Medical Report: Iraqi Male, Baghdad, Iraq re: Leg Amputation

KIEDICAL RECORD
COMPONENT REQUESTED (Check one)
.0(....S.E.D BLOOD CELLS
FRESH FROZEN PLASMA
PLATELETS (Pool of units)
CRYOPRECIPITATE (Pool of units)
Rh IMMUNE GLOBULIN
OTHER (Speci61)

VOLUME REQUESTED (If applicable)
ML

REMARKS:
'UNIT NO. TRANSFUSION NO.
PATIENT NO
DONOR RECIPIENT/..-
(byG)
-
ABO
Rh
PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)
AT (Hour)(/ 5' N (Date) IDENTIFICATION
NSN 7540-00-634-4158
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
PLCROSSMATCH
DATE REQUESTED ,--• i ty3
17 dulti
DATE AND HOUR REQUIRED _ .
e )11) cfi-e__L
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Speci64
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 REQUESTING PHYSICIAN (Print)
bc(( hYG )-2-
DIAGNOSIS OR OPERATIVE PROCEDURE
(0 1-e3 kThie-b44-06r
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 VERIFIE
(6)(6) -2-
DATE VERIFIED
I,
CiallY 01
TIME VERIFIED
/......34.b
PREVIOUS RECORD CHECK:
dtfORD
NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
(b)(6 )
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE I 6 "5 / 03
REMARKS:
trs,4143
SECTION III - RECORD OF TRANSFUSION
bYC2)-

I have examined the Blood Component container label and this form and I find all information identirying the container with the intended recipient matches item by item. The recipient is the same person na:ned on this Blood Component Transfusion Form and on the patient identification tag.
1st VERIFIER (Signature)
PRE-TRANSFU ION
TEMP. PULSE

.3/5 • 0 /9 1.p/c9-2/70z
DATE OF TRANSF7ION TIME STARTED
/ "cf-A 0-2, ta,;1. °
POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRU7ED 351:› ML aTac) /6 /;74, r 03 REACTION TEMPERATURE PULSE BLOOD PRESSURE
XIONE 0 SUSPECTED ) a 0 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 0 CHILL 0 FEVER 0 PAIN

El OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
tg-NO El YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE

PATIENT ID NTIFIC ION—USE EMBOSSER (For typed or written entries give: Name—Last, f rst, middle; grade; rank; rate; hospital or medical facility)
(b) (G) S /714-LC
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

LTA] t(9)
STANDARD FORM 518 (REV. 9-92)
MEDCOM - 14441
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
DOD-027993

"i;
518-123 NSN 7540-00-634-4158

-A ,T-Ai
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION 1 - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)
XRED BLOOD CELLS Products are requested.) (6)(6 ) --.
.
• FRESH FROZEN PLASMA PLATELETS (Pool of CRYOPRECIPITATE (Pool of units) units) TYPE AND SCREEN rs( CROSSMATCH DATE 'REQUESTED — ' • ' DIAGNOSIS OR OPERATIVE PROCEDUREsirro (...... iNiAlek-A1441-\
Rh IMMUNE GLOBULIN I 7 TiA III 0 I have collected a blood specimen on the below named patient, verified the name and ID No. of the
OTHER (Specify) VOLUME REQUESTED (If applicable) DATE AND HOUR RE..1111.40. , 0 Ai LL. KNOWN ANTIBODY FORMATION/TRANSFUSION patient and verified the specimen tube label to be correct. (04)-2--SIGNATURE OF VERIFIER

REACTION (Speci4,)
ML C447--
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
RhIG TREATMENT? DATE GIVEN: elen4 ''7 TIME VERIFIED
44,15
HEMOLYTIC DISEASE OF NEWBORN?
SECTION 11 - PRE-TRANSFUS1ON TESTING
U N
TEST INTERPRETATION PREVIOUS RECORD CHECK: CROSSMATCH
.YRECORD ill NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
OM (WODONOR RECIPIENT
(b)(6)—q P CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUE DATE 6 -s 33 ABO
ABO REMARKS:
34 03
Rh Rh
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
A
INSPECTED AN TIME/DATE COMP ED/INTERRUPTED
ML
(a-6 ) -z_ au)
REACTION
TEMPERATU ULSE BLOOD PRESSURE AT (Hour) NONE El SUSPECTED
ON (Date) /7 14/ 3 cr/ 111 lotlyg
IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
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 ( e)
DESCRIPTION OF REACTION URTICARIA CHILL El FEVER 0 PAIN
OTHER (SpeciW 2nd VE
OTHER DIFFICULTIES (Equipment, clots, etc.) PR NO ID YES (Specify) TEMP. SIG
DATE OF T CIA)
PATIENT IDENTIFIC
USE EMBOSSER (For typed itten entries give: Name--Last, first, mid rate; hospita or medical facility)
ei_90

