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DOD-030831 

•-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 TIMEPATIENT IDENTIFICATION DATE OF ORDER TIMK OF WIDER 

ORDER NOTED AND

0& f \ 
HOUR SIGN
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER 
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nit-_-_ F... 194a REPLACES EDITIO • F 1 JUL 77, WHICH MAY BE USED.
• 
1 APR 79 
10' U.S. GO' MEDCOM - 17243 710 
DOD-030832 
CLINICAL RZCORD • DOCTOR'S ORDERS 
For use "f this form, see AR 40-66, the proponent agency is OTSG 

THE DOCTOR SHALL RECORD DATE, 7 VD SIGN EACH SET OF ORDERS. IF PRO 'DRIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUI. IN COLUMN INDICATED BY ARROW BELO 
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER 1ST TIME 
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NURSING UNIT  ROOM NO.  BED NO.  li  
PATIENT  IDENTIFICATION  DATE OF ORDER 3 CvPPP  TIME OF ORDE ,720c e  HO  

NURSING UNIT PATIENT 1DENT IF  OOM NO. n.  BED NO.  2-6 19 atai kir"fir 1 DAT ' F ORDER  HOURS  
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NURSING UNIT ..vt° DA1 APR -19 FORM  4256 ROOM  BED NO .REPLACES  •  •  L7 OF 1 JUL 77, WHICH MAY BE USED.  

MEDCOM - 17244 

DOD-030833 

CLINICAL RECORD - DOCTOR'S ORDERS 
For. ,f this form, see AR 40-66, the proponent agency. In OTSG 
AND SIGN EACH SET OF ORDERS. IF P M ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM N._ AR IN COLUMN INDICATED BY ARROW BE. 
THE DOCTOR SHALL RECORD DATE 
PATIENT IDENTIFICATION  DATE OF ORDER ZL, 4-1,41, 0  TIME OF ORDER  OURS  LIST TIME ORDER NOTED AND SIGN  
pcAg. CD A 8C7 V GG (g) Pf2etz.e 6,-1 too 70  )R P)  
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PATIENT IDENTIFICATION  DATE OF ORDER  TIME OF ORDER  
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PATIENT IDENTIFICATION  DATE OF ORDER  TI  
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NURSING UNIT ROOM NO. ICI) I DA ,FAO,r,g 4256 D  BED NO. REPLACES EDITION  L  77. WHICH MAY  BE  2-6* if USED.  

MEDCOM - 17245 
DOD-030834 
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 
2.R1uNTED SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. 
DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION 
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DATE OF ORDEPATIENT IDENTIFICATION 
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REPLACES EDI I. 77, 
APR^79 4256 
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MEDCOM - 17246 
MEDICAL RECORD 
LIST TIME ORDER s NOTED AND SIGN 
HOURS 
HOURS 
DOD-030835 

CLINICAL RECORD - DOCTOR'S ORDERS 
For ••-1. of this form, see AR 40-66, the proponent age , OTSG 

THE DOCTOR SHALL RECORD DAT SYSTEM IS USED, WRITE PROBLEM PATIENT IDENTIFICATION  Alr DATE OF ORDER TIME OF ORDER 0----) .41LLG zoo 2 /4 ce, HOURS LIST TIME ORDER NOTED AND SIGN E AND SIGN EACH SET OF ORDERS. IF I EM ORIENTED MEDICAL RECORD .ER IN COLUMN INDICATED BY ARROW  
42)  A/C-- --7-12c-tcy  /0 (.1<sC  
NURSING UNIT IGO  ROOM  NO. 2  BED NO. Char-t-CAeck  tooi,c 29-74  ihtv /6/ .274  0­3  

PATIENT IDENTIFICATION  DATE OF ORDER .:78 4L,G cqz6,..---6 Ns c-rsc -k  a c..f 4--oent,,,/- HOURS  
NU SING UNIT  )(D. CA-) ROOM NO.  #0)  
PATIENT IDENTIFICATION  DATE OF ORDER TIME OF 9,11, Auz -1,45307.Ps°  URS  
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NURSING UNIT  ROOM NO.  . BED NO.  
DA  I F:PR:179  4256  REPLACES EDITION OF 1 JUL 77. WHICH MAY SE USED.  

MEDCOM - 17247 
DOD-030836 

CLINICAL RECORD - DOCTOR'S ORDERS For • -•••4 of this form, see AR 40-66, the proponent ace OTSG 
E AND SIGN EACH SET OF ORDERS. IF . _EM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM AER IN COLUMN INDICATED BY ARROW BELAY. 
THE DOCTOR SHALL RECORD DA1 
LIST TIME
DATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION 
ORDER NOTED AND
21 /NC 320 3 URS 
SIGN 
NURSING UNIT 
(Cu-
PATtENT IDENTIFICATION 
NURSING UNIT 
PATIENT IDENTIFICATION 
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PATIENT IDENTIFICATION 
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NURSING UNIT ROOM NO. 
FO RM REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USEO. 
1 APR 79

DA 4256 
MEDCOM - 17248 
DOD-030837 
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MEDCOM - 17249 
DOD-030838 
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
DATE OF 0 DER TIME OF ORDER 
HOURS NOTED AN 4-k SIGN 
PATIENT IDENTIFICATION 
NURSING UNIT ROOM NO. BED NO. 
PATIENT IDENTIFICATION 
NURSING UNIT fjOOM NO. BED NO. 
E OF ORDER TIME OF OFR
PATIENT IDENTIFICATION 
CS/ 
HOURS 
NURSING UNIT RO. M NO. BED NO. 
ORDER TIME OF ORDER
PATIENT IDENTIFICATION 
HOURS 
NURSING UNIT ROOM NO. .BED NO. 
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
,FAOPRRM„ 
MEDCOM - 17250 
DOD-030839 

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 OFRDERc CI LCD  TIME OF (5)  ORDER  HOURS  LIST TIME ORDER NOTED AND SIGN  
p9 NURSING UNIT 16q4-1 PATIENT IDENTIFICATION (_9') ><1)  ORDER  
NURSING UNIT PATIENT IDENTIFICATION  DATE OF ORDER  
NURSIN PATIENT  IDENTIF!CATION  BED NO.  E OF ORDER  DER  HOURS  
NURSING UNIT  ROOM NO.  BED NO.  

