Medical Report: 35-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wound

617914 - 1A100031/11

DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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STANDARD FORM 600 (REV. 6-97) BACK
FPI. LEX.GPrinted on Recycled Paper
PAt A c_ov, ,111

DOD-028030
NSN 7540-00-834-4178
HEALTH RECORD DATE CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION (Sbn each entry) 600-108

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PATIENT'S IDENTIFICATION
(Use this space for Mechanical
RECORDS
MAINTAINED
AT:

PATIENTS NAME (Last, First, Middle initial)
SEX
RELATIONSHIP TO SPONSOR
'STATUS RANK/GRADE

SPONSOR'S NAME 'ORGANIZATION
DEPART./SERVICE SSN/IDENTIFICATION NO. DATE OF BIRTH
CHRONOLOGICAL RECORD OF MEDICAL CARE
STANDARD FORM 600 (REV. 5-434) Prescribed by GSA and ICMR
MEDCOM - 14642

FIRMA (41 CFR) 201-45.505
DOD-028031
EV9171. - W001331/11

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
C o -

'U.S. Government Printing Office: 1996 - 404.763/40001 STAND RD FORM 600 BACK (REV. 5-84)
DOD-028032
558-103
(See Instructions on Back of this Sheet) NY:4
2L

NSN 7540-01-075-378E (Medical Record) LOG NUMBER
EMERGENCY CARE AND TFIRTMENT TREATMENT
ARRIVAL

TRANSPORTATION TO HOSPIT
I TIME (Attach care enroute sheet) ENT MEDS. (tetanus immun-
DATE ization and other data) HISTORY OBTAIN D FROM
DAY 1 MONTH I YR. (q1S-ri PRIVATE 0PATI ENT DOTHER (Specify)

1-1 A

L_J VEHICLE 1AMBULANCE
ALLERGIES
PATIENT'S HOME ADDRESS OR DUTY STATION

'4 I 01-03 ElOTHER (Specify)
(C:

d ZIP Code) HOME TELE. NO. (Inc. area co e
d--CHIEF COMPLAINT(S) (CV
(Include symptom(s), dura
SEF.i
A E POS IBL H RD P R Y

VITAL SIGNS El YES
DESCRIBE (1) &objective data (Pertinent History); NO
TIME bjective data
(Examination - include results of tests and
TIME SEEN BY PROVIDER
1-14 A-sis); (4) Plan x-rays); (3) Assessment (Diagno-
BP (Treatment/Procedures • inclu e medication given and ollow-up
I

5 p CiS1"(
PULSE
-

RESP. VS&. c70't .C.-0)11-Y6 (A13112(1,49 1-0(e9t tbd 51)
TEMP. TO a I /
r2.-•
Sljt
klur Li" h4+. r

CATEGORY (See reverse) Jr. *I
EMERGENT

-t-(610

ENT '%te-ainv. -
,1\ALA A rvi..1 rvka I

NON-URGENT each-, .
GAAI ov-tv-kg4 ItAtk
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r“,41.N, aco,,S,J kJ-n.)4.1/.41/ do "40,3),
ASSESSMENT/DIAGNOSIS
-
-

I(--1( - Oa* jcALA C(L
?a alky 144- aa.4
DISPOSITION (Check all that apply)
HOME ­
— to/PT10,1.4
I FULL DUTY
QUARTERS

24 Hrs. I 148 Hrs.
1172 Hrs. L -6
MODIFIED DUTY UNTIL: Is_et

DAY
I MONTH YEAR
Q) CZ
e rrvi.",1 eiv-171--pc t

REFERRED TO (Indicate clinic) ‘tri
Q.) artif

e ,P1(

EMERGENCY I I TODAY I requi,., r
-1 kr::perj

72 HOURS "44 1
ROUTINE
_ I

ADMIT. TO HOSP. UNIT/SERVICE `(Le
Lot. Mu @ 1.700
OHL

CONDITION UPON RELEASE La4i,
-PA‹kuin. .

J
IMPROVED

I UNCHANGED

DETERIORATED
TIME OF RELEASE:
PATIENT'S IDENTIFICATION_Ofechanical (CONTINUE ON SF 507, IF NEEDS

FOR WRITTEN ENTRIES GIVE: imprint) OF PROVIDER AND IDS AMP
Name - last, first, middle; IDSSSN: DOB, service status, name and relation of sponsor or nes
of kin.
(IMPORTANT: LIST FACILITY HOLDING TREAT.
MENT RECORD). ,) p me

T (Include

ications o ered, any limitations and follow-up . Flf
N(G¦

filliatc9()\-1 =Mr
EMERGENCY CARE AND TREATMENT STANDARD FORM 558 (Rev. 6-82)
MEDCOM - 14644

)yr Prescribed by GSA and ICMR FIRMR (41 CFR1 28.1-a.c cric
DOD-028033
9179t91 - IA100C13lAl

INSTRUVIONS FOR COMPLETION OF
THE EMERGENCY CARE AND TREATMENT FORM

NOTE: This form will he used to record all care rendered to patients in the Emergency Ro ,.-4-^ and will be used in lieu of all locally prepared emergency room forms. This form ;s not a substi­tute for line of duty, accident/injury or third party liability forms, but it may be used as a basis for completing those forms.
1.
Complete form for each patient entered on Emergency Room Log.

2.
Complete all parts of form.

3.
Enter patient's' log number from Emergency Room Log.

4.
Check appropriate condition in "category" block based on following definitions: Emergent—A condition which requires immediate medical attention and for which delay is harm­ful to the patient; such a disorder is acute and potentially threatens life or function. Urgent—A condition which requires medical attention within a few hours or danger can ensue; such a disorder is acute but not necessarily severe. Non-Urgent—A condition which does not require the immediate resources of an emergency medi­cal services system; such a disorder is minor or non-acute.

5.
Use SF 522, Request for Administration of Anesthesia and for Performance of Operations and Other Procedures, to obtain authorization for any necessary procedures.

6.
Orders: Provider enters orders: i.e., CBC, UA, etc. The person completing the action enters the time and his/her initials at the time of completion.

7.
Give "Pa -kint's Copy", cor:taining instructions, to patient, sponsor (NOK) or person accompany­ing patiert, except when patient is admitted.

8.
i=ie or;g:-.-ial in patient's treatinert record (i.e., Military Health Record, Outpatient Trotirrant Record or Inpatient Record) as applicable.

.Nd. File ind maintEin treat­ment record in accordance with appropriate directives.
9. Es:abli:3h treatment record for any patient who does not haw a rec: ­
STANDARD FORM 558 BACK (REV. 6-82)
DOD-028034
OPERATIVE/POSTOPEki,GNURSING DOCUMENT

FOR Use of this form. see AR 40-407: the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication)
1. AGE: 3 5--0 NKDA fPCN
0 LATEX E.-. IODINE

0 TAPE FOOD
REACTION:
HEIGHT:

3. PREVIOUS SURGERY
(1Q NO ( YES (type):

WEIGHT:
4. PROPOSED SURGICAL PROCEDURE:

Le.100-cA)G124—
5. ADDITI NAL INFORMATION: (Previous sureical and medical hist ) Skin Condition Tobacco ppd X vrs. Body Piercing A.)/4--Diabetes (Y) ROM
ASAlivlotrin w:72 his (Y
ETON a tkitil.f... Implants .W1--Respiratory Disease Asthma, (Y) (44-Anticoagulants (Y) ($44.
Glasses!Contact (Y) (N) Dentures .
6. PATIENT PROBLEMS AND NEEDS
A. PSY ()SOCIAL Potential for anxiety related to:// 1) Surgical Procedure &
Ope7ing Room Environment / 2) Separation Anxiety
3) Surgical Outcomes

B. AEI TION Potential for respiratory dysfu :ion due to: / I) Positionine
2) Effects of Anesthesia ./ 3) MedicallSmokine History

C. GUNIENT Potential impairment of skin
integrity due to: / I) Intraoperative Immobility / 2) ESU Pad Placement / 3) Positional Aids
4) Prosthesis / 5) Pooling of Prep Solutions
Hypertension (Y Herbal Medicines (Y) MEDS:
7.

7 P T
PATIENT GOALS AND EXPECTED OUTCOMES
o Pt. verbalizes any specific anxiety.

o Pt. Exhibits relaxed body posture.

o Pt. will be able to breathe without

difficulty during immediate intraoperative phase .

o Pt. will not exhibit signs of impairment of skin integrity (e.g., reddened areas).

9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91
Previous editions are obsolete. MEDCOM - 14646
3. OR NURSING INTERVENTIONS c Allow pt. to verbalize freely. c Explain OR environment and answer
questions regarding surgery.
c Offer comfort measures. (e.g.. warm blanket. touch). c Explain all nursing procedures before
they are done. c Remain with pi whenever possible. c Maintain family interface. Parents to stay with pt.
c Offer to elevate head of liner or offer

pillow.
c Observe pt. wink awaiting surgery for
signs of distress.

a Assist anesthesia during incubation
and extubation.

c Utilize pressure preventing devices on OR table and accessories.
o Check for proper positioning and support to maintain good body alignment.

o Pad pressure points.

o Place ESU ground pad on non
compromised skin surface area.

o Keep prep fluids from pooling.

VERIFICATIONS AT HOLDING AREA: ! ID/Allergy Band ! Dentures Removed ! H & P
! Contacts Removed ! NPO Since ! Jewelry Removed ! LIFICG/LNIP ! Body Pierce Removed ! Consent/Blood Transfusion Signed/WitnessediDated ! Surgical Site/Consent verified by
Pt./Anesthesia/Surgeon ! Contact Precautions (Y) (Y) ! Family/Friend:
1:SAP.N V

DOD-028035

6. PATIENT PROBLEMS AND NEEDS ••:
D. 91Rcuuknow: Potential for inadequate tissue perfusjon due to: l) Intraoperative Mobility //2) Positioninn A) Existing Disuse
G4) Safety Devices 5) Hypothermia
E. NEUROMUSCULAR
CONTR

E.1.GPotential impairment of mobility due to: G1) Pain G2) lntraoperative Hazards G3) Prosthesis G4) Positioning G75)/Transfer pt. to/from OR table
E.2. Potential discomfort due to:
1) Length of Surgery
G2) Positioning
G3) Arthritis

F. SP — IAL SENSES
F.1. G5r157thinished visual perception due to being: G1) Pre-Medicated
./7)( W .0 Glasses
F.2.GPotential for decreased
corarnunication due to:
G) Diminished Hearn_

71 1 Language Barrier 7.7.7(tr—Potential injury due to dentures: G1) UoberG4) Cans G2) Lower G5) Crowns
3) Bridees
G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problemsmeeds.
. PATIENT GOALS AND EXPECTED OUTCOMES
o Pt. will exhibit si gns of adequate tissue perfusion (e.g.. color, warmth, pedal pulse.

o Pt. will be transferred to OR table without
difficulty.

o Pt. will not experience unnecessary
physical discomfort.

o N. will be made aware of surroundings
prior to anesthesia induction.
c Pt. will be transferred safely to OR table.
c Pt. will be able to understand instructions.

o Minimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and
outcomes.

•S. OR NURSING INTERVENTIONS
o Check for support stockings or ace wraps. If none, check with doctors.

o Check that safety straps are
correctly applied.

o Offer pillow for under knees.

o Place and take down lees from
stirrups with slow bilateral motion.

o . Check that rines and all body

piercing hag been removed
o Have sufficient people available for tra

o itsfr.
Insure proper body alignment.

o Allow patient to lie in position of comfort while waiting for surgery.

o Offer support (i.e.. pillows. bath
towels. etc.) for positioning.

c Introduce self. Keep pt. informed as to
where he. she is and what is happening.
c Inform pt. in which direction to move
and assist if necessary.
r.. Speak clearly and slowly.

•
Address pt frcrr. G c Validate pr.'s understand:n• of verbal communication.

•
Verify removal of dentures.

OTHER NURSING INTERVENTIONS
Or continuation of above Interventions

10. OR NURSING INTERVENTIONS COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
.

a

Akitc. DATE

11. STOPERATIVE EVALUATION: SKIN Pad Site: _ Clean and Dry ^ Red NiA DGING DRY & INTACT:
G LEVEL OF CONSCIOUSNESS: rVA&O G
Drowsy SI . Intubated (G(N) GBRF,KfHING EASY:
Moves Upper ities

LEVEL OF ACTIVITY:GEi'Moves All Extremit
(N)

. Tra ferredGto liner with roller due to spinal
12. PREOPERA D BY \ 13. POSTOPERATI (Signature and Titl
4-4 BY (Signature and Title /k4a711%)
DATE: i t.4 TIME: t(57G DATE:
/kepo3 TIME: / 75D REVERSE OF FORM 5179, JUN 91 MEDCOM - 14647
USA PA V I

DOD-028036
4,...
-....et:p4,,:1,..• .J 1;444X.: 7 ' , INTRAOPERA

,.......,..-- G, DOCUMENT

or use of

ibis forM, see AR 40-66, the proponent agency Is the office of The Surgeon General.
EME Fkyrgatio'PPERATING ROOM .
2. PATIENT BYGfley.%A9 9171-erly-ND PROCEDUR
,
VERIFIED BY

TIME PATIENT ARRIVED IN
SUITE 4. PATIENT 1
1 7--3—Gt, ( b3 X_C-U0 ---0 R—

-. TIME C.)-7-;-0G

c00-7.-NUMBER
5. PREOPERATIVE EMOTIONAL S ATUS
CALM af
. ANXIOUS

.
EXCITED

.
CRYING

.
ANGRY

. WITHDRAWN El OTHER (Specify)

COMMENTS:ATV/rt.
p0 m
RELIEF SCRUB

ASSIGNED
RELIEF

CIRCULATOR
CIRCULATOR

VA
7. POSITIO ND POSITIONAL AIDS (Specify)
SUPINE
. LITHOTOMY

.
PRONE

.
KRASKE

LATERAL:
. LEFT SIDE UP
0 RIGHT SIDE UP

COMMENTS .W ,„ 711, po_d_cte,(_a_4,1,, .­ `, 0' l3ody -__e _

--t ( y,-,,,

6theYs"-17 0 ertA4 f-t•e/ 42) ez-lt,A mot-9..... . .,, ,,4.,,,l--)-14 a-.-e-,-, -;
--‘40i

8. SKIN PREPARATION

HAIR REMOVAL . YES NO
DONE BY: PREP S TION (Specify)
. OR -Y
. NURSING UNIT
SITE:

METHOD: . BY WHOM:ern--
DEPILATORY
. RAZOR
SITE:
BY WHOM:

COMMENTS:
COMMENTS: "1/2 re.N.2.1

CLIP

9. LOCATION OF EXTERNAL DEVICES
qe

1.
—
rt

f•
) re=e,19
LEGEND X Grokgd
s tyeaf
(C) '7144' 1

k
C = Correct I = Incorrect
10. COUNTS First Closing Final Closing \ (WC) 2
Other • • Count
Count
SCRUB

SpongeGf,Yes . No CIRC
Needle Sharp f Yes . No
Instrument . Yes

Other . Yes 17]GNo
11. PATIENT IDENTIFICATION (For typ d or written entries give:
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;) 12. ELECTROSURGERY DEVICE(S) (ESU) 'YES

. NO
ESU NO: kgrk.1 (..e2-Lt L

.s( TAD ill (.-I
GROUND PAD: BRAND PA LOT NO: +-O

. ESU NO: GROUND PAD: BRAND LOT NO:
. BIPOLAR NO:
r 0 di rz 0
t A.._ - 3 0

DA FORM 5179-1, OCT Err MEDCOM - 14648
REPLACES DA
- • - -. --•..
IS OBSOLETE.
USAPA V1.01 ,

DOD-028037

13. PROSTHESIS, IMPLANTS I'ES • NO -1ER: MANUFACTURER
617914 INOOCIg IN

lt.5(fya,-(-1,1,22 t ‘-
r,r,,,0 1 tt,„,„ /“,„( .1,4.-7_ .okl-gc-2 ,-/ -,,, .„.,.9 P al 24 Z . 33
Sr

z-v,tv-p-oi 4-,0---f itAM.,-,.. .--I
rpt 14‘.:''',',...1n.--- ----- ( 211. 05
Lzt 4040/5-2_ _ k..

