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SPONSOR'S ID NUMBER (SSN or Other) LAST
SPONSOR'S NAME
FIRST MI
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5)1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(10',
USAPA V1.00
Jr/
RELATIONSHIP TO SPONSOR
DEPART./SERVICE
WARD NO.
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO ID No or SSIV• Sex; Date of Birth; Rank/Grade)
I HOSPITAL OR MEDICAL FACILITY I RECORDS MAINTAINED AT
MEDCOM - 23641
MEDICAL RECORD ,-,,.. ,.,,,,.,-.,, run LOCAL REPRODUCTIO
PROGRESS NOTES
DATE NOTES
1PAArq3 !Plc f 4 5 -(..
c, e(„il (reites-vl170-\--01
A---) t t)--1/7 --cp 74 .12-44e ♦ -7A-- ,f/) 23",e5L--d
1--
0
• .
DOD-037219
ACLU-RDI 1682 p.1
MONTH-YEAR
DAY
19
HOUR
PULSE TEMP. F
(0) (°) 105°
180 104°
170 103°
160 102°
150 101°
140 100°
130
99° 98.6°
120
98°
TEMP. C
40.6 °
40.0°
39.4°
a) 38.9 °
38.3 ° rr
37.8°
37.2 °
37.0° cr
36.7 ° -0 Lt!.
36.1 °
35.6°
35.0°
I I :
4 • •
110 97°
100 96°
90 95°
80
70
60
50
40
RESPIRATION RECORD
BLOOD PRESSURE
1111111111111111111111111111111111111111 111111111 2111111111113 MINIM
0 0
HEIGHT: WEIGHT --O.
C :0:
• • •
•
•
•
co co
7.5 co
0
WARD NO.
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
DOD-037220
511-119
' MEDICAL RECORD VITAL SIGNS RECORD NSN 7540-00-634-4124
HOSPITAL DAY
POST- DAY
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO.
MEDCOM - 23642
ACLU-RDI 1682 p.2
73-113 rn , :ttl
7-22
3.34.7 rm-floVi
98-103 rarao111
18-33 rr..-noLl
WardiSectior 4A/Uc-
LAST, FLRST, MI.
REQUESING PiiC
GLU
! REFERENCE RANGE: co(5-40- 08/11/03
11:04
PATIENT #:
PICCOLO
5 BASIC META DISC LOT #: OPER #:
- SERIAL tCO2
_ .......................... au 112 73-118 MG/DL
BUN 7 7-22 MG/DL. TEST
- CA++ 9•7 8.0-10.3 MG/DL a.,13
CRE 1.1 0.6-1.2 MG/DL r_
NA+ 147* 128-145 WO M- W 'r
K+ 4.5 3.3-4.7 WOK LT
CL- 106 98-108 MMOUL
c tCO2 24 18-33 MMOUL 4Y
TEST RESULT I REF. RANGE
Na I r 13E - 14-6 namoIlL
€44.74- 47s
TEST I RESULT ?ER
I ALB
LAR PAN L-L ;1-E6g I
DISC LOT #: 3154AA7 OPER #: DR #: 000 SERIAL P
i/
ALB
4.0 3.3-5.5 G/DL ALP
88* 26-84 U/L ALT
35 10-47 U/L AMY
36 14-97 U/L AST
36 11-38 U/L TBIL 0.6 0.2-1.6 MG/DL GGT
13 5-65 U/L
TP
7.3 6.4-8.1 G/DL
INST GC: OK CHEM GC: OK HEM 2+, LIP 0 , ICT 0
3325AAI DR #: 000 CL
NAT
CAT Cu:
INST OC: OK CHEM GC: OK
S.2 HEM 2+, LIP 0 , ICT 0 CI
8.0-10.3 rr..edl
0.6-1.2 ruz/di
28-145 rr.rr.oli!
3.3-4.7 rt.-r.ril/i
98-108 mrro1/1
18-33 mrr,o1:1
JT TO-TEAILSTRY RESULT FORM (S1111ject to thc ?rivacy At of 1974)
TIME SSN/PSE.L'DO CqGT c-f
TEST Rc:S1_,T1"-- GE
(Ptcco1o)Liyerpn Plus
RESULT REF. RANGE
3.3-5.5 gill
26-84 ILI
10-47 till
14-97 till
11-38 WI
0.2-1.6 Cag/d
5-65 till
6.4-8.1 g/.1.1
I T 'RESULT REF. W.'GE
128-145 mmolA
K'
:L .
CO2
REPORTED NV: I DATE: 1 LAB fD NO.: ------ I 1
1
N4-23643
0
DOD-037221
ACLU-RDI 1682 p.3
14-18 r4:10,..f) 12-16 /c11 (i: 42-52% (M) . 37-47% (1--)
I 80-94 fl•(M) 81-99 11•(1)
Hct.
MCV
Segs MOM
Bands
Eos
Lymph
Baso
Atyp Imm
RBC Morph
pascioisinUric: . - •••• •-•
Spun liematocsit
42-52% (M) 37247°I; (F)
rckard./Section: • • - - — ..1
LAST, FIRST,.M1.
1- eroato .•. RESULT 5-EST 1 F
4.8-10.8 z 10'
::. 10• (-- "-‘ 1 ""r i 57C -6..., A.:;71 -NIA
(lit.: I N-7-batiVr-
13ili I Negati
Ket J Nevive NC 4
• !Urinalyses - , ogy:
N/A
REF. R.-LVGE I TEZT I RESUtT REF. -iNGE
Plt
Lymph %
RPR
I Mono
?NG&
Negative
Nfic rob iolo-gy Hgb
Blood.Ba.1c • .-- .. •
.. •
I LABORATORY FORNI Sub;cct to Ezc Privaci' Ad of 1974)
SSNiPS
TEST
R_BC
Sed Rate
Other
. • • ■
TEST 'RESULT_P_EF..-RANGE
17 I 1 9.8-13.6 secs
.A21T I i 21-34 secs
D &me:- j <20
rDp
REMARKS:
REPORTED BY:
<10
Cell 0:-.Anat
.._.• • MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
.4BO/R1-t I
= .Blood: Bank Unit 2-os:switch' (MUST, uBNut SF: 518.WITH: EVERY Qv BLOOD
ItEQLrESTED) UNIT i TIPE CROSS.L.fiCif
DI rcctlgen Negative
MEDCOM - 23644
DOD-037222
ACLU-RDI 1682 p.4
6)(c) Y
1111111111 08-11-03
10:50 Patient Limits
UBC 11.9 H x10"3/uL 4.5 10.5 RBC 5.48 210"6/uL 4.00 6.00 Hgb 15.7 g/dL 11.0 18.0 Hct 49.8 I 35.0 60.0 MCV 90.8 fl 80.0 99.9 MCH 28.7 pg 27.0 31.0 MCHC 31.6 L 33.0 37.0 Plt 231. x10"3/01 150. 450. LYZ 11.1 *L X 20.5 51.1 LY1 1.3 * x10"3/uL 1.2 3.4
RAPIPPnTmi SERL
a ) - Patient ID:111111 Test Name :PT Test Result:= 15.5 sec. Ratio = 1.3 Calculated INR = 1.47 Sample Type:citrated wh. blood Test Date :11/08/03 Test Time :11:01 Card Lot GYM} Operator
RAPIDPOINI COAG ANALYZER V4.54 SERIAL #005485 11/08/03 11:04
C6)(6) Patient ID:111111V Test Name :APTT Test Result:. 25.2 sec. ***RESULT OUT OF RANGE*4 Sample Type:citrated wh. blood Test Date :11/08/03 jest Time :11:02 Card Lot Me C 6)(-6') - 2-
Operator
MEDCOM - 23645
ACLU-RDI 1682 p.5
PATIENT IDENTIFICATION! DATE OF ORDER TIME OF ORDER
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.
DATE OF ORDER
fAIOV 63 TIME OF ORDER
// LIST TIME
ORDER NOTED AND
SIGN
URSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.
HOURS
NURSING NIT ROOM NO. ED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
Nu :776 (!ROOM NO .
/0 DA IFArm19 4256
3 @ 0 (60 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23646
HOURS
PATIENT IDENTIFICATION
CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-037224
ACLU-RDI 1682 p.6
For THE
DOCTOR SHALL RECORD DATE, SYSTEM IS USED, WRITE PROBLEM N
PATIENT IDENTIFICATION
CLINICAL RECORD - DOCTOR'S ORDERS use of this form, see AR 40-66, the proponent agencyis
UMBER IN COLUMN INDICATED
OTSG
BY ARROW BELOW. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
NURSING UNI
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
NURSING UNIT
REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED
MEDCOM - 23647
DOD-037225
ACLU-RDI 1682 p.7
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MEDICATION)
For use of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon General. MO. \ ( Yr. 2003
VERIFY BY INITIALING ; .,S., ' 'k.i4 . i,' im: gigyarie,-..„ .c<wisti INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
CLERK/ NURSE
RECURRING ACTION, FREQUENCY, TIME
HR DATE COMPLETED
4 (6 wc, ---2
6(a5-;-. Alit " k- )?Pr -RC:CC \il * ∎
. 4-1Q / I
cfra •.b;..)- , p_if.....3,\,,-- T . % b2,
RID bc,_5,km id) au chnyi- (f1-*PvtAitee-tc-,5 77
ALLERGIES: 11.1 YES l' NO
1\1■ P\ PRIMARY DIAGNOSIS:
PAGE
ADDITIONAL PAGES IN USE: YES MN NO
NO: Sc-W--PeNEL__ tKvso47--r p. c--t-AE
PATIENT IDENTIFICATION:
ACTION TIMES
AM. ( 6)(0-4'
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 - 23648
DOD-037226
ACLU-RDI 1682 p.8
M ')
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION ) Mo \\ yr 2003
Order
Date Clerk Nurse SINGLE ACTIONS Date to
be Done be Time to
Done Time Done Initials
Y\ftV t\c\rc-i\ ---b \CW I ( cx-NOvi---vcx\-- S)sci-_c___ (68 Lak9s - 'cp (Ds
- -
•• . A
■.. .... ■ ■..
0.• ■ ■• maw
... ... '..
'. ... .... I
. ..
.. ... ...
... ... •
... •••• ■•• ■
• • 1 • a■ ■ ■•
■• -
Order' FapIr Date
ClerW Nurse
PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED 65 10 —
ON.k-__,\_,fq) AC-I': K..0— •WIL.-(0.9.0 ( 44_
- - - - - - - - ... _ _..... _ MO NM ■1
.... .... ....
=a ■ ■•• ■ ...b .... .... ■
ow. ■• .... .... ..... .... .... ■
MEDCOM - 23649 USAPA V1.00
DOD-037227
ACLU-RDI 1682 p.9
PRIMARY DIAGNOSISt
Ar_4=1\IEL (1Nuue)/ e ADDITIONAL PAGES IN USE,
OYES c-j NO
I THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) I m0. 1 yr. co CLINICAL RECORD For use of this form see AR 40-407; the proponent agency Is the Office of The Surgeon General.
VERIFY BY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER CLERK/ RECURRING MEDICATIONS, HR DATE NURSE DOSE, FREQUENCY
P5 — 11111
2
•
DATE DISPENSED
IVF—
\\/?€39 BcD
9:k
CC )-
PATIENT IDENTIFICATION:
von
ALL ERGIEM El YES pi 0
N\
PAGE NO.
DISPENSING TIMES
JSE PENCIL CIRCLE MED TIME S
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 1 FFCM9 4678 EDITION OF 1 r-- - -
MEDCOM - 23650 HAUSTE D.
DOD-037228
ACLU-RDI 1682 p.10
•
-68 032_3 3 pol ; T. LAS ly-G) ... '..1 RANK /GRADE p MALE / HOMME
FEMALE/FEMME SSN/NUMERO MATRICULL SPECIALTY CODE ,01,11& RELIGION/ RELIGION
L. UNIT JUNITi 4
FORCE /ELEMENT NATIONALITY / NATIONALIT,
f al P.IT AF/Al TAM MOM
SIC/BC I NBI /BNC I DISEASE /MALADIE PSYCH/ 3. INJURY / BLESSURE
FRONT/DRY/TNT RACE/RARER!
.., AIRWAY /TRACHLE . , ...
HEAD/TETE
WOUND / BLESSURE
NECK/BACK IRISES!
BLESSURE AU COU/AU DOS
BURN/ BRCILURE
AMPUTATION/AMPUTATION
STRESS /TENSiON
■
OTHER (Specify) 1 AUTRE (Spteller)
•' 1,,,p....roki.1 (s.t.,...o . jr- 4
,.... -7\-- - ) in Li•Z 4 •--: .f.% U ...
es
:
f 4. LEVEL OF CONSCIOUSNESS / NIVEAU DE CONSCIENCE
ALERT! ALERTE Xi PAIN RESPONSE / REPONSE A LA DOULEUR
VERBAL RESPONSE! REPONSE VERBALE UNRESPONSIVE, SANS REPONSE
S. PUPOULS
.... 6) I TIMZ1SE V TOURNIQUET/ GARROT
110/140N ri VES/ OW
I TIME / HEURE
7. M DM /MORPH 0 SE/DOSE ri NO/ NON' YES/OUI \,...,
I TIME/RUSE! I I L IV !IV le; MAE , KURE
S. TREAT,/ ENT, OBS Anon's/ CURRENT 1.11 11/31:611011 I ALLERG1 7 Rain(N IANTATTE) TRAIL5tir ca7t110115 , PRESENTE NI KA vs. _.
•F • • N \Z.-.
1, .„..... -.-- pet
c 1 454-4 C1 1 t PA
'
I ■
. 1
- . •1 „,. • - , / JO i f r- ., J-T--_ • L • . -
. 1 ADA •
.
p• r 4. •••••••C - • , i•
•-') S i
%,..
f VA. /1" . 57c, 2 -: 10 CPT
16 D1SPOSMON , E5TURNED YDDLITY I RETOUR A L'UNITE ( WPM
11. PROVIDER
D Form 1380. rmira....u...................._ — ---
,.. ..- 2.-- kiktI)EURE
C11111 D
— -- el 131,04rd OD haw'
. . FICHE MEDICALE DE L'AVANT ETATsIDNIS
L CARD IMMO, ESH ERR atsokte.
DEC 91
MEDCOM - 23651
ACLU-RDI 1682 p.11
28 29 27
B. DATE OF BIRTH (Y Y Y YLIMDD)
19 20 21 22 23 24 25 26
7. AGE AT ADMISSION 9. ETHNIC
31
I
BACK. GROUND
8. RACE
30
16 17
" l i RELIGION
63 62
53 48 54 55 57 47 .59 60 61
69 67 66 64 70 65 68 'NO
49
17. UNIT LOCATION (Stale or. Country Code)
PREY ADMISSION
YEAR
19. TRAUMA
71
29. DATE INITIAL AD LOSS ON (Y Y Y YM.MDD)
115 116 1 117 118 1 119 1 126• 121' 1 .122
27, LOCATION OF OCCURRENCE
107 (Sallie Casually Only)
28. MTF OF INITIAL ADMISSION
109 110 111 112 113 108 114
. REPORTING MTF
2. a2 F LOCATION
ADMISSION AND CODING INFORMATION 1
A
2 3 4 6 (Slate or Country Code.)
For use of this form. see AR 40-4D0; the proponent agency Is OTSG
REGISTER NUMBER
NAME (Last, First, Middle inilla0
4. PAY GRADE
5. SEX
10. LEN 11. RAP
12. SOCIAL SECURITY NUMBER
32 33 34 45 .
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
HOUR OF
BRANCH / CORPS
46 ADMISSION
14. FLYING STATUS
15. BENEFICIARY CATEGORY
18. LP CODE OF RESIDENCE
20. SOURCE OF ADMISSION/ AUTHORITY FOR
WARD
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72
• ADDRESS OF EMERGENCY ADDRESSEE (Include 7.1P Code
__ • NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
• TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
73 74.
24, CLINIC SVC - ADMITTING
22. MTV TRANSFERRED TO
75 76 77 78 79 80
25. MTF TRANSFERRED FROM
23. DATE OF DISPOSMON (YYYYMMOD)
(
81 82 83 84 85 86 87 88
QO Z. 1 ( 28. DATE THIS ADMISSION (YYYYMMDD)
89 90 • 91 92 93 94 95 96 97 98
100 101 •102 103 104 105 108
cc/
2 0
5
O
FOR LOCAL USE
WI/ ADMITTING OFFICER (Signature, as required) SIGNATURE OF ADMITTING CLERK
DA FORM 2985, MAR 2000 EDITION OF MAR a9 IS OBSOLETE USAPA V1.00 MEDCOM - 23652
DOD-037230
ACLU-RDI 1682 p.12
1. Reporting MTF (.)(2._)2&TF Locati_.,
IZ Admission alga boding Information
rvi ubC VI U115101111, see HK 4U-400; the proponent agency is OTSG
3. Register Number ame (Last, First, MI) 0)(6) — 4-( O -
MONCO
4. Pay Grade
FGN
5. Sex
M
6. DoB (YYYYMMDD) 7. Age at Admission
UMW 27Y
8. Race
X
9. Ethnicity
9
Religion
10. Length of Service ETS 11. FMP
99
12. Social Security NyCrrp.suf Warsa(b)) 7. i
Organization (Active Duty Only)
i.
13. Marital Status Hour of Admission
10:35
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
DIS
Prey. Admission
NO
20. Source of Admission
Direct from ER
Ward:
ICW1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Name and Location of Medical Treatment Facility: IIIIIIIIIIIINk(lrVll Provided
Telephone Number of Emergency Addressee
21. Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-11
24. Clinic Svc - Admitting
-
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-08
27. Location of Occurrence
[--
28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-08
1 FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: SHRAP INJURY L CHEST
Procedure Narrative(s):
Cause of Injury Narrative:
1--- Admitting Officer (Signature, as required)
---
Si natur of Admittin C rk W — Z-
Automated Facsimile - DA FORM
MEDCOM - 23653
DOD-037231
ACLU-RDI 1682 p.13
21. Source of Admission
Direct from ER 22. Hour Of Adm:
10:35 23. Clinic Service
AAA - INTERNAL MEDICINE
24. Name/Relation of Emergency Addressee
27a. Address of Emergency Addressee
25. Type Disp TRF-OTH
27b. Telephone No 28. Date This Adm:
2003-11-08 AdmittingOfficer:
( 0(60) —rp■ 29. Reportin MTF
DOD-037232
( 1°) 012) —
31. Selected Administrative Data
Marital Status: Z
In/Out Patient: Inpatient
I
• • ivicivt mck, l)111_,-:1;LoVtli SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
3. Grade
FGN Admission Remarks
6. Race 4. Se(
M 7. Religion
11. FMP
20
15. FlyStatus
13. Organization
17. Dept / Ben
K78-PRISONER OF WAR/INTER uic ZIP
14. Ward
ICW1
20. Type Case
DIS
12. SS
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
INTRATHORACIC SHRAPNEL
35. Total Days This Facility
Absent Sick Days Other Days
35. Total Days This Facility
ConLv / Coop Care Days
ConLv / Coop Care Days Bed Da s Total Sick Days
(I MED 0 - 23654
Signature
Automated
)
Supplemental Care Bed Days I Total Sick Days
26. Date of Disp
2003-11-11
10. PrevAdm
NO
32. Units Blood Components 30. Date !nit Adm
2003-11-08
ACLU-RDI 1682 p.14
ABBREVIATED MEDICAL RECORD 1. ADMISSION DATE (YYYYMMDD)
2. CHIEF COMPLAINT, PERTINENT HISTORY, AND PERTINENT SYSTEM REVIEW
( -27 j17 0 4-4=,--A---4— SA-0.-810"9-4 4 .-1, ./..„..ik x 3 Q_. -r`--62- r -.L„,_,-../1 -' di ,4---0 'T i‘ "--AYak-44 l'-C.-
■ ee arti_e., C6► • rP r7SCE ISI"---eil-e--0 4- ..ro-/i- .
3. PHYSICAL EXAO/IINATION (Including pertinent positives --1 1-> — 1 33 / g Y. 1-1-ez -?z---
,--,c.'' .14,s-e-ir'T - C-12-'—e— A—
A ...4.....,.....2,--n___
0--(7---e-- $.,„0,_ - AA,L___(,)„,"_ ,-,
L'—'1‘ • _Ct1,--If-P-7 ,-->
LA......6 ,--- • cri-P
and negatives) .
a/ - 2-7' 7- - ? :7-` C° / -f:
. /,7
LI,
r, r-2., A y\ / , Q-1
4. IMPRESSION (Enter admission note with plan on progress
64Q-M- ,-
notes)
5. ADMITTING OFF
a. SIG C‘.K) — 2- b. DATE SIGNED (YYYYMMDD1
6. DISCHARGE NOTE (Brief hospital course, diagnoses, procedures, condition on discharge, pertinent discharge information (including medications, diet, activity limitations, follow-up instructions).)
7. DISCHARGE DATE (YYYYMMDD)
8. DISCHARGING OFFICER a. NAME (Last, First, Middle Initial) b. GRADE e. TITLE d. SIGNATURE
9. PATIENT IDENTIFICATION (For typed or written entries: SSN, dare of birth, hospital or medical facility, ward number,
Name (last, first, middle), grade, and register number)
MEDCOM - 23655
10. OUTPATIENT/HEALTH RECORD MAINTAINED AT:
11. COPY PLACED IN OUTPATIENT (X when done) _ RECORD
L DD FORM 977n ADD loact tct-21 USAPA V1.00
,
i.
DOD-037233
ACLU-RDI 1682 p.15
AUTHORIZED FOR LOCAL REPRODUCTIOI
PROGRESS NOTES
DATE NOTES
0 0 \ 1 153 ---- A ss L)V1A_R__C) Ce4-1r. _.__ 6;` ,/- e i a_ itis G r-- , ►,-(5) 444 EMT I Ltap yc_e u.)1(\_e,--Q-c_(N_0_,, n .)_MX ,s1,-Lir-e-e fm e_ \, .,D Ou y___s to
tTee r locx_c-L vick--t Q_A/Ac, _s . F c& r, p c_ d ra_ u3 N.
(re _„-,.31..--k 5 at loPd ... ■ 070 Pr) (P.A. Ve-vvt is, 0 p 6 Ur 1 i----1-
re, - k_ tAz2__C-5-c e\ -S C ' / r Po z_ ?eozo • 12-14
S 6 itin -le__ 14 22 a A c__+- 1,.A., ES e__,z/i-k_c} iiL,s JJ PC. P U fl c._ 1,e__@ 12_,c-- r- c_./ if_i--- pecf €.4-d- (e--- sus 6 iccog
1 t--/e-c-77-7r., ,,_. w; I 1 (93\--Li 4) /y•t,..9, 1
v)(7f3 1 )--t- A--e-)x3 s5 c--v 7.- la g A __->
2-1 0 25 ,i,.1---,e --elr-c_-k- , e5 c----)D - - ar -rtc) .1 Wok A ✓\ Ac --(-- r ai '-- C- .\..,kr e_e_.c. 1,--Da c \_ --ki,e_y-Nke_ir- Cly---nvArN A_ \fv(-)‘.kr\,
tY\ ■ ,11 hr- SIN
Cl n -c-,A----e_ t \-ex---Ot1 \ g-es -t-'2, 1 C_Li V\ v-- ‘Q Po
rx)E_--i--0 2)12_. s C.LNvmpi i on_S ) 7IV et_b.,
po)1--N-1-- rfry-c--r--rk,iTh--v. i_., )i Di'\,3 •
---
i
X- 0 A. C, ' 4 IV/P62 /, )- A 'e? d. ,-7,tx-Z--, ,e4 1---,----4,e---/ RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
(SSN or Other) LAST FIRST MI
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)
I REGISTER NO. WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10
USAPA V1.0K
MEDCOM - 23656
MEDICAL RECORD I
DOD-037234
ACLU-RDI 1682 p.16
WU- 2 LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
,/,- 7r P ,Zi -.--Z,
P/P0 ------- friY" 1( ,z- .
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ARIMIIMIAMII k/s/0 .. OVN b_ 1 • OO tp---
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il■ • • alb 0 * Ak-. •. It a .., LAIllfik.■ • oft. flb
is ' . MA f\ la_ ti
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ke 0 r. i %
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xie:de,=-ted 0 4 5 e,,, / /, - A4n4,04 „. L--
MEDCOM - 23657
oc2 8,
STANDARD FORM 509 (REV. 5/7999) BAC: USAPA V1 .0
DOD-037235
ACLU-RDI 1682 p.17
MEDICAL RECORD PROGRESS NOTES
HU 1 nuniz.tii run LIJUAL hitPHODUCTIOI
DATE NOTES
uovo,e/ri,f (,e,,,,,,t),,%_w}_e_,_ _A Axif iri-i .A 4/1 ft'. .,,,,,-, 1/47 ASA 9 ( ,,, Q/D3o , -,1‘, A, e„, z9 i
4d.i; ==,-e
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A. !
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LAST
RELATIONSHIP TO SPONSOR
DEPART./SERVICE
SPONSOR'S NAME
FIRST
HOSPITAL OR MEDICAL FACILITY
MI
RECORDS MAINTAINED AT
SPONSOR'S ID NUMBER (SSN or Other)
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; REGISTER NO. ID No or SSN; Sex; Date of Birth; Rank/Grade) WARD NO.
