Medical Report: Partial Medical Record of Medication and Treatment of an Unknown Person with an Unspecified Medical Condition

1
DOCTOR'S ORDERS
MEDIC L RECORD I (Sign all orders)
DATE AND TIME
DOCT OR'S NunsE.s
DRUG ORDERS SIGNATURE SIGNATURE
START STOP 11
• b)(6)-2
-I 10 l 4, vacv› :a +0 T C tA. : Tea I
÷\ 0,
4r---v--. % 4 4 . Coy-, tk--a-
1 G -s-s0J
P- .......¦-rfr-

-
, m. -, S I p .— W- 1 -.)..--te.e. 6 S ka..) •
— T %), CA r.tviteer ,tr — t" C "V eck ,-,-, el, Ik, a i itt) n '• Gift c..v-ti c.61/4 Esta-cor.
cliv-f,--._N-i4G\RA--- "Z. C. cr. lf¦ktt"i" "A.-
rD A t\. s. v‘t\ WeniZiA.
IC)I r4CAN' : €:. ,::N. vc_ois-3________QR 2. 1-t rtfs .
k\s_vt 1,a11., ) silti e r
.T r_c5Ls I' v
146 -1-- 'No L\ s— 3 KM1) )4. st_iiir-ci,
,4--f-toi VVN ; vz
f-0.et. "i-. ' jfiX‘ri PEEP: .1—
Vv,t-rs--. k.f t®o , v--Lizicri •
% \ \e, 1 0 .5 1/2, s C 2- '4 t‘- I t- 1.c.- t e
1 25 cc /1-4(1--cA5-6-f_c_'. LA% Cf_)-::)(;? AYYv. - exL tc-C- . Mg 1 r%-)tom,
:. kA 1.4 g: CCISC. CS1vr
.Tc- rt_t,..-itd, -ro --_,.1% s ta_..--, kiN.Art,
il C-- X. ( GArlok.., 1 czmo.i., 1 1 ) -, ICU` "A t-) -
IA-C. ›C, ; &rt... ri-. C
Th N.--c.d•-, : Ie octigArel 2 5r,-, 1 RI F
(
Thlovarhrin 100 - % qem
PiP LA Caf-, LIM l 0 7.9
ua4r-A-Cel rOfrvati) • A .1\% . ¦..v,144,(3.*_en174 f... - w.. ,
3,-) c- 61-c_xEa s Ics:.,
(Continue on reverse side)
;b)(6) -2
REGISTER NO.
PATIENT' S IDENTIFICATION (For typed or written entries give: Name - last, first,
middle; grade; rank; rate; hospital or medical facility)

:b)(6)-4
DUG I UK"S UKUS KS
STANDAr 1 608 (Rev 10-75) Prescribe( ,d ICMR FPMR 10 8 508-110
MEDCOM - 5630
DOD 12842

DOCTOR'S ORDERSMEDICAL RECORD
(Sign err orders)
DATE AND TIME I DOCTOR'S NURSE'S
DRUG ORDERS
SIGNATURE SIGNATURESTART STOP
3

yr-es.03 ,/Halt; K 14' .2.

iv/'6 r V
_zi Kf b)(6)-2

_____.....---^-
(b)(6)-2
b)(6)-2
—
toIrsIA
,T,.. _AI b)(6)-2
(b)(6)-2
7,146,1 Ti %7Z-(I

ft. ge(2_. Dir IN\Cm tuftys-JulQ:7------' rDT\C-'iast, t Na• ,,,,; 1 ScLuhect
(b)(6)-2 b)(6)-2
'''' ,(1 • cra--6/K.--
----.------"----..,.............,

---------...,,,...„............„„

. ..
(Continue on reverse side) N
REGISTER NO. WARD NO. k
PATIENT'S IDENTIFICATION(For typed cr written entries give: Name - last, rust, Imiddle; grade; rank; rate; hospital or medical facility)
tt-61A,
b)(6)-4
DOCTOR'S ORDERS
vANDARD PORM III IMT. 10111 Nflbs1 be GSA and ICIAR
4 (41 CFR) 201-45.505 111
trU.S. GPO: IIIII-201.710/80071
MEDCOM - 5631
DOD 12843

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orders)
•

DATE AND TIMETI RX DRUG ORDERS eiefinflif€ SSE
START STOIN.I
I\
91171 ,33. CAL" rAtt..•. L 'VI NIT AC-*MS Sia v."-is 1 r • la 110 1 YV1 c . it-'-r F.r I ron: ch r.1
,
(10 eteto clead, (e lice 1® C21-1--‘401 elIree•N =CL" CX.n•-•..
JC.. S''. +0 LE, (b)(6)-2
12I
Ci PSGTtz.S.... ilib•
Lk \\flql •
Vii`l- I) .. !Tad mo (13/'-V" % do
Vit'4.-
de, i -2 tad *''1---T. co Net.--‘... LT
._) clit* (Y--': •
(1) ittty-tcznrin C -% Ice/1C) ICeSsr Ift, .
.4%) 5C•43II. CSZN• .r• e: Ci-7).
Cf..J../e.I• t.--e....1., .
(b)(6) 2
1
.T.-
(Conitnue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name lass, first, REGISTER NO.I WARD NO.
middle; grade; rank; rare; hospital or medical facility)
b)(6)-4
DOCTOR'S ORDERS
STANOARO FORM 509 (Rev. 10-75)Prescribed by GSA and ICRIR FIRMR (41 CFR) 201-45-50550B-112

MEDCOM - 5632

11111116111111M11111
DOD 12844

DOCTOR'S ORDERS
MEDICAL RECORD (Sign all orders)
S
DATE AND TtstE ajpNATUIIE
DRUG ORDERS

b)(6)-2
i °'. I b62 :4
N^• / G

b)(6)-2

'