,,,,,,,,-„...

14. --ii.,1-=: -...‘1#4140 MEDICATIONS/ORDERS:- x : "-; t_ ' Aryttigigenalagalitk
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO El
MED ICATIONS.SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY
,
5 .
l

WOUND IRRIGATION CES . NO, TYPE(S):
1

OTHER ORDERS TIME CARRIED OUT BY ,.
done,
.
.
.

PHYSICIAN'S SIGNATURE
,. .

15. X-RAY I OPERATING ROOM IF YES, SITE
C—A-em a(//3,11
YES NO .
16. LABORATORY SPECIMENS
SPECIMEN (SI NAME NAME
YES . , . NO
FROZEN SECTION (FS) NAME NAME
YES • NO re./
CULTURE (C) . NAME NAME
YES . NO ----.
NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
Vu. P1141-r f, p ) i t-+
17. TUBES, DRAINS/PACKING YES ¦ NO g
TYPE/SIZE 1. 2. 3. 1C-..-e-v-W. YUCYDrrY)
-l-eoi7

SITE 1. 2. 3.

A-uL_____

19. ADDITIONAL INFORMATION
PL--o
-c Q' .19-)

UTC--
.

C1(01 --L
--.

20. OPERATION(S)'PERFORMED
0 r 3-7-r 0
21. PATIENT TRANSFERRED TO TIME 5-Q2..2— METHOD .,. :..e _ ', .,x, A
eA.,t_.. 1,‘ A

TERED
' , l' -
(,q

DOD-028038
;.v "' -G-G ' VSIA:: : '
.11'81k-4

.INTRAOPERPLG

% GDOCUMENT
-c, •• q..GFor
I' Gthis G
gA:FE Qhs R see AR 40-66, the proponent agency is the office of The Surgeon General.
SOTWIOPERATING ROOM

NIA'0.: 2. PATIENT IDENTIFIED, RECORD REVIEWID AND PROCEDURE BY.tittp,sL i.m q VERIFIED BY
ii TIME PATIENT ARRIVED IN SUITE
4. PATIENT IN ROS,

f434.11-
1(045

TIME 1 6/t 6 (....GA\ ---(,_ NUMBER I -1
5. PREOPERATIVE EMOTIONAL STATUS
. CALMG

21 ANXIOUSG. EXCITEDG.
CRYINGG. ANGRYG

. WITHDRAWNGCOMMENTS: . OTHER (Specify)
nnb19 spezEI-TAAAMFGAr'd n sh Intnta ar)e)

6. NURSING PE .
0SONNEL

ASSIGNED
5Sref
RELIEF SCRUB

SCRUB
ASSIGNED
RELIEF

CIRCULATOR
CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
)X1 SUPINEG. LITHOTOMYG. PRONEG.
KRASKEGLATERAL:G. LEFT SIDE UP

RIGHT SIDE UP COMMENTS:
hire 151) rnb

8. SKIN PREPARATION

HAIR REMOVAL . YESGNO
PREP
LUTION (Specify)

DONE BY: [C] etacun e,
OR . NURSING UNIT /101
SITEG

METHOD: 11)r ea r Y,•,GBY WHO
. DEPILATORY
. RAZOR
SITE- O
BY WHO .

. CLIP ttfpe,r
COMMENTS:
COMMENTS:

69((

9.
LOCATION OF EXTERNAL DEVICES
ob\

LEGEND
trap

= = ourniquet Correct
I = Incorrect
10. COUNTS First Closing Final Closing
Other" Count
Count
SCRUB

Sponge CIRCU
No
Needle SharpGVi6 Yes

. No

Instrument . Yes 121-No
OtherG

. Yes 12] No

11.
PATIENT IDENTIFICATION (For typed or written entries give: 12.
Name - Lasr, first, middle; Grade; Date; Hospital or Medical Facility;) DEVICE(SI (ESU) ®YES

ELECTROSURGERY
Li NO
A4-G
® ESU NO: Uc

1111111(y(01--
GROUND PAD:GBRAND
tab
LOT NO:
. ESU NO: G
GROUND PAD:GBRAND G
LOT NO:
. BIPOLAR NO:

DA FORM 5179-1, OCT 87 MEDCOM 14650
REPLACES DA
CO "Ct.. 04 vvpucli IS OBSOLETE.
I IC OA SI.

DOD-028039

'''R; MANUFACTURER

13. PROSTHESIS, IMPLANTS . YES Zig NO
1.99174 - INOOCIRIAI

.1 MEDICATIONS/ORDERS At.
GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES . NO
NMEDICATIONS.SOLUTIO/ DOSAGE TIME MET OD PREPARED Y GIVEN B

.

/ y/OUND IRRIGATION YES . NO, TYPE(S):
Ol.cl°fro N5 4
TIME CARRIED.OUT BY OTHER ORDERS
PHYSICIAN'S SIGNATURE IF YES, SITE
15.
X-RAY IN OPERATING ROOM

YES . NO VI LABORATORY SPECIMENS

16.
SPECIMEN (SI NAME AME YES . NO IX

NAMEFROZEN SECTION (FS) NAME

YES . NO X
NAMECULTURE (C)

•YES . NO NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
NAME NAME
17. TUBES, DRAINS/PACKING YES . TYPE/SIZE ' 1. 2.
SITE 1. 2.
19. ADDITIONAL INFORMATION
Sweleon :16111
krvad'hasio
20. OPERATION(S) PERFORMED TIME METHOD
21.
PATIENT TRANSFERRED TO OA. I.

22.
ST R D NURSE SIGNATURE .1 '•ftP-14.444-1W

T 87
USA PicArt :01 .1: • RE ".'"!•.• ;
• -4.,
•

DOD-028040
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY

POST-
DAY

MONTH-YEA•'
DAY

19 PULSE TEMP. F . .........
(0)
(.) .
105°

HOUR awn moinomm TEMP. C
40.6° 180
...
104°
•
' • ..
40.0°
. G

170 .....
103° 39.4°
C
0

160 102°
U

38.9° ....
150 101° .. ....
a)

38.3° cc 140
8

100° • •
37.8 °
C

... .
a)
130 99°

8.6. 1 ®® a)
11211•21111EMMAIMMCINMIIIMMISM21111113111111111111
.

El= 37
120 '2 :
9 98° w

IIIMMINIMAINIEE1111111191111111111111111111NIONIMMI
37.0 CD
36.7' Ca
as
110 97°
47-•
36.1°
IllaN I
90

oo imonimomEN NN
80 0
70
60
....
......

50 ...... ....
....

40 . .
RESPIRATION RECORD
BLOOD PRESSURE

311 .G1111111111111111/11111111111
imi7inErmarmemeznimmemummilm
numynsiaminumEtwommumum
0; izdt)
HEIGHT: I WEIGHT
lth

PATIENT'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility) REGISTER NO.

WARD NO.

STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 14652

DOD-028041

£9914 - IA100C131A1

511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR DAY WI 30 3 1 i 2.-5 '11
5. ..

19 HOUR . ....,• W • 131( yk-A a Axlia--• ivi 9 -q 1•.: i ;
k
:
•
•
:

V —I
COCOL..) CO CO C.t) COCO CO COA .m
91(II co o) -.1--I-403CO(00 0K CD6I-, -.16IVCoZO (0:A. b0) r°
0 0 0 o a o 0 0 0 0 0 00
(Centigrade Equivalents, for Reference only)

PULSE TEMP. F
.t.
:
.

(0) (-) •,.,
%

:

:

t
•

105° r
I.••.

•
"
• • "
)4 ), -•
1
. .

104° \ . ; 1 -

180
1

.
.
.
N: :
• • • ki • ••
• •. \%N. : : : . .
. . . .
. •

170 103° •• •
. .. . . . . . .
. . . . . . . . . .
. . . . . . . . . .
. . . . . . . . . .
" ' • "
' • " "
"
' • "
.
.
. .

160 102° • •
. .
. . .
•• "
"
. . . . . .
. .
• \/1
•

150 101°
*••
. . . .
. . . .
re • • •
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e
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140 100° I.' •
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. .
. .
1.\
: :. . .

. . . . . . . .
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•
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.
99°
-
;

130
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x .., . a -
)5? . 4) •• o' : ••

98.6° 4?
.
0

a
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....
. . .• • 0

120 98°
.

•
. . . . . . . . . . ......
• • • .4
•
•
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. .
•'
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..
. .

•
311; • •
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110 97°
44.• • •
. w . . . .
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•
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100 96°
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90 95° •
L•
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80
70
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60
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. .

50
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' • . .
. . ...... . . .
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40
1
. • i• 1 • •• • ••1 ..... -• • •• I
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RESPIRATION RECORD
"4 ,;'¦; MI Il

BLOOD PRESSURE 'el ' ¦ 7*
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8
a.,
cc PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility) --4,. e-A-kA
VITAL SIGNS RECORDS
Medical Record

—11111117)(0-"\

STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

DOD-028042

MEDICAL RECC
VITAL SIGNS RECORD
HOSPITAL DAY

POST-
DAY

MONTH-YEAR
DAY

19 PULSE (0) HOUR TEMP. F (•) 105° atIMPAIR NIMMIElliNk310 AMMMM TEMP. C
40.6°
180 104° •
40.0°
170 103°
39.4°
160 102°
38.9°
150 101°
38.3°
140 100°
v. 37.8°
130 99°
120 98.6° 98° 37.2° 37.0°
36.7°
110 97°
36.1°
100 96°
90 95° CP 0 : 35.6°
35.0°
80

70
60
•
50

• 40
RESPIRATION RECORD t• •1• BLOOD PRESSURE
ri '2
0
HEIGHT: WEIGHT
Mat'

Miirte=c01111111116111021EUMMI
a)
a
0
a
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; /D No.
(SSN or other); hospital or medical facility) REGISTER NO.

WARD NO.
0
a)
cc 5
u
a)
5
cr
w a)
D
a)

STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 14654

DOD-028043

999171• WOOCIMAI
NSN 7540-006344124

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY
MONTH-YEAR :,,,k/ DAY 4 i 5 t A ( 1. t t Cl LC) 19 2 HOUR 1'1: . F
Wel
17
Oa•

*? •
• 3 t • •

'' •
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6 .
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• , •
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-

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o0) :--4 co (0)co bin :0
1-. ON 41. 0 0 0 0 0 0 0 0 0 ,
(Centigrade Equivalents, for Reference only)

PULSE
TEMP

(o) c• )
105°
•
• -4 °
• fl 01:a. •
.... • • •
. . . . .
• . . . .
. . . . .

180 104° . . . .
: .
.
"
..
. . . . .
•
I • • -• " ' • •
• • • ....
•
•- •
•• ,•
•.
• ' "
. • . " . . " . . . .

..
. . .

170 1 03° -
. . . .
.
.
"
.
. .
. . . . . .
•
••• ".

160 102°
-
. .
. .. .
. . .
. . .
. . . .
"
• Ai

150 101° . f .
140 100° ••
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. .
. .
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130 99° 9 . .. • • trk/ ,
91 • • • •• a'
•

120
•
•
...
•
.
• • " • •

. . . . . . ... . 110 97° p .K -.0 . .
•

•
•
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•: ••: : : :
0 :
•
. 6:
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100 96°
,.,
..
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....

90 95°
•
•
...
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. .
. .
•

80
70
•

. . • . . . . .

•
. .

. . . . . . •• • •
60:
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. .. . .
. . . .
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60
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. . .
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.
. . . . . . . . .

. .
.i. 1. . . . 1.1

40 i.
I. . . . /
.

i I . RESPIRATiON RECORD 5 1,210% ‘ 1 to
ii

BLOOD PRESSURE .9, ,. 'Zi ,AI a (Ir a t X" •
—
milEV;
-,..

HEIGHT: I WEIGHT 9$/O 93. q w-, C(47 Prio
((7a 2

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. REGISTER NO WARD NO.
Record special data only when so ordered
(SSN or other); hospital or medical facility)
¦
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 611 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

DOD-028044

511-119
NSN 7540-00-634-4124
MEDICAL RECORD
VITAL SIGNS RECORD
HOSPITAL DAY

POST-
DAY

MONTH-YEAR , (ME DAY
•
19 , II PULSE
(0)
180
170

160 150 140 130
120 lio 100
90
80
70
60
50
40
RESPIRATION RECORD BLOOD PRESSURE a F 0
o HEIGHT: WEIGHT
fag
-0
P_
8
PATIENT'S IDENTIFICATION
HOUR r
''''''''

TEMP. F ''''
'''''
(•) 105° 104° 103°
102°
1T
101°
100°

.
-98.6° • • 980 •
99°
.
.
97°
96°
A
95°
a
¦41..

'''''''''''''''''' TEMP. C
4

. ' . .
40.0°

''''''''''''''' •

39.4° 54
c
0 0

38.9° c 92

0 ..... .. • . • a)38.3° cc
............ ....
......
oi
37.8°
c

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

......
...... .... .......... ....
(For typed or written entries give: Name—last, first, middle; ID No.(SSN or other); hospital or medical facility)

401(10)0¦ -`11
a) co
. .
........

. . 37.2°
0-'

37.0° w ..
a)

36.7° -0 t..0 ......
E'
36.1° a) 0

35.6 °
35.0 °
.............. ..... •
..........

REGISTER NO.

WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 14656

DOD-028045
L9914 - 1/1,100CIRIN

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY POST-DAY MONTH-YEAR DAY
19 PULSE TEMP. F . . . . . . . . • • • • •
. .

(0) •• •• •• •• •• ••
(•) : : : : . : .
105°

-I COCOCOCO CI.KilCOCO C,) COAArn al al a) 0-.I-.I-..I OCCO(C)00E
O0) i—^4 0 KilCOCOie.:Ab'a) 70
0 0 0 0 0 0 0 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
. . . . . . . .
. . . . . .
• ' " "
•
"
•
• . .
•

180 104°
. . . . •• •• •-
....
. .
. .
. .
•
•
. . . .
. . . . . . . . . . . .
. . . .. . . .

170 103°
. • . . •. . . . . -• •• • • •• ••
160
•. . . . . . . . .
"
. .
" " " • •
. . . . . . . . . .
. . . . . . . . . .

150 101°
140
130 99°
•
•

98.6° . . . . . . . . . . . : : : : : . . . : : : : : . .
•

120
110 97°
....
. . . .
•
.
•
. .
. . . .

