Medical records of an 8 year-old Iraqi male civilian involved in a motor vehicle accident. Medical procedures included a craniotomy, chest tube and a tracheotomy. Patient was described as unresponsive.
EPW / IRAQI UNKNOWNS INFORMATION
b)(6).4
NAME: Unk PSEUDO SSN:
_)(64
CHCS NAME: Home:Unk
DOB/AGE/YEAR:Unk Capture site:Unk
MILITARY STATUS: Iraqi civilian
Rank:N/A
DIAGNOSIS:TCHI with complications as listed above Chest tube for complications arising after his trach
TREATMENT:TTrach, G-tube, J-tube
RECOMMENDATIONS: 1. Keep head elevated. 2. Ventric to 0 cm. 3. Requiring hyperventilation, mannitol, propofol, nares to control ICP.
Other names: NONE
MEDCOM - 4891
DOD 12103
b)(3)-1
Name: ,
b)(6)-4
CHCS Name
Iraqi civilian Date of Admission: 4/18/2003
Pro•nosis: Guarded Date of Transfer:
History: 8ish y/I IM in MVA. Treated atr x3)-1 I Had a CHI and an intraparenchymal monitor was placed. However, he developed a SDH secondary to the monitor, placement and required a crani for evacuation. That was evacuated and a ventriculostomy was placed.
Hospital Course:
ICP very labile and somewhat difficult to control. But gradually improved with mannitol, fentanyl, versed, intermittent vecuronium and thiopental. Ventric elevated to 7.5 cm on 4/25. Plan OR for replacement 4/27,(cancelled), CT repeat shows improvement, CT planned 4/29. D/C ventric and begin wean sedation.
Diagnoses:
CHI with complications as listed above; Chest tube for complications arising afle rach;
Ventriculostomyculture positive from 4/22 for gm positive cocci on 4/25. Started intrathecal vanc
4/25.
Trach, G-tube, Aube; ex-lap 4/13 for ct finding of ? Air near Ligament of Treitz. Ct also noted R
adrenal hematoma and fracture L kidney below pelvis. Ex-lap noted only duodenal hematoma (D4)
and colonic serosal tear.;
Recommendations:
1. Keep head elevated. 2. Ventric to 0 cm. 3. Requiring hyperventilation, mannitol, propofol, nares to control ICP. 4. +/- gastrostomy tube for feeds. 5. Wound care left flank. 6. Trach care and decannulation when appropriate.
SpecialNeeds:
Will need continued ICU care until ventriculostomyout and intracranial pressure issues resolved.
Then will need several weeks of inpatient rehab.
Physician:
b)(13)-2
5/30003
LCDR Dept of Neurosurgery
MEDCOM - 4892
DOD 12104
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MEDCOM -4893
DOD 12105
AUTHORIZED FOR LOCAL REPRODUCTION
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STANDARD FORM 509 1REV 5-99) Prescribed by GSA/ICMR FPMR (41 CFR) 101.11 .203(b)(10)
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DOD 12106
DATE o WNif 03 l1/R- 11/bi NOTES
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STANDARD FORM 509 (REV 5.99)Prescribed by GSNICMR FPMR (41 CFR) 101-11 203(0)(10)
MEDCOM -4896
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DOD 12109
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Medical Record STANDARD FORM 600 (REV. 6-90
Prescribed by GSA/ICMR
FWMR (41 CFR) 201-9.202-1
MEDCOM -4898
DOD 12110
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1=1 SPPPEFLUD (8555) PRESCRIBE BY GSAACMR
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MEDCOM - 4900
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DOD 12112
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MEDCOM - 4901
DOD 12113
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 I N COLUMN INDICATED BY ARROW BELOW.
LIST TIME
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DOD 12114
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. E. PROEICEM 4DRIE I. ORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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re-A-1 Ge.,,y,9_
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORD
IRS
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER E OF ORDr.
PATIENT IDENTIFICATION
RS
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256_
1 FA7174419
37 U.S. GOVERNMENT PRIMING OFFICE: 1994-363-710 MEDCOM - 4903
DOD 12115
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 PROIStiEht4GRIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT It)ENTIFICATION 'DATE OF ORDER TIME OF OR R LIST TIME
ORDER NOTED AND
(b)(6)-4 I* iTe 3 ( HOURS
SIGN
,
1144.i—.. 1/ I,..T
f ar.A0..4T4i
A I I I WI ir WIMP/ ill I I
/ )/0.d-As ro
b)(6}2
Mr 11
bX6)-2
Ai
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF. ORDER . TIME OF ORDER
i #14TOi3TOURS -,
. kr lir .. .c../T../ 11211111111 11111=i-moror.------....Tfrirri-1-
bX8)-2
M11111...#0Vi7 I 1
I• IP
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER'
f
1)(8)-4 _HOURS
4
r
i
MetiV.4
/ I V
4 Ar4,4201/
/A-41 1
Mr
FAM,
NURSING UNIT ROOM NO. BED NO. (bX8)-2
(b)(8)-2
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 1 FAm. 4256
* U S GOVERNMENTPRINTING OFFICE 1994-363.710
..-_-..--_
e--%_i.,--,_
pe"'s_ ir's
MEDCOM - 4904
DOD 12116
THenAPEUTIC DOCUMENTATION RIBEe APR LOIINON-MmDICA TION)
CLINICAL RECORD
the ptts?eonri nee is the Office of The Suwon Genetel. Mo.0 Yr. i.3
VERIFY BY INITIALING
, W : stommoemew INITIAL PROPER COLUMN EACH COMPLETION
HR rinnartif:DATE COMPLETED J
ORDER CLERK) RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
' 0/-• ,e.
rig xe)-2
MpTaffille. r'
_AM
/ ,T
,2 0 Eil )(8)-2
linil tr.
7 mb)(8)-2
WAIRIT6)-
0 — .
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MU
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Sae
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algi b)(8)-2Mill._b)(6)-2 lif /..
111M111IllintliM
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MMENIIIIM
I
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I
,0\--\Avivrx,_\-% Vey() \\*Ai 09 1
(8)-2
\ \
13 M/
liA )(8)-2
19 AZ I\ PIS IP
ALLERGIES: III YES III NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE c YES 1.1 NO
/ '%. _r°1 4 • ?
