Medical Report: 56-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound

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TOTAL TOTAL BALANCE
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MEDCOM - 13841
PAGE 40E 4
HOUR
LEGEND
SPON rANEOtESEY •
70 SPEECH
3
175 C Closed 10 by swelling
NO EYE OPEN.NG
4:WEENIE()
QN

CONE USED T Trach/Endo
2z
—o
mpAoZES S Slurring
ROCAELPES 0 Dysphasia
S NO VOCAL IZA 110n R Recepwe
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R RightER St .+ ERE ersacrrcssi L Lett

a .101NO.,1211. iLt .50r
An••0 RM., Ex it 11,0N
Record
+
Est NO RESPONSE
separately d 0 there is a
.oreAnt.rowrit difference
+between the E V
wEai reSS
two sides.
SE vERE ArEAE5ES5
.pli1011.141. 21E1105
ABNORMAL Ex TENSION
NO RESPONSE
Pi

i

U ICH T Sq. • s 8 nsk
P
• Slow
L. EFT SIZE AL AC K.N.1 No Response
PUPIL SCALE • 2 la 3 • 4 • S 4110 6 is 7 dun
ICP CEREBRAL PERFUSION PRESSURE 1 1I !II Intact -Abnormal

VASCULAR ASSESSMENT
HOURS
LEGEND
4. Normal

iirOPANIMPIPAIMPINVIMI

Weak

MIPANIONNUMNIMPAIMIN

-Absent

IPMWAVALWANWAPAIN

Doppler
Right Left
iNFAIMPWAVAIPANNIMEN

NEOPINNIMINORWANNOMON

MEDCOM - 13842
CAL RECORD—SUPPLtMENTAL MELACAL -u0-e11 : ire Proponent ,Ajenc• Are Oit,ueo, lb+C REPORT TITLE
APPROVED (DGA,
INTENSIVE .JURSING FLOW SHEET
A Appr B Mai 89
INITIALSHIFTASSESSMEUT
TIME I+,r411,1.1+
....t+)+I 1.1“., PUPILS
. .1'.. SENSORIUM
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LOCATION CONDi I luN
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1Continur vli leticrSe 1
AHED BY & DEPARTMENTISERVICE,CUNIC Al E
4lue- ,Varne—Inst. Ii
m.:adie groat dr11, ho,ota. r+jaczIit yI
0 HISTORY, PHYSICAL+0 FLOW CHART
0 OTHER EXAMINATION 0 WHEN OR EVALUATION
Ci PIAGNos TIC STUUIES
o TRE.A1MENT
DA 4700 WAMC OP 375 t Redesignated)
,MAY:„
Pi opunent Dept DI Nuts 1 Apr 90 (HSXC-NU)
-
Vc(ap-0 ‘CAL+ .3-.¢—al
•+t.7
MEDCOM — 13843
0.¦ Ft DI
110111,1. IL,
.+-1 T • A L TIME EP Al terial Lint al, curt Temperature Ps.gbc .,ne5ptratory MAW/ Rate ...'');_f. 6 i e:-. a C 3' 0 z ( 0 5-NMIBM Ill e4". 0 ';* 1 z--ceg t• t C)k:, Ctn._ Og' ,•,‘,7 / ‘:, ,.,7 . -• / / ,-f pzci-Vf(Iri I 97
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EMESIS C.J., STOO L PRAMS TOTALS i li 1 1 ME '

MEDCOM - 13844
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TIME
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N

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SKIN CARE

FOLEY CARE
MiiiiiIMEME

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U mairmEmno
ROM ExERCISES
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imummum 2
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womaimmu.

INTAKE u,,ne, OUTPUT
IvA
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:IE..
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BALANCE

111Wir

Ls- Li

MEDCOM - 13845
PAGE a if
NEU R,e-LOGICAL' ASSESSMENT .
C HOURS haAli r LEGEND

NS
SPON LANE3Lhky •
CAClosedJO SP EC.A3
by swellffig
1 0 RAIN 2 NO L It OPINING I
I EYES OPEN

A
S
A
E
atAOu.¦+su Zr-1 M7 MANI
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no VOCAL lb:1110ra 1
E Expressive.
ow..rs
co...m..4:6
L OCALI2LS PAIN S
r L c xsOrr
VVII.ORAvrAl. ABNORMAL
11 i 110.1 3 LA 1 L rys.i0r.
10 PAIN
2
NO MO 1 OR
tal S.POthig. 1
110NrAIA e0WE A MILD VwciiiiineSS St v e RE erLAAne.SS A 13 no...I. nt SLOP. AlilhORA1AL Exit 1.11.0r1
NO tat `,0.5,
hOnhIAL POWER iSaih0 niLAAnt SS SE REnt wt.a....Ess ABNORMAL nE SION AfirrORAILL El It hvOni NO RI seOrtsi
Sra
RIGHT
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3

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it+R.gnt
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Record separately a there is a cf,fference between the two s.cles
• .+aft,.
REAL; ION

._ SlOw SIZE 3 5 -+NO REACTION L-I . -. Ret.pone
LEFT -r-t-
•

PUPIL SC.%LE
.+Intact

ICP
CEREBRAL PERFUSION -+Abetorma:PRESSURE
-_ 1 HOURS LEGEND
4. . 2.202 Tel

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MEDCOM - 13846
—.CAL RECORD—SUPPLEMENTAL MEDICAL DATA
For use ro tars tr
REPORT TITLE
INTENSIVE CA
.
TIME PUPILS SENSORIUM
RESPIRATORY PATTERN
BREATH SOUNDS
Pr?
SECRETIONS
y::
COLOR

INTEGRITY
TO
LOCATION
CONDITION

fs ABDOMEN
BOWEL SOUNDS

11;:. "
URINE.
COLO R/CLARITY
CARDIAC RHYTHM
A
If
O.
V
A' S •
C.
u:
:R .
ARED BYA

se AR 40-66: the pnaponent agency is the °Rice of The Si,
UnSING FLOW SHEET
__12_(a_n.0
.
+c91‘7, -3
vaA-14,5r I i`ze 5n-uz
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L.Ae e',Err
,r)
4/7-/VP,ni.s
vo+v"a..
.91,52/+.S.),Z.

