Medical Report: Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wounds: Femur, Tibia and Fibula Fractures

519-21B
NSN 7540-00-834-4182
PATENT IDENTIFICATION (For _typed or wn,o,ntries glue: AGE SEX SSN (Sponsor) ARD/CLINIC 'REGISTER NO. . Name — last, first, middle, Medical FiiillIty)
(b)(6)-4
CCOPer-

MI NATION REQUESTED (Use SF 519-B for multiple exams)
i t51%-t.,

E A,
TELEPHONE NO.ob)(6)-2REQUEST R

"PI---
FILM NO. DATE REQUESTED PREGNAN f YES riNO 'ION OF MEDICAL RECORDS
(Complaints and findings)
SPECIFIC REASON(5) FOR REQUEST DATE OF REPORT (Month, daY, Year) DATE OF TRANSCRIPTION (Month, day. year)DATE OF EXAMINATION (Month, day, year)
RADIOLOGIC REPORT
54111e Wein)
7;-)ft4(11-"-9'"-y
L

2 \,:wt-i 0 41 2-r.-zik,--/o, A-
/L-1/1041(0/f;
NSN 7540-00-834-4162
519-218
PATIENT IDENTIFICATION For typed or written en tries li(de: 'AGE SEX SSN (Sponsor)
WARD CNIC (b)(6)-4

Name —l Facility) obieeLI REGISTER NO.
b)(6)-4
' . o

ALO 1IC
E(IN )TION REQUESTED (Use SF 619-B for ultiple exams)

/Pt I Ca- CO
REQUESIT
!TELEPHONE NO.
TION FILM NO. DATER PREGNANT
D YESo0 SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
FOO
DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC REPORT
e.) £4'1', rt. n't4 )4-A. 16,
.b)(8 )-2
SICs NA I UHE LUL,A I ION OF HAUIULUCAL. FAL.ILI I V
1 — MEDICAL RECORD
RADIOLOGIC CONSULTATION REQUEST/REPORT STANDARD FORM 519-A (REV. 6-83)
Prescribed by GSA/ICMR
U.S covssisissr PRINTING OFFICE(1967-181-243/40522 FINIR (41 ,-;,-R) 201-45.505
MEDCOM - 4988
DOD 12200

NeuroVascular Check List
(

N33H3 1V31901011naN
DATE REM TY PAIN
SENSATION
BLANCHING N = NORMAL S-SLUGGISH (
:b)(6)-2
ACTIVE( normal MOTOR( limited
RESPONSE(
SIGN OF COMPARTMENT SYNDROME
COLOR
SKIN TEMPERATURE
Ca
PULSE -•'--7"
SITE
EDEMA
SITE
INITIAL SIGNATURE/TITLE
fb)(6)-2 (b)(6)-2
• (b)(6)-2 lb)(6)-2
patient stampo b)(6)-4
(
TIME 090
LL -4
absent
(
mild
moderate
severe

(
normal
numbness
tingling
absent

absent
pain on passive
ROM
pain unrelieved by
analgeisa
red pink pale blue
hot
(
(b)(6)-2
warm cool cold
weak absent
none small moderate large
..
b)(6)-2
(b)(6)-2
010
b)(6)-2
b)(6)-2
A)
INITIAL SIGNATURE/TITLE,INITIAL SIGNATURE/TITLE
(pilot 3/03)

NNMC CRARiti-eMBRAL CHECK SHEET

. TIME
)ATE
gib
• • y •
¦ a L I
MIL Stu MALI (MK) 1
S IRE

• al
-• • • • • ¦¦•
REACTION
1 2 4.3.
I
111-
n
swans uses etztT/Ams Ibitti) maws
/
ITORMWRILMOSCAA‘rDe, CleNi61-5 MOSS
MONI
• nos ono 65-5. 0 Per3 srouunousu •
a le =sus 3
TO FAIN 3
van mama mama= (711=tpincerso I
•

emus= •
m
a
ISSITROPRIMTS WORDS 2
tacoonnaststs WOMOS 2

•

MONS
E MT MOMS 111•OME111oCOSTS COM MOI 6
u.6a-e-tza-sex:Isc.4
I= 20 PAIN I
•
WITUDRAWS TO PAIS
maim TO PRIM I
must= 20 PAIS 2

Er4e2?)d 7nyam=
IRRSOWLIR
OAS =PURRo • Pruesart / a •AUPIT

ssarranums MA21 009 Mte,).
¦
SIONAXONE / !ITU
6101321322 Tara
IRMA& 1111M•ZNINI / ?ITU
(I(
•
Patter% IdentIIIAattalA

CASUALTY RECEIVING

INITIAL ASSESSMENT 'IDENTIFY INJURY SITE BY LErrER
1oCHIEF COMPLAINT:
(3/3 /1) 25 'MECHANISM OF INJURY
LLA L ,
VITAL SiGNS BP- ‘; '1 11 R- LI--T= eM 4 7
*41,P-
HISTORY
Allergies: l.i.,P-A---
Medications:

Past Illnesses:
Last Meal: Last Tenanus:
Events:

Pregnant? ¦ Yes ¦ LMP ¦ No Spine protection device removed ©
PROCEDURES BEFORE ARRIVAL
¦
Oral airway ¦oNasal ainkay ¦oEOA / PTL
ilin. it

¦
Err # ¦oRSI

¦
Crico # . 02 @ Urnin via Breath Sounds: L: 0 R C/.•

¦
Iva # it„ Peripheral ¦oCentral ¦oIntraosseous REM 3 4 5 6 ¦oBlood 1 2 3 4 5

0 CPR PASG: . Legs . Abdomen 0 Urinary cath . Gastric tube
.
o Chest tube: . R . L . Both
0 C-spine protection . Spine protection, Time on: Splints Type:
Medications:
.
0 Other procedures:
PATIENT IDENTIFICATION:
FULL NAME:
FULL SSN:

AIRWAY Er.7flo rmal ¦ CompCompromised
6.
C-SPINE E Normal ¦ Suspect Injury'
K-

JIIIPL,
/
BR HIND
limU"s414 ( 1
VNormal

'"- I OP /41 li / kt\I
. Tracheal Deviation V .. i -• .-
fir- - •
-
• Rev. Distress 4 (; I + j 14
'Tar %oi
¦
Tension PTX o• ; it i
, I 1 I I

¦
Chest Wall trauma
4r_l' 1 11 ei ? .1

u..,,....._,
. .
cep_ ,01A.-6 _,o......t
CIRCULATION
Skin/mucous: ¦ Pink Pale A - Abrasion F - Fracture T - Temdemess
Membrane color 0 Flushed 0 Jaundiced F3 - Bum G - GSW
'Ashen ¦ Cyanotic C - Contusion H - Hematoma
Pulses: armor, Site 0 - Deformity L • Laceration(

I
Bounding. Site E - Edema S Slab Wound
. -
¦ Weak. Slte Head: L.) IL" L.-_,.., . Absent, Site
Rate 7-/'/minute Rhythm
Skin temp: . Warm . Hot . Cool/cold Maxillofacial: LA 1-57_
Skin moisture: ¦ WNL ¦oDry ¦oMoist
DISABILITY

GCS Score: Eye opening score /4 C-spine/neck: id iu
Verbal score /5
Best motor score V
TOTAL GCS SCORE: /15 Chest: L.