up (6)(6 ) -y

BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDCOM - 14442
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescnbed by GSA/ICMR. FIRMR (41CFR) 201-9.202-1

DOD-027994

•
'
518-123 _ NSN 7540-00-634-4158
MEDICAL RECORD BLOOD OR BL6OD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)(1)2)( ,.-(% Products are requested.)
I —2.---
K RED BLOOD CELLS
IN) (____:1111
FRESH FROZEN PLASMA TYPE AND SCREEN DIAGNOSIS OR OPERATIVE PROCE URE
/
PLATELETS (Pool of units) 51 CROSSMATCH
Sie lb Le_cs
CRYOPRECIPITATE (Pool of units)
DATE REQUESTED . I have collected a blood specimen on the below
1 la -1,j,-\. %..
Rh IMMUNE GLOBULIN named patient, verified the name and ID No. of the DATE AND HOUR REDUIREbri patient and verified the specimen tube label to be OTHER (Specify)
correct.
Pt--AP
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION (L1)(6)"."-27
SIGNATURE OF VERIFIER
REACTION (Speci61)
ML &/9
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DA ERIFIED
RhIG TREATMENT? DATE GIVEN:
Clot-i tig TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN?
SECTION 11 -PRE-TRANSFUSION TESTING
UN
TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH
RECORD
LI NO RECORD PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST
,0 A/ WG)
RECIPIENT
0 CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED I DATE i‘3....d a
(6P/S 111111111
ABO ABO REMARKS: F"ijeco ( g5.0„/ 0.3
Rh Rh
SECTION III -RECORD OF TRANSFUSION
INSPECTED AN AMOUNT GIVEN TIME/DATE OMP ETED/INTERRUPTED
70741.-- ML (53,
rb)(6)_ 2_
REACTION TEMPERAT PULSE BLOOD PRpSURE AT (Hour) ON (Date) NONE El SUSPECTED
(t4-3 2-63 3.6"-it 'I tt Otifo
IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1.
Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person na.-ned on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on th ient identification tag. L v 4.

Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. Solutions to the Blood Bank. ER (Signature)(
DESCRIPTION OF REACTION
.9t 6 /-2--
•
URTICARIA El CHILL FEVER 11 PAIN

•
OTHER (Spech),)

OTH NRoDIFFICULTIES (E(cisupipecmie67, clots, etc.) 03)(6)
TEMP. SIGN TUR DATE SIO
P I T Er TIO USE EMBOSSER (F typed or written entries give: Name—Last, first, mid rate; hospita or medical faciliM
Mole_
:FPI)((h10-Lf

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

MEDCOM - 14443
DOD-027995

'HE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROEILEM ORIENTED MEDICAL ECOFID :YSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW,
'ATENT 10ENTIFICATION DATE OF -ORDER TH41E.OF.0RDER LI 1
0 D
03 HOURS NOT .SI
(7) /PC- LA.5
(b)( 0-`i e4/4447

IURSING UNIT ROOM NO. BED NO..
'ATIENT IDENTIFICATION DATE OF ORDER - TIME OF ORDER
a e/3 HOURS
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(b)10—ye /-14e. /41/ NS.
IURSING UNIT ROOM NO. BED.
'A T IEN T I D ENTIFICAT ION
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IURSING UNIT ROOM .NO. BED NO.
ATIENT IDENTIFICATION .- DATE OF ORD R TIME OF ORDER-
NN 4/0 )r-19( I -c--/3 /7" HOURS
/rX
5URSING UNIT noom BED NO.

MEDCOM - 14444
DOD-027996

THE DOCTO-R SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECO
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARFIOW BELOVY.