0(0_ Ek. ( 14 p, PAGE NO:
PATIENT IDENTIFICATION:
Sb1 81-4
ACTION TIMES 1 TPENCIL CRCLE ACTION TIMES DT8T9T10T11T12T13T14T15 ET16T17T18T19T20T21T22T23
NT24T01T02T03T04T05T06T07 ... ........ .......T. --- --1
EDITION OF 1 DEC 77 MAY BE USE].
USAPA V1.00
MEDCOM - 4905
DOD 12117
....a1APEUTIC DOCUMENTATION CARE PLAN
(NON—MEDICATION)
Order
Date SINGLE ACTIONS Date la Time to
be Done he Done • Time Done Initials
e-c-c 3
Order)
Clerk)
Est* PRN I
Nurse INITIAL PROPER COLUMN FOLLOWING COMPLETION
Date ACTION, FREQUENCY
TIMEIDATE COMPLETED
U51111 e 1.00
MEDCOM - 4906
DOD 12118
T ERAPEUTIC D BVI ,
CLINICAL RECORD -01CA E..T.."TICA IONS)
is form, 4 7;
NMA
03
th _proponifx*p Is the Orf loe,Al Tlit Burgeon .Germiral.
_ ...
VBRIFY BY INITIALING _
USUI3 L P/40P;BR COLUMN FOLLOWMO EACH
ADMINISTRAT70.N
ORDER DATE CLERK/ NURSE RECURRING MEDICATIONS, • DOSE, FREQUENCY HR DATE DISPENSED
b)(6)-2
)(6)-2
b)(6)-2
bX6)-2 T
bx6)-2
b (6)-2
b)(6-
b)(6)-2
6)(6)-2
AI bX6)•2
ipr
Lory; k de MA 13 p
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b)(6)-2
4/
b)( )-2
/1D
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S4_(..) , 3 1^ 4-
6)(6)-2
ALL ERGI ex
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ADDITIONAL PAGES IN USE cj Y ES Q NO
P A TIEN T I:0E4N TIFIC 4 TION,
DISPENSING TIMES
USE PEROL, CIRCLE MED TIME S
D 7 8._9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
D A1VEng 4678 N 23 24 01 EDITION Of 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. 02 03 04 05 06
MEDCOM -4907
DOD 12119
Verify by
2RAPEUTIC DOCUMENTATION CARE i
Initialing ,4
NEDIcAr(olys) • • •
•
Time to km' Given
Time Given InItlalx
(b)(6)-2
Orris./
Clerk/
Explr PRN INIVAL PROPER COLUMN
-FOLLOWING
Nurs• ADMINISrRA74ON
Date DICAYION, DOSE, FREQUENCY
TIME/DATE DISPENSED
bX6)-2
bX6)-2
V.S. GPO: 1990-454.11 0/952 1 PI
MEDCOM -4908
DOD 12120
I
THERAPEUTIC DOCUMtNIATKIN olatrigittlatICA VOW)
CLINICAL RECORD
PoTt "le term,TA
the oroponentrerne .Ie the °Mee of ThOSuroiron Gummi. Mo. Yr.
VICRIFY BY INITIALING
•
_144LIII.. I
..,40,fraWAL PROP-ER COLIMN P014.0WINO BACK AbleNISTRATTON ORDER CLERK/TRECURRING MEDICATIONS, HR DATE DISPENSED
DATETNURSE DOSE, FREQUENCY uyrirvi 0-ed1 151 6 1 7 bX6)-2 2 al J o _ t tz t_.I4 11 tt
'03
Os
ni.1 03 'Foal Ccur. `A 8 S oo OS; b)(13)-
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4-.4"et-60—eln
-KrArrn-TCJI/-12
ALL ER EIE
Ores ONO PRIMARY CIAO/40111M.
ADDITIONAL PAGES IN
LO Y El 0 NO USE1
PACE NO.
PATIENT ID EN TI PIC ATIONs
bX6)-4 DISPENSING TIMES USE PENCIL. CI RCL
E MED TIME1 DT7T8 9T
1110. 12 13 14
ET15T16T17 18 19 20 21 22
DA ,F,ing 4678 NT23T24T01 EDITION OF I DEC 77 WILL BE USED UNTIL EXHAUSTED. 03 04 05 06
MEDCOM - 4909
DOD 12121
....
z.
.__
WSELE'ET
b)(8)4_
SECTION I - PATIENT ASSESSMENT DATA
DATE: O'S AY5 CLi
PATIENT NAME: PATIENT ACUITY: HOSPITAL DAY: POST OP DAY:
DIAGNOSIS: Oa TIME: amo 010b 0 26.) 6.6c-C.V°b 05e› C.C.D b C,"7. (
DP .ARTERIAL LINE
/3 13,V8i /23/24 /`-3,0../6A4 /$ ---/244.) 9/ /0 a-Al-72-S'Y
/0 / // () / /JD f7 (-1z, g '2—
.:,:-.-— 20 ?Z. 1 -F
PUL.S'EOXIMETER JDA J 0 / CY'D 1 00 /OD /0J 160
PAIN_(0— 10)
OXYGEN (L/%)
1 C
R E -r e.-er-c.---a-7 L 7L 7 Y--
S
VENT SETTINGS:
P
i 1,102 ( (
R
MODE
A
T TV /
0
RATE
it
Y PEEP
PS
ti Respiratory Treatments e
i
V = Ventilator TI = '1 ...h collar
NC ,-‘ Nasal cannula NR m Non-rebreather FM - Face mask VM ... Venturi mask CPT = Chest physiotherapy IS .- Ince dive spin meter
Oxygen Method Key:
Respiratory Treatment Key: HHN — Hand-held nebulizer MDI = Metered-dose inhaler
$`0 DC7 DC7 gC) P,0 g'c , r-(1-cD
I
N
T
A
K
L _
PO
b (tD /CD rb o v --o --D
WirZY
TOTA LS
URINE
P
(
l!
'I
STOOL (r) 0 (r) C', C7 (-
TOTALS ,2251
t",
1)56)-4
Page 1 of 4
MEDCOM -4910
DOD 12122
MEDICAL RECORD - ICU FLOWSHEET SECTION I - PATIENT ASSESSMENT DATA
PATIENT NAME: DATE:
CCfa.1ur)c-.Cc4 —z
CC 4._
TIME: BP ARTERIAL LINE
i -r A I., S I G N s BP CUFF MM' TEMPERATURE PULSE RESPIRATIONS PULSE OXIMETER CVP — I _-
PAIN (0 - ID)
") METHOD VENT SETTINGS: F102 MODE
TV
RATE
PEEP
PS
OXYGEN (11%)
Respiratory Treatments --1
Oxygen Method Key: NC= Nasal cannula NR = Non-rebreather FM .. Face mask VM .. Ventini mask V = Ventilator 'IT. -Trach collar Respirator)• Treatment Key: HHN .. Hand-held nebulizer MDI Metered-dose inhaler CPT .. Chest physiotherapy IS -, Incl dive spill meter
.