RTS Score: Respiratory score Systolic BP score GCS Score Abodomen: , . .2 f pt.o'
I r
TOTAL GCS SCORE: P T,1 ok 4,6,:,1
1.11MMIRII
Right Left Perineum. F 4 Cl-L.4. 6, t Pupil Size: '3,mm,3omm
Reactive? V a/ Musculoskeletal:
"¦......-¦..."
HO r -0,l Arms move? .V---,er 1... ;
KAM. IP ....11W(
%MEP,
. .1..
GI/
Legs move? I -oL-11111M11NMILNM.dg_.......

MI..1
¦111MIN
:13)(6)-4
MEDCOM -4991
DOD 12203

(b)(6)-4
CASREC PROCEDURES TIMEo32 3 NOTES/PLANS:
. Oral airway . Nasal airway El E0A/PTL Cuff BP 49/ ger
ETT #( 0 NTT if El RSI Pulse
• Crico#(. 02 @ oL/Min via (Resp,
/co
Breath Sounds: L:(R: S
(
PfIVs # 1334ripheral . Central(. Intraosseous

1,- "tooI IL,
.24\/ Fluids 1 2 3 4 5 6( I=1 Blood 1 2 3 4 5
. CPR(PASG: . Legs(. Abdomen
t eV*. it
.
Urinary cath(. Gastric tube ood Out

.
Chest tube:(. R . L,. Both( Fluid In

?
.
C-spine protection . Spine protection, Time on:

.
Splints Type:

-17g4-`-1A7(1 14, .f/.111 ,(
0-11
. Medications: At"( t-41 ( (
r4A ./ PI, ,CI
M-4 0 /o(t) D
l -titDm Ar ORDERS
I _ADMIT TO:o[ ]oORIPREP 4AC ] ICU
2. DIAGNOSIS (print):
3 VITAL SIGNS: [ ]01° tocw
4.
ACTIVITY: lecl3edrest 4 I Up with Assistance

5.
ALLERGIES:

6.
NURSING: [ ] I/0 [ ] Foley to gravity [ ] NG to LIS

[ CT to -20CM H2O Suctiono[ ] IS Q1° while awake
7.
DIET: . 4,[ ] Reg [ ]gaear Liq [ ] Full LIq

8.
IV FLU • S: ntlactd Rngr gzoWC C/h r [ Normal Saline A CC/hr

9.
LABS: .1)1 C E1C,] Chem 7 [ ] CAMP [ UA
[ ] PT, PTT [ ] LFT's [ ] NOW [ ] am [ ] Type & Cross units

10.
PARAMETERS: Call MD T101, SBP18090, DBP100, Pulse120, U.O. cl h r

11.
MEDICATIONS:
NT' MSO4 --/ 13 mg, Q -,Yhr PRN PMN
[ Demerol mg, Q hr PRN PAIN IV
[ I Percocet 1-2 Q4° PO PRN PAIN

[ j Zantac 50mg IV Q8°
[ ] Phenergen 12.5-25 mg IV/IM PRN N N
[ Oxygen @ oL Per Titrate to keep sat 92%
Ancef I g IV Q8°

[ ] Rocephin I g IV Q12° Di Gentarnycin y 6 a mg IV load & pharmacy to dose "------) 171 0 o ....,..-.,, q citt.,... X 74-a-rcA—. 7-3.4-79 [ ] Cipro mg IV Q12° u I 0 [ ] Clindamycin (mg IV, Q ohr
[ ] Unasyn ogram IV, Q ohr
[ ] Transfuse units packed cells
b)(6)-2
12.
CULTURES:

13.
RADIOLOGY:

nr.

:!).1
)(6) 2
STA ,
b)(6)-2
DOCTOR SIGNATURE:
PATIENT IDENTIFICATION:
FULL NAME:
FULL SSN:

NSN 7540-00-634-4121
DOCTOR'S ORDERSAEDICAL RECORD
Sion all orders
DATE AND TIME DOCTOR'S NURSES
DRUG ORDERS
R
START STOP SIGNATURE SIGNATURE
(b)(6)-2
I/ (4/4i
((b)(6)-2
.-..
AAPC)
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41,c;..,
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n
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acrcril , S.A.A_s(64..,..-s—,,_:_4, ...Xt e-kr-•--A-----,kr
0 9 6 a i
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fliy,-loppr-
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1
e
•
(Continue an reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, REGISTER NO.o WARD NO; middle; grade: rank; rate; hospital or medical facility)
DOCTOR'S ORDERS Medical Record
STANDARD FORM 508 (Rev. 3-94)
Prescribed by GSAIICMR, FIRMR (41 CFR) 201-9.202-1

(b)(6)-4
MEDCOM - 4993
DOD 12205

Post-Op Orders
Date L Psr Time
. ADMIT TO: a CW
[
. DIAGNOSIS/PR , EDURE (print):
VITAL SIGNS: er Po op Routine [ ] Q4hro•
ACTIVITY:

LL
J "4 ,O(E-
LLERGIES:
URSING: I/O ] Foley to gravity NG to LIS
[ ] Clz...9CM H2 O Suction Q1° while awake(b)(6)-2

IET: I ] NPO Re! [ ] Clear Liq [ ] Full Lid'„d-Z_-
II
IV FLUIDS: [ ] actd Rngr @ CC/hr [ ] Normal Saline @ CC/hr
61(6)-2
WM:EU' CBC ] Chem 7 ] CAMP [ UA PT, PTT ( I LFT's Frequency (such as STAT, Q-AM) Type and Cross Units
,b)(6)-2
ARAMETERS: Call MD T101, SBP18090, DPB100, Pulse120, tAP...-4-S,R5-2-4
--L—
EDICATIONS: ,1
'b)(6)-2
PoMorphine .___Ilmg IV, a

h i ne Z--.hr, PRN Pair
] Demerol mg 1 ] IM [ ] IV, Q hr, PRN Pain

'6)(6)-2
ylenol #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 NN

Oxygen @ L per Titrate to keep sat 92%
Ancef 1g IV 08°

] Rocephin 1g IV Q12°
[ Gentamycin mg IV load & pharmacy to dose
) Cipro mg IV Q12°
[ ] Clindamycin mg IV, Q ohr

[ i Penicillin G, Million Units IV Q hrs
[ Unasyn gram IV, Q hr
[ ] Transfuse units packed cells

b)(6)-2
13.
DR SSINGS:

14.
DR • INS:

15.
RAD OLOGY:

16.
OTH

)(6) -2
b)(6)-2
DOCTOR SIGNATURE:
,TIENT IDENTIFICATION b)(6)-4
LL NAME:
LL SSN: U`)
MEDCOM - 4994

DOD 12206
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PHOBLEM ORIENTED MEDICAL RECORD rEm IS USED, WHITE PROBLEM NUMBER IN COLUMN INDICATED RY ARROW BELOW.
'ENT IDENTIFICATION
DATE OF ORDER LIST TIME ORDER NOTED A :b)(6)-4 SIGN
A,, ti ,=(-(Kn.\--
L'))
14 ,,5.1/ is,-(2D
(
NC UNIT ROOM NO BED NO.
IENT IDENTIFICATION
TIME OF OROER
HOURS
•,ry
•,•
1.) { ,
LAD
CI UNIT(ROOM NO. BED NO.
TENT IDEINTIFICAT1C.)N DATE OFCADERI ve..4
(b)(6)-2 VS /ler 0 30°
URS
151N0 UNIT ROOM NO. BED NO.
IENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
IS INC UNIT ROOM NO. BED NO.
o
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
ic.opnR ,9 4256
O U.S. GO"..."...".( '^"(— 0
MEDCOM - 4995
DOD 12207