DEPARTMENT/SERVICE/CLJNIC
9/k/44
0/1A arne—last. first.
e: gra . spsat or medley( facility)
DA I 2,11,m78 4700
Proponent Dept of Nurs
Gen Op__ APPROVED (Date) QA ADP
, a mar 89
to FrectIon,
• Saturouon
mac.,

(Curt roue on reverse)

17,5717,--03
.
HISTORY/PHYSICAL

. FLOW CHART
.
OTHER EXAMINATION

. OTHER (Spectiyi
OR EVALUATION
. . DIAGNOSTIC STUDIES

. TREATMENT

WAMC OP 375 (Redesignated) 1 Apr 90 (HSXC-NU)
MEDCOM - 13847
PAGE 2 01,

TIME y + G2 03 0 4, C7_Og" n /0 // 1.2_ / 3 /k4
BP Arterial brie
PP C.111
Temperature ., i -1

-
:-' :o+-•+ 3:+
Pulse
g5
Res to Rate
ag
I LP
co
S“)
S

V-a....---
,,:S.,,,s. 4.-.."--.
TimE

'-/ 0/_02_03_Ci'l 425-06 o2 FC'T OjJ /..)--ErT
4)1 i/° // /2 H Pi
44
-TOTALS
''' 7/.//////
/ //////
URINE
sm
wimp
NG p.

Luac
EMESIS
STOOL

DRAINS
TOTALS

MEDCOM - 13848
PA GE 3 OF .1
NAT

KIJITT uIIF. 1:1.43,0 SAM.
J4. /7 51 1-.3 TIME
MODE

T
TV
A
RATE
PEEP
PN
A PCO,
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HCO3 SAT RASE
G
S

TIME GLUCOSE
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cf D. TIME L A MOUT,. CARE EBBE
BATH SKIN CARE N
FOLEY CARE
TRACH CARE • ROM E XE ACISES C T 0 I.
WI YesterdayA Cd y SIGNATURE .111.4.4
INTAKEA OUTPUT ivA . Orme:
707ALA TOTAL BALANCE

\.3 L. --L4
4111111

MEDCOM - 13849
MEDICAL RECORD-SUPPLEMENTAL MEDICAL Um IA
For use of this form. see AR 4066: Me proponent agency is the Office of The Surgeon General.
OTSG APPROVED Ware)
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet

Date:A Anesthesia Type (Circle)): General Spinal Epidural Drains Airway
Time In:A IV Sedation Nerve Block Hemovac Nasal
Allergies:A OR Intake: CrystalloidA/tat,AColloid NG Oral
Pre-op V/S: OR Output: UOPA"AEBL JP DT
Procedures:A/46 (PA-A-i-w, .MedsMmes: 0 CA}12 A/+-LK 'Me ' T-tube Foley Trach Other
Pre Op Meds Time M !‘„,s, R is v ., '. , History Pacu Intake TLS
Sa02 Al) .4. rIC 43 r(3 Time Solution Amount Site By Infused
F102
Methods
240

220 X-rays: . Labs:
. Post-Anesthesia Recover ,score 200 Criteria ADM 30' D/C Codes
Activity
AIRWAY

(2) Moves 4 Extremities 180 (1) Moves 2 Extremities
j. g

,,t‘
B B= Blow-by

(0) Moves 0 Extremities A A -by
M - Mask
Airway

160 FT = Face
(2)
Cough. Deep breath

Tent

(1)
Dyspnea, limited breathing

(0)
Apnea / I RA = RoomAir

V V
140
NC = Nasal

Blood Pressure
. Cannula
(2) SBP =/- 20 of Pre-op 120 • •v V V . (1) SBP =/- 20-50 of Pre-op
(0) SBP =1-50 of Pre-op _ ot V/S X= A-line BP
Conscbusness •100 a .2. • * * -= Cuff BP
(2) Fully Awake, audible
1 = Pulse
(216/19

(1) Arousable to verbal or pain I / i
80 A A A
TEMP
/1 Color

A A A S = Skin
(2) BaselMe color & appearance 0 = Oral
60 (1) pale, mottled, jaundiced
A = Axilla
Axillary

(0) Cyanotic U -co'
T =TympanicCirculation (Peds 5 Years)
40 R = Rectal
(2)
radial Pulse Palpable

(1)
AxiHary palpable. not radial

(0)
Carotid only reliable pulse LOS

20

C = Cervical TOTALS: Must be 9 or
T = Thoracic

greater to D/C. otherwiseRR
L = Lumbar

111-\ 14 lb k.riP Ikt needs anesthesia approval for
S = Sacral
D/C,
T

Time Patient teaching done; Wound Care, Pain Management,
Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained
Ilonnnue on reverse/ ' nature & T M . i DEPARTMENTISERVICEICUNIC DATE
6e/ 771/t/ /6fy /ratk.( d.3 PAAT'S IAIAor e:.Name -last, first, middle; grade; date ; hospital o medical feat 'v) I .., )-
• HISTORYIPHYSICAL U. FLOW CHART
OTHEREXAMINATION . OTHER away,
1\06 —1-4

• ¦ DIAGNOSTIC STUDIES
U TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAPeC V2.00

MEDCOM 13850
-

DOD-027402
Allergies: MEDICATIONS NURSING NOTES
Time Pain Medication & Route Pain I/E By
1-10 rtoncte 1-10

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion Adm A LU
0 (J Pt

15'
a e 6 A___
p

30'
0 p ')-) (.,Li S;21-

45' 1
60'
90'

Movement/Sensation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P = Palpable, D =Doppler, A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= S uggish P = Pale, Pk = Pink
C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C Fund. .Height Lochia Peripad# Fund. Cond.
rj/4
DRESSINGS Location Type Drainage
Time

Adm ) vlAIJ-K itbAg 11(211 q 30' tuv rityky, Accio.--60'
DIC
PACU OUTPUT
Time Source Color/Appearance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?

