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.', ' • :...-.:.. — '''. .::..;.:-;I::•-•: ,;I: III.I''i., .. . .. ITIFTASSESSMIRNT -' ' ̀"'• -.,':=: , TIME 0700 INITIALS TIME / /0 0 INITIALS:

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NAME: b(6)-4 RANK: AGE: ❑ OTHER EXAMINATION ❑ OTHER (Specify)

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❑ DIAGNOSTIC STUDIES

STATUS: US: AD / CIV IRAQI: CIV / ❑ TREATMENT

MEDCOM - 21242 DA FORM 4700. MAY 78

DOD-034818

ACLU-RDI 1661 p.2

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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


QA APPR 08MAR8

INITIAL SHIFT ASSESSMENT , N E U

R 0

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PREPARED BY (Signarure & Title DEPARTMENT/SERVICE/CLINIC

ICU3, PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; grade; date; hospital or medical facility)

-2.) ❑ HISTORY/PHYSICAL

O OTHER EXAMINATION OR EVALUATION


❑ TREATMENT

❑ FLOW CHART

❑ OTHER (Specify,

DA FORM 4700, MAY 78 USAPPC V2.00

MEDCOM - 21244

DOD-034820

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ACLU-RDI 1661 p.5

Ironticon, nn rein,rcxq

DATE

_ RECORD-SUPPLEMENTAL ME. For use of this t, .. see AR 40-66; the proponent agency is the Office oi

REPORT TITLE INTENSIVE CARE NURSING FLOW SHEET

rA surgeon General.


QA Appr 8 Mar 89

REFT ASSESSME INITIALS: TIME: INITIALS:

PUPILS SENSORIUM EXTREMITY MOVEMENT SEDATION PAIN CONTROL

RESPIRATORY PATTERN BREATH SOUNDS SECRETIONS 02 SOURCE/FLOW/SA02 VENTILATOR SETTINGS

CARDIAC RHYTHM CAPILLARY REFILL PULSES

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VOIDING COLOR/CLARITY

COLOR INTEGRITY

#1 TYPE/LOCATION/SIZE DRESSING CONDITION IV FLUID/RATE

#2 TYPE/LOCATION/SIZE DRESSING CONDITION

DEPARTMENT/SERVICE/CLINIC

ICU #1

PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last,

first, middle; date; hospital or medical facility)

NAME: t.,\ RANK: AGE:

UNIT: GENDER:

STATUS: US: AD / CIV IRAQI: CIV / EPW

❑ HISTORY/PHYSICAL

❑ OTHER EXAMINATION OR EVALUATION


❑ TREATMENT

❑ FLOW CHART

❑ OTHER (Specify)

MEDCOM - 21246 DA FORM 4700, MAY 78

IV FLUIDS/RATE PREPARED BY (Signature & Title)

DOD-034822

ACLU-RDI 1661 p.6

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DOD-034823

ACLU-RDI 1661 p.7

Automated Facsimile APATIENT TREATMENT RECORt- -,OVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

- %.,---, • 1. ter Nbr Nam

3. Grade FZ:Frn- ission Remarks FGN

14. Sex

M

5. Age ,

23Y

6. Race 17. Religion

i X i ISLAMIC

8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP 99

1 13. Organization -

14. Ward tCW1

15. FlyStatus 17. Dept / Ben -

K78-PRISONER OF WAR/INTER

18. BranchCorps 19. UIC / ZIP 20. Type Case

BC

21. Source of Admission

Direct from ER

22. Hour Of Adm: 17:43

23. Clinic Service AEA - ORTHOPEDICS

24. Name/Relation of Emergency Addressee 25. Type Disp TRF-C-ICU

26. Date of Disp

2003-10-15

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:

2003-10-06

mitt ngOfficer: r 12U') -1--'

30. Date nit Adm 2003-10-06

32.0 Blood Components 29. ortin m beo ;2_

31. Selected Administrative Data

Marital Status: DoB: 141)

In/Out Patient: Inpatient MOS:

33. Cause Of Injury:

34. Diagnosis / Operations and Special Proced

L FEMUR FX W/ EX FIX,

ires: WI g -) ) ) \

' Plq ‘ T4--"-A-44A--

9

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35. Total Days This Facility

Absent Sick Days 0

1

' Other Days 1 0

ConLv / Coop Care Days I Suppl - • ental Care

0 J

Bed Days

5) Total Sick Days

5 35. Total Days This Facility

Absent Sick Days

i Signat re of Attendin

Other Days ConLv / Coop Care Days

C.-) 4.))

1 Supplemental Care 1 Bed Days

0 1 q .

. - ick Days

q ,3 •1,2/ - ' ds Officer icer 11 1

- -

Automated Facsimile - DA FORM 3647, May 79 DCOM - 21248

DOD-034824

ACLU-RDI 1661 p.8

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS MLR 141 CFR) 201.45.505

OCTOBER 1575 USAPPC V I BO MEDCOM - 21249

(For typed or whiten entries give Name last. first. middle; grade: date; hospital or medical facility)

REGISTER NO. I WARD NO. PATIENT'S IDENTIFICATION

ABBREVIATED MEDICAL RECORD

Standard Form 539

DOD-034825

MEDICAL RECORD ABBREVIATED MEDICAL RECORD

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

Y614'z-m-0 5-

104,0A °Le.,4n,11 ctak. Y/frptitil4 si

PHYSICAL EXAMINATION

PI GG . /■.:1-

C4511-

A-02 7 21-0' f cx.S `fL-.7

61-6-51 , af-bor

( PROGRESS (Enter dote 4 dischargegfirm!t al diagnosis)

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ACLU-RDI 1661 p.9

AUTHORIZED FOR LOCAL REPRODUCTION

OF MEDICAL CARE CHRONOLOGICAL RECORD

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION

(Sign each ent

HGT: MEDICAL RECORD

AGE .

CURRENT

PROPOSED SURGICAL PROCEDU :

SEX:

ALLERGIES: 1..3 A

DICATIONS :

Mallampat6. 3 4

CARDIAC.

DISCUSSION OF RISKS AND BENEFITS:

first, middle; ID Mo or ssN;

(For typed or written entries, give: Name - last,

VAI)

MEDCOM - 21250

ex, sae

CHRONOLOGICAL RECORD OF MEDICAL Medical Record

STANDARD FORM 600 (REV. 6 -97)

FIRMR (41 CFR) 201-9.2021

usAPi Prescribed by GSNICMR

SPO

PATIENT'S IDENTIFICATION: of Birth; Rank/Grade.)

ASA:1i9. 3 4 5 E

ANESTHESIA PROVIDER.

DOD-034826

ACLU-RDI 1661 p.10


MEDICAL RECORD I

CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, -I- KEA I NU VFW/ANIL" 1 RAI fotgr/ udGII Cultyl

• .

,

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HOSPITAL OR MEDICAL FACILITY .

STATUS DEPART./SERVICE RECORDS MAINTAINED AT

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

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; RanWGrade.)

_ Int AA

REGISTER NO. WARD NO.

1;4 4-a1 10 L MEDCOM - 21251

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00

rs I

DOD-034827

ACLU-RDI 1661 p.11


‘4011-1- PROGRESS NOTES MEDICAL RECORD 1

DATE NOTES

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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; Ra /Grade/


-11

ME DCOM - 21252

PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 5/1999)

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

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DOD-034828

ACLU-RDI 1661 p.12

LAST NAME I FIRST NAME

NOTES DATE

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r ... .-41....AA...■ _ ■ 1 r

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i., COP 0 I Atkta KUDgf 0 A 6W/I b Lik / an

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C Sni cult- 5ao .- -1,u Cbilf' VUTa-g , --IV / i I d v veD _._

1(Pia --f & 4.11 [4\ (./ LUCA lx-e_ v - GoNirlD - .„-Amnft. pnREA_Arma.......rigammim

MEDCOM - 21253

DOD-034829

ACLU-RDI 1661 p.13

DATE

>v.5

(1-/&{

yr

MEDICAL RECORD

A. •

5L4 urt-,d 4-0

ga. cuf d 14- /(100 Pte

• 6 9

o • e•

ELay.../ 1 NO 4 ei

1

°O Z.)

rtl 't

h •

(Continue on reverse side) WARD NO.

REGISTER NO.

PROGRESS NOTES STANDARD FORM 509 (Rev. IS-77)

?Mated IN GSA/OR ,

MIR (II WO 101-11•36-

509-11 0

PARENT'S ,DENT ■FicKnoN7n, typed or written entries give: Nome—last. first. middle:

grade: ran medical focally)

k; rote: hospital or

MEDCOM - 21254

PROGRESS NOTES

A

T-6Jet. ),zir

rae

r'"

0

DOD-034830

)1- Mir

ACLU-RDI 1661 p.14

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

DEPART./SERVICE STATUS

RELATIONSHIP TO SPONSOR SSN/ID NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE

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

ef A, Co

MEDICAL RECORD

DATE

It)

41° af

q__75 L

I PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;

REGISTER NO.

Date of Birth; Artnk/Grade.) i

•

()) ........k.f.

WARD NO.

RECORDS MAINTAINED AT

MEDCOM - 21255



STANDARD FORM 600 1REV. 6-97) Proscribed by GSA/ICMR FIRMR 141 CFRI 201-9.202-1

DOD-034831

ACLU-RDI 1661 p.15

RELATIONSHIP TO SPONSOR RECORDS MAINTAINED AT


MEDICAL RECORD NOTES

DATE

toci sisx, vo -calm (IL GP yin P ry

2/1 C-b oinfuji) A aA/V ■ Or1N, 0-AA/UtUl) 01 A itchu).

Utuk, Watiaktri&

f

G 41 Lit

AG

La _

ha,

A • t

AA _ _Al oki,

416

"All AL it 0

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.

• LA ALIA e a

/ tO

PA 0,1 jo

t l4_41

401 4 Ova .

oeu-a_ pie ob5o

\WI'S SPONSOR'S ID NUME

ISSN or Other)

DEPART ./SERVICE

PATIENT'S IDENTIFICATION:

(For typed or written entries, give: Name - last, first, m

ID No or SSN; Sex; Data of

iddle;

( f Birth; Rank/Grade) \to (3) 1

56


STANDARD FORM 509 (RE

Prescribed by GSAIICMR FPMR 141 CFR) 101-11

PROGRESS NOTES

DOD-034832

ACLU-RDI 1661 p.16

MIDDLE INITIAL ID NUMBER

S ANDARD FORM 509 (REV. 5/1999) BACK

USAPA V1.00

MEDCOM - 21257

DOD-034833

ACLU-RDI 1661 p.17

AUTHORIZED FOR MAL REPRODUCTION

DEPARTJSERYICE

PATIENTS IDENTIFICATION: (For typed or written entries, give: Na • 114 Via mid*:

. No or SSt Sec Date of lionlAnde1

05)—y PROGRESS NOTES

Medical Record STANDARD FORM 509 IREV. 611E

Pmsaibed by GSANCIAR FPMR 141CFRI 101-11.2 03iM

USAPA V

SPONSEIFII ID NUMBER (MX or Merl •

WARD NO.

PROGRESS NOTES MEDICAL RECORD

NOTES

RELATIONSHIP TO SPONSOR


DOD-034834

ACLU-RDI 1661 p.18


PROGRESS NOTES

MEDICAL RECORD



DEPART ./SERV I CE

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

ID No or SSN; Sex; Date of Birth; ff k. Grade) PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 5/19!

Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203A

03H

USAP V I

259

DOD-034835

ACLU-RDI 1661 p.19

MIUDLE INITIAL ID NUMBER

DATE NOTES 7 iLpt.s PAI-(r6- - ))6)-2..

8 oc...4,,3 its s, ,,,,-.4- c ...xc... 4, 10 T- 0-c Coo , V3 3 LA k.)..-...A- it-) .t, t rttr A.- 4-4":: j ,

it ig‘ rv..crc-rN.,%N.) . _F-56' C K CWR-S sc-vrk.v...r c_ c,(. r cp (,,,,.. a J, , c,c_..r____ L ca,tct,zy t c_ .

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1" -c-c-s--7- ,CA7 , (rk

• IA AV 6-64-L eY1/4 LI e-- "1-"ci //1"ci/lAciC

‘3,,ci-era27_3St) )55zAA.A.A. Cer.f.e_C-1) ► Rs3-01 AI vs 5 ) 4-e -..e s It()LArt7 m,40,,,;. J) ,;:-

IT c5 ...)-,-,..._ 7 --C- G v... AA Sr 4 4.4.....„-s+2_,-.4 .m, -. .-7-P) ,i,s3 .4,9 r, ,,,,,,,,„ fizr 3 5

V 1.- CA)T_ intit-,T),,,,t' 9 1A.rrfrff i ( c ,11.5 1 1-L ?p 1,,, c•,,e 0_,,r- 4.. ,,c-F-e-*--eA i,j- ; FTE 1

P _rt,a,..-/C ,,,.a,....... . , 0 , • 4 . __ k ,

,tae i er...i. e ) (50 r _.ji-c... .42) $ ikik-, 1.0-4‘t i,,Y--_,-/ig-s-,),..\ C.A9-1,-..* ." ,f0.-+..„.%. r - i _,-,... . ...

/q" c-t(2 "--2-(1,-Y- ✓7 11--fte

OVZ, 3 t a-Q.1,-s- 71/ ' 5 l(Lbc•i-c_ '2-19/ P / alla

--r- r. 9 5- (o / 6 7115- e :i 2--) .5-i- 5g -Z , , A ,

0-2)-15 12a- e- 1A1--

! tiOC.6-3 As 5 t.euv•-C cam_ c,-t, -Pr-' Co ( ,)K , 5„_.., 6 4 A., ttc.,4-4_ oi-acAr-

1-„, Tr-k••• ■eve .. C/o per,;,.. ve-fr. re4-e..._ch_v ..e...t..4--(,.....Li- 5 .,

totr..!„,..t_. r ) d-c)m-k_ Coto kr. //e- 0 t.reN...1 --.A- s i (...._ fo_ce- rxr.) s . k.irl ; 44-04ALX.P. yaigg,t, t 1

umbit 0 ft-3 c4A-. k_ A, cc, K.oll'Inve— Vek iltn.av-t_ter; --"------.___... ■-■.-------- eV*

V10 40?4%) 2-° IS 4,s ...14 CA---c (;) I q-ce-t-, ; At. ki- S5/ Ail) X 3/ c--e( Lei Z.- 2S .- r.,,,.. p"..rs A--er ;8152 400 ,

LE-- c 2- . • , ; L . u . s-., • 0 ,,, ,

4 ■ - - • .. • i...-__.. cLa r_t ' • _ IsL.. •

,.::. .ILIP ft.- _ Co a .

+1. l•-e--P-1.,.., i-0,1 • - - -

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

MEDCOM - 21260

DOD-034836

ACLU-RDI 1661 p.20

STANDARD FORM 509 (REV. 5/1999)E

SAP) MEDCOM - 21261

_AST NAME


DOD-034837

ACLU-RDI 1661 p.21

INJURYISAFETY FORMS

HOME PHON

NO Na

1112 IS II I

DATE LAST VISIT

NAME OF INSURANCE COMPANY

EMERGENCY ROOM VISIT

24 HOUR RETURN '

YES • NO

NSN 7540-01-075.3786

EMERGENCY CARE AND TREATMENT

(Patient)

PATIENT'S HOME ADDRESS OR DUTY STATION

MEDICAL RECORD ARRIVAL

TIME

W111111111111:1221311

111231011011 VIM

`NM

\ e.IVOC THIRD PARTY INSURANCE

ADDITIONAL INSURANCE

DO 2566 IN CHART

TETANUS -- COMPLETED INTITIAL ETES

0 YES -0 NO

TRANSPORTATION TO FACILITY

ND

DUTYILOCAL PHONE

AREA CODE

MEDICAL HISTORY OBTAINED FROM AGE

INJURY OR OCCUPATIONAL ILLNESS

:STREET ADORE

ALLERGIES

DATE LAST SHOT


TREA

CITY

SEX

AREA CODE

CURRENT MEDICATIONS

•

I PULSE OX

TIME ORDERS

ECG •

ADMIT TO UNITISERVICE

TIME OF RELEASE

PATIENTIOISCHARGE INSTRUCTIONS

WHEN

REFERRED

I have received and understand these instructions.

PATIENT'S SIGNATURE

EMERGENCY CARE AND TREATMENT (Patient)

Medical Record

STANDARD FORM 5581REV. 9-961

Plescaol by GSAIICMF1

f PIM 141 UM loi.11.2630Atio)

USAPA V1.00

UNCHANGED

DISPOSITION QUARTERS loEE DUTY

24 HRS. 48 HRS. 78 HRS.

RETURN TO DUTY

(Fol typed or written entries, give. Name - lase

lust. middle' 10 no. ON fr other/; hospital m medical facility'

CONDITION UPON RELEASE

CI IMPROVED

CI DETERIORATED

PATIENT'S IDENTIFICATION

MEDCOM - 21262

lY1

INITIALS

C-SPINE CXR PA & LATIPORTABLE a SPINE LS BHCGIURINEIBLOODIOUAN T

CT HEAD ›- CC ¢ CC >k

CHIEF COMPLAINT

CATEGORY OF TREATMENT TIME

EMERGENT

URGENT

ION-URGENT

CBCIDIFF 1111331111111231111111111

1111013311111111 BLOOD C&S X

VITAL SIGNS

MEM

11111111111111

111.11111111

11111101111111111111111111 ■ ACUTE ABDOMEN

1111=1111111.111111111

ORDERS

MONITOR

COMPLETED BY

DISPOSITION

HOME

MODIFIED DUTY UNTIL

• • FULL DUTY

PATIENT'S RESPONSE

DOD-034838

ACLU-RDI 1661 p.22

PROVIDER

73° t7C eT° 712,1-#--rt-4-11-/L-4-t d 7i" 717.4_ s/ P (Z)3 .

3

HISTORYIPHYSICAL

11 4-- eS-4 p7 - cq

„ --- / 24

All!16-

CONSULT WITH RESIDENT/ EDIC

P

NT SIGNATURE AND STAMP TIME ACTION

DIAGNOSIS

0o0 IMPLI I 00

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

WBC

HIH

PLT

PT

APTT

ABGIPULSE OX

PH

SAT

RADIOLOGY

Check if read by radiologist

SUP 02

PCO2

DIP

MICRO

P02

RESULTS

OTHER

EKG INTERPRETATION

BHCG

ETCH

GW

PATIENT'S IDENTIFICATION For oyes or written entries, give, Name - less, fest, middle;ID no. ISSN Of oared. hospital or nese, feelkyl

111111' (') ' EMERGENCY CARE AND TREATMENT (Doctor)

Medical Record

STANDARD FORM 558 IREV. 9-96I Prescribed by GSAI1CMR FPMR 141 CFR; 10 1•11.21:131611101 USAPA VI.00

MEDCOM - 21263

DOD-034839

ACLU-RDI 1661 p.23

MEDCOM - 21264 STANDARD FORM 510 (REV

NURSING NOTES (Sign all notes)

OBSERVATIONS

Include medication and treatment when indicated

DOD-034840

ACLU-RDI 1661 p.24

ASSIGNED CIRCULATOR

2L1 2 RELIEF CIRCULATOR

LATERAL: ❑ LEFT SIDE UP 0 RIGHT SIDE UP

• AI

HAIR REMOVAL 0 YES

DONE BY: ❑ OR

METHOD: ❑

DEPILATORY

CLIP

NO

eINDWE BY WHOM: BY WHOM: 19 Li) r-

COMMENTS : 9. LOCATION OF EXTERNAL DEVICES

•

LAN

Afiri2.91:44

ID --........,..-..■Iiiiiiiiiiiimil•IIIIIIII.....- -It" -, ....

...--

Illlit-iiii• _At ''s

15V1 -NM111411111111ter...

'411111r

INTRAOPERA OCUMENT

;icy is the office of The Surgeon General.

VIEWED AND PROCEDURE For use of this form, see AR 40

-66, the propos,

MEDICAL RECORD ROOM

2. PATIENT IDENTIFIED, RECORD

BY Oirt/f—

VERIFIED BY 2 1. PATIENT TRANSPORTED TO OPE R

TIME PA IENT ARRIVED IN SUITE

4. PATIENT IN ROOM

/1.‘c TIME • it/5 6 NUMBER

VIA ‘...t TIME INC

❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)

5. PREOPERATIVE EMOTIONAL STATUS

6. NURSING PERSONNEL

ASSIGNED SCRUB

\AO A-- RELIEF SCRUB

R

3. DATE

06'

❑ CALM

COMMENTS:

ANXIOUS ❑ EXCITED

.et.-12 (Pr

❑ CRYING

• NURSING UNIT

❑ RAZOR

7. POSITION AND POSITIONAL AIDS (Specify)

SUPINE 0 LITHOTOMY

❑ PRONE

COMMENTS:

0 KRASKE

S. SKIN PREPARATION PREP S UTION (Specify)

SITE: Lgt, SITE:

COMMENTS:

•

LEGEND X Ground Pad

— Safety Strap === Tourniquet

C = Correct I = Incorrect

First Closing Final Closing 19 (3 —I— CIRCULATOR

10. COUNTS Other" Count

Count SCRUB

sponge 0 Yes ❑ No MN

11111111111

Needle Sharp .4 Yes ❑ No

11111111111 15

Instrument 0 Yes b. 11111111111

111111111111111

Other Yes .4 No 1111111111

1111111111111111111

11. PATIENT IDENTIFICATI Hospital or Medical Facility;) O or typed or written entries give:

Name - Last, first, middle; Grade; Date;Facility;)

12.ELECTROSURGERY DEVICE(S) (ESU)

?

(ESU NO: -5E1)

GROUND PAD:

6 BRAND 30'1 1/11

LOT NO:

b N/Iti t

b■d — 5 b1111111/

MEDCOM - 21265

❑ ESU NO: GROUND PAD:

BRAND

LOT NO:

❑BIPOLAR NO:

IA

DOD-034841

ACLU-RDI 1661 p.25

13. PROSTHESIS, IMPLANTS ❑ ,L NO IF YES NAME: ID NUMB JUI- AL; I UKtIl

1 . J.:: . 4'',.Z,O,'. wa., , ;;, PT:- ' ; , :4K,, :,. - ;:i MEDICATIONS/ORDERS,,::„ '3 ,. g.

/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO V, IRRIGATION

MEDICATIONS/SOLUTION DOSAGE TIME... METHOD PREPARED BY.

:WOUND IRRIGATION Ki YES ❑ NO, TYPE(S): p5

;OTHER ORDERS ;, TIME CARRIED OUT BY

.cti 'PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE

YES NO r 16. LABORATORY SPECIMEN

SPECIMEN (S)

YES ❑ NO lyr

NAME NAME

FROZEN SECTION (FS)

YES ❑ NO

NAME NAME

CULTURE (C)

YES ❑ NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION

Kalor-01z-w.

liki Ors'ISIV Ve..-i.ix Ace kA), ..e

(Specify)

0

17. TUBES, DRAINS/PACKING YES NO •

TYPE/SIZE 1. 10,.. ri,ki ,-)7 2. -

SITE 1

(

_,,,

9 1 IN15k

. 3. s,de,Y4AA 6(4)e

19. ADDITIONAL INFORMATION

51-kor -1 ,- - : 13351,4,

tri 11--E" -- 153 I m ,

--51..- )a)fri_

20. OPERATION(S) PERFORMED

'1-1'N,--A)N's I 1)ep".;.-k G--) PI Pt,.-A-- -E Eyk----t -F;x..76,- -6 Ci.L- i- 6-A.,r-

6(6)-L.

21. PATIENT TRANSFERRED TO

1_31— (elk MEDCOM

1TIMeEi. Li kir. t

- 21266

1 METHOD 1.--C1rErz.,

122. REGISTERED NURSE SIGN

DOD-034842

ACLU-RDI 1661 p.26

INTRAOPERATIVF DOCUMENT MEDICAL RECORD For use of this form, see AR 40-407, the propon 3cy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATII' - JM . ,

VIA j.t„4:a).1) BY at./1.-e--4, -4.4-4.-R_A-

2. PATIENT IDENTIFIE LORD REVI WED AND PROCEDURE

VERIFIED BY aerr/ A-A3 3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT I

TIME 045-3 NUMBER /"! () gOeT-03 5. PREOPERATIVE EMOTIONAL STAT S

cg. CALM ❑ ANXIOUS • EXCITED U CRYING • ANG • WITHDRAWN • OTHER (Specify) -- - -

OMMENTS: piLii:efoi,,,,_„. 4,,,,,..,4 .,:m .......... . .... 1 („of )...2 6. NUR51NGT)ERSO NE/EL

ASSIGNED SCRUB

'SS a IIIIIII4 .----.Itio-.. - -"RELIEF SCRUB

ASSIGNED CIRCULATOR

C..;Pr i G6 RELIEF __CIRCULATOR . .__. _ ..... .

7. POSITION AND POSITIONAL AIDS (Specify) --,-

g SUPINE • LITHOTOMY • PRONE • KRASKE. LATERAL: • LEFT SIDE UP • RIGHT SIDE UP

COMMENTS: b LC) -L 8. SKIN PREPARATION -

HAIR REMOVAL DONE BY: METHOD:

COMMENTS:

• YES NO

• OR • NURSING UNIT

U DEPILATORY • RAZOR . 2 • CLIP

..

PREP • UTION (Specify) 4e,.."-X1 r..6e.„/e-

SIT AOCQJ B WHOM: ejor- SITE:.s- BY WHOM:

--r---. COMMENTS: 11-.0 rile, A4 d IC2-d—i--&-+' ,..81

9. LOCATION OF EXTERNAL DEVICES

. _

• •

- , t :OE- - - --'°■--**Namemmo.-- -

• Torim--- ......_ .

LEGEND X Ground Pad ety Strap = = = Tourniguet-• ••-:-•:.-- • vt §

10. COUNTS

C•= Correct I = Incorrect

V-10., I Other ••

First Closing Count .. i , :.

Final Closing CoLint .SCRUB ' IRCULATOR

Sponge Yes Vo e_ Needle Sharp Yes Vo

Instrument D Yes Vo _ - _ ,. Ur.;11:1_,.:, ,

.. _ Other U Yes Vo

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

- \I/A ...

12. ELECTROSURGERY DEVICE('.) (ESU) • . iil,

ESU NO:

YES NO

Co AG : i •A i- 7S-7) - GROUND PAD:

_..._._ - . . , LOT NO: 0 Oil , .1-c) 0 5- -Cy- .:':'..ESU NO: NO:

,• . .. • •"GROUND PAD: BRAND

. r ._.. LOT NO:

r-1 nine. A [I NO:

g (0 dr 0 3 MEDCOM - 21267 I

DOD-034843

ACLU-RDI 1661 p.27

DOD-034844

I TIME_ — IMETHO '

MEDCOM - 21268 21. PATI NT TRANSFERRED TO

la_ it_.3 OCI'ZICTCDC/1 MI IOCC C1r2h1 ATI IOU

YES ❑ NO, TYPE(S): MOUND IRRIGATION

13. PROSTHESIS, IMPLANTS ❑ YES I NO IF YES NAME: ID NUMBER; 'ACTURER

MEDICATIONS/ORDERS 14. IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT.BY ANESTHESIA)

MEDICATIONS/SOLUTION DOSAGE . TIME METHOD PREPARED BY GIVEN BY

IF YES, SITE

PHYSICIAN'S SIGNATUR (:)

15. X-RAY IN OPERATING ROOM

YES ❑ NO

16. ' SPECIMEN (S)

YES ❑ NO

NAME

FROZEN SECTION (FS)

YES ❑ NO

NAME

CULTURE (C)

YES ❑ NO

NAME

NAME NAME

NAME NAME

17. TUBES, DRAINS/PACKING YES

TYPE/SIZE 1. 2.

SITE 1. 2.

NAME

NAME

NAME

3.

19. ADDITIONAL INFORMATION

NAME

18. DRESSING/IMMOBILIZATION (Specify)

:-",=LABORATORY SPECIMENS

0 ( 6

CARRIED OUT BY TIME :OTHER ORDERS

7)?

20. OPERATION(S) PERFORMED

NO YES

ACLU-RDI 1661 p.28

• MEDICAL RECORD

INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-407, the prop(' ency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERATh DM •.