DOCTOR'S ORDERSMEDICAL RECORD
(Sign all orders)
DATE AND TIME RE
DOCTORS NURSE'S START STOP SIGNATURE SIGNATURE
DRUG ORDERS
7;"211.-•---.0to.--oCo--.--Y-4:71C-*-.
34—. 'Le-45
/ 4".:4".'"oa.-,,y-4.-4Are.,
h)(6)-2
1_7 C 6 C
kbt-Ye34
4,,d
I:
5)(6)-2
_0 "7 #f ir 62.41:,
.01°43 /,
L.,... 1-6(----l%(/lloxo-2
0 .M 6 iliet
o
61116P
(Continueon reverse side) PATIENT' S IDENTIFICATION (For typed or written entries give: Name • last, first. middle; grade; rank; rate; hospital or medical facility) REGISTER NO WARD AO
:b)(6)-4 DOCTOR'S ORDERS
MEDCOM - 4996 STANDARD FORM SOS Mow. 10-761 PTsacribed by GSA and 108411 FIR MR (41 CFR) 201-45.505 508-111 U.S.G P.O., loss -491-248/20237

DOD 12208

(

MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
START STOP sx DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE
.oA . . (1 k kW\o40.oQV\-V) •ot‘)oOV - . . -\-oc\ a \/
ci),.(65 ,/(L (tkektt(AVq,
h) (L\(--
t.(\Q,ANit(oclk(fic(stcq_skil M V-. ck5
0.,N)-),6)),( ciki ,.),.iadt 1 ' s
.0itiN\, ;ovi,s.­_Ct\cl i
\J l')( s\oki.--
k.;,),‘ i,6cVogj
k,r( ttO I I I(A , I II. 1210
b)(5)-2 ;:-(,.'\,=,'J,0,L ,09.,-k) Ac.i,
Aftck(1.__.1)(t;1 t .
1\1(°
tto* i(
1\('(rie,t) R f-t\T
1,w0A__ u ())=. b)(6)-2
l;M' IX.C.,D 5 ic$1

(Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or writlen entries give: Name - last, first. middle; grade; rank; rate; hospital or medical facility) REGISTER NO. WARD NO.
b)(6)-4 DOCTOR'S ORDERS
STANDARD FORM 508 IRev. 10-75)Prescribed by GSA and ICMR FPRIF! 1 01-11. 8088 nob-110 .
MEDCOM - 4997

DOD 12209

DOCTOKo.ORDERS
MEDICAL RECORD
(Sign all orders)
--DATE AND TIME---- - -o--
DOCTORS NURSE'S
FIX DRUGORDERS SIGNATURE SIGNATURE
START STOP
(b)(6)-2
6 6 Lz €-----,r,..._,
_
b)(6)-2
¦ 'AL
b)(6)-2
b)(6)-2
(b)(6)-2$ A-"C-, Q SVLR.
b)(6)-2 lr. •
0
b)(6)-2
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• (Pe) c-c/
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— A&C-erVie
b)(6)-2
¦OM=
O ele,4(lifil¦-• vAi, L.,,f' '(a

i
.......

(b)(6)-2
(Confirm, on reverse side)
REGISTER NO. WARD NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first,
middle; grade;r ank; rare; hospital or medical facility)
(b)(6)-4 DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75)
Prescribed by GSA and OAR FIRMA (41 CFR) 201-45-505 508-112
MEDCOM - 4998
NS": 7.5.16--634--:
DOCTOR'S . DEP"
MEDICAL RECORD
(Sign all o. _ 5)
DATE AND TIME
START I STOPoFRX DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE
1 AINES1•HES1A YALU-0R1LKS
• .mit to • •,I

y ir oiy,1111),
•
ap,•,ergies: ft,(4 ..."
WO-, ..(.
3.(Vital signs per PACU protocol.
b)(6)-2
_
02:(FM (q) 10LPM,(% Blowby,(/NY @ 2 LPM.
vo-oLA,oato1190occ r On ward: 02 @ 2-3 LPM via NC:(ES(NO ; 1(
Pain medication:( / Ketorolac(mg IV xl dose (adults 30 mg maii;•keds cOsider 0.2-0.4 mg/kg) ' b)(6)-2
1(
I( 1, CU,'' 't(, i •:!
(b)(6)-2 I MSO4 2 mg IV(q min pm; maxcclo,sE , , k(g
1(( .
! i Fentanyl(%-smcg IV q 10 min pm; Max cite(/OD mcg
/

Percocet(tab(s) p.o. with sip of water Other: L'1 8(Antiemetics:
\ -
Ondansetron(mg IVP, may repeat xl in $5 min co !mg/kg; max 4 mg) ; ‘NZ. -
Metoclopramide(Sing IV xl (0.15 mg/kg; max lb mg)(gdie,0,/-
fk-i(it° CC-:.-Droper4clal (mg IV x 1 dose (0.01 mg/kg; mar 0.625 mg) Must have baseline EC
available before administration.(

, ,.. l
)(b)(6) 2 L
Other( il(I--(' i./(Clear liquids as tolerated:(kj.1)' i(NO
----......--.
iNotify Anesthesia (pager 1506) for airway issue, pain, nausea/vomiting 1(
(
1(13)(6)-2(1
not responsive to above orders or other patient ploblems/con ern
[(per(PACU(protocol: .(
.( /(16,-)---/ (rev; 3/2002)( OVER)
)(6)-2
iCeniira.:e on reverse si PATIENTS IDENTIFICATION (For typed or written entries give: Name—lasElirst. WARD NO. rate: hospital or medical facility)
(b)(6)-4
DOCTOR'S ORDERS Medical Record
STANDARD FORM 508 IRev. 3-971 Prescribe:I by GSA.ICMR. FIRMA fa 1 CFR! 201-9.202-1
MEDCOM - 4999
DOCTOR'S ORDERSMEDICAL RECORD
(Sion all orders)
1,,,,I.,11.,, ¦¦ ,,,,Un- %.,
P. X,I DRUG ORDERS
SIGNATURE SIGNATURESTART I STOP,j,
I'
• • g II 411 'o I I *--t----,
* Uischarge patient horn PACU per protoco .(Y S(0
i(i .(I
121 When epidural/spinal patients meet discharge cr teria per PACU proto1ol,

b)(6)-2
discharge to ward. On ward: bedrest pending ft 11 recovery of sensory and
motor function; progress to ambulation with assistance.
(b)(6)-24---
FOR PACU KEEP PATIENTS ONL'
el