PROGRESS NOTES Medical_Record STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)110)
USAPA V1.00
MEDCOM - 23658
DOD-037236
ACLU-RDI 1682 p.18
AUTHORIZED FOR LOCAL REPRODUC
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
plc, ,,,,„,__ ,......_., ...:__
e5 F.36 ere,(J ,i- / E- c_47 „---ac; cc,scf---0-- A-e---/
( A___, c.,,,-, s-es7 c—gc.,E -71-; -% 7 40,s6 ( / bcpt t t q1/4--- 74 ca,...,„___e 0.- ql 2 • aa.,......zry,
d---14--7,W .0L LI7 J-- .^(2- g--(--P-.' •
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. -
LAST
RELATIONSHIP TO SPONSOR
DEPART./SERVICE
PATIENT'S IDENTIFICATION: (For ty
ID No
SPONSOR'S NAME
FIRST
HOSPITAL OR MEDICAL FACILITY
MI
RECORDS MAINTAINED AT
SPONSOR'S ID NUMBER (SSN or Other)
WARD NO. ed or written entries, give: Name - last, first, middle; REGISTER NO. r SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/199 Prescribed by GSA/ICMR FPN1R141CFR) 101-11.203(b)(1
USAPA vl.:
MEDCOM - 23659
DOD-037237
ACLU-RDI 1682 p.19
(2.1) 3
Sensory No impairment Perception Slightly limited
Very limited Completed
Mobility No limitations
CD Slightly limited
3 Very limited Completely immobile 1
Nutrition Excellent 4
Adequate (Eats >50%) C;) Adequate (Rarely eat4 2 Very poor , I
Moisture Rarely moist Occasionally moist Moist Constantly moist I
Friction and No apparent problem CD
Shear Potential problems
Problems 1
Activity Walks frequently Walks occasionally 3 Chairfast Bedfast
Total Score 22 Add the total score
Above 20
Low Risk
Between 16 and 20
Medium Risk
Size: Yellow slough
MEDICAL RECORD
PROGRESS NOTES
Admission Date: - D a gn o s is: HD: `-f
POD:
Braden Scale Evaluation- (See Braden Evaluation Table for Details
Between 11 and 15 High Risk
Below 10 Very High Risk Note: A Braden Scale Score of less than or equal to 15 indicates HIGH RISK —Requires immediate Ulcer prevention program.
Surgical wound (s): No Location: )54-6x Tubes:
Dressing change:
Size: Appearance:
/1,1 Drainage:
CaU
0
Pressure Ulcer (s): Yes • Stage 1, II, Ill, [V (Circlet e one that applies and describe below)
Location: Wound character: Pint Moist
Odor Purulent discharge Dry
Eschar Granulation tissue
Exudates
SKIN AND WOUND ASSESSMENT
Type of dressing change: Wet-to-dr/ Comfeel dressing
Carrasyn V-Gel Alginate
Physician notified consulted for wound debridement: Yes No
I CNS notified/consulted for Stage II and greater: Yes No
Nutrition Referral: Yes No
Physical Therapy Refermi: Yes No
Ac:ion Taken: Date Time:
WARD NO.
REGISTER NO.
Patient's :densification( For ryped or written entries give: Name-last. first. middle:
(,trade: rank: hospital or medical facilithv) PROGRESS NOTES
Medical Record STANDARD FORM 509
r.
(As -se-55,D 1 / NOI / 0'3)
MEDCOM - 23660
DOD-037238
ACLU-RDI 1682 p.20
c.. "1-2A—cx N .. 35- I u 6.1-) I u _)\9_
-1— cc--
DISPOSITION LIUARTERS rT
n 24 HRS. n 48 HRS. n 78 HAS.
RETURN TO DUTY
.0 POSITION
HOME FULL DUTY
MODIFIED DUTY UNTIL
S
NSN 7540.01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT
(Patient)
LOG NUMBER
RECORDS MAINTAIrlill.W.1
1 PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADORESS DATE (Day, o4(h,p1.0 TIM)0 LK CITY STATE ZIP CODE TRANSPORTATION TO FACILITY
SEX DUTYILOCAL PHONE MILITARY STATUS THIRD PA NSURANCE
AREA CODE NUMBER ITEM Y NO NIA IT YES NO
PRP ADDITIONAL INSURA
AGE HOME PHONE FLYING STATUS DO 2568 IN CHA
AREA CODE NUMBER MEDICAL HISTORY OBTA 0 FROM
_...- •
NAME OF INSURANCE COMPANY
CURRENT MEDICATIONS
/Cell
INJURY OR OCCUPATIONAL I EMERGENCY ROOM VISIT
ITEM YES 0 WHEN Ore) DATE LAST VISIT 24 HOUR RETURN
n YES n NO ' IS THIS AN INJURY? WHERE TETANUS
ALLERGIES
tj Y\i"--) (is%
INJURYISAFETY FORMS DATE LAST SHOT COWL 0 INTITIAL SERIES
YES NO HOW
CHIEF COMPLAINT
CATEGORY OF TREATMENT VITAL SIGNS
❑ EMERGENT
VURGENT
❑ NON-URGENT
TIME
‘4,-,,,..7pULSE
TIME I t )43 BP
.;)) 1
I ..•`',# RESP (-
TEMP ,4,.., t
WT ' Sli30
80
eve
1....., CBCIDIFF AB 1 TIPTT BHCG/URINE/BL000/DUANT
—1-1130H
0 I
AVII•X I
CXR PA & LATIPORTABLE C-SPINE URINE C&S UA MSCCIC TH K... CHEM: ) D... c ACUTE ABDOMEN LS SPINE
BLOOD C&S X SINUS HEAD CT
7z- c ANKLE RIL
ORDERS PULSE OX
TIME n MONITOR
ORDERS I BY I COMPLETED BY n ECG
PATIENT'S RESPONSE
PATIENTIOISCHARGE INSTRUCTIONS
ADMIT TO UNITISERVICE TO WHEN REFERRED
TIME OF RELEASE I have received and understand these instructions.
CONDITION UPON RELEASE
IMPROVED
UNCHA NGED
DETERIORATED
PATIENT'S SIGNATURE PATIENT'S IDENTIFICATION (For typed Of written entries Ore: Name lest
lirsr, m4id/e /0 no. (SSN ar orhed, hospital or masa! facility/
6)(6)
MIR EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 IREV. 9.961 Prescribed by GSAACMF1 FPMR 141 CFR) 101-11.2030111101 USAPA V1.00
MEDCOM - 23661
DOD-037239
ACLU-RDI 1682 p.21
WBC
.5 • k
HIH
Ai. PLT
PT
APTT
SUP 02
PCO2
DIP
MICRO
RADIOLOGY
CL "Jr- ° S CL64—
EKG INTERPRETATION
BHCG ETOH GLU
SAT
PH
ABGIPULSE OX
PO2
OTHER
RESULTS
0 Check it read by radiologist
NSN 7540.01-075-3786
MEDICAL RECORD EMERGENCY CARE AND TREATMENT
(Doctor)
TIME SEEN BY PROVIDER
TEST RESULTS
tx-o_A c\c-T\70.Q.a v; (1_ fpNtoc2,00...)\,bciall.0--ui PROVIDER HISTORYIPHYSICAL au_. rk.a k9V
cu
Lo c_ 1
1Q A
—
cd, 0,-(Vr Ai, a-- clacf (go
cr7+ TSS
GLA-- • CL-fINO E
CONSULT WITH TIME ACTION ACTION RESID NTIMEDICAL STUDENT SIGNATURE AND STAMP
PROVIDER SIGNATURE AND STAMP 111111$ DIAGNOSIS co
11"ral Co
O G PATIENT'S IDENTIFICATION
For toed or Millen enlres, Name lest, first, Toddle: ID no. ISSN or other'• hospital or medical facility'
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
(OW STANDARD FORM 558 !REV. 9.961 Presaked by GSAI1CMR FPMR 141 CFR) 101-11.2133041101 USAPA V1.00
MEDCOM - 23662
DOD-037240
ACLU-RDI 1682 p.22
• 511-119
NSN 7540-00-634-4124
MEDICAL RECORD
VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONTH-YEAR DAY c' I 104.)(4b -3
19
PULSE TEMP. F
(0) (•)
105°
180 104°
170 103°
160 102°
150 101°
140
130 99°
120
98.6°
980
110 97°
100 96°
90 95°
80
60
50
40
RESPIRATION RECORD
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'Rec
ord
spec
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ata
on
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hen
so o
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ed BLOOD PRESSURE /Pi , „ \\41,9% P-0)
91si-i 4,1?:4 i.
TV .5 q V 94+-1 HEIGHT: I WEIGHT —1■• Cr4 e6*/ ./44i- 4 .'
fill RA • I ic ‘T-470
pii5 e Se
PATIENT'S IDENTIFICATION (For typed or written entries give . Name—last, frst, middle; ID No. (SSN or other); hospital or medical facility)
REGISTER NO WARD NO.
Anift ax‘" VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23663
DOD-037241
ACLU-RDI 1682 p.23
I I SPECIMEN/LAB RPT. NO
a. DATE
LAB. ID. NO.
TECH 15" A-47 lic:),S
'OTOLOGY URGENCY
❑ ROUTINE
TODAY 0
❑ PRE-OP
STAT ❑
SPECIMEN SOURCE
❑ VEIN ❑ CAP ❑ OTHER (Specify)
PATIENT STATUS ❑ BED DAMB
OUTPATIENT ❑ NP ❑ DOM
let ec iao
(-z) gmagpc')""
Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
1.111111e
0
11111111111111111111111111111111WBC DIFF 'c AND 8 Li0 0 D CELL M0RP! 11111111111111111 mu
=. - • rl ci 6 irO Z- t. 2 .r. g .;
2 & E 5 . ' IN II .
ID:11111 a)(6) - WB 08-11-03
14:07 Patient Limits
NBC 8.6 x10"1/uL 4.5W110.5 RBC 5.80 x10'6/1:I 4.00 6.00 Hgb 16.2 g/dL 11.0 18.0 Ha 50.7 Z M.0 60.0 IV 87.3 ft 00.0 99.9 MR 27.9 P9 27.0 31.0 IOC 31.9 L gAIL 33.0 37.0 Pit 243. z10"3/u1 150. 450. LY): 23.5 X 20.5 51.1 LW! 2.0 x1003/u1 1.2 3.4
c0 (6)- 2- REQUES ING PHYSICIAN'S SIGNATURE REPORTED BY
r\ C
REMARKS
c-.
z
z
MEDCOM - 23664
ACLU-RDI 1682 p.24
N/A
"NIA
6)- 2- . .
... .•
I LABORATORY RESULT FORM .- (Sub'cct to the Privacj. Act of 1974) t ___,. L.'s.f ',
I! /.AC i
T' ) t6-5-D I r (.b) (G) - i i . 1.11:-iailysis ' ...• ' .. . .::•
. . . .
. . . ,..Niis-c.. ro ov: •• . . •• 1 . .iNG,r.:: -. 72S.T . I RESULT I REF. RANGE' TEST
08-11-03! ''Dior i e /4..a_.
11:03 1 -77.-i ; ( Patient ■ 1"--11 1-4_ Limits
& 8.1 x1043/u1 4.5 10.5 Gig j I Negative-
& 5.66 110"6/uL 4.00 6.00 Bill . /1313 15.6 g/r1 11.0 18.0 ILLe.---a-rfr>z 35. 0 60. 0 Ket 80.0 999 , IV 87.2 fL Negative
. . ICH 27.6 pg 27.0 31.0 ; ,-, IOC 31.6 LI V& . 33.0 37.0 1 - ,̀"f /. 0 2 5' Plt 315.
Lymph % "- x10"3/aL 150. 450. Did in 26.8 Z 20.5 51.1 Are Negative H. pylori ale tayfll 2.2 x1043/aL 1.2 3.4 ' pH . • - - . ‘.. 0
Se - 61 C)
Urob
Baso e
MCV
PIE
/1.
Negative Source
N/A
Ock: Bid
J RPR
I Mon o
lyric rob iology
Gram Stain
RESULT
Negative
REF. RANGE
Negative
• Negative
Bands
Lymph
Eos
Mono
Nit
Prat .
V
Negative
0.2-1.0
Negative
N/A
Other
O&P
Malaria
Micro Parasites
Negstivc Atyp I mm
pasciipk Urini Lcuk
HCG RBC Morph
N...gstivc
Spun Hematocrit • Blood Bank •
42-52% (14) 37247/. (F)
Scd Rate
Other
oaguLitioii "Stti "e;::
TEST RESULT REF. RANGE
PT
I ADTI-
h dimer i - <20 uzja-ll
, rF DP I I <10 Lg/m1
I REMARKS:
I REPORTED BY:
91-13.6 sc
21-34 secs
Directigen
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
I Negative ABO/Rh
BloOdltank Unit Croisntitch . • - (MUSTS UBMIT SF 518. WITH EVERY urirr O r BLOOD . •
tit trEsTED) UNIT TYPE C ROSS A-L-iTC 11 .
LAB ID NO.: .
MEDCOM - 23665
DOD-037243
ACLU-RDI 1682 p.25
I I
vianvs01 fltSTG - ' ' \ - ---C67 _ - --- ,
CHEMISTRY RESULT FORM (Subject to the Privac .i‘ Act of 1974). LAST, FIRST, Mi. ATE ' TLME
1-7 Nov t t 0'1 --,i . .. .iSTA -44.10.9 1 .i. 4 „ 7.,.k. (1cLuIuj jv&tLd uulIcPJael.::.; '.-..2
TEST RESULT REF_ RANGE, 11.,- 1-3.--z-4-42 7-------PfF. RANGE
TEST RESULT 1 - REF. RANGE
Na 138-146 rnmo4/L ALB 3 . 5-5 . 5 Val GLU 1 73-118 ma.kfl K 3.549 mmol/I ' ' ' BUN I I 7..221.13EVCI CI 98-1G9 erool/
PH 7.31.-7.45 -=.=-=,== PICCOLO - PCO2 08/11/03 11:27 35-45 mmHg ( PICCOLO 41.51.-Ez(v, REFERENCE RANGE: von/LE
0n/11/03 ' 11:1K AM ACI-K15 "14" PATIENT #1111111`J "D' - 14/ANe0
PO2
TCO2 REF ERENCE. FZANGE : CO asiliNE 23-27mmouL(. LIVER PANEL PLUS
24-29 =non (,. PATIENT #: HCO3 DISC LOT #: 3154AA 7 22-26 mmoVL (a METLY1E 8 23-2S mruot/L (v OPER ft: IN DR #: 000 s02 95-98% SERIAL #: DISC LOLL 3151AA1
OPER #:111, DR #: 000 BEeef (-2) — (+3)
SERIAL #: 11111111111, mmon ALB 4.5 3.3-5.5 (3/DL ArtGap 10-20 mmol/L ALP 105* 26-84 U/L Ca GLU 114 73-118 MG/DL 1.12-1.32 mrno ALT 60* 10-47 U/L
BUN 8 7-22 MG/DL BUN 8-26 rag/d1 AMY 52 14-97 U/L
AST 37 11-38 U/L CRE 1.4* 0.8-1.2 MG/DL GLU wmosmot TBIL 0.6 0.2-1.6 MG/DL CK 233 39-380 U/L
NA+ 130 128-145 MOUE GGT 38 5-65 U/L Creat 117-4-5 mWdl TP 8.9* 6.4-8.1 G/DL K+ 4.5 3.3-4.7 MOM._
Hcc 38,-51% PCV CL- 103 98-108 MMOtt tr)::, 21 18-33 MMOL
Hob 12-17 gicli 1NST OC: OK CHEM OC: OK . HEM 0 , LIP 0 , ICT 0
INS1 GC: OK CHEM OC: OK. TEST RESULT REF. RANGE HEM 0 , LIP 1+, ICI 0
Troponin-1
Drug of Abuse
REMARKS:
REPORTED BY: r--- DATE: LAB ID NO.:
MEDCOM - 23666
DOD-037244
ACLU-RDI 1682 p.26
i PACç
I 5: ..7.-",A7u•-. -.......- "..:E.::'---.-S• 70 =••
ckc, sl- siNk_tcq
AEC-t-:F.S7E3 3Y (...n.7;
•Cf.-_- C2.•-•ELTE
CT 51-
F:.ALT.)IOLOGIC CONSULTATION REQU:_--ST7R=POR.T
• -:.7E OF EX.--,•-•-•:.',A7iON ', -1:.,..:::.:7. ;••cr...-- .1 0A7 OF AE.?"3;■ 7 ('4.-, :-, ..--..y. 7 "•-). I
DA 7 E 0F 7 A...NS C r.... I •=-7 IC •N O., c''': ..-..., . e•---7.• . .1- c--:
COclC
•
f
.01r Oz)(a) - 2
S 7 :2
09)()1 7,2 • - r••• 2: - •
Nig •": E - 2 -; 7
MEDCOM - 23667
, • • 1-•-e C • • . ,v=2 ,,r■
DOD-037245
ACLU-RDI 1682 p.27
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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
0)(C)
DATE OF ORDER TIME OF ORDER
ti.,01/1:5- / L.--.1> HOURS
LIST TIME ORDER
NOTED AND SIGN
4 1 -/- _L- a, ,/,!. d',1 .0
■9 '''' -1-4,3„,.... 6.:1>-04-- c-e--,-..se , ./ #•14
e' co,42, (-01., - cs-f--",.(12 vq-A-Q--4S- ex-- N c O -2._ 4, 1 -k---4--- -I-- ft
iii..., ..),_.. .. .
NU RSING UNIT ROOM NO. BED NO.
ci PO (Sr-f t
PATIENT IDENTIFICATION / DATE OF ORDER TIME OF ORDER
HOURS
/V
\\„.
71--
4,1„,,int_e_41
Pli /
.0...1 ...„ 4, . 1 i- f- ■ it ---ei 4,.. PL----,0
:;' y (-6 NURSING UNIT ROOM NO. -",..7. BED NO.
C. 6 I— C_ ? 4y,r-ce. At--12__ 7 f t_12, -, , < S.-13
ri-17- >,- 7 I- tr p-- ( Cap PATIENT IDENTIFICAT •
, r J„4„
■Ir 11
11, t
■
DATE OF ORDER TIME OF ORDER
? HOURS
-(-)1s)c <4 ?r-70 6 4-- g is c?'
9 Dit 01 _. )---Po 41) c_409-5 c- (2.4,(2.,4--- e_y C
ttzr:_v4 -2—k I 2_ g" c (,_(2 -71---- NURSING UNIT ROOM NO. 8E0 NO. '
riA4),- ifit. Soy - r RAJ iv, s .?—r sr—
_i_ 2- , er I ,„", aipiag PATIENT IDENTIFICATION DATE
‘4
OF ORDER TIME OF OR ER
e_i---6 1---(_ a •--- 60-74-- TC6) - HOU -
2--
\ -...
' •
's I ,
lir -.,- NURSING UNIT ROOM NO.
C-- 4- °I(eri?3L— BED
Mk
?Ll
90 DA 1 FAOP RR M79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23668
DOD-037246
ACLU-RDI 1682 p.28
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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATI ENT IDENTIFICATION
WIN. r
) (6) 4
i
DATE OF ORDER
/6 ,4raU .63 TIME OF ORDER
6 $ X_.‘ HOUR
LIST T I MEe ORDER
NOTED A SIGN
•-• .r,,,
-..
Air 0 '
NURSING UNI
le td ROOM NO.
. : •• o •• C6) (6) I
fi-N IV .-'• _,
k
PATIENT IDENTIFICATION • TE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO.
X;
BED NO.
PATIENT IDENTIFICATION
/-.
DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
DA ,FAr, m79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED .
MEDCOM - 23669
^V
DOD-037247
ACLU-RDI 1682 p.29
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION ) For use of this form, see AR 40-407;
the proponent agency Is the Office of The Surgeon General. Mo. ( ( Yr. 2003 VERIFY BY IIVITIALING g 311ni
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
CLERK/ NURSE
RECURRING ACTION, FREQUENCY, TIME
HR DATE COMPLETED
TO `I b zt..
roff) ---006d- : fer,)..k_rdrocd M -n(
5 --- Iwo 00 so _... "F.--...1.. '' r . # I
...
• 1 .411 " • a -
Ara
1
n c) V1/416--1 AM D \-e.)-- ‘ V_ - ( r ,,/,
ALLERGIES: .111 YES
\A6C
FM NO PRIMARY DIAGNOSIS:
1 ITVAM-OP-ACA C- 5:tiVeLeNa--
ADDITIONAL PAGES IN USE: -YES M. NO
PAGE NO' PATIENT IDENTIFICATION:
-AIIIIIIIIII 6)(6) - I 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 MEDCOM - 23670 nn re.tonw A"-1-1 A I* • •••■■•• ••■ oh ...^... USAPA V1.00
DOD-037248
ACLU-RDI 1682 p.30
(WO — 2 ..,1(
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo ti yr 2003
Order
Date Clerk Nurse SINGLE ACTIONS Date to
be Done Time to be Done
Time Done Initials
AcIroi- -i-cD -\(aM • No,165
CP3 11111111 ce Cr \ K \ -AO --1N)-- OD V3 Q " -RI.C/.-JL' 4Z:f. X V:r.D7' )S5 (P r0
p 1,6 eaAry X iox o ____...
___ .... 4..
Order/ Expir Date
Clerk/ PRN Nurse ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED drib,/ NCOZ-the..-)TD Iffili lIZIA-). ,c) Vox '>=,F-1, _ ems_
N • rc re0 Cz-0C >t 11111, (TAL P-V> lb-PI-105
_ii_
:SC c-101570 +425>iaq ris-- :1-516 leg-- >---S t y- - <I (-6 _ _ _ __ __ -c<9s, or ,so6
I
_
MEDCOM -23671
DOD-037249
ACLU-RDI 1682 p.31
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407; the agency is the Office The Surgeon General. proponent of MO. I( Yr.q)--
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE
C6AJYA/0 "
CLERK/ NURSE
-
RECURRING MEDICATIONS, DOSE, FREQUENCY
K_IF C7 \MC 2--*
HR DATE DISPENSED 01 0 II
EPIN lej I k■illi I
OA.
lita
2411111
1111. ill 111111 -
,
ll
ALLERGIES-YES YES Eti:leo
NWP \
PRIMARY DIAGNOSIS:
1 NT12P-TfiCe-ACI C.- \-41einVerv___
ADDITIONAL PAGES D Y ES 0 NO
PAGE NO
IN USE:
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL, 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 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 23672
DOD-037250
ACLU-RDI 1682 p.32
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. yr
Order Date
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES
Dote to be Given
Time to be Given Time Given Initials
if
F'
Order/ Explr Date
Clerk/ PRN Nurse MEDICATION, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED
M5(1'` z -4-e`-5 \\-Pe 9 Up 3_: °43f1-Th _
D q.
'111-
‘010.\ Li
woroov (76-3<to3c
AiNtl'
U.S. GPO: 1998-454-110/95216
MEDCOM - 23673
DOD-037251
ACLU-RDI 1682 p.33
Procedure Narrative(s):
' IL'-) 1. Reporting MTF CIDD2. V 1'. (h) (6) —
11.11 Admission a..., Coding Information , For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number )
-.Name (Last, First, MI) co --,(
Cb)C-/-) — 9( 4. Pay Grade
FGN
5. Sex
M 6. DoB (YYYYMMDD)
MIN 27Y 7. Age at Admission 8. Race
X
9. Ethnicity
9
Religion
10. Length of Service ETS 11. FMP
20
12. Social Security Number
OCO -- C 1(
Organization (Active Duty Only) 13. Marital Status
Z
Hour of Admission
10:35
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
DIS
Prey. Admission
NO
20. Source of Admission
Direct from ER
Ward:
ICW1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Name and Location of Medical Treatment Facility: ► rag; No Install Provided
Telephone Number of Emergency Addressee
21. Type Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-11
24. Clinic Svc - Admittinn
AAA - INTERNAL MEDICINE . Date this Admission (YYYYMMDD)
2003-11-08
MTF Transferred From
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-08
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: INTRATHORAC C-SHRAPNEL
--r-,- I fp g va 0
E 3
Cause of Injury Narrative:
'omated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 23674
DOD-037252
ACLU-RDI 1682 p.34
ea, 0 _I/ i INP/4:11E\1T TREATMENT RECORD COVER SHL.....
For use of this form, see AR 40-400; the proponent agency is OTSG
- REGISTER NUMBER 2
C(6) 3. G E
10. PREVIOUS 0 SION
14. WARD ---
ADMISSION REMARKS
`c
ADMITTING OFFICER
4. EX 5 AGE 16. RACE LIGIO 8. LENGTH OF SVC 9. ETS
' 61■ Nil& .-- I ..
0 112. SSN to rOANIZ4ArTION
15. FLYING STATUS
16. RATING/ 050
....___ 17: DEPT./
BEN 118. BRANCH/CORPS 19. UIC:ZIP
.,4•
20. TY E CASE
B 21 SOURCE OF ADMISSION:AUTHORITY FOR ADMISSION 22. HOURS OF
ADMISSION 23. CLINIC SERVICE
24. NAME/RELATIONSHIP OFEMERGENCY ADDRESSEE
..s.S
25. TYPE c SPOLITION
-...-401.-
275. _ EPHONE NO.
