, op. V-2-- riampormr-divm mum - Torture Database

—J ---TDRLLG.:

ivi EL) !UM L litl;UKLI - ANESTHESIA For i, ,lis form, see AR 40-66; the proponent agency . OTSG

i !i)in

----

co

••s _ n 2 <

ili

.40

.- 17'

.:F, :DI u, -2.

'Q:

,,,.. .._r .• f:P'644:

TOTALS ::::.TOTALTE, • ......„

DI

Li L. - 0 , 2, E ,- z ,.,

In 2. V)

E 6 21- ')

F. ,Y, --- ;6-25 ■ .)

0 1). . 3. • ( -

1 la ( f ram ( -

( Mg OTAL ORII\C

0

PM , op.

11111111011MI . 0..F_...AT:

AGENT % del

'',A-- • -, ... 1 4::Ulp-s::::s '' IVIAW;:':.

AIR L/Min

1101.1 1---

CRYSTALLo D ir-r/ 020 02 LIIIMMiitn1 IIIIIMIIIMINMII

COLLOID- 500IVIC gt. SINGLE oOSE DRUGS-MARK ON GRID

WITH NUMBERS & ENTER IN REMARKS BLOOD-

. . .. . . EMARKS:',--, EM ARKS . .......... ::.-:...

so' 1:1.

-.:,.1: L1...

LINE see it ,3 armed i argC • armed 1111111TEMIN

:-. ■ .1411KISIIMMIIII II Warmed Code drugs with numberS.

events with Fellers -

rtire,„±(4C (......... 11 -FP

f) • -E- -C*7 • I

, ZEr -1--,---A -r- ) L....., 0 acj e, k5, •v71 `;''' ' ?

.4,- / ei'i 45 p.x- fr ./..

V-2--

ROOVERY.,../VI. PACU Cu Specify)

ft OTHE'

❑ Warmed CAD

EYEAMIIIIMErffa = MONLVM

7 :11 . 10

■

I DO ' •.: - • - • LOSSES. :.<-, .. .....-

PHYS• STATUS,

2345

EST URINE

BLOOD LOSS 7, - 'lid) TIME

0

E ,--------- • • 6k:0, ■A/fIGHT:

..... SYMBOLS. ' LS SY •.:.::.....:. : ,,,:r..:,..,.. 220

200

180

160

140

120

60

40

20

111M11353AMILT111.111 IMIIIICIVOIMINIIIINE WW= • - KG

LB ,,,--- 1-1EIVI.A OCRIT:Y, •-

80

BP by cutt V A

Heart rate •

Resp rate

BR (transduced)

J.. T

TOURNIQUET 2.

ANES- X-X P ROC-e_0

0. ,

o. IIMMEIIIIM PIMINST I n.

,--,,

INI:ri ,\ L DATA:'.. 77-) BA ,

_

WEIN .

1110111=111'

‘s, i;

11.31-17111111 r in IMIlf

174.11111CZNAIII VIM

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=CZ

100 0 • 42 ..5 9 .' • IIIME . 41.

-.- MU HECK - nil

IMIIIIM agM ELIINSI

• . I.

()I':'- / V N -• -f- Olr l'n ' Pt;! - is-:Et TIME

i ••

UM111.111111

MENIMIPM11/WAIRMI•

VTarSlalIM IMPRIMEMIIMMIIVarrilir

riampormr-divm

•

IIMIlaill, .._"1141111111111111.4111111111111111111...-"LillgEril

. •

NMI

to

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•ro o

sz Pollrlininal

q 0 0

mum

e0 0

-Mill

00

11RESP•

,-, - •1 •• ______

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0

MIERIIIIIMMINIMINIMMIIIMI

miMMLEIMINFIE

• 9

"Q C) ellaINEREEMIIMMEraummErriory:(Alelpann.

o

00

I - T CO2 (Um) IEWILMallrgUlraleiginlgallMIEINII

Iairan

f - breaths/min z • Peak in f pres / PEEP tm DOE ,Ionl, A(ssistl. Cion)

6' int cc Cult ,.. , ,: u) .-, ,

:0 W• .BP,otil ,

41 -,'"i\ RT Hilo. - • •- ----- In PC/ES

7 JuLl C,,s analyzer .0

1 02 (Prat or %I 1 Sp02 (%)

CONDITIMDC,'

BP- U --44; 7 .t ,,

co Ct 0:

-4-

a

1 I -•

• , Id k

4f■IES QC URE: ...,. MYSES :

11 Room End L.

,. warmer

, ,..,1.,; ,r ;71111g 61 k t

',Cum ill gliargintlI

11111MM.

^-•-■-+ mipprippmp..--... 1...mIlln I WIN/

Mark ,, ; ,,.' ,, ,i1,., S bols EVENTS_ ID explain•,•.,,:, 1:FlIARKS Position " 111.1n 0 -eD IV 0 Ready Begin End

0--4 co 1 PROC,DURES .,nu CPT Codes: `,)

o_ ANESTHETIC TECHNIQUES: Describe block technique under Re arks

I

pATIEN- :.,, v, ON Typed or written entries: Name, Gracie/Rare, 1 AIRWAY MANAGEMENT)/n ub

11

\--------,

tion route, blade, te uriqu con) ems

SURGEON PROCEDURE A / \P \''' 0'.1.'

LOCATION: / CIA kik. DTE:

/-1 , 1.1 2 Seal 0•3 CPVitkr DA FORM 7:1Rci PPR 1 acia ..— 1 PAGE '' /CF

NIL LiCi(J117

DOD-032015 ACLU-RDI 1647 p.1

MEDICAL RECORD - ANESTHESIA For u .tis form, see AR 40-66; the proponent agencN,

OTSG

ci) cc) DRUG f:(:Q.'.66).: : : cq. o _..i TOTALS I': TOTAL D. D Z Z C-. 4 L Coo( rol ) cl k--, 2 b-,sol cisi ( en )

`3 MI NM

.

•6: Le; 2 ur 6 C.401 ( i.b ) z )- 6 z is A_ t • .- 1 ; .1, 2 JR 1 .. 11" } d.- TOTACURINC ..:,.. .:.

.. ol 0.-„ 1, 2 --.1-- I--

( ) cr) -- tr, ... w ± 0.

"-:‹ :.: 0 -..

SDO :V.:6LAT.- - % del D>- (_>

/,`-( a, 4

:::,4dg '''''' 'X, e.t. Z B.- , i . pc.).

. .?3,..!P:Sq:S.VM!VrABY::: b, tn - AIR LiMin CRYSTALLOI

Om t N20 L/Min 1-. L) COLLOID- tn. 02 L/Min tu. :2- SINGLE DOSE DRUGS-MARK ON GRID •< WITH NUMBERS & ENTER IN REMARKS BLOOD -

REMARKS:": :, :- Code drugs with numbers, evenrs with terriers

..-

,-) 2 455658 rt.123 C...--

(V ,,c4,..):

t.

at /1": ' GD-t-,0 tf-J

-ro.:I:( U. — 7--

/V;s+-0A,VCl2A: 6V 0 ) o, ,y ,c,........re„.

---,

re (?---) I,lvC&-S2ei

1..;,, ••• to , . x• ,,,,A

0 F.Je . -70. S -T" J

-r5i3 ES-p- 1 : 2-

-1.-3 goo ciN%- -

RECOVERY

LINE site glf Warmed

5

s .„.

'.i • Warmed !

I Warmed EST BLOOD LOSS L/00 LOSS ES :. URINE - •21700 r

R1i.:KS:4TAT.0.$.:5 TIME .30 t.1S00 - STAT

3 E 3Z:-, 1603 .. .... ,Y. IVIB.Oti$ ::, ?4

. ..:-. .::.

B 3 KG LB

BP by cuff

V A

Heart rate

20C11 ftettuATci(F0T: . ::

, III 180

CP -; .:11nir(IALI:)4174:1 160 •

Resp rate

BR (transduced)

_L T

TOURNIQUE .../. T T —ri

140 . BP-

120 immustimprintimi ill

- __ t; HR -

100 IBM_ INEEMIXIMMIRINillIMI •• . ..... • _

, Ezzalr a • iiima • .

OK? 1WIL/IIPIN 0,E,,,,,,...K.

:312';fil

6° TrAM-araseraasi 0 ... ............... --Ialiimm •• .., • •••••••-• -

OK for PROCEDURE?

TIME-

ANES• X - X PRO C- 0_0

40

20

. VT - ml q 01-) 7 9t) 1S--0 11.0 73 ' -, F.,-, '

Z, 1- breaths /min 1 0 /0 '0 I'd 0 tit >

Peak at ores I PEEP 2'1' 'ea' 7r4 -z,% vg MODE - S on). AIssist). Clon) (..• C.,

BP/Auto Cult ET CO2 ftorr1 -:;# BP/oth F102 (Frac or TO

0 ART line Sp02 MI

.„ • MILMININIIMI

"". PACtrO______ISpecityl

cyr.3 1Q0 rig 1 00 I 0 ul Steth• PC/ES ?'ECG

.12 i Gas analyzer immgEtingsmianwima 91. ff

I ar■ iLima HR-✓,.4

'a_ RESP-

CONDIT!

p02. BP-

Q N-M Block (T/4) NM • ',4 1 ct

t ,:a

I [ill 4VOYFtle40:'4PF1!Pqn:NFle::.•

,WIL

0

iroP- 2 Room -- armin blkt innompArlirlia-- lm- A

Cony warmer z <

Mark with letters & symbols, EVENTS__„ )

c.) 1 Ready "•-:-- Begin n explain nodes REMARKS ..- Positron

cr ci., PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES Describe block technique under Remarks

PATIENT IDENTIFICATION: Typed or mitt el r s. Nam e rade/Rate, , y

- AIRWAY MANAGEM bat n I. e e, ech ,que, commentS

SURGEONS:

./ 1..... PROCEDURE•.----- LOCATION: Vok.,tin4 DATE:

Z SQ.Pt °3 ir act, C S 'le if .RAGE OF 3 DA FORM 7389, FEB 1998 RAF nrnnii _ 1 RA - -- - Ay* t

P'ATIB[ S MEDIC E RD USAPA V1.00

DOD-032016 ACLU-RDI 1647 p.2

C) E4 ANESTHE

/

TIC TECHNIQUES: Describe block technique under Remarks

0.

PROCEDURE LOCATION: (-)-e DATE:

PAGE

EDICAL RECORD

OF

USAPA V1.00

DOD-032017

Fr

9

DRUG (Units},

.to ( \if/if 5

fryb/ l

( 32)

DIS

:;17 (ii:At;,:01§(N

. . % del

:AGENT:: % e.t.

AIR L/Min N20

02 L/Min SINGLE DOSE DRUGS-MARK ON GRID ♦

WITH NUMBERS & ENTER IN REMARKS

LINE site ❑ Warmed (0, ac ❑ Warmed

❑ Warmed

OWarmed

EST BLOOD LOSS

-5 7, n

-P_

BLOOD-

nEma

MEDICAL RECORD - ANESTHESIA I this form, see AR 40-66; The proponent agen ± OTSG

TOTALS TOTAL:; ESL

URINE -

:iPtiY.4:017AT.V.4. :::: .;

BODY vs/mHui,

TIME SYMBOL

220

BP by cult

V

A Heart rate

tN (DATA; •

BP- Resp rate

200

180

160

EctutP.;:pHEG.K,

DV-

pAt,IEkr: geHgcks

BR (transducer')

80

TOURNIQUET

T —4/ 60

4 DIC for PROCED

TIME-

ANES- X-X PROC. e_0 I

O

NJ

ce

O

- breaths/min Z-

Peak int pres / PEEP

ODE - SI on), Aissist), Clon) L. BP/Auto Cull

T CO2 (ton) Fl r 2 (Frac or %) Sp02 1%)

E G

S .TEMP.site

N-M Block IT/41

Warmin blkt

Cony warmer Mark wnle letters & Symbols. EVENTS__._ explain under REMARKS Position ("J

PROCEDURES and CPT Codes:

8P/oth Fig0:00f1:,At PACU FCU

OTHER

SpecIty}'

CONDITION:

RESP-/V Sp027/65 BP-I

.4.0g4.7:kfiggPV:

4 ti;(03 Reedy

Start Room End

Cr

End

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

Medical facility AIRWAY MANAGEMENT: Intubanon route, blade, technique, comments

A

DA FORM 7389, FEB 1998

MEDCOM - 18443

ACLU-RDI 1647 p.3

ASSESSMENT PAST SURGICAL/ANESTHETIC

•

PHYSICAL EXAMINATION BP HR . R T _ Pain Scale 0-10 HEENT - Teeth

Trachea TMJ/Neck Oropharn Nares

CHEST:

CARDIAC:

EXTREMITIES:

IV Access: Ulnar Filling:

BACK:

OTHER:

NPO Since

Y Y

C kj

N Y

Y Y

N N N

N9

T U2V3Z1tS) (e),r3-• ,51-61-Q, !LW

N Y N Y N Y

N Y N Y N Y

N N N

Y

Y

SEDATION KEY:

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

2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or accompanied by light tactile stimulation. Airway assistance is not necessary.

3. DEEP SEDATION/ANALGESIA. Patient re4otnis purposefully following' repeated or painful sti rrn= Airway assistance may be rY.

4. ANESTHESIA. Patient does not respond to painful stimulation.

Signed:

discu

The pa

Signed - a-Date: 7-- :..74.---'62„

e. Time: C-3 &C)- Hrs

POST-ANE THESIA EVALUATION AND N • ASU) ) NO APPARENT ANESTHETIC COMPLICATIONS { ) OTHER

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternativ Trit‘he pa ent/legal guardian.

t-i-t1) 1 agrees. Questions ans

7-‘

CAL- •

Date: Time: Hrs

and risks of anesthesia including death have.been explained to and

Previous edition is obsole e

DOD-032018

MEDCOM - 18444 WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS

Patient Identiftication: (Ward)

- ok_

. ii LI •1 • I I Age "9 DAYS MOS YRS Sex (.)--MALE ) FEMALE

ASA Physical State 1 20) 4

c) 51r

WT: KG/LB HT: ' I . ALLERGIES: /O(C i -JR—

ANESTHETIC PLAN: { } LOCAL ( ) MAC ( } Regional (Specify):

( I-General: Mask Intubation

PROPOSED PROCEDURE: SURGICAL SERVICE: •)- NPO

p3.7

HABITS; TOBACCO: f)

ETOH: ""Z DRUGS:

CURRENT MEDICATIONS: ( )= ordered as premed

()

()

() () () ()

PREMEDICATIONS: None Yes (0 Hrs) /CC mg IV IM PO

mg IV IM PO mg IV IM PO

LABORATORY STUDIES:

HB/HCT: WA: OTHER:

3, 0

zo , iq7 101 rt

39• Familial HX

()--S(•

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:

Hypertension Angina MI N Y CVA N Y Other N I Y

Pulmonary System: Asthma Bronchitis/URI COPD Other

Renal System: Acute/Chronic RF

Gastrointestinal: Hepatitis Hiatal Hernia PUD/GERD

Endocrine System: Diabetes Steriods Thyroid

Neurological: Seizures Neuropathy Other

Gynecological : Pregnancy

Other Significant Hx:

fr-E14:_a_Qp

ACLU-RDI 1647 p.4

ty PHYSICAL EXAMINATION BP 4 1 HR 7 R T _ Pain Scale 0-10 HEENT - Teeth

Trachea TMJ/Neck Orophamyz Nares

CHEST: C-r Pt

CARDIAC:

EXTREMITIES:

IV Access: Ulnar Filling:

BACK:

OTHER:

SEDATION KEY:



3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

4. ANESTHESIA. Patient does not respond to pairdul stimulation.

14/0 toi-= ,1

`t. 139 CiZeO• b 3

i C14. 62 Z

HB/HCT: U/A: OTHER:

LABORATORY STUDIES:

CURRENT MEDICATIONS: ( ) = ordered as premed

T) E.c IAD 'Flo I-3 t CE-16,6E; ,26-,t-m T-f_go oi_ PA,.1

PREMEDICATIONS: None Yes (0 Hrs) /CC mg IV IM PO

mg NIM PO mg IV IM PO

0 ( )

( ) ()

0

HABITS:

TOBACCO:

ETOH: DRUGS:

Sex MALE f)FEMALE--

PROPOSED PROCEDURE: 1-g-0.12 I1 E06-1-co-u-t 2 Ac,-21-1* SURGICAL SERVICE: e oiutF NPO SINCE:

Age-DAYS MOS

CY

Z

. la al • 11.761. 1.16, , •

ASA Physical State 1 2 4 5 E WT: KG/LB HT: IN. ALLERGIES: AW4(.1-


Hypertension 1Y Angina MI CVA Other

Pulmonary System: Asthma Bronchitis/URI

• COPD Other

Renal System: / ir;EN,3/44._ Acute/Chronic RF N Y /0

Gastrointestinal: Hepatitis N Y Hiatal Hernia N Y PUD/GEFID N Y

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

Neurological: Seizures N Y Neuropathy N Y Other N Y

Gynecological : Pregnancy N Y

Other Significant Hz: N Y N Y

Familial HX

N Y

N Y

N Y

ra-L C014 go I Kr_ Y

ASSESSMENT PAST SURGICAL/ANESTHETIC

} FAITce, ii2 0 6' LL , col-op Ad,4,,.?, A c4..s., .. zspo 5

I x P LAPiLez7t,1 '

NPO Since

ANESTHETIC PLAN: { } LOCAL { } MAC { Regional (Specify): et/ (+`} general: Mask Intubation

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia discussed with the patientfiegal guardian.i,

The patient legal u rstand and agrees. Questions answered. Signed: I , 4 Date: 011 ()E/1 63

POST-ANESTHESIA EVALUATION AND NOTE (NON1ASU) { NO APPARENT ANESTHETIC COMPLICATIONS { OTHER

Signed: Date: Time: Hrs

Patient Identification: (Ward) /C

AM% elm \oL

WAMC Form 2300 (Revised) 15 Mar 01 itICXC-DOS MEDCOM - 18445

including death have been explained to and

firs

Previous edition is obsolete

Time: .X 5-.5-

DOD-032019 ACLU-RDI 1647 p.5

vc...z.,--1-1,4"---•

NSN 1540-00-634-4159 518-124

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION

SECTION I - REQUISITION

COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

Li FRESH FROZEN PLASMA

PLATELETS (Poo, of units)

LJ CRYOPRECIPITATE (Pool of units)

a Rh IMMUNE GLOBULIN

OTHER iSpecify)

VOI. OW REQUESTED (If applicable) •

ME

REMARKS:

TYPE OF REQUEST (Check ONLY if Red S'OCRI Co Products we requested.)

E TYPE ANO SCREEN

)23r L,R OSSMATCII

DATE REQUESTED

S DATE AND HOU IRED

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION fSpecif)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhiG TREATMENT? DATE GIVEN:

I ICMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION TESTING

REQUESTING •H

DIAG

I have collected a blond specimen on the below named patient. verified the name and ID No. of the oat. ent and verified the specimen tube label to lie correct.

S I GNA

IRE°

UNIT NO

Dqc54,5

6

oS

TRANSFUSION NO

PATIENT NO i) -11.

ABO

Rh pos

DONOR

ABO

Rh

REMARKS:

ANTIBODY SCREEN CROSSMATCH

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ

.NA

TEST INTERPRETATION .

C oe('

PREVIOUS RECORD CHECK

1_1 RECORD

SECTION III - RECORD OF TRANSFUSION

PRETRANSFUSION DATA

ML

1NIPLETF - -ANT ERRUFTED

off- 03

". ;Ski ()TED AND ISSUED BY (Signdlui

POST•TRATI"

--rsitMOUNI GI "N TIME/DAIL

AT (Hour/ IS C.)

ON (Date) 2:

IDENTIFICATION

I have eLaitimeo the Blood Component containe: Label and this form and • find all int crinetior. identifying the container with the intended recipient matches item by item.

•ecipl'ent is the same person named on this Blood Component Transfusion Font, And on :ne °anent Identification tag

1st VCRIFIE11 (Signature)

TEMPERATURE PULSE! BLOOD PRESSURE ONE ID SUSPECTED

If reaction is suspected—IMMEDIATELY:

1. Discontinue transfusion. treat shock it p ■ fiscal!. keop intravenous line 01>t1 2. Notify Physiran and riansfusion Set VICI,

3. Follow Transfusion React on Procedural. 4. Do NOT distort, unit. Return Blood Bog. Filter Set. caici I.V. solutions to the Blood Bank.

DESCRIPTION OF REACTION

liRliCARtA CHILL • FEVER L PAIN

[3 OTHER (Specify)

OT R DIFFICULTIES (Equipment. clots. etc.!

LI NO LI YES (Specify)

TE S I PULSE (C)

DATE OF TRANSFUSION TIME START

C-4 °--; PATIENT IDENTIFICATIOT --USE EMBOSSER (For typed or wntten entnes give: Name -•L rate: hospital or medical facility)

Cleir1141

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARD FORM SIH (Rev. 9-92) Prqscnben Ey (ISA/It:MR. FIRMA (41 CFRi 201-9.2112-1

Medical Record Copy MEDCOM - 18446

DOD-032020

ACLU-RDI 1647 p.6

591-3(

I...-

WARD/CN REGISTER NO ...c,t..4_ .-r.

REQUESTED

PREGNANT

YES ❑ NO

SPECIFIC REASON(S) FOR REQUEST (Camp/aims and findings)

TELEPHONE/PAGE NO.

DAIE_IRE(OlUgSlieD t-

• A1C CONSULTATION REQUEST/F SRT 3d/eine/Ultrasound/Computed Tomography rations )

AGE SEX SSN (Sponsor)

FILM NO.

NS/4 7 540.01-155-7294

RADIO ( Radiology/Mx

EXAMINATIONS (S) UESTE ...;

DATE OF EXAMINATION ( Month, day, year) 1 DATE OF REPORT ( Month, day, year)

TE TRANSCRIPTION ( Month, day, year)

RADIOLOGIC REPORT

LOCATIONLOCATION OF MEDICAL RECORDS

LOCATION OF RADIOLOGIC

SIGNATURE

RADIOLOGIC CONSULTATION STANDARD FORM 519-B is -sal REQUEST/REPORT Prescribed by GSAJICIVIR

PkV, TENT'S IDENTIFICATION (For typed or written entries give : Num,: - luvr, first, middle, Medical Facility)

1 —MEDICAL RECORD FPMR (41 CFR) 101-11.806-8

MEDCOM - 18447

DOD-032021 ACLU-RDI 1647 p.7

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

STATUS

SSN/ID NO.

DEPARTJSERV ICE

RELATIONSHIP TO SPONSOR

RECORDS MAINTAINED AT

AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD 1 CHRONOLOGICAL RECORD OF MEDICAL CARE

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

\I

0 . 51.-..?v8,2,T AN-7, ,•;, ) .-N1,...) /L.:. • 10,• lar--: 5-,.1- ,, ,Ltiri.

T P )44 4-t6. ,\Z 4 ev.4-11- 2.45) e, 7 c.4 c4 iss 0 c ;

PlIZ4— '' e''("A-aS;" i'g'S-C-- C 17- l I A.) Ti-rtjczc, I ■ ;) •Z, 1-'4 wt." .-c / u-..- .— ck '.-e.) 9 (I.

19 oir rizA-ca..

nc

c N10f ,-4.1.i 1 1.\18C. '6`it. -

b3L ,

_rit.2 / .0 s., ?,:oo orq a.° ih( 1DD (oi10(idi L)()

L.,--...Q1 , L. rn-1 i c;s• :

Prn tl ,I. 'V 5.1-A 0 1 r.-1 13 t' -0 tP (-,436i:1"-- 01, 1.1111c_c4 cs„...\. etNc....,;t

5u. ... - 6+•.-Vj ''

'404

..,... .