PATIENT IDENTIFICATION
+ DAT:a ORDER
TIME OF OFIDER Llg;
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HOURS
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DATE 0 ORDER
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PATIENT IDENTIFICATION
DATE ORDER
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IDENTIFICATION DATE OF ORDER ' OR0ER
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REPLACES EDITION OF 1 JUL 77, V0.11C/-I M
1 A R 9 ,
•
)17478-200
MEDCOM - 14445
9 )
CLINICAL RECO
DODTOR'S ORDERS
For use of this form,
see A 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD
TE, TIME AND SIGN E CH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECO-R-D
SYSTEM IS USED, WRITE PROBLE
UMBER IN COL N INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF 0 DE
TIME OF ORDER LIST rtmE
,
ORDER
61 0-S-0(NOTED AND
l HOURS
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DATE OF ORDER
TIME OF ORDER
1
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PATIENT IDENTIFICATION
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BED No.
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PATIENT IDENTIFICATION
DATE
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NURSING UNIT
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REPLACES EDtTION OF 1 JUL 77. VVHICH MAY BE USED.
I A R 79
JO
.0 MEDCOM - 14446
DOD-027998

i
nsk.
'
CONICAL RECORD --OCiCTO
RDERS For use of this harm, se.e MI 40-66, ih oponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, AND SIGN EA T OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE. PROBLEM NUMBER IN COLUM INDICATED BY ARROW BELOW.
—
PATIENT IDENTiFiCATION
DATE OF ORDER
LIST TIME ORDER
T'"Eig4RF-a Hburr SIGN
NOTED AND
//GI —/

qii/J1111111,
NIJRSING IJNIT ROOM NO.
BED NO.

PATIENT IDENTIFICATION
DATE OF OR
NURSING:UNIT ROOM NO.
BED NO.

PATIENT IDENTIFICATION
DATE OF OFIDER
TIME OF ORDER

erpt-.63
HOURS

NUFISING UNIT ROOM NO.
BED NO.

PATIENT IDENTIFICATION DATE OF ORDER
E. OF ORDER 7L
HOURS

12-tr-st=1--
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NURSING UNIT ROOM NO.
BED NO.

REPLACES EDITION OF 1 JUL 77. WHICH
DA 4256
,FLP.m7g
4 L MEDCOM - 14447
DOD-027999

„
CLINICAL RECORD - DOtTOR'S ORDERS
For use of this form, see A(3 40-66, the'proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACFi SET

OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORDSYSTEM IS USED, WRITE PROBLEM NUMBEFI IN COLUMN. INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDE
TIME OF ORDER LIST TIME ORDE R
NOTED AND
.0-3 /5-'1
HOUFIS
SI N

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NURSING UNIT
I
NO. BED NO.

PATIENT I DENTIF !CATION
DATE OF ORDER
TI OF ORDER
HOURS

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:NURSING! UNIT ROOM NO.
BED NO.

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PATIENT I DENT I F ICAT ION
DATE OF ORDER TIME OF ORDER
NURSING UNIT
BED NO.

PAT IENT IDE NT IF ICATOAI
)
HOURS
WK/L

NURSING UNIT
j 1
ROOM NO.
BED NO.
r6 6 -

MEDCOM - 14448
DOD-028000

,•
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CLINICAL RECORD - DOtfOR'S ORDERS
For use of this form, see A.F1 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
ir
DATE OF ORDER
TIME OF ORDER LIST Time OF1DEH OTED AND
HOURS
SIGN

NURSING UNIT
ROOM NO.
BED NO.

ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF,__
OFIDER

(b)(61-2-(Ils-e.
HOURS

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NURSING" UNIT
ROOM NO.
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PATIENT IDENTIFICATION
DATE OF OH R
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NURSING uNIT
ROOM NO. BED NO.
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PATIENT IDENTIFICATION
DATE OF ORDER
OF ORDER
HOURS

(6)(6)-(1 /7 ¦Tbl-G3 p T.I I Li°
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NURSING UNIT
BOOM NO.
BED NO.

