Medical Report: Iraqi Male, Baghdad, Iraq re: Multiple Gunshot Wounds to Legs and Pelvis

ATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
l'll­
aSTER NUMBER Fust,
GRADE
(b)(6)-4
AUE ErTNACE RELIGION
LENGTH OF SVC ETS
ASH
13. ORGANIZATION
14. WARD
mo-4
/ay /
S. RATING' 17 DEPT.!
18. BRANCH/CORPS 19, UIC/ZIP
20. TYPE CASE
DSC, BEN
1,.1...Er:E 0- ADMISSIOEI:AUTHORITY FOR ADMISSION
22. 1110016MMIN.23. CLINIC SERVICE.
-a—Ct.713 — CI' EMERGENCY ADDRESSEE
25. TYPE DISPOSIMON 26. DATE . DF DISPOSITION
EMERGENt , ADCRESSEE !Include ZIP Code) 27b. TELEPHONE NO.
Y 30.
DATE OF INTIAL
Iraq ADMISSION
N ArminrsraA . M.1 DATA.
ee.ruR).
11,•;;;NOSES OPERATIONS AND SPECIAL PROCEDURES
1774
LODI
35. Total Days This Facility
b OTHER DAYS CONY. LV/COOP SU PL M CARE DAYS CARE DAYS
zJ
3G. Toil Days All Facilites
•,, b
01-TER DAYS [c.
CONY. LV/COUP SUPPLEMENTAL BED DAYS
CARE DAYS
CARE DAYS
,b613)-2
(MIT
S :NATI IRe Cl rIn b)(6)-2
13-e M , X IA Fctre RALIvaYmEoN
MEDCOM - 5148
ADMISSION REMARKS
ADMITTING OFFICER
32. UNITS OF WHOLE BLOOD ,
COMPONENT TRANSFUSED

Check it Continued on Reverse
I ififiAL §lEg BAY§ 1
2-
TOTAL SICK DA YS
USAPPC VI 10
DOD 12360

-
-
..'ATIENT TREATMENT RECORD COVER SHEET
For
OSC of this form, see AR 40 ­
400; the proponent agency is OTSG
•••\IFil.6
(b)(6)-4
RsC 7. RELIGION •
4.4_021 b)(6)-4
zip I;
GEN
•
..• -4DisusSi(N'31 Ii HORITY P OP ADMISSION
1 •:I" p\AERGVNCv ADDRESSEE
'
roc.li,de ZIP Codel
LENGTH OF SVC 9. ETS
13. ORGANIZATION
16. GRANCHICORPS 19. 1..11C/ZIP
22. HOURS OF
ADMISSION
"-C17131
25. TYPE OiSPOSiTiON
276.
TELEPHONE NO.
b)(3)-1
Iraq
.1Pi:HATiONS AND SPECIAL PROCEDURES
/
77 57 ,
.35 foial Days This Facility
h DAY:, ; I OTHER DAYS
GRADE ADMISSION
1
14. WARD
tA
20.
TYPE CASE
23.
CLINIC SERVICE '
26. DATE. OF DISPOSITION
-49
2B.
DATE OF THIS AUNWIT;W: OFE!t":EP ADMISSION
4jUwo
30. DATE OF INTIAL 32 UNITS OF I-/HOLE 31.000
ADMISSION COMPONENT
Che ,A C.011;01lligi 011 .r
TT CONV. LV:COOP A.
SUPPLEMENTAL e. BED DAYS
CARE DAYS
CARE DAYS
L./
,.6 Total Days All Facilites );i-i[:i•i 616.;:s
Ic:. CONV. LV/COOP
CI. SUE LISMTAL e. BED DAYS
CARE DAYS
b)(6)-2 SI
0(6)-2
b)(6)-2
X
)A-F0dti
PY1
31.YRUEON
MEDCOM - 5149
DOD 12361

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
MI (S3141 or Otherl
LAST FIRST
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DEPART/SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entries, pare: Name - lest, first ...middle; REGISTER NO. WARD NO.
• .i.i,i ID No or $SN: Sex: Date of Birth; Rank/Oracle) ' rb)(6)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99) Prescribed by GSAIICMR FPMR (41 CFR) 101.11203(b)(1 0)
MEDCOM -5150
DOD 12362

DATE NOTES
Ow

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FPI LEX y Printed on Recycled Paperi STANDARD FORM 509 (REV. 5-49) BACK MEDCOM - 5151
DOD 12363

MEDICAL RECORD PROGRESS NOTES DATE
PRE OPERATIVE EVALUATION
icAlck.-nrikr.,4jz Proc. Planned: .TAFgo evac, ott, Anesth: Anesthesiologist:i Surgeon: Anesth. Risk Classification: General Diagnosis: i±c_ij
..i.
Vital Sians:
Physical Exam Highlights:
Procedure & risks discussed with patient: iYESiNO
Prognosis:

`74
Signature POST OPERATIVYKNOTE
Pre-Operative Dx:i4 Tz A V Post-Operative Dx:iEA pi._ IIVJ I1G I . A I .. I ' (b)(6)-2 1 4,...1,4-t, 1 PIu.,l,JW G. ' 0 ' Oruloiroc.1, ,‘,, _ • . p – , rA dy241Aige 111,1 "...GI . fia
—irgeOn : b)(6)-2Si1.1 ii de,,,A,,. .........—iillis;___g)___t_akP'i
.
Findings: 0 1. a -4.19 CI A A t.t .1 t944.j
1.

2.

3.

4.

5.

6.

EBL:i I/O: Tissue sent to lab: Prognosis:ir
,7
Plan: pet,/ e`e. higte '70ilet,' c7L 4C-,...44;
1 li A'67 t-10
)c-
i (b)(6)-2 VYt rt/ CD DJ t VCS. .
(b)(6)-2
Signature
(Continue on reverse side
PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first, middle; I WARD NO. grade; rank; rate; hospital or me Ica lam try)
VI
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5 -.99)
Prescribed by GSA/ICMR FP14R (43. CFR)I0 I -11 203(8)(10)

M EDCOM - 5152
DOD 12364

NOTES
DATE
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A • a
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(b)(6)-2
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PAPT Rfir IICNR FPI LEX 0 Printed on Recycled Paper STANDAIr ":""ancng it REV. 5-991 BACK
b)(6)-2

MEDCOM - 5153
DOD 12365

AUTHORIZED -FOR.IXICAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES

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No
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
I
ISSN or Other/
LAST FIRST
ri,
DEPART./SERVICE HOSPITAL OR MEDICAL: PA ...ILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: IFor typed or written entries, give: Nome - lest, firer. 'toddle, REGISTER NO.
WARD NO..
ID No or SSN; Sex; Dote of Birth; Ronk/Grade!
PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5.99) Prescribed by GSAIICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 5154
DOD 12366

NURSING NOTESi
CLINICAL RECORD (Sign all notes) •
HOUR OBSERVATIONS
DATE
P m Include meditation and treatment when indicofad
A.M.
1 1 105 / MK N-amked L rel. littlia b,. Sek' 70, aktua evt-401, 014
.atiottitiftit, act/laid— IOD * e 4,,,. v_ tAtty
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:b)(6)-2
Continue on reverie ride
PATIENTS IDENTIFICATION
(For typed or written entries give: Name—la„ /in–, REGISTER NO WARD NO. middle; grade; date; hospital or medical facility)
:b)(6)-4
NURSING NOM
Standard Form 510
General Services Administration and
Interagency Committee on Medical Records
FPMR 101-11.806-8—October1975

-_
510-109i
MEDCOM - 5155
DOD 12367
CLINICAL RECORD I NURSING NOTES (Sign all notes)
HOUR OBSERVATIONS
DATE A.M. P.M. Include medication and treatment when indicatedf

oce____
6‘10,7 1 t°71 Ar‘ ezrAJ

4. al
I I'Malt • 0 4 a
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PATIENT 5 (For typed or written entries give: Name—le ts, firs:, middle; grade; date; hospital or medical facility) Continue on reverse tide REGISTER NO. WARD NO.
(b)(6)-4 NURSING NOTES Standard Form 510 General Services Administration and Interagency Committee on Medical Records FPMR 101-11.806-8—October 1975 510-109
MEDCOM -5156

DOD 12368

MEDICAL RECORD PROGRESS NOTES DATE
PRE OPERATIVE EVALUATION
General Diagnosis:i Proc. Planned:i Anesth:
Anesthesiologist:i Surgeon: Anesth. Risk Classification:
..i.
Vital Signs:
Physical Exam Highlights:

Procedure & risks discussed with patient: iYESiNO
prognosis:

Signature POST OPERATIVE NOTE
a 1 ,p .) i-,00 /- Pre-Operative Dx:i e.ib.„•,.... A. Post-Operative Dx:i5 A 4-Anesthesia: Procedure: Surgeon: /:0( (b)(6)-2 R 4/14.0274 ,k' /X il-e-twt -g6)-2tr. 7;4 ie,
Findings: ,,. -(14 (­CI‘.._....i.--
. Ar
.
3.
4.
5.
6.

EBL: 110:i Tissue sent to lab:
Prognosis:
1(---
Plan: j'4 0 (.(--di9 , t-ti c,
(b)(6)-2
Signature
(Continue on reverse side) PATIENT'S IDENTIFICATION(For typed or written entries give: Name-lost. lirsi. middle: I REGISTER NO.i WARD NO. arade: rank: rale: hospital or medical leicilitv)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5-.99)
Prescribedby GSA/IC M R FPWIR (41 CFR) 1 0 1-I 1.203(3)(10)

MEDCOM - 5157
DOD 12369

b) (3)- 1

l'A I ,1 0 I I)
Patient Profile
b)(6)-4

Allergies Vital Signs Activity
(..‘ 1 1 MI) lor:
Il 1 3 /_____
R R ____ Dressin 7 Chan les
S1)02 _ _
Temp
LIOP
Fl u id
—
Mode
Rale
I YI gni INIs Daily Labs/Xrays/Procedures

ONE TIME ORDERS

MEDCOM - 5158
DOD 12370

TE WARD - 24 HOUR FI.,

1800 1900 20:00 21 00 23 00 0:00 1:00 3:00. 4:00 500 6:00
iN

V% ¦.¦
Is ZZ

•
L.