\
26. DATE OF DIS TIO
' l'C%\\ ''
28. DATE OF THIS ADMISSION
- 0 QC\)-
27a. ADDRESS OF EMERGENC ADDRESSEE (Include ZIP Code/
\‘...:1\,....
29. A ND LOCATION OF MEDICA CO (Z) -2-
I
30. DATE OF INTIAL ADMISSION
32 UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED
Check if Continued on Reverse
33. CAUSE OF INJURY
34. DIAGNOSES/OPERATI NS AND SPECIAL PROCEO 'ES s'..
I kj ) X' 1 1 ... .--..
-11 .
if --..,______. ..........-
. ........—.......... -
/
35. Total Days This Facility
a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE
d. S LEMENTAL i a• 0 GAYS
I
TOTAL SICK DAYS
36. Total Days All Facilites
CARE DAYS
a ABSENT SICK DAYS 1 b. OTHER DAY;
I
c. CONY. LV/COOP CARE DAYS
d. SUPPLEMENTAL BED DAYS TOTAL SICK DAYS
;7 7- 7}5FICiR
illibl - - ICER •: ; 6)(6) - I_
i RE
i . m
DA FORM 3647, MAY 79 cnrnnN r. • It SAPPC V1.10
MEDCOM - 23675
DOD-037253
ACLU-RDI 1682 p.35
1. REPORTING MTF t f 2. MTF LOCATION ADMISSION AND CODING INFORMATION
For use of this form, see AR 40-400; the proponent agency is OTSG ' I 2 3 4 con 7
8 (State or Country Code.) A \ \ \ \ -
3. REGISTER NUMBERAl
1 11 al 13 14 0 NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
16 17 18 9 1 10 / ay6)-7
6. DATE OF BIRTH IVVVYMMD0) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
'J\..\
19 20 21 22 23 24 25 26 27 28 29 30 31 RACK-GROUND ...3\,
10. LENGTH OF SERVICE ETS
-
11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 35 36 37 38 39 40 --
41 42 43 44 45
c Q\ ORGANIZATION (Active Duty Only 13. MARITAL STATUS HOUR OF
ADMISSION
D....____
BRANCH / CORPS
46
14.1 FLYING STATUS 15. BENEFICIARY CATEGORY .. e 16. ZIP CODE OF RESIDENCE
50 51 52 53 54 55 56 57 58 59 60 61 47 48 49
17. UNIT LOCATION (State or 18, MOS 19. TRAUMA PREY. ADMISSION
NO 64 65 66 67 68 69 70 71 YEAR
y 62 163
Country Code)
-M.
20. SOURCE OF ADMISSION/ AUTHORITY FOR ADMISSION
WARD NAME/REL IONS EsM RGENCY ADDRESSEE
72 ADDRESS OF EMEDGEKT*DDRESSEE (Include ZIP Code)
..'.......
°F
\
E
.\\...\-■ 0
)(4)-- 2tELEPHoNE NUMB ADD RESSEE
E19 . RENCY
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (VVVYMMDC))
81 82 83 84 85 86 87 88 73 1 74 If I 75 76 77 78 79 80
..11CWILMMCi \ EN 26. DATE THIS ADMISSION /V Y Y I'MMD01
MI Al 25. MTF TRANSFERRED FROM 24. CLINIC SVC - ADMITTING
99 100 101 102 103 104 105 106 89 90 91 92 93 94 95 96 97 98
XFX ')C- A 4111 iL INEanin 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IVVVYMMIDDI
107 108 (Battle Casualty Only)
.... 115 116 117 118 119 120 121 122 109 110 111 112 113 114
FOR LOCAL USE '
:_,ThNK. __-N,,,,,,,,,_.• -,,,,,,,,k _
; AI3MITTi • -,- tilled ING CLEW%) — 2_
MEDCOM -
DOD-037254
ACLU-RDI 1682 p.36
Automated Facsimile
•._ INPATIENT TREATMENT RECORD COVER 6HEET For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register N Olt( 2. Name (b)(j------17 3. Grade FGN
-I
Admission Remarks
i 1 i4. Sex i 5. Age 6. Race
M 1 x I 7. Religion
.
8. LnthOfSvc 9. ETS
j 10. PrevAdm
NO
I 11. FMP 12. SSN
20
13. Organization
J6b() --""
14. Ward ICU1
15. FlyStatus
NO
17. Dept / Ben K78-PRISONER OF WAR/INTER
18. BranchCorps 19. UIC / ZIP 20. Type Case
DIS
21. Source of Admission
Direct from ER
22. Hour Of Adm: 09:20
23. Clinic Service ABA - GENERAL SURGERY
24. Name/Relation of Emergency Addressee 25. Type Disp HOME
26. Date of Disp
2003-11-23
27a. Address of Emergency Addressee
a)(2)-2-
27b. Telephone No 28. Date This Adm:
2003-11-11
30. Date !nit Adm 2003-11-11
Admitting0fficer& )(c )_ z_
OEM
32. Units Blood Components 29. Reporting MTF
31. Selected Administrative Data
Marital Status: DoB:
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
GSW R CHEST/ ABDOMEN RENAL FAILURE
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
I 35. Total Days This Facility
, Absent Sick Days I Other Do I ConLv / Coop Care D s Supplemental Care Bed Das I Total
I.
Sick Days
(51
I. Signature of Attending Medical Officer
SUNDBORG
MEDCOM
0 ..
,-, ._.... . .
DOD-037255
ACLU-RDI 1682 p.37
Automated Facsimile IENT TREATMENT RECORD t,,IJ . 'BEET
For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr 2. Name G)(c) - 3. Grade
FGN Admission Remarks
t_-_(-
4. . Sex
. M
---•
5. Age 6. Race
X 7. Religion ; 8. LnthOfSvc ; 9. ETS
I 10. PrevAdm
NO
,11. FMP
20 0
12. SSN 13. Organization 14. Ward
ICU1
15. FlyStatus
NO 17. Dept / Ben
K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case
DIS
21. Source of Admission
Direct from ER 22. Hour Of Adm:
09:20 23. Clinic Service
ABA - GENERAL SURGERY
24. Name/Relation of Emergency Addressee 25. Type Disp HOME
26. Date of Disp
2003-11-23 27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:
2003-11-11 Admitt
Milli
ng0ffice6.. „..., _ 2_
C-"-() 29. ReportingMTF
02)(2) - Z- 30. Date lnit Adm
2003-11-11 32. Units Blood Components
31. Selected Administrative Data
Marital Status: DoB:
In/Out Patient: Inpatient F MOS:
.I.
1 33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
GSW R CHEST/ ABDOMEN RENAL FAILURE
l \ %
. ,
1 .
)
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days
I
!Supplemental Care I Bed Days I Total Sick Days
35. Total Days This Facility
Absent Sick Days
C,
Other Days
0 ConLv / Coop Care Days
I ; Supplemental Care
C.) 1 0
Bed Da s
(
Total Sick Days
11-- Signat -of t ' Me '
44) - Automated Facsithile - DA FORM 3647", May 79
MEDCOM - 23678
DOD-037256
ACLU-RDI 1682 p.38
PRO GS E SS :i:-,: t• , ■ :. ;:e gi :lisr:or!re f ill final dita;:ws: ; /el
Fitt)
c6„. chi/ tie e c4, a.,/ re,
/u7/ /774/
MEDICAL RECORD I
ABBREVIATED MEDICAL RECORD F E'n. r;E: .... d!S OFY. C 1-1 ,1 EF cc .IFIAlry-A40 CtP: 011- 0% ApM ■ SSION 'Ewer dc:e eim a,;III:sion)
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P.EGIS TER %0
ABBREVIATED MEDICAL RECORD
Standard Fun n 539
G.F. ,;;L;'..CEZ
i f
.1.•,,en..;
MEDCOM - 23679
DOD-037257 ACLU-RDI 1682 p.39
RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER ASSN Ar Othtd • FIRST
HOSPITAL OR MEDICAL FACILITY DEPARLISERVICE
I REGISTER NO. PATIENT'S IDENTIFICATION: IFot typed or wirten whits, give: Name - kst lea Diddle; ID No or SSW Sex; Date of Bilk liank/6ndel
/9-416 (4_1 /S36
— z
/530
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RECORDS MAINTAINED AT
WARD NO.
/
6-117 eet-A--e.d six •
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r te,t-ft/ /?-77-p 1G _ reie- /71 /1-ex-r/ 6r-A_ (.41-*-ez-
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
PROGRESS NOTES
DATE
NOTES
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PROGRESS NOTES Medical Record
STANDARD FORM 509 DIEU. 6119991 PrescrAnd by OSAIICMR FPIAR 141CFN 101-11.2031141101
USAPA V1.00
MEDCOM - 23680
7
7400)5tA
DOD-037258
ACLU-RDI 1682 p.40
LAST NAME FIRST NAME --1 MIDDLE INITIAL ID NUMBER
BATE NOTES
t I ArtNeb' Pl -e_r__ if31. .° Lk - ?-t ‘ 1Vc"C'"\- I'D`-\ -1) VI 1 arlS •
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STANDARD FORM 509 no. Num BACK USAPA VIDO
MEDCOM - 23681
DOD-037259
ACLU-RDI 1682 p.41
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
PROGRESS NOTES
DATE NOTES
14itidCP3 - G. N,I;00,y-) - 1■2..-cec -5 cr.Ne. R5Y\ 9 'SW() Pc °°r14° f)(0). q(a - 12:'E -A \- \-UcES gD . 3■133, cl1/4k0 N v■A-Vv. \\
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or &heti • LAST FIRST MI
DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY I RECORDS MAINTAINED AT
'S IDENTIFICATION: For typed or written gneiss, give: Nome • last, fist middle; ID No or SSV• Ser; age of Kr* Rank/Grade I RESISTER NO.
wrL
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PROGRESS NOTES Medical Record
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MEDICAL RECORD
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ACLU-RDI 1682 p.83
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ACLU-RDI 1682 p.84
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ACLU-RDI 1682 p.87
HEALTH RECORD CHRONOLOGICAL RECORD OF Nb—ACAL CARE
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DATE ARRIVED AOR SSN/IDENTIFICATION NO. DATE OF BIRTF
CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD (REV.5-84 Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
STANDARD FORM 600 BACK (REV. 5 -84)
MEDCOM - 23728
DOD-037306
ACLU-RDI 1682 p.88
PATI T COMPLAINT: DATE:
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SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (sign each enirp
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Prescribed by GSA and ICMR FIRMR (41 CFR) 201 -45.505
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MEDCOM - 23729
DOD-037307
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ACLU-RDI 1682 p.89
HEALTH RECORD
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SUPERVISORS NAME / RANK ORGANIZATION HERE
DATE ARRIVED AOR SSN/IDENTIFICATION NO. DATE OF BIRTH
CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD FORM 600 (REV. 5-84) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
STANDARD FORM 600 BACK (REV. 5-84)
MEDCOM - 23730
DOD-037308
ACLU-RDI 1682 p.90
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HEALTH RECORD CHRONOLOGICAL RECORD OF M1,...a1C.AL CARE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (sign each entry)
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CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD FORM 600 (REV. 5-84) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
STANDARD FORM 600 BACK (REV. 5 -84)
MEDCOM - 23731
DOD-037309
ACLU-RDI 1682 p.91
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HEALTH RECORD I CHRONOLOGICAL RECORD OF 1`.-JICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (sign each entry)
DATE: PATI T COMPLAINT: 0(;' iLl
TIME: ALL a IES: ' CURRENT MEDS:
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CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD FORM 600 (REV. Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
STANDARD FORM 600 BACK (REV. 5-84)
MEDCOM - 23732
DOD-037310
ACLU-RDI 1682 p.92
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HEALTH RECORD For
CHRONOLOGICAL RECORD OF NI—ACAL CARE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (sign each entry)
DATE: 1 1\49 \i 03 PATI D COMPLAINT: Pi- 407- TIME: tall? ALLE IES: CURRENT MEDS:
BP: LMP: 1 SMOKER: YES NO FLYING STATUS: YES NO
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PATIENTS NAME (Last, First, Middle Initial) SEX
TENT NUMBER STATUS / SERVICE RANK / GRADE
SUPERVISORS NAME / RANK ORGANIZATION HERE
DATE ARRIVED AOR SSN/IDENTIFICATION NO. DATE OF BIRTH
CHRONOLOGICAL RECORD OF MEDICAL CARE : STANDARD FORM 600 (REV. 5-84) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
STANDARD FORM 600 BACK (REV. 5 -84)
MEDCOM - 23733
DOD-037311
ACLU-RDI 1682 p.93
Braden Evaluation Table for Details) Mobility No limitations
Slightly limited Very limited Com s letely immobile
Nutrition Excellent Adequate (Eats >50%) Adequate (Rarely eats) Very poor
Friction and No apparent problem
Shear Potential problems Problems
4 3
CD 4 3 2 1
(.0
3
1
SKIN AND WOUND ASSESS1VIEN-1 PROGRESS NOTES HD: MEDICAL RECORD
Admission Date: VD Diagnosi
Skin assessment must Braden
be done initially and every 7 days. Scale Evaluation (See
4 3
1
2 1
4 3 2
S:
Sensory Perception
No impairment Slightly limited Very limited Corn feted
Moisture Rarely moist Occasionally moist Moist Constantly moist
Activity Walks frequently Walks occasionally Chairfast Bedfast
Add the total score Low Risk Above 20
Between 16 and 20 Medium Risk Total Score: -2-
Between 11 and 15 High Risk Below 10 Very High Risk
Note: A Braden Scale Score of less than 15 indicates HIGH
RISK-re uires immediate Ulcer Prevention •ro am.
vy, Surgical wound (s): Yes ✓No_ Location:
Size: Drainage: Tubes:__________— Pins:_____ Appearance:
.."t,
Dressing c ge: Location: Size:
Drainage: 5e-rt,Sex.v-,
Tubes: CA- 77-1b__AgE— — Pins:A__ Appearance:
Dressing change: -r\-Orq..
Yes_ NoX % BSA Location: Appearance: Dressing change: Location: Appearance: Dressing change:
Pressure Ulcer (s): Yes__ No 1,7 Stage I, II, HI, IV (Circle the one that applies and describe below) Size: Location: Wound character: Pink Moist Dry Granulation tissue Yellow slough
Eschar Undermining Odor Purulent discharge
Carrasyn-V Gel Type of dressing change: Wet-to-dry
Comfeel dressing
Physician notified/consulted for wound debridement: Yes__No CNS notified/consulted for Stage II and greater: Yes
No
Nutrition Referral: Yes No Physical Therapy Referral: Yes Action taken:
L Date & Tif22,,__:-------------
Patient's Identification (For typed or written entries give: Name-last, first, middle: Grat;e: rant:: hospits! or medical facility)
• -r)
Burn wound (s): Partial Full
Size
Size
No
e
Tunneling Exudates Alginate
Date/time MD notified
REGISTER NO. t WARD NO.
PROGRESS NOTES Medical Record
STANDARD FORM SO4
MEDCOM - 23734
DOD-037312
ACLU-RDI 1682 p.94
HD: 6 c
abrasions, surgical wound, skin tear.
.N BREAKDOWN AND: 2 NI - EMENT
PROGKE— 1 INLIEI)IcLii7RECO Admission Date:
PLAN OFC.. Z
Diagnosis:
Date: Time: RN Signatu Skin breakdown as evidenced by immobility, friction, shea
Wound type: Surgical wound (s) Location: Size:
Diabetic ulcer Tubes: Venous stasis ulcer Dressing change: Other
Burn wound (s): % BSA Location: Appearance:_ Dressing change:
Pressure Ulcer (s): Stage I, II, III, IV (Circle the one that
Location: Wound character: Pink Moist Tunnelin Undermining Odor
Partial
Drainage: Y OY‘9.._
Pins: Appearance:
Describe Full
Size
Exudates
, mois
applies and describe below) Size:
Dry
Granulation tissue_ Yellow slough Purulent discharge Eschar
Refer to SOP for Dressing Change Instructions.
Please check the appropriate dressing Change:
❑ Wet to Dry Dressing
❑ Carrasyn-V GelDressing
❑ Alginate Dressing
❑ Comfeel Dressing
❑ Pin Site Care
❑ J-Tube Care
❑ Colostomy Care
❑ Chest Tube Care
❑ Burn Care
Select the appropriate products used:
0 Sterile 4x4 gauze dressing ❑ Sterile 2x2 gauze dressing ❑ Sterile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage ❑ Sterile Normal Saline O Sterile Water ❑ 8 x 4 Sponge gauze ❑ Op-site ❑ Tegaderm clear dressing ❑ Alkare skin prep ❑ Comfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel O Alginate ❑ Bacitracin ❑ Silvadene Cream
❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film ❑ Sterile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ 0.125% Dakins sol ❑ Betadine Swab sticks ❑ 'A Hydrogen Peroxide &
Sterile Normal Saline
Select the frequency of dressing change:
❑ b.i.d. ❑ t.i.d
qd
MD Signature and Date:
NOTE: Document daily wound and dressing change on Progress Note or Nursing Note.
CNS Signature and Date:
Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade; rank; hospital or medical facility)
Medical Record, SF 509
MEDCOM - 23735
ACLU-RDI 1682 p.95
PLAN OF CARE FOR SKIN BREAKDO AND WOUND MANAG MEDICAL RECORD 1 4 PROGRESS NOTES Admission Date: /imp -3 Dia nosis: a Sttie2", -A-' HD: f POD:
Date: 1 I I Time: /5 RN Signa r 6)(0 - Z Skin breakdown as evidenced by immobility,
Wound type: Surgical wound (s) Diabetic ulcer ,-/)-- Venous stasis ulcer Other ...e. Describe
friction, s e , moisture, abrasions, surgical wound, skin tear.
Location: (21-vte Size: r2k 1-) Drainage: ..p- Tubes: Cr Pins: Appearance: et.lc-e-t-2, Dressing change: p
-er- Burn wound (s): % BSA Partial Full
Location: Size Appearance: Dressing change:
Pressure Ulcer (s): „a"- Stage I, II, III, IV (Circle the one
Location: /1/ r
that applies and describe below)
Wound character: Pink Moist Dry Granulation tissue Yellow slough Tunneling Undermining Odor Purulent discharge Eschar Exudates
Refer to SOP for Dressing Change Instrucitons.
Please check the appropriate dressing Change:
❑ Wet to Dry Dressing
❑ Carrasyn-V GelDressing
❑ Alginate Dressing
❑ Comfeel Dressing
❑ Pin Site Care
❑ J-Tube Care
❑ Colostomy Care
❑ Chest Tube Care
❑ Burn Care
NOTE: Document daily wound and dressing change on Progress Note or Nursing Note.
Select the appropriate products used:
❑ Sterile 4x4 gauze dressing ❑ Sterile 2x2 gauze dressing ❑ Sterile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage ❑ Sterile Normal Saline ❑ Sterile Water ❑ 8 x 4 Sponge gauze ❑ Op-site ❑ Tegaderm clear dressing ❑ Alkare skin prep ❑ Comfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel ❑ Alginate ❑ Bacitracin ❑ Silvadene Cream
❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film ❑ Sterile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ O. 125% Dakins sol ❑ Betadine Swab sticks ❑ 1/2 Hydrogen Peroxide & 1/2
Sterile Normal Saline
Select the frequency of dressing change:
❑ b.i.d. ❑ t.i.d
MD Signature and Date:
CNS Signature and Date:
Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade; rank; hospital or medical facility)
Medical Record, SF 509
MEDCOM - 23736
DOD-037314
ACLU-RDI 1682 p.96
SKIN AND WOUND ASSE6SMEIN FIN4EDICAL RECORD PROGRESS NOTES
Admission Date: Diagnosis: HD: POD:
Skin assessment must be done initially and every 7 days.
Braden Scale Evaluation (See Braden Evaluation Table for Details) Sensory No impairment 4 Perception Slightly limited 3
Very limited C3 Completed 1
-2/ s
Mobility No limitations 4 Slightly limited 3 Ver limited .4 2 Cordpletely immobile C9
Moisture Rarely moist 69 Occasionally moist 3 Moist 2 Constantly moist 1
Nutrition Excellent 4 Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor
Activity Walks frequently 4 Walks occasionally 3 Chairfast 2 Bedfast
Friction and No apparent problem 3 Shear Potential problems 2
Problems CD k
Add the total score
Above 20 Low Risk Between 16 and 20 Medium Risk
GH
Total Scor Between 11 and 15 High Ris Below 10 y e • at • s
Note: A Braden Scale Score of less than 15 indicates RISK-requires immediate Ulcer Prevention program. Surgical wound (s): Yes,KNo Location:
Size: i 7- if Drainage: a--A-e Tubes: d--1" Pins: — Appearance: Dressing chan • : 40 /4" Location: il AL
/ /
Size: Drainage: e...., A2-s9 e-eet.- 112.-.4 d-S Tubes: Pins. --- Appearance: Dressing change: -----
Burn wound (s): Yes_ No_ % BSA Partial Full Location: Size Appearance: Dressing change: Location: Size Appearance: Dressing change:
Pressure Ulcer (s): Yes Nom <— below)
Size: Stage 1, II, III, IV (Circle the one that applies and describe Location: Wound character: Pink Moist Dry Granulation
Yes
tissue Yellow slough Tunneling Undermining Odor Purulent discharge Eschar Exudates
Type of dressing change: Wet-to-dry Comfeel dressing__ Carrasyn-V Gel Alginate
Physician notified/consulted for wound debridement: CNS notified/consulted for St9ge II and greater: Yes
No_ Date/time MD notified No
Nutrition Referral: Yes V No Physical Therapy Referral: Yes No Action taken: Date & Time
REGI::XER NO. I WARD O.
Patient's Identification f For ;flied or written entri•s give: Name-last, first. middle: Grzeie: rank: hospital or medical facility)
PROGRESS NOTES
Medical Record STANDARD FORM
MEDCOM - 23737
DOD-037315
ACLU-RDI 1682 p.97
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MEDCOM - 23738
ACLU-RDI 1682 p.98
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MEDCOM - 23739
ACLU-RDI 1682 p.99
DOD-037318
• • TEST(51
SPECIMEN TAKE)
REQUESTED
RESULTS
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MEDCOM - 23740
ACLU-RDI 1682 p.100
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MEDCOM - 23741
DOD-037319
ACLU-RDI 1682 p.101
H411111
3.00 x103/ 1
x10'6SIL
12-11-0.3 U4*2
Fr.3t3.21
Mgt 2.4 _ gAiL 11.C, 18.0 Pg_t L 35.0 60.0 ITV F.5 fl S0.0 9-5',9
2E1.1 ra 31.2 L
pr: glt
21.0 31.0
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--------
11 80.0 9.9
450, 10 4, JZ.z
1•= 7 4 .
tb7
1.2 3.i..
•„7.
L C P,
1 -t.THT
144 mmol/L
mmol/L
TCO.? 23 mmol/L
iCa ______ ]1. .01 mmol/L
Hct 18 PCV
Ht.*. g/dL
*via Hct
At 37C
pH ______
PCO2 45.1 mmHg
PO 127 mmHg
22 mmol/L
necf _______ -6 mmol/L
98
*calculated
At Patient Temp
pH 7
Ptna ______ 49.9 mmHg
P02, 133 mmHg
Patient Temp: 100.1F
F102
Sample Type_:
\ I
„ t uol
Pt Name: ------------ RAPItA,OfNi ANALYZER V4.54 SERIAL #0064813 11/13/03 04:57
Patient WOW Test Name :PT Test Result: = 16.2 sec. Ratio = 1.3 Calculated INV= 1.5t' Sample Type:crtrated wh. blood Test Date :1P-13/03 Test Time :04:55 Card Lot Ope
a. rator
RAPIDPOINT RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/13/03 05:00
Test NamM Patient ID
T Test Result:= 32,8 sec. Sample Type:citrated wh, blood Test Date :11/13/03 Test Time :04:57 Card Lot
Operator
MEDCOM - 23742
DOD-037320
ACLU-RDI 1682 p.102
• Ee
L
cv2rf. P.nier;7:
HC7
:4. 35.0
2M 511
:r It
Ver:
C
W(c)- -/ -?//
i-STRT EG7+
Pt:11111g Pt NaMe:
i7D
f,
1
pt:
NAme:
TCO2 19 mio1'L
At 37C
pH 7.272
PCO2 37.5 mmHg
P02 97 mmHg
HCO3 18 mmol/L
BEecf -9 mmol/L
302* 97 %
*calculated
Sample Type_:
17110 1403 0G:07
°Perlin.
Physician:
f ;
- - r
D II— CO:41
Patient t Limits
IMC 19.8 H 2101/IL 4.5 10.5 I RIC
3.141 drift 4.00 6.00
Rib 9.0 L eiti. , ILO• ILO 1kt 28.3 1. I 35.0 610 ID 90.1 ft Itit 99.9 , MI 213.7 mg 21.0310 ICC 3L9 L V& 3L0374 Pit 298. LYZ 5.1 MEDCOM - 23743 Lill 1.0 41 :101/21. iii ii_
Na 148 mmol/L
TCO2 i.a. mmol/L
iCa 0.92 mmol/L
Hrt .PCV
,h* 12 ci/dL
*via Hct
At 370
pH 7.041
PCO2 53.1 mmHg
PO2 4,r; mW-Ig
H003 14 mmol/L
BEecf i186i mmol/L .
