Medical Report: Medical Records of Various Enemy Prisoners of War and Detainees, Baghdad, Iraq, Nov. 2003

This document contains the medical records from numerous detainees during the summer and Fall of 2003. The records are not separated to distinguish from one patient to another. However, the records cover the medical treatment of numerous Iraqi Enemy Prisoners of War (EPWs) for war-type injuries, i.e. blast effects, gunshot wounds, shrapnel, etc. The records require a close reading to be able to distinguish between one patient to another.

Doc_type: 
Medical
Doc_date: 
Thursday, November 13, 2003
Doc_rel_date: 
Sunday, October 30, 2005
Doc_text: 

PAGE 2 OF 4

DATE 61 DX HOSPITAL DAY
101/QC) P 3

TIME

C6-5 oq 0 -0a off. 04_1D .a._413_,10.
8P Arterial
Arterial Line
BP Cuff
/(og 7q) 1.5c5, 1%?4,DtP131 / ' 11%9 "YiyDtg 11,Ck
Temperature
q7 (g '76

Pulse
-
77 '76 -75f —2 (0 GS( 15v(11 76 7 7/7 -S
Respiratory Rate j
/2.0D2(D(9Diq 111 19/15 )D/8 .)4
_540 -z_ 70 co 91 q( ciS c'4,0/,17 cr7 671 6 95
L aL , az. 2L QV, 9L-J91,
&D 1/V&, itILNG vVu 7\1--NL NC, (AC..D At-

TIME/01. Co (Th C C•5 06 d Cf6 og /c)/la /1//8°T psis k is jo ia-L /co /00100 IOC 00 (60 Imo loG_ co() Jo /W P° /D6 lot /06 t'u Ito .goo rws o IfD9D t4DLt/ '1D3
a
e 'Xua if ,a 9-fD \-3vI/ olL,
D /
ip P 50 5()
5P9T
STA
OUTPUT

NG
GU IA C
EMESIS STOOL
O

Cr CI -o 'viSvIPDtO
TOTALS
MEDCOM - 25041
DOD-039430
PAGE 3 OF 4
POST-OP DAY ACUITY LEVEL CLASSIFICATION
v
TIME
17 tS lq aovz1 ;2-6
MODE
F 1 02, ci --'-'-;--- ----D
-A. _;(-.1 --7e'll Y3 tYL ,R) siZ RATE TV 1' ‘20 _A' 17 If 1 7 70 p
. PEEP
qh Qi-% i'l q 17
pH
te'/,J
S D NCiv At_ A PCO2
PO
B 3HCO
SAT
G BASE
TIME
IL0, 17 Db lb() is /9 0.2o 8°T IOL) Ivo l(26 1 a) /Op 02 g`iDr t 7-? GLUCOSE Na/K Cl/CO2 BUN/Cr WBC/PLATELET HctiHgb PlaPAIMMITILIPMEMVAIVIVALIMMIS r/.'/.

TIME
TIME
U
MOUTH CARE
R
BATH
N
SKIN CARE
FOLEY CARE S U
TRACH CARE
C
ROM EXERCISES 0
D
4,46 TOTALS
URS E'S SIGNATURE -DarnAt.9 wt Yesterday wt Today
INTAKE
OUTPUT IV
Urine: (
6)(10-z_
70
pia
101AL TOTAL BALANCE
MEDCOM - 25042
DOD-039431

REPORT TITLE OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET • QA Appr 8 Mar 89
TIME INITIAL INITIAL S INITIALS
N.
PUPILS
E
SENSORIUM
Iv\/Ail)kfia
RESPIRATORY PATTERN
f`\on
:s: BREATH SOUNDS SECRETIONS
D6-4-Nuu,)hcL,h--(A
6 , 1,Lvf
LD 1
'
LOCATION „)0L,
CONDITION

(J-(Z7
att.L. `-)

' ABDOMEN BOWEL SOUNDS
—k 4 A)t)._ .
is
URINE: •
qE, Lcies poL,
COLOR/CLARITY
CARDIAC RHYTHM s
k&-T
D occ, ki,jk t
+- L41,D•s.
Cr • Creatinine ICP -Intracranial Pressure SIA • Fractional EE F 1 02- Fraction of Inspired 02 SA1 • Saturation
PCO2 • Pressure of Arterial CO2
A;-:
HE03 • Bicarbonate - I racheOstomy
PEEP • Positive End Expiratory Pressure
(Continue on reverse)
0-7
ure & Title) DEPARTMENT/SE RVICE/CLINIC DATE
a/6i../ 6
6ii(Z(6'1/1.71° 63
N ortyped or written entries give: Name—last, first,
, grade: date; hospital or medical facility) .

HISTORY/PHYSICAL . FLOW CHART
.
OTHER EXAMINATION

. OTHER (Specify) OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA 1 TARy"78 4700 -MEDDAC FBg OP 375, 1 Apr 90 (HSXC—NU)
Proponent: Dept of Nurs MEDCOM - 25043
DOD-039432

HOSPITAL DAY
DA" j G.
TIME
Vac 0/01) 0-00 WI =MN 15 ST
min m
BP Arterial Line

Imnuensummin MM MIMI=
BP Cuff
mismiamimas MMMEIMMESM
DEINIMMISS RUM MMMIMMMM
Pulse
MMMMMMM
Respiratory Rate
1.1111MMIRIMI IMUMMMMM

MMINAMMMOMM MENUAIMMM

rnal
MEMEMIMMMENI MMMMMMM

MEM= MEM
Ern wanmiminum ENE Min IIII MUM
NUM MEM 1111111

MINIMMINI
TIME
02 8° T 8° T
oboo 0700

M ME
I01; 100 ins IUD 100 PD. &bi) M NM 100
MEMa,
1.1

MUM MMMMEAMIMMEIMMM MIMEO
MMEMEMMEMMMMWMWMM

MUM= EMMMOIMMIIIMMM

IMAMIN
MINIM ' DD IIIMMEMMEM
MIMIDNMDM

MMINIMIIIM
TOTALS
NM= MMAINIMM D
AMOMMMEM1IIMEMEN
URINE
SP 9r
SIA
OW N!

MEW mi
D

NG pH
GU AC

1111DII
EMESIS
14111111111ME INIM MEM=

STOOL
111111111111111111 NMI MINIMM

WM NMI MI EMIIMMIll
DRAINS
TOTALS
MEDCOM - 25044

DOD-039433
PAGE 3 OF 4

POSTOP DAY
ACUITY LEVEL CLASSIFICATION
8° T
Na/K CVCO2 BUN/Cr WBC/PLATELET
1 Hct/Hgb

TIME TIME
MOUTH CARE BATH U R
SKIN CARE
FOLEY CARE TRACH CARE S U C
"MO TOT ROM EXERCISES wt Yesterday wt Today O 1 tun
IV INTAKE OUTPUT
DO

TOTAL TOTAL

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this lam. see AR 40.66: the proponent agency is the Office of The Surgeon General.
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED IDatel
Date: Anesthesia Type (Circle)): General Spinal Epidural Drains Airway
Time In: IV Sedation Nerve Block Hemovac Nasal
Allergies: OR Intake: Crystalloid Colloid NG I Oral
Pre-op V/S: OR Output: UOP EBL JP ETT
Procedures: 11,,. \ ".1 Meds/Times: ' T-tube Foley Trach Other
Pre Op MepsD11.4-T History TLS

Time
x?c,

,--,
n .
1,,,,, ,1 .--/\
Pacu Intake
0 el

Sa02 Time Solution Amount Site • By Infused
CH CC Id)

Fi02
Methods -
240
220 X-rays:J . Labs:
Post-Anesthesia Recovery score
200 Criteria ADM 30' DIC Codes
Activity

AIRWAY

(2) Moves 4 Extremities
180 (1) Moves 2 Extremities

A = Ambu

(0) Moves 0 Extremities BB = Blow-by , M - Mask
Airway

160 FT = Face
(2)
Cough, Deep breath

Tent
(1)
Dyspnea, limited breathing

(0)
Apnea RA.-RoomAir

140
t/ NC =Nasal
Blood Pressure
Cannula

(2) SBP =/- 20 of Pre-op
120 1 0

(1) SBP =/- 20-50 of Pre-op

(0) SBP =1- 50 of Pre-op V/S
V
1/
X = A-line BP
Consciousness

100 . -.-Cuff BP
(2) Fully Awake, audible
= Pulse
ung
(1) Arousable to verbal or pain

80 0 A j
TEMP
Color


S = Skin
A ii 0
(2) Baseline color & appearance
0 = Oral

60 (1) pale. mottled. jaundiced

A = Axillary i
, (0) Cyanotic

T =TympanicCirculation (Peds 5 Years)
40 R =Rectal
(2) radial Pulse Palpable
( 1 ) Axillary palpable, not radial
LOS
(0) Carotid only reliable pulse

20 Cu Cervical
TOTALS: Must be 9 Of
T = Thoracic
greater to O/C, otherwise
L =Lumbar

RR ro
needs anesthesia approval for DIC,

S = Sacral
T (fL , 1,

r_.4-

Time Patient teaching done; Wound Care, Pain Management,
Pain (0-10) T, C, 8 DB.. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

aontmue aa (event/ PREPARED BY (Signature & Wei DEPARTMENT1SERVICE/CLINIC DATE
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, last, middle: grade: date: hospital or medical tacky'
. HISTORY/PHYSICAL FLOW CHART
.

.
OTHER EXAMINATION . OTHER Openly, OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-ON)J Previous edition is obsolete
USAITC P2 .00
MEDCOM - 25046

DOD-039435
DAN D
)s)
REMA R KS
O

or
U
ca
O

U)

CC t

28TH COMBAT SUPPO RT HOSPITA L

MEDCOM r 25047

DOD-039436

Inte. as

MEDICATIONS

Airway / Breathing: iyitz_bcde v
8, 0

Circulation:
cg-ce/yricAe0 Other: C(W h-Q116'
ce p (cc( ed )201--tr? c fru4-
t/Cra)Y7(-1z? ( mac ,- vyz.g rdz.xvi
Vital Signs
Time B/P Pulse Resp Pulse Ox Tem GCS

/
/

,-----.
..-

NOTES:
Time Drug Dose Route Initials
imrimmineMIWIEW.

immuunziall
Blood Components Unit # Type Time Response
I
2_ 01-2" /(!s"
Transfer Instructions:
n-LWe Ci
0-°
MEDCOM - 25048

DOD-039437

Medical Record Progress Notes
(
Wound and Skin Assessment.

Date and Time 1c1 NOU Cb3 Wound number
Stage I-IV 1V Surgical or Non-Surgical GSW -
Location Scala vJLa.-
S hape zvy, ; rOd Measurements
Tissue Color N FrQ. / reit
Drains and Type
Drainage (amt and color) IA,
C6 _ Dressing Type
Dressing Change Frequency 4S Wound Cleansing
Additional Info (turning, elevation of extremeties, etc.)

Date and Time Ic3( NOV Cb3 Wound number
0

Stage I-IV (V tigW- • r Non-Surgical CiSul
D k,41,p.R„ eA,Jusk Location
Shape Measurements (0
Tissue olor
Drains and Type 01

shn Drainage (amt and color)
Dressing Type Li x4 'S c kg,e2.-
Dressing Change Frequency e:;,‘ p I pe....n) Wound Cleansing
Additional Info (turning, elevation of extremeties, etc.)

Date and Time IR OD 0 ED 72. Wound number 5. / 4 / F-)
Stage I-IV (r.ir—or Non-Surgical a Jp. f el-1 I CT ?-

-Egici-
Location. (!.. (Apo 0 A r),,\04-

1.---.

Shape Measurements
Tissue Color

P - -

Drains and Type TP I CT
Drainage (amt and color)
Dressing Type 4,X t-t-CLee.-
Dressing Change Frequency PZ-t0 Wound Cleansing
Additional Info (turning. elevation of extremeties, etc.)

Patient ID: Unit No.
Standard Form 509

MEDCOM - 25049

DOD-039438
Medical Record Progress Notes

Braden Scale Evaluation
Da.: 1
Sensor-N . Mobility No Limltatons

Perception SlhtIN. Limited Sli ,-11[1: . Limited Vers. -Limited Ven. Limited Completely lmpaired 1 Completely Immobile
:Moisture R.aceIN Moist Nutrition Excellent occasionally Moist Adequate (Eats 50%) 3
-Moist Adequate (rarely eats) cz) Constantly Moist 1 Very Poor 1 Activity Walks Frequently 4 Friction No Apparent Problem 3
Walks Occasionally 3 and Potential Problem Shear Problems
c:C±J±I-12a`:-E:Th Bedfast 1 Total Score: / Above 20 Low Risk Score 15 requires Im. m.ediate 15-19 Nted Risk Licer PreNention Program I 1-15 Below 10 Risk
Date: Sensory Perception
Moisture
Activity
.Above 20
1S-19
1i-15 Belo.': 10
ID:
No Irnoait-ment Slightly Limited Very Limited Completely Impaired Rarely Moist Occasionally Moist Moist Constantly Moist
Walks Frequently Occasionally
BecIt'ast
Low Risk
Risk

Risk

Mobility No Limitations 4 3 Slightly Limited 3 Very Limited 1 Completely Immobile I Nutrition Exce/lent 3 4Adequate (Eats 50?-1o) 3 Adequate (rarely eats) 2
1 Very Poor

4 Friction No Apparent Probiern-ii
3 and Potential Problem i Shear Problems
Total Score: Score 15 reci.:Hes Immediate Licer P;everor: Program
No. 3 Sndard Fomi 509
MEDCOM - 25050

DOD-039439

PLAN OF CARE FOR SKIN BREAKDOWN AND WOUND MANAGEMENT MEDICAL RECORD PROGRESS NOTES A,4iii4iioli2Datii:;01,...,q1WOVVF. _ , 'V.=Iiiigti•6b::.W..ft% .,ZAWitiAHOW-i::-rC-.., li.=:-. iT ,-:,:.: POD;,'.:7,4ra:)7,;•.-,:. gliNe41.::*.it:.,x4;,c.,T:F4;,.?-,;Q:--J.Facv..valint,-*VklciMZIftii,V -" ' '"."''' ''''''""',". -,-'''EAii'';:-?--75 ,','''..,'_.'::i,--..:.':•4'-:.4i,Y.:.:::-:,:--.;..i.;-
Date: ICI 1.(2)\.) Time: OSS 0.RN Signatur
Skin breakdown as evidenced by immobility, friction, srTar, moisture, abrasions,

Wound ty. -: Surgical wound (s Location:@2-19 4.1-11.143fze: II 1. eJ•Ju cer Tubes: SPA CA32.. Pins:

Venous stasis ulcer Dressing change: Pf-10 7 fg ID
Other Describe
Bum wound (s): % BSA Partial Full
Location: Size
Appearance:
Dressing change:

Pressure Ulcer (s):
Stage I, II, Ill, IV (Circle the one that applies and describe below)

Location:
Wound character: Pink Tunneling Undermining Refer to SOP for Dressing Change lnstrucitons.
Please check the appropriate dressing Change: tl?‘_ Wet to Dry Dressing 0 Carrasyn-V GelDressing 0 Alginate Dressing 0 Comfeel Dressing 0 Pin Site Care 0 J-Tube Care 0 Colostomy Care V Chest Tube Care 0 Burn Care
NOTE: Document daily wound and
dressing change on Progress Note or Nursing Note.
Size: Moist Dry Granulation tissue

LOI o_z_ surgical wourid, klari tear.
r+.1-4,+,

' (a 8 A Drainage: t1%,;1"1 SQ
. Appearance: tAralt opionsx
Yellow slough
Odor Purulent discharge Eschar Exudates
Select the appropriate products used:
RI. Sterile 4x4 gauze dressing 0 Sterile 2x2 gauze dressing 0 Sterile gloves CI Kerlix (super sponge) 0JGauze bandage 0 Sterile Normal Saline 0 Sterile Water 0 8 x 4 Sponge gauze 0 Op-site CI Tegaderm clear dressing 0 Alkare skin prep 0 Comfeel clear 0 Comfeel pressure ulcer drsg 0 Carrasyn-V Gel 0 Alginate 0 Bacitracin 0 Silvadene Cream 0 Petrolatum gauze
El Hibicleanse

0 Non-adhesive dressing
0 Telpha Pad
0 Carra-smart film

0 Sterile Q-tip applicator
0 Xeroform 5 x 9.

0JMoisture barrier cream
0J0.125% Dakins sol
El Betadine Swab sticks
0J172 Hydrogen Peroxide &Y2
Sterile Normal Saline
Sect the frequency of dressing change:
z,

tEr. b.i.d. p-e...) , -)
0 t.i.d
MD Signature and Date:
CNS Signature and Date:

Patient's Identification (For typed or written entries give: Name-last, first, middle: Medical Record, SF 509 Grade; rank; hospital or medical facility)
MEDCOM - 25051

DOD-039440

Medical Record Progress Notes Wound and Skin Assessment
Date and Time /23/0 3 Wound number "--
Stage I-IV 2 urgic , or Non-Surgical
Location
Shape er-o

Tissue Color
Drains and Type
Drainage (amt and color)
Dressing Type beg.-erb Lcz-
Dressing Change Frequency Wound Cleansing
Additional Info (turning, elevation of extremeties. etc.)

roti iti ,s (j /

Date and Time Pi I Wound number
Stage . tirgi 1 or Non-Surgical
Location

cs.1-6". Measurements 3
Tissue Color
Drains and Type ,t6

P( Drainage (amt and color)

We‘r (3Q s c, LL:77r Dressing Type
Dressing Change Frequency iS 0 Wound Cleansing NS
Additional Info (turning, elevation of extremeties. etc.)