•
1
-I
PO
TOTALS
URINE 0 II T •--P
i: T
STOOL a TOTALS
Page 2 of 3
MEDCOM - 4911
DOD 12123
MEDICAL RECORD ICU FLOWSHEET
-
SECTION I - PATIENT ASSESSMENT DATA
PATIENT NAME .T DATE: IV SITE ASSESSMENT:
LEGEND: WNL NO REDNESS/SWELLING/OTHER S/S INFILTRATION/INFECTION R -REDDENED P ..• PUFFY I INFILTRATED CL .. CENTRAL LINE
n.
LOCATION CONDITION LOCATION CONDITION
IV SITE # 1 Eitrir: ---(IV IV SITE # 1 IV SITE # 2 IV SITE V 2 IV SITE # 3
IV SITE # 3
TIME TIA I TIMETINITIALS
1 %6_2 _____
IV PATENCY CHECKED C/ .6 IV PATENCY CHECKED
..,)
IV SITE CARE PROVIDED IV SITE CARE PROVIDED IV TUBING CHANGED
IV TUBING CHANGED COMMENTS: /2275/_,.*)e ze.„,___ COMMENTS :
-
A") -5 5 .7— .
,Tr
T) S-14 A ) S i 4,), — ,3 (g-) P11(
LIT I
AM STRIP
P M STRIP
SECTION III • SHIFT NOTES
. ...
Page 3 of 4
MEDCOM - 4912
DOD 12124
MLEITIZWERECORIT-lttr LOVN 4TT
1
J.CTION If - PATIENT ASSESSMENT DATA • REVIEW OF SYSTEMST '
PAT! ENT NAM
NEUR01...T Alert and Oriented to time, place and name; Responds appropriately; Communication Is adequate to expressneeds; Pupils equal and reactive to light.
CARDIOVASCULAR Age appropriate Rate, Rhythm, and Pulses; Capillary refill 3 sec; No dependent edema, Nailbeds and mucous membranes pink. No calf tenderness. Prtraurc monitoring
PULMONARY Respirations within normal limits for age; Breath sounds quiet and regular; Depth is regular; No dyrpnca; No cough: Suction; Secretions; Oxygen; ETT; Trach
Cl. Abdomen soft a nd non-distended; Bowel sounds active in all quadrants; No difficulty chewingor swallowing; No abdominal pain; Frequencyand type of stool; No diarrhea; No constipation; No NN; NG Tube placement; Type of sccrctlons
G.U.
Voiding; Catheters; Urine clear yellow/amber
No odor, discharge, frequency, urgency,
nocturia
MUSCULOSKELETAL: Normal musde mass and dtvclopment Tor age; No ddormities; No assistive devices ncedcd: Normnl movement and lone; Normal active ROM without pain; No Joint swelling, tenderness, weakness, or paresthesia
SKIN Color: warm; dry: Intact; Turgor; No Wounds; lesions; rasher, Inflammation,
ulcers, breaks In skin: No redness, blanching, irritation, over bony promlncnces; Mucous membranes moist Wounds' location, condition, drainage, dressing
PAIN No complaints of pain/discomfort; Note Location; Duration; Intensity
• ATE:
TIME t7Z) INITIALS: €-D TIME:T
INITIALS:
/0/3:i te-*fr-/
774ic4 40roe..
rreVX)..-),""-')Co
s7-tiaes-, it „1,...0
S Ce416,/
71:14
A--74`a" e
/oag
--)
O 2-• 5r4-.0.1:7 56 "t°
7 4o r e_19, .
At,/ -5 .
• AP*11•-.--c) rit)
Cly;-' P/ic e
-e-
"-wz,'
ne -IA.) 5
•••• _ieWeAE°2.•-/C
7c7dld O1
Dy-s-kvn-fr
e‘d
/W" s
-
••¦
Pia
)71. c?c,‘ .5e.•;•,-) Are." f(clg,-) 1:‘,/ ‘74eYr 31:i) A' -1-14 60444— ogee'c Iv... 574
Sk,", we-
lir79
PSYCHOSOCIAL:
Pr -
siv°
Behavior Is appropriate to the situation; Anxiety is controlled or mild and
No 5/5,, 4 AA appropriate lo the situation; Interacts appropriately with others
Page 4 o f4
MEDCOM - 4913
DOD 12125
•-1 -'-
FLOWSHEET SECTION I -PATIENT ASSESSMENT DATA
,•.. ..................._ _ _ _
)16)-4 I14__
DATE:PATIENT NAME: POST 01' DAY:
PATIENT ACU TY: HOSPITAL DAY:
DIAGNOSIS:
i too I-70,-_, N 9. va a,k06 a,30,„, 0 ‘4,3 0300 cr. s-c) a
TIME: C760 Cqt)(-1 !JO 0 ic_IL,
l31' .ARTERIAL LINE
. Pr ..
UI' CUFF I Z 1 . $ L, °II' I *-Tia, 17-, /7i 43 1-4-1-
..., MAP 11 Ciflpd ei Ci SpLI-kil4i-DI. 4,1?!°1155E, 9 j`91 CI .4; it.: C14 . - Y41
TEMPF.RATURE
PUL417 10 '2--61 q 13 (xi( 61° ca. t V1 v as- tp, i 1,9 •y3 1,1,g
RESPIRATIONS '3 i 1)-. 1 R 4/ 33 22_ 3t4, a.1-1-'w-t &t. 0 3g 3-
LOa (Op too tga I
PULSE OXIMETER 1" on TOO t top 160 AOC) MO
CVP ic" •I
got
PAIN (0- 10)
OXYGEN (11%)
12
E 02 METHOD
S
VENT SETTINGS:
P
1 P102
R
MODE
A
T TV
0
RATE
12
Y PEEP
I'S
Respiratory Treatments
Oxygen Method Key: NC =. Nasal cannula NRR Non-rebreather FM m. Face mask VM = Venturi mask V = Ventilator TC - Track collar
...,(
Respiratory Treatment Key: HHN .. Hand-held nebulizer MDI .• Metered-dose inhaler CPT = Chest physiotherapy IS - Incentive spirometer 5 o Ss o (di c) A
T‘i ax o tti.
