Medical Report: Medical Records of Various Iraqi Enemy Prisoners of War and Detainees, Baghdad, Iraq, July 2003

i t :
„ITN', SIZE • PUPILS
MOTOR FUNCTION -
CHART CODES
1 nun =
Equal 0 = No Movement
'2 nem R Present
Reactive
1 = Slight Flicker/ Trace of Contraction _
3 nun NR . NonReactive
2 Active (Gravity Eliminated)
Not Applicable ./Absent (blank)
3 = Active: against gravitj; Fut not against resistance
4 nun L R Left Larger
4 = Active: Against Gravity and Resistance, not Pall strength
Refer to Nsg. Notes X
5 Full Strength against Examiners Resistance
5 nun . R L Right Larger
No Change from
Previous Assessment . TIME
Sye
00
54
en

0
4
41 11
or

0111 1 111'111i 22 22
'•
•
PO 12 34 Si 711
fa 12
3 4
it BEST EYE-OPENIP(Q. RESPONSE
.ETT I
I1111
(4) Opens Spontaneously (2) To Pain•(3) To Yoke ---.- (1) -Does Not OpenB. BEST VERBAL RESP.ONSE . (5) Oriented (2) Garbled(4) Confused • - - ' (1) No Response(3) Inappropriate Verbal Response C BEST MOTOR RESPONSE . (6) Obeys Commands (3) Flexion to Pain(5) Localizes to Pain (2) Extension to Pain(4) Withdraw to Pain (1) No ResponseGLASCOW COMA SCALE (A+B+C) ¦• ¦ I
PUPIL RESPONSE R
Size (mm), React to Light (+) No Response (-) L i
MOVEMENT Mohr(See Mor FunctionScale at Top of PagePage) GRIP (S) Strong • ..(W) Weak (-) absent .. RESPIRATIONS . RUE LUE -.RLE • - • LLE •R L REGULAR . IRREGULAR - . I11 05 S 1 0u V, si • i . n I III
UNLABORED LABORED • . n
- - • SHALLOW ' " • RETRACTIONS f
BREATH SOUNDS (5) MAW (4) Crackles (3) Rhonchi (2) Wheeze (1) Diminished BOTH BASES ' RUL LUL . RLI. LLL . 1
COUGH NONE
'SPONTANEOUS
• NONPRODUCTIVE PRODUCTIVE SPUTUM COLOR (5) Tin (4) Grams (3) Pink 3 (2) Yellow (1) Clear VENTILATOR -Vt . 1 SPUTUM CONSISTENCY (3) Thick (2) Frothy (1) Thin PRESS. SUPPORT Ft02 riaImmogatimicellIKIPEEP/CPAP • • • U OXYGEN DELIVERY NC (Yndn)DEVICE FM (Yalu) 1 ia WA II • .' I1111111 III LEFP.. II •
ETT ii '3 .°h NRBM(1/m s) 11 1 .

• CM pan Err CARE / POSITION CHANGE
GE
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IMMO MUM '
INCENTIVE SPIROMETRY DONE COUGH/DEEP BREATH
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VITAL SIGNS
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1600 1700 Mill NMI -Li OMEN • .
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MEDCOM - 2018

NSN 7540-00-634-4123
MEDICAL RECORD • NURSIiv))1 ES
HOUR
DATE OBSERVATIONS
Include medication and treatment when indicated

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REGISTER NO. (Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or written entries give: Name-lest. first. middle; grade; rank; rate;hospital or medical facility) WARD NO.
PROGRESS NOTES Medical ReOard
MEDCOM - 2021 STANDARD FORM 509 (REV. 7-91) Prescribed by GSAIICNIR, FIRIVIR (41 CFR) 201-9.202-1

DOD 006073

CRITICAL CARE FLOW SHEET
(b)(6) -2
LOS DATA
24 HOUR DATA DOA 24 Hour Balance
11%1'03 — I csq DOS 24 Hour-Intake
ll Wil t3507
31 2-6 POD 14 24 Hour Output
'/3 IRO Weight on Admission Weight Yesterday Weight Today
NURSE'S SIGNATURE Initials Safety Checks I I) E I N
(b)(6)-2 BVM at bedside Monitor Alarms On ID Bracelet On Allergy Bracelet On Call Light Within Reach b)(6)-2 v. y
Side Rails Up
Bed in Low Position

PREPAKhD )(Sigriatore and title)). Department/Service& lune VAlk.
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PATIENT'S IDENTIIkItATION For typed or written entries give: Name-last. first.
0
Middle; grade:date; hospital or medical facility)
HISTORY' PHYSICAL WCHART
(b)(6)-4
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°TILER EXAMINATION . OTHER(Spicibl Or EVALUATION

.
DIAGNOSTIC STI•DIES

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L 1- 2
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%
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(zeroed & calibrated)

/
/
HYGIENE BED BATH
FOLEY CARE

4 ORAL CARE
MOBILITY ' BEDREST
BSC
DANGLE
CHAIR
POSITIONED RIGHT

LEFT
SUPINE .
1 .
HOB 30 DEGREES
FALLS PROTOCOL INITIATED

PROTECTIVE DEVICES fame le FHNIDA OF132-26)
PAIN I PAIN FREE
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PAIN SCALE (1-10) • 1
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2
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NG / DOBHOFF PLACEMENT VERIFIED RESIDUAL ASSESSED Ph
• FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s. SKIN INTEGRITY No Breakdown
V ve• /Surgical Wounds
V Rashes, Lac's, etc
DRESSING (Dry & Intact: specify site below)
" th(gireSS) ' S #2
INVASIVE LINES SITE .
DATE INSERTED DESCRIPTION (SITE. DSC.)
RINI 1b4

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PUPIL SIZE PUPILS MOTOR FUNCTION (:HART CODES
1 mm = Equal No Movement Present
2 mm R Reactive 1 = Slight Flicker/ Trace of Contraction
3 mm NR NonReactive 2 = Active (Gravity Eliminated)

Not Applicable /Absent (blank)
3 = Active: against gravity, but not against resistance
4 min L it Left Larger -I = Active: Against Gravity and Resistance, not full strength Refer to Nsg. Notes

X
5 - Full Strength against Examiners Resistance
)
5 mm R L. Right Larger No Change from
•
1
1° ­
rcevious Assessment
1"1_ I
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r-r
0
1"I

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0
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t 2 2 2 2 2
f 17 I
5 6 7 I I 0 1 2 1 4
4

1 I

A. BEST EYE-OPENING RESPONSE
(4)
Opens Spontaneously (2) To Pain

(3)
To Voice (1) Does Not Open

2.
9-

i

B. BEST VERBAL RESPONSE
-.
(5) Oriented (2) Garbled
I

/-
(4) Confused (I) No Response v.
OT
f
(3)
Inappropriate Verbal Response

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain i,i

(5)
Localizes to Pain • (2) Extension to Pain I

(41 Withdraw to Pain (1) No Response GLASCOW COMA SCALE (A+B+C)
1 % 1
PUPIL RESPONSE . R
Size (mm), React to 43 4' 3,-A-Tv Z.%

14.

A-

Light (+) No Response (-) L
34-
13
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Ll"
MOVEMENT RUE
q 4-qt , -1.,
(See Motor Function LUE
Scale at Top of Page)
RLE
% 6I1

1 -Li
4-
0

LLE GRIP (S) Strang -(W) Weak (-) absent R L RESPIRATIONS RETRACTIONS REGULAR IRREGULAR UNLABORF,D LABORED SHALLOW ' BREATH SOUNDS (5) Clear (4) Crackles (3)Rhonchi (2) Wheeze .(1) Diminished RUL LUL RLL LLL BOTH BASES COUGH NONPRODUCTIVE NONE SPONTANEOUS PRODUCTIVE SPUTUM COLOR (5) Tan (4) Green (3) Pink (2)Yellow (1) Clear u 5 S I 0 T c 1 I -e-5 'c V 5 S i i 1/ 4-11-1.11 r I I V3 1r 1 , . 19S v50,.. 5 S n 1 3 I3I ---• . V 1.-5 *c IA iii If 3 /C:-14-1--5-3 1 tk I t l; .
SPUTUM CONSISTENCY (3) Thick (2) " Frothy (1) Thin VENTILATOR ) PRESS. SUPPORT lit F102 RATE,. SIN, NIV) PEEP /CPAP -OXYGEN DELIVERY DEVICE ' ETT # %.0 NC (intin) FM (1/min) NRBM (I/min) '1(1) tAi 12-5- ILT) IA 11 - I 6' 0 ttaqs 01 tigH ( 0 i v r if -.0 0 a 1) 10'3 44-1 R C - : ?1T)10. Cl.. f 0
ETT 7.1 cm punts ETT CARE /POSITION CHANGE ' ETT / NT SUCTIONED INCENTIVE SPIROMETRY DONE I/ J I I ,/./ %/1 . 1 ¦
COUGH/DEEP BREATH
' INITIALS (b)(6)-2 (b)(6)-2
¦ ar-nr.,-.. I nun A

VITAL SIGNS
TIME 11 100 T P 11 R I B/P ill 56 SAT 100% A-line MAP PA RA PCW CO CI PVR SVR ICP CPP COMMENTS
ONO 101 1 130 14 1 610 MM.
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NSN 7540-00-634-41 23
MEDICAL RECORD NURSING NOTES
(Sign all notes)
HOUR OBSERVATIONS

DATE
Include medication and treatment when indicated ) —
A.M. P.NL
I (1)5w8 oot o Phrermik%s 3tLai -k versa al-91 R2 t9 -Ft
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eirtryn en flIó'#-,.."- t (1)
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CRITICALFCARE FLOW SHEET
;13)(6)-2
LOS DATA DOA
11 DOS ti ScV3 1(35.0'0 POD bid
24 HOUR DATA
24 Hour Balance 24 Hour Intake 24 Hour Output Weight on Admission Wight Yesterday Weight Toda$,
'':NURSE'S SIGNATURE Initials
(b)(6)-2
Safety Checks BVM 0 bedside Monitor Alarms On
'ID Bracelet On Allergy Bracelet On Call Light Within Reach
Side Rails Up Bed in Low Position
N
(b)(6)-2
• Pith? llepartmentThemce/Lluuc VA 1 h
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LTA f Cu. 41-5VP0.5
PATIENT'S IDENTIFICATION For typed or written entries give: Naine-last. first.
Middle; grade; date; hospital or medical facility) . HISTORY/PHYSICAL

. OTHER EXAMINATION 0 OTHER(Speci6) (b)(6)-4 Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

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(1)
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SKIN
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Dry (4) Cool (7) Jaundiced

(2)
Clammy (S) Finked (8) Color Normal
) Warm (6) Cyanotic (9) Pale ' ' I•.

EDEMA. MI¦MI HEART SOUNDS Clear, Re • , No Rubs, No Murmurs Si MI CI !
n'
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SWAN GANZ CATHETER
Zeroed & calibrated
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH

MOBILITY FOLEY CARE ORAL CARE BEDREST BSC II CFA IE II IN 1 I I
DANGLE
CHAIR
POSITIONED RIGHT
LEFT
SUPINE . • • • •
HOB 30 DEGREES
FALLS PROTOCOL INITIATED . -
PROTECTIVE DEVICES Queer ea MAIM OP132.20)
PAIN I PAIN FREE
PAIN SCALE (1-10)
PCARCEA IN USE (Retie **PIMA onn-7)
ABDOMEN (2) Soft & Flat (11 Distended •
BOWEL SOUNDS ( active all quads)
NG l DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown
Surgical Wounds
• . Rashes, Lac's, etc
DRESSING (Dry & Intact: specify site below) #1 a 11,10e. 6 , ...,ns
#2
N3
INVASIVE LINES mgairrtirs. SITE IN bat-'um, , . DATE INSERTED (6seeo3 zgoo( oLgeo 25,z DESCRIPTION (SITE, DSG.)Emu= Lltrimmiresi ,•IIIIIMENEEMM1110.MV, .-

PUPIL SIZE PUPILS
MOTOR FUNCTION
CHART CODES
linm = : " Equal 0= No Movement ri
Present
2 min R ......Reactive
1 = Slight Flicker/ Trace of Contraction
3 zum NI2 NonReactive
2 = Active (GrMity Eihnisiated)
Not Applicable /Absent (blank)
3 = Active: against gravity, but not against resistance
4 mm L R Left Larger
4 = Active: Against Gravity and Resistance, not full strength
Refer to Nsg. Notes X •
5 = Full Strength against Examiners Resistance
5 mm R L Right Larger
No Change from
........ ,....0
Previous Assessment-
.
[!.:_.1
0
TIME
I
00 09 01 11
11--11 11 12 22 22
12 3 54 -9'0 90 12 34 16
'
7 •11 90
12 34
A. BEST EYE-OPENING RESPONSE
(4)
Opens SpontaneouSly (2) To Pain

(4
(3)
To Voice • (1) Does Not Open

B.
BEST VERBAL RESPONSE

I . •
(5)
Oriented

' (2) Garbled '
(4)
Confused

(I) No Response
PT
(3) Inappropriate Verbal Response
-r

C. BEST MOTOR RESPONSE* ' '
(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to P9131 (2) Extension to Pain if 4

(4)
Withdraw to Pain (1) No Response
GLASCOW COMA SCALE (A+B+C)

1,r

PUPIL RESPONSE . . R
2*
24 •
Light (+) No Response (-) L 21-21--

Size (mm), React to 21.
21Y
MOVEMENT RUE
.q 4-
(See Motor Function LUE
Scale at Top of Page) -4-

RLE
LLE --
V er
GRIP (S) Strong R

(W) Weak (-) absent L 5
5
.
RESPIRATIONS REGULAR
. , ,
IRREGULAR -S1 V

.
UNLABORM E Q
LABORED 'l

14_.
SHALLOW
7 4--
RETRACTIONS
BREATH SOUNDS RL'L

51
(5)
Clear

LUL
(4)
Crackles S c c '

(3)
Rhone's! •

ALL I A
(2)
Wheeze I

LLL
(1)
Dimhthhed I I
BOTH BASES

COUGH NONE
SPONTANEOUS V/ J
PRODUCTIVE
NONPRODUCTIVE

SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear
SPUTUM CONSISTENCY (3), Thick
(2) Frothy (1) Thin VENTILATOR Vt ----
-7)D 1a) o
1002
114
ILA
RATE (SIMVICMV) 2 12. 12PEEP /CPAP -5-
Ar
PRESS. SUPPORT
--0.
OXYGEN DELIVERY NC (I/min)DEVICE
PM (1/min)
ETT N O.0 NRBM (limns) i
'
ETT 7.4.. an :urns •

J
ETT CARE / POSITION CHANGE
ETT / NT SUCTIONED
.
INCENTIVE SPIROMETRY DONE .
COUGH I-DEEP BREATH INITIALS (b)(6)-2 (b)(8 r)(6)_
_)-2 '
MEDCOM - 2030
VITAL SIGNS
TIME ' T P R B/P SAT A-1Ine MAP PA RA PCW CO Cl ; PVR SVR ICP CPP COMMENTS
0100 1 0 1 I g 1 01153 103t
' . . ,
0200 19 1 11/0"/81. V- . . V. . _
. .
0300 . 6_ /6.10.. 91S -
• ... . .
0400 ig 103/53 MX, - . •,). - •
0500 11( 110a icoll
0600 18 ftrws-t/ 1col, ..
0700 IO2. I3 ' il ()3ts1 10064 . •
0800 (O2,) S Hass' too? .
0900 .
. .
1000 .
•
1100
, . .
1200 ‘.•3.r..•-p .
1300
1400 V . . . .
1500 . V
1600 -
•
1700 •
1800
.
1900
2000 V •
. . .
2100 .. . •
. ,
2200 • V.
. • ..,... .
2300
.
2•10a
. ,
MEDCOM - 2031

NN 7540-00-634-4123
MEDICAL RECORD NURSING NC IS
(Sign all notes)
HOUR -OBSERVATIONS
DATE
Include medication and treatment when indicated
AM. P.M.
ooic t ib 11 A4,61aallaz abo I c (et ()IA bite a-INI Cikitte avoL(1.9 rexot , 66141,4e.
_ .
.
tiatin Sbyl&4- (Yzeiw4 . thrtal a/awl Win Irkte.11 to,,trA9;,)ez-A-ituraXwk, 064:f.a.46-7, (IA` kzurtir 61 'orx
44 (Axe ‘620 AM-0 n'/ed. Os Ars zo r1-7g e 4ceeiv,. vgiesew 2,5 1A
4 R.it-taxhii 10 0 eA t c5:11/
VivoNex Q. 91) vko(5.-eva-k. canvi WiteA ('outcl, e(xyl (:44L SLgk4Xtrv-i-uv \\not, 40 WumAlw 1000 vv--,s —6-avka-ev" CsAt-evi • (1
II 1 Uri ivy .
0100
13/1171MIBEIVANI

"2°' PAIIIMIN AMIE
0300 umemestrardwo
0400 rsrommairigmum
PAMM111!: EMI

0500 KrilifiraliMPATIM
'0600 ifigKeD ittigNAKIPDra -°8°° LaraartiMENE
e)t 4c5o 3-0 iv) 02 ha 'D° riv gliR-b
0900 ramiorrearret. .

1000 INIMINIMMIEMPATI
PILIMEMB/111151

1100 PAPANIMELEIMIN
1200 mirolimonams
1400
1300 mossomairmai
1500
PlardrIMPIEBrdrd

1600
MINIMPIMIner%

no 1111111111._ 6-

PluHR
1800
BINSIMEISMINSILI

WEILINIZIE1112

2000
1900 Prommaramorm
2100 riordrimmordem
2200 PAIMPRIMMILIMPla •
2300
PAIMMINCIPAIN

"00 M11111EIMELPRI
8 241IR.
r I ,v¦vsinc., • a
RIM ANINI •
El '10.11.1%
EZIESUNI
AVA IMMO
miramorta
ErtIANIASIi
Arialrifini
PANIFOILM
go 0.n bx6.
Allem .v.d
MINISPIIPAI
PSIEWAIMPAI
IZEINIMPA -
marmanni
maisrata
MIWIMIPA
LONIMES11 IL
IL_ AA A
EPP
112111KIMMI
PARINIMINI
rataardara
airammisi
MEMS1/21
12111.111111%
101
%/riffl
24 HR
HR

MEDIC.. - ;ORD - PATIENT RELEASE / DISCI.-.77.: • asISTRUCTIONS
For use of this form, see MEDCOM Circular 40-5 DIRECTIONS: To be completed by attending provider and other staff at time of patient release following an outpatient procedure, extended
49#-/47'4 . 111)AMBULATORY II CRUTCHES . WHEELCHAIR STRETCHER
care/treatment or discharge from an inpatient hospital stay.
SECTION I SECTION II
TO BE COMPLETED BY PRIVILEGED PROVIDER TO BE COMPLETED BY OTHER STAFF, AS APPROPRIATE
1. DATE OF PROCEDURE/ADMISSION: t211 1. DISPOSITIONED TO:)I)HOME 111 our,)II)OTHER
2. ADMITTING/DIAGNOSIS:Cy (0)•),,,,)

3. PERTINENT LAB, X-RAY, FINDINGS:
..E0 t., .....,t.,— (1, ; — e
P11—.
La
4 • 4,-e. ,
/
•°' if/e0sk, -•,-,
kler .1
A.)lite..-.. /P Cfr-•-7-
.
./* . 2. ACCOMPANIED BY: II FAMILY 0 FRiEND 0 OTHER
K--- (.7"•••%--, .
3. PATIENT EDUCATION: W.,-Ile— / irc4:4Completed and patient prepared for home care. I res . NO
.....,,
4--/-Le.-- If no, explain: Patient li states I demonstrates understanding of home care needs.
4. PROCEDURES, TREATMENT, HOSPITAL COURSE:
Printed educational materials provided:
—)(°--4°')I• ---.74, —144/4— of . -X-V6
-.4.--L.-•
(,/,p 4.,,,..L.,. , g0,--, 1 74. ite ,..e.)1-69" fies• Litezot.,,,A.o.-..

/1/4 tog- a-eir--- . Th..„...,._;‹ ;--7-1,-,--)- iaj .
4:)Clinical outcomes met and post-discharge/release referrals made.
1-a , i, / c
/, 4..,....0 YES I NO If no, explain:
I* 444-, 1.- 13. °A2-i. 491yr
5 .)t•)• :)..)•).)• :): 5.)If transferred to another health care facility, report called to nurse. Pre - 1)501""‘"h1,¦ • 46 -74,Sei..7-/-ae I YES I NO If no, explain:
--,,
3-P ,e4-4 ;•••••
'". l6/r!Q
,, - Vi%-ial-nr•k__JC2c.44

A 1/ OP: + / - A c( l'"e---NUTRITION CARE - Comments:
N. a, /.0,,,,,7 / r 704,-e... 74f- • .(if:-.e P./c74-•••-G .
6. ACTIVITY: ,/,. C es,-,,,./7/
o.„:".-/-
7.)DIET: - ,V11,62/ rafe F-1.-„,/../.
B. MEDICATIONS:
. Medications have been prescribed for home use.
IIII See separate list and special instructions or see below.

SI-i '''‘illri-e'ci \-S -/-7,---;-.)-e.
rs: ...% 1-d°-%7 / S ''‘. c.," ...-• ''-% ..e.--.
.....)-
frt.f, r-'-5 i -- d-7';-"U .P L tov. z._ pi). — .5—E/ 7 .„Z`---er.0
9. INSTRUCTIONS (To Home Hearth Providers, Patient, etc):
M • 1 ty--5. kg,/ -a, L, .., 71-
7)MEDICATIONS:
Explained by:)¦ NURSE 111 PHYSICIAN . PHARMACIST
Printed medication literature provided. )I)YES I NO
Patient states understanding of .
I YES 0 NC
prescribed medications.)
8 EQUIPMENT/SUPPLIES PROVIDED:
9 FOLLOW-UP APPOINTMENTS, POINT OF CONTACT & PHONE:
76 4,--": ¦ . 1-'i--0-.,...5,e-tf--.6.e.._
r---, t A--Se. )1 ,----% — 0-1a-,j-P 74-f--1 S' 1--- t-74s,-l..-0)---,-,el( ig-%-r, — 9/-... e* ?I--c_..1-- - - ,—. 10.DISCHARGINn 13841V1PIR' ."--.
ti3 t,i) 10. FOR PROBLEMS OR EMERGENCY, CONTACT & PHONE:
(b)(6)-2
PATIENT IDENTIFICA N 11. COMPLETED BY:
(b)(6)-4).
(Signature and Title) (Date and Time)
I HAVE RECEIVED A COPY OF AND UNDERSTAND THESE . INSTRUCTIONS.
(Patient/Responsible Adult's Signature) Ware and Time)
MEDCOM FORM 691-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC VT.00
MEDCOM - 2034

DOD 006086

)

MEDICAL RECORD INTRAOPERATIVE DOCUMENT
For use of this form, see AR 40,407. .the proponent a
/1. PATIENT TRANSPORTED TO OPERATING ROOM

2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE -
VIA eretA_ BY p r (b)(6)-2
VERIFIED BY r4Ar 0)(6)-2
I a DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
EPS 0) 4 0 0) TIME)6/6 0) NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
. CALM)(2.--05(10US)5-EXCITED). CRYING). ANGRY).

WITHDRAWN). OTHER (Specify)
COMMENTS:)Ert.E. Xe_c.../ V--- ?//0 CC_ Di.) ft-t• ) .

8. NURSING PERSONNEL
ASSIGNED)SOC)(b)(6)-2) REUEFSCRUB) SCRUB
b)(6)-2ASSIGNED)
/%1 A r-)RELIEF
CIRCULATOR) CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
Gi---SUIT4). LITHOTOMY)
. PRONE). KRASKE)LATERAL:). LEFT SIDE UP). RIGHT SIDE UP
COMMENTS: 44 )..f.„.,cf-, A etc / kr poso

8. SKIN PREPARATION
HAIR REMOVAL)G7—YES). NO)
• PREP SOLUTION (Specify) gcrA / Kc r-?)
DONE BY:). OR . NURSING UNIT)t)(6).2
SITE:Al/Mai)7-c,)e,1/..r)BY WHOM: /1•1 a r •
METHOD:). DEPILATORY)Ig—POR) SITE: )BY WHOM:
. CLIPCOMMENTS:)Al) 8).?? (....o oz)An_ .. f.---/C,") COMMENTS: /Jo)p504.,„-6..)et),ecy cv—ead).
9 LOCATION OF EXTERNAL DEVICES
7CP)i
•-: t ,) .
..
111.11P-
i
LEGEND)X Ground Pad)-- Safety Strap)--- Tourniquet
C - Correct I)
Incorrect
First Closing)Final Closing

10. COUNTS )Other"
)Count)Count)
SCRUB) CIRCULATOR
Sponge .les . No C--
C 1
Needle Sharp Ely.e s . No)0)(6)-2
C____
b)(6)-2
Instrument 3yes . No
C )C )%
Other). Yes . No •
11. PATIENT IDENTIFICATION (For typed or written entries give: )12. ELECTROSURGERY DEVICE(S) (ESU) -DYES0 NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility,) )
.11-4—
:b)(6)-4)
er-ISU No- Ac odoY7 GROUND PAD:)BRAND)/10-a
• LOT NO:)O 7/1///
. ESU NO:
GROUND PAD:)BRAND MEDCOM - 2035)LOT NO:
f„ ,,;$,...3.f.;',.:!4,1' tk.P'.:4....iig:t;g:Z101,40..M.K40.,i=44:„4.;t4 MEDICATI ONS/ 0 RDERS 41t.., .01.AVQ:44:44"4"4",01,VVIlarghtk'eatter a ,,,,,, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES 0 NO 0 TIME METHOD PREPARED BY GIVEN BY
7),AEDICAT1ONS/SOLUTION DOSAGE
tJ

WOUND IRRIGATION 14ES 0 NO, TYPE(S):
/•) r 5. /

TIME CARRIED OUT BYOTHER ORDERS /ti
b)(6)-2
',PHYSICIAN'S SIGNATURE
,... Y.--."7., '40''' ,,,,,g, '.....,,' • .!,;^','''Of4fiegt.,4*^,7,1).4.A.0,-;WA,
15. X-RAY IN OPERATING ROOM IF YES, SITE
q___
YES 0 NO
LABORATORY SPECIMENS
16.
NAME

SPECIMEN (S) NAME
YES 0 NO 2-------
FROZEN SECTION (FS) ..„NAME

NAME
YES 0 NO3
CULTURE (C) NAME NAME
YES 0 . NO

NAMENAME NAME , 18. DRESSING/IMMOBILIZATION (Specify)NAME NAME
6C-7 (° C,
17. TUBES, DRAINS/PACKING YES 0 NO 0 0_6Jc/ten fy 070.11/4 J p,t_Es-7.4._
TYPE/SIZE 1. 2. 3,

/6 At fir
SITE 1. 2. 3.
19. ADDITIONAL INFORMATION (b)(6)-2
-
1J C
S'1.1 ..:34. ..5 ri-C d.c.-._ 41-),Ea.
20. OPERATION(S) PERFORMED
.
Clef' 6-AP
.. -
...
.
METHOD
21.
PATIENT TAANSFERRED TO
/Ad- c./ /'¦ ,-, Olf6-e.... / ../7C1,_

M*2

22.
REGISTERED NURSE SIGNATURE .

\.F1EVERSE OF DA FORM 5179,1, OCT 87 0p0: 1096-4044113/40440
-
V
.........m.
... , MEDICAL. RECORD INTRAOPERATIVE DOCUMENT

For.use of this form, see AR 40-407, the • • •rtent ar Is the office of. The Su neon General
1. PATIENT TRANSPORTED TO OPERA ING 2. PATIENT IDENTI b)(6)-2 EWEitAj PROCEDURE _
(b)(6)-2
VIA .• ... Jattt., .BY VERIFIED BY
3. DATE TIME P TIENT ARRIVED IN SUITE 4. PATIENT IN R ...
•/3 o3 TIME NUMBER g
6. PREOPERATIVE EMOTIONAL STATUS
. CALM . ANXIOUS . EXCITED . CRYING • . ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS:
•
6. NURSING PERSONNEL
(b)(6)-2
ASSIGNED RELIEF
SCRUB SCRUB

nil(b)(6)-2
ASSIGNED RELIEF
CIRCULATOR CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) _ _ f 4p-/ . te-a . .
Dr SUPINE . LITHOTOMY . PRONE . KRASKE LATERAL . LEFT SIDE UP . RIGHT SIDE UP
COMMENTS: (224exo afrvi ilaetA,VP--A.90 .41-bLetip t el f.}-lte-4,4.-0
--1-4211-1
;,. 8. SKIN PREPARATION HAIR REMOVAL 0 YES al N 'PREP SOLUTIO (Specify) 060D41-141.1 Al-A4-4-DONE BY: . OR . NURSING UNIT SITE: BY WHOM: ;Ill , METHOD: . DEPILATORY . RAZOR SITE: • BY
b)(6)-2BY WHOM:
. CLIP
COMMENTS: COMMENTS: • ............
9. LOCATION OF EXTERNAL DEVICES tf
Alla°
•
-
s•
-
•
.• .
• —
1111101.-
.

b)(6) MEI
• 1111111 .
LEGEND X -- Safety S ••••••• oumlquet -7Ake\O.)
C •• Correct I •• Incorrect First Closing Final Closing
10. COUNTS Other" Count Count SCRUB CIRCULATOR 111111111, (b)(6)-2 (b)(6)-2
es . Needle Sharp v-E"es . o
S••nge No IMMEIMPAIWINFal •
MI=
instrument . Yes r No
Mil 41 '
Other . Yes ZETA= 111PI;
11. PATIENT IDENTIFICA • (For typed or en entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) Gf/YES . NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
I
(b)(6)-4 ESU Na
. VA -t- f 1904319-
GROUND PAD: BRAN', , 1 „ 1 • LOT Na Milff 7
....;Pnav•Ir
. ESU NO:
GROUND PAD: BRAND '
•
LOT NO:
MEDCOM - 2037
. — ..,,,,AR NO.
DOD 006089

-. .-;,==5W,'1::gilf:g.'..:'jV.:Vir4-M:edg*i.igf4eV,v4mEDrcArloNs/oRDERs ,,;giiwog;:4;gk IgVitlk, . , -,.ti .. IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES 0 NO 0 we,,t
WEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY - GIVEN BY
V . k

'WOUND IRRIGATION YES 0 NO, TYPE(S):
LO
fit) 5
fOTHER ORDERS TIME CARRIED OUT BY
_
I
iPHYSICIAN'S SIC
1.5xiitw,TtmmmTf4li
15.
X-RAY IN OP,..r.,,..w ,,..., . IF YES, SITE
YES 0 NO 0

16.
LABORATORY SPECIMENS
SPECIMEN (S) NAME ' NAME
YES NO 0 1-tetil 0

FROZEN SECTION (FS) NIP/ NAME
VES t] NOD •
CULTURE (C) NAME NAME
YES 0 NOD
NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS YES ,,6 NO 0 :
,v_. 4 15
4
TY2,P145 1. 3.
, bt, all-1.--ble

SITE 3.
2.
)526
4r 7-,--1
19. ADDITIONAL INFORMATION
/ Ac-,x / r ,
(b)(6)-2
:b)(6)-2 / (b)(6)-2 b)(6)-2
.
20. OP ATION(S)
Id.441,,oect aj-el. AfsitAk
/1-FIA9 -i iebtX-0-11-e-- i
•, Oel 1 ..-.. • „1-4-tkie .
21.
PAT? TRANSFERRED TO ejzz. i TIME METHOD
/LA /

22.
REGISTERED NURSE .. (b)(6)-2
. .. , • v --

REVERSE OFDA FORM 5179-1, OCT 87 "U.S. GPO: 1698-404-813/40440
MEDCOM - 2038

DOD 006090

Ventilator Flow Sheet
Date Time Mode VT Rate F102 PEEP PIP MAP SpO2 HR BP I:E
griA WO MIWV /2 70 .5-Fa /0 P 0 1,3 go(..2‘ 3
MIIMII OPMI .100 -7 P 5 13 Ell OD DM t.1 WI coo FAI WO a --it 5-: . 2-3 a t ov MUNE VII/2a2 mAtt co // 517 Winn /X F" MITEA
PI 7t0
PA -po CP4(/ /2. (7 5 22_ Io mega=
4 700 12
7 7 (VD "al vo (2 0 5 ,z5 GM 09 WAN= movo zmg -3,7z)(z_ 0 s--2z. / /op Nam= 22 Millo D /035E 1:2i
00 1:2-WAINII23 WI co WINNE
5c 5
55222A" WILl' IL
MI 00 tiqJ 7" MAIMI11111111Prif. Z III cls FANAI WIE101117 00 it Ell 5 Z3 ill 00 MINI 1•z,3 ' MEIN] 70 IL 35 Ellin 11 00 MEE :/,)A0600 671-10° lL 3 5 5'9 rz--100. i NEEd Min:1703 ( lb 5 0 \ mi in t'23
00 Nr11111111111113101111MINNINE ViVityll= 60 liati 6 EllIVIEWNIMENIM
M (1/41o0 Eri vm iti o 5 ab Ell loe , iol um 1:23wririmml)-90 EIRIFIENZI loz ffilla3MIENIEMEIM 0-L-/6 Igliraill 15' els MiSti FINIMEMI-to a 0 "Mb IMIFINIERINf FFAMIMMEMIIIM II BMW=
01
Diff. voo ilAki lou w' 5 UMW cl 1 MEIrimmEmigia_ yo S rijnewilmApiFicrmingbo la--go s-1111111INFIRIMEM Mc, iu CURIO ce )• Ell (6 too Iwo ODE MI=04 -?cPrillrMICII-26, a Y NM Ffin Om Eit10) f 2-`10 5' EiNko MEM
. ./0 $20 =MI (2 tfo g -).5 wow= v 9 /3 gv •-; 1411 z 5 -27 U /n, TZ tili
(b)(6)-4
MEDCOM - 2039
RT Ink
b)(6)-2
Ventilator Flow Sheet
, boa‘V I 1
Date Time Mode VT Rate Fi02 PEEP PIP MAP SpO HR BP I:E RT Inst _
Ci /5 290 v, 1.00 5 :3:1 W

BECI_ tio O
ITAIR / b)("2 f ok 1\
-
2280 11M -1(90 1z_ LIO 5 27 V._/00
/67620:2,,
FA eplo Mho IL 26 a as
[ 0 Fgap2i
Mt 5.71II -It° BM C‘e2 5 25 0 /00 /35-Kim /:.2.3
rall000 mi-700 /2-5

.1'2 l-1-- -/00 MINNIE
MEN 4 0_ Ko 5-o5 12 1 of NAIWAIIM

EfiMM
rillEIFILIIIMIIMINIEINNITIMINFI
ii71315EIMIl. MI 1.111111 OM
i AIIIMIINIE co LV1 i(o IMICIEMPAMOIE11111
Ina
ilia /fa
MIMI
MifilliffiNIVIEMILIIFIIIII /00 ND I1E 125
rianzawiraranvimminnral•
FfiltEMPINTROCII vo s la1111291011E351 iz
DIM /20 Mco INIrimmin 100 mom7=mEZns win 0 immuratnoulla5 c•
"6)-2
i itlMII$PDn VI
fil MINIIMIFIE1 f
.4211P11 IMO in Vat raitafinua. /50I NFER,EN 11
FECIIMIERNIENFIVIUNIVIIEMBIEINUISilifilMIMEIIIIIIM '5 21 Pillrafro SETO
ilitC1113rifl ()to la La IMEMITIGNI eDciarj 01
EISV 0 s'Irml 0 qo Ea Z3 13 /00 iis p./EWA one -700 s/v RIM lt
14( 1:2.1
.
via 00 CE74 -100 IL. ral 3 ; ggi 00 p5--N./
Via 03c'EMIMI U 410 S / IS-111r Sillit1 WO 1° tO (5—
• Ia. IZIc sfiztv 1-ou 7 'O svilawirwoo in 5 -2, 12-fey (23 # r' )O -1315 S71 40Z) : trO C
'115 13(iS rim 96D /2 ito
(b)(6)-4
MEDCOM - 2040
DOD 006092
Ventilator Flow Sheet
Date Time Mode VT Rate Fi0 PEEP PIP MAP SpO HR BP I:E RT !nit
go1 00 =Ea (z, IMIKII-2, Frim-gnoubm-2
VII. E M=160 1-2. L 0 MN ¦ `Il Ell IMEifil
rEatioo c3.14 1v Eil s 22: /.3 /6v Roo /: 2•1
gm 00 loll -r0 i2 go .5 23 / 2--ai7 )21 A M.1 WavaA00 Erj700 IL qa 5 .ro 1 I 1-0D Mg AgEArjaziallyil -0_, qo c ri 111211F111_,._AMAI
wig oily lEm -in, A 0 5 22 7 /bo (24 mign
riii c(0) tm p /2_ mum (•f / /d, (4 NEE ifIEVIEMBIRIEMISIII '13 •6 C5 Pt l'a 1:.2. EIMICIIMENIVIII c/t, MAI ish5 EIRVAN1
si • (6)-2
GifillIZEIMEMIIII El
ql 0 Di P IBM ti /0 o CYJNIMIETW715111eMI 5 Vi 10 Ito MI[11 ( e b)(6)-2
FAINEIRMEM q Yo MIMI
Pgffilmc El ; r C/ ON :111INIIVIIMM 5 140 5 MU 1 co Fluz
ii1PIMMEEP EMMINIVIIIMITIWAINI C11/111MMIETIMIK11111211 G • o WM FMRNASMIBSIEl 6 IMPLII IZ Ve0 1 1° Ti NIIIMIVIIMINNIIMINSIMINAI 1E1 illiTMEIMIFInsialial lb tco "-7 ranial 101=01191115111 clo =12111111111MM11111111 MI LZ MUM 5-MINIM 71
II ME
j
b)(6)-4
I
LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Subject to PrivacyAct of 1974) I AST FIRST MI UNIT RANK SSN (b)(6)-4
ak...,
:b)(6)-4
Ph sici-"• Ward: )( STAT Date and Time: Reported by: Date and Time:
(b)(6)-2 b)(6)-2
. Routine tbs• • ,at. P'
zok::•.iV4z:,:M '''Wr .Arg3 'Zf' M1.0: .;,....65*;Wir i: ; •:MSt.M.
''¦ 2 ....' ' ':. • 7a,'::itt..:;::&0: r.Z.r.7.4.Ax • litWitti• liNa MAW "?.' ii ' *
‹..".".''.'" ,l

