. .-AND CODING INFORMATION
. (State or
(b)(3)-1
Country Code) OTSG
For use 01 this form, sue AR 40.400; proponent agency is
. REGISTER NUMBER e
fi)(6)-4 . PAY GRADE 5. SEX
16 17 18
6. DATE OF BIRTH (TYYYMUDD)
AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 2 1 22 23 24 25 26 27 BACK-
28 29 30
GROUND
)1/

•‘1:7
M iii
10. LENGTH OF SERVICE 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 35 36
ririgirEIPOlitsrum
b)(6)-4

— -
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH/CORPS7 ADMISSION
i 11 30
14. FLYING STATUS
15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 51
53 54 55 56 57 58 59 60 a 61

52 ING/111MIRESo o •
17. UNIT LOCATION (State or 1
OS 19. TRAUMA
PREY ADMISSION

Country Code)
62 63 5 6 7 71 YEAR
7
1
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME' )(6)-4
ADMISSION
72

SS OF EMERGENCY AOdRESsEE (Include ZIP Code)ADDRE
1`1)

.
NAME AND
b)(3)-1 TELE b)(6)-4
21. TYPE 0 utbrubitioN
22. MTF TRANSFERRED TO
.5. UAt of DISPOSITION (YYMMOD)

73 74
75 76 77 78 79 80
81 82 83 184 85 86

3
3 0

24. CUNIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)
87 88 89 90 91 92 93 94 95 96
A
97 98 99 100 101 102
ig r o 3 9 _3
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INMAI. ADMISSION (YYMMDD)
(Battle Casualty Only)
103 104
105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCA
1
SD

)5-0
b)(6)-2
O
ADMITTING OT..W(Vgnm_yre, as required) b)(6}2
SI
..ib)(6)-2
C.9/
kkjcl.M4,4%4 .4J st
MEDCOM - 3897
DOD 010376
53. NUMBE OFPROCEDURALFIELDS )RIMAE NIDER ILOODUSAG E
I-6;71 OFDIAGNOSTIC FIELDS CONTAININGCODES
SPECIALTY CODE Y/N
CONTAININGCODES
la OL Z 69Z 179T
99Z S9Z

MEDCOM - 3898
DOD 010377
••,• , "‘•

ea.
245
.
1-179Z-1 I Z9ZI
..:K;::k•

09Z
16SZj
LIL1

8S Z ISZ 9SZ I SSZ VSZ ESZ ZSZ lSZ OS Z 61/1 I
10EDUF 51. EIGHTHPROCEDURE
1:W:MP.1

Age

I
6ZZ 811 LZZ
on Ir7.617-1 LEZ I9EZI CEZ I PEZ EEZ I TE-I[ IEZ OEZ 9ZZ 11
1 48• FIFTHPROCEDURE
:EDUR1
111

MOW

bZZ ZIZ LZZ OZZ I 61Z I.stz I LIEI I91 ZI stz 1 v " I ELZI Z lZ Pi' 1 [O I ZI1_60Z
"'
i.:&ftz4;
I BOZ 10Z 90Z SOZ VOZ EOZ ZOZ -t-OzI

I
I
)URE O
46. THIRD:PROCEDURE
451 SECOND PROCEDURE
AMMO
07)Z 1 66L
711I L61
....,
Lgq
I S61d P61 E61 I al 06 L 681 88 1 Lel 1-99 1 I -sotI
1.¦¦¦¦¦1
43. EIGHTHDIAGNOSIS
3NOSIS
1
I
I191I
9/1 SLL VLI FILTIIu ILLI OL t I 691 I 7971I L9L [ 991, S91 V91 £91
40. FIFTHDIAGNOSIS
NOSIS
Cr
IZc
F911 6St 8St LS I 9St SS L LAI I ESL FS11 LSI Ost 6tiL op l /VI 9VI IsotI IortI Iart I .LbI Otrl 6E1 BEL ILEI I
..%:
38. THIRD DIAGNOSIS
37. SECOND DIAGNOSIS
• 1I
138. FIRST DIAGNOSIS(Principal Diagnosis)

9E1
SEL bEl rEET1IzE I 0E 1 6Zt SZ 9Zt Isz trZ t EE L
Li l
l
OF DEATH/ SEP
IZII OZ t
}
us
a z
I

611 811
lGE AT
pi

ANfll
35. CAUSE OFINJ
JNDERLYING CAUSE 1ESIDU ...ABILITY 34. DONOTUSE-DATAFILLER//1
11
For use of this form. see AR40.400: the proponent agency Is the OTSG
1
ADMISSION ANDCODINGINFORMATION

Doc_nid: 
7027
Doc_type_num: 
72