. . . . . . . .
II •• •
....
. .
. . .

. . . . . . .
. . . .
• • • ....

• •-••
100 96°
. .

. .
. . . .
•' " " •" " ••
" -•
•
. . .
. .
.
. . .

90 95°
80
. .
. .
•

•• " •' " •• " " •• •• ••
"

•• •• •• •• •• . • . • -. -.
70
. . . . . . . . . . . . . . . • . . . . . . . . . . •• •• •• •• •• •. •. •• •• . • •• •• . .
•
•

. . . . . . . . . . . . . . . . . . 60 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-. •• . . . . •• •. . . . • •• . . •• • • . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .

50
. . .
. . . .
. .
....
. . . . . .
.-.

. . . . . .
40
RESPIRATION RECORD
Record special data only when so ordered
BLOOD PRESSURE

HEIGHT: 'WEIGHT —.1.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. REGISTER NO WARD NO.
(SSN or other); hospital or medical facility)

STANDARD FORM 611 (REV. 7-95) BACK
DOD-028046

Ward/Section:

JESTING PHY
.elISTRY RESULT FORM
LA

S ML IME (subject to the Privacy Act of 1974)
SSN/PSEUDO SSN:
hemistry 12
TEST RESULT REF. RANGE
RESULT
REF. RANGE
138-146 mmot'L

ALB
3.5-4.9 minol/L 73-118 mg/d1
ALP
7-22 mg/dl98-109 mmol/L
ALT PICCOLO .
8.0-10.3 mg/d1
AMY 14/07/03.14:47
11111111111111111111

35-45 mmHg (art) REFERENCE RANGE:.0.6-1.2 mg/d1
AST MALE
MI
41-51 mmtle (yen)

P02 80-105 mmHg (art) TBIL PATIENT #:11111VW1
N/A (yen)
GENERAL CHEMISTRY 12

TC O2 3.3-4.7 mmol/1
23-27 romoliL (art)

BUN
24-29 mmol/L (yen) DISC LOTAL+1_3082AA4
HCO3 98-108 inmol/1
22-26 mmol/L (art)

CA++ OPER #:W DR #: 000
23-28 mmolit. (yen)

95-98% SERIAL #:
CHOL Panel
ALB

CRE 3.2* 3.3-5.5 G/DL
AnGap RESULT REF. RANGE
10-20 mmoUL ALP
74 26-84.

GLU U/L
Ca

1.12-1.32 mmoIlL ALT 89* 10-47.
TP U/L
BUN AMY 36 1426-84 al
8-26 meal -97.
U/L

_

AST 63* 11

-38.l0 47 u/i —
U/L.

70-105 mgidl TBIL
0.6.

0.2-1.6 MG/DL

BUN 14-97 oil
8 7

-22 MG/DL

GLU CA++

8.6 8.0

-10.3 MG/DL

BUN CHOL 187 100
-200 MG/DL

0.2-I.6 mg/di
RE

12-17 Wdl CRE

1.2 0.6-1.2 MG/DL

GLU

CK 113 73-118 MG/DL
TP

6.8 6.4-8.1 G/DL 6.4-8.1 g/dl
RESULT REF. RANGE

NA' Electrolyte
Mrormin4

Drug of
Abuse

128-145 mmol/1 3.3-4.7 mmol/1
98-108 mmol/1 18-33 mmol/ 1
REMARKS:
REPORTED BY: DATE:
LAB ID NO.: ki,17-J (1\

allitq(0-`1
MEDCOM -14658

DOD-028047
MEDCOM - 14659

/
DOD-028048
MEDCOM - 14660

DOD-028049
Ward/Section: ESTING
L IATORY RESULT FORM C --(so ect to the Privac Act of 1974
—
LAST, FIRST Ml
TIME SSN/PSEUDO SSN:
c (1)—L\

• L nc0C::::-.:.1c-57:5 ,-; '.!--. .'..;1-...=:J.:; "-Ai a - ' ."':-:"._:' . ' -,. -c Gpro ogy•
--;,:s7.7 ::":„.1 .-g:',;4•;.:',1-t-...:,,5,,,,,;;:,--_-=',.. .,:',„..;:,..
".;-; ••:.:-2;,.
74W-4stre,,,..... --,. ---

TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 103 Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
14-18 g/d1(M) Negative
Hgb Glu ::.,:;••':-.:.; ..-4 ''; . crObj0161&-F'‘.,.:;'-' ...,:
12-16 dl
Hct 42-52% (M) Bili Negative Source
37-47% (F)
MCV 80-94 fl (M) Negative

Ket Gram
81-99 fl(F)

Stain
Pit 130-500 x 103 SG N/A Occ Bld Negative
verified
Lymph % 20.5-51.1% Bld Negative H. pylori Negative

N/A
Micro

IVY:, kr,..-ef.-pH
'-"g:',.:21?-Parasites
Segs Mono Prot Negative Malaria

Bands Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
'-‘ C•-'114#•,-6.1116'
jr,;i-”,tili),,-:
.., :*
RBC HCG Negative
Morph

Spun 42-52% (M) c...11:; g:1-,,Ifi,:,.-...r-i- • -kps,:,... „:0.3.. , - -•
-,•a"?.,,i......,-W-s;-.i., .,---'-' q•O
Hematocrit 37-47% (F) a-.2.44.',.i.../-e..... --
4151:.:,; , .:: ,-;,v
Sed Rate

t.7'.°;P!W!."--.,.-•:-.::

Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
.

n. -' ' - rlitv ''' . --*At§V:'• " Z:97,gg-t-MIRA -. :a_:..-.-,-..:::, ii**,#t*ift::-ISW:41iigii•i ---1,
':*; 4 ''
!6' ''';:' T3,1''12A141;t1111411711fillia;*Vjlei:,.. "WltVik6°t, t m: '
''14414SiglitdiAlirl:rni11?4ti

TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/ml
REMARKS:

REPORTED BY: c, DATE: LAB ID NO.:
iti -Yskt 61

i
l) 401­
-

IliaE
MEDCOM - 14661

DOD-028050

MEDCOM - 14662

DOD-028051
MEDICAL RECORD - ANESTHESII
For

this form, see AR 40-66; the proponent agent.
.e OTSG

( TOTALS
ee_
% e.t.
AIR L/Min
N20 L/Min
02 L/Min

SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS

LINE site
A. Warmed
.
Warmed

.
Warmed

Code drugs with numbers, events with let:revs
. Warmed
EST BLOOD LOSS
UR NE -

.0C TIME +
BP by cuff
V
A
Heart rate
•
Resp rate

BR
(transduced)

OURNIQUET
T —Al

OK for
PROCEDURE?
ANES- X-X

VT-ml
f - breaths/min
Peak inf pres / PEEP
MODE -on). A(ssist), Clan)
/Auto Cuff ET CO2 (torr)

:f3gggli

BP/oth
F102 (Frac or %) PAC ICU Specify)ART line
Sp02 (%)
Steth- PC/ES OTHER
Gas analyzer CONDITION:

N-M Block (T/4)

Warming blkt Cl) S art Room End Cony warmer
Fo-Alif I

Mark with letters & symbols,
EVENTS__b. e_if z

explain under REMARKS ..ao,„1- cr.va,L e. Ready Begin
Position -
7:11//Yr7/

PROCEDURES and CPT Codes:
. 65;2- MP-, 7V
ANESTHETIC TECHN12UES:

Describe block technique under Remarks
9 0 Ae96,6 A-ft-, C67-
ATIENT ID IFIL TION:
Typed or written entries: Name, Grade ate,
c?1"
Alf5WAYMANAGEMEBT:

Medical facility r/eT Ci°, a Re Intqbatiph route, blare, technique, comments j:4 Sco r K i
77eletet-;9/,

2 1.97'1121.1_
'691)414fff Gl‘rRjr.0_,--- ill

EPS y-e'CO;7 '4P ze-S17_ C.
SURGEONS:

PROCEDURE ,..7 /1111111VA3 LOCATION: ‘-' `""
111114(0)-k-i
DATE: vt“.4
A EST
PAGE OF

DA FORM 7389, FEB 1998
COPY 1 -

PATIENT'S MEDICAL RECORD
MEDCOM - 14663 USAPA V1.00
DOD-028052
MEDCOM - 14664

DOD-028053
MEDICAL RECORD - ANESTHESI.
For this form, see AR 40-66; the proponent agerk. .e OTSG
O no
TOTALS

del
% e.t.
L/Min

CRYSTA LOID-L/Min
(1 oa 02 L/Min COLLOID-pi
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
BLOOD

LINE site C
.
Warmed

.
Warmed

:t
. Warmed
Code drugs with numbers,

. Warmed events with tethers EST BLOOD LOSS
• • s 11/ A)'41""
URINE
TIME op° g
220

BP by cuff
-LB 200

15 V
A 180

2. q
Heart rate
160
•

BP-Resp rate 140
/to
120
HR-7 -1_ BR

(transduced) 100
J-80

T

OK?-N
TOURNIQUET 60

CK T
OK for

40
PROCEDUREILO

ANES-

20
TIME- C.:71-..0

PROC- 0_0(

VT-ml rJ file.£ Tou4 c. 2J f - breaths/min
t 4074

Peak inf pres / PEEP
MODE - S(pon), A(ssist), C(on)

7r 1.-Y2-

BP/Auto Cuff
ET CO2 (torr)
BP/oth WOW

F102 (Frac or %) ART line Specify)
PACU ICU

Sp02 (%)
Steth- PC/ES

ECG OTHER
Gas analyzer

TEMP-site P.C, CONDMON:
N-M Block (T/4)
RESP-
Sp02-BP-
HR-
p

43. Warming 4111, Vl Start Room
End

Cony warmer 2
4 Olio 073,

Mark with letters & symbols,
EVENTS__,

explain under REMARKS Position 0 Ready Begin
— 71n1 4442444 0
— AkuV-44 End
PROCEDURES and CPT Codes:
E 074c. opo
ANESTHETIC TECHNIQUES:

Describe block technique under Remarks
A Ellfre-L, x: 8, 04. ST
A ,4444 3/.4c- 41 3- c I y...a..rA.0-44, -
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY, MANAGEMENT:

Medical facility LAY).-Intubation route, blade, technique, comments
as,. 6, .fxre-04 ,
SU
—#111111,
PROCEDURE LOCATION:
DATE:
ANE

(c)( . o,
DA FORM 7389, FEB 1998 PAGE / OF
COPY 1 - PATIENT'S MEDICAL RECORD
MEDCOM - 14665 USAPA V1.00
DOD-028054

MEDCOM - 14666

DOD-028055
„?Nm'
MEDICAL RECORD - ANESTHES,
For

ee-ni this form, see AR 40-66; the proponent agent
le OTSG

(/) Pr)7 „e f •J 1 2 41-4
7 41'

TOTALS
r2o.00 #.4, 1 )

D 2
/40/o0/te

cc Z0
14 to 0 —
Uw CAI (ri
-Ct e 2 Li

Z z ( r
g w 2F 5°1-.4.(
211
Z ( )
F-L..( y
u) u) ,..)

(2)
?I, 0 0 GCo.t % del g,
X

-AO.R.54;:;::1 % e.t.
pr.).
AIR L/Min CRYSTALLOID­
W. CI-
Our
Z N20 L/Min
.Ca COLLOID-

02 L/Min

t.12:
SINGLE DOSE DRUGS-MARK ON GRID.*
WITH NUMBERS & ENTER IN REMARKS

BLOOD-
LINE she LA

.
Warmed /Org.. —110 .700

.
Warmed

. Warmed Code drugs with numbers, events with lettters
. Warmed
EST BLOOD LOSS

LSStSj
URINE -
ogst.A
TIME 4.0

)1 30
1 00¦ 143° )( '( 30
..........

220 ot-o-c-LA
BP by cuff
200

•' l'eti l•
014 .4:7TPP.i! V 180
A

Prfcti,
Heart rate
160
•

BP-Resp rate 140 t./
sev
120

R-BR
(transduced) 100

• a
T
8O
/` A AAA

OK?- Y N
TOURNIQUET 60

0441.00.*00.0:00:: —47
40

OK for
PROCEDURE?

ANES- x-x

20
TIME-

PROC- a.25
VT - ml
gti;i0
?10 ‘2‘"
Yvo
f - breaths/min 7 7
Peak inf pres / PEEP

21

MODE - S(pon), A(ssist), C(on) e-
5.

BP/Auto Cuff yET CO2 (torr)
vs 3 2 33 5"s" #0000040;
BP/oth y F102 (Frac or %)
.1 7 , 7 PACU Specify)
ART line
P'Sp02 (%) C2

fl 1 0 0 loo tcv
OTHER e01•44'

Steth- PC/ES X ECG S e{
.s.g s 4 S4
Gas analyzer IC TEMP-site Ka". CONDITION:
a 3 S 3 51 317 N-M Block (T/4) 41 1-RESP-'1 k Sp02-
1 r sir 4 t A AP.P.Piggga.:PAPPAMM,::]:
co Start Room End

Warming blkt U2
Cony warmer CC

J/70

Mark with letters & symbols,
EVENTS_._
Ready Begin End

explain under REMARKS
Position ---"" C166---1104,edeM014-1-••et k ° O
cc

PROCEDURES and CPT Codes: o.
ANESTHETIC TECHNIQUES:

Describe block technique under Remarks
PATIENT IDENTIFICATION:
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT:

In,...40,ion route, blade, technique, commentsdical facility
•••"
41

PROCEDURE LOCATION: Erre '2_ DATE:
T ST •
/7Gc 3
PAGE 2, OF "?...

DA FORM 7389, FEB 1998
COPY 1 - PATIENT'S MEDICAL RECORD
USAPA V1.00
MEDCOM - 14667

DOD-028056

MEDCOM - 14668

DOD-028057

MEDCOM - 14670

DOD-028059
•

PROPOSED PROCEDURE: 0 CZ-1 F-gr) ASA Physt State 1 2 4 5 E SURGICAL SERVICE: d (e (5-30-) P.-r
T____0 -•5 VVT:
NPO SINCE:

ALLERGIES.

HABITS.
TOBACCO:

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW
ETON: ASSESSMENT
Cardiovascular:

DRUGS: PAS1
AUSICNJANESTHETIC
Hypertension
7 1". `:

Angina •
CURRENT MEDICATIONS:

MI 19 'Tv
0 = ordered as premed CVA
N

Y Other
(11\0 4 IV f P---P

Pulmonary System:
1217

-11Mr_
Asthma

() . Bronchitis/URI
O
COPD PHYSICAL EXAMINATION
• H

() . Other
Renal System: Pain Scale 0-10 .5. Ve.e49 "
Acute/Chronic R HEENT - Teeth 10 IC, r PREMEDICATIONS: Gastrointestinal: Trachea None Yes (it
Hrs)/CC Hepatitis TMJ/Neck
NY
mg IV IM PO

Hiatal Hernia N Y Orophamyx, mg IV IM PO Nares
PUD/GERD A mg IV IM PO Endocrine System: CHEST: _a
Diabetes
Y

LABORATORY STUDIES:
CARDIAC:Steriods
ThyroidHB/HCT: V2• I

U/A: / 2 -'1 Neurological: • EXTREMITIES:
Seizures

OTHER:
IV Access: Other Ulnar Filling: Neuropathy Y
Gynecological : BACK:
Pregnancy

Other Significant H OTHER:
Familial HX

NPO Since 7-14 0 (.-/
ANESTHETIC PLAN: { LOCAL { } MAC
{ ) Regional (Specify): „{:0eneral: Mask Intubation
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
discussed with the patient/legal guardian.
The patient/I erstand and a
ees. Questions a4swered)

Signed:
Date: —71 .f)

-at ¦14 (1 9-7S— Firs
POST-ANES N ASU)
) NO APPARENT ANES SEDATION KEY:
IC COMPLICATIONS { OTHER
(9((ol ---(

1. MINIMAL (Anxiolysis) Patient
responds normally to verbal
Signed: commands

Date: Time: Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or
Patient Identification: (Ward)
cu._.)

accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESIA.
Patient responds purposefully
following repeated or painful

stimulation_ Airway assistance may
be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation_
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS Previous edition is obsolete
PATIENT RECORD COPY
* U.S. GPO- 2002-729-283

MEDCOM - 14671

DOD-028060

MEDCOM - 14672

DOD-028061
•
C AT V
•

-
a/Wcier460,-
_
/CA
•
4
'
.c...)ENT!F CAT!•.