VIA BY (1 1...-E/ R ,..12;(..4'6Z./)..

2. PATIENT I AND PROCEDURE

VERIFIED BY p77--/-i-A1 3. DATE TIME PATIENT ARRIVED IN SUITE

/3 0 c7-- a 4.. PATIENT

TIME 0q,33---- ) 2.— NUMBER / — / (Z)

5. PREOPERATIVE EMOTIONAL STATUS

V CALM ❑ ANXIOUS ❑ EXCITED. CRYING

... U ANGRY U WITHDRAWN II OTHER (Specify)

"COMMENTS: .....

6 . NURSING PERSONNEL

ASSIGNED SCRUB

SSG - "" ";q/p) — - - RELIEF SCRUB

19(6)— 2., . / Nq -0....

ASSIGNED CIRCULATOR

CP-1 66.-

.. . .. .._ . . .... RELIEF

___CIRCULATOR .... _CIRCULATOR iwl . ..

41111111. “E (__Sz-Lk., p_telo)

Cfr MI ( ‘2. I 5- — (3 OD) 7. POSITION AND POSITIONAL AIDS (Specify) _

11-4 SUPINE ❑ LITHOTOMY II PRONE U KRASKE LATERAL: U LEFT SIDE UP • RIGHT SIDE UP

.. ' ' v COMMENTS: 6-t-i--h.1.4A3 frae_.... 7( c.--"...d-e---L L-Q-1171:::A(7.f9

HAIR REMOVAL (11.. YES MII NO 1>e_

KIN PREPARATION

DONE BY: U OR M

PREP SOLUTION (Specify) i-Se SITE:L1F BY HOM: Oct-j-

SITE: BY WHOM: /4 METHOD: U DEPILATORY II RAZOR (9(0--L.--

II CLIP

COMMENTS: 1.4-0 1.4.-t..to ak Q.-Li-to 1-L4) 424------ .. _______ .

tcitviiiikrsgs:h0 rIX/C-4.0 PI d.2-,- 5-1 e_P( • 9. LOCATION OF EXTERNAL DEVICES . ....; _ ..

4(4)-Z •

. ....

,. A - - ..t • ASAIIIMI.m.o-st. - .• _ ......„„,..„,„, . _ . . ^1-- Via--

- —

.....,,....§-: &(0-- -z- LEGEND • • • -d . trap = = = Tourniquet. -.-.4.--•-• :"- --"5(A ----

.. , 1

10. COUNTS % vw-i-uk....f

= Correct I = Incorrect A lf

Other • • First Closing Count -.:.

Final Closing CdUnt SCRUB • •

Sponge 1

Needle Sharp

Yes

Yes

U U

Vo

No

d ...... _

---NMITZ""sir . , — 66'

Instrument Yes fl lo .. - 1..1.6.:,i,1._%, - • .

Other D Yes h Vo . .,.

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

12. ELECTROSURGERY DEVICE(S) (ESU) (a YES

b-,17---- 5)3 /9- —2)

U

6 NO

-,' v

-p ESU NO: Va_Li. — ,C.. e5-3os'

GROUND PAD: AND V.et--0.eti Of r F 7,37r \

0 () "—k1 -. ' --:::- L LOT NO: -2 oos- -c;

i . . ', 0._ESU NO:

7 .. "GROUND PAD: BRAND

LOT NO:

r--1 --- 'R NO: MEDCOM - 21269

3 o ey- ) 9 I

DOD-034845

ACLU-RDI 1661 p.29

13. PROSTHESIS, IMPLANTS El- YEF ] NO IF YES NAME: ID NUMBER; FACTURER

SI n.4.1.-.7 'Dee ()--ccu-e., s v,,,-.1-4,--Q "I S. -t -F7.- S cie--610C L_oeul-44- 01-1-)4500, " (- °act -th roli- - :ii's:' o a., , %

/4/7.4,-4. ivia.--- if. crk,r., tor-h dca Sfix tt- 34-k- 1

32K '2- tl-iric I !MEDICATIONS/ORDERS ,, ,4,- ?

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT.BrANESTHESIA) NO

1MEDICATIONS/SOLUTION DOSAGE:... TIME: METHOD PREPARED BY GIVEN BY

:)/JOUND IRRIGATION .0 YES ■ NO, TYPEIS):

i.,--- _

.!'. ID .cr r, I) /IQ I --

,'OTHER ORDERS TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM „._.... IF YES, SITE •

YES K1 NO ■ e.4)12.4-11 - t...e.p.L. . .e ,„

16. - I .' ' f.':'-.LABORATORY SPECIMENS j

SPECIMEN IS)

YES 111 NO r] , - _

NAME _ ___________ ---;--------- -. . ... _.... - NAME

FROZEN SECTION IFS)

YES ■ NO ■ NAME NAME

CULTURE (C)

YES 111 NO ❑

NAME ...,___, ... ____.

NAME

NAME NAME NAME

NAME NAME ....... __----- - 18. DRESSING/IMMOBILIZATIpN (Specify)

— FA-ti--° -- V-CA_.a(

17. TUBES, DRAINS/PACKING YES lj NO Vlifr

TYPE/SIZE 1. 1k?„,

1. rvq4-3

2. •

SITE '' 2. 3.

19. ADDITIONAL INFORMATION -

...? 46) -

b (6) -I- 0,1-z, 0--{2-,2-401/4_ ” _ Pin-J- 11111111(C-W-Wit

20. OPERATION(S)

bRi F Ler--4-- rerri Et 1--- --- .

21. PATIENT TRANSFERRED TO I TIM I kilfir f 6CitM I ett,, 3 MEDCOM - 21270

DOD-034846

ACLU-RDI 1661 p.30

MEDICAL RECORD VITAL SIC RECORD

HOSPITAL DAY

POST- DAY

13 OCc---- M 0 >1 .-.) ....

MONTH-YEAR DAY

19 HOUR • ' • " " " • • ' • • • " ' •

TEMP. F

(0) (*) 105°

180

170 103°

160 102°

150 101°

140 100°

130 99° 98.6°

120 98°

110 97°

100 96°

90 95°

80

70

60

50

40

RESPIRATION RECORD

...4PULSE . . .

" .r) •

. .

"

:

" " " . • . . . . . . . . . . . . . .

LA) CO

CO

C

O C.,.) L

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J U.) C

O 4=

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of

al c

s) 0 --

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0 (S) 0

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b)

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N b

o

Ea (o

4=

. b

b)

:0

0 0

0 0 0

0

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(Cen

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hen

so

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ere

d BLOOD PRESSURE lughv

1- cti OAS I C(1:1

rt fil it I/) HEIGHT: I WEIGHT —0

cern %lc MO 461-1-

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

REGISTER NO WARD NO.

STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 21271

DOD-034847

ACLU-RDI 1661 p.31

VI IML OIUIVJ r‘C.t..AJIALJ

HOSPITAL DAY POST- DAY f

Zan' . . Fil

e E

y;

'22

IA

. . :

. •

WeiallIrt EIRMIENIENII MIER

Mall MONTH-YEAR 1 /03 DAY

19 HOUR

PULSE TEMP. F (0) (*)

105°

180 104°

170 103°

160

150

140 100°

130

98.6°

120 98o

110 97°

100 96°

90 95°

80

70

60

50

40

REPI T1ON RECORD

• . ' •

• ' . . • ' . .

" . . • ' . .

. . : :::::

, , . ...... • • . . • •

• • . . • •

• • . . • •

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" . . • . ::::::::

. .

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::: : : • .

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• • . . • •

. ' .

•

• • •1

• . ' .

• • . . " . .

" • - . . " • • . .

• . .

..10111. i MINIM

marvAn TrAPHIVAIIMaill&SII : . .. ..

1

IIIMAINIIIIIIIIIIIII

. .

1111=.11

.

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. ..0_

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

—....-T

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. . . . . . . . . . .

GO

(...) 0.) (..)

(...)

( CT

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a) -

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b b

i- :-.

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(Cen

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.•

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• • Irja

7# AS ""• 1 111M 0 :- . ,,a_

• • ••

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rte .:

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aVist i► ar

Rec

ord

sp

ecial data

on

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he

n so

ord

ere

d BLOOD PRESSURE

,, ffix , i I

rrli li 1 WEIGHT HEIGHT: —+ e ?V eiri

i ► •o CtPfl. LII 0 461, /€.4 cilt WA) e., (2P■ qtr, PA,

13A eicr

PATIENTS 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.

VITAL SIGNS RECORDS

Medical Record

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

MEDCOM - 21272

DOD-034848

ACLU-RDI 1661 p.32

FLOWSHEET FOR VITAL SIGNS AND OTHER PARAMETERS For use of this form, see AR 40-407; the proponent agency is the OTSG

WARD

/ C__ Ct-

This form may be used for more than one day by drawing a heavy line and adding date. Insert column headings as required.

DATE

( 69

/ \O C —1 ' 9Y-5 c 94 1 i 1.-(f/F- ttro. !mac et' r8 ogis9 /f IG33 -2 ,:?3 (1 10 _.1-(3

I (00t _, ---2e "(0 13(1. - (C/0

63 / (2) 1 .3(tO NO AR 1 S eB I/6(

ilenljr, 111 nn

DA FORM 3950, JUN 91

Previous editions are obsolete.

MEDCOM - 21273

DOD-034849

ACLU-RDI 1661 p.33

TWENTY-FOUR HOUR PAT' - ii f E AND OUTPUT WOKSHEET FRO' (OURS

TO .(OURS

T OTAL HOURS O VERED C OVERED

DATE

6 INTAKE

ORAL INTRAVENOUS

TIME TYPE AMOUNT ACC UM TOT AL

TIME El AMOUNT ST ART E

TYPE (Include Medications)

AMOUNT RECO

TIME COMPL

ACCUM TOTAL

A) C 1.- /45,3 1

/63S a /u d O 5

IRRIGATIONS (N/G, Bladder, etc.)

TIME TYPE AMOUNT ACCUMULATIVE TOTAL

BLOOD/BLOOD DERIVATIVES

TIME STARTED

PRODUCT (i.e. DI,

Alb, P. cella, etc.)

TIME COMPL AMOUNT

ACCUM TOTAL

OTHER INTAKE

TIME TYPE AMOUNT ACCUMULATIVE TOT AL

GRAND TOTAL INTAKE

r I' 1,.• • ••• • • ....ors two. •••• 1,1—•

INTAKE EQUIVALENTS (Serving levels cc)

MEDICINE GLASS (1 oz) .30 HALF PINT MILK 240

SMALL FRUIT CUP 120 LARGE SOUP BOWL 240

COFFEE CUP 160 LARGE WATER GLASS-240 LARGE COFFEE MUG 190 PLASTIC OR PAPER

JUICE CONTAINER...180

li a or medical lacilit )

DD FORM I JAN 74 792 EDIT ION OF 1 SEP 54 IS OBSOLETE. REPLACES DA FORM 3630ITEmP1

MEDCOM - 21274 'U.S. Government Printing Office: 1994 — 300-727/10426

DOD-034850

ACLU-RDI 1661 p.34

OUTPUT

URINE) NAFFeeS ..J.1, ::-- = ::(

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE A CUM TOTAL

22 I e.00CCe_ hoa.DC_C- Defeo c(C) . c k\C, c) °t.0c c

Vaal icoacc itCOCc a55 M---c go i.._ ' `-/ bcc.

W) ()-D 10- , 077) au j (coo 13-1a) e)5 , 10 .... • .. ii 3-e

(L-1/4c, ID m„,r,,,,,A1 2< /

CHEST EMESIS

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

STOOLS

TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT

TIME AMOUNT TYPE ACCUM TOTAL

..... GRAND TOTAL OUTPUT

REMARKS

k.

•

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle: grade: date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)

EDICINE GLASS 11 oz) . 30 HALF PINT MILK 240 120 LARGE SOUP BOWL 240

SMALL FRUIT CUP 160 LARGE WATER GLASS ... 240 COFFEE MUG 180

1)(0 --1 PLASTIC OR PAPER

JUICE CONTAINER 180

Page 2

MEDCOM - 21275

DOD-034851

ACLU-RDI 1661 p.35

IS SUBJECT TO THE PRIVACY ACT OF 1974) .- -

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM HOURS TOTAL HOURS

COVERED DATE

TO HOURS

INTAKE

ORAL INTRAVENOUS

TIME TYPE AMOUNT ACCUM TOTAL

TIME STARTED

AMOUNT TYPE

(Include Medications) AMOUNT ,

RECD TIME

COMPL ACCUM TOTAL

WS-1--V A / o crxx a000 )IXOCC,

, . A nce4 56Cci 63*

„ .

IRRIGATIONS (N/G, Bladder, etc.)



TIME STARTED

PRODUCT (i.e. BI, Alb, P. cells etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

OTHER INTAKE


GRAND TOTAL INTAKE

DD FORM 792, JAN 74 (EG)

EDITION OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94

MEDCOM - 21276

DOD-034852

ACLU-RDI 1661 p.36

4.3ger9"All ...

i 7 _ NASOGASTRIC


2_2oo 142D 112-

055,5 21'2-5 —1-14.45 .

Ci3O 41$- 0

S2.2,3 L175 ct a 3 22 1s5 LO-S- P43

CHEST EMESIS


STOOLS


TIME AMOUNT TYPE ACCUM TOTAL

GRAND TOTAL OUTPUT

REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: first, middle; grade; date; hospital or medical facility)

\O (0

Name - last,

---11


MEDICINE GLASS (1 oz) . 30 HALF PINT MILK 120 LARGE SOUP BOWL

SMALL FRUIT CUP 160 LARGE WATER GLASS ... COFFEE MUG 180 PLASTIC OR PAPER

JUICE CONTAINER

240 240

240

180

DD FORM 792, JAN 74

MEDCOM - 21277

Page 2

DOD-034853

ACLU-RDI 1661 p.37

10162-1 19( ) -

Ward/Section: -&,- ; A.-....c RE UEST1NG P 0

LABORATOR RESULT FORL1 I Su 'ect to the 4 Act of 1974 LAST, FIRST., MI.

--- — TIME - SSN/PSE

iliietnattilogy) CB-. U

.... • •: -

- ' • . .' .2 "•: -, -.:‘-_-M1141..S.1-°1QtY: TEST:-..._RESULT :— REF. RANGE ' TEST RESCILT — REF. RANGE TEST RESULT REF RANGE

WBC 4.8-10.8 x 10 Color yellow N/A RPR Negative RBC 4.74.1 x 109 App CI•eLtr WA Mono Negative

Hgb 14-18 g/d1 (M) 01u G_ Negative - . Kikrobio!ogY . Hot 42-52% (M) .

37-47%(F) 80-94 II (M) ill99 fi (F)

Bill - -

Ket

/k, e (:,..

, G Negative

Negative

Sour

Gram Stain

- -- . __ e . - . MCV

Pit 130400x 10' verified SG 1,0 I 0 .N/A . Occ Bld Negative

Lymph % • 20.5-51.1% Bid 1 (c)- Negative H. pylori Negative ' ..matolo) . Y9nual Pifff:rentiiil ..,.. pH -- 7 , WA - Micro

Parasites Segs. Mono Prot A fe (-__ Negative Malaria Bands. Eos !hob Q c." -) 0.2-1.0 0 & P

Lymph • Baso • Nit jfze. c..... Negative Other

Atyp Imm Lea Negative

RBC Morph

HCG Negative

•' . ..

('Dd.— i —5

Spun Hematocrit -

42;52% (M)37247% (F)

. - • • . - - • . • •

. ' •• • Blood. .. .... .. . . .

Sed Rate

-. •:. Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other . Directigen Negative J. ABO/Rh I

Coa tIOlLSttidIe3 -40:''' -

,.... ,...::•.:..-...• --...;.' . - :',:s.'•':: • :-:::::1' ..:-. .: 1 .

-.:!:-.- - . ... .Blood 130k IlititOoisistiteli. (MUST SUBMIT. Sr518.V.4#1XYERY UNi*170.4P01) -.• -

...:... -:;.-,.- ; .-: , • ": . - 1- .... :•,• •....Z.- 1! -..,:

REQUEST}D) .!...: • -.:.....- ,......-....;.•!. "..: .. ••••••: • , .; RERLIL T REP. R AFGE UNIT TYPE CROSSMATCH

PT 9.8-13.6

.

APTT 21-34 se

• • <20 ug/ml •

FDP <10 ug/ml

• REMARKS:

REPORTED BY: •

I DATE:

•

1 LAB ID NO.: • •

MEDCOM - 21278

DOD-034854

ACLU-RDI 1661 p.38

6(6) rf al woccuun: .---

i ,

I k-/ \

REQUEST-11%1U P REQ I V b (

CHEMISTRY RESU T FORM L (Subject to the Privacy • of 1974)

LAST, FIRST, ML TIME SSN/PS n o

':-• .. i.i' 5,-,-"-tit- TA- , - i7..i..!;,..,4•;+;:e•-;;-::; :: ... . . .. , , 4,0. P,TR. .SJ Y. jp: '.' 'A -5: ; , :f 7. ...,, :••.rii,S):?

v:•.,,r: ; ,0§1 6 :

k4" '7... ' ';:s

-4..•".■ ,?

...,,.

-4111.0. - ;:. 7: .'..i:_Y-- i4RZ:, -; TEST RESULT REF. RANGE TEST RESULT REF.

RANGE TEST RESULT REF. RANGE

Na 138-146 tranol/L AT .11 1 c-c 4 °MI 1 GLU 73-118 mg/dl K 3.5-4.9 mmol/L' 1UN

- - — - - - PICCOLO Tr—

7-22 mg/dl

Cl 98-109 mrooVL 8.0-10.3 mg/dl

PH • .

7.31-7.45

4 35-45 mmHg on) 41-st trunHR vest)

10/06/03 18 : 16 'RE 0.6-L2 mg/d1

PCO2 REFERENCE RANGE: MALE IA+ PATIENT # •

1111 44)-1 :*---- NEIL YlIE 8

126-145 mmol/1

P02 80-105 mmHg Out) WA (veu) 23-27 annol/L (art) 24-29 mrnol/L (yen)

334.7 nuoolil

TCO2 DISC LOT # : I.: c,„_,.., u1-1-1-c : DU 000 •02

98-108 mmol/1

HCO3- 22-26 mnaol/L (art) 23-28mmoUL6c4 95-98%

# SERIAL Pa IIIIIIIIIII, -

18-33 mrno1/1

_iliV.,1*.tit -g sr:':.:4 s02 • . --.,-.. ,,.,

. P.,,i014 ' .; „i'.0 ..

BEecf (-2) - (+3) mmol/L

GLU 1 13 73-118 MG/DL TEST BUN 7 7-22 MG/DL

RESULT REF. RANGE

AnGap 10-20 mmoVL CRE 0.6 0.6-1.2 MG/DL LB 3.3-5.5 01

Ca 1.12-1.32 mmol/L CK 1384* 39-380 U/L LP 26-84 u/I

BUN 8-26 mg/di ': NA+ 135 128-145 MMOUL LI K+ 4.3 3.3-4.7 NMO&L

10-47 IA

GLU 70-105 mg/dl CL- 103 98-108 MMOL MY tCO2 22 18-33 MMOR_

14-97 u/1

Creat 0.7-1.5 mg/dl ST 11-38 lei

Het . 38-5 MI PCV INST 0C: OK CHEM 0C: OK BEL 0.2:1.6 mg/en

Hgb 12-17 ed1 HEM 0 , LIP 0 , ICT 0 GT 5-65 u/I

•-• .....':. -.N. .; `'• .:. ..'

...i.iiiik . .:-.; "f; . "?..sv,-.:7. 2.;•::;•;"'', ' . •-.;.::::I•V:•::4-:- :!:4:4•.".J

P 6.4-8.1 01

TEST RESULT REF. RANGE . " -.. :":.. -'. •., .. ' - • e-01-). " ."- .":". :•.•..,

Troponin-1 PEST RESULT REF. RANGE

Drug of Abuse

Al.

.

128-145 mmol/1

3.3-4.7 mmoV1

L 98-108 inmolfl

:02

. 18-33 rnmo1/1

REMARKS:

REPORTED BY:

-

DATE: •

LAB ID NO.:

_ .

MEDCOM - 21279

ACLU-RDI 1661 p.39

rySil 7.18 L

La III ,:eL

AT COAG A. ALYZER V4.54 ,005485 1006/03 18:19

Patient ID: Test Name Test Result:= 12.7 sec. ***RESULT OUT OF RANGE*** Ratio = 1.0 Calculated INR = 1.07 Sample Type:citrated wh. blood Test Date :10/06/03 st Time :18:18

-d Lot ID — 1 arator

DPOINI COAG ANALYZER V4.54 AL #005485 10/06/03 18:22

Ient ID 14) -1

Test Name PTT Test Result:= 27.3 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Bate :10/06/03

Test TiCard Lot... ‘o-t6) --1

me :18:19

r■n9r#or

•

MEDCOM - 21280

ACLU-RDI 1661 p.40

516-108

MEDICAL RECORD

NSN 7540-00-634-4156

OPERATION REI-.,,AT PREOPERATIVE DIAGNOSIS

C-n5v3 -va, —11."' 3 1'

SURGEON

ANE THETI

GAN: I zO Fv-3

TIME ENDED: IS-2 " TIME OPERATION COM-PLETED 50 / Adj..

/111111111.11rAilli 11111Ell T ME °PERATI4AM 3 • Cl21

RCULATI

T-

P,ROSTHETIC DEVICES (hot no.)

DATE OF OPERATION

010 2o..›;3

OPERATIVE

6 a °

L_

SPONGE C NT VERIFIED DRAIVS (kW and number)

MATE IAL F1RQARD D 0 LABORATO Y FOR EXAMINATION

OPERATION PERFORMED

CDL reim butr-,1,,Ic s --4-4 ) J

DESCRIPTION OF OPERATION (Type(s) of suture used. gross findings. etc.)

ourNe 4

cir

DATE

()

or ype or wri en/entries give. - Name - last, first. • date; hospital or medical facility)

-71

REGISTER/I.D. NO. WARD NO.

bDi5

ovith 23 )1.

OPERATION REPORT

Medical Record

STANDARD FORM 516 (REV. 5 -83) Prescribed by GSA and ICMR, FPMR 101-11.806-8

MEDCOM - 21281

DOD-034857

ACLU-RDI 1661 p.41

/1A7 C F4J4 ATIENT'S MEDICAL RECORD

vv\

MEDCOM - 21282

ANESTH

..J,

1131131 13 Warmed 1M2 IMMO 1°`:'z'rES:11011110711111ill - 6'0

MI 00104k. . ' ?:;:::',. SINGLE DOSE DRUGS-MAN( ON GRID

-•b; - 1 L P. El Warmed

rag:511121111:5311:911MBIZSIERI ..° NM Code drugs with numbers,

WITH NUMBERS & ENTER IN REMARK

Tr 5 ❑ Warmed 1111111111111111111111111111111111111111111111111111M11101111111111

events with krttets

CI Warmed IIIIIIIOIIIIIINIIINIIIIIIIIIIIIIIIIIOIIIIMINIIIIINNINIIIIIIII

kTfib l'+' T-9-4k .

EST BLOOD LOSS

11111111111111111111111011111101111100111111111111111111111111111111111111 sx Aitel;e

11110

111111111011111011111011111111,11111111111111111111111111111111111111111 No'ne ,,,ast. pois,i-1

00 6;,...- st...,A-i-vucA, te!

m.tls,:..

..n :„.::..... 220

11111011 VISENIEMMISSIMMININSIMINNIMMINENNISIMINNIN 7_,..0,-6A- ;- 12.-. cr amoulaummiummommummil ei ; 0---- - 37. v-ii i ki

MI" BP by cuff

200

111111111111111111111111111111111111111111101111•111111111111111111111111111111111111111 WIENNUNIESIMERNIMINUMMEUESSIMIESSEINWENI mirk 1111111111111111111111N111111111111111111111111111111111111111111111111111111111111

r ‘3 T-',v1,9-f.. 1 elAttAcv14,..,, av-vo..

urnimg..... Heart rate

A 180

160

1111111511110110111111111111115ENINISSEINVENIESTIMMEINEINE i. v.-. .

-ItiTE-rT.

111111a111111M1111111111111111111111111111M111111101111111 ■11111111111111111110111111111111 ' 1...S? 71-4 3 PI AC

11111111SNIMINIMININGUSIONSMISMOSIONINEMNISSUMBIN iDE„,

C11111111111 Resp rate 140

INIMININIMENIVESIONIONINEMISSIVIUSESS

IillIMMINIIINIIIIIMIIII"IONIIMMINION11111011111111111114Z:(3

isionsmassamonsinessitassaganiestionmensumM

. •

IMINIIIIIMINIMIIIMII____...111.111111101111111111111INIMUMIMINII

4 80

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PROCEDURE? ANES- X-X 20

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r g T CO2 (torn 1111111111111•111111111111011■

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....,.F.F

111111111111111 111111111111111111111111•111111111111111111101111111111111111111111111111111

*11 omen

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RIM:MINI 11111111111111111111111111111111011111111111111111111111111111111111111111111

ing 13....

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gin

osblain under liE11.4ARKS

Position 1.-- J • I Wt E , e › ,...,..e ANESTH IC TECHNIQUES:

Describe block technique under Remarks

Ers 131S"

PROCEDURES and CPT Codes:

E. X le-f ; v,..

PATIENT IDENTIFICATION: Typed or Written entries: Name, Grade/Rate,

Medical facility b(6)-It

MEDICAL RECORD - ANESTHESI! ,r this form, see AR 40-66; the proponent agen.

IriM2311M1111111 3"-a RD

_ inOMeirmonommommonoloomotinsi

iremmilmilmmiammummoimmummemommoommos WNW

3551111111111111101111011EM 111111111111111111111111111111111111.1w. CRYSTALLOID-

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COLLOID-

BLOOD-

02 LiMin

e OTSG TOTALS

Merle with laws symbols, EV ENT S__,...

comments

AIRWAY MANAGEMENT: Intubation route, blade, technique,

-""

DATE:

/0-6 -c

DOD-034858

ACLU-RDI 1661 p.42

r ptp 9.1 PS it: 1-An, t-44 rA-4

Alla Av-fs_b <-7V I" • ,1"

..., .,.._ , - _ . " - MEDICAL RECORD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG e 2_

. _ SINGLE DOSE WITH NUMBERS

DRUG (Units) TOTALS TOTAL EBL

14 ("(

TOTAL URINE ( fed /57) ()

P • I) i I ( VOLAT AGENT

del (-OVA* (f__Y: r ) 1p ' FLUIDS - SUMMARY

% e.t. CRYSTALLOID-

AIR L/Min • et)

N20 L/Min COLLOID-

02 L/Min P,' maw DRUGS-MARK ON GRID ,‘

& ENTER IN REMARKS di

BLOOD-

LINE site 0 Warmed REMARKS

1$ ,- (A.itZ/ 57 ❑ Warmed Code drugs with numbers,

El Warmed events with !enters

❑ Warmed Sri -- /13 :a iatit

EST BLOOD LOSS 1./K aitchit

LOSSES UR NE el 441 - 0 z - inCA .

PHYS STATUS TIME +-0-0 0830 3 1 2 3 4 5 E

SYMBOLS:

Crcit To pOlet4

BODY WEIGHT: 220

(o g LB V BP by cuff

A

• Resp rate

BR (transduced)

J_ 1-

TOURNIQUET

T -41.

ANES- X- X PROC-10.0

' • 1--- 200

HEMATOCRIT: 180

Heart rate 3 (-)10 4/ INITIAL DATA:

160 • . .

BP -

19 St..-

140 rararg LIFKKIVATM

.

,

120 mom •

HR- ii._. .

100

EQUIP CHECK 80

OK?- Y N

RN • 60 ,111911ffin

PATIENT RECHECK

OK for PROCEDURE?

