C) C co4
0 CD
c
/3
I T
otal
DR
AIN
STOO
L [N
GT
U
RIN
E
OU
TP
UT
T
otal P
O
NG
T
IV
PB
IVF
INT
AK
E
MA
P
So
urc
e
Fi02
ISa
02
IRR
IH
R
ITEM
P
INB
P
A-Lin
e
VIT
AL
S
06
06
06
07
07
1(0'3 [%.111621
07
W
08
08
08 0
9
09
09
10
10
10
11
11
11 r1
2
12
12 13
13
13
14
14
14
15
15
15
g
16 r 16
16 17
17
17
Total
Tot al
18
18
18 1
9
19
19
20
20
'N., 2.
4 i;s:
1.1 v.
97,6
20
21
21
21
950
22
22
22
23
123
p3
-7
00
00
00
01
Loi
1-07
02
02
02—
03
03
lOT 70-14 ,1
04
1-0
4
O c.),
05
nAcr-Ar•rAnn IQAAI
O 03
. I 1
DOD-029830
ACLU-RDI 1637 p.1
PREPARED BY (Signature & Fidel
DEPARTMENTISERVICE/CLINIC t5b, DATE
PATIENT'S IDENTIFICATION /for typed or written entries give: first, middle; grade; date; hospital or medical facility)
tAi
[11 HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
111 DIAGNOSTIC STUDIES
❑ TREATMENT
❑ FLOW CHART
❑ OTHER apead
Name — last,
DA FORM 4700, MAY 78
MEDICAL RECORD-SUPPLEMENTAL MEDI, - ,or use of this form, see Ali 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET QA APPR 08MAR89
INITIAL IFT SSESSMENT -,, '---,
N E U R 0
i Time: Cp .( Initals: Time: /960 Initals:11111111 Pupils 3mm P&12-R1---
_...,0_2_ 1 00(3.19- -c)1:>\\ (..A.3 II II _.-I__ 'ft AI a* aka • •
- SS y-)t. -eck) — 0 CP
4CdC Alec, 01-- ('iieelei X 3
g0/77/91eo-15. _f0//6v✓-.4
Sensorium
LOC / GCS
A/S4 C A R D I A C
Cardiac Rhythm
PRI: / QRS: Pulse Strength • 4_ - j • I i ' .
0 th re._.‘ t -<- .) 3^c.,
ek in&VC1
-i Z 4//5?_.6 0.// gxf,e07/1--& Cap Refil / JVD t'4,4 re//// 43 see Edema
Chest Pain r , ass., kiLab eheSt V Se_,
CT) -11/1 0. Ai' (7) In01--esi P --k-Ilf-li-e, G)Mnd
Pa etzi- £4/
R' E S P
!Respiratory Pattern
Breath Sounds
Secretions
Cough
S K I N
Color 1/∎ V.L. ?Or' f\OCfi-
141--1
IG..)_______a_kaaeailcr
(p 5/5ILInc±i_on
EUT.__ LA 301 A yid i---- clurn Ahrinal 714 rete e-
a• 2M --CV
Integrity Backside
I V
Access Devices
Location 0 SA o7C ii-77‘17c5r) Condition
G I
Abdomen 344' 1 ncrri-eindeP CO 'in a l I 4 c.,y,coccirctr*S
Soc/- 217 0.-- gor--)77054eb/e .// 41 'a. ti
Bowe] Sounds Stoma/Ostomy a) Irl6i--fd
G LJ
Device U-6((k N.A...__O MI _
T-Ns. ,,
#4 ---e2r-i41 A f/ Jar C/ear- ///
i/7‘4,-- z/rir, (-- Color / Clarity
USAPPC V2 DO
MEDCOM - 16442
DOD-029831 ACLU-RDI 1637 p.2
C L.)
:ew
eN
Wel
led
ro
sp.
Tot al
[DR
AIN
I S
TO
OL
ING
T URINE O
UT
PU
T
Total
PO
I NG
T
I IVP
B
I IVF
_
[ INT
AK
E
OA
P
Source
Fi0
2
ISa
02
IRR EHR
' TE
MP
'N
BP
Ik
Lin
e
VIT
AL
S
th°2' 4 06
i-c-0 41a/
06 roT, w 07
07
'1, 08 t 08 08
09
09
09
10
10
(02
rTA
11
11
11
12 Z 12
12
13
13
13
14
14
s
71
-
15
15
I 15
16
16
16
17
17
17
Tot al
Tot a I
18
18 19
19
19
20
20
21
21
21
--g
22
22
22
23
23
23
00
00
00
01
01
01
02
02
02
. F
03
03
FE-
04'
04
04
05
.
05
,
05
... R •1- r, I,
r 1
DOD-029832 ACLU-RDI 1637 p.3
,.:AL RECORD-SUPPLEMENTAL MEC ..,ATA For use of th.._..orm, see AR 40-66; the proponent agency is the Office -. he Surgeon General.
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET OTSG APPROVED (Date)
QA APPR 08MAR8
INITIAL IF ASSESSMENT N
E U
• R 0
ime: )fps Initals: -,-) (c.t) - 2 Time: 2V-00 Initals: (6, - Z ecrlet Pupils /8-44//iti
A- 9-61 )6 3 Sensorium Ads 0 ,Y3 LOC / GCS /, I ,..i_ i ,- tdcaa.-.1. / A.,...-- 0 ' , i,
. ... --'
e:
C A R D I A C 1
Cardiac Rhythm t PRI: / QRS: Pulse Strength 4- 3 .f.ra, 0 .. I . ) 1 ,..0V,,,u_
4 3 .4.e.e...4 / 0. o'll 6 +.3, W5". X // eiece.,-,:te's.
gi, rees / e 3 see...- Cap Refil / JVD Edema A.)o-vt_P-
A)a-vLe., Chest Pain
R E
S P
Respiratory Pattern / 4•1,00 /2 a 9' .oid pg___
—0
Breath Sounds - / c4-4- 1 , / i
a-y.t...e._
Vo-vt-e._
Secretions Cough
S K I N
Color 1)02444 4...a /7 4.-e—...C_
it) Z &e-- •
/00-4--C--
A/OK-ma/ jra Aeef. iii &67i" W-moirp 4 to 4/, Integrity
Backside
I V
Access Devices Pf6 /0/24A. 6,)/EC Location
/ • i-rif ae--
Condition a s ./ - 4 j ; - -
---, -- _r at') . A ke 7 -.2,-) Or' _ls 1 r, I I trez-6,
G I
Abdomen :..,/,/ , , 40, 4 z /. 4 . %,- 1
I / .1 ..d . .
l-iti
soft- "iofi .,44-i-e.,46d0,Z Bowel Sounds J
Stoma/Ostomy 0
G Device . ..'%,,_. g-s/ 1/ . / 'I
/, 9 MI ffd la Irl /a/A 740 vr /Ad
U Color / Clarity
____ _ I Irnntinuo nn reversPI
DEPARTMENT/SERVI E/CrC
ICU3, PATIENT IDENTIFICATION IFor t n entries give: Name —last, first, middle; grade; date; hospital or medical facility)
DATE
❑ FLOW CHART
❑ OTHER (Specify)
❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
DA FORM 4700, MAY 78 USA PPC V2.00
MEDCOM - 16444
DOD-029833 ACLU-RDI 1637 p.4
I Tot al
IDR
AIN
IS
TOO
L N
GT
R P
LI T1
IPO
INGT
[
IIVP
B
IV
F
GL
I IN
TA
KE
]
IMA
P
Source
Fi02
[SaO
2
[RR
H
R
[TEM
P IN
BP
IA
-Line
I V
ITA
LS
06
3o
06
06
]
07
\A ()
07
07
08
Jo 08
08
09
3o 09
09
10 164
10
10
11
30
11
11
,u.-b
0
12
4),o-
Vt.t
0 12
ld ok --to
c'
qZ1 rz/a
12 13
13
13
8
14 0
14
14
15
30
15
15
16 O
16
16
17 cs
17
17
\14
,Total
■_./ 18
118
19
19
20
20
20
21
21
21
22
22
22
23
23
23
00
00
00
01
01
Lo
t
02
02
02
-4' 03
03]
103
s. 04
04
04
0 a' 7
-
-I
g at
t
CD
C
DOD-029834
ACLU-RDI 1637 p.5
1-e6P rJs
RECORD -SUPPLEMENTAL MEL DATA
For use of form, see AR 40-66; the proponent agency is the Office......fhe Surgeon General.