(CD. I
ifIXD(\ re
glabellar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus glabellar tap or loud auditory stimulus
ZOO 100 100 170 160 150 140
160
120 110 100 60
. ea 63 so 53 40
ao
10
Temp
MEDCOM 5159
FLTHOSPPNCLA 5320/1 (1/03)
DOD 12371

(b)(6)-4
(b)(3)-1
Addressograph: 7:00 Imo 900 1000 11:00 12:00 1300 1400 15:00 16:00
(b)(6)-4
Sp02
Respirations

Date: L-1 / f
Allergies

Diagnosis
Age:
DOB:

4 §IGNATURE
00
b)(6)-2b)(6)-2
No 6 Or
(b)(6)-2 (b)(6)-2
60
so
.
30
20
Temp • •
`'l c' .-
NI,„5 f()On
(

boa
PctCki C.0-1

PO
NG/TF

F-
Q
Other
2

Cummulative Intake
Urine Volume
Emesis
NG Residual/sump

o. Bowel Movement
I-
=
0
OTHER
Cummulative Output
RAMSEY SEDATION SCALE: 2 -Cooperative. oriented and tranquili 4 -Brisk response I 1 -Pt. Anxious and irritated or restless 3 -Responds to commands onlyi 5 - Sluggish response
`Medicated
Dose / Route
Intensity (1-10) Pre/ Post Med

Sedation Scale
BATH PARTIAL/COMPLETE
2 ACTIVITY(Tum L, R. B. ch. amb)
3 IV Site CD? 02 hrs

01
IV Site CM? 02 hrs
TCBD
2 Wound care

Lar=rir

MEDCOM 5160
DOD 12372
c,
J )
,,;,
00:020M4K, I Vifilla.41,,i("M-.fir'iX/ i Level of Consciousness 14 e .= r-N,i q s, 5 „-----
-r
, Oriented to: Person 4 Place 4 Time K p IC=P:f i
e--ICa----
Responds to: Verball PainiUnresponsive b)(6)-2 —
Pupils RiL

Size /
4 1
Motor Strength S = StrongiUpper L R
Extremities: W = Weak ,5-
TR = Trace

I 3.I i1I-.III .61
t -:
A = Absent Lower
See Narrative
-Pulses RiL
frA q mum
Radial Posterior Tibial
Femoral Mil Dorsalis Pedis
IIMI 71---
+ = Normal - = Weak 0 = Absent
Rhythm: Ectopy:
Murmur: Rub: Si: S2:
Neck Veins:
Edema:

See Narrative
Breath Sounds: LAClear Bilat
Location:

Crackles /Rales: Dim:
Wheezes: Absent:
Rhonchi:
MICough: Productive/ Unproductive: ;W: Sputum: Color and Character: Tubes: MI ET L, j Trach
Size' Location:
02: Q Canula U Mask
Chest Tubes:
See Narrative

Observation:
Auscultation: it
Palpation: 4/'..1-e0141 162
Stool: . IncontinentiFormed Soft

. FrequentiE Liquidi•Hard
km-
Tubes / Bags / Suction / Drainage:
See Narrativei•iNGT Placement
VoidiUrine: Color/C erecter

1 ?Sow
Catheter: JJi
1 ff.;
Other:
See Narrative
Color / Turgur I Temperature I Mois pre

(I
..., Incisions I Dressings I Leirons I Dermal Uiers
4 ii i kg.isk, 1„o t ..‘
. .
.,, i ,...., v. a M.... ,e MEDCOM - 5161 I

DOD 12373

3
Jr

t1C1 910 IT, "-4-t 166tai -Dt ---r i--k, •S F..x -i--0(E.7..,.. (\NJ Level of Consciousness v E,13,ca_ a1/4.5E..5 "1-"I C.i-Nr-'1 ,("" rt-..,c 5.1--:11-Oriented to Person Place Time ---rrs• r. 07 1-0 "(::::-E_Tr",
Responds to: Verbal Pain Unresponsive
Pupils RiL --2L.

9 ....z.e...1...-pv.-,%Z• Size / Reaction: I ,2_. 14 Hz iir-7 cyi-• 0 c. enr.....2LLI,Tnr.
R iii
Motor Strength S = StrongiUpper feN '
A¦.:11-111Vi r
1 remities: W= Weak 5 I
TR = Trace
A = Absent Lower
aSee Narrative
Pulses RiL R

Radial .--i--r Posterior Tibial ,„.4. Femoral Dorsalls Pedis 4-4-
+=Normal - =Weak 0 =Absent
7,
,,, Rhythm: Ectopy: a Murmur. Rub: S1: S2:
at Neck Veins: -ii-A--r-Edema:
riSee Narrative
Breath Sounds: ISj Clear 12KI Bilat
Location:

Cracides /Rales: Dim:
Wheezes: Absent:

Rhonchi:
Cough: Productive /Unproductive:
Sputum: Color and Character:

at
I4-'44 Tubes: NM ET 0Trach
Size: Location:
02: Canula Li Mask
Chest Tubes:

1
See Narrative
Observation: F c_ f i -"T
Auscultation: _4- 14 (-0
Palpation: J r DI ro-V--cme.:1-
Stool: IncontinentiFormedi.Soft
Frequenti.Liquidi.Hard .Diet:
t.
Tubes / Bags / Suction / Drainage: 14,
See NarrativeiIi1 NGT Placement
LiVoidiUrine: Color / Character

Catheter: Other: See Narrative Color I Turgur / Temperature I Moisture .t4.5.,q.1-z;;)-1 Pior_ -DZ., L ...., Incisions / Dressings I Leisions / Dermal Ulcers
Em( F 1 4.F-5 ON 13O1n-1
L66-­
)A
I See Narrative MEDCOM - 5162

;:_-(_ --r-t-e t_q..o'S
(--.F..1:21PrIn ¦4:1
b)(6)-2
arm_
b)(6)-2
DOD 12374

b)(3)-1
Addressograph:
(b)(6)-4
Sp02 Respirations
20C
lea
Date: Li /Psi 03 17 Allergies '
60
$0
Diagnosis 40 Age:
120
1 DOB:
110
7-) yGNATURE
100
(b)(6)-2 (b)(6)-2 60
(b)(6)-2b)(6)-2
60
so
40
30
20
Tern p
,„5 lour)
/000 2,u pactel cA,11
PO NG/TF
Other
Cummulative Intake Urine Volume Emesis NG Residual/sump
n. Bowel Movement
0
OTHER
Cummulative Output
RAMSEY SEDATION SCALE:

1 -Pt. Anxious and Irritated or restless Medicated Dose / Route Intensity (1-10) Pre / Post Med
n.
Sedation Scale
BATH PARTIAUCOMPLETE ACTIVITY(Tum L. R. B. ch. arn13) IV Site CDI? 02 hrs
co IV Site CDI? 02 hrs
a
TCBD Wound care
700 900 10:00 11:00 12:00 13:00 14:00 1500 1600
crl
I to
9c1:3
sr
2 -Cooperative, oriented and tranquil 4 -ensk response k 3 -Responds to commands only 5 - Sluggish response

41:1
1;14 4A
==•._11-,9

MEDCOM - 5163
DOD 12375
011 - 0 igliite. -S:40? .
Level of Consciousness Orientedto: Person iIt.-PlaceiTime X Responds to: Verbaikg_ PainiUnresponsive
Pupilsi RiL
Size /iI 7) 14 6 I 5 /I a I Motor StrengthiS = StrongiUpper L R 3 "D
'' Extremities:iW = Weak
L 7--
TR = Trace A = Absent Lower
erg..
g

/70 - 0.r.),-1,4-4 1-1;-..... „ill ii,:-.r.L PI--reG/P,6 1-$1;04, 4-1-`,4-4.z.,,,, , Ati, ,52, ,_t p,...„4_.
th,kr..91-- -,,-, v-r-a-el •i177x—s-g...:,-- A 0, 5
14(6)-2
,s104.r.e...ttz J J r'?
1--) 7/0i' Aia•-,-iSC, P:i 7/‹.ie,. /-..-e-/.74, (Z)
FA. 8/„,d. ,..,,„..,_,..-44 si-k A "4-4-..„..C) ea-40 Ct-. P-4. . A-4-e, 4-- "...d_ 4.1,./.6„ 1.4e .04 „:.,„;. ),I.,,
(6)-2
c.....• i// C.....-,,I:n ...,f____i4.0, ni , • I-1.-r-
. -
See Narrative
PulsesiRiLi R
Radial -4- + Posterior Tibial 4- 4_
Femoral 4- Dorsalis Pedis A-

+ = Normal - = Weak 0 = Absent
Rhythm: /vs (z._iEctopy: °iMurmur:iRub:iS1:i,..-'iS2:i.--V
,_.
, Neck Veins:_p_jrd--,LLLat j.. Edema:
See Narrative Breath Sounds:iLigl-Cleari[J Bilat Location:
Crackles /Rales: Dim:
.•-;,
Wheezes:i Absent
Rhonchi:
1:21
a Cough: Productive / 2nproductive:
:A.,: Sputum:iColor and Character: .7 ET UTrach Size: Location:
':Sputum:
02: E CanulaiMask Chest Tubes:
See Narrative Observation:i• a..iAi/i\-\ 421
- Auscultation:iGA, a H •-1 ''.re.r---.L. Palpation:ii).i,.....‘ ].% O. P•iP,-. 11.2, nom kiJ.4" Stool:i.IncontinentiLiFormediLiSoft
.Frequenti.LiquidiHard
Tubes I Bags I Suction I Drainage:
See NarrativeiIiIiNGT Placement LiVoidiUrine: Color / Character . Fn i,._( ,/ ic r.kri 4-1 Cie,no
_ ( 7),
4, ,.. Catheter: / cpOther: See Narrative Color! Turgur I Temperature / Moisture
/°6n k./i1,..,-.....-...../. rp, ofa di-" Incisions / Dressings I Leisions / Dermal Ulcers ' wt.., e,, 4-,t- 1,;k7t- L E cire„.1a7. .I
.
See Narrative
MEDCOM - 5164
DOD 12376

j))(6)-4
i i90 lAvoi r ^el P A— I r r\ I k '+-7'174 v z-NE„.zpv c... c_ug s-
Level of Consciousness
Oriented to: Person (1,PlaceC.----Time (----------6 •rAFAS MI S IiPRY

b)(6)-2
Responds to VerbaliUnresponsive IMIEFORZL-
Paini04==frAMMINFAM7/5611ffffail9
Pupilsi R ? eeft.i..- L V
Size / Reaction: El ffil 2 /
Motor Strengthi= Strong Upper

iW = Weak Extremities:
S ill
TR = Trace

A = Absent Lower Ell
n See Narrative
PulsesiRiL R
Radial =CMPosterior Tibial
Femoral INIEM Dorsalls Perils

+ = Normal - = Weak 0 =Aso ent
Rhythm: M?ri . Ectopy:
Murmur: 6 Rub:iSi:
Neck Veins: --x_ch-r
Edema:

n See Narrative
Breath Sounds:iLx-i Clear U Bilat
Location:

Craddes Males:i Dim:
Wheezes: Absent:

Rhonchi:
Cough: Productive (Unproductive:
Sputum:iColor and Character:
Tubes: PET LiTrach

Size:i Location:
02: nCanulai{Mask
Chest Tubes:

Ti See Narrative
Observation: R f)-r
Auscultation:i4_ f_.1
Palpation:i

i\)/) r,. Ornt'rle
Stool: .IncontinentiFormedi11Soft

. equenti.Liquidi.Hard
Diet:
Tubes / Bags / Su g•n I Drainage:

LiSee Narrative . NGT Placement
VoidiUrine: Color / Character

Catheter.
Other
l'iSee Narrative
Color! Turgur / Temperature / Moisture

) 4)t...,rr)
Incisions / Dressings / Leisions / Dermal Ulcers
Nr L . 5r-rihl
7" I See Narrative
MEDCOM - 5165
DOD 12377

1TE WARD - 24 HOUR F
7T (-7)
000 600) 3:00-400 5:00 6:00
18:00 1000 20:00 21:00 23:012 1:CO
22-
200
100
160
170
160
IGO
140
120
120
110
100
SO
AL . ao
70
60
12: 50 ao 30 20
64-#14_1 Temp
IDDO)rc
I glabellar lap or loud auditory stimulus 6 - No r tali° h. gl,heall.. fn' sr l•-le stimulus
iht glabellar tap or loud auditory stimulus

MEDCOM — 5166
m TI-inqPPAIC.1 A timm
DOD 12378

Vf.10TfilOtggtgOara*af3 eN,(..-. "Rr•-•.v i -
,,..-......
te,e,
Level of Consciousness 1-•1 ,,,.iOriented to: Person _4 Place j(_ Time ... •4 457iI C.`4:-V 9r i g ---lic
rs)-2
Responds to: Verbal iPainiUnresponsive
4---
Pupils RiL
Size /

