› files › foia_subsite › ... Acum illEM MIIMINI e3e Min L 1111 11 II I II I 1 A ...MODE F,O, TV RATE PEEP Acum LEVU OASSMaLMION V 4' /7 /S , -21 - 27 illEMMIIMINI Min L 1111

MODE

F,O,

TV

RATE

PEEP

Acum LEVU OASSMaLMION

V 4' / 7 /S , -21 - 27 illEMMIIMINI

Min

L 1111 11 II I II I 1 * Ai ;:i

A,

111111111 WEEP FOIE

IN NMI 111

NOPIPAIMMEli 111111111111MIIIIIIIIIMI

•11•1111111111111111•11M 1111111 1 11 w, Veste lday

111111111

IV INIARE

1.1.1.111M11.1111

TIME

e3e

,r1)-102-

NAN

CLCO2 011D

ft, A BUN Cr

WBERLATELET

IMV14913

MOUTH CARE

BATH

SKIN CARE

FOLEY CARE

TEACH CARE

ROM FEE ROSES

2f160 707ALS ,_ ;NURSE'S SIGNATURE mums

WI

TOTAL TOTAL

A PCO2

902

B HCO3

SAT

6 BASE

TIME

GLUCOSE

TIME

1111 1111•11111111111111MMIIII -10111M111111•1111-

11111-1111111=111111 IIIM11111 IIMM-1111

111111111111111--- 11111111111111-1111

PAPIMINIPAINE APSEi PA 121Mi main MEI

PAPISIMIIIGMSin %MIN

iii mu. ••• aim mono OUTPUT

. Ur*He:

BALANCE

MEDCOM - 13841

ACLU-RDI 1623 p.1

R Right

L Lett

Record separately d there is a difference between the two sides.

• s 8 nsk

Slow

No Response

Intact

- Abnormal

•

HOUR

SPON rANEOtESEY •

70 SPEECH 3

10

NO EYE OPEN.NG

PAGE 40E 4

LEGEND

175

C Closed by swelling

S

E

QN 2z —o

scoz_;.

4:WEENIE()

CONE USED

mpAoZES

ROCAELPES

NO VOCAL IZA 110n

Oat PS

CO•AREANOS

OCAt1I ES PAIN 5

Pt tilde wEINDRAINAi. •

it EtriOrs 3

LU 1c NS‘ON

10 PAIN 2

No •4010P ,YOPs1.2

T Trach/Endo

S Slurring

0 Dysphasia

R Recepwe

E Expressive

NO.ARE. POwER

MILD we••NESS

ER

St .+ ERE ersacrrcss

a .101NO.,1211. iLt .50r

An••0 RM., Ex it 11,0N

Est

NO RESPONSE

0

V .oreAnt.rowrit

E

wEai reSS

SE vERE ArEAE5ES5

.pli1011.141. 21E1105

ABNORMAL Ex TENSION

NO RESPONSE

P Sq.

U

ICH T P

SIZE L. EFT

AL AC K.N.1

PUPIL SCALE

ICP

CEREBRAL PERFUSION PRESSURE

• 2 la 3 • 4 • S 4110 6 is 7 dun

1 1I !II VASCULAR ASSESSMENT

HOURS

LEGEND

4. Normal

Weak

- Absent

Doppler

Right

Left

iirOPANIMPIPAIMPINVIMI MIPANIONNUMNIMPAIMIN IPMWAVALWANWAPAIN iNFAIMPWAVAIPANNIMEN NEOPINNIMINORWANNOMON

MEDCOM - 13842

ACLU-RDI 1623 p.2

DEPARTMENTISERVICE,CUNIC Al E AHED BY &

4lue- ,Varne—Inst. Ii m.:adie groat dr11, ho,ota. r jaczIit yI 0 HISTORY , PHYSICAL 0 FLOW CHART

0 OTHER EXAMINATION 0 WHEN OR EVALUATION

Ci PIAGNos TIC STUUIES

o TRE.A1MENT

DA ,MAY:„ 4700 Pi opunent Dept DI Nuts

WAMC OP 375 t Redesignated) 1 Apr 90 (HSXC-NU)

CAL RECORD—SUPPLtMENTAL MELACAL -u0-e11 : ire Proponent ,Ajenc• Are Oit,ueo, lb C

REPORT TITLE

INTENSIVE

.JURSING FLOW SHEET APPROVED (DGA,

A Appr B Mai 89

INITIALSHIFTASSESSMEUT

. .1'..

it

TIME ....t ) I ,r411,1.1 I 1.1“.,

PUPILS

SENSORIUM I

.... ,et.".

, - ea .__ •-- V.......—■ 15

RESPIRATOkt PAi 7ERN a. . • 13REA1H SOUNDS

•••••••- 111, ' ■- CL7,4 k51 . 1ePi

NS ,. ,4 C Ck

I

SE CRF IION,

_CC ô

-

cow.: r- - --41.(242„—C

• ,..: iiiirt. #_ VI I Y INI1 i 6PI

— —14pfirC‘ -P -60_04_

P."

LOCATION

CONDi I luN

L L. 4.., .- p (-- ov 4_ 0,4_ . - - &Ea j.,./4

- t-31-141-vi 4-04

ni-

44

ABDOMEN

_ A.>

.4.! - '

- —13:r 7C Flom l SOUNDS

t. )01.11(10 •• .1 r__. - - i J

.a.......-...01.0.‘

C----CXZ---

• t.7

UPIN/' f , & .. 0., -__prii i

CO: L I 1 ,...>„.....kzzs...=

t.

AN r.A;_ lit-11!,IM

71-- ill -11(-71/t Vc

(a p

-0>‘C

AL

+.3

-.¢ —al

-4) (4 — —114x,Ac.,_6_ ■-i_ t2.__ p_.s., (-) IV, -

LECeND ,,:•,.. i-,„,,,....,1,.....,.welo,. YC.:), • P,-,...r. •-...lc, JP 1.0..

