CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE LAN ( NON -MEDICATION )
For use of this form, see AR 4 07:
the proponent agency Is the Office of The S goon General. Ma 1 t yr: 2003 VERIFY BY INITIAIJNG aNiMMAig*I% *' , ,40* INITIAL PROP COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
CLERK! NURSE
f RECURRING ACTION, FREQUENCY, TIME
HR DATE COMPLETED
‘ r. " - - - -0111 07-C\C\I di: \(1C1 2" sCiS
iiiiiip
• - i
op i-c) lov\ec 1e-z1,
•
ALLERGIES: IM YES MN NO PRIMARY DIAGNOSIS:
- slp asw Q.up‘sc— / 1 1-CIC3
ADDITIONAL PAGES IN USE: MI YES 11/ NO
PAGE NO' PATIENT IDENTIFICATION:
USE PENCIL.
li - D 8 9 10
E 16 17 18
N 24 01 02 mpnrcun _ 78441
ACTION TIMES CIRCLE ACTION TIMES
11 12 13 14 15
19 20 21 22 23
03 04 05 06 07 mr,a-r."•• *,..0 • ...mi.,. •• ■••,./ ro e,r-r% el. ■ ••• 1,4
DOD-037019
ACLU-RDI 1681 p.1
HR
7 13
ENSE D
15 kc7
DATE DISP
VERIFY BY INITIALING
ORDER DATE
CLERK/ NURSE '
•
RECURRING MEDICATIONS, DOSE, FREQUENCY
=1_0
-Zvi Ion
K i\J (-4 I fl d
Val t(4 ,-) Pc-3 "tg°
IdEMINILIMIMEr
ND% Nov m-,5 Tie/r-t ringlara
Wan 5
INITIAL OPER COLUMN FOLLOWING EACH ADMINISTRATION
ALLERGIES YES El NO PRIMARY DIAGNOSIS:
PATIENT IDENTIFICATION:
111111111bit!
CLINICAL RECORD THEfrAPEUTIC DOCUMENTATIO CARE PLAN (MEDICATIONS)
For use of this form, AR 40-407; the proponent agency Is the Office f The Surgeon General.
ADDITIONAL PAGES IN USE:
YES Q NO
PAGE NO
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA 1 FAFIr/9 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM -23442
DOD-037020
ACLU-RDI 1681 p.2
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.
Order Date
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES
Date to be Given be
Time to Given Time Given Initials
/VD LO - e-l- ------- Order/ Expir Date
Clerk/ PRN Nurse MEDICATInN, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
- TIME/DATE DISPENSED
lilliDe ill I • Cl7bi 523 li 01-
OA ° et,,,. .Ntr-•iLtilitrk .
7\--k-k/
., -e.-rCCDCe4 --- On 1 l ‘`' 017
7ivot,
1 °3° Adv
2")- 3 3 v.,2)
!goo 61464-eti Vi3o 36 '
14 '''
)0,4' visS ittxt-plow
Zt3r) ( trill 06Lit
atis* 11 1414
1 psi 12°
0 ' 0.4, .
Ucl ° pn,1\3 , 11. I - --- (1.4"
... _ ! r a ,ec, -;
-5--------. _prtAJ
7 )
101cdpr) A Sb :,-,ky
0 (e 9-Pi"' f-) nel utS-e___
gen 12 1 '?c) 20 V 0 14tJa 1- ix)
lord Or-
160 Q
x-54rally*:,
•
atAl 4
M 04,r 1S511,K
Nmsiii---iWTW, , csuv
(Q H- P-4---i krtu'lq ►nt,..._. INItosef - po
.y 0 pi, 1-....
'U.S. GPO: 1998-454-110/95216
MEDCOM - 23443
DOD-037021
ACLU-RDI 1681 p.3
TRAUMA FLOWSHEET The proponent is Dept of Surgery
ABDOMEN
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-88; the proponent agency is the Office of The Surgvn General.
REPORT TITLE OTSG APPROVED (Date)
QI Appr 11 Jun 97
TIM IV x
Meds: ❑ UKN None ❑ Yes:
Allergies: ❑ UKN one ❑ Yes:
Tetanus: ji( UKN
LMPI,
M c
PRIMARY SURVEY
hrs
❑ 02 1 /min ❑ C-Spine Immob
❑ Current Last Meal/Fluid Intake
AIRWAY-:
(1Z4atural
ETT
❑ Secretions
Patient 0
0 0
CIRCULATION • • . "....
❑ Labored 'Jnlabored ❑ Absent
TRACHEA: 9tidline ❑ Deviated
CHEST SYMMETRY:
PULSE: 0 Present ❑ Absent
BLEEDING:
HEART TONES: ❑ Clear ❑ Muffled
SKIN: yl(Warn ❑ Cool ❑ Hot
Pink ❑ Pale ❑ Cyanotic ❑
Dry ❑ Moist ❑ Diaphoretic
a a > = <
SECONDARY SURVEY DISABILITY
. AHEART
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN IAB)rasion
(AMPlutation
(AVlulsion
Battle's Signs
(BL)eeding
(B)urn
(D)eformity
(E)cchymosis
(F)oreign Body
0-0ematoma 0 1144
(LAC)eration
(P)uncture (W)ound
(Pain)
(S)eatbeIt (S)ign
(S)tab (W)ound
(GSW) Gun Shot Wound
SPHINCTER TONE:
Ceis.U21.
❑ None
GCS: E
M
V
C-Spine Tenderness:
Pain @
JVD:
PUPILSXLEqual a Fixed ❑ React ❑ Dilated
TM: 0-Clear ❑ Blood
NECK
sO,
CI
CI
a a
Decreased
Wheezes
LUNGS
BREATH SOUNDO:Nat ;ig:Equal ❑ Clear
Absent
Crackles
RHYTHM: ,...ellegular ❑
PULSES: ❑ Central ❑ Peripheral
a a
VASCULAR ASSESSMENT
a a
4.1
per-Soft ❑ Rigid ❑ Non-Tender
Heme + / - Prostate: ❑ WNL ❑ Abnl
❑ Stable ❑ Unstable 0
Blood at meatus/vagina:
❑ Tender:
0
PELVIS .. • • ..
D Dopler RN
PREPARED BY (Signature DEPARTMENT
Continue on reverse DATE
PATIENTS IDENTIFICATION (For typed or written entries give: Name--last, first, middle; grade; date; hospital or medical facility) ❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
t-7 TREATMENT
❑ FLOW CHART
❑ OTHER (Specify)
DA , 117A A
MEDCOM - 23444 .
DOD-037022
ACLU-RDI 1681 p.4
DOD-037023
VITAL SIGNS Rectal Temp:- tQc.. , ( 0 ‘ke cc, GCS: TIME BP HR RHY Ri# a0 l FIO 10:6E:
1 &̀ C:)%0. ̀1Cl 1\J
)'• CO/ 01\ \ 141 AP- 03- 1 103/ vgx ocV,
1,20/,2 )27 NVa .,7
c- `)SL co
Al
0 Downgraded
CO- Spontaneous
3 - To Voice
2- To Pain
1 - None
Oriented
4 - Confused
3 - Inapp Words
2 - Incomp Speech
- None
Obeys Commands
5 - Localizes Pain
4 - Withdraws to Pain
3 - Flexion to Pain
2 - Extension to Pain
1 - None
PERFORMEIZBr'
BY:
BY:
NOTES
4041.1_0'- E .ABI r;
OC,EDURI
0 Backboard Removed
GLASGOW COMA SCALE
EBLE RESPONSE
MEDCOM - 23445
ACLU-RDI 1681 p.5
E
S
TDiIE 'PROCEDURE . .
.,,DIEE ,,SITE. RESULTS
. . . ,i ROCEDUREz ,
-..-...,. _ , COOOPMED RY RN
'- -
ET
Intubation
0 Oral
0 Nasal
Teeth
❑ ETCO2 Change
❑ BBS Post Int
0 Post CXR
CT Scan Xtontrast C)CIA
1,7. ead gAbd Velvis
0 C-Spine ❑ T/L Spine tl(hest Gastric
Tube
❑ Oral
❑ Nasal
0 Air 0 Contents
0 Verified 0
Suction: Y N A-Gram Site:
IV ACCESS & FLUIDS ) aop Urinary
n, {Meatus
❑ Supra-Public L
—
A Return (57,0 LI cc a Heme Dip: + -
• Secured
DPL LI Opened CI Closed
ii&--D- CI Grossly: + -
Cell count
Sent@
TIME l GA •i. I■1!,
) N
Y N Chest
Tube #1 L R
0 Air 0 Blood
0 Pleuravac cm
0 Autotranstuser
Y N
,, ..iyiecile4I1Olt .
MEDICATIONS DOSE f-, RTE TIIN DOSE -,,
4'
Chest
Tube #2 L R. .„
•
0 Air ❑ Blood
0 Pleuravac cm
0 Autotransfuser
12 Lead Rhythm: Comments
0
a siT 1 lCoi: ' Q2zit111cch
11
Ewa.
2) - LABS ,,,.. X-RAYS
a
.. 1...... , AMMINEEINE
11,715M7MMINIIIII ❑ D-stick 0 SHct ME _r Chest Initial - MEM
❑ D-stick 0 SHct , 0 Chest Post ET
BLOOD PRODUCTS nirifil
-\...
,,,\ 4....7
CBC CZhem El=1‹topTT
❑ETOH KtiS "45C&C x \,
❑ Chest Post CT
ail ❑ C -Spine
nal Pelvis 0 Tox Screen
1 4JA 0 HCG Mlle \
-COTNER i) \. () 1 .• iN\ lA., r , A „;5,,,
7IyLEA
TRAUMA TEAM AF, RIVAL
mESI11046ED 'f'4K W ..,eM F
VALUABLES & CLOTHING ,I '''' N'.
D Phys None Found
urgeon Given to Patient
.nesth Given to Family ..,
Inventoried and Released to Patient Trust FundINCOD See DA Form 3696
0 Home
Admitted
❑
Other: See Nursing Notes
DISPOSITION X-Ray
RT
Ortho to
Called to
Transferred
td By
\!) ( - Z....
Neuro Report
Chaplain
- .
MEDCOM
Time
23446 — .... . . .
DOD-037024
ACLU-RDI 1681 p.6
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA lot use 01 this form. see AR 40.66: the proponent agency is the Office of the Surgeon General.
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED aid
Date: —1 PO %) Anesthesia Type (Circle)): Spinal Epidural Drains Airway Time In: (").3 C55 IV Sedation Nerve Block Hemovac
• NG JP
T-tube
Nasal Oral
Trach
Other
Allergies: 13 E—DP1 OR Intake: Crystalloid 2300 Colloid.... •
Pre-op V/S:120All °MR,— OR Output: UOP EBL <50 Procedures: .a.rt:1612Arreol 0 (PrahMeds/Times: ficen±)cfezt2. 6 t •
Pt-Lad fax.2.44417'onire i6Wr of TLS Pre Op Meds
..0 History .....
Time ci
° ..
01M1.
.0
.1 E .
PhO r Pacu Intake
Sa02 El ig co gni F-0 turt iN crc E Tin Solution Amount Site • By 'Infuted
Fi02
Methods WHEERIVAS lig4
•
33%vli 240
111 4 11 220 X-rays: . Labs:
• Post-Anesthesia Recovery, score
200 Criteria ADM 30' D/C Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities
(0) Moves 0 Extremities
AIRWAY A= Ambu BB= Blow-by M =Mask
180
160 Airway (2) Cough, Deep breath
(1) Dyspnea. limited breathing
(0) Apnea
FT = Face Tent RA =RoomAlr NC= Nasal
' 140 V V
V v ir V
V
Blood Pressure (2) SBP =/- 20 of Pre-op (1) SBP 4-29-50 of Pre-op (0) SBP =/- 50 of Pre-op
Cannula
V/S X =A-line BP
120 V
V v
100 * Consaousness
dying (1) Arousable to verbal or pain
•■■•■•••■•••
. =Cuff BP = Pulse
TEMP
. •
(2) Fu lly Awake audible
80 a 6 •
• • • A A A A A ii Color
121 Baseline color & appearance
(1) pale. mottled. jaundiced (0) Cyanotic
S = Skin 0 =Oral
A = Axilla T = Tympanic
60 A A
A
40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse
R = Rectal
LOS -
C = Cervical I 20 TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for mc.
T - Thoracic L = Lumbar s=sacral
RR HINNBIllpffliqfflInallin T 77, •• Time Patten teaching done; Wound Ca e. Pain Management, Pain (0-10) T. C. 8 DB.. Incentive Spirometer, Comfort Measures LOS Safely: SR up X 2, Falls Precautions. Privacy Maintained
on ewe ao reverse
DATE b(0- GT11 0
DEPARTMENTISERVICKUNIC
-7 pov c)
Mitten entnes give: lest, middle; grade; date; hospital or medical tackle
111111 ikt) -
Name — last. ❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
❑ FLOW CHART
❑ OTHER ormari
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete MARC 62.00
MEDCOM - 23447
DOD-037025
ACLU-RDI 1681 p.7
PACU OUTPUT
Time Discharge Criteria: Dater-1 /00‘) Time: PARS: Bp:135/77 T: HR: 92... RR: i Z SaO2: qv, Pain Level at D/C (0-10):
Output: ZOO
Ambulance
Source Color/Appearance Amount
Intake: kDC>0 Additional Data: Transferred To: let's,/ 2_ Report Given To: Transferred Via: W. Transferred By: Cleared IAW Recove Charge Nurse Signatu
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
1) Lib°
MEDICATIONS Allergies:
Medication & Dosane
Time Route Pain 1-10
I/E By Pain 1.10
NURSING NOTES
OS&D - oau6, o ctufu9;19 • .1 - • '
12et 01 C-ict/ i t km ,(31 q i 5 p-\- drituku3vi2
(11690INA-0 MCA/
NEUROVASCULAR Time Site Range
Of Motion
Sensory P Cap Refill
T C
Adm
0'
36.......,
45'
D
15;
60'
90'
Movement/Sensation: + = present,- = absent Temp:C = C• • W =Warm Pulses: P = Palpable, D =Doppler, A= A Color: C= Cyanotic,
Capillary Refill: B= Brisk, S= Sluggish P= Pale, Pk = Pink
.; CTIONS
Adm 15' 30' 45' 60' 90' D/C Fund. Height
Lochia
P d#
und. Cond.
DRESSINGS
Time Location Type Drainage
Adm k_OIVV in kl.A6-1) 25/ °
30' kiodicra;r1 t . / , ti,oPaboittn he,;11A
70_1(11R_ [Chi 60' KDOCUT0`^ tc 1.
D/C
LI lb - brao.A1,1A fin yv olooce_a .cto r . 2 tkipin A_op ccuak d
du-bp pket +c) -75% . P-€ p tin ek c 12- L 0z.. Th-AA . anza
o2' rk ■ . oz. n 1 Tkr) bo%
0ukf pf c-32Apoiteive, -b v9/006-0
t-r) / ID titc-h . S 11-v\pov; f\S firrike (A) SS
ACLU-RDI 1681 p.8
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this term. see AR 40.66; the proponent agency is the Office of The Suntan General.
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED /Due)
Date: t1)00; Anesthesia Type (Circle)at)• pinal Epidural Drains Airway
Time In: i Ns Iv • - lon Nerve Block Hemovac
• NG
CE) T-tube
Foley
TLS
Nasal
Oral ETT
Tra
her
Allergies: NOVI OR Intake: Crystalloid 9,(N)0 Colloid. ...
Pre-op V/S: lq.1/u2- 101 OR Output: UOP 350 EBL SO Procedures: 1 1,4 nal:11'1-1g Meds/Times: 500.-1 Pit.-1- •
1C15h ou..4' le-1-1- lel . We:L/03A IC :cajt,tin 4.- levee 3vni
Pre Op Meds Histor
Time 4 .--....
,.-,
-, to --
cl -....
,•-3' --. Pacu Intake
Sa02 19
IA
e Ars
g
tirok
,... ,f).
Itly
.. Tin Solution Amount ile • By Infused
Fi02
Methods
240
220 X-rays: . Labs:
Post-Anesthesia Recovery_score
200 Criteria ADM 30• D/C Codes Activit (2) Moves 4 Exlremities (1) Moves 2 Extremities (0) Moves 0 Extremities
AIRWAY A =Ambu
BB = Blow-by
M. Mask
180
160 Ainvay (2) Cough, Deep breath
(1) DY tinkled breathing (0) Apnea
FT = Face
Tent RA= RoomAir
NC = Nasal 140 V
\/ VI
V Blood Pressine (2) SOP =/- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SE =/- 5Ciof Pre-op
Cannula
V/S
X = A-line BP
120
•
100 •
Consciousness (2) Fully Awake. audible
crYilvg (1) Alousable to verbal or pain
..... ■■
■
.. ■■......'
' =Cuff BP
= Pulse
TEMP •
80 e\ A
A I\ A Color 12) Baseline color A appearance (1) pale, mottled, jaundiced (0) Cyanotic
S = Skin
0 = Oral A = Axillary
T =Tympanic
60
40 Circulation (Pads < 5 Years) (2) radial Pulse Palpable (1) Naar/ palpable. not radial (0) Carotid only reliable pulse LOS
R = Rectal
C = Cervical 20 TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C,
T = Thoracic
L =Lumbar
S= Sacral RR l' ialit lb T
Time Patient teaching done; Wound Care. Pain Management,
Pain (0-10) T. C, & DB.. Incentive Spirometer, Comfort Measures
LOS _____ Safety' SR up X 2, Falls Precautions. Privacy Maintained Ilonnnue on reverse)
bL(/ - / DEPARTMENTISERVICEICLINIC
PA CU DATE
0? Nov 03 PAT first. middle: grade: date;
Or yp or WI7 Name —last, hospital or medkal teary!
0 J (j1 •
❑ HISTORYIPHYSICAL • FLOW CHART
❑ OTHER EXAMINATION ■ OTHER amde OR EVALUATION
❑ DIAGNOSTIC STUDIES
5 TREATMENT
DA FORM 4700, MAY 78
WAMC OP 173-E, (Revised) I Apr 01 (MCXC-ON)
Previous edition is obtolete irSAPPC 67.00
MEDCOM - 23449
DOD-037027
ACLU-RDI 1681 p.9
PACU OUTPUT
Time Source Color earance Amount
CARDIAC RHYTHM
Time Rhythm Symptomatic?
O N se_ Rhythm Strip Run?
Discharge Criteria: Date: cgt,sev Time: rd-t-RD PARS:1 BP:131 -70kT:i(Yllf 11R: C 'c) RR: I Pain Level at DIC (0-10): --Intake: Output: Additional Data: Transferred To: C Report Given To: Transferred Via: W Transferred By: Cleared IAW Recov oom Charge Nurse Signature:
Sa02:
MEDICATIONS Allergies: Time Pain
1-10 Medication 8 Dnsane
Route Pain 1-10
I/E
12-2.D an A-46614 1U
►g3tP aon oiti_ak ft/ l!-4L t nv) K61)/1 l)
NEUROVASCULAR Time Site Range
01 Motion
Sensory P Cap Refill
T Color
Adm 12.1 er, —t- —I-- (-1 y2 \/`-) p v., 15' e( -P -.1 13 Vi f t c- 30' --k. --k P 6 v./ p IC_ 45' ...
60'
90'
D/C Mr -1- -V f 105 W W movemenuseaation: + = present.- = absent Temp:C = Cool, W=VVarrn Pulses: P= Palpable, D =Doppler, A =Absent Color: C= Cyanotic,
Capillary Refill: B =Brisk, S = S uggish P= Pale, Pk = Pink
C-SECTIONS
Adm 15' 30" 45' 90' D/C Fund. Height
Lochia ---------' Peripad#
Fuotleelrid.
DRESSINGS Time Location Type Drainage
Adm r I , +. AMU=
- 4 1 k_ • D
illillinlillil IIII
Mill 30' At 60' D/C , I 111 '4 '
NURSING NOTES
recevele (Ye. 5/ itAk
+VI e ,roi•r, . k-4 V z 99
010 poi n er\c3 AkSO4 ka-3ce r94--
WAMC OP 173-E
MEDCOM - 23450 "ram.mme./Imya.■8•4••■•■
DOD-037028
ACLU-RDI 1681 p.10
Pre Op Meds
Time
Sa02
F102
Methods
240
220
200
180
160
140
120
100
80
60
40
20
RR
T Time Pain 0-10 LOS
,C)
ADM 30' DIC
1L0nrirtUe an MOW)
DATE
119
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet 7 Date: 5 iq k`f 0.5 Time In: 1.) Allergies: Pre-op V/S: Procedures:
X-rays:
Criteria Activity (2) Moves 4 Extremities
Moves 2 Extremities (0) Moves 0 Extremities
Airway (2) Cough, Deep breath (1)Dyspnea. limited breathing (0) Apnea
Blood Pressure (2) SBP =1- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =1- 50 of Pre-op
Consciousness (2) Fully Awake, audible
crying (1) Arousable to verbal or pain
Color (2) Baseline color & appearance
(1) pale, mottled, jaundiced (0) Cyanotic
Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse
TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for 0/C.
DEPA ENTISERVICE/CLINIC
Anesthesia Type (Circle)) {gene Spinal Epidural LI-{_A, 1V-Sedation Nerve Block
Colloid
E OR Intake: Crystalloid
Immo OR Output: UOP Imviip um , Meds/Times:
Nit ci
Drains/ Hem9,/ac
JP - pG.
T-t Foley
TLS
Airway Nasal
Trach
Other
Time Solu on A cunt Site By _ fiamintAramr— "sr , Pacu Intake
Labs:
Codes
Post-Anesthesia Recovery score
Patient teaching done; Wound Care, Pain Management, T. C. & DEL. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained
lien entries give: Name —last,
, m • de: grade: date; hospital or medical leafy) ❑ HISTORYIPHTSICAL
❑ OTHER EXAMINATION
OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
❑ FLOW CHART
❑ OTHER /Away/
Histor
•
AIRWAY A = Ambu BB = Blow-by M — Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula
VIS X = A-line BP
= Cuff BP = Pulse
TEMP S = Skin 0= Oral A =Axillary T =Tympanic R =Rectal
LOS C = Cervical T = Thoracic L = Lumbar S = Sacral
ACLU-RDI 1681 p.11
DOD-037030
Time Source Color/A earance mount
MEDCOM WAMC OP 173-E
NEUROVASCULAR Time Site
-
Range Of
Motion
Sensory P Cap Refill
21111.MNIIIIIIr
T Color
Adm
15' wr riumilwas
30'
45'
60'
90'
D/C
Movement/Sensation: + =present,- = absent Temp:C = Cool, W =Warm Pulses: P = Palpable, D= Doppler, A = Absent Color: C= Cyanotic,
Capillary Refill: B= Brisk, S=S uggish P= Pale, Pk = Pink
C-SECTIONS _...-------. Adm 15' 30' 45' 90' D/C
Fund. Height
Lochia ----------
Fund. d.
DRESSINGS
Time - L• . tion Drainage
Adm r r. I I, 1 ,11 ,_ .
30'
60'
D/C
NURSING NOTES
,_...- CARDIAC RHYTHM
Thile Rh thm S mptomatic? Rh thm Strip Run?
;DID
BP: it-4T: `it Pain Le er it D C 10-101: Intake: Additional Data: Transferred To: (,l)
Report Given To. Transferred Transferred By: Cleared IAW Rec
Signatur - 23452
PARS: RR: / Sa02:ioa
Output
Discharge prq Date:(--,7u
2 MEDICATIONS
Allergies: Medication & Onsaae
Time Route PIE By
z
Pain 1-10
P.' 1-10
PACU OUTPUT
ACLU-RDI 1681 p.12
)
2. MTF Location
Reporting MTF
Admission and ..04D-Aing Information
4 ; Register Number
IL For use of this form, see AK 4U-4uu; me proponent agency is u i ou
Name (Last, First, MI) 4. Pay Grade
F GN
5. Sex
M
6. DoB (YYYYMMDD)
1968-06-01
[
7. Age at Admission
35Y
8. Race
X
9. Ethnicity
9
Religion
. . 10. Length of Service
Organization (Active Duty
ETS
Only)
11. FMP
13. Marital Status
_ ...
L
12. Social Security Number
Hour of Admission
01:00
- Li . . ..
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
DIS
Prey. Admission
NO
20. Source of Admission . Ward: Name / Relationship of Emergency Addressee -
Direct from ER ICW 1 Address of Emergency Addressee
N . .ie and Location of Medical Treatment Facility: 1
b (1 t
Telephone Number of Emergency Addressee
21. Type of Disposition 22. MTF Transferred To
TRF-OTH
23. Date of Disposition (YYYYMMDD)
2003-11-18
24. Clinic Svc - Admitting
GG - FP ORTHOPEDICS
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-07
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-07
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: S/P GSW L GROIN R LEG g7V, 1--- is4 se, 5'
0
Cs 7.3.
41/9, 81
Procedure Narrative(s):
Cause of Injury Narrative:
MEDCOM - 23453
DOD-037031
ACLU-RDI 1681 p.13
ETHNIC RELIGION 6. DATE OF BIRTH (Y Y Y YMMD D) 7. AGE AT ADMISSION 8. RACE 9.
BACK-GROUND
19 20 21 22 23 24 25 26 27 28 29
32 34
50 ENO 47 48 ' I • 49 60 61
22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (Y YMMDD)
EN11111311121011311 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y Y MAID D)
90 87
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS •
46 I HOUR OF ADMISSION .
BRANCH / CORPS
14. FLYING STATUS 15. BENEFICIARY CATEGORY
17. UNIT LOCATION (State or 18. MOS Country Code) 62 63.
16. ZIP CODE OF RESIDENCE
5.3 154 I 55 I 56 57 58 I 59
• •
PREY. ADMISSION
YEAR
NO
19. TRAUMA
64 65 66 67 68 69 70 71
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
72 ADMISSION 1
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
•
_ • - -• ••_ -•
91 " 92 93 94 95 96 97 98 99 100 .101 102
28. MTF OF INITIAL ADMISSION 29. DATE INITIAL.ADMISSION • (YYMMDD)
21. TYPE OF DISPOSITION
24... CLINIC SVC - ADMITTING
27. LOCATION OF OCCURRENCE (Battle Casualty Only)
103 104
OR LOCAL USE
r-t-ttiol c"-)
1
703
A FORM 2985, MAR 89 EDITION OF MAY 79"IS OBSOLETE USAPPCV1.00
MEDCOM - 23454
DOD-037032
ure, as required) DMITTING OFFICER (Sign SIGNATURE OF ADMITTING CLERK
30 31
11. FIMP 12. SOCIAL SECURITY NUMBER
MEND 40 enzuramamm
rt."LJC 1 5. SEX
16 17 18
10. LENGTH OF SERVICE ETS
9 I 10
/
11 I 12 I 13 I 14
•
r
ACLU-RDI 1681 p.14
riProperty/Contraband J weapon Photo Taken of Suspect with Weapon/Contraband: Yes/ No
0 YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
Ofense against CiviIin(s) [check one] Ff "Other" then de&cribo •:::
:: .. .. .. . . .... . . .
. ....
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- . — – -
Date of Report: (D/M/Y) Time of Report:
/ / hrs
1
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM 0
Place of Birth:
Ethnaribe/ Sex:
Sect:
Type: [Model:
Serial No.: Quantity: Make:
Other Details: \o, - r 1 Where Found:
Color/Caliber Receipt Provided to Owner: Yes/ No
Owner
DOD-037033
ACLU-RDI 1681 p.15
Automated Facsimile I. ATIENT TREATMENT RECORD-- ,vCR SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr ' 2. Name 3. Grade FGN
Admission Remarks
‘
4. Sex M
5. Age 24Y
6. Race X
7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
NO
11. FMP
99 12. SSN 3. Organization
6 ( (-L \ - (4 14. Ward
ICW1
15. FlyStatus 17. Dept / Ben
K78-PRISONER OF WAR/INTER
18. BranchCorps 19. UIC / ZIP 20. Type Cas.
DIS
21. Source of Admission
Direct from ER 22. Hour Of Adm:
03:00 23. Clinic Service AEA - ORTHOPEDICS
24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH
26. Date of Disp
2003-11-13
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:
2003-11-08
. in Officer:
\Th M -1-
29. Re
( 't_ - Z
30. Date Ink Adm
2003-11-08 32. Units Blood Com onents P
31. Selected Administrative Data
Marital Status: DoB: 1979-01-01
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and-Special-Procedures:_ „,- _____..
S/P VD R IF DPC OPEN MC FX VD BL LE
/2 - OD V 1
01-616 , 6,2F /
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8)6 ,'6/'
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1 1 g
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g ca. s- -
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.
35. Total Days This Facility._ Absent Sick bays
0
Other Days ConLv / Coop Care Days Supplemental Care
0 Bed Days I Total Sick Days
6 I 0 35. Total Days This Facility
s
i
Lt-7
Supplemental'Care
..4 Bed Days Total Sick Days
. .
Absent 'ck Days . ■•
Other Days ConLv / Coop Ca a
Signature of Atte
Automated Facsimile - DA FORM 3647, May 79 MEDCOM -
DOD-037034
ACLU-RDI 1681 p.16
ABBREVIATED MEDICAL RECORD MEDICAL RECORD
-PERTINENT HISTORY. CHIEF CONFLAINT. ANO CONDITION ON }OMISSION ( ft, •bitc .. ,ionJ
2 9 P r 9'05: Ct' 5/Arl f'6.
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SIG NA7
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ABBRE'HATED MEDICAL RECORD Standard. For= 339
OE .RAL SER'/;CES AND
:NTEPAGENCY DC,mmITTES ON A_-LICA(.
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CC:C.3,7A I375
MEDCOM - 23457
DOD-037035
ACLU-RDI 1681 p.17
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10
USAPA V1.00
MEDCOM - 23458
DOD-037036
ACLU-RDI 1681 p.18
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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DOD-037037
ACLU-RDI 1681 p.19
b10 -7-
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DATE NOTES
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111111V- MEI - 23460
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10
USAPA V1.00
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ACLU-RDI 1681 p.20
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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DOD-037039
ACLU-RDI 1681 p.21
AUTHORIZED FOR LOCAL REPRODUCTION
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101 - 11.203(b)(10
USAPA V1.0C
DOD-037040
ACLU-RDI 1681 p.22
AUTHORIZED FOR LOCAL REPRODUCTION
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USAPA V1.00
MEDCOM - 23463
DOD-037041
ACLU-RDI 1681 p.23
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
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t ,2--,c- 4094 g ,...1_, 6 (4) --z_ ft--v( ON„--- - --A-----riftr<- Cbt&---"Q c
PI - {v--( PLA,12_ ._ t-t- Cars.
Iv AP ( i.ite tir_ Aisci,f,t i„,,ze,,_ ci_ To _.- 2-X6),
HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; Date of Birth; Rank/Grade.)