MEDCOM - 14449
DOD-028001

CLI ICAL RECO -pcittoR'S ORDERS For use oi this orm, see
40-66, the'proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND IG EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS
USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELO1N. •
PATIENT IDENTIFICATION
T/ME OF OFiDER LIST T
ORDER
HOURS NOTED AND GN

NURSING UNIT ROOM
NO. BED NO.

PATIENT IDENTIFICATION
DATE OF ORDER
TIM
_HOURS

_NURSING; UNIT FlOOM NO.
BED NO.

PATIENT IDENTIFICATION
DATE OF ORDER
RDER
HOURS

NUFISING uNIT
ROOM NO.
BED NO.

PATIENT IDENTIFICATION
TIME_ OF ORDEFI
2424)2)
HOURS

NURSING UNIT
ROOM NO.
BED NO.

MEDCOM - 14450

DOD-028002

)
".. . ... • .

CLINICAL RECORD - DdeTOR'S ORDERS
For use of this form, see AXI 40-66, Me 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 IIYDICATED BY ARROW BELOW.
•

PATIENT IDENTIFICATION
DATE17
TIME OF OR sti LIST TiME OR
NOTED ND
i-000ns
SIGN

WO-2--
NURSING UNIT
PATIENT IDENTIFICATION
(b)(6k-1

NURSING/UNIT
PATIENT IDENTIFICATiON
NURSING UNIT
ROOM NO.

PATIENT IDENTIFICATION
NURSING UNIT
noom NO.
BED NO.

MEDCOM - 14451
(12)(6)

DOD-028003

oft'u'r .\414'
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6.0‘tk.
46Y

INICAL RECORD - DD. OR'S ORDERS
For use of form, see Ati 40,6 e proPonent agency is OTSG
THE DOCTOR SHALL RECORD DATE. TIME AN SIGN EACH T OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN DICATED BY AFIROW BELOW.

PATIENT IDENTIFICATION LIST TIM
ORDER
NOTED AND
SIGN

TI
NURSING.'UNIT
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
BED NO.

MEDCOM -14452
DOD-028004

-4/
CLINICAL RECORD 00C1Q(1":; ORLIEK.ti,
of In.s h;rnb. A/3 40-6G,
filo f .1. ¦ ;
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M IS USED. vvi-I 11 E t p., .
AA NUMEIER IN COLUMN INDICATED BY AHROW
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ICA /11..)N

DATE 01, 0110€1•1
1 IME • :4;7
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NUI-1!.,..N6 UN! r
BED NO.

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IDEN1IFICATiON L-44.4(
OF OFIDEF1

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MEDCOM - 14453
DOD-028005

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 TI E ORDER ifZIC) HOURS
NOTED AND SIGN

ro'fil
q
( b )

NURSING UNIT
BED NO.

PATIENT
IDENTIFICATION

DATE OF ORDER
TIME OF ORDER
0/
HOURS
(6)(0°V

NURSING UNIT ROOM NO. BED NO.
TIME OF ORDER

DATE OF ORDER
PATIENT IDENTIFICATION
HOURS
-41111p
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NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
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NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF .1 JUL WHICH MAY E
D A 4 2 56
, nr 9

MEDCOM - 14454
A it (46)—v (.)( 6) —2--

CLINICAL RECORD DOCTOR'S ORDERS
r use of this form, see A 0-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TI ND SIGN E CH SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER I COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME
ORDER
NOTED AND

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-SIGN
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NURSING UNIT ROOM NO. BED NO.

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PATIENT IDENTIFICATION DATE OF OR T, ME OF 0
7--7-c-n 6.3 . • 06 2-6
HOURS

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NURSING UNIT ROOM NO. BED NO.

PATIENT IDENTIFICATION oz, -T OF ORDER TIME OF ORDER
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PATIENT IDENTIFICATION DATE 9F ORDER, TIME OF ORDER
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,
NURSING UNIT ROOM NO. BED NO.

