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Prescribed by GSA/ICMR FPMR (41 CFR) 1 01-11.203(0(10)
MEDCOM - 4064
DOD 010543
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
b)(6)-2
b)(6)-2
b)(6)-2
/ff¦ A 0 L.Ill l I 1. I I /4.11,
1Sm Nee) an/t b)(6)-2 ;13)(6)-2 b)(6)-2
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written enrnes, give: Name - last, first, middle; 'REGISTER NO. WARD NO.
10 No or SSN; Sex; Date of Birth; Rank/Gradel
b)(6)-4 PROGRESS NOTES
b)(6)-4 Medical Record
STANDARD FORM 509 (REV 5-99)
Prescribed by GSNICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 4065
DOD 010544
NOTES
DATE
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1..a.
ilS
.
ii, • 11
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b)(6)-2 MintaMiginell & II.eat 0 / /
FPI LEX Printed on Recycled Paper STANDARD FORM 509 (REV 5-99) BACK
MEDCOM - 4066
DOD 010545
VITAL SIGNS RECORD
iviLumir._ I ¦ L....,...,..— HOSPITAL DAY
DAY
POST- A _-
I At..
MONTH-YEAR DAY 0 ' ' I ME 'r I 2,ft"'
1
040, eV& • WI: Jo p i. ' - • 0 OW
HOUR jik,i) • • 4...itc • • 14 ...
19___ _ . . . . . • . .."' TEMP. C
_
TEMP. F . . • • • . • .
PULSE
. • •
(0) I.) • • 40.6 ''
.. . .
105* • : , , 1 . . . .... . . 40.0'
..... . • ....
180
'
...... " ' •
•
.• .• " . . ...... . . . . • -3..-
•
39.4'
. . -C'
o
170 . • • ..... • •
• • . . a)
•
. 38.9* c
. . . . 92
. . -
160 . a)
" ' • " • • .. " • • • " .o38.3' ce • • • • • • • 8
150 • • • .
• ..... . .
. -. . . . oi
. -• • • • Ili' • 37.8'
c
140 100" To
' • • • • • • ... ..„. ... .?.
m
. . V 37.2'
i . . • IMIII IVAIIIIIMEINSIKAIIIIME • •
37 .0° wQ
130 99" a,
98:6' . . . . filliffilMffilliM : : : n
36.7"
co
120 98' .Io-a • • • • .. . ..... . . -c-'
36.1"
" • ' .... (...)
, . . . • .
110 97'
. . .
. • • . . . . . . . . .
.
. . . . . . ..... . . . . . . . . . . 35.6' 100 96' . ' • "
. . P : P. 0 0 • • :
:
35.00 90 95' . • -
. . .
: . . . . . . . g . . ...... • . .
. . • . .....
80 • • . . . . . . . . . . . . . .
. . •
. . •
. • • • • • • ..
70 • • • • •-• • A " 1.11/4 • • • IM i.V . A. •: NM I; -•:: 60 . .
•• • • • • • • . . . . . . . .
. . .
..... .
50 . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . .
. . . ..... . . .
. . . . . . . . . . . . . . .
. ..... .
. . .
. . . .
40 . . . 7 2 2-2-' ao Z, 24,
RESPIRATION RECORD , 1q 11 / III la' 7 V
-a BLOOD PRESSURE
92
I 111111111111M151
4 .¦ ,
Y, 5 ,• I V-161" BERMIIIIIIMIEgl t ql°7-. PO
53 Al
-04 .
a, HEIGHT: WEIGHT --IP•
atI i ?..P14 °Z.. ••°;•f•J 91/Z?
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—111/i id 4,1 CI "
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a
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-a
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cc WARD NO.
REGISTER NO.
PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, I rst. middle: ID No.
(SSN or other): hospital or medical facility) (b)(6)-4 STANDARD FORM 511 (REV. 7-95) BACK (b)(6)-4 •U.S.GP0:1998-404-783/40069 (b)(3)-1
oD all(b)(6)-4
MEDCOM — 4067
DOD 010546
511-119 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST- DAY MONTH-YEAR DAY 19 HOUR ‘15-• .a t/ 04;0 Ilpilf4 7% -. • g ' ¦;11 ii,, 4-in 9..v.:i% • • 4Q2-1g A Pk 1140._ .<0 N510 0 • Aze erg? .4. • ov • • • 16 V& , t1 P ,Au‘U. • • •
. . . . . . . . . .. .
TEMP. CPULSE TEMP. F . . . . . . . . . . . .
...
" " " " "
. . . . . . . . . .
(0) (.) •• •• • • " 40.6°
. .
•
105° " • •
. .
. .
. .
. . . . • . . . . . . .
. . . .
. .
•
•• •• • • • •
40.0°
. .
. . .s
180 104° " " " • • .. ..
. . . . . . . . . . • •
.• • • •
• • •• • • •• •• • •• ••
• • . ..
39.4°
. .
170 103°
T: :1
c
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. . . . •• . • . . • • . • •• • • •• • • •
....1
. .
o
. .
a)
• • •• •• •• •• •• • • •• •• • • •• • •
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38.9° c
102° " • • " "
.
• • • • •. •. •. •. •. • • •. •. •. •.
160
. .. .. . . .
. .
.
22
• " " • •
. . . . . . . . 4:2
"
• "• • •
.
0
. . . . .. .
38.3° ce
150 101° " " " "
•
" " " " " ' • •' "
• • ' • • ' . . . . . . . . ..
. . . . . .. .. 5
..-
• •• • • •• •• •• • • •• •• •• ••
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....
37.8 °
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100°140
. . . . . .
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•
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cl
. . . . . . . . . v.
• •. 4 . . .
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99. •• •• • • •• •• •• • • •• •••
37.2° =
0-
37.0° u..1 130
. . .
•
. . ..
.
t>. •.•
98.6° : : : : •. : : • ; .".
: :
. .
. . . . . .. .. .. ..
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36.7°
se
120 98°
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•
•
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110 97°
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. .
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. . . . . . . .
. . . . . . . . . . . . .. .
•
35.6°
100 96°
. .. . . . -. . . . . .
.... ....
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. . .
•.5. •
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. . . . . . . . . .
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. . . . . . . . . . . . . . . . . . . . . . . . .
50
•• • • • • • • •• •• • • •• • • • • • ••
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• • " • • • • •• " " •• • •
. • •• . • • • •• •• • • •• •.
40 . . . ‘... ......4. 1 . . .
" it%" 10,7 1% 1,, „; .
Il v Inv tozr ityv
RESPIRATION RECORD Tok 4.2. i,.f, -Ill Ado 46 :-/o• rt 7+
4..e. 03 ei4o/ C
Record special data only when so ordered
a I &f, co 85-
BLOOD PRESSURE
b c q (11 f2y iG
OD Tr7;
Op It q, 92,10 RAF 45 7,1051 OA 76 6W/. cii, 95°/
quL
,
Ttrf-f"
%ea* I V-gat' Acs-t %5 qvb 41° cItti 7•0 cla
HEIGHT: 1 WEIGHT •Ii.
ca•,
01.11 075 3-16 itio 815 1 03o it60 (Ion
4 As,* . . ..
PATIENT'S IDENTIFICATION (For typed or written entries give* Name—last, first, middle: ID No. REGISTER NO WARD NO.
(SSN or other): hospital or medical facility) (b)(6)-4
IA b)(6)-4 VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4068
DOD 010547
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-•••; -. MONTH-YEAR., 19 `cDAY. DAY HOUR i-9.44643 " • • • • • • • • • • • • •
PULSE TEMP. F
• • • • • • • • • • • • • • • • • • • • • : TEMP. C
(0) (*) "" • • • • • • • • • • • • • • • • • • • • • •
. . . . . .
. . . . . . . . . . . . . . . .
105° **
** 40.6°
180 104° ****
•
. .. • • • • • • • • • • • • • • • • • • • •
** • • • • • • • • • • • •
• . . . . . . . . . . . . . . . .
170 103° 39.4 ° 5,-• • • • • c
. . . . . . . . . . . . . .•.•.••. . • • . .
'it. o
.-...“.•,,, 1020 .• k. ,......... . . . . . . . . . . . . . . . • . • . • . • . • • • • •
. . . .
c...)
160
. . . . . . . . . • . . • • . • • • • • . • 38.9° c
• . . . . . . . . . . . . . . . . . . . . . . E'
.:...,sip . xc..4... . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. cu
.. .. .. .. .. .. ..
..--150
. . • • . . . . . • • •. •• • • • • . . . • • . 38.3° cr ,....." . 8
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4— 140 'IOW • • . 1%4 • • • • • • ' • • • ' " " • • • • •• • • • • .... a
-1-11'
37.8° o
• c
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. . . . . . . . . . . . . . . 37.2° 98.6° v. :
. • . • . . . cr
• •• •• 37.0° t.0 •
• • -• • • • • • • • • • • • • • • • • •
120
98° . .
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40.0°
. . . . . . . . . . . . . . . . . . .
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. . . . . . . . . . . . . . . ta
o. . . . . . . . . . . . . . . .
.•
110 97°
• • . • . °36.1 o.)
. • • • • • . • . • • • • • • . ...... • . . 0
•
,.. .. ,,.... .. .. .. .. .. .. .. .. .. .. ..
.. .. ........... .. .. .. .. 100 96°
.. . . . . . . . . . . . . . . . . 35.6° .. • • • • • • • • • • • • • -• • •• •• •• ••
• • • • • • . • . • •
0
90
95°
35.0°
..
-‘.
. .. . . . . . . . . • . . . . .
. . . . . . . • . . . .
•• •• •• •• •• •. •• •• .• •• •• •• •• •• •
•• •• •• •
80 • •-• . • • • • • • - • • • • • • • • • • • • •
..
. . . .
....
. . . . . . . . . . . . . . . . . . . •
.11 .. --• • • • •• • • • • • • •
70
. .
I••• • I
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• • • • . •
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60
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• ' • • • • • • • • • • • • . • • • • • • • • •
..
. • • • • • • • • • • • • • • . • • •
.. . . . . . . . . . . . . . . . . . . • . • . •.,• • . .. . .... . . . . . . . . . . . . . .
. . . . . . . .
50
.
. . . . . . . . . . . .
•• . . . . . . . . . .
. • • . • • • • • • • • • • • • • • • • • • • • •
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. . . . . . . . .
. . . . . . . . .
. .
. . . . . . . . . .
. . . . . . . . .
40
. .
......
Ii'? 6
RESPIRATION RECORD
!Record special data only when so ordered
BLOOD PRESSURE
f0 I
HEIGHT: WEIGHT —lio '17
'ATIEN 'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. REGISTER NO
WARD NO.
(SSN or other); hospital or medical facility)
•V'
-f7
'I • STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM — 4069
DOD 010548
:74 - AS A CLINICAL RECORD FORM, IT IS COVERED BY DO 22C
(THIS FORM IS SUBJECT TO THE PRIVA
DATE
[ .17 P47..
OR NO
TOTAI
SYMBC
X
ANESTH
0 OPERA1
V
A
IMP CL
PRESS'
ARTER LINE
PRESS'
I T
I
• PULE
C
SPOTS', OEM R,
ASSIS RES
CONTRC RES
TOURNA
F
CATS' L010 F
B
DLO'
Tourniquet Time:
ANESTHESIA RECORD
I_
SURGEON(S)
OPERATION
PERFORMEDf...-2!(
CPA) P6)/1 'In-114U3
PREOPERATIVE
. QUESTIONING CHART REVIEWED . NPO SINCE
a
PRE-OP MEDICATION:
Drug Dose Route Time
IDENTIFIED 0. ID BAND
fi AWAKE
CALM
Pre-Anesthetic Slate:
SEDATE
APPRE HEN SIVE
UNRESPONSIVE
.
MONITORS AND EQUIPMENT
ANES. MACHINE II —1,_ 6 EQUIP. CHECKED NON-INV. B/P . PNS CONT. EKG
V LEAD EKG
M
PRECORD STETH. PULSE OXIMETER 02 ANALYZER ENO TIDAL CO2 MASS SPEC.
J ESOPH. STEM.
. TEMPERATURE
• WARMING BLANKET . FLUID WARMER
¦ AIRWAY HUMIDIFIER
• N/G TUBE 0 0 /G TUBE
4 IV(s)
ARTERIAL LINE
CENTRAL LINE
SWAN-GANZ
.
FOLEY INSERTED: Q O.R. . FLOOR
.
EYE CARE
.
PRESSURE POINTS CHECKED / PADDED
0
. 0
ANESTHETIC T1CHNIQUE
.
GENERAL LOCAL /6)
.
REGIONAL El NERVE CK
.
INDUCTION
.
PREOXYGENA ON . INHALATION
.
RAPID SEQUELA . INTRAMUSCULAR INTRAVENOUS . RECTAL
..
AIRWAY MANAGEMENT.
. INTUBATION 0 ORAL 8 NASAL
8
DIRECT VISION BLIND AWAKE FIBER OPTIC STYLET USED . ATTEMPTS x _____ . BLADE
all ETT SIZE . DOUBLE LUMEN
. STRAIGHT . . RAE . ANODE
ML AIR INJECTED
.
CUFFED
.
UNCUFFED. LEAKS AT CM H2O
I
CMETT SECURED AT BREATH SOUNDS AIRWAY . ORAL A NASAL .NATURAL
MASK CASE
VIA TRACHEOSTOMY NASAL CANNULA 1)1(SIMPLE 02 MASK LMA SIZE
0
RECOVERY
TIME IN P¦c;;LI CONDITION
09 `f .QTYa-r>zA<
p733E RESP -SAT
70)11.7f
TEMPREMARKS
PARRS:REPORT TO:
IN FLUIDS TOTALS OUT
Crystalloid Wt... 1 EEL /1E.--1-k• Urine ,...--_21 121) Gastric ......-----Blood
0, 4
. Ern EMMEN_
p r of-6Z_, et)
A
G
N T S
(7
Umin
1Jrnin
///e..
F
U
Urine
EBL
EKG
54 02 Inspired
M
02 Saturation
O
End Tidal CO2
N
Temperature
T PNS
0
R
S
TIME a:
PRE-OP
200
VALUES
180
fo el 160
V
B/P'
140
T
J^J
A
120
100
S
BO
G
N
60
S
SAT
40
20
H / H
Tidal Volume
R
E Reap Rate
S Peak Pressure
Symbols for
Remarks
Qi
Position
.TART
frage7Tof
6AR
SieIlJI4G2ST4RT
.,t3 .
MEI MI NM
MIN MINION
OMNI
111111111111.1111
11111111111111111111
Pat nt reevaluated. No change from preop plan / evaluation. Significant changes from preop plan! evaluation.
REMARKS:
PATIENTS IDENTIFICATION b)(6)-4
(b)(6)-2
(b)(6)-4
RNA
• • _
MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 21 MEDCOM -4070
DOD 010549
Planned Surgery Date:
t.,
1 HEIGHT r Y 1 WEI_GAT
6.
— -- - — — -
NAIVit:
PLL
I
AGE i
7
Jowl n
ANESTHESIA PREOPERATIVE EVALUATION
e---
?CY ,5
PREOPERATIVE B ip P
1 di-7i„..- R
PROPOSED ,..---,p, r) ...,,,) ,
VITAL SIGNS:
.
OPERATION I V (...) (....,./L.)01/ ?Oc" kt-i--11``--yr-
CURRENT MEDICATIONS oNE
thATIVE
PREVIOUS ANESTHESIA/ OPERATIONS
EGATIVE ALLERGIES )(1.17ICDA
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS _. .
AIRWAY / TEETH /HEAO & NECK
t,-) 2
l
6-17c1
PERTINENT STUDY RESULTS
COMMENTS
SYSTEM
Chest X-ray Pulmonary Studies RESPIRATORY Asthma Bronchitis COPD Dyspnea Pneumonia Productive Cough
Tobacco Us 140 Yes Pack/Day for Years
•
TuberculosisRecent cold SOB
• EKG
CARDIOVASCULAR Angina Arrhythmia CHF Exercise Tolerance Hypertension
MI
Pacemaker •
Murmur MVP Rheumatic fever LFTs
HEPATO/GASTROINTESTINAL Ethanol Use : Na Yes Frequency Bowel obstr lotion Cirrhosis
Hepatitis
NEV
Hiatal Hernia Jaundice
Reflux/Heartburn Ulcers
NEURO/MUSCULOSKELETAL
Arthritis Back problems CVA/Stroke Loss of consciousness
Headaches
Neuromuscular disease Paralysis
DJD
Paresthesia
Syncope Seizures TIM Weakness
Urinalysis Thyroid FES RENAL/ENDOCRINE Diabetes Renal failure/Dialysis Thyroid dl Urinary retention Urinary tract Infection Weight lose/gain
Hgb / Hct I CBC Lytes OTHER Anemia Bleeding tendencies Hemophilia Pregnancy Sickle cell trail Transfusion history
PREOPERATIVE MEDICATIONS ORDERED
PROBLEM LIST / DIAGNOSES ASA
i'l 2 LI '— ! a 1-0e.
/ 's71)1D('1. 7 zien2eNee.m 1 Al/ --• i (-•,"-V-' ,...,
AO s 4.1
5-gee/Li ( ) (?)
5
POST ANESTHESIA VISITSCOUNSELING. STATEMENT
ANESTHESIA RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE. SO
Anesthesia alternatives, benefits and risks from minor-to
STATE)
death explained. All questions answered.
Patient I legal guardian voices understanding and gives
consent for :
General Anes.
Local / MAC, SAB, Epidural, IVR,
Other:
Appropriate alternative as backup.
DATE:
NPO status explained.
. .
TIME:SIGNED:
DATEPATIENTS SIGNATURE
EVALUATORS) SIGNATURE
. DATE
CRNA
DATE
PHYSICIAN
MEDCOM - 4071
DOD 010550
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER NOTED COMPLETEDORDER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
NUMBER TIME & INITIALS TIME & INITIALS
b)(6)-2 11)„...
POST ANESTHESIA CARE UNIT ORDERS II OXYGEN: 3 litres via Mask /Prongs to maintain 02 Sats greater than 94%; Wean to room air.
,
IVF: Lk @ 42i. cc/hr, bolus cc x 1
MORPHINE: 2 mg IV q 5-10 minutes PRN pain. MAX dose of / ° mg
-
4 DEMEROL: mg IV q 5-10 minutes PRN pain. MAX dose of ,id mg
•• AN . • -- -..
• • • 'peat after TO-Trrintttes-X-1--
,
• • ,. • .. • : : I • • • t
_7 RE .1.
. . •..
• : • i -_ _______RelpacP from "PACU" when Aldrete score is or greater
?
Call Anesthesia for any questions or concerns
b)(6)-2
Sal"Ve-. 471/d--
¦
PATIENT IDENTIFICATION 1(3.b • b)(6)-4 (b)(6)-4 -- Complete the following information on page 1 on y. Note any changes on subsequent pages. Diagnosis: Sff) 67-11,MV-1/71--, iCi
Height: -.1.r C-1 Weight: jtia)-(- Diet:
Allergies: 4.14-64.,
Nursing Unit c---, Room No. Bed No. Page No.
8-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MG V1.00
MEDCOM - 4072
DOD 010551
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 MEDIdAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIPDATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
OROEF b)(6)-4 — C NOTED A
HOURS
0„A03
SIGN
gi, Admit Patient t )
ICU
i -"In_
OM Dial • .8I.'5, ,
' / 44)
WOOPPIPPIF
air-!RIPRIMIllkel,4 ' • -trill ;I • -
Aft - •• • I zaw• 4 • . sMP • • • • •
NURSING UNIT ROOM NO. BED NO. ww”
Cardiar reqpiratnry mnnitnrin.
14r, Diet: '4 -. - . - . s
PATIENT IDENTIFICATION -ilPir DATE OF ORDER LTrAE OF • - •
Ig re#Aritcec 5 .P41-4 - HOURS
8 Activi ir.
•1.BR with BSC/
NWB R or L LE
HOB up 31
.-grees
Nursin-
I
CDB/ NG to LIS/ LCS
11 Labs:
Chem 7/ H/H/ PT/PTT/
NURSING UNIT ROOM NO. 8E0 NO.
CBC q AM/ 4 hrs/ 8 hrs/ BID
--Fi. 0 /4f,ii
0
dIVEK791:4
PATIENT IDENTIFICATION -DATE OF O ROER 0 TIME OIF ORDER HOURS
...L), i to it b)(6)-2
• 13 PCXRAY q AM/QOD
...(
.44, -
IVF NS/6) D5NS/ D51/211 To run @42 cc/hr +7
5 Ancef 1 GM IV Q 8 hrs 40
aiadtzP (ft
16 Gentamycin IV Q
17 Cefoxitin 2gm IV q8hrs. e,e `
UP"` W
NURSING UNIT ROOM NO. BED NO.
5
19 Versed gtt 1-10mg/hr IV titrate to
8 02 titrate to keep SPO2 >
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
(b)(6)-4
HOURS
b)(3)-1
Ramsey Scale of -; b)(6)-4 20 Fentanyl Rtt start at 50mcg/hr titrate for adequate pain control. MAX DOSE of -Vecuronium lmcg/kg/min 2 MSO4 .2....:47 HR PRN Pain
MG IV q
.1--
NURSING UNIT ROOM NO. BED NO.
Phenergan 12.5-25mg IV q 4-6hrs PRN N/V .t MOM 30cc PRN Gastric upset
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1 FAVRM79
MEDCOM -4073
DOD 010552
n caArrtul s t.en J warn-,c 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 MEDIChl RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. LIST TII
0.) TIME OF ORDER PATIENT IDENTIFICATION
DATE OFDER
OBOE I NOTE!"
HOURS
SIGN
25 NS/ LR bolus X liters
Neuro checks q lhr/ 2hr/ 49/ 6hr/ q shit
Vascular checks a lhr/ 2hr/ 6hr/ q ift
NURSING UNIT ROOM NO. BED NO.
TIWE OF ORDER PATIENT IDENTIFICATION
DATE OF ORDXFI
-(QAA01 30 v -1,t/ y 7 04,) b)(6)-2
MPU, t.ThrXisik_
DEPT 0 B/GYN
ROOM NO. BED NO.
NURSING UNIT
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION ,;b)(6)-4 ;b)(3)-1 OD -g4(b)(6)-4 DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT ROOM NO. BED NO.
•• NO MC IOC= rb
MEDCOM - 4074
DOD 010553
CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
PROBLEM ORIENTED MEDICAL RECORD D
SIGN EACH SET OF ORDEARROW BE THE DOCTOR SHALL RECORD DATE, IME AN COLUMN INDICATED BY
IN CO
TAMER
SYSTEM IS USED, WRITE PROBLEM NU TIME pATE OF ORDER
I
PATIENT IDENTIFICATION
Pon
. =
NURSING UNIT
110.11.2.vi ...‘110111
PATIENT IDENTIFICATION
4IM
ESI
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
REPLACES EDITION OF 1 JUL 77. HIGH MAY BE USED.
DA ,F37^79 4256 MEDCOM - 4075
DOD 010554
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.
LIST TIMEDATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION ORDER NOTED AND
HOURS SIGN
1 3 /4-PAE8 1:246 Y:5
Pt-eVIA•-ed pve.4ASQ-A4-T eacideirf
b)(6)-2
BED NO.
NURSING UNIT ROOM NO.
0.4105
TIME OF ORDER
DATE OF ORDER
PATIENT IDENTIFICATION
HOURS
/220
/3 19/1469.3
T-
Ae
b)(6) -2
NURSING UNIT ROOM NO. BED NO.
•
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
t.+4
trpto4
11C1M-2 I,.1 5000 S Q tkr
b)(6)-2
41-fZ ‘99.s7 4Gtiedsc-A" .1 1 72 ...jel—f4"
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME ur vnucrPATIENT IDENTIFICATION
(b)(6)-4
'HOURS
/41 AN.ai it9 dP
1>1 ,..t„ ,0
to
--6)--/Gr?
;b)(6)-4
c:)=. d
b)(6)-2
(b)(3)-1
4/6
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
FORM
DA 1 4256
APR 79
• • tru:s . a
MEDCOM - 4076
DOD 010555
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG RECORD E DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL STEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. ORD
TIME OF ORDER
.TIENT IDENTIFICATION
J-.))(6)-4
.IURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
13)(6)-4
:b)(6)-4
:13)(3)-1
NURSING UNIT
'
EDITION OF 1 JUL 7tW HIGH MAY BE USED.
REPLACES
4256
MEDCOM - 4077
1ForRm79
DA
DOD 010556
CLINI..r' Arm" - ULM. _
For use of this form, see AR 40-66, the proponent agency is OTSG
'F PROBLEM ORIENTED MEDICAL RECORD
4TE, TIME AND SIGN EACH SET OF ORD' SYSTEM IS USED, WRITE F
THE DOCTOR SHALL RECC
:M NUMBER IN COLUMN INDICATED BY , 1 BELOW.
LIST TI•
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION ORDER
NOTED AND
HOURS
a7-1 OD
Ho e -63r
f ¦
) °A 62i-f--3 1 SIGN
— ....
b)(6)-4 ga__.
ill 0 an 1_¦, -I(
b)(6)-2
II 116—1
'
i
b)(6)-2
r
,b)(6)-2 -
All
NURSING UNIT ROOM NO. BED NO.
NG(1t .1 . 1
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
Ir30
HOURS
fir Apr 03 re
I (b)(6)-2
lib
Cbt
D
b)(6)-4
0 40
b)( • )-
NURSING UNIT ROOM NO. BED NO. ( VI"—
I I
1
DATE OF ORDER TIME OF ORDER HOURS PATIENT IDENTIFICATION
I q aP12 03 OF4D --r-, k A C., • . , , ID
r -14 I f' -72.Ct:k •
Cil
VIOMay iVij&t.G( AX
2) h0 , 1.zsieltrx S I %
b)(6)-2 (. (6)-2
b)(6)-2 a--fa-.
-II
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
;b)(6)-4
HOURS
90 a Po- cy) ab
ki-Aela \ 0..Y. SAAR ?Q,
13)(6)-4
:2) 2102.2(-3 AS )1(4% VI --rtsrti6t+ IA NO reathfs
_k b)(6)-2
e-e) kio . i.>51 b)(6)-2
(b)(3)-1
. ..
NURSING UNIT ROOM NO. BED NO.
-----.1
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA IFLRAM79 4256
MEDCOM - 4078
DOD 010557
CLINICAL RECORD - DOCTOR'"RDERS
For use of this form, see AR 40-66, the pr gency is OTSG
THE DOCTOR SHALL RE. ATE, TIME AND SIGN EACH SET OF OR, sF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIN
DATE OF 014001 TIME OF ORDER
PATIENT IDENTIFICATION
ORDER NOTED A
HOURS SIGN
RR r t9
L
5771 Y
e/i/E-til-d-, .57)' ,O ry %_ I -2-A--e
b)(6)-2
(b)(6)-2
NURSING UNIT ROOM NO. BED NO.
t&'. l 03kA-s
=r-Gtt
DATE OF ORDER TIME OF ORDER HOURS PATIENT IDENTIFICATION
ati kr 67) CP201)
Thi x
Ly,m_eiat-- .6-7) -i a A 11.004Ai 0 a .
(b)(6)-2
V . 0
NURSING UNIT ROOM NO. BED ,NO........._...,....yloft)
6er LI I if lav (
&. 0.3°S-1
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
e) 63 0-63° HOURS
act.k.
(b)(6)-2 b)(6)-2
\ J D cfr.
NURSING UNIT ROOM NO. BED NO. ....._____
1
IP S 1 6-1.b K 0 PATIENT IDENTIFICATION
DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT ROOM NO. BED NO.
. .. .
FORM • REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
425
DA 6
1 APR 79 •
11F
* U.S. GOVERNMENT PRINTING OFFICE: 1994-383-710
"USE BALLPOINT PEN—PRESS FIRMLY I NO CARBON PAPER REQUIRED"
MEDCOM - 4079
DOD 010558
...CRAPEUTIC DOCUMENTATION CARE PLAN ..JEDICATION)
CLINICAL RECORD For use of thistom see AR 40.407; YO`, Yr. Oa the prominent mem is the Office of The Swann General.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INITIALING
HR DATE COMPLETED
ORDER CLERKI RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
i 0 1 1 la
0)(6)-2
b)(6)
Vital signs q hr q 2hr q6h4 / q8hr / 07
/0 *V.%
q shift 19
Q 413
Cardiac Respiratory Monitoring 07
/04ro3
19
Diet: NPO / Regular / Soft CleaTiN 07
1-045r03
Ligui ex,,(,4„..6_4_4(1,,,,,,, N., 7ix. 19
Activity: Ad Lib /6rict B BR with 07
/04" S
BSC / NWB R or L L 19
ae. aizi
HOB up 30 Degrees 07
it Ap-a5
19
Nursin D / NG to LIS / LCS 07
/04Y03
1(
tabsrElieni-7-141&11.1...111LEML__
are—trAlot-i-4-k-e-1-4-1u-s-/-131.11..
1
b)(6)-
. t Ota3 002 ikse4 40 1-9.3 6,12 '6 20 24 EKG q AM / QOD 06 PCXRAY q AM / QOD 06
•
b)(6)-2 'WA
Neuro checks q lhr / 2 hr / 4 hr / 6 hr / 07 i
tall,-
q shift 19
Vascular checks nq lhr / 2 hr / 4 hr / 07
6 hr / q shift 19
b)(6)-2
, 71:,b)(6) 1 loApra3 t
4
7
ALLERGIES: .1 YES f7 ND PRIMARY DIAGNOSIA ADDITIONAL PAGES IN USE
/0 gia-k) 5ilAitt 17)(1 YES MND
GSI /e
11/411Z-O iti PAGE NO:
/
Or
PATIENT IDENTIFICATION:
;b)(6)-44t, (b)(6)-4
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 I tit
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07 Treatment Facility: "3" DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 4080
DOD 010559
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) I
For use of this form, see AR 40-407;
CLINICAL RECORD Mo. It
the Proponent.rncy is the Office of The Surgeon General.
VERIFY BY INITIALING = INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
FIR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
.a its
(b)(6)-2 ..
— i ) A tr-osS) ( cale oq st
C6/91"8
—
ci410 tefali ta
ci..741- 4,4jes.,ate D1.) i
/
. ,
ALLERGIES: ED YES tilq A NO PATIENT IDENTI FICATION: P RIMARY DI AGNOSIS: V, el SIVI/ ,d (9 Q4p/di-Or .,(94c2A' SIP AOOI TION AL P AGES IN USE:. FIN YES El NO P AGE NO: 02
si b)(6)-4 (b)(6)-4 ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
i CIA3 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
DA1 FOOCRTM78 4677 EDITION OF 1 DEC 77 MAY BE USED.
MEDCOM - 4081
DOD 010560
Thcri,...:UTIC D06-JMEICATION CARE PLAN (NON-MEDICATION)
CLINICAL RECORD
For'use of this form, see AR 40-407;
. . ... I : ..:, : • I' MO. Yr.
• A .
... .
VERIFY BY INITIALING
' ' -'' ,. INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK! RECURRING ACTIONS, HR DATE COMPLETED
DATE b)(61V-U2RSE FREQUENCY, TIME
CUM 12 MEIMEMIPlinnil.
10R-Pg
intingurammrsim
IMANIM b)(6)-2
14611492 IMAIMIV
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M 1111/1111•1111,
NI ilatialligitifilll
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b)(6)-2
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b)(6)-2
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ALLERGIES: YES NO PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE:
I. YES MI NO
/1/0/9 C.,) 4.-)
(c) ECIC / TA %I k. '
PAGE NO:
PATIENT IDENTIFICATION:
/ e.,gif
b)(6)-4
ACTION TIMES b)(6)-4 USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 ,14 15
DD.i4 E 16 17 18 19 20 21 22 23
(b)(3)-1
N
24 01 02 03 04 05 06 07
)A FORM 4A77 1 nr_T 7Q
EDITION OF I DEC 7 7 MAY BE USED.
USAPA V1.00
MEDCOM - 4082
DOD 010561
. . ,
Verify by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing ,
(NON-MEDICATION)
'(Mo Yr
Order Clerk
SINGLE ACTIONS Date to Time to
Date Nurse Time Done Initials
be Done be Done
b)(6)-2
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II ' -2, Al At a
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b)(6)-2
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a.
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Order/
Clerk! PRN
Expir INITIAL PROPER COLUMN FOLLOWING COMPLETION
Nurse
Date ACTION, FREQUENCY
b)(6)-2 TIME/DATE COMPLETED
in 0 224, M. )6
1
b 6)-2
I / -b)(6)-2
P.k
USAPA V1.00
MEDCOM - 4083
DOD 010562
r 1 hrr1APEUT1C DOCUMEnirru AToflOilyftr,Isie! APRI.4m7(NurV-iva-cDICATION) 41:
CLINICAL RECORD MO.PrVTr. 7-1)b?;
the r oonent a ncv is the Office of The Surgeon General.
;g:1:;0RtRMii;iiidi;::Ii INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY B Y INITIALING ;ii:' i1;:l .
ORDER DATE 10 Or Cr. CLERK! NURSE RECURRING ACTIONS, FREQUENCY, TIME V5 COS a-pu4se OK ank HR 7 27' 2.3 ori (b)(6)2 2'1 Z.0 7-lo DATE COMPLETED Z7 7-2 74 cV
AMA 0 VDU W.04)1, / 1 all
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r a hp' oz.; l Mr c''' Ilia-•p DSS A (a k)) cob to Trac-h'e>n 1-1.-t= & 07 4FDLLA,Aa-A-11
ALLERGIES: I I YES PATIENT IDENTIFICATION: NO PRIMARY DIAGNOSIS: 9 fe-radu-A--r-\16.,._esw ..4...„ (b)(6)-4 ADDITIONAL PAW: YES ACTION TIMES (
(b)(6)-4 0 USE PENCIL. CIRCLE ACTION TIMES 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA VI.00
MEDCOM - 4084
DOD 010563
..
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; MO. Yr. 03
the proponent a•ency is the Office of The Surgeon General.
: INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY INITIALING
HR DATE DISPENSED
. ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE :s DOSE, FREQUENCY
/0 i i
a
0 •• linglan Wr: '. Vel 41
7
.
b)(6)-2
c,
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ALLERGIES-PRIMARY DIAGNOSIS: ADDITION AL PAGES IN USE:Ej YES INO
0 YES ED NO
5/P ash( 0
2Li , (c ituA
Al le-4A
PAGE NO
p 57/ eisi it,t— Aid - --
PATIENT IDENTIFICATION:
;b)(6)4
DISPENSING TIMES
(b)(6)-4
USE PENCIL. CIRCLE MED TIMES
•
D 7 8 9 10 11 12 13 14
I Ca 4 ‘.3
E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
D Ai F 473^79 4678
MEDCOM - 4085
DOD 010564
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mn. Yr 473
(MEDICATIONS) it .
Initialing
Date to Time to
Order Clerk/
SINGLE ORDER, PRE•OPERATIVES Time Given Initials
be Given be Given
Data kl
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R.—)
AS.49 0830
istytqC,M 3D/yi.a tV X. ?'per
_...
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Order/
Clerk/ PRN
Dater
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
(b)(6) -2
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MEDCOM - 4086
DOD 010565
CLINICAL RECORD , THERAPEUTIC Destili t IN; rr9nNs2/01143,07; EDICAPIONS) th.Pm.".n Mo. Yr.
VERIFY BY BYITIALING
r.r lith. °the.° Th. aura." G.h.r.i.
I
m...3 .
,46,,n4L PROPER: COLUMN
FOLLOWINO EACH ADMINISTRATION
ORDER CLERK/
RECURRING MEDICATIONS, HR
DATE NVIISE DATE DISPENSED
DOSE, FREQUENCY
b)(6)-2
11111TMEIMITIM1113111111611MBE
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ALLERGIEtr DYES
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Ems ummummin
ADDITIONAL PAGES IN USED
O YES O NO
PATIENT IDENTIFICATION, PAGE NO.
'‘b)(6)-4
DISPENSING TIMES,
japieta
Oz)
;b)(6)-4 CI RCL E MED TIMES
D 7 8. 9 10 11 12 13 14 E 15 16 17
18 19 20 21 22 N 23 24 01 02 03 04
DA I VEN9 4678 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM -4087
DOD 010566
b)(6)-2 Verify by Initialing Order Clerk/ Daft, Nurse 1-1 ,UTIC DOCUMI!ITATION CARE (MEDICATIONS) SINGLE ORDER. PRE•OPERATIVES Agin A T 7¦Vi 6'11 Date to be Given S Mo. Time to beGiven Yr Time Given Initials b)(6)-2
I, AAA. it 14-A-s• pv3 f22yAl 01 0
El
RitriAL PROPER COLUMN FOLLOWING ADMiNISTRAPON
Clerk/ PRN
Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
b)(6)-2
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,,......../(e)-2
INN III
1:1 61,0-4 6 cosiuTo
--0 1) 54.11019521 q-b9 frt--r '1 Ll cob f,/
© 30
NtO
NEDCONA 4088
DOD 010567
I
APEUTIC DOCUMENTATION i PL .EDICATIONS)
CLINICAL RECORL I For use of this forrn, see "ri 40-40, ' Mo./1/47K Yr. 2-0
the proponent agency Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADIENISTRATION
VERIFY BY INITIALING
I
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
/ 22 IZ ' l N125-1 2-6 [2:7 a 24
(b)(6) -2
16 AfY1P 14 vii etkALPL ppIp aa ID i2 i'vr o?, _CLUL6-0— /bOrrkj 0 BO D 10 27-141 03 Love r L))< 3D Mq 361 B )3 R9
72-
ALLERGIES. ED Y ES NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USES Q V ES RIO
6-50j 0 bcta.(4-14
• s'()' \ &AAA. PAGE NO. PATIENT IDENTIFICATION:
(b)(6)-4 DISPENSING TIMES USE PENCIL. CIRCLE MED TIMES
b)(6)-4
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
D A 1 FFOEFEN9 4678 EDITION OF 1 DEC 77 WILL BE USED UN TIL EXHAUSTED.
MEDCOM - 4089
DOD 010568
1
APEUTIC DOCUMENTATION Z PL .EDICATIONS)
CLINICAL RECORL I mo.iiYr. 2-421
the propon:gaTng tInhfrOmtilce of Surgeon General.
,
VERIFY BY INITIALING! INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE CLERK/ NURSE RECURRING MEDICATIONS, DOSE, FREQUENCY HR / DATE DISPENSED 22-I Z3I Zi I z,5I zi, 27 4? 24 Fe)
15 NY to,-(b)(6)-2 1.4y-a_vix.., pc) Qb ID (b)(6)-2
iS AlparA roba_.61, IDOrA JJ b IP 10 -;,1-
t9 Apr Lovenox 3D nrS4: 30-D 0 /D
V--
ALLERGIES. =I YES PRIMARY DIAGNOSISt • -- ADDITIONAL PAGES IN USE;
AYES RIO
'f()'\kAiil 1 6,(A) 0 baa.(4-td.-9 C. PAGE NO.
PATIENT IDEN TIFICATIONt
13)(6)-4 DISPENSING TIMES
))(6)-44.1 USE PENCIL. CIRCLE MED TIMU
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
D A I FFOEFAI9 4678 EDITION OF MEDCOM -4090 XHAUSTE D.
DOD 010569
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
0
0.3
initialin g (MEDICATIONS) Mo. Yr
Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
aa 0-, °RFD -ft
9 b/eMAJZA4) ( . 5 b h1-1;y- 1 61) Ihi X ( 67( 001
corv.5 52 11-ZA.I., 3e. 57) 1 00 n:y. i 2./ 0-6 46 033 ) U b)(6)-2
1Alld6/ S.-1 rvne i stAgn. 033o (1/00
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ P RN
ExpirBare Nu rse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED
i i> 4b) (6)-2
ilii b) 1-4 50 4 1 2 V Ot-I,
Fizt\i -eV paivt,
v-b ' Dill a)/64,54-pos-•/' ?A
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1 mil
7 tri rib 61 ii-coonv )(8)-2 '
wilm¦I U.S.. .NPAENT PRINTING OFFICE: 1993 342-027/70450
MEDCOM - 4091
DOD 010570
0(6)-2b)(6)-2
Surgeon
b)(6)-4 RECORD-SUPPLEMENTAL ME For et, of A. .410 AR 40-66; the proponent agency Is 41
REPO ANESTHETIC RECORD Preanesthesia Assessment, Ti
17:1A74
Dtv ea Premed: Doug. me Wt S A Effect: Chart Reviewed Pt I
/
Pre-induction Vital Signs 1 , BP '4' •
TOTAL
24 HR. TIME:
rito
•
N, 0/AidHe LM IN
Sevofiurane/desflurane/fo r.22175-' Sord MUM 11:117 Pt Or:Immo
111.1.1.1.1111=11111.11NIMMIMME . I
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140 FAIIM111111111M11111111111/11111111111.111••• AI\
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Total Urine: it Fluids Summ
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DEP(b)(6)-2
PATIENT'S IDENTIFICATiON (Fortyped or written entries give: Name —last, first, middle; grade* dat ; hospital or medical facility]
b)(6)-4
;13)(6)-4
Cf)AS
er
0 as
eon General.
OTSG APPROVED at //
Date •
Plan Re ewed Pt. E
a1"-Itfl-404/lipy•d
Remarks:
Phys. Status: 163 4 5 treb
gel-f 5)19 431%1(0
ucr
REVERSAL:
Naloxone
Edrophonium/N -z 4..
' Atropine/GA), • .)41.1*-:e
N. Slim. Respo
PACU/CCU/ICU Tine In:
Mode: BP:
°Guarded pota •
0 Unresp. woks 0 ETT 0 NC/AFMIT.Piece 0 Ventilator 0 @ Lim 0,
TV: -R: Ft02 b)(6)-4
P: R: JNIC
. HISTORY/PHYSICAL
.
OTHER EXAMINATION OR EVALUATION
.
DIAGNOSTIC STUDIES
.
TREATMENT
Time
UgM
, mgU g mg % TOF 0 Sust .TET.
tory
Anes In Roca)?Out Roorlig', Anes Enclgi TOTS Surg St S Surg Encb 9!
DTEitik
FLOW CHART
. OTHER ityresoyi
DA FORM 4700, MAY 78
MED FC OP 562 (Rev)1 girtuu1
MEDCOM - 4092
DOD 010571
kfrnICAL RECORD - SUPLE?ENTAL Nx 7-"ir ' . LiA i A
Fr use of this fonn, see AR 40-66; nt agency is the Office of the Surgeon G
L t'IP:
thief Complaint:
-rfr.atments PTA:
VrrAL SIGNS: BP: //2
Sxmr
WES ABD
112AIIMACJYEsENO . WARM . SOFT PAM Das ONO . DRY . DISTENDED S DB OYES Q NO . PALE . TENDER L LING SOUNDS .DUSKY BOWEL SOUNDS
L . MOIST YES . NO 3 CLEAR GUIAC TEST j 0. WHEEZES [1:3 POS .NE°
DECREASED
J
3 . ABSENT
EXTREifETTES::'
Cl DISTAL PULSES,
Cl RT X 20LT X 2
CI MOVES EXTREMITIES
X4
NO EDEMA
D. NO DEFORMITIES
EXCEPTIONS TO
A B 0 VE SPLINTS: •
f ARAM ETERS -jRgeitNETI
2: L PM NC MASK ORAL AIRWAY Err # MM NASAL AIRWAY MONITORE Y ON EKGEY MG TUBE # FOLEY: # DPL . posCHEST TUBE DR
CM H2O
PREPARED BY (Signinure & Title)
PATIENTS IDENTIFICATION
(For typed or willten 'tries give: Name - last: first: middle: cmode• datp•
(b)(6)-4
2.rpital or medical facility)
(b)(6)-4
(b)(3)-1
Medications:
RR: 3 Z TEMP:
SAO2: 72(
PERRL . YES . NO R mm L mm GLASCOW SCORE:
• 39 4 5 • 6 •
7 8 9
I. EYE OPENING 2. VERBAL RESPONSE 3. MOTOR RESPONSE Spontaneous-4 Oriented • 5 Obealent • 6 To Voice -3 Confused • 4 Purposeful • 5 To Pain • 2 Irtappropiiate 3
Wilhoravnl Flexion • 3
I ncomp I el-tensible-2
None - I Extension • 2
None
None - I
A . Was=
A? • kraitanco
AV • Arms=
• Ban C • Contact+
D . Oslorrnry E • Erissraum OF • Open F:-Jcui. CF • C'aseo Fraena G • GSW. (I Susi
I.
• Lacst-xcal FW • Purcue wound S • Sue warn O • Cyr(
. NEG
FRONT
BACK
ront(rrue of rrPe e)
DEP
.
HISTORY/PHYSICAL
.
FLOW CHART
COMER EXAMINATION
. OTHER (Specify)OR EVALUATION
DIAGNOSTIC STUDIES
. TREATMENT
Ropm .elqa. MA V la
MEDCOM - 4093
DOD 010572
(Medical treatment facility)FROM traitement medical)
nor INF /Installation de
b)(3)-1
le initial),
NAME (Lea— irst—nn prenom—initialu deuxit%ne pririom)
famine—Pre
M Nom de fa b)(6) -4
b) (6)-4
NNEL (Semi.. or employer and CATEGORY OF
national ity)
SERVICE NUMBER employeur et
(Service 011
CATEGORIE DE PERSONNEL
NUMERO MATRICULE
natfonalitj)
DIAGNOSIS
DIAGNOSTIC
-
giu ...-_,Iki-axava3. 1n
INJURY
BATTLE CPSJAL
DISEASE BLESSURE
,mow AU oomeAT
MALADIE
1.1111113125231111111111
11:1111111111111110 11111111111111111
BUNK NUMBER CABIN OFLCOMPARTMENT NO.
T NUM60
NO. CABINE DU COMPARTMEN COUCHETTE
1:1¦1111111111
VSI BAGGAGE TAG NUMBERIS)
VIES GRAV. MAL. NUMEROS CTIOUETTES BAGAGE
r—IN0
Y.
LiNun
0
oui SHIP/AC (NumberItype)
NAVIRE/AVtON (Matricole/type)
DESTINATION
DESTINATION
(f no treatment is reynired a otation to this effect is made) I
TREATMENT RECOMMENDE9 EN ROUTE ndiquer sl auctto traitement n necessaire)
(I
TRAITEMENT RECOMMANDE EN ROUTE
i-evactL.6 n 5b0
-po b6c4.4.4aci n scooLL.
8011A-6 Sb
i_sb¦Nrvoc
Pit
DATE DATE SIGNATURE OF MEDICAL OFFICER SIGNATURE DU MEDECIN
sPgclat. Digr (Describe)
REGULAR DIET
REGIME SPECIAL (Description)
REGIME NORMAL
SHIP'S RECORD OFFICE TAB — FICHE POUR ARCHIVES TRANSPORTS
(Medical treatment facility)
FROM
(Installation de traitement medical)
ORIGINS
(Last—first—middl• initial)
NAME delixi6ne prenom)
ier prd'Imm—bdriale
NOM (Nom de famine—prem
CATEGORY OF PERSONNEL RANK/RATING/G RADE CATEGORIE DE PERSONNELSERVICE NUMBER
GRADE
HUMERO MATRICULE
DATE Of SHIPMENT
BAGGAGE TAG NUMBERISI DATE DEPART
NUMEROS ETIOUETTES BAGAGES
ARRIVAL DATE
DATE ARRIVESDESTINATION
DESTINATION
EMBARKATION TAB — FICHE D'EMBARGUEMENT
MEDCOM - 4094
DOD 010573
ts(0)( 6) -4
,¦I 3a. STATUS 3b. SD,. -4. PRECEDENCE 5. GRADE
1. NAN' "--' r. ' ' A .'"I'' '-'tial)
. ;:
' ' ' :. U IP IR \•(., '.:-.'zi::'':: :::: ::;..::" :::' : : ,;
'ENVil:Ve
''''
6. AGE t. SEX 8.WEI HT 9. BLOOD TYPE 10. CLASSIFICATION (1A TO 5F)--11.ACCEPTING MD 12.CITE/AUTH #
ALE 'FEMALE I W
13.APPT/SURG DATE 14a. ORIGINATIIp3)r" l-r‘i
14b.ORIGINATING FACILITY PHONE NUMBER 558-4987
17. ID AGN• SI
Var.-0ill r sillrere:151111111UMELFEviiriTIE'
i I
(../ -t( ' • 14,44
18. fyiBATTLE CASUALTY 'DISEASE I I NON BATTLE INJURY
20. PHYSICIANS ORDERS
20a. DAT ,_ 20b. TIME (...120c.ptLaa.
....) ES
la 0?-ro
20d. DI T )(IREG I3GM NA I 'CARDIAC I 'DIABETIC CALS RENAL _Gm Prot Gm Na MagK mg PO4 TUBE TYPE _cc/hr. 1/2, 3/4, FULL STRENGTH PEDIATRIC: AGE 'OTHER (Specify) TPN: Change to D10 at cc/hr for max of days TUBE FEEDING: at s rength at cc/hr
20e. IV / BLOOD ,-9 Oct-
20f. SPECIAL EQUI M NT I FOLEY CATH SUCTION TRACTION I ORTHO BRACES NG TUBE IV PUMP I CHEST/HEIMLICH STRYKER TRACH 'RESTRAINTS INCUBATOR MONITOR I OTHER (USE 23)
OXYGEN: PERCENT or LITERS ROUTE: VENT SETTINGS: 20g. ALTITUDE RESTRICTION: Yes No feet
20h. RECORDS TO ACCOMPANY PATIENT ..../. OUTPATIENT RECORDS XRAYS OTHER: NA INPATIENT RECORDS OB NARRATIVE SUMMARY DENTAL FINANCIAL
20i. MEDICATIONS / TREATMENTS
.7
-U pp
flf.c.pacv-ro 7 Lf-1. fg.Airt,-,
4,,,f___ 141'4A-- ST)C 7 /Drr r
(b)(6) -2 24. STAMP AND SIGNA (b)(6)-2
AF Form 3899 (433 AES OD b)(6)-4 (b)(6)-4 4 pri9). 1#412SK, MC EVEPT OF OR/rwm MD •
AMBUL OrLITTER 124241945H: . 15a. DESTINATION FACILITY 16. # OF ATTENDANTS 16a. MED 16b.NON-MED (b)(6) -2
15B. DESTINATION FACILITY PHONE NUMBER (b)(6)-2
19. CLINICAL ISSUES (Please indicate Yes or No on c s. Exp a n YES comments in Section 23 YES NO ISSUE YES NO
a. -"*"--Hypertension liC-Bowel Problem
Hertension i
b.
Cardiac Hx j. Self-care
c.
Diabetes k. Ambulatory
d.
Respiratory I. Ambulatory Aid
e.
Ears/Sinus m. • /Self-meds
f.
Motion Sick n. Adequate Supply of Meds
g.
Vision Impaired o. Other:
h.
Voiding Prob.
21. PRE-FLIGHT VITALS
21a. DATE / TIME 21b.TEMP: 21c. PULSE 21e. BP 21d. RESP:
22.
BRIEF NARRATIVE
23.
ASSESSMENT / PROGRESS DATE / TIME NOTES
25. STAMP AND SIGNATURE OF FLIGHT SURGEON
MEDCOM - 4095
DOD 010574
1. REPORTING MTF .1:3LOCATION
ADMISSION AND CODING INFORMATION
7 (State or
1 r2
I 3 1 4
b)(3)-1 Country
Code.) For use of this form, see AR 40 -400: the proponent agency is OTSG
#,b)(6) -43. REGISTER NUMBER
NAME (Last, First, Middle Initial)
4. PAY GRADE 5. SEX
oFo
li
9 10 11 12
13 14 15 (b)(6)-4 (b)(6)-4
16 17 I 18 :
w Mt
6. DATE OF BIRTH (YYYYMMDC))
7. AGE AT ADMISSION 8. RACE 9. ETHNIC
RELIG ON
19 20 21 22 23 24 25 26 27 28 29 30
31 BACK -GROUND
\ c IIMNINI 1 11119ffliall
1
10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 1
MEI 37 38 39 40 41 42 43 44 j 45
1;))(6) -4
I I aIra
ORGANIZATION (Active Duty Only 13. MARITAL STATUS
HOUR OF BRANCH i CORPS ADMISSION
46
2--(67)
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49
El 51 la
53 54 55
56 57 58 59 60 61
memo
17. UNIT LOCATION (State or 18. MOS
19. TRAUMA
PREY. ADMISSION
Country Code)
62 63 64
65 66 67 68 69 70 71 YEAR
.....47/.....7.
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION
ADDRESS OF EMERGENCY ADDRESSEE
(Include ZIP Code)
10,01/
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
86TH CSH LSA ADDER, IRAQ
21. TYPE OF DISPOSITION
22.
MTF TRANSFERRED TO
23.
DATE OF DISPOSITION (YYYYMMOD1
73 74 , ric,„_s 75 76 77 78 79 80 83 84 85 .! I
1-L'i 88
I) 11.411101 0 0 3' 0
24. CLINIC SVC -ADMITTING
25.
MTF TRANSFERRED FROM
26.
DATE THIS ADMISSION 11, Y YYMMDD)
89
90 91 92 93 94 95 96 In 99 100 101 1021.¦ 105 1 106 :
Si11 MSil. a a o IIINff 1(9
27. LOCATION OF OCCURRENCE
28.
MTF OF INITIAL ADMI SION
29.
DATE INITIAL ADMISSION IY Y Y 1'MMDD)
(Battle Casualty Only)
107 108 .
109 110 111 11 113 114 115 116 117 118 119
120 121 1 122
1
FOR LOCAL USE DX : re)/ b I
i Aukivi„.A.
XIV 1._ ThiVil „
)
Fq#0 , 0 ---• Z, - l) ?ff3e,54
Cry- (./,100
-la Eq ,b5e1
Pr; 7(t)
ADMITTING OFFICER (Signature, as required)
SIC;NAIJRF (1r AnnArrplidh.1.1Lor,e
;b)(6)-2 b)(6) -2
,
¦
111 FfirtIVI 9c15:/M lump •Irinn
-
AR 89 IS OBSOLETE
USAPA VI 00
MEDCOM - 4096
DOD 010575
ats :4-1 4-6 • -. • . .. -.INPATIENT TREATMENT RECORD C. :SHEET For use of this form, see AR 40-400; the proponent agency is OTSG
REGISTER NUMBER 2 13)(6)-4 GRADE ADMISSION REMARKS
1 15. :-. LA 1 b. FLYING STATUS A(L I b. RACE CCA b)(6)-4 16. RATING/ DSG 7 . 17. RELIGION DEPT.! BEN 8. 18. LENGTH OF SVC '" GANIZATION BRANCH/CORPS 9, 19. ETS UIC/ZIP .. . 10. 14. 20. PREVIOUS ADMISSION WARD TYPE CASE
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF' . , ADMISSION 23. )CLINIC SERVI E
2 ,1 . 27a. A 1 V NAME/RELATIONSHIP OF EMER ..". C ADDRESSEE ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Coda) 25. 276. 0, i)0 TYP DIS OSITION . A. TE EPHONE NO, 26. 28. DATE OF DISPOSITION DATE OF THIS ADMISSION ADMITTING OFFICER
29 NAME AND LOCATION OF MR-At-AL TRFATMFNT FACII !TY I 30. DATE OF INTI ADMISSION 32. UNITS OF WHOLE BLOOD COMPONENT TRANSFUSED
31. SELECTED ADMINISTRATIVE DATA
33. CAUSE OF INJURY F-7 Check II Cominued oil Iritmw;L:
34. DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES b K-4
CODE:
35. a. Total Days This Facility ABSENT SICK DAYS b. OTHER DAYS C. ' CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS 0. BED DAYS I. TOTAL SICK DAYS
36. a. Total Days All Facilites ABSENT SICK DAYS b. OTHER DAYS C. CONY LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS 1t. TOTAL SICK DAYS
SIGNATURE OF ATTENDING,MEDICAL OFFICER X :6)(6)-2 DA FORM 3.7 SIGNATURE OF PAD OR MERICAL RECORDS OFFICER EDITION OF 1 Al _L. . USAPPC V '. :i...
MEDCOM -4622
DOD 011101
.(PATIENT TREATMENT RECORD CO ' SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
1.
REGISTER NUMBER NAMF II ant Firnt Mn
2.
3. GRADE ADMISSION REMARKS
I.b)(13)-4 .6)(6)-4
4. SEX 5. AGE 6. RACE 7
10. PREVIOUS ADMISSION
arD
11. kNIZATION 14. WARD
b)(8)-4
15. FLYING 16. RATING/ 17. DEPT./ 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE
STATUS DSG BEN
_. .
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23 CLINIC SERVICE
ADMISSION
..,----
L 3-_, P--
t e
24. NAME/RELATIONSH IP O F EMERGENC ADDRESSEE 25. TYP DISPOSITION 26. DATE OF DISPOSITION
a,
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
27b. TE EPHONE NO. 28. DATE OF THIS ADMITTING OFFICER ADMISSION
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30. DATE OF INTI 32. UNITS OF WHOLE BLOOD/
86th Combat Support Hospital, LSA Adder, Iraq ADMISSION COMPONENT TRANSFUSED
31. SELECTED ADMINISTRATIVE DATA
I I Check if Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
Of
.....g:41.--.."
,...•
0.75
CODE:
95
35. Total Days This Facility 0(05(
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d.
SUPPLEMENTAL e. BED DAYS I. TOTAL SICK YSCARE DAYS CARE DAYS
,'-4
1 1....°.
36. Total Days All Facilites
a . ABSENT SICK DAYS b. OTHER DAYS c.
CONY. LV/COOP d. SUPPLEMENTAL e. BED DAYS f.
