ATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400; the proponent agency is OTSG
l'll- aSTER NUMBER Fust, GRADE (b)(6) -4 ADMISSION REMARKS
AUE ErTNACE RELIGION LENGTH OF SVC ETS
ASH 13. ORGANIZATION mo-4 14. WARD /ay / S. RATING' 17 DEPT.! 18. BRANCH/CORPS 19, UIC/ZIP 20. TYPE CASE DSC, BEN
1,.1...Er:E 0- ADMISSIOEI:AUTHORITY FOR ADMISSION 22. 1110016MMIN 23. CLINIC SERVICE
-a—Ct.713 — CI' EMERGENCY ADDRESSEE 25. TYPE DISPOSIMON 26. DATE . DF DISPOSITION
EMERGENt , ADCRESSEE !Include ZIP Code) 27b. TELEPHONE NO. ADMITTING OFFICER
30. Y DATE OF INTIAL 32. UNITS OF WHOLE BLOOD , Iraq ADMISSION COMPONENT TRANSFUSED
N ArminrsraA .M.1 DATA.
Check it Continued on Reverse ee.ruR).
11,•;;;NOSES OPERATIONS AND SPECIAL PROCEDURES
1774
LODI
35. Total Days This Facility b OTHER DAYS CONY. LV/COOP SU PL M CARE DAYS CARE DAYS I ififiAL §lEg BAY§ 1 zJ 2- 3G. Toil Days All Facilites
•,, b 01-TER DAYS [c. CONY. LV/COUP SUPPLEMENTAL BED DAYS TOTAL SICK DA YS CARE DAYS CARE DAYS
,b613)-2 (MIT S :NATI IRe Cl rIn b)(6)-2 13-e M , X IA Fctre RALIvaYmEoN MEDCOM - 5148 USAPPC VI 10
ACLU-RDI 1260 p.1 DOD 12360
- -
..'ATIENT TREATMENT RECORD COVER SHEET For OSC of this form, see AR 40 - 400; the proponent agency is OTSG
• • •••\IFil.6 (b)(6)-4 GRADE ADMISSION
RsC 7. RELIGION • LENGTH OF SVC 9. ETS 1
4.4_021 b)(6)-4 13. ORGANIZATION 14. WARD tA 16. GRANCHICORPS 19. 1..11C/ZIP zip I; GEN 20. TYPE CASE
•
..• - 4DisusSi(N'31 Ii HORITY P OP ADMISSION 22. HOURS OF 23. CLINIC SERVICE ' ADMISSION
"- C17131 1 •:I" p\AERGVNCv ADDRESSEE 25. TYPE OiSPOSiTiON 26. DATE. OF DISPOSITION
' roc.li,de ZIP Codel 276. -49 TELEPHONE NO. 2B. DATE OF THIS AUNWIT;W: OFE!t":EP ADMISSION 4jUwo b)(3)-1 30. DATE OF INTIAL 32 UNITS OF I-/HOLE 31.000 Iraq ADMISSION COMPONENT
Che ,A C.011;01lligi 011 .r
.1Pi:HATiONS AND SPECIAL PROCEDURES
77 57 ,/
.35 foial Days This Facility
h DAY:, ; I OTHER DAYS TT CONV. LV:COOP A. SUPPLEMENTAL e. BED DAYS CARE DAYS CARE DAYS L./
,.6 Total Days All Facilites
);i-i[:i•i 616.;:s Ic:. CONV. LV/COOP CI. SUE LISMTAL e. CARE DAYS BED DAYS
b)(6)-2 SI 0(6)-2 b)(6)-2 X )A-F0dti PY31.YRUEON1 MEDCOM - 5149
ACLU-RDI 1260 p.2 DOD 12361 AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD PROGRESS NOTES
DATE NOTES
°Li vv‘-t"'°-1-:' r..k }gin- Mi. .1, 2 • -, a u9 e„ xy _ Ily\io 4
t'-k i ■TA di ■ 1 \A\S)9 h. al ..11-72 i -1-1179 i OJrj ctvr 44_,74kkt, kl\ssli A G7oT-Rrf-T-19 rir-A-eigtv. 19,4- ---' evotx. LJ- 13 ups- m-c vo L cf_.-e- frittovs . Ci td\f 9s c ri ea r 7- /1\IP
C (. ..hic ' 1 l .1 ANA \ )--- Z7- C k i c'e_r_ cirv‘i 6 RS A45.k, 9,A , uk,..4 7 (-: • / ( c-Xert)-4 -stfir' P e 0)1 ‘r-4- _r-,-,1 'Fb6--,— /1,-9 Cel l% g'' ,r le _c--cfz.e.97\4/s• e 601-EPE-4 11 d 1---.1 t ON.JF? .c.1 5 -19. 4 < HCriz- ' , wa\ivue e_o 'c3.plro c_ i i , P t- r t[e(;) “ ,-(1, tru6‘Akio 1 3 ,v). __gNi (. 44 . 1 IC a , k C7.- iii., - E t: A ■t, iaut ■24- IN 61,-*1\19 L i . . Pr • b)(6)-2 ;2 0 a_ rti c A --; I V ( %./NI 0 . ire LE-.9 . 1-1.4k L. 9p)64) .0.4 r( oi 5 QUI igs I CT V.A1 I )7,NctAi -444-k.-0-1- (1-ictorn 1,14-Ak , .. 0 ,,,-,/c)41 On.riA Okm, cii-Pil - L -L p>c f n1 a -ceg fa-, -Ph q- cl ) U:SinM--C, , LN 1, OF a Lq , tot 1-- re I F1S L (IN J--K Pi zit.c:&4 1---kt\-\S 13 CFAt cliqh4cie peNs0 C ')-X Q-)P-M4-4 , 1 4- ").0 Q 4.)8/ b)(6)-2 clf-fAr ito°,trif-(pr , Ar.wspo.)_.6,18%. 2 ernfQ Jp,* -cl l_f; m f5c/.3 0 \ \I 0-- p in- -ti\,- 40.., .A4t. cse- m.-( Aill ? \ try) (b)(6)-2 i ' -11)- t 1 I t aikviswi4A - , — 01,-/- hif\) -6a141.01;1AketAlt tt:,/,' t 01 a-61 , ' ' • ii - 05-tt.,LQ-- --- i
(b)(6)-2
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER LAST FIRST MI (S3141 or Otherl
• , • DEPART/SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entries, pare: Name - lest, first ...middle; REGISTER NO. WARD NO. • . . , ID No or $SN: Sex: Date of Birth; Rank/Oracle) ' rb)(6)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99) Prescribed by GSAIICMR FPMR (41 CFR) 101.11203(b)(1 0)
MEDCOM - 5150
ACLU-RDI 1260 p.3 DOD 12362
DATE NOTES Ow IL, /i3 ‘S T 11 ° I 2- =1 -r., .
A. Iii• I A • ii. .26. .1 ....- •► .: elb
% , 4L a_. I _ ) ■ • A. / ■ 01 2 lb. albs! k■ • e A ' .041, _.: _... Abe 5P 1 1 AA 6 $ 4 11P ih. a ■AP ma% 1 , Je -, - sr". . I. Ivo _ b rr .... r 1 r a Ail i •• t_ 61 . 1 . J L 0 .t 7 As2 a A /10 Pit . • ■ . . 1 I `j.A-t-LALLP - ' I % ili.i. ! - NIA -_._•_,. , "4-541' 1 b)(6)-2 RAM 6.11(0.). 0 1.11 1-.3--Z\--0 it Q.- .4 ' , V %% AllC).5 5471 r40 Ar -; '6/ 4'
.140,.... i 0 0,- Ar , .0 "if-h-, Oa ...le ..t..4 ....,... /CL A 2 /_ . /I
#"? A . blegg 14 0 I4, fiber •A; 14--i 4 - exF0 1X`4 NkS8 A .1•..t/- .1- - C.O7 /3 07.4- A/Pe.< 14-, gi, sc. i fi .3.0A . A'S .9e.4c._ Xi{ 1.1,--,4- .4,.. AI ...."7 02;4- A--- 4,14te,:._4, i9414-les c' c,-/-e..4..s • ,„1,,, c 7t3 ,c,.// .,;., ek/ 3(z./ )(6)-2
6,9 r 1, A . 11 < 3 Sr_s_ s / ? 3 00 5/hAyo ? S> BP 1°6/6,q P 41' 12 )6 T7-- 7 >2 . 9, apst---e_460,-,,i2AAL 0_6-1A,1_ a-4, 0 s T ht A CAA fitb-- (95 ' i • i catqL4-21 01-10,,k_ L/friiiiri4) ; IIP / 2 J1k , 0 - o 1 -i . En , „...., i 1 i)j 1"/'"D" D Vi2-)S n \--ti g4 tA''k CAO t L 60,7 b c1,41- e-i (--h T_--.)Q-5--e- V ,9_,WA,b•_,) Wil01-- t 11--vvjA,4, -4-IAA) — b-,--.kzit.to bt--(1-1 4Lik
LC-to-Q-7:k -c----- bx6).2
i .vim i;).. 1P iGq A/tA,- j- )(6)-2 o
Z7 AfAy q V 5 BP likI41-LP 94 g--16' 7t37(a)(5P 9? ?Zz-
J lip 11 *a/. • _ . . l 1211r..e _ ! 0 b)(61.2 I A OA As
_ _ q 0- f - AL _ .all. L _I_ IIP
FPI LEX y Printed on Recycled Paper STANDARD FORM 509 (REV. 5-49) BACK
MEDCOM - 5151
ACLU-RDI 1260 p.4 DOD 12363
MEDICAL RECORD PROGRESS NOTES DATE PRE OPERATIVE EVALUATION General Diagnosis: i±cicAl_ij ck.-nrik r., 4jz Proc. Planned: .TAFgo evac, ott, Anesth:
Anesthesiologist: Surgeon:
Anesth. Risk Classification: .. . Vital Sians:
Physical Exam Highlights:
Procedure & risks discussed with patient: YES NO
Prognosis: `74
Signature POST OPERATIVYKNOTE Pre-Operative Dx: 4 Tz A 4,...1,4-t, Oruloiroc.1, ,‘,, , dy241Aige 111, rA"...GI 1 V 1 1 Post-Operative Dx: EA pi._ IIVJ I1G I . P Iu., l,JW G. _ • . p a .. . f A I I ' (b)(6)-2 ' 0 ' – —irgeOn : b)(6)-2 de,,,A,,...... — ill s;___g) ___ t_akP' S 1.1 i i . Findings: a 0 1.- 4.19 CI A A t.t .1 t944.j 1.
2.
3.
4.
5.
6.
EBL: I/O: Tissue sent to lab:
Prognosis: r ,7 Plan: pet,/ e`e. higte '70 l 4C-,...4 1 li A'67 )c- t-10 et,' c7L 4; i (b)(6)-2 VY t rt/ CD DJ t VCS. . (b)(6)-2 Signature (Continue on reverse side
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last, first, middle; I WARD NO. grade; rank; rate; hospital or me Ica lam try) VI PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5 - .99) Prescribed by GSA/ICMR FP14R (43. CFR)I0 I -11 203(8)(10)
M EDCOM - 5152
ACLU-RDI 1260 p.5 DOD 12364 DATE NOTES ' ' i —1
/ _ /.A ea , ? 1 /Ai ' , IIIIP' A • < a
1/1 c/ (b)(6)-2
1//103 '37°1 i..p.i4A, e-iit.,:,g ,C4,kwIF 11 30 #2- /./Lexpo-w-e-do . Pe 5S #-,3 aue44424
Pad tt-12,4 fri-b evytiA ivirmci.:, . e,` ,ti - 711ce,I Xe.fAt 0 ni ' A--kt:t-e-e° 0- // 0137 fr&i: 1tot-t-2 -' /--1 -44-4,2-"w)- 644-4 a/ze i-i-s-tc-les„. ..Ji,f,L. / rr 74 1. ho, /1.0-4frf.zild>-.)-iee-?. 7`•A/___
' 5- ri i r. °. - 4,.-a-e4,0--p-e41- -;1 z-1,,i-i-r/1,41,-..*47 (4,-.--/( /Ocif.
4/2 . 44/2;n e6C(f 6-012-61---t ta-iev4 lytd" -21/2, 4 A/4 4-4A-e -,:/0-7-7,e1, a,e/r4,(4,i4A Yivtl, )/64,_
4tzevt L1 i4 - x- --v.41.t.-rAf ai-4-e-1-1) --i:2. ,4,---, /l i) Cerz--eAt-e," a--ii-oLd.ti4 . 2.17". ,e44.4 oite444-v-e?
(b)(6)-2
° 3 V Lam..., LI. :- - ' Ael...■/:■-+, ' / / 61 2-5 4il-v2.1-e___ 27 ..4...4-6,.....,.....- if .77/ 2 . 6 -z, A-4-4-- `2" di 7- 1 C 2 . 62.2A-.4-e. , ;. xliz&IA, '7-diz-L.,-
(b)(6)-2
. MD PAPT Rfir IICNR FPI LEX 0 Printed on Recycled Paper STANDAIrb)(6)-2 ":""ancng it REV. 5-991 BACK MEDCOM - 5153
ACLU-RDI 1260 p.6 DOD 12365 AUTHORIZED -FOR.IXICAL REPRODUCTION MEDICAL RECORD PROGRESS NOTES
DATE NOTES
.._ 71o3 _ r' ‘ 5o j kei4 -, 4 4-ee -&e...,,,,,,,,,\ --trio . 74 :i . . o 2_ /064_.4.-- 92 ^} f 2- Pc, eli._ .4„...o-cp-p.L ,C1,Z,_ 6Z-Z.4.4.4-1.6,2.-241 -Ce Xa -LA- a-L., Ut. 1 Cell C -1-W. jrZIA-rirl'it , 794:7t- /s..0.-Le a-74,/ 6LA.....e ..12(.6xr- LA A.A.-fr.-IA—a e-?c-c-P.--/--
,P1 • tj•Lej 1/ a KA— • )14-‘-"(/14- a//4-e..644'--19
l--ttf- .eA4.1tirtslA: (4/14/1-71"42 /1.47•24^----* -.. efecrzvozx , , . ...„..„„...„:„„„ 74 t,e_240. i-E.___A0 kJ d_ ...a.-etw 07(4
l U cp 6.04-c_ -1 // orv-z) 64-106
0 f 3 o CXR — deal -0.4.." keLe .0- • 774-G.,--1- ae....--a_c_.---e_ ..e..".. _ ..e.,,,_.6& c"._ z4...,,,,.._.g,„ , c_f 4..e...e_
&zit, a._ 1_,„_,A2 orb 6.1..t....4- ( 4 .-,9,,,,-, . , ... !t-- 'Tr 4e...",--2..e_ti..e.,-/--- 6 1 e2.-g- S 0)(6)-2
No
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER I ISSN Other/ LAST FIRST ri, or DEPART./SERVICE HOSPITAL OR MEDICAL: PA ...ILITY RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: IFor typed or written entries, give: Nome - lest, firer. 'toddle, REGISTER NO. WARD NO.. ID No or SSN; Sex; Dote of Birth; Ronk/Grade!