0—, ',Jr, (.\ 0 KThs.
lss C-
r 1-1 (-E L "

Date and Time i) / Wound number Stage I-IV V ttrgi or Non-Surgical C.1,1.1­Location. L(D.'''L-41`43 -Shape g-vtc.AA-4 -1-Lar/Measurements D4- c Tissue Color vV2-c-----() . Drains and Type C Drainage (amt and color) AML. cc. Dressing Type UP S/ c 4e=cf Dressing Change Frequency a 10. Wound Cleansing N .,S Additional Info (turning, elevation of extremeties. etc.) il‘s. C-4D1 C--'tl56VtDPD t. pC,C.vse 3
e/.
Patient ID: Unit No. c Lk3 Standard Form 509
MEDCOM - 25052

DOD-039441
4 --) FSB / FST Trauma Flow , zet Name: loqi S'SN Unit Lim_ LIF Blood Type
Date and time of injury: Time of Arrival
MOI:
HPI:

Primary Survet4Q--7--

PMHX: Airway: Patent Mechanically maintained by SN-hAoalicl b..1 AMIN PSHX: Breathing: Spontaneous Assisted by Cervirar
...._
Circulation:

Meds:
Pulse: CPR Ctfi t U'e6 Is

Allergies:
Color: orm Ab Cap refill: orm. Delayed

Secondary Survey u-4-$1-c'd Intial Vital Signs: b/p 1W7)/ pulse -V. Resp Pulse Ox 441 Temp Ica() 7­
GENti/linP- 61ct
IlE.AD: kic, A i
NECK: /( .)71 .
HEART: p LA-v

LUNGS:
CHEST: P y1 chvdvC-)41tJA
ABD: sty _I-(Arl (Of),

PELVIS: (Si. vl '`) hiPti Cf117 CdP C/C-L,
O

EXT:
L_AcT ‘2.1.4-1P0-6 7 x

Th,i A Ntff-

tfri) irCe-if¦ -60601c)/
CO

I S.Paeo
Se oCiA a.irn ,
GLASCOW

TAD 5iftaiCe. 225'7.) Revised
\z`. Trauma Score

.2-3.1.5.-COMA

€9e4ra Spontaneously 4 13-15 EYES
69,A RECTAL: erre d
OPEN To Speech 3 GLASCOW 9-12 3 To Pain 2 COMA TOTAL 6-8
2

NEURO:
None 1 4-5 I 0 tL-142the61 CA? Alf c Oriented 5 3
0
1--
BEST

89 mmHg -4 VERBAL Confused 4 RESPONSE
Inappropriate 3 SYSTOLIC 76-89 mmHg 3
sounds BLOOD 50.75 mmHg 2 Incomprehensible 2 PRESSURE
01 -49 mmHg 1 sounds No pulse 0
None 10-29 / min
4
Obeys 6 BEST Commands
3

RESPIRATORY 29 / min
MOTOR
Localizes Pain

X-RAY: LAB REPONSE 5 RATE 6-9 / min
2

jr I p/4(6.47-7e4-1 Withdraws to 4
1. l— 1-5 / min (41-01--4tv) Pain None
0

2.e.7-1-cls l Flexes to Pain 3 TOTAL
3 . Extends to Pain 2
None 1

4.
TOTAL

MEDCOM - 25053

DOD-039442

IZ For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
oFirstNameGiven FGN M

Mgr 111
6. DoB (YYYYMMDD) 7. Ag- at Admission 8. Race 9. Ethnicity Religion
X 9

(0

10. Length of Service ETS c....., 11. FMP 12. Social Security Number
C

99
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:

23:50

14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
K78-PRISONER OF WAR/INTERNEES

17. Unit Location 18. MOS 19. Trauma Prey. Admission
BC NO

20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Address of Emergency Addressee
A..--

Direct from ER ICU3
Telephone Number of Emergency Addressee\ Name and Location of Medical Treatment Facility:

• Install Provided

21. Type of Disposition 22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
TRF-OTH 2003-12-02 1_
24. Clinic Svc - Admitting 25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
ABA - GENERAL SURGERY 2003-11-18

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
IZ 2003-11-18

FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW SHRAPNAL CHE

•-,-_-_:-;. i-' i:., CI -? 0
i ' \ A._ ,,t, ', g 1 r,,no/1 ' .
-.3 1_1

Procedure Narrative(s): i
SG O1 1

7 9 Icte ) ', -4 /
'
n, 9 c 4-I/.4..
-:,L.
./

Cause of Injury Narrative:
\-----___,__s_._.___________ ,,-,---
_...--

Admitting Officer (Signature, as require •
Automated Facsimile-DA FORM 298 ,
MEDCOM - 25054

DOD-039443

D

Automated Facsimile
IIN.--ATIENT TREATMENT RECORD C. . ER SHEET
For use of this form, see AR 40-400. the proponent agency is OTSG

1. Register NbrD2. Name 3. Grade
Admission Remarks FGN
4. SexD5. Age 6. RaceD7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm MD45Y
NO MI.LVitA

11. FMPD12. SSND13. Organization 14. Ward
99 ICW1

D DD

15. FlyStatusD17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 20. Type Case
DD

NOD K78-PRISONER OF WAR/INTER ARMY BC
D D

21. Source of Admission 22. Hour Of Adm: 23. Clinic Service
D D

Direct from ER 23:45 AEA - ORTHOPEDICS
24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp
TRF-OTH

2003-12-27

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: AdmittingOfficer:
2003-11-19

29. ReportingMTF 30. Date Ina Adm 32. Units Blood Components 2003-11-19
INENNIM N (7)-1-
31. Selected Administrative Data
Marital Status:D DoB: 19587.1) -01
In/Out Patient: InpatientDMOS:
33.
Cause Of Injury:

34.
Diagnosis / Operations nd Special Procedures:

frA L TIB FIB FX VA %
R
ciA),4/4

35. Total Days This Facility Absent Sick Days Other DaysDConLv / Coop Care Days Supplemental Care Bed DaysDTotal Sick Days
0/0
35. Total Days This Facility Absent Sick Days Other Days ConLv / Coop. Care Days Supplemental CareDBed DaysDTotal Sick Days
0/0

Si Medical Officer Signature of PAD or Medical Records Officer
Automated Facsimile - DA FORM 6 , May 79
MEDCOM - 25055

DOD-039444

MEDICAL RECORDD ABBREVIATED MEDICAL RECORD
FERT!%ENT :IiSTORY, CHIEF COMP! AINT. AND CONDITION ON ADMISSION (Enter daze of adlniSSIOlt)
71--(6-11

PHYSICAL EXAMINA . f ION
PROGRESS , E:ger thne discharge and final thaynosist
G-S i-J
1-.20 Lf
Ak-3 Q-6z3jD
IDENTiFICATION NO ; ORGA%:ZAT , LIN
1/4
pelt/na res/:mt..firsl. REGISTER NO. awe: ;WT:al or Ine,..1( fact!ity)

AB3REVIATED MEDICAL RECORD
Standard Form 539
GE;IEFAL SEW-ACES ACV;%1S7i OITERAGEI:Clf:01.ZO77:E
CFR- 701-IS ON
CYTSEY J75
u.V.PPG '11 GO
MEDCOM -25056

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
rwk,/

ID. &10 Ve3
go xe, ik-cr9 'D,via. j./,, C1 1.,'DL 71-7Z i ,
D/1-1/-e/ re to /44--/et 1-I C.-, 70 4 9 ( -e/. 'U'

.2J trp
(6/-7
e-pt ve.-lie4-vr6-ihniv6,-v-10-011-----
/Pp, 0 v /If , 1.,t,, ke_orz.t.s, •
A ki9 4- (iii64Z,v4d,

le C(11.414 / h-1--art " X--/...7? 14----1./A/WV/
/

ki,/79/
,I3L)kr I 11141
Lif //1/I //1/ 1DJO ils--t
' -'--,i--fr 7cs-.,/q iet_el 74 hi v -c_ /0/edev 044‹le/ lzfl-ge/4 ,
1-1.)-/lotel/74/7e-et/ (x'1'6 / 4/ r-V- )-ele.--)

Okei/hajA./c1-0 i0LOX/h ti ,et -/
1/'79 SSS'(,---LOX /i /J rD/97/1Dceki-r-44(11-77 D•
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MEDCOM - 25057

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MEDCOM - 25061

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MEDCOM - 25063

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MEDCOM - 25081

DOD-039470
; FIRST NSM: miGO:.F. iNVI:Al. I
ID NUMBER
DATE
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STAUOMM FORM z09 !REY. E.!1•2, 9.:i
-25082

DOD-039471
AUTHORIZED FOR LOCAL REPRODUC1tOr4
D
MEDICAL RECORD PROGRESS NOTES

NOTES

DATE
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R¦ ti_ATIONSHIP TO SPONSOR
SPONSO NAME ! SP
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DEPART..SERVICE HOSPD .
I TAINED AT

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name • last, &sr. middle; REGISTER NO. WARD NO.
1
ID Plo or SSA'; Sex; Dare of Birrh: Hank/Grade)
1 C-A}J

••¦•••••¦•••¦¦••¦D¦•••¦••¦•••¦¦•¦••¦¦•¦••••¦••••••••••¦••••¦•••••••••••••
PROGRESS PIOTES Medical Record
STANDARD FORM 509 P•3.3cr,becDGSA/ICA/IR ; ,:.1CFP.)
PA
MEDCOM -25083

DOD-039472
51 7 4wite oo/eó /60 alcf) /6 lade
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MEDCOM - 25084

DOD-039473

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
C--50%1(4°El-41—

p„,_.7,, 7-cil C f-z-ez-", Gitcyt-e,"‘A-4 :itAs. .eel -D/.e (..:4-1.D
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;, ELATIONSHIP TO SPONSOR
SPONSOR'S NAMED ' SPONSOR'S ID NUMBER LAST (....SN or Other)
FIRST ! MI
D

FDEPART., SERVICE
HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

TIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; PEGISTER NO.D I WARD NO.
ID No or SSN: Sex; Dare of Birth; Rank/Grade)

PROGRESS NOTES Medical Record
STANDARD FORM 509 !REV. 5;1290 PrescnbecDGSA,ICMR FPMR 141CFP.) 101-11.203iNfl r-.
USAPADOC;
MEDCOM -25085

DOD-039474

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) 1 NioU 03 SEX: OA AGE: WGT: HGT:
ALLERGIES: ASA: 1 2 3 4 10

I 4:141-5
CURRENT MEDICATIONS:

PROPOSED SURGICAL PROCEDURE:I &--Cjii.,/,' I

6.t.t2A5..e...c.-cekt
PAST MEDICAL HISTORY:
AIRWAY: Mallampati 1 2 3 4 Dentition Status:

RESPIRATORY:

CARDIAC:

9\''
RENAL: 1V)//1/4)
ENDOCRINE:
PROPOSED ANESTHESIA TECHNIQUE.
-1.4.-,vt
DISCUSSION OF RISKS AND BENEFITS: 61,44.2_,F
ANESTHESIA PROVIDER: 111111111111 ci-pA-

HOSPITAL OR MEDICAL FACILITY
STATUS DEPART./SERVICE RECORDS MAINTAINED AT g6st DFs7-SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR ".....--z.F.
PATIENT'S IDENTIFICATION:D(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date REGISTER WARD NO.
REGISTER NO.
of Birth; Rank/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE
-VM-qr P vJ Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1DUSAPA V2.00
MEDCOM - 25086

DOD-039475

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
/ q /1/0 v d 3 1/.97--tie'4, -/-/n/lW/6ric.../41-/lc/ •=2 / z / 7-7-e,-!Az I r it/4// t//i/ii A ii. D/7- .v ,q r/L-f,,,ts/e c.e,
6 5 (t/ L.
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. qv iu si-4/fro4e/i.-/Rietil/4C
icril X Ply 5/I/c 0 u, ,e.,f/1 ( 6

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name -last, first, middle; ID No or SSN; Sex; IREGISTER NO. WARD NO. Date of Birth; Rank/Grade.)
EP vki

CHRONOLOGICAL RECORD OF MEDICAL CARE
1---01/4-q ieD
Medical Record STANDARD FORM 600 IREV. 6-97)
Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 25087

DOD-039476
i,s, 1.

5S2-2.04 7540-01-075-3781
LOG NUMBER T

EMERGENCY CARE y 2
MEDICAL RECORD AND TREATMENT -.7
RECORDS MAINT

(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION

ARRIVAL
STREET ADDRESS DATE (Day, Month. Year) TIME

/ f go.Dc.i 4'-i5 4(
CITY STAT_ E ZIP CODE TRANSPORTATION TO FACILITY
i4if e..04c..
DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
AREA CODE NUMBER

ITEM YES NO N/A ITEM YES NO
PRP ADDITIONAL INSURANCE
AGE

35
H.ONE FLYING STATUS OD 2068 IN CHART AREA COD UMBER MEDIJTORY OBTAINED FROM NAMEC.531:46VAANCE COMPANY
I
CURRENT MEDICATIONS

INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURN ITEM YES NO YESJ, IS THIS AN INJURY? TETANUS ERGIES INJURY/SAFETY FOR . DATE LAST SHOT IFT'''J. INITIAL SERIES HOW
. YES .JII NO
_

n v_ 0 0
HIEF COMPLAI
rmed
GSw /54.

CATEGORY OF TREATMENT VITAL SIGNS
TIME

TIME 1.17

EMERGENT
BP t(p
PULSE

Pam]ls
.JFIGENT
RESP
(49 TEMP qatz-

. NON-URGENT
WT
sn ,„/CSC/DIFF ABG ,/PT/PTT BHCG/URINEJBLOOD/OUANT CXR PA & LAT/PORTABLE C-SPINE

cr
Lu
URINE C&S C/C ATH CHEM: -ACUTE ABDOMEN LS SPINE
Qw

BLOOD C&S X
cc SINUS HEAD CT
O

Ec

(six z—'PA-NeL ' c)ANKLE R/L
0.4c1Afpuc,
ORDERS
/ J

PULSE OX Al MONITOR ECG
, TIME ORDERS

BY COMPLETED BY TIME PATIENT'S RESPONSE
DISPOSITION !DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
7 HG)iIE n FULL DUTY 1,r1 24 HRS. fl 4B HRS. ii 79 HRS
MODIFIED DUTY UNTIL 'RETURN TO DUTY

CO'IDITIOH UPON RELEASE ADMIT TO UNIT/SERVICE ' TO WHEN
REFERRED
IMPROVED . UNCHANGED
TIME OF RELEASE

OETE.RICRATED I ha VA TPCPIVPCI arirl linrinretanri sheep inctra yr-tint-1c
ATIENT'S SIGNATURE

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last,
"Irv, middle; ID no. ISSN Of other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient]
Medical Record

STANDARD FORM 558 (REV. s-asiPrescribed by GSA/ICMR MAR (41 CFR, 101-11.2031MM
038
• "
MEDCOM - 25088

DOD-039477

MEDICAL RECORD WBC H/H PLT Xco U U EMERGENCY CARE AND TREATMENT (Doctor) TEST RESULTS ABG/PULSE OX PH P02SUP 02 PCO2 SAT OTHER AIDJ RADIOLOGY RESULTS TIME SEEN BY PROVIDER Chock id road by radiologist -
DIP EKG INTERPRETATION
.PTTJ BHCG ETON GLU MICRO
'ROVIDER HISTORY/PHY SICAL
CJ

CONSULT WITH ACTION RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP
PROVIDER SIGNATURE AND STAMP
.TIENT'S IDENTIFICATION (F-or typed or written entries, give: Name — last, first, middle; ID no. (SSN or other); hospital or medical laci.fity) EMERGENCY CARE AND TREATMENT (Doctor) Medical Record STANDARD FORM 553 IRE/. 9-96) Prascrib*ci by GSA/ICX1f1 FF1.411 (41 CFR) 101-11.2031b)(101
MEDCOM - 25089
DOD-039478

NSN 7540-01-075-3786
LOG NUMBER TREATMENT FACILITY
C
MEDICAL RECORD AND TREATMENT

EMERGENCY ARE
RECORDS MAINTAINED AT

(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS DATE (Day, Month, Year) TIME
CITY STATE ZIP CODE TRANSPORTATION TO FACILITY
SEX DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE AREA CODE NUMBER ITEM YE NO N/A ITEM . YE NO PRP ADDITIONAL INSURANCE AGE HOME PHONE FLYING STATUS DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT YE WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
ITEM NO

S n YES II NO IS THIS AN INJURY? WHERE TETANUS ALLERGIES INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTITIAL SERIES
HOW YES • NO
.