TOTAL SICK DAYSCARE DAYS CARE DAYS
pb biZej-2
DA FORM lAZI-7 MAY 7Q
M-2 I EDITION OF 1 Al
( IRA pot" VI to
MEDCOM - 4623
DOD 011102
AUTNORVED FOR LOCAL REPRODUCTIOI
MEDICAL RECORD PROGRESS NOTES
DATE NOTE iN4, r,k fi--4 ",. c f c. f /--/-f9 .1 /l/k a .0 '`'1 r v-0 1 1 ,-... 4" r' )4A- /--((a '4.• • / r7 (..._, 0 ,.., —. r t-v,
V a" f< Gam, 1L 0 0 fr.-4-a , a., : I 6"7 Y fiK , C-fr, • "i" ( I ' .4.. C. J
--/-/) 0 ,I Ierl.'Ln . f LA.)
C./1.2 G
l ._....
_- -.
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A9 031210d38 3aniyNois s.tivulsimd
ON '01 . 9Y1 3/Y0 Ow
asocis 0.000 a d. 31'v0 — ON OBVM —
A1111DY1 ONILY391--N011YD11111,001 IN311fd
(A)!DadS) B3H10 .
iviS
dY) . NI3A .
rndf/e/p
d0'321d . nanos N3WI)3dS
(6)(6)-4
WOO D dN . . Avaoi
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mina .
rt 9WV . MD .
0
SIIIVIS 114311Vd 101439B11
A90101VIN3H
ON 1dd 9V11N3W1)3dS SPECIMEN/LAB. RPT. NO.
I I
(6)(6)-4
CHEM I
URGENCY PATIENT STATUS
. BED . AMB
5ROUTINE OUTPATIENT .
TODAY .
. DOM
.
NP
.
PRE-OP
SPECIMEN SOURCE STAT .
.
BLOOD
.
OTHER (Specify)
Ewer in obove space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
REPORTED BY MD DAT LAB. ID. NO. (6)(6)-2
REQUESTING PHYS b)(6)-2
731
TECH
gaitir )5
REMARKS
j
to 0
Las z .
S
0 1=-
4 O
0 re
F4-0 2 U
4.a
S
r-
MEDCOM - 4639
DOD 011118
, t
z;
NAME:
SURGEON: ANESTHESIA PREOPERATIVE EVALUATION
PROPOSED
OPERATION PREVIOUS ANESTHESIA! OPERATIONS 0 NEGATIVE
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS
0 NEGATIVE
AIRWAY / TEETH 'HEAD & NECK
SYSTEM
RESPIRATORY
Asthma Bronchitis
Dyspnea Pneumonia
Recent cold SOB
CARDIOVASCULAR Angina Arrhythmia Exercise Tolerance Hypertension Murmur MVP Rheumatic lever
HEPATO/GASTROINTESTINAL Bowel obstruction Cirrhosis Hiatal Hernia Jaundice Rallux/Heanburn Ulcers
NEURO/MUSCULOSKELETAL
Arthritis Back problems DJD Headaches Neuromuscular disease Paralysis Syncope Seizures
Weakness
RENAUENDOCRINE Diabetes Renal failurelDialysis Urinary retention • Urinary !reel infection
OTHER Anemia Bleeding tendencies Pregnancy Sickle cell trail
PROBLEM LIST / DIAGNOSES
.
COPD Productive Cough Tuberculosis WN Q Tobacco Use:
CHF MI Pacemaker Hepatitis NEV ¦ Ethanol Use : 111
CVA/Slroke Loss of consciousness Paresthesia TIAs
Thyroid dl Weight loss/gain
Hemophilia Transfusion history
• . •
COUNSELING STATEMENT
Anesthesia alternatives, benefits and risks from minor to
death explained. All questions answered.
Patient I legal guardian voices understanding and gives
consent for :
Local I MAC, SAB, Epidural, IVR, General Anes. Other: • Appropriate alternative as backup. NPO status explained.
PATIENTS SIGNATURE DATE
FVAI tiAVIRIS) SIGNATURE
t)(6)-2
CRNA/ DATE /0,44/ j• c73
/i/r9Trx,v4-7 •,..,.
DATEPHYSICIAN
Planned Surgery Date:
AGE HEIGHT WEIGHT
F
PREOPERATIVE B /P VITAL SIGNS:
CURRENT MEDICATIONS
0 NONE
r.
ALLERGIES NKDA
COMMENTS PERTINENT STUDY RESULTS
No Yes ' , PackMay for Years Chest X-ray Pulmonary Studies
EKG
No Yes Frequency LFTs
•
Urinalysis Thyroid FBS
Hgb / Hct / CBC Lyles
PREOPERATIVE MEDICATIONS ORDERED
ASA
4
5
E
POST ANESTHESIA VISITS
ANESTHESIA RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE. SO
STATE)
. .
•
DATE:
SIGNED: TIME:
MEDCOM - 4640
DOD 011119
(THIS FORM IS SUBJECT TO THE PRIVAC I - AS A CLINICAL RECORD FORM, IT IS COVERED BY DO 22C
ANES. START IN OR ANES. END
1. DATEPage I of •1 _.,.., (....
ANESTHESIA RECORD /1 Z/90 .,9 3,/y ) 0 fv44 Y 0 1 TOTS SURG START DRESSING
OPERATION SURGEON(S) 1,0)-2 OR NO
PERFORMED .0 4: a' .6 .6i. 4. -1-/3 Li-re 2/i715-2/ 5-c -7.3 3 b -L—
TOTAi
PREOPERATIVE 1
;2 IDENTIFIED ' ID BAND DOUESTIONING AAA-ad jive •) 7 dc
Z-)
CB CHART REVIEWED . NPO SINCE 4 ..5 - S
. PRE-OP MEDICATION: IIIIP y! r``l 4.: A • ,J 7. . - -;0° Drug Dose Route Time 2 1' i., AT: ,
o
Stale: AWAKE
f:aCALK, .0 SEDATE
O APPREHENSIVE UNRESPONSIVE
¦
. .11.2CUJmin A „
i
02 limn
MONITORS AND EQUIPMENT
1U. •
LA
aA
NNOENSINMVACB/HPINE If & EQUIP. CHECKED
M CPNS EsOoNpTH. EKsTGETH. V LEAD EKE PRECORD STETH.
PULE OXMET ER 02.ANALYZER
S I
END TIDAL CO2 MASS SPEC .
Urine EBL
•
Q .0z —0ct
I I t
I
MIMilIMI MIMIIMIMI
III
SWAB(
x
)
.
TEMPERATURE
.
WARMING BLANKET . FLUID WAR EKG
A
AIRWAY HUMIDIFIER
N 1 G TUBE
% 02 Inspired pry ,<4.1 /C4 M
KA iLA 4 02 Saturation r'(} `14 cj /0 0
/CD
,,_
0 0 /G TUBE ANEsn-
@ iX )00 44
'V] iv(s)
2.4.,
LFA
End Tidal CO2
Temperature
ARTERIAL LINE
CENTRAL LINE
SWAN-GANZ
.
FOLEY INSERTED: . O.R. . FLOOR
.
EYE CARE
OPERA
PNS
V
A
6/P C
PRES:
'' 'PRESSURE POINTS CHECKEO / PADDED
1
,
.
..
T
,3'' $ Rv Coca. ..5y,
.
1t3'TIME
V ,_ f 0
ARTEI LIN
ANESTHETIC TECHNIQUE
PRE-OP 200
PRESS
VALUES
i__i GENERAL GI LOCAL / MAC
0
•
PIA:
REGIONAL . NERVE BL OCK 180
160
/Di /5 4.-C Vora
El / P
140 . To—v ,d1 OUS R
> — .4 J (+I —ZN
INDUCTION
. PREOXYGENATION . INHALATION
%./
(-1‘
120 %. OW II
I
. RAPID SEQUENCE . INTRAMUSCULAR
P
ASSTS 100 RE
. INTRAVENOUS . RECTAL
I
.
. 4 Ail A
80 r-•
03
CONTE
A
RE:
—
R
AIRWAY MANAGEMENT
AA itia A ,t
ORAL 8 NASAL
8 DIRECT VISION INTUBATION
BLIND AWAKE ' -
'
SAT
ED
STYLET USEFIBER OPTIC 40
'
. ATTEMPTS, . . BLADE 1
. ETTSIZE DOUBLE LUMEN
.1 TOURN
20
STRAIGHT RAE 0 ANODE
¦ .. 1--,'
111H
CUFFED ML AIR INJECTED
F
. UNCUFFED, LEAKS AT CM H2O
ETT SECURED AT CM
BREATH SOUNDS
AIRWAY . ORAL NASAL .NATURAL
MASK CASE • VIA TRACHEOSTOMY NASAL CANNULA SIMPLE 02 MASK
LMA SIZE
IIX US CO O.
Tidal Volume
Resp Rate Peak Pressure
Symbols (or Remarks 5 ti 5 Ni 5 v 5 , S / 5 1 .5N1 1V E
•
CRYS
,7 C., 00 / A...4,f a
(• ip b.d
LOrD i
-
Position BLO
0_4 --- .- .
RECOVERY REMARKS : Patient reevaluated. No change from preop plan / evaluation.
TIME IN PACU CONDITION Significant changes from prdop plan I evaluation.
t2.3 '4/ C') -<1;*/C.
B/P / PULSE RESP 02 SAT
)0. ? 5— /G; /e) 0
REMARKS TEMP
Tourniquel Time:
REPORT TO PARRS:
IN FLUIDS TOTALS OUT b)(6)-2 b)(6)-2 PATIENT'S IDENTIFICATION
cry5talioid• d00 ER /0 L•7 (b)(6)-4
Urine Gastric Imp: ( ..- ,...v..?<7 .............— --...
Blood
/ MEDCOM - 4641
DOD 011120
Iv me ”KiVAGY ACT OF 1974 •
N tSTHESIA-RfCORD As A CLINICAL RECORD FORK IT IS COVERED BY DO 22(
PERATio,
S. 41. ORME°
• 1
- • PERATiVE
:U.NTIFIED 010 BAND
. QUESTIONING
(II ). r (3 :oral
IHART REVIEWED
NPO SINCE PRE .OP MEDICATION '
klle.LZZ2all.N.IIIIIIMMIMHMIIIIIIIMNMIIMIIIMIMMIMI 31"--?--
,- t-----.._571111B11111111111111011111111111
0, "g Dose Route NINNWIININIIINIIIIININNININI
Time
A i-- • ' id.% WANNrll:iD7NNIONMINIIMIIIIIIIIINIOMMNIINIININNIIMNINNINI ,__..-aVLILLINIMMINIWG30/MIMMIIMMIIMMIIIMMININIIIIIMMIOMMIIMI
' .•., ..lifl ,-
•
aNliNINIMIIIIMINIMMIMMIIIIIMINIIIIIIIININNIONIIN
Ariitairjelnral/MMEMEnin C ..../..Atisinotic State ...,;1291912&11111111MINI 111111 MIMMIUMMINNI — 7-
AWAKE
MMIIIMMialralriNINNINMININININ -k
CALM
. SEDATE
MIIIMMIMONMOMMIIIIIIIIIMINMINIIIIIN
APPREHENSIVE
. INNOMNIIIIIMNIM
UNRESPONSIVE
INMIIIIIIINIMIN
N20 Urnin 111.1M111.11011=
ME 1.111 111112 ME 11 ................9,
MONITORS AND EQUIPMENT
°2 Lim'a NIMOMMIIIINNIINIIIMO
F SCEMMERIVA3=1:241MLIIMIA=PIIRIMMIIIIIIIIIMIIIIN
S MACHINE
EQUIP. CHECKED MMOIMIIIIMMIMMIIIMI
0-.N.INV B/P PNS L PAMINIMININIIIIIMIIIIMINI
ONT EKG U
v LEAD EKG
IIMIIIIIIII
SOPH STETH
1/
,MM 1-7.1:MINIIIIII
PRECORD STE TH.
Y .,Slie ¦
!LSE OXIMETER Urine
0? ANALYZER
MNseammilmmi
N0 TIDAL CO2
1111111111/11S111111
MASS SPEC. ESL
211111111111111111111•111111111111 1____ii
MP E RA TuRE
S 11111•11111111111111
1111111111111111•1=1
ARMING BLANKET
. FLUID WARMER MIN NM
FM AY HUMIDIFIER EKG INIIIIMIIINIMENIIIIM
sY-8c
1 UElk-_ % 02 Inspired
0 /C TUBE
,7-ZISSILIAKIIMIIIMISMIR41111111111111111111111111111111111 - ,
02 Saluralion
IMIEWINIMIllarillEMEN111111111111111111111111111111111111 1 ^
End Tidal CO2
• 0 1/43EIRDINCIIIMMEINTIMPTINIIIIIIIIIIIIIIIIIIIIIIIM
11111111=11011111111 A"" '
Temperature
LINE N 1111111111=1111111
UNE
111111111111111111111111 Mow
T PNS
•GANZ 11111111.1111111111111. ®
0 OP Tp,,
,Et INSERTED
OR 9 FLOOR
E CAPE
IIIIIIII ; i X
S '
E suti
POW TS CHECKED / PAODED
mormo. lc '
ANESTHETIC TECHNIQUE__
.. PRE-OP :ERAL
Ert-—VALUES 200
TIME 1111111111111111¦¦11111111¦1111111111111111111111•1111111111111 ¦1111111111 1 An EP
.0CAL MIPP
.
NERVE BL.CK
11111111111111111111¦¦¦NIMMINI¦¦NNI1111111111111111111111111111111101 1 pnEL 's's!
ummumumumummanummun
18° muummummnnumummummunu..1p
".:
160
IIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII L. 1
INDUCTION
T 111MYAtthillINIF,AIAMNINIINNINNINIIIIIIIIIININNIMININIMININ
OXYGENATION 0 INHALATION
I( 14° m¦mstuccenriri m ¦onimmummium i °u"9
!;EOUENCE
. A 1131111 ¦11 ¦111111 ¦11111111141CANUAIIIIII¦ INNININNIN1111111 1 SPC
INTRAMUSCULAR
;AVENOVS
. RECTAL ri
120 muummum mumunnuommumom
1 4-
100
111111111111111111111111111111111111111111111111111111111111111111111111111KIIIIIMIN .1I .:Is
12111111/1111411111112111111111111111111111111111111111111111111111MMIN .11 .1 .6'
AIRWAY MANAGEMENT G
N " IIWVA!!IIIEtitltNlr,%lbMflli1!IPIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
RATION
B nllIllKILlnllillLIMIEYANk'diCakIIIIIIMIMIIIIIMIIIIIIIIIIIII r : X
NASAL S
C vIS.ON
ORAL till1111011111111111111111111111111111111111111 IIIIIIIIIIII•IIIIIIIIIIIUII , 0„,,,
B LIND
AWAKE
oirric
STYLET USED
EIP TS 6
_ BLADE 40
11111111111111111111111111111111MIL RE 5
51ZE
8DOUBLE LUMEN
•IGHT RAE . ANODE 20
ED
ML AIR INJECTED'FP ED. LEAKS AT H rH
11111111111111111111111111111111111
CM H2O
iECUREO AT 1111111111111111MINNIMININININMININ 1 'cuRT
Tidal Volume
TI NININININININIMMININ N'
•TH SOUNDS
E Resp Rate
A'T CM R MIIMICVIIIMAINENKNLIIIMIONININomm•
IN
. ORAL
F
NASAL S
. .NATURAL Peak Pressure
IMIIIECIMIIM91111611111111111111111111111111111111011NM CRYS
CASE CHEOSTOMY P
L CANNULA
LOIO r
SIMPLE 02 MASK
Symbols for
Remarks
; 1 0E (-Ai ID t.
1111111111.11i11ii
11111111
• • sition
limmimasimmillii E
8ic
RECOVERY REMARKS: 0
Patient reevaluated.
No change from preop plan / evaluation.
'ACU
CONDITION 0
Significanl changes from preop plan/ eyaluallon.
0. 1)
P I R EJSy
(5%-rt-fr
TO
PARRS:
b)(8)-2
•F DS TOTALS Tourniqvei Time
OUT
•• pa'
EBL _ PATIENTS IDENTiF (66., Urine b)(6)-4
3a,
6
S
PHYSICIAN
pfiNAZ),•
bl
Sr
-.1.01•1••••••••¦••••••••¦••••••••••
¦••••••••••••••••.- "NM
MEDCOM - 4642
DOD 011121
srANDA Ress
, "L)
Presc,bed ,140 FORm s Pin Pxo4 GSVICAR ,
f3(4 7 CFR)2r, ' 17?)
509.1,1 1'45 sos
519-301
FlArapwaic.cgmputTATOkftEM1EST REPORT
(Radio/ogYAWicicar titedkiiiiAlltrateglii0/0101#10 Tomography Eiaininations,)
EXAMINATION(S) 'REQUESTED
40•E -4ttl :(SPonsor) WARD/CLINIC REGISTER NO.
)4.f LC4-I ['9
FILM NO.
PREGNANT YES NO
;b)(6)-4
REQIKESTED BY (Pri TELEPHONE/PAGE NO. SIGNATURE OF REQ
b)(8)-2
&ATE REDUE.STEL.:— SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
ck fLftcir --c1/4
DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year)
DATE OF TRANSCRIPTION (Month, : yr;:
0C).
RADIOLOGIC REPORT
rx b/a c readiAs kJ/
00
-
(Ape rl y r /vIo 5 Co tycive-'1' f ttio-
TT
7‘-c-. e. 0 7'
e/GOIra/21? (4 S
PATIENT'S IDENTIFICATION' (For typedName — kart, first, middle, Medical Facility) oe written entries live: LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC FACILITY
MEDCOM - 4643
DOD 011122
-
"" • !!.., VS
• .atkitix
Etit's
8151 S^GNA
L./R E
SIGNED
For usTaiirmr:
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. in the column provided. Orders completed during the shift in wnici ,
list the time the new order(s) are noted and initial-
. .
require recopying. They may be signed on, as completed, in me Tar rigm column.
ORDER NOTED COMPLETED ORDER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER QS SET OF ORDERS
NUMBER TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS 1 OXYGEN: litres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air. 2 IVF: LK,— CO /DO cc/hr, helits-cc x 3 MORPHINE: ,2-1-.1 mg IV q 5-10 minutes PRN pain. MAX dose of / -1---mg 4 DEMEROL: ,2 s-----.0 mg IV q 5-10 minutes PRN pain. MAX dose of /42) mg
5 ZOFRAN: Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 DROPERIDOL: 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1 7 REGLAN: Give 10 mg IV PRN nausea X 1 8 Release from "PACU" when Aldrete score is or greater 9 Call Anesthesia for any questions or concerns
• h--sed 2 / /7-7 -.2 .//dh,..-.. /2"7.01v 44.e. ./.1,14',,
1
O (b)(8}2
,-
SIGNED
"472//i/414A
,
.
PATIENT IDENTIFICATION :b)(6)-4 Complete the following information on page 1 on y. Note any changes on subsequent pages. Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page N,"
MEDCOM -4644
DOD 011123
31v
. -.,„.
P we Mit -' ,,,,,,,,,q, c„ , ,,1, ,, . , ,,....6 --'14 , . -r) 0.Zxg•rd Vim
F, ! t., a: 4q,;-, -•,,, z ,
--•,-7-1.9.44.,
''''
' 1f41- REDO' ,
'''''0 '; 606teiki :i$tiOstlik'
For;use of'_ tlfiq4:9Firi'iiiii Er014::00440'iOc.:.,
DIRECTIONS: The provider wilt DATE, TIME
and SIGN each order*
list the time set iftitide4'r:a4drcliid ,1Q91* . e'riir order ta :0(404 aer:Iiiiri,:l ¦Wfsing: will
the new order(s) are noted and initial, in the column
PreVided:;:oritare -CoMPlatect du4ntilite inIff*
require recopying. -WhiCh:tileiWere;wiitten do not
They may be signed off, as completed, in the
far right eOltinn:
ORDER
ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS --. TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS
1 OXYGEN:
litres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air.
2 IVF: /a()
Z-2 @ cc/hr, bows----cnt I
3 MORPHINE: ,2— LI mg IV q 5-10 minutes PRN pain. MAX dose of .2 b mg
4 DEMEROL: 15-0 mg IV q 5-10 minutes PRN pain. MAX dose of /0") mg
5 ZOFRAN: Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 DROPERIDOL: 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
7 REGLAN: Give 10 mg IV PRN nausea X 1
8
Release from "PACU" when Aldrete score is
or greater
9 Call Anesthesia for any questions or concerns
Kw./ c.: ,,,,, v,,,,,
41-7 .)--
/7 Af' , /7?-174^1 ---l inl 4A—,
.b)(6)-2
SIGNS
vy) — C/AriA,
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any
changes on subsequent pages.
!b)(6)-4 Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page tk.
MEDCOM FORM ARS:2_1, rrce•ri r....1,.,, a • Am. ...._ MEDCOM - 4645
DOD 011124
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5 DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order Is allowed per line. Nursing
list
will
the time the new order(s) are rioted and initial In the column provided. Orders completed during the shift in which they were written do not
require recopying. They may be signed off, as completed, in the far right column.
ORDER
NUMBER
DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
POST ANESTHESIA CARE UNIT ORDERS
j) OXYGEN: )--(11 litres via Mask /Prongs to maintain 02 Sats greater than 94%; Wean to room air.
IVF: @ C3-'c7 cc/hr, bolus cc x 1 MORPHINE: )- S
mg IV q 5-10 minutes PRN pain. MAX dose of
3 omg
DEMEROL: C
mg IV q 5-10 minutes PRN pain. MAX dose of
g
ZOFRAN: Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
DROPERIDOL: 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1 REGLAN: Give 10 mg IV PRN nausea X I Release from "PACU" when Aldrete score is
or greater Call Anesthesia for any questions or concerns
ORDER NOTED
COMPLETED TIME & INITIALS TIME & INITIALS
PATIENT IDENTIFICATION
b)(6)-4 Complete the following information on page 1 Only Note anychanges on subsequent pages.
Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Unit
Room No.
Bed No, Page Nf
I
MEDCOM_ 4646
-
mEonnivi PrIDRA con rs _
DOD 011125
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed nor line. Nursi;:.; , `me the new orderls) are noted and initial in the column provided. Orders completed during the shift in whic;h they :„, ;;;,oyii -,.;" They may he signed off, as completed, in the far right column.
• ORDER NO I'ED COM:1.1 1 1. 1'Y , T , MC. & S!GNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & L1ML
POST ANESTHESIA CARE UNIT ORDERS'
3 litres via Mask /Prongs to maintain 02 Sats greater than 94%;
wean to room mr.
1VF: cc/hr, bolus --- cc x 1
MORPHINE: mg IV q 5-10 minutes PRN pain. MAX dose of /Ging
DINFROL: mg IV q 5-10 minutes PRN pain. MAX dose of ring
:i;01s:PAN• Oi,c4 mg IV PRN nausea. May repeat after 10 minutes X I
0R0PERIDO1 • 0.625 mX ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
Giv.e. 10 mg IV PRN nausea X I
Relea:,e from "PACU" when Aldrete score is or greater
lin. any que:irions or Concerns
t..{.(4Liqa=v /IAA/ 1747,-//7.4:67,2-ext7(C"'"--4°
,
1' 4...Ili:NT IDENTIFICATION
Complete the following information on eago 1 only t‘.1f;:.! zt%,
changes on subsequent pages.
Diagnosis:
Height: Weight: _ Piot:
Allergies:
Nursing Unit Boom No. am w.
i .•,'IEDCOM FORM 688-R (TEST) (MCHO) M.
MEDCOM - 4647 RE OBSOLETE
DOD 011126
. 7 •.-9•IRO pi:4qm
AC
a. 3 iitcROP'
'DOPTQ RI it RS
0.0t0
EM fs ;994,14170,k, A"T o . , pecOppenta§ericy is OTSG
.E *pm- EAvO.
NUMBER: SE OF ciFiriEFik. IF
IENT IDENTIFICATION IN COLUMN INDICATED BY ARROW BELOW.
PROBLEM ORIENTED MEDICAL RECORD..
(b)(6)-4
ISING UNIT
I ENT IDENTIFICATION
ISING UNIT
1EN T IDENTIFICATION
ISING UNIT
IENT IDENTIFICATION
ROOM
NO.
REPLACES EDITION OF 1 J 77„ WHICH MAY BE USED
U.S: GOVERNMENT-PRINTING OFFICE: I984-383-710
("ti.
....-..¦
,.....c
:"+, ....4.,
• ,.....,,N
.,...s.
MEDCOM - 4648
DOD 011127
X
THE 1.10Crt.)R SHALL
DA +
SYSTEM LS USED, WRITE PROBLEM A4it5 SIGNEAcii SEThlr-oRDERS. IF • JLEM ORIENTED MEDicAl HE,;011(.)IN COLUMN INDICATED BY ARROW
BE LOW.
!ENT 11.)11FICATION
DATE OF ORDER
TIME OF O90ER • LIST TIME b)(6)-4 I ORDER
I
NOTED AN()
_
HOURS
N
ODAA. 7 20 ,Dr fi
/0 t
I
liZ
J... 74
.NGUNI L ROOM NO (eFt.
3E DO.
itz.= -
;DENT O .-ICA -HON
DA TE ORDER
TIME OF ORDER
11/144 7
z ocrl
1 .101.1 1-15 ;
r f (
4'ti V V 2-
X .1
/ .1 2-4. ••¦ kfr_
DATE
TIME OF CMDE. b)(8)-2
•
A I 4"‘ P1. 1 c 1
I ROOM NO.
BED N-6.
t• i i()r
DA TE
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HRS ILIV5 IRATE
HRS I cA . :5,dc(2 .26-p
DRESSINGS: LOCATIONS L L TOTAL
.9R
STATUS:
cp )
STATUS:
I
ti4
! REMA RKS /AS NUMBERED) AND PERTINENT PATIENT PROGRESS NOTES •
ENDOTRACHEAL TUBE -ORAL OR NASAL
.
Ercra-MER-acrarraby---
0 YES
J2 NO • , 0 YES
I NO
AIRWAY AMU! SIMS IL` Fan)
CLEAR c-,)-PLAST STATUS: Neuro: A
Of 3 (28y5 uon r1-N=6
AIRWAY
0 OBSTRUCTS EASILY
Pain Action: fit ' Lola eooT.Tb (me-
POST•ANESTHESIA RECOVERY SCORE
:515?
IALDRETE SCORE) A 0 . PftrieNIT
Mom to move 4 extremist volt/nu/11y
otter: ggs. 444 4 LA-)M2-M e(.14100.0-A PIC/C?).
Or on Camino Ad
Able to move 3 antrarnit a voluntarily
Cl on command IDONTD ON REVERSE)
I . Amity
Able to move 0 ganarnings valuntindy
NAUSEA ANO VOMITING: NO
0 YES I 2 3 4 5 5 TIMES
Able mono Dreamt and canon Imlay
Cl an command
2
CAUDAL. SPINAL. OR EPIDURAL BLOCKDirumva or limited breathing
A
1 Row. an ! ' / MOVEMENT PRESENT AT
Almeic I MRS
0 SENSATION PRESENT AT HAS
BF420% of Pr tanintnetic Iona
2 •
.10120-50% at onlanettuelic level
1 Circulation '
•Pt50% al or CONDITION ON TOW: 0 GOOD
lhunt lora) 0 0 FAIR 0 POOR 0 CRITICAL
1:414 atm. •
2 ill RECOVERY:
PATIENTS IDENTIFICATION:
Aroutable en canonic
Canteiouthest
Not /mending
0
Pink 0 COMPLICATED
Paw. dudte. biotelw, lauhdieed. other
1
C anent
UNEVENTFUL i -
TOTALS)
)(3)-1
SIGNATURE OF
RECEIVING AND
RELEASING
OFFICERS
MEDCOM -4592
DOD 011071
NAMMED11320=11AC I
HOUR'S) 15 45 15
45 IS .45 15 30 45
--I —L _L
TEMPS:
1111111111111111111111111EMMIZIESI
Spinal
7 -
. - EMU
ELIIIIMICIE11121111211111111111M1= I - -
110
EIG Rrythn
1111111111=11711/1111111i .ids T= rie 11
110 1211111111M1111111111111111111111111111111=
140 Milinfliant=11111111111EZIEVIIMMESE1111
EP +- art 120
V
1111=1111111111111211112=1111 4 METALICIPIA
EP A cuff 103
PuLse = .
EM11111111111111111111111111111111111011 MEL'
11111111111121111111
% Sat:
EIRESEINEMIIIIKEILIZIMEN1111111 t
I
RATE
I I I
•
NUNS RS I
,_ FOR RE ARKS
•
MEDICATIONS
•v,
DRUG
TIME DOSE POLITE bX8)-2
1505 e.fit We u( ANTE ti E
•
FtlinanrY: (ID IA h
CV: Atf14----EiC Rhythn:
11:FA /11 1-F A 6-
SthAlairl: Lt-t" ' Drairege Y Warm Yes/6j
al:,
611.or of: urire:
D-e to void: Instnrticre/IntervEnticre . in PPCA:
'b)(8)-2
Report called to: ( e
luktil to:
By:
MEDCOM -4593
DOD 011072
LINICAL RECORD ABBREVIATED MEDICAL R
(Sign all notes)
: 570-0 arrived on board USNS Comfort TIeGnfEGORY mmediate. pm. ens)
Boat Pier Other AMBULATORY HEIGHT (ft' in"): Weight (lbs): rORY:
ERGIES:
1RENT MEDS:
'ST ILLNESSES:
IT MEAL: (Date) (Time)
.nts Preceding Injury: • a 0
AL SIGNS TIME TEMP PULSE B/P RESP RATE
MISSION
CHARGE I
pits: :Ask arm) . OR 113447P sluggish / • ed (Circle ore)• • luggish / fixedreactive / •• • 121
WRMS
Away Obsduclim Dy“ Ei No
b/H
Breath Sounds
$-) sztes/BUN/Glue
'Hanicahage
ABG
Lacandion
Pundsme
GCS
units
Wound
43:1'00.1, e 4440165
Trams, Amputation
Conansion
XRAY
Fract=ra
C-spine
Ciskscalion
CXR
Sum
Abdominal
Er?e.Aof
AGNOSIS:
Fcrpto,r
Penvveri I V Crop\ A
4
b)(8)-2
Continue on reverse side
)ATIENTS IDENTIFICATION (For typed or written erdnes give: Name—last. first, grade: REGISTER NO. al locally)
MEDCOM - 4594
Delayed
Minimal
Expectant
Glasgow Coma Score (GCS)
A. Eye Opening Spontaneous To voice To pain None
B. Verbal Responses Oriented Confused Inappropriate words
Poin s
3
4
1
(Total "A")
4 •
3
Incomprehensible words 2
None
Total "B-
C. Motor Responses
Obeys command
Localize pain 5
Withdraw (pain) 4
Flexion (pain) 3
Extension (pain) 2
None
Total -C-
• ousness (LOC) mkt* ono)
-Alert . - Responds to Vocal Stimuli P - Responds to Painful Stimuli
U - Unresponsiveness
ARO NO:
ABBREVIATED MEDICAL RECi S TANDAEZZIaLL3 9
DOD 011073
NICMC 612CV179 (Doc-nD)
: Pre / Post-anesthetic Summar).
Age Weight Height ASA Status Allergies (kg) (in)
22 -70 (go 2 3 4 5 E
Chemistries
Jiematology Coags Urinalysis / HCO
NPO—
H / H pr Teeth —
Platelets -Airway — MP I / II / / IV
WBCs -FROM. FB 0, FB HM Respiratory
CNS / Skeletal Pik!
Cough:
HTN: Seizure: Hepatic:
Sputum:
CAD: CVA
Renal:Asthma:
Ml: LOC: Qt:
•COPIDi
CHF: Nairn: Endo:
Recent URI:
VHD: Muscle: Herne:
TS: Arrythmias: Skeletal: Exercise Tolerance: EtOH:Lung Ex
-"
Cardiac Exam:
CXR: ECG: Tobacco:
Previktts Anesthetics:
Current Medications: Preinediapion: -+4-10e— e
-2-X441r,0"' a „5/4 .
Z1
A
• .0-virKt /q97 /CV vv¦-c)
e_ 7,1p 54:z 4r...ivy,
ty )1•A
Family
57? AvA 1/11.45, Pre-op i3P.:1110 Pre I*: IS Resp: 1-0 Tenn): 7- DOS RevieWed / patient-exantine.d ' . 'thetteOtsf options discuss -ed. with Patient ant qnestiOnsaits*ered -I•Panent /1guardian understands and accepts risksafter my. g4., Spiids
FUR: &-4 /. .6171
Evaluatig S piano* Staff MPACRNA signatureOb)(8)-2 :b)(13)-2 & Time
1CPR-
Patient identification b)(6)-2 Post-operative note .
0 No apparent anesthetic complications
I Signature MEDCOM - 4595 Date
DOD 011074
•
ANESTHESIA RECOR
..4til;11 Wt Ht (in) -
Pmc .gies
(b)(6)-2
Anesihrrialovi•i/CR. ignaiure Surgeon
11)(6)-2
(b)(6)-2
y
ORH
.1 /6
Date Ai.. sun See Pae
L
"—In Room Surg. Stan
ESIOCIIIMKPIA
20 03 Page --or One
Titre
7,30
t1.0-0
Checklist -
a0
El t.% Halo/ .°2 INNMHEIRIEOP4 . O. . Suction . Machine . Consent . NPO Monitors
ClIONMI=LUMENIMINE=./1111.
. Sa0, ¦ a • • ¦I:3 NBP L / R 1111
STP / Prop. / Domidate
.
EtCO3,, 0 PCS / •d PNS
.
PIP . Te Sue / Cistraeurittin Mass Spec ¦ cabal .
.. Fluid warmer Ro / Rapa / Yr cmonium CI Air 0 Foley . FHT .11
Pulm Art cath
111 •
' U./.$C/F• LIR 0 s
ii
Lidocaine G L / R
. A_-Line Rad
Nemilimine/Plyco
PositiOnr
Ephedrine / pima
Supine
Os ilthotoritY Sitting
Widazolars L / R
Drawn__ Used.
MSO, . Remi / S4 /6:4tatyl Wasted Witas
d. Lido / Bupiv /Ropy Drawn Used 11 Wasted 'Wiens
.IV -Ga L / R Ha Wrist FM AC El
Tourniquet _mmHg Tithes 1 .
601 90 /120 /130 /140 /150
Sur co Antibiotics
as
IMO MI
mom 'Is5.1f7C Total Agem -
0'0 NS mum ;2A4
itotal
6-8 MINIPIPF3 WA= 0•••••sw••••inniVi== =Irm¦•••¦ ••¦•¦•¦ =Mr 111g
it ammomma
Total over
Mintites
Total
• = ulse
180
0 = Spout. Reap.
0 = Ant. Reap.:
160
Ito
X =MAP
ta..VermliuM
A/V=Pnrip
•140 1
psi
. / T ..A.T.arie. •
I
111111 II
120
E Eaten=
120 IIIMINIM81113111111111110711111/M1111111111111M
'A CU / ICU 100
11111111111 11111M7111111111111111111111=111111111!
1 00
11111111111111111MIIIIMIEMI1111111111111 ill
IF •
1111111111111 11111111111101111111111111•111•111
80
ertm -
111 •111111111•11111111111111111111111111111111111•111111111611111MMI
tR •
CS 1/11111111/11111111111111111111111111111111111111111M11111
ia, •
11111111111111 1MINIIIIIIINIMMI11111111111
:omps - +
/ Np / At Ternp
:SS%
Tv
PIP (cinHi0
Rem. Rate
111111111M511=111111
Iduetion - hiciniiorS On
Preezygenated Smooth Inhalation /IV Cricoid Resume Rapid Sequence Mask ventilation easy Y / N
Indianian: –Mut/ Mil
Grade
view Tube Size Anemic Oral / Nasal L / R W/o w/ .Cuff Stylet Y / N
• Bil BS / EtCO3 z 3 / CIN
Tube ,caped
em 61 lips / teeth / Dares Trauma Y / N FOB /
DLT Fr L / R
maintenance. -
Smooth Cuff cheiked
bed anittation - Smooth
Reversed
Full T4 THErd•lift-ISustainedsetanus Suctioned
— • Awake / Deep
qsposition - PACU ./ ICU
Awake / sleepy Extubated / incubated. Regional Regional Comments / Drugs: . 0Sterile Technique . Spinal / Epidural
0 Catheter out -tip intact 0D' lekit . Touhy / Whitacm / Quincke . level Beiadine prep 1 3 5 , • It gunge
.
Lacalinfiltration Lines
.
Siuing El. Site • 1./ R • Seklinger Technique
-erect R / L
.
Attempts . CVP transduced
.
LOR to Air / NS
.
Gordis 9.5 / 8.5 Fr
.
Pareuhesia + /
.
RIC .
.
Herne + / -
Nerve Stith . CSF + / -' 0 2 / 3 • lumen
.
Trans•nerial '
.
Tca dose 13
.
Dual cull,. jaCSF 9 5,61
MEDCOM - 4596
DOD 011075
)64mC
A NESTHESIA RECoR Wt -t in - •
., - , -
'mdr c. vu
.0 f. )8-iue
sren
()2
O /
ZS eP
Mr j.., rs tn I lor uf in Ae.Ed Rsdn/RA •
---Oe e
7 1309 1 o
5 I05 1'3 15 ae
Tm oy
i L0 ) .,..• /:d
o l 5
— t,.-heds
11 1
M I
i e; ifrcin9:hn osn
p 4 an (9ppfe1--. Mntr
–i
tN
-------- Ya, aC dO NB i
F\ rn
BC,
T triae 79 0PS /E I PS . PP Tm als pc . Vra
E ;udwne
u r i am`Pk H umAt ct
aRp ecr 9
i IcP US/e / 0/GLRLcoan
-ieRd/FmL
unmn lo
Psdn-(3s onspde rs<9' Ehdie e
... rn ihtm itn aea /Mdoa 7 Rnc_ sdlWte
,Wlr e ._
AO%Rm u/ =f
0 's..
rw' g) Ue atd ,.A Ws tl
pd io/Bpv oi V-i I aLF ad'rs 0. 0 F
<tR ef
I oriutmH i=I I
610/10/10/10/15 rn-Smn nomd niitc
V .10-oa et-9MCPI N L(
--o- "^"
,-. o ra o 1
w
Ttloe i -sm
O
oa i
S --7 . r
•=Ple
Rp 8
D=p.
". 1 CD JC•\' J k k 0=As.Rs. k , rVCk 1 -, .tli
l=Vniti 10 10 t
X=!A
.
V IP10
10. A ,J
L -i
AI d 1 . 4z-m
I nuae 11
2
allt '
sr. . (V V
C IU to i . -. y1
N0
7 .. .
N J 4 .
le-IC
P alg . • 4
•0 . *
cu
i E
0 i s
.,
op N, ,.. ¦ AA EG 5..,._-.,g_ p... 1_--lz_—s,r_ -— -i — 5t -.t.e/k/A ap.--.-1..
., . 0 --36., 7--,0_4--46-
n;tr e —
e—9—9 -q— iD i
S0 , s a -
r ed td.- e 96 ih .-10—( -
) -o—3 3 -5—l 1—l -T 3 "
-
P D 7
V 5 O '5—15—cT "n-9 7a b()2
•
PP(m2)
71 -•• 10 - i --7, l --V A .- .1 -
4. 0%t''/1 ).
u. Rt
- I--1-_ .
-
nduetion ...
On oxyge ted Inhalation Cricoid Pressure Rapid nee Mask venqlation
ntubation. _,,,.... view Tu Size 3L,C2 Attempts (9/ Nasal L / R win Stylet &IN 3 / CN
To lips / el nares Trauma Y 10 FOB I LW / Blirid LMA # DLT Fr L/R 4aintenance -
ed E eil'e , / lubed
:xtubation -
Reve9g Full T4 / ea / Sustained tetanus Ciii/r4 wa / Deep
Regional
)isposition -/ICU SV 1"s OISP e / sleepy d / incubated P''E Regional Comments / Drugs:
. Sterile Technique LinCat.
Catheter out - tip intact Q Disposab 0
TSPory i/ Whitacre / Quincke . Level
'a lien t Ickbx614r
.
Betadine prep a 3 ¦ Needle page 0
.
Local infiltration . Sitt ldinger Technique
.
Site L / R aLateral R /
.
CVP manually transduced
0 Attempts . LOR to Air / • a 9.5 / 8.5 Fr
. Pars + / -Blocks . RIC .
me + / -0 Nerve Saim • . 2 / 3 - lumen
m 0 CSF + / -
0 Trans•arteriat
.
Test dose 0
.
Dual
JD CSF El swirl
MEDCOM - 4597
DOD 011076
.11OIMC
ANESTHESIA RECOR Jen. VA(kg) -AJ-1 Ht (in) -
9(11001 .
gies f\)1.C..-0, A
1(b)(6)-2 r
Procedure Anesthecio4nobelh Surgeon -
13)(8)-2
0(6)-2
OR II
T70
See Page
Date Anes. &an
KVA , Surg..End .0 Ants. End ••-•esident/SRNA
Page of
0
1 X0 r-Z-2 1.30-7) LI t 35 "2-'/ One
71--. 0 .1 I -so F-4 0 . 1 c
0, LIM !0 ,7
. -7-- 4 (I'
N,0 / Air UM
I / 10 (1. li'Suction 1:14. chine 0 consent it NPO
b 'GM Haln vo / Des Monitors -1:11416: ECG . .RO, 11-1# Illrr. STP Etomidate O, PCS /ES 0 PNS nip
".) Mass Spec Cil-verirai . TEE . Mild wanner
So....92istricurium i07)
0 Air Warm 0 Foley . FHT 0 Pulm Art emit
Ro / Rana1Cle em onium
OCVP LI/SC/Fero L/R 00G/NG L/R
Lidocaime
CI A-Line Rad /Fein L/ R
Ncostirrnine/ Glyeo
l',.-_:, - &-IP..— use points padded arts c 90°
‘frifrcerise/ Neo Supine Prone Lithotomy Sluing Lateral L / R
1... .11 Li 94asso1#01
Drawn/11 Used_ZQ_Wastedni
MSOd Rani /Su / aa
Drawn, C---Q1sed7- (wasted otZ, .Witns
Epid. Lido / Bopiv/ Remit,
IV -Ga L / R Rand Wrist FM AC EJ 0 Tourniquet ___rmaHg Times I' II_ 60 / 90 / 120 / 130 / 140 / 150 min - Surceons informed
. Antibiotics, Total Agent -NS 300 ... 416.b .... . I.Toul mg -Ilia U/
.....___ Total over minutesESL <, 62) ce__ Toed •
• = Pulse .
0 = Sports. Resp. 180 180
0 = Asst. Resp.
0 = Ventilator ISO • 160
X = MAP
A/V=N1BP 140
140
1 / T =A-Line
1 = Intubate12' I
120
E = Emanate AMIN IIIIIIRCITIM211¦111'
100 Ili,alrilli II
PACU / ICU 100 Pulse • Sys Bp i151Lw rgemi
1 \ 80 :21 ning
80 Temp - ilIPT6 60
RR - i 4 . 6n
ay 4 a il NWIFIMANIEIGNIIIIIIIII
Sa0, - ay 4o(lb
_ 40
Comps • ECG
JP 111 A g
Es/Np Or/ k / Aa I r . -
3 41
•
1 FI°' kJ .,I . io irk .
% Sa01
id.0 Al
EIC°' Lb . '; 9 Li.6, wo
.
TV
e? clj Z E)
PfP (cmH2O) ep .
00
Resp. Rate
q ci 1(.0 J4-/
Induction - Monitors 6f Prcoxygenat Srnoode Inhalation 'cold Pressure Rapid Maskve 'Mon e
Intubation - Mace R. Grade I
view Tube Size Attempts Nasal L / R w/o Stylet BillLirrgtC CIN
Tube taped @ cm @ tee / nares
yT /Trauma Y di) FOB / LW / Blind LMA # DLT Fr L / R
Maintenance -Smooth Off check Eyes lata • lubed
Eaubation
Rot everg VS's Fu T4 F14;71114/ustained tetanus----Suction Deep
Disposition / ICU SV sleepy ted / intubated Regional Rectorial Conunems / Drugs. . Sterile Technique .
Spinal / Epidural . Catheter out - tip intact
.
Dispooakte kit . T y / Whitacre / Quincke . Level
.
Betadine prep x 3 . Nee gouge
Patient Identification
10(8)-4 . Local infil akin . Sitting Lines
. Seldinger Technique
0. Site L / R . Lateral / L
.
CVP manually transduced
.
Attempts . LOR in NS
.
Gordis 9.5 / 8.5 Fr
.
Paresthesia / Blocks . SUC
.
Herne + / -
.
Nerve Sam mA
.
2 3 - lumen
CSF + / -
.
Trans•arterial
0 Test dose 9
.
Dual curl
CSF 63 swirl
MEDCOM - 4598
DOD 011077
NNW G320779 (t -4E)
Pre / Post-anesthetic Summ.
Proposed Operation
Age Weight Height ASA Status Allergies
(kg) (in)
—10 213 4 5 E-
( Chernistriel
kiematolozv
Coags Urinalysis / HCG NPO — fJ'fir+)
H/H- ?•12 /5,S PT-Teeth
Platelets -52AD INR -
WBCs -13. 5 — M II / III / IV
FROM, 0 FB HM
Respiratory.
CNS / Skeletal
Cough:
HTN:
Seizure:
Sputum:
CAD:
CVA:
Asthma:
MI:
LOC:
COPDi
CHF:
Neuro:
Recent URI:
VHD:
Muscle:
TB:
Arrythrnias:
Skeletal:
Exercise Tole
Lung Exam:
Cardiac Exam:
OCR: ECG:
PreviTus Anesthetics:
Current Medications:
Premedication:
PNA-/
'
69cJ°
Family Hx: EnpenfiralagEsmaa Vi Pre-op DOS Pay of Sureery BP: ti/r/
Gy . Chart Reviewed / patient examined ' • FIR: yea._ . Risks / benefits / options discusse • with patient
. Patient questions answered
Resp:
.
Patient / pareht / guardian understands and accepts risks
.
NPO after
Temp: liq., clears, solids Plan:
FHR:
Evaluator Signature Staff MD / CRNA sienanue
Date & Time
L. car,-
2 Ae.c.c...)_
(A
'at tent identification
Post-operative note
•.b)(13)-4
. No apparent anesthetic complications
Signature Date
MEDCOM - 4599
DOD 011078
ANTDEIICTITC: nia TIME GIVIEN:
c
)."7
rr NNMC 6320/16 (05/91)
OOH R:
RECOVERY ROOM RECORD
HAVIAED 6320/1111REV 11.771 SA D 1 05-L F- 20C.: 3281
10
• _ _ A
OPERATION PERFORM
-TALENTS AND TEH ICS OF ANESTHESIA .
/11.....
OXYGEN THERAPY
11 ROUTE ON OFF
4.
LE 1151111111
HOURISI 15 MASK
15 45 4
—1_ MEM
30 mortimi
TEMPS: 7.8AR
.pinal
EEL
VENTILAT. .
FLUID THERAPY
DC to 180
TYPE OTHER
:rrnitor 160 1081.004=
OPERATING ROOM 495
nn
RECOVERY ROOM
140 7311111
120 MUM
TOTAL
EP = art 100
BLOOD LOSS IN OR• e CC
WARD PRE-0P BP Hg
Erltaff
TUBES: El-Pef8-13-Pet•E
IV 1
Rd..% = . SO ec
OF AT VC) celisr pcw
-I-Gulf,
IV IN
°o Sat: T cc
RESP.
OF AT 1 cr./11. mq
RATE ' w
NUMBERS ART. LINE IN
FOR REMARKS
1
.", T•TUBES. HEMOVAC IN
ADMISSION URINARY OUTPUT
FROM MOR/SPEC. STUDY
MADAM
TO WARD
TIME
DATE t1"?3-130? HRS 4-5".. DATE 11-°13-0 HR
==111111M
DRESSINGS: LOCATIONS Mleor=1.51.N • TOTAL WM
SP, GR
STATUS:
STATUS: C O. WA
REMARKS MS NUMBERED) ANO
ERTINENT PATIENT PROGRESS NOTES
ENDOTRACHEAL TUBE - ORAL OR NASAL
1) KW fran NLR a:carpooled
0 YES NO
0 YES NO
br 01 0 ThlY
AIRWAY ABM
B. aff:A91-.
/1 CLEAR 0 PLAST
STATUS:
14303: SIcrpY g rc,j .C. ,; inc, LIerLe/ S'1(,a
AIRWAY
0 OBSTRUCTS EASILY
A-Pain YeseiP Icticn: Ne A C4-:an fv k
POST•ANESTHESIA RECOVERY SCORE I
3
1ALDRETE SCORE/
A
Able to move 4 extremities colonially Otter:
A aY , Sor
co on command
Able to more 2 extremities voluntarily
or on commend
f‘
1 Activity
Able to move 0 extremities rolumarily NAUSEA AND VOMITING:I:I.-F.4...
r 0 YES + 1 2 3 4 5 6 TIMES
Of On command
Able to ditto breathe and cough freely
2 CAUDAL, SPINAL, OR EPIDURAL BLOCK
Osionee or limited breathing
1 Respiration MOVEMENT PRESENT AT HRS
*mem
0
SENSATION PRESENT AT HRSBP/20% of piunesthetic level 2
BPI20-50% of oreeaneithetic level 1 Circulation
CONDITION ON TOW:151'
BPS50% at eeeee Mimic level 0 000 0 FAIR 0 POOR 0 CRITICAL Fully awake
2 11 RECOVERY: PATIENT'S IDENTIFICATION:
ASOUlable on Calling
1 Consciousness
Not ffillaancl.
0
Pine 0 COMPLICATED
2
Pale• dually. blataty. jaundiced. other
Color
abbe
NEVENTFUL
O AU
b)(6)-2
X )-2
SIGNATURE OF
RECEIVING AND
Ain
RELEASING
FE
OFFICERS •X6)-2
NAVNED-6320115411ArK I
NOURISI 15 45 15 15 15 30 .5
45 45
1 . I /
4.••• ¦ ¦¦T ¦i1••• -1 ...1 ;P. I i i._ :. _L _ 1__ L _i. i_ __I _:..1...I_ _ ._ ;_ 1 1_ J. j_ _..1.__:_:
TEMPS: . 11 I ' I
I I! I 1
1
1 • I , :
?inal
220 II=11--4 -1 1-7-I--4- 1--4--1 -- I---I -I--!-- -L--i--I- Jr -7 ---1-1 -r -
mei: 200 I 1 li .
1111=1:1 u IF I--1 -4 -1i --!. 4 -
140 Rrrithrt lim
fir -•1--1--r r _ , i _I :__J_ h --- /---i-÷--1-4
-4 --r-r _i _ i' -1-1— .- — — : — H- .— Ira I_LI_LL 11 I I 1 1 ' _i .L•7.:!"I F 1 " _L I I I I / I 1 i •
• 140 77 tt 1 1 7T-1-1 I-:—. 1 -17 -M .--E 7 -17 -1-4. -7-f----' -1--. --- '- '
I 1 ,
-71 1 ..-LI -.. 1._1.--1-1-1-1__ LI-..I. L _.' _1 __I_4L 1. 1 _1_1_ LL' 4_ :_. _ _l_ _;_i _!-_-. P 4: art 120 ' 1 1 I, I ii 11 I: ': _. 14 -, 1,1 is 1 : :-- -I-- 1--1 --I- i---f, + -1 -i -r--1 -- --- -1 - H - H--I-I--I -t 71--. ---1--I- -/-.-; -.---1-4 H -
103 :I 11 1
V II 1 I I .. -1 1 1 -1 1 r, I 1 , , , ! , ---
P a cuff !
--; -+ -1-t-.1- r
-r r--I- 1--1 -r - --'-7 '---I- -t--11 - r-1-T T -1 t --1 --I-Tr -1 " '
1 IL_1; I I 1 ".I I I . . t 1 1 -1 -ij 1 , , : •., 1
am =. -I --I - - -1-r--7 --1-1---r -r --;--, ---i 1-1--Ii-i--I - j i--7 !---7 7 -:-1-.-7 7--
ea ; 1
7 i_ _ _i 1. -I I I I ' 1 1 ._ _ _ i_ : . _i _;_ _ 1_ ; _
71 7 7 i71 1 •1 1 17 - 17 '7-1 7-1 -r 1I_ -r T -I. 7 -; • ! 7 T -1-1---1
40
Sat: -H 4 --: •!--i 11 —F--.-;--!--c —H — H7 + -' ji
-L-- Hr- -1.1
RESP. I 1 .1... L :1 ..1. 1 ...1 1 ! 1 II li 1. 1 la : . ; .-.... ii_ _
•
RATE 7 -. 7-1 ! 1 i 11 1 1--t• ! i-I I I 7 7 1 .- -.-- .--r-, 7 . NUMBERS : .11 II Iii 1, Ii . 1 ji ; . j i I i 1 I
MN REMARKS , i ,_ i . I ! I I I ; I II i 1 I I . I 1 , I I I .1 I •i ' I
MEDICATIONS
ti
TIME DRUG DOSE ROUTE b)(6)-2 'NjOkE ,
1 III
S ME : , ' IIPEEMIIIIM11111121i1M1
I.
REMARKS IAS NUMBERED) AND PERTINENT PATIENT PROGRESS NOTES ICONT'D FROM FRONT)
Niazb: S leery e_ctiisre e?fooS9.1. ifer ire I g. -1-,t4tO/I'
Pain: Ya681 Pctiai: NO
A- c./1--1 'of-7 4-4 K,
MirrriarY: 1(37, C__T-CtSL .-S• crs-Vc, oi gA
arrOc'e .,,Isc e...,E140 Ryan: to :5 Iv:
Ta /'L
SkinAbsrl: 1,4).1-„, fr, "or Drainage Yeste Caw: •
alma YesAee------
NPO Aho /ardS'eqidn,4-c, L4-/ Q7L h
GU: Fbley Yes) Color of urine: -Dm to wad: / 1 1.1
Instrtrticns/IntenEnticrs in PPCA :R e 1/ COF .9417 4e-S SIIS 1-4.p7 c
4/a
MEDCOM -4601
DOD 011080
c.0,0c) 69 t(ki
NAVMED 6550/8 (REV. 4-74) SM 0111 - .,--G16-558 1
MEDICATION ADMINISTRATION RECORD
. ot MESICAL RECORD
MONTH
SCHEDULED DRUGS
MEDICATION-DOSAGE- FREQUENCY cVa.
2o
HOURS
ORDER
ROUTE OF ADMINISTRATION b)(6)_2DATE
Pin( C-F i rV\ IV, h oao
111111111111 IT/A Pv
t 000.
roar
b)(6)-2
10311 11-1
bx6).2
—
Loven.ox 30fY\ S 121,) ••¦••¦•••
b)(6)-2 b)(6)-2
eSO 4 3-15
Co ace 100 ,-k _ o 131!
F
6 tate
INITIAL CODE
FULL SIGNATURE & TITLE
INITIAL
FULL SIGNATURE & TITLE
INITIAL b)(e)-2FULL SIGNATURE & TITLE
INMAL
,b)(13)-2
(b)(6)-2
P(8)-2
WARD NO. Injection Site Code
ADDRESSOGRAPH PLATE 1)) ( 8)-4 = Left Buttock 0 = Left Leg
SINGLE DOSE,
= Right Leg= Right Buttock
PRE -OP PRN
0 = Left A:m
= Left Deltoid
& VARIABLE O = Right Arm
= Right Deltoid DOSE ORDERS SEE REVERSE
Og = Abdomen
MEDCOM - 4602
DOD 011081
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
MEDICATION-DOSAGE FREQUENCY
ORDER
DATE
ROUTE OF ADMINISTRATION
NEM212=1
-r lax° I 6,5 ry)
r'
1'0 9 q h
0, or' pr
,)1 aC1 ntiP a54:1 PO C4 ,
ABLE DOSE MEDICATIONS
DOSES GIVEN
DATE
IMIESZIVIIIMPZETIMIENETIMMI
INITEMMMEIMMLIECETEMMTM
DOSE
TIME [1111311C11211r41121v to rmirnraclana
b)(8)-2
INIT.
'112.
TIME
1706 )r)24
DOSE
st • 6, u
WM-2
INIT.
DATE
TIME
DOSE
bX8)-2
INIT.
DATE 1111111111111
DATE
EZIWARIVASIEREIMINIEHRIMINIM
TIME
WIFIZZIEMEE 00121113 IMEN ibt,b
DOSE
sva EIMEIPOIMPM
b)(8)-2
INIT. DATE
mumicattwirmiramiiignimunciak MUM=
TIME
INIETIELI deo 14-16 MilEti avov or° IS
DOSE
tEMBISNIMISIOSITEIMMEMMOZREI
toN
8)(6)-2
INIT. DATE
wasmagnorMEINETfilg 25211111EIMIIMINNI
TIME
MEM mob MMEIMMISISIITIMIrar
DOSE
INCEIIIMEINIFEEMEIMMANIEVAIr
b)(8}2
INIT.
11111111M11
DATE
TIME DOSE INIT
MEDCOM - 4603
DOD 011082
NAVMED 6550/8 (REV. 4-74) S/N [165581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
SCHEDULED DRUGS MONTH 19 DATES GIVEN ,
ORDER DATE 4/2D MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION tove,nox ')D m33Q 9 12h HOURS octoo 4 6)(6)-2 6/ Co
31 b0. .
00 ce.50i 32601 po Ti D alod
I, oc2
r-LQc
Vzo co bre mor ,' po 1 06 04oc,
Li co
4A0 Fo In tE irrn 14;7 t•-dk V I --pp po (t)ci (1c1 m00 in 00
9 /.2-01 .P0C-11.0,4). -i- com i vv1 00° 06r-r)
X" ". 6(-)Let5s I 1-1 6C..)
22a6
9121 C.,[1>12-2::> se>7) r,6, 90 61. O 001.0D
21 0c
INITIAL CODE
b)(6)-2
& TITLE INITIAL Fill /4175a
l TURF Z TITI F
. INITI1L I ,i^wiFULL SIGNATURE & TITLE
b)(8)-2
b)(13)-2
ADDRESSOGRAPH PLATE b)(6)-4 Injection Site Code WARD NO.