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

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

MEDCOM - 18448

NO. REGISTER NO I WARD NO.

DOD-032022 ACLU-RDI 1647 p.8

c urs

‘ 1 ,1-(5)(4 i1314 PATIENT IDENTIFICATION TIME OF ORDER

HOURS

NURSING UNIT

PATIENT IDENTIFICATION

MEDCOM - 18449 U.S. GO'

, PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS

LIST TIME ORDER

NOTED AND SP PNI C'19 c3

NURSING UNIT ROOM NO.

PATIENT IDENTIFICATION OF ORDER TIME OF ORDER

HOURS

NURSING UNIT ROOM NO. BED NO.

BED NO.

HOURS

(-\ ,

NURSING UNIT ROOM NO, 8ED NO.

z FORM 4256 1 APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED

0

DATE OF ORDER TIME OF ORDER

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

I-HE 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-032023 ACLU-RDI 1647 p.9

-CT 7L' e S-cv 11-1c 1 /7 4 ck.A.-rLstr? e_


NURSING UNIT

3--ak. 44- L


oe

LIST TIME ORDER

NOTED AND SIGN HOURS

BED NO.

NURSING UNIT

a,t- 41/

ROOM NO. BED NO,

ATE OF ORDER TIME OF ORDER

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FORM 4256

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

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DATE OF ORDER

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CLINICAL RECORD - DOCTOR'S ORDERS For -if this form, see AR 40-66, the proponent agenc•• OTSG

THE DOCTOR SHALL RECORD DATE AND SIGN EACH SET OF ORDERS. IF PI IA ORIENTED MEDICAL RECORD SYSTEM IS USED, WR/TE PROBLEM A .R IN COLUMN INDICATED BY ARROW BE,

MEDCOM - 18450

DOD-032024 ACLU-RDI 1647 p.10

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DOD-032025 ACLU-RDI 1647 p.11

For of this form, see AR 40-66, the proponent agenc, • - OTSG

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DOD-032026

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DOD-032027 ACLU-RDI 1647 p.13


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DOD-032028

ACLU-RDI 1647 p.14

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DOD-032029 ACLU-RDI 1647 p.15

c\b .i.c6. CLINICAL RECORD - DOCTOR'S ORDERS

For •• , f this form, see AR 40-66, the proponent agenc‘- rifSG

PATIENT IDENTIFICATION DATE OF ORDER ER

PATIENT IDENTIFICATION TIME OF ORDER

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MEDCOM - 18456

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DOD-032030

ACLU-RDI 1647 p.16

EDITION OF T DEC 77 MAY BE USED. DA FORM 4677, 1 OCT 78

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DOD-032031 ACLU-RDI 1647 p.17

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DOD-032032 ACLU-RDI 1647 p.18

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DOD-032033 ACLU-RDI 1647 p.19

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DOD-032034

ACLU-RDI 1647 p.20

CLINICAL RECORD THERAPEUTIC DOCUIVIENTATION CARE PLAN (NON-MEDICATION) '

For use of this form, see AR 40-407; . Yr. 2003 the or000nem aoencv is the Office of The Sumeon General.

VERIFY BY IN1T7ALINO '. 4:07-1E-:k.-.. :- . 1,i4-PAL.V40.1-4124-;: INHZAL PROPER COLUMN FOLLOWING EACH COMPLETION

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DOD-032035 ACLU-RDI 1647 p.21

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For use of this form, see AR 40-407: the Proponent aaenc is the Office of The Surgeon r-neral.

INITIAL PROPER COLO N FOLLOWING EACH ADMINISTRATION

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DOD-032036

ACLU-RDI 1647 p.22

Verify by Initialing

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DOD-032037 ACLU-RDI 1647 p.23

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th-9 lrgocoent agency is the Office of The Surgeon General. ivio.fp Yr. 03

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DOD-032041

ACLU-RDI 1647 p.27

FATiENT'S ID_. rmc'd.,q; grecle; eater hosp1 cr raedicz.l

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-- IVtCLJJML Kti-orw - urt-Lt-mtNTAL MEDICAL DATA

A

( For Lse .cf this tc.-7r.. see AR 40-65, :he .P,0pent--4,7-r7--ir--is•OE -Officeof -T1). a •Stirciti•or' I Ge4 a'.

R=PORT .- . • • OTSG- APPROVED ;a.;:a) ...--

INTENSIVErARE NURSING PLOW- SHEET - Q.-\ Appr S Mar S9

INITIAL SHIFT .ASSESSMENT -.. -----. —

E :

_... R o

I Time: Ini tals: - TiT-11:1 11/0 • .:Inital . Pupils . _ 1.4_Qrt--\ - raw, . (rows - , 0 vv.., T .f.t rix....

-1,Se-nsoriu:th - - - 6, ifk, it vitigattmgyaArlimmArffigetgrowamiyorr,

[mCy--1_. vy) .1cbi‘-cf,i-r6y-F-7-

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

LL,OC / GCS - -:---- 4 -. , 4r er-JuSont, I leo c.c:,))Droct, ) kity‘-acA .9.41,1.9° L-1)-Pc

C A

- R D

I A

C

tcar.i.-iiac Rhythm A\A).›.... .:._L=S_CLANLeo_aa

tS-2_gpt:1- q-cP-qtQ6 ̀i----‘uL ) t'N) 2"-. PR.

zizz.:/9Rs: Pulse Strength

0-67)4Z-Ftf . ak u?_..lik - - - " - - PZ-i_Viaa...../(tte&-kfn4L7- /

1—:Z_SEEC-1,41_ e/Krire.ON -.1.YX— " Cap Refit 4 jv D _ .

Edema Chest Pain C-I'

. • .

R

E

P

Rfspy_ a to ry Pattern

I',eath Sounds

secretions Cc, ugh

VA-1- l'-1 - 2 -12Nri m70.f,lig-icti,,A

17)E:FD ,,[4b.,,A -1-,,,,k 1.14_.._.___.______ ,

C.)11:-/Ii0104.1 _. r_Y.V_I-A, 71. rS4 I. prxXi_fccz_li:(ir's a4 JA.,;a- 4 1r,e. .

it:').D‘Q .C. kf--. t'- t,30 ■.•k:_-j - C2f-ire'y--1 oL.:0 I :\;\_20-22-.A ----N \1/4-ViCkt_ PC.,(e_Q \---161-6

E:rp -1AnVil-li

-1( ok-on R

I

N

Color ...,_ Integrity

Backside LI-C--)11k-P I Irs(1.'61-t-n-t fri )- ), 04-Kul ni

k rOCACt\ v\)0t.unelS 0), rr-01,-e-I-h uyyntx-- ./-nD\1,\-3(\ I ion G)Vi-e-

r-C--)t< .t_ k_ % c,\ ',---, i'c-- -

5144., '-1---." -6

I V

Access Devices

Location ___ Condihon E.Pc-DIPti... - ■212,C__\ 6.74)1V3

PA (:)(:Q r..-L ,

L' I

Abdomen

5.:".. .21 So unds___ _ Storn3/05tomy

S 1)-T. PD.. _ /-- it2 [:c S X ti jrt !A_ _.■..,LQ0(

1 : - _ r

r, ' De. ie ItAt7A_L'A.1-9 )1()LC_P 2-19i o-b

C Li 1,i ---... l CO -1-0T) c.L. li I Fo Lot

. (evirriateitaA) r-olor / Cl?ritv - - I •

_ .

... . _ __„

UNIT:

STATUS: US: AD I

. DA - FORM - 4,700, MAY 78 ..

•

MEDCOM - 18468 — -

DOD-032042

DEPARTMENT2SERViCE:CLINIC.

t:I,-287-1 Com:oat Suppe:7 Hospi:al ,

AC-F: n HISTDP. Y:P'riYSICAL

OTHER EXAMIN'ATiON OR EVALUATiON

q 0:AGNOSTIC STUDIES

TREA7.tIENT

0 FLOW CHART

0 .'5?4,5,

GENDER: 11A..ck.

IRAQI- ' EPW

ACLU-RDI 1647 p.28

DOD-032043

UNIT:

IRAQ STATUS: US: AD / CIV

. , MEDICAL RECORD-SUPPLEMEish -ALMEDIC4L FoT use .cf this !c7. -r.. see R 40-55; -1!•. ,e p,oPOnent 2,..,?.."Ce -is te- v! The Sue"Ge e 3.

OTSG APPROVED to..,:a;

• '

- INITIAL SSESSMENT -

i E

- ■ - R 0 I

_ Pupils - --- —

Time:07QX-) Irdtals inle:. 4.;;.)6__Initais: •

riyiA— pu.91: - - - Ifik,-•-i...- . lb ;:' ' wog - 1 1. _ riTanTiTril.111111LAMINfaas.MtlaAlle ....„. ..„ _ ---1_,L1Serisoritifit - - — - .______-.

__: LOC/GCS---- / GCS --- ---- vpvrt .11- e_LP....V1k il.D..A.X.-

..._:_wun - rr \ "i "-ct-

--- Z ST._ OrCi. va.--

-MIT

ou,c) #_,/ 1

_

file -

• 4.1-7_ 1(_, ----1

C : A - R

pI A

-,..C.

Cardiac RhY thn)

3 PRL / QRS: Purse Strength-

tkA- . - • 2 -_+. : „...- tg:_,: c:..Z.2,,s_2_,--!--1"&c,.u..k:untki.. - !-ISNJ 0 .. . • _

.5- -3 G-

Cap Re.fil /. JVD .___ - • . Edema.. . 0" ik.e •

.cel____2-0 - ,

_. s Chest Pain

_... .

E 'L 5

P

R 4PsPirat°1-Y Pat tern

oa il SDUI1Ci5 (tik.V.a VIA_ biciaXa__ p*on.utA,i,h, p1,14 E,Solliq ")-tp,,11.-:

alAka.- bUirlDC1 1'er‘Al ,-cD64,ii,1-104 ; 1,10

, OVori_-_.. 'WIWI.: ___,,iiitti2L-4- ib .,o al/lib/AD ciclAra - Qp-G'4 nilowv_ 11-6o 'vile,

it 6rri ' ta irou+haitkr&. eArc_th -oilyi

•te 1-- ix ,-;, 4-- N--t;

Ili-L1 th- FALL631-1r Ott:

0-15)- E 2) 1 (4 -ii PoffilPLI#0.1.--91.

'

eo_ita,i-t-civ I

... .

aticY1 I opents- ,

NJorm Gil

-=:.._e_c.r_c-L. 2'.-t. .. _ ._ . ..._. co, igh

-

5 K

N

Color A zif-

,- !i2 elect

adeoi-

,,,,,gs--

I integrity Backside 1--: , 1(p pc

1 IV

I

V

Access Devices ptiko- . Location

Condon I/rIblei• (75 qs_vlOcclior) Os- ,.,_"•11-- Jr7r--)-(c(_-_-1- 1/1 ,

G Abdomen 1 )33-1_41> _ _

i 4ctei. 4 rvn .,-.-,--k,,_plas- 1 i-Nr■ ,--%;rne",( <3/ ,..e_II.i.o__L-Ok- ___

_ ___

- ---- ------ - — - , .rA6- i-A,c, _45./..x_i______._ , ---. - -- - .--.- - ---1------

Bo,..-ei Sounds

k_J 7 7

• -

y) /0 _ k----

1 4

■, .-- - LI h ;M- - -

- ' -- . • - _

E,, ..i: _ .._-

. Color / Cla rity YY) I c- - _ y 111

I.&IPA ..-

P.P:EPAP.ED BY I.Sicr:a.-:.'re & 77:te) UARTiENTSEPViCICLINK;

ICU :ft., 28. -Fri Cc:Inbar_ Sur:pon Hof.pial

FAT:P.NT'S IDENTIFICA TION 'Foe' typee or oiri,t1en en:ries Name -les:,

mfeele: grade; eve; hospi:p1 cr

- — DA F 0 C-1 4700TMAY 78 _„ _

MEDCOM - 18469

GENDER: p/1

EPW

HETOP.(:PHYSICAL 0 PLOW CART

0 OTHER E_XMINATION 0 OTHER

OR EVALUATION

DiAGNOST;C STUDIES

El TREATMENT

RPPORT TITLE INTENSIVE CARE NURSING FLOW SHEET

-----kAppr - S Mar 89

ea)

ACLU-RDI 1647 p.29

tVItUIL;AL iitl:01-1U-SUFFLtMENTAL MEDICAL DATA . • . •

..For use .c! tis fc:1-r_ see AR 43-65; .t!'e-pFsponent –ese,cy -is -tIse Office crf The-S ugeon.Ge .--e-.3'.-7— 0TS 13 APPROVED

QA Appr S Mar S9 REPORT TITLE INTENSIVE CARE NURSING FLOW SHEET

NI E _._.

R o

1Sensori

i ;Pupils - --

- -

Time: 0101) Inital, - t _ .....iiiiimigarialtaingni.

Ad litliti. 7 - , .. : • .Vbtr.._ ,, ' 4••__4•ilic FillMNIM. ___ - - . .

-,-ii,y.,

1711,1119111Mr• -C- 7 ' 47 fiff1MR1211S2.'-l ir : .'" 1:■,,..J14 77:21r- 27; • t _7777 ZE________ diF

urn

LOC / GCS ----- t3 ffitki il igtt,q0/04 04 /. .irtaxgz..- ,-., I, kg e 5b

csii !

c A R D I

A C

s arcliac Rhythm

!PRI: i - QRS: .. _. Pulse Strength

1-- --- In, - 110 sp.), . . i 51 e ctivipitAak, tot: • 1.4--se- f a -7.—_-

Cap Refil / JVD

Ed ern a

'51‘ . ' z 3-Pc4: -.11a44144 • S_C --kill - 3Set-

(riCAIL-i- • sitd (1 • • , - 1 a. Chest Pain TY. 11;

V 4

_ •

s P

!Respiratory R r-------- Pattern —

: 8i- ea th Sounds

'.17.-ecretions

Cough

1 j

0.1' tt.Seattr 4(4a6i 018 3i

- C L4iI....ii ___

i 4. AAlitir LL SPCI a . ...L__ 0 ao, 1h614•64)v do so 't

603 le I /4

Tome n .

.e.4.,..t.,4 rr.se.,04' 1. er

- •• 4‘.,7'.__bil414 ) .__..c6n-a.74a___,a.-4_ ,eoses-__

4zik -k-_..44,ie. k -.6' ra_c.-o-cil . .07-6 _

r -C -

Ni•OhTtal • pl O- S K

I N

Color

integrity . ..,_ _ Backside

isitici 5i 1 hitifj. ' OulOcir (=W) - SGIAlArdr 'V 4-4 OE At4i7 r 1 he tif sad 14 iiict .s;ci, 1r gr. 1 A(2-,0 7

I . .

I V

Access Devices 1(4 11 PIV .4t & po6i4 /firket Location

I 13 . • are-4 ig' e .

'1-1\ a_C_J-n -keAtt_n• '

4itt_ .4.--_MIVI £ Ait9%61:431104i)

---1 Condition Alta A,k (Jib& ) Oiki if

11

k..., 1

_.. Abdonlen

5, tom alOstomy.. _

- -

pc , 1,1144 . X f /4./4 Ac:74 .,.."._.- k

-- -

T P 'C 4 - ------ 2--- Yrt.:_._.. _ _1. .L.4 . . . _______ PEO Igt •ii.4 igt3et 3 r 3x _. 11(' I

14 /(7 . 1 64-if -tb G U

De% ice

Color / Clarilw . • . 4 c1,04 -41,e,t1.01A) (A ntli__

DEP,ARTMENTISERVICE2CLINIC

IOU I, 28TH Combat Supper Hospi:a1

DATE -

to sa 03

PA; nospr:p.

writrea entries •,..:”ve: PlernLz

r:..q facillryl STOP.V:PI-IN'SICAL 0 FLOW CI-4A7

NAME: . ..• •RANK: Li OTHER EXAMINATION Li OTHER

UNIT: GENDER: • - . •. :

OR EVALUATION

O;ACRIOSTIC STUDIES STATUS: US: AD CIV IRAQI: CIV EPW

DAT" 0 :F--IM 4700, MAY 7S .

MEDCOM - 18470

DOD-032044

ACLU-RDI 1647 p.30

1. REPORTING MTF z. ,OCATION ADMISSION ,-...J t,ODING INFORMATION

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

1 2 3 4 5 6 7 8 (State or Country Code.) A

0 ::,...,:-:•;..

3. RE ISTER NUMBS AME (Last. First Middle Initial) 4. PAY GRACIE 5. SEX 9 10 11 14 15 12 13 16 17 ‘, 18 W A P APO" v (L6- 4

. 6. DATE OF BIRTH (YYYYMMDD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION 19 20 I 21 1 22 I 23 24 25 2 27 28 29 30 31 BACK-

--1- (6 C-) 6 A_ C y )(

GROUND)

10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL S URITY NUMBER 32 33 34 35 36 37

' ■ -

ADMISSION

ORGANIZATION (Ac ive Duty Only)

-

13. MARITAL STATUS : 4'

46

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61

,e_ 7 17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV ADMISSION 62 163

-r i

Country Code) 64 65 66 67 68 69 70 71 YEAR

[ ° I N

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

72j ADMISSION

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD) 73

4 1

7,, I - -,--- 75 . 76 . 77 . 78 .. 79 80 81 82 83 - .. 84 v 85 . 86 -

24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMOD) 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102

27. LOCATION OF OCCURRENCE . 28. •MTF OF INITIAL. ADMISSION - . _ 29. DATE INITIAL ADMISS ON (YYMMDD) 103 104

'Only) (Battle. Casualty 105 106 107 108 109 110 . 111 112 113 114 115 116

---F0 OCAL USE

DX 0,2 , .,5- 2k3 0 g900 MO 7.-- 80 (31 ?.?..-3cz. V5s0 5-41-2 7673 / 4.s---0

1,_,5 . / ( V-55/ 93/9 02'25,2

7 HI, 63 8.6,2f / / g73 9, 12-1, 73 q - --- ,F.9 "pA2 76 7 ADMITTING OFFICER- (Signature.as required)

SIGNATURE OF ADMITTING CLERK ..--------- ..--------

' DA FORAn 98 5. MA 12 RQ -- • - -

USAPPC V1.00

MEDCOM - 18471

EDITION OF MAY 79 IS OBSOLETE

DOD-032045

ACLU-RDI 1647 p.31

1. REPORTING LITE

2

3. REGISTER NUMBER

1111111.11=11 a 10

S. DATE OF BIRTH (YYYYMMOD)

20 MO 23

16. ZIP CODE OF RESIDENCE

IMIESECIEIEREI

22. MTF TRANSFERRED TO

IIIIMISIENEI 11111111111111111111

25. MTF TRANSFERRED FROM

80

■•e., LOCATION

ADMISSION

For use of this form,

J CODING INFORMATION

see AR 40-400; the proponent agency is OTSG

4. PAY GRADE 5. SEX

7. AGE AT ADMISSION 8. RACE

30

9. ETHNIC RELIGION

Ell BACK-GROUND

NAME 'Last,. Fast. Middle Initial)

10 q

8 (State or Country Code.)

10. LENGTH OF SERVICE ETS 11. RAP • •

11:1113

ORGANIZATION (Active Duty Only)

12. SOCIAL SECURITY NUMBER

EllinEarlirrunirmali0

46

HOUR OF ADMISSION

0-( 5'

BRANCH I CORPS 0-4

13. MARITAL STATUS

14. FLYING STATUS •

48 49

16. BENEFICIARY CATEGORY

11311113 50 59 60

72

17. UNIT LOCATION (State or 18. MOS Country Code)

20. SOURCE OF ADMISSION/ AUTHORITY FOR

ADMISSION

CATION OF MEDICAL T

EllE11111131:11 111

11111111111.1111111111M111 NAME/RELATIONSHIP OF EM RGENCY ADDRESSEE

lc 1

WARD

6-2 z

19. TRAUMA

ADDRESS OF EMERGENCY ADDRESSEE (include DP Code)

TELEPHONE NUMBER OF EMER E CY ADDRESSEE

PREY. ADMISSION

YEAR NO

21. TYPE OF DISPOSITION

74

24. CUNIC SVC • ADMITTING

011E3113111

27. LOCATION Of OCCURRENCE (Battle Casualty Only)

103 104

1131111111311, 1111131 III MEM= 28. MTF OF INITIAL ADMISSION

105 106 107 108 109 110

11111111111•1111111111

23. DATE OF DISPOSITION IY YMMDD)

ElE110113131 co

Q 26. DATE THIS ADMISSION (Y YMMDDJ

EZIECIEI 29. DATE INITIAL ADMISSION (YYMMOD1

11111111111111113MEMI 1111111111111111111111111

81

100 101 102

PI

FOR LOCAL USE

67-5 tA) IA, cc u1/4,

- 7- SI

MEDCOM - 18472

CLERK AD

PI A C

DOD-032046

ACLU-RDI 1647 p.32

...70, INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40.490; the proponent agency is OTS6

REGISTER NUMBER NAME (10$1, Rut, PAH 4)

OAK ."- EPW

3. GRADE

_FPI.) ADMISSION REMARKS

1k

.

AGE

/11 1 g / RACE 1. RELIGION

,tis

8. _ .

10. PREVIEWS

NOADMISSION

14. WARD

pre d i

20. TYPE CASE

1 FMP 12. SSN 13. ORGANIZATION

15 FLYING STATUS

18. ON BEN

18. BRANCH/CORPS

b ( Ut)

le ICIZIP

21 SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION .

Di r f_CI" {-row .r_-.2

22. HOURS OF ADMISSION

t $00

23. CLINIC SERVICE

. 24 NAMEIRELATIONSINP IIF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION

C, o carte 26. DATE OF DISPOSITION

2 se 3 R 0IS 20 BATE HIS

27,. ACIIPS‘Fl/MERGENCY ADDRESSEE (Include ZIP Cede)

Uotig

21b . TELEPHONENO.

VAIK

ADMISSION

30. DATE OPINTIAL ADMISSION

Q .20,F O

ADMITTING OFHCER

32. UNITS OF WHOLE 610001 COMPONENT TRANSFUSED 29. NAME AND LOCATION OF MEDICAL TREATMENT

10 / --t, ) - Z--

31.

Check it Cominund on Reverse

33. CAUSE OF INJURY

In Pio( CsI6 le.. ACC 14". /11- • 34. DIAGNOSES/OPERATIONS AO SPECIAL PROCEDURES "7?o,o1

DX; ft/ o LT/ Co A) ru s / atif ci /MAAS-494s 910,0

I '73 • 1 q1z, t-,■

eiaas 1 .0 ,..,

e? 1 9. D.

35. Total Days This Facility

e. ABSENT SICK DAIS b OTHER DAYS c. CONY. LWCOOP CARE DAYS

d. SUPPLEMENTAL CARE DAYS

e. BED DAYS I. TOTAL SICK DAYS

36. Total Days All Facilites

e. ABSENT SICK DAYS b OTHER DAYS c. CONY. LYICOOP d. SUPPLEMENTAL A. 8E9 DAYS CARE DAYS CARE OATS

IlD' t I. TOTAL SICK DAYS

SIGNATURE OF ATTENDING MED

no toVt6 7- i , • ',It • A nA

USAPPC V1.10

DOD-032047 ACLU-RDI 1647 p.33

\c) ( ct,.., .-- c_-- (

lila

:-..-. .

