€¦ · DOD-033816 REGISTER NO. WARD NO. MEDICAL RECORD I PROGRESS NOTES DATE NOTES aZ ,`9 5 .) /l...

DATE

Arm* al a a A

AST NAME MIDDLE INITIAL ID NUMBER

. K.4

• Agromisce

• -_Aal ye.

Aa AI AA I 0$! on at\OISNeek-f(i). Pr; 'moo wa

lorl di Oft ni A N P( ano/rutdo (a. b12., (=Orb . ! • qt_ou) t .uLifNto

1)JUI aN\-- KG■06) a lo ss vb DLt

NOTES

U 40 * 0 At" 1_0 1.t__.0 4 A IL A CA • ._1_44

-- ■. a .' slop .:1,1 , 0 AAA___b j / 0 #t* 1 I . ./11 ° _. _ _. 1 i a(2„ TUC \-toprs cW,t-

t3s)k-cfrE L_VsjA OV,ivrtsDn(tc\

MEDCOM - 20241

FIRST NAME

DOD-033815

ACLU-RDI 1656 p.1

DOD-033816

WARD NO. REGISTER NO.

MEDICAL RECORD I PROGRESS NOTES

DATE NOTES

aZ ,`9 5 .) /l 774 ) ., .

1- -? -(3.-r --ex-e" ,-') . e War Z-)

k ,

6al-L1,-; ■-•Liz' • ---- r>,1 a2., ../. .c._. _,.. ✓

CAt' dh i tir ,

„

--r",7", )--21"' -• ../

- /72c1, ' ,f--) -, ----,-4-s",/-Y;;--1/.--

/ • .„....,_ I- ,

),Z7 ;256 1)/) , JO •)‹ 1D .1 .

1 4" '

<--- 1..., "---1.-c

RELATIONSHIP TO SPONSOR

DEPART./SERVICE I HOSPITAL DR MEDICAL FACILITY"

SPONSOR'S ID NUMBER ISM of Otbed LAST FIRST

PATIENT'S WENTIFICAT/ON: /far typed or written mines, give: Name • landist, fnifdlc•

1C Na of SSM• Sex; Dee of Bit* RatilArede)

low EL)(G),(i PROGRESS NOTES

Medical Record

STANDARD FORM 509 IREY. MORI PracnIsd by GSAACIIR FPMU ‘41CM)101.11.2D31131110)

USAPA VI.00

MEDCOM - 20242

SPONSOR'S NAME .

RECORDS MAINTAINED Al

ACLU-RDI 1656 p.2

sti 63- pf A-re, p' c/0 rc). -6; r rtro

tAiore

k - F;Sco.r-A 4 AR, PAI. riu,x4ri , p rei-e

- e

PATIENTS IDENTIFICATION: (For lYPIti or mine?. egUir4 ply Pent • kat an didk • ID No co r Sat Seg. Dna el Bitic fisalanal

IUTH ICED FOR LOCAL REPRODUCTION

■■••••■•■10

MEDICAL RECORD PROGRESS NOTES

SPONSOR'S NAME LAST


DEPARTISERVICE HOSPITAL OR MEDICAL FACRITY •

MI

RECORDS MAINTAINED AT

SPONSOR'S ID NUMBER ISSIi waiter) FIRST

I REGISTER NO. WARD ND.

PROGRESS NOTES Merkel Record

STANDARD FORM 509 MEV. WINO Pr.:wiled by GRAMMA FM 14ICFle 101.11203INI/0

US ?A vita

MEDCOM - 20243

DOD-033817

ACLU-RDI 1656 p.3

LAST NAME

I MAST NAME

I MIDDLE INITIAL ID NUMBER

DATE NOTES

CALLith ajtaia) O WBA-T- s CLitti OLE. I tiaffd Mk kri. --)wmAovad t/t/fad c 2f---p-(do

(3 Wi_A) W Es01.61YL4 MAY i)Le-,eiataz A,o-ktivt

eV( c cl AATAit fiA & PAl (_10-

STANDARD FORM 509 RV. 5i1099, BACK USAPA MOD

MEDCOM - 20244

DOD-033818

ACLU-RDI 1656 p.4

MEDICAL RECORD DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/

STATUS .. DEPART./SERVICE

SSW) NO. RELATIONSHIP TO SPONSOR

'RECORDS MAINTAINED AT

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

AUTHOR/ZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE

PATIENT'S IDENTIFICATION: Woe typed or written envies, give: Name - lest, fi Dote of Birth; Rank/Graded

middle; iddle; Ill No Or SSN; Sex; IREGISTEp NO.

WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM BOD (REV. 6-97) Prescribed by OSARCAIFI FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20245

DOD-033819

ACLU-RDI 1656 p.5

HANGED

CONDITION UPON RELEASE

❑ IMPROVED UNC

❑ DETERIORATE

"TO WHEN

CATEGORY OF TR TMENT

0 EMERGENT

ICJ URGENT

❑ NON URGENT

URINE C8S

PULSE OX TIME

PT/PTT UA MSCC/CATH

ORDERS

CXR PA & LAT/PORTABLE ACUTE ABDOMEN SINUS

C-SPINE

LS SPINE

HEAD CT

n RESPONSE

DISPOSITION

HOME n FULL DUTY MODIFIED DUTY UNTIL

DISPOSITION QUARTERS /OFF DUTY n 24 HRS. n 48 FIRS. n 78 HRS. RETURN TO DUTY

PATIENT/DISCHARGE INSTRUCTIONS

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

REFERRED ION.

I have received and understand these instructions.

PATIENTS IDENTIFICATION (For typed or Rattan entries, give: Name — lest, first , middle; ID no. (SSN or other); hospital or medical facility)

PATIENTS SIGNATURE

TIME

BP

PULSE

RESP

TEMP

ti

ID cc 0 co

NSN 7540-01-075-3786

EMERGENCY CARE AND TREATMENT

(Patient)

MEDICAL RECORD

RECORDS MAI AINED AT

PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS

DATE'Day Mon , Nu) TIME V,oci

CITY STATE ZIP CODE TRANSPO TATION TO FACILITY

rySEX

,

DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO

PRP ADDITIONAL INSURANCE AGE

.-. ,..1

3 1--

HOME PHONE FLYING STATUS DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS

\c tb ffi' \

INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN n YES n NO IS THIS AN INJURY? WHERE TETANUS ALLERGIES .

INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTMAL

SEND YES ❑ NO i) ti rl\ 6

HOW

CHIEF COMPLMNTr

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-96), Prescribed by GSMCMR FPMR (41 CFR)101-11.203(bX10) USAPA V1.00

MEDCOM - 20246

DOD-033820

ACLU-RDI 1656 p.6

NSN 7540-01-075-3766

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

Check if read by radiologist ❑

ABG/PULSE OX RADIOLOGY

SUP 02 PH U

U P02 RESULTS

C.)

2 co

WBC

H/H

PLT

PT DIP

EKG INTERPRETATION

PCO2

APTT

PROVIDER HISTORY/PHYSICAL

BHCG ETOH GLU MICRO

SAT OTHER

ki/icr-vt Amon.61(m. h( 011.1.1

mq_2_

411111111111■

TIME CONSULT WITH i ACTION RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP

PROVIDER SIGNATURE AND STAMP

DIAGNOSIS

Ill O 0

PATIENTS IDENTIFICATION For (Wed or written entries, give: Name—last, &M. middle; 11:1 no. (SSN or other); hospital or medical facitny)

11111111 (40-1 EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSAACMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 20247

DOD-033821

ACLU-RDI 1656 p.7

510-112

MEDICAL RECORD

NURSING NOTES NSN 7540-00-634-4123

k.,611 an 1 ItilCJ)

DATE A.M.

OBSERVATIONS P.M. Include medicaton and treatment when indicated

0 ,... ....... I'

FRIMIrMENNIMINEVI■ la. i • AVIIMANIK L. f - - c

.

M I . i 1 . A. t • Erb .,S PU( \\ . 3 t, ('

r .

(_ v (()---

. .

Int-infiri i,. nn renimr•rs r•;.-1...1 PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate;

hospital or medical fad ity)

REGISTER NO. WARD NO.

NURSING NOTES

Medical Record

STANDARD FORM 510 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20248

DOD-033822

ACLU-RDI 1656 p.8

A. PSYCHOSOCIAL

---<;otential for anxiety

related to traumatic injury; language barrier;

surgical environment

B. AERATION , -----Potential for

respiratory dysfunction due to sedation; positioning; injury

Pt. verbalizes any specific anxiety.

Pt. exhibits relaxed body posture.

C. INTEGUMENT

impairment of skin integuity due to bovie pad; position; fluid shift

PT. will not exhibit signs of impair-ment of skin integrity (e.g., reddened areas.

9. PATIENTS IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)

MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT For use of this form. see AR 40-66: the proponent agency is The Office of the Surgeon General.

1. AGE:

HEIGHT:

WEIGHT:

2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):

3. PREVIOUS SURGERY ] NO

YES (type):

4. PROPOSED SURGICAL PROCEDURE:

Leit I-62r/

5. ADDITIONAL INFORMATION: Last PO: Medical FIN: Jewelry removed: yes/no Family waiting: yes/no

Implants: Medications:

6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS

Allow pt. to verbalize

ree4plain OR environment nd answer questions egarding surgery.

Offer comfort measures, e.g., warm blanket, touch)

Explain all nursing rocedures before they are one.

Remain with pt. whenever ossible.

o Maintain family interface.

Offer to elevate head of itter or offer pillow.

Observe pt. while awaiting urgery for signs of distress

Assist anesthesia during tubation and extubation

Utilize pressure preventing evices on OR table and ccessories.

Check for proper ositioning and support to aintain good body alignment.

Pad pressure points.

Place ESU ground pad on n compromised skin surface

rea. Keep prep fluids from

ooling.

1111111111(96s)1

DA FORM 5179, JUN 91 Previoius editions are obsolete.

USAPA V1.01

MEDCOM - 20249

DOD-033823

ACLU-RDI 1656 p.9

7. PATIENT GOALS AND EXPECTED OUTCOMES

--K- Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse).

8. OR NURSING INTERVENTIONS

o Check for support stockings or ace wraps. If none, check with doctors.

eck that safety straps are correctly applied. o Offer pillow for under knees. o Place and take down legs from stirrups with slow bilateral motion.

9. PREORERTIVE EVALU (Signature and Title) 1,14:\

BY 13. PREOPERTIVE EVAL BY (Signature and TitI

DATE

14. POSTO ION:

DATE: 22.24(153. TIME: loll 1 DATE: —22 I

REVERSE OF DA FORM 5179. JUN 91 USAPA V1.01

MEDCOM - 20250

6. PATIENT PROBLEMS AND NEEDS

D. CIRCULATION

Potential for inade- quate tissue perfusion due to anesthesia; traumatic injury; position;•simtt;,.prc.v-itltrs-SMFr ry

that rings have been removed.

Have sufficient people vailable for transfer.

insure proper body lignment.

Allow patient to lie in osition of comfort while aiting for surgery.

Offer support (i.e., pillows, athtowels, etc.) for

positioning.

Pt. will be transferred to OR table ithout difficulty.

Pt. will not experience unnecessary physical discomfort.

E. NEUROMUSCULAR CONTROL E.1. --Potential impairment

of mobility due to sedation; pain; inittry

E.2. _ Potential discomfort due to injury; pain

F. NEUROMUSCULAR CONTROL F.1. ,...--13Mminished visual perception due to being injury: sedation;

F 2 /Potential for decreased communictaion due to language

barrier; sedation

F.3. Potential injury due to dentures.

Pt. will be made aware of s rroundings prior to anesthesia

duction. Pt. will be transferred safely to

R t ble. o Pt. will be able to understand

tructions. o) danger of injury during intraop period.

iiIntroduce self. Keep pt.

nformed as to where he/she is nd what is happening.

inform pt. in which rection to move and assist if ecessary.

Speak clearly and slowly. Address pt. from

-e--;11-01/7 side. b Validate pt.'s understanding of verbal communications. o Verify removal of dentures.

G. OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.

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

OTHER NURSING INTERVENTIONS. Or Continuation of above interventions.

10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.

DOD-033824

ACLU-RDI 1656 p.10

1 ARRI

121CALM ❑ ANXIOUS ❑ EXCITED .

COMMENTS

CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)

2. PATIEN

VERIFIED

1. PATWNITRANSPORTED TO OPERA VIA 4■I eL.,

3. DATE TIM

e2.2, SUITE 4. PATIE

TIME, iRy& ERATIVE EMOTIONAL STATUS

MEDICAL RECORD INTRAOPERP' tE For use of this tom, see AR 40-407, the pa

IMENT is the office of The Surgeon General.

WED AND PR CEDURE

4

NUMBER 5. PRE

Sponge

Instrument

11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

6 Nt RSTNG PERSONNEL

ASSIGNED

--_

m twA_

SCRUB SCT ,-7-...;-:.---• ----RELIEF

.. SCRUB

ASSIGNED

___ AND _______

tAkit — RELIEF

:1‘,1:-;•

1$kf's- — EOC.) CIRCULATOR _ ....,.. ........ . .. __CIRCULATOR

AIDS (Specify)

cki SUPINE ❑ LITHOTOMY 0 PRONE ❑ KRASKE LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP

COMMENTS: CIA6 (314_ Ctivin_bc)ctACCO L.-, 6 ° Ccete4c,-(2-0 t q

8. SKIN PREPARATION

Er YES 0 NO DONE BY: METHOD: ET--_OR ❑ NURSING UNIT SITE: Liz,. A p-. vp_e_t, B WHOM: rwij

❑ DEPILATORY 42RAZOR ' . SITE:. Li BY WHOM: 111 CLIP _. ____

COMMENTS: 4$ Ke.k.c_e.5 617 d.i...4.-+ 9. LOCATION OF EXTERNAL DEVICES

• . 1*-.011111111 --"'"•---oisimaromp- iropp.4-40111111*r.

•

HAIR REMOVAL PREP SOLUTION (Specify) boskot,

. •, • ttimikdiENTS:

LEGEND et

10. COUNTS

Other

RIMS

102311 1M211111/111=1111111111111IN INMYIME 0111M23211111111111MIE1 PM111601111 11111111

_ Yes -g" o

= Correct

Incorr First Closing

Final Closing

Other• • Count

Count

12. ELEC OSURGERY OF.VICE(SI (ESU) IZYES 101 NO Cut - 30 coa 3c--/

ESU NO: V &IL-QS &Are CibTI:rro GROUND PAD: BRAND'

• C0-4,A sL

J LOT NO: —70")/ I Er.,E$A1 NO: •7'- -.•7:43DUND PAD: BRAND

LOT NO: ❑ BIPOLAR NO:

DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179.1 (TESTI, DEC.82, WHICH IS OBSOLETE.

. . MEDCOM -20251

USAPA V1.00

DOD-033825

ACLU-RDI 1656 p.11

13. PROSTHESIS, IMPLANTS sgt,. 'JO IF YES NAME: ID NUMBEh, .CTURER

1 4. `:'1W'''''',:a6.9111440124agiti.(g4VA'MEDICATIONS/ORE)ERSIATii,r4a, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA}

e-

eigr4*

tAJC-27

S çivt

CLUOVekt41.--k_.

FAC '4% 6 V`-ee Ct arit/Kr .

4

20. OPERATION(S) PERFORMED

21. PATIENT TRANSFERRED TO

CLL

RAI 5179-1, OCT 87

. • • • • ■ —■

MET 9D

USAPA V1.00

TIMES.

MEDCOM - 20252

DOD-033826

mtvicATIONS/SOLUTION DOSAGE ... . . ._...

TIME - .. METHOD PREPARED BY LJ •-•-• z_NI,

GIVEN BY ..

li , • - ii

-_—.... . _,.... ... .... ............ ,,

1; 1

.. - IRRIGATION 134ES • NO; TYPE(S);.

'MOUND f!

. /\,(•• _ . ...

. . . . .

!OTHER ORDER • . TIME ' CARRIED OUT BY ticcy wi ,

- .

t, .1 ,............_.

. t : HYSICIAN'S SIGNATURE . . ...

.....,_„,-,..,„—_,.....„. —, - .,,..¢..rfe.s.....-+4,,,,,,-sier,"-,,......,,,,717......2.14...4.106-07.ern.a.,...}," or. .....-”vs,tow•erntmeateo,o..--tcp,...,,,e.,..

........wm..."-...hl.

•.t: .15. X-RAY IN OPERATING Rø

YES • NO IF YES, SITE

16. - .''f.'4.LABORATORY SPEDIMENS

YES • NO

azNAME SPECIMEN (5) -- ------------ --4------- - NAME

FROZEN SECTION (FSVIAME YES • .. .. .. ... CULTURE IC) YES • NO p/''

NAME .. NAME

NAME

NAME /"--------

NAME .. „..

NAME

NAME -- - -

. _. ....:_. •

-

18. DRESSING/IMMOBILIZATION (Specify)

ae.A. CO('V, 6..A.14 17. TUBES, DRAINS/PACKING YES p - NO TYPE/SIZE 1.3(.9 1' .

fi÷A-,Icse_ 2. 3.

SITE

I Q A nnrrinki A I

1.

II\ 11,,I,D. • w -we ■-a .

2

ACLU-RDI 1656 p.12

DOD-033827

HOSPITAL DAY

DAY POST-

NSN 7540-00-634-4124

VITAL SIGNS RECORD

MONTH-YEAR

19

PULSE (0)

180 104°

170 103°

160 102°

150 101°

140 100°

130 99° 98.6°

120 98°

110 97°

100

90 95°

80

70

kitimeram

ritr7-11 _ !ze •

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

MEDCOM - 20253

REGISTER NO WARD NO.

'VITAL SIGNS RECORDS

Medical Record

STANDARD FORM SU (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

peda

l da

ta o

nly

whe

n so

a

MEDICAL RECORD

DAY

HOUR

TEMP. F (•) 105°

TEMP. C

40.6°

40.0°

39.4° 0

38.9 ° cu to' a)

38.3° cc

37.8 ° a)

37.2°

37.0° o-

36.7°

09

36.1 ° a) c.)

35.6°

35.0°

• •

•

ACLU-RDI 1656 p.13

KG LB

Tooerrm:

OTHER

•NDmON:

*ESP- 1/ cit;;1

BP- Sdf HR-

AK tiSTRETIC TEC HNIQU ES: 044edb• bkck AKIK,Atio wide

O

z

1- z w

17- ILI x

z

RECORD MEDICAL 3S

o I z

D 5 3 z

g

DRUG (Unite)

• texi./11/1

I VOLAT rarki dpI AGENT % e t.

IVR LIMen N20 tJMIn 02

SINGLE DOSE DRUGS - MARK on ortig, WITH NUMBERS &ENTER IN REMARKS

co O 5

LINE snit a Warrred

yv5 f 5"-/o O phr....4

u. Warned

Wormed

LOSSES

EST BLOOD LOSS URINE -

PH,. STATU TIME 'a Emzzio SY MEOLS;

BP by cuff

V A

Heart rate

•

Rasp rate

OK?- If

OK tor PROCEDURE?

TWE-

O 8P (transduced)

TOURNIQUET

T

ANES- x-x PR000-0

120

100

80

60

40

140

220

200

180

160

2D

ANESTHESIA

Code drugs with numbers : we", with totters

i/75 74_411)

-, 10e4-01kt._

jf)

/roceje -4e-.4/9x•

,lAPe-e1uf''--,c.,-

/9-A-/-1 ref R17

70,

FLUIDS - SUMMARY CRYSTALLOID- ;25--d, c

OLLOID-

TOTAL URINE.

MWWIN11111111111

i , MillIMISEMINOWS1121 MI now oil

U= wag ' tun= - .di Arm utmanampummilli um i i MI IMEWASPERNIMIMinuismaffis::::::.:::::K::: , SIEWAM1114 MMIIIMISIMIMIIIIMMINUI i i IIIMMIHIIIINI EZEIMPENZIMERMIEMMNIM MORMININ =MOM ATIMVAIIMPIMI mmIIIIMM WE> ASENDEVORIAMMERN :A.:V:: MUM= KM MINIMA ; I : - , 1; i WM ; ; ; ; IMIMIIERMIIIM qr

WIEN MAW

11111111111111M 11•11 SIMMENNIENEEMMIGNIM

(iii Ensm -WAIMM'KEE 11101111=111

TOTALS

: ''''

BLOOD-

REMARKS-

RECOVERY AT

BP/Auto Cu

131, / oth PACU ICU ISP•cIPP) 02 (toff)

k I ART line pp graMENIMINIIISTarE

Conv wanner

s analyzer TEMP- she N4A Block T14 ■

Ing blkt EM.Aallill=nrtat

ISA Start

Room

End

PROCEDURES and CPT Codes

Me• with letters s ayrnbets. EVENTS "Mein wider REAfARKS posidon

777 Cle5kre----

---,Pekdke 410/ kiPce4.-

End

Remertia /83 ig_ff /9

PATIENT I NT1FICATION- Typed...arm sneer GredwRet.. Medics, belly

-Ail II IP lli AIRWAY MANAGEa p . blade, technki" comments

99A/It

SURGEONS:

ANESTNE

PROCEDURE LOCATION

DATE

re)}

PAGE / OF WAMC OP 376 REVISED

MEDCOM - 20254 . 1 Jan 99

DOD-033828

ACLU-RDI 1656 p.14

CURRENT MEDICATIONS: ( ) = ordered as premed

()

() 0 ( )

PHYSICA,L. EXAMINATION Bp bifIR 224 R i T kr...,) Pain cale 0-10 HEENT - Teeth M-e

Trachea TMJ/Neck it2

Oropharnyx f-z3 Wares it--

CHEST: • 13SCTlf

CARDIAC: AA( $4,.--k

EXTREMITIES:

IV Access: (C) eh/ 4., Dinar Filling:

BACK:

OTHER:

POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) } NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER

Signed: Date:

Time: Hrs

SEDATION KEY:

1. MINIMAL {Anxiolysis) Patient responds normally to verbal commands

2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or 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.

1113/HCT: U/A: OTHER:

LABORATORY STUDIES:

PREMEDICATIONS: None Yes (0 Mrs) /CC

mg IV IM PO mg IV IM PO mg IV IM PO

Age 3 113AYS MOS

ANESTHESIA PLAN OF PRF

37 '4-

HABITS:

TOBACCO:

ETOH:

DRUGS:

PROPOSED PROCEDURE: SURGICAL SERVICE: NPO SINCE:

I

c=RAL ASSESSMENT (Sedaties-/Ar sial Sex KMALE, FEMALI

.0A Physical Stat 3 4

14 e WT: 7o .C1.4..B HT: IN. 12.1"0 Fx ALLERGIES: ,S:Er

glyG2+-■-1

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:

Hypertension N Y Angina N Y

N Y N Y N Y

Familial HX

N Y N Y N Y

Other N Y Renal System:

Acute/Chronic RF N Y Gastrointestinal:

Hepatitis N Y Hiatal Hernia N PUD/GERD N

Endocrine System: Diabetes N Y Steriods N Y Thyroid N Y

Neurological: Seizures N Y Neuropathy N Y. Other N Y

Gynecological : Pregnancy N Y

Other Significant Hx:

MI CVA Other

Pulmonary System; Asthma Bronchitis/URI COPD

N N N

ASSESSMENT PAST SURGICALJANESTHETIC

NPO Since 070 C) 4 rk lea4451Ayt

ANESTHETIC PLAN: { ) LOCAL { } MAC { } Regional (Specify): General: Mask Intubation

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and

[co) —1_ ms to understand and agrees. Questions answered.

Date:

ANESTHESIA SERVICE RECORD Previous edition is obsoie e

'U.S. -SPO: 2001429483/40002

MEDCOM - 20255

discussed with the patientllegal guardian.

The patien

Signed: Time: Hrs

WAMC Form 2300 (Revised) 15 Mar 01 mckpi pos

Patient Identification: (Ward)

-CA 1t2 ,e4." j°

DOD-033829

ACLU-RDI 1656 p.15

MEDICAL RECORD - DOCTOR'S ORL. For use of this form, see MEDCOM Circular 40-5

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.

ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS

ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS .---

t. t.. ' , 1 j POST ANESTHESIA ORDERS (circled Items) ab '2_ 1 tk? Cf

5-rain g--X--1 itdischarge.

2 Stip21e4neutal-elefgen,

,3 Morphine / Meperidine mg IV now and mg q 3-5 min for a pm pain max dose n1_, mg.

4 _ ' • q 1 , -. • -. ; • 1/V x 1.

-,____.6—Bracerttlar mg IVprifIcrtra-1-r--- al Phenergadi.s't {rng IV pro N/V x 1.

t: - - .. • 9 g !Pc! p , : • .- - 'ACU. VF -4----ec-Ahr,—,

10 Discharge from recovery status when PACU discharge criteria met.

S1A-.53 ( 1 C 2.4,---..-

( (4())-7--

PATIENT IDENTIFICATION

1

*IVO ((o)(13)'-L1

Complete the following information on page 1 only. changes on subsequent pages.

Diagnosis:

Note any

s. Height: - Weight: Diet:

Allergies:

Nursing Unit

PACU, 28th CSH Room No. Bed No. Page No.

1 of I -iS t t 1 S I J UVIGIiUI MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC Vt .00

MEDCOM - 20256

DOD-033830

ACLU-RDI 1656 p.16

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

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.


HOURS

io)( 2'13

c2)--1-0

NURSING UNIT ROOM NO. • NO. 102113 a .

WI 7 -6 21 I 2f 6 ,4" PATIENT IDENTIFICATION qk

0

t4

DATE OF ORDER TIME OF ORDER

0 lig /L1)°0 HOURS _......„ %.2 dc)L. ?, — 1%-.7d.-- 1L'? .hti mi

I • NURSING UNIT ROOM NO.4 = 0 NO.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

r

Z-(77f i 915,-.. HOURS ransmi pow _..f--e1/4 ,,,i-,___,.,,,,,,,. ,e, ..... NI ra b

. .a.-.4,-)fr-"ir

rOi /) W 2,-) >g 4 NURSING UNIT ROOM NO. B E 0 0. r ,..2_ xsiz.,,,,6- ... A e. .04-

U IZAC-42)-L., i', 14-ft PATTEN IDENTIFICATION

, 4

NURSING UNIT. A

VIIr

RO NO.

DATE OF ORDER pz

ers TIME OF ORDER

l,c1,-,vk-/ ‹.,4,44.s. 447., OURS

igivl- KZ in ,)Z Cri.'/OL ... SOLE AO. 0 # '4,65 it.,./

Mr-44.8 <es"- ,O, e V--e4) -/t) WI , . e- 11/P 40 ) A) ,z. OW rie - 1-C<ci7-r ' 2 - /Lie I" . 1111

BE0 N Ipplin of . ..., .....

DA 1APR 79 4256 REPLAC F 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 20257

P2) (s)

DATE OF ORDER TIME OF ORDER LIST TI ME ORDER

NOTED AND SIGN

DOD-033831

ACLU-RDI 1656 p.17



PATIENT IDENTIFICATION DATE OF ORDER J TIME 0)279 h) .5. ,4)7/2)

tO, eon- -;) ,6. 4 K ces )17/Z9,d-1-a-2

x25"L'i)c AO, • Jo >' vi-)c--) . )2. 0.)-I4 -6 /3v vi4770A) IBJ

)00.

TE OF ORDER TIME OF PAT

NURSING UNIT

((,1cov`k HOURS

LIST TI ME ORDER

NOTED AND SIGN

NURSING UNIT

PATI ENT IDENTIF IC

ROOM NO.

ATION

BED NO.


HOURS

BED NO. NURSING UNIT ROOM NO.


HOURS

PATIENT 00ENTIFIC ATION

NURSING UNIT ROOM NO. BED NO.

DA , FAOPr479 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 20258 Watms./..ziares

DOD-033832

ACLU-RDI 1656 p.18

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON —MEDICATION )

For use the proponent ageneyotstitre ff.fgrieSOMIFIt 4SC=On General. MO. yr. 2003

VERIF T BY INITIALING iliMert! tzs,A=;Z., ,,,' 4 itt INITIAL PROPL1? COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

\I5 ... t-

DATE COMPLETED

c i cu_ 9(7 Daaq c9RAu.2) - 1111.

a)- -- 11111krxi, rccs\l-- \e,

a-

illik7-kur. - -1:)

;D- ( aa Olo. WWI- 1 , _ OrFie-Va te (0 l-.- c.

. -

...... tiP)__ ... ..... ...... ...

sN, (,)(

. . • •

- . . 4

. .

" .

. .

ALLERGIES: MI YES IN NO PRIMARY DIAGNOSIS:

(C) —e-1 0 -TAB\ k\- 15c 4:31 / i-A0 ADDITIONAL PAGES IN USE: we YES IM NO

PAGE NO' PATIENT IDENTIFICATION:

1111111. (9 (C.) —1

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07 M DCOM - 20259 ___

LISA PA I/1.00

DOD-033833

ACLU-RDI 1656 p.19

Date to be Done

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN' Initialing

(NON-MEDICATION )

Order Clerk Date Nurse

- Gc'c'cv --Tr) oL7

\C)

I Ain Yr 2003

Time Done Initials SINGLE ACTIONS

-

Time to be Done

ICW 1 AzOdic2 ?4-

Ft_r- ca3c-\-es/ambtAJN-Do \i\x-sf7r _ a+ Soruce.s )■r, _ _ _ <99-

(

— –

Order/ Expir Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

•■■

MN MI NO MS

USAPA V1.00

MEDCOM - 20260

DOD-033834

ACLU-RDI 1656 p.20

MEDCOM - 20261

DOD-033835

ACLU-RDI 1656 p.21

(-

;• 1'2:

_ +MeCt'..(c-z<-,Q5)"0 Vc 1cD

' • r :-.17; Y.; ;

MEDCOM - 20262

DOD-033836

ACLU-RDI 1656 p.22

Pre Op Meds

Time

Sa02

Fi02

Methods

240

, 7.1k

• • 4 *426.

220

200

180

150

140

120

100

80

V

a

rd

a

60 a NA

A 40

A

Airway (2) Cough, Deep breath (1) byspnea. limited breathing (0) Apnea

Blood Pressure (2) SBP =-/- 20 of Pre-op (1) SBP =I- 20-50 of Pre-op (0) SOP =1- 50 of Pm-op

Criteria ACtivily (2) Moves 4 Extremities (I) Moves 2 Extremities (0) Moves 0 Extremities

Post-Anesthesia Recovery store ADM I 30'

2-

D/C

-z,

PREP

PATIENT'S IDENTIFICATION (For typed or mitten en fiat middle; grade; dare; Ample or medical faulty! D FLOW CHART

0 EITHER turd/ .; •

MEDICAL. RECORD-SUPPLEMENTAL MEDICAL DATA For use of thio tom. see AR 40.66; the propellent agency is the Office of The Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet .....i OTSG APPROVED Water

Date: 27 Sacp Time In: ri/

Allergies: 'Lk-DA

Pre-op V/S: i7-̀ 11 Procedures:

Anesthesia Type (Circle)): General Spinal Epidural IV Sedation Nerve Block

OR Intake: Crystalloid i41 Colloid

C OR Output: UOP EBL

Meds/Times: .

Histor

Time

Solution

11C:A7.1 14S

X-rays:

• IIMIII•■•••M■,

Apr— Drains Airway movac asal NG

. JP T-tube Foley

NA) TIS

Pacu Intake Amount Site Infused

tor)0

Labs:

iffiE012, Trach

Other

L

9 T.

20

RR

Time Pain (0-10)

Consciousness (2) Fully Awake, audible dying (1) Arousable to verbal or pain

Color 12) Baseline cam & appearance (1) pale. mottled. jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (I) Axillary palpable, not radial (0) Carotid ordy reliable pulse

TOTALS: Must 45> greater to DIC. otherwise needs anesthesia approval for DC.

1

1

2--

N 9

nagement,

Codes

AIRWAY A= Ambu BB = Blow-by M= Mask FT = Face Tent RA = RoomAir NC = Nasal Cannula

V/S X =A-line BP ' =Cuff BP

= Pulse

TEMP S = Skin 0=Oral A = Axillary T =Tympanic R = Rectal

LOS C = Cervical

=Thoracic =Lumbar =Sacral

'n done: Wound Care. Pain Ma ncentive Spirometer, Comfort Measures

A

13

16 lz 11

13 4

LOS

Sa ely: R up X 211s Preca . Privacy Maintained

DEPARTMENTISERVICEICLINIC

7

IL Ofirnlut Oft *wen*

DATE ? Cr' cf.7

Name -last.

1111.1(9( -I

D HISTORYiPHYSICAL

P OTHER EXAMINATION OR EVALUATION

CI DIAGNOSTIC STUDIES

El TREATMENT

OA FORM 4700, MAY 78

WAMC OP 173-E. (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPCY2 00

MEDCOM - 20263

DOD-033837

ACLU-RDI 1656 p.23

MEDICATIONS Allergies: Time Pain

1-10 Medication 8 Dnsant.

Route Pain 1-10

I/E By

1 q3C- VI. .ti- i'l-,c PA ) I 1,8

oi,)--7._ 111111

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Adm 4- -1-- P ,.., 15' --f- ÷ 1 13 C P 30'

45'

60'

90'

DIG ( t_ -_ p ,e. c Pi — Movement/S sation: + =present.- =absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D = Doppler, A =Absent Color: C p Cyanotic.

Capillary Refill: B-Brisk, S= Sluggish P= Pale, Pk =Pink

C-SECTIONS 15 30' 45 60' D/C

Fund.'Height .,.......,_ .

Lochia ------ Peripad#

Fund. Cond.

NURSING NOTES

j )(

Lic- -1-A4)A

PACU OUTPUT

Time

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? 11.-15-- 1.-). , e--- t--k-)

WAMC OP 173-E

Discharge Criteria: Date: 9.2-?z)3Time(2-0 PARS: BP: I ryciT: q77 HR: Loa Mit/ Sa02: ID 6 Pain Live! At D/C 10-101: Intake: U0 0 Output: \ON additional Data: Transferred To:

Source ' /Appearance Amount

Report Given To: Transferred Via: W/C Transferred By: Cleared IAW Recovery R

Et Signature. MEDCOM - 20264

DRESSINGS Time Location Type Drainage

Adm its VOMIIIIIMMTAllimii111111

• . _ 4.

IIIIIIIII,Il

30' 604 DIC MN •4. •

DOD-033838

ACLU-RDI 1656 p.24

1 . REPORTING MTF -- 2. MTF LOCATION ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400: the proponent agency is OTSG 1 2 3 4 5 6 7 8 (State or

Country Code.) A 1 ,

3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX

9 10 in 12 13 14 15

H (V " '

16 17 18

• , . Al

7. AGE AT ADMIS ION 8. RACE 9. ETHNIC RELIGION

1) N) k 19 20 21 22 23 24 25 26 27 28 29 30 31 5ACK- GROUND

7.--

10. LENGTH OF SERVICE EIS 11. RAP

*i'L 12. SOCIAL SECURITY NUMBER

32 33 34 35

-110

36 37

ADMISSION

38 40 41 42 43 44 45

ORGANIZATION (Active Duty Only)

.-----.

