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PAGE OF

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

DA FORM 7 98 3. 5-C_

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180

160

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

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PROCEDURES and CPT Codes: "21----- cc a. 0 0 OM /214-

ANESTHE HNIQUES: Describe block technique under Remarks Cs t---- • . D , v

Medical lac i

C *-

PATIENT IDENTIFICATION: Typed or wrii7 n nties: Name, Grade/Rate, AIRWAY MANAGEMeNT: In tuban lac&Anique, comments

Mark with letters & symbols, EVENTS_,. explain under REMARKS Position

PROCEDURE LOCATION:

40

■

SURG

TAI.

10-0

TOTAt UMW

30x, 2e2

*svmw CRYSTALLOID-

— 2.XTZ-LjeC)

COLLOID- 2 z SINGLE DOSE DRUGS-MARK ON GRID ct WITH NUMBERS & ENTER IN REMARKS

02 L/Min

VT-ml

I breaths/min

Peak inf pres / PEEP

MODE - Spon), AlssisO,

N-M Block IT/4)

BP- >1/4. / 03 / 37

HR- 9 171

ECK

EST BLOOD LOSS

pqt Ole TIME iml■ r? X

URINE -

3 0

Code drugs with numbers, events with lettters

OTHER

CONDITION: 7-.55. 7 RESP. SpO2- F3%.1 BP-iz HR- / 1) 1

BP/Auto Cuff

BP/oth

ART line

Steil'. PC/ES

Gas analyzer

V

ACLU-RDI 1651 p.1

HABITS: TOBACCO:

ETOH: v525- DRUGS: sa

CURRENT MEDIATIONS: 0 = ordered al premed

()

()

()

()

()

()

PREMEDICATIONS: None Yes (t) Hrs) /CC

mg IV IM PO mg IV NA PO mg IV BA PO

LABORATORY STUDIES:

HBMCT: U/A: OTHER:

1,3 3 Z 4°1 C

z F( iti

7, RS

Patient Identification: (Ward)

WAMC Form 2300 (Revised) 15 Mar 01 IACXC-DOS MEDCOM - 19242 PATIFNT P Fryman nr1PY

SEDATION KEY:

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

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

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 Patient responds purposefully following repealed or painful stimulation.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

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

Previous edition is obsolete * U.S. GPO: 2002-723283

DOD-032816

ANESTHESIA PLAN OF CAPE PREPROCEDURAL A:=AENT (Se. NAnesthesial Age)-DAYS M Sex ( ) FEMALE

PROPOSED PROCEDURE: 0 ft- A _A_ SURGICAL SER E 111 I Iva NPO SINCE: EllirirY l. MIMIC

N Y N Y

Familial )IX

N Y

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:

Hypertension Angina MI CVA Other

Pulmonary System: Asthma Bronchitis/URI COPD Other

Renal System: Acute/Chronic RF

Gastrointestinal:

Y PUD/GERD

Hepatitis Hiatal Hernia

Endocrine System: Diabetes Steriods Thyroid

Neurological:

Y Other

Seizures Neuropathy

Gynecological : Pregnancy N Y

Other Significant Hx:

N Y N Y

Y

ANESTHETIC PLAN:PLAN: { LOCAL { MAC

yot61124,Ad

{}

I •

I ev kir, 411C ,

1.

Regional (Specify):

0

ASSESSMENT PAST SURGICAUANESTHETIC

PHYSICAL EXAMINATION BP la' 5-tIR 0(5" R T Pain 0-10 HEENT - Teeth

Trachea _m

EXTREMITIES: Fcctorn ..C1Q ey_ IV Access: Ulnar Filling:

IRY

imp++. r 6,0 • •

{ Mas ntubation

Orophamyx Nares

CHEST: C114

IN- MO —rift

CARDIAC: 22. P.()

BAC

OTHER:

NPO Since fj-

INFORMED CONSENT/COUNSEUNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and discussed with the patient/legal guardian.

(C.e2j The nd d ag Questions an Signed:

POST- A EVALUATION NON A ) () NO PPARENT ANESTHETIC COMPUCAriONS { OTHER

Date: lime: Hrs

Time: Hrs

ACLU-RDI 1651 p.2

REGISTER NO.

PREGNANT

0 YES U NC TELEPHONE/ PAGE

REQUE TED BY

STOR

vv p w uti-A

E/13.TE REQUESTED

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60-177d lel

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RADIOLOGIC CONSULTATION REQUEST/R

ExaminEPOR

tions) WARD/CLINIC

CA).-3

(Radiology/Nuclear Medicine/Ultrasound/Computed Tomo raphy a

AG I

2-) iC.VOJL oSseA to

3) f\'(eccrYY1 ae-t4}-4 PA-1W- c,-ci

1,as,ck

NS$ 7540-01-165-7294

EXAMINATION(S) REQUESTED

PAI FILM NO.

S La", lA4e-WZ134 CC14 PO16045

- -

SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)

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.7( -̀ 1,,C,-4 May i,cc,.,wcyi —

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

(Month, day, Year) DATE OF TRANSCRIPTION

(Month, day. Year)

Wc,V-se CLIO<

-diE yy) r017 1‘54-1

0 id-

j (X)(01-Q RADIOLOGIC REPORT C-..k4

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_ Cfi nu

1cvn -sc./4 ,/,47 OLA-41

nvii 5Cj? L°1714a

Or Mc/

PATIENT'S IDENTIFICATION (For typed or written en

Name — last, first. middle, Medical Facility )

ANN

s give: LOCATION OF MEDICAL RECORDS

LOCATION OF RADIOLOGIC FACILITY

SIGNATURE

MEDCOM - 19243

10 -FIORE. 0 64 2-3 Yr Yr! S

DOD-032817 ACLU-RDI 1651 p.3

4)0 oce,id

PATIENT'S IDENTIFICATION (For typed or written entries eine: Name — last Pleat, middle, Medical Facility )


RADIOLOGIC CONSULTATION REOUEST/R EPORT

— MEDICAL RECORD

STANDARD FORM 519-B (8-83) Prescribed by GSA/ICMR FRIAR (41 CFR) 101-11.806-8

SIGNATURE

RADIOLOGIC CONSULTATION REQUEST/REPORT (RadiologyAudear Medicine/Ultrasound/Computed Tomography Examinations)

AGSEX SSN (Sp WARD/CLINIC REGISTER NO.

221 EXAMINATION(S) REQUESTED

CT c Prc-E-

N x■cx_f2_, Gor ono-- (2 ■ eA-&-mcS 31-rwy-% Q'i-\-y

FILM NO. PREGNANT " -q YES [NO

TELEPHONE/PAGE NO.

DATE REQUESTED.

153 SPECIFIC REASON(S) FOR REQUEST (Complaints and finding

s \... (:).e.A. °Irv&

Lee -v- 2_nr\c_.

DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Mon

RADIOLOGIC REPORT

cen,",./z-G42„4, 144 (4,-e-e 6

4

MEDCOM - 19244

DOD-032818 ACLU-RDI 1651 p.4

111 ' leoIo leo' leo DOD Sep/15/03 12:24

GAIN: 67dB TGC : -6d13/cm DC.

B 60mm B Log In 50dB • a

GAIN: 71dB TGC : -5dB/cm

B 60mm FPEE2E El Log 'W El 50dB • B ®

•

CA•

'Air 1 ' " lin" '' leo' Imo I Ittou " i lEi3 MOD Sep/2I/03 13:20

I CV I GAIN: 67dB TGC : -6dB/cm

lo ' ho I leo' DOD Sep/21/03 13:20

( - ci

60mm • Log B 50dB El AiN

FREEZE

El CARD

i I Igo leo I "• Ilia''' . leo' lab

DOD Sep/15/03 12:23

GAIN: 71dB TGC : -5d8.cm

B 60mm FREEZE .t I I Log .

1 0 P .

90 90 40 50 SO OD Sep/21/03 13:22

MEDCOM - 19245

a 50dB

DOD-032819 ACLU-RDI 1651 p.5

LI T TI • ORDER

• TED A IG

DATE OF ORDER TIME OF ORDER

15-5' 'ZIC•IC) HOURS

PATIENT IDENTIFICATION

NURSING UNIT


Oi-Pvi(r otvz%' 6 0" ve, 1+1A-4,

NURSING UNIT


C \/1

1111111

NURSING UNIT

C MZ PATIENT IDENTIFICATION

111111MIM 111111111111 - nrimmIllf,

c1r7111111116111

DATE OF ORDER TIME OF ORDER *2 HOURS

III St1K „ firM&4 IIIMM DA

ROOM NO .

OF ORDER

ci v

URSING UNIT

1 APRFORM

79 4256 DA

HOURS

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

For use of this form, see AR 40-66. the proponent agency is OTSG

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

MEDCOM - 19246

DOD-032820

ACLU-RDI 1651 p.6



PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

ROOM NO. BED NO.

NURSING UNIT ROOM NO. BED NO.

-

BED NO.

C_ PATIENT IDENTIFICATION

NURSING UNIT

wZ


eel i

DA 1 FAOPRRM79 4256

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

MEDCOM - 19247

LIST TIM ORDE

NOTED SIGN

DATE OF ORDER TIME OF

DATE OF ORDER TIMI 6F 0 ER

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

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

DOD-032821 ACLU-RDI 1651 p.7

AL;


HOURS

4JJ1/4_e_x- 1-Dt- -Df4

0,4,10-14 ac3.1/43a_b PL,LAS °,

\--VL k not, r\r‘oiLk ty-s ir iry)

HOURS

CA_A-rn 1 S 64CD D

re Pc 19,9 rt, DATE OF ORDER

TIME OF ORDER

cazti' in

NURSING UNIT

ROOM NO. BED NO.

PATIENT IDENTIFIC ATION

ROOM NO. BED NO.

OCUU-4601.11111 UV-MO f9 01- iS TJ 1 APR

FORM 79 425 DA

NURSING UNIT

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE


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

PATIENT IDENTIFIC AT DATE OF ORDER TIME OF ORDER LIST TIME ORDER

(-')3 0-) 415(441- HOURS NOTED AND SIGN


Arvi t -PfNe q-Ane.n

1. c, \ FIL C31,-) Le c C. -Er

Clicr-N (9,

Drt -eA 0 31..o__"_)Th <VA,o

rkAaic a-s

BED NO. co NURSING UNIT

ROOM NO.




U.S. GOVERNMENT PRINTING OFFICE: 2001-478-200

••I ICC CA/ I nelno, Ott, OCCOC C In•M v I min f, A nam-NM n A na, n Cryl no cn••

MEDCOM - 19248

DOD-032822

ACLU-RDI 1651 p.8

BED NO. ROOM NO. NURSING UNIT

+ DATE OF ORDER

.5A fel0 3

-

DATE OF ORDER TIME OF ORDER PATIENT IDENTIFICATION


4

NURSING UNIT BED NO. ROOM NO.

113 0 HOURS

\ed

ckomp

NURSING UNIT ROOM NO. BED !zO.

9-4.° Cir. o c_t_ D-nsete PATIENT IDENTIFICATION TIME OF OR. R

HOURS 2-1A S-t-131 0-11rN C,9-4)

PATIENT IDENTIFICATION DATE OF ORDER

20-1"

TIME OF ORDER


DAApFi FORM REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED. 4256

LIST TIME ORDER

NOTED AND SIGN

I 3 373 TIME OF ORDER

HOURS


Aim

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

MEDCOM - 19249

DOD-032823 ACLU-RDI 1651 p.9

6(a) -

NURSING UNIT

ON OF 1 JUL 77, WHICH MAY BE USED.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME ORDER

NOTED AND SIGN

HO

NURSING UNIT

N

NURSING UNIT


NURSING UNIT ROOM NO.

nb 03 tass- PATIENT IDeNTIFICATION DATE OF ORDER TIME OF ORDER (53

sar_02).L._ HOURS

a U.S. GOVERNMEN- MEDCOM - 19250

1( (0 7-

DA F 0 , APR 79



DOD-032824 ACLU-RDI 1651 p.10




\.° )c7

U DATE OF ORDER TIME OF ORDER

71 .1_,- 1,1'4 0 HOURS

LIST TIME ORDER _..e

NOTED AND

OC ( J i\.:C.., AAA&

NURSING UNIT

Erj

ROOM NO.

)CiSeA, ca -'

BED NO.

co3C) ‘ L-T 1 cit-Lailrt , ._,.26..- 7_ PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

/ 03 MO HOURS b i r/i 1 1 Li I ,, 0,41 I / t ...

- AllpiPPImr` I / I / 112. /A i '11 P • ' - • - •

Ct-s' °- . V 111 'r t ' 0 ) i i AAP-

BED NO.

NURSING UNIT ROOM NO 1' A


HOURS


PATIENT IDENTIFICATION DATE OF ORDER TIME 0 ORDER

HOURS

, 4 ' 411i NURSING UNIT

.....”

ROOM NO. BED NO. illi.

FORM 1A T9 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

U.S GOVERNMENT PRINTING OFFICE: 2001-478-200

"USE BALL POINT PEN—PRESS FIRMLY I NO CARBON PAPER REQUIRED"

MEDCOM - 19251

riv

DOD-032825 ACLU-RDI 1651 p.11

..../ CLINICAL RECORD

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON4IEDICATION) 7 the proponent agency Is the OffICesZT4hRe 4Surg0eCsn General. ma CA Yr. 2003

l'ERIFTBY IA7T1ALING / 4 ' INITI4L PROPER COLUMN FOLLOWING EACH COMI'LETION

ORDER DATE

/ CLERK/ NURSE

RECURRING ACTION, FREQUENCY, TIME

HR DATE COMPLETED

IBMIBIEfilliM PI - --- -

15-

T

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1..dt„.„.0s.:( 2 ,---_-f—rEp..N— milt. / Pr li -

d ALLERGIES:

Pe.,d4

M YES MI NO PRIMARY DIAGNOSIS:

0 -eft_ Fi-c 4, 0 S A i-e—, re

•

MI NO

PAGE NO•

PATIENT IDENTIF CATION:

b (U Y 1

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

MEDCOM - 19252

DOD-032826 ACLU-RDI 1651 p.12

Verity by Initialing

7..--- THERAPEUTIC DOCUMENTATION CARE PLAN

7. (NON-MEDICATION) / 0q yr 2003 order Date

Clerk Nurse '

, SINGLE ACTIONS Date to be Done

Time to be Done Time Done Initials

1.S 1/-124- LCC-1 I- Oa vLS) :‘ C.6-?-1. (11Ls- 5I-tVc

1 61 kJ VO -9- I\AI\I q - II: t1O1

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2.--143 QS t-Lu ,....1– 0 Ce∎ *x—/(..ei: -WI cl) r- , 4L r--.1 .

i.

- _ — —

.% t • 1 I

- _ — —

Order/ Expir Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

---- ----

le

- - - - - - - -

- - =A ■•••

■■• ■ .... .... -.. ■■.. ■ .■

rm. ■ .... .... ■ .... .... ....

■ .■ .... ■ ..... ..■ ■ ■

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MEDCOM - 19253 USAPA Vi.ee

DOD-032827 ACLU-RDI 1651 p.13

/-r CLINICAL RECORD

THERAPEUTIC DOCUMENTATION CA PLAN (NON-MEDICATION) i-

For use of this town, see A 07; MO. yr. 2003

VERIFY BY WMALING 7 :47i2 721.T; tt,71,..4trerw. 75:. 4 7 is the Office of ThpRecSItufaeocnoleneral

FOLLOWING EACH COMPLETION

ORDER DATE

CLERK! NURSE

RECURRING ACTIONS, FREQUENCY. TIME

HR 1 DATE COMPLETED

IA _

Clis (94 -- 111111- q\.X-ca_L) v t-1lJ-\.C\."..it-1. -f•C\_Q- 0 £.-

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ALLERGIES:

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ON YES 1NO

v()P.1

PRIMARY DIAGNOSIS:

'4tiv\-0 L\2..A.,ift,,,A,k&.

,

ADDITIONAL PAGES IN USE:

0 YES MI NO

PAGE NO"

PATIENT IDENTIF

\-- ACTION TIMES

C ( 0

AI ( U) - q

USE PENCIL. CIRCLE ACTION TIMES

KAAA C.k (- -InitcAl_Q__;\ 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


EDITION OF 1 DEC 77 MAY BE USED. USAPA v1.00

MEDCOM - 19254

DOD-032828 ACLU-RDI 1651 p.14

CLINICAL RECORD THERAPEUTIC DOCUME

ForNTATION CARE

40-407; PLAN (MEDICATIONS)

use of this form, see AR the .ro.onent a.enc is the Office of The Sur.eon General. Mo. 0 Y r.

VERIFY B Y I N I T I A L I N G ;i;.50::::::;j::i;i:g::::.;:n .:i: -;.!:M;:i;:;M::::;;;Mf;:g:N::;.::; i:.:;M I N I T I A L P R 0 P E R C 0 L U M N I: - 01_ L 0 IF I N G E A C ll A I) ii, II N I .S' 17? A T I 0 N

HR DATE DISPENSED ORDER DATE

CLERK/ NURSE

RECURRING MEDICATIONS, DOSE, FREQUENCY 11616/ t& RV IIIMPAILI/

c - - A) So Lc (o ti/t) ri ' 1■PE I litailllEMM ,,)

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I. YES - NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:

C7 .PIC flc, ..t. O 5 r., ,b,„/ t„1,.4.y L.7._ •• YES III NO

PAGE NO.

PATIENT IDENTIFICATION: DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES C111111.

,

10 is. ,.._,, D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

DA FORM 4678, 1 FEB 79

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00

MEDCOM - 19255

DOD-032829 ACLU-RDI 1651 p.15

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. o 7 ,. 1,

Order Date

Clerk/ Nurse

SINGLE ORDER, PRE-OPERATIVES Date to

be Given Time to

be Given Time GINAIII Initiate

4,

■

t

11:

1

(C___ — ?_ A A :,:

Order/ Expir Date

Clerk! Nurse

PRN INITIAL PROPER COLUMN FOLLOWING ADMINIS7 RATION MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED

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DOD-032830

ACLU-RDI 1651 p.16

( - 2 ec- CLINICAL RECORD

THERAPEUTIC DO For use

ENTA TION CAREo LAN (ME IIICATIONS) of Ihis form, see AR 40,

thepr ponent agency is the Office of The Surgeon General CI (--1" Mo. ) Y r. 3 V E I? I l: Y BY I N MA LING „..::.: :::;1::ii:;:.:::: : ::;.ii:; :: : i . ' .:f ::::::;.: ...A ..::::. .:. .- ' ::.i::.i.: :: INITIAL MOP El? COLUMN POLL i IF ING EACH ADM/MS./RA HON

ORDER DATE

CLERK/ NURSE

RECURRING/MEDICATIONS, DOSE,,FREQUENCY

HR DATE DI PENSED

Ito 17 miluiniiiisimm0 • Ito

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1

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ALLERGIES:

)0

I I YES MNO

K--13A

PRIMARY DIAGNOSIS.

-gCjiv'f-A-C ir\ -erneirr V\ 0.0e--


I I YES M NO

PAGE NO.

PATIENT I NTIFICATION: DISPENSING TIMES

CIV . USE PENCIL. CIRCLE MED TIMES

I. (u_ - cil D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06


EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1,00

MEDCOM - 19257

DOD-032831 ACLU-RDI 1651 p.17


THERAPEUTIC DOCUMENTATION CARE PLAN (XI EDICA TIONS) Mo. _

Order

Date

Clerk/

' Nurse

4r SINGLE ORDER, PRE -OPEhATIVES Date to

be Given

Time to

be Given

cool

Time Given

Ccolli

Initials

1'17- lb /V lo i 5A-art-NISO P.5 'tlivi A .

i 1.

A-L.) (_0) - 2 S1L, \ ,. a

to

Order/ Expir Date

Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUENCY

INFIIAL PROPER COLUMN FOLLOWING rlDMINISMATION

TIME/DATE DISPENSED Fr.7

1011 PV(Y16-, 0r.b pe> 14°1 (1'1/1 -!,svv 1 -E., o-i)

2.264C3 yr-.

of,.

(I249c

e-ftc4

'2. (j15, -1"2..6

011 1 1

inS pr A I r\fw,-,,,,vi '

)

6-10111111111*

ci4.

1

eiz-cocc--1- ere, il--46t-

----

•

USAPA V1.00

DOD-032832 ACLU-RDI 1651 p.18

CLINICAL RECORD/ /..

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;

the prom-lent agency is the Office of Tae Surgeon General . Mo. Y r.

I/ E It I E Y II l 1 N I T I A L I N G ,g-;;;:.;:;; ,:g;M::;:g4m i:ii,:iO3:0:::;; I N 171 A L Pl?qPI:. I? (-GLUM N F 0 L LO I V I NG EACH A DM I N I STI1 A T I ON

RECURRING MEDICATIONS DOSE, FREQUENCY

HR

0

DATE DISPENSED ORDER DATE

CLE NU, SE ,41

//iii iit v-t

rurk CA cemts,__V1- . D S (DLe'

I

R,— t . 0 )( ;

S RI

2_

OE "

4 _ .

/ jci

ALLERGIES:

1 v

I I YES INC,

v ) A

PRIMARY DIAGNOSIS:

(2--Q- -V ■ t- at- VA,ecc, I livc"- LA , 5aqi,*... co_ c(.4, ADDITIONAL PAGES IN USE:

I YES NI NO

PAGE NO.

PATIENT IDENTIFICATION: DISPENSING TIMES • ... __ _

C_ t.: (.1 USE PENCIL. CIRCLE MED TIMES

(u

D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22 VQ i)Iblri- 5 otsx 42- N 23 24 01 02 03 04 05 06


EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00

MEDCOM - 19259

DOD-032833

ACLU-RDI 1651 p.19


THERAPEUTIC DOCUMENTATION CARE PLAN 1 j i (MEDICATIONS) , Mo. Yr.

Order Date

A Clirk/ Nurse

.. _

SINGLE ORDER, PRE -OPERATIVES Date to

be Given Time to

be Given Time Given Initials

'f45'

. .

. .

4-

tli

Order/ Expir Date

Clerk/ Nurse


INITIAL PROPER COLUMN FOLLOWING ADM/NISI RATION

TIME/DATE DISPENSED

25 ,..p 2659.

. _ Vic rx 0-t- MIT PD

Zs---3-ruAl ,.,..-? k„ .T:)

& 0

gitSA ...

InU

-yam d

c7W-K 050 11 4

( k-l- 6 0--(N)

.,

°.5-€1- 01110PWL Qs.0-y, tR.S rr.s3

The (''t-- PQ-w nio

MEDCOM - 19260

USAPA V1.00

DOD-032834 ACLU-RDI 1651 p.20

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA for use of this form see AR 40-66; the proponent agency is the Office of The Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet

7--‘( OTSG APPROVED Wares

Date: ft.-E. (.11-) Anesthesia Type (Circle)): General Spinal Epidural ,5 Drains Airway

Time In: 1 61I C- IV Sedation Nerve Block Hemovac NG JP

T-tube Foley

TLS

Nasal Oral ETT

Trach

Other

Allergies: /\/163 /(4 OR Intake: Crystalloid N ' Colloid 1.0'.

Pre-op V/S: fl.::)/14/ q 5- • • Output: U 0 EBL KA 1-1.A • 7(P1'. , Procedures: r - 0.•..., ill • Meds/Times: V e,,,, ,,,-,,e /• F.-1r---i -i— J _

Pre Op Meds -

i , 1- 4 N

-7, . 2- ' 3

His t;N- V

Time 1—, - c17, • o-- x s)

......,

I

Pacu Intake

Sa02

Fi02 f?.. Time Solution Amount Site • By Infused

t9 51) (-le- (IC) / ( Pi V Methods

240

220 X-rays: . Labs:

• Post-Anesthesia Recovery score

200 Criteria ADM 30' D!C Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities

(0) Moves 0 Extremities

Z.,..... AIRWAY A =Ambu BB = Blow-by M- Mask

180

160 Airway

(2) Cough. Deep breath (1) Dyspnea. limited breathing (0) Apnea

?____ FT = Face Tent RA = RoomAir NC = Nasal 140

, Blood Pressure (2) SBP =1- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =/- 50 of Pre-op

2....-

Z...... Cannula

V/S X =A-line BP

120 \ V

'k/ X r. 7 ft 100 a 04

Consciousness (2) Fully Awake, audible

aYing (1) Arousable to verbal or pain 1

' = Cuff BP = Pulse

TEMP

z

80 Color

d appear (2) Bas eline color ance (1) pale. mottled. jaundiced (0) Cyanotic

2_____ .._. S = Skin 0 = Oral A = Axillary

-Tympanic

60

AI\ A 40

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial

(0) rood only reliablg puise ...

R = Rectal

LOS C = Cervical

1

20 1 TOT S: Must be 9 M

approval to D/C, otherwise

needs anesthesia appval for DIG.

T = Thoracic L = Lumbar S = Sacral RR 4 Z2. C

T

Time ( Patient teaching done; Wound Ca e, Pain Management,

Pain (0-10) NY-k Ai T. C, & DB,. Incentive Spirometer, Comfort Measures

LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained ILonlInue all reverse!

(()\) '-2-- DEPART NTIS

1

ERVICEICLINIC

7

DATE

AS 6-V ei3

PATIENT'S IDENTIFICATION we: Name - last, list middle: Fade: date: hasp

( Ck) - (J1

. C 1 t/ -

',2 \i .- q

.

• HISTORYIPHYSICAL 0 FLOW CHART

IN OTHER EXAMINATION III OTHER rs,..6/0 OR EVALUATION

• DIAGNOSTIC STUDIES

III TREATMENT

DA FORM 4700, MAY 78

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

Previous edition is obsolete USAPPC V2.00

MEDCOM - 19261

DOD-032835

ACLU-RDI 1651 p.21

NURSING NOTES

1(4‘) /GO— L

Com) 2—

PACU OUTPUT

Time

12

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Run?

1 ,1 -70 ...(2.,__

WAMC OP 173-E

Discharge Criteria: Date: IST- 00,7Time: PARS: 10 " BP: 12,21(ittT:act HR:I 0 (-P. RR: 14 Sa02: Pain Level at D/C (0-10): 0

(c" Additional Data: Transferred To: Report Given To: Transferred Vi Transferred Cleared IAW Charge Nurse Signature:

Source Color/Appearance Amount

Output: 2"-

Intake: t OND.

y Ambulance

Ro

MEDICATIONS Allergies: Time Pain

1-10 Medication 8 Drisane

Route Pain 1-10

1/E By

JA'

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Adm :-...„ . 15' 30'

> 45'

60'

90'

D/C

Movement/Sensation: + = present,- =absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D =Doppler. A = Absent Color: C= Cyanotic,

Capillary Refill: B = Brisk, S = S uggish P = Pale, Pk = Pink

C-SECTIONS

30' 45' 60' 9D' D/C Fund. Height

rAr it....,,I ,...115'

---------- Lochia ----...„...,.........e.....„..--

Peripad#

Fund. Cond. ---

■-'' ---.............._

DRESSINGS

'Time Location Type Drainage

Adm 0 __S b.)\ pC- 30'

60'

D/C

-

MEDCOM - 19262

DOD-032836

ACLU-RDI 1651 p.22

DOD-032837

"D?.p ( 0 cc

14 Ib 10 ► z

Pre Op Meds

Time

Sa02

F102

Methods

240

220

200

180

160

140

120

100

80

60

40

20

RR

T Tim Pai LO

PR

PATI

X / Hf v

a

• •

Site • By Infused Time Solution Amount

X-rays: Labs:

Criteria ADM 30' D/C Codes

Activity (2) Moves 4 Extremities

Moves 2 Extremities (0) Moves 0 Extremities

Airway (2) Cough. Deep breath (1) Dyspnea. limited breathing (0) Apnea

Blood Pressure (2) SBP =/- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP 50 of Pre-op

Consciousness (2) Fully Awake, audible crying (1) Arousable to verbal or pain

Color (2) Baseline color a appearance

(1) pale, mottled, jaundiced (0) Cyanotic

Peds < 5 Years) (2) radial Pulse (1) Axillary palpable, not (0) Carotid only reliable pulse

TOTALS: Must be 9 or

greater to 0/C, otherwise needs anesthesia approval for D/C.

Name —last,

❑ HISTORYIPHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER {Spear/

OR EVALUATION

❑ DIAGNOSTIC STUDIN

ci TREATMENT

DEPART7 SERVICE/CLINIC

ACU

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4066: the proponent agency is the Office of The Surpon General.

V

•

DA FORM 470 , WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete uson P2.00

MEDCOM - 19263

Histor

en entries give:

aryl

,REPORT TITLE

(0ry Date: t 460 Time In: I )eCO Allergies:

Pre-op V/S: Procedures:

Post-Anesthesia Care Unit (PACU) Flow Sheet

Anesthesia Type (Circle inal Epidural

I ion Nerve Block

OR Intake: Crystalloid OC.0°C-, Colloid

9/ OR Output: UOP ;010 EBL ( 00 Ti1 0, -. >7 Meds/Times:

t0

03 0

Post-Anesthesia Recovery score

OTSG APPROVED Ward

Drains Hemovac

NG JP

-tube

Airway Nasal

Oral ETT

Trach

Other

Pacu Intake

Patient teaching done: Wound Ca e, Pain Management, T. C, & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

AIRWAY A=Ambu BB = Blow-by

M = Mask FT = Face

Tent RA = RoomAir NC = Nasal Cannula

VIS

X =A-line BP

=Cuff BP = Pulse

TEMP S = Skin 0 = Oral A = Axillary

T = Tympanic R = Rectal

LOS = Cervical

T ...thoracic L = Lumbar S = Sacral

2

(1)( li.onimue on reverse/

DATE

ap

ACLU-RDI 1651 p.23

MEDICATIONS Allergies:

Medication & Drisacie

Time Pain 1-10

Route Pain 1-10

I/E _ By

Discharge Criteria: Date: 05k tOD Time: 13.W PARS: BP: 122/a, T: 9q. HR: 8 RR: Sa02: Pain L vel at D/C 0-101: Intake: J Output: 3? s- Additional Data:

Transferred To: ICU)

Report Given To: Transferred Via: W/C Ambulance Transferred By: Cleared IAW Reco Charge Nurse Signature-

- -- NEUROVASCULAR

Time Site Range Of

Motion

Sensory P C efill

T Color

Adm

15'

30' ./"..'. 45'

60' 90>-----fr

D/C

Movement/Sensation: + =present,- =absent Temp:C= Cool, W =Warm Pulses: P= Palpable, D =Doppler, A = Absent Color: C= Cyanotic,

Capillary Refill: B = Brisk, S= S uggish ale, Pk = Pink ,

C-SECTI Adm 15' ...301 45' 60' 90' D/C

Fund. Height -------' Lochia

Peripad#

Fmock't-ond.

DRESSINGS

Time i-N.Location Type Drainage

Adm 0±_) Gtovt CD:1- 30'

60'

D/C

RSING NOTES

6-11024 40?Acu e (ASO' 06(0, opiJ e„0 •

ice Go,ko-K-1 cfko, (t-,1 kik?' cc/kr

PACU OUTPUT

Time Source Color/Appearance Amount

I . 40 --Po le y )?J tcx.,) 2, a s--

• CARDIAC RHYTHM

Time Rhythm Syn,tomatic? Rhythm Strip Run?

i nD k),564

WAMC OP 173-E

MEDCOM - 19264

DOD-032838

ACLU-RDI 1651 p.24

1 . REPORTING MTF 2. MTF LOCATION ADMISSION AND CODING INFORMATION

For use of this form, see AR 40-400: the proponent agency is OTSG 1 2 3 4 5 6 7 8 (State or

Country Code.) A 1 r.-1

9

3 . REGISTER NUMBER NAME (Last, First, Middle Initial)

)r V C,e_ - L\

4. PAY GRADE 5. SEX

10 11 12 13 14 15 16 17

C iv

18

BIRTH (1" Y Y YMMDDJ

Vi'l

6. DATE OF 7. AGE AT ACE 9. ETHNIC RELIGION

ri (:),C i--- , i 01

19 20 21 22 23 24 25 26 27 28 29 30 3 1 BACK- GROUND

U A.) 14 ti).- a_, g

10. LENGTH OF SERVICE ETS 11. FMP

y

12. SOCIAL SECURITY NUMBER

32 33 34 35 36 37

- - .1-7 44 ADMISSION

i

38 39 40 41 42 43 44 L.

