aclu-rdi 1263 p

Preop Labs (HSG, etc):

Dnia/Latex Allergies: Nonete"Yes NKDA

Test/Results: Allergy/Reaction:

Pre-Op Pain: 3 N

es Level

(0-I 0)

Action Taken: Location/type: In Chart: m, AT&P ❑ /es ❑ No 7 EKG 0 Yes ❑ No 3 OCR ❑ Yes ❑ No D Other:

Ski Condition: mad

0 Other:

Past Medical History: ❑-NOne known ❑Smoker ppd/yrs /

0 ETOH ❑ Asthma ❑HTN ❑ CAD ❑GERD 0 CBR exposure ❑Other: Past Surgical History: ❑None known :4•16.s

List:

Cultural Needs Addressed: ❑Yes JJ:lo List:

Last PO In/ake: (date/time) Solid: / v /r z, ■-■-)

Liquid: LH/ a 1/ 4 j z "

Limitations: 0 NIA IT6nguage

❑ Other:

Lc

0 Auditory ❑Visual 1:1 Prosthesis

Pers al Items: one

0 Military gear 0 Glasses 0 Dentures 0 Jewelry/wallet 0 Other

Disposition:

10(3)-1

erative Plan Of Care & Nursinf

Patient Assessment For Surgery - Potential For Injury - Outcome: Patient is free from signs and symptoms of injury ❑ Yes ❑ No

Trauma# or Patient #

b)(6)-2

. mac. rse Diagnosis: `Ti) t Procedure: Planned Pcedure: /

Date: t-/ ti ,, Arrival Time: / o u Interviewer:

a- 1.1

? d„..) {ic

1 Slae• n NIA n Right rrf rt

Age: HT: WT:

From: 0 CASREC 0 15,U Thud 3 OTHER:

Trassport Via: D•Grumey 0 Litter 0 Ambulated ❑Wheelchair O Other

Patient ID: 0 Trauma card 0 Verbal 0-ehart Q-emband 0 Other

Bloo rdered: /A Comments:

❑Yes 0 Consent q T/C #Units ❑ T/H #Units

Surgical/Anesthesia Consent Verified: ❑Procedure 0 Consent completes dated, signed q-Erhligent case; no consenk,MD note

Present On Admission: ❑NIA 0 Oxygen ❑-P/ Site: #1 (9 A-

#2 ❑Foley DEndotrachial Tube ❑Arterial Line Site: ❑Drain(s) 0 Chest Tube(s)

0 See RN Note #

Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological responses to an invasive procedure ❑ Yes ❑ No

ted sponsive

Mental/Emotional Status: 311ert/Oriented 0-K1; J Disoriented 0 Sed a 3 Anxious . ❑ Unre 3 Appropriate for age 3 Other

Comfort Measures Implemented: 0 Clear, concise explanations ❑Communicated patient concerns to other staff

members ❑Remain with patient during induction

Pre-op-Teaching Included: &IVA due to patient condition ❑Physical layout of OR ❑Personnel present during procedure ❑Environment (noise, temperature, etc.) ❑Post-op expectation (PACU, drains, etc.)

Potential For Im Dperative Position: 3-51-opine ❑ Beach chair J Prone ❑ Sitting 3 Jackknife ❑ Lateral L / R

Lithotomy ] Other: ?SU # 'ad Site: Q) e 'ad Lot # -1 —.) ;ite Clear at end of case? ID No ❑ Yes f No, see RN note # 3ipolar: Max Cut 4._) Coag

Related To Sur Positional Aids:

❑Airplane ❑Arms <90 Cefficture Table Armboard: 1:1- 0-R" ❑ Hand Table Tucked: OLOR ❑ Stirrups

0 Other: DVT Prevention:

SCD used 1;1-2Ci 0 Yes Pressure: ❑ Left ❑ Right

Teds: ❑ No 0 Yes Bair Hugger used: 0 No alg's

Other warming techniques:

ical Procedure — Outcome: Patient is injury free ❑ Yes 0 No Comments:

0 Axillary roll

❑ Bean Bag 0 Gel Pad

❑ Gel donut ❑Leg Holder ❑ Pillows 0 Tape ❑ Wilson Frame

Tourniquet: ❑Arm ❑ Leg 0 Left ORight 0 webril applied

Comments:

Applied by:

Total Min: •

aired Skin Inte rit

Comments: :6)(6)-4

USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note of 2 (Rev 3/03)

M EDCOM - 5246

DOD 12458 ACLU-RDI 1263 p.1

Shave Prep:

Area: By:

( /1

Skip-Prep: netadine Scrub 0 Hibiclens 0 Duraprep ❑Other:

I 0 II ❑ III V 0 Shave 0 Clipper Vound Classificatiork, Solution..

EFIC-ormal saline 0 Sterile water ❑Local ❑Antibiotics

ations: ❑Other:

Date/Time Relief OR RN Signature 1JSNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note of 2

' P ry agRN Signature

Potential For Infect' ̀uteome: Appropriate Actions Taken to P lfection es ❑ No

Tains/Packing: ❑ None 'Foley FR: / 2l'JP #1 Fr Location: #2 Fr Location: Hemovac: Size Location Chest tube: Location Size H2 0 Pressure . Packing: typellocation: See RN Note # for comments

mints: (initials) rub: RN: Correct?

Sharps 0 Yes 0 No 0 N/A S Sponges 0 Yes ❑ No 0 N/A

DI- Ivo- Instruments 0 Yes 0 No 0 N/A

Dressing: Location: (MI ((-•) (t Si 0 ABD ❑ Cervical Collar

0 Cohan ❑Bias ❑ Drip Pad ❑Band-Aid(s) 0 Fluffs ❑Cast OX rlix

0 Benzoin ❑Mastisol ❑Bacitracin

Kling 0 Steri-strips ❑Immobilizer ❑ Tape El-Prains 0 Webril ❑Sling EI-XEroforrn ❑Splint 0 Other:

Miscellaneous Xrav: Skirl,Integrity:

0 None 0 Other: aClear & Intact (other than incision) 0 Portable Comments:

AFF1X M MEM- RECORD Ihrulaybirol orblbtrbulod

SYNTHES° XLZI7:= 1 nol TI CANNULATED TIBIAL MIL

- STERILE CAT 8 485.138S ICH e 4499711 MP: 12/2011 MT: Ti-6A1-Tlib

See RN note #

for additional comments nplants:

/ Lot t# / Exp Date: ilk • 40

L/ J it m (-1,C

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0 See RN note # for additional comments.

AFFIXTOPMIEWRECORD Manulbehred or INVYOU*1 by

q _el ,(

O WAY771,55r 11018ynNee Avenue

11MM TI CANNULATED THAL NAIL 380MM STERILE 1-5 'Leo

rcl FIN f $113inks rAP: 12/2011

MAT: TI-SAL-7NN g■ps.■ga■

omilications: one Comments:

See RN note # for additional comments

Discharge from Operating Room Transport From OR: 041-rney w/ siderails up 0 Litter w/ safety strap in place 0 w/ Oxygen ❑w/ Monitor ❑Other:

Transfer d To:

0 ICU 0 Medivac ❑Ward 0 Other

Report by: 0 Anesthesiaprovider 0 RN

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MEDCOM - 5247


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SURGEON

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FIRST ASSISTANT SECOND ASSISTANT

ANE THFTIC b)(6)-2 i 1 2 ,s' TIME BEGAN: ANESTHETIST

b)(6)-2

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TIME OPERATION COM-P ETEO

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DRAINS (Kind and number) di MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION (

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MEDICAL RECORD

OPERATION REPORT

PREOPERATIVE DIAGNOSIS

C— k C t.c ICK

— Fi

OPERATION PERFORMED

• 1•

DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings. etc.) PROSTHETIC DEVICES (tot no.)

DATE OF OPERATION

(/ 1/111 —../ d 3 AFMXTOFMMENTRECORD

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SIGNATURE OF SURGEON

PATIENT'S IDENTIFICATION T /38 or Lunt en en les give: ,Name kat, first, middle; Kturs rt Ft-71.u. NO. grade; date: hospital or medical raelitY)

WARD NO,

MEDCOM - 5249


RUM

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RECOVERY ROOM RECORD .14AvmE0 6320/16 (REV. 11.771 S/N 0105-1S- 206- 3281

O se ' Po

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1110

160

140

120

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NUMBERS FOR REMARKS

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Cd

TOTAL

_se. ori S/A

306

REMARKS (AS NUMBERED! AND PERTINENT PATIENT PROGRESS NOTES

1) 10.4 fLcm M R accatpanied Ly 4 6X6)-2

RC: •

Nawo: IN_ O r Pain Y ‘194 0);#48-7.47r44.

CAUDAL. SPINAL. OR EPIDURAL BLOCK MOVEMENT PRESENT AT SENSATION PRESENT AT

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NAUSEA AND VOMITING: $'i10 0 YES 1 2 3 4 5 6 TIMES

A

CONDITION ON TOW: COD 0 FAIR 0 POOR 0 CRITICAL

DOD 12463

PATIENVS IDENTIFICATION:

(b)(6)-2 1 RECOVERY:

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MEDCOM - 5251

bX6)-2

ANTIBIOTIC: TIME GIVIEN: OMER:

FLUID THERAPY

WARDPRE-Op BP, ..3.LT tiJBES: O N/G*AFOLEY

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DISCHARGE

FROM MOR/SPEC. STUDY TO WARD

DATE 410..3 .HRS /5.45 DATE 11 0 MRS

OREA1N_M. :TT LOCATIONS (4) "-'b 4 gi-e- it. - 5"

STATUS:.

' 7/1r.-A-iN;a4,01 XLe cur

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.BPI50% of preanerthelic level Fully wake

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ACLU-RDI 1263 p.6

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Ilrirtha

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% Sat: RESP.

-RATE

NUMBERS FOR REMARKS

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140

120

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MEDCOM -5253

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D a 0 Suction 0 Machine ❑ Consent ❑ tt PO - D Sao. 0 ECG 0 no, ■

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Air Wenn ley 0 FHT D Palm Art cath iscocm.t.in'DOG/NG L/R

LIM Rad I Fein L / R

Position 0 Pm-sun:trawl padded CI Anna c 90' Supine Prone Lithotomy Sluing L/ R

Drawn, Used W Witn5

Drawn U Wasted • 'Mins IV - L / R Hand Wrist EM AC El

ANESTHESIA RECOR Pmcedurc

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MEDCOM - 5255

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DOD 12467 ACLU-RDI 1263 p.10

Rapid Sequence

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ANESTIIF-51 RECOR Vt k - 1° It5Ht in - Pmeedure( (--J Lit )

\

6)(6)-2

OR # 0(6)-2 Surgeon boy,

."1.- ■ \014 ‘sir M. 1.10x; 3 • See Page

I Page of 7.--- One

Doe

-V11. ctS Ares. Stan

Ikoo n mien

1125

Sorg. Sun

Me 0 Sart. Eand............

1513 Me a End

1 535 Residen t/SRNA

--

Time t3/3 st \ 7.-41Q .% 31.7 s..1 1300 '30 '1C., I LI !_10 S o, 1 t/ i 1 1. i 1 I 1 % \ Checklist •

..121:r.; erguction .1;110% chine rrEonsent •••15-NPO Monitors -

Wil. um 7- 7- 2 7i 2 2. '2. "2. 2. -2.. rt va. Ha Sevn /Des

. 'A . 'A . sr . L. .1 ..„.1 ... .-1 . ri ., .-1

-1:31;0, -15106 -BTO; -8-NIBP 1.<2)cm -Ertico, 0 PCS / ES GMs -Erflp.1;1-remp ❑ Mass Spec ❑ Verbal ❑ TEE ❑ Fluid warner 12Ki Warm ,..ragley 0 FHT ❑ Pulm Art nth

.1:1CVP LI/SC/Fern L/R 00G/NG L/R

S1-7-6,P I Etomidate ZOO ua Cistracurium 1 C 0

ROI Raps ecZ

• • C 0 0 A-Line Rad / Fem L / R tieostigwie /Glyet, Position - -ItYfressure points padded F11<ts c 90°

lirgiin-P Prone lithotomy Sitting Lateral L/ R Ephedrine / Neo

Midazolam 1-.....0■••• Drawn__ Used Wasted Whits

ms0d Rani /Siii 2,50 )_S 0 1 0 usesXno used i I 51-Nvested ■ o %vie. 1\ --•.- Eige. tidal Burin / RoplY 1V- ,11..M _Gart.) R C.- ) Wrist FM AC El

❑ Tourniquet nunfig Times 11____ 1

60 /90 / 120/ 130 / 140 /150 min - Surteons informed . MdibiOttet

Agent -

Mg -

over minutes

•

I'Loci.-e. _ Tout

t.Total NS 2.0 0 - )100' Vico 10D • taro 1 bti-tr Total

EBL V f Tb......0 Total

• = Pulse

0 =Sport. Rasp. IN

0 t-. Mu Rap.

s Velttaillar 160

X MAP A/V=N1BP 140

_L / T =A.Line

1= Intubats Do E = &tame

180 :

160

._ . •

140

ICO

SO

+A

i,13

•

-

‘• V v Y VNI/ 11/ V

1.1 •

- • se Nit rrill / ICU SOO

s ------

IP - SO

60 tR -

ia0, •

:omps • + / - 4°

1 6. • a r e ow,aft,••

a

. 'N

•

7171

ECG G 2.- SR 5 R- a It 52 .(Z- 5 S2 .st"Fil, Or / Sk / Ax Temp - ^"5 Jr Si% -,..36 . 36 . Cs . . 2. --8,i,s -I L. 5 16 _5

2- 1 4, 34,1, .

%FA i .0 . a .. 3 . 3 . . s I • 3 .3 . 3 , 3 % sic). 1 cs v I on I tip loo lb° Lou lb° (bO (6o i t:so act), .A. s A 35 3c1 "1, L. 3 iz, 3 . I 31 -3 "7 I rl

."1-111C .1 1 li. ON cis.) '-‘( IA lv .,1 -rts 1, 4 Cg u c .4 -74 ° c 4 . v

c- PIP (aoH2O) VA . 2. 44 '2.4 Naz 1- 2- t. ' Rey. Rate ri ) '2.. 13 13 ‘`I I I.4

iduclion onito n n ififia="ir ► 4=1Ir Inhalation CC::) Cricoid Pressure

intubation - et/ Mil Grade view Tube Size TO Attempts 1cCA-:a Nasal L / R

Tube taped @ te,g, teeth stares Trauma Y rip FOB / LW / Blind

yes tape / tubed

Blocks cme Stun

❑ Trans.ertertial

❑ Dual a-di,

MEDCOM - 5256

1 ati rat 1.1..otifl,..ttnw b)(6)-4

Dee

Regional ❑ Catheter out - tip intact

❑ Level

Comments / Drugs:

lingers Technique

U CVP manually transduced

❑ Cordis 9.5 18.5 Fr

o SLIC .

❑ 2 1 3 • lumen

ft:oltat

❑ Smile Technique ❑ Spinal / Epidural

❑ Disposable kit ❑ Touhy I Whitacre / Quincke

❑ Bat-Wine prep x 3 ❑ Needle gouge bjy, ❑ Local MOM-mien ❑ Sitting

❑ Bite

❑ Miempts LOR to Air / NS

❑ Rareuhnsia + /

❑ Hems 4- / -

MA ❑ CSF + - ❑ Test dose 161

j=1 CSF e

DOD 12468 ACLU-RDI 1263 p.11

Olha

Hepatic: Renal; 0: Endo: Herne:

&OH: 7

Tobacco: .