REGISTER NO. I WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 6001REv. 8-971 Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1
MEDCOM - 23464
DOD-037042
ACLU-RDI 1681 p.24
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT MEDICAL RECORD
FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) ❑ NKDA RPCN 5 ❑ LATEX ❑ IODINE ❑ TAPE 0 FOOD REACTION:
3. PREVIOUS SURGERY y NO [ YES (type):
1. AGE Z9
HEIGHT:
WEIGHT:
9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
Ina C -57)
MEDCOM - 23465 F I CVIUUJ CUILIOI i aic UUJIJIGIC.
DA FORM 5179. JUN 91
4. PROPOSED SURGICAL PROCEDURE:
14-r) kowsol
5. ADDITIONAL INFORMATION: (Previous surgical and medical story) Skin Condition zetiwci,'\ 1-1- lAicrs^"^c-A
Tobacco ppd X_vrs Body Piersirgi Diabetes (Y) ( ROM 41 EMve`^^,N5ASA/Motrin W 72hrs (Y)(j ETOH Implants Respiratory Disease (ASthma COPD) (Y) lel Anticoagulants (Y) Glasses/Contact (Y) (N) Dentures Hypertension (Y) 11 Herbal Medicines (Y N) MEDS:
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS
A. PSYCHOSOCIAL --- potential for anxiety related Pt. verbalizes any specific anxiety.
Pt. Exhibits relaxed body posture.
! , - ‘ ..t..-------,
– q) . i I( .;.< ‘ ,..A.--0.82 ,....."4-v-..e,v
t
0.
stay
. Allow pt. to verbalize freely.
. Explain Or environment and answer
estions regarding surgery.
. Offer comfort measures. (e.g. warm
anket. touch).
. Explain all nursing procedures before
ey are done.
. Remain with pt. VVherrver possible.
Maintainifarnily interfAe. Parents to
with pt.
to:
..---- 1) Surgical Procedure& Operating Room Environment
2) Separation Anxiety
)! (Cy 3) Surgical Outcomes
B. AERATION ----- Potential for respiratory
_.-0—Pt. will be able to breath without
difficulty during immediate intraoperative
phase.
. Offer to elevate head of litter or offer
illow.
. Observe pt. While awaiting surgery for
•gns of distress.
. Assist anesthesia during intubatior
d extubation. 1. -,/
dysfunction due to: ....--
1) Positioning
,"--- 2) Effects of Anesthesia
3) Medical/Smoking_History
C. INTEGUMENT Potential Impairment of Skin
9- Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).
. Utilize pressure preventing devices
OR table and accessories.
. Check for proper positioning and
upped to maintain good body alignment.
. Pad pressure points.
. Place ESU ground pad on non
mpromised skin surface area.
Keep prep fluids form pooling.
Integrity due to: ---- 1) IntraoperativeL-nrnotility
----. 2) ESU Pad Placement
3) Positional Aids
ProstheSiS
----"-4) 5) Pooling_gf Prep Solutions
VERIFICATIONS AT HOLDING AREA: ID/ID/Allergy ../ y Band Dentures Rertil6ved
H&P
! Contacts moved
NPO Since
I Jewel Removed
-E4-1.GGM14172, ! Bo Pierce Removed
Consent/Blood Transfusion Signed/Witnessed/Dated
Surgical Site/Consent verified by
Pt./Anesthesia/Surgeon
Contact precautions (Y)piK
. Family/Friend: ps'..
USAPA v1.0
DOD-037043
ACLU-RDI 1681 p.25
7. PATIENT GOALS AND EXPECTED OUTCOMES
will exhibit signs of adequate tissue
----perfusion (e.g. color, warmth. pedal pulse.
8. OR NURSING INTERVENTIONS
O Check foe support stocking or ace warps. if none, check with doctors.
--45—Cfieck that safety straps are correctly applied. O Offer pillow for under knees.
O Place and take down legs from stirrups with slow bilateral motion.
r0' Check that rings and all body piercing has been removed.
6. PATIENT PROBLEMS AND NEEDS
Potential for inadequate tissue
perfusion due to:
Intraoperative Mobility
2) Positioning
•
45)) 5HaypthfeotyDeremv iiaCes
E. NEUROMUSCULAR
CONTROL Potential Impairment of
Mobility due to:
1) Pain
2) Intra operative Hazzards
4) Positioning
---"" 5) Transfer pt. To/form OR table E.2. --- Potential Discomfort Due to:
CI pt. will be transferred to OR table without gifficultly .
0 pt. will be not experience unnecessary
physical discomfort.
01 Have sufficient people available for trtmsfer. 0 Insure proper body alignment. q Allow patient to lie in position of
comfort while waiting for surgery. Offer support (i,e..pillows. Bath
t wel. etc) for positioning.
1) Length of Surgery
2) Positioning 3) Arthritis
F. Special Senses F.I. Diminished visual perception due to being:
1) pre-medicated
W 0 GLASSES
F.2. ----- Potential for Decreased
Communication due to:
1) Diminished Hearing
2) Language Barrier
F.3. Potential Injury due to
Dentures:
pt. will be made aware of surroundings p for to anesthesia induction.
pt. will be transferred safely to OR table.
Ipt. will be able to understand instructions. Minimize danger of injury during intraop
riod.
01 Introduce self. keep pt informed as to ere he. she is and what is happening.
01 Inform pt. in which direction to move aid assist if necessary.
Speak clearly and slowl . Address pt. from side.
Validate pt.'s understanding of verbal ommunication.
O Verify removal of dentures.
1) Upper 2) Lower
3) Bridges
4) Caps
5) Crowns
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 INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
tt-t\J DATE
11. POSTOPERATIVE EVALUA SKIN INTEGRITY: Bovie Pad Site: 12r Clean and Dry ❑ Red ❑ N/A DRESSING DRY & INTACT: ,%
LEVEL OF CONSCIOUSNESS: ❑ A&O L Drowsy ❑ Sleepy 1:1 intubated (N)
LEVEL OF ACTIVITY: lg MOVES ALL EXTREMITIES ❑ Moves Upper Extremities 6
EATHING EASY:
❑ Transferred to Litter With roller due to spinal
12. PREOPERATIVE EV PREPARED BY 13. PREOPERATIVE EVAL (Signature and Tir -- ) 7 cAn- iitiks, BY (Signature and Title) r c)A,
, i k.,.- 2., DATE: aV,\1613 TIME: 0 DATE: g \\JCV1/47 TIME: 09 1-(-5
REVERS OF FORM 5179, JUN 91
MEDCOM - 23466
USAPA VI.0
DOD-037044
ACLU-RDI 1681 p.26
MEDICAL RECORD f INTRAOPERATIvE nOCUMENT For use of this form, see AR 40-407, the prof , ;icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAT 1 iM
VIA ' . Y By 1..\--C.A" 2. PATIENT IDENTII AND PROCEDURE
VERIFIED BY CAVT •.. ( ) -..?-
3. DATE TIME PATIENT IN SUITE
-1K '1‘' sr,X) n 7 4; PATIENT IN ROOM
-2 TIME• ; 0 g 4-0 NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
ANXIOUS EXCITED.
VC\62-CX"
❑ ANGRY a CALM U II CRYING U WITHDRAWN U OTHER (Specify)
COMMENTS: ia (- 01")`"VVI7 _. ...
6. NURSING PERSONNEL
ASSIGNED SCRUB
._-)c;;C, -------- -""` "RELIEF .. .SCRUB
ASSIGNED CIRCULATOR
C TT 1111.11111N RELIEF —....CIRCULATOR
11‘.i .-f. • .
7. POSITION AND POSITIONAL
IN SUPINE
,=-(3,,r \-.2-0 COMMENTS:
AIDS (Specify)
LITHOTOMY , ❑ PRONE ....)/-Ace.A4n.e.2.A.nA . -''"
-•.,- ..-, .
LATERAL: U U KRASKE ,...,:AAckAAA.-A,7nA...ztki
• LEFT SIDE UP • RIGHT SIDE UP
4-=.. 8. SKIN PREPARATION
HAIR REMOVAL 0 YES II NO ' UNIT
-- .
PREP SOLUTION (Specify) C"...1CA-c",,-'--t— ICS•P-Ac\- - s sk SITEcgCs.,-, ‘,...N. BY WHOM: SITE: b‘ LE. BY WHOM:
..... COMMENTS:"1,...(7,' y TN( 9/,,,,1/4„,1/4 /1 ,l
DONE BY: 0. OR • NURSING METHOD: I/ DEPILATORY 0 RAZOR
• CLIP
— COMMENTS:
9. LOCATION OF EXTERNAL
•
.
- .
Pa
DEVICES
..,
s
.7.-N.,..,
-
.
- Safety Strap =
e.,"0...,V 1r611 ki,&& ' . ".""
1--.::-Nrts _ . .
Al' ....
kil..
-
..../ ...
k. 0 \ r
■
....
f • I .
LEGEND X Ground
-.MIMMINA.-4111/1-1111Mal I I raffP Til
= = Tourniquet
-.--
0‘i --. :• -2
10. COUNTS
C = Correct I = Incorrect ( (--c. - 2
Other•' First Closing Count . !,
Final Closing Count • E. __ CIRCULATOR
Sponge 0 Yes
Yes
Vo
o
..
......--"" ..,;-----
,----..-. .. ..-..... . Needle Sharp [2 Instrument ❑ Yes M o :, I. .;. -1 -,". T - . Other NI Yes kNI Vo 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
471)
,
i Q \ik\'iC,3 4' (2-11 '
12. ELECTROSURGERY DEVICE(S) (ESU)
‘kelic.:Ar"
• YES NO .2:1
-t L3Nr u)... Lk() kg ESU NO: VC\
GROUND PAD:
. ; ..0.4ESU NO:
BRAND VL V...;,/-A. ,,\ l'IQVII`rtil- LOT NO -.4" 4 . 5 g "7 4 x .)--s" -
- --GROUND PAD: ' -..-.
• BIPOLAR NO:
BRAND
LOT NO:
-1, LACES DA MEDCOM -23467 -I IS OBSOLETE. USAPA V1.00
DOD-037045
ACLU-RDI 1681 p.27
13. PROSTHESIS, IMPLANTS • YE._ ' NO IF YES NAME: ID NUMBER; ^OTURER
'MEDICATIONS/ORDERSM0 .. :,., '1' IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO
:MEDICATIONS/SOLUTION DOSAGE . TIME' METHOD PREPARED BY GIVEN BY
_.,
MOUND IRRIGATION 4 YES ❑ NO, TYPE(S):
. ,...„
OTHER ORDERS TIME - CARRIED OUT BY r'k,A_CD,.__Q_.
_ — --
PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING ROOM . -- IF YES, SITE
NO cg YES II
16. :LABORATORY SPECIMENS
SPECIMEN (S) . , ..- , ..,. NAME -
YES • NO E '
FROZEN SECTION (FS) NAME NAME
YES ■ NO r4 CULTURE (C)
NO
NAME - _____ __ _ ___. _ ...__
NAME
YES ■ NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
be_co
V._9-i•AX
Y....1./NAX i■ r.)../v ■All,
C2;t'i‘o1.‘ikk '
4.
17. TUBES, DRAINS/PACKING YES al NO •
TYPE/SIZE 120S
.. _ . 2. 3.
SITE if-,
.R) \ACT.A.Aek,
2. 3. ,_ .,„,,_____
19. ADDITIONAL INFOR gi
s/\/\( — CY\ .. ((): '.(..._ :, ..
itlkil.gki2Vi O■ . . . _ .... ,_
20. OPERATION(S)
-_-L--1 T
PERFORMED
1 c.,,,,t-A_Q L E 1e
21. PATIENT TRANSFERRED TO
I OA UAL%) A7 Cfb '1-'
T I M E ' ■2.2._
. it- 33
METHOD
Uti-Z.J.V 22. RE (STERE 1
‘ \.I MEDCOM - 23468
DOD-037046
ACLU-RDI 1681 p.28
. MEDICAL RECORD INTRAOPERATIVE. D" ''':UWIENT For use of this form, see AR 40-407, the - the office of The Surgeon General.
1. P TIENT TRANSPORTED TO OPERATIr ‘.
VIAS BY -
2. PATIENT WED AND PROCEDURE
VERIFIED BY CPT Ar,J 6 ( e., -2 3. DATE TIME PATIENT ARRIVED
10 Nov 03 IN SUITE
,-, 4. PATIENT IN R
TIME (103 MBER
5. PREOPERATIVE EMOTIONAL STATUS
ri CALM MI ANXIOUS ❑ EXCITED U CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL •
ASSIGNED SCRUB
Spc .
- - - -RELIEF SCRUB
...-- i.i
ASSIGNED CIRCULATOR
CPT RELIEF . .___. _ _ .. __CIRCULATOR .
7. POSITION AND
Q, y
POSITIONAL AIDS (Specify)
LITHOTOMY
a- Liriltitt Dtthi
...-
LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP 5 SUPINE • II PRONE U KRASKE
COMMENTS: prbp _ moi nicv-114:_..__-_-. 8. SKIN PREPARATION
HAIR REMOVAL
DONE BY:
METHOD:
COMMENTS:
❑ YES mi OR
DEPILATORY
CLIP
NO
UNIT PREP SOLUTION (Specify) SITE:Il-t-,aryy) SITE - .
8 ttacti vg_. c coi BY WHOM:
BY WHOM:
( ---Z- in of ftuids
U U NURSING • IN RAZOR II
_ COMaENTS: 1\10 Pot/
9. LOCATION OF EXTERNAL DEVICES
- —
•
a 4.
Ground Pad -- Safety Strap =
• -
•
LEGEND X
-
.0- !,
.1* '
--"simml.""4113.01111m11111W-
1-1716P-
= = Tourniquet...-.
. .... .: ,
-----
10. COUNTS
C = Correct I = Incorrect -BILI:-W" C ,i,.:. 1(2, ) l
Other• • First Closing Count , •
Final Closing Count SCRUB CIRCULATOR
Sponge Yes
Vo
0 0 0
I 0
7'
7 7 7
7 Needle Sharp f Yes . Instrument D Yes ........._------- ...,•1)1 f . ' -
- --c-:"- Other ❑ Yes
11. PATIENT IDENTIFICATION Name - Last, first, middle;
4 k0
11111111114.0
For typed or written entries give: Grade; Date; Hospital or Medical Facility;)
( Q.) - ' 11
-'7j1
12. ELECTROSURGERY DEVICEIS) (ESU) YES ❑ NO
, i2 ESU NO: FDIC Z.- 4-D IZSe OAS 4614b I D 5,.. i_3 GROUND PAD:
❑ ZE6U NO:
BRAND Va )(to (GEM LOT NO: 93 53
-• 'GROUND PAD:
III BIPOLAR NO:
BRAND
LOT NO:
DA FOHivi , OCT 87
REPLACES DA MEDCOM - 23469 I IS OBSOLETE. USAPA V1.00
DOD-037047
ACLU-RDI 1681 p.29
13. PROSTHESIS, IMPLANTS 1' ] NO IF YES NAME: ID NUMBER JFACTURER
, J-z.:7;A:,_ ,•,::::,..:;PMEDICATIONS/ORDERSi
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY. ANESTHESIA) YES • NO 7:1, MEDICATIONS/SOLUTION DOSAGE TIME - METHOD PREPARED BY GIVEN BY
, •, . .... — —. - •
WOUND IRRIGATION 2 YES • NO, TYPE(S):.
0.990 r■)S • 'OTHER ORDERS TIME CARRIED OUT BY T Dr JZ _ -
PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING RO IF YES, SITE YES • NO
16. s' - = LABORATORY SPECIMENS SPECIMEN (5) NAME
.._ -- , ., ---- — : NAME — YES / NO gi
FROZEN SECTION (FS) NAME NAME YES • NO MI
CULTURE (C) NAME ___ ._ .. - - - ----
NAME YE5 ■ NO N NAME NAME NAME
NAME NAME
- - ----
18. DRESSING/IMMOBILIZATION (Specify)
./ 1 15 6 Le V-e r Arm . NA AS "
)e,j(11 y, VtdilA 10.4114 Pkrlde-r spiA.A-1
Vel‘ art( )
17. TUBES, DRAINS/PACKING YES NO g TYPE/SIZE 1. 2. -' - .
SITE 1. 2. 3.•
19. ADDITIONAL INFORMATION
Suri . AYULS4d1 • cef\)A _Alks,s:fh. i
NC.-Lw i
! 6-evu_val brn.ii-
20. OPEFIATIOtO(S) PERFORMED
T:1. - i) id closLat 0+- al- hand 1,,)(5-Lvad, _ -
z. Clert_vi_ recly e ig;o, Lcuer eAt+. 1-ogiAA-d5
21. PATIENT TRANSFERRED 0 PA- - tk,
TIME
1201 METHOD
V -micirLer- 2 ATURE, frti
VT/ MEDCOM - 23470
DOD-037048
ACLU-RDI 1681 p.30
i .)11-119
MEDICAL RECORD
NSN 7540-00-634-4124
VITAL SIGNS RECORD
HOSPITAL DAY I POST- DAY MONTH-YEAR WiI. DAY irfallInfill11111 3111
.m ..13E1 HOUR ; • - PrIMII" 0 :
•• MIP.1211-41111111Will : : : : -. :
- - : : . . . . . . . .
PULSE TEMP. F (0) c.)
105°
180 104°
170 103°
160 102°
150 101°
140 100°
130 99° 98.6
°
120 98°
110 97°
100 96°
90 95°
80
70
50
40
SPIRATioN RECORD
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•
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BLOOD PRESSURE
im 123/a1111111g111111= ■Mill
AILIMINIMEADIAMIIIIIIMRIA UM km.
17' • - 4 ill ilaire , WEIGHT HEIGHT: .-110. MI bt A
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3 IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
REGISTER NO WARD NO.
ICS1 1
VITAL SIGNS RECORDS
Medical Record
MEDCOM - 23471 STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
DOD-037049
ACLU-RDI 1681 p.31
O
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
'AN
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r'l 1 a TOTAL URINE
C-C ( • AI .
I MI VOLAT % del lagliMillig FLUIDS . SUMMARY AGENT % e.t. CRYS Imo DI -
AIR L/Min . ale N20 L/Min COLL ID- 02 L/Min /111IIMMEIMMII
WITH NUMBERS 6 ENTER IN REMARKS SINGLE DOSE DRUGS-MARK ON GRID BLOOD-
to LINE si e 0 Warmed REMARK 2 immir CI Warmed V* •19ff -----•.------.---- tgt.))- Code dm s with numbers,
❑ Warmed events wiql a
enleris , . 30111 cttel
wo A-_--, ,,c.....,, •
❑ Warmed LOSSES
U• E - ri 1 Vtle-4-1 Cie(
EST BLOOD LOSS ,„-t t"./.1"\)r '
'Aji 1 S STAT UM TIME :,0 t.K 09ce is"
BP-IIIII ■ .
220 , Fe• DIZIEFWEIGM SYMBOLS: trc,...„, -CV /7
f / sir ( S
6 zr-2,6--- Y-
‘0 B BP by cuff 1 • I . ,) 1.,` d OG ../ tt-y0
V 200
HEMAT MN I I I I I (1 06 i 16 ( A 180 : : : : ■
' . ' 11/1/X4111 Heart rate 160 Eggs
CT : : : : . . . INITI • L A A: • cdti aw-52_
Resp rate 140 ■ IIIII , , , ' IIIIIIII : W (.6.L4' MiNtwq 120 marnAixamitilMersPISIMMETAFAMM ,
' ' ' 0/1 11 at/A— in= Itran:dRucec0 100 ' litillii "ain . . = ' ' ' # ME ,
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MEM k..1.--6. si L-4 PATIENT RECHECK T-
Lt& EVA OM ' . MEI
X- .U.f . —
40 , , d... Mill OK for 4
TIME- ipYtt PROC- 8_0 PROCEDU -- ANES- X-X 090 Ifif C-Xd
1 1 f I I I ■ I , 20 MIME ' ' IEEE
EMI OMNI 111111•Mii / it/ S>0.' t
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ut Peak inf pres / PEEP A. MIMI_ s-i- z
d At--1 MODE - St on). Issist). C(on) 11/111 ;NM =HMV
1- 0
14- BP/Auto Cuff r„ to_ ,T CO2 (torr) rep. 32- lairtir ICU Spacily1 ' P/oth 102 (Frac or %) —la fall,_ 'r "
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ur C Gas analyzer TEMP-site RESP. a SpO 9 iii C./Q g N-M Block (T/4) KI IM I
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CC CO
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Cony warmer t Ready Begin End Me k with letters & SYmbols. EVENTS_, 0 explan under REMARKS Position - 0.---1 ----41T-66 ------) a.cc . 6 1 eb •••••
PROCEDURE and CPT Codes: ANESTHETIC TECH IQUES: Describe block technique under Re narks
PATIENT ID TIFICA ION: Type/ or written entries: Name, Grade/Rate, A• i NAGEMENT Intubation route,h1We, technique omOenus_ vopic li CLA? c, L.C3clAe ;At' >4 A ...p`. E
.6-9 wock5 ,
AWAY 47 Medical facility 1 .. Ea............K. or - dr U.. PROCEDURE /7 / a
LOCATION: C"
‘c.(uk-S - 1-\1/4 AN •
DATE:9' ya) 0 3
1— PAGE J OF /
9, FEB 1998 MEDCOM - 23472 COPY 3 - ANESTHESIA DEPARTMENT r USAPA V I.00
DOD-037050
ACLU-RDI 1681 p.32
PHYSICAL EXAMINATION BP _ HR _ R T_ Pain Scale 0-10 HEENT - Teeth
Trachea ,4---212-0.--- TMJ/Neck Oropharnyx
CHEST: oV/4---
CARDIAC:
EXTREMITIES:
IV Access: Ulnar Filling:
BACK:
OTHER:
PREOP ATIVE PAST MEDICAL HISTORY EMS REVIEW Cardiovascular:
Hypertension N Y Angina N Y MI N Y CVA N Y Other N Y
Pulmonary Syst Asthma N Y Bronchitis/URI N Y COPD N Y Other N Y
Renal System: • Acute/Chronic F N Y Gastrointestinal:
Hepatitis N Y Hiatal Hernia N Y PUD/GERD N Y
Endocrine System: Diabetes N Y Steriods Thyroid
Neurological: Seizures Neuropathy N Y Other N Y
Gynecological : Pregnancy N Y
Other Significant Hx: N Y N Y
Familial HX N
NPO Since
ASSESSMENT FAST SURGICAIJANESTHEI1C
HABITS: TOBACCO:
ETOH: DRUGS:
CURRENT MEDICATIONS: ( ) = ordered as premed
()
( )
() () ()
( )
PREMEDICATIONS: None Yes (@ Hrs) /CC mg IV IM PO mg IV IM PO mg IV IM PO
LABORATORY STUDIES:
HB/HCT: U/A: OTHER:
ANESTHESIA PLAN OF CARE PREPROCEDURAL ASSESSMENT (Sedation/Anesthsial Age _&515AYS MCZ44: Sex ( ) MALE ( ) FEMALE
ASA Physical Stat 2 3 4 E PROPOSED PROCEDURE: WT: KG/LB . SURGICAL SERVICE:
1 ALLERGIES:
NPO SINCE:
POST-A AND NOTE (NON ASU) { ) NO APPARENT ANESTHETIC COMPLICATIONS { OTHER
Signed: Date: Time: Hrs
Patient Identification: (Ward)
.ttiaria.(c,S1
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
ANESTHETIC PLA { ) MAC { Regional (Specify):
‘ral: Mask Intubation
egal guprdi7. SELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
s to un erstand and agrees. Questions answered.
'--
_-z_ Date: /YbV)er 3
Time: 63.3/....>-Pa
INF disc
Th
Si • Hrs
PATIENT RECORD COPY
MEDCOM - 23473
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.
Previous edition is obsolete •U.S. GPO: 2001-62948300002
DOD-037051
ACLU-RDI 1681 p.33
R.ADIOLOGfC CONSULT.ATION RECUESTiS'EPOF:T
/VI I HI
To_YS
Gs-V\I
.A.... .= O .'. E X..'A' 4•4 "'"A . 1 °'.." r.'f.':: , . ‘, .Y. Yt----) 3.....7'.: OF A' E0=‘ - . (..-fon:.....,....y.
'AE OF 7-;...1ANSCRIPTION rolo.,:"1. e_..--7,
IC: L. 0 C R C,
I
- • F- • : 1.
=■
MEDCOM - 23474
DOD-037052
ACLU-RDI 1681 p.34
Yg •,.. P. iC RE C:IS -.- C,.
:=-7:c..t...:Zsrzo ay •, I YEiS
• 7. • • • 7.
•- •
• •
R.LDIOLOGIC CONSULTATION REO. ESYREPORT
K52f■—. jfi KO'
i cd \t&
Lf YO 1-1 1 c45I AAç
OF .10,N
A ,..:rO L OG f C 1
0...7E OF ;-1.=_?-o.;:(Hart:,. ezy. ' L -.3 .... 7 .:. OF 1- A.=..NS:....P.l. • i 0 :4 (11 0.... '..-, . L.--;.. -... ; 1 •
t
1 •
7... 0 7 A:4 1% • c - -
C FA; :a:•...- - •
MEDCOM - 23475
DOD-037053
ACLU-RDI 1681 p.35
14-97 ull
1-38 uil
0.271.6 ogld
I 5-65 till
6. .1 0.1
iT [IL
31-
RESULT REF. RANGE
3.3-4.7 trunoLii
9S-105 rrsaoLl
1:3-33
EST
LB
LP
LT
NtY
REOLIEST:". •
IL\ tE 8
--
CITEI‘ILSTRY REULTF0RI (Stzeto the ?rivacy Azt of 1374)
SSN/PS SSN: )7_)
L
ioIIL
(let) (vca)
(W)
(Nca)
ALB 4.4 3.3-5.5 G/DL 85* 26-84 U/L ALP
ALT 94* 10-17 U/L AMY 59 11-97 U/L AST 55* 11-38 U/L
••: TBIL 0.9 0.2-1.6 MG/DL GOT 33 5-65 U/L TP 8.0 6.4-8.1 G/DL
INST OC: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0
RESULT REF RANGE TEST
i-STAT
pow' Pt Name:
Clu 111 mg/dL
BUN 10 mg/dL
Na 138 mmol/L
1. 4.0 mmol/L
Cl 10g. mmol/L
TCU 22 mmol/L
AnGap 10 mmol/L
Hct 43
Hb* 15 q/dL
*via Hct
pH 7.329
PCO2 50.7 mmHg
HCO3 27 mmol/L
BEect 1 mmol/L
Sample Type_:
08NOV03
05:53
Oper:IIIIIII j- 1
Physician:
Ser# 42015
Ver: JAN304R CLEW R93
TEST I RESULT
8.0-10.3 rnEiiii
0.6-1.2 rid[
, 128-145 mrr.o1/1
3.3-4•7 runoli1
9S-108 mmol[
18-33 thrnoLl
• •
TEST RESULT I REF. RANGE
(art) • veal
o4.1 ALB
LI;
PICCOLO ----- 08/11/03 REFERENCE Ra PATIENT II:
AE:
LIVER PANEL PLUS DISC LOT #: 3154AA7 711- OPER AIMS DR #: 000 CO2 SERIAL #:k4 Q)=U000100491
03:51 CU MALE \IA-
)2C/2 -E.4
I GUI
BUN
CA.-
73-11S rr:•.'.:11
7-22 mi.-ft!
I R_EPORTED BY:
DATE: I LAB ID SO.:
MEDCOM - 23476
DOD-037054
ACLU-RDI 1681 p.36
MEDCOM - 23477
RAPIDPOINT COAG ANALYZER V4.54 SERIA1 41.105485 11/08/0j 04:09
1 Pi Patient ID: 1411111
- 4-1 1„: lest Name Tet)i Result.= 15.2 sec. Ratio == 1.2 Calculated INR = 1.43 St Si4.mple type:citrated wh. loud
Bi TeA Date :11/08/03 fet Time :114:08
L3 Card Lot :080201 Operator
RI RAP1DPOINT COAG ANALYZER V4.54 M SERIAL 4005485 11/08/03 04:14
'," Patient ID:
Sp Test Name (Cz-
Fie Test Result:. 31.5 sec.
Se. Sample Type:citrated wh. blood Test Date :11/08/03 Test Time :04:10
Or` Card Lot :100208 Operator
At
H
F.Vard: • - 'ScN:ticic. -i-- \ -AT i LAST, FIRST, MI.
L
I
I DATE:
n411111110OB-11-03III) a Q 04:06 Patient I Limits
UK 19.1 H x1083/uL 4.5 10.5 RX 5.37 x10*6/td. 4.00 6.00 0:11JSTSU Hgb 14.6 g/d1. 11.0 18.0 Ha 45.7 Z 35.0 60.0 U?v7T MD/ 811 ft 80.0 99.9 ROSSAL-f TCH ICH 27.2 pg 27.0 31.0 ME 320 I. g/dL 33.0 37.0 Plt 202. 110"3/uL 150. 450. LYX 11.7 *I. Z 20.5 51.1 LY11 2.2 * 110"3/uL 1.2 3.4
(C.e) --t- LABORATORY RESULT FORM I .- Sub;cct to tic Eciv:.•c ■,• Act of [9741 i, ---t: I 1 rivc SS2,:iPSEET-577----------''' 1 .,,\. 3 A5 03 1 S )11=. ti (a- -1 ‹).. ric../ ---- - .. . rooms
Z:S:-.11-7 Rib: R4 VGE
„ C
I LAB ID NO.: .
I Ncgati Yr,
I Nklp vc
I NVA
I-leg:at-lye.
NJA
Negative
0 2 - L 0
I Ne-3-3:ire
NcIpth-c.
N/A
Gram Stain CkzcBld
H. pylori Micro Parasites Malaria
O&P
(1Ik , e
I Sou; cc
TEST' ( RESULT 1 REF RANGE RPF. I I M.S.-1.1i rc
Nioao I I Nicabut Microb io-1 az), -
05. BLOOD •
1.13Ank
SF 518 WITH
nv_tivc4vc
TEST I RESULT j REF. RANGE
' 9.E-13.6 3CC3
1 21-34
L
rE"
f P_EPOR.TED BY:
DOD-037055
ACLU-RDI 1681 p.37
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
co
7
0 CI Z < 0) I • - • Z uj
(-2( 0 17- uj
1_. F co . Z <
crt
n 2 z
° S ,17) 2 2 r, 1- 0 __ ifj 2 i__
w co < --.1- 1-- 43 2 CO
(r) 6 R EL.>• (-)11 1:: (-) !-- Z It! 0ti
,.•.