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA ,FA°F.R.m79 4256

MEDCOM - 14455
DOD-028007
(b)(6)-2--

CLINICAL RECOR CTOR'S ORDERS
For use o forrn, see 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIG 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

f
ORDER

2-3 03 /.0-zrz' NOTED A
HOURS SIG
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DATE OF ORDE TIME OF ORDER
OideAd
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PATIENT IDENTIFICATION
a 7/e .741 e-e /a

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/OS /v --"--

PATIENT IDENTIFICATION
HOURS

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NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY SE
4256

DA ,FAcr:479
MEDCOM - 14456
DOD-028008

/1 tht6i / (b)(6)--

CLINICAL RECORD -TOR'S ORDERS
s form, see AR 4 6, 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 Li TIME
OR ER NOTED ND
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HOURS SIGN

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PATIENT IDENTIFICATION DATE OF ORDER TIME OF OR
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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BED NO.

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REPLACES EDITION OF 1 AIN 77
DA 4256
IFArRN;9

MEDCOM - 14457 kr2 '6LA:\ 03 e, vt %calk!
DOD-028009

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 T/ME ORDER
NOTED AN
Ar--"O
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PATIENT IDENTIFICATION DATE OF ORDER
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ev Art r(/77 6, /ej_ V,Ic-(4)10 --a-

REPLAC MEDCOM - 14458
ICH MAY BE USED.

DA 4256,FATiRm-,9
DOD-028010

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 LIST TIME
TIME OF ORDER ORDER NOTED AND
HOURS SIGN

_ . .
( L ' . 9 C---7-/k.)& -1 4-0 L.- I 1,-.., A
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CY.IME OF
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PATIENT IDENTIFICATION DATE OF
*13*
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HOURS

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(.07,
FORM

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
1 APR 79

4256

MEDCOM - 14459
DOD-028011

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 TIME OF ORDER LIST TIME
ORDER NOTED AND6-5 /e SIGN
HO RS

(b)(6) NURSING UNIT ROOM No. BED NO. /CY PATIENT IDENTIFICATION 1¦119 (W(6 )-V DATE OF ORDER (WO TIME OF ORDER rd (bro,2, 6e2 OA) -HoURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER 6 H URS r6)(6)-
NURSING UNIT ROOM NO. BED NO. (12)(6)
PATIENT IDENTIFICATION ROOM NO. DA IFArp,"79 4256 NURSING UNIT V.Art Dte. 4241,4 74-e. e 44 r d OF ORDER TIME BED NO. EfrilMZEINICrwilli MEDCOM - 14460 trire;-war4, ForREPLACES ED HOURS

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 •IICATED BY ARROW BELOW.
124.14p14 IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME ORDER
NOTED AND
HOURS SIGN

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PATIENT IDENTIFICATION DAT 0 ORDER
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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DA iF:pr79 4256 MEDCO -
DOD-028013

(
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 HY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TimE or-ora OE R LIST TIM ORDER NOTED AND
oi Au6c3 ae-1-/(
HOURS (V 6 ) - I/ SIGN
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PATIENT IDENTIF !CATION DATE OF ORDER TI ER
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PATIENT IDENTIFICATION OF ORDER TIME OF ORDER
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7 X() —AM,
REPLACES EDITION OF 1 JUL 77. INHICH MAY BE USED.
DA FAcgm79 4256
MEDCOM - 14462
DOD-028014

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 ARROVV BELOW.
PATIENT IDENTIFICATION DATE OF ORDER LIST TIME

TIME OF ORDER ORDER NOTED AND
HOURS SIGN

ica, 4-7 (,44 efW (b)(6)-y A —(s4ni ot-r
-- e— A/5

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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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HOURS

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HOURS
=
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/(74)4 / 10(P/
REPLACES EDITION OF 1 ICH AY BE uSED.
4256

DA ,FA0pRF,m79
MEDCOM - 14463
DOD-028015

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 PFIOBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOVV.

. PATIENT IDENTIFICATION DATE OF TIME g -LIST TIME
ORDER
NOTED AND
SIGN

PATIENT I.DENTIFiCATioN
PATIENT IDENTIFICATION
/1/

611b.)-
_ FORM REPLACE DITION OF 1 JUL 77, WHICH MAY BE USED. , APR 79
4256

s} U.S. GO' 710
MEDCOM - 14464
DOD-028016

CLINICAL RECORD - DOCTOR'S ORD'
if this form, see AR 40-66, the proponent alit OTSG

THE DOCTOR SHALL RECORD DATE, ..A4E AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFMATION + DATE OF ORDER TIM7 OF ORDER LIST T E
Zzg
ORDE
NOTED D
HOURS

C-7rEP°3
SIGN

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(b)to N . ,,

NURSING UNIT ROOM N BED NO.
IC
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PATIENT I DENTIF !CATION IAA. ' DATE 0 DER 15_,, r AP eu,._ &,.. a_ • OF ORDER (03/ HOURS it_
6
(b )(6:62-- VI (:)(6)--
PATIENT IDENTIFICATION 17)(C firNURSING UNIT c.)A42 BED NO. L'-'n—r3F C;F7 TIME OF ORDER (1210

rti.(6) _ye E D No.