Family Hz: 15 IIMOMIDI=Maggstra -

•csw s parol : 0'00

• Reviewed / pal10t,e4mined, • . bit004 .1400 dlscussed.With patient

pt q400).ni .1111Mi/.060' : 'au./ patehti,:60:114M undets4m4s and acCepts:titks

'after. • -clen! •-• SOlids Pun 6,v‘.A

NNW 61=79 fDis-110)

Pre / Pt:Kt-anesthetic Summary Age Weight Height

(kg) (n) .10 rit.14

ASA Status

(2) 2 3 4 5th

PC,3MA:teal:Inn

-11-,101 t-P

Allergies

r-no Chernistriel licmatolory

H / H -

Platelets •

WBCs -

Urinalysis / HCG NPO- /'"•4

Teeth - I )OCC

Airway - Mat II / IV

PROM, 3 FB FB HM

CNS / Skeletal

Seizure: CVk.

p LOC: Neuro: Muscle: — Skeletal:

Resairatory

Cough: Sputum; Asthma: COPD: Recent URI: TB:

Long Exam:

CXR:

a iv: CAD: MI; CHF: )

VHD: Arrythmias: Exerdse Tolerance:

3 Cardiac Exalt':

ECP1IL

tr

Previt.us Anestheti cs: Preineclication: Current Medications:

• Vitals

S BP HR:

Resp:

Terim:

FHR

Pre-op

341/6g

7

DOS

sicnature • b)(6)-2 b)(6)-2 b)(6)-2

(b)(6)-2

St Date v _S

Date 8t , tline II- t./.$

I °

Pmient identification Post-operative note kh)(6) -4

0 No apparent anesthetic complications

Signature Date

MEDCOM - 5257

DOD 12469 ACLU-RDI 1263 p.12

NPO — 17-.; 1\1 A

Teeth

11.,1) 11 / til I IV

FROM. FB O. FB HM

Da=

Hepati\s, Renal:

61: Endo: Hcmc:

PrevkAis Anesthetics: , 19-

/ A l■ 14% i--11.1

Family Hz:

TlinANr t)(

Current Medications: Premedication:

Post-operative note

: Pre / Post-anesthetic Sunlit Proposed Operation Age L Weight Height I ASA Slants

IT) FeillprtiA

s/7- (kg) (inr 3 4 5 E

MCMC 63201279 (Dec-1K9

Allergies

/VOA Chemistriris

Res.piratory

Cough: Sputum: Asthma: COPE): Recent URI: TB: ,

Lug Exam:

T A CXR:

liematoloev

H/H- 6,47111,1

Platelets -

WBCs -

a HTN: CAD: Ml: CHF: VHD: Arrythmias:. Exercise Tolerance:

Calfiettni: ECG:

Urinalvsis/HCG

CNS / Skeletal

Seizure: CVA: LOC: Neuro: Muscle: Skeletal:

EtOH:

Tobacco:

z

HR:

Resp:

Temp:

FHR:

Chart Reviewed / patient examined 0 Risks / benefits/ options diicussed with patient 0 Patient questions answered

parein! guardian understands and accepts risks

'Tule` liq clears solids Platt

Date & Time

^lt 4l03 Staff MD / CRNA sienanne Evaluator S gnature ;b)(6)-2

Patient identification

;b)(6)-4

402

MEDCOM - 5258

DOD 12470 ACLU-RDI 1263 p.13

b)(6)-2

131— spa

( b)(6)-2

Rua

%/Ng .1.0r161/.4tg

duct i on -

tubanan -

uintenanc

Aubation

7L. of (14- l'et& /o/s-- 4t*:e

env !L. I R.

ito / Rape Ve

alai MI

1,1S0d Rim* /SU

ESA& LW /RR*/ 4.01*

I. Deep. FAN TV•ReadfIft /.Su;iali;edt4tantia

Extubated/intubated. , acleei*ieeteOatve

• *400 EIR'1441.44.1!raan

L'/ R . P

BloCks Neel unN

atrint.itterial. •

Q

P ,Scididiit. T*4090.- CY.F,)1)*Oubieransiiced.

.0 c.oris* 9S / 0SLIC

' ❑ -2 , / • kiruin

:.Aretotttl kit4ow . /Oink .

Epiellita3 P CeritIne Out • iipieux, 114601.1y./Witituere / Quincke 0.lsVel .

Q .Oeiale &ate o S*Ilna

R / t. 13 I/3R ko Air I NS

+ / + /

CSF 4- I - El Tem dm a

CSF 1).irt p

ANESTHESIA RECOR .441;1, oh.dc.v.m al Or Dnc

CC,/

l

Halo / 410=1111111111111MINSEMEIF7-11. IiiIRCIPMERSECIPS "3 17 uvie .arr / WM Mg IMENIVAP„ ' „..

S 10i ECG. jg.Hor

1 (Ilan' -

Wasted .wit„,

11

RO

over

ird Cs

40* Total

160

..• bX6)-2

20

.11111111111111Kill irlIMICIACEIZIEMINWA a/i1111211 NINE HIEN MINIKAW FAS1 011111111111111114111111111111111111111111111 D°

1111111111111M111111111111111111111111111111111111111111111111111111NRIN MUM 111 N11111.111EINES11010111111MMEINICEMPNWES1111111M

altalitallit EMS 111 MEIN NAM 11111111r Via SINN ELI NMI MO NAM MEW MEW NW IMO 1111L11111111111117.0 MINN um 111M111151 IMMINFAI WAIII MAI 40,

b)(6)-2

- 1270 Ht (in) - Surgeon

• • g. es MO A-

OR tt

Time (.1( VT'

-4/2,Ead Resident/SRNA

CI, LA1 NIM11151E 110M MEI Mann Ina"

• STP Mei/ Etixiddi

Sue/ 111=1"1

IIII PFes;ustpopts padded .

uthoi*Y sitting

A MUM M RM I min =i• .111w,,4 mrainip. = vim rim 'Imiliginrn:ijaz

-• Artnbtonea Tof1 IIIIIII MM. 11111111 • "

EMI EMI Mill WIEN NUM MIMI 11111111111111111111MIIIIIIIIIINE111111111111111111111•11111111111111111111111 11111111111111111111111111111111111 MIN EMI MEIN MIMI 1111111111111111 110111111111111111111111111111111111111111111 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111121111 1111111111111111.1111111111 MIMI 1111®11111 WEE 111111VAI rwill111111111111111111111111111MENHIMIINIMPIENIIMI

ESL,

leo

.

TV PSP rettH2O).

VAR FEMS1 ERR EMIIVIDA Vitra WM Fa IFISAUE30 rit 1 Et Mel %IV! EMI .F. M1 %WA

SreA PAAIIIVW I Ill I it a 'A Mill lirgri gram Ma Irlig ° INES1111E- Irer.V KVA kr.:51a ULM Ut.

IMAM Will nom was mis re rfiZtilirAill DWI rAmmag LWAP, meza !vi(

rairmiliPrii: UM BMW IW4'al MEM

n

Wad MX EWE OM IP:MIME OW Ad** fY

Grade view Tube 0,4 2 .AttOtIPti . Yr4iuni Y

lobe

Nautii1:- .1 R . ■v./ Fog .t;ii..1431irid *4.

Iriukrinnlrladbo

Sty

vitt , ft

See Page

Page of One

action achier OrConscat $NPO

IMIN

WIS

7:.1.2 ilia MINI / R Hada:Oast Pm AC Li

IRS71.1 :Matt

Cheeldol

mitis laPc.$ / ES aP e,RAP temp 4e,c 1:1 ■400 TEE ❑ Flisid

Air Warm Xrcijoi NI., Art cath ■ OAP R DOG/NG 'L/R

.111d F.4., Arms <90*

Lateral. L/ R

Il tecr'Otigied ef 4-1 '03 .

/330/ I / urc itsjoifonecd

NS

pati

o

x m/up A/v..1,0P . 11T 'A-1ic

inigito0

;A' ilOU. •

/ ICU (skcpy

nient Identification b)(6)-4

MEDCOM - 5259

DOD 12471 ACLU-RDI 1263 p.14

Patient Identification

(b)(6)-4

ANESTHESIA RECOR Wt k .70 Ht in -

. ....wt) Cal Neu 1 ( 4 L .

• -••• „ler I I

4v tv me See Pay,e

of.3 One Arrs. Sun

14 I t 4 / 31 .

v

T A I ft D

0, LIM —

AWCAMENOil ❑ Consent ❑ NP • tow. Bak, Lso Se . /Des 4 ill

❑ BO, ❑ NIBP L arm ❑ E PNS ❑ PIP ■ Term ❑ Mass TEE ❑ El " wanner CI Air W FM ■ ' Im An cath 0 CVP U/ ■ OG I NG L / It ❑ A-Line Rad

mminov iamwdate 1.

Sus /Cistrannium . • RI) /Rape / Ve caronium

Lidocake

Nenstipaine /Gben —

PosIdon - 0 Pleas d ❑ Amu < 90*

Supine Prone IA Sitting Lateral L/ R Epheckke / Nen

Mideralam Drawn Used Wasted Willis

MSQ,?Read / So / fentanyt Drawn Used and itns

Epid. Larks / Bunn/ Reply IV - Cm Wrist FA. AC EJ

❑ Tourniquet Irtmkig T 1 I

60/90/120/1 min - umeons informed . Antibio

Agent-

mg -

over mi tea

@

• Total NS / LR

U/0

ESL

• = Pulse

. 0 .SponL Rasp. Ido

0 = tnsm. Req. •

0 4 VertabiOf 160

X =MAP AN . nue 140

1 / 1- - A-Line

1 ot Inaubate

. '

• •

Ifo

411 E c Ululate V

IOo PACU / ICU 100

. -

Pulse -

BP - to

Tempi; -

RR -

'

GO NS\

Sa0, - 40

Corps- + /

• .

•

ECG

Es/Np /Or/Ski

Ir. 14% I /0 . 00

00 scoff

S".. Z./ 3

^ 44 E .

PIP wat-1,0) Itesp.Rm.A.1_, ra/

- _

Maint

▪

ena

Exfoliation - Smooth

Disposition - PACU / ICU

Induction - Monitors On

Intubation • Mac / Mil

Tube taped @

Csieoid Pressure Rapid Sequence

Oral /y / Cuff

/ LW /Blind LMA a

Blocks

0 Nerve Stint inn

❑ Trana•anerial

❑ Dual curl

Preoxygenated

Smooth Inhalation / IV

Gra • ______ vie ube Size Attempts

ern 0 qpe 1 Beth g Trauma Y I N Cuff checked Eyes tape• lobed

Reversed SV VSS

SV VSS Awake / sleepy Extubated / innibated

Awake / Dee Revlon* 0 Spinal / Epidural ha Citketer out - lip irliaCi ❑ Terahy / Whitacre / Quincke ❑ Level ❑ Neer* page

L / R ❑ Lateral R / L

❑ Paresthesia + / -

0 Ilsee

❑ Salim

0 LC* to Air / NS

❑ Seldinger Technique

❑ CVP rrunullly transduced

❑ Gordis 9.5 I 8.5 Fr

❑ sue

Lines

" 0 2 13 • lumen ❑ CSF + / -

0 Test dose 8 J:J COP 0 Oda

!Lee n s-n,, Tedwalue ❑ Disposable kit

❑ Betadine prep x

❑ Local infiltration

0 Site

❑ Attempts

d lift / Sustained tetanus Suctioned

Mask ventilation easy Y / N

Stylet YIN Bil BS I Eta), x 3 / CIN

DLT Fr L / R

Cotruneau /Drops:

M EDCOM - 5260

DOD 12472 ACLU-RDI 1263 p.15

Induction - Monitors On

Intubation. M

taped @

Maintenance Smooth

Eambation - Smooth

Disposiuon - PACU / ICU

IV Cricoid Pressure Rapi

Oral / Nasal L / R w/ Cuff

Y / N / Blind LMA

Mask ventilation easy Y / N

Stylet Y / N • BS / EtCO, x 3 I CRN LT Fr / R

ANESTHESIA RECOR (b)(6)-2

Wt (kg) - Ht (in) - . ies -

Pr'.F;-lnOtia, .14 i t 4103 ( &id;

ARS. Sian

.... Surge° b)(6)-2

nUSFWA

10 OR N

RI(b)(6)-2

Sec Page

Page One In Room Slog StVl Sorg. End Me . •

%LIM ..._ 1 — i

FAIMPall heddist -

_.

❑ Consent 0 NPO .•

Fi0. 0 NIBP Li'arm PNS ❑ PIP g Temp TEE ❑ d warmer FUT • ' Im An cadi

❑ 0G/NG L/R

°-r!VAI. IIM i''''' Hahn/

. 401;:l

..*1 *MIR= e•i''

---

IRE

WM 21 P.- .2— "Z.- • * ❑ Suction ❑ Machine

0 IEW WA WM •13111111E1E•111 m rs" ❑ ❑ So l t—i ECG 0

❑ EtCO3 0 PCS / ES ❑

❑ Mass S. ❑ Verbal ❑

❑ Air Warm 1 Foley ❑

❑ CVP U/SC Fern L/R

IIII

STP / Prop. / Etomidate

. Sun /Cistramarium

Ro/ Rapa/ Ve (uranium

Eldon:me ❑ Aline Rad / L / R Neostipoure /Glmo PosItion - 0 Pressure

padded 0 Arms < 90'

Sitting Lateral L/ R Epliedrie/ Neo Supine Prone y

Drawn U led Witns m90."ilterni/ S ttle „,,t5' 5o si) 1.-5 ,2S 6.•1. I-6 Drawn Was• d • iens Raid. Lido / Reply/ Ropiv IV • a L / R Hand • Mt PM AC EJ

lik-ntl1117111111 LE7I7MVESI 0 T - • t______mmHg

60/90/ 0/130 /140/ ISO

Times I I

EMI min- informed 1 r low Era

.!1, g=1 61 I P i ii- " . nal i''' 'i li la il wa 1" 49 il I il I I 0 I • P II i I I I. . 4 11 ,I . i ap rep.. is ii a prii m pArl m- Antibiotics

,40z,m, mg =I} =calm :--.420 11111 Total Agent-

Mg - over minutes

@

tNS Aki 'KIP iIrro gill= • i n il• Iv- • i i .1 ill sir II MEI hin i NI 1rig" Wel •■••■••■ NW Vrotal

t40 /P.,0 4 .; / Test

EBL Total • = Pube

. 0 =Sporn. Reap. IN

O. Venulator IN

x =MAP A/V=NIBP 140 1/TnA4.2be

I. Incubate

"

ild Um f4

'in i Aet4-ed

IS 0(6)-4

YE 160 al 5

0 /ll IC) .

■III FA illifilallYAM

■nrammminammumwmfinmoymming, ■ 111111W/1

11111.1111 HIECENFAVA"VI

■EN 1. ■ •

140 (b)(6)-2

Ilg / \ A mown' " • -1- • 1 "---

IBD /2,zs-_, c ri,2/ • • conie ore- a

1-`14- c& u nil,

. •

E = Eembaio

MIMI 1111WAVIPKA

PACU / ICU IDO

Pulse -

BP -

Temp -

RR -

SaD, -

comps. .

III rg AM ITES ill■111

" MI■WEEP..2.1:11iiiii .

III

'ZIII

1101111111111

1_11112111111 MENEM

IIIIIIMPIME1411111ENIIIIIIMININ II

■I MIMEOMIMI MEM

q

MI

I

ILIIIIMMEIG011111M1

•

10711 WW1

IMI

■GPM LIMN WW1

Ma

11F11.■111E4/11M;IIIMMIKill

■wainwazdamaktal IVA

WWI birAill

imam.

Illt•MINE III■

101■1 M■tila!

arm

III■II WAN

■ .

• .

• Mil

ECG .;-..tl :al WWI 54 Es I NP /C'r IS" / " 1-' 4 '

%5a° swkIltatlripzil!Erslrall ria rA MO

MIMILSel E1' I

era 51.5

q UMMIIICLIII

LL1• II aim

cox FAN V.FAI ViNil KM RIJIIIIIM7 Ited1J.711n was rea

TM Liza imin UPAILMIIIMMILI:11111 WM

IMIIIIIMII

U27107.111M11 NM MIIII WA ■

PIP (emthOl

Resp. Rate IM'AIPTAIIIFE111 21 IA

I Inc

Preintygenated Smooth Inhala "

Grade view Tube Size A

m@ lips / teeth / mites T uma

Eyes taped / lube

V VSS Full T4 / Head lift / Sustained tetanus Suctioned

Cuff the

Reversed

SV VSS

Patient Identification

(b)(6)-4

telt

❑ Sterile Technique

Disposable kit

❑ Bmadine prep n 3

❑ Local infiltration

0 site

L / R

❑ Attempts

Blocks

❑ Nerve Slim mA

❑ Tianennerial '

❑ Dual cuff'

Awake / Deep R cul Reginal

Comments Drugs: .

❑ Sphul / Epidural ❑ Catheter out - tip enact ❑ Touky Whitacre / Quincke ❑ Level

❑ Needk guagc

❑ Sitting

❑ Lateral R L

❑ LOR in Au/ NS

❑ Paresthesia /

❑ CSF + / -

❑ SUC . ❑ HEM< / ❑ 2 13 - bunco

Lines

❑ Seldinger Technique

❑ CVP manually sransduced

❑ Conks 9.5 / 5.5 Fr

0 Test dose 0

CSF 9 s ■tirl

Awake / sleepy

Extubated / incubated

RAFnr.nm - c9A1

DOD 12473 ACLU-RDI 1263 p.16

ROUTE

MASK

TSAR

VENTILAT.

LAA

tDL

FLUID THERAPY

OFF

TYPE

OPERATING ROOM

RECOVERY ROOM •

TOTAL

BLOOD LOSS IN OR: ,9a) CC

Alevd L BLOOD LINE OTHER

• st-

WARD PREOP BP / mmHg

TUBES: 0 PUG 0 FOLEY

' ADMISSION

DISCHARGE

FROM NOR/SPEC. STUDY TO WARD

DATE 41 13104 Ian- &

STATUS

STA

ENDOTRACHEAL TUBE - ORAL OR NASAL

OYES NO 0 YES NO

AIRWAY ARMIN scars

dEr‘EAR. O . PLAST AIRWAY

O OBSTRUCTS EASILY

STATUS:

• POSTANESTIIESIA RECOVERY SCORE IALDRETE SCORE1 A

DATE

5 MRS'

DRESSINGS: LOCATI

0

I I I !

PPCU

URINARY OUTPUT,

TIME -

cd

TOTAL

SP, GR

S/A

Oa, NCO

REMARKS /AS NUMBERED) AND PERTINENT PATIENT PROGRESS NOTES

1) .PEW fran MR amatpanied, .b)(6)-2

1W: As 2.