Discharge Criteria:
Date: /Mus_ 10-3 Tiinp.: 0/A) PARS:q
BP: /6/74( T: (1Y HR: /01 RR: Sa02:
Pain Level at D/C 10-10):
Intake: Output: Cif
Additional Data:
Transferred To: 0_,t,L1 oZ
Report Given To:
Transferred Via: WIC Gurney Ambulance
Transferred By:
Cleared IAW Recovery
Charge Nurse Signature
WAMC OP 173-E
MEDCOM - 13851
DOD-027403

MEDICAL RECORD-SUPPLEMENTAL MEDICAL Um A
For use of this loan, see AR 4066; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED (Date/REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: ." 1 0111 L- 0 -; Anesthesia Type (Circle)): 4290 Spinal Epidural Drains Airway
Time In: 7---7.-‘40 IV edation Nerve Block Via/Scb Hemovac Nasal
Allergies: 11/4-k 101) OR Intake: Crystalloid Pre-op V/S: t 12 / OR Output: UOP01t-Procedures: -rib ap.A.....+Meds/Times: Kat ) --1) Ri Colloid EBL SOU..+'-i­i- NG JP T-tube Oral ETT Trach
Foley Other
Pre Op Meds — History TLS
Time 1: thr kr Pacu Intake
Sa02 W19 4) IOC ir,r, Time Solution Amount Site - By Infused
Fi02 filtAgAUt 0 _
Methods
240

220 X-rays: . Labs: . Post-Ane: thesia overt' score 200 Criteria I 30' D/C Codes Activity
AIRWAY

(2) Moves 4 Extremities 180 (1) Moves 2 Exlrernities A =Ambu
n Moves 0 Edrernities BB = Blow-by M = Mask
Airwa

160 FT= Face
(2 ) Cough, Deepy breath
Tent

(I) Dyspnea, firriled breathing
2

V (0) Apnea RA = RoomAir
140 NC = Nasal

4 V V Blood Pressure .
2
Cannula

(2)
SBP =/- 20 of Pre-op

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

^^^
v/S

(0)SBP = 50 ot Pre-op X = A-line BP
^ =Cuff BP
= Pulse
4

Consciousness
• a (2) Fully Awake. audible
• ung —Si
c)

(1) Arousable to verbal or pain
A A A bw--
TEMP
Color
S = Skin

(2) Baseline color & appearance
0 = Oral

(1) pale. mottled. jaundiced
.. A = Axilla
Axillary

(0) Cyanotic
= Tympanic
A

Circulation (Pais 5 Years)
40 R =Rectal
(2)
radial Pulse Palpable

(1)
Axiltary palpable. not radial

LOS

(0) Carotid only reliable pulse
20
C =Cervical

TOTALS: Must be 9 or
T =Thoracic

greater to D/C. otherwise
L = umbar

RR MU 24 16 rho needs anesthesia approval for S = Sacral
Lf D
D/C.
T cil it _

Time MAD p_(:t, Patient teaching done; Wound Care. Pain Management.
Pain (0-10) yi T. C, & DB,. Incentive Spirometer. Comfort Measures
LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained
ri.ontinue on reverse)

P 1111' A .
7:1_\,(u) ......)..._. DEPARTMENTISERVICEICUNIC DATE
J_LA „1/4 2_ 2_1 3-14(_

PAT (for typed or written entries give: Name -last. first,_ hospital or medical leaky)
.
HISTORYIPHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER amigo OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete
USAFPC V2 DO
MEDCOM - 13852

DOD-027404

MEDICATIONS

NURSING NOTES
Allergies: \03 Cp -3-
Time Pain Medication & Route Pain I/E By
1-10 Dosaae 1-10 ILISOL+(1121./"21

1--t5DL4 5 1-4, V?

PX-3 t TT
'2-2210 ge`fALY-Lit, c3), Ti ?
C 4 ;2 +t--rSo (4_ 1J'
1

ri .") L, (24°J 40--( 0 gbEre-t_"--
-
.

11F.+t-ti+
VS+1)--)n1((-
I

NEUROVASCULAR
Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm g,Lt-225 4-..i-0. g_ 44 NI_
15'
30'
45'
60'
90'
D/C 4-

2t-V. -k-t32 i/./ '`IC

X
Movement/Sensation: + = present,- =absent Temp:C = Cool,
W =Warm Pulses: P = Palpable, D = Doppler, A = Absent

Color: C= Cyanotic,
Capillary Refill: B = Brisk, S= S uggish P = Pale, Pk =Pink

C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C
Fund. Height
Lochia

Peripad#
Fund. Cond.

DRESSINGS
Location Type . Drainage

Time
Adm
30'
60'
DIC

PACU OUTPUT

Time Source Color/Appearance Amount . Discharge Criteria: Date: 0 i'S1,4 c5iTime: 2:2310 PARS: ID BP: (143/14T: e1 0 HR: q) RR: I 1?) Sa02: (ODPain Level it DIC (0-10): u Intake: 0 Output: Additional Data: J6
CARDIAC RHYTHM

Transferred To: -IC 0 61­
Time Rhythm Symptomatic? Rhythm Strip Run? Report Given To: Transferred Via: W/C =Gurney A bulance Transferred By: ,(61-+
%

Cleared IAW Recovery Charge Nurse Signatu
WAMC OP 173-E

MEDCOM - 13853
DOD-027405

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DA I A 14- \(\"131 For use of this form, see AR 4066; the proponent agency is the Office of The Surgeon General.
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: Vit24- 'f"t Anesthesia Type (Circle)): r412M- pinal Epidural
Time In: IV Se. ation Nerve Block
Allergies: MC_OR Intake: Crystalloid ((TO Colloid
.