TIME-

ritaik mows J__J_. 40

■___ 2

-

VT - ml L(6-0 70 StO f - breaths/min 11 71-- 11

Peak W pres / PEEP _- ,.../ •.../-

JVIODE - SIpon), Issist), Clon) 5v' S1( RECOVERY AT 6i3,,c

7BP/Auto Cuff CO2 (torr) ii, GO SV

ti‘ F(.2.1 ICU Specify)

BPloth 02 (Frac or %) b -V' 0 •(Pg 0 -(Jss ART line

Steth- PC/ES

at OTHER

p02 1%)

CG tO0

li 11.. _5____

i 54._. CONDITION: talli-

Gas analyzer T P -site I Sl at

RESP - / Z. 402- (o-0

-M Block (T/4) BP- "R " lo

1 NESTHESIA I PROCEDURE TIMES

Start

C 719

Room

0757

End

61C(C% Warming blkt

Cony warmer Ready Begin End

Mark with letters & symbols, EVENTS_ explain under REMARKS Position — (:)...___J ,,,„3-op.0 65,5./

CPT PROCEDURES and CPT Codes:

D LFA kit .!„._ ANESTHETIC TECHNIQUES: Describe block technique under Remarks

64- - ii9KK-

AIRWAY MANAGEMENT: lnuibation route, blade, technique, comments

MoISIC F d? 04 PATIENT IDENTIFICATION: yped or written entries: Name, Grade/Rate,

Medical facility

1111.10111111111111 q.( a) —1 SURGEONS.

10 0-2 PROCEDURE LOCATION: ( -(

DATE:

S: V" D cr e3

epr cgAm PAGE ( OF

- .._ ._...—

'3 .-jr.g,

I^K 4 6

DA FORM 7389, FEB 1998

MEDCOM - 21

COPY 2 - AN

DOD-034859

ACLU-RDI 1661 p.43

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

AN

ES

TH

ETI

C A

GE

NT

S A

ND

DR

UGS

CO

NT

INU

OU

S/R

EPE

AT

ED

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UG

S S

PE

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/MC

G/M

L,

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AN

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NFU

SIO

N

DRUG (Units) i TOTALS TOTAL EBL

(

( TOTAL INE

( r

( ) ( )

VOLAT AGENT

% del k.5.-- \ ,S O -. • FLU DS - S

CRY ALLOID

MARY

'-a-Zi-lk e,t,

AIR L/Min

N20 L/Min CaLL,01Q.- Z.--5e-t_ (0_ BLOOD-

0 -1^■...Q___ 02 L/Min

SINGLE DOSE DRUGS-MARK ON GRID •..* WITH NUMBERS Si ENTER IN REMARKS Vel,

FLU

IDS

LINE site \s6F-FkL 0 Warmed 1 000 - % Li 00 REMARKS

❑ Warmed Code drugs with numbers, events with Mutters

(1-1k)S ,..:(.. ,It'; Or‘ecti ❑ Warmed

❑ Warmed

LOSSES EST BLOOD LOSS 0-0 —2-00 e:kcececl!■ r X S-C-) .Srt;, ow ‘''cilk>. URINE - 11S

JALYS STATUS TIME +36 u \ -Sc,) ■ _5 -- ,---- ..,..- (.:1 345 E

220

200

180

160

120

1 oo

80

60

40

20

_,_,___ • . ' ,_

BODY WEIGHT:

Kb

SYMBOLS:

V

Bp by cuff , '

HEMATOCRIT:

40 A

Heart rate , INITIAL DATA: • --,

,

BP - Resp rate 140

( 1 -2D / S 3 ,

: . '

HR - .---c.) BR (transduced)

1

' . ■ ' -,"-

.

: : . . • . , . .

EQUIP CHECK T ' 1" "--.--"-t". — . . . • OK?- Y N TOURNIQUET ' -L- -L-- I I : 1 ■ i

' ' w,,_ :

PATIENT CHECK T -..--r- A4\eN L ■ ∎ J_ _LI___1_ L __I_ 1 _I_

OK fo PR EDURET

ME-

ANES- X-X PROC- 8_0

, .

1 i 1 , -L--1- J J. ■ ,_--.1 . J. --r-,

J. -1-- -1-___I_ _I --1.

. , „ . . ,

VE

NT

IL VT - ml -Ito 7,40 3;6 Vtt:-)

f - breaths/min "6 k /a ‘ 2- l'C Peak inf pres / PEEP 2.-S- ---- --

MODE - Sfpon), A(ssist), C(on) C._ S --- RECOVERY AT

I MO

NIT

OR

S/A

CC

ES

SO

RIES

I

1,43/Auto Cuff ET CO2 (torr) 3 6 Li-Li 446 4 (D PACU ICU Specify)

BP/oth 02 (Floc or %) 0 .. 0 065 0 '' OTHER ART line p02 (%) \ Dt) koo toe, )6 0 COND

RESP -

BP-

N:

Sp02 -

HR-

Steth- PC/ES G Sr(- S‹ -3K --ra- Gas analyzer MP-site .5 3 5- _3_:s---_ ,.,-C-f

N IVI Block (T/4) ANEST TIMES

iESIA / PROC URE

Room End INV

Warming blkt

Cony warmer Begin End Mark with letters & syn bats, EVENTS, ,....., explain under REMARKS Position ' 1...."--/


0 f7. \E \-'c cersn ■-) r ANESTHETIC TECHNIQUES: Describe block technique under Remarks

Se..,e AIRWAY Mie . Intubation route, blade, technique, comments

0 Ir\-

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility

C-Z. \- 1

-2..-- 6 SURGE. k

AN 11,1b. ' C42..K1 I

PROCEDURE " LOCATION:

1..

DATE W / k3/06 T

PAGE ' 11, OF -a_

DA FOR DCO - HESIA PROVIDER

USAPA V 1.00

DOD-034860

ACLU-RDI 1661 p.44


DRUG (Units) L (0-7— TOTALS TOTAL EBL

S V Fle.r-,)ca. (14.a..)_ s-- . a. 5-0 200

TOTAL URINE

es-oeem- -, ii, 01 ( i^,-,A. ) \ .Z 5' \Z-•• 0 ..----- ?fcCe:)CcA ( ■,-:::' )

k S-0 • ( ( )

VOLAT AGENT T0

del \ .> I..5- 1.5- \ . 5- \. ---. I .c. \ ,-'t 13 \ ,._ $- \ .-s-- FLUIDS - SUMMARY U I- uj z

w z <

z ,-.. i --" --) % e.t. CRYSTALLOID-

\ S-bC- COLLOID

1- 21.- ,,,:.• AIR L/Min 0 (0 u N20 L/Min

02 L/Min (..c. — A- SINGLE DOSE DRUGS-MARK ON GRID

WITH NUMBERS & ENTER IN REMARKS OW C., BLOOD -

Per

2 LINE site k.Wg Lae Warmed L.-'4 it' .0._ -- OD • —1 0 0 17CCI - REMARKS 7 06 LA,,, El Warmed

['Warmed Code drugs with numbers, events with rattlers

e -k \3 Or-scsCV. ❑ Warmed

LOSSES EST BLOOD LOSS I'. N O '- ;•-•-1.,<cy•-*cs,'S

II S -- URINE - feA - e C:inc--

. 5- v-sm-k- Pio,v-■ 4 \-s. PHYS STATUS TIME . 3D ....... \\ ,— 30 3 6--E--.-c- A . ID 345 E SYMBOLS:

220

200

180

160

140

120

100

80

GO

40

2

. ' ' . . . i --c:c rcic, - .. 4 c,

BODY WEIGHT: , . :

. : 1'e.K. t 3C. c '''`" -3.1 , 1k.

LB

A Heart rate

• Resp rate

BR (transduced)

_I_ + TOURNIQUET

T —4/

ANES- X-X pRoc- 8_0

BP by cuff

. . .

, . , . -_c__ - -- , , ioN e IV 91,1.4 ' AM

GM,

HEMATOCRIT: , , ' , '

Li . . . , II II . .

INITIAL DATA: .-- . . . .

BP- . . . 9-2- -

\-\3 /C 3 ' i MEI .ffir

W lir \.." HR- 0 -.

_ EQUIP CK . ■ ■ .

.

010- Y N -J--1 . A A 1 1 -1_1_ 6\7

. , . PATIENT RE2E55,1(

OK for PROCEDUR

__., ...". TIME- 09 -e.,_.

-L-L- 1 1

, „ -1__J--

. . . , —, . , .

I: Z Ill >

Goo (493 -110 12.0 /...- VT - ml

-No 736 fr-

-14 o IO

-I be \O

---vio g

- is-0 S z_ 5-

930

1J-1

----v2c_

2-3

f - breaths/min \O \e. \O \0 10

Peak inf Pres / PEEP 2- ZZ ZZ Z3 2. 3 .-

2-3 C

z Li C

24 c

z..4 c )44gooE - S(pon), A(ssist), CIon) C._. C c C C._. C. C RECOVERY AT

w(I) cC 0 cri tn w (..) <

cc 0 I-

0

11-BP/Auto Cuff \--Ef

BP/oth '---F102

CO2 (torr)

(Frac or °A) 3S 0--5

34- 0 S

3 C•:S

\

0 37

o.c. 0-

. t

33 (2) 3 65S

1 0.15

3 ,-1

a :LZ -1

O. to

I U Specify)

,...., ,ACU

ID-b "- ART line -602 (%) \ DO Non 1,0c. \oct \DO \ c. 0 10c, \ 00 ‘pc, \ Go

sg.

1 00 OTHER Steth- PC/ES L.-ECG -52 -Sre., -Se_ 5 (Z_ -512Z ■ ,SX gg tc... CONDITION:

3.._ REV- spo2.9 cie: BP. \ 09 6 ZHR-

Gas analyzer t--TEMP-site IN 3 ..s - 3 5- .5'_ --r--, 3 5- _3_c_ -- N-M Block (T/41

5v • .4

91

ANESTHESIA / PROCEDURE 0, TIMES

A- - 2 Start Room End Warming blkt Z z

CY/ZS-Cs:V-5 ..--- ---

l3z-3 Cone warmer <

Ready Begin End .

Mark with letters & symbols, EVENTS_ (,) , t explain under REMARKS Position "" "‘..? -...1,0

„fr....n.9,10 vao ‘....31 5

0R\ .:-- L r if KU ii,:.

PR OCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Re narks Cs-E, -rA

AIRWAY MANAGEMENT: Intpbation route, blade, technique, comments ___ i , i...= e -. -k-gfEtA „,_,„ -, ,,,...... „_...4., .-E-.. ,....„-z-,.,,,,,3.. -5/°C- k.-3-e'Ea C, -4c<)1

St.er ‘s, \-Ice_ le, kciti....e.„ ct •S- -E-c -T: ) -3 ,-...--,c..--- z 3 <--k-----

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility

✓ (.6)--Lt 1\\ v'bil

,__ '-.3 :21 C_ \”, A-

0 re.c- I C OU k

SURGEONS: 6 -Z. 1

ANES

, CCU/ A

PROCEDURE LOCATION: DATE: /

kO/i/CD-3

PAGE OF -Tv r-% A CAnwn -,,nn ,,r's A e. ■ ••• ■-• warn!, /'

SIA.pROVIDER

245

USAPA V1.00

DOD-034861

ACLU-RDI 1661 p.45

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will

list the time the new orderts) are noted and initial in the column provided. Orders completed during the shift in which they were written do not

require recopying. They may be signed off, as completed, in the far right column.

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

ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS

POST ANESTHESIA ORDERS (circled Items)

VS q 5 min X 15 min, then q 15 min until discharge.

Supplemental oxygen.

/ Meperidine ..5- mg IV now and S—me q 3-5 min pm pain for a

max dose of to mg.

Zofran mg IV prn N/V q 15 min, may repeat x .

Metoclopramide mg IV prn N/V x 1.

Droperidol mg IV prn N/V x I.

Phenergan mg IV prn N/V x 1.

8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.

9 IVF: (...(L @ KVO cc/hr.

10 Discharge from recovery status when PACU discharge criteria met.

.. i 4 1 Ar

. 1.4

ro3 0F 2T--

‘0(6-2_

PATIENT IDENTIFICATION

6)1

• -

Complete the following information on page 1 only. Note any

changes on subsequent pages.

Diagnosis:

Height: . Weight: Diet:

Allergies: .

Nursin Unit Room No. Bed No. Page No.

1 of 1

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS WRE OBSOLETE MC V1.00

MEDCOM - 21286

DOD-034862

ACLU-RDI 1661 p.46

•

arasi, %TIENT IDENTIFICATION

4URSING UNIT


) A i Fpp.:in 4256

TIME OF ORDER

( 5le."

REPLACES EDITION 0 1 JO HIGH MAY BE USED.

MEDCOM - 21287

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

)OCTOR SHALL RECORDDATE, TIME AND SIGN E CH SET O D B YARROW TE F ORERS. IF

ARROW BE

PROBLEM ORIENTED MEDICAL RECORD

EM IS USED, WRITE POBLEM NUMBER IN COLUMN INDICA

LOW.

,) -.>

TIME OF ORDER HOURS NOTED AND

LIST TIME ORDER

SIGN ENT IDENTIFICATION DATE OF ORDER

DOD-034863

ACLU-RDI 1661 p.47

DATE OF ORDER TIME OF ORDER

fc() -a- X3 0

HOURS

C

-r co,ko

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT ROOM NO. BED NO.

iAtct AAL-c4-6 -6)


HOURS

(( f6 >

Ta-rCArtivt 0 cr

0 la



NURSING UNIT

NURSING UNIT

ROOM NO

ED NO.

ROOM NO. BED NO.


CO —( 2 - c..3 0 Ho RS

.LAn tIA bt TIME OF ORDER PATIENT IDENTIFICATION

HOURS


DA , FAC M„ 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY DE USED.

MEDCOM - 21288


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.

DOD-034864

ACLU-RDI 1661 p.48

TIME OF ORDER Alr DATE OF ORDER

HOURS

LIST TIME ORDER

NOTED AND SIGN

DATE OF ORDER TIME 0 PATIENT IDENTIFICATION RDER

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


HOURS



NURSING UNIT ROO NO. BED NO.

(A) 1/1 1 3M-4-- cd1-01-41 ATIENT IDENTIFICATION

DATE OF ORDER

DATE OF ORDER

TIME OF oRDE

HO URS

TIME OF ORDER

6/tt) HOURS

a )14 ilt^-44-4

114

NURSING UNIT

DA 1 APRRM

79 4256 F O REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 21289



DOD-034865

ACLU-RDI 1661 p.49

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -111EDICATION ) For use of this form, see AR 40407;

the proponent agency Is the Office of The Surgeon General. Alo. (Yl. . 2003

VERIFY BY INITIALING , ,-'." , INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK/ RECURRING ACTION, NURSE FREQUENCY, TIME

HR DATE COMPLETED

(p 49 0 7/ / 13 P-/ / A01 -) 1. # 1176 .171.M/ rkILIIIRI1001 Ell

lo n-n1115 , crtAA-c)fie4 N vVI3 u,t, -o- I 1 Jill #

(TB

siS

cP5

Le PeCOrd ot.0 cAyn a .1-1 5

r BIN in

ris il J e lictril&ct,c0- -

"M111-1 =MI 41 1 13111120111i ra. Ole IIIIII

r

.

.

kik.- ...;:fl'' .t r• Wrrnr&TRIMIEMENNIMI

SIM .ffl=rig intRIECIP -' ti. A ,S, go 'Id. / ... \ to 461WEZSti ESEM

A--Vo co\ -.l a a c di'\\--

00 II

MEM INE

emu PAM

ar

0

kilin--milim

ALLERGIES: OM YES I. NO PRIMA DIAGNOSIS: r x

-htt,t,rt\/ C P)H1 )(

ADDITIONAL PAGES IN USE: IIII NO YES MI

PAGE NO . PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15

V ( ()) — E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

USAPA V1.00

MEDCOM - 21290

DOD-034866

ACLU-RDI 1661 p.50

Verity by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo yr 2003

SINGLE ACTIONS Date to be Done

Time to be Done Time Done Initials

Order

Date Clerk Nurse

OtAAA/U4 tau-I c ix.c.

loci-

--iociiiis z7-A-2--t.

1111 op: -icycv Q KiPo 1-5- JV

i op • Ill■ \ C-\1\PV \ 7R)

CCI-Ca 11 rf,,1172 NPO ---F MN _ 12- oc-rao 'VP' a., P - rA X-Ar‘"- t i "1-- -k -- ,JaA_ ri, ! ),,z____ Ii h-2- , , PP/ ) io tvl 'X 'Von

.......

_

Order! Explr Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

— — — — — — — —

---- ----

MEDCOM 11 1 1 1

- 21291

DOD-034867

ACLU-RDI 1661 p.51

CLINICAL RECORD THERAPEUTIC DC FroAt mAjle tin.em 4P0i.-41e WON-MED/CAT/ON) T

Mop- Yr. 2003 is the Office of Summon General,

VERIFY BY INITL4LING -4,:.

the. pr oner,..%_acrn . ,„., :;.•,.,,i,,, .a.,,-Ate. R„I'..;:e.

The INITIAL PROPER COLUMN FOLLOWING EACH COMPLETTON

ORDER DATE

CLERK/ NURSE

RECURRING ACTIONS, FREQUENCY. TIME

HR DATE COMPLETED

I *Q4'.(11(N

, --, -...5, .4/27x)e- fr; ;WE

t/LA

/.//

•

7/25 A a O.

.

-..•

/#1 -

- - - -

I

• --- -2.- I

•

.

ALLERGIES: - YES MI NO

-

PRIMARY DIAGNOSIS: • . /-

1 DS i Z) 4-iri 1--__.) _-,,;,,_c_k__

ADDITIONAL PAGES IN USE: MI YES MN NO

PAGE NO:

PATIENT IDENTIFICATION-

- USE PENCIL.

\O (-))L- D 8 9 10

E 16 17 18

1 N 24 01 02

ACTION TIMES CIRCLE ACTION TIMES

11 12 13 14 15

19 20 21 22 23

03 04 05 06 07

DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED. 1.1SAPA V1.00

MEDCOM - 21292

DOD-034868

ACLU-RDI 1661 p.52

Time Done Initials

Verit f by Initialing

Order Clerk Date Nurse

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)

SINGLE ACTIONS I Mo e Yr 2003

Time to be Done

Date to be Done

/.o/

Order/ Emir Date

Clerk/ Nurse


INITIAL PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED

MEDCOM - 21293

USAPA V1.00

DOD-034869

ACLU-RDI 1661 p.53

PATIENT IDENTIFICATION:

DISPENSING TIMES

NCIL CIRCLE MED TI ES

ADDITIONAL PAGES IN USE Y ES p NO

PAGE NO.

CLINICAL RECORD THERAPEUTIC CARE PLAN (MEDICATIONS) For use of this form. see AR 40407; the proponent agency is the Office of The Surgeon General.

INITIAL

DATE DISPENSED

VERIFY BY INITIALING 11.1•■■■,.,"

PROPER COLUMN FOLLOWING EACH ADMINISTRATTO.N

() 11111- .Dw2N)SP12 ccJh c

7 QC

/1

ALLERGIES: ED YES D NO P RI DIAGNOSIS:

mo.LOyr.

)A 1FFOEZP79 4678

8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 21294

DOD-034870

ACLU-RDI 1661 p.54

- lA1OO4AlAl

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN {MEDICATIONS) Mo. Yr

Order Date

Clerk/ Nurse SINGLE LE ORDER, PRE-OPERATIVES Date to

be Given be Time to

Given Time Given Initials

I III a I

Order/ Expir Data

Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED

PeilMCVD i 50 ---75M0

t ki Ql- • r214 ►?-xea, p i 111 .1 ilk

II. :

? if lewn laz9n-

r12-N r1P

,.. _ %MR

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li ■

..... cca-tt .Q0 ci4-- • as II NMI

utoo Ka • i" If I , lout z er

41 ‘ \I

U.S. GPO: 1998-454-110/95216

DOD-034871

ACLU-RDI 1661 p.55

CLINICAL RECORD THERAPEUTIC DUttlEptlitsCfroIrON CCAIRIE4 imly (MEDICATIONS) the proponent agency Is the Office of The Surgeon General. mo. ibyr. 63

VERIFY BY

ORDER DATE

CLERK/ NURSE

INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

RECURRING MEDICATIONS, DOSE, FREQUENCY

_

HR DATE DISPENSED

i /A ivfr---„0/.2._see =)4

i ? lee k / I / i.,..-, 5-

/by3 p-i.„. /2) to Is= /

16

ii-- IR Le 6:46,,i / v 72,), /z) z —7---iii

ALLERGI Eft 0 YES El NO PRIMARY DI AGNOSISt ADDITIONAL PAGES IN USE:

Ll ( Die I Fr,L)p,_,_ O YES 0 NO

PAGE NO PATIENT IDENTIFICATION:

" DISPENSING TIMES

\0(.0-1-1 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 1 FEB 79

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 21296

DOD-034872

ACLU-RDI 1661 p.56


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) two. Yr. C.)

Order Date

Clerk/ Nurse SINGLE E ORDER, PRE-OPERATIVES

Initials Date to

be Given be Time to

Given Time Given

^)

_Z Oil)

Order/ Exult Do

Clerk/ Nurse

PRN MEDICATION. DOSE, FREQUENCY

-i- INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED /4) 43

....J.--e c---nie-aCe-'7/ // fe) ---ro,,.."tir-D

3,4z,Q3,,+ 04.

ce►-o )9.0 ,..-55z, t2023

I 4cogivai-lacr lio0W

/_Pg i /264E L -r,i /VP -17,-.1t45

,Nte oat v '1-445

400 /

_11) 3 1 14—) ed--)Pkfire-/--) 025;h6

Ire ..../ Ar AI ...•

7La.1.4 tel'

MEDCOM - 21297 U.S. GPO: 1996-454-110/95216

DOD-034873

ACLU-RDI 1661 p.57

Drains Hemova

NG JP

T-tube Foley

TLS

Airway Nasal Oral ETT

Trach

Other

REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: g oe.4---cr5 Time In: in 315 Allergies: /\./ KA Pre-op V/S:

Procedures:

•-eit 61 ( Pre Op M

Anesthesia Type (Circle)): ederrl iM•i final Epidural

IV Sedation Nerve Block

Colloid 49.° EBL

Histor

OR Intake: Crystalloid OR Output: UOP

Meds/Times:

3aty

Name —last, PATIENT'S IDENTIFICA I or typed or writ en entries give:

first, middle; grade; date; hospital or medical facility) ❑ RISTORYIPHYSICAL


• DIAGNOSTIC STUDIES

❑ TREATMENT

DA FORM 4700, MAY 78 Previous edition is obsolete

USAPPC 62.00 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

DEPARTMENT a VICFJCLINIC

(11L

ILoalmue on fever el DAT/

MEDCOM - 21298

DOD-034874

Pacu Intake

Time Solutio Amount ite • Int sed

(1)) —1 '

X-rays: . Labs:

Post-Anesthesia Recovery score

Criteria ADM 30' D/C Codes

Activity

(2) Moves 4 Extremities

(0) Moves 0 Extremities (I) Moves 2 Ex tremities

Z2---

AIRWAY

A= Asmlobwu BB -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 Ft = Rectal

LDS C = Cervical T =Thoracic L = Lumbar S = Sacral

-

Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing

0 ) APnea (0)

' Z. Blood Pressure (2) SBP =I- 20 of Pre-op (1) SBP =/- 2050 of Pre-op (0) SBP =/- 50 of Pre-op

Consciousness (2) Fully Awake, audible

c(1400 (1) Arousable to verbal or pain

1

Color (2) Baseline corer & appearance

(1) pale. mottle d. jaundiced-

(0) Cyanotic

V

_

Circulation (Peds c 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,

1 ( 71 '1/4,-,

V

•

0 Time

Sa02

F102

Methods

240

220

200

180

160

140

120

100

80

60

40

20

RR

T

Time Pain (0-10) LOS

PREP

❑ FLOW CHART

❑ OTHER apecifyl

\'t 1lc

Patien teaching done: Wound Care, Pain Management,

T, C, & DB.. Incentive Spirometer. Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA Fur use of this ton. see AR 4066: the proponent agency is the Office of The Surgeon General

OTSG APPROVED IDarel

ACLU-RDI 1661 p.58

Symptomatic? ca3t thm Strip Run? Time Rh thm

CARDIAC RHYTHM

PACU OUTPUT

Time

Source • Color/A. • , e

Amount

MEDICATIONS Allergies: Time

Pain

Medication & 1-in nnsane

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Adm Uttc 1, '/ 101,_ _ -17 *I P ic_. 15'

)

30'

45'

60'

90'

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*-----66: 90' D/C

Fund. Height .-------- Lochia ----------

Peripae/

Fund. Cond.

DRESSINGS

Time Location Type Drainage.

Adm 6): y:( KJ, 14-1-- ix Altn kviul ,

30'

60'

D/C

Route Uy

NURSING NOTES

L ALewhIti / 8-7],( Ty,/c

o(c1/1-1,g,t6

--6) cit-U zvovw

6(17, - dioz7 -?)ce,

Discharge Criteria: Date: g cit1V -jime: Vq16 PARS: BP: ! p jp 97 4' HR: RR: / 6 Pain Leve --AilD/C (0-10): Intake: 'ZOO Output: "iif) Additional Data: Transferred To: Report Given To: Transferred Via: Transferred By:

Cleared IAW Reco Charoe Nurse Signatur

WAMC OP 173-E MEDCOM - 21299

DOD-034875

ACLU-RDI 1661 p.59

3"-- 8 .0

[ Time Pain (0-10)

rar- /-

LOS

Name - last,

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 21300

❑ FLOW CHART

❑ OTHER ay.*/

Previous edition is obsolete LISAPIT 62.00

--1 !ties give:

list, middle; grade: date; hospital Of m iral hate er

DA FORM 4700, MAY 78

❑ HISTDRYIPHYSICAL



❑ TREATMENT

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use ol this form. see AR 40-66: the proponent agency is the Office ol The Surgeon General

DTSG APPROVED 10atel REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: (OCTI

Time In: )

Allergies: V_ Pre-op V/S: I 9 5-

Procedures:

Pre Op Med

Time

_8. tr F102

Methods

240

220

200

180

160

140

V

100 I

BO

A 60

40

20

RR

PREPARED B

Anesthesia Type enerif-Spinal Epidural IV Sedation Nerve lock

I S Colloid EBL -"YD

Histor

Sa02

120

OR Intake: Crystalloid OR Output: UOP

Meds/Times:

Drains Hemovac

NG JP

T-tube

TLS

Na Oral ETT

Trach

Other

ILantowe on lover

DATE

)C 1-3 (15

Pacu Intake

Time Solution Amount Site • By Infused

1,'n t.) l_4____, .iry_x_..) Vitib)k- Oa i WO

X-rays: . Labs:


Criteria ADM 30' DM Codes

Activity (2) Moves 4 Extremities

(1) Moves 2 Extremities (0) Moves 0 Extremities ?"--..

7 .

7— AIRWAY A = Ambu BB = Blow-by

FTIvi = =tvF kaacse Tent RA = RoomAlr 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

Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing

(0) Apnea

(___

Blood Pressure (2) SBP ,--/- 20 of Pre-op

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

(0) SBP =l- 50 of Pre-op

2

/ Z.--

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

-7—

Color 9) Baseline color EL appearance (t) pale, mottled. jaundiced (0) Cyanotic

/

-7_

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 O/C. otherwiseneeds anesthesia approval for

D/C, °

DEPARTMENMSERVICEICLINIC

I • •

Patient teaching done: Wound Care. Pain Managem nt. T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

DOD-034876

ACLU-RDI 1661 p.60

Range Of

Motion

Sensory P T Cap Refill

Color

MEDICATIONS Allergies: Time Pain

1-10 Dr Medication &

am Route Pain

1-10 I/E By

1,2JY5- ?iv 1( IP eL

1=1 ,mmisommis amil iiminumr.mmuminartmnrai Moveme /S .tion: + = present,- =absent Temp:C =Cool, W-Warm Pulses: P= Palpable, D =Doppler, A =Absent Color: C = Cyanotic,

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

C-SECTIONS

Adm

Fund. Height

Lochia

Time Rhythm Symptomatic? Rhythm Strip Run?

WAMC OP 173-E MEDCOM - 213

DRESSINGS Time r ocation Type Drainage

Adm ' Iffilliii MOND P %

EP 30' • 60' D/C

PACU OUTPUT

Color/Appeararce------ Time Source Amount

CARDIAC RHYTHM

45'

60' 90 .

D/C

Peripad4

FuriaCand.

