Medical Report: Records of Iraqi Prisoners of War and Detainees, Baghdad, Iraq May - Nov. 2003

1Nr ,-. fIENT TREATMENT RECORD C.... ER ...E1-
For use of this form, see AR 40-400; the proponent agency is OTSG
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21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23. CLINIC SERVICE
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24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION 26. DATE OF DISPOSITION
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29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. DATE OF INTIAL
ADMISSION

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31. SELECTED ADMINISTRATIVE DATA
33.
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34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

35. Total Days This Facility
a. ABSENT SICK DAYS b.• OTHER DAYS c. CONV. LV/COOP • -d. SUPPLEMENTAL C. BED DAYS
CARE DAYS CARE DAYS

V.
36. Tota Days All Facilites
a. ABSENT SICK DAYS b. OTHER DAYS c. CONV. LV/COOP d. SUPPLEMENTAL e. BED DAYS
CARE DAYS CARE DAYS

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SIGNAT SIGNATURE OF PAD OR MEDICAL RECOROS OFFICER
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MEDCOM - 3918
ADMISSION REMARKS
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DOD 010397

INT TREATMENT RECORD C
For use this form, see AR 40-400; the proponent agency .jTSG
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I Check if Continued on Reverse
33.
CAUSE OF INJURY

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35. 3. Total Days This Facility ABSENT SICK DAYS b.. OTHER DAYS c. .. . CONY. LV/COOP CARE DAYS • d. SUPPLEMENTAL CARE DAYS e. BED DAYS 1. TOTAL SICK DAYS
36. 1. Total Days All Facilites . • ' b)(8)-2 IP -. • • . •• • d. SUPPLEMENTAL CARE DAYS BED GAYS TOTAL SICK DAYS
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DOD 010399

AUTHORIZED FOR LOCAL REPRODUCTION
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CHRONOLOGICAL RECORD OF MEDICAL CARE
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MEDCOM - 3921
DOD 010400

MEDICAL RECORD PROGRESS NOTES
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STANDARD FORM 509 (Rev. 11-77)
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MEDCOM - 3922

DOD 010401

PROGRESS NOTES

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MEDCOM - 3923
DOD 010402

AUTHORIZED FOR LOCAL REPRODUCTION
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV
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MEDCOM 3926
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DOD 010406

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MEDCOM -3928
DOD 010407

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MEDCOM - 3930
DOD 010409

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
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eg-uses Pip4p,Qactuo&A-skIn 2u2i, cad / 624,Lactot i 5Olvik-ib (Al\h.e)A Pt-641

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a afrO3 t%ei, 6t(eq3 y q71' 444 567971d.
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(b)(6)-2
—4-(,..z. rizek--,

RELATIONSHIP TO SPONSOR 4UMBER
LAST

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entnes, give: Name - ktst, first, middle; REGISTER NO. WARD NO. 10 No or SSN; Sex; Date of Birth; Rank/Gradel
:b)(6)-4

PROGRESS NOTES Medical Record
OVA Kin A on ,4,f,•1 ran
. 5-99) Prescribed by GSAIICMR FPMR (41 CFR) 1 01-1 1.2030)(10)
MEDCOM 3931
-

DOD 010410
ME 1 RECORD — S PPLEMENTAL MEIN DATA
For use of This form. set AR 40-5S: tbal 'pro' net !Raney Is the Office or,The Surgeon General: , REPORT TITLE 24 '". 71 1 • 1 •
1 OTSG APPROVED Pate)

HOUR COMPREHENSIVE CARE RECORD Part 1
-DATE: ' .-2d-- Mar (.).
7,.c",c¦
HOSPITAL DAY NO. L..131#111111— D . III \etc'' c., ' ce, tiP")) '41;•*•46.•:"!' 'l'; arfr
POST OP DAY NiO. ISOLATION DAY NO. ALLERGIES 6to_..1 PHM I /­DY -61 I. I? Y. ± g I I I I I I )--. nel. i-• D a jo: WI 1.
0
= ... o ID o lb .. V MMMMMMMM0 0 •-• 0 CU CD Is 0 o 0 ea I N -1 1.--01.... x 1.Z 1IN, • i4 .
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or .¢ to 0 — 8° 0