PATIENT'S IDENTIRCATION

PATIENT'S .CLEARANCE RECORD For uoo of this form, sae AR 40-2; the ProPonsra 4124rocY .1 , OTSG

DATE OF DISCHARGE

OSSZPO3

TIME OF DISHARGE

SIGNATU CER

•

/1„

ACTIVITY CLEARANC (The final activity with which the patient must dear will be the cftposition office.)

tAilftry INITIALS' _ Noo-nillsesy INITIALS'

1. Patient's Trust Fund 1. Patient's Trust Fund

2. Medical Services Account Officer 2. Medical Services Account Officer

3. Clothing and Baggage 3. Clothing and Baggage

4. Medical Holding Unit 4. Postal Service

a. Supply 5. Change of Address*

b. Pay Section

. 6. Other (Specify) -

c. Service Records . 7.

d. Insurance and Allotments a.

5. Postal Service s.

6. Change of Address i...

7. Other (Specify)

8. 12. 0( Li) ''.- Z—.

9. 0(0 ., I,. 13.

REMARKS

i

-2

DATE

S ' INITIALS OF PERSON AUTHORIZING CLEARAN

USAPPC V1.00

MEDCOM - 18474

p

DA FORM 4029, MAR 73 11•111111111111111*.. 1 DEC 59, WHICH WILL BE 1 ,"

DOD-032048 ACLU-RDI 1647 p.34

- MEDICAL RECORD I ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Ener dine of admission)

PHYSICAL EXAMINATION

PROGRESS (Enter date of discharge and final diagnosis)

SIGNATURE OF PHYSICIAN

DATE

IDENTIFICATION NO. ORGANIZATION

PATIENT'S IDENTIFICATION (For typed or written entries give Name last, first. REGISTER NO. WARD NO. middle; grade; date; hospial or medical facility)

ABBREVIATED MEDICAL RECORD Standard Form 539

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COFAM1TTEE ON MEDICAL RECORDS FIRMR 141 CFRI 201-45.505 OCTOBER 1975 USAPPC VT.00

MEDCOM MEDCOM - 18475

ACLU-RDI 1647 p.35

AUTHORIZED FOR LOCAL REPRODUCTION

•

NSOR

RECORDS MAINTANED EPA

JIPN: (For Typed or wrirren erirrieS, give: Naive - lest, ffrsr;ri7irldle; ID No or SSN: Sex: Dare of Birth; Rank/Grade,

tva ',.•:,•pfitibt:is.S,1407F55•. :::i.:....,:... iiie‘dic2;100410‘.: ,. • ::.1. -• ,.:.•. :: ' .--.7' :! • .

, • :9 TA.-144,7■.F14iS .:0:6R11.4 509 . iREV. 5n99. 9) . • •"FPMFI 141 C FR) 1 ... Prescr, e ,

b d by GSA/ICIAR 1 00 ...,

; .. . . 01-1 01 3.2A7Albv)( .10)

-.- •.:*.":::i•:' ,.::'•.:' , :-..,.,^,;;....••, ; :,,. .:.. ......r.,, i .. .. , . :,.:..... ; ...

flE

. , .

MEDCOM - 18476

DOD-032050 ACLU-RDI 1647 p.36


CHRONOLOGICAL RECORD OF NIEDICAL .CARE ..„..MEDICAL RECORD ----

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each sentry)

SEP 0 2 200: _ or • N.....k... . . ■

1 --).- - 7 JAAILA 411 - .4 -

0 )5 8 ) b:NaPALAMI r

A* illiakfti --

A. ja, , • .-e/..i ha...,..e..... ' ..

_efiararAll' -"--/ A / i • d , , ,.. ., _ Adar -."'" '• /Pr' In Pr r-i■ r • - - .., —

, I

A ,....rimir lob rigr r

f

b. 1.....01L.x. 1

ir ciLLib

1_,--

(CD '

-e./45:-*■- i 3 - cra ,

,-- .,4 AKIN --j• - r.- ... ..._

CtV-- 119 UtS ----1.-- --r- N.A.'s\

.. i ...4 0' • 4'. Mk

44.0... .I../..„ ...._

.

i A,

di' /, A/ 6-6,-)---( 11L-alrAl Al P"."'".4 Apir

10111■,. ..„„,..


iffoi _ STATUS

e s DEPART./SERVICE b

SPONSOR'S NAME SSN/I0 NO. RELATIONSHIP TO SPONSOR TO j

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

1 - \ ..I ,. . --' 1 ht-N1 i • Vo. 1 1

REGISTER NO. WARD NO.

HRONOLOGICAL 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

MEDCOM - 18477 CoB 109th ASMB MAP IRAQ

DOD-032051 ACLU-RDI 1647 p.37

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

Lz —ks-N, PL-cd\

s.

STANDARD FORM 600 (REV. 6.97) BACK USAPA V2.00

MEDCOM - 18478

DATE

DOD-032052 ACLU-RDI 1647 p.38

NSN 7540-01-05.3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Patient)

LOG NUMBER TREATMENT FACILITY

RECORDS MAINTAINED AT ..

PATIENT'S HOME ADDRESS OR DUTY ON ARRIVAL

STREET ADDRESS DATE IDay,_Monthr Year) TI

CITY STATE ZIP CODE TRANSPOR ATION TO FACILITY

SEX

/v.

DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER , ITEM YES NO N/A ITEM YES NO

PRP 1..., ADDITIONAL INSURANCE

AGE

.- i

HOME PHONE FLYING STATUS /„...---DD 2568 IN CHART 2-

AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

<",lind JILZ., 1Z/2•7/ .6-7..a,

CURRENT MEDICATIONS

i / ,a_j_cleir/l/W-4--•

INJURY OR OCC ATIONAL ILLNE S EMERGENC ROO VISIT

• ITEM YES NO

WHEN (Date) DATE LAST VISIT 24 HOUR RETUR V _....■-

n YES NO

IS THIS AN INJURY? 1/7 yVHERE TETANUS

DATE LAST SHOT COMPLETED INTITIAL SERIES

II YES . NO ALLERGIES

r

INJURYISAFETY FORMS L----

HOW

CHIEF COMPLAINT

NT VITAL SIGNS

II EMERGENT TIME

- i 10,0

TIME ?... ///le BP /17y'y ire}

U RGENT PULSE 7a

INITIALS RESP ... 0 /41- TEMP

1 , •

• NON URGENT WT L9A.-: .

ILAB

OR

DE

RS

'

CBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT

X-F

MA

_O

RD

ERS

R

S

gs.-A CXR PA & LAT/PORTABLE C - SPINE

URINE C&S T UA MSCCICATH X CHEM: .2_2, ACUTE ABDOMEN LS SPINE . .. .

SINUS HEAD CT BLOOD C& X ANKLE R/L t

ORDERS n / ORDERS

aa To( 0,5- cc X jr 17u /s c7 :/ c2e /5.020 re PA r r/. 1, 14 15' oCe- /5"..2p

1010) - 2-

71 PULSE OX

IME BY COMP

MONITOR

TIME PATIENT'S

ECG

RESPONSE 0

DISPOSITION

n HOME n FULL DUTY

MODIFIED DUTY UNTIL

DISPOSITION QUARTERS /OFF DUTY

n 24 HAS. n 48 HRS. F-1 78 HRS.

RETURN TO DUTY

PATIENT/DISCHARGE INSTRUCTIONS

TO WHEN CONDITION UPON RELEASE

0 IMPROVED 0 UNCHANGED

DETERIORATED

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

REFERRED 11111. I have received and understand these instruction S .

PATIENT'S SIGNATURE

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

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

"1111111117,111 STANDARD FORM 558 (REV. 9 -961 Prescribed by GSAIICMR FPMR (41 CFR) 101.11.2031b)110) USAPA V1.00

MEDCOM - 18479

DOD-032053 ACLU-RDI 1647 p.39

/V4225 ✓e

17 telt° di'Yt VZ/WP 'h ref /0

Caa_

DIAGNOSIS

PROV

MP

NSN 7540-01-075.3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TEST RESULTS .

to

WBC

U

ABG/PULSE OX

H/H SUP 02 PH P02

OTHER PLT PCO2 SAT

PT DIP

APTT BHCG ETOH GLU MICRO

PROVIDER HISTORY/PHYWAL

56 r ag/ • "'CA-4—

42- /a/ A- &AdeA_

EKG INTERPRETATION

Check if read by ❑

radiologist

cYr - )4

TIME SEEN BY PROVIDER

cc/4z--, 3 4f-j,

0 /444,""fir Ed"

RADIOLOGY

RESULTS/

.AP

/Yo tA/A

71/e /Y Fatr

• 77)7L-- /<((zilt 'riptiA-

TIME ACTION CONSULT WITH

0

RESI DENT/MEDICAL STUDENT SIGNATURE AND STAMP

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

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSAIICMR FPMR 141 CFR) 101-11.2031b)(10) USAPA V1.00

MEDCOM - 18480

DOD-032054

ACLU-RDI 1647 p.40

NSN 7540-00-634-4124 ' 511-119

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

.1-••• r)..

POST- DAY MONTH-YEAR DAY 7.4C•P Ob Carr:Jet:a

19 HOUR 1 • • ..... .. • •

• " • • •

• - 1.• PULSE TEMP. F • .. • . • •

(0) (9) • .... .. • • .. •

—4 co

0.1

(,

) co

(..) W

C.) (r

) C

s.1

CO

A A

m 01

al C

D O

4-

-, 1 C

O C

O 4.4 3

0

0 K

b o

i-

• :-.1

6 i..)

bi)

i.

,J io

'a b in

70 0 0

0 0

00 0 0 0

0 0 0 0

(Cen

tigra

de E

quiva

lents

, for

Ref

eren

ce o

nly)

C 0

l• • • •

•

• • • • : . .

180 104° . .

105°

•

• • - . ..... . . ' ' . ...... . .

• .. .. . .

. .

'• " •

3 F'

. . . 1' • • '

. . . . . . l• • •

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

•

• • .. . . . .

...... . . . .

170

1-

)

103° • • • • 160 102°

. . . . . • • . . . . . . .. . . . . . . • • • • .. • • • . . . .. . . . . . . . . .

. . . .

' • • • •

) C

-4

" •

•

• • • , • • • • . . . . . . . .

. . . .

. . . . . . . . . . " • • • • • •

. . . .

150

101°

. . . . 140 100° . . . . . ...... • • • • • • • • . . . .

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

•

. . . . . .

. . . . . . . .

•

• • •

. . . . 130 . 99°

. . . . . . . "

• • . . . . . . . . . . .

Lii

98.5° 120 98°

•

• • •

F.• : : : 1

•• • •

" • • . . • • •

• • •1

•

. . . . .

110 97° • • • • . . . • . 100 96° . . . . . . . . . . . . .

.

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

I • • • •

. . .

. : . . . . . . . . . . . . . . . . . . . . . . . .

80 .

90 . .

95° • • • • •

. . . . . . . .

.

70

In :: :•• :: •:"

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

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

. .

.. . . . . . . . . . . 60 . . • . . . . . . . . . . TTJ

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

. . . .

5 50

•

• • •

. . . . . . . . . . . • - • • . . . .

.

40

•

TE

l

. . . .

. . . . . . . . ...

• . . . . . . . . . . .

i.. • 6 i• • • • • •

RESPIRATION RECORD f/

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

'Rec

ord s

pecia

l da ta

only

when

so o

rdere

d BLOOD PRESSURE 0..4% e 0 ioEy i-,7 r,

HEIGHT: I WEIGHT —fib • 1411

PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, middle; IC) No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility) 1_)\,4140f°

VITAL SIGNS RECORDS

Medical Record

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

MEDCOM - 18481

DOD-032055 ACLU-RDI 1647 p.41

P, tint L. Lin

tCH 321LE Pit

47.

23. 3 51.9

h

t; Pg

X10'3.

1

919 99.9

31 0 3i. e 150.

MEDCOM - 18482

ACLU-RDI 1647 p.42

)RATORY RESULT FORM ,...iubject to the Privacy Act of 1974)

/Rh

n;,! avg- f0, 'IMPEL *7Agilr Yftk

Ward/Section: .,;QUESTING P 11110 1D (")- L I:

LAST, FIRST,MI. DATE I TIME

REF RANGE 4.8-10.8 xlb

RBC Hgb

42-52%(M) 37-47%(F) 80-94 RN!) 81-99 0(F)

130-500 x10' verilleil

Lymph %

fferenCtti

Lymph Baso

Imm

52%(M) -47%(F) .

TEST

Hct

MCV

WBC

Plt

RESULT

20.5-51.1% •

4.7-6.1 x16 14-180/1(M) 1246gM4n

Atyp

RBC Morph\

Lt

H4

N

Spun Hem atocri

nye

fin in

•

qlori

ro miles

aria

P

Bid

tqC:P.

RESULit

P4X440

Negative

Negative

REF RANGE

Negative

Negative

S

B ALB 3.6 3.3-5.5 G/DL ALP 72 26-84 U/L ALT 28 10-47 U/L

P: AMY 43 14-97 U/L AST 28 11-38 U/L

TBIL 0.8 0.2-1.6 MG/DL BUN 22 7-22 MG/DL CA++ 9.4 8.0-10.3 MG/DL CHOL 154 100-200 MG/DL CRE 1.0 0.6-1.2 MG/DL GLU 107 73-118 MG/DL TP 8.5* 6.4-8.1 G/OL

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

PICCOLO UT, 02/09/03 15:15 REFERENCE RANGE: MALE PATIENT #: 1111111)ck(,0-

no

GENERAL CHEMISTRY 12 o- f DISC 3204AA4

OPER # L` DR #: 000 SERIAL #v0-0000100676

Cem atolpg Segs Mono

Bands Eos

er

Set Rate ST SUBMIT SF 518 WITH i:RY UNIT REQUESTED

Cel Cot

Other Dir

CROSSMATCH REF RANGE RESULT

9.8-13.6 secs

TEST

PT

APTT

D dimer

FDP

21-34 SESS

REMARKS:

< 10 ug /ml

<20 nem!

LAB ID NO.: REPORTED BY: DAlE:

Moe- - yelloki AN _ Hazy

Gtvcost Ailp Ate6- Wryw -fra('

MEDCOM - 18483

siotaCt. x/9

.A/e

=41::

P 4 — 6.0 1 prat 11 –s0 -1- t/rAd- ad:- 0 .4

DOD-032057 ACLU-RDI 1647 p.43

Ward/Section: .STING PHYSI CAN: CHEI,AiSTRY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, F1RST,MI.

. V .

TEST RESULT

.

.= , 4: „,;,;;: •14,:',.,5,As- '---t,

REE RANGE

DATE TIME

,,

TEST

SSN/PEEUDO

41 ' e ' wi-41:1M-

RESULT

SSN:

MIS :WV fl' -",qi . RANGE

' ' xi;,--- ,.., .,,-

TEST

liftik ';'," w-' 4,4-vrgps IS ,`

-,. REE

RANGE

Na 138-146 mmolldL ALB 3.5-5.5 Will, GLU 73-118 mg/di

K 3.5-4.9 mmol/L ALP 26-84 u/I BUN 7-22 mg/dl

CI 98-109 nunol/L ALT 10-47 u/I CA++ 8.0-10.3 mg/d1

pH 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/d1

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

AST 11-38 u/1 NA+ 128-145 mmol/dl

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

TBIL 0.2-1.6 mg/dl le 3.3-4.7 rnmo1/1

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

BUN 7-22 mg/dl CL- 98-108 mmolll

HCO3 22-26 mmol/L (art) 23.28 mmoi/L (art)

CA++ 8.0-10.3 nag/d1 tCO2 18-33 nunall

SO2 95-98% CHOL 100-200 mg/d1 Aff ittd ', II:kW - , , ,r,*,ft,1,-m,-,,!, : TEST RESULT

Yie , ,,, -omv,: ,,1,--i;&-:,,0 REE RANGE BEecf (-2) - (+3)

mmul/L CRE 0.6-1.2 mg/dl

AnGap 10-20 mmol/L GLU 73-118 mg/t11 ALB 3.3-5.5 g/dI

Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/dl ALP 26-84 u/li,

BUN 8-26 mg/dl ', "

,Iete,1 0 -e4 ALT 10-47 u/I

GLU 70-105 mg/dl TEST RESULT REF RANGE

AST 14-97 p/1

Creat 0.7-1.5 mg/d1 GLU 73-118 mg/dl AMY 11-38 u/I

Hct 38-51% !'CV BUN 7-22 Ing/d1 TBIL 0.2-1.6 mg/d1

Hgb 12-17 g/d1 CRE 0.6-1.2 mg/d1 GGT r 5-65 u/I ----. ,, .,,,, < 1111 ,s, :."—k. ,e, :.i.:,,4 rig ;4.-; , S 4, ,-- PM' '

CK 39-380 /1 (141) 30-190 /1(F)

TP 6. 1 g/dI

TEST RESULT REF RANGE NA+ 128-145 mmol/1 A,C 0 IR >,. .,....; :.,. l -,..-. ,.., <,,, . t* - xg <N, <,,,,

Tropoin-1 ' 334-7 111m01/1 TEST E RANGE

Drug of Abuse

CL 98-108 mmol/1 NA+ 128-145 mmol/1

tCO2 18-33 mmol/I • 3.3 -4.7 mmol/I

CL 98-108 mmo1/1

tCO2 18-33 mmoUl

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 18484

DOD-032058

ACLU-RDI 1647 p.44

i -STAT EC8+

Pt: 11.11(°1 Pt Name:

Glu 101 AWOL BUN 27 m9/cIL Na 139 mmol/L

3.4 mmol/L Cl 105 mmol/L TCO2 26 mmol/L AnGap 11 mmol/L Hct 48 %PCV

Hb* 16 g/dL *via Hct

PH 7.501

PCO2 32.3 mmH9 HCO3 25 mmol/L EtEecf 2 mmol/L

Sample Type_:

02SEP03 15:18

Oper:IIIIIIII

Physician:

** PRINT CANCELLED **

MEDCOM - 18485

DOD-032059

ACLU-RDI 1647 p.45

0A1E 0E- ORDER IME OF octoery PATIENT i•DENTO, tcATioN

loxod

CYK

rae%

NiafiSING UNI T

•eArIttsvr IDENTfFi;cATION

CLINICAL RECORD DOCTOR'S- ORDERS .

For tap- of this fork, sed AIR otere.,the p!clOoright agency is CTTS6

THE. DOCTOR SRA LI. RECORD DATE,. TIME AtID. SIGN' EACH SET OF ORDERS. IF PAOELEM OF41 NTED M-Et4DAE_ R IC

, SYSTEM - IS USED, WRITE PFIQatEM„ Ntime-Eiti 1N COLUMACINORTED BY ARROW BELOW-

/0

5 tevidu aorlif)

.2th4 521:

- izaz`h of s heCi

rivne, NG UNIT

NVA-s4 4c.4 www

RATIL;Nr 10:eniTtFitAT ION

eCi NO.

DATE OF ORDER • TIME. OP ORDER

0-0 D HOURS

ROOM NO. EEO NO

REPLACES E OiTION OF 11 JUL 77. WHICH MAV BE USED.

MEDCOM - 18486

NOiiiI47.S UNIT

'ROOM NO.

•pATIGNT toslaTtFOZAT.toici

Ottli„:4?,C: gt-relM. AN

•••■••■•••■•••••••

RO NO RED : NO,

DOD-032060 ACLU-RDI 1647 p.46

CLINICAL RECORD r THERA • UTIC DOCUMENTATION ARE PLAN (NON-MEDICATION) For use of this form, s-= AR 40-407; Mo. Yr. 2003

VERtFY BY INITIALING ,.., ce : ,.,.44:0,g Nf..:-P 5-ftt-s-- i PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLE M/ NURSE

/ RECURRING ACTIONS, FREQUENCY, TIME

HR DATE COMPLETED

A -S I\ t

A Vsv,2_, ca Com_

I (4bucts, (e _

•

. ..

- - - - - -

ALLERGIES: - YES MI NO PRIMARY DIAGNOSIS'

A AV,

i- 1 4 1 t(,r , ■ of

AY1 1 - • I iiIii0


YES NI NO .

PAGE NO•


*16 ±)

D 8 9 10 .

( (--/^. (-1

USE PENCIL.

E 16 17 18

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. USAPA V1.00

MEDCOM - 18487

DOD-032061 ACLU-RDI 1647 p.47

DOD-032062

Date to be Done

SINGLE ACTIONS

I , N-rmA6-- L4

21--ourp 1-e)

EfW ca(41 ; tium/uruy4- arywrylvArAdoUt

PRN ACTION. FREQUENCY

Time to be Done

61L, -pciA THERAPEUTIC DOCUMENTATION CARE PLAN

(NON-MEDICATION)

IA7714 PROPER COLUMN FOLLG COMP TIME/DATE COMPLETED

USA PA V1.00

MEDCOM - 18488


Order Clerk Date Nurse

...71••■■S

Order/ Eepir C.lerk/ Date Names

1 M° 2003

ACLU-RDI 1647 p.48

CLINICAL RECORD THERAPEUTIC DOCUMENTATION For use

the orloonent men

CARE PLAN (MEDICATIONS) of this form, see AR 40-407: is the Office of The Suraeon General .

MoCR Y r. 03 VERIFY BY INIMILING

ORDER DATE

CLERK/ NURSE

- - - ; INITIAL PROPER COLUMN FOLLOWING EACH ADM INISTRATION

RECURRING MEDICATIONS, HR DATE DISPENSED

,- DOSE. FREQUENCY

isuiri7;-_41..ztrim ..,s ritli" "LamarammIIIMINIIIIIIr.

11-- • - - ''"' - iworillilllierilii■Immi

' '

ALLERGIES: • YES IIII NO PRIMARY DIAGNOSIS: .•

11/49Uat 0S-ffillt-S'& I MA AcX1a) I ntO r


1111 YES MI NO

PAGE NO PATIENT IDENTIFICATION: .,-(-C/rni,Ltiq- COYrilL/kY VT)

• -11111FA

b(Stj-

rs A [-Anna a a ftes . rrn. ■•••■ ---- -------- -

DISPENSING TIMES


D 7 8 9 10 11 12 13

E 15 16 17 18 19 20 21

N 23 24 01 02 03 04 05

14

22

06

MEDCOM - 18489 UNTIL EXHAUSTED. USAPA V7.00

DOD-032063

ACLU-RDI 1647 p.49

. Clerk/ PRN MEDICATION, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINIS7RA77ON TIME/DATE DISPENSED

Order/ Expir

ate


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Aio.EEL Yr. (2.3

Order Date

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Data to

be Given Tete to

be Given Time Given Initials

4

USAPA V1.00

MEDCOM - 18490

DOD-032064 ACLU-RDI 1647 p.50

. PAY GRADE

ADMISSION AND CODING INFORMATION

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

. SEX

RELIGION

inu

111113 MM.

1 2 8 (State or

Country Code.)