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5.99) Prescribed by GSAIICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 5154
ACLU-RDI 1260 p.7 DOD 12366
NURSING NOTES CLINICAL RECORD (Sign all notes) • HOUR OBSERVATIONS DATE A.M. P m Include meditation and treatment when indicofad
1 1 105 / MK N- amked L rel. littlia b,. Sek' 70, aktua evt-401, 014 .atiottitiftit, act/laid— IOD * e 4,,,. v_ tAtty 4 Piti MALY, A04-4b .p044{, eye, .,,,Ak 4Iv lid .1- Ata-Cae,ii . t C P4 4,614,4 IV st_51. ut Jo aote-04.0i,Xes14 ../fig ceiciA44:0.1. t 04 P i 0 wti4,0 4344 4 -t.:11 ,p,;13, i • 1 dibii i , , 0-1 -i4Loptill -0,i.t",. Pi--1,,le v La,,,b.t,e 41,,r- w . NI ,mi 6 44.. -t 1.■) _ 0444,c,-6b b)(6)-2
0 36'1% ( C. )(3)-2
()-'(.(() '- (6 (4) 4 (•- 7 (9/aercc C' (J
:b)(6)-2 3))(6)-2
Continue on reverie ride
PATIENTS IDENTIFICATION (For typed or written entries give: Name—la„ /in–, REGISTER NO WARD NO. middle; grade; date; hospital or medical facility)
:b)(6)-4 NURSING NOM Standard Form 510 General Services Administration and Interagency Committee on Medical Records FPMR 101-11.806-8—October1975-_ 510-109
MEDCOM - 5155
ACLU-RDI 1260 p.8 DOD 12367
NURSING NOTES CLINICAL RECORD I (Sign all notes) HOUR OBSERVATIONS DATE A.M. P.M. Include medicationoce____ and treatment when findicated 6‘1 0,7 1 t°71 Ar‘ ezrAJ
a I I ' Ma • 0 4 4. al lt , ■ l
b)(6).2 1 n91/ L2— 0)(6)-2 6)-2 -(z 0 rke..71 64)0A,/, s twaei-W 33)(6)-2
AZI5:0 0 I 33)(6)-2 C614 CSI l c eej t
Continue on reverse tide PATIENT 5 (For typed or written entries give: Name—le ts, firs:, REGISTER NO. WARD NO. middle; grade; date; hospital or medical facility)
(b)(6)-4 NURSING NOTES Standard Form 510 General Services Administration and Interagency Committee on Medical Records FPMR 101-11.806-8—October 1975 510-109
MEDCOM - 5156
ACLU-RDI 1260 p.9 DOD 12368
MEDICAL RECORD PROGRESS NOTES DATE PRE OPERATIVE EVALUATION General Diagnosis: Proc. Planned: Anesth:
Anesthesiologist: Surgeon:
Anesth. Risk Classification: .. . Vital Signs:
Physical Exam Highlights:
Procedure & risks discussed with patient: YES NO
prognosis:
Signature POST OPERATIVE NOTE Pre-Operative Dx: 1 e. b.„•,.... A. 4/14 0274 ,p .) a Post-Operative Dx: 5 A 4- 00 /- i-, Anesthesia: Procedure: R ,k' /X il-e-twt - :0( 6)-2 g Surgeon: / (b)(6)-2 tr. 7;4 ie, ,,. Findings: - (14 ‘.._....i.--(CI- . Ar . 3. 4. 5. 6.
EBL: 110: Tissue sent to lab:
Prognosis:
i c, (--- Plan: j'4 0 (.(--di9 , t-t (b)(6)-2
Signature 1
(Continue on reverse side)
PATIENT'S IDENTIFICATION(For typed or written entries give: Name-lost. lirsi. middle: I REGISTER NO. WARD NO. arade: rank: rale: hospital or medical leicilitv) PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5-.99) Prescribedby GSA/IC M R FPWIR (41 CFR) 1 0 1- I 1.203(3)(10)
MEDCOM - 5157
ACLU-RDI 1260 p.10 DOD 12369 b) (3)- 1 l'A I ,1 0 I I) Patient Profile b)(6)-4
Activity Allergies Vital Signs
(..‘ 1 1 MI) lor:
Il 13< /_____>
R R <____ > Dressin 7 Chan les
S1)02 _ _
Temp >
LIOP <
Fl u id —
Mode
Rale
I YI gni INIs Daily Labs/Xrays/Procedures
ONE TIME ORDERS
MEDCOM - 5158
ACLU-RDI 1260 p.11 DOD 12370
TE WARD - 24 HOUR FI., 1800 1900 20:00 21 00 23 00 0:00 1:00 3:00. 4:00 500 6:00
■.■ i N V% ZZ Is ZOO
100
100
170
160
150
V 140 • 160
120
110
100
60 L . ea
63
so
53
40 ao
10 (CD. I Temp
ifIXD(\ re
glabellar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus glabellar tap or loud auditory stimulus
MEDCOM 5159 FLTHOSPPNCLA 5320/1 (1/03)
ACLU-RDI 1260 p.12 DOD 12371
(b)(6)-4
(b)(3)-1
Addressograph: 7:00 Imo 900 1000 11:00 12:00 1300 1400 15:00 16:00 (b)(6)-4 Sp02 Respirations
Date: L-1 / f Allergies
Diagnosis Age: DOB:
4 §IGNATURE 00 b)(6)-2 b)(6)-2 6 Or (b)(6)-2 (b)(6)-2 No 60
so
.
30
20 Temp `'l c' .- • • NI,„5 f()On boa( Pct Cki C.0-1
PO NG/TF
FQ- 2 Other Cummulative Intake Urine Volume Emesis NG Residual/sump o. Bowel Movement I- = 0 OTHER Cummulative Output
RAMSEY SEDATION SCALE: 2 - Cooperative. oriented and tranquil 4 - Brisk response I
1 - Pt. Anxious and irritated or restless 3 - Responds to commands only 5 - Sluggish response `Medicated Dose / Route Intensity (1-10) Pre/ Post Med Sedation Scale BATH PARTIAL/COMPLETE 2 ACTIVITY(Tum L, R. B. ch. amb) 3 IV Site CD? 02 hrs 01 IV Site CM? 02 hrs TCBD 2 Wound care
Lar=rir MEDCOM 5160
ACLU-RDI 1260 p.13 DOD 12372
00:020M4K, I Vifilla.41,, ,,;, ("M<-.fir' X/ i -r q 5 „----- Level of Consciousness 14 e .= r-N, s, , Oriented to: Person 4 Place 4 Time K p IC=P:f e-- I—Ca---- Responds to: Verball Pain Unresponsive b)(6) -2 Pupils R L Size / I 3 I 4 1I- III .61 1 Motor Strength S = Strong Upper L R Extremities: W = Weak ,5- J ) c, TR = Trace t -: A = Absent Lower See Narrative - Pulses R L Radial frA q Posterior Tibial mum Femoral Mil Dorsalis Pedis IIMI 71--- + = Normal - = Weak 0 = Absent Rhythm: Ectopy: Murmur: Rub: Si: S2: Neck Veins: Edema: See Narrative Breath Sounds: LAClear Bilat Location: Crackles /Rales: Dim: Wheezes: Absent: Rhonchi: MICough: Productive/ Unproductive: ;W: Sputum: Color and Character: Tubes: MI ET L, j Trach Size' Location: 02: Q Canula U Mask Chest Tubes: See Narrative Observation: Auscultation: it Palpation: 4/'..1- e0141 162 Stool: ❑ Incontinent Formed Soft ❑ Frequent E Liquid • Hard km-
Tubes / Bags / Suction / Drainage:
See Narrative • NGT Placement Void Urine: Color/C erecter 1 ?Sow Catheter: JJ 1 ff.; Other: See Narrative Color / Turgur I Temperature I Mois pre (I ..., Incisions I Dressings I Leirons I Dermal U ers 4 ii i kg isk, 1„o t ..‘ . . .,, i ,...., v. a M.... ,e MEDCOM - 5161 I
ACLU-RDI 1260 p.14 DOD 12373 t1C1 910 IT, "-4- t 166tai - Dt ---r i--k, •S F..x -i-- 0(E.7..,.. (\NJ ;:_- (_ --r- t-e t_q..o'S Level of Consciousness v E,13,ca_ a1/4.5E..5 "1- "I C. -Nr-'1 ,("" rt- ..,c 5.1--:11- (-- .F..1:21PrIn ■4:1 Time Oriented to Person Place ---rrs• r. 07 1-0 "(::::-E_Tr", Responds to: Verbal Pain Unresponsive
-2L. • Pupils R 9 ....z.e...1...- L pv.-,%- Z b)(6)-2 Size / Reaction: I ,2_. 14 Hz iir-7 cyi-• 0 c. enr.....2LLI,Tnr. arm_ iii b)(6)-2 Motor Strength S = Strong Upper R A■ .:11-111Vi feNr ' 1 remities: W= Weak 5 I 3 Jr TR = Trace A = Absent Lower a See Narrative Pulses R L R
Radial .--i- -r Posterior Tibial
,„.4. Femoral Dorsalls Pedis 4- 4-
+=Normal - =Weak 0 =Absent 7, ,>,, Rhythm: Ectopy: a Murmur. Rub: S1: S2: at Neck Veins: - i -A--r- Edema: ri See Narrative Breath Sounds: ISj Clear 12KI Bilat Location: Cracides /Rales: Dim: Wheezes: Absent: Rhonchi: Cough: Productive /Unproductive: Sputum: Color and Character: I4- '44 Tubes: NM ET 0 Trach Size: Location: 02: Canula Li Mask Chest Tubes: See Narrative Observation: F c_ f i -"T Auscultation: _4- 14 (-0 Palpation: J r DI ro-V--cme.:1- Stool: Incontinent Formed ❑ Soft 1 Frequent ❑ Liquid ❑ Hard t.. Diet: Tubes / Bags / Suction / Drainage: 14,
See Narrative I 1 NGT Placement LiVoid Urine: Color / Character
Catheter: Other: See Narrative Color I Turgur / Temperature I Moisture .t4.5.,q. -z 1 ;;)-1 Pior_ -DZ.>, L ...., Incisions / Dressings I Leisions / Dermal Ulcers Em( F 1 >4.F-5 ON 13O1n-1 L66)A-- I See Narrative MEDCOM - 5162
ACLU-RDI 1260 p.15 DOD 12374 b)(3)-1
Addressograph: 700 900 10:00 11:00 12:00 13:00 14:00 1500 1600 (b)(6)-4 Sp02 crl Respirations I to 20C
lea Date: Li /Psi 03 17 Allergies ' 60
$0 Diagnosis 40 Age: DOB: 120
110
7-) yGNATURE 100
1 60 (b)(6)-2 (b)(6)-2
b)(6)-2 (b)(6)-2 60
so
40
30
20 Tern p 9c1:3 sr ,„5 lour) /000 2,u pactel cA,11
PO NG/TF
Other Cummulative Intake Urine Volume Emesis NG Residual/sump
n. Bowel Movement
0 OTHER Cummulative Output RAMSEY SEDATION SCALE: 2 - Cooperative, oriented and tranquil 4 - ensk response k 1 - Pt. Anxious and Irritated or restless 3 - Responds to commands only 5 - Sluggish response Medicated
Dose / Route 41:1 n. Intensity (1-10) Pre / Post Med 1;14 4A Sedation Scale BATH PARTIAUCOMPLETE ACTIVITY(Tum L. R. B. ch. arn13) IV Site CDI? 02 hrs co IV Site CDI? 02 hrs a TCBD Wound care
9 -, 1 1 •._ ==
MEDCOM - 5163
ACLU-RDI 1260 p.16 DOD 12375 011 - 0 igliite. - S:40? . /70 - 0.r.),-1,4-4 1- 1;-..... „ill ii,:-.r.L PI-- Level of Consciousness reG/P,6 1-$1;04, 4-1-`,4- 4.z.,,,, , Ati, ,52, ,_t p,...„4_. Orientedto: Person It.- Place Time X th,kr. 91- - - ,,-, v-r-a-el • 177x—s-g...:,-- A 0, 5 14(6)-2 Responds to: Verbaikg_ Pain Unresponsive ,s104.r.e...ttz J J r'? Pupils R L 1-- ) 7/0 ' Aia•-,- SC, P: 7/‹. e,. /-..-e-/.74, (Z) Size / I 7) 14 6 I 5 /I a I FA. 8/„,d. ,..,,„..,_,..-44 si-k A " 4-4-..„..C) ea- Motor Strength S = Strong Upper L R 40 Ct-. P -4. . A- 4-e, 4-- "...d_ 4.1,./.6„ 1.4e .04 „:.,„;. ),I.,, 3 "D (6)-2 '' Extremities: W = Weak • c.....• i// C.....-,,I:n ...,f____ 4.0, ni , I-1.-r - g TR = Trace L 7-- A = Absent Lower erg.. . - See Narrative Pulses R L R
Radial -4- + Posterior Tibial 4- 4_ Femoral 4- Dorsalis Pedis A- + = Normal - = Weak 0 = Absent Rhythm: /vs (z._ Ectopy: V ,_.° Murmur: Rub: S1: ,..-' S2: .-- t .. , Neck Veins:_p_jrd--, LLLa j Edema: See Narrative Breath Sounds: Ligl-Clear [J Bilat Location: Crackles /Rales: Dim: .•-;, Wheezes: Absent 1:21 Rhonchi: a Cough: Productive / 2nproductive: ':Spu:A.,: Sputum:tum: Color and Character: .7 ET U Trach Size: Location: 02: E Canula Mask Chest Tubes: See Narrative Observation: • a.. A / \-\ 421 - Auscultation: GA, a H •-1 ''.re r---.L.