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:HEST TUBEITOOL -UOUID
g

TUBEFEEDING
TOTAL*Unita BLOOD Given!
1---
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PREPARED BY (5ig/MUM & Me)
DEPARTMENT/SERVICE/CLINIC DATE
PATENT'S IDENTIFICATION
(For &peel or waft, entries give: Name - &W, erst,mice*: 911.)4.. AIM' Mena& Ige nuaerw1cI
. HISTORY/PHYSICAL
FLOW CHART OTHER EXAMINATION
. OTHER (SPecifY)
OR EVALUATION
b)(3).1
. DIAGNOSTIC STUDIES
blAGNOSIS:
. TREATMENT
WNW slime
MEDCOM - 3932
DOD 010411

24 -HOUR COMPREI CARE RECORD Part 2 Page 2 of 2
omo-l000 ACTMTY _BR - o - AA - A ,ea0-13700 TIME
BATH B -13 ., S RIGHT SIZE REACTION
FOLEY /PERI CARE " ORAL CARE LEFT SIZE
REACTION

ENDOTRACHEAL TUBE CARE
ORAL /ET SUCTION
OXYGEN AA AT IPM
vENTLAToR
Fi 02
RATE:
TIDAL VLOUME
PEEP
DIET:
C)
fw
0.
OMA SCALE

SPONTANEOUS 4
TO SPEECH 3
TO PAIN 2
NONE 1
EYE COMMANDS 6
PUU_S TESTERS HAND AWAY WHEN PINCHED'`'
YLEIOON WM4DRAVAIIL 4
DECORTICATE POSTURING 3
DECEREEPATE
Pomona 2
DRESSING CHANGE
NONE

I
b)(6)
INITIAL ,

MII:
3SNOdS31:1
I31VERMA1S38

ORIENTED 5
CONFUSED 4
INAPPROPRIATE 3
INCOMPRENENSAKE
SOUNDS
NONE

W 'I'w:T.
2
co
TOTALS
BR - BEDREST 13 - DANGLE

AA - AMBULATE WITH ASSISTANCE A - AMBULATORY B - BED

I

P - PARTIAL S - SHOWER
ME NARRATIVE NOTES (-94 0 o A . -\.f..ciz.:,-.),Lot 4-1.4,, (-344.5r-ct_c_1-,,,,,_ _tea s-
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(CIL 6 4'-'-'49 -daJed-eW. 4
e.t1
. - -
le

MEDCOM - 3933
DOD 010412

date
Recurrent Medications and Treatments

Vital signs
4
12 8 Olytio'MD 13 le/07/5 Lt v Ci0 't -9(A ,t24 Ir. 1/5e ,'*,',, $s Ir% r974 ,f,:ta 47 trt,.,a.
16
.3
20 Pgt
24
PRN Medications and Treatments
d/t amtlint zs pc4-42
d/t
9 amt/lnt
I MI5-t po 52%,ov (i -I: pry. -po iib d/t amt/int dit amt/Int .°) -Set '. ltvktor-N, nagt)) 030T,
dtt s•rm„,-1.0
amt/int 2 )45(2
d/t
amVint
Name 1,)(8)-4 • Dx: -T, b
SSN: All:
Unit: CH/ Blood type:

MEDCOM - 3934
DOD 010413

(THIS FORM IS SUBJECT TO THE PRNAC •
;TART iti9R e. ANES. END DAT a,.
‘,6,2 3
ANESTHESIA RECORD
'TOTS ,., SURG START DRESSING OR NO L50
OPERATION

PERFORMED: U 'Q t NO3 1 1-1( 1 946--
' TOTAI
PREOPERATI

h*S • Lt - 0

.
IDENTIFIED . ID BAND 0 QUESTIONING

.
CHART REVIEWED 0 NPO SINCE •

.
PRE-OP MEDICATION: e .c'c_

% Pose Route Time

Drug E
M-• • L--; -7-2-/ 1 i I/ I 4 N
T
Pre esthetic Slate: WAKE
ALM . SEDATE
APPREHENSIVE El UNRESPONSIVE

.
I N20 Umin 5 11
02 Umin

MONITORS AND EQUIPMENT
erlir-ES. MACHINE N - & EQUIP. CHECKED
L
0 NON.INV. B/P PNS

. CONT. EKG V LEAD EKG
ESOPH. STETH. PRECORD STETH.

