Medical Report: Medical Records and Treatment of Various Iraqi Detainees and Civilians from March and April 2003

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MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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(REV. 8-97)
'U.S. GPO: 2002.491-600/50619
MEDCOM - 3784

510-112 NSN 7540-00-634-4123
NURSING NOTES
MEDICAL RECORD
(Sign all notes) HOUR
OBSERVATIONS
DATE
A.M. P.M. Include medication and treatment when indicated
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(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; hospital or medical fac lity) 10 \.g(b)(6)-4 REGISTER NO. WARD NO. NI iPsinin mn-rpq
Medical Record
STANDARD FORM 510 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 3785

DOD 010264

MEDICAL RECORD
INTRAOPERAT3
C
1. PATIENT TRANSPORTED TO OPERATING ROOM For use of this form, see AR 40.66, the proponent agency is the once of The Surgeon General.
VIA

2. PATIENT IDENTIFIED, RECOR
BY AND PROCEDURE
6)(6)-2
3. DATE VERIFIED BY
TIME PATIENT ARRIVED IN SUITE

4. PATIENT IN TIME
0 3 .7
NUMBER 5 r

5. PREOPERATIVE EMOTIONAL STATUS
0
.
CALM\

.
ANXIOUS\

.
EXCITED\

. CRYING
. ANGRY
COMMENTS: trIPT.1\ . WITHDRAWN
/MV 1
M•M•
6. NURSING PERSONNEL
b)(6)-2
ASSIGNED
SCRUB
RELIEF
SCRUB
ASSIGNED b)(6)-2
CIRCULATOR RELIEF CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
In SUPINE
.
LITHOTOMY

.
PRONE

. KRASKE
LATERAL\
. LEFT SIDE UP
COMMENTS:2 /1 . RIGHT SIDE UP
HAIR REMOVAL 8. SKIN PREPARATION
. YES NO
DONE BY: \

. OR PREP SOLUTION /Specify) -3, ;
/
. NURSING UNIT -
METHOD:\ SITE: (-1
' . DEPILATORY -:6)(8)-2
. RAZOR BY WHOM:
SITE: ::)
. CUP \ BY WHOM \13)(6)-2COMMENTS: COMMENTS:9. LOCATION OF EXTERNAL DEVICES
X Ground Pad — Safety Strap\
-Tourniquet
10. COUNTS
Sponge

CIRCULATOR
Needle Sharp 11111M11111110 1111111111
Ej Yes . No
1/
b)(6)-2

Instrument II/A111111111111111111111M

411111W¦11=111111
11. PATIENT IDENTIFICATION Ay typed or wfitten entries give: W
JM
Name-last An middle; Cade; Detre Hospital or Markel FaeStrl 12. ELECTROSURGERY DEVICES) IESU)13)(6)-4 YES
LOG#
ESU NO: c,L
SSAN# GROUND PAD:

BRAND LOT NO:
NAME:
. ESU NO: GROUND PAD: BRAND LOT NO:
. BIPOLAR NO:

A FORM 5179.1, OCT 873
REPLACES DA FORM SIM-\MEDCOM - 3786
DOD 010265

13. PROSTHESIS, IMPLANTS\ ¦3Yr, 1=1 NOM, • IF YES NAME: 11,1 NUMlitit MANu ,„_...," /
ang.VtgEgZEZW:tes,ffig:,-,,a,:tx-610;:;:..Majla
MEDICATIONSIOODERS IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES\¦ NO "4 METHOD PREPARED BY GIVEN BY
-1 -tiMeMEAMCRIA5fflIg0:3F.CMt:Mta
DOSAGE TIME
01EDICATIONSISOLUTION
f ,
j
III3 ,..
WOUND IRRIGATION\ KJ YES3NO, TYPE(S):\ i.i
130.97 Mf`/Gn c 1—
TIME CARRIED OUT BY\I,
LUTHER ORDERS
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g e HYSICIAN'S SIGNATURE '
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A. IF YES, SITE
15. X-RAY IN OPERATING ROOM\
YES3¦3NO310

LABORATORY SPECIMENS
16.\
SPECIMEN (S) NAME NAME

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FROZEN SECTION (FS) NAME NAME
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CULTURE (C) NAME NAME
YES3¦3NO3¦

NAME
NAME NAME 18. DRESSINGIIMMOBIUZATION /Spay)
NAME NAME
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17.3TUBES, DRAINSIPACKING \ YES\01.-3ND3afik---73 A c.,, r_vo. , ..., . %.4 . « -I , 5 , i ,V-r fro-G-
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2. 3. 6,• ! ‘,.,..,e -a - 4
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19. ADDITIONAL INFORMATION
(b)(6)-2
SL./(1.4.0/1 I :M---M(
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20. OPERATION(S) PERFORM
11 i' T-1--1-1,c).MWO 1J1e-.1 ,
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2 PATIENT TRANSFERRED TO
b)(3)-1
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b)(6)-2

67 +'/O . IMP& III Al
REVERSFOF DA FORMU1179•1, OCT u
MEDCOM - 3787
DOD 010266

NSN 7540-00-634-4124
AL
RECORD VITAL SIGNS RECORD
IOSPITAL DAY

lit #111-10.5
DAY
1-YEAR DAY
1,o)
19 HOUR •eir • • •• •• •• •• •• • • •• • • •• •• •• ••
MM. . .M. ,M. .M. . .M. .M. .M
PULSEM TEMP. F .:MM:. .:MM:. .:M.
:.M. .MM:. .M. .M. .M. .MM.: .:MM:. .M. .M. .M.
:.MM:.
TEMP. C
(0)M (•)
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40.6 ° .M. .M. .M. .M. .M. .M. .M. .M. .M. .M. .M. .M. .
180M 104° •• •.• • • •• 40.0°
.M. .M. . .M. .M.M.M. .M. . .M. .M• • • • .M
. . .M.M. • • • .
170M 103° 5;
39.4 °
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38.3°Mrx .M. .M. •• •. .M• 8
• • •• •• • • • • •• •• ui
140M 100°
37.8°M
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36.7 °M-o ?2
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36.1 °Ma)0
100M 96°
• •• •. .M. •• .M. •. .M. •• .M. .M. .M. •• .M. 35.6° • • " 'M• " • • " " " " • • "
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40
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RESPIRATION RECORD 5 -etetreptaRgssuar...Vour
HEIGHT:MI WEIGHT —.4.
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Iss..) toads
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OV MP41.1"

,ekTIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, middle; ID No. REGISTER NO.
WARD NO.
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

'Record special data only when so ordered
MEDCOM - 3788
DOD 010267

01, a
MEDICAL RECORD VITAL SIGNS REC D
ri
HOSPITAL DAY ••
¦4 . .. •
POST-DAY
lidiroWAP's EELM
MONTH-YEAR . fiAllracliniErniarajrair
......
19 HOUR '
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PULSE TEMP. F .M. .M. .M• • • • • .M• •• •• . . •. .M. TEMP. C
(0) (•) •• " " • • " • • " " " •• • • 105° • • 40.6°
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180 104' •• • • ..
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A
RESPIRATION RECORD A
A A
(Record special data only when so ordered
BLOOD PRESSURE
A
HEIGHT: WEIGHT —4.
v3le •.G it r s •1
9-31 .3o. I ,i 9 9-9-IIIMIL5,11111•111 53
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DATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, midd No. REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 51.1 (REV. 7-95) BACK
• U.S.GP0:1 996-404-763/40069
MEDCOM - 3789
DOD 010268

511-119 NSN 7540-00-634-4124
•
vlkl i
MEDICAL RECORD h pji .. k....3 VITAL NGNS RECORDM
HOSPITAL DAY
-i4M4
itA 2
POST--DAY
l't a
MONTH-YEAR DAY 30/444 U..-f
Ita-at P1A VE OA Vs1;
19 HOUR Weil liv,i tel 'A t-• ...-? LI-4.! ...-e.q ?..`-•2.,' 5.P.:-ilt,
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PULSE-TEMP. F :-: :-: :-: :-: .
TEMP. C
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180-104°
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170-103° 39A °-S.
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RESPIRATION RECORD -
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(Record special data only when so ordered
2 0.4 'yup
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HEIGHT:M1 WEIGHT —.4. •
spot feno.us.c. An% vavr 967; ti5lf
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PATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, middle: ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
13)(6)-2
VITAL SIGNS RECORDS
Medicii Record
STANDARD FORM 511 (REV. 7-95) scribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 3790
14.v--ks5 ko-tv /Cook ,c
INTAKE\ OUTPUT
TIME TYPE AMT TIME TYPE\• AMT
OR rn (-0 6-.4st OR EBL ‘Z)t
CR fiFIZ•OC, S ((c OR Urine 2i1::.
PACA iti"30-A) er-­' 1;s Co --. FI)W -41---) 19A-40 •¦11( ii,..e______.
\--I •C1o1 g-2S2t5k9 3q­50

-----,-7-, TOTAL 1_, (IOW T)TAL
•
epAy:Ppll\
PROBLEM\ DENTIFIELLJittto FH MDA OP 39
•
.4.L0. . 1 :J= : =:..Y ---8:131XiETY: 9. MUCL.1 0. OTHER
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re-4/Wai v-v? cal 1A9 C
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ut.„s • •W I- )
EDICATION ECEIVED IN PACL (b)(6)-2
i31-CAYloN.r\\_ 1
EFFECTIVE-
GIVEN BY: cl"/ v — e-NJ
o
C-• 13Ci26 b)(6)-2
rr-)(r)
c. 12-ha31 )
DISPOSITION SUMMARY: Nursing Care Problems No.'s\
Resolved; No.'s\ Continue.
tient was transferred fr\
CU/ICU recovery room via litter crib with siderails raised, or held by parent in
heelchair.
D = ssing status: PA Score afety Stra Re. • rt given to
. Patient released b Anesthe
Time • • Nurses ignature:

0o4. pr iv/ MEDCOM - 3791 pr-.tsps
;b)(6)-4 :
rn
TEST(S) TEST(S)
D7E TIME SPECIMEN TAKEN E: DATE TIME SPECIMEN TAKEN In In
RESULTS REQUESTED\(XI RESULTS REQUESTED\(X) OC,;5 P.M.
133 20 GLUCOSE UREA N. CREATININE C.) O DIY 3 17 GLUCOSE UREA N. CREATININE
URIC ACID
URIC ACID
aCeY SODIUM POTASSIUM (b)(6) -2 5 21 SODIUM POTASSIUM
130 CHLORIDE CO2 PHOSPHATE (b)(6)-4 ds,1 31 CHLORIDE CO, O a
PHOSPHATE
CALCIUM
TOTAL PROTEIN O Ar4-er;.-J CALCIUM TOTAL PROTEIN (b)(6)
ALBUMIN GLOBUUN 0 r)73 75-61 ALBUMIN GLOBULIN -4
ACID ALKALINE PHOSPHATASE 4 fr-02. ALKAUNE PHOSPHATASE
PHOSPHATASE SGOT LDH 09C BILIRUBIN (TOTAL) BILIRUBIN (b)(6)-2 O POZ 5ry I4c03 3C, 'E M13 ACID PHOSPHATASE SGOT LDH CPK SIURUBIN (TOTAL) b)(6)-2
(DIRECT) CHOLESTEROL BILIRUBIN (DIRECT)
CHOLESTEROL
TRIGLYCERIDES AMYLASE LIPASE . 33 . 3 TRIGLYCERIDES AMYLASE rn IMI
LIPASE.
PROFILE (Specify) PROFILE (Specify) Vi

ON'1d1:1'8Y1/N3WIMIS
'ON131 '9V1
19 14-c4 (es
7,117-7 0
CHEMISTRY I 546-107
STANDARD FORM 546 Din arn
CH EMIAY I
546-107
PRESCRIBED BY GSA ICMR
cFR)io
STANDARD ORIA 541
FIIMR
PRESCRIBED BY GSA ICMR
Fir.m,M,
PATIENTS MED. RECORD PATIENTS MED. RECORD
TIME (9,r DATE 39)144 SPECIMEN TAKEN TEST(S) A.M. 0 P.M DATE TIME TESTIS) SPECIMEN TAKEN A.M. P.M. DATE TEST(S) SPECIMEN TAKEN TIME-A.M. ,10
REQUESTED REQUESTED 042S— P.M.
RESULTS REQUESTED (K)
//i GLUCOSE
RESULTS RESULTS I O UREA N.
CREATININE
3Ao GUJ VZ URIC ACID
(.42tris 4-7/rloAx. ZSR 7 31 ,3 3014 t2 CAM(01Z CP-E4 14 I 47.2 -si POTASSIUM CHLORIDE CO2 PHOSPHATE CALCIUM SODIUM Trt (b)(6)-4
hicl 130 TOTAL
PROTEIN
I.Y1Y11P,VD 10 9 M3 , Lo 4/;2 ALBUMIN GLOBULIN
CL lot ALKALINE PHOSPHATASE ACID
PHOSPHATASE
CoZ t SGOT
LDH
CPIC (b)(6)-2
BIURUMN
(TOTAL)
ISIURUBIN
IDIRECTI x
CHOLESTEROL
TRIGLYCERIDES
AMYLASE 70
LIPASE PROFILE (Specify{ (-1 . 0 g §D g

cf-O
0
MISCELLANEOUS MISCELLANEOUS
sIANDARD
FORM 537 May 3-771 EM TRY I
5145DAR0 FORM 557 1Rer 3 7 546-107Rld by GSA/ICMR Prewbed by GSA0CMR 57/4413413 FORA. 5411044 077/ CFEI 101-45-505
n4P7II
REHR MI MI 101-45-505
PRESCRIBED BY GSA ICMR
1 1M
1 FI1MR (4g CFR)101-41150 a
PATIENTS MED. RECORD
ON
MEDCOM - 3793
DOD 010272

MEDICAL RECORD • ANESTHESIA
use of this form, sea AR 40-66; the proNnent agency is the OTSb
mgmanzens
TOTALS

RIMEIL
UMW=
410
% del % Lt. "4' „ 'Aim. •
•
CRYSTALLOID­AIR UfAin
N20 LIMIn COLLOID-
02 UMW
.Z SUMS DOSE DIUGS4AARK ON GRID
wits NUMBERS & ENTER IN MAUS BLOOD.
UNE site\

Warmed 0 Warmed J raMMV"talli C\DWaimed ,JJ SlY 0 Warned EST BLOOD LOSS
URINE
TIME 1) J J
C.1131111
YMR ERMIHNIMIMMIRE MEM Bin
220
MINIEMERNI EMI BEM
I.'-BP by cuff

MIIIIIIM
LB 200
V

312 •111
400,' A 100 MUM ROM Men 19111MINIBB1 MOM 1111191N MIN3
BUNN WM MIN INIREI
21 111111111111111115111111•1•111=1111•1111111.1110111111111111111111111111111111111111111
Heart rate
150

111.11111111111111111111111111MMIENIMINI
Rasp rate 140

BP-
• 120, 4
• MEM .\MORRI..1"..;..:111111M
IIRM3
ME : *: Mil MOW Millii3
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MIRE PIIMINEVAI SWEIMIRMININ3idirAIR WA ITZM1 V :
as 88319988118/ffla MEI3• 1 r
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INPIXPV.*‘ T OK for
IIIIIININGOIMMI 11211.111/ra BIM : =II NEM Illb1110911111111MI .fit.........w.....\

PROCEDURE
ARES. X•X 111MMI

20 NIMIRRARMINNINININNMIMININSIMARINISIONINUMINISIMNIWWINIMI TIME-
PROC. eia

11111111111111111111111111111111111111111111111111111111111111\
VT. ml
f- broathskoll
Peak Int pres I PEEP

III

MODE .S •CAI slat) Clan)
f01110011WAIIMMIMISSIIECIMEIMMIRVAIMIIMINEmma
ET CO2 Ilard

...1111!MMIN F102 (Frac or X) tilliiiiiIIIIMMOIMAININIMINkillIMIIIEMMIE21/11 • ' -Pahl
PACU ICU

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• ART u..
3.61111111112111itanii21111111111111,4211=k1111 3v4
OTHEI

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cOpDniou

111=01011
ABP.\

NM Block (TM) 402. BP.\HI-
a
3
P,21,'gadiFf'w
Start Room End

Pill3
Cam WerMar z
Mwk *Matron & pogo &obi mar 414/412a EVENTS _It)Position Reedy Begin\End
PROCEDURES and CPT Codas: ANESTHETIC TECHNIQUES: Descris block tedmilow gam Remarks O 'I C •
PATIENT IDENTIFICAlION: Typed ar {Wimp wanes: Name aniclefieta, gla.C....1 i..00.• AIRWAY MANAGEMENT: £itubeonmum &a* read" CO.anIllIS
LOG # (b)(6)-4
S S AN# SURGEONS; PROCEDURE LOCATION:
NAME: ANESTHETISTS: DATE:
DA FOR/41389, FEB 1998 MEDCOM -3795 COPY 1 . PATIENTS MEDICAL RECORD PAGE OF USAPA1/100
DOD 010274

•

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMpOpl NT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood REQUESTING PHYSIC' AN (Print)
Cell Products are requested.)