Iii'I
^C- fig' ^
V(IT

11 ei G
d c

. ^? b)(6)-2
\ Ob 1 p C v A'
b)(6)-2 I
b)(6)-2

b)(6 -2
Ian ^ .
b)(6)-2
b)(6)-2

A1C
b)(6)-2

b)(6)-2
b)(6)-2

b)(6)-2

b)(6)-2
b)(6)-2

L 1
-
b)(6)-2

b)(6)-2

-I
LJ
REGISTER NO.
-last, first,
ENTIFICATION (For typed or written entries give: NEme
medical 1aci11!y) b)(6)-2

middle; gr.de ran ERS
bX6)-4

PA Lit vr Phorcc " b)(6)-2
I
Eat UMr. *7a) ad IGMM
EAR (41 CFR) 201.46.505
6-111

* U.S. Gro, tgt .-101.7IOIi007^
b)(6)-2

MEDCOM - 5633
DOD 12845

MEDICAL RECORD DATE AND TIME RXSTART STOP DRUG ORDERS DOCTOR'S ORDERS (Sign all orders) DOCTORS SIGNATURE NURSES SIGNATURE
(b)(6)-2
if 7.1(0
, \ ec....e. ..' ttr\ 4,..s-e_rel d.-.. 4-Nr

i 4_,,ytt_
ii
,frt •......rs1 i t-CIoecf....,„! 5-AN, F-„v4 k(
*?...," 3 fc,r.
V 1(b)(6)-2
bX6)-2 •
C
.I* _adill
Il k.17
Ark -.10.4%..
b)(6)-2 Itt.)aI 1 '6 1 17'14W i ../a 1114)c, 4.T--Tpeoui 4 C.4,:--5f" ccvI--r 1.) 4,4 1 9-Li
. PZ.
— el) „cc.%) "7° . fi_ ' Alr4C4k, A•4"-r 4 S j "--j k!..1 E,„-/ 4 0,-ti--pvc"5---g' aw /Z (AlvA-.
•)(8)-2
.....
A "4"4-t7:44 lesr(crwtAMIO(0 A-tg-r 0,4,t jy(vi-5(-(, I'
, ..1--
12.8:14 LI WM"' —..
Will
....' 4C4L11 I r-.7 -, -.o itill..e:(00/S .—e- 6INI A ,
_10-r .. 5ivicw: r„.... b
-i".1.— I,L Iv.3 upel,01,4" QZ-0..:4)((.7,4--
...
i—L9 ..) "'".VG---)c 04,,,,,7 41-0
-/- / 0 0-1`ti Or,),T.TreAty14,I0---I•
Ib)(6)-2 0 --. V I "r4N-4"Ta---7•1';lrh-------'
/1_____&,244(Conlinue on reverse sidsj___ 1.---
REGISTER NO. WA NO
PATII'I1DEN 1PSCATION (For typed or written entries give: Name - last, first,
middle; g d ; ran b)(6)-4
DOCTOR'S ORDERS
ST 0 FORM 508 (Rev. 10-75)
P. ,GSA and ICMR
vi I Ann,
MEDCOM -5634
DOD 12846

110 7 11
•

DOCTOR'S ORDEFRS MEDICAL RECORD (Sign all orders)
DATE AND TIME
DOCTOR'S

SIGNATURE
DRUG ORDERS SIGNATURE
RX
STARTISTOP
b)(6) 2
b)(6 -2
b)(6)-2
b)(6)-2
b)(6)-2
)(6)-2
)(6) 2
4-4
¦ .)(6)-2
)(6)-2
2Lf
PATIENTS IDENTI [CATION (For typed or written entries give; Name - last, first, b)(6)-2
middle; grade; lank; ra
:b)(6)-4 Doc-ro o DE S STANDARD FORM 508 (Rev. ak
Prescribed by GSA and ICMR
FIRMR (41 CFR) 201-45-505
5013-112

MEDCOM - 5635
DOD 12847

DOCTOR'S ORDERS
(Sign all ordersi ' •
MEDICAL RECORD
NURSE'S
DATE AND TIME DOCTOR'S SIGNATURE SIGNATURE

DRUG ORDERS
b)(6) 2
START
.

STOP rimeranilommi
d o3
MIS
11111110
SIM

111111
MIN b)(6)-2 b)(6)-2 mom

Magi
b)(6)-2
-111111111111111
111111111111111 b)(6)-2 if tA 3
1111111

111111111 (Continue on reverse side) WARD NO.
REGISTER NO.
•
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)
DOCTOR'S ORDERS
b)(6)-4
I1NDARO FORM 808 (Rev. 10451
Z111W GSA mid WAR
1-1 I . B0841 ..4111•110
MEDCOM - 5636
DOD 12848

MEDICAL RECORD
DATE AND TIME DRUG ORDERS NURSE'S SIGNATURE

b)(6)-2
b)(6)-2
)(6)-2
4b)(6)-2
Pia.T i 6ty
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility) h-* (Continue on reverse side) ;b)(6)-4 MEDCOM - 5637 1 REGISTER NO. WARD NO. DOCTOR'S ORDERS 'ARO FORM MS (Rev. 10-751 tad by GSA and ICMR 101-11. 106-11 —.410 131

DOD 12849

DOCTOR'S ORDERS
rE AND T TIMEII I STOP RA 1 DRUG ORDERS DOCTOR'S SIGNATURE 1 5 NURSE'S c
).-5 [ , co ,s--)egg")-IC.5 ¦ Ilr"--IA ..-ke_ (-P.k --kc i 1/ 7 t'-‘3_4='a ) A ,..2..._IVI 1-4-e'''"' • ,....I....---/ TS (-I-. d.(Fry.F An c -(--(4--1____.Cr1," J (a/te.. d -b)(6)•2 .. b)(6)-2 _ b)(6)_2

((Continue on reverse sid4 PATS IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; rank; ra ,e; hospital or medical facility)(b)(6)-4 MEDCOM - 5638 REGISTER NO. WARD NO. ta,114z. DOCTOR'S ORDERS STANDARD FORM SOS 1R.v. 10-7S1 'necribod by GSA and ICNIR PMR 101-11. 505-11 AN-110
DOD 12850