= Left Buttock C) = Left Leg
C) = Right Buttock 0 = Right Leg SINGLE DOSE,
= Left Deltoid 0 = Right Deltoid 0 = Lett Arm C) = Right Arm PRE- OP PRN & VARIABLE DOSE ORDERS
0 = Abdomen SEE REVERSE
MEDCOM - 4604
DOD 011083
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
ORDER MEDICATION-DOSAGE
FREQUENCY DOSES GIVEN DATE ROUTE OF ADMINISTRATION
2-6 m DATE la .**.6 / 57, Si Ft TIME MIMEOcCogairnallEN
W Q I l'il
MANI= DOSE MIREPWRI IGO INETAITI
/1,)(13)-2
INIT. I r:
.
4/2.0 li IWO', (Q.cOrnq DATE i/•ll
• • LI I-1 n '' TIME
Pr 0 r DOSE
INIT.
2 liknarlry I 25ryyj DATE
S-XS Q 4 S TIME
DOSE
illr n 1Lf)
bl INIT. liall
1
0 °, 0 TIME
RS-C)C,Q,., 2 (b.. DATE 1111113TENNIMA
C) in LIAM I) Mr 11 1)
MEI
bligNIIIIIIII DOSE MEM ( s . 7. . „, El
b)(8}2
INIT. DATE TIME DOSE INIT. DATE TIME DOSE ¦ INIT. DATE TIME DOSE •,
INIT.
MEDCOM - 4605
DOD 011084
N
PATIENT PROFILE
NAVMED 6550/12 (5-50) S/N 0105-LF-206-5560 ACTIVITY DATE g OATH DATE DIET MEDIEA VITAL SIGNS FRED J SPECIAL NOTES
Dentures
Bedrest I Bed beth NPO
MEMEMIIMI
ech ImpedimentBathroom Privileges I Shower
MilifilillEttill11111=101111111=11111Sp
MN
anguage barrier
A Up in chair gm Tub mimuoimino=IN 'Ambulate Needs assistance Prosthetic device
wiagl
—11I EFAWASIM
0P MII.
Commode Otr r Visual Impairment
II
Needs assistance i, Blind
I
--• Contact lensesRestricted to unit
Hospital Privileges ORAL HYGIENE -ATE 01
Other II Self FEEDING DATE FLUIDS Hearing defect
Needs assistance Sell Forced to: Other
I
I Special Needs assistance Restricted to: NMI Gavage I & 0 ic IMIll
II
DATIL DATE DATE DATE
TREATMENTS/SPECIAL NOTES TIMES TREATMENTS/SPECIAL NOTES TIMES
ORD. RENEW ORD. RENEW
_.,,,
V
.-
, . 1"/ AO DO /2 100 hr
IN 0. , ._s i 1 .
1 I k e 1,1Pc 1/1 ) 14 Lw 11 4 iii‘ 4-ol
I MINIMI lind IL Ulf . r a 0. ot Z 1:). to # •
0 ..-i, _ L L. f::--(7-pr. • 4-Gt. -i-:/;::.,,,,,, ..
..
bf r%1 ,-; Lit kz-
IMEINIMMENI
Li 2,0 Lk1 0 c,ve +0. ALE
b)(6)-2
MA IMMI1111
MEMW IGHT
ADDRESSOGRAPH DIAGNOSIS
0fanwc- CI, -z--,
PATIENT CLASSIFICATION Ly-k,e1 \ CAQ P CV \--/
OP/SPECIAL PROCEDURES , DATE DATE ON OFF
s 1p i ACLE1 L. • ,
11130 & \
- FINDINGS:
b)(6)4
VSI
RELIGIOUS ,
RITES
MEDCOM - 4606
DOD 011085
ALLERGIES:
TIME DATE
DATE DATE
MEDICATIONS (HOURS TO OF
ORD. RENEW
BE GIVEN) ORDER
9 Lo zifvf2E.• f •
t-1 1 I i( Li/g1) Pin • 6., i A LI 1. LL2t, 0 • A • Um s 2 1 09 LI) t c
tt an Fe y --t NA 0 T. :i- • 0. ° 1 1 1 S ' . Lt ?
1
0-1
l'ilt 4. ctizo qx: c Au,k_ 7 b y , s r ,, ,6
glic, `tjac, rvv.d z -- +11-!, 1 It 40 c Lace too o(9 y0 6 nD °q/zi LitIci % V c 1 k_._ o I, iif 2.2-• ,
i ifonfin 3 I
t7 CiprO ‘609 mg 9) 8/D tit° 7 le0 12- i C-E--4-1k 7. -fill9 Kt -3- \I P f5 I_ kik./ x '3 ck-LIca "11-Lt 'Th i 41C1
Lk IN OkOln "?:Oc-C, PO KI NotA)
Y
4),,,,
p,,,,,.„,,- 2 TA &S lb vt -Lc' F944 4 AO Ty le.41.04 &SO NI- po/i) r 9 4 h r po
rt)
1.11.4 M5Q-• ,Th
3-0 rA9 i \/ sg oil GID._ 1 AA .
-1.11y ZIP Wir4 .671114174.6 '1'
' I
C. -'1 6 )44 12A ( +ES ? /ZIA SA L..9
IN
c, I
0
., . Of ••• ¦ I%
k-11(1 i
Iwo NI V w "r Ur; 141-1-<( -.. -Rir a - •
4-ADDRESSOGRAPH _.• •
19(6)-4
LABORATORY/DIAGNOSTIC
DATE DATE
TESTS EXAMINATIONS/
SENT COMP
CONSULTATIONS
pi.
,0-.. do
if_.,
Of la PO (1-1-6a) U2 ' ,, C a .SP-. C.5 II r der..
CO emus, C, -
ca.c, Litao
.- . ,:f _ , ' 1.— , ..-
(b)(6)-2
es Id c),e. X Z- 4 O LO
ue-A nz ., cy nfil wa Kalik)
c,P)C,
11-c- -"ti 24.A-try- 0--0:-.)-12
CIS C 1 i/11 /Ill..% W1,)A.,
CRC in API ghtr -
(A64,10m,
.
. ,4 • . '*:: /
MEDCOM - 4607
DOD 011086
cyi et q/7
NAVMED 6550/8 (REV. 4-74) 5/N 01(n• . t 16 -5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
ORDER DATE SCHEDULED DRUGS MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION /-ovEnia M5 sq 1211 ?65o ti X25 r/13 11 0 CoGA c(--; 100 nj to MONTH HOURS c,?00 (b)(6)-2 St oo DI op. Bop i700 Of no 9--S 19 so DATES GIVEN
v' 20 ATE-, , v1 p IMEA/17^/ p 3,19 tf_111111.172_1 o 0100 ( ‘l/7 0(200
q/77 4121 ripro 5nOm8 C,E OrPtI q I A.. 1 35 109 Sin `J e ItA,b 22nD 2-ZOO
INTAtb)(8)-2 VIII I CIANATIIRF 01, TM G b)(8)-2 I INITIAL CODE .1 INMAL"TLE .."`"........-.... (b)(6)•2 1\151 it I FULL SIGNATURE & TITLE
. .
ADDRESSOGRAPH PLATE :b)(61-4 Injection Site Code WARD NO.
0 = Left Buttock C) = Left Leg
0 ... Right Buttock 0 = Right Leg SINGLE DOSE,
0 = Left Deltoid C) = Left Arm PRE- OP PRN
0 = Right Deltoid 0 = Right Arm 8, VARIABLE DOSE ORDERS
0 = Abdomen SEE REVERSE
MEDCOM - 4608
DOD 011087
MEDICATION ADMINISTRATION RECORD (Back) 5/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
ORDER DATE MEDICATION-DOSAGE FREQUENCYROUTE OF ADMINISTRATION
L
'( PinPiz. TIME DOSE
INIT.
11/,5 Yk&Stbi cp7(DKA1 11 I til t 14\A DATE TIME
'61.- pro DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
• DOSE
INIT.
DATE
TIME
DOSE
INIT.
PRN AND VARIABLE DOSE MEDICATIONS
DOSES GIVEN
aganillignakal
liFer.,0
IN Z
I
A
b)(6)-2
4101 IV) 1113 /51? .
2-1170
609 9K0J.8.44
b)(6)-2
.
Ai" 44
111"
i
-
•
MEDCOM - 4609
DOD 011088
NAVMED 6550/8 (REV. 4-74) S/N 01G, 561
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
SCHEDULED DRUGS MONTH cb3 DATES GIVEN
ORDER DATE MEDICATION- DOSAGE- FREQUENCY ROUTE OF ADMINISTRATION HOURS 19 20 2..1 23
A ri sibigm i vp15(414 0260 b)(6)-2
"%
% Lalenox
-77—12 quo ale-0 "1 CI S_ 0 L. yrs T-0-10-0 00)0
ort c2)-10 1-11 1 •
L..4110k
INITIAL CODE
INMAL I FULL SIGNATUr-BATITIE INITIAL FULL SIGNATURE & TITLE II INITIAL I FULL SIGNATURE &TITLE
:b)(6)2 (b)(6)-2
ADDRESSOGRAPH PLATE injection Site Code I WARD N
(6)(6)4 0 = Left Buttock 0 = Left Leg
0 = Right Buttock 0 = Right Leg SINGLE DOSE,
0 = Left Deltoid 0 = Left Arm PRE- OP PRN
0 = Right Deltoid C) = Right Arm & VARIABLE DOSE ORDERS
= Abdomen SEE REVERSE
MEDCOM - 4610
DOD 011089
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE GIVEN MEDICATION- DOSAGE GIVEN
ROUTE OF ADMINISTRATION DTE .., TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
\d\ CAI -)C-1: )20\letliow LICl e
MEDICATION-DOSAGE FREQUENCY
ORDER
DATE
ROUTE OF ADMINISTRATION (--t lig (Nosal_ 2.7:1-9,.
i \I ? PIM.
ruel.Q. paiK\
A 1 1% 7.-NflAr/31 43
--i----rr PC) t%-1 t TIME pg-1 P Ct-riin DOSE INIT.
4 (I 41 Ill9,1^61 .?,nny DATE '-
90 C))46 TIME DOSE
?R-I`k M i ld
INIT.
pouf\ \It pyrnbk on sl tinDATE p 0 Q t+s FM TIME
Nu_n_p DOSE
INIT.
DATE
.-M In OTSIV&Y-C ?O () 1Caafttfl Cil)ME DOSE INIT. DATE TIME DOSE INIT.
¦...¦...., DATE
TIME DOSE INIT.
i
PRN AND VARIABLE DOSE MEDICATIONS
DOSES GIVEN DATE 15 7t-1 11 10) TIME 1..,‘..0 0 0.15 DOSE IgIS,S 5 q . .
INIT.
DATE
(b)(6)-2
fq 1 pt
MO Min
;-----1) '14...
.f
)(6)-2
lif
Mg
tt
13)(6)-2
.
. ._
MEDCOM - 4611
DOD 011090
COUNT SHEET
ITEMS
SUTURE NEEDLES
KNIFE BLADES SCRATCII PAD HYPODERMICS CAUTERY TI PS
ILAYTEN
LAP TAPES
COTTONOIDS •1/4 r 114
EANUT/KITNERS ILILL DOGS FIFE! .S
EMOCLEPS BOATS
LUBBER SHODS RAINS
OODLES MBILICAL TAPES UBBER BANDS
lFETY PINS 'ECK SPONGES
NN. FISIL TONSI 3TTON BALLS :SCELLANEOUS
.DDRESSOGRAPH 13)(6)-4 INITIALS OR NURSE SIGNATURE
(b)(6)-2
MEDCOM - 4612
DOD 011091
ORATORY 1-71-0
18 Apr 2003@1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
jeportI/ requested by: System Generated
M6)-4
M/<ld 2395
ph#
Mil. Unit: UNKNOWN
Ordered by: ,bX6)-2
Col: 18 Apr'2003@1739
Acc#: 030418 CO 694
Specimen: BLOOD (PLASMA) Pri: STAT
Ord#: 030418-00526
Res Lab: LAB
Req Loc: CAS
Test name
Result
APTT Units Normal range
19.1 L Seconds
23.8 - 35.5
*** End of Report ***
HJ
MEDCOM-4613
DOD 011092
2 V
LABORATORY 1-71-0 18 Apr 2003@1840 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Report requested by: System Generated
,b)(8)-4
M/<ld 2395 ph#
Mil. Unit: UNKNOWN
Ordered by: 3)(8)-2 Specimen: BLOOD (PLASMA) Col: 18 Apr .2003@1739 Pri: STAT ' Acc#: 030418 CO 694 Ord#: 030418-00525
Res Lab: LAB Req Loc: CAS
Test name Result Units Normal range
PT 10.8 L Seconds 11.6 - 14.4
INR 0.7
Interpretation(s):
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.
*** End of Report ***
HJ
MEDCOM-4614
DOD 011093
LABORATORY 1-71-0 , 18 Apr 2003@1830 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Report requested by: System Generated
M6)-4 3)(8)4
M/<ld 2395 ph#
Mil. Unit: UNKNOWN
b)(6)-2
Ordered by: Col: 18 Apr •2003@1739 Acc#: 030418 HM 1255
Specimen: BLOOD (BLOOD) Pri: STAT ' Ord#: 030418-00523
Res Lab: LAB Req Loc: CAS
Test name Result Units Normal range
WBC 8.6 K/UL 4.8 -10.8
RBC 4.3 L 1X10 6/UL 4.7 -6.1
HGB 9.2 L g/dL 14.0 -18.0
HCT 29.2 L % 42 - 52
MCV 67.4 L fL 80 -94
MCH 21.3 L pg 27 - 32
MCHC 31.6 g/dL 31 - 37
RDW 18.8 H % 12 -14
PLT CNT 379.0 lx10 3/UL 150 - 450
MPV 6.7 L FL 7.4 -10.4
NEUT/100 WBC 71.6
NEUT% 6.2 lx10 3/UL
LYMPHS/100 WBC 20.0
LY# 1.7 lx10 3/UL
MONO/100 WBC 8.4
MONO% 0.7 1X10 3/UL
*** End of Report ***
HJ
MEDCOM -4615
DOD 011094
2 1 LABORATORY 1-71-0 18 Apr 2003@1851 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Report requested by: System Generated
M(8)4 X8y4
M/<ld 2395 ph#
Mil. Unit: UNKNOWN
13)(6)-2
Ordered by: Col: 18 Apr .2003@1739 Acc#: 030418 CH 1608
Specimen: BLOOD (SERUM) Pri: STAT Ord#: 030418-00524
Res Lab: LAB Req Loc: CAS
Test name Result Units Normal range
NA+ 133 L mmol/L 137 -145
K 4.4 mmol/L 3.6 -5.0
CL-96 L mmol/L 97 -107
BUN 9 mg/dL 9 - 21
GLUCOSE 97 mg/dL 76 -110
CREAT 0.7 L mg/dL 0.8 -1.5
PHOSPHORUS 3.6 mg/dL 2.5 -4.5
URIC ACID 2.4 L mg/dL 3.3 -8.4
ALBUMIN 3.5 g/dL 3.5 -5.0
AST 81 H U/L 15 - 46
ALT 52 U/L 11 - 66
ALK PHOS 118 U/L 70 - 250
TBILI 0.6 L Mg/dL 1.0 -10.5
GGT 58 U/L 8 -78
*** End of Report ***
HJ
MEDCOM -4616
DOD 011095
LABORATORY 1-71-0 18 Apr 2003@1904 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Report requested by: System Generated
(b)(6)-4 l(bX6)-4
M/<ld 2395 ph#
Mil. Unit: UNKNOWN
:13)(8)-2
Ordered by: Col: 18 Apr:2003@1739 Acc#: 030418 CH 1608
Specimen: BLOOD (SERUM) Pri: STAT Ord#: 030418-00524
Res Lab: LAB Req Loc: CAS
Test name Result Units Normal range
CO2 29 mmol/L 22 -31
CA 8.6 L mg/dL 8.8 -10.4
PROTEIN TOTAL 7.4 g/dL 6.3 -8.3
LDH 973 H U/L 313 -618
CK 330 H U/L 0 - 203
MG 2.3 H mg/dL 1.7 -2.2
Interpretation(s):
*** End of Report ***
HJ
MEDCOM -4617
DOD 011096
USN SHIP COMFORT 1-AH2O 22 Apr 03@0546 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
WM-2
Report requested by:
MM-4
Ph:
22 Apr 03 @ 0506 (Coll)
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLT CNT
MPV
NEUT/100 WBC
NEUT%
LYMPHS/100 WBC
LY#
MONO/100 WBC
MONO%
PATIENT LAB INQUIRY
For: 21 AD/ 03 - 22 Apr 03
12)M-4
M/4d
Military
13.5 - •(4.8-10.8)
3.5 •(4.7-6.1)
8.6 (14.0-18.0)
25.5 (42-52)
73.2 (80-94)
24.6 (27-32)
33.6 (31-37)
21.6 (12-14)
520.0 (150-450)
6.1 (7.4-10.4)
73.1
9.9
19.4
2.6
7.5
1.0
Reg #: 2395
Unit: UNKNOWN
BLOOD
K/UL
1X10 6/UL
g/dL
fL
Pg
g/dL
lx10 3/UL
FL
lx10 3/UL
1x10 3/UL
1X10 3/UL
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed
[]=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
MEDCOM - 4618
DOD 011097
MOH
Per Meratiye Plan Of Careutii u, 'cn
-Potential For In•ur -Outcome: Patient is free from signs and symptoms of injury . Yes . No
Patient Assessment For Sur
ICrauma# or
?atient # Diagnosi/: 4.<yrytMA.) Planned Procedure: b)(8)-2 Side: D N/A 0 Right D Left Age: HT: WT:
Date: P.3 Arrival Time In erviewer: Surgical/Anesthesia Consent Verified:
From: Transport Via: Patient ID: :1 , d Ordered: CA REC 0 Gurney .Trauma card N/A Comments: .Procedure
.
Verbal .Yes 0 Consent 0 Consent complete, dated, signed
.
Litter
gent case; no consent, MD note
ard .Ambulated 0 Chart 0 T/C #Units OTHER: .Wheelchair . Armband . T/H #Units 0 Other .Other 'reop Labs (HCG, etc): Dr atex Allergies: Present On Admission: AP t Medical Histor-Ctrftural Need. h.rldreesed:
'
one known
. Yes ICDA . N/A o
None rest/Results: A lergy/Reaction: . Oxygen smoker ppd/y1 :b)(8)-2 0 IV Site: #1 . ETOH . A
#2 0 HTN 0 C 0 Foley 0 GERD . CI UnIL 0i/Z0/03 Tilt0 Endotrachial Tube 0 Other:
..............................
me)
're-Op Pain: . Arterial Line Site: Past Surgical His 3 No . Drain(s) .None kna4,1 3 Yes Level (0-10) 0 Chest Tube(s) 0 Yes 5 SETT IC
List:
.ction Taken: Cp&---\1 N -ocation/typ . See RN Note #
Limitations: ROE TEST
n Char : Skin Condition: 135 OEG
] H&P Yes 0 No .Intact /A EXPOSURE TEMP Language
EKG Yes . No .Other: f:x EXPOSURE Ilk
Mobility Ni:t10 7--CXR . Yes . No
URY TIIE
b)(8)-2
. Other:1 Other:
00 MITERS
tY
...... • • •
........
...........
Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological respot
ntal/Emotional Status: Comfort Measures Implemented: Pre-o lert/Oriented Calm 0 Clear, concise explanations commilmG YE
.......................
isoriented . edated .Communicated patient concerns to other staff . Phy 00:04 YES
EXPOSURE
3 Anxious . Unresponsive Xembers ers OEG C,3 Appropriate for age Remain with patient during induction TEIP HIH 135 IRX 13?
Y ES
3 Other 0 Post 1:KLE COIPLETE
00:11
Potential For Impaired Skin Integrity Related To Surgical Procedure — Outc CYCLE Ilk
erative Position: .Beach chair . Sitting upine 3 Prone . Arms <90 Positional Aids: . irplane Fracture Table . Axillary roll . Gel Pad .Bean E . Gel do) CYCLE HOB HO 1IERIFIE0 El ................ b, ei z /OH
3 Jackknife 3 Lithotomy 0 Lateral L / R Arrnboard: OL OR Tucked: DL OR 0 Hand Table 0 Stirrups . Leg Holder . Tape . Pillows 0 Wilson BLIP BSSURNICE
3 Other: . Other:
11SU # I 1 'ad Site: C i 4 i.:. 4i, k 'ad Lot # IT lite Clear at end of case? 0 No Gl4 ces DVT Preventi : SCD used o . Yes Pressure.: . Left . Right Teds: . No 0 Yes Tourniquet: . Arm . Leg O Left . ight . webril applied Appli Main, ....... CHEMICRL, URCUUI CHECK............
f No, see RN note # 3ipolar: Max Cut Coag Bair Hugger used: . Noes Other warming techniq es: 1' 4, Total IRIMTEMMIE_ ....... .. FROE0 BY ..
Comments: 000103
'Vr11.7'1.1 LLL'I 01
$1. :101 rfl001 Nfl LuoinuL .
r utentiai r or Intecti• — Outcome: Ap
ro riate Actions Taken to Pr' it Infection 0 Yes
Nound Classification: Sh Prep: . No
Skin Prep:
Solutio . _edications:
LLH" 0 III 0 IV Shave
¦ Clipper line Scrub
ormal saline
. Other:
Area:
0 Hibiclens
0 Sterile water Duraprep
.
Local 0 Other:
.
Antibiotics
)rains/Packing: . None
D ssing: Location:
4'-roley FR:
ABD .Cervical Collar . Kling
3 JP #1 Fr Lo anon: .S 1-strips 0 Benzoin
#2 Fr Location: 0 Ace .Coban .I 6bilizer
Hemovac: Size Location .Mastisol
0 Bias .Drip Pad ape
lains . ebril
Chest tube: Location .Bacitracin
.Band-Aid(s) .Fluffs .Sling
)1141(Zeroform
Size H2O Pressure: 0 Cast . Kerlix .Splint
7 . Other:
See RN Note # for comments
Packing: type/location:
Miscellaneous
l'.ounts: (initials)
Xray: Skin Ditegrity:
lcrub: RNc
Correct?
3)(6)-2
.None .Other: P.
4•Crear & Intact (other than incision)
Sharps Olf
es 0 No . N/A 0 PoriAble Comments:
Sponges
121-es . No . N/A 2-CrArm
Instruments 0 Yes . No . N/A
) See RN note ft for additional comments
. See RN note ft _for additional comments.
mplants:
tern / Lot # / Exp Date:
) See RN note # for additional comments.
Dischar g e from 0 s eratin Room
2omplications:
T port From OR:
3 None Comments: Transit pred To:
0 gurney w/ siderails up
l:VrACU Report by:
.1.40.er w/ safety strap in place
.ICU
0 Anesthesia provider 0 RN
<-16-w/ Oxygen
. Medivac
0 w/ Monitor
I See RN note # 0 Ward
. for additional comments
.
Other:
.
Other
:urgical Procedure Performed: ,11,1 IQ
1; CO rewm-r---
Initial/Name Box: (please print)
'‘ b)(13)-2
rrimary OR RN Signature
Date Relief OR RN Signature
Date/Time
USNS COMFORT (T
AH 20) PeriOperative Plan Of Care & Nursing Note
Page 2 of 2
MEDCOM -4620
DOD 011099
28 Apr 2v.; @0807 Page 1
USN SHIP COMFORT 1-AH20
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
For: 27 Apr 03 - 28 Apr 03
WO-2
Report requested by:
1,0)4
WY,* M/10d Reg #: 2395 Military Unit: UNKNOWN
Ph:
BLOOD
28 Apr 03 @ 0454 (Coll)
6.5 - • (4.8-10.8) K/UL
WBC
, • . 3.4 L ' (4.7-6.1) 1X10 6/UL
RBC
. . 8.3 L (14.0-18.0) g/dL
HGB
25.7 L (42-52)
HCT
75.6 L (80-94) fL
MCV
. . 24.3 L (27-32) pg
MCH
. . 32.1 (31-37) g/dL
MCHC
. . . 22.6 H (12-14)
RDW
. 974.0 (150-450) lx10 3/UL
. .
PLT CNT . . .1/
wy2
NOT IED CDR @ 0600. SJC.
Result Comment:
5.6 L (7.4-10.4) FL
MPV
. • • . 51.9
NEUT/100 WBC. . 1
3.4 lx10 3/UL
NEUT% /
• . . 38.0
LYMPHS/100 WBC •
• • . . 2.5 1x10 3/UL
LY# I
10.1
MONO/100 WBC./
/ 0.7 1X10 3/UL
MONO% . . •
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed
[]=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
MEDCOM - 4621
DOD 011100
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
b)(64
,' REGISTER NUMBER 3. GRADE ADMISSION REMARKS
:b)(6)-4
i
4. RA7. HELIWON 8. LENGTH OF SVC 9. ETS 10. PREVIOUS ADMISSION
11. FMP 12. SSN 13. ORGANIZATION 14. WARD
(b)(6)-4
Te/taa
157FLTrING 116. ribk 111,1U. I / ucr id 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE STATUS DSG TN
I .
1
I
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF " . 23. CLINIC SERVICE ADMISSION
b—t A It- e--+ i )0 ( Aci=vA
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE OISPOSITION . 26. DATE OF DISPOSITION
'f-Ti/tiq-(I 03
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Codel 27b. TELEPHONE NO. 28. DATE OF/THIS ADMITTING OFFICER ADMISSION
2-/14-/-1y d 3
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. DATE OF I TIAL 32. UNITS OF WHOLE BLOOD.
ADMISSION COMPONENT TRANSFUSED 6)(3)-1
31 SELECTED ADMINISTRATIVE DATA
Check it Connnued on Reverse
33. CAUSE OF INJURY
_
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
•
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d. SUPPLEMENTAL e. BED DAYS I. TOTAL SICK DAYS CARE DAYS CARE DAYS
36. Total Days All Facilites
._
a. ABSENT SICK DAYS b. OTHER DAYS c. d.
r
CONY. LV/COOP SUPPLEMENTAL e. BED DAYS TOTAL SICK DAYS
CARE DAYS CARE DAYS
b)(6}2
SI GN A(b)(e)-2
SIGN S OFFICER
erwrinki nr •e•
USAPPC V1.1 C.
MEDCOM - 4504
DOD 010983
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40-400: the proponent agency is OTSG
())(6)-4
1. REGISTER NUMBER 3. GRADE ADMISSION REMARKS
b)(8)-4
,IE 6. RACE 10. PREVIOUS ADMISSION
16t
-a 14r
11. FMP 12. SSN 13. ORGANIZATION 14. WARD
-2-'
15. FLYING 16. ,-....-, 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE STATUS DSG BEN
--•
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23. CLINIC SERVICE ADMISSION
A 1..._e.-71- 1 )0( n.--,-,A
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION
26. DATE OF DISPOSITION
/ /al' '
If-/ i4 03
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28. DATE OF HIS ADMITTING OFFICER ADMISSION
2
/14 g y03
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 3D.
DATE OF INTIAL 32. UNITS OF WHOLE BLOOD/ ADMISSION COMPONENT TRANSFUSED
86TH COMBAT SUPPORT HOSPITAL, LSA ADDER, IRAQ
31. SELECTED ADMINISTRATIVE DATA
Check if Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
Kac.
),,......,.1.7.4t.e.„.:.,,,.....
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS f. TOTAL SICK DAYS
36. Total Days All Facilites '..-1-------- ‘-2.--
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d. e.
SUPPLEMENTAL BED DAYS 1.
TOTAL SICK DAYS
CARE DAYS CARE DAYS
SIGNAT(b)(61-2 SIGNA b)(6)-2 DFFICER
DA FORM 3647. MAY 79
USAPPC V1.10
MEDCOM - 4505
DOD 010984
PROGRESS NOTES
MEDICAL RECORD
5
PA1
WARD NO.
PAWStoorricicalON (For mod or written estria stm grotho rook ram hoptod or owolical b)(13)-4 PROGRESS NOTES
1,)(6)-4 STANDARD FORM 500 (Roy. 11-rn Prescdbed by CISA/ICMR, FIRMR (41 CFR) 201-45.505 509-111
MEDCOM - 4506
DOD 010985
PROGRESS NOTES
U.S. GOVERNMENT PRINTING OFFICE, 1990 262-081/20182
MEDCOM - 4507
DOD 010986
MEDICAL RECORD
PROGRESS NOTES
DATE
Afrt M rb' ii-tik,,, iv -A 9 • / /4-11 -2P' l' '
10)-(4-A 04-4 4 f-c6L1 43.%1
/2A-07-1u--,5r ;Flo
40-1,-A, 6-c,41 T ea-0.,
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4. .c 1-6 0 .R-
bX6)-2
ii 4 reilf,)
114 2,03 Mc/fcce,( //),41-11 hr
/6--0
6' p.e/r 0 - all-e laktdt
aecOCea,t_u r---.:_e--rt--
I ji- - e 2--60165 , LoL.19.s 11111:263 i6i) NI"q, iL / -Es., 24,0,
64-i Kca ( Keeis -=-- 36.--as-ked7/4----- 1F6LD, -2/00 1
n -e5v1 14eeds = I -57:91
idai -= 965 Idatj -;b I --c_q-di— buS II 14465-2,1N-Y E. FesoLit of tint (-,V, ,c_fd6 Po (iL4-174.1ce ojr.--y)e_e_m/444,evid cevilinoe go.e.„, e pp
'f---0) cur 0/(eAl .4--eYuccks / E,V,Soi2E TZO -
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(b)(6)-2
MPH, RD LT, MSC, USNR
' 6)-2
(Continue on reverse side)
PATIENTS IDENTIFICATION
(For oped or written entries give: Name—last. first. middle:
REGISTER NO.
grade: rank; rate; hospital or medical facility) WARD NO.
(b)(6)-4
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescrit40 Et GSA/ICMR, PAIR (41 CFR) 101-11 806-8 509-110
MEDCOM - 4508
DOD 010987
PROGRESS NOTES
DI%
f) 01.743
1
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(Lo
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STANDARD ORM 509 BACK (Rev. 11-77)
U.S.OP010.44421-521/124
MEDCOM - 4509
DOD 010988
DATE MEDICAL RECORD PROGRESS NOTES
44(1 c') Ds Of La 44., -I- - / 2-2 .
--riskw,i 11-kiv-i, ) lAn..4 82 A-14
23A0k 63 i":"P. A-Joie--17,4 g-osin Ori. S C41 nS2-4'5P S. + A . 4..rt0 4 - , -1 1 64,-.9 (A.4.3d. 0,,C ( 'N 227 u. :-..-1 f0 . , scr 4--4 st-gv,e1/4/ t P-I. up 0 i 0 4-Si enepc -,,,-
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LA.11 co,+__,_c_r_ 7 -.e. A. A 1. "6)-2
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.
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cir-4A 4°-' 1:1(5 (..4.(Ap 4— e 170 a-e44-7-, --,----7(
14 .LECI41.41cpt,1 214
(Continue on reverse side)
PATIENTS IDENTIFICATION (For typed or writtert.entrer sire: Name—last, first, middle;
REGISTER NO.
grade; rank row liosPital or medical facility) WARD NO.
II
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescribed by GSA/ICMR,
FIRMA (41 CFR) 201-45.505
509-111
MEDCOM - 4510
DOD 010989
PROGRESS NOTES
DATE
2/6 411-10 7. AorTL5-
APAAA1c14z
TA,42.0.3
b)(6)-2
)(6)-2
b)(6)-2
e<11C,_ t‘it 4
r
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CA.C.E.S
( 14--
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1/iote-. 14
Jo to 04_ 5 e'
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u.s.O.P.O.: 198e-491,248/20616
STANDARD FORM 509 BACK (Rev. 11-77)
(c/Z_ ..lriZne.s4 ay, elec.
MEDCOM - 4511
DOD 010990
MEDICAL RECORD
PROGRESS NOTES
DATE
/9./11140 i),/t
sctit( qg /ow
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kN1-
it
p‘ tvkAk3
(iAmAies
(AILU (CYU11( 4\P 14)164 14 sirt
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1402.,03 Me,d(ac,____LALkjiia2LMEL:
105"" 0: 116__e_e1-e‘i I cam, E.1,50,e_F (Przwc
dee&L 140 63 b gr-t 51/ 73-3/41: 41/12 PO C vt47-4,ke— cr, (60(?Sm,4,,, 6dcawil
ei/VoLlYZ.z” 190 t<1. 1 10-64 - I a,
b)(0)-2
AL/ iW
PATIENTS IDENTIFICATION (For typed or REGISTER NO.
WARD NO.
;'kL—=mswrarcgclmizim=u1=7(b)(8
b)(6).4 taPH, RD
LIQ INIbt" USINK b)(1*2
PROGRESS NOTES
STANDARD FORM 509 (Roy. 11-77)
Presatei by GSA/ICMR, FPMR (41 CR) 10141.806-8
509-110
MEDCOM - 4512
DOD 010991
PROGRESS NOTES
ti,D,...,(
AT 9.5
P 2 -) /o :1—ke” i` cf---) ^If f- cj cze /144.411 -. -
r\-171,7-O"-0 za4",143 /03, P t•c_( (24.,,i \A„..„--4, 1 61,,,,f ‘Le., (),.., co ii I, . i
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MEDCOM - 4513
(OJ
DOD 010992
rd..vvw-aj
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MEDCOM - 4514
DOD 010993
MEDICAL RECORD
PROGRESS NOTES
DATE
,2cPr-PRol Nr-07
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(Continue on reverse side)
PATIENT'S IDENTIFICATION
(For typed or written entries Rise Name—last. firs;
•
REGISTER NO.
rode; rank; raw hospital or medical facil(ty) WARD NO.
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescribed by GSA/ICMR,
FIRMR (41 CFR) 201-45.505
509-111
MEDCOM - 4515
DOD 010994
MEDICAL RECORD
PROGRESS NOTES
DATE
14 J-) 03
T .);! . , • /
0 ,
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(Continue on reverse side)
PATIENTS IDENTIFICATION
(For typrd or written envies sire: Name—favi.
middle: REGISTER NO.
grade: mik; rata WARD NO.
tal or medical
b)(6)-4
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescribed by SSA/IDIR,
MIR (41 CFR) 101-11506-8
509-110
MEDCOM - 4516
DOD 010995
PROGRESS NOTES
DATE
11 :,)Z UV.51/1-1/1 (i t A Cl 11-Q, 6 LClCk(
. ATV1 1 1Z . ) C
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STANDARD FORM 509 (Rev. 11-77)
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MEDCOM - 4518
DOD 010997
PROGRESS NOTES
MEDICAL RECORD
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STANDARD FORM 509 (Rev. 11-77)
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MEDCOM - 4519
DOD 010998
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PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
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MEDCOM - 4520
DOD 010999
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99) Prescribed by GSNICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 4521
509-114
DOD 011000
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DOD 011001
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MEDCOM - 4523
DOD 011002
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MEDCOM - 4524
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DOD 011004
NURSING NOTES
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HOUR OBSERVATIONSDATE A.M. P.M..
Include medication and treatment when indicated
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MEDCOM - 4526
DOD 011005
CLINICAL RECORD NURSING NOTES
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A.M. P.M.
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NURSING NOTES Standard Form 510 General Services Administration and Interagency Committee on Medical Records
FPMR
10 1-11.806-9--October 1975 510-109
MEDCOM - 4527
DOD 011006
CLINICAL RECORD NURSING NOTES
HOUR OBSERVATIONSDATE A.M. P.M.
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PATIENT'S IDENTIFICATION
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NURSING NOTES
Standard Form 510
General Services Administration and Interagency Committee on Medical RecordsFPMR
10 1-11.806-8—October 1975 510-109
MEDCOM - 4528
DOD 011007
NURSING NOTES
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HOUR
DATE OBSERVATIONS
A.M. P.M..
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DOD 011009
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DATE OBSERVATIONS
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Standard Form 510
General Services Administration and
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MEDCOM - 4531
DOD 011010
NURSING NOTES
CLINICAL RECORD
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PATIENT'S IDENTIFICATION
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NURSING NOTES
Standard Form 510
General Services Administration and
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FPMR 101-11.806-8—October 10Th
510-109
MEDCOM - 4532
DOD 011011
NURSING NOTES
Sign all notes
HOUR
DATE OBSERVATIONS
A.M. P.M..
Include medication and treatment when indicated
WPM
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NURSING NOTES standard Form MD (Reverse)
MEDCOM - 4533
DOD 011012
'
S,N 75 0-00.634.4156
MEDICAL RECORD
OPERATION REPORT
PREOPERATIVE DIAGNOSIS
F)c l C(04-e,
GE b)(6)-2
SECOND ASSISTANT
(A`N ES T H
ANESTHLI IL TIME BEGAN:
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TIME ENDED: tyr 3.C...3
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TIME OPERA1 I)N BEGAN TIME OPERATIpSi cow PLETED
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MATERIAL FORWARDED TO LABORA RV FOR(EXAMINATION
OPERATION PERFORMED
Fts-x&ea-ii-L I M Ai711L
DESCRIPTION OF OPERATION
(Type(s) of suture used, gross findings, etc.)
PROSTHETIC DEVICES (DATE OF OPERATION
(Lot no.)
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DATE
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STER/I.D. NO.
b)(8)-4 hospital or medical fact WARD NO.
OPERATION REPORT Medical Record
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STANDARD FOFIM 616 (RE v. 5-83)Prescribed by C-SA
MEDCOM - 4534 FPMR 101-11.806-8
DOD 011013
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MATER IAL FORWARDED To J. ,)-..?Qo",--m_f_T7 ?6,7:1---9-±,
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MEDCOM - 4535
DOD 011014
511-119
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR
DAY 19 HOUR
PULSE TEMP. F
(0)
(•) 105°
180 104°
170 103°
160 102° 39.4 ° C0
38.9°
150 101°
38.3°
140 100° .2
37.8 °
130 99° a)
98.6° 37.2 °
120 98° 37.0° 36.7° a)
110 97° .00
36.1° aCi
100 96°
35.6 °
90 95°
35.0°
80
70 60 50 40
RESPIRATION RECORD a
0
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C
O a a
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a
8
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cc PATIENT'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility) REGISTER NO.
WARD NO.
b)(6)-4
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM SU (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4536
DOD 011015
518-124
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
ED BLOOD CELLS
• FRESH FROZEN PLASMA
PLATELETS (Pool of units)
• CRYOPRECIPITATE (Pool of units)
• Rh IMMUNE GLOBULIN
OTHER (Specify) VOLUME REQUESTED (If applicable) ML
1U htf-
REMARKS:
1+114 ,e'
1-742.,4f
UNIT NO. TRANSFUSION. NO.
:6)(6)-4
PATIENT NO.
DONOR RECIPIENT
A80
ABO
Rh
Rh
6)(6)-2
INSPEC
AT (Hou
IDENTIFICATION
I have examined the Blood Compo
information identifying the contain
The recipient is the same person a
on the patient identification tag
1st VERIFIER (Signature)
.6)(0)-2
USION
FOS
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)
El TYPE AND SCREEN
CROSSMATCH
DATE REQI4ESTED
a 63
DATE AND Hig REQUIRED
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION ANTIBODY SCREEN
CROSSMATCH
CROSSMATCH NOT REQUIRED FOR THE COMPONI REMARKS:
E
x-19. 03MM 03
SECTION III -RECORD OF TRANSFUSION
.?/
nt ontainer label and this form and I find all wi the intended recipient matches item by item. d on this Blood Component Transfusion Form and
AMO NT GIVEN ML
b)(6)-2
REACTION NONE SUSPECTED
REQUESTING PHYSIC' AN (Prim)
(5)(61-2
DIAGNOSIS OR OPERATIVE PROCEDURE
virtLor
I have collected a blood specimen on the below named patient, verified the name and ID No. of the pat ent and verified the specimen tube label to be
correct.
SIG
DAT1 ventricle
,01/ /9/4 Cif
TIME VERIFIED
/°;2 C7 des
PREVIOUS RECORD C ECK:
RECORD
NO RECORD
POST-TRAN
A TIME/DATE OMPLETED NTERRUPTED a
I ap 03 Ocgc.5 6
TEMPERATURE PULSE
BLOOD P• SSUR
gf
R0
AF 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 0 FEVER
.
PAIN
• OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
TEMP. 013 PULSE ° 6)0)-2 DATE OF TRANSFJJSION
TIME STA TED
a 1,
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; SEX
rate; hospita or medical facility)
'6)(13)-4
M wAtwo
Al 0 YES (Specify)
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
-
car MEDCOM 4537 Medical Record Copy
DOD 011016
518-124 NSN 7540-00-634-4159 MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I – REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN (Print)
Products are requested.)
33)(61-2
'It RED BLOOD CELLS
. FRESH FROZEN PLASMA
PE AND SCREEN DIAGNOSIS OR OPERATIVE PROCEDURE
.
PLATELETS (Pool of
units) CROSSMATCH
.
CRYOPRECIPITATE (Pool of
units)
DATE REQUESTED
. Rh IMMUNE GLOBULIN I have collected a blood specimen on the below
9 / named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED
patient and verified the specimen tube label to be
. OTHER (Specify)
correct. VOLUME REQI1E TED (If applicable)
/1
bX6)-2
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
" .4
ML
REMARKS:
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
DATE VERIaEff
RhIG TREATMENT? DATE GIVEN:
Ar",
TIME VERIFIED /0&/- 0 HEMOLYTIC DISEASE OF NEWBORN?
SECTION II – PRE-TRANSFUSION TESTING
UNIT NO.
TRANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHEC : ANTIBODY SCREEN
(b)(6)4
CROSSMATCH . RECORD NO RECORDPATIENT NO.
• b)(6)-2 FORMING TEST
lug
131(6)-2 DONOR
RECIPIENT
.
CROSSMATCH NOT REQUIRED FOR THE COM ABO 0
DATABO
REMARKS:
Rh EX-e. OS Ml 06
Rh
SECTION III – RECORD OF TRANSFUSION
b)(6)-2 DATA
IN POST-TRAN TA
A our) IDENTIFICATION ON (Date) ONE 0 SUSPECTED AMOUNT GIVEN UMA" ML REACTION TEMPERATURE TIME/DATE COMPLETED a aA-p Repo PULSE TERRUPTED BLOOD PRESSURE Il
If reaction is suspected--IMMEDIATELY:
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. 1. Discontinue transfusion, treat shock if present, keep intravenous line open. The recipient is the same person named on this Blood Component Transfusion Form and 2. Notify Physician and Transfusion Service. on the patient identification tag. 3. Follow Transfusion Reaction Procedures.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1st VERIFIER (Signature) b)(6)-2 DESCRIPTION OF REACTION
.
URTICARIA 0 CHILL
.
FEVER
.
PAIN
cols-by
OTHER (Specify) ',b)( )-2
005 k
OTHER DIFFICULTIES (Equipment, clots, etc.) NO .
YES (Specify)cTEMP, 100 I
VLSE 10 -7 TE OF TRANSFUSION
TIME STARTED
12-03
Pp 610 €erckriAt
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank;rate; hospita or medical facility) SEX WLAR
.1)
1
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1
MEDCOM - 4538 Medical Record Copy
DOD 011017
MEDICAL RECORD DATE AND TIME DOCTOR'S ORDERS (Sign all orders)
START STOP RX DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE
b)(8)-2
6 ) t)L-ef a ev
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PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospitalpr medical facility) 0 11 '111S",
-b)(8)-2
Lo v't 0 Y 30,) 50_
DOCTOR'S ORDER
(8)-2
QIp -STANDARD FORM 508 IR
Prescribed by GSA end ICMF VtAtArAjA
FPMR 101-11. 806-8 508-110
(b)(8)-2
l M'r-fw- cief3 r ci-c-r4 1
MEDCOM -4539
DOD 011018
0 0°V
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all orders)
DATE-AND-TIME- -
RX DRUG ORDERS DOCTOR'S NURSE'S
START STOP
SIGNATURE
SIGNATURE
ici Apacze DZIO pirLj, Of 6.1 VE-2( . b)(6)-2 13)(6)-2
- u (kirt<7 b)(6)-2 —1))(13)-2
4110171? \r)-°\)... • 3 0 ?,-oo aut4 lxv-Icfruet: 0,3-a-r5 b)(6)-2 ,b)(8)-2
13)(8)-2
b)(6)-2
MSOL( g lu ( . 9(Z_(t 1•A
6,0
(Co f ue o reverse side)
ve (b)(6)-2
PATIENT'S IDENTIFICATION (For typed or written entries give: Nr_ last, first, REGISTI WARD NO.
middle; grade; rank; rate; hospital or medical facility)
Li. FWD
b)(6)-4
%5 AR-BO/MD
DOCTOR'S RDERS r
STANDAR ORM 508 (Rev. 10-75)
Prescribed by GSA and ICMR
FIRMR (41 CFR) 201-45-505508-112
\\A
VIEDICAL RECORD DOCTOR'S ORD —
(Sign all orders)
DATE AND TIME
RX DRUG ORDERS DOCTORS
START j STOP NURSE'S SIGNATURE
SIGNATURE
b)(6)-2
mit to ergies: Vital signs per PACU protocol. 1
02: --FM @ PM, % Blowby, NP (a) LPM ' i . IVF: bp._-1
at 14-r) cc r n war.: 02 2-3 PM via Pain medication: eT
Keirelac.—/ mg IV xl • ose (adults 30 mg max,
.4 mg/kg)
MSO4 mg IV q 5' min pm; max dos 4 mg min prn; d se
Other:
Antiemetics:
Ondansetron
mg IVP, may repeat xl in 15 min (0:1 mg/kg; max 4 me) etoclopramide
mg IV xl (0.15 mg/kg; max ID mg) _ .
.
avaiIMM administration.
Other
9. Clear liquids as tolerated:
NO IT; -
10. Notify Anesthesia (pager J.543
6') for airway issuel, pain, nausea/vomitin6 not responsive to above orders or other patient ploblems/concems per PACU protocol.
(rev; 3/2002)
(OVER)
side ;
T
\TIENS IDENTIFICATION (For typed or written entries give: Nor
REGISTER NO. b)(8)-2
de: rank: rate: hospital or r WARD NO.
et_v 1(1-‘ 1(04d4)R'S ORDERS
Medical Record
STANDAP. FORM 506 IRev. 3-94)
Prescribed by GSA.ICMR FIRMA (41 CFR) 201-9.202-1
MEDCOM - 4541
DOD 011020
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all orders)
DATE AND TIME
START STOP RX DRUG ORDERS DOCTOR'S NURSES
• ' - ' • . • 11 II '111 • II "11.1 P JIVIAMILJFIC. JIUN/A I Uhit
1 I .
Discharge patient from YALU per protocol: S . NO Iv en episura spina patients meet a sc arge crite
. D-MT 8 Drotodo,
1 isc arge to w wer",—;:114 'rest pen mg u recovery o sensor nd ........—.
motor unction; progress to am Du ation wit
assistance. FOR PACU KEEP PATIENTS ONLY
13. ;
Release patient from anesthesia care to KEEP stat .
- - • patient meetLI ,
resthesia discharge criteria: YES 0
14. i
Notifyariestbesia (1506) for airw.
. management and: (circle if applicable)
4 . I a. Pain man ement
b.
Fluid managem-
c.
Other
NN
1 ------------,—______1 1 TOW patient
:. ward in a.m. if patiatt meets distharge critei -ia: YES a
N I
•
-Signature
Keener
b)(8)-2
0" D117-.
bX8)-2
..? J2)(8)-2
¦ i /
i 1
STANDARD FORM 503 /Pev. 3-94) BACi
MEDCOM - 4542
DOD 011021
•
DOCTOR'S ORDERS
MEDICAL RECORD
(Sign all ordeal
DOCTOR'S START STOP SIGNATURE
Rx DRUG ORDERS NURSE'S
SIGNATURE CrAr¦rt\-YIAA4
0 b)(8)-2
c,tb,A0 -2? c
‘') 'Y314-) --
ifv\-0
-,)
tet i-75 CAC_ LI1-7m
"-)
1)1-40
.13 (8)-2
bX8)-2
Y)?1,1
x8)-2
G)4 01 111 110 r 0-4 It W t/7/C)/A
b)(8)-2
21 isPP---03 DP-EfiS(bX6)
Ni
C (J2S'Onr PO Yi1VW
(4-cf\ Nix.. MA(2(Kin
(b)(8)-2
b)(6)-2
"0—
,AUNIVINPARIMT ia rarlimArrerzkomiEsti -14pirait v
•ATI T'S IDE TIFICATION (For typed or written entries give: - last, first,
REGISTER •
rwArilJ NU.
middle; grade; rank; rate; hospital or medical facility)
pvvo,
3)(8)4
DOCTOR'S ORDERS S-17;‘
‘f-19°C1
STANDARD FORM 508 (Rev. 10-75)Prescribed by GSA and ICMR
FIRMA (41 CFR) 201-45-505508-112
DOD 011022
!PI
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all orders)
DATE-AND-TIME--- -•,
RX DRUG DOCTOR'S
DRUG ORDERS NURSE'S
START STOP SIGNATURE SIGNATURE
:b)(8)-2
NVI>ItAi"
4-1-tvv—l e.
AA D-3)
cuaf ') e 03 aq° CMAi-Vi2-446-1(0d-?en 110 citz2-iO3 OV0 111 .14GfaL
• )6eer to (S Comskot 1.5. 6
,rar 6-194ti5
b)(6)-2
b(a/.)6)/
f
3 2--,5
b)(13 2
417403
b5112 1 sce,f-ei,r
:b)(6)-2
b)(6 2
(3407 9 1" e/449-e--4-
1, 7
b)(6)-2
itr2L(415 P5N) oje° -
44 '71 0 &a1(4,2-1 Crscria‘d
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first,
REGISTER NO.
WARD NO.
middle; grade; rank; rate; hospital or medical facility)
roKi3O046
b)(6).4
DOCTOR'S ORDERS
P °rf
STANDARD FORM 508 (Rev. 10-75)
Prescribed by GSA and ICMR
FIRMR (41 CFR) 201-45-505508-112
MEDCOM - 4544
DOD 011023
508-111
MEDICAL RECORD NSN 7540-o0-634•4 121
DATE AND TIME
START DRUG ORDERS DOCTOR'S SIGNATURE NURSE'S SIGNATURE
AIME
EWA
NEM
)(13)-2
Pain medication:
Ketorolac Mid
mg IV xl dose (adults 30 mg m MSO4 2. mg IV q L Ilk
-
min pm; max dose
11111
Fentanyl
mcg IV q
min pm; max dosemcg Percocet
tab(s) p.o. with sip of water
111 Other: b)(8)-4
11111
1M
IIPHIN EL.....
Ondansetron mg IVP, may repeat xl in 1 •
Ell¦
min (0.Img/kg; max 4 mg)
Metoclopramide um
mg IV xl (0.15 mg/kg; max I
in
. MR available before administration. Mr illIPP
Other b)(8)-2
1111
Clear liquids as tolerated:
Notify Anesthesia (pages) for airway issues, pain, nausea/vomitin I not responsive to above orders or other patient prbblems/concems _ I
r--
per PACU protocol.
(rev372002) (OVER) I
b)(8)-2 !Cor:nue rm, reverse sicle,
PATIENT'S IDENTIFICATION (Fo
ed or written entries rve:
middle: ade: rank: rate:
I
WARD NO.
X6)-4
TOR'S ORDERS
3 Medical Record
A
MEDCOM - 4545
DOD 011024
MEDICAL RECORD DOCTOR'S ORDERS
CI
(Sign all orders)
DATE AND TIME START STOP DRUG ORDERS DOCTOR: NURSE'S
MI
SIGNATURE SIGNATURE
I • I
NM
isc arge patient rom A per protoco :
MI
en epidural/spinal patients meet discharge cri
eria per PACU protoc
disch ge to ward. On ward: bedrest pending f
III
motor fu lion; progress to ambulation with assi tance.
El
b)(13)-2
FOR P • CU KEEP PATIENTS ONL
ElIiii Release patient from anesthesia care to KEEP st. tus w patientIlk anesthesia discharge criteria:
YES NO
MI 14. IL otify anesthesia (1506) for airway managemen and:
(circle if applicable) MI 111111Pain management
¦11k
IN
111111¦ b. Fluid management
111111111111M I
lif
IIIIIIS TOW patient o ward in a.m. if iatient meets dis IREMII"
b)(6)-2
YES NO
IIIIIIII
..,,i
lay. Signature 'ilh"I'vj '-mihNI NMI.
NM
_affilliell
Ilige'Wrial EMZIPAII
111=11111111 1111111111•111
•
Ill
ISI
III
¦
¦
STANDARD FORM 508 (Rev. 3-94) BACK
MEDCOM - 4546
DOD 011025
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all orders)
DATE AND TIME
START DRUG ORDERS OR
DOCT'S
NURSE'S
SIGNATURE
SIGNATURE
b)(8)-2
b)(6)-2
bX8)-2
• )03)-2
III .111 .
)03)-2
0037 C tn,e.4 6)
)(13)-2
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, `REGISTER NO.
middle; trade: rank: MP. hrwinital WARD NO.
b)(6)-4
I
DOCTOR'S ORDERS
STANDARD FORM SIS (N.,. 10.711Annabel by GSA and ICSAR
FIRMA (41 CFR) 201-45.505
508-111
*U.S. GPO: IISS-201-780/1100711
MEDCOM - 4547
DOD 011026
•
MEDICAL RECORD DOCTOR'S ORDERS
Myr ell ordenj
DATE N TSSE
START STOP DRUG ORDERS DOCTOR'S Nunn
SIGNATURE savimum
6)(6)-2
./Ltafpg1-
1/A( /at G
0A.A/1.0.s.
v
Mc-AR N6 10 J/c 1
Of —
xtos .1-6r or\ 54/2-Y°.
14--e r II 1A1 frAci fi-)(0
"ci:— (Y.
acc'd rty4.11,1;:i 1.14(1/A L1
42i cf-tr'e OA( //nik -
telt ejfr 30 (1-3
• 7-1?,,.. 1 v E0
ME0-2
,ISd 2-6 fic./ceZ. ZU
6 YNR
1Cord On side)
PATISNT'S IDE
CATION (For typed or written entries sive: Name - IBAmiddle; grade; rat*: , hospital or medical facility)
3)(6)-2
b)(6)-4
ti"
POMMOIMmWM MOSAa(i/AGM
1AR (41 OFR 201-45.506 111
*U.S. GPO;
S-101410/10071
4 hub Par
MEDCOM - 4548
DOD 011027
THE DOCTOR SHALL RECORD
SYSTEM IS USED, WRITE PROB
PATIENT 10ENTIF4cIATI ON
X6)-4
NURSING UNIT
ROOM No.
PATIENT IDENTIFICATION
NURSING UNI.T
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
DA , APR 794256
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG DATE, TIME AND SIGN. EACH SET OF ORDERS II PROBLEM
TENTED MEDICAL RECORD
LEM NUMBER IN COLUMN INDICATED BY ARROW BELOW; . DATE OF ORDER
TIME OF ORDER• LIST TIME ORDER
•
NOTED AN(
' HOURS
SIGN
GlickL
‘E_
BED NO.
d e4 4 r)(ot
DATE. OF ORDER
TIME OF ORDER :b1 (81-2
)
) 1? vHouns
°((
?EO NO.
TIME .OF ORDER
-(6
BED NO:
•
DATE OF ORDER TIME OF OR LH
1 BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
U.S. GOVEFINMENT PRINTING OFFICE: 1994-363.710
MEDCOM - 4549
DOD 011028
Standard Form 508
CLINICAL RECORD DOCTOR'S ORDERS
Sign all
DATE AND TIME
DRUG ORDERS •
START STOP Be
(Another brand of a generically equivalent product, identical in dosage form and content of active ingrechent(s), may be administered
DOCTOR'S SIGNATURE NURSE'S UNLESS checked here) SIGNATURE
56)-2
I Al
Ia.•
4, , _
b)(6)-2b)(8)-2
(v t LI MAD
• • :13)(13)-2
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In
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-..
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q.
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?ATI • T'S IDENTIFIL
.14kIA11
;rade; c; hospital or e T . 71 b)(8}2 si miamirptimb)(6)-2 4 RIIIMa ARD NO.
b)(6)-4 /
IrRAFflf, .
I
and Form 508 508-109
General Services Administration and
M
Interagency Committee on edical Records
FPMR 101-11.806-8 October 1975
MEDCOM - 4550
DOD 011029
S08
Standard Form
DOCTOR'S ORDERS
Six n all orders)
DATE AND TIME
DRUG ORDERS
NURSE'S
START STOP
(Another brand of a generically equivalent product, identical in dos-DOCTOR'S SIGNATURE
SIGNATURE
age form and content of active ingredient(s), may be administered UNLESS checked here)
b)(6)-2
6 b3
r
absilliM
.11 .*
lik : tri
11110111ril -';-'r
•)(6)-2
r
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b)(8)-2
i ...),! i .
A , 0, ¦4 0 b a IIbm-zalm
AAA
t • .dA
. .
(Conese.onlyerse sure)
WARD NO.
REGISTER NO.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle;
grade; date; h
b)(6)-4
DOCTOR'S ORDERS
Standard Form SOS 508-109
General Services Administration and
Interagency Committee on Medical Records FPMR 101-11.806-8 October 1975
MEDCOM - 4551
DOD 011030
THERAPEUTIC DOCUMf thTisI0f.N C
CLINICAL RECORD ForEuroAseA ARRE PLAN (MEDICATIONS)
is the Office :f ThritiiRee. e ene a Mo. Y r.