15' 30' 45 60' D/C

Slifilini111111111111111MINMEIIIIIIMIN I di

L' J If ito 40 aialragarr masmearayars

PARS: q RR: ' Sa02:

IC/

6 -2__

Discharge Criteria: r Date: 1, C-4- Time: v BP: i'4.) T:q'/ HR:q Pain L Vel at D/C (0-10):

Intake:

Additional Data: Transferred To:

Report Given To:

Transferred Via:

Transferred By:

Cleared IAW Re rth.met Nurse Signature:

01

rney Ambulance

Output :

Time

Adm

15'

30'

NEUROVASCULAR

NURSING NOTES

12-1 ADD.-(i.4( ikaT)-vc Brut 14tOLD* Dor P1

TIMMIERMIM

DOD-034877

ACLU-RDI 1661 p.61

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19. CL

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(Please indicate

Yes or N

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n clinical issues. E

xplain YE

S

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X I

15a A

Clu

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15b.

AC

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DOD-034878

ACLU-RDI 1661 p.62

F3. Register Number I Name (Last, First, MI)

4 Pay Grade 5. Sex

FGN M

6. DoB (YYYYMMDD) 7. Ag at Admission

23Y

8. Race

X

9. Ethnicity

9

Religion

ISLAMIC

10. Length of Service

6 (0 1 11. FMP

99

13. Marital Status

12. Social Security Number

Hour of Admission

17:43

Branch / Corps: Organization (Active Duty Only)

14. Flying Status 15. Beneficiary

K78-PRISONER

Category

OF WAR/INTERNEES

19.

16. Zip Code of Residence:

17. Unit Location 18. MOS Trauma

BC

Prey. Admission

NO

20. Source of Admission Ward:

Direct from ER I ICVV1

Name / Relationship of Emergency Addressee

Address of Emergency Addressee

Name and Location of Medical Treatment Facility:

0580 - 28th CSH - Iraq; No Install Provided

Telephone Number of Emergency Addressee

21. Type of Disposition

TRF-C-ICU

22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)

2003-10-15

24. Clinic Svc - Admitting

AEA - ORTHOPEDICS

25. MTF Transferred From 26. Date this Admission (YYYYMMDD)

2003-10-06

27. Location of Occurrence

IZ

28. MTF of Initial Admission 29. Date of Initial Admission

2003-10-06

FOR LOCAL USE

Type Patient (Inpatient / Outpatient): Inpatient

Admission Diagnosis Narrative: L FEMUR FX WI EX

Procedure Narrative(s):

Cause of Injury Narrative:

FIX,

-7 : I Admitting Officer (Signature, as required) Si

Automated Facsimile - DA FORM 2985, MAR 2000

MEDCOM - 21303

DOD-034879

ACLU-RDI 1661 p.63

3. Register Number Name (Last, First, MI) 4. Pay Grade

FGN

5. Sex

I M

6. DoB (YYYYMMDD) 7. ge at Admission

23Y

8. Race

X

9. Ethnicity

9

Religion

ISLAMIC

10. Length of Service T \9(c).... 11. F MP

20


Organization (Active Duty Only) 13. Marital Status Hour of Admission

17:43

Branch / Corps:

14. Flying Status 15. Beneficiary Category

K78-PRISONER OF WAR/INTERNEES


17. Unit Location 18. MOS 19. Trauma

BC

Prey. Admission

NO


Direct from ER

Ward:

ICW1



Nam and Location of Medical Treatment Facility: Telephone Number of Emergency Addressee


TRF-C-ICU


2003-10-15


AEA - ORTHOPEDICS


2003-10-06

27. Location of Occurrence

IZ

28. MTF of Initial Admission 29. Date of Initial Admission

2003-10-06

FOR LOCAL USE


Admission Diagnosis Narrative: GSW L FEMUR, EX FIX, L FEMUR



Admitting Officer (Signature, as required Signature of Ad • •

Automated Facsimile - DA FORM 2985, MAR 2000

MEDCOM - 21304

DOD-034880

ACLU-RDI 1661 p.64

REGISTER NUMBER

NAME (Last, First, Middle 11

12. SOCIAL SECURITY NUMBER

11111,1111CMCNIEMICI

18. ZIP CODE OF RESIDENCE

©©E3©112® 11111111111111111111111111111111

53 60 61

111111:1111111113E113 11111111111111111111111 28. MTF OF INITIAL ADMISSION

•

6\

--1-41 ,s‘=rs.tA ..s— coef

Pr

ADMITTING OFFICER (Signature. as required) SIGNATURE OF ADMITTING CLERK

ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400; the proponent agency Is OTSG

I 8 (Stale or Country Code.)

A

4. PAY GRADE • R. SEX

16 17 18

DATE OF BIRTH (YYYYAIMDD) 19 20 21 22 23 24 25 26

10. LENGTH OF SERVICE ETS

Ella 34

7. AGE AT ADMISSION

11. FMP

3D

. RACE 9. ETHNIC

31 BACK- GROUND

RELIGION

45

HOUR OF

BRANCH/CORPS ADMISSION

1113 63

ORGANIZATION (Active Duty On!}) 13. MARITAL STATUS

46 I

15. BENEFICIARY CATEGORY 14. FLYING STATUS

50 11111131 11111•11 lfs. MOS

19. TRAUMA PREY ADMISSION

YEAR

49

17. UNIT LOCATION (State or. Country Code)

64 65 66 67 68 89 70 71 •

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD

72 I ADMISSION

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

ADDRESS DF EMERGENCY ADDRESSEE (Include ZIP Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

❑ 'NO • •

21. TYPE OF DISPOSITION

73

24. CLINIC SVC - ADMITTING 26. MIF TRANSFERRED FROM

113E1

27. LOCATION QF OCCURRENCE (Battle Casualty Only)

POR LOCAL USE

107 108 109 110

INIMIENEMEI 111111111M111111111111

22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYYYMAIDD)

11111311311:1121113111011E111

EINUMEIMI

80

29. DATE INMAL ADMISSION

12

(Y Y Y Y MUDD)

113111101E112111:11 0. ®®num

1111 3-- 28. DATE THIS ADMISSION (YYYYMMDD)

lala 100 101 102 103 104

0

O

105

O

106

DA FORM 2985, MAR 2000

EDITION OF MAR 89 IS OBSOLETE

USAPA v1.00

MEDCOM - 21305

DOD-034881

ACLU-RDI 1661 p.65

Automated Facsimile INPA IIENT TREATMENT RECORD eu .. _A SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

1. Re ister Nbr 3. Grade

2. Name 0 ...._ FGN

Admission Remarks

4. Sex M

5. Age 29Y

6. Race X

7. Religion ISLAMIC

8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP 99

12. S 13. Organization 14. Ward ICU2

15. FlyStatus 17. Dept / Ben

K78-PRISONER OF WAR/INTER

18. BranchCorps 19. UIC / ZIP

,

20. Type Case

DIS


Direct from ER

22. Hour Of Adm:

20:05

23. Clinic Service

ABA - GENERAL SURGERY

24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH

26. Date of Disp

2003-10-19

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:

2003-10-07

mitt ngOfficer:

q,)---__

29. Reportin MTF , -2-D ----R..- 2003-10-07

30. Date [nit Adm 32. Units Blood Components


Marital Status: Z DoB: NM In/Out Patient: Inpatient MOS:


34. Diagnosis / Operations and Special Procedures: ,F6 0,3- PENETRATING WOUND R BACK LIVER LAC, HEMO/PNEUMO & % /

g93• I 39/. 1 '7?-1

17s.9 -e- q9g

())- 2_ --/./, // 3 41, 4=11


Absent Sick Days

--40

Other Days

.0

ConLv / Coop Care Days

PX Supplemental Care

..0 Bed Days

) 3 Total Sick Days

/..:- 35. Total Days This Facility

Absent Sick Days Other Days oop Care Days

23-

Supplemental Care Bed Days Total Sick Days

.. .

DAVIS

cer • Signal

, .

3647, May 79 MEDCOM - 21306

DOD-034882

ACLU-RDI 1661 p.66

PERTINENT HISTORY, CHIEF COMPLAINT, AND CO

/I, 3 et

Ulek t 03,5

IDENTIFICATION NO.

Co T3 C- e21,5—: tot_ 4t.y Liesr

Cg- C-71—

114., SIGNA TUR

ORGANIZA ON

e Name last, first. middk: grade: dole: hospital or medical facility)

PATIENT' WARD NO. REGISTER NO.

PRO RES pier dute of dsci ml diagnosis)

MEDICAL RECORD

ABBREVIATED MEDICAL RECORD

PHYSICAL EXAMINATION %IC) 0 0 A- 0 . tree-Aft IP etIlL )44-1("4 01 < CL,V,yt,‘Pe-c_i ?

1251- 11-wtti.- (3 5 C— (A4a-P,L6 Grt—

ABBREVIATED MEDICAL RECORD Standard Form 539

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA 141 CFR) 20145.505 OCTOBER 1975 'ARK VI 00

MEDCOM - 21307

DOD-034883

ACLU-RDI 1661 p.67

MEDCOM - 21308

STANDAR • FORM 509 (REV. 5/1999) BACK USAPA V1.00

LAST NAME

DOD-034884

ACLU-RDI 1661 p.68

'MEDICAL RECORD PROGRESS NOTES


DEPARTJSERVICE

HOSPITAL OR MEDICAL FACT

PATIENT'S IDENTIFICATIOk /For twee/ wino Nd TX lime • last 674 Diddle;

No or at Sex; Date of BirthillaniSrade

1111111 6(9 4{)---2 WARD HO.


STANDARD FORM 509 IREV. 511998) Prescribed by GSAI1CUR FPMR 141Ciii1 101-11.203IbIDOI

USAPAVI.00

MEDCOM - 21309

• lids f 1.1


DOD-034885

ACLU-RDI 1661 p.69

MIDDLE INITIAL

17> rill MEDCOM - 21310

DOD-034886

ACLU-RDI 1661 p.70

MEDICAL RECORD PROGRESS NOTES



DEPART./SERVICE

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




USAPA V1.00

MEDCOM - 21311

DOD-034887

ACLU-RDI 1661 p.71

'ATIENT'S IDENTIFICATION: Fat typed smitten rank i/VC &Mt • fist middy

/0 No At SW; Sax Ibis of Ilia liontRIPiel


STANDARD FORM 509 IREV. 6/ Fhendbed by MARCIA FPMR

141CF10 101.1120.'

MEDICAL RECORD

PROGRESS NOTES



Use

MEDCOM - 21312

DOD-034888

ACLU-RDI 1661 p.72

.AST NAME ID NUMBER

FIRST NAME I MIDDLE INITIAL

DATE NOTES

XcOc ..71-- icitY) la,e,ee,vecd co) apt

MiliffifF1 pi/ AIM: At witawa„yv

As" ,A0

/Tie. ww," 17) 1/14(0/491 pc. cR011 6

01 00

At

) 46.A Pre) 561/1110M

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AHNIMMEMMI vaV v(s r. ► PAD (AliAsId I, -6

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-1e_. recitAia..R . k1.. I S 11N-RO■1 1/ •;rw

limmkilA 4!■.01■4

FAINON-41WalaraPIEM

Ord

11.

AAA.

0

STANDARD FORM 509 91EV.5119991BACK USAPA VI.00

MEDCOM - 21313

DOD-034889

ACLU-RDI 1661 p.73

%Z: / .fir!/

' MEDICAL RECORD PROGRESS NOTES


NOTES

ligehi , 400M,

RELATIONSHIP TO SPO

SPONSOR'S NAME

DEPARTAERVICE

HOSPITAL DR MEDICAL FACILITY

PATIENT'S IDENTIFICATION: for typed or wino ettlie4 &Me • kl4 frg, • ID No arSSN; Sex. Bete of ElitIc Rank/5We


PROGRESS NOTES Merkel Record

STANDARD FORM 509 PREV. mown PuescHlral by GSARCMR FPMR (41CFRI 101•1.203I141101

USAPA PLOD

MEDCOM - 21314

AZA

RESISTER NO.

DOD-034890

ACLU-RDI 1661 p.74

MIDDLE INITIAL FIRST NAME

CGLS Afc) kit,aftd./4?t0561-,4 6/- -Xaplai071-: *Id

-247(a)74g4-,i2/,avA

(%V0>;t7

• Aei `/2y 0a/5- 7 5-e-ce/ie‘K

4(ky #746571

41 //ea' aftvailc= fie2Aade, 1/'

SA9(0 772' ffit

(16177- g)K /i- 1/4 V?

4116 1/1/A- M ) 44111V STANDARD FOR BACK

MEDCOM - 21315 &SAP* V1 .01)

DOD-034891

ACLU-RDI 1661 p.75

'MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION

PROGRESS NOTES

AIR A. rammomms I ...,Ali 0 / Apitedritarririlo numALLi.it_• ell. _...A ♦ ,A161■

SAL._., P -t • al a . tit IIMI1 4 a .,

Al-di

ilk AI / .A.1 41 4 ■•

A la AL A t. .4A 0, • iLt._ • AL Its yl ze b Le 1, _ Ai& ' A A.4 ..'

-. A. _ li J at I I I ' / Mu" ...tc,Ail A 41 _A hilltritat I a kW iz t IL % .4111111 I A 11.. yi 10.34, --A 0 ' 1 efilimit i Ifi. if

oq


DEPAITUSERVICE

WARD NEL

PATIENT'S IDENTIFICATION (For typo/ or mitten wan Ow boo -Int first siger* ID No or SSN; Sac Date of Bind; lisokSnolol


STANDARD FORM 509 (REV. 5/1009I PrescnIed by GSARCMR FPMR 141CFRI 101-11.203(b1110/

USAPA VI.00

MEDCOM - 21316

DOD-034892

ACLU-RDI 1661 p.76

CIRAMb RM 509 nv. 5119991 BACK

USAP A VI -00 MEDCOM - 21317

DOD-034893

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

FA A no__ c 6-0 . I 0

t „ AA lir - 5 3

II t5e_d7- 953

r‘714114-z) 7":". ---orzk-et L 5 c.:1-A. Ts /c--bc Azky, 4e a 0 C r

br?5,, ® t_ caT f .orm>. (094,. Pro ASS c me,: K. .3c0 .

ea *

cc.c.X V A,,, s r 2.0.441. C 2_00

ay-

ACLU-RDI 1661 p.77




DEPART./SERVICE

ATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - lest, first, middle;

ID No or SS/V; Sex; Date of Birth; Rank/Grade)

AIM '1±

WARD NO.

Ic_\O-j{ 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 - 21318

DOD-034894

ACLU-RDI 1661 p.78

*)- LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

1 q sadf-0 t CL-Glit (0/UUNI)-- CO /29 '- ibtL e.f_ 1100 0 /6 10_, __ /A z.t;eL ---( cei-,__. oz/c i.e,t0-14,0,,63 C

'a/`-(----- A-A-<; er-1 0 tki: +ii-t---iz -1, Willi A Cd

Ofr-s)2aC ikl--0--Q 42.-cd___ .1 .- --,--c.-_ fk 94/1't-tf1^-QQ1 All-. ,C2frli

a0 1

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p----C - '-- -- -g2■ to r; li,7,..4-,f e.,- L IT-N 20,Dcd A 011T- - --' !--(-Q t ^4c-c_,

e C.:7 ' A . Aa . _.,.. __, _, _ , Adr . A..... 11CX T6 Calki/UWILI WS 61(39 . o (121,t-c46 4-k_ pl. Ci(tc Ofr iv CO l ■ P P

a/22g (it eiA, r t D ' / ' L) a k A 1 A b t ) 5 4 L96C1-(A 1 S.--PAA-C 6 2 - Lia(C.° 1 , cluLZ C2 cksAr &D 1 - Li Oa() W.t9 - 1

I

/ 1,D- r-eldi9 keA-]-40 rir-eL 14Louba2 6CGS-i)1 1 C9 &S, us- ort,o-uu_62_,, -71D ttiA. f Ar i1) 6 (+Vinci --Lb-bse 191,4 -Q ,

cuuA c,ca jvica

1 4-12P Vb-4-u, 046 I_A2. .0. ce_4° -177 CO)FA \ V.

RaitA 1 vuirtiuuttm A.tap ,:dtatzA2 ) ,f-- . +n,t/, owA 1 4) )1,0 c(rkt tn/ikuvuu+ift. Jo (A # . 094_ s

,;,r___titit (cm_wIct UtiviipliryvH,Lk. ----11111111K Isoc-i--b-- - cT oufp-u- apput ca0c-r)046.7RAM50-vAA-zit 4,6A

C__111) ■_}A-ertra tZt Led-f- _9-1-9, ,I,✓i,ci yvur v v , t a L --).

-- \

MEDCOM - 21319

STANDARD FORM 509 (REV. 5/1 9) BACK U PA V5.00

C

DOD-034895

ACLU-RDI 1661 p.79

MEDICAL RECORD

.ler4.11,24. 1111 1 /bre.

PROGRESS NOTES AUTHORIZED FOR LOCAL REPRODUCTION

DATE

to

/ V •

(MI a L

t.

.41,1111"' __IL

J . ...API

./ .0 • _A -70

-Air(

■••••• f/

tri

/rte atitrO,

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. / itIP CAL.... ■!, rrof.1..4 :mom- OA- _111S&; ■'/OU, / t Aid

z.6

I I I I I I I II I LI min in • • I I I I I I I I I I I I I I I I 11111:11. • • • • • • • •

RELATIONSHIP TO SPONSOR laiminSPONiikSO'IMINIMMinedk


NS ID NUMBER r Other(




STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10) USAPA V1.00

4

DEPART./SERVICE

•

(Zoo cc. Sec

4

4

•

3 s 26

• — et- • 678,

ATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - /ast, first, middle; ID No or SSIV• Sex; Date of Birth; Rank/Gradel

MEDCOM - 21320

DOD-034896

ACLU-RDI 1661 p.80


DATE NOTES

15 Oet 2- @ 2-M G:" VSS, 00;6 p cuAk, -6-2 ,12viyeAd ---1-7w A---ro X, 3 eAk.e4ti--7),196, ,)\,\,-fetpA - ----2 IVW411-1 orYt 7 -1 Lc 10. 1 CEJ C. 0\fiA C -C,(- c.D ) 0 otrAiimige_ O 7)K---0- ctiouyvy-c -i-P ) -I-ko 5a.c e (2.5-c_e_ L 44--4• -7 (q4-011:1 ;1141-)4:f f N

r

1 .. A_ A • -fro r-- IdweA__., tb-b 0-2 ,Ws(6) .61 - i/1 v-& ( 9s (-Le4-p (chem-). (V (.}eivefrukoLQ___. --t7, ( F-A---. c144,✓ ),/q 1_2_02,061 mID K etit , t(evA ► --1-6 modeyyta/K_(6))1, j Oasx/c--`' a #. • ,p, ,e_. ,mt..,

- ccaulcicAtst tgiccd2cieriii

Pi- ( 4,-kic.,c e_.p.„.s--1- s...c.„,, ' fweib NiAmii-W__

lock--r‘9__S i.z-.D..__Amci e_o,rt. Oc Pt @, ot-)00 .

/.23 * e, ,:,,,Iii q i',-,e,rip;r-, __cv-k, Di--- 9 c_ar - e.-7-- --> 11, 10 --,vvi , -;Ni--ctvl‘r, LS L D,",e j . (7,_ (DL

t AI _4■40, , , ( -1- 'v.:, al , _.411 . 1,7, i-v-)0,11-kr, . G q9i,Jr4

I (cc -V3 (.1(AAtaimA (LW Ob r- PJKDD V5s . -- r to w 0 actui G- 02- 02a) Mat t Si2C afrafxi c . C5C -b vucutQA scaQ

0 ts_a, vol-W cii9-- Col . cA-4-c_ctruistto pi -- -(ct-(0.< -4(-60 AtOutke_dit--6 ' 0 % P LS UP II DE \I/ _ t s eAA_cfniurcc__ r 0 24 1 aiwo u(A uuut LU d, i ailAs-i4-1- . I V ()iyo- . —p-C d.(127(-

WicAti W\ P 04p- /A,tniuctgu/Lag • ,ut,tk.A. yam/Lb:6-1 OT s e " 1 0


MEDCOM - 21321

DOD-034897

ACLU-RDI 1661 p.81


DEPART./SERVICE

bz t.,712 ,e_o'

417

z (2_2 tie-4174) --

Pe 5-S

I a, .e7

se/

ac. (./

e_d cr

e"k"

CerZ.La

Jr.

61-2_

Jolla./ MO 4141

(33 " -› ce-rkt-ej 3 0707) O t rwtp - Li;

cl -tug

latir) qac qb-q8 VDC01

:§ 0U/14-Ma-Ka-nA,Vitaft_

UiLlitat

YV1 (14,a(11 J.i/t 1-11-EACLIAJ aryl

'cLiSt 719-1V0.

a

/Ufa Rc-hie 65 us-v.:„..? Cx-2 e 6e•5-id

ire ae.5,14

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


WARD NO.



USAPA V1.00

MEDCOM - 21322

u✓-t 615.

Cecrce-eq, NUMBER

(SSN or rl

- • -

el3,- it

MEDICAL RECORD

DATE PROGRESS NOTES


NOTES

(7 oz-f- e S c "IA e...z)

/oz) E-t.)

k./ .3C-- 3 t).s.S (du

DOD-034898

ACLU-RDI 1661 p.82


DATE NOTES VC)-z— I RCTTO3 -- LA-- 6 t Com) ■ c_cie-c_ a, oh, e ,c4--,,S(1)\r- .

LS cAl---TI (VW- fyf 60CTC:c3 CIAAUillt_a_COAS. % pi-g-: (SW- VZ V. -1/Lo Go . ®°345 .a;ttA q-1 .-q610 n/t. 0_4,. Pi tA4 9 ci-ua- ; 6)6K, vo 0 po RA.Ciko4 . P-i- t ant-6 toDlc_, Aimmte,t. CLULZ diticiTht C) 1 0- CD) PtCuic- 4,titc- clAitub tivifyiAiry JO1 ettaii. • Jp- /awl& Avs so( A . (AA. ta,

mywrzyyta, Au 2.00-61,

(t) -


MEDCOM - 21323

DOD-034899

ACLU-RDI 1661 p.83

HOME PHONE

NO

EMERGENCY ROOM VISIT

24 HOUR RETURN

YES

\9(

MEDICAL RECORD

STREET STREET ADDRESS

CITY

SEX

AREA CODE

EMERGENCY CARE AND TREATMENT

(Patient)

PATIENT'S HOME ADDRESS OR DUTY STATION

LOG NUMBER TREATMENT FACILITY


TRANSPORTATION TO FACILITY

NSN 7540.01-0753786

ZIP CODE

ARRIVAL

TIME

cPel

MEDICAL HISTORY OBTAINED FROM

THIRD PARTY INSURANCE

ADDITIONAL INSURANCE

1111

1111

AGE

CURRENT MEDICATIONS

DO 2568 IN CHART

NAME OF INSURANCE COMPANY

ND

INJURY OR OCCUPATIONAL ILLNESS

MO

t‘i P71-7

TETANUS

COMPLETED INTITIAL SERIES

0 YES 0 NO

DATE LAST VISIT

ALLERGIES INJURY/SAFETY FORMS

DUTYKOCAL PHONE

AREA CODE

DATE LAST SHOT

CHIEF COMPLAINT

5_0 CATEGORY OF TREATMENT

• DISPOSITION

HOME

❑ EMERGENT

❑ URGENT

❑ NON•URGENT

BLOOD C&S X

II RE

1111..______101111111111/1211111111 1111=31111111 — cxnuagaminnit CBCIDIFF

EME116,11111M11111111111arallftimil IMEMIBMIIIIilid11111111.121111ningmml MINIM IIMS1211 E311111111111

13131111111111WAT64111111 1111111111111111111WATCHWIP"

BHCGIURINEIBLOOLVOUANT

ACUTE ABDOMEN

11111....„=„„mmill IN II

me CXR PA & LATIPORTABLE

VITAL SIGNS

C-SPINE

LS SPINE

HEAD CT

PATIENT'S RESPONSE

MODIFIED DUTY UNTIL

DISPOSITION OUARTERS /OFF DUTY

24 HRS. 48 HRS. 78 HRS. RETURN TO DUTY

FULL DUTY

CONDITION UPON RELEASE

IMPROVED

0 DETERIORATED


ADMIT TO UNIT/SERVICE

TIME OF RELEASE

Fa' Wady, *We: entdec give: Name - kst last, nil,14. 1171m ISSN," ohat hospital or meat/ /wiry,

REFERRED 110. I have received and understand these Instructions. PATIENT'S SIGNATURE

0 UNCHANGED WHEN

• PULSE OX ORDERS

MONITOR

COMPLETED BY

TIME ORDERS

CC

CC 1=1

CO .4C

PATIENTIDISCHARGE INSTRUCTIONS

ECG

\4) EMERGENCY CARE AND TREATMENT

/Patient/ Medical Record

STANDARD FORM 558 REV. 9.96I Presobed by GSAIICMA FPMR 141 CFRI 101•11.2031b1110/ USAPA V1.00

MEDCOM - 21324

DOD-034900

ACLU-RDI 1661 p.84

DENT SIGNATURE AND STAMP RESIOENTIM DI

PROVI

DIAGNOSIS

c :zz c11,9,

PATIENT'S IDENTIFICATION "Er typed o mite, elides gierNims - last first middl• na asN a °Med; hospital or malcal faatyl - -

NSN 7540-01.075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

CA

BHCG

too

Lt EKG INTERPRETATION

RESULTS

RADIOLOGY

cs

WBC

1

HMI

PL

4 PT

APTT

1L( SUP 02

PCO2

DIP

MICRO

ABGIPULSE OX

PH

P02

SAT

Chock if read by radiologist

ETOH

GLU

OTHER

d'RDIVIDER H170nRYIPHYg 2c4s 115 vc) ockilst- 2065

gtood anest- 2-43D 2i os NelTabe -Com 1 corrkyost- 2.11p cr. yam. 0:6 pc) \ --huot_A 2C60 (DT,v. Aty,-!A

Oz \Di_ 0314 reor-ccxhef__ L., a\ t. °"`f4

Fot-E1 CaThek-C- 2_0: ;(!),,\,,i,_,A

Bi taieraA IU b_gec, P*41. ;_ 13,414,w

■ epcqg (---)c tr,„!4.-AA c.--:: rAsT ?A/a t

,Q,,,k- 30 1/e)- -a-stcirk\ ke,elj -

c_k„\-1-Jvz r tc_qAA 3 Fr -L10,,

20-6

2°62 511 orwc.) 2c6ATnei

CONSULT WITH

TIME

ACTION

O O L.)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 IREV. 9.961 Prescrired by GSARCMR FPMR 141 CFR) 101-11.2030001 USAPA V1.00

MEDCOM - 21325

DOD-034901

ACLU-RDI 1661 p.85

C..f

Implants: Medications:

Pt. verbalizes any specific anxiety.

/ Pt. exhibits relaxed body posture.

MEDICAL RECORD

1. AGE: 30

HEIGHT:

WEIGHT:

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon

General.

2. KNOW

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

0/+- 3. PREVIOUS SRGERY [ NO

YES (type):

4. PROPOSED SURGICAL PROCEDURE:

skf? 5. ADDITIONAL

Jewelry removed:

Lips 0 C RMATION: L st PO: 114.w Medical flx: no Family waiting: yes/

7. PATIENT GOALS AND EXPECTED OUTCOMES

PT. will be able to breathe without ifficulty during immediate intra-

operative phase.

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

9. PATIENT'S IDENTIFICATION (For typed or written entries

give: Name- last, first, middle; grade: date; hospital or medical facility)

6. PATIENT PROBLEMS AND NEEDS

A. PSYPHOSOCIAL

Potential for anxiety

related to traumatic injury; language barrier; family

separation; surgical environment

B. A,EVATION V Potential for

respiratory dysfunction due to sedation; ositioning; inju

C. INTEGUMENT

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

8. OR NURSING INTERVENTIONS

Allow pt. to verbalize elY

x. plain OR environment and answer questions regarding surgery.

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

Explain all nursing procedures before they are done.

Remain with pt. whenever possible.

Maintain family interface.

Offer to elevate head of litter or offer pillow.

Observe pt. while awaiting surgery for signs of distress

Assist anesthesia during intubation and extubation

0/ Utilize pressure preventing -ffevices on OR table and accessories.