ORGANIZATION (Active Duty Only)

)r'CIUS1-1 06\ (MN/

13. MARITAL STATUS

raie

BRANCH / CORPS k.-- ( (,) - LA

46

C.--4

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE

47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 1 ._

k 7 C:

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION

62 63 Country Code)

64 65 66 67 68 69 70 71

1>j5

YEAR NO

_

20. SOURCE OF ADMISSION/ AUTHORITY FOR

ADMISSION WARD

I eC/1-

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

72 ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

,----

NAME AN -

21. TYPE OF DISPOSITION

CILITY

22. MTF TRANSFERRED

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

TO 23. DATE OF DISPOSITION IYYMMD DJ

73

0 74 1

K 75 76 77 78 79 80 81 82 83 84 85 86

0 T rial1M2 ADMISSION

24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS (YYMMDDI

87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102

27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYMMD DI 103 104

(Battle Casualty Only) 105 106 107 108 109

-- 110 111 112 113 114 115 116

FOR LOCAL USE

)61- i°7 a: 0 4 AP"Pll , f IVO

0 Z3V011tfirtlfailiM6 .6

0) 34146 1 9 1 1 1 7710lif 0 .

0 . agrinr ci.trz-- lc,lc,._ - -c-

ADMITTING OFFICER (Signature, as require

6 7

SIGNA

MEDCOM - 19265

DOD-032839

ACLU-RDI 1651 p.25

INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40400; the proponent agency*

\ 1 "' NAME ....... r.rit, MI)

6\1‘)V

N.. GRADE

KJ A- ADMISSION REMARKS

,

4 . SEX

1.'4

5. AGE RACE RELIGION

U 0 \e''' 0 1\J 1-- NG H OF SVC

koNJ N E TS

NJ Pk 10. PREVIOUS

k V/MISSION

NJ 0 I I. FMP ORGANIZATION

--Q_.) -

14. WARD

15. FLYING STATUS

NI

16. DEPT.! BEN

BPANCHICORPS

WA

19. UiCIZIP .

N. TYPE CASE

NC-a---

24

SOURCE F ADMISSION!AUTHORITY FOR ADMISSION

Ot rtdc -CDC ri-\ --c- „,---\--

22 HOURS OF ADMISSION

16- 1 s--

23. CLINIC SERVICE

},- -c- A- A- NAMEHIELATKINSHIP OF EMERGENCY ADDRESSEE

)- '‘\. V-

25. TYPE DISPOSITION

r) q

26. DATE OF DISPOSITIO

1 0 1 i L-1 OS

224. ADDRESS OF EMERGENCY ADDRESSEE lInclude ZIP Cod.)

V)• f \ \---

27b. TELEPHONE NO.

(-)`--1.3

28. DATE OF THIS ADMISSION

ca- 0

ADMITTING OFFICER

3P- 1111111111010 COMPONENT TRANSFUSED

9 NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

XZ") °".---

30. DATE OF INTIAL ADMISSION

31. SELECTED ADMINISTRATIVE DATA

Chock II Continued on 118.13.

33 CAUSE OF INJURY

34 DIAGNOSESIOPERATIONS AND SPECIAL PROCEDURES

,(:)... ea AT 1 7 9, (0 6

' l'.- t i 'F 1 & F X g....31 4

74/7 e q45 8(/'3-'

V

35. Total Days This Facility

a. A BSENT SICK DAYS b. OTHER DAYS I c. &ORNVE .GLATOP d. SUPPLEMENTAL CARE DAYS

.. BED DAYS TOTAL SICK OATS

36. Total Days All Facilites &

a. ABSENT SICK DAYS 16. OTHER DVS

0

c. CONY. LVICOOP CARE DAYS

1:---) ' irk i

d. SUPPLEMENTAL CARE OATS

'

t BED DAYS

-1 O'

I. TOTAL SICK DAYS

[CAL OFFICER . ..

SIGNATURE OF PAO 1 EOICAL RECOPDS OFFICER

,

(

OITION OF I •

LSAPPC 11.10

MEDCOM - 19266

DOD-032840 ACLU-RDI 1651 p.26

t- 16-2_0 /007„,,A •82 PG- PHYSICAL EXAMINATION

fL2,41-letg

PA ritten Cl,

P-CE

/e4L-cr L (v-f-pre

A - it4/4

tries div Name last. first. spat./ or ed middle; grade; dam: ho

IDENTIFICATION NO. ORGANIZAT ION

REGISTER NO. WARD NO.

ical facility)

SIG

MEDICAL RECORD 13 Ooc, ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY. CHIEF COMPLAINT. AND NRITION ON A ISSION /Ea.: Thin of ad Mi. On) .

2- o

VMS N 04 0

01-0 c7 ?

? 1E) Jt GS

PROGRESS (Enter date of 411441,1qm and final diagnosii 1

ABBREVIATED MEDICAL RECORD Standard Form sae

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA (41 CFR) 201-45.505 OCTOBER 1975 539-106

MEDCOM - 19267 [IT ACLU-RDI 1651 p.27

AUTHORIZED FOR LOCAL REPRODUCTION

' MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

g( -CePfra3 CO afirldb, (2 l& a-0 q yo ka19- P109146 /g Pira ei , -,_o_hvexied. --/91- c-1,10 iM 66-1-Ii LE c- 411 vAta.#95 - cra-ezei

A,Walbkad .-p9r) / .• 5_ttle_-, aeiii_iJe-i, )7 , LAI- rii-r-e-7

currtio ' ' ,a,t_extic_ert_id to maite 61,brazi--4-• vii/J-e_bodie,.

44 ." . i R...u.)e7.ie_144 i--c) owl. Li2,0 a LS /--r) S-e-L CK

kre-4-# 4-11-1-A-C, " ovi-2 11 gai-e. a- " arilbs we 'l AY-

c)/C_ J_ ILI„-, i,u,eik. -,-/- iset_tic- -to _l_d_e_.,__p. ■ 6‘_ pieze iri_lye-,,2zgi

(52-1--4 LA_ ci-ild e_i_ryfrIpIteoti-2-zolg, z--- e„,_/)-)h iz-e.4-1,

17) lv vii_ p la- ei - qh c-)-Ljk (pro akid-1-1-0 (-1,-- eDIA-6-e407

e 1-1€ 421--___44.4,- 4/--- -- Sansezi);),

(a-Jo-Pe-az/6) i-z9 Z-t6 4- 4-kze--e- ,..e,07_,a--/-?-ia-, & / /

a,J,J.€,..0 dA CLQ-t1 ,✓/-74, -Z i-/d.4.0e,,ejk?-f_c/ _.. - , g V33_ Z2,4 • th b-e • i-L-e-ii 1-e2 on

LP/ 5171/ • '' 5'fr-702- - '1..'/ o--)-7

POe . 111 irY3%. i man fo-Y- II/ 1 IliniAAJ /v--R , ciy,

f_472

ris 1 , ois.t.4 63 , "P,,,,'„i A-- V, _._ .-1)-r- Pi. ,pr 1 , .,-\ e. i k.,

I 1( 1 c Lt-c 7 4-,53 _,,J.v _ - ,,,L„ . s r 1,1e.,1 13 „21 li( 6 IU J a AL_ 1, _.\ a a 1S() „ / ft K IV

6 1-,, a AC si CLIT 41., P.' _ 6 s 5 0 RELATIONSHIP TO SPONSOR • SPONSOR'S NAME SPONSORS ID NUMBER

(SSN or Othed • LAST FIRST

DEPARUSERVICE

sX

HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (for IYPed or wimp entlies• g iVe: Pe."" • lest fir14 middle; /DM) or SSN; Sex Date ol Birk fisfik(Giffiel

REGISTER NO. WARS

PROGRESS NOTES Medical Record

STANDARD FORM 509 IREV. 611999) Prescribed by GSA/ICLIR FPLIFI141CFRI 101.11/03041101

USAPA VISO

MEDCOM - 19268

DOD-032842 ACLU-RDI 1651 p.28

STANDARD FORM 509 inv. 5119n) BACK

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

/1 Cy (1 r 4-L s r,-; Lk ....... .(.0 4-1- .. _ /G F 4 4

M rc'

t r a v i.- liNe Oirct'—.--\

y` t . - ; S PL (I c -1 - II Y. -.

CIO.- fie

r- / b'' __L., c. r?, ,11

IA r ■ — 4 -

r i' a. —41

4 - :1 KA,,

P 4.-1...- 1, h.) 1 8

a r- is. : — ._ J LI 44 .. _ wA ar _ _ •

hI! rt ‘.,.. ie_r ..,.) F L Q Sw.I/ €...,..._0„_ _ f Gk."... .4 ita ..1 Cif rcr /I 4, 0.. LE- -7 ? S j (.., . , r- c_ c) / 4

iv 4. p„ LI if i . rcit _,,i- 1, OLE SA_ /?s-0 ril C- I r 4 ,,,...1 ...,.. ;". • .L 1,4 ,1,11- ?al() i r-P# r- c a LA- t's — ?Ci g r- C•

■ 4/t 14) Z E. -

il L 4,,_,4.. rt. "......5 V J 6 • 3r r ,...,_ 4-- 4• It N di-- i 2 9 0 r f l s N a id. a cG k„....i...... /

.... L._ ?C 5

2 (1 1-1(--- P

T J.% ry- c- i'v ••". A --c le, I t_ 11 . 1 y IL ,',..-. I ■-- ..

1 A , , .... . r ,-....—

Sou P1. ,41;_..... , 4-1 E: -S ■ 1 a. .., C /

/ le / 4.1 ....

r, r 4 a 4- ik-1111111161 e-, ■ ,, . \,‘ .. . • \ .,_A --k ,., -L-J- __'_. __\__,.-__iiAllia_Q_ '

USAN

MEDCOM - 19269

DOD-032843 ACLU-RDI 1651 p.29

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MEDCOM - 19270

DOD-032844 ACLU-RDI 1651 p.30

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DOD-032845 ACLU-RDI 1651 p.31

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DOD-032848 ACLU-RDI 1651 p.34

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DOD-032849 ACLU-RDI 1651 p.35

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DOD-032852 ACLU-RDI 1651 p.38

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DOD-032853 ACLU-RDI 1651 p.39



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DOD-032857 ACLU-RDI 1651 p.43


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DOD-032860

ACLU-RDI 1651 p.46


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STANDARD FORM 509 (REV. 511BEHII Plestibed by SSAACMR FPMR (41011) 101.11_2(13(bR10)

USAPA VIDD

MEDCOM - 19287

' MEDICAL RECORD I

DOD-032861 ACLU-RDI 1651 p.47


`MEDICAL RECORD

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DATE NOTES

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USAPA V1.00

MEDCOM - 19288

DOD-032862 ACLU-RDI 1651 p.48

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DOD-032863

ACLU-RDI 1651 p.49


'MEDICAL RECORD

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MEDCOM - 19290

DOD-032864 ACLU-RDI 1651 p.50


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MEDCOM - 19291

DOD-032865 ACLU-RDI 1651 p.51

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. STANDARD DORM 509 (REV /1999) BACK USAPA V1.00 z

MEDCOM - 19292

LAST NAME

DATE

DOD-032866

ACLU-RDI 1651 p.52


MEDICAL RECORD

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USAPA V1.00

MEDCOM - 19293

DOD-032867 ACLU-RDI 1651 p.53

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DOD-032868 ACLU-RDI 1651 p.54

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DOD-032869 ACLU-RDI 1651 p.55

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DOD-032870 ACLU-RDI 1651 p.56

MEDCOM - 19297



DATE NOTES

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DOD-032871

ACLU-RDI 1651 p.57

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MEDCOM - 19298

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

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DOD-032872 ACLU-RDI 1651 p.58

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ACLU-RDI 1651 p.59

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DOD-032874 ACLU-RDI 1651 p.60

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PRP ADDITIONAL INSURANCE

AGE HOME PHONE FLYING STA DD 2568 IN C

AREA CODE NUMBER ME. - • L HISTORY OBTAINED FROM NA INSURANCE COMPANY

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT •

ITEM YES HEN (Date) DATE LAST VISIT 24 HOUR RETURN

II YES _I. • IS THIS AN INJURY? WHERE - , II S

ALLERGIES INJURY/SAF FORMS DATE 'OT COMPLETED INTITIAL SERIES

D YES • NO H

CHIEF CO PLAIT-

I

CATEGORY OF TREATMENT

VITAL SIGNS

C JIFF

URINE C&S

13'D C&S

TIME

IN

ABG PT/PTT

UA MSCC/CATH

0

—J

EMIMPAIMMEIII C211/b741dratism

PULSE

RESP,

TEMP

=4010MIESTEM BHCG/INE/Bl•D/QUANT

ar..D

O

10

. CXR PA & LAT/PORT • BLE

ACUTE ABDOMEN

SINUS

ANKLE R/L

1

❑ EMERGENT

IX1RGENT

V6-) ❑ NON-URGENT

/00

1- 1%

.(f)

>- Qw CC 0 X ¢

oao 107

0 /

C-SPINE

LS SPINE

HEAD CT

Gir ORDERS

.0* 4LIKVIroltralf PATIENT/DISCHARGE INSTRUCTIONS DISPOSITION

DISPOSITION QUARTERS /OFF DUTY

El HOME Ill FULL DUTY 1111 24 HRS. El 48 HRS. • 7B HRS.

MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE

0 IMPROVED 0 UNCHANGED

0 DETERIORATED

PATIENT'S SIGNATURE

ADMIT TO UNIT/SERVICE REFERRED 1100.

TIME OF RELEASE

TO WHEN

I have received and understand these instructions.

PATIENT'S IDENTIFICATION (For typed or w inen entries, give: Name -- last, first, middle; ID no- ISSN or other); hospital or medical facility)

1:11110 EMERGENCY CARE AND TREATMENT (Patient)

Medical Record

STANDARD FORM 558 (REV. 9 -96) Prescribed by GSA/ICMR FPMR 141 CFR) 10 1-1 1.2031b)110) USAPA V1.00

MEDCOM - 19301

DOD-032875 ACLU-RDI 1651 p.61

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

ro ro C.)

WBC

2 co

ABG/PULSE OX RADIOLOGY Check if read by ❑ radiologist

H/H SUP 02 PH P02 RESULTS 1„1_ 64" /0. PLT PCO2 SAT OTHER

PT DIP EKNA-ERPRETATIop oka.ee..4_

•

APTT BHCG ETCH GLU MICRO

PROVIDER HISTORY/PHYSICAL

r‘))4(k C)-=VLA./ Lk-4 ).-y111

d\Urc 34sv4\i/ Q C ='!?/-

- e) ckiv, •"),Ce-.-AWS

1\M-4‘k K)",1Ar' c--stry ‘t0 Lif- : ec.A it,s8 r

I 4-4 ,},-KA ou—A ® ckvv45-

129 p

1\e-r-1,

col t\

p, /Pr

-4-14 t Ac./AtAAA Phd-r- IA11.

CONSULT WITH TIME RESI ENT/ •EDICAL STUDENT SIGNATURE AND STAMP ACTION

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

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9 -96) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203lb/1101 USAPA V1.00

MEDCOM - 19302

DIAGNOSIS

C‘A1/1.10.- to

0

DOD-032876

ACLU-RDI 1651 p.62

fl

lc> c7p 'e-N. C-r>"-froliti) c,

Pi-Doe-)14ort

ii"

02/4.43

5.Wer.5

NURSING NOTES (Sign all notes)

DATE A.M. P.M.

HOUR OBSERVATIONS -

Include medication and treatment when indicated

--5Ger .5" e-ro,Scuriju /&iC F7u)V, ® g-N1

,i9,5‘ 4- (eft,.

K/C

—612.L.7.1 —044/,

°Lj O-, be A- 77i 'i

(R) Oku-Qc,

'U.S. Government Printing Office: 7996. 404-763/20

MEDCOM - 19303 STANDARD FORM 510 (REV. 7-91) BACK

DOD-032877 ACLU-RDI 1651 p.63

510-112

MEDICAL RECORD . ... _ ,

NURSING NOTES (Sign all notes)

DATE HOUR OBSERVATIONS

and treatment when indicated A.M. P.M. Include medication

. ir ,.._ • .0 a , I friall . 1...%). 0 V.-- 4 aii 0.

L.Lfit....46 81_51-, (S:1/1 I 4 •((. CZ) '', II 100. kaih1.....:,

rill % A II

lik •,

6 • 0 "• ,eu • •;..i.....i....

4, • LL ` -C) Th'Ikt,6-ir-Z"L

\-(ct--/- 1 col-LL

ck 0--(i. •Retki-, ogst---0 -1k qh % ct-tc.A C\ • ‘Ik' (ak-d-OLA,

11 l1 01...-4.....,------,c, • t Wk---6:z.- - (CL - ."---- A

•AA I. A11... P . _ . r / AL. al 0 .. :1-2

Ck_1. C r VC-IeN I \ cAY ..,, c_c- . • ..

•• ■ IS MTAISMENN --.1._:■...% ii■- •,—011alitiCf.s_' ',tail' IL. 2.1a.i.wo romponsowyma ''''''. ."441 ...4.-

•VS 5 A 4. ,9 ?.- 1.%... , ' , •. (G . I. r- _ • ,

, 6..j, [ c.d•-- '' c.. - II _...... 11,

c), --S-W ahl1A/YVII.A. CeW . I- 01M- v V . k. n.--( C teak-w otited/ric,, (5,am (Wife ( (P t5) 0 t •

0-19- yb)60 . ( )130, Ai Pi 1 @ )C-- l>f\ 61 15) E ki1 0.-i'dA CV (ircs -re

r

161Trit I V 1 b —<-6° -0 OVIM i5116

. 1\J 1 v. e., .1--h 19-6h -s s/sY (Afefi 1/1/1 Aii . t ----. ,:, ' 4- a4mi tryk. Sly /-.cKt/11 ( V-CCLUCh n 1 a- -0444

'NW KiMaiTh yviti - h 4 f . ATK a) 601/4- - .

\\\

, ontinue ontreverse side)

PATIENT'S IDENTIFICATION (For hospital

typed or written en ries give: Name—last, first, middle; grade; rank; rate; or medical facility) REGIS NO. WARD NO.

NURSING NOTES

Medical Record

ANN MEDCOM - 19304

STANDARD FORM 510 (REV. 7-91) Prescribed by G5A/ICNIR, FIRMR(A1 CFR) 201-9.202-1

DOD-032878 ACLU-RDI 1651 p.64

i. 41 L. nEtAiriu - rM I ItIll I AG I IVITIES F . iSHEET For use of this form, see MEDCOM Circular

SECTION I - PATIENT ASSESSMENT DATE: 7)4 Selz, O2 I PATIENT ACUITY LEVEL : 3 I POST-OP DAY: / I HOSPITAL DAY: 3

: .:.-T

• , ,

S

.

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time ( 1130 To _1"..1,,) I From Z-C__() 2 I - TELEPHONE REPORT:

AMBULATORY

Total ER/RR/PACU time Physician

I CRUTCHES I WHEELCHAIR WI STRETCHER

Anesthesia (Specify): , Procedure/4agnosis ''F,.--i2t.i.-e 4-1/)(A-41-1, B/P P R T LOC M ) /7-7/240•AA Ad.; Neurovascular checks Dressing/cast (,-(2,► 1(.., 4--0 & 8 1(4 Orej -e- LiC21, ex alE Tubes , .f,',‘ Intake (IV, poi 7CX2Zfr Output (EBL, r-rer. U No I Yes Amount:

other) Voided Medication

Other

Report From Received By

:., TIME: iii3 0 lefili ....-------... ..7 J

BP ARTERIAL LINE

BP CUFF 0 Xi lid TEMPERATURE

41 .1,1A /6 g)1 A. PULSE 10 10

) ID L RESPIRATORY RATE 1 , OXYGEN (L/%) 10 itir PULSE OXIMETER

- q75, 14.-1 . ' 02 METHOD CM

N.:

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar mask

TIME: I TIME: I i

PAIN

INTENSITY

iD "

• • ' • • ' • •

• •

. .

• •

. .

• •

• .

• •

. . s

p

E

1

A L

E.' E D S

'Skin breakdown prevention

'Falls prevention protocol

• • • • . . . . • • • • • • • • • 'Restraint protocol

*Seizure precautions

*Isolation precautions

.; MED ADMINISTERED IY/NI y

RELIEF ACCEPTABLE 'YIN) y

TIME: O

N.

FINGER STICK GLUCOSE

YESTERDAY'S WEIGHT: INSULIN IYIN)

• TODAY'S WEIGHT: E,'

WEIGHT CHANGE:

Per hospital policy. 24 HOUR PO TOTALS

IV #1 I IV #2

!

'TOTAL IN Urine I Stool I

I I TOTAL OUT


DIAGNOSIS: Ni ft DRG:

LOS:

CASE MANAGER:

PRIMARY CARE MANAGER:

ISOLATION REQUIRED (Specify):

17,10 /F,'b ADMISSION DATE: n 4.cr. 1/4D'"

EXPECTED RELEASE:

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.00

MEDCOM - 19305

DOD-032879 ACLU-RDI 1651 p.65

LAS! NAME I FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

16--/zi-o &J.A. .eLf-kr

'ilt-L4 a::■77_,6-2,_4 iirt6a.k Alt-J gt.tiz,,,„/ -r-/676,7 c„,A. 1-e-,,,k,„

.4-1411,1,4a-ea-I t- kt,%) iv, hp, 1 ,,,,n_ .41,t,,,,,LamitA. 724a, ",re“.4-e 6-P ii-,

b,,,,,,i,h,/,-ef .„,,,,&,, ,r-"a _7,4,#(4, e 61e4') iti ,))

# s/toz-tiei 1.04,/t.oLet , km z&peAlid e)rt iefi AtvtArtiA;A i/t/o-i wall,'" >Pi lip- frl

fruA (AA - elk° . 7-le 9 / ZR, 49-6u-Cal-e_a 6 iii,tc,/

, hfia w,e,40 1 - 4 , I 4 4 , 1c /I 1 ,- 40->i / fr i

k' / . , /

. i

•A' .

12. /414,144 /9/17 cry) Ne 12 ,14-1,nebtgi e,c7g-u-t-ce/E

eptt,1471 //ii-- ititte,/, e,:a (i 4, 1 —,

1t; A &,&. L/ii,e 4J ( / ii daajy

Coydrm,Ltt. ,?-ti--e .evciltirt-ft-tt-uf -"itpd-d wru.vti La:

6tr,,,wratv aiil,a ,R14407 livi 4.a ,z19/ AterkidAy

6,0 w_ed-e.6

b cL__,---L

MEDCOM - 19306

STANDARD FORM 509 (REV. 5/19991 BACK USAPA V1.00

DOD-032880 ACLU-RDI 1651 p.66

MEDICAL RECORD INTRAOPEP ATIVE DOCUMENT For use of this - • .

1. PAT ENT TO OPEN icy is the orrice of Ina Surgeon General.

lIeli:N/ SPORID . 1 (

VIAL h' hi er BY P-71.129., 7 Cl

2. PATIENT DENT!. 0 D REVIEWEDD AND PROCEDURE VERIFIED BY Cf/T . AD ICe\'')-- 7,--- . 3 DATE TIME PATIENT ARRIVED IN SUITE

1 S epo-3 // 3c) . lf IN RORM

4.

TIME

PATIE

I /3 C.) NUMBER as 3 5. PREOPERATIVE EMOTIONAL STATUS

PCALM •• ANXIOUS •• EXCITED. U CRYING ANGRY • WITHDRAWN El} OTHER (Specify) COMMENTS: 4;(in) I\I Kpr

_.... _

6. NURSING PERSONNEL

ASSIGNED SCRUB

ASSIGNED CIRCULATOR

1._ ,i'. _

--RELIEF SCRUB

64. 9 /D.

CPT (06' L...- RELIEF

.--......CIFICULATOR - INT:

MI

• •--. .— .. i 336 ,- / YO e-)

7. POSITION A D PO ITIO AL ADS (Specifylpt...- rgidecl -0,---.4,,L , ke_n_ 0, --P-oct ol.,,i-- le, 5i e.... 9.0- ig-- Ae'' , SU.INEI • LITHOTOMY ❑ PRONE ( • KRASKE , - LATERAL: , , LEFT Sr UP. • RIGHT SIDE UP S 4-fc p5, 13 -C -r-4 t.C41--r-4 I Le) IA.ta-r- E-Ni4,-,R,..4,44,-fie3 &wiped j).‘,4-r, 1 le ,e ,

COMMENTS: Civate a_ --so 4 6. i ,. 0,_,_, i,„„ei.., j___. :_m4b,-/-4 h., of 8. SKIN PREPARATION

\--, ( - e--- 'YE S

HAIR REMOVAL YES NO ''

DONE BY: OR • NURSING UNIT

METHOD: • DEPILATORY Mil RAZO: Dr: • CLIP

COMMENTS: "CI 141.0, r.- C.-LAIS —

PREP SOLUTION (Specify at-cfe'■ SITE: R., L a SITELL_E

1V1ENTS: AL/ per

C.,z

BY WHOM: L BY WHOM'

I

A-- Sti ttAtktICflAS 9. LOCATION OF EXTERNAL DEVICES

‘

• - 1-1 eigivf.1:91.:zo■ .-9-4;.say• • . -vf: . ' I I rfri 5, it pit 1 Ir 0 ri. 111111 . I i. 11A.A.,_•44•4 A:04 - , 4,4218/,--

"

1111/ 44*

LEGEND X Ground Pad

..:

.;0 1.-. Pe_1:4 -ate y Strap - = = Tourniquet-• --• ;•-.. ,71.=‘4

C ti= Correct I = Incorrect '''' ( )- "e. '14.41.14 10. COUNTS Other• -•

ng First Closi _ Count157 .

Closing Final CI s' rig Count .SCRUB CIRCULA Sponge Y Vo C e_ f'. ' -(1./.0

Needle Sharp

Instrument III Yes

Yes

Yes

\lo

o

o _

Other ❑ .'.1....00_',.::;'•: . ,

... —

11. PATIENT IDENTIFICATION (For Name - Last, first, middle; Grade; Date;

ped or written entries give: Hospital or Medical Facility;)

12. ELECT URGERY DEVICE(S) ESU) E , NO

SU NO: (17--.1 ,b 10° 31

-Gi

-:-

:. 111 b (

DA FORM R17A-1 nerr f:2"7

GROUND PAD: BRAND IL y tel 6 (ro ly k • srAir It q .: ... LOT NO:6g q5-/,_7,c6-- ,, I1 NO: 044 ...

-- •---GROUND PAD: BRAND . .,-

LOT NO: ❑ BIPOLAR NO:

-1 DEC.82. WHICH IS OBSOLETE.

MEDCOM - 19307 USAPA V1.00

DOD-032881 ACLU-RDI 1651 p.67

13. PROSTHESIS, IMPLANTS

E r( IF YES NAME: ID NUMBER; -URER

ta'MEDICATIONS/ORDERSC4 -*- IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)

TCO Li NU :MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY Pr/

GIVEN BY _ -

•

N71:3YES WOUND IRRIGATION • NO TYPE(S): 1

..,. OTHER ORDERS

TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE 1

15. X-RAY IN OPERATING ROOM IF YES, SITE YES ) NO I OLA (° U ‘.41, C7'07r(P'1\ ' Z..... (..✓ e,

16. -- - ." -fLABORATORY SPECIMENS SPECIMEN IS)

YES / NO

_ _._ .___ . NAME . ---;- --- -

- NAME

i FROZEN SECTION (FS)

YES ❑ NO

NAME • NAME

CULTURE IC)

YES ■ NO (17D NAME

_ .. _ - --- --- NAME 4

NAME NAME NAME

NAME NAME .. _ ' ' --- -----

18. DRESSING/IMMOBILIZATION (Specify) Gje,-+EC14°‘ 11).4 Ice fkey ra,445)-- 1-1-6

- e \f + Ka I) A e./6,- i.,J•re,12

IF- - K-,e.-1-eiy/ r ((A ,. 14.8'D (--EA-cy, ((- 0 / 1s 4

17. TUBES, DRAINS/PACKING YES I NO X- ___ 12,A TYPE/SIZE . __ 2. • .

SITE 1. 2. 3.

19. ADDITIONAL INFORMATION

(A) Cs- VC •. : Dr- d

47..es-Aee i:4- --* K}_ G-),Nii ci

4) Dr- -- _-__ r _____ _ .(.• D r- _ _1( 'el Illiti

1

1 '61,4c -e podA sj-•_ r,e _op C-01- S. .( 14-e- pi6 4-0 COT--- -,,}■ .-e old Yo ekn)i o )0 --c- p, (r69,(kt,i- , Jr_e__ LE pr, ,..apC__ os_o o__/L_L 6 _or pre cal_

Vki k.._ 4- -Or ei)l- - t ( IAA i n )9'75 ..__.... 20. OPERATION(S) PERFORMED ..._.---

CF-4, e- 'PkOkC..0--lev\--P-A- ' C Far 0r cyko LLC---.

21. PATIENT TRANSFERRED TO \-) (_ ._ . )6 . - 1-- ic,u,a___

., .-.-------- __ RE /

TIME ME METH t

utud ej 1 1 -e l'


DOD-032882 ACLU-RDI 1651 p.68

MEDICAL RECORD INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-66, the' .' nt agency is the office of The Surgeon General.

1. PATIW TRANSPORTED TO OPE 3 ROOM r 2. PATIENT ID D ED ND PRO EDURE VIA EZ4..1,5) 8). u1/1--P--C2-e-.9._.-/LiA__. VERIFIED B eff7

0 0 3 3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN

TIME / NUMBER 5" 5. PREOPERATIVE EMOTIONAL STATUS

5-<}, CALM • ANXIOUS • EXCITED • CRYING ❑ ANGRY • WITHDRAWN D OTHER (Specify) COMMENTS: Allergies: -1,‘,1c,c40,_


ASSIGNED 5s0 9 ID RELIEF Alli(tSC50-ettli_

-.((-c.- 2-

SCRUB / SCRUB

ASSIGNED C er 64) c RELIEF L ( GM - Eta_ CIRCULATOR CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)

2 SUPINE LITHOTOME . • PRONE

AL

j- • KRASKE - LATERAL: ‘ • LEFT SIDE UP • RIGHT SIDE UP

__ ..Ff 0 -- -r-v\O L."..n.nA-c"-------T■Q_C k \..\ , EN \ o-c,koki C-il.4 b 0 cAA'V

COMMENTS: ■ f.,. 6).\ 16 .6^2)irliLAA Cfr-Q,S,erA6-k_ .2...frk. ON S V.:x.4 ?Cin■Ch b'Ortr-4-(21% A5'. CYN ck--"-;•-e. --6-1'')e 5k th 8. SKIN PREPARATION

HAIR REMOVAL U YES N. NO PREP OLUTION (Specify) ca..34,sko.. \ 5.t...."-Ve._, \-.,. ( (.1._

DONE BY: LI OR • NURSING UNIT SITE "A-0 5K ,it BY WHOM: ....,

METHOD: U DEPILATORY U RAZOR SIT BY WHOM: / • CLIP

/ A - COMMENTS: COMMENTS: •VIC) VOKANN -KN `-§AtiovNi AA. - 9. LOCATION OF EXTERNAL DEVICES

- ,.

....-

LEGEND X Ground Pad - Safety Strap === Tourniquet (vic.;., mac )D L (,..-, - '-- C = Correct I = Incorrect

Sponge 0 Yes ❑ No -Needle Sharp 2 Yes • No Instrument II Yes ri No

First Closing Final Closin 10.COUNTS Other- Count Count SCRUB / CIRCULAT

Other • Yes n No ■■

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

-1111111111c)( Ct- - (4 M ESU NO: \)C-..il.k.flo...b A- G--"‘ U k-k

irirliallillia 3

b Lz., . -1 • BIPOLAR NO

O

GROUND PAD: BRAND Vt- R9 \..x." ? ■ i\k95PrZ 1- LOT NO: D22- kk'S ?•'• -13-?

• ESU NO: GROUND PAD: BRAND

LOT NO:

DA FORM 5179-1_ OCT R7 USAPA V1.01

MEDCOM - 19309

(TEST}, DEC oc, WHICH IS LJUSULETE.