Y‘. tr ....,,

......) LI, ."....1

•••:::.; 1.,...ne ■ . , KY Lr. • ie. r.•,-,,,,r,

1Continur vli leticrSe 1

MEDCOM — 13843

ACLU-RDI 1623 p.3

0.■ Ft DI 110111,1. IL,

. - 1 T • A L

I:

G Ai

TIME ...'');_f. 6 i e:-. a C 3' 0 z ( 0 5- e4". 0 ';* Og' ,•,‘,7 / ‘:, ,.,7 . - • / / ,-f

pzci- EP Al terial Lint 1 z- al, curt Temperature NM IBM

- ceg t• t Vf(I

Ps.gbc

Ill C)

k:, Ct n._

ri ., ne5ptratory

MAW/

Rate I

97

I I

t4 ._

A

, • • E

TIME 8T C4 c,',i - /0 // /2 ,-; - ' m 8 T

1 M I

I

1 __

I

1 _ ... TOTALS

o URINE

EMESIS

/ /17

oulow I

C.J.,

i

li

1 1

ME ' STOO L

PRAMS

TOTALS

MEDCOM - 13844

ACLU-RDI 1623 p.4

V

G

MODE

TIME

MOUTH CARE

BATH

SKIN CARE

FOLEY CARE

TRACH CARE

ROM ExERCISES

H

N

2

POS , 11...•

(

/ _2 1 5 2 1-

rA

a

A A

A

0

NURSE'S SIC.AA TUBE

wl Yestr: clay

womaimmu. INTAKE OUTPUT

Iv

u,,ne,

TOTAL

TOT AL

BALANCE

TIME

11,1111101 MENEME411 MI

rit Impail 1 II NE I. ............. ••••••—• •••••••mm ••••••,... .....m. ........... r

A A D 0

.111:11 1 A T

T A

blep,,min ••• mmai • ... ____ • IIIIIIMIIIIIIIIIIIIIIIIIII MiiiiiIMEME mairmEmno Nummusimma

iiirmommom imummum IN mmilmINE

:IE..

. ..

... ..

.. ... .

221•180 TOT ALS

wt Today

•LIOrt LEVEL CL•SS.If ec-oasom

U

111Wir Ls- Li

MEDCOM - 13845

ACLU-RDI 1623 p.5

PAGE a if

NEU R ,e-LOGICAL' ASSESSMENT .

C

NS

A

S

A

E

HOURS ha Ali LEGEND

IEYES

OPE

N SPON LANE3Lhky •

JO SP EC. 3

1 0 RAIN 2

NO L It OPINING I

r

C Closed

by swellffig

_ A

14MA

R 1

o.ot.ito con.. uskc, veRRALI.rt % .tri.Attzt s

no VOCAL lb:1110ra

45?- 5

T TrachtErsdo S Slurring 0 Oysph..t.a R Recepos, e E Expressive.

•

2

1

3

tga ism.

co...m..4:6 L OCALI2LS PAIN S r L c xsOrr VVII.ORAvrAl. ABNORMAL 11 i 110.1 3 LA 1 L rys.i0r. 10 PAIN 2

NO MO 1 OR tal S.POthig. 1

ow..rs

at O

> u.■

su

Z r-1

SVV

IIV

1

110NrAIA e0WE A MILD VwciiiiineSS St v e RE erLAAne.SS A 13 no...I. nt SLOP. AlilhORA1AL Exit 1.11.0r1 NO tat `,0.5,

• _

it R.gnt

I. Lett

Record separately a there is a cf,fference between the two s.cles

SO31

hOnhIAL POWER iSaih0 niLAAnt SS

SE REnt wt.a....Ess ABNORMAL nE SION AfirrORAILL El It hvOni NO RI seOrtsi

IP.

I

_ . M 7 M

N

I

RIGHT Sra REAL; ION

SIZE REACTION

3 • • . aft,.

. SlOw

- NO

. Ret.pon>e

. Intact

- Abetorma:

LEFT 3 -5 L-I . r-t-

-

PUPIL SC.%LE •

ICP CEREBRAL PERFUSION

PRESSURE - _ 1

HOURS

rill di

1

inissg

INIONEOPIAN

o Eptormirri El§INFA

1111/11/11E/1/1/11111/FA

ommrimpo / !Am,/ Alpo, es

AINTIONIPINgliffirj

/RIMMEINFAM5

LEGEND

4. . 2.202 Tel

Weal

. ::: :

Right

Lett

ICZ

—■

ler —II

E

MEDCOM - 13846

ACLU-RDI 1623 p.6

Gen

Op__ APPROVED (Date)

QA ADP, a mar 89

—.CAL RECORD—SUPPLEMENTAL MEDICAL DATA For use ro tars tr se AR 40-66: the pnaponent agency is the °Rice of The Si,

INTENSIVE CA UnSING FLOW SHEET

TIME

PUPILS __12_(a_n 0 SENSORIUM

.>+c91‘7, -3 va A-14,5r I i`ze 5 n-uz c9--n-ct7O-/ert.;`,'")

RESPIRATORY

Pr?

y::

PATTERN e L/121-1 44 It BREATH SOUNDS

SECRETIONS

COLOR

TO

14-faljr7 ice/ INTEGRITY

LOCATION L. e e',Err

CONDITION ,r)

fs

11 ;:. "

ABDOMEN 4/7- /VP,

BOWEL SOUNDS ni.s

URINE. vo v"a.. C O LO R/C LA RI TY

A CARDIAC RHYTHM .91,52 / .S.),Z.

If O.

V A' S • C. u:

:R .

REPORT TITLE

to FrectIon,

• Saturouon mac.,

ARED BY • • DEPARTMENT/SERVICE/CLJNIC

0/1 e: gra . spsat or medley( facility)

DA I 2,11,m78 4700 Proponent Dept of Nurs

❑ HISTORY/PHYSICAL

❑ OTHER EXAMINATION

OR EVALUATION

. ❑ DIAGNOSTIC STUDIES

❑ TREATMENT

WAMC OP 375 (Redesignated) 1 Apr 90 (HSXC-NU)

9/k/44 arne—last. first.

(Curt roue on reverse)

17,5717,--03 ❑ FLOW CHART

❑ OTHER (Spectiyi

MEDCOM - 13847

ACLU-RDI 1623 p.7

PAGE 2 01,

TIME y G 2 03 0 4,

C7

Og" n /0 // 1.2_ / 3 /k4

BP Arterial brie

PP C.111

Temperature ., i -1

Pulse g5 Res to Rate I LP S“) co

ag

S

V-a....---

,,:S.,,,s. 4.-.."--.

-

TimE '-/ 0/ 02 03 Ci'l 425- 06 o2 FC'T OjJ 4)1 i/° // /2 H Pi /..)-- ErT

44

TOTALS

:-':o

-•

3:

-

URINE ''' 7/.////// / /// / //

sm

NG

wimp

p.

Luac

EMESIS

STOOL

DRAINS

TOTALS

MEDCOM - 13848

ACLU-RDI 1623 p.8

TIME

/5 .2 a _23 8'1 GLUCOSE

AIMS

COCO,

BUM°.