DRUG (Units) TOTALS TOTAL EBL
( TOTAL URINE zikree0,,,, /,,, ► PI____
C I- • Z
1
1 --4_ VOLA? AGENT
.c..- f7941/C_ % del F, ,2 .y1 FLUIDS -SUMMARY
% e 1. CRYSJ.SLLOID AIR L/Min
N20 L/Min COLLOID- 02 —:3 L/Min —7—
SINGLE DOSE DRUGS-MARK ON GRID. ,s, WITH NUMBERS & ENTER IN REMARKS
iiiOlic- --
cn 0
5
LINE site ❑ Warmed REMARKS Code drugs with numbers,
events with lettlers
7;7 (9
a 2"th...4k) c ,/,.65re u, ,r9,41 --.4c.a ■ 7 Z4PC)0 (.4114/- .2-6At
D,dc)/1/9-41 /6"6 /k)
,Ifve, /five- /"°7 0 i-/14//1" -
El Warmed XL - — 1 -- 2 .90 ID Warmed
❑ Warmed
LOSSES EST BLOOD LOSS 0- 64)
UR NE -
PH a STATUS TIME -lialve- /5----- 3 r.s--- - .
1, 45 E SYMBOLS: 220
200
180
160
140
120
100
80
60
40
20
I---L- -1 -1-1- • BoSY WEIGHT: . . ,
—, ;
KG LB
BP by cuff
A Heart rate
• Resp rate
BR (transduced)
I. T
T —/-r"
ANES- X-X PROC- 8_0
• t
, . , V ------ — . , .
HEMATOCRIT: "
i-- '
1 1 . ( 400.6.1eve 47- f
17 r9igew-e--)Cer‹. Po.i';
INITIAL DATA: ■ 1
• •
BP-
; , ,
_2(2_ , 57 _ , .
.r., 2 bireii* p< •
A/e /I , Cad Xit,,r4 . -70 /a,e0Ar,27,
IL
RECOVERY AT
, „
. ,
'
,
R-203 ,e — , ----
EQUIP CHECK ' •
TOURNIQUET OK? - Y N
PATIENT RECHECK
' -, __,_
TT 1--
_L -1--1--
L -- -1 -1-
___ • --• --,—,---
OK for PROCEDURE?
TIME-
—i—r ,
—
--"
I / At
t "
_...t_._ i . ' i , , , , ,a
or . I- Z tu
VT-ml
f - breaths/min _ ZY 0
S-V
Peak int pros I PEEP
/MODE - SIpon). ssist), Clon)
LE2
CE 0 r0) ur (..) r.)
In CC 0 i- 2 o
BP/Auto Cuff E CO2 (torr)
BPloth F (Frac or %) .. dr PACU ICU Specify]
OTHER ART line S 2 1%) ,,,, • •
th- PC/ES CG 5 IrKa / 0.__ ,L.' CONDITION: 5'714 e
RESP -7 Sp02- 74, 9. BP-
PROCEDURE
f HR- 77 ANEST ESIA / PROCEDURE TIMES
`Gas analyzer TEMP-site
N-M Block (114)
to Start 'Li Room End
Warming blkt .1 /19,9/ /0 /2c( Cony warmer
Mark with letters a symows. EVENTS__ ...6 0 0 Ready . Begin End
expla n under REMARKS Position - e o,- // 2 3 //, 7 / 05,1 PROCEDURES and CPT Codes:
17 /fit/tit CI— C Z Ocare ° i "1j f" 72) 4?
ANEST ETIC TECHNIQUES: Describe block technique under Re narks
e/✓ C i /1/1 /4 AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
-# 9 .Z/)/W
PATIENT IDENTIFICATION: Typed or written entries: Medical facility
game, Grade/Rate,
(11)."'-' t - ''
PROCEDURE LOCATION: C....ilf
.-.... ----. -- --_ ____
DATE: A.
A9 <63 .127/.../11._.
PAGE / OF
MEDCO COPY 3 - ANESTHESIA DEPARTMENT USAPA VI.00
DOD-037056
ACLU-RDI 1681 p.38
DATE OF ORDER
NURSING UNIT ROOM NO.
BE• NO.
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 MEDIFAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFIC
HOURS
Acti,..4 44. Icta
ATION TIME OF ORDER LIST TIM ORDER
NOTED AND SIGN
-L
-3`
c . Dx- (R) r,4" I4itlitL
(fir
1A- 1--(s- G2 9 ° ROOM NO. BED NO. NURSING UNIT 411-- ?cf.) at\c,-147 - tvb b. I Apift-eD
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
CI)
N O - a., c...►J( A.6 CYC
r -7Ti I U 1"144-J--) ,.._ 10 ► 0 /121^1
ro imp - Lg..0 /00 c
HOURS
_ NURSING UNIT ROOM NO. BED NO. c9 PATIENT IDENTIFIC ATION DATE OF ORDER
0—. 0 Nt.■ Cc
Apt, tto oc1D-ki4 NAN) Dy-- T-a-b G (P meFx
IdD a. LE
4.) (29
B D NO.
()
PATIENT IDENTIFIC
vcvv,IN —c? tb x3 -7t Al\-- Po-) — gx., A Act- qa-io-
DATE OF ORDER TIME OF ORDER
O _ Lfzc, PLTU da6-A)
4-aL4r-ke-e-
HOURS
NURSING UNI
9 /202
DA , FAOPP M79 4256
- Av. ip.,,,1V Qt°
(t) (9+0`) P(4-.) ts-- iv avp
(ti)
RE ACES EDITION OF 'I JUL 77. WHICH MAY BE USED.
MEDCOM - 23479 t A J
DOD-037057
ACLU-RDI 1681 p.39
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 MTCAL RECORD
• i SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
r \--D ._(-k-
DATE OF ORDER TIME OF ORDER
Ct 1000 C80 [ 1 50 HOUR'S`.
LIST TIME ORDER
NOTED AND SIGN
Ai/lb — MA} do de cc. €P OR li, AM /0v 03 0 c 0,
lopoi sste0-11- IVF t.gco (o ull.„ il
Al i AAA- .- A ... • • d L LUM.X34,0)
vi NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE O • OF as • ER
W -V3 IR 16D HOURS 10 tft2
u) ALS, Kk Po) Iz_i-) I_ • ri _ .5-15 D 1 ( IP- 09k, kYt-Px
r sa -1,..,1 x3i-L_ a.sit, A6
NURSING UNIT ROOM NO. BED NO.
AG C e) 4-&5711: ?I) 6 C)
DO (5- Ar 14k- 1 ki Lula,—
ATM OF ORDER TIME OF ORDER
-1-ilork i, it u...e HOURS 1
PATIENT IDENTIFICATION
# 'i..
• 0 . , - . A. op E. \ \
& 0 asiP - (6 10-4-•--P 0 ANA— b,.. i ..1 ' I V OF x3 a
mS0,1 r -Tr Ka ty Q i° 1 P R P Ats.kilui eiv.t. zr 0, Q ° AZAJ
NURSING UNIT RO• BED N s
Z.5-,6 W RA,* ,f Pr— ‘50 0 PO (0 V—V461,/
PATIENT IDENTIFICATION
bkiA,Y- 1--
DATE OF ORDER TIME OF ORDER
D 1 c ... ,,, d.,,,c6 & ,.•. i • fli
6 _
• ...• r '•etif 0 NURSING U ,d, •
D FORM 4256 I APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED .
MEDCOM - 23480
DOD-037058
ACLU-RDI 1681 p.40
CLINICAL RECORD THERAPEUTIC DOCUMENTATIONtARE PLAN ( NON -MEDICATION)
For use of this form. see AR 40-407; the agency Is the Office Of The Surgeon General. proponent MO. ( Yr. 2003
VERIFY BY INITIALING ag**Otaetrin4M*tr.., ''' g INITIAL PROPER COLUMN FOLLOWING EACIt COMPLETION
ORDER DATE
CLERK/ NURSE
RECURRING ACTION, FREQUENCY, TIN
HR DATE COMPLETED
ilf01 06 I I V a n- F., NIDi \/1-VA_ q4-9 ‘3 I 0
.
4V-szn III . . _
•\--c--, S\C-■1B-- Aill
Illi 4)3 ---011pc_t ems- _
- 11111
_ _ 'c2k , (.0\1 c. - - aes--Jai f --3 4° - 0(1 -dpirp, dA,+.
!i n 4 - S cD
PM 01 ,
- 41,
ir .
- - - A at. LL mt-Lckc- 'RoirrA 01111r-An q 4--Q YN-) j
_
101' cl) iiirn 9
-Sioc iz\e■,0-cn.
1 sb - - .
93 _ F__-
s„ \„_,.,\\,), .
■ .1Li I' Ii C dsL.F. /
ALLERGIES: )0, YES
' PCNI
MI NO PRJMARY DIAGNOSIS: -pcC. s(p. VD ;" CD■._,N) t-(V____
VD "BL_ LF_.
ADDITIONAL PAGES IN USE: N. YES MI NO
PAGE NO' PATIENT IDENTIFICATION:
MI6 ACTION TIMES
L6 ' 4q 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 MEDCOM - 23481
•••■ Oh am.. N... • • ■■•• • "IP 11.4.• ••• •• Cu. I gun ur 1 UCL. s I Mar nt USED. USAPA V1.00
DOD-037059
ACLU-RDI 1681 p.41
Verity by Initialing
it HERAPEUTIC DOCUMENTATION CARE PLAN z
7 ( NON-MEDICATION) Mo Yr 2903
SINGLE ACTIONS Date to
be Done Time to
. be Done , Time Done Initials Order Date
Clerk Nurse
• i . m Lc) \c_.\k; \ - cie__1- -vc) - Dr- \Ni\f-■&._ , ma( \ (Ps N PO-cc c \ o-_ -ko Te, IrDi \ - / /0/9 /) hrliu r--- --Inoi c79-10
1/ (A/ 0 a, OA A 0 , .\-\- 47c3 -P\C_SD --=) \CAN) 1 - CCrd 72'8e- i0
Ordxped Elr Date
Clerk/ Nurse
' ` PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED
— — — — — —
•
— — — — — — —
— — — — — — — — .
USAPA V1.00
MEDCOM - 23482
DOD-037060
ACLU-RDI 1681 p.42
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
23 24 01 02 03 04 05 06 MEDCOM - 23483
r1:D a_‘) - a \ ,/
/ CLINICAL RECORD,/
a THERAPEUTIC DOCUMENTATION
For use of this form see AR 40-407; the proponent agency is the
q. 4.:a
. _ TIVERIFY EllyIVI ALING INITIAL N
OF1DER DATE
CLERK!/ NURSE
I
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
$ 01
Wart1 2 - --C:= \ Ticbcd \--1-- • -ok__.\\] 0..
..,
Ni O\. - A
r fum: AIM
16k-
As. \ Nir
-- MI :-.-Ar♦
ONAL. PAGES IN USE:
\
.F. /py ES 0 NO
r)C—.N--/
K—q71 N--3 cce
PRIMARY DIAGNOSIS:
mc 7._ ? V1-- , ..-. c(,.- 3 -( VI) ?3,_ (E
F: ES El NO
PAGE NO
I --------
DISPENSING TIMES
DOD-037061
ACLU-RDI 1681 p.43
Verify by THERAPEUTIC DOCUMENTATIUN LAKC
(MEDICATIONS) Mo. )\
SINGLE ORDER, PRE•OPERATIVES
Dote to be Given
Time to be Given
)rder Date
Clerk/ Nurse
Time Given Initials
PRN MEDICATION, DOSE, FREQUENCY
\\(Lf`cn \\I c\bc)
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
U.S. GPO: 1998-454-110/95216
MEDCOM - 23484
DOD-037062
ACLU-RDI 1681 p.44
■1111•11•111•
CLINICAL RECORD ■
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;
the proponent agency is the Office of The Surgeon General. Mo. Il Yr. VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED ORDER DATE
CLERK/ NURSE
I - I #
$ Id I 0 . l
(V----- - . .P.-S=D \ CACCA-`c ' 14-- \\/
4 \ ker \ "C)\ . (--) V\ i(D\ \ 1 . I •
Cra - 1111111Acce_V -‘--9 N cf-3- lb \dr
kt-_,- --.1")
ALLERGIES- I t.y E
- /
s QNo
PC-
Tot- .6't-/(-7.- \V-1 <P
PRIMARY DIAGNOSIS:
p vc_.(P \-- ic)(=r\ ,f,pc._ -i. V -1) F.3.-- ( F
AD TION AL PAGES IN USE:
YES p NO
PAGE NO i
PATIENT IDENTIFICATION:
DISPENSING TIMES
11111P)--
k USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
I N 23 24 01 02 03 04 05 06
DA 1 FFOE'r ;i9 4678
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23485
DOD-037063
ACLU-RDI 1681 p.45
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. ) r93-3
Order Date
Clerk/ Nurse SINGLE ORDER, P , PRE-OPERATIVES
Date to be Given be
Time to Given Time Given Initials
D Ai I ._ 2 A. .# ELL /1/P 4-4p/b(5&e
I //A/
,
7-
/
Order/ Expir Clerk/
Nurse / PRN
MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
gelDate
\EY r Co° Asti
rv3zsors\\! 960 %_
1_
T-ro c,esN c bp, 1 5
U.S. GPO: 1998-454-110/95216
MEDCOM - 23486
DOD-037064
ACLU-RDI 1681 p.46
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this Ione see OR 40.66; the proponent agency is the Office of The Surgeon General
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet '
OT55 APPR9VEO fibre
•
Date: T t■ 1 sf) i 03 Anesthesia Type (Circle)) pinal Epidural Drains
Time In: QQHS IV Sedation Nerve Block Hemovac
NG
JP T-tube
Foley
TL
• al
• ral
ETT
Trach
Other
Allergies: t Cd OR Intake: Crystalloid 400 Colloid
Pre-op V/S: lat-417 it 1 IS OR Output: UOP EBL MI r'-I
Procedures: (40'6 \P Meds/Times: I,,,, ArceF- , ,,c,, rnr ce,,,,f- SC Li 21-)Pfat'-•
Pre Op Meds History,
Time ‘1,2 2 . ). . .
I§ . :4 ' -. ;
. Z. tak Pacu In —.
Sa02 Ti it rft trn Tim Solution Amount Site • By used
Fi02 MN Methods RA& tik p _A eFt 240
220 X-ray . Labs:
Post-Anesthesia Recovery_score
200 Criteria ADM 30' DM . Codes Activity
(2) Moves 4 Extremities (t) Moves 2 Extremities (0) Mo 0 Extremities
AIRWAY
A= Ambu
BB = Blow -by
M = Mask
180
160 Airway (2) Cough, Deep breath
Dyspnea. limited breathing (0) Apnea
FT =Face
Tent_ I (I) OA n. Room
140 NC = Naiir" Blood Pressure (2) SBP =I- 20 of Pre-op (1) SEI P =/- 20-50 of Pre-op (0)SBP 4-50 of Pre-op
Cannula
V/S
X :. 'ne BP
120 V, i V "V V.‘„,
100 '4 . Consciousness
(2) Fully Awake. audible trying (1) Arousable to verbal or pain
drianlil■ = Pulse
TEMP 80 • • • • • Color
(2) Basehne color & appearance
(1) pale, mottled, jaundiced (0) Cyanotic
S = Skin
t3eralc
T = Tympanic
60
A INA,\ A
40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse
R = Rectal
LOS C = Cervical 20
TOTALS: Must be 9 or greater to D/C, otherwise needs anesthesia approval for ID/C.
T = Thoracic
L = Lumbar
S = Sacral RR N II II (0 T 0 , Time Patient teaching done; Wound Care. Pain Management. I
Pain (0-10) T. C. 8 DB,. Incentive Spirometer. Comfort Measures
LO Safely: SR up X 2, Falls Precautions. Privacy Maintained
P
i ib •(e) -.-
0 TMENTISERVICEICLINIC
ACU
aonrinue on revenel
DATE
03 PATI pe or written entries give:
first, middle: grade; date: hospital or medical facility)
jD ( (:,) ' ,
Name -last. ■ IIISTORYIPHYSICAL 9 FLOW CHART
In OTHER EXAMINATION • OTHER tsprarr
OR EVALUATION
❑ DIAGNOSTIC STUDIES
• TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 ( MCXC-DN)
MEDCOM - 23487
Previous edition is obsolete USAPPC 02.00
DOD-037065
ACLU-RDI 1681 p.47
Time Route Pain 1-10
I/E 13y Pa Medication & Dnsane 1-10
MEDICATIONS Allergies:
PACU OUTPUT
Discharge Criteria:
Date:gNOVI5S Time: 103 a PARS: 9 BP: lupt590 T: 47 • I HR: r71 RR: Sa02: Pain Level at D/C (0-10): — Intake: Output: Additional Data: A.)0).%-/C Transferred To:_ IC t/L1
Report Given To: Transferred Via: W/C Transferred By: Cleared IAW Recov Charge Nurse Signature:
Ambulance
7 NEUROVASCULAR Time Site Range
Of Motion
Sensory P Cap Refill
T Color
Adm 61615 -I- -I- P fl) C. VI 15' P(09< .--t -t P Y3 C f' 30' iNe5r 4 't p 6 C 45'
60'
90'
D/C s (e5, e 4- ri 0 C Movement/Sensation: + = present,- =absent Temp:C = Cool, W. Warm Pulses: P= Palpable, D= Doppler, A = Absent Color: C -= Cyanotic,
Capillary Refill: B= Brisk, S=S uggish P= Pale, Pk = Pink
C-SECTIONS
Adm 15' 30' 45' 60' ......913:—,—D7C--- Fund. Height
Lochia ---------- Peripad#
Fund. Con __.--
-..,..,_ DRESSINGS
Time Location Type Drainage
Adm 0955 a le3,S iCevles,- rv■.1^ 30' 6 fe3 c veytekc I.", h•-■
60'
D/C f3 irr\ s , IceAr lex ta.1 i...)
NURSING NOTES
received 'Pon, OR s/{) 1-'4) ( 13)456 harti • "4 SpOz PA Klo rib tA2ir-1
eA, (V) C/O
Time
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run? OC4.5 5 NS's o cp
WAMC OP 173-E
Source • Color/Agpaance Amount
MEDCOM - 23488
DOD-037066
ACLU-RDI 1681 p.48
REPORT TITLE
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this lana, see AR 4066: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED !Dater Post-Anesthesia Care Unit (PACU) Flow Sheet
Name - last.
❑ FLOW CHART
❑ OTHER aNa,./
❑ HISTOLPHYSICAL
❑ OTHEipAMINATION OR EVALUATION
O DIAGNOSTIC STUDIES
❑ TREATMENT
MEDCOM - 23489
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC 52.60
DOD-037067
Date: l b ki 0-4 CL3 Anesthesia Type (Circle)): General Spinal Epidural
Time In: 14, (..--.) IV Sedation Nerve Block
Alleigies: %--)V---6\ OR Intake: Crystalloid 'Z," Colloid
Pre-op V/S: 111 57 ) 03 0 Output: UOP EIBL 5-0‘.1— Procedures: j+ IN Meds/Times: 1 --rl-rar)L, j '
IP xti 1-ttS
-(:).- istor
Drains Airway Hemo c Nasal
C_Ota1 rP ETT
-tube Trach Foley Other TLS Pre Op Meds
Site Time Solution Amount
I? 00 By
1:>koilf6 Infused
- z_sn
X-rays: Labs:
Criteria ADM 30' Codes
z, 2_)
Activity
(2) Moves 4 Extremities Moves 2 Extremities
(0) Moves 0 Extremities
Airway (2) Cough. Deep breath (1) Dyspnea. fimited breathing (0) Apnea
Blood Pressure (2) SOP. =4- 20 of Pre-op (1) SOP =/- 20-50 of Pre-op (0) SBP =I- 50 of Pre-op
Consaousness (2) Fully Awake, audible crying (1) Arousable to verbal or pain
Color (2) Baseline color & appearance
(1) pale, mottled, jaundiced (0) Cyanotic
Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only reliable pulse
TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for DIC.
DEPARTMENTISERVICEICLINIC
iltaL
AIRWAY A= Ambu BB = Blow-by
M - Mask
FT= Face Tent RA = RoomAir
NC = Nasal Cannula
VIS X= A-line BP ,
=Cuff BP = Pulse
TEMP
S.= Skin 0= Oral A = Axillary T = Tympanic R =Rectal .1
LOS C = Cervical T = Thoracic L = Lumbar S = Sacral
RR
T Time Pain (0-10) LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained
Montrone on reverse!
DATE
lb ID
rl
Pacu Intake
Post-Anesthesia Recovery score
5, a Time
Sa02
220
Fi02
Methods
240
200
180
160
140
120
100
80
60
40
20
Patten teaching done; Wound Ca e. Pain Management. T. C, 8 DB,. Incentive Spirometer. Comfort Measures
Or ed w written entries give:
list middle: grade: date: hospital ar medical tank)
ACLU-RDI 1681 p.49
PACU OUTPUT
Source
Colerfl‘earance Time Amount
Transferred To: Report Given To: Transferred Via: Transferred By: Cleared lAW Rec
(‘ I
0
Gurney Ambulance b 10- t
- 23490 .e Signature:
MEDICATIONS Allergies: Time
V
NEUROVASCULAR Time Site Range
Of Motion
Sensory P Cap Refill
T Color
Adm (i)a ilit LIDP1 -I- . 6 ki Pig 15' g LI. re iyiut_ -- f —B b\I 12 le-- 30'
45'
60'
90'
DIC
Movement/Sensation: + = present,- = absent Temp:C = Cool, W= Warm Pulses: P = Palpable, D =Doppler, A = Absent Color: C= Cyanotic,
Capillary Refill: B = Brisk, S= S uggish P= Pale, Pk = Pink
C-SECTIONS
Adm 15' 30' _.--45-----60' 90' D/C Fund. Height ----"------- Lochia
Peripady-------
„Red Cond.
DRESSINGS
Time Location Type Drainage
Adm (6 tiZri,-- V L/ rit "Z-k t
c..--:-.7:=)- 30• E. LL, 60'
DIC
Pain 1-10
Medication & Onsaae
Route By
NURSING NOTES
k kStrvAq /1(6-mu Ls fp I -I- (6 -hard_ a-) X_ b;/
eftAtc. ic-41vAti t LI)--L
-)/4 ZX Z Lv /i )-)-PAJ JOTirvite,Y
ft "Lriki rikou 4\( trr(ae5f- . i V
bitA{)1AHLI/iy) -h). Orli et ILL(
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
c=:=,- 1 .Z.DO Ste _, c:L='-.
WAMC OP 173.E
Discharge Criteria: Date: loy.la-1( Time: / PARS: jo Bp: IDbiy tl' „ T: 9HR: , RR: a/ Sa02:q5— Pain Le er at D/C 10-101: Intake: 21 ) Output: --,-C---;) Additional Data:
DOD-037068
ACLU-RDI 1681 p.50
BLOOD PRODUCTS
❑ D-stick
❑ SHct
SBC • ,4:1 Chem ji(PT/PTT
:SIZE ACOOMPANEC, rrE
❑ Oral
❑ Nasal
Teeth
RESULTS ;-
O ETCO2 Change
❑ BBS Post Int
❑ Post CXR
fiOCEDURE
CT Scan: ❑ Contrast
❑ Head ❑ Abd ❑ Pelvis
PROCEDURE
ET
Intubation
❑ Air ❑ Contents
❑ Verified
Suction: Y N
❑ C-Spine ❑ T/L Spine ❑ Chest Gastric
Tube
❑ Oral
❑ Nasal
A-Gram Site: Urinary
IV ACCESS & FLUIDS ❑ Meatus
❑ Supra-Public
❑ Return
CC
❑ Herne Dip: + -
0 Secured AMT DPL ❑ Grossly: + -
Cell count
Sent@
❑ Opened
❑ Closed
❑ Air ❑ Blood
❑ Pleuravac cm
❑ Autotransf user
Chest
Tube #1 L R
Chest
Tube #2 L R ❑ Air ❑ Blood
❑ Pleuravac cm
❑ Autotransf user
12 Lead
MEDICATIODJS
AMMO =AIM M
MEDICATION DOSE TIME DOSE R PQSE
sO
Rhythm:
Comments
IC /5
ABS: PM
❑ Chest Initial ❑ D-stick
0 SHct
❑ Chest Post ET
❑ Chest Post CT
❑ ETOH ❑ T&S O T&G.-x ❑ C-Spine Mt* ❑ Tox Screen ❑ Pelvis
UA ❑ HCG
❑ OTHER
❑ OTHER
INTAKE & OUTPUT
INTAKE U Amovto- CBC: Chem: OUNT
c..)4, /0
IVF
NGT
Urine
NGT
5, /
P7/z7
2e2
/s-, 1/31 ;
Blood EBL
Other Other
TOTAL TOTAL
--- LE
TRAUMA TEAM 1404,—,E,t,,
AF-RIVAL
Eiikiiiiimi '
VALUABLES & CLOTHING , .
D Phys None Found
urgeon Given to Patient
nesth Given to Family
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
❑ Home
Other: See Nursing Notes
DISPOSITION
❑
X-Ray
RT
Ortho Admitted to
Neuro Report Called to
Transferred Chaplain
MEDCOM Time
- 23491 By
E
S
DOD-037069
ACLU-RDI 1681 p.51
4 - Spont
3 - To Vo
2 - To Pai
1 - None
3 - Inapp Words
2 - Incomp Speech
4 - Confused
5 - Oriented
13(g/73
PC/13
0396 f7/0 6 is-z to 04-01 IP oq w 12014o
Temp:
TIME
ti) 1) 3 I C
tr- 110
GLASGOW COMA SCALE VI AL SIGNS
GCS:
"SA°2 FiO2 :MODE'
1 - None
13.0CdijiME:: 0 Backboard Removed
CI Downgraded
.
-:NIOTOR;RESPONSE -,'`.
6 - Obeys Commands
5 - Localizes Pain
- Withdraws to Pain
3 - Flexion to Pain
2 - Extension to Pain
1 - None
.,.,PERFORME1); EY:,
BY:
BY:
RR'
10
VREBLE RESPONSE
-z_ '1
fr
MOO pi,- A - ekLi e.c
e3oLLA ----/
p c:a ■ l■ Or
MEDCOM - 23492
DOD-037070
ACLU-RDI 1681 p.52
AIRWAY BRETHING CIRCULATION
,LEkNatural Patient
❑ ETT
❑ Secretions
❑ Labored A4 Unlabored ❑ Absent
TRACHEAd Midline ❑ Deviated
CHEST SYMMETRY:
13
ci
PULSE: Present ❑ Absent
BLEEDING:
HEART TONES: ❑ Clear 0 Muffled
SKIN: )Warn ❑ Cool ❑ Hot
❑ Pink ❑ Pale ❑ Cyanotic ❑
Dry ❑ Moist ❑ Diaphoretic
SECONDARY SURVEY "DISABILITY'
GCS: E
V
HEAD
PUPILS: Equal ❑ Fixed ❑ React ❑ Dilated
TM: ❑ Clear ❑ Blood
HEART
RHYTHM: C14115trlar ❑
ABDOMEN
oft ❑ Rigid allNon-Tender
❑ Tender:
13 a a PULSES: ❑ Central ❑ Peripheral
M
SPHINCTER TONE:
❑ WNL
❑ None
NECK PELVIS
Getable ❑ Unstable ❑
Blood at meatus/vagina:
Herne +f - Prostate: ❑ WNL O Abnl
USE DIAGRAM TO' DOCUMENT INJURIES AND PAIN VASCULAR ASSESSMENT
(AB)rasion
(AMP)utation
(AV)ulsion
Battle's Signs
IBLIeeding
IB)urn
ID ► eformity
(E)cchymosis
(F)oreign Body
IH)ematoma
ILAC)eration
1Pluncture Mound
(Pain)
ISleatbelt (S)ign
(SItab (W)ound
IGSW) Gun Shot Wound — )2
+ + Strong + Palpable D Dopler
(Continue on reverse) DATE 3
PHYSICIAN
DEPARTMENT/SER E/CLINIC
ENTIFICATION (For typed or written entries give: Name--last, first, middle; grade; date; hospital or medical facility)
•
411111110 (1 -
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
❑ HISTORY/PHYSICAL ❑ FLOW CHART
❑ OTHER (Specify)
DA I FP ZYM7 8 4700 D BY DD FORM 2CO5. EAMC OP 503, 1 Dec 98 MEDCOM - 23494 _ETE.
LUNGS .
BREATH SOUNDS: ❑ Bilat ❑ Equal 0 Clear
II II
a a
Decreased a Absent
Wheezes LI Crackles
C-Spine Tenderness:
Pain @
a
JVD:
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE TRAUMA FLOWSHEET The proponent is Dept of Surgery
OTSG APPROVED (Date)
01 Appr 11 Jun 97
TIME:
MED COM: a ETA: 0 IV x r ❑ 02 . Vrnin ❑ C Spine Immob
Meds: ❑ UKN ❑ None ❑ Yes:
Allergies: ❑ UKN ❑ None ❑ Yes:
Tetanus: D UKN 0 Current Last Meal/Fluid Intake hrs
LMP:
PRIMARY SURVEY
DOD-037072
ACLU-RDI 1681 p.54
>,Q
1. Reporting MTF 2. MTF Loc....—•
IZ Admission and Cod,ng Information
For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number
0015197
Name (Last, First, MI)
(_4 3\
4. Pay Grade
FGN
i 5. Sex
M
6. DoB (YYYYMMDD)
1979-01-01
7. Age at Admission
24Y
8. Race 9. Ethnicity
X 9
Religion ‘
10. Length of Service ETS 11. FMP 12. Social Security Number
99
- Organization (Active Duty Only) 13. Marital Status Hour . of Admission
03:00
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
DIS
Prey. Admission
NO
20. Source of Admission
Direct from ER
Ward:
ICW1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
- • cility: i ,_ Telephone Number of Emergency Addressee
21. Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-13 /
24. Clinic Svc - Admitting
AEA - ORTHOPEDICS
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-08
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-08
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: S/P VD R IF DPC OPEN MC FX VD
Procedure Narrative(s):
Cause of Injury Narrative:
k
Admitting Offi :
BL LE
Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 23495
DOD-037073
ACLU-RDI 1681 p.55
4. Sex 5. Age 6. Race
M 32Y X
7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
NO
14. Ward
ICW1 11. FMP
99
12. SSN 13. Organization
MOM
Automated Facsimile - DA FORM 3647, May 79
Automated Facsimile INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
e ister me 3. Grade
FGN
Admission Remarks
15. FlyStatus 17. Dept / Ben ' 418. BranchCorps
K78-PRISONER OF WAR/INTER
19. UIC i ZIP 20 Type Case
BC
21. Source of Admission
Direct from ER
22. Hour Of Adm:
03:00
23. Clinic Service
ABA - GENERAL SURGERY
24. Name/Relation of Emergency Addressee
27a. Address of Emergency Addressee
29. Re orcin MTF t,
01111.111.1
31. Selected Administrative Data
Marital Status: DoB: 1971-01-01
In/Out Patient: Inpatient MOS:
25. Type Disp 26. Date of Disp
TRF-OTH 2003-12-17
27b. Telephone No 28. Date This Adm: AdmittingOfficer .