VERIFY BY INITIALING ercINITIAL PROPER GCOLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK! RECURRING MEDICATIONS, HR DATE DISPENSED
DATE NURSE
DOSE, FREQUENCY
b)(6)-2
b)(8)-2
111¦¦¦¦¦¦¦¦¦¦¦
¦1111111111111111111111111111
E 111111111111111111111111111111
Elm111111111111111111111111111111111
b)(8}2
4,4,
I -11111111111KMEIMI
ALLERGIES: YES I NO PRIMARY DIAGNOSIS:
cyie exr f'-4c
PATIENT IDENTIFICATION:
13)(8)-4
(}\1\\)11
111111111111111111111111111111
111111111111111111111111111
111111111111111111111111111111111
¦11111111111111111111111111111
11111111111111111111111111111111
111111111111111111111111111111
1111111111111
111111111111111111111111111111111
11111111111111111111111111111
ADDITIONAL PAGES IN USE E: YES n ND
PAGE NO. DISPENSING TIMES
D E N USE PENCIL. CIRCLE MED TIMES 7 8 9 10 11 12 13 15 16 17 18 19 20 21 23 24 01 02 03 04 05 14 22 06
DA FORM 4678, 1 FEB 79
EDITION OF I DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V IAS
MEDCOM — 4552
DOD 011031
Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.
Order Clerk,
Date Nurse b)(6)-2 SINGLE ORDER. PRE•OPERAT1VES Date to be Given Tme to be Given Time Given Initials
_,/fehla A w A 7.... '.b)(6)-2
Ge7- mar da" ,e../614e)
"64
Orderl Clerk,
Expir PRN
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Nurse
Date MEDICATION, DOSE, FREQUENCY
TIMEIDATE DISPENSED
.10 641. G° i
„bp
USAPA VI.00
MEDCOM - 4553
DOD 011032
1.
REPORTING MTF
MTF LOCATION
1 At _
7 ADMISSION AND CODING INFORMATION
(b)(3)-1
(State or Country
Code.) For use of this form, see AR 40-400; the proponent agency is OTSG
—3. REGISTFR NI 'MARFA
b)(6)-4 NAME a ast, First, Middle Initial)
. PAY GRADE
SEX
(13)(6)-4
18 1
DATE OF BIRTH
(YYYYMMDD)
ETHNIC RELIGION
19 , 20 21
• 30
ir 31
111111311CIEINEIEIICIEll
BACK-GROUND
10. LENGTH OF SERVICE ETS
11. FMP
12. SOCIAL SECURITY NUMBER
32 33 34
35 36
37 I 38 1 39 I 40 I 41 T47)7 1
A
ORGANIZATION
(Active Duty Only)
13. MARITAL STATUS
HUUR OF
BRANCH / CORPS 46 ADMISSION
14.
FLYING STATUS
15.
BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 48 49 50 5
52 53 54 55
4•1111••¦¦¦¦•¦¦••••¦¦ 56 57 58
59 1-6-0 I 61
17, UNIT LOCATION
(State or
18. MOS 0-0010
-
Country Code) 19. TRAUMA
62 1 63 PREV. ADMISSION
64 65 66 67 68
6 70 71
YEAR
20.
SOURCE OF ADMISSION/ AUTHORITY FOR
ADMISSION WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
72
ADDRESS OF EMERGENCY ADDRESSEE
(Include ZIP Code)
N2—th
N ME AND LOC
b)(3)-1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21.
TYPE OF DISPOSITION
22. MTF TRANSFERRED TO
DATE OF DISPOSITION
73 74 23. (Y Y YYMMDO)
80
85
86 87 88
24.
CLINIC SVC -ADMITTING v
25.
MTF TRANSFERRED FROM
_
-26. -..DATEJI-IISADMISSION
89 90 91
92 YYMMDD)
93 . 94
95 96 97
98 104 105 106
_cl 1.4
27.
LOCATION OF OCCURRENCE
28. MTF OF INITIAL ADMISSION
(Battle Casually' Only)
29.
DATE INITIAL ADMISSION
107 108
/V Y VYMA,404i;IN,
109 110 111
112 113 114
115 116 117 118
1 119 120 1 121 122 /
I_ •FOR LOCAL USE /r-ViC
• I tr0 1 I 1
9°1 (17
p
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0 (f-17
5e7/
ic-rJ)1Tici
AOMITTIN
-
SIGNATURE OF ADMITTING CLERK
b)(6)-2
DA FORM 2W:MAR 2'O0
MEDCOM - 4554
LISA PA V iol.
DOD 011033
. REPORTING MTF 2. MTF LOCATION
1 b)(3)-1 2 3 8 (State or Country ADMISSION AND CODING INFORMATION
LI Code.) For use of this form, see AR 40-400; the proponent agency is OTSG
9 wi, I tM INIUMUtH 10 11 12 13 14 15 NAME (Last, First, Middle Initial) 13)(6)-4 . PAY GRADE . SEX
6)(6)4 13)(6)-4 16 17 18
DATE OF BIRTH (YYYYMMDD)
19 20 21 22 23 24 25 26 27 28 29 30 I.. y. 31 t I HNIC BACK- RELIGION
GROUND
10. LENGTH OF SERVICE
ETS
11. FMP
12.
SOCIAL SECURITY NUMBER
32 33 34
35 36
37 38 39 I 40 I 41 I 41 I Al I AA I A,-
(b)(6)-4
q 9
ORGANIZATION
(Active Duty Only)
13. MARITAL STATUS
I • •
ADMISSION
46
1-7CS 1
14.
FLYING STATUS
15.
BENEFICIARY CATEGORY
16.
ZIP CODE OF RESIDENCE
47 48 49
50 51 52
53
1 I
54 55 56 57 I 58 59
60 61
17. UNIT LOCATION
(State or 18. MOS Country Code)
19. TRAUMA
PREY. ADMISSION
62 63
64 651 66
67 68 69 70 71
YEAR NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION
72
ADDRESS OF EMERGENCY ADDRESSEE
(Include ZIP Code)
, b;t4;_¦ 111,ir it Kill r-te,
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21.
TYPE OF DISPOSITION
22.
MTF TRANSFERRED TO
23.
DATE OF DISPOSITION
(YYYYMMDD)
73 74
75 76 77 78 79 80
81 82 83
84 85 86 87 88
2 6 0
24. CLINIC SVC -
25. Vf" 4'
ADMITTING MTF TRANSFERRED FROM DATE THIS ADMISSION
89 90 26. (Y Y YYMMOD)
91I 92
93 94
95 96 97 98
99100 101 102 103 104 105 106
r4
2_ C.)
27.
LOCATION OF OCCURRENCE d
28.
MTF OF INITIAL ADMISSION
(Battle Casualty Only) 29. DATE INITIAL ADMISSION
(Y" Y YYMMDD)
107 108
109 I 110 111
112 113 114 115
1 18 119 120
121 122
FOR LOCAL USE
0
b)(8)-2
b)(8)-2
ADMITTING
DA FOR
EUITION OF MAR 89 IS nRsni PIT
USAPA V1.00
MEDCOM - 4555
DOD 011034
MEDICAL TREATMENT FACILITY
USNS COMFORT (T-AH 20)
LIFT OF OPPORTUNITY
NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY NUMBER
RANK/RATE
OFFICERS ONLY
ENLISTED
BIRTH DATE
SEX
DESIG NOBC
NEC
BRANCH OF SERVICE
NAMED AND ADDRESS OF PARENT MILITARY COMMAND
SHIP HOMEPORT
U1 C
BLOOD TYPE
RELIGIOUS PREFERENCE
MARITAL
IS SPOUSE
NUMBER OF
STATUS
ACTIVE DUTY
DEPENDENTS
NAME OF NEXT OF KIN (NOK)
RELATIONSHIP OF NOK
ADDRESS OF NOK
PHONE NUMBER OF NOK
. t,`W=.11?1-4(
43,:;•L .
PRINTED NAME OF PATIENT RECEIVING FLIGHT TRAINING
SIGNATURE OF PATIENT
14,
YatteW ''''.:,,4±§.4 ;&4,frO'-0-11
:44
ku
--7PR1NTED.NAME.OF :6)(6)-2
MEDHOLD COORDINATOR
:6)(6)-2 LD COORDINATOR
PRINTED NAME OF ATTENDING PHYISICIAN
IING PHYSICIAN
tr,MA.,
VV&7 ft,N ax‘. 7FAT,ViWir25:MgrAVOI.W;MW.7trrag,N67,4
zalosimikacia4Agauftrai lift4U24,
.
MEDCOM - 4556
DOD 011035
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MEDCOM - 4557
DOD 011036
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Dal- Admission: 4/18/2003 iTransfer: History: Age: Gender: M 22 y/o Iraqi male s/p motorcycle MVA approx 5 days prior to admission; had ex fix placed to
road rash. L femur fx same day. Mild
Hospital Course:
begin crutch training, NWB LLE on 4/21
Diagnoses:
R closed proximal diaphyseal femur fracture which was converted to open by proximal ex fix pins which communicated
with
fracture site.,
Ion ghs,JK cuf ieAJ 400-
tivsw6""-q^4-° 6Lv-42 p-rAl-k500_0k—/
OLC--C--e (.1-Sx.)S ULA, I V ktvlie
b)(6)-2
Surgeries/Treatment:
ex fix in field on date of injury; 4/20 removal of ex fix and anterograde IM femoral nail; I&D of ex fix
packed with acetic acid packing.,
IM nail done; to begin crutch training NWB LLE on 4/21; needs packing changed with acetic acid through 4/28, then
change to wet to dry packing for ex fix wounds only.
Special Needs:
requires packing change qd and wound checks qd; will need staples removed.
Prognosis: Good
,X13)-2
Physician:
LCDR Dept of Orthopedics
4/24/2003
MEDCOM - 4560
DOD 011039
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DOD 011043
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MEDCOM -4566
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MEDCOM - 4567
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MEDCOM - 4569 ¦•••
DOD 011048
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MEDCOM - 4571 f.
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DOD 011050
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DOD 011051
INPATIENT TREATMENT RECORD C.. .J3 SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
REGISTER. NUMBER b)(6)-4 tn(6)-4 GRADE ADMISSION REMARKS
. RACE PREVIOUS ADMISSION
11. 15. FMP FLYINL, STATUS 16. 1,. S b)(13)-4 RATING! DSG 17. DEPT./ BEN [Z.......7 (( 3. . 8. ORGANIZATION BRANCH/CORPS 19. UIC/ZIP .. . 14. WARD 1 elAr 20. TYPE CASE 1 ilj
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF . ADMISSION 23. CLINIC SERV!
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TY ,2/13-1) DISPOSITION q 26.013TA2 DISPO T
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. ,........, 28. DATE OF THIS ADMISSION ADMITTING OFFICER
og
29. b)(3)-1 NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. DATE OF INTIAL ADMISSION 32. UNITS OF WHOLE BLOOD: COMPONENT TRANSFUSED
31. SELECTED ADMINISTRATIVE DATA
33. CAUSE OF INJURY Check if Continued on Reverse
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES .12)-tAA.A4 &#d--k.. qt,/-/qt_s-/ 114)-tii-I
35. a. Total Days This Facility ABSENT SICK DAYS b. OTHER DAYS C. . CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS I. TOTAL SICK DAYS
36. SIGN Total Days All Facilites ABSENT SICK DAYS b. b)(8)-2 OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS b)((3)-2 SIGNAT e. BED DAYS I. TOTAL SICK DAYS
DA FUNIVI it34/. MAY /9 Crw•inki nc 1 „„nin ,¢ is n170,1 L.', - — - ---- - - - - -
MEDCOM - 4494
DOD 010973
INPATIENT TREATMENT RECORD CC): .. SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
1. REGISTER NUMBER 12 NAMF II ast. First. MII _ — 13. GRADE ADMISSION REMARKS
.13)(13)-4
.13)(6)-4
,.. . RACE PREVIOUS NO ADMISSION
11. FMP S 13. ORGANIZATION 14. WARD b)(6)-4
C7 1C ani
15. FLYING 16. rw-s1.1 ,1 / Tal-r-I . I 1 .... BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE STATUS OSG BEN
. —
.
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23. CLINIC SERVICE ADMISSION
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYP DISPOSITION 26.0 ETEA.0,? DISPO IT
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28. DATE OF THIS ADMITTING OFFICER ADMISSION
o .tv-ca.
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. DATE OF INTIAL 32. UNITS OF WHOLE BLOOD/ ADMISSION COMPONENT TRANSFUSED
86TH COMBAT SUPPORT HOSPITAL, LSA ADDER, IRAQ
31. SELECTED ADMINISTRATIVE DATA
Check if Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
&,,uvibei R ow-) ) Li
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS I. TOTAL SICK DAYS
36. ( Total Days All Facilites / ( (
a. ABSENTc ICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS I. TOTAL SICK DAYS
SIGNA 13)(6)-2 ( SIGNAT b)(6)-2 ( /
EDITION OF 1 AUG 76 IS OBSOLETE USAPPC V 1.10
MEDCOM - 4495
DOD 010974
MEDICAL RECORD PROGRESS NOTES
DATE
t(, .-..i Is :14, ...... ¦,.. _ .1 a, —I •—¦ • - . & P-9
fi
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(Continue on reverse side)
I
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last lint, middle; REGISTER NO. WARD NO.
grade: rank rate: hospital or medical facility)
''
,13)031-4
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescribed by GSVICAIR.
FIRM R(4 1 CFR)20 1 -45.505
509-111
MEDCOM - 4496
DOD 010975
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 U GATE OF ORDER TIME OF ORDER LIST TIME
ORDER
NOTED AND
2 2 --) 0
"b)(6)4
HOURS
5/ '2- / 0 -7
Cs A (rt..... i 4 -6L) T c ") •
•)(6)-2
& ,/ -6 ti 0 5-e V,' I C -e OA-. (Z.N
b)(6)-2
Yl x /3 L.JC t" gj 4,4 ti, Yin L e
rtse 6 Lit (...,.,„ I t —f-
NURSING UNIT ROOM NO. BED NO.
c. -, 4-( fr., _t-(J5
1 r0
Pen( f kt 4 1,¦,-r i.4--1,11 Wo Sc l-f ceirr ( 0
PATIENT IDENTIFICATION DATE OF ORDER
TIME OF ORDER
HOURS
Pit) Li I fri -r _s
R.N., v--zi 5 I. Iui cho .e 1 ACI ." f.1 4- C (1? S) tae fri A 11/76 -e t\A er t2_,< A-0 rTCC
i.404,,, A ;C,. Ca y, 61,55° lkot-) 3a)
NURSING UNIT ROOM NO. BED NO.
5 C-c-cell ep.AJ
(IA 6 tivi
n G P-f ---c. kowtt
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
b)(6)-2 _ HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
(b)(6)-4
t 0 -( -1 03p1-‘-.,t J3 HOURS
(ThLc, (C.-(4-0140¦0.
•--------. 45-t-5
0 ,u L) r'''''1/4• ei j 0 p ( ec() 4Z ,:-e s ..,,, ( ; e"5
diA9-.4"fr•;--7 , 1-Si ( --C i r` - •=7
NURSING UNIT ROOM NO. BED NO.
b)(6)-2
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 1FAOPIIIM79 4256
MEDCOM - 4497
DOD 010976
CARE PLAN (NON-MEDICATION)
THERAPEUTIC DOCUMENTATION
CLINICAL RECORD For use ol this form, see AR 40-407; Nb . .. Yr. :.,.....,...,........,.....,...„......„:„................„.........„.............theprotmergAsen
v is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EAC'll COMPI.EI ION
vE.R I I , Y II Y INITIALING :;:iiiiiiii::::;:iiiiiigiiii,iii!:,:ii,:,:::::::::ii::;:,:*:::;::::::::;;;:::;:;:: Pii;ingi:::::;:!:].
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED
DATE NURSE FREQUENCY, TIME
Le•&L----_ b)(6)-2
• . -
1
.... . — _ _ •
I . ---VS-.S114k------- 4 1-
o v
b)(6)-2
._.. . -• . -----—.._ — — — -
. , -----------------'--------
1
ADDITION Al. PAGES IN USE ALLERGIES: Ei YES ED NO PRIMARY DIAGNOSIS:
El YES LINO
PAGE NO ....__ ____ ...... ____
egt.litAl 0eAAAvtgt.& bahk
PATIENT IDENTIFICATION
ACTION TIMES
:b)(0)-4
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 .11 12 13 14 15
E 16 17 18 19 20 21 22 23
Pd on ni rv) nq FM nr, ()R. (17
EDITION OF 1 DEC 77 MAY BE USED.
DA FORM 4677, 1 OCT 78
MEDCOM - 4498
DOD 010977
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) mo' D U3
Order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Dale Nurse be Done be Done
b)(6)-2
b)(13)-2
S-h.‘ 0,841,4____54.6Alli.e-1-si.), eim 3-..Oo 5)--
514-res rop
?300
i_a-Nc, ..g4.,,,,,.___e_ea,,„, -5b,. vi-cyre 1-300
19--Qac ..4. ,....„,,,.... ., .._ ,....._ „, 6-1.) ..4.,„,,,:,_0(.7.
IP
Order! Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Date TIME/DATE COMPLETEDNurse ACTION, FREQUENCY
1
.,.
USAP
MEDCOM - 4499
DOD 010978
Verify by
Initialing THERAPEUTIC DOCUMENTATI, (MEDICA TIONS) A..c PLAN Mo. — Yr.__
SINGLE ORDER, PRE-OPERATIVES Dote to Time to Rially14110•114¦Maran.
be Given be Given Time lilvnn Initials
Order/ Expir Date Clerk/ Nurse PRN MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING; ADMINISTRATION
b)(6)-2
too
0 • L.,
s
MEDCOM - 4500
DOD 010979
CLINICAL RECORD
1 -..A EUTIC DOCUMENTATION CARE PLAN
Fr use of this form, see AR
::: the pro onen o IDIFA77779)".".
................... 40-407; '
. .........:.::::::::: t a encu is the Office of The Surgeon General.
..................................... :::::::::::::::::::::::::::::
.......
...........................
....................... Ma.
....................................... Yr.
INITIAL PROPER
01.0111111¦••
RECURRING MEDICATIONS, COLUMN POLLOWING EACH ADMINISTRATIOI —
DOSE, FREQUEN CY
DATE DISPENSED
....—___
ALL ERGI Ej YES D NO RIM A RY DIAGNOSIS:
A DDITIONAL
ENT I DEN TI Fl C A TION:
(b)(13)-4
DISPENSING TIMES.
VAL
CIRCLE ME_ D TIMES
D 7 8 9 10 11 12 13 14
DA 1 am 4678 E N 15 23 16 17 18 19 20 21 22 01 02 03 04 05 06
EXHAUSTED
.
MEDCOM - 4501
DOD 010980
f
REPORTING MTF
MTP. LOCATION
ADMISSION AND CODING INFORMATION
(State or
bX3)-1 Country
1 I a
Cork) For use of this lurm, see AR 40.400; proponent agency is OTSG
)16)-4
1 faCricY=13 Pallamac13
NAME (Last, First, Middle Initial
bX8)-4 . PAY GRADE . SEX
(6)(8)-4 16 17 18
6 DATE. OF BIRTH (YTYYMMOD)
AGE AT ADMISSION RACE 9. ETHNIC
RELIGION
19 20 21 22 23 24 BACK
25 26 27 28 29
GROUND
NMI
10 LENGTH OF SERVICE ETS
11. FMP
12. SOCIAL SECURITY NUMBER
32 33 34 111111111111111111110,11•211=1•111
b)(13)-4
ORGANIZATION (Actrve Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH/CORPS ADMISSION
a 46
14 FLYING STATUS 15.
BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 50 Ck\
60 61
MIN 11111111111111111111111111
AILL'IM INVAM1C-IlreA rarias
17 UNIT LOCATION (State or
18. MOS
19. TRAUMA
PREV ADMISSION
Country Code)
2 I 63 64 65 66 67 YEAR
68 69 70 71
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAMEIRELATIONSHIP Of EMERGENCY ADDRESSEt
ADMISSION
7 7
ADDRESS OF EMERGENCY ADDRESSEE thiclible ZIP Coo&
b)(3)-1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21 TYPE OF DISPOSITION
22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (Y Y M M D D)
3 74
:3 75 76 77 78 79 80 81 82 83 84 85 86
24 CLINIC SVC • ADMITTING
25.
MTF TRANSFERRED FROM
26.
DATE THIS ADMISSION (YYMMD 0)
87 88 89 90
91 92 93 94 95 96 97 101 102
A PI P1
49
•
2 LOCATION OF OCCURRENCE,---' ---28. MTF OF INITIAL ADMISSION . DATE INITIAL ADMISSIOFI (Y YAI-P4D 0)
(Battle Casually...-0;ily)
103 104 105 106 107 108 109 110 111 112 113 114 115 116
a
FOR LOCAL USE
8011
R 0411'1,6.
94,D--13
,149 )
EgBP I
ADMiTTING,BrFicen (Sionature as roavdroril
b)(6)-2
DA FORM 2985, MAR 89
lull u MAY 7J w um:A AL I L
MEDCOM - 4502
DOD 010981
1. REPORTING MTF .
MTF LOCATION
ADMISSION AND CODING INFORMATION
(Siete or b)(3)-1 Country
i f
1 2 3 4 5 6 7 8
For use ul this tom see AR 40.400; proponent agency is OTSG
Code)
b)(6)-4
3 REGISTER NUMBER
NAME (Last, First, Middle Mille 4.
PAY GRADE 5. SEX
9 10 11 b)(6)-4
12 13 14 15
16 17 18 b)(6)-4
6.
DATE OF BIRTH (YYYYMMD0)
7.
AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION 19 20 21 22 23 24 25 26 27 31 BACK
28 29 • 30
GROUND
10 LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34
35 36 BIBILIIIIMMIIIIMIIIMPIIIIIRI
b)(6)-4
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH 1 CORPS ADMISSION
46
A ioa
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 50 51 52 53 54
55 56 57 58 59 60 61
17.
UNIT LOCATION (State or
18.
MOS 19. TRAUMA PREV ADMISSION
Country Code)
62 63 64 65 66 67 68 69 70 71 YEAR — NO .—.
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
,------
ADDRESS OF EMERGENCY ADDRESSEE (hvimle ZIP Cod&
72 (M3--
AMP AWL! nrArtruurtY 161Pfurel TAF NrA4c 12 F e II 120... bX3)-1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21.
TYPE OF DISPOSITION
22.
MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD)
73 74 75 76 77 78 79 80 81 82 83 84 85 86
At be----------
24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDO)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 1 101 1 102
A i2=' 0, i - 0 3—.¦ 0 5--- 0 --,
27. LOCATION OF OCCURRENCE (Battle Casualty Only) 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y YMMDD)
103 104 105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE '
81,041 g R dAdri}I p 6. s it
A rilLA ITTIAir .0¦FFIr•ela ic.,..-...... --..,--..... b)(6)-2 ,b)(6)-2
DA FORM 2985, MAR 89 La I KA, Ul MAY
MEDCOM - 4503
DOD 010982
• .JPATIENT TREATMENT RECORD CO, -SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
b)(8)-4
1. REGISTER NUMBER 2. NAME (Last, First MI) 3.
GRADE ADMISSION REMARKS
;b)(8)-4 b)(6)-4
4. SEX 5. AGE 6. RACE ......-..... .....,.._. ii ...... .......... J. ETS 10. PREVIOUS
A ISSION
2.15e41
11.
FMP
12.
SSN 13. ORGANIZATION 14. WARD
b)(6)-4
Ge
-reCO i
15. FLYING 16. RATING/ 17. DEPT./ 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE
STATUS DSG BEN
-. .
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22.
HOURS OF 23. CLINIC SERVICE ADMISSION
..1.0\9 0 k 23_0 7, Raz3-9‘
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25.
TYPE DISPOSITION 26. DATE OF DISPOSITION
G 3 rvi 4 v 0
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
27b. TELEPHONE NO. 28. DATE OF I-l'IS ADMITTING OFFICER ADMISSIO
dz. yz-zrqy 63
29.
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30.
DATE OF INTIAL 32. UNITS OF WHOLE BLOOD/
ADMISSION COMPONENT TRANSFUSED
b)(3)-1
31. SELECTED ADMINISTRATIVE DATA
Check it Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
\..i
$b
c / / ..."
t. 1 05
9.1 '.1
6
35. Total Days This Facility
a.
ABSENT SICK DAYS
b.
OTHER DAYS c. CONY. LV/COOP d. SUPPLEMENTAL e. BED DAYS t.
TOTAL SICK DAYS
CARE DAYS CARE DAYS
36. Total Days All Facilites
ABSENT SICK DAYS b. OTHER DAYS C.
CONY. LV/COOP d. SUPPLEMENTAL e.
BED DAYS f.
TOTAL SICK DAYSCARE DAYS CARE DAYS
SIG (b)(6).2 SIGNATURE OF PAD OR MEDICAL RECORDS OFFICER
b)(6)-2
DA j745RM 3647, MAY 79 FrIITIM Its 1 all.. ,..-..--...-.- USAPPC V1.10
MEDCOM - 4486
DOD 010965
• INPATIENT TREATMENT RECORD CL •.,‘ SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
b)(6)
1. REGISTER NUMBER 4
b)(8)-4 3. GRADE ADMISSION REMARKS
M03)-4
4. SEX 5. AGE 6. RACE r. RELIGION LENGTH OF SVC 9. ETS 10. PREVIOUS
r ADM ISSION
ITRATI
1 1. FMP 12. SSN
13.
ORGANIZATION
14.
WARD
qg
( b)(8 )-4
TC.C4.) i
15. FLYING 16. HAIIN(Ii I f. DEP I ./ 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE
STATUS OSG
BEN .. .
In
21.
SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22.
HOURS OF 23. CLINIC SERVICE,./ADMISSION
0 REi r
4 NAME/RELATIONSHIP OF EMERG ENCY ADDRESSEE
25. TYPE DISPOS TI N, 26. DATE OF DISPOSITION
6 3 11-7 41
27a.
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b.
TELEPHONE NO. 28. DATE OF T IS
ADMITTING OFFICER ADMISSIO
6Z rfri 14 d_5
29.
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30. DATE OF INTIAL 32. UNITS ADMISSION
D
:13)(3)-1
31.
SELECTED ADMINISTRATIVE DATA
Check if Continued on Reverse
33. CAUSE OF INJURY
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
35. a. Total Days This Facility ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS 1. TOTAL. SICK DAYS
36. Total .Days All Facilites ABSENT SICK DAYS b. OTHER DAYS C. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS I. TOTAL SICK DAYS
DA FORM 3647, MAY 79 „.,.-..__ . ..._
USAPPC V 1. IC/
MEDCOM - 4487
DOD 010966
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
I ID)
0 a-c { i
. LAI Ift DL415D — 1 c2 0 P 11._ IA A al
...A 4• ` — A &A at S b IL i I 1 LS ifit a t i s). . objx.A1
LOA4 C;<1*-Q_ 6; Sla- Ilb 'q--(7-11A4971 iei/O EL -Q ACIUL, 11-12-k_ust a ,:) 12 cVatcu nob 4'609—
1 -i ON-4-1rd IA , 1 \01,1AL a AnAl/ 1,10 V Y • 0(4-ACE} 0 a,,04--41) )2_ LE, - an)-i_Ls/ 0 n1evt-L0.071-04
1 b)(6)-2
• -/61k)
• 1 .1 .¦ 1 / a d a " ALA - - /61k)
I .
ib)(6)-2
lb ./. ... OLT'4 403 t pw°,9,4 0 /
II-1114 6 gm II' '
; / , • it , c-,,,ed -1 ay - .9 i . -5, R h Z ss MI b)(6)-2 7f1..7
„D Au ,.._ a , .F.Ral Ad b AI _ — . er.arA r•_. d ..• // I:lir ,..„-;
. __
41. 1 k • l a 2.¦ A/ ArLei __¦; ../ A po.,14,iL /mil- Plo
,
.4,, ...r : -A • ill .• :1 • Rh 1..:1.: to 4 .., • irk 1111 ,
L
e• • , I 4 1: a / /,.s. 4N a 77 R . _ IIIA'
il¦ill¦.10.¦-¦..
-4 A 2
• AP At , r . IP ilt_ A • P al ii d
1 .
1111' •I , 111l alb 0 lk .a Au_
b)(6)-2
OrA • 410. .
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
(SSN or Other)
LAST FIRST MI DEPART./SERVICE HOSEITAI OR MEDICAL FACILITY/ RECORDS MAINTAINED AT
bX3)-1 PATIENT'S IDENTIFICATION: (For typed or written entnes, give. ivame - Iasi, Mi(, ITIRIUM, REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Grade) b)(6)-4 /r/I /(-) /
PROGRESS NOTES
ecor
STANDARD FORM 509 (REV. 5-99) Prescribed by GSPJICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 4488
DOD 010967
CLINICAL RECORD • DOCTOR'S. ORDERS
Foruse 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 PROB-LJEM . ORIENTED . MEDICAL RECORD SYSTEM IS USED, WRITE PROB LEM NUMBER IN COLUMN INDICATED BY ARROw BELOW. PATIENT IDENTIFICATION DATE OF ORDER : LIST T IME
TIME OF ORDER 0110E9.
•,b)(8)-4
2.2--C2-C) HOURS NOTED AN(
e SIGN
c
„--,nmLL wc:r-
NURSING UNIT ROOM NO. 8ED NO.
_?‹ ork4:n ) c P X76)fp-
I.C.I
)-A)
PATIENT IDENTIFICATION
b)(6)-4
NURSING UNIT ROOM N.O. BED -NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF 'ORDER.
HOURS
:b)(6)-4
NURSING UNIT Room-No.• BED . NO
PATIENT RDENTJFicATioN DATE OF ORDER. TIME OF ORDER
,b)(13)-4
"PORS
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1vp9Rm79 4256,
* U.S. GOVERNMENT PRINTING OFFICE: 1994-303.710
MEDCOM - 4489
DOD 010968
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) I
For use of this form, see AR 40407; the ro mint c Is the Office of The Surgeon Demirel.
CLINICAL RECORD I Mo. 5 Yr. f. _
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INITIALING —
ORDER DATE W01'1 51a1) CLERK/ NURSE L, ...b)(6)-2 RECURRING ACTIONS, FREQUENCY, TIME I P-P-431141. .1)__)1),.slakiL-, (& _0 - HR al_3 L-I bm. 76)(6)-2 2()(6).(. 7kb)(6)-2 s- DATE COMPLETED to --+ 5C
b)(6)-2 L"b 01. // I(b)(6)-2
1 11 IS /
:x6).2
. .
ADDITIONAL PAGES IN USEI,PRIMARY DIAGNOSIS:ALLERGIES: 0 YES 0 NO
0 Y ES 0 NO
jr1 V75- R. Lail 0$) PAGE NO.
PATIENT IDENTIFICATION: 'CI
6)(6)-4 ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA F0748 4677 EDITION OF 1 DEC 77 MAY BE USED.
MEDCOM - 4490
DOD 010969
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
65
Yr
nit sling /NON MEDICATION) Mo
Order Clerk Dote to T me to SINGLE ACTIONS Time Done I Initials
Date Nurse be Done be Done
i b)(6-2
b)(6)-2
.
1 'i •• • 0 c i.ryud-1 Ct_i0 a3 auab etia5
...-I
, Ch - - • Ve Gl.k. j COS2PS' '6 V
._.___.
. . . . . .
•
. . . . _ . .
1 ........
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk/ P RN
Expir
Dote TIME/DATE COMPLETED
Nurse ACTION, FREQUENCY
. ..
U.S. GPOO997-08-290/55267
MEDCOM - 4491
DOD 010970
1 r-,'‘-rORTING MTF
ooTTF LOCATION
.ADMISSL..-AND CODING INFORMATION
3 " j 5 T6 I 7 181 (P•M or
'b)(3)-1 Country
Cody) see AR 40-400; proponenI agency is OTSG
For use UI this lurm,
6)(8).4
3. REGISTER NUMBER
L NAME (Last, First, Middle Innis°
(b)(8)-4 . -PAY GRADE
. SEX
b)(6)-4
1 6 17 18
6. DATE OF BIRTH (1. Y Y Y M D D)
. AGE AT ADMISSION
9. ETHNIC RELIGION
BACKGROUND 31
..1/0
10. LENGTH OF SERVICE
11. FMP
72. SOCIAL SECURITY NUMBER
32 33 34
37 38 39 40 41 42 41 ad ac
(b)(6)-4
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
if
HOUR OF BRANCH/CORPS ADMISSION
14. FLYING STATUS
15. BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 48 9 •• 53 54 55 56 57 59 61
58 60
17. UNIT LOCATION (State or
18. MOS
19. TRAUMA
Gauntly Code) PREV ADMISSION
62 63
64 65 66 67 68 9 7 71 YEAR NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
7 igRa
NAME Ab(D,LOCATION Of MEDICAL TREATMENT FACILITY :b)(3)-1 TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
22.
MTF TRANSFERRED TO
23.
DATE OF DISPOSITION (YYMMDD)
73
b)(3)-1 81 86
24. CLINIC SVC - ADMITTING
25. MTF TRANSFERRERBI E THIS ADMISSION (YYMMDD)
87 88 89 90
97
I 4 P1
27.
LOCATION OF OCCURRENCE
28.
MTF OF INITIAL ADMSSION
29.
DATE INITIAL ADMISS (Y
(Battle Casualty y) M M D D)
103
105 106 107 108 109 110
111 112 114
1
113 115 116 1
FOR LOCAL USE
-7772../AALL--
c3.0
EA44..
eyi '1
ADMITTINg OFFICER (Signature, as raquIreCi›.--:b)(13)-2 SIGNATURE OF ADMITTING CLERK
b)(13)-2
D—A7FORM 2985, MAR 89 LDi I ION U MAY 79 IS
MEDCOM - 4492
DOD 010971
1 . 14.1:FORTING MTF ITF LOCATION
•DMISSt...... AND CODING INFORMATION
12 13 7 T-8-1 (Stele or
b)(3)-1 Country
Code) For use of this form, see AR 40.400; proponent agency is OTSG
. REGISTER NUMBER
NAME (Last, First, MMus Initial)
. PAY GRADE
. SEX
9 I 10 I 11 2 13 14 15
13)(6)-4
3)(6)-4 16 17 18
. DATE OF BIRTH (YVYYMMOD)
. AGE AT ADMISSION IL RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 3 1 BACK-
GROUND
10. LENGTH OF SERVICE 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34
35 36 37
1
1 38 39 I 40 141 42 143 44 145
b)(6)-4
ORGANIZATION (Active Duty Only) 13. MARITAL. STATUS HOUR OF BRANCH/CORPS ADMISSION
46 I
14.
FLYING STATUS
15.
BENEFICIARY CATEGORY
47 48
49 50 51 52
17.
UNIT LOCATION (State or
18.
MOS
Country Code)
62 63 64 66
65 67 68 69 70
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD ADMISSION
72
OR_
NAME ANELLDC:ATION CIF ucrxrel TFIFSTUFAIT FA"Irry
MPH
21.
TYPE OF DISPOSITION
22.
MW TRANSFERRED TO
73 74
75 76 77 78 79
24.
CLINIC SVC • ADMITTING
25.
PAW TRANSFERRED FROM 87 88 89 90
91 92 93 94 95
A
27. LOCATION OF OCCURRENCE
28. MTF OF INITIAL ADMISSION
(Battle Casualty Only)
103 104
105 106 107 108 109
FOR LOCAL USE
16. ZIP CODE OF RESIDENCE 153 54 5655 57 58 59 60 61
19. TRAUMA 71 YEAR
NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
23. DATE OF DISPOSITION (YYMMDD)
80 8101 82 83 I 84 85 86
96 97 98
99 100 101 102
O °
1.3.
D)
110
111 112 113 114 115 116
. ADMITTING OFFICER (Signature, as required)
SIGNATURE OF ADMITTING CLERK
,b)(6)-2
b)(6)-2
DA FORM 2985, MAR 89
LUII La MAY 79 IS 1.30121. L I L
MEDCOM - 4493
DOD 010972
• INPATIENT TREATMENT RECORD COv,ri SHEET
For use of this form, see AR 40-400; the proponent agency is OTSG
b)(6) -2
2 NAME (Last. First Mt
(b)(3)-1 GRADE
ADMISSION REMARKS :b)(6) -4
SEX i5. AGE 16 RACE
leIVU In ur Jvk.
615
10. PREVIOUS ADMISSION
SMP ! 12 SN
13 ORGANIZATION
14. WARD
(b)(6) -4
9 cj
r c Lk .)
FLYING 16 HA I ING! 1
5. DEPT., 18. BRANCH/CORPS 19. UIC/ZIP 20.
STATUS TYPE CASE
DSG BEN
21 I.:OURCE CF ADMISSION /AUTHORITY FOR ADMISSION 22 HOURS OF 23 CLINIC SERVICE ADMISSION
24.
NAME:RELATIONSHIP OF EMERGENCY ADDRESSEE
25.
TYPE DISPOSITION
26.
DATE OF DISPOSITION
01,14-4 03
27a ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28. DATE OF THIS
ADMITTING OFFICER ADMISSION
2 IVO ti 03
29 NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30.
DATE OF INTIAL
32 UNITS OF wHOLE 81.001: b)(3)-1 ADMISSION COMPONENT TRANSFUSE(.
aLLL, I cu ANLAVIIIMIS ISA I IVt DA I A
IT Check 11 Commtleti LI. Rev..r..,
33_ CAUSE OF INJURY "
34 DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
but-
tAl
5)10 Gs
35. Total Days This Facility ABSENT SICK DAYS b. OTHER DAYS CONY. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS e. BED DAYS • 1 TOTA ICK DAYS
36. Total Days All Facilites ABSENT SICK DAYS b. OTHER DAYS CONY. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS BED DAYS
b)(6)-2 -ICER :b)(6)-2 SIG b)(6)-2
Afe 4-c we.
EDITION OF 1 AUG 76 IS DBSOI FTF
MEDCOM - 4462
DOD 010941
INPATIENT TREATMENT RECORD CO vcR. For use of this forrn., See,rAff40-,"4430;. the jirojicinentagericii; iS OTSG
,(b)(6)-42 NAME '11:0t,
MI)
GRADE
A.DMIiSION FIEMA! ,¦ K
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DOD 010952
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM -4474
DOD 010953
DATE NOTES
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DOD 010954
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DOD 010955
(--
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
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DA 1FA°419 4256
MEDCOM - 4477
DOD 010956
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 al,GN. EACH SET' OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER . IN COLUMN INDICATED BY ARROW BELOW. TIME
PATIENT IDENTIFICATION DATE OF ORDER TIM F ORDER ORDER
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DA ,FAOPRI:479 4256
vh. n < nnNi. MEDCOM - 4478
DOD 010957
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 :b)(6)-4 NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO. I Ia. I DATE OF ORDER ak" DATE OF ORDER HOURS LIST TIME ORDER OTED AND 7111.4a1PJb)(6)-2 allir SIGN TIME OF ORDER I (130 TIME OF ORDER HOURS
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NURSING UNIT ROOM NO.
DA
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
1FAOPHRM79 4256
U.S. GOVERNMENT PRINTING OFFICE: 1894-365-710
MEDCOM - 4479 •••••¦ • •••••••••¦
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DOD 010958
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) I
For use of this form, we AR 40-407;
CLINICAL RECORD MaftYr. 2005
the eroronont avency Is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
FIR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
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EDITION OF 1 DEC 77 MAY BE USED.
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MEDCOM - 4480
DOD 010959
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo W.,Yr _
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MEDCOM - 4481
DOD 010960
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD
For use of This form, see AR 40407;
liy. grap.m.nc 1 nu is the Office of The Sermon General . MOKftilt r. 2 VERIFY BY INITIALING !;;];:;;M:ANOMii ::;:kaniinniiii:OP.Oin,b; . INITIAL PROPER
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ORDER CLEM RECURRING MEDICATIONS, HR DATE DISPENSED
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USAPA1.11.0 .
MEDCOM - 4482
DOD 010961
THERAPEUTIC DOCUMENTATION CARE PLAN
Veiity by
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Initialing (MEDICATIONS)
Date to Time to
Order Clerkl Time Given Initials
SINGLE ORDER, PRE-OPERATIVES
be Given be Given
Date Nurse
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46
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14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
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17 UNIT LOCATION (Stale or
18. MOS 19. TRAUMA PREY ADMISSION
Country Code)
63 64 65 66 67 68 69 70 71 YEAR
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21 TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMOD)
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24 CLINIC SVC -ADMITTING 25. . MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y Y M D 0)
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27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL . ADMISSION. (Y.VMMD 0)
(Battle Casualty Only)
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DOD 010963
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t. REPORTING MTF . MTF LOCATION
ADMISSiuN AND CODING INFORMATION
(stale or
1 2
3 4 I 5 1 6 7 8
Count
For use of this lorm, see AR 40-400; proponent agency is OTSG
Code)
(b)(6)-4
3. REGISTER NUMBER NAME (Last, First, Middle Initial)
4. PAY GRADE 5. SEX
9 10 11 12 I 11 I 14 15
16 17 18
:b)(6)-4 (b)(6)-4
6.
DATE OF BIRTH (YVYYMMOD)
7.
AGE AT ADMISSION 8.
RACE 9. ETHNIC RELIGION •
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30
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HOUR OF BRANCH / CORPS
ADMISSION
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48 49 50 51 52
47 53 54 55 56 57 58 59 -60 61
17 UNIT LOCATION (State or 18. MOS
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19. TRAUMA PREY ADMISSION
Country Code)
62 63 64 65 66 67 . 68 69 70 YEAR
71
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20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD . NAMEtRELATIONSH F EMERGENCY ADDRESSEE
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23. DATE OF DISPOSITION (YYMMDD)
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75 76 77 78 ' 79 80
81 82 83 84 85 l86
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92 94
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28.
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.
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105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE
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MEDCOM - 4485
DOD 010964
•
.APATIENT TREATMENT RECORD COVE- _MEET
For use of this form, see AR 40-400; the proponent agency is OTSG
b)(8)-4
GRADE ADMISSION
NAME (Last. First. MI)
1b)(8)-4
REGISTER NUMBER
SE.x 15. AGE 6 RACE 7 RELIGION LENGTH OF SVC 9 ETS 10. PREVIOUS
ADMISSION
t-'711-1;
FMP 12. SSN 13. ORGANIZATION 14. YVARD
1D)(8-4
3
18. BRANCH/CORPS 19. UIC!ZIP 20. TYPE CASE
FLYING 16. RATING I uhP I .
STATUS DSG BEN
22. HOURS OF 23. CLINIC SERVICE ADMISSION 1 SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
Vt 2-Z 0S-2
25. TYPE DISPOSITION 26. DATE OF DISPOSITION
4. NAMeRELATIONSHIP OF EMERGENCY ADDRESSEE
28. DATE OF HIS ADMITTIN(.1 ADMISSION
27a ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO
2 mfivg 3
30. DATE OF INTIAL 2. UNITS OF WHOLE ADMISSION COMPONENT THANsr.:::,:,-
29 NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
31. SELECTED ADMINISTRATIVE DATA
.
Check .1 C0111 ¦ 1110,1i he,e,“
3 CAUSE OF INJURY
34 DIAGNOSES'OPERATIONS AND SPECIAL PROCEDURES
siff .s'Lti prezi< , C.94-0-661 piss-ze7 111-
T) (1-
1. t-H 5 r 1
35. Total Days This Facility
ABSENT SICK DAYS I b. OTHER DAYS CONY. LV/COOP SUPPLEMENTAL BED DAYS
CARE DAYS CARE DAYS
Z.
36. Total Days All Facilites
ABSENT SICK DAYS SUPPLEMENTAL BED DAYS 1) . 1 HI I, I
CARE DAYS
SIGNATURE OF SIG E OF PAD OR MEDICAL RECORDS OFFICER
(b)(6)-2
DA F cniTinki CIF 1 A
MEDCOM -4434
DOD 010913
(b)(3)-1
U§NS COMFORT , Date -` :,dmission: 4/10/2003
CH K. Transfer:
i)(6)-4
Age:18 Gender: M
History:
18 y/o Iraqi Woman, with GSW vs shrapnel to right side of neck, injury reportedly occurred 12 days ago, with exploration to neck 10 days ago at origina then transferred to /9/03, arrived to bx3H 4/10/03,for neuro eval and possiblesepsis
Hospital Course:
Admitted to ICU3 for close monitoring. Broad spectrum abx for presumed sepsis. Will require collar for 12 weeks. NEUROLOGY: Greenflield filter placed 21 APR due to excess rislcof DVT
Diagnoses:
GSW vs Shrapnel Right side Neck, with C-6 Spine injury with paralysis of all extremities except LUE., Rt. Parietal lobe stroke, Rt. Common Carotid traumatic aneurysm; Right vertebral and Right internal jugular occlusion
Surgeries/Treatment:
CT scan head/Neck 4/10/03; Head/Neck Angio 4/10/03; IV antibiotics,
Keep in C collar for now, may sit up. No surgical intervention required for c-spine. NEUROLOGY: Maintain on Low dose Coumadin (2 mg/day) for 3 mos due to Carotid dissection. Priorities are mobilization, rehab, optimize function r arm
Special Needs:
Prognosis: Guarded
(6)(6)-2
Physician: CDR Dept of NEUROLOGY 4/24/2003
MEDCOM - 4435
DOD 010914
APATIENT TREATMENT RECORD COW.. JHEET
For use of this form. see AR 40-400; the proponent agency is OTSG
FiEC:STER NAME iLast. First. GRADE ADMISSe.'N 46.4.•.r:r
6. RACE -17 RELIGION 8. LENGTH OF SVC 9. ETS 10. PREVIOUS
ADMISSION
SSN 13. ORGANIZATION WARD
70 (A) 3
RATING 19. UIC/ZIP 20. TYPE CASE
OSG
nj1
SDUI1C5. OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23. CLINIC SERVIC ADMISSION
C—ft-Q-- 0--4—
rlArne RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION 26. DATE OF DiSPOSil ION
AODF.E.S OF EMERGENCY ADDRESSEE (Include ZIP Codel 27h. TELEPHONE NO. 28 DATE OF HIS ADMISSION
( 03
2 in-/90'4 3
Nam': AND LOCATION OF MEDICAL TREATMENT FACILITY 0. DATE OF INTIAL 32. 01.1i1:i ADMISSION cOmP;iNL 6,' '••
SELECTED ADMINISTRATIVE DATA
1
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‘,S2 OF INJURY
::iiA;',NOSES OPERATIONS AND SPECIAL PROCEDURES
QSIJ c gez<
004-0
V)([ "13r
35. Total Days This Facility
APSENI SICK DAYS -F. OTHER DAYS CONV. LV/COOP SUPPLEMENTAL BED DAYS
CARE DAYS CARE DAYS
36. Total Days All Facilites
ABSENT SICK DAYS lb. OTHER DAY • LV/COOP SUPPLEMENTAL e. BED DAYS
DAYS CARE DAYS
S I GNATIM E OF b561-2 ECORDS OFFICER
(b)(e)-2
DA F EDITION OF 1 AUG
MEDCOM - 4436
DOD 010915
MEDICAL RECORD PROGRESS NOTES
DATE
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(Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or written entries give: Name—lass first. middle; REGISTER NO.
I WARD NO.
grade: rank: rate; hospital or medical facility)
I
PROGRESS NOTES
(b)(6)-4 STANDARD FORM 509 (Rev. 11-77)
Presaibs1 by SSMCMR.
FIRMR(41CFR)201•45.505
509.111
MEDCOM - 4437
DOD 010916
DATE
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PROGRESS NOTES
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MEDCOM - 4438
DOD 010917
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
1 a
DATE NOTES
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HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: For typed or written entries, give: Name -last, first, middle;
REGISTER NO.
WARD NO.
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b)(8)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REv.5-99)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM 4439
-
DOD 010918
AUTHOR r ED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-971
Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4440
DOD 010919
DATE
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MEDCOM - 4441
DOD 010920
AUTHORIZED FOR LOCAL R
MEDICAL RECORD PROGRESS NOTES
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MEDCOM - 4442
DOD 010921
DATE NOTES
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MEDCOM -4443
DOD 010922
MEDICAL RECORD PROGRESS NOTES
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(Continue on reverse side)
PATIENTS IDENTIFICATION (For typed or !waren entries give: Name—lots first, middle: REGISTER NO. I WARD NO.
gmde• rank rare; harpies/ or medical facility)
b)(8)-4
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77)
Prescrted by GSA/ICAIR,
FIRMR(41CFR)201-45.505 509-111
MEDCOM - 4444
DOD 010923
PROGRESS NOTES
DATE
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b)(8)-4
*U.S. GI) : 1995-397-405 STANDARD FORM 509 BACK (Rev. 11-77)
MEDCOM - 4445
DOD 010924
MEDICAL RECORD PROGRESS NOTES
DATE
LIAV b--6 , Oes 4 -iN0,1) tel_12_,u8
IA) ntk9icAv..4u e (-).5) hAA prn p th.);/ .
,a(VtA. /A,¦.."---j
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/ 0" D \Is .. al 1 (f) %‘ t W90 ea gc k -1 i?, . ..
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(Continue on reverse side)
PATIENT'S IDENTIFICATION (Foe typed or written entries glee: Name—last first, middle; gnsde; rank; rote; hospital or medical facility):b)(6)-4 REGISTER NO. I WARD NO.
PROGRESS NOTES
STANDARD FORM 509 (Rev. 11-77) Prescribed by GSA/10AR. FIRM R(41CFR)201 -45.505 509-111
MEDCOM - 4446
DOD 010925
.
174 - AS A CLINICAL RECORD FORM, IT IS COVERED BY DO 22C
(THIS FORM IS SUBJECT TO THE PRIVACyw
cS. START IN OR ANES. END Pagel 0f [ DATE 0/14•/O3
ANESTHESIA RECORD 1:9 1,24' 1,1,2?$ lb if
TOTS SURG START DRESSING OR NO
SURGECF;(8).2
OPERATION
PERFORMED: 5-up2A... ?ape 4,71 Rac'ekine-ri /-
TOTAL
PREOPERATIVE Cl
NTIFIED U IDBAND 0 QUESTIONIN9
CHART REVIEWED 9-NPO SINCE 1,1
. PRE-OP MEDICATION:
Drug Dose Route Time
stittilNA.a.j tYtl t
Pr e•Anesihelic Stale: . AWAKE
SEDATE
-APPREHENSIVE UNRESPONSIVE
ALM .
19 .
MONITORS AND EQUIPMENT 4
'Lt .
ANES. MACHINE I & EQUIP. CHECKED
•INV. B/P PNS
CONT. EKG V LEAD EKG
e
0PH. STETH. PRECORD STETH.
PULSE OXIMETER 02 ANALYZER
..F,..NO TIDAL CO2 .4vrL, MASS SPEC. SWAB(
4 TEMPERATURE
--WWARMING BLANKET . FLUID WARMER X
AIRWAY HUMIDIFIER
ANESTH
G TUBE (3 /rUBE
24.)1 p.
,„(5)
0 OPERAI
ARTERIAL LINE
LlCENTRAL LINE
V
A
LLJJ SWAN•GANZ
. FOLEY INSERTED: . O.R. . FLOOR 5/P CL
PRESS!
.
EYE CARE
.
PRESSURE POINTS CHECKED / PADDED _L
.. T
.. TIME ARTER
LINE
ANESTHETIC TECHNIQUE PRE-OP 200 PRESS!
VALUES
ja6ENERAL -43LOCAL/MAC •
. REGIONAL . NERVE BLOCK 180 PULS
1-Am
160 V C
SPONT, 0115 RI
140
INDUCTION
A
.
PREOXYGENATION . INHALATION 120
t.
.
RAPID SEQUENCE . INTRAMUSCULAR P ASS'S'
.
INTRAVENOUS . RECTAL RES
100
. S 1\
AAE‘
BO
R
AIRWAY MANAGEMENT.
N CONTRC
60 RES
S
. INTUBAT1ON ORAL . NASAL
8
DIRECT VISION BLIND . AWAKE
SAT
FIBER OPTIC STYLET USED 40
. ATTEMPTS x _ . BLADE
ETT SIZE _ . DOUBLE LUMEN TOURNI
20
STRAIGHT . . RAE 0 ANODE
11 / H
CUFFED ML AIR INJECTED
UNCUFFED, LEAKS AT CM H2O
F
. R Tidal Volume
ETT SECURED AT CM CRYS'
E Reap Rate
L010 F S Peak Pressure
BREATH SOUNDS
AIRWAY . ORAL 0NASAL .NATURAL
P
MASK CASE VIA TRACHEOSTOMY
NASAL CANNULA SIMPLE 02 MASK Symbols for 5.
7
E
LMA SIZE Remarks
C.
BLO
RECOVERY
TIME IN PACU CONDITION
-Sfr'h42-
foW
B/P 1(5/SI PU1liE4dRn'
TEMP leREMARKS
1/°
REPORT TO: yylvw --PARRS:
PATIENTS IDENTIFICATION
IN FLUIDS TOTALS OUT STF3}2
13)(6)-4
Crystai)tidi EBL 16 0
ti/Ci.-/AL/ ir Urine _Los_
Gastric
Blood
Anc I no inn aDo impar. APPROVED: 2 MEDCOM - 4447
DOD 010926
o fP ' •••• etsar_-
• .
b)(6)-2
NAME: SURGEON:
Planned Surgery Date: ANESTHESIA PREOPERATIVE EVALUATION AGE HEIGHT WEIGHT
.2c I
PROPOSED OPERATION BIP
PREOPERATIVE VITAL SIGNS:
PREVIOUS ANESTHESIA / OPERATIONS 0 NEGATIVE CURRENT MEDICATIONS
0 NONE
FAMILY HISTORY OF ANESTHESIA COMPL TIONS 0 NEGATIVE
ALLERGIES
NKDA
AIRWAY / TEETH! HEAD d NECK
SYSTEM WN COMMENTS PERTINENT STUDY RESULTS
RESPIRATORY Asthma Bronchitis COPD in Tobacco vss: . NO Yes Pack/Day for Years Chest X-ray Pulmonary Studies
Dyspnea Recent cold Pneumonia SOB Productive Cough Tuberculosis . •
CARDIOVASCULAR .
Angina Arrhythmia CHF . . -EKG
Exercise Tolerance Hypertension MI
Murmur MVP Pacern .aker
Rheumatic fever
HEPATO/GASTROINTESTINAL Bowel obstruction Cirrhosis Hiatal Hernia Jaundice Hepatitis N&V Ethanol Use : Illi No . Yes Frequency LFTs
Reflux/Heartburn Ulcers
NEURO/MUSCULOSKELETAL .
Arthritis 04 Back problems Headaches CVA/Stroke LOU 01 consciousness
Neuromuscular disease Paralysis Pareathesta
Syncope Seizures TIAs
Weakness
RENAL/ENDOCRINE
Diabetes Urinary retention Renal failure/Oialysis Urinary tract infection Thyroid di Weight loss/gain Urinalysis Thyroid FBS
OTHER
Anemia Pregnancy Bleeding tendencies Sickle cell trait Hemophilia Transfusion history Hgb/Hcl/CBC Lytes
PROBLEM LIST! DIAGNOSES ASA PREOPERATIVE MEDICATIONS ORDERED
.
4 5
COUNSELING. STATEMENT POST ANESTHESIA VISITS
Anesthesia alternatives, benefits and risks from minor to ANESTHESIA RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE. SO death explained. All questions answered. STATE) Patient / legal guardian voices understanding and gives
. .
consent for ; Local I MAC,
SAB, Epidural, IVR, General Anes. Other: • . Appropriate alternative as backup. NPO status explained.
DATE:
SIGNED: TIME:
PATIENTS SIGNATURE
DATE EVALUATOR'S) SIGNATURE
—:b)(13)-2 •
.!'m r .
DATE 4
,4./1,3
PHYSICIAN DATE
MEDCOM - 4448
DOD 010927
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEOCOM Circular 40.5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new ordertsI are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER NOTED COMPLETED DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER
NUMBER TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS _. . I OXYGEN: litres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air. 2 IVF: C./1.-@ flz-) cc/hr, bolus cc x 1 3 MORPHINE: ,.,)-11 mg IV q 5-10 minutes PRN pain. MAX dose of,,a2tng 4 DEMEROL: ,..--e) mg IV q 5-10 minutes PRN pain. MAX dose of gel mg
5 ZOFRAN: Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 DROPERIDOL: 0.625 mg ( 1/4 cc) OR 1,25 mg (1/2 cc) IV PRN Nausea X 1
7 REGLAN: Give 10 mg IV PRN nausea X 1
8 Release from "PACU" when Aldrete score is or greater 9 Call Anesthesia for any questions or concerns
FI7klIV/ S de .".". 4-1 / 47 pi,4 jOst C cn.... WI 4( do P-49.'"of
b)(6)-2
SIG
PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any
changes on subsequent pages.
• Diagnosis:
:b)(8).4 Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC V1.00
MEDCOM - 4449
DOD 010928
• CLINICAL. RECORD DOCTOR'S ORDERS
For Use of thit form, see AR 40-66, the prdpOnent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS: IF PROEfU'M 'ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION + DATE OF ORDER LIST TIME
TIME OF ORDER
ORDER
611. OPYC 74) a a 04.4 sip -'sui a) VC d ...- 4-.0s----C C"dlat HOURS 'b)(6)-2 a ' i Cceg 411%. 7 NOTED' AN( SIGN , t.
0 Vala_ LeAr1)S it..,.44...__L.
NURSING UNIT ROOM NO. ' ' BED NO, 6 1 )x o A ft. ( 4- Iv .. i si44+-ete d --no a . - •
PATIENT IDENTIFICATION 41i) IY e GATE OF ORDE l TIME OF ORDER
if - eo1 (czis- &. c% i ( 4-Le....5 _i VIA HOU lk
fa___Pia
Ii.° _____Pr...._.__Ver...e,__:......_pWeArk_.1eS____ _ _____, -___
Itt4,44 I _,c-LtrekAA.:(-01 ea.)4--4-7,c--t
.
-4
.4
NURSING UNIT ROOM. NO. . .BED NO.
;
,
,
e
U tI .a.c4' — — 42 (IAA} oc,.