I 3 14/51 3 II 5 1
Motor Strength S = StrongiUpper L R
Extremities: W = Weak
TR = Trace

"i• A = Absent Lower
r--
See Narrative
Pulses RiL R L

..
Radial gm Posterior Tibial rarA
Femoral Mil Dorsalis Pedis

Iril i-
+ ... Normal - = Weak 0 = Absent
Rhythm: Ectopy:

—
: Murmur: Rub: Si:_____ S2: Neck Veins: Edema: tf" 4 nSee Narrative Breath Sounds: LA Clear 11-Bilat , Location:
I Crackles (Rales: Dim:
Wheezes: Absent

t Rhonchi:
4:47
Cough: Productive I unproductive:
FA
1#3-Sputum: Color and Character:
0
Tubes: ET

[_]Trach
o Size: Location:
02:iili Capula LI Mask
Chest Tubes:

See Narrative
Observation:
Auscultation: 4
Palpation: /ii),-,-cok, 6,
Stool: IncontinentiFormed Soft

.FrequentiQ LiquidiQHard
,-,
Tubes I Bags I Suction I Drainage:
IiSee NarrativeiIiliNGT Placement
, ItiVoidiUrine: dolor I Tracter

_ h diet..4 ,_. /
Catheter
Other:
ElSee Narrative
Color! Turgur I Temperature I MoislI jre
iAniv

Incisions / Dressings 1 Lei ons / Dermal Ulf ers
1:4' pi:,,.jo
FiSee Narrative
MEDCOM -5167
DOD 12379

b)(3)-1
Addressograph: 790 840 ism 10:00 111 :00 12:00 13:00 11490 115:00 11a.nn
(b)(6)-4 Sp02
Respirations
LJ Ii
Date: 1—( iq /03
Allergies
Diagnosis
Age: 0
DOB:
SIGNATURE ••¦ 0
b)(6)-2
(b)(6)-2 b)(6)-2

Tem IcJ.
•
PO
NG/TF
Other
Cummulative Intake
Unna Volume
t-= o.I-= Emesis NG Residual/sump Bowel Movement
OTHER
Cummulative Output RAMSEY SEDATION SCALE: 1 -Pt. Anxious and irritated or restless Medicated z Dose! Route a. Intensity (1-10) Pre / Post Med Sedation Scale it 30( 96 2 - Cooperative, oriented and tranquil 3 - Responds to commands only arAL -OM iLloO rel 5 4 -Brisk response t lig 5 - Sluggish response to t
BATH PARTIA1JCOMPLETE ACTIVITY(Tum L. R. B. oh, amb) IV Site CDI? 02 hrs IV Site CDI? 02 hrs TCBD 1/4
Wound care

.AID=r177'1
[
MEDCOM -5168
DOD 12380
TE WA - 24 HOUR FLOW S

18:00 10:00 20:00 2100 2200 2300 0:CO 1:00 ZOO a:ou 400 5:00 6:00
62
V
\f
V
Wig c)N

250 190
100 170 160 150 1171
ao 120 110 100 00 so to
GO 50 10 30 20
Temp
6 - No response to light glabellar tap or lout Stigii81 810111118
t glabellar tap or loud miaow stimulus
iht glabellar tap or loud auditory stimulus
MEDCOM - 5169
FI TI-trIRPPKICti A A17191 (1/flat
DOD 12381

3

1_,f'--
flIci OUI ,l tai',ISib agate v2 --r-.1,--k,.5.E -El )e„ S (\t\i irc.Y-rt-- 1—E.6S Level of Consciousness v E agc4 L_ c.„3-E-25 . •Q r -rs.ffr "-"" 'D clean Oriented to: Person PlaceiTime -1--rs. a.7"i ,
Is Responds to: Verbal PainiUnresponsive Pupils R ?te...e L.. L esme.c. .i b)(6)-2 At Size / Reaction: ;2_ LifilliI fillIMAWL4 _
0 ct raAn.1112111E122---
L Ft III b)(6)
A1 Motor Strength S = StrongiUpper 1111M111111111101ff(ff ,
Extremities:xtremities: Weak 3 5 I
TWR1WT
A = Absent Lower

LC1 See Narrative
Pulses RiL R

Radial Jr--r Posterior Tibial
Femoral Dorsalis Pedis 4.-

+ = Normal - =Weak 0 = Absent
Rhythm: Ectopy:
Murmur. Rub: S1: S2:

• Neck Veins: . 1_6:1--i— Edema: ElSee Narrative
i
Breath Sounds: ilej Clear 1,Xj Bilat •
•-Location:
i Dim:

Wheezes: •
Rhonchi: : •-, Cough: Productive I Unproductive: Absent: a Sputum: Color and Character. Tubes: . ET LITrach Size: Location:
, Crackles lRaies
02: ElCanula L .1 Mask
Chest Tubes:

See Narrative
Observation: F (_.„1 -1--
Auscultation: ÷ 14 (0
Palpation: Nr-, int rrn-1-.-(--le.,-r: ,
Stool: IncontinentiFormediLiSoft

. Frequenti. Liquidi. Hard 14i
0 Diet:
.07 Tubes / Bags / Suction I Drainage:

tei
See NarrativeiIi1 NGT Placement
VoidiUrine: Color! Character

Catheter:
Other:
n See Narrative
Color! Turgur / Temperature I Moisture

LA2-' -,- rz.,^r-) P I 0 L 1)1?_ y .:a Incisions I Dressings / Leisions I Dermal Ulcers EY c'': kF-.5 CSN 13C5-n—r C -6
See Narrative MEDCOM - 5170
As
DOD 12382

TE WARD - 24 HOUR FLOW SHEET

i
18:00 19:00 20:00 21130 22:00 23:00 1:00 2:00 3:00 4:00 -6r00 0:00
q:37 o9fi
160
100
170
160
150
140
130
120
no
100
90
00
70
60
SO
30
20
Temp

t globe liar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus jht glab ellar tap or loud auditory stimulus
MEDCOM - 5171
THr1SPPNIC.1 A R:1711/1 r1m:11
DOD 12383

,b)(3)-1
Addressograph: 700 em 9:00 10:00 -11:00 12:00 113:00 -14.W 11500 1600
(b)(6)-4 Sp02 914 9l•
Respirations I lc
29C
9C
leC
Date: Li —1/03 rc
Allergies
so
Diagnosis ao
A e:
DOB: ICC
110
SIGNATURE 500
(b)(6)-2 b)(6)-2 so
10 1k.
so."
50
40
30
ZO
Temp • —1 1
A
N4 000
-tv Pb Sr)
rn -61A-P
PO
NG/TF
Other
Cummulative Intake
Urine Volume
E Meals
p-m NG Residual/sump
Bowel Movement
a
O OT1-191
Commutative Output
FtAM SEY SEDATION SCALE: 2 - Cooperative, oriented and tranquil 4 - Brisk response ti
1 - Pt. Anxious and Irritated or restless 3 - Responds to commands only 5 - Sluggish response
z Medicated Dose / Route riS
Intensity (1-10) Pre / Post Med
Sedation Scale
BATH PARTIAL/COMPLETE
61 ACTIVITY(Tum L. R. B. ch. amb)
a 4) IV Site CDI? 02 hrs
IV Site CDI? 02 hrs
is TCBD
z Wound care

,
-
,2:T=1!r1
91,-91%• 95 — cfq
MEDCOM -5172
DOD 12384

011.21Zaltrifir.'i10 Ig P. { 0,/,./0 -1....l. Pr/-Prr dam,-,. s...,1-4-9 -Lt. m(e)
rn
b)(6)-2
Level of Consciousness ....,)A go - /24,:-;.......4 ii,..4•71.....r 4 • Oriented to: Person _L,Place Time ,/,iiitri.. p.i. .g 1 .....-at-i....g. 07i
.Z.._ dre­
u-•, i'A.L.gr-J-...4...,.. b)(6)-2
L /
Responds to: Verbal Pain Unresponsive ris•
'a (Neil 'i9...4...1--.T..,-c-e,_"2... •
-a
Pupils ,W„-{4.1,1.,A R L
Size / /
C:1i
Motor Strength S = StrongiUpper

Mill
,.
Extremities: W = Weak
TR = Trace
A = Absent Low!
See Narrative

1
Pulses RiL RiL

ram
Radial Posterior Tibial
MEM
perica ERE.
Femoral Dorsalis Peck
...._ orrnal - = Weak 0 = Absent
Rhythm: Ectopy: Murmur. Rub: Si: S2: 1-Neck Veins:
Edema: •5-A ak L. t-i,,,,•,..—
1-1See Narrative
Breath Sounds: L.....51e-ar LikBilat
Location:
Crackles /Rates: Dim:

Wheezes: Absent:
Rhonchi:
,,
Cough: Productive / Unproductive:
Sputum: Color and Character
Tubes: Iffil ET -Trach
Size:i Location:
' 02: .CanulaiL Mask

l
bw Chest Tubes:
. See Narrative
Observation: f-kk-v
Auscultation:

'iPalpation:
Stool: . IncontinentiLi FormediL jSoft

. Frequenti.Liquidi.Hard
Tubes I Bags I Suction / Dr 'nage:
See NarrativeiIiIiNGT Placement
VoidiUrine:ioir / Character

Catheter:
,ai: i
Other: NW
IiI See Narrative
Color / Turgur / Temperature / Moisture

'fb.rno4J.
Incisions I Dressings I Leisions I Dermal Ulcers

I jellee Narrative
MEDCOM -5173
410
i-Dre --)
•
DOD 12385

• Level of Consciousness v tEr...43A 4--C-L..,E.5 FIRMAiIiAN„ ..i V`ta,
LiiHNIMAIIMA
Oriented to: Person Place Time . 0 ,_011FAIVAILINPAPINI_ _ to x
Responds to: Verbal Pain Unresponsive NWilITM"—IIIR_____fr ILIVIMII
, , ' ,
b)(6)-2
Pupils R L 11/1 . rtg...„
11
Size / Reaction: 1 2—
TIN 2- / M
Motor Strength S = Strong Upper
Extremities: W = Weak
l.r)

R f
L R
TR = Trace
.
A = Absent Lower 5 S
See Narrative

Pulses R L R L
Radial 4 Posterior Tibial
Femoral Dorsalis Pedls A-1,...
+= Normal - = Weak 0 =Absent
Rhythm: Ectopy:
Murmur. Rub: S1: S2: Neck Veins: Edema: nSee Narrative 61 Breath Sounds: W Clear IL Bilat Location:
Craddes /Rales: Dim: 1i 1 :-.-Wheezes: Absent:
Rhonchi:
t...
. Cough: Productive / unproductive:
Sputum: Color and Character.
Tubes: M ET Q Trach
Size: Location:

- 02: 11. Canula 1.1.Mask Chest Tubes:
See Narrative
Observation: rk_, -r
Auscultation: ,.... LA a

Palpation: NOiq+ 5c on-. 1"r3V---1-
Stool: .IncontinentiL j FormediLI Soft
Frequenti.Liquidi.Hard
Diet:
Tubes / Bags / Suction I Drainage:

`
g.4
See NarrativeiL NGT Placement
IVoid Urine: Color/ Character

Y

L
Catheter:
Other.
I

See Narrative
Color! Turgur I Temperature / Moisture
.., cz.,,,..., c.-iry-Not S "1-p , ti, 1C
Incisions I Dressings I Leis ions / Dermal Ulcers