REPORT TITLE
INTENSIVE CARE NURSING ',V SHEET
INITIAL SHIFT ASSESSMENT
OTSG APPROVED /Date/
QA APPR 08MAR8
Time: Pupils
Sensorium
LOC / GCS
Initals:
C A
R D I
A
C
Cardiac Rhythm _ PRI: / QRS:
Pulse Strength
Cap Refil / JVD Edema
Chest Pain
Respiratory Pattern Breath Sounds Secretions
Cough
Color -- Integrity
Backside
Access Devices Location
Condition
P
DEPARTMENT/SERVICE/CLINIC
ICU3, or written
first, middle; grade; date; hckspitafrpr medical facility) entries give: Name —last,
DA FORM 4700, MAY 78
❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
❑ TREATMENT
❑ FLOW CHART
❑ OTHER [Specify)
MEDCOM - 16446
USAPPC V2.00
DOD-029835
ACLU-RDI 1637 p.6
MEDCOM - 16447
To
tal
DR
AIN
S
TO
OL
N
GT
UR
INE
O
UT
PU
T
Total P
O
NG
T IV
PB
IVF
INTA
KE
MA
P
Sourc
e Fi0
2
S a0
2 R
R
HR
TE
MP
N
BP
A
-Line
VIT
ALS
06
06 1 1,
77,;] z2,sy
06
07
07
07
08
08
P15,'
08
09
09
09
10
10
10 I 11
11
12
12
12
13
13
13
14
14
14
15
15
15
16
16
16
17
171
17
Total
To
tal
18
18 1
18
119
19
1 19
20
20
20
21
21
21
22
12
2
22
I 23
23 I
23
I 0
0
j
00
of
o
01
02
02
02 03
03
04
04 FH
05 L _J
C CW
:ew
eN
slue
!led
DOD-029836
ACLU-RDI 1637 p.7
1 . REPORTING MTF 2. MTF LOCATION ADMISSION AND CODING INFORMATION I
For use of this torte, see AR 40-400: the proponent agency is GSSG
1 2 3 4 5 6 7 8 afore or Country Code.) A fl' ; , :
3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
9 10 11 12 13 14 15
'CO') ,),, ( c.t) - LI 16 17
expo 6, DATE OF BIRTH (VVVYMMO 01 7. AGE AT 8. RACE 9. ETHNIC RELIGION
LA. A..)1(...__. 19 20 21 22 23 24 25 26 27 28 29 30 3 1 BACK-
GROUND (9--q7 a - z -2_ Ez 10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
35 36 32 33 34 1 37 WI 39
HOUR OF ADMISSION
40 41 42 43 44 45
BRANCO-11 COR •--
10 ( c_ - Li ORGANIZATION (Active Duty Only) 13. MARITAL STATUS
46
14. FLYING STATUS 16. BENEFICIARY um CATEGORY 16. ZIP CODE OF RESIDENCE
53 54 55 56 57 58 59 60 61 47 48 49 50
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV, ADMISSION
62 in Country Code)
64 65 66 67 68 69 70 71 YEAR NO
. 20. SOURCE . . Of ADMISSION/ AUTHORITY FOR ..
ADMISSION
WARD
.i',C(A. 5
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
lit AN., 72
ADDRESS OF EMERGENCY ADDRESSEE (Include .VP Code)
tA ./t)
NAM
2 . TYPE OF DISPOSITION , _ SFERRED TO
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
23. DATE OF DISPOSITION (V VMMOD1
73 74 b L I) L
75 78 77 78 79 80 81 82 83 84 85 86
0 42 1 ?
24. CLINIC SVC . ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMOD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
Pc- E Pt- ft" (1) 3 (1) 9 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IY VMMDO)
103 104 (Battle Casualty Only)
105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE
U 1 (u 1 i -1-13
b Cc.6- Q
ADMITTING OFFICER (Signature, as required/
DA FORM 2985, MAR 89
MEDCOM - 16448
USAPPCV1.0
DOD-029837
ACLU-RDI 1637 p.8
SIGNATURE OF ATTE NG MEDICAL OFF
• DA FOR MEDCOM - CI,V1/1•1 rsr • • -re nne•on• r-rr
•
. INPATIENT TREATMENT RECORD COVER SHEET b(C52, For use of this form, see Ali 40-400; the proponent agency is OTSG
1. REGISTER NUMBER
411.111111 2. NAM La First. Mt
8tENGTWOF
4, SVC
791,A)
19. ETS
. DE
1 . PREVIOUS A DOB
ADMISSION REMARKS
i \ .
4. SEX
in 5. AGE
az; 6. RACE , 7. RELIGION
•••••••• 11 HAP
-O‘ 4 q 13.
-
12. SSN ORGANIZATION
4. _.... .
14. ' WARD ...---
15. FLYING STATUS
A ...) 0
16. R DSG
,...,..---
U. DEPT./ ,. BEN
K"-----iF 18.
. BRANCFUCORPS 19. uIC/ZIP 20. TYPE CASE
lobei- 21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
D/recr - ..om ,:e.e 22. HOURS OF
ADMISSION
IN5 23. CLINIC SERVICE
19--E /4-A- 24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
tLK-- 25. TYPE DISPOSITION ,
le.ev all 7 26. DATE OF DISPOSITION
17 i 27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
a fLif--
27b. TELEPH• NE NO. .
61 /7.1C.
28. DATE OF TH‘4 ADMISSION
/161-u403
ADMITTING OFFI
pe,
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
3 1 . SELECTEO ADMI NIS
30. DATE OF I
,
AL ADMISSION
32. UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED
Check if Continued on Reverse
33. CAUSE OF INJURY
34. OlAtNOSES/OPERATIONS AND SPECIAL PROCEDURES
.69,() czo CailA04it
35. Total Days Tis Facility
C. CONV. LV/COOP CARE D
a. ABSENT SICK DAYS
36. Total Days All Facilites
d. SUPPLEMENTAL BED DAYS CARE DAYS
0 e t. TOTAL SICK DAYS
3 b. OTHER DAYS
a. ABSENT SICK DAYS b. OTHER D YS .A\3 CONV. LV/COOP d. SUPPLEMENTAL CARE DAYS
I. TOTAL SICK DAYS BED DAYS
DICAL RECORDS OFFICER
CARE DAYS
DOD-029838
ACLU-RDI 1637 p.9
MDICAL - RECORD
PliYSICAL E XAMINATION :
. • ---ABBREVIATED-AEDICAL- -RECORD-- •
PERTINENT 14ISTORY.i.."FnErCOMPLARVLAX ON ADMISSION f F:atir rifift of
(
PROGRESS , 1•:ater dote of •if,filarge Grp/ distino.in
.midelle, &ids dAte: ',aspire: or rnecfrcel.tectiity)
SIGNATURE OF'PHYSICaff • - DATE IDENTiriCATION i 0.FAGANiZATiON
wARID NO.
(A. - ASBREVIATED MEDICAL RECORD
Standard 797311 dad GENERAL SERYtCES AbmiwTRATION ;AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA i41 CFR` 201-45,5C5. OCTOBER
MEDCOM - 16450
PATIENT'S IDENTIFICATiON (For typect ot written entrieb peer Name lasr. firer.
r 'MOISTER NO.