O Urine
PULSE OXIMETER . 02 ANALYZER

S EBL

.
END TIDAL CO2 . MASS SPEC. SYMBC

.
TEMPERATURE r.,

A F U EKG
. WARMING BLANKET . FLUID WARMER x
AIRWAY HUMIDIFIER % 02 Inspired

ANESTH
N / G TUBE rTUBE
02 Saturation

. IV(s) 0 r-'

Pt) 8 CO2 II ''" 11 1111
End Tidal

N 0
I Temperature OPERA1
.
ARTERIAL LINE

CENTRAL LINE T PNS V

.
SWAN-GANZ 0 A

.
FOLEY INSERTED: . O.R. . FLOOR R

B/P Cl
. EYE CARE S PRESSI
o PRESSURE POINTS CHECKED / PADDED
iimmimiiimiorme•mommiMi MIMI=
013 0
. 9 T
. TIME ( ARTER
ANESTHETIC TECHNIQUE LINE
PRESS'
0 GENERAL 0 LOCAL / MAC

VALUES Or I 11111111111111111 11111111
Ir
PULS
0 REGIrmw EQ:0 ,:\AkIt. IZRZE BLOCK IIMIIIIIIIIIIIIIIIMUIIMIIMIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIII •
C

SPONT, OUS RI
INDUCTION

.
PREOXYGENATION . INHALATION

.
RAPID SEQUENCE . INTRAMUSCULAR

ASSIS'
. INTRAVENOUS . RECTAL RES
AIRWAY MANAGEMENT
CONTRC
.
INTUBATION . ORAL. . NASAL RES

.
DIRECT VISION . BLIND . AWAKE

9
. FIBER OPTIC . STYLET USED
0 ATIEMPTS x _ . BLADE
Erf SIZE 9 DOUBLE LUMEN

TOURNI ,
STRAIGHT . RAE . ANODE
. CUFFED ML AIR INJECTED
1 11 1110111111 1 111
. UNCUFFED. LEAKS AT CM H2O

R Tidal Volume IMWILIMIIMMIMIIIMIIIMIIIIIIIMINIIIIMINIMINIIIIIIIII=111
ETT SECURED AT CM
Resp Rate DRYS'

NIEMIllig;WAYAM11111111=111 ¦=11•1111 ¦•=11111•=111111= LOID
BREATH SOUNDS
. ORAL 0 NASAL.JEKTURAL E =II111111111111E IIIIMIM111= MIN11111111111111111111.11111111=110 1111=111
S Peak Pressure

AIRWAY
MASK CASE U VIA TRACHEOSTOMY

P

NASAL CANNULA SIMPLE 02 MASK Symbols for
LMA SIZE Remarks

LOr
Positron

q 11111
REMARKS : . Patient reevaluated. No change from preop plan I evaluation.
RECOVERY

. Significant changes (min preop plan / evaluation.
TIME IN PACU CONDITION

Lr5.1 /455— (Y-Kj c---U - Lc -k-=,_QA,
B/P P UdiSF7 RESP
til
TEMPREMARKS

Tourniquet Time:
REPORT TO: PARRS:
PATIENTS IDENTIFICATION

IN FLUIDS TOTALS OUT •b)03)-2 :b)(6)-4
Crystalloid EBL
Urine
Gastric

Blood
II PHYSICIAN / CRNA

MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 29 h""
MEDCOM - 3935
DOD 010414

— . MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new orderls) are noted and initial In the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED NUMBER DATE, TIME, &•SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS /,r1D OXYGEN: 46 litres via Mask /Prongs to maintain 02 Sats greater than 94%; Wean to room air.
IVF: N.J9 @ / 7,5cc/hr, bolus —ac x 1
—

j") MORPHINE: -7mg IV q 5-10 minutes PRN pain. MAX dose of f Omg DEMEROL: 2--"S mg IV q 5-10 minutes PRN pain. MAX dose of 5o mg a ! • • -. -:.
- • --. • I., . X1 DROPERIDOL: 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
...:7 REGLAN: Give 10 mg IV PRN nausea X 1
8 Release from "PACU" when Aldrete score is oror greater
9 Call Anesthesia for any questions or concerns

b)(8)-2
SIGNED

•
•
. .
PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any
changes on subsequent pages.
13)(6)-4 Diagnosis:
Height: Weight: Diet:

Allergies:
• Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) MAR cm PRPVICII IC Fnmonic a PP OBSOLETE MC V1.00
MEDCOM - 3936
DOD 010415

DOCTORS ORDERS
RECORD CLINICAL RECORD -
For use of this form, see AR 40-66, the proponent agency is OTSG
;TOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL NUMBER IN COLU INDICATED BY ARROW BELOW. OF ORDERCOLUMN TIME OF ORDER
HOURS SII
IS USED, WRITE PROBLEM
DATE 2-26 Prrve
I DENTIFICATION

TENT IDENTIFICATION
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
1 JUL 77, WHICH MAY BE USED.
REPLACES EDITION OF

DA , 74°79 4256 MEDCOM - 3937
DOD 010416

CLINICAL RECORD - DOCTOR'S DEMERS For use of this form, see AR 40.66, the proponent agency is OTSG
DOCTOFi SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
LIST TIM ORDER
iTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
NOTED AND SIGN
TIENT IDENTIFICATION

4URSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
N
4256

DA ,F:pRAmig MEDCOM - 3938
DOD 010417

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN
For use of this form, (NON-kleDICATION)
. see AR 40407;
• • • • .

