Medical Report: Iraqi Male, Baghdad, Iraq re: Gunshot Wound to Abdomen

518-124
MEDICAL RECORD
CO PONENT REQUESTED (Check one) RED BLOOD CELLS FRESH FROZEN PLASMA PLATELETS (Pool of units) CRYOPRECIPITATE (Pool of units)
Rh IMMUNE GLOBULIN OTHER (Specify) I
VOLUME REQU STED (If applicable)
Licir)L+ .
REMARKS:
ML
UNIT NO. (3) TRANSFUSION NO. PATIENT NO.
NOR RECIPIENT

SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
. TYPE AND SCREEN
CROSSMATCH DATE REQUESTED
La Prk.k.ck 6
DATE AND OUR REWIRED
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
Lx-)101—no-1--rv-1
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
./.1."1:4
/1-1/0"
ABO ABO REMARKS:
4A.
Rh
PO Rh fo3
SECTION III -
PRE-TRANSFUSION DATA /INSPECTED AND ISSUED BY (Signature)
AT (Hour) ON (Date)
IDENTIFICATION
NSN
NSN 7540-00--834-415
BLOOD OR BLOOD COMPONENT TRANSFUSION
REQUESTING PHYSICIAN (Print)
c6A) I rh d.0v "&-+(l

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:
RECORDA
rNO RECORD
SIGNATURE OF PERSON PERFORMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
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 (Signature)
TEMP. AiA
I PULSE /i
DATE OF TRANSFUSION TIME STARTED

RECORD OF TRANSFUSION
POST-IRAN I 'WM' r)QA TIME/DAT COMPLETEDdITERRUPTED
-
3 Ca c.r.Th

TION
TEMPERATURE PULSE
BLOOD PRESSURE NE . SUSPECTED

If eaction 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)

OT DIFFICULTIES (Equipment, clots, etc.)
. YES (Specify)

PATIENT IDENTIFI
ON—USE EMBOSSER (For typed or written entries give: Name—Last, first
rate: hospital or medical facility)

(9 (CI ,-"Z_
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 16841 Medical Record Copy
DOD-030230

518-124
MEDICAL RECORDA BLOOD OR BLOOD COMPONENT TRANSFUSION NSN 7540-00-634-415
SECTION I - REQUISITION

.,bC MPONENT REQUESTED (Check one) RED BLOOD CELLS . FRESH FROZEN PLASMA TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.) . TYPE AND SCREEN REQUESTING PHYSICIAN (Print) (.1- 'L.c....e)DIAG SIS OR OPERATIVE PR CEDURE
PLATELETS (Pool of units) CROSSMATCH
6.-..S
. CRYOPRECIPITATE (Pool of units) DATE REQUESTED
Rh IMMUNE GLOBULIN 111 OTHER (Specify) bb A-04 4E41 DATE AND HOUR RgQ(JF I have collected a blood specimen on the betel named patient, verified the name and ID No. of thi patient and verified the specimen tube label to bi correct_
VOLUME REQUESTED (If applicable) 0 A/.-7 ML KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify) SIGNATURE OF VERIFIER

REMARKS:
IF PATIENT IS FEMALE. IS THERE HISTORY OF:
DATE VERIFIED RhIG TREATMENT? DATE GIVEN:
..iay
TIME VERIFIEQ,
HEMOLYTIC DISEASE OF NEWBORN?
/7 -7,2q
(q(
ACNN!
SECTION II -PRE•TRANSFUSION TESTING
UNIT NO.
TRANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHEC ANTIBODY SCREEN
CROSSMATCH
RECORD PATIENT NO.
DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT R ABO
ADO
REMARKS:
Rh Rh
s

CTION III -RECORD OF TRANSFUSION
INSPECTED
AMOUNT GIIN ATE COMPLETED/INTERRUPTED
ML
7 17/q
REAL ION RRE PULSE
AT (Hour) ON (Date) NONE BLOOD px.SSURE
. SUSPECTED
)
IDENTIFICATION If reaction is suspected—IMMEDIATELY: I have examined the Blood Component container
abel and this form and I find all
information identifying the container with the intend 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
d recipient matches item by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blo 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. DESCRIPTION OF REACTION on the patient identification tag.
. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
OTHER DIFFICULTIES (
ment, clots, etc.)
. NO •
city)
SIGNATU DATE OF RAN USION
9/4 o 3
PATIENT ID TIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, rate; hospital or medical facility) WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

MEDCOM - 16842 Medical Record Copy
DOD-030231
518-124 NSN 7540-00-634-41!
A
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.)
r
RED BLOOD CELLS
FRESH FROZEN PLASMA
0 TYPE AND SCREEN DIAG
RCCEDURE
O PLATELETS (Pool of units)

CROSSMATCH
• CRYOPRECIPITATE (Pool of
units)
DATE REQUESTED/
• Rh IMMUNE GLOBULIN I have collected a blood specimen on the belo
named patient, verified the name and ID No. of thDATE AltD HOUR REQUIRED
O OTHER (Specify) patient and verified the specimen tube label to b correct.
VOLUME REQUEST1.D (If applicable)
KNOWN ANTIBODY FORMATION/TRANSFUSION
SIG
URE • VERIFIER
REACTION (Specify)
Ilh ML
REMARKS:
IF PATIENT IS FEMALE, IS THERE H TO OF:
ATE VERI,..94
;2E3
RhIG TREATMENT? DATE GIVEN: TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN?

70_,
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO.
ANSFUSION,
TEST INTERPRETATION
PREVIOUS RECORD CHECK: ANTIBODY SCREEN
CROSSMATCH
RECORD
0 R
PAT T
DONOR
CROSSMATCH NOT REQUIRED FOR THE COMPONENT R
ABO REMARKS:
Ba 5
Rh
SECT 0 III —
RECORD OF TRANSFUSION
POST-TRANSFUSION DATAINSPECTED AND
AMOUNT GI
TIME/DATE COMPLETED/INTE UPTED
e3S;)17
REACTION
TEMPERATURE
AT (Hour) E BLWRVSSURE
ate)
ONE fl SUSPECTED IDENTIFICATION 7417
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component contain -r label and this form and I find all
information identifying the container with the inte • ed recipient matches item by item.1. Discontinue transfusion, treat shock it present, keep intravenous line open.

3
2.
Notify Physician and Transfusion Service.

3.

The recipient is the same person named on this B 'd Component Transfusion Form and
Follow Transfusion Reaction Procedures.
on the patient identification tag.
1st VERIFIER (Signature) 4. Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
URTIC
EVER El PAIN
`DIFFICULTIES (Equipment, clots. etc.)
PRE-TR
NO
TEMP.
PULSE
SIGNATURE
DATE OF TR7OSFU ON
1 TIME TARTS
0 4S--'

dJf
PATIENT IDENTIFIC TION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle, rate; hospital or medical facility)
WARD
-.44
Ir
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1

MEDCOM - 16843
Medical Record Copy
DOD-030232
518-124
NSN 7 540-00-034-415f
A
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST
(Check ONLY if Red Blood Cell
REQU HYSICIAN (Pent)
Products are requested.)
RED BLOOD CELLS
. FRESH FROZEN PLASMA . TYPE AND SCREEN
. . PLATELETS (Pool of CRYOPRECIPITATE (Pool of units) units) eCROSSMATCH DI ROCEDURE
DATE REQUESTED
. Rh IMMUNE GLOBULIN I have collected a blood specimen on the below
. OTHER (Specify) DATE AND HOUR REQUIRED named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
VOLUME REQUESTED (If applicable) I ML REACTION (Specify) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNAT

REMARKS:
IF PATTEN
FEMALE. IS TH E HISTORY OF:
ATE VERIFIED
Rh TREATMENT? DATE GIVEN:
IG
TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN?
d 7c7
SECTION II -
PRE-TRANSFUSION TES NG
UNIT NO.
TRANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHECK: ANTIBODY SCREEN
CROSSMATCH . RECORD
\ NO RECORD
't1G.NATUR
DONOR CROSSMATCH NOT REQUIRED FOR THE COMPONENT R
ABO DATE
REMARKS:
RhA
'35
III -
RECORD OF TRANSFUSION
INSPECTED AND ISS AMOUNT GIVEN
TIME/D TE COMPLETED/INTERRUPTED
ML
7 cf , /0)
REACT ON
TE PERATURE
PULSE ONE . SUSPECTED
AT (Hour) BLOOD PRE SURE
3AI Az._ 5/.7_
IDENTIFICATION
If reaction is suspected—IMMEDIATELY: -I have examined the Blood Component container label and this form
I find all
information identifying the container with the intended recipient matches ite 1. Discontinue transfusion, treat shock if present, keep intravenous Ilne open.
by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion
on the pa Follow Transfusion Reaction Procedures.

F m and 3.
4.
Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to the Blood Bank.
'DySCRIPTION OF REACTION
URTICARIA . CHILL . FEVER
[I] PAIN
. OTHER (Specify)
0TH IFFICUL •
nt, clots, etc.)
PRE-TRANSF!4§ON TEMP. . NO
PULSE
SIGNAT DATE OF TRAN FU O
TIME STARTRO
N L1
149A3A0 it
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or ritten entries give: Name—Last, first, midd , grade; rank;rate; hospital or medical facility) SEX WARD
Z-e4.774
ANN

BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. ARMR (41 CFR) 201-9.202-1

MEDCOM - 16844 Medical Record Copy
DOD-030233

518-124
NSN 7540-00-634-415
A
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST
(Check ONLY if Red Blood Cell Products are requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA
TYPE AND SCREEN
IS OR OPERATIVE PROCEDURE
0 PLATELETS (Pool of units) -CROSSMATCH

941
CRYOPRECIPITATE (Pool of
. units)
O Rh IMMUNE GLOBULIN I have collected a blood specimen on the belch named patient, verified the name and ID No. of the DATE AND HOU REQUIRED patient and verified the
O OTHER (Specify) specimen tube label to ts,
correct.
VOLUME REQUESTED (If applicable)

KNOWN ANTIBODY FORMATION/TRANSFUSI N REACTION (Specify)

1 Dir
REMARKS:
IF PATIENT IS FEMALE
T ERE HISTORY OF: RhIG TREATMENT? DATE GIVEN:
TIME VERI D
HEMOLYTIC DISEASE OF NEWBORN?
76
SECTION II - PRE-TRANSFUSION TESTI
UNIT
TEST INTERPRETATION
PREVIOUS RECORD CHECK: ANTIBODY SCREEN
C ROSSMAT C H
RECORD IGNATURE 0
DONOR
A
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ P
ABO

REMARKS:
Rh

Pu 9
SECTION III - RECORD OF TRANSFUSION
PRE•TRA POST-TRANSFUSION DATA
INSPECTED AND ISSUED BY
AMOUNT GIVEN
TIME/DATE COMPLET D/INTERRUPTED
t, Y/5/
REACTION
TEMPERATURE
PULSE
.01...¦iONE 0 SUSPECTED 7 s7 117
IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container labe nd this form and I find all
information identifying the container with the intended 1. Discontinue transfusion, treat shock if present, keep intravenous line open.