DOD-032883 ACLU-RDI 1651 p.69

II- YES NAME: ID NUMBER; MANUFACTURER i

i.:14. .::::::.;.::::i:::::::::::::::::::::::.;:imi::::::::::::::::o:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i::::::::g::::::::::::::::::::::.:::::0::;::::MEDICATIONS/ORDERS.:;.:::::::::::::::::::g::::::::i.,::i:.:::;.::::::::,;;:::::.:::::.::::::::::&:4:.:,:cR::::4::miii,:::*:*:;:::::::::::::::**.Mm&M;$4;,.i.:.:*.:'::*;NF

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES 111 NO VA NEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

WOUND IRRIGATION N YES • NO TYPE(S):

0 61 vfo Jo-C9.-

.. :OTHER ORDERS 'i TIME

.. CARRIED OUT BY

i_nA-6 1._

•:PHYSICIAN'S SIGNATURE

: . .. .... ... . . ... . ... ..... .. ............. ...................................................................................•........................... .... • .... . - .... . .. . ... 15. X-RAY IN OPERATING RO IF YES, SITE YES • NO N

16. LABORATORY SPECIMENS SPECIMEN (S)

YES • NO P.! NAME NAME

FROZEN SECTION (FS)

YES • NO Nj NAME NAME

CULTURE (C)

YES • NO 2 NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

-1--t.43 A-I3

eitiAX AC9-.1/■KCI

17. TUBES, DRAINS/PACKING YES RI NO • TYPE/SIZE 1. i i tA

S)CMY06e

2. 3.

SITE 1

EA2-ciV Co-Q-(r 2.

19. ADDITIONAL INFORMATION werit Surgeonsillip

lb to) Anesthesia: Anesthesia Type:

("i, 0-i- 5.52.A.Asuf0-9.--

6130-- ,... ..: ..I,

Bovie Pad site intact pre-op 1 ; post-op Boyle Settings: Coag/Cut Tourniquet Site intact pre-op 'J : post-op V Tourniquet Time: Up1531 Down 15.55 .:

S179 cv. c.A.,_0.--A , 0 0 '5 ,N--■ 0---)1 el.

20. OPERATION(S) PERFORMED

0 PI , .(-.'t--1/4-----/ "\--R-A-At\ (FY) , 2C-t- 0 Le2c

21. PATIENT TRANSFERREDY0 ,(7. TIME -(..;& (1 METHOD1Q,N j 22 P1111111mmital

TIM' ,,,-„„.. .4,,,.. 2111111111111111111#7- A -, REV

DOD-032884

ACLU-RDI 1651 p.70

ALM ❑ ANXIOUS 10 EXCITED ❑ CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)

P ,f e

7. POSITION AND

SUPINE LITHOTOMY

COMMENTS:

COMMENTS: COMMENTS:

Yes ❑ No Needle Sham

0 Instrument

Yes

❑ Yes M No Other

71D ASSIGNED SCRUB

RELIEF SCRUB

••:

RE t.:xlat„

INTRAOPERATIVE • • Ot foiksea AR 40-68, the • •

DOCUMENT • • • is the offi of The Sur.eon General. 4.11 RTEMITOTPERATING ROOM 2. PATIENT ID

BY 0 L 1.6 VERIFIED BY Ir TIME PATIENT ARRIVED ITE 4. PATIENT IN R • -

TIME MBER 5. PREOPERATIVE EMOTIONAL STATUS

COMMENTS:


ASSIGNED CIRCULATOR

❑ PRONE E1 , KRASKE r< LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP

N.;

b77- C Lr- •

POVIONAL AIDS (Sp )

RELIEF CIRCULATOR

8. SKIN PREPARATION HAIR REMOVAL

DONE BY:

METHOD:

❑

❑

❑

YES yeN0

OR

DEPILATORY

CLIP

❑ NURSING UNIT ❑ RAZOR

PREP S TION (Specify) SITE: SITE:

BY WHOM:

BY WHOM:

al

9. LOCATION OF EXTERNAL DEVICES

LEGEND XielloiLd Pad -- Safety Strap =Tourniquet = Tourniquet

9 SYS 0 No

C =.Correct I = Incorrect

Final Closing Count SCRUB CIRCU 1. • :

Sponge

10. COUNTS ck First Closing t er• • Count

111111i1111 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Dare; Hospital or Medical Facility;)

❑ ESU NO:

GROUND PAD: BRAND

MEDCOM - 19311 LOT NO: r ❑ BIPOLAR NO:

ES

imurompziommorg- imordis 12. ELECTROSURGERY DEVICE(S) (ESU)

4ESU NO: ki (-(9 GROUND PAD: BRAND VL

LOT NO: zr' eo CT

P_ott

DOD-032885

ACLU-RDI 1651 p.71

13. PROSTHESIS. IMPLANTS ❑ YES

IF YES NAME: ID NUMBER; M

IRRiGATION/MEDICATIONS GIVEN IN OPERATING ROOM NOT BY AN T MEDI CATIONS/ORDERS *MO

MEDICATIONS. SOLUTION DOSAGE TIME METHOD :,•.i': F-.::, 7-:';' ̀GIVEN BY

;

1 .

I r WOUND IRRIGATION YES • NO, TYPE(S):

.OTHER ORDERS . TIME . CARRIED OUT BY t.

PHYSICIAN'S SIGNATURE

_ 15. X-RAY IN OPERATING T R OM IF YES, SITE

YES E NO 16.

LABORAT RY SPECIMENS SPECIMEN IS)

YES ❑ NO . LI

E . ''\i /3 K.„01._ 7 To-Av1/4„.icit.4...i JJ NAME

FROZEN SECTION (FS) ,' \

YES ❑ NO i 71 CUAASk < cy k J e ce+ CULTURE p NAME

NAME •

YES &/' NO L3 ' • NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

by

A-42 d \

AU-t . 17. TUBES, DRAINS/PACKING YES ❑ NO TYPE/SIZE : 1. 2. 3.

SITE 1. 2. 3.

' ' " 19. ADD IT FORMATION

A) ( C6 ' 1--- 1c dA 4A-J--t--4 C--`- e--. • C, LA-4--

-,

20.

ceit:>

OPERATIONISI PERFORMED .

21. PATIENT TRiplER TO

( (--- - - 1 TIME ,n -r4-

6/-2,. ETHOD

.... ; e.:::: ;:-;,,i.;4- . Liatia ':, .40.,t,t, ... ,:i„.:4 0, .. -

22. Biailai ■ritairsitan.c__.

REVER 17'-1, OCT 87

14.

DOD-032886

ACLU-RDI 1651 p.72

MEDICAL RECORD INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-407, tk iency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPEI M 2. PATIENT IL • ECO ND PROCEDURE VIA By a/k1/2-a-t/J-?_,t, VERIFIED BY aer 3. DATA/14"V' TIME PATIENT ARRIVED IN SUITE 4. PATIENT I ...„, _ 30 Ste 0 .--..._ TIME- I© Ob \., CS ) NUMBER /-- - (0

5. PREOPERATIVE EMOTIONAL STATUS [71 CALM • ANXIOUS • EXCITED. • CRYING ❑ ANGRY • WITHDRAWN • OTHER (Specify)

COMMENT: I.- 'A- V JUA/4444t, aPliklytA, ? .4 14 - - .444•41111-.0-4/4--C-i-Alt74-e.,e


SCRUB ASSIGNED Sge IIIIIIII'. 4.-/b -RELIEF

(

64 E -

.SCRUB

NO ASSIGNED RELIEF CIRCULATOR . .. __CIRCULATOR

I ;,.11-; • . 7)SaTION AND POSITIO P-1- eimok..,4,4,4„:2_

S

ft,Y2NTs: k>.,. ei-.. prk_d62ft, ratA kx-.1 ltieittAd r

crh...

e6(

„.. p...e....,„ and C eLlttacte A • tritf-vc,--e,„

IF E ❑ LITHOTOMY PRON .. _ II KRASKE -, .., LA L: LEFT •SIDE UP • RIGHT ,SIDE UP

ozA (5,-- /zit_ - -1-0-0-f. is-e-A-F.. v..)47-A-AY-1 ia.teezi-

8. SKIN PREPARATION HAIR REMOVAL cis YES • NO )142-fr 4.- '' PREP SOLUTION (Specify) lat-ieti /3e-i-ic- DONE BY: M

rz .. 1__(_e)

OR ❑ NURSI G UNIT SIT BY OM: 0971111pP METHOD: DEPILATORY RAZOR SITE: BY WHOM: 10 - Z .... . p CLIP _______ •

COMMENTS1A0 vu.4.4 M 0..AA-10 fu.O.k.1-----., . COMMENTS: yk)p-o 4-3 rft1.40 • .,...

"44 9. LOCATION OF EXTERNAL DEVICES _ ..... _

_ . •• 10 V-Arrirm..._ . - :. • - ■ •I . I zaw■AL-4-4,r.ilt- — - _ I • • 11110IFP

' ' ' •

. . . 'pi Clad 101A•• DS, LEGEND X Grill -- Safety Strap = = = Tournilfuet•r•-•:-.,• P4-440' C = Cprrect I = Incorrect ( 61.- 11,410.-If First Closing Final Closing 10:. COUNTS Other • • Count .. -:,. Count SCRUB CIRCULA Sponge Yes Vo a _: 0 i''''• A. N ebcile Sharp /Yes o Q. — : .

Instrument ❑ Yes Vo :. ;:;2,.?1,■1_::-/ Other • Yes Vo

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

EP Ar 10111111116 (co.) - (I

.... .:'ItrAl) NO: -- ..

\ V If I I I liii I P b(-:0-

• BIPOLAR NO:

&Gt-7--_' _ d_.0 Av -43 (]ESU NO: V. A IA-- 0 0o I li

GROUND PAD: AND V 67 _,._ LOT NO Co t.P. 4 Q.o OS---0 eR

".•• ,"7-GFIOUND PAD: BRAND LOT NO:

DA FORM 5179-1. OCT 87 REPI Ar!FR net [nos. e" "eh 4 r4,'•••• e...-.-. ■ .. WHICH...

MEDCOM - 19313 IS OBSOLETE. TE. USAPA V1.00

DOD-032887 ACLU-RDI 1651 p.73

13. PROSTHESIS, IMPLANTS itN YES

'5 Yrr#11-eS Crinin-F' /0 ),1 ,,1 'nit to Ai L- 0 0 4,-0.44.. 02,... g o".3

,. ' .,..:' ::::' 4:5, a:

1a — 3 /S—

IF YES NAME: ID NUMBER, 'URER c_& - •I ntitfr,1*7T ill -1-11,9fru. c...,....4,c1- — ci-T4-1.0) JO. d-stsi,” 3 0-re-iti 1- 0;i1:-6 .:*g: Os" P--W-c)

.,,,, , . f'MEDICATIONS/ORDERSi ,77''z (4„ :1=1 '' r' '

S .

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ,- - MEDICATIONS/SOLUTION DOSAGE . . TIME - METHOD PRE D BY Y r :-..:-..:........._ . _ _ / -' 4:4_ - . !ZAP 1,7 r' Lel

•' - — _ - _

•_. . _

;WOUND IRRIGATION YES • NO TYPE(S):

(3,9 I. 11/4►I A- et-

;OTHER O RDERS , TIME CARRIED OUT BY '

.„,

13HYSICIAN'S SIGNATURE

,,, „„,„ „ ., ,,,....„,, , - , ,,. -, 15. X-RAY IN OPERATING

YES N. ROOM - „ IF YES, SITE

LI , ' -AJC NO • 16. - ' . ''':!ILABORATORY LIMENS SPECIMEN (S)

NO NAME „

'

NAME YES •

FROZEN SECTION (FS)

NO NAME -

- - NAME

YES •

CULTURE (C)

NO NAME

-- --- -- --- --

NAME YES • NAME NAME NAME

NAME NAME

- --

18. DRESSING/IMMOBILIZATION (Specify) t

- g p - t t .. 4 44 -

., Ki/.X

L. ito-2.4-\4 -- ' . CALA- w94

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

.. ___. . .

SITE 2. . . .., -

./ ' 19. ADDITIONAL INFORM/VI- ION -

-: ,------i--7,---.7" . ,

i'•

20. OPERATION(S) PERFORMED ,

00 / erne j 7L--

21. PATIENT TRANSFERRED TO

(.44", ( TI

33 METHOD

22. RE /..1,,,r, /0

REVE FORM 5179-1, OCT 87 MEDCOM - 19314

USAPA V1.00

DOD-032888

ACLU-RDI 1651 p.74

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

1. PATIENT TRANSPORTED TO OPERATING ROOM VIA k; 1.141,

EPCIA'44-/-644., 2. PATIENT IDENTI IEWED AND PROCEDURE VERIFIED B -

3. DATE TIME PATIENT ARRIVED IN SUITE

.29Aert- d -S c9/ o z_. 4. PATIENT

TIME 91 0 A7 62 NUMBER 5. PREOPERATIVE EMOTIONAL STATUS

El. CALM U ANXIOUS II EXCITED • CRYING • ANGRY U WITHDRAWN • OtHER (Specify) COMMENTS: Allergies:

Alici)/1- 6. NURSING PERSONNEL

ASSIGNED SCRUB

It RELIEF SCRUB

-- \ -

ASSIGNED CIRCULATOR I'M-T111111111

RELIEF CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)

VC. SUPINE U LITHOTOMY LI PRONE

COMMENTS: Coulis ticritAikaak crkl aftel-N:224cio

II KRASKE LATERAL: • LEFT SIDE UP 0 RIGHT SIDE UP

—90 'h,ValeAc ii a e ,, ( (..,, - 7— -

8. SKIN PREPARATION

HAIR REMOVAL • YES NO

DONE BY: • OR NURSING UNIT U

METHOD: II DEPILATORY In RAZOR ■ CLIP

COMMENTS:

446-

PREPAOLUTION (Specify)

/ 6 SITE: 0.3' BY WHOM: rnCtialla SITE: BY WHOM:

COMMENTS: C.4_, ihro0 ,..,

9. LOCATION OF EXTERNAL DEVICES

r .

.. -r -i — AI" - 17 - F.-- I I !lir/PP-- t

LEGEND X e d Pad

•

10. COUNTS

Sponge [2rYes Ell No Needle Sharp • Yes ■ No Instrument I. Yes No Other • Yes No

- Sa

C = Correct

Other'

==

I = Incorrect First Closing Count

'

Final Closing Count

C

/

rniquet AMC

CIRCULATOR

11. PATIENT IDENTIFICATION (For yped or written entries give: Name - Last, first, middle; Grade; Dale; Hospital or Medical Facility;)

°- eV ( (4 - t/(

12. ELECTROSUR ERY DEVICE(S) (ESU) KYES I. NO CA4,40" go c4a5, g(c)

ESU NO: C./0.-4_0_,LV GROUND PAD: BRAND

LOT NO: IP... • ESU NO:

GROUND PAD: BRAND

LOT NO: ri BIPOLAR NO:

MEDCOM - 19315

DOD-032889

ACLU-RDI 1651 p.75

18. DRESSING/IMMOBILIZATION (Specify)

a-1,e

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

14 •

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

4-

WOUND IRRIGATION YES El NO, TYPE(S):

ws CARRIED OUT BY

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE YES NO

16. LABORATORY SPECIMENS SPECIMEN (S)

YES L NO tg FROZEN SECTION (FS)

YES LIj NO) CULTURE (C)

YES U NO NAME

NAME NAME

NAME NAME

NAME NAME

NAME ME

OTHER ORDERS

ct TIME

NAME

17. TYPE/SIZE

NAME

1. /644-0s--e-

SITE

YES

NO

2.

TUBES, DRAINS/PACKING

19. ADDITIONAL FORMATION I

te-e- y wc - Surgeons: Anesthesia: Anesthesia Type:

Bovie Pad site intact pre-op V."; post-op ."...--*Bovie Settings: Coag/CutdiVro Tourniquet Site intact pr -op : post-op Tourniquet Time: Up own

20. OPERATION(S) PERFORMED

40hat 444 41-4061...4. le- CZA.-0( SISICLIPAtio

21. PATIENT TRANSFERRED TO

2 IGNATURE

kj- /4-7`i ORM 5179-1, OCT 87

1-1-1-tc)

METHOD

04144A

USAPA V1.01

MEDCOM - 19316

DOD-032890

ACLU-RDI 1651 p.76



DATE NOTES

/ /5,0-03 /C itt Pie.66 0 1AI OD 1 703 OD aq_23 0 4- lyio-,_. NIA. HI- 11-it 114 -a/ 0 a- 7- (14, 241 if-Z. /1SA°1 f 9(

M30 /0 4 11874g 14 Gr7

) to.35 /Oa -z4/72. IC, 94,

/640 107 /OZ.17-71 1 S (0c)

it S- 7 Itch-7a I S `/ -7 (v3 line) g• 1 I 17 1 1 1 1 IL f I s /ifs /03 /1 11/7-5 /c, 77

1150 / 0 / 113/-75 Ito 11 11(15 /05 1 aci173 /?-- 1 9,-3 na/ roc- r*/-73 17 f r - 92(3 No d/cd di,r,tfr fizoi ad-447 6,

11P115 6e --,--

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER

ISSN or &bed LAST FIRST AD

OEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed at ninon trt#104 ilW dime-last firg Aitkile; • ID No or SSN; Se; Dm of Birth; ling/eforkl



STANDARD FORM 509 IREV. snow Numbed by GSAIICAIR FPMR 14ICFRI 101-11.203114110)

USAPA VIAO

MEDCOM - 19317

DOD-032891 ACLU-RDI 1651 p.77

MEDICAL RECORD

VITAL SIGNS RECORD HOSPITAL DAY

•

19 - HOUR iraminoldanmairaimIFININEA

POST- DAY

MONTH-YEAR DAY -11,- MM% - ..1,...r4t. fiera7 11.11111:4.-

. . . . . . . . . . • . .

. . g. ,•0-1,49 PULSE TEMP. F ....... . #. . :•

(0) (*) , • . • . . . • • • di • TEMP. C 105° . . . .. ... . . . . 40.6°

C ci c)

38.9° c

38.3° cc 8 6"

z

36.7° -0 to

. 36.1° (i) c

35.6°

180 104° ...... '' " " • ... ' • " • ' • ' • '

. . . .

. . . • •

.

170 103° '''' • • • • • • • • • • • • • • • • • • • 39.4° -3-,

' • " " • • • • • • • • - - . - • • • • • • • • • • • 40.0°

160 102° . . ' . . • . . . . . . • . . . . . . . . . . -

....... • • • • ' • ' 150 101° a) . . . . .

. • . • • . • . . . . • • 140 100° ' ' • • • • • • • • • • • • " 4

' 130 99° . . . . .- 37.2° _ 9 : : •.. : " ' ..... 37.0° cr

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STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 19318

DOD-032892 ACLU-RDI 1651 p.78

NSN 7540-00-634-4124

RECORD

VITAL SIGNS RECORD 511-119

...__ _

HOSPITAL DAY

POST- DAY Xt 54 ErEllIZIEVIENEIMEEN

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MONTH-YEAR 19

DAY I'M HOU • 111 or . , • • 01 tR4IIMERIM 5

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


9 'AI I I 1 I VITAL SIGNS RECORDS

Medical Record

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

MEDCOM - 19319

DOD-032893 ACLU-RDI 1651 p.79

VITAL SIGNS RECORD MEDICAL RECORD HOSPITAL DAY

POST- DAY MONTH-YEAR DAY I_ ,,, s 2 ct. 6r, ' C.ICASC, A °aril. di' • "

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. REGISTER NO WARD NO.


MEDCOM - 19320

DOD-032894 ACLU-RDI 1651 p.80

NSN 7540-00-634-4124 511-119

EDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY

affOXIMM•VIALIFIE-graaWlairriblaill POST- DAY

MONTH-YEAR DAY

19 HOUR • • 2 : : D. 65 0410 i C Ivy PULSE (0)

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

REGISTER NO 'WARD NO.

410111176 - (-4 VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-i

MEDCOM - 19321

DOD-032895 ACLU-RDI 1651 p.81

NSN 7540-00-634-4124 511-119

ORD

VITAL SIGNS RECORD

HOSPITAL DAY

POST- DAY -

MONTH-YEAR

f :

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DAY HOUR

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

REGISTER NO WARD NO.

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, ARMR (41 CFR) 201-9.202-1

MEDCOM - 19322

DOD-032896

ACLU-RDI 1651 p.82

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY

MONTH-YEAR DAY I t HOUR •

PULSE

(0) (*)

105°

.

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160 102°

150 101°'

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80

70

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RESPIRATION RECORD

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*

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/IN HEIGHT: WEIGHT —0.-

(670

••

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

REGISTER NO WARD NO.


MEDCOM - 19323

DOD-032897 ACLU-RDI 1651 p.83

Ward/Section: --",4_7--- REQUESTING P IAN: 6 i(s)_, LABORATORY RESULT FORM I (Subject to the Privacy Act of 1974)

LAST, FIRST MI. A

k2_ , - 4 . / 8 Sip%/1— TIME • /9C0

SSN/PSEUDO

i( (6-1 1010 CBC '•

U.174talris • • •••:!. . . . . ., . _Mc; Sett*

. . . . •, .•

TEST . RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color - N/A RPR Negative RBC 4.7-6.1 x 109 API) N/A Mono Negative

Se, 14-18 skit (M) 12-16 e/d1 (F)

42-52%(M) 37-17% (F)

Glu

Bili . - - -

Negative

Negative

.... : - • - ..'. • • Source

Wrobk408Y ,. • . ..

• Het

MCV 80-9411(M) 81 -99 II (F)

Ket Negative Gram Stajn

- - -

Pit • 130:500x le verified

SG N/A Occ Bid Negative

Lymph % 20.5-51.1% _ Bld Negative H. pylori Negative

. ) Manual Differential *::-. : ... . • • • . . "

pH N/A Micro Parasites

.

Segs . Mono Prot Negative Malaria '

Bands Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other

Atyp I m m balk Negative - ' ::-Mii .cioscOPk OrhillYi4'

RBC Morph

HCG Negative ,

Spun Hematocrit

42-52%(M) 37247% (F)

• . .. . • . • .. : . . - • - : : ..

•

..` 7; ..Btoodik*' ,- -..:

Sed Rate . ,.

Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative j ABO/Rh 1 p° . Oligni* 0" - 01.clieS .

.:.' ''.!,.' '...•:"*- :-. .131p64.11ank Tiitit ,Ornasmatek : . ' • - -.. :, -.-: _ (MUST,SUBMIK SF :518.WITIitVERY UNIT OF BLOOD

_ :. : .. - ' 1 s. .,.. , ,.- '• .I REQUESTtD) ': ' '' ' : ' -:: :-: . TEST RESULT REF. RANGE UNIT TYPE CROSSAL4TC II

PT 9.8-13.6 SCR

• 4 i.,i3 1,-//4, 0,p_..0 __( (-------49 APTT 21-34 secs /

D dimer <20 ug/ml -

FDP <lout/LA

REMARKS: •

REPORTED BY: DATE: 5. — 2,i------

LAB ID NO.:. -

MEDCOM - 19324

DOD-032898

ACLU-RDI 1651 p.84

Ward/Section: FR—EQ STINLi PHYSICIAN: . . ' CHEMLSTRY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, MST, ML DATE TIME SSN/PSEUDO SSN:

• -.7;,-`:il.'-:ii:f'--.--;. 1.-.0:;:-It':::, -7.- .-- f;,,- --:-.- :;:-., ...:.fe ,i,,N,,,.., t.: ...:., ,,,..,,,,,,,., TEST RESULT REF. RANGE `EST • RESULT REF. RANGE

73-118 mg/c11

7-22 rag/d1

8.0- 0.3 mg/d1

Na 1118446umma. - - - - - - - PICCOLO :,U K 3 '54'9 "I/L‘ 18/09/03 10 : 33 IN Cl 98-109 rarnoVI- REFERENCE RANGE: MALE ir4---- pH 7.31-7.45 PATIENT # : \c ,( 0 -(--( - E 0.6-12 mg/d1

PCO2 35-45 mmHg (art) GENERAL CHEMISTRY 12 *--- 41-51 oui(vall DISC LOT #: 3142AA4 :

128-145 mmo1/1

3.3-4.7 rtuoul/1 P02 M-U15mmHg°4) OPER #: DR # • 000 . N/A (real ,

TCO2 . 23-27 malL 44 SERIAL . t ti,.-)

4-29 mmol/L (yea) YD- 98-108 mmo1/1

HCO3 22-26 mmeUL (11r0 52 23-21 nuudiL (vc112- ALB 2.7* 3.3-5.5 18-33 mmol/1

'::::.',.::.:Nrrs.:... ,'.::::: ,:;'-7. '..;..:

s02

G/DL . 95-98% ALP 34 26-84 11 ,, ...:-Oieii 0,4" -rifi41144,..?:.

— .-- 7,.4,tzi .,,,:41%.;.:;:k ./1. ...: BEeef (-2) - (+3) ALT 25 10-47 _ U/L EST

nunol/L RESULT REF. RANGE

3.3-5.5 01 AItGap AMY 15 14-97 U/L 10-20 mmoVL AST 50* 11-38 U/L Ca 112-1.32 mmol/L TBIL 0.6 0.2-1.6 MG/DL Y

26-84 u/1

BUN 8-26 mg,/d1 BUN 9 7-22 MG/DL T CA++ 7.1* 8.0-10.3 MG/DL i

10-47 4/1

GLU 70-105 mg/d1. CHOL 58* 100-200 MG/DL 111

14-97 u/1

Creat . 0.7-15 mg/c11 . CRE 1.0 0.6-1.2 MG/DL' i GL GLU 149* 73-118

11-38 u/1

Hct 38-51% PCV

MG/DL TP 4.8* 6.4-8.1

IL G/DL

02-1.6 mg/d1

Hgb 12-17 g/d1 IT 5-65 u/1

':.: iiiiii0 ' — ,..- .1 I NST QC OK CHEM QC: OK .:,.,_ -.;:-. --...:2:-'1- -;:,1C ..•. .45:--1:4'.':;.:: 1. 6A-8:1 g/dl

TEST RESULT REF. RANGE I-EM 0 , LIP 0 , ICT 0

Troponin-1 k3T-----RESULT---REE RANGE

Drug ofAbuse

*

' 111- / 128-145 mrrio1/1

5—' o 3.3-4.7 mmol/1

' .-, (o 5

98-108 mmolll

- 'co, . D V

18-33 rnmoui

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 19325

DOD-032899 ACLU-RDI 1651 p.85

(;)

18-09-03 WB 10:32

Patient . Limits

10.5 6.00

18.0 60.0 99.9 31.0 37.0 450. 51.1 3.4

WBC 16.0 H x10"3/mL 4.5 RBD 3.90 L x10"6/aL 4.00 AO 7.6 L g/dL '5J1.0, Hct 25.5 L % 35.0 MCV 65.4 L fL 80.0 MOH 19.6 L pg 27.0 oc 29.9 L g/dL 33.0 P1t 274. x10"3/mL 150. LP'. 10.5 *L X 20.5 LY# 1.7 * x10"3/aL 1.2

ID:11111111/ 18-09-03 148 19:20

Patient Limits

BC 6.7 x10"3/mL 4.5 10.5 RIC 3.41 L )1,10"6/mL 4.00 6.00 HO 8.2 1 g/daL 11.0 18.0 Hct 25.9 L % 35.0 60.0 no 75.9 L fL 80.0 99.9 iH , 24.1 L pg 27.0 31.0 MCHC 31.8 L g/dL 33.0 37.0 Plt 127. L x10"3/mL 150. 450. LYX 20.0 L % 20.5 51.1 LY# 1.3 x10"3/uL 1.2 3.4

ID: WB

18.09-03 14:25

Patient Limits.

WIC 12.5 H x10"3/uL 4.5 10.5

RIC 3.19 L x10"6/uL 4.00 6.00

Hgb , 7.4 L g/dL 11.0 18.0

Hct 23.4 L X 35.0 60.0.

NOV 73.5 L fL 80.0 99.9

MCH 23.2 L pg 27.0 31.0

MCHC 31.5 L 33.0 37.0

Pit 162. * -x10"3/aL 150. 450.

LYX 9.7 *L X . 20.5 51.1

L1# 1.2 *- x10"3/UL 1.2 3.4

I0:1M 19-09-03

WB 04:08 Patient Limits

WBC 5.7 x10"3/mL 4.5 10.5 RBC 3.05 L x10"6/uL 4.00 6.00 HO 7.3 L g/dL . 11.0 18.0 Hct 23.0 L X 35.0 60.0 MCV 75.5 L fL 80.0 99.9 MCH 23.9 L pg 27.0 314. MCHC 31.6 L g/dL 33.0 37.0 Plt 113. L x10"3/11L 150. 450. IY% 12.6 *L. % 20.5 51.1

LY# 0.7 * x10"3/mL 1.2 3.4

ID: 48 05:04

Patient Limits

WBC 8.2 x10"3/uL 4.5 10.5 RBC 3.43 L i10'61uL 4.00 6.00 Hgb 8.7 L g/dL 11.0 18.0

Hct 26.9 L X 35.0 60.0

MCV 78.5 L ft 80.0 99.9 NOH 25.4 L pg 27.0 31.0

ACHC 32.3 L g/dL 33.0 37.0 Plt 106. L x10"3/mL 150. 450. La 17.4 L X . 20.5 51.1 LY# 1.4 110'3/uL 1.2 3.4

7.9

vatlent

. 10'5.fuL H9b 7.5 L ILO i6.0

23.) L 55.0 60.0 72.5 L fL 9.

:Cfl L pg 31,0 iiCHC 2.3 L ga 53.0 37.0 Pit 1:4. L xla, a la 50. L'12 14.A -*L 2 20.5 51.1 LA 1.2 *L x10'31uL 1.2 .3.4

MEDCOM - 19326

ACLU-RDI 1651 p.86

MEDCOM - 19327

df10

210 0

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VN

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co

DOD-032901 ACLU-RDI 1651 p.87

Microbioloav Resort -

Name:

Patient ID: 111111 (C-t- Ward/Rm: /

penmen:

Source:

Ward of Iso:

Status: Final Collected:

Attd. Phys: d/Sterile site

1 Aeromonas hydrophila group Status: Final

1 Aer hydro group Druq MIC Interns Druq MIC Interps

Amox/K Clay (c) <=8/4 S

Amp/Sulbactam (c) >16/8 R

Ampicillin >16 R

Aztreonam <=8 S

Cefazolin >16 R

Cefepime <=8 S

Cefotaxime (c) <=8 S

Cefotetan <=16 S

Cefoxitin >16 R

Ceftazidime (a) <=8 S

Ceftriaxone (c) <=8 S *Moir Cefuroxime (b) <=4 S

Cephalothin >16 R

Chloramphenicol <=8 S

Ciprofloxacin <=1 S

ESBL-a Scrn <=4 •

ESBL-b Scrn <=1

Gatifloxacin <=2 S

Gentamicin <=4 S

Imipenem (c) >8 R

Levofloxacin <=2 S

Meropenem (c) <=4 S

Moxifloxacin <=2 S

Nitrofurantoin <=32

Norfloxacin <=4

Pip/Tazo (d) <=16 S

Piperacillin (a) <=16 S

Tetracycline <=4 S

Ticar/K Clay (a) <=16 S

Tobramycin <=4 S

Trimeth/Sulfa <=2/38 S

S = Susceptible N/R = Not Reported Blank = Data not available, or drug not advisable or tested

1 = Intermediate — = Not Tested ESBL = Extended spectrum beta-lactamase

R = Resistance TFG = Thymidine-dependent strain Blec = Beta-lactamase positive

MIC = mcg/m1(mg/L)

= Resistant due to extended spectrum beta-lactamases (ESBL) EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

IB = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs. Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1. >16=R). Footnote (c) applies to this drug.

(c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicithn/sulbactam with enterococci, refer to the penicillin interpretation.

(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) end moxifloxacin are based on FDA approved breakpoints For S. pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from patien ningitis. For non-meningitis infections, use =2=S, 2=1, >2=R.