DURAL BLOCK MOVEMENT PRESENT SENSATION PRESENT AT

CONDITION ON T .3 00D 0 FAIR 0 POOR 0 CRITICAL

CAU

z_ HAS

FIRS

RECOVERY:

0 COMPLICATED

NEVEitrFUL

PATIE DENT IF !CATION:

:Is)(61-4

if& /

NNMC 6320/16 (05/91) RECOVERY ROOM RECORD

.NAVMED 6320/15 (REV. 11.771 SIN 0105.4F-206-32BI

TIME G 011-IER:

GlerriertA LCrn4 OPERATION PERFORMED AGFNTS min TH•PINICS OF ANESTHESIA

13)(6)-2 OXYGE NTHE RAPT

oral i'ai( HOURIS1 15 ,0 15 45 2 15 45•

220 11111111111111111111MINIUMUM MI 1111111111111111111111111111111111M11111 1111111111111EME11111E111111110:111

EEC to nrnitor 111111111111M111116111111111 + 111M1111 . IMO-1 - 11111E1M11111111111111 RhYthn

140

ME ; IIIIIIIIETUUMIIIIIIIINEWIN IIIIMIIIMMINEMENRINIUMES 11.611111111011- 111E1111111111111111111■1111 IIIIIIMMEMILLIERIMEMENIZIE _ 111111111110111 'r t' HIUMUNIMMINIUMIni IN "5_1 1111111111MINEZIONEMEINIIIMIE FRIMININIERNELVIUMERIME

l i

A6les- •-fD r(5.perwt tail Pain Ye Peal:

01: (re% ,

OU en st Is X 2 war ,darV-ets . 2

ICONT •ON REVERSE/ 1. Activity

NAUSEA AND VOMITING: 0 NO 0 YES • 1 2 3 4 5 6 TIMES

ip 4- art 1°3

V BO

IP A cuff

Ram = • 40

% Sat:

RATE

NUMBERS FOR REMARKS

TEMPS:

Spinal Level:

120

160

!BO

lp

V IN OF

ADS.4INC IN

dgyp cc AT u7A oeA,r AGAT •

AT

Able to move extremities voluntarily or on command Able to more 2 extremiiieivolumarily ow on command

Able to move 0 extremities volumarily

or on convnand Able to deep breathe and cough freely 2 Drronea or limited breathing . I Respiration Apneic 0 BPI20% of preenesthetic keel 2 . BP420.50% of preanerthelle keel I Circulation

.101.50% of preanettbetie keel 0• Fully wake 2

.Prrousable Oil calling 1 Consciousness Not responding 0 Pink 2 Pale, dusky, blotchy, laundie4d. other 1 Color Gyanmk o

TOTALS

,(1:4(6)-2

SIGNATURE OF RECEIVING AND . RELEASING

TOW . bX6)-2 OFFICERS

MEDCOM - 5262

DOD 12474 ACLU-RDI 1263 p.17

TEMPS:

SPirk ' • Level:

BG Ftritha

EP T art V

W A cuff

FWD = .

% Sat:

(i) RE MARKr:4NUAIHEREDI AND PERTINENT TIENT PROGRESS NOTES (CON

. I . 6,)r) ra-4-ncr) CeArc4 s et:ono-40 'A S 4kS

u..a5 rte, • 5 rs a 0

a P.. A,21,4

0 1.. ■

cr th ■

/4•ALd rIMMIEMEEMMEMEIIN '?CW Nbte:, Nano:

.11V.•

111,fflingif....pEEMPO111111111=1! A "11111' 0,1 11 0112"111M g

t.MMI Rrai• I(.• 1111 Pain: y"z.,

(.5 . siat walk EEG Fdlythn: Oa-

4411 • - - 11° Ocacr: • s • • 'if eT,

V. • GU: Ebley

bX6)-2

b)(6)-2

b)(6)-2 ,

Report called to:

'IDAlad to:

Instrirticna/Intervelticre in MU:

°Dior of urine:

•: 1991... 501-10120625

DOD 12475

MEDCOM - 5263

De to 'void:

NAVMED toxvIelertio MOURI:4 15 30 45 15 30 •5 16 15 46 16

150

MILTMENIIIIIIIIIIIM1111111112111=1UMMIIII mobinunualnammonwanamminiarain MICIUMUIUMIIIIKIINCIEMENE1111170111111:1 160

ElkillingE111111111111111111MIIIIIIMI=11

twanumummoolognommunnimusErsoffi musanimmurnammunanummissusin MERIIINE11.1.111111111111111111111111118MMICI

140

120

RESP. RATE

NUMBERS 1 FOR REMARKS I '1

L _t_L II I

I, ,

! I I I

1 n

1 L I 1 1 1 1 1 1- r _II 7

I T : I i It• II -I I I I

• MEDICATIONS

TIME DRUG ROUTE iniiir RSE MEM

iiK0711161=11111111111111111111■111111MMIIIIIIIIIIIIMMIN -

111.15t Iffif.M711"F..e.A.M.1111.111111.111111WRIA.

11111=M

IMMIMIIIIIIWO.. MN IMEZMITAINII t v,..42

Millgrallii 2601 MEINAIII

INIIMiatiMMINFAris

b 6 2 )17- cm b)(6 )-2

b)(6)-2

• °Sant

"61-2 b (6 2

r • . )(6)-2

?eiePt (ifi4-4t Etta •Yr.- 413.)

• Pulnrrentr,

CV: I 5 ScinAband

GI:

ACLU-RDI 1263 p.18

UNIT NO.

(b)(6)-4

(b)(6)-2

AT (Ho

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle: grade; rank; I SEX I rate: hospital or medical facility)

518-124 NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION

COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA

PLATELETS (Pool of units)

CRYOPRECIPITATE(Pool of units)

❑ Rh IMMUNE GLOBULIN

OTHER (Specify)

SECTION I - REQUISITION

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

1=1 TYPE AND SCREEN

CROSSMATCH

DATE RENUESTED

1— kP cHEO

DATE AND HOUR REQUIRED

P Er ..EQu STINT s PHYSICIAN (Print! b)(6)-2

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.

MEDICAL RECORD

VOLUME REQUESTED(If applicable)

\ WV- ML

REMARKS:

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY CP

RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN?

CIrnI ATI inr (IC I/ ILIC

TIME VERIFIED

SECTION II PRE-TRANSFUSION TESTING TRANSFUSION NO.

(b)(6)-4

PF

RECIPIENT

ABC /4/3 Rh

TEST INTERPRETATION

CIC:h1/1TIlor nF oroc.ruu OrlareleonAski, TCCT

(b)(6)-2

❑ CROSSMATCH NOT REQUIREDFOR THE COMPONENT REQUESTED

REMARKS:

DONOR

ABO

0 Rh Pas

ANTIBODY SCREEN I CROSSMATCH

e&up

PREVIO RECORD CHECK:

RECORD ❑ NO RECORD

y//-)1:(3

it ote : BP/1-4/5-3 SECTION III - RECORD OF TRANSFUSION

PRE TRANSFUSION DATA POST-TRANSFUSION DATA

TIME/DATE COMPLETE I7FM INSPFCTPD AND ISSIIFD RV Icianaturpl

ON (Date)

CENT! TION

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.

REACT! TEMPERATUP;c PULSE RESS

ONE ❑ SUSPECTED 42122k ( r. 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.

AMOUNT GIVEN

c

ML

tfronir.u-n isCin,

',3)(6)-2 DESCRIPTION OF REACTION

❑ URTICARA ❑ CHILL ❑ FEVER ❑ PAIN

7r1ISR (Spec'fy)

(b)(6)-2

TEMP. tl 9 • I PULSE

DATE OF TRANSFUSION

PSCLQ-)6

Lecorer U5/V , I

TIME STAR1Eb

OTH DIFFICULTIES (Equipment, clots, etc.)

NO ❑ YES (Specify)

SIGNATIIPP nF PPPSnAl AICTIMP. Aprwr (b)(6)-2

WARD

5-RAD (b)(6)-4


Medical Record

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

MEDCOM - 5264 Medical Record Copy

DOD 12476 ACLU-RDI 1263 p.19

REQUESTING PHYSICIAN (Print) kb)(6)-2

OR CIPERAIIIVE 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.

CROSSMATCH

INSPECTE0.414D-LSSUX) BY (Signature) (b)(6)-2

AMIUNT

L UA

518-124 NSN 7540-00-634-4159



MEDICAL RECORD

COMPONIEf\fT REQUESTED (Check one)

1ZRED BLOOD CELLS

I=1 FRESH FROZEN PLASMA

El PLATELETS (Pool of units)

CRYOPRECIRTATE (Pool of units)

I=1 Rh IMMUNE GLOBULIN

I=1 OTHER (Specify)

VOLUME REQUESTED (If applicable)

ML

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

0 TYPE AND SCREEN

CROSSMATCH

rDATE REQUES

DATE AND HO R R.E9

KNOWN ANTIB DY FOR AT REACTION (Specify)

N/TRANSFUSION SIGNATURE CF VERIFIER

REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY CF:

RhIG TREATMENT? DATE GIVEN; ----

HEML1MC- DISEASE OF NEWBORN?

DATE VIFS-11-j y/

TIME VERIFIED

SECTION II PRE-TRANSFUSION TESTING

TEST INTERPRETATION PREVI RECORD CHECK:

RECORD NO RECORD b)(6)-4

PATIENT NO.

RECIPIENT

ABO

Rh 1.90....c

ABO

Rh

ANTIBODY SCREEN

\Pb REMARKS:

CROSSMATCH NOT REQUIREDFCR THE COMPONENT REQUESTED •

(b)(6)-2 SIGNATIIRF OF PFRSON PFRFORMINK TFq'r

tbe yer! /7 /1-"A_ -3 SECTION III - RECORD OF TRANSFUSION

PRE-TRANSFUSION DATA POST-TRANSF A

5TION

ONE [II SUSPECTED

TIME/DATE

TE E TURE

NTERRUPTED

)3 aLn

PULSE BLOOD PR SSU E

AT (Hour)

ML

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.

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 1=1 FEVER I=1 PAIN

OTHER (Specify)

rb)(6)-2

PULSE 90 I Bpi D TE F TRANSFUSION TIME STARTED

1.01),<- PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last,

rate; hospita or medical facility) p)(6)-4

MEDCOM - 5265

PRE-TR SFUSION

TEMP. Lig #5


Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribedby GSMCW1R, FIRMR (41 CR 201-9.202-1

Medical Record Copy

OTHER DIFFICULTIES (Equipment, clots, etc.)

NO ❑ YES (Specify)

ionvpr rIF DCDCrINI toriurrns. nnnur 'b)(6)-2

irst, 1111U le, grace; rank;

a

DOD 12477 ACLU-RDI 1263 p.20

SECTION II - PRE-TRANSFUSIONTESTING

TTNCFI Nri b)(6)-4

PATIENT NO.

RECIPIENT

ABO

Rh ?Qs

TEST INTERPRETATION

,I,k111.1. 1 ru-nnn Ill,Nr1111,1• 1-11,1,1.

1(b)(6)-2

DONOR

Rh ?G•5

PREVIOUS RECORD CHECK:

111 RECORD NO RECORD

14? ZO3 SECTION III - RECORD d F TRANSFUSION

UNIT NO.

(b)(6) -4 ANTIBODY SCREEN

E

CROSSMATCH

Co CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED I DATE At 05

REMARKS:

518-124

NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION


COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA

❑ PLATELETS (Pool of units)

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

TYPE AND SCREEN

CROSSMATCH

I REOUESTING PHYSICIAN (Print) b)(6)-2

DiAtNOSiS OR ERATIVE PROCEDURE

L ' i. '--(----- ? ❑ CRYOPRECIPITATE (Pool of units) DATE REQUESTED

./ '").-

- 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.

❑❑

- Rh IMMUNE GLOBULIN

DATE OTHER (Specify)

AND HOU QUIRED

,e' -c ;- /,

VOLUME REQUESTED (If applicable)

ML

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify) (b)(6)

SIGNATURE OF VERIFIER

-2

REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY OF: DAVIERIFIED

RhIG TREATMENT? DATE GIVEN: ...7„,..-....../.0.:./.......;__

HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED

0i00

WARD VOL,.

BLOOD CR BLOOD COMPONENT TRANSFUSION

Medical Record

STANDARDFCRIN 518 IRV. 9-92) Prescribed by GSA/ICA411, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

(b)(6)-4

PATIENT IDENTIFICATION-)SE EMBOSSER (For typed or written entries give: Name-Last &St, Mioaie, grace, rang, ratp• hnsnital or medical r= ■-ita+ , \

(b)(6)-4

MEDCOM - 5266

PRE.J.RANSP1J10 si DATA POST-TRANSFUSIONDATA

AMOUNT GIVEN

a?-5-40 ML

TIME/D TE COMPLETED/INTERRUPTED

4/17/ 44/03

(b)(6)-2

NrRour) OM -1 I ON (Date)

TEMPERATURE PULSE 1 BLOOD PRESSURE

317/ ( & S ia.(55

REACTION

NONE ❑ SUSPECTED

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.

If reaction Is suspected-IMMEDIATELY:

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


❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

▪ OTHER (Specify)

b)(6)-2 1st VERIFIER (Signature)

(b)(6)-2

2nd VERIFIER (Signature) (b)(6)-2

TEMP. 3 & 40 PULSE Pd7

PRE-TRANSI-USION V

TIME STARTED

/W :tr-

LCDR/USN ANESTHESIA

DAVARM

011-IER DIFFICULTIES (Equipment, clots, etc.)

M YES (Specify)

(b)(6)-2

(b)(6)-2 Cir'AIATi ion fIF DFPC/1N nicifirsin eoreic

LCDR/USN 2 ANESTHESIA

DOD 12478 ACLU-RDI 1263 p.21

518-124 NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION


COMPONENT REQUESTED(Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA

❑ PLATELETS (Pool of units)

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

• TYPE AND SCREEN

)g- CROSSMATCH

RFOlIFSTING PHYSICIAN (Print) (b)(6)-2

UIHUNUJIJ IJII UV IA I I Vt 1-.111-1l,tULIlit

■

— •

? Z------ ❑

CRYOPRECIPITATE (Pool of units) DATE REQUESTED

'

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.

❑

I

Rh IMMUNE GLOBULIN

❑ OTHER (Specify) DATE AND HOUR RE D

....'fr.' JO) —7 VOLUME REQUESTED (If applicable)

ML

c.r.AIATI Inc nr VICOtricn KNOWN ANTIBODY DRMATION/TRANSFUSION REACTION (Specify)

(b)(6)-2

REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN:

DATE VrRIEIED .

A or; 03 HEMOLYTIC DISEASE OF NEWBORN?

TIME VERIFIED

. '

SECTION I1 - PRE-TRANSFUSION TESTING

UNIT NO. TRA x S 1 ■ I TEST INTERPRETATION PREVIOUS RECORD CHFrw .

PATIN

b)(6)-4 ANTIBODY SCREEN CROSSMATCH ❑ RECORD NO RECORD

CI,KIATI Inc /IC nrnento rIFIICIVIKAIKI, TrIXT A., (b)(6)-4

CO r

I-- RECIPIENT

IV E DONOR

MO A

Rh r?:;/5

CROSSMATCH NUT REQUIRED FOR THE COMPONENT REQUESTED if (I DATE / - 1 of -U3

ABO A.-6

Rh 20.5

REMARKS:

C_4ept 44 A?P-03 SECTION III RECORD OF TRANSFUSION

PRE-TRANSFUSION DATA POST-TRANSFUSION De■TA

(b)(6)-2

AT (Hour) t d 7 ON (Date) 40'Cli'L.

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.

AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED

_q/(i//03

F;U.

41141

BLOOD PRE 2k

iz 7 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.

INSPECTED AND ISSUED BY (Signature)

ML /Z ZS-

REAC 0 TEMPERATURE

XINONE ❑ SUSPECTED 3,7 reaction Is suspected—IMMEDIAirLA


❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN (h)(6)-2

❑ OTHER (Specify)

1st VERIFIER (Signature)

(b)(6)-2

2nd VERIFIER (Signature) (b)(6)-2

PRE-TRAN FU ION,

TEMP PULSE DATE QF TRANSFUS1ONI

Ofi

Tlyly 7213TED

PATIENT ICENTIFICATIO 1%4 DOSSER (For typed or wrinen entries give: Name—Last rate: hospital cr medical facility)

(b)(6)-4

LTS5 LCDR/LiSN ANESTHESIA

1k' I BP 11 146 ER DIFFICULTIES (Equipment, clots, etc.)

NO ❑

YES (Specify)

SIGNATURE OF PERSON NOTIbIG ABOVE (b)(6)-2

(b)(6)-2

LCDR/IJSN ANESTHESIA


Medical Record smsuso Fcmi 518 (REV. 9-92) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1

MEDCOM - 5267 Medical Record Copy

DOD 12479 ACLU-RDI 1263 p.22

MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)

DATE AND TIME

DRUG ORDERS DOCTOR'S SIGNATURE

NURSE'S SIGNATURE START

RX STOP

I 7 Ob .b

Jb)(6) 2

ctrerqmFlei) 4(Dc( 1 ,

■

b)(6)-2

, RV 4 AI A li(T-CD

. ., „ _ UV/LC . P A__ A

•

• .

646, 2oy, MOOS ik • . i oA k . A4

b)(6)-2

wiLi. , i

D i op o?4;chtkA:-. Li-sqv,u3 ortPJ , I

_i: _ 2 6) c\-- 14,6 C_ A .,--(3-- qt-k-

0 31,4m, • A bX6)-2

IN b)(6)-2 (b)(6)-2

t O CAS • / b)(6)-2

• ••

(Continue on reverse side)

PATIENT ' S IDENTIFICATION (For typed or written enlries give: Name - last, first. middle; grade; rank; rate; hospital or medical facility)

b)(6)-4

REGISTER NO. WARD NO.