. -t-i-riN2i.44-1t /".2ie. ‘E:7 (.4
-•¦•
See Narrative
MEDCOM - 5174
DOD 12386

ITE WARD - 24 HOUR FLOW SHEET
'moo 19:00 20:00 21'00 223/0 23:00 0:00 1:00 Olt 33)0 4:00 5703 6:00
200
100
lm
170
160
• • .1 160
140
130
120
110
100
so
00
70
60
A 60
40
30
20
q"7 Temp
to0

t glabellar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus iht glabellar lap or loud auditory stimulus
MEDCOM - 5175
FLTHOSPPNCLA 632071 1103)
DOD 12387

VITAL SIGNS RECORD

MEDICAL RECORD
11111111111111111111111111111111111111111111111111•11111
1111111111111111111111111111111
HOSPITAL DAT
111111111111111111111111110111111111111111111 ¦1111111111111111111111•111111
my
rosr.
s zorriennWit
..„...„... TEMP.
lic:111comicilliiiillil40.6C
Fr
'2,0oi111111.11:11111111.1111MMIIIIIIM ° 105'
nxiF 1111=11111111111111111101111111111 40.0° in 10,. MIIIMMIIIIMII 39A° 170 103° INIEMMIIIIM
11111111111110111111111M1111111111111 38.9° C
160i102° 38.3°
111111111111111111111111111111111•11111111111
150i
EIM111111111111111111111111111111111101111 „.r
1,1*
110i
IIIIIIIIINEMMINMIN111111111111 yx
367.0° 1 9r .7° i1 30 96.6°i 36.1° 1
120
SWASS'AreliSSIGS r iit.
110 97°i
111111111110111111111111111MININIMIIIII u
35.0°
10, 11111111MINIMIIIMMINIIIIMIIIIIIN

90i95°i: MINE11111 • IP :. IBM 1111
ao
' N1111111111111111111MIMINIIIMII
70i' Bilv 1111
11111111111CIIIIIMMEINKM

60 IIIIMNIII1111111111111111111111111

50
M111111111111111M1111111111111111111111
10 TRW ( . 6 .111111111:M111110111111111111
RESPIRATION RECORD 01111111111111M1111111111111111111111111111111
1111111111111111111111111111111111111111111111111111111111111111111111111111111111
gal111111111111111111111111111111111111111111111111111111111111111111111111111111111111111
1
111111111111111111111111111
IMO 11111111111111111•111111111111111111111111111111111111111111111111111111111111

14.11.1
d1.111d11111111ffinerin
111111111111111a 11111111111111111111111111
WARD NO.
Bret, (Pot typorl or written
•nttiol give Name -la"•
middle; rank; rats; hospital or nurchc,a1 facility)
PATIENT', IDENTWICATION
VITAL SIGNS RECORD
STANDARD FORM 511 (REV. 949)
Prescribed by GSAMMR FIRMA (41 CFR) 201-45.505 511-113
• 11191— 2131-782/40093
'U.S. P . ,rnment Printing r
MEDCOM -5176
DOD 12388

.....
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAT .
POET.iDAT
WHITH-TEAK DAT L. k )
(‘‘ 1K
19
PULSE
(E)i(•)
. .i. .i. .i. .i. .i. .i. .i.
10r
.i. .i•
.i. .i•
.i. .i• .i• .i. .i• .i. .i. .i. .i• .i• .i• .i. .i•
ISOi104°
•• •• •• •• •' •• •• •• •• " •• ••
.i. .i. .i. .i. .i• .i. .i• .i. .i:
-i• •• ••
.i. .i. .i.
170i

•• •-••
103
.i. • . .i. .i. .i. .i. .i. .i-•• • :iI •. :i. :i. :i: .i. .i. .i. 160i102° 'i• " •
,i. .i• . 'i
.• .•i40.• f. :i. :i. .i. .i. :i. .i. .i•
• • • •• .i• .i• •• .i. . .i• .i. .i. .i. ,i•
150i
101
.i. .i• .i• .i. .i. .i.
.i• .i•

.i• .i. .i. .i• .i. :i1 .i• .i• • • A
140i-
10e
.i. .i• .i• .i. .i• .i.
III
9 . : : : •• . . . .
:i: :Ni? :i. :i. :i. :i.
.i. .i. .i.

130i
99 .i. . VI
98.6
9IP :i: :i•• :i: : i• fillikiMillIll • : NM •
V/ : :
120i
5
n
Eq
.. ..
. .. HIE •••i•• . •
WEIS MEI
wrimmin
..
• : .i.
• .
:
.

Ito
.
Iv o
:
:
100i 96°
'. . . . • . • . • . • . . ,....," : • : :: :: . . .
90i 95 : i1 ..i. .1./ , . , , , , , ,
90
.i• .i. .i. . .i.iII .i. . .i. .i. .i• .i. .i.
• •• •• .i. .i.
• • • • • ill-OP
• 70
. • . • .. . • .. ..
III ...i::
rwriarisE
•'
.i.
GO' .i.
MINIM .i• .i. —
50 :i: IFINEILEIMMIIMPIAMMIZI .i: .i. .i.
1 't . . 111111911/all . . . .
40
mg •,--
.i. 11r-. . • •
!RATION RECORD
Pi
10.000 PRESSURE
Lli,
MGMi1WEIGHTNI /204 ^
lb i 1 /01 :1-'"iti( .°1 It i .6 .

( I. Li C I h C t) Ii:; 'Mc
. _.
PATIENT'S IDENTIFICATION (For typed or written entries giro: Name—last. first. REGISTER NO. WARD NO.
I
Peened epeeisl diet& only when so ordered

middle; rank; rite; hospital or medical facility)
(b)(6)-4
VITAL SIGNS RECORD
STANDARD FORM 511 (REV. 9-79)
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-45.505
511-113

MEDCOM -5177
DOD 12389

MEDICAL RECORD I VITAL SIGNS RECORD
HOSPITAL DAY
POST. DAY.
MONTH-YEAH DAY 0
•• . • . • . . . • . • . . . . , . •. , . INKY TEMP• 1 .1 . i . . . • •• . • . • •. . •
(0) •.
(S) . .
.4.&' •• •• •• -. --•• : : • :
Ni:
. . . • . . • 180 104° • •
170 . . . • . . . • • . . . . .
. • . . . , . . 160 102° Niert . . , . • . • . . . . . • . • . • . •
. • . . . . . . . • . . . . . . . . •
. . . . . . . . . . . . . . . •
150 101°
. . . . . . . . . . . . . . • ••
140 me •• • : . . . • . . . • . . . • . . . . . . . • . -
•
130
99°
98.6° . . . . . . 120 9F . . . -. •: . . . . . . : . . •
. . . . . . . . . . •• . . . . . • . . . •
HO 97° . . . . . .
. • •• ••
100 96°. . • . . . . . . . •• •• . , •. . . •. . • . • i ; : ; : •• : •• •• •. •. . • . . •. . . . . . .
90
95° • . . . • . • •• •• . . •• •• •• . • ••
. •• . . •. •. •. •• . • . . . . . • . •. . . •. •. . . •. •• . • . .
BO . • . . . • ••
70 . . . •• . • •. . . •• . •
• . . . • . • . . . . . . . • . • . . . . . • . .
60 . • . . . • . • •• •• •• •• •• •• •• •• . . . •
. • . • ••
50 •• •' ' '
•. . . . . . . . : :
. . . • . • . • . •
40
RESPIRATION RECORD
BLOOD PRESSURE
HEIGHT: 1 WEIGNT4
PATIENT'S IDENTIFICATION (For typed or written entries give:• Name—last, first, REGISTER . middle; rank; rate; hospital or medical facility)
VITAL SIGNS RECORD
*U.S. Government Printing office: 1989-241-175/80290 STANDARD FORM 511 (REV. 9-79)
Prescribed by GSA/ICRIR
FIRMR (41 CFR) 20145.505
MEDCOM - 5178
ode Eq
I
pauapaoasclaw& Apo Inwppima*imam1

DOD 12390

VITAL SIGNS RECORD

MEDICAL RECORD
11111111111111111111111111111.1.11.11101.111111.11111.1111011111
.......r111111

....iii..11111.111111
HOSPITAL DAT
......1101111111.1011111
.....1:11111111
POST. OAT 1111111111
TEMP. C
11OOMP-YEAR
40.6°
nrola
sermi

10.0°
iffirear
105° ral ' NAM' 39.4°
---(o) Tr°i- 11. 4 PillIBM11111
180 104° IMINUMMIMMI1
INIMEN 38.9°
170 103° 111MMUNIMIUSII
102° MINIMW11 38.3°
leo150 101° 1011111"11111111111111111011
37.6° t4'
11111111111111111MMEIMMIIIMIM
.r i
140 100.
99° MIN0011111011111111MM „
130
1
120 98°
rutiarrovalsan36.1.357
110 97° INIIMIIIMMEMMOMMIIIMMI 35.5 I
35.0°
100 96° 1111111SMIIMMIMMIMMIN U 90 95° 11111111111111MMIMMEINIIMINI
80 IIIIIMMISMIIIMILIMMNIN
MIIMMINIUM
70
MIIMMIIM
60
SO EIMMIIIIIMBISMISMIM 40 IIIIIIIIIIMMINIMMUNIM
11111111111111111111111
1111111111111110111511i11111111111110111111111111111
RESPIRATION RECORD EMIESIWIEWSUINKIMP
BLOOD PRESSURE IMINIMMINICAREEMICIROMEMINNINIMMONI

MOM WEIGSI 111111111111111111111111111111111111111111111111111111111111 ar
Mr II M
WARD NO.
Piarne—last, first,
moolons•as

d iva:
(For typed or written entriea or medical lacilitY)PATIENT'S IDENTIFICATION middle; rank; rate; hospital VITAL SIGHS RECOR
STANDARD FORM 511 (REV. 9-1
Prescribed by GSA/ICMR
,vetment ntpting Office: 1989-241-175/80290

511-11 3 (b)(6)-4 FIRMR (41 CFR) 201-45.505
M EDCOM -5179
DOD 12391

LABORATORY REQUEST FORM
FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS.
FOR ALL OTHERS, CIRCLE DESIRED PANEL.

URINALYSIS Result RBC MORPHOLOGY

Check CHEMISTRY Result

GLU Spec Gravity
BUN pH
CREAT Leukocytes I

NA Nitrite K !Protein CL !Glucose MICROBIOLOGY CO2 !Ketones !Culture Site: Phos Urobilinogen AST Bilirubin !Results: ALT Blood
I

LDH !Hemoglobin
TBIL 1 MICROSCOPIC
ALB Sensitivity:

CK MATOLOGY ce3c.„

TP WBC 60,4
MG RBC 2.03

Pr/ •Akeiiiiirb4
AMYL HGB rior
LIPASE IHCT

C-D a ill clig-10))1
w9PMF MMOMPhRiNg4M MCV 9`r
co
SEROLOGY IRDW t3
MONOSPOT !PLT VS­
wlnam__porwmpv
.___ 1-‘D DIFFERENTIAL ti-c- 3 2_•
PT EUTRO
PTT scc, BAND
VNWOOKOWNWOWEBER META
BLOOD GAS MYELO

b)(6)-2

pH PROMYELO

PCO2 BLAST
P02 !EOSIN°

LACTATE IBASO
BICARBONATE I LYMPH
TOTAL CO2 I MONO
BASE EXCESS INUCLEATED RBC
02 SAT

J b)(6)-4
Patient Name: Location:
(b)(6) -2

FMP/S SN: Provider:
Date:
(b)(6)-4

MEDCOM -5180

DOD 12392

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DOD 12393

vas o

(b)(3)-1
r
ime co-hi Pe-Ere-A
LABORATORY REQUEST FORM
FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRLD TESTS.
FOR ALL OTHERS, CIRCLE DESIRED PANEL.