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orderst ' -
DATE AND TIME
DOCTOR NURSE'S
RXI DRUG ORDERS
SIGNATURE SIGNATURE
START STOP
b)(6)-2

lo-­
Z. r '''''1 ,...,A.--. .., ic.), i
-...-,--
ea
.-
0® 744---¦Tfca`2 :1. -67
a 4(/1-1,=- 74,.ors--(.7'((c6 '.

b)(6)-2 "6)-2 !
. 004 .4- r` 4 •IX
ig c.„•_

_.„„g2-c.T• fu
oo 14_ IIIIMIESIMIIIPM111.1111111111
WIN b)(6)-2
/

MU 4-14—r

i

ififi"Ns:
....7•
6-,../e...-+-.
llw
M
_\‘i
b)(6)-2

A i
! b)(6)-2
7G71

..--c—C) •t?F 2:/ .f.g°
40 7--.,.., 7"---a1.----c e 2.—"41
,_..__if 7,-6-ec s# Q7(
49 .'1---6 i7-;‹).¦-
,b)(6)-2
b)(6)-2
). ...
(Continue on reverse side)
REGISTER NO. WARD NO.,az
PATIENT "S IDENTIFICATION (For typed or written entriis give: Name - last, first, middle; grade; rank, rate; hospital or medical facility)
b)(6)-4
DOCTOR'S ORDERS
TANDARD FORM 5011 OW. 10451 ascribed by GSA and ICMR101-11. 8764 608-110
MEDCOM - 5639
DOD 12851
DOCTOR'S ORDERSMEDICAL RECORD
Sign all orders
—
DATE AND TIME DOCTOR'S NURSE'S
RX DRUG ORDERS
SIGNATURE SIGNATURESTART STOP
Li I Z 6 1 n140 40 Ion d
es?, eirich,s7 e7/2.. &5 6,3
(b)(6)-2
)V73
birtC/ 61
3 - ;
at, -*E s . 1 09(.
iji

IIIIIMIEEMVIRlir iiA C Ar -
,
f,ti 6 TE,6 S C--,16_5. .'
.
to • am
. 0 E, as 76A4j2.44,e b)(6)-2 ,b)(6)-2
I): if iip/v
a c17`i,/(a(z,Laa„L, 5./, ..k..-1..e 0
175(ooc(, .1(.r.1 1 4 „ . . n
LAC.-.-("Sct,c, /---' -0c2
b)(6)-2
¦ E Scc-/S 93a •
We-Tao )(6)
NV •i f,,, 5 /v. 4 476
UM/ (5)Mt 1 , 40 • II) ..6 Alf .41, / 2 s ^Ziaa
limn '
ON L7/1(4 ' ' OO ALIA V al V z 6 doo
, Po I yz b)(6)-2
or b 025-0
snue on reverse st e
PATIENT'S 1DENT ICATIO (For typed or written entries give: Name - last, first, middle; grade; rank; re hospital or medical facility)
(b)(6)-4
OITSIARIAR
a Pic:
ID FORM SOI (R.v. 1017E1 (b)(6)-4 3./ GSA and ICMR
I. 1106-8 SOD .
MEDCOM - 5640
DOD 12852
DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orders)
DATE AND TIME DOCTOR'S NURSES
DRUG ORDERS SIGNATURE SIGNATURE
' ART STOP
' _..4 ,a__411.6 ¦-...
cd 3 G_ b)(6)-2
I S 5 Z/ 3(4 0 II 0-7-5(vtme II 0 ,/, •
1 15i -25o.. _ _
Z5/-350 1 -1 55/-56 _ 111113V 565(?6e.R.Ot .a)c.d.Ca-0--ie
ral 1),(lrO V i /6 iv AI zezo
Am
b)(6)-2
an IV huh40.40 ellAal/(ArdiMMIIPII 1 4 hs a-CPT a / I -a)
N13)(6)-2
---26 Z1-00

V Li
MI ve4TO x 3o & 5(
• b)(6)-2
2 e/ttn/171G 571 & / V n V Cel
/ °
1h._ i ,_.......- --

• .AIN
_.....
.0.; -,
b)(6)-2
4or 0,
--i Dlet-r",„ 1 1 /_, ,,,,, , ¦ — _
ta,
beau in rh € 4- 5 .2)1 al hs . . .(.,.„. 01 G iv t(ALL. v ILLI bs • i(
ota - a 11 f, 3 J9o4ok-al kv-mceAliz- • a(LP.• _
,
REGISTER NO. WARD NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade L))(6)-4 a aclt
)(b)(6)-27Y/tr
T (0'1
.6
%HOARD FORM SOB (Rev. 10-7E1 bribed by GSA and ICMR iR 101-11. 806-8
Lit .Ps, .110
r)(6)-4
MEDCOM - 5641
DOD 12853

MEDICAL RECORD DATE AND TIME START DRUG ORDERS DOCTOR'S IF DERS (Sign ,/larders) NURSES SIGNATURE
b)(6)-2

.u1 Ly
)(6) 2
b)(8)-2
b)(8)-2
b)(6)-2
6)(8)-2
b)(6)-2
OA-L2,)( b)(6)-2 tl 39/6TVICOYI zu L4L ,b)(6)-2
,b)(6)-2
d'es..A.:T1 01,15 • b)(6)-2 b)(6)-2
PATIENT'S IDENTIFICATION (For middle; grade; rank; rate; hospital or medical facility) !b)(6)-4 DERS/ ISTANDARO roman taw. tom Norlbsel by SSA and ICIAR AR (41 CFR) 201-45.505 _411 *U.S. Gro, I SSI—t01-7110/110074

MEDCOM - 5642
DOD 12854

DOCTOR'S OADERS
MEDICAL RECORD
(Sign all orders)
DATE AND um
DOCTOR'S NURSE'S
DRUG ORDERS
START STOP SIGNATURE SIGNATURE
(Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first. middle; grade; rank; rate; hospital or medical facility) I REGISTER NO. WARD NO.
:b)(6)-4 DOCTOR'S ORDERS
STANDARD RAM IMO My. 10-781 7"" --tee * out ens nun 41 CFR) 201-45.505