13. MARITAL STATUS

46

BRANCH I C

14. FLYING STATUS i 16. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE

47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 1

-.•••--.. __ •-____________________--.---

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA

I

PREY. ADMISSION

62 63 Country Code)

64 65 66 67 68 69 70 71 YEAR NO

,---- = 20. SOURCE OF ADMISSION) AUTHORITY FOR

ADMISSION WARD

I awl NAME/RELATIONSHIP OF EMER ENCY ADDRESSEE

72 ADDRESS OF EMERGENCY ADDRESSEE (include ZIP Code)

INK QF Elt)ERNCY ADDRESSEE NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION 1Y YMMD01

73 74 75 76 77 78 79 80 81

01

84 85 NCI

INNIAMIlal THIS ADMISSION WY

86

24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE MMD01

87 f 88 8990 91 92 93 94 95 96 97

A E. [

A {

A . 11 27. LOCATION OF OCCURRENCE

1 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (V YMMDD1

(Battle Casualty Only) 103 104 105 106 107 108 109 110 111

FOR LOCAL USE

DX it OP) 1-- --ri 6 FrE), P r DC ??.(0(a

-Cro un‘q 9 - -tv_J q -

ADMITTING OFF1 SIGNA

9p-z. MEDCOM - 20265

DOD-033839

ACLU-RDI 1656 p.25

IEN,AL I. 051 :ATS )61-4. rout, SCR EAT;

pr „4,41 ' ti CIPS. CA IS

L.G121+: VS I. F:0 R N1

MEDCOM - 20266

•

30 I •- 5,E , N. ,Z C ,rr

•

INPATIENT TREATMENT RECORD COVER SHEET Fur usa of this form, see AR 40400; the proponent agency is OTSG

MC IJI I CM 41J,• - ,1 F I DAME am; ,7Hr.1, Eau GRADE

11 K — A/1HO .,-... EPtA)

ADI,IISSIFS ',IRA:PAS --

_

ac..-+ Qoo3

SE. AGE 6. PACE REX.; Gli 1

LENGTH SF 7216 EIS

tU t•iri

ID. PREVIOUS ACMiSSION

II EMP 1 II 1 13. ORG4 -84f(3) !

cici IA. WARD

J_Taic2. I 5 Ft TING aRANCKCDSPS

STATUS OSG DEN .•

■

I i k 70E3

19 UICIZIP TO. TYPE 6250

1,1)1A 71. SOURCE OF ACIARSS,Crt'Au THOR TY I;ORADMISSICS

b 1 r eC•i- rr-or, Elie _

72 HOURS OF ADMISSION

I900

23. CLINIC SERVICE

0-01- —reir . NA ME:RELATLC.SSHIP IF EMERGENCY ADDRESSEE TO TYPE OISPOSITTON

DiC 7.0 6frfte 26 DATE OF aisecw

'a7 27, 4COPESS CF EMERGENCY ADDRESSEE 110ciudf ZIP CAM) i 220. f TELEPHONE NO.

1

23 SATE OF TH ADMISSION

a? Set, aoc 2

ADMITTING OFFICER

O NAME ANO LOCATION CF MEDICAL TREATMENT FACILITY 3a. DATE OF TIM. ADMISSION

32. UNITS OF WHOLE ISAAC; COMPONENT TRANSFUSED

31. STP! TM OA TA

E DVC11 0 Cumin/4 An PAMIR

33. CAUSE Of INJURY

3 4 0:AGNDSES:GPERATI12IS ANO SPECIAL. PROCEDURES

1J'

X. -. sb9 • Ex LAP Gro/ .1-0 /fish

Di ......., P.„,

c( 7 s .47) r -7 q. 2.

q ct 1 Z. 1 ci cc, - 44 '

172 A 9

■.( .5"

sq,11 et 3.ski gt*.a Li Gtct.0t-t j

3:. Total Days This Facility

ASSENT SiCk CATS i b. OTrif: DAYS RT LV.CCOP i I. SVELEMENTAL I A. EEO CATS CAPE DAYS 1 CARE OATS

00 1

. 1. TOTAL 5160 TR IO

... 36. TEl Oa - s All , acilites • • ..,•

'- --------'

DOD-033840

ACLU-RDI 1656 p.26

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD I

PROGRESS NOTES

DATE NOTES

-/7 rt_r4-0 . Milk (07A_E4,t, a- . -1 1/1,1Vrt -or ,

(6 c1( I 52 vaatt Tvoli EPA) 6 ,CW Fact - I /I bd, - fh t',a1/1-d

_:_----7.- l(4) F' ecu - doi4 s IA 1 1- 1,-(1 ‘ in 1-1-a — 90 )--______:______ ..),.c .e...1, .Nr/ e.-icett4-a es-- ei-t,a__‘1611-6 j ;s ir-c ce-et4 S' (j° ee/ Lei . k)

• - Sr) 4/4 di0-0-614 A.pri A's c: cd -6779- -7krii-C- 'wail, 16/e._.‘clie-y-

--ik

„flea 1,1,, )2: .& .

pf—1 A 1,/-c ch "e114-1 e4,179$,4 1-e 1...0.4111 1.411101.- • forv-ea v✓-47 -

a i -er /-434 Ai

C„velo / kg /WA./- 1-- A-06 t4/ a cri/ CiAl-J • ..02 I- - /

a it 4e. ■ - / • G.,11/ Amiii6 , ed 4. 1

A- leA., kg": t •

.,06(2-frei5 — f•-ve-ezes . 40,--(L--c •(f/a4---acze ,a-44.

00P a cc )Z . --.(ori - bs..5-4-? -_:di-vi-i-e-ta

at d con,/ •,-c rf i Ast,

ia'P- /ic su<C 4 c ../tA-e-y/44--e. r, t ,,..,

rITA I/ r( . //tPt i 5-1.1v c j g ctl, h i-tt iry-lat w- if,f/t_clf

it-16 ,

wit/ Lok, A of-) t,,, ft. pi/

- — vedit,e,c_ si • en

RELATIONSHIP TO SPONSOR SPONSORS NAME

LAST FIRST

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name • last. first. middle:

ID No or SSW; Sex; Date of Birth; Rank/Grade,

I REGISTER NO. WARD NO.

Ntu PROGRESS NOTES

Medical Record

STANDARD FORM 509 'REV. 511999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203(b)(10)

uSAVA v1.00

MEDCOM - 20267

DOD-033841

ACLU-RDI 1656 p.27


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

'Cy-yip-5 ?,r-1 c..-c- cylP t.-) cm-yrc,

2-3 Ste, 03 Tom. cP c G--_,sLo -viz) Q-v-._e_ - vz1c,c) Tc,.-T-t-- 4::::. p c9,4_ , 5 4Q—..,...A....

li).3-1.aA.3-‘).4L _0 ,-1--4-- cis- .;Ek-,--,-e..›.. 0--'1f<krk,..T-4:e'rk._ _

•-___./..C.._. 0.---Q1,N4--4

...&_,-r._i..' 0------4ig. C__LoCs-k---IN-.... CC-

4-L\r1- ,_

ND MA-

' mrLeth:...t.....,C) ( iv-..._,Elt.,..)...s,t IrtuR-Ar,a)3.- \......--.(1.

.1.40..._ .....4.4& S. _A.A._.,.. - 3 ..-2•....-.J6... A.L.A\i"

C_....A3C. 2F c e.

t.A.10 1 . 1•I CC) e- 0 ' _ .

r. . 3ooL.R, 2..L.A. ? te_it,c, ocx:=) cc, k..1424, 0_,

-- -. 4) e D.,7uA.I. Skr:Al—sUL ls1—,,,,,--.c-, ..-....47 ̀ ■A-lfejia+2..YaiZI:r_90

1 ''‘I`-• 1C-3CL•VI ,‹p .b.St .S1,_ ' \'ZZ. ,„.SL Cki. -2_ ---- 4.).,-(_—_,&--

6-1-- 55--e-)------.41ep,..9 Niv•- ,-,-:r.,.,

(00

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

SPONSOR'S NAME SSN/ID NO, RELATIONSHIP TO SPONSOR

OM (For typed or written entries, give: Name - last, first, middle; ID No or SSN; (REGISTER REGISTER NO. " Data of Birth; fienk/Onide.)


STANDARD FORM 600 (REV. 6-97) Preseriled by GSA/ICIAR FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20268

41111111160,) (Gy-i WARD NO.

DOD-033842

ACLU-RDI 1656 p.28

‘Stic) 140 ta-79/

RECORDS MAINTAINED AT DEPART/SERVICE HOSPITAL OR MEDICAL FACIIITY

' MEDICAL RECORD I PROGRESS NOTES

DATE

NOTES


arvpio 1141-# 1.

.AssAic

sr Mitotfri wkeve

idt(

it/ friiO3

herAi d Cowt.

t;10 &A- 174 .' 4444. Coic eiated--- (r_

dy 544-0 Pob r 696o e

licV • (4.0. i515-td /fro%

aR 05)(L)-Z

NSOR'S NAME

LAST

FIRST

1

PATIENTS IDENTIFICATIOlk /for typal or mina, tot* g girt. Nome•kst, fiat risiddlc REGISTER NO. 1016 a Ige Ser Dote of NA' Roakaashr)

WARD NO.


PROGRESS NOTES Medical Record

STANDARD FORM 509 IREV. 5119981 Prascrated by GSAIICHR FPO I41CFRI 101.11.203041101

USNA VIDO

MEDCOM - 20269

DOD-033843

ACLU-RDI 1656 p.29

DATE NOTES

MIDDLE INITIAL ID NUMBER

703/ 3 gig 3 /f7th rigil

T4,171 -0.

t (DJ" t

STANDA

-1:4 1.291 4 3doito.t? ei) vittseil6t4 Vte. 3401. intsaimE › c of pot t +6 ItA it i' 1 '1 Vlud- 491 ; ' t Aid- : :1'61i- to P . -S 3—zo1 e. 6 Nan 4 ii.1- 44 ° @Alt

61134, ' 4 . s‘ 1 4dCfAi ek LIE CatibrriSat, AVidie 01141444344 as WY as Ea w. PI f 0 -c-, • i _1 . ,„

det_ uAaf 0 sst5 c.ilz Try,t_-- Tut , 0 i , e fit, c ita,4 z102 z-34ecs. ktfts tig coact% tto i Witte ctio4 cox .6.6061-, Ktrvia4 it; miz -I,

i---62_,

-?, t -{

Z4 s4 03 okt c e triakithc -h (Ow btr OncleAta

7,4 Sct) 03 (tatIti4

2,1sEt (t4--er), ri,6€0

tA"Vwt „ bhattyRkiell) jotiv Alt od ackS 1,(944.

t up:1)6366p

(7.6- ita

a

tact lc it etChil 4 P'7r , IDLE S SlaDit OK

PIO I !limit CotAse. CALA3 is . MciliketSk rAl. i‘Vt t 61ik f 1144 61' IC) b L1C

USAPA VI .00

MEDCOM - 20270

DOD-033844

ACLU-RDI 1656 p.30

AITIIIDR1210 FOR LOCAL. REPEDIDUCTNIR

'MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

(24-SE49 03) fetWi- covviimu -to A* tA fiat—xxt44410L i iko 3 Sak Ril, OA 01 tE' IMAS-e- at,e ts-15110

ks Y 1 it4 taiii kott-ta -1"

5 1+40p --t- ivIt-ciriptc ii s

• Cha 1444 .-0 ctikaP , . a/4444 leo , 3 Poe-Itt-tamti, 466, goad * ac-g t ,t.), I #49

ttarptu, 4i36 itatiats. 1 fii- 7. 34 re02. - 44.7 POI- (Th IJC07 - 26 BE- 0', s PA - ldle

filadt E SAN- C Cllg • 4 s Atra) cUrr ,,i eel& ets act -,-„,-, 2Y SEPTV •

— 4 • ' i ..e. . .,..• AL- / , tt, a _,, If _Air

4. - -‘3(9

iri j., e/ Cg '_;.4M, W../gi. :AVNIF*, - -; dr or , , - "P...f —...kw, ,

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USAPA V1.00

MEDCOM - 20271

DOD-033845

ACLU-RDI 1656 p.31


'MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

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STANDARD FORM 609 'REY. weal PreserIbed by GSANCMR FPIAR MICHN 101-11.203041101

LIMA WAD

MEDCOM - 20272

DOD-033846

ACLU-RDI 1656 p.32

LAST NAME FIRST NAME MIDDLE INITIAL 10 NUMBER

DATE NOTES

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MEDCOM -20273

DOD-033847

ACLU-RDI 1656 p.33

PROGRESS NOTES MEDICAL RECORD


DATE . NOTES

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MEDCOM - 20274

DOD-033848

ACLU-RDI 1656 p.34

'MEDICAL RECORD PROGRESS NOTES

NOTES

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MEDCOM - 20275

DOD-033849

ACLU-RDI 1656 p.35

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Medical Record

STANDARD FORM 509 IREY. 5119991 Prescribed by GSAROIR PPM 141CFRI 101-11.2031MT 0)

USAPA

MEDCOM - 20276

DOD-033850

ACLU-RDI 1656 p.36

STANDARD FORM 509 inv. wen RACK . . IMMO VI.00

MEDCOM - 20277

DOD-033851

ACLU-RDI 1656 p.37

ATHORVED FOR LOCAL REPRODUCTION

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•

DATE NOTES

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STANDARD FORM 509 IREV. 5115051 Prescribed by GSAIICMR Rao MUM 10 1 41 2030V

USAPA V1.013

MEDCOM - 20278

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ACLU-RDI 1656 p.38

..■•■■■ ANL • I •

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LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

OSS -Pt).1) va. (0

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STANDARD FORM 589 [REV. sneasi BACK mum vim

MEDCOM - 20279

DOD-033853

ACLU-RDI 1656 p.39

DEPARTJSERWCE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

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NOTES

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DATE

kir Ow*

'16 A 0 ot Lei 0 49.44 141..._ di

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USAPA V1.00

MEDCOM - 20280

DOD-033854

ACLU-RDI 1656 p.40

STANDARD FORM 509 MEV. rosew BACK USIPA VI le

MEDCOM - 20281


DATE NOTES

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DOD-033855

ACLU-RDI 1656 p.41

AUTHORIZED FDR LOCAL REPRODUCTION

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PROGRESS NOTES

DATE NOTES

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MEDCOM - 20282

DOD-033856

ACLU-RDI 1656 p.42


MEDICAL RECORD I PROGRESS NOTES

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MEDCOM - 20283

DOD-033857

ACLU-RDI 1656 p.43

LAST NAME

FIRST NAME

MIDDLE INITIAL

ID NUMBER

DATE

NOTES

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MEDCOM - 20284

DOD-033858

ACLU-RDI 1656 p.44

AUTHDRLEED FOR LOCAL REPRODINININ

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STANDARD FORM 509 MEV. 6191}91 hescribal by GSAIICNIR FPMR 1416F11) 101-11.2031blila

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(,qk)-`1

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DOD-033859 ACLU-RDI 1656 p.45

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Patient)

LOG NUMBER T

RECORDS MAINTAI D AT ,q-z) ,---L_

PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS

•

DATE 7, ,All -- 6 ft I

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SEX

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n 24 HRS. n 48 HRS. n 78 HRS.


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10. TO WHEN

TIME OF RELEASE I have received and understand these instructions

PATIENTS SIGNATURE PATIENTS IDENTIFICATION (For typed or waten entries. give: Name - last,

first, middle; ID no. (SSN or other); hospital or medical facility)


STANDARD FORM 558 (REV. 9-96) Prescnbed by GSMCMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 20286

DOD-033860 ACLU-RDI 1656 p.46

RADIOLOGY ABG/PULSE OX

GLU ETCH BHCG APTT

EKG INTERPRETATION PT

OTHER SAT

at 0

RESULTS P02 PH U

WBC

H/H

PLT

SUP 02

PCO2

DIP

MICRO

Check if read by radiologist ❑

vwcut pc44-tvy-- 5-a moyti u e aVp\s/ PROVIDER HISTORY/PHYSICAL

6IS C hiLet 14)-/- sl ot/ itb Re CiAs ki

a.V it - ( -59 11- liV-1,Lciky Kic - (6)0(6 A bek5 ccs

illytANEWq-

ts-bo —Fo cal+ I vl env 'ye.)cs bioeSvioicd .e Val/ rito-)A7 u v( frc C_ -6100

C\ ef dito --alvwou--) kvF C Sal 0-abOt pol-eylov ctuir

TIME ACTION CONSULT WITH

PRO VIDER SIGNATURE AND STAMP

RESI DENT/MEDICAL STUDENT SIGNATURE AND STAMP

DIAGNOSIS

Ca

Co Co

NSN 7540-01-075-3786



TEST RESULTS

"TV 012--e brat"

PATIENT'S IDENTIFICATION (For typed or written entdes, give: Name — leg 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 GSAICMR FPMR (41 CFR) 101-11.203(b)(la) USAPA V1.00

MEDCOM - 20287

DOD-033861

ACLU-RDI 1656 p.47

e-p lap (. 4,o--1

PATIENT'S IDENTIFICATION (For typed or written entries glue: Name — last, first, middle, Medical Facility)

LOCATION OF MEDICAL RECORDS

LOCATION OF RADIOLOGIC FACILITY

SIGNATURE

MEDCOM - 20288 LTATION )RT

3 RADIOLOGY

STANDARD FORM 519-8 (8 -83) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8

NSN 7540-M-105-7294 5t9.-301

BAlaidaharaICCONSU LTAT ION R EQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

EXAMINATION(S) REQUESTED

13 0 6's l

CSO tit Lek

SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)

•

SIGNATURE

11, /9"r: 1,./T

AGE

i‘4 FILM NO.

REQUESTED BY P

SEX SSN (Sponsod

k eV v1/4) WARD/CLINIC

t ti REGISTER NO.

PREGNANT

fl YES 0

TELEPHONE/ G NO.

DATE REQUESTED

AI

k to'rc

(1-1 &line /6501 fe.) e-e J D / /01.9-,fol 1-ee -fh, DATE OF EXAMINATION (Month, day, year)

DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, yawl

RADIOLOGIC REPORT

DOD-033862

ACLU-RDI 1656 p.48

MEDICAL RECORD Z'. PREOPERATI /POSTOPERATIVE NURSING DOCUMENT

For use of this form, see AR 40-66;( the proponent agency is The Office of the Surgeon General.

ots_ceswitau

1. AGE: 32 HEIGHT:

WEIGHT:


3. PREVIOUS SURGERY [ ] NO [ ] YES (type):

4. PROPOSED SURGICAL PROCEDURE: a

e 1'

5. ADDITIONAL INFORMATION: Last.PO: Medical 1.1x: Jewelry removed: yes/no Family waiting: yes/JO

Implants: Medications:


A. PSYCHOSOCIAL

VPotential for anxiety

Pt. verbalizes any specific anxiety.

7 Pt. exhibits relaxed body posture.

/

V Allow pt. to verbalize rely.

Explain OR environment and answer questions regarding surgery. 0 Offer comfort measures, ( g., warm blanket, touch)

Explain all nursing procedures before they are done.

Remain with pt. whenever possible.

m ilt' erfac2.

related to traumatic injury; language barrier; fliii :719---

.effaFrrt-iretrstt rgical environment

AER. B. A‘'5A / Potential for

PT. will be able to breathe without difficulty during immediate intra - operative phase.

surgery for signs of distress

)0( Offer to elevate head of 'litter or offer pillow. /5 Observe pt. while awaiting s

,ef Assist anesthesia during intubation and extubation

respiratory dysfunction due to sedation; positioning; injury

C. INTEGUMENT

Potential impairment

/ PT. will not exhibit signs of impairment of skin integrity (e.g., reddened areas.

,, Utilize pressure preventing devices on OR table and accessories. 9 Check for proper

/positioning and support to maintain good body alignment.

/II Pad pressure points.

9' Place ESU ground pad on lion compromised skin surface ;lea.

Keep prep fluids from pooling.

of skin integuity due ,to Bovie pad; position; fluid shift

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 Previoius editions are obsolete. USAPA V1.01

MEDCOM - 20289

DOD-033863

ACLU-RDI 1656 p.49

4. PREOPERTIVE EV BY (Signature and Titl

ARED

TIME: V;\,0-13


D. CIRCULATION

Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury;

position; shock; previous surgery

b Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse).

/6" Check for support stockings or ace wraps. If none, check with doctors. q Check that safety straps are

;b

c/orrectly applied. Offer pillow for under knees.

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

Check that rings have been removed.

Pt. will be transferred to OR table ithout difficulty.

Pt. will not experience unnecessary physical discomfort.

Irl Have sufficient people available for transfer.

Insure proper body alignment.

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

,,e(1 Offer support (i.e., pillows, bathtowels, etc.) for positioning.

E. NEUROMUSCULAR CONTR OL E.1. V Potential impairment

of mobility due to sedation; pain;

injury

E.2. Potential discomfort

due to injury; pain

F. NEUROMUSCULAR CONT F\tyL F.1. Disminished visual

perception due to being injury;

sedation;

F 2 ✓ Potential for decreased communictaion due to language barrier; sedation

F.3. Potential injury due to dentures.

Pt. will be made aware of surroundings prior to anesthesia induction.

V Pt. will be transferred safely to OR t ble.

Pt. will be able to understand instructions.

4 Minimize danger of injury during intraop period.

/5 Introduce self. Keep pt. informed as to where he/she is

nd what is happening. /t Inform pt. in which

direction to move and assist if necessary.

,6 Speak clearly and slowly. /X Address pt. from

-e-;r -`-4-tt side. Validate pt.'s

understanding of verbal communications.

A Verify removal of dentures.


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

OTHER NURSING INTERVENTIONS. Or continuation of above interventions.


DATE ,••efiQr-

11. POSTOPERATIVE EVALUATIO

cA ok ikAtuopook-zok

12. PREOPERTIVE EVAL EPARED BY (Signature and Titl

DATE: r5 TIME: 0

REVERSE OF DA FORM 5179, JUN 91 USAPA V1.01

MEDCOM - 20290

DOD-033864

ACLU-RDI 1656 p.50

MEDICAL RECORD INTRAOPERATIVE DOCUMENT , - For use of this form, see AR 40-407, the prop" .t vi i is t' ffice of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATIN- rtC,

VIA t,;:k*Ar BY ar\VS111.€Y1Ol

2. PATIENT IDENTIF-i L., VIEWED AND PROCEDURE VERIFIED BY CRT-

3. DATE TIME PATIENT IN SUITE

2 3 1) I 0 4.• PATIEVIIN ROO

TIME: :. t, ( 0 NUMBER 5. PREOPERATIVE EMOTIONAL STATUS

❑ CALM Cgl ANXIOUS

COMMENTS: .

0 CRYING ■ EXCITED. ■ ANGRY • WITHDRAWN / OTHER (Specify)

G. NURSING PERSONNEL

ASSIGNED. SCRUB' -- --

-• -,7:-- ;' - 7------ --RELIEF' SCRUB , ..,.

ASSIGNED . •CIRCULATOR

I . RELIEF

• \ /7/6.---- kreP)

. _ .___ . __CIRCULATOR

7. POSITION AND POSITIONAL

JSI' SUPINE LITHOTOMY

111,hr Cf3G-f- 0,-2 -%-tr,v■-..11-A,J1/4"7, COMMENTS: 1.-S.S ril-N.4,1/4--.. 0 ° , (s--, 0 ' ,h1:5--n.,

- ; LATERAL: Anc.,-i,‘,S

-r7,,,,,-&..,-,,,; -,...r.„,

III PRONE • KRASKE, .: U L DE UP ❑ RIGHT SIDE UP • 1" ,̀+-P.-c›—Z--,-A-COL

0,-,..yre-,e-co, N=. 6 rs,T43).• • • .., 1-1•■ "/••-•••∎ ‘=.0-.-0,..0 e■-dt. . •

';‘'et--

B. SKIN PREPARATION

HAIR REMOVAL P:

DONE BY: Ci YES ❑

OR DEPILATORY

II CLIP

NO ,:. UNIT

...6iiivWENTs:.rto rbizzoo

PREP SOLUTION (Specify) e,A1-1 SITE:A04,:rev•-tA-A, BY WHO SITE: BY WHO ... ...

- •-• --

3-.., sC.,,, 6 S ..-1.,„Aesk

• NURSING METHOD: U

rr cA.,,Al...N.„04.4.0A

jg RAZOR,

._ ____...._,......_.. COMMENTS: .ra v.-I c c...14 c. 9. LOCATION OF EXTERNAL

P

DEVICES

- -

Safety

C = Cori...correct

.., _..

.,...,.

A (,)

•• -•

s.. - r.1

LEGEND X Ground

11:11119

...

= = Tourniquet ( L 1 - -L

10. COUNTS rt-rA.sviAr zmi7

First Closing Count • :.1i ,;-...

(A.,;, Final Closing CCiint

'.

-SC UB IN I 4 ) •

Sponge Yes ❑ ‘ici C . C

Needle Sharp R Yes Vo C C. ... - C Instrument Ed Yes

Yes

0-7)

Grade;

❑

(01

(For

Vo Vo

Date;

C...- .....---

typed or Hospital

____---- written entries

or Medical

-----

give: Facility;)

12.

E.

____-------- ELECTROSURGERY

Other 11. PATIENT IDENTIFICATION Name - Last, first, middle;

OW

ECN.Nr •

DEVICES) (ESU) Z YES 111 NO

ESU NO: VO-Ate-'1(04.-V%-t- C...i2- . GROUND PAD: -.2.,;.- - ., _.. ..

J .-

BRAND VI, Ve_ra...---.i■ I' i ' bjr42.

LOT NO: 'TOO I k ... eV -01 -4

/

ESESU NO: .•

• - .e -:GROUND PAD:

BIPOLAR NO:

BRAND LOT NO:

REPLACES DA FORM 5179-1 (TEST). DEC 82. WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20291 ., • , •.

DOD-033865

ACLU-RDI 1656 p.51

13. PROSTHESIS, IMPLANTS NO IF YES NAME: ID NUMB I/ 7ACTURER

f. -:

art „s r^ ,. s^'" tlk MEDICATIONS/ORDERS Waif IIRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY_ ANESTHESIA)

YES 11 • NO _ MEDICATIONS/SOLUTION DOSAGE . TIME - METHOD PREPARED BY GIVEN BY

I CVI) Li,ot0 toi,:o.A.t- aeyn- I: teitoo 2.--c-c - 1:ii2 ;..._ • gr....„),4,0...c.z.,... em......tykk,..,4 as .... . ,

, - ,

( tL) Q . 'MOUND IRRIGATION jg YES ❑ NO, TYPE(S): .

0-9 c/o WD`-.0Z... :_ . . •-;m ?

l'

.. OTHER l'OTHER ORDERS ' -• . .

NO ❑

TIME CARRIED OUT BY

... ,„

i - OPERATING RO .-;-: IF YES. SITE - -

YES p-- 0,

'' i,..,.s - t ' 11-e.,A 16. -- ±-.: LABORATORY SPECIMENS SPECIMEN IS)

NO El

NAME : .-

•-------- NAME YES ■ FROZEN SECTION IFS) NAME

• NAME

YES ■ . NO n CULTURE IC)

NO 21

NAME NAME YES ■ NAME NAME NAME

NAME NAME .

- ''' -'


11-1(8

Torr. . 17. TUBES, DRAINS/PACKING YES • ____. NO 1344 • TYPE/SIZE 1. 2. .

SITE 1. 2. . ....._ •-...,- _

19. ADDITIONAL INFORMATION

S...A5 2A--1,-.;

`_Ibi--- Z-ke i (.0.-ca.. t...._ 0,,;-■- ■.)--Q- 'NV) VIZ";5(rcxc...-cA -----• 6-1 Y

20. OPERATIONS)) PERFORMED _ .

,Q.. _c..- O--O r 4.), e 1,2, 0 ,,, Ex L. k C ire-_, 1"3 ,,..47k

-.114--D ) C.A...NNAr\

AT 21. PATIENT TRANSFERRED. TO

1 CAA — TIME .S49---.

-sz 6.13?c1.- .. t;C METHOD

22. NATO

A--1J MEDCOM - 20292

°lc° USAPA V 1.00

DOD-033866

ACLU-RDI 1656 p.52

1-•

0. 0

m

3

O o

0

'41

m

O r- c

m

-n O

m

-o

rn x

0

w

CO 0 1'4 -0 0

133

0 0

cn 0 1.3

m 3

St)

• •

MEDCOM - 20293

DOD-033867

ACLU-RDI 1656 p.53

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY

MONTH-YEAR DAY 1.0 27 VE41111111K. 1. 1,M1M111111tiratirta 19 HOUR O'9 ' 12 11111.11111111111111111,111111 • • 71E11 • •

180 104°

120 98° . .

100 96°

70 .

50

40

•105° ieR

PULSE TEMP F : • ; r ei • OM •• •• LI •

ra p :. i i :. .: .: :. :• :. :": :. :' i i :. .

...... ...... . . . . . . . . . . . . . . . . . ...... • • • • • • : . . . . . . . . : . . . . . . . 170 03° ...... • • • • - - • • • - • • .• - • • . . . . . . . . . . . . . . . . . • • • • - - • • • • • • • • • • . . . . . . . . . . . . . . . . . 160 - 102° ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . . . . • . . . . . . . . . . . . . . . . . . 150 - 101° .... ' J 140 100° • ' " " " • ' " • ' "

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

• . . .

W C

..)

C.1. )

(..

.) (4

<A

L..) (...

CC

al a) a

) --

.1.-.J

-., a

O 6

I-. 1

-4 O

N b

i... o o ' o

a o

'

(Cen

tigra

de E

quiva

lents,

for R

I

98.6° Illr211 •

130 99° • • • • • • • • • • • • • - • - .

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

••

- - • • • • - • • - • • .

. .

.

• ■ • • - • IMEIMEBrid011ad • • • • : : : : " r." • ' • • , • " : : " : : : : 110 97° 1 ;

: -. INA

" • .....

. . . . . . . . F.I.--: . . . . . .

... V.

• •

•

• •

111 NIENII:: ::

Lim

imp.. • " ' • '

-90 95°

" •

. .

80

: Waif

ii, : :

•.: 111

. . . . • • • •

•

• • • • • • • ••••••••••••

•

• %I

60 .1§1111111111111111111

-‹

* • . . . • • . • • :: • . :. ESPIRATION RECORD tilliiiii

i • • • •

•••.00

,

• • • • • • • • • . . . . . . . . .

01111!

• • • • •

Is .

-.2

o. P. 8 c2

17* gma., HEIGHT: WEIGHT •—p. trz. - FM

-2 BLOOD PRESSURE L.L. - EffillEMIZEIIIIILVIIIMEI M.= P it i 7 WI RVAIMIni

II . , , tav e... •LA- mull --mq

CIA 'N 0 gli fl -th )14/(40 2,

■TIENT'S IDENTIFICATION (For typed or written entries give- Name—last, frst, middle,- ID No. REGISTER NO (SSN or other); hospital or medical Monty) ;..

STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 20294

DOD-033868

ACLU-RDI 1656 p.54

REQUES

TIME

-. CBC). -., : - .... ULT REF. RANGE

41-10.8 x 10' E-09L-03

15:06 Patient Lilits

-ii WBC - 11.3 li x10"3/u1 . 4.5 - 10.5 RBC 5.04 x10"6/d. 4.00 6.00

-i; , ftib .- 14.6 gal. 11.0 MI- " flet 46.0 I TLO 010 ..

IMAL3. fl ; 90.0. 99.9. PI MI 210 pg 27.0 31.0

MX 31.7 I. 9/dIL . 33.0 37.0 I.: PIt 25.: x10A3/d. 150. 450.

LYX 12.6 42 -- 7 .- -• 20.5 51.1 - :- LYN • LA '',I0 x10"3.N. 4.2 - 3..4 .

B J---

Lymph I • ----] Baso

C-F RAPID . . 7z: -----,!Aik ("› SERIAL -10.11A.,,,.., /F'

IDG s'--)

Patient ID:11111111 Test Name :PT Test Result:= 12.4 sec.

\\.\\

***RESULT NOT RANGE CHECKED:** Ratio = 1.0 Calculated INR = 1.03 Sample Type:citrated wh. blood Test Date :09/23/03 Test Time :03:05 PM Card Lot • 10301 Operator

E: J LAB ID NO.:. MEDCOM - 20295

R. wp

Nit

Urob

Bid

Prot

pH

Ket

Bili

SG

TEST

Color

APP

Glu

dil Dunt irectigen

RESULT

'N/A

Negative

Negative

Negative

Negative

0.2-1.0

Negati

wA .

Negative

N/A

Negative

- co,„__.,•-

, i, , ,,.....,,..4.41.4,,i ' - '''w".4‘SOrolpfly-

. ,

allt &thinly ' ::

'-

.ULT

' -' YTOWlit!,44.4...- •

Negative

Negative

I MUST SUBMIT SF SIB WITH EVERY UNIT REQUESTED

ABO/Rh

Mono

Other

O&P

Micro Parasites Malaria

H. pylori

Oce Bid

Gram Stain

S

' -.14arterubioloiry • - • '

rP$COOk Urian

Negati

Negative

REF. RANGE

Negative

Negative

•

\\b RAPT )0 I COAG ANALYZER V4.54 SERIAL 09123/03 03:10 PM

Patient ID:IIIIII, Test Name :APTT Test Result:. 16.5 sec. ***RESULT NOT RANGE CHECKED*** SampTe Type:citrated wh. blood Test Date :09/23/03 Test Time :03:07 P11 Card Lot :100208 Operator 1111111111

. - _ (MUST SUBMIT SF 518.1VITS EVERY UNTT Old-BLOOD

' • REQUESTED)' • UNIT TYPE CROSSMATCH

LAST, FIRST,.