Pre-op V/S:_ , OR Output UOP EBL 0+ V.LD"":)---Procedures: IA IS • u•-I r Meds/Times: IF-04-4,---7 l "if)ri 4., r i
-' -c .9 r¦ • y ry.-cid-rfryi.-...., i p,e_,,,e ar,._ /
Pre Op Meds History,
OTS& APPROVED IDalel
Drains Airway
Hemovac Nasal NG Oral JP EU T-tube Trach Foley
Other TLS
'§
Time 1,
1.-r.„
Sa02
w 'In

4 Milli
,1,-

Pacu Intake -.-t Time Solution Amount Site By
fb N
Infused

Fi02 4II 011-41 °A _ Methods ti) 211.
240

220 X-rays: . Labs:
Post-Anesthesia Recovery score
•

200 Criteria ADM 30' D/C Codes Activity
AIRWAY

(2) Moves 4 Extremities A = Ambu
(1) Moves 2 Extremities
180

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

160 FT = Face
(2)
Cough, Deep breath

Tent

(1)
Dyspnea. Milted breathing )-'

RA = RoomAir 140
(0) Apnea
NC = Nasal

Blood Pressure
• Cannula

(
21)) si3p20,oof rz.op
SBP :if-
205f0Pre-o120 )---
A
V/S

A X = A-line BP Consciousness
(0) SBP =/- SO of Pre-op
100 A ' = Cuff BP
(2) Fully Awake, audible
•:i = Pulse
crYlog

(1) Arousable to verbal or pain
i . a
80

TEMP Color
4 \iv S = Skin
(2) Baseline color & appearance
0 = Oral

60 V (1) pale. mottled, jaundiced
A = Axilla
Axillary

(0) Cyanotic
T = Tympanic Circulation (Peds 5 Years)
40 R = Rectal
(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial

()---- LOS

(0)
Carotid only reliable pulse

20

C = Cervical TOTALS: Must be 9 or
T = Thoracic greater to D/C. otherwise
u L = L mbar

RR p_. viAC 10 14 0 needs anesthesia approval for 1
S = Sacral
D/C.

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

01 7 117110 017 rev

DEPARTMENT SERVICE/CLINIC DATE
PAT give: Name —last hist, middle; Fa m date: hasp
.
HISTORY/PHYSICAL . FLOW CHART

.
OTHER EXAMINATION . OTHER ap.ar/ OR EVALUATION

.
DIAGNOSTIC STUDIES

.
TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) I Apr 01 (MCXC-DN) Previous edition is obsolete
USAPPC 02.00
. _

r .04Q.D MEDCOM -13854
DOD-027406
MEDICATIONS

NURSING NOTES
Allergies: Time Pain Medication & Route Pain I/E By
1-10 ;Insane 1-10 PIGovt2,-Le cl / a_ Gc-60--cr-WArzi,,,,( 4
NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion Adm 15' 30' 45' 60' 90' D/C
Movement/Sensation: + = present,- = absent Temp:C =Cool, W =Warm Pulses: P= Palpable, D =Doppler, A= Absent Color: C = Cyanotic, Capillary Refill: B= Brisk, S=S uggish P= Pale, Pk =Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C

Fund. Height Lochia Peripad#
Fund. Cond.
DRESSINGS Location Type Drainage

Time Adm 30' 60' D/C
PACU OUTPUT Time Source Color/Appearance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?

WAMC OP 173-E
o? 51-7/)( 7
/71

p
7a, e-4_,AA,K (3/\ X LE "7".+kfar,_ cl cee- a-e-e f\„0, c_
c. Cz4/10-a-e-+ LuvIce
CitA .rl50(/
/z)

Discharge Criteria:
Date: 4/4-PPP

teio 3 Time: PARS: 10 BP: 101/4 t T: HR: S'.) RR: t Sa02: 91,, Pain Level at INC 10-10): Intake: Output: Additional Data: Transferred To: c_t.A..) Report Given To: LP -' Transferred Via: W/C 1 er urneyi Ambulance Transferred By: • Cleared IAW Recovery R Charge Nurse Signature
MEDCOM - 13855
DOD-027407

MTF LOCATION

1. REPORTING MTF 2. ADMISSION AND CODING INFORMATION
(Stare or

li

1 2 3 4 5 6 7 8A

Country For use of this form, see AR 4.0-400: the proponent agency is OTSG ii c) k j......... -a. Code.)
4. PAY GRADE 5.ASEX

NAME (Last, First, Middle Initial)
3. REGISTER NUMBER
16 17 18 9 10 11 12 13 14 15

7.+AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION6. DATE OF BIRTH (YYYYMMDD)
19 . 20 21 22 23 24 25 26 27 28 29 30 31 BACK­GROUND

-?.. IA
12. SOCIAL SECURITY NUMBER
11. EMP10. LENGTH OF SERVICE ETS

37 38 39 40 41 42 43A44A4535 3632 33 34

NI/ri Q ot 4")-fi5 izr 0 0 .0-
13. MARITAL STATUS HOUR OF BRANCH 1 CORPS
ORGANIZATION 'Active Duty Only) ADMISSION
46

AMA is ir•X.
\zi-7"›.0
kh
16. ZIP CODE OF RESIDENCE
FLYING STATUS 16. BENEFICIARY CATEGORY14.

53 54 55 56 57 58 59 60 61 47 48 49 50 51 52
k 1-?_.
2
19. TRAUMA PREY. ADMISSION
17. UNIT LOCATION (State or 18. MOS
Country Code)

YEAR

68 69 70 71
62 63 64 65 66 67
NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
SOURCE OF ADMISSION) AUTHORITY FOR WARD

20. _...
ADMISSION

72

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
16 IA 1 TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
CATION OF MEDICAL TREATMENT FACIL TY _...
22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (V Y MMD 0)
21. TYPE OF DISPOSITION
82 83 84 85 86

75 76 77 78 79 80 81
73 74
0 3 ON g &
5 0
26. DATE THIS ADMISSION (YYMMDD)25. MTF TRANSFERRED FROM
24. CLINIC SVC • ADMITTING

91 92 93 94 95 96 97 98 99 100 101 10287 88 89 90
A Pc Pc rx --z-, m ,e5 .5-
29. DATE INITIAL ADMISSION fY YMMDDI28. MTF OF INITIAL ADMISSION27. LOCATION OF OCCURRENCE

(Bartle Casualty Only)

107 108 109 110 111 112 113 114 115 116105 106
103 104
FOR LOCAL USE
1)/,,, GkSi,..Cs o C-e.,vu_,r V-,
-..

N.PAcc,

..
DI I I.Sloo II ..