. . •
?" 4

••.
"rr; • •
MEDCOM - 14673

DOD-028062

MEDCOM - 14674

DOD-028063
CLINiCAL
-use of This rolio,
4C., -66, the

.s Hz:CORD DATE T iME AND SIGN EACH ST OF
.• .r.
it'RITE PROBL EM NUMEr­r.d COLUMN thiu ¦ Ciz.1D

JrL
DATE OF ORDER 09
k t 4-0

TLç
t. 0 an itik 1 L f -1‘21. 01
64 IA^

ROOM 04-
:" • r
.0c
c • ioN #.___41*13 ozoc)(CP/Z--"c 3L-)-(1 -et 5 00g0

1111 (*N'k -
ckI4 _

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ROOM NO BED NO
qC
{.

raA) I Q1) 0
CATION
CATE O 0A0T-
!I:7E Or

ROOrA NO.
: CATI O N
%Qat 11)
aplcs_ 5kri si-up quAirr)(49
ROOM NO (bYQ 9/6te-t-trY
Eilns a2c0 03
iipa5
MEDCOM - 14675

DOD-028064

MEDCOM - 14676

DOD-028065
• F-?,* tr
F3t,

ami .ktQ.L.\..VG‘tva rtF
qs; KIC) T
COS ME C3-
Nr21. .
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DOD-028066

MEDCOM - 14678

DOD-028067
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, me proponent agency is
OTSG

iE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED
ivIEDiCAL SCC.01-sE;
'STEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
1/4T1ENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER LIST TIT, ORD:. :1. NOTED A
HOURS
0
SIGN
5 (1.5 1 10 7 1,1 (r-
0 321-I__ 05 4 t 0

JRSING UNIT ROOM NO. BED NO.
\L5 5 4
Ake. e,
—

,TIENT IDENTIFICATION kij
DA-TrOF ORDER
TIME OF ORDER

MS O 4_ -- 5 iitcr7,11 ..."-A) 5 erter )
I 4 1/2-
JRSING UNIT ROOM NO. BED NO.
,TIENT IDENTIFICATION
ATF OF OROE
TIME OF ORDER
ctt
43 11.e-ey)-c e
2e4

Dr lit_ n/3 * Z-z k a- $412... s c_c_A
f 4Mvt po
JRSING UNIT k41
ROOM NO. BED NO.

c .e+. p
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\ic‘1, 4_ z -v
2,

TIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER , r I
e er-7 ( -orAg. 1-(i
e

IRSING UNIT
ROOM NO.
BED NO.
I
0030 -
MEDCOM - 14679

DOD-028068

MEDCOM - 14680

DOD-028069
A r 2€16

RIFY BY INITIALING 4F1 --,, r'044I,Vr#4 4tt
INITIAL PROPER COLUMN FOLLOWING EACH CO
ON
HR

ORDER CLERK/ RECURRING ACTIONS, DATE COMPLETED
DATE NURSE FREQUENCY, TIME

It4 is-Ito n le ii , zi I 25 21-4 z
i ll 11111, v s VotA--t IJ 't.--

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ALLERGIES: Mi YES - NO PRIMARY DIAGNOSIS:G•
ADDITIONAL PAGES IN USE:_I YES IIII NO57/0 i /-0&-01 "-l'A6.-4
PAGE NO: G
PATIENTJDENTIFICA ON:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIME
D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 22 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.
USA
MEDCOM - 14681

DOD-028070
Z89176 -1A100C131A1
.

tc)

Verity by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initiahng
(NON-MEDICAITONJ
Mo 2003
Order Clerk Date Nurse SINGLE ACTIONS Date to Time
Done Initials

I
be Done be D 4
-No &26

NPO p /AN 145,k) vioci 2416t)
Po . iit) i)( oe. ik) ao,„0-1 ri .1 03 6.
--Awl signors-mot miwarrr -
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Order/ ,
PRN

emir INITIAL PROPER COLUMN FOLLOWING COMPLETION
Date •• ACTION, FREQUENCY
TIME/DATE COMPLETED

DOD-028071
Verit y by
T11(G

Initialing iUTIC,p0CIMENTATION CARE PL

piON-PO_DreAnOro 1Mo
Yr 2003

der Clerk
tte Nurse SINGLE ACTIONS Date to Time to Time Done Initials
be Done be Done
1-0 E-P1)-D

Order/ Expir PRN Date ACTION, FREQUENCY TIME/DATE COMPLETED
11
1 1111111111111111
111111111111111
111111
11111111
MEDCOM - 14683

DOD-028072

1789174 - INOOCIRIN
imp. a2045

the proponent actencv is the Office of The Suraeon General.
RIFY BY INI77ALING -,7,4:ii7.1174'?'3•;— :,,r". ' -- 'Z'4:;.%:1-t INITIAL. PROPER COLUMN FOLLOWING EACH COMPLETION
HRG DATE COMPLETEDORDER CLERK/ RECURRING ACTIONS,G

0

DATE NURSE FREQUENCY, TIME
PFSTIFIESIMELIMI 2 NOME ( nG

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(0) A a ,..) i6 cA. LA 66 7-
• ADDITIONAL PAGES IN USE:
MI NO I PRIMARY DIAGNOSIS:
ALLERGIES: OM YES
YESGNO
I PAGE NO: G
—pilc(0) ,J2s) 104
PATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIME
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 22
N 24 01 02 03 04 05 06 07

G EDITION OF 1 DEC 77 MAY BE USE

DA FORM 4677, 1 OCT 78 USA
DOD-028073

THERAPEUTIC DOCUATION CARPLAN (MEDICATIONS)
MENTEG

CLINICAL RECORD
the prof:so:tent merles, is theogflicseeOf The Surgeon General. Mo.02-7r. (-),
VERIFY BY INITIALING : ---' -.s t:3;„ l`t.":'..-z-:-. 1 ,,, INTI ZAL PROPER COLUMN FOLLOWING EACH ADMBVIS7RATION

-
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE. FREQUENCY

i q 1 to n 15 A 73132/ -t-, -23.k Ls-GZ7 I LI gip 6Y2 1') -r7-014-C-L 5 )-105-cc-/ A r 14-13 '
MINI 116....firmill
lq Q .(9° 0 2.111111'
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ALLERGIES: 1111 YES IN NO PRIMARY DIAGNOSIS:G ADDITIONAL PAGES IN USE:
IIII YESG/111 NO Si() / +- VDGCD g-(26 I— Lrtl( (1/ PAGE NO G
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79
MEDCOM - 14685

DOD-028074
98914 - lA100C13lAI

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo. Yr. 03
Order Cleric/ Date to Time
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
Ok)-r

14 ilt,C

14 -. kittieurawc-Q 1p0 I'D x-1 n Ok.,'-) -a0 PrtAllOPhe:111;
z- PA Order/ . maid PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
ExPirDate NNurse MEDICATION. DOSE. FREQUENCYG TIME/DATE DIGSED
MargliakiN
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USAPA V1.

DOD-028075

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For u e of thio form, see AR 40.407;
Mo. Y r.
thelrornent slam Is the Office of The Sermon General .

VERIFY BY INITIALING INSEMINEENENENIMOS: INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED

ORDER RECURRING MEDICATION S,
NURSE DOSE, FREQUENCY

30 31 I PIIIME104 7 ellio TV FL li
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ALLERGIES:GMI YES M NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
I. YEG
11111 NO Si PG—I I 0G0 ,-elieP a— 4+1 17 ) (--,
PAGE NO.S

PATIENT IDENTIFICATION:
DISPENSING TIMES E(7(,c
USE PENCIL. CIRCLE MED TIMES 0G7G8 • 9G10 11 12 13 14
VIM (14-C)—L1G
EG15G16G17G18G19G20G21G22 NG23G24G01G02G03G04G05G06
1, • •••• ... Ns 2 IN. A mg. ¦• a. • .... a¦ .... .......

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. G
USAPA V1.00
MEDCOM - 14687

DOD-028076
MEDCOM - 14688

DOD-028077
Ven y by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
MEDICATIONS) Mo. Yr.
Order Clerk] SINGLE ORDER, PRE -OPERATIVES
Dem to Time toDate Norse Time Given Initia
Initialsbe Given be Given

Order!
Clerki PRNG

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
ElPir Norse
Dow MEDICATION, DOSE, FREQUENCY
TIMEIDATE DISPENSED

-%LkG- - --2-t .3Z at 1.-30 E, 6-4-t -'' ,
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USAPA V1.00

d:t-LI S1-1 MEDCOM - 14689
DOD-028078
MEDCOM - 14690

DOD-028079
CLINICAL RECORD tHERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)For use of this form, see AR 411407: the proponent aRency is the Office of The Sunman General. Mo.
Y r.

11 ER IF B 8117A I- /NG
rda tarn 111100:1 tiltSMA
INIT7AL PROPER COLUMN FOLLOWING EACH ADMINISIRA770N
ORDER CLERK.
RECURRING MEDICATIONS, HR
DATE DISPENSED

DATE NURSE
DOSE, FREQUENCY
IU v1 1,21s 14 )-5 )1,1711 )9 07),2/
-95)-000
;-64,0c16 air 4,0A.,.• as ADO 5
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ALLERGIES:GEll YESG
0 NO PRIMARY DIAGNOSIS: ADDITIONAL. PAGES IN USE
YESG
I I IGI NO
57/1 di +
IL/ PAGE NO.

PATIENT IDENTIFICATION:
DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES
AMP
D 7 8 9

10 11 13
12 14
(9 (GI -Li

E 15 16 17 18 19 20 21 22
N 23 24 01 02 03

04 05 06
DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V1.00
MEDCOM — 14691

DOD-028080

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
For use of this form, see AR 40-407; the Pro enentmenau is the Office of The Suwon General. Mo. Y r. VERIFY BY INLIZALING IROMMORMannibilig:i
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK! RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY

ALLERGIES:GIG1 YESG0 NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: I I YESGIGI NO
PATIENT IDENTIFICATION: PAGE NO. DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
ne rnnan AC70GI CCD 10G enrranat n• • 1.“.. ......... ................. -.......-MEDCOM - 14692 USAPA P1.00

DOD-028081

REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet USG APPROVED /Date
in.

131 Timee
Drains

Airway gie. s: t'/ Hemovac Nasal
GOR Intake: Crystalloid 515-De-C._ Colloid G NG
Pre-op V/S:G OR Output UOP G Oral
EBL G
JP

ofrit.GProcedures: —771 FirETTOVI-Meds/Times: G Akr6 51 ETT
T-tube

Trach Foley
Other

Pre Op Meds Histor TLS
Time
Pacu Intake

Sa02 cf+
A5d Time Solution Amount Site ByGInfused
FiO2 tft
Pt"

Methods
240
220 X-rays:
Labs:

Post-Anesthesia Recovery. score 200 Criteria ADMG30' DIC
Codes
Activity

(2)
Moves 4 Extremities AIRWAY

(1)
Moves 2 Extremities A = Ambu

(0)
Moves 0 Extremities

180 BB = Blow-by
Ainvay M = Mask
160
(2) Cough, Deep breath FT = Face
V

V V (1) Dyspnea, Broiled breathing Tent 140 (0) APolst RA = RoomAir
III
NC = Nasal
Blood Pressure

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

(1)
SBP =I-20-500f Pre-op

(0)
SBP =1- 50 of Pre-op V/S

120
X = A-line BP

100 Consciousness
(2) Fully Awake, audible =Cuff BP
• ung = Pulse 80 (1) Amusable to verbal or pain
/.\

A TEMP
Color S = Skin
(2) gaseine color &appearance

60 7/
(1)
pale, mottled, jaundiced 0 = Oral

(0)
Cyanotic A = Axillary

T =Tympanic

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

(1) Aviary palpable, not radial 20 (0) Carotid only reliable pulse LOS
C = Cervical
TOTALS: Must be 9 or greater to D/C, otherwise

T = Thoraciclit is -Kr 4 ts-ii needs anesthesia approval for L = Lumbar
T DX. S = Sacral
RR Io
I 1
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

Itontmue on reverse/
DEPARTMBITISERVICEICUNIC DATE

(, 10(704 re,a A ig fi-/‘
Name -last,

first, middle grade: d
.
HISTORYIPHYSICALG

. FLOW CHART
.
OTHER EXAMINATIONG

.
OTHER aged& OR EVALUATION

-411VG)-1
. DIAGNOSTIC STUDIES

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) . TREATMENT Previous edition is obsolete USAPPC V2.00
MEDCOM - 14693

DOD-028082
MEDICATIONS

Allergies:
Time Pain Medication & Route Pain I/E By
-

-

(1,0 # °
\;1
,
C7
L
NEUROVASCULAR

Time Site Range Sensory P Cap T Color
Of Refill
Motion
Adm 15' 30' 0 ? 0 i' )6-4' GO /11 yoie #
46 60' jr.46 r r t ig 4./ c
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= Sluggish
P= Pale, Pk =Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C Fund. Height
Lochia
Peripad# kA--1
Fund. Cond.
DRESSINGS Time Location Type Drainage
Adm ggly 4if tt_. Iwo(aq rou(30'
60'
PACU OUTPUT

Time Source Color/Appearance Amount
CARDIAC RHYTHM Time Rhythm G
Symptomatic? Rhythm Strip Run?
WAMC OP 173-E
NURSING NOTES

Wiam(lud ofk (t_ci-hvilgov62.0y V) 0 /0L4
,e(4,

ud (kw atrio(Olu7, (Am! crrp9,9,q Attionkk, vkwhet(ghntuk }. Luito bk(ach qac 6)-cth Q.(0010
6-OL lOL A1 126 . /kiw i hito_ is
6)W/o tut eft x qt 00a ,
Ai(10 ()tow_
WC1( &911-n(Ae j n/Lefi

Dischargg Criteria:
Date:GTime: /960 PARS: /(
BP: /GT: 19,6 HR: (42 RR: geG

Sa02: 9,r1.) Pain Level at D/C (0-10): Intake:G
Output: zoi Additional Data: Transferred To: / mallINIRM11111l_ Report Given To:
Allire2._ 4
Transferred Via:G

A bulance Transferred By: Cleared IAW Recovery -M1 cilk,l-Arr Charge Nurse Signatur
MEDCOM - 14694

