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1774 IA Fctre Ralivaymeon 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 .
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