VAUPLATELET

urr.Mgb

IIINIVIVAPAINIPAPS IPIIIPAPAIPAMMI Arr.dimv..PAPar-Ar-4 ../VAPAIVAIPAIIMMX1

cf D. TIME

L A MOUT,. CARE

BATH

SKIN CARE

FOLEY CARE

TRACH CARE

• ROM E XE ACISES

N

C T

0 I.

EBBE

WI Yesterday Cd y

INTAKE

OUTPUT iv . Orme:

707AL

TOTAL

BALANCE

SIGNATURE .111.4.4

4111111 \.3 L. --L4

MEDCOM - 13849

KIJITT uIIF. 1:1.43,0 SAM.

TIME

MODE

TV

RATE

PEEP

PN

A PCO,

POT

HCO3

SAT

RASE

PA GE 3 OF .1 NAT

T

A

J4. /7

G

S

51 1-.3

ACLU-RDI 1623 p.9

MEDICAL RECORD-SUPPLEMENTAL MEDICAL Um IA For use of this form. see AR 4066: Me proponent agency is the Office of The Surgeon General.

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

Date: Anesthesia Type (Circle)): General Spinal Epidural Drains Airway Time In: IV Sedation Nerve Block Hemovac

NG JP

T-tube

Foley

TLS

Nasal

Oral DT

Trach

Other

Allergies: OR Intake: Crystalloid /tat, Colloid Pre-op V/S: OR Output: UOP " EBL Procedures: /46 (PA-A-i-w, MedsMmes: '

0 CA}12 A/ -LK 'Me Pre Op Meds , History

Time M !‘„,s,

R is

v .,

'. Pacu Intake

Sa02 Al) .4. rIC 43 r(3 Time Solution Amount Site By Infused

F102

Methods

240

220 X-rays: . Labs:

. Post-Anesthesia Recover ,score 200 Criteria ADM 30' D/C Codes

Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

j. g ,,t‘ AIRWAY

A A B B= Blow-by -by M - Mask

180

160 Airway (2) Cough. Deep breath (1) Dyspnea, limited breathing (0) Apnea / I

FT = Face Tent RA = RoomAir

NC = Nasal 140 V V

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

Cannula

V/S X= A-line BP

120 • • v V V ✓

100 a .2. • * * Conscbusness (2) Fully Awake, audible (216/19 (1) Arousable to verbal or pain

1

I

•

/ i

- = Cuff BP = Pulse

TEMP 80 A A A

/1 A A A Color (2) BaselMe color & appearance (1) pale, mottled, jaundiced (0) Cyanotic U - co'

0 = Oral A = Axilla

S = Skin

Axillary T =Tympanic

60

40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable

(1) AxiHary palpable. not radial (0) Carotid only reliable pulse

R = Rectal

LOS

C = Cervical 20

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C,

T = Thoracic

S = Sacral L = Lumbar RR 111-\ 14 lb k riP Ikt

T Time Patient teaching done; Wound Care, Pain Management, Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained

Ilonnnue on reverse/ ' nature & T M . i

6e/ 771/t/

DEPARTMENTISERVICEICUNIC

/6fy DATE

/ratk.( d.3 PA T'S I I or e: Name -last, first, middle; grade; date ; hospital o medical feat 'v) I .., )-

1\06 —1-4 •

• HISTORYIPHYSICAL U. FLOW CHART

OTHEREXAMINATION ❑ OTHER away,

■ DIAGNOSTIC STUDIES

U TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPeC V2.00

MEDCOM - 13850

DOD-027402 ACLU-RDI 1623 p.10

MEDICATIONS Allergies:

Medication & rtoncte

Time Route Pain 1-10

I/E By Pain 1-10

Discharge Criteria: Date: /Mus_ 10-3 Tiinp.: 0/A) PARS:q BP: /6/74( T: (1Y HR: /01 RR:

Cif

Sa02: Pain Level at D/C 10-10): Intake: Output:

Additional Data: Transferred To: 0_,t,L1 oZ Report Given To:

Transferred Via: WIC Gurney Ambulance Transferred By:

Cleared IAW Recovery

Charge Nurse Signature

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Adm A 0 (J A___ LU Pt 15' e 6 pa

S;21- 30' 0 p ')-) (.,Li 45' 1

60'

90'

D/C

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

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

C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C Fund. .Height

Lochia

rj/4

Peripad#

Fund. Cond.

DRESSINGS

Time Location Type Drainage

Adm ) vlAIJ-K itbAg 11(211 q 30' tuv rityky, Accio.-- 60'

DIC

NURSING NOTES

PACU OUTPUT

Time Source Color/Appearance Amount

CARDIAC RHYTHM

Time

Rhythm

Symptomatic?

Rhythm Strip Run?

WAMC OP 173-E

MEDCOM - 13851

DOD-027403

ACLU-RDI 1623 p.11

MEDICAL RECORD-SUPPLEMENTAL MEDICAL Um A For use of this loan, see AR 4066; the proponent agency is the Office of The Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED (Date/

Date: ." 1 0111 L- 0 -; Anesthesia Type (Circle)): 4290 Spinal Epidural Drains Airway Time In: 7---7.-‘40 IV edation Nerve Block Via/Scb Hemovac

NG JP

T-tube Foley

TLS

Nasal Oral ETT

Trach

Other

Allergies: 11/4-k 101) OR Intake: Crystalloid ) --1) Colloid Pre-op V/S: t 12 / OR Output: UOP Ri EBL SOU.. '-i-i- 01t- Procedures: -rib ap. ..... Meds/Times:

K at

Pre Op Meds — History

Time 1: thr k r Pacu Intake

Sa02 W19 4) IOC ir,r, Time Solution Amount Site - By Infused

Fi02 filtAgAUt 0 _ Methods

240

220 X-rays: . Labs:

. Post-Ane: thesia overt' score

200 Criteria I 30' D/C Codes Activity (2) Moves 4 Extremities (1) Moves 2 Exlrernities n Moves 0 Edrernities

AIRWAY A =Ambu BB = Blow-by

M = Mask

180

160 Airwa

Co y

breath (2 ) ugh, Deep (I) Dyspnea, firriled breathing (0) Apnea

2 FT= Face Tent RA = RoomAir NC = Nasal

V 140

4 V V Blood Pressure . (2) SBP =/- 20 of Pre-op (1) SSP =/- 20-50 of Pre-op (0)SBP = 50 ot Pre-op 2

—Sic)

bw--

^^^

Cannula

v/S X = A-line BP ^ =Cuff BP

= Pulse

TEMP

120

100 4

• Consciousness (2) Fully Awake. audible ung (1) Arousable to verbal or pain

a •

80 A A A

Color (2) Baseline color & appearance

(1) pale. mottled. jaundiced (0) Cyanotic .. A = Axilla

S = Skin 0 = Oral

Axillary = Tympanic

60

40 A Circulation (Pais <5 Years)

(2) radial Pulse Palpable (1) Axiltary palpable. not radial (0) Carotid only reliable pulse

R =Rectal

LOS C =Cervical 20

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C .

f D L umbar T =Thoracic L = S = Sacral

RR MU 24 16 rho T cil it _ Time MAD , Patient teaching done; Wound Care. Pain Management. Pain (0-10) yi

p_(:t T. C, & DB,. Incentive Spirometer. Comfort Measures

LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained ri.ontinue on reverse)

P 1111 . ' A .7:1 \,(u) ......)... .