AT (Hour) BLQWPRESSURE
reci
nt matches item by item. 2.
Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Compon t 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 (Signature)
DESCRIPTION

F REACTION
• URTICA
FEVER PAIN
0-1
• 0TH
ntl VERIA
DIFFICULTIES (Equipment, clots, etc.)
PRE-TRA TEMP.
SIGNATUR
1 TIM

/I DATE OR SFUSION
PATIE ID NTI ATION—USE EMBOSSER(For typed or written entries give: Name—Last, first, mid grade; rank;
rate; hospital or medical facility) WARD
/tA 7".
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. FIRM (41 CFR) 201-9.202-1

MEDCOM - 16845 Medical Record Copy
DOD-030234
•

MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY If Red Blood REPU
Cell Products are requested.)
n RED BLOOD CELLS
FRESH FROZEN PLASMA TYPE AND SCREEN
• SIS ORO ERAT1vE PROCEDUREFl PLATELETS (Pool of units) ..,[eKROSSMATCH
11.11 C RYOPRECIPITATE (Pool of units)
11
DATREQUESTED
Ej Rh IMMUNE GLOBULIN
I have collectetL Iblood specimen on the be w

/0A C)'
named patient, verified the name and ID No. of
DA E AND HOUR REQUIRE
OTHER (Specify) the patient and verified the specimen tube label tobe correct.
. 7.----­
L
VOLUME REQUESTED (I applicable)
KNOWN ANTIBOD FORMATION/TR SFU• SIGNATURE OF VERIFIER
SION REACTION (Specify)
ML • /.7
REMARKS: (9(LYL
IF PATIENT IS FEMALE, IS THERE HISTORY
DATE VERIFIED
ci 97i A) OF:
Rh IG TREATMENT? DATE GIVEN'
HEMOLYTIC DISEASE OF NEWBORN?
5
SECTION II — PRE -TRANSFUSION TESTING
UNIT NO.
TRANSFUSION NO.
TEST INTERPRETATION OUS RECORD CHECK: A.._ ANTIBODY SCREEN CROSSMATCH
RECORD '•-eiallrITECORD
PATI ENT ct C Y\ FORMING TEST
DONOR ECIPIENT
iV/A—
A ROSSMATCH NOT REQUIRED FOR THE COABO ABO ARKS:

4,41,9_0_3
Rh
jo 5 /05
kiktat,k
Rh ri 44t • 17 Av301 J O SS
SECTION III REC
O F TRANSFUSION
PRE-TRANSFUSION DATA
POST•TRANSF
INSPECTED AND ISSUED BY (Signature) SION DA
AMOUNT GIVEN
TIME DAT
CIT E INTERRUPTED
04
ML
REACTION
AT (Hour) 11 ri SUS ECTED

ON (Date) itc ONE
IDENTIFICATION'

If reaction is suspected =MMEDIATELY:
I have examined the Blood Component container label and this to m and I 1. Discontinue transfusion, treat shock if present, keep intravenous line open,

2. Notify Physician and Transfusion Service.
find all information identifying the container with the intended r= ipient
matches item by item. The recipient is the same person named on this =food

3. Follow Transfusion Reaction Procedures.
Component Transfusion Form and on the patient identification tag, 4. Do NOT discard unit. Return Blocti Bag, Filter Set, and I.V. solutions to

the troTld Bank.
ist v
DESCRIPTION
Iia
URTICARIA El CHILL
FEVER PAIN
OTHER
PR DIFFICULTIES (Equipment, clots, etc. ) NO
YES (Specify)
TEMP. I V 1 PULSE
BP NG ABOVE
DATE QF RANSFUSION TIME STARTED
° Crr
/Pr.\
PATIENT DEN FICATION - USE
EMBOSSER (For typed or written entries Bice:
NAME - Last, first, middle; rank/rate; hospital number and name of facility.)
Icv WARD I
t5R
BLOOD OR BLOOD COMPONENT TRANSFUSION
STANDARD FORM 518 (REV. 8­
86)
General Services Administration Interagency Committee on Medical Records FIRMA (41CFR) 201-45.505
(,)(0
518.122
MEDCOM -16846
MEDICAL RECORD COPY
DOD-030235

•

MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one)

TYPE OF REQUEST (Check ONLY if Red Blood REQuES
Cell Products are requested.)
O RED BLOOD CELLS
(7 TYPE AND SCREEN
DI
n PLATELETS (Pool of .unit.) .....K C ROSSMATCH

FRESH FROZEN PLASMA
f• .]C RYOPRECIPITATE (Pool of unite)
DATE REQUESTED
ri
Rh IMMUNE GLOBULIN I have collected a blood specimen on the below named patient, verified the name and ID No. of
DAT AND HOUR REQUI RED
OTHER (Specify) the patient and verified the specimen tube label tobe correct.
VOLUME REQUESTED If applicable)
KNOWN ANTIBODY FORMATION/TRAN FU­
SION REACTION (Specify) SIGNATURE OF VERIFIER ML .
4C-YL
REMARKS:
IF PATIENT IS FEMALE, IS THERE HIST
DATE VERIFIE
OF:
RhIG TREATMENT? DATE GIVEN'
RA; Gc,ia/
HEMOLYTIC DISEASE OF NEWBORN'
SECTION II — PRE-TRANSFUSION TESTI G
UNIT NO.
TRANSFUSION NO.
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
ECORD NO RECORD
liGN • -
RFORMING TEST
DONOR
ROSSMATCH NOT REQUIRED FOR THE COMP N NT REQUESTED
ABO ARKS:
Rh
Arp, ,a,Stc 174ti 6 3
/OS
SECTION 111— RECORD bF TRANSFUSION
INSP POST-TRAN USION DATA
Signature)
AMOUNT GIVEN TIM DA •
INT RUPTED
t PcW lY)
ML
REACTION
our) II 'NONE 0 SUSPECTED

IDENTIFICATIoN•
If reaction is suspected IMMEDIATELY: find allI have exam'ned the Blood Component Domaine ton bel 2.1. Notify Physician and Transfusion Service. Discontinue transfusion, treat shock if present, keep intravenous line open. 1
and this form and I
identifying the container with e
intended recipient
mat . The recipient is the same person amed on this Blood 3. Follow Transfusion Reaction Procedures.
C orm and on the patient identifi tion tag. 4. Do NOT discard unit. Return Blocci Bag, Filter Set, and I.V. solutions to
Is

thud Bank.
DESCRIPTION
URTICARIA . CHILL {: FEVER Ej PAIN
2nd
0 OTHER
DIFFICULTIES ( Quipment, c ots, etc.) NO
YES (Specify)
TEMP, (0
PULSE C4. Vcl,
OT NG • BOVE
01G F TRANSFUSION BP
TIME STARTEt eto
17) 1,
PATIENT 1 ENTIFICAT1ON - USE EMBOSSER (For typed or written entries give:
NAME • Last, first, middle; rank/rale: hospital number and name of facility.) WARD

er.) 2 =r,(.3
BLOOD OR BLOOD COMPONENT T ANSFUSION STANDARD FORM 518 (REV. 8-86)General Services AciministratIOn
Interagency Committee on fvfedlcaI Records
4411111115
FIRMR (41CFR) 201.45,505
518.122
MEDCOM - 16847AMEDICAL RECORD COPY
DOD-030236
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
• SECTION I — REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood REQUEST!
.ACell Products are requested.) RED BLOOD CELLS
lEr.E..RESH FROZEN PLASMA LI TYPE AND SCREEN
•-0 • ivE PROCEDURE units) 5:‹CROSSMATCH
; 0 PLATELETS (Pool of.
CRYOPRECIPITATE (Pool of.units)
0
Rh IMMUNE GLOBULIN I have collecte
ood specimen on the
0-3
named patient, verified the name and ID No, of
AND HOUR REQUIRED
OTHER (Specify) the patient and verified the specimen tube label tobe correct.
VOLUME REQUESTED (If app KNOWN ANTIBODY r ORMATION/TRANSFU-SIGNATURE OF VERIFIERSION REACTION (Specify)
ML
.40
. (4)--
REM A4
IF PATIENT IS FEMALE, IS THER HIST•RY DATE VE
OF (IED sr
,-
RhIG TREATMENT? DATE GIVEN'
TIME - IED
typ. &Iv it
HEMOLYTIC DISEASE OF NEWBORN?
4,
SECTION II — PRE-TRANSFUSION TESTIN
UNIT NO.
TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH
CORD
PATIENT NO. (\,C W\
DO
ABO ABO
Rh
Rh
/7
SECTION III — R
CORD OF TRANSFUSION
PRE-TRANSFUSION DATA
INSPE POST-TRANSFUSION DATA
AMOUNT GIVEN
TIME DATE COMPEETE0
INTERRUPTED
ML
REACTION
AT (Hour) ON (Date) /6 ilf,C5 0 NONE 0 SUSPECTED