Name: Specimen: im

Patient ID: "1--\ Source: Woun• terile site

Status: Collected:

Ward/Rm: / Ward of Iso: Req. Phys:

Printed 9/24/2003 11:14:07 AM

Page 1 of 1 Tech:

MEDCOM - 19328

DOD-032902

ACLU-RDI 1651 p.88

Iv

MEDCOM - 19329

p (

Di/

:awil

O

0

CD :a

weN

ise1

a

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DOD-032903

ACLU-RDI 1651 p.89

Status: Final Collected: Req. Phys:

Tech: -11(11)11191111111111F

Microbiolo s Re • ort

Name: Patient ID: Ward/Rm: /

Specimen: Source: Ward of Iso:

Wound/Sterile site Status: Collected: Attd. Phys:

Final

Aeromonas hydrophila group Status: Final

1 Aer hydro group Druq MIC Interpa Druq MIC Interns

Amox/K Clay (c) <=8/4 S Amp/Sulbactam (c) >16/8 R Ampicillin >16 R

Aztreonam <=8 S Cefazolin >16 R

Cefepime <=8 S Cefotaxime (c) <=8 S Cefotetan <=16 S

Cefoxitin >16 R

Ceftazidime (a) <=8 S

Ceftriaxone (c) <=8 S

Cefuroxime (b) <=4 S

Cephalothin >16 R Chloramphenicol <=8 S Ciprofloxacin <=1 S ESBL-a Scrn <=4 ESBL-b Scrn <=1 Gatifloxacin <=2 S

1140,

Gentamicin <=4 S Imipenem (c) >8 R

Levofloxacin <=2 S

Meropenem (c) <=4 S

Moxifloxacin <=2 S Nitrofurantoin <=32 Norfloxacin <=4 Pip/Tazo (d) <=16 S

Piperacillin (a) <=16 S

Tetracycline <=...4 S

Ticar/K Clay (a) <=16 S Tobramycin <=4 S Trimeth/Sulfa <=2/38 S

S = Susceptible N/R = Not Reported Blank = Data not available, or drug not advisable or tested

I = Intermediate — = Not Tested ESBL = Extended spectrum beta-lactamase

R = Resistance TFG = Thymidine-dependent strain Blac = Bela-lactamase positive

MIC = mcg/ml (mg/L)

Ft' = Resistant due to extended spectrum beta-lactamases (ESBL) EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

IB = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs.

Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (B=S, 8-16=1, .16=R). Footnote (c) applies to this drug.

(c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.

(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints.

For S. pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from patient 'th meningitis. For non-meningitis infections, use <2=S, 2=1, >2=R.

Name: Specimen:

Ward/Rm: PIM Ward of Iso: Source: Woun erile site Patient ID:

Printed 9/24/2003 11:14:07 AM

Page 1 of 1

MEDCOM - 19330

DOD-032904 ACLU-RDI 1651 p.90

MCV 80-94111(M) 81-9911(F)

Ket Negative Gram Stain

P 401

Segs Mono

Ward/Section:

LAST, FIR

I 14

6-

II (Subject to the Privacy Act of 1974)

N/PEEUDO SSN:

LABORAI X RESULT FORM

TEST RESULT REF. RANGE TEST RESULT REF RANGE

4.8-10.8 x10

4.7-6.1 xlo 14-18 g/d1(M) 12-16 g/d1(F)

N/A

N/A

Negative

Negative

Negative

tiikr "

WBC RBC

Hgb

Hct

Color App Ulu

Bili Negative Source 42-52%(M)

37-47%(F)

SG Plt

Lymph

130-500 x10' verified

20.5-51.1%

lffer tial *ka,

N/A

Negative

N/A

Negative

Occ Bld

H. pylori

Micro Parasites

Malaria

Negative

Negative Bld

Prot

Bands Eos Urob

0.2-1.0

O&P

Other

ma to • 0, 42'4'

Nit

Negative

Leuk

Negative

Lymph

Atyp

Baso

Imm

RBC Morph

HCG

Negative

Spun Hematocrit

42-52%(M) 37-47%(F)

Set Rate Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Negative Other

TEST RESULT REF RANGE

Directigen

UNIT

ABO/Rh

TYPE CROSSMATCH

PT

9.8-13.6 secs

APTT 21-34 SESS

D dimer <20 ug/ml

FDP < 10 ug /m1

REMARKS: (

1WREPORTED BY:

DATE:

LAB ID NO.:

MEDCOM - 19331

DOD-032905

ACLU-RDI 1651 p.91

Code &nip with numbers. events will,

_VP r

1 ILjq /3c

EST BLOOD LOSS URINE -

T AMSIMON IME •"*Z3z) • 3 4 5 SYMBOLS

-7-magegmarr, urgreansmmem

• , ,, . .

CRY STALLOID-

COLLOID-

BLOOD-

LINE silo

AIR LiMin % e.t.

=MEMEM ; ME=MEMMN

ElINIEWM=MEMEMMENUME=IIMMINEEMM

DROMMENNEENUMMEM=EMIEMINESIMBUNEEN

FAMMEMEMIMSIMIESEINEUMENEUSINEMEIM 111•111111MVAIIIMI Wair47"Wit§"EssmakvAnniagsmorawyw Mill111111101:41E0WAIIWAIIKIMIMEMMITINviirrly7 aNNE=SWENZIMWSWMONVIMEASSONSUO

/111.912iiiMMI ISEMEMINEEMEMENEMENESSUMINSISIENEMISEN 11=111111111=1 516NEMMINFORIMINIMUMMERSUEBBNEWM IIIIMIIMMIIIIrAWINAWAVIMAIEWESIVAITWXVILLEM

EIZESISME=ENZIESE=MINEENZERWEEMENUMEIRE W;;ITMEL'IiliEt tinicAPLVAIMC4.1711/fr

BP (transduced)

.1 T

TOURNIQUET

AN ES- X-X

PR000-0

BP by cuff

V

A Heart rate

• Resp rate

TTF:=- /4

gagffigiIIIIMIIIMEMIRWArravAMTAKVAIEV IlEk:111/E4MaSSIIr.-- EMBIEMIITIIIILDPIOLTIE

Rio .1117M!VIErnfil: 15$11111111AMMINWIRIAMMIM11111111 IL • • 0 /270 - • 00 / 00 Zan timiErinyftwimi • Pr" sr- Asi- _4 .ar -4r/ 1r I /41-4, 4 . - 5(9,

. . lariMilW211EngerZiarergr" it:

REVERY AT

ART line Meth- PCIE

anal er

ET CO2 tort Isp•awY)

///0 ,63.5 o Ready Begin End

// 4(?) / 2C-C, Sb

gab-‘;,(61112-111.TrIM - Ct. ublitita n:L'itg -411"j4' At i94)ci vivr za

/7' e-c)Z- • PROCEDURE LOCATION 0 I'? DATE

i36153 PAGE OF

'U.S. GPO: 2002-729-180/40137

MIA ielln Wars i 3Ymb015. EVENTS • arpiain under REMARKS position

(-r, /, ;"/a

,

MEDICAL RECORD ANESTHESIA TOTALS

02 L/Min

RESP-

OP-

220

200

180

160

140

120

100

80

2-010 Ffg &L.c

/Zio P<A6`-S

PElAURES and CPT Codes ilLI.

M PATIENT IDENTIFICATION- Typed or written entries: Mem. GrodwRaft,

Medical fee/My

Ainisnirng TECHNIQUES: Dal • Nock tochniIPAP Lock/ Renswee

."17-1"

INEDICAL - ANEISTHESIA

WAMC OP 376 REVISED MEDCOM - 19332 1 Jan 99

DOD-032906 ACLU-RDI 1651 p.92

Cody *ups wah numbs. events with letters

INC 0 warned

EST BLOOD LOSS URINE —

PHYOMINN 1 2 3 4 5 E

AK Ir:STHET1C TECHN under Remoras


)

1.4'") 'A del % e.t

- 0 gz. d

▪

2 4 d,

al I 1- ▪ z •-

• P. Z 0 3 Z

2 t i•-• z O 1.= = u

Sep

CRYSTALL01%—co CJ

COLLOID-

BLOOD—

SYMBOLS:

MINIMMEMINSIMMIN lanaMinailMMWMM60 SSIMEMEREENEMEIRMINEBIONMENNEEMIDEMARM

MEM= MENEUMENUMEMEMENIERMESSI .9MM =a1=MEZEVERNMEIMIENNISMI= MIYATAMITHEIll =HIM " BMA IgME=

KG LB

180

160

140

120

100

BO

oK far PROC = RE?

BP by cuff

V

A Heart rate

•

Resp rate

X-X

PR°C1C)-0

RECOVERY AT

BP / oth ■111•IMIN/'

PATIENT IDENTIFICATION— Typed or widen metes: None Gedeltele. Medical fealty

Gi211-1 AIRWAY MAN ENT: boom/ion route. Wed., technique comments

SU PROCEDURE

AN LOCATION DATE

MEDICAL RECORD — ANESTHESIA g 5/W r:Lq


-U.S. GPO: 2002-729-180/40137

PAGE zd. OF —z

DOD-032907 ACLU-RDI 1651 p.93

ASSESSMENT PAST SURGICAL/ANESTHETIC

PHYSICAL EXAMINATION BP _ HR_ R _ T_ Pain Scale 0-10 HEENT - Teeth

Trachea TMJ/Neck Oropharnyx Nares

CHEST:

CARDIAC:

EXTREMITIES:

IV Access: Ulnar Filling.

BACK:

OTHER:

HAfflTS• TOBACCO:

ETOH:

DRUGS:

CURRENT MEDICATIONS: ( ) = ordered as premed

() ( ) ( ) () 0 ()

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

LABORATORY STUDIES:

1113/HCT: U/A: OTHER:

•

7

Patient Identification: (Ward)

ti \ -

V) (j° Sig POST ATIO AND NOTE (NON ASU) ) NO APPARENT ANESTHETIC COMPUCATIONS { } OTHER

understand and agrees. Questions answered. /e2W)- Date: iY.5/5.

ANESTHESIA PLAN OF CARE PrielTOCEDIJRAL ASS ENT (SedatiociAmithok) AgeZ2 DAYS MOS YRS Sex (1)7MALE ( ) FEMALE

ASA Physical State 1 2 3 4 5 E PROPOSED PROCEDURE INT: 70 164B HT: IN. SURGICAL SERVICE CO►10 ALLERGIES: A /4/.,77 -- NPO SINCE:

PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:

Hypertension Angina MI Y CVA Other

Pulmonary System: Asthma Bronchitis/URI COPD Other

Renal System: Acute/Chronic R Y

Gastrointestinal: Hepatitis Instal Hernia PUD/GERD

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

Neurological: Seizures N Y Neuropathy N Y Other N Y

Gynecological : Pregnancy N Y

Other Significant fix: N N

Familial HX N Y

NPO Since

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

{neral: Mask Intubation

INFOR

SEUNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and I guardian.

Time: //o7)

Hrs

SEDATION KEY: .

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

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

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

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

WAIIC Form 2300 (Revised) 15 Mar 01 MCXC-DO MEDCOM - 19334 PATIO-MT coor•rion rfIDV

Previous edition is obsolete ' U.S. GPO: 2002-729-283

DOD-032908 ACLU-RDI 1651 p.94

CI a

;t

SYMBOLS:

BP by cuff

V

A Heart rate • Rasp rate

PATIENT IDENTIFICATION— Typed or widen oning.8, NOM% GnickdRate, Medical lade*

CA.

'


PROCEDURFA LOCATION DATE

.30

BURG

AXES

zryo Q No 4 sine efecsitcsiL pie- -o0 r Sept 03

TOTALS

CRYST*01D- %.7

COLLOID—

r!ITMP...11171/7,41/1E-1=111M111==1 Code dugs with numbs's. events with kitten

EST BLOOD L ••• •

OK for

BP (transduced)

TOURNIQUET

T

AN ES— x-x pRoco_

MFAINFINISC+11 ElfoltIV.INFROMMMENIAVEMIMMI

MaNNNWWWW.A

Nilin ME =MIME

EMINIMINEINE==a=RMENEVE MEM MISIMMIUMBINNEMEMEMINVINIE=MINMEMI MBIFIVASIMERUMUMENZEMBMINE.MEMI MUMS FAVIAIIMMIIIIII KM

=PIPE=

MENEMEIREKNONWONNESEN 5=EME= MAI IMAMMINIIII • glasammummornmemmaissommEmsmomm

stalmniumurhs noser,,wwwwwasavvesammonffmasmanalgi ett4 A sxki 3(/ iditq MN NNW MNN

1-111777WM:i144.

BP/Auto C T CO2 tort

RECOVERY AT IMMO MOWIlrirMIRMELIINICIMIC BP / oth ART line

Steth- PC/E

AKIO beilK kith/3 A symbol. EVENTS orphan undw REMARKS position 6-1

PROCEDURES and CPT Codes

DSD

Ready Begin End

/5-17 Li3THE71C TECHNiQUES:Descnbo block heclefialle Udder RO/Plerk6 .7p. 4/,

4-3/16.2-ex,

ff-coc- t • .0

'U.S. GPO: 2002-729.180/40137 -180/40137

.••••• 410

MY134:.TAUM.

DOD-032909 ACLU-RDI 1651 p.95

ANESTHESIA MEDICAL RECORD (Unite) TOTALS

FLUIDS - SUMMARY CRYSTALLOID– toc)c>

VOL AT AGENT

COLLOID–

BLOOD–

% del e.t.

AIR UMIn N20 UMin 02 L/Min

SINGLE DOSE DRUOS — MARK ON ORR". WITH NUMBERS CENTER IN REMARKS

REMARKS-

Ne. PILe 00

TOTAL URINE

Cods ciuga wAh numberi. &whits wAh letters

dz , cLji

! :

IIIM• . ;:::1 =MM . . .

• ::Ki:::::6 :::::: -.i:::::::i:::::: EIRIMM MIIMINIMMOI . . MIMI

IMENNIIN::::1:::::1:::::MINIMEENSWASSUMMIM

E!•671Y.EiliffrAWAIAMMMUMUM IMMIMIIMMI11•••=11 i : MIIIHIENNE 1.:,:::;K:::::::1::::: ME:i:M1:::i:iffilnintale•Nal•ENSUMMI 11111 ,:,.,;: ::,;i.,::: 411MISis•Mil • MIIIIENZI•lompllo Inj MI ••••MENEN1:::::::::::::::::71110§ ME : 1 i i

SIMIMMIIIIIi i iIIRI1H

i El fliminiikin , li MENA gen umminM M nannaMENE MEMEM Effa EN 6 MEsEMZE M

NMI= 0 IrditillianuMMinsarannamnannus

I LOSSES EST BLOOD LOSS URINE–

S STATUS

2 3 4 5 E

BODY WEIGHT

KG LB

T..

BP (transduced)

.1

TOURNIQUET

T —/ ARES– X-X PROC-0– 0

SYMBOLS:

BP by curl

V A

Heart rate

•

Resp rate

1111Lavicw...luummiiiiii.41911 ET CO2 (torrl

ECG TEMP- site 5tPk) N 4 A Block TM

ng blkt

Cony warmer

M.* dh iMt.r a llanbok EVENTS forPMM un thhr REMARKS position


p k oLi f it_6(z_A-A, ,,k_ozzl.

RECOVERY AT

PACU Icy (SPecirld

AN ESTHETIC TECHNIQUES:Nnwth. Nock f.ehrg9.• un dw Remark.;

6A \--iLyrio‘

PATIENT IDENTIFICATION — TYP•Mcw .niton onMor AUme. Gr•ck/RIA", Medico, facility

AIRWAY MANAGEMENT: laubahion route. Moat hochnkuo. comments

iv Lt. 0 Loyk-cet,..2_ SURGEONS:

ANESTHETIST

MEDCOM - 19336

WAMC '76 REVISED PAGE

1 Jan 99

PROCEDURE LOCATION

'EQ

OK for PROCEDURE?

BPIAuto Cuff

BPloth ART line

Steth- PC/ES Gas analyzer

Ready Begin

• if"}-

DOD-032910 ACLU-RDI 1651 p.96

ANESTHESIA TOTALS

TOTAL URINE

LINE silo s a Warrred REMA Code dugs with number. events with bass

Pr 10 la4/

ed-61-2. -enern

PROCEDURES.and CPT Codes

z Ui

I- Ui

I-

Ui z

VOLAT .1/ h z -

4741MA2111111/Ari AGENT

mc. witt

1 I I 1 1 I 1 MI 1 I 1 1 II 1' I 1 1 I MI VI I PAWIrMAIIW fliTallird 1 1 1 1 1 I 1 1 1 1 1 I 1 1M I SINGLE DOSE DRUGS - MARK ON ORIti. WIN NUMBERS &ENTER IN REMARKS

FLU DS - SUMMARY CRY STALLOI

COLLOID—

BLOOD-

(Unite) MEDICAL RECORD

zs-r, 1

LOSSES'

PHYS STATUS

EST BLOOD LOSS

FR) s6r

OK 'for PROCEDURE?

BP -

Zte L2 1

BP by curt

V

A Heart rate

•

Resp rate

BP (transduced)

.1.

TOURNIQUET

T

ARES- X-X

PROC-0 -0

SRUU MM Ilala i i• IMININIMIMI

• aWra

, 1M MOSE Mallialumitaa 17A 1111111M11111 i i 1111a 11131111rn

Far ,MMILIIIIMMIMEMps OSE rAIRIMWAWIrinaMaESEM7

affi' IMENREMIKMN MLEMMil MEM , .E.ZAIMME ! M.:MMs

Mt ESSINIMMEMENUARESZNEVA NAIIIVAIM1 min i i win gimmi um *MEM! VAIN ESVIISWAY/AISSMEREM ME=1.WATAMPIEVAVi II RI ELINMI .MINIM MaaMbildiveiMUMMLOAMMaaa .:: .;:.1]:.'E:: a' a

U. . • • IIPPIP IIMllr iNMMIPAIIMIMMMMIIEIMMIII. RFS nvERY INIUNNEEIIIIMMIIMISMIMMMIEMI I BP/Auto Cu rr T CO2 torr ILThlig7MLWariMP7i 11111•111.1111111111111111MMIll

1 BP / oth PiAL04.41,ffrazwill t I ART line Cr WM= CrIZMIMIL

1.112111nElffiralliffWIM ; 1 Pr -M Block T14

1 11 i, I I .i 1 blkt

..11 Cony vrrm I aer

AN?....STHETIC TECHNIQUES:D.scribe Nock technique under Remark.,

6A- - fl,L4S4 11:24-- b PATIENT IDENTIFICATION- TYP•c I ix .,Ilett oni403 ' N.m.. GrodetRete.

Modcol foray

th c5,1')

PATIENT RECORD

C OP 376 REVISED 1 Jan 99

DATE

Lt't

PAGE ( OF

MEDCOM - 19337

DOD-032911 ACLU-RDI 1651 p.97

REMARKS- . LINE sib 0 INanned

/3

(Unite)

111111.1MIWIT41 - Nemormarasi wer-Parrmai • rammramtsmar I MI To" I I MI 11111111110

=SWF 111111WEINF IMINIPRIAMMOVIEBEMOIRSINIMMII

I picx.eolci,x_ ‘,1c0

. 1K10(4.. MEDICAL RECORD ANESTHESIA TOTALS

TOTAL URINE_ j

FLUIDS - SUMMARY

NR UMin CRYSTALLOID-4x

COLLOID-

BLOOD- SINGLE DOSE DRUGS - MARK ON ORICi. WITH NUMBERS SENTER IN REMARKS

Code drugs with numbers. events with letters

OSSES URINE -

P YS STATUS

ze

•:4:.

1:07

.--.::: , i:::::1 -. 1: ..az.: il:::::::::: .:.•,.1::::::t::::: • • i ;

i t::::::111:In::::1:::::::::::1:--:.:::j:::: : • •

Una M I ffill11111141 ! !

En &

IMMINIUNIM EMEMENEM MENSESSIONMEMERNISSE MUMIMPIIIMII ft- FWIPTrargirAMPAr4r1111 SMANIFA_ 111/1274,,, , fps, w, .1. AA &CAPRA EM kV vanA4111

EM kW ' ' ' IBM MINVIredialvtiMIZAZ YAW! _.,,,..IFAVIIIIT. ,,, AVICIFIrigNANTANAIWIAMIMIUM

VrAlietilirtLekle2k16■REMEMMIffiliTA:Yd.:41, MMEITNIMM MIHMMINIM .mmramemE....m.

OK for PROCEDU


, (\ad

PATIENT IDENTIFICATION- Ty, or written hicNey

Z

b - In- citArei

n•r, ....

misirroffwiraprovitelfs-ronranottaniAmmurimarmc ImMmullIIIIIINCAMINEENMIIMTWIHICIWAIIIINIIIMIIINValDIAll ■11102,1itima44111•1111M1 111IMINIIIIEIMMWAIMIN RECOVERY AT *Ilea"

td 1111acommaiwzmnoutRIMIrMAIMIVIVANIMMILVAITWAIIMNIWAI n 1 . . to Cu r' T CO2 toff 111111111K-WWINIMMTOPFM1101: III_MINg=M1111 ri:i ll r 1 BP 10th lialMriVirl igfcj

I ART line PLMIIIIIMIll ariiM IV P IMME.M111111111111AMMINCHIM111.6. 'WOW .IMITIMII=211111110,110111MCWIIIIMER WIIMMIMSWINII I:Kamm IIINNU7.0211111115

Al

7 I

IMMO 1'1 _II Cony wanner

11111=f111•1112=01111111/ u Start Room End

11111111WAL..._04MWSOAJMNIMIPITIN

aau,-4-t.A*Pf\. MAL,

qcY /6": co, ea, ell-

AN::.STRETIC TECHNIQUES: (3°'°11:' bi"1. --#

.s [tea 15 112 3-1-1/. d -,1+1

(■ 62 SURGEONS

b (C51-

A ) MEDCOM - 19338

376 REVISED 1 Jan 99

30 PAGE /

DOD-032912 ACLU-RDI 1651 p.98

LINE sae -I- REMARKS- o Warmed

o Wenrod Code caws with numbers. .o.1

with beers

tn DRUG (Unite) M 3

•

1 ( )

Z I 1 O w 2 f 1 Z 6- - v* LJL co F- w i . L__L z a Z ) )

• t; VOLAT cL k fifq

3 0 AGENT % e.t. U AR UMIn

iu x o' N20 L/Mln r- u) Linn Lu z SIMOLE DOSE DUOS -MARK ON ORIF < WITH NUMBERS &ENTER IN REMARKS


FLUIDS - S M ARY

CRYSTALLOID-

COLLOID-

BLOOD-

EST BLOOD LOSS LOSSES

0' ■ ga MII V Igi I ME IRU r:.:i::::

ism pania::::07:,.., aim 1 ! tr

: M:::::::::: ,::?:::::: , : 71:::::::;::.:::i::::.::ii:.,:: : 17 ::::40::-:: : : i i .2..«.- • Mg EMIR= MEE M . .

SISEEMMENEMENEEMMEMMEMOSEN EMIIIIMIINIMIIM111111111 IIIIIIII=E

l'gkv4 '

MIMI =IMM MSEREEKKEEN

MIMINMOMMIEMIM EllIAIM IIM I . ......a.,..th. .:::::,:..„:::::,. „q„,„. :,,::,:::::„m min. .„,,,„...,

m i i

vr.....mm...mm. mi....mmmmmmimmmom

PHYS STATUS

OK for PROCEDU

wazir !TordrrriNbitur* v

61MISEIM IMArt■ Ir7rneill116=701/aeNt.

.

ItiEi LI

I I r -

AMA with hears symbols. EVENTS under REMARKS posilion


PATIENT IDENTIFICATION- rYP•d or wilton entriOS: MUM GredeeRere. &Mace/ leciNty

MO' - S n • ssist on •

.

Auto Cuff BP / oth ART line

CO2 ton P 1 gi•i&-

N Block T/4

ng blkt

Cony warmer

K Att S i f#J2 :z. Elle TECHNIQUES:Chuff/W.. Nock technique uno" Fearmrk4

"S-e_t_ , ifp -j---- AIRWAY MANAGEMENT: Intubetion route, biodl. technique


RESP-

BP-

Sp02-

NR-

RECOVERY AT

PACU ICU tSlmcd'IN

ONDMON:

, v,--•rv t, • -T,Y ;7 ro , '' ''' •

Ready Begin End

DOD-032913

ACLU-RDI 1651 p.99

1st VERIFIER (Si

2nd VE

PR

TEMP. PULSE

7— e-ithk

oS BP

518-124 NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOO MPONENT TRANSFUSION

SECTION I - REQUISITION

,gr RED BLOOD CELLS

FRESH FROZEN PLASMA TYPE AND SCREEN

PLATELETS (Pool of units) ›aROSSMATCH

COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print) .t. Products are requested.)

CRYOPRECIPITATE (Pool of units) '-/ T,),/ ri b

\ c--- .(

DIAGNOS PROCEDU E.-

OTHER (Specify)

I have collected a blood specimen on the below named patient, verified the name and ID No. of the

DATE AND HOUR REQUIRED patient and verified the specimen tube label to be Rh IMMUNE GLOBULIN

DATE REQUEST cf

,AF S'r--- correct.

VOLUME REQUESTED (If applicable) KNOWN ANTIBODY ORMATION/TRANSFUSION SIGNATURE OF VERIFIER (Specify)

NC> REACTION (Spech

Lt_' --.--Z—

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DAIIIIIIIIII RhIG TREATMENT? DATE GIVEN: / ( ATe o 7•

i

b\ & TIME VERIFIED HEMOLYTIC DISEASE OF NEWBORN? i/ 910 ) ,

SECTION II - PRE-TRANSFUSION TESTING

IIIIIIIIIIII PATIENT NO.

UNIT NO. TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN

v

CROSSMATCH

(DONOR RECIPIENT

i

(t. (01"-'1) 4)

RECORD _1(-...NO RECORD SIGNATURE OF PERSO P T

Po) Rh Rh

° 5

ABO ABO a REMARKS: FEXe.,... -2". Z j 5,e, a'...

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED I DATE ,g5-Q-,.4.)?

SECTION III - RECORD OF TRANSFUSION

PRE TRANSFUSION DATA POST-TRANSFUSION DATA

INSPECTED AND ISSUED BY (Signature) AMOUNT GIVEN

1,44—ML TIME/DATE COMPLETED/INTE UPTED

ILAS1,151q f T

D3 REACTION

NONE El SUSPECTED

TEMPERATURE

oLo PULSE BLOOD PIESSURE

ioa 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 identif .1'.. ag.

DATE OF TRANSFUSION TIME STARTED

___./2 19yr- 6'3 ZZ-

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

El URTICARIA ❑ CHILL Li FEVER PAIN

OTHER (Specify)

OTHER DIFFICULTIES (Equipment, clots, etc.)

NO YES (Specify)

SIGNATURE OF PERSON

BLOOD OR BLOOD COMPONENT TRANSFUSION t Medical Record

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

cc)-

PATIENT IDENTI CATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middl rate; hospital or medical facility)

MEDCOM - 19340 Medical Record Copy

DOD-032914

ACLU-RDI 1651 p.100


PREVIOUS RECORD CHECK:

LI RECORD I;(/-0 RECORD

SIGNATURE OF PERSON PERFORMING TEST

UNIT NO. TRANSFUSION NO.:• TEST INTERPRETATION

ANTIBODY SCREEN CROSSMATCH

PATIENT NO.

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DAT

RECIPIENT

ABO

Rh

REMARKS:

SECTION III - REC

DONOR

A80

Rh

0 poS

518-124 NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION MEDICAL RECORD

SECTION I - REQUISITION COMPONENT REQUESTED (Check one)

fx, RED BLOOD CELLS

FRESH FROZEN PLASMA

PLATELETS (Pool of units)

units)

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

LI TYPE AND SCREEN

e.01, CROSSMATCH

REQUESTING PHYSICIAN (Print) i( / , 1/4,.. 1/4,k. 3 '-

DIAG

CRYOPRECIPITATE (Pool of

Rh IMMUNE GLOBULIN

OTHER (Specify)

DATE REQUESTED

/ ? f7-3 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.

DATE AND HOUR REQUIR D

/J>S:rt7 VOLUME REQUESTED (If applica0k)

e sKe . .(,/ ML

KNOWN ANTIBO FORMATION/TRANSFUSION REACTION (Specify)

-- "-L, SIGNATURE OF VERIF , ( (.42

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

RhIG TREATMENT? DATE GIVEN:

DATE ERIFIED

/ dr> f.e.",., ,e) HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED

70-(rD

PRE-TRANSFUSION DATA POST TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)

IIIIIIIIIIIe

AMOUNT GIVEN

/0/44-i--- ML

TIME/DATE COMPLETED/INTERRUPTED

/2' -7-- 3 REA ON TE4PRATURE

• -S

PLZEgz_S/,0

"S BLOOD PRESSURE

9 7i/ 3 AT (Hour) / a-0 p ON (Date) ( fr-j,v2czka NONE LI SUSPECTED

IDENTIFICATION -

I have Blood Component container label and this form and I find all infor the container with the intended recipient matches item by item. Th .e person named on this Blood Component Transfusion Form and o ion tag.



6 ( (,, S --i. Pr) 4-4, Lie-11-iitk


URTICARIA LI CHILL FEVER PAIN

OTHER (Specify)

_ - quipment, clots, etc.)

ES (Specify) PRE-TR.

TEMP. 362 , I PULSE . / I BP ci fig Z_ 'SON NOTING ABOVE DATE OF TRANSFUSION TIME STARTED

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

SEX WARD

ki

BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

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


DOD-032915

ACLU-RDI 1651 p.101

e os

DONOR

ABO

Rh

ANTIBODY SCREEN CROSSMATCH

1st VERIFIER (Signature) DESCRIPTION OF REACTION

URTICARIA 9 CHILL ❑ FEVER 9 PAIN

OTHER (Specify)

PRE-T

TEMP. S(67, b I PULSE

TIME STARTED

Z-CD

2nd

BP / 7/5-2

(Equipment, clots, etc.)

ES (Specify)

A MEDCOM - 19342

Medical Record Copy

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

WARD a,<7 BLOOD OR BLOOD COMPONENT TRANSFUSION

Medical Record

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

grade; rank; SEX

,4

SON NOTING ABOVE

)(-• (A) DATE OF TRANSFUSION

ig/%6,6,0

518-124 NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION


COMPONENT REQUESTED (Check one)

0 RED BLOOD CELLS

FRESH FROZEN PLASMA

, PLATELETS (Pool Of units)

units)


........■ ,..7a • ' •.-II SCREEN

kz, CROSSMATCH

REQUESTING PHYSICIAN (Print)

b '(_k_ — 2-

DIAGNOSIS OR OPERATIVE PROCEDURE

pi, i_c,71` 1--: 6 i-F/4 Pec. CRYOPRECIPITATE (Pool of

DATE REQUESTED

1 t 5:-W-- 65

.:. .. . 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

OTHER (Specify) DATE AND HOUR EQUIRED

'd VOLUME REQUE;:91icable)

)kP 0 ML

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

SIG

k . (..C.4., ----L.



DATE VERIFIED

orf _I 03 HEMOLYTIC DISEASE OF NEWBORN?

TIME VERIFIED

/0 •Cit)

'?- UNIT N0.

.111111111,



9 RECORD 4-A,10 RECORD

SIGNATURE OF PERSON TEST

TRANSFUSION NO.

PATIENT NO.

RECIPIENT

ABO 3 Rh f 05

TEST INTERPRETATION

DATE e REMARKS:

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED


PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED

ML 2,58 g s);53 REACT! N TEMPERATURE PULSE BLOOD PRpSURE

ONE SUSPECTED .3(0 •


INSPECTED AND ISSUED BY (Signature)

AT (Hour) 1(

IDENTIFICATION,

I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open. information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service. The recipient is the same person named on this Blood Component Tranifusion Form and 3. Follow Transfusion Reaction Procedures. on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

DOD-032916

ACLU-RDI 1651 p.102

UNIT NO. ( Cc) TRANSFUSION NO.

ATIENT NO.