PAT (for typed or written entries give: first, hospital or medical leaky)

DEPARTMENTISERVICEICUNIC

J_LA „1/4 2_ Name -last.

❑ HISTORYIPHYSICAL

❑ FLOW CHART

❑ OTHER EXAMINATION

❑ OTHER amigo OR EVALUATION

❑ DIAGNOSTIC STUDIES

❑ TREATMENT

DATE

2_1 3-14(_

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAFPC V2 DO

MEDCOM - 13852

DOD-027404

ACLU-RDI 1623 p.12

MEDICATIONS Allergies: Time Pain

1-10 Medication & Dosaae

Route Pain 1-10

I/E By

1

PX-3 1--t5DL4 5 1-4, V? '2-2210 ge`fALY-Lit, c3), Ti ?

I NEUROVASCULAR

Time Site Range Of

Motion


T Color

Adm g,Lt- 225 4- ..i- 0. g_ 44 NI_

15'

30'

45'

60'

90'

D/C 2t-V. X 4- -k- t32 i/./ 'ÌC

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

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

C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C Fund. Height

Lochia

Peripad#

Fund. Cond.

DRESSINGS

Time Location Type . Drainage

Adm

30'

60'

DIC

PACU OUTPUT

Time

Source

Color/Appearance

Amount .

CARDIAC RHYTHM

Time

Rhythm

Symptomatic?

Rhythm Strip Run?

\03 Cp -3-

ILISOL (1121./"21

t TT

C 4 ;2 t--rSo (4_ 1J'

ri .") L, (24°J 40--( 0 gbEre-t_"---- .11F. t-ti VS 1)--)n1((-

Discharge Criteria: Date: 0 i'S1,4 c5iTime: 2:2310 PARS: ID BP: (143/14T: e1 0 HR: q ) RR: I 1?) Sa02: (OD Pain Level it DIC (0-10): u Intake: 0 Output: Additional Data: J6

Transferred To: -IC 0 61-Report Given To: Transferred Via: W/C =Gurney A bulance Transferred By: ,(61- % Cleared IAW Recovery Charge Nurse Signatu

NURSING NOTES

WAMC OP 173-E MEDCOM - 13853

DOD-027405 ACLU-RDI 1623 p.13

DEPARTMENT SERVICE/CLINIC

PAT hist, middle; Fa m date: hasp

give: Name —last


❑ OTHER EXAMINATION OR EVALUATION


❑ TREATMENT

DATE

❑ FLOW CHART

❑ OTHER ap.ar/

14- \(\"131 MEDICAL RECORD-SUPPLEMENTAL MEDICAL DA I A

For use of this form, see AR 4066; the proponent agency is the Office of The Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTS& APPROVED IDalel

Date: Vit24- 'f"t Anesthesia Type (Circle)): r412M- pinal Epidural Drains Airway Time In: IV Se. ation Nerve Block Hemovac

NG JP

T-tube Foley

TLS

Nasal Oral EU

Trach

Other

Allergies: MC OR Intake: Crystalloid ( (TO Colloid Pre-op V/S:_ ,

. OR Output UOP EBL 0 V.LD"":)---

Procedures: IA IS • u•-I r Meds/Times: IF-04-4,---7 l "if)ri 4., r i - ' r■ • y ry.-cid-rfryi.-...., i p,e_,,,e ar,._ / ->c .9

Pre Op Meds Milli

History ,

Time 1,

1.-r

.„

'§ ,1,-

4 Pacu Intake

Sa02 w 'In fb -.- t N Time Solution Amount Site By Infused

Fi02

Methods

011- 4 II

ti) 211.

41 °A _

240

220 X-rays: . Labs:

• Post-Anesthesia Recovery score

200 Criteria ADM 30' D/C Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

AIRWAY A = Ambu BB = Blow-by M = Mask

180

160

(1) Dyspnea. Milted breathing (0) Apnea

Airway (2) Cough, Deep breath

)-'

FT = Face Tent RA = RoomAir NC = Nasal 140

Blood Pressure • ((21)) sSiB3pP :if-- 2020,o5f0Pre-oof rz.op

(0) SBP =/- SO of Pre-op )---

Cannula

V/S X = A-line BP

120 A

A 100 i

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

' = Cuff BP = Pulse

TEMP

•:i

80 . a 4 \iv Color

(2) Baseline color & appearance (1) pale. mottled, jaundiced (0) Cyanotic = Axilla

S = Skin 0 = Oral A Axillary T = Tympanic

60 V

40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only reliable pulse ()----

R = Rectal

LOS C = Cervical 20

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C.

1

T = Thoracic

S = Sacral RR p_. viAC 10 14 0 L = Lu mbar

Cat Time Patient teaching done; Wound Care. Pain Management, Pain (0-10) T, C. & DB,. Incentive Spirometer. Comfort Measures LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

01 7 117110 017 rev

DA FORM 4700, MAY 78

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

Previous edition is obsolete USAPPC 02.00

r .04Q.D _

MEDCOM - 13854

DOD-027406

ACLU-RDI 1623 p.14

DOD-027407

NEUROVASCULAR Time Site Range

Of Motion


T Color

Adm

15'

30'

45'

60'

90'

D/C

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

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

C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C Fund. Height

Lochia

Peripad#

Fund. Cond.

DRESSINGS

Time Location Type Drainage

Adm

30'

60'

D/C

NURSING NOTES

pcl cee- a-e-e f\„0, c_

c. Cz4/10-a-e- LuvIce

Cit ►rl<50(/

/z)

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

PACU OUTPUT

Time Source Color/Appearance Amount

WAMC OP 173-E

Discharge Criteria: Date: 4/4-teio 3 Time: PPP PARS: 10 BP: 101/4 t T: HR: S'.) RR: t Sa02: 91,, Pain Level at INC 10-10): Intake: Output: Additional Data: Transferred To: c_t.A..) Report Given To: LP -'

er Transferred Via: W/C Transferred By: •

urneyi Ambulance 1

Cleared IAW Recovery R Charge Nurse Signature

MEDCOM - 13855

PI Govt 2,-Le cl / a_ Gc-60--cr-WArzi,,,,( 4

o? 51-7/)( 7

7a, e-4_,AA,K

X

/71

(3/\

LE "7". kfar,_

MEDICATIONS Allergies:

Medication & ;Insane

Time Route Pain 1-10

I/E By Pain 1-10

ACLU-RDI 1623 p.15

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

For use of this form, see AR 4.0-400: the proponent agency is OTSG 1 2 3 4 5 6 7 8 l (Stare or

Country

ii c) k j......... -a. Code.)