'Tv 1F,9-s'D 5 0 ..,2 , S o 50 qtr
_to
K
1
b
PO
TOTALS lb o
URINE
0 u C -700 2-2-0 i 00 .ipo 1?c) ,a2) vo
VI)
0 5- I 0 2 • 0 5' 0
,i 6
STOOL
giffil)
TOTALS L12-.0 /oL3 t 0 L) 5L.,
Page 1 of 4
MEDCOM - 4914
DOD 12126
MEDICAL RECORD - ICU FLOWSHEET SECTION I - PATIENT ASSESSMENT DATA
_ 0)(8)-4
PATIENT NAME: DATE:
LEGEND: WNL NO REDNESS/SWELLING/OTHER 3/3 INFILTRATION/INFECTION R REDDENED P PUFFY I. INFILTRATED CL = CENTRAL LINE
LOCATION CONDITION LOCATION CONDITION
9,.u,i
IV SITE # 1 1.1 'CO30(4),_ IV SITE # 1
IV SITE # 2 f---e_-tio cces,., 9 ,--6,-I IV SITE # 2
IV SITE /I 3 IV SITE # 3
TIME INITIALS TIME INITIALS 0 1/4 o o
IV PATENCY CHECKED et..„, IV PATENCY CHECKED
IV SITE CARE PROVIDED IV SITE CARE PROVIDED
IV TUBING CHANGED IV TUBING CHANGED
COMMENTS:
COMMENTS:
3_ j_ii_(LA_ FL rc,c 1) fc c. 1-I (c-. I-1 .-.4)
SECTION III -SHIFT NOTES
010 0 ^...-_1... el 7-t.A._a Ice ier-L....1:-_(.5-e-t_S-c.ci ....Z. SO_ .F. caul_L. c.,4 4-,_(e., c_le". cl5r_) ._Q_ck •_._A
30 . 1.).-e cul-,,-t, c_(„,_,•F., 4:0 0,,,,..j_-_"_ act .1—Li pt,,•cs_„...._10,...–,_ii,A,_._-S.:ki_%,-k.,_1,--t_i--nr c c-,-...., q4,-k,c4,
x_
•k--- 1,,,..0,...„0_y -2_ ._-11/4/_i y...•-t-0...rn Q r i,...Z.,..i , --ire de-Mi-L .cr-• "e- lc •tr C t s t r j_a,_(.60_101.2
)2.C._P--),_-- C alC.i, 6.‘ Ci. 6_,-” f 2 . (2.0...k-e..L., 0 4200 t 0 1 • k . (-19-,,,,...-1 tzit Oa-v, t_e: i r f""2 I-
al_avt, A_6\r,c,
60- , 4 1/3 c t.¦._ft CO 4,,_C.3"_Ce 'rlft Weft . uvtew% 4..,,,,•-•-0 AI i 0, crvrcl,-,2,4_
11.4Y
—
Reek eu,.;-\ 0 cf 2 v \ s: + 1.-cci-- . --C. ttt L.,. @ no'ri , Op_c.i-, ....,_ , •7 1 6_,,,,J_to, vo_pa_
,k,,,-,-,,,--6,J_-7-:- ,,ct, . k-0,-c-_6.--:-E k-,_mcv---kl----v-k • Q- ic12-0-_-v_Ri • I_v-/oo , ri-
bxe)-2
-1-QrA."..At_(1.--".S6.i_5ta4._•_Feer-i--_km..e-Le_fver6.-Oct..a._Cc....A- t,-..:4.._ate"_"..\,...,,A:t....-
._...
Page 3 of 4
MEDCOM -4915
DOD 12127
.._•
T AEDICAL RECORD - ICU FLOWS)._
SECTION 11 -PATENT ASSESSMENT DATA • REV IEW'op SYSTEMS
PATIENT NAME:
NEUROLOGICAL
Alert and Oriented to time, place and name;
Responds appropriately; Communication Is
adequateto express needs; Pupils equal and
reactive to light.
CARDIOVASCULAR
Age appropriate Rate, Rhythm, and Pulses;
Capillary refill 3 sec; No dependent edema.
Nalawls and mucous membranes pink. No
calf tenderness. Pressure monitoring
PULMONARY
Respirations within normal limits for age;
Breath sounds quiet and regular; Depth is
regular; No dyspnea; No cough; Suction;
Secretions: Oxygen: ETT; Trnch
Abdomen soft and non-distended; Bowel
sounds active In all quadrants; No difficulty
chewing or swallowing; No abdominal pain;
Frequency and type of stool: No diarrhea;
No constipntion; No NN; NG Tube
placement; Type of secretions
C.U.
Voiding; Catheters; Urine clear yellow/amber
No odor, discharge, frequency, urgency,
nocturia
MUSCULOSKELETAL:
Normal musde MESS and development for
age; No deformities; No asslative devices
needed; Normal movement and tone;
Normal active ROM without pain; No joint
swelling, tenderness, weakness, or
paresthesia
SKIN Color; warm; dry; Intact; Turgor; No Wounds; lesions; rashes, Inflammation, ulcers, breaks in skin; No redness, blanching, Irritation, over bony prominences; Mucous membranes moist; Wounds location, condition, drainage, dressing
PAIN
No complaintsof pain/discomfort;
Note Location; Duration; Intensity
PSYCHOSOCIAL: Bchavlor is appropriate lo the situation; Anxiety Is controlled or mild and appropriate lo the situation; Interacts appropriately with others
1
TIME:T INITIALS:
OtC J
if)
nQ
•-•+_rvi
Cr? c.J
it-42_13tA-Q-u, C ui '4,n^
(4-11ttici.TVa•kl
S a"cP iv' tic 0 if tv-eA.AlurAp-1 p,'n k.