.. . .44&%..1's:MP ?.... , X TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
Na N I 128-145 mmoUL ALB 3.3-5.5 g/dL WBC 6,5 Ae 4.8_10.8,d0py.t. K 1,1 3.3-4.7 mmol/l. ALP 26-84 U/L RBC 11. -74, 4.2-6.1 x10(6)/uL CI 104i 98-108 mmoUL ALT 10-47 U/L Hgb IS, 1. 12.0-18.0 g/dL
pH 7.35-7.45 AMY 14-97 U/L Hct 16 • 5 35.0-60.0% PCO2 35-45 mmHg AST 11-38 U/L MCV qs4 80.0-99.0 fl P02 80-90 mmHg Tbil 0.2-1.6 mg/dL MCH 3 1 . q 27.0-31.0 pg TCO2 18-33 mmoUL BUN 7-22 mg/dL MCHC • •3.).1 33.0-37.0 g/dL HCO3 22-28 mmoUL Ca • 8.0-10.3 mg/dL Pit 30.3 130-400 x10(3)/uL
s02 95-99% Choi 100-200 mg/dl. . LY% • .te 5 15.0-55.0%
BEecf (-2) - (+3) CK 30-170 U/L LY# 4. 0.7-4.3 x10(3)/uL
AGap 8-18 mmoUL CL 98-108 mmoUL Differential
iCa 011-1.23 mmol/L TCO2 18-33 mmoUL Segs Mono
BUN IC, '-22 mg/dL Creat 0.6-1.2 mg/dL Bands Eos
Glu ai-siip 73-118 mg/d1. GGT 5-65 U/L Lymph Baso
Creat 1 7 0.6-12 mg/dL Glu 73-118 mg/dL Atyp Ly Imm
Hct 35.0-60.0% K 3.3-4.7 mmoi/L RBC Morph:
Hgb 12.0-18.0 g/dL TProtein 8.4-8.1 g/dL

Na 128-145 mmoUL Pit verify:
' -•:‘: ,•,-,, , -.44 ' ' allignallt. Spun Crit 35-80%
Elml m

Color
Straw/Yellow
Uggingiatt3
'ki ' ?.i. '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ?MI:Vail - 0"-"" -.."''A.100341
Clarity Clear Source: Thin No Plasmodium Seer
Glucose Negative FecLeuk Negative Bilirubin Negative Gram St Thick I No Plasmodium Seer Ketone
•::::::::?::-,:-., , •,• -• ,:•40i,orw.5:::::1
SG wnm,.::::::::::•:,.Blood Negative OccBid Negative Sed Rate 1hr = 0-20 mm
s5l::t is

pH 4. id'"'"'"KINENE Protein 10-13 seconds Urobili Negative APTT 22.1-33.7 seconds
Nitrite
. .
FDP Negative
.... — .
Leuko 13
Urine Microscopic tiiiiiit'''' '1 WEE
WBC Epi T&S Mono Negative
RBC Mucus RPR Negative
—71.1.11.1.¦PITIMIrrIMPPITTR,MITTITRITINIRIM.PMPHPIPTMPI.119.
Bacteria • HIV Negative
Casts: Urine Negative Meningitis Negative
Crystals:
Other:
'r^. Otheiinc.: -T7, c• ‘777.c.—sak--)0 • 1 — MEDCOM - 2042 :

Boa.
0
5 c-11)c_
LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL
(Subject to Privacy Act of 1974)
siguassuu
(b)(6)-4 UNIT RANK SSN -
phuctrinn •
v arc : STAT Data Time: 05/O riale-- k " Date d Time: Routine tr t)0-2--) / z5-
(b)(6)-2
,,,,
%,.:*:-.,, ,,,, ,,,,,,,,Ks w,.:
:i:W7FriMiriiiii''''. :'`'m"--j ...%5'"%1=--4..: ','.:'. + ''''".• 44'fir-'.4k 'w e::,?a2P.k :0"Aworima ,,:,-'''''""""-7---11-,.i:-,
X TEST ---RESTIPL-T---F. RANGE TEST RESULT REF. RANGE TEST trIRESULT REF. RANGE
Na 128-145 mmoUL ALB 3.3-5.5 g/dL WBC ,& 4.8-10.8 x10(3)/uL
/J
K 3.3-4.7 mrnoVL ALP 26434 U/L RBC Vf 00 4.2-6.1 x10(6)/uL
CI 98-108 mmol/L ALT 10-47 U/L Hgb /9,e/ 12.0-18.0 g/dL pH 7.35-7.45 AMY
77.,-Ige
14-97 U/L Hct 17,7 35,0-60.0% PCO2 37• o 35-45 mmHg AST 11-38 U/L MCV 2V, ..2
80.0-99.0 9
P02 W V 80-90 mmHg Tbil 0.2-1.8 mg/dL MCH 3 b , 9 27.0-31.0 pg TCO2 2,e) 18-33 mmoUL BUN
7-22 mg/dL MCHC ,.ei-33.0-37.0 g/dL HCO3 22-28 nvriol/L
iq Ca • 8.0-10.3 mg/dL Pit 130-400 x10(3)/uL
I9
s02 /00 re, 95-99% Chol 100-200 mg/dL LY% -7, 5 15.0-55.0% BEecf —7
(-2) - (+3) CK 30-170 U/L LY# i 1 1 0.7-4.3 x10(3)/uL
AGap 8-18 mmol/L CL 98-108 mmoUL Differential
iCa 0.11-1.23 mmol/L TCO2 18-33 mmol/L Segs

Mono
BUN 7 mgkil. Creat 8.8-1.2 mot. Bands Eos
Glu 73-118 mg/dL GGT 5435 U/l. Lymph Baso

Creat 0.6-1.2 mg/dL Glu 73-118 mg/c11. Atyp Ly Imm
Hct 35.0-60.0% K 3.3-4.7 mmoUL RBC Morph:
Hgb 12.0-18.0 g/dL TProtein 8.4-8.1 g/dL

Na 128-145 mmoVL Pit verify:
Viging'"' "
Color Straw/Yellow
Clarity
Clear
Spun Crit 35-80%
•Eigi-a Z" WMACti: " 4' ' '. itral4i:desei
Fit
Source:
Thin No Plasmodium Seen
Glucose Negative FecLeuk Negative Bilirubin Negative Gram St
Thick No Plasmodium Seen Ketone Negative WetPrep Negative •
SG 1.010-1.025 KOH No Fungal Elements
I

gitakriNVV: ''' taggiegine
Blood Negative OccBld
Negative Sed Rate 1hr = 0-20 mm pH 5.0-8.0 O&P
No Ova/Parasite .I YaRaffitietii nbigg Protein Negath/e-Trace
PT 10-13 seconds Urobill Negative
APTT 22.1-33.7 seconds Nitrite Negative i:,,-' ',- a5404p.A.m/,.. 4:•g:-;: -•;.: '',' FDP
Negative Leuko Negative ABO/Rh Urine Microscopic T&C ..iiii.:0.,:i: :::,:mai .., ,,,,,:::„: ...., WBC Epi T&S
Mono Negative
RBC Mucus RPR
Negative
Bacteria Yeast
Casts:
Urine
)I •,:.....,.,
V.:•
Mf
ztm::
L"
,:M.
• a
,tita
:mg,,,,,:*,..w:::?.: r7r7:::.„7==="----,,:::::g;::::0;:i.m*4i'
,

—
HIV Negative
Negative Meningitis Negative
Crystals: Serum
Negative
Other: ,:t:.':;. MEDCOM - 2043
II
DOD 006095
LABORATORY RESULTS FORM21st COMBAT SUPPORT HOSPITAL
(Subject to Privacy Act of 1974), FIRS
b)(6)-4 UNIT
DOB RANK SSN
isician:

Ward:
ISTAT Specimen Date and Time:
Reported Date and Time:}Routine _ • •• •
tre;MISIf*:"(I4 /1 03/5
Chem stay)...mcafemoy matibfii
kL.
fa
TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na
128-145 mmol/L
' ALB
3.3-5.5 g/dL WBC
/I 3 4.8-10.8 x1 orayui
K
3.3-4.7 mmoUL
ALP 26-84 U/L
RBC a,7/ 4.2-6.1 xl 0(6)/uL
CI
98-108 mmol/L 10-47 U/L
ALT Hgb y. 9 12.0-18.0 g/dL
pH 1.301 7.35-7A5
AMY
14-97 U/L Hct 5 35.0-60.0%
PCO2 30.3)35-45 mmHg AST
11-38 U/L. MCV 44.0 80.0-99.0 fl
P02 335 80-90 mmHg Tbil 0.2-1.6 mg/dL MCH 32,r 27.0-31.0 pg
TCO2
18-33 mmol/L
BUN
7-22 mg/dL MCHC 34. 33.0-37.0 gklt.
HCO3 15 22-28 mmol/L 8.0-10.3 mg/dL
Ca Pit 1/5 130-400 x10(3)/uL
s02
95-99%
Chol
100-200 mg/dL LY% 10.9 15.0-55.0%
BEecf li (-2) - (+3) CK 30-170 U/L LY# I. 0.7-4.3 x10(3)/uLAGap 8-16 mmoUL
CL
98-108 mmol/L
DifferentialiCa
0.11-1.23 mmol/L
TCO2
18-33 mmol/L SegS
MonoIBUN
7-22 mg/dL
Creat
0.6-1.2 mg/dL Bands
Eos
• 73-118 mg/dL
Glu GGT 5-65 U/L Lymph
Baso
Creat
0.6-1.2 mg/dL
Glu
73-118 mg/dL Atyp Ly
Immature cells
)Hct 35.0-60.0%
3.3-4.7 mmol/L RBC Morph:Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL
Lactate 0.90-1.70 mmol/L Na
128-145 mmoVL Pit verify:
000
Misc Chemistry Spun Crit
35-60%
Color
Straw/Yellow Mono Negative
Clarity
Clear RPR Negative Thin No Plasmodium Seen
Glucose
Negative HIV Negative
Bilirubin
Negative Meningitis Negative Thick I No Plasmodium Seen
Ketone
Negative DOA Negative
SG
1.010-1.025
CK-MB 4.3 ng/mL
Blood
Negative Troponln I 0.19 ng/mL Sed Rate 1 hr = 0-20 mm
pH
5.0-8.0
Myoglobin 107 ng/mL
Protein
Negative-Trace
PT
10-13 seconds
Urobili
Negative Source:
APTT
22.1-33.7 seconds
Nitrite
Negative FecLeuk
Negative FDP
Negative
Leuko
Negative Gram Stain
D-Dimer Negative
• Urine Microscopic
WetPrep Negative Fibrinogen
200-400 mg/dL
WBC Epi KOH
No Fungal Elements
RBC Mucus OccBld
Negative
Bacteria Yeast O&P
No Ova/Parasite ABO/Rh
Casts:
Spermatozoa
T&C
Crystals: Amorph Sed
Urine
NeeatIve T&S
Other:
MEDCOM - 2044 „
Inthaii,
DOD 006096
LABORATORY RESULTS FORM (Subject to Privac Act of 1974)
21st COMBAT SUPPORT HOSPITAL
RANK S :i. , b)(6)-2 UNIT C0 -, Physicia b)(6)-2 Ward: •STAT Date and Time: . , e.:4...L ...... Al, Date and Time: --la Routine J t ea % ) t( eAzro '' ',.44' ................... F, .eogmang....R.T.em OTI-Movog-.4; . -O. "alfAianlag
--- ~ i Ev..;:n; • ANAWMAKI. -..', .. k., ...:°. : ' .. -.IWO
REF. RANGElik170 REF. RANGE X TEST RESULTX TEST RESULT -REF. -"GE • X TEST
WBC 1),-1. 4.8-1O.8 x10(3}/UL
Na 141 122-145 mrnout. ALB ifil 3.3-5.5 g/dt.
-t,31 42-8.1 x10(6)IuL
K 'ili 3.3-4.7 mmoUL ALP i , 26-84 U/L RBC 1Hgb 134 12.0-18.0 g/dL
913-108 mmoVL ALT 10-47 U/L
CI II
35.0-60.D%
pH -44D,L. AMY I! 14-97 U/L Hct 0
7.35-7.45 80.0-99.011
PCO2 35-45 mmHg AST CI i` 11-38thL Pricy 90
27.0-31.0 pg
P02 80-90 mmHg Tbil Ir! 0.2-1.8 mg/d1 MCH 31'0 111 i 4 MCHC 33.0-37.0 g/dL
TCO2 a_g 18-33 mmol/L •BUN is 1 7-22 mg/dL g3.0 130-400 x10(3)/uL
8.0-10.3 mg/dL LY% , 15.0-55.0%
i 3 1 4.3. Pit Iq5-
•
)HCO3 ,j, I 22-28 mmoVL •Ca •
95-99% Chol 11:11111 100-200 mg/dL
s02 100 ° 6 • 0.7-4.3 x10(3)/UL
BEecf – 5. (-2) - (+3) CK 30-170 U/L LY# 1,0.
Differential

AGap 8-16 mmol/L CL 1 O, 98-108 mmoVL
iCa . 0.11.4.23 mmoVL TCO2 A at) 18-33 mmol/L Segs Mono
BUN 1 7-22 mg/dL Croat I. a.15,s-0.6-1.2 mg/dL Bands • Eos

Glu iS4 73-118 mg/dL GGT 5-65 U/L Lymph Baso
Creat 0.6-12 mg/dL Glu • t54 73-118 mg/dL Atyp Ly Imm
35.D-60.D% K Sx• 3.3-4.7 mmoVL . RBC Morph:

Het
Hgb 12.0-18.0 g/dL TProtein 8.4-8.1 g/dL
Na 12e-145 mmoVL Pit verify

Spun CrIl 35-60%
•igglega:NOW 7 Wildifig5415 •
HE iND leginkiaTir777.14111,
Color SIrawIYeIIow gadningir Thin fNo Plasmodium Seen
Clarity Clear Source:
Glucose Negative

FecLeuk Negative Thick —1 No Plasmodium Seen
Gram St
Bilirubin Negative
EFa
—Tiliq
Ketone Negative WetPrep , Negative
RenifiNggr ----tø FtfAigANSO:
Sed Rate ihr = 0-20 mm
1113580.0tOrif-

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

PT 10-13 seconds
APTT 22.1-33.7 seconds
•
KOH No F Elements
SG t.o13-1.025
Blood -Negative OccBld
•
pH Urobili
• Urine Microsco .ic
Negative
No Ova/Parasite
•O&P
5.0-8.0
Protein . Negative-Trace
Negative
EE4 m

FDP

Negative
MEITESNErISNERES

Nitrite Negative
Iri

•i.aregaiiitiij' Mono
Negative
RPRRBC Mucus
ABO/Rh
Leuko ' Negative
— .'''7.i•Signil
T&C
-
Negative
T&SWBC Eli
Bacteria Yeast
Negative
REINMU '.. lagliang HIV
Negative Meningitis Negative
Casts: Urine Negative
Crystals: Serum
Other.
r_ ac 1,.../i.,r_ t,_ , MED, ZOM - 2045 , , rkst
(r :— P 1 6A- St) c.
DOD 006097
LABORATORY RESULTS FORM (Subject to Privac Act of 1974)
21st COMBAT SUPPORT HOSPITAL RANK SSN
-
LAST, FIRST(b)(6)-4 UNIT
I . Date and Time:
Physician: Ward: STAT Date a d Time:
b)(6)-2
Routine fC I e . ::::g,I• ant•:, :.0 -• 0, ..::,:,,, .;4:t-g•-zw:::::wo:::-. ,, -,• •Kite;:o:.*: ;:i'igi,I.i.W::'5: ai. K.5,,AMIgMfMktgWiN'Oe 004%!
A2:V neall '. itio: ' '-' 0,, OMR %INES — 4: :::.1— ',, • • Nti?.?':' t:...,---t.FAin,3; -,iNOitiirizit . --'s ................

,,,
X( TEST RESUC11 111I Errr • GE X TEST RESrviluill"--REF. RANGE X TEST RESULT REF. RANGE
Na kit 128-145 mmoUL ALB 3.3-5.5 g/dL WBC 4.8-10.8 x10(3)/uL
42-6.1 x10(6)/uL
3.3-4.7 mmol/i. ALP 26-84 U/L RBC
K Sao CI 11). 98-108 mmolll ALT 10-47 U/L Hgb 120-18.0 g/dL 14-97 U/L Hct 35.0-60.0%
pH 7.35-7.45 AMY 38 U/L MCV 80.0-99.011
PCO2 35-45 mmHg AST 11 ­
MCH 27.0-31.0 pg
P02 80-90 mmHg Tbi I 0.2-1.8 mg/dL MCHC 33.0-37.0 g/dL
TCO2 18-33 rnmoUL BUN 15 7-22 mg/dL 130400 x10(3)/UL
22-28 mmoUL Ca • 1-.1 8.0-10.3 mg/di. Pit

HCO3 95-99% Chol 403 100-200 mg/dL LY% 15.0-55.0%
s02 0.7-4.3 x10(3)/uL
BEecf (-2) - (+3) CK 30-170 LI/L. LY#
AGap 8-16 mmoUL CL KA& 98-108 mmoUL Differential
iCa 0.11-1.23 mmol/L TCO2 Do 18-33 mmoUL Segs Mono
BUN 14-7-22 mg/dL Creat j•i 0.6-1.2 mg/dL Bands Eos
Baso

Glu 73-118 mg/dL GGT 6-65 U/L Lymph
tk3
Creat Lel 0.6-12 mg/dL Glu IS-61 73-118 mg/dL Atyp Ly imm

Hct 35.0-60.0% K g•O 3.3-4.7 mmoill. RBC Morph:
Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL
Na 13k 12E mmo111. Pit verify:

35-60%
:4P tt gr' ..... '' z..4z '' IldiisEso Spun Crit Color Straw/Yellow 1 , g1t!i,1,20.0Wr """. 44"'''' '-'w,migtiig, -di golligm— -ifit4a0gma Thin No Plasmodium Seen
Clarity Clear Source: Glucose Negative FecLeuk Negative I No Plasmodium Seen
Bilirubin Negative Gram St Thick (
Ketone Negative WetPrep Negative

SG
1.010-1.025 KOH No Fungal Elements
OccBld Negative
Blood Negative
mug.
. lig.;.0:.
WIRSINtt-Rg.4'413g4t01:M.M
.
Sed Rate ,o, I., 1 hr=0-20 ran
pH -8.0 O&P No Ove/Parastte til.;.::zvkid:::: i.?,.::::::: . --,,,,5o PT 10-13 seconds
Protein Negative-Trace
I

Urobili Negative APTT 22.1-33.7 seconds
Nitrite Negative garagetair ---' '''' tekeignit FDP Negativ
Leuko Negative ABO/Rh
Urine Microscopic . T&C ig:: .Lif.g,:a "' " hiNiff -odiegNi
WBC Epi T&S Mono Negative
RBC Mucus RPR Negative

ry w

Bacteria Yeast
•: 2. ''
.
' — '4:',:g "t.',W:Aqs,--a:ERM,; HIV Negative
Casts: Urine Negative Meningitis Negative
Crystals: Serum Negative
Other: -
ffOr::: -­finn,A4_. MEDCOM - 2046
DOD 006098

-Ta--Kp 9g l(
.
LABORATORY RESULTS FORM
21st COMBAT SUPPORT HOSPITAL (Subject to PrivacAct of 1974) ACT FIRCT un (b)(6)-2
UNIT RANK SSN _
-4e(t--I---Ph cir.inn•
Ward: I STAT Date and Time: Reported ,t,y(*6).2 Date and Time: / C CA f Routine I 03 OSDO
Chem -(I-STAT
.,:::.
::::;.QM.i.ilsOff
g.;;.4.-,

gca::P'::•00:7:::i:N"
.4', k-,..,,,, _
:
:m
:B.2,
:',‘-',(PO4
' rr.z4,14100
'
a..
gAte
.....-14 5
' ... : gi.Ntagi'i'VMO.,:g1PUggetZt: .
1amatoky
X TEST RESULT REF. RANGE TEST RESULT REF. RANGE X TEST RESULT REF. RANGE Na 128-145 mmoUL ALB 3.3-5.5 g/dL WBC 1/ • 3 4.8-10.8 x10(3)/uL K 3.3-4.7 mmoUL ALP 26-84 U/L RBC 1 , / 6 4.2-8.1 x10(6)/uL
CI 98-108 mmoUL ALT 10-47 U/L Hgb 12.0-18.0 g/dL
/ 01 r pH -I. 4 (A 7.35-7.45 AMY 14-97 U/L Hct 2 1, 6 35.0-60.0% PCO2 34,1 35-45 mmHg AST 11-38 U/L MCV c't ti, 2
80.0-99.on P02 1 P4 80-90 mmHg Tbil 0.2-1.6 mg/dL MCH 3 5. le 27.0-31.0 pg TCO2 18-33 mmol/L BUN 7-22 mg/dL MCHC "5c• 33.0-37.0 g/dL HCO3 a G. 22-28 mmoUL Ca . 7. (.0 8.0-10.3 mg/dL Pit / 2. (41, 130-400 xi 0(3)/uL
s02 i00 95-99% Chol 100-200 mg/dL LY% I 44. 1-15.0-55.0% BEecf p.. (-2) - (+3) CK 30-170 U/L LY# I' 6 0.7-4.3 x10(3)/ut. AGap 8-16 mmoUL CL lac, 98-108 mmol/L Differential
iCa 0.114.23 mmoUL TCO2 9.7, 1 8-33 mmouL Segs Mono
BUN 7-22 mg/dL Creat 6.i 0.6-1.2 mg/cil. Bands Eos
Glu 73-118 mg/dL GGT szs un. Lymph Baso
Creat 0.8-1.2 mg/dL Glu I 'I( 73-118 mg/dL Atyp Ly Imm

Hct 35.0-60.0% K 4 3.3-4.7 mmoUL RBC Morph:
2.
Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL

• Na L3(, 128-145 mmol/L Pit verify: q:A.Mlidiagi. .1 —ISMER& Spun Crit 35-60% Color Straw/Yellow gP.d.5:81:' •")'"Ifigatillie M-1 4.8111111; ''' '" r i "'""'141:t1PRIVR
511P'C '
Clarity Clear Source:

Thin No Plasmodium Seen
• Glucose Negative FecLeuk Negative
Bilirubin Negative Gram St

Thick I No Plasmodium Seen Ketone Negative WetPrep Negative .,.,:.,.....,••••• • •-• ,z,-;---;:-:•0•,% ::.,-...z.7.•:':' ,:•P -;• •: ,•:.,•••••;,:•mV,;•:,,::•.
SG 1.010-1.025 KOH
No Fungal Elements M 'iiiT:;';'Agii::PrN'tl *:•:.:ing:ANN Blood Negative OccBld Negative Sed Rate lhr = 0-20 mm pH 5.0-8.0 O&P
No Ova/Parasite in NRONS?' 7111111::::::Mita Protein Negative-Trace PT 10-13 seconds
Urobili -Negative APTT 22.1-33.7 seconds Nitrite Negative gi Nrignifill.---;:;ikagiatig
FDP Negative Leuko Negative ABO/Rh Urine Microscopic T&C
?Ig: Mg :;,.":.2140.ti;heinIti •%.%:ff:t.::::m:::: WBC
Epi T&S Mono Negative RBC Mucus
RPR Negative Bacteria Yeast igii4:::::.41t4.,;-:;t0No.HC . -'10100.,
:4:nig HIV Negative Casts:
Urine Negative Meningitis Negative Crystals: Serum
Negative
Other.

• so.....wma¦la
7510=5
CAC, A6(7-- Creed-
6 LABORATORY RESULTS FORM
21st COMBAT SUPPORT HOSPITAL (Subject to Privac Act of 1974)

RANK SSN -
LAST )74)74' a" UNIT
Repoopri kw Date and Time:
Physiciar(b)(6)-2 —VV rd: STAT Date and Time: (b)(6)-2
i3 )t 43 03'10
Clr.i Routine /3 0 S DC/ c
Z1,0i:PMbift4,)• z:::,-,-.. ...„
%'',.z ''' s* '' "'' :V..0:-a.k:Z - :MSt'i:01.2A' ....VZ-°V5* ,.; M A.:1".)
,:, f,7 q•;-P'" ' ':; -' ' ' ' " ' '''. -M ag',VEM.;:if.if!: 14104's
TEST REF. RANGE
X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE X RESULT
Na 140 128-145 mmoUL ALB 3.3-5.5 g/dL WBC T ,g-4.8-10.8 x10(3)/ul RBC 249, 42-6.1 x10(6)/uL
K '3. ‘t 3.3-4.7 mmoUL ALP 26-84 U/L 12.0-18.0 g/dL
l
CI (U S 98-108 mmoUL ALT 10-47 U/L Hgb g ,cf,
14-97 U/L Hct A S, 0 35.0-60.0%

pH 7, ki CY' 7.35-7.45 AMY MCV T 3,2 80.0-99.0 ti
PCO2 y0, 7 35-45 mmHg AST 11-38 U/L MCH 31( ip 27.0-31.0 pg
P02 ,1.. (% 80-90 mmHg Tbil 02-1.6 mg/dL TCO2 3 5 , 7 33.0-37.0 g/dL
3 o 18-33 mmoUL BUN 7-22 mg/dl. MCHC Ca 8.0-10.3 mg/dL Pit 1 3 j 130-400 x10(3)/uL
HCO3 ,29" 22-28 mmol/L
C a ..0
95-99% Chol 100-200 mg/dL LY% 15.0-55.0%
s02 too,.
LY# t - 0 0.7-4.3 x10(3)/uL
BEecf 5 (-2) - (+3) CK 30-170 U/L
Differential

AGap . 8-16 minol/L CL 98-108 mmoUL
iCa 0.11-1.23 mmoUL TCO2 18-33 mmoUL Segs Mono
BUN tcr 7-22 mg/dL Creat 0.6-12 mg/dL Bands Eos
Glu lot 73-118 mg/dL GGT s-es un. Lymph Baso
Creat /., 0 0.8-12 mg/dl. Glu 73-118 mg/dL Atyp Ly Imm
RBC Morph:
Hct 35.0-60.0% K 3.3-4.7 mmol/L Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL Na 128-145 rnmol/L !Pit verify: spun Crit 35-60%
7.'`.. iiiiiiiitilikaggE Fit HIERNIP'—iiiiiARIVOittirn
Color Straw/Yellow ItiliMMEE-51,1''' ' ir""I'' .;§ENENt
Thin No Plasmodium Seen
Clarity Clear Source:
FecLeuk Negative

Glucose Negathm Thick No Plasmodium Seen
Bilirubin Negative Gram St
Ketone Negative WetPrep Negative
.:;i:v -•
,Niiimm, z:.:::.,-:,.., -4V::::::V.4,Vi,.::
SG 1.010-1.025 KOH No Fungal Elements .. -,„ .. . --. .. ....
D

Sed Rate ) 1hr = 0-20 mm
q.1216
adiiitO0 ' ' 6 ' ...'" '"'"''''' .
Blood Neg ative OccBld Negative
5.0-8.0 O&P No Ova/Parasite
pH
lid I .
PT 10-13 seconds
Protein Negative-Trace
APTT 22.1-33.7 seconds
Urobili Negative
ANISEWHir
'''''' ' VitigNORM

Negativ
FDP
Nitrite Negative
ABO/Rh
Leuko Negative
T&C WEE -:Mtaidifir 772RENSE
Urine Microscopic
1

T&S Mono Negative
WBC Epi
RPR Negative
RBC Mucus
LLL'

g
=OMR *IOW '
"

iiglRiting

Negative
HIV
Bacteria Yeast
Urine Negative Meningitis Negative
Casts:
Crystals: I

Serum Negative
Other:
5, MEDCOM - 2048
'')•:'... ti6i.:;:;21,
DOD 006100
i1VAratOgrISP;it0
-
1 • BORATORY RESULTS FORM
,
21st COMBAT SUPPORT HOSPITAL . b'ect to Privac Act of 1974) LAS ? UNIT RANK SSN -
b)(6)- 2
to •
Physician 'a STAT Date an • . Date and Time:
R : b)(6)-2(b)(6)-2
¦ Routine . ii.__—..:.-2.:11 IL.¦ • 1 'a e..13,-0.4e.
:,
v . 2,%;:': a 1 ;% -, ' • ' ' ,r4+, ,,,A,,, 7 • ,
Ffr

TEST RESULT
.mq$N411.-"U:4%:. i.-..,„,„„,.,.,,-,v.,.. 7
1,5:::::::V::,:::
'i
leo vkitgiNg4
REF. RANGE X -TEST RESULT REF. RANGE
X

TEST RESULT REF. RANGE
Na 128-145 mmol/L ALB 3.3-5.5 g/dL WBC 4.8-10.8 x10(3)/ut. K 3.3-4.7 mmouL ALP 26-84 U/L RBC 4.2-8.1 x10(6)/uL Cl 98-108 mmoUL ALT 10-47 U/L Hgb 12.0-18.0 g/dL pH 7.35-7.45 AMY 14-97 U/L Hct 35.0-60.0% PCO2 35-45 mmHg AST 11-38 U/L MCV 80.0-99.011 P02 80-90 mmHg Tbil 0.2-1.6 mg/dL MCH 27.0-31.0 pg TCO2 18-33 mmoVL BUN 7-22 mg/dL MCHC 33.0-37.0 g/dL HCO3 22-23 mmoVL Ca • 8.0-10.3 mg/dL Pit 130-400 x10(3)/uL s02 95-99% Chol 100-200 mg/dL LY% 15.0-55.0% BEecf (-2) - (+3) CK 30-170 U/L LY# 0.7.4.3 x10(3)/uL AGap -8-16 mmol/L CL 98-108 mmoVL Differential iCa . o.ii-i .23 mmol/L TCO2 18-33 mmoVI. Segs Mono BUN 7-22 mg/dL Creat 0.6-1.2 mg/dL Bands Eos Glu 73.118 mg/dL GGT 6-85 Un. Lymph Baso Creat 0.8-12 mg/dL Glu 73-118 mg/dL Atyp Ly Imm Hct 35.0-60.0% K 3.3-4.7 mmoVL RBC Morph: Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL -
Na 128-145 mmoVL Plt verify VAIRMiva .44.1Y,41Asm,::::s . ,g::: „. ,., ,,,,,,,:,,.. S un Crit ,...„..:.„„77-1;611:12i
Color Straw/Yellow itaglii-4444
--1 Lai .....
.
64itAK..a..:A.2.1b::
s4191,
a „OA .:
: .: l'
.
Clarity Clear Source: Thin I No Plasmodium Seen
Glucose Negative FecLeuk Negative
Bilirubin Negative Gram St Thick No Plasmodium Seen
Ketone SG Negative 1.010-1.025 WetPrep KOH Negative No Fungal Elements in ..,,,...".: . v, r; ...,„...: .. ............. kagini.*:K ........ t.;5-(6 7
Blood Negative OccBld ..„.„,?,,,,.,...,Negative Sed Rate 110 him/. 1hr = 0-20 mm

pH 5.0-8.0 O&P
0
Mgr -''' .........................................

No Ova/Parasite
Protein Negative-Trace .,„„.,, „."..„. PT 10-13 seconds Urobili Negative APTT 22.1-33.7 seconds
I—
.,,:-..,:az::::,:.4.---"'
''iMPETMME
. FDP Negative Leuko " Negative ABO/Rh
,.„,„, „

7c1.-7
x
Urine Microscopic
WBC Epi T&S Mono Negative
RBC Mucus RPR Negative
Bacteria Yeast le attianliatif 7._.11MBNIN, HIV Negative
Casts: Urine Negative Meningitis Negative
Crystals: Serum Negative
Other
MEDCOM -2049 _°''

DOD 006101

0
LABORATORY RESULTS FORM
i
y
(Subject to Privac Act of 1974)
21st COMBAT SUPPORT HOSPITAL
RANK SSN
UNIT
LAST, Fl b)(6)-4
Physician:
I cv
................................................................

TEST RESULT REF. RANGE
128-145 mmoVL
Na
06 K 5,q 3.3-4.7 mmoilL
98-108 mmoVL
7.35-7.45
pH 7 4?
PCO2 2 b k 35-45 mmHg
P02 51 80-90 mmHg
TCO2 7
18-33 mmoVL HCO3 2.7 22-28 mmoUL s02 99
95-99% BEecf (-2) - (+3)
7
AGap 8-18 mmoVL iCa Ortt.c 0.11-1.23 mmoVL BUN 7-22 mg/dL
Glu
73-118 mg/dL Creat 0.6-1.2 mg/dL
10 35.0-60.0% Hgb 7 12.0-18.0 g/dL
Hct
Color Straw/Yellow
Clarity Clear Glucose Negative Bilirubin Negative
Ketone Negative
SG 1.010-1.025 Blood Negative pH 5.0-8.0
Protein Negative-Trace
Urobili Negative
Nitrite Negative Leuko Negative Urine Microscopic
WBC Epi
RBC Mucus
Bacteria Yeast
Casts:
Crystals:

Other:
,..¦¦¦¦¦
AT and Time:
Ine

X TEST RESULT REF. RANGE ALB 3.3-5.5 g/dL ALP 26-84 U/L ALT 10-47 U/L AMY 14-97 U/L AST 11-38 U/L Tbil 02-1.6 mg/dL BUN 7-22 mg/dL Ca 8.0-10.3 mg/dL Chol 100-200 mg/dl CK 30-170 U/L CL 98-108 mmoVL TCO2 18-33 mmoVL Creat 0.6-1.2 mg/dL GGT 5-65 U/L Glu 73-118 mg/dL K 3.3-4.7 mmol/L TProtein 6.4-8.1 01_ Na 128-145 mmoVL
igggeg
Source:
FecLeuk Negative Gram St WetPrep Negative

KOH No Fungal Elements OccBld Negative O&P No Ova/Parasite
`"NIRSQ‘
ABO/Rh
T&C

T&S pnrIrtizei hv-Date and Time:
Waliganir
Urine Negative
Assn am Native
MEDCOM - 2050

b)(6)-2
Az:VRVOMMR.
v.
'0;40*
TEST RESULT REF. RANGE
WBC 4.8-10.8 x10(3)/uL
RBC 4.2-6.1 x10(6)/til
Hgb 12.0-18.0 g/dL
Hct
35.0-60.0% MCV 80.0-99.011 MCH 27.0-31.0 pg
MCHC
33.0-37.0 g/di.
130-400 x10(3)/uL LY% 15.0-55.0% LY#
Pit
0.7-4.3 x10(3)/uL
Differential
Segs Mono
Bands Eos
Lymph Baso
Atyp Ly I mm .RBC Morph:
Pit verify:
Spun Cult
35-60%
No Plasmodium Seen
Thin
I No Plasmodium Seen
Thick
Sed Rate 1hr = 0-20 mm
PT 10-13 seconds
APTT 22.1-33.7 seconds

FDP Negative
Mono Negative RPR Negative HIV Negative
Meningitis Negative
DOD 006102

-:. - ,.,
LASAb)tej -a - 21st COMBAT SUPPORT HOSPITAL UNIT LABORATORY RESULTS FORM (Subject to Privacy Act of 1974) RANK SSN -

Color
SI Ie11ew
P • Ward: STAT . =te ..1 d u Re'..-. s Date an Time:
• dd
b)(6)-2._,.' . b)(6)-2

Routine 0lJ`^ I v^PL;
ff^,;f::fff r ; k:u$
.::: ............ ,-:.:. :: J.:.r ,. nn::::;r:S;2;..Sxt.:.^. ::air,.-,,.«,:r.:.:'71,'Y^,:r.)...)5:....)..: .:f:: b'SS$: ..:xi::c?^

.: r. •:.w.r :-i:!..n
^,. ^: rr.,,...i^'^r ..)... ..),. v)
.,.,. ... ".M ... ...)»... ^..:.)..v..)$Si$$
^^ ^I^ ^-..... -...f:3[:;: ot!...L!...-.,
X TEST RESULT REF. RANGE X TEST.REF. RANGE X.TEST RESULT REF. RANGE

RESULT.