3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX

18 16 17 9 10 11 12 13 14 15

6. DATE OF BIRTH (YYYYMMDD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION

IA

31 BACK-GROUND

30 19 . 20 21 22 23 24 25 26 27 28 29

-?..

10. LENGTH OF SERVICE ETS

NI/ri

11. EMP 12. SOCIAL SECURITY NUMBER

37 38 39 40 41 42 43 44 45 35 36 32 33 34

4")- fi5 izr 0 0 .0- 1 CORPS

Q ot ORGANIZATION 'Active Duty Only)

is ir•X.

13. MARITAL STATUS HOUR OF

ADMISSION

\zi -7"›.0

BRANCH

AMA

46

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

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

k 1- ?_.2 17. UNIT LOCATION (State or

Country Code) 18. MOS 19. TRAUMA PREY. ADMISSION

71 YEAR NO 64 65 66 67 68 69 70 62 63

20. SOURCE OF ADMISSION) AUTHORITY FOR

ADMISSION

WARD

16 IA 1

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE _...

72 ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

CATION OF MEDICAL TREATMENT FACIL TY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE _...

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (V Y MMD 0)

73

5

74

0

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

0 3 ON g & 24. CLINIC SVC • ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)

87

A Pc

88 89 90

Pc

91 92 93 94 95 96 97 98 99 100 101 102

rx --z-, m ,e5 .5- 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION fY YMMDDI

103 104 (Bartle Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 116

FOR LOCAL USE

1)/,,, GkSi,..Cs o C-e.,vu_,r V-, -..

N PAcc, DI I I Sloo II .

..

ADMITTI floe, as required) SIGNATURE OF ADMITTING CLERK

1111111111111111111111.11111- ,

DA FORM 2985, MAR 89 MEDCOM - 13856 USAPPCV1.0

DOD-027408 ACLU-RDI 1623 p.16

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

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

Country Code.) A

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

IN \C)49'.1-°\

4. PAY GRADE 5. SEX

16 17 18 9 10 11 12 13 14 15

ADMISSION 8. RACE 9. ETHNIC RELIGION

19 20 21 22 23 24 25 2 27 28 29 30 31 BACK-GROUND

10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER •

37 38 39 40 41 42 43 44 45 32 33 34 35 36

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF ADMISSION

BRANCH I CORPS

46

14. FLYING STATUS 15. BENEFICIARY CATEGORY 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 Country Code)

18. MOS 19. TRAUMA PREY ADMISSION

71 YEAR NO . 69 70 62 63

20. SOURCE OF ADMISSION/ AUTHORITY FOR ADMISSION

WARD NAMEIRELATIONSHIP OF EMERGENCY ADDRESSEE .


NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYMMDD)

81 82 . 83 . —85— 66 75 76 77 78 79 80 73 74

24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)

97 98 99 106 101 102 91 92 93 94 95 96 87 88 89 90

27. LOCATION OF OCCURRENCE Casualty Only)

28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYMMDD)

111 112 113 114 115 116 105 106 107 108 109 110 103 104

(Battle

FOR LOCAL

A:kJ

-- USE

-- --------''

/1-eA

/ r

7g45 _i___ 4-SO

eqid, va (5 ci

ADMITTING OFFICER OFFICER—(Signature_a_ required)_ _... SIGNATURE OF ADMITTING CLERK

......— ... „.. DA FORM 2985, MAR 89 EDITION OF MAY 79 IS OB

MEDCOM - 13857

DOD-027409

ACLU-RDI 1623 p.17

f

INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400; the proponent agency is OTSG

I. 2. NAME (Last, First, MI) 3. GRADE

h.1,/Aiz

ADMISSION REMARKS

0/\.

. --- •

567 .,

.- 7. RELIGION

(A/Ktk-

. GTH OF SVC

C\YAC

9. ETS

/WA

ADMISSION 10. PREVIOUS

Qt) 11. FMP

Clai

12. SSN 13. ORGANIZATION

OM-

14. WARD

/C(A 15. FLYING

STATUS

1\)//0c

16. DSG

. . BEN

if.-11

18. BRANCH/CORPS

14/A

19. UIC/ZIP 20. TYPE CASE

1:44 21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

----C. c e A --C-CrYIN- 4:-=. e

22. HOURS OF ADMISSION

s21? ??)'

23. CLINIC SERVICE

A Qt A

24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSI ON 26. DA OF DISPOSITION

17a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 28. DA1 e t..rcJHIS ADMISSION

D

ADMITTING OFFICER

\il°

29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY 30. Lis ADMISSION

32. UNITS COMPONENT TRANSFUSED

31. SELECTED ADMINIS

Check it Continued on Reverse

33. CAUSE OF INJURY

1 .e

34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

85 I D

35. Total Days This Facility

a. ABSENT AYS b. OTHER DAYS c. CONY. LV/COOP CARE DAYS

d. SUPPLEMENTAL CARE DAYS

e. BED DAYS f. TOTAL SICK DAYS

36. 'ate! Days All Facilites

a. ABSENT SICK DAYS b. OTHER DAYS c. CONY. LV/COOP CARE D YS


a. BED DAYS

/

f. TOTAL SICK DAYS

1

SIGNATURE OF A FICER SIGNATOR AL RECORDS OFFICER

FORM 3647, 3647, -MAY 79- -\ / OF 1 AUG 76 IS OBS

')••• MEDCOM - 13858 '\13 )"'" USAPPC V1.10

DOD-027410 ACLU-RDI 1623 p.18

DATE

e:ruy o give Name last, first, or medical facility)

MEDICAL I

ABBREVIATED MEDICAL RECORD PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)

# -

5„2„; 71; _sz_s2s .2

7L 4e4e-1 c_e)-5cLi 4>-11 11-?-S<;'

PHYSICAL EXAMINATION

G. v o )I ,4-9-r) 3 —,4,A--ece,7ts;

1"-/ /6' FL-t.e4.(15 str. #1^-e--e

>12: C P y c)

(-7Z f..)A 1/7 /1z ? j ?/ 1 1.0

71.