CHIEF COMPLAINT cz,
CATEGORY OF TREATMENT ID VITAL SIGNS
TIME TIME f9 I 0
lq 140

. EMERGENT BP /3, lie r-1 ji PULSE
F 7 g c

. URGENT
INITIALS RESP a '-1 a i y

TEMP
II NON URGENT

WT

IL4BORDERS
CBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT
URINE C&S UA MSCC/CATH CHEM:
BLOOD C&S X
St:130E10
AVEI-X

CXR PA & LAT/PORTABLE C-SPINE
ACUTE ABDOMEN LS SPINE
SINUS HEAD CT ANKLE R/L

ORDERS
PULSE OX MONITOR ECG
TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
n HOME n FULL DUTY n 24 HRS. ri 48 HRS. n 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE loo. TO WHEN
REFERRED
IMPROVED 0 UNCHANGED

• DETERIORATE TIME OF RELEASE I have received and understand these instructions
PATIENT'S SIGNATURE

PATIENT'S IDENTIFICATION (For typed Of wntten entries, give: Name - last, first, middle; ID no. (SSN or other); hospital or medical facility)
P
EMERGENCY CARE AND TREATMENT (Patient)

Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSNICMR FPMR (41 CFR) 101.11.203(b)(10) USAPA V1.00
MEDCOM -25090

DOD-039479

510-112 NSN 7540-00­634-4123
MEDICAL RECORD NURSING NOTES (Sign all notes)
DATE HOUR A.M. P.M. OBSERVATIONS Include medication and treatment when indicated

FIN0J (.aci \-. loPiz/P. 7.6/£: l./e,),,, ,6 5-/.• r F/.11
5-
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cAtrifPvc.Th 60-3-4, 7 c71 -Plc yl. fiLtp/7 so, Pi tWet 4 clb-tt-csi• ,a9,30 pi-
(Continue on reverse side)

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; REGISTER NO. I WARD NO. hospital or medical faci ity)
NURSING NOTES Medical Record
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 25091

DOD-039480

INTRAOPERA1JIOCUMENTMEDICAL RECORDJ

For use of this form, see AR 40-66, the propon. DAny is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE VIA BY VERIFIED BY
3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM IN1 Cr1/41—J03 TIME 4-3-15 Le NUMBER
5. PREOPERATIVE EMOTIONAL STATUS

CALM ¦ ANXIOUS . EXCITED III CRYING . ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL
_-­

P - all=

ASSIGNED RELIEF
SCRUB SCRUB
---4.-

ASSIGNED J_.) RELIEF
CIRCULATOR CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
SUPINE 1111 LITHOTOMY III PRONE ¦ KRASKE LATERAL: III LEFT SIDE UP U RIGHT SIDE UP
COMMENTS:
k 8. SKIN PREPARATION
HAIR REMOVAL YES NO PREP SOLUTION, S ecify) ,--
DONE BY: OR NURSING UNIT SITE: L \--•-e JBY WHOM: -5(•=,
METHOD: DEPILATORY RAZOR SITE: BY WHOM:

¦D

CLIP COMMENTS: COMMENTS:
¦D

9. LOCATION OF EXTERNAL DEVICES in
-

I.
..

).1. -. —

i• -
.

11¦011.---
I

ejtL0 111,a*_,,ej
f f-t/yy,
LEGEND X Ground Pad - Safety Strap === Tourniquet

C = Correct I = Incorrect
First Closing Final Closing

10. COUNTS Other** CountCount SCRUB CIRCULATOR
Sponge . Yes . No
Needle Sharp IIIII Yes . No
Instrument . Yes ¦ No
Other . Yes ¦ No

11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) YES ¦ NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

kESU NO:D 1 (o
V--? ti1/4) OM
GROUND PAD:DBRANDD31Y\

LOT NO: 9.0.-31\1
)5 " (:).-1
Lg) .b)'--1)
ESU NO: GROUND PAD: BRAND LOT NO:
III
. BIPOLAR NO:
MEDCOM - 25092

DOD-039481
13. PROSTHESIS, IMPLANTS I/ NO IF YES NAME: ID NUMB! 1UFACTURER
G .•_,...a.,2„

14')`Dq:t f• . D-$D',,t1D' .,,,i , :D4,,p,,D, ,, Cfm MEDICATIONS/ORDERS •* ..L-444A.I.i,, D44
ti Df', •i'lrg IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES IIDNO ,MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY IVEN BY
'i•
WOUND IRRIGATION YES • NO, TYPE(S):A/5
BOTHER ORDERS TIME CARRIED OUT BY
11111111pril-

PHYSICIAN'S SIGNATU
1,-..,mom,,,,,.....—,.., _;.
15.
X-RAY IN OPERATI IF YES, SITE
YES .DN • END •

16.
LABORATORY SPECIMENS

1SPECIMEN (S)\ . NAME NAME YES .DNO N FROZEN SECTION (F) NAME NAME YES .DNO CULTURE (C) NAME NAME YES .DNO NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
Iv 4

17. TUBES, DRAINS/PACKING YES .DNO
TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3.
19. ADDITIONALINFORMATION
5?
,......2.5---

F.-_' Ai \---\
20. OPERATION(S) PERFORMED
__._.„ vD4. .t.die..,freD
0_, 101.1.`.

21.
PATIENT TRANSFERRED TO TIME METHOD

22.
REGISTERED NURSE SIGNATURE
'541, 10 1 —:

MEDCOM - 25093

DOD-039482
INTRAOPERAT'J•OC-/MENTMEDICAL RECORDJ

For use of this form, see AR 40-407, the propol. . 7cy i tfie office of The Surgeon General.1"------.
1. PAT ENT TRANSPORTED TO OPERAlaNG ROOM . 2. PATIENT IDENTIFI r T • --s AND PROCEDURE
VIA ,
3. DATE /6"-b-e,C¦ 0 3
13(1 CALM
COMMENTS:
ASSIGNED
SCRUB

ASSIGNED CIRCULATOR
BY Oil _tosaX.....tAll...A. VERIFIED BY
TIME PATIENT ARRIVED IN SUITE 4. PATIENT
TIME, •

5. PREOPERATIVE EMOTIONAL STAT
. ANXIOUS • EXCITED. • CRYING . ANG
-....._
6. NURSING PERSON L
• 'sS /4° e -q-1 • ------- R IEF .. .SCRUB
C9U3) 1_
CPI- 66 e-RELIEF
...—..

7. POSITION AND POSITIONAL AIDS (Specify)
in SUPINE . LITHOTOMY 11 PRONE _
•_,-COMMENTS:
HAIR REMOVAL • YES 11 NO DONE BY: • OR • NURSING
r• •-- I -i
LEGEND
10. COUNTS Sponge Needle Sharp Instrument Other
• • •

X Ground Pad
t
.--'e.17a
II Yes • No 111 Yes ¦ No
. Yes p No
• Yes 11 Vo
_ ... . —_CIRCULATOR
ilii; •
-/-

,./.,,.•
KRASKE • LATERAL: , . •
-•- ---- • -
8. SKIN PREPARATION
". PREP - : UTION (Specify) UNIT SIT
s.

METHOD: • DEPILATORY • RAZOR ....;.. SIT' _
. CLIP ---
COMMENTS: -----_ . COMMENTS:
9. LOCATION OF EXTERNAL DEVICES

ha -----wi zoit/iNgsiff¦--111111-01P--
I.-.._.,.
'
.
r".
-Safety Strap = = = Tourniquet--...-----
= Correct I = Incorrect
First Closing Final Closing Other • • Count .,, , i,i, :Cdiint
i
-An

dimigrAmvi.._....
......_. _ _

11. PATIENT IDENTIFICATION (For typed or written entries give:Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
, ....

4111111 (9 ( 1°1 1'/
.--
,:._
((;)(/).:-/:
a 03

AA r.esm• a , 4 , A WI AAT A, --- . - -- _ _

SCRUB
# •

err/A-2
NUMBER /--/ WITHDRAWN • OTHER (Specify)
. LEFT SID P • RIGHT SIDE UP
_ P./IMLAYE_IFORIM
,. U.V.Eags . ,
IMIIIOF
. -

12. •ELECTROSURGERY DEVICE(S) (ESU) 'yi YES • NO
,-/.
BY HOM: Opt--BY WHOM:
4- "

413 le
Pr
CIRCULATO
M 74.
M. ESU NO: GROUN
.. ,/..
./.r ..
Er!. y NO:
., . . ----.,--:GFIOUND PAD:
...
• BIPOLAR NO:

0D ic\--6 ....—
.
B ND
g7,9)

LOT NO: ^(0C1 Ctitil/proc-n •
BRAND LOT NO:
D

-I, 179-1 'TESTI. DEC 82, WHICH IS OBSOLETE.J USAPA V1.00
MEDCOM

DOD-039483

13. PROSTHESIS, IMPLANTS ¦ Nig Al NO IF YES NAME: ID NUMBER; JRER
tl . ''v; V . : 47,,tv1; ,•„,,,.. -"7--st OMEDICATIONS/ORDERS • . ,'
' '''' r. ''' WS fr ,r4 If IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT. BY ANESTHESIA) YES ¦DN 0el
t'MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY
WOUND IRRIGATION YES ¦ NO, TYPE(S):.
PTHER ORDERS TIME CARRIED OUT BY
;PHYSICIAN'S SIGNATU •
.

. " -,,,.. ,,” (..D,12
15. X-RAY IN OPERATI - • • • IF YES, SITE
t

¦D¦ .. .
YES NO
16. ' ' '".!ILABORATORY SPECIMENS
¦D. . _
SPECIMEN (S) NAME _ _.______ -, '''' • • • NAME YES NO FROZEN SECTION IFS) NAME NAME YES NO
¦D
CULTUR (C) NAM NAME YES NO --- - -___ __ NAM NAME NAME
NAME NAME
: 18. DRESSING/IMMOBILIZATION (Specify)

17. TUBES, DRAINS/PACKING YES Ni Jo
TYPE/SIZE . .
SITE 1. hA 3. . . t(&ii

19. ADDITIONAL IN MATI

_
..
C6

20. OPERATION(S) PERFORMED
. v 0
j.2"..:

21. PATIENT TRANSFERRADL7 fimE-a..._____ . METHOD
/ I 7 OT 0 ' ___,P,,CI I_ P__11
.

22. REGISTERED N :
..... ___ .
CP1-4r)

REVERSE 0.
... EDCOM - 25095

MUSAPA V1.00
DOD-039484
INTRAOPERATIJ•rJAENTMEDICAL RECORDJ -"

For use of this form, sea AR 40-407, the propons .cy ii the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM . 2.• PATIENT ID , -• : a : IEWED AND PROCEDURE
E

VIA NreiChey BY ailk.SWIDAi?/ VERIFIED BY 1 CPT/ AKI
3A DATE TIME PATIENT ARRIVED IN SUITE 4.. PATXNT I 4 bec. 03 TIME:•1"61.3 NUMBER
D7:7
5. PREOPERATIVE EMOTIONAL STATUS

RI CALM II ANXIOUS . EXCITED. I CRYING II ANGRY II WITHDRAWN • OTHER (Specify)
COMMENTS: ..._ .....,. _........
.. . .
.
6. NURSING PERSONNEL

ASSIGNED 75r:7— — --RELIEF
SCRUB .SCRUB
SPCAW/

ASSIGNED P. 1 RELIEF
CIRCULATOR ....__. ...... _ .. __CIRCULATOR
''''..,,,N.

7. POSITION AND POSITIONAL AIDS (Specify)
RI SUPINE • LITHOTOMY . PRONE ... 111 KRASKE.: LATERAL: U LEFT SIDE UP RIGHT SIDE UP .:_:•: ,r-COMMENTS: n
vropu f5Dck,DMiTinon4-maini-ni..66i. ----.
B. SKIN PREPARATION

HAIR REMOVAL U YES lid NO • " PREP SOLUTION (Specify) Betadinp... SCXLL vil
DONE BY: • OR . NURSING UNIT SITE: U. 10Wer ta 9 BY WHO
METHOD: • DEPILATORY • RAZOR .. :-.;..._ sin: .,..,..DBY WHO

¦ CLIP
COMMENTS: ........ COMI¦A'ENTS-

--. ... ' • 06 pitim of -fitlicis

9. LOCATION OF EXTERNAL DEVICES 1
• '...

I o 1J
I •— VI hillatinIC iskawf II/
... TIIIVAPP—
iJ

LEGEND X Ground Pad -- Safety Strap = = = TourniqUet.,•,--..•;.:7-1..1.
C = Correct I = Incorrect a-hiiiat c....
First Closing. Final Closing .

10. COUNTS Other*• Count ..11-,.: Mint SCRUB CIRCULATOR
Sponge 111 Yes No
Needle Sharp Ef Yes Vo -......
(6)(6)-7"

Instrument III Yes lo . ::../.1 ,.. •
...__ ._ ._

Other ¦ Yes Vo
11.1111,

11. PATIENT IDENTIFICATION (For typed or written entries give: -12. ELECTROSURGERY DEVICE(S) (ESU) U YES NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

,. U. ESU NO: EAU_ 40DRB. p IO231 s
11111 Ll..16fr (-1 GROUND PAD: BRAND Vali ...9 lab MY)

LOT NO:
.D_ --.-=;-1---: .Diiilsit,
' ..zeo. No:
.. -D

•••• . ,GROUND PAD: BRAND
.. --...,
LOT NO:
. BIPOLAR NO:
MCDC M 26006
0CD1 Arce r1A Cf101111 C170_1 f7C0T1 rim-.J1111”.."Ll se.

DOD-039485

'7

13. PROSTHESIS, IMPLANTS L k NO IF YES NAME: ID NUMBER JFACTURER
,14. &;:i ----Th ,gr , 11: ;;:iiqr-,, -{,, ;.*. ` 2MEDICATIONS/ORDERS F. wif*tt,
-A, r IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) YES . NO • MEDICATIONS/SOLUTION DOSAGE TIME -METHOD PREPARED BY GIVEN BY
t/VOUND IRRIGATION U YES . NO; TYPE(S):
.. _

ibicicio NS
.

`OTHER ORDERS TIME CARRIED OUT BY
_ .

I.D
rHYSICIAN'S SIGNATU
1 ,: : . , ,
-

15. X-RAY IN OPERATING ROOM IF YES, SITE
---.7-
YES • NO

12

16. :''= LABORATORY SPECIMENS
SPECIMEN IS) NAME --::::::=,-1,,:--- -NAME
YES NO 1 • -

¦D
FROZEN SECTION (FS) NAME . NAME
YES . NO [X
CULTURE (C) NAME NAME
YES N NO

¦ D
0 p AfitritiC, — R II* LI Our)

NAME NAME NAME
NAME NAME -- 18. DRESSING/IMMOBILIZATION (Specify/
17. TUBES, DRAINS/PACKIN c YES . NO RI
TYPE/SIZE 1. 2. -- -

3-'

SITE 1. 2. 3.
;5C

19. ADDITIONAL INFORMATION
.

Sung AnKthDGeme,r0,1
,.-::D;,,; D
..../_. /_......
1/
i
(,(c,N:6)—

20. OPERATION(S) PERFORMED
I. aku ofDL4.Di , OoDck.
---D-D
-

21 . PATIENT TRANSF RED TO TIME METHOD
. Lt.

teLsT *tiches-

22 • EGIST • e ¦ , :JGNATURE ,
if AN/ MEDCOM : 25097. I

DOD-039486
ID INTRAOPERATI"-DOCUMENTMEDICAL RECORDJ

For use of this form, see AR 40-407, the propor w is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING A 2. PATIENT I WED AND PROCEDURE
VIA arr dehtr VERIFIED B
BY an ps+hesia PT/AN/
3. DATE TIME PATIENT ARRIVED IN SUITE 4; PATIENT I 26 l\iov 03D09 55 TIME. 066, NUMBER
5. PREOPERATIVE EMOTIONAL STATUS

g CALM • ANXIOUS . EXCITED. • CRYING . ANGRY • WITHDRAWN . OTHER (Specify)
.

COMMENTS: ._._ _........
6. NURSING PERSO EL

ASSIGNED -"-RELIEF
SPillIllIllP. ---
--r--:

SCRUB . SCRUB
cp

ASSIGNED RELIEF
CIRCULATOR _ ---CIRCULATOR

----------LATOR
•-

7. POSITION AND POSITIONAL AIDS (Specify) ..A•-
K4 SUPINE . LITHOTOMY . PRONE • KRASKE LATERAL: • LEFT SIDE UP . RIGHT SIDE UP . ,
COMMENTS:
8. SKIN PREPARATION c ^ IL
HAIR REMOVAL ''`I YES • NO PREP SOLUTION (Specify)Bektdi pit SCJ
..xii 1 i

DONE BY: • OR • NURSING UNIT SITE: a. isqDBY WHO
METHOD: II DEPILATORY 1 RAZOR. ,, SITE . BY WHO .
Ill CLIP i_

COMMENTS: No flicks observe() ______ .1.661viiiENTs:/.10 palln9 of _rims
9. LOCATION OF EXTERNAL DEVICES
----- T',

..
I iltak i Iffiftrihi,q,3)7;";:vjght/Itji .. . 1.11-11/6P-
LEGEND X Ground Pad -- Safety Strap = = = Tourniguat... --,.:::..-....,
C = Correct I = Incorrect n'ti+ja) .

First Closing Final Closing

10. COUNTS
Other • • Count .. I ,:,,, Ciiiint .SCRUB
CIRCULATOR
U

I0 0007 7 2 7
nie

Sponge la Yes
MINIFIIIMMIIMIErilli
ill
RWAIIIIMEMILMIL

Needle Sharp 1,,4 Yes
i
WAIIIIIA111111111EIVA

Instrument
0

Yes
limaiiir

Other III Yes 'V
11.
or

PATIENT IDENTIFICATION (For typed or written entries give: 12.
ELECTROSURGERY DEVICE(S) (ESU) r:.1 YES • NO
Name - Last, first, middle; Grade; pate; Hospital or Medical Facility;)
_ /_ i

n ESU NO: force 4oDR.V 1 0 6305D54,60 GROUND PAD: BRAND
VIP (-9(q_=-1 Wilma Rai
,D..D. LOT NO: 115%
•.r,E.8i,1 NO:
. _ • •---GROUND PAD: BRAND
LOT NO:
• BIPOLAR NO:
-r, 5179-1 (TESTI, DEC .82, WHICH IS OBSOLETE.
USAPA V1.00
MEDCOM -i-25098

DOD-039487
13. PROSTHESIS, IMPLANTS ri Yf ] NO IF YES NAME: ID NUMBEF UFA. .URER Sythles Ti b. Sei inlpinalsJgo' Y 345
tbeici a 02.32. 6107¦ . .. _ Provi ma.I.2 D X1
Claiye,ruti T;bio,i NCH I IrrOctab
Lea 4 41 0J' 01— Disitil 4 g 1
i14 gitintaamyw.1-4*.ti. k ii? 1.-ifo. 1-r., . ,ii.mos MEDICATIONS/ORDERS
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY. ANESTHESIA) YES NO •
D -, MEDICATIONS/SOLUTION DOSAGE . TIME -METHOD PREPARED BY GIVEN BY
6 I i 11 go ig.g kJ:
.