IDENTIFICATION'
If reaction is suspected — IMMEDIATELY:
I have examined the Blood Component container label 1. Discontinue transfusion, treat shock if present, keep intravenous line open.

d this form and I
find all information ' 2. Notify Physician and Transfusion Service.
container with e intended recipient
matches i 3. Follow Transfusion Reaction Procedures.
same p on named on this Blood
Com atient i 4. Do NOT discard unit. Return Blocd Bag, Filter Set, and I.V. solutions to
tification tag.
the Srortid Bank.
1 st
DESCRIPTION
0 URTICARIA 0 CHILL 0 FEVER
PAIN
2nd
OTHER
OTHER;DIFFICULTIES (Equipment, clots, etc.)
0 NO •
YES (Specify)
TEMP.
PULSE BP SIGNATURE OF PERSON NOTING ABOVEc•AttOF TRANSFUSION
TIME STAITglZ4:2
PATIENT IDE TIFICATION - USE EMBOSSER
(For typed or written entries glee:
NAME • Last, first, middle; rank/rate; hospital number and name of facility.) SEX A
BLOOD OR BLOOD COMPONENT TRANSF SION
STANDARD FORM 518 (REV. 8.86)
4410. M( ) A WA
General Services Administration Interagency Committee on Medical Records
FIRMR (41CFR) 201-45.505
518.122
MEDCOM - 16848 MEDICAL RECORD COPY
DOD-030237

MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one)

TYPE OF REQUEST (Check ONLY If Red Blood
Cell Products are requested.)
F1 RED BLOOD CELLS
IY....F.ZESH FROZEN PLASMA nTYPE AND SCREEN PLATELETS (Pool of .units) CROSSMATCH 1-L CRYOPRECIPITATE (Pool of.units)
DAT REQUEST D
n Rh IMMUNE GLOBULIN I have collecte blood specimen on the
11'
named patient, verified the name and ID No. of
DAT 41.2¦110 H EQUJRED
.....T
the patient and verified the specimen tube label to
OTHER (Specify)
be correct.
VOLUME REQUESTED (If applicable ) KNOWN ANTIBODY FORMATION/TRANS U-SIGNATURE OF VERIFIERSION REACTION (Specify)
ML
11(tjl
IF PATIENT IS FEMALE, IS THERE I T RY

(L9A9
DATE YES FIED
OF:
RhIG TREATMENT? DATE GIVEN'
TIM RIFIE1:41"
Fel) ocK
HEMOLYTIC DISEASE OF NEWBORN'
SECTION II — PRE-TRANSFUSION TES ING
UNIT NO.
TRANSFUSION NO.
PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH ci
TEST INTERPRETATION
rir RECORD H NO RECORD
tAL)-1
PATIENT N PERFORMING TEST
DONOR
0111111111.--
1)•1 SIG
j4
CROSSMATCH NOT REQUIRED FOR THE COMPONENT

ABO ABO REMARKS:
Rh Rh /C,
..3 fk.,„ikk 4.x./.. ad?: 7 Ay/ o3

1 1a O
SECTION III — RECORD OF TRANSFUSION
POST-TRANSFUSION DATA
INSPE
ture)
AMOUNT GIVEN Time DATE COMPLETED INTERRUPTED
ML
REACTION
NONE H SUSPECTED
AT (Hour ON (mktg) i 44,7 6-3 IDENTIFICATION"
If reaction is suspected — IMMEDIATE LY -
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
I have examined the Blood Component container la I and this form and Ifind al
2. Notify Physician and Transfusion Service.
tifying the container with th intended recipient
3. Follow Transfusion Reaction Procedures.
e recipient is the same person na ed on this Blood
4. Do NOT discard unit. Return Blom.; Bag, Filter Set, and I.V. solutions to
on Form and on the patient identificatio tag.
the Blood Bank. DESCRIPTION
El URTICARIA riCHILL 1-1 FEVER PAIN 2nd
OTHER
OTHER DIFFICULTIES (Equipment, clots, etc.)
El NO LI YES (Specify)
TEMP.
PULSE BP SIGNATURE OF PERSON NOTING ABOVE DATE OF TRANSFUSION
TIME STARTED
PATIENT IDENTIFICATION - USE EMBOSSER (For typed or written entries give:
NAME - Last, first, middle; rank/rate; hospital number and name of facility.) SEX WARD

BLOOD OR BLOOD COMPONENT T ANSFUSION STANDARD FORM 518 (Rtv. 8-86)General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505
518.122
MEDCOM - 16849
MEDICAL RECORD COPY
DOD-030238
518-124
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
. ,2•1
':LOOD CELLS se FRESH FROZEN PLASMA
.
PLATELETS (Pool of units)

.
CRYOPRECIPITATE (Pool of units)

Rh IMMUNE GLOBULIN
. OTHER (Specify)
LUME REQUESTED (If applicable) LLN)11--
REMARKS:
rAeti
ML
E)epA0),eh0`i
UNIT NO.
TRANSFUSION NO.
allingAPATIENT NL1-1
DONOR
ABO /I 6 A
A130
Rh
p
Rh Pc53
INSP
AT (H
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
p
ROSSMATCH
DATE REQUESTED
-3
DATE AND :H 17,
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTO 0
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II -PRE-TRANSFUSION TESTIN
TEST INTERPRETATION
ANTIBODY SCREEN

CROSSMATCH
A/ A. N
REQUESTING PHYSICIAN (Pr)
NOSIS 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 VERIFI D
TIME VER
PREVIOUS RECORD CHECK:
RECORD
NO RECORD
_CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED REMARKS:
Tiletved Lx, 6cA /S-Avd 03 AOC
SECTION III - RECORD OF TRANSFUSION
I have examined the Blood Component container label and this form nd I find all
information identifying the container with the intended recipient matches em by item.
The recipient is the same person named on this Blood Component Transfus n Form and on the patient identification tag.
1st VERIFI
2nd V ER
PRE-T
12;4
94gTEMP. I PULSE 1 B /
DATE OF TRANSFUSION
TIME STARTED
3.4-U gi.)
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, firsrate; hospital or medical facility)
MEDCOM - 16850
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 LI FEVER . PAIN
OTHER (Specify)
0TH DIFFICULTIES (Equipment, clots, etc.) NO .
YES (Specify)
SIG
POST-TRANSFUSION DATA TIME/DAT COMPLETES.NTERRUPTED
,§63
TEMPERATURE PULSE BLOOD PRESSURE
qb,
i / Y / 7.74.5
WARD iCk3
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
DOD-030239

518-124 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 (Printi
C Products are requested.)
ED BLOOD CELLS
FRESH FROZEN PLASMA TYPE AND SCREEN
OSIS OR OPERATIVE RE

0 PLATELETS (Pool of units) CROSSMATCH
6, SW 019-J)
CRYOPRECIPITATE (Pool of units)
DATE REQUESTED I have collected a blood specimen o -¦/z •A•WRh IMMUNE GLOBULIN
VM ,..h&r...„05
named patient, verified the name an a • of the DATE AND HOUR REQUIRED and verified the specim-nA.7.-A:bel to be0 OTHER (Specify) correct. S I. VOLUME REQUESTED (If applicable)
VOLUME
KNOWN ANTIBODY FORMATION/TRANSFUSION
SIGNATURE OF VERIFI R 0.
REACTION (Specify)
( otAV ll mL
(4\--
REMA KS: IF
IF PATIENT IS FEMALE, IS THERE HISTORYAF:
DATE VERIFIED
0 •
RhIG TREATMENT? DATE GIVEN: TIM , RIFIEDHEMOLYTIC DISEASE OF NEWBORN?
--xp 0 4-% 0 3 Pi . q
SECTION II — PRE-TRANSFUSION TESTING
UN
TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK: ATIENT NO. (_9,4"y/ ANTIBODY SCREEN CROSSMATCH
ECORD
0 NO RECORD
DONOR R ENT. Aik
OSSMATCH NOT REQUIRED FOR THE COMPONENT R
A80 ABO

EMARKS;
Rh Qo S
Rh
17 3 6
1—ksmAjcizi , &IC a?
Ar-S4-
SECTION III — RECJORD OF TRANSFUSION
IN
TEMPERATUR PULSE
AT (Hour) k-TS ON e) i 4.j o 3 SUSPECTED
//7
IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label d this form and I find all
1.. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipie- matches item by item.
2. Notify Physician and Transfusion Service.The recipient is the same person named on this Blood Componen ransfusion Form and 3.
Follow Transfusion Reaction Procedures.
on the patient identification tag.
4.
1st VERI

A Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions, to the Blood Bank.
ESCRIPTION OF REACTION .
URTICARIA
0 CHILL [1 FEVER PAIN
C OTHER (Specify)
TH' DIFFICULTIES (Equipment, clots, etc.)
PRE-TRAN
YES (Span
TEMP.A I PULSEA
I
BP
DATE IFAN FUSION -I TIME START 6_3AED/TO
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; ran ;
rate; hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescriber by GSA/ICMR. FiRMR (41 CFR) 201-9.202-1

MEDCOM - 16851 Medical Record Copy
DOD-030240

MEDICAL RECORD 1
COMPO T REQUESTED (Check one)
RED BLOOD CELLS

El FRESH FROZEN PLASMA
El PLATELETS (Pool of units)
•
CRYOPRECIPITATE (Pool of units)

•
Rh IMMUNE GLOBULIN

LI OTHER (Specify)
VOLUME REQUESTED (If applicable)

to ilt*)17-
-ML
REMARKS:
• , UNIT NO.
TRANSFUSION NO.
a
PATIENT NO.
DONOR RECIPIENT
ABO
p
ABO
Rh Rh
c)05\41\1,
ci 4;•%4\041...
INSPECTED AND
AT (Hour)
IDENTIFICATION