Palpation: i). ,.....‘ ].% O. P•iP,-.11.2, nom kiJ.4" Stool: ❑ Incontinent Li Formed Li Soft
❑ Frequent ❑ Liquid Hard
Tubes I Bags I Suction I Drainage:
See Narrative I I NGT Placement LiVoid Urine: Color / Character
. F n i,. _( ,/ c r.kri 4-1 Cie, , no 4, ,.. Catheter: / cp_ ( 7) Other: See Narrative Color! Turgur I Temperature / Moisture
/° 6n k./ 1,..,-.....- ...../. rp, of a di- " Incisions / Dressings I Leisions / Dermal Ulcers 4 ' wt.., e,, 4-,t- 1,;k7t- L E . cire„ 1a7. I See Narrative
MEDCOM - 5164
ACLU-RDI 1260 p.17 DOD 12376
j))(6) -4
90 lAvoi r ^el P A— I r r\ I k '+-7'174 Level of Consciousness v z-NE„.zpv c... c_ug s- -Time (------Oriented to: Person (1,PlaceC.--- 6 • rAFAS MI S IiPRY b)(6)-2 Responds to Verbal Pain Unresponsive IMIEFORZL-04==frAMMINFAM7/5611ffffail9 Pupils R ? eeft.i..- L V Size / Reaction: El ffil 2 / Motor Strength = Strong Upper W = Weak Extremities: S ill TR = Trace A = Absent Lower Ell n See Narrative Pulses R L R
Radial =CM Posterior Tibial Femoral INIEM Dorsalls Perils + = Normal - = Weak 0 =Aso ent Rhythm: M?ri . Ectopy: Murmur: 6 Rub: Si: Neck Veins: --x_ch-r Edema: n See Narrative Breath Sounds: Lx-i Clear U Bilat Location: Craddes Males: Dim: Wheezes: Absent: Rhonchi: Cough: Productive (Unproductive: Sputum: Color and Character: Tubes: PET Li Trach Size: Location: 02: nCanula {Mask Chest Tubes: Ti See Narrative Observation: R f)-r Auscultation: 4_ f_.1 Palpation: i\)/) r,. Ornt'rle Stool: ❑ Incontinent Formed 11 Soft
❑ equent ❑ Liquid ❑ Hard Diet: Tubes / Bags / Su g•n I Drainage:
Li See Narrative ❑ NGT Placement Void Urine: Color / Character
Catheter. Other l'iSee Narrative Color! Turgur / Temperature / Moisture ) 4)t...,rr) Incisions / Dressings / Leisions / Dermal Ulcers Nr L . 5r-rihl
7" I See Narrative MEDCOM - 5165
ACLU-RDI 1260 p.18 DOD 12377 1TE WARD - 24 HOUR F T 18:00 1000 20:00 21:00 7 23:012 000 1:CO 600) 3:00-(- 7) 400 5:00 6:00
22- 200
100
160
170
160
IGO
140
120
120
110
100
SO
AL . ao
70
60
50
ao
30
20 Temp 12: 6 4-#14_1
IDDO)rc
tali° h. gl,heall.. fn' sr l•-le I glabellar lap or loud auditory stimulus 6 - No r stimulus iht glabellar tap or loud auditory stimulus
MEDCOM — 5166 m TI-inqPPAIC.1 A timm
ACLU-RDI 1260 p.19 DOD 12378
Vf.10TfilOtggtgOara*af3 eN,(..-. "Rr•-• v i - ,,..-...... Level of Consciousness 1-•1 te,e, ,,,. Oriented to: Person _4 Place j(_ Time ... •4 457 I C.`4:-V 9r g ---lic rs)-2 Pain Unresponsive Responds to: Verbal 4--- Pupils R L Size / I 3 14/51 3 II 5 1 Motor Strength S = Strong Upper L R Extremities: W = Weak TR = Trace " • A = Absent Lower r-- See Narrative
Pulses R L R L .. Radial gm Posterior Tibial rarA Femoral Mil Dorsalis Pedis Iril i-
+ ... Normal - = Weak 0 = Absent Rhythm: Ectopy: — : Murmur: Rub: Si:_____ S2: Neck Veins: Edema: tf" 4 n See Narrative Breath Sounds: LA Clear 11- Bilat , Location: Crackles (Rales: Dim: I Wheezes: Absent t Rhonchi: 4:47 FA Cough: Productive I unproductive: 1#3-0 Sputum: Color and Character: Tubes: ET [_] Trach o Size: Location: 02: ili Capula LI Mask Chest Tubes: See Narrative Observation: Auscultation: 4 Palpation: / i),-,- cok, 6, Stool: Incontinent Formed Soft ❑ Frequent Q Liquid Q Hard ,-,
Tubes I Bags I Suction I Drainage:
I See Narrative I l NGT Placement , ItiVoid Urine: dolor I Tracter _ h diet..4 ,_. / Catheter Other: El See Narrative Color! Turgur I Temperature I MoislI jre Aniv Incisions / Dressings 1 Lei ons / Dermal Ulf ers 1:4' pi:,, jo
FiSee Narrative
MEDCOM - 5167
ACLU-RDI 1260 p.20 DOD 12379
b)(3) - 1
Addressograph: 790 840 ism 10:00 111 :00 12:00 13:00 11490 115:00 11a.nn (b)(6)-4 Sp02 Respirations LJ Ii
Date: 1—( iq /03 Allergies
Diagnosis Age: 0 DOB:
SIGNATURE ••■ 0
b)(6)-2
(b)(6)-2 b)(6)-2
Tem • IcJ.
PO NG/TF
Other Cummulative Intake Unna Volume Emesis
t- NG Residual/sump o.= I- Bowel Movement = OTHER
Cummulative Output RAMSEY SEDATION SCALE: 2 - Cooperative, oriented and tranquil 4 - Brisk response t lig 1 - Pt. Anxious and irritated or restless 3 - Responds to commands only 5 - Sluggish response to t Medicated 0( 96 arAL z Dose! Route iLloO it 3 rel 5 a. Intensity (1-10) Pre / Post Med Sedation Scale -OM BATH PARTIA1JCOMPLETE ACTIVITY(Tum L. R. B. oh, amb) 1/4 IV Site CDI? 02 hrs IV Site CDI? 02 hrs TCBD Wound care '1 ID=r177 A . [
MEDCOM - 5168
ACLU-RDI 1260 p.21 DOD 12380
TE WA - 24 HOUR FLOW S 18:00 10:00 20:00 2100 2200 2300 0:CO 1:00 ZOO a:ou 400 5:00 6:00
62 250
190
100
170
160
150
1171
ao V 120 \f 110 100
00
so V to GO
50
10
30
20 Temp Wig c)N
t glabellar tap or loud miaow stimulus 6 - No response to light glabellar tap or lout Stigii81 810111118 iht glabellar tap or loud auditory stimulus
MEDCOM - 5169 FI TI-trIRPPKICti A A17191 (1/flat
ACLU-RDI 1260 p.22 DOD 12381 flIci OU I ,l tai',ISib agate v2 --r- 1,--k, 5 E>< -El )e„ S (\t\i irc.Y-r t-- 1—E.6S Level of Consciousness v E agc4 L_ c.„3-E-25 . •Q r - rs.ffr "-"" 'D clean , Oriented to: Person Place Time -1-- rs. a.7" Is Responds to: Verbal Pain Unresponsive Pupils R ?te...e L.. L esme.c. . b)(6)-2 At Size / Reaction: ;2_ Lifill I 0 ct fillIMAWL4raAn.1112111E122--- _ Ft III b)(6) A1 Motor Strength S = Strong Upper L 1111M111111111101ff(ff , Extremities:xtremities: Weak 5 I
1_, 3 3
TWR1WT f'--
A = Absent Lower L>C1 See Narrative Pulses R L R
Radial Jr- -r Posterior Tibial Femoral Dorsalis Pedis 4.-
+ = Normal - =Weak 0 = Absent Rhythm: Ectopy: Murmur. Rub: S1: S2: • Neck Veins: . 1_6:1--i— Edema: El See Narrative Breath Sounds: ilej Clear 1,Xj Bilat • •- Location: Dim: i Wheezes: • , CracklesRh onchi:lRaies : i•-, Cough: Productive I Unproductive: Absent: a Sputum: Color and Character. Tubes: ❑ ET LI Trach Size: Location: 02: ElCanula L .1 Mask Chest Tubes: See Narrative Observation: F (_.„1 -1-- Auscultation: ÷ 14 (0 Palpation: Nr-, int rrn-1-.- (--le.,-r: , Stool: Incontinent Formed Li Soft ❑ Frequent ❑ Liquid ❑ Hard 14i 0 Diet: .07 Tubes / Bags / Suction I Drainage: tei
See Narrative I 1 NGT Placement Void Urine: Color! Character
Catheter: Other: n See Narrative Color! Turgur / Temperature I Moisture LA2-' -,- rz.,^r-) P I 0 L 1)1?_ y .:a Incisions I Dressings / Leisions I Dermal Ulcers EY c'': kF-.5 CSN 13C5-n—r C -6 As See Narrative MEDCOM - 5170
ACLU-RDI 1260 p.23 DOD 12382 TE WARD - 24 HOUR FLOW SHEET 18:00 19:00 20:00 21130 22:00 23:00 1:00 2:00 3:00 4:00 -6r00 0:00
q:37
o9fi
160
100
170
160
150
140
130
120 no
100
90
00
70
60
SO
30
20 Temp
t globe liar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus jht glab ellar tap or loud auditory stimulus
MEDCOM - 5171 THr1SPPNIC.1 A R:1711/1 r1m:11
ACLU-RDI 1260 p.24 DOD 12383
,b)(3)-1
Addressograph: 700 em 9:00 10:00 - 11:00 12:00 113:00 -14.W 11500 1600
(b)(6)-4 Sp02 914 9l• Respirations I lc 29C
9C
leC Date: Li —1/03 rc Allergies so Diagnosis ao A e: DOB: ICC 110
SIGNATURE 500 (b)(6)-2 b)(6)-2 so 10
1k. so."
50
40
30
ZO Temp • —1 1 A N4 000
-tv Pb Sr) rn 61A-P-
PO NG/TF
Other Cummulative Intake Urine Volume E Meals p- NG Residual/sump m Bowel Movement a O OT1-191 Commutative Output FtAM SEY SEDATION SCALE: 2 - Cooperative, oriented and tranquil 4 - Brisk response ti 1 - Pt. Anxious and Irritated or restless 3 - Responds to commands only 5 - Sluggish response Medicated riS z Dose / Route Intensity (1-10) Pre / Post Med Sedation Scale BATH PARTIAL/COMPLETE 61 ACTIVITY(Tum L. R. B. ch. amb) a 4) IV Site CDI? 02 hrs IV Site CDI? 02 hrs is TCBD z Wound care
91, -91%• 95 — cfq , - ,2:T=1!r1
MEDCOM - 5172
ACLU-RDI 1260 p.25 DOD 12384 011.21Zaltrifir.' 10 Ig P. { 0,/,>./0 - 1....l. Pr/-Prr dam,-,. s...,1-4-9 -Lt. rnm(e) b)(6)-2 Level of Consciousness ....,)A go - /24,:-;...... 4 i,..4•71.....r 4 • Oriented to: Person _L,Place Time L ,/, itr .. p.i. .g 1 .....-at- ....g. 07 .Z.._ dre-u- •, i'A.L.gr-J -...4...,.. / Responds to: Verbal Pain Unresponsive b)(6)-2 ris• 'a (Neil ' 9...4...1--.T..,-c-e,_"2... • -a Pupils ,W„-{4.1,1.,A R L Size / / C:1 Motor Strength S = Strong Upper Mill Extremities: W = Weak ,. re -
TR = Trace i l - D A = Absent Low! 410 -) •
See Narrative 1 Pulses R L R L Radial MEM Posterior Tibial ram Femoral perica Dorsalis Peck ERE. ...._ orrnal - = Weak 0 = Absent Rhythm: Ectopy: Murmur. Rub: Si: S2:
1- Neck Veins: Edema: •5-A ak L. t- ,,,,•,..— 1-1See Narrative Breath Sounds: L.....51e-ar LikBilat Location: Crackles /Rates: Dim: Wheezes: Absent: Rhonchi: Cough: Productive / Unproductive: ,, Sputum: Color and Character Tubes: Iffil ET - Trach Size: Location: ' 02: ❑ Canula L Mask bw Chest Tubes: ❑ See Narrative Observation: f-kk-v Auscultation: ' Palpation: Stool: ❑ Incontinent Li Formed L jSoft ❑ Frequent ❑ Liquid ❑ Hard
Tubes I Bags I Suction / Dr 'nage:
See Narrative I I NGT Placement Void Urine: o r / Character
Catheter: ,a : i Other: NW I I See Narrative Color / Turgur / Temperature / Moisture 'fb.rno4J. Incisions I Dressings I Leisions I Dermal Ulcers
I jellee Narrative
MEDCOM - 5173
ACLU-RDI 1260 p.26 DOD 12385 • Level of Consciousness v tEr...43A 4-- C-L..,E.5 FIRMAiIiLiiHNIMAIIMAAN„ .. V`ta, Place Time Oriented to: Person . 0 ,_011FAIVAILINPAPINI_ _ to x Responds to: Verbal Pain Unresponsive NW, ilITM"—IIIR_____fr , ' , ILIVIMII b)(6)-2 Pupils R L 11/1 . 11rtg...„ Size / Reaction: 1 2—
TIN 2- / Ml.r
Motor Strength S = Strong Upper R f
Extremities: W = Weak ) TR = Trace L R . A = Absent Lower 5 S See Narrative Pulses R L R L Radial 4 Posterior Tibial Femoral Dorsalis Pedls A- 1,... += Normal - = Weak 0 =Absent Rhythm: Ectopy: Murmur. Rub: S1: S2: Neck Veins: Edema: n See Narrative 61 Breath Sounds: W Clear IL Bilat Location: Craddes /Rales: Dim: 1 1 :-.- Wheezes: Absent: t... Rhonchi: . Cough: Productive / unproductive: Sputum: Color and Character. Tubes: M ET Q Trach Size: Location: - 02: 11. Canula 1.1.Mask Chest Tubes: See Narrative
Observation: rk_, -r Auscultation: ,.... LA a Palpation: NO q+ 5c on-. 1"r3V---1- Stool: ❑ Incontinent L j Formed LI Soft Frequent ❑ Liquid ❑ Hard Diet: Tubes / Bags / Suction I Drainage: ` g.4
See Narrative L NGT Placement IVoid Urine: Color/ Character Y L Catheter: Other. I See Narrative Color! Turgur I Temperature / Moisture .., cz.,,,..., c.- ry-Not S "1- p , ti, 1C Incisions I Dressings I Leis ions / Dermal Ulcers
. - t-i-riN2 .44-1t /".2 e. ‘E:7 (.4 -•■•
See Narrative MEDCOM - 5174
ACLU-RDI 1260 p.27 DOD 12386
ITE WARD - 24 HOUR FLOW SHEET 'moo 19:00 20:00 21'00 223/0 23:00 0:00 1:00 Olt 33)0 4:00 5703 6:00
200
100
lm
170
160 • • .1 160
140
130
120
110
100
so
00
70
60
A 60
40
30
20 q"7 Temp
to0
t glabellar tap or loud auditory stimulus 6 - No response to light glabellar tap or loud auditory stimulus iht glabellar lap or loud auditory stimulus
MEDCOM - 5175 FLTHOSPPNCLA 632071 <1103)
ACLU-RDI 1260 p.28 DOD 12387
VITAL SIGNS RECORD MEDICAL RECORD 11111111111111111111111111111111111111111111111111•11111 DAT 1111111111111111111111111111111 ■1111111111111111111111•111111 HOSPITAL 111111111111111111111111110111111111111111111 rosr. my ..„...„... lic:111comicilliiiillils zorriennWit TEMP. C '2,0o 111111.11:11111111.1111MMIIIIIIM 40.6° Fr nxiF 105' 1111=11111111111111111101111111111 40.0° 39A° in 10,. MIIIMMIIIIMII C 170 103°11111111111110111111111M1111111111111 INIEMMIIIIM 38.9° 160 102° 111111111111111111111111111111111•11111111111 38.3° 150 EIM111111111111111111111111111111111101111 „.r 1,1* 110 yx IIIIIIIIINEMMINMIN111111111111 367.0° 1 9r 1 30 .7° i 96.6° 120 SWASS'AreliSSIGS 36.1°r ii1. 110 97° 111111111110111111111111111MININIMIIIII ut 10, 11111111MINIMIIIMMINIIIIMIIIIIIN 35.0° 90 95° : MINE11111 • IP :. IBM 1111 ao ' N1111111111111111111MIMINIIIMII ' Bilv 1111 70 11111111111CIIIIIMMEINKM 60 IIIIMNIII1111111111111111111111111 50 M111111111111111M1111111111111111111111 10 6 .111111111:M111110111111111111 RESPIRATION RECORD TRW ( . 01111111111111M1111111111111111111111111111111 1111111111111111111111111111111111111111111111111111111111111111111111111111111111 111111111111111111111111111 1111111111111111111111111111111111111111111111111111111111 galIMO 11111111111111111•111111111111111111111111111111111111111111111111111111111111111 111111111111111111111111111 n 14.11.111111111ffineri 111111111111111d1.111d
11111111111111111WARD NO. a 111111111 •nttiol give Name -la"• Bret , (Pot typorl or written PATIENT', IDENTWICATION rats; hospital or nurchc,a1 facility) middle; rank; VITAL SIGNS RECORD STANDARD FORM 511 (REV. 949) Prescribed by GSAMMR FIRMA (41 CFR) 201-45.505 511-113 • 11191— 2131-782/40093 'U.S. P . ,rnment Printing r
MEDCOM - 5176
ACLU-RDI 1260 p.29 DOD 12388
..... MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAT . POET. DAT WHITH-TEAK L. DAT k ) (‘‘ 1K 19 PULSE (E) (•) . . . . . . . . . 10r . . . . . . .. . . • . . . • . • . . . • . . . . . . . • . • . • . . . • ISO 104° • • • • • • • • • ' • • • • • • • • " • • • • . . . . . . . . . • . . . • . . . : - • • • • • • • • - • • . . . . . . 170 103
. . • . . . . . . . . . . . . - •• • : I • . : . : . : : . . . . . . 160 102° ' • " • , . . • .' .• .• 40.• f. : . : . . . . . : . . . . •
• • • • • . • . • • • . . . . • . . . . . . , • 150 101 . . . • . • . . . . . . . • . • . • . . . . . • . . : 1 . • . • 140 - • • A 10e . . . • . • . . . • . . III . : : : . . . . : : :Ni? : . : . : . : . 9 •• . . . . . . 130 99 . . . VI 98.6 • : : : •• V/ : : : : • • : :
120 9IP fillikiMillIll NM .. .. 5 Eq . .. ..