DOD-028083

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this foam see AR 4066; the proponent agency is the Office of The Surgeon General. 770
G
G

REPORT TITLE
OTSG APPROVED (Dam)
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: Anesthesia Type (Circle)):Gcoral pinal Epidural
Drains

Time In: 44-4f Airway
IV Sedation Nerve Block
Hemovac

Allergies: Nasal NG
OR Intake: Crystalloid / GI) Colloid G
Oral

Pre-op V/S: OR Output UOP EBL 7C:e 4/ k/// JP
Err

Procedures: , reCia ire Meds/Times: T-tube
-° Trach
4-x2141 G e-/JP/ ;ad /
Foley
Other

Pre Op Meds History TLS
'NO

Time
Pacu Intake
Sa02 erVictyfirn' Time Amount Site -By

Solution
Infused

F102
Methods
240
220
X-rays:G
. Labs:

Post-Anesthesia Recovery score
200

Criteria ADM 30'

D/C Codes
Activity

(2)
Moves 4 Extremities --) AIRWAY

(1)
Moves 2 Extremities 7 A =Ambu

180
Il
(0) Moves 0 Extremities ..--....

BB = Blow-by
160 Airway M - Mask

(2) Cough, Deep breath Z. FT =Face
(1) Dyspreea, limited breathing Tent
140 (0) Arena RA =Nasal

V V
NC = Nasal
Blood Press=

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

(1)
SBP =/- 20-50 of Pm-op

(0)
SBP ­

120
2--

4-50 of Pre-op V/S
$.. X - A-line BP
100 a Consciousness
(2) Fully Awake. audible / - =Cuff BP crying = Pulse
i

80 A 1k (1) Arousable b verbal or pain
Il

z TEMP
Color

S =Skin
60

(2) Baser* color a appearance

(1)pate, mottled, jaundiced 0 = Oral
(0) Cyanotic . -2 A = Axillary T =Tympanic
40 Cirolation (Peds 5 Years)
R = Rectal
(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial ./.7 ,,,,,,/-

20 (0) Carotid ordy reliable pulse LOS
C = Cervical

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

RR
7d needs anesthesia approval for q. L = Lumbar
ce

T DC, S = Sacral
ft

Time Patien IGteaching done: Wound Ca e, Pain Management.
Pain (0-10)
T, C, & DB,. Incentive Spirometer, Comfort Measures

LOS

Safety: SR up X 2, Falls Precautions. Privacy Maintained

IL.OnfinUO On reverse!
DEPWTMENTISERVICE/CUNIC DATE
Name -last
-dare; hospital or medical farktyl

.
HISTORYIPHYSICAL

.
OTHER EXAMINATION . OTHER

+M)
(up3) -11
DR EVALUATION
.
DIAGNOSTIC STUDIES

.
TREATMENT

G DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)G
Previous edition is obsolete
USAFTC V2.00
MEDCOM - 14695

DOD-028084
MEDICATIONS Allergies: Time Pain Medication & Route Pain WE By1 -10 fknane
1-1n
0 I I I WISi
NIArd1111111
•
40.,„..

NEUROVASCULAR Time Site Range Sensory P Cap T Color Of Refill Motion
r

Adm intallagalrall2WWAIIMMIPAIr
•

15'
' Ora/7 -t -i-,E, kl P430' t i if I 1 //
/1 If
45' ;1 ,/
,l . 1/ i l ) I
60'
i /

71 ...."----/ l i l' (7
90' „ -
D/C 1 i
IC r/ ( c 1 ( t I, Movement/Sensation: + = present,- =absent Temp:C= Cool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C= Cyanotic, Capillary Refill: B= Brisk, S= Sluggish G
P = Pale, Pk =Pink
0-SECTION

Adm 15' 45' 90' D/CFund. Height
Lochia
Peripad#
Fund. Cond. -

DRESSINGS
Time Drainage

Location Type

Adm
relmwelmmusw
30'
74EMIIMINNEME 4
60' PO P1V fig YV-e -Afit,I1 D/C lG(G
l ( f
PACU OUTPUT

Time
SourceGColor/Appearance Amount
CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?
(
74\-

WAMC OP 173-E
NURSING NOTES

0)1 27°1 4 ci 1.0(rA6(0 (-0 ,
aris,`celf

(14)0jkit 71-1417 u cc/.,4),h
99 -4/ (P7 71V1( t
p0-7' Atifqh_
Ce-
AAA) (6i2

1/J -/UZ_ 1 P 6i:t0Z
Discheme criteria: Date:/ ZD3Time:032. PARS: /6 BP: 74. 2/09T:10, 3 HR: bt RR: /8 Sa02: `let
Pain 'Level at 11
7(0-10):
Intake:

Output: Additional Data: C25 Transferred To: --ropuz_ Report Given To: L. Transferred Via: W/C

Gurney Ambulance Transferred By: Cleared IAW Recove Charge Nurse Signature:
MEDCOM - 14696

DOD-028085
1. REPORTING MTF
MTF LOCATION
1 ADMISSION AND CODING INFORMATION
2 3 4

(Stare or CountryA Code.) For use of this form, see AR 40400; the proponent agency is OTSG
. REGISTER NUMBER
NAME (lags, First, Middle Initial/
4. PAY GRADE
5. SEX
16 17

6. DATE OF BIRTH
IYYYYMMDDI

7. AGE AT ADMISSION
B. RACE 9. ETHNIC

RELIGION 19 20 21 22
23 24 25 26

27 28 29
30
BACK­GROUND

2--—&" cD 5
10. LENGTH OF SERVICE
ETS

11. FMP
12. SOCIAL SECURITY NUMBER 32 133 1_34 1
35 36
IEEIDEll 40 IMIZEntriall 45
ORGANIZATION (A ctive Duty Only)
13. MARITAL STATUS HOUR OF
BRANCH I CORPS ADMISSION
46
(7,COD

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
19. TRAUMA

PREY. ADMISSION 62 63 64 65 66 67
1
Country Code)
68 69 70 71 YEAR
NO

20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72 tAAJ1c, ADDRESS OF EMERGENCY ADDRESSEE
(Include ,DP Code)
e__
(
ICAL TREATMENT NONE NUMBER OF EMERGENCY ADDRESSEE

21. TYPE OF DM b10 23. DATE OF DISPOSITION (Y YMMOD1
73 74 78 77 78 79 80 81 82 83 84 85 86
cP
24. CLINIC SVC • ADMITTING
DI
87 88 89 90 91 92 93 94 95 96 97 98 99 I 100 101I I I102
4- A'
104103 27. LOCATION OF OCCURRENCE (Battle Casualty Only) 105 106 107 108 109 1 10 111 112 1 113 1 114 0 DI 115 1161 1

FOR LOCAL USE
C-zsW
Dx ;
(
5c;

ADMITTING OFFIC
?---(,S
b)((0\ --1--
ilbi-, OOP

DA FORM 2985, MAR 89
USAPPCV1.0
MEDCOM - 14697

DOD-028086
USAPPC V1.0
217 218 21 9 220 221 222 223 1 224
2411242 243 244 245246 247 24e
0z

0
N
ao N
2
46. SECOND PROCEDURE
46. THIRDPROCEDURE
HPROCEDUR
FIFTH PROCEDURE
49. SIXTH PROCED UR E
IL 0
0
U

0 Z O0
ctc.

ai

cc .

0 0
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Za

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Z_ N Bei
co N

OD 0 N
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(U US

Ow .01 -Jo 0-
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C.) CD

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WO

4:

co
CL/
60. SEVENTH PROCEDURE
EIGHTH PROCEDURE
0
° E.

ZE

0
W2

(0-

2 1!

cat

48

to
N
0
C)
N
01—
CeZ
12. 0
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0
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2

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NF
0
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IN
0 0
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N IN
PAGE 2, DA FORM 2985, MAR89
C)
N
N
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0
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C`J

FIRSTPROCED URE
CS/ 0 N
ID
N
Cs/
7
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ID
N
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MEDCOM - 14698

DOD-028087

eAL0- 4
ID:

W. $ -, , 14149 Patient iglits
VAC 11.2 H -.10'3/aL 4.5 10.5 x10'61ai 4.00 6.00
i PK 115 gML 11.0 18.0
1 Hgb 17.9 X 35.0 60.0
Itt 47.4
mu 82.3

1

11 80.0 9-9.9 rc 250L
310 •._+
ME 304L gSL ,44. 00'3hL 1.1Ki. 450.
?it ::'

,r. e. sl .1
ra 213 & Z I 'qi 2.34, x10'3/11 1.2 14
DOD-028088

1.ASTIrrif
II, I
ir NAME/NOM Eirrri RAMC/GRADEG

MALE/ HOMIDE
FEMALE/FEMME
NUMOtOIMATIUCULE
I SPEOALIY CODE /GPMG

RELIGION/RELIGION
2. UMIT/UNITO
FORCE/ELEMENT NATIONALITY/ NATIONSU7S3
AAA, WM MOM
I

BC/IICG t
A/7 I NW/INC DISEASE/MAW:RE PSYCH /PSYCH
3.leuinni minus!
)1c1
AIRWAY/TACHES
FRONT/MANE BACX /ANDERE HEADrrtrc
WOUI101111ESSURE

NECIUDAOC INJURY/ DLESSURE AU COUIAU DOS DOM BROLURE
AMPUTATION/AMPUTATION
STRESS /TENSION

OTNER(SINN/PAI/AUTRE(SPOIDId
(i) rIS/Ock "-i-r);1."*... la 1414
rsj 0+4114. p.
II. LEVEL OFCONSCIDUSNESS /NIVEAU DI coNsavoce
V bNA4—ti. ,

ALERT/ ALERT!
I PADS RESPONSE / REPONSE A ta
VENIAL RESPONSE/ P2PONSE vEfteAu

UNRESPONSIVE SAM REPONSE
I

IL PIRSE/POUI3
1 ME / KUREGI G TOURIBOUDIVGARROT rAtE/NEUREEl NO/NON 1-1 YES/ OW
7. arolltHed /name
1

DOSE/DOSEGTIME / HEURE rAlt N
TIME/ NEURE
nYES/OUI
I

INSAIMENT/OISERVA710115 /CURRENT MEDICATION /ALLERGIES/ ADC DUTI1D0717
INAUTIMUIT/GIVARVATIONS/PRESENTE MEDICATION/ALLERGIES/ANTIDOTES

Q• 7. '

rt 044.6._ c•e-aa,
•ft-wimp TO Dun moot A curffrt TI NATURE
[Lick)
ken 1 nisG
U.S. FIELD MGL • RD
91 •tooronstnaperavesorrs
FICHE MEDICALE DE L'AVANT ETATS-UNDHMHErAwNtheammoica.
DOD-028089

,G
.

INPATIENT TREATMENT RECORD COVER briE.
For use of this form, see AR 40400; the proponent agency is OTSG
HG01-1

; 3. GRADE ADMISSION REMARKS
REGISTE NAM rt-MI)
I. I
/ .-.

• RACE 7. RELIGION 8. GTH ETC 10. PREVIOUS
12. 13. ORGANIZATION 14.
1 P
1 Q\b, Z Q,
5. MING 16. -18. BRANCHICORPS 19. UICIZIP 20. TYPE CASE
STATUS BEN

''­

A-a /4
22. HOURS OF 23. CLINIC SERVICE ADMISSION

21. SOURCE OF ADMISSIONIAUTHORITY FOR ADMISSION
QI alSQ ''' C (\ R.N. OQI gC.W\ &RELATIONSHIP OF EMERGENCY ADDRESSEE 25. • , ••••'0:7711011
25. E OF DISPOSITION

2 . IN
% f 4111 r 'Z 'N . 27a ADDRESS OF EMERGENCYADDRESSEE (Include IP Cork) 27b. TELEPHONE NO. 28. DATE OPTIC ADMITTING OFRCER
ADMISSION
\‘,....\\.....
\\,...._

29. TMENT FACILITY .....44.:\........ 30. DATE OF INTIAL 32. UNITS OF WHOLE BMW
ADMISSION COMPONENT TRANSFUSED

\•¦‘-.....•-•.....\,..
D MIN

Check if Continued on Rowse
33.
CAUSE OF INJURY

34.
DIAGNOSESIOPERATIOAS AND SPECIAL PROCEDURES

‘Q • 4 i„,..„..k\Q-,\,.. 2\y.G g / 07.ero
C a7/q,1
35. Total Days This FacilityG .G .
ABSENT SICK DAYS • b. OTHERDAYS C. CONY. LVICOOP CARE DAY SUPPLEMENTAL CARE S. BED DAYS TOTAL SICK DAYS
..., .„.
36. Total Days All Facilites
ABSENT SICK DAYS b. OTHER DAYS c. COW. LYICOOP d. SUPPLEMENTAL o. BED DAYS .TOTAL SICK DAYS
CARE DAYS CARE DAYS Ii
SIGNATURE OF ATTE
DA FoRar36ari01tr79 EDITION OF 1 AUG 76 IS OBSOLETE USAPPC V1.10
6- r-10tEDCO—M - 14701
) CGS

DOD-028090
AUTHORIZED FOR LOCAL REPR(
DICAL RECORD PROGRESS NOTES
DATE. NOTES

3.

P4-. (Y\.

4 L C uJ.Q rmho
6 Q) \ S5 •.c. C

-.p c. 1.1 - S ^°^cM^.
C, Poi (7(

.
\jj. jiJ L..

MC Urc) ckec.l S --n.0 s

Gc'(v-.

—k'.C Ds.1.

/L V i -0.

n

Li.CT/.Xy,.
4 , &)^O .--^r oc .
'W '\\ CUY1`^ o^

I CQ.14 ^^iPP.fYvY1.c vyjf _

1Jkl.`. (l )5prQ h\/ \mrh.

J r./
P-t
f^^1Ct.Slir^c-(.c ie,c rue_j.r^plo.c.
c„r'4.

\-4-.p .ISQ I -s-x4ICY ltbd -^y
^n.Ir-.rye, _.N I-.^i I , 't 'i I ..

mc) t?. -h r, .co• I.' 5.
'P4
t^

,.

ham.

vlq.ccp iecD j mOO.

qrm ej-s4.,,jn11 Can-I+ru rP

-I^R
r car-. S'3 ,.s ..

SSG.

(off, p.4f f.e_ C c.'
(C...

\1 C7. b_--y.

as
LQ W.«\ t.r.
r. LH ° (J t

4 U I'-. Co d ^i-e-r.

j^.a r.

(S ^-.__ ._.(.

c • -.-.

--- --^ /.1 vc
l. ,

DNSHIP TO SPONSOR.

I) .SPONSOR'S NAME
LAST.FIRST.MI.

(SSN or Other)
(M tC^'

r./SERVICE.HOSPITAL OR MEDICAL FACILITY.RECORDS MAINTAINED AT
'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; .I REGISTER NO..

,..WARD NO.

ID No or SSN; Sex; Dale of Birth; Rank/Grade) . ( )

.