SECTION I - REQUISITION
TYPE OF REQUEST
(Check ONLY if Red Blood Cell Products are requested.)
I=1 TYPE AND SCREEN
OSSMATCH

DATE REQUESTED
U')9161_,L5
DATE AN I-1 UR RE RED
KNOWN ANTIBODY FORMATION/TRANS SION
REACTION (Specify)

X61 Z
IF PATIENT IS FEMALE, IS TH' E HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION T
TING
TEST INTERPRETATION ANTIBODY SCREEN
CROSSMATCH
Covq4141,,--
CROSSMATCH NOT REQUIRED FOR THE COMPO REMARKS: (Do Dim
,L3) n
ECTION III - RECORD OF TRANSFUSION
AMOUNT GIVEN
ML
REACTION
I have examined the Blood Component container label a • this form and I find all
information identifying the container wah the intended recipie matches item by item.
The recipient is the same person named on this Blood Compone Transfusion Form and
on the patient identification tag.
1st VERIFIER
(b1c)-L
/ -17z
PRE•T
TEMP.
PULSE
BP DATET NSFUSION
TIME STARTED
"Ift4-163
NSN 7540-00-634-415E
BLOOD OR BLOOD COMPONENT TRANSFUSION
RE HYSICIAN (P nt)
IS OR OPERATIVE PROCEDURE
C
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.
SIG
TIME VERIFIED
QS-205
PREVIOUS RECORD CHECK:
14. I:ECORD Li
NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
POST•TRANSFU
DATA TIME/DATE PLETE
PULSE
NONE fl SUSPECTED
5
If reaction is suspected-IMMEDIATELY:
ERRUPTED
BLOOD PRESSURE
I le ,r
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 Li
FEVER Li PAIN
• OTHER (Specify)
OTHE CULTIES (Equipment, clots, etc.) NO
Li YES (Specify) SIGNA OF P
PATIENT IDENTIFICATION-USE EMBOSSER (For typed or written entries give: Name-Last, firs
SEX
rate; hospital or medical facility) WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSMCMR. FIRMR (41 CFR) 201-9.202-1

MEDCOM - 16852
518-124
MEDICAL RECORD
COMP ENT REQUESTED (Check one)
RED BLOOD CELLS

.
FRESH FROZEN PLASMA PLATELETS (Pool of units) CRYOPRECIPITATE (Pool of units)

.
Rh IMMUNE GLOBULIN

. OTHER (Specify)
REQUESTED (If applicable)

1 ML
REMARKS:
UNIT NO.
TRANSFUSION NO.
PATIENT NO.
RECIPIENT
ABO 11\24 ABO
SECTION I — REQUISITION
TYPE OF REQUEST
(Check ONLY if Red Blood Cell Products are requested.)
. TAPE AND SCREEN
CROSSMATCH
DATE REQUESTED
DATEAFWRED
KNOWN ANTIBODY FORMAT
N/TRANSFUSION
REACTION (Specify)

9(C)
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
. CROSSMATCH NOT REQUIRED FOR THE COMPON REMARKS: Al
1
ei4) • { 14'1
Rh DC'A" - Rh
SECTION III -RECORD OF TRANSFUSION

PRE-TRANSFUSION DATA
INSPECTED AND ISSUED BY (Signature)

(Date)
?r,
I have examined the Blood Component container label a
this form and I find all information identifying the container with the intended recipien
atches item by item.The recipient is the same person named on this Blood Component
ansfusion Form and
on the patient identification tag.
1st VERI re)

PRE-TEMP.
10/ 5 I PULSE IC01 BP
DATE OF TRANSFUSION TIME STARTED
ck0 -AA, 03Acaw
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, rate; hospital or medical facility)
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
AMOUNT GIVE
ML
L

REACT ON ONE . SUSPECTED
REQUESTING P
DI
IR OPERATIVE PROCEDURE
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.
SIGN
TIME VERIFIED
(7r?0 6
PREVIOUS RECORD CHECK:
RECORD .

NO RECORD SIGNATURE OF PERSON PERFORMING TEST
DATE lb
POST-TRANSFUSION DATA TERRUPTED
1110 . )41Adi ,O)
TEMPERATURE
77-P7)
illotAt$
PULSE
BLOOD PRESSURE
/(d' / •• 2
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)
OTHE FlCULTIES (Equipment, clots, etc.) NO .
YES (Specify)
GNATURE

ABOVE
I WARD L3
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 - 16853
MPriiral Parrort (nn,/
DOD-030242

518-124
NSN 7 540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I – REQUISITION
COMnerNENT REQUESTED (Cheoh' one) TYPE OF REQUEST
(Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN (Print)
Products are requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA 0 TYPE AND SCREEN
DIAGNOS -

ERATIVE PROCEDURE
Li units) CROSSMATCH

PLATELETS (Pool of
f'D CRYOPRECIPITATE (Pool of units)
/4 coo(' vwskb,u
DA7 RE UES:)fEk(LI Rh IMMUNE GLOBULIN I have collected a blood specimen on th
e below named patient, verified the name and ID N
. of theDATE, N OU lid Q ILRa patient and verified the specimen tube lab
OTHER (Specify) I to be
correct.
VOLUME REQUESTED (If applicable)

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
A ML
REMARKS: IF PATIENT IS FEMALE, IS THER (STORY OF:
RhIG TREATMENT? DATE GIVEN:
344,
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION U –
PRE-TRANSFUSION TESTING
"NIT NO.
TRANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHECK: ANTIBODY SCREEN
CROSSMATCH
0 RECORD
-5k...NO RECORD
PATIENT NO. SIGNATURE OF PERSON PERFORMING TEST
DONOR RECIPIENT
0)eps
CROSSMATCH NOT REQ k\44
UIRED Fk THE COMPONEN
ABO I\

ABO REMARKS:
Rh rrit
Rh p..)54i
SECTION III – RECORD OF TRANSFUSION
PRE TRANSFUSION DATA
POST TR
DATA
Siature)
AMOUNT GIVEN
TIME/DAT ESOMPLET NTERRUPTED
ML
33,5 it }V 3
REACTION
TEMPERATURE
PULSE
BLpek2RESSURE
NONE GSUSPECTED
IDENTIFICATION

1'6 10o , I ni
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label

d this form and I find all
information identifying the container with the intended recipier 1. Discontinue transfusion, treat Shock if present, keep intravenous line open.
matches item by item. 2.
Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component ansfusion 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 VERIFIE e)
(DESCRIPTION OF REACTION

El URTICARIA
. CHILL 0 FEVER
. PA I N
OTHER (Specify)
OTHER DIFFICULTIES (Equipment. clots, etc.) YES (Specify)
TEMP. 0/•.
PULSE13-S
BP
DATE OF TRANWION
TIME START
HA
PATIENT IDENTIFICATIOJNaUSE MBOSSER (For typed or vVritten entries give: Name—Last, rate; hospital or medical facility)
17AL( /
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 'REV. 9-92)
Prescribed by GSA/'CMR, FIRMS (41 CFR) 201 -9.202-1

MEDCOM - 16854 Medical Record Copy
DOD-030243
518-124
NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION 1 -REQUISITION
COMPO NT REQUESTED (Check one) RED BLOOD CELLS TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.) REQUESTING PHYSICIAN (Pring
. FRESH FROZEN PLASMA TYPE AND SCREEN Cx.
DIAGNOSIS CEDURE
PLATELETS (Pool of units) CROSSMATCH
r • . CRYOPRECIPITATE (Pool of units) DA15REQUESTED P (ktori fioctfrubut
Rh IMMUNE GLOBULIN I have collected a blood specimen on the below
named patient, verified the name and ID No. of the
. OTHER (Specify) DATE AND HOUR REQUIRED ¦Silke patient and verified the Specimen tube label to be correct.
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION '
ML REACTION (Specify)
REMARKS: (.(\IF PATIENT IS FEMALE, IS THERE HISTO 1 Y OF:
1A0i T RhIG TREATMENT? DATE GIVEN: HEMOLYTIC DISEASE OF NEWBORN? 2. sig-t-1 TIME VERIFIED
SECTION II -PRE-TRANSFUSION TESTIN
UNIT No TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
PATIENT NO. ANTIBODY SCREEN CROSSMATCH . RECORD IS: NO RECORD
IGNATURE OF PERSON PERFORMING TEST

RECIPIENT
OR \ACOAVP
. CROSSMATCH NOT REQUIRED FOR THE COMPONEN
ABO ABO
h
REMARKS: 61?
21 0.1
Rh eCrA

Rh
ii435WINg-

SECTION III -
RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
POST-TRANSFL A
INSPECTED AND ISSUED BY (Signature)

AMOUNT GIVEN
TIME/DAVE" 6.MAL-L7rnATERRUPTED
&a-7
ML 416 ..2t61.6
REACT' N
TEMPERATURE
AT (Hour) PULSE BLoog PRESSURE
I ir ON (Date) 'ref-13,s 43 NONE SUSPECTED
1,535/-7
IDENTIFICATION /05
If reaction is suspected—IMMEDIATELY: I have examined the Blood Component container label and this form and l 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 on the patient identification tag.
3.
Follow Transfusion Reaction Procedures.

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

1s DESCRIPTION OF REACTION
. URTICARIA
CHILL . FEVER . PAIN
. OTHER (Specify)
OTHE FICULTIES (Equipment, clots, etc.) NO
. YES (Specify) ATURE OF PERSON NOTING A: VE
DAT50tTRASFUSION
TIME STARTED
ti; • R ) l 2.
ATION--USE EMBOSSER (For typed or written entries give: Name—Last, firate; hospital or medical facility) WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 IREV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 16855 Medical Record Copy
DOD-030244

NSN 7640-01-165-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
( Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations )
EXAMINATIONS (S) REQUESTED AGE SEX SSN (Spo, WARD/CLING REGISTER NO.
FILM NO 17(—tiL 1 PREGNANT
REQUE (0 ;1. YES 1:2140 TELEPHONE/PAGE NO.