: igliZTS4 ift..•
.

!MOUND IRRIGATION jr,j YES • NO TYPE(S)
i
,

„.: LOTHER ORDERS TIME CARRIED OUT BY
IND nel
ii
t CC) (C)) . G
-:4'HYSICIAN'S l
1

gy ...Dh...,D:1,,,,,,,,,,,,..4.D
,e...D0,...,,,,,,....,-:

15.
X-RAY I ..... -:: IF YES, SITE:
YES r:,DNO • C - Arm

16.
_:' .` . : ';'.-' LABORATORY 'SPECIMENS

SPECIMEN (SI NAMEJ_ ______ .____ J---- --NAME
,J: ,....„, ..:.

YES NO n -J FROZEN SECTION (FS) NAME NAME YES III NO
CULTURE (C) NAME . NAME
._. YES • NO IN -- ,--NAME NAME
NAME

NAME NAME ...H. 18. DRESSING/IMMOBILIZATION (Specify)
— --- ---'"--XfirOfDrVY1 Au CCS YtrOkr/P0J1-4.
17. TUBES, DRAINS/PACKING YES ri NO
TYPE/SIZE 1. . :-... . Kent VJdortoi,,JkeJrryx ColionJj ot, er 1‘ Fe FeAe‘i IDA% ,IP fral n .J. 6itv.wetri I to
SITE 1. 2. 3. . ..44.140.PI3..Sier 49 .44Blv4ii&r L1. (01,VeY leg Ace wrap
19. ADDITIONAL INFORMATION _
. _ _
SurgJ ArtesJApeJkntra.1
WI-

.J_J.J..
... J
...J_.
0.(--) -7--J__......,, . ,J_

20. OPERATION(S) PERFOR . o
1. Li Ti hial TM 4 di lin3
Z. Soieus Mii s 4 "1 ski n graf4'J- ::J
21. PATIENT TRA FERRED TO TIME METHOD
PACJ(TCW.1) 17.15J--Stretchev
22. : t o k.,._: E SIGNATURE _
.D CPT/AO/nnEnenro . 7Rncm
DOD-039488

1J INTRAOPERATIV: 'DOCUMENT

MEDICAL RECORDJ
For use of this form, see AR 40-407, the propong 11` he office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING A 2. PATIENT IDENTIFIEL .ORD REVIEWED AND PROCEDURE
VIA (._..,---1-1--.2-u--BY /C11.1-3 VERIFIED BY M 4-c./
3. DATE TIME PATIENT A 4.- PATIENT IN ROOM --( Aia.—G-7,/ 1150 r TIME. ; (gci rDNUMBER
I
5. PREOPERA IVE EMOTIONAL STAT

(ALM M ANXIOUS U EXCITED U C YING U A RY . WITHDRAWN . OTHER (Specify)
COMMENTS:
. .
6. NURSI G P SONNEL

ASSIGNED ----RELIEF
SCRUB .. SCRUB
.6

Pt-
ASSIGNED /11A---J RELIEF-..„..
CIRCULATOR . . .,...._ . . __CIRCULA s t

7. POSITION AND POSITIONAL AIDS (Specify)
[SUPINE LITHOTOMY . PRONE II KRASKE LATERAL: . LE', SIDE UP . RIGHT SIDE UP
COMMENTS:
8. SKIN PREPARATION

HAIR REMOVAL U YES PP'O `' PREP SOLUTION [Specify)/
eif-cp_oter-e... ..s -c./"b J /C
DONE BY: M OR II NURSING UNIT SITE: LA-f4-i-A-7 4j kilo/BY WHOM:At,/
METHOD: U DEPILATORY • RAZOR . .. ; ,SITE: , BY WHOM:

¦DCLIP ... :___ :...... COMMENTS: ______----. -COMMENTS: A} e ii ,S ttD
[ ..1,..1/-I/s-d t (A41 11/..,--
9. LOCATION OF EXTERNAL DEVICES
• . •-• -T,i i_.
-

..- 1.lD.D(D •1111iD. '
,• -
- -i -Cl¦-

LEGEND X Ground Pad -- Safety Strap = = = Toumiquet....-:;;.k:::.:
' • ..

.-----
C = Correct t = Incorrect
nal
AN
First Closing Final Closing
7--

10. COUNTS
Other• • Count .. i.,, .: Cdurrt -SCRUB

,.-U
Sponge T. Yes ,),.

Needle Sharp (42 es
MEW

Instrument 11 Yes mi o _ -,., ppo. -4
'th;. An D
....

Other III Yes al o
11. PATIENT IDENTIFICATION For typed or written entries give: 12. 'ELECTROSURGERY DEVICE(S) (ESU)J• YESJ
NO

Name -Last, first, middle; Grade• Date; Hospital or Medical Facility;)
R. ESU NO:
"*0111111 GROUND PAD: BRAND

LOT NO: (,L -IW 1 "Er.....40NO:
..,J. v..-.
----.GROUND PAD:JBRAND
-J...,
LOT NO: q(?)-1— U BIPOLAR NO:

14 clic v----03
RM 5179-1, OCT 87 Kt LALtb un Purim otTg-darraTIOrcitp, WHICH IS OBSOLETE. USAPA V1.00
DOD-039489

13. PROSTHESIS, IMPLANTS r *"1‘10 IF YES NAME: ID NUMBER 71c-ACTURER ... „.......... --
}1 4. refiA0 ', '' '71A',.'aglittet. :114:tDr'11,-A,54:•:F MEDICATIONS/ORDER4 -4,51*,p 77D51;2D."1:r pnecri ., •D" y yiki•a, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO
:MEDICATIONS/SOLUTION DOSAGE. TIME -METHOD PREPARED BY GIVEN BY s1' , t
k

rA
1

WOUND IRRIGATION rJYEs • NO; TYPE(S): .. ikic -;
'OTHER ORDERS TIME CARRIED OUT BY
II

PHYSICIAN'S SIGNATUR E
.,

15. X-RAY IN OPERAT1 IF YES, SITE
1.9 lb\ .-L.-vi-. D,

YES • NO .D
16. -. ":".!LABORATORY SPECIMENS
,

SPECIMEN (S) NAME . -
YES • NO ' -
FROZEN SECTION (FS) NAME NAME
YES • NO
CULTURE (C) NAME NAME

YES • __________
NO E41
NAME NAME NAME

NAME NAME -- ..,.-. 18. DRESSING/IMMOBILIZATION (Specify)
-/----/-/----_-

17. TUBES, DRAINS/PACKING YES • NO
Rail
TYPE/SIZE 1. 2. V .

A

SITE 1 2 3.
•-- ----'4..--; A-r

19. ADDITIONAL INFORMATION
-
. , .
c.1.-N,. r•-? q--0/‘ -

..
.......—

CLICS.2-'d-:D1 /1-44D _
.D,

20. OPERATION(S) PERFORMED
.D_..

..----d---10DLfD//D/e=e4vFf .- -'D
21. PATIENT TRANSFERRED TO I TIMES .. METHOD
pA-cck c F _CO - .
22.' -r It-¦Dz ._ IG -
-4'1 11--3DlayD2-1: Ajciu--- 03

RFVFRRF nr n. .QCT R7. USA PA V 1.0r)
DOD-039490
J
J.
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR DAY
.9¦9'
./.10 .¦.„ -21 ..-
vim




.

i
J.:
-

19 -.1J HOUR 111111FATEIMMINIMPU ' • 't • • •
.f. :


11••J
610*

PULSE 1 F
(o)
105°
57.

'--"
0
al

--1

0.)F..
COCO (0o 9M Wb 40 b co :0

Arri
0
0 0 0 0 000 0n
(Centigrade Equivalents, for Reference only)
Cs)

li

. .



.
r _1


-
.J.

180 104°
170 103°
In
•J••

•• •'
. .

. . . .
I" ' •


: .: :.
. . . .
! •
' "
. .
. . . .

160 102°

w w
. .
•'
"


"

150 101°
140 100°


. . . . . . . . . . . . . . . .
....
.

(...)
-.I--I-4
ONto
1
. . ......
....

. . . . . .
. . . . . .
130 99° . . . . . .

" •


. . . .

w w w0....)
a) cri ci)
• •• •• "
.J. .J. .

98.6°
....
..4 .
• . . .

4, •
:
• : :J:

120 98°
cn

I• \11
I '9
O bI-..-.
0
. . ..
. / ....
•••• ••••¦•••••••••
.


. .
. .

110 97° ••..
100
96°





• •
I
):

.
• •
.
. .
' -
•'
.
.
.
.
1.--

.

1


........ ....
. ©'
I
. .

-.I • '
.r.

. ••••
. .• • • •
.
•• • ........ • ••
.. .

• ••-
III, • • •
1••¦•••••••••••



• • .1
. .

90
95°
. . .

co
. .
. . . . . . . • • .
. . . . .

80

. . . .
.D4Z)D
I .... .. ..-

70
. .
....
.

60 50
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. ...
.e•': ••
...
' •
..
.
... ...
• • • I
..
• • •'
... ..
.
'.•

40
.
111T

‘ii A

orthrominimwmaiimmare

RESPIRATION RECORD
BLOOD PRESSURE
m.
Viir/SIMII

11711
4.-..-
Mt
WEIGHT --.4

RgrAi
Lap,

limmilimmuilmiff.0

.
• HEIGHT:
..
o
-1
/

el
_
MTIENT•S IDENTIFICATION (For typed or written entries give -Name—last, first, middle; ID No. REGISTER NO
WARD NO.
(SSN or other); hospital or medical facility)

lCu) I
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 25102

DOD-039491

D
NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-D DAY

MONTH-YEARDkjZ5V DAY • ;15
ta°1 30 I abe c "At ioa
oc
a:w•
40.6°

1,9, 4z3444:63
HOUR PULSEDTEMP. F

f
iD• • • Q.J
• 11, " . ' 6.•
• • 6.• 1
-
:D: : f : I:
b's: c5
C.)•0
:

.

TEMP. C
.c •

(0). (.)
:D:
ya
105°

.D
0
::
. .
.D..
....
.
• • :D: :D: :D:

180D104° •
.D••
.D. •• " • • ••
• • • • •• • • .... .D.
.D. .D. .D. .D.

170D103° •. • • • • • .• .D.
40.0°
D
,
(
39.4°

.D
.D

.D
.D. .D. .D. .
o 0
. .D. .D.D.
.
.D

160D102°
.D. .D•.
a)
1(2
38.9° c
luaJala

.D. . .D.D. .D38.3°DIx
.D.D.D
'7)
.

.
. .D. .D• .D.
....
...•
......
.D. .D. .D. .D.D.D
......
.D. .D.
.
a)
. .

150D
.
101°
.D• .D.
.D. .D
. .

.

....
.D. .D.
......
. .D.•

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.
8
. .D.

. .
. .
. .
.D. . .
. .D.

140D100°
• •D• -D
.D37.8°
1). ::
of
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......
.D. .
.D•
. .D.

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. .D.
.
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dpi
.
To
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.
'D• • •

130D99° a''•
37.2°Dm
98.6°
)paMp.
11011111Mal

:D:D:D: .. or
37.0°D
.D. D.D.D.D. w
......
4.,
:: iits

120D
98°
:D. Illnli
. . 36.7° -o
! • • • •
l• •
. . ..o
-
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PI
.
..

....
40. •

1 •
1 °
EL
iD.D.Di

110D97
36.1°
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100D96° gi
iii

35.6°
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90D95 ° .
35.0
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IF I :: I MIll

:

80
D
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— —
.... ••••....
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60
....

'
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. . .
.
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50
....

.

40
......
• I.D•I • .........1D.Dli D

1 1 g If

iESPIRATION RECORD BLOOD PRESSURE
I 4 W..142MIIValLIMA
EVIIIIIMI

co
2
MEM1MEr

P 6

0
w J
c mi •J1 1 /// /0), 982
a) HEIGHT: I WEIGHT --11.
lo

,...
.c c .4 ', ,.kammu,17,1e.
vamtv

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0

a
,

14y.m_

147.0-PP 70i.Vt.
4*.74

3
1
. -1,' tx ATIENT'S IDENTIFICATION (For typed or written entries give Name—last, first, middle; ID No. /(SSN or other); hospital or medical facility) . REGISTER NO. ViRD NO. i

li1111 (6)(0 -Li

VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 25103

DOD-039492
MEDICAL RECORD VITAL 81GNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR ' 0. DAY ' 0
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PATIENT'S IDENTIFICATION (For typed or wri ten entries give• Name—last, fist, middle; ID No. REGISTER NO
WARD NO.
(SSN or other); hospital or medical facility)

STANDARD FORM 511 (REV. 7-95) BACK
M

PZI
MEDCOM 25104

DOD-039493

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR DAY 1,0. ,. . ral/WiEll .0 ,
-
'llec

19 HOUR PIAI • ' 'C'' ' 11.
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STANDARD FORM 511 (REV. 7-95) BACK

--44111111 gi.11

MEDCOM - 25105

DOD-039494

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DDA UM] 4-4 FO1MUMP.:IMIIIMET1111
MONTH-YEAR may PM. MEM /IMO19 HOUR alEMIIII 0 • Ell • • • • MIMI -J• 11=1111Mill
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PULSEDTEMP. I' •
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105°

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RESPIRATION RECORD

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'Record specialdata only when so ordered
BLOOD PRESSURE
,.9 k 0
MIMI
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aunt
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HEIGHT:JWEIGHT --10.
MI

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IMEIEIMINI RA Arti 11111

PATIENT'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

MEDCOM - 25106

DOD-039495

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST-DAY
DAY
p cu:-IIIIMPLIMANEVAIIIIMMUM1111

6 Mir

HOUR PULSE TEMP. F :
(0)J(.)

105°
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150 101°
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140 100°
180
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. . . . . . . . . . . . . . . . . .....
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98.6°

120 98° kimmaimi •:J: mom :J:. : .: :.: :J: • : RH IF
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Mill
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MEM MEI WS
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ERIMIWIIMIMILMONIIIMEME

!Record special data only when so ordered
BLOCe PRESSURE
HEIGHT: WEIGHT --4
lig

lialMinflinali Aleffilal
• I • TNIIMIRIIIITIMilra Ril MIIIIIIIIMILM

PATIENT'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)

STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM -25107

DOD-039496
NSN 7540-00-634-4124
VITAL SI(

MEDICAL RECORD

RECORD

HOSPITAL DAY
POST-DAY
MONTH-YEAR p...t..„ DAY -S.-a • 'ma
/t.(
MEMIElz•

10

1 t.t.
ic/il--

CMILTrAllgilin J,,•• 1-J
)

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19 HOUR (.)
105°
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180 104°
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170 103°
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160 102° : : : :
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.... , ,
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150 101°


140 100° _
waieNi Ipe.Mylu a0)
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....