Ward/Section:

ATE

LABORATORY RESULT FORM 1 (Subject to the Privaci, Act of 1974)

SSN/PSEUDO SSN:

DOD-033869

ACLU-RDI 1656 p.55

GU _ 7371.18 pied

CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)

SS

War/Section:

TEST RESULT REF. RANGE RANGE

(944- PICCOLO

09/23/03 03:16 PM REFERENCE RANGE: MALE PATIENT #: imor VETLYTE 8 DISC LOT OPM it: am SERIAL #:

3152AA4 DR #: 000

1111111111111

•:r

wa 144 mmol/L

3.6 mmol/L

TCO2 19 mmol/L

iCa 1.13 mmol/L

Hct 25 %PCV

Hb* 10 g/dL

*via Hct

At 37C GLU 105 pH 7.276 BUN 10 PCO2 39.0 mmHg CRE 1.5*

P02 399 mmHg CK 555*

HCO3 la mmol/L NA+ 122* K+ 3.7

BEecf -s mmol/L CL- 101 s02* 100 % tCO2 19

*calculated

09/ REFERENCE RN\! . .-.: PATIENF #: LIVER PANEL PP.3

OPER AIM SERIAL ,••

DISC LOT #:

111111111111k DR #: 000

3154AA7

3.3 3.3-5.5 G/DL 49 26-84 U/L 1 35 10-47 U/L 1 42 14-97 U/L 37 11-38 U/L I

0.6 0.2-1.6 MG/DL 21 5-65 U/L

6.3* 6.1-8.1 G/DL

73-118 MG/DL 7-22 mG/a.. 0.6-1.2 MG/DL 39-380 U/L 128-145 MMOVL 3.3-4.7 MMOIA_ 98-108 Mai 18-33 MGM_

PIC.:OLO - 03:43 PM

MALE

ALB ALP ALT AMY AST TOIL GGT TP

At Patient Temp

PH 7.304

PCO2 35.8 mmHg

P02 387 mmHg

Patient Temp: 35.0C

F102 : 76

5amplp Type_:

' INST QC: OK CHEM QC: OK •HEM 1+, LIP 1+, ICT 0 INST QC: OK CHEM QC: OK

HEM 2+, LIP 0 ICT 0

23SEP

°per:11111

;Physician:

5Prit 111111 •1';. •

giro RTED

•

MEDCOM - 20296

DOD-033870

ACLU-RDI 1656 p.56

Ward/Section: .....i: . D--- REQUJSTIN • --• - I LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST,M1. it

eijor ufx.ge:

DATE .;-23,S._f

1 -

TIM bo

i •,. ,..:

SSN/PEEUDO SSN: •

,.4„. „ 04::. fOlir 5. " ::::0:gmis-on,R32-44.9 a TEST 23-°9-°3 la ,

200 TEST RESULT REF. RANGE TEST RESULT REF RANGE

WBC (. )(:C.I'l Patient Limits

10'14 x10"3/aL 4.5 10.5 RN 473 t10"6/41 4

. . .00 6.00 HO 1.3.13 g/t1L • 11.0 18.0

ITV 90.2 - ft . 80.0 99. 9 rICH 29 .2 P9 : 27.0 31.0 111:1E 32.4 L VOL • MO 37.0 Plt 198. xl0Wal. 150. 450. LYZ 8.3 44. Z • 20.5 51.1 Ufll 0.9 4, al013/111 1.2

'Color N/A RPI( Negative

R BC illvt1B0*.' App N/A Mono . Negative

Hgb ■ Gilt Negative , ',. .:::..,,,:4P::',,: " , liftiki 1, 60%;O:vma.,::,:::-:•::ts{a. ii:..f.' . ,..'.10..., Hct Bill Negative ' Source

MCV Ket - Negative Gram Stain

•

Pit SG N/A . Oct Bld Negative

Lymph • . Bld Negative H. pylori Negative

4.,. .,,..,.... ::;..i., :w: ,:ii;,.. W

3.4 , tlairromfgatd ,,,,.,,,‘,, 00<zwat:-~,?;.V.O. ./.' "":'

.P11 - N/A Micro . Parasites

Segs Munn Pro ' N egative Malaria

Bands Eus Urob 0.2-1.0 0 & P

Lymph Bas() Nit Negative — Other

A ty p

I RBC I

'Via rph

Imm Lev& Negative "crOS,CO.PW.', ..,,a1M, P.

HCC • Negative

- -.- -

:

Spun H ematocrit

42 52/(M) 37-47 %1F)

-::-;:--

, .,, '''. el '

-

..'.. : '''

BIja , ' , ' a . . ""1'4 , '

Set Rate Cell Count

' — - - -

_ , MUST SUBMIT SF 518 WITH ' EVERY UNIT REQUESTED

Other Direction - Negative ABO/Rh

TEST RESULT REE RANGE UNIT . TYPE CROSSMATCH

PT 9.8-13.6 secs

APT T 21-34 S F-SS

D dimer i

<20 ug/m1

FDP

l

<10 lig /int

- REMARS: A(36 - --r- q-q- ,__.f..._. RNPORTEp BY: I DATE: LAB ID NO.:

-..—.--....

MEDCOM - 20297

DOD-033871

ACLU-RDI 1656 p.57

TEST

DATE

Ward/Scction: REQUESTING PHYSICAN:

LAST; PIRST,M1.


SSN/PEEUDO SSN: TIME

II_Crcat

Hct .

Tropoin-I

Drug of Abu*

Hgb

TEST

AnGap

Ca

GLU

BUN

SO2

HCO3

P02

TCO2

BEccf

CI

PCO2

nH

Na,

4,r4PM94YMfg11 — F ititito . et 41(c . Panel' 24 ,1 '

RESULT REF RANGE

TEST RESULT REF RANGE

3.5-5.5 g/d1 CLU 73-118 ing/d1

. 26-84 WI

BUN 7-22 mg/d1

10-47 WI CA ++ —

8.0-10.3 mg/di

14-97 u4 CRE 0.6-1.2 mg/dl -

11-38 u/I NA+ 128-145 mmolidl

01-1.6 mg/d1 K+ 3.3-4.7 mmoV1

7-22 mg/di C[, 98-108 mmol/1

8.0-10.3 mg/dl ICO2 18-33 nonoUl

100-200 mg/di ‘A ' 4:4110);' 14fitta11004 ' 4.

0.6-1.2 ng/dl TEST RESULT REF RANGE

73-118 mg/di ALB 3.3-5.5 ON

.,9-1117-

1

6.4-8.1 g/d1 ALP 26-84 u/1

,14140

; Mcll, tt: ,,V , :-t-* - ,,,,zri

ALT 10-47 u/1

1 RESULT REF RANGY

AST 14-97 till

73-1I8 angAll AMY 11.38 u/I

7-22 rughll T1111, • 0.2-16 m011 ,

0.6-1.2 mgidi GGT . 5-65 oll

39-330 (1 (M) 30-190 /I (F)

Tr 6.4-8.1 g/dl

128-145 mmo1/1

f kt016)Elec1hil'

3.3-4.7 rotrod/1 TEST RESULT REF: RANGE

98-108 mmoin NA+ 128 - 145 mmol,1

18-33 nono1/1 3.3-4.7 mmol/1

CL— 98-108 torno1/1

- — - 1CO2 18-33 mmo1/1

c)(6) -- `1 Pt Name:

Na 141 mmol/L

K 4.1 mmo1/L

TON: 23 mmol/L

i Ca 1.01 mmol /L

Hct 39 '.PCV ,4b* 13 q/OL

*via

Ht 37C

PH

PCO2 38.7 mmHg

POE 174 mmHg

HCO3 22 mmoleL

5Eecf -4 mmol/L

s02* 100 *calculated

At Patient Temp

pH 7.362

PCO2 38.5 mmHg

P02 174 mmHg

Patient Temp: 98.4F

:Sample Type_: ART

235EP03 20:23

Opera111111 4

Physician:

REPORTED BY: ' DATE: LAB ID NO.:

MEDCOM - 20298

DOD-033872

ACLU-RDI 1656 p.58

At 37C

PH 7.251

PCO2 43.4 MII1H9

POI! 485 mr0119

FICO3 20 mmol/L

BEecf -6 mmol/L

gOa* 100 %

*calculatpd . -

tit Pat ient Temp

7.2,3

.'UVE 41.5 rut g

480 ffi f H

Pa0ent Tef.;p: '.;•C

.atO 1 e

3!EPEI3 16:00

Opqr. am . , Phys an:

Seri a

lagf °C

f";c)

REQUESTING PHYSICAN: CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)

Ward/Sccficag

SSN/PEEUDO SSN: DATE TIME LAST, FIRST,MI.

NPST 'QAAWYX '4?0,41*,

(f,)

Pt: 11111/ Pt fl Bole

wto, TEST RESULT REE RANGE TEST •! RESULT REF

RANGE 3.5-5.5 g/d1 73-118 mg/ill

7-22 mg/d1

GLU

26-84 u/1 K

CI

BUN 8.0-10.3 mg/d1 CA ++ 10-47 u/I

Na !43

5.5 ffiffr3 1 /L

Tr- 02 22 Amoist.

Lua 1.12 Ar4o1/L

Hct 52 %PCV

HID* 11 9/CIL

*via Hct

0.6-1.2 mg/di

128-145 nunolidl

3.3-4.7 nuno1/1

14-97 u/1 CRE

11-38 u/I NA

0.2-1.6 mg/d1 K

CL 98-108 mmol/1

18-33 mmoUl

7-22 mg/dl

8.0-10.3 mg/ill tCO2

1,11$1,4sabl't RESULT REF RANGE

NAPV iccol 100-200 mg/d1

TEST mg/ill

ALB 73-118 mg/d1 3.3-5.5 g/d1

26-84 u/1

10-47 u/1

AnGap

Ca

BUN

GLU

Creat

H

ALP 6.4-8.1 g/d1

ALT PAV iv 4,N:

RESULT REF RANGE

AST

11-38 u/1

0.2-1.6 mg/dl

5-65 u/1

6.4-8.1 g/d1

ge;IION WNW

REF RANGE

128-145 mmoUl

3.3-4.7 mmoUI

98-108 mmoUl

18-33 mmoUl

73-118 mg/d1 AMY

TBIL

GGT

TP

7-22 mg/ill

0.6-1.2 mg/di

39-380 /1(14) 30-190 /1(F) ljea.

TEST 128-145 nuno1/1 •

TEST RESULT 3.3-4.7 nunolll Tropoin-1

Drug of Abuse

98-108 mmol/1 NA+

18-33 nuno1/1

tCO2

REMA,1

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 20299

DOD-033873

ACLU-RDI 1656 p.59

Ward/Section: REQUESTING PHYSICAN: _


LAST, FIRST,M1.

,keryfA •:e*,,JOIV ,..E.2- gi, IFFRIO'CheMPL .. N: :qr.'

DATE

;',"

TIME

.N.fter

SSN/P EEUDO SSN:

kCI)I4M04):01WPAO AURIAN.:44: ''''

4. 1. - 57,;7 C.C7

--1 TEST . RESULT

. . REE

RANGE TEST

._ ... .

RESULT REE RANGE

Pt: (t,)k_o .

Pt _. ALB 3.5-5.5 g/dI

GLU • 73 - 118 mg/di

'tame: ALP . 26-84 u/I

- BUN 7 -22 nig/d1

Na 142 Doh, 1 :'I_ ALT

K 3.7 En rn o 1 / L

10747 WI- CA +t 8.0-10.3 mg/d1

AMY 14-97 u/1 CRE 0.6-L2,11g/01

TCO2 23 ro) I r L t) n)

AST '11-38 WI NA + - 128-145 nunuUdI

i C 3 1 . C42 [mei /I_ rt) Hc t 39 :PCV

T13IL— - — - - - - ''0.2 = I.6 nag/d1' K+ - — - 3.3-4,7 ourial

1) Hb* 13 9/dL m)

BUN . _ 7-22 mg/di CI: 98-108 mmoUl

*via Hct 4) t)

Ci,t1- : 8.0-10.3 mg/d1 tCO2 18-33 mmolll

at 37C CHOL 100-200 mg/dI

4,W,A,- 4.04.

..zw, 1.,:-.,....,. v :4:

n.- M Atougto :,.w.:.,

was :

PH 7.363 CRE . 0.6-1.2 mg/d! TEST RESULT REE RANGE

PCO2 37.3 mmHg GLU 73-118 mg/dl ALB 3.3-5.5 gh11

P02 171 1,111119 . TP , 6.4-8.1 g/dl ALP 26-84 u/I

HCO3 22 wool /L t -*T 1Ck4 0 F t$1' g ''t..,. 'C .

ALT 10-47 u/I

• ' BEecf -3 mmol /L SO2* 100 %

TEST RESULT{: .REE . RANGE

,\§T .. 14-97 u11

*calcul ated GLU mghlt AMY 11 -3K till

7-22 tught I — T1111, ' ' 0.2-1.6 ing/d1

5 aMP I e Type_: • CRE - 0.6- " mghll- GGT - S-65 till .

ZSSEPOS ZS: 0 -9 ,., CK -- -- 39-380 /I (M) : TI, ' 6.4-8.1 g/dI

Oper: dm :NA ft..- 128-145 mmo1/1 K4.010 -

.. . 't0b. $, AFIK ..

Physician: Ki- :_: - __

Ser# SIM

3.474.7 nonoil TEST' _ RESULT . REE RANGE

CC C 98- 108 98-108 romol/1 " - • ' •

NA + 128-145 mmold

1CO2 - • 18-33 rronolil 3.347 mmii1/1

. -- CL 98-108 mnsoill

(pm 18-33 min111/1

REMARKS: - , • .-

REPORTED BY: DATE: LAB ID NO.: .

MEDCOM - 20300

DOD-033874

ACLU-RDI 1656 p.60

Ward/Section: —

REQUESTING PI It. ■

a ,.. LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST,MI. - I%

■IIII.....-

etliAtO A:, -V I

FAK,e -)C

tiiiityiit, ...,- ‘.4.

TIME

0

,,,,

SSN/PEEUDO SSN: I .

TEST wit . 05:v TEST RESULT REF: RANGE TEST RESULT REE RANGE Patient "Limits

Color ._ N/A RPR Negative

10. 0 x10"3/d.. 4.5 10.5 App' Gig- -

— Bili

- --•

N/A

Negative Mono

9 ? ,.

Negative Hgh x10"6/uL 4.00 6.00

o 011. 11.0 18.0 itrobit ge Ilaiwzo;::,

Hct Fkt 42.2 2 35.0 60.0

V J :fi- 80.0 99.9 ._. Negative _. __ . _ . _

Source

._ . . ... _

1 n 27.Q 31.0 fl 2 L 9./tEL . Z.0‘. 37.0

Ket Negative Gram Stain

Pit PIt 218. X10"3/1E 151 450. SG N/A Occ [Mgt Negative *L X 20.5 51.1

7 'IC z1V3/al. • 1.2 3.4 D I A /4 ID -..

- - -- - - Negati ve ---- — - 11 - PYI06 - Negative

tr 1 0 -- '1,-, H - -

N/A. . --

Micro Parasites

Seg Mono _ . . Prot _ . Negative . Malaria

Bandt Eos Urob 0.2,Lo .. . . 0 & P

Lymph Baso . Nit Negative Other . . • , .

Atyp 1mm 1411t: Negative . :-Lia4.-}4.tin esk1:./git

; _ „ _ HCG Negative :

.

..

.

Spun hematocrit

....

:, '•- i,--,,I,:%;x:: 4., , 4:>4 .., 7:, 3i ( --,?-4 „ , .. Set Rate Cell

Count

. . _ MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED -

Other Directigen • _ • Negative ABO/Rh .

TEST

, :il

'

vil :410p.::

RESULT REE RANGE

", „_00:„ ....

,....,: ,!,,,tg:'•': :,, '''" '0*67-,-''' v-Tfao-, emr-zz

UNIT

,,, 'q ,,, ,,,,, ',A

. .: ' - TYPE •

W ealk , wY..,,-,,,, ,:a:

CROSSMATCH .

PT . 9.8-13.6 secs . -

APTT 21-34 SESS •' •

.

D dimer <20 ug/m1 _

FDP <10 ug /m1 • -

REMARKS: (56-


MEDCOM - 20301

DOD-033875

ACLU-RDI 1656 p.61

16.

DOD-033876

o0004004, or

Wardlection: .141

LAST, FIRST,M1.

REptUESTMG

FOP DATIs

-111p0


TIME SSN/PEEUDO SSN:

^Io Mctabollc Panel `; TEST

Na

K

CI

PH

PCO2

TCO2

1-1CO3

502

BEecf

AnGap

Ca

BUN

GLU

Ctent

Het

T ST

Tropoin-1

Drug of Abuse

- 111*4-L1

FtO.

Pt Hame:

Ha 141 mmo 111_

3.8 mmo1/L

TCO2 23 mmola

1Ca 1.10 mmola

Hct 42 %PCV

14 gicIL

-*via HCt -

Rt 37C

PH 7.359

PCO2 38.3 mmHg

P02 93 mmHg

HCO3 21 mmo 1 iL

BEecf -4 "Mmol/L.

sO.?.* 97 %

*calculated

Sample3Me_:

E4S6:Pgiq,

aper:

Physi

- • RESULT

RESULT

-7-22114:M1

39-380 /I OM -39- 19011(F) -

128-145 rnmoItl .4:0;k•

0.6-1.2 mg/d1 GGT

3_3-4.7 ituno1/1 TEST

73-11/4mon Amy

7-22 mg/dl • CL

100-200 ing/d1 i lad 'Of 0.6-1,2 mg/dl TEST RESULT REE RANGE

73-118 mg/d1 ALS

0.2-1.6 mg/d1

8.0-10.3 mg/d1 1CO2

6.4-8.1 011 ALP

ALT

11-38 u/I NA

14-97 u/I CRE

16-47 uJl CA++

3.5-5.5 g/dI

26-84 u/I

AST

RANGE

REF: RANGE

TEST

K

GLU

BUN

p'leculo) Itirolj to

RESULT REF RANGE

RESULT REE RANGE

73-118 ing/d1

7-22 ing/d1

8.0-10.3 Ing/dI

0.6-1.2 mg/di

128-145 mmulldl

3.3-4.7 mrou1/1

98-108 mmol/1

18-33 nunolll

6.4-8.1 o/(11

11.2-1 .6 mg/di

5-65 u/I

3.3-5.5 g/dI

26-84 u/I

10-47 u/I

11-38 u/1

14-97 u/I

98-108 mmul/1 NA+ •• - • -- • --- •

128-145 mmol/1

-18-33 nuno1/1 k+ - 3.3-4.7 nimoh/T

98 - 108 tomo1/1

I-.... •

tCO2 18-33 mmo1/I

REMARKS:

REPORTED BY:

MEDCOM - 20302

DATE: LAB IDNO.:

ACLU-RDI 1656 p.62

•

VDATE

i W.

•(,)-(q . ;1

E0 111a1), wit,*

AN: warumcctip: 4 REQUE LSI( 7--

.,

LAST, FIRST,M1. A-

RESULT REF RANGE TEST

Na 138-146 mmolfdL

3.5-4.9 mmol/L --

CI 98-109 mmol/L

pH 7,31.1-7.45

PCO2 - 35-45 mmHg (art) 41-51 mmHg (von)

P02 - 80-105 mmHg (art) N/A (vcn)

TCO2 23-27 mmol/L (art) 24-29 mmol/L (yen)

HCO3 22-26 mmol/L (art) 23-28 mmol/L (art)

SO2 95-98%

. BEccf (-2) - (+3) tranoUL

AnGap - 10-20 mmoIlL

Ca 1.12-1.32 rnmo1/1,

BUN 8-26 mg/di

GLU

..._..

70- 105 mg/dl _ . .. _ .

Creat 0.7-1.5 mg/d1

Hct._ _ -- _ _ _ 38-51% PCV

HO _ . 1242 01 _

p TEST RESULT REE RANGE

Tropoin-I

Drug of Abuse

.

1

. .

in-..:er ,r4

c dr! vICE I /

TIME 154)

- T111 L

- GGT •

1CO2

TEST

NA +

K

, TP

ALP

ALT

AMY


SSN/P • SN:

IcOla) o iavie

AL13

AST

TES T .

TEST

CL-

K+

ICO2

GLU

NA

CA t4. -

CRE

BUN

RESULT

RESULT

RESULT

3.3-4.7 mmol/1

98-108 mmohl

128.145 mmol/1

1N-33 rninol/I

REE RANGE

REE RANGE

REE RANGE

- 14-97 u/I

73-118 Ing/dI

7-22 mg/d1 •

6.4:11.1 011

128-145 mino1.411

8.0-10.3 mg/dI

0.6-1.2 ing/ill

3.3-4.7 mmoUl

0.2-1.6 rug/dl

3.3-5.5 011

5-65 u/1

26-84 till

98-108 mmol/1

18-33 mmut/I

11-38 u/1

10-17 u/I

L.AB ID NO.:

MEDCOM - 20303

DOD-033877

ACLU-RDI 1656 p.63

MEP

CEQUESTI

(qt() 2511:76 Patient -

WBC 11.8 H x10'3/UL 4.5 10.5 RBC 4.80 - 741046/41 4.00 6.00 ligb 13.8- - .gidL 11.0 18.0 1kt 44.1 Z , 35.0 60.0 10 91.8 11 80.0 99.9 ra 28.7 P9 27.0 31.0 ttlf 31.2 L g/dL 33.0 37.0 Plt 296. x10"341. 150. 450. Ln 7.2 *L Z 20.5 51.1 LY# 0.8 * x10'341 1.2 4 • 2

vas

Fen iil

LAB RATORY RESULT FOR (Subject to the Privacy Act of 1974)

MEDCOM - 20304

(qt

DOD-033878

ACLU-RDI 1656 p.64

6 Wanl/Scction: vi0i#J.„ REQUESTI PHYSIC LABORATORY RE LT FORM

(Subject to the Privacy A, t of 1974)

LAST, FIRST,MI. DATE TIME 2-42 ZE5

SSN/PEEUD

0040)19 ' b.'4 •;-...--,-;.---i-, -;,:gffri,A;,

€ 'F''' , •--- ,:--- — .,

> : 1f111)i1 ,

. *.1)5

TEST RESULT REF RANGE TEST RESULT REF RANGE TEST RESULT REF RANGE

WBC 4.8-10.8 xto Color N/A RPR Negative

RBC 4.7-6.1 xlf) App N/A Mono Negative

Hgb 14-18 gicll(M) 12-16 g/d1(18)

(Au Negative ;.. „ ''' ,. 1#;(1. :,‘ T ''''''F-1

Hct 42-52%(M) 37-47%(1)

Bili Nep- --' -- - ---

MCV I 80-94 fi(M) go Ne PICCOLO

Pit ' ! Negative NI 27/09/03 06 : 02

Lymph % N, REFERE s 1 " • NGE : MALE i Negative

w • 1.. t ' . 5 '-'•;..s.w:'5 , 1

, NT #: NM NETLYTE 8

Segs

4L);-\

Ni DISC LOT #: 3151AM i OPER # : filk DR # • 000

Bands • (,( .A

o. SERI AL #

Lymph , nx „. '7 ---•:: 03

N ! GLU 95 73-118 MG/DL

Atyp ...43 ,:rff4i 12'..41qt

N BUN 10 7-22 MG/DL #1 , -,;,-, ...e. - ,,,q.,

RBC Morph

L.rdieS a t.) .:10 .',3lit 4.5 10,5 RR: 4:79 xio' 6! ci 4, C,C) 6.10 '4211:. 4 gle 11.0 2.1 ,

N CRE 1.1 0.6- 1.2 MG/DL i CK 968* 39-380 U/L NA+ 130 128-145 MMOVL

S p u n , Hct 42ra - 1 :15.0 :. -3.1 Hematocrit 7°X 9." 11 '00.0 F9.9

rirP 7q 4 Pi .77.0 31.0

K + 3.7 3.3-4.7 MMOVL -1? 0,' P .- 4.' . .,,,', ,% -,-.. CL- 100 98-108 MM0f/L '" ''-

tCO2 23 18 Set Rate 1.:•-E 31•2 L g ,'et_ 33.,-2 ..7.:-.

'rlt. 191 t l3,, u! _. J .., ;,._ i yz n : z a 5

-33 MMOVL j8 WITH ESTED INST OC: OK CHEM QC' OK

Other 51.1

LP 1.7 Y 5.' 3' 1.2 14 en HEM 0 3 LIP 0 , ICT 0 1 5,5:5-=,

p > . '

••=,,x ---e.

TEST RESULT REF RANGE UNIT MATCH

pT 9.8-13.6 secs

APTT 21-34 SSSS

D dimer <20 ug/ml

TDP <10 ug hul

REMARKS:


MEDCOM - 20305

DOD-033879

ACLU-RDI 1656 p.65

N LC) REQUESTING PHYSICJU ABORATORY RESULT FORM

(Subject to the Privacy Act of 1974) ,

t cm 110 yst

SSN/PEEUD

Negative ABO/Rh

•

Ward/Section: t

LAST, FIRST,ML bl

01141.4w

TEST TEST RESULT REE RANGE TEST RESULT REE RANGE N/A RPR WBC Negative

RBC

Hgb

Hct

mcv Pit

• 11 . :'; 1302 Bili. _ .

2& 27.0 Ket .-'

SG

N/A Mono

Negative

Negative Source

Gram Stain Occ Bid

Negative

IO 0

Negative

N/A Negative

Lymph % L:- --,.'-: . 1---;, ,.:. :1.1 Bid

11 i:15$,--777--mmurr; •—, 40.0v.,-,:::"..-vx:ww,...w..

.;,. Olig- Segs Mono

Bands Eos

Lymph

Atyp Imm

RBC ,

Morph

Spun Hematocrit

Set Rate

Other

42-82%(M) 37-47%(F)

Baso

Negative II. pylori Negative

N/A Micro Parasites

Negative Other

Negative Malaria

0.2-1.0 0 & P

' Negative

Negative

'MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

TEST

PT

APTT

D dimer

FOP

oz:S:

CROSSMATCH RESULT

9.8-13.6 sees

REMARKS:

21-34 SESS

< 10 ug

<20 ug/mi

TYPE


MEDCOM - 20306

DOD-033880

ACLU-RDI 1656 p.66

Ward/Section: REQUESTING PHYSI CAN: CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST,MI.

--, ‘v

. 5,, -, '

DATE

00k &

TIME I SSNIPEEUDO SSN:

tcr

TEST RESULT REF. RANGE TEST RESULT REF. : RANGE

06 : 00 R28EF/E°1-?9E/IP4C3F RANCE

Na 138-146 nunolidL ALB : MALE 3.5-5.5 g/dI PAT IENT #:

K 3.5-4.9 mmol/L ALP 26-84 WI: BASIC MET Aar (91c4 .41 DISC LOT

CI 98-109 mmol/L ALT #: 3203AA4 1 10-47 u/I opER # :Amok DR #:

AMY 000 14-97 u/I SERIAL 774 pH 7.31 -7.45

PCO2 35-45 mmHg (art) 41-51 mmHg (yen)

AST 11-38 u/I .. II! !' ............ !!!! GLU 104 73- !!! " P02 80-105 mmilg (all) 'mu,

N/A (yen) UI 0.2-1-6 mg) BW 8 7-22 MG/DL TCO2 23-27 nunoUL (art)

24-29 nunoUL (yen) BUN 7-22 mg/di CA + + 8.0 8.0-10.3 MG/DL 'VI

' CRE 0.8 HCO3 22-26 mmol/L (art)

23-28 mmol/L art CA++ NA

0.6-1.2 MG/DL a 8.0-10.3 m NA + 136 128-145 MMUL

SO2 95-98% CHOL 100-200 m K+ + 3.8 3.3-4.7 MMOVL ,..- BEecf (-2) - (+3)

mmol/L CRE 0.6-1.2 mg

CL- 96* 98-108 MMOtL ;E 1 t CO2 27 18-33 AnGap 10-20 mmol/L 1 GLU 73-118 nu MMOVL

Ca 1.12-1.32 mmoUL TP 6.4-8.1 0 INS1 QC: OK C-EM OC: OK BUN 846 mg/d1 ,, -'2 0$14110 ,, HEM 0 , LIP 0 , ICI- 0 GLU 70405 mg/dl TEST RESULT REP:

RANG

Creat 0.7-1.5 mg/d1 GLU 73-118 m -

Hct 38-51% PCV BUN 7-22 trig/4 /dl

Hgb 12-17 g/dI - CRE 0.6-1.2 int

,-; ..n...,, '' " '' • 4-...:14,-,- -, -An ---

CK ... 39-300 /I I 30-190 /I

TEST RESULT 'REF RANGE ' NA } 128-145 r ,,,-,>&...q.. iv,-, ,,,--,-

Tropoin-I 3.3-4.7 tri JGE

Drug of Abuse

Cr 98 -108 rr

1CO2 18-33 mmo1/1 3.3-4.7 rrunig1/1

98-108 mmol/1

. 1CO2 18-33 mmolll

REMARKS: ,

REPORTED BY: DATE: LAB ID 1NO.:

MEDCOM - 20307

DOD-033881

ACLU-RDI 1656 p.67

Ward/Section: ( C j̀vki : 1 REQUESTING PHYSICAN: FF

LABORATORY RE$ULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST,MI. — • . i dip' ../..siiiAn......_

- : o k

r

0 . IS.

*Al tag..._. . 1

TIME SSN/P • - . —

,, 01,..... ?LW -7',,

• 4

TES P. *V RESULT REE RANGE

WBC 4.8 L0.8 xIO CO 1 Negative

RBC 4.7 6.1 x1 Ah' ,

Negative

Hgb 1448waim 12-Ib 8/d1(b)

U Ncgativ. 4.ST ! :: .z ,, ,, • , • :'

,4

Hct 42-52%(M) 37-47%(F)

Bill tivr - . I

MCV 80-94 fi(M) 81-9911(F)

Ket Negatil PICCOLO

-

Pit, iln-crio -in3 crl N/A 29/09/03 03:55 Wye

Lymph %

L N ' NCL RANGE : MALE !tive

'''''''' ,,r,,, ,,: 01 0 ,... :,..:

N/A PAT TENT #: METLYTE 8 I

Segs Ncgativ DISC LOT #: 3141 AA4 OPER All DR #: 000 :

Bands 0.2-1.0 SERIAL #: 41111111111 1 Lymph Negativ

G_U 108 73-118 MG/DL

Atyp Negativ BUN 9 7-22 MG/DL it 0. CRE 0.7 0.6-1.2 MG/DL

RBC

Morph

,,, F-17.1Er.t .

L1-1111

Negativ r-'".•'`-a—

CK 145 39- 380 U/L NA+ 129 128-145 MMOPA_ K+ 4.3 3.3-4.7 MMO/L .77.77—

Spun Hematocrit

-' , i _''S' ..Pi

. • , ' ,.1 1.) 1.2.c '..:t ;_..: , - 00

1 CL - 97* 98- 108 MOM_ ,

tCO2 24 18-33 (410//L Pfx" Set Rate

,-;..., : :,,,,5 g,.i: -,'T. . lill 2..) a..,

:,.: ::.: ,:, '7 ,' INST OC: OK CHEM OC: OK = : ;.::: lf,c.

-.

5:.: Other ', 71,

HEM 0 , LIP 0 , ICT 0 [

. _; 4 1. A 1.1 ... . g t .4 le = p..

"4,-4 ;

rit , -ti , • gi P ,. :•,,,,A. , :

TEST RESD1 .

• • ':H

PT 9.8-13.6 secs

APTT 21-34 SESS

D dimer <20 ug/ml

FDP <10 ug Mil

REMARKS: (cecirret ravW ) REPORTED BY: DAT : LAB ID NO.:

MEDCOM - 20308

DOD-033882

ACLU-RDI 1656 p.68

0

OLU 102 73-118 MO/DL BUN 11 7-?2 MG/DL CA++ 8.6 8.0-10.3 MO/DL

CRE 0.9 0.6-1.2 MG/DL NA+ 133 128-115 MOM__

K+ 4.2 3.3- 4.7 MMOVL CL- 100 98-108 MMOV-L tCO2 25 18-33 MMOVL

.11 Negati

BORATORY RESULT FORM (Subject to the Privacy Act of 1974)

REQUESTING PHYSICAN: Ward/Section:

SSN/PE UDO TIME ooly

DATE -01

fir

LAST, FIRST,MI.

Mtfti: ..a4M1p)Maia

REE RANGE RESULT E TEST TEST Color N/A 4.8-10.8 x 1 WBC App 4.7-6.1 x lii N/A legative

too RBC

Negative 14-18 ghll(M) 12-16 /d1(1?)

42-52%(M) 37-47%(F)

Hgb

Bili Hct :-.--1-= PICCOLO 09/30/03 06:46 AM I REFERENCE RNNGE: MALE • PATIENT ill.

171MET IC I--- DISC LOT #: 32034 OPER #:41111 DR #: 000 SERIAL #:

80-94 fi(M) 81-99 fi(F)

Ket MCV

130-500 x10 verfied SG Pit

Lymph Negative

/A ato

Negative Segs

Bands 0.2-1.0

Lymph Negative

Negative Atyp

Negative RBC Morph

Spun Hematocrit

4 INST GC: OK Li-EM QC: OK 7" HEM 0 LIP 0 , ICT 0 Set Rate

Other

UMMW 7

4.1 *age an4:441:101*

UNIT 2K:o:4-me,

TEST

9.8-13.6 secs

21-34 SESS APTT

D dimer

FDP

<20 ug/ml

< 10 ug /m1

REMARKS:

DATE: REPORTED BY: LAB ID NO.:

MEDCOM - 20309

DOD-033883

ACLU-RDI 1656 p.69

Negative

Negative

i

OMR rSTED

Ward/Section: REQUESTING PHYSICAN: LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

TIME

z.

ks, aa,

LAST, FIRST,MI. SSNIP

° lab WIVM Nag nomgot._

DATE

Yr"

Hct

Spun Bongo(

MCV

Plt

RBC Morph

TEST WBC ;IBC

Hgb

Atyp

Lymph

Lymph

Bands

RESULT 17--

Set Rah

Other

TEST

PT

APTT

D dimer

FDP

RESULT

,

REF. RANGE Color

PP

01-1H5 ONO

Polar* Limits

tilIAL 4.5 10.5 4.00

1/41. 114 1.0 1 35.• ILO it ILI 1.9 pg 21.1 31.11

35.0 37.1 dna 151. 1 3.5 561 411/41. 1.2 3.4

It

Ftigen

Yt A

REF RANGE

9.8-13.6 secs

21-34 SESS

<20 'Wm,

< 10 ug hal

a'

Segs

RESULT

Ile 9.2 5.1

11,1 10.2 Oct 50.1 ICJ 10.4 ID 7LS

11.11 ?It 371. L11 17.0 4. LA 1.0 •

T ST 4.8-10.8 x10

4.7-6.1 x111 - PICCOLO .7.=

N 01/10103 05:50

•

REFERENCE RANGE: - MALE

N BASIC METABOLIC DISC LOT #: 3203AA4 N OPER AM DR #: 000

SERIAL #:

GLU 99 73-118 MG/DL N BUN 12 7-22 .MG/DL

CA++ 9.8 8.0-10.3 MG/DL 0 CRE 1.0 0.6-1.2 MG/DL

NA+ 137 128-115 MMOVL K+ 5.0* 3.3-4.7 MMOVL

N CL- 96* 98-108 MMOVL N tCO2 25 18 -33 MMOVL

N

INST GC: OK CHEM GC: OK HEM 0 , LIP 0 ICT 0

egative

egative

96

UNIT

MATCH

REMARKS:

REPORTED BY: DATE: LAB ID NO

MEDCOM - 20310

DOD-033884

ACLU-RDI 1656 p.70

BLOOD-

33( --/Ifyifr`

SINGLE DOSE DRUGS - MARK ON ORR", WITH NUMBERS &ENTER IN REMARKS

REMARKS- Cods drugs with numberaseseents

letters w

DRUG (Unite) MEDICAL RECORD ANESTHESIA

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110=111111111MINEBrIf.. ffiffelffiNINENINIff

•

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02 UM (U 2

FLUID MINA RY VOLA? AGENT

7-50

%_e.t. AIR UMIn

CRYSTALLOID-

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220

200

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160

140

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100

80

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BP (transduced)

T TOURNIQUET

T —/ ARES- X-X pRoc-0-0

LOSSES EST BLOOD LOSS URINE-

0/(7- 10 N

ANMICK:

OK ter PROCEDURE?

TIME-

PHYS STATUS 10)3 4 5 E

BODY WEIGHT

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V

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•

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LOCATION PROCEDURE 07...

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cc., eta" ter -

RECOVERY AT

P.1 '' . 1-ART line•' Steth- POE

6. I Gas anal zer r. I I

BP r oth PlAuto Cu MMIENMUNSEMIVEMWOAlr#MEMEIMIIINWJIBILIE

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CHIMMEMEI " • FesMira in

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G - M111.1111111 11 00 0 f

Cony warmer Meet with heirs d symbols. EVENTS deplete under REMARKS pos) von --.