SI DAT QUE)STED
7 (1/./o
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
DATE OF EXAMINATION ( Month, day, year) DATE OF REPORT ( Month, day, year) DATE TRANSCRIPTION ( Month, day, year) RADIOLOGIC REPORT
I) tot rem tpa a
d-. 4 cr--(6- v•e
411
3) etz-ue?
*-L
PATIENTS IDENTIFICATION (For typed or written entries give : Name • last, first, middle, Medical Facility) LOCATION OF MEDICAL RECORDS
gall/ 6‘\ LOCATION OF RADIOLOGIC FACILITY SIGNATURE
RADIOLOGIC CONSULTATION 'ORTMEDCOM - 16856ACORDA STANDARD FORM 519-8 03-831 Prescribed by GSAIICMR FPMR (41 CFR) 101-11.806-8
DOD-030245

C
NIS/4 7540-01-165-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/111trasound/Compu(edlcmography Examinations)
EXAMINATIONES) REQUESTED
AGEOSSN
WARP/CLINIC 1.
REGISTER NO.
llem*k
o) t t..A..› 5 1,1 FILM NO.
PREGNANT
4 `-r
0 YES TELEPHON /P
uto-t FIEQUE AGNE ONO.
SIP IDATE REQUESTED
SPECIFIC REASON(S)•FOR REQUEST (Complaints and findings)
rbc
omaA
is /01 ) ,./
10tol
0-e4Ars-q--G-143 Xv-0 Litt. LA..) 41,¦--00 drc
/

ci
DATOF EXAMINATION (Month, day, year) • f DATE OF REPORT (Month, day, year)
DATE OF TRANSCRIPTION

(Month, day. year)
R DIOLOGIC REPORT
ee„,yee-p5A-
a -7-Aill Cge,a
ni 0 F-Tisat RA;1 I /V0 44ci 66-;
/60, kld
•7—ccig---a
5
ma he aA
-
PATIENT'S 10E IFICATION (For typed or
teen entries give:
Name — laat. /Int. middle, Medical Facility) LOCATION OF MEDICAL RECORD$
LOCATION CF RADIOLOGIC FACILITY
S IC NA TUB E
MEDCOM - 16857
_TATION STANDARD FORM 519-8
REOUESTMEPORT Przsctunl
DOD-030246
cLitsitCALR ECORD; - 'DOCTOR'S . ORDERS
For use of chis form, see AR 4066.,- the proOcinerit agency is DTSC.i THE DOCTOR SHALL RECORDDATE, 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 GATE- OF ORDER • TIME OF 'ORDER
24OTER4. NOTED AND
Adyx.pi-
ral
LAP For ti 5 L.,-›
Iirck
NURSING UNIT'...
A_eL_ •
PA TIENT IDENTIFICATION
DATE . pfi.,9PPER•;-,
NURSING UNII•
PATIENT , ,
y. AT. EDE ORDER ,
PATIENT, JOEN-FIFfiCA:FtIO OF' 0140E11 • OF :OH
HOURS
NUR9.I14G'LINI7
f;.!PLA,CES EatTION -OF I AIL 4.7 )14111C,FI MAY Elf : USED:
DA APR I9'`
^^.
•
{f ,S GoyEfiNNIENT
' RAu I PIIINTI PAPFF-ff-rFOUIRF17-
MEDCOM - 16858
DOD-030247

PATIENT IDENTIFICATION
'DATE OF ORDER
LIST TIME
4, iliORDER
1_140~ 1.--7G60 TSEIODNAND
HOURS
6) I 4 (..xJ
175 bie e (60
NURSING UNIT ROOM NO. BED No. 5-6
PATIENT IDENTIFICATION DATE OF ORDER TIME 74(4 r O 6-1 __ (LT _cf rifr 0, HOURS
NURSING UNITAROOM NO. PATIENT IDENTIFICATION NURSING UNIT 1ROOM NO. BED NO. BED NO. 2., I DATE OF ORDER it=1_3 A TIME cAPP- OF ORDER -0 HOURS 44 '41111 0
PATIENT IDENTIFICATION 6' -V ,03 id. V.O. DATE OF ORDER TIME OF ORDER • Ar HOURS 40
NURSING UNIT — ROOM N0. 0 NO.

DA ,FAWA79 4256 _ R L 4 ariffoTZ(0 WHICH MAY SE USED. igi1, + if 041. V
()(k)Y .
I) S ..30vcrowiN-r PAIN riNG On.rICE: 1 956-403.824

CLINICAL RECORD •• DOCTOR'S ORDERS
FA
Of this Form, see AR 40-66, the proponent sgencv ' ''TSG
FHF DOCTOR SHALL RECORD DA'
E AND SIGN EACH SET OF ORDERS. IF PR-
ORIENTED MEDICAL RECORD
SYSTEM ;5 USED, WRITE PROBLEM ,. ..IBER IN COLUMN INDICATEC-. BY ARROW BEL,
PATIENT IDENTIFICATION
0 AT E OF ORf2FR
TIME-CM.-IDMIEB LIST TIME ORDER TED AND
AHOURS
12____A) 03
S
Ie
bohl b
rig_.L.r1C-v-e-.0 SC 2-12
-A-jo Ale A
1111
NURSING UNIT ROOM NO.
BED NO.
PATIENT
IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
1 A-0 (N. HOUR
4, 0 .1k • ( Sr-t)
NURSING UNITAROOM NO. BED N
PATIENT IDENTIFICATION
TIME OF ORDER
HOURS
; I ROOM N O.AEtKp NO. •
:
A7777f776EN-rlrferi

P ION PACE
NUN
-SING UNIT 1ROOM NO.
BED NO.
0-206 )/a tilt
REPLACES
,FAO,,r7 9
DA 4256
AY BE USED.
OS. GOVEriNIVIENT P•lINT:140
4 ()Prior: 1396-403-924
F-7
"USE BALL POINT PEN-PRESS.FIRMLY I NO CARBON PAPER REQUIRED"
MEDCOM - 16860
DOD-030249

CLINICAL RECORD - DOCTOR'S ORDERS
FrA1 .1 this torm,
see AR 40-66, the proponent agency "TSG THE DOCTOR SHALL RECORD DAT
AND SIGN EACH SET OF ORDERS. IF PR
SYSTEM IS ORIENTED MEDICAL RECORD
USED, WRITE PROBLEM h. ..dER IN COLUMN INDICATED BY ARROW BEL.
PATIENT
IDENTIFICATION
NURSING UNIT
PATIENT ID
DATE OF ORDER
IMP oc r%saricsa
NURSING UNIT1ROOM NO.
BED NO.
PATIENT IDENTIFICATION
PATIENT IOENTIFICATION
NURSING UNIT ROOM NO.
.FA7¦ FIRM„ REPLACES EDITION OF 1 JUL. 77. WHICH MAY BE USED.
DA 4256
U.S
...-; OVERNMENT Y`IIN I iNG
1338-40:)•;)24
• '"."
"USE BALL
POINT PEN—PRESS FIRMLY I NO CARBON PAPER REQUIRED"
MEDCOM - 16861
DOD-030250
CLINICAL RECORD DOCTOR'S ORDERS
Fr If this form, see AN 40-66, the proponent agency;. "'TGG
THE OOCTOFi SHALL RECORD DA1
AND SIGN EACH SET OF ORDERS. IF PR
ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM
IN COLUMN INDICATED BY ARROW BELL
PATIENT IDENTIFICATION 141101 DATE OF ORDER
TIME OF LIST TIME ORDER NOTED AND
11-Au (10S A HOUR
SIGN
6) Pao\ Ac 51p ClAto
sbabik_
¦ ulkt s at° -sfr-r-
NURSING UNI ROOM NO. BED NO.
Fit e_ i h Crirxt u I
PATIENT ?DENfr IF ICATION DATE OR ORDERA
TI E OF ORDER
OURS
D. 0 a ko
SLI C2T33.__"
A-LA
NUR !NG LAI.7) 1 ROOM NO. BED NO. ,A4.;) Lo TV 2,..7.10 Pet(
P al
17513

PATIENT IDEN IFICATION
DATE OF ORDERA
TIME OF ORDER
AHOURS
1,Thp .)-4 L., L. 4.4„ I La,4 p 141.-4 e_
zAe-grPre... 'Gt) tv 4528 1'(
NURSING UNIT
ROOM
ROOM NO.A
BED NO.
C_IS 1 MC, • Ctce.— 8
PATIENT IDENTIFICATION
DATE OF ORDERA TIME OF ORDER
________ HOURS ef •— 4-0._ 4-1v, . riOl_k VUocie- .,( t2
t 0 c C H•,.,,› 45). S
NURSING UNIT TROOM NO A
BED NO
, FAOPR
M79 REPLACES EDITION OF t JUL 77, WHICH MAY BE USED
DA 4256
7..S
2 U
t31)VERNMENT Pirt.iPM1 UPMC[:
, n9 1:--403924
"USE BALL POINT PEN—PRNSS FIRMLY I NO CARBON PAPER REQUIRED"
MEDCOM - 16862
DOD-030251
CLINICAL RECORD - DOCTOR'S ORDERS
Ff
f this form, see AR 40-66, the proponent agency —SG
rHE DOCTOR SHALL RECORD DAT.
E AND SIGN EACH SET OF ORDERS. IF PI-1
SY STEM IS USED. WRITE PROBLEM

ORIENTED MEDICAL RECORD
NuMBER IN COLUMN
INDICATED BY ARROW BEID,
PATIENT
IDENTIFICATION
DATE OF ORDER
TIME OF ORD LIST TIME ORDER
I
,
OANC
HOURS
0.9c
NURS;NG UNIT
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
NIJRSIHG UNIT
PATi ENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
NURSING UNrT • 1ROOM NO.
liED NO.
PATIENT
IDENTIFICATION
1/6-
N 1 "T".
7F-400M NO.
BED NO.
FORM
O REPLACES EDITION OF 1 JUL 17. WHICH MAY BE USED