1
13. Release patient from anesthesia care to KEEP status when patisztLeets -----,N\
\..* 1 anesthesia discharge criteria: (YES(NO
.1/.. \(14. Notify anesthesia (1506) for airway management and: (circle if applicable) ) tlf t1:1)-Z(hi \ I Pain management( / i
.
[
b. Fluid management
I

c. Other (
TOW patient to ward in a.m. if patient meets dis barge criteria:
NO
b)(6)-2
I
Signature( Beep I , .)(6)-2
b)(6)-2
STANDARD FORM 5.06 IPt.r. 3-941 5A(
DOCTOR'S °ROO".
cDICAL hituor(u
(Sign all orders)
/DATE AND TIME START i STOP RX DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE
• • 1 II 'A Io'

Admit to PACU. Allergies: Ax ital signs per PACU protocol.
b)(6)-2
• (cp, 1 OLPM,(% Blowby,(_ NP (a_,).— /it LPM .
, MP ---I
Allio /o
V oPAII,occ/hr
vl
/-y
6. On ward: 02 @ 2-3 LPM via NC:(YE(NO 7.!(Pain medication:
_ Ketorolac(mg IV xl dose (adults 30 mg max; peds c .nsider 0.2-0.4 m•
MSO4 /—,;Z(mg IV q p`rti Max dos .(
S-
An ' ' '; g
b)(6)-2
Fentanyl fSmcg IV qc"--(Qn pm; max dose /Q mcg Percocet(tab(s) p.o. with sip of water Other:(VfirMINIMMMIlinkgrean rAID ,, -Li* 11971,
Antiemetics: Ondansetron(mg IVP, may repeat xl in 15 min (o.Im g/kg; max 4 mg
Metoclopramide(mg IV xl (0.15 mg/kg; max ID mg)
Droperidol(mg IV x 1 dose (0.01 mg/kg; may 0.625 mg) Must have ba3clinc ECG available before adminisotion.
Other
9. Clear liquids as tolerated:(NO

T
b)(3)-1(b)(6)-2
10. ,,Notify Anesthesia (I( for airway issues, pain, nausea/vomiting ! I(
not responsive to above (loiciels 6r other patient loblems/concerns
"¦]..
1 per PACU protocol. .(
I b)(6)-2
..._

Age,
41,.1.-11"-.41.¦"-,-.' . •,A31;¦ i,
-A0111o'4CiFativ/..........mar,o,---o
-'4 'i. Agraka-' AVAMilill119".. P141A911/11b) .3_o

. iconiin.e an reverse 5ifei PATIENT'S IDENTIFICATION (For typed or written entries give: Namelast, first. REGISTER NO. WA
—
findale: grade: rank. rate: hospital or medical facility) .. .. _.
;b)(6)-4 DOCTOR'S I RDERS Q8APRO.7 Medical Record STANEARD FORF.1 508 (Rev. 3-941 Presc(foed by GSA (OMR FIRMA 14 7 CFA( 201-9.202-1
o DOCTOR'S ORDERS
MEDICAL RECORD
DOCTOR'S NURSE'S
DATE AND TIME
I RX j DRUG ORDERSo
SIGNATURE h. ¦
STARToSTOP
0 uischarge patient trom PACU per protoco1.40 NO
12. Wheri pidural/spinal paten• meet discharge criteria per PACU proto ol,
-
'Ise arg- to war..(en wars :(: -.rest pens ing u(recovery o sensory a.
1
motor uncti • I; progress to ambula on with assiistance.
FOR PACU KEEP PATIEN S ONLY
13(, Release patient from anesthesia care to KEEP status when patient meet's
anesthesia discharge criteria: (YES(NO
14. j (1506) for airway management and:Notify anesthesia (circle if applicable)
a. Pain management
b. Fluid management
c. Other( .
1

TOW patient to ward in a.m. if patient meets discharge criteria:
15.(! YES(NO
(b)(6)-2
7
Signature_ g.eper (../
. 0(6)-2 .,...., I i.CAUM
mrail:§0
b)(6)-2
.
STANDARD FORM 5081Rev 3-9,11
'IT/POST OP)

DOCTOR'S ORDERS (ORTHOPEDIC(.

MEDICAL RECORD
(Sign all orders:

.
DATE AND TIME

DOCTOR'S NURSE'S

.

.DRUG ORDERS

SIGNATURE SIGNATURE

START STOP

b)(6)-2
ADMIT TO: ORTHO STAFF; (b)(6)-2

.F

gEr4w.

393, WARD:.
DX :.

it c)e,./.--Pse. 0-1^0
-21.-.

14) (")444)L1:3

CONDITION: STABLE I
ALLERGIES:

&Mut-. --104--
VITAL SIGNS : Q 1 hr X 4 TBRU Q 4 hr X' 24 hr THEN
Q 8 hr
NURSING:

-N /V CHECKS W/ VITALS
-I & 0 s -

1 q 8 hr x 48 hrs.
..._

Foley to gravity (remew.e—ra
(Ili... .

drain to self suction -t.-

ar..aaz-i-n§-cdT-pory-r-2-
Diet: Clears, advance as tolerated

1-7)
Activity: +031())¦.,,Th 10hr S:a
0)(3)-1
Av,?ft.o\01.evyls.
CHEM 7, CBC in AM;; fCBC q AM POD # 2 & #3
hr

LABS-:.

Pus,J cx)c.c1 tr. r--
MEDS : -
Ancef ig IV q 8 hr x 48 fir 164 thiaBle 62'

AIC)42 aCIDS

--Gela4aMi-erjal-04-"Illg IV q 8 hr .x 48 hr OR
Gefttettlye4m7-1-57.5mg/kg).

-

mg IV. x 48 hrs
--Nimaari-n-stnnTlr-scr-TT-hr
ovenox 30mg SQ BID

9

-MSO4..

mg IM or Iv q 4hr prn pain significant 0 - Phenergan 25 mg IM or IV q 4 hr prn . Percocet 1 -2 tabs po q 3 hr--}.AM C
-pain moderate

c¦,),b)(6)-2
9 -Tylenol 650 mg po q 4 hr prn .

(b)(6)-2
-MOM 30cc po q 4 hr prn
-Benadryl 25mg po q 4 hr prn
Surfak 240mg po bid prn
Other Meds:

b)(6)-2
trz. -t)
Call Ortho tech for casts, splints, traction

b)(6)-2
7.PYI

.eJ__X=raysimt or cast bivalving .

v....(b)(6)-2
CL.-, iso -roc,bon lh
.

nits
Type and Screen for .

units

arse aide)

(b)(6)-2
PATIENT'S IDENTIFICATION

:b)(6) -4
r(3)-1
DATE AND TINE
START STOP

•

\

RX

r\R\
k --.)

0,

18

,n
20

(Ii)

23

S ORDERS (ORTHOPEDICS ADMIT/POL.Doctor's
(Sign all orders) Si nature

DOL.2)

-ta-all exposed
plas---

Fiff-care---4 striangth-14202,--q A /"1.

ch nges.)cn,

()Dossing 110s..A... lk.rok-- -4-0 ct.

-

(...VO.WreLC)

-.