,;b)(6)-2

ED BLOOD CELLS TYPE AND SCREENE FRESH FROZEN PLASMA
DIAGNOSIS OR OPERA TIVE PROCEDURE

P LATELETS (Pool of Wunits) OSSMATCH
p(4-1-a-h oyl

ri
C RYOPRECIPITATE (Pool ofWunits)
DATE REQU STED
Il
I have collected a blo od specimen on the below
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
• OTHER (Specify) be correct.
VOLUME REQUESTED (If applicable ) KNOWN ANTIBODY FORMATION/TRANSFU-IFP
SION REACTION (Specify) (b)(6)-2

- ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY DATE VERIFIED OF:
AV•947ACe,

RhIG TREATMENT? DATE GIVEN•
3TIME VE IFIED

"CPO

HEMOLYTIC DISEASE OF NEWBORN'
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO.

PREVIOUS RECORD CHECK:

TEST INTERPRETATION
13)(6)-4
ANTIBODY SCREEN CROSSMATCH
riRECORD-[1] NO RECORD
PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST

DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE C OMPONENT REQUESTED DATE
ABO ABO REMARKS:
Rh Rh
PDS

PCS

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
INSPECTED AND ISSUED BY (Signature)
AMOUNT GIVEN3TIME DATE COMPLETED INTERRUPTED
(b)(6)-2
3 ML 0130/ 3 0(rIPID- 03 REACTION3
NONE-r-1 SUSPECTED

AT (Hour) Z33ION (Date)
IDENTIFICATION'
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. Th: recipient is the same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions toComponent Transfu on ' orm and on the patient identification tag.
the Blood Bank.
•AI e
DESCRIPTION

b)(6)-2
3URTICARIA n CHILL-I-7 FEVER PAIN
r .
ID OTHER ­
b)(6)-2
OTHER DIFFICULTIES (Equipment, clots, etc.)
• RE-TRATISFUSION
Eg NOM
I I YES (Specify)
TEMP. 3(p (4 ) 3 3Mcigi5 (0 clnrslaTI tar (-IP °I. DON NOTING ABOVE
PULSE
B P

3 ( b)(6)-2
DATE OF TRANSFUSION TIME STARTED
301Y Na..4..„ 0
DOO

PATIENT IDENTIFICATION - USE EMBOSSER (For typed or written entries(
SEX WARD

NAME • Last, first, middle; rank/rate; hospital number and name of facility.)
..TC.0
/11 3
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86) General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518-122
(b)(6)-4
MEDICAL RECORD COPY

MEDCOM - 3796
DOD 010275

MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION COMPONENT REQUESTED (Check one)
1,1 Pt WI III

TYPE OF REQUEST (Check ONLY if Red Bloo W
Cell Products are requested.)W b)(6)-2
WRED BLOOD CELLS nTYPE AND SCREENFRESH FROZEN PLASMA
L. 'GNOSIS OR OPERATIVE PROCEDURE
;1`

PLATELETS (Pool ofWunits) CROSSMATCH
CRYOPRECIPITATE (Pool ofWunits)
DATE REQ TED
nRh IMMUNE GLOBULIN I have collected a blood specimen on the below named patient, verified the name and ID No. of
DATE EQUI RED
the patient and verified the specimen tube label to
1111 OTHER (Specify)
be correct.

VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSF SICNATLIRE C F VFRIFIcIR SION REACTION (Specify) b)(6)-2
- ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTOROF:
RhIG TREATMENT? DATE GIVEN . TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN? 14P
SECTION II — PRE-TRANSFUSION TESTING
(b)(6)-4 UNIT NO. TRANSFUSION NO. TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH PREVIOUS RECORD CHECK: nRECORD­1­1] NO RECORD
DONOR RECIPIENT PATIENT NO. N/4 SIGNATURE OF PERSON PERFORMING TEST

JCROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE
ABO
ABO REMARKS:

po s

Rh Rh
Pos

SECTION III — RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
POST-TRANSFUSION DATA

INSPECTED AND ISSUED BY (Signature)
AMOUNT GIVEN3TIME DATE COMPLETED iirrr-r11-11101-gn ',b)(6)-2
3ML3000 /30 rrtc...,0
n '3
REACTION
NONE-SUSPECTED

AT (Hour) .01...S.
77ON (Date) 2_7¦01.4-1(1---A3
IDENTIFICATION'
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 same person named on this Blood 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions toComponent Transfusion Form and on the patient identification tag.
the Blood Bank.
DESCRIPTION

URTICARIA LI CHILL-Ell FEVER LI PAIN
riOTHER ­
OTHER DIFFICULTIES (Equipment, clots, etc.)
NO-I:: YES (Specify)
TEMP. 3 up _ 2./ 3 CD 9 3/L/1
PULSE SIGNATURE OF PERBIDTING ABOVE
BP DATE fANSFUSION3TIME STARTED ,b)(6)-2
/r13A.0 3\yo
PATIENT IDENTIFICATION - USE EMBOSSER (For typed or written ent
NAME - Last, first, middle; rank/rate;hospital number and name of facility.) WARD
(b)(6)-4 C U3
BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86) General Services Administration Interagency Committee on Medical Records
FIRMR (41CFR) 201-45.505 518-122
MEDICAL RECORD COPY

MEDCOM - 3797
DOD 010276

518-124
MEDICAL RECORD
COMPONENT REQUESTED (Chock one) RED BLOOD CELLS FRESH FROZEN PLASMA PLATELETS (Pool of units) CRYOPRECIPITATE (Pool of -units) Rh IMMUNE GLOBULIN OTHER (Specify) VOLUME REQUESTED (If applicable) ML
REMARKS:
(b)(6)-4 TRANSFUSION NO.
(b)(6)-4
PATIENT NO.

DONOR RECIPIENT
ABO ABO
Rh ?C).5 Rh
PRE-TRANSFUSION DATA ;b)(6)-2
INSPECTED AND ISSUED BY (Signature)
;b)(6)-2

AT (Hour) /7(51-6.-T7:17
1(Date)

IDENTIFICATION
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Pr nt)
Products are requested.)

;b)(6)-2

TYPE AND SCREEN
.
DIAGNOSIS OR OPERATIVE PROCEDURE
CROSSMATCH

DATE REQUESTED I have collected a blood specimen on the below
30 Aar 03
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to be correct.
10 .13/410( D3 is LIC.
KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
RhIG TREATMENT? DATE GIVEN: ­TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN? ­
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD­. EL NO RECORD

N
SIGNATURE OF PERSON PERFORMING TEST
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED-I DATE -SO .oar 03 REMARKS:
SECTION III - RECORD OF TRANSFUSION
POST-TRANSFUSION DATA

AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUP5ED 21.51) ML BO­
/IS'

REACT TEMPERATURE
MPULSE Iric/SURE ONE . SUSPECTED
7-, 3

If reaction Is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
1.,Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by Item. '2. Notify Physician and Transfusion Service.

The recipient is the same person named on this Blood Component Transfusion Form and
3. Follow Transfusion Reaction Procedures. on the patient identification tag.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
ro vmDicirn
DESCRIPTION OF REACTION URTICARIA . CHILL . FEVER . PAIN b)(6)-2
El OTHER (Specify)

;b)(6)-2
OTH-IFFICULTIES (Equipment, clots, etc.) PRE-TRANSFUSION
NO-. YES (Specify)
TEMP. CH,,2 PULSE 4?)M I BP 103159t, SIGNATURE OF PERSON NOTING ABOVE DATE OF TRANSFUSION TIME STARTED ;b)(6)-2
/4140.3-kd M
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, st, middle; grade; rank;
SEX WARD

rate; hospital or medical facility) -Tr
(b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

MEDCOM - 3798
DOD 010277

518-124,
MEDICAL RECORD
COMPOlaalT REQUESTED (Check cne) RED BLOOD CELLS FRESH FROZEN PLASMA PLATELETS (Pool of units) CRYOPRECIPITATE (Pool of units/ IMMUNE GLOBULIN
SECTION I -REQUISITION
TYPE OF REQUEST (Check ONLY If Red Blood Cell Products are requested.)
.
TYPE AND SCREEN

.
CROSSMATCH DATE REQUESTED ­

)-1.0a- 63

DATE AND HOUR REQUIRED
Act.r tys ig
KNOWN ANTIBODY FORMATION/TRANSFUSION
, .*4REACTION (Specify)
Aon:'
"

IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN: ­
HEMOLYTIC DISEASE OF NEWBORN? ­
SECTION II -PRE-TRANSFUSION TESTING
TRANSFUSION NO. TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
;b)(6)-4
f'ATIZi;i&

A N A
DONOR VecigiENT
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
6r
REQUESTING PHYSICIAN (Print) ;b)(6)-2
DIAGNOSIS OR OPERATIVE PROCEDURE
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be
correct.
SIGNATURE OF VERIFIER
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:
. RECORD-NO RECORD
g
IDF flr DMJC/11\1\ rrrr
SIGNAT
b)(6)-2

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE /., Atkr 03
A. ADO REMARKS:
0

RI] Rh
SECTION III -RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
INSPECTED (b)Z6)_ 2 .01
oi,420 fateWI ON (Day/ lc, "cr- (93
IDENTIFICATON
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and °nine patient identification tag.
1st IngIIFIER (Signature) (b)(6)-2
6
ZiarVERIF1131 (Signature)
(b)(6)-2
I PULSE

//MBP 11,34.
DATE OF TRANSFUSIO1 TIME STA5Ey
--e22 K,

IDENTIFICATION--USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)
(b)(6)-4
MEDCOM - 3799
POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTE D
ML
REACTION TEMPERATURE • PULSE BLOOD PRESSURE
. NONE . SUSPECTED
If reaction is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous li ne open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

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

DESCRIPTION OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
.

OTHER DIFFICULTIES (Equipment, clots, etc.)
. NO-. YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
SEX )4 4. WARD .-C.,14-)
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

DOD 010278

518-124 NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I -REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN (Print)

Products are requested.)
1:7_1•1 RED BLOOD CELLS ;b)(6)-2
. FRESH FROZEN PLASMA . TYPE AND SCREEN
DIAGNOSIS OR OPERATIVE PROCEDURE

¦•••

.
PLATELETS (Poc(tOt units) CROSSMATCH

.
CRYOPRECIPITATE (Ppol of units)

DATE REQUESTED I-have collected a-blo d-specimen on the
. Rh IMMUNE GLOBULIN 30 Aar 463 below
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label
to be
. OTHER (Specify)
correct.

SO Mar 03
VOLUME REQUESTED (If applicable)
KNOWN ANTIBODY FORMATION/TRANSFUSION
SIGNATURE OF VERIFIER ..-. giST, -ML REACTION (Specify)
AM)

REMARKS:
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
DATE VERIFIED RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO-(b)(6)-4 RANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHECK: (b)(6)-4 ANTIBODY SCREEN CROSSMATCH
. RECORD­Nt• NO RECORD
PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST

NA N4
DONOR
RECIPIENT CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
DATE 10

ABO ABO Mar 03
REMARKS:
?o cap: 14 ()41 /4)3

Rh
Rh

SECTION III -RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
POST-TRANSFUSION DATA
INSPECTED AND ICCI irn Pv AMOUNT GIVEN

(b)(6)-2 TIME/DATE ,E6131715LJVD/INTERRUPTED
M
ML
3 O)50 3) )11141ZZY
REACTION
TEMPERATURE PULSE
BLOODP. ESSURE

AT (Hour) 1:23,415-OT,(Date) . NONE . SUSPECTED
9qb 101

IDENTIFICATION 1 1 LA
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all

1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1 b)(6)-2
DESCRIPTION OF REACTION

.
URTICARIA . CHILL . FEVER

.
PAIN El OTHER (Specify)

IFIER (Signature) VI 4-OTHER DIFFICULTIES (Equipment, clots, etc.) PRE-TRANS
Igl—me—• . YES (Specify) TEMP. SI060 PULSE
B SIC;NATIIPF on PPRCrIto nierrinir ennV E(b)(6)-2
DATE F TRANSFUSION T E STARTED 7 27:
S

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; Wade; rank;
SEX WARD

rate; hospital or medical facility)
4:0 (b)(6)-4 hia62-r
e-1) 14
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

MEDCOM - 3800
DOD 010279

518-124
NSN 7540-00-634.-4159
MEDICAL RECORDM
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN (Print)

Products are requested.)
Er RED BLOOD CELLS 3
(b)(6)-2
'Dr

Eli FRESH FROZEN PLASMA .
TYPE AND SCREEN
DIAGNOSIS OR OPERATIVE PROCEDURE El] PLATELETS (Pool of units) . CROSSMATCH
. CRYOPRECIPITATE (Pool of units)
DATE REQUESTED 111 Rh IMMUNE GLOBULIN
I have collected a blood specimen on the below

I Apr 03
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to be
1:11 OTHER (Specify)
correct.

0 100 I Apr o3
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATIA/TRANSFUSION SIGNATURE OF VERIFIER
REACTION (Specify)

\ ML REMARKS:
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
DATE VERIFIED RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
(b)(6)-4 ANTIBODY SCREEN CROSSMATCH . RECORD­j NO RECORD

PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST

NA 'II 4
DONOR RECIPIENT
XCROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
O
DATE /
ABO A130
REMARKS:

-Rh
o S
Rh

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANS­
DATA INSPECTED AND ISSI IsPhriv
b)(6)-2 ;b)(6)-2 AM TIME/DA /INTERRUPTED
ML
e)a REACTI
-
TEMPERATURE PULSE

BLOOD PRESSUREAT (Hour) d 010e) -ONE . SUSPECTED
ON (Date) I Apr 0 .-5
C/34

IDENTIFICATION 18($73
If reaction Is suspected—IMMEDIATELY: I have examined the Blood Component container label and this form and I find all
1. Discontinue transfusion, treat shock if present, keep Intravenous line open.
information identifying the container with the intended recipient matches Item by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.1st VI(b)(6)72
DESCRIPTION OF REACTION
URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify) N
2n14211-It-R
1::1)(6)-2 NL-f-
OTHER D ULTIES (Equipment, clots, etc.) PRE-IRANSFU ION
. YES (Specify)
TEMP. qt iMI PULSE 95
I BP / / W70 SIGNAT b)(6)-2 DATE OF TRANSFUSION
TIME STARTED
`T.