DOCTOR'S ORDERS

STANDARD FORM 608 (Rev. 1045) Prescribed by GSA and ICMR FPMR 101-11. 806-8 608110

MEDCOM - 5268

DOD 12480 ACLU-RDI 1263 p.23

=73

MEDICAL RECORD DOCTOR'S ORDERS (Sign all'orders)

DATE AND TIME

" DRUG ORDERS DOCTOWRS

SIGNATUE NURSE'S

SIGNOURE START STOP

I

2.1, 0 . . .. 1

4 . (6)-2

b)(6)-2

011 . . nzi s iinismaim IIII

% ■ b)(6)-2 S-A) t(-

ram b)(6Y2 We S(b)(6)-2

enammismarfimmarignm miumlimmram b)(6)-2 VI

III Illmit

6 b)(6)-2 IMMO

Miti MI th- :AIL .111M1111911p/IPMirr*6)-2

23 A • 3 011 A.,t, I ...s

.,.L. ■ •

1111 b)(6)-2

hilalMiler 4 k t 34M6 ,40

lag

=I ra 0 • ' '

b)(6)-2 suaku. i b)(6)-2 hiihh. . Ell b)(6)-2

AI IIIMION

lin...R..„ IM1111111■11■111111111111111111111• ■

animimumenimim ILIIIIIIIIIII■

111i._ awn

111■111111111■■111111M 111=111111111111■11■1111111111

1111

111111111M111111111M1111■1 tinue on reverse side)

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

(b)(6)-4

STANDARD PORN INS OW. 10451 Pilmer6m1 by GSA ard ICUS

FIR MR (41 CFR) 201-45.505 508-111 tr U.S. GPO: I0IS-201.710/10076

MEDCOM - 5269

DOD 12481 ACLU-RDI 1263 p.24

508-112 7540-01-044-5515

DOCTOR'S ORDERS MEDICAL RECORD

INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.

DATE AND TIME DOCTOR'S

SIGNATURE NURSE'S

SIGNATURE START STOP DRUGORDERS

Rx

4 26)03 2.4(30 `Jt DR_ (b)(6)-2 / 0 .3& (b)(6)-2

0 g\ (-)C ...

2a_URANk, A I Qc)

(b)(6)-2

. ')( (b 6)-2

- 3 61 t dldAL

t .... rd Ja ,............. 5-2,0 4 (b)(6)-2

4" l--- VI I! ..-F

&11% ' -...t SiT7 _... "?....--

b)(6)-2

S.c.........14. a...- (L..- aza)-711.74,-...... r)_(.6)-2

) (b)(6)-2 —

\._.../..-- (b)(6)-2

(b)(6)-2

oa 0 i, (b)(6)-2

0 Poi/DO Yt) ata V,,tidttitk

(b)(6)-2

(2; i 4- ctlAnv, it, ecri) (b)(6)-2

/at \ (/'(A - (b)(6)-2

A)(°103 b' e4' 5 (b)(6) 2

ChnAt rofv, :,-0 (con.e on reverse side) ANO.

PATIENTS IDENTIFICATION (For typed or written entries give: Name—last first, REGISTER NO.V1Pg—INIC

.e../ 1

(b)(6) -4 middle; grade; rank; rate; hospital or medical facility)

DOCTOR'S ORDERS 11.41..112.......1

STANDARD FORM 508 (Rev. 3-94) Prescribed by GSA/ICMR, FIRMR (41 CFR] 201-9.202-1

MEDCOM - 5270

DOD 12482 ACLU-RDI 1263 p.25

rative Plan Of Care & Nursin

Patieni AsseSiment For Sur er - Potential For In'ur - Outcome: Patient is free fr and s ptoms of injury es ONo

Diagnosis:

Date/1 ..,-,7Arrival Tr sport Via:

,eGumey 0 Litter ❑Ambulated 0 Wheelchair 0 Other

DruB/Latex Allergies: 0 A

llergy/Reaction:

Planned Procedure: b)(6)-2

Patient ID: 0 Trauma card herbal ?Chart FIA-rmband

Other at-w

Present On Admission: ❑N/A ❑Oxygen 121.-Kr Site: #1 r6co C-(A

#2 %a-Foley ❑Endotrachial Tube 0 Arterial Line Site: 0 Drain(s) 0 Chest Tube(s)

0 See RN Note #

Pasj.Medical History: one known

❑ Smoker ppd/yrs / 0 ETOH ❑ Asthma

❑HTN ❑ CAD 0 GERD ❑ CBR exposure 0 Other: Past Surgical History: 0 None known Nef es

List: ms's

Cultural Needs Addressed: ❑Yes KNo List:

Last PO Intake: (datdtime) Solid: -s aAIfig1111

A Liquid: SP.

frau ma# or ?atient #

:Trom: CASREC

a Ward I OTHER:

Su cal/Anesthesia Consent Verified: 0 Procedure

nsent complete, dated, signed 0❑Emergent case; no consent, MD note

Time

're-Op Pain: 2 No t30 Nble. 4o aces ] Yes Level (0-10) fiction Taken: Jocation/type:

?reap Labs (H 0, etc): ] None rest/Resul

Interviewer: Blood Ordered: 0 N/A Comments:

❑Consent ❑T/C #Units `2---

ibX6)-2

Li T/H #Units

Side: ❑ N/ Age:

Right ❑ Left T; WT:

❑Ai 0 Axill•roll ❑ Bean Bag ❑Gel donut ❑Pillows CI Wilson Frame

Tourniquet: IJ Ann ❑ Leg ❑Left ❑Right ❑webril appli

I' 4.

Applied by:

Total Min:

Comments:

. Comments:

firms <90/1 Annboardi❑ L 0 R Tooke

0 Hand Table ❑ Stirrups ❑Other:

DVT Prevent' . SCD used 0 No ❑ Yes

res • Right Teds: ❑ No ❑ Yes

Bair Hugger used: ❑ No Other warming techniques:

En Chart: I H&P &Yes 0 No J EKG 0 Yes Ei- o I CXR 0 Yes 'El-*Slo I Other:

Skin Condition: ❑ Intact FlOther:

Limitations: ❑ A ❑ Auditory

guage 0 Visual obility 0 Prosthesis

0 Other:

Personal Items: mwlone 0 Military gear ❑Glasses 0 Dentures 0 Jewelry/wallet 0 Other

Disposition:

Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological responses to an invasive procedure': Yes ❑ No

Mental/Emotional Status: omfort Measures Implemented: Pre-op Teaching Included: 3 Alert/Oriented /Calm 0 Clear, concise explanations ❑ UkA due to patient condition 3 Disoriented. 0 Sedated Communicated patient concerns to other staff

❑Unresponsive members Remain with patient during induction

Positional Aids:

ESU # AM. Pad Sit AIKIKTIMF Pad Lot • -

Site Clear at end o case? ❑ No 0 Yes If No, see RN note # Bipolar: Max Cut Coag

b)(6)-4

USNS COMFORT (T-AH 20) PenOperative Plan Of Care & Nursing Note Page 1 of 2 (Rev 3/03)

M EDCOM - 5271

DOD 12483

Anxious Appropriate for age

3 Other Potential For Impaired Skin Integrity Related To Surgical Procedure

Operative Position: Supine

0 Beach chair Prone

❑ Sitting 3 Jackknife

❑ Lateral L / R 3 Lithotomy 3 Other:

01?) ysical layout of OR sonnel present during procedure

nvironment (noise, temperature, etc.) st-op expectation (PACU, drains, etc.)

Outcome: Patient is injury free 0 Yes 0 No Comments:

ACLU-RDI 1263 p.26

■•••& ormal sai. 0 Sterile water ❑Local ❑Antibiotics

0 Other:

See RN note # for additional comments.

Transferred To: ACU

0 ICU 0 Medivac 0 Ward 0 Other

Report by:

Knesthesia provider 0 RN

,//fe

,,(,..3.-0- 3

te Relief OR RN Signature Datc/Time USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page-2 c'f9r

By:

Shave Prep: ❑Shave ❑ Clip Area:

31 y 0 III 0 IV Hound Classification:

Location: ze Location Location

H2O Pressure:

/rains/Packing: I Foley FR: I JP #1 Fr I Hemov I Chest to e: Size

0 Cervi D Coban 0 Drip Pad 0 Fluffs ❑Kerlix

Dressing: Location: 0 ABD 0 Ace ❑Bias 0 Band-Aid(s) 0 Cast

❑Steri-strips ❑Tape ❑Webril

eroform ❑Other:

Collar ■ Kling Immobilizer

Mains ❑Sling 0 Splint

v,fectiores ❑ No Solutions/r ions:

0 Benzoin 0 Mastisol 0 Bacitracin

'tcome: Appropriate Actions Taken to

erPrep:

Betadine Scrub ❑Hibiclens 0 Duraprep ❑Other:

None

Potential For Infec'

:ounts: ;b)(6)-2

Sha 46es 0 No 0 N/A Sponges iteYes 0 No 0 N/A Instruments 0 Yes 0 No 0 N/A

Xray: 0 None 0 Portable 1F(C-Arm

0 Other:

Dischar • e from 0 eratin Room !omnlications: Transport From OR:

t(tuitter w/ safety strap in place ❑

}'one Comments: mey w/ siderails up

w/ Oxygen D w/ Monitor

❑Other:

)

See RN note # for additionaltent

) orgical Procedure Performed: / / e

N Note: (number each note to corresponding area above)

14MM TI CANNULATED MORAL MIL 400MM-5TERILE cat r 474,4418 inn e 4455188 DPI 12/2011

MAT: Ti-MAI.TNN

Initial/Name Box: (please print)

kjn Integrity: Clear & Intact (other than incision) omments:

See RN note # for additional comments nplants: em I Lot # I Exp Date:

AFFIXTOMENTRECORD Membolone Etsvitulad by

ti SYNDIES.8"%t",7:7:.

0 See RN note # f o r additional comments.

ACLU-RDI 1263 p.27

508-112 7540-01444-5515

DOCTOR'S ORDERS MEDICAL RECORD INSTRUCTIONS: Place torm on firm surface; use pressure on ball point pen. Sign all orders.

Nurse: Remove one copy and send to Pharmacy after each order is written.

DATE AND TIME DOCTOR'S

SIGNATURE NURSES

SIGNATURE START DRUGORDERS

STOP Rx

14/.1)0 /lit, V° (b)(6)-2 ik. D..., (b)(6)-2

re ✓✓

Li Li-. 4,3q 1 4- f 4. S }J 84,,, le. 4LS o---et e. ICA .

b)(6)-2

a b)(6)-2 „'Eng• lalerldr-Wnr ...:■

i M Aar. -

c I 1 111 1

2 Io 3 A a " ._„ ... b)(6)-2

mlimil

si , ria .

IN, b)(6)-2 b)(6)-2

' ).b 0' a s It I, 6)

4 IA

(

MI J., ,. ._ - .. .. 4 ......./".....\--/'''''....''s•- ■•''....\.___., (b)(6)-2

= ,. .i D (2) ZZ b)(6)-1 (b)(6)-2

jeth

itnia 14050 ..)

2)

,........--. -v

■1....._ M1 i- -TA a Po a tpk\L Y‘e_ Slt 32-5 ttlier-- 0 CQ bAN .t-N.-

( )(6)-2

V 10 (6)(6)-2

174C6 0 in (b)(6)-2 OuminAiris

p on sine

PATIENT'S IDENTIFICATION (For typed or written entries give: Name--/asl,first, middle; grade; rank; rate; hospital or medical facility)


1(b)(6)-4 DOCTOR'S ORDERS Medical Record

STANDARD FORM 508 (Rev. 3-84) Prescribed by GSAIICMR. FIRMR (41 CFR) 201-9.202-1

Q MEDCOM - 5273

DOD 12485 ACLU-RDI 1263 p.28

508-112 7540-01-044-5515

MEDICAL RECORD DOCTOR'S ORDERS

INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.

DATE AND TIME

DRUG ORDERS DOCTOR'S SIGNATURE

NURSES SIGNATURE START STOP Rx

.....(b)(6)-2

_ -

2---2-zz, (........f e._ 6.....•_i_L_ (...„,-47 .., e2_,._ ; . /A - ci •

(b)(6)-2 (b)(6)-2

LtrYir

(b)(6)-2 (b)(6)-2

ten 'Ill C \ N IL "r-Al g ) '110 5 UL) , (b)(6)-2

V - ,5-4- i - '' --4̀ 4.47 ' - 7 b)p-Z—' ritatT"t''' ' 2Vraffi'MY-. - • 4,r_ZA v

4' 2-, 0 ) -...._------ b)(6)-2

4.6„,;( , t so a 4 -.), 0g I° Lk al e c i .A.: - Li , N-1—■----------,-----■---------

i Q.vii■ • . ■ Cr I, b)(6)-2

b)(6)-2

--. V•I 6' _____---....„

-1-1-4,-,--O N CA.,..e, -- .

■ i (Dc). 1 o 41-2.11- 03 „::::,(b)(6)-2

(b)(6)-2

(DD`

PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; hospital or medical facility)

REGISTER NO. I WARD NO.

(b)(6)-4 DOCTOR'S ORDERS Medical Record

STANDARD FORM 508 (Rev. 3-94) Prescribedby GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 5274

DOD 12486 ACLU-RDI 1263 p.29

b)(6)-2

a z. (6)-2

EDICAL RECORD

TIME

STOP RX STOP

DOCTOR'S ORDERS (Sign; all ordrrs)

DOCTOR'S SIGNATURE

DRUG ORDERS

(hi),(2.

NURSES SIGNATURE

b)(6)-2

b)(6).

0(6)-2

(6)-2

0 3 pil-z

1..CniintAc P11, erse .side)

'AT ATION (For typed or written entries gt

middle; grade; rank; rate; hospital or medical facility)

b)(6)-2

DOCTOR'S ORDERS

STANDARD FORM 500 (Rev. 10-15)

Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 50E-112

MEDCOM - 5275

DOD 72487 ACLU-RDI 1263 p.30

DOCTOR'S ORDERS (Sign all orders) MEDICAL RECORD

NURSE'S SIGNATURE

DOCTOR'S SIGNATURE DRUGORDERS


PATIENTS IDENTIFICATION (For typed or written entries give: Name - last, first, I REGISTER NO.


1 wrIA\10.

DOCTOR'S ORDERS 0(6)-4

STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 508-112

- MEDCOM 5276

DOD 12488 ACLU-RDI 1263 p.31

b)(6)-2

b)(6) -2

MEDICAL RECORD

DOCTOR'S ORDERS (Sign all orders)

NURSE'S SIGNATURE

DATE AND TIME

START

b)(6)-2

b)(6) -2

b)(6)-2

I DS b)(6)-2

MOM b)(6)-2

01"

4It` _va_i',41. UMW

AMP',

ketaillin 001111 ■

lirISWSMI"1"MjpWA i WAFTIFILILF-4L1.111111115 nin b)(6)-2

WPM ri

04■40 b)(6) 2

ing

I

4WRINI b)(6),At

_ 41 Immi"r4 olt7011

PATI NT'S IDENTIFICATION (For typed or wrier

mid •le; grade; tank; rate; hospital or medical facility) b)(6)-4

FIRMA (4 1 50S-112

f0 3 3Q

JEEP b)(6)-2

WARD

MEDCOM - 5277

DOD 12489 ACLU-RDI 1263 p.32


DATE AND TIME

Rx DRUG ORDERS OCTOR S SIGNATURD

E NURSES

SIGNATURE START STOP

1 S4Pte03 15 9 30 0 0 e (fpwtejr eitt4Ard-ciskicl

a y-

A' XQ -6- 5 0 ..«. ..f?fr.(35, ' , e,o, b)(6)-2

_ ME ■ (b)(6)-2 4.40

1 SA 13 I 6-6I . 1 t 1111 0

,et:t (6)-2

b)(6)-2 c-_,O____e_r_j_cl,J--4) va-vic5 Lp4t_L-In

C 4701)

,I / OM ft

U. 0 b)(6)-2 E )4 5" b)(6)-2

b)(6)-2

. . I■

(A ) . ellfil io yuce;469-1 .th 0 ..13 • \ ,

1 q 5 4

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

il b)(6)-2

b)(6)-2

2.-CiOrC — Nyman 1111Pr- 5 ipc

- i 1 •

d.

U . (b)(6)-2

a (b)(6)-2

t1°----r- _

fir ,

IIM AIMI.11 .11,1grip-Millnil aif II 1r b)(6)-2

b)(6)-2

MI 11-MIMII 11111111 --

• ei 611611111A1 - i


PATIE 'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)


j1)(6)-4 DOCTOR'S ORDERS

STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-505 508-112

MEDCOM - 5278

DOD 12490

ACLU-RDI 1263 p.33

DOCTOR'S ORDERS (oRTHOPED7 .IT/POST OP) (Sign all orda

DRUG ORDERS DOCTOR'S NURSE'S SIGNATURE SIGNATURE

MEDICAL RECORD

DATE AND TIME START STOP

afiLv_ekcide

i f (65 iS0

ftr (?,?1(

MEDCOM - 5279

al il+;D ll ...A.-L.7 ---/

b)(6)-2

PArIENT'S IDENTIFICATION

6)(6)-4

d b)(6 )-2

C

1 ADMIT TO: ORTHO STAFF: M(6)-2

b)(6)-2

Dx:4rho Ifq

Pe44 A7,00c4,2, ,41f Aer4 / K CONDIIION: STABLE

ALLERGIES: 14/,e.LADAk- VITAL SIGNS: Q . 1 hr X 4 •THRU Q 4 hr X 2411r THEN Q 8 lir NURSING: - N/V CHECKS W/ VITALS - I &O's q 8 hr x 48 hrs

6. Foley to gravity (remove 6 A.M. on - drain to self.suction - Remove wound dressing and replace w/ sterile dressing on POD #2

7 Diet: Clears, advance as tolerated— -- 'On a t-1, Gto-kc-

8 .

is

• CHEM 7, CBC in AM; )CBC q AM POD # 2 & 3_1

IV: D5LRa0100cc/hr

MEM: - Ancef ig IV hr x 48 At-

- h - Lovenox 30mg SQ BID - MSO4 LO, mg IM or IV q 4hr : prn pain significant- - Phenergan 25 mg IM or I1014 hr prn - Percocet 1 - 2 tabs po q.3 hr prn pain moderate - Tylenol 650 mg po q 4 hrpin - MOM 30cc no qH4 hr prn - Benadryl 25mgpo'q 4 hr prn - Surfak 240mg po bid prn ii Other Meds: immommilf

Tbtivcpc,tc.4,1-1 1 9-0 0-7 (J

9_, .