RECIPIENT

ABO .13

Rh ro,s

TEST INTERPRETATION

CROSSMATCH

SIGNATURE OF PERSON PERFOR

CROS MATCH NOT REQUIRED FOR THE COMPONENT REQUESTED

DATE

REMARKS:

c---- -1111=11111111aa


❑ RECORD NO RECORD

MINFO TEST

MO° rf-(e

DONOR

ABO

Rh

ANTI BODY SCREEN

5>5P BLOOD PRESSURE

y

PULSE

T I PULSE V DATE OF TRANSFUSION TIME STARTED

518-124 NSN 7540-00-634-4159



COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA


units)


TYPE AND SCREEN

liA CROSSMATCH

REQUESTING PHYSICIAN (Print) 4......6

DIAGNOSIS Of. 5

4: 4 r,./7 - - 1"): V F; ‘

CRYOPRECIPITATE (Pool (Pool of DATE REQUESTED

'/C)

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

Rh IMMUNE GLOBULIN

OTHER (Specify) DATE AND HOUR REWIRED

- / & f--ft 63

VOLUME REQUESTED (If applicable)

09/L2

. . ML

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

SIGNAT R

b (cIL - - IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN: )

REMARKS: DATE VERIFIED

/CF x-e,d-o- f TIME VERIFIED

0 , W' 0

HEMOLYTIC DISEASE OF NEWBORN?



PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

INSPECTED AND ISSUED BY

ON (Date)

I have examined the Blood Component container label and this form and I find all information i. ing the container with the intended recipient matches item by item. The re ame person named on this Blood Component Transfusion Form and on (cation tag.

AMOUNT GIVEN

t ML

REACTI

ONE LI SUSPECTED



AT (Hour) IDENTIFICATION

) 4e se 0_3

TIME/DATE COMPLETED/INTERRUPTED

$10 TEMPERATURE

-3G


URTICARIA El CHILL 111 FEVER 0 PAIN

OTHER (Specify)

e)

e)

OT• ULTIES (Equipment, clots, etc.)

YES (Specify)

RSON NOTING ABOVE

\y°

P1-1/4-Pq C/e9474- PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Las de; rank;

rate; hospital or medical facility) SEX WARD


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


DOD-032917

ACLU-RDI 1651 p.103

Rh

RECIPIENT

ABO

P°5 Rh

TEST INTERPRETATION

ANTIBODY SCREEN

111

MING

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ DATE yi ea 5c,pf REMARKS:

GAG kclPert 63

UNIT NO. 1,,

N A El 0110111


N PERFOR EST

RECORD ❑ NO RECORD

( DONOR

ABO

TRANSFUSION NO.

PATIENT NO. 79b CROSSMATCH

Com p


❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

❑ OTHER (Specify)


4 NO YES (Specify)

SIGNATURE OF PER

DATE OF TRANSFUSION

lei, PATIENT IDENNIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade;

rate; hospital or medical facility)

41 -1111111 BLOOD OR BLOOD COMPONENT TRANSFUSION

PR

TEMP. p PULSE

iflia .fatb

2nd VERIFIER (Signature) \_D LcC.,,

I BP

'Um

124 TIME STARTED

A s-3 r

INS' (Signature)

AT (Hour) 0 IDENTIFICATION

ON (Date) rt 5• ft 0 3

518-124

MEDICAL RECORD

NSN 7540-00-634-4159


SECTION I - REQUISITION COMPONENT REQUESTED (Check one)

ii RED BLOOD CELLS

❑ FRESH FROZEN PLASMA

❑ PLATELETS (Pool of units)

units)


❑ TYPE AND SCREEN

, CROSSMATCH

REQUESTIN PHYSICIAN (Print) ,.6( C...e.,\) - -7.-

pr. DIAGNOSIS OR CEDURE

' , , A' IC4 "r*- 4-PI --.E, r'.')g .❑ CRYOPRECIPITATE (Pool of

Rh IMMUNE GLOBULIN

❑ OTHER (Specify)

❑

I DATE REQU STED

IA 111 a 3 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.

DATE AND HOUR REQUIRED

VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

ill

SIGNATURE OF VERIFIER



DATE VERIFIED

HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED


SECTION III - RECORD OF TRANSFUSION PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

AMOUN GIVEN TIME DATE COMPLETED/INTE• •UPTE

ML pliCO [ C/ /3I a3

C ON

NONE 0 SUSPECTED TE ERA RE

PULSE BLOOD7ZESSURE


I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open. information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service. The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures. on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9r202-1

esz MEDCOM - 19344 Medical Record Copy

J O Co

DOD-032918 ACLU-RDI 1651 p.104

T REQU ESTEDIDATE 11520.63

TIENT NO. '11:30

RECIPIENT


&RECORD 0 NO RECORD

PERFORMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPON REMARKS: ABO

Sept 03 Rh Rh .

6 ABO

DONOR

TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH

AT (Hour) br IDENTIFICATI N'

epr 2hdVERIFIE

ZdZ7/- PRELTRANSF

SION RA TI DATE OF TRA

I ot

AMOUr GIVEN

1 (it


K_NO 0 YES (Specify)

SIGNATURE

(

PULSE TIM ES TART STARTED

0-755


SECTION 1 — REQUISITION COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA



TYPE AND SCREEN

IR CROSSMATCH

REQUESTING PHYSICIAN (Print)

Dr. (LeS --‹

DIAGNOSIS OR OP AT1VE PROCEDURE

5/P g tK4 n. TL-Plo rx .2-e J-_-_1 CRYOPRECIPITATE (Pool of units) DATE REQUESTED

lq 63 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

OTHER (specify) DATE AN HOUR REQUIRED

VOLUME REQUESTED (If applicable)

ML

KNOWN ANTIBODY FORMATION/TRANSFU- SION REACTION (Specify)

h E

SIGNATURE OF VERIFIER


RhIG TREATMENT? DATE GIVEN'

DATE VERIFIED

HEMOLYTIC DISEASE OF NEWBORN? _

TIME VERIFIED

SECTION II — PRE-TRANSFUSION TESTING

SECTION III — RECORD OF TRANSFUSION

INSPECTED AND ISSUED BY (Signature)

(Date)

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

TIME DATE COMPLETED INTERRUPTED

oWs- Piszele-3 0 NONE 0 SUSPECTED

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 Tfli:TOd Bank. DESCRIPTION

El URTICARIA 0 CHILL EJ FEVER D PAIN

Ei OTHER

REACTION

PATIENT IDENTIFICATION - USE EMBOSSER (For typed or written entries glue: NAME - Last, first, middle; rank/rate; hospital number and name of facility.)

SEX WARD

BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8.661 General Services Administration interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518-122

MEDCOM - 19345 MEDICAL RECORD COPY

DOD-032919 ACLU-RDI 1651 p.105

EXAMINATION(S) REQUESTED REGISTER NO. WARD/CLINIC SSN (Sponsor)

TokiJ- PREGNANT

[1 YES ri NO

TELEPHONE/PAGE NO.

FILM NO.

REQUESTED BY (Print)

DATE REQUESTED SIGNATU

SEX AGE

SP FIC REASON(S) FOR REQUEST (Complaints and findings)

-%7

4- L

NSN 7640-01-165-7294 519-301

RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

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

RADIOLOGIC REPORT

PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first, middle. Medical Facility)

LOCATION OF MEDICAL RECORDS


SIGNATURE

MEDCOM - 19346 rATION -•-----•.••--.1T _ .

STANDARD FORM 519-B ta.83) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806.8

DOD-032920 ACLU-RDI 1651 p.106

NSN 7540-01-165-7294 51S-301

RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

AGE EXAMINATION(S) REQUESTED SEX4SN (Sponsor) ✓

WA

P

RD/CLIN1C

.11

REGISTER NO.

G

PREGNANT

fl YES n NO

TELEPHONE/PAGE NO.

DATE REQUESTED,

FILM NO.

REQUESTED BY

SIGNATURE 0

5,.7, 0`3 SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)

DATE OF EXAMINATION (Month, day, year)

DATE OF REPORT (Month, dayl year) DATE OF TRANSCRIPTION (Month, day, year)

RADIOLOGIC REPORT

C

11/94,pa a.c/g„y-

11111 -

PATIENT'S IDENTIFICATION (For typed or written entries give: Name — last, first, middle, Medical Facility)

11. 1111.

OHM —



SIGNATURE

MEDCOM - 19347 1LTATION STANDARD FORM 519-13 (8-83) Prescribed by GSA/ICNIR FPMR (41 CFR) 101-11.134641

DOD-032921 ACLU-RDI 1651 p.107

LJ

L e 4_ -

NSN 7540-01-165-7294 591-301

RADIOLOGIC CONSULTATION REQUEST/REPORT ( Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations )

EXAMINATIONS (S) REQUESTED

FILM NO

REQUESTED BY (Pri

SPECIFI EASON(S) FOR REQUEST ( Complaints and findings)

AGE

1SEX

44 SSN (Sponsor) WARD/CLINC REGISTER NO.

PREGNANT

El YES ❑ NO

TELEPHONE/PAGE NO.

DATE REQUESTED

DATE OF EXAM! TION ( nth, da year)

DATE OF REPORT ( Month, day, year) DATE TRANSCRIPTION ( Month, day, year)

RADIOLOGIC REPORT

PATIENTS IDENTIFICATION (For typed or written entries give : Name - last, first, middle, Medical Facility)

(



SIGNATURE

.0•••"""s• ^^-1ULTATION STANDARD FORM 519-B (8-83) MEDCOM - 19348 'ORT Prescribed by GSA/ICMR

• ..=CORD FPMR (41 CFR) 101-11.806-8

DOD-032922 ACLU-RDI 1651 p.108

MEDICAL RECORD - DOCTOR'S ORL. For use of this form, see MEDCOM Circular 40-5

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column. •

ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS

ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS

POST ANESTHESIA ORDERS (circled Items)

VS q 5 min X 15 min, then q 15 min until discharge.

2 Supplemental oxygen. 5A1:5 -7 ("Y;1 Morphine Meperidine / -,ing IV now and -1g q 3-5 min prn pain for a

max dose of 10mg.

4 Zofran mg IV prn N/V q 15 min, may repeat x . 5 Metoclopramide mg IV prn N/V x 1.

6 Droperidol mg IV prn N/V x 1.

7 Phenergan mg IV prn N/V x 1.

8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.

9 IVF: @ cc/hr.

0 10 ) Discharge from recovery status when PACU discharge criteria met.

( ( \ - Z-

133


C -Q -

VI

Complete the following information on page 1 on y. Note any changes on bsequent pages.

Diagnosis: -,

Height:

Wight: Diet:

Allergies

Nursing -

PAC Room No. Bed No. Page No.

1 of 1 -R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLE

MEDCOM - 19349

MC VI .00

DOD-032923

ACLU-RDI 1651 p.109

BED NO.

TIME

BED NO

DA 4256 FORM 1 APR 79

CLINICAL RECORD - DOCTOR'S k use of this form, see AR 40-66, the proponem .L:y is OTSG

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


-I LIST TIME ORDER

NOTED AND SIGN


HOURS

NURSING NURSING UNfT

Tttft

ROOM NO. BED

PATIENT IDENTIFICA 11ION

NURSING UNIT

V . ROOM NO.


DATE OFOF ORDER TIME orO4RDER

,v___4 s ms 0y a - to *tAi al ' p tz#J Pe--r-cc, c—e_L-- --,-;:f- 1- --‘.. PT) C3 ► rr I P DATE OF ORDER - TIME OF ORDER A

HOURS

NURSING UNIT

IN' V ROIDM NO.

PATIENT IDENTIFICATION DATE OF.ORDER

coca IS S Fcc)-<.-

4- LAT_

NURSI UNIT ROOM NO. RAA

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED

-C.r U.S. GOVERNMENT PRINTING OFFICE: 1994- 363.710

.

MEDCOM - 19350

DOD-032924 ACLU-RDI 1651 p.110

,fig ftda-

PATIENT IDENTIFICATION DATE OFRDER

1491

03

TIME OF ORDER

(0CE) HOURS

u_ -Pn450._ IOD (AD

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT


NURSING UNIT


NURSING UNIT


NUBS! UNIT ROOM NO.

REPLACES EDITION OF 1 JUL 77, -WHICH MAY BE USED. 04

U.S. GOVER,.:.:ENT PRINTING OFFICE: 1994 - 363-710 •

MEDCOM - 19351 L],

,-;

4256 FORM 1 APR 79

.INICAL RECORD - DOCTOR'S ORL,LR For Lis, „.; this farm, see AR 40-66, the proponent agency


DOD-032925 ACLU-RDI 1651 p.111

,DATE OF ORDER

b HOURS

,, uRSING UN!' ROOM NO

; • 'ATIENT IDENTIFICATION

BED NO.

DATE OF ORDER TIME OF

NURSIN:.-; R O OM N O BE No —

CLINICAL RECORD - DOC. DERS ; F-or use of this form, see AR 40-66. the prom, agency is CTSC:

THE DOCTOn SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. tF PROBLEM OH;ENTED MEDICAL

SYSTEM IS USED WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

=ATIENT IDENTIFICATION

TIME OF ORDER •

INO / HOURS :3

L .

0

LV d 1( cArr Lis NURSING UiliT ROOM NO

l'CAA

D ATIENT IDENTIFICATION

NURSING UNIT — ROOM NO BED NO

cAA .4 1,

ICso

c.) - 7

ATI ENT IOE N T IF ;CATION DATE OF ORDER TIME Of OR

MEDCOM - 19352

DOD-032926 ACLU-RDI 1651 p.112

DOD-032927

LINICAL RECORD - DOCTOR'S ORDEL this form, see AR 40-66, the proponent agency is OTSG

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


Fo.,-,

NURSING UNI

-T


(

11P NURSING U,LNIT ROON1 NO.

3. CA- 0

PATIENT IDENTIFICATI

NURSING UNIT

7044 I/ PATIENT IDENTIFICATION

cl‘

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

U.S. GOVERNMENT PRINTING OFFICE: 1994-363-710

MEDCOM - 19353

NURSING TN T

DA 1FA04'79 4256

ACLU-RDI 1651 p.113


\((

C/\

TIME OF ORDER

b HOURS

DATE OF ORDER LIST TIME ORDER

NOTED AND SIGN

NURSING iNIT

G./CV PATIENT IDENTIFICATION

NURSING UNIT

JO. PATIENT IDENTIFICATION

NURSING UNIT

TC. 11/ PATIENT IDENTIFICATION

Cr NURSING UNIT

DAFOR

1 APRM

79 4256

U.S. GOVERNMENT PRINTING OFFICE: 1994-363.710

MEDCOM - 19354

A b REPLA ES EDITION OF 1 JUL 77. -WHICH MAY BE USED.

:LINICAL RECORD - DOCTOR'S ORDEft,._ For use cf this form, see AR 40-66, the proponent agency is OTSG


49,

DOD-032928 ACLU-RDI 1651 p.114


/0„zrsed)

LIST TIME ORDER

NOTED AND SIGN HOURS Go

NURSING NIT ROOM NO.

PATIENT IDENTIFICATION DATE OF ORDER ID,v /TS rizesi

/Ti ME O ORDER

HOURS

S(V -at/-11111 A

NURSING UNIT ROOM NO. RED NO.

6 e;- 3 at rb DATE OF ORDER TIME OF ORDER

304(: c).900 HOURS


NURSING UNIT

PATIENT IDENTIFICATION'-

rflf -

cre a-cro

UNIT

(1/

FORM

ROOM NO.

OVERNMENT PRINTING OFFICE: 1994 - 363-710

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DOD-032929

INICAL RECORD - DOCTOR'S ORDER- For use cf this form, see AR 40-66, the proponent agency is OTSG

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

ACLU-RDI 1651 p.115


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DOD-032930

ACLU-RDI 1651 p.116

CLINICAL RECORD I THERAPEUTIC DOCUNIEICITATION ARE PLAN (NON-MEDICATION) T. For use of this form, AR 40-407;

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DA FORM 4677, 1 OCT 78 onmnru no i nor r 11AV 'ISED. MEDCOM - 19357

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ACLU-RDI 1651 p.117

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ACLU-RDI 1651 p.118

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DOD-032933 ACLU-RDI 1651 p.119

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DOD-032934 ACLU-RDI 1651 p.120

DOD-032935

USAPA V1.00 MEDCOM - 19361


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ACLU-RDI 1651 p.121

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ACLU-RDI 1651 p.123

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ACLU-RDI 1651 p.124

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DOD-032939 ACLU-RDI 1651 p.125



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DOD-032945 ACLU-RDI 1651 p.131


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DOD-032949 ACLU-RDI 1651 p.135


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PREPARED BY

Pc PATIENT'S WENN! first middle; grade; date,' hospital or taetrical &city/

DEPARTMENTIMMICDOUNIC

k,(11C2_,

Name —krt.


Sol Bon

ICOnf► ue OA infidel

c23

REPORT TITLE

(2) Moves 4 Extremies, Moves 2 Extrernifies

(0) Wives .° Extiernities

Airway (2) Cough. Deep breath (1) tea. moiled breathing (0) API119 -

Airway ; -Nasal •

Oral . • ETT

Trach other _ .

AIRWAY A mAmbri • •• BB = Blow* M = Mask FT=Face. Tent RA•gRooMAir NC Nasal Cannuta

V/S X=A4ine BP

Cuff BP 1. Pulse

TEMP S = Skin 0 =Oral A = Axillary T =Tympanic R = Rectal

LOS -' C = Cervical T =Thoracic L =Lumbar S =Sacral

Drains Hemovac

NG

T-tu

e.Mvirf- Pacu Intake


`-\

180

160

140

120

100

80

60

40

20

ACLU-RDI 1651 p.137

DOD-032952

Nk i 4._. x 4

i ...,

Of

Time . Site ,

-

.._Range._..

M. ,..

P. ' ..Cap _._ Refill

.....T Color

Arlin U.k. atketik r- --4-2r-dr. ■.) , 15. 30' 45' i. :.1: "r --:.'" 44, . 60' ::- -- • __ ..... _ _

se_: ■ ;:' I

WC ' ' 1.-4.. datalaft A- Of ^341 W , Movernerit/Sansation: "4- = present.- = absent Temp:C= Cool, W =Warm Pulses: P .. Palpable, D = Doppler. A = Absent Color: C =Cyanotic.

. , Capillary Refill: B =Brisk, S = Sluggish p‘siPale. Pk-Pink '.; .

-C-SECT1 S Adri 15' 30' 45' 60' 90' 0/C

Fund. Height 3'

Lochia '

Fund-:Cond. .

NURSING NOTES

it4 IAJ-1/4/ 1-6 n tryi_ efia

a Mi93

ceme KT) 'CPT

PACU OUTPUT

Discharg griteria: Date: 1%[1103Time: f sic PARS: BP: • T: HR: RR:

ICS

Source Color/Appearance -1 Amount

CARDIAC RHYTHM

Time Rhythm Symptom./fic? Rhythm Strip Run? er"•\

WAMC OP 173-E

Pain Level at D/C (0-10): Intake:

Additional Data: Transferred To: Report Given To: Transferred Via: Ambu ance Transferred By:

mey / 9--

Cleared 1AW R Charge Nurse Signature:

MEDCOM - 19378

Ao .

MEDICATIONS • Allergies: Time Pain Medication & Route Pain

1-10 Onsane • - 1-1n l/E By

- DRESSINGS Location Type

Adm we the rketiloalic . •

efitniiiin I 30'

D/C Lti. to. ad Ivialw ymnitrvl

ACLU-RDI 1651 p.138

N

E

U

R 0

... ‘,2( Tin- _ Initala

31-vvrt pli,MCW3 Or3 Sli mut; _ _ _ .____ .._

0,%-q a.oepi 60 1,tige-i_ . 1 )ankji; , ( 2O 171151)14 %Vika-) Matt a+)

Th.,.... /13 ..) Initals: <-4------

._ cz44,,,___ ._ 1.4z - s , r

Pupils e___ectkpe Sens o rium 1140 LOC / GCS .. g..54.,-0

C A R

r D 1

A C

Cardiac Rhythm l'RI: / QRS: Pulse Strength .

C ID ap Refit / JV Edema Chest Pain

442.- i 02; S ST 6 11 .14 0. .C.471:8) t-6 . . . . i Dp

Oi- .. a 4- :bkt1" I ki4 .. 4 /0 Paille al _. e put ,se . 1■)0 gblY1A, Wkek_a_441V5 kin() - .

_1-1.t

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-

too - I( 0 R Z 1Z i. . 14:

-6) - 6 KA . 6 r.,..1

..-..... A....farkei

him) t ' .e Respiratory 'Pattern , Breath Sotmds

E ecret s Sions

Cough P - -

MUM.: 6p-js c.-..thr,,,t.irt;- vo UR- orta-J- %Nall . 01-Putriuse (---1*

. -- oy .:- - - skcialiuy, .... sPo. qg -10 . e_pt . . . .0 gAUSkr■ )CItafi

C-1-4 , RI- ..i- C:).

r ,.. L .1

0- - — -- n„ ..,,...,, cc. r..._. — c

S K I

Colo r Integrity Backside

NjOnyka 14-i_ L.--14_.

e"TrfCtO ) r,,,, ,-.. ... „.. "c% Pre..e vo reAt CeAcet bie) _L

....E

„. / - A - 4ce- 4-1 '13 -5 vf PLY 4' pers Witif -eill

di L E -_,..4:4_..1.1-41- e

1 V

Access Devices Ltk..040adlick-j--lkictietC.4- 6 , L //L.- c,L1L- - AJ /91. , • , . Loca ti on . .. .. .._.. ... Condition

e?.!capr_ -.;. vaci 1-4:44,A.k- I ikt. - le 4c. . 4 ... . . .. iS■ P. .. -. . . _ 0-C, I Le_ cz. AfARA4--V- ' rii A.C2'._ 11.0....6 1 :- rde -1 ,1 ',./.,d- / il L . . Abdomen

G Bowel Sounds I Sto in a/Ostom

. .. .._ . ..... y

II so pr Nr.r0.13 -e-, Il ct . P-mi f_) % k-r-- • - - - • 'QUI Cud 111 cw9a0ng, . [ A.,A,...„..\--.1 1 -

I

!Device G [iAlk q2)10. Rata LLL fl F i olor / Clarity

. , tr 1' Vk — aaf.) c c (9 t LOCO. C (LS. r - 1 ___■.e, -----

i I PREPARED BY tSigr..arare 6 Ti:/ei -

C-P-1-

DEPARTNIENT/SERVICEICLINIC

MC I.il. I

DATE

t 444403 )

HISTORYIPHYSICAL D PLO'A1 CHART

LI OTHER EXA.MINATIO.', CI OTHER OR EVALUATION

DIAGNOSTIC STUDIES

TR=ATP.IENT . _


MEDCOM - 19379

STATUS: US: AD I CIV

a- K..., I 'PO: y,)c or worr. ..e." Name -fag:, 1r:fgt, middle; grade,: date; nospifet or medical faciNy) NAME: RANK: AGE:

UNIT: GENDER: NA.

IRAQI: CIV F.F 1 W

DOD-032953 ACLU-RDI 1651 p.139

'BA

LAN

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MEDCOM - 19380

4,

DOD-032954 ACLU-RDI 1651 p.140

Respiratory Pattern Breath Sounds

- - Secretions

Cough P

F Lv•-51-el. 0111:72A74" W - g cezAt-rnpA,\s-

.Noz, 'bp ./ /40446,L rig_ N-r-AcT oF

Access Devices

Location

Condition

;Abdomen •

G Bol,vel Sounds • I Stoma/Ostomy

•• Device

T [Color / Clarity

I V

;r & Title) ‘4,

P

NAN

UNlT: k \\D(4 GENDER: ill

STATUS: US CIV CIV EPW

HISTORY;PHYSICAL

LI OTHER EXAP,!!;`,JATiO:

OR EVALUATION

LI DiAGNOSTiC STUDIES

J TREATMENT

# I.

AGE:

n .1 (For typed or written entries give: Nam ,. — last, spite/ or medical cikiy)

RANK:

DATE 5

pj-

LI FLOW CHART

CI OTHER

C:olor Integrity

Backside I N

Pupils

Sensorium

LOC / GCS

C Cardiac Rhytnin . A PM: / QRS: R Pulse Strength

' D Cap Refit / JVID I Edema

A Chest Pain

. _

Th- 110100 I ni

v51.141,4141_ t_c_

ak jgtoenA47.E, 5 )41'W (A) ihfriA.--OS

OL-z,Tpp../

914t.sez &AC z÷ ece siusr..1

9/1.14 4+ 671- C


MEDCOM - 19381

DOD-032955 ACLU-RDI 1651 p.141

cn 0 0 r-

0 C O

z c

Hm

Ci

ria

wm

aff

r-

H O H

e-

arit

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igi

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1111111111111111M MIN .11111111111111111121110

MIS 91114 M MIS MEE

',1k1111111111 MIME ME' Offli1111112 0112111 111111111 EMIL" 111111 IEEE - MIMI MEE

REM ENO r a Miff

1 NONE■ rid ram

I till111211 11111111j 11111111111111 Eill

I MEDCOM - 19382

1 4i

r.e

•

pl••■••■

0 LI

ACLU-RDI 1651 p.142

GENDER:

EPW

INTENSIVE CARE NURSING FLOW SHEET - -

QA Appr 8 Mar 80

N i E ;Pupils

Time: OWS InitaL 1tTime: ; A 3 (3 Illitc115: -- --------- --- 4p-k. b ePiA6 PEPTI-A -....■,,...■• 1

U Sensorium

R LOC/ GCS

0

-- MAItiei-tist 0.11 .41%;44:Ac 5C (91,c (Eir fid ItAk V L.-a-Jr X ..

0 YNAKI+40 iFts te.. gat A-25-foVtdc I) of A I k.- /. _ . tr . . .rt s ?1, i k ,) m

. rt---- . ). .,. re ,, r.,

/ jj

C A

R; D

f.

A

. C

1-; E

.

P

Cardiac- Rhythm _ PRI: / QRS:

Pulse Strength

Cap Refil „/ JVD

Edema 1 --.-.-----

Chest Pain ...

ST (I 92.1,

3131

li- b UE ; if 0 tc i dot014i- ' r 0 L.€ EEL- I Biza...e. Ite A. 3.,titur.. -ibtic -/ p VI) lt r+11- 111 we.

•

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_ __ _ - — - — __________ .

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. SeC...../-4.-\•- ■ ..- -"A. - 6 co.---- L.

I ..4..„ lc - 17°6 ..-- A V)r- re.‘,...4.-- - -- • -

• E,E. v1K,

, „.... 'ktA i ) T 4,.., tj rel S. ..... A.** .., i

Resniratory Pattern IR..,va - , -- -- ' Brea th Sounds 11 611 - - Secp,-.!tions Cough

' II 0164N+

A at al

.

ctttA R 16-2o 02 9k/i. i .21- O

0

I 95.506 S Color K Lite , rity I B1,- 3(.sitle

I- I' '

Irtfact u ovt.

S • cE 4'

, I

.. .

.. _ .

40145 ,5e4sG luta a . _ • ... . (f9 IC c IQ e 51 4 .

i . , .,=v.- cess Device5 F A B: .e 14v* I i_4 ( @ 37,9 , Sio c_._ L1-. / R(K

G. AC_ :, p-+-4. .--A- / ■ , ic. , 4-

C, Ac-.\_ tAt.- -1-- / ; ,-L-1" •

. 3 ,.._......,.. . .5 ...r- s o_c•A - el. ,k li -1. c-su%. LI 1,......k , vve a A.A.. I..

V , e in /.1., _ _ . .

1 `i

I Location 15 A )\C ,Qatt,o2 _ • - V conaition likE(5, ), Ac, • -1

a lactiL Nh--64 Indlic-f- (kk

ctiA ihtact- , 11.1.0

-1 1 :\ bdonlen — ....., N.,„-el sounds

- - - - - - - I StO IT) a/Ostoniv

; .

Cdkf 4 A41-- ditabe itto-b- .1.

f - I/ / A n.

I pat, Ir.- Wif iv '

1 sti,-.i ' '

1 , nattua 0 vo • 4/ i c 1(4=1 Vo R. c_,.AL ki Co!or. / Clarity lest.C1\

1 ■ .

v...7

7 i

,. ,

D=PARTMENT/SERVICP L

ICU #1,

DATE

ao E? 03 - .•. 8

firS mi !die; C are: hos.oi(at or medical facility) NAME: It RANK:

UNIT:

STATUS: US: AD I CR'

AGE: [1] HISTORY/PHYSICAL

LI OTHER EXAMINATION OR EVALUATION

fl DiAGNOST;C: STUDIES

TREATNIENT

F.LOV.; CHART

OTHER


MEDCOM - 19383

DOD-032957 ACLU-RDI 1651 p.143

z 0 0

0

r

C

r-

0 0

-1 0 C

co -1 0 -4

0 1 w <

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0

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3 I I li i c, - II , . 1115 • 1 11111111 111112L I 11111111111111 IIINAM I 1 1111111111111ME 1

111111111111111M1 1 1 II 11111111111511 1 ' I 1 111 INN= 1

1 1 11111111111

3 1 1 L I ' l'c'r• 1

" 1 I ill I 4 - :11 , 11 Eel

MEDCOM - 19384

CII z -0 C

ACLU-RDI 1651 p.144

Post-Anesthesia Care Unit (PACU) Flow Sheet REPORT TITLE OTSG APPROVED Orel ••

91 rY HiSto

• ,Time - •;i Solution

/731.):— "L7F-77

Sa02

F102

Date: 2 O- k-g,;0-3 Time In t-ils0.---/ 6s-s-

Anestheiia Type (Circle)): 6.7----s pine! Epidural IV anon Nerve Block

-- Allergies: OR Intake: .. Crystalloid :7* -° . . Colloid ' Pre-op WS: OR Output UOP goo EBL co

L.,,,fimmrix / Medsfrirnes: tom gw - ja,,,y-iyvy - • Procedures: r- /0 2) , .p,

240

Pre Op Meds

Time k

Methods

Drains Hemovac

NG

T-tube - Foley '-

us

Airway • -; Nasal : Oral ETT

••••'•, Trach

'''Other . • _

Pacu Intake - Amount -7 . - Site : • -By Infused cycio.ec--%

•

MEDICAL RECORD-SUPPLEMENTAL MEbtuAL A For use el this form, see AR 4065; the pregame wily• le The Office enhi Santo , 60Derai.

200

180

160 V

140 V

120

O V

100

80 A

A ne

60

40

20

4

RR

T Time Pain (0-10) LOS

17' /6

IL-onlinue in morsel

DATE

—rest,

❑ FLOW CHART

❑ OTHER Gram

111111111111 typ es. written softies give: fin walk- rade; date: hospital or medic:11.70RO

DEPARTMENTISERVI CEICHNIC

❑ HISTORYPHYSICAL

❑ OTHER EXAMINATION OR EVALUATION

❑ DIAGNOSTIC STUDIES

0 TREATMENT

220

Abway (2) Cough. Deep breath (1) Dyscoea. limited breatting (0) AWN" -

[now Plessure • (2)S8P 4-20 GIP:a-op (1)SBP 4- 20-50 of Pre-op (0) SBP 4 50 d Pre-op -

Consciousness (2) Fully Make. audible -

(1)/Vousabie to verbal or pain

(2) Bassani cobiA swarm= (1) pate;moMed. jaandold

Circulation (Pads < 5 Yews) (2) radial Pulse Palpable (1) Aillatipalpable. not radial (0) Carotid only ramble pulse

TOTALS: Must he 9 or greater to D/C. otherwise needs anesthesia approval for . . DX.

X-rays: Labs:

Post-Anesthesia Recovery_scere Criteria

ADM

30'

DIC

(2) Moves 4 ExhatnIfies (1) Moves 2 Extremities (0)14thMiOEictiernifies

Codes !

AIRWAY A = Ambu BB= Blow-by M Maik FT = Face Tent RA =RoornAir NC = Nasal Cannula

WS X =A-One BP

=Cult BP Pulse

TEMP S =Skin 0 -brill A = Axitlary T =Tympanic R=Rectai

LOS C = Cervical T =Thoracic L =Lumbar S = Sacral

Patient teaching done; Wound Care. Pain Management T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained

DA FORM 4700, MAY 78 WAMC OP 1T3-E, (Revised) 1 Apr oi (MCXC-DN)

MEDCOM - 19385

• • Previous edition is obsolete ustricvm

DOD-032959 ACLU-RDI 1651 p.145

MEDICATIONS Allergies: ./(j C Time

Pain Medication &

Route Pain

By 1-1n

Dnc --- 1 -10 ..•

. . NEUROVASCULAR --• _. __ __ Time . Site , Barige .