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1 FIPARM79 
MEDCOM - 17251 
DOD-030840 

( 
I THERAPEUTIC DOCUrnToAttiTION .CA PLAN (NON-MEDICATIO gT c/
CLINICAL RECORD is tor% me AR 	Yr. 2003
iMo• 6 
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HR 	DATE COMPLETED
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DA FORM 4677, 1 OCT 78  onmnu no % nor r UAW RF USED. MEDCOM - 17252  USAPA VI MO  

DOD-030841 

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by THERAPEUTIC DOCUMENTATION CARE PLAN 
Initialcrig 
(NON-MEDICATION) Mo0Yr 2003 
Order Clerk 
Date to Time to
SINGLE ACTIONS
Date Nurse be Dons be Done Time Done Initials 
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MEDCOM - 17253 
DOD-030842 
THERAPEUTIC DOCUMENTATION CARE PLAN (NONMEDICATION)
-
CLINICAL RECORD For use of this form, see AR 40-407; 
Mo. Inr. 2003
- • • • • I - It h . OA •f 
VERIFY BY INT17.4UNG Mragilagt IN I7AL PROPER COLUMN FOLLOWING EACH COMPLETION
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DA FORM 4677, 1 OCT 78 
MEDCOM -17254 
DOD-030843 
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Verity by 
THERAPEUTIC DOCUMENTATION CARE PLAN 
Initiakng 
(NON-MEDICATION) 
der Clark 
Time to
SINGLE ACTIONS
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ASO 
PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION ACTION. FREQUENCY 
TIME/DATE COMPLETED 
USAPA V1.00 
MEDCOM - 17255 
DOD-030844 
4/0/110V, 
CLINICAL RECORD I THERAPEUTIC DOCUM ENTATION CARE PLAN (NONMEDICA77019 
For use of this form, see AR 40-407: -
TMo. Yr. 2003
1ri1!„...twiae¦Tt !ty37 is the Office of The Suraeon General. 
INMAL PROPER COLUMN FOLLOWING EACH COMPLEI7ON
VERIFY RY INITIALING0 
DATE COMPLETED
ORDER CLERK! RECURRING ACTIONS, 
DATE NURSE FREQUENCY, TIME 

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EDIT1f1111 OF 1 DEC 77 MAY BE USED. USAPA V1.00
DA FORM 4677, 1 OCT 78 
MEDCOM - 17256 
DOD-030845 
Verit f by 
THERAPEUTIC DOCUMENTATION CARE PLAN
Inttialmg 
(NON-MEDIG4770N) 
Mo .Yr 2003 Order Clerk Date Nurse SINGLE ACT/ONS Date to Time to 
Time Done Initials
be Done be Done 
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Exult INITIAL PROPER COLUMN FOLLOWING COMPLETION
Nurse
Date ACTION, FREQUENCY 
TIMFJDATE COMPLETED 
USAPA V1.00 
MEDCOM - 17257 
DOD-030846 

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) -
CLINICAL RECORD For use of this form. see AR 40-407; 
TIfo. yr. 2003
the or onent asencv is the Office of The Surgeon General VERHY BY IA777ALJNG 44E0.724ZAV1434Z INMAL PROPER COLUMN FOLLOA7NG EACH C LE770N 
HR DATE COMPLETED
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DATE  NURSE  FREQUENCY, TIME  v7i3t1  
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PATIENT IDENTIFICATION: 
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ADDITIONAL PAGES IN USE: EYES (Z] NO 
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  
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DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. Lealli'A V1 AO 
MEDCOM - 17258 

DOD-030847 

Verif y by THERAPEUTIC DOCUMENTATION CARE PLAN WON-MEDIC4770N) Mo.yr 2003 
Order Ciark 
Date to Trne to
SINGLE ACTIONS
Date Time Done Initials
be Done be Done 
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USAPA V1.00 
MEDCOM - 17259 
DOD-030848 
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MEDCOM - 17260 

DOD-030849 

PR#11114MPII00. 

DOD-030850 

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THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407; Mo..Y r. the or000nent aciencv is the Office of The Surgeon General. 
, -,.; !,, -. iz-;.-.....,,.,.,,, INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY IIVITIALING .
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E 15 16 17 18 19 20 21 22 
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crImcm r1F 1 fist^. » wa1 es USED UNTIL EXHAUSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79 
MEDCOM - 17262 
DOD-030851 
Verify by Initialing  THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)  Ma.Yr. 03  
Order Date  Clerk! tireari  -SINGLE ORDER, PRE-OPERATIVES  Date to be Given  Time to be Given  Tens Given  Initials  
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DOD-030852 

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MEDCOM -17268 
DOD-030857 
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MEDCOM - 17271 

DOD-030860 

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THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
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MEDCOM - 17272 
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