12.

13.Call Ortho tech for casts, splints, traction equipment or cast bivalving .

14. X-rays: 011/41 (1-1"417 C;D)

Po-c_t_AL Transfuse units PRBC if HCT less than

15. Type and Hold for units Type and Screen for ' units

bX6)-2

DOD 12491

Activity:

LABS:

10.

11.

141 •••■•••••■

ACLU-RDI 1263 p.34

DATE AND TIME Rx

DOCTOR' BORDERS (ORTHOPEDICS ADMIT/POST .../P) (Sign all orders)

Doctor's Signature

Nurse's Signature START STOP

• t ,_. L15

Pin care - % strength H202 q 8 hr to all exposed 3_ gins

:-, •

■.. "Dressing Dressing changes

•

Traction - pin care to exposed pins

i

I

19.

20.

Misc: afat.-c--) C6)L E Lslii,a6 ,:)

.. •

If N / V changes occur, call Charge Nurse / Ward Medical Officer to assess and bivalve cast if

6,-,_a_ -'--- bx6)-2

it 5)-2

present 1

[

. 21:7 .

- '

If UOP < 30 cc/hr, bolus 500 cc NS and assess results. Call Ward Medical Officer if no

' improvement. i'• 22.

Oxygen:

23.

Physical Therapy: r

, I I=X6N

4 , lw NI

\..) Ifi 1511 1 SCO

A (b)(6)-2

(PErsicIAN-stsasuRE) ''y

iC 63 op_15 en^

PATIENT'S IDENTIFICATION

(b)(6)-4

MEDCOM - 5280 .-•

DOD 12492 ACLU-RDI 1263 p.35

506-U1

MEDICAL RECORD I DOCTOR'S OF,,--RS ' (Sign all orders)

DATE AND TIME

DOCTOR'S NURSE'S SIGNATURE SIGNATURE START I STOP '

RX DRUG•RDERS

IP'

ANES I HES1A PACU ORDERS

I I b)(6)-2 mit to

Allergies:

Vital signs per PACU Protocol.

4. 1 02: FM Ca; 10LYM, % Blowby,NI NP (a ,) / • '' - L. t - - LPM.: b)(6)-2

I ■-•••• - /

IVF: — at _____/:Th( )Whr . 1

-N On ward: 02 @ 2-3 LPM via NC: YES .1\10) /

k.,.....1.)r Pain medication: I

Isider 0.2-01 mg/kg) 1 Ketorolac mg IV xl dose (adults 30 mg max; peds

._._. MSO4 1=-. R" mg IV q--(LyIlin pm; max dose Z)mg _G...1 i

Fentanyl 025ncg IV q ._.5 min pm; max dose /1,0 mcg i e; b)(6)-2 Percocet tabe( p.o. with sip of water I e /_,....2, me -„ 1-0 agdvu-i-toil .4

Other: P it , or , .. , ' a 4 '-- ' I Ver 11

8. Antiemetics:

0 Ondansetron Li mg IVP, may repeat x 1 in 15 min (0 . 1 mg/kg: max 4 mg) ',

" Metoclopramide It) mg IV xl (0.15 mg/kgmax 11) mg)

a'.1 II • • - • • -..„. ...• • • e - ! . . .

1141-r available before administration. .„. .

Mi Other _

9. Clear liquids as tolerated: 411/0 NO

4111) Notify Anesthesia (pager (b)(3)-1 ;Dr airway issue , pain, nausea/vomiti 1 :.

not responsive to above orders or other patient piloblems/concerns

per PACU protocol.

40 vi 3/2002) - - (OVER)

(Continue on reverse side]

PATIENT'S !DENT! REGISTER NO. (b)(6) 2

DOCTOR' Medical Record

STANDARD CORM 508 I Rev. 3-04) Prescribed by GSA ICMR FIRMR 141 OFR} 201-9.202-1

!CATION (For type written entries give: Name-lest. first. nnielriln• morin • r,In• hernia I 'It

(b)(6)-4

1:77.7,17-CTWAT

MEDCOM - 5281

DOD 12493 ACLU-RDI 1263 p.36


DATE AND TIME 1 OPUG ORDERS

DOCTOR'S SIGNATURE

NURSES SIGNATURE START STOP RX

AIN ES 1 HES1A I'M- U * 9 I . fix 1

llischarge patient om PACU per protoco : Wile Alibl■.

I

0 I

1-2:- when ep urairspinal patipnts meet discharge criteria per PACU protodol,

discharge to ward. On war • bedrest pending ttill recovery of sensory and 1 1 I

/

.•• motor tUridtion;)rgress to ambulation with ass

ONLY'

stance. 1 1 c

-

SR PACU KEEP FA 1)1EINTS

13. Release patient from anesthesia care to KEEP st tus when patient meet is

anesthesia discharge criteria: YES NO • .

14. Notify anesthesia (1506) for airway management and: (circle if applicable)

a. Pain management

. . b. Fluid management

15. !

I C. Other

TOW patient i .

to ward in a.m. if patient meets disbharge criteria: i

YES NO

,• (b)(6)-2

■ .

; ! Signature Beeper

(b)(6)-2 b)(6)-2

LCDR/USH am i rmi , ir WM WArArro—A "A

1

. '

1 ' "

STANDARD FORM 5O (Rev 3-941 BACK

MEDCOM - 5282

DOD 12494 ACLU-RDI 1263 p.37

MEDICAL RECORD DOCTOR'S ORDERS

(Sign all atlas)

DATE AND TIME

FOC DRUG ORDERS

(b)(6)-2

DOCTR'S SIGNATURE SIGNATURE

START STOP

1 535 6 (o al(

..- lJ L c t__ J3C M 51,1 -_______-

1-•

.

\

-\\\

.\\\

\\*.\

\\*\

- \\N.

•

• —

. , fContrrrue on reverse it e

.

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

middle; grade; tank; rate; hospital or medical facility)


DOCTOR'S ORDERS

STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (45 CFR) 201-45-505 500-112

MEDCOM - 5283

nnn 124AS

ACLU-RDI 1263 p.38



DATE AND TIME

RX I NURSE'S

SIGNATURE START STOP

DRUG ORDERS I DOCTOR'S SIGNATURE

. 1 4 -Lin, 3

5 (s-o (cap V .o Dr . QAmb -I (b)(6)-2

'''s (b)(6)-2

0),(6).2 f IliP CZ (1. ?,54—kv--tAs—

-.._ ■pA--4:tud5)

(b)(6)-2

if i8 .ra- -Lte--

G1 l ► 3 15. (P Wce. A 2_ --(b)(6)-2

C._46 e_cleift5 - 6 itif ff, j

144 Lei / r'-i?

`2----- ...-----

D Aszc4 7- 6 ,c(e.i.4 t-?

eA-,-(,,-, 4-g Dik.e.g.( -14 fr*CLIZA

cevp( b)(6)-2

4

b)(6)-2

i(b)(6)-2

(b) 6)-2

AL1 ‹._

E../ (b)(6)-2 -------------

i CO51-)Caf2 .ti C-5110.- .)‘. /k 00 ., /10-- 1- 2G rg (b)(6)-2

/X/ VI-XL 1,e3in.- a/ 0 . (b)(6)-2

N( c3 e -,--9,Li° cA,,,,,i--- 00---"-; Q-eL. in`h---v-, "e) / 03 6


PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, I REGISTER NO. WED NO.

3 1)

DOCTOR'S ORDERS

STANDARD FORM 508 (Rev.10-75) Prescribed by GSA and ICMR FIRMR (41 CFR1201-45-505 50B-112

M EDCOM - 5284

DOD 12496

ACLU-RDI 1263 p.39

b)(6)-2

C01/NCI

MEDICAL RECORD

DATE AND TIME

RX START STOP

DRUG ORDERS

DOCTOR'S ORDERS (Sign all orders)

DOCTOR'S SIGNATURE

NURSE'S SIGNATURE

o$ 7 —6 / S-,fel

lq 's°

;13)(6)-2

(b)(6)-2

Wir-4-C-0-54411 (b)(6)-2

b)(6)-2

6) -2

1 4 P

b)(6)-2

b)(6)-2 .1/ o o e 44_4 irip

(2/00'403 /P50 b)(6)-2

b)(6)-2

b)(6)-2

0 20

"rife)

/ 5

b)(6)-2

3 05

(Continue on reretue side) b)(6)-2

b)(6)-2 WARD NO. PAT NT's IDENT (CATION (For typed or written era

DOCTOR'S ORDERS

STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-5D5 505-112

middle; grade; rank; rate; a ay)

b)(6)-2

CSC,

/,

MEDCOM - 5285

DOD 12497 ACLU-RDI 1263 p.40

'6X6)-2 •

9

10.

11.

12.

13.

14.

15.

MEDICAL RECORD • .1

1„. DATE AND TIME START STOP

aA.Ar O.

,b)(6)-2

IADMIT TO: ORTHO STAFF:

DX : .5h:3 (

/ A/

CONDITION: STABLE

ALLERGIES:

DOCTOR'S NURSE'S

SIGNATURE 017491111mp____

— /-2 b)(6)-2

1-1

DOCTOR'S ORDERS (ORTHOPED

MIT/POST OP) (Sign all ordc

1.

2.

3. 11

4.

DRUG ORDERS b)(6)2

1X6)- 2

VITAL SIGNS: Q , 1 hr X 4 THRU Q 4 hr X 24 . hr.THEN 0 8 hr NURSING: - N/V CHECKS W/ VITALS - I & O's q 8 hr x 48 hrs - Foley to gravity Cremeve-6--A-41-,-en - drain- -to—se-11 —suction_ - Remove wound dressing and replace w/ sterile dressing on POD #2

Diet: Clears, advance as tolerated Activity;

• (t):c'F

LABS: CHEM 7, CBC in AM: CBC q AM POD # 2 & #3

IV: D5LR@lOOcc/hr LI MEDS: - Ancef lg IV q'S hr x 48 hr =,„ Gentamicin 80 mg IV q 8 hr x 48 hr OP-

- - Lovenox 30mg SQ BID - MSO4 mg IM or IV q 4#r prn pain significant - Phenergan 25 mg IM or IV;ci 4 hr prn - Percocet 1 - 2 tabs po q 3 hr prn pain moderate, - Tylenol 650 mg po q 4 hr prn ,

- MOM 30cc po q 4 hr prn - Benadryl 25mg!po'q 4 hr prn. Surfak 240mg po bid prn

Other Meds:

Call Ortho tech for casts, splints, traction equipment or cast bivalving

Transfuse ' units PRB 1C if HCT less than Type and Hold for units Type and Screen for units

X-rays: -11-^) L,t1-7

b)(6)-2

aq-eade. (414 [o) TCbntinue on reveragZalittil)

ZS)

PATIENT'S IDENTIFICATION ,bX6)-4

N(6 )-4

MEDCOM - 5286

DOD 12498 ACLU-RDI 1263 p.41

(b)(6)-2

qiu )03-

24 50

,b)(6)-2

( PHY SI CI

(b)(6)-2

DATE AND TINE START STOP

p0)-2

DOCTOR. ,RDERS (ORTHOPEDICS ADMIT/POS'.. / Doctor' ■ Nurs (sign all orders) Signature Signa ∎

Pin care - % strength H202 q e hr to all exposed pins_

' '.Dressing changes

Traction -pin care to exposed pins

Mis c:

19.

If R / V.changes.occur, call Charge Nurse / Ward 20. Medical Officer to assess and bivalve cast if .present

lf tRIP,<130 cc/hr, bolUs 500 cc NS and assess 21. results.' Call Ward Medical Officer if no

improvement. Oxygen:

Physical Therapy:

b)(6)-2

PATIENT' S IDENTIFICATION

(b)(6)-4

MEDCOM - 5287

DOD 12499

ACLU-RDI 1263 p.42

DOCTOR'S OR 3 EDICAL RECORD 1 (Sign all order

/ DRUG ORDERS

ANESTHESIA YALU ORDERS

Admit to PACU.

DOCTORS NURSE'S SIGNATURE SIGNATURE

DATE AND TIME

START I STOP

LA , til 0 3 tilICI pv3; it 1---. u r 1 Vital signs per PACU protocol.

NP () LPM.; . , 02: 'fM (allOLPM, % Blowby,

r IVF: LS,- at \--7.--u cc/ b)(6)-2

On ward: 02 @ 2-3 LPM via NC: YES WO

1 i • Pain medication: .....

1.- .

Ketorolac mg IV xl dose (adults 30 mg max; iieds cinsider 0.2-0.4 mg/kg) 7:7

a-- -t--I

% I C MSO) '2- ' 5 mg IV q -5 min pm; max dose1-7--0—mg

Fentanylc"a mcg IV q57-0 min pm; Max dclse 490 mcg r)(6)-2

/ b)(6)-2

7/ Percocet - ,_tab(s) p.o. with sip of water ilkiP / 2,

Other:

Antiemetics:

\ Ondansetro• • mg IVP, may repeat xi in 15 min (0:1 mg/kg; max 4 mg)

. 2,..... ∎ ► etoclosr, " 0 mg IV xl (0. IS mg/kg; max I D mg)

C Droperidol mg IV x I dos,- (4).°1 mg/kg; --t-in 011ili in-;,) r`1,-- t h.r'c 6.1e1;%. E

available before administration.

• Other --, I

b)(6)-2

1 Clear liquids as tolerated: E NO

, • 1 . Notify AnesthesiE (b)(3)-1 i for airway issuel, pain, nausea/vomiti

I not responsive to above orders or other patient piloblems/concerns I b)(6)-2

per PACU protocol. ,

rn i 0

(rev; 3/2002) (OVER) b)(6)-2 'b)(6)-2

.. , .__

.A1 IIIA. ANL ./M —

9ATIENT'S I DENTIFItATIO , (For typed or written entr as give: mieifilm• nrmrita• rank - rale hospital

RE ST NO. ARD NO.

(b)(6)-4

DOCTOR'S ORDERS Medical Record

STA)404RO FORM 508 !Rev.

Presc:18ed Cy )354-1CAIR FIRMR (41 CFR) 201-9.202-1 (b)(6)-4

MEDCOM - 5288

DOD 12500 ACLU-RDI 1263 p.43

b)(6)-2

t(b)(6) -2 ))(6)"

4ce%- eAm lift-) 4- .

STANDARD FOSR1 505 IRttv. 3-9 41 3,

S b)(b)-

MEDCOM - 5289

b)(6)-2

MEDICAL RECORD . DOCTOR'S ORDERS

(Sign all orders)

DATE AND TIME

I • DOCTOR'S

RX 1 DRUG ORDERS SIGNATURE NURSE'S

SIGNATURE START S • ID ,

( 0 II 11 si I ` I I

INN& • isc arge pa ien rom per protoco : • • •

en epi•ura spina patients me - isc arge criteria per protolo ,

• isc arge to war.. •1 are :-- e • rest pen• ing u recovery o sensor . d

motor _tpetion; progress to am •u ation wit ass stance. b)(6)-2

FOR PACU KEEP PATIENTS ONL IIIIMIE.„

13. I Release patient from anesth - ' are to KEEP st tus when patient meet

anesthesia disc e criteria: YES NO

i 14. I Notif esthesia(b)(3)-1 for airway management and: (circle Ie applicable)

a. Pain management

b. Fluid management b)(6)-2

/ c. Other 1

15. TOW pat' t to ward in a.m. if patient meets d sbharge criteria: i

Y NO

b)(6)-2

S ignatu ! Beeper

b)(6)-2 b)(6)-2

/-/-(/- ;,,,,-

0 3 0 / , - .o. 0 ic Nan - .-

ye

ffitti

Yr n.S ,, /S

IIMPA A I3)(6) ..

I -Ca

b)(6)-2 _z

DOD 12501

ACLU-RDI 1263 p.44

MEDICAL RECORD DOCTOR'S ORDERS (Sign all tiers)

DATE AND TIME

NURSES SIGNATURE SIGNATURE START STOP

RX DRUGORDERS

(b)(6)-2

14(AT TA).

oa- 0 c--10 vt,t IU

71A4A

fi6t, it ;4- t) /IAA-

Aocif i vk 0.Jrz,tra:t., b)(6)-2

t/

644 (e, c0 II 12's b 1 1Air > (4 Ceo L/P7ho'7:

(b)(6)-2

46947ect—:

(b)(6)-2

24 50

/upo -

OtreCPC_, fr1))4-644--4))6/ /5)0

IVA-401 /Lt.

zio b)(6)-2

Itolos )(6)-2

( )P-2

PATIENT'S IDENTIFICATION (For typed or written enn middle; grade; rank; rate; hospital or medical facility)

ast, t,

se

WARD NO.