DOD-029839
ACLU-RDI 1637 p.10
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
IA k A(30 3
903o
\t, 0A„,___.ea Si P GS/,\DO, Ca
-60 -(..1,07.__ a l eSco co r4,1 frYcr, t.1 0::)- 2► ),-, 6-e \de , .67 , 1„_•2 r-4/
o,.\.
a 0r 0 4 v"..SS \ 0 \) S 0 / . g 0 • .?() 41\ii ) -P )--,C) I 1 y4 )-_, -Ve ► r-,Q .is-Psel,--(-- ,0 . 98- Z__ . ■,.,.-5S c SI\ e )1, . ,,,_).--eaze_c ) -c-e ocir--.(3 \-.-e___ , S Le 5-'1-9 - 9).56)?<- Li 90 a S - a - '-'--ee.e;i- t• ;
\ e C Uk_ sf■A S--tQ r, S a L ,\A co y_.--..r.,.., ,,ks , r"--- -e\ 1-8): S/- — •
io■ l C
`comet A CO TS wisca_ , a__ Q aDo-P oma .
...-I-cra) r4 a- si5 pa4--.4 /4406 0-s u55-- AL.,4 y 3 Rect,(4-1-4. t,„ - sct i k_cctoc, 1 l3 0 I. i , tl i.... Lc/ _ ...„...,. fz6he_L B i 2-
pa
p e.u,..,. r :. y-riz.— PQ4c(A_ pc). s G s -rt iZet. rit 4 --t. • 13 1-.-. 9 s 4- o' CC).
ki - — 8.s. ED K-21e‘e4:5-
1-e5- s rs......-ek cA,.:4-- Qe—b1.* Otravne VL 04-wt c,,,,t_ tv.,--1-4.,d-, 1'17 'Ai- Aw...b x t ac NA-C 4,) . ikas t? k a- v i
I r Pa • gal
CciA,Cit 5 er—Zikfil _ :. •
'Szir Kt_ -.IS: ..- k , - do AS k .. 1 ....
ff3 ,
611C tAin gAANd4 -6 0 SALO,- 416131 i ...• al Ai 2, • t . - 0
, roA6vi ., or ' 4 I ., • ,.. -. , ii. ...
3C-4, KS f )( . 0 fi. ILO CAt-t---
I ,,, A.A . A. 0 ..,.. ' A IL 1 . : ■■ 1, #1 . ttk-- . • al ■ _AKA
i .%-,41Ii714C6L-G 19A10110- Uta_ WA. CISC_ f:S '641- a
A 0 ::14
46 UppeA-414cpih HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE i
RECORDS MAINTAINED AT \-/ '
SPONSOR'S NAME mu NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (for typed or weten entries, give . Name - last, first, middle, ID No or SSiV; Sex; Date of Birth;
,...41111111111
Rank/Graded REGISTER NO.
rn(>1)7— CHRONOLOGICAL RECORD OF MEDICAL CARE
• Medical Record STANDARD FORM BOO (REV. 6.97)
Prescribed by GSAIICMR FIRMR (41 CFR)201-9.202.1
MEDCOM - 16451
USAPA V2.00
DOD-029840 ACLU-RDI 1637 p.11
69)- 2 ,L‘ q
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
takilA cia_vb, 2-GLooA(t() 40 urpRA. i z_tkoi,m4 40 tap-etc cage ,.
0......,sfzeck. easivi*-1 4tu- ie, ic,cy,,tta,Kelfro - 513 c*IN,c_e_diw.1, co -..z.,
Ace_ .0 _.--) 5s,,,, c9-11),-. , z---sac CAT ,03,QQ, VY\AZVA-Itorn Ch OtrAJIA1C)
51' ‘04.13 ' VL' -.. C49trn3104^. P- 44'\ - CY"- • VS5 • Mi CWMQL ivrrOAeRof
ISATIOD-)) (). IA- V,--de—P\C cc c " -e., GOO —'J 55 ) / /00.S — )-%?? ri-00 C-10 _*,11.,\\ s--t ,‘,r._02, - S Z_- l'o,--Ce.)__-/' - ciss a r__ ,y,6?;__
2-- os -- e- • - ,-.. 1, -(= .. ■-e 6D .-e Dy-46
-7t)b
p * r 1-o ©Ie5 ( i-,1 1,..‘ [IA-vet/4 Pectr- -cc 1,,,..
24 VIA-S 5 A N, aig, f ...A. i--n5 6 SQ 11tre_.-2•6 , PSal (413
tat pui6 q . G Gth :-) -7 (r.c) tolc-i A asiv-Sk5IX f Li Br . _
Pum p cei-,(At up 1/41-c e R
R , vu ,d(icf, p re5 , 0 cl .e__3 in ,, otiv ke5 ra c /_,E. 1. t. p q
itu.k9 cl, pa-11",r 57 , Gt
614)5(/ 1 C4' 19T 194 v
( 15e /1) s lie (2
5 4, ast . qi--(4," 17) A 5 tc-ere
O i A9--- J& el,)1. f , Afi at) ch
, .. / Aon/ " ..'_ 1.1. JO
1 CiailAtA ezLeir r 4") ' eitiod (1'21066 f.,_ a . age 4.itz, Ae..e...,-- _i / - 0 ‘ , - A 0 .
'4' 4 E- thicitede tQA1c_. aot - 6TANDABBRI0M 600 ,.....",, BACK ,,,„0, u„,,
USAPA V2.00
MEDCOM - 16452
DOD-029841 ACLU-RDI 1637 p.12
(
2 ) pc \I
MEDICAL RECORD I PROGRESS NOTES
DATE NOTES
V-PW uk..ii)3 0 55" •.-e--F1, ca IQ- 4ZP, V3C-7° — \L-S5"' r\ 0 C/ ?63‘1 @-;t\''‘--S
i q- SID '\-\\I-N-e.- — 5,r,-,ok \.\- 0, ,oukr-+- G .s2_cc__)sct , 5 , - A cot ‘v,01
u\_5\ ,,,3 c c u.i - rL-P S --VD c,,.-_), ,,,-_)- LA\ ocke
1444153 \--cek..As - o IPS to A) L-- i ( oc ekrt e sci-tioe\— 1(p2o 1r,OASi-fN gi Al--; hAfi (.,i 0 3 OS 5 - A. 1,,,54----,L (4,--s 5 5 tk--e, (1--) L0 du--)t cc -A0A-ce,.---i-- rer C/ z4 ,--t 2495'
2 0 pe Ci(( -- oil S Certeti- -(2 0 'et 0 r Pe- S Le-j ... P ie' a rt.--CA. - L! in c -51/ 61 letwitn 4-1 5 114 0,4„9
cal,„e._e„--z,s -1-0 tiop a_.,_ tc.,i9-. s to, L - [4 12 - tU S R._ -- ri S EL-3 NC GezCit / Pazeic42 S
sines oR2Lijzs _t_t‘ jli&12 tr,ALcs i.„ e, 4,,,sj1_,-, 4.„. , . -
411111111.L4_2x.- 0 3 / #
KC- . ek, Aag- di.Lir rrli ahoi pc:ft ief,,.? V. ax..i., 6 &I je,4,.. 4 84 . g -eft: 4, • - 0 e-..4 eD"----r. Okay) 0
i, 6) pi.ie_. )0,0/iva4r:if>-) oh Oi--.- "-- 33,,,xj tt16 Crain • St_ et-ef,A.- //hit', erne-- ii-2/ Oenik,t7 9fii4
.300 P6 , * 1 ' '
111.14€4- ,Y4"ey 4 a4A-V-01 c-An
"1 i
_
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
(SSN or Other) LAST FIRST MI
OEPART.ISER VICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (Far typed or written entries, glee: Name . last. !'at. middle, I ID No or SSN; Sox Dote of Birth; Rank/Grade)
REGISTER NO.
vl_r_ti .. &J f? PROGRESS NOTES
Medical Recoid
ePkD MEDCOM - 16453
STANDARD FORM 509 (REV. 511989) Prescribed by csanon FPMR 141CFE0 101 - 11.20314)11 (4
USAPA V1.00
AUTHORDID FOR LOCAL REPRODUCTION
DOD-029842
ACLU-RDI 1637 p.13
: or typed or written entries, give: Name • last, lust, middle; ID No or SSN; Sex; Date of Birth; Rank/Gredel
No ( (fl 'H MEDCOM - 16454
MEDICAL RECORD rm.. caunvr...1 FUR WWII-nu-m.1u LI 1. Hun J PROGRESS NOTES .