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, midcle; grade; rank;
SEXmlaitz

rate; hospital or medical facility) WARD
3

D
:b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

MEDCOM - 3801
DOD 010280

515402
1181176W-01-166-7314
RADIOLOGIC CONSULTATION REQUEST/REPORT
(bdinioN/Nuclear liedickteNltrasound/Coraputad Tomography Examinations)
REGISTER NO. EXAMINATION(S) REQUESTED
7/CLINIC

SE1SSN\
liVIPREGNANT
FILM NO.
YES inNO

C.y a AY-Pk---rr`
TELEPHONE/PAGE NO.
Y Minn

REQUF'cTED
,b)(6)-2
CDC0e0
DATE REQUESTED

SIGNATURE OV-Iffic.810ESTOR
(b)(6)-2

SPECIFIC REASON(S) FOR REQUEST (Complaints mid fiediej
.
DATE OF TRANSCRIPTION (Month, daY, year)
(DATE OF REPORT (Month. dey. year)
DATE OF EXAMINATION (Month, day, year)

RADIOLOGIC REPORT LOCATION OF MEDICAL RECORDS
PATIENT'S IDENTIFICATION (For typed or written entries Om: Name — last, first, middle, Medical Facility)
LOCATION OF RADIOLOGIC FACILI
SIGNATURE
8 (8-133)
STANDARD FORM 519­

ULTATION Prescribed by GSA/ICMR
MEDCOM - 3802
PORT FPMR (41 CFR) 101-11.806-8
DOD 010281

b)(6)-4
$18412 WIN 7640-01-161-7244
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear MedicirteNitnsound/Computod Tomography Examkadons)
' WARD/CLINIC REGISTER NO.

AGEISEX SSN (Sponsor)3
EXAMINATION(S) REQUESTED PREGNANT
FILM NO. YES3NO
oNcrumcmwr. RV rt34.0.1
TELEPHONE/PAGE NO.

;b)(6)-2
DATE REQUESTED.

b)(6)-2
e?9"JsPlaigi2 SPECIFIC REASON(S) FOR REQUEST (Complain& and ,f1ndines)
dae4-alad040a•Cl4471 RedAr
ATE OF TRANSCRIPTION (Month, day, year)

DATE OF REPORT:Woad'. de,. WW1DATE OF EXAMINAT N (Month, day, year)
a ' 3-‘77, -/4'‘gi RADIOLOG IC REPORT
cr" Aer-AerZe
F-de
fi/f ­

• 44 Ai aw-d
e
oe'de7t,g/A,17i
PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first, middle. Medical Facility) LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC FACILITY
(b)(3)-1
b)(6)-2
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DOD 010284
•¦•
(b)(3)-1
Doctor'S Orders—Post-OP
OP 4256

nit SOP R Notify Dr. for SBP
or ,HR
or\RR
6. Activities:\Bed Rest,\BRP,
¦ 0013 ASAP w/ assist,
Sit u and dan e when stable
.¦ Other:
9. IV: NS o\
TRAs-o cc/hr
.
DEXTRAN or . Hespan X 500 cc bolus titrated then

.
Albumin 100cc X\

TRA\cc/hr
When toleratin PO fluids, com i fete current fluid then SL.
10. BLOOD: ¦ T&S or L T&C\
units
Transfuse\
units UPRBCs or
m. Maintain sedation/ aral sis w/ Rocuronium and MSO 4 PER SOP
ct6.st b)(6)-4
b)(6)-4

eAti-rr
MEDCOM - 3806
',b)(3)-1

Doctor's Orders—Post-OP
OP 4256
Nurse Dr.'s
Corn lete DATE: .

Selec '
TIME:
¦

1. Admit to: OR PACU
¦ 1% ICW ¦ Patient Holdin
¦ • 2. Dia osis:
3. Condition: ¦ Critical "Guarded Stable
11111•4111111111110 4. Aller 'es: See SF 558 ¦ VSI I SI
5. Vitals: I nit SOP I otify Dr. for SBP \
or

DBP \or \
tr, or ,(;; RR .• or \
6. Activities:\Bed Rest,\ or Tem
BRP,\OB ASAP w/ assist,
Sit u and dan e when stable
¦ Other:

7. NRSG:
¦

a. Pro
monitor w/ Pulse-ox
b.
02 to maintain SAT's above 94%

c.

Maintain Vent settings at MODE=\
Vt=\
RR=PEEP=\FIO2=

d.

Reinforce or IChan.e dressin for bleed-throu, X1 then not Dr.
e.
I's & O's

c.
Suction NT ETT PRN

¦

d. CT to 11120 seal or ¦ Suction at
111111111111111M1 8. Diet: NPO
Clear fluids as tolerated
Other:
9. IV:

¦NS or ¦ LR. TRA / -.. cc/hr
.
DEXTRAN or 0 Hespan X 500 cc bolus titrated then\

.
Albumin 100cc X\ cc/hr

.
TRA\cc/hr • When toleratin PO fluids com lete current fluid then SL.

1 0. BLOOD: ¦ T&S or IT&C\
unitsTransfuse\
units []PRBCs or ¦Whole Blood1 1. Medications:
¦
a. Tobram cin 300m IV • 12hrs X Ceftriaxone 750 m IV
b. Clindam cin 600m IV f ¦ 'ENG 2 million Units IV
c.
Cefazolin 1 .,\

d.
Phener an 12-25 Titrate

C

IM
hrs PRN nausea/vomitin

. Dro eridol lm\
111M X 1 PRN Nausea/Vomitin •
h. MSO4 1-3m Titrate
rumIM QlOmin PRN Pain
i. Robinul 0.1m IV X 1
Zantac 50 m

IV or •IM or
6.25m' infusion
k. Tetanus Immune Globulin
ism

I. Toradol ¦ IV 30m • or SIM 60 m
m. Maintain sedation/ anal sis w/ Rocuronium and MSO4PER SOP
12. LABS:
a. iSTAT Glucose S ABG
¦BM1) ¦ CAP
13. Additional:
b)(6)-2

pr iv/mar' Pr-.-',9 ANO3
b)(6)-4 ­

MEDCOM - 3807
DOD 010286
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS TIME & INITIALS

86 th Combat Support Hospital - EXTREMITY TRAUMA ORDERS-.
5Wio
1. Diagnosis­

it\AIL\ rig\ 0 h, V A •3V
erstrA,
11Ir\ _„.1..4
2. Vital signs Q 4 h

;

3--Dig-as.lokralc4-.­
1/ (-a- 'V&' 4- -.' 0 i.
4. Lactated Ringers - 125 cc/hr
5.. Cefazolin 1gm IV Q 8 h

6.
Morphine sulfate 2 to 5 mg IV Q 1 hr pro pain

7.
Activity-g4 ,f r‘i $ ,_

F.% /1,1M
/...rM7 ae , -7
....., 1....374'
8. Wound care

9. Drains-( Z. ej 2L.W71 4.4...( -­
e„,,..4• i,..4.4-.t. ce — I f'.0 oN
10. Evacuation - circle one
.,sPriority-Urgent-Routine

1.- .. 11 f r•

DATE-TIME
0 q 1 1-

3 ° /1'1 4 ^4/13a i
(b)(6)-2

SIGNED
1°7PG
Ile.ecut Fa 4-fli P1.401 cit I ° Pal kD4-7700

(b)(6)-2
Y
. (b)(6)-2
d S." '.-4. '.r.

13(14
6

PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any changes on subsequent pages.
Diagnosis:
:b)(6) -4

Height:-Weight:-Diet:
Allergies:

Nursing Unit Room .No. Bed No. Page No.
-

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC V 1.00
MEDCOM - 3808

DOD 010287

MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
:b)(3)-1

VENTILATOR ORDERS
I. Mode­

C i A., V
2.
Fi02­

CP-0-'7-
3.
Rate­

( 7/
4.
Volume­

1 'C-‘°

5.
PEEP-5

6.
Continuous Sa02 monitor

7.
Wean 02 to keep Sa02 94%

8.
ABG Q AM or any signficant change in status

=nnig-Zneters-Q-AM
.

DATE-TIME­
k9 1 .1- -1-
3 o A e--k.L. 2,0 47 ?

b)(6)-2

SIGNED
I

5-0 0 c, c_ leW4
, /1/:34."‘ 1"J
(b)(6)-2 IV° (b)(6)-2
#M1# a _.•M•
b)(6)-2 W/1)(6)-2
SIGNED
PATIENT IDENTIFICATION
Complete the following information on page 1 on y. Note any changes on subsequent pages.
Diagnosis:

Height:-Weight:-Diet:
;b)(6)-4 Allergies:
-p
Nursing Unit Room No. Bed No. Page No.
E.
-

RM 688-R (TEST) (MCHO) MAR 99 \PREVIOUS EDITIONS ARE OBSOLETE MC V1.00
MEDCOM - 3809
DOD 010288

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG 3
THE DOCTOR SHALL RECORD 04 'ME AND SIGN EACH SET OF ORDERS. IF PROF3ORIENTED MEDICir¦ L RECORD SYSTEM IS USED, WRITE PROBLE..AGER IN COLUMN INDICATED BY ARROW BELO
PATIENT IDENTIFICATION DATE OF ORDER\ TIME OF ORDER LIST TIME ik. ORDER NOTED ANC
HOURS SIGN

2 liters

t\in
re/X lhr/.

urrch:lc:s hr/ 4hr/ 6hr/ q shift V
;! 47

111.
a.

• Vascular checks q lhr/ 2hr/ 4hr/ 6hr/ q Nit

O ,F3 v.9.71_ AC Z 1 900 ifISPS
i

lifir3

.. OZ3
NURSING UNIT ROOM NO. BE • N0\pliM;b)(6)-2

itlili.4/0 c:,3
.7

it, tir......7 o X-Ifege ---30••••,--SQ d:2 1 a
PATIENT IDENTIFICATION DATE OF ORDER\ TIME OF ORDER
HOURS

0 6 4; .(.0 'N''/E-3 4.s . ///
•
(b)(6)-2

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION TE OF ORDER\ TIME OF ORDER
Illjr\
v NV\
11 / t-ma 5-/ 90C.HOURS
3. _1 7/3f Y.
1 reri A
' kll'i .M.
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER\ TIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.
REPLACES . EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1 FLIIIM79

MEDCOM — 3810
DOD 010289

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDIC/AL RECORDSYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTI FICATION
b)(6)-4

LI T ORDER NOTED AN! SIGN
NURSING UNIT ROOM NO.

PATIENT IDENTIFICATION DATE 0 "5:":ER3 TIME OF ORDER
HOURS

HOB u. 30 de:rees

NURSING UNIT ROOM NO.

CBC AM/ 4 hrs/ 8 hrs/ BID

PATIENT IDENTIFICATION DATE OF ORDER3
TIME OF ORDER
HOURS

IVF NS/ D5NS/ D51/2NS To run @ 2c)c
Ancef 1 GM IV 18 hrs
Gentam cin
NURSING UNIT ROOM NO. BED NO. Cefoxitin 2 IV •8hrs.
02 titrate to keep SP02
PATIENT IDENTIFICATION Versed :tt 1-10m:/hr IV titrate toDATE OF ORDER3 TIME OF ORDER

HOURS

MSO4.MG IV.

NURSING UNIT ROOM NO. HR PRN Pain
BED NO.

Phener an 12.5-25m•IV 4-6hrs PRN N/V

MOM 30cc PRN Gastric u ,set

1 FAOPR
M„ REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

DA 4256
MEDCOM -3811

DOD 010290

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-400; the proponent agency is the Office of The Surgeon General.

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

PATIENT IDENTIFICATION 41(3b)(6)-4
DATE OF ORDER
TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
:b)(6)-2 SIGN
o.4)0

4/.­
`/C3 tre-t•cf) t-At 41147-06,A
Col fre-g--4-;'n..?,b)(6)
3 b)(6) 2
_Y

NURSING UNIT ROOM NC
(b)(6)-2

PATIENT IDENTIFICATION3 3
DATE OF ORDER
TIME OF ORDER
a•lelha_J-S
3 HOURS
/-am, Ay2:3
M
/00.-...i?Me
/
3

F314/01,„ 04e
NURSING UNIT ROOM NO.3BED NO.3
b)(6)-2
3

PATIENT IDENTIFICATION 3
DATE VRU CN
LIME OF ORDER
3 HOURS
3

NURSING UNIT
NO.
3

DENTIFICATION
DATE OF ORDER3
TIME OF ORDER
M HOURS
3 M
REPLACES EDITIC3
USED.
DA , AP R^79 4256 MEDCOM - 3812
DOD 010291

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

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

NURSING UNIT b) ( 6)-2
PATIENT IDENTIFICATION
DATE OF ORDER3 TIME OF ORDER
HOURS

NURSING UNIT
ROOM NO.

BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER3
TIME OF ORDER
HOURS

NURSING UNIT
ROOM NO.

BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER3
TIME OF ORDER
HOURS

NURSING UNIT
ROOM NO.
BED NO.

REPLACES EDITIOI MEDCOM 7 3813__ ii.r,

DA 4256
1FLRIRM79
DOD 010292

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

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

Natia3
HOURS SIGN
I

vbk. c
eAr
. 1-E
3

NURSING UNIT
ROOM NO.

BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME ORDER
St Al/IA.03 0-7
HOURS

LI (6)-2
0 Po 7
NURSING UNIT ROOM NO.
BED NO. I(b) (6)-2
a ) 5 r' «
LR IV
320.1

PATIENT IDENTIFICATION
DATE OF ORDER
(1 TIME GPF ORD
C9
b)(6)-2

GS-R. 5-az
b)(6)-2
b)(6)-2

( Avto b)(6)-2
NURSING UNIT3ROOM NO.3
BED NO.

-v' IVa 7C0
,b)(6)-2
PATIENT IDENTIFICATION
DATE OF ORDER
31 fl\PRo'b
HOURS

A 4.
-1 L-k-r-yr
At

b)(6)-2
,b)(6)-2
8-W""1

f L;i )ti/v
-

33 v-(4 1. kb)(6)-2
NURSING UNIT ROOM NO.3
BED NO.

\ 3
REPLACES EDITIO,

DA P:79 4256 MEDCOM - 3814MUSED.
DOD 010293

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

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

PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER
LI T I •
ORDER
NOTED AND
HOURS
SIGN
b)(6)-2

NURSING UNIT
ROOM NO.