Gictv 1a6

`..d care

PATIENT IDENTIFICATION- TYPea .rf wriko Nonr. CrnKOWnefe Modica/ liocAVy

.41111 P)-1

Ready Begin End

le-5-3 Ault:011E71C TECHNIQUES:D.5.db* t'schnkWe ""aw R"""1"

COUa4

Apr MANAGElletEV: @tubelike rout.. trgebnique erweenents feirbeet m /1-c7bacfe 101M).1 crS tile ,e--n-C),,2 Pt/

SURGEO

b) WAMC OP 376 REVISED 1 Jan 99

MEDCOM - 20311

CD, c9 (6) a. a. is

DOD-033885

ACLU-RDI 1656 p.71

P: •

OK?

OK lot PROCEDURE?

( 19) (C)1 - 1

AIWA, \ L AMC OP 376 REVISED

MEDCOM - 20312 1 Jan 99

DRUG (Unite)

VOLAT AGE NT

N20 UMin 02 L/Min

SINGLE DOSE DIMS -MARK ON ORI WITH NUMBERS &ENTER IN REMARKS

MEDICAL RECORD

TOTA URINE

F Ul UMMARY CRYSTALL D-

COLLO

BL

REMARKS- 1

■■

0 0

z

in ;- Z LII

U I- UI

I-

LU

Code *ups WV, numbtrs. lvvnts

with hitters

Igor) 16 e,P. Vat elicf,q; 10,7 vet iv-e

vcS "e per ri eh

BODY WEIGHT SYMBOLS:

EST BLOOD LOSS URINE -

111111 iSte 47t7: I

iM:.: ,::: ,:::: : DEMMER ELM= '`F frillatanni lLri JIJ

MIERVINEN I. ENIONIEN .:::::: 111111111r110 • MARI M, MinintrEM

entswA ,,womils ffiminvWguv

o .::W• j i __I • „4„,,i,. UI iliA ammtammummamm minium

i i Evicfseriffalswilwwwwww:::: ::::::::::110111 Mall MilleiMil lin 3 1 MilittrinNEM iliiMMIUMIIIIIMMIIIMINIMIMMIUM i fru MEREMERESEMEM ME SW tWEENEffal :.,:l.:W Immummumom i i Iii IMIIIIIIIMMI i ! ILIMMENIMMENNINMUSIMIONSEINEENSMI :i: :!i::!a SKI 1511111411111111111111111111.111111 FAMISMI=IIENNEE RECOVERY AT MEE

r 1111.1111

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ur Moto Cu I ET CO2 torr E-44111. rItSe I ?'

OP I oth .2 ill"MMT. MIEgfir I F11=21720===r91/PW■Mg ART line armgmommamr79 Gas analyzer

Ing DIM

Cony warmer

TEMP- she -PA Block TM

PROCEDURES and CPT Codes a, I. ill

co PATIENT IDENTIFICATION- TYP•dt, "aide^ anelw: Alamo. G'Reta

locIAiry

AJRWAY MANAGEMENT: roads, MEd., homPankpm. comments

DATE

013 Sell- 03 PAGE .9._ OF ...2_

ANESTHESIA TOTALS

DOD-033886

ACLU-RDI 1656 p.72

-CROSSMATCH

UIRED FOR THE COMPONE

AMOUNL GIVE

1

ML

REACT NONE SUSPECTED

TIME/DATE COMPLETED/INTERRUPTED

TEMPERATURE PULSE BLO?5 P ESSUR

518-124

SECTION I - REQUISITION COMPONENT REQUESTED (Check one)

kr—rd) BLOOD CELLS

❑ FRESH FROZEN PLASMA

❑ PLATELETS (Pool of units)

units)

TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

REQUESTING PHYSICIAN (Print)

DIA EDURE 1

111 TYPE AND SCREEN

C-6 IA/ hobei , (l---GROSSMATCH/Lt—f

II CRYOPRECIPITATE (Pool of

❑ Rh IMMUNE GLOBULIN

DATE REQUESTED

cr7.:.-4--P4--

‘ I have collected a blood specimen on the be)ow , named patient, verified the name and ID No. of the patient and verified the specimen tube label to decorrect. ❑ OTHER (Specify)

DATE AND HOURMIsRF.13,

VOLUME REQUESTED (If applicable)

ML ( VII

k- KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

s

e z........

REMARKS:

i

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED

/ 44r-3

SECTION - PRE-TRANSFUSION TESTING

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION

NSIti 7540-00-634-4159

ANTIBODY SCREEN

01.

TEST INTERPRETATION

❑ CROSSMATCH NOT REQ

UNIT NO. /0

NMI DONOR

ABO 0 Rh Na5

TRANSFUSION NO.

PATIENT NO. al RECIPIENT

PREVIOUS RECORD CHECK:

❑ RECORD NO RECORD

SIGNATURE OF P

PERFORMING TEST

REMARKS:

--exP 51a63

ABO

Rh

SECTION III - RECORD OF TRANSFUSION

PRE-TRANSFUSION DATA

INSPECTED AND ISSUED

r)

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.

1st VE

POST-TRANSFUSION DATA

If reaction is suspected—IMMEDIATELY:

1. Discontinue transfusion, treat shock If present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Alter Set, and I.V. solutions to the Bloc) / Bank.

./ DESCRIPTION OF REACTION

❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

OTHER (Specify)

PRE-TRANSFUSIO

TEMP 36, OTH DIFFICULTIES (Equipment, clots, etc.)

NO ❑ YE

SIGNATURE I

PULSE

B P

TIME STARTED

PATIENT I ENTIF1CA ION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; gr rate: hospital or medical facility)

111 WARtM7

DATE OyFir,F1709

e; ra

EX

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSAACMR, FIRMS 141 CFR) 201-9.202-1

MEDCOM - 20313 Medical Record Copy

DOD-033887

ACLU-RDI 1656 p.73

CROSSMATCH

Gov-004, f- DONOR

ABO 0

Rh

1st VERIFIER (Signature

DATE OF TRANSFUSI N TIME START.ED

71-'13 O3 llidiO PATIENT IDENTIFI ATION-=USE EMBOSSER (For typed or written entries give: Name—Last, first, mid

rate; hospital or medical facility)

518-124 -NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION

SECTION I - REQUISITION

COMPONENT REQUESTED (Check one)

REB-BLOOD CELLS

❑ FRESH FROZEN PLASMA

❑ PLATELETS (Pool of .- units) ......,-70SSMATCH

units)

TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

❑ TYPE AND SCREEN L___. ,e_q

REQUESTING PHYSICIAN . (Print)

DIAGNOSIS 0 IVE PRO URE

CS W-12 ❑ CRYOPRECIPITATE (Pool of

DATE REQUA a, I have collected a blood specimen o the below named patient, verified the name and I No. of the patient and verified the specimen tube I bel to be correct.

❑ Rh IMMUNE GLOBULIN .

❑ OTHER (Specify) DATE AND U KV

VOLUME REQUESTED (If applicable)

I .1-1AA-P-- ML--

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

SIGNATOR -

REMARKS:

RhIG TREATMENT? DATE GIVEN:

DATE VERI

5

5

d2.-

.

-e7121.-- HEMOLYTIC DISEASE OF NEWBORN?

TIME V7ItEfic , .

SECTION II - PRE-TRANSFUSION TESTING

UNIT NO. . TEST INTERPRETATION

PREVIOUS RECORD CHECK: TRANSFUSION NO.

111 RECORD • RK'No RECORD

SIGNATURE OF PERSON PERFORMING TEST

UIRED FOR THE COMPONENT REQUESTED ' DATE ,g

SECTION III - RECORD OF TRANSFUSION

PATIENT NO.11.01

RECIPIENT

ABO

Rh

ANTIBODY SCREEN

mar ❑ CROSSMATCH NOT REQ

(N)

REMARKS:

-tx00 .1 5€043

PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

a

INSPECTED AND ISSUED BY (Signature)

AT (Hour)

AMOUNT GIVEN

77 0 ML

REAL ON

NONE ❑ SUSPECTED

TIME/DATE COMP

/ rT3 17;s7761-. TEMPERATHRE PULSE BLOOD P SSURE

cr6 3 IDENTIFICATION .

I have examined the Blood Component container label and this form and I find all information identifying the container with the. intended-recipient matches item by item. • The recipient is the same person named on'this Blobd Component Transfusion Form and on the patient identification tag.

If reaction is suspected—IMMEDIATELY;

1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3, Follow Transfusion . Rdaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood B k.

DESCRIPTION OF REACTION

❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

❑ OTHER (Specify)

OTHV•DIFFICULTIES (equipment, clots, etc.) - • .

NO ❑ YES (Specify)

SIG

e: ra

MEDCOM - 20314

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/)CMR, F1RMR (41 CFR; 201-9.202-1

Medical Record CoDV

DOD-033888

ACLU-RDI 1656 p.74



PATIENT I DENTIFICATION

411116 ((,)(6)--i


23 Se_iec-3 ____accD____ HOURS

LIST TIME ORDER

NOTED AND SIGN

co cack, 4.. 4, 7 k c...u.. -kl- z.... ---2,-) Dr . S\ P 2-x._ L #4-1? Gs(...

vo IPPS 1}---oLrr 0 r-c),e-cazt-v- x...-\-- or- -ip._A__,1/4-\„, 4_ c_ v= NURSING UNIT ROOM NO. BED NO.

SkP r=.) S k../... PATIENT IDENTIFICATION

0 DATE OF ORDER TIME OF ORDER

S -1t-C"-CLQ..._ HOURS .,,,,,,Q. -

\1 t CI-CoL-(4 0 ‘` '.1i:t..-Ar. e-r) LD -11—t 1. ► —e.... ....

(C. 0) 1cv......1-1.' V • 12 ,-9....v-e-g-k--

3 N. k.,...ArE .. \- \-c,T iN 3Z 1--,,n, .,....../ 15-,r-c NURSING UNIT ROOM NO. BED NO.

'J3 SNI. A-- ' %'*" .- (-1 PATIENT IDENTIFICATION

(

5)


• c• - Q . N ' . 1A3 \ -2 C - -'' I ‘4•01_ HOURS

13 relr...Q3-0.• CLelf-N \...) S

(--, \ r) Virnb \ V CZ 2_3C)C \I ,..._

fie.,.-, NI-e.....c.a_81.3%,...,, S ."---W a X -2- ck tm &11-o C cbse r

Ac-C-G-y-, z>e-ex-ebire", Co v ‘ NURSING UNIT ROOM NO. BED NO.

X. -2_0(.cDs-,-0 ,AA-NeAr► t>1 - II ,Tlo..A 4. - ' -' i ,

..r. a .a.f.-. -....- PATIENT IDENTIFICATION DATE 0 •rel - DER ME OF • RDERAtp

HOURS

' :.0,-•-r.....A.._.)47-rse—Cr-r.._ .A:Z.N.-. CI --.0..-c Arr. (0 r 1}e -'- vv., v \0 -vv caco 5:3c45-F 1 0r

5 ........, mop.c)-4., a- cly, j , pry-y-1 NURSING UNIT ROOM NO. BED NO.

A 1 FAOPRRI 79 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

MEDCOM - 20315

DOD-033889

ACLU-RDI 1656 p.75

DOD-033890

CLINICAL RECORD . DOCTOR'S ORDERS For use of this form, see AR 40-E6, the proponent agency is CTSG


HOURS

+!DATE OF ORDER TIME OF ORDER

HOURS

LIST TIME ORDER

NOTED AND SIGN

og$

DATE OF ORDER

VL

rNj)

L4A46.41 4 . „...

46_..,AIIIM IN,,,P.MINV"19 '

NURSING UNIT

IC,1011- PATIENT IDENTIFICATION

NURSING UNIT 'ROOM

pi•

r-(\ _31 ••

PATIENT IDENTIFICATION'.

HOURS

TIME OF ORDER

NURSING UNIT ROOM NO. NO.

NURSING NIT

Jxv- R O OM NO. BED NO..

_Daft R FORM 4256

rti

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED..

MEDCOM - 20316 r nirr ■ ,r 14.54-3E3.710


PATIENT IDENTIFICATION DATE OF ORDER TIME OF DER

ACLU-RDI 1656 p.76

MEDCOM - 20317 11,Th c - ,537;Q


•


HOURS

LIST TIME. ORDER

NOTED AND SIGN

NURSING UNIT [ ROOM NO. BED NO.


NURSING UNIT

110 t

ROOM NO,

5-- PATIENT IDENTIFICATION

(q(€)-z_ NURSING UNIT ROOM NO.

• RSING UNIT

DA FORM 4256 , APR 79

BED NO.

REPLACES EDITION OF 1 JUL 77. 'WHICH MAY BE USED.

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 4 0-66, the proponent aoency is CTSG


DOD-033891

ACLU-RDI 1656 p.77

PATIENT IDENTIFIC ATION LIST TIME

ORDER NOTED AND

SIGN

DATE OF ORDER • -'

d.... TIME OF 0 DER ER

70 HOURS

NUR ING UNI

4

w it A 1ENT IDE IFIC

RDER E OF ORDER

HOURS

CLINICAL RECORD - DOCTOR'S ORDERS For use cf this form, see AR 4 0-66, the proponent atency is OTSG


.37 II NURSING GJNIT

SC101:‘

ROOM NO. laEo NO.

ROOM NO.

I

PATIENT IDENTIFIC

NURSING UNIT

PA IENT IDENTIFICATION


HOURS

BED NO.


E.

ATION

HOURS

NURSING UpIT ROOM NO,

DA F"M 4256 1 APR 79

C-7

BED NO.

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

. U.S MEDCOM - 20318 5f.3.710 •

DOD-033892

ACLU-RDI 1656 p.78



.''' PATIENT IDENTIFICATION

Vc

lik t *1'

II- DATE OF ORDER

2-1 SeiCt .03 TIME OF ORDER

6), ‘S \ 0 HOURS

LIST TIME ORDER

NOTED AND SIGN

0 b. d• -a- -Arc) , A•- . 4 ■A la E-MIIIII

NURSING UNIT ROOM NO. ././

75.1i Clq

BED NO.

(••)--q


V52‘

DATE OF ORDE

tiI

TIME OF • RDER

/41, HO

AQ.■ a "i_g_ I vit.

-

v 0 ,


PATIENT IDENTIFICATION DA ORDER TIME OF ORDER

HOURS


PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS


DA FAOPRAM79 4256 REPLi MEDCOM - 20319

HIGH MAY BE USED.

DOD-033893

ACLU-RDI 1656 p.79

ORDER CLERK!

RECURRING ACTIONS, DATE NURSE FREQUENCY, TIME

■

1 THERAPEUTIC DOCUMENTATION CARE PLAN NON-MEDIC4270N) For use of this town, see AR 40-407; 1: VERIFY BY IIVITIALING

0.q CLINICAL RECORD

Yr. 2003 the r neent wren is the Office of The Suraeon General INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

HR DATE COMPLETED

11110711MEETI ffl 1111111M111111 Efr _JAW er 4 E1127—`111111111111111M1111111119111 Iffil1111b1111111 - ..„4111111iiiiiiirECIIIIIIIIN voyA,L-4-.44----,),,i,'4,,,, s,,, 4 l' il4r, Arriz iod:,,,., ,,,- rill p,,, -A47'"„,1, 61:so EaieurFA a EUOMMIMaktisk.* 4......„.

PM 1 Ms iff

rn - 41:41,1,121111m. '' ' ' `-- ' x t.tw4:k-'...,v V aY Ji- 'FA, ' '‘ 4 `• "" di ' "Z iL '' ' ,'' 11. ' ' ''''`'‘ ,...

'''' - ' - 1:'' '■A '''4 1:1;),LiQ 1 d1 .dti:,11-124itr,16''' ,. EWiriiWelpfigq1P.:.'', !."1"11 71 1,4

_.2,___k ill4 mpc097,40 , 4 o... ,, isi.i . .L....-,. 7:77 7,

MN .111.11gri"'-- _....A111111111 V" AllIliS6aii2L4iIIIIIIIIIII 7111. 'IMPRINE111111111111E111

iNor11111411111111111 L O3 PP filr' -JIM. A Ai . -00§0191111111111/

Mr 111111111MAINCIME111111/ 01011 „Nall it ..,,- TIESSINE21•1111111M11111E

.. • NIGIFAL A111111111111111111111111111 11111MEMEMI,1111111111111111•

.. irtvIgs.t.lar4RA WM= C7.1 AOMP :;':1 201291114 MiteigESIWIM

ALLERGIES D YES El NO

unknoum 37/AaRisDylA2N617015:64sajz jbwomen orgy_ ADDITIONAL EPAGI E:c:N USE:

YES

learfiga-VFA "Teeth eAltriabh dasure kaal GE NO: PATIENT IDENTIFICATION:

Epbo • 4ter


D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED. USA PA V1.00

MEDCOM - 20320

DOD-033894

ACLU-RDI 1656 p.80

Veldt, by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN WON-MEDICATION) Mo

q

Yr 2003 Order DUO

Clerk NUNS SINGLE ACTIONS Data to

be Done Time to be Done Time Done Initials

Ai il Ith 2 1 6114-110 544hl 1 .11 e, 23 Sep Al I q 15-

_ 23

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ACTION, FREQUENCY .

• MEd PROPER COLUMN FOLLOWING COMPLETION TIMEiDATE COMPLETED

. . • .

.

- . -

. _ USAPA V1.00

MEDCOM - 20321

DOD-033895

ACLU-RDI 1656 p.81

VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER CLERK! DATE NURSE

RECURRING ACTION, FREQUENCY, TIME

HR DATE COMPL ETED

c27 niEriv-nicoti At* Le;

ALLERGIES: ED YES p NO

PATIENT IDENTIFICATION:

nA FflRM LI 77 I rInT 7R

PRIMARY DIAGNOSIS:

MEDCOM - 20322 •-•••• •••■••• VI..., I • M., 1 ••ii USED.

ADDITIONAL PAGES IN USE:

ElYES N°

PAGE NO:


D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

USAPA V1.00

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION ) For use of this form, see AR 40-407;

the proponent agency Is the Office of The Surgeon General. Mo. Yr. 2003

DOD-033896

ACLU-RDI 1656 p.82

Order

Date

Verity by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing

( NON-MEDICA770N) Clerk Nurse

Atg ir-n +dr! r■ ---, -

SINGLE ACTIONS

Mo Z19 yr 2003

Date to lime to be Done be Done Time Done Initials

— -

r

Order/ Explr Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

11ME/DATE COMPLETED

_ —

■•••■••■,

USAPA V1.00

MEDCOM - 20323

DOD-033897

ACLU-RDI 1656 p.83

VERIFY BY INITIALING

ORDER DATE

CLINICAL_ RECORD

cilliESMIElsiD zt 111111111111111111 DATE DISPENSED

TyJi7hr o4W _,__11111,11111tElialrim111111 1111111 11.10.1921.7til

flrf' 1tIdr -

CLERK/ NURSE

RECURRING MEDICATIONS. DOSE. FREQUENCY

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;

' affi .f r., .

INITIAL PROPER COLUMN FOLLOWING EACH ADMNISTRATION

ALLERGIES: = YES 1-1 NO

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 VIPPw 9 (0

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E1E11111111111111111111111111 iii 11111111111111111111111111 1111111111111 1111111111111111111 1111111.111111

ADDITIONAL PAGES IN USE:

El YES CD NO

PAGE NO.

PRIMARY DIAGNOSIS:

fal aPi aid A60 tedskutdeiF4- ?et/ eziradion, eltdarl. -cat WOurds

DA FORM 4678, 1 FEB 79 - - - - .."" USED UNTIL. EXHAUSTED. MEDCOM - 20324

r. . USAPA V1.00

DOD-033898

ACLU-RDI 1656 p.84

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. 1 Yr.O 3

Order Date

Clerki Nurse SINGLE ORDER, PRE-OPERATIVES Date to

be Given Time to

be Given Time Given Initials

02.3

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d eackon iari/ Iii e c?c3o0 4 43o00 ir. 11-60 30,%-ilog; Ta EMBATE.

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Order) Ex* Date

_ clew PRN ' MEDICATION, DOSE. FREQUENCY '

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION . • .:-, ,TIME/DATE DISPENSED

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MEDCOM - 20325

DOD-033899

ACLU-RDI 1656 p.85

C.;Li!Vi!CL.i.. RECORD

I ; i 1

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MEDCOM - 20326

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DOD-033900

ACLU-RDI 1656 p.86

Tima

V-.:-..rii'y by 11-1....-7.2..A; ,l'.7.', .0(.1.):(,JEf.TATI ,..)i'i C‘,212 PL-..

ca::-_!.14- i c</ Time to :LE OP -.)iiP,, P;r3E-CP;:iP.,T-:3

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MEDCOM - 20327

DOD-033901

ACLU-RDI 1656 p.87

L

REPORT TITLE Post-Anesthesla Care Unit (PACU) Flow Sheet

6- OR Intake: Crystalloid

. 1 .

rre up mead History

IS- AD 9>iri , • SaO2

I a , • • , 'FIO2

Methods - - -

240 -0‘

220 . ..

200 ' ••• _

.1 ■ 180

160

140 it • -

• iIi.

-

120 a 1 , .

Time ti if ' iq 11 a ' '

100 , . t

eo n g? 11 oe . . - I

60 i • ° ... ...

• 40

20

P.R. - lb li g ts le _

T r _ Time PPati^ - Pain (0-10) T. C LOS _ Safe

1/111EZIEVA

1.,...7.... c Pacu intake - - -- — - • - - ---„.- - -- - ,- Time • Solution ..- -Amount •-•. • -- Site : - - • -By : 'Infused ' ,. _ . : , ,.

' - - --, . • . ., ,

X-rays: - - Labs: • ,-

..•-; -Post-Anesthesta'Recoyety score Criteria .- . ' ' -71- --" - ADM : 1 •"30' , . D/C - Codes i• i

(1) Moves 2 Eiberniies A w Ambir ''': (0) MovetiO Extremities . BEIwBioiv-by

Actirily ..,, . (2)Moves 4 Exastaies .. .. _ — . AIRWAYAIRWAY.,:-

M =Malt .. •

NC-Nasal

- .

: . Puise - -

TEMP •

7-Tympanic RI. Recto! -

C .. Cervical

L w Lumbar 5= Sacral

Airway t.- : (2)

Cough, Deep breath FT Face (t) Dyspnee. MAW breathing . Tent (0/APnea -. s... - ... - --- - -- - RA wRoOrnAir

Ellood Pressure • . _,.,

(1)SBP wr- 2040 riPre-op ,.. .. (2)S130 4-20 c/Pre.op • . - 1-

Cannula

(0) SBP W-50 of Pre-op - . WS -

PYITJ (1 )AMvSeble.10 verbal Pr Fein ..

Consdousness • - .. - . X w A-Ine Bp•

(2) NOY &rice, 1.41ble - - .. . bA\t•tir .

- =Coif BP.

- -

,

- - • - - . -.:- •. . . - ...._....—

(2) amine clear 'Alamein= S - Skin (1)pale; inoMed, Jaundiced 0 -Orel .. M O/anode- _.:: ....i., ...,,.... .... , . . -, - - A= Axillary..... • .

(2) radial Pulse Palpable: .

(0) Candid °fey reiable pulse -, - 7.

Circulaiion (Pees < 5 Years) . . . .....

(i) Kwilariceloeble. 6:inlaid _

TOTALS: Must be 9r/r-

needs anesthesia approval Mr.. DM.

-. are mer to DC, Otherwise . .-...s: .: T =Thoracic

- •- .-

tteachir9 done: . Wound Care, Pain Management, I, DB,.- Incentive Spirometer, Comfort Measures

as

n

IV Colloid 1 7)-710 BIrc.- •

OR Output UOP EBL N ,,ales: •

„

__ X _ Falls _ hr: SR up X 2, Falls Precautions. Privacy Maintained

- Anesthedia Type (drciti)): General pinal Epidural Date: Time In: Allergies: I. Pre-op V/S: I Procedures: G.

Drains Hemovac

NG - • • JP -

T-tube - Foley

TLS

OTSG APPROVED Mary •

Airway Nasal Oral

(..gjt° Trach

Other

❑ IRSTORY,HySICAL

❑ OTHER EXAMINATION OR PIALUATION

DIAGNOSTIC STUDIES

TREATMENT

DEPARTMENTISONIOUCLOIC

',1(1

PREPARED BY Aortas a mu

PATIENT'S IDENTIFICATION (Fort yped fat sad* yak: Me; hospital w medical facto/

• • WOlfiMa -

DATE

0 FLOW CHART

❑ OTHER rsowaw

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA Forme vi this tam see AR 40-6a; amend paercv is win erlbalnleirallneral•

DA FORM 4700, MAY 78

WAMC OP 1T3-E, (Reviled) I Apr 01 (MCXC-DN) Previous edition Is °bloke - usernwas

MEDCOM - 20328

DOD-033902

ACLU-RDI 1656 p.88

MEDICATIONS Allergies: Time Pain

1-10 tdotication & Route Pain

1-10 -

By

CARDIAC RHYTHM

Rhythm Symptomatic? Rhythm Strip Run?

. _ i1C.i't

, • • - ; -.N.UROVASCULAR - , _ ___ _ _. ,

- .----• 1 T P Site -

...

Bantle— %d Of i _

- Motion

Serrsory__ .. . . . . .

_Cap _ . _Refill _.

•

r__ Cote _..

. . . Adm . r _ ..

38 45' 80'. • ;., • . ___. .. _._

.,,,,

91:1' , • :,: i .

Mnyament/Sensation: :+ m present,- =absent Tamp:Cm Cool. . . W Warm Pulsei: P m Palpable, D = Nippier. Am Absent Color: Cm Cyanotic, ,.__ .

Capillary Refill: 8 =Brisk. S m Sluggish . . P'm Pete; Pk -Pink Pink L . _

• C-SE S Adm 1 30' :45 6W 90' CUC

Fund. Height Walla ... Pedpad# Fund.-Cond..

..

Time. Location Type . .prWrisoe

Adm T4P19ft41 (5141161 0 n -1:4139--... —

W • •

DJC :! ..T.,. n 4 :

NURSING NOTES

-",- - - PACU OUTPUT !'•

Time Source ColodAppearance, . Amount D:65) FA., Nit lezr.14110) 1 0 p ci-

WAMC OP 173-E

Discharge Criteria: Date: Time: PARS: BP: T: HR: RR: Sa02: Pain Level at DJC (0-10): Intake: Output: Additional Data: Transferred To: Report Given To: Transferred Via: W/C Utter Gurney Ambulance Transferred By: Cleared lAW Recovery Room SOP B-3 Charge Nurse Signature:

-

MEDCOM - 20329

DOD-033903

ACLU-RDI 1656 p.89

BY (Sigry T;SERVICEJCLINIC ,

PRE P.LRE:D DATE -

a2ic5rtg 3

❑ ■=LQI:ti CHART

C] oTHiA

INTFMIVE CARE NURSING SHEET Q.A Appr 8 Mar 89

iNITIA1 SHIFT ASSESSMENT ' _ _ . ..

0

N i i lime: iq : Inital: :t■ (zi . ime: . Initals: . . --1

, E Pur.)ils =__—/_-)_g_rt Avf-,-:._. e kk • .. U Sensorium 2scoWdl 1V.r.-&ec1- .4/41 (c2rr\r\ "I kl'. R LOC / GCS • 4. _ (V(7-t P- -5- 4+RC4r

_

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R.: Pulse Strength X q eAcAirr--r2 vlig-- : .

D Cap Refil / IV D -3s(-( 4.1't / --0'dti p I EclernA 4-0 4be_4'.(m,./ 0 -CkLe._

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.

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1 1

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AGE:

PATIENT'S 1DENTIFIC$, ,..11 cr.* Name, fir v. grade; dere; hospital OimediCal laciNY) -1

-;

•

.

STATUS: US: AD ; CIV • IRAQI: CP.' .L U)*

HIsToR(P •. L

- 0 OTHER EXAMINATION

OR EV.ALUATiON .

DiAGNOSTiC STUDIES

—," TREAT .-1ENT

UNIT: ' ••

..• DA FORM 4700, MAY 78

MEDCOM - 20330

DOD-033904

ACLU-RDI 1656 p.90

1 I 1111. i alibi . oirgir 4 . §.4............p .€...

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MEDCOM - 20331

DOD-033905

ACLU-RDI 1656 p.91

DOD-033906

QA Appr 8 Mar 89 INTENSIVE CARE NURSING PLOW SHUT

MEDCOM - 20332

- .N1TIAL SI ASSESSMENT "- - -- • 7 - N E U R

._ . Pupils

I'ime: 0193044c Initals: Tu 'e ' InitaIs: 9,441,-& ffu oh .. . L . .en.m.

aveq ' ' , .

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DEPARTMENTiSERVICEICLINIC ; •...

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24-sr 03 ;

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PATEN

NANIF: 4

UNIT:

, or type.cf or written entries give: Name —lest, -; noSpitalGr modical racility)

RANK: - • ,

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ACLU-RDI 1656 p.92

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ACLU-RDI 1656 p.93

STATUS: US: AD cry -. IRAQI: CIV •

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MEDCOM - 20334

INTENSI k_.'.A Kt IN L.1

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DOD-033908

ACLU-RDI 1656 p.94

4

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ACLU-RDI 1656 p.95

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GENDER:

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HISTORY/PHYSICAL

❑ OTHER EXAMINATION, OR EVALUATION

• DIAGNOSTIC 5TUOIES

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UNIT: NtO

STATUS' US. AD I CIV

D FLOVV CH ART :

bOTHER


MEDCOM - 20336

PATiENT'S IDENT;Fl

first, middy• rr NAMr

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- —. ---- _... _ .. . .__... •

_ ....... ...... _. _ __.., Pupils __.

nso ._ _____ .. _________. Se i i LI In . _. Loc1 Gcs .._ .

- .

_.:. .:._.. Cardiac R h .l . thin

Pulse Stren.;rth CI; p Reli I / JVD ....... ...

Edema

AA s- Alit. ( i q. 61-.1 Lk al( it ‘ cc/1i

00 reAl 2-)e .0e_cd . i

4Let.o,o4e..4_ :-0.aufel.. c' Stl-q • i--41 Ape v d ea c 4 0 ict_qi

. , . ,.,..

. . ,

Chest Pain J

. .

Respiratory Pattern __.. .. -

Breath Sou nds Secretions cough.

41, .-q ilk. Ali' . A U. drift,

AU al-W . . _ ....

it ,..

1 Vultt °L-t) Attli..4_6__Lkii ( •

. _ - - • - . .. .

--'

Cohr Intec, ritv . . . . . . Backside

_,.

I ee ki-i7.. . dorlax. K h V_Ig..C.1-eeMt Oi; ttti1.1 ' . widow

. , .... . ___.... ...

.

.

kik dt.tic,&(.. tr ... . . ... ......._. ,...

.... : .. -.e. '-. - ye._....:. . _. _ •

Access Devices

L ..,

i_.. (At_ Q__ /,:c./ .

, . 111,2Clailig-4. 'f,42tokatetket

..1(4.k . - •. --.-

iti -01t(te_ go& k , vivit. i_tiaii-....c wit

- . . ii 0,(ite . nob d - Aiatt_11 .j,

Location

Condition

; ,AbLici [nen Bov. - ei Sounds

St-orna/Osto my

4 et A , t

,--- Device

IColor / ClaritV r,

t-- ; ,—..—

-DATE; ..... ..

–.4 Ili IDSF

.

ICU # efir(Sti

DrIPARTMENTISERViCEICLINIC ...._ ,, :

DOD-033910

ACLU-RDI 1656 p.96

MEDCOM - 20337

DOD-033911

ACLU-RDI 1656 p.97

k C A

Tac

k Q e I S i\iN c)

/ A CA.ICA A-2V Z._ a■ S

56_1111.11111A111V 11

L MEDCOM - 20338

DOD-033912

ACLU-RDI 1656 p.98

1 . REPORTING MTF

--,

2. MTF LOCATION .

ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400: the proponent agency is OTSG 1 2 3 4 5

,.... a I (State or

Country Code.) A L 1 P

:.,,, ... ,..,.

_ 3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX

9 11 12 13 14

6. DATE OF BI - (YYYYMMDDI

15

A ----.....„‘

.

1.),<JK - R ,PC-1 (c 16 17 '

Er ti 18

ri 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION

19 20' 21 22 23 24 25 26 27- 28 29 BACK -

GROUND MI

10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY UMBER

32 33: 34 35 36

409

38 39 '42 .43 44 45 ...■,....

=NM ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF

ADMISSION

BRANCH I CORPS

46

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE

47 48 1. 49 50 51 52 53 54 55 56 57 58 59 60 61

.,..--- 8 , i W 1 -7

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION

62 63 Country Code)

I . - 64 65 66 67 68 69 70 71 YEAR NO

(

20_ SOURCE OF ADMISSION! AUTHORITY FOR WARD

I

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ....-------

72 ADMISSION

. ,

ADDRESS OF EMERGENCY ADDRESSEE /Include DP Code) '

NAME AND NT AC LITY - .

(11-11)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE ,

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23., DATE OF DISPOSITION (V YMMDDI

0 -'5 (10 al 73 74 1 75 76 1 77 - 78 . 79 80 81

0 82

3 NI iNEMIIICII

84 85 86

0 5- ; 24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y YMMDD)

87

A- 88

0 89 1

4 90

44:A 91 92 93 94 95. ■ 96 97 98 1 99 100 101 102

• o .Y lo q ..2_ 3 27. LOCATION OF OCCURRENCE 28, AfTf OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IT YMMDD1

103 104 (flarne Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 116

FOR LOCAL USE

Pr Si_ Cx 4-.74, 6S-tj TO ARP •

°?( SS --) 3.: 40 y 2 3.4 3 . S q \ r CU...v., c. -, — . . _ __ _ ___ _ , S- ' c 1 -S ' 7 17 • . 2 q,_..Y %-- Y . .2 ci

ci s- L, 9'

Z ctcl i i 2- ck-1 . 1 f 1 • —A 1 -i

__..... ADMITTING OFFICER (Signatu

r A 1- we •e■oe A rs

MEDCOM - 20339

DOD-033913

ACLU-RDI 1656 p.99

. For use of INPATIENT TREATMENT

this form, see AR 40 -400;

RECORD COVER SHEET the proponent agency is OTSG

REMARKS . -

...------

1L. 0. PREVIOUS N ADMISSION 5 GE B. RACE

11. FMP 12. SSN _ _ 3. ORGANIZATLON

(._ '-

14. WARD

1 aW

20. TYPE CASE 15. FLYING

STATUS 16. . DEPT./

DSG girs;itn 01)

18. BRANCH/C BPS 19. UIC/ZIP

----------------' NI EIT

21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

D % ikcer r-f(mit LK 22. HOURS OF

ADMISSION

Iwo 23. CLINIC SERVICE

24. NAME/RELATIONSHIP OF

K

EMERGENCY ADDRESSEE 25. TYPE S ITION LIS 26. DATE F 0 SPOSITION O

0.1 i I 27e. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28- DA E 01' THIS

MI SSIO N

,16 ADMITTING OFFICER

29. NAME AN LOCATION OF

C 4:11VL

30. DATE OF INTIAL ADMISSION

32. UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED

Check if Continued on Reverse

33. CAUSE OF INJURY

34. DIAGNOSES/OPERATIONS

)(

AND SPECIAL PROCEDURES

e . 0e60

g of'el atiEsT tiO3 uk) 0

Ofv-K, Luoof\x)

35. Total Days This Facility

a. ABSENT SICK DAYS b. OTHER DAYS a. CONV. LV/COOP CARE DAYS

d. SUPPLEMENTAL j CARE DAYS

e. BED DAYS f. TOTAL SICK DAYS

36. Total Days All Facilites

a. ABSENT SICK DAYS

SIGNATURE OF

D

b. OTHER DAYS

OFFICER

c. CONV. LV/COOP CARE DAYS

d. SUPPLEMENTAL CARE DAYS

SIGN

e. BED DAYS TOTAL SICK DAYS

_

DA F

3647, M

EDITION OF 1

1.10

MG) MEDCOM - 20340

DOD-033914

ACLU-RDI 1656 p.100

MEDICAL RECORD ABBREVIATED MEDICAL RECORD

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

n y1a y )°1y,) (AZ'IPL 1 7° r°t>--1- •

7).7) to 1,,i1-zS z 2s L 1

k- --irl"AV

P 156;)1,- 6172))it_.