C1700
ceick''-±*-.^%
-Tr 4 \I\ N.. (fA‘Le_
GO l~
L
Y ,
o4
1,_1a c-k S g LAJ-8
0-1ut, V-01 etct--t do.ric_I breg kir
o'luu
¦9-\
lo‘tWc-A-c -
ettr-nne_
diOca 1..Joun
l.o P3c-'
t-t-t
1/1\-LL kk-`01.-e etti,L Scar
G s sc
L.k.,\o0(4._\-0_I s
0'7 0 C
(--I
_Like, D 3
TIME!T INITIALS: (puv k5 io-k\,,,A*A. raire(
T
(to-ck--c Act ot4jallan
--ct 1:605 aka
Cote c 3 Secs sajls
r o
ok--_krA )(A.5e5
'Rese 4,0-30 ariCiar 4-0
TfCtCk- G IPA
04' Vi u._Sia
1 -06
[3/S cArit,e_
GLey 4-6Tr-et.U;Tdelki4ikcj Ct-eotrT0/ s
rikusoce._t,ectk, i
Post (),Te .sCutl rmereze/1,-(-, Colk,cdifirts_keels (3;leef
.k
.5 (As- dcop V31tai-
eN7Y\. 17"T '(Z, k,a4r ar\I
AC C. S_3-0
UkCe_
r
V‘b(J Acty
INA:IJA'mt
egotia,,t ,scar
ncttot-ie
Page 4 of 4
MEDCOM - 4916
DOD 12128
MEDIcAL RECORD -1CU FLOWSHEE1 SECTION I- PATIENT ASSESSMENT DATA
b)(8)-4
DA f E:_ if ryka, u-5
_PATIENT NAMEL_
POsT OP 11AY:
PM non. ACUITY: HOSPITAL DAY:
tiT...\GNosis7— --kip C.R.r,.1, 0-1
im: (Two 0400 u to vr A3 ao isoo rw.%. t9 cm 240-6 2,3 Lib r190 0300 's) 6
131' ARTERIAL LINE 115 1 3-06 ti_en 4,
10% LAD -,:5.
I . 7',..41, 1
V BP CUFF /go itA l n _TIN (' _1 a. P
. -- — ------
I--------------- --- --------
V_..., -7
T M AP ._ -/---e)s,
.._ -----,
--------- — ---T
A TEMPERATURE coW6TNP_ qi CA IA) cm.' cro AV cit,J - q%,1% I 17 ,(L.--' .is',0__.7,-(
pi. 4,1 ii 122 F)..-c--toko -IS Ili i q R7 ;',""'_'I+
-
RESPIRATIONS it i i n 3 c'l 3 I 0-- _I "7-2--/ g IC ..W.a_As.k.
1
G puLsEuximrTER too I 0 6 1 o 0 --F0.,,,t, 0 _lo,) 41,..0._ ti ao _Lao h0
N
cvr _
_
___________________ _______ ___.— _
RA IN_(11 -- 10)
_.
OXYGEN (LPN
-W METHOD
S
VENT SETTINGS:
I' —_____
1 F2.
10
11
MODE
,,
TN' 1 o --
RATE
,___
V PEET
R
PS
_ _ 1 ..
.. Respiratory Treatments
/" _Method Key: NC =Nusal q" .o/^ NR - Non-rchccather FM = Foe ' mask N'M = Venturi mask V = Venelator TC = Trach collar
R !spiratory Treatment Key: HUN = Hand-lucid nebulize! . MDI = Metered-close inhaler crr = C Nest physiotherapy IS --- Inetntive spirMiWer
-re- fici"
TIME:
OW ( VW Pip 130 ) $.0(.) g , / Y o' 2.pro 2:368
Iv' _Is-o 5e) (Co ilgf-*00 f(6L _ /CO lipo
1 _ 1VN i -fa ) 50 14V
N ALI
A
I:
--_ ________ _ ._ ____.
E ----••---------—
--------- • — -------
-----------------------•----—
PO
----------------------_
• TO"I'Al..S
. .. _ _____ _ .. ..._ __I 1--(9 .2"•-__3 S 0 Cit A -
URINE I & k.) A? 0 MO ' I 2-_, 0 ;TO 3a6 /..,(--act) 53 0 'fp
0
t: . .
T .S-t--4L-1-C/O &it
v
I i
_I_
T
STOOL
,,. TOTALS ( WO ../WC 0 di 77D 4) 050 11/4? __. .....____...
a)---2_3P
— -----
Page 1 of 4
MEDCOM - 4917
DOD 12129
111.....JICAL RECORD ICU FLOWSHi._ i
-b)(8).4 SECTION I - PATIENT ASSESSMENT DATA
PATIENT SAME : DATE:T( _Ni 0
IV SITE ASSESSMENT:
LEGEND: WNL = NO REDNESS/SWELLING/OTHER S/S INFILTRATION/INFECTION R= REDDENED P = PUFFY I - INFILTRATED CL - CENTRAL LINE
LOCATIONTCONDITION LOCATION CONDITIOT
IV SITE # 1T/..-+T-Farec-,---, a-1,1/44 usITE#1
IV SITE # 2T I /SITE#2
IV SITE # 3T I' /SITE # 3
TIMETINg_LALS TIMETINITIALS
IV PATENCY CHECKEDTCI You i J PATENCY CHECKED
IV SITE CARE PROVIDEDTptc o SI)TI / SITE CARE PROVIDED
IV TUBING CHANGEDT" /A_ I / TUBING CHANGED
COMMENTS:T COMMENTS:
AM STRIP
PM STRIP
SECTION III - SHIFT NOTES
1700 .—T1 n 4; ..P 4 freff"A-1-s-f j-:-T.c e CItc e:;• IT-..Tro Li eg,;,,c ve 14, ,-,—, ji 4, ( le4.0a, C., A fi-,,
P.,,, s t,:„ OT._!' ('C 0.,, A,,,, . -'I 4.ss a. NA, j . tArk.;., elf! te ,) k. b-, A.e,-.1 . I uri....,{
ct 2 r. .Slir 5LO" as iot a_(A._c-1-.k„_,t,„,_nert .")4,-t -I—_A ,-,-f r--ed ut, .'1 g.t.s i ,,,j. ._
e 1 p4v,e cd4,-) , 0 8 ra,„ zi., pri e 1/4. ( .,-,70-4-r,,4. ' Fri le d Oz 112_8 ._-no ck
6)(8)-2
-' c (1/4-4-';'`C • 0,K, ,..J1, 1€ s art,: . . a...---.