3. REGISTER NUMBER

6. DATE OF BIRTH IYYYYMMO 7. AGE AT ADMISSION

47 48 50 51 52

64 65 66 67 68

WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

C_ I ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

75 76

22. M TRANSFERRED TO,

80

IMII1111111

109 1 10 11111181111 114

93 94

t A (3 12A-t lam UL 1 oiVI

106

ralfiranrain 29. DATE INITIAL ADMISSION (Y YYYM Ar1 D 0)

GENEEMEMICI 120 111111111111111111111111111

100 101 102 103 104 105

SIGNATUR OF ADMITT

DA FORM 2' ,M 2000 MEDCOM - 18491

•

I

CHM 5

FOR LOCAL USE

V AK Ztio gat! q Baa

a ITTING OFFICER (Signature

CI 7° MI -i l

E

NAME (Last, First, Middle Initial)

14. FLYING STATUS

Inman

ADMISSION

16. ZIP CODE OF RESIDENCE

PREY. ADMISSION

YEAR

17. UNIT LOCATION (State or Country Code)

23. DATE OF DISPOSITION Y YMM00)

0 Ellard 9 • WI 26. DATE THIS ADMISSION IVY YYMMDD)

R 1121

8. RACE

30

121

9. ETHNIC

BACK-GROUND

24. CLINIC SVC - ADMITTING

CCI 9° 1E11 EMI

27. LOCATION OF OCCURRENCE

107 108 (Battle Casualty Only)

1./SAP.A V1.00

DOD-032065

. REPORTING MTF LOCATION

63

20. SOURCE OF ADMISSION/ AUTHORITY FOR

72 ADMISSION

NAME AND L

21. TYPE OF

73

25. MTF TRANSFERRED FROM

CI 96 C11111 111111111111111111111. 28. MTF OF INITIAL ADMISSION

NO

22 23 a tal

24 25 26 28

32 33 36

NI

10. LENGTH OF SERVICE

ORGANIZATION (Active Duty On/y)

unitanna

MEI 13. MARITAL STATUS

46

PI 15. BENEFICIARY CATEGORY

pallmlInglim11111111Mell 44 45

12. SOCIAL SECURITY NUMBER

18. MOS

20

111111111111.111

ACLU-RDI 1647 p.51

• INPATIENT TREATMENT RECORD COVER SHEET . .. ee AR 41-400., the proponent agency is OTSG

Mt I

ePLO GRACE 7

Ki 14 ADMISSION REMARKS

,

O

4.

IA

AGE

9 6. RA

Ujr,-) I,

. LEND OF SVC

l.).. 0 t•-) Pr 13 A-

10. PREVIOUS DLCSI AI 8

t, FM? 12. - ..— 0flG0.lhZAi10M 14. WARD

15. FLYING STATUS

16. 1 " ,i DSG BEN

BRANCHICOPPS 16. UICIZIP 20. TYPE CASE

71 SOURCE OF AOMISSIONIALITHORITY FOR ADMISSION

10Q. --(1. - pf2,01,--k ev--t-i--

22. HOUF1S OF ADMISSION

oboo

23. GUMC SERVICE

./ a 24. NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE

U,A0 K130 i.)— ''--

25. TYPE DISPOSITION

1 0 26. DATE OSITION

A • IV • Y: . I; — i

27.. ADDRESS Of EMERGENCY ADDRESSEE Orchids ZIP Code/

LA--/4•) \)"."'

27b. TELE NO.

LA-40 K

29. DATE OF . S ADMISSION

Da S--)9 e)'-

ADMITTING OFFICER

29. d F MEDICAL TREATMENT FACILITY

(_ '-/,`) --1-- 30 . DATE OF MAL

ADMISSION 32. UNITS OF WHOLE BL DOW

COMPONENT TRANSFUSED

31. SELECTED ADMINISTRATIVE DATA .

■ Chub if Continued on flown

33. CAUSE OF INJURY

./

34. DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES

W; 0 1 ao ) A (1:4}.....4,4,40;_ \l I: 11PAAIEL

, 1 , V ► (.,s -Th 19{2_0“ L LEC ,, if q. ,-: -02...._

, I 09 0 I .

tc...: 9 r ci citill

\ .43- • t3e22-z-

. \ 35. Total Days This Facility

7 C-1.:;2—. 7. ABSENT SICK DAYS

c) b. OTHER DAYS LVICOOP \ CONY.

CAIN OAYS

n d SUPPLEMENTAL

CARE DAYS ..-21- \ 0

BER.OAYS

ja 211 TOTAL SICK OATS

36. Total Day. All Facilites \

o. ABSENT SICK GAYS b. OTHER DAYS c. CONY. LVICOOP ' CARE OATS

d. SUKEMENTAL CARE

a BED DAYS I. TOTAL SICK Dos

_.--------------"-------- .....

SIGNATURE OF ATT

/ME COM 18492

SI A DUCAL RECORDS OFRC

3131117- 1OTArTS on no t saw In to n ••••••••• • In i•

DOD-032066

ACLU-RDI 1647 p.52

L k ) ay 4 (t1-17 LI,Nkj -t . 69 1.0t4/. (z I J-

ax_

( or or written caries give hur, lira, middle; grade; dale; hospital or facifilY)

ON

WARD NO.

ABBREVIATED MEDICAL RECORD PERTINENT HISTORY, HIEF COMPLAINT, AND CONDITION ON ADMISSION

(Enter dole of admission)

o 7--nt V-"-stt- r 1 — ZAL- S-7". •

S"- 1 (LE--)

(c) _41 1-11 PI -7S

I

pv4-I F•7 D

Pt4441 ,y • . tAA'LA-1

PH SICAL EXAMINATION

L. i-4.44• &Ai S4 j çz.

. cfre,v(p LeA

C.1"13" C.6) . ' c,k) tc :PO GYY

ILDW"),0 Utb.-s‘ W.-4,1{ J\- - Cc'— j.

tk•In L4tL s..4d0—.4

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MEDCOM - 18493

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DOD-032067

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MEDCOM - 18494

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DOD-032068

ACLU-RDI 1647 p.54


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STANDARD FORM 509 IREV. 7.911 Prescribed by GSA/ICMR. FIRMA (41

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MEDCOM - 18495

DOD-032069

ACLU-RDI 1647 p.55

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MEDCOM - 18496

DATE

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DOD-032070

ACLU-RDI 1647 p.56

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DOD-032071

ACLU-RDI 1647 p.57

PROGRESS NOTES

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MEDCOM - 18498

STANDARD FORM 509 (REV. 7-91) BACK USAPPC V1.00

DOD-032072 ACLU-RDI 1647 p.58

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DEPART/SERVICE HOSPITAL OR MEDICAL FACILITY

SPONSOR'S ID NUMBER or Mkt/ • LAST FIRST

SPONSOR'S NAME


MEDCOM - 18499

PROGRESS NOTES Merkel Record

STANDARD FORM 509 mmwitisei Presersled by GSAIICMR EINAR MICFM 101-1 120302RICI

USAPA VIAO

DOD-032073 ACLU-RDI 1647 p.59

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MEDCOM - 18500

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DOD-032074

ACLU-RDI 1647 p.60


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TGA rataC REGISTER NO.

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PROGRESS NOTES Medical Record

STANDARD FORM 509 Kt win Presaibsd by GSAIICAIR FPhRI141CTR11D1.11.2031bf1D

MAR VIA

MEDCOM - 18501

DOD-032075 ACLU-RDI 1647 p.61

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DOD-032076

ACLU-RDI 1647 p.62

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MEDCOM - 18503

DOD-032077

ACLU-RDI 1647 p.63

NOTES

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MEDCOM - 18504

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DOD-032078

ACLU-RDI 1647 p.64

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MEDCOM - 18505

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DOD-032079 ACLU-RDI 1647 p.65

;MARREN TO SPONSOR


MEDICAL RECORD

DATE

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Iii--t. fl a LA— Ys-- 61.2 JP-S

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STANDARD FORM 599 mEV. WHIN

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MEDCOM - 18506

PROGRESS NOTES

NOTES

DOD-032080

ACLU-RDI 1647 p.66

LAST we

DATE

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ME DC OM - 18507 STANDARD FO 509 int snug Ci(

DOD-032081

ACLU-RDI 1647 p.67


11.

PATIENT'S IDENTIFICATION:Oar typed or mitten moils, give hoe • lest, fist node

ID No or SSN; Sec Date of Birdv RenklGrodel

1- (A) ' 7_

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STANDARD FORM 509 MEV. NMI

Ptescdbot1 by MOM EMS 141LIFO 101.11203W! USAPA VIA


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MEDCOM - 18508

DOD-032082 ACLU-RDI 1647 p.68


WARD NO.


DEPARTJSERVICE

MIDSIZED FOR LOCAL REPRODUCTION

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DATE er

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MEDCOM - 18509

PROGRESS NOTES *mini Record

STANDARD FORM 509 MEV. WWI

Presr.fibEl bP 13SARCHR PPMR (41CFRI 10141.20MM USAPA

DOD-032083

ACLU-RDI 1647 p.69

ALIT WIRED FOR LOCAL REPROORCTION

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SPONSOR'S NAME

HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

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MEDCOM - 18510


STANDARD FORM 509 KY. sow PH :sullied by GSAIICMR FPMR 141CFRI ID1.11.203(bH 1.

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WARD WI.

DATE

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DOD-032084 ACLU-RDI 1647 p.70

DOD-032085

LAST NM*

MEDCOM - 18511

ACLU-RDI 1647 p.71

DATE ID NUMBER

MEDCOM - 18512 STANDARD M 509 MEV. 6/19951 BACK

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Jill 41 t . ' &Al . AULIAIMAIALO COAAL A 4 et +LW

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DOD-032086 ACLU-RDI 1647 p.72



I

DATE NOTES

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MEDCOM - 18513


STANDARD FORM 509 (REV. 611990) Presuibed by GSAOCMR FMB HICFRI 101-11.203(14110)

USAPA VI AO

DOD-032087

ACLU-RDI 1647 p.73

DOD-032088


10. Arm_ _ —

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AMMO FOR LOCAL REPREIDUCITON

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HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

SPONSOR'S ID NUIABER (= or 000 •

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PATIENT'S WENT1FICATION: typed al wino oak Ike hint -int Mt mthfic ID Ns or SSIt Su; Dm el Di* &Nandi)

111111111110 1)\ MEDCOM - 18514

PROGRESS NOTES Mani Record

STANDARD FORM 509 (REV. 611991 Piestrind by GUAM FPIAR VI1CFR) 10141.2030411 1

usiPA V10

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WARD NO.

ACLU-RDI 1647 p.74

LAST NAME

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DOD-032089 ACLU-RDI 1647 p.75

MEDCOM - 18516

USAPA VI.

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DOD-032090

ACLU-RDI 1647 p.76

NOTES

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4.011 0(9)1




STANDARDFORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMRF

(41CFR) 101-11.203(b)(10)

USAPA V1.00

MEDCOM - 18517

c t-03 ax3 vSE

MEDICAL RECORD I PROGRESS NOTES


DOD-032091 ACLU-RDI 1647 p.77

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

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MEDCOM - 18520

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ACLU-RDI 1647 p.80


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DOD-032096

ACLU-RDI 1647 p.82

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b

palm

ithrlirk TIMA - 970/ in

ci L , fq

OXYGEN ON & RATE: (Q V y31,, Pi Ern SIZE: SURG. AIRWAY CT #I & SITE:

Fruu

4633858 MEDICATIONS

MIDAZOAM ANTIBIOTIC: PENTOTHAL frabr

4 OMIDA 4022Eakk.20.• REVERSAL:

• • ,

REGIONAL:

(6-EPTT 7-5/ Fetal

FLUID TOTALS

Sta UROtsI... At4f," OTHER:,-; DRAMS- VECURONIUM V AL6kArbt Xii,.... i i i 0"

4 2M1 FiAge Staftti4(1,40 614 I fs - ,---

LI Ok 01 b 1 ,

VITAL SIGNS. Me TIME: a z315-

MABEIM RR: /D

AD TEMP:

Ariz: slinuT13 444

CRYSTAL: COLLOID:

EBV: EBL: U.O.: Sp02:

ADMIT= 30 MIN=

D/C= DRESSINGS:

POST-OP MEDICATIONS MED & DOSE

V TAL SIGNS

TIME ROUTE BP: ADMIT D/C

LTa

O

HR: RR:

Sp02 TEMP:

DRAINS:

TOTAL= TOTAL=

MEDCOM - 18539

DOD-032113 ACLU-RDI 1647 p.99

B. AER-7•TION V Potential forrespiratory

dysfunction due to: V ) positionine

2) Effects of Anesthesia Medicat'Smoking History

WE IGHT:

4. PROPOSE tt-t-tA•

5. AD r;•ITIONIAL INFORMATION: Tobatco-- —13Pd XYrs. Body Pie ETOR 7 Implants

6.laspAsitslEICITonprRaocre(LzyN)

!MIS AND NEEDS Dentures

1. AGE= Q-3

45 /0 HT:

to: \V"..1) Surgical Procedure

Operating Room Environment 1) Separation Anxiety

Sureical Outcomes

; •

EfilUL

r

Respiratory Disease (AsthmwCOPD) (Y) (N)?Anticoagulants (Y) ASAAlotrin w:72 hrs ( ) (Z9) Y Hypertension (Y) (NT) Herb

-al Medicines (Y) (10MEDS: 4ez-

(Previous surgical and medical history) Skin ondition Cln

Diabetes (Y) (N) P ROM ?

Pt. will be able to breathe without difficulty during. immediate intraoperative phase .

7.PATIENT GOALS AND EXPECTED OUTCOMES PL

verbalizes any specific anxiety. r Pt. Exhibits relaxed body posture.

Potential for anxiety related

RATI REOPE VE/POSTOPEAJA FOR the of this form. see

AR 40-407: the pt pone

2. KNOWN ALLERGIC S ENSITIVITIES (e. NKDA PCN 0 LATEX REACTION:

Allow pt. to verbalize freely. )1/ Explain OR environment and answe

r questions regarding sureer-. Offer corn fon measures, w blanket. touch). arm

,e' Explain all nursing procedures berbre they are. done.

Remain with pt. whenever possible. V Maintain family interface. Parents to stay with pt.

nt agency is The Ogee of the Surgeon Central.

g.. Iodine, Tape, Medication) IODINE

0 TAPE 2 FOOD

FIVENURSING DOCUMENT

S. OR NURSING TNTERVENTIONS

ito

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

EP41111.

11) Lj(

C . INTEGUMENT V Potential impairment of skin

irue 'Ey due to: i) Infra° erative Immobility

-772) ESU Pad Placement 3) Positional Aids

Nii`j 4) Prosthesis 5) Poolin f Pre Ste

`

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

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

1

„V

7- Offer to elevate head ()flitter or offer pillow.

,/ Observe pt. while awantr.g surtzer.• for signs of distress.

/ Assist anesthesia during intubation and extubation.

Utilize pressure pre•eatine devices on

OR table and accessories. / Check for proper positioning and

support to maintain good body alignrnent. • Pad pressure points. / Place ESU ground pad on non • compromised skin surface area. 7 Keep prep fluids from pooling.

VERIFICATIONS AT HOLDEVG AREA: • ID/Allergy Band ! Dentures Removed ! ti 8: P

•! Contacts Removed ?JPO Since • ! Jewelry Removed UNCG/INIP ! Body Pierce Removed

Consent/Blood Transfusion Signed/WitnessedDated ! Surgical Site/Consent verified by PLIAnesthesiaiSurgeon ! Contact Precautio (Y) (Y) ! Family/Friend : ,

PSYC SOC/AL

DA FOR-"I 5179, JUN 9I

Previous editions are obsolete.

MEDCOM - 18540

DOD-032114

ACLU-RDI 1647 p.100

G OTHER PATIENT PROBLEMS "NEEDS. Or continuation of above problemsineeds.

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

outcomes.

PREPARED BY 17/ 19

bL6'

12. PREOPERATIVE V (Signature and Title)

DATE: 2 USA PA V I .9

/Li 4'7 fr-j TIME: 0

6. PATIENT PROBLEMS.AND NEEDS

D. .C1RCULA.....10N. • Potential for inadequate -tissue

perfusion due to: ∎ ,/ 1) Intrao erative Mobility \,/ 2) llositicitv,

3) Safety Devico

5) otherrnia

E. NEUROMUSCULAR CONTROL E.1. ►✓ Potential impairment of

mobility due to: • • 1) Esin

N/* 2) Intr aoperative Hazards 3) Prosthesis 4) rosijpL__..iino

f 5) Transfer pt. tolfrom OR table

E.2. Potential discomfort due to:

1) Leneth of Surcery 2) Positionine a) Arthritis

. PATIENT GOALS AND EXPECTED OUTCOMES

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

Pt. will be transferred to OR table without

difficulty. p Pt. will not experience unnecessary physical discomfort. -

...._

/2( ., OR NURSING INTER YEN_TIO Check for suppc. rt stockmes or ace

wraps. If none, chec k with doctors. / Check that safetl,:i

nstraderpsknaree

correctly applied. knees.

` bilateral motion.

1 I

iiilhlo:ito:

iistirniOfpfserwp.

y. Check that rings and all body

o Place and take clo wn te ,,,, from

cr •.:

/ Have sufficient people available for / transfer. • Insure proper body, alignment.

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

/1 Offer support (i.e.. pillows. bath

towels. etc.) for positioning.

V

F. SPECIAL SENSES F.I. Duninished visual perception

due to being: \dr 1) Pre-Nledicated

2) WO Glasses

F.2. \,/ Potential for decreased corrsnunication due to .

1) Dimir.ished Heannc \..7 2) Laneuacc Barrie:-

F.3. Potential injury due to

dentures: tJtx\e„ 1) Uoce- 4) Cans

2) Lower Crowns

3) Bridges

5,/ Pt. will be made aware of surroundines prior to anesthesia induction.

/6 Pt. will be transferred safely to OR table.

)6 Pt. will be able to understand instructions. Minimize dance; of injury during intraop

period.

Introduce h de.u hee self. an Keep pt. informed as lc :; e d v.that happen:me.

n o sc slf.

inform pt. in Which direction to move and assist if necessar-.

7 Speak clearly and mom• .

7 Address pt frorr. / Validate pt.'s understandinc of verbal communication. / Verify removal of denrures.

OTHER NURSING INTERVENTIONS Or continuation of above interventions

- 10. ING INTERVENTIONS COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.

(C6 DATE

11. POSTOPERATIVE EVALUATION: LEVEL OF CONSCIOUSNESS: 0 A840 LEVEL OF ACTIVITY: 0 Moves All

O N/A DRESSING DRY & INTAI (tp (N)

BREATHNG EAST• • (N)

SKIN INTEGRITY: Bovie Pad Site: Clean nd Dry 0 Red

❑ Drowsy 0 Sleepy

Extremities = Moves Upper Extremities

O Transferred to liner with roller due to spinal 13. POSTOPERATIVE EVALUATION PREPARED

REVERSE OF FORM 5179. JUN 91

MEDCOM - 18541

DOD-032115

ACLU-RDI 1647 p.101

ASSIGNED SCRUB 9/ t RELIEF

SCRUB

RELIEF CIRCULATOR — 11110

6. NURSING PERSONNEL

7. POSITION AND POSITIONAL AIDS (Specify)

El SUPINE ❑ LITHOTOMY ❑ PRONE ❑ KRASKE LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP COMMENTS:

ASSIGNED CIRCULATOR

MEDICAL RECORD

3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM i \

TIME OTIS– bk (-0 NUMBER -- (0 5. PREOPERATIVE EMOTIONAL STATUS ❑ CALM ❑ ANXIOUS ❑ EXCITED U CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify) COMMENTS: Allergies:

QYI

INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-66, the proponent agency Is the office of The Surgeon General.

k

1. PV.1%ArrRANSPORTED TO OPERATING ROOM . 2. PATIENT IDENTIFIED, VIA BY ,41/k25k5(7\0,1/4_ VERIFIED BY C,57 CEDURE

COMMENTS:

9. LOCATION OF EXTERNAL DEVICES

5-e 0 0 3

DA FORM 5179-1, OCT 87 REPLACES DA FO- MEDCOM - 18542

BsOLETE.

GROUND PAD: BRAND

LOT NO: ❑ BIPOLAR NO:

-2 )

8. SKIN PREPARATION

HAIR REMOVAL ❑ YES ►., NO PREPS TION S pe ci fy) Ay2F-7,... 4',..a..--,

DONE BY: ❑ OR ❑ NURSING UNIT SITE: a-A-41.-- BY WHOM: _/07-- METHOD: 0 DEPILATORY ❑ RAZOR SITE: BY WHOM: ❑ CLIP --____

_COMMENTS: /20 p--07--,--1--vj fi----i...ete

LEGEND X Ground Pad – Safety Strap === Tourniquet

First Closing Final Closing Other Count Count 10. COUNTS

Sponge Needle Sharp Instrument

Other

Yes ❑ No Yes ❑ No

❑ Yes ❑ No ❑ Yes ❑ No

C = Correct I = Incorrect

SCRU CIRCU

11. PAT/ NT IDENTIFICATION! (For typed or written entries give: Name - L t middle; Grade; Date; Hospital or Medical Facility;)

-ti

12. ELECTROSURGERMFVICE(S) (ESU)

C,0 A-6 `FZI ESU NO:

GROUND PAD: AND 14C6-1.t..‘ LOT NO: jerAq

❑

ES ❑ NO

ESU NO:

USAPA V1.01

DOD-032116 ACLU-RDI 1647 p.102

13. PROSTHESIS, IMPLANTS 0 YES r_NO IF YES NAME: ID NUMBER; MANUFACTURER

. i:"Akejaa:::,0::;g.::::::4:.:V;:M;::Mi:::;ENg::::::::;:::;;;:::W;1IMMEDICATIONS/ORDERSORME:MOOMM:MMEMERMSMONMSea

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

;MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

::WOUND IRRIGATION IR YES ❑

NO NOS TYPE(S):

ii ipTHER ORDERS TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING

YES

ROOM //11 YES, SITE

.-- ,W--/1-1 Cf_ ) A-r44 NO NO ■ 16. LABORATORY SPECIMENS

SPECIMEN (S)

NO

NAME NAME

YES ■ FROZEN SECTION (FS

NO

NAME NAME '

YES 111

CULTURE (C)

NO

NAME NAME

YES •

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

Vi>6: --- IL)(i't-

.--. gra...a- tt,"--01-r0 -

17. TUBES, DRAINS/PACKING YES II NO

TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3.

19. ADDITIONAL WC Surgeons:

Boyle Pad site intact Toutiet Site T rniquet Tii

INFORMAT1

pre-op in pre-op

Up

; post-op post-o .

Anesthesia:

. .

CW-AI

Bovie

Type:

A

Settings: Coag/Cut

(k.\Y1 \\'-

-iNS-V-ICk la.,—vx C.-ki\a-rk,

vn

10/4— 20. OPERATIONS) PERFORMED

cut-i- Qic

l

ctAy1-1A-- ,

1

21. PATIENT TRANSFEPMcD,10

I C--t(-.5 22.