Ito • : . . HIE ••• •• WEIS MEI : . . • ▪ • . : wrimmin • • v : 100 96° I o '. . . . • . • . • . • . . ,....," : • : :: :: . . . 90 95 : 1 .. . . /1. , . , , , , , ,
90 . • . . . . . . . II . . . . . . . . • . . . .
• • • • • . . . . • • • • • ill- O P • 70 . • . • .. . • .. .. III • ' ... :: . . rwriarisE . . GO' MINIM . • . . —
50 : : IFINEILEIMMIIMPIAMMIZI . : . . . .
. . . . . . 40 111 r't- . . •. 111111911/• mgall •,-- !RATION RECORD n
d Pi e 10.000 PRESSURE
der Lli, r o
so MGM 1WEIGHTNI /204 ^ hen
w lb i 1 /01 :1-'" t ( .°1 It i .6 . ly
on ( I. Li C I h Ct) Ii:; 'Mc t& e l di is ee d ep ne
Pee . _. I PATIENT'S IDENTIFICATION (For typed or written entries giro: Name—last. first. REGISTER NO. WARD NO. middle; rank; rite; hospital or medical facility) (b)(6)-4 VITAL SIGNS RECORD
STANDARD FORM 511 (REV. 9-79) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-45.505 511-113
MEDCOM - 5177
ACLU-RDI 1260 p.30 DOD 12389
MEDICAL RECORD I VITAL SIGNS RECORD
HOSPITAL DAY
POST. DAY .
MONTH-YEAH DAY 0
• • . • . • . . . • . • . . . . , . • . , . INKY TEMP• 1 . 1 . i . . . • • • . • . • • . . • (0) (S) • . . . .4.&' • • • • • • - . - - • • : : • : Ni: . . . • . . • 180 104° • •
170 . . . • . . . • . • . • . . . . . . , . . . 160 102° Niert . . , . • . • . . . . . • . • . • . • . • . . . . . . . • . . . . . . . . • . . . . . . . . . . . . . . . • 150 101° . . . . . . . . . . . . . . • • • 140 me • • • : . . . • . . . • . . . • . . . . . . . • . - • 130 99° 98.6° . . . . . . 120 9F . . . - . •: . . . . . . : . . • Eq . . . . . . . . . . • • . . . . . • . . . •
HO 97° . . . . . . ode
. • • • • •
100 96°. . • . . . . . . • . • • • • • . , • . . . • . . • . • i ; : ; : •• : •• •• • . • . . • . . • . . . . . . . 90 95° • . . . • . • • • • • . . • • • • • • . • • • . • • . . • . • . • . • • . • . . . . . • . • . . . • . • . . . • . • • . • . .
BO . • . . . • • • • • • • 70 . . . • • . • • . . . • • . • • . . . • . • . . . . . . . • . • . . . . . • . .
60 . • . . . • . • • • • • • • • • • • • • • • • • . . . • . • . • • • 50 • • • ' ' ' •. . . . . . . . : : . . . • . • . • . • 40
RESPIRATION RECORD I pau
a BLOOD PRESSURE pao as cl
a HEIGHT: 1 WEIGNT4 w& A po
Inw p pi ma * ima m 1 PATIENT'S IDENTIFICATION (For typed or written entries give:• Name—last, first, REGISTER . middle; rank; rate; hospital or medical facility)
VITAL SIGNS RECORD 511-113 *U.S. Government Printing office: 1989-241-175/80290 STANDARD FORM 511 (REV. 9-79) Prescribed by GSA/ICRIR FIRMR (41 CFR) 20145.505
MEDCOM - 5178
ACLU-RDI 1260 p.31 DOD 12390
VITAL SIGNS RECORD MEDICAL RECORD11111111111111111111111111111.1.11.11101.111111.11111.1111011111 ....iii..11111.111111...... r111111 HOSPITAL DAT ...... 1101111111.1011111 POST. OAT 1111111111.....1:11111111 11OOMP-YEAR TEMP. C 19 rola 40.6° sermni 11111 10.0° (o)105° Triffirear°i- 11. 4 PillIBM --- 39.4° 180 104° ral ' NAM'IMINUMMIMMI1 38.9° 170 103° INIMEN 111MMUNIMIUSII 102° MINIMW11 38.3° leo150 101° 1011111"11111111111111111011 4' 11111111111111111MMEIMMIIIMIM 37.6° t 140 100. .r i 99° MIN0011111011111111MM „357 130 1 120 98° rutiarrovalsan36.1. 110 97° INIIMIIIMMEMMOMMIIIMMI 35.5 I 35.0° 100 96° 1111111SMIIMMIMMIMMIN U 90 95° 11111111111111MMIMMEINIIMINI 80 IIIIIMMISMIIIMILIMMNIN 70 MIIMMINIUM MIIMMIIM 60SO EIMMIIIIIMBISMISMIM 40 IIIIIIIIIIMMINIMMUNIM11111111111111111111111 11111111111110111111111111111 RESPIRATION RECORD 1111111111111110111511WIEWSUINKIMP BLOOD PRESSUREEMIESI IMINIMMINICAREEMICIROMEMINNINIMMONI MOM WEIGSI 111111111111111111111111111111111111111111111111111111111111 Mr aII Mr
WARD NO. d iva: Piarne—last, first, (For typed or written entriea or medical lacilitY) mPATIENT'S IDENTIFICATIONoolons•as middle; rank; rate; hospital VITAL SIGHS RECOR STANDARD FORM 511 (REV. 9-1 ,vetment ntpting Office: 1989-241-175/80290 Prescribed by GSA/ICMR 511-113 (b)(6)-4 FIRMR (41 CFR) 201-45.505
M EDCOM - 5179
ACLU-RDI 1260 p.32 DOD 12391 LABORATORY REQUEST FORM FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS. FOR ALL OTHERS, CIRCLE DESIRED PANEL. Check CHEMISTRY Result URINALYSIS Result RBC MORPHOLOGY GLU Spec Gravity BUN pH CREAT Leukocytes I NA Nitrite K !Protein CL !Glucose MICROBIOLOGY CO2 !Ketones !Culture Site: Phos Urobilinogen AST Bilirubin !Results: ALT I Blood LDH !Hemoglobin TBIL 1 MICROSCOPIC ALB Sensitivity:
CK MATOLOGY ce3c.„ TP WBC 60,4
MG RBC 2 . 03 AMYL HGB Pr/ •Akerioriiiiirb4 LIPASE IHCT C-D a ill clig-10))1 w9PMF MMOMPhRiNg4M MCV 9`r co SEROLOGY IRDW t3 MONOSPOT !PLT VS- wlnam__.___ porwmpv 1- ‘D DIFFERENTIAL ti-c- 3 2_• PT EUTRO PTT scc, BAND VNWOOKOWNWOWEBER META
BLOOD GAS MYELO b)(6)-2 pH PROMYELO PCO2 BLAST P02 !EOSIN° LACTATE IBASO BICARBONATE I LYMPH TOTAL CO2 I MONO BASE EXCESS INUCLEATED RBC 02 SAT
J b)(6)-4 Patient Name: Location: (b)(6) -2 FMP/S SN: Provider:
Date:
(b)(6)-4 MEDCOM -5180
ACLU-RDI 1260 p.33 DOD 12392
I . 1113111 "4. .i. -- _v•-c-...m•••••m=.-4-..-- E..... :.:: : 94 I 1111E11111111iU111111t II., ' ill ipi 1 I 1•0 fast! .pmaaausa----= fin 11: 71111iid111l 110 ill -lithig Ei.azaP,Ilm:MEnsoMMIM. 0.2.1=-L-..-- igli,•i="maL ' Lakammill1 P;a.:111 -ligoalemlaintina , ailEnt-u! -.:::dr:MEglw..VMifil . Eiblikiffign.P..1111.1157 EKW, iIN'10.. iiiiitr" --miiE-3::zqranuM1 Er. frudilligMliiiiii.a.,• a_ms...--r iiiiiiiiiraWre-..■ W ■ NMI. ... is ...... ' .11•11./1..ffe ...... IMMINKIIMMEA KC.. iMMi .aill EridijilMiligr ''....lgr=2:=1".'''''''..1• ILIOni=aiCH:q111:1==rffiEFiralliii.41:11MFGEW . .1,.3..1:121 E .•-•iilpireelrE_;1100701111puntr.:11:..i.-.6--minalimilininirliin9/a L....a 1.:MIKINIININE.lilln..;11.. 41 iii riellimmi-IKEI--:.' MilhieVIHRIBP24199111Al2iiiff119ralliille.n iiirill""Ru lan"-..j" "1111111111■ PRESELAWIll n.lirlIIPLZ111--atritihnirl 111:111.11erarnnliiiiiiitaia rnghlretii.:5 rlagliM u alEE•lor.:s.suilml iff....., ..: ... i . .04iitign.nlitiftil6TELPerirvaPikAtiril. • Irea.murITIPIT EluEll'241:2" "Illimuu gel, • mi..• lMM--._4i 11-1: 1: Ili Elgi lli ihniFil iiii:Lillirt4i 111121 111111111111111:1111111111116. ---":": ' n'HiMimillitlIMPHEEMItilla.- !!"!•••-"E ''' 1143163,,.!!!!L4-r---9gbminalliiireq-Urinimlufi.=_:.:Ailiiiin„1ismiegfililhil'n'thig7.41raimaituniii:Itaarlia.a:r- • ,.:: Iiiiiiirdu rlioulummAlli1 190.•iiiiii m.-!!! !II iraan raillis.ras. 1:pestimrsiv eiLlpiLl.lositi. "Eihg ":11111111111i1-111 -- 1-----MEPPI:iwiirair'FBEEEdIEW211.1-1":9 It iterk••-•;,-11•5lananinenta:-..111::::::::"•onnalmini ir '' ' -!...- _n Fl inuncn; _m______=;..,1AIonirli iiik.::_ 1:ilit u" 21121421 111E111111111alivatr.rffiiril...- " '' "iiiiii,.M=m-111414B11 r: 1-- Ag "mmul ra1 llallin29411muman- :11EiliilflEM w of 116.21111111;61% ' -1 . ! .. len!Fill-tr, -ff am m:::..... 2 i..., .11::9;ilimiquir „=-imilimintliterpmittem...ni PullIA pi-1641-9Z .. TrIkirt1":1113!"-alli2.-. . _Ini ti o_apfijkiiiimplimilui• hiii.E__1741§1.73iimun-r"".61. mi ail Amami' EV' nuMmuE11-991° &Liiiiiir• uning.1,9!"1:-'1::11muk1 11:7--dein u.-0:6 ,,c 7 911 U nh uriminunr1111:111.11111iiiiril: IiilumnoritufilniM11111:11i111'"12 ''''' pH I '9111011illiiiiiiiiill=mn 111- am ---a•a: - aiiiiiiiiiiimr•-•Ei 1 ililmiloil'InSIFI- Millial____ 1: ...... igiiiiiiiipagrlrZIL,IP„%mszn-H;;; --':.....-.:.,-r iiii:iiiihnnumman•oma„imata-nalamgm_ -.:anneffdEilizigiiiiiergilEaisir nue- -- uilislliIIELEMIH-•••1m.r--niceimmadillPLIELarliETE::-: ::seil nainc. ...IA. J!!!noi.- Bilmun lautem.1:,:::-.:mm i JeragmbraFieulogrtaz:•2•A iga.,orisiummi Lealiiilum--••• ...... -smilimigel.z..• :....A.Jr.malabc..;.etilimaunaml-launa:.....-.:.:1::. .. -MiliiiiIMIIIII- -...... •:-Jr:Az-maiiiiiffil; Rillinnun nu EgilligitiLITLIEREF - agildiiiiiiiMile:S ERWAIEWELILMEPIP" :_r•i-ITuram -;:w.-;;;;,...... -_-1 .:+giar dinumplial.lit..2.. .. :.m .. itommine.:1_,"• Tammilin...- -pi_ ;nun HIMPAEFF"::: ::::::".•:Eisaint-lomomm•Fralmi-i:: antonam.- -•'-'13'-'" Imuni- mill_agma••••-•::: "Ica::::...... maipaammariq "VS Emimadiiiiitua mma: ea Aintr----- jai nuni.....1...... 1mmuur...."...n..1 m. O i. - .3,4AiiiiiiPiiirliiEV gi•t.-- :::::::....,„,irmi .. ::„:.:..:i - ma .;:ungilimiliiiiiiiiMEMIHRFa lisiiintumullsor• -- Mil-Isra:m• L.• ..... :mum ...... iu--Tml!" ; ;;;;;..-mpollm: ••-• -.,--:.:deanimdimliiall•-- II! HIE.- ' V: RP' In IIMUIU"""'""I'illr-eljoirolia":.13.11.11-1.-Ra.1112Puliriormidirniaii.91111. :91_!::: •--aiiIIMPE. O ....alsHa • 11111....:Ein 1 n 1111111 111""'"'",111F11.....mur i:--raimalaolinin 11111111 911M11111 • ':••1 . muIl 1'9 N Inn; ... ::: .... Oni= ..flailin...;, ...... nlimmem: .. !mil...... •••.-...• 11 . ..... ao i. . ramopillwa: ... ..-4 ii.hin O. iiiingiiiiii...mar7:' mud:: - - .1. 111111 Anma.::::::LummuHE?:::1 . ...... s .... .. .. :iiiros0. ufin.•..... -- .:1111111M 11111111 1111111um:::MEF4- - -mil .1111.10HU iiiimm :::::;;=;:nelalomimaiRS. ...... -Eiligat-1 - maim hleiiiraldREI:L . ; .. .. .rinUirmui . mum :1111.M111.1..-z.-:"-aininannIIIIII!!!!li"- ' 2 i ...... •••11.`911.'"" .11111111111111" "" ••Eien----H.+11 .... - ...... --a-maniulliiima..- .... 1 - lmmo '" '' ---m!!!! ...... ! .I:ffianna.: ...... ihm:"""m!!! unarliPlimae I: mona.a.:LEHIE.::- .10111 """'"•11111111" a. ;:""....11111"likir is ...... ea 11.1inrlilFallii4lillnrn'' .111111U11:1 ...•:11.1111 7g ""_____•_mu : 111..111...... 11..1...11 :".•11...... 1...... 