BED NO.
b)(6)-2

PATIENT IDENTIFICATION / V AN 0
NURSING UNIT ROOM NO. BED NO. b)(6)-2
PATIENT IDENTIFICATION 111111111111111111111111111111111111111DATE OF ORDER3TIME CaOFaORDER HOURS
NURSING UNIT ROOM NO. BED NO. 1111 1"15EAMNaaffil 111Mr NM! I is llt 1 b)(6)-2
PATIENT IDENTIFICATION DATE OF ORDER
11111111reen-WA b)(6)-2
',b)(6)-4 Ft' ...Z311111157 ¦b)(6)-2

NURSING UNIT
ROOM NO.
BED NO.
b)(6)-2
1111

REPLACES EDITION
DA 1 FAOPR
P479 4256 MEDCOM - 3815
DOD 010294

CLINICAL RECORD THERA. ¦ TIC DOCUMENTATION CARE PLAN (NON-A,
For use of this form, see AR 40-407;
Is the Office of The Suraeon General. 0 i yr. 0 3
VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED
DATE NURSE

FREQUENCY, TIME
b)(6)-2

-Vital signs q Itr-/-q2k46hr/4811r/ \07
b)(6)-2
19

9 3D ry% 0.5
Cardiac Respiratory monitoring\07

2!'‘vetica-
b)(6)-2
19

19
2--CANAcv.„ ursing I/0, CDB / NG to LIS / LCS\07

19
Labs: Chem 7 / H&H / PT/PTT / \04

BC q AM / 4 firs / 8 HRS / BID\08
12
16
24
i(b)(6)-2

KG q AM / QOD 06
CXRAY q AM / QOD
06
Neuro checks\i 2hr/ 4 hr/611r/\07
shift

19
Vascular checks q 1hr / 2 hr / 4 hr I.07
hr / q shift\

19
b)(6)-2

rAP" "Ty 700 oi
12. Peif 5 A0a 4O 19
ALLERGIES: njYES
NO PRIMARY DIAGNOSIS: ADDITIONA PAGES IN USE:
Ej YES\NO

Mc-ft
PAGE NO:PATIENT IDENTIFICATION:

ACTION TIMES

EP(A-/
USE PENCIL. CIRCLE ACTION TIMES 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23 Treatment Facility 0)(3)-1 N 24 01 02
03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.
USAPA V1.00

MEDCOM - 3816
Verify by (HERAPEUTIC DOCUMENTATION CARE KJ, _
Initialing (NON-MEDICATION) Mo. Yr
Clerk Nurse SINGLE ACTIONS Date to be Done Tme to be Done Time Done Initials
• Admit Patient to ICU -( b)(6)-2

Diagnosis:\5/p a eLs f-e_a LAAQ_./Mvp ID A K ft iik6 •
MM

Condition: Stable (SeriQ Critical \• liergies: „OP
1 b)(6)-2 -7. b)(6)-2ON v,&C\e, 11(3 C) 1900
rAm Pt-P44-X 1 -acN H (---1-'14 -A-4G--tr'f"\)0 me-._ Mb 0
36:1\TY\ A' 3 0-ia Ala_ &Got,
.(r ¦P' C, X 12 1:"-.\ftr'r\
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk/ PRN

Explr
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
USAPA V1.00

MEDCOM - 3817
..-..-..3
CLINICAL RECORD3in. inn,unnciv I AI IUN UAHE PLAN (NON-I CATION) I
For use of this form, see AR 40-407; \ Is the Office of The Suraeon General. Mo. 03.Yr.
VERIFY BY INIT1AUNG .-,;,,,,....;f.
.c., • 1!,

INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER3CLERK!3HR3
RECURRING ACTIONS, DATE COMPLETED
DATE3NURSE3

FREQUENCY, TIME
23 44
b)(6)-2

riuvb3 IVFN\D5NS D5 1/2NS To run 07 A
q'-ic, 0\ccihr 1 Y 2
1710:0 -b)(6)-2

ncef 1 GM IV q 8 Hits
giM

ITIN
\Gentamycin\IV Q
\Cefoxitin 2 gm W q 8hrs
\2 titrate to keep SPO2 07
19
Q\b)(6)-2-erred gtt 1-fbmg/hr titrate to•Ramsey 07
lop-%\IM

5 0 cc N S 19
- - - -\-\..4\t .

\•te for
\d\uate\'
\Vecuronium lmcg/kg/min\

b)(6)-2­

--o3Y-13,303S
3111
mil b)(6)-2 1
o

• 1070011.cct....,
mini•
b)(6) 2

\100 ac_ N $\So -% ST)
l't
..0M .....-M,
ALLERGIES:\Ill YES\
E4 NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: 0.—.-1.1-El YES\i'NOie. ANL 63dr\S'1/4'‘..al-S1-\ PAGE NO•
PATIENT IDENTIFICATION:
(b)(6)-4
ACTION TIMES
EiDLJ

USE PENCIL CIRCI F Ar ririm Trance D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23
Treatment Facility: 212th Mobile Army Surgical Hospital N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 783 EDITION OF 1 DEC 77 MAY BE USED.
USAPA V1.00

MEDCOM - 3818
,3
Verify by rHERAPEUTIC DOCUMENTATION CARE PL Initialing (NON-MEDICATION) Mo D3-Yr ()-3
Date to Time to

Order Clerk
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
A 0
IZr'le'.1

(b)(6)-2

2-Uxi...

rc,,,6,,,,0 tobnin hip x t I T40
L. 1

03P 2 a c aqtripk _a- 1 a I0
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12,c44 t„Kyt„
0

C.
-40-oex.)5
H(b)(6)-2b)(6)-2

Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk/ PRN ExP' rDate Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
3Morphine Sulfate3mg IV q3hr PRN pain
3Phenergan 12.5-25mg IV q 4-6 hrs prn N/V
3MOM 30cc PRN Gastric Upset
3NS / LR bolus X3liters
USAPA V1.00

MEDCOM - 3819
CLINICAL RECORD THERAPEUTIC. DOCUMENTATION CA F1 PLAN
(MEDICATIONS)

ro nr:trausinr3
VERIFY BY INI27AUNG
ail .3u 7; n General. Mo. Yr.
ORDER CLERK/ INITIAL PROPER COLUMN' FOLLOWING BAC.N AAVINISTRATIOIV RECURRING MEDICATIONS,
NURSE

DATE DOSE, FREQUENCY DATE DISPENSED
b)(6)-2

offlor---m ini30121111111 111111111111111111111

11111113eas rummummunnim
10

¦N¦¦ MOMM¦N
V2

MOMMUMEMO
1.111111111111....11 111111111111111 11111111111111111111111
b) (6)-2

M, r-11 111111111111111111111111111111
f=g1 11111111111111111MIN
1111111111•11 IM¦IMM¦ MIN¦¦¦I ¦

b)(6)-2

11111111111111111111111111111
MOINIMOIMIMENEMI
b)(6)-2

MEREVEMIEN
b) (6)-2

UNIMMOIMIMIUMMI
Liddiwielimmommul
1111111111131111111111111111111111111111111 11111111111111111111
b)(6) 2
baud

111111111111111111111E1
b) (6)-2

XIM \air3.1.4111111111111111111111111111111111
Lad in111111111111111111111111111
pEnsmimimmus EgraM2111111111111111111111
b)(6)-2

1.1—m 11111111111111111111111111111111111IMM b)(6) 2 IS 11111111111111111111111211111111111111111111111111111111111
10179

wifivarempfit . •1111111111111111111111111111111
MUMMENIM
tilffd
PATIENT 10EN
TIONs

DISPENSING TIMES jaeap iga D 7
8 9 10 11 12 13 14 E 15
16 17 18 19 20 21 22 24 0 / Oi '3 04 05 06
DA 1 FFM9 4678 EDITION OF N 23
MEDCOM -3820
USTP n
DOD 010299

Verify by
THERmr•EUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) 1M0. .Yr
Order Clerk/ Date to Time to
SINGLE.ORDER, PRE-OPERATIVES be Given be Olean Time Given' Initials
b)(6)-2 0.----

b)(6)-230 /444 -.3.5,63
67+/(0 -5-7­
E--2, 4- --r-A-r ikdo\I-) i300
$.-.)co-c-S

loni44 vecoloivium om.e) _vJ Pus-// A.,0 ¦„ /02ca
101144X
' 50t3cc Gke g(34-.'5
5771r0e)

30M/lig 1-70/¦15r1)-5e--'' -4-i-i-tii.,/-1-..1MPefic . ovate a"' exioti 3/3-443;1\M.M.'` b)(6)-2WS:
k/ PP/ .2 ° ArTA5M- • VA",-1 .M
• 342/23 4M•M' .M¦ :M, .
•
17,

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3014np • gig-• )3c/er, •reirps.
b 6)-

30MIV 6)CR-• 0 Ftti thi"Wouttel- X--"Pftl, ViVoT AS/i$'
31 At, Ned Ar-Tex- Mvoi+caer—
' 31S 11133 1403
001 31103 W31/03

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-btiv ¦ 01
31r% \-\-1--e-i3litient-, b tick in mk.. 3 3//ip 6640
Order/
Cletk/ PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
ExPlf •
Dote

Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
or

112 c,
frionem,v8 5.,.a..p,trrt, .
1 -31 ..._ fr‘,
-0,45e-ho c
A-5m5 r"3zr mi.,
3M,

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. 09 31r !z-ij • (8

veN$iso 1--,2/-4, -Tv Pus,' Oa 1M• ' Ili 11
CV4' Pit-I 51)4/17wp
0
U.S. GPO: 1996.464-110/95210
MEDCOM - 3821

DOD 010300

CLINICAL RECORD

THERAPEUTIC DOCUMENIATION CARE4gL6N
MEDICATIONS)

ti;*• ro euirftrous. :f3
viRrrr EY MIDIALING
Su '• n General. Mo. Yr.
.100na
.
INITIAL PROPER

ORDER COLUMN
CLERK/ '
DATE RECURRING MEDICATIONS, EL3. FOLLO WING WACO ADMINISTRATION
NURSE MX?
DATE DISPENSED

DOSE, FREQUENCY
b)(6)-2

61(1140.W
illainIMMINIIIIIINEMIIIIMIIIIIIIIIIIIMI IIIIIIIIIIIIII IIMMIIIIIIIIIIIIIEE
IIIIIIIMI
IPnllinnlllnnnnllIl
MEE ggi rdmill1111111111111111111111111111111111111
mmems 0 21111111111111111111111111111111111111111
MI Mtnimmuninnumus
iimm.... IIIIIIIIIIIIIINNNEIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IJ.-, e lascc, r
rirg b)(6)-2 11111111111111111111111111111111
11.1121.1111111.1111111111111M1111111111111111
MIM111111111111111111
IIIIIIIIIIIIIIIIIII RI rdillnill111111111111111111111111
MIM
IIIIIIIMIIIIIIIIIIMI III 1111111111111111111111111111111111111
IIIIII M
1111111111111111111111111 11111111111111111111111111111111111111
IIIIIIEEEI
MIM 111111111111111111111111 11111111111EnM ¦11111111111111111.11111111110 II 111111111111111111111111111111111111111111111111111111111.1111111111111111111111111111111111111 11111111111 M ¦1111111111111111111111111111 1111111111111
IIIIIII ¦ 11111111111111-11111101111111111

MIM 1111111111111111111111 11111M11111

11111111111111111111111111111111111111111
IIIIIIIIIIOIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
OMMIIIIIIIIINIIIIIIIIIIII

IIIIIIIIIIIIIIIIIII 111111111111111111111111111111111111111
IIIIIMIIIMIIIIIIIIIIIIIIIIIIIIIIIII 111111111111111111111111111111111111111

IIZIIKIMIIIIIIIIIININIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
1=11

MUM311111111111111111111111111111111111111111

¦111111111111111111111111111111111
AD DITIONAL
1 PAGES IN USE, DYES j

PATIENT IDENTIFICATION,
IIIIIIIIIIIIIIIII

IMIIIIMIIIIIIMIMIIIMNMNEIN
PAGE NO.

DISPENSING TIMES
jaultica.

D 7 8 9
10 11 12 13 14 E 15 16 17
18 19 20 21

22 N3
'14 01 02
03 04

DA , F
OE 719 4678 EDITION OF 1 DE MEDCOM - 3822 05 06
Verify by . "
THERAPEUTIC DOCUMENTATION• CARE' PLAN
Initialing (MEDICATIONS) .. Mo. .Yr
Order Clerk/
Data to Timtit to

SINGLE ORDER, PRE-OPERATIVESS
Dote Nurse Time Given Initials
be Given be Given
b)(6)-2
b)(6)-2

00411 3/#74ta 4„155%--,R355
6U,14 &i' l.t. CDR, ili3
( /

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.....:-

16Yr LIMY-1943CW/1-451-0 / 4-fr 0/073 0/0-1)
aK 1V15 iite4 9/aGOZ #c/' 44y) ap-c 07 c) Aes
/AK..

IMP sacnwitz,-rWvcru-r Foe— I Now, 1 IF Nor itee1tn1-04MPUti-e oN
900c4 M
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¦•¦•......r ....... 1

Order/
Expir Cleric/ PRN nyLnAL PROPRR COLUMN FO LLOWING ADMINISTRATION
Nurse MEDICATION, DOSE, FREQUENCY
Date TIME/DATE DISPENSED
-,
U.S. GPO: 1990454-110/9521e

MEDCOM - 3823
MEDICAL RECOD•SUPPLEMENTAL MEDICAL DATA
For use of this form, see MI 40436: the proponent may is Os Offee of The Suwon
REPoRT TITLE
ADULT TRAUMA FLOW SILE,E1
PREHOSPITAL INFORMATION
TRANSPORT\
TIME IN:
.
Scene­

.
Police

.
Auto­

.
Ambulatory

.
Ambulance­

B4FEDVAC Unit / .-fr"--
.
CCA1T: Report From:­

.
Ref Hospital­

.
Ref Physician

MECAHNISM OF INJURY
.
MVA: . Driver or . Passenger

.
Front . Back

.
Seat Belt on

.
MCA: . Driver or . Passenger

.
Helmet worn

.
Protective Clothing Worn
ID Speed:­

mph

.
BCA:

.
Front

.

.
Back Helmet worn

.
Pedestrian vs. Auto Speed:­

mph

.
Fall ­

ft . Assault

.
GSW . Stab Etlefcag wound . .

Crush Burn

.
Aircraft Type ­

.
Other

OTSG A PPRovED tone

PREHOSPITAL TREATMENT
PROCEDURES PRIOR TO ARRIVAL
Oral Airway­
.
Nasal Airway
10..t4 Tube # ­

. NT Tube #

.
Crico # ­

.
02 @ \L/min via

.
Wreath Sounds: LT:­

RT:
12-1#­
: Peripheral-Subclavian ­
Femoral

Intraossesous: Site
ga-Friids:­
. IV 1 2 3 463 12-1
od 4)3 45

. CPR: Time started­Stopped
. PSG Legs AM
nary Cath : Size-.

NG Tube

.
OG Tube
la...Oleg Tube:

.
RT\Both

.
Medication

.
C-Collar

.
Spine Immobilization Device Time On:­

.
Splints:­

Type:

.
Other:

.
Tourniquet: Time On­

Location:

AMPLE HISTORY
Medications:
DEPARTUnrriaTtUirCIPItator (b)(3)-1 DATE
._rtitten fame s give: first, middle: grade; date; hospital or medical be Name —last -79-
. HISTORY/PHYSICAL . FLOW CHART.
: b) (6)-4
. OTHER EXAMINATION OR EVALUATION . OTHER ckeap
. DIAGNOSTIC STUDIES
. TREATMENT
DA FORM 4700, MAY 78KECU OP 36, 1 AUG 98MRRC apprvl, 9 Jul 98 MEDCOM - 3824 UsAPPc vzon

3:1)(6)-4
0)(8)-4

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this farm, see AR 40-6& the proponent agency is the Office of The Surgeon General.
REPORT TITLE
ORATORY ype/Cross #
Drug Screen
DPL Fluid

FLUID INTAKE OUTPUT INTAKE
OUTPUT
RL NS
Urine

Total Prehospital­
ml ED: 1 2 3 4 5 6
NG
7 8 9 10-ml

Blood Products Blood Total Prehosipta1­
ml

Stool/Diarrhea
ED: PRBC's 1 2 3 4 5 6 7 8 9 10­
ml

FFP: 1 2 3 4 5 6 7 8
9 10­ ml Total Intake
Platelets Total Output

PATIENT'S IDENTIFICATION /for typed or written entries give: first, middle; grade; date; hospital or mace' facifityl
b)(6)-4

DA FORM 4700, MAY 78
MCEU OP 36, 1 Aug 98 MRRC apprvl, 9 Jul 98
OTSG APPROVED Atte

PROCEDURES
Lateral C-spine

Chest: Erect/Supine
Pelvis
Thoracic Spine

Needle Thoracostomy by:Lumbar Spine Odontoid ED Thoracotomy by: PTV: Size:\

Site:Abdomen PTV: Size:\

Site:Extremity: LUE/RUE

NV: Size:\Site:
Arterial Line: Size: \

Site: Central Line: Size:\
Site: "ocentesis by: ,
Color Rectal Tone .
Srrnt Void Di + -
PCO2

Name —last . HISTORY/PHYSICAL . OTHER EXAMINATION OR EVALUATION . DIAGNOSTIC STUDIES . TREATMENT . . FLOW CHART OTHER tsprifyi
MEDCOM - 3825 USAPPC MOO

M(6)4
NURSING FLOWSHEET
TIME CUFF B/P i‘Al r3v 0iv) 7'77",,, 17/VIZ
Pulse Rhythm i)ic)5 7-- / , -t
Respiration 047'1,44 tat= 0-A--
Temperature
A-Line
02 Saturation / A-re "Z /a0 15'
Ead Tidal Co2
CVP
Urinary Output
GLASCOW SCALE
Eye Opening Verbal Response V7iJtiljtj
Motor Response
TOTAL GSC SCORE
R Pupil size + react
L Pupil size + react

MEDICATION DRIPS
1.