PROGRESSPROGRESS (Enter date of discharge and final diagnosis)

e—Ase

6.) 0 i f G y :„.„ -77"F

\C -11

0"1111.. SIG

PATI NTS IDENTIFICATION (For typed or written entries middle; grade; date; hospital

IDENTIFICATION NO.

REGISTER NO.

ORGANIZATION

WARD NO.

ABBREVIATED MEDICAL RECORD

Standard Form 539

GENERAL SERVICES ADMINISTRATION AND

INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR MI CFR) 201-45.505 OCTOBER 1975 USAPPC VI.00

MEDCOM - 13859

DOD-027411 ACLU-RDI 1623 p.19

NSN 7540-00-634-4176

MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

g , i e_ I v b_; cf. . 0 . -yi,c_a41, 624,74;,aza __.1,,,,, Ex 7 (-- w-r-A-4._, D (,20 1/ t.e' PLe --ee- ik—cue_e_../24_6_..t v_e_4_,..Kez. ea, ..z...,:a4t..E-, -41.4,<,24,„ 4.t go- te_if j__,A„ce,„, te „,, zezt.. ek_ o ,„,, e,e, zo-„,- /„.._e_f_..4zeiz ,z,, , --iI.e z4-6, -e . pf u_57-4- 4,...z,L. ",...,' 'Litz a 7,,,,,,,,,..7 At , te,,,,,,e

L.:5-x. • ,z5-1) -)7 /9 . 0 • 0 / 0 4 i 7 7 . 4 , 171, pel..-,-- . P A, 4-e--.7 ,54,—,._( 10

Oz-e-4.---4.4. 4,Y -,4 4...ae-ea.....ez-, ,Z, eic, 0e, g 6 Fr-P2s . 47e/. ,D 1_..Leze_ie . U5 . 7-9 7. 8 _ 53_ / 2 - 76,6 e,

aec-"-e- .te-e4, 44 a - ...- Z,.. ,ei WO

kg.' /'W 13 20 xf_ed,t,i' (c._e,,te ".,- ti.., yle,„:" _ c ( c, bJ /60/5-2 ,tM )tee Ga..,,,--eAe (

.

Lzt4i,r,„4,,: de,,e_ede, . i°71 attr_e.,..c/ -E. ti,Z,1(..1_e_ .,7,-- /-1/7 0 . ee4-&--,--4; Ac, 7f-(-0,7;0Z-. d,--7o .. 17: -. i, Vo -_____I IMO ),,cto (

`fhat-(21,.

3 - /Si- /2 1 /Lea' 9c1;44 --,e46-/A. = -1Ze-reA•t-0, lb 6-71 /4v--,7,,,,,,,e,e 7 ex.2 /tea"- , . )„6.•:- ,

cc5 (A.K71(b

_ \o Lc. - :I_

lb i OA Ili •

rinit ,'

• a - 6 , „mol! •• a 0 ,A 14 UillA I I I 04 AA JVA_....,g_i V ,

1 I I. i ,e1 -A _AP-2 • A a Or. _ . IL .4 a Als • 1-1K- AA - ._,A .., la 0 All LA '1 . • AL DAL Ilia • • . A..4111I11.A.C. A Ai 11.- I MI • at f A o.

6 _A IAl A A. AL A CA ' HOSPITAL OR MEDICAL F • LITY STATUS DEPART./SERVICE

I - RECO" D M •

SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSIV• Sex; Date of Birth; Rank/Grade.)

REGISTER NO. WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMA 141 CFR) 201-9.202-1

MEDCOM - 13860

t.i

DOD-027412 ACLU-RDI 1623 p.20

y ♦ • .• a • 1 • • v 1 • • • - • 1 i 1 ign eac entry

c?—ep4L(1:1:: 7)-4-- kr, 1) -tlel qicc—itej , 2-0 CY3-0/".o d p matin eynd d paco (l e8 jALabturgaikke . Cap. _pl. i* V Ksee-__677). 1 e . l. . t-- „,k. . . A,...A , A A 016_ 4,! ,.. 1_4014 4 ' . / 0 t ...% .4./_...

1

j2-c1 ) P1- za_,-livp.<141 vt'ib e i. ›kva.:(-17 624., Z. / a ' '-/ _.

II/ 20 (1) /.../ of I . 1 AILI.,e_._ _ • Q

JAa4/1,e4 19_.1-- 77)4 F.‘191/0 coviAtc) ut a, , fAkTi3,-L, . /(7)

FPI. LEX. Printed- on Recycled Paper STANDARD FORM 600 (REV. 6-97) SACK

MEDCOM - 13861

DOD-027413

ACLU-RDI 1623 p.21

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

STATUS

SSN/ID NO.

DEPART./SERVICE

RELATIONSHIP TO SPONSOR

RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - fast, first, middle; ID No or SSN; Sex; REGISTER NO. Date of Birth; Rank/Grade) WARD NO.

NEN 7540-00434417e

MEDICAL RECORD

DATE

AUTHORIZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)

/ 4-

I) Cl"? /->44

r

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSAACMR FIRMA (41 CFR) 201-9.202-1

MEDCOM - 13862

DOD-027414 ACLU-RDI 1623 p.22

URGENT --•-

NON-URGENT

ABG PT/PTT

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Patient)

LOG NUMBER TREATMENT FACILITY

E-)1,1 7— RECORDS MAINTAINED AT

PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS

/ e)g- all ( 1 Y DATE (Day, Month, Year)

7 ,,, y 07 7 TIME

03,,2 .-, CITY STATE ZIP CODE TRANSPORTATION TO FACILITY

SEX

iV1 DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO PRP ADDITIONAL INSURANCE

5- AGE HOME PHONE FLYING STATUS DD 2568 IN CHART

AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MED ATIONS ,,,e5......,J,C INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN

n YES n NO IS THIS AN INJURY? WHERE TETANUS

ALLERGIES

/A O 0 L (A)

INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTITIAL SERIES

❑ YES • NO HOW

CATEGORY OF TREATMEN

TIME EMERGENT

TIME

BP 3

VITAL SIGNS

XCBC/DIFF

URINE C&S

BLOOD C&S X ›- cc < CC IM

X m 0 ANKLE R/L

ACUTE ABDOMEN

SINUS

CXR PA & LAT/PORTABLE

WT

UA MSCC/CATH

lc- 5;e

BHCG/URINE BLOOD/QUANT CHEM: /a/c.kver

C-SPINE

LS SPINE

HEAD CT

y 17

PULSE

RESP

TEMP

ORDERS

ri MONITOR

COMPLETED BY I TIME

PU LSE OX

TIME

polo

e90 14.)