302*
calculated
At patient Temp
PH 7.045
PCOZ 52.4-mmHg
PO2 G4 mmHg
Patient Temp: 98.0F
FIO2_a : 85
mple Type_:
19NOV03 05:19
Oper:llIl
Physician:
Ser*
Ver:
ACLU-RDI 1682 p.103
KAPIUF0INI CO...: ANA1.11EP. V4.54 SLOIAL 4005485 11120/03 08:51
Patient ID:. Test Name :APTT Test Result:=102,9 sec.
***RESULT NOT RANGE CHECKED*** Sample Type:citrated plasma Test Date :11/20/03 Test Time • Card Lot C4X0 - Operator
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Patient ID: ail Test Name :PT Test Result:= 39.1 sec. ***RESULT NOT RANGE CHECKED*** Ratio = 3.5 Calculated INR = 7.66 Sample Type:citrated plasma Test Date :11/20/03 Test 1 - me : Card Lol Operator
)(6)- Z
ID: 21146 04:44
Patient Lixuts
INIC 20.4 H xinitiL 4.5 10.5 ROC 2.95 L 110"6/uL 4.00 6.00 HO B.4 L 9/IL 11.0 18.0 Rd 25.9 L Z 35.0 60.0 In 87.9 ft. 80.0 99.9
28.5 pg 27.0 31.0 WIC MA L gAiL 33.0 31.0 Plt 315. 21013/el 1511; 45L LYZ 5.8 20.5 51.1 LYM 1.2 • :MAL 1,2 3.4
ID: 2141-03 04:57
Patient Limits
WBC 23.5 H x10A3AL 4.5 10.5
MC 156 I. x1046/uL 4.00 6.00
1.10 10.0 L g/dL 11.0 18.0
itt 31.5 I. I 35.0 60.0
NW 03.5 fl. 80.0 99.9
28. 0 vs 27.0 31.0 31.6 L gAL 33.0 37.0
Plt 317. 110'3AL 150. 450.
LYZ 4.4 Z 215 51.1
UM 1.0 *1 x10A3/aL 1.2 3.4
MEDCOM - 23744
DOD-037322
ACLU-RDI 1682 p.104
c)w> I -3 z rIH I
BE
] Sa0
2 H
CO3
19 j p
02
1,0q1
Egg
_
Rat e
PEEP
pH
DA
TE
TIM
E
Mode
Fi02
TV
196 I
76.6.
7t.n.a
AWa2
-.5kz
.c_ 11
--4.-
Q-.3 -1 5 .--, -.# 2...„ -- -34, 2
Hct / H
gb
WB
C / Platele
t I B
UN
/ Cr
Cl / C
O2 -
Na / K
Glucose
TIM
E
DA
TE
2120A
11Wo ufT1 gl
. , i
•
z
6\
MEDCOM - 23745
DOD-037323
ACLU-RDI 1682 p.105
Ptt
Lymph %
Giu n--4
Oce Bld
H. pylori
Micro Parasites Malaria
O&P
======= PICCOLO ....... 11/11/03 0::0: AM REFERENCE RANGE: MALE PATIENT #11111111 LIVER PA PLUS DISC LOT #: 3154AA7 OPERA.. DR #: 000 SERIAL #: MEI
ALB
1.7* 3.3-5.5 G/DL ALP
41
26-84 U/L ALT
57* 10-47 U/L AMY
41
14-97 U/L AST
65* 11-38 U/L TBIL 0.9 0.2-1.6 MG/DL GGT
9 5-65 U/L TP
3.8* 6.4-8.1 G/DL
INST OC: OK CHEM OU' OK HEM 0 , LIP 0 , ICT 0
171,: ardScctioc:
LABORATORY RESULT Subicct co the Privsc- C• Act of 1974)
SSN/PT: SSN:
WBC
RBC
Hgb
Hct
MCV
RANGE TEST 1 RES
I Sk-ra.,..„
I4-18 (M) 12-16 di (F) 42-52% (M) 37-47% .) 80-94 il - (M) 81-99 tl (•)
I30-500 x IC
20..5-51.1%
4.8-10.8 x 10',
4.7-6.1-;:. 10
RANGE
Source
TEST
RPR
Mono
rya.robk4ogy . • -
2N-cr.:alive
j . •
• _Bloodilank .-,
fu .C.11 C 1, 7 n
Other
COnuElition S di
T I RESULT I REF. RANGE
9.84.5.6s=
21-34 sc=
I D
rFD?
REMARKS:
DEPORTED BY:
==,:==== PICCOLO == =====
11 /11/03 E 09:36 AM
PRE RANG RANGEMALE c
BASIC METABOLIC DISC LOT #: OPER #111111 SERIAL #: ..................... GLU 101 73-118... MG/OL BUN 15 7-22 MG/DL CA++ 6.6* 8.0-10.3 MG/DL CRE 1.8* 0.6-1.2 MG/DL NA+ 138 128-145 MMUL K+ 5.61 3.3-4.7 MMOI/L CL- 112* 98-108 mam_ tCO2 20 18-33 MMOW
INST OC: OK CHEM GC: OK HEM 0 , LIP 0 , ICT 0
<10 uz' ■::21
3325M4 DR #: 000
MEDCOM - 23746
DOD-037324
ACLU-RDI 1682 p.106
Ward.'Section: REQUESTING FilYSICLA -
N: . ' CITEATISTRY RESULT FOR2■1 (Subtect to thc Privacy Act of 1974)
LAST, FLRST, Mi. i DATE ' TLkIT:. 1 SSN/PSEUDO SSN:
. -7:1'-:-v.sT.k. :-.-..- - '— ; • c'eolo),Cli -iri -it- 1.-. . . " (PiC'cologetaoliC:aciel : ...'.1-.....
TEST RESULT REF. P,...LNIG L" TPST -.."riFjillarAil" ?"- - 7. }W CE E
TEST RESULT REF: RANGE
Na 133-146 camoill_ ALB 3 . 5_5 . 5 g,,,:3 GLU 73-118 rri;rff, K 3.5-4.9 r.-,mo111. ALP 26-34 -21 BUN 7-22 m&'1 Cl 98-109 tamol/1_ ALT 10-4711,1 CA— 8.0-10.3 medl
PH 7.31-7.45 AMY 14-97 IA CRE 0.6-1.2 ragli! PCO2 35-45 mmHg (art)
4 1.$ L mmHg (Yen) AST 11-38 u/1 NA' 128-145 rr.rr.01/t
P02 80405 mmHg rt) Na (veal
TBIL 0.2-1.6 mg/d1 icr 3.3.4.7 aur.o1/1
CO_T 23-27 mmoVL (art) 24-29 =Ion. (yen)
BUN 7-22 mg/di CL- 98-108 ram WI
HCO3 22-26 mmot2 (i 11) 23-28 rnmoUL (vcn)
CA 8.0-10.3mg/d1 tCO2 18-33 ramol./.
s02 95-98% CHOL 100-2C0 mg/di '':(11itdiiit.T.X.'41fiflOtglii41:14:.:.-. -..:.::::::,..., : ,..-.,: 7:A.:•::-['...Y.:.. Essf. :. :' ::, ':.- .::-: ')...... BEecf (-2)- (+3)
turnout CRE 0.6-1.2 mg/d1 TEST RESIZT REF. R-4NGE
AnCrap 10-20 mrnol/L, GLU 73-118 mg/di ALB 3.3-5.5 gidl Ca i. 12-1.32 mrnol/L TP 6.4-8.1 g/dl ALP 26-84 ail
BUN 8-26 mg/d1 ' i.ec 6.10).14 e t Ikte..8...'l'::..• ::::. ;;.:::"4-i'f!',.......:7.i 7..:
ALT 10-47 u'l '•
GLU 70-105 medl TEST RESULT REF. RANGE
AMY 14-97 ill
Creat 0.7-1.5 mg/di GLU 73-118 ragfdl AST 11-38 ul H t 38-51% PCV BUN 7-22 mg/dI TBIL 0.2-1.6 m--.'cU 1-Igb I 12-17 g/dl CRE 0.6-1.2 ng/di GGT 5-65 &I
' - -.• . emisp....x-i,.: :: .'. ..
CK 3g-3 so un (2,) 30-190u:1(F) 128-145 =ail
HTP • - .1 gfd1
TEST RESULT REF RANGE NA ..1 -1 lec4O...:E1ectrolyt • .., • ' Troportir.-1 K" 3J47 rnrnol/I TEST
-- RESULT REF. RANGE
Drug of Abuse
.C1... 98-108 mol/1 NA' 128-145 mmol/1
• . ,
' 13-33 mmol/1 IC 3.3-4.7 mmoL/1
• CU .92-103 n---_, oll
tC0 13-33n...71oA
1 R_EN* A RES:
REPORTED BY: I DATE: I LAB ID NO.:
I I
MEDCOM - 23747
DOD-037325
ACLU-RDI 1682 p.107
• 17. •-• 3-r7 rx•
GLU BUN CA++ CRE NA+ K+ CL-tCO2
87 16
6.5* 2.1* 136 6.4* 110* 20
73-118 7-22
0.6-1.2 128-145 3.3-4.7 98- 108 18-33
MG/DL MG/DL MG/DL MG/DL MMOI/L MMOVL MMO/iL MOW
INSI OC: OK CHEM OC: OK HEM 0 , LIP 0 , ICT 0
1 LAB 113 NO.: a
CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
SSN/PSEUDO SSN:
.-(PigZOO eta101ieTaue
Het
Hgb
Creat
BUN
GLU
AnCrap
Ca
s02
BEecf
PO2
CI
TEST RESULT REF. RANGE
0.7-1.5 mg/dl
38-51% PCV
70-105 mg/d1
12-17 g/dl
(-2) — (+3) mrnol/L
8-26 mg/d1
35-45 mmHg (art) 41-51 tnrnFIR (yen) 80-105 mmHg (art) N/A (Yea) 23 -27 mmol/L (art) 24-29 mmol/L (yen) 22-26 mmol/L (art) 23-28 mruol/L (yen) 95-98%
L12-1.32 mmol/L
10-20 mmol/L
7.31-7.45
98-109 mmol/L
3.54.9 mmol/L
NA'
BUN
CRE
CK
GLU
TP
GLU
CRE
BUN
CHOL
TBIL
C A++
ALT
AST
AMY
40,00);Met1 ' ALT
TEST RESULT REF. AMY RANGE
73-118 rag/d1 AST
7-22 mg/di TBIL 0.6-1.2 mg/di GGT 39-380 un (N) TP 30-190 u/1 (F) 128-145 camoill
6.4-8.1 gjd1
73-118 mg/di
0.6-1.2 mg/d1
0.2-1.6 mg/d1
8.0-103mWdl
100-200 mg/d1
7-22 mg/d1
26-84 u/1
11-38 tit
10-47 u/1
14-97 &I
ALB
ALP
NA+
tCO
______= PICCOLO ------- 11/11/03 10:2? AM REFERENCE RANGE: MALE CRE PATIENT #:0.)(60- ,-/ BASIC METABaill DISC LOT #: 3325AA4 •OPER #: DR #: CL' SERIAL #:
CA++
TEST
138-146 mmoUL 3.5-5.5 g/dl GLU
REF. RANGE
pH
PCO2
TCO2
HCO3
Troponin-1 K" 334.7 mmol/1 1
TEST
98-108 mmo1/1 Drug of Abuse
tCO2
CI:
tCO2 18-33 mmol/1
REMARKS:
X1 2)2 '7516
18-33 mmol/1
REPORTED BY: DATE:
MEDCOM - 23748
DOD-037326
ACLU-RDI 1682 p.108
Other Directigen Negative ABO/Rh
PT 9.8-13.6 sees
• ••• • .. . C •. SF• . •. . . • . • . .
Cell Count
• Blood Bank •, . • ' • . .
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
•
Spun Hematocrit
Sed Rate
42152% (M) 37-47% (F)
- • •Bload.Bank Unit Cross:nit& . • (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
: • 1: I ' REQUESTED) • •: . • TEST RESULT REF. RANGE UNIT TYPE CROSSIVL4TCH
Coagulation Studies. • _
APIT
D d -uner
FDP
REMARKS:
21-34 sees
<20 ugh:n1
<10 ugirn1 1
REPORTED BY LAB ID NO.:
EQUESTLNG PHYSICIAN: Ward/Section: LABORATORY RESULT FORM .
LAST, FIRST, 0.1 '..--7'
1 ' DATE :.
, TIME • SSN/PSEUDO SSN:
(Hen cp - _Pins !s , . Misc. Serology : • ,. TEST REF. RANGE TEST RESULT REF. RANGE TEST RESULT 1 REF. RANGE
WBC 4.8-10.8 x 10 3 Color N/A RPR Negative
RBC 4.7-63 x 10) App N/A Mono i Negative
ligh 14-18 g/d1 (M) 12-16 g/d1 (F)
Gin Negative • 1!,Hrobiology ..., •• -•
.,, • • ... . . • .. • .
Hct 42-52% (M) 37-47% (F)
Bili Negative Source
MCV 80-94 fl (M) 81-99 fI (F)
Ket -
Negative Gram Stain
Pit - 130500 x 10 verified
SG N/A . Occ Bid Negative
Lymph % 20.5-51.1% Bid Negative H.pylori , Negative
(Hematology) 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 Imm •
Leuk Negative ' Microscopic Urinalysis' ... • .... :..,_ .. • . • , .. . , ... RBC Morph
HCG Negative • ,
•
MEDCOM - 23749
DOD-037327
ACLU-RDI 1682 p.109
DATE:
Ward/Section: REQUESTING PHYSICIAN: 1 LABORATORY RESULT FORM Sub ect to the Privacy Act of 1974)
LAST, FIRST, MI. 4- •
(---) -
.1 •°- I
DA
Li I TIME
1 SSN/PSEUDO SSN:
0.163apilog0 CBC s :Urinalysis . ...Misc. Serology: • . .- • • 4 -... .
TEST RESULT REF RANGE TEST RESULT REF RANGE TEST ya "'' . • *- • • e
WBC 4.8-10.8 x ios Color N/A RPR Negative
RBC 4.7-6.1 x 10 App N/A Mono Negative
I-Igb 14-18 edi (M) 12-16 edi (F)
Glu Negative - • ll i* . • :.
Hct 42-52% (M) 37-47% (F)
Bili - -
Negative Source •
MCV 80-94 11(M) 81-9911(f)
Ket Negative Gram Stain
•
Plt 130:.500 x 10 3 verified
SG N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
einatii :. ,:: •
• ) Manual Differentiiil .....:., .• :. • • • • - • - 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 Imm Leuk Negative '• Micioscipic Urinalysis, - .
RBC Morph
HCG Negative
,
•
Spun Hematocrit
42152% (M) 3747% (F)
. CSF , - . Blood Bank
Sed Rate Ceti l Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh I
• - Congulationi5tudies. ......... . , • . , :.
';'..' - - ' : ' : :-. .Bloixt Bank Unit .Croisinatch. : : ..•: - .: owsi. 5 umwrr. sv,518.WITH EVERY UNTT. OF BLOOD ..
' ' .: z. REQUESTED) .:. :. • f . -. . : :: " : '',
TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APT• 21-34 secs
D dimer <20 ug/ml •
FDP <10 ug/m1
, REMARKS:11M k.., 'REPORTED BY:
MEDCOM - 23750
DOD-037328
ACLU-RDI 1682 p.110
Ward/Section: ..--
11 ING PHYSICIAllys-)._ CHEMISTRY RESULT FORM Sub' ect to the Privac ' Act of 1974).
LAST, FIRS ..1 a ,Q)— 't DA E
"it 1,1 TIME
1°1-kt SSN/PSEUDO SSN:
:4- , , (pik6to.s:pjfijiliiirk":14.3,,.,-. -• : ' ,7f.Y.:.:''!,;:'.; !.:. ,.., i.7,..::, f C "':
''' ::' jrailii)*14414OtiOa:40i;.'. - ' '::-:,?7.: • :;!ie;:s5 - '7,.. :•::Y■ ::: : ;1.':..i , .:
' TEST —REF: RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na 138 - 146 unmol/L ALB , 3.5-5.5 g/d1 GLU 73-118 mg/d1
K 3.5-4.9 mmol/L . ALP 26-84 u/1 BUN 7-22 mg/di
Cl 98-109 rnmol/L ALT 10-47 u/1 CA" 8.0-10.3 mg/dl
pH 7.31-7.45 AMY - 14-97 all CRE 0.6-1.2 mg,/d1
PCO2 3 5-45 mmHg (an) 41-51 mmHg veil)
AST 11-38 till NA+ 128-145 mrnOUI
P02 80-105 mmHg (art) 14/A (veal
TBIL _ 0.2 - 1.6 mg/di '
3.3-4.7 mroolll
TCO2 23-27 mmoUL (art) 24.29 mmol/L (von)
BUN 98- 108 mmol/1
HCO3 22-26 mmoVL (art) 23-28 mrool/L (von)
CA"- PICCOLO 18-33 mmoUl
s02 95-98% . 'CO3,101.:,.6.,4 'due) ._ U - , CHOL 11/11/03 19 : 51 :: REFERENCE RANGL: MALE t::::::,'A•J.f.,...•N . 4:... ,.. ,,?,,....!, !7 .
BEecf (-2) - (4'3) nunol/L CRE PAT TENT # : gin 0(0- /
RESULT REF. RANGE
AnGap 10-20 mmo1/L GLU BASIC METABOLIC 3.3-5.5 ed, Ca 1.12-1.32 mmol/L. DISC LOT #: 3325AA4 TP
OPER #:1111111 DR #: 000 26-84 u/1
BUN 8-26 mg/d1 SERIAL # : UMW 10-47 un
GLU 70-105 mg/d1 TES: GLU 92 73-118 MG/DL 14-97 to
Creat 0.7-1.5 'fled] GLU BUN 17 7-22 MG/DL CA++ 7.0* 8.0 - 10.3 MG/DL
11-38 u /1
Het ' 38-51% PCV BUN CRE 2.3* 0.6-1.2 MG/DL 0.27 1.6 rag/d1
110 12-17 gicli CRE NA+ 134 128-145 MOM_ 5-65 &I
'!- -arig1.5.i "64,0 , rifi,s.,."7 -'1.-i .2r1 ',... .:!'....-Y' ' ''''''
CK K+ 5.7* 3.3-4.7 1110i/L CL- 111* 98-108 MMOM_
6.4-8.1 g/d1
TEST RESULT REF RANGE NA* tCO2 22 18-33 11101/L , q-11ct T1g01:9!-- q: .:, ..: ..... • ..•:
Troponin-1 . INST OC: OK CHEM OC: OK RESULT REF. RANGE
Drug of Abuse
_CI; HEM 0 , LIP 0 , ICT 0 128-145 mmol/1
tCO2 3.3-4.7 mmoln
98-108 mmolll
18-33 nuno1/1
REMARKS: )Ct.536 9g .07
Cshaervg REPORTED BY: ' .
$ ; •.! . DAT
MEDCOM - 23751
ACLU-RDI 1682 p.111
Ward/Section: -17Z-A) —
REQUESTING PHYSICIAN: ' !
CHEMISTRY RESULT FORM (Subject to the Privacy At of 1974).
LAST, FIRST, MI. DATE 1 TIME SSN/PSE(JDO SSN:
Ai.,-TAT) .. , ....(Pie•Olo)-,Clii.paiirr12 :::; ,.',, .;-- - ig-°16111;/041?..olic;?-.44 1
TEST RESULT REF. RANGE TEST RESULT .. REF. RANGE
TEST RESULT REF. RANGE
Na . 118-145 mmol/L ALB 1 c_i c ...,.. "- LU 73-118 mg/d1
K 3.54.9 romoL/L: IJN 7-22 mg/dl
Cl 98-109 mrool/L y ,,,,, p 1 ccoo ======= 6%." . 8.0-10.3 medi
PH 7.31-7.45 A 12/11/03 04:19 AM 0.6-1.2 mg/d1
PCO2 35-45 mmHg (a-1) 41 -51 mmEig (Yen) A REFERENCE RANI: MALE - l 128-145 mmol/1
P02 80-105 mmHg (art) N/A Neul
T. PAT I ENT # : ON METLYTE 8
3.3-4.7 mrnolil
TCO2 23-27 rnrnol/L (an) 24-29 mmol/L (Yen)
B. 3151M4 - DISC I_OT # : 98-108 mmo1/1
HCO3 22-26 mmol/L (arr) 23-28 mmoVL (Yen)
c, opER #: 11i DR #. 000 )2 18-33 mmoV1
s02 95-98% CI 'RI AL : (piteiilo)71.4iireif an d Plus : .......................... ..,,......„:...:...:1;.,,.&_,..,...;..:,, ,,,....i:...,...„: .. ....:::.,..,;.
BEecf (-2)— (+3) rumol/L
CT GLu 93 73-118 MG/DI- ',sT ,
7-22 MG/DL RESUIT REF RA_VGE
AnCrap 10-20 inmol/L • GL BUN 20
2 7* • 0 .6-1 .2 MG/DL 1 3.3-5.5 g/c11
Ca 1.12-1.32 mmol/L TP CK 771 * 39-380 U/L ' 26-84 on
BUN 8-26 mg/di ' NA+ 129 128-145 VIMOUL
' • K+ 5,1* 3,3-,4.7 mom_ .... 1047 till
GLU . 70-105 mg/(11
.. .
.( T CL- 109* 98-108 MMOVL
18 18-33 141°M- GLi
14-9' Lill
Creat 0.7-1.5 mgrdr — - tCO2 11-38 :A
I-let ' 38-51% PCV BUI INST GC: OK CHEM GC: OK 0.21.6 mg/d1
Hgb 12-17 gdz I CRE I-EM 0 , LIP 0 , ICT 0 5-65 ail
.. . .61451 " ;•!. , - 7 ;:, . •:' 1.1.'...-.... -.*;;* . ..',..
CK 6A-8.1 01
TEST RE:s'ULT REF RANGE NA' ,(Ptg...cO16.)peetroble:::: : :,;.,
Troponm-I .,.- RESULT rEF. RANGE
Drug of Abuse
.CL" 128-145 nnuoln
1CO2 3.34.7 mrno1/1
98-108 rr.moL'1
. , 1 -
18-33 mmol/1
REMARKS: vf4A37 (t -
-% 160A/414(2R
REPORTED BY: DATE: . .
LAB ID NO.: -
CNTh.evv\ uZ,c,
MEDCOM - 23752
DOD-037330
ACLU-RDI 1682 p.112
.BOR' ORY RESULT FORM Sublet he Privacy Act of 1974)
SS'/PSEUDO SSN: 0 tACDO
Ward/Section:
LAST, FIRST, Ml. CYO— q..
'JESTING PHYSICIAN:
DATE
. • (Hematology) .CBC Misc. Serology. . Urina
TEST RESULT TEST RESULT REF. RANGE
4.8-10.8 xt0' RESULT REF. RANGE REF. RANGE TEST
SVBC N/A Color RPR Negative RBC Negative ' 4.7-6.1 x 10' App N/A Mono
Mcrobio ogy Hgb 14-18 g/dl (M) 12-16 Rid! (F)
Glu Negative
Hct Negative Source Bili
MCV
Pit Negative
Negative
N/A
Ket
SG
42-52% (M) 37-47% (F) 80-94 f1 (M) 81-99 fl (F)
130-500 x 10• verified
Gram Stain Occ Bld
20.5-51.1% Negative Negative Lymph %
(Ilemato )1VIanua1Differential H. pylori
Micro Parasites
Negative Malaria Segs . Mono Prot
Bid
PH
Bands . Eos Urob L O.2-1.0 0 & P
Baso
Negative Microscopic Urinalysis . Atyp Imm Luk
Lymph Nit 'Negative Other
HCG RBC Morph
Negative
Spun Hematocrit
42-52% (M) 37:47% (F)
. - Blood Bank •
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
Coagulation Studies.. •
- ' - .BIood: Bank Unit Crossmatch. • -•
(MUST SUBMIT ST518 WITH EVERY UNIT OF BLOOD : • s . I ' 'f - ' :REQUESTED) .- • : ' .'.`: • : .
TEST RESULT REF. RANGE [NIT TYPE CROSSMATCH
, PT I . 9.8-13.6 secs - .