Na 13 6 126-145 mmoUL ALB 3.35.5 g/dL WBC 4.8-10.8 x10(3)/uL K j,S 3.3-4.7 mmoIfL ALP 26.84 U/L RBC 4.2-6.1 x10(6)!uL CI 98-106 mmoVL ALT 10.47 U/L Hgb t2.0-18.0 g/dL
(pH 7, C 7.35 7.45 AMY 14-97 U/L Hct 35.0-60.0% PCO2 57'. S 35-45 mmHg AST 11-38 U/L MCV 80.0-99.0 n _ P02 3 7 80-90 mmHg Tbil 0.2-1.6 mg/dt. MCH 27.0-31.0 pg
TCO2 3/ 18-u mmollL BUN 7-22 mgldL MCHC 33.0-37.0 g/dL
HCO3 yq 22-28 mmol/L Ca 8.0-10.3 mg/dL Pit 130-400 x10(3)/uL 602 t'3 41 95-9996 Chol 100-200 mg/dt. LY% 15.0-55.0% BEecf ^/ (.2) - (+3) CK 30-170 U/L LY# ______ 0.7-4.3 x10(3)/uL AGap 6 4 Q•nmoVL CL 98' ^°mmoVL Differential iCa /j Z 0.11 3 mmot/L TCO2 1i mmot/L Segs Mono BUN 7 rng/dL Creat 0.)! mg/dL Bands Eos Glu 73-. .J mg/dt. GGT ..-..9 un Lymph Baso Creat 0.6-12 mg/dL ' GIu 73.118 mg/dL Atyp Ly Imm Hct 35.0.60.0% K 3.3-4.7 mmovL RBC Morph:
/ /
Hgb 6 12.0-18.0 g/dL TProtein 6.4.8.1 g/dL

Na 128-145 mmoYL Pit verify:
Spun Crit 356096
r ,.•......,,... .-. .. i};±3,f^. GS -'.f ':.:.{.•l. ... w
I g111^llltlwlwww^
-':SS•f.:}ff. is/.;:. :J:i!$S$: y
^^5:./!r,
Clarity
Glucose Bilirubin Ketone
SG Blood
H
Protein

Urobili Nitrite Leuko
WBC
Clear Negative Negative
Negative
t.010-1.025 Negative
' " s.0
Negauve-Trace

Negative
Negative
Negative s PIc
Urine Microscopic Epi
f!Y.
:#.O^YS!.i fSf'r:
Source:
FecLeuk
Gram St
WetP rep
KOOH
OccBld
0&P
t % r,f^%' `.?:` ABO/Rh
T&S
4-'IYMMo1Ykjf!_f:
; ::f.. _
Negative
Negative No Fungal Elements
ung Negative
No Ova! Parasite
f:hrr
.. k31:af7+^.1^^.:.,Fi.!r$M's% ^'i•`!. "'.ic
J
^AT^tf.^^t%x'OJi:Y$:1,.Yrrn-:r/. r.
;w•wv;v::,.1.x.,.3: ^ i.:F^'^WIiSR'
Thin ( No Plasmodium Seen
Thick No Plasmodium Seen
r .
SdRa^... )
_)F
Sed Rate 1 hr = 0-20 mm
PT 10-13 seconds

APTT 22.1-33.7 seconds FDP Negative
_ . r.x..-.,x. +^:Misttrn5tty '.. .
Mono Negative
=::

RBC
Mucus _____
Negative
•-°,
, ::z:f
:yti£f;J^^°
-
tAVZ.
,R." ° .-i,
x
a
Bacteria Yeast
^
)0-f:
HIV Negative
;.,r
n!f. ri'J'.!5:.:%.9.^
rff_ : :;
: „'f.,)
Casts: Crystals: Other. ,,. Urine Serum `-` MEDCOM - 2051 Negative Negative Meningitis Negative
DOD 006103

.--,...
LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Subject to Privacy Act of 1974
, AQ.-• r•in"'Ir..l AI
LAS
6 (b)(6)-4
Physic:1w
(b)(6)-2
,,,, ....-''''' , ' - - —
X TEST RESULT
Na
K
CI
pH
PCO2
P02
TCO2
HCO3
s02
BEecf
AGap
iCa
BUN
Glu
Creat

Hct .
Hgb 12.0-18.0 g/dL

vva. u.
.:.:.:;.0.-ME:::',;:-.:,.;;;;;§:::ig
*INSI
v
REF. RANGE .
128-145 mmol/L
3.3-4.7 mmotIL
98-108 mmol/L
7.35-7.45
35-45 mmHg
80-90 mmHg
18-33 mmoVL
22-28 mmoUL
95-99%
(2) - (+3)

8-18 mmol/L oil-123 mmoVL
• 7-22 mg/dL
* 73-118 mg/dL 0.6-1.2 mg/dL
35.0-60.0%
UNIT
--3---C U i
1 STAT Date and Time: Routine IL( , • ( C-.::, iki5:4?:..1.:?45. --s,':.1:1x-4,'AZ. :g..;:k...,
1."' 1V.1 4,-­
-.,.. - , Aoty " -)'..-1 ,,,,
X TEST RESULT REF. RANGE ALB 3.3-5.5 g/dL ALP 26-84 U/L ALT 10-47 U/L AMY 14-97 U/L AST 11-38 U/L Tbil 0.2-1.6 mg/dL BUN 7-22 mg/dL Ca 8.0-10.3 mg/dL Chol 100-200 mg/dL CK 30-170 U/L CL 98-108 mmoVL TCO2 I I mmovi. Creat 0.6-1.2 mg/dL GGT 5-65 U/1. Glu 73-118 mg/dL K 3.3-4.7 mmol/L TProtein 8.4-8.1 g/dL Na 128-145 mmoVL
RANK SSN -Date and Time:
R b)(6)-2
i • n ..t)-
0.1.113
_...--2....., --
fil l,.,..4,4,..„,.,„,i,:.. .:.1,: . V..!gri .,.

A 0..
,,,. :ti.igm..io.--MI:ii
X TEST '‘'-RE&UL-T-------§EF. RANGE
WBC RBC Hgb Hct MCV MCH MCHC
Pit
LY% LY#
Segs Bands Lymph Atyp Ly
-7, 0 4.8-10.8 x10(3)/uL
..4 "( 4.2-6.1 x10(6)/uL
7 , 43 12.0.18.0 g/dL
aa,s 35.0-60.0%
9 5 i7 80.0-99.011
32.0 27.0-31.0 pg
1 g• 2 33.0-37.0 g/dL
/GI 130-400 x10(3)/uL
12.9 15.0-55.0%
0.9 0.7-4.3 x10(3)/uL

Differential Mono Eos Baso Imm
RBC Morph: Plt verify:
[
j
..."'"Illgintigli
Thin No Plasmodium Seen
Clarity Clear Source: Glucose Negative _Fec.Leuk Negative I No Plasmodium Seen
Bilirubin Negative Gram St Thick
Ketone Negative WetPrep Negative ::-.4 .. 4-" •: -YiWp:::$A1Win .....
SG 1.010-1.025 KOH No Fungal Elements li:Ik :M.::%,t.S• i...ViS 'r''''':
;:i:iaV'M.,:
Blood Negative OccBld Negative Sed Rate thr = 0-20 mm -w::, g;;;i72:1,4: ::,,,,-: 7 . =-4 '"??..,0-:444:kigii ik,:i.,pH 5.0-8.0 O&P No Ova/Parasite -xs:,: .giv:;;4:a•zi: U ,En.:'aggiN5.'
Protein Negative-Trace
PT to-i 3 seconds Urobili Negative APTT 22.1-33.7 seconds
mam.7.5.41.0.'
w,
Nitrite Negative mi:',ig:::::::_0.:;:::::A. .r. i4 F113 Vant:;..:i.:MY5' FDP Negative
Leuko Negative ABO/Rh :xs,,.14.-.-.._,."2 "....F7' .0.,,,,.....w
.-....*---',
Urine Microscopic . T&C -,:t.Mgwir ' ' .firriw . :::::,"Wm.:::r: WBC EpI T&S Mono Negative RBC Mucus
RPR Negative
Bacteria Yeast M.i,.f w.W.:Rg':' , / ' ill111,6 "li:‘ HIV Negative Casts: Urine Negative Meningitis Negative
Crystals: Serum Negative
Other.

—. --
MEDCOM -2052
..•:'!":,:01fi'l.:KNI . —
Igd

!,,1211.?.d.t.ri.„....,„„,

:212:111r liffilinif&Slaig'
.
35-60%
4i

.

,._

„ ..N014.0

SIP ''"

•gy p
Matiltrillir.v''''''
''''
Color Straw/Yellow
LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Subject to Privac Act of 1974) LAST, FIRST, 1))(6)-4 UNIT RANK SSN -
K6)(6)-2 warn: AT Date and Time' Report rl by Date and Time:
b)(6)-
(.1%-e 0c$1
T-610 Routine it/Se 057 5---... .s.i.y ,:. , s.„:, . ,:o:q,ii:m ,... AwmigigapapipAMIORla ;Mr....;7';'''''k : ' " " • 'te,::, 5:: .' .. 5:4r .:i'. :RR j::
:':::;:: _ ^ t3 F',," .::.?..x ,,:gtarg ,,, ' '1 I ;:-.. a4: •
X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE X TEST R• • a RANGE Na I $ I 128-145 mmol/L ALB 3.3-5.5 g/dL WBC -7 CI 4.8-10.8 x10(3yuL K 3 , c 3.3-4.7 mmoVL ALP 26-84 U/L RBC ,2 i 3 $ 4.2-6.1 x10(6)/uL CI /0 N 98-108 mmoVL ALT 10-47 U/L Hgb -7 tig 12.0-18.0 g/dL
pH 1.37 3 7.35-7.45 AMY 14-97 U/L Hct ,2 ,S 35.0-60.0% PCO2 9 c. 1 35.45 mmHg AST 11-38 U/L MCV q. 'f•S-80.0-99.011 P02 I 1 0 80-90 mmHg Tbil 0.2-1.6 mg/dL MCH -5A -27.0-31.0 pg TCO2 A. es 18-33 mmol/L BUN 7-22 mg/dL MCHC 3 q. (6 33.0-37.0 g/dL HCO3 2. C., 22-28 mmol/L Ca 8.0-10.3 mg/dL Plt [(o 1 130-400 x10(3yuL s02 / C/ 17 95-99% Chol 100-200 mg/dL LY% i a- ; 15.0-55.0% BEecf / (-2) - (+3) CK 30-170 U/L LY# 0. I 0.7-4.3 x10(3)/uL
AGap II 8-16 mmoVL CL 98-108 nimol/L Differential
iCa 0.11-1.23 mmoVL TCO2 18-33 mmoVL Segs Mono
BUN i (6 7-22 mg/dL Creat 0.6-1.2 mg/dL Bangs Eos
Glu 101 '4 73-118 mg/dL GGT 5-65 U/L Lymph Baso
Creat 1, 0 0.6-1.2 mg/dL Glu 73-118 mg/dL Atyp Ly Imm
Hct 35.0-60.0% K 3.3-4.7 mmoVL RBC Morph:
Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL

Na 128-145 mmoVL Pit verify:
Color
Clarity
gt kiNfitaliiiiiiiiii

TEN!

Spun Crit 35-60%
N,3'4 .," ,5 --14,,x,.-Amz;a4x,t: .:--:-.:Weir:Mia: , .4 ,rit=
,,,?..i.i., '.***Ei..:::;:::::..;:;F --,
g:,: 0 '',:fto:tg::,;nx .f,-.= 0 Rim
SA
•;.,,f4,ZZ,2-.,..,...,:,a
Thin No Plasmodium Seen
Glucose Negative FecLeuk Negative
Bilirubin egative Gram St Thick I No Plasmodium Seen
Ketone . Negathre WetPrep Negative
SG No Fungal Elements ," -0-Inginitt ''''' . ''''"'"%igkOMIE1
Blood PH Negative No Ova/Parasite . '''' Sed Rate Vit:/,':Eaftr: ,..koz;,:;:,,:;,•.o::.:::."...,-.,z.,.,-..,._.,,,. ..p;.:wE: .......L 1 hr70:20.... sim .,. U10111.011W.4.4,r;
Protein PT 10-13 seconds
Urobili Negative APTT 22.1 -33.7 seconds
Nitrite ..:!Iliiii„ . " itaigNIM FDP Negative
Leuko Negative ABOlRh
Urine Microscopic T&C gi:n ::,:. ."'"4"' — - ll..
,.%:,;:ww::::-:::
WBC Epi T&S Mono Negative
RBC Mucus RPR Negative
Bacteria Yeast —t. '"',:r !;::7-Wittilaraggia HIV Negative
Casts: Urine Negative Meningitis Negative
Crystals: Serum Negative
Other
--:::401fitiiiiff:,':::: K el i — nr¦ '—'7 _A. _ MEDCOM - 2053 , ,,c.)

(4-0°70 er-e (00, (
LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Sutject to Privac Act of 1974)
LAST rent-%-r sal
UNIT
(b)(6)-4
Ward:)_I-STAT Specimen Date and Time:
Physic (b)(6)-2
ALN 1'Routine )-Cfo ,2.10 reAnaryzer)
REF. RANGEX TEST RESULT REF. RANGE X TEST RESULT
Na 128-145 mmol/L ALB 3.3-5.5 g/d1. K 3e 7 3.3-4.7 mmoVL ALP 26-84 U/L CI t o ' 98-108 inmoVL ALT 10-47 U/L pH 7 ,4 U7 7.35-7.45 AMY 14-97 U/L PCO2 35-45 mmHg AST 11-38 U/L
1 7.9
P02 80-90 mmHg Tbil 0.2-1.6 mg/dL TCO2 33 18-33 mmoVL BUN 7-22 mg/dL HCO3 31 22-28 mmol/L Ca 8.0-10.3 mg/dL s02 t00% 95-99% Chol 100-200 mg/dL BEecf 7 (-2) - (+3) CK 30-170 U/L AGap 8-16 mmoVL CL 98-108 mmol/L
iCa 0.11-1.23 mmoVL TCO2 18-33 mmoVL BUN 7-22 mg/dL Creat 0.6-1.2 mg/dL Glu //a 73-118 mg/dL GGT 5-65 U/L Creat 1. 1 0.6-1.2 mg/dL Glu 73-118 mg/dL Hct 35.0-60.0% K 3.3-4.7 mmol/L Hgb 120-18.0 g/dL TProtoin 6.4-8.1 g/dL Lactate 0.90-1.70 mmoVL Na 128-145 mmoUL
rine yierrlir
• I 2
.
Color Straw/Yellow Mono Negative Clarity Clear RPR Negative Glucose Negative HIV Negative Bilirubin Negative Meningitis Negative Ketone Negative DOA Negative
SG 1.010-1.025 CK-MB 4.3 ng/mL Blood Negative Troponin I 0.19 ng/mL pH 5.0-8.0 Myoglobin 107 ng/mL
Protein ' Negative-Trace - . ierebtola
Urobili Negative Source: Nitrite Negative FecLeuk Negative Leuko Negative Gram Stain
Urine Microscopic WetPrep Negative
WBC Epi)-KOH No Fungal Elements RBC Mucus OccBld Negative Bacteria Yeast O&P No Ova/Parasite
Casts: Spermatozoa
)Crystals: Amorph Sed Urine Negative
1
Other. legative
MEDCOM - 2054
DOB IYRANK SSN
Reported by: Date and Time:
tb)(6)-
tc1S-eri 3 .13 /7 14E1414ta gY
X TEST RESULT REF. RANGE WBC 4.8-10.8 x10(3)/uL RBC 4.2-6.1 x10(6)/uL Hgb 12.0-18.0 g/dL Hct 35.0-60.0% MCV 80.0-99.011 MCH 27.0-31.0 pg MCHC 33.0-37.0 g/dL Plt 130-400 x10(3)/uL LY% 15.0-55.0% LY# 0.7-4.3 x10(3)/uL
Differe ntial
Segs Mono
Bands Eos
Lymph Baso
Atyp Ly Immature cells RBC Morph:
Pit verify
Spun Crit j 35-60% ....
Thin No Plasmodium See
Thick No Plasmodium See
Sed Rate 1 hr = 0-20 mm
. • ...
PT 10-13 seconds APTT 22.1-33.7 seconds FDP Negative D-Dimer Negative Fibrinogen 200-400 mg/dL
ABO/Rh
T&C
T&S

LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Subject to Privacy Act of 1974)
DOB RANK SSN
LAST FIRST MI UNIT
b)(6)-4
Physician: Ward: X STAT Specimen Date and Time: Date and Time:
b)(6)-2
.
-Routine er /S'Sveit/c
CCAA
Cheml '' • Hemi gy Crean MVO H/I
X TEST RESULT REF. RANGE
X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE 128-145 mmoUL ALB 3.3-5.5 g/dL WBC 4.8-10.8 x10(3)/uL
Na 135 G • r
K 3.3-4.7 mmoUL ALP 26-84 U/L RBC A. 34 4.2-6.1 x10(6)/uL 98-108 mmoUL ALT 10-47 U/L Hgb 12.0-18.0 g/dL
Cl
pH 7.35-7.45 AMY 14-97 U/L Hct 35.0-60.0%

1.311
PCO2 G.0.1 35-45 mmHg AST 11-38 U/L MCV 415.0

80.0-99.0 PO2 80-90 mmHg Tbil 0.2-1.8 mg/dL MCH 3 2.4 27.0-31.0 pg
91
18-33 mmol/L BUN 7-22 mg/dL MCHC 34.1 33.0-37.0 g/dL
TCO2
33
HCO3 22-28 mmol/L Ca 8.0-10.3 mg/dL Pit 007 130-400 x10(3)/uL
1
s02 95-99% Choi 100-200 mg/dL LY% ILI. w 15.0-55.0% BEecf (-2) - (+3) CK 30-170 U/L LY# I. 0.7-4.3 x10(3)/uL
AGap 8-16 mmoVL CL 98-108 mmol/L Differe ntial
ci f
iCa 0.11-1.23 mmoUL TCO2 18-33 mmol/L Segs Mono

BUN 7-22 mg/dL Creat 0.8-1.2 mg/dL Bands Eos
1.0
Glu 73-118 mg/dL GGT 5-65 U/L Lymph Baso Creat 0.6-1.2 mg/dL Glu 73-118 mg/dL Atyp Ly Immature cells
111
Hct 35.0-60.0% K 4.1 3.3-4.7 mmoVL ROC Morph:
Hgb 12.0-18.0 g/dL TProtoin 6.48.1 g/dL
Lactate 0.90-1.70 mmot/L Na 128-145 mmoVL Plt verify:

Unna Spun cat 35-60% Color Straw/Yellow Mono Negative Clarity Clear RPR Negative Thin No Plasmodium Seel
Glucose Negative HIV Negative Bilirubin Negative Meningitis Negative Thick I No Plasmodium Seel
Ketone Negative DOA Negative SG 1.010-1.025 CK-MB 4.3 ng/mL S:od Rata Blood Negative Troponin) 0.19 ng/mL t hr = 0-20 mm
pH) 5.0-8.0 Myoglobin 107 ng/mL
Protein Negative-Trace A)crop. o PT 10-13 seconds Urobili Negative Source: APTT 22.1-33.7 seconds Nitrite Negative FecLeuk Negative FDP Negative Leuko Negative Gram Stain D-Dimer Negative Urine Microscopic WetPrep Negative Fibrinogen 200-400 mg/dL
WBC)Epi • KOH No Fungal Elements
RBC Mucus . OccBId Negative Bloc Bank •
Bacteria Yeast O&P No Ova/Parasite ABO/Rh

Casts: Spermatozoa -i &C
Crystals: Amorph Sed Urine Negative TBS
Other: `legative

¦¦¦
COM - 2055
17
-
LABORATORY RESULTS FORM
(Sub'ect to Privac Act of 1974)
21st COMBAT SUPPORT HOSPITAL
LAST, GT kM
b)(-6)-4
TCO2 HCO3)5 ti s02 BEecf)/0
AGap iCa
BUN
Glu
Creat
Hct
Hgb
Lactate
Color Clarity Glucose Bilirubin
SG
Blood
pH
Protein
Urobili
Nitrite
Leuko
, n g
DOB RANK SSN
UNIT
STAT Specimen Date and Time:
35-45 mmHg AST 11-38 U/L 80-90 mmHg Tbil
0.2-1.6 mg/dL 18-33 roman BUN 7-22 mg/dL 22-28 mmoVL Ca
8.0-10.3 mg/dL 95-99% Chol
100-200 mg/dL 30-170 U/L
(-2) - (+3) CK 8-16 mmol/L CL 7 7)
98-108 mmol/L
0.11-1.23 mmoVL)TCO2)C, 18-33 mmoVL)Segs
7-22 mg/dL 73-118 mg/dL 0.6-1.2 mg/dL 35.0-60.0% 12.0-18.0 g/dL 0.90-1.70 mmolA.
rit181ysis Straw/Yellow Clear
Negative
Negative
Negative
1.010-1.025 Negative
5.0-8.0 Negative-Trace Negative Negative Negative
Urine Microscopic
WBC) RBC Bacteria Epi)• Mucus Yeast
Casts: Spermatozoa
Crystals: II Other: Amorph Sed
A

Creat)0 9)0.6-1.2 mg/dL)Bands GGT 5-65 U/L)Lymph Glu)/)73-118 mg/dL)Atyp Ly
TProtein Na
Mono
RPR
HIV
Meningitis
DOA CK-MB Troponin I
Myoglobin
Source: FecLeuk
Gram Stain
WetPrep
KOH
OccEild
O&P
Urine
Rcinirri
3.3-4.7 mmoVL 6.4-8.1 g/dL 128-145 mmol/L
/3- f3
isc .Chemistry`..
Negative Negative Negative Negative Negative

4.3 ng/mL

0.19 ng/mL 107 ng/mL

i46.6:16166
Negative
Negative No Fungal Elements
Negative No Ova/Parasite
Negative Negative
MEDCOM - 2056
Date ap.gp/e:
rata
RESULT
i9
7
MCV) MCH 33. 0 MCHC LeA 9 Plt)
7(9 LY% /61 LY# /, 0 Differe
RBC Morph:
Plt verify•
Spun Crit
Thin
Thick
Sed Rate I
050 PT APTT FDP D-Dimer
Fibrinogen
ABO/Rh T&C T&S
vii i
REF. RANGE
4.8-10.8 x10(3)/uL 4.2-6.1 x10(6)/uL 12.0-18.0 g/dL 35.0-60.0%
80.0-99.0 It 27.0-31.0 pg 33.0-37.0 g/dL
130-400 x10(3)/uL
15.0-55.0%
0.7-4.3 x10(3)/uL ntial Mono Eos Baso
Immature cells
35-60%
No Plasmodium See
No Plasmodium See
lhr vi 0-20 mm
at on 10-13 seconds
22.1-33.7 seconds Negative Negative
200-400 mg/dL
-t L.. VI
,A.

TORY RESULTS FORM
(Sub'ect to Privac Act of 1974)
21st COMBAT SUPPORT HOSPITAL
DOB RANK SSN
b)(6)-2 D to and Time: hucir Specimen Date and Time: )(6) 2
Routine
Cl m ttht.:(PW451.6.40AISiterte:i'''
RESULT REF. RANGE
X TEST REF. RANGE X TEST RESULT REF. RANGE
4.8-10.8 x10(3)/uL
Na 128-145 mmol/L ALB) 3.3-5.5 g/dL
4.2-6.1;x10(6yuL
K 3.3-4.7 mmoVL ALP) 26-84 U/L 1 .2.67.18.0 g/dL
98-108 mmoVL ALT) 10-47 U/L 35.0-60.0%
CI
pH 7tEte 7.35-7.45 AMY) 14-97 U/L 80.0-99.0 fl
PCO2 it60. 35-45 mmHg AST) 11-38 U/L 27.0-31.0 pg
P02 80-90 mmHg Tbil) 0.2-1.6 mg/dL 33.0-37.0 g/dL
TCO2 18-33 mmoVL BUN) 7-22 mg/dL 130-400 x10(3)/uL
HCO3 22-28 mmol/L Ca) 8.0-10.3 mg/dL
3 .
15.0-55.0%
s02 q3 95-99% Chol) 100-200 mg/dL 0.7-4.3 x10(3)/uL
BEecf (-2) - (+3) CK) 30-170 Ult.
Differential
AGap 8-113 mmol/L CL) 98-108 mmol/L
iCa 0.11-1.23 mmol/L TCO2) 18-33 mmol/L
7-22 mg/dL Creat) 0.6-1.2 mg/dL Bands

BUN
Glu 73-118 mg/dL GGT) 5-65 U/L
Atyp Ly Immature cells
Creat 0.6-1.2 mg/dL Glu) 73-118 mg/dL
Hct 35.0-60.0% K 3.3-4.7 mmoVL RBC Morph:
Hgb 12.0-18.0 g/dL TProtein) 6.4-8.1 g/dL
Lactate 0.90-1.70 mmol/L Na 128-145 mmoVL Plt verify:
Spun Crit 35-60%
Negative
RPR Negative
Color Straw/Yellow Mono No Plasmodium See
Clarity) Clear Glucose Negative HIV Negative Thick No Plasmodium See
Bilirubin) Negative Meningitis Negative
Ketone Negative
DOA Negative
SG) 1.010-1.025 CK-MB 4.3 ng/mL
Blood) Negative Troponin I 0.19 ng/mL Sed Rate thr = 0-20 mm
pH 5.0-8.0 Myoglobin 107 ng/mL 10-13 seconds
Protein) Negative-Trace 22.1-33.7 seconds
Urobili Negative Source: Negative
Nitrite) Negative FecLeuk Negative • FDP D-Dimer Negative
Leuko) Negative Gram Stain WetPrep) Negative Fibrinogen 200-400 mg/dL
Urine Microscopic
KOH No Fungal Elements
WBC Epi
Mucus OccBld Negative oo an

RBC
Yeast O&P No Ova/Parasite • ABO/Rh

Bacteria
Casts: Spermatozoa
Crystals: Amorph Sed Urine) Negative ¦T&S
Can en, Negative

Other
MEDCOM - 2057
Other
. I' ,,4 0/
LABORATORY RESULTS FORM
(Subject to Privacy Act of 1974)
21st COMBAT SUPPORT HOSPITAL
DOB [RANK SSN
UNITLAST Date and Time:
STAT Specimen Date and Time: Reported by:
Ph ciman- Ward:
(b)(6)-2 arC(?)
b)(6)-2
UW1 Routine 16cati:c. "Nie
RESULT REF. RANGETESTREF. RANGE
X
4.8-10.8 x10(3)/uL
1s ,f 128-145 mmol/L ALB 3.3-5.5 g/dL WBC / 3 4.2-6.1 x10(6)/uL
K
Lbt 3.3-4.7 mmoUL ALP 26-84 Wt. RBC 2.”3
12.0-18.0 g/dL
98-108 mmoVL ALT 10-47 U/L Hgb 7 . 7
35.0-60.0%
7.35-7.45 14-97 U/L
pH AMY Hct
80.0-99.0 fl
PCO2 35-45 mmHg AST 11-38 U/L MCV MCH -3 2. .2 27.031.0 pg
80-90 mmHg Tbil 0.2-1.6 mg/dL
P02
33.0-37.0 g/dL
TCO2 7-22 mg/dL MCHC 3 3
.18-33 mmoUL BUN 130-400 x10(3)/uL
HCO3 22-28 mmol/L Ca 8.0-10.3 mg/dL Plt 02 L6 15.0-55.0%
95-99% Choi 100-200 mg/dL LY% 2. I. S
s02 lv U cl
0.7-4.3 x10(3)/ul30.170 U/L LY#
BEecf (-2) - (+ 3) CK
AGap 8-16 mmoVL CL 7-7

Differential Segs Mono
98-108 mmoUL
iCa 0.11-1.23 mmol/L TCO2 18-33 mmol/L
7-22 mg/dL Creat 0.6-1.2 mg/dL Bands Eos
BUN
Glu
73-118 mg/dL GGT 5-65 U/L Lymph Baso
Immature cells
mg/dL Glu ift 73-118 mg/dL Atyp Ly
Creat b 2
35.0-60.0% K 3.3-4.7 mmoVL RBC Morph:

Hct
Hgb 12.0-18.0 g/dL TProtein 6.4-8.1 g/dL
Na 128-145 mmoVL Plt verify:
item Spun Crit 35-60% Lactate 0.90.1.70 mmoVL
rib
Color Straw/Yellow Mono Negative •atatik. 0 Thin No Plasmodium Seen
RPR Negative
Clarity Clear
Negative

Glucose Negative HIV No Plasmodium Seen
Bilirubin Negative Meningitis Negative Thick
Ketone Negative DOA Negative
4.3 ng/mL
SG 1.010-1.025 CK-MB Negative Troponin I 0.19 ng/mL Sed Rate 1hr =0-20mm
Blood pH 5.0-8.0 Myoglobin 107 ng/mL da6o al tan PT 10-13 seconds
Protein Negative-Trace 1brOb 010 APTT 22.1-33.7 seconds
Urobill Negative Source: FDP Negative
FecLeuk Negative D-Dimer Negative
Nitrite Negative
Negative Gram Stain
Leuko Negative Fibrinogen 200-400 mg/dL
Urine Microscopic WetPrep
WBC Epi KOH No Fungal Elements

RBC Mucus OccBld Negative kir) Bari
No Ova/Parasite ABO/Rh
Bacteria Yeast O&P
T&C

Casts: Spermatozoa
Crystals: Amorph Sed Urine Negative T&S
"3gative
Other.
MEDCOM 2058
DOD 006110

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MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-65; the Proponent agency is the OTSG
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:EDuRES and CPT Codes:
E -A ANESTHETIC TECHNIOUES:
Describe block technique under Remerife MWS'
IDEN
FICATIN: G crAc -Rs 1 c cP-
Typed or mitten 0170415: Name.Gmd./Rale. eyes ey61&;0, io OL
Mitclical lacINY AIRWAY
MA AGEMENT: Inrubafion mutt
OLY 101:111. Wi de. ko
(b)(6)-4 ycoeAv;rJ rrr-8.0 our ,e0 MShnique. apts. monis
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MEDCOM - 2059
Pciorrni me
.• •
of PT -16.0 TAAL_ 1_71
REANESTHETIC SUMMARY
OPERATION PROPOSED AGE WEIGHT (Lis.) SPECIAL INFORMATION
1 6t -)0e,) -
( ,.-p
PHYSICAL STATUS'
1 6 3 4 .5 .6 7 URINALYSIS Apr +Pr FL idol ' :4; 4- . erre-/4-,e,-
HEMATOLOGY
SCIINAL B LOOD alemtstRyi
HET

ABNORMAL Aim vorn
OTHER
RESPIRATORY SYSTEM CIRCULATORY SYSTEM CENTRAL NERVOUS SYSTEM
OTHER SYSTEMS
(*.HAY. ASTHMA. OTHER PATHOLOGY)

HAY*
(CEREENOYASCULAR,.POUO. NEUROLOGICAL) (ALLERGIES)ECG (if PERTINENT)
Matit
-9-
P1- 7,5)E4 pr 7-14 .2v„ ;i)
PREVIOUS ANESTHETICS AND COMPLICATIONS PRESENT DRUG THERAPY; EG...SIINADS. litANOUILIZERS
PREOPERATIVE DIAGNOSIS .
PREMEDICATION,
rtalq, 1011 4 VA\ LF

PP
URLUe
Gska L f•-it
SIGNATURE OF EVALUATING PHYSICIAN DATE
:b)(6)-2
6/7", Cg/v/t ri srffo:. io le-a) '145 KS POSTANESTHETIC VISITS
RECORD ALL PERTINTIT COMPLICATIOAS
/ 00Y6 0^ AJE.b
'U.S. Government Printing Otte: 1994 — 700-942/10029
(b)(6)-4
EPW

MEDCOM -2060
DOD 006112

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-68; the proponent agency is the OTSG
DRLIO TOTALS TOTAL ESL ) I
I

I. TOTAL URINE
I I
I % dal
•

FLUI03,41.1MMARY
AGENT;, it, a. cf.
CRYSTALLOID-
AIR IftAin
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;INGLE DOSE DRUGS-MARK ON GRID
WITH NUMIEKS & ENTER WREMARKS' C23)

@6)
LINE 3Fte RE0 Warmed
3 it LI 0 Warmed . Warmed C) Warmed lett MI3 Code drugs with numb.,,, 'UV with emzza id
LOSSES. I_ EST BLOOD LOSS . UR NE • It I/ IA u0,44,1 Affrvit5iLic.A.
PHYS:STATUS;:: 1 2 3it 5 6 B TIME Y 1S4..411 Set., ')OO Ete, 5) 64 cpr1(b)(6)-2

;
1
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:flOrt5S
BP/Auto Cuff ET CO2 (tori) -26 .10
PAW 1115.:-.15escIfy
BPloth . RO2 'Frac or %) ,"$3 ART fine 402 1%) 1130 100 OTHER Steth• PC/ES ECG Alia Vitt CONIMTION: $1.34
Coy analyzer TEMP-she .••••• •," KEEP. coos-/0C) N-M Block (TM .4, Vel sr-84 mi. 7j
----Arara,4414. 4
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Warming Mkt 2 Cony wormer Mate with tenon It zymboll. EVENTS
rsplwn uncle' REMARKS Position Dv,
0
PROCEDURES and CPT Codas: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
5?-e tt_l_ PATIENT IDENTIFICATION: -Typad or written entries: Nemo. Greda/Ratc AIRWAY GEMENT;
intubation rou • e. technique, comments Medich facility
-SURfanms: )-2 (b)(6)-2 LOCATION:
(b)(6)-4 PROCEDURE
MEDCOM - 2061
7 ' DATE:
MEDICAL RECORD - ANESTHESIA
For use of this form. sae AR 40.88: the proponent agency is the OTSG
TOTAL DLDRUG .11,tottoi
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(b)(6)-4
PROCEDURE
t.suntY.TS:
LOCATION:
MEDCOM - 2062
r
PREANESTHETIC SUMMARY
OPERATOR PROPOSED AGE WEIGHT (LBS.) SPECIAL INFDRmATiON
1I41'611) t„.., ao,,,,,c, G ( -.... PHYSICAL STATUS I 2 3 4 5'6 7 •
URINALYSIS HEMATOLOGY BLOOD CHEMISTRY
NORMAL,. MU RIC 140
ABNORMAL AND WHY? OMER

CIRCULATORY SYSTEM CENTRAL NERVOUS SYSTEM OTHER SYSTEMSRESPIRATORY SYSTEM
IP (CENERROVASCULAIN POW. NEUROLOGICAL) (AuctatEs)
ECG (if PERTINENT) PULSE(LIMY. AST/INA. 07140t PATHOLOGY)
PREVIOUS ANESTHETICS AND COMPLICATIONS PRESENT DRUG THERAPY; E.G STINDIDS. INANGOIU21R
,_c a/fry/A.4_ Q t ye..r—z.,
PREOPERATIVE DIAGNOSIS PREMEDICATION
kb)(6)-2 DATE
POSTAII
RECORD ALL PERTINENT COMPLICATIONS -
•
.
.
'U.S. Govemnent Printing Ms: 1594 — 330-822/10029
MEDCOM - 2063
DOD 006115

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print) Products are requested.)
(b)(6)-2 _
ED BLOOD CELLS
///TYPE AND SCREEN
FRESH FROZEN PLASMA DIAGNOSIS OR OPERATIVE PROCEDURE
1)PLATELETS (Pool of units) 1 CROSSMATCH
1)CRYOPRECIPITATE (Pool of units)
DATE REQUTED %
I have collected a blood specimen on the below Ct)IC) \O 'S
II Rh IMMUNE GLOBULIN named patient, verified the name and ID No. of the
DATE AND HOUR REQUIRED

patient and verified the specimen tube label to be
1I)OTHER (Speciry) 3-` OB correct.

¦k
`›.-% '''y \ toi
r•InklATI Ulf nr sire-nrno-n
VOLUME 'REQUESTED (If applicable) _ KNOWN)ANTIBODY FORMATION/T)SFUSION
;b)(6}2
REACTION (Specify)
(f OA t (VI
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: LAI b. vtvi-it.0)
RhIG TREATMENT? DATE GIVEN: Vi 03 TIME VERIFIED HEMOLYTIC DISEASE OF NEWBORN? 00E/6
SECTION II — PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTE RPRETATION PREVIOUS RECORD CHECK.
)
CROSSMATCHANTIBODY SCREEN
(b)(6)-4 PATIENT NO. 441,432/4. b)( DONOR RECIPIENT
b)(6)-2
0 CROSSMATCH NOT REQUIRED FOR THE COMP RE
ABO ABO REMAFtniv..)
LieVe)
PIT'Thl4614:1 A-4111" Rh Rh
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.
61--wflbsVi14110.11444IYA.vp SECTION III -YRECORD OF TRANSFUSION
tett...064n 44ALL )-14004-44:›tAki
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
AMOUNT GIVEN TIME/DATE dipliagat I/INTERRUPTED ;•‘,..7--)Nu. 9 .// ,c, --REACTION TEMPERATURE PULSE BLOOD PRESSURE NONE 0SUSPECTED /0 3
INSPECTED AND ISSUED BY (Signature)

AT (Hour) I ON (Date) 744—/
IDENTIFICATION If reaction is suspected—IMMEDIATELY:

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

1st VERIFIER (Signature) DESCRIPTION OF REACTION

1 URTICARIA)CHILL)1 FEVER)U PAIN
• III OTHER (Specify)
2nd VERIFIER (Signature) (b)(6)-2
OTHER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRANSFUSION Er-NO)1 YES (Specify)
TEMP.) I PULSE)jao as ')I Bp 51g6 c.. SIGNATURE OF PERSON NOTING ABOVE sb)(6)-2
DATE OF TRANSFUSWN TIME STARTED
,4,/.2 -.... o /a.c)
PAFNTIT)FNTIFWATIONI —IISF FMnossFo (For typed or written entries give: Name—Last, f rst, middle; grade; rank; SEX WARD b)(6)-4 dical facility)
E-flA k
. . ­
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. F1RMR141 CFR) 201-9.202-1

MEDCOM - 2064
Medical Record Copy
DOD 006116

MEDICAL RECORD
COMPONENT REQUESTED (Check one)
yl RED BLOOD CELLS • FRESH FROZEN PLASMA • PLATELETS (Pool of __ units)... a CRYOPRECIPITATE (Pool of 11)Rh IMMUNE GLOBULIN
. OTHER (Specify) ) VOLUME REQUESTED (If applicable)
REMARKS:
. units)
ML
TRANSFUSION NO.
UNIT NO.
(b)(6)-4 PATIENT NO.
RECIPIENTDONOR ABOADO (:)
Rh
PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)
ON (Date) IDENTIFICAT
AT (Hour)
ION
b)(6)-2
CROSSMATCH NOT REQUIRED FOR THE COM
SEC ION I CORD OF ANSFUSION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches Item by item. ... The recipient Is the same person. named on this Blood Component Transfusion Form and
1) on the patient identification tag.
ci VeRIFIFP 10 at;ilai
1
b)(6)-2
Cr"
Slid VERIFIER (Signature)
b)(6)-2

PRE-TRANSFUSION
Pk la-)I PULSE !Cr 5/ BP
TEMP.)TIME STARTEDDATE 05 TRANSFUSION
4) LeOrce
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
-REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)

0 TYPE AND SCREEN
. CROSSMATCH
-... DATE REQUESTED . 6110103 DATE AND HOUR REQUI9ED '2,Z8)cl110163 KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify) ' IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?