/115

T> >4

-1) /3 dilt

PHYSICAL EXAMINATION

s/r=? t' Lir

-6/4(

oir ,. or ate.

PROGRESS (Enter date of discharge and final diagnosis)

)#.e•-.../ -17 \4.46}.1-40/0_, i/i-1 G 11.-'7K

-4.); /1- /A-/ )2 ex )b.6 116-4

SIGNATURE DATE

is?•72),:i" IDENTIFICATION NO . ORGANIZAT ION

WARD NO. PATIENT'S IOENT2FICAT ION (For typed or written entries middle; grade; dale; hospiu

give Name last, first. I or medical facility)

REGISTER NO.

MEP (90

-1

MEDCOM - 20341

ABBREVIATED MEDICAL RECORD Standard Form 539

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS F1RMR (41 CEP.) 40145.505 OC.TOSER 2975 USAPPC Y1.00

DOD-033915

ACLU-RDI 1656 p.101



DATE NOTES

f Atii Z.-.,t( AL A. -Ai in

airy -8_eitotA) thoetio ktg Wad 0 O ad 06AA,9 r yaiel-pc/

eibbt}3 R.19(Y.t(c ) s nr)i-Qc,k, cri 0 (--C-: , '..6 q 1/XCI

11),--nd a 16' (Ai ke.-A -IA_ (A/ ./ )--(c),,city n om( Dale

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jt_AaM`Q Ae-k,4

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X .4.1 It/ i A-- - I d GE"../.• 4-../es, 4 _

_... , .i _....._ . .... " AA APSIIIIMIIIM11111lPrP"- / ..a. - -1.-..a.

RELATIONSHIP TO SPONSOR / SPONSORS NAME SPONSOR'S ID NUMBER (SSN or Other) LAST FIRST MI


PATIENT'S IDENTIFICATION: 1For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade/


PROGRESS NDTES Medical Record

STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203Ib1(10)

USAPA V1 OD

MEDCOM - 20342

),

N

DOD-033916

ACLU-RDI 1656 p.102

LAST NAME FIRST NAME


DATE NOTES

24 i9v9'b i T 2/J,..

r • ..,

(r) .,..,71_,,././,.__,,,,,.„.„,i,.,,,, 7

.......„ ,..... ____ .. ,._

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. .CS-

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1b ak r ci„) \\,. • ,:::_ itc...)c 411i -- c"..0_.

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NV--- krFur-;vin -c7-, r-V\r.F\v\--smicx--)" ,\Im-')--c) (0, -:-'..-,)

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b\Veiv. - CID ‘a2)\\ .---:3 SSS • \-pcwsN-- v,=.7\-c,-. .,c-N\--. "\x" .r- -A–

(_..-,-K c_cc\-\.-Accms--N- \NM\ Cs \--. ''c -t---) ,kx-,c-i--,■ror

tls.te ow-20..iger ?m- , ;A-i ois s,,,,K,;,3 ..4-.,10, ,,,oc,, I -v ., ,,1,5,—...e-a_c_,,D1 10A-,4.4, :.9

kAAAAiii-W-e- e-i1/4-t6"--'-'5.44 6":" ;"‘`''' '' ft' ; 0 . '1" .-f' 9'9::,)(Aa--,f.A'.,-.-c,-;.9:,;Z:,,;",:i„ PHGQAI RACK

USA PA V1.00

MEDCOM - 20343

DOD-033917

ACLU-RDI 1656 p.103

2cd

-TV Fad (no C C([ A4)-46A-4 c c-;...,1 46-rt's 14-- r

(1 eLz1 wrc6 „-) S"Xf^r \

1?)\IP \ISS "

'camd\C- \\ECsC\ --17L) Pf`e'c'-uNs- \7-c '.

\i\)\\ At) 4Q) "Vit. ') ■-c;S \ p11 S S

'rc-(='c"<Dr' ccN'c vcc d'7-\- we" .N.t)6‘cn CCA°— \3&(- Crl'°1?Vc \N"

(N)

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41"

2-1s-ef 05V. 1-0 • I 1 lo F -R

S

• 61-0.4c.ed

' MEDICAL RECORD

DATE NOTES

PROGRESS NOTES

HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

WARD NO.

1C\J\I - PATIENT'S IDENTIFICATION: /For typed or wines ffrtriex girr Nem, - kit, 674 a i* I REGISTER NO.

ID NI/ et SSN; Set; Doe of Birk Ronk/Bret)

SPONSOR'S ID NUMBER ISSI or Oast'


DEPARTJSERVICE


PROGRESS NOTES Medical Recoil!

STANDARD FORM 509 InEV.snsete Prescribed by GSAIICMR FPME I41CFRI 101-11.2031b1110)

=PA V1.00

MEDCOM - 20344

DOD-033918

ACLU-RDI 1656 p.104


'auk fro tow as Si.OM 111.. -V.aub---4--uis

• 164. Or- APS • r e IL /ma Mt a• • alkiat4A. &As at atiga.a4111

* 416 am Cs R. dizt, aka L. web% ei Pk- kX30 A:Or TWxr AVA‘k E1M 1)‘- (-E1-44

SAL tia bill At ziln4443)

725) 41.

0 • tam

• 00• ait) toill a ft

ita4i on . Ll 11 COO , Ao 151n c?-`i co +ime \tk:C4hi kP,\\ ,A)11\

•• 0

SAC airsa (A) 47 ou)

n 5f CIS G s L C9

LL

STANDARD FORM 509 MEL WMIINBACK

USAPA VI 03 MEDCOM - 20345

DOD-033919

DATE NOTES

LAST NAME MST NAME

ACLU-RDI 1656 p.105

ANITIORIZED FOR LOCAL REPRODUCTION

'MEDICAL RECORD PROGRESS NOTES

S


HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

DEPARTAERVICE

WARD NO.

PATIENT'S IDENTIFICATION: (Fa rpm) or twines entries, givc Name • kst fiat, ma* . ID No orSSA;'Sex Dee of BitIr &Mami►)


STANDARD FORM 5139 inv. 5110891

Putscribett by MAMMA FPN1141CFRI 101-11.20311411DI

USAPA V1.00

glig (0,01

MEDCOM - 20346

DOD-033920

ACLU-RDI 1656 p.106

STANDARD FORM 509 REV. snow BACK USAPA V1.00


DOD-033921

MEDCOM - 20347

ACLU-RDI 1656 p.107

MEDICAL RECORD

PROGRESS NOTES AUTHORIZED FOR LOCAL REPRODUCTION

C5C_T C25-?

030

C-`

LATIONSHIP TO SPONSOR

SPONSOR'S NAME

INIIII111111

111 HOSPITAL OR MEDICAL FACUTY

ed or written en RECORDS MAINTAINED AT


STANDARD FORM (REV. 5/1999) Prescribed by GSA/ICMR FPMR

509 (41CFR) 01-11.2031b)(1

USAPA V1.00

MEDCOM - 20348

'ART./SERVICE

ANT'S IDENTIFICATION: 1For typ

tries, give: Name - last, fiat, middle; ID No or SS/y,•Sex; Date or Birth; Rank/Grade)

DOD-033922

ACLU-RDI 1656 p.108

LAST NAME

MIDDLE INITIAL VD NUMBER FIRST NAME

NOTES

205

ca-4-;■

JI

1.2e"

Ai.. a

I_ Ai_ _SAI

_.,0AfFic0,51)

STANDARD FORM 509 (REV. 511999) BACH USAPA V1.0(

41Ip (610--ki MEDCOM - 20349

DOD-033923

ACLU-RDI 1656 p.109

MEDICAL RECORD


LATIONSH1P TO SPONSUR

ENT'S IDENTIFICATION: /For typed or written

ID No or SSN; entries, give: Name - last first, middle; Sex; Date of Birth; Rank/Gradel




Prescribed by GSA/IC STANDARD FORM 509

(REV. 5/1999) MR RD FORM

(4 1CFR) T 0 -77 .203Ib)( 10)

OSAP4 V7.00

MEDCOM - 20350

DOD-033924

ACLU-RDI 1656 p.110

MEDCOM - 20351

MIDDLE INITIAL

DOD-033925

ACLU-RDI 1656 p.111

MEDCOM - 20352

PROGRESS NOTES

NOTES


■

eCw

ELATIONSHIP TO SPONSOR

PART,/SERVICE

JEW'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Skth• Rank/Gradel

4111 m(g1 PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed

by GSA/1CMR FPMR (47CFR) 101-11.203(b)(10)

USAPA V1.00

DOD-033926

ACLU-RDI 1656 p.112

1 MIDDLE INITIAL1 ID NUMBER

.AST NAME FIRST NAME

NOTES

%Viz/iv/Z.(1,1.A

yv■._ 0,AINC■1 -0■ 1 1-• r)--Q STANDARD FORM 509 (REV. 5/1999) BACK

USAPA V1.00

71 us.s . tee k-1,- it) p o

0 IA ea .1( 1Z) /-Iu Mirki,t_;e_--ej LTr.

5rvIA-4( 0-0,14- 0,4 nerbv.:. 19 it76*-3e4. (Cl<I L''Ory

2 u r 6/e_ d 61. 12

‘_

t 3 _ _

fi•e u.) I Icp

SAX ./14-e<A*-'ktet--- ; ke I Cksr 4T 5 ( I

1 0 ( Pd) 77, ; 4.)

7_5 t,c

MEDCOM - 20353

DATE

1) pr-i- 02

DOD-033927

ACLU-RDI 1656 p.113

MEDICAL RECORD


/ 401, '

• 1 0 It* fig 1911


)EPART./SERVICE

.TIENT'S IDENTIFICATION: (For typed or written entries, give; Name - last, first, middle; ID No or SSN• Sex; Date of Stith; Rank/Gradel

.4111 )---`1 RECORDS MAINTAINED AT


STANDARD FORM 509 (REV. 511999)

Prescribed by GSA/ICA/1R FPMR (41 CFR) 101-11.203(13)(10)

USAPA V1.00

MEDCOM - 20354

DOD-033928

ACLU-RDI 1656 p.114

DATE NOTES

DOD-033929

i3(?6,4-0301-3j5

(Cce-tA ck,\oX srr„ 5_i

10„• c_ff wcintafs 1

4, 4, ti.,4.z -4r

0 , a • • . a. ^:: • ^. is.. 41,1- 0

I

• II

C

A Al

• 144Igir P d I

BACK USAPA V1.00

CISCAP) C<)c\C k Aocf.Pe — STANDARD

MEDCOM - 20355

CC3

dikn-12i OiOnf)UTQC1

• 11'..,sAilifffk,

aAt 0

9 AL

poyvity t±_)n P Leti Al ih, _i b

eAk. I 'It ics

• AAA ,te

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okt (04.00 (

Ma MON

4

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•


ACLU-RDI 1656 p.115

MEDICAL RECORD

I 5C010 PROGRESS NOTES

NOTES

AUTHORIZED FOR LOCAL REPRODUCTIC

ELATIONSHIP TO SPONSOR

PART./SERVICE

LENT'S FOENTIFICATION: /For typed

or SS/V; Sex; or Kaitten entries give: Name - last, first, middle; ID No Date of Birth; Rank/Grade!

44101, (6 A"

WARD NO

PROGRESS tC,

NOTES Medical Record

STANDARD FORM 509 (REV. 5/7999) Prescribed

by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)

1!" USAPA V1.00

MEDCOM - 20356

RECORDS MAINTArNED AT

DOD-033930

ACLU-RDI 1656 p.116


AST NAME

NOTES

1. Ital,mtk

t`brue,‘ 1117CL4

gaitU it) OE -9. -Dp i-v5

v.(c-ViauL. 611 , CA,i6aCcatgl\, CI ri,.A01.6.0_,).

k)DD 1■11■ oe) (iLA yj,tAA C,61/d1 -0-b

10- k.A

FP,

STANDARD FORM 509 (REV. 511999) BACK USAPA Vi .00

MEDCOM - 20357

DOD-033931

ACLU-RDI 1656 p.117


DATE NOTES

it (X21)3 ' kttiligl CIIV . ow. V. %pill Jo LLE (9.3- 50 5 tri-eace) ( P+- poutEL tb VULCACt -. U.( )-it_iievie

--teo c hat tit_ctQck, [s cc ,e S t i /Inc ci ' uL, lAteii ctiS.-C,F1-to c1 L:ik arccui) t-D (so- loa

UW iitA infi(b iat7 c 0 c Cl/LS WI cu a. 4 4 \SKIA .14A,L,iit C. ,ti C it. C.Q ( (Talc, 1 .,t (AY 9 6 (:- (M+ 1 i CtirX CU 61WBEI 1/1,(ALLL a Mil rj AKAVYIA ; RAM\ C(IWItV4 - hiA t A_CtIK+ M s tS134, 6 ZIA") 10 -Itikaith) KM ^NrAftArat • GCULI Cilitf- ton alai._ -II

@%'D ft 14,- 1 tbtaitt , Ins': WA: u)0,c oli-t -= u_019.-- 1E11111111111.

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STANDARD FORM 509 {REV. 5/1999) BACK USAPA V1.00

MEDCOM - 20358

DOD-033932

ACLU-RDI 1656 p.118



DATE NOTES

.• _ /

PA.

IS /

L ) I A , ik' ld 4 liel °SS' /i JI A A ...k-, i 0 / 5 g_Ar

. TILT I. I . A, /a . _

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, W GuL) 014,erw-a45-1, --jelA49-U911.1)-LetL irt_t Lan 4/1 fill pkntbro ,

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g 41 P...41 "I Ai. _ 41, , a/ , A 71 4 M. if 41., .. _Ilt...,* ' gAril_..4, 10

&Au/ 5 „atcy7w-x-6) x 7akeqz 0-at, pt chv-Lued-fairwow_

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3 NOV c4,27t, &Ex",

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MEDCOM - 20372

DOD-033946

ACLU-RDI 1656 p.132

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a A 46 i_41 /AA, 1 ) 49 JP taitAt c. 25 • frral

3 NOV

TAN 9 (REV. 511999) BACK USAPA V1.00

MEDCOM - 20373

DATE NOTES

(A7 u (A;(--7,61 -rte. OcAockpapt. Raoloopcd A -e

tR, ez5)Tuativrt_ed... (-5,6 W Guy 014-en,cae-L-ifuk9-u9h,5-14- f A lakAtfAo

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DOD-033947

ACLU-RDI 1656 p.133



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MEDCOM - 20374

DOD-033948

ACLU-RDI 1656 p.134

MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTIO PROGRESS NOTES

r • A L. _a

• pe

I1 1.

• P IL A II Si — /4

11 al A. • *AI PA

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/111111111111111111111 HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

DEPART./SERVICE

XTIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; Date of Birth; rank/Grade)

411111 c6)(0- -Li


STANDA FP

RD F 509 E. 5/1999) Prescribed by GSA/ICRilli NIR O (4

RM1CFR) 101 (R -11 03 (b)(10I

USAPA V1.00

MEDCOM - 20375

DOD-033949

ACLU-RDI 1656 p.135

AUTHORIZED FOR LOCAL REPRODUCTIOI

NOTES

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al I • i•mi ll .Wiff

tiriao _i A s *UMW: 3/ 1 k ,A I 4. lAliamplik _WI) AL!. . 4 4 _Lika ill ' ! :il 1■• • .1. al Ail SA •s L liA A CAALA 0 ..i, - ,moi le - -11 6 a • a Vs! qr. di 0 !6__, 0 04 Lon iN I a ,6 n ck .14_ Pi

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ili I At g i A 0

RELATIONSHIP TO SPONSOR T 1 c5ir\A- r-e

.....9EMSOR'S A

MEDICAL RECORD

DATE

NOV

PROGRESS NOTES

ram

DEPART./SERVICE


ATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade/



R STANDARD ISA

FM 509 (. 5/1991 Prescribed by G SA/ICR FPMR (4 O

1 CFR} 101 ;RE V -1 . 203lb/119

0J USAPA VI.00

MEDCOM - 20376

DOD-033950

ACLU-RDI 1656 p.136



NOTES

-1 NOV r, • 0 0 1) CIO 76 En 10__ ,, 1:, tiAi A.4 sictottr- At di, I lAarl i6ii, e. . c 56 i

LetO1 rt iIik AIPIC 4 . IA! i ^ ifl , ' . A it. t 0.0 A a ./ IA 10 vA,• #,_

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MEDCOM - 20377

DOD-033951

ACLU-RDI 1656 p.137

DOD-033952

MEDICAL RECORD

di.Np L ipAgg7) gri 74."

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PROGRESS NOTES

NOTES

e (aro • ws. clo (Y) T/40

t7,0/1 _rorm

...AAA., 4,10 Marna fr

iELATIONSH/P TO SPONSOR

)EPART./SERVICE

,TIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSIV• Sex; Date of Birth; Rank/Grade/

-am (40)1 PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by DSA/ICMR FPMR (41 CFR) 701- 11.203(b) 1 01

USAPA V1.00

MEDCOM - 20378

Ye. tiL0,41, 4N.


ACLU-RDI 1656 p.138

ST NAME i I 41 0 NUMtstm

MEDCOM - 20379

DOD-033953

ACLU-RDI 1656 p.139



NOTES

IS% r 1114.e,

r'N

re M (-01 -r ro A v I ct;(1

Si C LA Yr n

L.

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4b 411110.L.

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ATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)


STANDARD FR (RE V. 5/1999) Prescribed by GSA/lCivIR FFIVIR O (41CF

M R) 1101-11.203(b)(10)

USAPA V1.00

MEDCOM - 20380

I% A 1 ..i111.1.11.1.


DOD-033954

ACLU-RDI 1656 p.140


DATE NOTES

1\ OI P)

(coat) .DpVer--\ \,, :),x-yck_ e lj f1 l i S NNe3,1 1\cii=acrrs\kt-'.A-ir . \O. IrP- diet v\c6,N\ . Void ■ Nrl\o4-

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Cc'c'cTC`cc"x's‘ Awa rc ?A"J carnp. x..11 C-

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STANDARD FORM 509 (REV. 5/1999) BAC USAPA VI

MEDCOM - 20381

DOD-033955

ACLU-RDI 1656 p.141

V) 70

.9L 477--f2k

.b-q4 g

,i4 6,-44 ad/k-u

,v1K,

kifa

a:1746 i A 046A 000

MEDCOM - 20382

DOD-033956

ACLU-RDI 1656 p.142



MEDICAL RECORD

DATE:), , h z...._._

1.,

SYMPTOMS, I 1 GNOSIS, TREATMEI mingiwir cf____

j

i -1u ''.\ L // 4.. Z''' ....

If, .,

..

TREATING ORGANIZATIO (Sign each entry) f , r.., c

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Ir.

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SSNIID NO. R LATIONSHIP TO SPONSOR

MN: (For typ r written entries, give: Name • last, first, middle; IO No or SSN: Soy; Date at Birth. Raok1Grarte.1 REGISTER NO.


STANDARD FORM 600 IREv. 6-94

I WARD NO.

Prescribed by GSAOCM13

SPONSOR'S NAME

PATIENT'S IDE

CA

MEDCOM - 20383

AMR CFRI 201-9.202 1

USAPA 02.00

DOD-033957

ACLU-RDI 1656 p.143

MEDICAL RECORD I 0(24.) DATE

s P 33 or"7 ) ivso

YMFTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

1/6n-'

AUTHOWED FOR LOCAL REPRODUCTION


4g_

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s(teakg 47o(tu, 1 1)2j1V-rie440-4.- 12p

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MAINTAINED AT

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HOSPITAL OR MEDICAL FACILITY CA-Olt u,6 ea .11>

STATUS' -

SPONSOR'S NAME SSN/ID NO.

,• 17) gice-,- th, qr (if 04_ iduevie r

0110-1/4-

I

PATIENT'S IDENTIFICATION: IFor tired or volnen entries, give: Name - lest, fest, middle; ID No or SSN• Sex; Dare of Birth; flenkIGnsde.)

() (L 'WARD NO.

REGISTER NO.


FIRM 141 CFR) 201-9.202-1

STANDARD FORM 600 (REV. 6-971 Prescribed by GSA/ICMR

MEDCOM - 20384

DOD-033958

ACLU-RDI 1656 p.144

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Pati)

LOG NUMBER TR

RECORDS MAINTAI E AT

PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS DATE

S

(Day, Month, Year)

2- WO'S TIME

/040 CITY STATE ZIP CODE TRANSP TATION TO CILITY FA

C1rCtAnCk. IrYt P SEX

( \ A DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM Y 0 N/A ITEM

ADDITIONAL INSURANCE .._..--------

yE,s.- NO PRP

AGE

SI

ME PHONE FLYING STATU DD 2568 IN CHART

.C.480- AF, 1 I NUMBER MEDIC STORY OBTAINED FROM NAME OF I CE COMPANY

CURR.

ENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WH ate) DATE LAST VISIT 24 HOUR RETURN ,RN

IE-S-,--n N

US IS THIS AN INJURY? WHERE

ALLERGIES

(4"

INJURY/SAFETY DATE LAS T

........"........T..906„.„3.ETP

COMPLETED INTITIAL

SERB YES I NO HOW

CHIEF COMPLAINT

Tth fkb -11.1 CATEGORY OF TREATMENT VITAL SIGNS

Il EMERGENT TIME

i 0 0 URGENT

TIME 101.4 / if Oil BP i NM --------- (0

IN PULSE (5'2- "7 1

NON-URGENT

INI RESP VO / S ,— TEMP .1 r „,...----- , wr VA- 0 /Gtr:

ILAB

ORD

ERS K. CBC/DIFF ABG PT/PTT BHCG/URINE/BLOOD/QUANT SI:1301:10-1

A

V -X

CXR PA & LAT/PORTABLE C-SPINE URINE C&S UA MS /CATH

,ic CHEM: ttket it ACUTE ABDOMEN LS SPINE

BLOOD C&S X RertZ SINUS HEAD CT ,____,V..4) ANKLE R/L Liedi-

f I ---vr \ -7 kt, (0 1--cci PULSE OX 1013 ° Itt n

ORDERS MONITOR

TIME ORDERS n ECG

PATIENTS RESPONSE BY

COMP TIME

!WV ,s /Li /0 ,1 w.

DISPOSITION

n HOME n FULL DUTY

MODIFIED DUTY UNTIL

DISPOSITION QUARTERS /OFF DUTY

n 24 HRS. n 48 HRS. n 78 HRS.

RETURN TO DUTY



0 IMPROVED 0 UNCHANGED 0 DETERIORATE

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

REFERRED 100-

I have received and understand these instructions

PATIENTS SIGNATURE

TO WHEN

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


STANDARD FORM 558 (REV. 9-96) Prescribed by GSAIICMR FPMR (41 CFR) 101 -11.203(b)(10) USAPA V1.00

MEDCOM — 20385

DOD-033959

ACLU-RDI 1656 p.145

RADIOLOGY ABG/PULSE OX

GLU ETCH BHCG APTT

EKG INTERPRETATION PT

OTHER SAT

RESULTS P02 PH SUP 02

WBC

HM

PLT PCO2

DIP

MICRO

Check if read by ti radiologist

PROVIDER HISTORY/PHYSICAL

ii•ci 37 70 J--=KP, r riPtv c le 00\4-19160- -MO ite fulpy

1.11‘ . or 'I; CI 4- Tis V66 .th Lj-iy. Ice+119,4,Atik.

50 tht, tv1; t\- 0 41.e% f 3frei Ac,) 7'147 t r, Arse.

D . (4,10 -;16- -^

3—

RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP

PR

NSN 7540-01-075-3786



iOcc7

TEST RESULTS

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Loy feC•

COI 10/14‘5)

F-14. .1? Poy. T15;6 C e.10'041 hat icoree fit 404_

Ti‘ 13 it b C Op, pirol(hfr eDn:61 bl ,^it to

Tri),-6,-ehjo-eDi-E x-e-e .

c_cte- 216 Jay

5

I, t ee' )f 44

DIAGNOSIS

pr,0 ila y PATIENT'S IDENTIFI (For typed or written entries, give: Name — last, first, middle;

ID no. (SSN or other); hospital or medical facility)

1' I - 41)3

Lai

0

4 „ itthit 4) Lin i.

CONSULT WITH TIME

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSAACMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 20386

DOD-033960

ACLU-RDI 1656 p.146

NURSING NOTES (Sign all notes)

DATE HOUR OBSERVATIONS

Include medication and treatment when indicated M. P.M.

C.C)D - ' urrP 44 L- )--\s as - • of-X4-e r-S c \Y-N0y ___ - elf-

C_C-0(\ iN -

C.-0.1-= acs -t .c,‘ c,-)y-\ clU i-A ■ ....I

P-V --k--()\ PD -‘,,e_Al Y\cA,- off3 e--0.(k i ,cyrk t --IA/ 45) 0 i\f\-v.GA-- Tis•y, o - if\ •• -c-. 1 vy-, ,-;ki.-3/4(--„,,,,„.___ ,R____?-k- -c-es-b•-•-(3.1\v\--\- Irr. i-j\ac,e. 1

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C'Cr\CC)\(7Ck - --- -1Ck°"C\CQ ' CD‘.-. °C--)e) -17:1) - '1- pecs•co ‘(-\e,fx-7.. F. ,-As7,7,'s---- c.Q__ R,c) c'Nr ̀c--'_W. -1,4■A

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-6 A-;eac.. 1(--_:, VT.) LL _=d. --ay--(.__)-\t:D e_LE, --- (__J

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it cc-r. 03 21 -P-A- )1/4-k-c-m?, \is iy-\ A \c,(0-e ‘ r aig6

CstuA-- (N A OlAS .3\-k C_ -1c-c ‘cx\ -kms RLC - Ay- a i ,f-c 41

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• 1 Government Printing Office: 1995 - 404-763/20065


MEDCOM - 20387

DOD-033961

ACLU-RDI 1656 p.147

510-112

NSN 7540-00-634-41

MEDICAL RECORD NURSING NOTES (Sign all notes)

DATE HOUR OBSERVATIONS

Include medication and treatment when indicated' A.M. P.M.

CorN\---; \ aC_'-e ---C SI g2C (4 C (b ) C--0.-k—kb WI) 1 ILA/

. ,

N N

(Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or written en ries give: Name—fast, first, middle; grade; rank; rate;

hospital or medical faci ity)


NURSING NOTES

Medical Record

STANDARD FORM 510 (REV. 7-91) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 20388

DOD-033962

ACLU-RDI 1656 p.148

MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT For use of this form. see AR 40-66; the proponent agency is The Office of the Surgeon General.

1. AGE:

HEIGHT:

WEIGHT:


3. PREVIOUS SURGERY [ I NO [ 1.--r' YES (type):

4. PROPOSED SURGICAL PROCEDURE:

5. ADDITIONAL INFORMATION: Last PO:

Medical Hx:

Implants:

Medications: Jewelry removed: yes/no Family waiting: yes/no SC.ft- f

7 !


A. PSYCHOSOCIAL ...-/- Potential for anxiety

o Pt. verbalizes any specific anxiety.

o Pt. exhibits relaxed body posture.

...,o--,Offer

...„.cVRemain

o Allow pt. to verbalize freely. 0 Explain OR environment and answer questions regarding surgery.

comfort measures, (e.g., warm blanket, touch) o Explain all nursing procedures before they are done.

with pt. whenever possible. o Maintain family interface.

related to traumatic injury;

Ermage...laaa:i.ei:cznily separation; surgical environment

B. .E.-PIATION Potential for

o PT. will be able to breathe without difficulty during immediate intraoperative phase.

----9---Offer

--0---

....tr.-Assist

to elevate head of litter or offer pillow.

Observe pt. while awaiting surgery foi' signs of distress

anesthesia during intubation and extubation

res. ratory d ction due to eclat' d OS41011111 ; iniu

INTEGUMENT C. I

Potential impairment of skin integuity due t Bov ie

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

.

....e-Place

...9

o Utilize pressure preventing devices on OR table and accgssories. ,--V—Check for proper positioning and support to maintain good body alignment. o Pad pressure points.

ESU ground pad on non compromised skin surface are q. ,/"Keep prep fluids from

pooling.

bid; position; fluid shill

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 Previoius editions are obsolete. USAPA V1.01

MEDCOM - 20389

DOD-033963

ACLU-RDI 1656 p.149

4. PREOPERTIVE EVALUATI PREPARED BY 13. PR OPERTIVE EVALUATION PREPARED (Signature and Title

Aci 0.ev

A- */ BY (Signature and Title)

D E: TIME: -1:3 (

REVERSE OF UA FORM 5179. JUN 91-

DA 2Lsyofi a3

ME:

USAPA v1.01

MEDCOM - 20390


D. C,-ULATION

Potential for inade-

o Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse). ......er

o Check for support stockings or ace wraps. If none, check with doctors.

Check that safety straps are correctly applied.

0 Offer pillow for under knees.

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

o Check that rings have been removed.

sue perfusion due to , ratimalic injury;

position' shock; previous surgery

E. NEUROMUSCULAR I=. CONT3g-

E.1. . of mobility due to sedation pain;

o Pt. will be transferred to OR table without difficulty. .,...tayailable o Pt. will not experience unnecessary physical discomfort.

Have sufficient people for transfer.

Insure proper body

.— Allow patient to lie in position of comfort while waiting for surgery. o Offer support (i.e., pillows, bathtowels, etc.) for positioning.

Gury...)

E 2 Potential discomfort

due to injur<Fail.9

F. NEUROMUSCULAR CONTROL/ F.1. ' Disminished visual

o Pt. will be made aware of ....e-' surroundings prior to anesthesia induction. o Pt. will be transferred safely to ...,,P-- OR table. o Pt. will be able to understand instructions.

o Minimize danger of injury during intraop period.

A,/,.o

Introduce self. Keep pt. informed as to where he/she is and what is happening.

Inform pt. in which direction to move and assist if necessary.

,13-."- Speak clearly and slowly. o Address pt. from

side.

,...--var-sRption due to being injury; Seth 'on

z ,---"Potential for decreased unictaion due t language

barrier sedation 0 Validatept.'s understanding of verbal

ns. Verify removal of dentures.

F.3. Potential qry due to dentures. /V


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

OTHER NURSING INTERVENTIONS. Or continuation of above interventions.


03 DATE

11. POSTOPERATIVE EVALUATIO

e .t..1- ca. ircair Cit ftk 1.4.■ lotK-1 . C/LAt g exlitk

z •

DOD-033964

ACLU-RDI 1656 p.150

MEDICAL RECORD INTRAOPERATIVE DOCUMENT - For use of this form, see AR 40-407, the prop agency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATIN.- .+00

VIA I__C"\--A-- e„-," BY of)) 2. PATIENT !DENT!' ), RE EWED AND PROCEDURE VERIFIED BY ill fij

3. DATE TIME PATIENT ARRIVED I E

-2) t a cA- G3 ) lo Y--- 4. PATIENT IN ROOM

--) _ TIME.. : i Y 6 2-7- NUMBER 2

5. PREOPERA VE EMOTIONAL STATUS

XCALM

COMMENTS:

ANXIOUS I • EXCITED. IN CR ING NI ANGRY WITHDRAWN • OTHER (Specify)

-- -- 6. NURSING PERSONNEL

ASSIGNED SCRUB

FFc_ 77:r: ----- -'-- RELIEF . SCRUB

ASSIGNED CIRCULATOR

i k. r RELIEF __CIRCULATOR

i fa ; . .._... - .-. .


f:(SUPINE

/ .._7"1--- COMMENTS: j

AIDS (Specify)

LITHOTOMY

; ---

_..,,.

LATERAL:

tv1--- - - 5)6

MI ■ PRONE KRASKE . ; ❑ LEFT SIDE UP • RIGHT SIDE UP

4 (i. s) ../ CU44̂ -(.90I- -.:3 8. SKIN PREPARATION

(4 -2

HAIR REMOVAL

DONE BY: V 1YES ❑

OR

DEPILATORY

CLIP

tk, cy 1,...,...

NO " UNIT

. r...

PREP SOLUTION (Specify) /-3,k,A---,,<„, ..ccivm„..4, 1,---,s- c) $44. SITE: kV-. \-Qi BY WHOM: pevAr j OM SITE: BY WHOM: ... ... --_

M A ft; 61,./ty df- c c/1,4.4-i oi."._ ...COMMENTS:

■ NURSING METHOD: IIII pi RAZOR

... _......... ❑ COMMENTS: (4 9. LOCATION OF EXTERNAL bEVICES

' . '.-. 7 ' 1 ,

. ■• -; A :Ifs I • -.

• /- 4111M21P.-yririppT__

LEGEND X Ground Pad - Safety Strap = = = Tourniquet...

.. •-• ..' 1. .!_.':- .1

tr/r)-(1. k- C'S.P.-g

_ - . ..

-..... . (q( L)- Z-

10. COUNTS

=NM

C = Correct I = Incorrect

Other•• First Closing Count l•.;

Final Closing Mint SCRUB CIA ULATOR

le --iiimr.---- IIMENNI

-..1■11011111Wir-%1Sfal

Sponge LI c...L.: . .C._ Needle Sharp LI Instrument Other NI Yes

'MENEM EMILTIlal

Kil. o

.....„ ..,.._ . ' _ ____ .. ...'.1,;,, 44_aln,

'X-- ijt..., Pr-

11. PATIENT IDENTIFICATION Name - Last, first, middle; Grade;

0 -3

(For

c9(C)

typed or written entries Date; Hospital or Medical

'1

.:-

(1)/1-

Alinill1111

give: ) Facility;)

T

12. ELECTROSURGERY DEVICEIS) (ESU) DIES ❑ NO

SU NO: R ft" / a 2 Z Tsfi GROUND PAD:

.:itzifi - No: _..•

BRAND s...,1 (g 1 -Ale"-- .1./ Orr

3 I cot-

LOT NO: 5-7 Or6 f }—do.cf —

-• -'GROUND PAD: .,

I. BIPOLAR NO;

BRAND

LOT NO:

. -1, OCT 87

REPLACES DA FORM 5179.1 (TEST). DEC.82, WHICH IS OBSOLETE. USAPA V i.00

MEDCOM - 20391

DOD-033965

ACLU-RDI 1656 p.151

13. PROSTHESIS, IMPLANTS U YES I NO IF YES NAME: ID NUMBER; N IFACT'JRER

. - ...._ _

.1-..:;-.4Z,-1:4-5::!.*:it.PaggifliF ,::-!:344-ff134.44:741:;' MEDICATIoNsioRDERsqi0,. ,wRapN4 ksttlonmy ' og*, ,, :,_ iFi.„,, tf. 1RRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) YES II NO

MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

.. .. . . . •

'WOUN D IRRIGATION ii ...E14/ES II NO, TYPE(S): hi

OTHER ORDERS TIME CARRIED OUT BY

A- .--- - — -

_ .._

,PHYSICIAN'S SIGNATURE

t 15. X-RAY IN OPERATING Re 4M IF YES, SITE

YES ■ NO i% : ,.