APTT I 21-34 secs
D dimer 1 <20 ug/m1
FDP <10 ug/ml
1 REMARKS: CAZ■C DATE: LAB ID NO.:.
MEDCOM - 23753
DOD-037331
ACLU-RDI 1682 p.113
(TESTING PHYSICIAN:
CI3EMISTRY RESULT FORM Sub'ect to
the Privacy Act of 1974)
MALE /A PATIENT #: . METLYTE 8 1111111(6)(0-1 DISC LOT #:
31 52AA4 SERIAL : OPER /In DR #: 000
.......................... GLU 91 73-118 MG/DL. BUN 22 7-22 MG/DL
CRE 3.4* 0.6-1.2 MG/OL ALB CK 827* 39-380 U/L ALP NA+ 128
128-145 14,10//L ALT 4.8* 3.3-4.7 MOM_
CL- 1134 98-108 NNW AMY tCO2 18 18-33 1110t/L
AST
GGT
REF. RANGE
INST OC: OK CHEM OC: OK
HEM 0 , LIP 0 , ICT 0 TBIL
PICCOLO =-1C4==== 'AC+ 13/11/03 04:02 AM :RE REFERENCE RANGE:
CO2
I II-38 WI
0.271.6 arWdl
I 5-o5 WI
MEDCOM - 23754
DOD-037332
ACLU-RDI 1682 p.114
Glu
Bands .
Lymph
Atyp
Cell Count
Wars cti.on -LA. (
L
It I Ca) —el
RE OIJEST P YSI r LAW<ALU1X 1X ULJ r t..yruvi Sub'ect to the Privac Act of 1974)
SEUDO
matology) .CBC RESULT REF. RANGE TEST RESULT REF. RANGE
Misc. rology•
N/A
N/A
RPR Negative
4.8-10.8 x 10' Color
x109 App Mono Negative
14-18 (M) 12-16 di (F)
Negative Microbiology
Negative Bili
80-94 tl (M) 81-99 fl
130-5Q0 x to SG verified 20.5-51.1% Bld
Negative Gram Stain Occ Bld
Pit
Lymph %
• (Hematio ). -Manual Differential
Segs Mono Prot
Neigative H. pylori Negative
Negative
Micro Parasites Malaria
0.2-1.0 O&P Eos Urob
Nit
Imm Leuk
Negative
Negative
Other
Microscopic Urinalysis
Negative HCG RBC Morph
Blood.Baak •,•
Nega tive
Sed Rate
Other Negative
1
Directigen 1 ABO/Rh 1
Coagulation Studiel. - :' ;:.' - ' - Blood .Bank Unit Crossmatcli . • ; : (MUST,SUBMIT SF,518 WITH EVERY UNIT OF BLOOD • - :... ' - ' - . ' -- ' .,' REQUESTED)
TEST 1 RESULT REF. RANGE UNIT TYPE
PT
APTT 21-34 secs
Span Hematocrit
42-,52% (M) 3747% (F)
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
CROSS NL-ITCH
D dimer <20 ug/ml
FDP
REMARKS:
REPORTED BY:
MEDCOM - 23755
DOD-037333
ACLU-RDI 1682 p.115
t. •
e lo . .A1
RE to I . .. . (b LAB t RATORY RESULT FORM Suliect to the Privac . Act of 1974 .iiir._■■_
a I ' 9 VS TIME h
...... eniatrilogY : . 0 ::.
. Urina is
..... .• , •. . .. Misc. Serology : 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 App N/A Mono Negative Hob 14-18 ,Vd1 (M)
12-16 g/d1(7) Glu Negative - • . 11ECrobiology
Hct 42-52% (M) 3747% (F)
Bili - - •
Negative Source
MCV 80-94 11(M) 81-99 fl (F)
Ket Negative Gram Stain
Plt 130400 x 10' verified
SG N/A OCC Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Hematok).Manual Differential • -
• • • - • • • • • • - pH WA Micro
Parasites Segs • Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative •.MicroseOpiC Urixia '
RBC Morph
HCG Negative
",
•
1 Hematocrit 42;52% (M) 3747% (F)
I Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh •
uagulatioil 'Studies.- •.. s.
. •
' .... . . '.. ,.,,. ; : ,,,.....-7-- , 4,. ,. -7-- 7 -..---__ SF. I8.WITH EVERY R .UNIT BLOC T OC) (MUST SUBMIT S.-.. • . . . ... • . . . .. • ,..
•; .-,,....L..iiIECittggeS-TrA)); • TEST RESULT REF. RANGE ONT TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer <20 ug/m1 •
i FDP
i <10 ug/m1
REMARKS:
REPORTED BY: DATE: LAB ID NO.: .
(6)-r
MEDCOM - 23756
DOD-037334
ACLU-RDI 1682 p.116
Wa ction: c .,(4_ • • 1 ta • .1 CHEMISTRY RESULT FORM Sub'ect to the Privacy At of 1974)
•1 DATE
• ti
TIME SS /P
' '"`'': , ,- Sr(rA0114,..;- r e!iiiiti-i1;i:,:,,
icZolo : ttal3okilio,
7 ,,..4-,,,... T ..: .."....' . :.:::!, ..;i'? n .,T: '?:•T.-:::T: TEST RESULT REF. RANGE TEST RESULT REF.
RANGE TEST RESULT
k:
REF. RANGE "
Na 138-146 mrnoUL ALB 3.5-5.5 g/dl .
GLU 73-118 mg/d1 K 3.5-1.9 mmol/L' ALP 26-84 u/1 BUN 7-22 mg/d1
Cl 98-109 mmol/L ALT 10-47 u/1 CA++ 8.0-10.3 mg/d1
pH 7.31-7.45 AMY 14-97 till CRE 0.6-1.2 nag/d1
PCO2 3545 mmHg (wt) 41-51 mmHg veal
AST 11-38 u/i NA 128-145 mino1/1
P02 80-1(15 mmHg (art)
N/A (veul TBIL 0.2-1.6 mg/d1 K 3.3-4.7 mrno1/1
TCO2 23 -27 mmol/L (art) 24 -29 mmol/L (vcn)
BUN 7-22 mg/d1 CL- 98-108 mmol/1
HCO3 22-26 mmol/L (art) 23-2S mmoUL (vcn)
CA"- 8.0 -10.3mg/d1 tCO2 18-33 mmoUl
s02 , 95-98% CHOL 100-200 roWcil :-.-
1.0O310Aii;0e. p4nel 11-.....- :.i. , :ii.:,
ii• . ,.....: N:
BEecf (-2)— (+3) nunoLl.
CRE 0.6-1.2 mg/d1 TEST RESUT REF. RANGE
AnGap 10-20 mmol/L GLU 73-118 mg/ell ALB 3.3-5.5 g/d1 Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d1 ALP 26-84 u/I
BUN 8-26 mg/d1 ,..-, , . -
kcoio Act!. p ALT 10-47 till
GLU 70- 105 mg/d1 TEST RESULT REF. RANGE
AMY 14-97 till
Creat 0.7-1.5 mg/dl GLU 73-118 meidl AST 11-38 u/1
Het 38-5 I% PCV BUN 7-2.2 mg/d1 TBIL 0.2:1-6 =EV1
. Hgb. 12-17 g/dl CRE 0.6-1.2 mg/d1 GGT 5-65 u/I
7 ' -‘e.Ari:;.C 10t1i!..0
.:2'., .•:4.- CK 39-380 ull (M)
30-190 u/l(F) TP 6.4-8.1 g/di
TEST RESULT REE RANGE NA' 128-145 mmc4/I • c616): ectroljte -
.• Troponin-1 IC 3.3-4.7 mmoUl TEST RESULT REF. RANGE
Drug of Abuse
.C1. - 98-108 minoU1 NA.' 128-145 mmol/1
tCO2 18-33 mmol/1 K 3.3-4.7 mmol/1
• CU
,
98-108 mmol/I
[CO2 18-33 mmo1/1
REMARKS:
REPORTED BY: ..,. . DATE: LAB ID NO.:
MEDCOM - 23757
DOD-037335
ACLU-RDI 1682 p.117
• REPORTED BY:
DATE:
I LAB ID NO.:.
Negative Leuk Atyp Microscopic Urina s Imm
Negative HCG RBC 72h
42752% (M) 37-47% (F)
CSF Spun Hematocrit
Blood.Bank - . •
Other I Dircctigen Negative ABO/Rh
PT : 9.8-13.6 secs
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Cell Count
Sed Rate
.BloodBank Unit CrOssrnatcli . (MUST suBmq SF.518.WITH EVERY UNIT OF BLOOD
. • .s ...REQLrESTED)
Coagulation Studies
TEST RESULT PSF. RANGE TYPE CROSSIVLITCH UNIT
APTT i 21-34 secs
<20 ug/ml
<10 ughni
t '
D dimer
;FDP
REMARKS:
(6) —
REQUESTING PHYS
WardiSectiott: A LABORATORY RESULT FORM 1. Sub ect to the Privac • Act of 1974)
LAST, FIRST, MI.
tkr '
E‘IE •
SSN/PSEUDO SSN:
(HeMatcilogy) cpc .. - y - Urinalysis . ..1V-Iisc. Serology. .,,. 4 TEST • - . RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC i 4.8-10.8x 10' , 1
Color N/A RPR Negative
RBC . 4.7-6.1 x 10' App N/A Mono Negative
1-1gb 14-18 g/dt (M) 12-16 gidl (T-)
Glu Negative • Nifc.robiology . . .. . . . .• • .
Hct 42-52% (M) 37-47% (F)
Bili • -
Negative Source
MCV 80-94 11 (M) 81-99 fl (F)
Ket Negative Gram Stain
Plt 130-500 x to' verified
SG N/A . Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Hen:tato ) Manual Differential :. :.. • • • .. .. .: pH N/A Micro
Parasites Segs Mono Prot Negative Malaria
Bands . Eos Urob 02-1.0 0 & P
Lymph Baso Nit Negative Other
MEDCOM - 23758
DOD-037336
ACLU-RDI 1682 p.118
4.8-10.8x 10' Color
Gram Stain 130-500 x 10
verified OCC Bld Lymph % 20.5-51.1% H. pylori
Micro Parasites
Sed Rate Cell Count
Other Directigen
' B ORATORY RESULT FORNI ut,'- it to the Privac .• Act of 1974) TE •T LIE .-.;SN/PSEU i 0 S N:
RESULT
Bands Negative
Other
RBC Morph
II Spun
I Hematocrit
Negative
21-34 secs
<10 ug'ml
REMARKS:
u REPORTED BY:
G
MEDCOM - 23759
DOD-037337
ACLU-RDI 1682 p.119
Urinalysis • • • .
p ogy) CBC
Negative
3152AA4 DR #: 000
PICCOLO ------- . 14/11/03 04:04 REFERENCE RANGE: MALE PATIENT #: METLYTE 8 DISC LOT #: OPER #: SERIAL #:
RESULT
Negative
. , Microbiology
GLU 88 73-118 MG/DL BUN 29* 7-22 MG/DL CRE 3.2* 0.6-1.2 MG/DL CK 587* 39-380 U/L NA+ 128 128-145 MM0f/L K+ 4.5 3.3-4.7 NF1OM. CL- 113* 98-108 MMO&L tCO2 18 18-33 WM..
Lymph % 20.5-51.1%
42-52% (M) 37-47% (F) 80-94 fl (M) 81-99 tl (F)
130-500 x 10 verified
Negative
0.2-1.0
Negative
N/A
Negative
N/A
Negative
Negative
Negative
RBC Morph
Spun Hematocrit
• • . - .BloodBank ST,8UBMITSF.518.wlr,
TIP,
INST OC: OK CHEM OC: OK HEM 14, LIP 0 ) ICT 0
Sed Rate
Other
TEST RESULT REF. RANGE
9.8-13.6 secs
Cell Count
Dircctigen
FOP
R EMARKS.
REPORTED BY:
<I 0 ug/mL
LAB 1.1) NO.: DATE:
4.8-10.8 x 10 Color
Negative
Negative
Bands
Lymph
MEDCOM - 23760
DOD-037338
ACLU-RDI 1682 p.120
DOD-037339
Gram Stain 1300.500 x10
verified Occ Bld Lymph 20.5-51.1%
H. pylori
Micro Parasites
RBC Morph
Spun
I Hematocrit
Sed Rate -
742f4- rah . 13ORATORY RESULT FORM St; :t to the Privac Act of 1974) TIME SSy/PSEUDO
REF. RANGE RESULT
RESULT
DATE
0✓0 _Urinalysis
Color
Other
Cell Count
Dircctigen Other
- , Mobil Bank Unit Crossmatch . (MUST,SUBMIT SF: 5I 8 WITH EyERY UNIT OF BLOOD . •
RE LrESTED) UNIT
. TYPE CROSSitiATCH
TEST RESUZT REF. RANGE PT
APTT
D dirtier
9.8-13.6 secs
I REMARKS:
REPORTED BY:
MEDCOM - 23761
Ward/Section:
FlRST,ML
• Blood Bank
ACLU-RDI 1682 p.121
Negative Source
Atyp--
RBC Morph
,pun liematocrit
Other Dircc-tigen Negative
Negative
" 'ORATORY RESULT FORM ect to the Privac Act of 1974) TIME SSN/PSEUDO SSN:
(Hematology
RESULT
4.8-10.8 x 103 Color TEST RESULT RESULT
Lymph %
130-500 x10 verified 20.5-51.1%
Negative
Negative
Gram Stain Occ Bid
H. pylori
Negative
Negative
Negative
Micro Parasites Malaria
1 0.2-1.0
Other
Negative
Negative
42-52% (M) 37-47% (F)
Coagulation Studiea. .•
TEST RESULT
PT
APTT
D dimer
Blood Bank Unit Crossmatch . •
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . RE LrESTED)
TYPE I CROSSMATCFI 9.8- 13.6 secs
DATE: 14 Nov 0_3 I LAB m NO.: .
REMARKS:
I REPORTED BY: C
Cc-
6.Z6)-4 - 1
Ward/Set&
LAST FIRST MI.
MEDCOM - 23762
DOD-037340
ACLU-RDI 1682 p.122
Ward/Section:
• 1 Cli. — REQUESTING PHYSICIAN: ' CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974) LAST, FIRST, MI. WC-6) - 4
P DATE
lb Nid-i
TWIT
O(tg)
SSN/PSEUDO SSN:
,-, .LSTA ,. aCC616) .,CIii.ritiitry -)1 - =2:-.;.: 3. , ,'..:::. iCiiI6):: 44-tioi6ra:tii TEST RESULT REF. RANGE TEST RESULT REF.
RANGE TEST RESULT REF. RANGE
Na 138-146 aumol/L ALB 3 . 5-5 . 5 g/dl GLU 73-118 mg/d1
K 3.54.9 mmoVL` ALP 26-84 lilt BUN 7-22 mg/dl
C1 98-109 mruol/L :A.1.+ 8.0-10.3 mg/dl
PH 7.31-7.45 PICCOLO :RE 0.6-1.2 mg/dl
PCO2 35-45 mmFIg (at) 41-51 =Hz Yea) 16/11/03 04:23 W 128-145 mrno1/1
P02 8 O-1 °5 mmHg WO ' REFERENCE RANGE: LE , N/A (veil)
C)C6 -tf - # 334.7 mmolil
TCO2 23-27 mmol/L (an) • PATIENT : 111111 L' 24-29 rarnoln- (vcri) NETLYTE 8
98-108 mmol/1
HCO3 22-26 mmoVL (art) 1 3152AA4 :02 23-28 mmoVL (wn) DISC LOT # : 18-33 mmoVI
s02 95-98% I OPF_R #: lip DR #: 000 IcOilOgiSf•Of rano f,..*;-,:-.
SERIAL #. :::,:.:...v.-, ::,...,:... . : v:: . . :.....,:: '-.::::::::- '... BEecf (-2) - (+3) ( TEST
nunoVL RESULT REF. RANGE
ArtGap 10-20 mmol/L ( GLU 113 73-118 MG/DL LB MG /DL
3.3-5.5 g/d1
Ca 1.12-1.32 mrnoWL il BUN 34* 7-22
CRE 3.1* 0.6-1.2 MG/DL LP 26-84 ull
BUN 8-26 mg/dl CK 209 39-380 U/L LT 124* 128-145 MMOUL
10-47 u/1
GLU 70-105 mg/d1 +
4.1 3.3- 4.7 MMOIL 11-Y 14-97 till
Cleat - 117 * 98-108 NIVIA_ 0.7-1.5 mg/di ' 3T
C•=.: t 02 ?? 18-33 MMOR_ 11 -38 &I
Hct 38-51% PCV h 311, 0.271.6 mg/d1
Hgb 12-17 gidl F INST GC: OK CHEM GC: OK Yr 5-65 u/1
. ; 7 4einj0iYi C HEM 2+, LIP 0 ) ICT 0 ■ 6.4-8.1 g/d1
TEST RESULT REF. RANGE -N -04Ic«}.X1.ectroble,:-.
' 7: •-•--7:::: • ,..:7'f1. -:.: ..,.i::. : Troponin-I K EST RESULT REF. RANGE
Drug of Abuse
.0 C 128-145 mmoVI
tC 3.34.7 mmoVi
98-108 mmoVI
)2 .
18-33 mrao1/1
.
REMARKS: 10(1. ..Nr-Vii-A3_, ka) • .
REPORTED 13Y: I DATE: 1 LAB ID NO.:
MEDCOM - 23763
DOD-037341
ACLU-RDI 1682 p.123
7.3-11`1
7 -22
C.6-1.2
(Picco1oyLx' et ?e1 Ptus
I TEST !RESULT REF.
JALB ;
2.75-34
AST
GOT
T?
53-5?CV
-W-21
hemistrv- - - -
TEST ST
—
TEST T ! ;Z.: =
• i 2 .?- ,.4.5
aj(6)- CITEMLSTRY RESULT FOR:.;1
A:le:7:974)
. -q
-1:2 ;ccoic):\fe:;45cliPaoc2 1
1 TESr ' =S: -7 ,
R.-!..‘,Cr
I %;11.1s.S57.3._s: rzsr.T.., m.7.;',.
' 1 CI fu
I CI
3.f
; 7.3
PCO2 3-45 71:
P02 N:A.
TCO. 1 2j-27
HCO3 22-25 mmeLL 2.3-23:7.--JcVL
s02 ! 95-98%
BEc-z: ( -2 ) - (-3) In.=-....)L,L
PICCOLO ------- 15/11/03 04:27 AM REFERENCE RANGE: MALE PATIENT #: BASIC METAS IC tX‘)--• DISC LOT #: 3325AA4 OPER #: DR #: 000 SERIAL #:
GLU 138* 73-118 MG/DL BUNH--444 7-22 MG/DL CA++ 7.9* 8.0-10.3 M13/DL CRE 3.2 0.6-1.2 MG/DL NA+ 137 128-145 MMOVL K+ 4.3 3.3-4.7 MMOVL
-.QL7 120* 98-108 MMOVL tCO2 21
18-33 MMOVL
INST OC: OK CHEM OC: OK HEM_2+, LIP 0 , ICT 1+
• U`i.c.co10)-Fje..crrOly-tc._
MEDCOM - 23764
DOD-037342
ACLU-RDI 1682 p.124
14-IS
1 -42-52'..: 57-47% 80-94 fi I,
1
' " c
17:.• ar z:s,,.....c •: 0 , :
I LAST, Fr.R.Si..N11.
iL:_.. ' - I SS:-..,-7.-::;7'.:_:-.)
Cdfl 4_4 -L- (N•.:^ , ----;--- , '-c 7-..-;,..,-.- -',...:-;c:.'1‘:,7-!)
I 1 b1443i 3 ! -, ....).-,1 1.,. ---........-.....:_„_:...--
. .. . jiri..c.it`,-i is ' ..... . ... ... . . .. . . Miss-....'...S-croloa-v. ; .., -:',..--2- ! R4...7 5'•:::-: 7 i REF. .:7L-LVC::_.7 1 TEST I :•:' •r•- cr:*7 7- 1 REi:: .;;Li.v:.:.:_:: !, '.- olot.- i • i NIA
insto.k.
ns - C./L. I
,::1
•NGcrobic40,-;;;::
Lymph %
("11cca4 tiO10-irv)- 3.13.12 2.1 DifTerrati21 NIA
Nc
I 0.2-1.0
.A:YP
R3C Morph
1-.CMatOC:it.
Tjt.: 1ST
? T.
D;rcc:igen
7/7 '7 -: 4
DA T Et L._
ID NO.:
MEDCOM - 23765
• 7Bio.o41/3.a .ok [fait Cros...srzatc!:' .
(NMST.SCraNI:IT vani EvERy oF BLooD • • • :.R_EQUESTED)
-.:••
DOD-037343
ACLU-RDI 1682 p.125
Ward/Section:
kt,t/Lt
Q STING PHYSIC 71.7 t) 1.------ ' CHEMISTRY RESULT FORM (Subject Io the Privacy Act of 1974)
LAST, FIRST, ML CO ‘ q DATt I TIME
nik-V-Wa) I O'”ct SSN/PSEUDO SSN:
,-..ii-... T_ - • '':::(T*C010):1Clietniti-::::1, ig'Cia6).Mgt4bok41?P - ' ..'..----;.-'- --:.%,•:,:t-7':?,r ;..-,-..-.::: ..:' - •, TEST RESULT REF. RANGE TEST RESULT f REF.
RANGE TEST RESULT REF. RANGE
Na 161 138-146 mmol/L ALB 3.5-5.5 Wdl GLU 73-1 18 mg/d1
K 3.5-4.9 mmoL/L• ALP 26-84 till BUN
CA-
CRE
NA*
K"
CL-
RESULT
7-22 mg/d1
8.0-10.3 rngidl
0.6-1.2 mg/di
128 - 145 mmol/1
3.3-4.7 mrnoiii
98-108 mmol/1
18-33 mmoUl
phne1pi4--
REF. RANGE
3.3-5.5 g/d1
26-84 u1
10-47 till
14-97 11.1
Cl 98-109 mmol/L • "- -
PH 7.31-7.45 ,,,,, == PCO2
35-45mmlIgi'0 ..... -:= PICCOLO
4 1 -5 1 rnml -I g (veil) 03:56
81.3-1 °5 mmHg on) 17/11/03 N/A Nem REFERENcE RANGE„,,: ny P02
TCO2 q 25.27 mmol/L (art) • 24-29 mmol/L Neu)
PATIENT #: IIIIIIII 1/4-" )'
HCO3 22 -26 mmoUL (art) VET LYT E 8 23-28 mruoUL (wm) LOT #:
3152AA4 tCO2 DISC
s02 95-98%OPER #: DR #: 000 ;:c:ciloy:TI.,0:
FP BEecf (-2)— (+3) SERIAL TEST m•ol/L
AnGap 10-20 mmol/L GLU ' 99 73-118 MG/DL ALB
-4+4- 7-22 MG/D- ALP
CRE 3.5* 0.6-1.2 MG/DL (); 121 39-380 U/L ALT
44A.,+_-__12:3*-- 128- 145 MMOL- AMY
K+ 4.6 3.3-4.7 MOW
Ca L12-1.32 mmol/L
BUN 5s" 8-26 ma/d1 < 70-105 mg/dl ' GLU
Crczt 0 . 7-3 - 5 mg/d1 CL- 116* 98-108 111°M- 'AST tee2--444- 18-33 MOIL
MIL
QC: OK CHEM OC: OK 3GT INST
11-38 ul:
0.271.6 mg/d1
5-63 nil
Net r, 38-51% PCV
Hgb t 1• - 17 g/di
It'cl.S.. ..;c,i.i.ietiiiitiY:::: -- .....:.:) :"..i,.. , •:-,, --, :r, .-:- ."!.::: -7- : . HEM 24, LIP 0 1 ICT 1+ "P 6.44.1 g/c11
TEST RESULT REF. RANGE . ic:c.06.):Ele.ttrolvte:;,:.
TroponL-1-1 TEST RESULT REF. RANGE
Drug of Abuse
.( A' 128-145 mmol/1
1. ■ ,
3.34.7 mmoUl
_ _. 98-108 mmoll
, 18-33 mmol/1 .
REMARKS: •
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 23766
DOD-037344
ACLU-RDI 1682 p.126
Ward/Section: I RF-ric)
)( -1
, N: --- BORATORY RESULT FORM ' ( or t to the Privacy Act of 1974)
DATE T.L.,..E' _ - SSN/PSEUDO SSN: _LAST, FIRST, 1
(Hemato • ' 1 • .. 6 G -Urinalysis " - . • • . Misc. Serology -' ... - • . 1 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 App N/A Mono Negative
Hgb 14-18 Wdl (M) 12-16 edi (F)
Glu ' Negative Microbiology • :. • • ' - •
Hct 42-52%(M) 37-47% (F)
Bili -
Negative Source
MCV 80-94 fi(M) 81-99 fl (F)
Ket Negative Gram Stain
Pit 130-500 x103 verified
SG N/A . Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(FIematology) Manual Differential . : -: d pH • i , N/A Micro Parasites
Segs Mono Prot Negative Malaria '
Bands. Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative . Other
Atyp Imm Leuk Negative • : .:Microscopic Urina • . .• _ • . - • • . ' . •-
RBC Morph
HCG Negative
Spun - 1 Fiematocrit i
42-52% (M)37-47% (F) •. .• - - • .• . - . '•1 - Blood Bank -2 .. .•''..
• •
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABC/Rh
•Coagulation Studi • el.: . . . . • •Blorai Bank Unit Crossmatch• .: .
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD • . :,
TEST gEsuLT REF. RANGE UNIT TYPE CROSSIVLITCH
PT 9.8-13.6 sees •
APTT j 21-34 secs
D dialer 1 <20 ug/ml -
FDP I <10 ugiall
REMARKS:
■ REPORTED BY: DATE: LAB ID. NO.:
MEDCOM - 23767
DOD-037345
ACLU-RDI 1682 p.127
/ \l'ard/Section: Ft7EQ1' ESTING • HYSICIAN: CHEMISTRY RESULT FORM
Subject to the Privacy Act of 1974) LAST, FIRST, MI.