Tractio.. a--
cda,01-4-1A--,CArN C-z-RIC Icik .ii(-e
(Asp 0,45i2., _cb-voiret., ..f.C..-, Sia

•misc:
LEM

If N / V changes occur, call Charge Nurse / Ward
Medical Officer to'assess and bivalve cast if
present .

If UOP 30 cc/hr, bolus .50.0 -cc NS and-assess

-

Call Ward Medical Officer
improvement.
Oxygen:.n

results..-if no

„4:n.

oArzs-Lozst,ec

_Physical Therapy:_

l\st-Te_..

Tatil T1,-,o5c„92_ aoee4))c
:b)(6)-2
7
t-

Nurse's

Signature

0:0(6)-2

b)(6)-2

(b)(6)-2

'ICIAN SIGNATURE)
000)-2

.---.

....

L-C--

V,_,ca
Lex -I I ",
b)(6)-2

PATIENT'S IDENTIFICATION
b)(6)-4

DOCTOR'S ORDERS (ORTHOPEDIC.(-T/POST OP)
MEDICAL RECORD
(Sign all orders)

DATE AND TIME DOCTOR'S NURSE'S

. DRUG ORDERS

START STOP SIGNATURE SIGNATURE

ALLERGIES:
VITAL SIGNS: Q 1 hr X 4 •HRU Q 4 hr X 24ihr.THEN
O 8 hr

3
NURSING:
-N/V CHECKS W/ VITALS
-I & -0's q 8 hr x 48 hrs

-Foley to gravity tre--drave--6—A=M-r-len----(),
-drain to self. suction -Remove wound dressing and replace w/ sterile dressing on RD #2
•i Diet: Clears, advance as tolerated
F\40-e-e-Lifv

Isn- •
:b)(6)-2
• 11
LABS: CHEM 7, CBC in AMS CSC q AM POD # 2 & #3 1(D5LRG1100cc/hr MEDS:(.(.(
roJe-x:F4-°50
-Ancef lg IV(hr x 48 lir / 730
.,1.4"• ¦ - • ¦ ••
-Gentam -7.gmg/kg)..

mg IV x 48 hrs SQ q 8 hr i! Loveno 30mg. SC?BID.
•

-MSO4 IM or IV q Or :prn pain significant -Phenergan 25 mg IM or I10q:4 hr prn Percocet 1 - 2 tabs po q3 hr .pen-pain moderate
Chi r^
Tylenol 650 ng po q 4 hr!;prri. MOM 30cc pa cf:4 hr prn Benadryl 25mg:,po'q 4 hr prn
Surfak 240mcr do bid prn
Other Meds:

12.
Call Ortho tech for casts, splints, traction
equipment_ cast bivalving
x-rays: 4[1 pi/.

7k—

%TrAnqfvigip.unit-la—MK if HCT less than
15, Type and Hold for _____ units
Type and Screen for(units

CT WITCF)

(Continue on reverse aide)
ATIENT'S IDENTIFICATION (b)(6)-2
p)(6)-4

— — NA C 1)5)4--
b)(6)-2
MEDCOM - 5005
DOD 12217
DATE AND TIME
Rx

START STOP
16.

17.

18.

229

23.

PATIENT'S IDENTIFICATION
P)(6)-4
Nurse's

S ORDERS (ORTHOPEDICS ADMIT/POS 1).
(sign all orders) Signature Signature

ed

DOC.Doctorla

Dressing chan es

BSD +0
ose

misc:
scan .-:- ---J&f,-br.
ccto of4-(
tti
Iry„,\A eiv yU-1,VI-614 derPt-e-
•-_,i,,s,,,
,ceye5-t-r-.
a\ M e(\Pe ?Le)
If N / V changes occur, call Chaege Nurse / Ward

Medical Officer to assess and bivalve cast if
present
If UOP 30 cc/hr, bolus 500 cc NS and assess
results. Call Ward Medical Officer if no
improvement.
Oxygen:

Rs
Physical Therapy:

b)(6)-2
(b)(6)-2
ot
b)(6)-2
DOCTOR'S 'L.., ERSMEDICAL RECORD
(Sign all orders)
DATE AND TIME
DOCTOR'S NURSE'S
RX DRUG ORDERS SIGNATURE
SIGNATURE
START STOP
b)(6)-2
„•„.., ,,,,,_, ) 4-3,7
(b)(6)-2
, tv
c--,,...._(
g(,_,Co L,.,,..., ...(fi k,
3_,
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4-..,,
(b)(6)-2
,--401-e-,k v....,.Al..
P7 . - - (;A.,,,e_ Gam-, 4(C * 7c) 3 Arz-z
13)(6)-2
b)(6) 2 b)(6)-2
1

\14.3v,,,0,4)\\0 2--S -2-1-t, • :-.,,
07 .4,5s., \-5 d) (4 i.-..,(,s--4.-0--e__ ,...
4-6 -e....e.„-,....:1.--,--7.7
(b)(6)-2
,b)(6)-2
i.IIP 0,my III.•lIlie.
It 1 , ....-av•
b)(6)-2,
lir,- A--
(Conn
REGISTER NO. WARD NO
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)
DOCTOR'S ORDERS
;b)(6)-4
STANDARD FORM 608 Ines 10-75) Prescribed by GSA and ICMR FREI 101 11 806-8 508-110
MEDCOM - 5007
DOD 12219
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all orders)
DATE AND TIME,I
DOCTORS
START SIGNATURE

X
DRUG ORDERS NURSE'S
STOP SIGNATURE
,(b)(6) 2
Ila
6
II, •lIt 7... _
(b)(6)-2
0c

fee-L-, L4(iII
OV"
b)(6)-2
.
(b)(6)-2
--c
....
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-----sc o• o
bm-2
c.N--
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I.

/

cr.i ..,..' ,';'7'7' .,.Vs'',;•.;,',,' •,..,,,,..( ,...-:;,:.....,...,. (b)(6) 2
'..:44. N,,1-,.. : • -
.,,
.041,1.gm
srliellir ....1116/ 41o. ._ -00111111Mo:

Pr

AVIIIIMIIIMOr
difialki=1.44oimptALP___ IIIIP

t*Iiran
....--A.41111111/MIV
b)(6)-2
,e/t/t'Ll
t--,(.4.1
( D tw,`) 74,,
(b)(6)-2
64,
on :nue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries aive: Name - )a%r nr‘, (I mcnierro. middle; grade; rank; rate; hospital or medical facility)
b)(6)-4
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75)
PreacrIbeday GSA and 10.419 FIRMA (41 OFR)201-45-505 508-112
MEDCOM - 5008
DOD 12220

508-11 ),:sN(
I ,•
DOCTOR'S ORDE
MEDICAL RECORD
(Sign all orders)
DATE AND TIME
START i STOP RX DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE

--
N--¦ ;b)(6)-2
i 7.---7 .1/4 /
Allergies:(
aova
I _.,.
,

3.(Vital signs p -PACU protocol.
AL tow(• or •(
,(•(• 1r ,'o: OW • y, 1 •,,,• v
at(6-1g-) cc/Ir
IVF:(______(i(-7-¦
On ward: 02 @ 2-3 LPM via NC: (YES(NO Pain medication:
i I Ketorolac(mg IV xl dose (adults 30 mg m a ; peds c )nsider 0.2-0.4 mg/kg) I I.I. r/ ( i
1 MSO4 (— L_-mg IV q ...) ‘-Ymin pm; max dose, l't ..(mg Fentanyl(mcg IV q(min pm; max dose(mcg Percocet(tab(s) p.o. with sip of water
k----)(Other: Antiemetics: .(Ondansetron(mg IVP, may repeat xl in 15 min (0 1o)
-rn-.11:. -g; max 4 mg
, Metoclopramide(•(mg IV xl (0.15 mg/kg; max 10 mg) Draperidol(• :( e . .
available before administration.
Other Clear liquids(as tolerated:(YES(NO
1 0. i(Notify Anesthesia O b)(3)-1(f'or airway issued, pain, nausea/vomiting_
I not responsive to above orders or other patient pri o blems/concerns
(
I
¦(per PACU protocol...
1
i( (rev; 3/2002)( • • (OVER)
'(1 I((
(Cdminue on reverse side)
PATIENTS IDENTIFICATION (For typed or written entries grve: Name—last, first. REGISTER NO. middle: grade: rank: rate: hospital or medical facility)
b)(6)-4
1 Y(' DOCTOR'S ORDERS
_,
Medical Record

STAINIDAP.5 FOR1.1 508 'Rev. 3-941 Prescnnetl by GSA.ICMR FIRMR 141 CFR) 201-9.202-1
ig0 MEDCOM - 5009
DOCTOR'S ORDERS
MEDICAL RECORD
(Stan all orders)
DATE AND TIME START I STOP 1 RX ANESTHESIA PACU UKDERS — COM IN DRUGORDERS DOCTOR S SIGNATURE NURSE S SIGNATURE
.1...; thscharge patent trom PACU per protocol:(Y ' ,NO - )0)-
11(hen Cpl III d spinal patients meet discharge criteria per PACU protolol,
d s(arge to War21\ On ward: bedrest pending frill recovery of sensory and
motor fu ction; pro(ess to ambulation with assistance. .
FOR PACU KEEP PATIENTS ONLY
Release patient from anesthesia care to KEEP status when patient meets
anesthesia discharge criteria:(YESoNO
14. Notify anesthesia (1506) for airway management and:((circle if applicable)
a. Pain management
b. Fluid management
c. Other
15.(TOW patient to ward in a.m. if patient meets disbharge criteria:
YES NO
(b)(6)-2
Signature , b)(6)- Beeper I ."..1.81e4-

STANDARD FORM 5O IP.ev. 3-Sdi 3AC
....11r¦olari•¦••
DOCTOR'S OR, 4
MEDICAL RECORD
(Sign all orders)
DATE AND TIME
ittART STOP Rx DRUG ORDERS DOCTOR'S

SIGNATURE SISNRRIN
(b)(6)-2 _ b)(6)-2
\ \ p 1-4.11A.A. D 04.v%. .... _(.(... -
¦, ‘Si 9 11 7 , II( k
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•

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1-
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Ki¦mo‘ '

III •
11° a • L,. v-i---,
ta
tto
,b)(6) 2

,,..,*d Lct(Last­
-11
(Continue on reverse side)
REGISTER NO.

PATIENT'S IDENTIFICATI For typecrararrittesi-enteimgivralame-.4ast rErstr--
amlifY) middle; grade rank; rate; hospital or in

b)(6)-4
URI S ORDERS • STANDARD FORUM Mac WAR
Imierlbed by GSA andlOMI
FIRMA (41 CFR) 201-45.505 50B-111
st U.S. GPO: I 1111h201.7110/110874
DOCTOR'S ORDERSMEDICAL RECORD
town am oraerti
DATE AND TIME
DOCTOR'S NURSES START STOP SIGNATURE SIGNATURE
RX DRUGORDERS
-,.

—,A"....:) ;..1„...,-,,,,,..._ _ (... _ ,,v,..y.e... lam a/IA.1p , (-7.44--S 4 -73-1
.
b)(6)-2,
II
b)(6)-2

6\I 0 SAN.A2-
7
(b)(6)-2
e(CIA1 ,

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(b)(6)-2

7.-0 6 3
(,-;`-t`' cl"a„..a-• 'frb.--66 ID-
, 1 ,0 b)(6)-2
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•---ii.

•• EN
b)(6)-2
r rOS
(b)(6)-2

• _Am isl• 1 S-b`-
Alr

21
41.. (Continue on reveri tide)

PATIENTS IDENTIFICATION (For typed or written entries give: Name - I t, first. REGISTER NO. WARI1 NCI,
middle; grade; rank; rate; hospital or medical facility)

1(b)(6)-4
I
DOCTOR'S ORDERS
prItoTsiDyFORM2dOtr. 10-75)
FIRMA (41 CFR) 201-45-505508-112
MEDCOM 5012
-

DOD 12224

40".•
• WO

DOCTO. JRDERS
MEDICAL RECORD
(Signlordeal
-----... • -OkTE.ANDIIME-o-
NURSES START STOP aka% SIGNATURE
I RX DRUG ORDERS

G AK_ c) i Loo I ••
0 .._.--R_ gni (.:47 e_ 77 / /U1/
(b)(6 )-2

4i/i.;/P b)(6)-2
r-N 1 7•-•-.---_-----.
__.------\-

--.)-•
c2 4..( .4.,,,i--1,11 , i-,, 4.-. kli(
-' ( .
,....--...„.s
.
. . . . . . .

--__..(: 6 1 ,.-44,....5 ) 1...(...15 4:16....,esra-:-•-•'
.(:(, :10)(6)-2
••••______------. ,I

....., 00:'000,¦!..../•--
/11111111111)(6)-2

raggallin _.. ,
A Pr--03 cf(
C-4-. P 4) :oSI: Le-

t•• 6...-o1-1,-rfrt r t i-,f,SI:la
C.
IN--62 1.. -rs..-,.-.o1-:, r( n

(le4 CC101l(IA( (7.--5 41 ("n lei
(b)(6)-2

N-sNN-........___ (b)(6)-2

,--

(1....pia ,Kic...„ (b)(6)-2 UUP ( iv-
Vii )0 3 pr C 14-d J .(lit- IX! ,,,--(7 0 -(a i
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, REGISTER NO. WARD NO. middle; grade; tank; rate; hospital or medical facility) II
DOCTOR'S .ORDERS
(b)(6)-4
STANDARD FORM 508 (Rev. 10-75)
Prescribed by GSA and ICMR
FIRMR (41 CFR) 201-45-505
508-112
MEDCOM - 5013

DOD 12225

79 •

MEDICAL RECORu -----o-DATE AND TIME-- --RX START STOP DRUGORDERS DOCTO.oJRDERS (Sign all order:0 DOCTOR'S SIGNATURE NURSE'S SIGNATURE
13)(6)-2