------ . -. . : T)
•
PATIENT ICE IIT I.F.I CATION-' . ". :OWTE'OF'. ORDER TI. , OE. ORDER:
0 1 _____pp,...-MI__ rib u p s
-rer e40.( -.'1C:tb
zsi,t3
40 El.$12_,471___27-____ 4 40, iA,LsOy 3: -ci
-..5_%.,
,
ilLyt._ "4.1-LA 1%4'14 Po -i,
NURSING UNIT ROOM N. O. BED NO.
• ___•____. .,..... -
L...._
PRAK) ' -ek-
PATIENT IDENTIFICATION DATE OF OR ER TIME OF
ORDER 1/“(614Ck I` Sit( -21r-7.4k.A.& tQAV% 1:
—Pit...
Pe eA,L_e. T it, %.-
-,
.. IM 6 letb-sr I 7 > I 0 ( r" P 4? .3-c. 6 6
. Ili !li
.________Uk.>_490 . t_Let) ,, "zck < q2.20.
. . ..
NURSING UNIT ROOM NO. BED NO.
b)(13)-2
II
,--•
)(6 )-2
REPLACES EDITION OF 1 JUL 77, WHICH MAV BE USED.
DA ,AvRm79 4256 AC.
0 U.S. GOVERNMENT PRINTING OFFICE: 1994-363.710
MEDCOM -4450
DOD 010929
"At e 22 3
44-c(
MEDCOM - 4451
DOD 010930
HE DOCTOR SHALL RECORD DATA TIME AND SIGN EACH SET OF ORDERS. IF
--OBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLE MBER IN COLUMN INDICATED BY ARROI ON.
PATIENT IDENTIFICATION 6)(6)-4 DATE OF ORDER .ME OF ORDER 1/11‘0¦ •./0 e HOURS LIST TIME ORDER NOT AND IC
NURSING UNIT 4 4'? Cc±'1 —Lf.
PATIENT IDENTIFICATION DATE OF ORDER 441/.A.-.2)121/ /23 TIME OF ORDER HOURS 6
"flIoccg'ffe% 10 /2h.s •
NURSING UNIT ROO M NO BED NO. S
PA . 1 I ENT !C:E.t.rlIfICATION DATE OF ORDER TIME OF ORDER (f)_ HOURS...
NURSING UNIT ROOM NO. BED NO.
0 ATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
12 41;
RS
6)(6)-2
1144,02 et.
_2
NURSING UNIT ROOM NO BED NO.
FORM
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
I APR 79
MEDCOM - 4452
DOD 010931
THE .DOCTOR SHALL RECORD DA"— TIME AND SIGN EACH SET OF ORDERS. IF ^ -1BLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WR ITE PROB LE • IBER IN COLUMN INDICATED BY ARROW • N.
LIST TIME
PATIENT IDENTIFICATION DATE OF ORDER I ..4E OF ORDER
ORDER NOTED AND
(b)(6)-4 HOURS
kr/ I SIGN
11 A
)04 .• ierair4
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
b)(6)-2
?I't° Chi4cQjki 1.1
P 11 ENT IDENrIIcI,T Io N DATE OF ORDER TIME OF OR
ki rAg_ 43 1600
NURSING UNIT ROOM NO. BED NO.
"ATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
ikkke _
ct)
-
,
NURSING UNIT ROOM NO. BED NO.
FORM REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
R„
t.,
MEDCOM - 4453
DOD 010932
THERAPEUTIC DOCUMENTATION CARE PLAN NON-MEDIC'ATION)
CLINICAL RECORD For use of this form, see AR 40-407; Mo a5 yi o 3 th- pronnent • ,n is the Office of The Surgeon General. — i.i../uF Y BY INI11..ILING Mili:;:illia0:;;:;:i: .:: :1:;:.:1C INITIAL PROPER COLUMN FOLLOWING EACI1 COMPLETION
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
It 5 U /
g-
.,b)(6)-2 2-Ydried3 -/MAI 5re;yrt 5 "'a' giact tut_ 07 . ¦ ..... ¦ -
b)(6)-2
Y
i ----
6)(6}2
bX8}2
Irref46._____ --16t /7(e-5-4-Li .V ( (b)(6)-2
r
TrPe...-fiie‘t (S
Kb)(8)-2
74.07 el_ _ _ b)(6)-2 _ # //,,i.6,1
0
ac _ ____________••____• _
.. _
_
...
b)(6)-2
_____ __. ______________ _____________ __...._ ___ _____ __.
-,b)(6)-2
ACT-1D ( ret,A6-
zAto -
•
(b)(6)-2
-
6)(6)-2
b)(6)-2
Zi_47(1l 3 — -NO Akit7 Ac q fYal id e.0 _Pj__ 0 )(8)-2
b)(6)-2
_ .
-fid5e > 11.0 66c; 02,4 z137 . I
_ 54') P i )70 1.100 I
60)-2
h_f D 5144s-0 a
b)(6)-2
b)(6}2
13)(6)-2
LI" o -uc...,c. -('.cil e__I-
__c.z_.1. _
b)(6)-2
4--o 14 _ ....... ......-.
/
6tA4 °3 ---- ----c_._e ____ci.i-eyse-_ 0,-,....__ z
i 1
S P -I (AD e 5 ii C 0
ALLERGIES. I J YES ED NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE
Li VES El NO
C3-50U --, Com a-1-,
!/e) 0 s sir, itc ., , G ( 4
Akc& ,
PAGE NO
N VO
PATIENT IDENTIFICATION
ACTION TIMES ,b)(6)-4 USE PENCIL.. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF I DEC 77 MAY BE USED. MEDCOM - 4454
DOD 010933
THERAPEUTIC DOCUMENTATION CARE PLAN
Verify by Yr
Mo ......____..
Initialing (NON-MEDICATION) te to fl'.O
Initialste to Time Done
Order Clerk ACTIONS be Done be Done Dale Nur5e
b)(6)-2
2iffv; i b 1(8)-2 iir(mil 1 .7,z...)/13 Crefr ia,41 b)(8)-2 cc,,. ,,,// j\kuJ 'Jew 231C
V)( sit 6$4,)c) Neck 1 Cu97d pss eei-,,,,i ea,ii1- M itiat) Z.3(
.. 05 ea/di/70i ; l'e•76(e ' -. •. /Oat/ /ani
&sc. Pr scc. Paboillm bifrt. Fax. Poivt / 3 Ivo' AM
43 ___5•1.f. i '46 '
NIP 0 c‘5, t"i otvicrt-9-( etAN) TrAto b-,0-1)) 1
o-PP-Preva C- UTi6-1-Sfe— eiv-15(csrL) riter. l314.11
111 (b)(8)-2 os .1/2-- bp p eq.,1--Le_C---e ,,,- 1 1e5ccv,„t LI-041.0. 3 ASAP 1.3 3
Kitt. 6)(8)-2 ji. ekit'OL-k. Ofr-clei-s on La Pi\-41 073 — C__..L.4_,8 e ‘c 1-e 1
• 17 ,,),, Csjke k--e, b tCC_a P-N, -1-6 v-e4. Ceese evl_+ /
ce& CvnC s is)Ler._ ,rzLte
bX8)-2 1
___________. _____________ . 1 .... __.....
[
.. .1-
INITIAL PROPER COLUMN FOLLOWING COMPLETION
Order/ PRN
Clerk/
Expi TIME/DATE COMPLETED
Nurse ACTION, FREQUENCY
0 ill
.
.
I . ..i_. I I I
1
.,. .. ..
MEDCOM - 4455
DOD 010934
CL.,. CAL RECUR'
APEUTIC DOCUMEN
TATION
For u il
VERIFY BY
INITIALING ••, the pro For a 38 of this form, PLAN ..eDicA7
""--"Tror'."
.... ......................
........ ency Is the Office 40-407; r
...................... • ...........
....................
. .......
..................................................... rhe Surgeon General.
ORDER
CLERK/ INITIAL, P MO•Yr.03
DATE NURSE RECURRING MEDICATIONS,
ROPER COLUMN FOLLOWING EACN ADMINISTRArrol
DOSE, FREQUENCY
DATE DISPENSED •••••¦•=a
b)(8)-2
21.CLL{Zdeis
.27,Z:e9
P2
6)(8)-2
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Iliril
• Ei a_ • !
1 immaillerilialial
irrits.0,...x.dit....gal now mitommo
al-mhorin
ALLERGIES: nj Y ES El NO
PRIMARY DIAGNOSIS:
Imri Imil
mow shwa
001 TIONAL
P
• 6 .5 4) (AGES IN USE:
Ajt02/g &j •Ak-64// Ca it, d isse,..1-¦ &..-1, 6 v4.
PATI I
EN T !OEN TI FICA TION: YES CJ NO
PAGE NO.
b)(8)-4 DISPENSING TIMES
D_KLDENQL, CIRCLE MED TI
_ S
D
7 8 9 10 11
12 13 14 E
15 16 17 18 19 20 21 22
FE.79
4678
EDITION OF 1 DEC 77 WILL N 23 24 01 02 03 04 05 06
BE U SED UNTIL EXHAUSTED.
MEDCOM -4456
_ -
DOD 010935
THERAPEUTIC DOCUMENTATION CARE PLAN .11•1••••¦••¦¦•¦¦leimpsywanrasierill
(MEDICATIONS)
Order Clerk/ mo. Date
Nurse SINGLE ORDER, PRE-OPERATIVES
Date to
Time to bo Given Initials
be Given Time Give.
P11.4/411 _48 ,•• b)(6)-2 '13)(6)-2 b)(6)-2 b)(6)-2 6)(6)-2 Pit I t add( fi 1ZA)0 2-1( ' . PRN MEDICATION, DOSE, FREQUENCY a16. ° 41elyieei 120446/9_, 2 fi/re/ INITIAL PROPER. COLUMN FOLLOWING ADMINISTRA770N .. — TIME/DATE DISPENSEDI., n a --MA1111EMii )(6)-2 fe MilMEM 171irkilb 111 Ill to b)(6)-2 LIP*" ,..--... b)(6)-2
-,b)(6)-2
• I • 11 1.1 I
MEDCOM - 4457
DOD 010936
CLINICAL RECORr • Th....APEUTIC DOCUMENTATION (For use of this form, sof> PLAN
IFY BY INITIALING ............ the proponent a ency is the Office of • -0-4(17; FDICA79/".".
_
.. iiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiiii he Surgeon Gonaral.
.................................................................
..................
INITIAL PROPER COLUMN FOLLOWING EACH
RECURRING MEDICATIONS,
DOSE, FREQUENCY ADMINISTRATIOI
DATE DISPENSED
11111111DIWitil t
b)(6)-2
am-m. Ili r¦am
I
• III
inns
L—
ALLERGIES:
ED YES c--]
NO
M‘42119.
PATIENT IDENTIFICATION:
:11)(6)-4
DISPENSING TIMES
lla...fakt40L, CI RCL E MEDTIME D
7 8 9 10 11
12 13 14
E
DA
15 16 17 18 19 20 21 22 FFOEReg 4678 N 23 24
EDITION OF 1 DEC 77 WILL BE 01 02 03 04 05 06 USED UNTIL EXHAUSTED.
MEDCOM - 4458
DOD 010937
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
SINGLE ORDER, PRE•OPERATIVES Distrito ,n Given Time to be Given Time Given Initials
}
Order/
Expir
Date
b)(6)-2
bX6)-2
)1)(6)-2
.....
o Set%
bX6)-2
b)(6)-
)(6 }2
PRN MEDICATION, DOSE, FREQUENCY
NSA-4,,P/ I
,per
lis;"-evolr IF
1 t)ge1-04s,-wre%p
0,46,1 ae-r_iay,
41,5,6 re-
InS011 P-4cx-
11-2°
1N Sua-a-r-E ect1-4—
.re,,...10ka
Vev-Az-v41.sor„. b bcpx-Y,\\,,ss,..e. pale 1 "0-i
IC qii¦ 716,-ma:c.a.:1u, 16D 1 5 9
paw 5 &-icfc p.A1 4-
rib rofrt A !Ws
te\Spq .2.--1-4?n iv eit—a
INITIAL PROPER COLUMN FOLLOWING ADMINITRA 7701V
T ME/DATE DISPENSED not ter
b)(6)-2
bX6)-2 b)(6)-2 b)(6)-2 b)(6)-2
b)(6)-
b)(6)-2
b)(6)-2
MEDCOM - 4459
DOD 010938
elleum¦ple
REPORTING MTF MTF LOCATION
, ADMISSIL,ii AND CODING INFORMATION
, (State or
Country
1 8
For use DI this lurm, see AR 40.400; proponent agency is OTSG
-8)(3)-i
Code) bX8)-4
3. BEGIVER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
b)(8)4
16 17 18
6. DATE OF BIRTH (YYYYMMD 0) 7. AGE AT ADMISSION 6. RACE 9. ETHNIC RELIGION
BACK-
19 20 21 22 23 24 25 2. 27 28 MI :Idl
GROUND
ufiramilummunnim
12. SOCIAL SECURITY NUMBER
10 LENGTH OF SERVICE ETS 11. FMP
35 36 37 I 38 39 140 41 I 42 3 1 44 4 5
32 33 34
-1,)(6)-4
BRANCH / CORPS ADMISSION
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF
46
22101E
A
16. ZIP CODE OF RESIDENCE
14. FLYING STATUS 15. BENEFICIARY CATEGORY
47 48 49 50 51 In 53 mil 56 57 58 59 60 61
....
a
PAL Ili `i i e_eiVAIKIIMVAMPACAIMI
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV ADMISSION
Country Code)
YEAR .
62 63 64 65 66 67 68 69 70 71
NO
j"
NAME RELATIONSHI OF EMERGENCY ADDRESSEL
20 SOURCE OF ADMISSION/ AUTHORITY FOR WARD
ADMISSION
72
ADDRESS OF EMERGENCY ADDRESSEE tlnclude ZIP Cade)
1..51.Q...C.:t 1e ick 3
az AND LOrATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF t HANSI-tHItt TO 23. DATE OF DISPOSITION (YYMMDD)
73 74 75 76 77 6 79 80 81 82 83 84 85 86
•
......
aor I 05 3
. — – 1 I 0 9S
- DATE 'THIS . .... .,.
24. CLINIC SVC ADMITTING 25. MTF TRANSFERRED FROM 26. ADMISSION (YYMMD0)
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 ADMISSION (YYMPADD) (Battle Casualty Only) •-,
/
' 103 104 105 106 107 108 109 110 111 112 113 114 115 116
FOR .Lowil. . /
17)C (7.--z S 14) k"._ i cc cl c( C,f,c _.<2.1-f• c.:4,1_,
e
6) -1-/13
f7t ,Ii-,0 a
L, p.,, , ,,
I TAA Ron+ c or
•
4.0 x.-)
411 VA l'frt tO
ol , ,. t 5-
S GNATURE OF ADMITTING CLERK
ADM (Onatur as r L/
ii) X , 7 ) —7
' `....:"
b)(8)-2
9 1
b'
DA A5, LDi I luN LJI MAY 19 It.',
MEDCOM - 4460
DOD 010939
1. REPORTING MTF MTF LOCATION
ADMISSIC,.. AND CODING INFORMATION
(Stares.
1 2 3 4 5 6 7 8
Country
b)(3)-1 For use (A this turm, see AR 40.400; proponent agency is OTSG
Code)
b)(8)-4
4. PAY GRADE 5. SEX
3. REGISTER NUMBER NAME (Last. First, Middle Initial)
16 17 18
9 10 11 12 13 14 15 ,b4s)-4
RELIGION
AGE AT ADMISSION 8. RACE 9. ETHNIC 3 1 BACK
6. DATE OF BIRTH (YYYYMM00) 7.
19 20 21 22 23 24 25 26 27 28 29 — 30
GROUND
12. SOCIAL SECURITY NUMBER10. LENGTH OF SERVICE ETS 11. FMP
36 37 38 139 40 41 142 143 144 45
32 33 34 35
BRANCH / CORPS
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF ADMISSION
46 2O/Sr
16. ZIP CODE OF RESIDENCE
14 FLYING STATUS 15. BENEFICIARY CATEGORY
53 54 55 56 57 58 59 60 6147 48 49 50 51 52
19. TRAUMA PREY ADMISSION Country Code)
17. UNIT LOCATION (State or 18. MOS
YEAR . 62 63 NO
64 65 66 67 68 69 70 71 .
NAME/RELATIONSHI OF EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD ADMISSION
72
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Coded
0 tivz_Q-i- 3-e tO 3
NA.. arm, I rirArun., nr sAcnirei TREATMENT FArn !TY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD)
73 74 75 76 77 78 79 80 81 82 83 84 85 86
24. CLINIC SVC -ADMITTING 25. MTV TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)
87 88 89 90 91 92 93 94 95 96 97 98 1 99 100 101 102
0 cl,.., PI FY .o S- v 2.
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYMMDD)
103 104 (Battle Casualty Only) 105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE
&is fro 4 eek...... 1 Ca/z-ofc Id csrs er2-1-( czi,..
/ A
b)(6)-2
SIGNATURE OF ADMITTING CLERK
At
b8)-2
LDI I lul 1 UI MAY 19
MEDCOM -4461
DOD 010940
IIIIIPNT TREATMENT RECORD COV
For use of this form, see AR 40-400; the proponent agency is OTSG
1. .087,. 2 ,b)(6)-4
3. GRADE ADMISSION REMARKS
an 1 u. /AL= 6. RACE , 7 RELIGION 8. ILItgil4 OF-SVC 19. ETS 10. PREVIOUS
I ADMISSION
11. F^IGI P 12. SSN 1 13.ORGANIZATION I 14. WARD
15. FLYING 16. RATING/ 17. DEPT.; 18. BRANCH/CORPS i 19. UICIZIP 20. TYPE CASE
STATUS DSG BEN
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. 23.
HOURS OF CLINIC SERVICE ADMISSION
Yid? e,--(- (flp 0.--A 9.
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. T P DISPOSITION
26. DATE OF DISPOSITION •
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28 DATE 0 THIS ADMITTING OFFICER
ADMISSION
It ag/PA 0>'
29.
NAMF ANOI nrATInN CIF mrnirAi TRFATMFNT FACII ITV
30.
DATE OF INTIAL 32. UNITS OF WHOLE BLOOD! ADMISSION COMPONENT TRANSFUSED
013)-1
3 . SELECTED ADMINISTRATIVE DATA
...................,„...........„.----....-....„..„.....„......,
Check it Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
Oieri /y0Ate4-17,..b--'iz ,3-
.,
11 / PX, 86 I 3c), 1 * .
fto 3
f 601 1 ) ii.40
Eqb5'cf--
fix' go I
.....--
-
y...
35. Total Days This Facility
--..,.._ '''--...
ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP '"
d7-1"-St1PPCEI9lEg1All e. BED DAYS f. TOTAL ICK DAYSCARE DAYS CARE DAYS
36. Total Days All Facilites
a.
ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP d. SUPPLEMENTAL e.
BED DAYS f.
TOTAL SICK DAYS
CARE DAYS CARE DAYS
13)(13)-2 ,b)(8)-2
SIGNATIIRF OF
ATTFNIfIlk1/1 hscnir AL OFFICER
SIGNATU
b)(8)-2
9.a-`TI CA. 0.1
DA
•• • • • Igwv• • •
USAPPC V1.10
MEDCOM - 4381
DOD 010860
DOCTOR'S ORDERS (Date and sign all orders)
M aru
a chin du-ye(--ckS
fe 10-r)
a,4 -
(1Z-0A
cci
gi,g1
(t),
er_dP ps
‘SZ(fir V/ k( (C) rAIJ
kia
4/
--....-...---
(b)(6)-2
jt•%/'... ..-
ems _
EMPERATURE -PULSE RESPIRATION
DATE T P R STOOLS WEIGHTAND TIME
0'5730 qq, Z tVO (46 t2;j7 CtirAG 6 L
t-n4f-rie4 C. .20 C e. //$ 0 ?
Tvunl 'i ifk 41 ( 2/ e'fd C V it,e-V
/1,-vra 7 Ll «I 'ivy ki Ki
3 M.101 e a 3(..3 1400 ce, ucp
_ „,,,
MEDCOM - 4382
111 111 rkoll \
DOD 010861
•r•
08-4pg oy
VS /;,- A3 00 /30/73 27,-/C-4;61-- 9, a.. AA tz,lig) • ,1-'f't' CA) ‘Z--4-t'PlA: Pega oT # GCSE 7 91 `,/
-/7-er-ft-e4_7 /94 gedvez._ bx.)_2
44, t)-92-.¦ ff'2.4sze_A7 oje
MEDCOM - 4383
DOD 010862
600.-1 08
tati 7540-00-534-41713
HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTO S, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
iel/re
--1-2-At-)
kJ'
a Ar‘ ----jg
C) 915'. b
cfr-t3QP.')-() ' AritgiVur n-Mirr) , Lei (s1 (-0 filtyv),14-U rcia 0 A-04 i* Ahcilia,,y1' efel
13c) Al¦ G`hie-d P .9)„,fer .Nbe a o Q14,„,,,714,4,,,..i
PR G` cib.c)Q • • 0.' i -b1;44, \ SL itn 41A•rt/J33.61n41
. . @ k.) . • r(e's. e If tr. LA Or reAS(Vtf2 'tli)r.'s 04 048.)4NeLaNi
r•
ily/y-4
Ajk-1- rok-ityfrist(V. /411-y peihke-lkkt-Q-tk c
b)(6)-2
1
Ef) 1.. •-• 2,.0 C9--,
I%--OkA ¦C 4. .' fl'" 31 tUrl +-0" IA...#.11
F
0-01,1A .•
,b)(6)-2
C1,11 ¦1V 4.1 P-e...._ 0.19 te._,
b)(6)-2
(ire
i 4
__CumeASINere-A--•
:b)(3)-1
PATIENT'S IDENTIFICATION (Use this space for Mechanic&
RECORDS MAINTAINED b)(8)-4 AT PATIENT'S NAME (Last, First, Middle initial) SEX
rtnPrint)
RELATIONSHIP To SPONSOR STATUS RANK/GRADE
SPONSOR'S NAME
ORGANIZATION
DEPART./SERVICE sSN/IDENTIFICATION NO. DATE OF BIRTH
CHRONOLOGICAL RECORD OF MEDICAL STANDARD FORM 000 (REV. 5•4)Prescribed by GSA and /CMR FIRMR (41 CFR) 201-4
MEDCOM - 4384
DOD 010863
509-113 NSN 7540-00-634-4122
MEDICAL RECORD PROGRESS NOTES
DATE -,
8 e-Al. f 3 09Z-0 RiutA-0.-e _ 6fAA 6,R. 10( # e S
r (
-
Cir_ A • W-41;4) -, — C
/ C° Iib (+IR SA s .g.so tzez (5 2--
. .. or •
LO WV` milllipil • 1 6 -4' 2-S--
03 fp irc. 6c) i ( 6, -9-9 s-. ), ()PS— I S I:* k.
., 0 3 2-4d 1/8 8 Z r /Y3-/L3 itif
114,11-ic + • : r.e..?-c.L....-¢_ eD 3 2-5-)1 1 64 , / S-914-1 5' 0
...,,, t 4.4. I
c, 3 30 I °C) i.3-if ( ?.c. -z.z. -4---
‘..,
1 11 St...t...-4 ct_v-. d Z 1.--+ At- -
e) 3 3 ..C. i c.,-z-89! P., 3/ lc, 2-cm
I) 6 *--..42C-1 a 3 'YO .9i 92% 152)769 241 . AT i- 5 c_ ...J i 7.0.41 e>c 3Y s-92. 9y >: i i( 21 1-, -2-/ ,i. 3 1— 044- Aw a . t-c, 35-2) 92 7y ,/-rtny 69 z3 A4
L. LS a ¦••J NO, d,-.V 1 n I Ss-9-rf?-2. Y. i uy (:. 6 2. 4, 4-3..
c. o r , 9y 93 / 133
c. r 4.4_ a , A •.., f,.. 1 0 `too GG 11
( 0 [t s-Are , CloSs' 98 9,0'. all G3 Z 1-
Of (c, /Go PUY, aG/Gy I-1-
II
("yrs Z6
6 'Cc) - Po. rev-..: Tc.z 92> 96K ITV to 5". ir 34.
as "6
ic-........,!: .1.-a. o 30 R , pit-0 '-(2,r, too ,57: ize/ 4 z. 34 dr it.-
nut &el- a, - v. • CLI .,c_ 3 t-i., Kao r GMAT #*::).. ,4' il" 23
Ai ic_ . o Y3 o 102 ----.6,..-..:( 12.57 4. 3 22
0 NS--to 1 I z*-z 2-AA
97-j. / 2. OSS i / 5-
9e.K 133 oqpi toy TY t `6v .Z3 .2L
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; REGISTER NO. hospital or medical facility)
MMH
MEDCOM - 4385
(r 73‘...._(.43 &I,
advvijo "e LA.,
4t) • 0
"
+ AIOU .L--`‘
P—R (91/61-a-6, 6,..t.t Leq....
.
_Pie. 14.4.e4A-Z4-46 _dl__4,_____
(44-14.9-i--1---
-A,A 5 k_._s •....21 .
2..e.-r 1., 45.0-1,-S, Ye.) is.45( Lc "-',5 wavy
2,4paz....64,-,-,..._f p u - e 4 sa_s 4.1 ft-4,k,
.... c....19 4..eog <. 3 fo-c-, pate. sk,,
Sp6-c-e-hio.,A.A.git-4,0061Le.-k,
1 u r 6") Y 0 e-- /' &L. le-t.
pig. e/WA- - lt'24... . cl.
3c)c)c.) 1 V r 6:
100 A t—Esc• try, (A,... -...) I
/(,0e.) 06-T orA F( t
-i.
E.„11--`
c130 -PAc. .A-LI' Ll , r.,
z.‘%j imsoy, /tip
14-051 Dui-Vi-*1 Ttiey,,
WARD NO.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 7-91)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
DOD 010864
AUTHORIZED FOV LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
b)(3)-1
,...,
41/43
c.44,(4.1
kCe9 e 4-t.vv44-k in :I
"--ki C LAX c 4 CO is i1/419 4-
c----....,,
...__ 01)
.-
'
LI lV-1 -
/
1 .
.A. „...—._—..
‘....-1
S (I)
4,
....k..4 4 4. D__ e4_,--,(-,--,5 P
Fi-- (( AA_ 116 8c
. v"...4_,A.,..-.-
b)(6)-2
HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
REGISTER NO. WARD NO.
Date of Birth; Rank/Grade.)
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 - 4386
DOD 010865
DOCTOR'S ORDERS (Date and sign all orders)
Al .'d Ltuh dr0Q3t. buld lAir1/401, 644 -1114-e
ft cuil 41. w avAir). tuno
-
-LPN
L sid-c oth. os, vds. b).4
-3
u, lam. JGo6 /Is, I-Is ,s6e99_ ,_ ;c177/ C-9-) A.10
:b)(8)-2
.„.1) 71i.L c
TEMPERATURE. PULSE RESPIRATION NURSES NOTES
•
MEDICATION AND NURSE'S NOTESAND EM E PR
DA IIT
fc.736 - ' 74637
MT PI
g? izr 2,--La-6+ tuv512-
130 r3 5L PA1
4),,,,w
.5 tilo 614543 1326
2%4 tad mir 0245°1-Prler) • 6 iz 210
'`I.V711 91 Qa tk,t0 5..7-— --c c,— ::-Lid CT cc
G oa oQ Lt( 0 ,Incbc1 — t1 IALV t 74, c)
ilitSe9 1-/ • 0 3_.c0
-(-7 04 ee L1/0
. Liii, ¦ . A 7 1 40 rit6j 61-'as/
mtot cig,0 r
r'1311-17-A.1 6.-1 ct.-EN,
A Ci
MEDCOM - 4387 LQ1Z., -yo.NA0 p
DOD 010866
PROGRESS NOTESMEDICAL RECORD
DATE
13 Daae. kr3 l' +y <111,-4.7 . 5
)(3)-I
a°0 / Z t Thu-e--OL,-) itc,,,f,„4 1,--.63j
1.,,,o-3 V. ty,...--... --441 ..4/4-----.1„474c,
, —;., ......A..... /Arms& .. .¦ AI .
, o
0 / 1 .
--,
$4,11,i/p f i ivb< 0A 174-5-' 0 c-r ,_ L 44-7/ er-ZAA-Z-. CadtAIA-1'
jr — 3,1/7r -i 5
' 44 A.A-vvu-sX *--upi-I rikr-i--
01 77-tdD,1 P-' ?I.. 2- 16. Pq/72 Pc-if/ F,i-c.,-1I
4:tovc-s --75?..0,144 , 2_ . ice-6--e—r--,,,,-,...
..AA '-' J
0 i 0 i I
.
4-4--,,_
0 0 ii_r_ t--7 --Pl....,
A i To b ---/ tt.,....1 , /1.-)„,,.. (c-,.ems
:-2-) to 0--„,..1.4 ,,,....-6 C 1 c.,_. -XL. p6 v - L -4 I ' ,es,...--",--vt-,-.---0--,k___ e.,..,,AN-1,-----q-(..._ g-c, "'CC g ".0.---( -,.....,e___ 4-OA cd-r
b)(6)-2
of_ -7 r_ .13)(6)-2
4 ii44-6, yr, c.__
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; REGISTER NO. WARD NO. b)(13)-4 grade; rank; rate; hospital or medical facility)
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 7.91) Prescribed by GSA/ICMR, FIRMR 141
CFR) USAPPC V1.00
MEDCOM - 4388
DOD 010867
11 1 10 -Oa 1 ¦Z
MEDICAL RECORD 1 INTRAOPE, DOCUMENT ___, For use of this form, see AR 40-407, the pruFen..mt agency is the office of The Surgeon General.
1. PAIIE4e;TRANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE
VIA t BY VERIFIED BY - '
3. DATE a; i 1 r, TIME PATIENT ARRIVED IN SUITE IAA 4. PATIENT IN TIME f, -00M NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
. CALM ANXIOUS . EXCITED . CRYING . ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS:
b)(6)-2
ASSIGNED
SCRUB
)(6)-2
ASSIGNED
CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
)if SUPINE . LITHOTOMY . COMMENTS:
HAIR REMOVAL XYES . NO
6. NURSING PERSONNEL RELIEF SCRUB
RELIEF CIRCULATOR
PRONE . KRASKE LATERAL: . LEFT SIDE UP . RIGHT SIDE UP
8. SKIN PREPARATION PREP SOLUTION (SeciWirt 41 (b)(8)-2
DONE BY: X OR . NURSING UNIT SITE: Ntly.e.U.R.0 0 11BY WHOM: S S6. METHOD: . DEPILATORY Al RAZOR SITE: BY WHOM:
. CLIP
COMMENTS: COMMENTS:
TcAbr() 0,rta. CCWCtoPASA
9. LOCATION OF EXTERNAL DEVICES
— •
)
IIIIPP.
LEGEND X Ground Pad -- Safety Strap. --.. Tourniquet
C Correct I -, Incorrect First Closing Final Closing
10. COUNTS Other•• Count Count . CIRCULATOR
b)(6)-2 b 2
Sponge Yes . No Needle Sharp ErYes . No Instrument ErYes . No
Ci C./ Other . Yes . No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) !7 YES . NO Name - Last first, middle; Grade; Date; Hospital or Medica Facility,)
(b)(6)-4
. ESU NO qalleq1.019 4-1V1 0)killest lie
GROUND PAD:
. ESU NO GROUND PAD:
0 BIPOLAR NO-BRAND LOT NO-
5514)e
BRAND LOT NO-
DA FORM 5179-1, OCT 87 REPLAC FORM 5179.1 (TEST), DEC 82, WHICH IS 013SOL
MEDCOM - 4389
DOD 010868
3484(1-JOH -a 1 1.5
MEDICAL RECORD 1 INTRAOPE, DOCUMENT ,,, For use of this form, see AR 40-407, the prv vo.,..tt agency is the office of The Surgeon General.
1. PAIIEWANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE
VIA i BY VERIFIED BY
3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN -00M ; 9 0 H
TIME
NUMBER
5. PREOPERATIVE EMOTIONAL STATUS
. CALM xo ANXIOUS . EXCITED . CRYING . ANGRY . WITHDRAWN . OTHER (Specify) COMMENTS:
8. NURSING PERSONNEL
b)(13)-2 •
ASSIGNED RELIEF
SCRUB W SCRUB
b)(6)-2
ASSIGNED RELIEF
CIRCULATOR CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
A
' SUPINE . LITHOTOMY . PRONE . KRASKE LATERAL: . LEFT SIDE UP . RIGHT SIDE UP
COMMENTS:
8.
SKIN PREPARATION
9.
LOCATION OF EXTERNAL DEVICES
HAIR REMOVAL XYES . NO
DONE BY: METHOD: )4 OR . DEPILATORY . NURSING UNITA RAZOR
. CLIP
COMMENTS: Tvbrc, orta, co-1341110-r\
LEGEND X Ground Pad
10. COUNTS Sponge Crces Needle Sharp ErYes Instrument Ii es Other . Yes
.
No
.
No
.
No
.
No
11. PATIENT IDENTIFICATION (For typed or written entries give: Names . I AO fleet mititiloa• (:mein„ Date; Hospital or Medical Facility;)
,b)(6)-4
— Safety Strap ---. Tourniquet C — Correct I Incorrect
First Closing Final ClosingOther** Count Count
(.
C.C. C.../
b)(13)-2
PREP SOLUTION (SpeciWid 431.151 SITE: Mille WIP YIBY WHO M: 3 S4 SITE: BY WHOM:
COMMENTS:
—
'
/—*-4---)
Cr`DI ID
CIRCULATOR
13)(6)-2
b)(8)-2
12. ELECTROSURGERY DEVICE(S) (ESU) OYES . NO
II II,,,,
tavi Rd 4 'vs I lle 1----GROUND PAD: BRAND LOT NO
. ESU NO.
55e.g
.
ESU NO:
GROUND PAD: BRAND
LOT NO
.
BIPOLAR NO.
DA FORM 5179-1, OCT 87 REPLA Ginn. rreerrs "sr" en OBsoi
m2 ICH IS
MEDCOM - 4390
DOD 010869
13. PROSTHESIS, IMPLANTS . YES . IF YES NAME: ID NUMBEF JFACTURER
b)(6)-2
114: „ a. -MEDICATIONS/ORDERS ,_ , ' , ,,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES -. --'1 NO W___..
ffillEDICATIONS/SOLUTION
DOSAGE TIME METHOD PREPARED BY GIVEN BY
ICICce7,1'
MOUND IRRIGATION K. YES . NO, TYPE(S):
tITHER ORDERS TIME CARRIED OUT BY
t)(6) 2
b)(8)-2 !PHYSICIAN
¦tiatIES= e ....411i . -,,e,....L . „ 44,,,- ,.,-. ‘,.„, ,, ,,,..-
15.
X-RAY i IF YES, SITE
YES . NO A
16.
i
LABORATORY SPECIMENS SPECIMEN (S) NAME
NAME YES . NO FROZEN SECTION (FS) NAME
NAME YES . NO CULTURE (C) 4 NAME
NAME
YES . NO p,
NAME NAME NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES NO .
TYPE/SIZE 1. 2Fg. 2. 3. Thwaric, lube. -\\
SITE 1in 2. 3. k.L'i
19. ADDITIONAL INFORMATION
,-.e vLA,-,,, (z ..., . ...cy.-47— ¦Vb..tiN) A-r-Yry
)*z=.)'‘‘t-
1
. . .
20. OPERATION(S) PERFORMED
21. P NT TRANSFERRED TO TIM E0 0 METHOD
GM 22. REGISTERED N RSE SIGNATURE I i I I tili/
________ __ _ --__
MEDCOM - 4391 'U.S. GPO: 19913-404-813/40449
DOD 010870
DATE E S T(S) SPECIMEN TAKEN REQUESTED TIME A.M. P.M. )03)-2 )(6)-2 1:9(6)-4
RESULTS z
Z Z
L•ol !"" Z:, 0
lo , Ha"
RF
mot/ sy,o,
AO 25,
,()• 3
13)(6)-2
1714-323
ON CINVM-A1111DVA ONI1V3
IRO
pa -a o m —1 ,X. 0 0 r" > . > G
1-j 2/. , 0 . GI
--I 0 -C —I rn
rs
r-, 1, 1-1 z LJ LJ '^
-Q,
•N
5 z
,
. O .VA
MISCELLANEOUS 557-107 O
STANDARD FORM 557 1Rew 3-77/ 0 Preunbedby G5ANCMR DRAM 141 CFR) 201-45-505
PATIENTS MED. RECORD
ON AA 8Y1/NENI3
MEDCOM - 4392
DOD 010871
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER
NUMBER ORDER NOTED COMPLETED
DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
aFr I J OIL
1,9. „ Qof k-Prk --,-AsvkAl+r,..7
c5
jiYt
c
2_4,2 0 013° t47
Lp‘ 119 A,2,2 (206 502) 45A2,
el0
C
xey2
A I
Adma, b (8)-2
9.
..Sc
'
---`(
Ovriro-6 417 fig -
b)(8)-2
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any
changes on subsequent pages.
Diagnosis:
Height: Weight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) • 9 99 •PREVIOUS EDITIONS ARE OBSOLETE MC V1.00
MEDCOM - 4393
DOD 010872
DOCTOR'S ORDERS (Date and sign all orders)
TEMPERATURE • PULSE • RESPIRATION NURSES NOTES
DATE
T P R -Sgrr MEDICATION AND NURSE'S NOTES
ANO TIME
161843C
fid'
in 4" 65 cf6t 10 Wh o 96
1..`
USAPPC VI.00
MEDCOM - 4394
DOD 010873
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 MEDIChL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IOENTIF ICATION
•
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
.
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
%ors
NURSING UNIT ROOM NO.
DA 4256
1 FA?. r7 9
LIST TIME
4 DATE OF-ORDER TIME OF ORDER .
J
NOW
Alp
en
BED NO. V.
6
.._.../
8
ORDER NOTED ANI
HOURS
id A fj O37 SIGN
Admit-Patient to ICUS
Diagnosis . (e9-CLL) 0' 957
406 • •
Allergies. WM
. .4 4 4 460,404 4:4 4 4
Cardiac. reqpirarnry mnuirnrit-sg
Diet: / regular/ snfr/ clear • liquia
DATE OF TIME OF ORDER
HOURS
Activity: AD LIBLAt-fra Till/ At with BSC/ . NWB R or L LE
69) HOB up 30 degrees
10 Nursing T/0 •cm/ to LIS/ LCS
Labs: Chem H H/ PT/PTT/
BED NO.
CBC q AM/ 4 hrs/ 8 hrs/ BID
V/IKG q AM
....
DATE OF ORDER TIME OF ORDER
HOURS
)2/ PCXRAY q • QOD IVF NS/ 40110Nsi D51/2NS To run my...) cc/hr. Ancef 1 GM IV Q 8 hrs
• Gentamycin IV Q
Cefoxitin 2gm IV q8hrs.
L11/BED NO.
18 0 titrate to keep SPO2 > 93 .0
•ersed gtt 1-10mg/hr IV titrate to
DATE OF ORDER TIME OF ORDER
HOURS
Ramsey Scale of •
Fentanyl gtt start at 50mcg/hr titrate
../
r adequate pain control. MAX DOSE of
-Vecuronium lmcg/kg/min
22 MSO47 - 6 MG IV q/-/IHR PRN Pain
BED NO.
Phenergan 12.5-25mg IV q 4-6hrs PRN N/V
MOM 30cc PRN Gastric upset
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 4395
DOD 010874
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 MEDIChL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER LIST TI ORDS! NOTED I
HOURS
SIGN
/NS/ LR bolus R
liters
Neuro checks q lhr/ 2hr/ 4hr/ 6hr/ shif
27 Vascular checks
ft
:b)(6)-2
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDE
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDE R
HOURS
NURSING UNIT
ROOM NO. CBED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.
I
BED NO.
1
FOAM REPLACES EDITION OF 1 JUL 77, WHICH
DA 4256
7 APR 79 MAY BE USED.
MEDCOM - 4396
DOD 010875
TH. ..PEUTIC DOCUMENTATION CARE PLit.-(NON-MEDICATION)
CLINICAL RECORD For use of this form, see AR 40-407;
MO.afr. 0
. . . ..,. :n .e y is the Office of The Suraeon General. VERIFY BY INMALING 'e...c...-;:;-tY,,'‘... ,i . -,,?,: .`,-1-A. ,,W .:,--,'I.V.Z. INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR - DATE COMPLETED
DATE NURSE FREQUENCY, TIME lb I \ I
ID *114-2A_‘ V 0 Z IVF NS D5NS D5 1/2NS To run 07 / b)(6)-
0 i CO cc/hr 19 b)(8)-
1 O AV% (7) Ancef 1 GM IV q 8 HRs
Gentamycin IV Q
Cefoxitin 2 gm IV q Sirs
ID k'A 03 02 titrate to keep SPO > 93 / c77 . / me).
19 b)(6)-
Versed gtt 1-10mg/hr titrate to Ramsey 07
scale of 19
Fentanyl gtt start at 50mcg/hr titrate for 07
adequate pain control MAX Dose of 19
Vecuronium Imcg/kg/min 07
19
ALLERGIES: 0YES PRIMARY DIAGNOSIS:G5(A) C i k j4 ADDITIONAL PAGES IN USE: -YES NI NO
PAGE NO.
PATIENT IDENTIFICATION:
ACTION TIMES
'b)(13)-4 USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 1819 20 21 22 23
Treatment Facility: (b)(3)-1 N 24 01 02 03 04 05 06 07
— ---.. .--- - --- _— • 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 4397
DOD 010876
Verify by THERA. cUTIC DOCUMENTATION CARE PLAN
Initialing (NON-MEDICATION) Mo 0 Ll Yr 0 1)
Order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Date Nurse be Done be Done
- -. • .
Order/
Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Nurse ACTION, FREQUENCY
Date TIME/DATE COMPLETED
1° 1-1b)(8)-2 • - Morphine Sulfate42-q mg IV q I -LI hr
0 V-
". PRN pain Pherrargan12-1-45 6 lirs prn N/V MOM-3069-PRN-CAVETIriSat-
NS-f-L-R-boturX-Iliteca.
USAPA V1.00
MEDCOM - 4398
DOD 010877
CLINICAL RECORD
VERIFY BY INITIALING
ORDER CLERKI
DATE NURSE
\O ly te
Prb
ICI Pr OS
lb Ay, B
) D
NA 63 ID Ar 03
ALLERGIES: IIIIII YES
PATIENT IDENTIFICATION:
"b)(6)-4
1----.rIERAPEUTIC DOCUMENTATION CARE PLAIVIViii v-MED ICATI ON)
For use of this fo see AR 40.4 0T
M001( 31/%0
Office
the or000nent aa rice is the Office of The Surueon General.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
RECURRING ACTIONS, FREQUENCY. TIME
lb 11
Vital signs q hr / q 2hr q6h4 / q8hr / 07 )(e}/2
19 (b)(6)-2
q shift
b)(6)-
Cardiac Respiratory Monitoring 07 .
19 1(61-2 Di : NPO / Regular / Soft / Clear 07 /(b)(6)-2 Liquid 19 M2 )(6).
Activity: Ad Lire trict B BR with 07 /fb)(8)-1 BSC / NWB R or L LE 19 bm-2 1
4. b)(6)-2
eeri up 30 07
b)(6)-2
19
(b)(6)-2
Nursing I/ , CDB NG to LIS / LCS 07
7 1,_-'
2.113)(6)-2 •
Labs: Chem 7 / H&H / PT/PTT / 04
CBC q AM / 4 hrs / 8 hrs / BID 08 12 16 20 24
EKG q AM / QOD 06 PCXRAY q AM / QOD 06 Neuro checks q lhr / 2 hr / 4 hr / 6 hr / 07 q shift 19 Vascular checks nq lhr / 2 hr / 4 hr / 07 6 hr / q shift 19
4' NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE III YES M NO C-3 Lk) aLL: \ -
PAGE NO:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
Treatment Facility: 1*(3)- r DA FORM 4677,1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. IISAPA e1.00
MEDCOM - 4399
DOD 010878
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (NON-MEDICATION) Mo 0 11 Yr 65
Order Date Clerk Nurse SINGLE ACTIONS Date to be Done Time to be Done Time Done Initials
Admit Patient to ICU
Diagnosis: GSW C..A\-.
IP . Condition: Stable Serious / Critical 1/0 (b)(13)-2
Allergies: NKDA
Order/ Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Ejinat Nurse ACTION, FREQUENCY TIMEIDATE COMPLETED
. ._
USAPA V1.00
MEDCOM - 4400
DOD 010879
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
For use of this form, see AR 40-407;
I MOWYk
CLINICAL RECORD
the • ro • • nent . ene Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INITIALING
DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS, HR
DATE NURSE FREQUENCY, TIME
ra 6 t (1 i 7 IS NIESII
rall.6)(6)-2 PAMIIIMINri;
b)(62
" "• " i
MG
6)(6)-2 --
ri • .
.
wi n Es 02-CI M
6)(6)-2. “ .9. ---
FlIb)(6)-2
Mil -
.. ... .. Wil II_
..
b)(6)-2
- -. -
6)(6)-2
¦
151111 Mil
NM b)(6)-2
.. .. .. _ /
Si
b)(6)-2
.. .. _.
¦ .. -
/
gib)(8)-2
- - ••• -
WM if ree .--FL cle-h a
i I
b ¦
)(6)-2
1 1 .-M inl=11.11Rig
- - - -EPA
ADDITIONAL PAGES IN USEI. ALLERGIES: D YES Q NO
PRIMARY DI AGNOSIS: 0 YES El NO
P AGE NO:
PATIENT IDENTIFlCATION:
'b)(8)-4 ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA , FoOcR-P7,3 4677 MEDCOM - 4401
SIN
DOD 010880
THERAPEUTIC DOCU.NIE
CLINICAL RECORD
• gARE PI: ir MEDICATIONS)
For Ole Ofthli forril, um AR 40-407;
the •ro nent • e 1s the Onion of Th.-
V.BRIFY BY ENITIALJNO Sur eon General. mo.hityr.P5.
•• L13:441
PROPER COLUMN FOLLOWING "
ORDER CLERK/ CH AMIN:STRATTON
RECURRING MEDICATIONS,
DATE NURSE DATE DISPENSED
DOSE, FREQUENCY
111MINIMIZI11111111111111111
b)(6)-2 IN
e As -"
bX6}2 1111111111111
WN fin)
ItrLes,v,v-i-A UD,
0,-.411-,5
IIIIIIIIIIIIIII
111111.11ftillnammInN
IMME11112¦111111
moms
¦
¦
1111111111111111111111M1
Ir
11111mmimimmEN1111111111111111111mm
•
1111111111111111111111111111
•
•
11111111111111111111111111111 •
•
•
11111111111111111111111111
¦
11111111111111111111111111111111111111111111111111111 ¦
¦
111111111111111111111111111111 Ir
11111111111111111111111111111
•
Ir
111111111111111111111111111
•
111111111r"111"
•
1111111111m111111"
rl •
¦
• 111"111101111111111),,oill
..111ioll..
A.E.,„u3.111
ES NO
PATIENT IDENTIFICATION; PACE NO,
'b)(13)-4
DISPEN ING TIMES
jaultz CI R
D 7 8 . 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
DA 1F4r79 4678 N 23 24 01 02 03 04 05 06
EDITION 0° ' OEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 4402
DOD 010881
Verify by THEKAPEUTIC DOCUMENTATIONCARE PLAN—
Initialing (MEDICATIONS) . . Mo. Yr
Order Clark/ Date to Time 10
SINGLE ORDER. PRE-OPERATIVES
Date Num. TIrn• Given Initial a
be Given be Glynn
11.t'y'
.
, !ta,
. , , I.
•
•
-.
•I
Order/ Clerk/ PRN IPUT1.41. PROPER COLUMN FOLLOWING ADMINISTRAtION
Exalt Nurse MEDICATION, DOSE, FREQUENCY
Date TIME/DATE DISPENSED
/Mr , .--. 2 e Ali. 04 ,0_ (b)(6)-2 also,/ I-a ril Tug
!, OIL 4 'Awl 9r4j
036 17,..0 lea ITIP,
, )(6)-2
i—a° frps i136,; h.)
. '
•
•
U.S. GPO: I 991-4S4-110,95216
MEDCOM - 4403
DOD 010882
r•—•./TI
FROM (Modica treatmentfacility) ORIGINS (herkttion do tralbernant nelidicol)
'b)(3)-1
NAME Owe— • • n
NOM (None do fantilo-pronder pnenone—bdtisle desuditno printolit)'
SERVICE NUMBER RANIC/RATINGIGRADE CATEGORY OF PERSONNEL (Service or employ... and NUE160 MATECULE GRADE/4/0// nationality) CATEGORIE OE PERSONNEL (Senior on omployoor et nationolia)
E kil
DIAGNOSIS DIAGNOSTIC
6sw / UNC-,
iDISEASE Iggingoougav INJURYcums-ci.mog
MALAISE gulled MCGREW SEISOUSE IA 2A
IB 2B
CABIN OR COMPARTMENT NO. 'BUNK NUMBER , NO. CABINS OU COMPARTIMENT NUMiRO •.
IC
S
vo
Tolgs GRAY. MAL
BAGGAGE TAG NUMBERIS)
.", Yes NUMiROS tnaumEs SAGAGE
1..j Owl
.
PEr4
DESTINATION SPIP/AC(Noruslmrhype) DESTINATION NAVIRILIAVION alttrituLdeYPe)
g••• film torhoont !sax/oared a Rotation to this r( ea is nude)TREATMENT RLDOSNSBiOE9 EN ROUTE TRAITEMENT RECOMMANOB EN ROUTE (Indirior al amen trait mart Watt tacestaire)
-LA( ii5u
SIGNATURE OF GATE
SIONNIVVIE DU DATE •
=LW.. grgctiVIT (Describe) RE EINI SPECIAL (Description) /04A4.
I'D
SHIP'S RECORD OFFICE TAB FICHE POUR ARCHIVES TRANSPORTS ,
PROM (Medical troatiennet facility) bx3)-i
NAME (Lase—finut—middle den ache papa)
3)(6)-4
• ISLIFFILD NUMBER CATEGORY OF PERSONNEL MATRCULE CATIGORIE OS PERSONNEL
BAGGAGE TAG NUMBERIS1 OATS 0 OPIUM/JERI
NUMOROS ETIOUETTES BAGAGES DATE OEPART
:).-1 10 JAPa0 3
DESTINATION ARRIVAL DATE
DATE ARRIVEN
P. Pg
EMBARKATION TAB — FICHE D'EMBARCILIEMENT
••F
MEDCOM - 4404
DOD 010883
12. REASSESSMENT) REASSESSMENT
DATE / DATE (V YMMDE) TIME OF ARAN •ARRIVEE
TIME ! HEURE
BPI PS
PULSE / POULS
RED./ RESP
,.. .1. UST NAME. A1153/AME /1413Mer PRINOM FLANK /GRACIE • ' ..'"':,
•
&MALE / HOMMC.
DATE / TIME .••2•• . e,.. a .•
•
FEMALE /FEMME . •
ICagPALAfIgr 10 SD LI U E S S3/1/ NUMERO MATRICIDE SPECIALTY. CODE /GPMDATE I HEURE 11 MTE111216072:S RELIGION/ REUGION
•;
t.
URN' / UNITE '
NATIONALITY /GATIONAUTE
FDAE6/iiimENT •
. ,
A/1.. ' ADA : NEM ¦ ...MOM '
• 'BC/BL -, I ' Nal / BNC i DISEASE / MALAOIE I I PSYCH/PSYCH
3. INJURY/ ILESSURE . AIRWAY / TRACHEE
. ERE/NT / OEVANT .. • BACK / ARRIERE HEAD / TETE
• WOUND/ BLESSURE
. •
' ::1/4Fi..° ?„I,,T_...NOS / IV FLUI NECK/BACK IMLAY / BLESSURE AU COU/AU DOS
l' STEMNALIMI¦Lsier.VNLTT,Iott',..< k h.. 11/ r . ....
0-'
BURN / BROLURE
. i p 6 00 083 2.
AMPUTATION/AMPUTATION
t '',..v”"
_..-1.4.a.1) vr,,i0.
STRESS/TENSION
.------1i I e ..;•
OTHER (Specify)/ AUERE ESPE4lli4d
.--'
0
A.i
• 11 rttr / 4 . ' /1 f. e-
0\11C) V I
5c 4 er /awe /
ti •
. D.., b le,
Ni ,,. unrt-340-
r t
‘Aelt)' 0
4. LEVEL OF CONSCIOUSNESS / N1VEAU DE CONSOINCE
ALERT / ALERTE PAIN RESPONSE ! REPONSE A IA DOULEUR
0.* IX.
VERBAL RESPONSE/ REPONSE VERBALE UNRESPONSIVE/SANS REPONSE
(6 8
S. PULSE/ LS TIME/HEURE 4 TOURNIQUET/GA/MOT TIME / HEURE
1\ ii‘ IA (E0 / NON YES / OUI
7. MORPHINE/MORPHINE DOSE/ DOSE TIME/HEURE L iv , ni TIME/HEURE
i---INO ' NON AO YES / OUI
74,C".
9. TREATMENT 1 OBSERVATIONS / cuRNE NT 1AI DKADON / ALLERGIES / NBC (ANTIDOTE) • b)(6)-2 MENAI ENT / OUSERVATIO S / PROEM MEDICATION / AU.ERGI IS / ANTIDOTES • . .
'•
I 43E4 OfFSClcaDATE (Pimp
0 •
14 DISIXITION / ix RETURNED TO DUTY ArL1UNITE ' , TIME/ HEURE
D'SPOSMORI DECUs.Ectr:.
EVAEAAtT0ED/tLIADCtUr:,,, i.,.,.,
A
It. RELIGIOUS SERVICES/ BAPTISM / BAPTISE:, ,.,....," . PRAYER / PRIERE
SERVICES RRIGIEUR AmitL7INGioNcTioN :. .11: , . 7
COMMUNION/ COMMUNION
CONFESSION/CONFESSION • OTHER L AUTRE
CHAPLAIN/ 04APELAIN
.:17: •
.
,
•I
DO Earn 1380, DEC 91 (Back)
YL INSPOSMoN / TIME /HEURE
RETURNED TO DUTY / RETOUR A L'UN1TE DISPOSITION
EVACUATED / EVACUE
b)(6).2 EDE
DATE/DATE (VEIAAIDO) '
difJoret ., ..' . •oi, )4X, FIELD MEDICAL CARD rieuE-MitIldlingThr L AVANT tTATCLILIIS
lisonEsa wNCAN atioNte.^
DOD 010884
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)
b)(3)-1
90,1A)
(401AZ 7%
tolyku,,e)i 67.. 9A; ZZL 1 "LearAex, c cx-4(-4.4‘4.4,
T16,0
PHYSICAL EXAMINATION •
_I P loo dr M/410! O? s4 //'/(—” t es, tf,A /VC
Citto,; az/ 14i4,0
Fior , • I' En_tc.4 . 3.o dt(AcippA.
/111-3
scv
As iket ,41.6 71(-314-11 /-0 17 ALT
cr/‘ 83 194) ..tr 14A_ tt,
Q,,AJ Awl ,frx,,,r1 dc
PROGRESS (Enter date of discharge and _final diagnosis)
+41(ite,/ C/19
APO 9 G c)
11X «
CaPLI1
b)(3)-1 ,
eat
13)(6)-2
DATE IDENTIFICATION NO. ORGANIZATI N
PATIE 'S iBiNTIFICATION (For typed or written entries give flMrae Ian, first, REGISTER NO. WARD NO.
middle; grade; date; hospital or medical facility)
13)(6)4
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS
PIRMR (41 CFRI 201-45.505
OCTOBER 1975 USAPPC V1.00
MEDCOM - 4406
DOD 010885
LJA A
)ICAL RECORD SUPLEMENTAL Ii
this form, see AR 40-66; the prclxrtsent agency is the Office of the Surgecn Creep—
Tr use of
OTSG APROVEI› (D4,41
SPORT 'TITLE
TRAUMA FLQWSHEET DELAYED . . mirnMAL
I O IMMEDIATE . .. ASSESSMENT
ate: /14..2.3— Arrival Time: CI c..C0 Sex: Age:
Unknown
• Tetanus Status: LIM
Ilergics• ../t/ A
Last Meal:
hief Complaint:
I
Medications:
v0-1:
reatmenu PTA:
SA02: S
RR: z 0 TEMP:
'
BP:/3/ -2 3 P:
ITAL SIGNS:
ABDOMEN mm
R mm L
(12 yiki'm • sorr PERRL . YES . NO
RAtJM r: ES Oso
DISTENDED GLASCOW SCORE:
[a_ DRY
AIN • .
TENDER. PALE
DB . Y ES .
5 9
0 DUSKY BOWEL SOUNDS 2 • 30 40 50 6 • 7
UNG SOUNDS
. MOIST 0 YES ria• NO
R L 3. MOTOR RESPONSE
GUIAC TEST 2. VERBAL RESPONSE
I. EYE OPENING
CLEAR Obedient
Oriented • 5
. POS . NE° Spontaneous • 4 Purooselul • 5
WHF.EZES
Contused • 4
To Voice • 3 Wiinorawai • 4
D ECREASED Irtappropliate • 3 • 3
FlexionTo Pain • 2
0 Incomprenensible • 2
Extension • 2
. ABSENT -None • 1 • 1
None None •
XTREMET7
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MEDCOM - 4416
DOD 010895
• AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: b)(8)-4 (For typed or written entrees, give: Name - last, first, middle; k/Gradel REGISTER NO. WARD NO.
a-C. I •
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5-99)
Prescribed by GSA/ICMR FPMR (41 CFR) 101 -11 .203(b)(10)
MEDCOM 4417
-
DOD 010896
NSN 7540-01.075-3786
LOG NUMBER TREATMENT FACILITY
EMERGENCY ARE
C
MEDICAL RECORD AND TREATMENT
RECORDS MAINTAINED AT
(Pat)
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE (Oay, M nth, Yawl TIME
ers 1W
O
CITY STATE ZIP CODE TRANSPORTA ION TO FACIUTY
SEX DUTYILOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE AREA CODE NUMBER ITEM YES NO NIA ITEM YES NO PRP ADDITIONAL INSURANCE AGE HOME PHONE FLYING STATUS OD 2588 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
WHEN (Mel DATE LAST VISIT 24 HOUR RETURNITEM YES NO
n YES n NO IS THIS AN INJURY?