130 99° ...
98.6°DD
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110 97°
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HEIGHT: I WEIGHT --I.
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RESPIRATION RECORD
-

'Record special data only when so ordered
010,08 9D: 1117e ay%DiiD• 4 CZ • (Ph' Man: g
,L' m wallinilailIMM
tip

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.
VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICWIR, RRMR (41 CFR) 201-9.202-1
MEDCOM - 25108
DOD-039497

WarcUSection: rREQUESTING PHYSICLN.N:
CHEMISTRY RESULT FORM.
(Subject to the Privacy Act of 1974)
LAST, FIRST, MI. [ DATE TILE SSNIT'SEUDO SEN:

..: ,.(PictOlo):;Chernisr6r. ictolc9Vetabolk,Panet
TEST TEST RESULT REF. TEST RESLET I: R.E. RANGE RANGE
Na &'cll GLU 73-118 mgidl
K 35-4,9 =on. ALP 26-84 10 . BUN 7-22 mgidl
Cl 98-109 nncl_11_ 10-47 url CATR-8.0-10..3 rug&
p11 731 -7.45 AMY 14-91 GRE 0.6-1.2 md1
PCO2 3545 mmHg Crit • , NA-121-143 unnol'I
41-51 mmlieKyco)
PO2 80-105 mmHg (all 3.3-4:7 mmolil

1'.I',1.!veui
===---- PICCOLO ­

TC'02 23-27 nuuoliL (arti 98-108 mmal
24-29 mmon (Yen 07:39

20/11/03­

r 11CO3 21-7.6 mmota. (art) MALE-18-33 rumoLl
-tCO2

23-28 mme1/1_ (yen REFERENCE RANGE: s02 95-980/0 PATIENT PanetPla••:, -;• -:''. BASIC METABOLIC
BEiecf (-2) 3325AA1 TEST RESULT REF. RAWGE 3
mmoll DISC LOT #:­
DR #: 000

rAnGap 10-20 mmo1,11, OPER #: 172-ALB 3.3-5.5 g1(.11 -----• 0000100494
.1

Ca 1.12-1.32 rumot'L SERIAL #:-ALP . 26-84u,1
BUN 8-26 mg/J1 ALT 10-47 u1
GLU 122* 73-118 MG/DL

• 7-22 MG/DL

GLU 70-105 ragidt BUN 7 AMY 14-97 till
8.0-10.3 MG/DL

CA+4 8.5
0.6-1.2 MG/DL

Creat 117-1.5 Ing/c11 CRE 0.8 AST 11-38 :0
NA' ....135

128-145 mom_

Het 38-51% PCV TBIL 0.2-1.6 medl
3.3-4.7 MMOVL

K+

1-Igb 12-17 eicli GGT . 5-65 WI
CL-106 98-108 MMOVL 18-33 MMO1A_ TP I 6.4-3.1 ell
tCO2 26

..v.v.
TEST RESULT REF. RANGE '-'....-/.:.:. (P01o)....,fle4rolire, -

CHEM OC: OK

INST QC: OK­Troponin-1 HEM 0 , LIP 0 , ICT 0

TEST RESULT : REF. RANGE
.•

Drug of 128-145 mrnot'l
Aboge
3.3-4_7 mmo:11

98-108 mmol
---7----1

i 18-33 Enmoi,1 1 1
REMARKS:
REPORTED BY:
1
MEDCOM - 25109

DOD-039498

REQUESTIN3 P YSICLAN: LABORATORY RES-01511-1 71-CAA) (Subject to the Privacy Act of 1974) 11 LAST. tERST, DATE TLME SSN1PSF . 62D A,C4J05 1 07410
(11 matology) CRC asc. Serology
= .
Th.Y. RESULT I REF ..., .E...1=ESUL7' REF. RANGE RESULT i REF RANGE] -
4.8-10.1i N. 10' Color RPR I ' Native
RBC 4.7-6.1 App , Mono I ...._::
L.
Igh 14-18 gigit (N) Gin Mkrobtiology

12-16 gidl (F) Het 42-52% (A) Source 37-47% (17) MCV S0-94 II (M-) Gram S1-99 ti (F)
Stain Pit 130-509x 10• Occ Bid Neptiw verified Lymph ')A, 20.5-51.1% Bid Negative Negative
(lematOlogy)-Manual Differential PH NIA Micro . ...-Parasites Segs Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 0 & P
Lymph 'Bast) Nit Negative Other
Atop Imm Letk . Negative Microscopic Urináysis
RBC HCG Negative Morph
Spun I 42-.52% (M) CSF . • Blood Bank -. • 71
Hematocrit . 3747% (Fy

.D .
/

Sed Rate Cell 1 MUST SUBMIT SF 518 WITH
Count EVERY UNIT REQUESTED

Other Directigen I--Negative ABO/Rh

Coagulation Studies . -Blood Bank Unit Crossmatch - • . • ..-. • . . • . (MUST SI SF 518 WITH EVERY UNIT OF.•LOOD
.

• • . .. • • •REQUESTED) -. • : '
-TEST i RESULT 1 REF. RANGE UNIT TYPE vCROSSALLTCH
I
PT 9.8-13.6 secs

.1 P.17 : 21-34 secs
• .
D dimer 20 tsWrril
ID •i 1-D.

I' DP 10 Acorn! ,
_

REM.AJOKS;
i4.7,PORTED BY: DATE:' LAB Ii) NO.:
MEDCOM -25110

DOD-039499

20-11-03
00:03
Patient Limits
88C 10.0J10•3/uLJ
4.5 10.5
RBC 4.08J
0"6/uL 4.00 6.00
110 12.4J9.
11.0 18.0
Hct 37.8JIJ
35.0 60.0
MCV 92.7JfLJ
80.0 99.9
NCH 30.5J
P9 27.0 31.0
MCHC 32.9 L g/dLJ
33.0 37.0
Plt 253.J
x10A3/uL 150. 450.
LYZ 15.7 *I IJ.551.1
LY#J1.6 * x1043/uLJ
2 3.4
20-11-03
07:54 Patient
Limits UBC 8.2 * x10"3/uL 4.5 10.5 RBC 3.94 L x10"6/uL 4.00 6.00 Hgb 12.1Jg/dLJ11.0 18.0
Hct 36.7JZJ35.0 60.0 MCV 93.2JfLJ80.0 99.9 101 30.9JpgJ27.0 31.0
ICRC 33.0Jg/dLJ33.0 37.0
Plt 234. 110"3/uL 150. 450.LYI 19.1 *4_ ZJ
20.5 51.1LY#J1.6 • x10"3/uLJ1.2 3.4
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/20/03 00:17
Patient

Name :PT
Test Result:= 14.6 sec.
Ratio . 1.2

atiligmAreeetuyem044
Sample Type:Otrated wh. blood
Test Date .

:111/20/03
Test Time­
00:15
Card Lot -:08
Operator

RAPIDPOINT COAG ANALYZER V4.54
`TRIAL #005485 11/20/03 00:23

Patient ID
Test Name :APTT
Test Result:= 31.2 sec.
Sample Type:citrated wh. blood
Test Date :11/20/03
Test Time :00:17
Card Lot­
:11021
Operator

MEDCOM - 25111

DOD-039500
1_, •kl;OR_L_TOR:: RESULT FaR_'.: ; • ..
!.:4)
LAST. F

SN:


•• i

cE
V, :DC
! I •

L. 4 7 -6.1 :: 1'2'
; --':•i'
1 "
I 1 4--1S (-...i") I iok-z-ry


i 12-16 ,-..1,..: ;TN, I 1
1.---
42-2'..: 0.E) . I-Bill_
1

. •
S:2-:.::: c --: ::.A

,.. ¦., 0::-.7. 5
Bl , IN.c..r..ii.-c H. P:,:iori
ta-Lo4-v) ;.‘.f.i.n a al Differential pH NiA . M.icro

-

Parasil . ', Sc • Nfono PTO:: Malaria v
Nz--,2!_is-.:. 1

Bv, z.,.ds Ec-s Urob 0.2-1.0 0 8.: ? 1
. Nic ...,
Ly1----2 Baso . 0:::::::-
..ktyp r7-1,-:.-.., Lu k ! -..---... - • .. -ro-s.cbioic .L7 ri_nily-s-is: R3C ECG Morph V , -• ' • ." Blo-od.B-a ri k ' •, • ..
• .
..

37L-17/. (r-) . •... .... .• .-• . • .. -. . . . . , . . -. .: . -..
-. . . . Scd :Laic I
Cc'vl MUST SUBMIT SF 51S WITH Cert EVERY r...7N-rr REQUESTED
I D:.r-cc:igcn ocp..-_-yr: .A..B0/?,:-1 I 1 I 1v •
V•

. :-ozgu btio a Sc7.-lies.— .-. • ; • • • . .. v. . • 'M ;o.,xi F3ar..rk Ca i t Cross vtcl.--.' : • .: • . • ' . ' -
• . ........... . . .. ....

--. OfUST,SUB:vtITSF.513 C', 1.1.ti EVEPY U7N.T.T* OF BLOOD
, .1 - . ? i Al G ;:-C..r.V17-v'v . ;v9.:. -1 3.•.', :::-.7,-,

I
¦
IkTED BY: LAI?. NO.:
MEDCOM - 25112

DOD-039501
D
C_,qC1

CITE ‘ILSTRY RESULT FOR:, Az( SSN.'?S 7:. -•-•••\ SSM:
I
02,3q,f-T;czoloYer7577­
2:.
-PICCOLO --­1:/11/03-01042: AM

-

L ­REFERENCE t:'

PICCOLO --

PATIENT #11111111111

20-00:24

$3

LIVER PANEL PLUS

PCO2
REFEREN MALE

3154AA7

DISC LOT #:­

P02 PATIENT #:
DR #: 000

OPER #: 013­
BASIC META

TCO2 0000100684
- -2 SERIAL #:­

DISC LOT #: 3325AA4

HCO3 22-2D rnmet.'...
I 7.3.23 OPER #: 013 DR #: 000
ALB 3.6 3.3-5.5 G/DL

95-9S%

s02 SERIAL #: 0000100494
ALP 61 26-84 U/L AL1 23 10-47 U/L T

GLU­
144* 73-118 MG/DL

AMY 38 14-97 U/L

BUN­
9 7-22 MG/DL

AST 27 11-38 U/L

CA++ 8.2 8.0-10.3 MG/DL

TBIL 0.6 0.2-1.6 MG/DL

CRE 0.8 0.6-1.2 MG/DL

BUN GOT 8 5-65 U/L
NA+­
135 128-145 MMOVL

IP 5.9* 6.4-8.1 G/DL

K+­
GLU 4.2 3.3-4.7 MMOVL CL-­
107 98-108 MMOVL .

INST DC: OK­
CHEM OC: OK

Crez: tCO2 23 18-33 MOM_
HEM 14, LIP 0 , ICT 0

pct ?CV
INST OC: OK-

Hg CHEM OC: OK HEM 0 , LIP 0 , ICT 0
.'A‘...t.ssc.Cherraistr-ry: •

T S I RESULT
D. ¦ -1-E.:
MEDCOM -25113

DOD-039502
NSN 7540-00-634-4156

MEDICAL RECORD
OPERATION REPORT

PREOPERATIVE DIAGNOSIS
SURGEON FIRST ASSIST SECOND ASSISTANT
c.Pr-
4.1111.

ANESTHETIST ANESTHETI
TIME BEGAN:
.118/1111

TIME ENDED:
CIRCULAT
TIME OPERATION BEGAN TIME OPERATION COM-PLETED " 411111111trill..M.."11. 11-1
OPERATIVE
6c Iv 19; 3'4 of
DRAINS (Kind and number)
SPONGE COUNT VERIFIED

LC-faCi 64k^edD-t-tz
MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION
I €4-4DC,o ertilAJ
OPERATION PERFORMED
L/0v-e_al -F?kzva 176u( I

DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.)
PROSTHETIC DEVICES

DATE OF OPERATION
(Lot no.)

/6131P/&-7r 194/
'144'614 Zv/Igo/ 94_5/ze evf /STSG ,
14/7 044.,vc (7/776. / 4/4.7
C% gt(Defr-tpt74-,-
u4(.1--t

SIGNATURE
DATE
it)a 6:613

PATIENTS
r written entries give: Name - last, first, middle;

REGISTER/I.D. NO. WARD NO. AI v
grade; date: hospital or medical facility)

C_S)
OPERATION REPORT
Lt-) l(-i'`1

Medical Record
STANDARD FORM 516 (REV. 5-83)
Prescribed by GSA and ICMR, FPMR 101-11.806-8
MEDCOM - 25114
USAPPC V1.00

DOD-039503
Micro b io logy Req ues t Form

E

0

co
M0
MEDCOM - 25115

DOD-039504

Ivitcropiology Neport ---

t4C.,\ oratory
Name. 1111M1.111Pcb 2)— Status -Final Patient ID: WI Source• Wound/Steri.e Sisi e Collected Ward/Rm Ward ()I Iso -Attd Phys
Acinetobacter baumanniiihaemolyticus Status Final

Ac baumann/haem DrugD MICDInterps clirug MIC Interps AmikacinD =16 Amox/K Clay (c) 16/8 Amp/Sulbactam (c) =8/4 Ampicillin 16 Aztreonam 16 Cefazolin 16 Cefepime 16 Cefotaxime (c) 32 Cefotetan 32 Cefoxitin 16 Ceftazidime (a) 16 Ceftriaxone (c) 32 Cefuroxime (b) 16 Cephalothin 16 Chloramphenicol 16 Ciprofloxacin 2 ESBL-a Scin 4 ESBL-b Scrn 1 Gatifioxacin 4 Gentamicin 8 Imipenem (c) =4 Levofloxacin 4 Meropenem (c) =4 Moxifloxacin 4 NitrofurantoinD64 Norfloxacin 8 Piperacillin (a) 64 Tetracycline 8 Ticar/K Clay (a) =16 Tobramycin 8 Trimeth/Sulfa 2/38
Z.;D,- ..,..s.:,,tont:eD N.".:D, Nr,! Ple::.C . :e3 irseooer_baleD ..D
r NO, TAste.7E:7;1:1DF •: -D 7 sr e.-1!, , )., ,-. D
R : Res,s(ance 7F:: , tc,:n..),,,, :',:erenneni 1:..1.:' rho'.
B,,,a Fr:'a:--asr: L•cs: :--

!Olt,D:. ,cu..,,,, , rngil
R' i4 es.s:are •1:.e oec, n be;e: acJaclases ,E EBL , SL.spec:ec F.SBL C:,,,firmatory tesis neeceu oliterent.we FEEL !tom dire' :a ¦ a•:aciamases 1ndoc.ble Beta-lac:arcase Appears .n place 01 Sonsa.e w:1^ spaces known :o possess ,nduc,ble Cara-laciamases tr.ey 'nayD .7e•a Momlortng 01 p&.eols Cuongiatier 1Oernoy •s reCornmenaea D .aeia -lactam onrgs
7.00 ane CSF :a0, 31eS a neia:ractamase rest ,s reco,nclendea E .1 :e 1Cco.7,C,,S s.eC as
•JseDloses .71Damoog1y,:05 ,0e for P ^Lsa paben:s :7 "- 'l'vIot c snrec: , 0,:s
Brea,,i)n.nis oaseo paremara. ;lase F,), zerurox:nle deer:. .se irS 'FL= R: F0oinoie ap,s,ns •J
Co, Slr.i..p..01;i1Cr.,D0 nenic, 1 1 ,n.olef0.etat•o .ls For amos:or, a• -:-7 ,!.01su1t.,...!a,D •
oeta• 1 :1L713,,,rSeD ,11 ;Pe/•D ;.D,z., s sr ,;.;.

oreanpowesa Cased NCCLS M IGC: -S12 Jan 2002 S;:s -cr.ac.n cior O•ar-Negn;we ., eDF1.1A ar_•7 For S a,,S•Jrnor,ae Ce101.3..me and CeIr tawnr creai,po,res are case^ L _:halesDanisD „g,,sD . 2 , n
Name: Specimen: W .173D Status: Final Pa en t iD• Source: 'Around/Sterile site Collected: \Nord/Rm . Ward of Iso: Req Phys
Piin`ed 12/12/2003 2:30:33 PM Page 1 01 1
MEDCOM - 25116

DOD-039505

Micro bio logy Req ues t Fo rm

0
CO
Patient # or SSN:
el 1%.JMEDCOM - 25117

DOD-039506
e\ Microbiology Report
pop. howaboratory

Name: Status:DFinal
Patient ID: Source:DWound/Sterile siteD Collected: Ward/Rm: Ward of Iso:D Attd. Phys:
1D Acinetobacter baumannii/haemotyticus Status: Final
1JAc baumann/haem
Druq MIC Interps Druq MIC Interps Amikacin =16 Amox/K Clay (c) 16/8 Amp/Sulbactam (c) =8/4 Ampicillin 16 Aztreonam 16 Cefazolin 16 Cefepime 16 Cefotaxime (c) 32 Cefotetan 32 Cefoxitin 16 Ceftazidime (a) 16 Ceftriaxone (c) 32 Cefuroxime (b) 16 Cephalothin 16 Chloramphenicol 16 Ciprofloxacin 2 ESBL-a Scrn 4 ESBL-b Scrn 1 Gatifloxacin 4 Gentamicin 8 Imipenem (c) =4 Levofloxacin 4 Meropenem (c) =4 Moxifloxacin 4 Nitrofurantoin 64 Norfloxacin 8 Piperacillin (a) 64 Tetracycline 8 Ticar/K Clay (a) =16 Tobramycin 8 Trimeth/Sulfa 2/38
SD= SusceptibleD NIRD= Not ReportedD Blank = Data not available, or drug not advisable or tested ID= IntermediateD
= Not TestedD ESBL = Extended spectrum beta-lactamase
RD= ResistanceD TFG = Thymidine-dependent strain D Blac = Beta-lactamase positive
MIC = mcg/m1(mg/L)
R'D= Resistant due to extended spectrum beta-lactamases (ESBL) EBLi = Suspected ESBL Confirmatory tests needed to differentiate ESBL from other beta-lactamases 18D= Inducible Bela-lactamase Appears in place of Sensitive with species known to possess inducible beta-laciamases potentially they may oecorne resisiant in all Deta.laciam drugs MOntloring of patients auringrafter therapy is recommended Avoid otherrcomoined beta-lectern drugs
For 01000 entl CSF isolates a beta-taciamase test is recommended for Enterococcus species
(a) Use maximum doses of drug with an aminoglycoside for P aeruginosa in patients with granulocytopenia or serious infections
(b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S. 8-16=1, 16=R), Footnote (c) applies to this drug
(c) For streptococci refer to penicillin interpretations. For amoxicillinIK clavulanate or ampicillinfsulbactam with enterococci. refer to the penicillin interpretation
(d) F or non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCIS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxilloxacin are based on FDA approved breakpoints For S pneumoniae. celotaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis For non-meningitis infections. use 2=S 2=1, 2=R
Name: Specimen: W186D Status:DFinal
Patient ID: Source:DWound/Sterile siteD Collected:
Ward/Rm: 011D(6/-1 Ward of Iso:D Req. Phys:
Printed 12/18/2003 1:53:52 PM Page 1 of 1D Tech:
MEDCOM - 25118