ORDERS • ECG

RESPONSE PATIENT'S

DISPOSITION

n HOME n FULL DUTY

MODIFIED DUTY UNTIL

DISPOSITION QUARTERS /OFF DUTY

n 24 HRS. n 48 HRS. n 78 HRS.

RETURN TO DUTY

PATIENT/DISCHARGE INSTRUCTIONS

CONDI

IM

❑ D

TION UPON RELEASE

PROVED ❑ UNCHANGED

TERIORATED

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

REFERRED 11110.

I have received and understand these instruction s.

TO WHEN

PATIENT'S SIGNATURE PATIEN T'S IDENTIFICATION (For typed or written entries, give: Name -- last,

first, middle; ID no. ISSN or other); hospital or

C,) v EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-961 Prescribed by GSA/ICMR FPMR (41 CFR) 1 01-11.203(b1(10) USAPA V1.00

MEDCOM - 13863

DOD-027415 ACLU-RDI 1623 p.23

RADIOLOGY ABG/PULSE OX

P02 RESULTS z PH

- v47 3 3

to

OTHER SAT

PT EKG INTERPRETATION

ETOH BHCG APTT

Check if read by ❑

radiologist

_

WBC

7d (0

H/H 74/0

PLT

If 2o 1 <

PI

GW

SUP 02

PCO2

DIP

MICRO

RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP CONSULT WITH TIME ACTION

PROVIDER SIGNATURE AND STAMP

DIAGNOSIS

afze-Y-1-c-° 0

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

PROVIDER HISTORY/PHYSICAL

5A0 3C-7

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

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9 -96) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203(b1110) USAPA V1.00

MEDCOM - 13864

DOD-027416 ACLU-RDI 1623 p.24

TIME:

PATIENT ASSE'qMENT

SIGNATURE: ■TIENT ASSESSMENT

• • .7 r\ III IA Nu muuous ME BRANES

Skin Loose / Tight / Diaphoretic / Shiny Dr SKIN AND MUCOUS MEMBRANES

Skin : Loose / Tight / Diaphoretic / Shiny / Dry Skin Temperature w2..-4-0--- Skin : Temperature Color. Pale / Cyanotic / Jaundiced kit- Color: Pale / Cyanotic / Jaundiced Mucous Membranes:(Prao / Dry / Cracked Mucous Membranes: Moist / Dry / Cracked Skin Breakdown:o- ,ri Location: Size: Skin Breakdown: None Location: Size: NEUROLOGICAL NEUROLOGICAL Loc _/ ler Lethargic / Unresponsive GCS: Loc /Alert / Lethargic / Unresponsive GCS: (-Drierse-red / Disoriented Pupils: g ow 4 Orientated / Disoriented Pupils: Extremity Movement: F / Limited / None . Extremity Movement: Full / Limited / one CARDIOVASCULAR CARDIQVASCULAR Pulse ( 0 - 4): Radials + -- - . Pedals Pulse ( 0 - 4): Radials Pedals Capillary Relill:/..3

(...0 . Seconds Homan's S gr16--) Capillary Refill: Seconds Homan's Sign Jugular Venous Distension (-__) Edema

Heart Sounds 1 5 2, ---) Jugular Venous Distension Edema

Heart Sounds Rhythm 56 a, 4(5 61914 PRI: QRS: Rhythm PRI: ORS: Vascular Catheter Central- 9-Arteria) Peri•heraf-<-. Perinheral 2 Vascular Catheter Central Arterial . Peri•herat 1 Penpher Waveforms ••:-:.:•:..:::;'::':'.. Waveforms

Site Site

Solution Solution

Chest Pain -.6.-- ,

Chest Pain RESPIRATORY

RESPIRATORY ----7- ._. Chest Expansion / tnr......inetricax.7 Asymmetrical Chest Expansion / Symmetrical •Asymmetrical

Respiration / No Distress / SOB / Labpred Respiration i4goke kurit

Breathing Patterns: . tr...4.4,_i-ne-ft I Use of Access Muscles Breathing Patterns:

Cough: Productive / Nonproductive / None Cough - Productive / Nonproductive / t or

Sputum: Color / Amount / Consistency / Odor gi-- Sputum: Color / Amount / Consistency / Odor Chest Drainage System Gravity: -,C)._ Suction cm: Chest Drainage System Gravity: Suction cm Air Leak .,--No — Yes ---- Crepitus - Air Leak No Yes Crepitus Character of Drainage: -

._ Character of Drainage:

Trachea / f(i_tioe:iDeviated (R) / Deviated (L) Trachea / Midline / Deviated (R) I Deviated (L) Artificial Airway Size: Type: Position: . Artificial Airway Size: Type: Position:

Breath Sounds • Anterior/Location Posterior/Location Breath Sounds 'Anterior/Location .+.a, Potterior/Locati, Crackles Crackles

Wheezes

.

. •

Wheezes 6--(11.- .

Diminished Diminished

Absent Absent ‘ .;

GASTROINTESTINAL GASTROINTESTINAL' Abdomen: oft Firm/ Hard / Distended cm Girth Abdomen: Soft / Firm / Hard / Distended cm firth -. Bowel Sounds: Car-frre/ Hyperactive / Hypoactive / Absent Bowel Sounds: Normal / Hyperactive / Hypoactive / Absent Dressings: sC2 . Dressings:

146-T-1,14e t-io-piCapi4,-8-ti-etiorrtD16-5-e-ndent Drainage NG Tube: Clamped/Inter. Suction/Cont. Suction/Dependent Drama N-G-D-a.i.riaqe: Col Character NG Drainage: Color Character -Tube Feeding: Day.44e•-- Strength: Rate: Aspirate: Tube Feeding: Day No: Strength: Rate: Aspirate

Stodl: Character .-S4e.s..k-G4-1.al-a-crerr

.._ . Drains: GENITOURINARY .. ._

GENITOURINARY Urine Color: Character: Urine Character: Voiding. Continent / Incontinent / Catheter Color:

Voiding: Continent / Incontinent / Catheter

EMOTIONAL/PSYCHOSOCIAL EMOTIONAL/PSYCHOSOCIAL-

tat4.4_ t epe.A__62.4....-& f-c.--3.

OTHER OTHER:

MEDCOM - 13865

DOD-027417 ACLU-RDI 1623 p.25

iii

TO

TA

L

,

I S

TO

OL

.