Of - .

Sensory._

::.... Motion'

P _Cap _ _Refill

—T 4 1

.. .

Color

_ Adm , !. 15' 30' • . :a. _ . ........, .. .1/4...:.: 45' ---

. ..... ___ _ ...

D/C :

MOYemerit/Se nsation: + - present,- =absent Temp:C =Cool, W ...:Warm Pulses: P Palpable; ii - !Nippier. A...Absent Colon C.I.Cyanotic. ..,,.; ..,,r. ,A

Capillary Refill: B -Brisk, S = Sluggish 13 ..Pale,Aci..iFink . -

C-SECT1ONS - - - Adm 15' 30' 45' 60' D/C

Fund. 'Height

Lochia .

Fund..Cond. .

NURSING NOTES

cf;-;

• 1 5

.; .

A4r- 1;1

/°- griutii3 • . _c).6/7

I

17 44- ip

--Pech(

6 Agte ,)e /1st . a

Zet-4.-G) - PT A-, t .S:ng

?T S9 • 69--

VAL . ei; I Iv 77

06(4014 (i( ,

5 1 - 4 (.4

-e/H. 94— C- et-

- DRESSINGS -

Time Location Type ,Dralnage

Adm

30'

60'

D/C • •

„ . . J'M-1 ei

,

?!. • e.)-- ( let el--2-d I Q J.2 :44- cola-,

PACU OUTPUT

Time

CARDIAC RHYTHM

Time

Rhythm

Symptomatic? Rhythm Strip Run?

WAMC OP 173-E

Discharge Criteria: Date: Time: PARS: BP: T: HR: RR: Sa02: Pain Level at DIC (0-10): Intake: Output: Additional Data: Transferred To: Report Given To: Transferred Via: WIC Utter Gurney Ambulance Transferred By: Cleared LAW Recovery Room SOP B-3 Charge Nurse Signature:

Source Color/Appearance Amount

MEDCOM - 19386

DOD-032960

ACLU-RDI 1651 p.146

For use .cf this fora!, see AR 40-66; he OrOpo.7:111 is the Office 0; The Surgeon Gene,S.

REPORT TITLE OfST7, APPROVED

INTENSIVE CARE NURSING 'IEET

QA Appr 8 Mar 89

INITIATIFT ASSESSMENT N E

U R o

1Time: 06301W Initals:W (6(c_t.) - 2— 3114.-'1 PUN-

—.44tOtki ', (& Ur

ittOtc tt i , , • /

) V, .b, vitee ,, ./A4 il g,. cep.)

Time: Initals:

-T -

_ .... _... .. _ ._____ . .. ... ... .... .,

Pu pi's Sensorium LOC/GC S __..... ..... ....

C A R

D

I

A

C

Cardiac Rhythm PRI: / QRS: Pulse Strength :ap R'efil / TV D

Edema

STe 924x. 1 5.2.. 3" e as,., -1.dg. 'C

3 1-(P VE c2 -F ait 01E, 1 • i

Z hca le . ?..1 Q .9710

. ._....... ... .

. ... _ . ._..._.

.... ...

Chest Pain - ,--r Respiratory Pattern

E

Breath Sounds Secretions Cough P

s ..

iatE- an O-!l

a.tae4f- ateilf /

At-,/pie:7 VDt A4aick (hYoce 1 A stip, /initOct ) -0 Ski. at O-

1,51 y 210 (49- sce 4 114,124

.... __... . ...__..... . ..

... S K I

Color Integrity Backside

N alk4

1 k 0 : elk paWiliiika- I V

Access Devices Location I

Condition ift _CO ft a 05becik

4 0 /,/t ,i? A

— —

Abdomen .. c Bowel Sounds I Stoma/Ostomy

t. / at SO' '44 t. cidiVt, t.

/tall. ,er yo ' f.

G U

Device IPMEiglar , OC V

Color / Clarity IWO (fat S SY I

...._., Title)

T/M -D (U) - -7 ICU til,

DEPARTNIENTISERVICE/CLINIC .

DATE

2- I SO 63

NAME:

UNIT:

STATUS: US: AD I

fil3:, n7: dle;

grace; r typed or written entries give: Name —last,

Cal or medical tacifity)

RANK: AGE:

UV IRAQI: CIV ' EPW

GENDER: Cc

D.'•-•

• HISTORY/PHYSICAL 1111 FLOW CHART

0 OTHER EXAMINATION OTHER /3,,,,,?/) U OR EVALUATION

• DIAGNOSTIC STUDIES

• TREATMENT

DA FORM 4700, MAY 78 USA.,,PC V2.C,r)

MEDCOM - 19387

DOD-032961

ACLU-RDI 1651 p.147

TI

0

!BA

LAN

CE

I

—I 0

-I

(-- -

1 RE

SP

'PU

LS

E

BP

INV

b., 5

LIE 61

08

0 .. 1

Rit ---(1 ial foo I 15/

71

7

0151 8 1

11

. . , 075i

Iso

i IOC

) 01 I kis R 12

11 ] INE 13 "1".."1.44"'"

. _ 0 _ r . I 1111

II I IP I MEDCOM 19388

I

DOD-032962 ACLU-RDI 1651 p.148

n.onlinue on reverse!

DEPARTMENTISERVICEICLINIC

ICU "I DATE

2-2-11p0-3 PREPARE

PATIENT'S I entries give:

fiat middle; made; date; hospital or medical . lanky'

\-D

❑ HISTORYIPHYSICAL


O DIAGNOSTIC STUDIES

❑ TREATMENT

❑ FLOW CHART

❑ OTHER ap=dyl

Name -last,

MEDICAL RECORD•SUPPLEMENTAL MEP' "'.TA r use of this torn, see All 40.66: the proponent agency is the Olfx General.

Post-Anesthesia —ire Unit (PACU) Flow Sheet DTSG APPROVED Word REPORT TITLE

Date: ",2 C3 Anesthesia Type (Circlely 41=ly. pinal Epidural Drains Airway Time In: 863 S. IV eia ton Nerve Block Hemovac

NG

. JP i T-tube Foley

TLS

Nasal

Oral ETT

Trach

Other

Allergies: NIV-Vt OR Intake: Crystalloid i CVO Colloid Pre-op V/S: 1 . Oaot tO 2 OR Output: UOF an, It A.Vvilif'4.1, Procedures: t \o • Meds/Times: Sp -c-t,vuF-0..A.L1 I

JO e, VA 1 k l .ok iL. cruA- Ar) Sol-sl-

Pre Op Meds History

Time 6".( te).. 0 etc Aft) 1.-.

Pacu Intake

Sa02 f0 aQ)

/ to /:// r co

V,s1_

Time Solution Amount Site • Infused al_ • / F102 Uf— r Doo pit- _:9_,

il Methods 00- Witiylit.rck51-

240

220 X-rays: Labs:

• Post- Anesthesia Recovertscore

200 Criteria ADM 30' DIC Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

.3 e g tre4-

I

AIRWAY A= Ambu BB= Blow-by

M- Mask

180

160 (2) Cough. Deep breath (1) Dyspnea, Funded breathing (0) Apnea

Ain vay

2. FT = Face

Tent RA = RoomAir

NC =Nasal 140 Blood Pressure (2) SBP =/- 20 of Pre-op (1) SBP =/- 20-50 tat Pre-op (0) SBP =/- 50 of Pre-op 2.

Cannula

VIS X= A-line BP

120 \'''‘V V

V

V V

100 Consciousness (2) Fully Awake, audible aYing (1) Arousable to verbal or pain (

- = Cuff BP = Pulse

TEMP

o

80 I A • •

• A A

Col (2)1 t appearance (1) pale mottled, jaundiced (0) Cyanotic

2

S = Skin 0= Oral A = Axillary

T = Tympanic

60 A A A

40 Circulation (Peds <5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

R = Rectal

LOS C = Cervical 20

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for WC,

C2)

T = Thoracic

L = Lumbar S = Sacral

RR \IL VI- gl it (24

T 11:

nri4 1 I. Time Paten teaching done; Wound Care. Pain Management, Pain (0-10) T. C, & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

Previous edition is obsolete USAPPC112.00

MEDCOM - 19389

DOD-032963

ACLU-RDI 1651 p.149

Discharge Criteria: Date:22_3e Tieme:D(p2-5 PARS: BP: 1119 T: HR: '3 RR: \I Sa02: 6r,1, Pain Le erit D/C (0-10): Intake: Output. Additional Data: Transferred To: Report Given To: Transferred Via: A /C y j Ambulance Transferred By: 11:1-

Cleared IAW Recovery Charge Nurse Signat


1-10 Medication & Insane

Ro Pain 1-10

I/E By


Of Motion


T Color

Adm ler LiT/4- IA 15' 2( V-ra P r_s, kij P le- 30' 1i1l'al-c.1 4- t a iv P lc- 45'

60'

90'

D/C .,t)it I LtAI-4,9,1 -4-- "P :"?- 14) q V.-- Movement/Se W =Warm Pulses: Color: C = Cyanotic,

Capillary Refill:

sation: + = present,- = absent Temp:C =Cool, P= Palpable, 0 = Doppler, A = Absent

B = Brisk, S= S uggish P= Pale, Pk = Pink

C-SECTIONS _

Adm 15' 30' 45' 60' 90' C Fund. Height .---------- Lochia -.------------ Peripad# _.----------' Fund.Coad.-------

DRESSINGS

Time Location Type Drainage

Adm 61-cedpsfix_.0 --4.02114-'-c.to •25"

30' 6-,t 01)^10 1-. Z Et-et Cr

60'

0/C

NURSING NOTES

h_cut.,„„L _kr, we i.A.„

Cle-N A-4 f f/ o-od >q-SY- Uth5-Y1(4-

ockt

1/11— c S (0(003--)ptiertrn,i-

'TN

PACU OUTPUT --------

Time Source • Color/Appeareoc.e--A-mount

----------- c.‘

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? 6 SI-tc C.T2- A:r )2(

WAMC OP 173-E

MEDCOM - 19390

DOD-032964

ACLU-RDI 1651 p.150

REPORT TITLE Post-Anes..., sia --re Unit (PACU) Flow Sheet OTSG APPROVED Wald

MEDICAL RECORD•SUPPLEMENTAL MFP' — qL r 'TA use of this form see AR 40-65: the proponent agency is the 0 • leneral.

Date: ,2 / „le I) Anesthesia Type (Circle)): General Spinal Epidural Drains Airway Time In: 2 IV Sedation Nerve Block Hemovac

NG . JP i

T-tube Foley

.... TLS ."-L.,,y, i-f c.,

N• al Oral ETT

Trach

Other

Allergies: /Y1{0 OR Intake: Crystalloid ZAer Colloid

Pre-op V/S: /.2 7 OR Output: UOP EBL if

Procedures: rii rem X) /If//laic, Meds/Times: Xidr yfrig 4,bri...4-1 A a, 2- Z. firoxy

Pre Op Meds Histor

Time .1

a

.41 ' Asti Pacu Intake

Sa02 e1111 Solution Amount Site By jpsed

F102 IIIII 7z K i.er Vi) 0 M In

--41.

Methods

240

ill 220 X-rays: . Labs:

Post-Anesthesia Recovery_score

200 Criteria ADM 30' DIC Codes Achvity

(1) Moves 2 Extremities (0) Moves 0 Extremities

(2) M oves 4 Extremities AIRWAY A =Ambu BB = Blow-by M —Mask

180

160 Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing

(0)APnea

FT = Faie Tent f RA =ROomAir NC = Nasal 140

V Bloc Pressure (2) SBP =/- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =/- 50 of Pre-op

Cannula

VIS X = A-line BP

120 ✓ ./ v V \I

100 Consaousness (2) aYi n9

Fully Awalce, audible

(1) A rousable to verbal or pain

N

' = Cuff BP = Pulse

TEMP 80 • •

• , • 0

A ( Cola

p Baseliner color /1 appearance

(1ale, mottled, jaundiced (0) Cyanotic

S = Skin 0 = Oral A = Axillary

T = Tympanic

60 I I • I

)

40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) AiiMary palpable, not radial (U) Carotid only reliable pulse

„ft= Rectal

LOS C = Cervical 20

P TOTALS: Must be 9 or greater to O/C. otherwise needs anesthesia approval for 0/C ,

T = Thoracic L =Lumbar S= Sacral

RR 2- if i

r' T

Time Pahen teaching done; Wound Care, Pain Management, Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

on awe Oil reverse DATE

❑ HISTORYIPHYSICAL

❑ FLOW CHART

❑ OTHER EXAMINATION

❑ OTHER tsp.*, OR EVALUATION


❑ TREATMENT


/e2/#ten entries give: Name — last,

first, middle; grade; date: hospital Of medkal leaky)


WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-ON) Previous edition is obsolete 0SAPPC V2.00

MEDCOM - 19391

DOD-032965

ACLU-RDI 1651 p.151

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

779, 1

Color/Appearance Amount Time /00.61.7.-Ce Discharge Criteria: Date:2 11 Sip -17 Time: PARS:-P. BP: 12r/-L( T: I FIR: 6 k• RR: 12_ Sa02: Pain Level at D/C. 10-101:

Output: utput: Additional Data: Transferred To: fC,

Report Given To• Transferred Ambulance Transferred By Cleared IAW Recove Charge Nurse Signat

PACU OUTPUT

WAMC OP 173-E


1-10 Medicatio & Dnsaa

Route Pain 1-10

I/E By


Of Motion


T Color A

Adm A - P A

15' 4 e MISIIIIIIMIVall 30' '- i' 45'

ill 1 60'

II 9u

D/C pigaTim , in digm • Movement/Sensation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D= Doppler, A = Absent Color: C = Cyanotic,

Capillary Refill: B= Brisk, S= S uggish P= Pale, Pk ---- Pink

C-SECTIONS _.----'

Adm 15' 30' 45' 90' D/C Fund. Height

Lochia ----------- Peripad

nd. Cond.

NURSING NOTES

11 arrtiveL7 e vaThyakr,,,7 7

ev-e7/ f4n, -1,Z2- Y777/4/9, /22

14, /;.7)&) (..fel,fr7",749,"/CA /1(. 7417e r?

tke

DRESSINGS


Adm C8E/2..h- .eeie./ (15

30'

60'

D/C 4-, L.C.i... /TI■e---

MEDCOM - 19392

DOD-032966

ACLU-RDI 1651 p.152

MEDICAL RECORD-SUPPLEMENTAL MEDI, use of this form. see AR 40.66; the proponent agency is the Office of Th.

Post-Anesthesia Unit (PACU) Flow Sheet REPORT TITLE

Airway Nasal Oral ETT

Trach

Other

Drains Hemovac

NG JP ■

T-tube Foley

TLS

CITSG APPROVED /Dare)

Date: Time In: Allergies: Pre-op VIS: Procedures:

Histor

Pacu Intake

Time Solution Amount Site . By Infused

I 2. y Lg_ ')—)--o L Foy 1c, —arc

X-rays: . Labs:

Post-Anesthesia Recovery_score

Criteria ADM 30' WC Codes Acti

Mvity

(2) oves 4 Extremities E_ (1) Moves 2 xtremities

(0) Moves 0 Extremities

fit- . / .c :)\ . 2 AIRWAY A= Ambu BB= Blow-by M — Mask

FT = Face Tent RNAC =

RNirsmal Air Cannula

V/S X =A-line BP

- = Cuf f BP

TEMP S =Skin OA = OArxailliary

T =Tympanic

Airway (2) Cough, Deep breath (1) Dyspnea• Wiled breathing (0) Apnea

(:)\ Blood Pressure

of Pre-op (1) SBP =/- 2 (0) SBP =/- 50 of Pre-op

(2) SOP =/- 20 0-50 of Pre-op

I 472\ Consciousness (2) Fully Awake, audible

aYing (1) Arousable to verbal or pain /

Color (2) Baseline color & appearance

(1) pate. mottled, jaundiced (0) Cyanotic ., 2-•,-..

2.....

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only reliable pulse P

R = Rectal

CL =Cervical TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for DIC.

T =Thoracic L = Lumbar

S =Sacral



C

Pre Op Meds

Time

I..

Anesthesia Type (Circle)): General Spinal Epidural IV Sedation Block

R Intake: Crystalloid ') bb Colloid i OR Output: UOP EBL 61 /4

1 5 F to A--) Meds/Times:

EIIIIIIIMMIN11111111111111111111IM111111 Patien teaching done; Wound Care, Pain Manage ent, T. C, & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

!Continue on reverse)

DATE Title)

"

(For typed or written entries give:

it grade; date; hospital Of medical laukyl 0 HISTORYIPHYSICAL



❑ TREATMENT

FLOW CHART

❑ OTHER gxcitri

Name —last,

••.,

ja::3

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 19393

— tneral.

2_6 75 ePoj

Sa02

Fi02

Methods

240

220

200

180

160

140

120

100

80

40

20

RR

Previous edition is obsolete USAPPC 02.00

DOD-032967 ACLU-RDI 1651 p.153

PACU OUTPUT

Discharge Criteria: Date: WC. 140 S Time: IZ- 41a PARS:

''

BP: /25(766, T: HR: RR: )Z-- Sa02: gr Pain Level at D/C 10-101: Intake: LT L L Output: Additional Data: Transferred To: /C-1-/ Report Given To:

ransferred Via: W/ Transferred By: ec

Cleared IAW Recovery Room SOP B-r3neY Ambulance Charge Nurse Signature:

Time Source Color/Appearance Amou

Time Sym tomatic? Rhythm Strip Run?

12Y0 Rtlythm

g:v".„.•

CARDIAC RHYTHM

WAMC OP 173-E

MEDICATIONS Allergies: . Time Pain

1-10 Medication & nosane

Route Pain 1-10

I/E By

V..2-C-1 Lt ■P-A1V.A-6c9 Z\) e 1\19 "...._,


Of Motion


T Color

Adm 11L Iwo-) f D b ---- 15' • 30' C( (Ra-' t P S c 7." 45' 60'

90'

D/C ttc az) ,y) I.-- P c...-

Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: 7P = Palpable, D = Doppler, A = Absent Color: C= Cyanotic,

Capillary Refill: 13= Brisk, S= S uggish P= Pale, Pk = Pink

C-SECTIONS

Adm 15' 30' 45' ,....-691-- 457---17V Fund. Height

Lochia _.-/--- Peripad#

Fun . ond.

DRESSINGS


Adm (--/ / (j/rC'ell• ?r

30' W-3 LLL CV/-C? A 1 4" 0 la 4,ei-fr, I 60'

D/C I ZLY 0 I_ ct- 6 6,--te 1 1 1/.1" v, 441.-k/` L

NURSING NOTES

to i74-6 eit,e. 419 Low rk ohof)

41_6\ f_L_S_Ze_kea ij_K___

Oresso y r ✓ r✓ s e KA Pi- di.ce-,116. ,ted

r/l q L (9 RS Score

MEDCOM - 19394

DOD-032968

ACLU-RDI 1651 p.154

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete OSAPPC V2.00

MEDCOM - 19395

Time

Solution

Amount

Site

By

Infused

RR

T


21 n l k

Patten teaching done; Wound Ca e, Pain Management. T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained

icanttnue an reverse)

DATE

Name — last,

❑ HISTORY1PtfSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER am,y0

OR EVALUATION


❑ TREATMENT

DEPARTMENTISERVICEICUNIC

Pigeu PREPARE '

PATIE entries give: S161&12--Y-

fiat, middle; grade: dare: hasp, c auk]

X-rays:

Labs:


Criteria Activity

(2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing (0) Apnea

Blood Pressure (2) SBP =1- 20 of Pre-op (1) SBP 20-50 of Pre-op (0) SBP =/- 50 of Pre-op

Consciousness (2)fully Awake, audible crying (1) Arousable to verbal or pain

Color (2) Baseline color & appearance

(1) pale. mottled, jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for D/C,

ADM 30' DIC Codes

AIRWAY A =Ambu BB = Blow-by

M – Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula

V/S X= A-line BP

=Cuff BP = Pulse

TEMP S =Skin 0 = Oral A = Axillary T = Tympanic R= Rectal

LOS C =Cervical T = Thoracic L = Lumbar S = Sacral

Sa02

F102

Methods

240

220

200

180

160

140

120

100

80

60

40

20

REPORT TITLE

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this font. see AR 41166: the proponent agency is the Office of The Surgeon General.

OTSG APPROVED !Dare/

Post-Anesthesia Care Unit (PACU) Flow Sheet

Ai ay Na Oral ETT

Trach

Other

Date: 30 Scp 03 Anesthesia Type (Circle)): ene Spinal Epidural Drains

Time In: 133 -1 ,...., iv Sedation Nerve Block Hemovac , ,

Allergies: Alec*, OR Intake: Crystalloid P. , °L./ Colloid NG

Pre-op V/S: in// .g0 OR Output DOP cp" EBL tit JP

Procedures: I 114 iUnAl r s e i,e Fr Medi/Times: ,51,7.0 I ,P,L,), &&-, Avv- el! T-tube

le) --(::: 1115rr—

Histor TLS Pre Op Meds

Time

Pacu Intake

DOD-032969

ACLU-RDI 1651 p.155

Dischar e Criteria: Date SP OS Time: PO PARS: /0 BP:

I443 T: e c HR: 9 r RR: Sa02:5g Za

Pain Level at D/C (0-101: Intake: 0 Output: Additional Data: Transferred To: Report Given To: Transferred Via: W/CLi nce Gurney Transferred By: SS Cleared IAW Recovery Roo

- 19396 m Signature:


1-10 Medication & nosane

Route Pain 1-10

I/E By

#1-41

NURSING NOTES


Of Motion


T Color

Adm Lk 1,,,,4-td -4-- p f5 l px, 15' 1- ► . I i neu.1-rSc 4.. P 6 WM Plc 30'

45'

60'

90'

D/C

Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P =Palpable, D =Doppler, A= Absent Color: C= Cyanotic,

Capillary Refill: B= Brisk, S= S uggish P= Pale, Pk= Pink

C-SECTIONS Mm 15' 30' 45' 60' 90' ___--131C--

Fund. Height ------------- Lochia .--------s' Peripad# ..-/--.--- Fund. Cond. _...../

...---"-- DRESSINGS


Adm L 1 e3 4--AV1 Oa IA). r Idi 30'

60'

D/C

PACU OUTPUT

Time

Source

Color/Appearance

Amount

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

631 Nele 9f MEDCOM

WAUr no 479 C

DOD-032970 ACLU-RDI 1651 p.156

SWORN STATEMENT For use of this form, see AR 190-45; the proponent anency is ODCSOPS

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943 ISSN).

PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately

ROUTINE USES: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.

DISCLOSURE: Disclosure of your social security number is voluntary.

1. L sp t -0 L., 2...pATE (YYYYMMDD)

I e- V° 3. m 3. TIME, '

z9v 4. FILE NUMBER .

.

( fn)-a- b

6. SS

o- - -Q- -

7. GRADE/STATUS !' 6_ 2

- E' ( t -)

_2 - 7 , WANT TO MAKE THE

r2ec ctv-t-i - ve-s

, w e,

CAStA a-(141-e

t" c14- 1-kvs‘e 0 /Ai

[A2 I

o WiliRvi f- v

FOLLOWING STATEMENT UNDER OATH:

D vv (0 C ct± ra (I

(- G3 fe Y.SC`, k (.1_2, 1

s' /A- 0-01 /4-cD i--4 , ,

a vc,/( c vv {_f_f__ ( ./n "pet 1 • 1'6 i n a. in 01

neo{ N 1 d4 IA D (. ., s- , 0 (...e_ ( .e.

) )2-- 5 0( t\i4sst wi,pi

0111110) c›-4 14 ,v4

N1 10- i

CSW t\,' e_Ot a^ v— vs° K 1 AAA f

\--Ect 1c ( vv-t.tc C -') , a

.-) '-- \ Yli —f- .0 NY OA

0 1.11 / g` oo c-r_e_p 0 3 r'-Re V MP p,v1\17c2.- itos't (-

5'w eC t Cc--vcot_ (bp (c 1 -1\c3 V

v\, e_ w A., -e-j e, A $ (.4_ ,

_ G ia a LcVI_ . We- -1( frk.

a_vD twi-y- v\i c. tr9 _ e. FL c ( UV 1 A G‘ o.o tw

1 6-: GI c-a e- I tioveu,p( v-c,--ck--v ,,, _ Pt sc a 31.4

cll vl kG\I -

kre---C6 V-- ir' -e---e---S t- D

li \- I- tm -V-6 \D- '

ct 0 5--c-- - 0-G ME .-VAC g N

s'-eC.-.-k 17D C t(- 1

fr i i-e-5

ckv\-tt tk_01

blr

il()\'i

i c ( - 1'' L , C.ke,_

r, 1 V VI__

-tb .,) v v. o Ca.e?broy-

a''' .( ti\j- --Lc 10. EXHIBIT 11. INIT SOI5M/7,KIN STATEMENT

LIZ \)— Z- TAKEN AT DATED

PAGE 1 OF 1./PAGES

ADDITIONAL PAGES MUST CONTAIN THE HEADING "TATEMENT

THE BOTTOM OF EACH ADDITIONAL LUST BEAR THE INITIALS MUST BE BE INDICATED.

OF THE PERSON MAK!. STATEMENT, AND PAGE NUMBER

DA FORM 2823, DEC 1998

rIA COPRA /A iv 71 IC nBSOLETE

USAPA V1.00

MEDCOM - 19397

To

DOD-032971 ACLU-RDI 1651 p.157

USE THIS PAGE IF NEEDED. IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED TO FINAL PAGE OF THIS FORM.

STATEMENT OF c(i)

TAKEN AT DATED

9. STATEMENT (Continued)

\AI U4‘. NttC vvOk ak A fre (c2( -2D O wk. vo

viv.A.dvd(A s* e-I 0 oc't tvo. 1-ea ko f_A,u_AcA. wc-ki

kis' k\(Ovidt Akk1/4-tock(A- C2Ae • IV Ice a v-e-v-ed

\14 Qv:1r v\--& vot ‘'cactkizAreA 41AAV(N6A s rbe ,

c d 0-V..e0t.

t. Ct-Aj likjkaC a-z t&a,g . Ai c

A CGS ,l t vt 6V-vIAJ 0LA-s0:( (k-e_ kt vt_ ci-Ce U

avi_of -fa k-e-t_ -to IWO MO v(tko-vj )E>

INITIALS OF PERSON MAKING STATE

PAGE OF OF cz, PAGES

USAPA V1.00

PAGE Z DA FORM 2823, DEC 1998

w4u1/4-0:ed P61 ' s U, c -Elk \A^4111-L ve. a-kikok inx (A--q

MEDCOM - 19398

DOD-032972

ACLU-RDI 1651 p.158

DATED /g/q TAKEN AT

AFFIDAVIT

STATEMENT 0


111110;.9

, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1, AND ENDS ON PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, 0

WITNESSES:

e o •erson

Subscribed and sworn to before me, a person aut onzed by law to

administer oaths, this IS day of 5re-er , 2,03 at

—U - h)

(Typed Name of Person Administering Oath)

CPT v_s 11-1 ORGANIZATION OR ADDRESS [Authority To Administer Oaths)

INITIALS OF PERSON MAKING STATE" PAGE OF OF PAGES

PAGE 3, DA FORM 2823, DEC 1998

MEDCOM - 19399

USAPA V7.00

DOD-032973 ACLU-RDI 1651 p.159

1111111( hCts -AO e,

e q1111111111,-___ €)) /() c

STATEMENT OF TAKEN AT DATED


iTc p r /70c

11111.1111.11,

AFFIDAVIT

, HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT

WHICH BEGINS ON PAGE 1, AND ENDS ON PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE

BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFfT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.

(Signature of Person Making Statement)

WITNESSES: 4:.

Subscribed and sworn to before me, a person authorized by law to

adTinister oaths, this day of

at

ORGANIZATION OR ADDRESS (Signature of Person Administering Oath)

(Typed Name of Person Administering Oath)

(Au. To Administer Oaths) ORGANIZATION OR ADDRESS

INITIALS OF PERSON MAKING STATEMENT MEDCOM - 19400 ne

PAGES

DOD-032974 ACLU-RDI 1651 p.160

75 76 77 78 79 80

25. MTF TRANSFERRED FROM 24.

MEDCOM - 19401

DOD-032975

ND CODING INFORMATION 2 MTF LOCATION REPORTING MTF

5 (State or Country

Code.)

8 AR 40-400; the proponent agency is OTSG For use of

-2- 4. PAY GRADE

NAME (Last, First, Middle Initial) REGISTER NUMBER

RELIGION 9. ETHNIC 7. AGE AT ADMISSION DATE OF BIRTH (Y YYYM

12. SOCIAL SECURITY NUMBER

DD InallrEllell 10. LENGTH OF SERVICE

BRANCH / CORPS HOUR OF

ADMISSION 13. MARITAL STATUS

16. ZIP CODE OF RESIDENCE 15. BENEFICIARY CATEGORY

14. FLYING STATUS 61 60 59 58 56 54 53

PREY. ADMISSION 19. TRAUMA

71 4 18. MOS

NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE WARD il■) 20. SOURCE OF ADMISSION/ AUTHORITY FOR

I ADMISSION ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

1A7-c.Li•Ja ) le-- TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

TY

23. DATE OF DISPOSITION (1' YMMDDI 22. MTF TRANSFERRED TO

21. TYPE OF DISPOSITION 86 84 85 82 83

73

0 '5 1 26. DATE THIS ADMISSION IYYMMDDI

LINIC SVC - ADMITTING

88 89 90

A sst

102 101 100 99 98 96 95 94 93 92 91 87 1 C A 29. DATE INITIAL ADMISSLOIL(Y YMMOD)

26. MTF OF INITIAL ADMISSION 27. LOCATION OF OCCURRENCE

(Battle Casualty Only) . 1 107 108 109 106 105 103 1041

---

FOR LOCAL USE

Dy.. (bile, - ) 61

ADMITTING CLERK SIGNATURE ADMITTING OFFICER (Signature, as required)

b (0

ACLU-RDI 1651 p.161

INYA I 'LAI I I HEAT MENT RECORD COVER SHEET For use of this form. sec AR 40400; the proponent agency is OTSG

NAME (Last. First. MD 3 . GRADE

N R ADMISSION REMARKS

l IL

4 SEX AGE 6 RACE

LID 0---P\L

7. RELIGION

u-0\2- LENGTH OF SVC

I; ET

A

S

A 10. PREVIOUS 0. ION

I I FMP 12. SSN

qct ORGANIZATION

1\.) Pc WARD

i_CLAA 15. FLYING

STATUS

0 N I

I B-

)

DEN

1 NJ

8. BRANCHICORPS 19 UICIZIP 20. TYPE CASE

-1\....) (2;a7

21 SOURCE OF AOMISSIONIAUTHORITY FOR ADMISSION 22. HOURS OF ADMISSION

,-- i--Lq-I5- 0 I cr . C2V Cc—Orr \ "E M4-- /

23. CLINIC SERVICE

.iA-A.,A- 24 NAME/RELATIONSHIP OF EMERGENCY AOORESSEE .•

i A\ ) \ /

2R TYPE DISPOSITIO 26. DATE 4F DISPOSITION

L7E-0

273 ADDRESS OF EMERGENCY ADDRESSEE Unclude ZIP Code/ "

L.)1/4 .0 \L-

3 71_2:___TELEPHONE NO.

U-1 \N -

28 OAT • OF THIS ADMISSION

q ( I (a/OnD

ADMITTING OFFICER

6 ( C...42

a

2 or

32. imalimill COMPONENT TRANSFUSED

29. NAME AND LOCAL :ON OF MEDICAL TREATMENT FACILITY

111111111111.■11111W — -7--

30. DA E OF INTIAL ADMISSION

3

•

r

)

/ Ei .,..,,Continund on &versa

33. CAUSE OF INJURY

;

34 DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

P IA RI C-TA L G VA LLL c / & Pt afL_pAL 1--k t H--r, -R-A---t A

4

35. Total Days This Facility

i. ABSENT SICK GAYS 6 OTHER DAYS c . CONY, IVICOOP I d. SUPPLEMENTAL CARE DAYS CAPE OATS

3 0 0 a. DED OATS I. TOTAL SICK DAYS

I 'I 36. Total Days All Facilites

ASSENT SICK DAYS

...—..

h. OTHER OARS

C

COW LVICOOP CARE DAYS D

4 SUPPLEMENTAL CAPE DAYS

e. BED DAYS I. TOTAL SICK DAYS

:.