WHERE TETANUS
ALLERGIES DATE LAST SHOT COMPLETED INTITIAL SERIES
INJURYISAFETY FORMS HOW • YES • NO
CHIEF COMPLAINT
&"(cC44 S ei-i-
,
CATEGORY OFFTREATMENT ' VITAL SIGNS
TIME TIME
pr5
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3s.,r6
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PULSE
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I LABORDERS
URINE C&S UA MSCCICATH CHEM:
BLOOD C&S X
X-RAY
ORDERS
ACUTE ABDOMEN LS SPINE
SINUS HEAD CT ANKLE RIL
PULSE OX TIME /05 Z ORDERS BY ORDERS MONITOR COMPLETED BY TIME . PATIENT'S RESPONSE ,
DISPOSITION n HOME ri FULL DUTY MODIFIED DUTY UNTIL DISPOSITION QUARTERS ;OFF DUTYri 24 HRS. n 48 HRS. n 78 HRS. RETURN TO DUTY PATIENTIDISCHARGE INSTRUCTIONS
:13)(6)-4 CONDITION UPON RELEASE • IMPROVED . DETERIORATED PATIENT'S IDENTIFICATION • UNCHANGED ADMIT TO UNIT/SERVICE TIME OF RELEASE medical lociityl • (For typed or written enttin give: Name •• lest, fiat, addle:10 no. ISSN or MK hosPite eff . REFERRED 100. TO I have received and understand these instructions. PATIENT'S SIGNATURE .. WHEN
EMERGENCY CARE AND TREATMENT (Patient) Medical Record
STANDARD FORM 558 (REV. 9-961 Prescribed by GSAIICMR FPMR141 CFRI 101.11.203168101 USAPA V1.00 'bX3)-1
MEDCOM - 4418
DOD 010897
NSN 7540.01.075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC Check if read by
ABGIPULSE OX RADIOLOGY
radiologist
HIH SUP 02 PH P02 RESULTS
PLT PCO2 SAT OTHER
PT DIP EKG INTERPRETATION
APTT BHCG ETOH GLU MICRO
PROVIDER HISTORYIPHYSICAL
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CONSULT WITH TIME ACTION RESIDENTIMEDICAL STUDENT SIGNATURE AND STAMP
DIAGNOSIS
(For typed or written entrin give:Name last, list, middle,
ID no. ISSN or othert hospital or medical facility!
PATIENT'S IDENTIFICATION
EMERGENCY CARE AND TREATMENT (Doctor)
b)(8)-4
Medical Record
STANDARD FORM 558 (REV. 9961 Prossrbe4 by nano FPMR 141 CFR) 101.11.20311M10} USAPA V1.00
MEDCOM - 4419
DOD 010898
FJMc Ii cic-1 Fi -t A SN 3a. STATUS 3b. SE
,56)-4
419:-116)
6. AGE 7. SEX • F.:.WEIGTV 9. BLOOD TYPE 10. CLASSIFICATION (1A TO 51
VMALE !FEMALE AMBUL !LITTER ).APPT/SURG DATE ".-ArZITY, 15a. DESTINATION FACI'
t_'7ORIGINAT
1(1110)-1
TING P ONE NW: R 15B. DESTINATION FAO ,bx3)-1 U
17. DI • 19. CLINICAL ISSUES (P:
YES comments In Se.: c, caes.7 YES NO
ISSUE
a.
Hypertens
b.
Cardiac
18. I illBATTLE CASUAL IDISEAS -: I 1 NON BATTLE INJURY C. Diabetes
20. PHYSIC-, ORDERS d. Respirator 2:ia DATE !'!• LME 120c. ALLERGIES e. Ears/Si in AO? 6'5 1. Motion Si:-20d. DIET. EG NA I 'DIABETIC CALS g. Im: ,Vision NAL _ MagK mg PO4 h. Voiding Pr ytJE T1 cc;. 1/2. :=ULL STRENGTH 21.
frbIATRIC:i 107" ' (Specify) 21a. DATE/TIME TPN: Change ccil . max of days TUBE FEED!! !rength at cc/hr 2
20e. IV / BLOOD 20f. SPECIAL EQUIPME!,-ALEY CATH
,1 C I RTHO BRACES CHEST/HEIMLICH IT ACI !RESTRAINTS !AONIT:. I OTHER (USE 23) OXYGEN: PERCE LITERS ROUTE:
VENT 20g. ALTITUDE RESTRICT 1. Yes feet 20h. REC9RDS TO ACC' 1' • , 1:-:.NIT
OUTPATIEN1 )C !XRAYS OTHER:
INPATIE' IT R 10B
NARRATIVE . • .;.•.P,Y i DENTAL
FINANCIAL
20i.. MEDi / 7 23. DATE/ TIME
6L--K
G7
,-0
T-et -ct 70
5. GRADE
U IP IR
11.ACCEPTING MD 12.CITEJAUTH
/Th 71-Viafq%-t.k"r
,b)(3)-1
16. # OF ATTENDANTS
(V
16a. MED 16b.NON-MED Y PHONE NUMBER
.6-77rtliegie Yes or No on clinical issues Explain
: 23
YES NO Bowel Problem Self-care
k.
Ambulatory
I.
Ambulatory Aid
m.
Self-meds
n.
Adequate Supply of Meds
o.
Other:
RE-FLIGHT VITALS 21 b.TEMP: 21c. PULSE 21e. BP 21d, RESP:
-3RIEF NARRATIVE
11111MMIIIIMIIIWAVIAWlith
1#1111111WAW11,1171111
iSSMEN ' / P OGRESS NOTES
24. STAMP AND SI( 25. STAMP AND SIGNA -OF FLIGHT SURGEON
AF Form 3899 (433
MEDCOM - 4420
DOD 010899
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-DAY MONTH-YEAR DAY a ,I3kv-ram til pa Per 7.4) 4)r-19 HOUR POO OJ)t Ite. la• ;-412.• Vim t 3 WO WO :Is • • • . •
, -
41e70D PULSE TEMP. F . . . . . . . . : . TEMP. C
(0) (•) •• •• " • • " " •• •• " •• " ' -" 105 40.6°
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180 104° " •' •• ' • " ' ' " " •' •' ' ' • 40.0°
. . . . . . . . . . . . . . . . . . . . . . . . . .
•• •• • • •' •• •• ' • " ' • •• ' • •• "
. . . . . . . . . . . . . . . . . . . . 170 103° •• • • 39.4°
5;
. . . . . . . . . . . . . . . . . . •• •• •• • • • • •• •• •• •• • • •• • • •• •• o . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 160 102° . 38.9°
. . . . . . . . .. . •• •• . • . . . . •. • • •. . .
2
c . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
" " •• • • • • " ' " " " " " " •• "
. . . . . • •• . . •. •• •• •• •. •• •• •• . • a) 150 101° 38.3° ix
. . . .
"
. . . . . . . . .
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130 99 ° • •••••
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. . . . .
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98.6° •
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. . . . . . . . . . . . . V a)36.7° •ci
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110 97°
. . . . . . y . . . . . . . . .
0
• • • • • • Ce • • • • • • • • • • • • • • • • • • •
100 96 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.6°
95 . 0 •. . . •. 1 . . , . •. . •. . : . : . •. . •. . •. . : . •. . •. . •. . : . •. . •. . : . : . •. . •. . •. . •. . •. . •. : r., .
90 . . . . . . . . . . . . • • • • . . " • • • • " • . 0 0 " • . • • . • • . • .• • .• 'r . . . . • 35.0 °.
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70
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. . . . . . . . . . . . . . . . . . . . . . . . . . . .
60
. . . . . . . . . . . . . . . .
.. . . . . . . . . . . . . . . . . . . . . . .
•• •• •• • • •• •• •• •• . . . . . .
. . . . . . . .
50
• " •• " •• •• . . . . . . . . . . . .
"
• " •'
. . . . . . . . . .
40
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RESPIRATION RECORD 16 Ito au xi 10
BLOOD PRESSURE 12,1/(j7 ivfrg I*D 04 IA ve Mt 1
r'hs pel t Willi: 14 % g6t I
l'in If opt i.9:i.
53L4 94 Gliqqncld -
HEIGHT: WEIGHT 7171 -I _
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'Record special data only when so ordered
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN or other): hospital or medical facility) REGISTER NO. WARD NO.
13)(6)-4
VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV, 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4421
DOD 010900
MEDICAL RECORD VITAL SIG RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY I / I
19 HOUR
(i•Vi.ti c-'i • • • • ' • ' " • • ' • " " "
•
•' • •
•
—I 43CO03434343 COCO 43 43 41. .4. M 01010 CO-J-4-.1 CO CO CO 0 0 K O in 1-• L., ON 0) 1,3 1c3 .e. bb
0 0 0 0 0 0 0 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
PULSE TEMP. F . :
(0) (') " . . . . . . . . . . .
.
. . . . . .
•
I••-1" • •
105
. .
. .
. . •. .
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180 104°
. . . . . . . . •• . . •• . . • •• ••
. . . . . . . . . . . . . . . . . . .
. . . .
•
170 103°
. . . . . . . . . . . . . . . .
....
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160 102°
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. . . . . . . . . .
•
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. . . . . . . . . .
. . . .
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150 101° . . . . . . . . . . . . . . . . __• . • . . . . . . . . . .
. . . . . . •• •• •• •• ....61e;,• •• •• • •• •• •• •• •• •A • ' • •.• ' • •' " ••
140 100° . . . .
. . . . . . . .
" " ' • •' " ' • '
. . . . . . . . . .
•
. .
. . . . . . . . .
..• .X . . . . . . . . . . . 130 99° . . . . . . . . . . . . . . . . . . . . . . . . . 98.6° •• •• •• •• •• •. •• •• •• •• •• •• •• •• •
• • •• • • •• •• •• •• • " • " •• ••
120 98°
•• " "
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. . . . . .
. . . . . .
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. . . . . .
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. . . . . . . . . . . . . . . . . . . . . .
07
110
100 96°
• •. • •
. . . . . .
. • . . . .
....
...
•
. .
. . . . . .
. . . . . .
90 95°
. • •• •• . • •• •• •• •• •• •• •• •• •• •• • • •• " ••
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40
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i
RESPIRATION RECORD 6
Record special data only when so ordered
1
BLOOD PRESSURE
13.51.<
HEIGHT: I WEIGHT —O-
le', 4.14:k•C
e....1
OU
()OP 200 PATIENT'S IDENTIFICATION (For typed or written entries give -Name—last, first, middle; ID No. ISSN or REGISTER NO WARD NO.
other); hospital or medical facility)
!b)(6)-4 STANDARD FORM 511 (REV. 7-95) BACK 1J.8. Government Printing Office: 1995 - 509428
MEDCOM - 4422
DOD 010901
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.
LIST TIME
PATI NT I. E. NTIFiCATION DATE OF ORDER TIME OF ORDER
ORDER NOTED AND
b)(6)-4
HOURS
hittOk...: 073
SIGN
b)(8)-2
nL GidatrUCt,
act -s (P /4t0
r+44
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NURSING UNIT ROOM NO. BED NO.
DV e4-Por-
PATIENT ItrENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
.7
se-47
WC_ & 64'
d`
1,1424,-Oak ) ettev-Q LO
NURSING UNIT ROOM NO. BED NO. Atke-eE qI.-I WO
g
b)(8)-2
PATIENT IDENTIFICATION DATE OP ORDER TIME tlf ORDER
1714,604&.J-0. r RS
ti44 14PECI411 (s )O-o< 4c
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faitivc. - to€0-,/
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b)(8)-2
NURSING UNIT ROOM NO. BED NO.
b)(13)-2
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
4 LS—
HOURS
APk. r) ojes1
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NURSING UNIT ROOM No. BED NO.
X„,-/%' 3 LI/ &Aria( /ceky.5 .o
REPLACES I(171.67E AY BE USED.
T5ON OFJUL-1:97
DA FPFIN' 4256
1 APR 79
.I.J.S,..GOYtRNMO,r ,PRINTINP,OFFICE: 1998-409-924
r,
MEDCOM - 4423
DOD 010902
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
SYSTEM IS USED, WRITE RECORD
PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT It/ENTIFiCATION
DATE OF OFIDER
at'dOwtFER
Ti, e.IST TIME
ORDER NOTED AND
HOURS
SIGN
b)(61.2
'4-r (C NAt
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cq< "YU -Th ' n D ML
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NURSING UNIT ROOM NO. Q
BED NO.
)°
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;d /-
PATIENT IDENTIFICATION
DATE DP ORDER
TIME 60 DA ER
I-
a4 C(-.. URS
&X CA 4-e s; ) C 2' J
b)(6)-2
vURSING UNIT
ROOM NO.
BED NO,
03 j44)4e1P713,'--6rf -e•I"'01
CAT 10
DATE OF ORDER
TIME OF ortrwa
b)(8)-2
b)( )-2
,91-19(4,0-4-(.144ta-1/6 Afr4X 0,3 MAO
YURSING UNIT
'ATIENT IDENTIFICATION
DAT Of ORDER
T b)( )-2
RS
YuRSING UNIT ROOM NO.
BED NO
FORM
REPLACES EDITION
OF 1 JUL 77. WHICH MAT BE USED.
4.256
DA ,Ap.7.
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S.GOvERNmENTPRINTINO ,OFFiCE: 1994'-361.710
MEDCOM -4424
DOD 010903
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.
LIST TIME
PATIENT IDENTIFICATION ORDER
DATE 0 ORO IR TIME OF ORDER
NOTED AND
(b)(6)-4
. C5,7 Cc HOURS
SIGN
( .7 1.
PATIENT IDENTIFICATION ,bX6)-4 NURSING UNIT ROOM NO. BED NO. DATE OF ORDER 'bX6)-2 b)(6)-2 TIME OF ORDER HOURS 13)(6)-2 c.,(\j\0714 ¦
ED NO.
13)(8)-4 OF ORDER TIME Of ORDER• HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION b)(8).4 DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT ROOM NO, BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1 APR 79FORM 4256
07 I C
MEDCOM - 4425
DOD 010904
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see'AR 40-66, the proponent agency is OTSG
MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN gOLUNIN INDICATED BY ARROW BELOW. LIST .TIME
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN. EACH SET OF ORDERS, IF PROBLEM ORIENTED
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
ORDER • NOTED AND
HOURS SIGN
M6)-4
1-11 (-P.1ii z cb -to c
'
BED NO.
DATE OF ORDER TIME OF ORDER
n-y-; 0
HOURS
zD o3 ReNA4r4b— S-044 Le—c
a..Artn<
e-P Non, e
irsz, rs-C
b)(6)-2
NURSING UNIT 010 14(6)-2 D NO. X61-2
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
NURSING UNIT ROOM NO. BED NO.
ect_)/
DA 1 FAOPR:79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
nrsvg
MEDCOM - 4426
DOD 010905
THERAPEUTIC DOCUMENTATION. CARE PLAN (NON-MEDICATION)CLINICAL RECORD
For use of this form, see AR 40.407; ,.: • • • • . _ . is the Office of The Surgeon General. MO. r.)03
VERIFY EY INITIAUNG ' ' '
.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED DATE NURSE FREQUENCY, TIME
,1 (D-13 1,1 /3
I1 -{ b)(6)-2 6)(8)-2 Vs ,
0 '. 4 )(6)-2 '
REA 1) /Er LI
I c,,
yl
-b)(6)-2 -4.f b)(8)-2
-'
fiC
I (1
_
--tip 03
b)(6)-2 • WM-2
.
0 1
arro-5
aiirm
-oy )(6)-2
I I-11-P" 63
I • .
--14-bt. eii 40
b)(6)-2" — tile rQ 3 (6)(6)-2
.. -Po r T loi gc-P -71 <Go Sge >rib </aD 1 iv
k ( — Y21/40-
6)(8)-2
0 bA C. -
00 ,,IJA-;frac, 40 keep
.5 - -L ,„7
14491- • (8)-2 - ex---'h gz...e) Soil_ b )(6)-2 I . I. • _ .2¦,..-.. aro
.
ALLERGIES: E YES &I NO
PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE: YES IIII NO
Ai DA . VP 64 (4
PAGE NO:
g-:)- -44-io(-6, h,f
PATIENT IDENTIFICATION:
b)(6)-4
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 Ilti Pnom zial7 I rosy -le -------
USAPA V1.00
MEDCOM - 4427
DOD 010906
Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo Yr
Order Date qit5. 1$ kurn. Clerk Nurse sb)(6)-2 1 SINGLE ACTIONS ild4r. ° ..1 ("‘ t,t_C a_ °/C._ @ eo,r?-1: ') p(e-e , f-AriohAel -1-til Date to be Done be Tme to Done Time Done i ( 03n OHL Initials
_. .. .
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
Clerk! PRN
Expir
Date Nurse ACTION, FREQUENCY TIME/DATE COMPLETED
; ;.
USAPA VI.00
MEDCOM - 4428
DOD 010907
I THERAPEUTIC DRCU, uMmifikar CARE PLAN NON-MEDICATION) 1 merii. es
(
CLINICAL RECORD
the froponent arci Is the Office of Thu Surgeon General.
VERIFY BY INI77ALMO .. INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME
Ara(giffinrillgL.
6)(6)-2 b)(6)-2
• ./....., b)(6)-2
16
/
X6)-2
X6)-2
hifiAltki SieW4/701;44
b)(6)-2
(
773 I b)(6)-2
V6)-2
W
— V< : 7.-It' z/1.I I I r
.7
b)(6)
/17 bX6)-2
6)(6)-2
(6)(6)-2
f
I p bX6)-2 Ming d &Arc q 7'6)(6)-2
/ — v —4-
.4 ... .— .4 .4.
ALLERGIES: O YES 1:=1 NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:. 0 r Ell El NO
. ..
P AGE NO:
PATIENT IDENTIFIC ATION:
'6)(6)-4 ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
. N 24 01 02 03 04 05 06 07
FOOCRTM7 8
kEDITION OF 1 DEC 77 MAY BE USED.
D 4677
. MEDCOM - 4429
s." 1/4%
DOD 010908
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo 6774 yr
Init aling (NON MEDICATION)
r
Dote to rmat to
Order Clerk
Tlm• Done InitialsSINGLE ACTIONS
be Done be DoneDote Nur5e
bX6}2 bg6}2
00 . k641: ietip — Tin.98,4(2, /PIA / ),/idf' C K — hog 0-5 AN' 1( k)
)miiii-3.40&2‘t au4
Llek, (2 1\164C-5P 9191-05
)(62
QC TO io¦Ai CMVO CAP VS NOVIC
ap91--
19r1--ii7 (1--67. -
. .. . ..
. . . . _ . .
. .
Order/ INITIAL PROPER COLUMN FOLLOWING COMPLETION
, Clerk/ PRN
ExP ' Nurse ACTION, FREQUENCY
r
Data TIME/DATE COMPLETED
.. ..... .
. . .-
lk U.S. GPO:1997-418-290/55267
MEDCOM - 4430
DOD 010909
THERAPEUTIC DOCUMENTATION CARE PLA N (MEDICATIONS) 1
UM NTA
For use of thi s form ass AR 40-407; Mo.407Yr.
CLINICAL RECORD
the proponent :yang Ie the Office of The Surgeon General.
e INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY INITIALING'.
r
DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS, HR
DATE NURSE DOSE, FREQUENCY
J 1(4 I-1 \8 frA 711
,b)(6)-2
,3x.) fih
,_ b)(6)-2
0,, fAh 794 0
ri
1 WS
IF r li
(b)(6)-27
id ° 11
13)(6)-2
b)(6)-2
(13)(6)-2
\1\ a Q 0'0 0 N SAG TY—o 1 1-i
I).
4
ALL ERGI EU El No PRIMARY DIAGNOSIS? ADDITIONAL PAGES IN USE1Y ES 0
• 0 Y ES 0 NO .
•
PAGE NO.
PATIENT IDENTIFICATION: '
DISPENSING TIMES
I I
•)(6)-4
• USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
DA 1 FFO4 9 4678EIr
MEDCOM - 4431
DOD 010910
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN _Initialing (MEDICATIONS) Mo. Yr
Order Clerk/ Dore to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Dote Nurse be Given be Given
I
¦
Order/ INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Clerk/ PRN
Expir
Dore TIME/DATE DISPENSEDNurse MEDICATION, DOSE, FREQUENCY
it
1 8ftfai b)(6)-2 • r\I V 45 \-3 Rritl
cv, .2160 3 411
• . „
0 „ _ ,rdit
1-177" v 0 tkI--v-to rew ov.
)-2 b)(0_2
* U.S. GPO: 19913-432-796/8S214
MEDCOM - 4432
DOD 010911
1 . REPORTING MTF 2. t .. r LOCATION
ADMISSION AND CODING INFORMATION
1 r 2 3 4 1 5 6 7 8 (Stare or
6)(3)-1
Country
For use of this form, see AR 40-400: the proponent agency is OTSG
Code.)
b)(8)-4
3. REGISTER NUMBER NAINI E (Last, First, Middle Initial) 4. PAY GRADE 5. SEX b)(6)-4
9 10 11 12 13 14 15 16 17 18
-
6 . DATE OF BIRTH (VVVYMMDC)) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 31
BACK-
El
1,,
12iiim
GROUND -
I --)
L DIMENIIMMINESIII if,
10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 35 36 37
38 39 40 41 42 431 4 ' 45
rxs)-4 I
¦ 1
ORGANIZATION (Active Duty Only 13. MARITAL STATUS HOUR OF BRANCH I CORPS ADMISSION
46
n os'
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_1 61
17. U NIT LOCATION (State or 18.
MOS 19. TRAUMA PREY. ADMISSION
Country Code)
62 63 64 65 66 67 68 69 70 71 YEAR NO 5
20. S OURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72
I eboi
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
NAMF AM") I (KATION OF mmirAi TRF TMENT FACILITY
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
r
b)(3)-1
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (VVVYMMDDI
73 T 74 I( ,-llik5 75 76 77 78 79 80 81 82 83 84 85 87 j 88 1
24. CLINIC SVC - ADMITTING 89 90 91 is IMMO 27. LOCATION OF OCCURRENCE 107 ---108 (Battle Casualty Only) 25. MTF TRANSFERRED FROM ,...../....--...., ... 93 94 95 96 llil Ell 98 28. MTF OF INITIAL ADMISSION 109 110 1;11 112 113 114 . ° c'"4" / 26. DATE THIS ADMISSION IV -Y" M C) al 99 100 101 102 103 1S 10 ...106mi. ,41),,,61--0 0 Io 29. DATE INITIAL ADMISSION (1M"IMMOD) 115 116 117 118 119 120 121 , 122 \
--i
FOR LOCAL USE
1,C . bb f36
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6 co k &Lee-eivo 3
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ADMITTING OFFICER (Signature, as required) .0(6)-2
.13)(8)-2
,b)(6)-2
4.4141( e, 64e A D
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EDITION OF MAR 89 IS OBSOLETE
USAPA V1.00
MEDCOM - 4433
DOD 010912
1. ..:AL RECORD — SUPPLEMENTAL MED, _ DATAFor use of this form, see AR 40-66: the proponet agency Is the Office of The Surgeon General.
OTSG APPROVED (72010)
*P°R1: TITLE 24 - HOUR COMPREHENSIVE CARE RECORD Part 1 •
(b)(3)-1
DATE: d.,2 /1.4.0-r 40 -3 . ; Ceil,s v,-) 1-0CPS fl&-A-Q0(4-9-c-E 4e)-2110 1111111 I . I I
.., F:
OPITAL DAY NO. C1/4.)-Phszke2 (71/4----akilaPe " e." . .
D -:_..
,
i—
I .9.
POST OP DAY NO. ""° c.N"4---w 0-E1 64)-d-boi-Z n'Will
3 151 :-71
ISOLATION DAY NO. _.i I--n a, 6 S ri-. ea
Y 8s-a FL E (±) m1.-1.c.)1
indino l
„,
a, .7.5
ALLERGIES Luvt.1-in"_01,--
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BLOOD
ITOTALStUnits BLOOD Given'
•
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INASOGIASTRIC
I sis3vral
'CHEST TUBE
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PREPARED BY (S19nelure & nife) DEPARTMENT/SERVICE/CLINIC DATE
c9i9-Alta.,r 0.3 PATENT'S IDENTIFICATION
(For /}pod or written sables girls: Name - Ia5l, ffist,middle; grade; data; hospdalornreefreal batty)
• HISTORY/PHYSICAL • FLOW CHART
3)(6)-4
• OTHER EXAMINATION • oTHER (spm•OR EVALUATION
(b)(3)-1
• DIAGNOSTIC STUDIES
ty;)-1-07,1v,-b
DIAGNOSIS:
• TREATMENT
RA-L.44,12) • MEDCOM - 4373
'1;”" c-Ji_L,Lic. • -
C-tri2_-I ft('),.. j L
DOD 010852
24 - HOUR COMPREFZNSIVE CARE RECORD Part 2
Page 2 of 2
07111- 900 I SOG.0700 TIME ACTMTY FIR-O.AA-A
NEURO GUIDE
RIGHT SIZE
BATH B S
Normal
17. —e
° REACTION
-Sluggish O. <
IZE
SIZE
7 MI
0_ fC
+ Fixed
REACTION
EIRIOTRACREAL TUBE CAM
C Eyes Closed
by Swelling
ORAL /ET SUCTION
OXYGEN
IAA AT
verrtucroR
EYES O PEN
SPONTANEOUS 4
TO SPEECH 3
TO PAIN 2
NONE 1
Fi 02 .ell
EYE COMMANDS 6
COMA SCALE
RATE:
MAL VLOUME sj2D
PEEP 91
re KRIS TESTERS /WA 5O TU, AWAY wee PimmEn
v) Ftzoou
o z vanirsawAL
2 o
4
DECORTICATE
POSTURNG 3
DIET:
PUPIL pag DECEREERATE POSTURING
DRESSING CHANGE 2 mm •
NONE (:14-
4 film
• E
ORIENTED
SIGNATURES
INITIAL
:b)(6)-2 6 mm CONFUSED 4
)(6)-2
Miff
INAPPROPRIATE 3
)(6)-2
INCONVEHENSIME SOUNDS 2
NONE
TOTALS
BR - BEDREST D - DANGLE
AA - AMBULATE WITH ASSISTANCE A - AMBULATORY
B - BED P - PARTIAL S - SHOWER
TIME
NARRATIVE NOTES
iLs-3n 012.
.
1027(
e-0-IV -Li& (Z "1-K- 0 r 1VP'
VQ,L459-sa,t1-54
cfrANLV Auk(_ 1 -D-. 1 (--71o, a-e7 , 'TV spo , 114 0A-A-.6
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l'-eAt0(
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4/-ittrj&O ,x-141-1„t/ea-c,(_ ce"-IA 4.94--(Ld, riv¦-e ,4 Gt.freM ;b)(6)-2
C
b)(6)-2
li9.A.4 p ,t
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MEDCOM -4374
DOD 010853
• "
'.b)(3)-1
Initial assessment
icui.../--.--
Date litNA.,75/__ Time 11n15Hfti5 OR
M. MIMI MP PIIII¦¦
,..
NEUROLOGIC; _ ASSESSMENT r
Time emo R B/P NURSING OBSERVATIONS IINTERVENTICNS
MINIM MI
^_\
2 3 a 5 6 7 a
g ;,.
ILI( , 9r61 " l
•• • • II 0 • • ,
i II
¦ 11.• 9 f/0 • II. vI I. I. • 41.
1
1 1 1 Ike I. ...• • .
,..
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Pupil I Size I Ream n ?uoil I Size I Reaction
00 I I OSI Pupil Reaction: R - PE-active N - Non-Reactive 14r \;),/ F. V tis on 0. rrUni. PA- hcks cilos+ vel on C)nsciousnsss INTEGUMENTARY ZAwake ZAlen _Drc.vsy Color: Skin: icke +0 FOsicsIP j
Akirin i s +b low st ic9rior._ _ Restlessness _Lethal ;lc I )(Normal ,. ,i'Verm
_Unconsccus _Pale Dry • Dr.., -q
.„„ ... •• t. I 1d or i • ¦ _Fiushei _ Diaphoretic
•
_Cyanotic _Cool _ I
)(Time XsP'ace !.:.-sr ion 11N) 1%3 T k9. 4",-) lil¦ nt SUC.,l'irin Cirri i rli no rtarY, ff A
Orientation: i I I ..
_Jaundiced _Clammy _.,/
RESPIRATORY
Eyes Open: c104 13(.• 1\/ +-,-, L wt-s-;-.ccilinP inc,Ke•e4
AUniacored _Labored
XSpontanecus
_To Speech Ig3o. arc,ID AC i cSk in,)c ISCa 1 50 A .
Breath Sounds:
_To Pain I
_Cear Bilaterally
_No Response b..id --.0 a . .
. .
_Absent R L `'^ LA.Raies
IIICIP'
Best Verbal: I L wheezes R L 11 e ' k
v Lcl
'
1
X. Oriented A Converses _Dlionenteo l. 7.onvefses ABDOMINAL L
c ilettcifyi mil . • CP.:Kt 7+0 eiCs
_Inaoprcona:e ..7crcs ' Sci: )c.rencier
— • ,
_Incomorenerszte Scurc ; . — F-lig.c •_Non-Tencer
AlArmo r' and Mt ine rtVIcir*¦.ork ad 7., Kg(11-
_No Resccnse : ._:.:istencea _Rebcunc -1-5.113j lktfi . . 064:1:4(13*0.'
I Ci:Li$
Best Motor:
_Acnve _ l.,•oca-cOve
4Cbeys Cornn-arcs
(\LC1+thi(1:17,411 U.b Oh
Bowel Sounds:
_.-!.-cerac:iye _Atsent II siv• I• itRi L.
1
• • i A . .. ----.
_Localizes P.-:.n bX6)-2
_Extension CARDIOVASCULAR
•
tA. .9 ifAi_No Resconse Lett
I Pulses Ricr.t
=--(=c-iial fqlz
inx.frtker ey.flo.inti -.frit t‘ SCC46 1-0 ..c:ai
i-e 14 u•Ao verlydi
+2_
Motor Ability &Strength Fmorail
I OnAvirskoAt,y r.nri
3:ove 115 ParAP awl Grip- ?am lotel wns1/10
Strong -Nees .:-.7se,:t I 4.2_ I J b)(6)-2
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RA I (....------: •••ema
II I III,
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LL
1
Allerg:es
NKDA
PSYCHOLOGICAL $Calm _Comoam: Time IV t EDICATICNS (dose,route s;:et
I
cooperative _Anxious •
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1 ‘ \)/
INTAKE.iOUTF UT Time I IV
Urine I Chest I Gastnc iuPe 'raer_n5 .Lat waiues
Brn'-, -, li y Na 136 I :b)(6)-4
22
25-trs 6 ta‘
SO-?;3") r S IVORKUP SHEET 00^"b)(3)1
DA FO.
MEDCOM - 4375
DOD 010854
..1AL RECORD — SUPPLEMENTAL MED. _ DATA For use of this form. see AR 40-66: the proponet agency Is the Offke of The Surgeon General.
REPORT OTSG APPROVED (Oats)
TITLE 24 - HOUR COMPREHENSIVE CARE RECORD Part 1
b)(3) -1
DATE: .:2 S 1414.c-0 3
ud I 1
1 1 i 1 I I I
HOSPITAL DAY NO. 2-. o
D cn1`1 I I
POST OP DAY NO.
1.= I I 1 I III
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ITOTAL # Units BLOOD GIvieni
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1-.9.gE. PREPARED BY (Signabge & Title) DEPARTMENT/SERVICE/CLINIC DATE PATIENT'S IDENTIFICATION
( For (y7:ed cr wrdlen eabies give: Name - tag ffist, middle; grade; date,- •• , , or medis/ holly) . HISTORY/PHYSICAL
FLOW CHART
.
b)(6)-4
. OTHER EXAMINATION OTHER (Specify)
.... ... . .
OR EVALUATION
13)(3)-1
DIAGNOSTIC STUDIES DIAGNOSIS: (irk 11,1,(1,-
.
. TREATMENT
• I • .
11006.
7C446,101'e.
CSC) MEDCOM - 4376
0
DOD 010855
..Pagel of 2'
Part 2
24 - HOUR COMPREHENSIVE CARE ,CORD
0700. 1 900 1900-070D TIME
ACTNITY BR.O-M-A NEURO GUIDE >-z RIGHT SIZE
BAlli B - P - S 7 Normal REACTION
FOLEY / PERI CARE ORAL CARE — Sluggish + Reed n TO B. EC SIZEIZE REACTION
,ologoges TUBE CARE ORAL JET SUCTION C Eyes Closedby Swelling 0. SPONTANEOUS 4 TO SPEECH 3
.-COCYGEN TO PAIN 2
• AT
iiEEMLAILOR NONE 1
Fi UI EYE COMMANDS 6 PALS TESTERS MID .A
RATE: TIDAL VLOUME PEEP DIET: a`ljr WO 111 B) X4C M BT • AWAY WIIERRITICITER LIMN INTINDRAW.N. DECORTICATE —IMMO -• DECEREBRATE 4 3 2 4 1
MESSING CHANGE 1mm • NONE
4 TT • ORIENTED 5
SIGNATURES (b)(6)-2 INMAL b)(6)-2 5 wee CONFUSED 4 INAPPROPRIATE 3
(b)(6)-2 "A*44;11J b)(6)-2 mm 0. INCOTAPREHENSE12 SOUNDS 2
NONE TOTALS •
B -BED P -PARIIINL S-•
_111/t-BEDREST D- DAWDLE M- AMBULATE WITH ASSISTANCE A- AMBULATORY
NARRATIVE ROTES,
AA-f-t.
cx 1kr 4e4AA.ti,
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roe
MEDCOM - 4377
DOD 010856
-..,..... am
1 t..4-.FORTING MTF ; LOCATION
'I ADMISSIOI.
.0L.CODINPANFORMATIQN.•
i 2 3 (Rocor
Count/v.: ,
(b)(3)-1 t::w Ctx(e) ' .7 ::. FFil'Oie.01 *Cori*. Arlo AR 40 .,.400 ¦ 400114)1:4064,.lit. T
V::: -. .' ::::: '';'• ;.' ..'.':'''• . .:. '''''.. -.: :':.:::': : .r-'' ',?-:,','. ,:i:::y:.:: .,:,.'
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REGISTER NUMBER AME (Last, First, Mrdla lnttlall .
-: PAY GRADE . SEX
b)(6)
-4
9 10 11 12 13
4(6)-4 16 1.7 1.8
1:))(6)-4
AA
6 DATE OF BIRTH (YYVYA41,400) 7. AGE AT ADMISSION I. RACE 9. ETHNIC • RELIGION
19 20 21 22 23 24 25 26 27 28 fl 30 3 1 BACK-
GROUND
M19111110011M11111P7111,3111111wmIll/INNIN161111/1411(T
Will
10 LENGTH OF SERVICE ETS 11. FMP 5.4......) 12. SOCIAL SECURITY NUMBER
32 33 34 35 1 36
37 1 38 1 39 1 40 1 41 42 1 43 1 44 1 45
(b)(6) -4
-1....--.3''(ff ORGANIZAT ON (Active Duty Only) 13. MARITAL STAT
S HOUR OF BRANCH / CORPS ADMISSION 46
0 0
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
'464C ri \A
FriWi Rill MIAllallarAPARIPIri,
17. UNIT LOCATION (State or MOS
18. 19. TRAUMA
PREY ADMISSION
Country Code)
..„,„,:.----)
62 63 64 65 66 67 68 69 70 71 YEAR
Aii
......------ .
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
7 0.472_
7 [ c-vv . --
ADDRESS OF EMERGENCY ADDRESSEE (Include LIP Code)
-
NAME AND (b)(3)-1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21 TYPE OF DISPOSITION 22. MW TRANSFERRED TO 23. DATE OF DISPOSITION (YYlellifDD)
73 74 75 76 77 78 79 80 81
82 83 84 85 86 _ __ ..__. .
----._.-. __. _____
_
V) S 0 3 0 c---0 (4-'
24. CLINIC SVC - ADMITTIN5,.....-25. MTF TRANSFERRED FROM
367:71—.-T3A..E.,714S-ADMISS ON (VIMAIDD)
87 I
0 91 92 93 94 95 96
97 98 99 Ito IMIEM
LOC •TION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION
27 29. DATE INITIAL ADMISSION (YYPIIND O)
(Battle Casualty Only)
103
105 106 107 108 109 110 111 112 113 114 115 116
y
OR LOCAL USE '
as-yv I-) f twit.g. i Glq.. pit S IU h vatisl-- . -1-5-ciLls
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11-A— P011M t985. MAR 89 I MEDCOM -4378
. I 711,7,
DOD 010857
MTF , -( LOCATION
ADMISSION ...ND CODING INFORMATION
1 2 (State or
3
fl
Country
b)(3) 1
Code/ For use oI this Wm. sou AR 40-400; proponent agency is OTSG
•
REGISTER NUMBER hoNfth
tAME (Last, First, Middi
PAY GRADE
b)(6)-4 5. SEX
b)(6)-4 b)(6)-4
AA
6. DATE OF BIRTH (YYYYMMOD) . AGE AT ADMISSION RACE 9. ETHNIC RELIGION
9 20 21 22 23 24 25 26 27 28 29 30 BACKGROUND
10. LENGTH OF SERVICE 11. FkIP
12. SOCIAL SECURITY NUMBER
32 33 34 35 36
40
1121111111111 131111111111,1!fl
ORGANIZAT ON (Active Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH/CORPS ADMISSION 46
gt
14. FLYING STATUS 15. BENEFICIARY CATEGORY
16. ZIP CODE OF RESIDENCE
47 48 9 SO 51 52
60
111112101111111111111111
17. UNIT LOCATION (State or Country Code) 18. MOS 19. TRAUMA PREY ADMISSION
62 63 64 65 6 6 68 69 70 71 YEAR
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72 C.11\)— ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Cale,
NAME A hb)(3)-1
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21.
TYPE OF DISPOSITION
22.
WIT TRANSFERRED TO
23.
DATE OF DISPOSITION (YYMM00)
73 74
75 76 77 78 79 80
1911111115111211T11191
0minumrara
24.
CLINIC SVC - ADMITTING
25.
MTF TRANSFERRED FROM
26.
DATE THIS ADMISSION (YYPIND0)
87 88 89 90 91 92 93 94 95 96
101 102
11111111111
A
27.
LOCATION OF OCCURRENCE
28.
MTP OF INITIAL ADMISSION
29.
DATE
DATE INITIAL ADMISSION (YYMMOD)
(Battle Casualty Only)
103 104 105 106 107 108 109 110
11111101111113111111111
FOR LOCAL USE
QSW euijcgioq_
. IN 1-1 t-owcr iGtetew,n-t-
a.bd.akm
,
:b)(6)-2
(b)(6)-2
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SIG
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MEDCOM - 4379
DOD 010858
-
10
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in
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241 242243 244245246 247f248
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SECOND PROCEDURE 46. THIRD PROCEDURE
FOURTH PROCEDURE . FIFTH PROCEDURE 4
9.
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PROC
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FIFTH DIAGNOSIS SIXTHDIAGNOSIS
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For use of this form, see AR 4
N
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SEVENTHPROCEDUR TH PROCEDURE 2. SEVENTH DIAGNOSIS .EIGHTHDIAGNOSIS
N
N
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N
RESIDUAL DISA
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MEDCOM - 4380
DOD 010859
INPATIENT TREATMENT RECORD COVE... a.
For use of this form, see AR 40-400; the proponent agency is OTSG
( b)(6)-4
2. NAME (Last, First. MI) 3. GRADE ADMISSION REMARKS
1•(b)(6)-4
(b)(6)-4
4 RACE 7. RELIGION LENGTH OF SVC 9. ETS 10. PREVIOUS ADMISSION
Z91-1
11. FMP 12. SS 13. ORGANIZATION 14. WARD
(b)(6) -4
15. FLYING 1B. !IA! Nt / 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE STATUS DSG BEN
.. .
22. HOURS OF 23. CLINIC SERVICE ADMISSION
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
09 z.O A .6fA A
0 __C.-71-
24. NAME/RECATIGNSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION 26. DATE OF DISPOSITION
6 2-lz)
28. ADMITTING OFFICER ADMISSION
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. DATE OF THI
/4Pko 3
i
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 3u. DATE OF INTIAL 32. UNITS OF WHOLE BLOOD/
ADMISSION COMPONENT TRANSFUSED (b)(3)-1
IRAQ
31. SELECTED ADMINISTRATIVE DATA
Check it Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
fil c .
4f9 r7 i K 6 ji, S
'&71 'Ir\r. k? g_ .t-/iiil h„e, f i. t,'Y p Oti ' -
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1 00,v #6aca0‘jjc
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61-cti L t-tcl 1",,,
i --4rt A -_-;-tkCt Ind
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONV. LV/COOP d. SUPPLEMENTAL e. BED DAYS I. TOTAL SICK DAYS
CARE DAYS CARE DAYS
H It, 1v
36. Total Days All Facilites
a. ABSENT SICK DAYS b. OTHER DAYS c. CONV. LV/COOP d. SUPPLEMENTAL e. BED DAYS I. TOTAL SICK DAYS
CARE DAYS CARE DAYS
/1
,b)(6)-2 (b)(6)-2
SIGNA SIGNAL CER
DAF MITICM (1F I Aim 70 IR (IFICCII FTF IICA0171" III in
MEDCOM - 4310
DOD 010789
-._4
INPATIENT TREATMENT' RECORD_ COVE.
For use OfthiS•form; see AR 40-400;. the proponent agency is OTSG .
(b)(6)-4
RFC;ISTFR N iMRFR 2. NAME (Last, First, MI). 41
3 . GRADE ADMISSION RFJOIARKS
(b)(6)-4
,b)(6)-4
10. PREVIOUS ADMISSION
4. SEX 5. AGE 6. RACE 7. RELIGION a LENGTH OF SVC 9. ETS
L1_ IQ ;A
14. WARD
13. ORGANIZATION
b)(6) -4
11. -FMP 12. S9N
17. 18. BRANCH/CORPS 19. UIC/ZIP 20. TYPE CASE
STATUS DSG BEN
... .
15. FLYING 16. RATING/ DEPT./
./D--•
22. HOURS OF 23, CLINIC SERVICE
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION ADMISSION
,t,?Ls .c7i--- d9 2O A OPi A
25. TYPE DISPOSITION 26. DATE OF DISPOSITION
24. NAME/RELA I SHIP OF EMERGENCY ADDRESSEE
infi 1 d 5-
-3
CS 2-ADMITTING OFFICER
28. DATE OF THI ADMISSION
27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO.
)?/1Pe-0
3D. DATE OF INTIAL 32. UNITS OF WHOLE BLOOD/
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
ADMISSION COMPONENT TRANSFUSED b)(3)-1 IRAQ
31. SELECTED ADMINISTRATIVE DATA
Check it Continued on Reverse
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
(--"4-4-1-7---) v
-/viz il
-(( 1
....,
x_ i„vveit 04,1_0ttlg...A..-1-•-)i 41---'
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35. a. Total Days This Facility ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS d. SUPPLEMENTAL CARE DAYS e. BED DAYS I. TOTAL SICK DAYS
q 36. Total Days All Facilites a ABSENT SICK DAYS b. (b)(6)-2 OTHER DAYS t. CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL r1 ,C n""`b)(6) -2 l e. BED DAYS I. TOTAL SICK DAYS
R
C EDITION OF 1 AUG 76 IS OBSOLETE MEDCOM - 4311 . USAPPC V1.10
DOD 010790
DEPARTMENT OF THE ARMY
(b)(3)-1
(b)(3)-1 IRAQ APO AE 09331
02 MAR 03
MEMORANDUM FOR Record
,b)(6)-4 b)(6)-4
SUBJECT: Hospitalization for Patient # ',b)(3)-1 f',b)(6)-4
1.
Patient 70)(6)-4 admitted on 23 March 2003 during the Operation Iraqi Freedom war to thcP)(3)-1 located at ;b)(3)-1 Iraq. His injuries consisted of gun shot wounds to the right anterior and posterior chest and gun shot wounds to the right lower quadrant of his abdomen.
2.
On 23 March 2003, Patient (b)(6)-4 received an exploratory laparatomy discovering a right liver fracture and repaired two gastrointestinal injuries. Surgeon noted a negative pericardial window and placed a right chest tube, naso-gastric tube, foley catheter and patient placed on oxygen per nasal cannula. These injuries occurred during his service
(b)(3)-1
with the Iraqi military unit assigned to protect
3. On 18 April 2003, Patient ;b)(6)-4 transferred to the (b)(3)-1 to
(b)(6)-2
the Intermediate Care Ward #2, under the care of LTC staff. Patient's wounds cared for with wet to dry wound care twice each day that the nursing staff taught the patient to perform. Nursing staff assisted patient with his personal hygiene each day. The patient ambulated without assistance, but used crutches at times to provide support. He is being discharged on 2 May 2003 with Ibuprofen 800mg every 8 hours for pain. His wound today is clean, free of infection and healing nicely by secondary intention with bright red granulation tissue. Patient will receive 7-10 days worth of dressing supplies to care for his wound himself at his home.
4. Point of contact is the undersigned.
(b)(6)-2
(b)(6)-2
Lieutenant Colonel, Army Nurse T-Tearl Niirce Tntermediate (Thre Ward #2
(b)(3)-1
13)(3)-1
Iraq APO AE 09331
MEDCOM - 4312
DOD 010791
4
0 0
,(Nn
1 a-) CD
DOD 010792
E.3 dcloz
Name:
SSN: (b)(6)-4
DOB:
Unit:
Nationality:
HT:
WT: lb
WT: kg
DATE: 2-%01C1--o r2
TIME:
Additional
Orders/Charting:
b)(6)-2
b)(6)-2
1.Admit: ICU:
2. Dia osis: Tfkr ciraVA4-444,,
3. Condition: VSI Stable
, then Q1 • Q2 hi Q4 hrs;
?t-or < '70 ; DBP: >
; RR: > < 'I >
t5.6 cc/hr; NS @ cc/hr;
cc/hr; Hes an Car
Monitor: Cardiac -; Nem, Q m/117-; A-line,
ins: NG to ont suction; Foley to !ravity 1 #1: 20 cm H2 suction, a1 ---1441.plicia— twit
11. CT #2: 20 cm H2 suction, H2O seal; Hcirrilich 12.LABS: ABG no PRN
Hct now & Q hrs; Chem now & Q 7-Y,1rs; 13.BLOOD: T&S units; T&C Transfuse: units r Whole Blood for He: <
14.
Oxygen: 2L NC, L FM; NRB;
Kee • Sta 92%, > 95%,
15.
VENT: SIMV; ; RR: - Fio2: (3f3; PEEP
ABG Q Ins;
16.X-Ray:
17 MEDS:
Morphine 2, 4, o Q it Ira. Pain
Demerol 12.5 m:; ; 50-75 m! IVP l'ain/chills
tac 50 mg IVP
2.1 1 II
. 111
Dri•: Ativan 0.05-IV over 2-5 min; la-4mg IV)
18.B 6 ''S: IVF: 4 c/% BSA burn/kg
Give Y2 over 1 sc8 s from Time of Burn
19. Head Injury: N uro checks (GCS) Q
C-S • ine: Clear/NO Clear; Kee Head in midltheyosition;
Mannitol (20%): 0.2 /0.50/1 gm/kg IVPB over :3D-50 min Notify MD for Me Status changes
20. EVAC: Priori /in 4-6 hrs; Routine w/in 24 hrs;
rders B CPT b)(6)-2
b)(3)-1
Post-OP s i:of 2 001
b)(6)-2 b)(6)-2
MEDCOM - 4314
LI I 1
DOD 010793
MEDICAL RECORD •ROGRESS NOTES
DATE b)(3)-1 b)(6) 4
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.14141 - (Continu ttlIOMPAgdy LAIN:
r Irr di PATIENTS IDENTIFICATION (for typed 1 iitten entriu Ow Name - lag fust, middle,-REGISTER NAIrpr/ , A „ NO c ¦ ;rank; rate; hospital ar medical facility)
' i 274
A
b)(6)-2NAME: (b)(6)-4
UTE SSN: b)(6)-4
•, rd b)(6)-2
UNIT: / -MEDCOM -4315
USAPPO V100
DOD 010794
M ED11:411. RECORD PROGRESS NOTES
DATE
,b)(3)-1
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PAllENTS IDENTIFY :ATI() typ•d for written ...via V
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STINOARO FORA. 509 (Vim 11 b)(6)-2 Prirsaib.9 by GSA/IOAR,
BRIAR (41 CFR) 201 -45.505
b)(6) 4 509-111
MEDCOM - 4316
DOD 010795
:b)(3)-1
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MEDCOM - 4317 4?-2_104
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DOD 010796
MEDICAL RECORD PROGRESS NOTES
....) 6 /4-r5 3
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I
grade: rank rate: hospital or medical facility)
(b)(6)-4 PROGRESS NOTES
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DOD 010820
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
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STANDARD FORM 509 (REV. 5-99)
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MEDCOM - 4342
DOD 010821
NOTESDATE
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MEDCOM - 4343
DOD 010822
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
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PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV .5.991
Prescribed by GSAACMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 4344
MPhil&
DOD 010823
DATE NOTES
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MEDCOM - 4345
DOD 010824
AUTHORVED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
vtA,A1-( Do.1-Atateo c-ckeou nv-k- -6(A.4- (V,YLA-y7 (b)(6) -2
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LAST FIRST MI ISSN Of Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entnes, give: Name - lest, first, middle: REGISTER NO. WARD NO.
ID No or SSA,: Sex; Date of Birth; Flank/Grade!
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5-99)
Prescnbed by G5.4/1CMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 4346
00.02•• I 11.0
DOD 010825
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Intraoperative ,_. ,cumentation
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1. Patient Id entification: 2. Assigned Scrub: S. 4: b)(6)-2
42
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4. Position and Positio • I Aids:
Supin: Prone Lateral -Right Side Up Left Side Up
Comments: --•
5. Skin Preparation:
Hair Removal -Yes (0 Prep Solution - Betadine Paint Razor Clip Site: 4gooint ../ By CPT (b)(6)-2
Comments: Comments: No pooling noted
6. Location of External Devices: e sei4k
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First Final • Other
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Needle/Sharp -:
....
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Medications !Dosage Time Method Prepared By Given B
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Wound Irrigation: .9% NaCI
Other Orders: Time Carried Out B
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11. Additial Information , 12. Dressin./Immobilization
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13. Operation Performed 14. PT Transferred To Time Method
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MEDCOM - 4347
DOD 010826
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MEDCOM - 4348
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DOD 010827
FLOWSHEET FOR VITAL SIGNS AND OTHER PARAMETERS For use of this fOrm, see AR 40-66; the proponent agency is the OTSG ARDWARD ..1"6:(
This form may be used adding date. Insert column for more than one day by drawing a heavy line and headings as required. DATE 103
07 ay PATIENT'S c ftt //1" NAME 64 , s .( X-- i,.,/, ear,,, c, i i S Eia ti V( 62 /7/Z.. f/q g K i ‘ Cp69 /cit't 2111= 0 i,c0 e VD f, CI ,z /
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DA FORM 3950, JUN 91 Previous echelons are obs etc. us...PA ...n o:
MEDCOM - 4349
DOD 010828
• 511-1 1.9 NSN 7540-00-634-4124
• MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY 'X7 //1.8 g 1 'tato, .
19 HOUR " ' ' 1100 1 boc, ' • " " " " " " • ' " ' •
PULSE keg6116 3iip) TEMP. F (*) 105° . . . . . . . . . . . . . . . . . . . . • . • . • . • . • . • . . •. • . • . . • . " • . . • . . • • . • . . • . • . . • . . " . . . . • • . • . . • . • . . • . • . . • . • . . • . • . . • . • . . • . • . . • . • . . •
Jl A 180 170 160 104° 103° 102° • • " . . • • . • . • . • • • . . " . . • • • . . • • . . • • . • • • . • • • . , • • . • • • . • • • . • • .• . • • • . • • • . • . • • • • . • . • • • • . • . • • • • . • . • • • " . . • • . . • • • - • . • . • • • . • . • • • • • . . • • . . • • " • • • . • . • • • • . • . • • •
150 140 101° 100° . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . • . • . •
130 99° 98 . 6° : : • ; : ; ; ; . . • a ; ; . • ; . . • • . . • : . . • • . . • : . . • : . . • • . . • • . . • : . . • • . . • • . . • . . . • .
. . • . . . • . . . • . . . • .. . . • . . • •
120 110 98° 97° . . . . •• . . . : . . . . . • •"• . . . . . V . . . . . • \ • .1• . . . . : . . . •• . . . : . . . : . . . : . . . : . . . •• . . . •
. . . • • . • . • • . • . -" . • . • • . • . • • . • . • • . • . • • . • . • • . • .
100 90 96° 95° •. . . . . : . . . . : . . . . •• . . . . . V • . . . . . . . . @ . • • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . . • . . . . • . . . . • . . . . • . . . . . • . . . . . • . . . . . • . . . . . • . . . . . • . . . . . • . . . . .
80 . . •• . . . • • . • . • . • . • . • " . . • • " . . • • • . • • • • • • • • • • . • . • . • . •
70 " • • " • • " • • " ' •
• • • • • • • • • • • • • • • • • • • • • • • • • • • •
60
• • A : : •• : •• : •• •• : : : •• " ' •
50 • • • • • •• . • . •• • •• • -• • . • • • • • . • . • . • . • . • . • . • . • . • . • . • . • . • . • . • .
40
RESPIRATION RECORD
—I CO COCO C..0 COCO COCO COCO .4. •r=.rT, 1 CM0a) (3) -.I---1 -J CO00CO 0 0 K i
o 6) l--. :4 biv bo i..J to :4 b 6:0 1
0 0 . 0 0
(Centigrade Equivalents, for Reference only)
._.. ... ..
Record specialdata only when so ordered
BLOOD PRESSURE
HEIGHT: WEIGHT —10.
7:0
C9(Airtfi-
2119 .,4-- /3 0 Tti "
PATIENT'S IDENTIFICATION (For typed or wri ten entries give• Name—last, first, middle; ID No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility)
,1))(6)-4
MEDCOM — 4350
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM S11 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
DOD 010829
511-119 N SN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS SEC!
HOSPITAL DAY POST-DAY ralIMIM 1 ' 1M a I
iiiiMIffilaiW
MONTH-YEAR DAY e2i WOMI 'i NiM M IIII¦Kr
Il0 0 ' 1.8-DV)
HOUR COI • • mucricia-. NI •• rgicapim 131 1=:
:
PULSE TEMP. F
(0) (9)
105°
...
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.... . .
. . . .
180 104°
... . . . . .
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150
..
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140 100° • • . ..-•-' ••
•
,
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99°
98.6°
130
. . . .
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120
98°
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110 97. : 1
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100 96° It
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90 95°
1111
Il 111111111. :. :• 111
FREE 1
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80
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70
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l(51)%l' PlIV
'ATIENT'S IDENTIFICATION (For typed or written entries give• Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
60
• " •• •• • •
. . . . . .
.
..
•¦•¦•••••1
40
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41 li
RESPIRATION RECORD 11-4
1Record special data only when so ordered
BLOOD PRESSURE
tat L
MIMI
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HEIGHT: WEIGHT
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REGISTER NO. WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM OA (REV 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 4351
DOD 010830
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST- DAY
MONTH-YEAR 19 DAY HOUR A,(9 •480 1./.0.A • 2.1— J • • . IA t:PECC9P 1.2i J. ••10 ...0 1 M411(5 2. MAy 63 • -101•031 0% • KO 41 11 ,4111,_
PULSE TEMP. F .... • • • • .. . . . . . . . . . . . .
a TEMP. C
(0)
(*) • " • ' • ' " • •' " ' •
. . . . . . . . . . . . . . . .
105°
40.6°
..
"
. .
. . . . . . . . . . . .
180 104°
40.0°
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RESPIRATION RECORD
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'Record special data only when so ordered
BLOOD PRESSURE
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HEIGHT: I WEIGHT ---+
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,ATIENT'S IDENTIFICATION (For typed or wri ten entries give• Name—last • first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK
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MEDCOM - 4352
DOD 010831
712
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SPECIMEN TAKEN DATE ) TIME A.M. '• DATE SPECIMEN TAKEN A 3'
RES LTS 1)03 REQUESTED (X) P.M. SULTS REQUESTED
GLUCOSE
GLUCOSE
44 UREA N. CREATININE UREA N. CREATININE ¦ ',b)(6)-4
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PHOSPHATE
ALBUMIN CALCIUM TOTAL PROTEIN 7o prn rrs 0 Z rn C) CALCIUM TOTAL PROTEIN ALBUMIN ¦
GLOBULIN ALKALINE PHOSPHATASE GLOBUUN N ¦
LDH ACID PHOSPHATASE SGOT (b)(6)-2 S. Ci O PHOSPHATASE ¦ (b)(6) -2
r a Z Y35-14rt 1-46,5f)0 L1 CHEMISTRY I STANDARD 5,16 (Rev. 8-77) •Prescribed by G5A7 ICMR FIRMR (41 CFRI 201-45 505 AMYLASE TRIGLYCERIDES UPASE CPK BILIRUBIN (TOTAL( DIUDUBIN (DIRECT/ CHOLESTEROL 346-107 O PATIENT'S MED. RECORD ¦ ¦acamsamms cassa ¦ r. BYrmn¦ „ *Na¦ CHE n MI RY I 548-107STANDARD FORM 5.5 (R.. II-17) PRESCRIBED BY GSA ICMR FIRMR (41 CFR) 201-45.505 1 1 1 1 1 IL UBIN TOTAL BILIRUBIN DIF CHOLESTEROL PATIENTS MED. RECORD
MEDCOM — 4353
DOD 010832
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.