MEDCOM - 5643
DOD 12855

DOCTOWS,ORDERSMEDICAL RECORD
Min all orders)
DATE AND TIME
I I
OCICT011'11
MlC DRUG ORDERS afranVes
%TAMS
V" ite• sql 2.1 Te-14
t-(b)(6)-2
1 4 P 65D
r(rE4t.v.fre--'
11)(3)-1 b)(6)-2
WI(
-)4 o
C41-513 (4,0((12.- /us(4-D

t) Tc-‘..."
b)(6)-2
PATIENT'S IDENTIFICATION(For typed or written entries give: Name - hut, first, middk; grade; rank; rate; hospital ce- medical facility) REGIST514 NO. WARD NO.
b)(6)-4 DOCTORS ORDERS
STNNOARD roam Es 10411
Numbed by OSA and CHO

1MR (41 CFR) 201-45.505
(7--A.)Ig-
J5-111
*U.S. C•Ch 11111118-201-7110/11007111
tviEDCOM - 5644
DOD 12856

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all ordere
DATE AND TIME
DOCTORS NURSES
Rx DRUG ORDERS
SIGNATURE SIGNATURE
START STOP
b)(6)-2
b)(6)-2

immlnuilim
Fall" , •
¦
iF

Tmom
• b)(6)-2
¦ b)(6)-2
¦ 2
• MN PI
G
MEM
b)(6)-2
EMU
1111111111FEMEMBIIIM
1 MEW
¦
b)(6)-2
b)(6)-2
11=11
)(6)-2

111111111—
WARD NO.
PA TI ID N ICA I
mi dl te; hospital or medical
(F.YPed
MODOCTOR'S ORDERS
TANDARD FORM 505 (Rev. 10-75) ascribed by GSA and ICMR :b)(6)-4 PMR 101-11. 000-11 I 1 1 0
MEDCOM - 5645
DOD 12857

DOCTOR'S ORDERSMEDICAL RECORD
Sign all orders". ' -
DATE AND ME
DOCTOR'S NURSE'S
RX DRUGORDERS SIGNATURE SIGNATURE
START STOP
b6)-2
. es• ....
( t 0(6) rat ‘,....z
:b)(6)-2
.()A-i, -scc.
-
,
C_-)\ 3-11c) 1Mdcz--6) -___. 1 00.1 \-A^, -1 -=. l''. ) 4. ck
()
) 1(b)(6)-2 b)(6)-2 At.T...---sOgetiPialba..._
2....--........

1701. ._T,l1¦ 3/ 5'..-
• (6)2
b)(6)-2
....-
,,,-
, ........--

b)(6)-2
ArMIEZA
. ._
13)(6)-4 Jr on reverse side)
I REGISTER NO.I WARD NO.
PATIENT'S rie - last, first,Tmiddlverall I
DOCTOR'S ORDERS
rx3)-1
STANDARD FORM SOS INN. 10419
Proscribed by GSA and !CAR
PERSONAL DATA ..PR'" ACT 1974 FPMR 101-11. 8068
V6-110
MEDCOM - 5646
DOD 12858
DOCTOR'S ORDERSMEDICAL RECORD
(Sign al orders)
DATE AND TIME DOCTOR'S NURSE'S
DRUG ORDERS SIGNATURE SIGNATURE
START STOP
(b)(6)-2
c.., (.1 K,
„..., c
¦ O -,., (‘ c-x-,I74'
VAI ,--e rid.if-Qs r-(..,4„(/ Ar.c,, 7 7 ? • ' 14 r.(--)
(
NV c A jz
C Y ec ­
(r
PG''''''' 4-7 G G(C C- re. 1-6) .....--e=. r-, /75
F b)(6)-2
1111 1: I II(__.(i •,__
0 (b)(6)-2 (b)(6) -2
-t 0 rta i Pi MI D.R.MULMi1 , 7,
r7qA `'' (,,q,(l --
v... 4 --(,.,,,-e.,-7I11 1•1111MMTIII
k °dela 111 C)o'l .) c17
F-4, I5—c/C3 -c., Z-c../ 14ac(e Baa 1111'.0;-r.5--c=Q .-7 Z-C i c;), ..----' I." cf
1-4,4-.-,-...-,4 ---) ((1Tb)(6).2
( UT ..."-' g
¦ It ° / 6.-'1 i, d
b)(6)-2 Ar
(Continue on reverse side)
REGISTER NO. WARD NO.
PATIENT'S IDENTIFICATICN(For typed or written entries give: Name -last, first,
middle: grade; rank; rare; hospital or medical facility)
(b)(6) -4
DOCTOR'S ORDERS
)ARD FORM 508 (16,.. 10-75) eel by GSA and ICMR
101-11. 806-8 .10
MEDCOM - 5647
DOD 12859

DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all orders)
DATE AND TIME DOCTOR'S NURSE'S
RXI DRUG ORDERS SIGNATURE SIGNATURE
y b)(6)-2 STOP swim mb)(6)-2
hI

MEN U a Ln b,j4_ri-k. „AA till )(6)-2
ip1b)(6)-2
I rb , go•
b)(6)-2
1
M
Min
IIIII b)(6)-2

IIIIIM IIPPArri111147iter
.
—
iver........_

....---.
NI
AiIII
-I-Ii
a 4
bIqtrirt.0 t–t.,I.'-ri Cti9SIa NIT?(2- P
II I b ' ( 6 '2 IIIIII -
CM ° SKIIMLIEIMIEEI I i.g
PEIIV
-S )(6)7
WrItirAG (ILIJC

Imilliiill

b)(6)-2 b)(6)-2 ...,.._;. toWwil u 0 I, EMI
, le,

. .,..........46

,

b)(6)-2
fa ....--
..--.
—...woMMEOMMOWASEMPEREPA¦ AimIA i ; 11111" Al l anieell b)(6)-2I
liming=
,_ ....