DATE NOTES
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME UMBER LAST FIRST MI (SSN or °timid
OEPART.ISERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. snsas) Prescribed by GSAIICMR FPMR 14ICFRI 101.11203041W
USAPA VI 00
REGISTER NO. AR 0. 6,5-L._
DOD-029843
ACLU-RDI 1637 p.14
MEDICAL RECORD PROGRESS NOTES DATE
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(Continue on reverse side) PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle;
grade; rank; rate; hospital or medical facility) REGISTER NO. WARD NO.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR 141
USAPPC V1.00
MEDCOM - 16455
DOD-029844 ACLU-RDI 1637 p.15
DOD-029845
MEDCOM - 16456 MI11111.011
yr
•■•11 .,aiNI4 NRIMNIMMOMPINIMMOIMMIIMMIMMINININ OA. 41...p.....1°..1.2."..1r2tocrl
MEDICAL RECORD CHRONOLOGICAL RECORD OF IIM3OICAL CARE
PATIENT'S 1111301i1CATINt rue tweet ar memo esurka. Ow= Mobs - bat Sat. mai= NM or SS* Se=
.13gase of Sith; 01011115)0000
CHRONOLOGICAL RECORD OF MEDICAL C Medical Record
STANDAbyRD FORM 60D akEv_ 6-971
Peaseas4 -66ANCINI FIRMA 141 M* 1 20/-9,202-1 - g2.
ACLU-RDI 1637 p.16
NSN 7540-00-634-4176 AUTHORIZED FOk LOCAL REPRODUCTION
MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTONS, DIAGNOSIS. TREATMENT REATING ORGANIZATION (Sign each entry)
4)YN:56,-:- C-
1 • . 1 x . `.- - 5 1 ? .SOC"- t_1SS (It- GSAOca(k-1A-k. le-
---Yce_--P,--ta -e asr.c ei./ Y-e-leir io■ ,--a d fe., SS \ il E-S _ate- Co c----\6 r....1"re- Ax-es_s ' , N-5 %I. S> uk r k \ tiNDou,,AAs gcci,L,L 0C+/—e-^—
I. HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade.)
REGISTER NO. WARD NO.
E 11111/ air MEDCOM - 16457
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 2014.202-1
DOD-029846
ACLU-RDI 1637 p.17
NSN 7540-01-075-3786
MEDICAL RECORD EMERGED CARE AND TREATMENT
(Patient)
LOG NUMBER
RECORDS MAINTAI
TREATMENT F CI
AT
AO 2.) -7-/ PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE (Day, Month, Year)
14A-Vel 0 3 TIME
10 5 CITY
,
STATE ZIP CODE TRANSPORTATION TO FACILITY -
A4,4/A-c., SEX
?...d.....
DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE
AREA CODE NUMBER ITEM YES NO N/A ITEM I YES NO PRP ADDITIONAL INSURANCE
AGE HOME PHONE FLYING STATUS DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
ITEM YES NO WHEN (Dare) DATE LAST VISIT 24 HOUR RETURN
0 YES n NO IS THIS AN INJURY? WHERE TETANUS
ALLERGIES
i
INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTI IAL SERIES
0 YES 0 NO
CHIEF COMPLAINT
CATEGORY OF TREATMENT s.._..-
VITAL SlithrTS
❑ EMERGENT
1:1 URGENT
RNON URGENT
TIME TIME
BP NV V) PULSE c?
INITIALS RESP it TEMP
WT
LA
B O
RD
ER
S CBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT SM3O
U0
A
b1:1- X
CXR PA & LAT/PORTABLE C-SPINE URINE C&S UA MSCC/CATH CHEM: ACUTE ABDOMEN LS SPINE BLOOD C&S X SINUS HEAD CT
ANKLE R/L
ORDERS ri-RULS E OX MONITOR ECG TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE
DISPOSITION n HOME n FULL DUTY
DISPOSITION QUARTERS /OFF DUTY n 24 HRS. n 48 HRS. D 78 HRS.
PATIENT/DISCHARGE INSTRUCTIONS
MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE
❑ UNCHANGED • IMPROVED
• DETERIORATE
ADMIT TO UNIT/SERVICE REFERRED lop. TO WHEN
TIME OF RELEASE I have received and understand these instructions .
PATIENT'S SIGNATURE PATIENTS IDENTIFICATION (For typed or written entries, give: Name — last,
first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Patient) Medical Record
STANDARD FORM 558 (REV. 9-96) Prescribed by GS/VICMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00
MEDCOM - 16458
DOD-029847 ACLU-RDI 1637 p.18
PROVIDER HISTORY/PHYSIC
65a.9 z
tr f,,eple•
S/7
NSN 7540-01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)
TIME SEEN BY PROVIDER
I
TEST RESULTS
ABG/PULSE OX RADIOLOGY q Check if read by radiologist
WBC
H/H
3,6 PLT
A 711 -
7.'4N OTHER ' PCO2
DIP
MICRO
RESULTS
?ErAff A
EKG INTER RETATION
FPA-1) Vt° di/ ( 5'.
I/ :6 '0- eassof
BHCG ETOH
PT
U SUP 02 PH
SAT -- •
APTT
P02
CONSULT WITH ACTION REST
7-- - F9
Abti 0-toe /t,
RAZ-- .4 7z -cee-a-
5, 6-
kci
TIME
Scarte--- k 9, et.,
DENT/MEDICAL STU
Mtal
G -es
SK-
IGNATURE AND STA
5.A t
P
DIAGNOSIS 6,-4,, c /-1-4 0- ca
0
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last, first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(6)(10) USAPA V1.00
MEDCOM - 16459
.s-4‘,0752_ /,14-4144-
DOD-029848
ACLU-RDI 1637 p.19
4TH FORWARD SURGICAL TEAM PATIENT RECORD
DTG IN: - "1 / (3 I ,... f ..1
J TIME OF INJURY: ,
AIRWAY: ORAL NASAL TO OR: ,---'
DETAILS OF INJUR TNT: NbIrVI. (111(11 CalS
NAME: ilk gLO SSN: NI Je UNIT: CHEST: itcmtac ,scarc Or
GAL RIGHT BS= t-OkhO erctrikt@t.
WT LBS: WT KG1.\- ALLERGIES: TA
NEURO: GCS= ft+-0
.
TIME /
4.12.0
IV
2
SZ
11111Lii MIMI
SITE tM711S,111 , CS PRIOR TO ARRIVIAL= . _ .
-
I
TR.: Pa•k
a0
CT #1 & SITE:
HEAD, FACE, & NECK:
CiS- 4 ITERS OF FLUID IN:
t /..g. I L'Dp C,c,e9/0---\. 4_. --- Y.)