2003-11-08 IMO (66
30. Date Mit Adm 32. Units Blood Components
2003-11-08
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
GSW L BUTTOCKS AND THIGHS
19-6,a 10 02 / t
ges-S-7
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care
0 C 0 0 Bed Days
Total Sick Days
1-a 35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Suppl*ental Care Bed Days Total Sick Days
avitor**: ,o Signature of PAD or Medical Records Officer
(
MEDCOM - 23496
DOD-037074
ACLU-RDI 1681 p.56
IDENTIFICATION NO. ORGANIZATION
REGISTER NO. WARD NO.
MEDICAL RECORD ABBREVIATED MEDICAL RECORD PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITI N N ADMISSION (Eair date of .1 Ini?fiott
ilk 1 114(1i
S /?, J'e s
r
Lail '9-5%14C4(
/ ier7r= Itl/2,1.0 Oa= /.-z
g 771172 /1/2<14 •
PHYSICAL EXAMINATION
7 . /02 /V :- /1(0/7 i r (0 ('4? (r'' ' / EA,
14: i 1 A / : _ e ,,,eia tio, f,ori ad,d;
PROGRESS l „= „/6„ clale( 6)/i„Anr„and final dtil„724cjj
cf fcciki /go( (11A va° 0-7
NI 11111111111111111 A I E '5 '5 IOENTIFiCATION (Fodr dry.P ii.
1 heon:;: te.eitee
Dtkv03 d elv1Z7
ABBREVIATED MEDICAL RECORD Standard Form aft
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106
/IT MEDCOM - 23497
k 4/7,1{ Jd vo.46 I
DOD-037075
ACLU-RDI 1681 p.57
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
(MVO S? 0 ejcb Jed PI . °I NY\ (t b-ta_ ti o/c) . 1)7_0,12_14)/v if • • 1 1 k i a ..1.1)4, iii_ti affils <bpii. . F 2.' , __L :„, _ ws M. 11/F_IUS- a_'- 26 MG (p r-CL etzsL c fill>, Aix 1125
j. ' , 77V e h-c , • -I .4 1 4 .I4 . 4/106 4 06 .. Ai /L' )-td 76
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I _Lac /0, ,16,,L,er • (7, -0 (32Acz.l.„; ,,,i
IBP TREND
TIME
HH: MM
HR/PR 3p02 SYS / DIA
BPM X nolig - MEAN I
RI 08:10 92 100 139 I -,6 101 08:00 103 100 145 / 24 102 07:50 91 100 141 / ?D 103 07:40 94 100 141 / 77 101 07:30 92 100 166 / 77 110 J 07:20 97 100 139 / 70 96 07:17 09 inn 1 /
OF)L-I 3 Da• I -01 ,1 .1 tat 0,4 ,A ultDri({, • Ribttathrith flGet ,oxj
gLopkicpci tA.> i-Ltv, 1,:r 44,4;r__ «Z. 6) ;)4!.. Ap /,'
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, 1P A( till i
. AO( 0 t ,)
(''Ykill ,,de
.
0 tide 11 1 to -1e5 intoldeo ( )1617-0
, Q,Fr-----
RELATIONSHIP TO SPONSOR SPONSOR'S NAME IMI
I SPONSOR'S ID NUMBER
(SSN or Other) • 4
.-
LAST
•
HIST
, ..---- ...,---,. DEPARTJSERVICE HOSPITAL CR MEDICAL FACILI
PATIENT'S IDENTIFICATION: (far typed Of written entries, give: NNW • lay, fen, made; No a SU; Sex; Date of Beth; .9ank/6tede1
vw1111li
••••■••11,11■111••••••••=..,
..■111.11
PROGRESS NOTES Medici! Record
STANDARD FORM 509 my:. 511599
Prescribed h•..• GSAIICMR FPIAR FlItER) 101.11.2231M
US' PA V; CO
rEGISTER NC. WARD NO.
MEDCOM - 23498
DOD-037076
ACLU-RDI 1681 p.58
LAST NAME FIRST NAME 1 MIDDLE INITIAL ID NUMBER
DATE NOTES
I UNA .01
:- 6. I 0--g ( /4, ‘,/_7616 41- -7e, iri of-61 K La
)Ce, 6 '' M 1 ,i7e) ,/ - / 61ifi-oi--/ '7
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= 6cc i
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c., %
'(- ' e_C • (I/ — / --a- ' f O cii- -I— . A .4-i Q--(c, 4 7 e
01- i-k-- 2 g'; /
6 / Pi:6p/
Ili 2 57 o
7 3 7/t. e72z l 71k
MEDCOM - 23499 STANDARD FORM 50S IREV. 5119991 I3ACX
DOD-037077 ACLU-RDI 1681 p.59
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES _
ab 1 Mtn J A. I Li I i la A I a' i • 115 1 113- `R )5 7 $ • )' ol E, -0
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RELATIONSHIP TO SPONSOR 4/4.
SPONSOR'S NAME LAST FIRST MI ISSN Of 'Other)
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed 01 written entries, give: Name • last, lin mahlle•
/D No ar SSM- Ser; Date of Birth; Rank/Grade)
‘ I /. N . i
REGISTER NO. WARD ND,
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PROGRESS NOTES Medical Record
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DOD-037110
ACLU-RDI 1681 p.92
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PROGRESS NOTES Medical Record
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DOD-037112
ACLU-RDI 1681 p.94
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DOD-037113
ACLU-RDI 1681 p.95
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ACLU-RDI 1681 p.96
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ACLU-RDI 1681 p.97
AUTHORIZED FOR LOCAL REPRODUCTION
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ACLU-RDI 1681 p.98
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DOD-037119
ACLU-RDI 1681 p.101
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REGISTER NO. WARD NO.
STANDARD FORM 51.1 (REV. 7-95) BACK
MEDCOM - 23542
DOD-037120
ACLU-RDI 1681 p.102
511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST - DAY
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170 103°
160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96
90 950
80
70
60
50
40
RESPIRATION RECORD
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VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23543
DOD-037121
ACLU-RDI 1681 p.103
NSN 7540-00-634-4124 511-119
D VITAL SIGNS RECORD
......._
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160 102°
150 101°
140 100°
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120 98°
110 97°
100 96°
90 95°
80
70
60
50
40
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REGISTER NO WARD NO.
<111111P VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41.CFR) 201-9.202-1
MEDCOM - 23544
DOD-037122
ACLU-RDI 1681 p.104
VITAL SIGNS RECORD MEDICAL RECORD HOSPITAL DAY
POST- DAY
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160 102°
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140 100°
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120 98°
110 97°
100 96°
90 95°
80
70
60
50
40
RESPIRATION RECORD
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PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
REGISTER NO WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 23545
DOD-037123
ACLU-RDI 1681 p.105
511-119
MEDICAL RECORD
..._...._........, ______
VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONTH-YEAR k ur-rt....- DAY VC, nkr- (-)0£ (-. 'bit r JO— t 1 ..,14 4Yip'2) HOUR i l' • 0 • I • cvA • " & • • o• • ' I ' a • 1 • 6.
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180 104°
170 103°
160 102°
150 101 °
140 100°
130 99° 98.6°
120 98°
A10 97°
100 96°
90 95°
80
70
60
50
40
RESPIRATION RECORD
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REGISTER NO
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23546
DOD-037124
ACLU-RDI 1681 p.106
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONTH-YEAR DAY fi. 0 il... 13 Di"' `t- fi t.`' ig 10 i7 19 HOUR •O• • • •(I • t • •0 '
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180 104'
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160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96°
90 95°
80
70
60
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1111011111iiiiitar...._
REGISTER NO
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 23547
DOD-037125
ACLU-RDI 1681 p.107
5. ADDITIONAL INFORMATION: (Previous surgical and medical history) Tobacco ppd X_yrs :ody P' rcin - Diabetes (Y) (N)
w',ETOH ff. W
sease
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT MEDICAL RECORD
FOR Use this form. See AR 40-407: the Proponent agency Is The Office of the Syrgeon General.
1. AGE .3\
HEIGHT: ,
WEIGHT:?
2/- NOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) A—ICIKDA ❑ PCN ❑ LATEX ❑ IODINE ❑ TAPE ❑ FOOD •
REACTION:
3. PREVIOUS SURGERY [ ] YES (type):
4. PROPOSED SURGICAL PROCEDURE:
1M\ u_OicY (jf ASA/Motrin W 72hrs (Y) (N)
s ma COPD) (Y) (N) Anticoagulants (Y) (N) Herbal Medicines (Y) (N) MEDS:
8. OR NURSING INTERVENTIONS
Skin Condition ROM
act (Y) (N) . Dentures
6. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL potential for anxiety related
to: >C> 1) Surgical Procedure&
Operating Room Environment XS) 2) Separation Anxiety
CCdd
\• 3) Surgical Outcomes
Hypertension (Y) (N) 7. PATIENT GOALS AND EXPECTED OUTCOMES
O Pt. verbalizes any specific anxiety.
O Pt. Exhibits relaxed body posture.
0. Allow pt. to verbalize freely.
0. Explain Or environment and answer
questions regarding surgery.
0. Offer comfort measures. (e.g. warm
blanket. touch).
0. Explain all nursing procedures before
they are done.
0. Remain with pt. Whenever possible.
0. Maintain family interface. Parents to
stay with pt.
B. AERATION Potential for respiratory
dysfunction due to: \\O 1) Positioning
2) Effects of Anesthesia
3) Medical/Smoking History
O Pt. will be able to breath without
difficulty during immediate intraoperative
phase.
0. Offer to elevate head of litter or offer pillow.
0. Observe pt. While awaiting surgery for signs of distress.
0. Assist anesthesia during intubatior
and extubation.
C. INTEGUMENT 70 Potential Impairment of Skin
Integrity due to: 1) Intooperalivearnaokilfly
r>0 2) ESV__Pad Placement
\,/-1 3) Positional Aids
4) PEgstheis V, 5) Pooling of PrepSolutions
O Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).
0. Utilize pressure preventing devices
on OR table and accessories.
0. Check for proper positioning and
support to maintain good body alignment.
0. Pad pressure points.
0. Place ESU ground pad on non
compromised skin surface area.
0. Keep prep fluids form pooling.
9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
L dk
VERIFICATIONS AT HOLDING AREA: ! Dentures Removed
! Contacts Removed
! Jewelry Removed
I Body Pierce Removed
! Consent/Blood Transfusion Sig ned/VVitnessed/Da ted
! Surgical Site/Consent verified by Pt./Anesthesia/Surgeon
! Contact precautions (Y) (N) ! Family/Friend:
ID/Allergy Band
! H&P
! NPO Since
! UHCG/LMP
DA FORM 5179, JUN 91 MEDCOM - 23548 USAPA VI.O
DOD-037126
ACLU-RDI 1681 p.108
E. NEUROMUSCULAR CONTROL E.I. -Potential Impairment of
obility due to:
Pain
Intra operative Hazzards
prosthesis
Positioning
Transfer pt. To/form OR table Potential Discomfort Due to:
Length of Surgery
Positioning Arthritis
6. PATIENT PROBLEMS AND NEEDS
D.-NC4CULATION otential for inadequate tissue
perfusion due to:
>0 1) Intraoperative Mobility
\IO 2) Positioning
Sr") 3) Existing Disease V") 4) Safety Devices \,9 5) Hypothermia
7. PATIENT GOALS AND EXPECTED OUTCOMES
0. Pt. will exhibit signs of adequate tissue
perfusion (e.g. color, warmth. pedal pulse.
8. OR NURSING INTERVENTIONS
O Check foe support stocking or ace warps. if none, check with doctors.
O Check that safety straps are
correctly applied.
O Offer pillow for under knees.
O Place and take down legs from stirrups with slow bilateral motion.
O Check that rings and all body piercing has been removed.
O Have sufficient people available for transfer. O Insure proper body alignment.
O Allow patient to lie in position of comfort while waiting for surgery. O Offer support (i,e..pillows. Bath towel. etc) for positioning.
O pt. will be transferred to OR table without difficultly. O pt. will be not experience unnecessary
physical discomfort.
F. Special Senses F.1.....,42Diminished visual perception due to being:
K31) pre-medicated
2) W 0 GLASSES
F.2.. Potential for Decreased
Communication due to:
-7,!:-.D1) Diminished Hearing
---Z5 2) Language Barrier
F.3. Potential Injury due to
Dentures:
1) Upper 4) Caps
2) Lower 5) Crowns
3) Bridges
o pt. will be made aware of surroundings
prior to anesthesia induction.
o pt. will be transferred safely to OR table.
o pt. will be able to understand instructions.
o Minimize danger of injury during intraop
period.
O Introduce self. keep pt informed as to
where he. she is and what is happening.
O Inform pt. in which direction to move
and assist if necessary.
Speak clearly and slowly. O Address pt. from side.
O Validate pt.'s understanding of verbal
communication.
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 INT DDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
infl DATE
11. POSTOPERATIVE EVALUATION : LEVEL OF CONSCIOUSNESS: 1:1 A&O
LEVEL OF ACTIVITY:
12. PREOPERATIVE (Signature and Title)
DATE:0 )A,,,sj
REVERS OF FORM 5179, JUN 91
SKIN INTEGRITY: B vig> pad Site: Clean and Dry ❑ Red ❑ N/A
❑ Drow
EXTREMI/TIES
❑ Trahsferred to Litter With roller due to spinal
P PARED BY 13. PREOPERATIVE EV PARED BY (Signature and Title)
USAPA VI.0
VES ALL
leepy Ointubated Moves Up-cie-l'Extr,emities
ESSING DRY & INTACT:
(N) ATHING EASY: N)
TIME: 01P DATE: M TIME:C2
MEDCOM - 23549
DOD-037127
ACLU-RDI 1681 p.109
INTRAOPERATIVE For use of this form, see AR 40-407, the pro:
1. PATIENT TRANSPORTED TO 01-._riATING !.. A
VIA GAA' 1 BY f4 2. PATIENT ID
VERIFIED BY 3. DATE
62 ►1/4se,)ak53 TIME PATIENT ARRIVED IN SUITE cp3q 4: PATIENT IN R
TIME. :6143 14 5. PREOPERATIVE EMOTIONAL STATUS
LI CALM ANXIOUS ❑ EXCITED ❑ CRYING ❑ ANGRY
COMMENTS: 31 \i t, (la,.
r)CUMENT ,cy is the office of The Surgeon General.
RD REVIEWpiln PROCEDURE
11] WITHDRAWN ❑ OTHER (Specify)
MEDICAL RECORD( r
NUMBER ,9c-cyr. g
__ _....... ._ --......-
'; ASSIGNED SPC -- --RELIEF SCRUB
E
. SCRUB
ASSIGNED c RELIEF CIRCULATOR ..____ - ... . __CIRCULATOR
IN.1.., 7. POSITION.ANQ.ROSif ION • 1-:-.,.4 id ifb.^ 6,..-z-v- c• (I-I ,..1) , .)
10--S S. (./J5- 1 @5' SIJ II 0-1 bl•c LiNisa'....b‘'fl• • COMMENTS:
1'11)1 A ( Ap, O. ..sin esj-4.1. i.74.9.11 di of • Pcit\l'!.', i.... (!tY*,Ovel C ■0 •-": ..,1) ,..., WI-S OsiN 43 (sin boa i e m., ‘ UPINE LITHOTOMY PRONE U KRASKE. LATERAL: LEFT SIDE UP 5CRIGHT SIDE UP
- - -•-------. 8. SKIN PREPARATION
HAIR REMOVAL U YES pN • PREP OLUTION(Specify) 62f0,-5,7,ft„b ipao. DONE BY: M OR • NURSING UNIT SITE Hoi eiwttoi-U BY WHOM: J1}0,7
COMMENTS: -_-__--_—__ COMMENTS: (IQ ec.,,,,;,,,JJ \P
METHOD: • DEPILATORY Il RAZOR SITE: iiri7t--C) +06 BY WHOM: Olin --1 CLIP ..._-__..—__ L4)
9. LOCATION OF EXTERNAL DEVICES
...._ 1. :Mat - - r•I . -
_ i-•
--nu"."1"11.MINIMI11111.-- _
0
...
..,.,.•....
LEGEND X Ground ad -- Saf = = = Tour 114 niquet .• .. ----- l'A C = Correct I = Incorrect `-'5-ii4--.:.12 ei>.)a • .
Needle Sharp NI Yes AIM . c C.
10.COUNTS Other•• Count .. ,• Cciiint SCRUB First Closing Final Closing
Sponge nilYes C
---
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
Instrument MSZERAEWAIIIIIIIIESEII__. c_ . •-...• Other El' Yes ►1_IEMIIIIIIIIIPAIIIIIIIIIVAIIIIIIIIIIPw PP"
Illti
11. PATIENT IDENTI !CATION (For typed or written entries giv • . 12. ELECTROSURGERY DEVICE(S (ESU) VI YES • NO
.....:-_ ma
' yeaSU NO: g? (s 1b93
--lam) LOT NO: ...--,
GROUND PAD: BRAND 04(1 e kb LOT NO: -1353 ..•,-:- ".'ID:7,ESI.lNO: , .. .
.•- --GROUND PAD: BRAND . .,-
MI BIPOLAR NO:
DA FORM 5179-1, OCT 87 REPLACES rut Frirmn 5170_1 rrcen, r.r......... ......-...- OBSOLETE. _ USAPA V1.00
MEDCOM - 23550
• IS OBSOLETE.
DOD-037128
ACLU-RDI 1681 p.110
13. P _ _ _, „....., /
,/ ,•.“-, it r to INAPilt: IU NUMBEr IUFAC" lER
14 - -,, MEDICATIONS/ORDERS', = &- . IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO MEDICATIONS/SOLUTION DOSAGE TIME : METHOD PREPARED BY GIVEN BY
40UND IRRIGATION C)fizz.YES • NO, TYPE(S): Vcron
!OTHER ORDERS TIME CARRIED OUT BY
.,,
;PHYSICIAN'S . SIGNATURE
. . 15. X-RAY IN OPERATING ROOM
_ - _, IF YES, SITE
YES 1111 NO .(6 16. ':' LABORATORY SPECIMENS SPECIMEN IS)
YES • NO
FROZEN SECTION (FF
NAME .. _ _ ____ ___.. NAME r,
YES • NOFA
NAME NAME
CULTURE (C) YES / NO crcl
NAME
___ NAME
NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)
PO Ct Tle - - - --- - 17. TUBES, DRAINS/PACKING YES yn NO / TYPE/SIZE i.re. 2. .
SITE 1. ft
K ,,t
J01-1- ;1‘.1 2. 3. - . ---_.
19. ADDITION T N
si r ta--m- Dr
_ ... . .
20. OPERATION(S) PERFORMED
ctIb )1) ho 'D el l / _5-d h 0 trN'T f _TS D 61j' -.P. Bvi4AL / -j ( D ed6f6-P -frit L
21. N, PATIENT TRANSFERRED TO ti„ % „...-
C I TIME__
'' lA 1 C176-1 22. REGISTERED
METHOD I ,
1-14 NURSE SIGNATU
REVERSE OF DA FORM 5179-1, OCT 87 USAPA V1.00
MEDCOM - 23551
DOD-037129
ACLU-RDI 1681 p.111
ke) ti tt) INTRAOPERATIVF - 1CUMENT
MEDICAL RECORD .-- For use of this form, see AR 40-407, the proponi is the office of The Surgeon General.
1. PATIENT TR • 'ORTED TO OPERA1IN .it.)0M.
i lam, BY
2. PATIENT IDENTIFIED . I ' ND PROCEDURE
VERIFIED BY Ala VIA. di
-- '7 • 3. DATE e TIME PATIENT ARRIVED IN SUITE
? 1P/01/-0 2 l 04/C--- 4.' PATIENT IN ROOM
TIME : / 0 11.5---- NUMBER ....-,....)... - 3 5. PREOPERATIVE EMOTIONAL STATUS
CALM
COMMENTS: /1)101
ANXIOUS • II EXCITED • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)
1.
6. NURSING PERSONNEL
• ASSIGNED SCRUB
9 //›.; — . — "RELIEF SCRUB
ASSIGNED CIRCULATOR
CZAIIIIIW:__r- 66-t RELIEF __CIRCULATOR
ilq .1;. ..__ . _...... . ..
0,-, -Pot 7,-; doe, _,,,(4 Fs ..1f!-- , 4T--/ ,9;0-5 . atm , fr/r15 (7) -P
1.1
5:e(2A-4,-et i pe LEFT, SIDE y P $ RIGHT SIDE OP
P-r, 1 .5 1a.a k., 1Qe___J-60.e. /c4, 3-€7/ eso- r 7 k:A
. t . . ) 0 3 efr .15 --e.C:A-t ,-"eY, 4;30,7 3qcji CiSe
r, __J- AI 7. POSITION AND PQSITIQNAL A.45 (Specify/ .51-012 d o z- peo. • ..g, .grel _.hk '''S'Li pv.Q... *or- .5.. rry31 n-1-- i---r Le, ...G,-(111—. e,d,,5 A
UP NE LITHOT Y WO KRASKEi• „, LATERAL: 40 ' cq r rv-‘. c".e/ e- C C "'",•-- 9 - . $ Iii - ,9 . 5- pi 1(0 i.c.) ci
-.e " 8N4 f r 0 (ls- - eo,_ t -I-, )C4. --, _ci I 1.cc,,-- " -..1:<eci r 1:k pi I Icy L(1 ,Cyn e z 0 renr=)o-clr C pi OW or, ny -i- /N6 -6'4-J-el° 0+79, 110 Crre,t, 4- I Cily RI I D,r) vz.t.e.,1+- etc) , 4642,4<1 PREPARATION
HAIR REMOVAL Ri YES/OR DEPILATORY CLIP
Yln cre
• NO
UNIT
etalk e p •
•• "--PREP SO1_UTION (Specify) B.4-eLel, i'i r SITE:13,1At KW(' I -Thi a.45 BY WHOM: api
IT • i-gKr°1 a BY WHOM: 1-t p t- i..1--Pfd, ' , . bia ,r,..,,,
COMMENTS: 0 pc° , • C-3 .-1- SO/ l %a', S' '1 d kJ
DONE BY: •
d
U NURSING METHOD: • ► RAZOR By
Slik4-140-a-.4.1
ae ..4,144.4.--A" COMMENTS. 11° n1 c_LA .-1---, 9. LOCATION OF EXTERNAL
•
d Pad
DEVICES
t.,,,..
.-7/Safety-S ,
ANNixbutz...aw,.; „......--, .- -4 : -, a
,--..N..-4-44 '11",'"IIN
fr
44 Akatb...-gew'
Alikt N1:1114
I fb I
--- I... ."....
- ,., ,•
LEGEND lecclun
111117Aro - • ■• , I 16-. ...;:-..--■---
, Clef ' f il` 7 .--- -: -::.-:- (Of tr- = = = Tourniquet
10. COUNTS
Sponge -% Needle Sharp m Instrument ❑
Other U
=II cm Yes Yes
- --
Grade•
;I.i
A
__
MI
For
.
C = Cor ect I = Incorrect
ME:IMMO/AIM
E3F4111111/1/Aill
Date;
b(-1/ -/-1
‘ Mil IA Other• •
typed or Hospital
MEIWAIMIMIIMPIP'
First Closin Count .. ∎ ..
written entries or Medical
11141■111111111111W11111111121i Final Closing Count .SCRUB
,.....
CIRCULAT• : ...
give: Facility;)
......:,.;,1,4..,.:.;-. -
12. ELECTROSURGERY DEVICE(S) (ESU)
ESU NO: K ri3 (c12..aci_r
_„------ , Er YES • NO 11. PATIENT IDENTIFICATION
Name - Last, first, middle;
411111Q62')
71‘101,-- 0 3 - - -- - - - -- -
GROUND PAD: BRAND kick-,t tek rak- LOT NO: , 5-76 -4 E,, -2ed if-ti -, .; ESZSU NO:
•••- -GROUND PAD:
. BIPOLAR NO:
BRAND
LOT NO:
- 1,
REPLACES DA FORM 5179-1 (TESTI, DEC 82, WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 23552
DOD-037130
ACLU-RDI 1681 p.112
13. PROSTHESIS, IMPLANTS ❑ iiiVNO IF YES NAME: ID NUMBER; II TURER
14.- - - - ,,, --111EDICATIONS/ORDERS L .;,. ' .',-,- ', .-TAWI:-' '- ,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ❑ NO Nti MEDICATIONS/SOLUTION DOSAGE TIME • METHOD PREPARED BY ( GIVEN BY
. ..
i
WOUND IRRIGATION ES NO, TYPEIS):
,OTHER ORDERS TIME CARRIED OUT BY
PHYSICIAN'S SIGNATURE
- - - .- I ^ r ,,. . •- _
15. X-RAY IN OPERATIN Rt,sM IF YES, SITE YES ❑ NO ri.- ,
16. :".LABORATORY SPECIMENS SPECIMEN (S)
NO
... AME ._
YES • FROZEN SECTION (F )
NO
NAME NAME YES II CULTURE (C)
NO
NAME _ ,_. _ ___ - - —
NAME YES •
NAME NAME NAME
NAME NAME
/_ 18. DRESSING/IMM BILIZATION (Specify) , ,
K-clit-e-.6 got ls1 IC k k K fl(-4 -4s 4-e pciols, acc -1-0 t x _
\\(._ A-mp--e_ -4-0 134A-71--izi
17. TUBES, DRAINS/PACKING YES NO TYPE/SIZE 1.4_0yleK 6
/VaC12- 2.
.„.. .
SITE 1. 31441-aek .t--
bielaVtThillt CV/G
/- 2. ■,
19. ADDITIONAL INFORMATION cue_ __Iir
cut, t t.4 ; it).- -- -esq- /1.
Frm\e_ ,pa ct s , k pre -op- CDL zs -I- -op CD-I-- i
IDA 5-1?? p cev le...AA ss 17 fr-L...,_. 20. OPERATIONIS) PERFORMED
LA.)0,,st.A1 6.A- ca-- 5.e(...A.e.0,A. c7.1.4.,4„.(..s:. . Qi.., -..--...A.. -14NI'k_ L,..$ 0446,4tr -
21. PAT ENT TRANSFERRED TO
Ar-.14. TIME METHOD
' . R ISTE -- ......._.
CST/ /(111✓
MEDCOM - 23553
USAPA V1.00
DOD-037131
ACLU-RDI 1681 p.113
b \ MEDICAL RECORD E INTRAOPERATIVE r .00UMENT
For use of this form, see AR 40-407, the prof :y is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPriA, .‘1G hjOM
VIA 11111b. BY Ito es-th , 2. PATIENT WED AND PROCEDURE
VERIFIED BY CPT IAA) 3. DATE TIME PATIENT ARRIVED IN SUITE
'/1 AJOV 03 --- 4.- PATIENT I
TIME:1,051• NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
U CALM 11 ANXIOUS • EXCITED U CRYING ❑ ANGRY • WITHDRAWN gri OTHER (Specify)
COMMENTS: -li red -fibm .., arnb. LL stai, pi crithhAs 6. NURSING PERSONNEL
: ASSIGNED SCRUB
PFC ..._ _.. --'-REL1EF SCRUB
ASSIGNEDCIRCULATOR --1111k4--C - . . .- -----
_, ..., RELIEF ..C.IFtCULATOR
alirin0-154)
7. POSITION AND POSITIONAL AIDS (Specify) - •--- .. ,.."-_...,
PI SUPINE • LITHOTOMY ❑ PRONE • KRASKE
Bean back .-kr posi-horay . • COMMENTS: ft. s, • t i ' • - 1,,
1) rIllaos klitanItqc au llny( roll ) pitusto= -eitown
LATERAL: •
3afe Irms
LEFT SIDE UP 6 RIGHT SIDE UP
81rap etcYos 1.95 I [at. piPion
? SKIN ) 8 . PREPARATION
HAIR REMOVAL ❑ YES g NO ' '
DONE BY: U OR • NURSING UNIT
METHOD: M DEPILATORY U RAZOR
• CLIP
COMMENTS: .
PREP SOLUTION (Specify)beAd(nt 5C SITE: ja. 112C./ BY WHO
',.' SITE: Leili BY WHOM.
-,T•gutto 6 Cdm " NTS: 0 poo)inol of .-Flutt
9. LOCATION OF EXTERNAL DEVICES J
A ifei,M59502•74,.. 6IPL:' At, . ,
• / ,7--------------4(Tisaw."11"---v-m -4=0ff)74/11.7 7 J .-=s - , ------ , . ....•,..
.- .
LEGEND X Ground Pad -- Safety Strap = = = Tourniquet ---..,--......-
10. COUNTS
C = Correct
Other' • First Closing Count .. !,:.
= Incorrect /.,
Final Closing . Count SCRUB CIRCULATOR
Sponge Eg
Needle Sharp Z
Ye
Yes
o o I 0
0
Z 7 7 7
. V
IIIAMIIIIIIIIIIMIr Instrument ❑
Other •
Yes
Yes WMIIIMMIIIIIIVAIII.__ _.
11. PATIENT IDENTIFICATION For typed or written entries give: Name - Last, first, middle; Grade Date; Hospital or Medical Facility;) in
A .
12.
•
ELECTROSURGERY DEVICE(S) (ESU) ❑ YES V NO
ESU NO: 30130 GROUND PAD: BRAND
----.:— LOT NO: ,_ :`ILSESIJ NO:
_ • - -GROUND PAD: BRAND
LOT NO:
U BIPOLAR NO:
DA FORM 5179-1, OCT 87
REPLACES DA FORM 5179-1 ITESTI, DEC.82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 23554
DOD-037132
ACLU-RDI 1681 p.114
■ o. r r iv., i n coio, iivirLHIN I 3 Li T L.. A !Nu IF YES NAME: ID NUMBER; A : IER
1..
14. ,; -. 'MEDICATIONS/ORDERS ;TtcW-1 i IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY. ANESTHESIA) YES NO 10
MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY ( GIVEN BY
-MOUND IRRIGATION (211 YES IN NO TYPE(S):
Acl ph) NS ..,
OTHER ORDERS TIME CARRIED OUT BY
Q., ...,.....,--
,PHYSICI
15. X-R.
YES
.. _ IF YES, SITE
II NO o:IiI 1 ::;
16. :LABORATORY SPECIMENS SPECIMEN (S)
YES ❑ NO cm NAME
--:- L=..------- NAME
FROZEN SECTION (FS)
YES U NO ki NAME NAME
CULTURE (C)
YES • NO
NAME NAME
NAME NAME NAME
NAME NAME
_ — —
18. DRESSING/IMMOBILIZATI
FirA r-E ON
nak
(Specify)
13J bi- tlerY.5 AND larli Le 6talcd6 4 Y 4
Ace' la. pt
17. TUBES, DRAINS/PACKING YES El NO IN TYPE/SIZE 1..,/ „.
-3/8 Pkrivose 2
1" an rose, .