^.I

P
PROGRESS NOTES Medical Record
STANDARD FORM 509 (RE
Prescribed by GSA/ICMR FPMR (41CFR) 101-11
MEDCOM - 14702

DOD-028091

LAST NAME . FIRST NAME
MIDDLE INITIAL ID NUMBER
DATE NOTES
(Th kr) r
V

t' 0 0 S ,-,A4N-Q-Pyrr
MEDCOM - 14703

DOD-028092
558-103 (See Instructions on Back of this Shet NSN 7540-01.075-3786 TREATMENT FACILITY (Stomp) LOG NUMBER
EMERGENCY CARE AND TREA I MENT
(Medical Record)

TRANSPORTATION TO HOSPITAL CURRENT MEDS. (tetanus immun-IS ORY OBTAINED FROM (Attach care enroute sheet) ization and other data) nOTHER (Specify)
ARRIVAL

TIME PATIENT 1-1 PRIVATE
DATE
4AY MONTH YR. AMBULANCE ALLERGIES
I I VEHICLE

ty 03 e.c.,3 n K.._b A
OTHER (Specify) 4. 1 PATIENT'S HOME ADDRESS OR DUTY STATION (City, State and ZIP Code) H E TELE. NO. (Inc. area code)
CHIEF COMPLAI (S) 4nclude symptom (s), duration) SEX AGE POSSIBLE THIRD P PAYER?
Pt' c2 Ei YES El NO
0,21, VITAL SIGNS DESCRIBE (1) Subjective data (Pertinent History); (2) Objective data TIME SEEN BY PROVIDER (Examination -include results of tests and x-rays); (3) Assessment (Diagno-TIME sis); (4) Plan (Treatment/Procedures - include medication given and follow-up o
BP
irCk'f5'

PULSE
?/‘C‘''‘

RESP. Cf4r"r
TEMP.
2-4/0 el‘ $, . ‘' 7 I r 60
WT. (Clu
CATEGORY (See reverse)
/ I Ad-1.1 A.,;( 14,4_

EMERGENT /4?15\ /la e,•1
URGENT
S. A- -P-20 dam ,

NON-URGENT
ORDERS IN ITS. TIME
Jo 4-t-Ni-t/ IC A-CO pe.,61,-;
4rry.
cgC ;p7 /2
fr vir
AJf"E-1 "I "-(-fe,
Alift9-73

ASSESSMENT/DIAGNOSIS
P:

C?-, 71,w "e- ter(./,f
DISPOSITION (Check all that apply)
HOME 'FULL DUTY
Er "A'1 e /74—)
QUARTERS a-es-C./
24 Hrs. 1 148 Hrs. I 72 Hrs.
1

MODIFIED DUTY UNTIL:
DAY MONTH YEAR

REFERRED TO (Indicate clinic)
EMERGENCY TODAY -
(q (C\

72 HOURS ROUTINE
of a
ADMIT. TO HOSP. UNIT/SERVICE
fkva-y-f,

CONDITION UPON RELEASE
PIMPROVED UNCHANGED
II

DETERIORATED
TIME OF RELEASE: (CONTINUE ON SF 507, IF NEEDED)
PATIENT'S IDENTIFICATION (Mechanical imprint) SIGNATURE PROVI P FOR WRITTEN ENTRIES-GIVE: Name - last, first, middle; SSN; DOB, service status, name and relation of sponsor or nextof kin. (IMPORTANT: LIST FACILITY HOLDING TREAT­MENT RECORD). edications ordered, any limitations and follow-up
plans)
(4f31--L
Efa
EMERGENCY CARE AND TREATMENT

STANDARD FORM 558 (Rev. 6-82) Prescribed by GSA and ICMR
:opy

MEDCOM - 14704 FIRMA (41 CFR) 201-45.505
DOD-028093

600-108
NSN 7540-00-634-4178
CHRONOLOGICAL RECORD OF MEDICAL CARE
HEALTH RECORD
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
5 ) ,A ( v) 5 ." ruN._4-....-
1 eL 29 IC9_ 1 ('L.". vo. e rtt 5 , 4 - 5 5 itb
r 1 r..._ (.4._ , ,,,,, 1 Qr.-WIGc. r,,..)--
dr"

E 1),

9G-tv Ind/ (... triv.--
,...., 6 wk
pi e Ea-) F- (%)1 '6 Z.,
A

PATIENT'S IDENTIFICATION (Use this space for Mechanical RECORDS
Imprint) MAINTAINED
AT:
PATIENT'S NAME (Last, First, Middle initial) SEX

STATUS RANK/GRADERELATIONSHIP TO SPONSOR ORGANIZATION
SPONSOR'S NAME

DEPART./SE R VI CE SSN/I DENT I F ICATI ON NO. DATE OF BIRTH
ructrouno rtrzwe I 12Crellan OF MEDICAL CARE STANDARD FORM 600 (REV. 5-e4) Prescribed by GSA and ICMR
MEDCOM - 14705

FIRMR (41 CFR) 201-45.505
DOD-028094
NSN 7540-00-634-4124
VITAL SIGNS RECORDMEDICAL RECORD

HOSPITAL DAY
POST-DAY al-YEAR DAY . . . ..... . .
yr 212:03 HOUR
. . .

•..52 . ••
TEMP. F .
-1 COCOCOWWCOOOCOCOCO41. .4.tri 01co co co -4-.I--.1 COCOCO00K
6Co i-, ^4 ON Co 6.3(0 :r0. b0) 77
0 00 0 00 00 0
(Centigrade Equivalents, for Reference only)

PoLSE
" .... . " " •.
0) (') •
105° •°
•
.
.

. ..... . ....... • •. ...... : :

•
. .
. . . . . . . ..

180 104° .. .
. .. . ...... . .
170 103° . . ........ .......... : : ....... .
.•.•...•
160 102°° . . ...... . .
..... • . • . . ..... ..... . . . .
150 101 ............ • • • . . . .
...... . . . .
140 100° ...... 4 ........ .. ....
.• : .• .. . ...... . .. . . ... . . ..

130 99° 98.6° V "" ........ . ..... ... i . . . . . . . . . . . .
. .
120 98° i„ ..... . ... . . . . . . . .
. . . . . . . .

110 97° ..
0
. . . .
. . . .
. . . . . . .
"
• • "
IIIII ki.

100 96°
. . . . . .
•
•

90 95°
80 70 60 . • •. . • •. . • • . • •. . • -. • ' . . - . - 11 .-1Para!I• l• . . . . ••• i• . . . . .1 .1 . . . . r .G. ...i . . i .....G............ . . -..G..
.G
. . . " . . .G
. G" G. .. .. G
. . . . . . . .
40 . . • . . . • . . . • . . . • . . . . . • • . . • •
RESPIRATION RECORD t)

Record special data only when so ordered
BLOOD PRESSURE • •
al A

HEIGHT: WEIGHT
.

.
.
. ..
PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO.
(SSN or other); hospital or medical facility)

I ----( 1-2
--T12

VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR• FIRMR (41 CFR) 201-9.202-1

MEDCOM - 14706

DOD-028095
Ward/Section: REQUnTING P
c„:70,A_ 1

t r.G
LAST, FIRS" t DATE
ir"'cl

Iallal¦
I

• ematology) CB(`.'G Urinalysis
TEST
WBC RBC

RESULT REF. RANGE '
F1.8--10.8 x 10' 4.7AI \ in'
)V'e\
Aim (L"
IZ 111111""
Pr:!.tient Liglits
, 2 x103/11. 4.5 10.55,66 A10'6/0._ 400 A. Ot,
.
16. G
6
L ItEr v . 60.0
11C:.; , 3. 99 n
_

P -.;
20. 5,1 -
Coagulation Studies
RESULT REF. RANGE
9.8-13.6 sees
PT
-----r.
yJJ
APTT ;7.3 i-, 21-34 secs
D dirtier -.20 tigiml
FDP -:10 up'ml
REMARKS:
TEST RESULT REF. RANGE
Color N/A
App N/A
Glu Negative
Bili Negative
Ket Negative
So N/A
Bld Negative
pH N/A
Prot Negative
Drub 0.2 -1.0
Nit Negative

Leuk Negative I-ICG Negative
CSF
Cell Count
Directigen Negative

• P LABORATO Y RESULT FORM
(Subject to the ` ivac Nct of 1074) TIME S N:
• /.
c % I-

..Gtsc. ,_e ology
TEST
RPR Mono
Source
Gram Stain Oce Bld
H. pylori Micro
Parasites
Malaria 0 & P
Other

RESULT REF. RANGE Negative Negative
Microbiology
Negative
Negative

Microscopic Urinalysis
, Blood Bank
MUST SUBMIT SF 518 WITH j EVERY UNIT REQUESTED
ABO/Rh

Blood Bank Unit CrOssmatch
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
REQUESTED)

tTNIT TYPE CROSSA1ATCH
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 14707

DOD-028096
ISTRY RESULT FORM
„eel to the Privacy Act of 1974) DATE
0 9.

• (PicCo (:) lc Panel
TEST RESULT REF. RANGE TEST RESULT REF. 'TEST RESULT REF. RANGE BANGED
Na 138-146 mmol/L ALB 3.5-5.5 gicli GLU 73-118 mg/dl
K 3.5-4.9 mmoUL ALP 26-84 oil BUN 7-22 mg/d1
98-109 mmol/1- 10-47 IA CA++ 8.0-10.3 mg/dl
7.31-7.45 AT 0.6-1.2 mg/diA --_::::: 128-145 mmoli]
35-45 mmHg (art) ' 2 15/07103
41-51 TrunFIE (yen)
P /CCOLO -=':-=:=

80-105 m inFip (an) T 3.3-4.7 mmo1/1 N:2276(vmmen) 0
2232/Arnmi -STP EC8+ ........„24-___ nin HEI t RACE-PAINT: 00 :55 98-108 mmo1/1
Pt: 1. 41111. MALE 1 18-33 mmoUl
(.(;4"--23-28 nunoI/1 (0a,reln) .
1771EPU s TR y 12
DISC LOT

Pt Name: (picc6TF7
95-98% #: piaci V.::::':.::..'-''' :-
ti ...‘ ikl 1 --7.3082,1-:04

(-2) -(+3) ET ' RESULT
OFR # firar(,/‘' DR
SER/AL :
..,,,8 mg/dL ouL

Glu. #: 000
_,B
10-
20 mmol/L

10 mg/dL...AL6. . . , . . ........... • .... • .

Ri IN . •
1.12-1.32 mmold 3.? LP
Na.31 4:17 1: / LP.

1L 3.3-5a G/cli_ LLT
0: 1
...... i-8-26 mg/di 89g 26-84
ALT
.?St 10-47.U/L .
AMY.

ri 107 mm01/1_ 70-105 mg/dl 41.AMY
AST 14-97.

r:lia . Set WL
o.7-l.5 mg/dl 11-38.AST
c.InGaP :: r El
.. ::L-U/L
r¦¦ fril U/L
BUN

TAIL0.8 0.2-1.6 MG/OL

,,, "38-51%137 TBUL .
'-v

CA .7-22
12-17edl 3.6 GGT
iii NG/DL
.7-..0-01._

Hb* 176 8.0-10.3 MG/DL
114.

,,z,C.

:,,:iv,

700-200 MG/OL
1.1.

7.3“ REF. RAI 0.6-1.2 NG/GL
0H.GLU 10? 73—'16

TP.

.. MG/DL

-1-..::,1 mmft,.!

pc02. ?.6 6.4-8.1.I

INST :.G/DL .

OK VI NA-

REPre .4 wfiol/L.I-EM CHEM

1+,. LIP 0 , OC: OK m

.

ICT 0

5 a m P 1 e

CI;
tCO2

DA 8. ID NO.:
-
MEDCOM
14708
-ORID'EF-tS

For use this torm .1, : opor-¦ k•tirt
¦ !'

Ton c;c:1)..-:+0.0 0A.TE. TIM7: EACH F.!,,IT !F ''T1: PROBLEM Ntit,:10;--:
4,7
DAT (P
Zit 5 3 Cej-
A-
414,4-

NURSING UNIT Ir-loom ro 8E0 N . 0 a--
"f
,. .rATIENT IDENT I C,6,TION , ATE OR 0E R ( 2- TIME 0 , Or-':OV "tiA--salyf

— -----:-.-_ ::::::.--.7.:!'!u.'..":.'-. .I.... •
.
..L.-e ,
,....?
•i b ,....4.-.....s- ; _ 4....."--0...0,--
.. ..i

ir
......_._, .-,,,. -A-jaft-t, 0 r 114., -Veal -/0,4 4 /0 •
'ar ­evse7 GAVIA--0 7

N I.) P. SING IJ N IT ROOM No. i
EC)-NT I F!C 4T O NI DATE
L. 4111011P
,. • r r,r 11N t- r- I C N. C ]••I i r F E 1 7.1 9'4 Et' ce--i R'rc ce_lT7 Pc/upcf;. i; ' Pd QY-6Q)

MEDCOM 14709
-

DOD-028098

MR.

RIFY BY I J1AIJNG -:1:. .4;700S,M±.4g INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE CLERK/NURSE RECURRING ACTIONS, FREQUENCY, TIME HR S fie 1 DATE COMPLETED wp ;_,D
_

!Ipr- v A-ei [s em r a 01-:TiLD . 5 i3
J
41 .
11

...
i
„......._

:1713 -41. &Ares+
(i
1,3
i
C...............) 4

3

¦
. _. ...
¦
•

ALLERGIES: al YES 7 0 PRIMARY DIAGNOSIS: • ADDITIONAL PAGES IN USE: III YES - NO
"

0 k um• - ( 0.5
... r)( • PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIME
-44111*

D 8 9 10 11 12 13 14 15(9(6 E 16 17 18 19 20 21 22 22
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USA
MEDCOM - 14710

DOD-028099

Veal . In Initial.ng Order Date Clerk Nurse 7' IS glirlICi m THL.APEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) SINGLE ACTIONS Dots to be Done -I--bTcuu-v 7--/ S Imo Time to be Done 02y ----7-', 1 Time Done 0 ,NS 2003 Initials 4{3
_Alp 4 -.±) ---),--N1eect5 t-6 Pu+ on 0 clicto 1-e Ct\ -/--is •
arm ro at' Q -F-1-3 09-00

Order/ Ezoir INFI7AL PROPER COLUMN FOLLOWING COMPLETION
PRN
Date ACTION. FREQUENCY

•
MEDCOM - 14711

DOD-028100
r.,\ .7

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407;
Mo. ':--)

the or000nent agency is the Office of The Surgeon General.
VERIFY BY INITIALING :.-.: -;, INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED

ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

6 flo 13 17S . _
.____...0

\ 7-----
6 giffi-
t 7 ri
-(\7 • 1 -'7---
a1
•

•
•

•
•

ADDITIONAL PAGES IN USE:ALLERGIES: Q YES 0 PRIMARY DIAGNOSIS:
•YES MN NO 0 i) Ur-hCrU 5 - r)( -NO.
PAGE PATIENT IDENTIFICATION: DISPENSING TIMES
• USE PENCIL. CIRCLE MED TIMES
(9(L \—L1 D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79
MEDCOM - 14712

DOD-028101
" Initialing (MEDICATIONS) Mo. I'LLD
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN A---,
order Date to Time to
! SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
, •
.

