Medical Report: Iraqi Male re: Gunshot Wound

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I -REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood REQUESTING PHYSICIAN (Print)
Cell Products ore requested.)
VI, RED BLOOD CELLS

b)(6)-2
0 TYPE AND SCREEN
. FRESH FROZEN PLASMA DIAGNOSTS uu t wE HA I IVE pROCEDURE
CROSSMATCHEI PLATELETS (Pool of units)
6SW
. CRYOPRECIPITATE (Pool of units)
DATE REQUESTED
I have collected a blood specimen on the below

2,4, /pi, z...s,3
Rh IMMUNE GLOBULIN named patient, verified the name and ID No, of

O
DATEDAND HOUR REQUIRED the patient and verified the specimen tube label to OTHER (Specify) be correct.
0 26 PP r;2,0-00
VOLUME REQUESTED (Ifapplicable) KNOWN F RODY SIGNATURE OF VERIFIER
OMATION/TRANSFU-SIONREACTION (Spifyec b)(6)-2
R )

D ML
REMARKS: I F PATIENT IS FEMALE, IS THERE HISTORY DATE
OF: Ed IAA, 4?3 RhIG TREATMENT? DATE GIVEN:
TIME VERIFIED
,10
HEMOLYTIC DISEASE OF NEWBORN',
SECTION II - PRE-TRANSFUSION TESTING

UNIT NO. TRANSFUSION NO. PREVIOUS RECORD HE K5
TEST INTERPRETATION
:13)(6)-4 (b)(6)-4

ANTIBODY SCREEN NO RECORD

DONOR RECIPIENT
CROSSMATCH NOT REQUIRED OR THE
REMARKS:
ABO

exit) Y/373
Rh Rh
0.1

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA F OST-TRANSFUSI INSPECTED AND ISSUED BY (Signature) AMOUNT GIVENDTIME DATE OMPLETED INTERRUPTED :b)(6)-2
Get)

ML ozLo 7 2.7 REACTION
SUSPECTED

AT (Hi ) 3 (b)(6)-2 )N (Jets) 2141,11r
IDENV Ago If reaction is suspected -IMMEDIATELY:

1. Discontinue transfusion, treat shock if present, keep intravenous line open.I have examined the Blood wmponent container label and this form and I 2. Noti fy Physician and Transfusion Service.find all information identifying the container with the intended recipient 3, Follow Transfusion Reaction Procedures. matches item by item. The recipient is the same Person named on this Blood 4. Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to
Component Transfusion Form and on the patient identification tag. the eloud Bank.
VE IR IER eqienetube DESCRIPTION
:13)(6)-2

D

URTICARIADCHILLDFEVER PAIN
2ndV:WIEF---17 &,eel 7" n

---OTHER (b)(6)-2
R DIFFICULTIES (Equipment, clots, etc.)
PRE-TkANSFUSlectil, 0 1111 YES (specify)
SIG

TEMP.e8e.9 PULSE BP 1 t i 1r b)(6)-2
DATE TRAA FUSION TIYISA--R.TED
W 3 eftlYDtis?,

0 pw

PA1(ENT I DEVTIFI CATION - JSE—...-----3'or typed or written entries give: I SEX 'WARD
NAME -Last, nrst, middle; rank/rate; hospital number an name of facility.) ,

. ...-

5 1C,(4? ;13)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. B-86) General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505
518-122
1(b)(3)-1

PERSONAL DATA PRIV AC ? 7 A MEDICD:CORD COPY
MEDCOM — 5628

DOD 12840

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one TYPE OF REQUEST (Check ONLY 1-fRed Blood REQUESTING PHYSICIAN (Print)

Cell Products ore requested.)

RED BLOOD CELLS
:b)(6)-2

TYPE AND SCREEN

EI FRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE P ROCEDURE
CROSSMATCH
EI PLATELETS (Pool of .units)
S
CRYOPRECIPITATE (Pool of.units)
DATE

2,42 /1-Pel;,.e? I have collected a blood specimen on the below111 Rh IMMUNE GLOBULIN named patient, verified the name and ID No. of DATE AND HOUR REQUIRED the patient and verified the specimen tube label to
111 OTHER (Specify) ct3 .2-0 pp be correct.
VOLUME REQUESTED (Ifapplicable) KNOWN ANTIBODY FORMATION/TRANSFU-SIGNATURE OF VERIFIER
SION REACTION (Specify)

',b)(6)-2ML
REMARKS: I F PATIENT IS FEMALE, IS THERE HISTORY DATE VERIFIED .
OF: Zlo dve‘ 3 1,2 RhIG TREATMENT? DATE GIVEN'
TIME VERIFIED

HEMOLYTIC DISEASE OF NEWBORN' 0 / 0
SECTION II — PRE-TRANSFUSION TESTING
UNIT NO. cyc

TRANSFUSION NO PREVIOUS RECORD E :
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH RECORD b)(6)-4
(b)(6)-2
PATI

b)(6)-4
DONOR RECIPIENT

CROSSMATCH NOT REQUIRE FOR TI-{COMP b)(6)-2
ABO ABO REMARKS:

t—.(e
Rh Rel
pas

SECTION III — RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION
INM,FC.TF11 AND ISSUED BY (Signature) AMOUNT GIVEN TIME DATE, C INTERRUPTED
b)(6)-2

(frt7 ML O' Dq
REACTION

N-NONF rI SI ICPFCTFD
ON (Date)

AT EMU ri
IDE lip CATION' If reaction is suspected — IMMEDIATELY:

1. Discontinue transfusion, treat shock if present, keep intravenous line open. I have examined the Blood Component container label and this form and I 2. Notify Physician and Transfusion Service. find all information identifying the container with the intended recipient 3. Follow Transfusion Reaction Procedures.
matches item by item. The recipient is the ame person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to
Component Transfusion Form andion their tient identification tag. the DICTA Bank.

n trirn
DESCRIPTION
10)(6)-2

ri URTICARIA n CHILL n FEVER PAIN Ei OTHER
OT ER IFFICULTIES (Equipment. clots, etc.)
PR -USION NO YES (Specify)
siG(b)(6)-2
6I1 q .0 0
DATE OFRAN FUSION TINE STARTED

TEMP, PULSE BP
T
ti

PATIENT I DEN IFICATION - USE EMBOSSER (For typed or written entries glue. SEX 4/.\,_ WARD
NAME -Last. first, middle; rank/rate; hospital number and name of fpcility.)
_,.

7 /
b)(6)-4 BEESDICREEFIlagal2b EtlINIRONENETORANSFUS ION
General Services Administration Interagency Committee on Medical Records FIRM -2 (41CFR) 201-45,505
518.122
(b)(3)-1
ME'.RECORD COPY
MEDCOM - 5629

DOD 12841