1 NarctsQ. ki . Eitti ocks
SITE
R-4.- -fttiqh
.
LI . -kick) 19. ADDITION MA ON
Sul. Anesth; Sar 4i0
. _
AM ) jpe : Ceoeval
01 e9 In pbct PTA 20. OPERATION(S), PERFORMED f
1 , T. 7D 1 . 1, , U-. Legs wl elostwe of wouods
2.1 4,1) e4. 13cd-i-bcks lb) C:fo&ai'L Of wounds 21. PATIENT TRANSFERRED TO
Nal TIME
13 23
METHOD, ,
Stretchier 22 ATUR E
OPF/A 1
/
1/ In a1 \ .4-,,,/ REV , OCT 87
MEDCOM - 23555
USAPA VI .00
DOD-037133
ACLU-RDI 1681 p.115
i -STAT CREA
Pt :1111111. -4
Pi Name:
Crea 0.9 mg/dL
Sample Type_:
08MOV03 08:19
Oper:11111 \-2)(-2'
Physician:
SPr# 42011
Ver: JANSO4GA CLEW A33
i -STAT'EC8+
Le • Pt Name:
Glu 190 mA/dL .
BUN 10 mq/dL
Na 13" , mmol/L
4.1 mmol/L
Cl 1 -,J7 mmol/L
TCO2 zc mmol/L
AnGap 15 mmol/L
Hrt 34 %PCV
Hb* 12 A/dL
*via Hct
pH 7.325
pr:n2 39.2 mmHg
HCO3 20 mmol/L
BEecf -e
Sample Type_:
08NOV03 08:14
oper:IIIIIII, , )
Pt hysician:
Ser# 42015
Ver: JANSO4GR CLEW A93
i - STAT EGG+
Pt:
Pt Name:
Na 135 mmol/L
4.1 mmol/L
TCO2 24 mmol/L
ftct 35 PCV
Hb* 12 g/dL
*via Hct
At 37C
pH 7.337
PCO2 41.G mmHg
P02 114 mmHg
HCO3 22 mmol/L
BEecf -4 mmol/L
s02* 98 %
*calculated
At Patient Temp
PH 7.334
PCO2 42.1 mmHg
P02 115 mmHg
Patient Temp: 99.0F
Sample Type_: ART
08NOV03 08:12
°per: 111111111 Physician: = /`~~°12
Ser# 42011
Ver: JANSO4GA r!FH A93
MEDCOM - 23556
DOD-037134 ACLU-RDI 1681 p.116
Negative Malaria
(? c
LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
SS
REF RANGE RESULT REF RANGE RESULT REF. RANGE Color Negative
11101111--- 08-11-03 Hgt WB 08:52 Patient Hct Was
HNC 15.9 H :10'3AL 4.5 10.5 MC NBC 4.23 x10"6/tiL 4.00 6.00 HO 12.4 g/c0. 11.0 18.0
Plt Hit 38.6 1 35.0 . 60.0 KV 91.1 fL 80.0 99.9
1,-r y 101 29.2 pg 27.0 31.0 111C 32.1 L g/d. 33.0 37.0 Plt 281. 110"3/111 150. 450. LY1 9.4 *I. 1 20.5 51.1
Seg LYN 1.5 * x1083/01. 1.2 3.4
Negative
Negative
Negative
Negative Gram Stain Occ BEd
Source
IVficrobiology
Negative
Negative H. pylori Negative
Micro Parasites
0.2-1.0
Negative
Spun Hematocrit
42-52% (M) 37-47% (F)
CSF , . - . Blood Bank ,
Sed Rate . ,
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh 1
'Coagulation : Studies:: ' ' ' ::::' ; :: .. .- •
:' .. - - : : .. . Blood Bank Unit Crossmatch (MUST SUBMITSr518 WITH EVERY wir OF BLOOD
TEST RESULT REF. RANGE UNIT TYPE CROSS.(114TCH PT 9.8-13.6 secs
APTT 21-34 secs
D dimer <20 ughnl
FDP 10 uglail
REMARKS:
D Dfl D'T-E'T% DJ . •-■ - "•-•-• - - - _
RBC Morph
Negative
Negative
•
MEDCOM - 23557
DOD-037135
ACLU-RDI 1681 p.117
n t, 1
I LAST, FIRST„M
1-2 (.1) -(A TT\ LE
LABORATORY RESULT FORM (Subiect tc- the Frivaci- Act. F
SS' -
RESULT
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/08/03 03:20
Pat ient ID: lip Test Name Test Result:. 14.1 sec_ Ratio = 1.2 Cd1culated INR = 1.26 ..,ample Type:citrated Nh. blood ;est Date :11/08/03 les; Time :03:16 La; t i (4 :080201 Opeldtor : JACKSON
;;APIOPOIN1 COA.1 ANAHLER V4.54 SERIAL 4005485 11/08/03 02:22
Pat lent IT.) 1243 rtz:1- Name. :OTT
Rez,ult:= 21.5 :;ec. 4,4kESOLI OUT OF RANGE.4:“
Sample Type:citrated wri. blood Test Ddto '11/08/03 Test Lmi'
Card rut -1 .
Opelator )o
-- - 1 - -- - I -
zf.'olor 1 N./. A
-F-T l
C I 11 N'A 1
Gid
1 CC:
i Ncgativc
Bili Ncsztiyc
; Kct 1
Ncgitivc
'SC 1 1.030 NIA
Bid I I Negative
P ' ., A . N/A .
Prot
Urob
Nit
Lcuk
HCG
N141.1.ivc
. . .
Cell Count
Dircctigcn
\t›
INkgplivc
0.2 - 1.0
Negatirc
Negative
11/11111 WB
08-11-03 03:31
Patient Liiits
IBC 37.5 H x10"3/111 4.5 10.5 RBC 4.01 110"6/uL 4.00 6.00 Hgb 11.9 VA. 11.0 18.0 Hct 31.4 Z 35.0 60.0 HD 93.3 fL 80.0 99.9 tCH 29.7 pg 27.0 31.0 MC 31.8 L g/cR. 33.0 37.0 Plt 464. H x101/uL 150. 450. tyz 11.9 •1 Z 20.5 51.1 LYB 4.5 * x101/u1 1.2 14
CROSS:I.L1TCH
I Ncptivc 1.4.BO/Rh I
Bloo:d..B.s -ak Unit Crossmiitch . (NIUST,SUBNUT Sr 518 WITH EVERY f..)7.̀/TT Or. BLOOD • .
RE Q LrESTED) UNIT TIPE
21 -3 4
<20 =
D
FD:
REMARKS:
P_EP-ORTED BY:
<:0
DATE: LAB 137
MEDCOM - 23558
DOD-037136
ACLU-RDI 1681 p.118
73-118
7-22
8.0-10.3 ria al
0.6-1.2 ruE ,J1
128-145 mmol/1
3.3 -4.7 rurri.11,1
1 93-108 mmol/1
118-33 mroobl
-cOloylli.e2ePdnel
TfC (42 -FS
Ward,'S eztictivvi
LAST, FLRST,
TEST
Na
Cl
K
pH
PC 02
P02
TCO2
HCO3
s02
BEecf
An Gap
Ca
BUN
GLU
Creat
Hct
Pgb
TEST RESULT
138-146 m.mol.c1..
98-109 Eamon
7.31-7.45
35-45 mmHg (Ln) 41-51 mmHz (vool 80-105 mmHg a.rt) NIA (veul 23-27 mmoV1._ (&i1 24-29 mrnol/L (vca) 22-26 mmoVL (art) 23-28 mruoVL (vca)
95-98%
(-2) — (+3) romoilL 10-20 mmol/L
1.12-1.32 mmol/L
8-26 rr,g/cil
70-105 med1
0.7-1.5 mg/d.1
38-51% PCV
12-17 g/dl
REF. RANGE
Drug of Abusc
REQ
RESULT PP.F. R4.NGE
BUN
GLU
TP
GLU BUN CRE
CHOL CK NA+ K+
GLU CL-tCO2
CRE
BUN
CA"-
TEST PICCOLO 08/11/03 • 03:16
ALB REFERENCE RANGE: MALE ALP PATIENT #: ALT METLYTE 8
DISC LOT OPER #: 269 SERIAL #: AST
AMY
TES:
1 -7.7:72== PICCOLO ----- -- 08/11/03 09:10 AM
- REFERENCE RANGE: MALE INST OC: OK CHEM OC: OK PATIENT #: 1111111) _ ck _ HEM 0 , LIP 3+, ICT 0 LIVER PANEL /078-- DISC LOT #: 3154AA7 OPER #1111111.1.,.... DR #: 000 SERIAL #: \:>(''' 0000100684
240* 73-118 MG/DL
11 7-22 MG/}DL
1.2 0.6-1.2 MG/DL 711* 39-380 U/L 129 128-145 MMOVL 3.4 3.3-4.7 MMOVL 99 98-108 MMOVL 2? 18-33 MMOVL
CITEINILSTI2YRE(SULTFOR.411 (Subject .to the ?riva!:).Azt of 1974)
1 2,A ; T1.1\ 13 . I_ 1,1711 "62910 6 (C-e) -
co tetabolieTaaer... -.:- :.---.-
RESULT 1 REF. ,R..-INGE
3151AA4 DR #: 000
0000100494
tCO 2
NA-
CRE
CK
CL'
ALB 3.1* 3.3-5.5 G/DL ALP 89* 26-84 ALT 41 10-47 AMY 36 14-97 U/L AST 42* 11-38 U/L TBIL 1.0 0.2-1.6 MG/DL (3(3T 51 5-65 U/L TP 6.3* 6.4 -8.1 G/DL
INST GC:- OK CHEM OC: OK HEM 1+, LIP 3+, ICT 0
TBIL
tCO 2
P.I.I'ORTED BY: DATE:
I LAB ro NO.:
MEDCOM - 23559
DOD-037137
ACLU-RDI 1681 p.119
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
AN
ES
TH
ET
IC A
GE
NTS
AN
D D
RU
GS
I
CO
NT
INU
OU
S/R
EPE
AT
ED
DR
UG
S
SP
EC
IFY
UN
ITS
- M
G/M
CG
/ML
, 'I
" =
CO
NS
TA
NT
INFU
SIO
N
DRUG (Units) TOTALS TOTAL EBL
, (,)-) " , .›,,, ,a,-,0 D-o-0
--,-
P-€."-----Ri"1 L. ( c` C..- ,
I
1,7 t Sp <,... TOTAL URINE
4) 05-t$ t,-,-.1•R- /gal r),-e) . .><
3-117,5 lap, .-N .&-)- ntul?"11°Q
) (
0'12(
VOLAT AGENT
ge`c"4" % del C i b / --- /----. FLUIDS - SUMMARY
% e.t. CRYSTALLOID-
--36ri, -3?.' AIR L/Min
N20 L/Min
q
- LIC.Q......
02 L/Min a— — ---_ BLOOD - .\.......„............ SINGLE DOSE DRUGS-MARK ON GRID _,„
WITH NUMBERS & ENTER IN REMARKS
FLU
IDS
LINE site LA Itfvb gg War -• -., ).-- fah
ir• 1.• (N)
REMARKS
Code drugs with numbers, events with Millers
"a-k..k ..,-. erk.;. -1-,-. cyt - .........,--.13 do, se S.
;n,"6-,S. i."- Irk \SSS. . No,
(-)a.. Sr-Q-str....yz&k 1 c
E,-.1 e_s. l'y %I? stj MT- 11 (off — 5-1
ate, N.<3.,„__
S-Ic . C.,751 C/b..-
C1-11--40-$4 ; 66>\
""Rtia=f3re*, -
-C).-■ e 5.2 .
sc.. ,I_/ MI- iico/k"
0 0 55_
Ltn-gyro ,..-lcr."-e
-ne-A-.--ivni-T .
RE OVERY AT
❑ Warmed t9.,i4) A. La-., .9.5A) /16 xd- t_ ❑ Warmed
❑ Warmed
6 Gsp
EST BLOOD LOSS ..--C LOSSES
UR NE --)4.- .
PHYS STATUS TIME ♦opo oCo- 663" 1c. 3 4 5 Ir.,...)
SYMBOLS: BODY WEIGH : 220 .
..,/ 50 1) BP by cuff
V
A Heart rate -
• Resp rate
BR (transduced)
_L T
TOURNIQUET
T -4/
ANES- X-X PROC-0_,25
. L m :
200 ,
HEMATOCRIT:
1. 'C 31• 14 180 .
INITIAL DATA: 160 '
, BP- 051 C:i5
140 , F—I--
/ II II II
120 ERNI/111E1MM I into ipzer.Artgliffah• HR -
6 ' 100 SEI . Mr= IMMUMMA' DS , . . . NUM . .
EQUIP C ECK 80 . OK? - Y N 60 411P . MN PATENT RECHECK PA EMPAN,WittArAvA ma OK for PROCEDURE? \
TIME-
40 -1111FIEWAVIAM1111111111311MMIll THAPAILI111111111111 .
2.1111.1111....011. 20 .. ,
,,
i VT-ml 9 s-,.., 1.) .4 i f a 4s t., n
il f - breaths/min (O R -K Peak )nf ores / PEEP a) 42_
RI MODE - S(pon). ssist). CIon) M WM %./ C‘i CA/ —
BP /Auto Cuff ET CO2 (torr) 3 -= / -“,- IESINIEVALIMIIM Nrap Specify) BPloth F102 (Frac or %) .i.,-( M - S3- ., 4 • 8 58• MN
OTHER ART line Sp02 (%I i o...2 6.,J too fa., /V itso 1.153 CONDITION:
RESP- ).., Sp02- -53g
BP - HR - ), ,
Steth- PC/ES ECG S A 5- Si 5/7 ., . i 11-
Gas analyzer TEMP-site'
LC
7
N-M Block (T/4) Eja 411( li y
MN Er ,
ANESTHESIA / PROCEDURE' TIMES
co Start Room End
MI CSt NE Warming blkt
Cony warmer Ready Begin End Murk with letters a syn bots, EVENTS_.... — LL — explain under REMARKS Position - 02C•6 : ,111 C So 4. - S.L.
PROCEDURES and CPT Codes:
CAolvOgivg,a ,, _Dr/3 &a-n-0,4s., criii (.41- -tATII,GIA ANESTHETIC TECHNIQUES: Describe block technique under Remarks
CE- 771- AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
6-r :-.1 fhok-lr) * Ec-5 6-t- ev-'')P3= 65 (-fit` -colfi. 21 ,— (4/1 C-N--) 6(74_.D,z5u,„ .KI,
PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
Mpclical facility
jr LI 1-- aill
SURGEONS: PROCEDURE 4,1 LOCATION: C̀ .11- `-'9--- DATE:__, \r0 PAGE g OF
DA FORM 7389, FEB 1998 MEDCOM - 23560 COPY 3 - ANESTHESIA DEPARTMENT
USAPA V1.00
DOD-037138
ACLU-RDI 1681 p.120
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
.PRO.O.:::: :si::MJnit.$) TOTALS - TVP.44::: ..c.e.,0- 4,,,,ik. 4)-3 ) mobcre 1 ($15 1\-t.
(I, e)0\ /rep twi ) NtY 1 ac. I pig
fs-t.m.K (,),- ) 1 VD j tikViiiiiiti Ins-c.,,,er", I sbaz I
I 1 004 I ) . .. . . . . .
..,,votAT::: : :A0E611.::::
I Su % del WNW ti:S.UMW.01 % e.t. CRYSTALLOID-
1 OO AIR L/Min
N20 L/Min COLLOID-
L/Min lex --.1.--1- .4-3) SINGLE WITH NUMBERS
02 DOSE DRUGS-MARK ON GRIL ♦
& ENTER IN REMARKS
BLOOD-
LINE site ❑ Warmed REMARKS:,::ii: ::n::::i.: ::::
$t- ❑ Warmed 1 ---4---,----0------, Code drugs with numbers, events with tethers
Q tr) , utn.c....--i- 1.4.,4•....
12.posss.(41.L..."-s-4,-; .
Stu', el.,' Inu) ,
I ..-ay 4,0011.. b\iLlr.t -, A4-r--4 eyvar-oL
A sc. -cuttt. ❑ Warmed ...---,----1...-..........-,
❑ Warmed
Ad-Ogts: EST BLOOD LOSS
::::.:::::::::::::::.::: URINE -
:'PertS:iSTATLIS: TIME +NI' C) • x. • ti• ), • 13
:°' :1,?-1:FR:q:f. :;
BP by cult
V A
Heart rate
• Resp rate
BR (transduced)
41
TOURNIQUET
ANES- X-X
PROC-eizi
.
11001'.:41:00.k1V
t C3600 LB
zzo ' izsusr.sc -1-1,-4(- pta..cli T tiv-e-N-t4
r•--•?(J—.... ,, 0 Co*PLate-rke•-1 ie
200
: , HEM4179GRIT::: 180
-1.1.-- 1.
rei 4.,...... vf-vt .1C 1 fo
-ilt.4.P7jA4::PATI.A:':!. 160
et* is 1-1-b p-trai.kA
140 V c.N. V 3.2o.-e-La..rs of....14-,,t 1 BP-
1710 (t V
----V . ... v v
120 V V N1 Cbrfr isnr.-aa Crvio.-4-4
HR - I it.
.
Ni V V ♦
V NI • A • • ... - %-c1, ta.m#010.1411. 100 to y • • • • • • . . •
80 To Eitta t , v.--p.,--4- ;:EQUIR.::CHECV;
0 K 7 - C.3 N A A, "A • 60 ''''/%,
AAA z1A±A_A A f•
- . ... . . ... . . .... . . F9kTIPOT:likctIgcK T —/1/
,
OA for PROCEDURE? Y
TIME- tor!
40
20
6y_____, . o ii3. i) VT - ml epeo Pa eat. Elio 1-000so GOO Co tit) b T•1100iZ6 3 /
f - breaths/min - 1 4-1 12• is t-z 8 e 1 to >tv
•roLa.A., 8.41 Peak Mt pres / PEEP Zel 21 2.1 21 - '
MODE - Sfponl. A(ssist), Cloo) S C C. C C CIA S .1. tigOdYtiiO411 1310 Cep/Auto Cuff )QET CO2 (torr) - 74 24 3e. il IN S/ 44 PAC ICU Specify)
BP/oth aF102 (Frac or %) 8J0 11 /I 'II -11 II -re, -to ART line Sp02 (%) qi (CSD lib lab I an tub lab Io? OTHER
Steth• PC/ES k:ECG ST Sr SR, s•t_ Sn_ sr 5T tr CONDITION: V-...4(4,
Gas analyzer >zoTEMP-site t - al •eo 17.7 11--r- STT 374, 27.1 37•e REV- I, Le 5902- ilElk%
N-M Block (T/41 BP HR- 1U•2 01451!g.$*::■.!:imP...FL.- 1 ,•rimes.:::,.,:::::::::::::,,,,,:::::::::::%.:::::::::,:.:::::—.
Start Room End
Warming bIkt 10q0 10 1(4 11 10
Cony warmer Ready Begin End Mark with lerrors & symbols, EV ENTS__.® t que 0., 606.441 . c
S.4. 14 .
esplainoneter REMARKS Position c Q•..r.kiLe.-04 . pr- Q --tmr.'r 1050 77z.s- 12.1-o PROCEDURES and CPT Codes:
I -4- 12:) Las / 601-1..*#p CA_S
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
GSA- A
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
ile•c) Gem Z; 4..t..:,,, . al-r #-Ivtle. 3 PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
Medical facility
ePt.),) SURGEONS: PROCEDURE LOCATION: DATE:
A ANESTHETISTS: OS kJeu 0.3
MEDCOM - 23561 PAGE 1 OF i
not CelIntRA -soork CCO 1C1C10 r^110V i DA TICMT•C RACrtIP AI DCrf1011
/1.CPDA %/I /VI
DOD-037139
ACLU-RDI 1681 p.121
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40.66; the proponent agency is the OTSG
.::.:SOlf11:
3;;ON
VI,S
IN3
Dr:01.14
111$::
CO
NT
INU
OU
S!R
EP
EA
TE
D D
RU
GS
S
PE
CIF
Y U
NIT
S -
MG
/MC
G/M
L,
'I' =
CO
NS
TA
NT
INF
US
ION
...1301.1 .......................... :,ILInit0.: TOTALS TOTAL :
Pi40v-c7_ (# ) --)17 .. -2-ef* ,•-•'`.. I in- Ix2 q°
a -- l c4- ::I Ii4:::jAiNC -Itir-IL 1 cc ) lhoLpiPI/vg- (/ ) 9 'A- 2_1_.
(d) ( )
L5' v a % del citA.I::::-Ic-N,e.. 1,j- .'c--- , — .' i. a —t,2 AGENT % e.t. CRYSTALLOID-
AIR L/Min
N20 LlMin
— ' . a LLOID-
BLOOD- 02 L/Min - VERMIZMIIIMINEIIMILI
SINGLE DOSE DRUGS-MARK ON GRID.* WITH NUMBERS IS ENTER IN REMARKS _.........—..,
LINE site Lii (4.1001-C.Allamed( 1-
g 0 Warmed Code drugs with numbers, events with !enters
fir,.....1...-W 4 4-0 'TO cY2-2t a. An...At- 3
ill C--tc--•-‘ E-14'i9
Z •:_s ID Warmed
0 Warmed
tii.: gig EST BLOOD LOSS
UR NE -
.4TN1114::::; . E _.. TIME '-' TIME
,, •ilBttii 'T •
220
KG LB
BP by cuff
V A
Heart rate
• Resp rate
BR (transduced)
+
TOURNIQUET
T —/1/
ANES- XX PROC-C>.0
200 —
.. ,
•:::',HPYYIPOPIT.:., 180
160
INRIW.Prk.r.k . BP- Di (-1.< 140
/ 120 HR-
1:::tQL/W.i 6
100
MIT'XIIIMIIIPIIPIIIMINPMEIMMEIPAP IIMIWAILIVANIMENVONSFAIONTflarJ i7iro misivisamingram,
80
OK?- Y NI 60
PATIENT R ECHECK 111111111111111GLIENENIIIIIIIMINrinAmmirm A Or( for PROCEDURE?
TIME-
40 Lim. IIMITirALTAATATINFAVIMIII 2
VT-mi t d'° /r 0 I • breaths/min I g- ( "-,- f .1 Pr
44 Peak inf pres / PEEP a 'I_
MODE - St on) Alssist), Cf on) C.A.) CV SNI V SV SV S V SV sv RECOVERY 41 ab
M 2 0
41
ta *I
cc 1.-.,
BP/Auto Cuff ET CO2 (ton) Z.S" S Ek1111111ffilliM 0 '3 3 BP/oth F102 (Frac or %) t 8 L . &0 • 81 • 5.c.) lo • g i r Fr I et3
AC ICU Speclly1
OTHER ART line Sp02 (%) ECG
1'-' jr., i LW i.-• -r - 51 - s—
(03 ICJ OA sf c Cr
i 0) 5 Steth- PC/ES
Gas analyzer
CONDITION:
RESP- Sp02- BP
TEMP-sItecOV Liallklall1501111EMILNIIIIIME PIM N-M Block IT/4) litareMIEMI
14
o
. Start ua Room End Z 0 a
Warming 1311(1 1 Pic 1 05/.... Oa:
Cony warmer 0 Ready 0 T. IloS
Begin
tll
End
iVt, Mark will, letters & symbols, EVENTS LI-4 explaiir under REMARKS Position -&-"Pr',-"-- • 6'-‘•-"S /4-V3=4:1C PROCEDURES and CPT Codes: L..t. j
UOCk.g.ti Otic lic"-hal? ClaS 0-ll_ e PrtYci- ill-dr- 4-K 4-ca-"J'S
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
AIRWAY MANAGEMENT: Intubation route, blade, technintet„com&eei(sjo 44„&c,
01.-sfi nIteCt
PATIENT IDENTIFI AT1ON: Typed or written entries: Name, Grade/Rate,
Medical facility
C 1 , 41110 (7) (.(.4_, (
SUR
b 4 t
PROCEDURE LOCATION: "--‘. (--- DATE: I
IC lOCO 6-1 ANESTHETISTS: .._,
MEDCOM - 23562 PAGE 1 OF
q rnpv 1 _ PATICHT•C prrnan IISAPA VI MI
DOD-037140
ACLU-RDI 1681 p.122
a11111 .1-11115 TT V ,11.• a, . l ••..•-,-..........-. _--
MEDICAL RECORDPROGRESS NOTES
(..tital-ID: POD: Admission Date: W jt ,(2)1f (*),,... Diagnosis:6W
t i
Skin assessment must be done initially and every 7 days.
Braden Scale Evaluation See Braden Evaluation Table for Details)
Sensory No impairment Perception Slightly l imited
Very limited 2
Completed I
Mobility No 4 Slightly limited CT,
Very limited 2 Completely immobile I
Moisture Rarely moist 4 Occasionally moist 3
Moist C7 Constantly moist I
Nutrition Excellent 4 Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor ( r)--- I
Activity Walks frequently 4 Walks occasionally 3
Chairfast - 2
Bedfast (4)
Friction and No apparent problem 3
Shear Potential problems (2) Problems 1
Add the total score
Above 20 Low Risk
20 Medium Risk Total Score: 1 .-6 Between 16 and R . Bet ween anc111.__tIlig-i Risk_
Below 10 Very High Risk Note: A Braden Scale Score of less than 15 indicates HIGH RISK-requires immediate Ulcer Prevention program.
Yes_ No_ Location: to A a A Surgical wound (s): • e '. Size: Drainage:
Proc_edUr
Pins: Appearance: P-e.)( -5 ∎ I Tubes:
I Dressing change: 0Y.-bpq -btbrsctn-4,-.-4' 4- Location:
(,D(., Size: Drainage: Cil Pins: Appearance: Tubes:
Dressing change: Yes_ No_ % BSA Partial Full Bum wound (s): Location: Size
Appearance: Dressing change: Location: Size
Appearance: Dressing change:
Pressure Ulcer (s): Yes No Stage 1, II, III, IV (Circle the one that applies and describe below)
Size:_ Location: Dry Granulation tissue Yellow slough Tunneling
Wound character: Pink Moist Odor Purulent discharge Eschar Exudates Undermining
Wet-to-dry Comfeel dressing Carrasyn-V Gel Alginate Type of dressing change:
for wound debridement: Yes No Date/time MD notified Physician notified/consulted CNS notified/consulted for Stage Il and greater: Yes No
Nutrition Referral: Yes No Physical Therapy Referral: Yes No
Action taken: Date & Time
REGISTER NO. WARD NO.
Patient's Identification (For typed or written entries give: Name-last. first, middle: Grade; rank; hospital or medical facility) PROGRESS NOTES
Medical Record STANDARD FORM 509
MEDCOM - 23563
DOD-037141
ACLU-RDI 1681 p.123
PLAN OF CAKe., FO` K DROGKT, IN BREAKDOWN AN PROUD NAGEMENT
P._ . NOTES MEDICAL RECORD Admission Date:
Diagnosis: MEM& IR MEWS*
D. POD:
Date:172MM_____ Time:_ bD,-)-, RN Signature: Skin breakdown as evidenced by immobility, friction, shear, moisture, abrasions, surgical wound, skin tear.
Wound type: Surgical wound (s) Location:_ Drainage: Size:
Diabetic ulcer Tubes: Pins:
Venous stasis ulcer Dressing change: Describe
Other
Burn wound (s): % BSA _ Partial Full
Size Location:
Appearance: Dressing change:
Pressure Ulcer (s): Stage I, II, Ill, IV (Circle the one that applies and describeselow)
Location: ize:
Wound character: Pink Moist DDT Granulation tissue Yellow slough
Tunneling Undermining Odor Purulent discharge Eschar Exudates
Appearance:
Refer to SOP for Dressing Change Instructions.
Please check the appropriate dressing Change:
❑ Wet to Dry Dressing
❑ Carrasyn-V GelDressing
❑ Alginate Dressing
❑ Comfeel Dressing
❑ Pin Site Care
❑ J-Tube Care
❑ Colostomy Care
❑ Chest Tube Care
❑ Burn Care
Select the appropriate products used:
❑ Sterile 4x4 gauze dressing
❑ Sterile 2x2 gauze dressing ❑ Sterile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage ❑ Sterile Normal Saline ❑ Sterile Water ❑ 8 x 4 Sponge gauze ❑ Op-site ❑ Tegaderm clear dressing ❑ Alkare skin prep ❑ Comfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel ❑ Alginate ❑ Bacitracin ❑ Silvadene Cream
NOTE: Document daily wound and dressing change on Progress Note or Nursing Note.
❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film ❑ Sterile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ 0.125% Dakins sol ❑ Betadine Swab sticks ❑ 1/2 Hydrogen Peroxide &1/2
Sterile Normal Saline
Select the frequency of dressing change:
❑ b.i.d. ❑ t.i.d ❑ qd
MD Signature and Date:
CNS Signature and Date:
Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade; rank; hospital or medical facility)
Medical Record, SF 509
MEDCOM - 23564
DOD-037142
ACLU-RDI 1681 p.124
NSN 7640-01-18S-7294 518-701
RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AGE SEX WARD/CLINIC
J
SSN (11,
if FILM NO.
REQUESTED BY (Print) cxR
REGISTER NO.
PREGNANT
11 YES n NO
TELEPHONE/PAGE NO.
SIGNATURE OF RE „du)
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
/04eniew14--
DATE REQUESTED
DATE OF EXAMINATION (Month, day, year) 'DATE OF REPORT (Month, day, year)
DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC REPORT
PATIENT'S IDENTIFICATION (For typed or written entries glue: Name — last, first, middle, Medical Facility)
JAM
b(61Y-
MEDC ION STANDARD FORM 519-B 4 -83) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8
DOD-037143
ACLU-RDI 1681 p.125
EMERGENCY RELEASE OF BLOOD COMPONENTS SECTION I - REQUISITION ..
❑,R
IPONENTS REQUESTED (Check One)
RED BLOOD CELLS (Crossmatch not performed)
CYTOMEGALOVIRUS
OTHER (Specify)
❑ THE FOLLOWING TESTS HAVE NOT BEEN PERF1RMED:
ALANINE AMINOTRANSFERASE RETROVIRUS TESTS
TEST SYPHILIS SEROLOGY TEST
HEPATITIS TESTS
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST PRODUCTS FOR TRANSFUSION WITHOUT COMPLETE TESTING. I UNDERSTAND RESPONSIBILITY FOR THE ADMINISTRATION OF THIS TRANSFUSION.
THE IMMEDIATE RELEASE OF THESE BLOOD THE INCREASED RISK TO THE PATIENT AND ACCEPT
PFIY ' __. ---e___ DATE
- - - - TRANSFUSION NUMBER
SECTION II - ISS
RECIPIENT INS ABO/Rh .
A our)
/TRANSFUSION DATA re)
3 v , - s
.
U_(-6.)