CO ocl(u-1-4-_•,•

q 3
aei„,14,e. .g-D Ali .e, ! . '
0
I I. ii (bAa, &K. si 0-
cc,,,,,,,R.,s,..,,--T---(eEc._
b)(6)-2
IL&(C--• 6o1VC/LjA__¦
4thoiA-Tol ... 761-ogieD
. b)(6)-2 b)(6)-2

tr14Y, °—
US14

b)(6)-2
,),,,c1 o3 77 ,LA.,A .e__l_l.. ' )(6)-2
elti4a a,ii(e A„_ a-tc f ,„t,„....!
b)(6)-2

s.
--..
.._
On I) CLPNA,C.i,tif C.c.:-A--1 0"-.lr- a
ctlitio 3o004
(Continue on reverse tide)

PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first. REGISTER NO.o WARD NO.
middle; grade; lank; rate; hospital m- medical facility)

:b)(6)-4
DOCTOR'S ORDERS
STANDARD FORM 505 (Rev. 10-75) Presclibed by GSA and ICMR FIRMR (41 CFR) 201-45-505
5013-112
MEDCOM - 5014

DOD 12226
DOCTO. JRDERS
MEDICAL RECORD •
(Sign all order!)
---• DA:7E AND.TIME-• -
• ----
DOCTOR'S NURSE'S
DRUG ORDERS
SIGNATURE . SIGNATURE

START STOP
b)(6)-2

I gi 517 • DU-e_A/ (1-,-P-0 15/A
b)(6)-2 b)(6)-2 t)(6)-2
/lam
' J

. .
-(b)( 6) -2

e),9)
2.n id ....4,•
Iff6 .R-
AA. .[CAF2SZ .

..)

--•
. )(6)-2
113)(6)-2

• 1-R7 kier i I V4
(

1'4 C---
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fiq3

..:50
p7(.
.....--la P .5 expo 0 r At 44424, P 0 IRA( I_ 0 0 ,1) Fe 0 te S7);..., 1-1 0 : 4 „, ,e, (b)(6)-2
0 ,
(b)(6)-2
'I),

_
3,231r,0-n9ke igNITY--
(Continue on reverie iielel
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last. first,
middle; grade; rank; rate; hospital or medical facility)

b)(6)-4
DOCTOR'S ORDERS
STANDARD FORM SOB (Rev. 10-75) Prescribed by GSA and ICMR FIRMR 141 CFR) 201-45-505508-112
MEDCOM - 5015

DOD 12227

DOCTOR'S ORDERS
MEDICAL,RECORD
(Sign all orders)
DATE AND TIME DOCTORS, NURSES
RX, DRUG ORDERS,

START,STOP SIGNATURE,SIGNATURE (b)(6)-2
.7,AAA °Pio,A,veu.) 00)05 57,4,0e, 2.0,003 6 1130 —
4123q53,
'Ltd),

(b)(6)-2 6 1 S-6, i dr,UL.U;31tdee:a.;N•--), X1/4--it
b)(6)-2 — q 25 03,Fir
c,,r2i, 0 _dolt,
c.„..3i--,-if---,ilex).,74,40,
,-
7 b)(6)-2 ill
mi
Mk

b)(6)-2
4/ I 3 ,, #,rAge 0..¦

afi,il,A.,-,
b)(6)-2 &,DO Tf..S --, , e,------
(b)(6)-2
111,10,

R1.111.111Mal -
v ti Qv.3
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4

W ,b)(6)-2,
1,1-Ab b)(6)-2
i

b)(6)-2, ,kL.S4.,
b)(6)-2
EL 3 COS",APA-

NN,

iTilLg-
a
(Continue on reverse side)

PATIENT'S IDENTIFICATION (For typed cr written entries give: Name — last, first, I REGISTER NO. I WARD NO
middle; grade; lank; rate; hospital or medical facility) 1(b)(6)-4
DOCTOR'S ORDERS
STANDARD FORM 608 (Rev. 10-75) Prescribed by GSA ind ICMR FIRMR (41 CFR) 201-45-505 508-112
MEDCOM - 5016

DOD 12228

Standard Worm 508
DOCTOR'S ORDERS
CLINICAL-RECORD (Sega all oregss)
D M AND TUNE
DRUG ORDERS'

START STOP
Be DOCTOR'S SIGNATURE age form and content of active ingredient(s), may be administered SIGNATURE UNLESS checked here) -. (Another brand of a generically equivalent product. identical In dos-NURSE'S
A ti Able o3 IC AA all -lftt. f
' it c_sFly 3 2 C --..ts Rd gi n 44a CfrefLo[
6-Qc.ckl( c r- 2 .....xlro 6.1 0le/ec¦-)o3 Q, 4 - - - c . .a
cercoi-60)-0--Pc7 11(-/tr 7 r,-(.. leAl leil-.e.-•--..,l-... 41/.
0 ge,,lja„,,4o"fri_vt--tc-. `--*
,(b)(6)-2
,0.4,74•11,9-th-;-a4-%,ce5_____ __,2----16--•
44-Le-c.,,v14, 6011L---t 1

,:::,,g..e.
b)(6)-2
‘... \'`,............................ b)(6)-2

A__
_,b)(6)-2

k) e 0 e /VW 4;3-6-'De,_ 1,1 .....

)
it 4cle (1161)
b)(6)-2
0)(6)-2 --Thjele-k,Czt/ t I i‘ 4 hif 64/
b)(6)-2
OPAJ

g:I LIZLV___
(Continue on revery, Jide j

REGISTER NO WARD NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, fist, middle; grade; date; hospital or medica facility)
(b)(6)-4
DOCTOR'S ORDERS

g Standard Fawn SOS 50S-109
General Services Administration end
interasency Committee on Medial Records FPACR 101-11.806-8 October 1975
MEDCOM - 5017

DOD 12229
(
508-
o
MEDICAL RECORD DOCTOR'S ORDERS

o
NSN 7540-00-634-4121
o
(Sign all orders)

DATE AND TIME
oRXo o

STARTo DRUG ORDERS DOCTOR'S
STOP NURSES
SIGNATURE

SIGNATURE

ANESTHESIA PACU ORDERS
Admit to PACU.

.06 ileP9-7,riov
o
b)(6)-2
ergies: Nikoa ita signs per 'A i protoco

02:(M @ 10LPM,(% Blowby, NP @ 6 —IVY': Rt.-iso(( b)(6)-2
cc/hr

On ward: 02 (g), 2-3 LPM via NC: YES NO ft,v,.% 957
Pain medication:
Ketorolac(

mg IV xl dose (adults 30 mg max; peds u nsider 0.2-0.4 mg/kg
MSO4 4-mg IV q S mm pm; max dose / a- mg Fentanyl(mcg IV q(min pm; max do Percocet(
tab(s) p.o. with sip of water vner: ( Antiemetics: Ondansetron(

mg IVP, may repeat xl in 15 min (O. Img/kg; max 4 mg) Metoclopramide (
mg IV x I (0.15 mg/kg; max 10 mg)
b)(6)-2
I
" •

0.625 .11g) Muat Ilnyv Inwtlint E 1 Gavailable before administration.
Other
0)(6)-2
Clear liquids as tolerated: NO
b)(3)-1,
Notify Anesthesia (page(I for airway issues pain, nausea/vomitin

1 _.1(13)(6)-2
not responsive to above orders or other patient prbblems/concems
-
I—
, per PACU protocol(
b)(6)-2

iri/2-002)
(OVER) I

PATIENT'S IDENTIFICATION (For typed or vitit
't te -atries give: Name-last,V.
REGISTER NO.