2.

3.

4.

Time Aim Not • ' .x.—ie ,3-......\,3r.,0"3-,0 -3_......, -34,,3e" ,f-c....\-4,111r3
1111111MINSAr _ p".j0„mwi,017l•3, EJWAVA INNINIMICW___ IFOIMP407.
___ArlialiM

_efor _ •3izik,, "2/71ms
/ ' rgrilliiMil foi rinimmitir4w_
, / 11 WA PIP11P.WMIN II PZ:3- . • _3
•
I I III MAU....tro," 01.
I •I 0 M INI FMfiNff\ v _iISOMII1 IP 3I_TO IIIPMGEMI111 II M/ratfAIDIMIMMILPWRIEZAtillle.22/FrArriMallIll
Wm „,..,344,. ..ffly, ,1a 41Fii..4175TOP:gaz
L,401604, erTAW4tmoillaw.„ ._, .1W_ ,,,W..,.__3utiorpirlwayarr:-,_.0-AMOIroWfr ,,. riArzmar., .,_i
...i.egfr, 3
Imirsirr -3 „Apirrrewr-A-reMd-c-..

,3

)(6)-2
_.:1-41.

• -, e sawn:-. ' ;L v e Time Out:-To:-1-----
Signature and Title: . Dead Time Out:
c-rr--1-----—
'Ll To:
)(6)-2
5
Operative Permit Signed: . Yes . No . NA
3
Valuables/Clothing: Family Notified: ¦ Yes 0 No . NA 5 Chaplain Service Notified: . Yes 0 No 0 NA
6
-
MECU OP 36, 1 Aug 98 PAGE 4 OF 4 MRRC apprvl, 9 Jul 98
MEDCOM - 3826
DOD 010305
..... ',cm ir .....Daunt.\RATIO
FLOW
ALARMS TEMP INITIALS

3 41 610,) ami iz /to3putI r-d — b)(6)-2
--iYr ,Mf:2-chti_/4,
7/2.? 14Z J srip4 I L • j 3/ , 3'
(to
349 ar05— S1-1X13 / 1 • 7d ) 'Zi

i'fL" 5-3.2 I , L -
49 03qc ,ii%k) Q ita
\ I-1« 6 °L.& I: z-
./

1,134. et6o4 sirtw /2-'t .G, /as
.

,•• _
_ I
_ •

.
,
. , ...

.
.. . _ ... . _ •-, . -. ,
(Continue on reverse)

PREPAREDB \
DEPARTMENT/SERVICE/CLINIC DATE
Respiratory Care Servlee
5Y634(.3r/r4-e/er 4/27,y
Department of Medicine
PATIENT'S IDENTIFICATION (For typed or written entries give; Name—last, first, middle; grade; date; hospital or medical facility)
. HISTORY/PHYSICAL . FLOW CHART
1.3 OTHER EXAMINATION
. OTHER. .(SpecifY)

OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DATMA 78 Previous editions are obsolete ILS.bevier;nani Pendell Office: 331143019
FOR" 4700
MED FC OP 12-1 (Rev), 1 Mar 95

MEDCOM - 3827
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
Far usa of ft farm SU AR 404E4 68111110nm atony is Re No of ills SUrPln
REPORT TITLE
ADULT TRAUMA FLOW SHEET
PREHOSPITAL INFORMATION
TRANSPORT TIME IN:
.
Scene\. Police

.
Auto\. Ambulatory

.
Ambulance\VAC
Unit: fr-3-r

.
CCATT: Report From:\

.
Ref Hospital \

.
Ref Physician\

MECAHNISM OF INJURY
.
MVA: . Driver or . Passenger . Front . Back

.
Seat Belt on

.
MCA: . Driver or . Passenger . Helmet worn

.
Protective Clothing Worn

.
Speed: \mph

.
BCA: . Front . Back . Helmet worn

.
Pedestrian vs. Auto Speed: \mph

.
Fall \ft . Assault

.
GSW . Stab 133/Flag wound . Crush . Burn

.
Aircraft: Type \

.
Other\

AMPLE HISTORY

Allergies:
L'it14414d, /3°c1 Medications:3i v 11"ri r
Ne, / ¦¦-..-- TAF

Past Illnesses:3i (.41/161141V1•4 /a1-% 11 4
p FPARFn RY Iginnabins R Thlol
( b)(6)-2

Pl. 11014.3.140LIII I II IUM111.111 INT typerrur-WlitteD Main give: First, middle; grade; date: hospitalOr 'Baffin' heft'
b)(6)-4
OTSG APPROVED Ord

PREHOSPITAL TREATMENT
PROCEDURES PRIOR TO ARRIVAL
.
Oral Airway\. Nasal Airway Cl/E4 Tube # .. NT Tube #.

.
Crico # \

.
02 @ \1Jmin via\

.
Breath Sounds: LT: \RT:\

#\Subclavian\
Intraossesous: Site

121: Peripheral\Femoral
.
IV I 2 3 4a Gilfood 1 (t3 4 5

.
CPR: Time started\Stopped\

.
PAS/G Legs Abd ¦ . NG Tube

-.‘rinary Cath : Size\iLcAliest Tube: . RT\T . Both
.
Medication\

.
C-Collar . Spine Immobilization Device Time On:

.
Splints: \Type:\

.
Other:\

. OG Tube

.
Tourniquet: Time On\Location:\

Last Meal:360.44444.‘
, p 3
Last Tetanus:3
....,, li 'a. '''...

,,,,,,-, .3

'A".7 Events: 'Or3
/

'Vie,d4014 fil-.e4.22.4' .471444 rClidtV•S'(e ,,,ta Li„0,0• 4— co,A.54.-A-Y Pregnant/D Yes . No Alai
n;pprrr.nralTrrrenterrum later
DATE
' (b)(3)-1
79--44rs--iaD

Name —last,
. HISTORYIPHYSICAL -. FLOW CHART
OTHER EXAMINATION3. OTHER (Spec& OR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78
USAPPC 52.00

MECU OP 36, 1 AUG 98
MEDCOM - 3828
MRR pi miry 1 _ Q .Till OR

INITIAL ASSESSMENT
AIRyVAY/BREATBING

0 Obstructed
tent­

. Asymmetrical
12•6mmetrical­

.
Labored 5d, is W—a r /577

.
Unlabored­

. No
. Trachea Midline [WPC
L

Breath Sounds:-R­Present-EV Ell
Clear-. .
Decreased-. .
Absent-. .
Rales/Rhonci-E2/ .

.Yes ENS'
Crepitus:
CIRCULATION rep
.CyanoticSkin/Mucous
.Pale

Membrane Color .Flushed ['Ashen
.Absent

Pulses: .Normal OtWieak Mi3dinding
Rate: /

Rhythm: .Cold

Skin Temp: .NVami .Hot­
.moist

Skin Moisture:-raD4­
DISABILITY\
Glascow Coma Scale
3. Motor
1. Eve Opening

4-Obeys Command-6Spontaneous 3-Purposeful Movement 5To Voice 4
Withdrawn­1-Flexion-3 2­To Pain
None

2 None Extension­
2. Verbal­Oriented­
5
Confused­

4 Total Score
Inappropriate Words 3
Incomprehensive-2
None­
I r.---01 +
-1c
-LT' size

Pupil Reaction RT size
.\mm
Brisk-I:3-mu Constricted­
.t CI rmn
Sluggish-CI-mm 0-mot Dilated-.­
mm 0 mm Nonreactive-CI­
mm 0-ono

MECU OP 36, 1 Aug 98
MMRC apprvl , 9 Jul 98

INDENTIFY INJURY SITE BY NUMBER
3. Hematoma

1. Laceration 2. Abrasion
4. Contusion 5. Deformity 6. Open Fx
7. GSW 8. Stab 9. Burn
10. Cold 11. Edema 12. Amputation
13. Avulsion 14. Frag Wound 15. Pain

READ At'lf'n"
MAXILLOFACIAL
1t2„,"

C-SPINEINECK­
CHEST 6S)dital--Wr-fftW)16M
/41,d,,eZ-0WC sg2)
04-t.ez-

kez...1 4-
ABDOn5160•'I 4i-/t PERINEUM MUSCULOSKELETAL
PAGE 2 OF 4
MEDCOM - 3829
ID

MED-RECORD-SUPPLEMENTAL MEDICAL REG ro onent a ency is the Office of the Surgeon General
For use of this for m_ , see AR 40-66;\ proponent OTSG APPROVED DATE
REPORT TITLE­
CRITICAL CARE FLOWSHEET
TIME ' ING PRTySS NOTES

1­
0 •-#-4r... • .-ii.ala '11.-•-ijim...d..,..,
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apjmnirlig--Irmr="-ti-

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VIP-(---)­(.l'-Q---v-rvC) *-..I-. 1 e-(4 -'i) •-A.444-- -f-A.

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4./..../(9-10•••-,\ t-
nt-/-C.40, 4/
"tom­
C230 0 -(,-OlOt--0L Ct‘iL4 .
_, )(6 -2 )
F-ire & Title)-DEPARTMENT/SERVICE/CLINIC
CA91 75/KA-ICU D1677?clip TION (For typed or written entries, give: Name-last, first,
1-D HISTORY/ PHYSICAL-. FLOWSHEET
e; a e; r ospital or medical facility) 0 OTHER EXAMINATION-0 OTHER (Specify) c-OR EVALUATION
ID DIAGNOSTIC STUDIES -Supplement to SF 510 middle;-6..")tt
. TREATMENT
FORM

MCEUL OP 365 (Rev), 16 July 01 DA 1 MAY 78 4700 Page 1 of 8 MRRC apprvl — 07 June 01
MEDCOM -3830
rjnotrS7:-;
Heart Rate NBP NMAP ABP AMAP Sp02 ICP/CPP CVP PAS/PAD PAWP PVR CO/CI SVR
Cardiac Rhythm/ Ectopy Circulation-RUE
RLE Responsiveness Best eye opening Best verbal response Best motor response

Pain/discomfort scale: genies 0 (no pain) — 10 (worst pain gets)
Location: Quality: Sharp Dull Pressure Radiating to-Other­Intervention: Medication Hotpack Coldpack Reposition Other Pain Reassessment: Denies 0 no .ain —10 worst •ain ets
41.

Mode Rate Tidal Volume Fi02 Pressure Support/ PEEP
PdiPMI /I MI MI MI 1.1%
AU3
MEDCOM - 3831
DOD 010310

MEDI\CORD-SUPPLEMENTAL MEDICAL RECO form, AR 40-66;\ proponent
ro onent agency is the Office of the Surgeon General
OTSG APPROVED DATE

REPORT TITLE
CRITICAL CARE FLOWSHEET
NURSING PROGRESS NOTES
TIME . _\
_ .\flie., 0\42—o..tero '..9.4a-A.
a.,\-• .."
•• 0 130"M4P.k,,.__
• 1.

civ-selA\0..„,„,s,c.r....c.dtad-1...-v­
\c ArnAD-"v4X.-4
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r‘
1
i

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Ile3
irdh.-41.2.
1 13

a.'_. a -\1 ,...L....f.
_As... I&.41.:!...-- r--._\...11 1\,,, 1.MEM11 -M.#
..

_ •.. .MAl • - ALt._—_-1!¦M I
W
DEPARTMENT/SERVICE/CLINIC DATE
(b)(6)-2 le)
ICU-3 7J oirn.„.._03
(-41)1-74—k---or typed or written entries, give: Name-last, first, . HISTORY/ PHYSICAL\. FLOWSHEET
Crntndie; grade; hate; nospitat or n edical facility) (b)(6) 4 . OTHER EXAMINATION\. OTHER (Specify)
-
p(,)

OR EVALUATION
.
DIAGNOSTIC STUDIES\Supplement to SF 510

.
TREATMENT

FORM\ MCEUL OP 365 (Rev), 16 July 01DA 1 MAY 78 4700 \ Page 1 of 8 \ MRRC apprvl — 07 June 01
MEDCOM - 3832
ICU Day \Dia nosis/Stsgery Post Operative Da\
:Date
. 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300
TIME
Temperature
Heart Rate
NBP Jo s a 1(,3 lot qs15-2,

\
NMAP 7 7/ o e6
ABP
AMAP
Sp02 q qq cit3
ICP/CPP
CVP aa a'4
PAS/PAD
PAWP
PVR
CO/Cl
SVR

Cardiac Rhythm/ Ectopy
5 r ST

Circulation RUE -LUE 3+ 0+ +
RLE-LLE a t-DA-k

Responsiveness
.Ced S4

C­
Best eye opening

N
Best verbal response

S
Best motor response

- ¦111/%/all
/211112¦11-PwillPiIIP"/-id%%
Pain/discomfort scale: Denies
0 (no pain) — 10 (worst pain gets)
Location:

Quality: aharp Dull Pressure Radiating to-Other­Intervention: Medication Hotpack Coldpack Reposition Other­Pain Reassessment:2enies 0 (no in — 10 worst .ain :ets
,-;-LI1-R
Lni

Mode Rate Tidal Volume
-C.
Fi02 4 b Pressure Support/ PEEP
LA Po 130 1@
lb 10 10 1 0
1 S Is IS 1

ea-ero-Ck_M ?ISO
TOTAL INTAKE ....MAIMIW.10051Urrig LFEArire.111 PP'
• \
W%\
Urine Stool
111111111111111111111111111111\
i 3
MrT­
30
TOTAL OUTPUT
b)(6)-2
COMMENTS Nurse's Initials
MEDCOM - 3833
TIMEM &too
,Mr .:22',;,M,M...,i u .,..,,-'
• i '..-'M

-1. -W'f,..s 1 S-'M1 t ,M•'M' 1
.!.1',, 'M,,,­
... W.,- „ r....?.... v.W,„„ , 'W`alkeiL4h6:.-aS0.4.3=42..?4‘gi:g1E12.1a111 .11 4, 1Zili: '1,4AbLALLea 'k.L.Ttsiearaiki.gatdlLiahaiiat,i+bi—LL.ili;.ls:'i,
Method of Urination: Normal Foley Suprapubic Condom Cath In/Out Cath Ostomy Incontinent r Urine Color: Yellow Amber flematuria
V

Urine Character: Clear Cloudy sediment
C L

Blood clots Genital Edema: y. NN Ai Genital Discharge: White Yellow Green Bloody None Menstruating
.M -rw,r;-, ,„;.... :m P t r,,i1ARE,-A.‘7 .ftMZ .7 ^MA: 1.,-. -v t ..:MI, _.7.,g qv.... ii ,M4 •
,\.\...„\f\Pit, 1 , , \liti ¦ EaLt_:11,--i ! • ..:1—.V.,/.2,..i.4g11. - , 1.4.,1 17,M1 ff.Y ••\Y. 1ft.. .\.\- e• Ahl.
..