- Li S ATE
a A/ )
TIME SSN/PSEUDO SSN:
., -t • . . , (Pi .colo):,C,hiriii5t-ryl -7.. k.c016);g041-icoliga.41::,::::::-..:-. TEST RESULT REF. RANGE TEST I RESULT 1 REF. TEST RESULT REF RANGE
Na 119 .8.146.omnoUL AL J 73-118 mg/d1 K 3.5-4.9 mmoVL AI -7. = = Ricca.° ,..-- _____ 7-22 mg/di
CI 98-109 mrnon Al 18/11/03 04 18 8.0-10.3 rogidl
pH - 7.31-7.45 PF_FERENCE Al RANGE: 101 F E 0.6-1.2 mg/d1
tItt PCO2 35-45 nanFIg (a.-t) 41-5t mrnHz (yen)
PATIENT ', #: 0)(0 Y A + frETLYTE 8 128-145 mr.r.o1/1
P02 so-los rnmi.is Out) N/A (yeti)
-,.., T DISC LOT # :
3152AA1 • 3.3-4.7 rrunom
TCO2 23-27 mmoln. (arr) 24-29 :nrnol/L (vca)
OPER g #: _ DR :
Ilk # • SERIAL 000
98-108 mmoln
HCO3 22-26 mmoL/L (irt) 23 -28 rnruoUL jvc.n)
# : C D2 .......... 18-33 mmoUl
s02 95-98% ................ " - . . .. C GLU frip. ,r_s. i:::-..tri.coloy.:4:.ref 109 73-118 ....„, uf_. •::....-...-_:: ':.:1-. 4..'..., , .-:;:..,:....':: . Plus.. . ' P an el " el
BEecf (-2) - (+3) mmol/L
1 •%,...'.: BUN 58* i'-'....- : ." ... r C 7-22 MG/DL EST CRE 3.8* 0.6-1.2
RESULT REF RANGE, 46,11Crap 10-20 Eamon MG/Ct ( CK 62 39-380 "'I3
3.3-5.5 g/d/ Ca 1.12-1.32 mmol/L ", 461 4 U/L
• 0 • 128-145 *loft LP K4
26-34 u/1 BUN 8-26 mg/d1 4.6 ;
3.3-4.7 MMOL LT :( CL- 118* 98-108 MMOL ) 10-47 u/1
GLU 70-105 medl tCO2 18 18-33 Nmol .MY 14-97 u4 .
Creat 0.7-L5 rag/di INST QC: OK CHEM OC: OK LST HEM 0 LIP • t 1-8 ul:
I-jet 3S51% PCV i 0 , ICT 1+ :BIL 0.2:1.6 rag/di Hgb 12-17 Wcli 3GT
IT
. 5-65 O.
6.4-8.1 g/d1 - • ' ' iieitiiittl::: -: - _ • . : • .' -• . '-''',!.! . :‘,--. 1.... ;.: ....-....;-V--fr• - •' '•-•.
TEST RES'ULT REF RANGE :::;- :''' : :-. (1,,i.06.1-0.),Elett-r iiIvte;:- :: ::,
'"` ..-:.':':.';:.'::'-..•:::, ...-...71. ).:-jr-:•:....:1.: . ‘-.;:,..::,:f, Troponin- 1
TEST RESULT REF. RANGE
Drug of Abuse
NA"' 128- 145 mmo1/1
3.3-4.7 aunoVi
CI: 1
•
98-108 rrano111
18-33 mmo1/1 _ i
tCO2 ,.
REMARKS: At
REPORTED BY: I DATE: I LAB ID NO.: 1 •
...i
MEDCOM - 23768 S JJ
DOD-037346
ACLU-RDI 1682 p.128
(WO leC5
CC7T
;#17
0rl4e-rt.-.Y
r cb)(6)-21 .4ISTRY RESULT FORM
(Subject to the Privacy Act of 1974)
6„ ;du SSN/PSEUDO SSN:
Ward/Section:
LAS
Clzger-A
0ii.sTiyrplr
.iColei):(b-eniiit-6,:',.121:7
Na
K
Cl.
PH
PCO2
P02
TCO2
HCO3
SO2
BEecf
AnGap
Ca
BUN
GLU
Creat
Hct Hgb
TEST
Tropori 4
Drug of Abuse
RESULT
RESULT REF. R4 ..VGE
RE":„-iii1VGE TEST RESULT 1 REF.
RANGE ,
05:31 --
MA1E ___
,±
3154AA1 #: 000
GM U/L U/L U/L U/L
MGM U/L
G/a.
OC: OK. ICT 24
138-146 mmol/7
PICCOLO 18/11/03 REFERENCE RANGE: PATIENT #: LIVER PANEL
DISC LOT #: OVER #: DR
Pill SERIAL
ALB 4.4 3.3-5.5 ALP 70 26-84 ALT 14 10-47 AMY 76 14-97 AST 90* 11-38 TBIL 6.5* 0.2-1.6 GGT 12 5-65 TP 044 6.4-8.1
INST OC: OK CHEM HEM 1+, UP 0
3.5-4.9 mmon
98-109 mmol/1
7.31-7.45
35-45 mmHg (2 41-51 rremHz (ye, 80-105 mmHg (;u N/A (veul 23-27 mmol/L (al 24-29 mmol/L (v( 22-26 mmoUL (ar 23-28 mnaoUL 95-98%
(-2) - (4-3) rornol/L 10-20 mmoVL
1.12-1.32 mmol,
8-26 mg/d1
70-105 mg/dl
0.7-1.5 mg/dl
38-51% PCV
12-17 gicii
icZOTOYMeiabOli6Pauel..
PICCOLO 19/11/03 06:02 AM REFERENCE RANGE: MALE PATIENT #: BASIC META!" DISC LOT #: 3325AA4 OPER # : SERIAL
DR #: 000
g3LU 106 73-118 MG/DL BUN 444 7-22 MG/DL CA++ 8.0 8.0 - 10.3 MG/DL
0.6- 1.2 MG/DL 128-145 MMOVL
K+ 5.6* 3.3- 4.7 MMOL CL- 120* 98-108 MMO&L tCO2 16* 18-33 MOM_
INST OC: OK CHEM QC: OK HEM 0 LIP 0 , ICT 2+
REMARKS:
93-1U3 mmota
18-33 mmolll
CL" I tCO2
REPORTED BY: 1 DATE: 1 LAB ID NO.:
MEDCOM - 23769
DOD-037347
ACLU-RDI 1682 p.129
Ward/Section: a_cti• etil l REQUESTING PHY SI T • I)
LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FIRST.,.MI. 0)(c?—f
— ' DAT Nirtiir
TIME
36)°
SSN/PSEUDO SSN:
..(Hematology..) _CA . - Urinalysis . . .. Mi5c.. Serology: .
TEST-- __RESULT ....REF...RA - GE 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 10" App N/A Mono Negative
Hgb • 14-1 3d1 (M) 12-16 g/c11 (F)
Glu Negative .. iNicrobiolcra . • .• .. • . • - ' • •
Hct 42-52% (M) 3747% (F)
Bili Negative Source
MCV 80-94 II (M) 81-99 fl (F)
Ket Negative Gram Stain
Pit 130-500x 10' verified
SG N/A . OCC Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Tema to ).1V.I.riziu al pifferential :.. • •.......: ...
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 Imm Leuk Negative . • :.MicroscOpk Urinalysis . - . ....
RBC Morph
HCG Negative . ,
Spun Hematocrit ,
42 -52% (M) 37-47% (F)
. CSF •
. *-- .... . .
• Blood.Bank .,..- .• • . : ... . •. • •
• • . ., . •
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
•Coagulation Studies' ,-.. . • . .
•.' . . .
•••:. - •• ‘ '" - Blood Bank Unit Crossmatch . . (MUST,SUBMIT Sr,518 WITH EVERY UNIT OF BLOOD
TEST FIrEalLT REF. RANGE UNIT TYPE CROSSILLITCH
PT f 9.8-13.6 secs •
II APTT 21-34 secs
D dimer ' <20 n&11
FDP 1 <10 ughni
REMARKS:
(REPORTED BY: DATE: LAB ID NO.:. '
MEDCOM - 23770
DOD-037348
ACLU-RDI 1682 p.130
•
v., arcvoection: ( , / " •1 eprc t2,. ( ( IBPRATORYRESU. LT FORM I
"Eat i c -1- -/ • '. Su`,.. zt to the Privacy Act of 1974) LAST, FiEtST., axG)- Y DA '
1.•
(Hematology) .CBC
TIME • SSN/PSE • (VC)
' • Urinalysis .- .:- :. .
.--•.. '. . • .. .. ,..Misc:Serology : . . •. - • .. .• :... .- 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 10' App N/A Mono Negative
Hgb 14-18 girl! (M) 12-16 Rid' (I')
Glii. Negative • .1yliCrobio ogy . . • : . . . •. . .... .
Hct 42-52%(M) 37-47% (F)
Bill • - •
Negative Source
MCV 80-94 tl (M) 81-99 fl (F)
Ket Negative Gram Stain
•
Pit 130500 x10) verified
SG WA Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Hemato ).1Manual 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 Imm Leuk Negative - - .icroscopic Unn ' •
RBC Morph
HCG Negative
Spun Hematocrit
42-52% (M) 37L47% (F) •• .- • • • . • - . • • • • •
- • •
' • : . Blood.Bank • , ,. • • • .. • . .
. .. . . . • • .
Sed Rate . .,
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
.. : • Coagulation 'Studies.: - ...
• .- •
:.:... - - - :. • '. .. .BloOd. Bank Unit Crossmatcli. .- - ; . - : ....- MUST SUBMIT SF 5I8.WITH EVERY UNIT OF iii.pori.• • •• • • "•:. • • " . . : ,... . REQUESTED)
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 s=
APTT 21-34 secs
D dimer , <20 ug/m1 -
FDP <10 ug/m1
REMARKS:
r REPORTED BY: 1 f
DATE: LAB ID NO.: - • •
MEDCOM - 23771
DOD-037349
ACLU-RDI 1682 p.131
Ward/Section • ;
kA ( REQUEST I G PHYSICIArc).. 2_ - CHEMISTRY RESULT FORM
Sutiect to the Privacy At of 1974) LAST, FIRST, ML 60(0 —Lf DATE
'A A-42,10 TIME SSN • 'UDO SSN:(4) (-6.) _ I b--
. - T ST - ELT REF. RANe E TEST RESULT REF. TEST RESULT REF.RA]VGE
LI MI K
138-146 ol/L ALB 3.5-4.9 mmo1/1.; ALP 26-84 u 1 BUN 7-22 mg/dI
CI 98-1 mrool/L ALT 10-47 &I
pH 7. 1-7.45
PCO2 545 mmHg (ILI) 4)-51 mrraz vela)
PO2 80-105 ounHg (art) WA (veal
TCO2 23-27 rarnoUL NI) 24-29 rnmala. (yen)
HCO3 22-26 mmol/L (2r0 23-28 mmotiL (vcn)
SO2 95-98% CHOL 100-200 mgic2 (p:k6lo)liS,ef Panel pliis:-...,...;-..: -...:;
mmoi/L CRE 0.6-1.2 mg./d1 TEST RESULT REF. 1W/GE
AnCrap 10-20 mmol/L GLU 73 - 118 mg/d1 ALB 3.3-5.5 g/c11 - Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d1 ALP 26-84 lill
BUN 8-26 mg/d1
GLU $.103 mg/d1 . REF. AMY 14 -97 ull RANGE
T. .5 mgidl GLU 73-118 mg/d/ AST 11-38u/
38-5 A PCV BUN 7-22 mg/dl ma, 0.2-1.6 mg/c11
ET 12-17 gldi I CRE 0.6-1.2 mg/d1 GGT 5-65 u'l
.C: 7 heirtisAly.::::,:..":z..: ..',:..!.. CK 39-380u:1 (M) 30-190 u/1 (F)
TP 6.4-8.1 01
TEST RE.S7R.T REF. RANGE NA 128-145 mmolll iCcO16.)EIec:trobte' ,
Troponin-1 "4-
3 -34.71=01/1 TEST RESULT REF. RANGE
Drug of Abuse
_CI: 98-108 mmo1/1 NA 128-145 mmo1/1
tCO2 18-33 moron Ic 3.34.7 mrno1/1
' CI: 98-108 mmo1/1
1CO2 18-33 mmoIll
REMARKS:
WO REPORTED BY: I DATE:
I
LAB ID NO.:
MEDCOM - 23772
DOD-037350
ACLU-RDI 1682 p.132
GX-0-Y L.,?/gs 7 ,c4CO34ed
C NN'ard/Section: g..
"t-Ct4 I REQUEST TO P ' ildly-6) _ 2._ ' CHEMISTRY RESULT FORM
(Subject to the Privacy At of 1974) LAST, FIRST, MI. i- DATE
2t Pti 0 TIME
e5 ) SSN/RSEUDO SS:
(a)-!,TY:f.'..... :•i':::.;.*:7 .. :.;(Pi'teolo) .,C.linaiit-ii;71:1.-. i.0.0 o : et411opel".ariel . TEST RESULT REF. RANGE TEST RESULT- REF.
RANGE TEST RESULT 1 REF. RANGE
Na 138-146 mmol/L ALB 3.5-5.5g/d1
K 3 -54 .9 mmon: ALP 26-84u/1 PICCOLO Cl 98-109 mrnol/L ALT 1C1-17 &I 1?/11 / 03 06:0> AM
PH 7.31-7.45 AMY 14-97 &I REF ERDICE RANGE. MALE
35-45 mmHg (trt) 41-51 mmHz (yen)
AST MilliPCO2 11-38 til PAT I ENT # :l VETLYTE 8
P02 80-105 mmHg (art) N/A (yen)
TBIL 0.2-1.6 mg/c11 DISC LOT #: 3152AA4 -
TCO2 23-27 rnmoln- (m) 24-29 mmo1/1. (yen)
BUN 7-22 mg/di OPER #: Iii. DR #: 000 AL # : SERI HCO3 22-26 mmoVL (art)
23-28 mrooL/L (von) CA4- 8.0-10.3medl
s02 95-98% CHOL 1°G"2°°1118/dj GLU 155* 73-118 MG/DL MG/DL BEecf (-2)— (+3)
mrnol/L CRE 0.6-1.2 mdl
Bu4--444- 7-22 CRE 6.5* 0.6-1.2 MG/DL
AnGap ' 10-20 mmol/L GLU 73-118 mg/d1 OK 362 39-380 U/L Ca 1.12-1.32 mmol/L TP 6.4-8.1 gidl ,444----4-44 128-145 MMOVL
4.7 3.3-4.7 MOIL BUN ' 8-26 mg/d1 K +
-Kcpy.f.):AiIetly-te 8
-i CL- 103 98-108 MMOVL . :.......-: ":.,•-•::-.:--.: GLU 70-105 mg/d1 TEST RESULT REF. tCO2 22 18-33 MMOR_
RANGE Creat 0.7-1.5 nag/c11 GLU 73-118 ragidl I NST OC: OK CHEM OC: OK
Net 38-51% PCV BUN HEM ) LI 7 7-22 m 0 P 1 # ICT ,.....--77 Hgb 12-17 g/d1 CRE 0.6-1.2 mg/di
CK 39-380 &I (M) 30-190 u/1 (F)
TEST RESULT REF. RANGE NA CZU.,jel 12 8- 145 mmolil X 7..J
Troponin-1 " 1 3.34.7 mmol/1
Drug of Abuse
.0 ' 98-108 rarno1/1
tCO3 18-33 mmolil
tCO2 18-33 mi-Ao1/1
•
REPORTED BY: DATE: I LAB ID NO.:
MEDCOM - 23773
DOD-037351
ACLU-RDI 1682 p.133
COC)— cy,ge r
Ward/Section:#, 'ECU. I "
REQUESTING PHYSIC:A' i.G — CHEIVIISTRY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FERST, MI. DATE 1 TIME Li rs-
- SSN/PSEUDO SSN: 0
- --...:. ':.-..,?':,::.;-:.:::-7,77::...:::.:r:::%- ,=. - ..-:4'''-.:.:•- ,.;:- :,(Pie Ccilo):,cb fui .5-t-6, :IP (Pic016):Nlet4lioliC:I'.ate1':-..-.
TEST 7L,5 (7Li ---PF. RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na 138-146 mmol/L ALB 3 - 5-5 . 5 01 GLU 73-118 mWdl
K 3.54.9 mmol/L: --- - BUN 7-22 mg/dl
Cl 98-109 mmol/L PICCOLO =======
CA" 8.0-10.3 mg/c11
PH 7•31-7•45 z z. = := 04:55 CRE
./03 MALE 0.64.2 mg./di )
PCO2 3545 mmHg (m) 41 -51 rnrnHE (veal
22/11 R
IA- REFERINCE: AI
128-145 mmol/1
P02 80-105 rzunHg On) N/A (veul
PAT 'ENT #: C 8
3.3-4.7 rnmold
TCO2 23-27 mrnol/L (art) 24-29 :ninon (ven)
VETLY VE. 3152AA4 71- DISC I.D....imaT #:
98-108 mmo1/1
HCO3 22-26 mmotiL (3n) 23-28 nuuoUL (ven) opER # 11/11,
DR #: 000 20 18-33 mmo1/1
s02 95-98% SERIAL # ....... ;i5..;•• --Vicciiloy:Lii.,it Panel rlii ..,..,::-:- :-
BEecf (-2)- (+3) =non
'' ' .. 6 ... ,.;0'; ;•'31;1;3 TEST GL MG/DL
RESULT REF. RANGE
AnCrap 10-20 mmol/L
( 1444-444- 7 22
7* 0.6-1.2 MG/DL LB 3.3-5.5 g/d1
Ca 1.12 - 1.32 mmol/L I CRE 6 '• ,..„..., 0,,,, U/L -_,I) CK 790 * '5-J - '3°v
26-84 un
BUN 8-26 mfal ' .7 NA+ 136 128-145 MMOVL :r
4.6 3.3-4.7 MMOVL 1047 un
GLU A .
70-105 mg/dl _
K+ CL - 103 98-108 t"- fy
18-33 MMOVL A 14-97 ul
, Creat 0.7- 1.5 mg/di "—o-... tCO2 24
T 11-38 :III
Hct - 38-51% PCV 31 INST (C: OK CHEM GC: OK m 0.271.6 mg/di
Hgb 12-17 g/dl CI HEm 0 , LIP 1+ , ICT 2+ T 5-65 al - Misc:Oilii.)5i .' ' ' -F. .!. CI
• - .._ 6A-8.1 01
TEST RESULT REF. RANGE NI! ri.c044).'gied.t.01.57te'...,f-:
Troponin- 1 7+
bijn
ST RESULT REF. RANGE
Drug of Abuse
_Cl... 128- 145 mmol/1
tCC 3.3-4.7 mmo1/1
98-108 mmoLl
18-33 m.mo111
REMARKS:
T 131 Sov- r. 01,-- 1° 1
• REPORTED BY: DATE: LAB ID NO.: ..
MEDCOM - 23774
DOD-037352
ACLU-RDI 1682 p.134
WardiSection: "ICIAN:
C' kk° OrG —2- n-RATORY RESULT FORM
ct to the Privacy Act of 1974) LAST, FIRST. IV GA= DATE
ab/VIN
TL\1E
b'f3 SSN/PSEUDO SSN:
ematology)cpc Urinalysis „Misc. Serology. ' . •-• • • TEST RESULT IIEF. RebyGE TEST RESULT REF. LINGE TES7i RESULT REF. RANGE
WBC 4.8-10.8 N: 10' Color N/A RPR Negative RBC 4.7-6.1x 1 09 N/A Mono App Negative Ligb 14-18 (M) Glu Negative .11,1irobiology 12-16 g/dl (F) Hct 42-52% (M) Bili . Negative Source 37-47% (F) MCV 80-94 fl (M) Ket Negative Gram 81-99 11 (9
Stain Pit 130-500 x 105 SG •N/A Occ Bld verified Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative (Hernato ) M.anual 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 Imm Leuk Negative ....MicroscOpiUUrina
RBC HCG Negative Morph
Spun Hematocrit
42 -52% (M) 37:47% (F)
CSF •
, Blood.Bank , - • - •
Sed Rate .
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
Coagulation Studies.' - ' •;. • .' • . - •Blood:Bank Unit Crossmatch (MUST SUBMIT SF 518 WITH EVERY UT OF BLOOD .:
TEST RESULT REF. RANGE (WIT TYPE CROSSMATCH PT 9.8-13.6 secs •
APTT 21-34 secs
D dimer <20 ug/m1
FDP J
<10 ug/ml
I REMARKS: -pi- 1 L...__....__________„,____________
: LAB ID NO.:.
MEDCOM - 23775
DOD-037353
ACLU-RDI 1682 p.135
I Ward/Section: f '•
f, REQUES G PHYS4SW5-....,2_ . ' CHEMISTRY RESULT FORM
(Subject to the Privacy At of 1974) L. ST F a)(6)- r DATE
9t NJ TIME
, M-- SSN/PSEUDO SSN: _
, , i-sa.4.1):::: :, ,JEOleiYaleriliir6,..'12:-,:::-...,,, r(I'iC'COTO):KetabpliC 1 1"ar.1111';'::::: ,..,--:. - .-,:::-->7..4.-,.:*:!..,.--nr.;•:::,....- :-.-.: -,-:........:,..-,...,:; .:4: ..-.-'•
TEST RESULT REF. RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na 138-146 =non. ALB 3.5-5.5 edi GLU 73 - 1 I S mg/d1
K 3.5-4.9 ramoVL: ALP • 26-84 u/1 BUN 7-22 mg/di
Cl 98-109 mraol/L ALT 10-47 u/1 CA''' 8.0-10.3 rnedl
PH 7.31-7.45 AMY 14-971i11 CRE 0.6-1.2 mg/d1 •
PCO2 35-45 mrang (Ert) 41 -5 1 mrnHg (veal
AST 1l-38u11 NA 128-145 mrno1/1
P02 80-105 mallig (an) N/A (veal
TBIL 0.2-1.6 mg/d1 K 3.3-4.7 artulii
TCO2 23-27 rnmol/L (art) 24-29 rnma1/1. (yea)
BUN 7 -22 rpg/d1 CI; 98- 10S mmol/1
HCO3 22 -26 mmol/L (art) 23-28 mruol/L (yen)
CA 8.0 -10.3medl tCO2 18-33 mmoUl
s02 95-98% CHOL 100-200 ing/cil .;• it Co]o)71..iy... ei Pan el - F.14i.,:,:-.•.::.;
BEecf ' (-2) - (+3) rarnoi/L
CRE 0.6-1.2 mWd1 TEST RESULT REF. RANGE
AnG-ap 10-20 nnol/L GLU 73-118 mg/d1 ALB 3.3-5.5 g/dl
Ca i 324.32 nunol/L Tp 6.4-8.1 g/dl ALP 26-84 al
BUN 8-26 mg/c11 ks010.MetIkte. 8::. , :.-,;. .- ALT 10-47 till
GLU 70-105 mg/d1 TEST - RESULT REF. RANGE
AMY 14-97 al
Creat 0.7-1.5 inedl GLTJ 73-118 rzedi AST 11-38 a;
1-lot 38-51 .% PCV BUN I 7-7 " mg/til TBIL . 0.21.6 rag/d1
Hgb 12-17 g/di CRE 1 0.6-1.2 mg/dl GGT 5-65 u/I . .. . . . ...
C:C,4eirtistry.:: ...1,.,. . CK 39-380 u/1 (N) 30-190 u/1 (F)
TP 6.4-8.1 g/dl
TEST RESULT REF RANGE NA' 128-145 rnraoLl - :
.CCOIO.>Electrohle::" ..:'.;
.... .. . . .. ... ..,. Trcponin-1 • 1 334.7 mmol/1 TEST RESULT REF. RANGE
Drug of Abuse
..CL- 98-108 mroo1/1 NA' 128-145 mmol/1
tCO 2 18-33 mrao1/1 K 3.3-4.7 mmo1/1
• C[..- 98-108 mmoL'I
tCO2 .