Check for proper positioning and support to maintain good body alignment.

Pad pressure points.

Place ESU ground pad on non compromised skin surface ar a.

Keep prep fluids from pooling.

DA FORM 5179, JUN 91 Previoius editions are obsolete.

USAPA VI.01

MEDCOM - 21326

DOD-034902

ACLU-RDI 1661 p.86

D. C\ ITULATION

Potential for inade-

quate tissue perfusion due to anesthesia; traumatic injury; position; shock; previous surgery

DATE

10. 0 SING INTERVENTIONSCOMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.

0C-41)3

11. POST

0437_

a-ov-Lk ,-„7foz.

12. P RT (Sig

DATE: A TIME:

eE RED

c-,1>1 33

13. BY

DATE: 0 TIME: 0 053

REVERSE OF DA FORM 5179, JUN 91

MEDCOM - 21327 USAPA V1.01

PREPARED

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

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

,6 Check that safety straps are correctly applied.

/0 Offer pillow for under knees.

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

o Place and take down legs from s •rrups with slow bilateral motion.

Check that rings have been removed.

1/ R L

E. NEUIMUSCULAR CONT E.1. Potential impairment

of mobility due to sedation; pain; injury 1 E.2. V Potential discomfort

due to injury; pain

F. NEUROMUSCULAR CONT L

F.1. Disminished visual

perception due to being injury: sedatio ;

F 2 Potential for decreased communictaion due to language harrier; sedation

F.3. Potential injury due to dentures.

Pt. will be transferred to OR table without difficulty.

i

tPt. will not experience unnecessary

hysical discomfort.

Pt. will be made aware of urroundings prior to anesthesia

induction. / Pt. will be transferred safely to OR

Xble. Pt. will be able to understand

instructions.

Minimize danger of injury during intraop period.

Have sufficient people 'pvailable for transfer. /0 Insure proper body .Ffignment.

to Allow patient to lie in position of comfort while

iting for surgery. Offer support (i.e., pillows,

bathtowels, etc.) for positioning.

Introduce self. Keep pt. informed as to where he/she is a what is happening.

Inform pt. in which direction to move and assist if necessary.

Speak clearly and slowly. Addresys_pt. from

-e1+1A-1-- side.

/ Validate pt.'s understanding of verbal communications.

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.

DOD-034903

ACLU-RDI 1661 p.87

vn I CU I U OPERATING

BY

TIME PATIENT ARRIVED IN

acre Mrl ■u-407, the propd ncy is the office of The Surgeon General.

VIA

❑ CALM

COMMENTS: NXIOUS ❑ EXCITED 0 CRYING

t 4. PATIENZI RO

TIME , 3 5. PREOPERATIVE EMOTIONAL STATUS

2. PATIENT IDENT

VERIFIED BY PROCED

B. NURSING PERSONNEL

ASSIGNED CIRCULATOR

ASSIGNED SCRUB

COMMENTS:

HAIR REMOVAL

DONE BY:

METHOD:

RELIEF

7. POSITIONAND POSITIONAL AIDS(Specify)

• SUPINE 0 LITHOTOMY

❑ PRONE ❑ KRASKE COMMS TS: '

LATERAL: 0 LEFT SIDE UP

0 RIGHT SIDE UP

c3,k_ p -14-43(e_ _YES ❑ NO

OR

DEPILATORY CLIP

❑ NURSING UNIT

RAZOR....:' BY WHOM:

BY WHOM:

LEGEND X Gro

C = Correct I = Incorrect

=First Closing- Final Closing

MUNIAZ3111M111.21/110

1

Count .COUnt Needle Sharp o' CIR ULATO

-1111 f2M11127111ra1111MHT______MINEE Instrument

EM111710115i11..__BermImAti .411101IL Other 1142:31111V211111 11mimilMip p Name - Last,

first, middle; Grade; Date; Hospita/ or Medical Facility;)

11. PATIENT IDENTIFICATION

(For typed or written ent s give: 12. ;ELECTROSURGERY DEVICE(S) (ESU)

-- Safe

10. COUNTS

Sponge

A FORM 5 179-1, OCT 87

SU NO:

GROUND PAD: BRAND

LOT NO: .113,0 NO

-'..GROUND PAD: BRAND

LOT NO ❑ BIPOLAR NO:

REPLACES

DA FORM 5179.1 (TEST), DEC 82. WHICH IS OBSOLETE.

USAPA V1.00

MEDCOM - 21328

DOD-034904

ACLU-RDI 1661 p.88

13. PROSTHESIS, IMPLANTS U Y

Zx

,. IRRIGATION/MEDICATIONS GIVEN

MEDICATIONS/SOLUTION

jjtu

IN OPERATING. ROOM

DOSAGE

MEDICATIONS/ORDERS

it YES NAME'

..............._

(NOT_ BY ANESTHESIA)

TIME •

INVIVIL., ... , ,..1

&

METHOD

fl...I • Vt•I..1 •

YES III PREPARED BY

.:., ..„

N.•

GIVEN BY

...... ..,. ..-., . .

. , ...---,— , .,

- ...

2

MOUND

IRRIGATION r......„(l

ES II NO, TYPE(S):

9

0 • .-t'› ki (_ C. 1 . _ •

,-

THER ORDERS TIME CARRIED OUT BY

■ dr'

PHYSICIAN'S SIGNATURE ✓ -- P 49f,

t.0 ,...:4 - .63,,,,,,MMS reate,,,,,,,,,,,,,

-

15. X-RAY IN OPERATIWOM

YES ■ NO !i

IF YES, SITE

16. - ' ' :-.'._'.LABORATORY SPECIMENS

SPECIMEN IS)

YES ■ NO

... NAME - ------ ---- ------- -

_ -. NAME

FROZEN SECTION (FS)

YES II NO

NAME ---_; NAME

CULTURE (C)

YES ■ NO

NAME -

NAME

NAME , .

NAME NAME

NAME NAME - - - 18. DRESSING/IMMOBILIZAN (Specify) W

Pe' ( _•019

I -,,fiC e..y,

t*Li364-4\a" C 2Y L i,--pri

17. TUBES, DRAINS/PACKING YES NO 111- •

TYPE/SIZE

c Ar 1,11_

i .vd,,2)

2. -:::: - -- •- • „_..:

SITE cA,i ‘„( 2. 3.

19. ADDITIONAL I RMATION

_-: -- ----------

20. OP MED

.

e'c'5' L--"-P ..,_ . -

21. PATIENT TRANSFERRED TO TIME 2..-, ME OD ..--- az),,,......•

_ -4 C.) _ A:= 22. RE

REVERSE USAPA V1.00

MEDCOM - 21329

wrn KI KAr ma IRAQ r

DOD-034905

ACLU-RDI 1661 p.89

11-J

Er-3 1 <

0

cD

3

r >

m

ii

<74 iP !

>

1 °

I I

m(I)

1111 1 1 I I 111111. II I I I i 11111111 I I MIL, 1 11111 III 11111111111111 IMRE I "II mon iminimmemmonmenmo

imummunmom 1 in11111111111111 1111111111•111111 MOM I

111111 I I III 11111111111

11111111111111111111 11111111111111111111111111111 11111111111111141

UMW 1

IN as

g „

111_1/1 -.4 MEDCOM - 21330

--r r-

cj

ACLU-RDI 1661 p.90

DOD-034907

ACLU-RDI 1661 p.91

MEDCOM - 21332

DOD-034908

ACLU-RDI 1661 p.92

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY

(4)* MONTH-YEAR DAY !Co-̀t- I7 1 -7 /

19 HOUR tik - • 040 pco pot :so ? 0 0 t 2, : Olcv

.

" 4 • • • •

I

_

-I

CO

CO

CO

)W

CC

O CO

03 C

O co

.

rz. .

D. m

(.7

1 e

l c3

a)

-4

-4 -4

03

C

O C

O P

o E

O

i:r) i- -.

1 b iv

bo 6.

) (o

*.rz

. o

b)

:0

0 0 0 0

0

0 0

0 0 0

0

0 o

(Centi

gra

de

Eq

uiv

ale

nts

, fo

r R

efe

rence o

nly

)

PULSE TEMP.(0)

TEM F (*) 105°

180 104°

170 103°

160 102°

150 101°

140 100°

130 98.6°

120 98°

110 97°

100 96°

80

70

60

50

40

RESPIRATION RECORD

. . ' '

. . .

• • • • : : Z- 6.

, , . . . . ••

• - • • . .

..

.. : : : : t. : : :

•

• • •

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, ,

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• •

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• •

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. .

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. .

. .

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. .

. . • • • •

. . .

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. .

• •

. .

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• •

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••

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. .

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"

. :

.. ..

......

. . • .

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. . - • . .

. . • • . .

. . . • . .

.

. .

. .

. .

. .

: :

......

.... •

. .

. . .

. . . • • . .

. . . .

. . . .

.

. . • • . .

. .

. .

•

• '

:

•

: : : .. I! • . „ • ” .

" • ' " • '

•

• • •

.

: •

. .

..

..

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4

' . . . . . . e• • •

•

• "

•

• •

•

:0•:

. .

• :

. .

•

•

•

•

• • • • . V

. .

. .

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. . • • . .

. . • • . .

•

• • • . .

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. . . .

. . . .

I

. .

....

.... .

.

. • .

. .

. . " . .

. .

. . • • . .

• 11111.111

• • . . .... .

• . •

. . • • . . • •

•••• Milli= . I 1111111.11 1

•

• •

• • . . "

.

. • . . . . • •

•

• • •

. .

. .

. . ' • ' • . .

: . •

. •

•

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'4- • •

-"<

r•

.

• • . .

.

- • • • • • • • . . - • . . • • . .

. . • • • •

'• . . . .

. . . .

. . • • . . . . . .

• • . .

. . .

.

• • . . . .

•

•

• •

• "

60 . .

k 116.5" 070471

. .

-rim

. .

i

tatio IEVIEMbil..

. . .

I I ■ 5

. . . . 1

11 13

EllZ7,

. . . . . .

-a e. -2 o 0, . L >,

(uo

To a

;,-

Pa . o.) cc

BLOOD PRESSURE LtI4-r

fil-1 pi 74 r r 17s-

HEIGHT: I WEIGHT --10...111, cril) "CR 0 10k 9)1c crib 1 1Vin ellelo reit

.

4

Rei.

PATIENT'S IDENTIFI"RON (For typed or written entries give- Name—last, first, middle; ID No.

-17( it

(SSN or other); hospital or medical facility) REGISTER NO WARD NO.

STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 21333

DOD-034909

ACLU-RDI 1661 p.93

511-119

NSN 7540-00-634-4124

M EDICAL RECORD VITAL SIGNS RECORD

POST-

MONT

HOSPITAL DAY DAY PULSE (0) TEMP. F

(9) !tgliiii6M°: . . . INI

IVIIIIRMIIIIIIIIFSWIre

...... 'D•D

H-YEAR • DAY , ai 304,--r Ir--IIM 19

105 °

180 104° i 11111111

iS 4.

170 103°

140

150

160

100°

101°

102°

I .............. III A .... . .....

...... ... • .. ......

120 130 98.6°

98° 99°

.............. MIIIIERWO

lima-- - r illmititill

110 97° !

80

90 95° 1111111/1116

100 96° 1

70 Immummismilimit. 60 LI • 1111111111111E11 40 I IIIIII1

50 . .

f ON

MAIIIII6ITAIRIMILT IZIEW MIIIIENIETIIIIIIIIIIIIMINIMZEIMMINIEN F;EI•M'rplAlteaIIIIIIMIIIIIIIIIIII

rtiall11111111121111...1111111riAlcaffl'. . t:e) W wf

V 0/0 'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. REGISTER NO (SSN or other); hospital or medical facility)

RESPIRATION RECORD

oc! O

0 a

a

8

PATIEN

HEIGHT:

BLOOD PRESSURE

WEIGHT

(12P0 0

TEMP. C

40.6°

40.0°

39.4°

38.9 °

38.3°

37.8 ° a)

Ta

37.2 °

37.0° cr

36.7° -o

to

36.1 °

35.6 °

35.0°

WARD NO.

1 MEDCOM - 21334

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 512. (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

DOD-034910

ACLU-RDI 1661 p.94

Designed using Perform Pro, WHS/DIOR, Jun 94

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET

DD FORM 792, JAN 74 (EG/ EDITION OF 1 SEP 54 IS OBSOLETE.

MEDCOM - 21335

DOD-034911

ACLU-RDI 1661 p.95

OUTPUT

URINE NASOGASTRIC

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL •TIME AMOUNT TYPE ACCUM TOTAL

°-14° 1201) 1-2Lb _.

(Z15-0 acs •

iMe,

4

161k-43 21oD qnoe_c_

rI L2-ve_ vob Ilyy_ • .

();0

... _ . ... _

CHEST Thi43jej -- EMESIS


16

(tsv-O.. I iia 1.

STOOLS


• TIME AMOUNT TYPE ACCUM TOTAL

. .

GRAND-TOTAL OUTPUT . _

REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or nredical facility). .

19(t)-1-i


MEDICINE GLASS (1 oz) . 30 HALF PINT MILK

120 LARGE SOUP BOWL

SMALL FRUIT CUP 160 LARGE WATER GLASS ...

COFFEE MUG 180 PLASTIC OR PAPER

JUICE CONTAINER

240

240

240

180

792, JAN 74 Page 2

MEDCOM - 21336

DOD-034912

ACLU-RDI 1661 p.96

al man Nom ACCUM TOTAL 1111111111111111.111.1111MINIMMIll

AMOUNT

1111.111111111111.1111111111111111111111111111111111 1111111111111111111111111 GRAND TOTAL OUTPUT

IIIIIIIIIIIIIIIIIIIIIII MIMI 1111111111111111111111111111111111111111 MIMI Mil IIIIIIIIIIIIIIIIIIIIIIIII

coTIME AMOUNT 1111110111111 ACCUM TOTAL

111111/11111111111111111111111 1111111111111111111111111111111 MI IIIMMIIIIIIIIIIIMmmIIIIIIN

IIIIIINIIIIIIIIIIIIIIIIIIIII 1111111111111111MIN STOOLS IIIII 1111111.111.11 TIME

TIME NASOGASTRIC

MalACCUM TOTAL

AMOUNT

1111111111111111111111111111=111111111 111111111111111111111111111111 11111111111111111111111.1 111111111111111111111111111 1111111111111111111111111111 IIIIIIIIIIIII

COLOR AMOUNT

AMOUNT

ACCUM TOTAL"

ACCUM TOTAL

OTHER OUTPUT

OUTPUT

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,

first, middle; grade; date; hospital or medical facility) .

DD FORM 792, JAN 74


MEDICINE GLASS 11 oz) . 30 HALF PINT MILK ....... 240

120 LARGE • SOUP BOWL ..... 240

SMALL FRUIT CUP ..... 160 LARGE WATER GLASS ... 240

COFFEE MUG ........ 180 PLASTIC OR PAPER

JUICE CONTAINER ...... 180

10(G) -Li

Page 2

MEDCOM - 21337

DOD-034913

ACLU-RDI 1661 p.97

IS FORM IS SU

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM HOURS TOTAL

COVERED HOURS DATE _

TO HOURS H Oc 3 INTAKE

ORAL INTRAVENOUS

TIME TYPE AMOUNT ACCUM TOTAL

TIME STARTED AMOUNT TYPE

(Include Medications) AMOUNT

RECD TIME

COMPL ACCUM TOTAL

9b0C2 02p sop 5-?io 000 t__1 14(00 I.Snr C 50D ∎ GIM !SOP c3 c. Lg \--c.)-c (21-6GG- isct) AA, JCP IF30 Oa)

. _ .

IRRIGATIONS (N/G, Bladder, etc.) . ...


. __ .....__. _ .. .


TIME STARTED

PRODUCT (i.e. Bl, Alb, P. cells etc.)

TIME COMPL AMOUNT

ACCUM TOTAL OTHER INTAKE


GRAND TOTAL INTAKE

DD FORM 799_ .IAN 7 LI. 1P0.1 -- – — — - --- - Designed using Perform Pro, WHS/DIOR, Jun 94

b(0-1

MEDCOM - 21338

DOD-034914

ACLU-RDI 1661 p.98

RESTILT I REF RANGE

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

al TR.VT REF RANGE

.DPOINT COAG ANALYZER k;

1111

10/07/03

PaTient ID:

HIAL

Test Name :PT Test Result:= 14.2 sec. Ratio = 1.2 Calculated INR = 1.28 Sample Type:citrated wh. blood Test Date :10/07/03 Test Time :21:16 Card Lot Operator

RAPIDPOINT COAG ANALYZER V4.54 SERIAL=1111111-8q01

Patient ID: Test Name :AP - T Test Result:= 29,9 sec. Sample Type:citrated wh. Iylood Test Date :10/07/03 Test Time :21:1? 4- Card Lot Operator

Ward/Section. REQUESTING PHYSICAN:

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

3.5-5.5 g/dI

RESULT

------- PICCOLO 26-84u/1 07/10/03 21:04

REFERENCE RANGE: 10-47u/1 R MALE — PATIENT #: 14-97 u/1

METLYTE 8 • ‘4)-1 —

11-38 u/1 DISC LOT II 0.2-1.6 mg/d DR #: 000 OPER #: SERIAL 7-22 mg/di

8.0-10.3 mg/ GLU 170* 73-118 MG/DL -- BUN 14 7-22 MG/DL TT 100-200 mg/1 CRE 1.4* 0.6-1.2 MG/DL di 0.6-1.2 mg/d CK 137 39-280 U/L

127* 128-145 MMOVL -- 3.8 3.3-4.7 MMObL —100 98-108 MMU/L

t102 24 18-33 MMUJL REF: RANGE I TQC: OK CHEM GC: OK

73-118 mg/d

0 , LIP 0 ICT 0 7-22 mg/dl

0.6-1.2 mg/dl

39-380 /1(M) 30-190 /I (F)

128-145 mm(

3.3-4.7 mmol

73-118 mg/d • 6.4-8.1 g/dl

98-108 mmol

18-33 mmol/

18-33 mmol/1 tCO2

MEDCOM - 21339

DOD-034915

ACLU-RDI 1661 p.99

Ward/Section:rA ivt.

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

DATE: LAB ID NO.:

Baso Lymph

Imm Atyp

Spun Hematocrit

Set Rate Cell Count

MUST SUBMIT SF 518 WITH EVERY UNTT REQUESTED

TEST

<20 ug/ml

APTT

dimer

FDP < 10 ug /nd

'.'112Apn , RESULT REF RANGE TEST RESULT REF. RANGE TEST RESULT REF: RANGE TEST

4.8-10.8 xla Color kft6 „, Negative WBC N/A RPR

4.7-6.1 xl6 14-18 g/dI(M) 12-16 dI(F)

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

App di4,c( N/A

GTu

Bili

Mono

Avg r '

Source

RBC Hgb

Hct

Negative

Tp.

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

Ket Negative Gram Stain

Pit

Lymph %

- 510 Segs

Bands

Occ Bid

0 & P

Negative

Negative

130-500 x 10' verified

73 pH

Bld

SG 1, 3 .0 N/A

tites:tIr Negative

N/A

Mono Prot

Eos Urob 0.2-1.0

H. pylori

Micro Parasites

Negative Malaria

20.5-51.1%

RBC Morph

Negative 554 - -race Fro,- s---ro HCG

Neu- V - Pri ("C°5

Directigcn ABO/Rh Other

4:;WWAr ,

CROSSMATCH

b(6)_ DATE TIME SSN/PEEUDO SSN:

Negative

Negative

LAST, FIRST,MI.

REMARKS:

REPORTED B 4.(4'

ACLU-RDI 1661 p.100

Negative

Negative

Gram Stain

Oct Bid

II. pylori

Micro Parasites

Malaria

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

TIME

GE RESULT REF. RANGE TEST g*N.A...410.:m:WwS,wR*.

RESULT REF RANGE WBC 4.8-10.8 xlh Color Negative N/A RPR

Source

Other

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


D diner <20 ughnl

FDP <10 ug /m1

REMARKS:

I LAB ID NO.: DATE:

CROSSMATCH

MEDCOM - 21341

DOD-034917

ACLU-RDI 1661 p.101

CHEMISTRYAESULT ORM (Subject to the Privacy Actbr 1974)

SSN/PEEUDO SSN: LAST, FIRST,M1. 3

DATE TIME 7Z6-

90 1 ti

REQUESTING PHYSICAN Ward/Section:

TEST RESULT REE RANGE TE REF RANGE

1,4614 %Mgr

TEST I RESULT

is

J J, GE

REMARKS:-

TEST RESULT REE RANGE

Tropoin-1

Drug of Abuse

itkiat If,

TEST RESULT REF RANGE

NA+ 128-145 mmol/1

K+ 3.3-4.7 mmol/I

CL 98-108 nunol/l

ICO2 18-33 mmolJI

138-146 mmol/dL

3.5-4.9 mmol/L

98-109 nunol/L

7.31-7.45

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

80-105 mmHg (art) N/A yen 23-27 nunol/L (art) 24-29 mmol/L (ven)

PICCOLO ==:-=- 07/10/03 22:58 REfERLNUE RAN2L. MALE

111111 PATIENT #: 12(0_1 BASIC METABOLIC DISC LOT #: OPER #:111 DR : 000 SERIAL FTP-Z,

73-118 mg/d1

7-22 mg/dl

8.0-10.3 mg/di

0.6-1.2 mg/dl

128-145 mmol/dl

3.3-4.7 mmol/1

98-108 mmol/1

Na

K

CI

pH

PCO2

P02

TCO2

GLU

BUN

CA ++

CRE

NA+

K+

CG

iteatm.sawitftw.,

22-26 mmol/L (art) 23-28 mmol/L (mg, GLU 91

HUN 9 CA++ 6.8* CRE 0.7 NA+ 133 K+ 4.1 CL- 104 tCO2 19

12-17 g/dI

73-118 MG/DL 7-22 MG/DL 8.0 - 10.3 MG/DL 0.6-1.2 MG/DL 128-145 MMOtiL 3.3-4.7 MMOVL 98- 108 MMOVL 18-33 MMOVL

(CO2

18-33 nno1/1

TEST RESULT REF RANGE 3AVeat.. OR3A. ,-;g1PR4 ,

Tit:WV

ALB

3.3-5.5 g/d1

ALP

26-84 u/I

ALT

10-47 u/I

AST

14-97 u/1

AMY

11-38 u/I

TBIL

0.2-1.6 mg/d1

GGT

5-65 u/1

TP

6.4-8.1 g/dl

HCO3

SO2

BEecf

AnGap

Ca

BUN

GLU

Creat

Hct

Hgb

95-98%

(-2) - (+3) mmol/L

10-20 mmol/L

1.12-1.32 mmol/L

8-26 ing/d1

70-105 mg/di

0.7-1.5 mg,/d1

38-51% PCV

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

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 21342

DOD-034918

ACLU-RDI 1661 p.102

17 )

TEST

Ward/Seetion:.

IEVMM.,.

• 'QUESTING PHY 0

rl --,,N;; • Y<4.0V, ,. .a, :Wit,NO,„011'Ckibijfkil

ULT REF: RANGE TEST RESULT

DATE TIME cf-63 23

, r

REF. RANGE

CHEMISTRY R r SULT FORM (Subject to e Pr' acy Act of 1974) Ell t i'r

4140,104:::' 4 ' - " ' ' imit:,,, , :„ a TEST RESULT REF RANGE

Na ilil 138-146 mmoUdL ALB 3.5-5.5 g/dI GLU 73-118 mg/d1

K : -.1 3.5-4.9mmon ALP 26-84 u/I BUN 7-22 mg/dl CI 98-109 nunol/L ALT 10-47 till CA ++ 8.0-10.3 mg/d1 pH

- . si g 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 ing/d1 PCO2 s i . ii 35-45 nunlIg (art)

41-51 mmHg (yen) AST 11-38 u/I NA+ 128-145 nunol/d1

PO2 4 S Li SO

-2 0(5enunin) 1g (art) TB1L 0.2-1.6 ing/d1 K+ 3.3-4.7 nuno1/1

TCO2 23-27 trunol/L (art) 1-2) 24-29 nunol/L (yen)

BuN 7-22 mgidl Cr 98-108 nuno1/1 HCO3

- 22-26 mmol/L (art) 2- -2. 23-28 trunol/I, (art) cA++ 8.0-10.3 mg/d1 nun ICO2 18-33 o111

SO2 i t;j0 95-98% CHOL 100-200 Ing/dI REF: RANGE

BEeef — 1) (tut -0171,3) CRE 0.6-1.2 Ing/d1 TEST RESULT AnGap 10-20 nunol/L GLU 73-118 mg/dl ALB 3.3-5.5 g/dI Ca 1.1 I 1.12-1.32 mmol/L TP 6.4-8.1 g/d1 ALP 26-84 u/1 BUN

GLU

8-26 mg/di

70-105 mg/d1

-7 : .' ,,,,t '''':: ' ''. ' %

TEST RESULT

'A . M` , "%

REF RANGE

ALT 10-47 u/1

AST 14-97 u/1

Creat 0.7-1.5 mg/dl GLU 73-118 mg/d1 AMY 11-38 u/I Hct 23 38-51% POI BUN 7-22 nig/d1 TBIL 0.2-1.6 mg/dl

Hgb Mme2,0 0

IC 12-17 g/dI ' ' wi. ir Rifff'2fri`-,01W:

CRE

CK `-`1-

0.6-1.2 mg/dl

39-380 /1(M) 30-190 /1(F)

GGT 5-65 u/I

6.4-8.1 g/d1 TEST RESULT REF RANGE NA +

,

128-145 nuno1/1

Tropoin- 1 3.3-4.7 mmo1/1 TEST RESULT REF RANGE Drug of Abuse Cr 98-108 mmo1/1 NA+ 128-145 mmo1/1

tCO2 18-33 mmo1/1 K 33-4.7 mmo1/1

C 98-108 mmo1/1

tCO2 18-33 mmo1/1

REMARKS:


MEDCOM - 21343

DOD-034919

ACLU-RDI 1661 p.103

Bands

Lymph Baso

Atyp Imm

TI ,

Negative

'Ward/Section/,(

LAST, FIRST,MI.

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

SSN/PEEUDO SSN: E

• TEST WBC

RESI REF 4.8-10.8 x10

kE4-X.Wegz:40A 0111ySIA Asoc.isior 4mawfs-to

TEST RESULT REF RANGE TEST RESULT REF RANGE Color N/A RPR

Negative

RBC

Hgb

Het

MCV

Pit

Lymph %

Segs

4.7-6.1 xI6 App N/A Mono Negative 14-18 g/d1(114) 12-16 0111p)

Glu

Eos

Spun Hemalocri

Set Rate

Other

.TEST

PT

APTT

D dimer

FDP

RESULT REF RANGE

UNIT

TYPE

9.8-13.6 secs

1-34 SESS

<20 ug/nil

<10 ug /ml

•

CROSSMATCH

RBC Morph

detn REPORTED B : DATE: LAB ID NO.:

REMARKS:

MEDCOM - 21344

ACLU-RDI 1661 p.104

Negative

Ward/Section:jaiL)._

LAST, FIRST,ML

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

TE SSN/PEEUDO SSN:

Al• TEST RESUL TEST RESULT I REF RANGE RESULT

Nib Color REF: RANGE

RPR N/A Negative 4.7-6.1 xld App N/A Mono Negative

'croJnOttigApfs

TEST WBC

RBC

Hgb 14-18 g/d1(M) Glu 12-16 g/dIQ.')

Source

Negative

Negative Bili

Ket Negative Gram = = PICCOLO = = = 08/10/03 04:52 REFLRLNCE RANGE: MA! I' PATIENT #: 11111 1L-19 (0_,4 MEILYIE 8

LOT # : OPER # : SERI AL. # :

OLU 146* 73-118 MG/Di BUN 10 7-22 NU1'I CRE 1.0 0.6-1.2 MO/D OK 905i 39-380 NA+ 131 128-145 MOO. Ki 4.3 3.3-4.7 MM,M. CL 103 98-108 nut_ t CO2 20 18-33 MOM_

Negative

01-1.0

Negative

Negative

Negative

Micro

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

REMARKS: 0. 1

REPORTED : DATE: I LAB ID NO.:

MEDCOM - 21345

DOD-034921

ACLU-RDI 1661 p.105

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

LAST, FIRST,MI.