SIGNATURE OF ADMITTING CLERK
ADMITTI floe, as required)

1111111111111111111111.11111- ,

USAPPCV1.0

DA FORM 2985, MAR 89 MEDCOM - 13856
DOD-027408

1.+REPORTING MTF 2.+MTF LOCATION ADMISSION AND CODING INFORMATION .
1 2 3 4 5 A 3.+REGISTER NUMBER 9 10 11 12+13 6 14 7 15 For use of this form, see AR 40-400; the proponent agency is OTSG 8 (State or Country Code.) NAME (Last, First, Middle Initial) INA\C)49'.1-°\ 4.+PAY GRADE 5.+SEX 16 17 18

ADMISSION
24 25 2 27 28 29
21 23

19 20 22
ETS 11.+FMP10.+LENGTH OF SERVICE

35 3632 33 34

13.+MARITAL STATUS

ORGANIZATION (Active Duty Only)
46

15.+BENEFICIARY CATEGORY14.+FLYING STATUS

50 51 52

47 48 49
17. UNIT LOCATION (State or 18.+MOS Country Code)
69 7062 63

WARD20. SOURCE OF ADMISSION/ AUTHORITY FOR

ADMISSION
72

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
22.+MTF TRANSFERRED TO21.+TYPE OF DISPOSITION

75 76 77 78 7973 74

25.+MTF TRANSFERRED FROM24. CLINIC SVC -ADMITTING

91 92 93 94 95

87 88 89 90
28.AMTF OF INITIAL ADMISSIONLOCATION OF OCCURRENCE

27.A
(Battle Casualty Only)
105 106 107 108 109103 104

FOR LOCAL USEA
-- --------'' /Ar /1-eAA
_i___ 4-SO 7g45+
eqid,.va (5 ci

A:kJ

ADMITTING OFFICER
—(Signature_a_ required)_ _...
8.+RACE 9.AETHNIC RELIGION
30 31 BACK­GROUND

12.+SOCIAL SECURITY NUMBER •
37 38 39 40 41 42 43 44 45
HOUR OF BRANCH I CORPS ADMISSION
16.AZIP CODE OF RESIDENCE
56 57 58 59 60 61
53 54 55
PREY ADMISSION

19.ATRAUMA
YEAR

71
NO+.

NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE +.
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
23.+DATE OF DISPOSITION (YYMMDD)
—

80 81 82 . 83A. 85— 66
26.+DATE THIS ADMISSION (YYMMDD)
97 98 99 106 101 10296

29.ADATE INITIAL ADMISSION (YYMMDD)
110 111 112 113 114 115 116

SIGNATURE OF ADMITTING CLERK
......— ... „..

EDITION OF MAY 79 IS OB
DA FORM 2985, MAR 89
MEDCOM - 13857
DOD-027409
f

INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
I. 2.ANAME (Last, First, MI) 3.AGRADE ADMISSION REMARKS
h.1,/Aiz

. ---A• .-7.ARELIGION .AGTH OF SVC 9.AETS 10.APREVIOUS
ADMISSION

0/\. 567 ., (A/Ktk-C\YAC /WA Qt)
11.AFMP 12.ASSN 13.AORGANIZATION 14.AWARD
Clai OM-/C(A
15.AFLYING 16. .A. 18.ABRANCH/CORPS 19.AUIC/ZIP 20.ATYPE CASE STATUS DSG BEN
1\)//0c if.-11 14/A 1:4 4
21.ASOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22.AHOURS OF 23.ACLINIC SERVICE ADMISSION
----C.Ac e AA--C-CrYIN-+4:-=. e
s21? ??)' A Qt A
24.ANAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25.ATYPE DISPOSI ON 26.ADAAOF DISPOSITION
17a.AADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b.ATELEPHONE NO. 28.ADA1 e t..rcJHIS ADMITTING OFFICER ADMISSION
\il°
D

29.ANAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30.ALis 32.AUNITS
ADMISSION COMPONENT TRANSFUSED

31.ASELECTED ADMINIS
Check it Continued on Reverse

33. CAUSE OF INJURY
1 .e
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
85 I D

35. Total Days This Facility
a.AABSENTAAYS b.AOTHER DAYS c.ACONY. LV/COOP d.ASUPPLEMENTAL e.+BED DAYS f.ATOTAL SICK DAYS
CARE DAYS CARE DAYS

36. 'ate! Days All Facilites
a.AABSENT SICK DAYS b.AOTHER DAYS c.ACONY. LV/COOP d.ASUPPLEMENTAL a.ABED DAYS f.+TOTAL SICK DAYS
CARE D YS CARE DAYS

/

SIGNATURE OF AA FICER SIGNATORA AL RECORDS OFFICER
FORM 3647, -\ / USAPPC V1.10
3647, -MAY 79-OF 1 AUG 76 IS OBS
')•••A

MEDCOM - 13858+'\13+)"'"
DOD-027410

MEDICAL I ABBREVIATED MEDICAL RECORD PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)
#+ 5„2„;+ 71; _sz_s2s 7L 4e4e-1 c_e)-5cLi 4-11 11-?-S;' .2 -
PHYSICAL EXAMINATION G. v o )I ,4-9-r) 3 —,4,A--ece,7ts; 12: P C y c)
1"-/ /6' FL-t.e4.(15 str. #1^-e--e (-7Z f..)A 1/7 +j ?/ 1 1.0 71. /1z ?
PROGRESS
(Enter date of discharge and final diagnosis) e—Ase 6.) 0 i f+G y+ :„.„ -77"F

\C -11
DATE

IDENTIFICATION NO.
ORGANIZATION

e:ruy o

SIG0"1111..
PATI NTS IDENTIFICATIONA(For typed or written entries give Name last, first,
REGISTER NO.

middle; grade; date; hospitalor medical facility) WARD NO.
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR MI CFR) 201-45.505 OCTOBER 1975 USAPPC VI.00

MEDCOM - 13859
DOD-027411
NSN 7540-00-634-4176
AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
g , i e_ I v b_; c. f . 0 . -yi,c_a41, 624,74;,aza __.1,,,,, Ex 7