NURSING UNIT ROO/M
DATE OF ORDER TIME OF ORDER
HOURS

NURSING UNIT ROOM NO. .BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA ,FArAm„ 4256
•

MEDCOM - 14465
'_INICAL RECORD - DOCTOR'S ORDET
For this form, see AR 40-66, the proponent agent SG

THE DOCTOR SHALL RECORD DATE. TirnE AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TiME
ORDER
NOTED AND

PATIENT IDENTIFICATION ATE OF ORDER TIME OF ORDER
HOURS
— SIGN

67E(M 6)(0 -2 07s3-
16)16) -1
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PATIENT IDENTIFI TI N DATE OF ORDER TIME OF
..,k. ORDER
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HOURS
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HOURS
1/14; T pz, y )46z_ /6c/ /DO 4 75
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NURSING UNIT ROOM NO. BED NO.
,

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REPLACES EDITION OF 1 JUL 77. wHiCH mAY BE US
DA 4256
,FAum,9

MEDCOM - 14466
DOD-028018

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
113)(6) '--L)
1:0-
NURSING UNIT ROOM NO.
1 (..) IA) (
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
.
NURSING UNIT ROOM NO.

DA 4256
1FAcgm79
BED NO.
REPLACES
BED NO.
BED NO.
BED NO.

DATE OF ORDER
D‘Oci 3

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(WO--2--
DATE OF ORDER
DATE OF ORDER
DATE OF ORDER
Forrinig OF 1 toI 77 IAIMICH
MEDCOM - 14467
TIME OF ORDER
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HOURS
TIME OF ORDER
HOURS
TIME OF ORDER
HOURS
MAY BE USED.

LIST TIME
ORDER
NOTED AND
SIGN

.
-441,

411111k
la

THERAPEUTIC DOCUMEIOTATION CARE PLAN (NON-MEDICATION)
For use of this form, see AR 40-407;
INIl7AL PROPER COLUMN FOLLOWING EACH COMPLETION

^ A'., 1 v. 1 P.^r1
2ZUe--2 .L „
a°*^•
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
,D 8 9 .10 11 12 13 14 15
E 16 17 18 .19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM . 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. -USAPA Vi .00
MEDCOM - 14468

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THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(NON-MEDIC4770N)
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Date Nurse SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
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Nurse

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USAPA V1.00

MEDCOM - 14469
(Alta)(6)-; fz/uzeiro,

0 A
THERAPEUTIC DOCUNItNIATION CARE- PLAN (NON-MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407; Mo. Yr. 2003 VEJUFY BY IMITALING IMTIAL PROPER COLUMN FOLLOWING EAC7.1 COMPLE770N
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PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 22 23
N 24 01 02 03 04 05 06 07

USAP;

EDMON OF 1 DEC 71 MAY BE USED.
DA FORM 4677, 1 OCT 78
MEDCOM - 14470
Aii (h)(6)
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MEDCOM - 14471

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CLINICAL RECORD
Far use af this form, see AR 40-407; ­
VERIFY BY INITUUNG
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ORDER CLERK/ RECURRING ACTIONS,
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PATIENT IDENTiFICATION:

ACTION TIMES --
t-pW((b)A) -
USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 -23 N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. LtSAPA V1.00
MEDCOM - 14472
DOD-028024

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(

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATIOIV)
CLINICAL RECORD For use of this form, see AR 40-407;
Yr. 2003

the cora • anent sr!, is the Office of The Suraeon General.
VERIFY BY INITIALING '4';:itti INITIAL PROPER COLUMN FOLLOWING EACH COMPLE770N
kl=t
DATE COMPLETED

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DATE NURSE FREQUENCY. TIME

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