(Continue on reverse side)
b)(6)-4
REGISTER NO. WARD NO.
PATIENT' 'me - last, first, middle; sr
I
•
DOCTOR'S ORDERS

:b)(3)-1 CARD FORM WS IRw, 10-75)
sd by GSA and ICMR
101-11. S.08-9
_ _I10
PERSONAL DATA PRIV ,T MEDCOM 5648
-
DOD 12860

Standard Form SOS
DOCTOR'S ORDERS
CLINICAL RECORD (Sign all orders)
DATE AND TIME
DRUG ORDERS '
START STOP 13t (Another brand of a generically equivalent product, identical in dos-DOCTOR'S SIGNATURE NURSE'S
age form and content of active Ingredient(s), may be administered SIGNATURE
UNLESS checked here)

ql3p3 ( Di/ -,...6 072z5.T2,3,„4-1-0,_ c4;13)(6)-2
t=IN D /(7 V'eAnn,c_cp
es-)-5 b)(6)-2
3 Li a I tni--eirt51 k.\:f6 47-Mald z;),.e (32__(-)L -r V/ -a,ri (
b)(6)-2
;
.7)/(_._ -1,==Dy (
‘ b)(6)-:(8)-2
.5 WT(-7 to r vi e; _----1.1)(6.., 1 ,,r)(1,,tc_ -‘ . woyyn41 \t,_a
6 .1)/(_ (La) l y C.9.(c6
b)(13)-2
-
-P-P ceo -51& \ --\-, - dc-i-Vewv, e o.vi 0 eA 4-...
111
•L618)-2
_ 1 le,
b)(6)-2
1 "Y\ ZON,11 R-LN4e -i 1
b)(6)-2

b)(6)-2
ro Dk cem-i--A) 1
bx.)_2
q-eqq\-0-4)5L (
CO e.,tua,-1b)(6)-2
NC--
.(..
(Continue ow totem side)
REGISTER NO. WARD NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; date; hospital or medical facility)
:b)(8)-4
DOCTOR'S ORDERS
Standard Form 10S 10S-109
'rid Services Administration and *regency Committee on Medical Records 101-11.806-8 ..“.tober 1971
MEDCOM - 5649
DOD 12861
NAVMED 655018 (REV. 444) S/N 0105-LP-21e-5581
-Pc-1 z of
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES
SCHEDULED DRUGS MONTH PPR_ 19 zon GIVEN
ORDER MEDICATION-DOSAGE•FREOUENCY LI 4 4 / LI
HOURS 14
DATE ROUTE OF ADMINISTRATION
Z2-'41g.,3 / Z.1-1 2-',) Z.6
)(T)
4 19,0 ID * r. lb ¦ ( a o o , , sal b 6 2
"Tb)(6)-2
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII iyetz)T
.. b)(6)-2 IMIIIIIIIIIIIIIIIIII 4
I ii.0 iffilMEMMINIMINI 060 ° Ira.111111111111111=111. IIIIIIIIIIIIIIIIIIIIIIIIIIIII / goo.b ' (8 ) -2 11111111111111111.011111 v-40v,v.
INITIAL. FULL SIGNATURE & TITLE INITIAL INITIAL CODE FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
. ..
ADDRESSOGRAPH PLATE b)(6)-4 MEDCOM - 5650 Injection Site Code 0 = Left Buttock (f) = Left Leg 0 = Right Buttock a) = Right Leg 0 = Left Deltoid 0 = Left Arm ® = Right Den , t).. Right Arm (3, ,en I WARD NO. 10.U, 47t2, SINGLE DOSE, PREOP PRN & VARIABLE DOSE ORDERS SEE REVERSE

DOD 12862

NAVMED6550/8 REV. 4-74 SIN 01 -.L.„--216-55131
MEDICAL RECORD MEDICATIONADMINISTRATION RECORD
DATES
SCHEDULEDDRUGS , 1. 1,1 A9 is 12_ GIVEN
MEDICATION- DOSAGE- FREQUENCY
ORDER
DATE

ROUTE OF ADMINISTRATION HOURS
_2 1 z 7
a.i -F I .2 r le ' •. s
1))(8)-2 2_0 0
1110
b)(8}2 60
2.-‘1 0 0
•
L1i2 -c F(kk C,01^C., 1 ...,1 e Zoo KAs all-) 070 b

03)-2
7-4 06
'I
4/12,1 ..rZ in. o7-36 Sc 61r, OC" °I'
Zit) (..)
_ ._ ..)4,+-4.4' I–. rz..;)-, 0 TOL) ilw-r •

Mi
1(6)-2
--1,0()-14%,._k- a' 1r)(. .2-0)(..)
bxe},
po-r—c. T) 6700 .-
' r` sP1 7 l'1.-
'1 l
/ /60 •
i `PM , tV(1/4.V. -i . 10 ro tisc.-A-a el. ' er, Tr-i P to CLI. / • "..3- .. -Ct. sin i -703 6-700 liwb)(6)-2 (' DO Mj110-1 61,pac7 Callr •)(6)-2 •)(6)-2 1 Ltb 0
INITIAL ,b)(6)-2 X€9-2 SIGNATURE & Trrt r 11,GULLIINITIAL INITIAL CODE FULL SIGNATURE & TITLE INITIALI b)(131-2 bX81-2 RLL SIGNATURE 6 TITLE
TIIT
b1(8)-4 M EDCOM - 5651 , 2) Injection Ske Code 0 e Left ButtockIO o Left Leg C) o Right ButtockI= Right Leg 0 = Left DeltoidIC) = Lett Atm o Right De'I0 o Right Arm tbeomen WARD NO. SINGLE DOSE, RE- OP PRN A VARIABLE DOSE ORDERS SEE RNERSE

DOD 12863

MEDICATION ADMINISTRATION RECOR :k) SIN 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION-DOSAGE GIVENI II MEDICATION-DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIMEI_ L .111ALL___ ROUTE OF ADMINISTRATION DATE TIME INITIAL
b)(6)-2I'
..74 (Le/Y \.0I7P.— G SD "ri '-1,)•:- 0
11-61A01 (oftvv-A— c(.1- 64L"
( \

PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE MEDICATION-DOSAGE FREQUENCY ROUTE OF ADMINISTRATION DOSES GIVEN
DATE
TIME
DOSE
INIT
DATE
TIME
DOSE
INIT
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
. DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
.........
DATE
TIME
DOSE
INIT.