18-33 ni-no1/1
REMARKS: frr PIT
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 23776 •
DOD-037354
ACLU-RDI 1682 p.136
Specimen: Source: Sputum Ward of It:
Status: Final Collected: Attd. Phys:
Name: Patient ID: Ward/Rm: U1/
1A EmpeClobacter (F.) brevis - 4 - - Status: Final
1A E. brevis Drug MIC Amox/K Clay (c) >16/8 Amp/Sulbactam (c) >16/8 Ampicillin >16 Aztreonam >16 Cefazolin >16 Cefepime >16 Cefotaxime (c) >32 Cefotetan >32 Cefoxitin >16 Ceftazidime (a) >16 Ceftriaxone (c) >32 Cefuroxime (b) >16 Cephalothin >16 Chloramphenicol >16 Ciprofloxacin <=1 ESBL-a Scrn >4 ESBL-b Scrn >1 Gatifloxacin <=2 Gentamicin >8 Imipenem (c) >8 Levofloxacin <=2 Meropenem (c) >8 Moxifloxacin <=2 Nitrofurantoin >64 Norfloxacin 8 Pip/Tazo (d) >64 Piperacillin (a) >64 Tetracycline >8 Ticar/K Clay (a) >64 Tobramycin >8 Trimeth/Sulfa >2/38
Interps Drug MIC Interps
R
R R
R R
R S
R R . S R
R R R R R R
S = Susceptible N/R = Not Reported I = Intermediate
= Not Tested R = Resistance TFG = Thymidine-dependent strain MIC = mcg/m1(mg/L)
Blank = Data not available, or drug not advisable or tested ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive
FR' = Resistant due to extended spectrum beta-lactamases (ESBL) EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases. IB = Inducible Bela-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 ampicillin/sulbactam with enterococci, refer to the penicillin interpretation (d)
For non bela-lactamase producing enterococci, refer to the penicillin interpretation Footnote (a) also applies to this drug
FInterpretive breakpoints are based on NCCLS M100-512 Jan 2002. Sparfloxacin (for Gram Negative isolates) and
moxifloxacin are based on FDA approved breakpoints or S. pneumoniae. cefolaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis For non-meningitis infections, use <2=5. 2=1, >2=R. Name: aY0 _y Specimen:
Patient ID: Status: Final Source: Sputum Collected: VVard/Rm: U1/ Ward of Iso: Reg. Phys: .
Printed 11/16/2003 9:03:57 AM
MEDCOM - 23777
Page 1 of 1 Tech
Cb)(6) 2-
DOD-037355
ACLU-RDI 1682 p.137
w UZI
a_ cu 9-
7
N
MEDCOM - 23778
DOD-037356
ACLU-RDI 1682 p.138
MEDCOM — 23779
CD
0
0 0
CO
CD .0
OCD
11) Cl) O ris
O 3
▪ u)
Z sza
3 3 CD C
tori.
DOD-037357
ACLU-RDI 1682 p.139
H 3 cD P.
MEDCOM - 23780
DOD-037358
ACLU-RDI 1682 p.140
.Z.I.
CA
71.1
Z I
JC
/LI
AJG
.1.4G
IV .1C
74
tAJ
I IIN
.aP
CD
(i)
CD 0 .
B CD
a
MEDCOM - 23781
DOD-037359
ACLU-RDI 1682 p.141
Pre-Proovo
B/P rt PI RVO 'nsooseeprodechwe
, reroous nsonewal0Crem More Currin II ge* I on s
EKG
roma/Molloy d Matthews Corvolications n Non* O
AIRWAY/TEETWHEAD a NECK
4)14 4114
RESPIRATORY 404 hr 8mA:tam Ploglisame Ceup CCPD Rowe Cold
DMA's SO6 errePnesa Tubs Rows
CARDIOVASCULAR
Arps,* • MI
ANIsythmu
CHF MVP
breccia. Wawa. Pacemaker
Hype/tans/on Rheumatic Feuer
Allem/es N1
History From: o Patient o ParengGuardian o Significant Ott
CharlivoN-r xioi« ro.Poor Histatiarf
NEPATO/GASTROINTESTINAL Dowel Obi:ruction N&V Cirrhoms ReltathearIburn HerOMIlia Lacers
: Maui Harms JaLrocks
NEURC(MUSCULOSKETAL Arthrits Pentlyvi
6b4 .QTDIgn" Paresthel Se Syncope
Seizures Heads ►we TIAs Leas d COnsootnness Weakness Netalornuenear dawn*
Ethanol Us*: o Yes o No F
l.NAL/ENDOCRINE Diabetes Wmghi loss/gam Renal FselLre/Malyus
Throd Disease Unnary Reterreon Unrary Imo ,n/eanon
OTHER Anerres Transiusion resswy BleeOws, teroenoes Pregnancy Irternopno!.a S ■doe r.1; Ines
Problem bst/Osegnos,s
CSS (Pc t., ccl- ASA PS
2
LAB STUDIES h9b/KAIC BC 11.1 ,0,yle 1 l!frr, aryan
doer
Planned AnesiremalSpooal Moreton
Pre-Aneethem Mealcations OnNireO
Evaluator Sgnuureis)
5
r..— MEDCOM - 23782
DOD-037360
ACLU-RDI 1682 p.142
RATE MEDICATIONS ADDED
IME START
)(VD 04./.2t)
Ot/2.0
4114., • i IFAIM
INITIAL TIME STOPI INITIAL
(b)co- 7".
F /00"c Ot00
MEDCOM - 23783
DOD-037361
ACLU-RDI 1682 p.143
•
a
AIRWAY MANAGEMENT
STt ITT STOP
771A .4112sisea.TriV,
RECOVERY ROOM
5;1
Inweelion DOM ON's., Owed I/mon 0 Maga' s 75and DM. see Arras OFaseer 05 DStylet Alternate s 7846e Tube els Endooromast Regular ORAE OA/meted 3Leser Cutlet 011et. ace. part 3Aw ONS Wolfed. *RS at an I120 Secsorel al 0 ET 032 p464 email% Sands
3Cecie QPIon-tebreetlea; Amway: ]Oral Misr' , Natural Mark Case O Ws Trecasocomy Nasal Camas CIG.mase 02 Mask
RIP
PACU QICUCIUD
Awake page Out Am... Asleep laVentderat Wiese, Slabs* 0 Exwbatos 0 Fa= snood o; unotabiAint(bated °team
• CONT ROLLED DRUGS '.
Pla/din/i0=1
■ • • ■
11
TIM E :
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EMEIZETLIM Ural ISM El MIX:Z./UM!' MIN NM III =Tam= Imo IMT.ZINIMIII Illeti ■
Ball MN ■ 1111EMMIIIGII IMO II 1 VMILIMIIIIIIIIMMIN
• ■
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ANESTI IESIA RECO
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dye cam 001rinssal 0 sahr• moped 0 Pads Goggles
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a bet Mock OAnue BlIt enerel: Rapid Sewer& 0 Camel Parssum
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Rectal mtrier Rectal twat OPostkon
Prep °Lees, a
Needle DIM*) • Dose Sas Cromer
MOTORS 8 EQUIPMENT
- OPres0a1"00ther save ER 014twve Slaver'
mucus EKG OU teed EKG Cornwter Q0emn Analyse
ct2 0 Rasp Gas Aryl, 0 EEG
nail DPW Warmer Pkomdifee Q Tata fiefekry Celheott
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1•11111111111111•111111=1111111111 PIPE INN IIIIMIIIMINII IIIIIIMIll IIIII• UM NINI 1 Mk/ MCA MIIII E.4111 IfilMI 10:51 AXE Min MI MI II1= MIN 111111111=111 MEIN NM MIMI iga CIAUFfiL211MIN Mal Mil I152 =II MINII MIII NM MIN MN MEM NM MO 11:1:111 WEN IL II VELA Mal FA= lEka MR MIIIIIMMIN MIRII NMI RIM MIN MIN Mins KM 1011111M11111.10 MA IGUN MIME MI 1=0 NM NMI MIN ME KM Ilias LIM LIVIAL54•11 1061Z I IIMMXil MIN MX =II =MIME MI= MN NS NI Mill 1111111111111111111111111111111111111111111 111111 mum NMI Wm 11 NMI MN mis am am Emu Imo aim= Ems Nom mint mow Inn MI MIR •11111111/1111111111111111111111111111111111111 111111111111.1 ERN RIM MN NM Innl IHIIIIIIIIMIIN111111111111111111111N1111111111111111111 iiimmlimmilammi." MIN NM min 11111111111111 Num Rim IN mai 1111111011m1mull Ma MN RINI ERR NMI UM EU MI II ON MN ERN III II MI 1111111 111111111111112 IIIIEI BIM NMI 1111111111111 IIIIIIIIIIIIIIRIMIRIIIIIIIIIIIININI ERR IRER 9mail MIMI RIM MR • RIM MN 1111111111111 MIR PRI MI REM 11111111111111111115111111111111111110 ME 1111111111111 'NM Inr2TRIMPIVRZMVArlIIIIPI =NM MEW RIM ME REIN ME OM RI I BAIA &AN II ill11111111 UR If /A /4 IIEWANIIIII NMI 11•1111111111111111X11 SillA Xi RXEMIIIIII RUA E1012 NIIIIMII11111111111111 NM MA '411011 Min 11111111111111111111111111111 OM MEI MIN MIR NM 11111111111111111111111111 MIN 1111 ■ 11•■ 111111 ■MIR111111 ■ 1111111 MI NM 111111111111111 IILIMI mum mia MINI EMI OHM mum iminutmenna 11111111111111111 MWIII MUM 1111111111111M11111 IIIIMI Mr MAI MIL Lim PRI IRE 1•11111111‘11111111•1111111111111111111 MN NMI MUM NUR WM MR ICI 11411111111 awn NU NEN NMI NEN NEN MIMI II NM IMO II 111M1 MEM OM ME MR t1111111/1111 UM ORS 1, L II ALL: au 111111111111/1111111 ME 111111111101 MIR ESIXIII NE X DOM WREN milt warm Lx, a VIWIENNENNIMIN ME NINN ERN MIR RI ESC= MEE UNMANS NI Wel ILYA/ 311111 1111111111411111111111111• MIMI MIN RIM 11111111111111 MAN MEM 111111.11 1111111111111111111111111111111111111111111111111MMIIM111111111111111M 11111111111113 MUNI= MEM , 0 I MN 1111111111 EMI IIIIIIII 1/1111111111111110111= 11111111111111111 11111111111111111111111111 NNE MUM11111•11 MI • .. 11 . 11111111•1111111111111111111111111111111111111111111111111110111111111111111111111111111111111111111111111111111111111111111111 ES • NISI MIMI 11111111111111 NM YR MUM ERR INER1111111 IMO M•1111111511 HS ERN mos Min URI 11111111111111111111110 NUR 11111111111111111111111111•1111111111 IHUI RUM 11/1111 RIEJE ES 1111111 II Mil I 1121 Ma ROI MI PPM 11111P.M1 MIR MUM. RRI11111111111E ERN NMI NMI MI ■Itor.A MEI VIZ/ 1 VAII iNitull LIM 111■1 MI MN IMO MIS MINI NM NM MI MEI IIIM It= MEIN ii1101 UM 1=1 MO MEM ERR MIMI ME II= NO EXCEI IMO .2M' Ici-n11 ItSfY. E..= Er= mil man an NEN NNE NNE MIR ME MEM LEM MEI ME sr mown= sow um ism Imo Imo mow mime mom mil11111=111 nen fa= Frf.= rin7::!,:r ' 111111111111111111111111111111111111111111111E1& ":1 ;T:." L'agg KM .1.1 MO ‘ I I MIIIIIIIIIIIIIIIIIIIIIIIIIIII NM Ic MI
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09
AMP
MEAN ARTERI
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ILLSE
a.
ONE
V
MEDCOM - 23784
A IR II I"*. retts•• .1 • ...•
DOD-037362
ACLU-RDI 1682 p.144
❑ CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE AIDV 03
__— TEMP. t l PULSE
PRE-T OTHER DIFFICULTIES (Equipment, clots, etc.)
NO ❑ YES (Specify)
SECTION III - RECORD OF TRANSFUSION PIL-TRANSFUSION DATA
ML
/INTERRUPTED
19V
AMOUNT GIVEN
©3 R TION
NONE ❑ SUSPECTED
TEMPERATURE
rbi.a PULSE
I it ErQliiSSURE
A, AT (Hour)
IDENTIFICATION .
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
OF REACTION
❑ URT1CARIA ❑ CHILL El FEVER 0 PAIN
OTHER (Specify)
DATE OF
ZR3 PATIENT IDENTIFICATION—U E EMBOSSER (For typed or written entries give: Name—Last, firsm
rate; hospital or medical facility)
NNW MEDCOM - 23785
a.
TIME STARTED
INSPE
1st VERIFIER (Signature)
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
UNIT NO.
DONOR
ABO
Rh pps
TRANSFUSION NO.
PATIENT NO.
RECIPIENT
ABO
Rh pos
TEST.INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
SIGNA E OFPERSON PERF OR
PREVIOUS RECORD CHECK: us,,. RECORD ❑ NO RECORD
MING TEST
REMARKS:
ex //l/Vov43
cb)(E - 2_ d ver 1 # -
azgi
518-124 -0 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
IVI CROSSMATCH
REQUESTING PHYSICIAN (Print)
DIAGNO IVE PROCEDUR
6 1 - R?lb ❑ CRYOPRECIPITATE (Pool of DATE fIST)1/41) _
ACV 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,HOZ RFQVIRED
I, k) CrN) 0 "3
VOLUME REQU STED (If applicable) f
I V_ ML
KNOWN ANTIBODY FORMAT1ON/TRANSFUSION REACTION (Specify)
SIGNATURE OF VERIFIER
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
ON (Date) / "WV
z%'
DATE VERIFIED
2 3 4(-) 0 3 HEMOLYTIC DISEASE OF NEWBORN?
D TIME VERIFIE0 9 q 5- SECTION II - PRE-TRANSFUSION TESTING
DOD-037363
ACLU-RDI 1682 p.145
_ - PRE-TRANSFUSION TESTING
UNIT NO.
UM .
TEST INTERPRETATION PREVIOUS RECORD CHECK:
al RECORD NO RECORD
SIGMA E OF PERSON PERFORMING TEST
ANTIBODY SCREEN CROSSMATCH
NA up DONOR
ABO
p°.5
D CROSSMATCH NOT REQ UIRED FOR THE COMPONENT REMARKS:
Rh
TRANSFUSION NO.
PATIENT NO.
RECIPIENT
ABO
Rh F0 s
SOW I,..j I. Ai II A '''' ED ; DATE i ty Dr I,Li
3
POST-TRAN
INTERRUPTED
'1/4/ 0'7 PULSE
tt(
AMOUNT GIVEN
t4.4.4 " ML
TIME/DATE COMPLETED
If reaction is suspected--IMMEDIATELY:
REACTION
ONE DSUSPECTED
TEMPERATURE
1,1 •
BLOOD PRESSURE 169'4
518-124
(b)(6) -2- C-e.16rf 4c:14AI
NSN 7540-00:634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - RE QUI COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
PLATELETS (Pool of units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
CROSSMATCH
REQUESTING PHYSICIAN (Print)
DIAGN S
CRYOPRECIPITATE (Pool of units)
Rh IMMUNE GLOBULIN
OTHER (Specify}
DATE REQUEST
6V e) 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 N OUR IRED
03 VOLUME REQ ESTED (If applicable) 11
ML
KNOW A DY FORMATION/TRANSFUSION REACTION (Specify) OF VERIFIER
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
DATE VERIFIED w ,
No.) HEMOLYTIC DISEASE OF NEWBORN? TIME ERIF1ED
0
i i q c
SECTION III - RECORD OF TRANSFUSION
AT (Hour) Li% —+ ON (Date) DENTIF1CATION
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.
PRE- USIO
TEMP. JO/s I I PULSE 1 4 1 DATE OF TRANSFUSION
3 )Jv v.
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
URTICARIA CHILL FEVER 0 PAIN
OTHER (Specify)
T ER DIFFICULTIES (Equipment, clots, etc.) NO YES (Specify)
GN OF P RSO
I TIME STARTED
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, rate; hospital or medical facility)
MEDCOM - 23786
WAR
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-037364
ACLU-RDI 1682 p.146
UNIT NO. TRANSFUSION NO. PREVIOUS RECORD CHECK: TEST INTERPRETATION
ANTIBODY SCREEN
PATIENT NO.
RECORD ❑ NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
CROSSMATCH
RECIPIENT
ABO
Rh e—Ck5-
❑ CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
REMARKS:
L-3-61-100-‘ 3
i../01/4.t3-- 03 DATE /
DONOR
ABO
Rh
1stWERIFIER (Signature)
TEMP. T/
DATE OF TRANSFUSION .
LY. AA) 01,3 BP
TIME STARTED
I PULSE
MEDCOM - 23787
0)(6) _ 2 ,,ce ‘tme ve‘y 104"
518-124 NSIN17540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
❑ FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
❑ TYPE AND SCREEN
'd CROSSMATCH
REQUESTING PHYSICIAN (Print)
INIIIIP DIAGNOSIS OR OPERATIVE PROCEDURE
❑ CRYOPRECIPITATE (Pool of DATE REQUESTED
Ata (I / 'IL% O...? /
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
❑ QTHER (Spec(Specify)
DATE AND HOUR REQUIRED
'IV (1/174; d5 VOLUME REQUESTED (If applicable)
ML
KNOWN ANTIBODY FORMATIOWTRANSFUSION SI NATURE OF VERIFIER REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
DATE VERIFIE
HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED
SECTION II - PRE-TRANSFUSION TESTING
SECTION III - RECORD OF TRANSFUSION PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
INSPECTED AND. ISSUED BY (Signature) AMOUNT GIVEN
- iii/ V6 V V (6 3 ML i3 CTIO TEMPERATURE PULSE/ RI §WRESSURE
TIME/DATE COMPLETED/INT RUPTED
AT (Hour)' 4.9 17) ON (Date) • Pry ̀VY IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient Identification tag.
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2..Notify Physician and Transfusion Service. 3. Fellow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, rate; hospital or medical facility)
If reaction is suspected—IMMEDIATELY:
ONE El SUSPECTED 15(.- 1 I i 1
7 77-
DOD-037365
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
OTHER (Specify)
THER DIFFICULTIES (Equipment, clots, etc.) NO ❑ YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
WARD
(}Cit ttt
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1
ACLU-RDI 1682 p.147
UNIT NO. • - -
RECIPIENT
ABO
Rh
CROSSMATCH
COCO - 2_ vQ(
518-124 NSN 7540-00-634.-4156
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
❑ FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
❑ CRYOPRECIPITATE (Pool of units)
❑ Rh IMMUNE GLOBULIN
❑ OTHER (Specify)
VOLUME REQUESTED (If applicable)
ML
REMARKS:
TRANSFUSION NO.
PATIENT NO.
DO
ABO 6 Rh
REQUESTING PHYSICIAN (Print)
❑ TYPE AND SCREEN
❑ CROSSMATCH
DATE REQUESTED I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
SIGNATURE OF VERIFIER
ATE V
TIME VERIFIED
; ,ANTIBODY SCREEN
SIGNATURE OF PERSON PERFORMING TEST
❑ CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED REMARKS:
1-)A.a.p=rc,3
SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
DATE AND HOUR REQUIRED
A/0 t/t 03 KNOWN ANTIBODY FORMATION/TRAISFUSION REACTION (Specify)
)
)PREV OUS RECORD CHECK:
10(RECORD ❑ NO RECORD
DIAGNO 0
CI4e-sT
Yiver-zz
SECTION III - RECORD OF TRANSFUSION
POST TRANSFUSION DATA
REACXAON
ONE I I SUSPECTED AT (Hour)
IDENTIFICATION
ON (Date) /1/ AN/
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)
AMOUNT GIVEN
ML
i e (61 (72/ BI LAD TESSURE
If r action 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, Alter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER (Specify)
TIME/DATE CoMPLETED/INTERRUPTED
I I (IAA) RrE PU
I(IAA)
.... PULSE iq I BP DATE OF TRAN SI I TIME STARTED
if 3 3i6 PATIENT IDENTIFICATION—USE EMBOSSER (For typed written entries give: Name—Last, first, mi
rite; hosRital oLlmedical facility)
(,1')
-41 MEDCOM - 23788
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
yTHR DIFFICULTIES (Equipment, clots, etc.) NO Ej YES (Specify)
prq>ar ni ,
rank; I WARD
DOD-037366
ACLU-RDI 1682 p.148
-710 G)Lto-
CROSSMATCH
INSPECTED AND ISSUED BY (Signature)
AT, (Hour) Of ON (Date)
6)(c) ._ 2._ ex .c 1; erv-
518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
REQUESTING PHYSICIAN (Print) TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
CROSSMATCH j
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 RE UE TED
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
PLATELETS (Pool of units)
CRYOPRECIPITATE (Pool of units)
Rh IMMUNE GLOBULIN
OTHER (Specify)
SIGNATURE OF VERIFIER VOLUME REQUESTED (If applicable)
ML
DATE AND HOUR REQUIRED
19 110\1 15," M1131 KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED
0
SECTION II — PRE-TRANSFUSION TESTING UNIT NO. TEST INTERPRETATION PREV OUS RECORD CHECK:
)414 RECORD ❑ NO RECORD ANTIBODY SCREEN
TRANSFUSION NO.
PATIENT NO. SIGNATURE OF PERSON PERFORMING -TEST
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
REMARKS: frkin"--- 422
SECTION III - RECORD OF TRANSFUSION
DONOR
ABO
Rh
• po
RECIPIENT
ABO
Rh S
DATE
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
AMOUNT GIVEN
ML
TION
NONE ❑
SUSPECTED
TIME/DATE COMPLETED/INTERRUPTED
AAIV 1 7 03 TEMPERATURE PULSE BLOOD
/3r
P SSURE
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 perion named on this Blood Component Transfusion Form and on the patient identification tag.
If readtion 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.
PATIENT IDENTIFICATION— USE EMBOSSER (For typed or written entries give: Name—Last, firs rate; hospital or medical facility)
s.--5 DATE OF Ta NSFUSION TIME START60
A_Nz /
DESCRIPTION OF REACTION
URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
OTHER (Specify)
THER DIFFICULTIES (Equipment, clots, etc.)
NO ❑ YES (Specify)
SIGN
WARD /
TURE OF PERSON N • ING ABOVE
MEDCOM - 23789
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FiRMR (41 CFR) 201-9.202-1
A.
DOD-037367
ACLU-RDI 1682 p.149
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
a RECIPIENT
ABO
Rh
e"9-L-trvr- ce..r REMARKS:
UNIT NO. TRANSFUSION NO.
PATIENT NO.
DONOR
ABO a CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQU
PREVIOUS RECORD CHECK:
RECORD D NO RECORD
SIGNATURE OF PERSON PERFORMING TET p
Rh
DATE (p6- al<sel_?
24d VERI
TEMP.
DATE OF TRANSFUSION()
AMOUNT GIVEN TIME/DATE COMPLETED/WIEBRUPTED
7Crt:' ML OL.,< REACTION
NONE 111 SUSPECTED. TEMP
1R FLSE BL0 SSURE
k /0194P7
V 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.
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, ARMR (41 CFR) 201-9.202-1
DOD-037368
ay-6) —2 ei<oeor wpry hail:71
NSN 7540-00-634-4159 518-124
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
K RED BLOOD CELLS
FRESH FROZEN PLASMA
n PLATELETS (Pool of units)
❑ CRYOPRECIPITATE (Pool of units)
111 Rh IMMUNE GLOBULIN
111 OTHER (Specify)
VOLUME REQUESTED (If applicable)
ML
REMARKS:
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
jleZ TYPE AND SCREEN
CROSSMATCH
DATE REES-1Z7N(
DATE AND HOUR REQUIRED
( Tre0.16 KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
REQUESTING PHYSICIAN (Print)
DIAGNOSIS OR OPERA aCEDURE
675co-f-oh4 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.
TIME VERIFIED
FL)
SECTION III - RECORD OF TRANSFUSION PRE-TRANSFUSION DATA
INSPECTED AND ISSUED BY (Signature)
AT (Hour)
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the Same person named on this Blood Component Transfusion Form and on the patient identification tag.
1st VERIFIER
POST-TRANSFUSION DATA
DESCRIPTION OF REACTION
URTICARIA CHILL ❑ FEVER ❑ PAIN
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
NO YES (Specify)
SIGNATURE 0
ON (Date) ..4/r),e"
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, f rst, middle; gr rate; hospital or medical facility)
G)(6)
VIM MEDCOM - 23790
ACLU-RDI 1682 p.150
REc.,4uzsrcr
1\4 ktoGc,('s-
Czr -eV a(qctle. ,For
(eriava. zrtd fir.dirtzs)
PR:..C.NANT
T ELEPHON , ,PAC=-7
QTE
Sr; REGISTER NO.
I
L'.1 NO.
REC.'..JESTE0 BY (Prir.t)
I S:ONA Li:ZS OF REQUEST.OR
1 -.X.A.,.:hsi.A.TiC..N (Mon:h..:.'cy. Y211.") DATE OF REPO?. ■ (.:tort:.":. cl.zy, ye:zr) ;DATE OF T.R.A::SCR:PTION
P.E.P0,47
:7-7eo or :•GC::;)
IL3 C ,1.7 1C r4 D ir m = 0 1::-. A—.... ,..— DA. D S
cq
----- c0C6)-g • ,f
FI !C. .7.0.NiUL TA :ION
, —
MEDCOM - 23791
DOD-037369
ACLU-RDI 1682 p.151
!DATE OF REPORT (Month, day, year) DATE OF EXAMINATION (Month, day, year)
RADIOLOGIC REPORT
DATE OF TRANSCRIPTION (Month, day, year)
RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
AGE SEX
FILM NO.
REQUE ED BY Pr coxo- z
EXAMINATION(S) REQUESTED
• DATER QUESTED.
REGISTER NO.