Check CHEMISTRY Result I URINALYSIS IResult I RBC MORPHOLOGY GLU ec Gravity__ BUN PH
CREAT ILeukocytes
NA INitrite
K !Protein

I

CL Glucose MICROBIOLOGY CO2 Ketones Culture Site: riFios I Urobilinogen
AST IBilirubin Results:
!Blood
!Hemoglobin

MICROSCOPIC
ALB 1 Sensitivity:

CA
LH TOLOGY
IMTORMESIMI1111111
AMYL HGB r. I LIPASE IHCT
MCV
SEROLOGY RDW
MONOSPOT PLT

MPV I

DIFFERENTIAL
NEUTRO
BAND
META

BLOOD GAS MYELO
pH PROMYELO
PCO2 BLAST
P02 EOSINO
LACTATE BASO
BICARBONATE LYMPH

TOTAL CO2 MONO
BASE EXCESS NUCLEATED RBC

(b)(6) -4
Patient Name: _ Location:
(b)(6)-2
FMP/SSN: Provider:
Patient ID: Date:
FLTHOSPPNCLA 651 Oil (1103)
MEDCOM -5182
DOD 12394

(4104t7,0egE_
1;21 (0
LABORATORY REQUEST %.)1R/v1
FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS.
D

FOR ALL OTHERS, CIRCLE DESIRE

Check CHEMISTRY Result URINALYSIS Result RBC MORPHOLOGY
GLU Spec Gravity
BUN pH
CREAT Leukocytes
NA Nitrite
K Protein
CL CO2 Glucose Ketones MICROBIOLOGY Culture Site:
Phos AST Urobilinogen Bilirubin Results:
ALT Blood
LDH Hemoglobin
TBIL ALB MICROSCOPIC Sensitivity:
CA
CHOL
TRIG
CK HEMATOLOGY
TP WBC
MG RBC
AMYL HGB
LIPASE HCT
MCV
SEROLOGY RDW
MONOSPOT PLT

ANINftagliqq@MR MEW

,

TION DIFFERENTIAL

1 2.,41.EUTRO
META

N-‘

BLOOD GAS MYELO
pH PROMYELO
PCO2 BLAST
PO2 EOSINO

LACTATE BASO
BICARBONATE LYMPH
TOTAL CO2 MONO
BASE EXCESS NUCLEATED RBC

02 SAT

(6)-2
n—r-
Patient Name: let") Location:
(b)(6)-2
M(6)-2

FMP/SSN: Provider:
Dat O A eri-61
6go

°\17 LOWu-f-PAr MEDCOM-5183
DOD 12395

ed

LarIORATORY REQUEST kORM

FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS:'
FOR ALL OTHERS, CIRCLE DESIRED PANEL.

Check CHEMISTRY Result I URINALYSIS Result 1 RBC MORPHOLOGY

GLU ISpec Gravity
BUN ,T.T
CREAT Leukocytes
NA ( Nitrite

K CL 1 Protein I Glucose !MICROBIOLOGY
CO2 1 Ketones Culture Site:
Phos AST UrobilinogenI Bilirubin Results:
ALT LDH TBIL I BloodI Hemoglobin MICROSCOPIC
1 ALB Sensitivity:
CA
CHO L
TRIG
CK HFrMATOLOG
TP WBC MC a-SLIFD
MG AMYL RBC HGB SDEACaa,t)
LIPASE HCT
MCV
SEROLOGY. RDW
MONOSPOT_ PLT
MPV
DIFFERENTIAL
P . 2 . A I NEUTRO
PTT 7 1 BAND
REN: META
BLOOD GAS MYELO
pH I PROMYELO
PCO2 P02 LACTATE I BLASTI EOSINOI BASO
BICARBONATE I LYMPH
TOTAL CO2 BASE EXCESS MONO1 NUCLEATED RBC
02 SAT

Patient Name: PPL Location:
FMP/SSN: (b)(6)-4 Provider: (b)(6)-2
Date: 527J­/3 00

MEDCOM- 5184
DOD 12396

(b)(3)-1
0151
LABORATORY REQUEST FORMi
FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS.
FOR ALL OTHERS, CIRCLE DESIRED PANEL.

Check CHEMISTRY RBC MORPHOLOGY

MM-2
BUN PH
CREAT Leukocytes-.. NA Nitrite K Protein CL Glucose MICROBIOLOGY CO2 Ketones Culture Site: Phos Urobilinogen AST Bilirubin Results: ALT Blood LDH Hemoglobin TBIL MICROSCOPIC ALB Sensitivity: CA CHOL TRIG CK H. TOLO
TP WBC
MG RBC L76
AMYL HGB
LIPASE HCT

MCV pactIC 1971 RDW 13.6 PLT IS" MPV 1.6
DIFFERENTIAL

NEUTRO
BAND
META

BLOOD GAS MYELO
pH PROMYELO
PCO2 BLAST
PO2 EOSINO

LACTATE BASO
BICARBONATE LYMPH
TOTAL CO2 MONO
BASE- EXCESS NUCLEATED RBC
02 SAT

(b)(6)-4

Patient Name: Location:
b)(6)-4
FMP/SSN: tProvider: MM-2
67 API-e)5.10-185
Patient II): Date:
FLTHOSPPNCLA65 10/1 (1103)
MEDCOM -5185

DOD 12397

+-col-09'1a
r 5 T.R6,s0
MPP
LABORATORY REQUEST FORM
FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS.
FOR ALL OTHERS, CIRCLE DESIRED PANEL.

Check Result RBC MORPHOLOGY

CHEMISTRY Result I URINALYSIS

GLU Spec Gravity
BUN pH

I

CREAT Leukocytes...

NA Nitrite
K Protein
CL Glucose 'MICROBIOLOGY
CO2 'Ketones 'Culture Site:

Phos Urobilinogen
AST Bilirubin !Results:
ALT Blood
LDH Hemoglobin
TBIL MICROSCOPIC

I
ALB 'sensitivity:

CHOL
TRIG
CK (iE,MATOLOGILLCA5(,

TP WBC 6.8
MG RBC
AMYL HGB i3,1/
LIPASE HCT q
MCV 90.3
RDW /3.5 me. 2-4.•
PLT VI/ mclie es-- 12.1
MPV 6.9
DIFFERENTIAL
f-S NEUTRO
?. 0 BAND
META
BLOOD GAS MYELO
pH PROMYELO
PCO2 BLAST
P02 • EOSINO
LACTATE BASO
BICARBONATE LYMPH
TOTAL CO2 MONO
BASE EXCESS NUCLEATED RBC
02 SAT I
mn4 Patient Name: iLocation: P 3
FMP/SSN: iProvider:
(b)(6)-4
Patient ID: iDate:
MEDCOM - 5186 FLTHOSPPNCLA 6510/1 (1/03)

DOD 12398

Day Of Surgery Vital Signs 1 1112,
HOLDING AREA: Versed mg IV Fentanyl mcg IV Ancef/ gm NPB
NAVHOSPPNCLA OVERPRINT (10-94) IV 16 820 ga d / FA / AC
Pg 7
START STOP
7 Ko CLINICAL RECORD,,Amerman
M1'..,,s / Equipment / 02 / Suction / Checked
ANESTHESIA 7,)
Pencedure
dr UMIN 1 1 1 1 1 1 1 PRE-PROCEDURE
I
N20iAlr L/Len I I I 1 T 1 1 1 1 I 1 10 Band 0 OuesboningLr&-wErn .74.• f4a I 1 I 1 11 . • Floviewod . Pens Signedkawilugual r-; -1 - -r -*-4-- -i-1 . Since
ii 11111
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tarrawArai 1 1 "I" 1 1 s "1-1-
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1'1 1 1 1 1 I 1 I 1 1 1 1 1 1 1
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cagarago
1 I I 1 I 1 1 1
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- --4-4-
I 1 1 1 1 1 I 1 1 -1 1 -1 I "r"1"" I 1 _ --r-r-11-
IllikariL7111 -I-1 -- --4-- 4 4+ ;_r PATIENT SAFETY
Madan
MacChecked
MEM MN SZE RUM EMU MIME IRMO KIM IMRE MERIN= El= EMI . Bee Oni. Ndiery Rd1.0•1111N111111 el 7-Rimini' 0 Amu lard
ET CO, -4-4-Jr-4-
-1 1 1 , , . 1 I I Ores chocked and padded
—1,
no,
_Pi 1-1 1 I I 1 1 G-Eira • 0 Ointmenti0 Seine
—6—'—Sa0y% 1 1 1 1 1 1 1 1 1 1 0 Padsi. Goggles
+ -1--
1 I ANESTHETIC TECHNIQUE
-r— T
-1 1
-I -13Ichygsnawn . LTA.
1 1 1 1 1 I 1
0 Gleed Resew 200 1 1 I 1 1 1 -1--1-0 bralation
11111M -H-MENIME
0 fratamtrocalar . Read
• .PULSE
o SPORT RES? Reslonel: 0 Spinali0 Epidural 0 •MST RES? I.1 1 1 . Aviary . Mr Block 0 ANN Block
MEM tt-= MEMMIMMIUMM
180
• .011111. REM I 1 0 o
=I= -t -MINENIMUN• -VENTILATOR CI Poop i. kcali 1 1 1 1 I 1
0 'Neck i
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x CUFF IP 140 . Drugs(s) i 1 1 _L-i_ . Bae o Atlernrds
liret=fLI I=11-44-MUM
t MT LINE 120 1 1 0 Sl•i0 Level
I 1 CI Catheter . Seo Remarks
Iro wl
1- 4
1 1
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I .INTUBATE
AIRWAY MANAGEMENT
R .REVERSAL
181/1111iilinii111111111111111111111111111111111111/1 Intibedonund
E • EITIGATE
111111111111111E1111=1101111113/1111111-1-1- -4.--1111111111: :

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0 MA cm 0 Otd Lurn
111111211211131211111111111111111211111111UMENINI Megl
• INEMNIU ORMINI In Mann UM=
SERIEnnialimeMI'"130.5
MIIPMEICHUNEMEMENUMN
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L1 NUM NNN NNIN W NNINNd rui mi
Clreulb 0 deb 0 NAB see Remarks
. Moak Case 0 Nasal Ceram
Symbds tel Remarks
0 Me lechocolomi . Simple 0a meek-6 Blood I Producht
,
FLUID TOTALS
.141 11
Oyetelold 7C.n iBlood
RECOVERY MONITORS AND EQUIPMENT
Time
. Rimed 0 BOO 0 Mar
Tv 04 A-14 • POW 41-4-Al Al/ 0-4)..111t-i / SIP rMlf1172--11111 Or Sat.
. Leh0 NO
EKG 0 V Load EKG .....Ettr0 0 Rua! Oxygen
sygon Sensor /ova Z1Idel CChi0 Gee Antr 0 Unstelle.134451-Ceygen
ndy
n (h¦ (vet 7 (0 lX4IT ( SYM011111 0 imam 0 T-0108 Ctoron
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. LIMM111611 0 Vastasor o Osolinasal airway
.
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.
Akimy Humidifier . Foley Catheter MCUNOTES

.
NG I 00 Tubei. An. Linei Parr

MERGENCE
OW SuctioningiUtt x 5 sec &tubed=iASLEEP 0 FENTJSUF/REM 100AZ
I
SURGEON(S)

USED
13)(8)-2 1,103)-2
.4•01, I WASTE)
PATIENTS IDENTIFICATION (Far typed or written entries give Name—last, first.
(13)(8)-2 DATE
middle, grade, date, hospital or medical facility)
1—
.b)(8)-4
ANESTHESIA
Stardom' Form 517 Proscribed by GSA ICA4F1 MAR (41 CFR) 201-45 505 OCTOBER WS 51742
MEDCOM - 5187
DOD 12399