INDIVIDUAL A COMPONENTS
ggvd .3 UNIT NUMBER
1ST VERIFIER 2D VERIFIER A ABO/Rh ,
(Signature) (Signature) DATE/TIME STARTED
DATE/TIME COMPLETED
AMOUNT GIVEN REACTION YES/NO
0 11044 0 / 0
0 os U itA5
IDENTIFICATION VERIFICATION The transfusionist (1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate that the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block.
TRANSFUSION REACTION
If reation is SUSPECTED - IMMEDIATELY:
1. Discontnue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Procedures.
4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Desclepon
LI URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER
OTHER DIFFIClikTIES (EQUIPMENT. CLOTS.
IPI< ❑ YES (SPECIFY)
ETC.)
PRE-TRANSFUSION
TEMP: 9 7 S PULSE: I ra B/P: -77_
SIGN VE 6 ( (t)_ e. /11,-
PREP ' 1, (j.t )-- --L,
,(A7N/9--- /1.tr:7--
DATE
r0 --
PATI (NAME- LAST, FIRST: SSN)
,( )—(ji
One copy is placed in the medical records. One copy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.
MEDCOM - 23566
DOD-037144
ACLU-RDI 1681 p.126
EMERGENCY RELEASE OF BLOOD COMPONENTS ' • SECTION I - REQUISITION
C MPONENTS REQUESTED (Check One)
RED BLOOD CELLS (Crossmatch not performed)
❑
CYTOMEGALOVIRUS
OTHER (Specify)
❑ THE FOLLOWING TESTS HAVE NOT BEEN PERFrMED:
ALANINE AMINOTRANSFERASE RETROVIRUS TESTS
TEST SYPHILIS SEROLOGY TEST
HEPATITIS TESTS
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THESE BLOOD PRODUCTS FOR TRANSFUSION WITHOUT COMPLETE TESTING. I UNDERSTAND THE INCREASED RISK TO THE PATIENT AND ACCEPT RESPONSIBILITY FOR THE ADMINISTRATION OF THIS TRANSFUSION.
PHYSICIAN'S SIG
0 (-0-)- 2-
DATE
',-./0 -(1. C
SECTION . II - ISSUE/TRANSFUSION DATA TRANSFUSION NUMBER RECIPIENT
ABO/Rh •
IN D Y Signature) i )_... INDIVIDUAL ACCEPTING COMPONENTS
OU•4
A
I 8 /co v b'l NUMBER ABO/Rh
1ST VERIFIER
(Signature)
2D VERIFIER
(Signature) •UNIT
DATE/TIME DATE/TIME
STARTED COMPLETED
V-1.
Ir •
IiiiLIWMIrgalit 41 -14P1P-4 •
1111 CA agiii•gr,
/0
0
ID /112.-4 &Maga
■ (CL\ 'r° LA
IDENTWICATION VERIFICATION The transfusionisN1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate that the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block.
TRANSFUSION REACTION
If reation is SUSPECTED - IMMEDIATELY:
1. Discontnue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Procedures.
4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Descnalion
LI URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER OTHER DIFFI LTIES
0
(EQUIPMENT. CLOTS.
❑ YES (SPECIFY)
ETC.)
VE Lfte) ,,,z,
94,07A—/- PRE-TRANSFUSION
TEMP: PULSE: 12.5( B/P: 3
SI
P rm i s
—
(":-.. "17...-------
One copy is placed in the copy is return to the blood Pink top should be drawn retroactive crossmatch.
DATh/zO('
medical records. One bank. Red, Purple or and submitted to lab for
E- LAST, FIRST; SSN)
\,-) tck.---(4
MEDCOM - 23567
DOD-037145
ACLU-RDI 1681 p.127
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.
PATIENT 10ENTIFI TION •
'--\. I
ilii, rep , loec zoo
o 0
/1
DATE OF Op DE ,_, TIME OF ORDER
,i2 AY, _.5 HOURS
LIST TIME ORDER
NOTED AND SIGN
/70/T IC
, /7 (i& /1 7/
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER '
1 Dee 01 0 /5-00 HOURS
_C) DLit- 0 04 AX 50,p. PA k 7" NOW, V, 0 , DR OW c-r .QTY' ...
....,
NURSING UNIT ROOM NO BED NO.
(X C
t,- t
.2
L Q.-7 n PATIENT IDENTIFICATION
DL6 O`'
DATE OF ORDER TIME OF ORDER
V D &c o-7 0 t 30 HOURS
il, 51st 2 kckuse l
• • ,(3C t. f. c:.)
...
,
I liS 1'1 4 III
. _
Ftz---- NURSING UNIT ROOM N9.
A ,..,..,. tab.: tri_ PATIE' per• I ICATLON _A
le.
BED NO.
4. •nr_ • -- t
MEDCOM - 23568
DOD-037146
ACLU-RDI 1681 p.128
PATIENT IDENTIFICATION DATE OF ORDER • \ TIME OF OR R/
HOURS
LIST TIME ORDER
NOTED A D
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
DA FAOPFIRM79 ■ 2561
MEDCOM - 23569
DOD-037147
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
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 .
ko u_S - <_s5
(\circa GL
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
ACLU-RDI 1681 p.129
DITION OF 1 JUL TT, WHICH MAY BE USED
MEDCOM - 23570
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.
PATIENT IDENTIFICATION
110 )9( (ssly ig
A DATE OF ORDS TIME OF OR ER
it V . (,
HOURS
LIST TIME ORDER
NOTED AND . SIGN
rove' i IF r Air , u 0 . ailyi i J'/
rial — 5
[go ( f flalfflUt f IIINIMININY ____
NURSING UNIT ROOM NO.
• BE • NO.
, rel Ir Of _I , 04 C., ) g, * , tr, 77:7A-C ' 1V6 i',0 0` - (
PATIENT IDENTIFICATION
'Lut-S-1- i
pp. '
tr A DATE OF I!' DER TIME 0 DER
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PATIENT IDENTIFICATION
,,,,,. 4 DATE OF ORDER TIME OF OR ER
I( ( 4 HOURS
1 A PC0c ' rr 01 ,- rairaffiwxo. -/ nirrigr- fir' iar rowirmisimmars , ,,
No iv 'os I (iv r,, L
NURSING UNIT ROOM NO. BED NO. .„ .4 fi e --e
PATIENT IDENTIFICATION
i .
\
1 t■ / \
, u DATE OF OR ER TI OR E R
/0 oi HOURS
. ((i ./--7, • ci. et--(, / irk, 7
, iol• fi NURSING UNIT ROO . BED O. .
( (-e 7 7_ DA 1 FAOPRRM79 4256
DOD-037148
ACLU-RDI 1681 p.130
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.
PATIENT IDENTIFICATION
\
1, /7 + DATE OF ORDER
t( — 5— eDC)
TIME OF ORDER
HOURS
LIST I tmt ORDER
NOTED AND SIGN
i IA 100 1-01...AJ
NURSING UNIT ROOM NO .
PATIENT IDENTIFICATION DAT OF ORDER
),P0V P3 TIME OF 0
HOURS .01110 • i
°BF 70 /0 ----b 4y. -
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NURSING UN T )
,z)-- our ROOM NO.
(iu-Nv971 ED NO.
( (J.■ e____
PATIENT IDENTIFICATION
1. (S---,
ATE OF ORDER TIME OF ORDER
HOURS
;■ "
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
t
1
DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
DA 1FAVR°479 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23571
DOD-037149
ACLU-RDI 1681 p.131
NURSING UNIT D Nom=
DA ,FAOPRRM„ 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED.
MEDCOM - 23572
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.
PATIENT IDENTIFICATION TIME OF ORD IR DATE OF ORDER LIST TIME ORDER
NOTED AND SIGN
NURSING UNIT
PATIENT 1.TIF ICA G
Li V e c_,s7k., ej„
NURSING UNIT vi
b 0
PATIENT IDENTIFICATION
,
NURSING UNIT
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORO R
I'' HOURS
FM (tcc_ 64_cc
H CURS
ROOM NO. BED NO.
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-037150
ACLU-RDI 1681 p.132
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED
MEDCOM - 23573
DA 1FAOPRRM79 4256
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.
PATIENT IDENTIFICATION OATE OF ORDER 3, TIME OF ORDE LIST TIME ORDER
NOTED AND HOU
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-037151
ACLU-RDI 1681 p.133
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.
PATIENT IDENTIFICATION i ay
.11, ..„
14. 1„,..
AL
A f 41F411
1
DATE OF ORDER .1 TI M ! p c,,,F ry ER t . Aidip' " chf..zr HOURS
LIST TIME ORDER
NOTED AND SIGN
Lecic [Alf C Zvi ,--
.14 giliw-- immillomi
NURSING UNIT
AN C 0
PATIENT IDENTIFICATION
‘" • NO. N
DAT: - • - ON /0 )OURS
.
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0....0,- ,, . . , ir • 6•-0,/ C/
NURSING UNIT ROOM NO. BED NO. OM- Y i-r 14- . (71) 6 1 cbeffi 1 ll- lohde.„ ,- 1 ef.7-
,
eiiiii PATIENT IDENTIFICATION VATS 4 ORDER ' OF OR
/ CI, 6,4 eta 4 (I/
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
.:7\?
DATE OF RDER TIME OF ORDER
,bafr 3 HOURS
4-0 (..e__ sl, r , 7 c f -eaccie-/-
Po -- Zia Xe044/ it to A. , 6 :,‘..df -\.„
\c)
BE NO. NURSING UNIT
... ROOM NO.
' %/ -( 0 , 01)'abe:.M .. DA IFArRm79 4256
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23574
"/
DOD-037152
ACLU-RDI 1681 p.134
nA PnRm A.A77 I nm- 7R cu. Jam tar vas., is rami oc USED. USAPA V1.00
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
PATIENT IDENTIFICATION:
MEDCOM - 23575
CLINICAL
VERIFY BY IMTIALING
ORDER DATE
niiirr-
RECORD
CLERK/ NURSE , .
L JII
. IrterAtalianMME -
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THERAPEUTIC DOCUMENTATION For use the proponent agency iggattaktetalg
RECURRING ACTION FREQUENCY, TIM
of this Is the
HR
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DOD-037153
ACLU-RDI 1681 p.135
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) mo 74f1 1-') y, 2003
SINGLE ACTIONS Date to
be Dori Time to be Done Time Done Initial
Order • Dat
Clerk Nurse /
/ / . i<
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PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN . FOLLOWING COMPLETION
TIME/DATE COMPLETED
— — — — — — — —
— — — — — — — — i
— — — — — — — —
— — — — — — — —
MEDCOM - 23576 .11 Iiii I I I
DOD-037154
ACLU-RDI 1681 p.136
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.
/VO, ‘k Yr. 2003
VERIFY BY INITIALING r•-• ,8 '''' x:g ;,,,,.**;:::'V ' INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
RECURRING ACTION , FREQUENCY, TIM
HR
Co r2- i ifi "i glagare
DATE COMPLETED MEEMIThal 1 on
,
ORDER DATE
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ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
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b (LL -c E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07 •
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MEDCOM - 23577
JSED. USAPA V1.00
DOD-037155
ACLU-RDI 1681 p.137
2 AA\ Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) \\ Mo 1 2- Yr 2003 (
/
Order
Date Clerk Nurse SINGLE ACTIONS
Date to be Done
Time to be Done Time Done t Initi
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— - - - - - - ,
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Order/Explr Date
Clerk/ Nurse
PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMP! ETION
TiMEIDATE COMPLETED
- - - - - - - -
- - - - - - - -
- - - - - - - -
_ _ _ _ _ _ _ MEDCOM - 23578
DOD-037156
ACLU-RDI 1681 p.138
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION")
For use of this foim, see AR 401407; . .. the proponent agency. Is the Office of The Surgeon General.
ma 1.2_. __ yr 2003
VERIFY BY IMTIALING ?: ' :0 / ,̀ -'a '=', -:-:.. ,W',,::: nv''''' ,, ,A,:, , INITL4L PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
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DOD-037157
ACLU-RDI 1681 p.139
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Alo 2--, Yr 2003
SINGLE ACTIONS Date to
be Done be Time to
Done Time Done Initials Order
Date Clerk
e
10
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MEDCOM - 23580 t̂-, ^
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DOD-037158
ACLU-RDI 1681 p.140
CLINICAL RECORD THERAPEUTIC DOCUNIENTATIQN CARE PLAN (MEDICATIONS)
For use o this forrn;',see AR 40-407; the proponent anenc • is the Off ice\of The Surgeon General.
Mo. Y r. VERIFY BY INITIALING ' . IIVTI7AL'IstROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE
CLERK/ NURSE
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
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mpncom - 22581
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
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I
DOD-037159
ACLU-RDI 1681 p.141
Order Date
Verify by Initialing
Clerk/ Nurse
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
SINGLE ORDER, PRE-OPERATIVES
Mo. Yr. Date to
be Given Time to be Given Time Given Initials
Order/ Expir Date
Clerk/ Nurse
PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
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USAPA V1.00
MEDCOM - 23582
DOD-037160
ACLU-RDI 1681 p.142
CLINICAL RECORD i
THERAPEUTIC DOCUMENTATION CAR t PLAN (MEDICATIONS) For use of this form, see AR 17;
proponent agency Is the Office of T e Surgeon General. the MO. f t Yr. (11-13 VERIFY BY
CL /C/
N RSE
INITIAJONG , INITIAL PR PER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER
DATE RECURRING MEDICATIONS,
DOSE, FREQUENCY
HR DATE DISPENSED
..
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PRIMARY DIAGNOSIS;
6:_s\iNk -to ‘, ,so-Dc_r__/- -k ■ -c-,,-3
. ADDITIONAL PAGES IN
DYES ONO
PAGE NO
USE:
PATIENT IDENTIFICATION,
DISPENSING TIMES 41.0
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14 1\0 )1/41) - A E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23583
DOD-037161
ACLU-RDI 1681 p.143
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) fl' 40 Yr )-' d3 mo.
Order Date
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES
Date to
be Given Time to be Given Time Given Initials
1111P.-
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tvr vi is—oe_ef' mid 4 . 16 te-di)
-
Order/ Ever Dot.
Clerk/ Nurse
PRN MEDICATION, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
ce v\r5ocA_ z- • \\I c:\ a.-2, rn • • ' r 1 .. g l wo
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*U.S. GPO: t996454-110/95216
MEDCOM - 23584
DOD-037162
ACLU-RDI 1681 p.144
CLINICAL RECORD HERAPEUTIC DOCUMENTATION CARE P N (MEDICATIONS) '
For use of this form, see AR 7; the proponent agency is the Office of The S rgeon General.
\\ j /17 Mo. -yr. lap,
VERIFY BY INITIALING.m. ...
,
INITIAL PROPS: COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE
CLERK/ NURSE
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
(0
MgE Z7 irimmin 3 El 5 6 DIM ri (VD, apawn,e4-1-(TIM '71)
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ALLERGIES- 0 yEs O PRIMARY DIAGNOSIS:: - ADDITIONAL PAGES IN USE:
El YES El NO
PAGE NO PATIENT IDENTIFICATION:
-en DISPENSING TIMES QeW f t)
USE PENCIL. CIRCLE MED TIMES
OIL 1 . D 7 8 9 10 11 12 13 14 ')...... li
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA1FFOEFF(3"19 461 8 EDITION OF I nce'' " uu" " EXHAUSTED. MEDCOM - 23585
DOD-037163
ACLU-RDI 1681 p.145
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo. ‘k 3.
Order Date
Clerk/ SINGLE ORDER, PRE-OPERATIVES Nurse
Date to be Given
Time to be Given Time Given Initials
AO.M, "Occ 2,9irc eq is alio
ok-iiiiLdrid, c P x — ' a tiv\:, 7 oci— U I (1)
•
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Order/ Explr Dote
Clerk/ se
PRN MEDICATI9N, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
0 I.V.4 _ geuvt rikro ; 1+4
MSOLI 2.-5 rn5 2 V' z7- Lk 6
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U.S. GPO: 1998-454-110195216
MEDCOM - 23586
I
DOD-037164
ACLU-RDI 1681 p.146
CLINICAL RECORD ,THERAPEUTIC DOCUMENTATION CARE PLA (MEDICATIONS) ,-- For use of this form , see AR 40-407;
the proponent agency is the Office of The Sur n General. M0 I .10-` 1r 10
VERIFY BY INITIALING INITIAL PROPER LUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE
CLERK/ NURSE
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
M RNIIM, ,-- 1 \■ A. (lb
,
. Ihallmft 4 16 11.1kti 1 a 6
pm II
,
/
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cps - Cto\crP 1 VC 1 ei1D
ALLERGIES- 0 YES 0 NO PRIMARY DIAGNOSIS:
e:S\IN - \t_ - \ Ini h a/h-300c -- ADDITIONAL PAGES IN
D YES 0 NO
PAGE NO
USE:
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIM ES AM.. b( ,4 _,,c 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 1FEB79 EDITION OF I nFr. 77WIl l" . 1" m EXHAUSTED.
MEDCOM - 23587
DOD-037165
ACLU-RDI 1681 p.147
. Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. yr
Order Date
Clerk/ NOUS° SINGLE INGLE ORDER, PRE•OPERATIVES Dote to
bo Given be Time to
Given
4.--......
Time Given Initials
.
,
0, LQ Order/ Expir Date
Clerk/ PRN Nurse M 7 DICATION, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
il WI f - SYY; \k2 2: 4 _Aft • id
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U.S. GPO: 1998-454-110/95216
MEDCOM - 23588
DOD-037166
ACLU-RDI 1681 p.148
b CLINICAL RECORD
THE APEUTIC DOCUMENTATION CAR '11-A1.4 (MEDICATIONS)
i the proponent agency is the Office of The Surgeon General. Mo. / Yr. .e)-_?
VERIFY . BY INITIALING , INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
, ORDER
' 'DATE CLERK/ NURSE
RECUIRRING MEDICATIONS, , DOSE, FREQUENCY
HR ‘• TE DISPENSED
FL 1111PRIEIMENIEffil n7iiffil u MEI MIIIIIIIMENIN
APIAIMMIIIIMP ,411. 11111111.111111 a 1 g
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ADDITIONAL. PAGES IN USE:
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DISPENSING
USE PENCIL. CIRCLE
TIMES
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
DA 1 FEB 79 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23589
DOD-037167
ACLU-RDI 1681 p.149
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
G) Mo. r
Order Date
Clerk/ Nurse
SINGLE ORDER, PRE-OPERATIVES Dote to
be Given Time to be Given Time Given Initials
I i
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INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
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U.S. GPO: 1998-454.110/95216
MEDCOM - 23590
DOD-037168
ACLU-RDI 1681 p.150
43/0
b \\
TIME'r
E.
flue PROCEDURE
ET
Intubation
pastric
Tube
D3I 0 Urinary
DPL
Chest
Tube #1
SIZE-
0 Oral ❑ Nasal
Teeth
0 Oral
0 Nasal
eMeatus
7F1CO Supra-Public
O Opened
O Closed
RESULTS,
❑ ETCO2 Change
O BBS Post Int
❑ Post CXR
0 Air ❑ Contents
0 Verified
Suction: Y N
tiReturn cc
0 Herne Dip: + -
LI Secured
O Grossly: + -
Cell count
Sent@
0 Air ❑ Blood
0 Pleuravac cm
0 Autotransfuser
ACCOMPANED BY - RETURN ' -`
-.AMT
AJ5
CT Scan: 0 Contrast
0 Head GYAbd Q1elvis
0 C-Spine 0 T/L Spine 0 Chest
O
A-Gram Site:
L R Chest
Tube #2
12 Lead
O Air ❑ Blood
❑ Pleuravac _cm
O Autotransfuser ,MEDICATION
Vi a A.; R.Ak
DOSE "; . RTE'
032, X51- 3
L R Rhythm: Comments
TIME':
'co
a3:4c$
TIME:. DOSE RTE DOSE RTE
ABG ISITE
1)
Sat HCO3'
1--e+z1.4,1.4-5
03W
6,3
I T✓ TIME
BE pCO
oy 2)
X-RAYS /KO L1,1
TIME a
O D-stick
❑ SHct
hest Initial
o -\ ❑ D-stick ❑ SHct
TBC • GI/C11em ❑ PT/PTT
❑ ETOH ❑ T&S 0 T&C x
❑ Tox Screen
0 Chest Post ET
❑ Chest Post CT
O C-Spine
Pelvis
BLOOD PRODUCTS 'Nir EI
;
O UA
❑ HCG
017 c..•-t
$3-OTHER I I- C._ Le 032C0-1
0 OTHER
CBC:
Chem: MAO AMOUNT" U
AMOUNT
IVF
NGT
Blood
Other
Urine
NGT
EBL
Other
TOTAL
TOTAL
VALUABLES & CLOTHING CiPrin t) A ESRONOE0' TA1
ED Phys None Found
Surgeon Given to Patient
Ane s th
Given to Family
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
X-Ray
DISPOSITION RT
0 Home 0
Ortho
Admitted to
Neuro Report Called to
Chaplain Time Transferred
I By
....,retcher ❑ Wheelchair MEDCOM - 23591
DOD-037169
ACLU-RDI 1681 p.151
5 - Localizes Pain
O3? D3
Recta Temp: GCS: TIME RP HR RHY RR SAO2 F110' . MODE ; - E
63D c 72 / 3/ 12-SArS'e 410
JO O
/40
Fa
GLASGOW COMA
EYE OPENiNG VREBLE RESPONSE
Spontaneous (Oriented
4 - Contused
1 - None
T IME
SCALE
MOTOR, RESPONSE •
". beys Commands
PERFORMED BY .:'
0)u
Ilk
616 /1/ /2 /
/ol /oft.,
r AlsA, AISg- AJM 2--
3 To Voice
2 - To Pain 3 • tnapp Words C
2 - Incomp Speech
1 - None
4 - Withdraws to Pain
3 - Flexion to Pain
2 - Extension to Pain
1 - None
0 Backboard Removed BY:
0 Downgraded BY:
NOTES
/
/
/
MEDCOM - 23592
DOD-037170
ACLU-RDI 1681 p.152
REPORT TITLE OTSG APPROVED (Date)
QI Appr 11 Jun 97 TRAUMA FLOWSHEET The t is Dept of Surgery
tural
AIRWAr:
Patient
TRACHEA! ❑ Midline ❑ Deviated
II CHEST SYMMETRY:
0 PULSE: resent ❑ Absent
BLEEDING: —16
HEART TONES: ❑ Clear ❑ Muffled
a a
RHYTHM: ERegular ❑
PULSES: CTCentral lirKripheral
13 a Absent
13 Crackles
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-86; the proponent agency is the Office of The Surgeon General.
TIME -03
Meds:
Allergies:
Tetanus:
LMP:
x 02 . 1 /min ❑ C-Spine Immob
❑ UKN ❑ None ❑ Yes:
❑ UKN ❑ Yes:
❑ UKN ❑ Current Last Meal/Fluid Intake hrs
TIME:O 0
MED COM: a ©
❑ ETT
❑ Secretions
❑ Labored IdUnlabored ❑ Absent SKIN: Cf Warn ❑ Cool ❑ Hot
❑ Pink CI Pale CI Cyanotic ❑
Qdry ❑ Moist ❑ Diaphoretic
0 CIRCULATION
SECONDARY SURVEY DISABILITY
GCS: E
V
M
SPHIN,OtER TONE:
WNL
❑ None
PUPILS: erqual ❑ Fixed a-F‘ct ❑ Dilated
TM: Er...-1ear ❑ Blood
NECK
C-Spine Tenderness:
Pain @
JVD:
HEART"
LUNGS
BREATH SOUNDS:R-Ettfat rEqual Ci ear
Decreased
—Y11144teezes
HEAD ABDOMEN
Err Soft 0 Rigid err:on-Tender
0 Tender:
0 > = <
0
PELVIS
liKtable ❑ Unstable 0
Blood at meatus/vagina:
Herne +l - Prostate: Vb<VNL ❑ Abnl
E
VASCULAR ASSESSMENT
alpable
Dopler
DA 1'aRYM7 8 4 700
REQUI
❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ FLOW CHART
❑ OTHER (Specify)
❑ TREATMENT
USE. DIAGRAM TO DOCUMENT INJURIES AND PAIN
(AB)rasion
IAMPlutation
IAV)ulsion
Battle's Signs
(BL)eeding
(B)urn
10)eformity
IE)cchymosis
(Floreign Body
(H)ematoma
(LAC)eration
(P)uncture (W)ound
(Pain)
(S)eatbelt IS)ign
(SItab IW)ound
1-elSi9VY .r-tSTR5rV oun
RN
PREPARED
PH
DEPART LINIC (Continue on reverse)
DATE
/"`1_,.11 vs PATIENTS I pe' or written entries give: Name--last, first. middle; grade; date; hospital or medical facility)
MEDCOM - 23593 D BY DO FORM 2005 EAMC OP 503, 1 Dec 98 I ■.117,3,J1..ETE.
DOD-037171
ACLU-RDI 1681 p.153
PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, first, middle; grade; date; hospital or medical facility) NAME: RANK: AGE:
UNIT: GENDER:
STATUS: US: AD / CIV IRAQI: CIV / EPW
❑ HISTORY/PHYSICAL
• OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
[1] TREATMENT
❑ FLOW CHART
❑ OTHER IS-Pacify)
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE INTENSIVE CARE NURSING FLOW SHEET ..,
OTSG APPROVED (Dare)
QA Appr 8 Mar 89
SHIFT ASS T k, TIME: I INITIALS TIME: INITIALS:
Z PUPILS
4,..
SENSORIUM 9 LI „
id rvui ,rjox 41) C NA I ) '1,Jh
EXTRiF,MITY MOVEMENT SEDATION PAIN CONTROL
ek 1 (0
I X
(f)
RESPIRATORY PATTERN BREATH SOUNDS "-
SECRETIONS 4-077 n c/i.,.hto ("i.z,,G...) --zt/Z•ei 02 SOURCE/FLOW/SA02 VENTILATOR SETTINGS •
>
CARDIAC RHYTHM k-r-E_ 1a3 CAPILLARY REFILL + --35-ec..- ,t_e_ ( -"- PULSES "t) !lb._ i J)_30-a EDEMA -r : ) '
I C., ABDOMEN it- CLISIVIC-te al BOWEL SOUNDS
igl 1-1-1-090 0 q.1(Te 15F-7/-
BOWEL MOVEMENT I $iLtif -e t/1"- riLLI-kic ti-ty-i NGT'OGT TUBE FEDDINGS DRAINS
VOIDING qr. '1--e) 131 COLOR/CLARITY pal- frettIO
i 91/n14-11 A ek
I ci) COLOR INTEGRITY -4-1/0C t i / L
SaykS1
ut.1 rf)
#1 TYPE/LOCATION/SIZE (017671,„; -._
DRESSING CONDITION /7 ?-. V--121; 441-,Y1-- IV FLUID/RATE 1 0 c d6 44c-pirez. 0 aseel/fA
.42 TYPE/LOCATION/SIZE DRESSING CONDITION IV FLIMS/RATE (Continue on reverse)
PlitfrAlii:D BY !Signature & Title) DEPARTMENT/SERVICE/CLINIC
ICU #1, 28TH Combat Support Hospital
I DATE
DA FORM 4700, MAY 73
MEDCOM - 23594
USAPPC V2.00
DOD-037172
ACLU-RDI 1681 p.154
;re 11IIOW . 12 II II 111
11 111
1111 oc4
Irl ISI ISI I I
I I E s Ill
Ell■I II NV' INN
111■I 1111 CNN EMI
MI 1 E c7. IBM
1 I III 2 1N11
I I Ill ,c) I II
I I II ,c° 111 " ri■ gnaw* -6z. , UN
11 . 1 I ,-r` Ell
I I li ,c-0 Ill
MI I II 1E1
IF MI1 _,1 IRA
MISIBEIM ,_c#) Mil MISMEEIN ) V 6' ROI MIMI 1 1 ;:v-, 11571 1 ?-1113111EIM 1
cDtrs v_rz, 1-c212 EllisIM c-‘ Lau
III - Qco\r,) OEM .24... -1111- Icr:,t6_31t? 0 IEC,
IN lc-cg 1 loll
O
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co
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1.72. (13
CL
ACLU-RDI 1681 p.155
Pacu Intake Site By
SL dAv- LV -r V (Lt._
Infused Qo
Amount Solution Time
1-310
ADM 30' D/C
1Lan1nUO MIEVOISL9
T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained
PR Title)
i •
DATE
it (01 (..K DEPARTMENTISERVICEICLINIC
A
X-rays:
Criteria Activity
(2) Moves 4 Extremities Moves 2 Extremities
(0) Moves 0 Extremities
Airway
(2) Cough. Deep breath -
(1) Dyspnea. limited breathing
(0) Apnea
Blood Pressure (2) SBP =1- 20 of Pre-op
(1) SBP =1- 20-50 of Pre-op
(0) SBP =1- 50 of Pre-op
Consciousness (2) Fully Awake, audible
crying (1) Arousable to verbal or pain
Color
(2) Baseline color & appearance
(1) pale. mottled. jaundiced
(0) Cyanotic
Circulation (Peds < 5 Years)
(2) radial Pulse Palpable (1) Axiliary palpable. not radial (0) Carotid only reliable pulse
TOTALS: Must be 9 or
greater to WC. otherwise needs anesthesia approval for
0/C.
Patien teaching done: Wound Care, Pain Management, Time
L ra 1 j 1 /s- IC Is )1.11 I
/r1 RR
T
Time
220
240
200
180
160
140
120
100
80
60
40
20
Labs:
Post-Anesthesia Recovery score
Pain (0-10) LOS
Codes
AIRWAY A =Ambu BB = Blow-by M- Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula
V'S X =A-line BF' -
=Cuff BP = Pulse
TEMP S = Skin 0 =Oral A= Axillary T = Tympanic R = Rectal
LOS C =Cervical T= Thoracic L = Lumbar S= Sacral
2_
For typed or written entries give:
ate; hospital or medical faatyl P first,
Name - last,
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4065; the proponent agency is the Office of The Surgeon General.
OTSG APPROVED Waal
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: I / z 7 / b 3 Anesthesia Type (Circle)): General Spinal Epidural
Time In: I .{ t IV Sedationrve Block
Allergies: OR Intake: Crystalloid (S-\- --"o Colloid
Pre-op V/S: I )..-t,,, Lk"- LA 1-- OR Output: UOP EBL pr
Procedures: T-4 19 Li- atjT-4 Meds/Times: 1%-lifu-r■ A fj'IL,. ( t"•. r4c....1 . to nn 4,31,..co
(j....-.-,-../._,3 ,i ,2.,kii-oc..ics a 14' GS ,....3 -rt, riietickyts ,.,-DY 2"--1 -Tv,k..t. u •
Pre Op Meds Histor
Drains Hemovac
NG JP
T-tube Foley
TLS
Air2.va Nasal Oral ETT
Trach
Other
0 FLOW CHART
❑ OTHER tro=do
❑ HISTORYIPHYSICAL
❑ OTHER EXAMINATION
OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)
MEDCOM - 23596
Previous edition is obsolete USAPPC 112.00
DOD-037174
ACLU-RDI 1681 p.156
DOD-037175
MEDICATIONS Allergies:
I/E By Medication & nrr acv.