SIGNAT Ur.E OF FAO CR MEDICAL RECORDS OFFICER

,^ —,`,...."...

-

F 1 AUG 76 IS CM3LETE

MEDCOM - 19402

\D 1 1,5APPC Y1.19

DOD-032976 ACLU-RDI 1651 p.162

IDENTIFICATION NO.

REGISTER NO.

ORGAN IZATI N

WARD NO.

0111111111/ NTIFICATION (For typed or written entries give Name last, first

middle; grade,- date; hospital or medical facility)

DATE

ABBREVIATED MEDICAL RECORD Standard Form 539

MEDCOM -19403

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 USAPPC V1.00

MEDICAL ABBREVIATED MEDICAL RECORD

PERTINENT HISTO `CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)

A47 ;du, eed-r-e e (5' P4-11 ei L

4,0.4.:-'4 447e 5/ fY7 B-y) I tc-s- 4. ce /IT )4;

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fqp

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PROGRESS (Enter date of discharge and final diagnosis)

e:,c 5 /' Id '

e/r Of //e I"(

„:,,,-z A /,;.*, t-5 414-r..4 /4,1r-s- crT 5 e

DOD-032977 ACLU-RDI 1651 p.163


DATE NOTES

1171 0J IMP loo- (NI

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t .5),1( 0),;y1aAAA1 t 6_>) --t- )1. ) VU :1( v14 nfi carr

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of 0-e-of p g-vo- p-01- ETT MC ) au_.vvt 1? Cr owl& uncle cir cu,,,rvl via !4- ut..

ryttmulny

c- flown 313`) /A o /zo l- (.0/mO7, 146." 11) N D 60.-0,,,,./)

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STANDARD FORMIII9 MEV. 5119991 BACK

MEDCOM - 19404 USAPA YI IXI

DOD-032978 ACLU-RDI 1651 p.164

DEPARTJSERVICE HOSPITAL OI•MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Nome • kat, fig widd1e I RESISTER NO.

ID No or SSN; Set; Date of Binh; Rankl6ratie1

WARD ND.



DATE

P

NOTES

theP0 •

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(

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RELATIONSHIP TO SPONSI


STANDARD FORM 509 IREV. 5119914 Prescribed by GSARCHR FPMR 111CFFI) 101.11.20311111101

USAPA V1.00

MEDCOM - 19405

DOD-032979 ACLU-RDI 1651 p.165

LAST NAME - 'FIRST NAME TMluuLt INITIAL ID NUMBER

DATE ' iCIL-1--Y'a /\it--1--, CP-x-/ ' , '

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STANDARD FORM 509 MEV. W1999I BACK

USAPA111.00 MEDCOM - 19406

DOD-032980

ACLU-RDI 1651 p.166


DATE NOTES

4et.)-7 J. vs A- rt;

I • C 2 4-1, -I'S_ 2-.4J w I- 64,

d,-, Ai frZ E do d -5

x-e_ ' 4- a , V, : ....,.. . 4,,,Y

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RELATIONSHIP TO SPONSOR SPONSOR'S ID NUMBER ISSN or MeV

SPONSOR'S NAME

DEPARTJSERWCE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION:Ikt typed or written entries, give: Namelast, first, middle; ID Mo or SS11,• Ser; Date of Blair,• RankSradel

REGISTER ND. WARD NO.

PROGRESS NOTES Lfij

Medical Record

STANDARD FORM 509 91E8. 5/1899) Prescribed by GSAIICMR FPMR I41CFR) 101-11.203Ib810)

USAPA V1.00

MEDCOM - 19407

DOD-032981


ACLU-RDI 1651 p.167


MEDICAL RECORD

PROGRESS Id CI Ls

DATE NOTES

,q,04,3,,,,,e Ak i ' ' ,31 6 t -(P ̀I10 .1-S Co p-,04_,, j.)-(-- . 0 n trn - q I- .---' - / ._ - / 9/r; 22

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LAST FIRST MI

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT 1.

PATIENT'S IDENTIFICATION: /For typed or written emits, pie Name . ki4 (et, snirMk. ID No Of SSN• Sex; Date of Birth; Renk./Grade)

I REGISTER ND. WAA ND.

--Ve..—L, --1- PROGRESS NOTES

Medical Record

STANDARD FORM 509 IREV. 5119991 Prescribed by GSAIICMR FP/AR 14 1 CFRI 101-11.203(14110)

USAPA VI.00

MEDCOM - 19408

DOD-032982 ACLU-RDI 1651 p.168


DATE NOTES i

il—t 4 z_ir.,

V e-al,,,k • //

/_. .. ... .1,.. • ' ,e_.-1 _

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(2)-

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STANDARD FORM 509 IREV. 5119991 BACK


DOD-032983 ACLU-RDI 1651 p.169

7,3-L.—cry

••-


PROGRESS NOTES MEDICAL RECORD

DATE NOTES

e/

111

?xi? j);(-111111111111111 / cst-szif

0,41- "3/ 6Z •,4.--c4i/e(7-7

rk74 '

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90 SKr--/O I .

ei 65-3

i4?,ti gocri--,- (4; 124-A-64. P-1 (1 kc)

RELATIONSHIP TO SPONSOR SPONSOR'S

FIRST

NAME

DEPARTJSERVICE RECORDS MAINTAINED AT HOSPITAL OR MEDICAL FACILITY

REGISTER ND. WARD5, PATIENT'S IDENTIFICATION: Ifor typed or written mass, give: Nam • las& first, midilie;

ID No or SSN• Sex; Dots of Bit; Rank Sradel


STANDARD FORM 509 MEV. W1999) Prescribed by GSARCMR FPMR 141CFRI 101.11.2031b11101

USAPA VISO

MEDCOM - 19410

DOD-032984 ACLU-RDI 1651 p.170


DATE NOTES

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i

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STANDARD FORM 509 (REV. 6(19991 BACK

USAPA VI Al

MEDCOM - 19411

DOD-032985

ACLU-RDI 1651 p.171

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

4-7.-t gir /e 5 / • ey' /L,/e7t

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CTANDARD FORM 600 (REV. 6-97) BACK Iku.s. 7996-497_766/75236

MEDCOM - 19412

DOD-032986

ACLU-RDI 1651 p.172


MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TR TMENT, TREATING ORGANIZATION (Sign each entry)

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No or SSN; Sex; !REGISTER NO. WARD NO.


STANDARD FORM 600 IREV. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFRI 201-9.202-1

MEDCOM - 19413

DOD-032987 ACLU-RDI 1651 p.173

AUTHORIZED FOR LOCAL RE D

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

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

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1



STANDARD FORM 600 lam/. 6-97) Prescribed by GSA/ICMR FIRMR 141 CFRI 201-9.202-1

MEDCOM - 19414

DOD-032988 ACLU-RDI 1651 p.174

tAIT

NSN 7540-01.075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS f WBC

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1.14

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PATIENT'S IDENTIFICATION (Fir wed or wrirt en entries g Name - kW, firer, mickgre ID (la ISSN or other); hospital Of medal taaryl

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 MEV. 9.961 Prescrint1 by GSAI1CMR FPMR 141 CFRI 101.1 1.2031b11101 USAPA VI.00

MEDCOM - 19415

DOD-032989 ACLU-RDI 1651 p.175

5 PULSE OX

TIME .20

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PATIENT'S IDENTIFICATION lbw typed or written mines, give: Name - lest, milde• 10 no. ISSN or Wert hospital or

medical

MONITOR

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n 24 HRS. ri 48 HRS. n 78 HRS.

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y

DISPOSITION

HOME n FULL DUTY

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DETERIORATED

ADMIT TO UNITISERVICE

TIME OF RELEASE

REFERRED

I have received and understand these instructions.

PATIENT'S SIGNATURE

TO WHEN

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

Matientl

LOG NUMBER

RECORDS MAINTAINED AT

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STREET ADDRESS

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rii e-c16,..6 e. SEX DUTYILOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES NO NM ITEM YES ■ I

ADDITIONAL INSURANCE PRP

DO 2568 I r FLYING ST HONE AGE

AREA C NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS ----,

i .i) - ,ry-G, /8 to

Pe.

INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN'

(1 YES

IS THIS AN INJURY? --11WE'Rr TET

DATE LAST SHOT OMPLETED INTITIAL SERIES

YES NO ALLERGIES

114C- () ik

INJURYISAFETY FORMS

HOW

CHIEF COMPLAINT

CATEGORY OF TREATMENT

VITAL SIGNS

yy EMERGENT

atIIRGENT —

TIME TIME I (I ..,0

BP ( Ob (,-/ r

O..

/.// PULSE - 17

(c) - L P n 1

INITIALS RESP 5fr, 26 7-D 1b3....#

NON-URGENici (4 TEMP Pi

WT (DO 1-.. &),.., /'

LAB

ORD

ERS Ja► CBCIDIFF ABG P IPTT 1-I . WUANEIBLOOBIOUANT

RE1.4: i C... ty 1...,, s SI:130k10 AVH•X

A CXR PA & LATIPORTABLE C-SPINE

URINE C&S ' 4. kIV CICATH ACUTE ABDOMEN LS SPINE

BLOOD C&S X SINUS /K HEAD CT

- ANKLE RIL

ORDERS

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

cc2

STANDARD FORM 558 IREV. 9-961 Prescribed by GSAIICMR FPMR 141 CFRI 101.11.2030)1101 USAPA V1.00

MEDCOM - 19416

DOD-032990 ACLU-RDI 1651 p.176

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5

SECTION I - PATIENT ASSESSMENT

DATE: 1... f 5‘2/03 PATIENT ACUITY LEVEL : POST-OP DAY: HOSPITAL DAY:

COMPLETE 0>1 Y AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Time /i41 To -,Z--Z 1•'/7---- From -1.0 2-- 111 AMBULATORY M CRUTCHES V:HEELCHAIR I STRETCHER

Total ER/RR/PACU time (Specify): I, Physician _ Procedure/Diagnosis 5/P (4).1-161-; 76' (5 "// 4.1.4,, 2-- &7,--lia "'Q'"''`'mA Q6.'C/F5g, ' R T

LOC Neurovascular checks e- 1-7. 47 •—(:)/ -7

Dressing/cast Tubes Fel7 eecj

Intake (IV, po) Output (EBL • other) Voided Li No II Yes Amount:

Medication /68 , ,i-%4P,C, I'verl , Other

Report From ./14410— lari_ Received By LT-

- z

•

TIME: ID O OC 2qod BP ARTERIAL LINE .------: ------ ...---

BP CUFF 14/60 16 Ac .K $56,3 TEMPERATURE /60,7 IOU *1 ICM' PULSE /6/ /to 1G 0

RESPIRATORY RATE igg , i i Jr 02, 1 0 OXYGEN (L/%) -

e"..... /

PULSE OXIMETER C/174

(Z-A

qr.- V e7

gd.■

19 02 METHOD

NC = Nasal cannula NR = Non rebr tr FM = Face mask VM = Ventu i mask Oxygen Method Key:

eathe MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

•

. •

•.

..•

•

• •

• . ..

... • „

• .•.

.; •

TIME: f4i9C, 9_,Ifr) 22.3'

U) C

t. III O

- Q

J

Z W

U-1 C

I C/)

TIME: /600 AO, 'It

'Skin breakdown prevention /1/4 MA

PAIN

INTENS

to " . . • •

" . . • •

• • . . • •

" . . • •

" . . • •

• ' . . • •

• • . . • • 'Falls prevention protocol

'Restraint protocol

o ,z-:-

•

• • •

• • • • .

'

- • • • . .

k •

• • • • . .

"

. .

. .

. .

6-1

.•- I

. . • . . .

• Seizure precautions

• IsolatiOn precautions

MED ADMINISTERED IY/N)

RELIEF ACCEPTABLE (Y/NI

/4-6

] INT

NA

. 4- 6 1 7 ± 7 0J cc I TIME: /

A YESTERDAY'S WEIGHT: - FINGER STICK GLUCOSE 4 TODAY'S WEIGHT: INSULIN lYiN)

M

WEIGHT CHANGE:

•Per hospital policy.

24 HOUR TOTALS

PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT


Al CIMILD f \ -<_.) — C-(

DIAGNOSIS: -5'7, (04,/,.e X.(5-,k,g r-7 £ Cf, r4 DRG: ADMISSION DATE:

LOS: EXPECTED RELEASE:

CASE MANAGER:



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99

PREVIOUS EDITIONS ARE OBSOLETE

Page 1 of 4 pages MC V 1.00

MEDCOM - 19417

DOD-032991

ACLU-RDI 1651 p.177

SECTION 11- PATIENT ASSESSMENT - REVIEW OF SYSTEMS

DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.

TIME: /06.) INITI TIME:A913...) INITIAL E: INITIALS:

1. NEUROLOGICAL: Alert and oriented to

time place and name. Responds appropriately.

Communication is adequate to express needs.

Pupils equal and reactive to light.

I %-k /V 1.^.) NI_ ❑ trauco N/ L.-

-

❑

.

2. CARDIOVASCULAR: Pulse regular & rate

within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf

tenderness. (See page 3 for extremity perfusion)

I 1

3. PULMONARY: Respirations within normal

rate for age group; quiet and regular. Depth is

regular. No cough. No abnormal breath

sounds.

4. G.I.: Abdomen soft and non-distended.

Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/

swallowing. Denies constipation, diarrhea or

rectal bleeding.

C /. Ii`e , i‘e4 •

❑

5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear,

yellow/amber. No unusual discharge.

/74::8 -ej h W v

,,

12i ucids s ctibt ❑

6. MUSCULOSKELETAL: Normal muscle

development and mass for age. No

deformities. No assistive devices needed. Normal active ROM without pain. No joint

swelling/tenderness, weakness or paresthesia.

❑ bei.-.€,-.Jr -z...e,(/

UlACI k-Aec.5.

A ❑

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony

prominences. Mucous membranes moist.

❑ WO.4. 10 0

frr:t. -1-. I 5 tt. II s 1-,,(Az 5 /0

SI'1 2. (4(...ct

1.1& Pahit/A.ed) 3jai Q D - ti-curAD a 3i.A.iutes

fAki-ct.C.i-

❑

8. PAIN: No complaints of pain! discomfort. (See page 1 for documenting pain intensity.)

Er 0 ❑

9. PSYCHOSOCIAL: Behavior is appropriate

to the situation. Anxiety is controlled or mild

and appropriate to situation. Interacts

appropriately with others.

b(G:2. --- 1.___ ❑

10. IV SITE ASSESSMENT: EGEND: Puffy I - Infiltrated R - Redd OK - No swelling/redness * - Central line)

TIME: i .5-12D INITIALS:

IV patency V q hr:

TIME: r-90,-) INITIALS:

IV patency V q 2 hr:

TIME: INITIALS:

IV patency ✓ q hr:

IV site care provided: IV site care provided: IV site care provided:

IV tubing changed: IV tubing changed: IV tubing changed:

LOCATION CONDITION

IV Site #1:

LOCATION CONDITION

IV Site #1: (DK, NiN

LOCATION CONDITION

IV Site #1: 4(... ty-L- IV Site #2: IV Site #2: IV Site #2:

Comments: ,.,,,

Comments: neDYL n ,- -.e.. 2 111C.-t— ■f, IMU-Vrke

Comments:

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 2 of 4 pages

MEDCOM - 19418

DOD-032992

ACLU-RDI 1651 p.178

SECTION III - PATIENT INTERVENTIONS & TEACHING

SITE: TIME: 1990 TIME: 5e7 '2,

ID band visible/legible COLOR

Orient to environment prn CAPILLARY REFILL -

Side rails (2/4) up 4/7* TEMPERATURE

( -

---7-

Bed position low EDEMA

Call light within reach SENSATION

. MOTION

PASSIVE FLEXION

0 I—

L

u CC

Review & post lab results

Notify MD abnormal labs PERIPHERAL PULSE

LEGEND

Incontinent urine/stool 14 Color: P-pink (normal); C-cyanotic; W-pale, white

Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-)> 5 secs)

Temperature: C-cool; W-warm; H-hot

Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting

Sensation: A-absent; N-numb; T-tingling; S-sensation (present)

Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM

Passive Flexion: D-dorsal flexion p .ain; P-plantar flexion pain; 0-no pain

Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable

Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose q i

• .

..

....:

BREAKFAST LUNCH DINNER

TYPE: TYPE: TYPE: a, /,,

PERCENT CONSUkED: PERCENT CON PERCENT CON ED:

HOW TO ATED: HOWTpkrrATED: HOW TOLERATED:

❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

. .

• ...

. ,

et 0

•v,•

LLJ <

I) .±

'

0.

•• • •

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE 1:=1 SELF ❑ COMPL E

❑ ASSIST ❑ TO L

❑ SELF ❑ COMPLETE

E3----A-SSIST ❑ TOTAL


❑ ASSIST ❑ TOTAL

TYPE OF ACTIVITY (Circle all that apply)

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHA

BEDREST ❑ SEF

ter"—ASSIST

BSC # TIMES/SHIFT

HAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

TIME: /37,0 INITIALS'. TIME: =5...j INITIALS: .. TIME INITIALS:

CONTENT: r ,

,/iitn or Co---e

Or ,e, -1- 1 0 coe",

lj3/61 /Family Verbalizes Understanding

CONTENT:

pa.t n ma ncutru pkil

NQS) bci■ ary3Ldsi.y,cp,

Cil Patient/Family Verbalizes Understanding

CONTENT:

❑ Patient/Family Verbalizes Understanding


1111111

INITIALS \,_ i, r_,._, - 7_ SIGNATURE SHIFT

///7/fri

ki


Page 3 of 4 pages

MEDCOM - 19419

DOD-032993 ACLU-RDI 1651 p.179

SECTION III - INTERVENTIONS & TEACHING (Cont)

W

0

U

N.

D.

C.

:A R

T I

M E

LOCATION OF WOUND APPEARANCE TREATMENTS

s.

Auo DRESSINd CHANGE

pvt, ■ ‘ck./ ,e— /1 .5 At, e ..5 i h tA. / A , /6/0

l'Aree,Poz-), A/ pcist.As_tic0 olai,JIP "\- C-t.f.1.--E, `:.■ li OCOLkx c c, iktaci

c.., -- c ri\c_i) ,4 $ inpc.3,-, GuYa3caL_o_d

SECTION IV - NOTES

/ /K-( 1 7;-„,.,_,-,/,:„) 4 7-c 1),/,,, _7---c (12, v7. ,,,ie.z/c--h, Vs c /1/ 1 ) / /

, keti,i /(/ 6 ta/ded (.7-- Cit 10DI ( -- ITV -tn. ( t - 0 ., # '1 01_0 d n..Lie dc U ux. 16icli -1) P -70 . iL- 4--) O., i

eitzal vf) ( 0, (eriei tpf07 (

i i 61Iace04 loifu-A,r) a- _tow LooD elaery,7 ,

duo , a clio'_4x0 .. /)...p ,_0 ti -10 -MN- k inq Y / Win

b (c6- p.,___\ \

1 1 —I

MEDCOM FORM 689-R (TEST) (MC110) MAR 99 Page 4 of 4 pages

MEDCOM - 19420

DOD-032994 ACLU-RDI 1651 p.180



DATE: -_)q) I- 0 '-• PATIENT ACUITY LEVEL : • POST-OP DAY: 1/ HOSPITAL DAY:

:

: N S:

F

E

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE

Time To From I AMBULATORY

REPORT:

U CRUTCHES I ' • IR U STRETCHER

• - esia (Specify): Total ER/FIR/PACU time Physician

Procedure/Diagnosis B/P P • R T

LOC Neurovascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided U No I Yes Amount:

Medication

Other .,---

Re ort From Received B

, r•-

V .

T

•

G N

TIME: crtit IW .6ab ,t4i, di)

BP ARTERIAL LINE

arik,Aliv WA ---

El BP CUFF

TEMPERATURE LEM FARM

tcal ci /

mq 1 1 iff'

ctet.

Leg g-0 5

t

PULSE

RESPIRATORY RATE

OXYGEN IL/%)

PULSE OXIMETER . cf 02 METHOD l'A /17' K

NC = Nasal car nula NR = Non rebreather FM = Face mask VM = Venturi mask Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

• '

TIME: go • --eiv , ._ TIME: i On 0

PAIN

INTENSITY

10

5

0

• • • • • • • •

• • • • • • • • • • • • ' Skin breakdown

prevention

• Falls prevention protocol il'o0

'Restraint protocol r-) p

• • • • • • '0 •

. .

• •.

. .

• .

. .

. .

. .

. •

. .

. •

. .

. .

p

E

MED ADMINISTERED IY/N) w p 1 • Seizure precautions

'Isolation precautions RELIEF ACCEPTABLE IY/NI 'i PP A

L

.-- N

T H.

E R

TIME: Ippi E E FINGER STICK GLUCOSE YESTERDAY'S WEIGHT:

INSULIN (YIN) D TODAY'S WEIGHT: S

WEIGHT CHANGE: •

• Per hospital policy.

24 HOUR TOTALS



b \-

qiII • •. DIAGNOSIS: k.i,....j- Rixt,c .trx p ,...li•unikAt -6 elo (lam o herna j..

DRG: ADMISSI DATE:

LOS: \ EXPECTED RELEASE:

CASE MANAGER:



FORM 689-R (TEST) (MCHO) MAR 99

PREVIOUS EDITIONS ARE OBSOLETE

Page 1 of 4 pages MC V1. 00

MEDCOM - 19421

DOD-032995 ACLU-RDI 1651 p.181

SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS

DIRECTIONS.' A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.

1C%'(,(IL . ' Z -/--

TIME:Oyk' c) INITIAL TIME: 1 ,-1 61) INITIALS:11 TIME: g.g.30 INITIALS: all 1. NEUROLOGICAL: Alert and oriented to

time place and name. Responds appropriately. Communication is adequate to express needs.

Pupils equal and reactive to light.

ckt.,e.-) no-1,- . aZAS,z_- 0,1,frk

n f, ,5e€,-- .) Je----A, .5.3....44,4f

1. e Y<A?"-- 5 Aft, i-

4---- v_LA Cir-•-'-` " — L-" (4"'S5 -40•-t(

15,-Pf .,-G,Tt----4 4...c.z.,--- ...totb,-r....

I 6 A-2-e--n•-0 -OD e-ri d ("ru-Ts- -;

. - 1---0-eix71,0 C-0-YYLNYuyvt.71- AI) csz.,1*0-4-rr- ek--itin.* _,,',/v +.0 .12PiYk-VCX3,--IN

2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

LSA g . &I

3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

ri,1- Lt. hee-ii

6 _ t:::4e 14\ z_S

L.....V4 t I j_

4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

LI The-41-5 et-

P,,,15 Ltd i

Fl teit -erci-+)'il-5

CI-e_o-N--s

5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

V-LAja.L.);:?

brYtkizit.7.--- EV

6. MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed.

Normal active ROM without pain. No joint

swelling/tenderness, weakness or paresthesia.

[cr-Y\-e/NeZLZP,

ka--0--" Ui ng.- Yt-4(wt:4j fah

I FIAJLR_ 12(7)40

_Aa.0-ied tO CLA-Q,


No redness, blanching, irritation over bony prominences. Mucous membranes moist.

I I S - lip,4u.., -4e,

6COc ' cip ii,.-kii-,-.4

I I 4-93c,51,wt >Lid

5 I,-L. (-2 0 I. Ix :f:L (I . Irw-,5)--. i> ,-.4c"

1.‘-i. e./c/t 4yo., ,,,,,-.,y F.

1.12.9.2.0 a LA/Yk6-:

6 6 tA,11,2..cLC yt.3

4 8. PAIN: No complaints of pain/ discomfort. (See page 1 for documenting pain intensity.)

rq--- 1 I y --I I 1.-_-,-_-4- i,Ce4 ....„.....„ .....)-k.,e,

5-°'11(

9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

1.------- Di/

10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)

TIME: VI OV INITIALS: TIME: I `101-) INITIALS: TIME: (3D- 3o INITIALS:

IV patency ,,/ q hr: IV patency ,,/ q hr: IV patency ,/ q <9 hr:

IV site care provided: IV site care provided: IV site care provided:


LOCATION CONDITION

IV Site #1: -‘0_,e..„,_ _...fr.r..

OCATION CONDITION

IV Site #1: sr".-. 01---

LOCATION CONDITION

--1111. IV Site # c

1: ..\ r)‘(--- • 1 • )

IV Site #2: IV Site #2: IV Site #2: .

Comments: 1-\. j ) ele.747- , 14:

Comments: 05.-0 .5e- 2D t-:-0 )01)Vt..- Comments: cS-- N -C ao kc e, Do e3

MEDCOM FORM 689-R (TEST) IMCHOI MAR 99

Page 2 of 4 pages

MEDCOM - 19422

3

DOD-032996

ACLU-RDI 1651 p.182


-•. 2

>

SITE: TIME:

/

Cn < u_

>-

TIME: MD

COLOR ID band visible/legible

CAPILLARY REFILL Orient to environment prn

TEMPERATURE Side rails (2/4) up 1"-ift

EDEMA Bed position low

SENSATION Call light within reach

MOTION 4

PASSIVE FLEXION

= w

cc


PERIPHERAL PULSE Notify MD abnormal labs

END

Color: P-pink (normal); C-cyano ' ; W-pale, white

Capillary Refill: 1-(0-2 secs)• -(3-5 secs); 3-)> 5 secs)

Temperature: C-cool; arm; H-hot

Edema: 0-None; 1- • d; 2-moderate; 3-severe; 4-pitting

Sensation: A-a ent; N-numb; T-tingling; S-sensation (present)

Motion: U-u ble to move; M-move-no pain; P-move-pain; R-full ROM

Passive F xion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Perip al Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;


Incontinent urine/stool

Linen change prn 111111

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose

, ,


TYPE: ctit_c4....„ t P TYPE: TYPE: 0—

PERCENT CONSUMED: fol, PERCENT CONSUMED: crf.... -t-C, PERCENT CONSUMED:

HOW TOLERATED: Le, HOW TOLERATED: HOW TOLERATED:

la'S-ELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE vi SELF ❑ COMPLETE

A

. L

E. `A C .

0700-1500 1500-2300 0-0700

BATH/ORAL CARE ❑ SELF ❑ COMPLETE

10--IcS -g-ST ❑ TOTAL


jR1- ASSIST ❑ TOTAL


a ASSIST ❑ TOTAL


TIME ( 40D INITIALS:

EDREST ❑ SELF BEDREST ❑ SELF

AMBULATE ye ASSIST

BSC If TIMES/SHIFT

BRP

BEDREST ❑ SELF

AMBULATE ..Cg ASSIST

BSC 1/ TIMES/SHIFT

BRP

,..1-1A1101

ATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR (._ (_.„..----t_ ----

Illial TIME: 01D-3) INITIAL'S' TIME INITIALS:

CONTENT:

_ 5i,. - .pfl ,,,,,,

—6 i t ilf ") ,

CONTENT: 0 jsj

0,g-4 -̀-9 gio1/4„Cjws0eD

poi:N. cx-y.o.N-\0_ 52...,-N--,9__N—A-


CONTENT:


PATIE T IDENTIFICATION

IIPP (c.,\) - f

I

INITIALS SIGNATURE SHIFT

0 q- Z- 2_


Page 3 of 4 pages

MEDCOM - 19423

DOD-032997 ACLU-RDI 1651 p.183


W

0

N.

D

C.

R E

T

I M E


AND • .

DRESSING CWANGE i•

P ti._i ck..9- iZA f V.,..., Q avg..;\-\ ) 0. -Lr. . 05 f s t..1),*.

• .

SECTION IV - NOTES

/ 60D-:', ii,,,,. c( 1•1- 6% r c-, 45 54,5,-,-i- kg 4 li r 4 ,

&,,..„ 4..12,1,Acci x fat 0,6-v,--) Pi- cc, c,L.tr x 2.o :,\,...-Jc, 14, t) , (1, T1-, -.. -

e9g3- (Y.'S .:9-c) PE. /-..Q. 0. sue, ,. ser, , .ctr,s:;-,_.-z) , ro_SIS Q_. .77 %-:re—st„.9..

e____ • 1...„. . ► ...∎ kibab ' ,

• • 4— u. - e■ !&lb city\s. _t_11

,..., 5..i TV\ i x ( ; - 1 SL a x. C's :U 0 V\ SL OL. ..J..i\N-A- 0,.. C... VE, OR

A. .S.II eb • . ... t • CI 0 FeLx.,--(.. (_9. -5`Lsu cec,f... ,_,,,r,,,,g__ .\-i-) 0

i c1-QA- --ef ,Q .1;t-\x/v-r■ :.1):_51-0- 95 Ai % Nit Ir._tcol,r,gyi:_

11lNIIIIIIIIIIIIIIli&-' \A) Iv L.. RA/4-VA , pu rdi. I

— • • 14414. 4, 4 - ° i. do,sr,kt- i„,.tts..A-z_I-- )

0 A. -, as ‘ - ... A e. . • ' .: ..... • • ■ —• 11.. -.... . _.e/V... 9 #4..ik • A AIL ..._:.....2 b. "di • _ a,

lQ. R Q, -9-o A c..s? Q, --ko

:, )

:#

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 4 o14 pages

MEDCOM - 19424

DOD-032998 ACLU-RDI 1651 p.184



DATE: :,'1,1 ,3 A, it

PATIENT ACUITY LEVEL : ta_ POST-OP DAY: HOSPITAL DAY: (c7

T

1:1, 11; . N:

•s:

F .

E.

R.

7' ∎ '

le COMPLETE NLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time To From

- TELEPHONE REPORT:

I AMBULATORY I CRUTCHES II I WHEELCHAIR STRETCHER

Total ER/RR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P • T LOC Neo ovascular checks

------ Dressing/cast Tubes

Intake (IV, po) ----Output (EBL, other) Voided 111 No III

Medication .------------'

Yes Amount:

-------- Other

Reptrir(FT4; Received By

1— a -

cn.—

C7z

vi I

TIME: Irzzi /IA-NI /CC) ,904.) ,290b al) BP ARTERIAL LINE

,.il_

.

1w4 two.'

loitip,,,t) , 1%) .1.1006./66 :3 Ey6,0 8%6

wo,-)- BP CUFF

TEMPERATURE ?V9

PULSE ? S s-9 q(o 20

3 6' 1 g Z

8 3 7O

7-3.' 2O RESPIRATORY RATE 2_2_ o

OXYGEN (L/%)

PULSE OXIMETER 9k la KAP-A

It 9q 9q 02 METHOD ,k

dill Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask

MT = Mist tent PR = Partial rebreather A = Aerosol ' TC = Trach collar

O -

. H

Z

0

17-

TIME: li......3. /Al goo

p

C

N

TIME: 0 egb IV° Z30

PAIN

INTENSITY

10 • "

• • . . • • .

• • • •

• ' . . • Skin breakdown

prevention Mg At4 idil 'Falls prevention protocol tli/A• 5

o

A, .

" • '

• • . • • "

'Restraint protocol rIA

MED ADMINISTERED MN) • Seizure precautions

*Isolation precautions r, A MB

RELIEF ACCEPTABLE (Y/NI /\..t

TIME:

FINGER STICK GLUCOSE

D YESTERDAY'S WEIGHT:

INSULIN IY/NI TODAY'S WEIGHT:

WEIGHT CHANGE: R

Per hospital policy.

24 HOUR TOTALS



n f .) .

6(c5)— 2-I

DIAGNOSIS: V 19,1xu,--1—a 0 n .„ 0.1 G e c . ,6( .)12 ,44(0 .6 rit DRG: ADMISSION DATE: k 03 LOS: EXPECTED RELEASE:

CASE MANAGER:



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages mc %[.0o

MEDCOM - 19425

etc

DOD-032999

ACLU-RDI 1651 p.185


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. Ib (c,_ - --(-

TIME: INITIALS: TIME: 16,CD

INITIALS:.