VERIFY BY INITIALING • • •
Mo. Yr.
ORDER CLERK! INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
DATE NURSE DATE COMPLETED
b)(8)-2

ALLERGIES: 1-1 YES PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
ED YES F-1 NO
PATIENT IDENTIFICATION: PAGE NO: •
ACTION TIMES
bX13)-4 :b)(3)-1 USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.
MEDCOM - 3939 USAPA V1.00

DOD 010418

THERAPEUTIC DOCUMENTATION CARE PLAN
Verify by Yr -•
Mo­

(NON-MEDICATION) -,
Initialing
Order Clerk SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
Date Nurse
(b)(6)-2
2101P12- A bmir To ic.Am 2
DI Si e (1)11131er FX eitSr
e.t)t-JJ, In Qt).Srniu.e-

. INITIAL PROPER COLUMN FOLLOWING COMPLETION
Order/ PRN
Clerk/

Expir Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
Date b . i g 4 10 II i I-1 2 3cia Af flits c
thei5biti ri 5i-PO 4 q ° PP4-1 PAW

ezotvef-PtSdli 2--q.j. tifictervobti&I
u
is-1, b

ua hfiz-
Iv at.
-Pi Nel ve. #1,-.) 12,,s—zs 7" f40
eg-i l ON

USAPA V1.00
MEDCOM - 3940
DOD 010419
••• • --• - - --—

I.. al:c2TING MTF '.ATION
ADMISSIC. ., ODING 'INFORMATION

(Spate or
2 3 4 5
Country

b)(3)-1 For use ul thin form, sue AR 40.400; proponent agency is OTSG
Code)

3 . REGISTER NUMBER A E (Lae, First, Middle Initial) 4. PAY GRADE 5. SEX
9 10 11 12 13 14 15 16 17 18
b)(6)-4 bX6)-4
A
S. DATE t/F BIRTH (Y Y V Y M Af D D) 7.cAGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION BACK-
1 9 20 27 28 30
111111111111101, fl

GROUND
VI eaNIBliIfAIIINILI111L1111 _411. OM
1 0. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER

FaITN

32 33 3 4 35 37 38 39 40 41 42 43 44
MIN=
vii

...1
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCH / CORPS ADMISSION
46

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 rpm ri 51 IIMI -In 54

55 56 57 58 59 60 '61

1/.411111(41M1 cliar.ilicimucireArAro.1
17. UNIT LOCATION (State or 18. MOS • 19. TRAUMA
PREV ADMISSION
Country Code)

YEAR
62 63 64 65 66 Eli 68 69 70
m
Li NO
-

–.Ns= 11Calligginin = .
20. SOURCE OF ADMISSION./ AUTHORITY FOR WA -D NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION.— /
7 / ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP code/
AlG Li /

D `(-1/L

NAM b)(3)-1 •• - TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSMON (YYMMDD)
MEME 11111....

3 b)(3)-1
ri 82 1211 84 85 rill
km:
IP _ ,:#711eitrAZZIALrill
24. CLINIC SVC - ADMITTING srandiew -, -1• .i•i.), 26. DATE THIS AMISS'• Y M to D) ' 88 III 90 93 94 95 96 98 99 100
IEN. -92 im rim
,....„ ,
illiFIr'll'a ....---- .."– 40,72garantariarmi
_ _ III wiI

27. LOCATION OF OCCURREN 28. MTF OF INMAL ADMISSION 29. DATE INITIAL ADMISSION (YYAIMDD)cN.
\
(Battle Cassfalty Only)
...-

103 104 105 106 107 108 109 110 111 112 113 114 115 116
_Jr.! ,, .
FOR LOCAL USE
,.-- --
--1-0-ttn"-G------
.
0 9

7---, (77... -„,-.,,.
...

c(P..P-? - ....,
PI se 9 .
....._ ___-------A 71imp191;,4illii • -irf
SIGN 0A • ADMITTING CLERK
b)(6)-2
ll
bX6)-2
II •• " I • . • • 'afi. •
LENIILA1 Ld MAY 79