, „ , ,

. ."e'..- , '''''' 4 , ..tcgi,c0iilia(9k§:0115#14 ...'st. ?7:4,.‘v„..„A ' ":'-:c ,4:`:•z , A

DATE

4'.1:1RK-AtiL

TIME SSN/PEEUDO SSN:

' ' ik-r-, , 1 - — ' 0. "-:. ..4

TEST RESULT REF RANGE TEST RESULT REF TEST RANGE

RESULT REF RANGE

Na 138-146 mmol/dL ALB 3.5-5.5 g/d1 GLU 73-118 Ing/d1

K 3.5-4.9 nunol/L ALP 26-84 u/1 BUN 7-22 mg/ill

CI 98-109 romoI/L ALT 10-47 u/1 CA +4- 8.0-10.3 mg/di pH 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/dI PCO2 35-45 mmHg (art) AST

41-51 mmHg (yen) 11-38 u/I NA+ 128-145 mmol/d1

P02 N/A (ven)

80-105 mmllg (art) TBIL 0.2-1.6 mg/d1 K+ 3.347 nuno1/1

TCO2 24-29 mmoUL (ven) .

23-27 nunol/L (art) BUN 7-22 mg/d1 CL 98-108 mmoUl

HCO3 23-28 mrnol/L (art)

22-26 mtnol/L (art) CA++ 8.0-10.3 mg/ill 1CO2 18-33 nuno1/1

SO2 95-98% CHOL 100-200 mg/d1 4.4K ActijiattitireA#1901::::7? BEecf mmoUL

(-2) - (+3) CRE 0.6-1.2 mg/d1 TEST RESULT REF RANGE AnGap 10-20 rmnol/L GLU 73-118 mg/dI ALB 3.3-5.5 g/dI Ca 1.12-1.32 mmol/L T 14k dl ALP 26-84 u/I

...., --- ALT 10-47 oil

F AST 14-97 u/I RANGE

BUN

GLU

8-26 mg/dl (1,,= t. t J 7,..

70-105 mg/d1 RESULT

Creat 0.7-1.5 mg/d1 GLU 73-118 mg/di Amy 11-38u11

Hct 38-51% PCV BUN 7-22 mg/di TBIL 0.2-1.6 mg/di

Hgb 12-17 011 CRE 0.6-1.2 mg/ill GGT 5-65 u/I

'V '-4:Eik...laji.:,SZirik laa5,4. TEST RESULT

CK

REF. RANGE NA +

39-380 /I (M) TP 6.4-8.1 g/d1 30-190 /I (F)

128-145 mmol/1 voljz,J4.,sgre-soroy -ecftil "0:014'1P, °;;4•P' , g• tigia; V4).:A,r -wege

Tropoin-1 3.3-4.7 mmoUl TEST RESULT REF RANGE

Drug of Abuse CC 98-108 mmoUl NA+ 128-145 nunoUl

tCO2 18-33 mmoIIJ K 3.3-4.7 mmolll

CL 98-108 mmol/1

tCO2 18-33 mmoUl

REMARKS:


MEDCOM - 21346

DOD-034922

ACLU-RDI 1661 p.106

REF RANGE

l'CV

'dl

ANGE

GLU ,g/di BUN

CRE CK

133* 8

1.3* 1955*

NA+ 127* K+ 4.4 CL- 100 tCO2 23

73-118 MG/01_ 7-22 MG/DL 0.6-1.2 MG/DI _ 39-380 U/L 128-145 MMO/A _ 3.3-4.7 MMOR_ 98-108 MMOVL 18-33 MOM_

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

)7(6)---?-

REF RANGE

98-109 rnmoUL

731-7.45

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

138-146 'ImnoUdL

3.5-4.9 itunoUL

WardlTatiu

LAST, FIRST,M1.-77-0>

f

RESULT

Na

K

CI

PH

PCO2

PO2

TCO2

HCO3

ccolo);Qiintist

TEST' RESULT

3.5-5.5 gIdI

26-84 u/I

10-47 u/1

14-97 u/I

11-38 u/I

TEST

ALB

AL1'

ALT

AMY

AST

,I*10

REF RANGE TEST RESULT

GLU

Ne. 10- CL

tCO2

BUN

CA ++

CRE

73-118 mg/dl

7-22 mg/dl

8.0-10.3 rnWdl

0.6-1.2 mWdl

128-145 mmoUtll

33-4.7 mmoUl

98-108 inmal

18-33 mmoUl

TEST Al.ASIVAT 'Nft 'VW

REF RANGE RESULT

ALB 3.3-53 g/dI

26-84 u/I

10-47 u/I

PICCOLO 09/10/03 04:47 REFERENCE RANGE : MAI PATIENT # : 140_1 METLYTE 8 DISC LOT # :

SERIAL. It ALP OPER # DR

ALT

80-105 mmllg (art) N/A (yen) 23-27 mmol/L (art) 24-29 mmol/L (yen) 22-26 mmol/L (art) 23 -28 mmol/L (art)

toUL

mmol/L

'dl

14-97 till AST

11-38 u/I AMY

TB1L 0.2-1.6 mg/dl

5-65 u/I

3.3-4.7 mmo1/1

98-108 iniaoUl

18-33 mnto1/1

K÷

CL

tCO2

GGT 6.4-8.1 g/dI TP

REF. RANGE RESULT TEST

128-145 mmolfl NA +

REMARKS:

REPORTED BY: ).:

MEDCOM - 21347

DOD-034923

ACLU-RDI 1661 p.107

-7.0110.,-5.Cel.1,41.114.6....................

1............r.il

Ward/Section: REQUESTING PHYSICAN: ! LABORATORY RESULT FORM I (subko !,, the Privacy Ad or 1974)

È FIR ST.M1. 1 DATE I TI NI E 1 I

SSNIPEEUDO SSN:

=-->: diilt010 =-1 '" IRAIW .:, ..z,.

:.,.. ,t,, A ' ,..':,-- -" .:.

40' ''',,, iiiiMigi

--. '''''' ,, ..4a k ,.: iig6Set.iiio , :.;.:.;--,::.:,,,?, 1:'.;;;;,,,;:::<,.':.

TEST RESU ' REF GE TEST RESULT REF RANGE TEST . RESULT REF. RANGE

WBC 4.8-10.8 xtb Color I N/A RPR Negative

R BC 4.7 -6.1 x 16 App N/A Mono ono Negative

Hgb 14-18 g/I11(M) 12-16 g/dt(F)

(..viu Negatir e T Icrpbjolo

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

Bili Negative Source

MCV 80-94 11(111) 111-9911(})

Net Negative Gram Stain

Pit 130-500 x to' verified

SG NIA Oce Bld Negative

Lymph p h % 20.5-51.1% Bld Negative 11. pylori Negative

.. ,..,air ,,,,,,..„,,, i , l „..„.., „,,,

';.- V 7 , v -...:7;4",7, s4, & .5

PH

pH N/A Micro Parasites

Segs Mono Prot Negative Malaria

Ban ds Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other

A ty p Imm Leuk Negative

grO AlA; rips s %VI

a SCP ; - -Iis4,,,

RBC

Morph

HCG Negative

g., ..:Na, .,,,,,,,,3 ;,f.., '

.., - i, ....,A, OW ..,,, vga

,.,, ,,,, 4...V

' -r a „,,,,, ..,,, -----0,

6, An ,

'-' , S:..1. :Vq*,........,:.,„2..a..ic&..; , , , - -..1 Spun Hematocrit

42-52%(M) 37-17 % ( F)

ri—et Rate Cell Count


Other •

Direct' gen Negative A BO/Rh

'''"Orl ,r sr- T.,:,.,,, ortgubitiink v:,..., , _

-3; 4P I"' ' : titdi- ,,,,

REF RANGE

f *'''' ''-7 : A f ,I. 4* t'ilr, 4A,Y04. 48,1/13 "-tk to:v.:0.44>T;

iiir, lif:' iiiiiilie WI 14 11:',,t-; . ,,,— Sit , , . A3 &'. v:

FiSTEtirdo4..: .s,.14 ,:n. l'4.7kA

1 TEST RESULT UNIT TYPE CROSSMATCH

PT 9.8-13.6 sees

APTT 21-34 SESS

D (linter <20 nem!

FDP < 10 t:g /nil

_1 REMARKS: INKLA__.? /1)e..._,,,,,

REPORTED BY: I DATE: i LAB ID NO.:

ar•owaoaewuoclnae-..........J

MEDCOM - 21348

DOD-034924

ACLU-RDI 1661 p.108

TIME

ISO e a .Olie,:Pahel

ATE

17, c--.2 p iccolo):Eheinigt

138-146 nunulidL 7-22 mg/dl

11111E1

'RAMO

' '0.3 mg/dl

RESULT 3.3-5.5 011

26-84 ufl

BEccf

ALP

00 mg/d1

.2 mg/dl

18 mg/di

t.1 gitil

22-26 run 23-28 mn 95-98%

(-2) - (+3 mmol/L

10-20 mr

1.12-1.32

8-26 mg

0.7-1.5 r 0.2-1.6 mg/dl

38-51% 5-65 nil ing/t11

.2 nighll

in /I (hi) 90 /1 (F)

145 mmolll

12-17 g

Ise. Otlemisfx e41, REE fi RESULT

Tropoin-1

Drug of Abuse

98-108 nuno1/1

LAB ID NO.:

REMARKS: cith REPORTED BY: DATE:

fjSCi-%

CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974) REQUEST1N HYS1CAN:

RESULT REE RANGE

RESULT

73-118 mg/dl

3.5-4.9 rnmol/L 8.0-10.3 mg/dl AL1'

98-109 mmol/L

7.31-7.45 AMY

80-105 rnmllg (art) N/A (ven)

70-105 r

AMY

1.7 mtno1/1

08 mmoIII

a rnmo1/1

128-145 mmolll

3.3 -4.7 rnmolfl

18-33 mmol/1

MEDCOM - 21349

DOD-034925

ACLU-RDI 1661 p.109

Pt.:1E F.1...ERA PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:

Hypertension Angina MI CVA Other

Pulmonary System: Asthma Bronchitis/URI COPD Other

Renal System: Acute/Chronic RF N

Gastrointestinal: Hepatitis Metal Hernia PUD/GERD

Endocrine system:

Steriods Thyroid

Neurological: Seizures Neuropathy Other

ificant Hz: N Y

N Y N Y N Y Familial FIX

BP HR Pain Scale 0-10 HEENT - Teeth

Trachea TMJ/Neck Oropharnyx Hares

PHYSICAL EXAMINATION T

CHEST:

Avail DAYS MOS YRS PROPOSED PROCEDURE: SURGICAL SE NPO SINCE:

TOBACCO: ETON:

DRUGS:

CURRENT RI !CATIONS. w ordered al3 premed

( )

( )

PREMEDICATIONS: None Yes (0 Hrs) /CC

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

LABORA ORYSTUDIES:

HB/FICT:

OTHER:

ASA Physical State 1 2 3 4 WT: 42c2' KG/LB HT: IN. ALLERGIES:

ASSESSMENT PAST SURGICAUANESTHETIC

CARDIAC:

EXTREMITIES:

IV Access: Ulnar Filling:

BACK:

OTHER:

NPO Since

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

including d The pation

discussed with the patientfiegal guardian. 6 to_z_ risks of anest

INFORMED CONSENT/COUNSELJNG STATEMENT: Plans, alternatives and

anesthesia including have been explained to and Signed:

(P RE

POST-ANESTHESIA EVALUATION AND NOTE (NON ASU)

NO NT ANESTHETIC COMPLICATIONS I OTHER

Signed: Date: Time- Hrs

Patient Identification: (Ward)

WAMC Form 2300 (Revised) 15 Mar 01 PACXC-DOS

PATIENT RECORD COPY

MEDCOM - 21350

Previous edition is obsolete * U.S. GPO. 2002-729-Z33

rees. Questions ens gcI Date: 07 .03

Hrs

SEDATION KEY:

MINIMAL (Anxioinis) Patient responds

commands normally to verbal

2. MODERATE (conscious sedation) Patient responds PurPoseftAY 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.

DOD-034926

ACLU-RDI 1661 p.110

to

cc cc 0 0 2 •st rn 2

W 2

z cc-0

V

QEF•z co) a )-

u. z hu. r o

SINGLE DOSE WITH NUMBERS

DRUG (Units)

( Pt 4.

(

DZ z ) VOLAT AGENT

% del

% e.t. AIR

N20 L/Min L/Min

02 L/Min DRUGS-MARK ON GRID

& ENTER IN REMARKS


TOTALS TOTAL EBL

ai I FLUIDS - SUMMARY

CRYSTALLOID-

W vi COLLOID-

BLOOD-

sa TOTAL URI

U O

Mt4;11 Mi =1.1...111•1•1•11 s.mmu IMINIMINIIIMIIMMWANa. nill E

-47 - -y )..-- r.7 cow )C P SU X 01C10 sc. 0110

, , ■ . ■ . . 1 I ,

I .

I

I

. I

'

f P IP i 1

I • 1 P 1 i i

i ' 1

I 1

, ,

I I I I I I

i .

MMMT

REMARKS Code drugs with numbers, events with lettters

itrecAV-e /)e

Aest-de

8. sly-

1-(4/1t7'9e) GH,.-Anse4Leci or

91,1 Pt I lye .

the/s1 At;,,rt -

LINE site ❑ Warmed 11/2Ml

LOSSES EST BLOOD LOS URINE

"0r".1 1=1 Warmed •1 (• 0 ❑ Warmed

1:1 Warmed

gr.

reir't"

BR (transduced)

TOURNIQUET

T-X'

BP by cuff

V A

Heart rate •

Resp •rate

LL

BP- /y11

HR-

SO KG LB

HEMATOCRIT:

INITIAL DATA:

EQUIP CHECK

OK?- Y N

PATIENT RECHECK

OK for PROCEDURE?

TIME-

ANES- X-X PROC- 0_0

YS STATU

AIF P i

234 5 BODY WEI

TIME SYMBOLS:

VT-ml

I - breaths/min Peak inf pres / PEEP

MODE - Sipon), A(sslst), Clon)

BP/Auto Cuff ET CO2 (torr) BPloth ART line

Steth- PC/ES

Gas analyzer

Warming blkt

Cony warmer

F102 (Frac or %) Sp02 (%) ECG

TEMP-sIte

N-M Block (T/4)

tt O

0

CO) CC O

2 O 2

220

200

180

160

140

NAM ■IMÎ>filiiM^V EM

IINIIIIIIMMILANIMSAIMI211111110111N11111111111 40

20

I I

samaisa

Mark with letters & symbols, EVENTS Position explain under REMARKS sition 1

sra"rjareirM

alLEPIAIN miriamialmaiaLAMAIMMI 10111112111111s.r ry

11111111111111111111111MMIIIIIINIMINIIN 111111111111111111111NIIIMMIMIN

cc 0. STHETIC IEC NIMES: Describe block technique under Remarks

64r t+

AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

tu 2

120

100

80

60

PROCEDURES and PT Codes:

F)c- PATIENT IDENTIFICATI Typed or written entries: Name, Grade/Rate,

Medical facility

71111=2;

a

RECOV

PACU Specify,

OTHER lila. =II 1M

CONDITION: Vtie

RESP- Sp02- ftv BP. Z HR-

ANEST E IA / PROCEDURE TIMES

)2(0-I

DA FORM 7 89, FEB 1998

SURGEON

AN

PROCEDURE LOCATION:

DATE?

r

od- (73 „of WA-PAGE .1 OF f

ESIA OVIDER USAPA V1.00

MEDCOM - 21351

DOD-034927

ACLU-RDI 1661 p.111

CO ONENT REQUESTED (Check one)

ED BLOOD CELLS

FRESH FROZEN PLASMA

DATE REQU TED

POST-T

PULSE

units)

518-123

MEDICAL RECORD

❑ PLATELETS (Pool of units)

❑ CRYOPRECIPITATE (Pool of

❑ Rh IMMUNE GLOBULIN

❑ OTHER (Specify)

VOLUME REQ

REMARKS:

BLOOD OR BLOOD COMPONENT TRANSFUSION SECTION I- REQUISITION

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

❑ TYPE AND SCREEN

CROSSMATCH DIAGNOSI

DATE AND HOUR REQ MED/V./69

KNOWN ANTIBO REACTION (Speci6,)

FORMATION/TRANSFUSION SIGNATURE OF VERIFIER

NSN 7540-00-634-4158

REQUESTING PHYSICIAN Pnn

/ r •■•■•- y

have collected a blood specim on the named patient, verified the name

below and I No. of the

correct. patient and verified the specimen tub

bet to be

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN?

DATE VERI a E

TIME VE UNIT NO.

DONOR

ABO

TRANSFUSION NO.

PATIENT NO.

RECIPIENT

Rh

PRE-T INSPECTED AND ISSUED BY

(Stnature)

RANSFUSION DATA

SECTION II —

PRE-TRANSFUSION TESTING TEST INTERPRETATION

❑CROSSMATCH NOT REQUIRED FOR THE COMPONENT RE ESTED-

REMARKS:

SECTION HI —

RECORD OF TRANSFUSION

CROSSMATCH ANTIBODY SCREEN PREVIOUS RECORD CHECK:

AT

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item.

The recipient is the same person named on this Blood Component Transfusion Form and on th

Lst ntificatfon tag,

nd

2E•T

f r on is suspected —IMMEDIATELY: 1.

Discontinue transfusion, treat shock if present, keep intravenous line open. 2.Notify Physician and Transfusion Service. 3.Follow Transfusion Reaction Procedures. 4.

Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. Solutions to the Blood Bank. DESCRIPTION OF REACTION ❑ URTICARIA

❑ CHILL ❑ FEVER PAIN OTHER (Specify)

R DIFFICULTIES (Equipment, clots, etc.)

NO

LENT IDENTIFICATION—USE EMBOSSER (Fortyped or written entries give:

Name—Last, first, mid rate; hospital or medical facility)

MEDCOM -21352

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

TE OF TRANS

MP.

DOD-034928

ACLU-RDI 1661 p.112

D' E REQUESTED

NSN 7540-00-634-41

❑ TYPE AND SCREEN

CROSSMATCH

1. a •

DIAGNOSIS OR OPERATIVE PROCEDURE

BLOOD OR BLOOD COMPONENT TRANSFUSION SECTION I - REQUISITION

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

REQL/ESTI • -

UNIT NO. 19

DONOR

TRANSFUSION NO.

PATIENT NO.

RECIPIENT

ABO

Rh

ABO

Rh

3

P0,5

INSPECTED

PRE-TRANSFUSION DATA •

units)

ML

518-123

MEDICAL•RECORD

COMPO ENT REQUESTED (Check one)

,.......„ RED BLOOD CELLS

❑ FRESH FROZEN PLASMA

❑ PLATELETS (Pool of

❑ CRYOPRECIPITATE (Pool of

❑ Rh IMMUNE GLOBULIN

❑ OTHER (Specify)

VOLUME REQUESTED (If applicable)

REMARKS:

DATE AND HOUR EQIJ REDC113

KNOWN ANTIBO F .1aL

REACTION FOR ATION/TRANSFUSION (Spech5,)

I have collected a blood specime! on the below

correct.

named patient, verified the n4me and ID No. of the Patient and verified the specirnen tube label to be

SIGNATURE OF VERIFIER

units)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION TESTING TEST INTERPRETATION

ANTIBODY SCREEN

Cc> WI 0

❑

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ STED REMARKS:

Cil- 03 1,6)-L SECTION III

- RECORD OF TRANSFUSION

CROSSMATCH

10/A

DATE

DATE VERIFIE

TIME V ED

PREVIOUS RECORD CHECK:

ErRECORD NO RECORD

SIGNATURE OF PERSON PERFORMING TEST

I) 6 OC.50 I DENTIFICATION

I Dom - o

have examined the Blood Component container label and

tag.

this form and I find all on the patient identificatio

information identifying the container with the intended recipient matches ite

n The recipient is the same person named on this Blood Co

m by item. mponent Transfusion Form

and 1st VERIFIER (S:n

2nd VERIFIER (Signature)

6 ANSFUSIO

EMP.

ATE OF TRA SFU ION

•

TIENT IDENTIFICATION—USE EMBOSSER(For typed or

rate; hospita/ or medical facility)

AT (Ho

PULSE 7c) TIME STARTED

POST-TRANSFUSION DATA

T M DTE CO PL ED INTERRUPTED

Ara • .. 2.

Notify Physician and Transfusion Servicer. 1. Discontinue transfusion, treat shock if present keep intravenous

line open. 4. Do NOT discard unit.Ret

3.Follow Transfusion Reaction Procedures.

urn Blood Bag, Filter Set, and I.V. Solutions to the Blood Bank.

❑ CHILL

If reaction is suspected—IMMEDIATELY:

❑ FEVER

ESSURE

❑ PAIN

; /

e; ran

WARD

--L-

OA6 OTHER (Specify) ❑

DESCRIPTION OF REACTION Eil URTICARIA

OT ER DIFFICULTIES (Equipment, clots, etc.) NO YES (SpeciN

SIGNATURE OF ERSON NOTING ABOVE

tten entries give: Name—Last, first, middle; gra

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FiRMR (41

CFR)20I-9202-1

MEDCOM - 21353

DOD-034929

ACLU-RDI 1661 p.113

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

EXAM INATION(S) EQU TE (p

fir. . f._

Pl. L

110P 9/146,4k_ 67,v

RAD1OLO C CONSULTATION REQUEST/REPORT , ear Medicine/Ultrasound/Computed Tomography Examinations)

ElPC SEX SSN (Sponsor)

FILM NO.

SPECIFIC REAS N(S)•FOR REQUEST (Complaints and findings)

REGISTER NO.

PREGNANT n YES Ej NO

TELEPHONE/PAGE NO.

DATE REQUESTED

/ 2 oz.1-- o

I WARD/CLINIC .....-

,1.-- k-.) (

NS247840-01-185-7Z.2.4

fu ,(14,cov.QA

5dL- IDATE OF EXAMINATION (Month, day, year)

I 7 C)-1(— 1 RA °LOGIC REPORT I DATE OF REPORT (Month, day, year)

DATE OF TRANSCRIPTION (Month, day, year)

RADIOLOGIC CONSULTATION REQUEST/REPORT

— MEDICAL RECORD

MEDCOM - 21354

STANDARD FORM 518-B 1)8-83)

pres.stiono by GSA/tCHR FPMR (41 CFR) 101-11.806-8

LOCATION OF MEDICAL RECORDS

LOCATION OF RADIOLOGIC FACILITY

SIGNATURE

DOD-034930

ACLU-RDI 1661 p.114

w

onm NSM 7540-01-185-7214

RADIOLOGIC CONSULTAT(O REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/C uted Tomography Examinations)

EXAMINATION(5) REQUESTED AG SEX SSN (Spon (WARD/CLINIC

\C-WS A CKE

FILM NO.

REGISTER NO.

PREGNANT

Eli YES 0

TELEPHONE/PAGE NO.

DATE REQUESTED.

1a 1 r-IDU_ 012-52-

RE nt)

SI UESTOR

519-301

(0-2_ CG)-LI

6).00 (13-

V-1?(I)S. Q

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

DATE OF EXAMINATION (Month, day, year) • I DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year) iett

RADIOLOG REPORT

/1111-7,-4

-C11, P-e,

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

) LOCATION OF MEDICAL RECORDS

LOCATION OF RADIOLOGIC FACILITY

SIGNATURE

RADIOLOG IC CONSULTATION REQUEST/REPORT

I — MEDICAL RECORD

MEDCOM - 21355

STANDARD FORM 519-B t8 -83) Prescribed by GSA/ICMR FPMR (41 CFR) 101.11.806-8

DOD-034931

ACLU-RDI 1661 p.115

PATIENT IDENTIFICATION 1 DATE 0-ORDER TIME OF ORDER

06 3 HOURS

Illr )o(s7)

LIST TIME ORDER

NOTED AND SIGN

v In Nt33 CA4L' /0014

0 pb u) NURSING UNIT IROOM NO. i BED NO

PATIENT IDENTIFICATION!

(A41--ic

5 DATE OF ORDER TIME OF ORDER

-43


PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

DATE OF ORDER T ME OF ORDER

NURSING NIT



DOD-034932

ACLU-RDI 1661 p.116

DAT OF ORDER TIME OF ORDER

HOURS

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

-} U.S. GOVERNMENT PRINTING OFFICE:

MEDCOM - 21357

1 APRM

79 4256 FOR

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



LIST TIME ORDER

NOTED AND SIGN

I DATE OF ORDER TIME OF ORDER

0656 HOURS

I .- 1

NURSING UNIT


HOURS


cru l Ma c. PA1jIENT IDENTIFICATION

DATE OF ORDER

(51— /C oo


jj410 6(0-4

IG UNIT ROOM NO. BED NO.

DOD-034933

ACLU-RDI 1661 p.117


PATIENT IDENTIFICATION + DATE OF ORDER

tt, TIME OF ORDER

cy.D.CaD HOURS

LIST TIME ORDER •

NOTED AND SIGN

ff . -ID 5)(n

NURSING UNIT ROOM NO.

001-4P;A__


NURSING UNIT



ROOM NO.

REPLACES EDITION OF 1 JUL 77. -VVICH MAY BE USED.

U.S. GOVERNMENT PRINTING OFFICE: 16%94 - S53 - 710

. ; .\ MEDCOM - 21358

DA FORM 1 APR 79 425B

• -•

.2 .

BED NO.


DOD-034934

ACLU-RDI 1661 p.118


E 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.

TX T I ENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

\ li 0 Cr (—° 131 HOURS

LIST TIME ORDER

NOTED AND SIGN

4 ‘9,6)._, NURSING UNIT

. .0, '-'1 1 .4r4

ROOM NO.

t. io 4 - -- d!., - . -,•!P

, V ,

,,....-,,, , t t ft--

BED NO.

A or' .-,,,gs ... , a 3- .)506 a11 g..._ ,,g, A 4.. -'','",r 4 4,2 2' .1,'"k.4..k, ..3,--h's

1,...:,,! `- - ,,,,, e Zr..": +WV.,,,: l ., „. . ■-41•Vx. ,

'''.%., ppTIENT IDENTIFICATION ..... DATE OF ORDER TIME OF ORDER

HOURS ,./.°

1,---


/ATIE NT IDENTIFICATION

1 X 4

DATE OF ORDER E OF ORDER

HOURS


PATIENT IDENTIFICATION DATE OF ORDER • IME OF ORDER

HOURS

NURSING UNIT OOM NO. BED NO.

DA 1FA 9 4256

REPLACES EDITH

MEDCOM - 21359

3E USED.

DOD-034935

ACLU-RDI 1661 p.119




HOURS

DATE OF,0i1

p.mDER TIME OF ORDER

I YV ccr- LIST TIM

ORDER NOTED AND

SIGN

NMI

NURSING UNIT ROOM NO, BED NO.

Ic\Nitr-1 DATE OF ORDER TIME OF

1- HOURS

BED NO. NURSING UNIT

ROOM NO.

PATIENT IDENTIFICATI N


HOURS

NURSING UNIT

ROOM NO. BED NO.


HOURS

NURSING UNIT I ROOM NO. BED NO.

DA IFAOPPRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 21360

DOD-034936

ACLU-RDI 1661 p.120

ORDER DATE

l ocwire„,

DATE DISPENSED

I

DA 7 FFIIIM 4678

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407; the • ro nent army is the Office of The Surgeon General. yiO3 INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIOIV


Ob )0

i cb

L--4 EML.----- re4 i 11/ Atalel a

iiissiii MG NM ag111111111111111111 MI MN IMLoad

P 1_MLMMIIIIIIMEti 1111111inkidammrimmirglial 111=1111111mimlffilla war 7016741M04:. MVO ALLERGIE*4 0 YES PRIMA -Y DIAGNOSIS:

2101111111 • 411111111111111111111 .1111111111117PIPTIMPAIIII 111111111111•1 • 11111111111111111 • ■IIIIIIIII ■ 111111111111111 • ii•ME11111 •

EIPLIII'` • ENIENIFFSEW111111111 Ofillbiliii1111111

1111111

11111111111111111 • 111111111111M1111111 11117fillE1111111/114 miumummum

ADDITIONAL PAGES IN USE,

0 YES E] NO

PAGE NO.