(--w-r-A-4._,
.D (,20 t.e'.PLe --ee-Aik—cue_e_../24_6_..tAv_e_4_,..Kez. 1/ ea, ..z...,:a4t..E-,+-41.4,,24,„A4.t go-
_if j

+te__,A„ce,„,+te+„,, zezt..+ek_ o ,„,, e,e,
, +zo-„,-A/„.._e_f_..4zeiz ,z,,
+--iI.e +z4-6, -e . pf ' 'Litz ,,,,,,,,,..7 At+te,,,,,,e
u_57-4- 4,...z,L. ",..., a 7+,
L.:5-x.+

• ,z5-1) -)7 /9 . 0 • 0 / 0 4 i ,54,—,._( 7 7 10 . 4 , 171, pel..-,-- . P A, 4-e--.7 Oz-e-4.---4.4. 4,Y -,4 4...ae-ea.....ez-, ,Z,_eic, 0e, g 6 Fr-P2s . 47e/. ,D
1_..Leze_ie . U5 . 7-9 7. 8 _ 53_ / 2 - 76,6 e, aec-"-e- .te-e4, 44 a+-...-+
Z,.. ,ei WO
kg.' /'W
13 20 xf_ed,t,i' (c._e,,te ".,- ti.., yle,„:" _ c (

c, ( bJ /60/5-2 ,tM )tee Ga..,,,--eAe

. Lzt4i,r,„4,,: de,,e_ede, . i°71 attr_e.,..c/_-E. ti,Z,1(..1_e_ .,7,-- /-1/70 .
ee4-&--,--4; Ac, 7f-(-0,7;0Z-. d,--7o_.. 17: -. i,_Vo -_____I IMO),,cto ( _ _`fhat-(21,.
3 - /Si- /2 1 /Lea' 9c1;44 --,e46-/A. = -1Ze-reA•t-0, lb 6-71
,

/4v--,7,,,,,,,e,e 7 ex.2 /tea"- ,+.+)„6.•:-+
t.i

_ \o Lc. - :I_ rini' t ,
cc5 (A.K71(b

• a -_

„mol! •• a 0 ,A_14 UillA_I I I_04 AA.
6 , JVA_....,g_i lb i OA Ili •
V ,
I.+

1 I+i ,e1
-A _AP-2 • A ar. _ ._
O IL .4_-_a ._,A Als • .., 1-1K-la AA
0

All LA '1 . •_AL DAL Ilia • • . A..4111I11.A.C. .A Ai 11.-I MI •_at f o. A
6 _A IAl A A. AL A CA '

HOSPITAL OR MEDICAL F • LITY I -
STATUS DEPART./SERVICE RECO" D M •
SPONSOR'S NAME SSN/ID NO.
RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle; ID No or SSIV• Sex; REGISTER NO.
WARD NO.
Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97)Prescribed by GSA/ICMR FIRMA 141 CFR) 201-9.202-1

MEDCOM - 13860
DOD-027412

y . •_.•_a_•_1 •+• v+
1+•+•+• -+
• 1 i 1 ign eac entry

c?—ep4L(1:1:: 7)-4--kr, 1) -tlel qicc—itej , 2-0 CY3-0/".o d p+matin eynd+paco d
(l

e8 jALabturgaikke. Cap. _pl. i* V Ksee­

__677).

1 e .+l.+. t--„,k.A t. A,...A , A A+016_ 4,!+. ,..+1_4014+4 ' ...% .4./_.../ 0. +

1
j2-c1 ) P1- za_,-livp.141 vt'ib 624., Z. _. / a ' '-/

e i. ›kva.:(-17
(1) /.../ of I . 1 AILI.,e_._ _ • Q
77)

II/ 20 JAa4/1,e4 19_.1--4 F.‘191/0 coviAtc) ut a, , fAkTi3,-L, . /(7)
+

STANDARD FORM 600 (REV. 6-97) SACK

FPI. LEX.+Printed-on Recycled Paper

MEDCOM - 13861
DOD-027413
NEN 7540-00434417e
AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
/4-
I)

Cl"? /-44
r

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE
RECORDS MAINTAINED AT

SPONSOR'S NAME SSN/ID NO.
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - fast, first, middle; ID No or SSN; Sex; REGISTER NO.Date of Birth; Rank/Grade)
WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-97)
Prescribed by GSAACMR FIRMA (41 CFR) 201-9.202-1

MEDCOM - 13862
DOD-027414
LOG NUMBER TREATMENT FACILITY
EMERGENCY CARE

MEDICAL RECORD AND TREATMENT E-)1,1 7—
(Patient) RECORDS MAINTAINED AT
PATIENT'S HOME ADDRESS OR DUTY STATION

ARRIVAL
STREET ADDRESS

DATE (Day, Month, Year) TIME

/ e)g-all ( 1 Y 7
+,,, y 07
CITY 03,,2 .-,
STATE ZIP CODE TRANSPORTATION TO FACILITY
SEX DUTY/LOCAL PHONE MILITARY STATUS
THIRD PARTY INSURANCE
iV1 AREA CODE NUMBER ITEM NO

YES N/A ITEM
YES NO PRP
ADDITIONAL INSURANCE
AGE HOME PHONE FLYING STATUS

DD 2568 IN CHART

5
-
AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
,,,e5......,J,C
CURRENT MED ATIONS
INJURY OR OCCUPATIONAL ILLNESS
EMERGENCY ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO n YES n NO
IS THIS AN INJURY?