/Pi z g. Post-Op Orders Date Z 274( 2 Time 9-6-d 3
1. ADMIT TO:iI[ ] ACWi[ ] ICU (
2. DIAGNOSIS/PROCEDURE (print):
.4-.4111.1116.
All'.
3. VITAL SIGNS: [ ] Per Post-op Routine i[-,J44hr 4 ACTIVITY:iBedresti[ ] Up with Assistance
5.
ALLERGIES:

6.
NURSING:i[ ]1/0i[ ] Foley to gravityi[ ] NG to LIS

[ ] CT to -20CM H,0 Suction [ IS Q1° while awake
7. DIET: [ ] NPO [412egi[ Clear Liq [ ] Full Liq a IV FLUIDS: [ ] Lactd Rngr A CC/hri[ Normal Saline (a iCC/hr
9.
LABS: [1,KBC [ ] Chem 7i[ ] CAMP [ UAi[ PT,PTT [ ] LFT's Frequency (such as STAT, Q-AM) i

10.
Type and Cross iUnits

11.
PARAMETERS: Call MD T101, SBP18090, DPB100, Pulse120, UOP icc/ ihr, RR24

12.
MEDICATIONS: ['(Morphinei/ 0 mg IV, Q ihr, PRN Pain [ ] Demerol mg [ ] IM [ IV, Q hr, PRN Pain[xylenol #3, 1-2 PO q4hr PRN Pain [ ] Percocet 1-2 Q4° PO PRN PAIN [ ] Zantac 50mg IV Q8°

[ ] Phenergen 12.5-25 mg IV/IM PRN N N
.rOxygen @ 7 L per _A44iTitrate to keep sat 92%
[]'Ancef Ig IV Q8°i

x tart aill•Be •
[ ] Rocephin Ig IV Q12°
[ ] Gentamycin mg IV load & pharmacy to dose

[ 1 Cipro imq IV Q12°
[ ] Clindamycin mg IV, Q hr
[ ] Penicillin G, Million Units IV Q hrs
[ Unasyn gram IV, Q hr

[ ] Transfuse units packed cells
13. DRESSINGS:
14, DRAINS:
15. RADIOLOGY:inef)-74 z-
f)-P 777-147/44

b)(6)-2
b)(6)-2
(b)(6)-2
16. OTHER:
DOCTOR SIGNATURE:
PATIENT IDENTIFICATION: FULL NAME:
(b)(6)-4
FULL SSN:
MEDCOM - 5188
DOD 12400

-
Day Of Surgery ASP -z-E
Vital Signs
HOLDING AREA: Versed "--­mg IV Fentanyl —mcg N Ancefi gm IVPB

NAVHOSPPNCLA OVERPRINT (10.14)iIV 16i20 ga inCY L Hnd /@/ AC
START STOP
wr CLINICAL RECORD ....., Anesthesia
1 -rirugs / Equipment / 02 / Suction / Checked
ANESTHESIA n031
Procedure
6811•11=9111•1111Laill11111111110=1•11VIMIIIIIIMININIff 31 10 0a.3-
UMIN 1 1 I 1 PRE-PROCEDURE
1 1 1 1 1 1 1 1
Lamm= 1.1 J11.4 _ -I -
1 . 013and 0 Questioning P-St 44_ 1 1 1 1 1 1 1 1 1 d^srt Reamed . Penal Sligned lire 4 -Jr-4-•••4--4--r --1--4-NPO Sines
MEM
i-t--F-I-
1i1 1 I -1 1
-1 Preanesthelth Slats: . Can L 4 PR / PEN / ETO 1 1 r-r 1 I
1i1
L_1 - 13--raake . Anew
MIYA / ATFI 1 1 1 1 1 1 1 -r-1-1 1 -1 1 1i1
. noirpteherrim O Callused
1i1 1 1 1 1 1 1i1 1 1 1 1i1
11 1 1 0 Uncecoreles . Uruespaake
T T-•--I--I---4-44 7
Cs 1 - 1 1
I--, - 4 1-1--t- PATIENT SAFETY
1i1 1 1 1 1 1 1 1 1 , 1i1 1 1
crran. Maritu a Chicled
Liapia-k-omMB SIMI =MI 11111111111111 NEM Mil NM =MIN= MINE RERUN 1111111M Casety ea On 0 Way Rol
0,
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-4-4-
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1i1 0.'Eye Caw 0 Gamer! 0 Seine Sa07%
1i1 °A real . Pads 0 Goggles
Levi_

. --I--
ANESTHETIC TECHNIQUE
-r-r

Ii1 Game 04,8813.ypension 0 LTA
1 1
CrITIVIO Sawn= naked Ream 1i1 1iI
4 _1
G['Rawles0 Innalioran
WirdMiTirrIMEN nu
200 0 Inverreseiev . Rend
• .PULSE 1i1
0 -SPORT RESP 1 1 1 1 1 -f-i- Negionel: . Spinal ¦ Epidual
180 0 .ASST RESP 1i1 / 1 1 1 1 1 1 1 I 1 1 0 Aviary . Ea • 0 Snide Medi
-1-
• CURL RESP 1i1 Ii1 1 1 1 1 -11 -t-1 Poetise 0 ¦ VEIMLATOR P.O 0 LAW
1
-r . Needs
t-t
III MI MEI AIIMILUMEMI
140
X CUFF M - 1 1
&DAN
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,o,e)
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4-4-
X =KAP ,
100 MAC 0
I • INTUBATE
AIRWAY NANAGEts1EN T
R • REVERSAL
MI
E • EMIRATE kluballens o Ilse sies.2,2,_ ETSFAIN iam 0 Nasal 0 Recilsr
MIMIC MOE
CI Maps Galria 0 RAE 0 Fiber epic 0 Ethel 0 Alreuness 0-11ede Ht 4C '7 0 USA
0-Seind at74_.m 0 ow um 0-Anerpa Ream
1-1-
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142111IMPTIIIIIINIMMIUMNI1
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12:1112 Rm. — 3 • MU OHM HIM EH HE HE MI . 088:4
C=Mini MEM WWIIli
la OHM MR NM MR RIM IIIMUN IMRE NMI MIMI MR Cade 0 1/R13 sae Remoras
0 Mirk Cue 0 Nasal CarnesOinthels to Romanis . O Staple 01 male
. VII Aaaem
1.,
FLUID TOTALS2. 1941111
Mood
POSMON
R
REMARKS -) 2ni 1irc d St M..11 •iw *. tt
I,Ili
.68111 0 Record 0 E.* 0 Oiher
oT e .4 ay. I les (S1 sot.
lfran-kwasite BP 0 Leh 0 ROI 00(7 Errontnucus EKG . Vtyd EKG P IR 14, 5%.0 Crrul.• Oxlmeur .0 hats 0 Mad C•h•n
••1Sensor Eltteili
•411c110,4 g 0 Gas Antlyisr 8-1rrom 0 WWI* 0 Vssk Oen=
.
Temp. ig-r Shinthatg . Seardwil 0 Whaled 0 T-pOh• Orypwl O lkwouNable . Virilalor . Onabsul away

.
Wannip Shinichi . (11:d

iad Warm 0 Ainvay FiLrridirwir 0-1.6Q WNW PACU NOTES 0 NG/OG Abs 0 Art Line UST Parr
ISIERGENCE
God Suclionic CileiaUtt x 5 sac 0 5A1
&tuba.= MAKE 12rASLEEP CI ifIEM WW2-
1CIF 414 with 31.111TeLo ".
ISSUED
5-6 -7
PROCEDURE SURGEON(S) ANESINF-Giel
lolr use)
a 50
b)(6)-2
Le ft.tr,:-L SWIM
011 7
PATIENT'S IDiFICA • Ni(For typed or written entries give Name—fear, first,
DATE middle. grade, date. hospital or medical facility.) L" (b)(6)-2 It. 103
ANESTHESIA
Steriderd Form 517 Prissabod by GSA IC IR FIRMA (41 CFR) 201-45 SOS OCTOBER UPS 517.112
MEDCOM - 5189
DOD 12401

516-109 NSN 7540-00-634-4156
MEDICAL RECORD OR # t f, OPERATION REPORT
PREOPERATIVE DIAGNOSIS Co tR)c
SURGECp' FIRST ASSISTANT SECOND ASSISTANT
)(6)-2
ANESTHETIST r)(6)ANESTHETIC TIME BEGAN: C),ki)
-2 TIME ENDED: Cri' 23
Clpriu ATIKIn PJUDe= SCR jp " /RCP •• TIME OPERATION BEGAN rigrorrErumori-COM--

(b)(6)-2 (b)(6)-2
PLETED
OFSS t o
OPERATIVE DIAGNOSES
5 A A
DRAINS (Kind and numbef) SPONGE COUNT VERIFIED
MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION
OPERATION PERFORMED
0 (a) LE
al Le
(A.) 60 ).)
it,tA A gOs-X9.-
It
DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.). PROSTHETIC DEVICES DATE OF'OPERATION
(LOT no.)

Pre-Operative Nsg Assessment: '
Dentures:i, 4E/ Implants: i
Allergies: i.LP"' i.Foley inserted by: Kb)(6)-2
NPO:iNi Safety Straps . "514\

Intra Operative psg Assessment
Anesthesia: i Prep: i g2r
Bovie Equip #: .

Irrigation: N5 Bovie Pad #:i Medications: i
.
0
/Blood
Post Operative EBL: i1 0 0 Wound Class: 3 DSG: P/Aii‘"? aLTAA L U/O: Fluids : o
Final counts:
1v /4-
SIGNATURE OF SURGEON
b)(6)-2 DATE
PATIENTS IDENTIFICATION (For ryped or w give: Name • lase, first, middle; REGISTER/I.D. NO. WARD NO.
••,, de; date; he dical facility)

b)(6)-4
OPERATION REPORT Medical Record
STANDARD FORM 516 (REv5-83)
Prescribed by CISA/1CIAR FIRM (41 CFR) 201-44.505
MEDCOM -5190
DOD 12402
516-109 NSN 7540-00-634-4156 MEDICAL RECORD OR # OPERATION REPORT
PREOPERATI E
FY A IP
(51LOIL 1 Fx 2,1 •T-; 10//:-;&
S
b)(6)-2
SURtEt FIRST ASSISTANT SECOND ASSISTANT
ANESTHETIST 0)0)-2 ANErIEL TIME BEGAN: a;z s5
L.— I

TIME ENDED: C90 LS
(b)(6)-2 0
SCRIJR Nil 1RRF TIME OPERATION BEGAN TIME OPERATION COM­
',13)(6)-2
PLETED
00;-5"-
Uet1-1/1111/h UlAtaNUbb
DRAINS (POnd and rumba') SPONGE COUNT VERIFIED
/4. Fr- -4. y
MATERIAL FORWAF(DED TO LABORATORY FOR EXAMINATION
dr'
OPERATION PERFORMED
I
DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.) PROSTHETIC DEVICES DATE OF OPERAT
Pre—Operative Ns ssessment: (LOT no)
Dentures :iY Implants : 140L-4imecG‘c 0;4.11-1 I:. screw • 17 e/47°3 it77/°-2
Allergies : MN K iFoley inserted
NPO: Y (N) Safety Strapsi414

Intra Operative Nsg Assessment
Anesthesia : i Prep: 5.
Bovie Equip # : i Irrigation : /1)/9-C-4_