MT- ANi

TINIE2„,„7.6 METHOD

t,re_ 4 A/

REVE

USAPA V1.01

MEDCOM - 18543

DOD-032117 ACLU-RDI 1647 p.103

9. LOCATION OF EXTERNAL DEVICES

CIRCU

1 INTRAOPERATIVE DOCUMENT

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

2. PATIENT IDENTIFI Si G VERIFIED BY

TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM Q5-1 TIME (....cc10

5. PREOPERATIVE EMOTIONAL STATUS CALM ❑ ANXIOUS ID EXCITED ❑ CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)

6. NURSING PERSONNEL

MEDICAL RECORD

. PATI'NTT qANBPOIFR TO OPERATING ROOM VIA 14) '0J-cc Idler BY 3. DATE

aCtS6P0.3 NUMBER g

D AND PROCEDURE

V3 ( Cf2_

COMMENTS: Allergies:

ASSIGNED SCRUB RELIEF

SCRUB

ASSIGNED CIRCULATOR

7. POSIT • AND POSITIONAL IDS S ecify) On C), bed,.01k. e d 01 a n 64 X/-..1."'4-7 &i, /Of k 4 0e-a. / /frolY e)(4e nj f

SUPINE OW- ft, SI

LITHOTOMY 6 5 ed ,A 1-,. ,vokst - cii-r,1 roc C.) evl--e, Strelia eLi-i-25:- . i PRONE / Ei KRASKE, "(J._ i LATERA)_:, 0 LEFT SIDE U IGHTSID ,E UP (; Le. f;e161 -1-- peiza or, p..cruceicr do,46 ie. Q /"--, 67 CO NTS: (A ..,

R /,&ci ,z, ,,-)e_4- r A-eel S - Co (re c.--1 30d v A 1, g.--„,„„2..,471- ',lc, ,h ./PI 09

. 'SKIN PREPARATION

❑ NURSING UNIT ❑ RAZOR

HAIR REMOVAL DONE BY: METHOD:

COMMENTS:

❑ YES dg NO ❑ OR ❑ DEPILATORY ❑ CLIP

PREP SOLUTION (Specify) SITE:L1A E Y WHOM: C SITE:

BY WHOM:

COMMENTS:it 0 tbrdl jvy of Sb(tt,-(1'd

RELIEF CIRCULATOR

*-- LEGEND Xfokinpgark -;,--.74tifety Strap LY1urniquet C = Correct I = Incorrect

❑ Yes Other

❑ Yes 11. PATIENT IDENTIFICATIO (Fot typed or writ n entries give: Name - Last, first, middle; Grade; Date; Hospftal o Medical Facility,) 12. ELECTROSURGERY DEVICE(S) (ESU)

❑ YES ❑ NO

GROUND PAD: BRAN

ESU NO: 1 0 LOT NO:

❑ ESU NO:

GROUND PAD: BRAND

LOT NO:

0

I.e

❑ BIPOLAR NO:

DA FORM 8•79-1, OCT 87 REPLACES DA FORM A170_4 rrEcin - BSOLETE.

MEDCOM - 18544 USAPA V1.01

DOD-032118 ACLU-RDI 1647 p.104

13. PROSTHESIS, IMPLANTS ❑ YES xl NO IF YES NAME; ID NUMBER; MANUFACTURER

j(AS t pry; aleLA_s e.,x, .) re.2,q)h ..5

114. gibkigai.61M.:2ii:1]: .giUNk0:0:::66;:::::::%::g.;:ti:;.:1.:R;O:::::::::::MEDICATIONS/ORDERSkag.:AtaKaagga.:0;E::;:::;:!1.00:ZOW.:E::::NRIN •IRRIGATION/MEDICATIONS GIVEN WOPERATING ROOM (NOT BY ANESTHESIA) YES II NO

::MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY :.'i. 5.

.WOUND IRRIGATION \+-i,YES ❑ NO, TYPE(S): )

66. Or Ci Z 61 e---e.- ,

. :OTHER ORDERS TIME CARRIED OUT BY

`PHYSICIAN'S SIGNATURE

...„.....,.......,,,....,,,......„........,...,....,........ , . .. „. ... . , .... •.. ...... , .. .... . ..........................-„...„,..,............,..„.: 15. X-RAY IN OPERATING ROOM IF YES&T)EL...( E

YES NO ■ LA. 0 ro Vi ,--A

16. LABORATORY SPECIMENS SPECIMEN (S)

YES ❑ NO

NAME NAME

FROZEN SECTION(..F

YES ■ 1.40

NAME NAME

CULTURE CULTURE (C) .

YES ■ NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

)(- RI - ( U-Fry

4e,KL6, Ro Hs e,-0--,,e,-- G'

17. TUBES, DRAINS/PACKING YES ■ NO ■ TYPE/SIZE 1. 2.

SITE

19. ADD NAL INFORMATION WC Surgeons: Anesthesia: P1 Anesthesia Type: G-Siti t--- rl /9--

o c_iesv 4

Boyle Pad site intact pre-op; post-op( .Bovie Settings: Coag/Cut ‘-t q° Tht-c--Ld / Iffrinlizeettlit:PJp

intact

.post-op

1 •

20. OPERATION(S) PERFORMED

(A)0S)A 0144 L_ LA E cf- Cx, Fx G d_jiAs--yvk..0„,-1

21. PATIENT TRANSFERRED TO

LA ► TI N & ME;v1-1-1rure....e_ i

ncl

/„..ier_

22. RE

REVER

USAPA V1.01 - MEDCOM - 18545

DOD-032119

ACLU-RDI 1647 p.105

MEDICAL RECORD

G ROOM

3. DATE

S-CP

❑ EXCITED 1/p. eNSIO

OV V\ tInef321X

ASSIGNED SCRUB

1. PATIENT TRANSPORTED TO OPERATI VIA L i` BY

❑ CALM ❑ ANXIOUS

COMMENTS: Allergies:

❑ CRYING ❑ ANGRY 1.14.:41-ket

%.tevit 111e9 Cwth 6, NURSING PERSONNEL

❑ WITHDRAWN

NUMBER

V OTHER (Specify)

PROCEDURE

Cs (C4) -

RELIEF SCRUB

INTRAOPERATIVE DOCUMENT • For use of this form, see AR 40-66, the proponent agency is the office of

The Surgeon General. 2. PATIENT IDENTIFI

VERIFIED BY TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROAM

TIME 01 5. PREOPERATIVE EMOTIONAL STATUS

ASSIGNED CIRCULATOR RELIEF

CIRCULATOR

7. POSITIOprAIKOSI

2eSUPINE

COMMENTS:

ONAZIDS (Specify).‘rec.

LITHOTOMy 0 PRONE ❑ KRAS21.4„t A 5

...AA._ 43P-4A_ _,C LAT RAL: ❑ LEFT SIDE UP El RIGHT SIDE UP

HAIR REMOVAL

DONE BY:

METHOD:

COMMENTS:

9. LOCATION 0

8. ES ❑ NO

❑ DEPILATORY 1pAZOR R

OR fdRSING UNIT

O CLIP

6U &,/ _ct EXTERNAL DEVICES

SKIN PREPARATION

PREP LUTION (Specify) SITE: L2 SITE' L) AA..

COMMENTS: os p

t elelo

BY WHOM:

BY WHOM'

Of crore.,-144A.

LEGEND

Mit ►at! 10. COUNTS

Sponge

Needle Sharp Instrument Other

X Ground Pad i - Safety Strap == Tourniquet

CIRCULATOR

11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;) 12. ELECTROSURGERY DEVICE(S) (ESU) YES ❑ NO

ESU NO: VE4J21 /4- 4 c.) (Li6 to 2 gq_5- GROUND PAD: BRAND It l 2.0

LOT NO: 6 z-y r 7..,(44 GROUND PAD: BRAND

LOT NO: ❑ BIPOLAR NO:

❑ ESU NO:

DA FORM 5179-1, OCT 87 REPLACES DA Fe." °"^ - MEDCOM - 18546 113SOLETE. USAPA Viol

DOD-032120 ACLU-RDI 1647 p.106

13. PROSTHESIS, IMPLANTS ❑ YES NO IF YES NAME: ID NUMBER; MANUFACTURER

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES fd NO ❑

MEDICATIONS/SOLUTION DOSAGE

15:z.` TIME METHOD

ie,7--- PREPARED BY

t..."-k- (., ( I c.),:o «1 1 I e..w p.k.e...._ • ( _ i

;WOUND IRRIGATION W 'YES • NO, TYPE(S):

0-C1 D/o 1J-..C.t.. a s . is

OTHER ORDERS i v TIME CARRIED OUT BY ,'.

)3HYSI c? (C.12) , ... _ ...,w"... _ . ..,..................... . ,....,,

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

YES NO • c__ a_.-L. 0..,k_ (12;) ct✓ ?ti. 16. LA ORATORY SPECIMENS

SPECIMEN (S)

YES ❑ NO g NAME NAME

FROZEN SECTION (F b?:

YES ❑ NO

NAME NAME

CULTURE (C)

YES ■ NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRE SING/IMMOBILIZATION (Specify) .

t--1 (2. 1 1-2e- ek

7....a.. FA

i -)ce3

P/3 //i -1-731/4-‘e 67 A,..&e.,.

17. TUBES, DRAINS/PACKING YES 17S"/ NO •

TYPE/SIZE 1f

3e1 ( 66i 2. tk figu-A2t. 3.

SITE 1.( kci. ,tiLLAi) 2.Cp ai

3.

19. ADDITIONAL INFORMATION Ckl WC Surgeons:tr• Anesthesia:

Boyle Pad site intact pre-op ; post-op

(,c.,- —

Anesthesia Type: 4-61--4-w--e.

1----

(r. Boyle Settings: Coag/Cut 4614:tC, Tourniquet Site intact prep) ost-op ,--3/ 4.- Tourniquet Time: Up

-gbk

VI s noi al it4iteci 20. OPERATION(S) PERFORMED

(.1„...

(1—) q Z.A.k / 6/7---,2_,-e e.t, -.&_t•-7 a (12-1) ii..Q.....t,_ c7 „,e,-- isrc,c,u

21. PATIENT TRANSFERRED TO r --- i "

TIME ../ 0(.0 S

METHOD

Litter c. 02_ 22. ISTERED N b ,

(62,) -t

USAPA V1.0 1

MEDCOM - 18547

DOD-032121 ACLU-RDI 1647 p.107

TEMP. C

40.6° t

40.0°

C 0

38.9° 9

a)

38.3° cc 0

37.8° a)

To

37.2° >

37.0° 0- 1.0

36.7° a)

b.0 '47

36.1°

39.4°

•e. 0 0

S

0

P. 0 ao C

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

MEDCOM - 18548

511-119

MEDICAL RECORD HOSPITAL DAY

POST-

MONTH-YEAR

19

PULSE (0)

180 104°

170 103°

160 102°

150 101°

140 100°

130

99° 98.6°

120 98°

110 97°

DAY

DAY

HOUR

TEMP. F

105°

NSN 7540-00-634-4124

VITAL SIGNS RECORD

Olb •

100 96°

90 95°

80

70

60

50

40

RESPIRATION RECORD

BLOOD PRESSURE

MEW 1:1111MMIIIN IIMIIIMMINIM1111111.111111 1111.111111MINIIKII

IIIIM1.11111111= 1111111111111111111111111111 17111111111114111111111EVAIIIIM aimmuzizrz 111111111111MIMMilial•IIIMMIRMIIIMMIII 111111111•11111111MAILVAIMMILIIIM MINIM=

1111111111111111Wira7MENIIIIMMke111111111111•11 27011MINS11111aMillIMMINEMMINIum77771 =MI_ IN. NEM 11111•11^^^11111111111111111

• •

35.6°

35.0°

HEIGHT:

WEIGHT

WARD NO.

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-55) Prescribed by GSA/ICMR, FIRMR . (41 CFR) 201-9.202-1

DOD-032122 ACLU-RDI 1647 p.108

DOD-032123

■ NO

EMERGENCY CARE AND TREATMENT 1PatiOnt/ Medical Record

STANDARD FORM S58 REV. 9-9 Prescribed by GSA/ICMR 61 MEDCOM - 18549 41 CFR) 101-71.2031b)(10/

OG NUMBER


7540-01-075-371

AGE

HOME PHONE

DATE W ARRIVAL ar. Month. Year, TIME

II- Sop t- 03 -a. '3 4 5 TRANSPORTATION TO FACILITY

SEX

MED/CAL HISTORY °STARVED FROM

Ts )1FIED a/TY FULL DU /UNTIL

POSITION .

TIME

CHIEF CompuuNT

Gs w e cc I e..7 CATEGORY OF

0 EMERGENT

PULSE Ox

samarim gra .1122E11.11.•Anzerloliti o B

ORDERS

iiimmizammitagram u"Aiim,_2zuswiniziftwizommenum

razzazammis I I I I I lam .1.1" I I I I I main

TREATMENT

MONITOR

COMPLETED ay

1111111111 61111 " al - 11111111,11111ftimair JSPOSITION QUARTERS /OFF DUTY n 24 HRS. a

RETURN TO DUTY

I/■LIURY OR OCCUPATIONAL ILLNESS

1111:111M

43 Has. ri 72 MRS PATkNT/DISCHARGE INSTRUCTIONS

ORDERS

1 00

VITAL SIGNS 000 r

DATE LAST SHOT

kE OF INSURANCE COMPANY •

EMERGENCY ROOM VISIT DATE LAST VISIT 24

HOUR RETURN

LS SPINE

HEAD CT

C-SPINE

Srf∎ 9 YT‘c5r-

THIRD PARTY INSURANCE

CURRENT MEDICATIONS

bir) Kn n L.....)(-) ALLERGIES

LA YES TETANUS COMPLETED wriAL SERIES

YES O NO GSW pqr ar7.

4 ..111GENT

0 NON-1.4)aer cr) Ir14.1

O

ECG PATIENT'S RESPONSE

DMON UPON RELEASE

NO

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

sa"s IDENTIFICATION !'fir tYP'd or wrira.i .e4I•44.

give; N4me lass, facility)

fast,10 no. ISSN Of other): hospital or

tiPSIOYED 0 UNCHANGEDC. ATER/CPA TED

WH EN I

have received and understand these instructions. PATIENT'S SIGNATURE

1.04

'SET ADDRESS

MEDICAL RECORD EMERGENCE/ CARE AND TREATMENT

(Patient) PATIENT'S HOME

ADDRESS OR DUTY STATION

ACLU-RDI 1647 p.109

jPROV;OER SiGNA

b tuY O O U

>71E-NT'S 10e,ITIF1CAT1ON

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS WBC

a a X +a

ABG/PULSE OX RADIOLOGY Check if road by radiologist -"

U H/H SUP 02 PH PO2 RESULTS •

PLT PCO2 SAT OTHER

DIP EKG INTERPRETATION

WTT BHCG ETON GLU MICRO

'RC50c.4 lA. 14, 15 G sti-) t-1- tApeer Con • FC ^) 9 t +c) MD A/0ER HISTORY/PHYSICAL,

1,u?(DIN ckt rt- ro-.4 ct( -eoe (c.i-he-it.c- p('‘c r •

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51= 64c 0 A L ktio

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Cif Ci:ACZ)

(-46T Mv■A___ 04- (. 6("(

tt.A...e._ •

frvco s‘ CA,) 4 5-4,(5&- ty-r-

CONSULT WITH TIME ACTION

IAGNOSIS

RESIDENT/MEDICAL STUDENT SIGNA rr STAMP

MEDCOM - 18550

(Pot typed or written entries, give: Name — last. first, middle: 10 no. (SSN of other); hospital or medical .1*eilltyl

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 553 IREV. 9- 95) Pra4crib,td by GSA/ICX4R MAR (4) CFR) 101-11.2031b)1101

)-)

DOD-032124

ACLU-RDI 1647 p.110


POST- DAY

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

11.

REGISTER 140t ';

STANDARD FORM 511 (REV. 7-95) RACK

MEDCOM - 18551

DOD-032125 ACLU-RDI 1647 p.111

NSN 7540-00-634-4124

TEMP. C

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40.0 °

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511-119

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i 1111111111111111111111111111111 PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; 11) No. (SSN or other); hospital or medical facility) REGISTER NO.

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MEDICAL RECORD

PULSE (0)

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104° 103° 102° 101° 100° 99° 98.6° 98°

TEMP. F (°) 105°

WARD NO.

MEDCOM - 18552

VITAL SIGNS RECORDS

Medical Record STANDARD FORM 511(REV. 7-95) Frescribecf by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

DOD-032126 ACLU-RDI 1647 p.112


POST- DAY

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

REGISTER NO WARD NO.

STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 18553

DOD-032127 ACLU-RDI 1647 p.113

MEDCOM - 18554

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DOD-032128 ACLU-RDI 1647 p.114

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ACLU-RDI 1647 p.115

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

LAST, FIRS (LS (4

DATE TIME SSN/PSEUDO SSN:

•;'- S• z-•,,, i, 4144)p . " - ;pc* itaboogiliot • TEST RESULT REF. RANGE TEST RESULT REF.

RANGE TEST RESULT REF. RANGE

Na 138-146 mmol/L ALB 3 .5-5. 5 Wcil GLU 73-118 invdi K 3.549 truno1/1.; ALP 26-84 all BUN 7-22 mg/d1

Cl r 98-109 mmol/L ALT 10-47 u/1 CA+ 8.0-10.3 medl

pH • 7.31-7.45 AMY 14-97 IA CRE 0.6-1.2 nag/d1

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

AST 11-38 u/1 NAT 128,145 mrno1/1

P02 80-105 mmHg (art) WA (veal

TBIL 0.2-1.6 mg/di IC+ 3.34.7 ininoltl

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

' BUN 7-22 tug/d1 CI: 98-108 mmoln

HCO3 22-26 mmol/L tan) 23-28 unman (yen)

CA++ 8.0- 10.3mg1c11 tCO2 18-33 amo1/1

s02 9598% ' CHOL

CRE

100-200 mg/dl

0 .6-1 .2 Eng/d1 TEST

ICCO =s0...:,'.;;:i,::;;;:...;,.,,.:,. 1.c.,"?-.., ' 'tfre

RESULT

'n: ' .Z,s .,..: ,7:,,....i.,:::. '...:

REF RANGE BEecf (-2) — (+3) mmol/L

AnGap 10-20 mmol/L GLU 73-118 me/di ALB 3.3-5.5 g/d1

Ca

BUN

1.12-132 mmol/L ! TP 6.4-8.1 edi ALp 26-8411/1

8-26 mg/d1 ieCliki .' ' 9, . ALT 10-47 IA

GLU 70-105 mg/dl TEST RESULT REF. RANGE

AMY 14.-97 un

Creat 0.7-1.5 mg/dl GLU 73-118 mg/di AST 11 -38 un Hct 38-51% PCV BUN 7-22 mg/d1 TBIL 0.2:1.6 mg/dl ligb 12-17 g/d1 CRE 0.6-1.2 mg/dl GOT 5-65 till

,; c . ,..: ...-..4.60j.,..,;.: ':::-:.!'

:: , CK • 39-380 till (IA)

30-190 u/1 (F) TP 6.4-81 g/d1

TEST RESULT REF RANGE NA ÷ 128-145 mmo1/1 -a' , . .. ' 000 .

Troponin-! 4. 33-4 .7 mmolil • TEST RESULT REF. RANGE

Drug of Abuse

.CL 98-108 mmol/1 N + 128- 145 mmol/1

tCO2 18-33 mmol/1 K' 3.3-4.7 mmol/1

. CI: 98-108 mmo1/1

• 1CO2 18-33 mmol/1

REMARKS: •

REPORTED BY: imp

t€ p 6 3 DATE: . LAB ID NO.:

MEDCOM - 18556

DOD-032130 ACLU-RDI 1647 p.116

Cu) -z 1—LaTiflORATORY RESULT FORM Sub-ect to the Privac Act of 1974)

SSN/PSEUDO SSN:

Ward/ tion: iC

LAST, FIRST, DATE

Imm

Baso

Mono

Eos

GE

HCG

Leuk

TEST

Color

App

Glu

Bili

Ket

Bid

pH

Prot

SG

TEST RES

WBC

RBC

Hgb

Het • MCV

Plt

Segs

Bands .

Lymph

Atyp

AEC Morph

RESULT I REF. RANGE TEST

N/A RPR N/A

Negative

Negative Source

Negative Gram Stain Occ Bld

H. pylori

Micro Parasites

Negative Malaria

0.2-1.0

Negative

Negative

Negative

14-18 Wdl(M) 12-16 g/d1 (F) 42-52% OA) 37-47% (F) 80-94 fl (M) 81-99 fl (F)

4.8-10.S x 103

4.7-6.1 x 109

Urob

Nit

130-500 x verified

Lymph %

20.5-51.1%

(Hemabilogy) Manual Differential

Mono

'N/A

Negative

N/A

O&P

Other

Misc. Serology

oscopic Urias Is

Negative

Negative

Microbiology

RESULT REF. RANGE

Negative

Negative

Other I

Coagulation Studies.

REF. RANGE

9.8-13.6 secs

Cell Count

Negative

MOSTSUBMITSF:518.WFAil EVERY UNIT OF BLOOD .13104 Bt44:tri1it-croislItateh"

REQUESTED) TYPE CROSSMATCH

F DATE: FLAB ID NO.:

Spun Hematocrit Sed Rate

Dir ectigen

UNIT'

42-52% (14) 3747% (F)

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED ABO/Rh

TEST RESULT

PT

APTT

D dimer

FDP

REMARKS:

REPORTED BY:

21 -34 secs

<20 uging

<10 nem'

MEDCOM - 18557

DOD-032131

ACLU-RDI 1647 p.117

\Yard/Section: E. fr._ T

LABORATORY RESULT FORM I (Subject to the PriVacY Act of 1974)

LAST, FIRS'f,14.t

\a( (P ,

1ME

et3 SS

, ..(Rpiste? Cs : , • • _Units i! . ) ••:. • , . .., .• . . . . TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF RANGE

WBC 4.8-10.8 x 103 Color re x

„...) N/A RPR Negative

RBC 4.7-6.1 x 10° App Pir{

N/A Mono Negative

Hgb 114-2-1186 Z

didl () Glu 1 J66, Negative_ " - . 110krobiofogy -. .-... . - .. . • • - -

Hct 42-52% (F)

(M) . Bili Negative Source

MCV 80-9411 81-99 fl (F)

Ket MEC%

Negative '

Gram Stain

:.

Pit •

130z500 x te' verified

SG 1. 0117

N/A Ow Bid Negative .

Lymph % 20.5-51.1% Bid Negative H. pylori Negative

kiiiity)MinuaIPIffrentill - 1 pH 6.0

N/A . Micro Parasites .

Segs Mono Prot .1-2 Negative Malaria '

Bands Eos Urob 0 . 7..

02-1.0 0 & P -

Lymph Baso Nit 4

Negative Other

Atyp 1mm - . .

Leuk sG

Negative •AliciosCOPk X/rill .

RBC Morph

HCG

, .

Negative

Spun Hematocrit

42-,52% (M) ' 37=47% (F) -

; ' • - - .

: ,:* '..: ..... Blood•Ba# .-.• •-• .:.

Sed Rate Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative Ago/ Rh

' I ------------........

,:, COaguliition Stu' 'e3:. - ,.

_ , .11944.130ak tfiiit,VioisinitCh" '...:-..-- .: :. .- •.: • : ...:-' . (MUST SU411TSF,518. 1iri1Tii tvERy wir 0•)0Oiri . - - - , - ' 1. : . ..,. _,, ,•- itt<ititstiDy .5. :, f . . ;-... - *: '''''. .r': ..

TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH

PT 9.8-13.6 secs

.PT• 21-34 secs

D dimer <20 ug/ml

FDP <10 ug/m1 •

REMARKS: .

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

MEDCOM - 18558

DOD-032132 ACLU-RDI 1647 p.118

N Ward/Section;

`CYN -1— RE CHEMISTRY RESULT FORM

(Subject to the Privacy Act of 1974) SSN/PSElUDO

'A- .,„ . . ---.i.,;•-ff'..,174-,-;..e:,,..:4...w.f:Y.,;vphz,:vQr:-;;,:-. e6:1-1 444:4:5. ',,:: ,,:ti.:-.4gw-,-;p9i,L-..-.."..-.., ,. 44. j., ;.:).-.14,t_e !. i., he_ , ..:-..C.:4:11:..),'.., .,. ,, TEST RESULT REF. RANGE TEST RESULT F. RANGE

TEST RESULT .