WHERE
TETANUS
ALLERGIES INJURY/SAFETY FORMS

DATE LAST SHOT

COMPLETED INTITIAL SERIES HOW
/A O 0 L (A) . YES • NO
CATEGORY OF TREATMEN

VITAL SIGNS TIME TIME
EMERGENT
3 BP
PULSE

URGENT
RESP

--•-

TEMP
NON-URGENT

WT•

XCBC/DIFF ABG PT/PTT BHCG/URINE BLOOD/QUANT
CXR PA & LAT/PORTABLE C-SPINE URINE C&S UA MSCC/CATH CHEM: /a/c.kver
›- cc ACUTE ABDOMEN LS SPINE
BLOOD C&S X

lc-5;e_ CC IM SINUS
HEAD CT X0m ANKLE R/L A
17
y

ORDERS
PU LSE OX ri MONITOR

ECG
TIME ORDERS

COMPLETED BY I TIME
PATIENT'S RESPONSE

polo
e9014.)
+

DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
n HOME n FULL DUTY n 24 HRS. n 48 HRS. n 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN
REFERRED 11110.
IMPROVED . UNCHANGED

. D TERIORATED TIME OF RELEASE I have received and understand these instruction s.
PATIENT'S SIGNATURE

PATIEN T'S IDENTIFICATION (For typed or written entries, give: Name -- last,
first, middle; ID no. ISSN or other); hospital or

EMERGENCY CARE AND TREATMENT (Patient)

C,) v
Medical Record
STANDARD FORM 558 (REV. 9-961
Prescribed by GSA/ICMR
FPMR (41 CFR) 1 01-11.203(b1(10)
USAPA V1.00

MEDCOM - 13863
DOD-027415

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor) NSN 7540-01-075-3786 TIME SEEN BY PROVIDER
WBC 7d (0 H/H 74/0 PLT to 3 3 z ABG/PULSE OX P02PH OTHERSAT If 2o 1 _PI SUP 02 PCO2 TEST RESULTS RADIOLOGY RESULTS -v47 Check if read by radiologist _ .
PT DIP EKG INTERPRETATION
APTT BHCG ETOH GW MICRO
PROVIDER HISTORY/PHYSICAL

3C-7
5A0

CONSULT WITH TIME ACTION RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP
PROVIDER SIGNATURE AND STAMP
DIAGNOSIS
afze-Y-1-c-°
0
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last, first, middle; ID no. (SSN or other); hospital or medical facility?
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR
FPMR 141 CFR) 101-11.203(b1110)
USAPA V1.00
MEDCOM - 13864
DOD-027416

PATIENT ASSE'qMENT
¦TIENT ASSESSMENT

TIME: SIGNATURE:
.7 r\ III IA Nu muuous ME • •
BRANES

SkinASKIN AND MUCOUS MEMBRANES
Loose / Tight / Diaphoretic / Shiny A
Dr
Skin :A
Loose / Tight / Diaphoretic / Shiny / Dry Skin :ATemperature

SkinATemperatureAw2..-4-0---
Color.APale / Cyanotic / JaundicedAkit-Color:APale / Cyanotic / JaundicedMucous Membranes:(Prao / Dry / Cracked
Skin Breakdown:o-,riA
Location:A
Size:
NEUROLOGICAL

Loc_/AlerALethargic / UnresponsiveAGCS: (-Drierse-red / DisorientedA
Pupils: g ow 4 Extremity Movement:A

FA/ Limited / NoneA.
CARDIOVASCULAR

Pulse ( 0 - 4):ARadialsA+A-- - .A
Pedals (...0A
.

Capillary Relill:/..3ASecondsA
Homan's S gr16--) Jugular Venous DistensionA(-__)

Edema ---)
Heart SoundsA1 5 2,

Rhythm 56 a, 4(5 61914+
PRI: AQRS:

Vascular CatheterA
Central-9-Arteria) A
Peri•heraf--. Perinheral 2

Waveforms
••:-:.:•:..:::;'::':'..
Site
Solution
Chest PainA-.6.--A
RESPIRATORY
----7-._.

Chest Expansion / tnr......i
netricax.7 Asymmetrical Respiration i4goke kurit Breathing Patterns: Atr...4.4,_i-ne-ft
. Cough -A
Productive / Nonproductive / t or Sputum: Color / Amount / Consistency / Odor Agi--Chest Drainage System Gravity:A
-,C)._ASuction cm: Air LeakA.,--No —AYesA
----CrepitusA-
Posterior/Location

Character of Drainage: A -A ._
Trachea / f(i_tioe:iDeviated (R) / Deviated (L)
Artificial AirwayASize:AType:A. Position:
Breath Sounds • Anterior/Location

Crackles 6--(11.-A.
Wheezes Diminished Absent

GASTROINTESTINAL

Abdomen:AoftAFirm/ Hard / DistendedA
cm Girth Bowel Sounds: Car-frre/ Hyperactive / Hypoactive / Absent Dressings:AsC2 .
146-T-1,14e
t-io-piCapi4,-8-ti-etiorrtD16-5-e­
ndent Drainage

N-G-D-a.i.riaqe:ACol
Character -Tube Feeding:ADay.44e•--AStrength:ARate:AAspirate:
.-S4e.s..k-G4-1.al-a-crerr
.._A.
..
GENITOURINARY ._

UrineAColor:A
Character: Voiding.AContinent /AIncontinent / ACatheter

EMOTIONAL/PSYCHOSOCIAL-

tat4.4_
t epe.A__62.4....­
&
f-c.--3
.

OTHER
,
Mucous Membranes: Moist / Dry / Cracked
Skin Breakdown:ANoneA
Location:A
Size:
NEUROLOGICAL
Loc /Alert / Lethargic / Unresponsive A
GCS: Orientated / Disoriented A
Pupils: Extremity Movement:AFull / Limited /A
one
CARDIQVASCULAR
Pulse ( 0 - 4): ARadialsA
Pedals Capillary Refill: ASecondsA
Homan's Sign Jugular Venous DistensionA
Edema Heart Sounds Rhythm A
PRI:AORS: Vascular CatheterA
CentralAArterial .+Peri•herat 1 Penpher Waveforms Site Solution Chest Pain
RESPIRATORY
Chest Expansion / Symmetrical •Asymmetrical Respiration / No Distress / SOB / Labpred
I Use of Access Muscles Breathing Patterns:
Cough: Productive / Nonproductive / None Sputum: Color / Amount / Consistency / Odor Chest Drainage System Gravity: A
Suction cm
Air LeakANo YesA

Crepitus Character of Drainage: Trachea / Midline / Deviated (R) I Deviated (L) Artificial AirwayASize: Type:A
Position:
Breath Sounds 'Anterior/Location .+.a, Potterior/Locati, Crackles . Wheezes
.A
•
Diminished Absent
‘A.;
GASTROINTESTINAL'
Abdomen: Soft / Firm / Hard / DistendedA
cm firth -. Bowel Sounds: Normal / Hyperactive /A
Hypoactive / Absent Dressings:
NG Tube: Clamped/Inter. Suction/Cont. Suction/Dependent Drama
NG Drainage: ColorA Character
Tube Feeding: Day No:AStrength:ARate:AAspirate

AStodl: Character Drains:
GENITOURINARY
Urine Color:
Character: Voiding:AContinent /AIncontinent /ACatheter
EMOTIONAL/PSYCHOSOCIAL
OTHER:

MEDCOM - 13865
DOD-027417

.I¦
"2 CO 7C1 i —4 co
gMXIM-o
11
C KJ
-i -a
2 1,
0 ..k" 0
!OUTPUT

I.URINE
I
.NGT
I STOOL
TOTAL
iii
,

. . .
ITOTAL.

limo.