UNITS OF BLOOD IN:
BDOMEN: ' )( L( %OAS
PE & DOSE
lcil,c7, Atl i UPPER LEGS:
- squp.ramiL,„m , TIME INTERVENTION LOWER LEGS: 4) 3/- Si ep„,1s2_,--ptA9.4e_. +.0 i di 0-4112.4
1 I •
' OXYGEN ON & RATE: ETT SIZE: SURG. AIRWAY ARMS: 4a luD a,/-"W‘ CT #2 & SITE: FOLEY POSTERIOR: ir f
OAR 4AC14-1,431:71,v(161 0 GASTRIC
ix (;)
cn 44 = E. (et) W Z -*I
TIMES MEDICATIONS •FLUID- TOTALS VITAL SIGNS IN: MIDAZOAM CRYSTAL: -
COLLOID: -- TIME:
BP: q I S )5 e3
.3b 3g
i - INC [SION:
4TIBIOTIC: PENTOTHAL
PROC. END: ETOMIDATE FENTANYL EBV :
EBL: HR: RR:
.. / ,
9' 11,1 illirThil q
EN
MI TO AC W: REVERSAL:
MSO4 ANESTESIA TECH: SUCCINYL. UO.: Sp02: w .
MAC: ROCURONIUM OTHER: DRAINS. TEMP: REGIONAL: VECURONIUM
AGENTS: ■
GENERAL: • L'146 4 FiD 4k)C4
a fra 0> U w g
TIME IN: 02 VIA IV SITE RE-EVALUATION POST-ANESTHESIA RECOVERY SCORE
SURGEON(S): .i. 1.\(.3 6)-7 IV SZ SITE RATE AB IN BAG
PROCEURE: Ig irk w. ',AI& wan ADMIT= 30 MIN= 1 '. 1)4" bg S
x, IfC,1 ILI " en4-1 Y 1" e,y.. ) f DIC=
>., fami iiriA
11 i ' •A 6 .4. S .: 12 A IW • LA Q .. di - ALM
'RES GS: KVAIIMINIElraMMICEEMMEI
POST-OP MEDICATIONS VITAL
ADM SIGNS IT D/
TIME MED & DOS ROUTE BP: INEMIleja P
MIAIIEVAI wom m in
7mummPonen= HR: 41 RR:
TEMP: 7 7 g20 2 q k ' I 1
1 CUMULATIVE I & 0
TUBES: INTAKE OUTPUT SOURCE AMT
PSOURCE AM/T
W ailarglir I
DRAINS:
TCY1' A T = TOTAL= niim-v-srInn _ I RA Pll
DOD-029849 ACLU-RDI 1637 p.20
i -STAT EG?+
Pt: 00
Pt Name
Ha 140 001/L
K 4.0 mmol/L
TCO2 27 mmol/L
iCa 1.21 mmol/L
HCL 45 '.PCV
Hb* 15 g/dL
*via Hct
At 7C
PH 7.424
PCna 38.8 mmHg
P02 62 mmHg
HCO3 25 mmol/L
6Eecf 1 mmol/L
s0a*
*calculated
Sample Type_:
14FE803 14: a2
Oper• 0000000
Physician:
l'Ser# fillip Ver: JRMSO44C
CLEW R89 JAO LOT 98 / 8bT 86 ZS 00:0T AJO ETT BB / E9T 66 ES 05:14 JAC VTT E6 / 6ST 96 S6 SS:17T AJO !MT 08 / EST 56 66 00:ST AJO TOT 08 / EtT 86 L8 90:ST AJO 90T T8 / 5bT 15815 88 OT:ST JAC 1011135 96 Co ST:ST AJO HMS 66 68 OE:ST AJO 46 41. / OET 0 Z8 TEST AO 96 9L / BET 46 SB SO:ST
HO sHuu % WIR WW:HB _____ BB NUN - UI0 / SAS ZOdS NIL
E0/0T/80 ON32l1 EIBIB
MEDCOM - 16461
•
DOD-029850
ACLU-RDI 1637 p.21
511-119
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD • HOSPITAL DAY t
POST- DAY
MONTH-YEAR DAY 1 -i %'5 IL. I3. 1.., 19 HOUR
PULSE TEMP. F (0) (-)
180 104°
170 103°
160 102°
150 10
140 100
130 9
120 8°
110 7°
100 96°
90 9
80
70
60
50
40
4
RESPIRATION RECORD
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PATIENT'S IDENTIFICATION (For (SSN
typed or written entries give . Name—last, fist, or other); hospital or medical facility)
middle; ID No. REGISTER NO .
\c) VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 16462
DOD-029851
ACLU-RDI 1637 p.22
Ward/section: - : ! :11. : 11.i (f:
REQIX. ;17-.t.i..A.-:„.7,___ . - , 7. r' 7''il9'...7 ' 14' -...'
-
...CHEMISTRY_RESULTFORIYI . (Stil) r i to the Privacy Act of 1974) (:;::= '
LAST,.FiRS., ,b1
.
.. '.
DATE . T13.a - ,, SSN/PSEUPO S .1,1; ._ .,i .. i...Ji 1.;'4,! i
... P
. : ; 1 .., 4 , 1*.
:r. ..4., ,,,,,,, , :-...--,,,, ..), ,.::,.:c.... ,.... - _ ,et! . * -;oci,p, t ,,,„, TEST RESULT .
'i i . :,.' . - __REE RANGE LI i 1 ...1";
. __TEST_ I1 __RESULT • ' ; 1 1 •
I_REF. . ..: LI ZiAirr•ii I -". ...i - :
_TEST.::.:..R.ESULE : 3A 1 13,.._;
, &INGE _
• a ' 138-146 rnmp1/1- - _ ... ...
,, r ----73-118 mg7c11".•
3.5-4.9 %Ili:41914y' PI CCOLO 1
14/08/03 17:26 REFERENCE RANGE : MALE PATIENT # :111111 .::) IL.c.)) Li METLYTE 8 1 DISC LOT # : 3152AA4 0F;ER ft : 1.11 DR #: 000 SERIAL
3LNIAL #:
GLU 94 73-118 MG/DL BUN 11 7-22 MG/DL CRE 1 0.6-1.2 MG/DL CK 824* 39-380 U/L
Cl
-
___
- 7.77------' ---; - -7;22 eig/dl -- ...
,,,. ?8- Ig9 mm°vL CA++ :. ,...4, 1 r 8.0,10:3 nie/d1 - 7
pH —... .-. -. -7..31-7.45 -- -- 0.6-1.2 mg/dl..__..
PCO2 35 45 mmHg (T. 4i-51 miajg (yea)
,' - i 128- 1 triotil 45 rn
3.3 -4.7:mnolt1 i PO2 80-105 nunlig lam,
14/A (vela'_::..'': .._
+
TCO 23-27:Mniotil. Carr 24 -29 InrnoUL (vet
9.8:108 mmol/1
HCO3 22,..24 minwoo 2S.-28 nupol/L (vct
18-33 111117104 .1.::;
s02 95-98% ... -'''L . .. „ FAA - t- OA'
BE-ed -- • (-2):.- (t3) --;-;-- 1mn°11-;
-TEST --. -RESULT -REF:RANGE
AriGap ___....., 10-20 -amnia: '
• • - - ALB
__ . .. _T ,
I., , ; _ 3 5 _edi .__,.._ _
.3.5
- 73.: , , Ca V.12-1.32 mmobi NA+ 133 128-145 MDR._ . ■ ., ,
_ _26-84 a/A__ ____
BUN 8-26 rag/di Ki 4.7 3.3-4.7 MM0f/L CL- 99 98-108 11101?/L
T __, .... ____ ... i
1047 ail _._.... .,.. ._._...
GLU ' -' 70-105001 tCO2 19 18-33 11102/1._ AMY •- • ' ; 14-97 till1 • •
Creat 117-1.5 'g/di I NST GC: OK 01-EM GC: OK AST 11-38 u/1
Het 38-51% PC11 1--EM 0 , LIP 1+ , ICT 0 TBIL 0.27 1.6 rag/d1
Hgb .• . .. ,.......... - 4-1-17. ea_ 1 SST....._._
. . TP ; -..
__..__. 5-65 .1uAL . _
i ..7:::% .•:■.',
6.4-8.1 gidl ... .