INITIAL PROPER COLUMN FOLLOWING ADMINISTRAI7ON
°fl / Clerk/ PRN
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
-7-- 15
ito
111111 W18 M-S0y -IA) 6).-/
-Pe-M pc'', n ,
r,....9)
L..-

.7:-.5_
_LAMM '1 ..S 1-rk pkfni&-6-an (0-1 3 e(--N3 naka 5; \c.) \k-m\A1 u i; • -
... -3'Ocit-7
15 -111111 k co crt\--1 - - --ii i
Q,k-t--61e0
USAPA V1.00
MEDCOM - 14713

DOD-028102
•
' . R,S NAME/ NOM ET PRENOM RANK/ GRADE MALE / HoMmE 12. REASSESSMENT/ REASSESSMENT FEMALE / FEMME SPECIALTY CODE /GPM RELIGION/RELIGION
DATE/DATE (YYMMDD) TIME OF AFUuvAL /INURE WARRIVEE
S 07 LI-

2.war/ mot
TIME / HEURE ..-T,'. 11,0

72:A ii
FORCE/ ELEMENT

NATIONALITY / NATIONAUTE BP /PS
Air AF/A IGWM MUM
litP2ib
PULSE/POOLSBC/BC IGNBI /BNCGI DISEASE/MALADIEGIGI PSYCH/ PSYCH

3. INJURY / BLESSURE AIRWAY! TRACHEE e?.
RED, / RESP
FRONT / DEVANT

BACK /ARRIERE HEAD /TETE
WOUND / BLESSURE 219

DATE /TIME 13. gricA=Ergs I oticuosis es NECK/BACK INJURY !
DATE / HEURE BLESSLIRE AU COU/AU DOS BURN / BRULURE AMPUTATION /AMPUTATION STRESS/ TENSION \ 4OTHER (Sped/y)/ ALM1E Er.pedfiN5
(e) 06510Q i,viirtervi
igigj N 1/
_11)z 54-RPRErcilitsNMETZEisfaoUELN1747/11TANOS IV FLUIDS
4 VEL OF CONSCIOUSNESS / NIVEA/ DE CONSCIENCE
, 6 ALERT / ALERTE PAIN RESPONSE / REPONSE A IA DOULEUR

VERBAL RESPONSE / REPONSE VERBALE UNRESPONSIVE/SANS REPONSE
5. PULSE I POULS TIME / INURE 6. TOURNIQUET/ GARROT TIME / HEURE
riri
NO /NON YES / OUI
I

7. MORPHINE / MORPHINE DOSE /DOSE TIME/ HEM B. IV / IV TIME / NEI/RE
NO/NONGYES / OUI

9.GEATMENT/ OBGRATIONS/CURRENT MEDICATION I ALLERGIES / NBC IANTIDOT1)
TRAITEMENT / OBSERVATIONS / NIEUWE MEDICATION! ALLERGIES /ANTIDOTES

I , 0 ,„• .1.,,
cepti-ise ev v p7,1 Ex4---3,-,&.1
". IV1 .
._..-
_

f owoN, Li1 ¦ v‘..i.-
•
. .
IS. PROVIDER/ OFFICIER MEDICALE DATE/DATE (YYMMDC)

16. DISPOSMON / RETURNED TO DUTY/ RETOUR A L'UNITE TIME / HEURE
DISPOSITION

M. DISPOSITION/ TIME/ INURE EVACUATED / EVACUE
RETURNED TO DUTY / RETOUR A L'UNITE

DISPOSITION
EVACUATED / EVACUE

.11
.09
DEC ASED / DECEDE
17. RELIGIOUS SERVICES/ BAPTISM /BAPTISE

PRAYER /PRIER/ SERVICES REUGIEUXDECEASED/ DECEDEG ANOWTING / ONCTION COMMUNION / COMMumoN
M. PROVIDER/ UNIT/ OSTIOER MEDICALE/UNITE Gk..C.:1\ ' TYPD)
\;k.,DATTIDRIE CONFESSION/CONFESSION OTHER/ AUTRECr.i. c..)GIR
CHAPLAIN /CHAPELAIN DD Form 1380, TMS form repMces previamred/Uores U.S. FIELD MEDICAL CARD DEC 91Gof DO Fawn 1380 and DO Foul, FlGDICALE DE L'AVANT ETATS-UNIS
13130 (TEM, which are obsolete.
MEDCOM - 14714

DOD-028103
REPLACES DA FORM 5976, JAN 91, USABLE UNTIL EXHAUSTED.
MODERATE ,

DECEASED -^

Mass Casualty Incident Tag

$
©Eastern PA EMS Council - 1997

TIME 2 No

(A) (P) 41
AGE SEX M ) l
• A. it LUNGS 6cce 4 PULSE IA
1 If RESP.
Z7
.
B.P. I i Vic,

AVPU
¦ .

Patient Name (if known
Notes/Treatment ?ocs • br4.4",
cRr etur94--7C —7, PV ARIA
MEDCOM - 14715

1 . REPORTING MTF 2. . LOCATION
ADMISSION AND CODING INFORMATION
6 7 8 (State or
Country

1 2 3 4 5
For use of this form, see AR 40-400; the proponent agency is OTSG
Code.)
A \ \ ‘
\ a_---4._

3. REGISTER NUMBER NA E a First, Middle Initial) 4. PAY GRADE 5. SEX
11 12 16 17 18
9 ICI 13
..,---1---.

6. DATE OF BIRTH (YYYYMMDDI 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-
GROUND
N,..

-00 2- ---
=I 9

10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 36 37 38 FM • • IrelliMPOOMIIIMI 45 Mall
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 48 49 50 51 52 53 54 55 56 57 58 59 60 61
WIL Mill

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV. ADMISSION Country Code)
YEAR yN:
62 63 64 65 66 67 68 69 70 71
Ck

NAME/RELA HIP F EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION) AUTHORITY FOR WARD
ADMISSION \.,...S.......,
72

rs.,..i....Q. .... ADDRESS OF GEN 'Y ADDRESSEE (Include ZIP Code) -:.e--
E CILITY TELEPHONE NUMB EMERGENCY ADDRESSEE
.c.e¦s\t...._
\N......\,...

CIN._ .„
. TYPE OF DISPOS 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD)
73 74 75 76 77 78 79 80 81 82 83 84 85 86
Q

‘kN (t 0 -\ 5
24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION IYYMMDDI
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
'SZN l '\_N,. NitablAINOIMMI
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y YMMOD) (Battle Casualty Only)
103 1041 105 106 107 108 109 110 111 112
Illinilikallg.
NM

FOR LOCAL USE
1
'
L—

4-1
prat u`353 -Fro u yflo q /I (6--)((:))-2_. _t_ to
J • . •

ADMITTING OFFICER (Si• • equired) SI c G CLERK
4 -

.
r% A c AAAn on
DOD-028105

INPATIENT TREATMENT RECORD COVER SI-1(

For use of this forrk.asee AR 40-400; the proponent agency
1GREGISTER

12.GM flag, Fem.
GRADE ADMISSION REMALAS

E.PW
10GPREVIOUS
*omission

--.
ix &SR
13.GORGANIZATION -vc

qq It. wuoo ,•••¦•••••
5GMING
SIAM BRANCHLCORPS

4-7CC3 R 20GTYPE CASE
21 G&TanG

Er fa-Fatass& cunicstriiff
F ILO Yvi,
LATIONSFIP OF EMERGENCY ADDRESSEE
AC
28.GDATE OF DISPOSITION
laGADDRESS OF EMERGENCY 5 001E05EE110clude ZIP Codal
Tiji 0
28.GDATE OF TF1S ADAUSSION ADMITTING OFFICER

kil4 V\ 25G
NAME 5541 100811054 OF HELICAL TREATMENT FACILITY
0,GDATE Of INTIM

32.GUNITS ni WROLE MOULD COMPONENT TRANSPOSED
CAmt CANA..
.gkot )N Solail
DIAGNOSES1OPERATI PIS AND SPECIAL PROCEDURES

ts_AK--1.43G
vc soldier
Dx: slp

kin/TWA CAG) 0(41+00'
/

n.og-79,3/
35. Total Days This FacilityG
•
AOSENTSIFigii 111E5 c.

COME IV/COOP CARE OATS 010 osus

d.GSUPPLEMENTAL CARE DAYS J.GI.GTOTAL mai DAYS
35.GTotal Days All Facilitos
•GADTENT S1CA DAT(' -h.
LITHERDAYS 5.

CONY. EVECODP CARE OATS 1GTOTAL SICK DAYS
1
t.ITAMTUiXiiAlTEMAIIGMiDIC;IEIFFICER

VW"!
DA FO
ICEAPPCVI ,,i

MEDCOM - 14717

DOD-028106

MEDICAL RECORD
ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION
(Enter dale of admission)

Li/j 511SA--a4— c/Nrri ir„1,10,1\4,,i
PHYSICAL EXAMINATION

tAi\i) An-0 6---4-6
co‘n,fi,-(142.

PROGRESS
(Enter date of discharge and final diagnosis)

PATIENT'
or Typed or written entries give Name
, first,

ddle; grade; date; hospital or medical facility)
(4cArl--
MEDCOM - 14718

4&..-/v/4/0
-

-)J19 /14/3„c7
4i-tit
ORGANIZATION
REGISTER NO.

WARD NO.
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES AOMIMSTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA (41 CFR) 201.45.505 OCTOBER 1975 USAPPC V I DO

DOD-028107

AL. RECORD

All I I 1. 011 I.. )CAI
Iii- Ii
PROGRESS Nal-Es
NOTES

C1430 .
I.
e...T4-16s

.f24 E 6

rnada_or-62.-(4--Lta
ecc(AIJ .
CP- chQtTI­__ inr.r
_hypaic24.)/Cp

. . ccmg-Pee/
.±0-. Z7. LIZQ_hoo ej I .az-400
1.t
.6.../Acc.1(5 catered _
Cn
31c
• ­
0).('

1._.... ...__.. LAS I SPONSOR'S NAME FIRST
HOSPITAL OR MEDICAL I-ACILFFY I 1)1 . 1`4 1 If ICA ION -;/,,, pea wiqten effitics. Natilo • last, first, middle.:11) A,•• ¦¦ N SSN• Oat& of /la,:, "Grade) REGISTEF fvIAIN I A I
PROGRESS NOTES Meciica! Record
STANDARD FORM 509 hy GSA:ICiv111 WWI 1 ,11CI-1.11 10

MEDCOM - 14719

DOD-028108

NOTES

TE
„ \

(4,2,0,_

11---00 I'Cl_ieVu,-c. r---kDA .---- \(:_.c:)_,_:S/ c_?_L..3_ ac
.,' 2,­
.-
_-Ifr

C.-79/0 1,,,c.k.S\,(er)(A4-L'i__c_di,e7-Ns
c_o__,_„;

... *C) r -C.a..V) ..kiq_
_.-'.0!;_,____s_iK-1N „g___­
tIC

isa6c6 _ cujkc_ace:_`!..z
CI sboold4K PS(.7
scmnedni _du& tadat, Vem&scomg4
wior,
rek_vrfctL,._pc,Leh;cp:n__Akez..
17.a.turoo:it\e_A
—c-jutt

wt,01 3cL WLAAr\""Q"'
9

fv,aysAYtric,(¦014(M\
itAkv4/

\1SS
IG9

CiPt,

‘1/4Af=6D
¦0,1,,, -k, t kr_14 bowydki..,
Ju-e . Vz;" 0 s____P‘. _J)w...b._9 _
_;f:Q/-v_5-u-,,_ ) c_o_42______-_Oca_a___-_-ase_s_ .__ _
\O-1(3--
MEDCOM - 14720

DOD-028109
IEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION PROGRESS NOTES
NOTES
40

frt PT
0 ( 3 0 CACILOA,
rpt
• AIL '

IIP TO SPONSOR
PUNSOR'S JO NUMBER

ASSA/of&W
VICE
RECORDS MAINTAINED AT
NTIFICATION:

'for typed or written entries, give: Name - last, first, middle;
ID No or SSN . Sex • Date of Birth; Rank/Grade/

WAri0 NO.
/ UUD—

1-PROGRESS NOTES
*°).L1

Medical Record
STANDARD FORM 509 IR
PrescOndWRRABrmmummirmml,
MEDCOM - 14721

DOD-028110
JE
_Cs-prv-k GA CYc 4-c) U2 .
MEDCOM - 14722

DOD-028111

LAST NAME
FIRST NAME
MIDDLE INITIAL

ID NUMBER
11 CZe P t C_c; mosioti 55 mac 44 grek °ACC) NOTES
A.). 06 671 .J vase 4-
rs-6- -k)
G- e-feu io

A A.: IliitsaG
Al 41

Lit
S ANDARD FO M 509
IREV. 5/1999IBACIC USA:WA V1.00
MEDCOM - 14723

DOD-028112
AUTHORIZED FOR LOCAL. REPRODUCTION,
PROGRESS NOTES

MEDICAL RECORD
r) ( ---d-Artfe-

DATE 0( Tryi (..)GLi---A) a...._____.
p.d-rzil,0 1-ttAAA_____
(4--
.(CO6c-c
C-(2 ----
?1,1"-N

ic,-----L)
b PA'
,---tv tikA C,-,,-. fi)-2 Do .3
-
1
(c)(`-¦--1_

PONSOR'S ID NUMBER
RELATIONSHIP TO SPONSOR

SPONSOR'S NAME

SSN or Other!
FIRST
LAST RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITYDEPART./SERVICE

WARD NO.
REGISTER NO.

I I
(For typed or written entries, give: Name - last, first, middle;
PATIENT'S IDENTIFICATION:
ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203(b)(10)
USAPA V1.00
MEDCOM - 14724

DOD-028113
0040-00-8I4-4176
HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE 600_l08
SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION (Si n each ent

CG v)f
ED -L
Cr).
pkiker-ill 't ( acti-t cAx-)
eaeiNt444.

(cAll
coA--7-
41

4-tout 0 c AA° irj1--
14-1
itte r 0.e
Z

D300
NT'S IDENTIFICATION
st) (Use th
e •r ec anzea

PATIENT'S NAME
(Last, First, Middle initial)

RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
DEPART./SERVICE
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDCOM - 14725

NO -Z1
SEX

RANK/GRADE
ORGANIZATION

DATE OF BIRTH

STANDARD FORM SOO (REV. 5-84)
Prescribed by GSA end ICMR FIRMR (41 CFR1 Pni_en ravx
DOD-028114
ZAT ION (Sign each entry)
DA1 E
1 C-01,V%/. C y U. Trb./1h *) 0
01 2-e8 1(vIs cer A, (.01 50-0 -6,s51xy .
76 lt-\ /0 ia Ur k at. Athol, g.,
i t— 5 S icy OEM
JlIa It
.¦

4-0m-mnft, )(1 • Ono.si Id C)
' —i-1-0- l') paIv n.ve.:( 9-r cARI2 .. 1,T-,-Aileiur 1500 3.421cI4eA-CO3 . Pa sir of At-4w , gip ctriviue4 a-0 Cu eR bryta ft c1 1460j. gOAK5-0Pat i C i eileL, ))1144,1¦41" , 65-X q , Ect, 4,161.). FA
t-t ( Ate c o',6 c Ab 1,( 01-- uuPec/-70A i . VS-5 ' Pr t 6 Y )( 9 Fovey dyAi-xit)'? Mao or-TA-e, Gocci P/45 no PI( ,efrivt-e,t. /I y .
V( ( to(A-' 40 AA0 vrc., P , A)
ll

724.43 DI rt4er 4r eve.-A49 64.0a, (2,,det • /¦
—MI N
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'U.S. Government Printing Office: 1995 — 387-722120035
MEDCOM - 14726

DOD-028115
NS N 7540-00-634-4176
MEDICAL RECORD
AUTHORIZED FOR LOCAL REPRODUCTION
DATE CHRONOLOGICAL RECORD OF
SYMPTONS, DIAGNOSIS, MEDICAL CARE
03 TREATMENT, TREATING ORGANIZATION /Sign

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(For typed or written entries, give: Name - last, first, middle; ID No or SSN;
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retio (9(c\-1/47 CHRONOLOGICAL RECORD OF MEDICAL
CARE
Medical Record
STANDARD FORM 600

Prescribed by (REV. 6-97)
GSA/ICMRFIRMR (41 CFR) 201-9.202-1
MEDCOM - 14727

DOD-028116

SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE

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Printed on Recycled PaperFPI. LEX.