16. - ':.':".: LABORATORY SPECIMENS

SPECIMEN (S)

YES ■ NO El/

..-. , NAME — --- -.._:...—. -- - NAME

FROZEN SECTION (FS)

YES ❑ NO Mi NAME - : . NAME

CULTURE (C)

YES ■ NO 2 NAME

- -- - ----- --- NAME

NAME NAME NAME

NAME NAME - ..... K_

18. DRESSIN

6-0-4

G/IMMRBILIZATION (Specify)

) xi-- Le7/-t__. 61 as (i -c. i. - i )1C

fA"... ----- e,-/--

17. TUBES, DRAINS/PACKING YES ❑ NO ,,,, TYPE/SIZE 1. 2. " ''

SITE 1. 2. 3. -- - - -----

19. ADDITIONAL INFORMATION Ftp t

7 il-k..4:4))G 4-zz , ) y-t,t- / 9 1-------

SUS Q-erry■ ; bt, , - i)0,--0ftie C\AIV?.._5 :C -es. rOW II& G - --e_

' ,-- - CC---i-i;=-4r Ccs.' — '3 10 C . 0 .. . - a cni),„- pco, siL, p. St —Cr


21. PATrIV

■_

T TRANSFERRED TO TIME METHOD

/---k,"-- 22.

P)A---.1 AI 3t 6 c,1--- a 3 R 1, OCT c_9(6) MEDCOM - 20392

USAPA V1.00

DOD-033966

ACLU-RDI 1656 p.152

MEDICAL RECORD " INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-407, the prop ,dricy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATINL. .100M

VIA k..;■.' 'Vk-k.A/ BY Al.A.,2541Atc-A ckk 2. PATIENT IDENTIFitO, RECORD REVIEWED AND PROCEDURE

VERIFIED BY e_crk- , 3. DATE TIME PATIENT ARRIVED IN SUITE

?° OCU c CZ, ... 4.- PATIENT IN ROOM

TIME ; NUMBER

5. PREOPERATIVE EMOTIONAL STATUS

• CALM • ANXIOUS U EXCITED. ❑ CRYING ❑

_...._

ANGRY WITHDRAWN ❑ OTHER (Specify)

0 .5-L COMMENTS: „__

6. NURSING PERSONI4EL

ASSIGNED SCRUB

,.., -.7-.:=- "' "'RELIEF .SCRUB

ASSIGNED CIRCULATOR

i litit-j RELIEF --CIRCULATOR ..— .....- . .

7. POSITION AND POSITIONAL AIDS (Specify) _..,..

❑ LITHOTOMY ❑ PRONE . , . . ❑ KRASKE LATERAL:

• - - -------•

KI SUPINE U LEFT SIDE UP • RIGHT SIDE UP

COMMENTS:

8. SKIN PREPARATION

HAIR REMOVAL LTJ YES

DONE BY: ❑ OR

‘

DEPILATORY

■ NO '

❑ NURSING UNIT

‘..2 RAZOR

....... __......_ .

•.PREP SOLUTION (Specify) 64 ,.'illt atrts 4- c.S.-"ek.Vok,t... SITE: Ati_ BY WHOM:Oran.

. SITEL BY WHOM:

(,)R) - L .EcirvimiN Ts:/A/. f) ;, (1,-,.7 d f..... _ r a ((AA., ,

METHOD: MI

■ CLIP

COMMENTS: 19.4.:c.ft-L -f-- fek,v,t,..,-- 9. LOCATION OF EXTERNAL DEVICES

.

Pad

lan 1 ^ r1 orktivt,,

.

.. i .1 I•

LEGEND X Ground

- -Ili Apir

-- Safety Strap = = = Tourniquet.....4..;::::.

10. COUNTS

C = Correct I = Incorrect .

(?)- Other• •

Fust Closing. Count _I'm.

Final Closing CdUnt

(_G) ( SCRUB CIRCULATOR

Sponge IN Yes ___I No ,AP( 71/4-J Needle Sharp Yes lo _ .-

Instrument • Yes Ec No ,......„.„--- _. __. ._ - .:I ,J.:,Ja_: ,7-' - . ----- Other 0 Yes N No .‘-'-- 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

(_) ( c ) -1

`)0-7.-- - _ -Z. °k DCA' 13.-

- _

-

- . ----- -- _ - —_

SU

_._. . ..._ -- ❑ r_ESil .

• -• -GROUND .. _.:

• BIPOLAR

.

12. ELECTROSURGERY DEVICEIS) (ESU) Ers'ES fl NO

NO; kits-kIkt‘11b..1r k-17.,,r (St...

GROUND PAD:

NO:

fiRAND V(... rxi„,„‘ y SAN. 'Z- LOT NO: c? 0 c• i ( 41c 24 c'S`' .. 0 If

PAD:

NO:

BRAND

LOT NO:

- I.

REPLACES DA FORM 5179-1 (TEST), DEC.82. WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20393

DOD-033967

ACLU-RDI 1656 p.153

13. PROSTHESIS, IMPLANTS ❑ YES 1-NO IF YES NAME: ID NUMBER; M kCTURER

'O,r„,.:, APRiPetaWA.,::::;:, 1 N;.' 4- --_ 14' MEDICATIONS /ORDERSW&MUktalgt, - iiy i,;0,.,a1WITAVOJI80f,q _

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) YES ■ NO

`:MEDICATIONS/SOLUTION DOSAGE TIME • METHOD PREPARED BY GIVEN BY

!WOUND IRRIGATION RYES ❑ NO TYPE(S): .

.:,

,:OTHER ORDERS . TIME CARRIED OUT BY

#1-1YSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE

YES ❑ NO ■ 7

16. ''"'.LABORATORY SPECIMENS

SPECIMEN (S)

YES ❑ NO a _ Z.-.2..---.:.-- - NAME -- -------- . , NAME

FROZEN SECTION (FS)

YES ❑ NO E)

NAME NAME

CULTURE (C)

YES ❑ NO

NAME - .,- -- --

NAME

NAME NAME NAME

NAME NAME . . 18. DRESSING/IMMOBILIZATION (Specify)

sarG 'AM - Pr,— ?C ..._

Fiv._PEr .liC -<.,

17. TUBES, DRAINS/PACKING YES ■ NO

TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3. - . - --,..-.1..-


c "may W WI , Ck....1S i .S ■

----- q - --- frisi\Vialr\-9-Vt a "- . _

C 0._,..,.....-v-ti-.1 -.- C O. ,;:xy ',, .1 0 -: 3;; {---: 2 d

• . ..


.1.-k" .̀ k -Vi lit Oc..:


?it u\K cr- c\,k io ( 61- TIME SP...9.,

-Pinsilec -- METHOD

Vktitv 22. REGISTE

MPP) A-J/ al C.c2F o 3 E OF DA FORM 5179-1, OCT 87 -

USA PA V1.00

MEDCOM - 20394

DOD-033968

ACLU-RDI 1656 p.154

MEDICAL RECORD INTRAOPERAPIT DOCUMENT For use of this form, see AR 40-407, the prop am' the office of The Surgeon General.

1. PATIEN-RANSPORTED TO OPERATIUAltil i go 2. PATIENT IDENTIFIED, R ED AND PROCEDURE VIA i____t r BY VERIFIED BY 1 LT 3. Kb_ TIME PATIENT AR IVE

TIME - D IN SUITE 4.• PATIENT IN ROOM

I otts- - NUMBER c) - I 5. PREOPERATIVE EMOTIONAL STATUS

COMMENTS: :.,_.. ...._ _0

1 CALM • ANXIOUS • EXCITED ❑ CRYING U ANGRY • WITHDRAWN U OTHER (Specify)

1J6) 0 0 ...._ _, P '7-

6,...NURSIc G PERSONNEL

ASSIGNED --- RELIEF SCRUB SCRUB

ASSIGNED is RELIEF CIRCULATOR ..._,.. ...,... —_CIBCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) -.:•_-

ft SUPINE ■ LITHOTOMY • PRONE ❑ KRASKE -: LATERAL: • LEFT SIDE UP IIII RIGHT SIDE UP ;.: ,. '-' •

COMMENTS: out m%,•\01\it..„ tivot_oci.kad .

8. IN PREPARATION -Rib% cleyv, HAIR REMOVAL ❑ YES N NO ' • PREP SOLUTION (Specify)

DONE BY: ■ OR ■ NURSING UNIT SITE: kif:\\At BY WHOM: i I METHOD: IN DEPILATORY 0 RAZOR . . SITE: BY WHOM: I 1.-

. .CONTS: 13 DV ad,k)

Q9-(0 --e-L

1

CLIP —__ COMMENTS: k- _ _____

: r .M...ME......

9. LOCATION OF EXTERNAL DEVICES . _ ....._

' - ,.,_....__._

E E und - To 0/IN wtk

P rt-e LGN X Gro Pad -- Sa rap = = urniquet.- -., -

•I.

:gii"

r f,fArgram.,2111,""j,. 4,159x.r.,, /41:W

•

- i -I

ktswk-ml... GPC pal

C = Correct I = Incorrect ...

10. COUNTS IvrikkooAl Other** First Closing Final Closing Count .. '1-,4., Count .SCRUB CIRCULAT R

Sponge 61 Yes .. Vo .- It Needle Sharp 73 Ye'S Vo . ,..„.._. .,..„. — Instrument ❑0 Yes KI Vo . ._ _ .-. _ :::::,:1 ..._ . Other a Yes 1 Vo ..---- - 11. PATIENT IDENTIFICATION (For typed or written entries give: 12. 'ELECTROSURGERY DEVICE(S) (ESU) IN YES U NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

4 imp (.')((-0).=7.,A-,._

GROUND PAD:

• . __ _

A

• ESU NO:

•-•.:, LOT NO -,-• BRAND

EI,E$0 NO: -• -=GROUND PAD: BRAND

• . LOT NO: ■ BIPOLAR NO:

- , OCT 87

REPLACES DA FORM 5179-1 (TESTI, DEC 82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20395

DOD-033969

ACLU-RDI 1656 p.155

13. PROSTHESIS, IMPLANTS E 'EE .1 NO IF YES NAME: ID NUMBER IFACTURER

1 5;:, jp45_ -4;54:i4v.tizazi-gat-43:,.;:x1:,,c5i-.S.fga.' NI EDICAT ION S/ORDERS Maaignt945n14:Vit:F-NattnAgirikmar

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ❑ NO

IVIEDICATIONS/SOLUTION DOSAGE - TIME - METHOD PREPARED BY IVEN BY

ii MOUND IRRIGATION p YES • NO. TYPE(S):

i co_ct CYle, qkCA- c3kS fi

%DITHER ORDERS TIME CARRIED OUT BY

. _ . ,

'PHYSICIAN'S SIG ATURE ,

15. X-RAY IN OPERATING ROOM IF YES, SITE )f

YES • NO ,_ : 16. ' ="'-' LABORATORY SPECIMENS

SPECIMEN (S)

YES ■ NO

NAME ___ _,.•..••_ .-__. --,1.2L----- . NAME

FROZEN SECTION (FS)

YES ■ NO

NAME NAME

CULTURE (C)

YES ■ NO

NAME - -_ ----

NAME

NAME NAME NAME

NAME NAME ........ - -- - ---


RkL-Yis

:i_obn 17. TUBES, DRAINS/PACKING YES [4 NO 0 _ TYPE/SIZE 1.

10r4y, I- P 2.

-- --

SITE 1

Z -bbia 2. 3.

19. ADDITIONAL I ORMATION

Si. f)r\ !

-

__

,Vc 5)79 1 r) C hi r € 20. OPERATION(S) PERFORMED . _

,stc0 -b.Na-


PA TIME a.'_e_

tYkl Wi METHOD

L tktAr 22. REGISTERED NURSE SIGNATURE

11-7k0 - --- REVERSE OF DA FORM 5179-1, OC

MEDCOM - 20396 USAPA V1.00

DOD-033970

ACLU-RDI 1656 p.156

MEDICAL RECORD 1 INTRAOPERATIVE D' —,UMENT - V For use of this form, see AR 40-407, the ropc F, is the office of The Surgeon General. —.--. -

1. P TI ENT, TRANSPORTED TO OPERATI ..00M 2. PATIENT AND PROCEDURE VIA Li 4-A-E/Y BY 4 /31 CI VERIFIED 6 tiii' 3. DATE TIME PATIENT ARRIVED IN SUITY- 4.- PATIENT

IS OL 0-3 1 i() TIME . / /0 S BER / -.5--- 5. PREOPERATIVE EMOTIONAL STATUS

COMMENTS:

❑ CALM $_ANXIOUS • EXCITED. • CRYING ■ ANGRY 111 WITHDRAWN ■ OTHER (Specify)

c,L--1- ) 6. NURSING -- PASO NEL/

ASSIGNED SeC 111111 ''''--- - "" 'RELIEF SCRUB SCRUB

ASSIGNED Li\-- MOW RELIEF

II ■ri ;• CIRCULATOR __CIRCULATOR

COMMENTS:

3,-Inf-UA■V Pl-ii° a-Lt-it-c- 0 -Pa& 1-trla-U ea:. 7. POSITION AND PQSITIONAL AIDS (Specify) 1._. • 'T...e4\-f.x i. 4.144.E ctnirbryttee 1 11 j or (in i.4 ) l'

arms 80 4 own badre2,2_, less qv El SUPINE • LITHOTOMY ■ PRONE ■ KRASK - LATERAL: i_ _1 LEFT SIDE UP ■ RIGHT SIDE UP

- - --- • 8. SKIN PREPARATION

HAIR REMOVAL ■ YES 0 NO ' PREP SOLUTION (Specify) t:,.4-14-( 8,24-Y1 DONE BY: ■ OR ■ NURSING UNIT SITE' iL i e3 BY WHOM: kleallilla

, BY WHOM: METHOD: • DEPILATORY ❑ RAZOR .•-.: .__ SITE. • CLIP -.

COMMENTS: --- .. COMMENTS: pc„it,ri cit ,s,,lu IA. 11E14-"e -)

• )

9. LOCATION OF EXTERNAL DEVICES ... ......

i

- 1. . :W-

. Illilkilis-

'( Vil-- LEGEND X GroundPad -trap = = = Tourniquet.---:-

:- ..:..... -

-',1•:. .

p4-41

- -

Correct I = Incorrect FirstClosing Final Closing 10.COUNTS Other•• Count ...i-q...j Cceint SCRUB CIRCULATOR

Sponge • Yes No ... ...-------- Needle Sharp ■ Yes ... — -- . ....--..,..:. Instrument • Yes No _ _ ';„:1:,'i:,1„:7:," Other U Yes No 11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) ■ YES ra 1 • Name - Last, firs 'cldle; Grade; Date; Hospital or Medical Facility;)

(.)(?') .. . . . ... _ • ESU NO:

-

GROUND PAD: BRAND

' ,:tr..E.SD NO: LOT NO:

- • - -GROUND PAD: BRAND •...:.

■ BIPOLAR NO: LOT NO:

REPLACES DA FORM 5179.1 (TEST/. DEC 82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20397

DOD-033971

ACLU-RDI 1656 p.157

13. PROSTHESIS, IMPLANTS ❑ YE j NO IF YES NAME: ID NUMBER; FACTURER 1 _........ _ ...---

_ .

14. 4ig 4 ;tiii"15'427` aiii ,M. ,;,.q.ig r MEDICATIONS/ORDERS1'40W:i - ,V4,7 .iV--.^..;-i7-71

;;1..,- „..?r44-2,--,A ..

.w.,---5[ .t..:J"1,bt, . p.,i.;i2 * :.,.:,::f.5:?:,,4,..? %,..ii, 441,..7..

IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA) YES • N

4.4EDICATIONS/SOLUTION DOSAGE TIME : METHOD PREPARED BY GIVEN BY

..._ ,.... • ,

r;WOUND IRRIGATION tj--YES • NO TYPE(S):,

.-,-, - - I

.„......,.,,

=OTHER ORDERS TIME CARRIED OUT BY i

i

,_. . .. .

THYSICIAN'S SIGNATURE


YES • NO

16. :!:'.LAI3ORATORY"SPECIMENS

SPECIMEN (S) .

YES 0 NO gl

, ,,,, . NAME - ----:— --------

-

NAME

FROZEN SECTION IFS)

YES ❑ NO

NAME NAME

CULTURE (C)

YES ■ NO „Ilf._

NAME NAME

NAME NAME NAME

NAME NAME _ __

-- ... _—__ ,.. 18. DRESSING/IMMOBILIZATION (Specify)

1-1Lk t-1:3 JC0/1 t 1 4--

-10:7.,

17. TUBES, DRAINS/PACKING YES NO ❑ .... .

TYPE/SIZE 1. \ rt,"•‘ 2.

SITE 1,.--N

. e-.)%___""t-: 2. 3.

19. ADDITIONAL IN-FORMATION

S1-4-1),QC'N.

._....... __ . _ ........ . ,

... --

Q2)(y . --:-.1._/..-;.i

20. OPERATION(S) PERFORMED . .

r •A-- D ) 7 ' ̀ ''' .

21. PATIENT

FEARED TO

C__CA

TIME.

1 itf40 1

METHOD

-PI-12-r C di 22. REGI

A-74_ - ...--- - REVERSE

USAPA V1.00

MEDCOM - 20398

DOD-033972

ACLU-RDI 1656 p.158

MEDICAL RECORD INTRAOPERATIVF 90CUMENT

. For use of this form, see AR 40-407, the propi _ancy is the office of The Surgeon General.

1. PATIENT

VIA / i

TRANSPORTED TO OPERM IN ).. . )0OM

BY ( ,G,../.0 .1

2, PATIENT VIEWED AND PROCEDURE

VERIFIED liiU/ill 4.• PATIEN OM

TIME: •i t 1 I 0 NUMBER D - -1 3. DATE TIME PATIENT ARRIVED IN SUITE

0 007 D3 i, t 0 5. PREOPERATIVE EMOTIONAL STATUS

■ CALM•yi_ANXIOUS ❑ EXCITED. I CRYING III ANGRY ■ WI HDRAWN ■ OTHER (Specify)

COMMENTS: -.......

6. NURSING PERSONNEL

ASSIGNED SCRUB

Wit ' ' - - R E Ll E F

C

• . SCRUB

ASSIGNED CIRCULATOR

ILV 1 IMF Al— RELIEF JJ __CIRCULATOR

1 NT ; •

.40SITION AND IMOSITIONAL AIDS -e. (Specify) rD.1._ ,1-,(4011,-

rs ccot et Iv-, e. ic ....>4 ° - --' - ori- bile ctvtct in-A r-kv cortem -6 pdQ._;" ii ? SUPINE ■ LITHOTOMY ■ PRONE.

Lii_ KRAS E , LATE L: ten- SIDE UP " '1,1 RIGHT SIDE ki

COMMENTS: :.

8. SKIN PREPARATION

HAIR REMOVAL • YES - '

DONE BY: ❑ OR III

•

NURSING UNIT

METHOD: DEPILATORY ❑ RAZOR . . .

❑ CLIP

COMMENTS: -------- ...biikilkiNTs:

PREP SOLUTION (Specify) p_i" 1 9 - 1 q.P....414- SIT : f ,) 1,173 BY WHOM: Na SIT . BY WHOM:

jeara

59e , lks u( 4,1 3 I SU ic.r-41-0.... Ad ie )

9. LOCATION OF EXTERNAL DEVICES

001,44-

:•---- -'%',.. ■ :: 5,'

- - igiari-4.171w--4rrAEli"."1.1w-call - 0

,....: . 04'0:41 11111144‘ c-J-

016 CO° kiA LEGEND X Ground Pad -- Sat- trap = = = Tourniquet • -j, -.7.; -

10. COUNTS


Other" First Closing Count .. •N...

Final Closing ..COiint .SCRUB CIRCULATOR

Sponge • Yes pll No e - 4--"'e „. .

Needle Sharp Yes i■ No .......--. ..--------------

Instrument Yes 1 Vo /.. .... ... --... - _

,. •-L.1:,•'; -1-

Other Yes II No F .• •

11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

- C)(-6

)

- - __

12. ELECTROSURGERY DEVICE(S) (ESU) • YES NO

III. ESU NO: ■ GROUND PAD: BRAND

. - - LOT NO:

tr_E' . .1:1 • NO:

•••• ..G. 11OUND PAD: BRAND ••,..:.

LOT NO:

■ BIPOLAR NO:

M 5179-1, OCT 87

REPLACES DA FORM 5179-1 (TESTI, DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20399

DOD-033973

ACLU-RDI 1656 p.159

REVERSE 0 FORM 517 MEDCOM - 20400

13. PROSTHESIS, IMPLANTS • YES NO IF YES NAME: ID NUMBER; A .CTURER

14

. .. ............— .,!,

..:14,,:p1., %:%ii. .,,,... ,, =Atiti:TFYIS4„tit?agagg. M EDIC ATI ONS /ORDERS PArgilitrAiVireif-,..,-.141V- 7:01 rk-9-54,1,,-,' IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) YES ❑ NO r,

!:MEDICATIONS/SOLUT1ON DOSAGE TIME . METHOD PREPARED BY GIVEN BY

. .., ...- ,....... . - ----

MOUND IRRIGATION

.4.„. YES IN NO, TYPE(S):.

4 _ '!':OTHER ORDERS , TIME CARRIED OUT BY

;

. '

:PHYSICIAN'S SIGNATURE


YES • NO Ql. 16. - '- =17! LABORATORY SPECIMENS

SPECIMEN (SI YES II NO

NAME ____. _,......------ .. NAME

FROZEN SECTION (FS) . YES • NO

NAME ......

NAME

CULTURE (C) YES ■ NO 'q_

NAME NAME

NAME NAME NAME

NAME NAME ... --_ 18. DRESSING/IMMOBILIZATION (Specify)

f"---

KA/c,C--

17. TUBES, DRAINS/PACKING YES _gr. NO • . TYPE/SIZE 1. I (,),y1 vv,

4 2.

S ITE 1 Li_IS

3 .

19. ADDITIONAL INFORMATION . ...... , \StAr "e_c4N

- :-.i..1Z..,:id::

......, _ . _

( ) (() ) -1,:, ....-,

20. OPERATION(S) PERFORMED -„

21. PATIENT TRA - - ED TO i ,

17 i METHOD

I , V-P-r 22. REGI

Li. A- 11 AIL - - USAPA V1.00

DOD-033974

ACLU-RDI 1656 p.160

MEDICAL RECORD INTRAOPERA", .: Dk UMENT I For use of this form, see AR 40-407, the proponent agency is the office of The Surgeon General.

1. PATt&N,.1 TRANSPORTED TO OPERATING ROOM

VIA , BY CUL-61014-01-e.-4_.

2. PATIENT IDENTIFIED, RE WED AND PROLE RE

VERIFIED CI,PT 3. DATE TIME PATIENT ARRIVED IN SUITE

--7-° b'----6

..-------.. 4. PATIEN

TIME pptc NUMBER Jai (V


[it CALM

COMMENTS:

❑ EXCITED ❑ CRYING ❑ WITHDRAWN • ANXIOUS II ANGRY Ill OTHER (Specify)

t‘


ASSIGNED SCRUB

RELIEF SCRUB

C)

-.)

CIRCULATOR ASSIGNED.„,CZLIIIIIIP 60 E RELIEF

CIRCULATOR 1_1:PT 1500 - C OC )

7. POSITION AND POSITIONAL AIDS (Specify)

SUPINE E LITHOTOMY ❑ PRONE

COMMENTS:

LATERAL: LEFT SIDE • KRASKE • UP • RIGHT SIDE UP

B. SKIN PREPARATION

HAIR REMOVAL LI YES NO

DONE BY: 0 OR ❑ NURSING UNIT

METHOD: ❑ DEPILATORY 17 RAZOR

COMMENTS:

PREP SOLUTION (Specify) iereie-/Ae4-- SITE: BY ROM: SITE: BY WHOM:

COMMENTS:

9. LOCATION OF EXTERNAL

r. - IA

LEGEND X Ground

DEVICES

i

= = Tourniquet

4---

— At'

-"ffilmliP-411... 1,-,ipp

-- Safety Strap = Pad

10. COUNTS

c = Correct I = Incorrect ( —T L._1 ,, Other'- '

First Closing t Count

Final Closing Count SCRUB CIRCULATOR

Sponge 0 Yes •Ill No

Co

/

_

Needle Sharp II Yes . No

Instrument ❑ Yes No

Other ❑ Yes _

11. PATIENT IDENTIFICATIO (For typed or written entries give: Name - Last, first, fiddle; Grade; Date; Hospital or Medical Facility;)

()(C)----(1

iiMpir Cq 2,) ---c

12. ELECTROSURGERY DEVICE(S) (ESU) • YES IR NO

III ESU NO:

GROUND PAD: BRAND

LOT

■ ESU NO:

NO:

GROUND PAD: BRAND

LOT

BIPOLAR NO:

LOT NO:

DA FORM 5179-1, OCT 87

REPLACES al

MEDCOM - 20401

;H IS OBSOLETE. 1.15APA V1.00

DOD-033975

ACLU-RDI 1656 p.161

13. PROSTHESIS, IMPLANTS E YES N9 IF YES NAME: ID NUMBER; MANUFACTURER

'

4:54::::.:iii-.;!.;;::.A ............................................................................................................................................................. MEDICATIO NS/ORDERS ;M:::40;;;;;;Za:::.:Mai.g1::::::: ::::g:;:::0;;-:::::§AUME016:::;ii.MMii1;!.!11!: :e .:::2 .:: ::

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ❑ NO

;;MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

MOUND IRRIGATION YES ❑ NO, TYPE(S):

0,cr kiile,L, ]:OTHER ORDERS TIME CARRIED OUT BY

;Writ

::::PHYSICIAN'S SIGNATURE

... . .., .....,......„........ . . ........ ............... . . ........ ....... 15. X-RAY IN OPERATING ROOM IF YES, S)TE

YES / NO 14

16. LABORATORY SPECIMENS

SPECIMEN IS) NAME NAME

YES • NO

FROZEN SECTION (FS/ NAME NAME

YES • NO

CULTURE (C)

YES 0 NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify/

Vri

I 01 tial■--

17. TUBES, DRAINS/PACKING YES NO Ei TYPE/SIZE V p5 1

a-4,4d

2. 3.

SITE

l(g)

2. 3.

19. ADDITIONAL INFORM

31,t‘crl fo

A r) c..s.,-4 h

t\r.Q..1/4-I'v,, (2,-cin

. . .,

eval 1L) .os ic---/ Rk°

g '_4(4. /--

20. OPERATIONS) PERFOTED

21. PATIENT MAR FD TO

22. REGIITIll Cl

/

TIME

/51tr, MET 3D i

REVERSE 0

MEDCOM - 20402

USAPA V1.00

DOD-033976

ACLU-RDI 1656 p.162

MEDICAL RECORD I • INTRAOPERATIVE DOCUMENT

For use of this form, see AR 40-407, the propc agency is the office of The Surgeon General.

1. PATI NT TRANSPORTED TO OPERATING .100M

VIA BY alias<5 -0W-it-- 2. PATIENT IDEN. ' , P PROCEDURE

VERIFIED B ej,7 ' 3. ir5

,_—__TIME PATIENT ARRIVED IN SUITE

° 0:1- 0 b _, 4.. PATIE

TIME • " NUMBERC7.-C). (.--. ) 5. PREOPERATIVE EMOTIONAL STATUS

S4 CALM ❑ ANXIOUS ❑ EXCITED ❑ CRYING 0 ANGRY ❑ ITHDRAWN

COMMENTS:

■ OTHER (Specify)


ASSIGNED SCRUB

1'C . --„qt . - """ -RELIEF SCRUB r •-\ .7_____

ASSIGNED CIRCULATOR

I ..—. .. — .

.....\\ -

RELIEF __CIRCULATOR

" INT ;•

f /.../

7. POSITION AND POSITIONAL AIDS (Specify) . :.

l 'Eit SUPINE ■ LITHOTOMY ■ PRONE , D KRASKE, LATERAL: ■ LEFT SIDE UP RIGHT SIDE UP

COMMENTS:

8. SKIN PREPARATION

HAIR REMOVAL ■ YES NO '

DONE BY: ■ OR ❑ NURSING UNIT

METHOD: ■ DEPILATORY ❑ RAZOR • - ■ CLIP . _ _______.

COMMENTS: „....--.---- ------- .

PREP ION (Specify)

SITE p agy BY H SITE. 7 ,____, , BY WHOM:

—_ ,_.. .COMMENTSP)

06 v,,,,,,,,e

9. LOCATION OF EXTERNAL DEVICES _.,... _ - .•": i:: :1'.. • .

-441

:I- LEGEND X • • -- Safety Strap = = = Tourniquet- - -•:,-:-:-.

10. COUNTS

C = Correct I = Incorrect nth cf_ I Other ."

First Closing Count _ -i, Count

Final Closing

SCRUB aipa.:CULAT• Sponge Lil Yes

IIIIAI EMMEWAEI 0..._ _- Q . "!ilmr - •

Needle Sharp U Yes Instrument El Yes

_ _....._ .. .111 aUi53.111 7E111121111,111111111111=111 111111

Other ■ Yes Ii o r 1 1 . PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

AO" ( 1 )(C) 1

12. ELECTROSURGERY DEVICE(3)

0—U._

(ESU) ■

YES liq NO

c A c qj ESU NO:

GROUND PA. ? 0

• LOT NO ..p. , _•• --- 0 . .-,::: :: . =,:gS0 NO: , , .. -• --GROUND PAD: BRAND ,,,.

LOT NO:

41.110/111 (-(g)(1)-PC., • BIPOLAR NO:

1+0C-17)3 .

-1 , OCT 8

REPLACES DA FORM 5179.1 (TESTI, DEC.82; WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20403

DOD-033977

ACLU-RDI 1656 p.163

13. PROSTHESIS, IMPLANTS R YES 1,NO IF YES NAME: ID NUMBER; V FA JRER

- - ---„-

I 4.1-4:--:;=== -. ,74,M01,4*-0a,L ,,,,i,ta.od-it.Mq4,.V.:: MEDICATIONS /ORDERS 04f..44-;44b. ,,,- 4= eitt.,$, ,.i-4.'-41:,:::ft!t 4,-Agf,kit

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) YES U N

MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

I 'WOUND IRRIGATION KC YES • NO, TYPE(S):

I.; •

`_OTHER ORDERS TIME CARRIED OUT BY

i' : ----

I. .

;PHYSICIAN'S SIGNATURE 3 .,


YES ■ NO lt 16. :'`LABORATORY SPECIMENS

_._ NAME ----------- NAME SPECIMEN (S)

YES U NO

FROZEN SECTION IFS)

YES ❑ NO

NAME ._.

NAME

CULTURE IC)

YES ❑ NO

NAME

- NAME

. NAME NAME NAME

NAME NAME . _ . _

18. DRESSING/IMMOBILIZATION (Specify) •

--,

.- - a-t-IL kl.ilui3O

17. TUBES, DRAINS/PACKING YES NO ❑ - TYPE/SIZE '

'S r Dry,ri 2. . .

SITE 1. 40 2. 3. „. ... ..,--- .

19. ADDITIONAL INFOROA -

_ .

20. OPERATION(S) PERFORMED • I` !I/

_ .

21. PATIENT TRANSFERRED TO c. --.i(z. \-- 7. _ 1 u_3

TIME 1 ')31) -

METHOD - rA0A

22. REGISTERED eir)A7)

- • _._

USAPA V1.00

MEDCOM - 20404

DOD-033978

ACLU-RDI 1656 p.164

a COUNTS

-iTonge

Needle Sharp

Instrument

other

of The Surgeon General.

BY

TIME PATIENT ARRIVED IN SUITE

OMMENTS:

❑ CALM 5f- ANXIOUS EXCITED . ❑ CRYING ❑ ANGRY


THDRAWN ❑ OTHER (Specify)


ATIEN TRANSPORTED TO OPERATI

3AT E

I OCI"

MEDICAL RECORD INTRAOPERATIVE DOCUME For use of this form, see AR 40-407, t apone may

2. PATIEN

VERIFIED

4.- PATIENT I

TIME UMBER I- a

PROCEDUREA1,

ASSIGNED SCRUB

— RELIEF SCRUB

-

-7. POSITION AND POSITIONAL AIDS (Specify) .1)4_ ir gms t c ,.6 p-tu (.40W3,-C eat) uoc,. .p.SUPINE ❑ LITHOTOMY u PRONE . ,, ❑ KRASKE•

L.: COMMENTS:

ASSIGNED CIRCULATOR

RELIEF _CIRCULATOR

alta ryk mo '''t e cr" (

' LATERAL: Li LEFT SIDE UP RIGHT SIDE UP

8. SKIN PREPARATION. YES NO OR

❑ NURSING UNIT DEPILATORY ❑ RAZOR CLIP

PREP SOLUTION (Specify) 80-b1 (5-€.*) SITE /O) BY WHOM: C-P7M11, SITE: BY WHOM:

HAIR REMOVAL

DONE BY:

METHOD:

COMMENTS:

.fCOMMENTS: •

k n d 1-9 ,P

-67 LOCATION OF EXTERNAL DEVICES I

ypuod •

• -

and Pad Safety Strap /114

= Tourniquet• - LEGEND

X Gr


1., PATIENT IDENTIFICATIO (For typed or written - ntries give: Name - Last, firs iddle; Grade; Date; Hospital or Medical Facility;)

Vo

Other*• First Closing Count

Final Closing CoUnt SCRUB

Er_ESU NO:

--GROUND PAD:

❑ BIPOLAR NO:

CIRCULATOR

its 6:- /0 30_5

BRAND Val ley h.; 4 LOT NO: 7a / F, -° c•err--

12. ELECTROSURGERY L.LiE-d

ESU NO: //OS GROUND PAD:

DEVICE(S) (ESU) Di YES yLNO

BRAND

LOT NO:

-DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179-1 crEsT). DEC 82, WHICH IS OBSOLETE.

MEDCOM - 20405

US AP A V 1.00

DOD-033979

ACLU-RDI 1656 p.165

13. PROSTHESIS, IMPLANTS i YES NO IF YES NAME: ID NUMBS IUFACTURER

- - ---, ---

04, WS:niisfibts-ACCINIVitigrAitett45;60.0140,1;;; M ED !CATION S /0 RDERS fit,..=-4*,, 44,qattikati4_,,=-VAlarit0104 :7-- - IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA) . YES • - NO • ' ''

:MEDICATIONS/SOLUTION DOSAGE TIME:. METHOD PREPARED BY GIVEN BY

, . .

1.

WOUND IRRIGATION --pYES ❑ NO, TYPE(S):

0 - q - / - itlilj !OTHER ORDERS TIME CARRIED OUT BY fi

........ ______

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM -K i , . IF YES, SITE

7 .. YES ❑ NO

16. ' `'=:: .LABORATORY SPECIMENS

SPECIMEN (S) NAME

.,..-.±.......:-.:- NAME

YES • NO Z - . - FROZEN SECTION (FS)

YES ❑ NO &

NAME NAME

CULTURE IC)

YES ■ NO ]

NAME

- -----

NAME

NAME NAME :

NAME

NAME NAME - -

. _ ,_ 18. DRESSING/IMMOBILIZATION (Specify)

F u t-71---c i--- ,.,

7C2. e ( , L / e4 7 ✓ ; ".-

AC(: 17. TUBES, DRAINS/PACKING YES NO ❑

TYPE/SIZE 1. ,iinopivrprm

ithvj s, .;:iP Dirac, 2. 3. .

