Medical report of Iraq detainee. Medical conditions included, gunshot wound to pelvis; laceration of bladder and neck. Medical treatments included, right nephrectomy.
• INPATIENT TREATMENT RECORD l__R SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
1._REGISTER NUMBER .b)094 -lbX61-42 3._GRADE ADMISSION REMARKS
4. _SEX_15._AGE 6._RACE 7_RELIGION 8._LENGTH OF SVC 6._Ef S ivy 10._PREVIOUS
ADMISSION
NI 311"
11._FMP Cf 12._SSN 13._ORGANIZATION 14._WARD C., V,2__
15._FLYING STATUS 16._RATING! DSG 17._DEPT./ BEN 18._BRANCH/CORPS E.P W 19._UIC/ZIP .._. 20._TYPE CASE ----isij
21._SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22._HOURS OF 23._CLINIC SERVICE
ADMISSION
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24._NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25._TYPE DISPOSITION 26 ._PATE PF DISPOSITION
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27a._ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27k._TELEPHONE NO. 28._DATE OF THIS 1 ADMITTING OFFICER ADMISSION
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.b)(3)-1 30._DATE OF INTIAL 3 •_UNITS OF WHOLE BLOOD! ADMISSION COMPONENT TRANSFUSED
31._SELECTED ADMINISTRATIVE DATA
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3.i._CAUSE OF INJURY
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34_DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES_ 7-
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35. Total Days This Facility
a._
ABSENT SICK DAYS b._OTHER DAYS C._CONY. LV/COOP d._SUPPLEMENTAL e._BED DAYS I._TOTAL SICK DAYS
CARE DAYS CARE DAYS
.25
36. Total Days All Facilites
a._ASSENT SICK DAYS 5._OTHER DAYS c._CONY. LVICOOP d._SUPPLEMENTAL_i e._BED DAYS I._
TOTAL SICK DAYS
CARE DAYS CARE DAYS
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SIGN SIGNA In
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DA FORM RE47_ MAY 79_/4, a/1 A._
MEDCC)M -5662
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DOD 12874