LIST TIME PATIENT IDENTIFICATION ORDER
DATE OF ORDER TIME OF ORDER
NOTED AND HOURS
SIGN
b)(6)-2
NURSING UNIT
)(6)-2
DATE OF ORDER
PATIENT IDENTIFICA
(b)(6)-2
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION BED NO.
PATIENT IDENTIFICATION NURSING UNIT ROOM NO. BED NO. DATE OF ORDER o7 /1761 ;b)(6)-2 TIME OF ORDER (41/4 HOURS
NURSING UNIT ROOM NO. BED NO.
REPL , EDITION OF 1 JUL 77, WHICH MAY BE U...
DA 4256
1 FAOPRRM7g
MEDCOM - 4354
DOD 010833
AUTHOR ED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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HOSPITAL OR MEDICAL FACILITY
STATUS DE PART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO.
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give; Name - last, first, middle; ID No or SSN; Sex; REGISTER NO. WARD NO.
Date of Birth; Rank/Graded
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-97)
Prescribed by GSA/ICMR FIRMR 141 CFR) 9n1-9.202-1
MEDCOM - 4355
DOD 010834
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING C.1...JAN12.....JN (Sign-each entry)
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'U.S. GPO: 2002 491-600/504318
MEDCOM - 4356
DOD 010835
AUTHORIZEMFOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
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FIRST
LAST
HOSPITAL OR MEDICAL FACILITY DEPART./SERVICE
(For typed or written entries, give: Name - last, hist, middle;
PATIENTS IDENTIFICATION:
ID No or SSN; Sex; Date of Birth; Rank/Gradel
I *VS, • • a.
vs
e /50a
Medical Record
i,ecb)(6)_2
ANDARD FORM 509 (REV 5-99)
Ty-AN-A/ 71D
Prescribed by GSNICMR FPMR (41 CFR) 101.11.203(b)(10)
MEDCOM - 4357
DOD 010836
AUTHORIZES FOR LOCA' REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
NOTES
DATE
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ISSN or Other)
MI
FIRST
LAST RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITYDEPART./SERVICE
'REGISTER NO. WARD NO.
(For typed or written entries, give: Name - last, first, middle;
PATIENT'S IDENTIFICATION:
ID No or SSN; Sex; Data of Birth; Renk/Gradel
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11 .203(b)( 1 0,
MEDCOM - 4358
DOD 010837
AUTHORIZED FOR LOCAL REPRODUCTIOI
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
.(b)(6)-2 .
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SPONSOR'S NAME
SPONSOR'S ID NUMBER
LAST
FIRST ISSN Of Other)
MI
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HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or
written entnes, give: Name - last, first, middle;
REGISTER NO.
10 No or SSN; Sex; Date of Birth; Rank/Grade) WARD NO.
(b)(6)-4
r
PROGRESS NOTES
Medical Record
LI in A
ki n A co rs G• • "•••
FORM (REV. 5-99)
bed by GSNICMR FPMR (41 CFR) 1 01-1 1.203(bX10)
MEDCOM - 4359
DOD 010838
CUM., , u RD 1 h::.. APEUTIC DrCUMENTATION CARE PLAN (NON-MEDICATION)
..,..,
For use of this form. see AR 40-407;
h . ‘ t .. Mo. Yr.
v is the Office of The Surgeon General.
VERIFY BY INITIALING ,,'¦ •,' i ',:,: ,,',,-1,
' • '
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED
DATE NURSE FREQUENCY, TIME
al( as bb H at
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ALLERGIES: fl YES M NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
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PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
n A arlDRA A a77 I ne-..r -ro R Aril",-.1A An,"
USAPA V1.00
DOD 010839
Verify by THERAPtUTIC DOCUMENTATION CAH ' N • t ,(NON-MEDICATION) "-: : :11#. ' Yr
Initialing
. ' " i5iiiir p
Order Clerk i( Time Done Initials
SINGLE ACTIONS i be Done be Done '
Date Nurse
.., .
I
Order/ S)CaPt: Clerk/ Nurse fd_Api0 (6)(6)-2 PRN ACTION, FREQUENCY 6e-4.010L., .15.0 /oO tiPo z i-i-- as INITIAL PROPER COW IN FOLLOWING COMPLETION TIMEIO C')MPLETED _ —r` l .-- .
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MEDCOM - 4361 USAPA V1.00
DOD 010840
Ai C.-- \..C.,Recurrent . -dications and Treatments date ,.2.3 (41 `6 '
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MEDCOM - 4362
DOD 010841
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5- a
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IVF Time amount Total 4t,
1,1 r Os II 0 ct 7 k— Ec LA f1S r9 ( t F. .c._./ Pr— Ybt, r1-6 d(c,_i_lp , et v-ill of . . Is.4,c) OZ ,..)v `toe, 140 1CP 61k( r7d°
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0100
0200
0300
0400
0500
0600
0700
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8 hour totals
0900
1000
1100
1200
1300
1400
1500
1600 . S'L'R
8 hour totals 1700 CP (47P
1800
1900
2000 15'-
2100 5 P-
2200
2300
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8 hour totals .--c,J....,
24 hour totals Total mpu . : (V\ ...., ..? 0
Total output:
Balance:
MEDCOM -4364
DOD 010843
date
Recurrent Medications and Treatments
_. .
Vital signs 4 S" 79 ivi,k_ 741 4' ea
8
12
16
20
PRN Medications and Treatments 24 d/t amtInt d/t amt/int d/t amt/int d/t amt/int d/t amt/int d/t amt/int .
Name: Dx:
SSN: All:
Unit: Blood type:
MEDCOM - 4365
DOD 010844
date 1/3O
Recurrent Medications and Treatments
(•e/V\ d\ 4 3 b)(6)-2
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Unit: Blood type:
MEDCOM - 4366
DOD 010845
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MEDCOM - 4367
DOD 010846
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MEDCOM - 4368
DOD 010847
N7AT
THERAPEUTIC DOCUMEION CARE PLAN (MEDWATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; MO. DX'Sthe proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING : INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
IS/ ICI ‘20 LIELNIMIN a-te M* MM
1/(6006 (b)(6)-2 rivAa iitichaa DI
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PATIENT IDENTIFICATION:
Gfi f---6/1 /7
SPENSING TIMES
f
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USE PENCIL. CIRCLE MED TIMES
011 D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DAiFF1719 4678 EDITION OF 1 DEC 77 WILL BE USED UMEDCOM - 4369 NTIL EXHAUSTED.
DOD 010848
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Mo. Yr
Initialing (MEDICATIONS)
Order Clerk/ Date to Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse be Given be Given
ii/Fra3,[b)(6)-2 I Cepii./„.. 0 min, a4( 0.412 tumid
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U.S. GPO: 1990-454-110/9521S
MEDCOM - 4370
DOD 010849
1— THERAPEUTIC DOCUMENTATION CARE ov,ED;,..AnoNs)
CLINICAL RECORD
tis7. proponent anrcv is the Office of The Sermon General. Mo. 5Y r. (....3
VERIFY BY INITIALING iN;;;O::::ailmo...tionormandiiiiimii INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERK! RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY 5
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PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES
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MEDCOM - 4372
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It ,ENT TREATMENT RECORD COVER
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ADMISSION COMPONENT TRANSFUSED ;b)(3)-1
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33.. CAUSE OF INJURY
14. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
35. Total Days This Facility
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36. / '3 Total Days All Facilites /3
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INS - AT TREATMENT RECORD-COVER S
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MEDCOM -4221
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STANDARD FORM 600 (REV. 6-97) Proscribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
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MEDCOM - 4223
DOD 010702
AUTHORIZED FOR LOCAL REPRODUCTION
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DOD 010703
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STANDARD FORM 600 inv. 5•971 Palsorlbed by GSA/ICMR FIRN1R (41 CFR) 201-9.202-1
MEDCOM - 4226
DOD 010705
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DOD 010706
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MEDCOM - 4228
DOD 010707
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM - 4229
DOD 010708
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MEDCOM - 4230
DOD 010709
AUTHORIZED FOR LOCAL REPRODUCTION
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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-971
Prescribed by OSA/ICMR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4231
DOD 010710
AUTHORIZED FOR LOCAL REPRODUCTION
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DOD 010711
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DOD 010713
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STANDARD FORM 600 (REV. 6-971 Prescribed by OSA/ICMR FIRMR (41 cm 201-9.202-1
MEDCOM - 4235
DOD 010714
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DOD 010715
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CHRONOLOGICAL RECORD OF MEDICAL CAREMEDICAL RECORD
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STANDARD FORM 600 (REV. 8-97) Preserlbed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
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DOD 010716
AUTHORIZED FOR LOCAL REPRODUCTION
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SPONSOR'S NAME SSN/ID NO. ' RELATIONSHIP TO SPONSOR
. ..
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - kat, first, middle; ID No or SSN; Sex; I REGISTER NO. WARD NO. Date of Birth; Flenk/Grade.1
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-971 Prescdbed by OSAPCMR FIRMA (41 CFR) 201-9.202-1
MEDCOM - 4238
DOD 010717
DATE SYMPTOMS, DIA9NOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
10 03 0516/ oftuf-4
•-if-11-tovi/v;W
-.-0 1 ()tic106 i. ,-(i'&17c. . 6470 (.0.,,t,,e._,60--.4,c7
s( 6m) ticitA , IA/_ -4 --. J/0( i &-de, 4
r._) ezi.v.kid,.....,,0,0_,,,z,,e,4 .A.,"...,.... c _ , _, _ ice._
t ,,,i .., 2/ i tut( IA,,.....," 44-„,.„. Li?7 n(4;23C.CA
Cir.4,
. ,
STANDARD FORM 600 (REV. 8-97) BACK -U.S. GPO: 2002 - 491-600/50818
MEDCOM - 4239
DOD 010718
MEDICATIONS
Allerqie Time Fair Medication & Route Pain E By 1 DOSROP 1-10
or
11 11 Iv at,on,
IYOS p.S.,rs 5 IV
6 MSO u v griL444,
,223 6
Irni 5jfkiftSt
3o 09...3 PUN IV
NEUROVASCULAR
Time ite Range Sensory P Cap Color Of Refill Motion Adm 15' 30' .45' 60' 90'
Movement/ ier + present,- = absent Temp:C = Cool, W =Warm Pulse s: P = Palpable, D =Doppler, A = Absent Color: C= Cyan :tic, Capillary Refill: Ft = Brisk, S = Sluggish P = Pale, Pk = Pink
C-SECTIONS
Fund. Heig
Lochia
Peripad# Fund. Cond.
DRESSINGS
Time Location Type D -ainage
Adm 30' 60'
DIC
PACU OUTPUT
Source Color/Appearance Amount
/41, lL ment
.104 At-
CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?
WAMC OP 173•E
NURSING NOTES
/raY-ya/
c-v/o ,-/r. encl. ¦r/L/t ZI.4
d da.w... 8)-
a I, rAtt. af,
AJ r tATe la AFIrt 7.-e f:11.0 a slAn . ..70 02
4,44 c vpiL.,..r.T.( 02 -J.61 4-‘-' 7 IS
v.7 pat., e
j
,r
c4 'bX6)-2
1116Pr. 4./a.s.r./ 6)-2
1141-
Roo- heesTI.5_, 19 aim( Abr.," • ,471.. ,
-e
• e 7/5/ r11.11
¦ rf VSicq de 0
77iG
b)(6)-2
Id f r .
IT -. 'sr A • : C.:v offer?;,"
• a
.. fir.An /94,‘ J.1 .6(3/•1 / fy,o. /
13)(8)-2
,
•
Discharge Criteria: Date: Time:
PARS: BP: T: HR:
RR: Sa02:
Pain Level at D/C (0-10):
Intake: Output:
Additional Data:
Transferred To:
Report Given To:
Transferred Via: W/C Litter Gurney Ambulance
Transferred By:
Cleared IAW Recovery Room SOP 8-3
Charge Nurse Signature:
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this fens, see AR 40-66; the proponent awry is the Office of The Surgeon General.
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG PPRO"ED Ware)
Date: 1.211.(3r 1E33
Time In:
Allergies:
Pre-op V/S:
Procedures:
R I4f ,.../slowa_
Pre Op Meds
Time
k• no b.
Sa02
102 00 tet
F102
Methods' Jet.:(
240
220
200
180
160
140
120 V •
•
V r V
V V • • • 100 • •
80 A A A A A A 4 4
60 A 4
4 ./1
40
20
RR
15 /6 41 la II 16
T
Time
Pain (0-10)
LOS
PREPARED BY (Signature
PATIENT'S IDENTIFICATION For typed er written entries give: first, middle; grade; date; hospital or medical fauFtyl
b)(6)-4
12111••• •
Anesthesia Type (Circle)): General S nal Epidural
OR Intake: Crystalloid
OR Output: UOP
Meds/Tlmes:
Histo
sts. 4a Arp 10° 102 qf
fA 4 RA 0, AA IA a
V V V v • •
.25 Li 2‘,1:1425' iY ,f11
Drains IV Sedation Nerve Block
Hert>Qva is
Colloid
EBL
T-tube
Foley TLS
Pacu Intake Time Solution Amount Site 13y
•/1etro s -9 ivAct.
—700 RA IV -L Ono
X-rays:
Labs: Post Anesthesia Recovery scale
Criteria ADM
30' Activity
(2)
Moves 4 Ities
(1)
Moves 2 mines
(0)
Moves 0 mities
Airway
(2)
Cough, breath
(1)
Dyspnea, Prnited breathing
(0)
Apnea
Blood Pressure
(2)SBP =/- 20 of Pre-op
(1)
SBP 2C-50 of Pre-op
(0)
SBP =/- 5C of Pre-op
Consciousness
(2)
Fully Awake, audible
crying
(1)
Arousable to verbal or pain
Color
(2)
Baseline cols-& appearance (1)pale, mottled, jaundiced
(0)
Cyanotic
Circulation (Peds < 5 Years)
(2)
radial PulsI Palpable llary palkohlp not radio(
(0)
Carotid only reliable pulse
TOTALS: Mus be 9 or greater to D/C, otherwise needs anesthesia approval for D/C,
Pa err teaching done; Wound Ca e, Pain Maria ement, T, C, & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained
DEPARTMEITISERVICE/CLINIC
Name. —last,
.
HISTORY1PHYSICAL
.
OTHER EXAMINATION OR EVALUATION
.
DIAGNOSTIC STUDIES
.
TREATMENT
)/C
Airway
Nasal
Oral
ETT
Trach Other
Infused •
Codes
AIRWAY A = Ambu BB = Blow-by M= Mask FT = Face Tent RA = RoomAir NC = Nasal Cannula
V/S X =A-line BP
-=Cuff BP = Pulse
TEMP S =Skin 0 = Oral A =Axillary T =Tympanic R =Rectal
LOS C = Cervical T = Thoracic L = Lumbar S = Sacral
ILOI;Inie on roversei
( ATE
Ci f LOW (HART / T-IER simay/
DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MC X C-DN) Previow edition is obsolete
USAPPC V2.00
MEDCOM - 4241
DOD 010720
-..... MEDICAL RECORD ..irlAOPERi . DOCUMENT
For use of thls form, see AR 40-407, the pro omint a ency is the officio of Tlieon General.
1. PATIENT/, TRANSPORTED TO OPERATING ROOM
ils....LL(.—,_
TIME PATIENT ARRIVED IN SUITE
NE
GV > 4 r.
ID P URE
(b)(8)-2
..".). 4
VIA 1,7c,---
BY
A
3. DATE PATIENT IN RO M
23 Ifihie
07
13 5/ c"--
NUMI3E 3
MIR =
5. PREOPERATIVE EMOTIONAL STATUS
. CALM . ANXIOUS . EXCITED . CRYING . ANGRY . WITHDRAWN [] CTHER (Specify)
COMMENTS:
I (C4-4....51411,v-1 -i u—' -.
may. =
0 .
6. NU -SING PERSONNEL
ASSIGNED RELIEF
)(6)-2
CS 6--
SCRUB SCRUB
b)(6)-2
ASSIGNED RELIEF
CIRCULATOR CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
<SUPINE . LITHOTOMY . PRONE . KRASKE LATERAL: . LEFT SIDE UP . RIGHT SIDE UP
COMMENTS:
I MI MP
8. SKIN PREPARATION
HAIR REMOVAL AYES . NO PREP S9LUTION (Specify)
ep_AL b)(6)-2
DONE BY: . OR . NURSING UNIT SII E: Y WHC V://4iS idi 1
METHOD: . DEPILATORY g RAZOR SIT E: It WHCIV:
. CLIP
COMMENTS: ic 6,2 . CCMMENTS:
•
04 20••¦••
.
9. LOCATION OF EXTERNAL
--.. -
ID .._.
_ ... ....
.&-, -
.
LEGEND X Ground Pad - Safety Strap ---. Tourniquet
IN
C .. CO t I ... Incorrect
First Closing Final Closing
10. COUNTS Other Count Count SCRUB CIRCULATOR
Sponge eves . No
1*(6)-2
Needle Sharp L7 Yes . No
b)(8)-2
Instrument 0 Yes ErNo Other . Yes grNo
11. PATIENT IDENTIFICATION (For typed or written entries give: 12.ELECTROSURGERY DEVICE(S) (ESU) 1/..tRiES . NO Name first, middle-G .-s-z...-or Medical Facility;)
. ._
. ESU NO: F / O GROUND PAD: BRANDII V4. ff, 4-9 0
LOT NO:
E ESU NO:
GROUND PAD: BRAND
LOT NO:
C BIPOLAR NO:
lime Last m -r
.II IIII¦1 III
DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179.1 (TEST), DEC 82, WHICH IS OBSOLETE.
MEDCOM - 4242
DOD 010721
OPERATION REQUEST AND WOR KSI-
For use of this . ., see AR 40-407; the proponent agency is the Offi, he Surgeon General
SECTION A - REQUEST FOR SURGERY
1. PATIENT'S NAME (Last, First, MI) (Print) • 2. STATUS 3. AGE 4. RELI-5. REGISTER NO 6. SSN (with Family Member GION Prefix)
b)(6)-4
,
e)n N tAC 7 P NOSIS 8. NURSING UNIT (from -
to) litteA
p. riprios Q-04--corc.A c,.‘(.a
10. REQUESTING SERVICE9. OPERATION PROPOSE
CeiAt, •-• OV(.0S 'S,
••-•r...-
11. DATE OF SURGERY 12. TIME OR CASE NO 13. SCHEDULE PRIORITY (check one) 14. BLOOD REQUIRED 15. SEP
(Unit)
1 SI • EMERGENCY 1111SEMI-EMERGENCY
S47413 Itt
El ROUTINE cc
16. SURGEON 17. ASSISTANT(S) 18. POSITION OF PNT -19. PREP REQUIRED
lift 0(6)-2
te•At
1-.0'%3
1,42kCI
20. NURSING STAFF 21. ANESTHETISTS) 22. ANESTHESIA
23. SPECIAL INSTRUCTIONS AND REMARKS
JAAkm-r-Qt -
f,Coe,tr--12.-.A.A
:b)(6}2
24. REQUESTING OFFICER (Printed Name and Signature)
)(6)-2
141c (MC
SECTION B - OPER
25. OPERATING 26. TIME OR CASE NO 27. SEPTIC 28. FLUIDS (other than blood) 29. BLOOD ADMINISTERED ROOM NO
/%./ 5
30. SURGEON 31. ASSISTANT(S) 32. ANESTHETISTS) 33. ANESTHESIA
TIME (Began and
Ended)
34. AGENT TECHNIQUE 37. AIRWAY 39.SPECIAL PROCEDURES
INDUCTION (Anesthesia)
ANESTHETIC .., ' R5-2: .--- c '7 • 0 E 7 j •
35. AGE TECHNIQUE 38. RELAXANTS PRIMARY
INTUBATION OTHER
ANESTHETIC
CnitVi 87,9
-511roi.y/•-
AGENT TECHNIQUE
• SECONDARY
ANESTHETIC c-4. //, r -
40, NURSING TIME (Began 1. SCRUBBED PERSON(S) 42. cjActILATING PERSON(S) and Ended) 13)(13-)-2
07-3°
43. OPERATION DATE 44. OPERATION TIME 45. DRAINS 46. SPONGE COUNT 47. LABORATORY SPECIMEN
(Began and En d) _....,.., es-1--.‘ss-Jr-
,c-ADge :V 03
63 3 5' /61-5 (-1(
49. OPERATIVE DIAGNOSIS
49. OPERATIONS) PERFORMED • --al EPISODES OF SURGERY
50. COMPLICATIONS (Continue on reverse, if more space is required)
51. DICTATOR'S NAME, SERVICE & PHONE EXT RECORDED IN REGISTER
(Initials)
EDITION OF 1 JUN 73 MAY BE USED.
DA MAR 82 4107
MEDCOM - 4243
DOD 010722
',b)(6)-4
Name: SSN:
,
DOB: Unit: Nationali
HT: WT: lb WT: kg
3
DATE: '7..3 1414-c-TIME: et,„,
Additional Orders/Charting:
z'AJA-P.5 ie-,..-,
ho
9 t Lkv\e.z,
-L.-) A\ ,,.„...., 4 ./.
--C ---.
7r0 • -3 ‘P-'•AA‘l 5 •
b)(6)-2
WY
0 i ' . titallli . , ..riMilbtx6)-2 / • (6)-2 . A• .:0 1 1, • 0 LI,
•
1/&.1-0r0..aol -\-b re VP
0 (av, cs _ ,o. i( b)(6)-2
)
X62I
7-6 W4-0'5
kv,..,-.44,3\
r • ) CeLPA-A.kx.k
ac,t--\
/ .-2 , 0,.. ) s-0137
° '7,) 01( OvAc,4-71—
' i--;) ( )2 coArc11-0.^ "V (-5-
-
--3,-J 412 31\1-0
c LA) (.),.L.,,Nro....v\ k • • y .
r 6 ›vA\lv,\A\-c-(''' 1 •
e u qtc, ,4-3 i-
' 1" ) C)!: rd c.,4 .,..14,..A.1,\'
1.
Admit: ICU: . POST-OF
2.
Diagnosis: /.717 e.,41A -co--,c-, 1
3.
Condition: VSI Si
4.
Allergie • ...1\7.--40P-_______.„
a - Q2 lu•; Q4 hrs;
Notify MD for SBP: > IGc or < tc,< c-7' ;
5. VS: 3; Q1.0.. miL)3, th n Ql.
' ; DBP: > k'': HR: > \2.3 , < • ; RR: > •7 ,< i':=I; 'il'aup: > I' 7.--q0 cc/br; Az. _ c/hr.
6.
IVF: Iv, ...e -,.....44-. _ 7
Albumin cc/hr; Hes san • cc/hr
7.
Monitor: rardi uLse x; Neuro Q m/1 u -; A-line;
8.
I&O: • 1 Q hrs
9.
Drains N • Low/Cont suction; to gravity
.1-0": CT #1: -20-cm 112 CI suction, H2O seal; Heimlich ,,cam--L ! ..-1-1-. CT #2: 20 cm H20 suction, H2O seal; Hetailich
12. LABS ow & Q1 hr; hrs; Q .1111 ; PRN
He o . Q ( hrs; ow & Q (q___;:irs; UA W-00D: T&S units; T&C unit,. . -,
IiL
Transfuse: units PRBC or Whole Blood for He: < %
Oxygen: 2L NC; 4L NC; 5L FM; NRB;
Keep Stats > 92%, > 95%,
15. VENT: SIMV; TV:1; RR: cil- - Fio2: q;C(1'0; PEEP
ABG Q I hrs;
1X-Ray:
17 0 ! . ?
o • : - .00or 6 mg IVP Q '17'-' min/hr F7rti Pain .
.11 J.:- - of li.'5--ing; 25 mg; 50-75 mg IVP prty aiii/chills ;,413: 1 2-4 mg IVP Q 1. hrs pm Nausea
Z .4 -0 mg IVPB Q 8 hrs ,/''
priTn Dopamine: (400mg/250cc) 2-10 mcg/k; Epi: (8mg/250cc) 0.01-0.1 mcg/kg/min. Versed (1mg/m1) ling slow IVP q2-3mi.n11"3 to 5mg
•Ativan 0.05-0.1 mg/kg IV over 2-5 min; (:2:-4mg IV)
p: Norepi/Levo,hed: (8mg/250) 0.01-0.2 r3q/kg/min . •.. / C'/
--,IA : . BURAS:IVF:)4cc/% BS urn/kg = total ?..1. hr fluids;
rst8 hrs
. Head Injury; Neuro checks (GCS) Q minihrs;
C-Spine: Clear/NOT Clear; Keep Head in midline position;
Marmitol (20%): 0.25/0.50/1 gm/kg IVPB over 3D-50 min
Notify MD for Mental Status c es
G. - 'A over from Time of Burn
20. EVAC: Priority w/in 4-6 hrs; Routin w in •1 hrs;
_ _ ._......
274th FST Post-OP Orders, By S ,PNOV
)-2
MEDCOM - 4244
DOD 010723
FLOWSHE:ET FOR VITAL SIGNS AND 0 HER PAR WARD
METERS
For use %if This fbrm, see AR 40-66; the propon t agency is t
e OTSG
Ci
This form may b.? used .for more than one day by dr
DATE
adding date. Inserl 1:o141mn headings as required.
(/ /27
b)(6)-4
e4474-L A
// 7
IN111
16"11111 A
A PRI1111nall bxer2'"--1
MAIM e-e/ MIME M-
IMI .1111BMINE. b)(8)'e"
U MEM b)(8Y2
MiliMr—'111111
•
o (6_ 3 Cr7)
mr-2
, 02 /Y0 7 PM
4111111111111 L o 7 C illik
112
IIIIIIIMMEMPS
L t2 0 0
, MIMI=
0
11111111111MININIM
)(6)-2
6T»
AIIMINIMINIMM
b)(6)-2
I I
V Wall REIM
30 S
IS0-7 S • r
b)(6)-2
,
•
400( • AA
b)(8)-2
17k ••
•k s
17.. •
LI •
1 15 /
ictoo P-15 0 / ZZ 91 %
-
)A FORM 3950, JU 91 ••¦
Previous ecliTioi are obs • ete.
MEDCOM - 4245
DOD 010724
FLOWSHEET FOR VITAL SIGNS AND OTHER PARAMETERS
For use of this form, see AR 40-66; the proponent agency is the OTSG
DATE
This form may be used for more than one day by drawing a heav y line and adding date. Insert colUmn headings as required.
PATIENT'S NAME
b)(8)-4
P 5P 0.z.
I130 17)-ctine_A J?'s y6ieel •5cc tiZ Iteld0A
14ryvi (vv50i i\fr Po( 6/10 air, FtcO (/rp PT -4-0 54 t n beck apvel czoqk zovl -1-nr-cdni slow Off Por qv-er F., t4fotz 1:5ct 12-"KZ_ 90DZ Re.fivse A -CPme too
LL' MSO1 P ' q, 0 aa 93/,
4-ta pe..^ °A'rx6y v\ 0n1.5 pe) cOar.r rjeCtr d ark
yPILLAI tn;AR
O(,Oo Za dlc 5-0 v ivP B 1a5-
civo P+ folecf Wein' ry -t r+ kep 35-12 O7 3o 30 wi q Toy. - \
IA
0 1 30 uvovi v0 -Coe 07q7 DC'A 1-0-r-t.-I 64-rt-luff1 1;464
31o.;,-, 75 14
okit -17+ ov4 0
'
b)(6)-2
-catt y Av.:" 7OQcc. jc.d- if IUkn!
3 3
)03)-2
tvrk /6-5' q
itur101.1.-led crn rT (\nr)r /wk. +01 Diti:.( coky C'OUri"
c2-45 "ED fr),orn ct.ks c pa;r‘ tri6A- Mso P 99 • • v35 2=2-. APAr 0 uflyq SL No,-A I Ci AAA- )(8)-2 b)(8)-2
Teliartz, arty 1, V . vrials 13 7- 20 174' F:1-"41" l iv.ka Car,v1t., b)(13}2
H rArj M6 OLJ IV P. Trans err ' +-o v- 14.r trA Oler
USAF I C
DA-. FORM 3950, JUN 91 Previous ediTions are obsolete.
MEDCOM - 4246
DOD 010725
FLOWSHEET FOR VITAL SIGNS AND OTHER PARAMETERS For use of this fbrrn, see AR 40-66; the proponent agency is the OTSG WARD 13)(3)-1 .-
This form may be used ,for more than one day by drawing a heave line and adding date. Insert colUmn headings as required. DATE ;/4012 63
b)(6)-4 /03g PATIENT'S NAME fie,,,,,j 10 tiz.0,...." ,,,,,,:i — ./...., fn4,.Aarc., - - - b)(6)-2
,:2 1014 pi ...4,.-i....." 1-.. :,or,. ,.,f-, , cf. 104 A.)
""'Q Lei " pq..... -21,-Ar.) liza.r. • 0 7 /1/ b)(8)2
2Z6/0 111Sil d 4,..___70.1_41,Ar /i /02:a olG ,4b.c4: (b)(6)-2
...Z.35.0 .7.rP e i 1...:..-, e, . 7 "73- ----....,.....................,........ bX6)-2
A27.S. r."45/r 0 j9 dOgr... 4/0i .d ,P, Zoe A I.-I Am. 4' /2,-.1......., A- /1.74 7 ' it/4 /q3 • 13)(6)-2 ;13)(6)-2
i< 1 #C7 9 r-I 11-g• ' fil 4,M 6,- /.1 ./-- I 6. hi /S6 , .31." Ti.4-1-4,1 b)(6)-2
',100 itS ; 11, /Ali re. .2/ 4iP i'*
SA %1 9( ..W ....- e 1,,://1-1 41---.11
Vez...7.),5-ti._e ---0 y...-: .-,r...-1...-j. Zz_c„) -CA.; .1 • b)(6)-2
0.-4-00 V S . I-JR m ;4:1. I % r r .1(.. Sti,r11() .
0507 kior \Z 5 : 560. Ilk 133 A)( 6,0 10 .TP ifh r)7/. Pci r," 3 . .0 -
OC10a 9,r.1.-1,1 ; AC 13 11-1- tJ4: r 5/14 'it rr 3 _ ") po1 /2'2
i.,, c_, P 1So Mt., TPe IA
•1 C,ro a .4.3. iik 1 13 .9- AP 04 111$,-..--3 -
s41•0-..." 91, '%;
—
1.35.-4PA %.: 1 Cl
DA FORM 3950, JUN 91 Previous editions are obsolete.
MEDCOM - 4247
DOD 010726
OCco Lion
SP 6 0
ik 133
g p 1.14,
r r .23
spo a 16 "/,
75J6 th,„ MSG,1 •lo ry 11/ P
(b)(6)-2
11-</ or
MEDCOM - 4248
DOD 010727
VITAL SIGNS RECORDMEDICAL RECORD
HOSPITAL DAY
— Net o3
POST-DAY gill-PI Olt /9 14141), / 0/1a, MONTH-YEAR DAY
. . . . .
S5 '9 fr i 4'
1 .
2:3117) Tilt P',Itr tri-en 0'3in, 01-0
HOUR
() .-t c, -DOC-
TEMP. C
40.6' •
TEMP. F . . . . .. .. . p, . ...,
PULSE
(0) ( . 1 •• ••
........ .
40 -c;
NI
' 105' , , , • ...
P.0:1 OVIL m
' " • •
' • " " 40.0'
::
18u 104 . . ..
........ . .
dpz. 61MP(PAT
-:dt 9
. . . . . . . . . .
. . . . . . . . . .
39.4 . • -
-?-2-,
.-c,
170 103'
. ...... . :
6
_
. .
.: •
t—.......
.. ...
. . . . . . .
38.9 °
160 102'
)2.
.-a.) . .
a)
38.3' cc
Ix •
150 101 . . . . " it.'
. . ......
• • •• • • 37.8' •-u;
•
' '
140 100"
• .
. .. .
. . : : • • : : cu . . .
.. • . . . . . . . . . . . . To
.a •• 37.2" 0
130 99 . (s) . a 98.6' . . . . . . .
37.0 ° Lu
. . . . 120 98' .. . ...... . t.../ •. . . •. . 38.7 ° t
.....
. . .
T
.
ili •• : : : : : :
ta
:
:
. ..
...,,
/ .
.
'
36.1° (L)
c.)
110 97'
. . . . .
. ... .
: v . ........ , o : : : : :
. . . . . .
V 35.6 ° . : : .ti•/ ! . : •• • • •V : • • • ••
100 96' .
•
•
35.0 °
90
•
•
:
• . .. .
• . • . • . • •.
: :
. . . . . . . . . .
.
•.
. . . . . . . . y ..
. . . . . . . . . . . . . . .
•. •• • • ••
..
80
•
.. .
. . . . . . . . . . . .
70
60
. .
. . : ,2¦
: : : : ::.
. . .
. .
.
• ;% • : : '
... •• • • •• • • • •
: .......
•• „' A A
50
•
. . . . . . .. . . . . . . . . . . . . . . . .
• • • • •. •
40 I ...... i •i i / f 1
f' I ' ' •' ' •
tzet,
RESPIRATION RECORD C6 & 6 4 6
FO, tf
BLOOD PRESSURE 7;5
"774-4421AG ICq
T ,01 wc/77 TSA 4t3ie lie-
HEIGHT: I WEIGHT-.....0 402-,`7,
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PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first. midd1-1;1.1 • REGISTER NO WARD NO.
)(3
Record special data only when so ordered
(SSN or other); hospital or medical facility)
........”--b)(6)-4
. STANDARD FORM 511 (REV. 7-95) BACK
• U.S.GP0:1998-404-783/40069
moor-e-- ' ¦.
MEDCOM - 4249
DOD 010728
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY A'"7-17. •
•
POST-DAY
MONTH-YEAR DAY ref/ r 0 , MI gn Add 13
,L, HOUR
le ,, • MIEIMIMMIIMIIIIMMUMICarral
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. . . . .
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p ()
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. ..... . . . . .
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• • • • • • • • . . ...... . . . .
. . . . . . . . . .... . . . . . . 18 104°
. . . .
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...
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170 103° . . . . . . . . . • • . . . . . : : : : : : i : : ‘02) : . . . A; • • • V • •• 160 102° . . . . . . . . . . . i . . . ..... . . .
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140 100° -
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110 97°
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40
. . . . . . . . . . . . . . . .
RESPIRATION RECORD 4 45 II 1
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. . . .
BLOOD PRESSURE
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PATIENT'S IDENTIFICATION (For typed or wri ten entries give. Name—last, frst, middle; ID No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility)
•
. '
Medical Record
'b)(6)-4
STANDARD FORM 611 (REV. 7-95)
4r
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
r.1";o,
MEDCOM -6 4250
DOD 010729
VITAL SIGNS RECORD
,IEDICAL RECORD
HOUITAL DAY DAY :r11i-YEAR
I DAY --1"An 0010.3 HOUR PULSE
TEMP. F
(0) (•)
1.05 -
/(1 16(i :150
1. 41.'
ao
98.6" i '20 98
110 97'
15.6
96
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>IRATiON RECORD 131..00D PREDSURE
9 1-1._. 13A1 I, ii0 P.A__
-- ...... ---- ---1
i ._ _.. ___.....
WhIii1-1 I11E10-11:
6/1-. KA
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WARD NO.
REGISTER NO.
NJ'S IDENTIFICATION (For typed or Wri ten entries give: N)fI710---last, (irst, middle; II) No. (SSN or other): hospital cr faUllity)
(b)(6)-4 STANDARD FORM SU (INN I 95) DACR
U.S. Government Printing Office 19'3S- 509-6213
MEDCOM - 4251
DOD 010730
VITAL SIGNS RECORDMEDICAL RECORD
HO PITAL DAY a cs) 414-111) POST-7, ' DAY I 1
i I
MONTH-YEAR DAY
a
•
HOUR 1•P 011.•1 4 . / •i. • 1' Ci ,, 0)J ° •:,‘ °I. ' e ' • () b
19
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3)
b Co I-. :-.) bk.) 'co Ls) co.11. bCo NI 00000000000o0
(Centigrade Equivalents, for Reference only)
: 0 .
.. ••
PULSE
TEMP. F : : : . . : I.
(0) ( 6 ) " " "
L
105°
. . . .
. . . . . . . .
. . . . . . . . . .
....
. .
:
.
. .
180 104°
. .
. . . . . . . . . . . . . . • . . . . . . . . . . . •
. . . .
• • . • •• ••
•
.
. . . . . . . . • •. . . . . . . .
170 103° • . . . . . • . . . . . • . . . . . . • . . • . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . .
. . . • . . . • . • . • . . . • . • . • . . . . . • . . . • . • . • . • . • . • . • . . . . . • . . . . . . . •
160 102° . .
. . . . • . . • . . . . . . . • • . • • . • . . • . . • . . • • . . . . • . . • • . • •
150 101° " " . . . • • . . . .
• / •
:
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•
.
140 100°
. .
• Va
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:
: : •
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130 99
98.6 . V "4 4
•
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. . . . . .
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•
. . . .
110 97° .
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100
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90 95° • . . . . . . . . .
. . .
. . . . . . . . . .
A
•
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80
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. . . .
. . . . " : : : : A : :
70
: : 6 • . • . • •. . . . . . . .
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. . . .
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. . . .
60
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. . . . . .
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<--•
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ft : . : :
. . . .
. . •.
. . . . . .
40
• " " ' • " " " " " " • • " "
RESPIRATION RECORD
Record special data only when so ordered
1
BLOOD PRESSURE
vx 7 yi, I1‘ e`/ /:1 2)41
91 9Y 11 'It .14
W) VA
HEIGHT: WEIGHT —4.
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PATIENT'S IDENTIFICATION (For typed or written entries give: Nam -last, frst, middle; ID No. (SSN or REGISTER NO WARD NO.
other); hospital or medical facility) b)(6)-4 ' STANDARD FORM KU (REV. 7-95) BACK
'U.S. Government Printing °Moe: 1995- 809.828
MEDCOM - 4252
DOD 010731
511-118 NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST-MONTH-YEAR 19 ' DAY DAY HOUR iiia-Pc---)ft • tOie NIS a0-.A-P--li(X64 • tri6 05. ;415.0 O' }c i: fai-eVR inil_ )41 •00.? itubliqm
... . . . . TEMP. C
PULSE TEMP. F :
• " •• •' **** " "
(0) (0) • • . •. • . •. . . . •• •• .... . . . .
40.6°
105 °
,
. . . . . . . . . . . . • . .
• " ' •
-
.
•
•• • • •• •• •• — " "
. .. .
. . . . . . .
. .
. .
. .
. .. . . .
. .
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. . .
40.0°
77771
180 104° :
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•
. . . . . . . . . . . . . . . . . .
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. . . . . . . . . . . .
. . . . .
. . . . . .. , . . •• • • . . . . . . .
. . . . . . .
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'
38.3° ix
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. . . . .
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. . • . ; . . . . . 4'..3.
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. . . . . . . .
. . . . . . . .
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35.0°
90 °95
, . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . .
• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80 . • J. . . • . • . • . • . • . • . . . • . • . • . • . • . • . • . • . • ' . " . . . .
. " P • •• ' • " • • " • • " • • " • • •• ' • " • • •• " • • • • • • • • • • • •
70 .i,,., . . . . . . . . . . . . . . . . . . . .
. . . . • : . • . • . • . " : •. . . • •A. : • 6 • : . . . . . . . . . . . . . . . . . . . . . . . . . .
60
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40 4.0
. . . . . . . . . . . . . :
. . . . . . .
4
2--
RESPIRATION RECORD
6.
Record specialdata only when so ordered
1
BLOOD PRESSURE
• , \t;-rarafiliZENETWIMMONEMITIAILIZErtiy..
I' z. 1, /4•7),,
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1414 q621 qt?, ciqA Taik,L-eit . cislo 917Alfy eite , ets q49 HEIGHT: I WEIGHT —0 it:0)y qs .11.Z, 47.3
PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, frst, middle; ID No. (SSN or REGISTER NO. WARD NO.
–
.
other); hospital oq.msdiakfaciltty)?
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 4253
DOD 010732
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY MONTH-YEAR DAY 1 AM RS Ain--, al Apr
19 PULSE HOUR TEMP. F itLC : : " : : Re • . . . • 0.06;b . . : • : • . • . • . " . . • • • " • " " .. .. • •
-I CO COCc)COCOCO CO(...)COCA AA m
Bcn a) cc -.1 -.1 -4COCO CO00 b in I-.-.Ibk.)EC(AbAb673
00 0 0 00 0 0 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
•
" . . " . . • . • .- • . • . • . • . • . • . • . • .
. . . . . . . . . . .
. . . . . . . . . . . . . .
(0) (•) 105° . .
180 104°
. .
. .
. . . . . .
. .
1
170 103°
. . . .
•
..
. . . .
. . . . . . . . . .
. . . . . .
-
•• "
160 102°
. . .
I
. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
150 101° , ,
. . . . . .
. . .
" " "
•
"
. . . .
. . . . . . . .
140 100°
. . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .
•
. . . . . . . .. . . . . . . . . . . . . . .
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.
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130 99° •
. . . . . . p . . . . . . . . . . . . . . . . . . .
98.6° . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . .
120 98 • •
. .
I.
. . . . . . . .
. .
. .
. . . . . . . . .
110 97°
. . . . . . . . . . . . . . .
V• . . . . . . . . . . . . . . 0 . " . . " . . " . . . . . . . . . . . . . . . . . .
100 96° . . . . . . . .. . . . . . v . . . . . . . . . . . . . . . . . . . . . . . ...... . . . .
.. . . . . . . . . . . . . . . ...... . .
90 95° .. .. . )41 •. •. . •. •. •. •. •. . •. •. •. •. •. . . . . . .
. .
. . . . . .
. . . . . .
80 . . . . . .
70 . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . . . . . . . .
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. . . .
. . . .
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. . . .
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50
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. .
. .
. .
. .
. .
. .
40
. . . . . . . . . . . . .... •• ..... . • •
..
RESPIRATION RECORD
q (y5--,,Lift 46160,
'Record special data only when so ordered
BLOOD PRESSURE
OL,qe
9q1 9 4%,
HEIGHT: I WEIGHT —4
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN other); hospital or medical facili y) or ;b)(6)-4 REGISTER NO WARD NO. STANDARD FORM 611 (REV. 7-95) BACK 'U.S. Government Printing °Mom 1995 • 609428
MEDCOM - 4254
DOD 010733
Al: RECORD VITAL. SIGNS RECORD
'' HOSPITAL DAY
P03
DAY 5••••//79C-411
,8t•
MONTH-YEAR DAY frefalge ib —"WO, 6,/tofi-104" 67 iqi-lk-c 1 o4triv._ 03 C
.
19 HOUR at L • i 0 -•-r. 6sd3 4 . '260 IC • • • . 1i? • 0.-y-1 fjig g4
. . . . . . .
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000 00 0 0
0 sg.... 0
° °°
i
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(Centigrade Equivalents, for Reference only)
PULSE . • •
•
•
•
•
. . . • • . •
(0) ( .) • • • • " " • • " " . . " . . ' . • . " . . • . • . " . .
105
4j . • . • . . . . . . . . . •-.• •- . ' • " • ' •• •• " • •
. . .
1/ 180 • • -
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
• • • • • • - - • - • • • • • - • • - • • • - • - - - •
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
iestull, 170 103° , ... . . . . .. . . . . . . . . . . . . . . . . . . . . .
• • " •. . • . . . ' . • . • . • . . . ' . • . . . . . • . • . . . ' . . . . . .
...
160 102°
V . . . 1: : : : : " : • • :
150 101° .
• • /IN: • V: ij •• . . . . . . . .
. :
. . . _ . . . . . .
kV • sa
140 100°
. . . . . . '' ‘011 . ..b . . .
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' •
•P . . . . . . . . . . .
130 99° Li • -98.6° " " " • • . • " Y " . " " " .(.. . . . .
. . A : T : : : : : : : . : : : : : : : : :
120 . . . . . . . . . . .
. . . . . . . . . . . . . . .
110 . . . . . . . . . . . . . . . . . . . .
• • " •
100
. . . . . . . . . . • -• •• • • • • • •• • • " • " 90
" • •'
80 . . . . .
. . .
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:. ... :. :• .
:. :. :. . . . . .
. . . 70
" • ••
^ : : : : : : : : : : : : : : : : . . . : : . . . . . . . . . . . . . . . . . . . . . .
• • " •
60 •• •• •• •• •• •. •• •• • • • • • • •• •• • •
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
50 . .
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.. . . .
40
7No
L."0
.
. . . . . . . . . . .
A
121
1 4 i
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•
RESPIRATION RECORD
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Eu.eeerms-ssernEelc
VA
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U V 'NT'S IDENTIFICATION (For typed or written entries give: Name—last, Fist, middle; ID No. REGISTER NO WARD NO. (SSN or other); hospital or medical facility)
'b)(6)-4 STANDARD FORM 511 (REV. 7-95) B/
MEDCOM -4255
DOD 010734
NSN 7540-00-634-4124
ill-119
VITAL SIGNS RECORD
DICAL RECORD
........
HOSPITAL DAY
co3 Actrios c iliac, i o A..fp4
POST-DAY
if ,1^3 iti • otio7.. 0ar,3
MONTH-YEAR DAY 4fVfieCIS ‘.15 7 6 .3a.
•
HOUR IVO (1243 1
19
. .
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O co i-.. :...1 ON Co i.,..) (0 :r.. bb.):0
0 0 0 0 0 0 00 0 0 0 0 0
(Centigrade Equivalents, for Reference only)
PULSE
TEMP. F
: :
. . .
'
. . : . . . .
(0) (*)
.
105° ••
. .
•
• • " ' '
..
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................ 180
104° . .
. . . . .
.
. . .
.............
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. .
•. .
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170 103 .• . . .......
..
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102° •
160
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150
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.
......
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•. .. . .
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140 100° :
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. .
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130
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98.6°
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.
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120 98°
.
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.
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. . . . . . . .
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•
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. . . . . . . . .
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100 96° •.
. .
. .
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•
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80
.
. . . . .
. . . . .
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. .
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.
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. 40 . . . . . . . . . . . . . .
RESPIRATION RECORD 111/64 0 I .2,15 eit, ati
BLOOD PRESSURE ila 109 j2()
1311'
•
I toLb 1,c7a4 g3t)Ie ''')'t ,l iv i, 2-/ ...1
R 2
1 1 12 'D.
HEIGHT: WEIGHT —.—lio ..yc,i,
T1
1141 11 ' 3 lap iti . / k
QM l 7/
S ?Di a yrs
1 , c„. RI
IN -1451D—
bi6r-L5 0 CC._
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, frst, middle; ID No. • REGISTER NO WARD NO.
Record special data only whtan so ordered
(SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 51.1 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9. 202-1
MEDCOM - 4256
DOD 010735
Initial Assessment
;b)(3)-1
ICU
2 3 •• Date NEUROLOGIC; _ ASSESSMENT MI= MI Y117 -I. 5 6 •o• Time NMI MO 1111,111¦••••11 Time emo P R B/P OR NURSING OBSERVATIONS/INTERVENTIONS P-1 lb W• Pro, EL ck.wast(e-5
Pupil I Size ! React n Size i Reaction A-:
00 I
Pupil Reaction: R cove N • Non•Reactive
Level on Consciousn ass INTEGUMENTARY
_Awake _.Alan _Dm vsy Color: Skin:
Viesllessness Lethal gic _Unconscious yiormal _Pale __Warm _Dry
Orientation: _Time _Pace _Per ;on _Flushed _ Cyanotic _Jaundiced _DiaphoreticWool _Clammy
Eyes Open: RESPIRATORY
—Sponlanecus —Uniaoored '.abored
yTo Speech _To Pan Breath Sounds:
_No Response _C:ear Bilaterally _Absent F L
_Rates R L
Best Verbal: _Wheezes R L
_Oriented b Cznverses
_Diiorientec :znversas ABDOMINAL
_Inaopropria:e •.'(crcs _ Termer
_Incompreners.c:e Sour ._Non-Tencer
_No Resccnse _Cisienceo _P.ebcurc
Bowel Sounds: _Hycoac:ive Best Motor:
_Cbeys C.:;r17.arcs
_..-fycerac:ive __Abserp.. )aocalizes
_ Extension
CARDIOVASCULAR _No Resccrtis
F-JIses Riont
Left
R racn.el
Motor Ability & Strengrt :
F.morail Strong Nees :-:sei:t
?scat
—ema
RA
LAI
0-Absent 4-2-Normal
-1-Week 3-2ounding
RL
LL
Allergies PSYCHOLOGICAL __Calm Time
—Comoabv EDICATIONS (dose:route size: _Cooperative _Anxious
INTAKE!OUT
Urine I Chest I Gastric
Pertinent Lab Vaiues
(b)(6)-4
35 ii/o
Total:
EPco
AILS •RKUP SHEET
DA FORM 4700 274th FST OP 1
MEDCOM - 4257
DOD 010736
111.1¦11W
13. RROSTHESI
. . — —
..• • ." PI,/ ¦ i NAME: ID NU
MANUFACTURE R--
r- 'itid
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT B" ANESTHESIA) YES . 10 E
,!MEDICATIONS/SOLUTION, DOSAGE TIME METHOD PREPARED EY GIVEN BY
-. •
1 MOUND IRRIGATION iiK-YES . NO, TYPE(S):
:,-
N55
;OTHER ORDERS TIME CARRIED OUT BY
PHYSICIANS SIGNATURE
i
wmosing.ww&WAMMftw4KMORWIMRKOMRAPEW: R
' ' "Avi, ZE/E ZWEZE L I Z ZES=Eli
15. X-RAY IN OPERATING RO,,9M IF YES, SITE
YES . NO
4 illntal .M.
16. LABORATORY SPECIMENS
SPECIMEN (S) NAME NAME
YES . NO Irk'
FROZEN SECTION (FS) 1/NAME NAME
YES . NO
CULTURE (C) Es/(AME NAME
YES . NO
NAME NAME NAME
NAME NAME 18. DRESSING/IMMOBILIZATION (Spa :1) ,)
17. TUBES, DRAINS/PACKING YES f/. NO . 1/Xir 4.1/Z T-7—e
TYPE/SIZE 1. 2. 3.
/0(-:,< \ye K 3 F/115
SITE 1. 2. 3.
4g
# ..
19. ADDITIONAL INFORMATION
(b) (6)-2
Di-<
. :b)(6)-2
9t
p K.
(b)(6)-2
f (1))(6)-2
—
ka-C ' /14ACP
A, -5^-
I./
20. OPERATION(S) PERFORMED
_
014,
0-f6
21.PAT NT TRANSF RED TO TIME METHOD
6 A/ -
A
22. REGISTERED NURSE SIGNATURE b)(6) -2
7
REVERSE OF DA FORM 5179-1. OGs 01 112113(
*I I a rant...ern% an. 13.1114.... non..... •30,1•1,1YWIG•1
MEDCOM - 4258
DOD 010737
fMiNERNAIM
rl- MEDICAL RECORD
MIN
. .1-( ) ¦ ANESTHESIA TC TALS
1,1••.
¦ MM.
•
117.111ERIMIMINIMMI W4:
AIR UMin
CRY STALLOID11111.11
1111E1111111MINIFINCIMINEMINIJ ci LOID-
SINGLE DOSE DRUGS - MARK ON ORIQ .WITH NUMBERS &ENTER IN REMARKS
I i C3D-157:1----•
•
Code dugs wits numbers, event:-with Jeffers
111111101111
.17"11
W.t.10.47.4M0
TIME 104-
1 2 3 4 5 E Rep 1 /& c-g
SYMBOLS:
0#10S.:13t
..! #(4,41e/
KG
BP by cuff Wie; ,k e
LB NMI
U U 111M111111111111MMIIIHNIIIIIIIIMMI
kfft-g* . V I
Mani
A 1111MINIMMII
IMMINIMUIMMI
aBM
Heart rate
IrE11
• 1111011111111101M1
I BP
Resp rate
MINI1
1101101111111111111411111111#11111
HR-BP RAFAMag Mr IIAINIIMMI11101111 (transduced) IMIWAS1111110111111111101111111111111111111111.1111111MINIIIMINI
T J. 10111111111011M1112111110.111111MUM11111 alMOMMEM
kair
TOURNIQUET VINIMINIIMMIIMIL11111111111111111011111111M1110111111MMIIIMMII
ORM
Sp132-
l.....mmm.mons...._
MIIIMMIIME
nimmmn.M.I.M.MIIIIIIIIIIIIIIIM
T —/ MEE
TIME- AMES-X-X PRoc-0-0 NW XI•N• • ENE
• • ge.1 MEI
P
MODE-PlAuto Cu l oth 1,6464.,mr . .¦on 0 a .......wilN
IrS iannm02 •i... Steth-PCrE UMMIN Gas ana zer 'TEMP-site .eniglmisiminIWZ-MSMRT line I. . NNW 1.1i :0 , T IEN 11171 ICU p•oityl
'1 Iril HI: SI '-
IM' -
MI HR-1 4ffl
Warming bIkt 6 1.I Cony warmer Il mmum..______IN Sti rt
=1.1.1.MININIMINIMIlinimmill iii
Hark with Jolters & symbols, IF
EVENTS =
typlain under REMARKS ._-t-usitiOn
el ilea fy
DUREcand CPT des
47, colc6i0 Qu Es_
: IEJ
Describe black tech/ikon,
nckr Rernme ks
"
TIEN
IDENTIFI ATION
-Wed wrnen entri6s: AIRWAY MAN
Lf t-Nam% Gmckvneie. k t3.)(6)-4 conwr.. /AS
PR 'CEO 'ME LO 4:1 110 N DA I E
b)(3)-1
PA if! 2__OF 7
MEDCOM - 4259 an 99
DOD 010738
„.
:.z.,.i vEMM -MEDICAL RECORD ANESTHESIA TC TALS =MN
118MillmII
_.„.
I I I MEW/ • I M I I 1Min
I 1 i r- A
"Va1 MI 51
.. .
CRYSTALLOID
COL LOID-
SINGLE DOSE DRUGS -MARK ON °rug,
BLOOD-
WITH NUMBERS CENTER IN REMARKS
"nee
LINE site ~freed CrWarmed • .,a.• 0 Warmed Code dugs with numbers, events with letters
EST BLOOD LOSS
.$411'04,1'1WAWA URINE -TIME ow . fru. f
SYMBOLS: /ifs:
8P by cuff A V EIEMEREMEIENSEIEREEMEISMENEVEIMI WWIgREEI ESEASIE NESSIESISEN REM 1111111111111E REEENERWEEMMI $41,-)
Heart rate • Resp rate 160 140 EZIErAin SAIMTEMEMBESISFAi: Ems EMI ESENIESEM
BP 120 ENSIERE
(transduced) ERNE iE.ow:AEREIzw MEMEL:CAMAS
100
IMINIMMINELTaill11 80 IMEEIMMIEE
MEE= 110!WWW/IIININII
TOURNIQUET
SMSEMIEN imi,:z:,::. EMERNAILTMISIESEENEiriEMERAMESIN
.Vic;
T —/ mnrumgaimumums 1101“111611iliZ4M
OK for
ESE
PROCEDURE? ESEESSEEM
ARES- X-X
TIME-Saw
PR000-0
IEEE
BESEEISMEINE
14,4
ar( /1
Pe es / PEEP MODE-Si • on), Alssistl, C(on)
BP/Auto C ET CO2 torr PA! :u ICU (specify) BP loth ART line SDO2 (%1
OTI IER
Steth- PC/E ECG :OMI IMON:
Gas analyzer TEMP-site 5902-
N-M Block 174
Room I End
Warming blkt
Cony wanner
Mark with Idlers LC eymbeia EVENTS Vl L Ready Begin I Endexplain under REMARKS
Position
C HNIQU ES:Describe block technique under Remi, s
alt
PATIENT IDENTIF ATION-Typed .13 written • Name, Grode/Rate. AIRWAY MAN EMENT: 1.0• etiatlon route4ilecka techneyo nn:. rys Mortice' /
rn, 0 011" L. 4 r
b)(6)-4 b)(6)-2
SURGEON b)(6)-2
cztv9.3„.
ANESTHETI
b)(6)-2
MEDICAL RECORD - ANESTHESUI.
(b)(3)-1 PA GE \ OF 2_
ao.
Jan 99
12.9. GPO: 1999 - 528-336/10085
MEDCOM - 4260
DOD 010739
Planned Surgery Date:SURGEON:
NAME:
WEIGHTAGE HEIGHT
ANESTHESIA PREOPERATIVE EVALUATION F
P R
PREOPERATIVE BIP
PROPOSED
VITAL SIGNS: OPERATION
CURRENT MEDICATIONS 0 NONE0 NEGATIVEPREVIOUS ANESTHESIA! OPERATIONS
p NEGATIVE ALLERGIES 0 NKDA
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS
AIRWAY !TEETH / HEAD & NECK PERTINENT STUDY RESULTSWN COMMENTS
SYSTEM Years Chest X-ray Pulmonary Studies
. Tobacco Use: No Yes Pack/Day for
RESPIRATORY COPD
Bronchitis Dyspnea Pneumonia Productive Cough Tuberculosis
Asthma
Recant cold SOB
• , EKG
CARDIOVASCULAR Angina Arrhythmia CHF Exercise Tolerance Hypertension MI
PacemakerMurmur MVP Rheumatic fever
Ethanol Use : I Yes Frequency LFTs HEPATO/GASTROINTESTINAL HepatitisBowel obstruction Cirrhosis
N&V
Hiatal Hernia Jaundice
Reflux/Heartburn Ulcers
•
NEURO/MUSCULOSKELETAL
Arthritis Back problems DVA/Stroke Loss of consciousness
Headaches Neuromuscular disease Paralysis
DJD
Paresthesia Syncope Seizures TIM Weakness
Urinalysis Thyroid FBS RENAL/ENDOCRINE Diabetes Renal failure/Dialysis Thyroid disease Urinary retention Urinary tract Infection Weight loss/gain
Hgb / HG / CBC Lyles OTHER Anemia Bleeding tendencies Hemophilia Pregnancy SIckle cell trait Transfusion history
PROBLEM LIST! DIAGNOSES
•.