•TEST ,
Tropirt-1
RESULT. REF.jRANG ..: . 616itile'ctiti '• • --e .
---.—"—;:'i77 REF: RANGE
Drug of Abuse .i.: 1 r." - IU-.
-;:::,.:::: !
:', .1 ' i L
-1284,45 mmol/1 --=
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3.3-4.7 mmol/i
, , ., : ■ ,. , _
Ty .- 11 ko I
CL.- . ---- ,..-;----, :-,i 4.4. 1
..21710111R.111.1J1-_, ! ..
.__ ..___ _ -- 1 I WO -- 1- -- - - 18 -33 torno1/1 _ I 1-..'11
REMARKS: ----- -- - - --- , ; -2, , Z.:b . _ . .
REPORTED BY: ------- - • - - -
---
DATE:- -- - ' -
.• 71:7/. ri.-..7-. q-,-Z-. .....,
-LAB ID NO.: .-------- -- .---- 1,------... ;; t .., ....-z, -.,..7-. ...-.1.-i ::-...1.r: 1,
-.... -- . . . .
MEDCOM - 16463
DOD-029852
ACLU-RDI 1637 p.23
Ward/Section: L. REQ
LAST, FIRST MI.
;;4114'gY) c.
(TEST RESULT REF. RANGE TES
I
"Color
App
Glu
Bili
•Ket ; -
SG
"Bld
pH
RBC -Morph
Spun Hematocrit
Count
Diectigen
...Negative
42-52% (M)" 37A7/0 (F)
Sed Rate
Other
CSF • . •1
IllogiBaqk • , -. 4... •
, MUST. STIOI4t.j.0.50 WITR -EVERY UNIT REQUESTED
Negative ABO/Rh
IAN: 1\0
DATE TIME
RESULT.- :REF.-TRANGE
N/A.
Negative
LABORATORY RESULT FORM (Subject to the Piivaeji A:a -01,1974)
SSN/PSEUDO SSINT:
Misc. Serology - -
TEST RESULT REF. RANGE
RPR- Negative
Mono'
motive
Microbiology
Negative .
Negative
Negative , ;
WA —
.S.curce. •• Gram-Staik "'" Oce Sid
r •
H. pylot
1 1
Negative:
IlegaqY9 ": ;
Parasites • Prot -
Negati
Malaria - .; -
Urob
0.241.0
0 & P —
ympti Baso
Nit
Negative Other .._
Atyp --Imm Leuk
Ne F9ropic
Coagulation Studies Blood. Bank thiit ST SUBMIT SF,SIBWITil gy.mx_Oar
:..14,EQUESTED) .
TEST_ RESULT REF. RANGE _ _ UNIT
TYPE -
r CROSSILITCH
PT
AM
D dimer
FDP
REMARKS:
9.8-13.6 secs
21-34 secs
<20 ug/ml
<10 ughni
'
REPORTED BY: Millignel DATE: LAB ID NO.: . ---
MEDCOM - 16464
DOD-029853
ACLU-RDI 1637 p.24
‘)
‘tk
C0141-CAL RECORD . DOCTOR'S ORDERS b ( z ek
For usn-of this toren, see AR 4D.;8.6., the priiparierrt agency is crrsp 00 ,c.."
RECORD DATE TIME AND SIGN- EACH SET•OF ORDERS. IF PROBI_EM ORIENTED MEDICAL RECORD SYSTEM. IS USED., WRITE PROBLEM NUMBER IN COLUMN, INGICATED BY ARROW BELOW. _....... •I'T..1F.NT LOENTlfreATION.:: • •,' •••• DATE 9 0. :'0-1'1601':: ... TIME:.::00,
1 4:: .A.A.1 . :...:0 ̀..-3, _ ,,.,:, •,,. - ..-...... .• - • , -..:. : ,.,..*-1664it. - . e f. 0 -..:.• - . _Art...„-J4---.:- • ., ,,..•...d...... . 5 c., s / . .6D. D. C...-Q-;'•
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. PATIENT'
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ROOM NO. alp [ A4TE.•:-00-000.Eft: :TYfME OF. ..0ROEFI:'}' -
•
•PATIE•NT 1.00.NTT•teArt.0N.
NURSING UNIT
REPLACES ern -riots' OF ,t - JUL- /7,1 WHICH MAY RE USED MEDCOM - 16465
DOD-029854
ACLU-RDI 1637 p.25
• - Uuric DOCUMENTATION CARE PLAN -ML,iv-ME:D/CATiON)
CLINICAL RECORD For use of this form, see AR 40-407* the proponent agenc is the Office of The Surgeon General. -
A4.0. DO -3 VERIFY BY INITIALING
CLERK/ NU
;41girialrig.r; ', .1;fte'tf: INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
RECURRING ACTIONS, FREQUENCY, TIME
HR COMPLETED ti 1 go 1 v DATE
, . 21
as -eot . ot(* 1 J vt)y t)
2..1
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ALLERGIES: • YES IIII NO PRIMARY DIAGNOSIS:
GS i"- PO c-c'tC/44)9 ADDITIONAL PAGES IN USE:
I I NO
NO:
.YES
PAGE
PATIENT IDENTIFICATION:
. ...---7 LAJ
ACTION TIMES
U (Q - Li\
USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78
EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 16466
DOD-029855
ACLU-RDI 1637 p.26
Verify by Initialing
,,,,,../ 'THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo g--.......;a::
Order Date
Clerk SINGLE ACTIONS Date to
be Done Time to be Done Time Done Initials
■ a C\O-4 \"Y —. Oc--. \. 0
t \ / 1 0(9 723
DE --,--caf)-C> 1/0 Cos ■,‘,.-c how t -,c)
At:
3
Order/ ExP ir Date
Clerk/ PRN Nurse ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED
_ .. ._
USAPA V1.00
MEDCOM - 16467
DOD-029856 ACLU-RDI 1637 p.27
u)- CLINICAL RECORD THEPPEUTIC DOCUMENTATION
see AR CARE PLAN (ME viCATIONS)
For use of this form, 40-407; the proponent aggnc is the Office of The Surgeon General. gia5 Mo. Y
VERIFY BY INITIALING ig;;;M::;iiii;i:MENN•NCEi13>eingiiiin INITIAL PROP ER COLUMN FOLLOWING EACH A DMINISTR4TION
ORDtR '' DATE
CLERK! NURSE
RECURRING MEDICATIONS, HR DATE DISPENSED
DOSE, FREQUENCY li 1 _Ai ;
IIMIIIIIIIIii illEff
1111111.11 \ -
- - - - C18° il rCeK t ,,, I' ar..
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ALLERGIES: n YES - NO PRIMARY DIAGNOW, - ADDITIONAL
s IADQ-j• C° ICI-ONI% \-N
PAGES IN USE:
IIII YES I. NO
PAGE NO.
PATIENT IDENTIFICATION: DISPENSING TIMES
ecit USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
11111 NE3 ( 4) - V, E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
MEDCOM - 16468
DOD-029857
ACLU-RDI 1637 p.28
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) 7Mo. Yr.
Order
Date Clerk/ Nurse
SINGLE ORDER, PRE -OPERATIVES Date to be Given
Time to be Given
Time Given initials
; .
- .
,..
, .