1L'30 2 rrisy 0,4 ,4-4.4 -,e4-6,.... P 114,6 . 7151-rl.su..-, e e , /-7-7e ,„74,/
41o.,... TOTPCIST742,724
kj,44eke S-&f&44 b -a_ (644' • C-41. (%-...'S C d ) --17, C I . 7hicsk Ce.cr 41 .,-;_e....v, .,-, 0 . 7-(Jo .5_---7-7 (.6,..a i 32S-'
b)(8).2
"---e--
Page 3 of 4
MEDCOM - 4918
DOD 12130
.
EDICAL RECORD - ICU FLOWSI
SE PATIENT ASSESSMENT DATA . REVIE)V L .STENIS
b)(6)-4
PATIENT NAME:
DATE:_
%,e, I¦121 0 S
NEUROLOGICAL Alert and Oriented to time, place and name; Responds appropriately; Communication is adequate to express needs; Pupils equal and reactive to light.
CARDIOVASCULAR Age appropriate Rate. Rhythm, and Pulses; Capillary refill 3 sec; No dependent edema. Nailbeds and mucous membranes pink. No calftendemess. Pressure monitoring
PULMONARY
Respirations within normal Limits for am
Breath sounds quiet and regular; Depth is
regular; No dyapnea; No cough; Suction;
Secretions; Oxygen; ETT; Trach
G.I.
Abdomen soft and non-distended; Bowel
sounds active in all quadrants; No difficulty
chewing or swallowing; No abdominal pain;
Frequency and type of stool; No diarrhea;
No constipation; No NN. NG Tube
placement; Type of secretions
G.U.
Voiding; Catheters; Urine clear yellow/amber
No odor, discharge, frequency, urgency,
nocturia
MUSCULOSKELETAL :
Normal muscle mass end development for
nge: No deformities; S o assistive devices
needed: Normal movement and tone;
Normal active ROM without pain; No Joint
swelling, tenderness, weakness, or
paresthesia
SKIN Color; warm; dry; Intact; Turgor, No Wounds; lesions; rashes, inflammation, ulcers. breaks lo skin; No redness, blanching, irritation, over bony prominences; Mucous
membranes moist; Woun ds — location,
condition, drainage, dressing
PAIN No complaints of pairddiscomfort; Duration; Intensity -Note Location:
PSYCHOSOCIAL:
Behavior is appropriate to the situation;
A nllety is controlled or mild and
appropriate to the situation; Interacts
appropriately with others
TIME: 0-7 D1../_INITLALS: ref tri ft
1.1 1 L.,4
t‘p, gel (re( 4 2. se c .
1-14-.9 430‘^2/
e". GOVT ro-o, hr2., li
p .
‘A p I OVA 1. K ( VI[ 7bc L, 0,_LI -0 S' i` (4(-3 ?4,
I. c I r, •
or co, 091
r .-r-/ . crl,i.,14
54v ct I ip_„,
1^d.
c —FL(_q
you-, c
fur c¦
C-E1 "nein d
LILA,43.lTc.1./crl
-
s--k, -j-,
LA"do k-C_G-t J-cf)
?-4_ -Ts e_ •
IME:_ INITIALS:
f)--c OdyN (€sp.
OJN-A
t-_L.CAlAA.k(S PC-C4 rltehC
DishA p5C S
ctr
wc-c-
Res c)_verx0" Sc at 67.1\ (3_"`ruck 04, e+D 5 eoa tO w/o. SUCAt 6 \ fv\vcovs
WS_rd
Bowe
r1N(''''e-neA P'kess- 1.10/1-e
co\-e. y k-cuu:h dcrAnfrt 0/5 (..eac ‘ielt(Ad
1-\&e ur df exA-criArq-ie
kAunko.{-'il y, L_ext Ox id
PV./ 5 gC Atrse Wectite.
Cok6r jci?, Vckrvf, C19 pcte a &art° on Q 6,41,x-ks1,0,L,, i t, s
f
eriGtOC, A-0 GSS "55
uac4b(e ' -0 as.5C -S
Page 4 of 4
MEDCOM - 4919
DOD 12131
-SHEET
ICU FLOW b)(6)-4 SECTION I - PATIENT ASSESSMENT DATA
DATE: '-'1 (nal 0 3
PATIENT NAME: PATIENT ACU TV: HOSPITAL DAY: POST OP DAY:ni &GNOSIS;
11:6-6 z311 ..: k44 t)300 ()stk.) 6700
1540 1-700 igoo
TIME: 070 '• fe3O0 )103 13o0
BP ARTERIAL LINE Is II 10 2.1 tH.
iX
/6
ISP CUFF I 1°41/5-3 i1')/KD 17Wi 121 f7 A 1 • c MAP
00
TEMPERATURE q 1 S A q10) • ' Al
K3,q . is lirt 47.5 477 q7,97 96L:
ruEsr. Co 0 et z, 4o 172
1 OL. to 1 ct t /c..)-0 47 7 (la 76 95 j g'5
REsPIRATIoNs I S 'S 1--/ 35 3e )-7 ) C, i% -zz-a3 16 AO 14,a
io056 co,-.4
PULSE OXIMETER 100 100 100 10U ICICI q 100 /c)6 1d4 t4i, 703%
cvp
PAIN (0-10)
1-
OXYGEN (LI%) Li Q a ,414 Ad-
12
02 METHOD
S
E
VENT SETTINGS:
P
I P102
Ft
MODE
A 1
T TV
0
RATE
12
Y PEEP
PS
Respiratory Treatments
Oxygen Method Key: NC = Nasal entombs NR .- Non-re reather FM= Face mask VM.- Venturi mask V = Ventilator TC = Tv.ch .011.1.
IS ... Incentive spirt meter \Respiratory Treatment Key: 111-IN — Hand-held nebulizer MDI = Metered-dose inhaler CPT = C lest physiotherapy
c. o co g)-yo 50//(10 SO 46,0 Ceti
Tv( 50 5"t
J- kr SO js0 2a 3)x 6th /6,) /,O /6,a
sil,V- 9+
N
T
.1
A
K
E
r
J
..-----.
PO
6-76,22)
TOTALS !OD 90 0 tirb C...)
tiRINE
C
7 , Z) 3;1---sso -)0(37.,
(qo 1 (t) 120 neo
..7 Z .5 ,
STOOL
TOTALS 1 q I) & D o q2o (/-1,0 1-2,0() tss44s Page 1 of 4
MEDCOM -4920
DOD 12132
MEDICAL RECORD - ICU FLOWSHEET SECTION I - PATIENT ASSESSMENT DATA
PATIENT NAME: DATE: IV SITE ASSESSMENT:
LEGEND: WNL - NO REDNESS/SWELLING/OTHER S/S INFILTRATION/INFECTION R = REDDENED I" PUFFY I .. INFILTRATED CL - CENTRAL LINE
LOCATION CONDITION LOCATIONT CONDITION
c -t—cIA k.