...-.11,t,,-,. .11.•\•M..M,. M1...:M,.L.2.-:' 1.:'.Vt.' 1,"M
....,...... .....).M-..i.e..... •M
Color. Pale Pink Mottled Dusky Cyanotic
to e R-

Jaundiced Flushed Temperature: Hot Warm Cool Clammy
Diaphoretic Specialty bed Egg crate Qther Code (Document by Numbers) with Time and Initials
1.
Abrasions\11.-Laceration

2.
Avulsion\12.\Petechiae

•

3.
Bum\13.\Rash

4.
Cast\14.\Retention Sutures

5.
Contusion\15.\Staples

6.
Decubitus\16.\Sutures

7.
Dressing-17.-Tear "II

8.
Ecchymosis\18.\Wound

9.
Erythema\19. .-.--

10.
Incision\20. r;',','

igt
[ I Clear except as otherwise indicated

71 412
Wound Location:\ ! (A Approximated sutured staples ,Seri-strips to air LIsg llsgil Reinforced D.C.I D sca.P''
Drain: If Malencott Qther\ — Drainage: Serous auguineous f =lent None
i\other: \ Jr''
•1 b

Wound Location :\
Approximated Sutured Staples Skri-strips\i)
Qpen to air llsagg.4 reinforced D.C.I
Drain: jf Malencott Qther \—

Drainage: Serous Su% uineous Purulent None \Sons
Other:
Wound Location :\ COSS iie
Approximated sutured Staples Stgri-strips
Qpen to air 12,sg Dsg A Reinforced D.C.I Drbb
Drain:.It Malencott Qther

.......—

Drainage:lerous Sgaguineous Purulent None Other: Scvn
iA"`'.11.'"I'',-U47¦-.'*..rwi %WM 0"
/i::•,, 4 ^ ice, f) .„t, yAaagr..i.gyL, ,\... ,
,„.... .--M.......

.

Psycho-social: Calm & appropriate Anxious Angry
Denial Coping Withdrawn Combative Restless
Hygiene: Bath Qml Perineal Eye Cath

_....-

Linen changed _Shave
Activity: Ambulate BR- bedrest Kc Chair
ROM fumed ad eft Back Right)
HOB Up Repositions Self Dangle Q):CL

Call light within reach Side Rails up x\IO
Patient teaching provided 12.&
See\atient teachin • flowsheet

b)(6)-2

Nurse's Initials
MEDCOM -3834
-
..
+—

TIME AIRWAY:NI-nasalpharyngeal [ ]R nare [ ]L nare • #0 i, err — it­' . ., ,•,, w_i. 11.; ,M..M, !?­11',L, . . Lo.g.V.g.1.1.1 ... 1 kk ,31/0i 14­„ ...k....41.,A,
'y 7Qralpharyngeal Ira heostomy Size_ irE=cm @M[ IL side of mouth Size_ cm @ nare­R [ ]l- nare Size 99
RESPIRATIONS:­Ventilated­Regular­Irregular \I
EFFORT: Unlabored Labored SOB
Tach •neic D s.neic Accesso -muscle use
BREATH SOUNDS:­E. ual Unequal
•Clear­Diminished RUL (2.
..­"crackles­Wheezing Rhonchi­Stridor RML RLL (Z ft - t..
Absent * = Clears with suction/cough — LUL LLL R. R.— 0
COUGH: Productive Nonproductive 1e1/41
SECRETIONS : _Qral Nasal ETT Amount: Small Med Large C 11--S 0— S
Color: Clear White Yellow green Brown C•
Tan Bloody rink Cloudy Oral Nasal ETT
Consistency: Thick Thin Oral Nasal ETT -r
Pulmonary Toileting: IS-Incentive spirometry C ' -Chest PT Cou h DB-De • breath Suctioned G
Trach Care: pm A Inner cannula cleaned •
Trach ties A
CHEST TUBE #1: Location 1.-Mck
Suction 00 cm H2O­Water Seal
Air leak: +/- --
Drainage: Serous Sanguineous SAoSang Purulent .S, gas,
Subcutaneous emphysema: +/--Site: —
, CHEST TUBE#2 Location
X. Auction­cm H2O­Water Seal
Air leak: +1-
. Drainage: Serous Sanguineous SeroSang Purulent
Subcutaneous emphysema: +/-­Site:
f'a • .­.­, .,..i. 1,,.. • . ,­,,i s. -­..­I. .,­;`.­.­.. 4.,­.L
t. ABDOMEN: Soft Eirm -at Bound Distended .
Qbese Tender Nontender Ascites / \.)
,, -BOWEL SOUNDS: Active­RUQQ LUQ:hyper Huy) Absent I­1-
LLQ ,MTUBE: Ng Qg Dobhoff Peg PO 1A0 [lb AID &) (r I 1 - I I 1 1
Tube location: Qral Nare[ JR [ IL ­ L
Other
Position checked Egtent Feeding infusing -Po'Clamped LCS-low continous suction gravity
LI­low intermittent suction-Irrigated­ t¦'.
ti RESIDUAL check­ml le?'
Complains of Nausea Vomiting
... ,.Tube Drainage: Amount Small Med Large
Tube Drainage Color: Brown Green yellow
Clear Moody
STOOL: continent Incontinent -ostomy
' ectal tube Di ,.
.-Ostom Stoma :­' ink Dus-Drainin .
Stool Color/Consistency: Brown green Bloody
. Yellow Black Formed Soft Loose
. .DIET:
Route: Qral Illg -nasogastric QC- oralgastric
Dobhoff Peg
%Arm Consumed: Breakfast Lunch
,,­ Dinner Suelements
f
MEDCOM - 3835
DOD 010314

•

-----y -.we
TIME3 0 0 0
.3-

_3_
....\
¦ Amir
Fixed -plApir rAmirisrmarArrBrisk Sluggish
RESPONSIVENESS: Alert Oriented X1 X2 X3 Disoriented Lethargic Sedated Seeping
PUPIL SIZE/REACTION:
5

Arousable Pain onl-P ral-ed-nres .onsive­
BEST EYE OPENING: Spontaneously Or to: Speech rain None BEST VERBAL RESPONSE: Oriented Confused Inappropriate words Incom.lete sounds None Intubated Trach BEST MOTOR RESPONSE: Obeys commands _Moves all extremities Localizes pain Withdraws from pain
lexes to •ain Extends to .ain None MOTOR FUNCTION: StrongNo -Y_Veak-UE R/L Purposeful Spontaneous -e-LE R/L SENSATION: _Intact Tingling-UE R/L Numbness Absent-LE R/L MEMORY: Long +/- Short +/-
NEURO BLOCKADE: Y/N Train of 4 ___of 4 mAMP VENTRICULOSTOMY: Monitor Open to drain
CIa-.ed
Vent/drainage level: _cm above:
FOM-Foramen of Monro Other
Zeroed ICP monitoring system at:
FOM-Foramen of Monro Other
CSF drainage: Serous sanguineous

Clear Purulent

•..
lMtMi.MI'
.M..-.....­
¦

RHYTHM:-SR SA SB ST SVT VT VF JUNCT AFIB PAC AFL 1HB 2HB 2HB2 3HB PVC HEART SOUNDS: SI S2 S3 S4
Distant Murmur Rub

PACER:-Method Transvenous Tv­
Mode Transcutaneous Tc
Rate
Permanent (Implant)
Ou..ut/ Sensitivi
EDEMA: +1 Trace

RUE/LUEGeneral-+2 Minimal
RR!
14E1
-----""
7,,

4,1) ,'.,1i.::. .
i 5
L,....,-. e.
¦
s-r
S -S
442 4- a

None-a Moderate Pitting-RLE/LLE '""' 1%) +4 Severe Pitting-Facial-.1.-2
SCDs/TEDs-8MOI JVD + - 030 de? ees Homan's Sign (+) (-) CAP REFILL-B 3SEC S3SEC-RUE/LUE
RLE/LLE PULSES: Absent Doppler-Rad R/L1+ Faint 2+ Weak 2± Normal
DP-P R/L A arj1
+ Bounding Regular Irre:ular DP R/L rare , ,,v.f.14 ',.1,;..S.,, •)ii
7T•rzwr ..n.', ".'r ,.1. 1r ?!c rr , r¦¦•.;,.,,, ,•,-; --,-,,-,-i• , • i•M. L -ifMM141t.• -,,M...,M,,
.....,,,,.....:_—_--;

.......3' - n''= 4 'In 3' :3.3..... ..'i..1 r-. .M. .._

Appearance-Site-Date
Started
.-•4; Lk
goIMINA

Intact­
tact -MilrAlitiM edema-MI
Erythema
DU 11
Infiltrated flushed
Zeroed at Phlebostatic axis: -Y/N Swan-cm @ hub
0 -Cr
--.10
a-1-BI

Size ., :-.1 , ...
• '...'r. !,..)M,,,..; ,:.. -,M,....:ii111.1.,,,
:ri-• .-::,.:1 ,-• I

b
iv,-3r;• _
A
I If(s-IIIIM
'

;( ,',
M E DC 0 M - 3836
1111 (• •

RECORD-SUPPLEMENTAL MEDICAL- -;ORD For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General
OTSG APPROVED DATE

ignature & Tit e) DEPARTMENT/SERVICE/CLINIC DATE
/Iry ICU m111? 0 3
ICATION (For typed or written entries, give: Name-last, first,
. HISTORY/ PHYSICAL\. FLOWSHEET
„ hospi\acility)
b)(6)-4

. OTHER EXAMINATION\. OTHER (Specify)
tPw

OR EVALUATION
.
DIAGNOSTIC STUDIES\Supplement to SF 510

.
TREATMENT

FORM
MCEUL OP 365 (Rev), 16 July 01DA 1 MAY 78 4700 Page 1 of 8\ MRRC apprvl — 07 June 01
MEDCOM - 3837
co

TIME
PUPIL SIZE/REACTION: R/L Brisk Sluggish Fixed
RESPONSIVENESS: Alert Oriented X1 X2 X3 Disoriented Lethargic Sedated Steeping Arousable Pain only Paralyzed unresponsive BEST EYE OPENING: Spontaneously Or to: speech Pain None BEST VERBAL RESPONSE: Oriented Confused Inappropriate words Incomplete sounds None Intubated Trach BEST MOTOR RESPONSE: Qbeys commands Moves all extremities Localizes pain Withdraws from pain Flexes to pain Extends to pain None MOTOR FUNCTION: Strong Weak UE R/L Purposeful Spontaneous None LE R/L
SENSATION: Intact Tingling UE R/L Numbness Absent LE R/L MEMORY: Long +/- Short +/-
NEURO BLOCKADE: Yls1 Train of 4 _of 4 mAMP VENTRICULOSTOMY: Monitor Qpen to drain
Clamped Vent/drainage level: _cm above: FOM-Foramen of Monro ather Zeroed ICP monitoring system at: FOM-Foramen of Monro Other CSF drainage: Serous Sanguineous
Clear Purulent

RHYTHM: SR SA SB ST SVT VT VF JUNCT AFIB PAC AFL 1HB 2HB 2HB2 3HB PVC HEART SOUNDS: SI S2 S3 S4
Distant Murmur Rub PACER:
Method-Transvenous Tv
Mode Transcutaneous Te Permanent (Implant) Rate

Output/ Sensitivity EDEMA: +1 Trace
RUE/LUE­

General +2 Minimal
None j Moderate Pitting

RLE/LLE

+4 Severe Pitting
Facial SCDs/TEDs On/Off JVD (+) (-) g 30 degrees Homan's Sign (+) (-)
CAP REFILL B 3SEC S3SEC RUE/LUE
RLE/LLE PULSES: absent floppier Rad R/L 1+ Faint ;±. Weak 3+ Normal
PT R/L

4+ Bounding Regular Irre lar-DP R/L
Appearance
Dry Intact Drainage
Edema
Drythema flu A In filtrated Flushed
Zeroed at Phlebostatic axis: Y/N Swan -cm @ hub
MEDCOM - 3838
3(11111 Ilestatus: Full DNI Chemical DNR
Aller 'es
Physician 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400
1400

Reaction
Brisk 20 i• 4410 sluggish Fixed
3 APO.
ooli. I 101

s ri 9U ls 1130
I

ri s S ST
LR lav iao lac) It
40 f0
.9e14‘
• V 6
11(2o •

,....110redVIRP"
/I3IIPPWrill !MaIFT:., Flat-PA
MEDCOM -3839
Responsiveness Mode A-Alert V-Vent 0-Oriented TC-Trach collar D-Disoriented NC-Nasal Cannula L-Lethargic SM-Simple mask P-To pain only VM-Venti mask PR-Paralyzed NRB-Non-rebreather mask S-Sedated FT-Face tent U Unresponsive SL-Sleeping Ectopy
P-PVC Best Eye Opening PA-PAC 4-Spontaneous M-Multifocal 3-To speech N-None
2-To pain F-Frequent 10/min 1-None 0-Occasional
R-Rare Best Verbal Response 5-Oriented 4-Confused 3 Inappropriate 2-Incomprehensible 1-None, ETT, Trach
Best Motor Response Circulation 6-Obeys commands 1 +Faint 5-Localized to pain 2+Weak 4-Withdrawl to pain 3+Normal 3-Flexion to pain 4+Bounding 2-Extension to pain A-Absent 1-None D-Doppler
Cardiac Rhythm SR-Sinus Rhythm SA-Sinus Arrhythmia SB-Sinus Bradycardia ST- Sinus Tachycardia SVT-Supra Ventricular Tachycardii VT-Ventricular Tachycardia VF-Ventricular Fibrillation AF-Atrial Fibrillation AFL-Atrial Flutter 1 HB-First Degree Heart Block 2HB-Second Degree Heart Block Type I 2HB2-Second Degree Heart Block Type II 3HB-Third Degree Heart Block JUN-Junctional BI-Bigemeny TRI-Ttigemeny
Admission Wt Ventilator Day
Today's Wt Central Line Day
Site:

Arterial Line Day
Site:
Difference +/-nyaty
Site;
Total Input Site:
3
Total Output Foley Day 0 0 .

TIME
,.,:z....„ .1 ' '1M
I
..

AIRWAY: NI-nasalpharyngeal [ ]R nave ( ]L nare QralphwngealXich9ostomy Size_ EMncm @ ItliK [ ]L side of mouth Size dg
cm e nare-R-L nate Size RESPIRATIONS:-Ventilated-Re:ular-Irre:ular EFFORT: Unlabored Labored 10B Tachypneic pyspneic Accessory muscle use BREATH SOUNDS:-Equal Unequal Clear-Diminished RUL Crackles Wheezing
RMLEllon ch i-Stridor RLLAbsent LUL

= Clears with suction/cough LLL COUGH: Productive Nonproductive SECRETIONS : Oral nasal ETT Amount: Small Med Large
Color: gear White Yellow Green Brown
an Blood-Pink-loud-Oral-asal ETT Consistency: Thick Thin Oral _Nasal ETT Pulmonary Toileting: IE-Incentive spirometry CPT-Chest PT Cough DB-Deep breath Suctioned Trach Care: Esg A Inner cannula cleaned
Trach ties A CHEST TUBE #1: Location Suction 21) cm H2O-Water Seal Air leak: +/-Drainage: Serous Sanguineous SeroSang Purulent Subcutaneous emphysema: +/--Site: CHEST TUBE#2 Location Suction-cm H2O-Water Seal Air leak: +/-Drainage: Serous Sanguineous SeroSang Purulent
Subcutaneous emphysema: +/--Site:
,..­
...-.:,-. 1 ,.''5!.-'.--i '
ABDOMEN: Soft Firm Flat sound Distended
Qbese Tender Nontender Ascites
BOWEL SOUNDS: active per Ijypo A__bsent RUQ RLQ LUQ LLQ
TUBE: NG Q g Dobhoff Peg
Tube location: Oral Nare[]t [ ]L
Qffier

Position checked Patent Feeding infusing Clamped LC-low continous suction Gravity LIS- low intermittent suction-Irrigated RESIDUAL check-ml
Complains of nausea Vomiting
Tube Drainage: Amount Small Med Large
Tube Drainage Color: Brown Green Yellow Clear Bloody STOOL: Continent Incontinent-ostomy
Rectal tube Diaper Ostomy Stoma : sink Dusky Draining Stool Color/Consistency: Brown Green Bloody Yellow Black Formal soft Loose DIET: Route: Oral NG -nasogastric4:-.Q- oralgastric
Dobhoff Peg %Amt Consumed: Breakfast Lunch Dinner Supplements
ao00 ,.. , . iiii OI; .M.. --•Mi.lii.ili4tLak.i... .. . I 1 i i' I'V .I ¦ . -,).14a2).4 4.*).MA t.­,f .22a) , . ' ,,, )M¦ Oft. ,
U £ K g (t R A IJ E- S 0— C E -r .....¦ . vvt (V '-Syn .••••••"" •
• P S NI Ab A b fib lib N.Ils P4 t;C i-,'' :.1-I, , . • • • • 1 lg,".­.'••;
s c,l.