War J Oz 5

, ilammIELIZEIIIIIII

IMMEM11117111 Lidiud ord

immommn _____MEMOVEMN allin■14 EIS CALA— 1-€.h

PATIENT IDENTIFICATION,

We-MS-TWA woukib Patalo4o v

aVl 1, 6)-7/

DISPENSING TIMES

115. Es

0-1

D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 21361

DOD-034937

ACLU-RDI 1661 p.121


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) AfoaE-141I

Order Date

VI 4"

Clerk/ Nurse

—.

SINGLE ORDER PRE-OPERATIVES , Dote to

be Given Time to be Given Time Given Initials

) COM-1+ filD ICAA 2 Coll9UCAO/YA IR IY ai 3b 0-7 i ocyr CO 1.1...Ti ...I, ; 1-2NI V.-- 1 ocT

43c. 1.-It R,r-rrAF31.-E- CseiZ__ c TE; ° °el- CDU NW .-1 0aor

0-1 OCT 11/17 C-3 A'4 b 564Ze-n•-1 106r 2ii-i5 f:;2i uts cg ocl- fo --Aeur Ce, Lc [0 .1/4.)

gliv' i! i A. 640•1 9alfadar) afx1l Taf. cymba-07) 01 1 F loOd-0-24/ni .th 106i 0 b 1k

\ ID Mtge C)(C. cO•N \1 S___\-q3

"2- * gala Por kA0\e- oc-- R c400 Q00--t4,3 atvis 04cto

\0 6-

order/ Emir Date

clerk/

Nurse PRN

MEDICATION, DOSE, FREQUENCY


TIME/DATE DISPENSED

MEDCOM -21362 U.S. GPO: 1996-454-110195218

DOD-034938

ACLU-RDI 1661 p.122

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

CLINICAL RECORD

VERIFY BY IIVITL4LING

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.

AIMS INITIAL PROPER COLUMN FOLLOWING EACH COM LETION

HR DATE COMPLETED

11111.11111 MN. ■111111■ MM.

.w44

&Iraq nom=

ORDER DATE

CLERK/ NURSE

ALLERGIES: YES ED NO PRIMARY DIAGNOSIS:

PATIENT IDENTIFICATION: PAGE NO'

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

DA FORM 4677, 1 OCT 78

MEDCOM - 21363

M Yr. 2003

DOD-034939

ACLU-RDI 1661 p.123


THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo yr 2003


Time to be Done

,

Time Done Initials Order

Date Clerk Nurse \ \ . 4VjrD\ e O'cf:-. row

11111 PoC\-- b)s2- C)Cg- D ci_Acbbc2c \2-ccycZ—J3z3c6.4. k2.. ne

IA-47-A, liy,c= Ilp&)

C)17)------

)34 gri No 5 ,Xg 1/141-✓ (54 111( i 3d1)

i I//7 - t,(3

1 1 ti-k C 1 -4 ,)(rt-- 1rY-) ]s---oa Plc okio ____ - it9 ((,)_,,,

_ - Order/

Explr Date

Clerk/ Nurse


INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED _

— — — — — —

— — — — — —

— — — — — —

MO NM MM. Wm/ =IN ■■ 1M i■i

1=0 Mb MN 11“11 OW NO MO

wm. ■■ ■ am. ■ ■ ■ ■•

.., ome a■ m.. .... .■ ... ...e

•••■ ■ =Is •■ ■. ma Nom •■

1..• om ro v.. •••• am •••• .■

MEDCOM - 21364 USAPA V1.00

DOD-034940

ACLU-RDI 1661 p.124

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) For use u of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon General. M 0. Yr. 2003

VERIFY BY INMALING' „„tavailfsgraMMatity* RECURRING ACTION, FREQUENCY, TIME

mom! ?o uallill

HR INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

DATE COMPLETED ORDER DATE

1) Ana CLERK/ NURSE

i 11

- - - - - - - 19( ..... _ .

ALLERGIES: MI YES MN NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: - YES MI NO

PAGE NO' PATIENT IDENTIFICATION:

AC USE PENCIL.

D 8 9 10

E 16 17 18

N 24 01 02

ON TIMES CI - CLE ACTION TIMES

11 12 13 14 15

19 1 21 22 23

03 04 15 06 07 CIA FARM AC77 A r•■ ••••-r -so PrIITIrtKI rtc i nor. 7.7 ■ ./LW or ..L-1-l..

USAPA V1.00

MEDCOM - 21365

DOD-034941

ACLU-RDI 1661 p.125

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form see AR 40-407; the pro vent ency is the Office of The Surgeon General.

INITIAL PROPER COLUMN FOLLOWING

MIN M )0111111 NM=

'1:Ev t_r e., toocc ffe_ b6141111WERAIIII •

111110111111 IN 1 Erd • • !MS 1111111111111 • ffin us mow,. jo PAIMMEINEBRIMIS illainnimoreisE -3),/ 62 " INN 1101-11.11- 11111111111111 • dre OE ■ la' - 1,4 112 St VA Ken • IMIllianair /Do MNWIIIIIIMIII LIMN ■ ilfiliZ Ma -z-,9-0 ii__ Ilgo antmafi ■ wazoimmeml if imiatimum _imam

. DM OS nog EMEMIIIIIMIRPM IC Elt allargamems WM WNW 21026 III •

Inimintr/M■amill11111 all III

IMEIMIN1111111%.111111111111101111111111 •

INIME1.111.111111111111111111111111 ■

IIIIIIIIIIIIIIIIIIIII II

E1111111111111111111111 •

1111111111111111111 •

IIIIIIIIIIIIIIIIIIII ■

111111111111111111111 •

IIIIIIIIIIIIIIIIIII •

IIIIIIIIIIIIIIIIII II IlInntimuus j NO

ADDITIONAL PAGES IN USE; 111

Cl Y ES Cl NO

CLINICAL RECORD

VERIFY BY INITIALING

ORDER DATE

CLERK/ NURSE

RECURRING MEDICATIONS, DOSE, FREQUENCY DATE DISPENSED

ALL YES PRIMARY DIAGNOSIS:

PATIENT IDENTIFICATION;

DA 1 FEB /9 4678

PAGE NO.

DISPENSING TIMES

ELSE Not_ CI RCL E MED TIM t

D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01

EDITION 02 03 04 05 06

OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 21366

DOD-034942

ACLU-RDI 1661 p.126


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) mo. OCT Yr

Order Dote

Clerk/ Nurse

SINGLE ORDER, PRE-OPERATIVES Date to

be Given Time to be Given Time Given Initials

60 ii......4 L

T lk 4 r-r ppecs t401„/

I IC., k\I okr6 •\\ \\I fxvd5 \ po-cil.3 of...6

Order/ Expir Dote Clerk/

Nurse PRN

MEDICATION, DOSE, FREQUENCY

INITIAL PROPER CO FOLLOWING ADMINISTRATION

DATE TIME/ DISPENSED

TY \ 5 0 LI: -a -&,,,,,9 ogott c95,c-

- v 7, t- a Ille- ovnlan

.

1 0 A 10

pri 2-

aVO 16i, i

1,;),(1,-111

00-4-

225 a oc+- 06-0

;,,N. .10

gi-41°C-4 i to ilvz.:. , retlait.'P,A 7)0 i

'I) 9ill of

lo(t)--2 iil ,.... •

......

MEDCOM - 21367

'U.S. GPO: 199S-04-110/95216

DOD-034943

ACLU-RDI 1661 p.127

MEDCOM - 21368

74406/44940 444( /4.44QU'd r

ADDITIONAL PAGES IN USE: Y ES ED NO

PAGE NO.

ALLERGIES: EJYES 0 NO PRIMARY DIAGNOSIS:

PATIENT IDENTIFICATION:

DA 1 F41249 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

DISPENSING TIMES

^15E PENCIL r! RCL E MED TIM S. D 7 8 9 10 11 12 E 15 16 17 18 19

N 23 24 01 02 03 04 05 06

13 14

20 21 22


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.

ORDER CLERK/ DATE NU RSE


HR

Mo.Yr. INITIAL PROPER COLUMN FoLLOWNG EACH ADMINISTRATION

DATE DISPENSED

\I 5-- rq j Ib ) .7

DOD-034944

ACLU-RDI 1661 p.128

Time to be Given

Time Given

d. -Fi

I Mo. THERAPEUTIC DOCUMENTATION CARE PLAN

(MEDICATIONS)

SINGLE ORDER. PRE-OPERATIVES


Order Clerk/ Dote Nurse

Initials Dote to be Given

1 1 \\I as-AO a1 'f'rtids

Order/ ExpIr Dote

Clerk/ Nurse

'1 0

PRN MEDICATION, DOSE, FREQUENCY

ferwc,24-

INITIAL PROPER COLUMN FOLLOWING ADMINI

SPENSED

occr 41

TRA770N

150 1SnC-14 oe

!too- 1 2,o,

aim 013a 1130 a a ■%2

tccr cite

1104 filf Del

.1215 140)

MEDCOM - 21369 'U.S. GPO: 199e-454-110/95216

3 10Er0 Percoccr t-.2p 0 cr i-V° ?f•- ■.1 f

DOD-034945

ACLU-RDI 1661 p.129

OTSG APPROVED Mate

Drains Airway Hemovac Nasal

Oral JP ETT

Trach Foley

Other

Pacu Intake

Time Solution

X-rays:

Amount Site • By

Infused

Labs:

Criteria Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

Almay (2)Cough. Deep breath (1) Dyspnea, Wiled breathing (0) Apnea

Blood Pressure (2) SBP =A 20 of Pre-op (1) SBP 2050 of Pre-op (0) SBP SD of Pm-op

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

Color (2) Basane color A appearance (1) pale, mottled, jaundiced (0) Cyanotic

ADM 30' D/C Codes

1


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

V/S X =A4ine BP

=Cuff BP = Pulse

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

LOS C = Cervical T =Thoracic L =Lumbar S = Sacral

a

a Circulation (Peds c 5 Years) (2) radial Pulse Palpable (1) Axikary palpable, not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C,

t teaching done; Wound Care, Pam Management, DB.. Incentive Spirometer, Comfort Measures

: SR up X 2, Falls Precautions. Privacy Maintained

Anesthesia Type (Ci

OR Intake: Crystalloid

OR Output UOP EBL, • Medsirimes: so 1-75

Date: Time In: Allergies:

Pre-op V/S: Procedures:-

Spinal Epidural on Nerve Block

PREPARED BY ist

S6 / PATIENT'S IDENTI r or fag middle: grade: date; hospital or medical faanyl

REPORT TITLE

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this tom see AR 40-66: the proponent agency is the Office of The Surgeon General.

Post-Anesthesia Care Unit (PACU) Flow Sheet

rue up n.neas History Time 4.... ‘......

-zjr-'s 1,1 '1,-"Q

^• • -..

Sa02

Fi02

Methods

240

220

200

180

160

A sa 140 AV i• A A

120

100

80 VI Nr•

a .1• NAv

-. V 1 a

60 1 .1

40

20

RR tki)9 15 Sea* T

IPS Time

• 311 :-.E Ilt4

Pain (0-10)

1

Patiet

LOS I T. C, Seel

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

• Name -last,

(0 - 2-

IL.011 IMP on mverso DATE

Ok6C-M\3

Previous edition is obsolete USAPPC V200

DEPARTMENT/SERVICEICUNIC

❑ HISTORYIPHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER Am.& OR EVALUATION


❑ TREATMENT

MEDCOM - 21370

DOD-034946

ACLU-RDI 1661 p.130

15'

30' 45'

60' 90' D/C

NURSING NOTES

Tat

-0

■ . 1

-

60'

11

D/C

. 1 .

PACU OUTPUT

Time

Source

Color/Appearance

Amount

Adm

Time Site

-t- 1/1111110M114 MEM i WMMAIM

Range Of

Motion

NE ROVASCULAR Sensory P Cap

Refill

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

NNE

priu<Kno re arm .cjuj

100

_‘• v)bie at/c/Ykith-h-c3 . dpi Qiuguldg. biloodVAht3 -E bkpd owlifie'd&rn 012-

• it - €0,0 A

MEDICATIONS Allergies: Time Pain

1-10 Medication & ringsne

Route Pain 1-10

I/E By

C1Z3S — /1150 7-,vt9 tixj i_ wil_

. .

14 41 be rep/Awe-it ve2txt Iwo)

1 Vs p R 10)114,4:1 regbi hi:LI/tea/

exiap r

yAri_i_." s Lt -1

Era111 1111ERFAMT1. 1

ormaninimmitempi +-

Color: C = Cyanotic, Capillary Refill: B= Brisk, S = S uggish P= Pale, Pk = Pink f. , 1I. , 4 ' t.40

riuzyt -O 117) r..7- sit4 C-SECTIONS

Adm

1111MEM 15' 30' 45' D/C

• xJ i&Oce bloc fk) iotweir Fund. Height

Lochia

1111111■111111111 11111111111011

Peripad4t

Fund. Cond. #111. 1 a1ertooceecro.4,4,9.- DRESSINGS

.JI 04 D Location Type

rairJAMITITRIEUI 1\-

Drainage

/p)

rotnOvi-d dee) (A 912e.

Discharge Criteria: Date: Time: BP: ' T: HR: RR: Sa02:

Pain Level at D/C (0-10): Intake: Output: Additional Data: Transferred To: Report Given To: Transferred Via: W/C Litter Gurney Ambulance Transferred By: Cleared lAW Recovery Room SOP B-3 Charge Nurse Signature:

clitil,„(,)

CARDIAC RHYTHM

Time Rhythm Sym t tic? Rhythm Strip Run?

WAMC OP 173-E

MEDCOM - 21371

DOD-034947

ACLU-RDI 1661 p.131



Admitting Officer (Signature, as re

L.

1. Reporting MTF

0580 Admission ioding Information

For use of this form, see AR 40-400; the proponent agency is OTSG

2. MTF Lo .

3. Register Number Name (Last, First, MI)

0 -1

4. Pay Grade

FGN

5. Sex

M

6. DoB (YYYYMMDD) 7. Age at ission

29Y

8. Race

X

9. Ethnicity

9

Religion

ISLAMIC

10. Length of Service ETS 11. FMP

99


19(k) — "f Organization (Active Duty Only)

.. _. . _

13. Marital Status

Z

Hour of Admission

20:05

Branch / Corps:

raying Status 15. Beneficiary Category



17. Unit Location Prey. Admission

NO

18. MOS 19. Trauma

DIS


Direct from ER

Ward: Name / Relationship of Emergency Addressee

Address of Emergency Addressee ICU2

Name and Location of Medical Treatment Facility: 0580 - 28th CSH - Iraq; No Install Provided



TRF-OTH


2003-10-19




2003-10-07

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission

2003-10-07

FOR LOCAL USE


Admission Diagnosis Narrative: PENETRATING WOUND R -BACK LIVER LAC, HEAlidii5NEUMO

MEDCOM - 21372

DOD-034948

ACLU-RDI 1661 p.132

Automated Facsimile ATIENT TREATMENT RECORD t....,JER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

1. Re Nbr 2. Name Aii

Lq-, FGN

3. Grade Admission Remarks

4. Sex . 5. Age ! 6. Race ! 7. Religion i 8. LnthOfSvc ; 9. ETS : 10. PrevAdm • M : 21Y ! X ' UNKNOWN 1 ! NO . ,

• 11. FMP 12. SSN ' 13. Organization 1 14. Ward

Win (01 99

15. FlyStatus 17. Dept / Ben 18. BranchCorps 19. UIC / ZIP 1 20. Type Casel K78-PRISONER OF WAR/INTER ARMY BC

•21. Source of Admission 22. Hour Of Adm: 23. Clinic Service Direct from ER

ICW 1

09:30 AEA - ORTHOPEDICS

24. Name/Relation of Emergency Addressee

27a. Address of Emergency Addressee

29 ReportingMTF io(2) ._ 2_

25. Type Disp TRF-OTH

26. Date of Disp

2003-10-12 1_

27b. Telephone No 28. Date This Adm: Admitting0fficer: 2003-10-09

30. Date lnit Adm

2003-10-09 32. Units Blood Components


1 Marital Status: Z DoB:11111111111 i

In/Out Patient: Inpatient MOS:


34. Diagnosis / Operations and Special Procedures:

LEG INJURY

(_ ■/ 13 ,


Absent Sick Days j Other Days ConLv / Coop Care Days i Supplemental Care 1 Bed Days Total Sick Days

L 35. Total Days This Facility

Absent Sick Days . Other Days ConLv / Coop Care Days 1Supplemental Care Bed Da s 1 Total Sick Da s

Ing Medical Officer Si

11111111111111

Automated Facsi Ile- DFORM 3647, May 79 )

MEDCOM - 21373

DOD-034949

ACLU-RDI 1661 p.133

DATE OF TRANSFER:

TIME OF TRANSFER: A/ DESTINATION:

OCT- 03

19(2-)--1-

POC AT DESTINATION:

ANTICIPATED LENGTH OF TRANSFER:

EQUIPMENT REQUESTS:

DATE OF REQUEST: 07 REQUESTOR:

ISN #: kV/ feividaeT4m3:60/We26—

PRIORITY: hiS194) LITTER4MBULATORY) (CIRCLE)

DESCRi fi el,, T N O ' I , .M,'

bil VAIWM- Winnalliar il

• -4 0 / 1 -- 1 ilawfM ''• M y CAL PERS ti/ 4 ACCOMPANY 1

ttisul

EDICAL TRANSFER RE S UEST FORM

NOTE: COORIDINATION IS ALSO REQUIRED THROUGH MOVEMENT CONTROL FOR A TRIP TICKET.

fikreril

• MEDCOM - 21374

DOD-034950

ACLU-RDI 1661 p.134

DATE

. (

IDENTIFICATION NO. I ORGANIZATION

•or y d or 'Innen entries give Name last, first, middle: grade; date: hospital or medical fiallay,)


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

„5%.17 , 6-31-()

j1C LA_Y-e-C11./

f

A5;aFill

PHYSICAL EXAMINATION

E(N4t- AID

2_

PROGRESS (Enter date of discharge and final diagnosis)

77 riss.

ABBREVIATED MEDICAL RECORD Standard Form 539

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR 141 CFR) 201 ,15.505 OCTOBER 1975 LISAPPC V1.00

MEDCOM - 21375

DOD-034951

ACLU-RDI 1661 p.135

EDCOM - 21376 fill1,17/ I


MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entryl

07 0 C/ I 0 ,_1

IL _I P w

ap 4,v--re--

/ If , 4 Z 'iltiq- d ° ri7t, id • thlik_ NAmr, ii iuki,r 1 ...

.., 0 4f

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1

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off f i i / Al „.........ci Mal ._

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AVI

440 r , • A ...

MOM PILIA4A Ii

1 4_,

, J 4, A.

L. L. c ,..0 .eille _

6 fa) —1_

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

SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICA • - — - - • ten entries, give: Name - last first, middle; ID No or SSN; Sex; Date of Birth: Rank/Grade.) REGISTER NO. I WARD NO.


STANDARD FORM 600 (REV. 6-97) Prescribed by GSAIICMR FIRMA (41 CFR) 201-9.2021

USAP AV2.00

DOD-034952

ACLU-RDI 1661 p.136

DATE

MPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGAN. ..ON (Sigdench entry)

I a, C23 r

1/6-1 2 -o3 -rIL---o Lzt. cLi-A , i4 f- .,2-t-;,,

gr-uar 5k(A-2- L.-; t 1 \. ecA k.e_,,,

itu \--Q- L.r---S . -r-L. ..:„.....k es,..A._.„ t:), -)-t.t- I N 5,c—t -RI-Ct e,L■ii ' U_ -- frt-ft ALL1

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MEDCOM - 21377

DOD-034953

ACLU-RDI 1661 p.137

LAST NAME I FIRST NAME MiuuLE INITIAL ID NUMBER

DATE NOTES

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MEDCOM -21378

SAPA V1.00

DOD-034954

ACLU-RDI 1661 p.138


' MEDICAL RECORD I PROGRESS NOTES

DATE NOTES 7

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I REGISTER NO. WARD NO.

&/0 1111kit) PROGRESS NOTES

Medical Record


USAPA V1.00

MEDCOM - 21379

DOD-034955

ACLU-RDI 1661 p.139

511-119 NSN 7540-00-634-4124

VITAL SIGNS ktCORD MEDICAL RECORD HOSPITAL DAY

POST- DAY MONTH-YEAR DAY at!=grailFWEIMMIE

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VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 21380

DOD-034956

ACLU-RDI 1661 p.140

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% del FLUIDS-SUMMARY % e.t. CRYSTALLOID -

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

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ANESTHESIA / PROCEDURE TIMES

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Begin End Me k with letters & symbols, EVENTS__, expla II under REMARKS Position -


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ANESTHETIC TECHNIQUES: Describe block technique under Remarks

AIRWAY MANAGEMENT: Intubation route, blade, technique, comments PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility 41 111

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- - - - - - - - - - - --- -

SURGE b (i ' 2., PROCEDURE LOCATION:

DATE:

acr- o'3 Alf ANES

PAGE OF

COPY 2 - ANESTHESIA PROVIDER

USAPA V1.00

MEDCOM - 21381

DOD-034957

ACLU-RDI 1661 p.141


oRC THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL

RECORD

TIME OF ORDER NOTEt SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.


\IN

NURSING UNIT


NURSING UNIT

PATIENT IDENTIFICATION DENTIFICATION

NURSING UNIT


NURSING UNIT

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RE USED.

DOD-034958

ACLU-RDI 1661 p.142

DA,FAOPRRM79 4256 REPLACES „EDITION

40 • CLINICAL RECORD - DOCTOR'S ORDERS

For use of this form, see AR 40-66, the proponent agency is OTSG



Aak

v\IN

DATE OF ORDER

10-1 .2- - -3 D ( -6

TIME OF ORDER

0 146)0 HOURS NOTED NOTED

LIST TIA-r". '

AND SIGN

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NURSING UNIT ROOM NO. BE V PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS



HOURS



HOURS

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DOD-034959

ACLU-RDI 1661 p.143


THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICA770N ) Mo if Z.--1 yr 2003


Time to be Done Time Done Initials

order Date

Clerk Nurse

qd(

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- - - —

Order/ Expir Date

Clerk/ Nurse


INITIAL PROPER COLUMN. FOLLOWING COMPLETION

TIME/DATE COMPLETED

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USAPA V1.00

MEDCOM - 21384

DOD-034960

ACLU-RDI 1661 p.144

ALLERGIES- O YES

PATIENT IDENTIFICATIONS

ADDITIONAL. PAGES IN USES 0 PRIMARY DIAGNOSIS:

ED YES 173 NO

M /a- - 671) evatklis DISPENSING TIMES

PAGE NO.

ttP- mpg \9101 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

ITIL EXHAUSTED.

DA 1 FaliV9 4678

EDITION

MEDCOM - 21385

CLINICAL RECORD


r

ORDER CLERIC/ DATE NURSE

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

the proponent agency Is the Off ice of The Surgeon General.

INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

HR DATE DISPENSED

It

I Mo.*Yr. 4e)_


DOD-034961

ACLU-RDI 1661 p.145


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. PL. yr Q'3

Order Dots

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES

Date to be Given

Time to be Given Time Given Initials

Order/ Expir Dote

Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUEN Y


TIME/DATE DISPENSED

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MEDCOM - 21386

DOD-034962

ACLU-RDI 1661 p.146

3. Register Number Name (Last, First, MI)

MO 10

Admission id Coding Information 0580 MB )9(2)-7_ IZ For use of this form, see AR 40-400; the proponent agency is OTSG

1. Reporting MTF 2. MTF Lou

7. Age at Admission 8. Race

21Y X

6. DoB (YYYYMMDD)

10. Length of Service ETS 11. FMP

99

4. Pay Grade : 5. Sex

FGN

9. Ethnicity Religion

9 UNKNOWN

12. Social Security Number I • 0a)

Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps: •

Z 09:30

ARMY

14. Flying Status 15. Beneficiary Category


17. Unit Location 18. MOS 19. Trauma


Prey. Admission

BC NO

20. Source of Admission Ward:

Direct from ER ICW1



Name and cation of Medical Treatment Facility:

0580 rail; No Install Provided


21. Type of Disposition ( z)

TRF-OTH


2003-10-12


AEA - ORTHOPEDICS

1 27. Location of Occurrence 28. MTF of Initial Admission

26. Date this Admission (YYYYMMDD)

2003-10-09

29. Date of Initial Admission

2003-10-09

25. MTF Transferred From

FOR LOCAL USE

Type Patient (Inpatient / Outpatient):

Admission Diagnosis Narrative:

Inpatient

L LEG INJURY



Admitting Officer (Signature, as required

■0 Lt.) -

\41umown. Automated Facsimile - DA FORM 2985, MAR 2000

MEDCOM - 21387

DOD-034963

ACLU-RDI 1661 p.147

DoB:41111111

MOS:


Marital Status: Z

In/Out Patient: Inpatient

Automated Facsimile - DA FORM 3647, May 79 MEDCOM - 21388


34. Diagnosis / Operations and Special Procedures:

S/P EX LAP WOUND DEBRIDEM


lAbsent Sick Days I Other Days ConLv / Coop Care Da

I C)

Signature of Attending Medical Officer

Absent Sick Days Other Days


ConLv / Coop Care Days ; Supplemental Care Total Sick Days

INP-.. , iENT TREATMENT RECG.-a.; C. _ ..t.:R SHEET For use of this form, see AR 40-400, the proponent agency Is OTSG

1. Register Nbr I 2. Name

\9 (PI

3. Grade

FGN , Admission Remarks

I NM I i_ , .

I4. Sex 5. Age 6. Race 7. Religion 8. LnthOfSvC 9. ETS 10. PrevAdm i

M 20Y X • ISLAMIC NO

H , 11. FMP 12. SSN 13. Organization

99 I

! to (0 H

Automated Facsimile _

14. Ward

ICU3

115. FlyStatus 17. Dept / Ben 18. BranchCorps

NO

19. UIC / ZIP 20. Type Case

K78-PRISONER OF WAR/INTER ARMY DIS


Direct from ER

24. Name/Relation of Emergency Addressee

22. Hour Of Adm: 23. Clinic Service


26. Date of Disp

2003-11-03

25. Type Disp

TRF-OTH

05:30

T Admitting0fficer: 27a. Address of Emergency Addressee

29. ReportingMTF

Iraq

27b. Telephone No 28. Date This Adm:

2003-10-10

30. Date Init Adm

2003-10-10 (y) - - I

32. Units Blood Components

DOD-034964

ACLU-RDI 1661 p.148

DATE „cit4 c...% 5 &_,a_ Nr--o-cc,- CC ..,f3NT) NOTES

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER .

ISSN or Other) LAST FIRST MI


PATIENTS IDENTIFICATION: (For typed or written entnes, give: Name - lest, first, middle; ID- No or SSA,' Sex; Date of Birth; Renk/Grade) " ' —

REGISTER NO. WARD NO

AL. oriORRED FOR LOCAL REPRODUCTION



STANDARD FORM 509 (REV. 5/19991 Prescribed by GSA/ICMR FPMR (41 CFR( 101-11.2030)1(10)

MEDCOM - 21389

DOD-034965

ACLU-RDI 1661 p.149

LAST NAME FIRST NAME


DATE NOTES

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MEDCOM - 21415

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MEDCOM - 21416

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ACLU-RDI 1661 p.176

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ACLU-RDI 1661 p.178

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USAPA V1.09

MEDCOM -21419

DOD-034995

ACLU-RDI 1661 p.179

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ACLU-RDI 1661 p.180


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MEDCOM - 21421

DOD-034997 ACLU-RDI 1661 p.181

SESSMEN Name SSN Unit Location

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MOI/DESCRIPTION 0 Blunt enetrating 0 Burn ❑ Blast SW ❑ Heat

❑ MVC teSjirapnel ❑ Chem ❑ Fall ❑ Stabbed 0 Elect

0 Assault WITH SEE 9's j

EQUIPMENT ❑ Weapon ❑ Sens Items SPONT (4/ ALRT ALRT

CMND 3 CONFD 4 LCL P PAIN 2 INAPR 3 WDR P ❑ Other UNRSP I INCMP 2 FLX

UNRSP I EXT

0 Other EST % UNRSP 0 PERLA 0 ABNL ' ODIA ❑PIN OLTNI CIFIX OSLOW - 4 -,--...-

Vitals: HR B/P , -

DATE/TIME NOTES _

/et/ c(' .'B(, (V- ZO chi 050)- 0 V r t &(--(_ , 6006',Vg ce, to •

44- MIEZ c (-€70/1 , lallEraiNtW1417 111NEAMMIrir'-

_ : ,A' ely i , • 'rev err _ , . .., - - - ,

ET-CEi-,G4/1 L - 1-(41D6 - - -(M--

,... L._ • ,, „ , .. ,,,..• .-i.).::,4,i:;*:::,-;,.:.:.:,p.:;; ••.f.:..:.-..