(b)(6)-4

MEDCOM - 5290

DOCTOR'S ORDERS

STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA aid ICMR FIRMR (41 CFR) 201-45-505 508-112

DOD 12502 ACLU-RDI 1263 p.45

MEDICAL RECORD MEDICATION ADMINISTRATION RECORD

NAVMED 6550/B (RE V.4-74) S/N 01l. .16-5581

SCHEDULED DRUGS

MEDICATION- DOSAGE- FREQUENCY

ROUTE OF ADMINISTRATION

I MO TH edi

b)(6)-2

--■-■amumml

„ter.2491 DATES GIVEN

HOURS /3 IWUMWINE:

13

•

INITIAL CODE

INITIAL FULL SIGNATURE & TM.E INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE bX6)-2 b)(5)-2

. •'

ADDRESSOGRAPH PLATE I WARD NO.

Injection Ste Ne Code

0 = Left Buttock ® = Left Leo C) = Right Buttock 0 . Right Leg SNGLE DOSE,

C) = Left Deltoid C) = Left Ann PRE- CP PRN

C) Right Deltoid(D Right Ann & VARIABLE DOSE CftDERS

0 = Abdomen SEE REVERSE

bX6)-4

MEDCOM - 5291

DOD 12503 ACLU-RDI 1263 p.46

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-2165581

SNGLE ORDERS - PRE-OPERATIVE

MEDICATION- DOSAGE

ROUTE CF ADMINISTRATION

GIVEN MEDICATION-DOSAGE GNEN

DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

PRN AND VARIABLE DOSE MEDICATIONS

ORDER

DATE

MEDICATION-DOSAGE FREQUENCY

ROUTE OF ADMINISTRATION DOSES GIVEN

Li-t )1. --TA 4, Lisbiz. DATE

P R4° P TIME

DOSE

INIT.

4 t 0, ropm, 3kA__ po DATE

6? 4-° peiJ TIME 4 7.0

DOSE 3c0

INIT. b)(6)-2

41 11 ) 4 I ,„,,, ,, DATE 11 • ....------.....

T'

, iii a 1. , TI I , I ■ ./...

----(

DOS:

• )(6)-2 INIT.

it ( 1 ( 1.44 elk 2401146 DATE qk

1 ‘ P D 11 D 0 TIME 614

DOSE xiD

INIT. b)(6)-2

\----"

4/ IS ae teva-D avi 04---00,6DATE 4-7

I) 0 (06 . T RA) TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

MEDCOM - 5292

DOD 12504 ACLU-RDI 1263 p.47

Injection Site Code WARD NO ADDRESSOGRAPH PLATE

MEDCOM - 5293

0 = Left Buttock ® = Left Leg

(7)= Right Buttock 0 = Mont Leg SINGLE DOSE,

® Left Deltoid C) = Left Arm PRE- OP PRN

® Right Deltoid C) Right Arm & VAFRABLE

DOSE ORDERS 0 = Abdomen SE REVEFLSE

b)(6)-4

FULL SIGNATURE & TITLE INITIAL b)(6)-2

INITIAL Z.SiGNATUIC1T111 :b)(6)-2 'r< D)(6}2 b)(6)-2 b)(6)-2

b X6)-2 )(6)-2 b)(6)-2

V b)(6)-2

FULL SIGNATURE &TITLE INITIAL b)(6)-2

NAVMED 6550/8 (REV. 4-74)S/N 01t, 216-5581

M E D ICATI 0 N ADMINISTRATION RECORD MEDICAL RECORD

SCHEDULED DRUGS MONT ' . al—

01063 WEE:

ma it INEMI ORDER . ATE

TION- DOSAGE- FREQUEN MEDICAROUTE OF ADMINISTRATIO

CY

N HOURS

M ir LAMM rill DTMGIMI I CO 0 e. (19 CO MI 03 e giri PM

1

1

IMIERIMMri.

gatintk..-‘.

MERMIIIII

RIMINWAIMIlltillUir I ::. \)1):' 1,1 1 IT FA a a ifir al

ASIU'Ill iniliMPSIIWIIIPM.bX6■_,%man1011

nor * i CO

• oo

mod

IMIZIKSIW----

MIMI

hx6)_2

MINIM

VarilleffilMHIMI PAIMPaar

Adirl %,■.

m , Ki rim ,,, A . b),„ - - - - i 0 inivri/ MEW.:

■P

ll Fr._,AilIMBIWIMMIIII I1 I, 60 101KA b)(6Y2 maraca b)(6)-2 5112111M bX6)-2

✓jp21 ...),< im

MI' NW t:) i • ...,L 0

2• =FM

, 4 a co

simmutesnemr-Aummamirmormimsseit ..Ft:',... .__,v.. ---ts a & et. .AMIREIMIMINIIIIMILIMIr INIMIIIMINIIMIIM

wargirp EI

, , ;mum b)(6}2 .... 120 Com ( s?t541:€ _MIII.1 MIMI mmiimmloym ____„..a,

t)(6 }2 1 /1 Cle.pkr_ -r- (Do ik 0 9 6-0 bX6)-2 (3 YKD ht\ '3 o grc. 2 1 ID 10-0

a I ri)

INITIAL CODE

DOD 12505 ACLU-RDI 1263 p.48

MEDICATION- DOSAGE

GIVEN


DATE

ith9

_DLL 4.0.LA fig


DOSES GIVEN ROUTE OF ADMINISTRATION

DATE

TIME

rflEx iii„kt5-ionts I VD 2(!I 'fill VII 1 6 AO , 2o,A,

ORDER

DATE

4 )

INIT.

1 I T GQ*3 autto DATE

6)40 Piu) DOSE

(b)(6)-2 V

TIME

DATE 4 TIME

DOSE

if taii.vvu El+-s ► Tip P^

it l2 VI 113 en, Ise r

b)(6)-2

PATE

TIME

DOSE

INIT.

VASEMILTIEMEIVEI INSIMENTINITIMI

IsS110/1!!!!Itilffil!Migr' 2.140

6 INIT. b)(6)-2

i-f(u 'Plotopi*us-m r im.nok-nir &ft,

010 Imo

DATE

TIME

660 43/b

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581

SINGLE ORDERS - PRE-OPERATIVE

MEDICATION.. DOSAGE


GIVEN

11101,1 A. I !b)(6)-2

DATE TIME INITIAL


INIT. b)(6)-2

INIT.

DOSE

INIT.

4(1( pa.acd. 6230 PerJ TIME

DATE

DOSE

INIT.

til ke0

II II II

MEDCOM - 5294

DOD 12506

ACLU-RDI 1263 p.49

MEDICATIONADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581


MEDICATION-DOSAGE

ROUTE CV ADMINISTRATION

• GIVEN II MEDICATION-DOSAGE


GIVEN

DATE TIME INITIAL I I DATE TIME INITIAL


ORDER

DATE



L5kik 2-WIIF- NVPR1/4-4 L. DATE

m45 ....c...42 Mc cri TIME

C".0 irn c. P SZ.N. DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT. •

DATE

TIME

DOSE

INIT.

MEDCOM - 5295

DOD 12507 ACLU-RDI 1263 p.50

NAVM ED 6550/8 (REV. 4-74)51N.01%. [16-5581


DATES

ORDER DATE


ROUTE OF ADMINISTRATION HOURS • .sr .

411RA

!IfilMil ol■ IIMP,

RM._ ti.Mal. le.■ :19. 'b

'VI% rfflilkSAIPII■11111111111 V? Vli *WORM \ OA)

b)(6)-2

N..1 ffi.Wal 6.4 A.siPli■

b)(6)-2

so XI! 4. --a910

b)(6)-2

. C • 1 ll WI

'IL .orP,s_gnffitilMil■ kik - MI , ,mgivile

7/ IINRIPR .i.../w/Ell.

Ft k/9

/ YOU b)(6)-2

i A2C90

INITIAL CODE

INITIAL FULL SIGNATURE & TITLE 1111.__.„.. (b)(6)-2

( FUL/SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE (b)(6)-2

„.......\ v 1 ,„

. .-

ADDRESSOGRAPHPLATE Injection Site Code l WARD NO.

b)(6) -4 C) - LeR Buttock 0 = Left Leg

C) = Right Buttock C) = Right Leg SPIGLE DOSE,

PRE- OP PRN

MEDCOM -5296

- a.vn uonvm v - won ..gym

= Right Deltoid C) = Right Arm

0 = Abdomen

&VARIABLE

DOSE ORDERS

SEE REVERSE

DOD 12508 ACLU-RDI 1263 p.51

MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581

SECLE ORDERS - PRE-OPERATIVE

MEDICATION- DOSAGE

ROUTE CF ADMINISTRATION

GIVEN MEDICATION- DOSAGE ROUTE OF ADMINISTRATION

GIVEN

DATE TIME INITIAL DATE TIME INITIAL


ORDER DATE

MEDICATION-DOSAGE FREQUENCY •


-V \ \ \mt .1k or.., c....A.AG DATE .4;13 X \\ ie "1-1t PS), TIME 1.‘: a92J'i"

c-C-1?'■ Ot GN-TfN-ri 0 6 DOSE . V4 -5.-1,4A

INIT. bX6)-2

....\ \ ". IP:Ali, . ., • ". DATE ...1\1 \ ..)I l.S...1 I (2) . .

J W. 0 v v TIME El t el* ,C,\AC"; OM • -

?NM cb\rItc\cc-akIN DOSE. kCV.1. ior'. (ot-4^ 1, -

INIT. 'b)(6}2 b)(6)-2

--V \ \ cArrepi,-- c2(.. 5..1/4.c, DATE

1 t...k) N 0bl...A c. 9v.....1..::1/2 TIME

DOSE

INIT.

.41/ \ \ PEP-Cr—c_.e-T. 1-,,a-ippc DATE 115 ,...\\5y,1

R.-) c.• PRI.) TIME ) ..$ \e/cl-f' 0..2,0

eFews ts..)<,A—..-14... DOSE g O. ;2 bX6)-2

INIT.

\/ ` k -rLik ,00 .1 (cfr nt„„tc.‘ DATE

Pr') Cg(.4 * PR t■ \ TIME

DOSE

INIT.

`‘•-•\ ) \ \ poi—ICI-1 ••(*h c. c- . DATE all .

P() C-. .),'' Pe.1 TIME `0

DOSE ■

INIT. b)(6)-2

LAil \ F-A.RFPX... D\-10 .4, DATE '-\\ \a'

VC) C1-]Kr) cl?-3% TIME ...64)C'''

DOSE 2..)y'

MIT. (b)(6)-2

MEDCOM - 5297

DOD 12509 ACLU-RDI 1263 p.52

.;-5581 NAVMED 6550/8 (REV. 4-74)SIN 0105

MEDICATION ADMINISTRATION RECORD M EDICAL RECORD

DATES MONTH 49- GIVEN SCHEDULED DRUGS

ORDER nATE

MEDICATION-DOSAGE- FREQUENCY

ROUTE OF ADMINISTRATION HOURS

I

INITIAL CODE

INITIAL FUU SIGNATURE& TITLE INITIAL FULL SIGNATURE& TITLE INITIAL FULL SIGNATURE & TITLE

;b)(6)-2 :b)(6)-2

. .'

ADDRESSOGRAPHPLATE

Infection Site Code

C) = Left Buttock C) = Left Leg

C) Right Buttock © = Right Leg

0 = Left Deltoid C) = Left Arm

C) = Right Deltoid C) = Right Arm

0 = Abdomen

WARD NO.

(b)(6)-4

SFIGLE DOSE, PRE- OP PRN

&VARIABLE

DOSE ORDERS SEE REVERSE

MEDCOM - 5298

DOD 12510 ACLU-RDI 1263 p.53



MEDICATION- DOSAGE


GIVEN MEDICATION- DOSAGE


GIVEN



ORDER

DATE



1-1 /it

c

jedrum 5- iv p DATE , ht.

-no p rek TIME 1445.

et(1: f eh(bleU DOSE g.

INIT. b)(6) -2

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

DATE

TIME

DOSE

INIT.

MEDCOM - 5299

DOD 12511 ACLU-RDI 1263 p.54

FULL SIGNATURE & TITLE INITIAL FUL2.75),,NATURE & TITLE ;b)(6}2

b)(6)-2

b)(6)-2

1'

FULLMNATURE & TITLE

b)(6)-2

INITIAL

:b)(6)-2

b)(6)-2

bX6}2

'bX6)-2 e)(6)-2

b)(6)-2

ADDRES S GRAPH PLATE bX6)-4

MEDCOM - 5300

NAVMED 655018 (REV. 4-74) SIN 010e-LF-218-5581

MEDICATION ADMINISTRATION RECORD MEDICAL RECORD

SCHEDULED DRUGS MONTH ILI ,9 Y 19 09105 DATES GIVEN

ORDER DATE

MEDICATION-DOSAGE-FREOU ENCY ROUTE OF ADMINISTRATION

HOURS I. Z

11 Z - I' a, •O*1 al, 04 Mei IREMCIIIIIIIIIIIIIIIRIIIIEMO

kf -

1g5 • f

7 Mina

Ir IMMINIVA

-

MRIPAL

- ___IPIIMMI 118 CI IMMEAMMOIREINITO

LRINIMIIII1111111111111=1 ,.. i o

le . 2 AnliMIWillarchvektfo

' f I

FM6* ,

b

_

— Illffil 1, •"

oti Co Li /5" ArNMEIMIrill bX6)-2

; imfannalli zi

3 ,

bX6)-2 •

bX6)-2 •K

141 i

• '11 I 3 C.,_b...._ r Po 1r b

14 i #

ft„-W I, C - Se 4e

Milt Li -....LOLIIMPIN.I.

b::: 0 0 0

• bX6)-2

LUZZ r1 0 -tl'- 1 P'434.5 PO 'T-10 ,. (2s. I, f

0

L.1 I i in, Po 0 1

i .

• 7 0 Pr oo

INITIAL CODE

CD = Left Buttock 0 = Left Leg

(g) = Right Buttock 0 = Right Leg

0 = Left Deltoid (2) = Left Arm

(4) = Right Deltoid = Right Arm

= Abdomen

WARD NO.

PRE-OP PRN &VARIABLE DOSE ORDERS SEE REVERSE

Injection Site Code

DOD 12512 ACLU-RDI 1263 p.55

MEDICATION ADMINISTRATION RECORD (Back) 0105-LF-216-5581

SINGLE ORDERS — PRE-OPERATIVE

MEDICATION-DOSAGE ROUTE OP ADMINISTRATION

GIVEN MEDICATION-DOSAGE GIVEN

DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL

&'P

16/}111( 6617 6 el\e/i10/11 2cr/19 r 51.3 bX6)-2

2115

_6(42.xec (4z5-&_cusird i tt--,0 5-7zi b)(6)-2

&


ORDER DATE

NICIDICATKIN•DOSAGE

ROUTC OP ADMINISTRATION DOSES

2

S.. 1,

GIVEN

511/.,

61.01t0 4 1613 H113

(a3tIOVZ42"1 11440

1 _LI 14iPeruoc -els DATE iltillit1/1

75b ' .\‘131 5‘

ql Li y, __

crev 6

57 . .1

di 5] •/

A

t. (01‘64-c9tAlti

5/4 Di'75 0114 1 '. z. -TIN-9 S PZ3 TIME

(ALJ c' 17.-1k-1 DOSE 2 2. 2. _ 1. /, 1 2 INIT.

DATE

bX6)-2

gimpAraraltimg, . eg rt. 01-1 "1-10 A V Q-V-1° TIME 051/1 1036 153(1 1`33 •V 10 's LL: 11

DOSE jo-ym , st„,, ,,,,,,, c, 5 5. . INIT.

bX6)-2

•

enk C(.1--- _DATE 51-2I ,

'0 .

- ? 2 s po TIME 0 .

e.' S POJ DOSE 2. b)(6)-2

INIT. • -

. . PATE. ,

TIME

DOSE

INIT. .. , .• ..

DATE - . •

TIME

DOSE • 4

INIT. • -• .

DATE . .

TIME . •

• • DOSE

INIT.

DATE

TIME

DOSE

INIT.

.U.S • CPO, 1986-605-009/46155

MEDCOM - 5301

DOD 12513 ACLU-RDI 1263 p.56

MEDICATIONS

ID Olt

LI- 15- Ah-42_

MO, PO 6 4-3 'tip

4'

4

A DD RESSOG RA PR

MEDCOM - 5302

,b)(6)-4

(3

TIM C (HOURS TO BE GIVENI

DATE 1 LABORATORY/DIAGNOSTIC OF TESTS EXAMINATIONS/

ORDER CONSULTATIONS COltfir SENT

0 / I • / t2s Al.11164, AL ) 4L.1. 14.1 .*_■■ •1 6 L

. 11E.Mrl_Welferall '15131MINIM - ► / Gid11MMMani ill P.

4- 2_

DATE ORD.