SITE 1(g) t. ,..1 2. 3.


I

14 e'll

,

20. OPERATIONS) PERFORM

t

21. PATIENT TRANSFERRED TO TIME METHOD

: '-' m 22. REGISTERED S . _.-_ _

QP7 /Iry

REVERSE OF DA - , OC

MEDCOM - 20406

USAPA V1.00

DOD-033980 ACLU-RDI 1656 p.166

MEDICAL RECORD I INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-407, the prop , agency is the office of The Surgeon General. ... .

1. PATIENT TRANSPORTED TO OPERATINt....,OOM

VIA Li-k-el,'" BY kr1LS-41PcI1a

2, PATIENT l ECORD REVIEWED AND PROCEDURE

VERIFIED BY. 0,PriAN/ 3. DATE TIME PATIENT ARRIVED IN SUITE

faCt Sept-- is, f4.02, 4. PATIENT I

TIME- f1,07_ NUMBER 5. PREOPERATIVE EMOTIONAL STATUS

U CALM ❑ ANXIOUS ❑ EXCITED. [23 CRYING ❑ ANGRY

COMMENTS: -....._

• WITHDRAWN ill OTHER (Specify)


ASSIGNED SCRUB

-..

PFc etas, :7:7--..,--- .,_._.._. "RELIEF .. SCRUB

---e___ - - --------77"-----.....,

ASSIGNED CIRCULATOR

RELIEF —. ...— . ..

-

...........0 IRCULATOR

. .. . .... . 7. POSITION AND POSITIONAL

ES1 SUPINE

COMMENTS:

AIDS (Specify)

LITHOTOMY

-- - f-, - i

. LATERAL: E UP 0 RIGHT SIDE UP • ■ PRONE • KRASKE• ■ LEFT ,•

8. SKIN PREPARATION

HAIR REMOVAL ki YES

DONE BY: ❑ OR

METHOD: ❑ DEPILATORY

❑ CLIP

COMMENTS:

■ NO .

❑ NURSING UNIT

'Xi RAZOR .

... - .-__. .

--------

, „It PREP SOLUTION (Specify)Be, at SC'- ..-x-, L r) SITE: PNC'!. BY WHO SITE : RA . 1.29 BY WHO

„...,_. COMMENTS: tIC. c;00iisrl Of -FtLa cis

9. LOCATION OF EXTERNAL

•

Pad

DEVICES

. i iat„. iii 42, - _. ,_.4C." -tilliilia1■11-161P-

- ..Sffr,27/,'"'wrillIlrilass) 441,W.,. ' v.-

- Safety Strap = = = Tourniquet.•.•.... ,,,—..,-

-........-- - .

LEGEND X Ground

10. COUNTS

' .... . C = Correct I = Incorrect

Other** First Closing Count .. :iN:.,

Final Closing .Cciiint

- .. .- ..

- SCRUB CIRCULATOR Sponge ❑ Yes go Needle Sharp E Yes go

Instrument ■ Yes Vo . .. - -

_. !....ii;11..T.i - ' :

Other ❑ Yes No 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

* 11111 (_(,,IG -)-- \

MA GAM.. MAI -IA .• -Sr.-.-.- _-__ - --- - _ - -

12. ELECTROSURGERY DEVICE(S) IESU) 0 YES NO

. M. ESU NO:

GROUND PAD:

; .0.1E.60 NO: . ..

BRAND VtLi I e..tj lab

LOT NO: 03 2.15

-- --TGROUND PAD: . . •....-

■ BIPOLAR NO:

BRAND

LOT NO:

5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V .00

MEDCOM - 20407

DOD-033981

ACLU-RDI 1656 p.167


METHOD

liV5CCV

TIME

in 2r P ikett ixs3EcIL_ URE -

T 22. RE

13. PROSTHESIS, IMPLANTS ❑ YES NO IF YES NAME: ID NUMBER; IV FACTURER

;1F,51 .......

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT_BY ANESTHESIA) YES ❑ NO

DOSAGE . TIME' METHOD PREPARED BY GIVEN BY

',; ' - --- ------ - —

rED1CATIONS/SOLUTION

. _ , ... , t; ::

K ;MOUND IRRIGATION

' kg `;OTHER ORDERS

2 YES ❑ NO, TYPEISI:

CARRIED OUT BY

Nom

4)HYSICIAN'S SIGNATURE

-t-

c/o NS TIME

IF YES, SITE .

LABORATORY SPECIMENS

15. X-RAY IN OPERATING ROOM

YES ❑ NO Fel

16.

SPECIMEN IS)

YES ❑ NO ❑

FROZEN SECTION IFS)

YES ❑ NO ❑

NAME NAME

NAME NAME

NAME CULTURE (C)

YES 10

NO ❑ NAME NAME

NAME

RI. 1_9 LOU NAME

NAME

TYPEISIZE

icraputic ca.th

YES tgj

NO ❑

NAME

17. TUBES, DRAINS/PACKING

2.

SITE 3. 2.

[0u3or 13: ADDITIONAL INFORMATION

gritrat'

20. OPERATION(S) PERFORM

D taticn oc rne • 2.P erckAlan eo us .exc ern en1 Sp-pr - --

3. T Ri.Lcci ► uY-d 21. PATIENT TRANSFER ED TO

REVERSE OFD OCT 87

USAPA V1.00

MEDCOM - 20408

DOD-033982

ACLU-RDI 1656 p.168

MEDICAL RECORD 1 INTRAOPERATI"F DOCUMENT For use of this form, see AR 40-407, the propo: gency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERA ;ING .-.00

VIA 4......1 0--v- BY C Pr 2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE

VERIFIED BY /IAA- ,,„)

3. DATE TIME PATIENT ED IN SUITE

24 Sy,. v3 CI-LS— 4. PATIENT IN ROOM

TIME.. I -- 1S NUMBER -2.....

5. PREOPERATI E EMOTIONAL STATUS

Ler-CALM ❑ ANXIOUS • EXCITED . • CR !NG

COMMENTS:

• ANGRY MI WITHDRAWN ❑ OTHER (Specify)

6. N ' -'' 'SONNEL

ASSIGNED SCRUB

S',.5" " - --RELIEF SCRUB

ASSIGNED CIRCULATOR

RELIEF ___CIRCULATOR

. .

_ . _ .... _

7. POSITION AND POSITIONAL AIDS (Specify) ..•.

,....2•111PINE ■ LITHOTOMY ■ PRONE , 111 KRASKE . LATERAL ■ LEFT SIDE UP ■ RIGHT SIDE UP

COMMENTS: Lv..."F+. 0..V14.% 04x 1.4,sb.„,t ...„,k cnk. p.m...10 cl. it i,,,,t 61/44- < to 0 ct.t....t. r .t.. (9((\ Z-

8. SKIN PREPARATION

HAIR REMOVAL 'YES

DONE BY: Es- OR

METHOD: ❑ DEPILATORY

• CLIP

COMMENTS: at. it4„,.,

• NO '

❑ NURSING UNIT

.RAZOR. .

..

PREP SOLUTION (Specify) [..4-4....tihrtre,„, crva 'ttz- SITE: 1921- Alt y BY WHOM: AA.,4.4 SITE: BY WHOM: . ..

6 .cimrvi hwrs: At pa t 4.1 erp_ ..,( 14„4.4- 1 9. LOCATION OF EXTERNAL DEVICES ,....„... - :•-•-• - r".- 7: i::

_ . .. _..

• -,, , ,

'• • - -■■ •••....- 1.....liamm.0110._ -...1111•■■••••.. . - . * Iliriggi)

, . .

Z- LEGEND X Ground Pad -- Safety Strap = = = Tourniquet. --2.:-.--.7:-:- (9( L\ ---

10. COUNTS

C = Correct 1 = Incorrect

Other• First Closing Count ",.1-4..

Final Closing COunt SCRUB CIRCULATOR

Sponge 4ffirYes

Needle Sharp ;:Er-Yes

.0

D Vo

No <....-2''. C.:_. . - -... -..

instrument ❑ Other MI

Yes

Yes

No

No

.. ,z_.:t,::

11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospi al or Medical Facility;)

TAIIIIIMIN(c)-i .

..._ '

'

12.

.---.

. ELECTROSURGERY DEVICE(S) (ESU) YES • NO

ESU NO: SO / 62, 3 /....Ss GROUND PAD: BRAND ( Jett k teetep••

: - ..:t : LOT NO: 4. It 1? .C,- idp 2.oa.,r- :trESIJ NO: I 01 ,._

- -GROUND PAD: BRAND .._-,

LOT NO:

❑ BIPOLAR NO:

REPLACES DA FORM 5179-1 (TEST), DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20409

DOD-033983

ACLU-RDI 1656 p.169

16.

IF YES,•SITE.

--4 :LABORATORY SPECIMENS

15. X-RAY IN OPERATING r YES ❑ NO

NAME CULTURE (C)

YES ❑ NO t7

NAME NAME

NAME NAME NAME


2. 1. TYPESIZE

3. 2. 1. SITE

0- 1.4

PHYSICIAN'S SIGNATURE

SPECIMEN IS)

YES ❑ NO I2K FROZEN SECTION IFS)

YES ❑ NO e

NAME NAME

NAME NAME

NAME

17. TUBES, DRAINS/PACKING YES ❑ NO,Ja-


0.111111, _

00-Ma-)


PA. CAA_ 22. REG NATURE

44.6/ ) OWN -

REVERSE OF DA FORM 51 ,

syo e MEDCOM - 20410


Dr-ercr4y C-44L-c"-f

t", AL- COI

ok-cIty

SZA-7 TIME

( 3 .1-6

METHOD

USAPA V1.00

':OTHER ORDERS CARRIED OUT BY TIME

WOUND IRRIGATION del YES NO; TYPE(S):.

13. PROSTHESIS, IMPLANTS ❑ YES NO IF YES NAME: ID NUMBER; A JF. 'URER

14 ,70-4464.:MOtAiNia&t.titv!UAZgra' M EDI C AT IONS/0 RDERS _ 1,A.123 YE,...12/ NO b IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY ANESTHESIA)

MEDICATIONS/SOLUTION DOSAGE .. TIME" METHOD PREPARED BY GIVEN BY . .

- ' - ---- • . ._ . •

DOD-033984

ACLU-RDI 1656 p.170

. MEDICAL RECORD I INTRAOPERATIvE DOCUMENT

For use of this form, see AR 40-407, the propc agency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATING .100M

i VIA i (+I-tie- BY Cf 2. PATIENT IDENTIFIEU, RECORD REVIEWED AND PROCEDURE VERIFIED BY it( A- )

3. DATE TIME PATIENT ARRIV TE 4. PATIENT IN ROOM

TIME. • NUMBER 7 - 2_ 5. PREOPE iVE EMOTIONAL STATUS

❑ CALM

COMMENTS:

ANXIOUS ❑ CRYI

----- -

WITHDRAWN ■ Ill EXCITED ■ ANGRY ■ OTHER (Specify)

.-- : -- q -.:L


ASSIGNED SCRUB

_5 f c ________ ----RELIEF

. SCRUB

ASSIGNED CIRCULATOR

/)1 RELIEF __...CIRCULATOR .—. ...... .


'SUPINE

COMMENTS: I. fj /..... cri—

AIDS

LITHOTOMY

co,_ ctrirt^...

(Specify) -

..., - -

- •

❑ KRASKE- . LATERAL:

, „ ,,_ c_k_r r.t.... icso,,A,Ac-4-----(1,Lf- el A •-p

■ ■ PRONE III LEFT SIDE UP ■ RIGHT SIDE UP

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11. PATIENT IDENTIFICATI (For typed or written entries give: Name - Last, first, middle; Gr e; Date; Hospital or Medical Facility;)

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REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20411

DOD-033985

ACLU-RDI 1656 p.171

13. PROSTHESIS, IMPLANTS ❑ YES jNO IF YES NAME: ID NUMBER; I■. IFACTURER

.14. :i9gAR30.4VOM;V,-400:4:tatteigge MEDICATIONS/0 RDERS ONA-M:4VAIMMIMIN, ' aZ4,14FON IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT. BY. ANESTHESIA) YES 0 N

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MEDCOM - 20412 USAPA V1.00

DOD-033986

ACLU-RDI 1656 p.172


POST- DAY

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WARD NO.


MEDCOM -20413

DOD-033987

ACLU-RDI 1656 p.173

511-119 NsN 7540-00-634-4124

VITAL SIGNS RECORD MEDICAL RECD HOSPITAL DAY

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VITAL SIGNS RECORDS

Medical Record

STANDARD FORM Sit. (REV. 7-95) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1

MEDCOM - 20414

DOD-033988

ACLU-RDI 1656 p.174

511-119 NSN 7540-00-634-4124

VITAL SIGNS RECORD MEDICAL RECD HOSPITAL DAY

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VITAL SIGNS RECORDS

Medical Record


MEDCOM - 20415

DOD-033989

ACLU-RDI 1656 p.175


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*.g,

STANDARD FORM 511 (REV. 7-95y BACK

MEDCOM - 20416

DOD-033990

ACLU-RDI 1656 p.176

511-119 NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY POST- 17 DAY

IIMMINUMIUMMIFEIMPNIZAIMIIII MONTH-YEAR DAY 19 HOUR • • •0 • - P-. •

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F-A) PATIENTS IDENTIFICATION (For typed or writ entries give: Name—last, first, middle; ID No.

(SSN or other); hospital or medical facility) REGISTER NO. WARD NO.

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM S11 (REV. 7-95) Prescribed by GSA/ICMR, FiRMR (41 CFR) 201-9.202-1

MEDCOM - 20417

DOD-033991

ACLU-RDI 1656 p.177

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY

POST- DAY

aV i 0 4 ; ,-25 1-1,0Lt RC MONTH-YEAR DAY 2'

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



MEDCOM - 20418

DOD-033992

ACLU-RDI 1656 p.178

NSN 7540-00-634-4124 511-119

MEDICAL REC( VITAL SIGNS RECORD

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


VITAL SIGNS RECORDS

Medical Record


MEDCOM - 20419

DOD-033993

ACLU-RDI 1656 p.179

Ward/Section: r r LAJJUKATIJIII .K.Lbui.,1 r("tivit

Sulieet to the Privacy Act of 1974) ■

LAS FIRST

TEST

.-.. (Heins

MI - I

.100

RESULT REF. RANGE

DATE

TEST .RESULT

illig1140124aalltiPAIll

,00 SSN:

..Mise: rology.

TEST RESULT

_ .

REF. RANGE

WBC 4.8-10.8%10' Colot :e \ (-) it j N/A RPR Negative

RJ3C 4.7-6.1 x 109 App ‘ %A-7 ---- MA Mono Negative

Hgb 14-18 g/d1(M) 12-16 'di

Glu Is c_. Negative - . !ikrobiology

Hct 42-52% (M) 1 3747% (F)

Bili . , p._re__

tae- ..---.'d

Negative Source

Negative MCl/

880-1-9949 If11N) Gram Stain

Pit 130-50D x 10' verified

SG 1 1 .0. 1) 1

. NLA. Occ Bld Negative

Lymph 9/0 20.5-51.1% Bid LLD_ 4. dp. .e. Negative H. pylori Negative

(ifettintelligylMannaI Differential , • • pH V 0 N./ ''

N/A Micro Parasites

Segs Mono Prot 1 Negative Malaria

Bands Eos Urob I in ---, 0.2-1.0 0 Si P

Lymph Baso Nit c 11\-:c.L......i.

Negative Other

Atyp imm Leuk C. ji Negative - .Aftcrosciipie Urinalysis r •

RBC Morph

HCG Negative .

PC.- 1 0-2. 0 Aroticl,o..T4 Sedtv .,

6_, „c 4_, -.5-14" ...-5, :S 4 31

-YerAf_A"Cc,' c,e3.--A- ....L.s,,, e cv,„

Spun . Hematocrit

42,52% ( M) 374.7% (E)

. . CSF . . Bulk -..

Sed Rate . ..

Cell Count 1

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigeri Negative ABO/Rh

. • '.- • • . .., Blood Rank Unit Crossmatch . . :: . .

• (MUST . SUBMIT SF 518 WITH EVERY UNIT OF.B1.„00b. .= Coagulation "Studies:

ZEST RESULT 1 REF. RANGE &WIT TYPE 1 CROSSMATCH

PT 9.8-13.6 sees 1

AN'T'I' : 21-34 secs .

D dimer ; <20 ug/m)

FDP I <10 ug/m1

MEDCOM - 20420

DOD-033994

ACLU-RDI 1656 p.180

•

Ward/Se.ction:.----_ /A..14— REQ ' - SICI'AN: LABORATORY RESULT FORM Sulieet to the Privac ' Act of 1974

L . DATE Zr flej-53

TIME - i/d/0

SS • — . t9(6) '

- . : m 01.00..93c....i.ii-. ..- .001314 -.• -: ':?- - - -, .4 : -. ,.... TEST • • • P. RAN GE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color - N/A RPR. • Negative

RBC 4.7-6.1 x le API) N/A Mono Negative

Hgb 14-18 g/dt (M) Glu 12-16 g/d1 (F)

Negative -11 . . . - . Microbiology ..

Source 1i s Het 42-52% (M) . 37-47% (F)

Bili - -

Negative

MCV 80-94 fl (M) 81-99 tl (F)

Ket Negative Grim Stain

•

Plt 130:500 x10' verified

SG 'NIA Occ Bid Negative

Lymph % :, 20.5-51.1% • Bld Negative H. pylori Negative

....:. (Iligia#44Anousqpinc,renti -,.. pH WA . Micro Parasites

Segs Mono Prot Negative Malaria

Bands . Eos Urob 0.2-1.0 0 & P

Lymph Baso - Nit Negative Other

Atyp Imm Leuk Negative -s • - ::IVlicinscoPiC Urinalysis

RBC Morph

HCG Negative •

Spun Hematocrit -

42-52% (M) 37z47.4 (F)

CSF , .. : , . . BloOd.B24 ''.

Sed Rate Li 1 f

Cell MUST SUBMIT SF 518 W1T11 EVERY UNIT REQUESTED

Other Direetigen Negative ABO/Rh I

h-7-77.77.Ciagubiti0it-Studies: - - ' — ' • ..• — •

UNIT

• (MUST stfoitr 1964134ik Iiiiittiliisin'atili..'.......: . ...': SF:518.1;501i EVERY

TYPE

-.. .. . . -. um-17 (4..490 .

CROSS MATCH TEST RESULT REF. RANGE • 9.1143.6 secs

21-34 secs

D dimer <20 ug/mi :

PDP <10 ug/mi

REMARKS:

REPORTED BY: DATE:

51—Z r: g'S

LAB ID NO.: S -- - •

MEDCOM - 20421

DOD-033995

ACLU-RDI 1656 p.181

LAST, FIRST, ML

.v1:i144,t; TEST • RESULT

1111-14.4 rnrnnl/T

REF. RANG .E •

riuuuLu

25/09/03 j4 11 REFERENCE RANGE: L MALE PATIENT #: III, LIVER PANEL PLUS DISC LOT #: 3154AA7 OPER #41iii DR #: 000 SERIAL #:

ALB 3.6 3.3-5.5 G/DL ALP 65 26-84 U/L ALT <5* 10-47 U/L AMY 47 14-97 U/L AST 33 11-38 U/L TBIL 0.7 0.2-1.6 MG/DL GGT 16 5-65 U/L TP 7.1 6.4-8.1 G/DL

INST OC: OK CHEM OC: OK HEM 0 1 LIP 0 , ICT 0

DATE TIME SSN/PSEUDO SSN:

TEST RESULT REF. RANGE

TEST RESUET REF. RANGE

AT

R 09/25/03

A PATIENT T METLYTE

B DISC OPER

C SERIAL

C GLU

C BUN CRE CK NA+ K+ CL- tCO2

C INST HEM

C

A 1--)..--- !1:LO

REFERENCE R COI,

8 LOT #: #: EN

#:

95 7

0.5* 614* 136 3.9 104 19

OC: OK 0 ) LIP

===-7 === 12:08

3E: MALE

•3141AA4 DR #: 000

73-118 MG/DL 7-22 MG/DL 0.6-1.2 MG/DL 39-380 U/L 128-145 MMOVL 3.3-4.7 MMOVL 98-108 MMOVL 18-33 MMOVL

CHEM OC: 1+, ICT 0

73-118 mg/dl

7-22 inedl

PM 8.0-10.3 mg/dl

7 '

0.6-1.2 Tog/d1

128-145 reano1/1

33-4.7 cono1/1

98-108 mmol/1

)2 18-33 minol/I

us

?ST RES UT REF. RANGE

B 3.3-5.5 g/d1

P 26-84 &I

r 10 -47u4

1Y 14-97 u/1

OK 11-38 u/1

IL 0.2:1.6 mg/d1

5-65 u/1

6.4411 g/d1

#0


Ward/Section: REQUESTING PHYSICIAN:

EST RESULT REF. RANGE

128-145 mmol/1

3.3-4.7 mmol/1

98-108 nunolll

18-33 mmolA

) I REMARKS:

LAB ID NO.: REPORTED BY:

DATE:

MEDCOM - 20422

DOD-033996

ACLU-RDI 1656 p.182

:1 711 7

1::V 92.13

2,5 51.1 L')

RAP1Orlhh, :diUittR 14

SERIAL ,d/n/ni 11/ 10:

Patient 10: lest Name : Test Result:- 12. sec. ***MOLT NOT RANGE "NECKED*** Ratio = 1.0 Cflculated INR -= 1.03 ample Type:citrated wh. l lucid

lEriA Date :09/25/03 test Time :02907 PM Card tot :010301 . • Operator millp

RA DPOIN1 WAG ANAL? -R V4.54

-RIAL 09' 3/03 02:11 PM

Patient ID:11111, Test Name :APTT Test Result:- 31.6 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/25/03 Test Time :02:08 PM Card Lot :100208 Operator OM

MEDCOM - 20423

DOD-033997

ACLU-RDI 1656 p.183

4

MEDCOM - 20424

3 0• 2), O

n) n)

CD Q.

CD

SO.

:aw

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SJ{

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r:

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0

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r c• 0

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CD

Cl) 3 CD O

DOD-033998

ACLU-RDI 1656 p.184

2 P. aeruginosa gig,

MIC Amox/K Clay (c) >16/8 Amp/Sulbactam (c) >16/8 Ampicillin >16 Aztreonam <=8 S Cefazolin >16 Cefepime <=8 S Cefotaxime (c) 32 I Cefotetan >32 Cefoxitin >16 Ceftazidime (a) <=8 S Ceftriaxone (c) >32 R Cefuroxime (b) >16 Cephalothin >16 Chloramphenicol >16 Ciprofloxacin <=1 S ESBL-a Scrn >4 ESBL-b Scrn <=1 Gentamicin <=4 S Imipenem (c) <=4 S Levofloxacin <=2 S Meropenem (c) <=4 S Nitrofurantoin >64 Norfloxacin <=4 Pip/Tazo (d) <=16 S Piperacillin (a) <=16 S Tetracycline >8 Ticar/K Clay (a) 64 S Tobramycin <=4 S Trimeth/Sulfa >2/38

Interps

c6 *-7, Microbiology Report

Specimen: Status: Fina! Source: Wound/Sterile site Collected: Ward of [so: Attd. Phys:

Status: Final

Status: Final

Name: Patient ID: In Ward/Rm: W1/

1 2

Proteus penneri

Pseudomonas aeruginosa

1 P. penneri a-1.21 MIC Intel-Rs Amox/K Clay (c) >16/8 R Amp/Sulbactam (c) 16/8 I

Ampicillin >16 R

Aztreonam >16 R

Cefazolin >16 R

Cefepime >16 R Cefotaxime (c) >32 R

Cefotetan >32 R Cefoxitin >16 R Ceftazidime (a) >16 R Ceftriaxone (c) >32 R Cefuroxime (b) >16 R

Cephalothin >16 R Chloramphenicof <=8 S

Ciprofloxacin >2 R

ESBL-a Scrn >4

ESBL-b Scrn >1

Gatifloxacin <=2 S

Gentamicin >8 R

Imipenem (c) >8 R

Levofloxacin 4

Meropenem (c) >8 R

Moxifloxacin <=2 S

Nitrofurantoin <=32

Norfloxacin >8

Pip/Tazo (d) >64 R

Piperacillin (a) >64 R

Tetracycline >8 R

Ticar/K Clay (a) >64 R Tobramycin >8 R

Trimeth/Sulfa >2/38 R

5 = Susceptible _ ________ __________

= Inteunediate MR r= Not Reported ______

R = Resistance — = Not Tested Blank = Data not available, or drug not advisable or tested MIC = mcg/m1(mg/1.) TFG = Thymidine-dependent strain ESBL = Extended spectrum bete-lactamase

Bloc = Beta-lactamase positive Fe

= Resistant due to extended spectrum beta-lactamases (ESBL)

EBL? = Suspected ESBL. Confirmatory tests needed to differentiate Eat!, from other beta-lactamases. 10

= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible bola-tactamases, potentially they may become resistant to all beta-lactam drugs. Monitoring of patients during/afler therapy is recommended. Avoid other/

possess

beta•laciam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in

patients with granulocytopenia or serious Infections. (h) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=L >16=R). Footnote (c) applies to this drug. (c) For streptococci refer

to penicillin interpretations. For arnoxicillin/K clavulanate or arnpioillirVsulbactem with enterococci, refer to the penicillin interpretation.

(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

For S. pneumoniee. cefotardme end ceftriaxone breakpoints are basad on isolates from patie

Interpretive breakpoints are based on NCCLS M100-512 Jan 2002. Sparfloxacin (for Grant Negative isolates) and moxilloxacin are based on FDA approved breakpoints. Name:

Specimen: _.______ _____ _____ __...___ ..

____ _________ itis. For non-meningitis infections, use < 2=S, 2=1, >2.R. Patient ID: Met (.9(L)-1 Source: Wound/Sterile site Status: Final Ward/Rm: W1/

f-------- Collected: --------- --- --- — Ward of Iso:

— ------- Req. Phys: IIMIIIIR Printed 10/2/2003 9:56:38 AM

Page 1 of 1 Tech: Cb-)((1----(---

MEDCOM - 20425

DOD-033999

ACLU-RDI 1656 p.185

MEDCOM - 20426

•■•• 0 0 12". 0 0 CQ

CD

CD cn

O

3

C 3 0-

0 - $1

n) n) C)

(4

CD O.

CD CD Eil . .

DOD-034000

ACLU-RDI 1656 p.186

Interps R

R

R

R

R R R

R R R

R R S R

S R R

R S

R R R R R R

Status: Collected: Req. Phys:

Tech:

?,)

Microbiolo Re • o

Name:

Patient ID: al (s> (b) Ward/Rm: W1/

Specimen:

Source: Wound/Sterile site Ward of iso:

Status: Final Collected:

Attd. Phys:

1 Proteus penneri 2 Pseudomonas aeruginosa

Status: Final

Status: Final

1 P. penneri Drug MIC Amox/K Clay (c)

>16/8 Amp/Sulbactam (c)

16/8 Ampicillin >16 Aztreonam >16 Cefazolin >16 Cefepime >16 Cefotaxime (c) >32 Cefotetan >32 Cefoxitin >16 Ceftazidime (a) >16 Ceftriaxone (c)

>32 Cefuroxime (b) >16 Cephalothin >16 Chloramphenicol <=8 Ciprofloxacin >2 ESBL-a Scm >4 ESBL-b Scrn >1 Gatifloxacin <=2 Gentamicin >8 Imipenem (c) >8 Leyoftoxacin 4 Meropenem (c)

>8 Moxifloxacin <=2 Nitrofurantoin <=32 Norfloxacin >8 Pip/Tazo (d) >64 Piperacillin (a) >64 Tetracycline >8 Ticar/K Clay (a) >64 Tobramycin >8 Trimeth/Sulfa >2/38

2 P. aeruginosa Drug MIC Amox/K Clay (c) >16/8 Amp/Sulbactam (c) >16/8 Ampicillin >16 Aztreonam <=8 S Cefazolin >16 Cefepime <=8 S Cefotaxime (c) 32 Cefotetan >32 Cefoxitin >16 Ceftazidime (a) <=8 S Ceftriaxone (c) >32 R Cefuroxime (b) >16 Cephalothin >16 Chloramphenicol >16 Ciprofloxacin <=1 S ESBL-a Scm >4 ESBL-b Scm <=1 Gentamicin <=4 S Imipenem (c) <=4 S Levofloxacin <=2 S Meropenem (c) <=4 S Nitrofurantoin >64 Norfloxacin <=4 Pip/Tazo (d) <=16 S Piperacillin (a) <=16 S Tetracycline >8 Ticar/K Clay (a) 64 S Tobramycin <=4 S Trimeth/Sulfa >2/38

Interps

For blood and CSF Isolates, a beta-lactamase test is recommended for Enteromccus species.

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections (b)Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, >16.M. Footnote (c) applies to

this dr (c)For streptococci refer to penicillin interpretations. For amoxicillln/K clavulanale or ampicillintsulbectam with enterococci, refer (d)For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxiftoxacin are For S. pneumoniae, cefotaxime and . ceftriaxone breakpoints are based on Isolates from patie nts . For non-meningrtis

Ward of Iso:

MEDCOM - 20427

Name: Specimen:

Patient ID: (_,)((,,I Source: Wound/Sterile site Ward/Roo: W1/

Printed 10/2/2003 9:56:38 AM Page 1 of 1

6

R' = Resistant due to extended spectrum beta-lactamases (ESBL)

EEL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL other other beta-lactamases. A

IB = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible bet

gl apy is recommended. a-lactamases; potentially they may become resistant to all beta-lactam drugs. Monitoring of patients Burin after they Avoid other/combined beta-lactam drugs.

S = Susceptible N/R = Not Reported I = Intermediate — = Not Tested Blank = Data not available, or drug not advisable or tasted R .. Resistance

ESBL = Extended spectrum beta-lactamase Thymidine-dependent strain Bloc = Bele-la

MIC = mcg/ml (mg/I) TFG =

ctamase positive 3 ...... c; ej ,,I9t, A r j730 ,ib 1 t) C60

Ze5p I V 7M

ug.

to the penicillin interpretation.

based on FDA approved breakpoints. infections, use <2=S, 2=1, >2=R.

DOD-034001

ACLU-RDI 1656 p.187

0 O CD

CD 0_ 0-

/

:aw

eN 1

siu

:aw

eN Tse

l

E 5. O C. 5 0

f.C2

7) CD 12 C CD Cl)

-n O g

03 CD P-

X 0 0 3

I.M01

:13

-leM

MEDCOM - 20428

DOD-034002 ACLU-RDI 1656 p.188

2

_ _ qat

Microbiology Re ort Name:

_ ____ _______

Patient ID: fl C4()/ Sou

..)-1 rce:

pecime : VVard/Rm:_ W1/

Wound/Sterile site __ 1/4/ard of lso:

Proteus penneri _

Status: Final Pseudomonas aeruginosa

___.___.____ Status: Final

Status: Fula' Collected: Attd. Phys:

I P. penneri D- -ug

MIC liAel-p_s_ P. aeruginosa 2

Amox/X Clay (c) >16/8 R MIC . _DI L. gi Amp/Sulbactam (c) 16/8

Ampicillin 1 Amox/K Clay (c) >16/8 >16/8

>16 R Amp/Sulbactam (c) Aztreonam >16 R >16

Ampicillin - Cefazolin >16

R S

Aztreonam Cefepime >16 R >16

<=8 Cefazolin Cefotaxime (c) >32

S Cefepime Cefotetan

>32 R <=8 R

I Cefotaxime (c) 32 Cefoxitin

>16 R >32 Cefotetan Ceftazidime (a) >16 R >16 Cefoxitin Ceftriaxone (c) >32 R Ceftazidime (a)

>16 C S <=8 Cefuroxime (b)

R R

eftriaxone (c) >32 Cephalothin >16 R Cefuroxime (b) >16 Chloramphenicol <=8

S >16 Cephalothin Ciprofloxacin

>16 ESBL-b Sc

Chlorampherticol ESBL-a Scrn >2

R >4

S Ciprofloxacin m

SBL-a Sc >1 >4 <=1 E m G a t i fl o xa c i n

<=2 S <=1

ESBL-b Scm Gentamicin >8

R Gentamicin S

4

imipenem (c) >8 Imipenem (c)

<=4 Leyofloxacin

Not Tes

_

I S ,-...-

Levoffoxacin Meropenem (c) >8 R

S

<=2 M <=4 Moxifloxacin <=.2

S >

eropenem (c)

84 Nitrofurantoin Nitrofurantoin

<=4 PID/Tazo (d)

>64 R Piperacillin (a)

Norfloxacin <=32 Norfloxacin

>8 Pip/

S Tazo (d)

S <=16

<=16 PiPeracillin (a) >64 R >8 >

R

Tetracycline Tetracycline 8

S Ticar/K Clay (a) 64 Ticar/K Clay (a) >64 R

S Tobramycin

Trimeth/Sulfa >8

Tobramycin R

>2/38

<=.4 Trimeth/Sulfa

>2/38---____ S = Susceptible

INI/R = Not Reported

_

R ______ ______ r = Intenroediale

— a ted Bl

rug not advisable or tested

R = Resistance

TF0 = Thymidine-dependent strain ESBL = Extended spectrum

not

-- ----- --- --- --- MIC = mcvmr frivii.)

auk = Data not available. or d

Mac ,,. Beta-laciamase positive

Fe = Resistant due to extended spectrum

Mac

(ESBL) al.? = Suspected ESBL.

Confirma tory tests needed to dfferentiate ESBL from other beta-lactarna ses.

IB = Inducible Bete-lactamase. Appears in place of Se i

nsitive with species known to possess inducible beta-lactamases: potentially theyma y become resistant to all beta-lectern drugs.

Monitoring of patients during/after therapy is recOmmended. Avoid other/

possess

bola-lactam drugs. For blond and CSF Isolates.

a beta-/actamase lest is recommended for Enterococcus species. (E0 Use commended

doses of drug with an aminoglycoside fora P. aerugfnosa in patients with granulocytopenia or serious infections.

(b) Breakpoints based on parenteral dose. For cefuroxime xetil (P0)

use WS. 8-16=L =16=RJ. Footnote (c) applies to this drug.

(c) For streptococci refer to penicillin interpretatio ns . For

niK davulanale or ampicillinisubactam with enterococci. refer to the penicillin interpretation.

id) For non beta-ractarnase producing enterococci, refer to

arnoxicifli

the peniciliin interpretation. Footnote (a) also applies to this drug For S. F0eurrtoniae. cektaxime n

ffriaxone breakpoints are based on isolates from patie

IrderPrative break are basedadd ce

on NCCLS M100-S12 Jan 200Z Sparfloxecin (for Gram Negative isolates) and moxillo '

based on FDA approved breakpoints. Patient ID : III. (12,40_4

Name: ..______

Source: Wound/Sterile site

Specimen: gilts.