REE RANGE

Na 138-146 mmol/L ALB - 3-5-5.5 fld GLU 73-118 mg/di K 3.5-4.9 romo1/1; ALP 26-84 u/1 BUN 7-22 mg/dl Cl 98-109 Lonxin ALT 10-47 ull CA" " 8.0-10.3 mg/d1

PH 733-7.45 AMY 14-97 u/I CRE 0.6-1.2 mg/d1 PCO2 35-45 rmalig (art)

41-51 =lig (vca) AST 11-38 u/1 NA' - 128-145 mmol/1

.

P02 80-10 mmHg (art) WA (vett)

TEI•, 0.2-1.6 mg/di K4 . 3.34.7annal/1

TCO2 23-27romol/L (tut 24-29 mmol/I. (van)

BUN 7-22 mg/dl CL" .

98-108 mmol/1

HCO3 22-25 ma:AIL (art) 23-28 mmol//. (van)

CA+4- 8.0-10.3mpidl tCO2 18-33 trano1/1

s02 95-98% CHOL 100-200 ingidt igeo .tL;-%; ,̀;„...1,4,,

BEecf (-2)- (+3) mmon

CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE AnGap 10-20 mmol/L GLU '73-118 mg/d1 ALB 3.3-5.5 g/dl Ca i. 12-1.32 mmol/L TP 6.44.1 g/d1 ALp 26-84 u/1

BUN 8-26 mg/di ''

., ,._.........i. -:':;'.:: : .;:7::-1%:,". ALT 10-47 u4

GLU 70-105 mg/c11 TEST RESULT REF. RANGE

AMY 14-97 u/I

Creat 0.7-1.5 mg/d1 GLU 73-118 mg/dl AST 1 11-38 u/1 Het 38-51% PCV BUN -

" 7-22 mg/dl TBIL 0.21.6 mg/d1

Hgb ,12,47 dl .. _.

CRE 0.6-1.2 mg/dl GGT 5-65 u/I i Vika"

.;.,#7;,.-,.....:‘,"7.11:-'7,: -.,-;.i.:

' . 4j.. CK 39-380 Lill (M) 30-190 LA

TEST ' A 1 . RANGE NA+ 128-145 mmol/1 ' : !ti110: -ear. ' '':,,,;..:%t41:. ':...!;:c il.c.,,p1;;;;,;:,-.'4.1.', :::,•%;:..0,,:; ' ' '' ,

Troponin-( K+ 3-343 =WI TEST RESULT REE RANGE

Drug of Abuse

_CI: 98-108 mmol/1 NA' 128-145 mmol/1

tCO2 18-33 mmol!/ K+ 3.3-4.7 mmol/3

. CL: 98-108 minoL4

...-..... ._ 1CO2 18-33 mmo1/1

REMARKS: •

•

REPORTED BY:

...

DATE: . LAB ID NO.: ,

MEDCOM - 18559

DOD-032133

ACLU-RDI 1647 p.119

DOD-032134

Oper:

. TCO 2 18 mmol/L

-STAT G3+ • •

Pt1111111(3.,U) L\

Pt Name:

TCO2 23 mmol/L

At 37C

pH 7.422

PCO2 33.5 mmHg

P02 284 mmHg

HCO3 22 mmol/L

BEecf -3 mmol/L

502* 100

*calculated

At Patient Temp

PH 7.456

PCO2 30.3)mmHg

P02 273 mmHg

Patient Temp: 94.5F

FIO2 : 50

Sample Type.: RRT

08SEP03 07:17

At 37C

PH 7.483

PCO2 23.4 mmHg

P02 136 mmHg

HCO3 18 mmol/L

BEecf -6 mmol/L

502• 99 %

*calculated

At Patient Temp

PH 7.481

PCO2 23.6 mmHg

P02 137 mmHg

Patient Temp: 98.9F

FIO2 : 80

Sample Type_:

Na 142 mmol/L

K 3.7 mmol/L

TCO2 21 mmol/L

iCa 1.28 mmol/L

Hct 23 ':PCV

Hb* g/dL

*via HO

At 37C

PH 7.089

.E.; mmHg

P02 25 mmHg

HCO3 15 mmol/L

BEecf -11 mmoi/ ,_

27 %

*calculateri

Sample Type_:

10NAR03

7,erit 42011

JAMSO46A CLEW A93

Pt:

Pt Name:

1-75TPT EG7+

Pt:

Pt Name:

Se' Seri! 42015

Ver: JAM5046A

cC.

MEDCOM - 18560

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27 mmol/L

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05SEP03

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04:32

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TCO2 22 mmol /L

At 37C

PH 7.300

PCO2 41.8 mmHg

P02 310 mmHg

HCO3 21 mmol/L

BEecf -6 mmol/L

502* 100 "

*calculated

Sample Type.: „..

08SEP03 03:01

Oper:1110b (;)

physician:

Seril 42011

Ver: JAMSO46A . r.I 09:1

Pt Name:

TCO2 24 mmol/L

At 37C

ph 7.293

PC_ 02 46.0 mmHg

002 463 mmHg

HC 22 mmol/L

BEecf -4 mmol/L

100 %

*calculated

FID2 : 100

Simple Type.: ART

1-STAT

Pt: 10 6E- pa t00%

08SEP03 00:24

ACLU-RDI 1647 p.120

ALB ALP ALT AMY AST TBIL BUN CA++ CHOL CRE GLU Tl

3.4 41 36

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7.7* 58* 1.4* 125* 5.4*

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• STANDARD FORM 545 (rev. 10-75) 545-108

• LABORATORY REPORT DISPLAY

3141AA4 DR #: 000

0000100676 \4(.4.t

GLU 119* 73-118 MG/DL. BUN 12 7-22 MG/DL CRC 1.4* 0.6-1,2 MG/DL CK 2817* 39-380 U/L NA+ 136 128-145 MOM_ K+ 5.9* 3.3-4.7 MMOVL CL- 105 98-108 MMOVL tCO2 20 18-33 MMOVL

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

PICCOLO 08/09/03 00:34 RC1 EfOLt RANGE: MALE PAVILNT #: 0723 GENERAL. CHEMISTRY 12 DISC LO 3112AA4 OPER 0: DR #: 000 SERIAL 0000100884

3.3-5.5 G/DL 26-84 U/L 10-47 U/L 14-87 U/L 11-38 U/L 0.2-1.6 MG/DL 7-22 MG/DL 8.0-10.3 MG /P 100-200 MuiDL 0.6-1.2 MG/DL H

73-118 MG/DL 6.4-8.1 G/DL

INST 00: OK CHEM QC: OK HEM 1i, LIP 0 , ICT 0

------- PICCOLO ==== 08/09/03 00:34 REFERENCE RANGE: MALE PATIENT #: 0723 METLYFE 8 DISC LOT #: OPER #: SERIAL #:

O O AUGN ALL LABORATORY REPORTS ALONG THIS BASE UNE

FORMS DISPLAYED ON THIS SHEET ARE (Check one) INSTRUCTIONS: This form may be used to display laboratory reports as a flow sheet to be read as a progressive table. If so, a separate sheet should be used for each type of report form. When assorted report forms are mounted on the display sheet, both test names and results should always be visible.

ENTER IN SPACE BELOW: PATIENT IDENTIFICATION-:TREATING FACILITY-WARD NO.-DATE

CHEMISTRY I (SF 546)

0 CHEMISTRY II (SF 547)

El CHEMISTRY III (SF 548)

HEMATOLOGY (SF 549)

0 URINALYSIS (SF 550)

p SEROLOGY (SF 551)

t't

D SPINAL FLUID (SF 555)

PRESCRIBE BY GSA/ICMR FIRMR (41-CFR) 201.45.505

MOUNTED ON STRIPS 1 THROUGH 7

0 MICROBIOLOGY I (SF 553)

0 MICROBIOLOGY II (SF 554)

0 MISCELLANEOUS (SF 557)

ASSORTED FORMS

0 PARASITOLOGY. (SF 552)

IMMUNOHEMATOLOGY (SF 556)

0 ASSORTED FORMS

0 OTHER (Speci6)

MOUNTED ON STRIPS 1, 3, 5, AND 7

MOUNTED ON STRIPS 1, 4, AND 7

LABORATORY REPORT DISPLAY

* U.S. GOVERNMENT PRINTING OFFICE 2001-660-043

DOD-032135 ACLU-RDI 1647 p.121

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IMMATURE

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PLATELETS

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% ACTIVITY

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HEMATOLOGY 549-107 STANDARD FORM 549 IR. 7-761

PRESCRIBED BY GSA/1001 PRIM 51-CFR) 207

1 1 1 1 1 1

PHYSICIAN COPY

DOD 0 0

SEE RATE

PLATELET COUNT RETICULOCYTE COUNT

PATIENT

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O

P ; 11•09/03'" 04:40 RDERENCE RANGE: MALE PATIENT #: METLYTE 8 DISI; LOT 3111AA4 OPER #: it/DR #: 000 SERIAL #: 4_1dt-000010067G

GLU 106 73-118 MG/DL BUN 6* 7-22 MG/DL CRE 0.8 0.6-1.2 MG/DL CK 1709* 39-380 U/L NA+ 133 128-145 MMOVL K+ 3.4 3.3-4. 7 MMOVL CL- 101 98-108 MMOVL tCO2 27 18-33 MMOVL

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

FIRM1(41 Z115.5051

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MEDCOM - 18564

DOD-032138

ACLU-RDI 1647 p.124

PHYSICIAN'S COPY

HEMATOLOGY 549-107 STANDARD FORM 549 IT' 7-79r

PRESCRIBED BY GSANCMR FIRMR 14 FR)

1 1 1 1 1 1

TESTIS)

SPECIMEN

AE L'1 ;:M.

REQUESTED

EEC COUNT

HEMOGLOBIN

HEMATOCRIT

• rn rn 3 0 if

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5* m 0

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.

REQUESTED

GLUCOSE

UREA N.

B IN (DIRECT)

CHOLESTEROL

TRIGLYCERIDES

AMYLASE

PROFILE ESP•clEY)

CHEMISTRY I 546-107 STANDARD FOR... MR IRA. SYR

'PRESCRIBED BY GSA ICMR FIRMR (41 CFR) 201-45.505

I I

TAKEN

DIA2 se_42

RESULTS '

IMMATURE

NEVITIO-BANDS

NWT ROSEGS

LYMPHS

EOSINOPHILS

BASOPHILS

MONOCYTES

PLATELETS

RBC

BLEEDING TIME

CONTROL

PAINNT

RATIO

% AC IIVITY

CONTROL

PATIENT

SICKLING TEST

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a

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SULTS

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0

-4

5

O-4

2

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CREATININE MCV

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WBC COUNT POTASSIUM

CHLORIDE

PHOSPHATE

CALCIUM

TOTAL PROTEIN

ALBUMIN

GLOBULIN

NE PHOSPHATASE ACID PHOSPHATASE

PlO

W 1

13)

000

19

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BIURUBIN OTA CLOTTING TIME

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MEDCOM - 18565

DOD-032139 ACLU-RDI 1647 p.125

z

(5--el-r - 0

•

ar Aim SI

SPE

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Rall PATIENT #: _Li BASIC METABOLIC ') DISC LOT #: 3145AA4

OPER #.

DR #: 000 _ SERIAL[(;)4 000011Y0494 %2 GLU 120* 73-118 MG/DL

BUN 9 7-22 MG/DL CA++ 7.8* 8.0-10.3 MG/OL

CRE 1.1 0.6-1.2 MG/DL NA+ ♦+*43(128-145 MMOVL K+ 3.9 •.3-4.7 MMOVL CL- 95* 98-108 MOLL tCO2 25 18-33 MMOVL

INST GC: OK CHEM GC: OK 1 HEM 0

I LIP 0 T ICT 0

4, = rrt 2 3

a2 2

2 >

0 ❑ 0 8

cc

4TIENT'S MED. RECORD

os •

RESULTS REQUESTED

EEC COUNT

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

mcNC

WRC COUNT

IMMATURE

NEUTRO-BANDS

NEUTROSEGS


SEG. RATE

LYMPHS

fOSINOPBILS

BASOPHILS

MONOCYTES

PLATELETS

RBC

O 1 O

CLOTTING TIME

BLEEDING TIME

P CONTROL

T PATIENT

CONTROL

PATIENT

% ACTIVITY

SICKLING TEST

LE PREP

RATIO 2 g

0

HEMATOLOGY 549-107 STANDARD FORM 549 (Rey. 7-781

PRESCRIBED BY GSA/ICMA FIRMA 141-CFRI 201-45.505

PHYSIOAN COPY

MEDCOM - 18566

DOD-032140

ACLU-RDI 1647 p.126

SPECIM 'KEN

A.M.

P.M.

LABORATORY FILE

TESTIS) SpEC;mEN TAK

TIME A.M.

MD

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CHEMISTRY I 546-107 STANDARD FORM SAS IPw 6111

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Nysvibed 4 OSA/ICMR FIRM) Ill CFR) 201-AgE55,..

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TODAY ❑

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PATIENT STATUS kg (.BED 0 AMB 2

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DOD-032142

ACLU-RDI 1647 p.128

DATE

RESULTS

n

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HEMATOLOGY URGENCY PATIENT STATUS la

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a.

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PRESCRIBED BY GSA ICMR FIRMA (41 CPR) 201-45.505 3111 .131

GV

DATE

Enter 41 alarm Waco

PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE

REPORTED BY MD

TECH REMARKS

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__---_= PICCOLO == === == 08/09/03 0?: 53 REFERENCE RANGE: M LE . z

- PATIENT #411111 .0_ - METLYTE 8 . - DISC LOT #: 3141AA4

OPER #: DR #: om SERIAL c„,1-0000100676

_ GLU 133* 73-118 MG/DL - BUN 12 7-22 MG/DL - CRE 0.8 0.6-1.2 MG/DL - CK >5000* 39-380 U/L - NA+ 132 128-145 MMO&L

K+ 3.5 3.3-4.7 MMOL CL- 108 98-108 MMO/iL tCO2 19 18-33 14101/L

_ INST QC: OK CHEM QC: OK _ HEM 0 1 LIP 0 , ICT 0 3

4 II

TESTIS)

SPECIMEN TAKEN

TIME

REQUESTED

R8C COUNT

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

MCHC

WIC COUNT

IMMATURE

NEMO-BANDS

NEUTROSEGS

IYMPHS

EOSINOPHILS

BA SOPHIL S

mONOCY IES

PLATELE IS

RBC

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DA

TIF

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DOD-032143

ACLU-RDI 1647 p.129

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REPORTED BY

PATIENT STATUS ❑ BED ❑ AM!)

OUTPATIENT 0 ❑ HP ODOM

SPECIMEN SOURCE ❑ VEIN ❑RAP ❑ OTHER (Specify) LAB. ID. NO.

PATIENT IDENTIF

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TODAYD ❑ PRE-OP

STAT ❑

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V a.

0

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n#/ HEMATOLOGY

URGENCY ❑ ROUTINE

TODAY ❑ ❑ PRE-OP

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SPECIMEN SOURCE

Enter in oboe. space PATIENT IDENTIFICATION— REQUESTING PHYSICIAN'S SIGNATURE EATING FACILITY—WARD NO.--DATE

REPORTED BY MD DAT5,24 5

TECH 45?

❑VEIN ❑ CAP STAT OTHER (Specify)

LAB. ID. NO.

TECH

•11111111 7111111111111111.11.11:BCID: AND LoCELL ‘''M MORPH P 11111111 111111

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MEDCOM - 18570

z

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DOD-032144 ACLU-RDI 1647 p.130

PICCOLO : 15/09/03 04:24 REFERENCE RANGE: MALE PATIENT #: 111111 \,(0LN)-c,) METLYTE 8 DISC LOT #: 3141AA4

#: 000

GLU 110 73-118 MG/OL BUN 8 7-22 MG/DL CRE 0.6 0.6- 1.2 MG/DL CK 149 39-380 U/L NA+ 121* 128-145 MOW K+ 3.8 3.3-4.7 MMOI/L CL- 98 98-108 MMOI/L tCO2 26 18-33 MMOL

INST 014°: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0

SER OPER #: DR

0000100404 ..................... ..

DOD-032145 ACLU-RDI 1647 p.131

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- Test Date :09/08/03 Test Time :08:16 AM Card Lot :010301 Operator •

RAPIDPOINI COAG ANALYZER V4.54 SERIAL #005485 09/0 /03 08:22 AM

Patient ID: Test Name :APTT Test Result:= 67.1 sec. ***RESULT . NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/08/03 Test Time :08:19 AM Cald tc:7 .114.1217 iipei

RAPIDPOINI COAG ANALYZER V4.54 SERIAL #005485 09/08/03 02:06 PM

Patient ID fest Name :APIT Test Resul1:-, 46.3 sec. ***RESUL1 NO1 RANGE CHECKED*** Sample lype.citrated wh. blood Test Dale :09/08/03 Test Time :02:06 PM Card Lot :100212 Operator

:Y411; iZER V HOft: - 03

Patient estZ111111 est Result: = 13.4 sec.

***RESULT NOT RANGE CHECKED*** Ratio = 1.1 Calculated INR = 1.16 Sample Type:citrated wh. blood Test Date :09/08/03 Test Time :12:36 AM Card Lot :Ul Operator ,:-

m - - - -

RAPIOPOINT COAG ANALYZER V4.54 SERIAL 1005485 09/08/03 12:40 AM

Patient .1111111 Tes ame :APTT

st Result:= 32.3 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/08/03 Te7:1- Time :1?:Ti AM

A I "Tti4'::;N;

; f r4

W.J:b6 PM

Patient ID: Test Name :APTT Test Result:= 53.0 sec. ***RESULT NOT RANGE CHECKED**4 SaMPJA.We:citrated wit. blood Test bale :09/08/03 Test Time :09:54 PM Card Lot :100212 Operator

!RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 09/08/03 09:56 PM

PatientAl

Test Result:= 13.1 sec. ***RESULT NOT RANGE CHUWED**4 Ratio = 1.1 Calculated INF? = 1.12

Type:citrated oh. blood Date :09/08/03

EE C i lime :09:57 PM Caro Lot :0103(

*4:4:

1AP1OPuiNI i;,Np, tiltR 4.54. SERIAL #005485 09/0 - 3 02:05 PM

Patient ID:

Test Name I Test Result::: 14.5 sec. ***RESULT NOT RANGE CHECKED44 Ratio = 1,2 Calculateo 1NR = 1.32 Sample Type:citrated wri blood Test Date :09/08/03 lest Time :02:04 PM

Card Lot :010301 Operator IlimorT

WWI

;-■ `"F_I 1,-,

• '

•

MEDCOM - 18572

1,1

L7-• "?. ••••• -.4

"C"i, ■ -• 727.; fr: re

DOD-032146

ACLU-RDI 1647 p.132

kAPIDI SWIA1

1 .A

...! ,1

Pd!lehi 1 e- • Nifilie

Pc...;u11::- 14.1 sec. .4.44P1SULF NUT R1-011:iL CHECKED*** Path, 1.2 Ca lcu I a l ed I Nk 1.26 SamPit, iYor:citTaLed wh h1 00d

Rite :09/09/03 Htit :u4:56 AM ler :010301

Up!dtor

RAPIDPU1N1 CHAU ANATY.0 V4.54 MO5485 09/09/03 05:02 AM

Patici f0. 1t:st Nagle :APT1 Test Rewit:;- 43.8 sec. 44*RESULT NOT RANGE CHECKED**;Y

Typemtrated wh. bluod :09/09/4,

Test floe :64:59 AM Card lot :10r.212 Opereltor

•

WMI. N-0543

qv 12:28 Ratient Lviits -

x 1 ;7ii 4.00

.H2P 7, F. i ,./fl_ 11.0 10.0

I4.- :f,..3 L .: 715.0 40.0

'',C:tf ••?' _ :: .FL 01 .,. 0:71 Q

P.:1-i 2'?: 5 py 77.0 5L0

iJ 55.0 37.0 150, 450.

LI'. 16: -..f ift % 20.5 51.1 ! ! •(!z: 1: t: * KT•31 ,1_ i - - 1.2 3i; i•

i i

111111111111

I ■

MEDCOM - 18573

ACLU-RDI 1647 p.133

2! WiT23 4

P:

RAPIDPOINI ANAWft SERIAL 40W405 U6/iU/W 04:J5 AM

Patient ID: Test Name :PT Test Result:. 12.4 sec. ***RESULT NOT RANGE CHECKED*** Ratio = 1,0 Calculated IMP = 1.03 Sample Type:citrated wh. blood Test Date :09/10/03 let Time :04:34 AM Card Lot / :010301 Operator

RAPIOPOINT COAG ANALYZER V4 SERIAL #005485 09/10/03 :

\ RAPiPPULNI LIJAL ANAI'Zi

4‘i 'i • 4 •

Patient ID:011" Test Name :PT Test Result:. 12.2 sec. ***RESULT NOT RANGE CHECKED*** Ratio = 1.0 Calculated INR = 1.00 Sample Type:citrated wh blood Test Date :09/11/03 Test Time :04:51 AM Card Lot :010301 Operator

IDPOINT COAG ANALYZER V4.54 #005485 09/11/03 05:01 AM

1'

Patient ID: Test Name .A TT Test Result:. 35.7 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/10/03 Jest Time :04:35 AP Ord Lot :100212 operator

Patient I Test Name :APIT Test Result:. 25.9, sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/11/03 Test Time :04:59 AM Lal Ci Lot 1u02L upetau.!

t•

MEDCOM - 18574

ACLU-RDI 1647 p.134

um

".1X, •

KAP.OmulN;i !ER V4.54 04:19 AM

Patient Test Name :PT Test Result:. L. sec. ***RESULT NOT RANGE KED*** Ratio = 1.0 Calculated INR = 1.00 Sample Type:citrated wh. blood Test Date :09/12/03 Test Time :04:18 AM Card Lot :010301 • Operator

RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 09/12/03 04:23 AM

•

Patient ID: NMI 0,4, Test Name :APTT Test Result: = 26.3 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated wh. blood Test Date :09/12/03 lest Time :04:19 AM Lard Lot :1uu212 Operator

ANAWER V4.54 alflAt '05485 09/13/03 04:34 AM

Patient ID:111111111P06-9-.) -14 Test'Name Test Result :4.3 sec. ***RESULT NOT RANGE CHECKED ** Ram = 1.1 Calculated INR - 1.11 Sample Type:citrated wh. blood Test Date :09/13/03 Test Time :04:32 AM

Card Lot :010301

( \ Operator :111111111.)

RAPI0POIN1 COAG ANALYZER V4.54 SERIAL #005465 09/13/0j 04:40 AM

Patient ID: b\,' Test Name :OTT Test Resifit:= 31.4 sec. *RESULT NOT RANGE OHECTID**4 ,

Sample Type:citrated wh blood Te:it. Date :09/13/03

lest Time :04:31 41.1

Card Lot :100"1 -z

Operator (

MEDCOM - 18575

3152AA4 DR #: 000

0000100676

GLU 108 3-118 MG/DL ! BUN 6* 7-22 MG/DL I CRE 0.6-1.2 MG/DL CK 712x 39-380 U/L NA+ 44413128-145 MMOtt. K+ -3.6 3.3-4.7 MOM_ CL- 97* 98-108 MMOVL t002 22 18-33 MMOI/L

INST QC: OK CHEM OC: OK HEM 0 ) LIP O1 ICT 0

#: OP #: 034

IAL #:

12/03/03 04:11 REFERENCE RANGE: MALE PATIENT #: METLYTE DISC L

DOD-032149 ACLU-RDI 1647 p.135

311111 04:10 Patient

Limits VBC 7.6 x101/a1 4.5 '10.5 RBC 2.50 1 1101/11 4.00 6.0D ligb 7.6 1. g/d1. 11.0 18.0

22.71. 1 35.0 MV 90.7 11 MI.099.9

MN 30.5 27.0 3L0

33.6 33.0 ILO

Pit W. H 110A3AL 150. 450. UM 21.5 % 20.5 51.1 VM 1.6 1101/61. 1.2 3.4

411111 14-09-03 gg 04:49

Patient Limits

ICC 8.8 MASAI. 4.5 10.5 MC 265 L 7.10A6/d. 4.00 6.00 Hgb 7.8 1 g/t1. ILO 18.0 ILI 24.5 L I ILO 60.0 MD 92.4 IL 80.0 99.9 MN 29.6 pg 27.0 31.0 IOC 32.1 1. 9/di 33.0 37.0 Pit 443. z109/aL 150. 450. UM 19.5 *I. I 20.5 51.1 LYI 1.7* 1101/t 1.2 3.4

15-0H3

• NA:.' /C' .