MEDCOM - 5652
DOD 12864

NAVMED 6550/8 (REV.444) SIN 0105-LF416-5581
' %) Z-. OCi
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
D AwTEENS
MONTH 44.1LT_,„ a.....--17,e--2).G
SCHEDULED DRUGS
-
Ltti¦)
1

ORDER MEDICATION-DOSAGE-FREQUENCY HOURS
ROUTE OF ADMINISTRATION
DATE 2C / ' 1
.ar._.e...
1-14) i SA I et--,10 ""- .c . 0 C? in ) YM 41 -111° II.
b)(6)-2
1 •
2•••• • •O b)(6)-2
_ —

b)(6)-2
0"k 2.-0 . 0 0 .. PO -I,

... ,
b)(6)-2
(2.4-TG b . Co
.4.)
_ b)(6)-2 -e-". 1'5 0 I I . N ¦ . .)-
. _ __.—
- b)(6)-2
i:,...,..
;.-705
_...di b)(6)-2
A ird-vS iI
-I - g‘,,14. .1-.,P tsric-itu-PLq A AilM11
..".111Pri b)(6)-2

7f, --if., 17.0
,I, Act-i
kb)(6)-2
15/ --E....4%.16 P-46, kr6.4../.5,c? a 1

• 3 -,ei..., :((444 ds.... d S4
340 -14-v i. 1.4. d -zs (..44 idS....,4 la
45-0 g 1.4,Liss ......430. GII,Mt 1111.11a...
¦1111111 b)(6)-2

000 k4 mamirks
•
Ida t I II a. • V; 4,..i.
I' out," a 0...____ r i a.,_ .,.100 to k', afti—

IIWIAir
1 /4 gffetimimpAir b)(6)-2 )
b/L/WriA/ /,.
a
4 jay E -,46 Zest. &/(1 rywrfrAvem ..,
it ?:y0
60 O r 1 , r
mid b)(6)-2 ill ac _,_/ i _AtiO / / il it.d.....¦ 06CO(
)(6) 2
MiLICO5 4 yte-6 5 c-/24-0
CP; 9ey, 6tri,,,,), /goo
tVO 4
INITIAL CODE
FUI7 L SIGN,TUR & TITLE INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE b)(61-2
INITIAL
:b)(6)-2 :13)(6)-2;b)(6)-2
WARD NO.
ADDRESSOGRAPH PLATE
Injection Site Code

0 = Left Buttock ® = Lett Leg
= Right Buttock = Right Lag SINGLE DOSE,
0 = Loft Deltoid (2) = Left Arm PRE-OP PRN & VARIABLE
0 = Right Deft°• = Right Arm
DOSE ORDERS SEE REVERSE
en
0 =
MEDCOM - 5653
DOD 12865

00) A-
MEDICATION ADMINISTRATION RE (Back) S/N oloS-LF-216-5581
SINGLE ORDERS — PRE-OPERATIVE
MEDICATION-DOSAGE GIVEN MEDICATION-DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIMEIINITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

'
a._(. to =FM
1.,oe, A._ __... A NJW1 i. MEE1
-
. _ vt, )4,1-T-T1 v ' MIMI
5%.4
b)(6)-2
piigib i I 7.6./vev FA ftp
I ° X -r-MI=-......_
MilI Zr--'b)(6)2
cl 0 . 5co....
_ L.

1111111111111111=1M
PRN AND VARIABLE DOSE MEDICATIONS
MEDICATION-DOSAGE 13"FcRAECTE. nrcOvs A G E DOSES GIVEN
ORDER
D TE •
D ROUTE OF AMAIN ISTRATION
1
,_(,..(0,w E '
C2444 -1-,,
t ..? ­
ii,,,E
... A .......„id.

. , DOSE 2,, .
0(6)-2 ,
INIT.
) if,/ PI
-lagu.i.‘
n .(
el DATE
z . Ali --rf(or4.041
ck6,(TIME
DOSE
INIT. DATE TIME
DOSE INIT. DATE
TIME DOSE INIT. DATE TIME
::,
DOSE INIT. DATE
•
TIME DOSE
. INIT.
DATE TIME DOSE INIT.
" rosip
cf==
A
stqb l
:6x8)-2
.
• .
`,.../
s
MEDCOM - 5654
DOD 12866

NAVMED 6550/8 (REV.4:/4) S/N 0105-LP-216.558 1
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
19 Zeal, DATES
SCHEDULED DRUGS MONTH" GIVEN
ORDER MEDICATION-DOSAGE-FREOUENCY HOURS Mimi Arm Ar
1/I TE ROUTE OF ADMINISTRATIONI yz5-jewinex 3:0n2e.o. s41, 8,46 0900 bX6)-2
bX6)-2

9/ 6, (/x,0 .., 5:17x8 / I/ 9 8 O 05130
zt a°(
bX6)-2 i
144 4:47re174.11-WI, Arlyv,n,r9p fiz,-60
ftizo_ -Set(¦
,'"' /(4.,

0 11. W UN \ t.
_ . , Itt.11 \¦...I1111 • •All 'PPM

bX6)-2
InlaW. . -1• Mil IIII¦
IMIRIM
PiiiM • All aINM' ,.
1A a .1

.
q z _.1 ILIA II - t. M. •., 11. 'I
--. r. 1.111".( 41
'4111111111;6)-2I
MainglIMMENIPMMI
. w:,...„.. 0.
ii4
t k. ifs ' _ ' C._ $11. Or
. ,
EMNMIRMIIIM 2..k0 • Ai.
--.-1. - -
„„„„-
IA IIMM.(00.7) JPIZAIMIIMIftlalli".¦..-
Ini711,4 If1c
. (IF(
Prh-MOIM
1 INITIAL CODE
INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE [IN I TIAL! b)(6)-2 b)(6)-2 FULL SIGNATURE.ATITLE