SECTION 11 - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH

AMOUNT GIVEN.
eqe7C) ML
REACTION (ONE . SUSPECTED REQUESTING PHYSICIAN (Print)
-
pa. (b)(6)-2
DIAGNOSIS OR OPERATIVE PROCEDURE
Ps g0 'GSus
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
SIGNATURE OF VERIFIER (b)(6)-2 •
DATE VE IFIED7
ale3
TIME)RIFIED
noll.(7
POST-TRANSFUSION DATA TIME/DATE(COMPL70,INTERRUPTED 5/4)7//0" TEMPERATURE PULSE
BLOOD PRESSURE
S4--c
,
If reaction is suspected—IMMEDIATELY:
1.. Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

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

DESCRIPTION OF REACTION
. URTICARIA 0 CHILL . FEVER . PAIN
. OTHER (Specify)
ER DIFFICULTIES (Equipment, clots, etc.)
g.NO . YES (Specify)

SIGNATURE OF PERSON NOTING ABOVE (6)-2 WARDS
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hosplta or medical facility)
Nap-e7114 4
BLOOD OR BLOOD COMPONENT TRANSFUSION
rale
Medical Record
006
STANDARD FORM 518 (REV. 9-921 Prescribed by GSABCMR, RRMR (41 CFR) 201-9.202-1
MEDCOM - 2065
Medical Record Copy
DOD 006117

)
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS

. FRESH FROZEN PLASMA
• PLATELETS (Pool of __units)
. CRYOPRECIPITATE (Pool of units)
El Rh IMMUNE GLOBULIN

. OTHER (Specify)
VOLUME REQUESTED (If applicable)
i/4"..." .A., ML

REMARKS:
UNIT NO. TRANSFUSION NO.
(b)(6)-4
PATIENT NO.
DONOR RECIPIENT
ABO ABO
D

Rh ec.),....5
PRF-TRANSFLW4CIAIDATA
(b)(6)-2
AT (Hour) ON (Date) (( IDENTIFI TION
5 ie}-,„7.66.3
I have examined the Blood Component container label and this form and I rind all information Identify ng the container with the intended recipient matches Item by Item. The recipient is the same person named.on this Blood Component Transfusion Form and on the patient identification tag.
1st VFRIF1FR (Sign ture)
:b)(6)-2
cieir/AA,A-
ture)
b)(6)-2
PRE-TRANSFUSION
TEMP. qt )I PULSE 77 P
DATE OF IRAN SIO ) TIME STARTED
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
TYPE OF REQUEST (Check ONLY If Red Blood Cell Products are requested.)
111)TYPE AND SCREEN
[ROSSMATCH -- • • •
DATE REQUESTED.,
7 // e
DATE AND HOUR REQUIRED
. 61,5r—rf:0
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN'
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN)CROSSMATCH
e,o&
REQUESTING PHYSICIAN /print)
;b)(6)-2

DIAGNOSIS OR OPERATIVE PROCEDURE
g , -..‘,0)/24r-"/fr......_
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
StertrATRIK.OF VFRIFIFR
(b)(6)-2

0A' E VERIFI) \‘ \
TIME VERIFIED
PREVIOUS RECORD CHECK:
. RE9piTI: NAICOSEr-Th
(b)(6)-2
. CROSSMATCH NOT REQUIRED FOR THE COMPONI b (6)-2 REMARKS: D.,4
AAA. el"CaA tOD4Z ;OA/ • 024.kot, 44.-e el 4 IrSV4.73 itNIS;c;1).1 .A)140‘44.2.3s)04.-t•$1, r71 r t-ct.c4s.t.
66°1 P-c1,,ck cu.) 4.-,0 a'`4 4s
CA rev.", r 4
SECTION III — RECORD OF TRANSFUSION
POST-TRANSFUSION DATA AMOUNT GIVEN, TIME/DA /INTERRUPTED ML 9 1% Z5 REACTION TEMPERATURE PULSE BLOOD PRESSURE NONE . SUSPECTED qg 477/3 7....
7C
If reaction Is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

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

DESCRIPTION OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
.
OTHER DIFFICULTIES (Equipment, clots, etc.) 5(240 . YES (Specify) SIGNATURE OF PERSON NOTING ABOVE
• (b)(6)-2
(b)(6)-4 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, mid rate; hospital or medical facility) e; grade; rank tA. /749­t- WARD 45-/s2 --
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1
MEDCOM - 2066 Medical Record Copy

DOD 006118

518-124
NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION -
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQL,PCTINIC D vcIrwa rn • •1
Products are requested.) :b)(6)-2

WREEH3LOOD CELLS
II FRESH FROZEN PLASMA II)TYPE AND SCREEN
DIAGNOSIS OR OPERATIVE PROCEDURE

El PLATELETS (Pool of units) elEZROSSMATCH
- - • • .
I CRYOPRECIPITATE (Pool of units)
DATE REQUESTED I)have collected a blood specimen on the below
III Rh IMMUNE GLOBULIN , /We, 5.---
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to be I OTHER (Specify) correct. ). C,g.G.Z7)
VOLUME REQUESTED (If applicable) ii....._ KNOWN ANTIBODY FORMATION/TRANSFUSION ir4rnio?•nc 1/ oi cn
REACTION (Specify) (b)(6)-2

4 (1)4J. ML
Ak„, ------
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY 04..._. \
: DATE VERIFIED)
RhIG TREATMENT? DATE GIVEN: al k‘c.V.5 TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
ION II - PRE-TRANSFUSION TESTING
)
UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHEC
))
(b)(6)-4 ANTIBODY SCREEN CROSSMATCH )
0 RE
RECO PATIENT NO.
b)(6)-2
rthf Fer70)0
DONOR RECIPIENT
0 CROSSMATCH NOT REQUIRED FOR THE COM• • N..1=11.1.1
1...
ABO ABO REMARKS: • 40 gArs m." o?-„ oak,. wie
rf,„5 410 PII-Vsk-A" requeavls Wig itneKccUaie (461a,
Rh Rh : 5
4143 k/codprcatcf Withwett acnytVele ii-e640.19 61A-dAS
• /
(1-1000142/ttzly
4443,44...IAN.9-4.44 .244.A.esstitak,,,,O) ... •
SECTION III - RECORD OF TRANSFUSION;
b)(6)-2
POST-TRANS=A
AMOUNT GIVEN TIME/DATE /INTERRUPTED
70 ML oitoo
REACTION
TEMPERATURE PULSE c‘, BLOOD PR SSURE
T (Hour) ON (Date) grrIONE 0 SUSPECTED

e r-C1 gffi ril
.• 02 EMI
/6 1/58
IDENTI)ON
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information Identifying the container with the Intended recipient matches item by Item. 2. Notify Physician and Transfusion Service. The recipient Is the same person named on this Blood Component Transfusion Form and
3.
Follow Transfusion Reaction Procedures. on the patient identification tag.

4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
let VERIFIER (Signature)

DESCRIPTION OF REACTION
(b)(6)-2
URTICARIA 0 CHILL . FEVER 0 PAIN

e/r) r6AA
OTHER (Specify)
nature)

(b)(6)-2
TH DIFFICULTIES (Equipment, clots, etc.) PRE-TRANSFUSION 0 0 YES (Specify)
TEMP. I PULSE 7G 1 BP 1437/ecca GNATURE OF PERSON NOTJNG ABOVE DATE OF TRANSFU5I)ON) TIME STARTED b)(6)-2
427// c;'
3,._ e' 3 4/ ----. 9/7 ti—A, A
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, D,rate; hospital or medical facility)
"12E—
b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

Medical Record Copy
519-301
)
NSN 7540-01-155-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
AGE SEX SON (Sponsor) WARD/CLINIC REGISTER NO.
EXAMINATION(S) REQUESTED
PREGNANT
FILM NO.
row-T*3LE. C.,\IC
YES)NO
TELEPHO GE NO.
REQUESTED PY (Print)
b)(3)-1
-De (b)(6)-2
(b)(6)-2 DATE REQUESTED
F REQUESTOR
LT I 14, 1
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
--zta-Tu s A-mo
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0--

TUBE
-TuV3V-
LUvneckYL SEItt3i. ex

DATE OF TRANSCRIPTION (Month, day, year)
DATE OF REPORT (Month, day, year)
DATE OF EXAMINATION (Month, day, year)
RADIOLOGIC REPORT
0;1-p.COAI
C 1/4 LC
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(b)(6)-2
PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first, middle, Medical Facility) (b)(6)-4 LOCATION OF MEDICAL RECORDS LOCATION OF RADIOLOGIC FACILITY
SIGNATURE MEDCOM - 2068 c-rAmnAran Fruans glan •n_01%

DOD 006120

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
DATE OF ORDER TIME OF ORDER ,b)(6)-4 NOTED AND PATIENT IDENTIFICATION ORDER
or ).'
HOURS SIGN
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TIME OF ORDER
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PATIENT IDENTIFICATION ADATE OF ORDER
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DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION
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REP S EDITION OF 1 JUL 77, WHICH MAY BE USE
DA , ,,epine 4256
MEDCOM - 2069 I • 51K7
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 RECORD­SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW:
PATIENT IDENTIFICATION ',b)(6)-4
NURSING UNIT ROOM PATIENT IDENTIFICATION NO. BED NO.
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. BED NO.
NURSING UNIT ROOM PATIENT IDENTIFICATION NO. BED NO.

NURSING UNIT ROOM NO. BED NO.
LIST TIME
ORDER
NOTED AND

DATE OF ORDER TIME OF ORDER
HOURS SIGN
ti Wp3 OV3?)
•
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DATE OF ORDER TIME • F 0 TER
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DATE OF ORDER TIME OF ORDER
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il(b)(6)-2
b)(6).2
0 6 IOC
( ,b)(6)-2
• b)(6)-2
zv

b)(6)-2
REPLACES EDITION OF t JUL 77, WHICH
DA I FAOPR
M79 4256
MEDCOM - 2070
DOD 006122

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 RECORIS 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
it J. 03 14 ti I HOURS SIGN "
,b)(6)-4 ,b)(6)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDE NTIF I CAT ION DATE OF ORDER TIME OF ORDER
HOUR
S
II • ¦ '• 11116111Mail UM E161 I
)(6)-2
il MI I n rili I ill illil III W." -t. . (6) 2 M ¦ii
111111111111M201.1.1.1.111.1111.1 4 . ,
UNITNIT ROOM NO. BED NO.
iff
AllIM-yriffa n J
Mr
iiiiiinamillliMA -
PATIENT IDENTIFICATION DATE OF ORDE TIME OF ORDER
04e-cl
NI
/01 -47 f gJ —41-CL— HOURS %p6-
`
/14,6/ C.dC PA. ao 2
bX6)-2
. • 'NUR ROOM NO.
PATIENT FICATION
b)(6) 2 b)(6)-2
b)(6)-2
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OP 1 JUL 77, WHICH • ' • BF USED.
DA 4256
,FArR19
MEDCOM - 2071
DOD 006123

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.

ATICtorr ry
t."...
DATE OF ORDER TIME OF ORDER LIST TIME
b)(6)-4
ORDER NOTED AND
HOURS
0
SIGN
..f.„ y72
b)(6)-2
(6)-2
NURSING UNIT NO. 8E0 NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
,b)(6)-2
NURSING UNIT
PATIENT IDENTIFICATION DATE OF ORDER T ME OF ODER
/4243t. Wr'. HOURS
TiFitML 76412K
0 •
b)(6)-2 b)(6)-2
b)(6)-2
(6)-2
NURSING UNIT ROOM BED NO.
It.it A I I P,? 1'ilAl.T ICE
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
/r
/ 6t) HOURS 004e1
;,,, 3as
4 -1ff #14,"
••••¦
r-R
iff--
,M(6)-2
NURSING UNIT ROOM NO. 8E0 NO.
9-`-t ° Otitt
FORM79
REPLACES EDITION OF 1 JUL 77. WHICH .f BE USED.
DA 4256
MEDCOM - 2072
DOD 006124

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
(b)(6)-4
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
LIST TIME ORDER HOURS NOTED AND SIGN
DATE OF ORDER TIME OF ORDER
if II 471-0-1
ro c 1 tly -Lf/-A -y (4.
/-32 4-50"
BED NO.
71-,
(.1
_
412,./
DATE OF °ROE* TIME OF ORDER
HOURS
A'A
4 fir
F
A

BED NO.
741: OF ORDER TIME OF OR R
OURS
gl —7"e ,
al° cc,-/s 1,.6 CSC A46 j /14— )
"
P-67)4' 7: 6
BED NO.
tie/ 4.-
)(6)-2
./.4d
F4.
,
DATE OF OREMR TIME • RDE..) 40/¦ HOURS
A-14‘;‘(.040r'
ao
de‘ 673-g,)_2
.5-1'`ND
BED NO.
REPLACES EDITION OF , i • • , r7g I MAY BE USED.
DA I FAcg:19 4256
MEDCOM - 2073
DOD 006125

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER , LIST TIME ' ORDER
;b)(6)-4
OT D AND
It . 3
(f) (111c HOURS SIGN
b)(6)-20 C 47
i)
v `f-,(-: Ce-e L-2-kl-••••.e re
by6)-2
NURSING UNIT ROOM NO. P TIENT IDENTIFICATION BED NO. DATE OF ORDER TIME OF ORDER HO •5 .
NURSING UNIT • ROOM NO. PATIENT IDENTIFICATION BED NO. DATE OF ORDE - TIME OF ORDER HOURS
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED O. DATE OF ORDER TIME OF • t DER HOURS

NU ;NG UNIT ROOM NO. 8E0 NO.
REPLACES EDITION OF t JUL 77. WHICH MAY BE USED.
DA ,FAOpng 4256
MEDCOM - 2074
DOD 006126

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, sea AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER LI)I
TIME OF ORDER
ORDER NOTED AND
(b)(6)-4 HOURS
lt-( t V SIGN
b)(6)-2
NURSING UNI ROOM NO.
clv4 qfg/t t • PATIENT IDENTIFICATION DATE' OF ORDER TIME OF ORDER
b)(6)-2
7././_
HOURS
-f-rt—of
iy / )1/ ie-k
14,2
Ay -6.-/1
(b)(6)-2
4
NURSING UNIT 1400 0
rife pi4
P, LAc-C-rd
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDEA...,
R%/C-7/ 24° off HOURS
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
b)(6).2
fe$ ;$1 ,b130
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA ,FAcg:19 4256
MEDCOM - 2075
DOD 006127

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 NUMBE2 IN COLUMN INDICATED BY ARROW BELOW.
;13)(6)-2 PATIENT IDENTIFICATION DATE OF O: Atilgv A oarir:14 ovi­ab 6fci cge
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. b)(6)-2 DATE OF ORDER
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. 1 BED NO. GATE OF ORDER (b)(6)-2 1 0
b)(6)-2

y
LIST TIME
ORDER
NOTED AND

TIME OF CIDER
HOURS
SIGN
12.
b)(6)-2
2,1-)
TIME OF ORDER
)(6)-2
C)

TIME OF ORDER
(6)-2b)(6)-2
TIME OF 0
b)(6)-2
b)(6)-2
(b)(6)-2
ai\cQw)N.
NURSING UP. IT 6 rtiSEC
FORM REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
,DA • 4256
, APR 79
MEDCOM - 2076
DOD 006128

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OM
THE
DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD­SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW;
:b)(6)-4 DATE OF ORDER . TIME OF ORDER LIST TIME ORDER ED NAND
ir 41.-.°I)/22.....)
HOURS
7—
NOTSIG
l/a".../75Z-.
Zoce/(---
I-C-2 a( /-ae
I
r-= (-4-, c ....7--744, -t--.7-'0 cc_
.....-..4,,,..--a ,/,‘,q. ' ` 0.1_,-,
I J., ;, ,..
).. .1.---.Lvj
NURSING UNIT ROOM .641 BED 0. —
to , ‘...
r- c,
•)(6)-2
/I
"... /clWI PATIENT IDENTIFICATION
IDENTIFICATION DATE OF ORDER TIME OF ,b,,,,_2
( .
NURSING UNIT ROOM NO. BED NO.
•
PATIENT IDENTIFICATION DATE 0 ORDER TIME OF ORDER
V
-../
Ai dLO a / HOUR-
k
00 ra111 Ea I I LIM Iri1 I111111111lir
is-i I 1.•- .
c-e(, 1,5 c /A =. ; ., • II -'*
ur
firfi
Li
---kb)(6)-2
NURSING UPIIT Clivvi. FI00 NO B , NO. i ur4c-N--• IN
PATIENT IDENTIFICATION DATE OF OER TIME OF ORDER
;NIL. (‘ ° j1. .u. 7-s," rofi C4c , 4-4'6'01 , 0C .L. a HOURS 1 0 P°1 -T? i -‘A P
(b • I, LCL( .. -f- . 95--­4 l ( b)(6)-2 —
NURSING UNIT ROOM NO. BE• • ..01. 1711r1re \`r . . ,I i _
-2

DA ?PLACES EDITION OF 1 JUL 77. WHICH MAY MED. 1FAOPRRM9 4256
MEDCOM - 2077
DOD 006129

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 inFNTirire.Tintu
DATE OF ORDER LIST TIME
TIME OF ORDER ORDER
;b)(6)-4
NOTED AND
.e:23 /0 d0 HOURS
iti
SIGN
I
y , (-1 i
c:%'c",/-
I t
fab 14. t )(6)-2
NURSING UNIT ( ' II
ROOM NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
i it(fir'fai —411—HOURS
4
v lipi
(b)(6)-2
NURSING UNIT ROOM NO. BED
dti
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HO -S
fs, traJ
SP Z— 7C' 4
:13 (6)-2
NURSING UNIT ROOM NO.
BED NO.
."--••74"-/
PATIENT IDENTIFICATION DATE OFOF ORDER TIME OF ORDER
I TIO-0
H U S
t656eolp
1 -7-• b)(6)-2 ..•
b)(6)-2 VI¦
11111L'Pr
NURSING UNIT ROOM NO.
BED NO.
:PLACES EDITION OF 1 JUL 77, WHICH MAY ism
L)A 1 F4256
AOPARM/9
MEDCOM - 2078
DOD 006130

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 RECORD­SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION f DATE OF ORDER TIME OF ORDER HOURS LIST TIME ORDER NOTED AND SIGN
• Vt'‘...,/
a%:‹7-0
a 47(
pooh
87c_
NURSING UNIT , ROOM NO. BED NO.

b)(6)-2
PATIENT IDENTIFIC ATION, DATE OF ORDER TIME 0
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
NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
FORM 79
DA 4256
1 APR
MEDCOM - 2079
DOD 006131

RECORD - MEDICATION ADMINISThp...ail RECORD
For or of this farm. as MEDCOM Cie:NW 40-5
=cum t DA1VTIME DATEMME
MIMS DELAYED =mix. ACTION ORDERS a PREOPERATIVES TO BE GIVEN AND worms
b)(6)-2 I gh, 71 a "1. b)(6)-2
" 410E* ' /
'4 b)(6)-2
/7.9.7 AtiG DA/ ester:1".fire 05-02, 0)(6)-2

IV¦ 11
IEMPl
a%
aim PATIENTS] ON
(b)(6)-4 4/4- z:rtn-r/ Ie", n ft-A /5,
ALLEReES: A
Cielo minimiser:60A times Or¦ p 0 07 03 09 10 E 1S 16 17 13 N 23 24 01 02 tor recurring .s—a 11 12 13 14, 19 20 21 22' 03 04 05 (16

MEDCOM FORM 690-R CTEST1 MACHO' --RS ARE OBSOLETE aro vcao
Pap 7cJ4 pa9.s
MEDICAL RECORD - MEDICATION ADMINISTRATION RECORD
INMAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER
DATE ADMINISTERED
DATE
1111111111/1111111111111
1111111111111E
111111111 I
11111111111
11111111111
WOCOM FORM 6904t mg= IMMO) MAR SS
:b)(6)-4 :•.2,2.!On:2 of 4 ADS'S
MEL, RECORD - MEDICATION ADMINISTFIAlsON RECORD
PATIENT IDENTIFICATION X,)(6)-4
DIAGNOsts: Gehfj 1-V P,e
ALLEMIES: At14.A4
arde administration ties= On pencni,fpiiiiietanirg tnedianion.
D . 07 Oa 09 10 11 12 13 14.... E 15 16 17 16 13 20 21 22 N 23 24 '01 02 03 04 05 06
. :1.!!•!'
MEDCOM FORM 69D-R (rEst tife.NO) MAR RS MEDCOM - 2082 Paps 3.14 pip=
NIEC..—e“. RECORD • MEDICATION ADANNISTRA1 suN RECORD
PST1A1; PROPER COLUMN 1:01.1.DWRIGEACH ADMINISTRATION
=gum I Met,
ORDER •DATE ADKUNISMED
1101111111111 RECURRING MEDICATIONS.
DATE 4
DOSE. FREQUENCY
10 11 I 15"
11.)I 1G 7 lFf fi -to JIf
b)(6)-2 (b)(6)-2
/ °
n sct 07
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if 51,01
/50 cc # obi
11101
b)(6)-2
•( Stt,
ier: WIPO
b)(6)-2
111
11.11.11111 11111111111111 1M
11 3c/ 63 I ow KI
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/UMWAIM
11111111WAIIIMNI

11. Se /47'
1220"EMZIMMIENIMIN •••••.11111111111/41111111111111M1111111111M111111111111M
1.15(007
PATIENT IDENTIFICATION (bX6)-4 DIAGSI0565 I&VL9/9- laouseg Av
.
ALLEADIES: /VXM?
. ,
aide administrsoon limes On plena) Rx manning siedicsdos.
D 07 OS 09 10 11 12 13 14
E 15 11S 17 15 19 20 21 22
N 23 24 01 02 03 04 05 06

MED COM FORM 6ari4t (1 77 oscrav Amur as MEDCOM - 2083 Page 3 of 4 pages
DOD 006135

MEDICAL RECORD - MEDICATION ADMINISTRATION RECORD

MOM TRANSCIONIN SECTION ¦ MOTU& PROPER COUDAN FOLLOWING ADMINISTRATION
0:111RATION mono RIEDICATTON. DOSE.
Dna INITUILS ROUTE. FREQUENCY. REASON TOILE/DATFJREASONANITIALSJEFFECTiVENE= CODE

A.5ov ,-, v i y e is Ag.,
I°1 It gm% `moi' =All
ve•
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EZINTOIMMININIMMINIMAInallEMN
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IMITIIEIWIMIPINORLPNIMIIMRIRNIEIIIIIIIII
' (:)1( .
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1.1. A .
pp:.._,_. Th 1
Od
lommaill
pp
111111
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P••• • . •• • .:)••••)•
CODES: Inidancely ss Mordadion ado :awned Nhitials and I ss Maersenkm ineffeedo• %Wait and E Passrowiors affective :shins and 0 ssPawfwasion withheld! . i'4.1
70ER,IF!..t°!muigegormy ,-,
MEDCON FORM ego4 mtrithictiol Auti.sr fase-4411.4.paiss-
.4^ MEDCOM - 2084 •

DOD 006136

¦7¦11¦11
M87 L RECORD - MEDICATION ADMINIST— -ION RECORD
INITIAL. PR IFLOMN FOLLOWING EACH ADMINISTRATION
SECTION
ORDER DATE ADMINISTERED
RECURRING leariCATIONS.
DATE DOSE FREQUENCY
ID Il IZ 17 14 IS 16 17 It za 2 / "2:2 b)(6)-2
ISO
0
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.71EiiCtlif FORM 6saa or= OICII01 MAR SS
(b)(6)-4 fter 2 el 4 Pages
MEDCOM - 2085
DOD 006137
FOLLOWING EACH ADMINISTRATIONSECTION II
/ER
DATE ADMINISTERED
HR
RECURRING MEDICATIONS.
DOSE. FREQUENCY

ATE
t3 ty
b)(6)-2 .b)(6)-2
.33EPOS Ov4-421)CZ' I
(b) (
1350'6 0-Beac-es+ -1e5 re-,t1 nr.1 ¦ ,
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scci EMNIMIPPIRMI
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b)(6)-2 t•
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DI 1111111111111111111111111111
35,203 1e 4-n c-Pt 4
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111111111111111
1111111111=111111
11.1.11111111111111•1111111111T1 1111•111111111111•11111 1111111111111111111
ilaiRMIEM mannlioliffli
b)(6) 2
misitorimmi
4 1111111111111L--1111111
"
a
41111111111111111111=1
PAIMININIMINIME
1111111111111111111111111
111111111111111111111111111
bx6)-
3e4t; bo I b z I) •
b)(6)-2
111111111111111111111111111
Irerarnsgimilm
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353 1111111 1111111
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1EncOM FORM 691:LR 1TES77 !MOM MAR 29
Paget 2 of 4 pages
I •
MEDCOM - 2086
DOD 006138
RECORD - MEDICATION ADMINISTIs....../N RECORD
For use of this forte. sae MEDCOM Circidar 465
SECTION I
DATE/TIME DELAYED SINGLE ACTION cams & PREMERATIVES TO BE b)(6)-2 WHY
b)(6)-2
13.50963
A
Ow 4 ir 04/ w v.) f 4- ("al /zie 30
66.
b)(6)-2
b)(6
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r

tooirel frvivo - (9;30 ok320.,-,, (00
b)(6)-2
b)(6)-2
ry

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b)(6)-2
thicer I
b)(6
PATIENT ID 10N I -2
(b)(6)-4 SIP (j-ti
DIAGNosts:

AVbe ft9 Pf1r.-) / 145 13
611 5 AlLialGtEs:
Ni( (V;
Circle nation times 6n pencil) for recurring ineefication.
07 Oa 09 10 11 12 13 14 E
15 16 17 18 19 20 21 22 N
13 24 01 02 03 04 05 06
MEDCOM FORM 690-8 (TEST) MACHO) MAR 99
PREVIOUS EDMONS ARE OBSOLETE
Peso 7 of 4 pages
MEDCOM - 2087
DOD 006139

Md iRECORD • MEDICATION ADMINISTt..-. st/14ECORD
1121111PankAra
2
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1111111111111111111111111111
1111E111111111111111111111
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11111111111111111111111
IIIVIIMPIP11111111
nun
.........
mom.

PATIENT IDENTIRCATION
(b)(6)-4 DIAGNOSIS: 31t3 re— eff31.e.wASVICIOil
ALLERGIES: 1,,yr_DA 37-tolzbe / AS() Clod_. re,
CA.cle administration times tin pencil) for recurring medication.
D 07 03 09 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 OS 06
MEDCOM FORM 17=77 IMMO, MAR so Paste 3 of 4 pages
MEDCOM - 2088

MEDICAL RECORD • MEDICATION ADMINISTRATION RECORD
SECATTC
INITIAL PROPERPRN
MB^RCATIORY. DOSE
COLUMN FOLLOWING ADMINISTRATION
ROUTE FREQUHiRCY
. REASON
TIMEJDATFJRWASONANITIALS/EFFECTIVENESS CODE
.........______,

...,..„,„,
.........

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awireg=11111111miiiiiii111111111111111
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im1111111111111011111
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/"W_ MINIIMIIIIIiiiiiii11111111111111111111111111

...--,.,„=
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CODES: thins
' Wanly I. Matheation admirestratad
kafth. am. E . MetraMlion Initial* and I .. Aleafim insffecdve :_. ..•• ., •.•::, J.- :

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legitsdd. (-:••SmEmgFORIAIRSWMY .LW PORN Mt" •( r7M77 fM°1°1 MA" . • est4I perm
RECORD - MEDICATION ADMINIST' 13N RECORD
INITIAL PR, ..GLUMN FOLLOWING EACH ADMINISTRATION
ACTION V
ORDER DATE ADMINISTERED
FM
_ _RECURRING MEDICATIONS.
DATE DOSE. FREQUENCY
t(d
b)(6)-2
b)(6)-2 • trmiLi These. G 30

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*Ebethificiam .mrsrlissafor awe as
Pag•.? of 4 poses
•
(b)(6)-4
MEDCOM - 2090
DOD 006142
MEL........i. RECORD - 11/IEDICATION ADMINIST11"....iN RECORD •

•
For use of this form. owl MEDCOM Greadar 40-5
ORDER isooKosir
SECTION I DNIEMAIE Dawn=
legit TO BE GIVEN
DATE . DELAYED SINGLE ACTION imam a PREOPERATIVES
wow GWEN AND INITutts
(a, l(b)(6)-2 ..... eir2 j fitt, ,A._?.. 10 Ain
(i/P'tirdP oSx) (b)(6)-—. /VI 1?-..,'01/ 6-0il'lS Spre fiz X / plo.0 . 9A 1 4 b)( + 7.1.'
9 k _ 5t 1.br
ailOP ''' 0 tf Mi r ko ir • VIA.
1(V39 — 41, (-Prkt=' -AV C, 9 t6

1 t„,-0
k ticeP - p‘eci t tr)oor A--F-roalc 0C-- 1,3 . . .. f2
7: (b)(6)-2
t k..f. -4 (-tyke .1-.T. 1-1--, 1 c-
-
-
•
.
. •
,
• - •
—
PATIENT IDENTIFICATION (b)(6)-4 DIAGNOSIS:
ALLERGIES:
Circle acniniotralior dews CM per) for recurring smoc6cation. 0 07 06 09 10 11 12 13 14
•
. E 15 16 17 18 19 20 21 22

•
N 23 24 01 02 03 04 05 -06

.. -r, MEDCOM FORM 690-R awn. • zn MAR PREVIOUS exhorts ANI. 4ETE Pop I of 4 pages sac MAO
, •
•
)
MkaasCAL RECORD .SUPPLEMENTAL MEDICAL IATA
For use of ttiis form, see AR 40-400 the PrelsonetlIagens? es The OfrIce of The Sligleee General
REPORT TTTLE

OTSG APPROVED /Dare/
POST ANESTHESIA CARE UNIT FLOWSHEET
'17 Jan 80
PROC DURE:'3 ALLERGIES: ASA

History
• Al: AYS: Time DC'D Cardiac Rhythm
PHYSICIAN: .43WP Nasal Oral Tyartitli m IVe1
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POST A 'AA .
tvs y• entre, lie a il DRESSING: Status Location
2—Mamtam head lift and open eyes

Gauze '
1-Unable to maintain head lift and open eyes
0-Unable to lift head and open eyes Opsite

Bandaid
Activity • SAB orSubarachnoid Block
2-Moves all four extremities with control -4 Surd-strips
m oyes both upper extremities

-J 1 -
Collodian
2-5Pontaneous restoration: needs no support

I ritS02f3LORS
-10 Pen-pa
• -Lonstedseffort needs artificial airway or taw support ' d
0-Needs ventilator; no spontaneous respiratton Cohan
Larculeuon

Cotton Balls
2-BP 20% orearaistbetic level
1 -BP,•ea.• 50% prearwithenio level Ace Wrap
0-EIP SO% or more Dreams-Mete level

Lever 0 -=Aisne=
2-Awake and alert seldom dozes
1 -Awakens when gently stimulated •:

0-Awakens only omen vigorously samulatod TUBES Hemovac Foley NGT
AND Chest .cmlumn-Pmat
2-Normal skin color & teneaerature greater than 96 °
1-skin is hale, blotchy, dusky &Ior temperature 95 • 96 DRAINS:

-
0-Cyanotic 1. or temperature less than 95 °
(Carninee on reverse)

PREPARED BY DEPARTMENT/SERVICEICUNIC(b)(6)-2
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OR EVALUATION
0 DIAGNOSTICS STUDIES
0 TREATMENT
• FH !IDA Cl' 132-11a (Rev)

DA 1 MAY 7B 4700
1 Sep 99

MEDCOM -2092
DOD 006144

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1 2 3 4 5 6 7 8 (State or
Country

For use of this form, see AR 40-400; the proponent agency is OTSG
A 1 4 A 1 I Z Code.l

3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
(b)(6) -4
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6. DATE OF BIRTH (Y Y Y YMMODI 7. JYGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 I 20 21, 22 23 24 25 27 128 29 I 30 31 BACK-
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10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34- Pellr'''sa• 37 38 39 40 41 42 43 44 45
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DMISSION
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17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION
Country Code)

YEAR NO
62 63 64 65 66 67 68 69 70 71
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
20. SOURCE OF ADMISSION! AUTHORITY FOR WARD
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
B CO, 21st Combat Support Hospital, Mosul, Iraq
21. TYPE OF DISPOSITION . 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYYYMMDD) 73 A. 75 76 77 78 79 80 81)82 83 84 85 86 87 88
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24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION fYYYYMMDD
89 90 91 92 it 93 •94 95 96 97 98 99 100 101 102 103 104 105 106
o -3 , /
Pr. 6 AA
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y V YYMMDDI (Bette Casualty Only)
107 108 109 110 germigin 114 111 116 IIIIIIIMMI
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DOD 006147

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(b)(3) -1
I NPATIENT TREATMENT RECORD COV ER SHEET (For Plate Imprinting)
For use of this form, see AR 40-400; the proponent agency is the Office of The Surgeon General.PATIENT DATA ITEMS I • 30 (Excluding Items 25 & 26) LINE LEGEND ADMISSION REMARKS
;b)(6)-4
1 REGISTER NO. - NAME • GRADE
2 SEX - AGE - RACE • RELIGION -
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LENGTH OF SVC • ETS PRE­
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",b)(6)-4
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5 SOURCE & AUTHORITY FOR ADMISSION - HOVR OF AD­MISSION -CLINIC SVC
6 NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
7 ADDRESS OF EMERGENCY ADDRESSEE • PHONE NO. -(b)(6)-2 DATE OF THIS ADMISSION
8 NAME & LOCATION OF MEDI­
32.UNITS OF WHOLE
25. TYPE DISPOS TION 26. DATE OF D' PO CAL TREATMENT FACILITY BLOOD/COMPONENT DATE OF INITIAL AD MISSION
TRANSFUSED
P c__ /h. 40 c7L-3
31. SELECTE ADMINISTRATIVE DATA
0 CHECK IF CONTINUED ON REVERSE
33.
CAUSE OF INJURY

34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

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35. TOTAL DAYS THIS FACILITY
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c. CONY LV/COOP d. SUPPLEMENTAL a. BED
DAYS DAYS t TOTAL SICK
CARE DAYS
CARE DAYS DAYS
DAYS
II I
36. TOTAL DAYS ALL FACILITIES
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DAYS I. TOTAL SICK
,, DAYS CARE DAYS CARE DAYS DAYS DAYS
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(b)(6)-2
,b)(6)-2 MECtiCAL RECORDS OFFICER
EDITION OF 1 AUG 76 S
DA I ,74'79 3647-
MEDCOM - 2096
DOD 006148

MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Feuer date of admission)
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p
SF 5-5
PHYSICAL EXAMINATION
PROGRESS (Enter date of discharge and final diagnosis)
WB-2
ENTIFICATION NO. ORGANIZATION
PATIENT'S IDENTALCATION (For aped or written entries give Name last, first, REGISTER NO. WARD NO. middle: grade: date: hospital or medical facility)
(b)(6)-4
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR 141 CFR) 201.45.505 ---OCTOBER 1975 USAPPC V1.03
MEDCOM - 2097
DOD 006149

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD I PROGRESS NOTES
DATE NOTES
2. OCt V-5 .
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(b)(6)-4 PROGRESS NOTES
Medical Record

STANDARD FORM 609 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.20304(10)
USAPA V1.00

MEDCOM - 2098
DOD 006150
LAST NAME
DATE
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NOTES
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MEDCOM - 2099
DOD 006151
AUTHORIZED FOR LOCAL REPFI
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MEDCOM - 2100 9
DOD 006152