LI pi_ 5J,-c,-kot ,---5.1, ‘ E t.,J L..e._ 4.---LL -,1,5 ,

TIME . ..37 1403 INITIALM

'‘A as A k_3 cb t-Y -- SQL-

(,

1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

Ll s„,---- ,„(ukts (:)...a. r. (C)_O ■--1-.. CL

0,t 11-,--,riz)

2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema.

Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

3. PULMONARY: Respirations within norman-i rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

I D'

4. G.I.: Abdomen soft and non-distended.H._ Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

I /3 k2-

tl --- 6

tf_-, iz. 1 (-&--.- LA c•- -

p • c.-_-. . , (--+ ;4m

• i ToC CL ij--

,...„, t17

".•-•7 et,

•

5. G.U.: Reports no dysuria, retention, —•-..L urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

6. MUSCULOSKELETAL: Normal muscle ----I-, development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

I

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

I r ,_., v......1 i , as d4.,.. ,:o N-5:- 0 13 (-4 pi L --; ...S iti i- t")</z0 L,....-/- .7. b,-

I I .--+-,t& 4-(9 5(--(e c rt. 57: 1 tj

I 114401s) 3uto (C' ,

-10(0 k_

8. PAIN: No complaints of pain/ discomfort. f.. (See page I for documenting pain intensity.)

I 0-0 C10 PakfiL)

9. PSYCHOSOCIAL: Behavior is appropriat to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

.

ZtA- *1.3k 16115 4hDYLO *

10. IV SITE ASSESSMENT: (LEGEND: P Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)

TIME: ./%a INITIALS:111 P"'

IV patency ✓ q hr: 1 J 1

i _

TIME: (6 017 INITIALS: IIIIIII 1/43,3-4. TIME: r_.) INITIALS: IV patency ✓ q1 hr: IV patency ✓ q hr:

IV site care provided: ( " 1-"'" Ic-c-C.. IV site care provided: IV site care provided:


LOCATION CONDITION

IV Site #1: tdA",-.1 .9

.., LO 0 CONDITION

IV Site at: 463 pf r.).(___ LOCATION CONDITION

w Site #1: OK-

IV Site #2: " IV Site #2: IV Site #2:

Comments: p cik i 1 -0 2 4 r'''''''' - /c tQCornments: 64,A,IS r 212)(c 0 feybe,-/V Comments: 0 Ill 5 —c, 20 Icc...te... 100 CC-th7

0 / EVZ% C-.....( C.".,..

MEDCOM FORM 689-R (TESTI (MCHO) MAR 99

Page 2 of 4 pages

MEDCOM - 19426

DOD-033000

ACLU-RDI 1651 p.186


N.

O V

A

,

':U` :[... . A R.

SITE S io:_-, td--:- til<ADTIME: 4-1-ta

S

TIME: IP Z fr

COLOR r3 ID band visible/legible

CAPILLARY REFILL ) A F E T y

Orient to environment prn

TEMPERATURE ki-, Side rails (2/4) up

EDEMA ) Bed position low

SENSATION -S Call light within reach

MOTION (13 i

PASSIVE FLEXION 0

O

T H

E R


PERIPHERAL PULSE 2 li Notify MD abnormal labs

LEGE s

Color: P-pink (normal); C-cyanotic; sale, white

Capillary Refill: 1-(0-2 secs); 2-1 secs); 3-(> 5 secs)

Temperature: C-cool; W-w. ; H-hot

Edema: 0-None; 1-mil. -moderate; 3-severe; 4-pitting

Sensation: A-abs-• ; N-numb; T-tingling; S-sensation (present)

Motion: U-un . c to move; M-move-no pain; P-move-pain; R-full ROM

Passive FI , ion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Perip - al Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose:

11.1 1--


TYPE: aLZ---e...-L-t (j am TYPE: —e-..... (AC-- - TYPE: i".I.-t- PERCENT CONSUMED: 2.S 4 & PERCENT CONSUMED: 2_1. Nee PERCENT CONSUMED: 5? 2.

HOW TOLERATED: Oy._ HOW TOLERATED: HOW TOLERATED:

.-II SELF ❑ ASSIST ❑ COMPLETE ..E1 SELF ❑ ASSIST ❑ COMPLETE SELF ❑ ASSIST ❑ COMPLETE

A.

1....

S.

I*

C H I

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE c11. SELF ❑ COMPLETE

gk• ASSIST 17:1 TOTAL

rtil SELF ❑ COMPLETE





BEDREST lEi• SELF

2,--!---- ❑ SELF

.41401111115P'' .:i.. ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

AMBULATE 41 ASSIST •

BSC 11 TIMES/SHIFT

BRP

CHAIR

TIME: INITIALS: TIME: it,9 00 INITIALS: 111111 TIME: INITIALS:

CONTENT:

r - 9-"r TO e'-S ./c- 'SI Is._

"13 • -rJ I—L:52c -

1-- 0) iz-'' 496'7/\i/'-iA St. A/ ("i‘•& ti & fir .----► gi


CONTENT:

-- 5% ep-N--4 -1--

- aa -4, Le (37 L-Ls-ei

/Cs; L L • --,f(-)G.c h),_

.

amily Verbalizes Understanding

CONTENT:

I

CI Patient/Family Verbalizes Understanding

PATIENT IDENTIFICATION INITIALS SIGNATURE SHIFT

C t O b ( - Gi - -z_

AI I WITN._ p


MEDCOM - 19427

DOD-033001

ACLU-RDI 1651 p.187


W

O

o

r:a •

<7.c

c w

I

T I

M E


AND

DRESSING CHANGE

o b 0,t-, z ,e-- A-1-6-,, c, r-' (\r-,-,n .3 ei c. Gr c

"0\_■ .`"6

L,

-

_s ,--i—.... f•-:.--i)

.

SECTION IV - NOTES

0 ■67)- ar-{-As--cl-- ..,(A_—_,-t tr\i't ..e..---1--t-o.{ )0 3 , ad"(--e- Cz-ww-i......----,:.k..-t. ,...,-,*.-- ),_.:__ C_9.7.--ixe...._._:Ce„.,_.4-, /-4...._r--- r;,_,,_ "" i' ii"" ,€-•---t--6 --

.1.-

--.r4or 'r t-,--/._ „ec..;-- - 6--.--cl , ff • • .(../...---6,

,,,A 0 cc .0----0/ Q,,,,.___-&.-7,-. /

.... . -AL i / ..-..a. v444 &_.,. / - • t ■ ( ' -Yd.- e;>C-- --e ."-.41 9-4 I p....-•.--C.,1---., 4 66, 4FD_,14.„,

4Y___L-2--/„I_

- ...

)-dgxeovi

(-10b

et.s. td---g. 1.•ii 193-D -,

/00, Z.

" ; ? .... ......4.. 45! illi (,,_')

01 Do.- / ,. . O All (

. -c, (ca. - -1-

MEDCOM FORM 689-R T) /MCHO) MAR 99 Page 4 of 4 pages

C(L)

i((t MEDCOM - 19428

2

DOD-033002

ACLU-RDI 1651 p.188

MLUICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5

SECTION I - PATIENT ASSESSMENT DATE:4(.1 r12 (- PATIENT ACUITY LEVEL :a/ POST-OP DAY: (p HOSPITAL DAY:

S .

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

1 To From El AMBULATORY U III I CRUTCHES WHEELCHAIR STRETCHER

Total ER/RR/PACU time Physician Anesthesia , (Specify): Procedure/Diagnosis . P - R T LOC eurovascular checks

Dressing/cast Tubes

Intake (IV, pa) Output IEBL, other) Voided 111 Yes Amount: Medication

Other

Report From Received By 2c. 4

i

,.

T IME: MCC.) 0y5 /6.0 2.03:1 0(0

BP ARTERIAL LINE — ,../- .1.'"'.

BP CUFF gy 6 /

1 /6

---

W45 1(76

6?

/'

...--

nd 494i9

5 Y 3 C.-2

g----' -N" 10 . 6

g, IF- ---

9415-Q cig.q 16 26

TEMPERATURE

A PULSE

RESPIRATORY RATE

OXYGEN 11_/%)

PULSE OXIMETER /6-13

M- 1

RA- q?')V ri co,

02 METHOD

•N.

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM =-: Ventu i mask MT = .Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

1

TIME: (..1630 12 e, /koc, tni 1 - $.

p

E

I

A L

N

E

D $

TIME:( WI) NZ)

PAIN

INTENSITY

10 •• . • . . • •

• • • . . • •

• • • • . . • •

• • . . • •

• • . . • •

• • . . "

• • . . • •

• • . . • •

• Skin breakdown prevention

"Falls prevention protocol •- - • -• ••• ---- - - - *Restraint protocol

* Seizure precautions

'Isolation precautions

Ag 414

. . . •

. .

•;,_

. . • " • • ' • • " . •

MED ADMINISTERED IY/N1

RELIEF ACCEPTABLE (YIN)

0. TIME: /OW

e9104

T • FINGER STICK GLUCOSE A) 4

1

_f____

E YESTERDAY'S WEIGHT:

H. INSULIN IY/N) TODAY'S WEIGHT:

• , ER•

WEIGHT CHANGE:

Per hospital policy. •

24 HOUR TOTALS

PO IV # IV #2 TOTAL IN Urine Stool TOTAL OUT

PATIENT IDENTIFI

ei v \ _,---- j \ b ( Lc.)

1P r-‘, DIAGNOSIS: Q.0 paild IQ0 plbt_q o p i. -(i, ofyi .k tnictify -Le4 84 :a( DRG: ADMISSION DATE: iw f3e. of 03 LOS: EXPECTED RELEASE:

CASE MANAGER:



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages mcvi.00

MEDCOM - 19429

DOD-033003

ACLU-RDI 1651 p.189


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. 6 ( u-S - -2.-

1. NEUROLOGICAL: Alert and oriented to -----'"F time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

TIME: INITIALS: TIME: 0 INITIAL

L"

TIME:Aq INITIALS

M

2. CARDIOVASCULAR: Pulse regular & rate -----+.41 within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

K- Is) r 146,

12 c--1 .-. r-t „r 0 6_4--,-.D. cs ,

F

3. PULMONARY: Respirations within norma rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

l

4. G.I.: Abdomen soft and non-distended.

with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

Bowel sounds active. Reports no N/V/pain

1v I---'


L. ----

6. MUSCULOSKELETAL: Normal muscle

development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

-r

fv■ ;1 ,, C_/ al-1 1--) ` -1

/us i s .r.:4 ,- c- ,F... it

a0 n lit-- ,-1 - 4. 0, 1-0, n" 4, c ,

I 1 Arn bl.ACtk

, Qt5 Si 34" j .1

Ur)51-c-ockt.-0-. -

6 a/110A ab.13

CCOLT/j



1 , 1 1 J .* ,,,0 L.,... x(2-p' ``3 ,.,...

-c2 4 _ -,- ,ri-Z---S_, 14 f'sf-f''' of o "-01,:_-.611 pfP;t.x.oceiv),o re-7.

1 I (.... 10_4._ ,r0 3-1- .. Gt., -12-e.-e -

5vll-re 3 0 114- _

tity!,0.CCur---, . ,• . vo ..-

.5ktraft940.. -TA

8. PAIN: No complaints of pain/ discomfort. (See page 1 for documenting pain intensity.)

rt . (--.0 lo /3 • r--. 17= r''.C-ipi., C. ), .-.7_,,,-.

Lci-

...----.

1-1/

9. PSYCHOSOCIAL: Behavior is appropriate -----F1 to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)

TIME: D f•- `-"-"---'"- INITIALS= TIME: /COO L INITIALS: JIM TIME: (--(-1(.2C) INITIALS:

IV patency ✓ q S/ hr: IV patency ✓ q hr: 11/...) _ IV patency ✓ q S. hr: 12)<A,

IV site care provided: IV site care provided: ri3 sitS, se c; (.— IV site care provided:


LOCATION CONDITION

IV Site #1:

LOCATION CONDITION

IV Site #1: Kt/ 0---

01C

LOCATION CONDITION

IV Site #1: A E., nK

IV Site #2: IV Site #2: IV Site 112:

Comments: /21 0 -- J9 ,S--"kr ..- Comments: 13 s Ar3 6 /0,„ Comments: 0 Se /a)e..c/A.A.-- A,,, 1.--- E--.F.L le c-e -e ( -c".° '-'1 /ivy


Page 2 of 4 pages

MEDCOM - 19430

DOD-033004

ACLU-RDI 1651 p.190

I SECTION III - PATIENT INTERVENTIONS & TEACHING JO

Cn

-1?

<

-rn

SITE: 01 1 ,9 a fi r- , r- i A-EiVir I M E : 9--ik r TIME: ,, li COLOR N ID band visible/legible

1

CAPILLARY REFILL i Orient to environment prn

Side rails (2/4) up ill TEMPERATURE ∎•J

EDEMA / Bed position low

SENSATION S Call light within reach

MOTION

PASSIVE FLEXION

0 I—

I u..1 CC


PERIPHERAL PULSE Cr' C‘A18.4k, 2 Notify MD abnormal labs

LEGEND

Color: P-pink (normal); C-cyanotic; W-pale, white

Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-(> 5 secs)

Temperature: C-cool; W-warm; H-hot

Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting

Sensation: A-absent; N-numb; T-tingling; S-sensation (present)

Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM

Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose

i

—


TYPE: C2,±,,=% L.̀ • TYPE: /-C—c-.... (-....."--1, ..._ TYPE:

PERCENT CONSUMED: 9 0 ">_,:„ PERCENT CONSUMED: 9.-1(:) %. PERCENT CONSUMED:

HOW TOLERATED: C___, t «- HOW TOLERATED: (r.y.-_-.L L.._ HOW TOLERATED:

DIQSELF ❑ ASSIST ❑ COMPLETE ❑ SELF -16 ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

.A D

L

0700-1500 1500-2300 2300-0700


'ASSIST ❑ TOTAL


XASSIST ❑ TOTAL


El ASSIST ❑ TOTAL


BEDREST ❑ SELF

AMBULATE - ASSIST

B ❑ SELF

AMBULATE ASSIST

// TIM /SHIFT BRP

CHAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC // TIMES/SHIFT

BRP

CHAIR

BSC 11 TIMES/SHIFT

BRP

CHAIR

E:.

I N G

TIME: INITIALS: TIME: (f)

INITIALS TIME: INITIALS:

CONTENT: I . •-i-b, (if.,E- Qe-, •.1 1- PP , r-)

ri ,z-,-0_s (-04`• °,-% c-,r-kr--' -̀ c

p S n, 4-1---Zi P ' ---:::4:-) • i

i ,...) p,4_0,-,G. ia e


CONTENT:

`T\f -el(iol_ -Pe'-) fejl/C/)


CONTENT:


PATIENT IDENTIFICATION INITI SIGNATURE SHIFT

SCJ (GL - 1.- -- (A SW1E,


Page 3 of 4 pages

MEDCOM - 19431

DOD-033005

ACLU-RDI 1651 p.191


w O

N

M E

LOCATION OF WOUND

PeAft d-ct VOccro i;Ln J rtcis KLOLCA

APPEARANCE

„fLe

eee, 119 ` 6,3 r/i cl

C / 5(-Au S ol-/1

otuilD3 l iptct-PhADL4V

TREATMENTS

AND DRESSING CHANGE

st, s Re. <-1, 17-4 ct

0

a

SECTION IV - NOTES

Cf

`-- 2.-c> 0--t-&- )C CL/ . 4 (1,,,_61,-2_ L.5— /t---•-kje. gi,,,,,,,,-, r ‘i... .r.: ,, ae:-:, ---21.-- 6.- • ,:l /^ -4 t ' ° ,62---d

z5,.. j._z.- _..a----0, 6—.0g—re. A-r',-4- t/.?,,L•—,4S

VS). (C() — 7- -N\ \


MEDCOM - 19432

DOD-033006

ACLU-RDI 1651 p.192



DATE pi. n , ...?_ , PATIENT ACUITY LEVEL : POST-OP DAY: 7 HOSPITAL DAY:

T

k;

S: F E R

,

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time To From

- TELEPHONE REPORT:

111 AMBULATORY I I II STRETCHER CRUTCHES WHEELCHAIR

Total ER/RR/PACU time • ) sician Anesthesia (Specify): Procedure/Diagnosis B/P P • R c T LOC

ovascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided U No es Amount: Medication

Other


,!;I:

.:

T A

'

L

S

N S

TIME: I CP I260 1k * 10 f, „,*)(5 oyet, BP ARTERIAL LINE .../ f"---

BP CUFF 61. 9,

G'n ,q .1()

90

-''g

MI

q9

tP •

CO

ell

'i r'

9vs

flalirlrinINi

' ''efe

', 6

69

fOr

to

cy,c-it

Cff 3

ió°

Inini

.. ■ TEMPERATURE

PULSE

q RESPIRATORY RATE

PULSE OXIMETER

G 02 METHOD

' ? 4

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

p A

N

TIME: rfi60 Oa? kt -za2()

S

p

E

I

E E D

TIME: ota) hos daY PAIN

INTENSITY

10 • •

• • . . `Skin breakdown

prevention

'Falls prevention protocol

Alk NA A-)4

. . . e Dt

. . • • • Restraint protocol

MED ADMINISTERED IY/N) Y L 4,/

'Seizure precautions

• Isolation precautions RELIEF ACCEPTABLE IY/N)

0

H .

TIME: CCI 1(000 - • - --- FINGER STICK GLUCOSE ILA AP

S

YESTERDAY'S WEIGHT: i\r/q—

• INSULIN (Y/NI

TODAY'S WEIGHT:

WEIGHT CHANGE:

Per hospital policy.

-

R

24 HOUR TOTALS MA



fililliW

' '

' DIAGN S . 16,6 I (119 ,. .,451 • -iipm aka i v ♦ DRG: ADMI

iION DATE: a 4ppi 03

LOS: EXPECTED RELEASE:

CASE MANAGER:



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages mcvi.00

MEDCOM - 19433

DOD-033007

ACLU-RDI 1651 p.193


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET, If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.

(->

- Z-- ^

( Co.. TIME: MO INITIALS: TIME: /6no INITIAL. TIME: \ ) INITIALS:L

r10 rpLaka PD

en


time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

I . I— CtO H A C/0 1-m-

2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

yr


/

4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

---------

5. G.U.: Reports, no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

F---

6. MUSCULOSKELETAL: Normal muscle development and mass for age. No

deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

V 111--

-



I 1--S-1-8(01Z lei a.--a.(2.p

r &ICU+

Li . 1-e-ti:A.-e s 4-0 RC1 LA- CrtA ) 7 sis ki\--c.c. ct. e,fr, ,

I I Nckfaslo +DO

kok_t, (56 +itit.o..6 1 ,4.0.1c_) cyr A

8. PAIN: No complaints of pain/ discomfort. page 1 for documenting pain intensity.) (See

CO ff k I I ii A 11/


V I 1/-

10. IV SITE ASSESSMENT: (LEGEND: P Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Centrane).- -

TIME: pele0 INITIALS:

IV patency I q hr: &-ra"

TIME: HOC ° INITIALS: TIME: aail_ INITIALS:

IV patency / q K hr: IV patency I q .z hr: pir jv IV site care provided: IV site care provided: ccasi„, IV site care provided:


i LOCATION CONDITION

iV Site #.'I': Ae 014- LOCATION CONDITION

IV Site #I: 4G 0 4_.. LOCATION CONDITION

IV Site #1: AC- oic IV Site #2: IV Site #2: IV Site #2:

Comments Ce/Wr W-jvc Comments: 9 ykikis ptoocAi Comments: 05(\i, p taL)cRx„,-- Lida 7- 3/6- cfideciP-.06141


Page 2 of 4 pages

MEDCOM - 19434

DOD-033008

ACLU-RDI 1651 p.194


,.,LI,

V

A .

.-- .L.1 .. ,. ., . L

A

SITE: TIME:

S

A F

T

TIME: 4 A.) COLOR ID band visible/legible r -

...

CAPILLARY REFILL Orient to environment pm t

TEMPERATURE i x IIIIWIW ir a Side rails (2/4) up I

EDEMA Bed position low

SENSATION . A Y Call light within reach

1

MOTION -

PASSIVE FLEXION

0

H E R

Review & post lab results I PERIPHERAL PULSE I

Notify MD abnormal labs

LEGEND

T

Color: P-pink (normal); C-cy otic; W-pale, white

Capillary Refill: 1-10-2 se ); 2-(3-5 secs); 3-1>5 secs)

Temperature: C-cool• r -warm; H-hot

Edema: 0-None; mild; 2-moderate; 3-severe; 4-pitting

Sensation: A- sent; N-numb; T-tingling; S-sensation (present)

Motion: U nable to move; M-move-no pain; P-move-pain; R-full ROM

Passiv- lexion: D-dorsal flexion p'ain; P-plantar flexion pain; 0-no pain

Pe • eral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn I I

Turn/reposition q2h i

ROM q2h if immobile

.... ji ■ Antiembolic hose

.

E . . T.-


TYPE: _OA— TYPE: (----kj2 .4),..1 GL.,-1

PERCENT CONSUME .

TYPE:

PERCENT CONSUMED. PERCENT CONSUMED:

HOW TOLERATED: (At HOW TOLERATED: HOW TOLERATED:

Lc.SELF 0 ASSIST ❑ COMPLETE ❑ CI SELF ASSIST ❑ COMPLETE ❑ SELF CI ASSIST ❑ COMPLETE

D

1-

36 .„ ...

H.

rsi ., G

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE


SELF ❑ COMPLETE

CI ASSIST ❑ TOTAL


PcASSIST ❑ TOTAL

BEDR ST CI SELF

AMBULAT ASSIST



BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

INITIALS:

.::2ZZ :, „„)KOELF

' ❑ ASSIST

# TIMES/SHIFT BRP

BSC

BRP # TIMES/SHIFT

C_HAIR \s:).Liz, L CHAIR

TIME: (VD INITIALS: TIME: I 1000 ------..

INITIALS: TIME:

CONTENT:

` c-COL'" z_

e ig‘ //4 ' •

Patien Family Verbalizes Understanding

CONTENT:

- an(-)10 C) Cacl)

dnkY) V--PLOC1-S


CONTENT:


'TIFICATION INITIALS b( 0 \y/.. SIGNATURE SHIFT

CO/ 11111p b( (), "A a

PATIE

A--Ai cg (-1 1 uorst■k-z


MEDCOM - 19435

DOD-033009 ACLU-RDI 1651 p.195


W

U

"

T

I M E

LOCATION OF WOUND APPEARANCE TREATMENTS '• 4'''''

AND .

DRESSING CHANGE -40*,

A3)(3 0 cf' 0 6 .16.0 D kut6 CIS 1 u_.) cii.y) • , d,„

.

R w it.. "

SECTION IV - NOTES

- „

'

MEDCOM FORM 689-R (TEST) (WHO) MAR 99 Page 4 of 4 pages

MEDCOM - 19436

DOD-033010 ACLU-RDI 1651 p.196

IVItUlUAL Hhuoi-iu - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5


DATE - ( n io of 0 .4?) PATIENT ACUITY LEVEL : -77r POST-OP DAY: , HOSPITAL DAY: .. ,....

'

-1.:-.

-:.

s

,F•

E R

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Time To From ❑ AMBULATORY . CRUTCHES 111 a STRETCHER WHEELCHAIR

Total ER/RR/PACU time Physician Anesthesia (Specify): . Procedure/Diagnosis B/P P R

( ■ T'

LOC Neurovascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided i Yes Amount: Medication

Other


:.5

Vi.

‘. T

,

L ;

S.;

• .

N . S

TIME: 640.) VLrilktiStte 6 1 /OD BP ARTERIAL LINE ,...-----

BP CUFF 1(.'r 1 47 C,. - 0 WC)/ TEMPERATURE 063

Col

l (0 ...----

B (

X))

SOU/cm-6; VP

I tp

Ob fact A4

PULSE

RESPIRATORY RATE

OXYGEN (L/%)

PULSE OXIMETER Ko

KA' CMZ

4---kA Gm; /66

02 METHOD

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

p

.

.

TIME: alic Ivo gto . .

p

E C

L

N E E D

TIME: (IS !,/. WQ-3

PAIN

INTENSITY

10

. . 'Skin breakdown

prevention .

• Falls prevention protocol •

• Restraint protocol

• Seizure precautions

fIsolation precautions

0 A /179 104)

o ' • o• • ->,

• •

• .

MED ADMINISTERED IY/NI 'Y 414 Pi .

RELIEF ACCEPTABLE IY/NI 4/4- A

-

TIME: CIS-- ,- ,... FINGER STICK GLUCOSE 4(.. I I r

ill - .dill .. ,

YESTERDAY'S WEIGHT: Ai IA-." TODAY'S WEIGHT:

INSULIN IY/N)

• WEIGHT CHANGE:

R • Per hospital policy.

24 HOUR TOTALS


PATIE T ID NTIFICATION

ht\

° DIAGNOSIS: (... min 1 L I .A. C. I PLO I A/ IL MII • el/C DRG: I

ADMISSI 6 DATE: i9Ap43)t- 03

./ Lk LOS: EXPECTED RELEASE:

CASE MANAGER:


ISOLATION REQUIREOSpecily):

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

Page 1 of 4 pages mcvtoo

MEDCOM - 19437

DOD-033011

ACLU-RDI 1651 p.197


DIRECTIONS: A check I in the small box indicates patient assessment criteria explanation of abnormal findings will be noted in the appropriate column.

have been MEQ. If all the stated criteria are not met, a brief

1-D( c_e_,,\:\ - --2_

TIME: INITIALS: TIME: /F INITIALSAIMPIME:e AD INITI :


Communication is adequate to express needs. Pupils equal and reactive to light.

time place and name. Responds appropriately. I I Er 40 ittit i...)

T I 2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

1 07


F(

4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no NN/pain

with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

fi/ 27...-


d 14

6. MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

r 4 t 1 / 1

r gi ) • 4 I 72,1,6-t, // - 7:: eel

ive,t A.... e_515-

0).romOLO 1 -0-NOLD-P°


No redness, blanching, irritation over bony prominences. Mucous membranes moist. ,

n ,,, ,L, ,,e5. w....„e ,c7i,,,,,,idi- 5

FO /"., / 5' ," I) A c' ,'• I f —

.1 ic, e .5 /5 - t' ',0 '' fer://, ,1

c:kaioto If .Z.ittitilli3 (- 9 131.-6-1)

KQ 6) D-C3 adaz i 8. PAIN: No complaints of pain/ discomfort. (See page I for documenting pain intensity.) /SA 0 ti A

27' EY


I-9(

•

. 10. IV SITE ASSESSMENT: (LEGEND: P Puffy I - Infiltrated IR - Reddened OK - No swelling/redness * - Central line! _

TIME: CY-14c INITIALS:

IV patency V q F) hr: 6:1,ccri

TIME: i ffri:12 INITIALS:111. TIME: A.:... X) INITIALS: 111111

IV patency V q hr: IV patency V q ( hr:

IV site care provided: NpQU ID ntaact. IV site care provided: IV site care provided:

IV tubing changed: ,::: (0_,Scp. IV tubing changed: IV tubing changed:

LOCATION CONDITION

IV Site #1: (pp-4_ CV--

°CATION CONDITION

IV Site #1: ( (5/F/4" i')

Aln.00ATION CONDITION

IV Site #1: .

IV Site #2: IV Site #2: IV Site 1/2:

Comments: Dc 13,s Q ( cocci vv. __,......

Comments: STA/ 5&170_C,9c_c -1--

Comments:IMAIC-)@... ia.)C111 41•1 0 f

, c.-- Vile t` or lin VI ilia on . MEDCOM FORM 689-R (TEST) (MCHO) MAR 99

Page 2 of 4 pages

MEDCOM - 19438

DOD-033012 ACLU-RDI 1651 p.198


Ir. cn

> <

0 c

rn z

SITE: TIME:

(../) <

LU

›-

TIME: =

COLOR

f

ID band visible/legible

CAPILLARY REFILL

It Orient to environment prn

TEMPERATURE Side rails (2/4) up MUM

EDEMA Bed position low r- MEI

SENSATION Call light within reach

MOTION

W1/41

Review & post lab results PASSIVE FLEXION

0 I—

w cc

GEND

PERIPHERAL PULSE Notify MD abnormal labs

Color: P-pink (normal); C-cyano ; W-pale, white

Capillary Refill: 1-10-2 secsl• -(3-5 secs); 3-( > 5 secs)

Tem erature: C-cool; W arm; H-hot

Edema: 0-None; 1- 'd; 2-moderate; 3-severe; 4-pitting

Sensation: A-ab t; N-numb; T-tingling; S-sensation (present)

Motion: U-u .le to move; M-move-no pain; P-move-pain; R-full ROM

Passive F • ion: D-dorsal flexion Pain; P-plantar flexion pain; 0-no pain

Perip ral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn

Turn/reposition q2h 6,..„,,i ROM q2h if immobile WM

■ Antiembolic hose N

•

I.LJ


TYPE: i:.. 4 koLuks. TYPE: TYPE:

PERCENT CO 4UMED: PERCENT CONSUMED: PERCENT CONSUMED:

HOW TOLERATED: .

HOW TOLERATED: HOW TOLERATED:

SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

•D•

0700-1500 1500-2300 2300-0700


ASSIST 0 TOTAL /K

❑ S,..UF ❑ COMPLETE

MN ASSIST CI TOTAL

❑ SELF 0 COMPLETE



BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC ES/SHIFT

BRP TI

0- CHAIR ( L-

BEDREST ❑ Scl.

MBLc7g. 111- EfUPASSIST

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC

BRP # TIMES/SHIFT

CHAIR

B BSC B

it TIMES/SHIFT

T E.. A C .

N . G

TIME: -45--- INITIAL n TIME: 6‘ "2_0 INITIALS: TIME: INITIALS:

CONTENT:

el- (. P tA-e. t

.

ON! Patien /Family Verbalizes Understanding

CONTENT:

il

6% vi Cr (--e-f-e

*Patit/Family Verbalizes Understanding

CONTENT:

...-- .

CI Patient/Family Verbalizes Understanding

P. IE\

i .

----

TIFICATION f (0

.. INITIALS (CR_ ...---i, SIGNATURE

41A) _ ,,v„a --- L.-% /1- /1"-- ,

?IOU1

*.... — -

SHIFT

Cfri-N --- ----

7

ki


MEDCOM - 19439

DOD-033013

ACLU-RDI 1651 p.199

SECTION III - INTERVENTIONS & TEACHING (Cant)

T

W' M I LOCATION OF WOUND APPEARANCE AND,

0. E DRESSING CI-IANGE

TREATMENTS

. N • 01K •-.-0-1) )5,-KT S(s of - -or

U - 5 -doe( _t . gtez. , ,r,-bc+,r\o, 5 —ciae/rL-,

.r...,..1-0c,t"

'. .13 ̀ j.- I • i ; o, 0-) Scar V I ilk.,.„, If --"- 4 ' if°' -a Qv, 0 ,--f , „..- f ri.‘ti

t .4/0 .5;/ , -,., P.t,,,_ ,,ei.,1 .

93DC_-) Qtek0. 6b Oc.0,0p •-j-ctpbs E.f ad-Let.on LitirtirJ- (r)-Fi

E LI '\) P-e.._

Opple .t" ci.-4 5 01,. e c ,'

R:

SECTION IV - NOTES

lt-r- L b q / I 0. •• 6 FA lb C <". • IL OA Al (0

tiZ/ 0 : }tfr170,4 ...1„-- ea /e4 , zV_6__f,_,2_jn_:L_4 0:;— 4/> 1,-x,.. s- i ft' ? /42451,-

J ,

7‘&41!.‘ 6"/- r,5-‘,/1 / C ___EL1-- A. /1 r f- i _.4,,,e .., tv,. // CO,JYYL,:e o_ 42..„.7, 0 fr5 A? Y, '4 VI

, .4.

MEDCOM FORM 689-R (TEST) (WHO) MAR 99 Page 4 of 4 pages

MEDCOM - 19440

Tif

DOD-033014 ACLU-RDI 1651 p.200

pqt 3 0 11 - search | · 2019. 12. 12. · nursing unit patient identification oi-pvi(r...

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