MEDCOM - 3840
•

TIME\ tr ibo
, u.. ,!1A...--7)1,..,1,74.;;;,.,:i.-
; .-M‘ ',---,-;- ---;s7.-.. ,M,, -M— , , ,,1 )' \•: • ,,
-M0A.1.54:c ,,,h
;,:rk'utM iliktep.,-, 1 .1134 '-'s I)3' 311--e,-,,,-11. 12,-1., ' 1,1 04" i1111111iiiglik...g::"Cds:t'
''-lutt_teza_vii araeiliata...: 4taiQz2—.V.
IV'' ' .M d...t, fitkian
rM

Method of Urination: Normal Foley
F

Suprapubic Condom Cath In/Out Cath-
Qstomy Incontinent
Urine Color: Yellow Amber Hematuria

Y

Urine Character: Clear cloudy Sediment
B ood clots
Genital Edema: Y/N
Genital Discharge: White Yellow green
Bloody None Menstruating

••-au ri-w., w

,., ,,,,.......,,-„, „L...6,2: wiaili" 7,, ;,..1.1.;.,-7,.Trt71075 ,01,,,p-4 tM4-',-.' •

ell .
., ,.,.E.,,-, ,( ;42:5-El sM_,M• .MtaF. M. ¦Mti• •M'.fMtia iM• 7,..)',4-, al,M!!"mta, 1441 , 44, ,'
,,,........M...0M
L..52M.M,...iM1-.4M......LI.:1A). ....:1::./.... . 4.. ..:..M‘M,

Color: Pale Pink Mottled Ruslcy cyanotic
Jaundiced Flushed
Temperature: Hot Warm Cool Clammy
Diaphoretic-(&)
Specialty bed Efig crate Other­
.........-.
Code (Document by Numbers) with Time and Initials

1.
Abrasions 1 I . Laceration

2.
Avulsion 12. Petechiae

3.
Burn 13. Rash

4.
Cast 14. Retention Sutures

5.
Contusion 15. Staples

6.
Decubitus 16. Sutures

7.
Dressing 17. Tear

8.
Ecchymosis 18. Wound

9.
Erythema 19.

10.
Incision 20.

[ I Clear except as otherwise indicated
b)(6)-4

Wound Location:
Approximated sutured Staples Steri-strips
Open to air Dsg Dal A Reinforced ID,CI

Drain: AZ Malencott Other ­Drainage: Serous Spigo

t ineous Purulent None
Other:­
Wound Location :
Approximated Sutured Staples agri-strips
Open to air Dsg Ds2 A Reinforced D.C.II
Drain:E Malencott other

i ineous Purulent None
Other:

Drainage: Serous Sgrgu
Wound Location :
Approximated Sutured Staples 5/gri-strips
Open to air Rsg D52 A Reinforced D.C.1
Drain: Ji Malencott Other

Drainage:lerous loguineous Purulent None
Other:

Psycho-social: Calm & appropriate Anxious Angry
Denial "in: Withdrawn ombative Restless
Hygiene: Rath Oral Perineal Eye Cath

Linen changed have
Activity: Ambulate BR- bedrest BSC Chair
ROM iumed eft Rack Right)
HOB Rp Repositions Self Dangle

Ii

Patient teaching provided
b) (6)-2

See atient teachin flowshee
Nurse's Initials
MEDCOM - 3841
N1. C RECORD - SUPLEMENTAL MEDIL. OA 1 A
Yr use of this form, see AR 40-66; the propene \.cy is the Office of the Surgeon GoneraI

EPORT TITLE
OTSG APROVED (Base)TRAUMA FLOWSHEET .„..1NrrIAL.AssEssm.ar.r •
[ATB . DELAYED . . MINIMAL
ate: \orinatiAgiv.aI Time: £' G-t.5 \

Sex: Age: \Wt:
flergies: \
Tetanus talus: UTD Unknown
ViP: Last Meal:
hid Complaint .

6--7)

al)/ Medications:
reatments PTA:\ r.
ITAL SIGNS: BP: 1 11/31 p: RR:1:4,4-1VTEMP:
SA02: 98% CO/

L
HEST :'SKIN` • • .::
RAUMA.YEs . NO 0 WARM . SOFT PERRL . YES • . NO R\mm\L\mm
AIN OYES ONO DRY . DISTENDED

. GLASCOW SCORE:
DB .YES . NO PALE TENDER
..
UNG SOUNDS . DUSKY BOWEL SOUNDS

2 • 3. 4 IP 5\
6

R L MOIST El YES NO 73
4) 839 9 el
..
] . CLEAR GUTAC TEST

1. EYE OPENING 2. VERBAL RESPONSE\3. MOTOR RESPONSE
.
WHEEZES

.
POS .NEG

Spontaneous-4 Oriented\- 5\Obedient\• 6\•
. DECREASED
To Voice\- 3 Confused\• 4\Purposeful - 5
3 ABSENT a To Pain\- 2 Inappropriate - 3\Witharawal - 4

. Flexion\- 3
Incomprehensible- 2\
None\- 1
. \- 2None 1\

None\-1

XTREMET7ES:::.
DISTAL PULSES
RT X 2OLTX 2

A • Abrasion

MOVES ECTILEMETIES
AP • Ana iamn

x4
AV. Avuisen

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B • Ban

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C • Cal=41
XCEPTIONS TO ; D • 011armri
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ARAMETERS:
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. OTHER EXAMINATION . OTHER (Specify)OR EVALUATION
DIAGNOSTIC STUDIES
. TREATmErrr
SA rORM rmn. MAY 151
MEDCOM -3842
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I TOTAL IN: OUTPUT:
NURSING NOTES
TIME i BIP-P I RR I 02 SAT I NURSING ASSESSMENT
LABS: CBC T&S T & C # UNITS-PT/17T LYTES UA
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PROCEDURES/PROGRESS NOTES
MEDCOM - 3843
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AEROMEDICAL EVACUATION PATIENT' RECORD
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MEDCOM - 3844
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111111,111row (Rae or ADMISSION A610 CC\
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NAME (Last, F ,b)(6)-4
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14. FLYING STATUS
15.

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16. ZIP • DE OF RESIDENCE
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WARD NAME/RELATIONSH1
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72

0A I ADDRESS OF EMERGENCY ADDRESSEE (lnciudo ZIP Code)
NAME AND LOCATION •
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23. DATE OF DISPOSITION (tYMMDO)
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103 104 29. DATE INITIAL ADPAISI°P1(T M D)

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DA FORM 2985, MAR 89
LDillutqL4 MAY 79 IS OUSO LIE
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MEDCOM - 3845
DOD 010324

.TION
SIIMUISM

ADMISSION AND CC3Pot use 01 this lurm, see INFORMATION
AR 40.400; proponent
agency
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4.
PAY GRADE SEX

8. RACE RELIGION
BACK-GROUND

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15. BENEFICIARY
CATEGORY
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ADDRESSEE
ADDRESS OF

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23. DATE OF DISPOSMON
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24. CLINIC SVC - ADMITTING
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27. LOCATION OF OCCURRENCE
(Bettie Casualty Only) OF INITIAL ADMISSION re' Sejyyy),y;)3
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ADMITTING OM ER (Signature, as rectuir.:4)
:b)(6)-2
b)(6)-2

DA FORM 2985, MAR 89
t:))(6)-2 WI I
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MAY 79 IS OLiSOL I t E
-
MEDCOM - 3846
DOD 010325

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• MCERTIFICATE OF DEATH (OVERSEAS)'
Acte de dices (1YOutreJfer)

NAME OF DECEASED (Lace. First. Middle) Non, du diced; Morn m prir'iornsl GRADE\Grad. BRANCH OF SERVICE
SOCIAL SECURITY NUMBER
Arens ‘........„

b)(6)-4 Nurniro du Filo:swan= Social.C., 0/
ORGANIZATION\Organisation
NATION (e.g.. United Stoles) DATE OF BIRTH SEX Semi Pays Dote de naitasnce
X:tAALE Masculin
\Fin
0 FEMALE

RACE\Remo MARITAL STATUS\Etat Clyll RELIGION\Cult.
OATuHvE. Rap/LT:4 CAUCASOID\Caucaslqua
SINGLE\Celibmaire DIVORCED PROTESTANT Divorce
Protestant
CATHOLIC

NEGROID Miriade
MARRIED\Hand M(13i W\
Catholique

OTHER (Specify) SEPARATED
Autre ISpEciller) WIDOWED Vee( Sigma JEWISH\Jut)

NAME OF NEXT OF KIN\Non, du plus precise parent RELATIONSHIP TO DECEASED\Parente du decide nmc le stodit
• STREET ADDRESS\Domicil: a (Rue) CITY OR TOWN AND STATE (Include ZIP Code) Ville (Code postal compris)
MEDICAL STATEMENT\Declaration medealit
INTERVAL BETWEEN CAUSE or DEATH (Enter only one commix,' IMO
ONSET AND DEATH

CPUse du dices (N'Indiquar qu'une eat.. VIP lip.) Interval!' Am . ransom! et la deem
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH'
alka)Cf(....\ek¦ Ceti A 6
• (\/1eq• Ot I• 3MJ 4 i i
.. ..... ou condition directernent response*, de Is morn .
MORBID CONDITION. IF ANY, p PJ 1— e i c, 4_ J /1.Oo 1-,...... 0 I,- ...-.4 7 I-M1 )
fAbf J\
LEADINGTOPRIMARY CAUSE
,

ANTECEDENT Condition morbid*. I'll y • lieu.
/-1,\le i (Mfilf,M1,-....4M. IM
,,,,,,,,...f- ' (C,.... -
CAUSES
monant I; la cams primaire ,. /iv f-,'P "k
EirmOternes
UNDERLYING CAUSE, IF ANY.
pricurasurs
GIVING RISE TO PRIMARY ^,,L.\i (A C\GA --ejMl eL
cla la mom
/0 .os f- 0 "4 I
CAUSE
//rte

Raison fondarnentale, I'll y a Wm,
avant wade; Is cam. prirnair• ,

il,.../ rr, "-/-7\ en. tc.
OTHER SIGNIFICANT CONDITIONS2
2 Autres conditions signIficatilms

CIRCUMSTANCES SURROUNDING DEATH DUE TO

AUTOPSY PERFORMED Auttemitr etlactuie \0 YES Oul\
EXTERNAL CAUSES
Condltian ds dews

MODE OF DEATH 0 NO Non
MAJOR FINDINGS OF AUTOPSY Conclusions or:mimeos de route/mit, CIrconstances de la mort tuteltioes per des cituset exteiOunn
NATURAL
Mort nsturells
ACCIDENT
Mort accidentetl•
SUICIDE NAME OF PATHOLOGIST Non, du pathologists
Suicide -

..
HOMICIDE SIGNATURE Signature DATE\Data AVIATION ACCIDENT\Accident i Avion
Herr:ride
. YES Oul\ . NO Non

DATE DF DEATH (Hour, day. month. year) PLACE OF DEATH Lisu de dices
Oats as dicifs (rheum. is four, IF mote. ronnie I

I HAVE VIEWED THE REMAINS tSF THE DECEASED AND DEATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE. .'1i anarninif In rust. martslf du di hint at j• corm., 005 I. dial .1 Suisionu a Maur* Incinwie IT S. is Wits ril. eanan Irrourniirifits Ci donut.
TITLE OR DEGREE\Threats diordine
NAME OF b5(6) -2
GRADE\Grape\ "'"`\,_-._n_
INSTALLA ."... ^." a"\
',b)(3) -1

L T-(-

DATE Oats SIGNATURE Si \
b)(6)-2

0 (Mr• 1 IM2,o ,03
1State disease, injury or complication which caused death, but not mode of dying such as heart failure, etc.
2State conditions contributing to the death, but not related to the disease or condition causing death.
Prieiser la nature de to maladie, de to blessurc ou de k complication qui a contribue a' la mod, mais non la maniFre de mourir, lelle qu'un arrh do coeur. etc.
2 Pricier, la condition qui a eon tribui a' to mart, Wait n'ayernt t•••-•n rapport avec la maladie op a k condition qui a provar

mort.

......
FORM REPLACES DA FORM 3 JAN 72 AND DA FORM 3.565-R (PAS), 26 si NHICH ARE OBSOLETE. I APR 77
2064

MEDCOM - 3848
DOD 010327

NAME AND LOC ATIOA OF HoS
HOSPITAL REPORT 01- ..cATH
Fat IKE 5/ 71112 FMN, WE M WE; TEE NOM M MEET IS TE OFF ME OF TIE SOWN GENERAL .
Ina/motions -Medical Officer in attendance will:
Send form, without delay to the Registrar or Administrative Of-Propels, In one copy Gray, Items I throdgh 10 and sign Item 11.
Deer of the Day, for necessary action and for preparatiOn of re-Print or type entries.
quired number of copies. SECTION A • ATTENDING MEDICAL OFFICER'S REPORT
PERSONAL DATA
*.PATIENT DATA (Pa tyala data if available) • b)(6)-4 e will be used to imprint identi- 2. TIME OF DEATH (Hose-daywusnth-yeas) b. MEDICAL EXAMINER/ CORONER'S CASK
0 YES\• NO
0 4. RELIGION\I S. CHAPLAIN NOTIFIED
. Al ii\(1 frk In YES\NO

AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH S. NAME. ADDRESS
•

Patient's name (Last, first, middle initial), Grade,
Social Security Account No., Register Number and Ward Number

APPROXIMATE INTERVAL BETWEEN ONSETCAUSE OF DEATH AND DEATH

7e. DISEASE OR CONDITION DIRECTLY DUE TO (or as a consequence of)
LEADING TO DEATH (This does not
mean the mode of dying, e.g., heart failure,

Airk 0yic. a I, (...,(ii4x( 0 /1 4 gl 33.1- Ai 1
asthenia, etc. It means the disease, in-itry, w complication which caused death) a consequence of)
DUE TO (or as

(Morbid eon. tit ditione, if any, giving rise to the above JtOff C 6.t-' 4 i kc-\
7b. ANTECEDENT CAUSES d 1 , -.. X ./---1,,,,, : 4-
‘

cause, stating the underlying condition
last) 12)
...it

S. OTHER SIGNIFICANT CONDITIONS Sii0 6S 1/1,
10 lP)1M

CONTRIBUTING TO THE DEATH. BUT NOT RELATED TO THE DISEASE OR
.

CONDITION CAUSING IT
4.-;\ A vivv•-r L.-A ,vy vi-A. 11./SIGNATURE OF MEDICAL OFFICER IN ATTENDANCE
10. TYPED OR PRINTED NAME AND GRADE OF
D. DATE
' MED io(b)(6)-2 (b)(6)-2
\
SECTION II - ADMIHISTR E ACTION
TYPE OP ACTION HOUR DAY YEAR INITIALS OF RES0001• *ISLE omen
lg. TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON
II. POST ADJUTANT GENERAL NOTIFIE0
14. IMMEDIATE CO OF DECEASED NOTIFIED
III. INFORMATION OFFICE NOTIFIED
10. POST MORTUARY OFFICER NOTIFIED
17. RED CROSS NOTIFIED
IS. OTHER(Speelly)
1S.