IV SITE # 1 LI f;) re c.-e• e', IV SITE # 1 IV SITE # 2 I2--i re ..,0,-, c•r.,...„-t. IV SITE # 2 IV SiTE# 3 IV SITE # 3
TIMETI NZ, S TIME INITIAI-R
IV PATENCY CHECKEDTCr? 00 IV PATENCY CHECKED W SITE CARE PROVIDED TIV SITE CARE PROVIDED IV TUBING CHANGEDTe-1,1. IV TUBING CHANGED COMMENTS:
COMMENTS:
AM STRIP
PM STRIP
SECTION III - SHIFT NOTES
5w44.1
r) - )0k) -- 7 ii• t`f J , _((e 1 ( tr-v—T -5 (...e ce.C4-....o .:, _Tr— . 0 RP Cc/'C 1 Le,,e;. , :13 I c„.7 Cur
i");,
ILO(_4 0/ted ._6)_O€ [S --( e-1 ';"_-1- 4 7'1' ""j"- ( ' /3e) ' .."- "1_ik `."1.9"44*.6--"4-
L(1
-I/ .. d,11.11.-c_ (i, c,,, _t(OL--,_--k--(„ii,_C,..,ac_v..,"-,s_,D_,_V_+Intel:-_cc--.:,%_,
Q.-_I 2,00_' (ALAN A 4 61 c t I a Ar vo../..- 4,9_ i OL4-1-P—"LTCY 4-4--krpt -tLe ‘ .6,_cr-dc,_-r II I 0 0. L ,,,
4 A_1 -) 1-e,,c'N_7 )._cs te—\6 Cia---k t et-a-kl3 Yvvor¦ ctor. -Lc...N.--1, ._WI .1-_, GAL._(A , ,...1
b)(8}2
IA-Cc-49
. .1...., _ • ,
il_re,._ 2 .._....,......? ,.. A -
d-/-4,-,-if or 4-,ff , IT ..,, , stay_y7_,e3' • Li
Ad
St k ix ,.'te z-Y , , -g4 ,W1 0 ' 1/.4 frg , i ere/
-4-0,4 .-13S_4/ vtLe5.-_ c_ CAto• -(-'i , \--C CI- - e f/acti ¦ -,,---ics.c.-1 doct,i
c---tb..luiC -t-,'15 140 ,_011N-_S,4_.sbe_,k_I ll -. 0'_ 1-l-/ ' //Of -
tie
..... "dr'
xo¦wmfits.sma-
Fammoriat e."
Page 3 of 4
MEDCOM - 4921
DOD 12133
MEDICAL RECORD - ICU FLOIN SET
,Intet-4
SECTION II -PATIENT ASSESSMENT DATA • REVIEW 'OF SYSTEMS
PATIENT NAME:
NEUROLOGICAL
Alert m d Oriented to time, place and name; Responds appropriately; Communication Is adequate to express needs; Pupils equal and reactive to light.
CARDIOVASCULAR Age appropriate Rate, Rhythm, and Pulses; Capillary refill 3 sec; No dependent edemst. Nailbeds and mucous membranes pink. No call tenderness. Pressure monitoring
PULMONARY
Respirationswithin normal limits for age; Breath sounds quiet and regular: Depth is regular; No dyrpnea; No cough; Suction;
Secretions; Oxygen; ETT; Trach
G.I.
Abdomen soft and non-distended; Bowel
sounds active In all quadrants; No difficulty
chewing or swallowing; No abdominal pain:
Frequency and type of stool; No dfnrrhea;
No constipation; No N/V; NC Tube
placement; Type of secretions
G.U.
Voiding; Catheters; Urine clear yellow/amber
No odor, discharge, frequency, urgency,
nocturia
IMUSCULOSKELETAL : Normal muscle mass and development for age: No deformities; No assistive devices needed; Normal movcmcnt and tone; Normal active ROM without pain; Na joint swelling, tenderness, weakness, or
paresthesia
SKIN Color; warm; dry: intact: Turgor; No Wounds: lesions; rashes, Inflammation, ulcers, breaks in skin; No redness, blanching, irritation, over bony prominences; Mucous 'membranes moist; Wounds' location, 'condition, drainage, dressing
PAIN Iib complaints of pain/discomfort; Note Location; Duration; Intensity
DATE:T
-7 'n11 03T
TIME:T INMALS; TIME:
INITIALS:
U :•"N — (ca c b -1 to ,-i, pt/n0...1 n..-, rot Cu-•f we Ice ,-c -C'LL,Ltfos lt Ivs-k, vu e ,t, 8,l.teJ
Pe Ve_rte pLftld.at L1P iCs CIO. CA.,
fel
30 120,..-k_ ns/
rt_ s--t C.
sau4( ciLii;.
L.ort_b
0 7 4-St
c4
a
(2_,5
plcco,
0C--k Pa---
ccv,b,
4-. SS t C" c-L
L
e•4,-;
I
600,1. c‘C--; Sdc_r...S woo,.
LVO-I"A_
GSCc -Ock r( LT8_r-,
c 1/4, l( acct (Vs.('
PSYCHOSOCIAL: Behavior is appropriate to the situation; c Anxiety Is controlled or mild and -appropriate lo the situation; Interacts appropriately with others
Page 4 of 4
MEDCOM - 4922
DOD 12134
MEJLACAL RECORD ICU FLOWSHEIL,...