'
U) 1--tr) U.!
PREOPERATIVE MEDICATIONS ORDERED
.
POST ANESTHESIA VISITS
COUNSELING. STATEMENT
RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE, SOANESTHESIA
Anesthesia alternatives, benefits and risks from minor to
STATE)
death explained. All questions answered.
Patient I legal guardian voices understanding and gives
consent for :
Local / MAC, SAB, Epidural, IVR, General Anes.
Other: •
.
Appropriate alternative as backup.
DATE:
NPO status explained.
TIME:
SIGNED:
DATEPATIENTS SIGNATURE
Fvet-rtzTORIS) SI NATURE
--(b)(6)-2 DATES 4/° -'
CRNA ./477 rir/vr
DATE
...
PHYSICIAN
,
.
, .
MEDCOM - 4261
race. c v r_
DOD 010740
rt / (THIS FORM IS SUBJECT TO THE PRIVACY ACT Or AS A CLINICAL RECORD FORM, IT IS COVERED BY DD 22C
PART IN OR ANE T D
. DAT
Pap/ of
ANESTHESIA RECORD . 0 0 a 1 5— 1/ AM() 3
OPERATION ,e2_,A.... ., , _,,, qi IRCIFCINIS) ', b)(6)-2 TOTS SURG STA13T ORES ING OR NO
',b)(6)-2
PERFORMED:Li, --y 7-4 • 682-o. 6,1.3 r /d5
TOTAI
PREOPERATIVE
A, 2
EJ IDENTIFIED TA ID BAND DQUESTIONING
.
CHART REVIEWED . NPO SINCE /70
.
PRE-OP MEDICATION: 1 r khoi4v /00 .,
Drug Dose Route Time
P 3 ...Z
..4.4,....,„
)
AliPoS14vAA-P
4f29Umin ivie
¦ J
I-to I LLJp-' ta
< W 0-1-0rC > -<-I N -C7 2 1.0
1
Pre-Anesthetic Slate: . AWAKE
R64-6-', / .....-
M CALM SEDATE
.
.
APPREHENSIVE UNRESPONSIVE
.
MONITORS AND EQUIPMENT
MANES. MACHINE # 3 & EQUIP. CHECKED
' NON-INV. B/P PNS
i CONT. EKG V LEAD EKG
ESOPH. STETH. PRECORD STETH.
PULSE OXIMETER M 02 ANALYZER
END TIDAL CO2 MASS SPEC. -
.1. .r.1 Ar •/..,y, . "Er /• S,
f- 1 9 gpri& Jo .7., .?•0 ..17 • -f• q
02 Umin -
5--R — ...1 — -Z "---A.— ck .2 .----ri. A, --...}:g *---•
N5 ASV-.V00
Urine
EEL -e4a —4Jr
SYMEC
. TEMPERATURE
leWARMING BLANKET 0 FLUID WA RMER EKG 5T S 4. . 5 i 4_ _5,,‹ sr .54 .54 54 sK $ r
IRWAY HUMIDIFIER ...., % 02 Inspired ..7/ ,17 r -4 .75 ,-, 77 , 78. 111 .-78-, 79 X U 0 /G TUBE ANESTH
N l G TUBE ,......) .02 Saturation
cs iv(s) 1)::, ce,,A,„..—... ....
/04 /a o ife 0 /00 io• /ea /ea /A D /4..n,
/0‘)
/
End Tidal CO2 -7, ii/ 'r7 f 1 V. 3A. 3 11 2 y
0
.
A ARTERIAL LINE
,_, CENTRAL LINE
. SWAN-GANZ
a FOLEY INSERTED:/ gi O.R. 0 FLO OR
Temperature
OPERA1
ILIMIIIIIVAIMEI/MONSIIIIEMIIIMMINIAT4-- V
''''',7 A
PNS
IMP CL
EYE CARE -1,7-/ze A'i
PRESS'
.
PRESSURE POINT CHECKED / PAD
.
0 1.
0
OSlsd .
3‘)
woo
70 • //DO
.
3,5 T
TIME
arY
ARTER
ANESTHETIC TECHNIQUE PRE-OP
UM
200
VALUES
PRESS'
K-
GENERAL . LOCAL / MAC
.
REGIONAL . NERVE BLOCK -- •
0 PULE
C SPORT,
OUS Ri
INDUCTION 140 '/ '
ti V V V V V
aPREOXYGENATION
0 INHALATION
RAPIO SEQUENCE . INTRAMUSCULAR
Of
I.
1
I
.,
V Y V 1.1
-/` V '1
I
INTRAVENOUS . RECTAL s./
ASS'S'
.
AIRWAY MANAGEMENT
laINTUBATION ORAL. NASAL DIRECT VISION BLIND A AWAKE
RES
ic
R
I A A 1 A l
CONTRC
A
RES
A A / i
A
SAT , 4
A
f , AA
FIBER OPTIC STYLET USE
,
BLADE .1///14.-a1'
T
ATTEMPTS x _ TT SIZE
• 0 A
DOUBLE LUMEN
(..m
:
E GHT STRA RAE TOURNI CUFFED -'1` ML AIR INJECTED
. UNCUFFED, LEAKS AT CM H2O
Tidal Volume • Y3-0 -7) 0 75-x, 1.Q00 1.7. //5 Paz 737-13 72.0 F
1EBRIT STEHCLIER0EuDNDAET , CM
E Rasp Rate /y ,c, / i a /0 /0 7-/ i /..
CRYS-AIRWAY 13 ORAL 61 NASAL °NATURAL S Peak Pressure 2 .' .7. .Q$ ..X,. • .28 .7y .zy I4 L010 F
i"
i
MASK CASE ¦ VA TRACHEOSTOMY P 5i/1i CM V en, V r . AV 4 V AV A v CM . NASAL CANNULA ¦ SIMPLE 02 MASK Symbols for LMA SIZE Remarks a
se
Position
01 b...".
RECOVERY REMARKS : . Patient reevaluated. No change from preop plan / evaluation.
TIME IN PACU // 6 V 6 B/P kg,/ REMARKS •CONDITION t.....,sv 96Z.. 6. PULSE RESP 02 SAT9e. TEMP . Significant changes from preop plan I evaluallon. .
REPORT TO: PARRS: Tourniquet Time: /1/41/,_.-T.
IN Crystalloid Blood FLUIDS TOTALS EBL Urine Gastric OUT (b)(6)-2 :441:3"fsitb, AICIAN I CRNA PATIENTS IDENTIFICATION ',b)(6)-4
MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 29 MAR 99 Pace 1 of 2 MEDCOM - 4262
DOD 010741
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF ' - AS A CLINICAL RECORD FORM, IT IS COVERED BY DO 22C
ANESTHESIA RECORD
OPERATION )),‹.." ot-5E-' 4
PERFORMED: 1-'"1\7()14.1)
PREOPERATIVE
0'2 IDENTIFIED tit ID BAND . QUESTIONING
¦ CHART REVIEWED . NPO SINCE
.
PRE-OP MEDICATION: Drug Dose Route Time
Pre-Anesthetic Stale: IR-AWAKE
.
CALM . SEDATE
q.
APPREHENSIVE . UNRESPONSIVE
MONITORS AND EQUIPMENT
ANES. MACHINE * & EQUIP. CHECKED
NON-INV. B/P . PNS CONT. EKG V LEAD EKG ESOPH. STETH. PRECORD STETH.
E PULSE OXIMETER 02 ANALYZER END TIDAL CO2 MASS SPEC.
.
TEMPERATURE WARMING BLANKET . FLUID WARMER AIRWAY HUMIDIFIER N /G TUBE 0 /G TUBE Kr(s) IA O -. 1 ....... oc
ARTERIAL LINE
CENTRAL LINE
.
SWAN-GANZ
.
FOLEY INSERTED: U O.R. . FLOOR
EYE CARE U PRESSURE POINTS CHECKED / PADDED
..
0
ANESTHETIC TECHNIQUE
El GENERAL . LOCAL / MAC
. REGIONAL . NERVE BLOCK
INDUCTION
PREOXYGENATION . INHALATION
g
RAPID SEQUENCE . INTRAMUSCULAR INTRAVENOUS . RECTAL
AIRWAY MANAGEMENT
INTUBATION ORAL . NASAL
1171
11. DIRECT VISION BLIND . AWAKE
FIBER OPTIC , TYLET USED .., ATTEMPTS 5 _I___ BLADE )41,AC---.2
Ili ETT SIZE ) • it . DOUBLE LUMEN STRAIGHT .,2. . RAE . ANODE CUFFED \-.-7 ML AIR INJECTED
U UNCUFFED, LEAKS AT CM H2O ETT SECURED AT '''.1.---CM .BREATH SOUNDS 'P• CP AIRWAY ?ORAL 0 NASAL .NATURAL MASK CAE lUll VIA TRACHEOSTOMY
NASAL CANNULA . SIMPLE 02 MASK
LMA SIZE
.
RECOVERY
TIME IN PACU CONDITION
Ire-AN bNet
t 'A 3 1.45k) Ler23Tbi,
PULSE RESP 02 SAT
k( 5/4
1/ ) ,24
TEMPREMARKS
REPORT TO: PARRS:
IN FLUIDS TOTALS OUT
Crystalloid EBL
A"5, Urineftt •
Vestnc
Blood
Page
54,-VC SI iRCIFONNI (b)(6)-2 TOTS r SURG START DRESSIN,0--/C.) / 1 A- 9tig TOTAI
A G E N T S ii1511—S 41) Iwiimilimmummwzi 14%.7—.11111P W.1111611•1111171111111111M NMI /49 40 615247 4-
u7n1101111111411102
F L U
D S O N O R S Urine EBL EKG Si 02 Inspired 02 Saturation End Tidal CO2 Temperature PNS EILTA IVA Mg iria monaural WI WM MUSH Iffia v/ UM Ma SYMBC X ANESTH 0 OPERA? V A B/P CL PRESS!
TIME PRE-OP VALUES T ARTER LINE PRESS!
• PULE
T A B P C •WONT, OUS 131
A ASSIS' RES
G N S R 47 5 SAT CONTRC RES T
TOURNI.
E S P R H / H Tidal Volume Reap Rate Peak Pressure F CRYSLOID
Symbols for Remarks Position ce B EILOI
REMARKS : Al Patient reevaluated. No change from preop plan / evaluation. . Significant changes from preop plan / evaluation.
Aro ti4 () kr-45?
Tourniquet Time:
PATIENTS IDENTIFICATION
:,)(6)-4
;b)(6)-2
TIA-41-3
frA43216 r
r1111J1,•1 1V • So NA
MCEUH OP 100, APR 00(Rev) (MRRC APPROVED: 29 I
MEDCOM - 4263
DOD 010742
b)(6)-4
(b)(6)-2 / :b)(6)-2
NAME: SURGEON: Planned Surgery Date:
)HEIGHT
w
AGE
ANESTHESIA PREOPERATIVE EVALUATION
WEIGHT
. f t,
5 5
— ( s76A's
cll 5 PROPOSEDtp.....bli , 1:\q!, i j tn)y,M DcrIA-13,6-yutt.6--/5/p el44.5-461.3-7,vi-r) PREOPERATIVE
B /P P R
OPERATION VITAL SIGNS:
7-itiLCIASO L—Pili 1 37 1_ lip
1 3,N
PREVIOUS ANESTHESIA / OPERATIONS 0 NEGATIVE CURRENT MEDICATIONS . NONE
44 `0 ,4--A
-I,L) ---> Prci;S (2-1.1"3,41-o 35 •/.`"1"-- S P a (5 ") ik-hz-J.-, „...14_,,,-.
to-pp 1.— .. LAP, 3(P 6g:a ' Q" • 7143 -70 C4r.r1JZ>vs"7..", '\1 V3 tg-2 i pa ibtl,
ecre,...t.3..,7b w-v 7
yi-fc_6-€) dam'
i'clil'lP4-1 .8.t)-0---.) 9 ci.
. el L - erf.r., iv-.-
FAMILY HISTORY OF ANESTHESIA COMPLICATIONS 2Z1EGATIVE ALLERGIES /239JKDA
AIRWAY / TEETH / HEAD & NECK
i ft.fl')It.q.:
. 1:571-Z..; ‘.--'n-A ASINr3-4.1— .5%--)—p1.1.5 ' 07-1/114) PA- ? 2_
I
SYSTEM WN COMMENTS PERTINENT STUDY RESULTS
RESPIRATORY cer Tobacco Use: No Yes Pack/Day for Years Chest X-ray Pulmonary Studies Asthma Bronchitis COPD
Dyspnea Pneumonia Productive Cough (11,?ut-CA.PEZ¦ L'AZI-r'£3 t-2-177---crilil 421'-
Recent cold SOS Tuberculosis
I• 1•Z?-1,L-7\--12—te"---LT-4> F--A60--,
CARDIOVASCULAR ' q,
• EKG
Angina Arrhythmia CHF
Exercise Tolerance Hypertension MI
Murmur MVP Pacemaker
Rheumatic fever
HEPATO/GASTROINTESTINAL ? Ethanol Use : Yes Frequency LFTs
Bowel obstruction Cirrhosis Hepatitis
Hiatal Hernia Jaundice N&V
Reflux/Heartburn Ulcers
•
NEURO/MUSCULOSKELETAL 1 c1,1,-T 1'''.4)41'
Arthritis Back roblem CVA/Stroke
DJD n6daches Loss of consciousness
Neuromuscular disease Paralysis Paresthesia
Syncope Seizures TIAs
Weakness
RENAUENDOCRINE Urinalysis Thyroid FBS
)21
Diabetes Renal failure/Dialysis Thyroid disease
Urinary retention Urinary tract Infection Weight loss/gain
OTHER Hgb / KG/ CBC Lyles
Anemia Bleeding tendencies Hemophilia
Pregnancy Sickle cell trail Transfusion history
PROBLEM LIST I DIAGNOSES PREOPERATIVE MEDICATIONS ORDERED
ASA
-gZa, \ 5 / 2P--,'Th....),,--x.X1Aid-t___ -e9-,(2....,
1--c71 D'Ts 'c1
-31K-tt) 74' ...Fc-6 ciik.„.
`k-1-3, Prz----ILWA515N.--s 51".--
!---" 171---0-1-D / Eii i.,4..(7-11131-1111:r .1 c& '6 ,4h.,,e,-,,,y_e, 4S--( -, PO/a, 4
D4. rviz,...
-f9-E-7. Ins p4,--c(70-1,J3 a..., fr,,,,,,, , --,
_>
a6 PAT77
-6-ertoGeek-vet-Y-CL-4-W PAIS P. 6-114n, At7-7; OF--
Ai
COUNSELING STATEMENT POST ANESTHESIA VISITS
ANESTHESIA RECOVERY COMPLICATED BY THE FOLLOWING PROBLEMS: (IF NONE, SO
Anesthesia alternatives, benefits and risks from minor to
STATE)
death explained. All questions answered.
Patient / legal guardian voices understanding and gives •
consent for :
Local / MAC, SAB, Epidural, 1VR, General Anes.
Other: •
.
Appropriate alternative as backup.
NPO status explained. DATE:
SIGNED: TIME:
PATIENTS SIGNATURE DATE
EVALUATORS) SIGNATURE DATECRNA DATEPHYSICIAN
•
MEDCOM - 4264
DOD 010743
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 14 - AS A CLINICAL RECORD FORM. IT IS COVERED BY DD 22C
ANUS. START IN OR ANES. END pop
Page / of
19 (Vei 2.::,
ANESTHESIA RECORD /9a -7‘,Pga-t ..1-'Viz. 03
-
OPERATION „_„1 SI IRGFONN1 /,,•b)(6)-2 TOTS SURG START pRESSING OR NO
--.. /.4
PERFORMED: t 1' -.. 'b)(6)-2 /9 Ye' 191-s."--°?'2/0CI
PREOPERATIVE TOTAI 4 .„. tar. -as -.1.S r
CS IDENTIFIED ENID BAND °QUESTIONING
LS CHART REVIEWED . NPO SINCE / 4 /SO /
I'moi
PRE-OP MEDICATION: re,. .44/5•0 /04. /00 A Drug Dose Route Time 4-4 . • k 5" /-49-0-
.
Vat.4. /n 10 Id at,
Pre-Anesthetic Stale: 0 AWAKE
-.
M CALM SEDATE
. ,
0 APPREHENSIVE 0 UNRESPONSIVE F01-11"-/C-.1. Y ..7.;"" _2,5 .7,— -7.)--.7. .2.0 /.., 2 g. --N20 Llmin ei lc / - I.-i -•— 1 --I — i x
02 L/min --- , - . -I ---— — I— /-2.--• aq p
MONITORS AND EQUIPMENT
.g ANES. MACHINE 0 j& EQUIP. C ;KED NON•INV. B/P U
. PNS
CONT. EKG A V LEAD EKG .600 4,b. 5.0----goc *.pc)
i -.& 7an
ESOPH. STETH. PRECORO STETH. •
Urine .to ...tfp
,0 PULSE OXIMETER Al
Al 02 ANALYZER
END TIDAL CO2 . MASS SPEC.
EBL NO -20-sou
SYMEIC
°TEMPERATURE
. WARMING BLANKET -LUID WARMER
FEKG S 5 37 _. 5 i ..77' ST sr S 7-ST S 1
AIRWAY HUMIDIFIER % 02 Inspired 9 X
:70 - S.0 •-r° .55 .54 5.•C '3. 7 .99
N/GTUBE
ANESTH
02 Saturation /00 9,g 97 9b
IVO) ft5 ( v./ .4r'e46448F-- 18 s'eS 95 A90 100
8
G. End Tidal CO2 i-35 -Jy 3'7. .3 -.77. 3:‘ 3 "" 3(, 28
0
. ARTERIALL LINE Temperature
OPEFtAl
B CENTRAL LINE PNS v
litAIVAWSBESIBIRSAIVAIKTAMIIMMI7
a FOLEY INSEpaSWAN-GANZ ../. 0 O.R. aFLOOR A EYE CARE B/P CU
PRESS'
. PRESSUREI111CNT-S CHECKED / PADDED I
.. 1
,
.. TIME I 9r3--3000 . .:. .=t/0 0 0 . d ZOO • .. )3o a T
ARTERANESTHETIC TECHNIQUE PRE-OP LINE
200
VALUES PRESS'
RGENERAL 0 LOCAL / MAC REGIONAL . LOC •
NERVE BK
180 0
-, PULE
/35 160 C B / P sPONT, INDUCTION 140
OUS Ri
LPREOXYGENATION . INHALATION /.3(4, 111111=3•11111.1=fmr.
120 '
. 1 I
ERAPID SEQUENCE INTRAMUSCULAR
P INTRAVENOUS . RECTAL
ASSTS'
. too A
RES
• 3/
-.-
R
AIRWAY MANAGEMENT 80 X
I
El INTUBATION ORAL 0 NASAL 2y 60
RES FIBER OPTIC STYLET USED SAT , II IrdMIIIIIM LLIIIM, ,
M DIRECT VISION BLIND . AWAKE 11111111fitairriAwornrvii1111111M1/111/ CON
40 ATTEMPTS kJ— 178LADE if %., ETT SIZE ' 0 A DOUBLE LUMEN T
STRAIGHT RAE . ANODE 20 TOURNI. ffiCUFFED il ML AIR INJECTED H/ H
. UNCUFFED, LEAKS AT CM H2O
Tidal Volume g...30 no g90 '9Y. 730 7 a o 7y0 7..?0 5 0 ;-&i. F
RouEDN DA sT a CM :REASTEHCUS CRYS1
Rasp Rate I A R /3 /51 pf 1., /y PT /5-3 AIRWAY 0 ORAL NASAL . NATURAL Peak Pressure 5 19 3 i 30 30 29 979 ..10 -3° 30 LOID Fl
MASK CASE VIA TRACHEOSTOMY .54, r.4n. CMI/ C/4`i cm./ ce..”/ CAV cm,/ CivisT Cm V 0 f IV
NASAL CANNULA . SIMPLE 02 MASK Symbols for
LMA SIZE Remarks
B
Position
BLO<
a--1
RECOVERY REMARKS : Patient reevaluated. . No change from preop plan / evaluation.
. Significant changes from preop plan / evaluation.
TIME IN PACU CONDITION
.
57 ii, 4 2.6'
c2R7 3
/Atm Apo' E 7, '
B/P PUL S3 IRES!./ 0245 . / SE ) ,/
REMARKS TEMP
Tourniquet Time:A_
REPORT TO: PARRS: t
IN FLUIDS TOTALS OUT • PATIENTS IDENTIFICATION
Crystalloid WO EOL -300 ,b)(6)-2
/b)(6)-2
Urine a2C:24,
(%-eft/fr rbr A. 2 <
Gastric < M(6)-4
Blood _-...------
ous/c1r1 it ki / /.0hIA I MEDCOM - 4265
/LIZ I— U3 la.—I — 0 IA 20Z -1-0=u) N -l7 ZV1 IX ILI ffl
RAr'Cl 114 no -I run A oo nrwin....., /RAMC", A rirunnv ir n. .1e• ,
DOD 010744
Planned Surgery Date:
SURGEON: /-1
I WEIGHTNAME: AGE rr/ HEIGHT
If /00
ANESTHESIA PREOPERATIVE EVALUATION F 7o
PREOPERATIVE BIP
VITAL SIGNS:
PROPOSED
OPERATION
0 NONE
CURRENT MEDICATIONS
0 NEGATIVEPREVIOUS ANESTHESIA I OPERATIONS
0 NKDA
ALLERGIES0 NEGATIVEFAMILY HISTORY OF ANESTHESIA COMPLICATIONS
AIRWAY I TEETH! HEAD S NECK
PERTINENT STUDY RESULTS
RESPIRATORY Asthma Dyspnea Recent cold SYSTEM Bronchitis Pneumonia SOB COPD Productive Cough Tuberculosis WN COMMENTS Tobacco Use: Ei No . Yes Pack/Day for Years Chest X-ray EKG Pulmonary Studies
CARDIOVASCULAR
Angina Exercise Tolerance Murmur Arrhythmia Hypertension MVP CHF MI Pacemaker
Rheumatic fever HEPATO/GASTROINTESTINAL Bowel obstruction Cirrhosis Hiatal Hernia Jaundice Hepatitis NW/ Ethanol Use : . No ri Yes Frequency LFTs
Reflux/Heartburn Ulcers
NEURO/MUSCULOSKELETAL
Arthritis Back problems DJD Headaches Neuromuscular disease Paralysis Syncope Seizures CVA/Stroke Loss of consciousness Paresthesia TIM
Weakness Urinalysis Thyroid FBS
RENAL/ENDOCRINE Diabetes Urinary retention Renal failure/Dialysis Urinary tract infection Thyroid disease Weight loss/gain . Hgb / Hot / CBC Lyles
OTHER Anemia Pregnancy Bleeding tendencies Sickle call trait Hemophilia Transfusion history
PROBLEM LIST DIAGNOSES ASA PREOPERATIVE MEDICATIONS ORDE RED
HESIA VISITS
POST ANES
COUNSELING. STATEMENT
E FOLLOWING PROBLEMS: (IF NONE, SO
ANESTHESIA RECOVERY COMPLICATED BY TN
Anesthesia alternatives, benefits and risks from minor to
STATE)
death explained. All questions answered. Patient / legal guardian voices understanding and gives consent for : Local I MAC, SAB, Epidural, IVR, General Anes.
Other:
Appropriate alternative as backup.
DATE:
NPO status explained.
TIME:
SIGNED:
DATE
PATIENTS SIGNATURE
EVALUATOR(S) SIGNATURE
(b)(6)-2
DATE /3 iier/e.
CR /14/17 r/a1/4— 03
• DATE
PHYSICIAN
MEDCOM - 4266
Paae 2 of z
DOD 010745
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not
require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS
1 OXYGEN: _3 litres via Mask /Prongs to maintain 02 at greater than 94%;
Wean to room air.
2 IVF: 14-S @ to 0 cc/hr, bolus cc x 1
3 MORPHINE: -Z mg IV q 5-10 minutes PRN pain. MAX dose of / 0 mg
4 DEMEROL: ,=.? S IV q 5-10 minutes PRN pain. MAX dose of <-0 mg
5 29113, IsA jiGi¦ie 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 -DROPERID-014 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
10 mg IV PRN nausea X 1
8 Release from "PACU" when Aldrete score is or greater
9 Call Anesthesia for any questions or concerns
f...) /°,ens77-77 —23-- TV P1211 10" /9 7 ,1.54,44-74-em-r---e_7 —
(b)(6)-2
SIGNE, /14 T3; , CX4/41- .
•
PATIENT IDENTIFICATION ;b)(6) -4 Complete the following information on page 1 on y. Note any changes on subsequent pages. Diagnosis: Height: Weight: Diet: Allergies:
• Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) Mt— 1E OBSOLETE MC V1.00
MEDCOM
DOD 010746
NSN 7540-00-634-4169
518-124
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
0 RED BLOOD CELLS
.
TYPE AND SCREEN
.
FRESH FROZEN PLASMA
.
CROSSMATCH
.
PLATELETS (Pool of units)
.
CRYOPRECIPITATE (Pool of units)
DATE TUE TED 6,5.
.
Rh IMMUNE GLOBULIN
DATE AND OU RE RED
. OTHER (Specify)
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
ML
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
REMARKS:
SECTION II - PRE-TRANSFUSION TESTING
TRANSFUSION NO. TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH PATIENT NO.
DONOR RECIPIENT
REQUESTING PHYSICIAN (Print) (b)(6)-2
r
DIAGNOSIS OR OPERATIVE PROCEDURE
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.
SIGNATURE OF VERIFIER
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:
RECORD NO RECORD
.
SIGNATURE OF PERSON PERFORMING TEST
CROSSMATCH NOT
REQUIRED FOR THE COMPONENT REQUESTED DATE le Art-&a)
ABO ABO REMARKS:
Rh Rh
P6t)
SECTION III -RECORD OF TRANSFUSION
AP 15-4(P
PRF-TRANSFUS ON DATA ..• (b)(6)-2
AMOUNT GIVEN.. A-
INSPECTEDIAND ISSUED BY I
(b)(6)-2 mt.
REACT
NONE . SUSPECTED
g 4pl
AT (Hour) 067,00 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.
1St VERIFIFR (Signal-r (b)(6)-2
l/LFZI.P1FR ISlon:417 rP)
;b)(6)-2
I/E-TRANSFUSION
TEMP. /61 3 PULSE / / 7 IBP
DATE OF TRANSFUSION TIME STARTED
A
POST-TRANSFUSION DATA
TIME/DATE COMPLETED/INTERRUPTED
q/f /94 a 3 i!),/ 38 TEMPERATURE PULSE BLOOD PRESSURE
/14
/00
If reaction is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.
2.
Notify Physician and Transfusion Service.
3.
Follow Transfusion Reaction Procedures.
4.
Do NOT discard unit. Retum Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
.
URTICARIA . CHN.. . FEVER . PAIN
.
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
. NO . YES (Specify)
AIATI nrrtrroa
b)(6)-2
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank
• hospital or medical facility)
b)(6)-4
(b)(6)-4
MEDCOM - 4268
Ant,'
SEX "A^
61k,
WARE1
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
Medical Record Cody
DOD 010747
NSN 7540-00-634-4159
518-124
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION 1– REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell
COMPONENT REQUESTED (Check one)
rA RED BLOOD CELLS FRESH FROZEN PLASMA
.
.
PLATELETS (Pool of
.
CRYOPRECIPITATE (Pool of
.
Rh IMMUNE GLOBUUN
.
OTHER (Specify) VOLUME REQUESTED (If applicable)
REMARKS:
Products are requested.)
TYPE AND SCREEN
.
. CROSSMATCH
units) units)
DATA, 03
DA.Tf AND REQUIRED
S)
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTIOXS5774,
ML
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN: HEMOLYTIC DISEASE OF NEWBORN?
SECTION II – PRE-TRANSFUSION TESTING
TEST INTERPRETATIONTRANSFUSION NO.
UNIT NO.
',b)(6)-4
ANTIBODY SCREEN CROSSMATCH PATIENT NO.
RECIPIENTDONOR
REQUESTING PHYSICIAN (Print) ',b)(6)-2
t)
DIAGNOSIS OR OPERATIVE PROCEDURE
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.
SIGNATURE OF VERIFIER
DATE VERIFIED
TIME VERIFIED
PREVIOUS RECORD CHECK:
. RECORD NO RECORD
e
SIGNATURE OF PERSON PERFORMING TEST
DATE IP 4pf-Da
e'rROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED REMARKS:
ABOABO RhRh
b)(8)-2
SECTION III -RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
/ar
ooencn mon eel inn RV tqi•cm.urpi "b)(6)-2
ON (Date)
AT (Hour) 0q Ob
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient Identification tag.
1st VFRIRFR (Signature) ',b)(6)-2
2nd VERIFIER (Signature)
',b)(6)-2
-5/e/AO
PRE-TRANSFUSION 4'1. /15 6
TEMP. ma • '7/ I PULSE /„ 2 BP
DATE OF TRANSFUSION TIME STARTED
POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
ML
fific03 Ep733z
REACTI N TEMPERATURE PULSE BLooD PRE URE
(16-
ONE . SUSPECTED u7 74"
/4°6.3
If reaction Is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock If present, keep intravenous line open.
2.
Notify Physician and Transfusion Service.
3.
Follow Transfusion Reaction Procedures.
4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION URTICARIA . CHILL . FEVER . PAIN
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
. NO . YES (Specify)
c:NATI I RF OF PERSON NOTING ABOVE
b)(6)-2 SEX WARD
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, firs , middle; grade; rank* rate; hospital or medical facility)
1
:b)(6)-2
11/44
,b)(6)-4,:b)(6) 4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 4269
Medical Record Copy
DOD 010748
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER NOTED COMPLETED NUMBER ORDER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
TIME & INITIALS TIME & INITIALS &
( b)(6) -2 i 1 0_6
POST ANESTHESIA CARE UNIT ORDERS
OXYGEN: litres via Mask /Prongs to maintain 02 S -ati greater than 94%;
Wean to room air.
/9 IVF: i. le--@ /2..c cc/hr, bolus c2 623 cc x 1
MORPHINE: ,X— Lt mg IV q 5-10 minutes PRN pain. MAX dose of / ( mg
(.r.)
(% DEMEROL: 496-mg IV q 5-10 minutes PRN pain. MAX dose of t-5-b mg
-i -: •
•
•• • . !be • it---;. cc) I• . ' : h. ¦ .
17 Release from "PACU" when Aldrete score is I or greater
Call Anesthesia for any questions or concerns
42--
(b)(6)-2
Al it, e/4'-‘/ Or0 id)"6
PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any changes on subsequent pages. S7/9 ecr 1, rj%),•-1 ri71K673 C"-b)(6)-4 Diagnosis: 6//P 1111 14-42-e-'aL,41415.,
r
,. 0. 6irL
Height"-1--Weight: l7 Diet:
: (.5.. 7
Allergies: it/(..-6 ig-
• Nursing Unit Room No. Bed No. Page No.
MEDCOM FORM 688-R (TEST) (MCHO) MAP PP PPPulniis PnITIrmIc APE OBSOLETE MC V 1.00
MEDCOM - 4270
DOD 010749
AUTHORQED FOR LOCAL REPRODUCT
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
07,10,0A
TESTIS(
TESTIS)
op "5-Z-
SPECIMEN TAKEN SPECIMEN TAKEN
DATE TIME TIMEI
b1/0 G(tkca, c
RESULTS REQUESTED
C=11113
RESULTS
GLUCOSE GLUCOSE
¦
Ce
UREA N.
CAMS
CREATININE
12:2=••
URIC ACID
SODIUM
11=01•1 A
POTASSIUM
C=••
CHLORIDE CHLORIDE
7 gliq
,
Zz j3t.`
PHOSPHATE
1==•lIl 39..)
PLO.
CALCIUM
1=11•11 pot (9Z.
TOTAL
PROTEIN
• Fr6i-e,n 36 +
ALBUMIN 07 5.
1:=5¦ 0 Nto3
¦
GLOBUUN GLOBULIN
6f„C Olph, ' ,levy, = 2 no . 4,0,1
PHOSPHATASE PHOSPHATASE
p.
azio
0
C11•11111 0
MINS 0
UMW IN
OTAL M
BILIRUBIN
DIRE •¦ V 11¦
1111101101W 11
CHOLESTEROL
IMO 040,EsTER0L ¦
TRIGLYCERIDES
• 1111•11111==i¦
¦¦ 1
AMYLASE
• 1101.11111=11111111
111111•11=1111111
00,011rAwripi
'MINE 1111141
IllEie NIWAIIII ¦
546-107
CHEMISTRY I • 548-107 HEM STRY I
-0 On. 1,71 847)
-LABORATORY FILE
STANDARD Pontius ow
MR eammi Sanne.Rwa.ds, FRIAR (41 CR1) 201-46 605
Commam a.
15 1
I
SPONSOR'S ID NUMBER
SPONSOR'S NAME
RELATIONSHIP TO SPONSOR ISSN or Other)
MI
FIRST
LAST RECORDS MAINTAINED ATHOSPITAL OR MEDICAL FACILITY
DEPART./SERVICE
WARD NO.
REGISTER NO.
ped or written entr'es, give: Nome • last, first, middle:
PATIENT'S IDENTIFICATION: (For r
ID No or SSN; Sex; Date of Birth; clank/Graded
PROGRESS NOTES
0 Medical Record
STANDARD FORM 509 (REV. 5.99) Prescribed by GSNICMR FPMR (41 CFR) 101.11 203(8)(50)
MEDCOM - 4271
DOD 010750
13. PROSTHESIS, IMPLANTS . YE NO IF YE3 NAME: ID MANUFACTURE'
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES .
L
TIME METHOD PREPARED GIVEN BY
MEDICATIONS/SOLUTION DOSAGE
-
44. U.S.GOVERNMENT PRINTING OFFICE 1896-404-755/40O08
*U.G.GOVERNMENT PRIM
12. REASSESSMENT/ REASSESSMENT
0 0
0
Q
NSN7540-00-181-835B DATif TEAM4e0D) TIME OF ARRIVAL / HEURE D'ARTUVEE
NSN 7540-00-1 8 143511 A A MC
/Z J2
0 f. TIME / HEURE
TEST(S)TEST(SI •
b.t42 ier
SPECIMEN TAKEN SPECIMEN TAKEN RP /PS
,
TIME
TIME DATE
DATE
.M. O IAA, ,to 4,1/10 ir-Va9
PULSE/ FOULS RESULTS REQUESTED RESULTS (XI . 1110 Ip g /0 g //0
REQUESTED RESP/ RESP
GLUCOSE GLUCOSE . ,
JOG 0)(6)-2
UREA N. UREA N.
DATE (TIME DATE / HE URE "" Alanie:IIZGIOSlIQUE 5
iF
ICNE711rU c c;ateG
CREATININE. CREATININE .
•
SODIUM SODIUM
POTASSIUM POTASSIUM .
CHLORIDE CHLORIDE
CO.
PHOSPHATE PHOSPHATE
CALCIUM
URIC ACID URIC ACID
14. ORDERS ieiI.41 I laSSe (Spec/Ni/on TA NUSfsIV i er
TAL O Eg NTE, 9. FLUID S PROTEIN
li )IT ET ANOS / IV FLUIDE
11111111111E01111 II
ALBUMIN ALBUMIN
to
MIN
GLOBUUN GLOBULIN
rn ALICAI.INE •
PHOSPHATASI PHOSPHATASE
A D
ACID
PH . PHOSPHATASE
(b)(6)-2
SGOT. SGOT ' i ka. LDH
...v
CPK
BILIRUBIN
...,
(TOTAL)
BILIRUBIN
(7_, L vs( ...
(DIRECT)
CHOLESTEROL
TRIGLYCERIDE TRIGLYCERIDES
AMYLASE AMYLASE
UPASE UPASE.
P._.
b)(6)-2
PROFILE (Sp•cify)
t i\Q (b)(6)-2 b)(6)-2
0 1S.
• igiannir: 474 DO)
M. -, -TIME / HEWN DISPOSIT(014
56.
EVACUATED/ EVACUE
546-107
• CHEMI TRY I CH EMI RY I
STANDARD FORM MA IRA, on _ DECEASED / DECEDE PRESCRIBED BY GSA I PRESCRIBED BY G 17. RELIGIOUS SERVICES/ BAPTISM /BAPTISE PRATER / PRIERE FIIMR (4I CFR101-4 FIIMR (CFR)^09-41SERVICES REUGIEUI STANDARD FORM'I I/1/N.
55
ANOINTING / ONCTION COMMUNION/ COMMUNION CONFESSION /CONFESSION OTHER / AUTRE CHAPLAIN/CHAPMAN
20. OPERATION(S) PERFORMED DO Form 1380. DEC 91 (Bac
21. PATIENT TRANSFERRED TO TIP
22. REGISTERED NURSE SIGNATURE REVERSE OF DA FORM 5179-4 OCT 87 MEDCOM - 4272 'U.S. Goverrmi r t Prl ring UWE 1995 — 388-733123952
DOD 010751
-
.
*U.S.GOVERNMENT PRINTING OFFICE 1996-404-765/40008
'4 PREVIOU55:10N USABLE
7540-00-18 1-8358
XI RI
TESTIS) Fri E SPECIMEN TAKEN DlIT a.„..7, A.M. (b)(6)-4
,,,E1V..30 P.M.
SA?, Tr
RESULTS QUESTED IP
-.
GLUCOSE
1.441
5-
UREA N.
CREATININE
URIC ACID
SODIUM
/33
3
POTASSIUM
CHLORIDE
/00
c;e3 co, 0
PHOSPHATE
AB 031110d1S
CALCIUM
TOTAL PROTEIN
ALBUMIN
GLOBULIN
ALKAUNE
r"
O
4
O
PHOSPHATASE
ACID
i.d /y
PHOSPHATASE
SOOT
k 3. 3
z
LDH
O
CPK
O
1l
BILIRUBIN
!TOTAL)
BIURUBIN
O
(DIRECT)
O
-o CHOLESTEROL
TRIGLYCEVOIS
6 / o
70
AMYLASE LIPASE fl
/J cr
4/ 0
PROFILE ISpecily)
a•wl Iknuvillag
'ON'01 •1Y1
7-
CH EMISTRY I 548-107
STANOARO MEM 546 1614 5451
PRESCRIB ED BY GSA ICMR FIRMA (41 CFR 201 -45.505
PATIENT'S MED. RECORD
I
I 1 1
MEDCOM - 4273
DOD 010752
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is 01
THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEA 1:NTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME
ORDER
NOTED AND
PATIENT IDENTIFICATION DATE OF ORDER TIME 0 40ER HOURS
SIGN
2, 01° e Gi3G 1 r 1-
LIVE
(b)(6)-2 (4 it". teit 7.= v
b)(6)-2 Cliktetc.4, c 112.0
NURSING UNIT ROOM NO. BED NO. :6 Ae )2 0 (b)(6)-2
PATIENT IDENTIFICATION DATE OF ORDER TIME OF 4
(b)(6)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOUR
Q.
(b)(6)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
0"?.) HOURS
Db c_/Ny-icr.J.Aft-y 10 tiln NRS p aect Inv-n AMEIZ
,b)(6)-2
f\t\Th
;b)(6)-2
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA,FAOPRRM„ 4256
MEDCOM - 4274
DOD 010753
MEDICAL RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED
NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS--..
(....07 OXYGEN: 3 litres via Mask /Prongs to maintain 02 Sats greater than 94%;
¦- Wean to room air.
2) IVF: ,ALS I@ ,-) t) cc/hr, bolus cc x 1
'-` MORPHINE: . mg IV q 5-10 minutes PRN pain. MAX dose of /0 mg
DEMEROL: ,-.,)S" mg IV q 5-10 minutes PRN pain. MAX dose of SD mg
5 ZeFRAls1-;--Give 4 mg IV PRN nausea. May repeat after 10 minutes X 1
6 nROPEBInOL• 0.625 mg ( 1/4 cc) OR 1.25 mg (1/2 cc) IV PRN Nausea X 1
7 REGLAN: Give 10 mg IV PRN nausea X 1
8 Release from "PACU" when Aldrete score is or greater
Call Anesthesia for any questions or concerns
a, ,,,, iv 74,../ A1/4 ,„40, ,.....,.-,9„,
(b)(6)-2
SIGNE D rx.A,4-.
PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any changes on subsequent pages. Diagnosis: Height: Weight: Diet:
(b)(6) -4
Allergies:
Nursing Unit Room No. Bed No. Page No.
R A M-11,r•t11 A An -yr
1111-Crtrrtnn CtIDB/1 APCI-C1 ITFCT1 mnruni -II ell um, (IRSC11 PTF MC V1.00
DOD 010754
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.
LIST TI ME
ORDER
NOTED AND
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
HOURS SIGN
'b)(6)-4
.e0_10.73,
b)(3)-1
NURSING UNIT ROOM NO. BED NO.
I
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER
HOURS
t)/2. )S1C:r 6/5
(c_fri r0 (e9-e.-S
-e
•-t
,r— L-71
NURSING UNIT ROOM NO. BED NO.
.651 pedr,/4---n SC9 11 (7)( Cipt
PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORD EM
HOURS
P ( 47/a
U (-4 3-C9 t
7r,--4z-e 50 11 ° .2
LI .
NURSING UNIT ROOM NO. BED NO. / b)(8)-2
PATIENT IDENTIFIC ATION DATE OF ORDER TIME 01
.5741z 4i itY5 0 RS
CAP% 7' eiL4 ee-gtn aqt: /24:r2A0
041 A.. .b)(6)-2 b)(6)-2
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 441'19 4256
t
MEDCOM - 4276
DOD 010755
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION + DATE OF ORDER TIME OF ORDER LIST TIME
',b)(6)-4 ORDER NOTED AND
HOURS
elPt.r, 6 SIGN
4474Fitd,
L-OLS
;b)(6)-4 L 'b)(6)-2
b)(6)-2
t41.1
I Ku
NURSING UNIT ROOM NO. BED NO.
/k 7' 311-(i.e. PS.
k
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
,b)(6)-2
104" S
HOURS
et4(1-0;
Liks4 1,4
L 6F
NURSING UNIT I C/Ck ROOM NO. BED NO.
pfk 2 lid. (1P141 PATIENT IDENTIFICATION i?ov 44-4 DATE OF ORDER 60,411-‹ TIME OF ORDER HOURS
gS 144)? ZS ?4b AN TCG z, 26. y. fsA, so- 6/090 14 "z. NI (19- z p d 612. * l rZ NURSING UNIT ROOM NO. BED NO. -37 ° (2 e2=) - — A 4jeo3 0.1\041_ b)(6)-2 14414?% 4,1b0,2
PATIENT IDENTIFICATION DATE OF ORDER "7 Amos TIME OF ORDER Li> HOURS
/q /1°-qoo -vaA (1`62
NURSING UNIT ROOM NO. ado P• 'b)(6)-2
)(13)-2
2
CN: e b)(6)-2
REPLACES EDITION OF 1 JUL 77,
DA 4256
1 FAOPIIIM79
MEDCOM - 4277
DOD 010756
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.
PAT N • , LIST TIME
DATE OF ORDER TIME OF ORDERb)(6)-4 ORDER NOTED AND
2465 0 l't 50 Z HOURS SIGN
b)(6)-2b)(6)-4 b)(6)-2
.411111K 1)
. •
Ai
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
OR
DEER
1.01.ri 0 6o ( b)(6)-2
2 D (.1. 4-AtemA
;b)(6)-2
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
(b)(6)-4
5,f7 y t:),-• /6 OD
HOURS(
(b)(6)-2 Y( 60 0 5-6/2( AD Y( Dose-
giwo
VI a Vig.,_
NURSING UNIT ROOM NO. BED NO.
• —\....„................
j„„ , .-61ii.i
.1.-
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
(b)(6)-2
HOURS
CI. A P ZZ:L iiii)
— b)(6)-—
0
4(6____-
biC, 0 ,
-.I AIILIWZMN1116116)..:
b)(6)-2
(b)(6)-2
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1FAOpz9 4256
MEDCOM - 4278
DOD 010757
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.
ON
DATE OF ORDER
TItift OF. 0.40E R •.-LIST TIME ORDER NOTED AND
HOURS
SION
fl 474 2-6°3
NURSING UNIT ROOM NO. BED NO.
oo
1 6C/
b)(6)-2
PATIENT IDENTIFICATION
DATE OF ORDER
ois
Algil .5 HOURS
A Puf:12;ei' h. Cry Sob P012.10 fit)54,40.iFn ) pa 13/D
O/c te'
vo ; Or. b)(6)-2 b)(6) 2
(
/ cr lakplas/vAle. yca
b)(6)-2
NURSING UNIT ROOM NO.
BED NO.
3 ATIENT IDENTIFICATION
DATE OF ORDER
IIM t VI- UR DE R
HOURS
VitOc -Po ai '116 5—
a.
NURSING UNIT ROOM NO. BED NO.
'ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER 0 /07 tcca HOURS
b (6)-2
KiZe tfri
(b)(6)-2
fo , Or( /„7-(b)(6)-2
NURSING UNIT ROOM NO.
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1 FA°F. AR '47 9 42:56
tr US; ei1IVFPNEJFkli1'OCE/Nrriumekeeig4e. es:%4!
MEDCOM - 4279
DOD 010758
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 ",b)(6)-4 ,b)(3)-1 DATE OF ORDER TI TN 5" V6 HOURS :111ST- TIME ORDER NOTED. AND SIGN
b)(6)-2
5
NURSING UNIT ROOM NO. BED NO.
tot -I
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDE
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE,OF ORDER TIME OF ORDER
e S"
HOURS
2003
iss:j bpAA-
66A)(ft _alio,.
Px:.
b)(8)-2
az, 9.04 '76/' 1122
6 0.
NURSING UNIT ROOM NO. BED NO.
5
b)(6)-2
PATIENT IDENTIFICATION DATE OF ORDER Ti
21€60 .4=1/Att ae.,..4
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
IP/
M REPLACES EDITION OF 1 JUL TT, WHI
DA 4256
FOR 79
1 AFR
MEDCOM - 4280
DOD 010759
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. - • PATIENT IDENTIFICATION DATE OF ORER TI t CW451,115 CR
U'LIST I.IME
f
;b)(6)-4
NOTED
eill HOURS
/7SIGN
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
•
NURSING UNIT . ROOM NO.
PATIENT IDENTIFICATION
b)(6)-2
NURSING UNIT NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
M
4256
DA FOR 1 APFI 79
6 1/1
14
(2)
BED NO.
0
6)
g
BED NO.
‘ (--).
0)
ED NO.
(1)
0 &tort) Atfr 171.5 OA, -14'
,b)(8)-2
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY SE USED.
MEDCOM -4281
tr rt111,1111,1U ,Urrit, c: Inv+ — 40.7./ tO
'k Yfrij-Cet---(Ce.A,CA-&-, 61.49,.--, ) Cr Iry7S'051.--. e0 A O b)(6)-2
&14,e4,06A7-75.1 YV e31A
. ''.b)(6)-2
YA/e) 3 /off 35 iii6V'e 7-77-)
DATE OF ORDER TIME OF ORDER e„<",.—.37 '.,5 6,)/72:ii9:-)
HOURS
0
Li
4/4.iitr. ko-i/a, Sc,/1 4
_/7-1.)/(6e ir/..-? U -7. 7 ?CA
(If/C/ f /AX.....) : b)(6)-2
b)(6)-2
DATE OF ORDER TIME OF ORDER
. /IZ43 Cqq6- HO .S
-...4
0
4 ai,j(Q/-71-"-)7'?-9i‘i7(4,0,..-ri v.___&_iy.
,b)(6)-2
dope
effOrrntea4jei 6?4--ao
:13)(6)-2
DATE OF ORDER TIME or ORDER
v a HOURS
• 12-7IttP /2,1)3 by.„3-c 1,4-1.1z/Arp, ,Ple-evi) op_40,0)1
Fri'm
DOD 010760
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 rGENTIFICATION Z-lee'.a 3 ra re44.-on 30 1111 fDATE OF ORDER c)14i• E.R L24 I If C B 6 HOURS •LIST TIME DRIDER NOTED AND SIGN
NURSING UNIT/ROOM NO. PATIENT IDENTIFICATION BED NO.
,10
NURSING UNIT ROOM NO./BED NO. 'ATIENT IDENTIFICATION •• DATE OF ORDER TIME OF ORDER HOURS
OOM NO.NURSING 'ATI ENT IDENTIFICATION/ BED NO DATE OF ORDER TIME OF ORDER HOURS
NURSING UNIT FORM 1 APR 79 ROOM NO. 4256DA BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED. 7
tr U.S'. GOVERNHEBTPAIN7INEPOFFiCE:
1184-363-710.
MEDCOM - 4282
DOD 010761
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-6B, the proponent agency is 01NG
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 f DATE OF ORDER TIME (SP ei*DER ' LIST TIME ORDER NOTED AND
HOURS
SIGN
1 P /1-e/5-,/,.., ,c.,-,/-
1111,
. -/8 °2_"i.,,
1 Ls)/c. , 7/ '77 57Chi D
9\ttb74)
NURSING UNIT ROOM NO. BED NO.
(3ce-irp, st /? litqa ZO co
5.-Lr, e t-77/6,1
PATIENT IDENTIFICATION DATE OF ORDER TIME OF OFtbER
HOURS
N 6 .6-7.5‘-• C )10n-N ---1
P3 Le ,./-4-e-,•4_ Q rc/.
-7--6 .,.4,.6-._ S Com.-` ...,
ilq,
/3 yrr-c.5„_....„ 27L.-7. ce L.) e7&_,-(r7cirr-5- r 4.c.---c-
NURSING UNIT ROOM NO. BED NO.
_ob._.4
Z.) P ATIENT IDENTIFICATION DATE OF TIME OF
ORDER ORDER
HOURS
1)/iNic 140e cji-e--
' (94/ ("q/ft.(3V v7ram./cam-,1 C) ..„,Le1)03}2
' IF ¦AIWBNIMPAMMINIMIR l• M —
U 1.4._ C, 5 L.,/3`r '7-2111 62C °
NURSING UNIT ROOM NO. BED NO. CC----.-.L.C.,--.._.C , --1- AI- •¦V ' -- \ if
, ATIENT IDENTIFICATION . "Z.G-----' r...:: 'VD DATE OF ORDER7 7:1A(P i 2 ME OF ORDER
HOURS 0 -40, gJITAI ;ISINIMNIMIWADEMI
. - • away ..... b)(6)-2
., a. 'VA—, -4I¦ 411 4
NURSING UNIT ROOM NO. BED NO: Aiatt 1-44.Cae, se;ce. P. UGC,/el, • b)(6)-2 40
DA REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.IFA,OpRRN79 4256
U.S: MEDCOM - 4283
DOD 010762
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 SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
RECORD
PATIENT IOENTIFICATION
DATE OF ORDER/
t6it47E'"-d.P'64Cor • LIST TIME
'b)(6)-4
ORDER NOTED AND
HOURS
SIGN
30 -
• b)(6) -2
r7 -/
6. 51
7rit,terr‘..4)
NURSING UNIT
ROOM NO.
BED NO.
PATIENT IDENTIFICATION
DATE of ORDER.
TIME OF ORDER
al7ogl /HO S WS bs7500
b)(8)-2
,ov
/4.4-eit 4:)37
itio o
NURSING UNIT7BROOM NO.7Lb c •
BED NO.
b)(8)-2 b)(8)-2
:b (6)-2
'AT IENT IDENTIFICATION
DATE OF ORDER
7! twit o HOURS
70 Tint)
b)(8)-2
LU'C .(0.44( / go-t- IV(
b)(6)-27
b)(6)-2
b)(6)-2
NURSING UNIT
ROOM NO. BED NO, DAA /
.'
NI(l, St105
'A TIE NT IDENTIFICATION
E OF ORDER
TIME OF ORDER
IS HOURS 'V iv 01'4
fiZ
b)(6)-2
(b)(6)-2
Y- g"
I /1 •
'b)(6) -2
It •
NURSING UNIT ROOM NO.
BED NO
•
.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 4256
1F37:479
trU.S./MEDCOM - 4284
DOD 010763
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFiCATION
DATE OF ORDER
"LIST TIME OFWER
:b)(6)-4 NOTICE) AND
44 /‘ na3 elpe
HOURS
SIGN
ie a.am>,z-•
(b)(6 -2
b)(6)-2
NURSING UNIT ROOM NO.
8E0 NO. 'b)(6)-2
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF CODER
;b)(6)-4
"b)(6)-2
1 A.
NURSING UNIT
'ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
:b)(6)-4
NURSING UNIT ROOM NO. BED NO.
, ATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
& 1-0\
HOURS
\,b)(6)-2
,b)(6)-4
"D
/ilwpa441
0 au. 5 c„, I t.t.4g,U A r t7
1 ' 7 "Ir t 1
NURSING UNIT ROOM NO. BED NO,
"r7 to( ,(b)(6)-2
DA FORM71 APA 9 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE
.7_ .
xr U.S. GOVERNMENT PRINTINWOFFICE: 1139*-363-710
MEDCOM - 4285
DOD 010764
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.
LI? I.i mc
TIME OF ORDER+ DATE OF ORDE
PATIENT IDENTIFICATION ORDER ,.....jtJbOx NOTED NAND
HOURS
.4
do).6)3.O/
(b)(6)-4
) 4 vi/-7- ,0 d 6/.00. _
;b)(6)-z CO 6 / C I"Ct)7kk+1"•4•"1,1
1. S/41 S ( b)(6)-2
Recm.-.tr/...go ge /
6 u
r...—.r A......-..
NURSING UNIT ROOM NO. BED NO.
TIME077ER
DA -OF ORDER
PATIENT IDENTIFICATION
/4-0) HOURS
ird
' > I./ 5-0n,/Oa 7 / 1 Avt '4PO 0a) lb 1/141-1
k
.Ili j / 1
I.1.r r-a, 6G''
T,,-1deek) te:p0
NURSING UNIT ROOM NO. BED NO. / ,E
b)(6)-2 . .
61
,ATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
HOURS
I
/lit"1).(///1
,b)(6)-2
NURSING UNIT ROOM NO. BED NO.
DATE OF F TIME O
OIDER ORDER
PATIENT IDENTIFICATION
CY1V:3
HOURS
Le IA 1,6
b
iaidwiLit (b)(3)-1
;13)(6)-2
NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION. OF 1 JUL 77; WHICH. MAY BE USED.
FORM
DA 4256
1 APR 79
* U: S.7MEDCOM - 428673.710
DOD 010765
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing
(NON-MEDICATION) Mo
Order Cl erk
Data to T me to
SINGLE ACTIONS y Time Done Initials
Date Nurse
be Done be Done
(ffpx b)(6) -2 '0)(6)-2
144 gi t____ChdA,, 7/ezAcm-7oft 0 51:17
f-A4741
An-I Mi4 60,L,calk, 6-0)(--Oa,/ oalf
01 pelt
0 .) 67ArC, a io c.) 0715--
0 A76t.?
.. -1,-A-.77 43X-# oS7
702. e6302._ < t.2,,,,,4.,67.074 q.iffig bc,662, otis-
,.,
q / DillA OC(41 f ov-14/
61-0 (' './0 6 140 60-6e? ota/
Order/ Expir Date Si$01- Clerk/ Nurse PRN ACTION, FREQUENCY 64/ smo 4, Ito 6,4.4 x6)-2 -.00ficAk, -sa,4-turigiqui. INITIAL PROPER COLUMN FOLLOWING COMPLETION TIME/DATE COMPLETED •
•
411 i
/
USAPA V1.00
MEDCOM - 4287
DOD 010766
CLINICAL RECORD
VERIFY BY INITIALING
ORDER.CLERK/ DATE.NURSE
fhP,4"°+
b)(6)-2
-5#/trr-os
..cdilad 3
sew) sm d 3
THERAPEUTIC DOCUMENTATION' CARE PLAN
(NON-MEDICATION)
For use of this form, see AR 40-407;
• .f'/ r I./ dorit—Yr. 03 INMAL PROPER COLUMN FOLLOWING EACH COMPLETION
HR.
RECURRING ACTIONS, DATE COMPLETED
FREQUENCY, TIME
7eo7r •711
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DOD 010767
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION)
CLINICAL RECORD7
For use of this form, see AR 40.407;
is Mo./Yr.
the Office of The Surgeon General.
VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED
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USAPA V1.00
DOD 010768
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Order Clerk
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DOD 010772
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MEDCOM - 4294
DOD 010773
. THERAPEUTIC DOCUMENTATION CARE LAN (MEDICATIONS) hia,e--.A
For use of this form, see AR 40-407; Mo./Yr..-,
CLINICAL RECORD the proponent skinny Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADIPMNISTRATION
t .
VERIFY BY INITIALING .
HR DATE DISPENSED
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DATE NURSE DOSE, FREQUENCY
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DA 4678 MEDCOM - 4295
DOD 010774
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MEDCOM - 4297
DOD 010776
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MEDCOM - 4298
DOD 010777
CLINICAL RECORD THERAPEUTIC-Oa • .•T B N
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MEN EMitiME
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1 DEC 77 WILL BE USED UNTIL EXHAUSTED,
MEDCOM - 4299
DOD 010778
Verify by
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DOD 010779
THERAPEUTIC DOCUM E
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UNTIL EXHAUSTED.
MEDCOM - 4301
DOD 010780