111.:. -1.11....91L in "iiiiiiii:1141Minrin ...... "rn-77.intini.. wimill ... :6 .. :M.' .... am.,n - - 111...... i...... 6:...... 1:...... a Mu:aim" -...::::::-a- •::::raiiSsrdiELmm ...... ... milglin....1- -..lanamilmmnaan 'mu ml-Hilm mum' -••:- EihmirMilii!IER:"1 -iii-•••::EilignimariERIEEHIP,. .. :::: . thuliu m Amman mILE! . - .7":431::cipiumniBill!Bilirrannor.=::: - r- mr:IiiiiIii " ' inueisle -"24: ..1 I rusnuiniMPatiornma -Ell . : ...... -nriilFrlummull. I .: :-:--411:::011:0114:1111=t46--_.6.9.1..!mplp ani-1":11i1,Bi!!!!!3..nrcaiull'iiiinizz...1.-xis:1:1=11.....TC:;:ilim in MUM 11; Mr: . .1rigIUM1111iii4111MCIA... 1191t:. : aziiiiiiiiiimmaRE nulEill umulli -: .... _ All.:1; iii-iiiiiiiiiiiamelnimiadomiliEre- - idgmiismironnimliar : Isumin-19111 'NU" ; acia"•••:•::finiiii.••••--E1-• 111111111F11.1 1111....11111111i11111 a mp= Q. '1 ■ _cSEE IIILIIIfful .. e:•11%-11-9 .::: imilll'IM I Bili9111111111iiLibiIr-u! . ! .. '• ... ---111-231111EL-1:1,2U-I SEMElleall''''''!!!..9,-um...... nr.... ------r_.....•.141.... ...... = _ ...... ilmw ..... _ ...--._.. ...-- c-2 Mr- . mu .mi„ -qmutua-r.. • •2••••%'ff. . mumiinipmapa.6-::- ..... - ••°" • Himigi:Jmnsi •-ang 1•••:-Ir- MilffirlEIEL ' ir'll...R:1-..:Iii:LI ...... 1..T.' .... 61...... E:::::: min nun ,....riF111.14.... '.311 1"11:1"..71111V;P . v-:-.1ffiliiiitirmdr..6•...2 . waralw-ThosizturimilmilEF:niumlum:-.alli....m...... mma...... 2h {.90...... anals...... MEMEH-- iiiiiiiiimlaim .„ V: 7C limill e....ii.uulm. ...i....: EIEEINfailliiiinglit7:"irillar41911U.M16:11Aliti1912a1211E.::: IMPRIVASHMEmillittirdelliML9 .. :Ca 9 LilliZiniallIONM:::!: 1BEIRILI.IMI Ei'f ElliiiibirdEb1 l 71:=11 :U.: . LIPPIIMILHH:TOSir2114111111"a . numr Him= 0 MICA miluing=r3E -1--lanliaqupmmgrup...- .sniuri, 411-4P-....-oui affinsl'ainirapniu____.nunigu.. . ----:::;---rangal n.:umr-.;,.... 0x.mc211.-1 :::...... - 1---:P." ,m1 -....._.... PliffiimluireoluiMILIRr ....r.______BI, .21'n...."' an=iir 0 ""`". Iiiumalasa•mlumwriA"---ni--anniinclaranarmia.a.m.a.1.HUMlin nee_. iv• lawill .,..„„,-..MiirdilIPMI''''' .... 7...... . 1...... V:Ar.nalimm."".' . ili1114.1In le"j 111r1::1.n.:::::::::::...111111:11.4/.4----Ta.sumv,monn.- .. mudynnurmimmunr.F.-1 1 . -- nun... .7;.- ■ 1.,111:1-7.-11.1.--.9pkitinfidl .. Msg-.4.1-.-:: ac ..61.uniZeral •1:10 01731": .. .. {.-2"11="1"...r ii=' -11_61.11.11ihrumiiii.ffir....u 2.9 ."titslitmi.1.--.1-- i7' YIH '...... ilikilhilrugr u. =1 nu'LlUrinull=6u g'iiiiint;F" .r-jal menu:iiiiiiiiMunP-i --Aar19. 6:::::EriiiiiniiiMiS...... •:: ------aglemar-z:11MHElleji cd IFILITMINifiliiimaimmiTliiralfl"25k1P1°"1"."" idi: HilirmulaWifilimadie:•°mInifffira....„A ;E:dib ti Immo "-&1zu11 21lai:..r.:::-...... • - . ; :-.:91; • jolasi.._-,1 iiiiim==;....n 3 Ir. aulag_i iiini __. ol 1-11016--fraiiiiisin-.iirM.0 .:,ih mlu E iiiiw ommai:,;1.---. i iiiiihMMISPiummuIVITE1-unnineniiiiimmu m.,ir ...UM •:•:Era::::11:.-l ... . nit r;;;;; .=;;;.....; IEnimnisi: _uria -'1iiiiiilzilS11111p;691*MWSSIENNIEriiiiii F- ,.....-. ...1121E1111/11. aa...L11=1. '111111111..... :.:::nl• pil...... liNfrwuirlri. r. ..lrhin."rulinCihTHI muHan. ldl.: ...... "„Walr. oz..7.-.aoA: 11111111111NEdnirlialEiNiiiilargilffilliginilmaitlIV1..1111111101IEnnIll"r 111111E11MLIMIN11110 ...... V111111...mul.iiiiiiliejnin.... um.:non....11iiii i''' 111241"111111111rISFP . 1 ".saamiltunai:::n ...pmilummin: ....''''''...... "15:6 ENII:11111Maalliii;T:iiiraillammina[q]sraill,:• ::id.U.!!!!.1 - . ...- IiiiiiiiIiinignill-::--ismparam=ai:Frau-...... diu .. --• -:-::::kr.::::--1.- • •• ,.- ...... ...... aliiii "i' 141112- iifrir-EE61111Apffaiirr----=2"iiii:EPH . !I ...... :i-...... ;-1. ;;;,Hiris-isiRe- iefighr9;:giir... ;.-.3.iiiaaahlingibmw.-.. slaw...4 11111101iiirrull•m9m9.%:.-1-.-:::hinam4 1.:::. 11!..=.31:0Tdr: . ----; :81unien-Ilfh, anisnannana:- • f"-"Efflu-"tita ...... 7111111.1.1981111- :1409aumr-10141 111:14 ...... ::11.2.--ra'..U -liffilientlifigiSimlw -"um_111„8:''..mniulalai'n' - mram- Hiriliim:::-.m.waiiiiiiiiiiffeciernin===.„.,:uumm. iiii ”....=:-- -iiiiiiinnuorimra... ••• :_aillant:: iiiharran::::::::E4.a.:41:ffilfitagiatimiEMEMErair.niredFdalneemming L-. - ... ..... --.-.-- - m-
ACLU-RDI 1260 p.34 DOD 12393
vaso (b)(3)-1 rime co-hi Pe-Ere-A LABORATORY REQUEST FORM FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRLD TESTS. FOR ALL OTHERS, CIRCLE DESIRED PANEL. Check CHEMISTRY Result I URINALYSIS IResult I RBC MORPHOLOGY GLU ec Gravity__ BUN PH CREAT ILeukocytes NA INitrite K !Protein CL I Glucose MICROBIOLOGY CO2 Ketones Culture Site: riFios I Urobilinogen AST IBilirubin Results: !Blood !Hemoglobin MICROSCOPIC ALB 1 Sensitivity: CA
LH TOLOGY IMTORMESIMI1111111 AMYL HGB r. I LIPASE IHCT MCV
SEROLOGY RDW MONOSPOT PLT MPV I DIFFERENTIAL NEUTRO BAND META
BLOOD GAS MYELO pH PROMYELO PCO2 BLAST P02 EOSINO LACTATE BASO BICARBONATE LYMPH TOTAL CO2 MONO BASE EXCESS NUCLEATED RBC
(b)(6) -4 Patient Name: _ Location: (b)(6)-2 FMP/SSN: Provider:
Patient ID: Date:
MEDCOM - 5182 FLTHOSPPNCLA 651 Oil (1103)
ACLU-RDI 1260 p.35 DOD 12394 (4104t7,0e 1;21 (0 LABORATORY REQUEST %.)1R/v1 FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS. FOR ALL OTHERS, CIRCLE DESIRED Result RBC MORPHOLOGY Check CHEMISTRY Result URINALYSIS GLU Spec Gravity BUN pH CREAT Leukocytes NA Nitrite K Protein MICROBIOLOGY CL Glucose CO2 Ketones Culture Site: Phos Urobilinogen AST Bilirubin Results: ALT Blood LDH Hemoglobin TBIL MICROSCOPIC ALB Sensitivity: CA CHOL TRIG CK HEMATOLOGY TP WBC MG RBC AMYL HGB LIPASE HCT MCV SEROLOGY RDW MONOSPOT PLT ,ANINftagliqq@MR MEW TION DIFFERENTIAL 1 2.,41 EUTRO META N-‘ BLOOD GAS MYELO pH PROMYELO PCO2 BLAST PO2 EOSINO LACTATE BASO BICARBONATE LYMPH TOTAL CO2 MONO BASE EXCESS NUCLEATED RBC 02 SAT (6)-2 Patient Name: let") Location: n—r- (b)(6)-2 M(6 )-2 FMP/SSN: Provider: 6go Dat O A eri- 61 °\17 LOW u-f-PAr MEDCOM- 5183 ACLU-RDI 1260 p.36 DOD 12395 ed LarIORATORY REQUEST kORM FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS:' FOR ALL OTHERS, CIRCLE DESIRED PANEL. I Check CHEMISTRY Result I URINALYSIS Result 1 RBC MORPHOLOGY GLU ISpec Gravity BUN ,T.T CREAT Leukocytes NA ( Nitrite K 1 Protein CL I Glucose !MICROBIOLOGY CO2 1 Ketones Culture Site: Phos Urobilinogen AST I Bilirubin Results: ALT I Blood LDH Hemoglobin TBIL I MICROSCOPIC 1 ALB Sensitivity: CA CHO L TRIG CK HFrMATOLOG TP WBC MC a-SLIFD MG RBC SDEACaa,t) AMYL HGB LIPASE HCT MCV SEROLOGY. RDW MONOSPOT_ PLT MPV DIFFERENTIAL P ►2 . A I NEUTRO PTT 7 1 BAND REN: META BLOOD GAS MYELO pH I PROMYELO PCO2 I BLAST P02 I EOSINO LACTATE I BASO BICARBONATE I LYMPH TOTAL CO2 MONO BASE EXCESS 1 NUCLEATED RBC 02 SAT Patient Name: PPL Location: (b)(6)-4 (b)(6)-2 FMP/SSN: Provider: Date: 527J/3- 00 MEDCOM - 5184 ACLU-RDI 1260 p.37 DOD 12396 (b)(3)-1 0151 LABORATORY REQUEST FORM FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS. FOR ALL OTHERS, CIRCLE DESIRED PANEL. Check CHEMISTRY RBC MORPHOLOGY MM-2 BUN PH CREAT Leukocytes-.. NA Nitrite K Protein CL Glucose MICROBIOLOGY CO2 Ketones Culture Site: Phos Urobilinogen AST Bilirubin Results: ALT Blood LDH Hemoglobin TBIL MICROSCOPIC ALB Sensitivity: CA CHOL TRIG CK H. TOLO TP WBC MG RBC L76 AMYL HGB LIPASE HCT MCV pactIC 1971 RDW 13.6 PLT IS" MPV 1.6 DIFFERENTIAL NEUTRO BAND META BLOOD GAS MYELO pH PROMYELO PCO2 BLAST PO2 EOSINO LACTATE BASO BICARBONATE LYMPH TOTAL CO2 MONO BASE- EXCESS NUCLEATED RBC 02 SAT (b)(6)-4 Patient Name: Location: b)(6)-4 MM-2 FMP/SSN: t Provider: Patient II): Date: 67 API-e)5.10 -185 MEDCOM -5185 FLTHOSPPNCLA65 10/1 (1103) ACLU-RDI 1260 p.38 DOD 12397 r 5 T.R6,s0+- col-09'1a MPP LABORATORY REQUEST FORM FOR CHEMISTRY, SEROLOGY, AND COAGULATION, CHECK DESIRED TESTS. FOR ALL OTHERS, CIRCLE DESIRED PANEL. CHEMISTRY Check Result I URINALYSIS Result RBC MORPHOLOGY GLU Spec Gravity BUN pH I CREAT Leukocytes... NA Nitrite K Protein CL Glucose 'MICROBIOLOGY CO2 'Ketones 'Culture Site: Phos Urobilinogen AST Bilirubin !Results: ALT Blood LDH Hemoglobin TBIL MICROSCOPIC I ALB 'sensitivity: CHOL TRIG CK (iE, MATOLOGILLCA5(, TP WBC 6.8 MG RBC AMYL HGB i3,1/ LIPASE HCT q MCV 90.3 RDW /3.5 me. 2-4.• PLT VI/ mclie es-- 12.1 MPV 6.9 DIFFERENTIAL f-S NEUTRO ?. 0 BAND META BLOOD GAS MYELO pH PROMYELO PCO2 BLAST P02 • EOSINO LACTATE BASO BICARBONATE LYMPH TOTAL CO2 MONO BASE EXCESS NUCLEATED RBC 02 SAT I mn4 Patient Name: Location: P 3 FMP/SSN: Provider: (b)(6)-4 Patient ID: Date: MEDCOM - 5186 FLTHOSPPNCLA 6510/1 (1/03) ACLU-RDI 1260 p.39 DOD 12398 Day Of Surgery Vital Signs 1 1112, HOLDING AREA: Versed mg IV Fentanyl mcg IV Ancef/ gm NPB NAVHOSPPNCLA OVERPRINT (10- 94) IV 16 8 20 ga d / FA / AC Pg 7 START STOP 7 K o CLINICAL RECORD,,M1'..,,s / Equipment / 02 / Suction / Checked ANESTHESIA Amerman 7,) Pencedure PRE-PROCEDURE dr UMIN 1 1 1 1 1 1 1 I N20 Alr L/Len I I I 1 T 1 1 1 1 I 1 10 Band 0 Ouesboning ii 11111 I 1 I 1 1 . • Floviewod ❑ Pens Signed Lr&-wErn .74.• f4a 1 r - ; -1 - -r -*-4- - - ❑ Since kawilugual - 1 I 1 1 1 1 i- s I . t 1 4- 4 Stein ❑ Calm 1 1 "I" .1 1 1 1 s "1-1- tarrawArai ❑ Awake DAWN) 1'1 1 1 1 1 I 1 I 1 1 1 1 1 1 1 iglzumml ❑ Appohmaies ❑ Callum] 1 I I 1 I 1 cagarago 11 1 1 • I I -4-4- 1 UnceopNalim o UnreettcnIAN IllikariL7111 - - -I- 1 -- -- 4-- 4 4+ I 1 ;1 _r1 1 1 I 1 PATIENT SAFETY 1 - 1 1 - 1 I "r"1"" I 1 _ --r -r- 11- MacMadan Checked MEM MN SZE RUM EMU MIME IRMO KIM IMRE MERIN= El= EMI . Bee On ❑ Ndiery Rd 1.0•1111N111111 el 7- Rimini' 0 Amu lard ET CO, -4-4- Jr-4- - 1 1 1 , , . 