Time Pain 1-in
Route
NEUROVASCULAR Time Site Range
Of Motion
Sensory P .
Cap Refill
T Color
Adm ".8) t: 4; Q■ (1) P B 0 {lc-
15' -711,,eht, w 1:: 25' P a ek--- 30'
45'
60'
90'
D/C
Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic,
Capillary Refill: B= Brisk, S= S uggish P= Pale, Pk = Pink
C-SECTIONS Adm 15' 30' 45' 60' 90' D/C
Fund. Height ''-----
Lochia ..........._____________
Peripad# --........_____s___
Fund. Cond. ----.....„ -.,_
NURSING NOTES
Pain 1-10
PACU OUTPUT
Time Source • Color/Appearance Amount
Sa02: 9V"6
Discharge Criteria: Date:10 1-a Time:, 4/3 1' PARS: BP: i .sae, HR:j2.3 RR: / Pain Level at D/C 10-101: Intake: Output: Additional Data:
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run? / 3/ s S 1..
1 114.—e-j -5,J r
• •-- --• WAMC OP 173-E
Transferred To: c-4-1
Report Given To: Transferred Vi Transferred B Cleared IAW Re
23597 e Signature:
DRESSINGS
Time Location Type Drainage
Adm 1 z. , - eg>4 41,66-s• ,w- -4- R- c?. 4Tt —) 30' ,s lc 7-i.i.Kie3 p ,._ (...; 4- /c......41-Z-1-. iii.,:: C.---
60'
DIC
/ 2
0 4eXar-it-
b U6-1 p\-\\
ACLU-RDI 1681 p.157
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this Ione, see AR 4066: the proponent agency a the Office of The Surgeon Omni-
REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED Wale
Date: I it (r-,, 0-- Anesthesia Type (Circle)): a pinal Epidural Drains Airway •
Time In: IV • .. .n Nerve Block Hemovac NG J r
• , - 1W
TLS
■rinlilll. • &b . OR Intake: Crystalloid Colloid Allergies: 1 - ' " Oral
ETT Trach
Other
Pre-op VIS: 3 1lb OR Output: UOP 0 E
Proced res: Mal■Wiggi -b Meds/Times: Ivl.i..)1 , t ll- t.-r-W 1
► .) i , 1 , - u 1
Pre Op Meds History,
Time 'f,n _ •,_._ — gl # _ Pacu Intake
Sa02
ni ba2,-..3-- Tim • Solution
41LIIIIINIMMIIIMMORIMIMIINET Amount Site - By Infused
Fi02 _.i.c, _ :;=,
._... um.
Methods Z -- .-.•&=.1.c...)
240 - .
220 X-rays: . Labs:
• Post-Anesthesia Recovery score
200 Criteria ADM 30' DIC Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities b 2 ..)
7
AIRWAY A =Ambu BB = Blow-by M - Mask
180
160 Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing (0) Apnea
(,
N
/
Z__ FT = Face Tent RA = RoomAir NC = Nasal
V
140 1
\../ \-, Blood Pressure (2) SBP 4- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =/- 50 of Pre-op
'
2--
Cannula
V/S X =A-line BP
120 pritt
•
100 Consciousness (2) Fully Awake, audible Ming (1) Arousable to veinal or pain I ( I
' == CpuuflfseBP
TEMP
i,
80
A A N Color (z) Baseline cotor & appearance (1) pale, mottled, jaundiced, (0) Cyanotic L Z. 2,
S =Skin 0 =Oral
A = Axillary T = Tympanic
60 r■
40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse
R = Rectal
• LOS C = Cervical 20
TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for WC.
-:,
T = Thoracic L =Lumbar S = Sacral
RR --1- taz tr ..)
v4 0... C T -
.. Time Patien teaching done: Wound Care. Pain Management,
Pain (0-10) T, C, & DB.. incentive Spirometer, Comfort Measures
LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained tcontinue on leVefiel
PRE
q6t,)-'
lien mules give: Name - las: 11/11U
OEPArr TiSIERVICEICLINIC DATE (
i i A4 lt(()
list, midd e; grade; date; hospital or medical lactEtyl
— L.
• HISTORYIPHYSICAL U FLOW CHART
• OTHER EXAMINATION • OTHER axed,' OR EVALUATION
4 • DIAGNOSTIC STUDIES
0 TREATMENT
DA FORM 4700. MAY 78 WAMC OP .173-E, (Revised) 1 Apr 01 (MCXC-DN)
MEDCOM - 23598
Previous edition is obsolete USAPPC V2.00
DOD-037176
ACLU-RDI 1681 p.158
DOD-037177
Time Source Color/Appearance
NEUROVASCULAR Time Site Range
Of Motion
Sensory P '
Cap Refill
T Color
Q(' ',...- Ju
Adm t'' LI l-ipx.: -- --t (1) N 15' 4 . . . iy,N.- .1.. .._ "a, _I VL 30'
45'
60'
90'
D/C \l/ y Movement/S nsation: + =prese ,-=abs t Temp:C= ool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C = Cyanotic,
Capillary Refill: B = Brisk, S=S uggish P= Pale, Pk = Pink
C-SECTIONS r- ' Adm 15' 30' ,45. fi0' 90' D/C
Fund. Height
Lochia
Peripac
Fund. Cond.
DRESSINGS Time Location Type Drainage
Adm L k. . .)<- . 30' MEM IneWrirall PBMI _ — 60' D/C
larill..
NURSING NOTES
k-leb h P r.(fik (...A_Llyo
LaLipt,`.&QD I . 1lf Hart- , d,/t-Pco&n MW-) /r tidilti&FD
( V L6sz 06
Wm/
CARDIAC RHYTHM
Time Rhythm ;V Syroplornatio? Rhythm Strip Run?
BLID 1/4s1,-1-
i_-(----)- (-1:-----)
- --- - - - WAMC OP 173-E
Date: 11 VI Time: (<-1-1 - PARS:' BP: 1%1% T: 011 HR:ITZ--RR:7C Sa02: Pain Level at D/CA0-10): Intake: . •(7: -" Output: Additional Data: Transferred To: 1 C 1,0 I Report Given To: Transferred Via: Transferred By: Cleared IAW Recove
""•--,e Signature - 23599
MEDICATIONS Allergies:
Medication r)nsaae
Route in 1-10
I/E By Time Pain 1-10
PACU OUTPUT
ACLU-RDI 1681 p.159
NATIONALITY NAT iONALITE
M OM
I PsYcH PSYCH NRI F INC
FORCE / ELEm
A.T A
13C% BC
3. INJURY.' 0LESSURE
FRONT; DEVANT
DIS ASEI MALADIE
AIRWAY TRACI-If(
BACK ARNERE NEAD/TETE
2. UNIT/Lima/
SSN/ MERO
NA FIRST ME/ NOM ET RANK /GRADE
Arifria4101111 FEMALE /FEMME
RELIGION / RELIGION
MALE/ HOMME
WOUND / BLESSURE
NECK/BACK INJURY :
BLESSURE AU COU/AU DOS
BURN , BROLuRE
AM pu TA Non AMPUTATION
STRESS/ TENSION
OTHER apcory.1 , AUTRE (S0e0lied
CONSCIOUSNESS NIVEAU DE CONSCIENCE
TIME / NE URE E. TOURNIQUET, GARROT TIMNEuRE n NO / NON n y ES /OLR
7. MORPHINE, MORPHINE ri NO/NON r---1 DOSE/ DOSE 1 TIME /NEURE IL IV nmE / NE URE yES / out
S. PULSE POULS
PAIN RESPONSE / REPONSE A LA DOuLEUR
UNRESPONSIVE /SANS BEPONSE
ALERT ALERTE
VERBAL RESPONSE, REPONSE vERBALE
7
10. DISPOSITION/ DISPOSITION RETURNED TO DUTY /RETOUR A L'UNITE
f'411',"EVATT ,O7s1RAVATalss',`ARE:ggem42OUZ4frittclul I ■orgiTt?r"
TIME/ NE URE
Ti. PROVIDER, UNIT/ DEEMER
DD Form 13E0, formmo/«. DEC 91 or 00 Ft:WM 1300 and E■0 Fonn_L 13E10 fTES17. rrhkh ore obsok Ts.
S. FIELD M LE DE L'AVAN ET
MEDCOM - 23600
ACUATED EVACUE
r • -... i,
IL: I I
/2(-7/ //z / -zo
3 zo/ c izo ca/
LO
ACLU-RDI 1681 p.160
36 35
2. .11 F LOCATION ADMISSION AND CODING INFORMATION . REPORTING MTF
8 (State or Country
Code.)
6 4 3 2 1 For use of this form, see AR 40-400; the proponent agency is OTSG
A 117, (QA - . SEX . PAY GRADE • NAME (Last, First, Middle Initial) REGISTER NUMBER
17 14 15 10 11 12 13 9
9. ETHNIC RELIGION
31 BACK- GROUND
E. RACE . AGE AT ADMISSION 6.
19
CI 0
30 29 26 27 28 23 24 25 22 21 20
1 0 12. SOCIAL SECURITY NUMBER 11. FMP ETS 10. LENGTH OF SERVICE
32 33 I 34 44 39 40 41 42 43 45 37 38
C) O C) 0
BRANCH/CORPS HOUR OF ADMISSION
13. MARITAL STATUS ORGANIZATION (Active Duty Only)
46
16. DP CODE OF RESIDENCE 15. BENEFICIARY CATEGORY 14. FLYING STATUS
47 48 49 I 56 57 58 59 61 54 55 60 53 52 51 50
8' 7 K PREV ADMISSION 19. TRAUMA MOS i7. UNIT LOCATION (State or
Country Code) 62 63
YEAR 71 70 67 68 69 66 64 65 NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE WARD 20. SOURCE OF ADMISSION/ AUTHORITY FOR 1 ADMISSION
72 ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
23. DATE OF DISPOSMON (YYYYMMDD) 22. MTF TRANSFERRED TO 21. TYPE OF DISPOSITION
81 82
2 0
83 84 85
0
87 86 88 80 75 76 77 79 79 74 . 73
-Z.
26. DATE THIS ADMISSION (Y YYYMMD D) 25, MTF TRANSFERRED FROM 24, CLINIC SVC - ADMITTING
102 J 103 f 104 I 105 106 97 100 101 95 . 99 96 98 93 92 91 90 89
3 I R" .2 0 0
29. DATE INITIAL ADMISSION (YYYYMMDD) 28. MTF OF INITIAL ADMISSION 27. LOCATION QF OCCURRENCE (Battle Casualty Only) 107 1...__ 115 116 117 118 119 120 • 122 121 111 112 114 113 108
S GSci (2) ZS-
FOR LOCAL USE
,&• q (i) 2--
re.-0 , Th
Li- SO
SIGNATURE 0 DMITING CLERK ADMITTING OFFICER (Signature, as required)
OA FORM 2985, MAR 2000 EDITION OF MAR 89 IS OBSOLETE UWAVLW
MEDCOM - 23601
DOD-037179
ACLU-RDI 1681 p.161
Signature, as required)
C2"
inmaled Facsimile - DA FORM 2985, MAR 20(
1/ 1. Reporting MTFN:7:1-- 2 MTF L.,cation
1111.11111.
IZ
3. Register Number Name (Last, First, MI) 4. Pay Grade
MIE 6(..9-)
FGN
5. Sex
M
Admission and Coding Information For use of this form, see AR 40-400: the proponent agency is OTSG
6. DoB (YYYYMMDD)
1971-01-01
10. Length of Service
1 7. Age at Admission 8. Race 9. Ethnicity Religion
32Y X 9
ETS 11. FMP 12. Social Security Number
MEM 99
Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:
03:00
14. Flying Status
17. Unit Location
20. Source of Admission
Direct from ER
21. Type of Disposition
TRF-OTH
24. Clinic Svc - Admitting
ABA - GENERAL SURGERY
27. Location of Occurrence
IZ
15. Beneficiary Category 16. Zip Code of Residence:
K78-PRISONER OF WAR/INTERNEES
18. MOS
19. Trauma Prey. Admission
BC NO
Ward: Name / Relationship of Emergency Addressee
I CW 1 Address of Emergency Addressee
Telephone Number of Emergency Addressee
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-12-17
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-08
28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-08
Name and Location of Medical Treatment Facility:
3
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW L BUTTOCKS AND THIGHS
Procedure Narrative(s):
Cause of Injury Narrative:
Signature of Admittin C
MEDCOM 23602 rD
DOD-037180
ACLU-RDI 1681 p.162
'Automated Facsimile
....PATIENT TREATMENT RECOk ,;OVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
's Name
1-, (6,
5. Age
27Y 6. Race
X Religion 8. LnthOfSvc
12. SSN /13. Organization
3. Grade
FGN
10. PrevAdm
NO
14. Ward
ICW1
4. Sex
M
11. FMP
20
9. ETS
Admission Remarks
15. FlyStatus 17. Dept / Ben
K78-PRISONER OF WAR/INTER 20. Type Casei
DIS
18. BranchCorps 19. UIC /ZIP
21. Source of Admission
Direct from ER
24. Name/Relation of Emergency Addressee
27a. Address of Emergency Addressee
29. Re ortingMTF
-
26. Date of Disp
2003-11 ;0r LJ 28. Date This Adm:
2003-11-;,1
30. Date Init;ly
2003-11- 1
AdmittingOfficer.
111111W6( - t_
32. Units Blood Components
22. Hour Of Adm:
10:35 23. Clinic Service
ABD - NEUROSURGERY
25. Type Disp TRF-OTH
27b. Telephone No
31. Selected Administrative Data
Marital Status:
In/Out Patient: Inpatient DoB: 1976-08-19
MOS:
33. Cause Of Injury:
ConLv / Coop Care Days Supplemental Care
Signature of
Automated Facsimile - DA FORM 3647, May 79 MEDCOM - 23603
Absent Sick Days Other Days Bed Days Total Sick Days
C)4
icer
34. Diagnosis / Operations and Special Procedures:
L FACAIL HEMOTOMA, L SHOULD SHRAPNEL,R HIP SHRAPNEL
35. Total Days This Facility Absent Sick Days i Other Days
35. Total Days This Facility
ConLv / Coop Care Days 1 Supplemental Care 1 Bed Days Total Sick Days
DOD-037181
ACLU-RDI 1681 p.163
P"SICATZ;
•
pito x 3 v-y-Ncersl
®
3 ,, Ccycp s\P
Laacs\-‘ N‘A-NO .
Ti lryl \-1c -PS
ae;r1 ve-S
von,
e_Nr. ‘R_Ap_e_ 127r1c,0
Nrr t.s5
.)4-IrcL‘tp
sv, 0%.,..Lcsk,\.
Orvo
DATE
IOENTIFICATION P40.
N)0N-) st Li ORGANIZATION
0' Or UP, ttttt n enrrIos lie •Verne tear. Ar.t, middle; trade: dote: ho•pir•I or mechc•I Iwcility) REGISTER N.O. WARD NO.
ABBREVIATED MEDICAL RECORD Standard For= 839
GENERAL SERvICES ACMINISTRAr.CN AND !•TERAGENCY COm?.iiTTEE. ON ME.7.1iCAL RECORDS P4r1..IR 4: CFR) 201-15.505 CCTCEER 1975 539-156
MEDICAL RECORD, • ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY. CHIEF C MPLAINT. AND CONDITION ON ADMISSION (Eol g r doff of off ofwion
PRoGRES f Enter date of di:charge a nd /Inca diagram.)
MI? LA_Thc
ov)5
l iT MEDCOM -23604
DOD-037182
ACLU-RDI 1681 p.164
DATE NOTES
LAST NAME MIDDLE INITIAL ID NUMBER FIRST NAME
/4/6-3t-I old .
Of- _AAILL.A LA Pt CIO pain 40 phip, itednoz6 0(141 rnD oam qpnithmo-
aciz-,61
MEDCOM - 23605 \ID ((t t
tit06 5/1999) BACK
USAPA vi.00
PA t AA,
WAR. OnOnckbni -C
DOD-037183
ACLU-RDI 1681 p.165
MEDICAL RECORD ...., . 1 r.,....,.... . - .n a.v.,,u_ ncr-nuuuu I luri
PROGRESS NOTES
DATE NOTES
119,, A Av.t....-0..9.41 ,re.... e •-• /e040 4 1 o 4IP _01P ar 1 %^AO WWI 4(7•S■4 la A Nb. AL ' .6 At A .... ... ...- 4.
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AP/ IP ' mad" MO 0411i I . 411 ii,` ItE, r fl, la Ir L
- IIJ -...■
40 i I LW a
0 i\ov Pt A 0 - A • la ..mte a. 01 tA (0) a 1 i ' 2X2 a 1 I / .. 4 OM il I i A. 0a&. .1a.
Ai i A • i i i L _ ... . . . , _1!, ii, t
r $ 111 41 11: A / 0. .. _0 t _IAA A Cal 1 .. A.A.,._Aitt Is Abt a! 11LIONte, t ■ At • L.. 11 41:1 _AAA Al / ki141\ ow .cCAQ, P o e II
.
* • O&O-40 LIP YULAA- nokock) L IA 0 .. tiuut.A 1 • 4 tip 1 .. IV ' . 0 • Ili A 0 Liles
III to Pi • , k tinslice, A L. 'us # *Ai tit 0 ir•i bpi
IF _ SA 114 0 0 - al ,i •!_. ■ A: H it 6.s'. if
mi•
0 6, A ° 1 .., _01 w .0 NCO i I 1 1 0 2P._ V.A. (LA14 ■ 0 # ,t, ,- 4,0 'fir ..• o g_1.4141_46 ' • A
WWI
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• b RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER (SSN or Other) LAST FIRST MI
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 SSN; Sex; Date of Birth; Rank/Grade)
REGISTER NO. WIR(9.,]0_. 1
11111111 LA
MEDCOM - 23606
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(1 0)
USAPA V1.00
DOD-037184
ACLU-RDI 1681 p.166
b-v63 akeiNtAkuuoLu_O lam, eto ( 1,1(17)
C- izd IA-0012, (5 MI,
.47)-P „oi-r-e-wa--
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Plattit; AA,ITykbt(k ea.tit4 d/a ..AA-vuo tauttittliu .tcez(1,4Lufna t
A AVbrapy.e.e \AMU/1a 01 Er Chatitag ,
-124-einkarRA (07 got (Lattle/1 6 19W-131/W 0-1( Ji)(042-l- c, vvi..oW/p/t044',
UtS4.6k- AtV91)1- , i&Ct4 01M CPO( 2 6t, -0- A 410
yr, t 00-4 cLEOL (
tubl'A --0 1R)buLaocta
PROGRE: JTES
AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD
DATE NOTES
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)
DEPART./SERVICE
LAST
I HOSPITAL OR MEDICAL FACILITY I RECORDS MAINTAINED AT
SPONSOR'S NAME I SPONSOR'S ID NUABER I FIRST
I REGISTER NO. I WARD NO.
MI ISSN or Other)
141111111!11144 MEDCOM - 23607
PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00
DOD-037185
ACLU-RDI 1681 p.167
LAST NAME FIRST NAME MIDDLE INITIAL !D NUMBER
DATE NOTES
lt ObV" 03 6RITAID C,0N-sour
c -6- .t,t.,t c CL/(416, IL , PI 4 diar4 we.kaq3. --PosA-Ar Att=r-4( clid41 rts,15-N. As 4 ()5(k) -F,5 *A---- ri-D,--
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tr Wrsi 4-43)".•
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sit,traAr P e--)k 1 20 CL4-4't 1 180 pt-cq)-. 61-2. • iic (AA-6-t. L-tcpitssii-c-
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\ L4-e,t_44 Aurs5 s la 4- d4 64 s'' CLC 5C1
Aar VI r
MEDCOM - 23608
TANDARD FORM 509 (REV. 5/19 9) BAC
USXIPA
DOD-037186
ACLU-RDI 1681 p.168
MIDDLE INITIAL ID NUMBER
LAST NAME I FIRST NAME
NOTES
(410A-C tJt)i/tilVv-ai.
haf atta,A s/s)( 0-) Akvtit (Walt a 4- 1 OA (aa cAmi- 1\ 049X WA/Ca GO- cul mako-U.
Axin (rAti) vo l ,A10)6 (DM-. _
DATE
JP 'V
Ad s-ovri 4
Wow- Mut cryucta fia imn/t, / 1 wzicac 1440-14 •
02 xa .mow; , 1/vg, cwilutcl vvt5-1A-Atiasattattoz_ aa Ai/ I ( ac
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NO •
STANDARD FORM 509 (REV. 5/19991E
USAF',
MEDCOM - 23609
DOD-037187
ACLU-RDI 1681 p.169
DOD-037188
t DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY
AUTHORIZED FOR LOCAL REPRODUCT10
PROGRESS NOTES
DATE NOTES k (ce. L
1 1 OV 1 0 VA1 , 4-03174! " til I a A ie ill 1 itiL174.1.1.41.-41si •
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RECORDS MAINTAINED AT
MEDICAL RECORD I
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)
411111 k-)Lu\,•) -LA
I REGISTER NO. WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0
USAPA V1.0C
MEDCOM - 23610
• RELATIONSHIP TO SPONSOR
LAST SPONSOR NAME
FIRST
ACLU-RDI 1681 p.170
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
R KkAt - 03 6RTT-0 GotNYSuur
@ -ibritrAy I.vkv-..-41 cialna rtg,1).-.. Has ill (,5 b1/4) fn szt— 14,124.- LIN.,-.. tom- \r1 to-?.r- Prwilk,41_ 0,171.az,„ tAzo, clz‘,_ F.S-ei feu_ PE 1 cv.t1-r-wv--L1-. u4--"4-c.9 0510- 1.,1,„114„,._ 194 Si,,,e-.11A3 Nt.,-,70
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c VS- ctre.t, CD Dr) Aivr---TcSi- .
Xy-t. ■ ? . C ik"14 al- IA-k° tA4-1 s IrtWeAriA .
1 ' -D (.4-41 iv,tx-149_ Ivitt 0 - .ttq, or ,%-sitrz.r-4-61Ar AAt.7 rokhvut:14e4kr
Rt.-1- 6in ias."- galer use o 101k k . a it'thetitijI6‘ '
cI4L-12,A,,_1 7616
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.
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MEDCOM - 23611 TANDARD FORM 509 (REV. 5/19 91 BAC
U PA V ,
DOD-037189
ACLU-RDI 1681 p.171
Ara so7.ax`
af-17& •-aeg02-0. Le2e/te
•e'Zg4le /1'441- 54t 6 .4.•4(44 121-es,zr-44-1
/2.,e-13 W
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
FIRST
DEPARLISERVICE
SPONSORS ID NUMBER =V or Mai
RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION; /for typed Of fatten exam Pile Name las4first Diddle • ID NoarSJI4Ser,OtteofBc fianklfiradej REGISTER NO.
WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM 509 mEv. snow Prescrillad by csAnon FPMR CFR) 101.11203112/110)
USAPA VISO
MEDCOM - 23612
'MEDICAL RECORD PROGRESS NOTES AIITHO
DATE NOTES
7/-4=44)Pid-7-0=-7- 4,444._;z„ A ..i.A47)4314_. dx*At. /iffes_z.
A_zrtr_< te.e..e4t,„ed Apgd 444 /4
DOD-037190
ACLU-RDI 1681 p.172
C. fVe.rr Evvvz V\t. e-e_An
MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) DATE
i■ o\J 03 cx11/4.),Jua ■Arno1/43...sz... ctS-
Wm *.
si...yevels%•arry■a..,
C:1) "N:ks0-Apaski.9-z- Or CiCtAo t3e-‘.‹7
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Sltr-A- ziemsb___--- •
® a/vsr,Ls
HOSPITAL OR MEDICAL FACILITY
SPONSOR'S NAME
PATIENT'S IDENTIFICATION:
I WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSNICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 23613
■sittrus
SSNIID NO. RELATIONSHIP TO SPONSOR
DEPART.ISERVICX_) k.sLt-5)-
1 RECORDS MAINTAINED AT
ifor typed or written entries, give: Name - last lust, middle; ID No or SS1V; Sex; Date of Birth; Rank/6lat/0 I REGISTER NO.
DOD-037191
ACLU-RDI 1681 p.173
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
\r‘ h-Arctt.71
PQ'
-. 5..111111111111. )\A g
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b u -
STANDARD FORM 600 MEV. 6-97) BACK
:1?
MEDCOM - 23614
USAPA V2.00
DOD-037192
ACLU-RDI 1681 p.174
NSN 7540-01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT
(Patient)
LOG NUMBER TR
RECORDS MAINT ED AT
PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS
DATE Day, MOTnth, Year TIME tio 70
CITY STATE ZIP CODE TRANSPORTATION TO FACILITY
"- SEX
pl\ DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO PRP ADDITIONAL INSURANCE
AGE
....0 HOME PHONE FLYING STATUS DD 2568 IN CHART
AREA CODE NUMBER MEDICAL HISTORY OBTA.rED FROM NAME OF INSURANCE COMPANY
;CENT MEDIC TI 1 _k
, ( INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN n YES INO
IS THIS AN INJURY? WHERE TETANUS ALLERGIES
(\'
r.MIFF rnhADI AIMT I A
INJURY/SAFETY FORMS DATE LAST SHOT
'--1
COMPLETED INTITIAL SERB YES • NO
a
HOW
.
rue k VITAL SIGNS
i. 4.-c1- N ^
CATEGORY OF TREAiiMENT
TIME
BP
PULSE
RESP
TEMP
WT
❑ EMERGENT
URGENT
❑ NON-URGENT
TIME
k0 INITIALS
C22-k /71.1 / 85-
r0 /4/0/ y 7
r
/ 0
51/e/ / vim
LA
B O
RD
ER
S
>- cc < CC tm X CC
0
C /D F
URINE C&S
BLOOD C&S X
ABG I PT/PTT A SCC/CATH
BHCG/URINE/BLOOD/QU • NT CHEM: ( 2_ z-
CXR PA & LA RTABLE
ACUT ABDOMEN
SINUS
19
C-SPINE
LS SPINE
HEAD CT ANKLE R/L
ORDERS ,MONITOR
ORDERS OMPLETED BY /40 11
61,A. d rb to - t A-7,\
TIME n ECG
PATIENTS RESPONSE
ViPULSE OX
(o •
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
PATIENT/DISCHARGE' INSTRUCTIONS
CONDITION UPON RELEASE
IMPROVED ❑
UNCHANGED
❑ DETERIORATE
ADMIT TO UNIT/SERVICE
TIME OF RELEASE
REFERRED ON.
I have received and understand these instructions
TO WHEN
9
PATIENT'S SIGNATURE
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
PATIE TS IDENTIFICATION (For typed or written entries, give: Name — last first, middle; ID no. (SSN or other); hospital or medical • '
Ica
MEDCOM - 23615
DOD-037193
ACLU-RDI 1681 p.175
ABG/PULSE OX BC
YE C- RADIOLOGY Check if read by radiologist
10.6/ — -- n H/H
-5.) SUP 02
'. 3 RESULTS P02 PH
C7- PCO2
U
PLT SAT OTHER
PT EKG INTERPRETATION DIP
APTT MICRO GLU ETOH BHCG
kkk
CONSULT WI
DIAGNOSI
PATIENT'S IDENTIFICATIO
{,n1
(13 S
Lketv- C-L4-4—.— U-Otr-A e cetp-r 2._
5--P °If L,44
/ RESIDENT/MEDI ) AL STUDENT SIGNA
PROVIDER SIGNATURE
11.1 0 0
NSN 7540-01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)
TIME SEEN BY PROVIDER
TEST RESULTS
PROVIDER HISTORY/PHYSICAL
.5**64\ Cr." Or. CAI ■ lis r-3US c.2.9kt t ..ory 064(6.,s vok-koas_g 4,, .
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TIME
\ rita
(For typed or written entnes, give: Name —last, first, middle; ID no. (SSN or other); hospital or medical facility)
ACTION
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(bX10) USAPA V1.00
MEDCOM - 23616
DOD-037194
ACLU-RDI 1681 p.176
Pressure Ulcer (s): Yes Stage Ill, [V (Circle the one that applies and describe below)
rgical 1.vound (s): es No L.ocation Tubes: Dressing change:
°utter zed 2-CM COC(Drainage: rrIn • bloody. Appearance: VA" - • ram
01,101 GLIF5 ► \
• • _._.. –, •,•.. —J....30,1w i MEDICAL RECORD , PROGRESS NOTES
Admission Date: //`77-03 Diagnosis: ...)
-7;2-7.4,/ ,_,./..,..,,-...-+-, •e. L a eiez/ /-c- - - /1-:HD: POD:
Braden Scale Evaluation (See Braden Evaluation Table for Details )
Mobility No limitations Slightly limited Very limited Completely immobile
Sensory No impairment a Perception Slightly limited 3 Very limited 2 Completed t
Moisture Rarely moist Occasionally moist Moist 2 Constantly moist I
Nutrition Excellent 4 Adequate (Eats >50%) 3' Adequate (Rarely eats) 2 KIP01 Very poor 1 3dows)
Friction and No apparent problem 411* Activity Walks frequently 0 Walks occasionally _, Chairfast ., Bedfast
Shear Potential problems Problems 1
Add the total score
Above 20 Low Risk Between 16 and 20 Medium Risk Between 11 and 15 High Risk Below 10 Very High Risk
Note: A Braden Scale Score of less than or equal
Total Score
to 15 indicates HIGH RISK -Requires immediate Ulcer prevention irct, r-r1 nne 1 .\ program.
Size: Wound character: Pint Moist Dry Granulation tissue Odor Purulent discharge Eschar Exudates
Location:
Yellow slough
Type of dressing change: Wet-to-dry Comfeel dressing
Physician notified/consulted for wound debridement: Yes CNS notified consulted for Stage I1 and greater: Yes No Nutrition Referral: Yes No Physical Therapy Referral: Yes No Action Taken: Date & Time:
Carrasyn V-Gel Alginate
No
REGISTER NO. i WARD NO.
Patient's Identification (For typed or written entries give: Name-last. first, middle:
Grade: rank: hospital or medical facilithy) PROGRESS NOTES
Medical Record STANDARD FORM 509
AIM MEDCOM - 23617
DOD-037195
ACLU-RDI 1681 p.177
. 511-419
M
POST-
MONT H•YEAR
19 HOUR
PULSE TEMP. F (0) (S)
105°
180 104°
170 103°
160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96°
90 95°
80
70
HOSPITAL DAY
DAY
111112MIMMIMITUr
1111111111 0
aitargumn 1,11 11111
NSN 7540-00-634-4124
.. •
........