AUTHOMZED FOR LOCAL REPRODUCTION
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MEDICAL RECORD

NOTES
DATE
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DOD 006153
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Prescribed by GSAACMR FIRMR (41 CFR) 201-9.202-1
MEDCOM -2123
DOD 006175

,AIN 7M0-004314170
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
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(b)(6)-4
CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM SOO (REV. 8-97)
Proscribed by GSA/ICMRFIRMA (41 CFR) 201-9.202-1
MEDCOM - 2124
DOD 006176

MIN 7140-00434417G
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS DIAGNOSIS, TREATMENT TREATING OR ANIZATI
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(b)(6)-4
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 inv. 8-97)
Prescribed by GSA/ICMR F1RMR 141 CFR/ 201-9.202-1
MEDCOM - 2125
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(For typed or written entries, give: Name - Wt. Fan middle; ID No or DSN• Sex;
Date of Birth; Rani/Grade./ REGISTER NO. WARD NO.
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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-97)
Prescribed by_GSMCMR ARAM (41 CFR) 201.9.202-1
MEDCOM - 2127
DOD 006179

AUTHORIZE) FOR LOCAL REPRODUCTION
NfN 15411•0•4114176
CHRONOLOGICAL RECORD OF MEDICAL CARE
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MEDICAL RECORD
SYMPTOMS DIAGNOSIS, TREATMENT TREATING ORGANIZATI •
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PATIENT'S IDENTIFICATION: (For typed ot• written entries, give: Nem* - last, first, middle; ID No or SSN; Sex; Date of Birth; Rartk/Grsdej

--.7HRONOLOGICAL RECORD OF MEDICAL CARE
b)(6)-4
Medical Record STANDARD FORM 600 (REV. 6-97)
Pmerlbed by OSAJICMR
FIRMA (41 CFR) 201-9202-1
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MEDCOM - 2128
DOD 006180

DAIS i
SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
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MEDCOM - 2129

S58-10 (Sec Instrticdons on Back of this Sheet)
NSN 7540-01-075-3786 TREATMENT FACILI (Stamp) N M
EMERGENCY CARE AND TREATMENT
(Medical Record) TRANSPORTATION TO HOSPITAL CUR RENT MEM. Ihr tutus zrnmun• HISTORY oarAtmem FROMARRIVAL
(Attach care enroute sheet) nation and other data)
PATI ENT DaTHER (Specify)
TIME
I-1 PRIVATE

DATE
DAY MONTH YR. ,e) VEHICLES AMBULANCE ALLERGIES
..)CA' Cf3 0 OTHER (Specify)
PATIENT'S HOME ADDRESS OR DUTY STATION (City. State and Z.Z.P Code) HOME TELE. NO. (Inc. area code)

0 .a (.
CR1EF COMPLAINT (S) (Include symptom(s). duration)
6-3 w 0 YES 0 NO
VITAL SIGNS

DESCRIBE (1) SobJeetiue data (Pertinent History); (21 Objective data TIME SEEN BY PROVIDER (Examination tnelude results of tub and x-rays): (3)Secrument (Diagno-
O ZZ G
TIME • sis); (a) Plan (Treatment/Procedures - include medication even and follow-up
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EMERGENT

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14,....‹rtGENT
NON•URGENT /te.3 Ot-A-no
ORDERS INATS. IM

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ASSESSMENT/DIAGNOSIS (3 - 513 3
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DISPOSITION (Check all that apply)

aSw 46D C
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HOME FULL DUTY Art, LL) .R. Li a. +
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QUARTERS
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24 Hrs. 11" i-rs. 172 rrs
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MODIFIED DUTY UNTIL: /
DAY MONTH YEAR

C-4,4 f-v-c„
REFERRED TO (indicate Gc s /
,^Qititit,u -

-..0:1-124/14.
EMERGENCY
TODAY
72 HOURS

ROUTINE
ADMIT. TO HOSP. UNI /SERVIC

a C 6 -2 eM
CONDITION UPON RELEASE
IMPROVED

!UNCHANGED
DETERIORATED
TIME OF RELEASE:

(CONTINUE ON SF 5O? IF NEEDED)
PATIENT'S IDENTIFICATION latsekanteal Imprint) •
FOR WRI TTEN ENTRIES GIVE: Mane • last, first. middle;

SST,: DOB, service status. name and relation of sponsor or next 144 ittT
of kin. (IMPORTANT: LIST FACILITY HOLDING TREAT. 14AC
!VENT RECORD). INSTRUCTIONS TO PATIENT (Include medications ordered, any imitations and (ollow-up
Plans)

:b)(6)-4
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STANDARD FORM SSB (Rev. 6-82)
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MEDCOM -2130 •e•
DOD 006182
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;41
MEDICAL RECORD INTRAOPERATIVE DOCUMENT
For use of this form, see AR 40-407, the proponent agency Is the office of The Surgeon General.
2. PATIENT IDENTIFIED
AND PROCEDURE VERIFIED BY
Leda-
3. Dig) TIM PA IE ITE 4. PATIENT IN R
O s,

TIME 0 OS NUMBER g /
5. PREOPERATIVE EMOTIONAL STATUS
. CALM (ANXIOUS . EXCITED . CRYING $ . ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS:

8. NURSING PERSONNEL
ASSIGNED
RELIEF
SCRUB
SCRUB
ASSIGNED
RELIEF
CIRCULATOR
CIRCULATOR
b)(3)-1
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AT" SUPINE . LITHOTOMY . PRONE . KRASKE)LATERAL)
. LEFT SIDE UP). RIGHT SIDE UP
c.
COMMENTS:
_ AN

.s....1.7.7........ 41, 1‘. . 0 As. .is.• i A

¦ t 8. SKIN PREPARATION
HAIR REMOVAL 'YES I NO

PREP SOLUTI (Specify) FSS
b)(6)-2
DONE BY: Craf.SR 0 NURSING UNIT SITE: ab
BY HOM.
METHOD: . DEPILATORY c., 11;;ZRAZOR) SITE

C vlst &it-BY WHOM:
. CLIP k
COMMENTS:
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES
LEGEND X Ground Pad)— Safety Strap)•••' Tourniquet
Correct I Incorrect First Closing Final Closing
10. COUNTS Other" Count Count.,. _ X I-Spo)a IfYes . No C.--
Needle Sharp (ir;yes . No
O.,'
)
nstrument 12( Yes . No
)

Other Yes . No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICES) (ESU) . NO Ni"'ryes f nr mintetiel• f' ri • • s • Medical Faciiity•
i
jb)(6)-4
.
ESU NO:

GROUND PAD: BRAND LOT NO

.
ESU NO:

GROUND PAD: BRAND LOT NO:

.
BIPOLAR NO:

MEDCOM — 2131
•
11. 0.1¦ 11.111 .IA1 I% 01010 04
_ • - • - • - - • • _
DOD 006183

MEDICATIONS/ORDERS AMET-ogi ••¦••.4) •
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES 0 NO
gAtIOiCATIONS/ SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY qt

I
•.-YOUND IRRIGATION PY(--.YES 0 NO, TYPE(S):
z.'.1THER ORDERS TIME CARRIED OUT BY 1
1',
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PHYSICIAN'S SIGNATURE
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...... . IS. LABORATORY SPECIMENS t'''ECIMEN (S) NAME . NAME YES 0 NO • f POZEN SECTION (FS) NAME NAME :KS 0 NO , CULTURE (C) NAME NAME NO : NNAME NAME NAME
; NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
TUBES, DRAINS/PACKING YES 0 NO 0
LI-NIJ/S
'frPE/SIZE 2... 3.
-CCI44

3.
ADDMO -r • - ,, T •N
b)(e) 2
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4
::.0 OPERATION(S) PERFORMED
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PATIENT TRANSEERRED TO • MET OD
Di 4-• . . _so . ti,
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1.1 S. GPO: 1998-404-013/46440
0
MEDCOM - 2132
DOD 006184

•CRITICAL CARE FLOW-SHEET

(b)(3)-1
LOS DATA P A
2 ock 953
DOS
.z0c,4-03
POD
Do
NURSE'S SIGNATURE
t-OttrAt.) AAkT
treAtthi) U Y (SI= e and 1 Hie)
•x
24 HOUR DATA 24 Hour Balance 24 Hour Intake 24 Hon'. Output Weight on Admission Wei0TYesterday Weight Today
Initials Safety Checks -:E N xe).2
BVM at bedside
Monitor Alarms On
ID Bracelet On
Allergy Bracelet On

MA Call Light Within Reach NA
.
, .
Side Rails Up A) iA Bed in Low Position
AI (4
Department/Service/Clinic IJAlh I c-C.C. 2,C)Cf
PATTENTSIDENTIFICATION For typed or written entries give: Nome-last. first.
0
Middle; grade; date; hospital or medical-wilt:0 HISTORY/PHYSICAL . FLOWCHART
. OTHER EXAMINATION . OTHER(Specl6)
(b)(6)-4
Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FoRm 47W)
I MAY 78
0 0 0 0 0 0 1 1 1 1 1 I 1 2 2 2 2 2 .
2 ;'3 '5 6 7 8 9 0 1 4 6 7 S 9 0 1 2 3 4
PULSES (4) Bounding (3) Full RADIAL R L z. 2- d.
(2) Normal DORSALIS • R
(1) Faint(0) Absent PEDIS L
SKIN
(1) (2) Dry (4) Cool (7) Jaundiced Clammy (5)_ Flusbed (S) Color Normal 4 3
(3) Warm (6) C7gpode (9). Pala EDEMA t ar2at nu* by (b)(6)-2
HEART SOUNDS w
(Clear, Regular, No Rubs, No Murmurs)
HEART RHYTHM (Normal Shins Rhythm, no ectopy) . sl 51'
SWAN GANZ CATHETER
(Zeroed & calibrated) ARTERIAL LINE (zeroed & calibrated) I
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST V
BSC
DANGLE
CHAIR
POSITIONED RIGHT

PAIN I PAIN FREE
PAIN SCALE (1-10)
PCA/PCEA IN USE (Ref* t. rwau 01.132-7)
ABDOMEN (2) Soft & Flat
(1) Distended
BOWEL SOUNDS ( active all quads)
NC / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED Svcitito.
Ph
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown
INVASIVE LINES SITE DATE INSERTED DESCRIPTION (SITE, DSG.)
'rip-red let-A ti-M: DeMlai 2 Oct 03
Ito 2 of n3
'4 Oct 03

,PUPIL SIZE PUPILS
MOTOR FUNCTION CHART CODES
1 mm = Equal 0 = No Movement Present..
2 nun R Reactive 1 SlightiFlIcher/ Trace of Contraction
3 mm NR NonReactive
2 = Active (Gravity Eliminated) Not ApplicabtelAbsent (blink)
3 —Active: against gravity,•bat not-against resistance
4 mm• L R Left Larger _ .
4 7 Active: Against Gravity and Resistance, not Ml strength Refer to Nsg. Notes
X5 = PUA Strength against Examiner, Resistance
S R L Right Larger
No Change fromPrevious
Assessmest
\ems
. TIME • • o 0
eo aril 1•1 ­
111 -2 .! 2 2 • 2 2
2 2 3 4
7 • 6 0' 2 2
* 3 4 . 5 6 1 1 1 f 0 1 2 3 4
A. BEST EYE-OPENING RESPONSE
I 1 14

.
(4) OpeiiiiSiintaneously
_
(2) To Pain
2-
•(3) To Voke
(1) Does. Not Open
3

if
B. BEST VERBAL RESPONSE
(5)
Oriented (2) Garbled '

(4)
Confused (1) No Response . 5

(3)
Inappropriate Verbal Response

C.
BEST MOTOR RESPONSE '

(6)
Obeys Commands (3) Flexion to.Pain

(5)
Localizes to Pain

(2) Extension to Pain 0

(4)
Withdraw to Pain

6

(1) No Response (O
1
GLASCOW COMA SCALE (A+B+C) •
7 I
I7
i i
PUPIL RESPONSE R
I
25
She (mm), React to
IV-
31
nil
Light (+) No Response (-) L
C3
Li i"
MOVEMENT RUE
(See Motor Function LUE 3 3 Scale at Top of Page) S
MR LI 3
3
LLE • GRIP (S) Strong R.
(W) Weak t) absent L
RESPIRATIONS REGULAR. •
IRREGULAR
UNLABORED
LABORED
SHALLOW
RETRACTIONS •

BREATH SOUNDS RUL
(5)
Clear • ' LUL 3 5

(4)
Crackles

(3)
Rhonchi RLL ,5'

(2)
Wheeze I-

3
LLL
BOTH BASES (
COUGH NONE
SPONTANEOUS
PRODUCTIVE •
NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink

(1)
Diminished

(2)
Yellow (I) Clear JCJ
SPUTUM CONSISTENCY (3) Thkk

(2)
Frothy (1) Thin

VENTILATOR Vt
F102
RATE (SIMV/CMV)
PEEP/CPAP . •
PRESS. SUPPORT

OXYGEN DELIVERY NC (Volin)
DEVICE 594
FM (I/min) ETT # NRBM (!/min)
ETT an gams ETT CARE / POSITION CHANGE ETT / NT SUCTIONED INCENTIVE SPIROMETRY-DONE
.
/
COUCH 1 DEEP BREATH • V
INITIALS b (42
bX6)-2 b)(13}2
VITAL SIGNS
TIME 0100 T P R B/P SAT A-line MAP PA RA PCW CO CI , PVR SVR ICP CPP COMMENTS
0200
0300 .
0400
0500
0600
0700 0800 91 z 125 25 b)(6)-2 t 46f-t1 100 5LNIC-
0900 1000 1100. 9e3 ico isle tztz (39- 2:4-22 30 145//9 143117 i4Z[lZ too t too st.r.lc._ 5umr--SL.J3c-
1200
1300 1400 1500 1600 too r 11-i-32, 17/ — 1004 1 ` /14 ,0 •,( 1% 3-2, / qq% it iv .) /so 2 ,
" I 97e (2-v rP101 2' • it• OW r. 1S3 32 11 1/6e) qii 1 Ilpigel/ 13 .. ; is7 b)(6)
1700 1800 /52. 37 1117 h391 wanrimour oo 1.5N/i3O b)(6)-2=raw
1900 2000 2100 2200 2300 2100 kV@ 1 1-1(s5 X 11 45— 100 r" • gy, i oempic 2/6 Ily45-lz inq Ili 6 a101 1 4co 3L 13/(,2 10,040 piLl cvl 11446 IOD . 40/65" /60 /g" //8/S4 qe lzW, f ?6, 34,4 1.3 is , 7p/A 5-)60 /234 111 v./
MEDCOM - 2136

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MEDICAL RECORD)
NURSTN SrEs
(Sign all notes)
HOUR
DATE
OBSERVATIONS Include medication and treatment when indicated
AM.• P.M.
2ect
cti n rr--4ZirCP,1 iLkia3.)gvici/ke ixclAtia . 1-W/4-13 rra•)(a.Aw)))pE, ar71.6
-kirtues_fita-140 &jet-01;A ilk c (i).-01,1/4. 4 cls. A id
o-vc x 2 aNCI-taaj) sit _ )PN_
au) as.61
3 it4
b)(6)-2
14-1A,L.) (.4. -c-r. •
yowl 1
b)(13)-2
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6:­
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.b)(6)-2
MEDCOM - 2138
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA - --, 24 HOUR DATA
DOA DOS POD el 06-0 3 . o? Oeii 0. -P65— I . 24 Hour Balane 24 Hoar Intake 24 Hour Output 741­AG- 3402.5-+ iso
Weight on Admission
Weight lrfisterday
Weight Today

. NURSE'S SIGNATURE Initials Safety Checks
X61-1
BYM at bedside x6}2 ctdT Monitor Alarms On
161-2 -
(41117--1 ID Bracelet On I Allergy Bracelet On F
Call. Light Within Reach ii Side Rails Up
Pc
Bed in Low Position
• FNI-PAN14.1) HY lomatnre and I itle
)(6)-2 llepartment/Seryice/CliluC
DAlh
-
ti k)
aarave. al...All ANati t i avli
vor
or written entries give: Naine-last, first,addle; grade: date: hospital or medical facility)
. HISTORY/PHYSICAL FLOWCHART
.
OTHER EXAMINATION OTHER(Specit51 (b)(6)-4 Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

llA FORM 4700
1 MAY 78
t o 0 0 O 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2
11 2 3 4 $ 6 1 9 0 1 2 3 .4 5 6 7 8 9 0 1 2 3 4
PULSES (4) Bounding (3) F011 (2) Normal RADIAL DORSALIS R L a 2 2.. 2. a
(1) Faint (0) Absent PEDIS L a- 2.
SKIN (1) Dry (4) Cool (7) Jaundiced (2) Clammy (5) Flushed (8) Color Normal (3) Warm (6) Cyanotic (9) Pale 3 3 3 3 1 a 3
EDEMA, . A,
HEART SOUNDS (Clear, Regular, No Rube, No Murmurs) V
HEART RHYTHM (Norval Sinus Rhythm, no ectopy) ss Sf sr
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH

MOBILITY BEDREST I 1/ BSC DANGLE CHAIR
POSITIONED RIGHT LEFT SUPINE i./ HOB 30 DEGREES ,/
FALLS PROTOCOL INITIATED PROTECTIVE DEVICES (Ro are flThWA or132-26) PAIN PAIN FREE
PAIN SCALE (1-10)
SA1 14°
PCA/PCEA IN USE Odor to FRMDA 010132-) ABDOMEN (2) Soft & Flat
•

2 2
(H Distended 2.
0
BOWEL SOUNDS ( active all quads) NG / DOBHOFF PLACEMENT VERIFIED RESIDUAL ASSESSED
1-i
Ph
FOLEY CATHETER PATENT .. tx• VI VOIDING CLEAR, YELLOW URINE cp. . SKIN INTEGRITY No Breakdown
Surgical Wounds ti
J
Rashes, Lac's, etc DRESSING (Dry & Intact: specify site below) #1 Cie,_ . V V
I.

#2 1./
e A(.416
#3
X8 2 bX8)-2
INVASIVE LINES SITE DATE IIID LRTED (DESCRIPTION (SITE, DSG.) ptaglo. ho-K COX of.i/W e.eoth — od & /T5/.9( is eftft, m Ma)
-
,PUPIL SIZE PUPILS
1 mm Equal2 nun R Reactive 3 mai NR NonReactive
4 nun L R Left Larger
5 nun - L Right Larger
• TIME
,
MOTOR FUNCTION
0= No Movement -
l '7 Slight Flicker/ Trace of Contraction
2 = Active (Gravity Eliminated)
3 Active: against gravity, but not against resistance
4 = Active: Against Gravity and Resistance, not full strength
5 = Full Strength against Examiners Resistance
flue—/S21
1," I Ca:
9
o o o o o I 1 t i 1 3 1 1
°•1
CHART CODES
Present Not Applicable /Absent (blank) • Refer to. Nag. Notes
X_ .
No Change from Prelim Assessment
1 1122222
2
4 54 7 B 0
A. BEST EYE-OPENING RESPONSE
(5)
Oriented (2) Garbled

(4)
Confused (1) No Response

(3)
Inappropriate Verbal Response

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to Pain ' (2) Extension to Fab

(4)
Withdraw to Pain (1) No Response GLASCOW COMA SCALE (A+B+C)

o 12 31 5 c 1 11 90 1 2 34
(6)(b)sF
3 2
(4) Ogietii Spontaneously (2) To Pain
+ 1
ci.
.

•
(3) To Voice

(1) Does Not Open
B.
BEST VERBAL RESPONSE

Li

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PUPIL RESPONSE -Size (mm), React to Light (+) No.Respouse ()
MOVEMENT
(See Motor Function
Scale at Top of Page)
GRIP (S) Strong
(W) Weak (-) absent
RESPIRATIONS

BREATH SOUNDS
(5)
Char

(4)
Crackles

(3)
Rhonchi

(2)
Wheeze

(1)
Diminished

COUGH
.NONPRODUCTIVE SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear
SPUTUM CONSISTENCY (3) Thick

R
L RUE LUE RLE LLE
R L REGULAR IRREGULAR UNLABORED LABORED SHALLOW • RETRACTIONS: RUL
LUL
ALL LI BOTH BASES
NONE SPONTANEOUS PRODUCTIVE
(2) Frothy • (1) Thin VENTILATOR
OXYGEN DELIVERY DEVICE
ETT N
Vt Fi02 RATE (SIMV/CMV) PEEP/CPAP
PRESS. SUPPORT NC (Untin) FM (I/min)
NRBM (I/min)
ETT cm gums
ETT CARE / POSITION CHANGE ETT/NT SUCTIONED INCENTIVE SPIROMETRY DONE COUGH / DEEP BREATH
INITIALS
VITAL SIGNS
TIME 0100 T P i9 B/P la* SAT A-lint 1317o MAP PA CO CI ; PVR SVR ICP CPP COMMENTS
0200 lig4 ('? 43 Pia/75
0300 -7 ta/4,1 111/7o
0400 91 1 d.3 11 191/13
0500 0600 0700 0800 135ark) 12.1- app, Acohz, Infx 1s6 14s 2-4 21 1 2-2. 167 27. Wig oFfl. b)(6) -2 b)(6)-2 2 1321 14t .q14. ••
0900 ioot4). 31 1zt too cl
1000 1.23 1100 . 122q91.0 tc I KI 161 (44. `41, VI? 131113 ris-Prt
1200 1300 12S-1 24tki-det. 1241* 132165 9(.. 174194 (o1ca7,
1400 1500 11 1-6 11% 1.1 q4-1104.?4 •110111, °C41,t 5-V40.?. R103-
1600 123 1 24­711c-' 178 115-
1700 t24-- 1b3Ibi 1 10112.171,,
1800 135-I OD 'Ito SO 1 9(9s- Mil 1
1900 2000 2100 13Clog 11101 017 to43 31 97% fls tiy-f3 cIA1 2-fk -t-' 41/41 129-917eri-
2200 100 .9 H igfrey. lc 3/43
2300 13 3 11%k 9.3
2400 13 ,1 3(7 lAtif62 c, /sops '36

P /3404/L1.0.39-4 12i
MEDICAL RECORD NURSING PES
(Sim all notes)
HOUR

DATE OBSERVATIONS
Include medication and treatment when indicated

P.M.
Od 03 zoo /45 Oct A NZ/v) Vo PRiot hho
l-wno itinla 141 0 hro 55, lig.1;11qo's o , 6,196r-m-02,
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ior c .040 -?ran ad-,h,p Us:5 tint mi ea/PC.474j,
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0800
0900
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1600
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2400
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8 HR HR l' 60 /000 r "' )5
2461 5-
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INIFIEMENIMPANI
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1900
stived-smorm
2000 MILMIANIMMIMILI

PAIPAINEMPALTER 2200 2300
2100 IrAMMITABIMPLIE
PAMMETIIIIKIrMril
COMMENTS
ME AM MI
INK NN
NATIMMILI
MISIMIEN1
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CRITICAL CARE FLOW. SHEET
(b)(3)-1
1
LOS DATA
DOA 24 HOUR DATA .. A od o 3 24 Hour Balance DOS
3 od 24 'our Intake POO d'Afil' 29%
I 24 Hour Output
,1071--11-15 Weightion Admission Weight Yesterday Weight Today
-
NURSE'S SIGNATURE Initials
Safety Checks
N
b5(8)-2
4A) BVM at bedside Lc 4-,-. Sis2 Monitor Alarms On
ID Bracelet On Allergy Bracelet On Call Light Within Reach Side Rails Up
)474,
Bed in Low Position
(
llepartnenVNerviceiChruc
e I 0}..t ,4/0 e018
PATINVI''S IDENTIFICATION r
For typed or written entries give: Name-tast. first.
Middle: grade: date: hospital or medicaljaciliry)....
HISTORY/PHYSICAL
)7(..
FLOWCHART
. OTHER EXAMINATION . OTHER(Spec(*)Or EVALUATION
DIAGNOSTIC STUDIES
. TREATMENT
—
DA Font 4700
I MAY 78
I o' o 0 0 0 0 0 0 1 I 1 1 1 1 1 I 1 2 2 2 2 2
1a 2 4 5 6 7 8 9; 0 1 2 3 4 5 7 S 9 0 1 2 3 4
PULSES (4) Bounding (3) Full (2) Normal RADIAL DORSALIS R L -R 2 2 Ail ¦6 -z. 2. 2_
(1) Faint PEDIS
(0) Absent L
SKIN
(1) (2) Dry (4) Cool (7) Jaundiced Clammy (5) flushed (F) Color Normal 3
(3) Warm (6) Cruldic (9); Fab •
EDEMA -4v
HEART SOUNDS
(Clear, Regular, No Rubs, No Murmurs)
HEART RHYTHM (Normal Sinus Rhythm, no ectopy) Sr
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated) %."
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST V
BSC
DANGLE
CHAIR
POSITIONED RIGHT
LEFT 1
SUPINE
• 110B40 DEGREES I
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES Nest is Flom 0P132.24)
PAIN I PAIN FREE
PAIN SCALE (1-10)
PCA/PCEA IN USE (Rohr to FHMDA 0F132-7)
ABDOMEN (2) Soft & Flat (11 Dbtended •f
BOWEL SOUNDS ( active all quads) . I. f
NG I DOBHOFF PLACEMENT VERIFIED RESIDUAL ASSESSED I
Pb
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE cps.
SKIN INTEGRITY No Breakdown
Surgical Wounds
Rashes, Laces, etc
DRESSING (Dry & Intact: specify site below)
#1 6-x. Lass.; 0 *ear 66 1-4 ; t-)9-4...;,-a A. V t
ito ga_ PR/ W44_, F a-PA/ flc-C) INVASIVE LINES SITE c",) Od 03 P60104ct 5 5/sx cairnk Or Get) c9 fnjed 9r l d • off DATE INSERTED DESCRIPTION (SI TE, DSC.) tht_frld

.PUPIL SIZE PUPILS MOTOR FUNCTION CHART CODES
1 mm = Equal 0 = No Movement Present .
2 nun R Reactive 1= Slight Flicker/ Trace of ContracUon 1,
3 mm NR NottReactive 2 = Active (Gravity Eliminated) Not Applicable /Absent (blank) -
3 = Active: against gravity, but not against resistance
4 nun L R Left Larger 4 = Active: Against Gravity and Resistance, not full strength Refer to Nag. Notes
X
5 •• Full Strength against Exiiiiners Resistance
5 MII1 R L Right Larger No Change from

• 46 (4--0 Previous Assessment
cr.7,
F
F

1-1
--1)I
1"-1)I
"
I--1-I

1-ill
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1— -I

l' • 2
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o
• TIME
4
5
A. BEST EYE-OPENING RESPONSE
(4) OpenssSpOntaneouslY '(2) TO Pain •
-
(3) To Yoke (1) Does Not Open

B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled

(4)
Confined (1) No Response I

5 C

(3)
Inappropriate Verbal Response •

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain

4
1

i

t

4.

(5) Localizes to Pain (2) Extension to Pain
(0
(4) Withdraw to Pain (1) No Response GLASGOW COMA SCALE (A+B+C)
IS it 3 ) ! lis4A .24.2-t-
2t*
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4-0 0 CJ yv
4 0 D 6 ft 4
4. D 0 0
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17
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1-
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5
'3 S 3 5 I i •,,
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• 10, JO S 10 to •
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1
PUPIL RESPONSE Size (mm), React to Light (+) No Response ()
MOVEMENT
(See Motor Function
Scale at Top of Page)

' GRIP (S) Strong
(W)
Weak (4 absent
RESPIRATIONS

BREATH SOUNDS

(5)
Clear

(4)
Crac kles

(3)
[Monett!

(2)
Wheeze

(1)
Diminished

COUGH IS
34
34
if
..
4
-Li
14
.
. ,,,/
3
3
•S
l
I
. .
SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2)
Yellow (1) Clear

SPUTUM CONSISTENCY (3) Thick

(2)
Frothy (1) Thin

VENTILATOR Vt
F102
RATE (SIMV/CMV)
PEEP/CPAP •
PRESS. SUPPORT

OXYGEN DELIVERY .NC (1/min)
DEVICE

12M (Umin)
ETT P 43. 648M alnikii) e-• tu-Err .2,...cm J.g
Err CARE I POSITION CHANGE
•ETT I NT SUCTIONED
INCENTIVE SPIROMETRY DONE
1../ COUGH / DEEP BREATH -
I/
-06­
0.
INITIALS R
L RUE
LUE -
RLE
LLE
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LUL •
RLL
LLL
BOTH BASES
NONE ' SPONTANEOUS PRODUCTIVE
NONPRODUCTIVE .
VITAL SIGNS
TIME P R BIP SAT A-1Ine MAP PA RA PCW CO CI , PVR SVR ICP CPP COMMENTS
... 0100 rNalairarEln EY'lf
0200 13 3o in k; (5" 1) c_.-/ • ..
0300 0400 )m, I) MEMIEI;a EM= -rimpagnumg. g 5
0500 122. So lat /ir
'0600 0700 Da 4) IZLI 21 5C A, 14( 42. rig/ 1-3 qq, . 10 q I is °to Re IS- 1 in
0800 0 i.) ip.. EgirMIT53 . (0
0900 1000 et /IV =MIMI 4.4.1 EMISIMMEM
1100 1200 1300 IMIIIIIMMENEIfili qiigz MIMEI12, lob 4E9-MIEngin c, ET .IT cos-/to 1 02 .,.
1400 • .. .
1500 1600 . 50:1 akiti q bi AlligrAMME 92. WY 1- 6-: 0 LI '
1700 1800 1900 ELNISIIIMAIRIMICIE i MNIEMBRIMIESTIMINfi Mil MIMI)D alIMIGUIMMOIrg ; 0 r I 0 l
2000 2100 ' IFZENIMINIMINI4 rimoisim 1 of 1 00
2200 loi - i g gegunign ito ,t
2300 2400 112_ = 101 III MOM9A-0.0 12./40c nmastaris l'14

MEDICAL RECORD NURSING Eb
DATE HOUR OBSERVATIONS
Include medication and treatment when indicated

-A.M. P.M.-._
110 CI 63 n.... ,. . 73.),..9./3„..J. bLIefk, sa -to ..,A
• 1))t)')....-. -1....6)54 , PBC, : •)
PE's)h.Aecattotto/u4,
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geZre3
.
Meet 00? /f3l. A.ej 14274, °r'I ,e444, o'reit,--C . , k•4 as. e6 (e .,0/1 7 *Aug 74..f-i4z. , ..
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fav }co 3 40 254 _m ( 1 -+, 24 HR T2 (05- 100
HR
BILTILMIWAN/11

INK EarIIMUI
. , PMEIMMINISIMI

OUTPU
COMMENTS
$15
87:id St s
bl-S9e
CRITICAL CARE FLOW SHEET

•
1(b)(3)-1
LOS DATA DOA ., DOS '
3 oci--s5
POD -
NURSE'S SIGNATURE
6)-2
IL kAlr
[6).2
LICI
6)4)-2
• Pith.PARED HY (Signature and title}
_16)(6)-2
lutAl-n-73
)I
PATIENT'S IDENTIFICATION For typed or written entries give: Nanwelast, first. Middle; grade:date; hospital or medical jaciliod .
(b)(6)-4
DA FORM 4700
I MAY 78
MEDCOM - 2151
)A,
24 HOUR DA"
24 Hour Balance 24 Hour Intake 24 Hour Output
. .
Weight on Admission
Weight Yetterday
Weight Today
Safety Checks BVM at bedside Monitor Alarms On ID Bracelet On Allergy Bracelet On
Call Light Within Reach
Side Rails
Rails Up Bed in Low Position
Department/berme/L.1mm
1w-
(AT-0
a-13-
.Q
e.. 2ctirg
--'19-*-
. ..7. , E N
bx )t
....
1)A1
5ock
.HISTORY/PHYSIC.4L)FLOWCHART
.
OTHER EXAMINATION)OTHER(Speci.69 Or EVALUATION

.
DIAGNOSTIC STUDIES

:'fit." :
. TREATMENT
0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 . 1 1 1 1 2 2 2 2 2 1 2 3 4 5 6 7 8. 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 PULSES RADIAL R 4 2
2.
(4) Bounding
L)2. A a
(3)
Full

(2)
Normal DORSALIS). R

(1)
Faint PEDIS •

(0)
Absent L oL SKIN r

(1)
Dry (4) Cool (7) Jaundiced 3

3 3
(2)
Clammy (5) Flushed (8) Color Normal

(3)
Warm (6) Cyanotic .(9), 5 1 EDEMA e HEART SOUNDS (Clear, Regular, No Rubs, No Murmurs) 5(n-J. 4142-' HEART RHYTHM

3
NOZ
(Normal Sinus Rhythm, no ectopy)
FOLEY CARE
ORAL CARE ./
MOBILITY BEDREST

POSITIONED RIGHT
PROTECTIVE DEVICES (Rohr to FIDIDA 0173244)
PAIN PAIN FREE
PAIN. SCALE (1-1 0) ent

14-
PCA/PCEA IN USE (Rohe to FDMDA OP132-7)
ABDOMEN (2) Soft & Flat

L
(1) Distended
BOWEL SOUNDS ( active all quads)
dt

NG / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Pb

J
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown

Surgical Wounds •
Rashes, Lac's, etc

AB
DRESSING (Dry & Intact: specify site below)
#1 A op (smi.,V,$)

I)
• CT 2._
. DATE INSERTED DESCRIPTION (SITE, DSG.)
INVASIVE LINES SITE
(UAC-3 cr/to3)ef14,401) tttr' Atd 5oef sisx pfAly..:„ 1„X#R7,1 AC 3 cr.r0:5 PriV sa461ent sisx of /014‘4,4_ev /AAA." cRot 4 ca D3 A.AVent-,3' AL /04K 4oa 03 '1.GDT 140leiPt teRA-
6;
PUPIL:SIZE PUPILS • • • MOTOR FUNCTION CHART CODES
1 mm -Equal o = No Movement • Present .
2 NMI R 'Reactive -1 = Slight Flicker/ Trace of Contraction
3 nun NR NonReactive 2 Active (Gravity Eliminated) NOCApplIcible /Absent (blank)

3 .= Active: against gravity, but not against resistance
4 nun L R Left Larger 4 = Active: Against Gravity and Resistance, not full strength Refer to Nsg. Notes

X .• Full Strength against Examiners Resistance$ tom R I RIghj1rã No Change from -• . . LIA 2 E.: ..." 1.A....4 1-2 Previous Assessment
•
TIME 0 0
-
10nl
0
4
0:
2.L10
0
1:22

1
"7--
0
1
ew

1 II
o
1
2 2 22
2
--1...,
0 Il
4
4
II
C 2 3
e'
4
A. BEST EYE-OPENING RESPONSE
-.
.. .
(4) Opens Spontaneously (2) To Pain
1 -
el • I
I
•
(3) To Voice • - • - -

(1) Does Not Open
B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled i

(4)
Confused (I) No Response -1 gr 64-.

1.- f
(3) Inappropriate Verbal Response
.
C BEST MOTOR RESPONSE •'
(6)
Obeys Commands (3) Flexion to Pain I

(5)
Localizes to Pain (2) Extension to Pain I I •I

(4)
'Withdraw to Pain (1) No Response
GLASCOW COMA SCALE (A+114-C)

I
25.° ST 0 2.T
PUPIL RESPONSE R '
7_f-
Size (mm), React to 2. 74. 7.). 2A-
Light (+) No Response (-) L
MOVEMENT RUE
11, 41

\44, 414
(See Motor Function
1

LUE • -es1 b
Scale it Top of Page) -at, 4 1 71P:3 '
RL,E
La -,s-;
• LLE 14 * et
GRIP (S) Strong R

(W) Weak (-) absent L N.
RESPIRATIONS REGULAR.