Orderf Clem
txaPteir Nur e PRN
MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
- Ilk - 1-4Z)41 (DSD a.._! 141K` ,. • ffklA3 I%di ' • <
al
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USAPA V1.00
MEDCOM - 16469
DOD-029858
ACLU-RDI 1637 p.29
7. LAST NAMI. PAST NAME /NOM ET MINOT/ RAM/ GRADE MALE , HOMME
PENAL/ /FEMME
SSKI NUMEAO MATRACULE SPECALTY CODE /GPM RELIGION/ RELIGION
X LAMT/UNAlt
WKS ELEMENT NATIONALITY I uArioftwure
Alt AF/AI WM MVM
BC/ BC I NEN / BNC 1
DISEASE 1 MALAO ■ E I I PSYCH /PSYCH
3. INJURY
FRON
/ ILESSURE
I' / DEIMOS
..,
le _IL_
BACA
S.I
/ ARRIERE
AIRWAY i TRACHEE
HEAD/ TETE
!r
WOUND / BLESSURE
NECK/BACK NIAJRy I
BLESSURE AU COU/AU DOS
BURN /111AOLuRE
AMPutATION A AMPUTATION
STRESS/TENSION _
OTHER (Specify), AUTRE (SptuReN
A. LEVEL OF CONSCIOUSNESS / NIVEAU DE CONSCIENCE
ALERT, ALERTS PAIN RESPONSE /REPONSE A US DOULEUR
VERBAL RESPONSE , REPONSE AERIALS UNRESPONSIVE , SANS REPONSE
S. PULSE /FOULS TIME /HELM S. TOURNIQUET I CARROT
n .0 , HON r---1 YES/QUI
TAAE ; HEWN
T. M °RPM! A MORPHINE
1"-1NO/ NON f--1 YES / Ow
DOSE 'DOSE TIME /INURE IL IV / P., 1 Mst.A.,-.I.RE
/ .
S. TREATMENT /OBSERVATIONS , CURRENT MEDICAThALIERGAII / ANC (ANTIDOTE) TRAITEMENT/ OBSERVATIONS • AREHART MEDSCA / ALLEKIES / ANTIDOTES 1
',... ,.._ A 6..S A -4:2 i(Z;)
04 .,.-
/6- C." r Li C,.....44e - Satt a..s.A./5
#1 57.
ID DISPOSITION I DISPOSAPON RETURNED TO DUTY / FIETO ' ME / Wpm
A EVACUATED / EVACUE
DECEASED A DECE OE
It. PROVIDER/UNIT/OFFICER Mil:OCALA /UNIT/ DATE/DATE (rrupADD)
DD FQPRN , mb PORN relation ARA NO teRtiOnS DEC tI al OD Fens IMO *Rd DO F.,
1380 (TIM whkh Pn otemgett.
U.S. FIELD MEDICAL CARD FICHE MEDICALE OE L-AVA/IT ETATS-WEBS
MEDCOM - 16470
ACLU-RDI 1637 p.30
1 . REPORTING NM 2. MTF LOCATION )MISSION AND CODING INFORMATION
For OW ot this torm. see AR 40-400: the proponent agency is OTSG
1 2 3 4 7 a (Stare or
ccoc,ounar.7 A D ..
-- 3. REGISTER NUMBER NA erra'st, First, Middle Initial)
b1 0)-
4. PAY GRADE 5. SEX
9 12 13 14 15 1.6 17
er 18
6. ATE OF BIRTH IVY YYMMDDI 7. AGE AT ADMISSION 8. RACE 9. ETIIC
ex_ OUND
RELIC! ON
OPZZ-, 19 20 21 22 23 24 25 26 27 28 29 31 a-r3-
1 30
10. LENGTH OF SERVICE ETS 11. MP 12. SO AL SECURITY NUMBER
32 33 34 35 1 36 MeelliierUMMETIIIPTIIIINIIIrml
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF
ADMISSION .
:7214.)t?
BRANCH ! CORPS
-OW 46
14. FLYING STATUS 16. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
53 54 55 56 57 58 59 60 61 47 48 49 50 51 52
17. UNIT LOCATION (Stare or 18. MOS 19. TRAUMA PREV. ADMISSION
64 65 cun 68 69 70 YEAR NO
62 63 Country Code)
20. SOURCE .ADMISSION
Of ADMISSION/ AUTHORITY FOR
(_1) '--P--
WARD
224
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
0404.-- - 72
ADDRESS OF EMERGEV;EZSEE (Include ZIP Code)
2 .
_ 1TELEPH0NE NUMBER OF EY ADDRESSEE ,0
RRED TO 23. DATE OF DISPOSITION (t' YM/HD D)
73 74 75 76 77 78 79 80 81 82 83 84 85 86
5 3 0 S i g•-• 24. CI. NIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y YM MOD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101. 102
72 .
Ammo" Num 3 - D
0dm 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IYYMMDDI
103 104 Mettle Casualty Only)
105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE
bk .. CeSw*-(9-, CaJf/V-4,6jii, roc, • g A4,5
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1 ‘ .
ADMITTIN OFFICER ISignalur , as required) CLERK
DA FORM 2985, MAR 89 ' MEDCOM - 16471 USAPPCV1.0
DOD-029860
ACLU-RDI 1637 p.31
, 5.1F.N7 Si . s•
DA FORM 364,,
_1 INPATIENT TREATMENT REDOR far use ef this tom:, see AR 40-400, the p:cpcnerl i> OTSG
Ar.,.4'.SS::.N
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MEDCOM - 16472
DOD-029861
ACLU-RDI 1637 p.32
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Enter dare of admission)
PROGRESS (Enter date of discharge and final diagnosis)
141.2
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
t PHYSICAL EXAMINATION
14e,c 2 01
e; grade; dare: hospital or medical facility) or wrinen entries give Name last, first, WARD NO.
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION ANO INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR i41 CFR) 201-45 505 0000E91975 OSAPEC Vi 00
MEDCOM - 16473
GATE ORGANIZATION IDENTIFICATION NO.
REGISTER NO.
DOD-029862
ACLU-RDI 1637 p.33
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
/ 05.
SYMPTOMS, DIAGNOSIS, TREATMENT, TREAT' -,ANIZATION (Sign each entry)
_ ---
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. HOSPITAL OR MEDICAL FACILITY , STATUS OEPART3SERVICE RECORDS MAINTAP. u
SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: If& typed or written entries, give: Name - last first, middle:10 No or SSN; Sex; Date of Birth; Rank/Grade.! REGISTER NO. WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 IREV. 6.97) Prescribed by GSAIICMR FIRMR 141 CFR) 201-9.202-1
USAPA 02.00
MEDCOM - 16474
DOD-029863
ACLU-RDI 1637 p.34
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USAPA V1.
MEDCOM - 16475
DOD-029864
ACLU-RDI 1637 p.35
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/
1(‘' 41-r -Refe\AA fit-Proyy) .71/C, i Tab, p.wp 5, F
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SPONSOR'S NAME SSNII0 NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: 1 REGISTER NO. (for typed or written entries, give: Name - last, first, middle; ID No or SStV; Sex; Cate of Birth; Rank/Grade.)