DA , 4256
tiOVCANMENT pnii.o orrice /SSEe--403.924
LA
"USE BALL POINT PEN—PRESS FIRMLY I NO CARBON PAPER REOLJIRED"
MEDCOM - 16863
DOD-030252
CLINICAL RECORD - DOCTOR'S ORDERS
i,or use of This form, see At; 40-88, the ornonop-ot acppry
THE occ.rop SHALL RECORD DATE, TI

N EACH SET OF ORDERS. IF PROBLEM ORIENTED ME.
SYSTEM IS USED, WRITE PROS
UMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIF

DATE OF ORDER TIME OF ORDER
c.)7
HOURS
-J.*,Aer cc /Le
NURSING UNIT ROOM NO.
BED NO.
TIENT IOENTIFICATIO
DATE OF ORDER TIME OF
HOURS
PATIENT IDENTIFICATION
NURSING UNIT
410. AR.
PATIENT IDENTIFICATION
TIME OF ORDER
1ck
HOU R S
lc\ 10Der f.__--\L2
I I
NURSING UNIT iii0OM NO. 1.
BED NO. I
1
DA , F,, , 7,AA-79 4256 REPLACES EDITION OF i JUL 77, WHICH MAY BE USED
RECORD
LIST TIME ORDER NOTED AN SIGN
if
S. GOVFFIFIMFNT 1,30,17 , 14‘; OFF.CE: !15-409-FLI1
• '
-USE BALL POINT PiEi
MEDCOM - 16864
APES REQUIRED"
DOD-030253
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, AR 40-66, the proponent agency 'is 01-5G
THE DOCTOR :HALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL
RECORD
SYSTEM IS USED, I1RITE
PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
I DATE OF ORDER
TIME OF ORDER I LIST TIME ORDER a NO
HOURS
;-CLK.C.A
/ NURSING UNIT TOOM NO. [BED NO.
4
p
J
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
4zz‘ip--3
...$) NURSING UNIT ROOM NO. — BED NO.
I
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS .
T-11-Q5 c" fe: 2— V61,,c,,,,c,

74
NURSING UNIT
ROOM NO BED NO.
I
ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
DA I FAOP R
M79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
Sl s, C¦ 07....kNfvt,7 NT F, 91r!T14:1
"USE {BA: .. l_ POINT EF MEDCOM - 16865 , APER REQUIRED"

DOD-030254

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
SIGN
vv

air
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION \ BED NO. art-Cd DATE OF ORDER ER ri HOURS
NURSING UNIT ROOM NO. ED NO.
ATIENT IDENTIFICATIO DATE OF ORDERT TIME OF ORDER T HOURS
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. BED NO. DATE OF ORDERT IME OF ORDER T HOURS .4L
NURSING UNITTROOM NO. D'A-z FORM1 APR 79 4256 BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED. U.S. GOVICMEDCOM - 16866C 10

DOD-030255

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
+
DATE OF ORDERT
TIME OF ORDER LIST TIME
ORDER NOTED AN
VI/44 CI 07 I t THOURS
SIGN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF
ORDERT TIME OF ORDER
Q3 SCA2) HOURS

NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
NURSING UNITTROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
T HOURS

qiII* RSING UNIT ROOM NO.TBED NO.
DK, FORM 1 APR 79 4256
MEDCOM - 16867

DOD-030256

CLINICAL RECORD - DOCTOR'S ORDERS
r
use of this form, see AR 40-66, the proponent ageni
-- is OTSG
HE DOCTOR SHALL RECORD f

'IME AND SIGN EACH SET Of ORDERS. IFT
EM ORIENTED MEDICAL RECORD
i3 USED, WRITE PROBL.
JMBER IN COLUMN INDICATED Ire ARROW L
LIST TIM
ORDER
NOTED AND
SIGN

NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNITC
ROOM NO
PATIENT IDENTIFICATION
NURgING—U-NTTC
ROOM NO.CRED
PATIENT IDENTIFICATION
NURSING UNIT -TROOM NO.T
BED NO.
FOAM
REPLACES EDIT
1 T JUL 7.
WHC
DA 4256 BE USED
1'4 IST
PRINTING GrIC5 .5.196-403:112: 4
"USE BALI_ POINT PEN—PRESS FIRMLY I NO CARBON
PAPER REQUIRED"
MEDCOM - 16868
DOD-030257
CLINICAL RECORD - DOCTOR'S °ROW'
Fa'Cthis form, see AR 40.66, the proponent ager T
TSG
THE DOCTOR SHALL RECORD DATE.
AND SIGN EACH SET OF ORDERS. IF Ph. _cM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE 15gri*-----
TIME OF ORD LIST TIME ORDER
HOURS NOTED AND
---zo 4O403

SIGN
NURS11•IG.-UNIT ROOM NO. BED NO.
I
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
(27 1 O.;
V- v . ILv
;) 12eilseetAZ eeo
NURSING UNIT ROOM NO. BED NO.
DENTIFICATION
TIME OF ORDER
O e'36 HOURS
NURSING UNIT BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
2 7 AV-03 /2.5 Z_ HOURS

NURSING UNIT
ROOM NO.
A BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1FAOPARM79
MEDCOM - 16869
DOD-030258
''.IN)CAL RECORD - DOCTOR'S ORDERF
For i
his form, see AR 40-66, the proponent agenc SG
THE DOCTOR SHALL RECORD DATE,
_ AND SIGN EACH SET OF ORDERS. IF PRO. ._nt ORIENTED MEDICAL RECORD
SYSTEM is USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
9
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
Y1/1
4 Ite SIG
VUR' )
NURSING UNIT 6 ROQM NO. BED NO.
PATIENT IDENTIFICAT ION TIME OF ORDER 6,)y-fCe Agc (17;C1/4-(-D `41-`7car . DATE OF ORDER HOURS Al
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ER HOURS
NURSING UNIT ROOM NO. IBED NO. (0-1, ,,7/ 44 6c Ps4-144,4A a.) 7 ( Olt G4 744/(4 C--eV­e--
PATIENT IDhN riFICATIO DATE OF ORDER TIME OF ORDER HOURS
INURSING UNIT ROOM NO. DA 1 APR 79FORM 4256 BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 16870
DOD-030259
CLINICAL RECORD . DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
.-90-3ifutzt3 ---Jitabs___RoyRs SIGN
0-71 0
co Mk/ 7-F
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
ESE OF ORDER
TIME OF ORDER
cb-rags
HOURS
p,..-----NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
TIME OF ORDER
N RSING UNIT
ROOM NO. BED NO.
PATIE IDENTIFICATION DATE OF ORDER
TIME OF ORDER 081—
HOURS
UNIT ROOM NO.
BED NO.
FORM
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256 ...—
Yr U.S. GOVI
U 10MEDCOM - 16871
DOD-030260

-DOCTOR'S ORDERS
CLINICAL RECORD -f this form, see AR 40-66, the proponent agency ^TSG
For us,. %ND SIGN EACH SET OF ORDERS. IF PR . ORIENTED MEDICAL RECORD
THE DOCTOR SHALL RECORD DATE, IN COLUMN INDICATED BY ARROW BELL.
SYSTEM IS USED, WRITE PROBLEM NL LI T
ORDER
PATIENT IDENTIFICATION NOTED AND
SIGN

NURSING UN PATIENT IDE ROOM NO. BED NO.
ROOM NO.NURSING UNIT PATIENT 1DENIFICATION BED NO.
OOMNO.NURSING PATIENT !DENT FICATION RDER TIME OF ORDER HOURS

NURSING UNIT ROOM NO. BED NO.
454t
DA 1FAOPRRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 16872
DOD-030261
CLINICAL RECORD - DOCTOR'S ORDERS this form, see AR 40-66, the proponent agency ' "`TSG
For 'IF-.4 . ORIENTED MEDICAL RECORD
%ND SIGN EACH SET OF ORDERS. IF PR
THE DOCTOR SHALL RECORD DATE.
1 IN COLUMN INDICATED BY ARROW BELL—
SYSTEM IS USED, WRITE PROBLEM NL
LI!."1 TI iE
TIME OF ORDER
DATE OF ORDER ORDER PATIENT IDENTIFICATION NOTED AND HOURS SIGN
3
BED NO.
ROOM NO.
NURSING UNIT
6. 0 I ,21(
/A( I/101
DATE 0
PATIENT IDENTIFICATION
7.5b c— ;-)cst.,)
I BED NO.
ROOM NO.
NURSING UNIT TIME OF OR
DATE OF ORDER
PATIENT IDENTIF {CATION

ego--
UNIT I ROOM NO.
NURSING
TIME 0
DATE OF ORDER
PATIENT IDENTIFICATION
HOURS
BED NO.
NURSING UNIT
cwehejial-
LACES EOITION OF 1 JUL 77. WHICH MAY BE USED.
FORM
DA 4256
1 APR 79
MEDCOM - 16873
DOD-030262
CLINICAL RECORD - DOCTOR'S ORDERS
'TSG
this form, see AR 40.66, the proponent agony
For
I ORIENTED MEDICAL RECORD
AND SIGN EACH SET OF ORDERS. IF PR
THE DOCTOR SHALL RECORD DATE,
IN COLUMN INDICATED BY ARROW DELI,—
_A
SYSTEM IS USED, WRITE PROBLEM Nt..
LIST TIME
TIME OF ORDER
DATE OF ORDER ORDER PATIENT IDENTIFICATION NOTED AND HOURS N
1 2,
70r*—C
k-kA.r
OM NO. u I PATIENT IDENTIFICAII ION NURSING BED NO.
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BE NO. a TIME OF ORDER /t000 / .42./1" .HOURS

BE
NURSING UNIT ROOM NO.
c,LA.
PATIENT IDENTIFICATION
NO. I .BED NO.
NURSING UNIT ROOM
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
FORM
DA 4256
1 APR 79
MEDCOM - 16874
DOD-030263