Bovie Pad # : i Medications: i
/Blood

Post Operative
EBL:i100 cc Wound Class : i DSG: i U/O: faOct Fluids •i,n /I LA
" co--Initial
Counts:
SIGNATURE OF SURGEO Kb)(6)-2 DATE
PATIENTS IDENTIFICATIO N (For typed or written entries give: Name -last. first. middle; REGISTER/I.D. NO. WARD NO.
rade' dale' hos • ital or medical facility)

b)(6)-4
OPERATION REPORT Medical Record
STANDARD FORM 516 (FtEv s-e3) MEDCOM -5191 d by GSA/ICMR FIRMA (41 CFR) 201-45.505
DOD 12403
MEDICAL RECORD BLOOD OR BLOOD. COMPONENT TRANSFUSION
SECTION I—TRANSFUSION REQUISITION
ED BLOOD CELLS UNITS/ DATE9QUEST ,, DA? ND OUR WANTED PHYSI b)(6)-2
ige
OTHER (Specify) OR...t .ML /.7 a 3 , 7b 3 /700
KNOWN IMMUNE ANTIBODY FORMATION PREVIOUS TRANSFUSIONS REACTIONS TO PREVIOUS TRANSFUSIONS
RhiOthers D Yesi0 Noinknown Unknowni0 Noi0 Yes (Type)
..
o 'IF PATIENT. IS FEMALE, IS THEE HISTORY OF
Ivzot uert, . Hemolytic Disease of Newborni0 RhIG Treatmenti0 Stillbirthi0 Miscarriage 0 Delivery
REMARKS (Pertinent Patient History) I have taken a blood specimen on the below named patient , verified thyname, and verified the specimen
-•
.tp 'AWN ----,:b)(6)-2
SI 2.2 ?,2s..
VER1E,•0)_2 ---— '"'' ' • led) c.4t.....
I _
PATENT SG'. ATURE (or verifier if patient unable to sign)
SECTION II—BLOOD TYPE, COMPATIBILITY INFORMATION AND CERTIFICATION
TRANS mins NO COMPATIBILITY INFORMATION
b)(13)-4
SALINE ABUMIN COOMBS
MAJOR (DC/PS)
1:13CR

1+-
MINOR (PC/DS)
Compatibility Tests Not Performed (Explain below)
.
ABC TYPE ABO TYPE
REMARKS:
Rh TYPE Rh TYPE
sexp 4111103
VL
,414VItune (r.

SCINAOURE ( Verifier, ilPequired)
:b)(6)-2
;b1(6)-2

DI •
SECTION III—RECORD OF TRANSFUSION
ADMINISTRATION POST TRANSFUSION DATA
DATE OF TRANSFUSION MONTH (( 4 Li DAY e ANCLNI OMEN I V.7.4. ..ML I TIME COMPLETED/INTERRUPTED
YEAR .200.2
?St_ TIME STARTED /6 •3 REACTION:j&NONE . SUSPECTED N.' ICENTFICATEN If reacti is suspected—IMMEDUITELY:
I have examined the blood or blood component container label and 1. Discontinue transfusion; treat shock if present, keep intravenous
blood or blood component transfusion form and I find that ail infor-open
mation identifying the container with the intended recipient matches 2. Notify Physician and Transfusion Service
item by item. The recipient is the same person named on this blood 3. Follow transfusion reaction procedures
or blood component transfusion form and on the patient identification DESCRIBE: 0 URTICARIAi0 CHILL/FEVER 1:3 H :LYSIS/PAIN

r
its e ig 6e1560 r So RECORD: Temp t"' I Pulse 'n B/P %31 oi&riv 014 kYES . NO Other difficulties (equipment, elate, etc.) 0 No Ve: Yes (Specify) 40...... E....T 4'1,1 v-nion RV ../^i
b)(6)-2 IN STAMM TRANEFUSON SIGNATURE OF PERSON NOtb)(6)_2
r
)(6)-2i 4. 4 v V.411).,i.
6/73
PATIENTS IDENTIFICATION—U6t tivoubLtc—iyilr typed or written entries give: Name—Last. first. m-icia"7"-7.7E(—WARD NO
rank/rate; hospital number and nante of facility.)
b)(6)-4
'BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (17E1/. 9-76) Prescribed by GSA aid Interagency Committee m Medical Records FRvR (41 a9 101-11.806-8
518-318
MEDICAL RECORD COPY
GPOi1982 0 - 381-531 (3530)
MEDCOM - 5192
DOD 12404

MEDICAL RECORD BLOOD OR BLOOD. COMPONENT TRANSFUSION
SECTION I—TRANSFUSION REQUISITION
DATE7 DATE AND OUR WANTED privsicuom-2
-K
'RED BLOOD CELLS UNITS et 770 (tH
OTHER ( Sp ecif y) OR.. ML d 6 (a)
IG 'N MUTE ANTIBODY FOFMCION PREVEDUS TRANISFUSICNS I NS TO PREVIOUS TRANSFUSIONS
0 Rh Others 0 Yes 0 No L14nknown Unknown . No . Yes (Type)

.
14 PATIENT. IS FEMALE, IS THERE HISTORY OF
0 Hemolytic Disease of Newborn . RhIG Treatment . Stillbirth . Miscarriage . Delivery
REMARKS (Pertinent Patient History) I have taken a blood specimen on the below named patie erified the name, and verified the specimen
tU
I
Lin i6n V()
bX6)-2
eYe__
5,K.L,;(6}2s
cAPC,-
PATIENT SIGNATURE (or verifier if patient unable to sign)
SECTION II—BLOOD TYPE, COMPATIBILITY INFORMATION AND CERTIFICATION
NT Nn TRAIV,V61)!1nN en COMPATIBILITY INFORMATION
PX6)-e SALW AU3UMN COOMBS
MAJOR (DC/PS)
DONOR

MINOR (PC/DS )
Compatibility Tests Not Performed (Explain below)
O
ABO TYPE ABO TYPE
REMARKS:
Up. Li (n
Rh TYPE Rh TYPE
pcs
SIICNATIIRF (Person nerformina teats) DATE 921¦1411SIE (Verifier, if required)
b (6)-2 b)(6)-2
z D Guts fJe- ca Ng_
SECTION III—RECORD OF TRANSFUSION
ADMINISTRATION POST TRANSFUSION DATA
EWE CF TRMSRDON nrasrrH MY 7 YEAR Vt.) ki AmouNr TIME COMPLETED/INTERRUPTED
TIME STARTED
((') REACTION: /NONE El SUSPECTED
IDENTIFICATION: If reactio is suspected—IMMEDIATELY: I have examined the blood or blood component container label and 1. Discontinue transfusion; treat shock if present, keep intravenous blood or blood component transfusion form and I find that all infor-open
mation identifying the container with the intended recipient matches 2 Notify Physician and Transfusion Service
item by item. The recipient is the same person named on this blood a Follow transfusion reaction procedures
or blood component transfusion form and on the patient identification

DESCRIBE: 0 URTICARIA 0 CHILL/FEVER . HEMOLYSIS/PAIN tag.
REOCRD Tema 1 113 Pulse 143 B/P )3VR)41
S . NO Other difficulties (equipment, clots, etc.) 7No Yes (Specify)
S VIAIIIRF OF PFRCON STARTING TRANSFUSION SIGN
b)(6)-2 b)(6)-2 bX6)-2
cvic u5n)
PATIENTS IDENTIFICATION—USE EMBOSSER—(for typed or written entries Dive: Name—Last, first, middle. I SEX /719 r WARD NO.rank/rate; hospital n mber and name of facility.) u
( 17/
b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
STANDARD FORM 518 (REV. 9-76)
Prescribed by GSA and Interagency
Committee on Medical Records
FPMR (41 CFR) 101-11.806-8
518-118
MEDICAL RECORD COPY
GPO : 1982 0 - 381-531 (3534)
MEDCOM - 5193
DOD 12405

7540-00-634-4162 519-218
/ PATIENT IDENTIFICATION (For typed or writfrn entries g(ve: AGE SEX SSN (Sponsor) . {WABD/D)... REGISTER NO. Pane — last. first, middle, Medical Facility)
EXAMINATION HEQUES* SF 619-B for multiple exams);b)(6)-4 •
FE.14()4 4/0 c& 2 G. r//361-.f /c )(4,
REQUESTED BYr(6)-2 TELEPHONE NO.
LOCATION OF MEDICAL RECORDS FILM NO. 'DATE REQUESTED I 0 •••1-S PREGNANTE. YES fl NO
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
b)(6)-2

DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day; year) DATE OF TF C R I PTION (Month, day, year)
•
RADIOLOGIC REPORT
fr...„.
-7-74,,,,_
-,,,f /Lcs,
e—f-Te ern ,Y ,y, E.,-)? ­
24:11 rx . Ai?". ec.
c.9"-1.3A-:,-­
51.,4-/krdtAm&i'L.
-1-1 ilk )41
8:-,. 74.4-47 erirr/a 4Al hi-414, j 4k7 ? dili,e/4 C?4,,-, iht( "i 77-4-b- vizi..il
' h - / , : 4 a 7 , 4 .5 L 0-4, v - lA J); A- hAi i-, - g ke,c
SIGNATURE LOCATION OF RADIOLOGIC FACILITY
1 — MEDICAL RECORD STANDARDFORM 518-A (REV. S-83)
RADIOLOG IC CONSULTATION REQUEST/REPORT
Prescribed by GSA/ICMR
FPMR (41 CM 201-45.505
U.S GOVERNMENT PRINT/NG OFFICE 1987-181-243/40522
MEDCOM -5194
DOD 12406
"
/J
1:31
• 7117.r`
3-\)
, )

— 214171: 4111
w w 9,41
-;4:0/72-C in
)
S 6rer..1
MEDCOM - 5195
DOD 12407

NSN 7540-00-634-4121
DOCTOR'S ORDERS
MEDICAL RECORD
Sian all orders
DATE AND TIME bX6)-2 OCTOR'S NURSE'S
R X DRUGORDERS
START STOP ,GNATURE SIGNATURE
.
1/ , 4 ,, _
4L793 /Lain
93 ,b)(6)-2 0? ,-o :b)(6)-2 CAS(
W7/1 a t / - r, i r'/, 4 t - e 2 2—
-
/ ,,,,,,I.,..,... (2/ tri 1-0-et,-
4 ,e„..124,„-,... A..--i,.// ,.,,,,,,,-/.4a...(,,,.
,4--6 ,..,,,,vt ,,,,e.. /0 o. ,../Gt,$).44.-L.
a
/C.,-cilif ye T7 -e-tt_ C 4-6,-(4,-,-9 ---
b41
)(6)!2"1
0 3
1 1 ›D
LI 7 Li. MPS - t Ai 1‘01 J6fri-L gil
b)(6)-2
.
4..)
4 (21?CrAti N CI lfz 1
b)(6 )-2 1......,
IL "7-ier le 2400 CZ Cavv-pcer&-N-7 L-n b-,,
(Continua on reverse side)
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, REGISTER NO. WARD NO. middle: grade: rank: rate: hospital a medical facility)
:b)(6)-4
DOCTOR'S ORDERS Medical Record
STANDARD FORM 508 (Rev. 3-94)
Prescribed by GSAIICMR, FIRMS (41 CFR) 201-9.202-1

491111, MEDCOM - 5196
3e
DOD 12408

DOCTORS ORDERSMEDICAL RECORD
(Sign all orders)
DATE AND TIME ril DOCTOR'S NURSE'S
DRUG ORDERS
START c SIGNATURE SIGNATIM
STOP
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MEDCOM -5197
DOD 12409
Post-Op Orders
Date Time 1-/- (P-0 ",

1.
ADMIT TO: [ ] ICUi[ ] WARD 1i[ ] WARD 2 M. WARD 3

2.
DIAGNOSIS/PROCEDURE (print):i/0 _7; eP A.4 L.,--(tz, 27 cjrc

a VITAL SIGNS:i[]'Per Post-op Routine i[ ] 04hr
4.
ACTIVITY:i' K3edresti[ ] Up with Assistance

.. .