DATE KNEW

ALLERGIES:

DOD 12514 ACLU-RDI 1263 p.57

f ; ACTIVITY DATE N./ BATH DATE DIET DATE ‘i VITAL. SIGNS FRED 4 SPECIAL NOTES

fr./Bedrest Bed bath NPO Temp A Li.o ';', Dentures

Bathroom Privileges Shower Pulse CA' 1- ( Ilk) Speech impediment

Up in chair 4, 1 Tub 1 11,12 1.1 III Resp h.4.131 L Language barrier

Ambulate Needs assistance (...) 0(4\1 2") Pro sthetic ,..,

B/P r. 0

1,, device

C ommode Other Visual impairment

Needs assistance r Blind

Restricted to unit • Contact lenses

Hospital Privileges ORAL HYGIENE DATE NN 1/ V •& Glasses

Other Self FEEDING DATE FLUIDS Hearing defect

./CLVAA)017 St e Li Needs assistance Self Forced to: Other

Special Needs assistance Restricted to:

Gavage I & 0 CZ3x i-g •

DATE 0 D.

DATE RENEW TREATMENTS/SPECIAL NOTES TIMES

DATE ORD.

DATE RENEW

TREATMENTS/SPECIAL NOTES : TIMES

t

(R

E ) 0 /4-0 6 ftw. 12)0 D 1s bstv. /00(k r 1 .... ),„7„

I (0 - gtiv.; .i, 4-, t. -_,64.... z;? to° 02 0t ,K,-2_0 t

, I A .,

td-- .

., .1 I r .,,,. ,,,-- 1 coi.,-. , ,-,_- kik...)

Cv-4-ELLLA',1 go iE) U6ki:b Th lANINA... kr

(11.iv

c ,..1 isks.55 4vog icklt -...i.:7-spc:citty.1 • - ....1. • •■•••

. 11 \ &7' ■-i-t):30,6, ca. r-t—, 1..e1ivis f''''.4.."--

4 - r ■)), /A) 6 N-= bU:).6 ')Lti (VI) /-4*-- i I .1)."..t.:6(t-,,,#'

1

1 <) 1 1(6 3(", IAA eij_tZ) Sbo ce., PJS QAC Acy:.,i..: -.) LA/40 (7 .( .!1 (I f , )01 0 if\

1`. J

. „,, 0:4.1-ittiv iror AireArt .1TO T

r ....,,Q - - t...---n r' g... - • ''' ' . r

6 L

, ./1 r) —

AO OR ESSOGRAPH 0.1AGNosi . .

..-

AGE HEIGHT WEIGHT

caAAA.U.A. c)f•- c Ex. )

PATIENT CLASSIFICATION

. ....6 f It SIP& I IA NajiA:4 Tthi'w

if pP/SPgCIAL PROCEITLI

14 SI to ) lik tiad,;Af Pitiy-ce,14,44,v, DATE

ON DATE OFF

SI

`,1'::**.-. • ,....1

A • IP;:•. ,„

MEDCOM

FINDINGS:

- 5303 RITES

VSI

RELIGIOUS

PATIENT PROFILE NAVMED 6550/12 (5-80) S/N 0105-LF-206-5560

DOD 12515 ACLU-RDI 1263 p.58

ALLERGIES:

DATE ORD.

TIME DATE LABORATORY/DIAGNOSTIC DATE DATE DATE

MEDICATIONS INCURS TO or TESTS EXAMINATIONS/ RENEW SENT COMP

BE GIVEN) ORDER CONSULTATIONS

i..---....

"VII

---. —77,7;:zr..,..:.....-- ------7r.:-;-Flmm --m • a EIMMIVILUMEMINIMPA ME/

1-111 .11- 7` .1-1. 11-a, jA 12) AilL11 11111 C 3C cc. • 1 b cl 1,1 anIIM111MKTPIIIM.

t3 cdc- 1 PO 1 cog Ea. . 7-- ' a-p, In I. be • . _ A 1 , 1 MI PT wil

. InNAIEMMEEMMM En - Vali ' Milrial. el

• 0 uhet ' -1, . 1et1

IEIIIIII[GI_MVL. IMEMIIIMELVIMMIE leir ' '. _i IS

4 t1 o au,L,„,i 4 6 (o) @ o a VAPNIMPIfflinta . • (41' c,060 MIR" ,.111 4212 -=1,--- ..______

4 cs MUM" •. Ca- i -2.0 Mil WIMP ai-IT '''' 'MI LI) - WM LI 74*:-- , - u.

146 ► L.....•• 'B1 raMIVAII PM In1214 A ins 4 b:z. of 12 00 „,_ ' • A = IM . Ori k Ilb P 0 f3 urriffillil

417_-J__ 3Z . - .._ '0 t WO Mil mmolASO_ 4- ;... uniimmrismi e 4 h2__ MIINIEFIIEIIWTPMIIIIM 0 41 too ` - 13 • IF K 4-,-, L.. X 3 • gwar-To MEI

4 'co itk504 2-10nst\I ();- -11 ° PA114 15R.N A A I • ,b, u 1,101-1) IF S ATt%)

,, ,-.- .-. , ii • WA/

4 iLl -61°Vkk . C'Si) PO &V Pfd if fq -1-(u/not (psbou Po G Li 6 po 41)4

I A If kert_el- 1-2-rtabo ?c, (V.` plao 4 (1 ¢vtQ d - im(/ 0 k-i 'PR_,,,. q, )4 I lon i io rohokm ADDRESSOGRAPH

b)(6) -4

MEDCOM - 5304

DOD 12516

ACLU-RDI 1263 p.59

PATIENT PROFILE NAVMEO 6550112 (5-80) S/N 0105 - 11 - 206 - 5560

ACTIVITY DATE BATH DATE DIET DATE VITAL SIGNS FRED SPECIAL NOTES

Bedrest Bed bath NPO Temp Dentures

:athrOOm Privileges Shower Pulse Speech Impediment

in chair Emu Tub 1 lin 11=MI7DIEMII Language barrier

Am late Needs assistance Prosthetic device

Comm e Other Visual impairment

Needs assi ance Blind

Restricted to nit Contact lenses

Ho pita! PrivIleg

a •

ORAL HYGIENE • ATE 1\1 kJ ''//

1-4, Glasses

- _ Self FEEDING DATE FLUIDS Hearing defect

eeds assistance Self Forced to: Other rr, 1 Special Needs assistance Restricted to:

I Gavage I & 0 (DS

DATE ORD,

DATE RENEW

TREATM TS/SPECIAL NOTES TIMES DATE 0 D.

DATE RENEW

TREATMENTS/SPECIAL NOTES TIMES

4D /1 3 i #X €A,,L..e., i;L7

fj....cAlve .

,- /.. P-1- - fZ-bM PVL LE Col &A p35 4 ' I N 1.013 E.: ( aim 14.5 i, - -TR

Lfh tO 1..., , r.

‘,..11

t.....) -.NT.

witniii now( MM. /1 0 < 2 _e ', a

b)(6)-2

) -A A DORESSOGRAPH DIAGNOSIS

• -- 11. 1,-..tS OCI--kf

(9

AGE

b)(6)-4 PATIENT CLASS IC ATION

•

OP/SPECIAL PROCEDURES

47/1 V I tA N.\ ;..\t.. \ Ot 13- CC:tt'''' ).

‘'N q't)C..) , \ V ''')

'..-

DATE ON

DATE OFF

SI

MEDCOM

FINDINGS:

- 53n5

VSI

RELIGIOUS RITES

DOD 12517 ACLU-RDI 1263 p.60

ALLERGIES:

DATE ORD.

IFIDATE ENEW.

MEDICATIONS

TIME (HOURS TO

BE GIVEN)

DATE OF

ORDER

LABORATORY/DIAGNOSTIC TESTS EXAMINATIONS/

CONSULTATIONS

DATE

SENT

I

DATE

COMP

Lib hk0 M 30 c.c. TO 'BID 09 - 2.1 1/1:::eild-? ,..1mrc.6 a ._de,, ,ey,„„ LOG SURFAK r.AP P 0 CO 0900 ,a,t-kle ̀Av ',LI, _- A Lqi 5 0 G. Tp ;LLhtags tAt_q eL3L1LZ1 - 61:t

4̀hci, 1.114-t■MA 5 web P47 1 b se_Noz-z) OH- 14 -20 4 117- - 1 ̀600 PO -rib 06-11-ZZ 9 it-) At mp( 20rri5P 0 'D13'.) 09 - 2.1 4/ 21 e.S(014 12.5 n,01) 1)0 Q 14y 090 0

4 122 MV I t Trt8 PO Q A V Olo 0

V14-1( in 1 Sol XIII ay 3 t b./01( lac, a

yir PT Sou "I rn4-to i e rt -eh,--. rn ✓ ..;(1/ a? c;i6

V.Y1 — ryt. c4 eXi/ 2 l 2-! Ikt- (00 t4 r) i / t

•

..,

411c.6 WO 4 2-10 frf,01 Q 1 - q ° PRN 4 1 1 ',I 11E11TV:312N I 15- 50 re% l'O Q b° PR N 4 114 -1\11..g0 L (0 0,4 0 0 u° ...TR N 4 liu -PEP-scoter t -ii - raS PO (Ve ?SW

4114 TIAE_NERGA si DS rof.L6 11011V 0 21° PRO ADORESSOGRAPH

;b)(6)-4

MEDCOM - 5306

DOD 12518 ACLU-RDI 1263 p.61

PATIENT PROFILE NAVMED 6550/12 (540) S/N 0105 -LF-206-S560

ACTIVITY DATE V OATH DATE DIET DATE */ VITAL SIGNS FRED si SPECIAL NOTES

Bedrest Bed both NPO Temp Dentures

Bathroom Privileges Shower RE.. G 41114 Pulse 3 .3 Speech impediment

'..4 Up i.chalr 4i(I4 Tub Rasp Language barrier

Ambulate Needs assistance B/P Proithetle device

Commode Other ti tv Visual Impairment

•its Needs assistance 11h4 Blind

Restricted to unit Contact lenses

Hospital Privileges ORAL HYGIENE DATE D l

Other Self FEEDING DATE FLUIDS Hearing d fact

x1•40)3 3et. 4114 Needs assistance Self Forced to Other

Special Needs assistance Restricted to:

Gevags I & 0 45 D ATA ORD.

DATE RENEW NESTS/SPECIAL NOTES TIMES

DATE ORD.

DATE TREATMENTS/SPECIAL NOTES

RENEW TIM ES

4

W-4 b in.EsstaCT -r0 tistto% 1- CALM E-S .

4 - R• 2.11.. LE

0 Rigo -1)R. :13)(6)-2

ADDRESSOGRAPH bIAGNOSIS

.(t1 YE.PAORfN L F X 6 'TM -FIB FX

AGE HEIGHT WEIGHT

PATIENT CLASSIFICATION (b)(6) -4

OP/SPECIAL PROCEDURES

51P NimuNG 01 TF-INUK MA ROD -nsIA )42-

DATE ON

DATE OFF

SI

FINDINGS. VEI

MEDCOM - 5307 RELIGIOUS

RITES

DOD 12519

ACLU-RDI 1263 p.62

MEDICATION ADMINISTRATION RECCRD MEDICALRECORD

SCHEDULED DRUGS A DATES

MONTH 11A( -4,9""°202) GIV N

HOURS MEDICATION- DOSAGE- FREQUENCY


NAVMED 6550/8 (REV. 9-74) SIN 0 •216-5581

NiVAVAIME GgrfAl rrimm b)("2

b)(6)-2

b)(6)-2

b)(6)-2

0 DER ATE

. 7 a S766 • -)0 ► Mr1111 i‘The

Ce...x 2 0,19 Po 7:2no C4160

7, I 00

2_1 r o -0.s- 5 Oq GO)

yh^ A

:b)(6)-2 INMAL

b)(6)-2 I INITIAL b)(6)-2

FULL 'SIGNATURE &TTTLE b)(6)-2

INITIAL b)(6)-2

b)(6)-2

,b 6)-

FULL SIGNATURE & TITLE FULL SIGNATURE & 1TTLE

INITIAL CODE

ADDRESSOGRAPHPLATE

injection SiteCode

0 = Left Buttock.. 0 Left Leg

02 o Right Buttock, 0 = Right Leg

(a'=....._Left Deltoid 0 = Left Arm

0 = Right Deltoid C Right Arm

0 = Abdomen

WARD NO.

:bX6)-4

SPIGLE DOSE. PRE- OP PRN

& VARIABLE


MEDCOM - 5308

DOD 12520 ACLU-RDI 1263 p.63

MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581


MEDICATION- DOSAGE


GIVEN MEDICATION-,thsAGE


GIVEN


I •

•

L


ORDER DATE



1/1 '?P /- Z DATE IMMIITEVIIIIMIZEMITIEFEEMPEPARTZ q ,t,,. 7,0 e• 1 ° TIME Iff MEErilIMOMMEMINirS118=El 0 7°A A) 7 A I A) DOSE 1,- 11021AMIBM 1, Fs t in -7, ,i, ,)-- 7 2

INIT. b)(6)-2

/11 NtnAr:5 0,1 1 \l/ DATE

7-71-1 ?). Lt° '1"Z. Ni TIME

DOSE •

INIT.

17// CI Ty /e .t, 0 1 2-0 f,,,, DATE 40.5 0,1 Ili

' - P r) a9 0 7qZ/\) TIME tEll' j4T°12‘ DOSE IP (05-70 a

INIT. (b)(6)-2

9//q /116147 .-?0,c, DATE

rj 7,0 (/ el .p-k A) TIME DOSE

INIT.

120 Li pile, dry i DATE Ifil.5 Aq24. '

ZS' 1'79 0 TIME 11i$ 2-3{6 .

' Rk) DOSE 2,3 2 ...) 6)(6)-2

INIT.

CO Al eo L./ z ... 1 0 A c, DATE IP M2\ :Or 4tk Alt kV% qh15 42A-04 VI 74 413) :7:-.:v al -LI ° ") TIME 0)."161 VO 104). iv) 0 fo4 ooter)32- 0 4

...rh,N) ?/:1 i N DOSE I 0 nt4 5 5 ? < (b)(6)-2

..)ktotii\ A 9`k 6-1-1 fT4 509 z3nr Nal d ; C serial-eii INIT.

DATE

TIME

DOSE

INIT.

MEDCOM - 5309

DOD 12521

ACLU-RDI 1263 p.64

1.1OLD IF' SEDATE D

ORDER

(IPATE ROUTE OF ADMINISTRATION

\iktibiA 5frrviPO "Tib


22.

NAVMED 6550/8 (REV. 4-74)SIN .--216-5581

MEDICAL RECORD

MEDICATION ADMINISTRATION RECORD

SCHEDULED DRUGS

MONTH APR) L t432.._00 3 DATESGIVEN

412-1-• NVITAIN %Mfr....16,M 11 D Oh og 11 040 )

b)(6)-2 '-'<'- .<

...■- (b)(6)-2

2100

14122— !X.-W.0( 2Orry.c0b Bin oc)00 -< -4. .. .....›<.... am -im„.....„4 b)(6)-2

4 2-1-- NI I " --IN• ;.. PO ik D') 00 411.■ MR.% k 422— F • • ...• cP• lb ► " • 9tro I -'11111*-4 111'" ►

I-- g- 9 e to - - i 0 . 1... ,a) X >e. ■ . rice;

I NMAL CODE

INITIAL FULL SIGNATURE & Trfft INITIAL FULL SIGNATURE & TITLE INITIAL Fy ly9GNATURElli TITLE

b)(6)-2 b)(6)-2 b)(6)-2 (b)(6)-2

l

ail

( )(6)-2 (b)(6)-2

/ •oe

(b)(6)-2

momme...--

II nIb76)p-Tno.POPI-1 PI ATF

Injection Site Code

Left Buttock 0 Leh Leg

Right Buttock 0 = Right Leg

Left Deltoid C) = left Arm

Right Deltoid 0 = Right Arm

0 = Abdomen

I WARD NO.

SINGLE DOSE.

PRE- OP PRN

&VARIABLE


MEDCOM - 5310

DOD 12522 ACLU-RDI 1263 p.65

MEDICATION ADMINISTRATION RECORD (Back) 5/N 0105-LF-216-5581


MEDICATION-DOSAGE ROUTE a: ADMINISTRATION

GIVEN 1 I MEDICATION-DOSAGE

ROUTE OF ADMINISTRATION.

GIVEN

DATE THE ITIMA. DATE TIME INITIAL

1 • NIT IC N'' K I VI 0 L4 5 ; b :b)(6)-2

„„Iii =Va.— , .

A b)(6)-2

If - z. "I.A.MiiiIIIIIM

i imi o.-


ORDER DATE



.

ff-f--,miarwairmulitgoingrt tp3 r. d 1 3 TIME di 14 plii 55 ig 421, vi a.

p c-,.. DOSE r ir -Tr- -21 "t.-

INIT. b)(6)-2

71/ L( I k kJ, ella 1 DATE 21

TIME eff15 rttl a ti_ p g

V

DOSE

INIT.

/) it -7- (e ISL! i DATE

p 0 TIME 4,„, 3 DOSE

INIT.

lilif (Ylon? DATE

3ncn p 0 TIME .

- io ir‘si

II A– 1

DOSE I

INIT. I • Pi ,r3 e n c tp 1 r L DATE

/ 25 nig 0 TIME

.,,2i Li A,.. ,oRA/ DOSE

INIT.

I 1 1 01 6. 61 It cO, -) Q, 7) c DATE lible

-r i) a 3 -If A) TIME PIP

Ll

T? .

-lain PIN DOSE 16., id 6,, r t C ij 1 f' ,5ettifdPNIT. :b)(6)-2

DATE

TIME

DOSE

INIT.