__

Status: Frn a I Itt 1-..'—'-':•---

gilts. For non-meningitis infections. use ,c2=S, =L .2=R. Ward/fpm ;

mu ___:_ j___ I_ I______ Ward of Iso: ______ _ Req. Phys:

Collected: Printed 10/5/2003 1 0:0.4:45 AM

Page 1 of 1 -tech:

MEDCOM - 20429

lutes

DOD-034003

ACLU-RDI 1656 p.189

Name7 ----------- (41) - ---

_ _______________ ____..___

Patient IDAIIII Specimen: by- ).___ Source: Status: Final

Ward/Rm: W1/UI-C

Ward of !so: Collected: 'Wound/Sterile site _____

_ __________ Attd. Phys: _

1 Proteus penneri 2

Status: Final Pseudomonas aeruginosa ___________________________

Status: Final

1 P. penneri ___________________ ______

Drug NC Interns P. aeruginosa

2 Amox/K Clay (c)

twerps

r_a_gj

Ampicillin Amp/Sulbactam (c)

>16/8 R D

>16 16/8

R I

Amp/Sulbactam (c) >16/8

MIC Amox/K Clay (c) >16/8

Aztreonam >16

R >16

Ampicillin Cefazolin

S 32 Cefepime

Cefepime >16 R Aztreonam

16 R >

>16 Cefotetan

Cefazolin <=8

Cefotaxime (c) > R =8

S >32 R Cefotaxime (c) 32 • I

< Cefoxitin

>16 R >32

Cefotetan Ceftazidime (a) >16 R Cefoxitin >16 Ceftriaxone (c) >32 R Ceftazidime (a)

S <=8 Cefuroxime (b) >16 R

R Cefuroxime (b) >

Ceftriaxone (c) >32 Cephalothin >16 R

16 Chloramphenicol <=8 S--- >16

Cephalothin Ciprofloxacin >2 R

>16 Chloramphenicol ESBL-a Scm

S Ciprofloxacin

>1 ES - ESBL-b Scm

>4 Cipro

>4

<=2

<=1 131..-a Scm Gatifloxacin <=

0 , ,..e

<=1 ESBL-b Scrn

>8 G Gentamicin in

R <=4

Levofloxacin S Gentamicin Imipenem >8

R S

lmipenem (c) 4

I ---- S

<=4 Leyofloxacin Meropenem (c) >8 R Meropenem (c)

S

<=2 <=4 Moxifloxacin

<=2

Se' >64 Nitrofurantoin Nitrofurantoin

Norfloxacin <=32 Norfloxacin >8 Pip/Tazo (d)

<=4 Pip/Tazo (d)

>64 R Piperacillin (a) S-, <=15

Piperacillin (a) >64 Tetracycline etracycline

<=16 S Tetracycline >8 R 64

S Ticar/K Clay (a)

>8 Ticar/K Clay (a) >64 R Tobramycin

<=4 Tobramycin

>8 Trimeth/Sulfa S •---- >2/38

R >2/38

Trimeth/Sulfa • R

------- S = Susceptible — --- —

N/R = Not Reported —

— -----

AMC = mcg/ml(mg/L) — —------

I = intermediate

= Not Tested Blank = Data not available. or drug not advisable or tested

-- R = ReSistence

TFG = Thymidine-dependent strain ESBL = Extended spectrum bele-lactamase

EBL? Bloc = Beta-lactamase positive

IB

R* = Resistant due to extended spectrum beta-lactamases (ESBL)

= Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-laaamases.

g of patients during/after therapy is recommended. A

= Inducible Eteta-lactarnase. Monitorin Appears in piece of Sensitive

with species known to possess inducible bela-lactamases void olher/cmb

potentially they may become resistant to all beta-lactam drugs. i For blood and CSF isolates,

a beta-tactamase test is recommended for Enterococcus species. (a)

Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenie or serious infeciions. (b)

Breakpoints based on parenteral dose. For cefuroxime axetil (F0) use WS, a-16=1, >16=R). Fo lbs otn

aote (c) applies to this drug.

(c) For

streptococci refer to penicillin interpretations. For ammicillin/K ciavu/anate or arrpicillin/sUctm with

enterococci, refer to the penicillin interpretation.

(el) For non beta-factarnase producing enter refer

to the penicillin Interpretation. Footnote (a) also appiies to this drug. For S. pneumoniae, cefotaxime 'axone

breakpoints am based on isolates from patie

Interpretive breakpoints are based on NCCLS M100-S12

Jan 2002 S a b

(for Gram Negative isolates) and motato ' are based on FDA approved breakpoints.

_ . __

Name:

Specimen: rigifis. For

non-meningitis infections , use <2=S, 2=1 >2=R. _ Patient ID:

('')(q-1 Source: Status: -F-inal

VVard/Rm: 1/

Collected: ('9 'tinted 10/11/2003 1 0:20:26 AM ( 9 --(-

Wouncl/Sterile site __

_Ward of lso:_______ _________ ._ Req. Phys:411111111111111_

• Page 1 of 1 _ _

Tech:

Microbiolo Report

MEDCOM - 20430

DOD-034004

ACLU-RDI 1656 p.190

VOLAT AGENT

OK for PROCEDURE?

nIAE-

PATIENT I DENTIFICA ON- P.do' *neon ynkies: Mime. Coliek/Raro. Macke hiclay

DRUG (Unite) MEDICAL RECORD ANESTHESIA

TOTAL URINE

COLLOID-. 02 L/Min

z SINGLE DOSE DRUGS -MARK ON ORI < WITH NUMBERS &ENTER IN REMARKS

o Wamod Wormed

1:1 Warrrad

Warned

REMARKS- Coda rings with numbers. dwent.t with hiders

er / got -or -4tc-74

BP by cuff

• V

A

P/Auto Cu BP / oth ART line

.a.a.:::ii::::::„.:: 11111MISSIE

?i,::: *id i i • ,

MINI lina M

1 nifffln IIHN Arkififfif vaMilliii

lamoNIMIIIMI Mir INHAIVAr A : ; INA

W10:7,011 : : IIMI i

NM- 1:::::

■ ti:::P:: :::::,r-i:;;V:' :::-,• , i:'I::::: :::::::;:

/11 BIM i aa M vairdritonalummirasamavr::.,, sammai mommemni.summassosam :::::::::::,::.:::: snessemas inimmunimimmianne mmisr)..7. ismaryiu.„1„,proa, .I A.., 2.144Artanzauraw_m_____II___

ssISt on jamigunrumor !. E C ,VE RY AT

E CO2 (tory)

Heart rate

•

Resp rate

BP

transduced)

TOURNIQUET

T —/ All ES- X-X

PROC-0-0

120

100

80

60

Al /04-e4,1

PACU IOU (SP0c1,11

ONDfflort: P. site

-M Block TM

Ing blect

. .....

art Room End

Cony warmer qr03 8 a_ ((gq- I.I çL 7/3"- re

AKEsTHET1C TECHNIQUES:0°4°1h* Nock Mc/vague unad, Ronwrks64-mAlgee

Ready Begin End

ANESTHEll

(461-Z. W AM

PATIENT RECORD OP 376 REVISED

1 Jan 99


PROCEDURE Oft LOCATION

MEDCOM - 20431

DOD-034005

ACLU-RDI 1656 p.191

TOTAL URINE

goO

0

0 z 4

z 11)

4 (-)

w x I-

ui z 4

U) 0

-J

:

•

lEtt 3 4 5 E

BP

HR- 3 0

OK Par PROCEDURE?


PATIENT IDENTIFICATION- TYPed entiss: AHme. Credo/Rae. Acay

376 REVISED 1 Jan 99

SURGEONS:

r.""231-ima

PATIENT RECORD

MEDCOM - 20432

PROCEDURE LOCATION

E

Octd 3 PAGE OF /

g g Ft; 24,

II-

DRUG (Unite) MEDICAL RECORD ANESTHESIA TOTALS

111 0

jo

U

FL IDS - SUMMARY CRYSTALLOID- y 00

COLLOID- I

SINOLE DOSE ORUOS - MARK ON 0/9. WITH NUMBERS RENTER IN REPAARKS

BLOO

RE

ARKS-

Warned Coda drugs with numbers. twordi

with Soffera ri Warned

LOSSES OC)

EST BLOOD LOSS URINE—

PH YS STATUS TIME 3° • LOD° 1 10D

R- && IAN,Lcal SY MROLS:

220 BP by cuff

V

A Heart rate

•

Resp rate

BP (transduced)

TOURNIQUET

T

ARES— X-X pRoc-0-0

200

180

160

DOM Mill irk 1111MINOMMMIliP

t-z)

> cimo

ni,f)

120

cjc Lk.

c_The

100

80

60

20

RECOVERS' AT', . .

NP/Auto Cu

I ART line ,!' 4 •

Com"

i. g Gas analyzer p

I ..• L4

‘,1 warmer

I Si

._-""imm,---"41111110111 111111•11111

qr; 8 tc

0? 1/4tZ 074 eL AN:=STH ETC TECHNIQUES:DmeritoNo4k lechniru• undw Rom.14

End

/ 01 • •

9' VC1 AIRWAY MANAGEMENT: route. Weds, technique. conwpont• c46. 1-as

LON

MarA with /offers Jymbols. EvEN Ts uncia REM4RKS Position —•

DOD-034006

ACLU-RDI 1656 p.192

TOTALS

1.111 /Cc/ !LW.

MIMI"

min BLOOD-

So

CRYST LOtp-

COLLOID-

DRU Minks) essmarsenraommio wArawrimmimm itermaimmitiN wagnimerilli

=PAM MUM INNOMIIIIIIIIMINNIMila INIMMINECIMIIIIMI 1.1.1•11111M1

M Mil IMEENCWANINTIMMI

.1.0111111 N20 L/Min 02 L/Min

SINGLE DOSS DRUGS-MARK ON GRID I WITH NUMBERS II ENTER IN REMARKS

;tot ❑ Warmed

❑ Warmed

EST BLOOD LOS

UR NE -

td 100 I ---

ErvirAgnicinworammumnrisu winimaistraiircrmannol

111•1111111101

GO HR-

EQUIKC

OK?.

PATIENT:11E0E0K

PROCEDURP-A OK for

TIME-

BR Gransducedl

TOURNIQUET

T -1' 14111ILLWAYAIEWAPIGEMS11.11.

MIN 119111Iiiiiililie=

NMI

IMAIPEORMIUM 1 1/14111M111111MIUMIFAI

/501112011111111 EINIMINIILV•1011111111

T CO2 (torr) ravamirawaskao KF1021Frac or %) nr10110111111MIIMMI fl Sp02 .1%1 wareasurammurzeal NMEIMIIIIKAIIIKAIrfAIMIET/N1 GGMZMITIV!/hNEPMP-MIMIIII

11111KWIE MINE/LIM IMMIIIIN IIVIIIPOMIIIIMIll

-M Block IT/41

ANES-PROC.0.0

VT-ml

1 gimi YVE10

B

lgt) . BP-

TIME YMBOES:t 220

BP by cull

V 200

A Heart rate

•

Reap rate 140

120

MIN

80

60

40

20

!Auto Cuff BP/oth

ART line

Steth- PC/ES

cv rU

cc 0

Warming blkt Cony warmer

I

I Gas analyzer

f - breaths/min

Peak MI Pres / PEEP

MODE - SI .onl, Alas1st). Min)

180

160

tcu

Alikr (.4) DA FORM 7389, FEB 1998

ii CFI`

r--2F1P WI

(6— 51-50 PATIENT IDEN C NT Ty tld or written entrie

Medical facility

PROCEDURES anC odes:

me, Gra /Rate,

10 ((i)14-- 14 6 1051 OTAC-344L z9 o13 MEDICAL. RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG

Code drugs with numbers. events wit #eUtg a z/

C WC;6 1

CPZ, .571/

I®Cxt Lrrs

IA:61t: 1'1-L(5G-11-if

f-5,twet-, moil •

5 gig,

5C-g- 4v1

liar

CONDITION:514 it

S15021 CV BP- t HR-

to Sten Room End z Q

yfY LI site

❑ Warmed

174) 1,7(751

Mark wife halms b symbols, EVENTS..._,. explain under REMARKS Position ”"

Reedy End

53k aa ANESTHETIC TECHNIQUES: Describe block technique under Remarks

60"it AIRWAY,MAtiGMENT: intonation rout blade, tec.71)".ue6e,com entE i

7"' I 6 01 3 , ... 7, 0 r SU •

'7'2 0—• "Fr.r-41a1.? t)VP7(.6-^,1 PROCEDURE fir ---, LOCATION: I--/' -- C—

DATE:

z_oc/ . t-c/_,r PAGE /

COPY 1 - PATIENT'S MEDICAL RECORD

OF /

USAPI V 1.00

tea

MEDCOM - 20433

DOD-034007

ACLU-RDI 1656 p.193

16 UMW

1a-0 PATIENT MEN ar mean enfries: Giodelts*

fixity N-

SURGEONS: PROCEDURE Az

LOCATION

DATE

INDICA!. ECORD ANSSINeSIA

OP 376 REVISED J 99

PAGE OF Jan

.u.s. GPO: 2002-729.180/40137 MEDCOM - 20434

FP, :,wFMIgno ME . ICAL RECORD ANESTHESIA TOTALS IMP.51•111Mmr4L-wwlElmolimummominnimmmlil MMAEI KawrimiwP.mr:pawAmmnimim......____._____........m.m avaimmump I

COLLOID-

BLOOD-

▪ Wormed O Warns,*

O Warmed - ElAlernud

EST BLOOD LOSS URINE —

BP by cuff

V

A Heart rate

•

Reap rate

220

200

180

160

140

120


EMI MEI kEnaliEMEVESSEEEK=Mil

gesslitg Waninanninta Migin animostatmamsetsmosamens rsinnomumn

MEI ENSMEMINOWASEEN ,i.i;;;EREEMENSISSEINUMEEE MIME IMRE lEIMIERII Env Earannn Row INVEINMEPESIMI 11110111•101111111111MINEMINEMINI Eta REEKIREMEENEEEENEES EMMEN IENTAMIFWV11771:11IMINII 11=111=111 MINSIMAI IME MIUMMEn::::m. mon= MEN NM memummorriprim()36 sorgormannewasunims am nun In■mmrp#01.11

111111m5yrninii

wv.2 ..11'"-IM74rr71 l. 10th I ART line

WPM)

- UIiU

1r321=- MrilmoullEVITW MIrilimenimmimmummemomml

man cfi36 oci .0 0 EVENTS

End aepben undtr REMARKS position ___64

110

ARaisTHETIC TECHNIQUES:poser/be block tochniqua undir

REC:r, ..'cRY AT

AIRWAY paANAGEmENT; mintAhly_

hi** gwehniqu4 efirn FM( ° (

Ctet1.-'

15)0 . 4111111 gor-1

DOD-034008

ACLU-RDI 1656 p.194

- A-2 )4.- 6 -cy Y.,"2 MEDICAL RECORD - ANESTHESIA


VI

,g cc 0 0 Z et u) ,_ 2 iu C, „.„. -"" ° ._- W,

IF co) w Z ct

en

g - ' z .- -8,7,0 e, 2,?, i- 0 z ilt, , EL- • E c t LO 4

I-1- V) 2 In D D Z o o DLO z _ ii 1.7. 1.) . zttir

8°

DRUG ( Units) TOTALS TOTAL EBL

A-44 _AI I

/Lit ...R,' AD TOTAL URINE CWIrilyillf witseidroz-,/ r la rher maim

1.11 © (0 VOLA?

AGENT del d FLUIDS-SUMMARY

% e - t. CRYSTALLOID- AIR IJMin N20 L/Min CCI-LR) ,..1D-

81.00 P;r19.7. 02 L/Min

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

),01

G _, LL

LINE sit ❑ Warmed REMARKS D Warmed Codedrugs with numbers.

events with tethers

fin P (Ai

KW, — MOV

-e f( pia 54E7-1,

414, ,11 - OZ-

mat 10 ttity4A

6497— rl

(/e/t1

RECOVERY AT

D Warmed

D Warmed

LOSSES EST BLOOD LOSS URINE -

PHYS STATUS TIME *05 14 6 1 3 4 5 E

SYMBOLS: 4

--.1.-1 _I_

MI BODY WEIGHT: 220

200

180

160

140

120

10 '

80

60

.

2

' MN. MEM • 0

CE0 LB

BP by cuff

A Heart rate

0

Reap rate

BR (transduced)

+ TOURNIQUET

T —.41.

ANEs_ x_x PROC-®_0

= o t

' t 1 ---ra

HEMATOCR : JT , . , rr...„.....,....,,, . I

: 1 I

I I TIAL DATA: • t

BP-

Mill 11/111111111/ 111 A " .

R -

g-

FAME

1111=

ratingiriwir 11Z1b0110,'

IMMILEMWAY 1111111EMMIEW/111

Ititralial

IIPME

0 ' .

FrjrA .

„ .

EQUIP CHECK CHECK ... : o K 7- erg PATIENT RECHECK

—1-1— _1_1_ I !

' , ' ,

. . . , , , :__,_ OK for PROCEDURE?

TIME

, , . ,

i • •ii •r•- ,

VT-mi tg001 $( 0 ri:

f • breaths/min ‘ Lu Peak Int pres / PEEP . laPlar-

effi LT ,--,-----

. 'DE - S(,on) • ssist), Clon) 11

tn uz

0 u) tO

P/Auto Cuff B P /oth

RA T line

r CO2 (torrl r IO2 (Prat or %TVA,

1 02 CYO

'

40 la

UN

0. i

i I

DE

p

0 i - ..4 41 g P Sper.1/0

OTHER

SI teth- PC/ES CG CONDITION: af=1L-:.4 ui Gas analyzer P-site

rirm Block (T/4) i X, ME

..e. RESP- 402- t BP.

ANESTHESIA / PRO d- i EDU E E TIMES

O I ll = .

0 1 1= . tn Start Room End

g 'Warming blkt .2 Ffilifflir Y?5---- Z Cony Warmer .1:2131231 End Mark with letters & symbols, EVENTS_, explain sender REMARKS Position - a 'Fa la,

PROCEDURES

h

and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Rema

?) X era Gi ---AQ5k.,

ks

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWAY MANAGEMENT: lntubation route, blade, technique, comments Medical facility ittask. c t1-7 0,4

2 6 VIP

L.) ei _Z t. ((a) -t_

(9 (.. il

PROCEDURE i LOCATION: / -1 DATEi7

(961-v3

Ismitto-)

PAGE / OF/

Y 2 - ANESTHESIA PROVIDER

USA PA V1.00

MEDCOM - 20435

DOD-034009

ACLU-RDI 1656 p.195

InVr eue Abevcifr)

to 941

DRUG 4 (Units) u) e 'ef/S

rz

•

cc —o 04 ( At ) en °Bo— i coo gig,4 ( / p 2 2

Z 0 z ( I 4:C g ( ra 0-

Z 0- rill <

( • (1) CI) • D Z Z VOLAT 60446 del < 0 AGENT % e.t. Z

po• AIR IJMin z wr w m • °to

I'120 )./Min t- u

02 L/Min SINGLE DOSE DRUGS-MARX ON GRID...* 2 WITH NUMBERS & ENTER IN REMARKS Q

Et MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

TOTALS TOTAL EBL

/6" TOTAL URINE

FLUIDS - SUMMARY

Its

CRYSTALLOID.

1- i< COLLOID-

BLOOD-

LINE site /MID Warmed

❑ Warmed

CI Warmed

❑ Warmed

LOSSES EST BLOOD LOSS

UR NE

5

ANES- PROC- 0_0

VT • ml

f - breaths/min Peak In/ pres / PEEP

2

1:2

1•2-;e) End

;-Z

TIME SYMBOLS:

Heart rate

Resp•rate

BR (transduced)

J. T

TOURNIQUET

T —Ji

220

200

180

160

140

120

80

60

BP by cuff

V A

REMAR KS

Co

to

O

C.) C./

CO cc 0

2 0

rc

PH YS STATUS

1(2)3 4 5 E

BODY WEIGHT.

G L

HEMATOCRIT:

INITIAL DATA:

BP- qv HR-

EQUIP CHECK

OK?- -(1) N

PATIENT RECHECK

OK for PROCEDURE?

TIME- I leb

mu .ms-ansmi waimpirsomm MODE - SI M. Aissist), Moll FRIMMidvillIM

Cuff E IN

_ P/Auto Cu . ET CO2 (tort) MIENIIIIMIIM MR169 h

BP/oth F102 (Frac or %I . ART line I p02 I%) ' Steth- PC/ES 022111.1M IMMIlige Gas analyzer I EMP -site II

N•M Block 11/41 =

Warming blkt Cone warmer

PROCEDURES and CPT Codes:

7-16 CD 7-fLiac /7!7L-fixe va PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility

Code drugs with numbers. events with /enters

if Pte r iloY S",r,frotiec:7

pio re4 /

ISX—C

/260...cp frit rn -

piarc9=V0-,e/ i,/)c- 7ti7/A--fiii.

k-,L7

Mark with letters & symbols, EVENTS_, explain under REMARKS Position

RECOVERY AT I ',RCS— 6 ) ICU --iSpeclly1

OTHER

CONDITION: et c-‘1::;Kto

1.4 /A-f... _ A nESP- to /51302- ICO BP- R-

ANES

8rf&H )0FIPROda—

TIMES

Start Room End

-1N/qose 4./ tlane .X.,Z ANESTHETIC TECHNIQUES: Describe l;lof technique undernmarks

Ready O

j126

(Dif

AIRWAY MANAGEMENT: intubation route, blade, technique, comments

rL 7 (62- (I-) 415-

OOP

SUR

DA FORM 7389, FEB 1998

PROCEDURE LOCATION: u DATE:

PAGE / OF/

HESIA PROVIDER USAPA VI.00

O

MEDCOM - 20436

DOD-034010

ACLU-RDI 1656 p.196

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

7 , 7- c - o/

VI_A-14.._

URINE

EST BLOOD LOSS

1 4 5 E

BODY WEIGHT:

LB HEMATOCRIT:

INITIAL DATA:

DRUG (Units) rn .j

0 0 LW) 2

z I—

r 7

CH H C/5 C/) Z z 0 0

Z a

0 z rn

VOLAT AGENT % e.t. FLUIDS - SUMMARY

CRYSTALLOID- ' iz te—Z

AIR

N20 L/Min 02 L/Min COLLOID-t,

BLOOD-

REMARKS

4 — SINGLE DOSE DRUGS-MARK ON GRID .4. WITH NUMBERS & ENTER IN REMARKS

LINE silo I1 Warmed

❑ Warmed

0 Warmed

to 0 Code drugs with numbers, events wirh !ewers

ION ✓

frt•-•

ter.,

❑ Warmed

LOSSES

PHYS STATUS TIME I'

SYMBOLS:

BP by cuff

V A

Heart rate

Resp•

•

rate

220 ..?)21...,.. , ,

, _L_ •

180

1 60

200 • •

• ,

i r

. , BP-

, .

1 I

BR (transduced)

-L.

TOURNIQUET

T

EQUIP CHECK

OK?- —r

—L __I_ • _I_ L. PATIENT RECHECK

OK for PROCEDU

TIME- p

• —L—

Tr— • _1— —I_

• s •

ANES- X-x PROC. 0_0

VT ml

f breaths/min LU Lu Peak int pres PEEP

MODE - Sfponi, A(ssist). C(on) BP/Auto Cuff .4 T CO2 Herd BP/oth r F102 (Frac or %I

EE

•

ART line Sp02 (%) • Steth- PC/ES 6 ECG U Gas analyzer ■ TEMP-site N-M Block (T/4) •1C

OTHER

CONDITION: ...r 1

RESP- 144 4 Sp02-

ANESTHESIA I PROCED

BP- HR- I TIMES

(,n

0

0 2

Start rn ct ct

Room End Warming brkt

Cony warmer /05-0 /10; Mark wig, fellers & symbols, EVENTS___, explain under REMARKS Position —

Ready Begin End O 0. 0. lir 0 pt PROCEDURES and CPT Codes: 1 1 )-0

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

ret., it-Wt PATIENT IDENTIFICAT/0 : Typed or written entries: Name, Grade/Rate,

Medical facility

Liq ./3e-, V3 (t) -

AIRWAY MANAGEMENT: lntubation route, blade, technique, comments

PROCEDURE - LOCATION:

ANESTHETIST

DA FORM 7389, FEB 1998 PAGE

COPY 2 - ANEST SIA PROVIDER

MEDCOM - 20437

DOD-034011

ACLU-RDI 1656 p.197

del Scod %

C A

GE

NT

S A

ND

DR

UG

S

ut

4

cc .

ANESTHETIC TECHNIQUES:Describe block technique under Remarks

DRUG

(Units) TOTALS

100 TOTAL URINE

3o-d i(5 ILCK__ FLUIDS - SUMMARY VOLAT

AGENT e.t.

AIR LiMsn

site

CRYST

C

BLoob-

REMAR

N20 L/Min

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

to ❑ Warmed

❑ Warmed

❑ Warmed Code drugs with numbers, events with tourer( ,

OP

cJi LOSSES

N-M Block 1T14} 4

Start Room End 2 O Warming blkt

2 Conv warmer Mark with letters & symbols, EVENTS explain under REMARKS Position

/IR) PROCEDUR

la) f-- tiAes MEDICAL RECORD RECORD - ANESTHESIA


EST BLOOD LOS

URINE -

02 L/Min

❑ Warmed

RESP-

BP-

ANEST SLA / PROD TIMES

Sp02- HR.

TOTAL EBL

STATUS

45 E

HEMATOCRIT:

INITIAL DATA:

BP.,

TIME

SYMBOLS:

BP by cuff

V A

Heart rate

Resp•

•

rate

180

HR- Z)

EQUIP CHECK

OK7-

PATIENT

OK for PROCEDU

TIME-

BR (transduced)

T TOURNIQUET

T —)1'

ANES-PROC-825

VT-ml 1— z f - breaths/min

Peak Mf pros / PEEP

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

P/Auto Cuff ET CO2 (ton)

B h 102 (Frac or TO ▪ ART line p02 I%) 0 • Steth- PC/ES • — tu Gas analyzer MP-site

--ISPecItY1

CONDITION:

PATIENT IDENTIF 71rION: Typ or written entries: Name, Grade/Rate,

Ica' facility AITY111.11, NAGEMENT: lnithation route, biade,oet rnique, comments

v' k_ 0-vvci

PAGE r OF

PY 2 - ANESTHESIA PROVIDER USAPA V1.00 DA FORM 7389, FEB 1998

MEDCOM - 20438

DOD-034012

ACLU-RDI 1656 p.198

MEDICAL RECORD - ANESTHESIA For use of this form,, see AR 40-66; the proponent agency is the OTSG

AN

ESTH

ETIC

AG

EN

TS_

AN

D D

RU

GS

I C

ON

TIN

UO

US

/RE

PE

AT

ED

DR

UG

S

SP

EC

IFY

UN

ITS

• M

G/M

CG

/ML

, "I

' =C

ON

ST

AN

T I

NFU

SIO

N

DRUG (Units) TOTALS TOTAL EBL

co 473> re—e-- TOTAL URINE

16c) ( ( ) ,

VOLAT AGENT

.1t1 %del / 1 3- ,ci, A FLUIDS-SUMMARY

CRYSTATOJEI.,

COLLOI -

% e.t.

AIR L/Min

N20 L/Min

3 -1) 02 UMin 3 — SINGLE DOSE DRUGS MARK ON GRID ...,,, WITH NUMBERS & ENTER IN REMARKS

BLOOD-

FLU

IDS

LINE Warmed site El L - REMARKS

I fir- 1/ I ) El Warmed It Code (hugs with numbers, events with I mam

PO irk4 id 0, (

61.4,--i- cfe-tivtin,-4-r( ,

at (015-- 1-, ve-e.--,, 4

,

I, (ik, L LL ‘.14

C.Ift-5 +cc rti0.56-

.("ae-e- ttI LC55"M7. ,

1 0 S- PL

....,-----1

-.)/ 0 Warmed

0 Warmed

EST BLOOD LOSS LOSSES UR NE - OU

PHSTATUS TIME 41 od C 1121345 E

SYMBOLS: . . _1._

BO WEIGH . , ■ 220

B BP bY cuff

V

A Heart rate

• Resp rate

BR (transduced)

_L T

TOURNIQUET

T —4 .

ANES- X-X PROC- lag

200 Mill= I ' ...... , . , .1.- 1 • J

HEMATOCRIT: . : . .

' — 180

' " .

. 1 1 1 -.---' .--- 1 1

INITIAL DATA: 160 ; :

------ • .

. 140 IMI . . .

. ,

-f7PACI-) — 5 itk I 120 = ' • ' HR - ,----r)

`") , . . , . , --,--1

100 . . . . "law %E. . EQUIP CHECK 80 : ! H : :

,.--,- OK?. N

r --e 60 =M.=

.; .

H , „ , : PATIENT RECHECK i r—

.. .

OK for PROCEDUR 7

TIME-

• ' ....M. '

,

' '

2

40 = —r- r

° MIMI 1 1 1 1 1 1 I 1 lipi VT - ml ...,-- _

f - breaths/min

(Eh

Peak Mt pres / PEEP KIM

MODE - S( , on), AlssIst/. C(on) iij_Tn;:VERY AT mil er: .1Auto Cuff ET CO2 (ton) IVOR q3 =p 'Cu Specify/

BP/oth ylo2 (Frac or %) Elal MI • HER MART One \<Sp02 (%) OU WO coNomoNS c- FIESP- 7 SPO2 - 00 ca-pli N'' HR.

AN ?...3

ST SIA1PROCEDURE TIMES

• Steth- PC/ES X...ECG IMAINAll' 0 o Gas analyzer TEMP-site MIME I N-M Block (T/4)

I I SR

NV

30

111a!

Start Room End I

ION lor //7 Warmin , bIkt Cony warmer Ready Begin End

hfa A wish terra f s & symbols, EVENTS_, explain under REMARKS POSitiOri - .-- 0---1 -------> /QO (10 br

PROCEDURES C

i--). Acc, es ANEATHETIC TECHIXIAZtscribe block echnique under Remarks

VirAI"..rxkr. / ---- (../..--A. l 111./Ay

AIRXYcnGEMENT: inicbm,on route, &due, techrlque, comments

II% /14ask PATIENT IDENTIFIC

4411.

N. Typed written entrios: Name, GradefRate,

Medi 1 lacilitY

_ u SURGE

I j-Citt):1- C PROCEDURE LOCATION: N-, DATE: zi

PAGE /

7 1

DA FORM 7389, FEB 1998 - AlkitS I HESIA PROVIDER USAPA V1.00

MEDCOM - 20439

DOD-034013

ACLU-RDI 1656 p.199

N20

02 SINGLE

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

❑ Warmed

L/Min L/Min

p.gmA.mf. Code drugs with numbers, events with lowers

{:Units:

TOTALS Ai 1111MMIIMIUMNIMINIMI totortaLe ... , 111111111111111111.111 PITRVmp-AliCSI111111111111111 1111111.11111111111111111111.111111111 Mitlill iminm......_1111 1111111•111L._1111111111111111111111 1.11111111111111.111111111111 .........m.mamill111111111116muma111111111111111111111111111111 *lt.AT: IIIIMMINIRRII - .0 IMMIRED:411111111111111111111 kgErgr OW • immillin

111.1111111111111111111111111111111111 1.111" minanumalliallIMMINIMMEMIll MIME mmiall.11111111 n1=247AMIIIIValltalkalliM11.1111111.Maril allt F-Cgar.SMIIMMINIallalffill- ME

lnilm.._IIIIIIIIIIIIIIIIIIIIIIIIIIIMIMNIIIIIIIIIIIIII immumillill1111111 numni mm......._111111111111111111WAIIIIIIII 1 IIIIIII illniumi

ll1111111111111111111 IMMICs. ■III mann

inkl,,

/ 80

""minammimmenimmen______Inemininumumalmm. .-.00: 4,,

mummoommenirammuummomm aimumummuomummewwwrnsimumuliem ::,:106#00q0

8P by cuff 200 ....m....ramerm......rja,..... mar ,.. ....„........_

40 11111111111111111111111111_1•1011

MAIMINOMMINIUMMUNINIIIIIIMInumillINIMIlial

Resp rate 11 IMINIUMMUMMINIMEMMW,___IMMENIEN

4.4:i'.

gwimmill1111111mamm.1111111111111111111111111111111...m1011111111111L

....._____1111111111.monmi.____IIMIIIImmiummlIMIInummul.,_'• 11.—n1 120 111111111111M130111111111111111111111111111111111111•1•1•111111111•111 111111111111AMM191611111111111111

11111111111111111BRION !transduced}ic 100 r ,IIIIINNIIIIIINIMIIIMININIMMILE

BR rrAprf.,L___PAErmisiathatmenummumm,___amummo..._____Imminno simounnumums,__Innummoni,____Nummo

+ i 80 innumummumme-wminwinammommanniammen 11•11111111MINEIMMIIMMINIIII

IIIIIIIIIIIIII.._____111111.111 TOURNIQUET

60 viumzuommurwasemamiam T —71/ rampsonnummensanniummin

DIC for q0 amish irAmanumestywainow,___Resimmusinuani—i=omme 101111111111111111NWAIIIMOW01111w

wungaill111111111.1111 1110111NNIMIIMMIIMINNIMMIIIMMINI._____11111 ,_____ 1111.11111111111111.111111111111111M11,__INIMMIENOmms11111•■=in 11101111111111111111411111111211111MMINU6

smown111111111MEMammil

1111MmeaciammartindairaiiiieliMMINNINIMMUNN

IMINCrezzffiramenfintillitliMEIMMEN

NOMM C :Not/limn/II

c,..________ammia unewinammervafral mannem cannampamommum

rwirmiromihram iratarmummulliillail ii....__mtmaricmillilleezamm. ,.....,n-mmuialmilE4aira,__Irlldierl 111111.1111111 CONDITION, ~^

,11 sanw.mwoGamidatiourol.N.Ia -,,,,■._„itlf2M3111111111...m.m1111111111111111111111 1111111.1.1111111111111111111111.11111111111111011.1111111111111111111M1111111111111111

:_____EmonumwommimmuiramminummummolommaimOgs.

, ..eacktPRO WF' . . Ilm111111111Mornimmull11111111111111111111111111111111111111111

111111111111111111111111111111111•11 ark wgh lellerS & symbols, EVENTS el

Ikammignerli.m.mm ilAILIZMIIMal-11,_111111111111111 11111111111111111111111111111111111111111111111111111111111111111

IIIIIII .mpmpmmIIIIIIIIIIIIIIIIIIIIIIIIMII CPT Codes ANESTHETIC TECHNIQUES:

MD am illgrkorm airlall

Memel FiOCEDURES and •

plain unr/er REMARKS Position

07141 ..,. - __.,„ .,

IQUES: Describe block technique under

yped or written e Remarks 1TIENT IDENTIMMN:

I es: Name, Grade/R Liliet Medical facility AIRweikVA

EM T: Int

num./IL:AL RECORD - ANESTHE: .f

this forrn, see AR 40-66; the proponent agent, OTSG

■ f

EST BLOOD LOSS

❑ warmed Warmed

LIth

41111- itu • soon ro

FORM 7389,1998

MED AL RECORD USA PA V . 00

tle))( MEDCOM -2044

DOD-034014

ACLU-RDI 1656 p.200

€¦ · DOD-033816 REGISTER NO. WARD NO. MEDICAL RECORD I PROGRESS NOTES DATE NOTES aZ ,`9 5 .) /l...

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Transcript of €¦ · DOD-033816 REGISTER NO. WARD NO. MEDICAL RECORD I PROGRESS NOTES DATE NOTES aZ ,`9 5 .) /l...