•
IRREGULAR

4
...
1.
UNLABORED 1.. _14
LABORED
6
SHALLOW
. RETRACTIONS
BREATH SOUNDS RUL

!i/j,
(S)
Clear 3 NO' •

(4)
Crackles LUL 3/2-3/2-3 lb. •• -5is -•

(3)
Rhonehl RLL

g-3/2

(2)
'Wheeze )12-

.
LLL
(1) Diminished 1/2
9/1.. . .1 • 12-
BOTH BASES
I
312-, I
COUGH NONE
I :I
V ... ' .
SPONTANEOUS .
PRODUCTIVE
NONPRODUCTIVE

SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear
•
SPUTUM CONSISTENCY (3) TMck

(2) Frothy (1) Thin
550
VENTILATOR Vt
5Su kfrcu beo io:o
F102 I. D ib-& qv 40 To 40 5n
RAT
rt /1. ii• ri. II-0-I iORE -HO ID
la to fa I 0 HI
S. SUPPORT
-
OXYGEN DELIVERY NC (I/min)DEVICE
FM (1/min) .
•
'
zrr # r1.6 NR.BM (I/min) MT 22 an gums
I
Err CARE / POSITION CHANGE ETT / NT SUCTIONED J
. J V v
INCENTIVE SPIROMETRY DONE
. COUGH / DEEP BREATH
•
b)(6)-2
-INITIALS bit)-2 t7-611----143)-2 .1,56)-2 '0)(8)-2
V .---
VITAL SIGNS
TIME 0100 T FM P R B/P SAT A-Une MAP 109 mommozwas n PA RA PCW CO CI , PVR SVR ICP CPP COMMENTS
0200 0300. mom laIna IOU Ico Irl 103 "9 &z.
0400 0500 ye, 39 ag ming 073 Icn/54, boa: 105 3 1-2
0600 /OD I ivitl. Wt. io3iszt 68
0700 cri kl otiz 1.00. a s-3 &
0800. MOM1111V-. Leap RS' GO T4-0900 minim Ice& 914,53 6. 1000 ION mg go iimmarmati (.9 1100 =Fawn a eio . ,To 11.1111111Mi nillWri 14 1200 moutammillW ('t-1 NI 1300 ritEmiga Mlf112Ic a • 1400 g , mingicannumagEmmin • . ... . INEEMEME

1500 MIME!
1600 r
edffliallni NM
1700 EIZI MI WICMN
1800 00 • 0 an
1900 00 MUM NV
2000 Eimmytil
2100 2200 2300 2400
limg Fa
MI
urn grapimMIMI
Enpm .gmWI
=win 111111111111
MENEM hrii TN 1 gill 11551111011031 MIMI" 11' ' A , ,,, Ve, 09. , .;
MIME/2111M11 IMINSTAILla FMNW/ OBI SIVENIMEI111=111=1Mill 1.4•t; . -

•
ox.0.1E.,3
° 100 MIENSME1110111 Etanal%
0200
KLIK earamwdra onirsii-ormi
0"0 remirdearteras ramision
0400 ore:Ego' Erns LENISESIIMI
050° ANIVISENSIMIBI 2112/1¦11rd
°6°° Pro F701#701MIII0 EPATNIMMI
070° WarProP FillEMEM/11 FEMPIMIN
0" FA ILIEliviro RIM Etralltan

://1
&op goo 4o 1111 Ltb NNE 42k AO R 0 111
0900 .61 -44

AEI AFAMMI ktea/ AA/ .
1°°° LTIMEIVAP7; EMI '°801111111¦1111
1100
1200 MAIEEMIFIEFIIMI REPARINI
EVILIKBV" erMILI agan11/2
1300 immordeloriorom EWA In MI
140° FREIMMIL1111/ NITO111111%
1500 RAPro Rs woman arirdiffila

1600
WIEWEIMPlarda qoq MIKIMIS1 I V
111 (CO
9 9Cr° pis inamm i coltl. q3, i 160 1;4,0 .413 1 "01i.idAlF21141MMI/ 5
14/ AA//
"°° V; 'wet .MIELTIMISIIII MORAVRIPli
"°° MINFAMEEMEM op I tiardwan
2000 wirdeararford to rid ilii
22002100 arirmairamRIEVEPARIM AN REIMANI

Aro avaaniami
2300 MIIK mumAn FARIMMIS
ElIVA PA rteltAll WM PA NM
HR)
2400 ISO 300 ,s9 ,s 11111611124: 4s :277/
110 2
MEDICAL RECORD NURSING NOTES

(Sign all notes)
DATE HOUR OBSERVATIONS
Include medication and treatment when indicated

4c:003 •
(La
bX,}2
02
---)3L/kOoy 641.'771 4111111111
)1111L111 dc d Li ctcL w-P)
Sett( etAa-0.0A4

tykr-A3
—
•Oita 41 62) t-5!7/44, PkeCW-Wom 3 -7/4. /0014. bcMs 20,
Kest c E ,57? 4.00/04/1-em.7 74, ekv ea/a,- / eervie cypea. /55: /g7ibler /dfrea?*,3- eve,-ete7i 6e/ 5:E;77k, ai/e6 e;4ey Avr7e, 4 • / Sac-rb 3 9:0 6o7 90 4/.•dz sr4-7- &say, r
cocrrs O730 FiOz •I/ g070 0 ? S',41-r Icia % . lig/ P/01464-1/ 5elv- sconzy unia-r[
04=7/4.1e ,c14 : & er". WO e e.,-*. 4---;fete, ro 3 /02S" 4 VeVC"I' 4, Ltr$5 /Iv iia 40 0.440
W-arlel‘%
new fss c-f-
axe)-2
Som it.3 .V3o • Fi-o; loc.( SArrt Vs_S
123° rioz -(0010. SATs q4-99 ?TaDo-i--;*1 Per Srecrft-rate -
X I-2CT( "2..-GoAkit avvv.4....t4ô4 Sev-cus SA-nluii.texts
1613o
VP. ¦ ••:. Al• .'L.01
de.,4
AbA IJ4 44A4. /64 (AA ht, —4Aet tt'4A 1
r
A-0441A, Silk 98 -iv
13X6)-2
041 I
1 io ..1An
(9O FO2_. tb Stk07. tict 1 1 4, Veirsti IL
•
Jr le, t i too XI}
0X8)-2
17o0 }17 q ikve g
• 10.
130 rc;o7 —to svz, 'olt' 3-jo Fi o, Pt WI,
YrA Mai aPti 51)7, 3 #7
04 4j eitoo
4
,f
4../.4 ._„/• •
PULSES (4) Bounding (3) Full(2) Normal RADIAL R L DORSALIS fbsents 1 0 jl 0 2 2- 0 3 2 0 0 0 5 6 7 8 0 9 1 I I 1 1 1 .2 3 4 5 1 1 1 1 6 7 8 9 2 2 2 0 1 2 4
(I) Faint PENS
(0) Absent
SKIN
(I) D17 (4) Cool (7) Jaundiced
(2) (3) ClummY (5) Warm (6) Flushed (8) Color Normal. Cyanotic (91 Pale
EDEMA
HEART SOUNDS
(Clear. Regular, No Rubs, No Murmurs)
HEART RHYTHM
°mil Sines Rh no ecto tSse.
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST
BSC
DANGLE
CHAIR
POSITIONED RIGHT
LEFT
SUPINE
HOB 30 DEGREES
FALLS PROTOCOL LNTTIATED
PROTECTIVE DEVICES (Rotor to imam OP132-26)
PAIN I PAIN FREE .. PAIN SCALE (1-10) 4­ 4 4,4

PCA/PCEA IN USE (Row to FffidDA 0P132-7) ABDOMEN (2) Soft & Flat
(1) Distended
()-
BOWEL SOUNDS ( active all quads) NG / DOBHOFF PLACEMENT VERIFIED RESIDUAL ASSESSED Pb
FOLEY CATHETER PATENT VOIDING CLEAR, YELLOW URINE q.s. S1U1s1 INTEGRITY No Breakdown
mu"Milli 111111 IN

1111111111111E111111E
DRESSING (Dry & Intact: specify site below)
#1
#2 crwt
1. #3 7 412_,
eratIMMINIMIIIMMINIUMMEICIIMEMINIMINFAMPANIUMINI
INV SIVE L ES SITE
DATE INSERTED DESCRIPTION (SITE, DSC.)30d t) -s 14
,Le• oa
minplamL
ra
34' 03 dr, ,
. Nirawswarm eo 11.
IMEIMMailML&
,
res 0 • al:4•-.i._ obi
PLIP4KE, 6­
2 Oct es3
FOff,271M
MOE • oct 03
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA
24 HOUR DATA
0)(6)-2
DOA 24 Hour Balance
._. 3 od 43
/ 0( 1 i.12.../
nos 24 Hour Intake
3 o c1 03 -z1 -alS-1 6 POD 24 Hour Output , M
3 -3
on Admission Weight Yesterday Weight Today Weight on
NURSE'S SIGNATURE Initials Safety Checks DIE N
b 6}2 b0}2
1b0}2

BVM at bedside
bX6y2

Monitor Alarms On
bX6)-2
ID Bracelet On
b)(6).2
Allergy Bracelet On
..42 _Pr
NerA11111
Call Light Within Reach
Lwow
"11
Side Rails Up
r
Bed in Low Position
PHI:PAK ) HY (NI.FTLIIIIre and "1 tle) Departmern/ServiceLtuuc
1,0}2

FA HWY IULN Elf it;Al 101% For aped or written entries give: Name-last, first,
Middle; grade;date; hospital or medical facility) HISTORY/PHYSICAL . FLOWCHART

. OTHER EXAMINATION . oTHERapeci:61
. . . • Or EVALUATION
(b)(6)-4
.
DIAGNOSTIC STUDIES

.
'TREATMENT

DA FORM 470U
I MAY 78
PUPIL SIZE
1 nun 2 nun 3 mm
•4 nun. 5 mm
PUPILS
Equal

R Reactive NR NonReactive L R. Left Larger R L Right Larger
?. •
MOTOR FUNCTION
0 = No Movement
1= Slight Flicker/ Trate afCantraction
2 = Active (Gravity Eliminated)
3 .= Active: agahnt gravity; imt not against resistance
4 = Active: Against Gravity and Resistance, not fell strength
5 = Full Strengh against Examlnen Resistance " - -
DATE: (U CA­
0
0 0 •
(MART CODES
Present
Not Applicable /Absent (blank)
Refer to Nsg. Notes X
_
Previous Assessment

TIME 0 •
NI

IO.

*1 1

1 1.1
1 .'2 1 .'1'2-.2. 2:2
1
2
2
4
6
710 112 3
A. BEST
4:5 6 7 X
EYE-OPENING RESPONSE
X 0•1 2'3 4
(4)
Opens Spoittaiieinsely (2) To Pain

(3)
To Yoke

1
I
1
/
. . . (1) Does Not Open
B. BEST VERBAL RESPONSE
(5) Oriented
(2) Garbled •
1
1-1

de 1
1
I
•-"s
(4)
Confined

(1) No Response
(3)
Inappromiate Verbal Response

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to Pain ' (2) Extension to Pain ..

4 Withdraw to Pain
1 No Res . me *
GLASCOW COMA SCALE (A+B+C)
-r
PUPIL RESPONSE R Size (mat), React to ?A
j 4+ 1).,LLight (+) No Response 0
•
24

Ak 2*.
"e..
L..
MOVEMENT
RUE
•
I

P

1 5 7
a
(See Motor Function LUE
Stale t Top of Page)
RLE i LLE
r
GRIP (S) Strong •R
(W) Weak () absent L ,
. :
.
RESPIRATIONS REGULAR .. 1/4
.... •
IRREGULAR
UNLABORED .

LABORED . ' ' C; SHALLOW •• i°
-/),RETRACTIONS
r
BREATHSOUNDS RUL r
(5
) Clear 5

(4)
CracIdes LUL " 'oh .. jz, ; '7 .

(3)
Rhonchl RT.T. .

(2)
Wheeze

(1)
Diminished LLL

3
3
BOTH BASES 9z
COUGH

.1
1
SPUTUM COLOR (5) Tan
(4) Green (3) Pink
(2)
Yellow (1) Clear
SPUTUM CONSISTENCY

(2)
Frothy (1) Thin
VENTILATOR

4(1)3
PP-
VU

T432 0
RATE (SIMV/CMV) 5
1.7
PEEP/CPAP l0
PRESS. SUPPORT

5?
OXYGEN DELIVERY NC (tmln)DEVICE •• • •
FM (/mtn) Erru NRBM (Ilinta)
ET7' cm gums J ETT CARE / POSITION r./ ETT / NT SUCTIONED
INCENTIVE SPIRQMETRY DONE COUGH / DEEP BREATH
)-2
VITAL SIGNS

TIME 0100
0200
0300
0400
0500
0600 0700
0800 0900
1000
1100
1200
1300 1400
1500
1600
1700
PA RA PCW CO CI , PVR SVR ICP CPP COMMENTS
T I' R B/P SAT A-line MAP
SINUESUMMIEMIffirAIMM IINNENININI
NM
prim
IN FZINIIIINI Ell 1111
a t, El
INN
ViiiIMIWAI
NE
mom
or
MIiyfv
NI
nammais
MIMINNIIIMI MEMIEMI
lob VIM:
mammuta wilmarara
WRIFEESREM
MI 12, HIM /I MIMI loo
Ma 13 31 EMMET=cfS-
US- 7131M11 Za i2i, GS' 234
Ili M.

CM] kii. larilE1 33 WIIIII /VA 01 15 131p (4, gal razz_ Lia d2. 6 °. =MITI GM '0 WM .
mininsmunionmitaraivairoffsra,
NM
:1:-
MMI 'MIZEMialli
0/ .
IIIII
FIVAVICUI PANS101
NMI NI
morigrsi
irM 6 pfA
1800 siftwangsmunmarnmal

71MIIMEZ
1900
2000 mum=
2100 102_ rgi
IN
TLIE11/21 2300 magirmwmIIIII NI
2200 NMI
2400 Ems atr Aff, or
GRUM i-
INN
grammal MIMS 4a 11151110011113
MN
ISMINI
0 UM
gramma
MEDICAL REUUKI,
(Sim all notes)
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated
A.M. P.M.
L 64 NA np . .4-/r.m, , 0 5, R4,--t-. -
etivud ,,,,..04; ,i,,..,, itc ,,,,,,,,,..,,,
. •• ,y,_ b)(8)-2
cal5o 'A . etzs.cti 9, % , 06-71f4)kr,
F, itoryyn". ' : Th.;. COL°
, ,
.D,4 nu 444/1, 44 11.0.,1 ji V5.. Si-cri 3, .
6 t1 )os fy-.4-,9,--L.). C • fir.floml an). t-rrs y2,114'41 .0,64e , A c 4. I.
(SYY1 dr-%1, , PrP 6630 6-Syr2444 /;') '70 'it" 1)7asWed /,-, -iceilts: U lk 14v.k6 -5 4 /Welt /De' r/ (5: er i4 e" .)-2 Sei-etis fa ,1vI"ov S
--,
65 crec3 niz9 ; 0, /21 -(...3od /s-o - 6 o , r 71 Vtrft 1 ay /X, ti...-ri nA..---'6a. r./‘ 0 0 ,.,7,-,74( l brz. : SEP.
b)(62
l oser-53 _T.A.,q),...eP by AT l'ee
6p ex. 40-56'.5.. ()I..c,g.iA..10
place& 0, %I . A.-- toct.tctr5 Vein} --... +)‹ --3(5 Wose,i- 7.-'2-065 Versed-,K s",,-3, ioctersz
, .„ ef,ro,ctmii.ci-Et., ­ele v so ,,-:.-s.. RA-S_AAILK--e,LA- t C\ 02. /4 MID SCIS 0 e35; 34 7
K. ii zo '6'. it-tfavyte 64 40 Wear, down ..E.o.z_. i., vesoc-b144 4/ 01. cgfg /lb r-c. -r, 67 plecek Cm. 6Ot ... gki-S. -6-cteti:-
TVaeeLaft. tke. t-P111) '11. th11,. . -it; ..
' t 'Crd tel'e A
' t Ldrit"^
4.00.. 6 17 4k tio -54:,
r.).2

,r1/ 7 6 -17f /490/3: 0)6 -e:) -.44-.712 . 4cif '619/
MiMie4 'X' ("{ 344-74./ /4G7cni. brig 672,-r 1..--
t ,..r. 4,—,
SS 6 oa-v3 t-tob fttaw ot. cacam. Set. ort.q1.044-,,,( 'A . p(-- c74 0.9040, if it/Gt i 1242Kal-Mv el- -pl , &l, a/ ?a yf ,94i,d,• c-:--
r
44,1)
0 e.,,?,
•
1 ' ' t, A: 44/P ' ' I_Ali -.41 i./LAS)4 4 10-1. li
1 . am ' 1 6 tttie— ,
-196e us) L i k ,i)i :-(m...
+44-e-42tci id .. .4 I / ' .. s /i ! ' ll ' "---ALO /A-lit do
..1 'd , ..aavA
LMit.­
1 U;(z ALL . —
led .,iliatis#40 othurv.1
-. . , g., 'A . , A L.,..., A 0 # .1 IAA 1 I 1.2.4ILlic¦ i
..4 ' -.. _ IBMIIMMINE M
INTAKE OUTPUT
IV
'4J L .* \J()) tit'
Ns \ %')/
COMMENTS
0100
rowinarim AM FM AMEI
0200
Promarairard. onriranam
0300
MINIMIEWOMMI PleMLOPPIRMIMI
0400
PardrigiaMIEVALM VtiffirilEIP2
0500
allrArdirertWAN WM AMP%
0600
ZSMIRIMEINIMI MENEM
0700
EMINEMENBISIIMI R.3rosorma
0800
areffirasoraum Easomm
2.-Zr zoo go
8-45-273
el 2-3 14 500 IN 8 HiLg FAIII
0900
EMILIFEIMIUMMI FaTillIMPATI
1000
EININFINNIATM FAMIERISI
1100
ElIPARLIMM112 Balleard%
1200
FAV ifilEIK FAME AWE Ala
1300
EariFEHMINFIRM rardatillffl
1400
EIPAIMMEMINIrd ammo.
1500
MdFBIBMFAPAEIMI MI MUM
1600
FAIERIBIFIIMAKI
16 lilt
32.
1700 Goo SZ) zco sz) 11%.0 07-7— 2
alatriFIESINIEVANIEMPIMPIM
1800
APIMIKIMMI MIME%

1900 MilaglailfeWA MAIMINIP2
2000
UTIMICIPAMPIMEMMINITI
2100 LOSIMITAMPAri EMPRINISTI
2200 EIMPBEFAISIME ITS AGEIN
2300 PR V WA Fil PA El I INIM
2400
b)(6)-2
8
HR halarr9,-.2 631051fita,m1 .,
D •
MEDCOM - 2162
.

0 0 0 0 0 0 1 1 1 I 1 1 1 1I I 2 2 2 2 ; 2 3 4 5 6 7 8 9 0. 1 2 3 4 5 6 7 8 0 1 2 4 PULSES RADIAL R
A 2_
(4)
Bounding

(3)
Full L

(2)
Normal DORSALIS

(1)
Faint PEDIS

(0)
Absent L 2, 2-
SKIN

(1)
Dry (4) Cool (7) Jazmdlced

(2)
Clammy (5) Flushed (8) Color Normal

(3)
Warm (6) Cyanotic (9) Pale . • 8
EDEMA

3
60'
51 S
LEFT
SUPINE
HOB 30 DEGREES

I f)
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES (tidy MAMA OPUS-U)
PAIN • I PAIN FREE

Ft irA
PAIN SCALE (1-10)
PCA/PCEA IN USE (now bFHMDA OP132-7)
ABDOMEN (2) Soft & Flat

(1) Dlitended 2 2_
BOWEL SOUNDS ( active aB quads)
•••••••1
NG / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph

FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.a.
SKIN INTEGRITY No Breakdown

Surgical Wounds
mvla t no l'hi3k,prtsn
Rashes, Lac's, etc
DRESSING (Dry & Intact: specify site below)

NI clic)
AT, P Aryl
#2 1 IN -fAlle1,41 11 p.Z,00
83 (1:r1
C4— S+
ENV INES SITE DATE INSERTED DESCRIPTION (SITE, DSG.)

4AN. 4 N 4., trv14..., cqci.
• iity4 ./t-.RINVIEWN .04 eq-cz.
11141"21111111111
A/Ant;
vt tt
t.,t ure
tt Lat41(rs Sitt of ii. CAA- a Ptillir trt C t4-)et744-4v 10 —
gissurm•Its
-r .
MEDCOM - 2163
DOD 006215
CRITICAL CARE FLOW SHEET

(b)(6)-4
•-• :
LOS DATA
DOA
0 3 0 cA-03
bos
t)" 0 c-N-0 -3
POD 3
NURSE'S SIGNATURE
b) )-2
•ILT. A"-
%A)
7 . 1E33203:1=OnSEM:Tiffer-
CA
Weight Yesterday
... Weight Today
Initials Safety Checks BVM at bedside Monitor Alarms On ID Bracelet On Allergy Bracelet On
Call Light Within Reach
Side Rails Up Bed in Low Position
Department/Service/L.1=c
•C
PATIENT'S IDENTIFICATION For typed or written entries give: Name-last. first. 0
24 HOUR DATA
24 Hour Balance 24 Hour Intake
...
24 Hour Output Weight on Admission
•.
b 0}2
DAM
0 (7 0 cA-7-)
)
Middle; grade:date; hospital or medical facility)
HISTORY/PHYSICAL FLOWCHART (b)(6)-4 o OTHER EXAMINATION 0 OTHER(Specify)
• Or EVALUATION
DIAGNOSTIC STUDIES
0 TREATMENT
DA Foam 4700.
I MAY 78
TIME
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
a3
2400
VITAL SIGNS
))))
T P B/P SAT
A-line MAP PA RA PCW CO CI PVR
11111rE/MUNCRI
IMIN1111111111111
raf:ZEIVAVOARNIVAIMIMI
NM El RUM
111111=911
4111111111111111111011111111111
WW1: I

RIM NM
b I 0:1- 6 O WEI
101101571111M1 II 2-=SUMI37-1 (as" got. =IS
118-151-
MIMI NI
GANIEVEZIMIG172MI INMEMIMMIMIMS11
MN
ill WEEZIELM 121 Zoil
Nu
IMMIEWORSAM201111
MI MI
Io iligiVAUTAITAZI logLE 73 essimmwassmavarmam
MN MI
VAIIMERIBMI
111111 MIMI=
100
JO) 10o MIUIREIMME111101
III Ell
00 6(0 (og"
till
MOM ME
cec) 101 MIER Ain E
NM
D • LWAINRICAISEll
MI NM
MIN=/4
NI
005—
MI MEM
9
MEMO ILWA 111W
SVR ICP CPP COMMENTS
PUPIL SIZE PUPILS MOTOR FUNCTION CHART CODES . v
1 mm Equal 0 s No Mcivement . Present.
2 nun R Reactive 1= Slight Flicker/ Trace of Contraction
3 mm NR NonReactive 2 .. Active (Gravity Elintiniktid) Not-Applicable/Absent (blink)
3 .= Active: against gravity, but not against resistance ,
4 mm L R Left Larger 4.. Active: Against Gravity and Resistance, not MI strength Refer to Nsg.NOtes
X
El
• ••- •- • • _ •-
5 .. Full Strength against Examiners Resistance '
5 nun R L Right Larger No Change from

•
Previous Assessment
DATE: j 1/4—A-4
1
4
Ft
F.;

t
1 '
•
•
4
OOH
00.
v.4.6
0
TIME
-1

I
0
I
0 2
4
f
4
A. BEST EYE-OPENING RESPONSE (4) Opens Spontaneously (2) To Pain (3) To Voice (1) Does Not Open 1 I 2.. . . _
B. BEST VERBAL RESPONSE (5) Oriented (2) Garbled (4) Confused (1) No Response (3) Inappropriate Verbal Response I 1 I I I I I-t I —
C. BEST MOTOR RESPONSE (6) Obeys Commands (3) Flexion to Pain (5) Localizes to Pain (2) Extension to Pain (4) Withdraw to Pain (1) No Response GLASCOW COMA SCALE (A+B+C) 1 e)• 31 1 T 31 14 tI t LI II--tr ----
PUPIL RESPONSE Size (mm), React to Light (+) No Response (-) R L Sk. 24 2F. 24' .., 1'4-
MOVEMENT RUE % t i I / .---
(See Motor Function LUE i 2. 2
Scale at Top or Page) GRIP (S) Strong (W) Weak () absent RLE LLE R L filb Y 3' Is 1 I v't IA i 2-2 Z V7A OA ...---* —•
RESPIRATIONS - REGULAR
IRREGULAR . s.4
BREATH SOUNDS (5) Clear (4) Crackles UNLABORED LABORED SHALLOW RETRACTIONS RUL LUL ... - •Ci lliA • ii ' . `4 1 A) 1 3 3 1,5r --, — . .
(3) Rhonchl (2) Wheeze (1) Diminished COUGH - .' ALL L LL BOTH BASES NONE .4) g,- 3 V 3 3 V 3 "2— y ..z./ *-3 23v .---(--/
SPONTANEOUS
PRODUCTIVE
NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink (2) Yellow (1) Clear 0
SPUTUM CONSISTENCY (3) Thick
(2) Frothy (1) Thin VENTILATOR _ - . Vt 1002 RATE (SMIVICMV) PEEP / CPAP • PRESS. SUPPORT ‘.7 I ; A — 'OP 17 0 tow b.IP 1.5 4, 0 .1:4 (..,rixA be.. 41X DO . 6c. 5 .4.S ,14 ?t 2; rV ...4 • -•
OXYGEN DELIVERY NC (I/ndn)
DEVICE FM (I/min)
ETT # 1 g NRBM Q/snia) ETT 22. an gums Err CARE / POSITION CHANGE ETT / NT SUCTIONED INCENTIVE SPIROMETRy DOM.'. ii Ni I J v. i i 7-Jrig _
COUGH / DEEP BREATH , sow
INITIALS )(5)-2 b)(6)-2 )(0)-2 b ,11)-2 10-2-- .
MEDCOM - 2166

DOD 006218

INTAKE OUTPUT /Z2 2
r`i.4./ •k'r
1,3/1) LI,-
0 IP
0100
FAMITMIVEIPATird rdita .411P11
0200
FIRLOBACIMPINIBI PITIVA A Am
0300
rimorm-nommi ;REVAMP%
0400
FASTSIMPREMI
0500
Elamireamarirm ram AM
0600
EMP111211
0700
mum Pozeormis EITAKISINI
0800
romaAB111111111111MIMPIII
8 d2) 34 ,70 F8O
0900
XI MIPAIP2EWIPAP%
1000
1/111671111M1/11 Milarda
1100
LOVIMPAIMMIPAI EMENAMMI
1200
Pr IBM AATIMI
1300
LOOMMIIKONIMILI EMMA%
1400
ITIMMENIMINI FRIA/Ana
1500
memo !Ammo mum=
1600
KoriMMILMEIBPD EOM PM
t qg 3(0 ¦ 100 vi Emmailiso . 3 0 ESNI
550
'
1700 HEIM%
1800
BMW
1900 PAIMINPREMINI EPASIDEPAI
2000
PAV IMPINalri¦ TAIMMEIPPA
2100
AMENVABINFIN NEMO%
2200 INEWAIMIENBRI EMBIELI
2300 FAMMENIEIPMEINMEMEMPAI
2400 MILIMICILM•111 PIARCANIA
HR vkq Tlizo lq° 14)
11/441°
COMMENTS
8 HR
•

11146
214qHi Rt

MEDICAL KECUKD NUfthINt,)CJ
(Sign all notes)
)
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated
M-L! lag 1 1/FAIr ra- 46: (6 bieq 4$ ciivoillo. 91t. Ani,)-(eyo. I Mos; Taw kl". d14-,gx,/i/v4 alke 2/ . A5-,776 ,fr) /7 /5-2)1441
bolos 5:4 - . /' J4 ./ . /yA 9W-1)4 ..0-0 ..,2-. V 710 ,c(LtA/v. 6 _p) thaw -70.g.5e“ ra"--t,,w i sir( '.,.
l
leen, 6. aS -4 sArr .,)s--( ri %1---/-2V / a, /V led rad'? /' 4ad .Q-de S7;4/9 fr/l/
4 f Ire,fir-iikt-8, 041,1,4 14 g'14tilly e,...-aty dea' am/. , Yin' 4 1,04)3 Se ti.-,ie/e4fel 6-t iait Airei -(4&/.1,4c/
b)(6)-2
I Al $1/ /DP Vegi-eJ Sex. 614.24 — 47/40/0 ifthenft )494
bm9'
avvu iid-in,y4iiis t.-1-. zitl Lk) diC-K (a --sl
iZCAT-6 &Jail) • SV ts t$1 54.a. -64-4 OP/Atiet-74;-. e).'/Azoix,-, Owe .T2/ eactee 6-6 741/4-fi,te/ ,c . E., .st-sx. 0-Fei-rlec--6:--of.- fr,.74.1,4vh:---x air A-t
131T 71-c3Ace .grial.y c:1‘4--a-(ert.. -Iirtva s(,t. i • 62 et. I t-eil. 20,,e1 ..14,411,1.1; (.
6..glotiroici vt--a+cti 204' lie frk a IV VrTipt-ueiv CAA+ Os SA:ts • ',157., Pitlja¦ Vexklalev • eo66, ---• m or Gar v6 eptal.i4
-
Aroz&s,
LL aa„..0 ,L6s A‘) ,5,4,„Aff (.tea frkettov Aktkr;trt:APruS -attiLe WA 4LO totibleP .7 tkrzytta P645 doid (I at-41a
17 bo sit t-t Ca.V-•- en h-CIJ ./.31 M (AAA 61-c-e 11/ 2 /US E; weci VA Lee.. -e,;) 56 rke, evimc./ L4 0-4 kL-Yz /vs t. Zo I cor, zt.u..)41-te.
¦ ikpoS
altracia
(b)(6)-2
MEDCOM - 2168
DOD 006220
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA 24 HOUR DATA
DOA DOS 03 0LA-017 24 Iiiiiiillislince 24 Hour Intake ". ( D 1266
POD 24 Hour Output .--3 Gs-al
Weight on Admission
Weight Yesterday
Weight Today • •

/NURSE'S SIGNATURE Initials Safety Checks D
b)(6)-
I2
b)(6) -2
BVM at bedside
Monitor Alarms On
ID Bracelet On
/
Allergy Bracelet On Call Light Within Reach Side Rails Up
IA

Bed in Low Position
WWII MT, !Al fl Ill !WA/INT:TM ..ger•pro
-T1'77
b)(4)-2
Department/Service/Cluuc. DAM
I OCA-0
PATIENT'S IDENTIFICATION
For Oped or written entries give: Name-last, first, Middle: grade; date: hospital or medicalfeedlot)
HISTORY/PHYSICAL . AWCH.ART
(b)(6)-4 . OTHER EXAMINATION . OTHER(Spec/MOr EVALUATION
. DIAGNOSTIC STUDIES
• TREATMENT
DA Emud 4700
I MAY 78
o 0 0 0 0 o 0 0 0 1 1 1 1 1 1 1 1 1 2 2 2 2
2 3 4 5 6 7 • 8 9 0 1 2 3 4 5 6 7 9 0 1 2 3 4
1
PULSES RADIAL R ;2-2
(4) Bounding
L 2-
(3)
Full

(2)
Normal DORSALIS

(1)
Faint PEDIS 'Z

2.
(0)
Absent L SIGN

(1)
Dry (4) Cool (7) Jaundiced

S 3
(2)
Clammy (5) Flushed (8) Color Normal

(3)
Warm (6) Cyanotic '(9) Pale 3 13 EDEMA

In.
HEART SOUNDS
dr"
(Clear, Regular, No Rubs, No Murmurs) e-
HEART RHYTHM 1 sof (Normal Sinus Rhythm, no ectopy) SWAN GANZ CATHETER
(Zeroed & calibrated) ARTERIAL LINE (zeroed & calibrated)
HYGIENE BED BATH FOLEY CARE ORAL CARE
MOBILITY BEDREST BSC DANGLE CHAIR
POSITIONED RIGHT
LEFT
SUPINE
HOB 30 DEGREES

1
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES (luno FH MDA OP13226)
PAIN PAIN FREE. cP RA-fr

1
PAIN SCALE (1-10)
PCA/PCEA IN USE (Raft Is FHPADA OPIXt-7)
ABDOMEN (2) Soft Jr Flat
Distended

BOWEL SOUNDS ( active all quads) •
ayf
NC / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.

SKIN INTEGRITY No Breakdown
Surgical Wounds
Rashes, Lacs, etc
DRESSING (Dry & Intact: specify site below)

V/)
#1 (i'e)te, OA-Pr
#2 A.-4141 ."Lwi.e.13st-o-• 7;-'AVIS (TIP..
43 e h k, )
1.111111

DATE INSERTED DESCRIPTION (SITE, DSC.)
INVASIVE LINES SITE
ID&D2 fity72o1 ,r1-7 /At°/ fIOD obovbrop .1,-.R.,4 Wei , / ill in 6oc)--0S 116-0„1-CD1 41'SIS ti4r^jki
Sze WA J117.4^,
91AP(Sh o (4-753 Apr /400
VITAL SIGNS

TIME T P R B/P SAT A-line MAP PA RA PCW CO CI i PVR SVR ICP CPP COMMENTS
0100 :.: .. tc% P- 1 "/$-1- l 1 cy .
0200 clip to c..1 t 4i A k'' -/5D cilliir 11
0300 1. 1) 44 a3 lf,-1z) 3 (1* il 01 •
0400 4t-D__ rod--Ici 1 5-s-wf ,q 7,c 11.\
0500 9 S.-F-(z, elYg. cal :.% 9
0600 /Oh7,0 RIO Klic, . cirto t.57,1U 060
0700 al Pl* ggle (2S11-2 S'g
0800 106) 41) Plu,, qta (2341-3 go
0900 a‘ 14i(4, cis Walt. q
. 1000 01) tot it,lrt Giglot4-MqR Pk
1100 lcq ktlic 9i-1• izs13-.5 ri ....
1200 . (OW qt4 cr10 i 26t4q- 89 •
1300 q41 108 14'11.g 106, 05/6s % •
..i....
1400. II o 354 HA q11:5-1- 0
1500 ?Pie) 'Ds— 166 111/1 1051177 11-
1600 Nik, 103157-1i,12 02679 7,--
1700 1/1 St,. qb ,iviw. . ',ma 107143 'fig
1800 10k • t611t, It 1121K iil .
1900 9//Of Ill Vrt IIE /'°f(4 liq
•
2000 Icar(i) IQ( 114) q/ 1°v/u4 19
2100 9/ 4(A \ ii3 40,.1 qtg 1 . 50 (f) " ' gr-Te
2200 10/6-(4) it -5• 111 ,._ °I t, 'i-k) 1c1
_ .
2300 IOW, wq 1711 Pc15--)- 16 1?-Y1.9 irl,
2400 ‘01, 4‘ to°‘ 111)- 101ir li 1 t 4/,-
.. .
MEDCOM - 2171
DOD 006223

PUPIL SIZE PUPILS . MOTOR FUNCTION CHART CODES
•' !
I inn-= Equal 0 - No Movement Present.;
2 nun R Reactive 1... Slight Flicker/Trace nIContraction
3 mm NR NonReactive 2 = Active (Gravity Eliminate:4 Not Applicable /Absent (blank)

3 = Active; against gravityibut not against resistance
4 mns L R Left Larger 4 - Active: Against Gravity and Resistance, not fall strength Refer to Nsg. Notes

X 5 = Full Strength against Einuta
l rs Resistance R L Right Larger . ....._ No Chan e from '.-DATE: -690K(.9 Previous Assessment
• 0 2 2
H

1
H
'••¦
H

1
•
H

•
a••¦
1
OH

o4
TIME
2 420
2_
A. BEST EYE-OPENING RESPONSE
(4) Opens Spontaneously (2) To Pain 1 I I
(3) To Voice • (1) Does Not Open
B. BEST VERBAL RESPONSE
(5) Oriented (2) Garbled I.. I I I I
(4) Confused (1) No Response dr T. 1.-
(3) Inappropriate Verbal Response
C. BEST MOTOR RESPONSE
(6) Obeys Commands (3) Flexion to Pain 1 1 I
(5) Localizes to Pain (2) Extension to Pain I I I
(4) Withdraw to Pain (1) No Response
GLASCOW COMA SCALE (A+B+C) Al fl sr sr Fr
PUPIL RESPONSE trt l'4' V.4- 2* gy‘'
Size (mm), React to
Light (+) No Response () L 0-- /frrlt 1,4 Z?--a-4"
MOVEMENT RUE P (t. te fp
(See Motor Function LUE s (P (0 6 I,
Scale at Top of Page) itRLE . 1 1/7 il 0 I:0
LLE -- (1, b to ...
GRIP (S) Strong R (9 lo 6
NM
(vv) Weak (-) absent L As (0 (2
RESPIRATIONS REGULAR . V ki /
IRREGULAR
,------7
UNLABORED e, fa
LABORED - I)
)--
SHALLOW
RETRACTIONS
BREATH SOUNDS RUL
(5) Oear (4) Crackles 0"' LUL • ,-.)- 5 2. 3ii 2- ,...../
(3) Rhonchi RLL On 5 . 1
(2) Wheeze (1) Diminished LLL . •.,... -,-, 3 '3 3 3 3/1
BOTH BASES `) li V V 1 ....
COUGH NONE ./ 20'"
SPONTANEOUS
PRODUCTIVE
NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear
'
SPUTUM CONSISTENCY (3) Thick
(2) Frothy (1) Thin
VENTILATOR Vt 1.0*- ItOD 201-) 490 dgD ' 1 i re
F102 0.4) 0 q 0 LIO r ..0 50
RATE (SIMV/CMV) P-- iv too IZIIMIIIIIIIIVPAIIMIMNIMI
PEEP / CPAP • cel to J 0io to
PRESS. SUPPORT
OXYGEN:DELIVERY NC (1/min)
DEVICE '
FM (Fudn)
Err it 151 NRBM 0/min) •
•
ETT ...cm gums 79' • '1
ETT CARE / POSITION CHANGE
1 4
ETT / NT SUCTIONED
INCENTIVE SPIROMETRY DONE
COUGH !DEEP BREATH -- 50-2
INITIALS b)( )-2 56)-2 56)-2 (b 56)-2 56) 2 xe)-2
— _