DOD-039507

Micro bio logy Req uestFo rm

O O O op O cn 0
r— r
•••

Z

Patient # or SSN:
MEDCOM - 25119

DOD-039508
LI;)(i1111:..1 1..)J1 ....//.1 .•,....
aboratory

piiillillt,...1
r

Name: pecimen: W186 Status: Final
Patient ID: Source: Wound/Sterile site Collected:
Ward/Rin: Ward of Iso: Attd. Phys:

Acinetobacter baumannii/haemolyticus Status: Final

1JAc baumann/haem
Drug MIC Interps Drug MIC Interps Amikacin =16 Amox/K Clay (c) 16/8 Amp/Sulbactam (c) =8/4 Ampicillin 16 Aztreonam 16 Cefazolin 16 Cefepime 16 Cefotaxime (c) 32 Cefotetan 32 Cefoxitin 16 Ceftazidime (a) 16 Ceftriaxone (c) 32 Cefuroxime (b) 16 Cephalothin 16 Chloramphenicol 16 Ciprofloxacin 2 ESBL-a Scrn 4 ESBL-b Scrn 1 Gatifloxacin 4 Gentamicin 8
1

Imipenem (c) =4 Leyofloxacin 4 Meropenem (c) =4 Moxifloxacin 4 Nitrofurantoin 64 Norfloxacin 8 Piperacillin (a) 64 Tetracycline 8 Ticar/K Clay (a) =16 Tobramycin 8 Trimeth/Sulfa 2/38
S = Susceptible NIR = Not Reported Blank = Data not available. or drug not advisable or testaft, = Intermediate ---= Not Tested
ESBL = Extended spectrum beta-lactamase R = Resistance
TFG . Thymidine-dependent strain Blac = Bela-lactamase posttrve MIC = mCg/m1(mg/L)
R' = Resistant aue to extended Spectrum beta-lactamases (ESBL) EBL 7 = Suspected EMU. Confirmatory tests needed to aifferentiate ESB1. from tamer beta•lactamases IB = Inauciole Beta-lactamase Appears in piac.e of Sensitive volt, species known to possess incuonte beta-aciamases potentiank tnek may pecorieriitSittlaiii ,,a! Monitoring of patients auririgrafter tneraps s iecoi•iinenaec A. 0 iC otheirc,itr•pinea netaiiaciarn drips
For ooc anc CS1 'spates a peta-iactarnase test is •ecommenaec to , Enterococcus species
ia; Use maximum aoses of drug wan an aminoglycoside for P aeruginosa in patients wan granulocylopenia or serious of ectrons ,bt Breakpoints based on parenteral dose For cefuroxime axetil (PO) use (8=S 8-16=1. 16=R) Footnote (c) applies to irks drug ic) For streptococci refer lc penicillin interpretations For amoxicillina( clavyanate or ampicillin/sulbactam with enterococcr refer to the penicillin interpretation ici For non beta-lactamase proaucing enterococcr refer to the penicillin interpretation Footnote la) also apples to this drug
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002 Sparfloxacin (for Gram Negative isolates) and moxinoxacin are based on FDA approved breakpoints For S pneumoniae celotaxime and ceftriaxone breakpoints are based on isolates (torn patients vain meningitis For nonimeningihs infections use e2r S ..2=R
Name: Specimen: W186 Status: Final Patient IDI Source: Wound/Sterile site Collected:
C6LK

Ward/Rm: Ward of Iso: Req. Phys )(
Printed 12/18/2003 1:53:52 PM Page 1 of 1 Tech:
MEDCOM - 25120

DOD-039509

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG

DRUG (Units) TOTALS TOTAL EBL
_4 oU

R...iralpi (No) ) ...3 EC; 0
V r‘,4,...10-A ( t•-•.? 2-S Q 1004 .:(.:,k.-iti-ol 1H4 N.-. 140 TOTAL URINE
y ,p \ fo ;,t el. ( P4...) -; J'-i) 1 ( ( 0
VOLAT r-/, % del . c,r) .5 SQ FLUIDS - SUMMARY AGENT tinix "?--% e•t. CRYSTALLOID-d AIR L/Min
110 0 f,1
N20 L/Min COLLOID-,4,
02 L/Min I (;) ---I-S --1.0 I.() --,0 SD
SINGLE DOSE DRUGS-MARK ON GRID _.1,,, BLOOD

-

WITH NUMBERS & ENTER IN REMARKS
LINE si L-Vi te(,,ErWarmed Q). REMARKS
. Warmed

Code drugs with numbers,
events with !enters
.
Warmed

.
Warmed 1515 II? r 0 ,110...)

_

EST BLOOD LOSS
1-i 00/V Ii,AA/.4. UR NE -
LOSSES Ms.t ­
korf,- ,

fg-, Ple vv-'iv/)
PHYS STATUS
TIMEJ3%Jik..0t)
1# 3 4 5 E J 1525 ..1.--} co— (JD
SYMBOLS:
BODY WEIGHT: 220 . i Mrti,..1 • \C r4:
0 D
Clill BP by Zt LB 10-1/M ILA
200
1 1/52-‘
HEMATOCRIT: —

AAP"-180
.---_._-.___

02 40-tcc4
Heart rate
160
INITIAL DATA: • .--

Resp rate 140 , . rb P MA)
BP-
q%TeAc..9
i'10v1 -10 120

BR

HR--skumnimmummemre rkr:r.cvi...3
(transduced) 100
%2—
J..
Ell n UMMII

EQUIP CHECK 80 ,---
T liaLw

"IMIEEM11,1111
OK? -J N TOURNIQUET 60 Mall

kW

PATIENT RECHECK T --.1`
40 nal /WM Walii

OK for
PROCEDURE? \i) ANES- X -X 11 11

20
.1 11

TIME-1 5 2.0 PR°C. 0-0 I I, ¦¦ it
. . . . .
VT - ml

JW 1u3DIpsoD500 iisk)J..°6

f. breaths/min % -i_. k 5 to lob 10
Peak inf pres / PEEP EMIJ.----
MODE - S(.on). • ssistl. Mon) \ MI MIK RJ

VERY AT J/BP/Auto Cuff g T CO2 (torr) 4-sallEMI ,i-2.
1 PA ICU Speclly)
BP/oth 5E102 (Frac or %) , C 0 „ go Km .110 ,ioJ. co)
ART line g Sp02 (%) 100JEa 1,b to,J041 OTHER

1 tie,
Steth• PC/ES g ECG SR SV-D'DSSL c CONDITION: itArI-jt
7 Gas analyzer TEMP-siteklA

RESP-1r. Sp02-CIVil N-M Block (T/4) BP-teto I A HR-RA
ANESTHESIA/PROCEDURE TIMES '
Start Room End Warming blkt 156 6a5 no Cony warmer
Ready Begin End
Ma k with letters & symbols,/EVENTS_ , ,, explain under REMARKS/Position ---'''" /-I/. N4-2_
IVO i U50 iblia
PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES;

Describe block technique under Remarks
I'VN (j) LsweR-Lit Cx.,--i-A-

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT: Intubation route, blade, technique, com/n„I/,.... i Medical facility 1.1_17 t-N4LIA oe,A4 -L v11, k-J, q.? Ovtis cI C-t-r)D(A,03-;-14opEi
5.N-cm-KA I L4-)Foi..(FigtA . 5eL,Nive,r° 2. 1-1),- ? Dt.A F./All yr/AI-16
SURGEONS:

, PROCEDURE ,,r, i
LOCATION: v"-'
6 N---L

101.111 (_b)(f011
DATE:
ANESTHE
1510e-46 -3

PAGE 1 OF 1
2 -ANESTHESIA PROVIDER USAPA V1.00
MEDCOM -25121

DOD-039510
pr..
le1*.
r' j-
Z

LINE site
. Warmed

cl)
9. i Mak&an:r . Warmed
-/¦
-I/ 0 Warmed
...
0 Warmed EST BLOOD LOSS
LOSSES
BRINE -

PHYS STATUSJ
TIME +-

1.212MI
SYMBOLS:
BODY WEIGHT:
220 43 co BP by cuff
200
V

HEMATOCRIT:
iso
A
Heart rate

.INITIAIL DA TA: •
160
Resp rate 140

BP-IIIMIM 120 BR

,pli:k
et (transduced) 100
J_

EQUIP CHECK
Tov- ID TOURNIQUET
N
PATIENT RECHECK T —4/ OK for
'IA PROCEDURE
ANES- X-X TIME- \ tlb
PROC- 0_0 VT - ml
..,
I-f -breaths/min
z
80
60 40
20

LU Peak inf ores / PEEP MODE • SO on). A(ssist). Clon)
Ej e 'P/Auto Cuff lir T CO2 (ton) f/u) IBP/oth r..102 (Frac or %) O 111ART line Vp02 (%53 111Steth-PCIES DIMILIM111 gj) ,Gas analyzer. C TEMP-sit NC\
C.)
0 I N -M Block (T/4)

a
Z/5 II
GC
11I 1
¦

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
-4Dk1C
ills
UM •
li•
neit , '171
I ­l. l .l.,
,
eibeal
aS
MEM.
cJ1 •
MIMI , MIIIIIINNI
, . , , .
i ,
. ,
' ' ,J.

11 V . .

F
¦

_ARNE '
, .
11111111¦442,:.
. .J, MN
' „
• .,,, AM
„ 11 11 11 IV If
MIMI rel% Stb
IA
filk riffltigiIVIM¦
k12111Mr•SIPAIII
kifi-. IIMSONKIMIIlin _

J
011111S1311VI ItCs)
1,,ttati7r ' •
W.IMI •

4N11
27 gam :„,, 4
-—
Liet

g Warming MktIJllrhi 2 Cony wanner
Mark with letters & symbOrs, EVENTS___, f•kykliN9exo,.. wide, RemARKs/Position —""v""'
PROCEDURES and CPT Codes:
4J
4 a •
110k i II . It
MIR
minamilb•""Ill
MIMI 11010
,
wan
..imi.

ilffirivil CR-A 2--ACISZgial JONTOILJ)_.
11 • AtkVja a , ,*
Mtr. -•
kiO4COn
.J, .',.....1J
It..,
I.I
,
0) 5Oliat r t A .4 P61 00• illv lib I r •
—trri¦D

11 ikilLt205:10^0
-ikr%t:,14 IN,Ct. Mi.
am

irtaM VOUSZtealci. liZW
.a...a3
:01:3 19Jr: 0112

.--tcl,.,• e,
Milk
, I

ECOVERY AT CU SpecIIY1
CONDITION: 0-3. RESP-Sp02- 9,4,
BP-JA • H11.
ANESTHESIA / PROC DURE TIMES
to Start Room End 42 111M721 lb
0 Ready Begin End ‘, 035 VW) & I Asa
irT,HETIC TECHNIQUES: Describe block technique under Remarks

TOTALS TOTAL EBL
TOTAL URINE

FLUIDS - SUMMARY CRYSTALLOID-E_ 4tCZ A.1 C6LOID
BLOOD­CD
REMARKS
Code drugs with numbers, vents with killers
V 8_

-ALA,

S% °
-A-\ •

r written entries: Name, GraMedical facilityv de/Rate,.AIRWAY MANAGEMENT: Intubadon route, blade, technique, comagif3 ..26uittit1 Call 'ecl -0­1 k "NUL 3 . IJalittAreCtlIC.­1 '3' 0 f-A -
SURGEONS: PROCEDURE
111111 (.6/ °-Li l' - -L. LOCATION: DATE:
CI •
rs A FORM 7389 cc 13 4 nno io,sisvoctiD3l k. _.3-1egt -0-1.0CLAAY)S c,sur MEDCOM - 25122 PY 3 - ANESTHESIA DEPARTMENT USAPA V1.00

PATIENT IDENTIFIC . TION: Type v
DOD-039511

FLUIDS !ANESTHETICAGENTS AND DRUGS
MEDICAL RECORD — ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG J 4 41` (-IA (11 e4

DRUG,J(Units) TOT .'LS TOTAL MI,
-f (fq ) ( 4C, ) _/____ /J• 0421•21,J(....x.e% ) 11.
( J) MEEK URINE
(J)
( (JJ) ) PA

VOLAT ,:r-cz % del 0 FLUIDS - SUMMAR AGENT % e.t.
YSTALLOID-
AIR L/Min
N20 L/Min COLLO -
02JL/Min i I / SINGLE DOSE DRUGS-MARK ON GRID ..i. BL
CONTINUOUS/REPEATEDD RUGS SPECIFY UNITS -MG/MCG/ML, "I" =CONSTANT INFUSION
LOSSES
WITH NUMBERS & ENTER IN REMARKS
sr

LINE siteJ. Warmed
REMARKS VGA (r? A/J. Warme Code drugs with numbers,
TT
events with !enters
0 Warmed

El Warmed e1.•-i I/ 642.v, r, ,
EST BLOOD LOSS PO
ur
-irli.----WAI
CO 4hW 3.--
PHYS STATUSJ

TIME +it . OP • ' zoo , ‘239 , /300 , /33

1 2345 JE ' •5/r-49 r--5-
,

SYMBOLS:
.

: ODY WEIGHT: 220 t)^4/C4 -145J.
KG BP by cuff „ ,.. ,,fri-/0 /, '616

200

LB
'
V .

ii:DATOCRIT: ,, ,, ,,
180 /(/'vie-5-e,
I/ II II
A

Heart rate

160Jh
INITI , L DATA: 41, __,___,_ _„___,__ ____,_____,___,_

Resp rate 140J:J: :J" 'J' 'J'

BP-J
AI /
. , . , .
'.49­
71/
120 „

7111111!
'

HR- iira ,. ,
BR (transduced) 1'r Irvi'sAMMICIVA'11.¦J.
EQUIP C MI -L,T Bo MIMI ,J, , ,

.

OK?•JY 13
60 grAfford mi ,

TOURNIQUET
PATIENT RECHM T —4/
40

OK for
: --r-r-­
, . IJF ,

PROCEDURE?
ANES- X-X
20

PROC• 0_0
TIME i IDI ID¦ —7-1
VT mlJ7

6 (e 6 giO tb
_9___

kC( (EP
f - breaths/min
_L„c___
___I___

Peak Int Pres / PEEP _a_ __1_ MODE - SIpon), AIssistl, C(on) C. L
RECOVERY AT
8P/Auto Cuff ET CO2 (torr)
JPACUJICUJSpecify)
BPloth F102 (Frac or %)
7 1 1___

ART line Sp02J(%)J/67/ /Do tv) .a— ;00 OTHER Steth- PC/ES ECG 5 (t. CONDITION:J
Ea

S e
Gas analyzer TEMP-siteJ
-M1111-RESP-J Sp02-
74:

N-M Block (T/4) BP-J HR.
ANESTHESIA I PROCEDURE TIMES
tn Start Room End
et

Warming blkt Z
4

Cony warmer
U Ready Begin End
Me k with letters & symbols, EVENTS__,_
0

explain under REMARKS.Position ---"-
O.

PJ PT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGE , • ntubation roe/, be. e, tec ni.. •/. - •• :.
Medical facility
. I
SURGEONS: PROCEDURE j

LOCATION: ( 111(.......,(,. E\ -q DATE:0

c-I GI -1
6 ..c_io ,..c..z3

PAGE 2./OF L
,... n ertrfna —I•lesen. r- •••••• .• ..........J

J
COPY 2 - ANESTHESIA PROVIDER USAPA V1.00
MEDCOM - 25123

DOD-039512
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG

TOTALSJTOTAL EBL
(-b If° 0
Yb TOTAL uRINE
/47 J
5319

)( I .Sr FLUIDS -SUMMARY
' CJ4-d— lic ir C /5y' 1.5 I. 1,_ 45-

CRYSTAI.g17-, /
6 wo

COLLOID-
Y — 'L-2

81.000
,9
id ---K

LINE siteJ. Warmed
REMARKS , .
to
° ley-,., a) #./111 Warmed 000 A Code drugs with numbers,
'`7+ —

0 Warmed 711s with letiscz,..7e .
u.
. Warmed

EST BLOOD LOSS
LOSSES
iii4-,4,7....-seo.
7/

UR NE-ci
PHYS STATUS

TIME 4110.°11" • 0,,y3D•DL.9....7 gJC"/"_?.-Jick..7? •.J(0.$'.•

‘r)A,,,=-4,,p

345JE
ID1 I

dJiikriStioft
SYMBOLS:
.J. . .J . .

BODY WEIGHT:
J220
•. -, (
akex/yye 47521°'17
BP by cuff ¦J¦ .

7L9.LB 200 Iper.,--,,root.PLe V • , ..__.
HEMATOCRIT: .J¦ ao,../,44/1.Z
180 'J'
A .

3 ‘. 7 160 •. \
Heart rate
INITIAL DATA: •

.J, . ,_____ ,J. \
Resp rate 140

BP-.
120 M.• IJ. EMI PI

// ‘/
HR-J0.-J---BR Ens AMIIIMI rrpipkr.Ak,nx,:d&v r yr Mir

(transduced) 100 Nii 5
i '

WE winti

EQUIP CHECK 80 NE
.1" 0
010-aN NMW. .