5.
ALLERGIES:i

6.
NURSING:i[ ]1/0i[ ] Foley to gravityi[ ] NG to LIS
[ ] Crtiii-,29CM H2 O Suctioni[ ] IS Q1° while awake

7.
DIET: [ ] NPOiX...Beg )i[ ] Clear Liqi[ ] Full Liq 1 a IV FLUIDS: [ ] Lactd-Rngr §iCC/hri( ] Normal Saline (4 CC/hr

9.
LABS: [ ] CBCi[ ] Chem 7i[ ] CAMPi[ ) UAi[ ] PT,PTT [ ] LFT's i Frequency (such as STAT, Q-AM)

10.
Type and CrossiUnits

11.
PARAMETERS: Call MD T101, SBP18090, DPB100, Pulse120, UOP cc/ihr, RR24

12.
MEDICATIONS:

171 Morphinei• I 0img IV, Qihr, PRN Pain
1 3 Demerolimg [ ] IMi[ ] IV,iQihr, PRN Pain
b.? Tylenol #3, 1-2 PO q4hr PRN Pain

[ ] Tylenol, 325 mg, 1-2 PO q4hrs PRN
[ ] Motrin, 800 mg po q8hrs prn
[ ] Zantac 50mg IV Q8°

[ ] Phenergen 12.5-25 m g IV/IM PRN N N
1 1 Oxygen © L periTitrate to keep sat 92%
b4rAncef lg IV 08° ye.... V,fir.3
[ ] Rocephin I g IV Q12°
[ ] Gentamycinim g IV load & pharmacy to dose
[ ] Cipro img IV Q12°
[ ] Clindamycin img IV, 0 ihr
[ ] Penicillin G, iMillion Units IV 0 h rs
[ 1 Dicloxacillin, 500 mq PO q6hrs

[ 1 Keflex, 500 mg po q6hrs
] Milk of Magnesia, 30-60 cc po qhs pm constipation
Benadryl, 25-50 mg po qhs prn insomnia
Transfuse iunits packed cells

13.
DRESSINGS: i st-z,„J

14.
DRAINS:

15.
RADIOLOGY:

16.
OTHER:

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DOCTOR SIGNATURE PATIENT IDENTIFICATIO
(b)(6)-4
FULL NAME: FULL SSN:
MEDCOM -5198 Modified 4 April 2003
DOD 12410
CASREC PROCEDURES TIME NOTES/PLANS:
.
Oral airway Nasal airway EOA/PTL Cuff BP 11Y0A-AA-Cc

.
ETT # . NTT # RSI Pulse -7,o a.9

1:1 Crico # . 02 @ L./Min via Resp
Breath Sounds: L: R: Temp
.
!Vs* OP eripheral . Central . Intraosseous 02 Sat

.
IV Fluids 1 2 3 4 5 6 . Blood 1 2 3 4 5 GCS

.
CPR PASG: . Legs . Abdomen Urine Out

.
Urinary cath . Gastric tube Blood Out

0 Chest tube: . R . L 0 Both Fluid In
.
C-spine protection . npipe protection, Time on: Blood In

.
S Ints Type:

0 edicalions:
p c i C r 41\g'
ADMISSION ORDERS
1. ADMIT TO: R/PREP [ ] ACWi] ICU
2. DIAGNOSIS (print):
A-d r1(1

h r;119
3.
VITAL SIGNS:i 1°i[ ] Q4°

4.
ACTIVITY:iedresti[ ] Up with Assistance

5.
ALLERGIES:

6.
NURSING: "1010i[ ] Foley to gravityi[ ] NG to LIS
[ CT to -20CM H2 O Suction ] IS Q1° while awake

7.
DIET: [NPO [ ] Regi[ ] Clear L iq [ ] Full Llq
a IV FLUID-6: [Inactd Rngr 6,4512CC/hr [ ] Normal Saline @ CC/hr

9.
LABS: [ .]CBC [ ] Chem 7i[ ] CAMP ( UA
[ PT, PTT [ J LFTs [ ] NOW [ ] am [ ] Type & Crossiunits

10.
PARAMETERS: Call MD T101, SBP18090, DBP100, Pulse120, U.O. _j_hr

11.
MEDICATIONS:
[ ] MSO4img, Qihr PRN PAIN IV

Demerol mg, Q hr PRN PAIN IV
[ 1 Percocet 1-2 Q4° PO PRN PAIN
[ ] Zantac 50mg IV Q8°
[ 1 Phenergen 12.5-25 mg IV/IM PRN N N

[ Oxygen @ L per Titrate to keep sat 92%
[ 1 Ancef I a IV 08°
[ ] Rocephin I g IV Q12°
[ ] Gentamycin im g IV load & pharmacy to dose
[ ] Cipro img IV 012°
[ ] Clindamycin mg IV, Q hr
[ ] Unasyn gram IV, Q hr
[ ] Transfuse units packed cells

12.
CULTURES:

13.
RADIOLOGY: [ ] Port CXR [ ] KUB

b)(6)-2
DOCTOR SIGNATURE:
(b)(6)-2
PATIENT IDENTIFICATION: FULL NAME:
CDR MC USN
STAFF FAMILY PHYSICIAN
FULL SSN:
l(b)(6)-2
MEDCOM -5199
DOD 12411

•

4p RECEIVING
INITIAL ASSESSVP AIRWAY er„...cyaal . Compromised
CHIEF COMPLAINT:
C-SPINE Normal . Suspect Injury
BRWHING
Normal
MECHANISM OF INJURY
.
Tracheal Deviation

.
Resp. Distress

.
Tension PTX

.
Chest Wall trauma

CIRCULATIONHISTORY
AA/ Skin/mucous: ..er/Pink . Pale
Allergies:
Medications:

Membrane color . Flushed . Jaundiced O Ashen....0 Cyanotic Normal, Site
past illnesses: V AA Pulses:
.
Bounding, Site

.
Weak, Ske

Last Meal: Last Tenanus: . Absent, Site
Events:
Rite D /minute Rhythm

. No Skin temp: Warm . Hot . 9ol/cold
Pregnant? . Yes . LMP
WNL n Dry rd/Moist DISABILITY PROCEDURES BEFORE ARRIVAL GCS Score: Eye opening score /4 Oral airway Nasal airway n EOA / PTL Verbal score /5
Spine protection device removed @ Skin moisture:
(7
:5—
Err #

NTT # RSI Best motor score /6
clic° # Umin via TOTAL GCS SCORE: f /15

0 02 @ Breath Sounds: L: R: RTS Score: Respiratory score 'vs # . Peripheral Central . Intraosseous Systolic BP score
.
IV Fluids 1 2 3 4 5 6 0 Blood 1 2 3 4 5 GCS Score
CPR . PASG: . Legs . Abdomen TOTAL GCS SCORE:
Urinary oath . Gastric tube
Chest tube: . R .

Ln Both Right Left C-spine protection . Spine protection, Time on: Pupil Size: mm 7 Splints Type: Medications: _Reactive? .0
7 Otherprocedures: Aims move? LG
legs move? . El
PATIENT IDENTIFICATION:
FULL NAME:
FULL SSN: :b)(0)•4

IDENTIFY INJURY SITE BY LETTER
I 11
A -Abrasion F - Fracture T - Ternderness
-Bum G -GSW
C - Contusion H-Hematoma
D - Deformity L - Laceration
E - Edema S - Stab rund

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Abodornen:
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Musculoskeletal:
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MEDCOM - 5200
DOD 12412

PRN/ONE TIME MEDS
Medication 7 43 Do se/I n it Date/Time Yif i:i 1 dot 0 z,jr--
PRN MEDS Dose/In it Date/Time 4, 60 ;1.., 4iii9 "-- 2,bp,6 Dose/I nit Date/Time Dose/I n it Date/Time or ) Seri Dose/I n it
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MEDCOM - 5201
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DOD 12414

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency Is 0 rSG
DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS.

IF PROBLEM ORIENTED MEDICAL RECORD
TEM IS uSE D. WHITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
VEN T IDEN T IFIC A TI O N DATE OF ORDER TIME OF ORDER LIST TIME
ORDER
CJ)
NOTED AND
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,
;SING UNIT ROOM NO. RED NO.
IENT IDENTIFICATION DATE OF ORDER
TIME OF ORDER
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tDINC. UNIT 'ROOM NO BED NO.
itiNT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
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ifs
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ISINO UNIT ROOM NO. BED NO.
,b)(6)-2 !ENT IDENTIFICATION DATE OF ORDER TIME OF ORDER-
HOURS
iSINO UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
I r49"Mg 4256
MEDCOM - 5203
DOD 12415
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) 4
CLINICAL RECORD For u e of this form, see AR 40.401;
Yr.35
the ro anent ag ocy is the Office gf The Surgeon General.
V E R I F Y B Y I N I T IA L I N G ;NNW.1ing 1 MEOMME: ;MEM INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS,
DATE NURSE FREDUENCY, TIME

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ALLERGIES: I i YES 1 I NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE
YESill NOIIII
+Tr Li a_ —4 PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES
;Is)(6)-4 USE PENCIL CRCLE ACTION TIMES
0 8i9i10 11 12 13 14 15
E 16 17 18 19 20i21i22 23
Ni24i01 02 03i04 05i06 07
DA FORM 4677, 1 OCT 78i EDITION OF 1 DEC 77 MAY BE USED. USAPA 01.00
MEDCOM -5204
DOD 12416

Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
.1* ON' -MEDICATIQN) M0
Order Clerk Date Nurse SINGLE ACTIONS . Date to Time to
Time Dene Initialsbe Bone be Done
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Dc_._. 4, 1 L• Q. (11 Avik 5/5 4, Ca 0 c__ 1--0 5/(,,
Order! Clerk/ PRN
INITIAL PROPER COLUMN FOLLOWING COMPLETION
Nurse
ACTION. FREQUENCY
TIMEIDATE COMPLETED
USAPA VI.00
MEDCOM - 5205
DOD 12417

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For u e of ihi form, 313B AR 40.407;
MO. s Y
kheE rip front a; ncv is he Office of The Suroeon General.
VERIFY BY INITIALING enr,anatERNEF•11.,. :40A INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLEM RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

-I _ .
ALLERGIES: III YES 1111 NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE
111. YES • NO
PAGE NO.
—1-1•1.) e& .-_ rie. 1 •
i ri
IiPATIENT IDENTIFICATION,
DISPENSING TIMES
:b)(6)-4 USEPENCIL. CIRCLE MED TIMES
D 7i8 9i10 11 12 13 14
Ei15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA FORM 4678,1 FEB 79 i EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA 41.00
MEDCOM — 5206

DOD 12418

i I
THERAPEUTIC DOCUMENTATION CAAE PLAN
Verify by MO' Yr.
I
(MEDICATIONS)
Initialing
Ii
I Order Data Clerk! Nurse SINGLEORDER. PRE.OPERATIVES DUB to he Given Time to be Given Time Given Initials
I
I i
Ii --i• I

•
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Order! Clerk/ PRN
Ell* Nurse MEDICATION, DOSE, FREQUENCY

TIMEIDATE DISPENSED
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6° i°
M EDCOM - 5207
DOD 12419