MEDCOM - 14728

DOD-028117
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)
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RECORDS MAINTAINED AT
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cma-

CHRONOLOGICAL RECORD OF MEDICAL CARE
Av Mir Mico
Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 14729

DOD-028118

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FPI. LEX. Printed on Recycled Paper
MEDCOM - 14730

DOD-028119

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) 'Cr .,
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VI

RECORD MAINTAINED A
AT

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 SSN; Sex; REGISTER NO.
WARD NO.
Date of Birth; Rank/Grade.)
I CM .9-

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 IREV. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 14731

DOD-028120

MEDICAL RECC DATP T ..•.- y „ , •
r-
-
• •

,;0AL O P. ,V!L
ICAL .
NA ME
¦ OENT4'ICAT
-•.
MEDCOM - 14732

NSN 7540-01-075-3786
MEDICAL RECORD TIME SEEN BY PROVIDEREMERGENCY CARE AND TREATMENT
(Doctor)
TEST RESULTS
WBC
U U ;,:e • . 7 PLT H 7//H(,Lf (.1 4 3.6 /6 6 Pe3 PCO2 SUP 02 ABG/PULSE OX PH SAT OTHER P02 RESULTS eic41 — 1-'47 — RADIOLOGY 04.14-1-"› li-ao--cs: Check if read by radiologist .
PT • bc, DIP EKG INTERPRETATION
APTT BHCG ETON GLU cRo- ti MP: 5°1,2$ 144

PROVIDER HISTORY/PHYSICAL
ivvr-1

fro/ -AO'
A-0Q AW7 1444,-r-c_42,./arsc,4-"e --c:P-T-6--.11
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L 1._ M \
CONSULT WITH TIME
ACTION

RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP
C•YtP
6 Ae 4,e4w(
PROVIDER SIGNA

DIAGNOSIS
09/ f6
5 "CcA')
C!), C e.te:
C., . tu 0
() 6.s., 6-Fe.ri Aro,
C.)

PATIENTS IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other): hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101 -1 1.2031b1(10)
USAPA V1.00
MEDCOM - 14733

DOD-028122
NSN 7540-01-075-3786
LOG NUMBER TREATMENT FACILITY
.

EMERGENCY CARE
fort T
MEDICAL RECORD AND TREATMEN T
RECORDS MAINTAINED AT
(Patient)

PATIENT'S HOME ADDRESS OR DUTY STA ARRIVAL STREET ADDRESS DATE Way, Month, Year) TIME ( 4Jt,.(ci o5 c9 --3e
STATE ZIP CODE TRANSPO - TATION TO FACILITY
CITY
SEX DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
ITEM MI NO N/A ITEM NO PRP ADDITIONAL INSURANCE • -HONE DD 2568 IN CHART
AREA CODE
AGE 111=1.—.1111..
• NUMBER MEDI • HISTORY OBTAINED FROM NAME OF • : • -ANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO
Y NO

illifir l
u
IS THIS AN INJURY? WHERE TGUS ALLERGIES INJURY/SAFETY FORMS DATE LAST S. '• COMPLETED INTITIAL SERIES HOW • YES II NO
, 60s.1/4
CHIEF COMPLAINT
CATEGORY OF TREATMENT VITAL SIGNS
TIME TIME

• EMERGENT
BP
(v5 St PULSE

Er URGENT
,NIT RESP _Sky. TEMP MI NON-URGENT
\II" wr l , 64 5)
ILAB ORDERS]
X-RAY ORDERS ,

›..' CXR PA & LAT/PORTABLE C-SPINE
ACUTE ABDOMEN LS SPINE
SINUS HEAD CT
ANKLE I:Mr\
5F9 derg.-.--)

CBC/DIFF A G PT PTT BHCG/URINE BLOOD/QUANT
CHEM: 11,C eijr.5
URINE C&S UA MSCC/CATH
BLOOD C&S X
ORDERS

in PULSE OX 13:a MONITOR ECG TIME ORDERS COM TIME PATIENT'S RESPONS
C.
f%i

efd*-fole,(1) (..6ted r¦ 75z
DISPOSITION DISPOSITION F • ISCHARGE INSTRUCTIONS
ri HOME ri FULL DUTY 24 HRS. n 48 HRS. n
.

MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN
REFERRED OP.

0 IMPROVED 0 UNCHANGED
I have received and understand these instructions.

TIME OF RELEASE PATIENT'S SIGNATURE
0 DETERIORATED
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- lest,
first, middle; ID no. ISSN or other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/IC MR

-
411111m(c
FPMR 141 CFR) 101-11.2030)1110) USAPA V1.00
MEDCOM - 14734

DOD-028123

a. •
PREOPERATIVE/POSTOPEIL. AVE NURSING DOCUMENT
,).
R :.COR

FOR Use of this form. see AR 40-407: the proponent 3gency is The Office of the Surgeon General
2. OWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication) NKDA . PCN 0 LATEX IODINE 0 TAPE 2 FOOD
I . AGE: 21V Yk -c
REACTION:
HEIGHT:

3. PREVIOUS SURGERY [ NO TS (type): KerKAATvx..t_
WEIGHT:
117,JR.

4. PROPOSED SURGICAL PROCED
91/1/0-14-1 '
ry d Lr
ADDITIONAL INFORMATION:(Previous surgical and medicalAsto ) Skin Condition5.
Tobacco ppd X yrs. Body Piercing tik Diabetes (Y) ROMe A-114," 1.-7-4.4t.ARYlotrin w:72 hrs (Y) (N) ETOH Implants Respiratory Disease (Astluna.•COPD) (Y) (tfi Anticoagulants (Y)
?-57

Dentures 79¦ Hypertension (Y) (N) Herbal Medicines (Y) MEDS:
Glasses/Contact (Y) (
7. PATIENT GOALS AND EXPECTED OUTCOMES S. OR NURSING INTERVENTIONS
6. PATIENT P,ROBLENIS AND NEEDS
c Allow pt. to verbalize freely.
°SOCIAL o Pt. verbalizes any specific anxiety. c Explain OR environment and answer
Potential for anxiety related o Pt. Exhibits relaxed body posture.
to: questions regarding surgery. c Offer comfort measures. (e.g.. warm
(l) Surgical Procedure
blanket. touch).

Ooeratin9. Room Environment
c Explain all nursing procedures before
2) Separation Anxiety they are done.
(Zd)
a Remain with pt. whenever possible.
/3) Surgical Outcomes c Maintain family interface. Parents to stay with pt.
B. AER. TION Potential for respiratory
7
dysfilnction due to: 1) Positioning 2) Effects of Anesthesia
3) Medicanmoking History

C. INTE UNIENT Potential impairment of skin integrity due to: / I) Intraoperative Immobility
f/-2) ESU Pad Placement / 3) Positional Aids /-4) Prosthesis
5) Pooling of Prep Solutions

o Pt. will be able to breathe without
difficulty during immediate intraoperative phase .
o Pt. will not exhibit signs of impairment of skin integrity (e.g., reddened areas).
9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
12) (6Y( ¦ --LI
DA FORM 5179, JUN 91 Previous editions are obsolete. MEDCOM - 14735
a Offer to elevate head of litter or offer
pillow.
a Observe pt. while awaiting surgery for
signs of distress.
a Assist anesthesia dining !ntubation
and extubation.

c pressure preventing devices on
OR table and accessories.
c Check for,proper positioning and
support to maintain good body alignment.

o Pad pressure points.

o Place ESU ground pad on non compromised skin surface area.

o Keep prep fluids from pooling.

VERIFICATIONS AT HOLDING AREA: ! ID/Allergy Band ! Dentures Removed
! H & P . ! Contacts Removed
! NPO Since ! Jewelry Removed
! L1-ICG/LMP ! Body Pierce Removed

! Consent/Blood Transfusion Signed/Witnessed:Dated ! Surgical Site/Consent verified by
PL/AnesthesiaiSurgeon ! Contact Precautions (Y) (N) ! Family/Friend:
I:5A P. % . ;

DOD-028124

LENT PROBLEMS AND NEEDS
o enGfor inadequate tissue perfusion due to: Intraoperative Mobility
,--. 2) Positionin g G3) Existing, Diseitse G4) Safety Devices
-----5) Hypothermia
E. NE OMUSCUL.A.R CO
E.1.GPotential impairment of
mobility due to: r"--1) Pain 7-• 2) Intraonerative Hazards
3) Prosthesis
G4) Positioning
5)" Transfer pt. to/from OR table
Potential discomfort due to:

1) Length of Surgery
G2) Positioning
G31 Arthritis

F. SPE IAL SENSES
F.1.GDiminished visual perception due being:
-I) Pre-Medicated
\V 0 Glasses

F.2.GPotential for decreased
communication due to:
G1) Diminished Hearing
G24 Language Barrier

F.3. GPotential injury due to denrurcs: 1) Ulmer G4) Cans
77-1) Lowe-5) Crou-ns ,-G3) Bridees
G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
o Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse.

o Pt. will be transferred to OR table without
difficulty.

o Pt. will not experience unnecessary
physical discomfort.

o Pt. will be made aware of ser7oundin2s
prior to anesthesia induction.
c Pt. will be transferred safely to OR table.
c Pt. will be able to understand instructions.

o Minimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of ave goals and
outcomes.
8. OR NURSING INTERVENTIONS
o Check for support stockings or ace wraps. If none, check with doctors.

o Check that safety straps are correctly applied.

o Offer pillow for under knees.

o Place and take down legs from stirrups with slow bilateral motion.

o . Check that rings and all body niercing has been removed

.

o Have sufficient people available for transfer.

o Insure proper body alignment.

o Allow patient to lie in position of comfort while waiting for surgery.

o Offer support (i.e.. pillows. bath towels. etc.) for positioning.

c Introduce self. Keep pt. informed as to
where he. she is and what is happening.
c inform pt. in which direction to move
and assist if necessary.
c Speak clearly and slowly.

•
Address pl.
c Validate pt.'s understanding of verbal
communication.

•
Verify removal of dentures.

OTHER NURSING INTERVENTIONS
Or continuation of above mtcrve lions

OMPLETE D/A DITIONAL INTRAOPERATIVE INTERVENTION S NOTED.
rc prr ATE
11. POSTOPERATIVE EVALUATION: 'SKIN INTEGRITY: Bovie Pad Site: = Clean and Dry E Red O NiA DRESSING DRY & INTACT
LEVEL OF CONSCIOUSNESS: 0 A&O . DrowsyG:.... SleepyG0 lntubated (Y)(N) BREATHING EASY:
LEVEL OF ACTIVITY:G. Moves All Extremities GD movesUPper Extremities
(Y) (N)

. Transferred to liner with roller due to spinal
12.
PREOPERA

13.
POSTOPERATIVE EVALUATION PREPARED
(Signature and Titl

BY (Signature and Title)

DATE: (3 G
DATE: TIME:

REVERSE OF FORM 5179, JUN 91
USA PA V I
MEDCOM -14736

DOD-028125

•

--• , • Tt. P; . r/i;.: 5 ' -' •
1.-•7 "( 4:: .1. " ' l. INTRAOPERA ..., E DOCUMENT $t; or use of this form, see AR 40-6E1, the proponent agency is the office of The Surgeon General.
. 4,,s ,.G.t. ,:,.p. i -.. rGPAVEG'Gitik:rgrp'PPERATiN. G oomGa . ,..7 /. ,2. PATIENT ND PROLE Illktki
.'0'G'.'.
0 AA'sG,.
•., ,Gi':.''... ,: -G tc ( ICG**) VERIFIED BY
3:' DATE •G, TIME PATIENT ARRIVED IN SUITE 4. PATIENT I-IGlid C)G ( C., LAY'.G'—') o-9..._. TIMEG/c..-----( .k:3\r-(-NUMBER
5. PREOPERATIVE EMOTIONAL STATUS %ALM ¦ ANXIOUSG¦ EXCITEDG• CRYINGG• ANGRYG• WITHDRAWNG
• OTHER (Specify)
COMMENTSN 160 11-1—

/ k p 0 1) A".1 ki
6. NURSING PERSONNEL

r1---,,,,..,
ASSIGNED P c--( V7,5 / ) RELIEF
SCRUB SCRUB
(0 1

ASSIGNED l RELIEF
CIRCULATOR CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify) ,
• SUPINEG• LITHOTOMYGU PRONE . KRASKEGLATERAL:GLEFT SIDE UPGU
RIGHT SIDE UP

COMMENTS :,,..„7
3 6,,g_,_,A ,_ 1F,-pa-).7e-1,-,--,, pc v( o-,-) a . oce„ ,t4. ,-,,,,,fit.,.., A.- b.66ge--11 te-31
8. SKIN PREPARATION
HAIR REMOVAL EG• NO PREPGION (Specify) rG C.i....,Z-

DONE BY: OR GU 9URSING UNIT SITE .G2477GY WHOM:
METHOD:GMI DEPILATORY RAZOR SITE•G BYGHOM: T.G

. CLIP fi dt,C. G
COMMENTS:G C f--)-742,,t COMMENTS: lipG —G cq(C 1 "Z-
•

9. LOCATION OF EXTERNAL DEVICES
Q.. it
... 41
-

' Nit
11111111.11air

. '
.• MMad tor*
,a1---1-1...,..4aNaNsgs--¦- Op
,4.0-­
.

.....* lrimr
t: intb-v)
"St.....

LEGENDGX G -G.trapG., ,- ..-... 'hiquet
orrectGI = IncorrectG

b) ( (z)) --. Z--

First Closing Final Closing
10. COUNTSG_ Other• • Count
Count SCRUB CIRCULATO •
SpongeGVIGes . No

111111111111E11111111M111111111Wa ' III
Needle SharpSharpGP_2 Yes U No
111•1111L111111111¦1111111IMPL 1111111H
ILMI7
InstrumentG• YesGFAG'
OtherGal YesGNo
11. PATIENT IDENTIFICATION (For type , or written -ntries give 12. E ECTRO•URGERY DEVICE(S) (ESU)G[EIE ¦ NO
Name - Last, first, middle; Grade; Date; 'spiral or edical Facility;)

vc
ESU NO:G

(.0 4-
GROUND PAD: BRANDG
4-/A-N-LTC____

LOT NO:G 1-2.
¦ ESU NO: t'IC)—(1
GROUND PAD: BRAND LOT NO:

. BIPOLAR NO: -
*AS ' \G CA.04" 1 17
-----. .--..... .. .......---RAM-11-st-NRA 4 A707 4 REPLACES C ICH IS OBSOLETE. USAPA V1.01
DOD-028126