1 I I Ores chocked and padded —1, no, 1 1 I I 1 1 • 0 Ointment 0 Seine _Pi 1- —6—'— G-Eira Sa0y% 1 1 1 1 1 1 1 1 1 1 0 Pads ❑ Goggles + -1- - 1 I ANESTHETIC TECHNIQUE -r — T - - 1 I 1 -13Ichygsnawn ❑ LTA. 1 1 1 1 1 I 1 0 Gleed Resew 1 1 I 1 1 1 -1--1- 200 - 0 bralation 11111M H- MENIME ❑ 0 fratamtrocalar Read • .PULSE -t - o SPORT RES? 180 MEMMIMMIUMM Reslonel: 0 Spinal 0 Epidural MEM tt-= ❑ ❑ 0 •MST RES? I 1 1 1 Aviary Mr Block 0 ANN Block 4- I • .011111. REM I 1 0 o • -VENTILATOR =I= MINENIMUN CI Poop ❑ kcal 1 1 1 1 I 1 0 'Neck x CUFF IP 140 MST-;- MI= 1 1 - -- - 1 1 1 1 - i" I 1 ❑ Drugs(s) 1 1 _L-i_ ❑ Bae o Atlernrds 1 1 t MT LINE 120 liret=fLI I=11-44- MUM 0 Sl• 0 Level ❑ o wl I 1 1- 4 CI Catheter Seo Remarks X .11AP 1(10 Ir J 1 - t 1 1 1 1 1 1 " I " " 1 011w: ❑ RAC ❑ I .INTUBATE R .REVERSAL AIRWAY MANAGEMENT E • EITIGATE 181/1111 ilinii111111111111111111111111111111111111/1 Intibedonund: 111111111111111E1111=1101111113/1111111-1-1- -4.--1111111111: Megl ;Ramo. ME 0 MA 111111211211131211111111111111111211111111UMENINI cm 0 Otd Lurn • INEMNIU ORMINI In Mann UM= SERIEnnialimeMMIIPMEICHUNEMEMENUMNI '"130.5 krri7-rromr.!_ i/r.immullnummiimnimmilmi 111111111111111 HMI EN OMNI IBMII :h1.1 . CI Ord 1:11tasal 0 Odkul, L1 NUM NNN NNIN W NNIN Nd rui m Clreulb 0 deb 0 NAB see Remarks ❑ Moak Case 0 Nasal Ceram Symbds tel Remarks 0 Me lechocolomi ❑ Simple 0a meek -6 Blood I Producht, FLUID TOTALS 14. 1 11 Oyetelold 7C.n Blood RECOVERY MONITORS AND EQUIPMENT Time ❑ Rimed 0 BOO 0 Mar A-14 • POW 41-4- Al Al/ 0-4)..111t- i / Or Sat. Tv 04 SIP ❑ Leh0 NO rMlf1172--11111 EKG 0 V Load EKG .....Ettrsygon Sensor 0 /ova 0 Rua! Oxygen (h■ (vet 7 (0 lX4IT ( Z1Idel CCh 0 Gee Antrndy 0 Unstelle.134451-Ceygen n Nana Stimulator SYM011111 0 imam 0 T-0108 Ctoron ❑ LIMM111611 0 Vastasor o Osolinasal airway ❑ Printing Blanket ❑ Fluid Wenner ❑ Akimy Humidifier ❑ Foley Catheter MCUNOTES ❑ NG I 00 Tube ❑ An. Line Parr MERGENCE OW Suctioning Utt x 5 sec &tubed= ASLEEP 0 FENTJSUF/REM 100AZ SURGEON(S) USED 13)(8)-2 1,103)-2 .4•01 I , I WASTE) PATIENTS IDENTIFICATION (Far typed or written entries give Name—last, first. (13)(8)-2 DATE middle, grade, date, hospital or medical facility) 1 — .b)(8)-4 ANESTHESIA Stardom' Form 517 Proscribed by GSA ICA4F1 MAR (41 CFR) 201-45 505 51742 MEDCOM - 5187 OCTOBER WS ACLU-RDI 1260 p.40 DOD 12399 /Pi z g. Post-Op Orders Date Z 274( 2 Time 9-6-d 3 1. ADMIT TO: I[ ] ACW [ ] ICU ( 2. DIAGNOSIS/PROCEDURE (print): All'. .4-.4111.1116. 3. VITAL SIGNS: [ ] Per Post-op Routine [-,J44hr 4 ACTIVITY: Bedrest [ ] Up with Assistance 5. ALLERGIES: 6. NURSING: [ ]1/0 [ ] Foley to gravity [ ] NG to LIS [ ] CT to -20CM H,0 Suction [ IS Q1° while awake 7. DIET: [ ] NPO [412eg [ Clear Liq [ ] Full Liq a IV FLUIDS: [ ] Lactd Rngr A CC/hr [ Normal Saline (a CC/hr 9. LABS: [1,KBC [ ] Chem 7 [ ] CAMP [ UA [ PT,PTT [ ] LFT's Frequency (such as STAT, Q-AM) 10. Type and Cross Units 11. PARAMETERS: Call MD T>101, SBP>180<90, DPB>100, Pulse>120, UOP < cc/ hr, RR>24 12. MEDICATIONS: ['(Morphine / 0 mg IV, Q hr, PRN Pain [ ] Demerol mg [ ] IM [ IV, Q hr, PRN Pain [xylenol #3, 1-2 PO q4hr PRN Pain [ ] Percocet 1-2 Q4° PO PRN PAIN [ ] Zantac 50mg IV Q8° [ ] Phenergen 12.5-25 mg IV/IM PRN N N ✓rOxygen @ 7 L per _A44 Titrate to keep sat > 92% []'Ancef Ig IV Q8° x tart aill•Be • [ ] Rocephin Ig IV Q12° [ ] Gentamycin mg IV load & pharmacy to dose [ 1 Cipro mq IV Q12° [ ] Clindamycin mg IV, Q hr [ ] Penicillin G, Million Units IV Q hrs [ Unasyn gram IV, Q hr [ ] Transfuse units packed cells 13. DRESSINGS: 14, DRAINS: 15. RADIOLOGY: f)-P nef)-74 777 z- -147/44 b)(6)-2 b)(6)-2 16. OTHER: (b)(6)-2 DOCTOR SIGNATURE: PATIENT IDENTIFICATION: FULL NAME: (b)(6)-4 FULL SSN: MEDCOM - 5188 ACLU-RDI 1260 p.41 DOD 12400 - Day Of Surgery ASP -z- E Vital Signs HOLDING AREA: Versed "--- mg IV Fentanyl —mcg N Ancef gm IVPB NAVHOSPPNCLA OVERPRINT (10.14) IV 16 20 ga inCY L Hnd /@/ AC START wr STOP CLINICAL RECORD .....,1 -rirugs / Equipment / 02 / Suction / Checked ANESTHESIA Anesthesia n031 6811•11=9111•1111Laill11111111110=1•11VIMIIIIIIMININIff Procedure 31 10 0a.3- UMIN PRE-PROCEDURE 1.1 J11.4 _ 1 1 I 1 1 1 1 1 1 1 1 1 Lamm= - I 1 ❑ MEM - 013and 0 Questioning P-St 44_ 1 1 1 1 1 1 1 1 1 d^srt Reamed ❑ Penal Sligned lire 4 - Jr-4- •••4- -4- -r - -1--4- NPO Sines 1 1 1 I - - -F-I- 1 1 i t- - 1 Preanesthelth Slats: ❑ Can PR / PEN / ETO 1 1 r-r 1 I 1 1 L 4 L 1 13--raake ❑ Anew MIYA / ATFI 1 1 1 1 1 1 _ - 1 - 1 1 -r-1- 1 1 1 1 ❑ noirpteherrim O Callused 1 1 1 1 1 1 1 1 1 1 1 1 1 1 T T- --I--I--11 -4-44 7 1 1 0 Uncecoreles ❑ Uruespaake Cs • 1 - 1 1 I--, - 4 1 - 1--t- PATIENT SAFETY 1 1 1 1 1 1 1 1 1 1 , 1 1 1 1 MB SIMI =MI 11111111111111 NEM Mil NM =MIN= MINE RERUN 1111111M crran. Maritu a Chicled Liapia-k-om 0, Casety ea On 0 Way Rol -4- 0.00mboard MOWS °Amelia/XI wU , To-T -4-4- a'Pressure poi* ducked and padded F10, 1 1 0.'Eye Caw 0 Gamer! 0 Seine Sa07% Levi_ 1 1 °A real ❑ Pads 0 Goggles . --I-- ANESTHETIC TECHNIQUE -r-r I 1 Game 04,8813.ypension 0 LTA 1 1 4 _1 CrITIVIO Sawn= naked Ream 1 1 1 I 200 WirdMiTirrIMEN nu G['Rawles0 Innalioran ❑ • .PULSE 1 1 0 Inverreseiev Rend ■ 0 -SPORT RESP 180 1 1 1 1 1 -f-i- Negionel: ❑ Spinal Epidual 0 .ASST RESP 1 1 / 1 1 1 1 1 1 1 I 1 1 0 Aviary ❑ Ea • 0 Snide Medi -1- • CURL RESP 1 1 I 1 1 1 1 1 - 1 -t- 1 Poetise 0 ■ VEIMLATOR P.O 0 LAW 1 -r ❑ Needs 140 - t-t 1 1 X CUFF M III MI MEI AIIMILUMEMI &DAN 1 1 1 Dose 0 AllerraPts IL— ,o,e) + ART UNE 120 sae O Level 4-4- came ❑ See Remarks X =KAP 100 , MAC 0 I • INTUBATE R • REVERSAL AIRWAY NANAGEts1EN T E • EMIRATE MI kluballens o Ilse sies.2,2,_ ETSFAIN iam 0 Nasal 0 Recilsr MIMIC MOE CI Maps Galria 0 RAE 0 Fiber epic 0 Ethel 0 Alreuness 0-11ede Ht 4C '7 0 USA 0-Seind at74_.m 0 ow um 0-Anerpa Ream 1-1- 011rassh sande 0-) 0 Unailed, Wks al ern E1.0 142111IMPTIIIIIINIMMIUMNI1 0-thalled alert occ. • 0. 0 NS 12:1112 Rm. —3 • MU OHM HIM EH HE HE MI ❑ 088:4 C=Mini MEM WWII lali OHM MR NM MR RIM IIIMUN IMRE NMI MIMI MR Cade 0 1/R13 sae Remoras 0 Mirk Cue 0 Nasal Carnes Ointhels to Romanis ❑ VII Aaaem. O Staple 01 male 2. 1.,1 941111 FLUID TOTALS Mood POSMON R REMARKS -) 2n 1irc tt d St M..11 •iw *. I,Ili .4 .68111 0 Record 0 E.* 0 Oiher oT e lfran-kwasite BP 0 Leh 0 ROI ay. I les (S1 sot. 00(7 Errontnucus EKG ❑ Vtyd EKG P IR 14, 5%.0 Crrul.• Oxlmeur ••1. Sensor 0 hats Eltteili 0 Mad C•h•n •411c110,4 g 0 Gas Antlyisr 8-1rrom 0 WWI* 0 Vssk Oen= ❑ ❑ Temp. ig-r Shinthatg Seardwil 0 Whaled 0 T-pOh• Orypwl ❑ Virilalor ❑ Onabsul away ❑ Wannip Shinichi ❑ (11:diad Warm O lkwouNable 0 Ainvay FiLrridirwir 0-1.6Q WNW PACU NOTES 0 NG/OG Abs 0 Art Line UST Parr ISIERGENCE God Suclionic CileiaUtt x 5 sac 0 5A1 &tuba.= MAKE 12rASLEEP CI ifIEM WW2- 1CIF 414 with 31.111TeLo ". ISSUED 5-6 -7 PROCEDURE SURGEON(S) ANESINF-Giel lol r use) a 5 b)(6)-2 0 Le ft.tr,:- L SWIM 011 7 PATIENT'S ID FICA • N (For typed or written entries give Name—fear, first, DATE middle. grade, date. hospital or medical facility.) L" (b)(6)-2 It. 103 ANESTHESIA Steriderd Form 517 Prissabod by GSA IC IR FIRMA (41 CFR) 201-45 SOS OCTOBER UPS 517.112 MEDCOM - 5189 ACLU-RDI 1260 p.42 DOD 12401 516-109 NSN 7540-00-634-4156 MEDICAL RECORD OR # t f, OPERATION REPORT PREOPERATIVE DIAGNOSIS oC tR)c SURGEC ' FIRST ASSISTANT SECOND ASSISTANT p)(6)-2 ANESTHETIC TIME BEGAN: C),ki) ANESTHETIST r)(6) -2 TIME ENDED: Cri' 23 Clpriu ATIKIn PJUDe= " /RCP •• TIME OPERATION BEGAN rigrorrErumori-COM- - (b)(6)-2 SCR (b)(6)-2jp OFSS PLETED t o OPERATIVE DIAGNOSES 5 A A DRAINS (Kind and numbef) SPONGE COUNT VERIFIED MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION OPERATION PERFORMED 0 (a) LE l (A.) 60 ).) it,tA A Le It gOs-X9.- a DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.). PROSTHETIC DEVICES DATE OF'OPERATION Pre-Operative Nsg Assessment: ' (LOT no.) Dentures: , 4E/ Implants: Allergies: .LP"' .Foley inserted by: Kb)(6)-2 NPO: N Safety Straps . "514\ Intra Operative psg Assessment Anesthesia: Prep: g2r Bovie Equip #: Irrigation: N5 Bovie Pad #: ✓ Medications: 0 /Blood Post Operative EBL: 1 0 0 Wound Class: 3 DSG: P/Aii‘"? aLTAA L U/O: Fluids : o Final counts: 1v /4- SIGNATURE OF SURGEON b)(6)-2 DATE PATIENTS IDENTIFICATION (For ryped or w give: Name • lase, first, middle; REGISTER/I.D. NO. WARD NO. ••,, de; date; he dical facility) b)(6)-4 OPERATION REPORT Medical Record STANDARD FORM 516 (REv5-83) Prescribed by CISA/1CIAR MEDCOM - 5190 FIRM (41 CFR) 201-44.505 ACLU-RDI 1260 p.43 DOD 12402 516-109 NSN 7540-00-634-4156 MEDICAL RECORD OR # OPERATION REPORT PREOPERATI E FY A IP Fx 2,1 •T-; 10//:-;& (5S1 LOIL 1 b)(6)-2 SURtEt FIRST ASSISTANT SECOND ASSISTANT ANESTHETIST 0)0)-2 ANErIEL TIME BEGAN: a;z s5 L.