ADDRESSOGRAPH PLATE WARD NO.
Injection Site Code
(1t = Left Buttock (3) = Left Leg
b)(6)-4 (2) e Right Buttock = Right Leg SINGLE DOSE,
0 = Left Deltoid 0 = Left Arm PRE-OP PRN
= Right Deltr 7 = Right Arm &VARIABLE DOSE ORDERS
= 'en SEE REVERSE

MEDCOM - 5655
DOD 12867

ce.--1A,1(PR° 4-0
MEDICATION ADMINISTRATION REt-_.iD (Back) S/N 0105-LF-215.5581 SINGLE ORDERS - PRE-OPERATIVE
' MEDICATION-DOSAGE M DI AT ROUTE OF ADMINISTRATION ' ' DATEITIME INITIAL DATE TIME INITIAL
ROUTE OF ADMINISTRATION
PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE mE O ireA..Tc=;:catv AG a *OLIVE OR A DMINISTMATION DOSES GIVEN .I..
k' OV A LID/psi, j po DATE (I F k1.0 ,,,,,,rydi., TIME oi'r -IA 16 .v -POUT POSE • INIT. .• . . .
iCL l-1°'"I 1 v OVER 1 MS ) P F OR OfC V....4t RAI Feet) c011.. k k• 0 CAL.,,,,,,,„,I1,,.,„,..;A-1._ I la e(I , 0,,f,,, DATE TIME DOSE INIT. DATE TIME • ¦
iTTVI;t4IIC ToNtiet DOSE 6 4+ J.'S INIT.
1443Ne5i.ni Sactrist, DATE
2. T.,, IV oveK 30 . , __ rrr 1 IV / f /mayt zi 2.0 ipo m 30,...„.... 45 1 TIME DOSE INIT. DATE
IN 250 - TIME
ore, NS ry ovt.," `I ° IFPZ•0 DOSE INIT.. '
DATE .
TIME
DOSE .
INIT. .
DATE
TIME
DOSE
INIT.
irk)I 1(b (6)-4 1 MEDCOM - 5656 .

DOD 12868

NAVM ED 6550/8 (RE V. 4-74) S/N 0105-LF-216-5581
MEDICAL RECORD I MEDICATION ADMINISTRATION RECORD
DATES SCHEDULED DRUGS WITH /for 44- .4004 GIVEN
MEDICATION- DOSAGE- FREQUENCYORDER
HOURSI
ROUTE OF ADMINISTRATION 3 -/ ,5 -1/44 tovo,k-.scf,,,,.SLS 13/D Of 00 DATE
bX6)-2
A100 11& 2-4: eViTf.4c--„c114-1 --lie, . carr.:. 05-00
.„ Aloe
— b)(6)-2
VAA MA/GO ..0.1 )(CIAO •T-; 6", .7t//9---6E-la—...---. -0911."._ ..
bX6)-2
'./?., 6 inwhvh-",, . ratz-75Tiv eizs-' 07041
')(6)-2
813 X 6 rwsr¢ p /Ida'
A 300( •
--er.

44.r 446,47-aeoz..4 r% Na ct. 0--1 0100
513,0 L'a -It) Op; 6a ti' I Ada &rag,
114v 4/41k-AciAr I j--"," Zei 4Ay ON
r,9 ON
Cc", 7-,e),-/i4zzw-iz 1% ce.E-Aw 7-0 of ao

b)(6)-2
CZAR/4/ cit-6A-C c Old R /o/ .
4 X r) nierrp Olan I
INITIAL CODE
INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE& TITLE
.I..
ADDRESSOGRAPHPLATE WARD NO. injection Site Code
:b)(6)-4
C)T= Leh Buttock C)I= Lett Leg

0I= Right Buttock © = Right LegISFIGLE DOSE,
rnc -rnn
® = Left DeltoidI= Left Arm & VARIABLE ® = Right Deltni4
().1)= Right Arm DOSE ORDERS tbdomen SEE REVERSE
MEDCOM - 5657
DOD 12869

NAVMED 6550/8 (REV. 444) S/N 0106-LP-216-5561
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES SCHEDULED DRUGS M O N T H 19
GIVE N
ORDER MEDICATION-DOSAGE-FREQUENCY
HOURS
DATE ROUTE OF ADMINISTRATION
b)(6)-2

gif4
2E, L.:0NC
b)(6)-2
Fin
PI
AKINIELMM11.1
13)(6)-2
M M I I I„I I • II= WI

_ I I I• Mr I I I I I I I I
1111111MIIIIMIN111111111SIIIIMI
111.1.111111.11.1111111111 IKE
1
b)(6)-2

b)(6)-2
.m,,.

sommimeiumm
b)(6)-2
M1
1111
Iffialrato e•Of 1
4191tWAMIZL-4.* a
1 1"-
b)(6)-2 b)(6) 2 40.
+I
Aal it.k• 1 -
_ ,i
25 1111
IIMINI)(6) 2 11101°
4• 2.1MI: b)(6)-2
b)(6)-2
111 MEMb") 2(41/111
b)(6)-2
NIMP070d
PRIN.11II_ IIINWEIM11
ipleir:44F1P 4011074-ri'
-dr¦W
b)(6)-2
b)(6)-2
INITIAL CODE
INITIAL (b)(6)_2T I NITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
I
(b)(6)-2 'b)(6)-2 b)(6)-2
(b)(6)-4
WARD NO-
b)(6)-4 Injection Site Code
(1) Left Buttock • = Left Leg
-Right Buttock © = Right Leg
SING14DOS
,b)(6)-4 0 = Left Deltoid . = Left Arm RE-OP PRN E.