.e” L1 0-

_

, : • • ../.: ,i• 4 , ii

_ . r-, • i

. i

t -- •

' • ; ' , : - ,:;_l'i,:.::;-;":,:f::, ':f.r_ • ;,,,,

,g,4,10R:Vgar,

"4 1

- ,,,K,,..?,.;.?: ''4 404:atitt ,,,e, -aig-, --g* ,..., 4-T:' ,..144 . 3 .;'''.,' q41172,, ",. .41-:fd':"-r3 '' 11? .: 'S ''.:•': ''_______,_::2:_______;2. rA::;;;iii, ,,__,;,. ';'-AW.::'" r..; '

6.-ti. --;:r;:v: .:,1: . ',-,- ...i..,,,....--: • ",, ,fr ;-,_ P4,A,,,i. ,..,... ,, •

•:-;.' 4=,',;; :k.40:* ,- :4,0k.krf: - 1',1 = '' '`..--'"7--.)14,4C. NPAMV.: gL 1, 5'' :': 'W;X:. ' MEDCOM - 21422

DOD-034998

ACLU-RDI 1661 p.182

Tieran'ir. 77.2;Y4:7-74(. :.• b

ALLER.GIV DN MEDICATIONS A )0N. PREVIOUS HX , i c,lU k LAST MEAL. is.) tK EVENTS (see MOO

Description of Illness

• = • `.TERVENTIONS . .,„.

.stiotiorn ❑-Pbsition ❑ Oral ❑ Nasal rach ❑ Crich By Whom

reathing IfAssisted. n 0, L/min 0 Ambu ❑ Vent

0_Chest_tube_R #1 #2 L #1 #2

. Time. By _D_Needla.decomp=_RITime: Circulation:Baptand:time.

bags HI .02._ 03__-

13 oOfERIMELWEole - ❑3•- -

PASO 0 Legs 0 AB 0 Both .

Other0 ILI 0 NOT

Other

MEDICATIONS TIME MEDICATION

Att-W-0-

. - •

DOSE RTE BY

MEDCOM - 21423

DOD-034999

ACLU-RDI 1661 p.183

Name SSN

PRE-OP/POST-OP INTAKE OUTPUT

Time Source Amount Time Solution Amount

iY<Alri L IUB r

VITALS

02.

Temp Notes

44117ffiriAMINI • too

Time

(97a9 ,02 1 0

HR B/P RR SaO

(0

q3/so 10

CNS.... EYES 4 • VERBAL MOTOR

SPONT 4 ALRT 5 ALRT. CNIND 3 CONFD 4 . LCL P '

PAIN 2 1NAPR 3 WDR P UNRSP INCMP 2 FLX

--

.

f,1

v.N.RsP I EXT UNRSP

: PERLA = ABNL ,. 77 DIA 7 PIN 7 UNI r7 FIX rSLOW

Time Site ROM P Cap Refil

T Color ROM + or - Temp C=cool W=warm Pulse + or — Color C = cyan P = pale Pk= pink

MEDCOM - 21424

DOD-035000

ACLU-RDI 1661 p.184

Airway: Breathing: S Circulation:

Pulse: Color:

Cap refill:

Absent Abnormal

Is(61 Delayed

OM, echanically maintained by

s Assisted by -- -

CPR

7èvS1--

WART:

,UNGS:

:HEST:

.BD: AttA9A-- g1/1— 0'' -

ELVIS: 0 (----

:XT: OLIO— StIAV-31-15W4

(

0 'dielECTAL:

'50015:

PDLL-ttt) CtS —

19(Y) 1 Trauma F1(

Nam SN Unit Date and ti jury: Oct 63 Time of Arrival

S

Blood Type

MOI: HPI:

PMHX: PSHX: Mids: Allergies:

Secondary Survey Intial Vital Signs: b/p 1(01 pulse Resp Pulse Ox I ( Temp 11 F

GLASCOW COMA /—**\ c"

EYES Spontaneously ,....j

OPEN To Speech 3 To Pain 2 None

Oriented BEST

VERBAL Confused 4 ' RESPONSE Inappropriate sounds 3

Incomprehensible sounds

2

None Obeys . Commands

BEST MOTOR Localizes Pain 5

REPONSE Withdraws to Pain 4 Flexes to Pain 3

Extends to Pain 2 None 1

MEDCOM - 21425

Revised Trauma Score

13-15

GLASCOW COMA 9-12 3 TOTAL 6-8 2

— , 4-5 I 3 D.,..,

>89 mmHg .•'.4 (...---

SYSTOLIC BLOOD 76-89 3 PRESSURE ' -• mmHg

50-75 mmHg

2

01-49 mmHg

No pulse 10-29 / min '= 1 .:.

RESPIRATORY >29 / min 3 RATE 6-9 / min 2

1-5 / min I None 0

TOTAL

C14-$ -:-.271.r2/4.(4 1- IN'

rt,„ c. ex- Di t--

Sp0A-111-%1!01-L LN.

DOD-035001 ACLU-RDI 1661 p.185

Interventions

Airrei (7- Airway:

Breathing:

Circulation: _z7v r 15/z/)..,

11 6

Other: 6ip ii 900,1 J. rrl LA

Transfer Instructions:

MEDICATIONS

Time Drug Dose Route Initials

111111 I \ 3c, 1144y4-ri,. CV 1 —1,0 emtiar, '3: AA/

a

Blood Components

Unit # Type Time Response

Vital Signs Time B/P Pulse Resp Pulse Ox Temp GCS

ibc/x 'U" / 5-- ► 9 ►

0/4" 0 96) / 1(3 c? 1 IT 9t '4,

/

NOTES:

0.6/ C 4 5 --.) 6 _ c

• St/ 61- Pe v 1 c / )'2-‘ -in cp

-----r-r-6 SW 0 41-•(--ZP' /15A.

p .CLA" L SN'S ,, ,?: 1 61,,, ,0 I ./---

MEDCOM - 21426

0)- op

DOD-035002

ACLU-RDI 1661 p.186

17 (0-2_

BREAKDOW AND WOUND MANAGEMENT MEDICAL RECORD PROGRESS NOTES

,Admission Date: la My( v 3. Diagnosis: CS 6.0412,34/14-, HD: POD QOJ

Date: i you in, Time: 1 cv--k - RN Signature: - - Skin breakdown as evidenced by immobility,

Wound type: Surgical wound (s) Diabetic ulcer Venous stasis ulcer Other Describe

friction, shear, rn rasions, surgical wound, skin tear.

Location: e) .4?----( 11./ 1 c-•---1 Size: 9 vr-,01--N. Drainaae: S"""') Tubes: pA,,rrv--L Pins: Appearance: Dressing change: 11 r)

Burn wound (s): % BSA Partial Full Location: Size Appearance: Dressing change:

Pressure Ulcer (s): Stage 1, II, III, IV (Circle the one

Location:

that applies and describe below)

Size: Wound character: Pink Moist Dry Granulation tissue Yellow slough

Tunneling Undermining Odor Purulent discharge Eschar Exudates

Refer to SOP for Dressing Change Instrucitons.

Please check the appropriate dressing Change:

S--....„Wet to Dry Dressing

❑ Carrasyn-V GelDressing

❑ Alginate Dressing

❑ Comfeel Dressing

❑ Pin Site Care

❑ J-Tube Care

❑ Colostomy Care

❑ Chest Tube Care

❑ Burn Care

NOTE: Document daily wound and dressing change on Progress Note or Nursing Note.

Select the appropriate products used:

g-__ Sterile 4x4 gauze dressing ❑ Sterile IQ gauze dressing ❑ Sterile gloves

Kerlix (super sponge) Gauze bandage

,K. 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

❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Teipha 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 & 'A

Sterile Normal Saline

Select the frequency of dressing change:

❑ b.i.d. 2(7 ._... t.i.d

6 (4) -- -7.—

MD Signature • d Date:

a Dttri

Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade: rank; hospital or medical facility (

COM - 21427

Medical Record, SF 509

DOD-035003

ACLU-RDI 1661 p.187

SKIN AND WOUND ASSESSMENT MEDICAL RECORD PROGRESS NOTES

Admission Date: ( d D 11 1/1" Diagnosis: 1 ■. CL--, (c--. HD: CI uA POD: d) ° S. Skin assessment must be done initially and every 7 days... — .. - -

Braden Scale Evaluation (See Braden Evaluation Table for Details)

Sensory No impairment 4 Perception Slightly limited 3 '

Very limited 2 2

Completed

Mobility No limitations Slightly limited Very limited Completely immobile

Moisture Rarely moist 4

Occasionally moist Moist

Constantly moist

Nutrition Excellent Adequate (Eats >50%) Adequate (Rarely eats) Very poor

3 2

Activity Walks frequently ' 4

Walks occasionally "5 3

Chairfast 2 Bedfast

I

Friction and No apparent problem Shear Potential problems

Problems

Add the total score Above 20 Low Risk Between 16 and 20 Medium Risk Between 11 and 15 High Risk

Total Score:

RISK-requires immediate Ulcer Prevention program.

('Below 10 . ‘. Very High Risk - Note: A Braden Scale Score of less than 13 indicates HIGH

Surgical wound (s): YesX No_ Location: ( ( c. 4-1 -----, Size: Drainage: Tubes: per„ ,,N.t._ Pins:

—t ( Appearance:

Dressing change: /,

Burn wound (s): Yes_ No_ % BSA Partial Full Location: Size Appearance: Dressing change:

Pressure Ulcer (s): Yes No below)

Size: Stage I, II, III, IV (Circle the one that applies and describe Location: Wound character: Pink Moist Dry Granulation tissue Yellow slough Tunneling

Undermining Odor Purulent discharge Eschar Exudates Type of dressing change: Wet-to-dry Comfeel dressing Carrasyn-V Gel Alginate

Physician notified/consulted for wound debridement: Yes CNS notified/consulted for Stage II and greater: Yes

No Date/time MD notified No

Nutrition Referral: Yes No Physical Therapy Referral: Yes No Action taken: Date & Time

REGISTER NO. I WARD NO.

ACLU-RDI 1661 p.188

• NURSING NOTES (Sign all notes)

OBSERVATIONS Include medication and treatment when indicated'

73.-

) L)_ _

■ HOUR '

A.M, DATE •

k 0-1

(i c(L-ors _ _

c1^-'1:14

2

s )• '' 7 ) .

ODt ' - • •

( • c:71 I

0 .;\

6/01-11' ---_---J

c L

,r 4

,-- a a&

E),A, J _ _

ttl

ur •i I

'U.S: Government Printing Office: 1995 - 404-763/20065

MEDCOM - 21429

FO M,510(REy.7.7G- 91.)BACI STAN

9

DOD-035005

ACLU-RDI 1661 p.189

/d

MEDCOM - 21430

DVIE

510=112,-, - NSN 7540,00-7634-4123

MEDICAL [RECORD

DATE

:-NURSING NOTES. r( (Sign all notes) '

" HOUR OBSERVATIONS Include Medication and treatment when indicated A.M. P.M.

pc, aktylyi

-

6 ( ;,t,IX.

T v A. )

1-. P . 4j7 c:i., - • CIA (k L) ---c l t10---,) - e? '"" -

tis ti._ -- c'T : 6? s r) ogi).0 _5 ✓ C - C_;:, tff. ber (--ke,' _)

.. _ ) I- ) • it,fq._ . (4-8, -,:_,,k \' 4., -, 1.1.,-tiqi, cip-ci,..„.

,,),1,- , Loe.-z' l t.-1-f i. ''rLIT-.;- c c2,-,,-i-) ,2111 e-5-426 3 ., (.... A...,

-'' c; ',j •.;,_ CC-1. -1- Ok '_) pbe(-- ,,.), Aga; ,66, 3

J

L; 1:4:e-:'- rg:-=-> C40/ 4-1-%- a`:-, (-- .k( (t-,. '- J /1,, 3 J

e-)7(.., -„\ -t _<_ ,.,‘,--,-__ j. _ 1.------C,31 - , L .-C (,.: 04-c. -K-1 L- , ,•„

1))1,/ ' 9/

(Continue on reverse side

/i)•-) tit-, - -

r.

PATiENrt ThENITIFICATioN ?Far tj;ped,o -ni.gitt6n -eh ries -eiv0: Name15M; first,"friiildre';'grade; rank; rate; hospitt31 or medical faCi ity) - _) .:; • -

REGISTER NO. WARD Nb.

NURSING NOTES

----Medical Record-----

STANDARD FORM 510 (REV. 7-91) Presofilied by GSRICMR, FIRMR141-CFR)-261-9.2D2-1

DOD-035006

ACLU-RDI 1661 p.190

NSN 7540-00-634-4123

SING NOTES (Sign all notes)

U S

■01- -

MEDICAL rRECORD _ .

DATE OBSERVATIONS

Include medication and treatment when indicated HOUR

A.M. P.M.

00 o P ,

3 A-5 10--pc

stku le2C_

• Plq.. ^--) a-0_1

-----1":74% •-••/`

`1 V fr

I 00.m-0;5 0 61c° lq) VC 141,0 or' 3 -Pc

, : 1:-- 1 . "l l c t • : • - 1 - ,,..,..., ' •?c• ' , .: id finiv-, , , ; .-; - - - .- . .-;----- 17 Z

' ,. j .: , • 1 n- ' lei p a 0 l-- 1 t.p ,,,1 Cl, -AAA-6 ' Ri)-- LL .

.._.

I I-. - -. . , . -y

(Continue on reverse side)

PATIENT'S IDENTIFICATION (For typedor wtten en nes give: Name—,last, first, middle; grade rankrater' REGISTcRik10. --' '-' -- i - T 7,74 ':- -- , WARD NO-.- - — - — , . .

' 1 hospital or medical fac lity) ...

4 .

NURSING NOTES

----- Medical Record

STANDARD FORM 510 (REV. 7-91) — Prescribed by GSAjICMR:F1RMR (41 CFR) . 2014.202-

MEDCOM - 21431

fiE

DOD-035007

ACLU-RDI 1661 p.191

'U.S: dOiamment Printing Office: 1995 - 404-763/20065

ODETEL •-• CI!


OBSERVATIONS Include medication and treatment when indicated t-'=•

HOUR

to ocro Mkt_ &A/ 4._ 0 A LA

11/ ' ..,•■ .

11111 .. A JP,i4b i 4 _.• -. L . , , • : ,.... , •

IIMMIONIMMI.1.11111111111111111111.1.1

—

I .01 111 A A%

MIR tit 2

1. •

11111I4_144.4 . •

MEDCOM - 21432

r 44 1 _1 it A .44

tifilanie

/Ram. /1121/...... 1

STANDARD FORM 536 (14EV:7-91)BAqi

.110.1%..."

DOD-035008

ACLU-RDI 1661 p.192

L.),C(1) 14 D 'II& Government Printing Office: 1995 - 404-763/20065 STANDARD FORM, 5.1.0(REVi77791) 3A

(AD NURSING NOTES

(Sign all notes)

C2 S /1 tit&

OBSERVATIONS Include medication and treatment when indicated DATE

:M. - P.M.

16 -Our 193

I'D trots

qe-r6.3

r

MEDCOM - 21433

•

i HOUR'

DOD-035009

ACLU-RDI 1661 p.193

1-V3

G

(01i RSING NOTES

(Sign all notes)

NSN 7540-OO-63j1

RECORD - NU 51041'12 ;

MEDICAL HOUR

A.M. P.M.

OBSERVATIONS Include medicatio n and treatment when indicated DATE

oce co Ib )

: I • ,

‘-'et CetTA&ISO 405 DAO 3

Noc03

ts •

1

1,M

Pro C)

i-- ,- "t

tuar..-4 0..9....1. ca,p-A I.A.M,,,I.Alkadk

• ;',.. , , : , c'tsa AJCP 4t."., 1 A---

---, 1.-_, ( r 1 ,

vg 4_ Ms c 0 lc Q (Mc& . -,e_.1.ra E cx....z,.0...Q U4./9%-t _ , , v

U P . 1 a . - 0;4" qt-tAl.Abili; .ArttX."=5,>-%, `lam . ---------iIlla

Iv a it "Kn 1 lidAik, eis - ,a

____, -

to

()Lel 541-s icy .nsig

(..;

UriA___t_ G co- )-

,

57-c‘-.." fio > I /1/5.nci

cttr 11/01 0-z7P 2 Llc (../1 Cf" it) / o

r 5 +0. VtiLcit - t 1 1"-,.' A- bd.. -FGl S >t t

Li-kb—c-le..'es- dj. G&

le-4A e rci :of ref, L IA) a) ,av,

7\)1A r tA;41(it c-77,f --7(771-77 j QA-661/0...A ce

0(14: c,t arc/ Q

(Continue on reverse side)

22o6

ngsr)

I. a L-tit"

S (4. e_ CC 4>i 1>i 4-0 y 64-y. 0(01' LI

L 9 ,

(Al

s-e. r. or✓ 5 circa 0r

L-c-a

REGISTER NO. PATIENT'S IDENTIFICATIO N (rOrtyfed rorvi-iiitterien des give: Narne--4a:St, first; middle; gfadd rank) rate: • hospital or medical faCifity):-

•

WARD

11111-4"1--

L. :

v -(7,

MEDCOM - 21434

'' 1 NURSING NOTES

- Medical Record

STANDARD FORM 510 (REV. 7-91) Prekribed - by GSA/ICMR, F1RMR (41_ CFR)20i-4.202-1

DOD-035010

ACLU-RDI 1661 p.194

• .;NSN -7540.7037:634-4123 616-112'--

MEDICAL RECORD _

----- NURSING NOTES (Sign all notes)

OBSERVATIONS Include medication and treatment when indicated

DATE A.M.

HOUR

P.M.

LflLL LL y Ai/n-7 fk-D

kTh /UL I (2,

01-) S 2

0 61., G1 nc i Orb -( "( -1, --G- ) (

L. s5 ))11 'Le d141c.

cu-ui c (7( t .1

68 (6-1

--s

1— S7

■


. .•,

. . . . i ... (Continue on reverse side) (For typed or written entries eye: Name-•—last, first middle:- grade; rank; rate:, REGISTER NO. . ,- WARD ivci:.: hospital or medical facility) . • ," : rs-- 1

) C - t..:.

11 L--7.ic- ...7,1H ...-;...C.;.; -,;;.;;. NURSING NOTES

1 f:: -47i111; ---.. •: -. - i;1.:- -; .= -- .Y.32E2.-\ ':".1.:f-;...'

-

3,;:i.; :;:; .;,%::::.•,; "Med ib-81 - 17ed - '------- .- - .-.:-21:.i. :

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

MEDCOM - 21435

DOD-035011

0 (0 co

ACLU-RDI 1661 p.195

'U.S. 661ramment Printing Office: 1995 - 404-763/20065 STANDARD FORM 510 (KV. 7-91) BACK

)20.2, (cti)


MEDCOM - 21436

DOD-035012

ACLU-RDI 1661 p.196

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

MEDICAL RECORD

2. KNOW

(

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

1\1 3. PREVIOUS SURGERY [ I NO YES (type):

C. r'Sl-

AGE: '3(:=3

HEIGHT:

WEIGHT:

.Medical Flx:ee.sc-- 1.3 • Implants:

4. PROPOSED SURGICAL PROCEDURE:

(e. Sae, ra OU06 (la c4- I (A) t/t4- r -1-en‘

Medications: Jewelry remove no Family waiting: ye

riA r g ock 1-cw_ci GhaV-1-- cvik (4,14.)ctrvL A-antei 6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS

x•• A -PSYC GbOCIAL

io.

•otential for anxiety

6. Pt. verbalizes any specific anxiety. -- __________

(5---‹-exhibits rela - I • e • eistiire.

--------------- •

I

/PT. will be able to breathe without difficulty during immediate intraoperative phase.

4

1,..10!:,

pt. • • a

--"°'- xplain OR environment and answer questions regarding surgery.

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

all nursing r•riicEgijar-in s before they are done - " : 41- i n with pt. whenever possible. o Maintain family inte a

et-r6ffer to elevate head of litte or offer pillow.

Observe pt. while awaiting surgery for signs of distress

Assist anesthesia during intubation and extubation

related to tram c injur ;

language barrier; faint

, separation; surgical environment

B. AE ION Potential for •

respiratory dysfunction due to sedation; positioning; injury

C. INTEGUMENT

Potential impairment

i■---11T. will not exhibit signs of impairment of skin integrity (e.g., reddened areas.

-

■:.,,,,d-tilize pressure preventing evices on OR table and

accessories. Check for proper

positioning and support to maintain good body alignment.

.. 6..--F'ad pressure points.

/lace ESU ground pad on non compromised skin surface area.,, 6----Keep prep fluids from pooling.

:

of skin integuity due to Bovie

pad; position; fluid shirt

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

DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01

MEDCOM - 21437

5. ADDITIONAL I ORMATION: Last POliet

DOD-035013

ACLU-RDI 1661 p.197

D. CII,ULATION

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

position; shock; previous surgery

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

OTHER NURSING INTERVENTIONS. Or continuation of above interventions.

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

PLETED/ADDI IONAL INTEROPERATIVE INT ERVENTIONS NOTED. 10.

/d4err er5

IVE EVALUATION:

ls5)

Evin\ep S'i 2 C-Dr 7

ritq-77.7 eivh 5 ")1,: '"?° ► • P 1,°)

DATE

• 1:4 i PERTIVE EV

0 REVERSE OF DA FORM 5179, JUN 91

ON PREPARED

e;tarfrr USAPA V1.01

13.

MEDCOM - 21438

NP ARED BY

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

g)....r.htEicfor support stockings or ace wraps. If none, check with doctors.

to......64.tetrihat safety straps are correctly applied.

w--CfrerPillow for undeil knees.

0_21a.eeind take down legs from stirrups with slow bilateral motion.

ILC.laet4tat rings have been

removed.

c..../flave sufficient people available for transfer. Q...-I-nsure proper body alignment. b----ATIow patient to lie in position of comfort while

gailirg...) for surgery. ffer support (i.e., pillows,

bathtowels, etc.) -for positioning.

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

tE)--""6t. will be transferred to OR table without difficulty.

will not experience unnecessary physical discomfort.

E. NEUROMUSCULAR CONTROL,/

E.1. I/Potential impairment

of mobility dt e to sedation; pain;

injury

E.2. otential discomfort

due to injury;'pain

F. NEUROMUSCULAR CONTROL

• Disminished visual

perception due to being injury;

sedation;

F.2. Potential for decreased

communictaion due to language

barrier; sedation

F.3. Potential injury due to dentures.

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

danger of injury during

intraop period.

o Introduce self. Keep pt. informed as to where he/s is and what is happeni g. o Inform pt. in whi direction to mo s if necessary. o Sped rl nd slowly. o A drf pt rom

side.

• lid e pt.'s and -rs nding of verbal CO nications. o erify removal of dentures.

DOD-035014

ACLU-RDI 1661 p.198

....

,'INITRAOPERATIV - UMENT --- ---- - MEDICAL RECORD

For use of this forrh. see AR 40-66, the proponeii . — y is the office of T urgeon General.

1. PATIENT TRANSPORTED TO OPERATING ROOM

VIA BY

2. PATIENT IDENTIFIED, PROCEDURE

VERIFIED BY

3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM

TIME 6 0

NUMBER

5. PREOPERATIVE EMOTIONAL STATUS r—

OTHER CALM ANXIOUS 0 EXCITED ❑ CRYING 0 ANGRY 0 WITHDRAWN .. L_I (Specify) — _

COMMENTS:

6. NURSING PERSONNEL

ASSIGNED RELIEF SCRUB SCRUB

40 —1---

ASSIGNED RELIEF CIRCULATOR CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) A44) 71 ,,,,A-l• - •, , ,..,,, gl.e..) Z-,V° i

SUPINE LITHOTOMY . , PRONE 1 ■ KRAkKE e,... L)TERAL: • I LEFT SIDE UP RIGHT SIDE UP

4/7401.1/55 ji•-2? 3:4-i--% /6 t-/— , te-a) f").° ..,

COi MENTS. _

Ai 8. SKIN PREPARATION

HAIR REMOVAL _YES NO . 1 PREP SOLUTION pecif/1 ‘

DONE EzY _ OR _— NURSING UNIT I SITE: BY WHO A

METHOD: DEPILA ORY RAZOR ! SITE: BY WH M: , .

CLIP

COMMENTS. . COMMENTS: 21'.17

9. LOCATION OF EXTERNAL DEVICES _ -_--;---;

— ■ ill !..-- i l ::

_ r------, \ •‘.....

LEGEND X Ground Pa -- Safety Stra = = =. Tourniquet

6 (t) -2_

I C = Correct I = Incorrect First Closing

0. COUNTS I Other — 1 c

1 Count tClosing

SCRUB CIRCULATOR

Sponge : No 1 7 /

L

LQ

,/

Needle Sharp Yes ri No 1

Instrument ! Yes 1 ! No I 1 Other Yes 'No I -

I 1 1. PATIENT ENTIFICA ON (For typed or written entries give: Name - Last. first. middle; Grade; Date; Hospital or Medical Facility;)

if z .44--Q Af47(0 Ar 11-c--

. ...---...

12. ELECTROSURGERY DEVICE(S) (ESU) YES E NO

I ESU NO:

GROUND PAD: BRAN 71!' LOT NO: //519 -1/ .1z-f .

III ESU NO:

GROUND PAD: • BRAND

LOT NO:

IN BIPOLAR NO:

— .—

DA FORM 5179-1. OCT 87 IVILVVVIVI -

REPLACES DA PC..., . ..--... .....-...S OBSOLETE. USAP A V1 . 01

DOD-035015

ACLU-RDI 1661 p.199

13. PROSTHESIS, IMPLANTS YES 12r., NO Ii- Y Lb NHIVIt: IU INUIVIDc.n; viimimur,,, t v11,r'1-110CD1 111 NUMBER,

14 7. ,;::::-;g,:.4;,!: !,. :,it , .;7,:' MEDICATIONS/ORDERS4;;K.: ....;,.....,;: ;,,, .:,... .._.r..i.j.L..4.::.:::: ----. . . . :;:;..1:

IRRIGATIONIMEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES E NO

MEDICATIONS. SOLUTION. DOSAGE TIME METHOD • PREPARED BY 1 GIVEN BY

i"

WOUND IRRI...ATION ' 7 YES ! : NO; TYPEISI:.

/ f/55 _

■ ri:::-. ....

OTHER -.Liz...1- TIME • CARRIED OUT BY

to 6 .. .

A - A OM IF YES, SITE

• YES:. — NO 1a. LABORATORY SPECIMENS

SPE-Cit.:EN S NAME NAME

YES :!C FRCZE(‘: SE.:-•:.71.ES NAME :. . NAME

YES :7';'' . ',IC. .. CULTURE .C. NAME NAME,

YES 1 'IC mE-ii. NAME NA • NAME

NAME NAME 18. DRESSING:IMMOBILIZATION iSpecilvi . :....•

17. -_?EE -.FA. :::-.3'PACKING YES NO . TYPE SIZE .. - 5/y g-----

.,: ...

SITE 2. 3.

• ,A0/04r 19 ADDITIONAL. INFORMATION

A/Z-i-----__—..

111

Ao-

. ...._ -

20. OPERATFDHISI PERFORMED •

-16)-2_

21. PATIENT TRANSFERRED TO TIME METHOD

, "1/467:47 .-

1 - 22. REGISTERED NURSE SIGNATURE •

REVERSE OF DA FORM 5779-7, OCT 87 OM - 21440

USAPA. V1.01

RA 1,1 IC

DOD-035016

ACLU-RDI 1661 p.200

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