TEMP. C
40.6°
40.0°
39.4° 0
38.9°
a)
38.3 ° cc
37.8°
37.2°
37.0° 0-
36.7 °
36.1 ° a) 0
35.6°
35.0°
EDICAL RECORD VITAL SIGNS RECORD
........ • -
.... • . • • • •
........ • •
60
50 • ...........
40 ...
RESPIRATION RECORD
0
0
BLOOD PRESSURE
HEIGHT: WEIGHT
/17
122i-p-f
IL) 1 0 (RA
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
(
REGISTER NO. WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511. (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23618
DOD-037196
ACLU-RDI 1681 p.178
RAPIDPOINT CiAGANALicm V4,54 SERIAL #005485 '11/08/03 10:44
Patient ID:11,1111 \:,(C;.) -" Test Name : T Test Result:= 14.0 sec. Ratio = 1.1 Calculated INR = 1.25 Sample Type:citrated wh. blood Test Date :11/08/03 Test Time :10:42 Card Lot :080201 Operator
RAP DPOINT COAG ANALYZE V4.54 !AL #005485 11/0: 3 10:48
08-11-03 10:36
Patient Limits
WBC 8.5 110"3/uL 4.5 10.5 RBC 4.87 x10"6/u1 4.00 6.00 Hgb 10.6 L g/dL 11.0 18.0 Hct 35.5 X 35.0 60.0 HCV 72.7 L fL 80.0 99.9 MCH 21.7 L pg 27.0 31.0 rete 29.9 L g/dL 33.0 37.0 Plt 294. x10"3/uL 150. 450. LYX 19.2 L X 20.5 51.1 LY# 1.6 xtill/u1 1.2 3.4
/ IC Test . -ult:= 19.8 sec.
***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/4-wi It,-,A Time 1H11.4d
d 10t -:100 08 erator
up!
/' /
RAPIDPOINT COAG ANALYZER V4.54 c1ER1Ai #005485 11/08/03 10:50'
1 it ID: ame : I
lest suit 15 sec. ***RESU T 118T RANGE CHECKED*** Sample T e:citrated wh. blood Test Dale ;11/08/03 Test lime :1Q:46 Card Lot :10 208 Operator =MIN
U,1-5"/-V!
-- i -STAT EG.S+
09-11-03 06:06
Patient Limits
W 5.8 x10'3/ig •.5 10.5 RRE 4.64 x10'61:IL 4=00 6.00 HIb 10.2 L g/TL 11.0 18.0 Hct 33.9 L 1 35.0 60.0 riCV 73.1 L fL 80.0 79.9
.1E8 22.0 L p9, 27.0 31.0 DC ,. 30.1 L g/dL 33.0 37.0 Flt 26Y. 6r3/iii 150. 450. LY1 34.8 1 20.5 51.1 LA 2.0 x10"3/11L 1.2 3.4-
Pt :111111111 Pt Name:
Na 132 mmol/L
4.3 mmol/L
TCO2 22 mmol/L
Het 37 %PCV
Hb* 13 g/dL
*via Het
at 371:
PCO2 47.0 mmHg
P02 31 mmHg
HCO3 26 mmol/L
E;Eecf 1 mmol/L
502* 55 %
*calculated
Sample Type_:
08NOV03 10:56
Oper: 0
Physician:
Ser# 42011
Ver: JANSO468 CLEW R93
lu. IJSiTT
MEDCOM - 23619
DOD-037197
ACLU-RDI 1681 p.179
r , WayilS . -tion: - ;II 1—R. EQUESTING PBYSICIAN: 1 L: jRATORY RESULT FORM
(--/ / I I (Subject to the Privacy Act of 1974) . A ST.. FIRST, Nil. I DATE Ii VAC 1 SQN/Prs-
._____ .-.. (Herna ,, 4. 1 . ,
• . . . . - • CJOrialysis . ... . . 'Misc. Serology
:1E87' RES , R.L.v. RANGE TEST RESL11,7' L RE.F. RANGE TEST RESULT I REF. RAA . rGE
.--"IBC 4.8- 10.3 x 10' Color ! NIA RPR 'Negative
BC RBC 4.7-6.1 x 10° App ' i
----1 I t Nfi -1 Mono 1_
eolt;ve I - "
Hgb 14-18 aid( (M) 12-16 p/c11(T)
Glu •-..ce..,ailve . . :Microbiology .. . *
Hct 42-52% (M) . 3747%(F)
Bili ' Neo_atiVe i " i
Soarce
MCV 30-94 il (M) . 31-99 fl(F)
Ket I Negative Gram Stain
Pit 1301.500 x 10" verified
SG Ni:' O. cc Bid Negative
Negative Lymph % 20.5-51.1% Bid Negative H. pylori
M icro Parasites
1
. •
.• (Hematogy).MOunlpifferentill pH N/A
Seg Mono Prot I Negative Malaria •
Bands ; --I
Eos Urob I 0.2 - 1.0 0 & P
Lymph i Baso Nit Negative Other
Atyp Imm Leuk Negative • Nflci-oscopic Vrizialysii: •
RBC Morph
HCG • Negative
.
Spun Hematocrit ;
42-52% (M) 37-47% (F)
• . CSF • . . Blood Bank .. . . . . .
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other
----
Directigen ; I
Negative ABO/Rh _.
. .
- ' • •••••• CosgubitionStudies, •
• . .
. .. BloOd Raiik. Unit Crossinatch . ..: . • . : :-: • . (MUST,SUSMIT SE 518.WITH . EVERY UNIT OF BLOOD . . •
.•.- REQUESTED) .. . •• - -. . - ... •-.. I - . TEST RESULT 1 REF RANGE UNIT 1 TYPE , CROSSAL4TCH
I-1 PT
Ir 9.8-13.6 secs I
A PIT ; 21-34 sets I
D dimer : n0 tiwird . - --'-
F DP
4 1 <IOug/m l ! I
REMARKS: 1 . J
REPORTED BY: ( DATE: LAB ID NO.:
MEDCOM - 23620
DOD-037198
ACLU-RDI 1681 p.180
REPORTED BY: LAB ID NO.: .
MEDCOM - 23621
DATE:
Ward/Section: r REQUESTING PHYS1Cr
4.8-10.8 x 10'
4.7-6.1 x 10
======= PICCOLO
08/11/03 10:39
REFERENCE OALIE PATIENT min k-( 4A)- METLYTE 8
DISC LOT #: OPER #: 3151AA4 • SERIAL DR #: 000
:
. 0000100494 ..... . .
............
GLU 157* 73-118 MG/DL BUN 7 7-22 MG/DE CRE 1.7* 0.6-1.2 MG/DL CK 163 39-380
U/L 128-145 MMOI/L K4
4.8* 3.3-4.7 MMO//L CL- 100 987108 MMOt/L I 18-33 MMO/iL
INST OC: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0 Spun
Hematocrit
RBC Morph
Lymph
Lymph % 20.5-51.114 •
130-500 x 1 verified
Negative
0.2-1.0
Negative
Negative
Negative
'N/A
Negative
WA .
Negative
Negative
Negative
Directigen
COagulationtudies.
=OLT
9.8-13.6 secs
21-34 secs
<10 ug/m1
DOD-037199
ACLU-RDI 1681 p.181
Ward/Section: REQUESTING PHYSICIAN: .• - CHEMISTRY RESULT FORM (Subject to thc Privacy Act of 1974)
LAST, FIRST, ML DATE TIME SSN/PSEUDO SSN: •
:‘3...-. .,:0:. . ' iT ....„-,,-.....i,zWg .V..ig:7-/ ..•;.;;';?pi.f.1'.`:-:*.-0-:-.-,:l.;S,,r..-tit,:r.:;:..1.Z:a--37in,:(,:f:la
it'i'W Vkliiaiii llAtT,i,:f: :e:::.1,::-..A,.r...;-:;E:$:':-•.': ,.;74.-:.4.,..lis.s1/4.-'4.7.1:!,‘4,g. :•:"•.....--: .t01.4% ' /6 raii 0;-":='.'- -.'lc.:f.t..-,-, xtA::.-:....-.4i,rii. ,. "..t.5,..*..3'..K:,.. -$1:
TEST RESULT REF. RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na 138-146 mmoUL ALB 3.5-5.5 rid GLU 73-118 mg/dl
K 3.5-4.9 mmol/L: ALP 26-84 on BUN 7-22 Ing/d1
Cl 98-109 mmol/L ALT 10-47 ull Cg+ 8.0-103 mg/dl
PH - 7.31-7.45 AMY 14-97 u/1 CRE 0.6-U Ing/d1
PCO2 35-45 mmHg (art) 41-51 mmHg (vas)
AST 11-38 u/1 NA* 128-145 ramo1/1
P02 111-1435 mmHg (.rt) WA (yen)
TBIL 0.2-1.6 mg/d1. ic.4 . 33-4.7 ramolil
TCO2 23-27 rmnoVL (art) 24 -29 mmol/L (veu)
BUN 7-22 mg/d1 CL . 98-108 mmol/1
HCO3 22-26 roma& 04 23-21 mud& Nen) CA'* 8.0-103medl tCO2 18-33 mm..4/1
s02 95-98• CROL 1D0-200 raga !yr.%"' k6i Iiike " -.-..Milkx,if.. `1:24....,.....k..14'.:
*I- iligg':.7%.:.?
REF. RANGE BEecf (-2)-(+3) • mmol/L
CRE 0.6-1.2 mg/dl TEST RESULT
AnGap 10-20 mmol/L GLU 73-118 mg/d1 ALB 33-5.5 g/d1
Ca 1.12-1.32 mmol/L TP -8.1 g/dl ALP 26-84 till
BUN 8-26 mg/d1 ''''-''... •;;. 7.5..".tip.;."-i
ieiiii:b . ' —dr ...' :-.-: t.,; ir.j.-5-L- ..
ALT 10-47 u/1
GLU 70-105 mg/d1 TEST 41K •" REF. RANGE
AMY 14-97 tit
Creat 0.7-1.5 mg/c11 GLU 73-118 mg/d1 AST 11-38 till
Hct 38-51% PCV BUN 7-22 mg/di TBIL 027 1.6 mg/dl
Hgb 12-17 01 CRE 0.6-1.2 mg/dl GGT 5-65 u/1
F.:W .4iiii- ..;:•;•L'-.1=.11.. •. .;:',' .1:':‘z-7..71..-.:Zfai,...I. :..r.:- ,::‘• -- ":". :.'74:'-:.g, CK 39-380 u/1 (M)
30-190 u/1 (F) TP 6.4-8.1 g/d1
TEST RESULT REE RANGE NA' 128-145 mmo1/1
Troponin-1 IC 3.3=4.7 mmol/1 i TEST `GE
Drug of Abuse
_CI; 98-108 mmol/1 NA"' 128-145 mmol/1
1.0O2 18-33 mmol/1 K4. 3.3-4.7 mmol/1
CL: 98-106 nyro1/1
tCO2 18-33 mnIo1/1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 23622
ACLU-RDI 1681 p.182
I , YES 1 • E:
''•-" N " • ION 7. / OA 7r: OF E.P-3,1- (Hon:A.d.y. y) (716 x
-,•••.:•10LOGr- RT I DA ••.‘ OF TRA.NSCREF-TION (1•1•x■ -•7‘. - --7 . .. _ •
OA- 4e•A'(
peiu- f -t- s ale(
RADIOLOGIC CONSULTATION REQUST7RE-POT
SS•N
11.P.O/CLiNIC
0
1 REC , S7C R. r, .
LVD 6,rovzikid -4\ 11c-k ( i \ --A
• •-•••:"..7c.:*-
F-0 F.1 3-C 5
MEDCOM - 23623
DOD-037201
ACLU-RDI 1681 p.183
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM 15 USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION LIST TIM
ORDER NOTED ANO
SIGN
DATE OF ORDER TIME OF ORDER
-2_
I • ,.. ILt ... .. IIIIIIMPIMIMMILIAlt _ . . III
1 BED NO rg
DATE OF ORDER ^
41
Ell
a (3
40 IN Fr 401 is
1111 DATE OF ORDER TI OF ORDER I
Esimmaraing ,,,,,I,' st, NI
TIME OF ORDER
NURSING UNIT
PATIENT IDENTIFIC • ION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
HOURS
NURSING UNIT
c740/
ROOM NO.
DA 1 FArRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23624
HOURS
ROOM NO.
BED NO.
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-037202
ACLU-RDI 1681 p.184
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
41111111 I ROOM NO. B f 0 NO.
NURSING UNIT
PATIENT IDENTIFIC
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.
PATIENT IDENTIFICATION DATE OF ORDER
12' 1 i ' ON 3 TIME OF ORDER
HOURS
LIST TIME ORDER
NOTED AND SIGN
\NI 0
In1 r AP a • • A 111 a le •
....0 ..'
fry} i(0 --,
) TIME OF ORDER
HOURS
--..
DATE OF ORDER TIME OF ORDER
HOURS
DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
DA 1 FAOPRRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23625
DOD-037203
ACLU-RDI 1681 p.185
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.
PATIENT IDENTIFICATION
•
...
DA T77 RDER TIME OF ORDER
ill /P.,,..7 HOURS
LIST TIME ORDER
NOTED AND SIGN
./. .-...,
I URSING UNIT
o---- ROOM NO. 111 .
\ . ATIENT IDENTIFICATION DATE OF ORDER TIME C.:4F4RDER
11 Oar)? 1 HOURS
0
,%,) ,,z _„, WV \ Off111/1/1 e h
,t
Viw qyiltA p• e-?( D- Vvy-coce,i- ' ro (0 ° 1 •
qirrlie NURSING UNIT
PATIENT IDENTIFICATION
ROOM NO. BED N
t.
NURSING 7-
F 0
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO. •
DA IF:4419 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23626
DOD-037204
ACLU-RDI 1681 p.186
6((S-7 AAA
DA FORM 4677, 1 OCT 78 USAPA V1.00
CLINICAL RECORD
VERIFY BY INITL4LING Mo. ( Yr. 2003
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
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. SONDMISPaneSOMOSA
RECURRING ACTION, FREQUENCY, TIME
-111111Nct\wf
MAdsw. \ ∎b T.
---111111Kic-):40e)3(:5"
HR CLERK/ NURSE
ETED
13 PI
St
b.
ORDER DATE
DATE COMPL
Pe)
ALLERGIES: ED YES 5I NO P._ MARY
APs S-r ^tt t"PsPc^i_,
PATIENT IDENTIFICATION:
AIM -7(0)
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 MEDCOM - 23627
ADDITIONAL PAGES IN USE: DYES n NO
PAGE NO•
DOD-037205
ACLU-RDI 1681 p.187
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo Yr 2003
Order Date
Clerk Nurse SINGLE ACTIONS Date to
be Done Time to be Done Time Done Initials
NOI 'k ii ' . -:-'. \C- .-\A) L--- - P\-C\ I-C3.\ . . (ZY= f VW
CAS
Com. — --allb■ -• ,
((-0 t___..,b,,_ C-P--___ ‘,(- .t-Nr) q5c1 I\LVC4.3
- _
- - - - -fm
— - -
- _
- _
- — — —
Order/
Dan Date Clerk/ Nurse
PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED - - - — - -
- - — - - - -
- - - - - - INI. ■I
... ... ... ... ... ..
... .... ... ...
USAPA V1.00
MEDCOM - 23628
DOD-037206
ACLU-RDI 1681 p.188
CLINICAL RECO,U THERAPEUTIC DOCUMENTATIO CARE PLA_N (MEDICATIONS) For use of this form, see AR 7;
the proponent agency Is the Off co of The Surgeon General.
.., Mo, 1 Yr.
VERIFY BY
ORDER DATE
INITIALM
CLER / NUR E
, INITIAX, PROPER COLUMN FOLLOWING EACH ADMINISTRATION
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
C14 ',_ D Niim 4 K . . tft\l' NSD \2_Gcc) 1-1 ('-c\ zt, ‘ 8
.\ \ \ k--- \r\l\rvC t- __if- MI i (ISS alliONCCS : -ter' \\/
Ka i
. = ,
3NOV • \AOXY- 9) VD 91Z) (.0 ??-7
ALL ERGI EY ED YES
MIZP)
PRIMARY DIAGNOS 5^
,-- L--
• Sk1-00t.DE IF— .-k-k.e,i2t.-L>,
' . t P F-Ak-CAPNEL,
ADDITIONAL
0 r ES
PAGE NO
El PAGES
NO
IN USEt
PATIENT IDENTIFICATION,
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14 -f (62S 14 E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06 Pak a cnom • ^Rim
1 FEB9 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23629
DOD-037207 ACLU-RDI 1681 p.189
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. c ( Yrq
Of Date
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to
be Given be Time to
Given Time Given Initials
I
(C-L --- 2— kcli\\
Order/ Expir Date
Clerk/ N urse
PRN MEDICATION, DOSE, FREQUENCY
INITIAL . PROPER COLUMN FOLLOWING ADMINISTRATION —
1 TIME/DATE DISPENSED
,i _,,,1
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'U.S. GPO: 1990-454-110/95216
MEDCOM - 23630
DOD-037208
ACLU-RDI 1681 p.190
MCAT
MEM J. INJURY , BLESSUPE
PIL ■ • •.:1,Z I • MiC.15:: 0.11 r3 CH F:1,04
P..VVAIr IRAQ-It( C,CK ,ARaiERE
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BURN mot tin -----
AMPUT or:ON• amP,../1"..1TION
STRESS, TENSION
OTHER (SP.N,Y) . AU THE (.5,2t,ci led
5 t—tsi—d- riA/EL frism t F
7 0)
I
•
17:
F :MADE MOLE .'NOMINE ji 1E1 (PeN11.-11—
2 U .
i Oki; .• ELWIN:
r•r,ri4
4. LEVEL OF CONSCIOUSNESS,
NO/EAU DE CONSCIENCE
TiME NEURE
6
MORPHINE :MORPHINE I DOSE /DOSE
NONHC A ' SFS /Our ••
.2. TOURNIQUET !GARROT
"RI/NON YES / OUI
PAIN RESPONSE R:PONSE 4 LA liOULEUr. LHNIRE'WON5IVE SANS fiEPOA-;T--H
174 T/ME / 11E101£
9. g.,* C ■ ob
Uk
VIEIZIgT,M17,°07:51421W-Em426,.11%;;IMZE,101,`, TWark-4
(c_c)
(3e 13-7 /F'?.., list:- v P 97 e4-
lIME
S . •
ID grpgaic?' TIME /11E000
DECEASED / DECEot 11. PROVIDER/ UNIT / OFFICIER M DICALE /UNITE
DO Form 13 DEC 31
8o, rt. fonn reNacer ortwovs ..d/hons of DO Tom, ,380 and OD torn 7340 (mix
which obsolete.
DATE/DATE (YYMMOC)
U.S. FICHE MEDICAL FIELD MEDICAL CARD E DE L'AVANT ETAES-UNIS
MEDCOM — 23631
ACLU-RDI 1681 p.191
22 23
Co I 0
26 27
9 a BA GROUND
19 20
21 24 25
s- 28 29
30
31
10. LENGTH OF SERVICE
ETS
11. FM13
43 44 45
53 54 55 56 157 58 .59 60 6
PREY ADMISSION
YEAR E2 63
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO
73 74. 75 76 77 178 79 BO
24. CLINIC SVC - ADMITTING 26. MTF TRANSFERRED FROM
28. MTF OF INITIAL ADMISSION
109 110 111 112 113
8
114
9D 91
92
93 94
95 • DB 89
27. LOCATION OF OCCURRENCE
107 108 (BaWe Casualty Only)
.• i F LOCATION
8 Mate or Country
Code.)
ADMISSION AND CODING INFORMATION . 1
For use of this form. see AR 40-400; the proponent agency Is OTSG
REPORTING MTF
2
3
4
6
A
REGISTER NUMBER NAME (Last, First, Middle Initial) 4, PAY GRADE • 5. SEX
16
17- 18
D. 6. DA MISSION 8. RA E NIC RELIGION
ORGANIZATION (Active Duty Only) , 13. MARTIAL STATUS HOUR OF
46
ADMISSION
12. SOCIAL SECURITY NUMBER
14. FLYING STATUS
16. BENEFICIARY CATEGORY 18. ZIP CODE OF RESIDENCE
WARD
17. UNIT LOCATION (Mate or. Country Coda)
20. SOURCE OF ADMISSION/ AUTHORITY FOR
72 ADMISSION
le. TRAUMA
71
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
50 51 52
71 a 18. MOS
64 65 6
67 68 69 70
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
23. DATE OF DISPOSITION (Y YYYMMD D)
81 182183 I 34 se es 871I88 a.10 IC) 13
I 12
I 28. DATE THIS ADMISSION Y YY MMD
99 I
c.) _3 ( / s'd
100 I 101 1.102 103 104 I 105 I 106
20, DATE INITIAL ADMISSION (Y Y Y YA4./fD.D) 115 116 117 118 119 120 121' • 122
FOR LOCAL USE
R`703
44 (43
ADMITTING OFFICER (Signature, as required) SIGNATURE OF ADMITTING CLERK
DA FORM 2985, MAR 2000 EDMON OF MAR 89 IS OBSOLETE USAPA V1.00
MEDCOM - 23632
DOD-037210
ACLU-RDI 1681 p.192
z. iviir Locatk... I
IZ Admission
For use of this form, and Coding Information
see AR 40-400; the proponent agency is OTSG 3. Register Number Name (Last, First, MI)
\O 1 C,2,
4. Pay Grade
FGN
5. Sex
M
6. DoB (YYYYMMDD)
1976-08-19
7. Age at Admission
27Y
8. Race
X
9. Ethnicity
9
Religion
10. Length of Service ETS 11. FMP
20
12. Social SecurityNumber
Organization (Active Duty Only) 13. Marital Status Hour of Admission
10:35
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
DIS
Prey. Admission
NO
20. Source of Admission
Direct from ER
Ward:
ICW1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Name and Lo • ' Facili • eb 1 1),,„ t Telephone Number of Emergency Addressee
21. Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-14
24. Clinic Svc - Admitting
ABD - NEUROSURGERY
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-14
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-14
mp i rv,ei I !cc
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: L FACAIL HEMOTOMA, L SHOULD SHRAPNEL,R HIP SHRAPNEL
Procedure Narrative(s):
Cause of Injury Narrative:
- Z.--
11111111.111111 11r Admitt
Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 236
DOD-037211
ACLU-RDI 1681 p.193
Automated Facsimile
INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
. Register Nbr .2. Name
)"c, - IA
3. Grade
FGN 1 Admission Remarks
;20. Type Case
4. Sex 5. Age M 27Y
I i 6. Race 17. Religi I
X I
8. LnthOfSvc 9. ETS
-I
10. PrevAdm
NO
11. FMP 12. SSN 99
13. Organization ..,----
14. Ward
ICW1
15. FlyStatus 17. Dept / Ben-- -
K78-PRISONER 0 WAR/INTER
18. BranchCorps 19. UIC / ZIP
DIS
21. Source of Admission
Direct from ER
22. Hour Of Adm: 10:35
23. Clinic Service
24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH
26. Date of Disp
2003-11-11
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:
2003-11-08
Admitting0fficer:
6( i -2-
30. Date !nit Adm
2003-11-08
32. Units Blood Components
31. Selected Administrative Data
Marital Status: DoB: 1976-08-19
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
SHRAP INJURY L CHEST
• "A 11 . 0 1 ..-1 9 Q616.0 T5 , '5 1 `615.0
15;clet 5
35. Total Days This Facility
Absent Sick Days
0
Other Days
0
ConLv / Coop Care Days Supplemental Care
0 Bed Days
L-f Total Sick Days
v I
35. Total Days This Facility
Absent Sick Days
0 Other Days
0 ConLv / Coop Care Days
0 Supplemental Care
0 Bed Days
If Total Sick Days
q Signature of Attend' • Officer Signature of PAD icer
Automated Facsimile - DA FORM
MEDCOM - 23634
DOD-037212
ACLU-RDI 1681 p.194
PHYSICAL EXAMINATIONEXAMINATION
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
IRTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION ( Enkr dare of ad twerian,
e-i. &at) _TO-0 cry
sclt-i/191—e-e t' r(7 e .19 6 4P- ii(-1-7 ele 5 •
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7:49
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PROGRESS ( Eater dart of dirrhorge and final diaynme
Ad&c-19-
-
'
ABRREWATED MEDICAL RECORD Stands.rd For Safi
GENERAL SERVICES AOMINis -r-r-,Ar.cm AND INTERAGENCY COMMIT-TEE ON MEDICAL RECORDS PRL1R (41 CF.. ..) 201-45.505 CCTCEER 1575 539-106
MEDCOM - 23635
LeA)rEreUt53
5IG 10ENTIFICATION O. ORGANIZATION
middle; /r ide; d•re; llorpir•l or medIcel !>•c lily) f typed or retur n r. P.'. i.i•f le rear. Arra, NCO ts-rcR NO. I WARD NO.
ACLU-RDI 1681 p.195
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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STANDARD FORM 509 (REV. 5/1999) BAC:-
USAPA VI.0
MEDCOM - 23636
DOD-037214
ACLU-RDI 1681 p.196
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
qeN0453 (51 6'._- \(- ,̀ id cue S DV --c-CIMNIM f'n---C " \ N' \- -..9-- C Thc"--Cii1 ,_----X-1
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER (SSN or Other) LAST FIRST MI
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 SSN; Sex; Date of Birth; Rank/Grade)
I REGISTER NO. WARD NO.
PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999:
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10:
USAPA V1.00 4-(
MEDCOM - 23637
DOD-037215
ACLU-RDI 1681 p.197
AUTHORIZED FOR LOCA
`MEDICAL RECORD I PROGRESS NOTES
DATE NOTES
raON 63 r--- .4_
--D 7 VSS V Oi C g-e__. 0 ,D a\irN of- 20)30 NC I C(Y-\ -4--, N .__-S 0 -(--•C - -
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER ISSN or Dried LAST FIRST MI
DEPARTJSERYICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entrie4 gin: Name • int fiat, middle ID No Of SSN; Sex,- DM of Birtk; fiankffliffki
I REGISTER NIL WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM 509 MEV. 0/19051 Prescribed by GSABCAIR FPMR KIM) 101-11.203M110)
USAPAVIA
MEDCOM - 23638
DOD-037216
ACLU-RDI 1681 p.198
(See Instructions on Back of this Sheet) 558-103 NSN 7 540-01-075-3786
TRANSPORTATION TO HOSPITAL (Attach care enroute sheet)
I-1 PRIVATE VEHICLE H AMBULANCE
D OTHER (Specify)
DUTY STATION (City, State and ZIP Code)
CURRENT MEDS. (tetanus immun- HISTORY OBTAINED FROM ization and other data)
El PATIENT DOTHER (Specify)
ALLERGIES
HOME TELE. NO. (Inc. area cosiV--
DAY MONTH Y
0 ol L.) PATIENTS HOME ADDRESS OR
DATE TIME ARRIVAL
(CONTINUE ON SF 507, IF NEEDED SIGNATURE OF PROVIDER AND ID STAMP
INSTRUCTIONS TO PATIENT (Include medications o plans)
n•MTIC HIVU I IsEATMENT STANDARD FORM 558 (Rev. 6-82)
DOD-037217
CHIEF COMPLAINT(S) (Include symptom(s), dura t on)
VITAL SIGNS TIME
BP
PULSE
RESP.
TEMP.
NON-URGENT
EMERGENCY TODAY
72 HOURS ROUTINE
ASSESSMENT/DIAGNOSIS
DISPOSITION (Check all that apply)
HOME I 'FULL DUTY
QUARTERS
124 Hrs. I 148 His. 172 HI'S.
MODIFIED DUTY UNTIL: DAY I MONTH I YEAR
REFERRED TO (Indicate clinic)
ADMIT. TO HOSP. UNIT/SERVICE
CONDITION UPON RELEASE
IMPROVED I 'UNCHANGED
DETERIORATED
TIME OF RELEASE:
PATIENT'S IDENTIFICATION (Mechanical imprint) FOR WRITTEN ENTRIES GIVE: Name - last, first, middle; GSM; DOB, service status, name and relation of sponsor or next of kin. (IMPORTANT: LIST FACILITY HOLDING TREAT-MENT RECORD).
OF,
SEX
7A °)
AGE POSSIBLE THIRD PARTY PAVER?
0 YES n NO DESCRIBE (1) Slibjective data (Pertinent History); (21 Objective data TIME SEEN BY ROVIDER (Examination - include results of tests and x-rays); (3),Aisessment (Diagno-sis); (4) Plan (Treatment/Procedures - include medication given and follow-up
s and follow-up
MEDCOM - 23639
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EMERGENCY CARE AND Tr 'ATMENT (Medical Record)
TREATMENT FACILITY (Stamp) LOG NUMBER
ACLU-RDI 1681 p.199
SKIN AND WOUND ASSESSMENT MEDICAL RECORD PROGRESS NOTES
Admission Date: //--er"."-- () --'',' Diagnosis - '-----Z<.____,_.
/— eibp---"i2...y 1--): POD: C-X-- -ii;y-'
(See Braden Evaluation Table for Details) Braden Scale Evaluation .
Sensory No impairment 4 Perception Slightly limited 3
Very limited 2 Completed I
, Mobility No limitations 4
Slightly limited 3 Very limited 2 Completely immobile
Moisture Rarely moist 4 Occasionally moist 3 Moist . 2 Constantly moist 1
Nutrition Excellent 4 Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor
Activity Walks frequently 4 Walks occasionally 3 Chairfast 2 Bedfast I
Friction and No apparent problem 3 Shear Potential problems 2
Problems I
Add the total score
Above 20 Low Risk Between 16 and 20 Medium Risk Between 11 and 15 High Risk Below 10 Very High Risk
Note: A Braden Scale Score of less than or equal
Total Score
to 15 indicates HIGH RISK –Requires immediate Ulcer prevention program.
Surgical wound (s): Yes No Location: Tubes:
Size: Drainage: Appearance:
Dressing change: Pressure Ulcer (s): Yes No Stage I, II, 1(1, IV (Circle the one that applies and
Location:
describe below)
Size: Wound character: Pint Moist Dry Granulation tissue Yellow slough
Odor Purulent discharge Eschar Exudates
Type of dressing change: Wet-to-dry Comfeel dressing . Carrasyn V-Gel Alginate
Physician notified consulted for wound debridement: CNS notified/consulted for Stage II and greater: Nutrition Referral: Yes No
Yes No Yes No
Physical Therapy Referral: Yes No Action Taken: Date & Time:
REGISTER NO. WARD NO.
Patient's ldentification (For typed or written entries give: Name-last. first. middle:
Grade; rank; hospital or medical facilithy) PROGRESS NOTES
Medical Record
STANDARD FORM 509 sr
MEDCOM - 23640
DOD-037218
ACLU-RDI 1681 p.200
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