-
:Dx6)-4
SECTION I - PATIENT ASSESSMENT DATA
DATE:TI (Al DIAGNOSIS:T'-s70, C w• („ t,.....1T PATIENT ACUITY:THOSPITAL DAY:TPO T OP DAY:
TIME: 01 0 e C` 0,1 k I 0 r) 13 00 6 G•) (icZ, 749 G O )1L0 0140 0164 :=3-6 0 OC" BP ARTERIAL LINE PATIENT NAME: T 3
iiql
BP CUFF 1 6 3/71. II VG l I 41111
MAP
TEMPERATURE
tici 9W-7 q11' 96 " fir 1
PULSE 6 2-% O 7 0
(0 3 11
RESPIRATIONS i L. D-. I 17 1 i ll
PULSE OXIMETER
l ot 7,1, 1 tt• 1 AO ‘115 9 1
CVP
PAIN (0 -10)
OXYGEN (L/%) 02 METHOD VENT SETTINGS:
FIO2
MODE
TV
RATE
PEEP
PS
Respiratory Treatments
I
—Zt—..et2 c4
Oxygen Method Key: NC = Nasal cannula NR = Non-rebreather FM = Face mask VM = Venturi mask V = Ven•lator TC = Trach collar Respiratory Treatment Key: HHN = Hand-held nebulizer MDI = Metered-dose inhaler CPT = Chest physiotherapy IS = Incentive spirometer
TIME:
6 -7 6' nqup fl o 0 (500
Iv e a 3„.5 5 0 2 0 0
..
1 .1. ci ,-( 0
PO
•TTOTALS
50 (000
URINE
7) Ce¦ aso Iv) /00 ...
STOOL TOTALS( 4/41—A)50 _G3 0 71. b
Page 1 of 4
MEDCOM - 4923
DOD 12135
MEDICAL RECORD -ICU FLOWSHEET __SECTION I - PATIENT ASSESSMENT DATA 71-IENTNAME: DATE
IV SITE ASSESSMENT:
LEGEND: WNLTNO REDNESS/SWELLING/OTHER 515 INEILTRATION/INFF,C:TION
R -REDDENED I' •=• PUFFY I INFILTRATED CL CENTRAL LINE
LOCATION CONDITION LOCATION CONDITION
IV SITE tf i_1....-c IV SITE 4 2 [ IV SITE # I IV SITE # 2
IV SITE # 3 IV SITE 4 3
TIME INITIAL TIME INITIALS
IV PATENCY CHECKED 3 0_an IV SITE CARE PROVIDED _ b)(01-2 IV PATENCY CHECKED IV SITE CARE PROVIDED
IV TUBING CHANGED IV TUBING CHANGED
COMMENTS: COMMENTS:
AM STRIP
PM STRIP
SECTION III -SHIFT NOTES
•TSp te iT ...6-0, 1 *w..4 %-k,.........1_,.. .T1?-4T
a... 1 C. CI -c i ( ..-f.--,../ 2-r1TPar. --1-. it( -V-...kJ 44-1.`T.1 „.. T9TI ,T9 i
—5 C _...-S.-_P._c.:.tu,.:_ 7..r .......T
_2_L P. c__ - o ,._
„., ,_,_.,_. T e-,-4 t-Cs-L4-^ -Li+ r-e.,.. , 4....,-.c . q ISn GT1 2 1 V" tTa&.. da. tI b„T2.Trp.3_.(D,, _0T9,..9-,., fal_1,-,..c r5i,.,t, ._% uryl„,,,_\g.,1(5,_,..,"1-L
2,P -6.
_._(-44 Lt•A Tc 4.TL . J
a :, ck -t- , ,,.::,' ,___,_ -P 11-Q-i-N,_( c.,,,,a 4.....) e: c, 9_c c.,-, --I
e 4-' b)(8).2
¦I c -4, im 1.4Tti-, 4 , ,7, :,...-,_,Titt,Tvy,.. e-kt _ ... ,.
e. - 3 1 0, t-,•"-", ( x i r-kenn t-t-.( e s ,, S._T—b...-sil w_ I
S m.....1LP U&-L¼ C \ ;L.( r 0 G-A-4., (I .-un 4 ,,TrLA-T1 640 VI:CT.60 ^..o..T.
ro r
.T._
r
1);1gc. 3 0 r
MEDCOM -4924
DOD 12136
•
_
MEDICAL RECORD - ICU FLOW....-4;ET
SECTION II -
PATIENT ASSESSMENT DATA - REVIEVY OF SYSTEMS
PATIENT NAME:
NEUROLOGICAL
Alert and Oriented lo time, place and name:
Responds appropriately; Communication is
adcqualc b express needs; Pupils equal and
reactive lo light,
CARDIOVASCULAR
Age appropriate Rate, Rhythm, and Pulses;
Capillary refill 3 sec; No dependent edema,
Nailbeds and mucous membranes pink. No
calf tenderness Pressure monitoring
PULMONARY
Respirations within normal limits for age;
Breath sounds quiet and regular; Depth is
regular; Nb dyspnea; No cough; Suction:
Secretions; Oxygen; ETT; Trnch
G.I. Abdomen soft and non-distended; Bowel sounds nclivf in all quadrants; No difficulty chewing or swallowing; No abdominal pain; Frequency and type of stool; No diarrhea; No constipation; No N/V; NG Tube placement; Type of secretions
CU.
Voiding; Catheters; Urine clear yellow/amber No odor, discharge, frequency, urgency, norm Ha
MUSCULOSKELETAL: Normal muscle mass and development for age; Nb deformities; No nssistive devices uccricd; Normal movement and Ione; Normal active ROM without pain; No joint swelling, tenderness, Weakness, or paresthesia
SKIN Color; warm; dry; intact; Turgor; No Wounds; lesions; rashes, inflammation, ulcers, breaks in skin: No redness, blanching irritation. over bong prominences; Mucous membranes moist; Wounds - location, condition, drainage, dressing
FAIN
No complaints of pain/discomfort;
Note Location; Duration; Intensity
DATE:
TIME: En 3 ()_ INITIALS:
TIME: 1,,0, (( `7 csfSla,A:(_far. Lu•sfr Lies;
'4;-C_Cik-is L15_cit (s•k.ii
1\-) "_
Q44
povbiLA I 3G LA,..11) se.,
t(c,tt_
P) e. ek-P-aync
(L.c:t7sce.
lot ,5s C‘ e v
et
Oa, Po et
f
4-• is./L e...r1
C_I
kler— c1/4,
j, re 1 c-.4
m
t-._or f \
LA r ¦ A—L
12-t;
g-6,u
socr,9
eti s...to.t,-4.
arc
(nn c
PSYCHOSOCIAL: Behavior is appropriate to the situation; (Ai\ 1,1.sT41.1TC s) tl
Anxiety is controlled or mild nod
appropriate to the situation; Interacts
n ppropria Lely isilk ethers
Page 4 of 4
MEDCOM -4925
DOD 12137