& VARIABLE
.(4) 'o Right Dalt(' Right Arm
PERSONAL DATA P IY ACT 197/ DOSE ORDERS @-= an
SEE REVERSE
MEDCOM - 5658
DOD 12870

b)(3)-1 cx...42.01y-fe_, PAcr)-oc..4.
)RD (Back) S/N 0105-LF-216-5581
•
SINGLE ORDERS — PRE-OPERATIVE
MEDICATION-DOSAGE , M DI AI• ••IA b)(6)-4 •E • TIME INITIAL ROUTE or ADMINISTRATION DATE TIME INITIAL
—
"..7 1E11 ----"fZI--1";, =i7ky

b)(6)-2
D tiag-r)1,1 tito...,4 1 ¦ins -•-5`/t7 1$3o
DUanfi n 5t014,(1'1.Evvg x I ' d_.9 to5o
Albenckyi e 40/46( Po x 1 4/el I 1 Pe

PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE
AL

LI
(2L.
, ,
12r,
V24.
/24
litilp:
4/2G
'NEOICAraiii;oeswoiI'
ROUTE OF ADM INUT RATION.
LID DATE
i'Okiik
-nset po
k.4/.0 0, -,ildi: TIME

IF 'IA k,... e0
gcL hic,....,..1Ii v
oveg 1 has ) I F
;;..Fi s.A T`' - -
FeRJ coA k 11.0
CAlt.v,,,i, 6,4 u .„„..4.1...
i• %rile • 1 V ovt...4--.
...10„,,,z.z . DOSE •
1 5 ry., ; ts) , ; %..

G114 1.15
AttNes,.„,s,IV,449._
0.,IIV 0 ve4 3-0 .I, ... ..1.1 //NlI/ r in -Z 2. 0IIQ Kpo...4. 3 .0 .....• ", ,,,,.6)
/N 7,6f:::0 ...b5 W
on. N5 IV evedt
hi ° IF .PZ.CD • . ..Ty enAL62 i;
fl
DOSE
INIT.
-‘'I er.TIME
-,-
•-••••
.

DATE Luta ciiikiittfilaT i'dt fon
TIME tri000400(ate 170'010 all DOSE Z14111 pailektgekttolbe'41
INIT. fb)(6)-2
9...,...-FE -
.
INIT.
DATE •
TIME ..

DOSE
•
-
INIT.
DATE
TIME •
DOSE
INIT: .
DATE ger
T }riot
1il'en.P14:5124_ /Z. s' ...Irm. Fob
J
aLt PA ki ri,,, ,.._
DOSE A-
L INIT. 13)(6)-2
DATE
TIME
•
DOSE
INIT.
DOSES GIVEN -IN..... ..,•+¦.4. . ..- --... .I. • . .. •._.. . . -
• . hI';: .. , ,.¦ ••i -. . ._ ..... .. ......... .... . .
. -. • .. . .•
•'
.

MEDCOM - 5659
DOD 12871

n II A
NAVMED 6550/13 (REV. 4-74) SIN 0105-LF-216-5581
(-e•=0(4-0•`-_
. MEDICALRECORD MEDICATION ADMINISTRATION RECORD
DATES SCHEDULED DRUGS MONTH 19 GIVEN
ORDER DATE
MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION
551a -InsulinTturn rt SQ
0-45Tvs, 1041 D50. catt HD 140 -15e, Oaction 61-25V: a u_n;43(ukarIrstil PS1-350:4 uniisT. SO 351-4to: 6 Luirts
450: Yfurit5 SQ c 4.0. e-{1,
1 act 03 PI Rrbt,{6._Poirk/ Or OR 415 '1111(141in MPH& -1,\I TiD
*403 I 14M 7/o man Ivt ti Pn T/ -)
LI
7c75 AL-gvAr•c/2-0L(t.).D(CP f .1)
INMAL FULL SIGNATURE & TITLE INITIAL
15

L 1 it C.
NL
ADDRESSOGRAPHPLATE
HOURS 4(v et / 5/1 6- 2__ 5.--Vd.t1
Q( 14 FORWar=71Mara
1
Laxe) ® WAVPigi lic: IIM

Azimgra
tise0 M3 ,-1
aLtvp WiliViiiiiiiiall
W1MirqM*
MI¦¦•¦ al¦-
oa_oo WAWA
t000 Ow .
1 VM 1¦,

A
0400 •-•41

¦¦
lava I• IPRI
am 1.

0)0
., 90,:,
i ...2e 1 r,
.2c, or)
Deco
1106

i Sb
If 300
INITIAL CODE
FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
'7"-C.-•
• --
WARD NO.
Injection Site Code
Left Buttock 0 = Left Leg
Right Buttock C) = Right Leg SFIGLE DOSE,
PRE- OP PRN
Left Deltoid • Left Ann &VARIABLE
Right Deltoid ® a Right Arm DOSE ORDERS
dolmen SEE REVERSE
MEDCOM - 5660
DOD 12872

MEDICATION ADMINISTRATION RECORL 5/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

PRN AND VARIABLE DOSE MEDICATIONS
• ORDER
MEDICATION-DOSAGE
FREQUENCY DOSES GIVEN
DATE

ROUTE OF ADMINISTRATION
•4?-403 71:MOCtl UM 1 IPO
DATE
TIME
PM (13+"(
DOSE
INIT.

tA3 Tryieri o f [,,sD,,
--L _ DATE i....1 '-
g
116r 11

TIME 173D DOSE (abs
b)(6)-2
INIT.
DATE .I•
41(1'VZtAd•-) it W 0...9
TIME p..

\)-(3IQ e7. )
DOSE
X6)-2
INIT.

DATE 0415A
Elzcooi-T5 Tr 9; 5 3 5
TIME 1•23, tr5 JJ)01 .36# 1 .. al
VO
"'k Li
DOSE TT Tr a-IT II

b50)-2
INIT.
DATE
LUS9 - HILI; r. rtst, .25 r,,. Po cth 12 I fa U
TIME DOSE
ilosinfreY1isielou-r.s .1'
INIT.
DATE

.
TIME DOSE INIT. DATE TIME DOSE INIT.
MEDCOM - 5661
DOD 12873