PREGNANT
Ei YES NO K SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)
ASN 7540-01-165-7294
519-301
, ATIENT'S IDENTIFICATION (For typed or written entries give: 'Jame — last, first, middle, Medical Facility) LOCATION OF MEDICAL RECORDS
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
RADIOLOGIC CONSUL TATiory
MEDCOM - 23792 STANDARD FORM 519-B (8 -83) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8
DOD-037370
ACLU-RDI 1682 p.152
(7.0() -- 9 .ak-coff very ha
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 RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
NURSING UNIT ROOM NO.
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ACLU-RDI 1682 p.153
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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
RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION
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MEDCOM - 23794
NURSING UNIT
DOD-037372
ACLU-RDI 1682 p.154
TIM ER
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NURSING UNIT ROOM NO. -45 now
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 IDENTIFICATION
HOURS
DATE OF ORDER TIME OF ORDER
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CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-037373
ACLU-RDI 1682 p.155
PATIENT IDENTIFICATION TIME
r-
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NOTED AND SIGN
DATE OF ORDER
Sfr HOURS
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DATE OF ORD TIME O ORDER
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MEDCOM - 23796
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
DOD-037374
ACLU-RDI 1682 p.156
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PATIENT IDENTIFICATION
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DA 1 FAV:479 4256
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USEp.
MEDCOM - 23797
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN CO UMN INDICATED BY ARROW BELOW.
DOD-037375
ACLU-RDI 1682 p.157
BED NO.
HOURS
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
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NOTED N
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ACLU-RDI 1682 p.158
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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ACLU-RDI 1682 p.159
DATE OF ORDER
jUCk./ C
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TIME OF ORDER
DATE OF ORDER F DER
BED NO.
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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
HOURS
DATE OF ORDER TIME OF ORDER
/Ob() LIST TIME
ORDER NOTED AND
SIGN
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
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PATIENT IDENTIFICATION
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION
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ACLU-RDI 1682 p.161
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
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MEDCOM - 23802
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
ACLU-RDI 1682 p.162
FORM 1 APR 79 DA
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
ATIENT IDENTIFICATION DATE OF ORDER aplE OF ORDER
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
a) CGO - '(
DATE OF ORDER
70\\.b4 (03 TIME OF ORDER LIST TIME
ORDER NOTED AND
SIGN
NURSING UNIT ROOM NO.
NURSING UNIT ROOM NO.
ROOM NO
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
4256
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23803
DOD-037381
HOURS
DATE OF ORDER TIME OF ORDER
HOURS
ACLU-RDI 1682 p.163
BED NO.
ROOM NO. BED NO.
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PATIENT IDENTIFICATION
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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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION • DATE OF ORDER
d TIME OF ORDER
41/7
PATIENT IDENTIFI DATE OF ORDER
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
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MEDCOM - 23804 REPLACES EV. UI- Jut. DA
DOD-037382
ACLU-RDI 1682 p.164
TIME
1 BED NO.
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S -71-42(...,--) A CAN) -74-C-f
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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
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PATIENT IDENTIFICATION
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DATE OF ORDER
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ACLU-RDI 1682 p.165
DATE OF ORDER
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LIST TIM ORDER
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2:5`i 4),J (53 DATE OF ORDER Aid
I E OF ORDER
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 RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFI
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DATE OF ORD R T1 E OF ORDER
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PATIENT IDENTIFIC ATION
DATE OF ORD R TI E OF ORDER
CATION
NURSING UNIT !ROOM NO. ! BED NO.
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DA 1FACPRM79 4256 fREPLACES EDITION 0 1 JUL 77. WHICH MAY BE USED:,..
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DOD-037384
ACLU-RDI 1682 p.166
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ROOM NO
DATE OF ORDER TIME OF ORDER PATIENT
HOURS
NURSING UNIT ROOM NO. BED NO.
DA 1 FAOP FIRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23807
DOD-037385
HOURS
NURSING UNIT
LIST TIME ORDER
NOTED AN SIGN
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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 RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
ACLU-RDI 1682 p.167
VERIFY BY RVITIALING
ORDER DATE
CLINICAL RECORD
CLERK/ NURSE
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THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) For use of this form, see AR 40-407; the pro nent agency Is the Office of The surgeon General. Ma Yr. 2003
INITL4L PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED
ALLERGIES: D YES 1:::]
PATIENT IDENTIFICATION:
DA FORM 4677, 1 OCT 78
ADDITIONAL PAGES IN USE: DYES ED NO
PAGE NO:
EDITION OF 1 DEC 77 MAY BE USED.
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
1 USAPA V7.00
PRIMARY DIAGNOSIS:
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DOD-037386
ACLU-RDI 1682 p.168
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo y, 2003
Order Date
Clerk Nurse SINGLE ACTIONS Date to
be Done Time to be Done Time Done Initials
I .
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ACLU-RDI 1682 p.169
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THERAPEUTIC DOCUMENTATION CARE PLAN ( RON -MEDICATION ) . A '4 For use of this form, see AR 40-407;
the pro • •Aent agency Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ECURRING.ACTION, FREQUENCY, TIME
113 1111111,1EINIP.M.ENEVIIERM _A■
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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.
MEDCOM - 23810
USAPA V1.00
DOD-037388
ACLU-RDI 1682 p.170
CA() - 2 .J1
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo y, 2003
order Date
Clerk Nurse SINGLE ACTIONS Date to
be Done Time to be Done Time Done • •
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ACLU-RDI 1682 p.171
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INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED
CLINICAL RECORD
'VERIFYBY INMALING
CLERK/ NURSE
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION ) For use of this form, see AR 40-407; • -
the proponent agency Is the Office of The Surgeon General. ,
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ALLERGIES: =I YES Q NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: AYES Q NO
PAGE NO:
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 - 23812
DOD-037390
ACLU-RDI 1682 p.172
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION) For use of this form, see AR 40-407;
the proponent agency Is the Office of The Surgeon General. Ma r0 y,-. 2003 VERIFY BY INMALING 1. : ''' eiMAIRSO*el .' INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
CLERK/ NURSE
RECURRING ACTION, FREQUENCY, TIME •
HR DATE COMPLETED ;p 2-2- 23
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ACLU-RDI 1682 p.173
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CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40-407; the or000nent anenc is the Office of The Surgeon General.
Mo. Y r.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
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MEDCOM - 23814
USAPA V1.00
DOD-037392
ACLU-RDI 1682 p.174
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THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. I I Yr.
Order Date
Clerk/ Nurse
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Order Date
Clerk! Nurse
SINGLE ORDER, PRE-OPERATIVES Date to
be Given Time to be Given Time Given Initials
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Mo. Y r.
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MEDCOM - 23818
DOD-037396
ACLU-RDI 1682 p.178
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.
Order Date
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to
be Given Tme to be Given
Time Given Initials
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MEDCOM - 23819
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MEDCOM - 23820
DOD-037398
ACLU-RDI 1682 p.180
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CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;
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MEDCOM - 23822
DOD-037400
ACLU-RDI 1682 p.182
MEDICATION ADMINISTRATION RECORD (ALL ENTRIES MUST RE PRINTER)
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MEDCOM - 23823
DOD-037401
ACLU-RDI 1682 p.183
ID-SUPPLEMENTAL L A:. For use of this form, see AR 11•..,-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET
OTSG APPROVED (Date)
QA Appr 8 Mar 89
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QA Appr 8 Mar 89
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PAIN CONTROL
TIME: 02+
TIME: ac) INITIALS: -S\yche-1
• =21tp,A<•c5 LveNdadi
r^t--%So
PUPILS SENSORIUM EXTREMITY MOVEMENT
RESPIRATORY PATTERN BREATH SOUNDS SECRETIONS
02 SOUkCE/FLOW/SA02 VENTILATOR SETTINGS
CARDIAC RHYTHM CAPILLARY REFILL PULSES EDEMA
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DRESSING CONDITION b IV FLUIDS/RATE
I DEPARTMENT/SER
I rcu PATIENT'S IDENT!FICATION
(For typed or written entries give: Name-last ; ,lirgt, middle; grade; dare; hoEpitel or medical facility)
UNIT:
.4%
PREPARED BY- (Signature & rive) DATE
NAME: AGE:
GENDER:
MEDCOM - 23829 USAP PC V 2.00
Li HISTORY/PHYSICAL FLOW CHART
OTHER EXAMINATION OTHER !specify) OR EVALUATION
C1 DIAGNOSTIC STUDIES
TREATMENT
DOD-037407
ACLU-RDI 1682 p.189
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ACLU-RDI 1682 p.190
I INTILAS
COLOR
INTEGRITY
• • PAGE 1 OF 4
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see, AR-4Q-66; the proponent ageney`is The Office of The Surgeon General
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET OTSG APPROVED (Date) QA Appr 8Mar 89
PUPLIS
SENSORIUM
TIME O(0y0 IwAn. . INITIAL SHIFT:ASSESSMENT
1136 I INTILAS 1111 2.. roleA-„Peitt(A.
Ltc. L Ms •
FM OmmIA
- E- RESPIRATION PATTERN
P BREATH SOUNDS
SECRETIONS
N
LOCATION Z0-71 t P-Pcfr Ve
CONDITION
URINE
COLOR/CLARITY
P17.41 4- ik 1,.. 4,\-cs zy, trill Mk" -I gio-) . i sis :A& ilf,LA, a•., ,0 ESS•Ofiat., ,
1141. .,....J 1 N.,-' ' / 4. -.8 -,
• • i•--- 1 to its 14. st-0.-s PL,1 4---.. 4 1)(1 rt-..ir.
ABDOMEN
BOWEL SOUNDS
C AJ;
CARDIACRHYTHM
Cr - Creatinine
LEGEND F, 0 - Fraction of inspired 02
F., 02 - Bicarbonate
t• ■, L5 (etc s tocl.-.4 44. ),
S.V6 03 5 S/A - Fractional SAI - Saturation TRACH - Iracheostomy
ICP - Intracranial Pressure PCO 2 - PRESSURE OF ARTRIAL CO2
PEEP - Positive end Expiratory Pressure
PREPA (Continue on reverse) (b)76) — 2-
i L-17.4>j I DEPARTMENT/SERVICE/CINC C.,k.4 /7" ,r
I DATE 7 7_ ilerl di PATIENT'S IN CATIONS (For typed or written entries give: Name- - Last, First,
• middle; grade; date; hospital or medical facility) ❑ HISTORY/PHYSICAL Irsj FLOW CHART
❑ OTHER EXAMINATION ❑ OTHER (Specify) ' OR EVALUATION .
❑ DIGNOSTIC STUDIES
0 TRETMENT
DA1 MAY78 FORM 4700
Proponent Dept of Nurs
MEDCOM - 23831 "'AMC OP 375 (Redesignated) 1 APR 90 (HSXC - NU)
10111116q) (0-4
DOD-037409
ACLU-RDI 1682 p.191
BP Arterial line
BP Cuff
Temperature
Pulse
Respiratory Rate
/4.c
TIME
icor IOD
ivP8
Jot
Vet; I
MSO
1:-te QJ-5 17- 13e
TOTALS
SP gr
X.).../ 6, TIME
URINE
PAGE 2 OF 4
( Z-
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07 08 al co b$ n. p.3 / (Psi V le 1.7 is 17 za 1$ ,iiii
V
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mapautalimartir
DX HOSPITAL DAY
3o
efo f KO
24"
4
S/A
OUTPUT
PH
GUIAC
NG
EMESIS
STOOL
DRAINS
TOTALS
111111111 =MINIMUM MEDCOM - 23832
ACLU-RDI 1682 p.192
DOD-037411
• ACUITY LEVEL CLASSIFICATION
wtZy WT rclay
RATE
PEEP
MODE
F10 2
TV
I A
B T pH
A PCO2
p0 2
HCO 3
SAT
BASE
B
G
T
U
R
N
S U C
0 N
40°
TIME .1" 4
TIME
A Ts
CLUCOSE
Na/K
Cl/C0 2
BUN/Cr
WBC/PLATELET
Hct/Hgb
TIME
'0F3SiEAf0MtioRE INITLALS
5-
le 1-7
AFIEVAMMEr
c, to lot, 110 M
)c.
Sin✓
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150 16'1'
1(9 V.
51° 3 10
to p
A
t 3 1.
PAGE
3 1
0;1 DC OM 23833
8 °T
€)— 2_
s . POST-OP DAY
22. TS zei e g 03 al dr
TIME Ivo
MOUTH CARE
BATCH
SKIN CARE
FOLEY CARE
TRACH CARE
ROM EXERCISES
4'180' TOTALS
INTAKE
IV
Po
TOTAL
OUTPUT
Urine:
TOTAL
ACLU-RDI 1682 p.193
I INTILA
I INTILAS PUPLIS
• PAGE tOF 4
REPORT TITLE
MEDICAL. RECORD-SUPPLEMENTAL MEDICALDATA For use -;:)f this form see, AR.40-66; the proponent agency is, The Offide of The Surgeon General
INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIFT ASSESSMENT
I OTSG APPROVED (Date) QA Appr 8Mar 89
SENSORIUM
RESPIRATION PATTERN
BREATH SOUNDS
SECRETIONS
COLOR
INTEGRITY
LOCATION
CONDITION
eklie2.4 I Ila ta
ABDOMEN
BOWEL SOUNDS
MAL URINE
COLOR/CLARITY
CARDIACRHYTHM
Cr • Creatinine
F 0 - Fraction of inspired 02
F 02 - Bicarbonate
ICP - Intracranial Pressure PCO 2 - PRESSURE OF ARTRIAL CO,
PEEP - Positive end Expiratory Pressute
S/A - Fractional SAI • Saturation TRACH - Tracheostomy
(Continue on reverse)
PATIENTS INDICA or typed or written entries give: Name - - Last, First, middle; grade; date; hospital or medical facility)
nvismiii
DATE 4/ cV
❑ HISTORY/PHYSICAL El FLOW CHART
❑ OTHER EXAMINATION' ❑ OTHER (Specify)S
OR EVALUATION
❑ DIGNOSTIC STUDIES
❑ TRETMENT
DEPARTMENT/SEVICEJCINC
1A/A 111C op —, MEDCOM - 23834
3 / 5 (RedeignatecilfL....4, 1 APR 90 (HS>(C - Nu)
DA1 MAY78 FORM 4700
Proponent Dept of Nurs
ti tent,.., .e 3Vti
LEGEND
DOD-037412
ACLU-RDI 1682 p.194
1,51t)
GUIAC
EMESIS
TOTALS
PAGE 2 OF 4
DATE C) DX
HOSPITAL DAY
08 Ei 104 nom i Enri 99 2.4 t$
1111111111111111111mEMIN1111111111111111111111111111111111 PANIIIDEN1111111111111111MIRMEN Mlie NMI EIGNEMINEMEIMENIMEMIMMISIEMIIII INIMINNEMENUMMEINUMBI So MIEN 30 IN
IIINIMEMEMIEMMILIMEMMTERIMMUM1111 ramIsiEi,ranizEavnmmatmuEimuEntmaiwI- IERaIIEI1FZ1&Ml1MM11IWiM21II1BMiEfiI1RilMlrUlIIl MINX SIUMMENUCIATARE1111E1
WEINERE2D EMU 1311111111111111 IMIRSINGENIERIMI go MEM 77- Ell 80 RN WINNIfillkilalnWABRIEMILUITAIM q c ISM&
• 4, ..• 8°T , too
1111
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IN c8 Ell g M117 Mill 7 7 EINIFIVICIIIMEMPTAIN ISMIIIMEMISINSIUMENSIMINal 30
1 1 11111111111111111111
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1•••••mmimmammonm• Nummommmommomminn. a ■ mm■mmitmli ■■■mm. sumnimmumminomm• immiumulmnimmummilmml mummmimminimmumonmu.
TIME
BP Arterial line
BP Cuff
Temperature
Pulse
Respiratory Rate
Peef ri 01-
(.4
UR INE
NG
TOTALS
gat
ACLU-RDI 1682 p.195
PAGE 3 OF 4 ■AitPOST-OP DAY
GLUCOSE
Na/K
Cl/CO 2
BUN/Cr
WBC/PLATELET
Hct/Hgb
21 22 23 8 °T
(60 101) (61) 28"V
1 52 (0 10 1(7 go
%-(
(e q q Lf
3 0 (,7' V- 33. 0
SI
TIME a.co VW"
MOUTH CARE
BATCH
SKIN CARE
1(0* $::§104#91,:itic INITIALS
Yesterday wtoday
INTAKE
IV Z4- 7_ Po
OUTPUT,
Urine: 201
'boa° TOTAL tga5 1— TOTAL 7-1..47
MEDCOM 23836 :s'E (661 5-1
af /1— i %XI i:LX3 i ,1721
Sef Go i-C,
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c 1 0 eti
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40. 61., eo
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(4
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ti $C
16 17 19 20
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'
1 0
1z 3
3D
SI 1111
t-1-2
40
to)
ACUITY LEVEL CLASSIFICATION
TIME
MODE
FIO 2
TV
RATE
PEEP
A pH
PCO 2
PO 2
B HCO 3
SAT G
BASE
TIME
0 gZ
‘../(:1--7-70 1 °
24 °laO TOTALS
(b)(c
FOLEY CARE
TIME 26" t ape °Los
W _ &or° III
ACLU-RDI 1682 p.196
OTSG APPROVED (Date) QA Appr 8Mar 89
INTENSIVE CARE NURSING FLOW SHEET
INTILA 123
A BOWEL SOUNDS
URINE
U COLOR/CLARITY
C. A
CARDIACRHYTHM
ICP - Intracmial Pressure PCO , - PRESSURE OF ARTRIAL CO,
PEEP - Positive end Expiratory Pressure
Cr - CreatInIne
Ft 0 - Fraction of inspired 02
Ft 02 - Bicarbonate LEGEND
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see , AR 40-66; the proponent agency is The Office of The Surgeon General
PAGE 1 OF 4 •
CE737) c„). <1414.-
fwv1.010....t .44 40, 11. 1/".444 / Oef
51 0614414
• Th-rY
-i-l,n , . .5 co "A.r. }A5°,4
I INTILAS
INTILAS
INITIAL SHIFT ASSESSMENT
MIRMINITSW'
sk, friax44.5-cir
713MMIONEE giliPMERMEM 3#011 eLt
ka.,Ls . S. .01MIRMIERMIng LOCATION
CONDITION
ABDOMEN
C.
P
SAS --4,4-, . DP" )40
.06s DALf4 . -r
).3 (i''' I.....___t• 0*-fisr. N6 le ,DA.A. WVIARINENEW4 1,....1,e,..i MIMINAmmig
. . •
lets
MEDCOM - 23837 " 1 4MC OP 375 (Redesignated)
1 APR 90 (HSXC - NU)
r type. or written entries give: Name -Last, Frst, middle; grade; date; hospital or medical facility)
;FL. „filIWW1911/ ANIAMIPM
MAMON...1 , MRPREMmang
mmaff,
REPORT TITLE
I 63...6.4.11
DEPA
:•E S P
• 1••
A. T.
N
COLOR
INTEGRITY
RESPIRATION PATTERN
BREATH SOUNDS
SECRETIONS
DA iFf t y784700 Proponent Dept of Nurs
S/A - Fractional SAI - Saturation -MACH - Tracheostomy
(Continue on reverse)
C c.Ibd
Pr (0(2)--2-
❑ HISTORY/PHYSICAL
❑ OTHER EXAMINATION OR EVALUATION
❑ DIGNOSTIC STUDIES
❑ TRETMENT
DATE
FLOW CHART
❑ OTHER (Specify)
/vow
TIME
N PUPLIS
E SENSORIUM
U R
DOD-037415
ACLU-RDI 1682 p.197
3o ge2
TOTAL
TOTALS
MEDCOM - 23838
//
DX
CDcii r /7 11 4114-- ic( is, G /7 HOisrAlir a...x:3 2
08-09--1-0-17 12 13 14r 15 TIME
PAGE 2 OF 4
Pulse ii3 115--
S it-t7
LIG grfirt IP s l
14 15 8 °T
?JD
BP Arterial line 01,/ 1G
BP Cuff
sr1-146k% kr. 1 1 1 7 13.•
(11
Piti5,7t i'45/4 fq
T Temperature 10"
11V 1b1 11 ,0 7r7
Respiratory Rate 30 3D 3o
IV 11 -1 61 3 git 4-14
7_ $D S S _5 lS tr
h '2. .3nayz, vr -tfieF ((o gr IV pc) Up 23 3 cra 07377,045
V-131 Mr7 S 5: S S V is i5 16
47 -5/0 7/ Yip
til
s-
Sidiv 5 /0,14/ QSind 5 IJAU
Is' )S' is" 15. is Qs-
24' 30 1 3 21 1 3
t 1 23 0 0- qs" circILI is- qg
zr?
iS
a3
15
9 ct
27
011111111E182_1
proc.,g. Gxg
fcej 15-C 1-M Tve
to 10
9 kotizr) .
GL.t4 A14+441 a 11
LA-c,\/ zpo ti0 tt) to 70
151, 160 )66 kt kgp
/b. IO 1.9 aq Io lb lb lb fj
Lt y qt 9
10 qo 21?).(-6 I° 30 -(70% 3gfr
15-0 Citz ro
1 1) 10 t 0 6
61 I 1 0 iv t c-, 1 0 to 10 10
s it
8 °T :Cre-* 1)6-y, fes„/
Icl) 1517 19 ic-b
►
CO
to 10 to
-)1-- 11- I-1 vi (,4 g
37P LI "0 LP "io tip 31.9 le Y2 Go •lv 30 3D
tI 6 1 1 1-I ib Io.
HOUR
URINE • SP gr
AVAINFAIMAIV Ar SFA
OUTPUT
NG PH
GULAC
EMESIS
STOOL
DRAINS
TOTALS
DOD-037416
ACLU-RDI 1682 p.198
RATE
PEEP
A pH
PCO 2
p02 B
HCO 3
SAT
BASE
WBC/PLATELET
ir
s -7
?)v
vc" rf
s r'
IA
BT
A A
R
6 15- 5-
22 23 8°T
( 0 IP) 12A
A
cD TA
R
N
F
• PAGE 3 OF
ir,or-e ‘
ACUI LEVEL CLASSIFICATION PO ST- PAY
1 TIME 22 23 igh vly 114/
/o0i oit f9 41 MODE
F10 2
95/--q5/ (7 10 ote
(.0 Ib) ID4, Mg, I&
30 )0 3o 3t) .5 0 'VI
vi 74 Irg 71 It-
11 -Li 11 13 It 15- 7L( q) /3 1) etcf cu n Viv n fl
5 1r i atAll 50J 5)rti/ co% s,Av i c I.$ ( 5- IC IS 1S
• Ft Sig 1-11 Lit
16. 17 18 19 20 21
jro 19 (51) (V) icy
54,
5-b
J1'
TV
ql
—3 TIME
CLUCOSE tea
WON I I SW I PrAd vA Hct/Hgb .40'D
d ° it456
Na/K
Cl/CO2
BUN/Cr
A-0
Lt , 40 -ko ,10
30 3D 60 -ID >0w 43.
pr
MIT
BATCH
SKIN CARE
No 5tii? 5D3 T 20" 2..
u •
TIME
TIME
MOUTH CARE
Yo
157) 'Aft)
- C c.
I - 240180 TOTALS -
WT Yesterday wt Today
INTAKE OUTPUT
IV Vivi Urine:
Po
N
U
TOTAL' (;124 TOTAL SY? DAI ALICE 95-21-7
MEDCOM - 23839
DOD-037417
FOLEY CARE
TRACH CARE
ROM EXERCISES
ACLU-RDI 1682 p.199
'0 10 zs-i r
MAL RECORD-SUPPLEMENTAL MEDICAL A For use of this form see ; AR 40-66; the proponent agency is The Office of The Surgeon General
PAGE 1 OF 4
INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIFT ASSESSMENT
OTSG APPROVED (Date) QA Appr 8Mar 89
PUPLIS
SENSORIUM
INTIL INTILAS
INTILAS
RESPIRATION PATTERN
BREATH SOUNDS
SECRETIONS FMNIKIMFAIWAIN
0 2
COLOR
LOCATION
CONDITION
URINE
COLOR/CLARITY
Cr - Creatinine
F, 0 - Fraction of inspired 0 2 F. 02 - Bicarbonate
ICP Intracranial Pressure PCO 2 - PRESSURE OF ARTRIAL CO 2 PEEP - Positive end Expiratory Pressure
S/A - Fractional SAI - Saturation TRACH - Tracheostomy
❑ OTHER EXAMINATION ❑ OTHER (Specify) OR EVALUATION
• j73 DIGNOSTIC STUDIES
❑ TRETMENT
WAMC OP 375 (Redesignated) MEDCOM - 23840 1 APR 90 (HSXC - NU)
oco-41 IOW c
DA FORM 4700 MAY78 Proponent Dept of Nurs
n en entries — middle; grade; date; hospital or medical facility) give; Name Last, First,
zc 1/-70/
(Continue on reverse) COC6)- I DEPARTMEN xz)- 2_ I DATE
l7A/Bi/ ❑ HISTORY/PHYSICAL ❑ FLOW CHART
REPORT TITLE
LEGEND
DOD-037418
ACLU-RDI 1682 p.200