I06 I07
2

III

I 08109 I10 I112 1 13-1-714-Jis 116 17 M 119J 201 211­
2r177117 I 01J 02 l 03 1 04
1/sal
El

.. 1 2
. _.
.
.

..
. _
b

MEDCOM -13866
DOD-027418

\ipo -LA
PATIENT ASSESSIAA9\ITaW
PP ---NIT ASSESSMENT

TIME: • 6;1-

, ,+/-',""
SKIN AND MUCOUS MRRMEIIIIIF

,Skin ..pose.
Tight / Diaphoretic / Shiny.r Skin :.Temperature.LA)-0-_yri Color.Pale / Cyanotic / Jaundiced .
1/1..)10(.._14)i— ra oz..
Mucous Membranes:.• ois.•.ry 1 Cracked

Skin Breakdown:Q)one) Location: ------,. .Size: "."---
NEUROLOGICAL

Loc / dis Lethargic / Unresponsive .
GCS: .-----Orieniated)Disoriented.Pupils:
Extremity Movement:CriOLimited / None
li.

CARDIOVASCULAR
Pulse ( 0 - 4):.Q 1--.Radials.(Di-.

--- -.Pedals Capillary Refill:. -,.?.,.Seconds.
Homan's B(gn CZ)
Jugular Venous Distension.— .Edema)
heart Sounds.Fla

Sr -
Rhythm 6,Ft, PRI:.

------.QRS:'----• Vascular Catheter Central Arterial Peripheral 1
Peripheral 2
---_____ -`

Waveforms M!;;;i:;:::"-:!:!
W' ,:•-:::!:,::;!::."•:•!::":.;.,-:,.!']'!':". Site .......„
''''\ ( .t.(fisi---:
Solution

H. L

Chest Pain.
r
RESPIRATORY

Chest Expansion I ‘y-mmetric-:ThAsymmetrical
Respiration /(•:io DistresSy SOB / Labored / Use of Access Muscles
Breathing Patterns: .1:2R
Cough:.Productive / Nonproductive // (11-5-R-i)
Sputum: Color / Amount / Consistency / Odor .Km
Chest Drainage System Gravity: .----------.Suction cm :.--------..
'Character of DraiaagaLl
Trachea.idlinD Deviated (R) / Deviated (L)
,, .•.•.•

Breath Sounds : Anterior/Location
Cr ackles Wheezes Diminished Absent
Abdomen ­
Posterior/Location

Imre
die Ter
i
.GASTROINTESTINAL
)11.1)Firm / Hard / Distended.
cm Girth

Bowel Sounds: Normal / Hyperactive.¦
H poactivellAbsent

Dressings:.(75
.;.-;":::..•.:.• 1.• a.

•.• •.P.'.• , :

-44G-C4r-a+fitte-e-oirrt
Chdrdctel , .
-.: -:.-.T ..7.
.•
•

Stool: Character 0 ey-tecis -Fifyt_Q_
Drains..?).

--- _
._
GENITOURINARY

Wine.Color:.
Character:
Vowing.CoTrunent ) incontinent / .Catheter

EMOTIONAL/PSYCHOSOCIAL•

OTHER:
I IME: SIGNATURE:
SKIN AND MUCOUS MEMBRANES

Skin :.
Loose / Tight / Diaphoretic I Shiny / Dry Skin :.Temperature
Color: Pale / Cyanotic / Jaundiced Mucous Membranes: Moist / Dry / Cracked Skin Breakdown:.None.Location:. Size:
NEUROLOGICAL

Loc /Alert / Lethargic / Unresponsive .
GCS: Orientated/Disoriented.Pupils:
Extremity Movement:.Full / Limited / None
CARDIOVASCULAR

Pulse ( 0 -4):.Radials. Pedals
Capillary Refill:.Seconds.
Homan's Sign Jugular Venous Distension.Edema Heart Sounds
Rhythm. -.
PRI:.ORS Vascular Catheter.Central.Arterial
Peri.heral 1 Periphera! Waveforms
Site
Solution Chest Paln
RESPIRATORY

Chest Expansion / Symmetrical t Asymmetrical Respiration / No Distress / SOBL_•abored / Use of Access Muscles Breathing Ppttems•
Cough•_Productive / Nougioductive / &De Sputum: Color / Amount / Consistency / Odor Chest Drainage System Gravity:. Suction cm:
Air Leak.No.Yes.
Crepitus Character of Drainage: Trachea / Midline / Deviated al" Deviated (L) Artificial Airway.Size:.Type:.
Position: Breath Sounds -Anterior/Location'..r. ,.Posterior/Location Crackles
Wheezes
Diminished
...

Absent
GASTROINTESTINAL"

Abdomen: Soft / Firm / Hard / Distended .
cm firth
Bowel Sounds: Normal / Hyperactive / Hypoactive / Absent
Dressings:

NG Tube: Clamped/Inter. Suction/Cont. Suction/Dependent Drainage NG Drainage: Color Character Tube Feeding:.Day No:.Strength:.Rate:.Aspirate Stool: Character Drains:
GENITOURINARY

Urine.Color.
Character:
Voiding:.

Continent /.Incontinent /.Catheter
EMOTIONAL/PSYCHOSOCIAL

n-rupa•
MEDCOM - 13867
DOD-027419