— I TIME ENDED: C90 LS (b)(6)-2 0 SCRIJR Nil 1RRF TIME OPERATION BEGAN TIME OPERATION COM- ',13)(6)-2 PLETED 00;-5"- Uet1-1/1111/h UlAtaNUbb DRAINS (POnd and rumba') SPONGE COUNT VERIFIED /4. Fr- -4. y MATERIAL FORWAF(DED TO LABORATORY FOR EXAMINATION dr' OPERATION PERFORMED DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings, etc.) PROSTHETIC DEVICES DATE OF OPERAT I Pre—Operative Ns ssessment: (LOT no) Dentures : Y Implants : 140L-4imecG‘c 0;4 11-1 I:. screw • 17 e/47°3 it77/°-2 Allergies : MN K Foley inserted NPO: Y (N) Safety Straps 414 Intra Operative Nsg Assessment Anesthesia : Prep: 5. Bovie Equip # : Irrigation : /1)/9-C-4_ Bovie Pad # : Medications: /Blood Post Operative EBL: 100 cc Wound Class : DSG: U/O: faOct Fluids • ,n /I LA " co-- Initial Counts: SIGNATURE OF SURGEO Kb)(6)-2 DATE PATIENTS IDENTIFICATIO N (For typed or written entries give: Name - last. first. middle; REGISTER/I.D. NO. WARD NO. rade' dale' hos • ital or medical facility) b)(6)-4 OPERATION REPORT Medical Record STANDARD FORM 516 (FtEv s-e3) MEDCOM - 5191 d by GSA/ICMR FIRMA (41 CFR) 201-45.505 ACLU-RDI 1260 p.44 DOD 12403 MEDICAL RECORD BLOOD OR BLOOD. COMPONENT TRANSFUSION SECTION I—TRANSFUSION REQUISITION ED BLOOD CELLS UNITS/ DATE9QUEST ,, DA? ND OUR WANTED PHYSI b)(6)-2 OTHER (Specify) OR...t ML / 7 a 3 ig,e 7b 3 /700 KNOWN IMMUNE ANTIBODY FORMATION PREVIOUS TRANSFUSIONS REACTIONS TO PREVIOUS TRANSFUSIONS ❑ Rh ❑ Others D Yes 0 No nknown Unknown 0 No 0 Yes (Type) o 'IF PATIENT. IS FEMALE, IS THEE HISTORY OF Iv zot uert, . Hemolytic Disease of Newborn 0 RhIG Treatment 0 Stillbirth 0 Miscarriage 0 Delivery REMARKS (Pertinent Patient History) I have taken a blood specimen on the below named patient , verified thyname, and verified the specimen - • .t p 'A WN ----,:b)(6)-2 SI 2.2 ?,2s.. VER1 E,•0)_2 --- — '"'' ' • led) c.4t..... I _ PATENT SG'. ATURE (or verifier if patient unable to sign) SECTION II—BLOOD TYPE, COMPATIBILITY INFORMATION AND CERTIFICATION TRANS mins NO COMPATIBILITY INFORMATION b)(13)-4 SALINE ABUMIN COOMBS MAJOR (DC/PS) 1:13CR 1+- MINOR (PC/DS) ❑ Compatibility Tests Not Performed (Explain below) ABC TYPE ABO TYPE REMARKS: Rh TYPE Rh TYPE sexp 4111103 VL ,414VItune (r. SCINAOURE ( Verifier, ilPequired) :b)(6)-2 ;b1(6)-2 DI • SECTION III—RECORD OF TRANSFUSION ADMINISTRATION POST TRANSFUSION DATA DATE OF TRANSFUSION MONTH (( 4 Li DAY e ANCLNI OMEN I V.7.4. ..ML I TIME COMPLETED/INTERRUPTED YEAR .200.2 ?St_ TIME STARTED /6 •3 REACTION:j&NONE ❑ SUSPECTED N.' ICENTFICATEN If reacti is suspected—IMMEDUITELY: I have examined the blood or blood component container label and 1. Discontinue transfusion; treat shock if present, keep intravenous blood or blood component transfusion form and I find that ail infor- open mation identifying the container with the intended recipient matches 2. Notify Physician and Transfusion Service item by item. The recipient is the same person named on this blood 3. Follow transfusion reaction procedures DESCRIBE: or blood component transfusion form and on the patient identification 0 URTICARIA 0 CHILL/FEVER 1:3 Hr :LYSIS/PAIN %31 o it s e ig 6e1560 r So RECORD: Temp t " ' I Pulse 'n B/P &riv 014 kYES ❑ NO Other difficulties (equipment, elate, etc.) 0 No Ve: Yes (Specify) 40...... E....T 4'1,1 v-nion RV ../^i b)(6)-2 IN STAMM TRANEFUSON SIGNATURE OF PERSON NOtb)(6)_2 )(6)-2 4. 4 v .411)., . r 6/73 V PATIENTS IDENTIFICATION—U6t tivoubLtc—iyilr typed or written entries give: Name—Last. first."7"- m-icia7.7E(— WARD NO rank/rate; hospital number and nante of facility.) b)(6)-4 'BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (17E1/. 9-76) Prescribed by GSA aid Interagency Committee m Medical Records FRvR (41 a9 101-11.806-8 518-318 MEDICAL RECORD COPY GPO 1982 0 - 381-531 (3530) MEDCOM - 5192 ACLU-RDI 1260 p.45 DOD 12404 MEDICAL RECORD BLOOD OR BLOOD. COMPONENT TRANSFUSION SECTION I—TRANSFUSION REQUISITION 'RED BLOOD CELLS UNITS et DATE7 770 DATE AND(t HOUR WANTED privsicuom-2 -K OTHER ( Sp ecif y) OR.. ML d 6 (a) IG 'N MUTE ANTIBODY FOFMCION PREVEDUS TRANISFUSICNS I NS TO PREVIOUS TRANSFUSIONS 0 Rh ❑ Others 0 Yes 0 No L14nknown Unknown ❑ No ❑ Yes (Type) 14 PATIENT. IS FEMALE, IS THERE HISTORY OF 0 Hemolytic Disease of Newborn ❑ RhIG Treatment ❑ Stillbirth ❑ Miscarriage ❑ Delivery REMARKS (Pertinent Patient History) I have taken a blood specimen on the below named patie erified the name, and verified the specimen tU I Lin i6n V() bX6)-2 eYe__ 5,K.L,;(6}2s cA PATIENT SIGNATURE (or verifier if patient unable to sign) SECTION II—BLOOD TYPE, COMPATIBILITY INFORMATION AND CERTIFICATION NT Nn TRAIV,V61)!1nN en COMPATIBILITY INFORMATION PX6)-e SALW AU3UMN COOMBS MAJOR (DC/PS) DONOR MINOR (PC /DS ) O Compatibility Tests Not Performed (Explain below) ABO TYPE ABO TYPE REMARKS: Rh TYPE Rh TYPE pcs Up. Li (n SIICNATIIRF (Person nerformina teats) DATE 921■1411SIE (Verifier, if required) b (6)-2 b)(6)-2 z D Guts fJe- ca Ng_ SECTION III—RECORD OF TRANSFUSION ADMINISTRATION POST TRANSFUSION DATA EWE CF TRMSRDON nrasrrH MY >7 YEAR Vt.) ki AmouNr TIME COMPLETED/INTERRUPTED TIME STARTED ((') REACTION: /NONE El SUSPECTED IDENTIFICATION: If reactio is suspected—IMMEDIATELY: I have examined the blood or blood component container label and 1. Discontinue transfusion; treat shock if present, keep intravenous blood or blood component transfusion form and I find that all infor- open mation identifying the container with the intended recipient matches 2 Notify Physician and Transfusion Service item by item. The recipient is the same person named on this blood a Follow transfusion reaction procedures or blood component transfusion form and on the patient identification DESCRIBE: 0 URTICARIA 0 CHILL/FEVER ❑ HEMOLYSIS/PAIN tag. REOCRD Tema 1 113 Pulse 1 43 B/P )3VR)41 S ❑ NO Other difficulties (equipment, clots, etc.) 7No Yes (Specify) S VIAIIIRF OF PFRCON STARTING TRANSFUSION SIGN b)(6)-2 cvic u5n) b)(6)-2 bX6)-2 PATIENTS IDENTIFICATION—USE EMBOSSER—(for typed or written entries Dive: Name — Last, first, middle. I SEX /719 r WARD NO. rank/rate; hospital n mber and name of facility.) u b)(6)-4 ( 17/ BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 9-76) Prescribed by GSA and Interagency Committee on Medical Records FPMR (41 CFR) 101-11.806-8 518-118 MEDICAL RECORD COPY GPO : 1982 0 - 381-531 (3534) MEDCOM - 5193 ACLU-RDI 1260 p.46 DOD 12405 7540-00-634-4162 / 519-218 PATIENT IDENTIFICATION (For typed or writfrn entries g(ve: AGE SEX SSN (Sponsor) . {WABD/D )... REGISTER NO. Pane — last. first, middle, Medical Facility) EXAMINATION HEQUES* SF 619-B for multiple exams) ;b)(6)-4 • FE.14()4 4/0 c& 2 G. r//361-.f /c )(4, REQUESTED BY TELEPHONE NO. r (6)-2 LOCATION OF MEDICAL RECORDS FILM NO. 'DATE REQUESTED PREGNANT NO I 0 •••1- S E. YES fl SPECIFIC REASON(S) FOR REQUEST (Complaints and findings) b)(6)-2 DATE OF EXAMINATION (Month, day, year) DATE OF REPORT (Month, day; year) DATE OF TF C R I PTION (Month, day, year) • RADIOLOGIC REPORT fr...„. -7-74,,,,_ -,,,- f /Lcs, —f- T ern ,Y ,y, E.,-)? e e . Ai?". ec. 51.,4-/krdtAm&i'L. c.9"- 1.3A-:,-24:- 11 rx 8:-,. 74.4-47 erirr/ a 4 Al hi-414, -1-1 ilk )41 77-4-b- vizi..il j 4k7 ? dili,e/4 C?4,,-, iht( "i ' h - / , : 4 a 7 , 4 .5 L 0- 4, v - lA J); A- hAi i-, - g ke,c SIGNATURE LOCATION OF RADIOLOGIC FACILITY 1 — MEDICAL RECORD STANDARDFORM 518-A (REV. S-83) RADIOLOG IC CONSULTATION REQUEST/REPORT Prescribed by GSA/ICMR (41 CM 201-45.505 U.S GOVERNMENT PRINT/NG OFFICE 1987-181-243/40522 FPMR MEDCOM - 5194 ACLU-RDI 1260 p.47 DOD 12406 "/J 1:31 3-\) • 7117. r` , ) w w 9,41 — 214171: 4111 -;4:0/72-C in S ) 6rer..1 MEDCOM - 5195 ACLU-RDI 1260 p.48 DOD 12407 NSN 7540-00-634-4121 DOCTOR'S ORDERS MEDICAL RECORD Sian all orders DATE AND TIME bX6)-2 OCTOR'S NURSE'S R X DRUGORDERS START STOP ,GNATURE SIGNATURE 1 . / , 4 ,, _ 4L79393 /Lain ,b)(6)-2 0? ,-o :b)(6)-2 CAS( W7/1 a t / - r, i -r'/ , 4 t - e 2 2— / ,,,,,,I.,..,... (2/ tri 1-0-et,- 4 ,e„..124,„-,... A..--i, // ,.,,,,,,,-/.4a...(,,,. ,4-- 6 ,..,,,,vt ,,,,e.. / 0 o. ,../Gt,$).44.-L. a/C.,-cilif ye T7 -e-tt_ C 4-6,-(4,-,-9 --- b41)(6)!2"1 0 3 1 1 ›D Li. - t Ai 1‘01 J6fri- LI 7 MPS L gil b)(6)-2 . 4.4 (21?. ) CrAti N CI lfz 1 2400 b)(6 )-2 1...... , IL "7- ier le CZ Cavv-pcer&-N-7 L-n b-,, (Continua on reverse side) PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, REGISTER NO. WARD NO. middle: grade: rank: rate: hospital a medical facility) :b)(6)-4 DOCTOR'S ORDERS Medical Record STANDARD FORM 508 (Rev. 3-94) Prescribed by GSAIICMR, FIRMS (41 CFR) 201-9.202-1 491111, MEDCOM - 5196 3e ACLU-RDI 1260 p.49 DOD 12408 DOCTORS ORDERS MEDICAL RECORD (Sign all orders) DATE AND TIME ril DOCTOR'S NURSE'S DRUG ORDERS START STOP c SIGNATURE SIGNATIM iffil elite IMRE MI I I• II 111 I I I. I III III I 1. I I 111 Ilil TO - A o irli f e eT iii b)(6)-2 , • al • 10 . ea/A dlli L_ CIVD • is IL Asi °A kLIIAA LOO a. L. IA khr.IIMI A■i f- k mffi, M... 1...11rr.., AW 'a 41,....‘ (19113 goo() orLooti .C10 T 1)0 / 7 it./1-AlSci4.4 602 sb)(6)-2 L.7 / of...i__ b)(6)-2 2. 6"---41-- o 1111 - rce--e f...4...... 4 b)(6)-2 b)(6)-.1111M2 11 4o.iii 2; 1.-GP•IF IE _# - . b)(6)-2 Ai b)(6)-2 til■ ./....low_---fraw -...7via-"-b)(6 -2 rmi , ,,, ./ A 93, ... 64...,„ 1 . ... - b)(6)-2 b)(6)-2 b)(6)-2 MD • _ _ titErgiaAra b)(6)-2 (b)(6) -4 STANDARD FORM 508 (Rev. 3-94) BACK MEDCOM - 5197 ACLU-RDI 1260 p.50 DOD 12409 Post-Op Orders Date Time 1-/- (P-0 ", 1. ADMIT TO: [ ] ICU [ ] WARD 1 [ ] WARD 2 M. WARD 3 2. DIAGNOSIS/PROCEDURE (print): /0 _7; eP A.4 L.,--(tz, 27 cjrc a VITAL SIGNS: []'Per Post-op Routine [ ] 04hr ' K3edrest [ ] Up with Assistance 4. ACTIVITY: .. . 