ex \Ss'
V MEDCOM - 16476
WARD NO
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORPA 600 1REV. 6.97) Prescribed by GSAIICMR FIRMA 141 CFR) 201.9.202-1 USAPA V2.00
DOD-029865
ACLU-RDI 1637 p.36
\D C - 2 -\,\
DOD-029866
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MEDCOM -16477
(REV. 5-971 BACK U•V2
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ACLU-RDI 1637 p.37
► SN 7540-00434-4176 AUTHORIZED FOR LOCAL R
MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE
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ACLU-RDI 1637 p.62
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DOD-029894 ACLU-RDI 1637 p.65
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DOD-029895
ACLU-RDI 1637 p.66
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ACLU-RDI 1637 p.67
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ACLU-RDI 1637 p.71
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ACLU-RDI 1637 p.72
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ACLU-RDI 1637 p.73
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MEDCOM - 16514
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ACLU-RDI 1637 p.74
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DOD-029904 ACLU-RDI 1637 p.75
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MEDCOM - 16516
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DOD-029905 ACLU-RDI 1637 p.76
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ACLU-RDI 1637 p.77
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DOD-029907 ACLU-RDI 1637 p.78
MEDICAL RECORD PROGRESS NOTES
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ACLU-RDI 1637 p.79
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MEDCOM - 16522
DOD-029911 ACLU-RDI 1637 p.82
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MEDCOM - 16523
ACLU-RDI 1637 p.83
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DOD-029913 ACLU-RDI 1637 p.84
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MEDCOM - 16525 IMP DOD-029914
ACLU-RDI 1637 p.85
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ACLU-RDI 1637 p.86
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MEDCOM - 16527
DOD-029916 ACLU-RDI 1637 p.87
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DOD-029918 ACLU-RDI 1637 p.89
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MEDCOM - 16530
DOD-029919 ACLU-RDI 1637 p.90
MEDICAL RECORD PROGRESS NOTES (--)( 6-13 '--- Z A-
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Medical Record
STANDARD FORM 509 (REV. 7911 Prescribed by GSA/ICMR, FIRMR 141 CFR1
USAPPC V1.00
MEDCOM - 16531
DOD-029920 ACLU-RDI 1637 p.91
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DOD-029921 ACLU-RDI 1637 p.92
MEDICAL RECORD
PROGRESS NOTES 1) --7 -Po DATE
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PROGRESS NOTES
Medical Record
STANDARD FORM 509 MEV. 7.911 Prescribed by GSA/1CM11. FIRMA 141 CFRI
USAPPC V1.00
MEDCOM - 16533
DOD-029922 ACLU-RDI 1637 p.93
MEDICAL RECORD PROGRESS NOTES DATE
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111111.1 _ _ - • -)D ( u-- (-- MEDCOM - 16534
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 7.911 Prescribed by GSA/ICMR. FIRMA (41
CFRI USAPPC V1.00
DOD-029923 ACLU-RDI 1637 p.94
PROGRESS NOTES DATE
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MEDCOM - 16535
DOD-029924 ACLU-RDI 1637 p.95
PROGRESS NOTES
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MEDCOM - 16536
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DOD-029925 ACLU-RDI 1637 p.96
MEDICAL RECORD PROGRESS NOTES DATE 6444.44,4
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PATIENT'S IDENTIFICATION For typed or written entries give: Name - last, first, middle; grade; rank; rare; hospital or medical facility)
( 6L `)
`\ _ PROGRESS NOTE
Medical Record
40, STANDARD FORM 509 IREV. 7.91) Nescfibed by GSA/ICMR. FIRMA 141 CFR)
USAPPC V1.00
MEDCOM - 16537
DOD-029926 ACLU-RDI 1637 p.97
47Cfcb--?ko AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade.)
REGISTER NO. I WARD NO.
MEDCOM - 16538
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 6 - 97) Prescribed by GSA;ICMR FIRMR (41 CFRI 201-9.202-1 USAPA V2.00
DOD-029927
ACLU-RDI 1637 p.98
DATE
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MEDCOM -16539
DOD-029928
ACLU-RDI 1637 p.99
PROGRESS NOTES
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MEDCOM - 16540 S A 10 FORM 509 IREV. 7.9,, BACK
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DOD-029929 ACLU-RDI 1637 p.100
MEDICAL RECORD PROGRESS NOTES
DATE •
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,...: 0 , --) REGISTER NO. r _ , ■ 4.7-
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STANDARD FORM 509 IREV. 7.91) Prescribed by GSA/1CMR. FIRMA 141 CFRI USAPPC V1.00
MEDCOM - 16541
DOD-029930 ACLU-RDI 1637 p.101
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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ACLU-RDI 1637 p.102
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ACLU-RDI 1637 p.103
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MEDCOM - 16548
DOD-029937 ACLU-RDI 1637 p.108
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DOD-030016
ACLU-RDI 1637 p.187
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PATIENTS IDENTIFICATION (For typed or written entries, give: Name — last, first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00
MEDCOM - 16628
DOD-030017 ACLU-RDI 1637 p.188
510-112
NSN 7540-00-634-41 3
MEDICAL RECORD NURSING NOTES (Sign all notes)
DATE
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hospital or medical favi ity)
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REGISTER NO. WARD NO.
MEDCOM - 16629
NURSING NOTES
Medical Record
STANDARD FORM 510 IREV. 7-91) Prescribed by GSA,ICMR. FIRMR !Si. CFR) 201-0.202-1
DOD-030018
ACLU-RDI 1637 p.189
NURSING NOTES (Sign all notes)
HOUR DATE
A.M.P.M.
OBSERVATIONS Include medication and treatment when indicated
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DOD-030019
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ACLU-RDI 1637 p.190
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OBSERVATIONS Include medication and treatment when indicated
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MEDCOM - 16631
DOD-030020
ACLU-RDI 1637 p.191
CATION (For typed or written entries give: Name—last, first, middle; grade; rank: rate: hospital or medical lad itY)
MEDCOM - 16632
REGISTER NO. WARD NO.
NURSING NOTEli
Medical Record
STaNOARD FORM 510 (REV. 7-Si;
510-112 - • - - -,
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(Sign all notes)
DATE HOUR OBSERVATIONS ‘, .
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DOD-030021 ACLU-RDI 1637 p.192
MEDCOM - 16633
510-112
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NURSING NOTES (Sign all notes)
DATE HOUR OBSERVATIONS
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PATIENT'S IDENTIFICATION (For typed or written en ries give: Name—last, first. middle; grade; rank; rate: hospital or medical facility) • REGISTER NO. WARD NO.
NURSING NOTES
Medical Record
STANDARD. FORM 510 (REV. 7-91) Prescnbeci by GSA/ICMR. F1RMR 141 CFR) ::01-9.202-1
DOD-030022 ACLU-RDI 1637 p.193
NURSING NOTES Sign all not
DATE
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OBSERVATIONS Include medication and treatment when indicated
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MEDCOM - 16634
DOD-030023 ACLU-RDI 1637 p.194
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DATE HOUR OBSERVATIONS
Include medication and treatment when indicated A.M. P.M.
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MEDCOM - 16635
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DOD-030024
ACLU-RDI 1637 p.195
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DATE HOUR OBSERVATIONS
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Medical Record
MEDCOM - 16636 STANDARD FORM 510 iFtEV. 7-911 Prescribed ty GSA/1CMR. FIRMS (41 CFR; ::01-9.202-1
DOD-030025 ACLU-RDI 1637 p.196
510-112
NSN 7540-00-634-4
MEDICAL RECORD NURSING NOTES (Sign all notes)
DATE HOUR OBSERVATIONS
Include medication and treatment when indicated t A.M. P.M.
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NURSING NOTES
Medical Record
IMP MEDCOM - 16637 STANDARD FORM 510 jRF.V. 7-91) Plescrted Iry GSA/ICA/IR. FIRMR CFR: 201-9.202-1
DOD-030026
ACLU-RDI 1637 p.197
PATIENT'S IDENTIFICATION For typed or written en ries give: Name—last, first, middle; grade; rank: rate: hospital or medical lac, ity) REGISTER NO. WARD NO .
510-112
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DATE HOUR . OBSERVATIONS
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NURSING NOTES
Medical Record
MEDCOM - 16638
STANDARD FORM 510 [REV. 7-91) Prescribed by GSA/ICMR, FIRMR ;41 CFR) 201-9.202-1
DOD-030027 ACLU-RDI 1637 p.198
'U.S. Government Printing Office: 1995 • 404-763/20065
NURSING NOTES
DATE HOUR
v OBSERVATIONS I A.M. P•M. Include medication and treatment when indicated
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MEDCOM - 16639
DOD-030028
ACLU-RDI 1637 p.199
510-112
MEDICAL RECORD
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DATE HOUR OBSERVATIONS
when indicated A.M. P.M. Include medication and treatment
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hospital or medical fedi ity)
MEDCOM - 16640
REGISTER NO. WARD NW4
NURSING NOTES
Medical Record
STANDARD FORM 510 ;REV. 7-91) Prescribed by GSA/ICMR, FIRMR i41 CFR) 201-0.202-1
DOD-030029
ACLU-RDI 1637 p.200