1

MEDCOM - 531 1

DOD 12523 ACLU-RDI 1263 p.66

a

NAVMED 6550/ (REV. 4-74) SN -216-5581


SCHEDULED DRUGS MONTH teic>0 s GDATnEENS

ORDER DATE


ROUTE OF ADMINISTRATION HOURS 1 i 1

. 07-D z:z. -7... --3 4 fluyinedactt -amte4h0,,,,1901 16 t)t.p 60

b)(6)-2 kb)(6)-2 —

- _

_

As b)(6)-2

JLt/i. dr_40 )(6)-2

MIN lig [WM

4 17 4111111MMIMINIME • IMil

IIIRMIC4_ IMINIMICIIIIIMMIgk. (b)(6)-2

14 ri ■ . .1111P1MiliTIMPLIMMINE1 a _ • ALI. _... . )(6)-' Ems li IM MI IIE 0 a • a 4 ' MARTMIM ,11112111MINMIMMINIENNIM MIMS= b)(6)-2 . Elf‘: •

. Mb

b)(6)- I 1 b iltl-b

11 cob

4 ... Gm. _ A cum b)(6)-2

INITIAL CODE

INITIAL j FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE

(b)(6)-2 1/1"A l

r—la

(b)(6)-2 (b)(6)-2 (b)(6)-2 b)(6)-2 (b)(6)-2

b)(6)-2 (b)(6)-2

,b)(6)-2

ri_41 ,b)(6)-2

JL Ot741.'-' b)(6)-2 EMI (b)(6)-2

b)(6)-2 ,

idkVIL 4

(b)(6 ) -2 b)(6)-2 .ir 0 ADDRESSOGRAPH PLATE I

Injection Site Code WARD NO.

b)(6)-4 CT) .. Lett BUSIOCK (1) = Len Leg

® = Right Buttock 0 = Right Leg SINGLE DOSE.

0 = Left Deltoid C) = Left Ami PRE- OP PRN

0 = Right Deltoid 0 = Right Arm & VARIABLE

C) = Abdomen SEE REVERSE

MEDCOM - 5312

DOD 12524 ACLU-RDI 1263 p.67

GIVEN MEDICATION- DOSAGE


MEDICATION- DOSAGE

ROUTE OF ADMINISTRATION INITIAL DATE TIME TIME INITIAL DATE

GIVEN

. ILL "ta () Valit ory, 10in

d Vet 1, Prb-5-m

NitrK loo recIP/ Ain- K 1.0 70


catane) ei>11r co Liax sitpf Pik M.A4 REP EAT TO ri1o12.11_ov,1 PR. eJ



ORDER DATE



4 14 idtcyvkg, 11,1,.) DATE

cPS—akk kW TIME 04 6 Tie0 DOSE

INIT.

11211111 DATE MEM fill IDESIMIMENIERVIIMEM ..2't-- IN ,... eR .Willito TIME WAIIMOSO 012-EMU DS, ,, A. a:: ;:_ IA A. 2,° :, . or = CeuX 7

(r) ee4,1 DOSE ail 7.- M 2 --ir .2.. --6..„ A 2._ EM 0._ 2_ e__. O ill 6.

INIT. b)( • )-2

4 gurvk DATE V

tp. orLA t-)6 TIME )1A Q 4 —p lezi,..) DOSE 44114,

INIT. 'b)(6)-2

4 111 M31111.1.1 DATE Tama 31) .e. Po TIME B igif 0/7•

INIT. b)(6)-2

DATE varmiummi mrgagroom ORMUZ HAMM TIME foSITEM z355

g DOSE 5re M SO ,. INIT.

bX Y 11111 I II 4 .6 DATE BEINIIMMIRMIE11112,1

Eliriab EiMEMPSEEIMERIMIEMEM EPRIEMFAIMIE 4, 1124

VI • a IMMEPOPIN TIME

MffirMINI DOSE ortmo) efE `, Ilnin er 1 mirarm

, ....li . INIT. b56)-2

DATE ,

TIME

DOSE

INIT.

MEDCOM - 5313

DOD 12525 ACLU-RDI 1263 p.68

MEDICATION ADMINISTRATION RECORD

MONTH coo3 DATES

GIVEN

lc

de. 1 • :b)(6)-2

V


ROUTE OF ADMINISTRATION HOURS

NpA x ()GOO '&"n

14- A b)(6)-2

b)(6)-2

FULL SIGNATURE &TTTLE

b)(6)-2

MIME b)(6)-2 I

MEINUI=.1111111

FULL SIGNATURE & TITLE b)(6)-2

INITIAL

b)(6)-2

b)(6)-2 FULL SIGNATURE & TITLE INITIAL

b)(6)-2 b)(6)-2

b)(6)-2

ADDRESSOGRAPH PLATE

Injection Site Code

0 = Left Buttock C) = Left Leg

0 = Right Buttock © = Right Leg

0 = Left Deltoid 0 = Left Arm

= Right DeltoidBQ = Right Arm

0 = Abdomen

WARD NO.

-9=nEtz::1--- _,, ‘.... SPIGLE DOSE.

PRE- OP PRN &VARIABLE


MEDCOM - 5314

NAVMED 6550/8 (REV. 4-74)5/N L -216-5581

MEDICAL RECORD

SCHEDULED DRUGS

II/IEIBIIIIIIEMIMMIE!44V'ZFMEMfgv MITIVIWIPANI*Wnier Wit-

b)(6)-2

ORDER ATE

4 14

b)(6)-2

b)(6)-2

1.1.6MIIMILIMP3511111 MEM W:41101

(b)(6)-2

iO0

0100

lgc0

b)(6)-2

.)< 1(b)(6)-2

INITIAL CODE

DOD 12526 ACLU-RDI 1263 p.69

GIVEN GIVEN


MEDICATION- DOSAGE


MEDICATION- DOSAGE


14\11- 1et0 _CDO.[N-N-xei;AN tOnK1

ORDER MEDICATION-DOSAGE FREQUENCY

DATE ROUTE OF ADMINISTRATION

WirgeMili—g4M11111

IL:

DOSES GIVEN •

riliNAMMIVINIZIELIFIMINIZEI11111111111 MIMMEETEMENdegiMMUM mmamorsoloammunmero

414.

DATE

TIME



MIIP MIN DATE 7418E2211111112/200.10;91012111111111111•11 TIME FENNEIMMEITMENIIEMIIIIII

MM DOSE EIDIMMIElla- FIE111801119111111141■■■ b)(6) 2

INIT. MENEM Lvtundlosn DATE

tO4 R Poi' TIME

al to Cito

A5C-

cP4 t) Pb orb

MEDCOM - 5315

MEDICATION ADMINISTRATIONRECORD (Back) S/N 0105-LF-216-5581

DOSE

DOD 12527 ACLU-RDI 1263 p.70

11 4111e; (b)(6)-4

..NG FLOW SHEET 6550/l 2/Tenip Form

Date: !// /_ ct

Time 07

08 09

10

200

180

11111111111111.111111111111111111111M1111111111111111•111111111111111111•11111111111111111111•IMINIMIIMMINI 1

I MIE111111111111111111011111111111111111111111111111 11 I 160

.111111101111111.1111.111111111111111111111111111111111111111111111•111111111111111111 11111111111111111111111110MMIIIIIIIMIMIMIREIMIIIIIIIIIME11111111111111111.1111111M1111 I 1111111111111111111111111MMININA111111111111•11111111111111111111MINIIMMINIMINIMBEINIIIIIIII 1111111111111M1111111111111111111•1111111=1111111111111111111111111111111111111111111111111111M1111111111111111•11111 11111111111101111111111111111111111111=111111111111111111111111M1111111MIMINIMIIIMMIIIIIIIIIIIIIIIN 11111MAIIIIIIIIIIIIMEN11111•111111111111111111111111111111111•11111111.1111111111111111111111111111111111•11111111111 INIIMIIIIIIIIIIIIMIE1111111111111111111111111111MMIIMMENIMINIIIIIIENI 1111•111h111111111 1111111111•11111111111111111111111111111111M11111111111111111•1111111111111MIUNIIIIIIIIIIIIIIIMMIIIIII

IM11111•11=d10111 \ MIMI nom ismommuriammurimmumInmu =num

CUFF

A

-

L

—I-

*

03

11111111110111=RIMIIIIIIIMMIEMI Milli 11111111111111111■ ■■11■11■11■■■■1111111111

EIMIEMBIEDIREI 16 MI 18 19 20 ILIIIIENIEMIES 01 02 04 05 06

140

120

100

80

60

40

RR. TEMP SA02

"

MAP

02 Mode

D R

O

MEDCOM - 5316

:ZsZ

le O

W

•

ACLU-RDI 1263 p.71

NURSING FLOW SHEET MEDTFtEFAC 6550/l2/Temp Eben

20

iName:

Time 07 08 09 10 11 12 23 24 01 02 03 04 105 06

Date:

13 14 16 17 15 18 19 21 22

CUFF

AL

•

200

180

160

140

120

Mee 1 ri

60

40

100

80

RR TEMP SAO2 MAP 02 Mode

R _i

O

E

ft I

• ZSZ

a •

ACLU-RDI 1263 p.72

Time

200

180

160

, 140

120

100

60

08 09 10 . 1111 13 14 - 15 en MEM 01 0203 04 05 06

11111111111111111111111111111111111111

1111111111111111111111111111111111111111111111N

1111111111111MIININNIIIIIIMINNINNINIIMINININIIIIIIINNNIIIIIIIIIIIIIIINIIMINII I NM 1111111111111111111•111EIMMINIMMINNIIIIIIIMIIIIIIIIMMIIIIIIIIIN 1 111111•1111111111NNE1111111111 1111111111ENNINE111101111111111111111111111111111111111MININ1111111111111111111111111111111111NIMENHINIII

40

Ira 1 •• • ,

RR TEMP SAO2 MAP' 02 Mode

MEDCOM - 5318

ICSZ

le O

W

FP

L tL

F

• HP.

ACLU-RDI 1263 p.73

0 413 cn cc a. 1 •

• ( -2 I-- • '4

0 c3- 6,,

cr

■ O

■

) •

E z

0)

C7) lf)

2 0

• 0

Lu

DOD 12531 ACLU-RDI 1263 p.74

4

O

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k71 I g

erel

M l!

MP-

Zi,

• t I- • 0 Cl2

Ctl. CC

O • •

•••■.....■., )1. s <

O C.7 I

0 X

9 - 0

DOD 12532 ACLU-RDI 1263 p.75

toys

II•1

M t_kl

E

IHDI:4M IN3S3I1c1

IHDIRM SCIOIAMIr1

mail 21110H Pr.LN35311c1

21f1OH PZ %IMAMId

• Irian° mon PZ .LNEISHIld

Lfld.Lf10 21110H PZ S1101A3Ic1

ZO 190

co

£0 1 Z 61

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•

I! I I I_ I - -I I .1 "_l_ • I I I I I I

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I I I I - I I I •

I.. II

II .

s 1 Ii

II ...

0Z EZ ZZ ' SI I0 LI 91 SI 171 EI Z 1 II 0 1 60 801 LO

111-1 • dg

I

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044 ATIOd

8 Z1 OZ I Z 61 II 'ZZ OZ 01 El LI ZO EZ I0 91 1V10.1. . 01 LO 80 co 60 PO E0 SI 190

ACLU-RDI 1263 p.76

bate] , Olt • `11--

wet b)(6)-4

Nare: . . pmiNG 511 MEDIREEAC• i2framp Farm

180

Time 07'

200

140

160 .

11•11111••111111 111111111•1•1111111•1 MIN 11111=1111 111111•111111111111•11111111•11MMIEM IIMM■ I WM MAI I OM i 1111111111111111•011

HIM 111 IINIIIIIIIIIIIIEIIIIIIIIII IIIIMENINEMEMEM Mil NM min

16 1 18 . 19

••111•111111111.10111111•

20 21 22 23 24 01 02 03 04 05 06

40

- it

111 WR FM um

•

MEDCOM -5322

• r •

RR TEMP

SAO2 MAP' 02 Mode

L

F

• HR

P R

rio

E

v£9Z

le C

I %II

ACLU-RDI 1263 p.77

IHDIHRt ..1.143011d

IHDEM

Szt

• ZZ 1Z OZ

1.)1 C191

- £1 to 1 Z1 , 11 01' 60 80

.1.1111•1111110H 6Z ..1143MM

indwi unoli tz lil

wti

dO CI, sz 1.3

61 sO 1$1.1.0.1. - 1 60 01 EI . V I 91 81 £0 tO LI SI' 190 LO EZ , Z1 , 1I co _ . V0 , bZ

VZ 61 CO 90 1Z 10 to SO EZ ZZ _ 91 SI • Sr _ LI

. . • oRtivegeonemialOPMET2=Kizzezipi*,

SI "tv

ItcL1110 liflOH 17Z INaSalId

.111c1.111011f1OH 6ZS1101A311c1

•• 2

(PI /11 8 , HdA w Od 2

LO 1■11

.1.11(1.1110/llicINI

•EONTS

ACLU-RDI 1263 p.78

O

-CA—.co_ O 0 CP■

.73

O

B

f- F2

1 00111- 101110:ju

II III • II II ■

111: II il III II 2 II IN III

1-1-1-:9 1 I , rno , -MEM Min' 1

G^f .y 0 v <

MEDCOM - 5324

DOD 12536 ACLU-RDI 1263 p.79

Ke D

125

3

.111&■1111110H bZ .1.1%6Salid

IfIdNI 11110H VZ SflOTAMId

INgSnd IfId1110 )1110H vz Diasua

.LHDIRM SflOTARIld

1f1aino11110H VZ SflOIAMId

e Oil I41 • NEI

101 90 170 £0 ZO 10 bZ EZ ZZ I Z OZ 61 11/1.01 81 LI 91 • Si bI Et Z1 11 01 60 80 LO

don P-10.3

in°

- II

0 1 . 60

SO

EldAI Od

NI

90 ISO

170

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ZO

10

EZ

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TZ

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61 IY.L01

81

LI

91

Si

bi

El

JA11,1110/IflaNI

SOWN

A I

a BI• 1

01 M

I M1:

PA

43. .12 h ' Q07

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owl!

trA

b 001

9•) g

bog 9),

I 70 cab

'&10 or! A /

g ' hl oh -set

?It c / < N9IS 'oalm 17;'

ACLU-RDI 1263 p.80

DOD 12538

O

do• c4 CL — 0. N1e,,,,V ise

co CV •■•

LL 1 • 1

■■■■■•■■■■•■•■••,■

•

1,0

r

02 0 0 0 Go 10 et

8 (1)

A:I

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W1:

EM

rj

0 r

0 ,==t tag.-

&2,

ACLU-RDI 1263 p.81

. •

FREQ. VI SIGNS

TIME BP • HR RR TEMP SAO2.

INPUT/OUTPUT

IN m PO 0 IVPB O

cn CA)

07 08 09 10 12 13 • 14 15 16 1 .7 18 . TOTAL- 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL

11 :-OVY Nomommom I

07 08 09 10 11 12 13 14 15 16 17 18 TOTAL

mum 111119 1' INII mum= 1 19 20 21 22 23 24 01 02 03 04 05 1

,0 mt_mmeimmnam:m■ I

• C

SZ le

CI o

R

PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT

PREVIOUS WEIGHT

PRESENT/4HOUR INPUT PRESENT 24 HOUR OUTPUT

PRESENT WEIGHT

ACLU-RDI 1263 p.82

j

9 00 0

0

0

0

7i1 A

1 01•

181:

140,

4::

VI 0

0 0

0 O

N 0

0

N

N

N N

N

O N

0I

00

N

VD

of •••

•

. 0 sr; •tr N 0 0 0

CO V)

(=> 00

DOD 12540 ACLU-RDI 1263 p.83

1 1

-

g 1 rn B o -

-cn —

07 08 09 10 11 12 13

.,•

14 15 16 - 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL

OUT FOLEY UOP

BM

07 08 09 10 r 11 12 tab

13 14 15 116 17 18 D• 510

TOTAL 19 20 21 22 23 24 01 02 03 05 06 TOTAL

PREVIOUS 24 HOUR INPUT

PRESENT.24HOUR INPUT

PREVIOUS 24 HOUR OUTPUT

PRESENT 24 HOUR OUTPUT,

PREVIOUS WEIGHT

PRESENT WEIGHT

FREI); VI

SIGNS

TIME BP • HR RR TEMP SA02.

Notes:

INPUT/OUTPUT

ACLU-RDI 1263 p.84

m ME

ME MEM m •

MEM MEMMEM MEM II EN MINIMMEM UM MEM • M ME

NURSING SHEET tabrIkEFAC.6550112fienp Forrn

Date; • 0350

0 Time 06 03 04 05 21 7 19 20 18 22 4 15

60

40

9 10 16 1 23 24 01 02

L

V

4

•1r

1'

100

80

V

V

441•41■■■•■•

RR TEMP MIIMMMMIIMMMMIMMOMMI

MMIMMIIIIMIMMUR MIM . M MUM 1=1111MIMMI ENE ABM III IIIII ■ IIIMMIMMIMIMMIMIMMIMI =MEM

MO= MEM=

11111=IM MOM.=M11.11 MI IMI= 11111111====== MEM MEM EMI=

P-11,

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M E DCOM - 5330

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DOD 12546 ACLU-RDI 1263 p.89

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PREVIOUS WEIGHT

PRESENT WEIGHT


PRES INT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT

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TIME BP HR

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19 20 21 22 23 24 01 02 03 04 05 06 TOTAL

ACLU-RDI 1263 p.90

aclu-rdi 1263 p

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