5. ALLERGIES: 6. NURSING: [ ]1/0 [ ] Foley to gravity [ ] NG to LIS [ ] Crtiii-,29CM H2 O Suction [ ] IS Q1° while awake 7. DIET: [ ] NPO X...Beg ) [ ] Clear Liq [ ] Full Liq 1 a IV FLUIDS: [ ] Lactd-Rngr § CC/hr ( ] Normal Saline (4 CC/hr 9. LABS: [ ] CBC [ ] Chem 7 [ ] CAMP [ ) UA [ ] PT,PTT [ ] LFT's i Frequency (such as STAT, Q-AM) 10. Type and Cross Units 11. PARAMETERS: Call MD T>101, SBP>180<90, DPB>100, Pulse>120, UOP < cc/ hr, RR>24 12. MEDICATIONS: 171 Morphine • I 0 mg IV, Q hr, PRN Pain 1 3 Demerol mg [ ] IM [ ] IV, Q hr, PRN Pain b.? Tylenol #3, 1-2 PO q4hr PRN Pain [ ] Tylenol, 325 mg, 1-2 PO q4hrs PRN [ ] Motrin, 800 mg po q8hrs prn [ ] Zantac 50mg IV Q8° [ ] Phenergen 12.5-25 m g IV/IM PRN N N 1 1 Oxygen © L per Titrate to keep sat > 92% b4rAncef lg IV 08° ye.... V,fir.3 [ ] Rocephin I g IV Q12° [ ] Gentamycin m g IV load & pharmacy to dose [ ] Cipro mg IV Q12° [ ] Clindamycin mg IV, 0 hr [ ] Penicillin G, Million Units IV 0 h rs [ 1 Dicloxacillin, 500 mq PO q6hrs [ 1 Keflex, 500 mg po q6hrs ] Milk of Magnesia, 30-60 cc po qhs pm constipation Benadryl, 25-50 mg po qhs prn insomnia Transfuse units packed cells 13. DRESSINGS: st-z,„J 14. DRAINS: 15. RADIOLOGY: 16. OTHER: b)(6) 2 (b)(6)-2 NW A DOCTOR SIGNATURE PATIENT IDENTIFICATIO (b)(6)-4 FULL NAME: FULL SSN: MEDCOM -5198 Modified 4 April 2003 ACLU-RDI 1260 p.51 DOD 12410 CASREC PROCEDURES TIME NOTES/PLANS: ❑ Oral airway Nasal airway EOA/PTL Cuff BP Cc - 11Y0A-AA- ❑ ETT # ❑ NTT # RSI Pulse 7,o a.9 1:1 Crico # ❑ 02 @ L./Min via Resp Breath Sounds: L: R: Temp ❑ !Vs* OP eripheral ❑ Central ❑ Intraosseous 02 Sat ❑ IV Fluids 1 2 3 4 5 6 ❑ Blood 1 2 3 4 5 GCS ❑ CPR PASG: ❑ Legs ❑ Abdomen Urine Out ❑ Urinary cath ❑ Gastric tube Blood Out 0 Chest tube: ❑ R ❑ L 0 Both Fluid In ❑ C-spine protection ❑ n pipe protection, Time on: Blood In ❑ S Ints Type: 0 edicalions: p c i C r 41\g' ADMISSION ORDERS 1. ADMIT TO: R/PREP [ ] ACW ] ICU 2. DIAGNOSIS (print): A-d h r;119 r1(1 3. VITAL SIGNS: 1° [ ] Q4° 4. ACTIVITY: edrest [ ] Up with Assistance 5. ALLERGIES: 6. NURSING: "1010 [ ] Foley to gravity [ ] NG to LIS [ CT to -20CM H2O Suction ] IS Q1° while awake 7. DIET: [NPO [ ] Reg [ ] Clear L iq [ ] Full Llq a IV FLUID-6: [Inactd Rngr 6,4512CC/hr [ ] Normal Saline @ CC/hr 9. LABS: [ .]CBC [ ] Chem 7 [ ] CAMP ( UA [ PT, PTT [ J LFTs [ ] NOW [ ] am [ ] Type & Cross units 10. PARAMETERS: Call MD T>101, SBP>180<90, DBP>100, Pulse>120, U.O. < _j_hr 11. MEDICATIONS: [ ] MSO4 mg, Q hr PRN PAIN IV Demerol mg, Q hr PRN PAIN IV [ 1 Percocet 1-2 Q4° PO PRN PAIN [ ] Zantac 50mg IV Q8° [ 1 Phenergen 12.5-25 mg IV/IM PRN N N [ Oxygen @ L per Titrate to keep sat > 92% [ 1 Ancef I a IV 08° [ ] Rocephin I g IV Q12° [ ] Gentamycin m g IV load & pharmacy to dose [ ] Cipro mg IV 012° [ ] Clindamycin mg IV, Q hr [ ] Unasyn gram IV, Q hr [ ] Transfuse units packed cells 12. CULTURES: 13. RADIOLOGY: [ ] Port CXR [ ] KUB b)(6)-2 DOCTOR SIGNATURE: PATIENT IDENTIFICATION: (b)(6)-2 FULL NAME: CDR MC USN STAFF FAMILY PHYSICIAN FULL SSN: l(b)(6)-2 MEDCOM - 5199 ACLU-RDI 1260 p.52 DOD 12411 • 4p RECEIVING INITIAL ASSESSV P IDENTIFY INJURY SITE BY LETTER CHIEF COMPLAINT: AIRWAY er„...cyaal ❑ Compromised C-SPINE Normal ❑ Suspect Injury BRWHING MECHANISM OF INJURY Normal ❑ Tracheal Deviation ❑ Resp. Distress ❑ Tension PTX ❑ Chest Wall trauma HISTORY CIRCULATION I 11 ❑ Pale A -Abrasion F - Fracture T - Ternderness Allergies: AA/ Skin/mucous: ..er/Pink ❑ ❑ - Medications: Membrane color Flushed Jaundiced - Bum G GSW O Ashen.... 0 Cyanotic C - Contusion H- Hematoma past illnesses: V AA Pulses: Normal, Site D - Deformity L - Laceration ❑ Bounding, Site E - Edema S - Stab rund ❑ Last Meal: Last Tenanus: Weak, Ske 12E AM ❑ Events: Absent, Site IIMIPMEM111111111111=11111111 Rite D /minute Rhythm Pregnant? ❑ Yes ❑ LMP ❑ No Skin temp: Warm ❑ Hot ❑ 9ol/cold EMETIMrargyrifpgMl Spine protection device removed @ Skin moisture: WNL n Dry rd/Moist DISABILITY PROCEDURES BEFORE ARRIVAL GCS Score: Eye opening score /4 Oral airway Nasal airway EOA / PTL Verbal score /5 n (7:5— Err # NTT # RSI Best motor score /6 clic° # 0 02 @ Umin via TOTAL GCS SCORE: f /15 ■ Breath Sounds: L: R: RTS Score: Respiratory score INEWL4111.111 111111= 'vs # ❑ Peripheral ❑ Central ❑ Intraosseous Systolic BP score WM" IV Fluids 1 2 3 4 5 6 0 Blood 1 2 3 4 5 GCS Score Abodornen: ❑ CPR ❑ PASG: ❑ Legs Abdomen TOTAL GCS SCORE: I -K • Urinary oath ❑ Gastric tube Chest tube: ❑ R ❑ Ln Both Right Left C-spine protection ❑ Spine protection, Time on: Pupil Size: mm 7 Splints Type: Medications: _Reactive? ❑0 Musculoskeletal: 7 Otherprocedures: Aims move? LG Immatcermortaffogizi ((FIE legs move? ❑ El WiTMEMIPMFAI■1 "maiiummigumm. LTi PATIENT IDENTIFICATION: FULL NAME: FULL SSN: :b)(0)•4 MEDCOM - 5200 ACLU-RDI 1260 p.53 DOD 12412 £1, 17Z1, 000 ACLU-RDI 1260p.54 i Medication Medication Pa Pled iz.inc.X15 !(2 len b)(6)-4 3-ti P • ° rot_ 6 ma Date/Time O \Op I1, l ii i 7 i 43 1- 11 V 4 Dose/I nit Do se/Init . dot 0 Date/Time Yif . i:i z,jr p 3 1 Medication 6 14-- . -- - Dose/In it 4, 61 ONE TMEMEDS 2. 9 PRN/ONE TIMEMEDS PRN MEDS MEDCOM -5201 60 im Date/Time Date/Time ;1.., "-- 2,bp,6 4 iii 9 Dose/Init Dose/I nit . Medication Date/Time w.6„ , bx )4 Dose/I nit ' Date/Time Date/Time or ) Seri clifi Dose/Intl a Dose/I nit (— -,..... _ _ ACLU-RDI 1260p.55 pul awry IINII Hul IND!' !UI aupi aliflIVNOIS HUI OUJU aZ10338 NOUVW.LSIAIIIVad 7V3I(THIN 111.11 ZOZg -lA10003V\I auu liui aiuu ilui awl' —, j2L9 b 1-, ;pi auni . Oahe I cx4c, gm . Z{91!9 Hui (q $ 6 COW ow outi umi. WITI z-(9,s,0 Nu' L cloll CONe .00SC - ooh( w!1 }I . • ."4-4001 gl pc)ri070 ri/ 0 • 7;67N1 Hoc' 5 000 , -.1 1 f l eAl try) P 'I lug l a iJ3?Pli ( uogeolpavy 9 (i) .1..ss.) n-A tip De - r"- - rxd e - 0 algia qtrti I - PE(' , /1, _ ic , 1 DOD 12414 CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency Is 0 rSG DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD TEM IS uSE D. WHITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. VEN T IDEN T IFIC A TI O N DATE OF ORDER TIME OF ORDER LIST TIME CJ) ORDER 27 <-1/ '' ) NOTED AND :b)(6)-4 4 HO SIGN :I-. , I / 1 4 ". . ,1 A ;SING UNIT ROOM NO. RED NO. IENT IDENTIFICATION DATE OF ORDER TIME OF ORDER rY tel._ _._—_ L., '7 ( +— 12 6 Vt 10 4 bI(6)-2 tDINC. UNIT 'ROOM NO BED NO. itiNT IDENTIFICATION DATE OF ORDER TIME OF ORDER HOURS ifs a_v Q Cc) p) -0 c ISINO UNIT ROOM NO. BED NO. ,b)(6)-2 !ENT IDENTIFICATION DATE OF ORDER TIME OF ORDER- HOURS iSINO UNIT ROOM NO. BED NO. REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED. I r49"Mg 4256 MEDCOM - 5203 ACLU-RDI 1260 p.56 DOD 12415 THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) 4 CLINICAL RECORD For u e of this form, see AR 40.401; the ro anent ag ocy is the Office gf The Surgeon General. Yr.35 V E R I F Y B Y I N I T IA L I N G ;NNW .1ing 1 MEOMME: ;MEM INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION ORDER CLERK! RECURRING ACTIONS, HR DATE COMPLETED DATE NURSE FREDUENCY, TIME - S (P i LI . wow V 1201A1 KIL__I % 1 111 / 13)18)-2 . i ra b)(8)-2 0)(61-2 01/4.c.162.0 I, 0 i - 1 0x6}2 II -z3 , 13)(0)-2 61(.1 • - 13)(8)-2 rj ii21._ .LO n. ir"-- b b)(8)-2 ALLERGIES: I i YES 1 I NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE ill YES IIII NO +Tr Li a_ —4 PAGE NO: PATIENT IDENTIFICATION: ACTION TIMES ;Is)(6)-4 USE PENCIL CRCLE ACTION TIMES 0 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 01.00 MEDCOM - 5204 ACLU-RDI 1260 p.57 DOD 12416 Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing .1* ON ' -MEDICATIQN) M0 Order Clerk SINGLE ACTIONS . Date to Date Nurse Time to Time Dene Initials b)(6)-2 be Bone be Done kJ Liki • \ -- 41) Mt/ 34 5(1-1 de)ite.—. Dc_._. 4, 1 L• Q. (11 Avik 5/5 4, Ca 0 c__ 1--0 5/(,, Order! Clerk/ Nurse PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION ACTION. FREQUENCY TIMEIDATE COMPLETED USAPA VI.00 MEDCOM - 5205 ACLU-RDI 1260 p.58 DOD 12417 THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) CLINICAL RECORD For u e of ihi form, 313B AR 40.407; MO. Y ncv is he Office of The Suroeon General. s kheE rip front a; VERIFY BY INITIALING enr,anatERNEF•11.,.:40A INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION HR DATE DISPENSED ORDER CLEM RECURRING MEDICATIONS, DATE NURSE DOSE, FREQUENCY -I _ . ALLERGIES: III YES 1111 NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE 111. YES • NO PAGE NO. —1-1•1.) e& .-_ rie. 1 • i r I PATIENT IDENTIFICATION, DISPENSING TIMES :b)(6)-4 USEPENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06 DA FORM 4678,1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA 41.00 MEDCOM — 5206 ACLU-RDI 1260 p.59 DOD 12418 i I i Verify by THERAPEUTIC DOCUMENTATION CAAE PLAN I MO ' Yr. I Initialing (MEDICATIONS) DUB to Time to Order Clerk! SINGLEORDER. PRE.OPERATIVES he Given be Given Time Given Initials I Data Nurse I I I -- • I • INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION Order! Clerk/ PRN Nurse MEDICATION, DOSE, FREQUENCY TIMEIDATE DISPENSED Ell*Dkate -M - • 9• tors.2 ti .6 im iv I tlf-') 5C. 5rnilvf 5 64212ii API 10(8)-2 ..... 1 .0. I V AivAs _r_ a.:71 tk-t, a ■ C ell 13)(6)-2 a fii .)(8}2 eD ab 4-L: 1-i ( ?ge 'IA b)(6)-2 • ../.4%° (b)(8)-2 EXE—.. LI mi 6 yi, 6° i° M EDCOM - 5207 ACLU-RDI 1260 p.60 DOD 12419