TOURNIQUET 60 '' MI
A . Ini VINI —Tr

PATIENT RECHECK T —A`
40 iD

_i.
, 1 1

OK V
OK for
IDI 1D1 1D1

PROCEDURE? ( ANES- X-X 20 1DI t
1D1

0/100 PROC-0_0 I ¦
TIME-J, . JD. 1 I
./1
VT-mi

0 CG 10 W 7 0 o bo 30 MIKISI
I= f - breaths/min

1 um 1r " EMIIEMWO

Peak int pres /PEEP IMI
I 11_ / ‘ )6 me
MODE - S(..n), Alssist), Clon)JInn L. C....
1 r RECOVERY ATJ4,5--
BP/Auto Cuff ET CO2 (ton.) 3 .
3 I 12 31 3 2 FallrElliar

-I• 6....9) ICUJSpecify)
2 BP/oth F102 (Frac or Ty)
. it $ __La2 __9__. 5_q C 5

LC ART line Sp02J(%) 00 go /00 /00 / a0 44 too ,., OTHER CA Steth- PC/ES ECG 5g 5 R 5 4 L• 6p CON ITION:)0 rfr /A .4,1
vi 1-2_
us 1 9""-
Gas analyzer TEMP-site -
WIT MUNI 0-3-1 FM11 , RESP-4, Cp02- The
C)
N•M Block (T/4) BP-1.HR-A,4,c:C li
to ANESTHESIA I PRoCECIURE
cc TIMES
0
1— W
u) Start Room nd p Warming blkt ., es.--D 0 go.s 2 Zo 2 Cony warmer Mark with letters & symbols, EVENTS_,
o Ready Begin End
0

explain under REMARKS .Position/' 0....1--......., gc-611511 6tf-' le/0
PROCEOURES and CPT odes:J
.5156" ANESTHETIC TECHNIQUES: Describ/block technique under Remarks

oix I2 is4 c/ g 1 /-/$i =Zs , t-K -7-c i./
3-112 ti/f/111 illuii I/i/,/.-SG/e FA. ft_i
CI') ,0/6..-TT C 2Y/

PATIENT IDENTIFICATION: Typed or written entries: Name, Glade/Rate! 6. 015 .
AIRWAY MANAGEMENT: Intutati n route, blade, te.-c2:e, commMedical facility
SURGEONS:

Ur.rif. PROCEDUREJi LOCATION:J(( 0 —Z._
DATE:
C(')(61'— ......, la 4 Izse,
IC /L/aL-,3
PAGE /JOFJe
rift CIIDR11 7' Or]Jcm7) inn^.-
COPY 2 - ANESTHESIA PROVIDER USAPA V1.00

(.ti.410,A) .J
EN1
S/F1IIT.STI
.....

,_,,

MEDCOM - 25124

DOD-039513
In iSTHETICAGENTS AND DRUGS
CONT INUOUS/R EPEATEDDRUGS SPECIFY UNITS -MG/MCG/ML, 'I "= CONSTANT IN FUS ION
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG

DRUG (Units) TOTALS TOTAL EBL
0.eiriegbojav-4 ,..) 2-.
ro'N'50 I'ertM 10 M IYM
0 115 •• -a --A-r, CA of ( 4 .:...-....,IRi — ) _3/.2J ----- TOTAL URINE N IS.
VOLAT S % del 2,0 Z.• 2.S _i_A31 FLUIDS - SUMMARY
AGENT % e.t. CRYSTALLOID- c-t
AIR L/Min 7519 i'LP\---­AZT
N20 L/Min COLLOID:43_,

02 L/Min SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
derri,

WITH NUMBERS & ENTER IN REMARKS
LINE site . Warmed
REMARKS
)„,m,„

fiSe5 L.v...1. . Warmed 460 I% SJ1 J J
Code drugs wilh numbers,
. Warmed events wit/11011m
. Warmed No L ', --, s-keziro s
LOSSES. EST BLOOD LOSS ...p.... er`01-
--,
UR NE -Y11..e.'SlerC ¦C .
PH S STATUS

TIME 1100)SD,D3vD,›.--..›-30D-D20 ..N.K a3 --sc el av"\ &et/4...
tree ....... JI i

1 CEJ331r ..D , .J
SYMBOLS:
. i

BODY WEI 1;44-se , 50c- ^err)
220 : 7— iJi I

1 IJ1 ---..-_L._ ¦ ¦ P7 oz.,
BP by cuff , i i ,

1 0 200 , , C,-i.r :.,0l)-A
--LB 1D¦ IDIV 1 . ix...NAJe In e-eoiet .
HEMATOCRIT: , ,
180
A

,-i-'
. i . 4; . i
I NITIAL , , Cf2"r4

" B 5\1
. .
,Y(%,-; t

1LV^, 120
Jvle',"r''%.)4,4 ,___,__ 0)41.44-‘,4
• H , 1 ,
, 1 I

EQUIPAi „
OKI-
PA air '—'—'k14-X(V0' & i--, ,
0 PR , -I
1 —r—r— rDi -1

I IDI IDI 1 TI , I , , , , I IDI IDI I I
. „ ,
¦ ¦D1
300 2..S 0 Z-tS6 7_,.0

f - breaths/min \L1 14. 1(' rE,
Peak inf pres / PEEP — -----
ft190E - Strm), Vest), !Mon) !''S-5 S ‘S

RECOVERY AT ?Gt.:
‘.Bf/Auto Cuff Nre CO2 (torr)Dq Ca O _s-a 911 4121 ICU Speelly1
BP/oth L-WO2 (Frac or %) tol .1),-1 a .1 co ART line P02 (%I IV, 830 : • \O0 IOU OTHER Steth- PC/ES t/E1C' G SO.,. J'S. SYL Se CONDMON: --r. 9-7
Gas analyzer TEMP-site
RESP. I jp Sp02-Tn. N-M Block (TM)
BP-1 l/ / OMR- id
ANESTHESIA !PROUD RE TIMES
Start Room End
w
Warming blkt

Z

4 )Eoo ITAS" rit7--Cony warmer U Ready Begin End
Ma k with letters 8 symbols, vEVENTS_,_ ,...,
1U.N3A
IMONITORS/ACCESS ORIES
o

explain under REMARKS vPositionv'" '-"*"-----) '--
EF. ‘El° 1 tk3g -5 ;7
PROCEDURES and CPT Codes:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
7.-. 'S'D 12cD--k-; ‘7'f'ck 6 Z k-x-) & L YN., lt,

PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,

AIRWAY MANAGEMENT: Intubation route, blade, technipucomments Medical facility E -asej.5/c
-kcAfie4k , ‘--r•NA A__4-D...., --z-D\ "0., ¦-,&I'ft ,.. ---\d,
39D...,
—5.-,--0,,t_i ,,,? , .D
SURGEONS: C.° 1-..... sf.e%J.S.-"r"1/4 \-'-'.rje-tD4--­
PROCEDURELOCATION:
4D N .-V A (Jo 1 URE
J DATE: 1 I z., ) 93
31--N--. C:. k..- 6) (01
PAGE 1 OF 1
.MAJEflt,1111J7 ,3orsJr-r-r, .11,fleS SDVIDERD USAPA V1.00
MEDCOM - 25125
DOD-039514

MEDICAL RECORD - ANESTHESIA
,J..ois form, see AR 40-66; the proponent agent Jb.. .. rSG
BLOOD-
J...................................................

Code drugs with numbers,
events with haters

.
Warmed

.
Warmed
EST BLOOD LOSS
URINE

TIME

12345
11131
1
J220
KG

BP by cuff 200

UNMENEIMMEEM
180 • • •
A • •
J
.. ••
Heart rate
160
0

LB V •im •
Rasp• rate 140

BP-
41111111EMEMIMINNISMOINSEINSIBEMIIIMMISSEMBIEMBIBI

136 /G; 120
WOEJMIIIIIIIWZNIPPMEMITAJ=NI

HR-BR IMEMPINEWIFIFIMMIWAVARATIE IMMI
(transduced) 100

OK?. MatiMEdkendiadidE MEE EMS
OURNIQUET 60
rAIIIIMEIMUFWVAIPMNil/Nall

f
T -.T FM.k"JMalitIMOMINIIMILISEMINVESSESIMIENEIMEIMERIEN

OK for PROCEDURE? ANES- x-x 20
1111
1"
PROC- 0_0

TIME- te:VS1.7 VT-ml f - breathe/min Peak inf pree / PEEP ODE -JA(ssist), C(on) '15 BP/Auto CuffJET CO2 (toff)
1 PACU CU 1Spedf^
IDBP/oth F102 (Frac or %I
J

ART line p02 1%)
I 1C21 Q MM.
I Steth- PC/ES CO GrAOTAI. CONDITION:
Gas analyzer TEMP-site

RESP-J5p02-17 N-M Block IT/41
BP-47/12-iiR-

Q
to Start Room End

z
Warmin blIct
0
4z 15741S-Zaeat

Cony wanner
Ready Begin End

Merit with letters & symbols, EVENTS_,, O0 explain under REMARKS.Position -I"-cc
ealo 210
o.

PROCeURan.d .SPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
a,)t-614. So5W,
drk /4r7frq 41";&c.-4-4--4-e-
PATIENT IDENTIFICATION: Typed or written entries: ems, Grade/Rate,
AIRWAY MANAGEMENT: Intubatla route, blade. jeclinlqh, comments Medical facility

p
1126

SURGEONS:J PROCEDURE
ePto
LOCATION: c.--)
csr-J

DATE: ANESTHETIST
APV 0 IDPAGE 1 OF /
MEDCQM - 251D

DOD-039515

754*-01-)116-72114 514-3o?
RADIOLOGIC CONSULTATION REQUEST/REPORT
Ordiology/Nuckar Medicine/Mrssound/Computed Teemeirgdsy Extecaraeiseed

EXAMINATIONS) REQUESTED SSN MP°Read IVAT:11 ......" REGISTER NO.
FILM NO. PREGNANT
YES El NO
REQ TELEPHONE/PAGE NO.
( SIGNATURE NNW .(J() -2_ 0E • (5-ra

SPECIFIC REASON(S) FOR REQUEST (Comp)aants and Midi:sir)
DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Mena, day, yogis) DATE OF TRA?GCRIPTION (Month, day, year) RADIOLOGIC REPORT
PATIENT'S IDENTIFICATION (Por.d or asuil-Prn ambits ghat: Nance — last, first, middle, Ifealiose.ry) LOCATION OF MEDICAL. RECORDS
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE

RADIOLOGIC CONSULTATION STANDARD FORM 515-B (8-43)
REQUEST/REPORT Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.806-8
t — MEDICAL. RECORD
MEDCOM - 25127

DOD-039516

kW. 7540-01-165-7204
RADIOLOG IC CONSUL I A I ION HEUUEST/REPC•rg e
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Exa/it s)

EXAMINATION(S) REQUESTED AGE SEX SSN REGISTER NO.
FILM NO. PREGNANT
YES El NO
t'=-)N

TELEPHONE/PAGE NO.
DATE REQUESTED. SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year) RADIOLOGIC REPORT
PATIENT'S IDENTIFICATION (For typed or written entries glue. LOCATION OF MEDICAL RECORDS •
Name — last, first, middle, Medical Facility)
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
M EDCOM -25128

DOD-039517
MEDICAL RECORD DATE AND TIME RX START STOP (q ivil 0 _.----------- DOCTOR'S O ... -riS (Sign all orders) DRUG ORDERS DOCTOR'S SIGNATURE /eat"-74 id kA41/ (-,tU 6,' .71.) r -tlx/A.D71r„ '6( NURSE'S SIGNATURE
ft/rey----/i/.e,c(3 FiSey / — V -kp ) 1 / 1 -2
v v
r -eLe__ i.-?,/k)_ 4....,;... ,m,t_J414,,...41,J.,J\eh- cx. , / 4:—... II qJ -

D

STANDARD FORM 508 (Rev. 3-94) BACK
MEDCOM - 25129

DOD-039518
AUThunIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD I DATE
1(50
CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
()),--/Itc/C JA-e -r-c)
r(Ci-CL-71evP-63(2,cnI/is . a pr-erVi 240 / 01--t-CrI1
car o/ (10-c."( 1c / .c-';-f 61A- r

01vefett41-74 )17691/_(/(Thiel / ol-ti Lc/ "6.) • Ile/ 11-Y/ ((Lb skile.ef rd-ct

oeD/ Aic-L 1 74') :T/0/jer icsx 6 a it 17ig-/-/,-aci 6 sitv c_ Al)
keind
ec'e/
s'r_s 6 C(or-c,--{
tvolzted-, cakactit-,1-ti2A72,
/

etttc/ etc/ pi freltif/tut teticert4--
14-44.. 7 4(1v- Vec vfe/4,11A-j v142.1,4-7/10-?Vt-
C.41 ve'41-1 c-cd L e/19-1-L
tic(/49/7L'OY//let; I/etete-c

HOSPITAL OR MEDICAL FACILITY
STATUS DEPART./SERVICE RECORDS MAIN AWED AT
SPONSOR'S NAME
SSN/ID NO. RELATIONSHIP TO SPONSOR

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - lest, first, middle; II) No or SSN; Sex; 1JREGISTER NO. WARD NO.Date of Birth; flsok/Grodoi
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 ;REV. 6-97)
Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 25130

DOD-039519

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 IDENTIFICATIONJ DATE OF ORDER TIME OF ORDER LIST TIM E
ORDER
/ L JHOURS NOTED AND SIGN

c4-7 ^/6 7t
NU SING UNIT ROOM NO.
IENT IDENTIFICATION DATE OF ORDER J HOURS
C6C., 640;441/o/"-t . c)

NURSING UNIT ROOM NO.JBED NO.
/PATIENT IDENTIFICATION DATE OF ORDERJ TIME OF OR J HOURS
NURSING

o Min

DATE OF ORDER

.7:3ATIENT IDENTIFICATION 1—.0)
BED NO.
ROOM NO.

NURSING UNIT
DOD-039520
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER •
DATE of / NDNI 43 1 7o e) ,LD 6X 1.le NOTES n'it6L2 0dzi_e, ,if,/f4" --.
ruoza,,i ,/i?„2„, _-4­----T3/g r?-/L g(---X-er—/1111111111/. (,- 4_,-PY1 -24---‘5 c-/2ZN 1%—i---f v7­95 rc-7_,,,,j,z,e -fr-l_aflo(----fil Az , f,--4_55 (r----ACLe A/,,Ce_s CTL c/l. et-c-Q/C-) I=Vc) --
1111111,rn lIllIllrvAIIIIIII- _ .__, _ _ _ _ _ , , _ ,. JIN I VA I I I I I I I I I I I I I I

STANDAj3D FORM 509 (REV. 5/1999) BAC}
USAPA V1.0
MEDCOM - 25132

DOD-039521
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 LJT TIME ,
DATE OF/ORDE TIME OF ORDER
E

i( (47/4 3Ji /%B 3 6JHOURS b p.--...e,l/t/ DER 11 NOJD AN IGN
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER ('VL/ :Z TIME OF ORDER J HOURS ti N
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDER TIME OF ORDER J HOURS
NURSING UNIT ROOM NO. DA1FAOPRRM9 4256 BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM -25133 DOD-039522

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.
LIST TIME
ORDER
NOTED AND

///2(/i 3 /2-3civHOURS
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
SIGN

kl ..ada4"--1-.---,4._Je ..,,,,/0.2,..Lei ee'er .2.i 1—) ( (9
cl7_ 41...0
hIL/6)-(24..-h, 6
S
e.-- arAYwte 4--g--1 1 lij¦
'-' ree-ii¦ea fft-tird-:

NURSING UNIT '00 ¦ iiiA . '' P 1- //
5 d-vg4---w---
,f--.,_ .3,11z-v-e Nz.,c-211--
-1
PATIENT IDENTIFI' DATE OF OR DER TIME OF ORDER
- •/RS
4411(11111$11


to •
........... ........:.............e. •

...

/ 1 /El F b (1_ . lift tcyD.-..D. 11
-4111 -1"°-41lArg iJ4-A-te4

NURSING UNIT ROO VWJIP 1 Ift-&-d1"1--JI

PATIENT IDENTIFIC • IST DATE OF ORDER TIME •J• RDER
HOURS
LDz- ,)--5 [01(5-v

--9J., IN/A1--6,/lc IV .-----N . -/-_lop/0 co/
,.1..........
._..3J)

t-+t
Oa 37Dw is6--9 L

NURSING UNI ROOM NO. BED NO.
KtU kJ
2 30......--03.S

PATIENT IDENTIFICATIO ORDER TIME OF ORDER
HOURS

NURSING UNIT ROOM NO.
BED NO.

DA REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED
1FAOpRAM79 4256
MEDCOM -25134

DOD-039523
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD ID PROGRESS NOTES
DATE

„,,

tibLitel-446---r-C A9 i4A '-¦1129 - 7 - ) 2 7( /5 01-r---12--t-t-67
sA--"-----49
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-

ridoi,tt-. ; 641 N-•—'¦-c-i1:—,-/J—5---e21,--1/3
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or Other)
LAST FIRST MI DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; .REGISTER NO.
I

WARD NO.
ID No or SSN• Sex; Date of Birth; Rank/Grade)

PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203lb/001
USAPA V1.00
MEDCOM -25135

DOD-039524

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 ORDERJ TIME OF ORDER LIST TIME ORDER .....z., ¦Jt.C.,.._J...0. ''',J )
NOTE 0 AND &.5 ‘JHOURS
SIGN
4......_
+2,J&'c--J
9I cJcii----P
r( wDk ...,,,_,edc-

(.. 0-
'11% — ,
SO
-'.
---...............„...