CLINICAL RECORD - DOCTOR'S ORDERS
" SG
this form, see AR 40-66, the proponent agencyFor v • ORIENTED MEDICAL RECORD
kND SIGN EACH SET OF `ORDERS. IF PRL THE DOCTOR SHALL RECORD DATE,
SYSTEM IS USED, WRITE PROBLEM Nth....cf‘ IN COLUMN INDICATED BY ARROW BELOW.
LIST T TIME OF ORDER ORDER
DATE OF ORDERT
HOURS NOTED AND PATIENT SIGN
IDENTIFICATION
/.0-0C
BED NO.
ROOM NO.
NURSING UNIT
IDENTIFICATION
PATIENT
BED NO.
NURSING UNIT
IDENTIFICATION
PATIENT
NURSING UNIT
PATIENT IDENTIFICATIO
¦
Ada
H
WA I to

BED
ROOM NO.
NURSING UNIT
.0111111111116m.mimm ew
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 FAOPARM79
MEDCOM - 16875
DOD-030264
CLINICAL RECORD - DOCTOR'S ORDERS
`SG
his form, see AR 40-66, the proponent agency '
For ur
ORIENTED MEDICAL RECORD
I ND SIGN EACH SET OF ORDERS. IF PRI THE DOCTOR SHALL RECORD DATE, .ft.
SYSTEM IS USED, WRITE PROBLEM NUt..—_r1 IN COLUMN INDICATED BY ARROW BELO
LI T TI TIME OF ORDER ORDER
DATE OF ORD =
NOTED ANDPATIENT IDENTIFICATION C3?-4DC. HOUR SIGN
Oh
BED NO.
NO.
NURSING UNIT \ ROO
TI. E ORDER
DATE OF ORDER
PATIENT IDENTIFICATIO

Cr-t,C
HOURS
Ke, 05 (.
cn Cc.
CD V-C—R. 4
00.—a—e Z 44,„‘el _
BED NO.
ROOM NO.
NURSING UNIT
fik) 01 50
DER
DATE OF ORD
PATIENT IDENTIFICATION
67 I 0 HOURS

510

3.9
4 . .... •¦•
BED NO.
ROOM NO.
NURSING UNIT
PATIENT IDENTIFICATION .BED NO.
ROOM NO.
NURSING UNIT 77. WHICH MAY BE USED.
Di% 4256
1 FAOPTA79
MEDCOM - 16876
DOD-030265
INICAL RECORD - DOCTOR'S ORDERS
For t.
lis form, see AR 40-66, the proponent agent ;G
THE DOCTOR SHALL RECORD DATE, AND SIGN EACH SET OF ORDERS. IF PROb..—M ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLliM INDICATED
BY ARROW BELOW.
PATIENT IDENTIFICATION TE OF ORDER TIME OF ORDER LIST TIME
ORDER
h Sep D3 0 b3c, . HOURS NOTED AND SIGN

NURSING UNIT
ROOM NO.
TIFICATION
/URSING UNIT
PATIE
'CATION
fr)

NURSING UNIT ROOM. N
.2r
1 APR 79 OF 1 JUL 77, WHICH MAY E USED.
DA 4256
(9 \r1
MEDCOM - 16877
DOD-030266

,C. .CLIN;CA i. fifif;(;•RO. • -:iX.C1.';..', TC.710.'S ..6-5.4!T
:;%.3C4047 '13j : ¦ 4.4
its&itT
E NI • s t.1 ,CT:%C5•1,1Coftt-giff,s,Ty
vii, i El; sCkt•iCilC1.C;61•5' AlitC0;Y- I_CYA`d.
7 • • 777 T3;77 *. . :1; .1 ?T • • ..._ 4404). Vilf,
S-101'?
L4,T.....
• 4.'777= • • 1. 0 tp I
) IC
'CI.C l•
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-
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1C1
., -4,A, ir, !1•;‘,r;Pic ,:srr,f,1
•--Vrt, z",,
1 ,F 0a0t:11C
TgAlt 4.:ig OfIDE.41
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A34
is!
•••• • —C•C—C 1"4:2l:P,C•
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5:1,c) rn Fvsru,Ce
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-Mt=
• 16:C eC
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,
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. r n.?;T.1451p, ri
Ca
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'Nu F114i5?-3714,;"..
MEDCOM - 16878
DOD-030267
P 4gti3s. cb7"- :-¦•
is T
.C— •C— .
4.;:i..1ATi);;;T:E,TAM')T
SE "7 • 0.1':
STET
1
.C. • t 11A3T
•T i.F11.).41.1!T.TT1"..titAlr.
t
•
-1654-t9C I f '"IlL'.14,7,..,4'`-‘• 4.•:"
•k CPe‘T5t)T/42'3 d.
f? vs
e,
t ,
114. 1,
C);')T.4C
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(E U(
6 PA-ic_
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• FA rflf.,NtCf"fai\f•T". • 140_
r Isola c.)T t
O
.
I. f;T;46, U."
..•.
j
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• .L31,:::.4istkiT
-
-".i‘j(4...T
1;,ipp:=
MEDCOM - 16879
DOD-030268

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME
ORDER
jSSz p 0 3 /1 D a HOURS NOTED AN SIGN
del LA-1,c (ero1 rC)
Lop-2s L-*--4 '2--

NURSING UNIT ROOM NO. BED NO
aCvz.-
Tr J--t) 1Z-6".H1
PATIENT IDENTIFICATION
DATE OF ORDER TIME OF
HOURS
r4-1-AL/1 )-1-t-
NURSING UNIT ROOM NO. BED NO.
2Y.°C,1-ta(t-alect41111111pC
W03 OWs-
PATIENT IDENTIFICATION
DATE OF ORDER
20 5,279 a' 3
HOURS
(14-ivnA) 1 -2 ° A-11/3
(
UT"3 Pa4A
(4-3
/ LI 6U-ic
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER TIME
HOURS
ZO Sr 03
NURSING UNIT ROOM
NO. BED NO.
RICH MAYBE USED.
DA ,FLARK4,9 4256
MEDCOM - 16880
DOD-030269
CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66. the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION-
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER C'V CS3 tl NOTED AND
T HOURS
SIGN
RSING UNIT ROOM NO
PATIENT IDENTIFICATION
DATE OF ORDERT
TIME OF ORDER
T HOURS
4-
f--4-
(4-) C
z cc-/Ck-----
ra C zoci. i
NURSING UNIT
ROOM NO.
BED NO.
(IDSC00
PATIENT IDENTIFICATION
DATE OF ORDERT
TIME
( 2-j z
HOURS
NURSING UN
.2 ct
PATIENT IDENTIFICATION
DATE OF ORDERT
TIME OF ORDER
HOURS
('2' T kr)3 T71fr--tom 7
G UNIT ROOM N
a
: FORM
rl 1 APR 79 F 1 JUL 77. WHICH MAY BE USED.
4256
4111111t/
0
U.S. GOVT
MEDCOM - 16881 10
fl

DOD-030270

CLINICAL RECORD - DOCTOR'S ORDERS
For of this form, see AR 40-66, the proponent ager OTSG

THE DOCTOR SHALL RECORD DATI
AND SIGN EACH SET OF ORDERS. IF /
.M ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM t.
..ER IN COLUMN INDICATED BY ARROW BEL..,ilf.
PATIENT IDENTIFICATION C(04W'.-1 NURSING UNIT ROOM NO. J.PATIENT IDENTIFICATI N BED NO. V 4-u C.1 RiCriTEvt DATE OF ORDER TIME OF ORDER DATE OF ORDER TI I f" OF ORDER HOURS HOURS LIST TIME ORDER NOTED AND SIGN
NURSING UNIT ROOM NO. BED NO.
PATI ENT IDENTIFICATION DATE OF ORDER q TIME OF ORDER Kt° 9 HO RS
ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER 6 TI OF ORDER
L)

NURSING UNIT
ROOM NO.
BED NO.
.11111.111111i4
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE
DA 4256
t FAC4M711 -.USED.
/71
MEDCOM - 16882
DOD-030271

CLINICAL RECORD - DOCTOR'S ORDERS
For r this form, see AR 40-66, the proponent agery 'MSG

THE DOCTOR SHALL RECORD DATE AND SIGN EACH SET OF ORDERS. IF Pi .M ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM Na.......AER IN COLUMN INDICATED BY ARROW BEL....“. PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME
ORDER NOTED AND
HOURS
0CU3 101-N°
G. r ativGn in h SIGN
-kink ea
NURSING UNIT ROOM NO. BED NO.
CCUI z
PATIENT IDENTIFICATION DATE OF ORDER TIME OF
ORDER O2-624,71 ci 3 Sri) HOURS
. 12.1e it& eat16e4-2-61 Z-Ze
I G UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
OATS OF ORD ER
TIME OF ORDER ( J (--2.--
14,30
HOU
PT C/CV1-1 ,-• (-1--
0-1
NURSING UNIT IROO
02 17
r' (
PATIENT IDENTIFICATIO DATE TIME OF ORDER
.
HOURS
ago v 05061-06 ctr-,53
4 0 10 (0 \if 01 P r tiViicjvyko cfrr
(-1410.7ie/1
towli VAC
NURSING UNIT vIiprat NO. BED NO. C-714 V71, (CAI) REPLACES EDIT
, FAOPPM79 WHICH MAY 9E ..USED.
DA 4256
MEDCOM - 16883
DOD-030272

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66. the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIM( .OF. ORDER. I.. NatEU-k
HOURS
SIGN
s,A)
-i-E4Y-
10 64) ,;,.