, I WARD NO.
cal facility)

b)(6)-4
b)(6) 2
DOCTOR'S ORDERS
Med,;:al Record

DOCTOR'S ORDERS

MEDICAL RECORD
(Sign all orders)

DATE AND TIME,]
DRUGORDERS DOCTORS
FIX
sEVAERE ANESTHESIA PACU ORDERS -- CONTII-N 1.:1)
START,STOP SIGNATURE
,.•
0)(.)-,

AMIN
MIA3_,uisc arge patient rom (A i per protoco :(' 10 • II t•SAYM 2ticil) c't .) MI
!ii(When epidural/spinal patients meet discharge cri eria per PACU protoc•1
I
• scharge to ward. On ward: bedrest pending f 1 recovery of sensory •nd motor(nction; progress to ambulation with assi.tance.
F 0 R KEEP PATIENTS ONL

I Release patient from Ilesthesia care to KEEP st. tus when patient meet
13. ,..
I.(
ani stkesia discharge criteria: . YES NO

14. Notify an-, esi. b)(3" • • • and: (circle if applicable) NN
a.
Pain mangy ement

b.
Fluid management.,

,,
c. Other

15. TOW • atient to ward in a.m. if • atient meets dis har e criteria:
¦
YES NO
b)(6)-2

Mill

wiorm
(b)(3)-1

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STANDARD FORM SOS (Rev 3--941 BACK
MEDCOM - 5019

O
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
START NURSE'S SIGNATURE

09 5 b)(6)-2 b)(6)-2
(b)(6) -2
Do 0 MERL

b) 6)-2

b)(6) 2
c:2 1-11 r (Con PATIENTS IDENTIFICATION (For typed or written entries give: Name - last, first, middle: wade: rank: rate: homiest nr 1,,..a• r (b)(6)-4 GiSTER NO. b)(6)-2 b)(6)-2 JY11j/
b)(3) -1o DOCTOR'S ORDERS
MEDCOM -5020 STANDARD FORM SRI IRot. 10411 Procriboi by GSA and ICRER FIRMR (41 CFR) 201-45.605 508-111 *U.5. O.O.o$$$$$

DOD 12232

DOCTOR'S ORDERSMEDICAL RECORD
(Sign all orders)

DATE AND TIME
START STOP RX DRUG ORDERS DOCTOR'S NURSE'S
SIGNATURE SIGNATURE
b)(6)-2 . a,b)(6)-2

V/ 6 Ia a y /4 4.--ltk: Afi , -- - ditl,,,.. 6±d,
b)(6)-2

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b)(8)-2 b)(6)-2
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/ z It . .... [(Continue on reverse side[

PATIENT'S IDENTIFICATION(For type(4nten entries give: Name)last, first, middle; grade; rank; rate; hospital or medical facility) (b)(6)-4 IwiAL
STANDARD FORM 508 IRev. 10-751 Prescribed by GSA and ICMR
FPMR 101-11. 806-8 508-110
MEDCOM - 5021

DOD 12233
508-112,
7540-01-044-5515
DOCTOR'S ORDLAS

MEDICAL RECORD
INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send b Pharmacy after each order Is icitbm. DATE AND TIME DOCTOR'S NURSES
DRUG ORDERS

START STOP SIGNATURE SIGNATURE
•b)(6)-2

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)(6).2

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al

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111

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b)(6)-2
drtimrh4.

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1,b)(6)-2

e,e side) .
rim

PATIENT'S IDENTIFICATION (For typed or wr ten entries give: Name—lest, first, .I REGIS1 1.1Z2,...._
S.

• :(.s•-•:• • C-L( •
(b)(6)-4
^ r(1' • • "
MEDCOM - 5022

DOD 12234
,
508-112 7540-01-044-5515

DOCTOR'S ORDERS
MEDICAL RECORD

INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S NURSE'S
DRUGORDERS

START STOP Rx SIGNATURE SIGNATURE
• )(6)-2
....,.

Ok (72.-07 -.
------¦Al

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1 b Ari ( V; cec
b)(6) 2
.

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t)...)-(b)(6)-2

0 151'7 e-t -tel'L" °,n¦%A-,
.,
.
1COniniue on reverse side)

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first,lREGISTER NG. WARD N3• middle; grade; rank; rate; hospital or medical facility)
••_.(•-- ....(•
-- • -•, -
,(k hecc;L

^ r,,,• coo !!7., • r r •
MEDCOM - 5023

DOD 12235
(
THERAPEUTIC DOCUMENTATION CARE PLAN (NON MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407; -Mo. yr.
thp o ownegt actRrN is he Office of The Surgeon General.

-(--(-----
I,Ill/It li I 1AT II A L I N G :::1:;:10;11k:;'; ..:.' INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK./ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

--k %
46.

0)(6)-2 (b)(6)-2
44.ca.: -11,c.--pp._ 6-7
b)(6)-2 K b)(6)-2

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ALLERGIES(111 YES(El NO PRIMARY DIAGNOSIS' ADDMONAL PAGES IN USE
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61.2.vi
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1 f
PATIENT IDENTIFICATION'( 7
b)(6) -4 ACTION TIMES USE PENCIL.. CIRCLE ACTION TIMES
r-1.ll,fl,4 /-1,44,A ,1,4 .J,14,i 0
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 o EDITION OF 1 DEC 77 MAY BE USED( US A PA
MEDCOM - 5024

DOD 12236

Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
Order,Clerk Date,Nurse b)(6)-2 L7( SINGLE ACTIONS (6'43,6i91-6 Data to be Done 13 T rne to ne Done ST-4 Time Done I i a Is ,b)(6) -2
,b)(3)-1 40-, tifr7A,/

Order/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk/Expir
Dale Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
LISA PA V •
THERAPEUTIC DOCUMENTATION CAk.
(MEDICATIONS) Mo.
SINGLE ORDER, PRE-OPERATIVES Date to Time to
be Given bo Given Tim e Given loltlais

Order/ EVIr Clerk/
Date Nurse INITIAL PROPER COLUMN FOLLOWING; ADMINISTRA770N
b)(6) 2 TIME/DATE DISPENSED
X.)(6)-2 b)(6)-2

MEDCOM -5026

DOD 12238

CLINICAL RECORD
Th.....APEUTIC DOCUMENTATION CARE PLAN
For use

of this form, see AR 40-407; 2DICA
oTIONS
the pro nent a ency Is the Office of The Surgeon General.
o)

................. Mb. __Yr,

... . .
.PROPER

COLUMN FOLLOWING
EACH ADMINISTRATIOI
DISPENSED

ALL. ERGIES:
y Eo
0 NO
V DIAGNOSIS::
g ts-kv
TIONAL
P
AGES IN USE,

PA rIEN T IDENTIFICATION, )YESoNO PAGE NO.
Alp

DISPENSING TIMES
(b)(6)-4
P NCILC/RCL E MED TIME.
D

7 8 9 10 11 12 13 14
E
15 16 17 18 T9
20 21 22

DA
FF-7 1
(ng 4678 EDITION OF N 23 24 01 02 03 04 05 06
1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 5027

DOD 12239