NURSING . . ES

(Sign all notes)
DATE HOUR
OBSERVATIONS AM. P.M. Include medication and treatment when indicated
Okvat )16 IA.)!to to4 ,t4 4, 4 -li S --"P
6
04),), S ( SAO in 0-1Z -S)k k)r‘ 0
4P.- S \)4 C.
4 1 e¦ "2-40
. .
4.4;2-i=. 1 T)Ago
1,-1-
C. 4-,e_d sue' 5 ' S, Si S,P t1-7
Ur-S.-0,4'4 ,1.x' 5
1:-'-o de-0 I
aizA40.,..)
/olfleA 0-410
:70Grp /00764 ) d6.4ei V-ettc ( Aszo..f reL_%Afsessze( 4._.
tz: 9;.-. ¦k‘ . 11.107; Cred"
? .re 1 Sexy .81.74,..,1 5.
46-#,:necs5) e. as3'e
/ak/a-2 07'0
/61&t.
74/C./C
4!&I-
69.0/P.2
ak-sn (3)frptetak,
arecic,fre
7e6.61/e-i — L- ert4/ 4 ibt;prie,-gr.s. /130 ivethe /el Sera/ la r15 zt ?yr( g) -Qafe. 1/--CS. a/166 624/4 il..652,ft
DD
Fed 2004v1iivr V tirszt Wtilin,v- V ttd i/LitS Pek
041 o0
Aka, vt) 6-C-o-,. 4- •
4 c • A ) 6 is./ to-friAQ to uk Co.,* a., evvil..Sh..e. c‘ A. Vt.
I I V 1,"-Q 5 47 LeOkee r.t.5
3. 1/41 c .ict Vie( C.-0 „A-0RA to C. 5 / 0 rd. t (ref ti L., 4, c±-et 3 +" ail-
(VVe a`e-e-1:-4-0
F 5 4 - -1 °` -1--s Ale-e%)Jo,ss.-5 tv)
Hruia-e
MEDCOM - 2173
4 ti-c
. . )Y.") vi c..,.
0100 0200 0300 0400 0500 0600 0700 0800
0900
1000
1100
1200
1300
1400
1500
1600 8 1700 1800 1900
2000 2100 2200 2300 2400
HR
INTAKE OUTPUT
o
t74
c

COMMENTS
earEMPPIIMMI
rd¦aillIMPA
EFISTIELTIMPAI
P27011BEIBMIL2111/
IF El /I
MISMILWILIMIE
MIMEi°100 IMP%
Mr MEI elf° EMI%
ss isu gap ¦ ck,sq Liao C
:.11.06113/1/M111
Pro BILISTMEMEI
IRIEVAMIDAMMII
Pr IMERMEIIMI
EllELIMEMEI
PAINENNIMENIN NEEMEleilall
PEI 100 . 0 zsi¦ 041
AMIPMEIMPLIMI
NAMPA LAMM
&MEW% ARM
MINIEBEIDel APAS
wor VEINIER/
INFIMERIVARELI
EINEMILIME Ard
k `k
IkailEIMENTMAN
0
56 10 D ;19
)
RADIALPULSES
(4) Bounding
(3) FuE(2) Normal (1) Faint (0) Absent DORSALIS PEDIS
SKIN (1) Dry (4) Cool (7) Jaundiced (2) Clammy (5) Flushed (8) Color Normal (3) Warm (6) Cyanotic .(9) Pale a
EDEMA
HEART SOUNDS
Clear, Re , No Raba, No Murmurs
HEART RHYTHM
(Normal Sinus Rhythm, no ectopy)
SWAN GANZ CATHETER'
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated) HYGIENE BED BATH
FOLEY CARE
ORAL CARE.
MOBILITY BEDREST
BSC
DANGLE
CHAIR
RIGHTPOSITIONED
LEFT
SUPINE
HOB 30 DEGREES
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES %do. t• HAMA 0713240
PAIN . PAIN FREE
PAIN SCALE (1-10)
PCA/PCEA IN USE (Raw to FlEdDA 0P132-7)
ABDOMEN (2) Soft & Flat
(1) Distended
BOWEL SOUNDS ( active quads)
NG I DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown
Surgical Wounds
Rashes, Lac's, etc
DRESSING (Dry & Intact: specify site below)
#1 01/834-40,6-e)e,tv."4-
82 ore, -)i.,..,51etne-s OT N-
L
+IN-4-Aat4t I' ?3 INVASIVE LINES SITE DATE INSERTED DESCRIPTION (SITE, DSG.)
i-017e -r-r).5:nn k
rt. f_tq,..)47 til
1 ,6-5 ,0p Gon.a )

-(.1?). (D,

CRITICAL.. CARE FLOW SHEET
(b)(3)-1
LOS DATA , 24 HOUR DATA 24 Hour Balance 1--3 -..).._6
DOA 03 0 cA1)-5
DOS . 24 HoUi• Intake
6 POD 24 Hour Output.
—2;b0
Weight on Admission
Weight Yesterday
Weight Today •
NURSE'S SIGNATURE Initials • Safety Checks D E
)(8)-2
13)(6)-2 bS(6) 2

BVM at bedside
A./
Monitor Alarms On
pc. Walle
ID Bracelet On
ArPra-N
itetrAu Allergy Bracelet On
ak Call Light Within Reach
AA -p Sklie Rails Up
p(ft
Nip
Bed in Low Position
t
• PRIXAKhl, H Y. (Signator rid I die), •( Department/Service/Clinic UA'1 t1
(b)(6)-2
0 6) 0 CA—C15
PATIENT'S IDENTIFICATION ,For typed or written entries give: Name-last. first.'
Middle grade;date: hospital or medico/ facility) HISTORY/PHYSICAL FLOWCHART

(b)(6)-4
.
OTHER EXAMINATION . OTHER(Specit5) . Or EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700
1 MAY 78
VITAL SIGNS

TIME 0100 0200 KA, k P R B/P 106 'eta-'t Viii 110 I/12 111k6 SAT CO lb A-line 11 /5"li .1%349 MAP q ) PA • RA PCW CO CI , PVR SVR . ICT CPP COMMENTS
0300 1%0 1I1-"Yg4-6 c\ —) ' t 14, Ft­ —
0400 toils. ' '/la- 1 151 . 019 "/“, 06-1-f
0500 IQ/ lqty- "7 11 ? ;0010"711,i" 11 )-
0600 0700 ID S loos la $2'12 1I/Y64 1 04 Inq taw /12 0 3/sq 1W/0' 1213y, St s t
0800 0900 . .... I • Ya 114 /tob t00% "A/0 9( low 'lin 1084-100 w5/62. 1-(2) . . . . .
noo Icn 1 ill- .. .
1100 101 JD] 13/m '3Vits,9190 '471-0 .100 •
1200. Hs-"A.136/1 1, 98%-riffkit lot. . .
1300 1400 0-0 ices. Il3 °I C 114/1D to-b7. -""I51 144— 1 itjp, 95 II Vez sl 7R . ..,.:.
1500 jci)50116.Y, 113/420 qc li`lin 77 ..
1600 I o i (Di 02, 14112 /2-uk 14 IPO / 0.5775 vi .
1700 04 1 1 t.1 Zia. I 1 u/65 WO /16AiLl 11
1800 po'€) ib(o lY2., 1P-As- cici liy4s frD
1900 il9(fOl°7--z°//Z 136/7/ cii 11 1/47 K • . .
2000 2100 99'6.) cis-yid' ) 1 14/fa. 11-1ki q9 Ne 1 34/61 too I-114o / -1 'Y/(ob. 4 •
2200 i no a el J-. 1 -W/514 IQ() •
2300 2400 /00.• 10)-1 . 1/515 til() CO5--AL46-DY:Cci g Ti c,

?Inn SIZE - PUPILS MOTOR FUNCTION _ CHART CODES
1 nun Equal 0 No Movement' --Present
2 mm R Reactive 1 Slight Flicker/ Trace of contraction_
3 nun NR NonReactive 2 — Active (Gravity Eilminited) Not Applica hie /Absent (blank) "

3 •.= Active: against gravity; but not against resistance4 nun L R Left Larger 4 Active: Against Gravity and Resistance, not fall strength Refer to Nsg. Notes X 5 Full Strength against Examiners Resistance 5 mnt R L Right Larger kr 2(a4 d C .weAie..o.)r..)-1\ No Change fromDATE: N) Previous Assessment
5 0 0 5 I
5 6
1
CLL.:1

1 I I I
I-wl
1
2 2
TIME
211,1
0rj
ow

.
flYt 01!
4 6 I
0 1 2 4
I
0 2 4
A.BEST EYE-OPENING RESPONSE
(4) openisiontaneousii)(2) To Pain (3) To Voice ... (I) Does Not Open I I 1 I il I
B. BEST VERBAL RESPONSE Ell
•(5) Oriented (2) Garbled (4) Confused (1) No Response (3) Inappropriate Verbal Response 1 1 I i )
C. BEST MOTOR RESPONSE
(6) Obeys Commands (5) Localizes to Pain (4) Withdraw to Pain (3) Flexion to Pain (2) Extension to Pain (1) No Response •. I , . 3 • •
GLA$COW COMA SCALE (A+B+C) PUPIL RESPONSE Size (mm), React to Light (+) No Response ( -) R LL. MOVEMENT. (See Motor Function Scale at Top of Page) RUE LUE RLE 41 •.' I-, 1 6, - II /A. VC V U 2/1( .. (.1 1.// to .. 5 v.3 -r . -2.34. 2. 7 2• • C , 2. 2-2. • i, 9-1, 6 tt L
GRIP (S) Strong LLE R U \t (.1 • 2, 6 b
(W) Weak (-) absent RESPIRATIONS L REGULAR U ...0' , .
IRREGULAR . " .
UNLABORED
LABORED
SHALLOW
RETRACTIONS
BREATH SOUNDS (5) Clear (4) Crackles (3)Rhonchi (2) Wheeze (1) Diminished LUL LLL V I NI 3 3 3 /1 3 3 .." 3 3 3 3 '3 - 3 '2, S
COUGH BOTH NONE / t ...." I .4 ' I
SPONTANEOUS
PRODUCTIVE NONPRODUCTIVE -• • , f
SPUTUM COLOR (5) Tan (4) Green (3) Pink (2)Yellow (1) Clear 1
SPUTUM CONSISTENCY (3) Thick (2) Frothy (1) Thin • VENTILATOR Vt 1102 RATE (SINIV/CMV) PEEP / CPAP • PRESS. SUPPORT OXYGEN DELIVERY DEVICE NC (Midis) FM (Lade) V1e, iP Sbc iD 11 i 0 ••' t0 In ?V= Peti ace (toC )IC a t) Pc 12 N. in tv tOE g 2-tax tro 17 to fix 2 Ira qoIQ% Pr • .
ETT # NRBM (Vmin) •
ETT ETT CARE / POSITION CHANCE cm gums ..,r / . ..# V. V r•` ..---'°•
EFT / NT SUCTIONED INCENTIVE SPIROMETRY DONE COUGH / DEEP BREATH INITIALS , • b)(6)-2 ,/ IbX8)-2 b X )-2 . b)(6) 2 b)(6)-2 / —....—L--____,,
–.–

INTAKE
OUTPUT
F) 7 0 g)\.ri 1)\
a
-f ,.t v '10
V

R,
3
0100 COMMENTS
NAM ALIKIVM
AVIril
0200 PIV20.1
KINAILISNA
0300 NV OE AMMO 21A AKI
0400 IESTIEEMBINiffi eitT011Mil
0500
0600 MiraAnus 0700 LNIMMIlialniNESERIMISI %D.bob

8 0800 OF2511111ALIE
HR

0900
aAl
1000
1100 11140111ASTIM
IMAM Al%151/
1200
1300 ;Er-P37 .Fr LOAM=
1400 NEEPAININIKErd
EardLEIMEMPAPITI
1500 UMW ALMILIV
1600
WASMERIMPAIII
8 Lib 1
EAAAP11 Eliffi
MES.611Aril
81IR
16 HP 0.
0 MIN= 5. / D e •
1700
kaariKvaromme
RETIPIMINI
1900 0111.E.4,412-2ro
1800 eastraran
nerws7Agrirdre2 AMEN

2000
V
MINIUM
2100 rfraro Fro FAINISSINI ARNIM
2200 2300
ETIRMINNI
2400 WOrdreiffill%
SEIGESIBEI
Framordemarimummiarallaw

voiaroinliatEM
MEDICAL RECORD NURSING ;ES
(Sinn all notes )
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated
A.M. P. .
,....,
N brik151) oast,.—too,. ,,,,,,,,A— o s, e_k , „, t W' 44\ 1 C-c, ,-, e of f ,t9
mpl-cpk. a ft, 0 ,,./f_t_gb, u v... sic)7•11, A ref -Iv 6-ts /0 i 4.1C,--1-..)t-t-P 7. f ).Ceed #4.5.4 I
—
A e, or&P.(edi TIC- ill ..(0 ..-,16 (bl".0 ,-, 7 J u 4( ofit s 4 5 (*.-rrfiere-efi k-{44¦4
. i-t-L. t -(L, (e.: uo a 5'r- C-43 t--7 tolvf. 5vc;k0._
*QWn St--r,e.. - o e.e( , . .17
40 0, ye-5i- 4-0., e. ,„ it i):)a -14., r, S (-01-.4v 14 1100 07-14- 7 - 6 4 04r1 e-S' cntal
1),-,0,,(3 41, 4. 6 11-13 ID)c-D ..T_)i 34.1_ t.t.-5-e.4 -... +n (C. ii, A yl,, DTP!? .,.
,-A•-)1-•t i)(.1) u-t- 40)vur,v, 4f ...1A-_114,114°..--AD )•-¦\ /f---.-+ qS 0 -fge..4^"r-C °WC) AlthalCelL t
0 iC(a Aria MAD; cukuaa4444 040,1rIx2cw4,,,,_ takpi tWo citfeid&I eisil d WhYdit cchIS A - lewle. -Vu6n5 145 Nek ;_brez1c. abv4ri -it, la) t,zry-1 Pyrrtr, robl sver,z_ A . CCACCiin user "I-0 l'i A Irk A -..". 1 i he . i bx; piact sr:). A-k:i.yr 17,24.0 0\ti cyf n-nee_ i r* . OW' Vet* se1695 . NA tb --47 ISO m L , n Oa qpio -Per P e. i a
r... 15)(8)-2 . r3+e Q... ; 4-u be .Peediri • r . :., • cc-
1030 Ve.c-kf ,--irrcit,ret ciceke_ct. --VIz . 3'49 , r ' Cera -.).
b)(6)-2
• 13(n \lex-u rim', v vv•)+ur ne—ct .)0 P-' ; Will Cal* 'VD wILTIet.' 5 D f03 1170)14A.4eSi J)- Z-71--, •)r k J, s()/, ( . Au
/ AIA
...t a• to 11-t ..,i, . • 1000 c c , -4-H030)Vo Ani. At As() r , 1. -._ Ai, . 12 1 16_ 1 /coca: , . ..- R:01 -14070 kf P- /0 0 -ectis-$51))kR_ 18 A-L te_ --,,,,Q. .Ak,-tG . . Occ. .1:24.4 1, .
;-t. ) 1C-0 al.. .s (11 law x--it: Le .. P cav\i- .frD 20a/%. . EiT &-t-1106 Utz, -rpAp-f'D 1600tuziA-11)1. --\0
Y -11211"
6„5-0 .6=_. D gilc . t/tAceit)i- Pi)AA -FP..-0-I001— ")( 2,:f
.0r5. 64,5.-4 1_0W1Plet-lAr 0 S . /1 g30 ociA 5)__ CvAllt ice 4, s il peTte . L.161-
I. Ps "A, P °I/1-T ") 1,4Aas? Lit,„„Atx,_ Li-`a ( .
ka •
("---rit,2„. . )16,4 J:
, /lir c.„-,M-o..vis Vit.,,,,v, s ID ea.,() -t-trtnTc.:t . -I . t,wt.Ct i' QCs eD 1130 AOS CV 1.4.,14•44 . TCAAAS )a Ff.z..,,,s
AA)
1 z - i i 0 f;1 tritOS .
C 40LOCO 4s0P. I r 14(6"
•
CRITICAL CARE FLOW SHEET
(b)(6)-4
LOS DATA 24 HOUR DATA
DOA b3 ocA-03 24 II­00 Balance
DOS 24 Hour Intake
POD 24 Hour Output
Weight on Admission
Weight Yesterday
Weight Today

NURSE'S SIGNATURE Initials
Safety Checks A_) BVM at bedside
97/0,44.2 Monitor Alarms On ID Bracelet On
-
12 6).2
Allergy Bracelet On
Department/Service/C.111m
UA' ! h,
ic
10 ocA-0 3
PATIENT'S IDENTIFICATION
For typed or written entries give: Name-last, first. Middle; grade; date; hospital or medical facility)
. HISTORY/PHYSICAL FLOWCHART
OTHER EXAMINATIO
OTHER(Specifi)
Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA Foam 4700
1 MAY 78
( o;1 0 0 0 0 0 0 0 2 3 4 5 6 7 8. 1 1 0 1 1 2 . 1 1 *4 4 1 5 1 6 7 2 2 0 1 2 2 2 3 2 4
PULSES RADIAL R , ,A-F!
(4) Bounding 2.
(3) Fun (2) Normal DORSALIS /14-1110 R Z.
(1) Faint PEDIS
(0) Absent
SKIN
(1) Dry (4) Cool (7) Jaundiced
(2) Clammy (5) Flushed (8) Color Normal
(3) Warm (6) Cyanotic (9) Pale
EDEMA
HEART SOUNDS
(Clear, Regular, No Rubs, No Murmurs)
HEART RHYTHM (Normal Sinus Rhythm, no ectopy) 59- 5
SWAN GANZ CATHETER
_i_Zeroed & calibrated)
ARTERIAL LINE (zeroed & calibrated) ,/
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST
BSC
DANGLE
CHAIR
POSITIONED RIGHT
LEFT
SUPINE
HOB 30 DEGREES V
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES (Rea to IIIMDA oPtay26)
PAIN PAIN FREE
PAIN SCALE (1-10)

PCA/PCEA IN USE (astir to FIIMDA 01•132-7) ABDOMEN (2) Soft & Flat
(1) Distended 3, 2 z
BOWEL SOUNDS ( active all quads)
)(4

NG / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED Ph
FOLEY CATHETER PATENT VOIDING CLEAR, YELLOW URINE q.s. ob4 Row SKIN INTEGRITY No Breakdown
Surgical Wounds Rashes, Lac'a, etc DRESSING (Dry & Intact: specify site below)
ai Tr.cis IN, A-OTA (_110.51:40vz (-DT 7 #3 lA 6 n cn
-tiet -T--z"..c.6/01%. INVASIVE EVES SIT DATE IN SERTE D DESCRIPTION (SI TE, DSG.) k\JITi2 h AY" t c4oz. /fob/ eo —Li vte rakft 02-1 'PM* hex,
• CCIllaex /vizi
C-kiV)C-(zA( kit OvN
,FUPIL SIZE PUPILS
MOTOR FUNCTION
CHART CODES
Equal
= No Movement
2 mm Present
R . Reactive.
1= Slight Flicker/ Trace of Contraction
3 nun
NR NonReactive
2 = Active (Gravity Eliminated)
• .... Not Applicable /Absent (blank) -
3 = Active: against gravity f•but not against resistance
4 mm L R Left Larger
4 = Active: Against Gravity and Resistance, not MI strength
Refer to Nsg. Notes
5 = Full Strength against Examiners Resistance
5 mm R L Right Larger 6 a 5COAI1;O
No Change from
Prelim) AssessmentTIME 00 00 00
OI
011.,
0
01 11
11 1'1
1112 22 22
12 34 56
A. BEST EYE-OPENING RESPONSE
(4)
OPerii Spontaneously (2) To Pain

(3)
To Voice 1

(1) Does Not Open I

B. BEST VERBAL RESPONSE 1

I
(5)
Oriented (2) Garbled

(4)
Confused (1) No Response 1

(3)
Inappropriate Verbal Response

-r (-
C. BEST MOTOR RESPONSE
(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to Pain (2) Extension to Pain 1 ) I

(4)
Withdraw to Pain (1) No ResponseGLASCOW COMA SCALE (A+B+C)

I 7f
-- -I
PUPIL RESPONSE R
Site (mm), React to r ? 4-
3 ,(5
Light (+) No Response (-) L i g* 3* -13 44)
MOVEMENT RUE
(See Motor Function LUE 117 5 I Scale at Top of Page) (P 5
RLE it i 5
(I
I
I
90 12 34
56 7 8 90
12 34
LLE El
GRIP (5) Strong R
I:=1
id I I ; ce)
1 . 1.1-1 I 111:4-4\J

IlJI)1 1)I
131

(W) Weak (-) absent L
(0
RESPIRATIONS
REGULAR •
MI
II.
mu
IRREGULAR UNLABORED
In
LABORED
Ng
MAI
SHALLOW
Ull
RETRACT IONS
BREATH SOUNDS
RUL
(5)
Clear

LUL
(4)
Crackles

•
/
(3)
Rhonal

(2)
Wheeze .

(1)
Diminished

LLL 3
3
BOTH BASES 3
COUGH NONE SPONTANEOUS PRODUCTIVE • NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear
SPUTUM CONSISTENCY (3) Thick
(2) Frothy (1) Thin
VENTILATOR

F102 i ' '
5.1 I.ki RATE (STMV/CMV)
PEEP /CPAP
PRESS. SUPPORT

OXYGEN DELIVERY NC (1/min)
DEVICE /
—1... el -W4 Wrilh2) V 111 q01Z,
ETT #.i ' NRBM (I/min)
Err 7:l' cm gums
ETT CARE / POSITION CHANCE

ETT / NT SUCTIONED
INCENTIVE SPIROMETRY DONE
-COUGH / DEEP BREATH
r)(6)-2 A I )(6)-2
PI F-X6)-2 1
INITIALS 2NO-
VITAL SIGNS
TIME 0100 0200 0300 T P R B/P SAT A-Ilne MAP 99 2D to AM ttyy M..,..MIMI .. dE TMFa Fit"I MEI Ga Ego MaONEMMENEFERndu .MN ni. PA RA PCW CO CI : PVR SVR ICP CPP COMMENTS www www NEM' •.E .9= Nimmosion=rmessminiv•m 0
0400 0500 • 11111 EMI • ENMEE KIIIIMIN. II%WRIVRAIWAI .111111111 MEImangiraml OD gimigra ELI ""ZI: wommilommrn • Ems= MIllonsmorm 4 .
0600 IIII -Min, qa.-WM 111.11RIVIIMIESS
0700 Imo riliii m w gr

MEM" oo frlifflaill . 0900 KIM no-UM 82.-www -wwww
08e0
loon 0 MEI i Dzirirami
In
Hoo zigsi rim DAWORM
.. •

ME NI

1200 Or WM Ob IMItal
1300 Ems oa go WIEWIElisramourem •
NNE

1400 Oa i 00 22. WO 1 50/61 Si EN: •
Mil
1500 IMI 071EIEll SS grasuram
MN Ell
1600 gram I00 ma I
II

1700 num 10a 12&-7 I 8 (o dil
l
I 1800 gm g .
RotMIERIEW ICI
ME

1900 0 wil 1Nal No-.:1-1 III
I
nu
2000 am ,E3 wa /60 immlnal
simpTuri. ' ..I.W.E1EmilIM rintrerthi
2100. MEI =MEM 2200 MIEN= NE
..m... b)(6)-2
• ies-MINIMINSIMIWASKINI am ....m.
....... • 111111111111111111

2300 ww ° Iic--limi Mil
MIME MIIIIME

milmuNIMINIIIIIIIIIMMIM
2400 MUMriiMP ilMEI Wien 0 MIN
KM
MEDCOM -2184
DOD 006236
faCIJIUAL KECURD)
NURSING JTES
Si e all notes
OBSERVATIONS Include medication and treatment when indicated
#(-241,4-GT k-"d
b)(6)-2
le/to /03 'Afre d ;1 14.4 b)(6)-2 4-1:fr, •
AO .
b)(6)-
b)(6)-2 bX8).2
b)(6)-
b)(13)-2 bX6)-2

A .4.'4114.
AO 4. 1 r
/ •
INTAKE OUTPUT
(,ftY ft,
L
3 e
0,
ka'
COMMENTS
0100
&MOD ACEIPAMEIRSIMPAINI
0200
0300 wrire7rir, ANISIMPABITEMPII
FAMMIRE AIMITIPMAIMIIIMP21
0400
rdr111111P" PAILKILEFIIIIEFAMMILV
0500
VFr EMI EINIEMEARIPITIERI
0600
IMMINNEffil% MEPAIMMil
0700
riva
0800
NEWATMEMPAIIMMERISMIM
Itob o I e
r3sta
111 11Ob4%6 mom 8 HR
0900
aromirm2° JARIFBIEMPAMPATI
1000
1100 ITIMEIM EN/ ELIPINard
EirlIBERM12111111gto 01/011111151
12®
VAISKIMIV FIB !o. 7/A Lltroximm
1300
1400 ray samordw3/31 ETIENNE%
17511151E AMMO" MINIM
1500
1600 AMIIIMPASIM frigIMMII1
EFIELTIMIMPIMINI NOME/
RR IN 2 0 26 130.Big
1700
AMIEAI A A Ininrina ll.
1800
KNIMENHAMMI DIER1/1101%
1900 MI MI API WI EPA OM
2000
2100 ETORIPIRM
2200 ERMINIM
2300 MPIIIIMIRMINI ormolu
2400
MEINIMPABE APATI EMTIERWM•11
24 HR.
24 HR
/ 110g
CRITICAL CARE FLOW SHEET
",b)(3)-1
LOS DATA
24 HOUR DATA
Ci I"
rIsOK Od c)3 24 Hour Balance
DOA egaail
DOS • 0 .1-*
24 Hour Intake
ivrt‹ n c,t 03
1430g
24 Hour Output
POD rik t q 358 5 Weight on Admission Weight Yesterday Weight Today
NURSE'S SIGNATURE Initials Safety Checks D E N
bX6).2 6)-2 lk.,24((Tr' i- (b)(6)-2 BVM at bedside Monitor Alarms On bX6)-2
ID Bracelet On
Allergy Bracelet On .
Call Light Within Reach
Side Rails Up
Bed in Low Position /

• Fithi i)nammand Ittle)
Department/Service/c luuc
=27VAI
.
(5ft $9/t.i-Gs? 1/ Oaf 03 ) 'ION (
, For typed or written entries give: Name-lost. first. Middle; grade:date; hospital or medical facility)
. H1STORY:PHYSICAL At. FLOWCHART
(b)(6)-4 . OTHER EXAMINATION Pr.— OTHER(Spec•) Or EVALUATION
Nu fa
.
DIAOMMTIC STUDIES

.
TREATMENT

DA Fonm 470U
MAY 78
a 0 0 0 0 0 0 1 1 I 1 1 1 I 2 2 2
PULSES (4) Bounding (3) Full RADIAL 17 b)(6)- L 1 2 3 4 9 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 2- 0 2 3 4 2_ 2
(2) Normal (1) Faint (0) Absent DORSALIS ,cr R PEDIS 2- 2, 2-
SKIN (1) Dry (2) Clammy (3) Warm (4) (5) (6) Cool Flushed Cyanotic (7) Jaundiced (8) Color Normal (9) Pale 1 5 3 3 B 1 3
EDEMA
HEART SOUNDS (Clear. Regular, No Rubs, No Murmurs) VI
HEART RHYTHM (Normal Sinus Rhythm. no ectopy) Sit SIZ
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated) .
HYGIENE I BED BATH
FOLEY CARE .
ORAL CARE
MOBILITY BEDREST 1 .
BSC
DANGLE
POSITIONED CHAIR RIGHT /}v
LEFT
SUPINE
1 HOB 30 DEGREES FALLS PROTOCOL INITIATED I iv i I J r vt i I.i 1 ....-
PROTECTIVE DEVICES Outer to FHMDA OP132-26)
1".-1.1N . PAIN FREE1 1 PAIN SCALE (1-10) PCA/PCEA LN USE (gem. to FHMDA OP1.12,7) 4-; drA 4-Ica tj :
ABDOMEN (2)(I) Solt & Flat Distended 2- 2 2.
BOWEL sourips ( active all quads) NC / DOBHOFF PLACEMENT VERIFIED 111=11.11111111CAIIIIIIIIIEMIIIIII I IMIIIIIIIIM
RESIDUAL ASSESSED I

Ph -

FOLEY CATHETER PATENT )
VOIDING CLEAR. YELLOW URLNE q.s. J

N/t. ¦ ...../.
SKIN INTEGRITY No Breakdown Surgical Wounds .
,µ1D Ume. Ado Z...STAel .
1.0/ 1./.
Rashes. Lac's, etc
DRESSING (Dry & Intact: specify site below) (la, e•
#1 41 ,fe a r i
...." , .42 A.4 /rib rue: .y tiCdS/ .".) 074
i.../. / e-r 7t% 1I /
I
INVASIVE LINES 1 SITE DATE INSERTED DESCRIPTION (SITE. DSC.) -I! i 05uhz 6via.,0 7 A ed: , i 4WDkavizt°v
•
a f) . raa c/i . -/ (7 7p--a al as la aa r
• ,/D d . le
PUPIL SIZE PUPILS
IOT( FUNCTION
(:HART CODES
I nun
)Equal 0 = No Movement
2 mm R Present
Reactive 400(
SUI Flicker/ Trace of Contraction
3 mm
NR NottReactive — Active (Gravity Eliminated)
Not Applicable /Absent (blank)
3 =Active: against gravity, but not against resistance
4 mm L R Left Larger
4 =, Active: Against Gravity and Resistance, not ruu strength
Refer to Ns g. Notes
5 Full Strength against Examiners Resistance N
5 rom R L Right Larger
No Change from
vv
Previous issessmentTIME a to
o a
o
1:21

I
1
11111 11 13
12 22
12 14
6
22
S 0 I 2 3
4 56
A. BEST
78
EYE-OPENING RESPONSE
98 12 30
(4)
Opens Spontaneously (2) To PainI (3 To Tice (1 Does Not 0 n 4-

B.
BEST VERBAL RESPONSE IN

(5)
Oriented

(2) Garbled

(4)
Confused (1) No Response C 5 5-
(3 Ina . . ro date Verbal Res .. nse

I C. BEST

MOTOR RESPONSE

6

I-5

•
1 (6) Obeys Commands
(3) Flexion to Pain
(5) Localizes to Pain
(2) Extension to Pain
(41 Withdraw to Pain
(1) No Response
--5:712T-E1

GLASCOW CONIA SCALE (A+B+C/
I
1
3 4-

PUPIL RESPONSE : R
If 7)
I

Skit (nun). React to Light (-I-) No Response (-) I L
MOVEMENT RUE
I e5 Al 3+ i I •
3 t. 1 .6
(See Motor Function Scale at Top of Page) GRIP (5) Strong 'V1 Weak (..) abse t RESPIRATIONS LU E RLE LLE R L 4 0C';.7 1.An ""1:7_,CA. GAR , iI I 4-MEL111.11111. I.I 4 4. 1 q n i I 4 1+ E I i 1111.11.11M11.11111MIIMIEHIM• riMillialliriMIEMINUMINIMMIMEMIMMIIIIII 9 ' i II ....1' ' IBM S i er.
UNLABORED LABORED ei I- I I I z 1 s/. 1,
BREATH SOUNDS (5) Clear (4) Crackles(31 ahn.rhi SHALLOW ! RETRACTIONS j RUL • LUL —. - I ../f ; 51 I*1 i I I 1
I I I1 I 1 13 1 I ICi . 5. 2. I i I 1 15 I --
LLL BOTH BASES 15 5-* 2_ 2 2
. NONE
SPONTANEOUS 1
5
3 3
RATE (SIMV/CMV)
PEEP/CPAP
PRESS. SUPPORT
NC (L/min)
3L 3L 3L L A

J.
INITIALS . -"65612 1 ,/ / 458)-2 65612
•
MEDCOM - 2189

DOD 006241

VITAL SIGNS
BIP SAT MAP RA CO PVR SVR ICP COMMENTS
A-I Ine PA PCW CI CPP
TIME : T .P R
1......1 )(6)-2
-1 100 ;4 -I
RageAINOIIIIRAIIIIM _
MINIM • -
MEI
0290 I lifai 1171 .1092-11KaraillE e _ I 11111111111111 MI II¦111=11I _
(13I 10 1 IN aRI1)41181 MI I _
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9400 I -ffahvammimmamp2moline .1. _ mum _
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OUTPUT
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0100 AraffIrATIMMIIIIIIMP1111111
0200 MriFIASSIIIMMIN2 moon
0300 EVIRM11111111111 LEITINTINUEI
0400
0500 ETAINIMIONIPIN
0600 HIPIOMPFAUffirillIMPIMEIMI

0700 PIAILWEILIP1111111MONINIIS
0800
8
MELTMISI
90D 300 8 HR 0900 244
141 El PIM 1 MI ordsorm
1 000
INFROBIMPIELVISI FINIPARIM
1100 MrdWIEWM1111111 1011/11212
1200 1011112111111112
1300 MIIIMEMPATIEN211111- -AMMO
1500
1400 MISPARD2
ralv F1111112/1212111 Eigrardan
1600 WaBAIIIIININ AV AINI
5:5-0
I 100)D 16 HR.
33 wi
1700
1800 PA EN MIN=ri 1
irmrem savi
ERIMEILEMIIMPIIIIIIIMEMIMPI
1900 LONLIEMININWIIIIIIMOMM2
2100 .41.A
2000 3° 111,10012 .011012111
EMIR 4/1112/112 Pla AEU
2200 MINISIVERNIMIla INIBIENEM
2300
rterilf010%
2400 LEMMIETIMBillata VASIMINIO
HR 24 Mt
8 •
I,
10 i 1 R 1PULSES RADIAL (4) Bounding 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4
L(3) Full(2) Normal DORSALIS. rp R(1) Faint PEDIS -lib(0) Absent L
SKIN
(1) Dry (4) Cool (7) Jaundiced(2) Clammy (5) Flushed (8) Color Normal(3) Warm (6) Cyanotic (9)".Pale
EDEMA
HEART SOUNDS
Clear, R No Rubs, No Murmurs
HEART RHYTHM
(Normal Sinus Rhythm, no ectopy)
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY _ BEDREST
BSC
DANGLE
CHAIR
RIGHTPOSITIONED
LEFT
SUPINE
HOB 30 DEGREES
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES (Rsew to mum or:32-2 )
PAIN PAIN FREE
PAIN SCALE (1-10)
PCA/PCEA IN USE (R.t rn rindus OP132­71
ABDOMEN (2) SoR & Fiat
(1) Distended
BOWEL SOUNDS ( active all quads)
NC / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph
FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SIMI INTEGRITY No Breakdown
tUtal,ne- thc6)0.,a Surgical Wounds Rashes, Lac's, etc
DRESSING (Dry & Intact: specify site below) ikas#1

#2 11111111111=1.1.111001e111111.111n11111111M1111111111MME
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. Irralr—li It
m- EXAMMINIIIIIIIIIIMIIIIIIIIMICIIIIIIIMIIIIIMIIIIIIIIMIIIIIIIIMIIIII
4!?LMKI
IIIIIIIIIIIIIMIIIIMIIIIIIIEIIIIIIIIIIIIIMIIIIIIIIIIILMIIIIIIIIIIEIIIIIIII
INVASIVE LINES SITE
DATE INSERTED DESCRVTION (SITE, DSG.)
tarinirMIMINIMMINIMEMEMI
111Wril 1 r .W*.A.
, 101Mlir h UV be/ ....Agy
_ CIIIMMIDALGWRIEMINIE
, MME.141
0111111,11A32131211727:011111111
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA 24 HOUR DATA DOA 3 cro3 24 HoUr Balance 9,.. DOS 24116iir Intake
e%l q715
POD 24 Hour Output
elal
Weight on Admission Weight Yesterday Weight Today
NURSE'S SIGNATURE Initials Safety Checks b)(6)-2 (b)(6)-2
BVM at bedside
4/(-1.44'
Monitor Alarms On
b)(6).2
ID Bracelet On
(612 y
Allergy Bracelet On Call Light Within Reach Pt.i Side Rails Up Bed in Low Position
• ,ERtYAKEI) IJY (Sig.nature and lnle) DepartmenlThervice/Uunc
5Y E-2-14
-- • WILLY 1 IDEN 1 MUNI ION For aped or written entries give: Name-lost, first. Mi e; grade;clate; hospital or medical facility) . HISTORY/PHYSICAL FLOWCHART
o OTHER EXAMINATION OTHER(Spectfr) Or EVALUATION
(b)(6)-4
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700
I MAY 78
-. : . ,PUPIL SIZE PUPILS MOTOR FUNCTION
CHART CODES
1 mm — Equal 0 - No Movement Present • — • -2 rum R Reactive
— Slight Flicker/ Trace of Contraction
3 mm NR NonReactive 2 = Active (Gravity Eliminated)

Not APpliciible./Absent (blank)
3 = /Wive: against gravity, but not against resistance4 mm L R Left Larger • , •• I
4 — Active: Against Gravity and Resistance, not full strength
Refer to Nsg. Notes X
5 Full Strength against Examiners Resistance
R L Right Larger

No Change from ; • —
••• • -utt z r...: -,•• -, ,'" V
Previous Assessment
TIME 90 00 00 09 01 II I I II-1 "] 2 2 2 2 212 14 56 70 90 12 3 . 56 72 94 12
34
A. BEST EYE-OPENING RESPONSE
(4)
Opens Spontaneously (2) To Pain

(3)
To Voice (1) Does Not Open il 4-• 1.1

B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled

-c
(4) Confused (1) No Response
6 s-. 5
(3)
Inappropriate Verbal Response

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to Pain (2) Exterudrrn to Pain JO to (o ;

1::)
(4) Withdraw to Pain (1) No Response
GLASCOW COMA SCALE (A+B+C)

---'
i 15
IS
PUPIL RESPONSE R
Size (mm), React to II"

S-• 31-Ili--
Light (+) No Response (-) L
Sk-
Si-'5r.
MOVEMENT RUE 11 6 5-
(See Motor Function LUE 5
Scale at Top of Page) 1.;‘

RLE 5
4.
5 5—
Lif .
LLE .
1 ti. 5' 5-
S
GRIP (S) Strong R S
5 c
(W) Weak (-) absent L S
S
S IRREGULAR UNLABORED Ni ../
RESPIRATIONS REGULAR ..¦
...../
LABORED
SHALLOW. •

1
RETRACTIONS
BREATH SOUNDS RUL

(5)
Clear 6-b. 3

LUL 5 s

(4)
Crackles 3/2.,

(3)
Rhonchi JILL 11-3 ii. . 5

(2)
Wheeze LLL Z• i .9. lia-ff• 5

(I)
Diminished

b. TO
BOTH BASES 5
g.
I I f ..-/
COUGH NONE
SPONTANEOUS ,.--s
PRODUCTIVE

* I.,
NONPRODUCTIVE
-,./.
SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow COLOR
SPUTUM CONSISTENCY (3) Thick
(2) Frothy (I) Thin
Vt . 3
VENTILATOR
F102
RATE (SIMV/CMV)

PEEP/CPAP •
PRESS. SUPPORT
OXYGEN DELIVERY NC (L/min) .
DEVICE

a.fi
FM (1/min) 3-e
FM
ETT # NIIIIM (Venin)
ETT cm gums ETT CARE / POSMON CHANGE
Err / NT SUCTIONED
INCENTIVE SPIROMETRY DONE './ / .,VV,
COUGH / DEEP BREATH
..7 i v . j-1 /1/V //,/INITIALS ' (b)(6)-2
. xo
'=--L""---'--
MEDCOM - 2194
DOD 006246

VITAL SIGNS
TIME 0100 0200 T P R B/P SAT A-lint MAP PA - RA PCW CO CI , PVR SVR ICP CPP . COMMENTS
0300 0400 11111111111111111.11 KI rta-I Ira"EMIWA CUII IIIW
0500 0600 1111111111111111
0700
0800
0900 1000 IIISILMEERIGETVIIIIIIME
1100
1200
1300 1400 MIVEWElignikedv
1500
1600 1700 Klmagammi. IIMIIIIIIIII 1800 ifillikaWIIVERS 1900 7 .a111P71111:111
2000 2100 2200 EMI ra SiReaEfilWAIIMIllIMMai . • b)(6)-2
2300 '
2400 •
MEDCOM -2195

rlJri ..V4U-1)(1-ti -4 11
MEDICAL RECORD
NURSINC _,TES
(Sip all note%)
DATE OBSERVATIONS
Include medication and treatment when indicated

.
/'4do X936 6 er Ailee 1oi Ii_D hc7/e/Yetd-c. aemeoter 164. aed. IL 30 G/ deW. /i/o cPAil )4 i-d /4.
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ve-Cf 12 :-1/0/C. '1-2 • (,21 .,2/ ek?A 6if .c/s.
74( 11 ;-).v_s-(4c-1711 / 4,00 ntts;c (,/Modly
CO ENTS
mulwiP211112111121111/ ME AM%
02" rAMITIWIrdrIMMIIIIIIMPASPIPIM
PARIENSIMINLIM FICKIWINTI
0300 PASTAVIOAKIMMEMENIPATIMO
0400
0500 IrdritP2P21/12/12-BM \AEI%

FEWAIMIllan EP,M21/1111
0600 RIIIMPIMEM/ EIPSWILIM
0700 080° EINEINNIIIRIM WIPMCPAM
8 HR.
. too AO /7." 1161' ¦ I D 2, + +IS'
1
0900 EinaMIPIIIMPII EINISINIPM rj 930"
im VIIIIIMANIITMAKI Millaird'ar ,
1100 BEIBM2/12011/1¦1 EPAITOAIKTILKII 1;;P .