NURSING UNIT
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
7 6,:(
L fie •ni
eitt ­
-k 2 7 2-3 0'477.1
Of"' we —5.4c
S ING U T
Ski-7
PATIENT IDENTIFICATION
DATE OF ORDER
tt TIME OF ORDER
epo
NURSING UNIT ROOM NO.
BED NO.
1

t PATIENT IDENTIFICATION
DATE OF
TIME OF 0
NURSING UNIT
tir
REPLACES E0
DA 1 APR 79FORM 4256 AY BE MS
MEDCOM - 16884
DOD-030273

CLINICAL RECORD - DOCTOR'S
RS
use of this form, see AR 40-66, the proponen,
,tcy is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT
IDENTIFICATION
DATE OF ORDER

TIME OF ORDER LIST TIME
7 D ORDER
2--Z
NOTED AND
-SIGNHOURS
Zg. fp,)
NURSING UNIT ROOM
PATIENT IDENTIFICATION
HOURS
NURSING UNIT ROOM NO.
BED NO.
PATI ENT IDENTIFICATION
DATE OF ORDER

TIME OF
ORDER
HOURS
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
FORM
REPLACES
DA 4256
1 APR 79 EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 16885
DOD-030274
CLINICAL RECORD • DOCTOR'S ORDERS
rC'Se of this form, see AR 40.66. the proponent ager--- is OTSG
THE DOCTOR SHALL RECORD D iME AND SIGN EACH SET OF ORDERS. IF
.EM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEis .AMBER IN COLUMN INDICATED BY ARROW b .4.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME ORDER NOTED AND
oc_TtZ) .Cel LC, 6.• HOURS
tTSIGN
GG I
YoC
ulelms fhb, gi , Eit
NURSING UNIT ROOM NO. BED NO
PATIENT IDENTIFICATION
TIM OF ORDER
40 .°411¦
4,24T2fp 0(4-6 1..". tir
HOURS
ZC G9-00
eo
S 1-0 p
on cs.i( A GA-
NURSING UNIT
c cr'y ag o Ca o
sV-7
PATIENT IDENTIFICAT ON DATE OF ORDER TIME OF ORDER
7-1 t,. 3 C17"6 .0
HOURS
Ba)
PATIENT IDENTIFICATION TIME OF ORDER
TcCrcp3 abd
.)--HOURS
CCt2_§.
v[ O.
NURSING UNIT ROOM NO. I BED NO.
.4-03Q z.65.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA FORM
1 APR 794256
MEDCOM - 16886
DOD-030275

CLINICAL RECORD • DOCTOR'S ORDERS
•se of this form, see AR 40-66, the proponent agP -—• is OTSG
THE DOCTOR SHALL RECORD C.
IME AND SIGN EACH SET OF ORDERS. IF
...EM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLE.. .UMBER IN COLUMN INDICATED BY ARROW L
II.

PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER.28 o Cf? NOTED AND
HOURS
SIGN
NURSING UNIT ROOM NO.
/CDQ1
PATIENT IDENTIFICATION

NURSING UNIT
PATIENT IDENTIFICATIO
NURSING UNIT
PATIENT IDENTIFICATION
IDENTIFICATION
NURSING UNIT
c?i(VtFiEb
REPLACES
DA 4256
1 FA7' riOF 1 JUL 77, WHICH MAY BE USED.
7 9
MEDCOM - 16887
DOD-030276
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER TIME OF ORDER LIST TIME
ORDER
Z c:co 3 IC)? HO NOTED AND SIGN
Ali 4- .4L¦ PA-c.‘-)
S ct b Md
A ci-v.L
csz ‹Ls CA,
NURSING UIT) ROOM NO. BED NO. Art(
LAla .
PATIENT IDENTIFICATION 5_12_t.;b DATE OF ORDER 7 f"I Tr c.-TIME OF ORDE 6

HOURS
‘,..-105L9.- J.-.
/40C IryCD,e,f,p,-.1 sofC kra­
Qfb1:)(
NURSING UNIT ROOM NO.
BED NO.
l_s c-kc_
ATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
r-R.r t ^rcICNerds
1 A.
,_,31 I t A S 7s
NURSING UNIT BED NO.
iFICATIO N
DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.
8ED NO.
REPLACES EDITION OF 1 JUL
77, WHICH MAYBE USED.
DA1FAOPRFIM79 4256
MEDCOM -16888
DOD-030277

alEDICAL RECORD - DOCTOR'S ORDEh—
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Tlist the time Only one order is allowed per line. Nursing will the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do notrequire recopying. They may be signed off, as completed, in the far right column.
1•
ORDER
ORDER NOTED

NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS COMPLETED TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
X VS q 5 min X 15 min, then q 15 min until discharge.
A, Supplemental oxygen. ..k„.ka (,/,,,,.".T
c..--/ 7 9-170
X
Morphine / Mrpefidinniglynow and /mg q 3-5 min pm pain for a
max dose of /C) mg.
4-----

TZofran 77 mg IV pm N/V q 15 min, may repeat x
.
Metoclopramide /0 mg IV pm N/V x 1.
6 a -N,

e : -• •
7.__ PhenerganTil • • —
4 111.,....,,-1.-.,1 ac cn---VIM __• • -
• . •
9 IVF:T /cio cc/hr.
1 0 Discharg

ACU discharge criteria met.
ttic •erC)/.yeti f X / A
I
PATIENT IDENTIFICATION
Complete the following information on page 1 on y. Note any changes on subsequent pages.
Diagnosis:
Height: Weight:T Diet:
Allergies:
Nursing Unit Room No. Bed No.
Page No.
PACU, 28th CSH
1 of 1
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MC V1.00
MEDCOM - 16889
DOD-030278

IEDICAL RECORD
-DOCTOR'S ORI,
Foruse of this form, see N
T0171-eireer-4-6-o
DIRECTIONS:
The provider will DATE, TIME, and SIGN each order or set of orders recorded. Tlist the time the new
Only one order is allowed per line. Nursing will order(s) are noted and initi2I in the column provided. Orders completed during the shift in which they were written do notrequire recopying.
They may be signed off, as completed, in the far right column.
ORDER
ORDER NOISED

COMPLETED TIME & INITIALS
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS
i 1 rl N1)k5T

POST ANESTHESIA ORDERS (circled Items)
MI:5 .t
VS q 5 min X 15 min, then q 15 min until discharge. .`r
2 Supplemental oxygen.T..e-i Dz.,

O: C1L07-
(3) foine / Meperidine 3-4Tme IV now and 3TJ 00 4'0
mg q 3-5 min prn pain for a max dose of .2_0 mg.TWt TN,-4 TZSL: . ta,t, ,,,i tog r---
( 3' Zofran 4Cmg IV prn N/V q 15 min, may repeat x ', i ,C
/ 5 MetoclopramideTmg IV prn N/V x I. 6 DroperidolTmg IV prn NW x 1. ./. i 7 PhenereanT'rig IV prn N/V x 1.
7---
8 Benadryl 25-50mg IVP qI hr prn, itching while in PACU.
‘--....._.
.---...,,
3 IVF:T1-(2--.C@C15.)Tccihr. go o rot,1,1 .3C---C 10
Discharge from recovery status when PACU discharge criteria met. ---1 0. -'1 ,6,), e
1( .
LrAct—lTh\ 4JC.,C
cit--:CQC-lOr-1.--¦ --T,CAA.A.
-r)-%CSY? ? s I -10C4.--)(%,--1 tA? GM

PATIENT IDENTIFICATION
Complete the following information on page 1 only.
Note any
changes on subsequent pages.
(G)(L)
. Diagnosis: r"--o.
illikr Height:T Weight:T Diet: T Allergies: Nursing Unit
Room No. Bed No.
Page No.
PACU, 28th CSH
I of I
. /1Cfli^r-tit ¦ ertnnw.,nn.rt . -.- 1- .-....... .. . .... . ..... .

PREVIOUS EDITIONS ARE OBSOLETE
MC V 1.00
MEDCOM - 16890
DOD-030279

CLINICAL RECORD • DOCTOR'S ORDERS
•Ise of this form, see AR 40-66, the proponent .Is OTSG
THE DOCTOR SHALL RECORD.
TIME AND SIGN EACH SET OF ORDERS. I,.
,BLEM ORIENTED MEDICAL RECORDSYSTEM IS USED, WRITE PROBLEM NU BER IN COLUMN INDICATED BY
ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER -.TIME OF 0 LIST TIME
ORDER NOTED AND
i1/0 3
HO RS
SIGN
NURSING UNIT
01016-1)
PATIENT IDENTIFICATION
NURSING UNIT
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATIO
NURSING UNIT ROOM NO.
FORM
EPLACES
DA 4256
1
MEDCOM - 16891 ( .
k..41,.)-1
DOD-030280

THE DOCTOR SHALL RECORD SYSTEM IS USED, WRITE PROBL
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
DA, F4256
AOP M„
CLINICAL RECORD - DOCTOR'S ORDERS
" • use of this form, see AR 40-66, the propone .icy is OTSG
TIME AND SIGN EACH SET OF ORDERS..
ROBLEM ORIENTED MEDICAL RECORD
.DUMBER IN COLUMN INDICATED BY ARROW BELOW.

DATE:..C7DEiite9
ETImE OF ST TIME
OR R DER NOT p AND SII N
TIME OF RDES
HOURS
BE D NO.
DATE OF ORDER.
TIME OF ORDER
REPL/CES EDITION OF 1 JUL. 77, WHICH MAY
BE USED
MEDCOM - 16892
DOD-030281

CLINICAL 11tL.LatU -DULIUR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DAT
AND SIGN EACH SET OF ORDERS. IF Pr.'A ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM ER IN COLUMN INDICATED BY ARROW BE
PATIENT IDENTIFICATION
LI 0 0 NOTE . SI ,
NURSING UNIT ROOM NO..BED NO.
)00
PATIENT IDENTIFICATION
HOURS
NURSING UNIT FlOOM NO.
,x-0.4fal 2
PATIENT IDENTIFICATION
or
NURSING UNIT ROOM NO..BED NO
211 I le‘tc,11 0
PATIENT IDENTIFICATION ATE OF ORDER.

DER
(.
(-9)(0 . HOURS
NURSING UNIT ROOM NO,
BED NO.
DA I
FAVIRM79
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
4256
MEDCOM - 16893
DOD-030282