MEDCOM — 3941
DOD 010420
1. ' 1,11-F;ORTING MTF 2 IL L'ATION
ADMIS;,....N AN-, CODING INFORMATION

1 1 2, 3 4 5 6 7 8 I Mote or
l I 1 l

(b)(3)-1 Country
cod For use ul this lurm, see AR 40-400; proponent agency is OTSG
e)

3 . REGISTER NUMBER NAME (Last, First, Middle lnklal) )(6)-4 4. PAY GRADE 5. SEX
1I

9 10 11 12 13 14 15 16 17 18
b)(6)-4 b)( 6)-4
6. DATE OF BIRTH (YrIVAilifDD) 7.cAGE AT ADMISSION 8. RACE Ell ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-
GROUND

W i q,

10. LENGTH OF SERVICE 11. FMP 12.
SOCIAL SECURITY NUMBER
32 33 34 35 36 11111141IPOIMINIUM111111111

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS FOUR OF BRANCH / CORPS ADMISSION
46

irOD

14. FLYING STATUS 15. BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 48 49 50 51 52 ..-

53 54 55 56 57 58 59 60 '61
17. UNIT LOCATION (State or 18.
MOS 18. TRAUMA PREV ADMISSION
Country Code)

62 63 64 65 66 67 68 69 70 71 YEAR
Af

NO

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION--/
72

ADDRESS OF EMERGENCY ADDRESSEE (1riClinte DP Coda)
DIV" /116 ti (

NAM b)(3).1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMD D) 73 74
75 76 77 78 79 80 81 82 83 84 85 86
0 3 v / 0
24.
CLINIC SVC - ADMITTING

25. MTF TRANSFERRED FROM

26.
DATE THIS ADMISSION (YYMMOD)
87 88 89

90 91 92 93 94 95 96 97 98 99 100 101 102 1

(9 as q 6
27. LOCATION OF OCCURRENCE
28. MTF OF INITIAL ADM SSION 29. DATE INITIAL ADMISSION (YYMMDD)(Battle Casualty Only) •
103 104
105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE
• .
4:::

„.
ADMITTING (ICER (Signature, as required) b)(6)-2 SIGNATURE OF ADMITTING CLERK
6)(6)-2
ow
DA r-Larun cuop, MATS OU LUI I ION Lil MAY 79 It
MEDCOM - 3942
DOD 010421

r
ADMISSION AND .CODING INFORMATION
For use of this form. see AIR 40-400; the proponent agency is the OTSG
IIGE AT UTOPSY
3snv0ONIA11:130N I
Y / N
118
d3S /H1V30JO
1

33. RESIDUAL DISABILITY [34. DONOT USE • DATA FILLER#1
177.77.=

Auni
9E L1 I PE I EELI ZEn LEL OEL 6Z L [8ZLI
"` 1EZ L1
I
.7.i
ISIS(Pr I
37. SECOND DIAGNOSIS
1 I38. THIRDDIAGNOSIS
140
,-

09L1 6SLI LS L
8511
VS l
1 zs i. I IS L I osi. I 6PL I 8111.
(OSIS
40. FIFTH DIAGNOSIS
41 SIXTH DIAGNOSIS
I
TETI
42. SEVENTH DIAGNOSIS
BLl t_
1 9L L IsLL vci I ELL 2 L1 1-57
I1
171777.7
43. EIGHTH DIAGNOSIS
Ioo z 1661 I861 L6L 961 F6T. 1Z6t L6L 06L 68L 88 L
Lal FEW. 1 -i9T1
1 I1 1

UMW
.

. .

.
44. FIRST PROCEDURE(Principa
20 1 ] 202I 203I 204I205I
209 I 210 I 211 I 212 I

1 48. FIFTH PROCEDURE
-I
.
45.
SECOND PROCEDURE

46.
THIRD PROCEDURE

1 I fill
EZZ Izzz LZZ
I "z I OZZ6118 LZL12 9 1ZISLZIAZ 1—£Te

229 230I 231 1232
ovz '6E?1 13E2 LEZ I 9EZ 117E21
UGHTH
IIE 75;1 ...._.
...
25 3_1 254 =.

Z9Z
.
II

1 I

L
MEDCOM - 3943
DOD 010422

OF DIAGNOSTIC FIELDS
53. N
CONTAINING CODES
267I
=
OF PROCEDURAL. FIELDS
IVIDER
CONTAINING CODES
SPECIALTY CODE
or
ru
ui N
r¦
,LOOD USAGE
Y/N
...- ....