14 ,'01 ;;.! AM

hi len! ID:111111.\7 ( 06-- i Naikt i lest 13.! .144k1:;1111 NOf PANNE. I.:11ICE[D44i,

Rani: , 1.1 1.12

fype:c)Itated wh lest hale :0J/14/03 lest lime :04:50 AM Lald Lot :010301 Uperdtor

'APIOPtittll LUAU ANAL EN FRIA! auD!,4815 09/14/03 l':55 AM

it toil Ill: IMP. Tebt Name :APII Fez-A kesolt:= 35.8 sec. 444HI:JULT NOI RANGE CHEEKID+44 Sample lype:citrated MI. blood lest Date :09/14/03 lest lime :114:52 AM Culd Oper,

: PICCOLO -- 14/09/03 05:24 REFERENCE MALE PATIENT #: t)(0- BASIC MET LIC

MALE

DISC LOT #: 3145AA4 OPER #:11111111. DR #: 000 SERIAL #(1 /1-0000100494

GLU 111 73-118 MG/DL BUN 3* 7-22 MG/DL CA++ 8.1 8..0-10.3 MG/DL CRE 1.1 0.6-1.2 MG/DL NA+ 44.60 128-145 MMOVL K+ 4.1 3.3-4.7 MOW CL- 96* 98-108 MMOVL tCO2 25 18-33 MMOVL

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

Pd1 )(f)t) - LA lest Name het Fe ril l ' I .1 svc.

r NU! Ciltr:10.11 ,+.** Rat 10 z 1. I

Calroidted ihltt !.II Iykr!:(Allolvd Nh. biOud

lest s hite :09/1 1J/03 Iesl lime :04:16 Am Lard lifl . ;wl03O1 Operalc4

RAI'li#1.11N1 LUAU ANA! V4.54 !-;/ NIA! 0005485 119/15/1.li 04:20 A14„-- ---

Pntlent lb lest NdMe :AP:1 le6t ***tiL:.;11Li NO 1 RAN A UHLLkt9“4 !;dmple 1/pu:(,itrated wh. blood feet Dole :ftvi!i/03

PM (.df .1 I ill HhOn? 60t.J1Jtur

MEDCOM -18576

DOD-032150

ACLU-RDI 1647 p.136

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

O % del

rEfitkr:

G sko AND O.

AIR UMin

N20 L/Min

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

COLLOID-

❑ Warmed

❑ Warmed

❑ Warmed

❑ Warmed

EST BLOOD LOSS

• ' -•••• ••••••,••••.,•••

ggiVENVI OK for PROCED

TIME-

HR. 163

TOURNIQUET 6 r.

T -4/ 40

ANES- x-x 20

PROC-0125

BR (transduced) 100

gist BP by cuff

V A

Heart rate

•

Resp rate

t 11111111111111•111/111111111111111,1111111.1111

NM NI IM-111111111101% Ole NOM .

MI mAl b.. - ErAvAn 11!Alti &V&A IMUMNIE I I NEM 111.11111111111111111/111111111110‘111.11.1M9PWIMARLIffiailidia7721

11111111111111111111.61111111/41MIMMON wraniminvermeir isvirm-acirmintri illaill11111111111E pajia EMEMNIIIMINIMMINIMINNIIIIN Mal

345 E i4ODAlfddit

LB

ATO.OrrO

,,-.1 1111111111111111111M1 ZUMMIIIIIFINIVIRINIM■ .a I Conv warmer III MO

Math with lentos & symbols, EVENTS_,_ explain undo, REMARKS Position ---"-

4

cc • am

r- I— PYAIIMIMParMitill'AIRFINNTAIr47111M1MIUMMN II IRTII'Mg.%71111MigellaSIMENISIMILCIIIMMIIEMIKSJ•Efal IMMEINIMIIIVAINCEMIVAIMMEMIKAMMIIIIMIWIEMEIYA INImirrearmaminsitutommuairmpap ma NEECEEMILMMNIImairiMIM- IDIM11711FAMM1011111110111DAMENIWAI EVEMaIr"-- 1111111111111111111111111M Braminurranso I II 111111110111111111111111111 ENO MI

ART line

BP/oth

- SI rd, Aissi , Cfon)

Peak la pres / PEEP

VT -ml

- breaths/min

P-site

N-IVI Block IT/4)

ITMEQUIVEINFIP

MINSIINIMISONSUMM11527/074-11M11111MIN211

Spoc11y1

CONDT6N:

RESP- r-ie> RP- HR.

PR ANESTHETIC TECHNIQUES: °scribe block technique under Remarks

entries: M91170. Grade/Ra e facility AIRWAY MANAGEMENT: Intubarion rou blade, technique, comments

PROCEDURE LOCA 10 DATE:

PAGE OF

COPY 1 - PATIENT'S MEDICAL RECORD USAPA V1.00

MED OM - 18577

DA FORM 389, FEB 1998

r

w

DOD-032151 ACLU-RDI 1647 p.137

• MEDICAL RECORD ANESTHESIA TOTALS

CRYSTALLOID...

COLLOID.-

BLOOD–

Code Ows with numbers. events With Jotters

1,2f1:77,Mran EMINUN

Illin MEN

Kummes

BP by cull

V A

Heart rate

•

Resp rate

BP (transduced)

J.

TOURNIQUET

T —/ ANES– X-X

–0

MN ERNI MINNWIE

0E2 SIMOUSINUE IMIN

S,NE 1111111111111111111

&Su

NENE Miliff2511

111111MII ) . • • . .

RECOVERY AT

PACU ICU (SPecifV)

PROCEDURES and CPT Codes

PATIENT IDENTIFICA Ted Malice/

SURGEON& PROCEDU LOCATION

MEDCOM - 18578 )P 376 REVISED 1 .7 w, on

DOD-032152 ACLU-RDI 1647 p.138

K BP by cuff

V

A

ileart rate

Resp rate

OK?-

OK lav PROCC12F=:i

TOSE- y-

BP ffransduced)

TOURNIQUET

T

AMES- X.-X

-

4361681 1863590

/f140 A9losleinArtu IC

iri{ererl frvu

. eve boo FIITTIIM

ae? egs-t) ANpTHETtC TECHNIQUES:1:42mb, bbeI tafanigeor undr Ammar pre.5'617/ .(41 ec.fulti/ x / if> „es x ‘4-rfrTy-

AIRWAY MANAGEMENT: kramedonorao. erode twang" eornmants_A:e.cKeel.Cgeet, ///47.,- Te5

End

ire

NEM% RECOeD - Anamaam MEDCOM

..)P 376 REVISED

PROCEDURE LOCATION DATE

7 9 0,3 PAGE / OF

Ir) PATIENT 10I-KTIFICATION-- tYP•Kor widow: Name. 12,.daft Akorssol hobby

• cA.A, sJve 6 s L -a&

:1;i0 a e t:,7 a A.,

fr.?' 02- 3- .7/f Y714. Mow

•

MEN•rr11.2Pill SZ,ANNEVAInumME11111.1111 1111Mmmminnumminum NV ,

P1M1 mmmmomminl

EvErwm Immionniumonmir elr.3>f IIINVIII

M.11111MMINoarlinievy. tAlimminiammu■immoweislt EPAIIIIIMINnimimimmumummumummom liMnfrA

MEDICAL RECORD

,Z

(.j /274 S4 Oz_ '/ A KJ, a 0.90,

ICI AAr7 1.2

4.1 Ail rs

z. 3 "A;

ANESTHESIA

. LCsA4s.,..11 V C73

TOTALS

2 3 riv 4;tr'S •vk,4 40," crift-•

3 CRYSTALLOID-

COLLOID-

ely • 4 5 E

0 Irtoe mmumNB■MM=MinimmVS____...,.mmmmo

wITO,NaMminginu2=012,'-.1/41•111..imr7 iNMIIIM =.111 -9A.______nommionemommummmine

• SYMBOLS:

220

200

180

160

140

120

100

80

OMNI ass 111111E111111111MMIIIIIMIIINMIIMINWilMEMMINIMIIIMMI KaistiVISMNIVWSiritY.,F4,VWM,74

1101111W 201111111.11KLTA'All.11111 Ras PROC-0 WW

PROCEDURES and CPT Codes

9/7

'LOA — mut° c CO2 DP / oth

1 ART line

Gas analyzer

P. I

...I Ccwwmer l atm* wits ISO 6 symbols. EVENTS .sepkeki ursctw REIKAAKS position

UMW: NOVA ,11111 ,WIRK1 I 111.11memnimm Ellff/Mir/VAIENIIKFM/krkalVmminimminne Nftgl/IPAIMEIMINS,0/1ffgARM511111111.1..mmumml II IIKM:4BUCtw-

analerA PC/E • 117411011.1MINIM

Qat:: IIIIMM111.111 a „ a"Mait now

on toff

l'AIIIM11111111MI 111111111111111111111M1 Borm.Affil Untwasniumnft64!MiL;:siiieg 11111•111111111MMINHINUMAIRINI LE.Stmomm.IMMEM ORM

malswas onriMENZ nnigrAtirA

111111r1W211111•111111111MAICIA411111111111 mungEmE723r, ENSISMIN IMMIIMIAlLiTECLIILIPIIVW1.116MIIIMMI1 MIMI MIME was mor

ESEREGE Nan

End

BLOOD- a fig,451:y.

Caoala *ups wlh 111011b. with Mears

0311,•-"I Ole pieve.jov

DOD-032153

ACLU-RDI 1647 p.139

::1100:16.3*EIGHle

Code drugs with numbers, events with Murets

AN CI' C...—e14 CG.,

, 7yreote/

0.)-Kr".{4 rfrAl — C77.9-

111

rOi *7.


. t O_; /17/M11111171310MIWOM p z t 01 kiSIMMIIIMIIIVAill e a R 4A ,...MIDANIIIIMMIIIII t . z IAIIIIP,_ m"°' t4D Z.- Zw

0 D 0

Z Li- y AGENT

p u.

o u, o

% e.t.

L/Min

L/Min z & : AIR I

02 L/Min SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS ENTER IN REMARKS

warmed 0 Warmed

0 Warmed

Warmed

EST BLOOD LOSS URINE •

010E30 • .

BP by cuff

V A

Heart rate

Rasp rate

VT - ml

I. breaths/min

Peak inf ems / PEEP

BR (transducer!)

212

TOURNIQUET

ANES. x-x PROC. 0_0

CO2 (ton) 2 (Frac or %)

02 1%)

Pio, 1_,..22-1211=11 111MadMll ____IMIWSIIIMAINNXIMAIIIMIM Now 1111LIMMILIUMMIN weinmensuimetrwm

reim

1111101111111 waririmmincorzwewnzmarfogiail mi ININUMINVIIIIMEMIKIUMW12111/EMMIIIMII kialltiMINWSPOJAIIMITOTAILIMITUFAMEAll -2-1'.41111011=233

MIIIIM11621111150WAIIVAWAI 7 WinXei MA Ta NM aMINIM MI R:WM riiMMIITM11012e14114:161- wiRmirisams-a worammomrd NM MI M Sp02- 111 EI UT BP- HR- e)0 warMaim

OTHER

CONORION.

ICU fspaclfyl

th

1RM

End

Cony warmer

PR CEDURES and CPT odes:

PA T IDENTIFICAT : Ty d or wrl en entries: Name, Grade/ ate, Medical facility

cc

ANESTHETIC TECHNI UES: Describe block technique under Remark

94Y . Intubation rotg: bfair,41 e, COMML

As. c ' fiezzae

PROC URE LOCATION: DATE:

DA FO

ME DCOM - 18580 MEDICAL RECORD uSAPA vt.00

DOD-032154

TOTALS

BLOOD.

...R IA ..............................................

ACLU-RDI 1647 p.140

CONDITION:

RESP- Sp02- BP- Hit-

PROCEDUR LOCATIO DATE:


DRUG Units)

% e.t.

L/Min

L/Min

02 L/Min SINGLE DOSE DRUGS•MARK ON GRID WITH NUMBERS & ENTER IN REMARKS

LINE site

El Warmed

El Warmed

El Warmed

BLOOD LOSS

:IVIVIEK)L

BP by cuff

V

A Heart rate

•

Resp rate

(It

D2 in LI—

UV) L9M2 0- Z5Z UK, M

• Z IL eC to

O

•

0 • K 17;o. z

TOTALS

COLLOID-

BLOOD-

Code drugs with numbers,

OK7-

PikftEN OkEOK: Off for PROCEDURE?

TIME-067

BR (transducedl

512

TOURNIQUET

—4f

ANES-PROC- 0121

,

111.11111111111111111MMIll DMIN.11111=11111M11:11111

ri/AWFAMMIIIIWAIIME RITIMMEIrrn2 lailL'ORIVAIIF. AMMON IM (ton)

0 a

•

IIIIIIIIMME131 rg oirmimp-efratimaral Pilammtro 00

( - breathslmin

Peak Int pres / PEEP

M E • S( on), A(ssist), Min)

Steth - PC/ES

N-M Block (1/41

11M-rmli 11111Eralli TEMP-sIte

PACti ICU S ty)

IMMELIMIM7121011011111E Cony warmer

Mark we:blotters & symbols. EVENTS_,_ explain under REMARKS Position

PROCEDURES end CPT Codes: Aevi ek

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rat:' Medical facility

L, 0

a. ANESTHETIC TECHNIQUES: Describe ock technique under Remarks

--Seek 5

AIRWAY MANAGEMENT: tubet r ute, blade, techni men

End

Cf

SURGEONS:

DA FORM 7389,

MEDCOM - 18581 MEDICAL RECORD APA vi.00

DOD-032155 ACLU-RDI 1647 p.141

PURRENT MEDICATIONS: 0 = ordered as premed

PREMEDICATI d S: None Yes (a Nrs) /CC

mg NIM PO P/ ILI PO IV IM PO

AYS MOS YRS

PROPOSED PROCEDURE: t ,,:

SURGICAL SERVICE: i( NPO SINCE:

I • ■ 1 L.

() FEMALE

Questions ens

Date:

HB/HCT: / WA: OTHER:

MUM

TOBACCO:

ETON:

DRUGS:

RAT •1 - Y

)61


Hypertension N Angina MI CVA Other

Pulmonary System: Asthma BTOrIChiliSAIFIJ COM Other

Renal System: Acute Chronic RF

Gastrointestinal: Hepatitis Metal Hernia PUDIGERD

Endocrine System: Diabetes Steriods Thyroid

Neurological: Seizures Neuropathy Other

Gynecological : Pregnancy -11—Y._

Other Significant Hz: N Y N Y N Y

ASSESSMENT PAST SURGICAUANESTHEITC

CARDIAC: ci

EXTREMITIES:

BACK:

OTHER:

Familial HX

Ulnar Filling: :W . W Access: iy(

•

NPO Since

ANESTHETIC PLAN: } LOCAL ( ) MAC ) Regional (Specify):

POST-ANES ALUA ON AND NOTE (NON ) NO APPARENT ANESTHETIC COMPUCATIONS I } OTHER

The

Signed

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of a discussed with n. (C) -

including death have be7en expire to and

telY&AD Ccil Tyne: 3 i0144

Patient Identifica

163 MEDCOM - 18582

SEDATION KEY:



3. DEEP SEDATION ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

4. ANESTHESIA. Patient does not respond to painfulnimulation.

WAMC Form 2300 (Revised) 15 Mar Di ismer-rim

DOD-032156 ACLU-RDI 1647 p.142

518-124

MEDICAL RECORD


RED BLOOD CELLS

❑ FRESH FROZEN PLASMA

D PLATELETS (Pool of

❑ CRYOPRECIPITATE (Pool of

❑ Rh IMMUNE GLOBULIN

units)

units)

REQUE AN Print

DIAGNOSIS OR OPERATIVE PROCEDURE

G5cd..1 r

I have collected a blood specimen on the below

named patient, verified the name and ID No. of the patient and verified t correct. tube label to be

NSN 7540-00-634-4159

float,

REMARKS:

UNI

BLOOD OR BLOOD COMPONENT TRANSFUSION SECTION I - REQUISITION

TYPE OF REQUEST (Check ONLY if Red Stood Cell

Products are requested)

VI TYPE AND SCREEN

▪

■ ACROSSMATCH

DATE REQUESTED

-2-124- 0

3

SIGNATU


RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN?


❑ OTHER (Specify)

VOLUME REQUESTE (ff ap

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

Rh

Pc

ANTIBODY SCREEN TEST INTERPRETATION

CROSSMATCH

ea imp

❑CROSSMATCH NOT REQUIRED FOR THE COMPONENT RE

REMARKS:

DONOR

ABO

PREVIOUS RECORD CHECK:

❑ RECORD ❑ NO RECORD SIGNATURE OF P

INSP

AT

PRE-TRANSFUSION DATA SECTION III - RECORD OF TRANSFUSION

POST-TRANSFUSION DATA

TIME/DATE COMPLETED/INTERRUPTED

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification t.1

P

If reaction is suspected—IMMEDIA 6

T Y: 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)

BLOOD PRESSURE

TEMP.

)ATE OF TRANSFUSION BP 133 /70

ATIENT IDENTI

TIME STARTED

7 CATION--USE EMBOSSER (For typed or written entries give: Name

rate: hospital or medical facility)

OTHER DIFFICULTIES (Equipment clots, etc.)

NO ❑ YES (Specify)

SIGNATURE OF PERSON NOTING ABOVE

MEDCOM - 18583


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

Medical Record Copy

ELEJUMECYCLIGNPER

DOD-032157

ACLU-RDI 1647 p.143


TYPE OF REQUEST (Check ONLY if Red Blood Cell

Products are requested.) REQUESTING PHYSI •

DATE

TIME VERIFIED

TEST INTERPRETATION ANTIBODY SCREEN

Wi4 ❑

efo‘iip


❑ RECORD [ANO RECORD

DATE

CROSSMATCH

SIG

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ. STED REMARKS:

AO Ste' Aco3 (ck

450

WARD

CO


Medical Record

STANDARD FORM 518 (REV. 9-92; Prescribed by GSA/1CMR. F1RMR 141 CFR) 201-9.202-1

518-124

ML

MEDICAL RECORD


g RED BLOOD CELLS


❑ PLATELETS (Pool of

❑ CRYOPRECIPITATE (Pool of


❑ OTHER (Speci6,)

VOLUME REQUEST (If ppfi ble)

TYPE AND SCREEN

CROSSMATCH

DATE REQUESTED

Sailoir 0 3 DATE ANDBOUR REQUIRED

0 C;:s.• C. 5. KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

NSN 7540-00-634-4159

DIA OSIS OR OPERATIVE PROCEDURE

C c5 I

I have collected a blood specimen on the below named patient, verified e patient and verifie and ID No. of the correct. tube label to be

units)

units)

REMARKS: w}-t

PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)






UNIT NO TRANSFUSION NO.

PATIENT NO.

DONOR RECIPIENT

ABO ABO 0

Rh Rh Par

POST.TRANSFU

TIME/DAT N DATA

ET INTERRUPTED

AT (Hour)

IDENTIFICATION

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

1st VERIFIE

2nd V

BLOOD PRESSURE


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)

N (Date)

li't

TEMP. 'Al OT ER DIFFICULTIES

(Equipment, clots, etc.) NO ❑ YES (Specify) PULSE

DATE OF TRANSFUSION TIME STARTED

40 /5 lo PATIENT IDENTIFIC ION—USE EMBOSSER(For typed or written entries give: Name-

2Last, first, rate; hospital or medical facility)

allifEC. 0.ECK,EDPAYE0.

Bp 125-

MEDCOM - 18584

Medical Record Copy

DOD-032158 ACLU-RDI 1647 p.144

RE PHYSICIAN (Print)

)0 (a-


SIGNA

518-124


RED BLOOD CELLS


❑ PLATELETS (Pool of units)

❑ CRYOPRECIPITATE (Pool of units)


❑ OTHER (Specify)

REQU

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

DATE REQUESTED

NSN 7540-00-634--4159

I have collected a blood specimen on, the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.


MEDICAL RECORD


REMARKS:

DONOR

UNIT N TRANSFUSION NO.

PATIENT NO.

RECIPIENT


RhlG TREATMENT? DATE GIVEN:


SECTION II – PRE•TRANSFUSION TESTING TEST INTERPRETATION


DATE VE

TIME VERIFIED


❑ RECORD Wt"...NO RECORD SIGNATU

ADO ❑CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ

REMARKS:

Rh

INSPE

?Ds

PRE-TRANSFUSION DATA SECTION III – RECORD OF TRANSFUSION

d all item.

rm and

AT

IDENTIFICATION

I have examined the Blood Component container label and this form and I f Information identifying the container with the intended recipient matches item b The recipient is the same person named on this Blood Component Transfusion F on

1


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

2nd

URTICARIA CHILL ❑ FEVER PAIN OTHER (Specify)

PRE-TRANSFUSION

TEMP.

DATE TIME STARTED

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, firs rate: hospital or medical facility)

PULSE TRANSFUSION

OTHER ICULTIES (Equipment, clots, etc.)

❑ YES (Specify)


Medical Record STANDARD FORM 518 iREV 9-92) ?rescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

Medical Record Copy PRIARDV.E.T.LEORPER

MEDCOM - 18585

DOD-032159

ACLU-RDI 1647 p.145

NSN 7540-00-634-4159

• •

S1GNAT

DATE VERI a

TIME VERIFIED

d a•



CROSSMATCH

AJA ❑

CROSSMATCH NOT REQUIRED FOR THE COMPONENT R REMARKS:

kci"' OT a? A003

ABO

Rh Rh Petio„5

ABO 0

POST-TRANS

518-124

MEDICAL RECORD


❑ RED BLOOD CELLS


❑ PLATELETS (Pool of units)

❑ CRYOPRECIPITATE (Pool of units)


❑ OTHER (Speci6,)

VOLUME REQUESTEr (If a, plic le)

INN

ML

REMARKS:


TYPE OF REQUEST (Check ONLY if Red Blood Cell

Products are requested.)

TYPE AND SCREEN


5 -52-9 14- ct., Cr>,

have collected a blood specimen on the below named patient, verifi ame and ID No. of the

correct. patient an.

n tube label to be


REQUESTING PH

CROSSMATCH

DATE REQUESTED cep*

DATE AND HOUR REQUIRED

elZ9 0

UNIT NO.

DONOR

TRANSFUSION NO.

PATIENt NO.