SECTION C - RECORD OF AUTOPSY
21. AUTOPSY ORDERED DY (Signature) MO Yes30 NO
20. AUTOPSY PERFORMED (If yes, give date and place)
22. PROVISIONAL PATHOLOGICAL FINDINGS 25. SIGNATURE OF PHYSICIAN PERFORMING AUTOPSY
22. DATE 24. TYPED NAME AND \OP PHYSICIAN PER-FORMING AUTOPSY
R 25. SIGNATURE OF REGISTRAR27. TYPED NAME AND GRADE OF REGI \SI. DATE
3
•U.S. GPO: 1993-342-027/80481

REPLACES DA FORM fI-257, 1 JAN 61, WHICH WI LL BE USED.
A 1'0.'1'72 3894 3
MEDCOM - 3849
DOD 010328

CERTIFICATE OF DEATH (OVERSEAS)
Acte de dices (IYOurre-Mer)

NAME OF DECEASED (Loaf. First. Middle) Nom du dicedi (Nom et Panorml GR ADE\Grade BRANCH OF SERVICE SOCIAL SECURITY NUMBER
b)(8)-4 CI V mAr. Nuowiso de l'Assurance Social.
ORGANIZATION\Organisation NATION (s.... United Stales) DATE OF BIRTH SEX\Saxe
RaVI Deo de naissance
it-- Cl (\ ....i,,, illtet/A MALE L Manulin LJ FEMAE\Foirninin

RACE\Race MARITAL STATUS\Etat Civil RELIGION\Cult.
OTHER (Specify) Aura, (SpEcifier)

CAUCASOID\Cmacasiten SINGLE\Dilibeteira DIVORCED PROTESTANT Divorce;
Protestant
CATHOLIC

NEGROID\Pitistrcilda MARRIED\I.A.rtli i6/141
Catnoiluue
SEPARATED Sipari

OTHER (Specify)
Autrs (SpEcifierl WIDOWED\Veul JEWISH\Jail
NAME C,E)(s)..4- RELATIONSHIP TO DECEASED\Parente du cackle .sec I. audit
5..... /NY

STREFT Anni...ec\n.....-iii . 111410 CITY OR TOWN AND STATE (Include ZIP Code) VIII. (Code postal compria)b)(6)-4
MEDICAL STATEMENT\Declaration miclesIe
INTERVAL BETWEEN CAUSE or DEATH (Enter only one cause per line)
ONSET AND DEATH
Intervale env. . ratteouto at le decesCaul. du daces Dorkodicluer qu'une cause par liens/

rr.i

.e./L¦,--.4/. C-5\--. -'(3'--¦_.
\DISEASE 014 CONDITION DIRECTLY LEADING TO DEATH

Melodic CIO condition diniebornent respon.obie de I. mart.'
MORBID CONDITION, IF ANYX1 C-1-rc..._...........,„\,.....:,:::,t__:\...\ ,...„,------c_____

'

LEADING TOPRIMARY CAUSE ANTECEDENT
Condition morbid.. tell y a lieu. CAUSES manent ¦ la cause primaire
Symptellnes UNDERLYING CAUSE, IF ANprecursor%
GIVING RISE TO PRIMARY de la mart.
CAUSE

Raison tondernentele, s e ll y a lieu.
.yeast susciu; Is cause prim e:re

OTHER SIGNIFICANT CONDITIONS2
sIgnilicHi.H2 Aurae conditions

CIRCUMSTANCES SURROUNDING DEATH DUE TO MODE OF DEATH
AUTOPSY PERFORMED Autopsie eftectu.\. YES OW\ .42F NO Non EXTERNAL CAUSES
Condiden d. dlia;d Circonstancirs de I. mart amities par des caws, . milieu,.
MAJOR FINDINGS OF AUTOPSY Conclusions principelet d. l'eutotasie _.
NATURAL Z. Ca:,\:/-1 .,\tLC....‘,...C, i Mort neturrall•
6.........r ( ,...._2. ___..M1 G.' c-,-) C

_...„..

ACCIDENT
Mort accidental le
4 cl.,,_ --/ ...e, of
1—

SUICIDE NAME OF PATHOLOGIST Na.., du pathold9im
11.,....\..,...... ej,,,,,/ 01....,-........-Suicide
SIGNATURE\Signature DATE\Date AVIATION ACCIDENT\Accident 1i AnionHOMICIDE
Homicide
• . YES owM. NO Non
DATE OF DEATH (Hour.day. month, year) PLACE OF DEATH\Lieu de decois
Data de dials frtsure. Iour. IC mai.Q . ' 1 49C:=,
L( I tfM: e" -5M20 f" c.
'I HAVE VIEWED THE REMAINS dF THE DECEASED AND D6/4TH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE.
!pi carotin: Its rests moms!, du di lune It le concius owe le d‘cils est ....valid 3 I'neure inchoate on S. la suite des causes finumirEes ci demos. .\..
Intoneu modern. sonnei..
NAME 1,)(6)_2 TITLE OR DEGREE\Titre ou diparnoi
GRADE\Grede a i i .T. ...•1 ren an...no-cc.32..•31.1..• b)(3)-I
0

DATE\Dee.
SIGNATURE Slow b)(8)-2
OZ-1/6 11 /\b"..
i

IState disease, injury or complication which caused death,
are, etc.2Slate conditions contributing to the death. but not relate
h.

1 Priciser la nature de la maladie, de Is blessurc ou de Is
_ mi rg. mais non la maniFre de mourir, telle qu'un emit du cocur, etc. 2 Pr6ciwr la condition qui a contribui a' la moll, mais n',-
nucun rapport avec la maladie 0. a la condition qui a p• ..1b." la molt.
FO M REPLACES DA FOP 5, t JAN 72 AND DA FORM 3565-R(PAS).. 75, WHICH ARE OBSOLETE. DD I APR 7
7R2064

MEDCOM - 3850
DOD 010329

14.1.4 ,1 IT;', LOC ATIC714 OF HOSPITAL
HOSPITAL REPORT OF DEATH
fie IME N PSIS 84419 . RE OR ms-0; TEE PMPOIEIT SPIKY IS TOO OF ICC OF TIE PRIM GENIAL .
Instructions - Medical Officer in attendance will; nepare, in one copy only, Items 1 through 10 and sign Item 11. Send form, without delay to the Registrar or Aebninistrative Of-Print or type entree.3 Beer of the Day, for necessary action and for preparatiOn of re-
quired rumba, of espies.
SECTION A • ATTENDING MEDICAL OFFICER'S REPORT
PERSONAL DATA
1, PATIENT DATA (Patient's ward plate will be used to imprint identi-2. TIME OF DEATH (Nor e-day-memeh-yeat0 S. MEDICAL EXAMINER/lying data if available) CORONER'S CASE
:13)(6)4
1.1 YES3No

Z9 0 G/303
4. REilGIONJ 5. CHAPLAIN NOTIFIED
•

PR'S ti i1/1 IVYILS\NO
S. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH
13)(8)-4

Patient's name (Last, first, middle initial), Grad,.
Social Security Account No., Register Number and Ward Number

APPROXIMATE INTERVAL CAUSE OF DEATH BETWEEN ONSET
AND DEATH

75. DISEASE OR CONDITION DIRECTLY DUE TO (or as a consequence of)
\

LEADING TO DEATH (This does not
mean the mode of dying, e.g., heart failize, • '
asthenia, etc. It mean. the disease, in-
key, or complication which caused death) ,--,----...—.,

iti•–•`--/

DUE TO (or as a cortsap uence of)
7b. ANTECEDENT CAUSES (Morbid con-til ditions, if arty, giving rise to the above -
\_l_ds CA-...^–,..

cause, stating the underlying condition
last) (21
a.

13, OTHER SIGNIFICANT CONDI TIONS CONTRIBUTING TO THE DEATH. BUT
NOT RELATED TO THE DISEASE OR CONDITION CAUSING IT
9. DAT- I0. TY PED OR PRINTED NAME AND GRADE OF 1. SIGNATURE Of....919EDI CAL OFFI CER IN ATTENDANCE
mFmrAL OFFICER IN ATTENDANCE 12)(8)-2 (WM-2
3 r'6 ()0
SECTION B - ADMINISTRATIVE ACTION
IN TIAL! OF RESPON.

TYPE OF ACTION HOUR DAY MONTH YEAR IIIIPLE OFFICER
I2, TELEGRAM -TO NEXT OF KIN OR OTHER
AUTHORIZED PERSON\ •
III. POST AD.I \GENERAL NOTIFICO
14. IMMEDIATE CO OF DECEASED NOTIFIED
' 111 • INFORMATION OFFICE NOTIFIED
IS. POST MORTUARY OFFICER NOTIFIED
IT. RED CROSS NOTIFIED
IS. OTHER(Sprocify)
IL
SECTION C - RECORD OF APTOPSY

20. AUTOPSY PERFORMED (If yes, give date and place) 21. AUTOPSY ORDERED DY (SIOnaturs)
• YES3• NO
22. PROVISIONAL PATHOLOGICAL FINDINGS ..\
. .\.-
2). DATE 24. TYPED NAME AND \OP PHYSICIAN PIER. 2S. SIGNATURE OF PHYSICIAN \ING AUTOPSY FORMING AUTOPSY
ES. DATE 27. TYPED NAME AND GRADE OF REGISTRAR as. SI \ OF REGISTRAR
FORM72

REPLACES DA FORM 8-257, 1 JAN 61, WHICH WI LL BE USED: •U.S. GPO: 1993-342-027/80481
OC T

MEDCOM - 3851
DOD 010330

(bX8)-4

MEDCOM - 3852
ATIENT TREATMENT RECORD COVER SHEE .
For use of this form, see AR 40-400; the proponent agency is OTSG
.MGRADE ADMISSION REMARKS
b)(13)-4

c,zrvr FR NI MARFR
b)(6)-4

6)(6)-4 CAW
10.MPREVIOUSr RACE 7.MRELIGION LENGTH OF SVC 9.M616

SEX 5.. AGE 6.MADMISSION
IA
hrlM
14.MWARD13.MORGANIZATION

11. FMP 12MSN
20.MTYPE CASE

18.MBRANCH/CORPS 19.MUIC/ZIP
15. FLYING 16.MRATING/ 17.MDEPT./ STATUS DSG
BEN
T

22.MHOURS OF 23. CLINIC SERVICE
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION ADMISSION
11.3 11-A-
ISPOSITION .MTYPE DISPOSITION 26. DAMT1 OFM

24. _NAME/REL ATIONSHIP OF EMERGENCY ADDRESSEE 6)(8)-4
ID OW ti 0 3
M28 DA E OFMHIS ADMITTING OFFICER
-27b. TELEPHONE NO.
27a. ADD ESS OF EMERGENCY A DRESSEE IInClude ZIP Code) ADMISSION
(b)(6)-4
Dr,\0• •
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. DATE OF INTIAL ADMISSION 32. UNITS OF WHOLE BLOOD, COMPONENT TRANSFUSED
'b)(3)-1
31. SELECTEE) ADMINISTRATIVE DA/A
ri Check it Continued on Reverse
33. CAUSE OF INJURY
re), c,kf
3 MDIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

11'

6VR/ 71q
riLA1.0 AM
) 6- I

pLAKM
35. Total Days This Facility
ABSENT SICK DAYS b.MOTHER DAYS CONY. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS BED DAYS 6TO SICK DAYS
36. Total Days All Facilites
ABSENT SICK DAYS b.MOTHER DAYS CONY. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS BED DAYS TOTAL SICK DAYS
)(b)(6)-2
SIGNATURE OF ATTENDING MEDICAL OFFICER 1))(6)-2 (b)(6)-2 141/47/L-4-te. SIGNA
AY 79 EDITION OF 1 AUG 7675-0650CErt USAPPC V1.10
MEDCOM - 3853

DOD 010332

INPA tENT TREATMENT RECORD COVER SHEET
For USO of this form, see AR 40-400; the proponent agency is OTSG
LiRADE

6)(8)-4
CAV

S.MAGE CM11/1o...1: NO11101. SVL.M9. 10,MPREVIOUS
AIIM 1551(5

]JT . LLY,.. . WARD.SN
13.MORGANIZATION

illM1311A14C1-pCORPSM19.M20.MI YPF, SAFT DSC;M 13E61
rlM (5.MRATING.'M1 17.MDEPT., I IICIZIP
.----

;our,(1E. OF AOMISSION.AUTHORITY FOR ADMISSION M 22. HOURS OF 23.MCLINIC suRVICE
ADMISSION

Y\M

I,Mb
26MDAT OF DISPOSITION
i,FAME.R1ILATIONSHIP OF EMERGENCY ADDRESSEE. M F25MTYPE DISPOSITION OAT
;13)(6)-4
CI 3
Ant,A0-1 !NI:

ADDI1ESS OE EMERGENCY ADDRESSEE (Include ZIP Cock) M 276. TELEPHONE NO. 26.MDA E OF (DISM
ADMISSION
30141X03 ­
30.MDATE OF IN I lAl.M or vIlE SI '/O!' ADMISSIONM COMPONEN I
LjAm!] AND LOCATION OF MEDICA1 TREATMENT FACILITY
I-I) Al1r411,11, I NA inn, u k¦
11M 3.• -- . , .

cAusE or INJURY
r k-e

DIA(11•10SES OPERADONF. AND SPECIAL PROCEDURES
„
Cc AM
6 _

H 6
35. Total Days This Facility
!liCI,; UM'SM6.MOTHER DAYS C.661V. LVICC1OP IS.MSUPPLEMENTAL FIE n 1455.M I
SARI) DAY5M CARE DAYS

1--

36. Total Days All Facilites
ASSENT SICY. DAYSMb.MC)THER GAYS CONV. LV/COOP /.1. SUPPLEMENTAL Ti.MBED OA V S
C:ARE DAYS CARE DAYSM

1

r)1( Ai. OrEICER CIGNA
0//43' LA-Le
'140

k NI 79 Eon ION OF 1 AGO -/6 IA QUM/Lt. t
MEDCOM - 3854
DOD 010333

NSN 7540•00-534-4122
MEDICAL. R EC 0 IT'D PROGRESS NOTES
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WARD NO.

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade: rank: ;ate; REGISTER NO. hospital or medical facility)
PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 7-91)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

MEDCOM - 3855
DOD 010334
NSN 7540-00-634-4122
509-ii3

PROGRPSS NOTEc.
NiEDICAL. RECOND
DATE
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PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle: grade; rank; ate;
hospital or medical facility)
PROGRESS NOTES

.b)(13)-4
Medical Record
STANDARD FORM 509 (REV. 7-91)

Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 3856

DOD 010335

4

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD kt421,1 kb- --aEtefffm. NOTES
NOTES

DATE VILLMO,3
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PROGRESS NOTES ,3Medical Record

(REV. 5.99) Prescribed by GSNICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 3857
DOD 010336
AUTHORIZED FOR LOCAL REPRODUCTION
3

PROGRESS NOTES
MEDICAL RECORD
DATE ,TES

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M(8)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV 5-99)
Prescribed by GSNICMR FPMR (41 CFR) 101-11.203(b)(10)

MEDCOM - 3858
DOD 010337

DATE NOTES
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MEDCOM - 3859

DOD 010338

(
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99)
Prescnbed by GSNICMR FPMR (41 CFR) 101 ­1 1.203(3)(10) s

MEDCOM - 3860 ros-114
DOD 010339

DATE NOTES
ti•

p 134
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STANDARD FORM 509 (Re/ 5-99) BACK
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