1200 Vo V76 misrdwri -miserarm -
1300 EFAMMIPArarel BIONEMBEI
1400 ratempasromm. EMINPAII •
"°° PAIBLRESPIRIELM IPAIMMIPP% •
1600
,7• BlinallinE NIIMMEI
8
100 19) 130 ME 53.11
1201011111KIEME M E MEW%
..
"00 IRWICESIPAIWIEREI ar
1700 Lderam
1900 WM: DIMMILVOSI E111121111/2
2N° E.MNIMMILSEIMI IriMIONIPAI
210° riardIMM111/11%1 FelVirtiMil
220° Figalnitariffillard -FIZEPAIMI
LATIMAIMPACIME EVIEMPAPTII
2400
2300 MPAIME1121111/11% MBIPAIIM
24 HR. 24 HR :IR (15() 1 • \ I'Gka '. Ca
I I
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA
24 HOUR DATA DOA 24 Hour Balance
5 DO—CZ ' 85– DOS 24 Hour Intake
3250
POD 24 Hour Output
53qC
Weight on Admission Weight Yesterday Weight Today
NURSE'S SIGNATURE Initials Safety Checks N
BVM at bedside bX6}2
Monitor Alarms On
ID Bracelet On
Allergy Bracelet On V
Call Light Within Reach
Side Rails Up
Bed in Low Position

PREPAIthll 1:3 Y ..(Xgnature and I gin)). Department/Service/L lam UA tb
6)(8)-2
Siwe ^ Oct
eATIENT'S IDENTIFICATION (For typed or written entries give: Name-last. _first. Middle; grade:date: hospital or medical facilio)
HISTORY PHYSICAL)FLOWCHART
. OTHER EXANIINATI N)OTHER(Spec01(b)(6)-4 Or EVALUATION
.
DIAGNOSTIC ST1 'D IES

.
TREAT:WE:VI'

I)A FORA 4700
I MAY 7i1
ELIO
1N
L-LL1-
E 1

[0 0%
I

°
1 NI
1 04.0
1
10
tf)

0 'I'
1° H
0 N
[
•
11r•1...
I N 0
00
I1.LJ
N r1
1N N
RADIAL R ej,
2

PULSES
2...
Z.-2.-•
1)I
,, 1)1
17.1
2

(4) BotuldIng
1.-
2-
L .", -i.., 2
(3) Full
(2))Normal
DORSALIS 176.irr R
X
9••
.1
2-
(1)
Faint PEDIS

(0)
Absent

2....
0 L ? .• 2,
SKIN
1
(1)
Dry (4) Cool (7) Jaundiced

(2)
Clammy (5) hushed (8) Color Normal Y

(3)
Warm (6) Cyanotic (9) Pale

1
01,)-1
te,
I

Olen
P

EDEMA freil' le,r0 1/IA t... HEART SOUNDS S)5z
J '' C2.
(Clear, Regular. No Rubs. No Murmurs) R f
HEART RHYTHM (Normal Sinus Rhythm. no ectopy) 1\)Q jek.. Kg--10e
,
SWAN GANZ CATHETER
(Zeroed & calibrated) •
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH

FOLEY CARE
ORAL CARE .
I MOBILITY BEDREST
i'''l )
BSC

DANGLE •.
CHAIR • i .

. POSITIONED RIGHT
5
LEFT
SUPINE ) I I I. ...
HOB 30 DEGREES I Pi I c-
FALLS PROTOCOL INITIATED ,

PROTECTIVE DEVICES (Rotor to FIEMDA 01, 1)2-26) ! I I PAIN I PAIN FREE 104 I ft-2-* PAIN SCALE (1-10) --
FCANCEA IN USE (Rem of MAIM OP1JZ-7) •
ABDOMEN (2) Soft & Flat
-7.-
6.D. 2 2
(I) Distended
../
BOWEL SOUNDS ( active all quads)
,..4f )C )cif
NG / DOBHOFF PLACEMENT VERIFIED

RESIDUAL ASSESSED
Ph ' -
FOLEY CATHETER PATENT
VOIDLNG CLEAR. YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown
Surgical Wounds ./
Rashes. Lacs, etc

I DRESSING (Dry & Intact: specify site below) #1
, G. l-lhalifERNIIIIIIM PAN MUM
112131MMILIIIIIMEINIIIII¦ME 1111 MI MIN 111110111111
irMENNIMMEMIT311111 WWII
Eli t RI 1111401
6.---4 in 1 ,(.../ 0 1-I4-a ri et SI v.,
INVASIVE INES 1 SITE DATE INSERTED DESCRIPTION (SITE. DSG.

V.,C , 1 (!-1.- ,5:,!-,cic. vtoo-¦ C-1") i-414) (60
11
MEDCOM -2199
DOD 006251

PUPIL SIZE PUPILS
I mm = Equal
2 mm R Reactive
3 mm NR NonRiactive
4 nun L R Left Larger
5 mm R L Right Larger

MOTOR FUNCTION
0 = No Movement 1= Slight Flicker/ Trace of Contraction
2 = Active (Gravity Eliminated)
3 = Active: against gravity, but not against resistance
4 = Active: Against Gravity and Resistance, not full strength
5 = Full Strength against Examiners Resistance
DATE: 1.....-L.' L.") 0 "
CHART CODES
Present Not Applicable /Absent (blank) Refer to Nsg. Notes
X
No Chance from Previous tssessment
1=2J
0 0
HL°
0 V)
.

2
I "

L.

1 •
TIME 4.
1
,

I 2 2 2 2 2 11 1 2 3
•
1 °z
...I I
4
A. BEST EYE-OPENING RESPONSE
(4) Opens Spontaneously (2) To Pain
4""
(4
f
Cf 4

(3)
To Voice (1) Does Not Open

B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled

(4)
Confused (1) No Response

C
(3) Inappropriate Verbal Response
C. BEST MOTOR RESPONSE
(6) Obeys Commands (5) Localizes to Pain (3) Flexion to Pain (2) Extension to Pain Is . - .Lcs
(4) Withdraw to Pain (1) No Response
GLASGOW COMA SCALE (A+B+C) PUPIL RESPONSE Size (mm), React to R i litii 1 -)J-L P -)- 1 I'S" !SI i 5-,
I Light (+) No Response (-) MOVEMENT (See Motor Function Scale at Top of Page) L RUE LUE RLE LLE I I ?)t -5.‘ c' I k l 1 1 SI3F q 5 4' i 5' S.— 1 5'
(W) Weak (.) absent g R L I l l Y i ' 1 S
RESPIRATIONS REGULAR •
IRREGULAR ' • • i
• UNLA BORED
LABORED ..
SHALLOW Vir
RETRACTIONS
BREATH SOUNDS (5) Clear (4) Crackles RUL LUL ..D S.
(3) Rhonchl (2) Wheeze (I) Diminished ALL LLL i I 51 ,i) 3 e". I .--....
BOTH BASES.
COUGH NONE • .
SPONTANEOUS PRODUCTIVE J
NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2) Yellow (1) Clear I 1. • I
SPUTUM CONSISTENCY (3) Thick (2) Frothy (1) Thin VENTILATOR Vt 3 3
F102
RATE (SIMV/CMV)
PEEP / CPAP.
PRESS. SUPPORT
OXYGEN DELIVERY DEV10E NC (/min) FM (/min) Er
ETT M NRBM (Vsnin)
ETT cm gums
ETT CARE / POSITION CHANCE •
ETT / NT SUCTIONED
INCENTIVE SPIROMETRY DONE COI T:11 /DEEP BREATH, INITIALS • )(6)-2 / •b)(5)-2 `...(f1., 6( )- i bX0)-2 V .

VITAL SIGNS
1INIE)T aim , P)R B/P SAT A-line MAP)PA RA PCW CO CI PVR SVR 1CP CPP COMMENTS
ono 1)300 -70 i al EMI NE
0-100
0500
0600 0700 • ' 1,53 I o4/ 36'
0800
0900 _
1000
1100
1200 9904 6, !7,, 1!: 4-2- 96vA .4(.. ..
1300 1400 I
1500 1
1610 1700 rfilileVIUMILIONMEWAINI1 1111111
1300
1900
2000 2 11H) oo KIWIIMMO I 1 -t .
2200
231)0 24110 1 IS • , - - ..mtamii. .

Lummtri i
aWASSILMINIKONIMPAISPAINI •

"21 "0 s; ° q.41MirdrarAlla ERINNIMIll
0301
) APTMWANIE11111 FAILMITIIS
040" AWAMPANIMIIIIIIMELPTIMIIII
()500 -5-,
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0
1 0 flkaoAllaVrAVAIMUIMPAPPAOKIINII
08
8 07°V. AIIIIMINSIPIr ANINIVAINI
/1R Acc0 a6-13
StY0 ay 27s-
FIRrNZ -t-
AA ii A A
0900 '111411
"00
1° "P)2gDPAPwm.airMIWAPPv
Ati.
1200
1AKItsia. AMITIMIMMIEMITMEMIIIIII
' 300 (.4:MMV APAINEVAIIIIIIIIENNIIIII
1400
Anwasormordnmrdowear-
15°0 ardwv mr-mmirmiumuraimum
iog AirtMEIY4011111811111EMINVISal
l6 HR
, 6-Drb ­
icy 5--a ME
1700
afirPaDWAMEINISINIMMIERIEMPIA
1800
IMPIORMILIIMILI EVAS1121/1111
"00 Ard.HEIMM112 AMMILISIKI
200° gro 1111116/111/ENTI 1111111111111
210° VAMIIIMINNIV
AIIIMINNIVIMPII
2200
IMIKIIINIMPAIM EISPIVAFAI
2310 P-#111/1111.1112MIS reINERVII .) 0D
24°"1.M.NMPARISPIE5" NOMMEMPI . nrsiN -c.
HR M P° DE -¦C`IR.0 IN 111111-:--------­
33 25-
NSN75404/0-634-4123
MEDICAL RECORD NURSING NOTES
(Sim all notes)
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated
A.M. P.M.
0 AP -) •_ ...,...5.• , • h
A,,.0/ eCI Aor,c66 45 C?)/ 44 0 66/)(1,7)evc). cii di_r..
077) 0.71A/K"1 /76/7';‘c/d4c (3/LTS/.. c-eCo4 A ki../C4 /1/q//// 4-

.
zyriq ;fe(sif;),., CDT , /2 7/.--c/a aisco,( ra,7 ,A r / A, 714 .ck-
-e-7
f
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3 p , 41, V*/ t 3.7t.7,ifr, / ?c.-4, 5 A GIFl )6}z p4- s 1p-i, , 6.,,1l
)(6m-,/,-)1, t h /2-76),(7z-,? . . 3t._?..
3 0(,03 ,A00 emlakr re cl-, v, @ 41 - t % s -I-, v04? tA ) ¦ I k C- ovA, Zt "... fr ))inn A PI ,Ann¦---
(b)(6)-2
(
ROUT) ' ,10 C-4 D erh p...) --V h ro de 11 ehn c_l ivIcA4 0 ,,..3 to Aa p , poi.)
d b)(6)-2 eri t ct14.0 .., et, i ,e r.) Siae OnAk 1 0.2t1 1 C 0.1-4-)."/1r,r111-0,--fa -...
1 IDa1.3 0517l 11/P I OP..4 k (.5 -44ei e :.-0 .1 1 ( n Ailtt U ,vi-t"));..TVe g 13)(6)-2
150.C.703 0) ® Oe../d2 Z.7. A71704Utl.4 ht,tpee vial mize, 4 4ev 4- 'S
b)(8)-2
wt-A"--. • . , oc.1-63 I c T-1-fh,t..ts tati .e.ierroKtn,a-kd .. ,k MVO' 11 ChaliK
ex6). 0 //'. , „a6,,t it i¦ -1-
,
r5ocrt 11111 .__ /. izAJWININIMPF11 , 1-
111M

KIIMMIIIMMINWANNWild Ili r I-_.
/kJ
iitti//A.
o)A., /)
C-3)_A.)...)Au. V., -)L,/, '//‘ /— 10
It a A A . .4 , / . A, ,,4, ,
iffliifinVir tiMEr
Jo ,41. _ ')•)'74/
A ,
fl.. J-70 jr
/10, Pl. Q
ANMEZERNing 4 111 .
raMgignritbalLIMIIMMI

IIMIIII
T. ,
rico ¦M......WMN..i
-1,...4,32, ...-—
Al- Iris 6. (11 4 .. c11AS0,4 .5;1).ci,j-i",, Q VSD h "Q (Lek Vati4,6t
(41 , CA ii, -o at2'20 avt-A.41314A-ezzA-,
bX8)-2
)
•)•)
It/t4 yikliu)tir`.-CO W ....s..1).A.. 4 • ,)...a .t.qAtki
MEDCOM - 2203
CRITICAL CARE FLOW SHEET
(b)(3)-1
LOS DATA
24 HOUR DATA
24 Hour Balance
DOA o.-; cAlf-
DOS
24 flour Intake
POD
24 Hour Output
Weight on Admission
Weight Yesterday
Weight Today
Safety Checks D E N
BVM at bedside b)(6)-2
Monitor Alarms On
ID Bracelet On
Allergy Bracelet On
Call Light Within Reach
Side Rails Up
Bed in Low Position ro)(6)-2j

Department/SenweiCluuC
LJA(b)(6)-2 CAU
PATIENT'S IDENTIfiCATION 3
For typed or written entries give: Name-
lust. first. Altddle: grade:date: hospital or medical facility)
• IIISTORY PHYSICAL . FLOWCHART
:b)(6)-4 . OTHER EXAN/INATtoN . OTHER(SpecO)Or EVALUATION
• MOM )STIC smniEs
. TREAT M ENT
tENT
DA FORM 4700
NIAY
I Osto
I -C IC es 10 H

I° hI
1 •1
N fol
IN 01
I
N0.1

01 C
I00
N
I
10 I
—C1 4.c.0
I ° -1
I")I
I
1
I0"NI
PULSES RADIAL R
(4) Bounding
2-

2.,
(3)
Full L

(2)
Normal DORSALIS R

(I)
Faint PEDIS

(0)
Absent L SKIN

(1)
Dry (4) Cool (7) Jaundiced

(2)
Clammy (5) Flushed (8) Color Normal

(3)
Warm (6) Cyanotic (9) Pale

-2
1
1
rsr‘
1,
.1161
....
EDEMA
_..-
0
HEART SOUNDS (Clear. Regular. No Rubs. No Murmurs) -../ 1/ I
HEART RHYTHM
(Normal Sinus Rhythm. no ectopy) S(Z' Oft.
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE
(zeroed & calibrated)
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST BSC )' t/ I •
DANGLE
POSITIONED CHAIR RIGHT / I
LEFT
SUPINE I
HOB 30 DEGREES FALLS PROTOCOL INITIATED . *,
PROTECTIVE DEVICES (Raw I. FliMDA OP132.261 I
PAIN 1 PAIN FREE i IV .
Pali SCALE (1-10)
4
ABDOMEN (2) (1) Soft & Flat Distended a E -2-
BOWEL SOUNDS (attire all NG / DOBHOFF PLACEMENT VERIFIED iii vf fN teA 1,—
RESIDUAL ASSESSED
Ph • • -
FOLEY CATHETER PATENT VOIDING CLEAR YELLOW URINE q.s. 1/ 1/ V-
%A.ACH tr) MC. Si a /3 1 • ". I'''' 1
Rashes. Lacs, etc
DRESSING Dn & Intact: specify site below)
1 #2 43 IN )Ci .614-4^2_ 1\/21C{ I A C" ( INC."1";,./3 IV 17)N, tZ.1-or91 46(4. IVE LINES)SITE b( ()6 r / v . v /, 1/ ./. . DATE INSERTED 1I It 1 1 Ii I . DESCRIPTION (SITE. DSG.)(4-)\:_ AsStb Ib/G A 04 Der.

I
I
MEDCOM - 2205
DOD 006257

PUPIL SIZE PUPILS MOTOR FUNCTION
C:HART CODES
t 1 mm -• Equal = No Movement
Present2 mm R Reactive 1— Slight Flicker! Trace of Contraction
3 mns
NR NonReactive 2 = Active (Gravity Eliminated) Not Applicable /Absent (blank) c'
3 = Active: against gravity, but not against resistance4 mm L R Left Larger 4 = Active: Against Gravity and Resistance, not full strength Refer to Nsg. Notes.X5 = Full Strength against Examiners Resistance5 min R L Right Larger
I No Clump from
_ . -- —.• -
. — rrevaous Assessment
TIME o • 0 o • o 0 0 t 1 a
1 2 3 4 5 6 7 11 1 2
A. BEST EYE-OPENING RESPONSE 3
(4)
Opens Spontaneously (2) To Pain

(3)
To Voice (1) Does Not Open

B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled

(4)
Confused (1) No Response

(3) Inappropriate Verbal Response 5
)-

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Flexion to Pain

(5)
Localizes to Pain (2) Extension to Pain 10

(4)
Withdraw to Pain (1) No Response
GLASCOW COMA SCALE (A+B+C)

6 PC
PUPIL RESPONSE R '5—
Size (mm), React to . ‹ 31'
Light (+) No Response (-) L

Y )' 4
MOVEMENT RUE
5 3-
(see Motor Function LUE
Scale at Top of Page) Ce_.

RLE
tr
S
LLE s r
GRIP (S) Strong R
S S
(W) Weak (-) absent L
5 s I
RESPIRATIONS REGULAR
/ t."
V./-
IRREGULAR
UNLABORED .7.....__—

A v
LABORED
SHALLOW
RETRACTIONS
BREATH SOUNDS RUL

(5)
Clear •

LUL

(4)
Crackles

(3)
Rhonchl RLL -5-

(2)
Wheeze

i
LLL
(1) Diminished
BOTH BASES

COUGH NONE
,ig--'

SPONTANEOUS
k/ 5/ i 1 w/ kt
PRODUCTIVE
ij iv t/
NONPRODUCTIVE
SPUTUM COLOR (5) Tan (4) Green (3) Pink

(2) Yellow (1) Clear t
I I t 1 I
SPUTUM CONSISTENCY (3) Thick
(2) Frothy (1) Thin
a
VENTILATOR Vt
F102
RATE (SIMV/CM
PEEP/CPAP •
PRESS. SUPPORT

OXYGEN DELIVERY NC (I/min)DEVICE
FM Ohnin) 2L 1 lief.
Err 14 NRBM (I/min) ETT cm gums Err CARE / POSITION CHANGE
ETT / NT SUCTIONED
INCENTIVE SPIRONIETRY DONE ..-/"
COUGH/DEEP BREATH / ...."
bx., .-1 . . ....-
INITIALS
• 8)-2
b)(6)-2 I
VITAL SIGNS
TIME 1 T P 1 R 1 B/P SAT A-line MAP PA RA PCW CO CI PVR SVR ICP CPP COMMENTS
0101)
0200
0300
0400 0500 0680 I 111111111M1 4 MUNNIMNE ;,MIIIMME IIIIII -4 ITAFTIMBIPAIIIM . ii. . 1
0700
0800 t 0900 I . 1000 i - JRUMEIMMI ,,a,-1100 1200 I I I I
1300
. 1400)4 : q i a 1 s-(4, . 31-QC.,
1500 I)t
1600 1 _
1700
181W SID 1900 1920 21100 2.0 2100 a t 4 5 " 2200 2300 clq I JIMENAIIMMAM I p , '7 o 4 ma " 7 E . _ IMP drAIIIIIIIIIIifR ,ol)0 /3 / _DEM= i.I I IN= OE --.MEI raw_ .‘ NM •
2400 1 I

•.7
ID\(.6L-' INTAKE
cosinams
°N.11
""") . PANIPAIMPIMINIIMEWAITA
"" AIPAIIPIIIVAUPIIIIIIIEINIPAIIWIM
"2 AV
030" AFAIMMIIIMIIIIIMPAIINIMM
`"" ArArdErAMPATAMIII=PINIMI1111
"5""146/P101010102/11111MISIIMIrdy
060" 0 " Av AINWANIIIIVAVAIIVAIM•11
0
Ammannalov
"7° AP' AwAr-
Amommuma 8 HR
"80"top Airtido-Norio-
8 1
H t 1( 00 i0 874r
APP
IlartirlirAIUMPAIMMEffirdr
-AIV.
1""° Iv2A° INIMIBMINPAIV
""" ' ANEVAINPAIIIIMIN
AMEM111111200 AIMPAIPINIEMIVAIIIIIMIRVAPPAIIIII
AINIKUVAPASEPAPIMIVAV
1300 "ALWIEEIM111111112PAV
""" ANIP'1AAMV
150
" APAIIIMMIUMMINIIIIMAIBENI
AVAMEMITAMINIMEIGIVAVAPAI
1600 16 HR.
8 '
1700 111111111111MIMPAMPAIIIIIMEMPIIMIII

1 800 111/41/1/MMINIMMIIIIENVAPALT111111
190" 9% ¦11/1/11112111111¦0/2111111
2"0" INIPM/11112/1M111 MIIIPA/11/11
ALW%MMIVAPAM MilfirdriM
2100 APP
2200 Ariu-Argermormumw-Am
"0o Amirolownsimmorrommm •
24"0 ArdriMPAIRINIIIIIPAMPAPAPrill1111
'4 HR
2
144
¦ it. .0
HR -
NSN 7540-00-634-4123
NURSING NOTESMEDICAL RECORD
(Sign all notes)
HOUR OBSERVATIONS
DATE
Include medication and treatment when indicated
146E1.03 . A.M. P.M.
65i' )er.,...1,7)5 S s -)LI t/ ,s • .1 .. ., _ 1
).11‘Ct A....a.1,4, L)CDs 14.4.4c) L 4 e , Aot--A st..i.c...,,,-ePP..-.1...144..17,
.i.4-e,..,r . .sce., ycey et ely, e4v4t,..4„, i/e7 ./ ..a r,W,•f)S)/56,71 elt-t ,:40
.6t. PAA•(( c,,...Th), 1.---..1(..-efiZs-- PEC-.21Id a
fe441
r"*") .... L. .1-.-- 644,4
10c' c3f CA, foil!t4 711 soIf 54' (i 4
k..,..A4 (.....A I 1....-,.. Ireb• ev1/1:1%..a.% s''‘1••••" SP-4. (b)(6)-2
-wil wth,s,...Q 0.4,3A,00-44ck .-.-raj, ka to-
14 oct 011 11430 R. a-i) 4 clew". IC U k 2.
DR- Avt71. --, ICU) P.AA-Fii,ce ---, I C U cLAJ
ccv, k v 2-1 --t,,,-e s_..±.1.,..1)L. .) mt,)(a()4.0-.01Jn5. LOrtj o'^-itA . 5 nz cm IZA 7 an 91C (A A9 -'}oho )
:1 Id, 1 L ' -. 'L • . , C.. ' 1,44.A.&. -S C• *IT
4
4370. ----_ A) . w i .. e z i „ .. L t cp r irni 0 1 lift P 1.164 , ...iktik Ainwtrel-0 (TO -A.10 .54)e ctINN 0-1 JiAtiello ttill'id .)..DaTi kh,)cl.a.,..A. x ( L
/ 4..4
c,.-tP ttrete -7
14 nc.io /315 ?if NAIL ,., 257, ittriwt afttniline;))c)t..tra)/ .! • 0

.ter PrOLCAM nfil.4.ta a tArt if
s'e pM Jp .. ••:. ' ... fluz et -, Li Ls.)Pi-t.l.)a.p.v,-.)I f
_ b ." 1 . -.41.¦ . i b L ng
Tt-17)t—.0 701c NI &St,- a..—LA.--t 01„i_e tom”`)c7 -1--i s -&c, cal wok, -&-lc 0 p,„,--b---ci.alcu_D back ---'? cha.A.A --:tt2,52r.“—e_ ai, itA t t ?I - 93 7..)-4-aXo•kr itt--0,0 af
ha;
P AstA(=-.0S (-e.k CrAta,41tRA ) r )0 1'1 Otto; ;WS A1 P tj b C.aw,p0;t0 ti) 2.13o 14,..s 5)TA)1,,, 0,80v,/,,, u)i
LiV1114.4 2-2P 0 by— 6-4-e4 . 71 A.A.ryi 0AT:4 D t0-4-1--1-1.,-9.. R tAhaD 15 r...-D Ci-tbi,S -F 71P)A.)---)L-Ti'U ccrull- 07US-E)-, tw,,---h .--) Y . 41,-kre.„-tt 47t.,),,s
,..,
02 qs-9 Z ov, fA)24_).:--____A_A-;
)1 ..-4-_.
MEDCOM - 2209
CRITICAL CARE FLOW SHEET

:13)(3)-1
LOS DATA
24 HOUR DATA
DOA 24 Hour Balance
h; OcA--o
DOS 24 Hour Intake
POD 24 Hour Output Weight on Admission Weight Yesterday Weight Today
Safety Checks , E N
BVM at bedside x6)-f
Monitor Alarms On
ID Bracelet On
Allergy Bracelet On
Call Light Within Reach itik .
Side Rails Up '
Bed in Low Position

"1 V.411 q11:1WIMUMUMriTill11117
epartment/SenriceiCluuc DA'Ft.
,P cod j r dc+0 3
AI IDENTIFICATION For typed or written entries give: Name-last. first.
0
Middle; grade;date: hospital or medical facility)
HISTORY/PHYSICAL . FLOWCHART
. OTHER EXAMINATION . OTHER(Spec/6);I:)(6)-4 Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

llA FORM 4700
I MAY 78
2 2 2 2 2 0 1 2 3 4
0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1
1' 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
RADIALPULSES
(4)
Bounding

(3)
Full

L
• (2) Normal DORSALIS eeo9i R
(1)
Faint PEDIS 'CO

(0)
Absent L
SKIN

(1)
Dry (4) Cool (7) Jaundiced

(2)
Clammy (6) Flushed (8) Color Normal

(3)
Warm (6) Cyanotic Pale
EDEMA

HEART SOUNDS
(Clear. Regular, No Rubs, No Murmurs)
HEART RHYTHM

ornial Sinus Rh • • no ecto
SWAN GANZ CATHETER
(Zeroed & calibrated)
ARTERIAL LINE

(zeroed & calibrated)
HYGIENE BED BATH
FOLEY CARE
ORAL CARE
MOBILITY BEDREST.
BSC
DANGLE
CHAIR
POSITIONED RIGHT
LEFT
SUPINE
HOB 30 DEGREES
FALLS PROTOCOL INITIATED
PROTECTIVE DEVICES (Mot to FIDIDA 0P13244

I Po
PAIN • PAIN FREE
PAIN SCALE (I-10)
PCA/PCEA IN USE (ado n FIBIDA OP1i2.7)
ABDOMEN (2) Soft & Flat

I ) deal
BOWEL SOUNDS ( active all quads)
NG / DOBHOFF PLACEMENT VERIFIED
RESIDUAL ASSESSED
Ph

FOLEY CATHETER PATENT
VOIDING CLEAR, YELLOW URINE q.s.
SKIN INTEGRITY No Breakdown

Surgical Wounds Rashes, Lac's, etc DRESSING (Dry & Intact: specify site below) 11111E11111111111.011111kM11111...MIUM11111.11.1E111111
raWailf
#2 I.¦AhD oreSs cta: 111=11.1111.111111.001111.1111.1111111=11111111111111111.MIUM 11111111111111111M111.1.1.110111,41111.1
IMBEINMIZINESM11.111V111111.11111111111.11 Chr ccAl • $ 4G.5 C,C2E
DATE INSERTED DESCRIPTION (SITE, DSC.)
INVASIVE LINES SITE
CHART CODES
MOTOR FUNCTION
PUPIL SIZE , PUPILS
Present
0 Movement •
1 nun Equal
)
1— SlightElicker/ Trace of Contraction
2 mm R Reactive
No Applicable /Absent (blank)
NR NonReactive 2 ¦r, Active (Gravity Eliminated)
3 mm
3 = Active:ugainst gravity; but not against resistance
Re to Pin. Notes X •
4 = Active: Against Gravity and Resistance, not full strength •-
4 nun . L R..LeftLarger
5 Full Strength against Examiners Resistance
o Chan e from .
S mm)It L Right Larger
Previona Asstssmen
DATE: 661-0 5)
0 1
ew

. .
1 I 1 1 '1-1 1 2
el[7.17.
1.
1 0 2 3 4 5 6 7 I 9 0
O
00 0 0
'
TIME
11
6
1 2 4
.
A. BEST EYE-OPENING RESPONSE
(4)
Opens Spontaneously (2) To Pain

(3)
To Voice (1) Does Not Open

B.
BEST VERBAL RESPONSE

(5)
Oriented (2) Garbled

(4)
Confused (1) No Response

(3)
Inappropriate Verbal Response

C.
BEST MOTOR RESPONSE

(6)
Obeys Commands (3) Fkrion to Pain

(5)
Localizes to Pain (2)131.ln:don to Pain

(4)
Withdraw to Pain (1) No Response

GLASCOW COMA SCALE (A+B+C) PUPIL RESPONSE A Size (mm), React to Light (+) No Response (-) L
MOVEMENT RUE
(See Motor Function LUE Scale it Top of Page)
RLE
LLE . .

GRIP (S) Strong R
(W) Weak (-) absent L
RESPIRATIONS REGULAR
IRREGULAR

UNLABORED LABORED SHALLOW
RETRACTIONS
BREATH SOUNDS RUL

(5)
Clear

LUL
(4)
Crackles

(3)
Rhonchi RLL

(2)
Wheeze

LLL
(1)
Diminished
BOTH BASES

COUGH NONE SPONTANEOUS PRODUCTIVE NONPRODUCTIVE SPUTUM COLOR (5) Tan (4) Green (3) Pink
(2)Yellow (1) Clear
• •
el
C ¦
(.0
,...1115
d•-l"
4—
C
I
I
1 If1 c
I 7/ .
...-

-r

(4'
41 1-1
4
if
..)
S-
VI
I ,
•
5'
T
5
•
.
. .
SPUTUM CONSISTENCY (3) Thick (2) Frothy (1) Thin S 3
VENTILATOR Vt
F102
RATE (SIMV/CMV)
• PEEP/CPAP • PRESS. SUPPORT .
OXYGEN DELIVERY NC (I/min)
DEVICE FM (Nobs)
ETT 0 NRBM (11min)
ETT cm gams
ETT CARE / POSITIONCHANGE
ETT / NT SUCTIONED -
INCENTIVE SPIROMETRY DONE ../.—
COUGH / DEEP BREATH INITIALS b)(6)-2 b)(13}2 )(6).2 No
--i---

MEDICAL RECORD NURSING _ . ES
Si: all notes
DATE HOUR OBSERVATIONS
Include medication and treatment when indicated

A.M.)P.M.
•
0 Al orr.

•
IS—de-re3
gde,rd
t IbtevaA-cl_ S. • • YO lb ° n JP YZ
MINFM§I
,
bX13}2
AMI ND tit ,. ) Are .
A ....
Or
LIMINZMMIT. Wenhin r?..etI
II
Al / "
MRM. 4 AI .— . .•• .ice 4 rI „11, Lam. _ ¦ A iA A! -4C .
INEMPIMr
PMMIMMA II_____
0 .1 / '.1
I ' ' r / fI CI i1 a -.
!fit rw
C3o
EIMININIPAMILIETI
0100 PAMLUSINIPIAMI
0200 PA" El./IPASIBIE
0300
040° PAIMAIDISMINIZI
0500 MITAIIMIAMI

Ar/NBILMLILPEIMP%Ml
0600
0700
11%/1/11IMPAPAM
"00 KIIIENNISMINIM

1400
1211P261/511.1%

1500
IMMEMNIMIS

1600
VO ISIMMIEMPII

! . (po
16 HR. 176
111111111INVEME

1800 1
D r%/127111/0211

1900
armardommord

2000
PAZIEVERMI
lararld
2100
Wil/EPIIIPAMBil

PAMERIPArliffirdi

2300 2"
2200 EIMEPAPAREMPIPA
IIAKIENSEEMPAN

24 HR.
'
Ifi7 NIENNEVE' ISPIPP'
8 Amordr.s...' ..11. AA A
1 19IL ' ardrimmiansi Lwow.
110° Mr11/511111/Elrd IMATINSI
1200
KMISIMINIMPAMI 1102,401111

1300
ARIPAROSIBIMPDP2—MENEM

PIM APR%

FAIMP2111/1

1111MINIM

111
IMPAMIMPAI

MEIMPAPNI

IIIMPIIPB

IIEMPAINI

MININIEM

PAPAMMII
Ennriffil if., ., „ .

IMPAIMEN1
ta
16 HR.
MEMO%
NIMPAIMPAV
PAILUBMW11
rdrillMINNI
IIIIMMIPAI
APargEnialv
lairlard.
Er•
EMPAriffil
24 HR
CRITICAL CARE FLOW SHEET

;13)(3)-1
LOS DATA DOA 0 -c (4-r)3
DOS
POD

NURSE'S SIGNATURE
1))(6)-2
• Cel 1 . I • . tl.
(b)(6)-2
24 HOUR DATA
24 Hour 'Mance 24 Hour Intake 24 Hour Output Weight on Admission Weight Yesterday Weight Today
Initials
Safety Checks -E N BVM at bedside Monitor Alarms On ID Bracelet On Allergy Bracelet On
Call Light Within Reach Side Rails Up Bed in Low Position
Departznent/Service/Linuc DA I
/ 6 n (A-o
-•.--.. -
PATIENT'S IDENTIFICATION
For typed or written entries give: Name-last. first. 171 Middle; grade;dote; hospital or medical facility) . 1--'
HISTORY/PHYSICAL . FLOWCHART (b)(6)-4
-O OTHEREX.AMINATION . OTHER(Spec/6)Or EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700
I MAY 78.