NURSING UNIT - "NO.
(q(C) 'L -¦AA4Dlir 404., il¦
[11: sa Da 410
41 V 6A14E4F6RIOU
/ 1 NloJA NOUS

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDERJTIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDERJTIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.
DA REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.IFArm 6
MEDCOM - 25136

DOD-039525
FIRST NAME MIDDLE INITIALDID NUMBER

:A ME
DATE NOTES
, %,J
-
/D
-1P4---(-5L-) 14/ketiDA.4...xD7, fr4 vc_ Dbie_f_A)c
,
6 -
,D•

(G1'01
STANDARD F ORM 509 IREV.511999) BAC ii
USAPA V I . T.:
MEDCOM - 25137

DOD-039526
AUTHORIZED FOR LOCAL REPRODUCTION
J

MEDICAL RECORD PROGRESS NOTES
DATE NOTES
1
Dti jOU'

c 4-A---0 0 1))L -D) uf&v,A+)(9,71 ( t-4A-voi,6--AA--
.0V---/-

D 0 ti, 5 Li& aD[NAks,,,,A.,.1-6,--,-, v(J2-0-frivii-dc.„-e-,...,/pvt-e-tt ,,..._.
4-4,,,fiD1,,..)-zniv,tb. L,,..,//, D
_. 6

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
LAST FIRST Mt ISSN or Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries give: Name - last, first, middle; REGISTER NO. WARD NO.
ID No or SSN; Sex; Date of Birth; Rank
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/19991
Prescribed by GSA/ICMR FPMR 141CFR)101-11.203(b)(10)
USAPA V1.00

MEDCOM - 25138

DOD-039527

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 IDENTIFICATIOJ ''' ¦J!JDATE OF ORDERJ TIME OF ORDERJ LIST TIM
ORDER
D,
NOTED

41 D12. 4P ..-DI ti.5---6DHOURSD
SIGNAND
itD,DrD—
un..J.e.A .
, 'D-+--4. LS
¦ '16' tD
alD, D,
ril0 111111111IND

-DOW ,D0D11 3 0D"7-
4
-airD "AI 1 .1 !air:D•

NURSING UNITDR.D-: o 0.
r D11111

1t1D;, D,
PATIENT IDNTIFI ATION Nat) Of4C6Dc
iii
¦:
i L.-3 ID

ND 2---/..S'- - c-)'--D"NNN
•D6.). m- ,
,......._.--P t z...y

1D 1--16-(1)D

ovill 6D tillD11/0 NURSING UNIDROOM NO.DAkirl
illo".t'D'44111

PATIENT IDENICAD0DID -IME OF ORDERD/19D
/,`";,----D,. 5C TAW
w•P"
HOURS

NURSING UNITDROOM NO.DBED NO.D \
PATIENT IDENTIFICATIOND DATE OF ORDERDIME OF ORDER DHOURS
NURSING UNITDROOM NO.DBED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

DA 1FORM; 9 4256
MEDCOM - 25139

DOD-039528
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE Ja 0 oz NOTES (D 4....,
...). AA it, /. Ems? ,..-zik."---c ,5Z.e.,,,.....a.—....J.---

if.:17)/Mc.
f --Y,9-.)-----tiz.------i-cc-v-kD CcD(6 . --1
(DJO '-
-D,,Ttly 62 L-144.-.-(2-,-.-t-,-if

RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER
(SSN or Other)
LAST FIRST MI

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries give: Name - last, first, middle; /I REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/19991 Prescribed by GSA/ICMR FPMR 141CFR) 101-11.203Ib1(101
USAPA V1.00
MEDCOM -25140

DOD-039529

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is O1SG

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 HOURS
SIGN
72 (0/03

NU RSI
PA TENT 10ENT F {CATION
TIME OF ORDER
• 1 ---41JE4

1.s
NURSING UNIT
IF ICAT
TIME OF ORDER
1b kY- HOURS

NURSING UNIT ROOM NO. BED 0.
PA ENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS

NURSING UNIT IHOOM NO. BED NO
F 0 Ir REP %ACES EDITION AV • BE USED
DA 1 APR; ‘ 79 4256 4'f 16 00005 owea ,
MEDCOM - 25141

DOD-039530
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 IDENTIFICATIONIDENTIFICATION DATE ORDER TIME OF ORDER -N\ LIST TIME ORD ER
-L t& -?-) i--) HOURS NOTED SIGN AND
• (C ) F-17 ‘----1
011111.-11
Myq
(q01-­-z

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
II

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 IFA0pRI:479 4256
MEDCOM - 25142

DOD-039531
IEDICAL RECORD - DOCTOR'S ORDER-
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. Rasing will list the time the new orderls) 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 & INITIAL TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
1 VS q 5 min X 15 min, then q 15 min until discharge.
2 Supplemental oxygen.
3 orphine_Meperidine 7 mg IV now and /-L mg q 3-5 min pm pain for a
max dose of_/5—mg.
4 Zofran_mg IV prn N/V q 15 min, may repeat x_.
5 Metoclopramide mg IV prn N/V x 1.
6 7 8 Droperidol 04 46­IV prn N/V x 1. Phenergan /2.5-iiit5i­V pm N/V x 1. Benadryl 25-50mg IVP ql hr pm, itching while in PACU. fillibMglro_ifsmriarV' _v._
9 IVF:_Lin_.(al_X2A5' cc/hr.
10 Dischar e_ve_status when PACU discharge criteria met.
C

PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any
changes on subsequent pages.
Diagnosis:
IIII1Pf .v Height:_ Weight: Diet:
Lit I
Allergies:
Nursing Unit Room No. Bed No. Page No.
PACU, 28th CSH 1 of 1
MEDCOM FORM 688-R (TEST) (MCI-10) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE_ MC V1.00

MEDCOM - 25143

DOD-039532
dei tiw Z,Wc®

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)

CLINICAL RECORD For use of this form, see AR 40-407;
Yr. 2003

the proponent agency Is the Office of The Surgeon General. Mo..
VERIFY BY I ALING INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED

ORDE CLERK/ RECURRING ACTION, DA NURSE FREQUENCY, TIME
i530 E; Dr,

ALLERGIES: n YES Q NO I PRIMARY DI GNOSIS:
ADDITIONAL PAGES IN USE: r---1 YES riNO
PAGE NO-
PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
1111111 MGYI
N 24 01 02 03 04 05 06 07
EDITION OF 1 DEC 77 MAY BE USED.

DA FORM 4677, 1 OCT 78 USAPA V1.00
MEDCOM - 25144

DOD-039533

Verity by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo.(. yr 2003
Order Date Clerk se SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
30 agAAA,u-lavb-(limpg-

xl c chr/E07 p p7o0 201Q0vo Nis-
24 (/e,.,It) 5czy-fem7 eivil
-
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Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
CI W PRN
Expi r
Nurse ACTION, FREQUENCY
Date TIME/DATE COMPLETED
g2.2.. _111111V4tiva/ Avseyry b 0 46
tv„)
r

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Mwn NM* ..ew ¦ ¦• Nom ¦• ...a
..¦ ••¦ •¦ ¦ ¦ a¦ ¦ ¦
.¦¦••=, ,
USAPA V1.00
MEDCOM - 25145

DOD-039534

THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MEDICATION )

CLINICAL RECORD For use of this form, see AR 40-407;
Mo. 12-Yr. 2003 VER/F7BYWITM.UNG ' A .INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
the proponent agency Is the Office of The Surgeon General.
,:i'''1tAILs4,,-‘ la :#.,,, ,..43qe:ingattAW
HR DATE COMPLETED

ORDER CLERK/ RECURRING AC 110N,
DATE NURSE FREQUENCY TIME

24-I
ibil ,ill¦ ;Vern. -"" Mi M
• 111111111

,.... pto
V S'. k-,. r ieeeeeeee
PH/Mr Oka,.12 e.(,/,--Y l
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6

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Ill
•411

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. =nr old
a . )6.4-(15

P.. ct./)---anstardennuata . • -
,,(:)„.... ,
MINK" III

ALLERGIES: /1111 YES MN NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: YES.ME NO elle) 'F1 (b . 1(-C., V\ 1\11Pik L j.\--( PAGE NO: . PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
111.1 LL) (CI Ll
E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 Y BE USED.. USAPA V1.00
MEDCOM - 25146

DOD-039535
THERAPEUTIC DOCUME.NTIThIi OFN CARE PLAN (NON -MEDICATION )-.- 1-4--
CLINICAL RE-CORD .
the proponent agency Is the OftIeesgtthRejig)Lin General. Ma il.Yr. 2003
4S0

VERIFY EY INITIALING _
,k,5;_'47.-VY,IRAT_3, :0:Mai0V,_INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER_CLERK/_RECURRING ACTION,_HR_ DATE COMPLETED
DATE_NURS._FREQUENCY, TIME_
all_MIOFZrlanrARMO WM 1
... VS.- rLot,ufo,e,_ eo PA_ .--7
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En mar_.vglii-c ®L/_
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ma _ rii_MI
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ALLERGIES:_MI YES_MI NO_PRIMARY DIAGNOSIS:.

ADDITIONAL PAGES IN USE:
Ns YES_MI NO
\(-Dk,_ 71131•913 F)( g c,---Qc.FOL_ PAGE NO' _
PATIENT IDENTIFICATION:
ACTION TIMES

USE PENCIL. CIRCLE ACTION TIMES
illik Lt)(..0 -(7_
D_8_9 10 11 12 13 14 15
E_16_17 18_19_20_21 22_23
N_24 01 02 03_04 05 06 07

_......... _.... ___ MAY __ ____

DEC / MAT BE USED.
USAPA V1.00
MEDCOM - 25147

DOD-039536

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing ( NON-MEDICATION) mo.fl 2-y, 2003
Order Date Clerk Nurse SINGLE ACTIONS Date to be Done be Time to Done Time Done Initials
1111111PcrTh ___P_c___-co.•.\r\ .tr(-1 SC—
r bet_ le-e‘u vue-.i i...,.,., '.s./A.i ,.... tit, .c, ..-I-.di ei-_ _ _ _ "N„,,,,..................„ --
(2\ — Z ,..........

Order/
Clerk! PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Explr
Nurse ACTION, FREQUENCY
Date TIMEIDATE COMPLETED
— — — — — —
— — — — — — — — — _ _ — ¦...
¦ WM ow. ¦ NM MO •••¦ .¦1
al“. .¦1, OM, =MP ¦¦¦ •=1 Ms
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.... •••• ¦ ¦ ¦• ¦•• ¦•• ....
USAPA
MEDCOM - 25148

DOD-039537

wil..... ¦.
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDT'.''INS)CLINICAL RECORD Mo.. 1 2--Yr. (rb '
For use of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon Gene.

VERIFY BY INITIALING I . INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

,e27 g3 ..w
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t I ..NIIVAIr
AM

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_ T
ALLERGIES 0 YES Q NO PRIMARY DIAGNOSIS: ADDITIONAL. PAGES IN USE: 0 YES 0 NO
TA - r-n PAGE NO
PATIENT IDENTIFICATION,
DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES J
NMC90-C
I D 7 8 9 10 11 12 13 14
n A F.M. AR 7R E 15 16 17 N 23 24 01 EDITION OF 1 DECNIfCiritImEref2ab UNTIL EXHAUSTED. 18 02 19 03 20 04 21 05 22 06 •
DOD-039538

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo. 03
Order Clerk/ Date to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Dote clerk/ PRN
r Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED

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by -
..4._ e-s-

U.S. GPO: 1998454-110/95216
MEDCOM - 25150

DOD-039539
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

CLINICAL RECORD For use of this form, see AR 40-407;
Mo. 12. Yr. 03
the proponent agency Is the Office of The Surgeon General.
1

VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
7
.

ORDER CLERK/.RECURRING MEDICATIONS, HR. DATE DISPENSED
DATE.NURSE DOSE, FREQUENCY 29°6' OM 1-41/00 UM/ 500,1 Po QD 5" 6 '? /D II ) 7, 1 3 /V- /5-
c7)3101. INRAIOCV Y_PaCAD Ot .,.De
tober OM ,z_rcf-tir) qi) Cisr-tblai/a) u rneirhr) 5a)r15PO D7o icf Do
ILI
-49

ALLERGIES. yEs El NO (PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USEt
PATIENT IDENTIFICATIONt pli OYES ONO PAGE NO. .
DISPEING TIMES

USE PENCIL. CIRCLE MED TIMES
411111111 ('')In ti

D 7 8 9 10 11 12 13 14
E 15 16 17

18 19 20 21 22 N 23 24 01 02
03 04 05 06
n A .Fgakl. AR7R EDITION OF 1 DECMFITIR.V BirkiiiD UNTIL EXHAUST
DOD-039540
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
1
Yr 7).

Initialing (MEDICATIONS) Mo.
Order Clerk/ Date to Time to
SINGLE ORDER, PRE•OPERATIVES Time Given Initials
Date Nurse • be Given be Given
6-2,
_52_ ,111. c.._ t__evc)c-sk._) i'--. is-

tC-¦ c_ \\j .A6-4 Clk C___ V -91
Order/ Clerk/ PRN
Exult.
Num, MEDICATION, DOSE, FREQUENCY
Date
2"3111/11e0/4 2-1/9.I/Q1'
feav ivi av

ro ivcv ytovo L 6. 3-6,7
Q 1 0 PRA'

low*, poecoce7.#-iv a tee ?RA/
Mlle PAIN
74, rev Arno/o ,/ /Op, Po diel 5 PAW
eiVov ft/twat' tf fIN •.5"7 1V cu, 0
1101cA

-- — -1111111 AA, 4,0
.ft:tawl-f24, 77-744(-tVir ifiPM
.----------
.--

INITIAL, PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
,r
04
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,

PAT

'U.S. GPO: 1995-454-110/95216
MEDCOM - 25152

DOD-039541
THERAPEUTIC DOCUMENTATION N (MEDICATIONS)TI

CLINICAL RECORD
the proponent agency Is the Office of The Surgeon General.

VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSEDORDER CLERK/ RECURRING MEDICATIONS,

---,
DATE NURSE DOSE, FREQUENCY
fie 21) -.41 Za 2 L A 1 2...• al) 2 Thl a,- F21- ql/Y) i V rb tg /-
aq' lit Ali 22-7111)
.

r20 Op LefogyAmn -001(r-OP A
1\fili) 0-,'A 1 S C. ''7 8

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ab--cosillial v....AD, u4 ",,N..37.) Pb do
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, .

ALLERGIE.S-ED y Es.El NO PRIMARY DIAGNOSISh ADDITIONAL PAGES IN USE*Eiy ES.
N)rp,6, 12-rtint?,17}( a-r-ix 0 NO
PAGE NO .
PATIENT IDENTIFICATION:

DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES

111111 (9 ( C) - 7
D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
.
EDITION OF 1 DEC WiEffIKON3E2ISSEM UNTIL EXHAUSTED.

DA I F
OEV9 4678
DOD-039542
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS)

IMo• 1( l'i(1-8
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Dote Nurse be Given be Given
b civ tviol. _iie., Iv 63

ii:ns .
tA"3 (
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN
Datepir
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
iv cpo iy
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11/44.0.
r O. tit5 14.i.c.s.
WI
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IP

U.S. GPO: 1998-454.110/95216
MEDCOM - 25154

DOD-039543

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

CLINICAL RECORD --For use of this forro, see AR 40.407; Mo. \( Yr. (i: )3
the proponent agency Is the Office of The Surgeon General.

VERIFY BY INITIALING : INITIAL PROPER COLUMN FOLLOWING EACH ADMINiSTRATION
HR DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
a 'tifi 21) -la. /2-L 5

24 2-' M)
_

W 11114 Thice,f. 4-q/07) ion i,
.
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di

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— 111 11110 r-irdaw.,•weAra
ALL ERGIEU E3 y Es.iti NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
DYES O NO
N)rp,6,.
tg-nt3.19&Fx c-0-(-RX
PAGE NO

PATIENT IDENTIFICATION'
DISPENSING TIMES
11.111 CC-*)---I USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12'13.13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
D 1 F EB 79 _ EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 25155

DOD-039544

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo.

)( 13
Order Clerk/ Dote to TIme to
SINGLE ORDER, PRE-OPERATIVES Time Given InItiol•
Date Nurse be Given be Given
v:Rsi) b -. 1.c.. XV %c63 tow
e...sv A-6,

Order/
Expi r
Dot,
(;/-0
. -
No 0
Clerk/ PRN Nurse MEDICATION, DOSE, FREQUENCY
' Xt0, (9-4.1,,1 w q20
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fievocc?t-if-r. firpcin
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INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
ets , /OW
226 1 417_,..c WI ro= ' ! 4(sfo
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111

U.S. GPO: 1998-454-110,95216
MEDCOM - 25156

DOD-039545
.(1--enj12)7±
.THERAPEaltli CU TATION CARE PLAN (MEDICATIONS)

CLINICAL RECORD For use of this form, see AR 40-407; Aro.1Z__yr.CES,
_
the proponent agency is the Office of The Surgeon General.

VERIFY BY INMAZJNO INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
DATE DISPENSED

OR R CLERK/ RECURRING MEDICATIONS,
D TE.NURSE DOSE, FREQUENCY

iiramitrarawmaramcgamo.
il
rllv. P\-i-i2.f 2-1
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PRIMARY DIAGNOSIS: YES JNO ALLERGIES EJYESEJN0 ADDITIONAL PAGES IN USE,
6-4. 4..d4z4_, .
PAGE NO.
PATIENT IDENTIFICATION:

paur' ,t+re-h:
DISPENSING TIMES

fPW
USE PENCIL. CIRCLE MED TIMES
\Cu) -4c. D 7 9 10 11 13 14
8 12

E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
r% A F_ORNI_ Aft-in
EDITION OF 1 DEC FVFIAIIWTFn

DOD-039546

Doc_nid: 
4032
Doc_type_num: 
72