RECIPIENT


❑ RECORD Q0•10 RECORD

SIGNATURE OF PERSON PERFORMING TEST




PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)


PIED

A 4.1:11111111111

ID NTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the pad ion tag. 1st VER

2nd

PRE-TRANSFUSION

TEMP. 3C DATE OF TRANSFUSION

/ 4 .0

URE

If reaction is suspected—IMMEDIATEL

I 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 0 PAIN

OTHER (Specify)

CULTIES (Equipment, clots, etc.) ❑ YES (Specify)

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or w tten entries give: Name—Last, first, m rate; hospital or medical facility)


Medical Record STANDARD FOpi4 518 (REV. 9-921 Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

Medical Record Copy

f luvrel.RECCLENINA

MEDCOM - 18586

DOD-032160 ACLU-RDI 1647 p.146

REQUESTING PHYSICIAN (Print)

-L

DIAGN ROCEDURE

correct. patient and verified the specimen tube label to be named patient, verified the name and ID No. of the

I 71P

ha collected a blood specimen on the below

. uk)

DATE VERIFIE

TIME VER/RED

PR PR VIOUS RECORD CHECK:

RECORD NO NO RECORD

REMARKS:

PULSE /C>C7

B

1-As

1RDcAA -


Medical Record

STANDARD FORM 518 (REV. 9-921 Prescribed by GSA/ICMR, FfRMR (41 CFR) 201-9.202-1

Medical Record Copy

518-124 -Kt

MEDICAL RECORD !

NSN 7540-00-634-4159



RED BLOOD CELLS


Li1-1 PLATELETS (Pool of units)

Ei CRYOPRECIPITATE (Pool of units)

0 Rh IMMUNE GLOBULIN

O OTHER (Specify)

VOLUME REQUESTED (If applicable)

ML

SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

❑ TYPE AND SCREEN

CROSSMATCH

DATE REQUESTED

CEAq S121)1-0;1 DATE AND HOUR R IRED







REMARKS:

1

UNIT NO ‘) if) t

DONOR

ABO 0 Rh la L2 S

RECIPIENT

ABO 0 Rh PTS

TRANSFUSION NO.

PATIENT NO. CROSSMATCH

DATE 03

to P SIGNATURE OF PERSON PERFORMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED


INSPECTED AND ISSUED BY (Signature)

PRE-

TEMP. "3.Z DATE OF TRANS S/ON

49ft Le,

2nd

POST-TRANSFUSION DATA

ML

PE A TE PULSE BLO D RESSURE


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

0 URTICARIA 0 CHILL 0 FEVER 0 PAIN

OTHER (Specify)

OTH D ment, clots, etc.)

AT (Hour) L9 -7 7 I ON (Date) 4, 3 IDENTIFICATION

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

1

AMOUNT GIVEN

FtEACTION

PIE4ONE 0 SUSPECTED

TIME/D TEOMPLETED/INTERRUPTED

d; 61770

TIME STARTED

PATIENT IDENTIFICATION--USE EMBOSSER (For typed or written entries give: Name—Last, first, 'm rate; hospital or medical facility)

MEDCOM - 18587

DOD-032161

ACLU-RDI 1647 p.147

DONOR

ABO

Rh 19 05

RECIPIENT

ABO

Rh

SECTION II - PRE-TRANSFUSION TESTING TEST INTERPRETATION


arr" yc'

518-124

MEDICAL RECORD 1

NSN 7540-00-634-4159


N RED BLOOD CELLS


❑ PLATELETS (Pool of

❑ CRYOPRECIPITATE (Pool o


❑ OTHER (Specify)

OMPONENT REQUESTED (Check one)

to iec units)

units)

SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

❑ TYPE AND SCREEN

CROSSMATCH

DATE R

C-4

EWESTLert

1!) (1:33 DATE AND HOUR


REQUESTING PHYSICIAN (Print)

GNOSIS OR OPERATIVE PROCEDURE

)

I hay collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.

VOLUME REQUESTED (If applicable)

ML

REQ 4

REMARKS:

TRANSFUSION NO.

11111111TLENT NO.

UNIT NO.





RECORD ❑ NO RECORD IGNATURE OF PERSON PERFORMING TEST

❑dc)

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE "" "' REMARKS:

j y S--te 6 3

DATE VERIFIED

TIME VERIFIED


INSPECTED AND ISSUED BY (Signature)

,17(9-)- AT (Hour)

"It"--

ON (Date) IDENTIFICATION

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

POST-TRANSFUSION DATA AMOUNT GIVEN

TIME/,DATE COMPLETED/INTERRUPTED

REACTION

NONE 0 SUSPECTED

ML

TEMPERATURE PULSE

70* OeX.x.

ASI I, K reaction is suspected—IMMEDIATELY:

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

❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

OTHER (Specify)

e-rc- b(ct)-t WAR

C BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

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

Medical Record Copy

3

TEMP. O7 PULSE /10 DATE OF TRANSFUSION TIME STARTED

/ /1 103 0 3 r0 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first,

rate; hospital or medical facility)

, b4)

If ID

I BLOOD PRESSURE

.?9/.3•0

QTHER DIFFICULTIES (Equipment, clots, etc.) NO ❑ YES (Specify)

SIGNATURE OF PERSON NOTING ABOVE

MEDCOM - 18588

DOD-032162

ACLU-RDI 1647 p.148

T 1 JUL 77, WHICH MA

MEDCOM - 18589

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

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

NURSING UNIT

NURSING UNIT


PATIENT •ENTIFICATION

NURSING UNIT

DOD-032163

ACLU-RDI 1647 p.149

BED NO.


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

TIME OF ORDER

6c

NURSING UNIT

/GU PATIENT IDENTIFICATION

NURSING UNIT


DATE OF ORDER

Y LI

ORDER NOTED AND

SIGN

NURSING UNIT

PATIENT IDENTIFICATION DATE OF RDER

NURSING UNIT

7.4

DA 1 FACIIRM79 4256

11111■11mir

c fL7fa

JUL 77, WHICH MAY BE USED.

TIME OF ORDER

HOURS

MEDCOM - 18590

DOD-032164 ACLU-RDI 1647 p.150

MEDCOM - 18591

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

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

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IFage

PR

ncy is OTSG

OB SYSTEM IS USED WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELEM ORIENTED MEDICAL RECORD

LOW. PATIENT IDENTIFICATION

LI T TI ORDER

NOTED AND SIGN

NURSING UNIT


NURSING UNIT


NURSING UNIT


NURSING 16141T

'2A4

DA FORM APR9

M

DOD-032165 ACLU-RDI 1647 p.151

DOD-032166

ea r

NURSING UNIT


NURSING UNIT


NURSING UNIT


NURSING UNIT

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

MEDCEOM - 18592

74' r"-1

4256 ,24")

DA FORM I APR 79

COLUMN INDICATED BY OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD PATIENT IDENTIFICATION ARROW BELOW.

THE DOCTOR SHALL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN , TIME AND SIGN EACH SET DATE ponent agency is OTSG

CLINICAL RECORD - DOCTOR'S ORDERS of this form see For use AR 40-66, the pro

ACLU-RDI 1647 p.152

TIME OF ORDER

4906

LI T TI ORDER

NOTED AND SIGN



DATE OF ORDER

- 1(-0

(Z. -

NURSING UNIT


BED NO.

Li‘



NURSING UNIT

PATIENT IDENTIFICATIO

E OF ORDER

NURSING UNIT

DA 1 FACPARM79 4256 REPLACES EDITION OF 1 JUL WHICHMAY BEUSED.

MEDCOM - 18593

DOD-032167 ACLU-RDI 1647 p.153

11111111111111111....... 11

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT BED NO.


NURSING UNIT


NURSING UNIT



THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF

ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION


MEW

11111111M11.11111.1.11111

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111111111111111111M1111.11111111

1111111111111111M111.1111111111 DATE OF ORDER TIME ORDER

HOURS

NURSING UNIT

FORM 1 APR 79 4256

. HOURS

11111111111 11111111111111111.111111111MIN

1111

111111111111111111. momm........11111111111111111

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

s'r U.S. GOVERNV`"-

MEDCOM - 18594

DOD-032168

ACLU-RDI 1647 p.154

DOD-032169





NURSING UNIT

p

NURSING UNIT

I JUL 77, WHICH MA BE USED.

MEDCOM - 18595

ACLU-RDI 1647 p.155

CLINICAL. R,L:ttnla.-.".00,CTGOt T.I.; ■ :c4111g 4oprn, ...3•4 AP r Ot6iSkAllg izeporftyril. 4*IF tfi, 01 SG a-PE tx:C;; r).P smat.% PECC44-0 f>AE AII4f; NiCitt; EACH $E-7 .1.. .r Okiof;PV:i iF PRORI.Vm opikhrtpb uZEti, Kt-Creufzi tiLmilg. .41 .14 COLtAiN,41,401-tAlt0 01," tiF4 Aceei 't-vT c

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MEDCOM - 18596

1

DOD-032170 ACLU-RDI 1647 p.156

DATE OF ORDER


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

PATIENT IDENTIFICA TIME OF ORDER

/Z4

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LIST TIM ORDER

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ROOM NO.

ATION

BED NO.

DATE OF ORDER TIME OF 0 ER

ROOM NO. BED NO.

HOURS

,K4

NURSING UNIT

PATIENT IDENTIFIC ATION DATE OF ORDER IME OF ORDER

POURS

DA 1 FO RM7 9 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY . BE USED.

MEDCOM - 18597

NURSING UNIT

1 ROOM NO. BED NO.

DOD-032171 ACLU-RDI 1647 p.157

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MEDCOM - 18598

DOD-032172 ACLU-RDI 1647 p.158

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DOD-032173

ACLU-RDI 1647 p.159

PA T IDENTIFICATION TIME OF ORDER

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PATIENT IDENTIFICATION DATE OF ORDER HOER

12.)

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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

OF CA2 HOURS

LIST TIME ORDER

NOTED AND SIGN

ROOM NO. BED NO.

PATIENT

ROOM NO.

NUR \I G UN ROOM NO. BE

NURSING UNIT

DA 1 FAOPRRM79 4256 REPLACES Erai ioN OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 18600

TIME OF ORDER

HOURS

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-032174 ACLU-RDI 1647 p.160


CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATIO1V) . " Fa use of this form, see AR 40-407; Mo.SEftr. 2003

DOTAL PROPER COLZThW FOLLOWING EACH COMPLETION ORDER DATE

CLERK/ NURSE

18 2.0

a

1:3 YES Q. NO --

PAGE NO: 11,7)/ 1•1.1.

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RECURRING ACTIONS, tt FREQUENCY, TIME ONINIMEMMEERI

DATE COMPLETED

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3 03

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ALLERGIES: Q YES Q NO


D 8 9 10 11 12 13 14 15

23

07

E 16 17 18. 19 20 21 22

N 24 01 02 03 04 05 06 DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED.

USAPA V1.00

MEDCOM - 18601

DOD-032175 ACLU-RDI 1647 p.161

Verit by Initialing

Mo SEP Yr 2003 THERAPEUTIC DOCUMENTATION CARE PLAN

(NON-MEDICI770N) Order Clerk Date Nurse Time to

Time Dons Initials be Done

Date to be Dons

I2.

rt


INITIAL PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED

SINGLE ACTIONS

USAPA vi.00

MEDCOM - 18602

DOD-032176 ACLU-RDI 1647 p.162

EDITION OF 1 DEC 77 MAY BE USED.


THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) 1- For use of this form, see AR 40-407; the a nent anericv is the Office of The Surcteon General. MO. yr. 2003

•' 1111177AL PROPER COLUMN FOLLOWING EOM COliPLETION HR

CLINICAL RECORD

RECURRING ACTIONS, FREQUENCY, TIME

DATE COMPLETED

PRIMARY DIAGNOSIS: • 51,0

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YES Q NO

PAGE NO:


PATIENT -IDENTIFICATION:

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

FORM 4677, 1 OCT 78

DOD-032177 ACLU-RDI 1647 p.163

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DOD-032179 ACLU-RDI 1647 p.165


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DOD-032181 ACLU-RDI 1647 p.167


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DOD-032183 ACLU-RDI 1647 p.169

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DOD-032185 ACLU-RDI 1647 p.171


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ACLU-RDI 1647 p.172

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DOD-032187 ACLU-RDI 1647 p.173


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R:' Richt

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DOD-032196 ACLU-RDI 1647 p.182

,AL RECORD-SUPPLEMENTAL MEIIIIIDATA of For use of rm, see AR 40-66; the proponent agency is the Office o ine Surgeon General.

0

REPORT TITLE

OTSG APPROVED (Date) INTENSIVE CARE NURSING FLOW SHEET r 8 Mar 89

SHIFT ASSE0117 ..,.

E M R 0

TIME: C 6 3 0 TIME: /cW • INITIAL _ PUPILS i....m.y. SENSORIUM .-;‘,..0 t, 4-0 P0:;111,01,: X- 4 EXTREMITY MOVEMENT ....:,.. .4.,.. .• >,-. ' ,..,-Z4,-c4) .4),..-- - 0 ct--- i fivei" SEDATION

"....•><J-• CCI . •-■41,---....

er ,... PAIN CONTROL 74/.4>/:? 1,1

. .4 ..•E

•, r :• - . ...,

, .

RESPIRATORY PATTERN z-7..Q.,, BREATH SOUNDS C.. (jT-14 e>99 SECRETIONS (1 02 SOURCE/FLOW/SA02 /7.4-..s., 0,.....:_ VENTILATOR SETTINGS Ai 0 /104

CARDIAC RHYTHM CAPILLARY REFILL .< 3 ,_4. __K_L ec

^ - ' • ':

PULSES EDEMA '.".6..' /0,4

.:..G ABDOMEN 4: BOWEL SOUNDS

--17 '›-2- ' i it C22.--, .t' 'izta'i BOWEL MOVEMENT U T A

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1 IV FLUID/RATE ISq..)1.5 c f ..

r'S,:fg #2 TYPE/LOCATION/SIZE

4 DRESSING CONDITION

_.. IV FLUIDS/RATE ___ eik*Gi 4/ (Continue pn reverse)

ICU #1, IL)hNTIFPLPq or written entries give: Name —last,

first, middle; grade; date . hospital or medical facility) NAME: RANK: C-7,..r AGE:

UNIT: /e4/70/ GENDER: /if ,•

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

INIC DATE

28TH Combat Support Hospital

El HISTORY/PHYSICAL p1"5LOW CHART

CI OTHER EXAMINATION rj OTHER (Specify)

OR EVALUATION

El DIAGNOSTIC STUDIES

LI TREATMENT


MEDCOM - 18623 USAPPC V2.00

DOD-032197 ACLU-RDI 1647 p.183

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T

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E

L 8E1E1111 11139

MEDCOM - 18624 0 a

a) a) c o_ cv N h_

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DOD-032198

0 T••

C) O

ACLU-RDI 1647 p.184

CAL RECORD-SUPPLEMENTAL ME - DATA For use of .rm, see AR 40-66; the proponent agency is the Office Surgeon General.

REPORT TITLE INTENSIVE CARE NURSING. FLOW SHEET


Appr 8 Mar 89

N E

R 0

SHIFT ASSESSMENT

PUPILS TIME: INITIALS:

. PEr L. TIME: 2 INITIA

..0, -,13e. g' cx4:4;zi-

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RESPIRATORY PATTERN ,,,,, .,, .;.___C„1„;,d Ag ??,,,,,h.k.,-,./ BREATH SOUNDS e-i f) 0.1) 44,-, -7:-/(0 SECRETIONS & 0: 02 SOURCE/FLOW/SA02 fe^cr-- t-1:...-- 40 ,tIk' VENTILATOR SETTINGS \c" 0

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.,–,— IC9ntintre On reverse) DATE

-

9/zeir//7

;SERVICE/CLINIC


yped or written entries give: Name –last, first, middle' date; hospital or medical facility) NAME: RANK: (4'7- •

UNIT:

❑ HISTORY/PHYSICAL 1-FLOW CHART

❑ OTHER EXAMINATION 0 OTHER (Specify)

OR EVALUATION

AGE:

GENDER: /77

STATUS: US: AD / CIV IRAQI: CIV • / EPW/C: ❑ DIAGNOSTIC STUDIES

❑ TREATMENT

DA FORM 4700, MAY 78 MEDCOM - 18625 USAPPC V2.00

DOD-032199

ACLU-RDI 1647 p.185

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MEDCOM - 18626

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DOD-032200

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ACLU-RDI 1647 p.186

CAL RECORD-SUPPLEMENTAL M

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

REPORT TITLE

INTENSIVE CARE NURSING. FLOW SHEET OTSG APPROVED (Date)

QA Appr 8 Mar 89

SHIFT AS

N

, e

TIME ,.->445--- INITIAL TIME: 2 INITIA

E[21 A -3 kr r" PUPILS Nr--,--. v".--, P e4-.. W? SENSORIUM - 14.,-.)‹.0-. i:,) Lt-rt t ) v._ bit.:-- icZr+ 1 Po i to.) 5 ce_.3t-y1 rnanci EXTREMITY MOVEMENT - e • - go, .ata• IP* ' -C. ' -c,-,,--e.., L „„.A1 --i-V, - t.„ _ :0, , ,,, kl. SEDATION Pi. .rrtn.,,e_ v...ci-V,c, ,,--t- cl. rif-C:.11 of _ 41. 7 * - rs. ki J.- -e-2,11 •..

PAIN CONTROL —

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DEPARTMENT/SERVICE/CLINIC - nature & Title

IvaN (For typed or written entries give: Name —last,

first, middle; • hospital or medical facility) NAME: .ie RANK: AGI

GENDER: 7)/

STATUS: US: AD / CIV

IRAQI: CIV / EPW

UNIT:

DATE

❑ HISTORY/PHYSICAL

❑ OTHER EXAMINATION OR EVALUATION


❑ TREATMENT

[FLOW CHART

❑ OTHER /specify/

// 472 3 ICU #1, 28TH Combat Support Hospital

DA FORM 4700, MAY 78 •

MEDCOM - 18627 . • USAPPC V2 00

DOD-032201

ACLU-RDI 1647 p.187

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DOD-032202 ACLU-RDI 1647 p.188

Time Solution Amount Site • By Infus d 71111111WMINM

X-rays:

Labs:

Criteria Post-Anesthesia Recov ery_score

ADM 30' DIC Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

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

Blood Remote (2)SBP =1- 20 of Pre-op (1) SBP =/- 20-93 of Pre-op (0) SBP 50 of Pie-op

Consciousness (2) Fully Awake. audible Ming (1)Atousable to verbal or pain

Color (2) Baseline color & appearance (1) pale, moteed, jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for DIC.

Z_ 2_ z

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

ILUntinD0 OW foveae DATE DEPART7EIMCEiCLINIC

1,k-

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 40-66; the proponent Witty is the Office of The Suspeon General.

REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED tDa

Date: I -Z.— Anesthesia Type (Circle)) ne pinal Epidural Ti 1 me In:

s: Pre-op VIS-:TrZ t). OR Output: UOP JBL Procedure 4- I 1ViedsMmes: KI"\-km-rw■

-Jr

Pre OD MaMeds Histo ry Time

SaO2 FIO2 Methods 240

220

200

180

V 160

140 V .

120 a

100

80 A A

60

40

20

RR a

Time Pain (0-10) LOS

IV Sedation Nerve Block g L_AC-1 OR Intake: Crystalloid 1.41>C1-) Colloid Aller ies:

Drains Hemov .

Ne JP

T-tube Foley

TLS

Pacu Intake

Airway Nasa 0 I

Trach

Other

Codes

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

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

= Pulse

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

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

Nome —fart, VIM written emirs gin: est, midtlic gra& date; hospital or medal !NIRO

111111. ce.) I eu_41-

❑ HISTORYIPHYSIC.A1 ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER ISpecite

OR EVALUATION


❑ TREATMENT


WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC V2.00 • MEDCOM - 18629

S

DOD-032203 ACLU-RDI 1647 p.189

Transferred Via: WIC • 11 ance Tat

411asj_ri=Mtain

Discharge Criteria: Date: Time: PARS: BP: \ 110T: OA' HR: RR: 1*- Sa02: 9t> Pain Level at D/Q0-10): Intake: Outpu Additional Data: Transferred To: Report Given To: lk

r:- Transferred By: Cleared IAW Recovery Charge Nurse Signature

WAMC OP 173-E

I

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Adm

15

30' 45

60'

90'

DX

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

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

C-SECTIONS ---/ Adm 15' 30' , 45 DiC

Fund. .Height

Lochia ----------.- Peripad# ...------- Fund.concr

DRESSINGS

Time Location Type Draihage

Adm li) VW-, '' la-t- D k 4--- ----

30'

60'

WC

NURSING NOTES

lit -ID kLuAlikti Anyk__ b.,C& L ok )k,

12E / a lokideLb --(z)

ISAMMIEw immeome Milmmalif

-ft tio-su

MEDICATIONS Allergies:

Medication & Dosaae

Time By Pain Route Pain 1 -1 0

MEDCOM - 18630

PACU OUTPUT

Time

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? 'Lia2., L...51 G:),--- c:i.: ,----------

Source Amount pearance

•

DOD-032204

ACLU-RDI 1647 p.190

UNIT: GENDER:

RECORD-SUPPLEMENTAL ME DATA For use of rm, see AR 40-66; the proponent agency is the Office of The Surgeon General.


QA Appr 8 Mar 89

SHIFT. ASS ADtU')--

t; E _ •Y

R ei

TIME: 06 --iG INITIAL . TIME: INITIALS:

PUPILS gee c. A _jr) fir:iaz, 0 SENSORIUM il +0 K 3 /yd.!'' -eli'l X.P./74-- ,iii ei,,/,22 te EXTREMITY MOVEMENT /902mv., ;A4 POE d - ALE- 0,6ve..1,24.c LOG:ivi/e;061 eli.e SEDATION A) / A a, PAIN CONTROL H ' ygeA 4 ei4.'A;,a 45(*ilA,tee-wi '

' '

RESPIRATORY PATTERN ÷ a.p, Pr-a/Wyse /4/4 , r4/ X BREATH SOUNDS e A

SECRETIONS /J -,.,.,& ar 02 SOURCE/FLOW/SA02 RA tf-1....',1 ,i,:;" VENTILATOR SETTINGS /UM ///4'

CARDIAC RHYTHM 57, .75__Ize-e-ep -A7-?r,...1/4Z e7h4,1

Ae CAPILLARY REFILL z- 3 4..e.,—.4 <3 5:r X e.t14-erPini f PULSES 4- 3 .4,„, c-0 „24,e_ite-ystei-w- 61) ,;:i i/exre.414-e5 EDEMA Lt.)5- cf- -,6' 10 1/

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#2 TYPE/LOCATION/SIZE g R,2 4;A.0 kV' DRESSING CONDITION 41. :__ '/o I 7: 05 7,5 _...-_{ ....e, '— IV FLUI

REPORT TITLE INTENSIVE CARE NURSING.FLOW SHEET


6ICT/Alij PATIEN ped or written entries give: Name —last, first, middl NA K: AGE:


DATE

IZSEPO3

❑ HISTORY/PHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER (Speray/ OR EVALUATION


❑ TREATMENT


DA FORM 4700, MAY 78 • MEDCOM - 18631 • USAPPC V2.00

DOD-032205

ACLU-RDI 1647 p.191

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AL ECORD-SUPPLEMENTAL MED DATA For use of this orm, see AR 40-66; the proponent agency is the Office of The Surgeon General.

REPORT TITLE i

INTENSIVE CARE NURSING .FLOW SHEET - t_


r 8 Mar 89

SHIFT: ASSESS

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DOD-032208 ACLU-RDI 1647 p.194

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DATE PREPARED BY (Signature & Title) DEPARTMENT/SERVICE/CLINIC

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INITIA SESSMENT N E U

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r 8 Mar 89

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