I N

GT

I

I U

RI N

E

■

!OU

TPU

T

I TO

TA

L

iiia

2 0 ..k"

1,

"2 11 C -i

CO

0

7C1 gMXIM-o KJ

i —4 co

-a

. . .

limo. 2

i III 2 I 0

6 I 07

..

I 08

1 0

9 I 1

0 I b

1 2

1 1

2

. _. El 1/ sa

l

1 1

3-1-7

14- J

is

. .

1 16

17

M

.. . _

1 19 J 20

1 2

1 1-

2r 1

77

117

MEDCOM - 13866

I 01 J

02

l 03 1

04

DOD-027418 ACLU-RDI 1623 p.26

\ipo -LA

PATIENT ASSESSIAA9\ITaW PP --- NIT ASSESSMENT TIME: • 6;1-

SKIN AND MUCOUS MRRMEIIIIIF , ,+/-',"" I IME: SIGNATURE:

SKIN AND MUCOUS MEMBRANES ,Skin . pose Tight / Diaphoretic / Shiny r Skin : Temperature LA)-0-<_yri

Skin : Loose / Tight / Diaphoretic I Shiny / Dry Skin : Temperature

Color Pale / Cyanotic / Jaundiced 1/1..)10(.._14)i— ra oz.. Color: Pale / Cyanotic / Jaundiced

Mucous Membranes: Moist / Dry / Cracked

Skin Breakdown: None Location: Size:

Mucous Membranes: • ois • ry 1 Cracked

Skin Breakdown:Q)one) Location: ------,. Size: "."--- NEUROLOGICAL NEUROLOGICAL Loc /dis Lethargic / Unresponsive GCS: .----- Loc /Alert / Lethargic / Unresponsive GCS: Orieniated)Disoriented Pupils:

Orientated/Disoriented Pupils: Extremity Movement: Full / Limited / None

CARDIOVASCULAR

Extremity Movement:CriOli Limited / None

CARDIOVASCULAR Pulse ( 0 - 4): Q 1-- Radials (Di- --- - Pedals Pulse ( 0 - 4): Radials Pedals Capillary Refill: < -,.?., Seconds Homan's B(gn CZ) Capillary Refill: Seconds Homan's Sign

Jugular Venous Distension Edema Heart Sounds

Jugular Venous Distension — Edema) heart Sounds Sr Fla - Rhythm 6, Ft, PRI: ------ QRS:'----• Rhythm - PRI: ORS Vascular Catheter

Waveforms

Central ---_____

Arterial -`

Peripheral 1 M!;;;i:;:::" -W' :!:!

Peripheral 2

,:•-:::!:,::;!::."•:•!::":.;.,-:,.!']'!':".

Vascular Catheter Central Arterial Peri.heral 1 Periphera! Waveforms Site .......„

''''\ ( t.(fisi-- -: Site Solution H. L Solution Chest Pain r Chest Paln

RESPIRATORY RESPIRATORY Chest Expansion / Symmetrical t Asymmetrical

Respiration / No Distress / SOBL_•abored / Use of Access Muscles Breathing Ppttems•

Cough•_Productive / Nougioductive / &De

Sputum: Color / Amount / Consistency / Odor

Chest Expansion I ‘y-mmetric-:ThAsymmetrical

Respiration /(•:io DistresSy SOB / Labored / Use of Access Muscles Breathing Patterns: 1:2R Cough: Productive / Nonproductive // (11-5-R-i) Sputum: Color / Amount / Consistency / Odor Km Chest Drainage System Gravity: ---------- Suction cm :.--------.. Chest Drainage System Gravity: Suction cm:

'Character of DraiaagaLl Air Leak No Yes Crepitus Character of Drainage:

Trachea idlinD Deviated (R) / Deviated (L) Trachea / Midline / Deviated al" Deviated (L) Artificial Airway Size: Type: Position:

,, • • • Breath Sounds : Anterior/Location Posterior/Location Breath Sounds -Anterior/Location'..r. , Posterior/Location

Cr ackles

Wheezes die Ter Imre Crackles

Wheezes Diminished i Diminished Absent

Absent . .

GASTROINTESTINAL GASTROINTESTINAL" Abdomen - )11.1)Firm / Hard / Distended cm Girth Abdomen: Soft / Firm / Hard / Distended firth cm Bowel Sounds: Normal / Hyperactive H poactivellAbsent Bowel Sounds: Normal / Hyperactive / Hypoactive / Absent

Dressings: Dressings: (75

■ .; -;":::. • : • 1 • a • • • P ' • , : NG Tube: Clamped/Inter.

NG Drainage: Color Suction/Cont. Suction/Dependent Drainage -44G-C4r-a+fitte-e-oirrt

Chdrdctel Character

, • - : -: - T . 7.

• Tube Feeding: Day No: Strength: Rate: Aspirate Stool: Character 0 ey-tecis -Fifyt_Q_ Stool: Character Drains. ?) --- _ Drains:

GENITOURINARY ._

GENITOURINARY Wine Color: Character: Urine Color Character: Vowing CoTrunent ) incontinent / Catheter Voiding: Continent / Incontinent / Catheter

EMOTIONAL/PSYCHOSOCIAL EMOTIONAL/PSYCHOSOCIAL•

OTHER: n-rupa•

MEDCOM - 13867

DOD-027419 ACLU-RDI 1623 p.27

Ward/Section- tcr,QTJ'ho WIG IMF \C*A":** CHEMISTRY RESULT FORM

(Subject to the Privacy Act 1974) of LAST, FIRST, M . \\0 '‘°\ -71)-la? -

TIME de2 6? f—e

SSN/PS \''L2 id = I- cPiceiWiCTiein fCcii10 i'.) c ane] ,..

TEST RESULT REF. RANGE RESULT REF. . ' GE

TEST RESULT REF. RANGE

Na 138- 146 mmol/L ALB 3 1-1 3 . 5-5 . 5 g/dl GLU 73-118 mg/c11 K 3.5-4.9 mmol/L 1 ALP 51 26-84 u/1 , BUN 7-22 mg/di Cl 98-109 mmol/L ALT (2- 10-47 u/1 ' CA++ 8.0-10.3 mg/dl pH 7.31-7.45 ! AMY ql 14-97 u/1 ' CRE 0.6-1.2 mg/di PCO2 35-45 mmHg (art)

41-51 mmHg (ven) AST 23 11-38 u/1 NA+ 128-145 nuno1/1

P02 80-105 mmHg (art) N/A (ven)

TBIL o a 0.2-1.6 mg/dl IC 3.3-4.7 mmol/1

TCO2 23-27 mmol/L (art) 24-29 mmol/L (yen)

BUN : I 1

7-22 mg/di ' CL" 98-108 mmol/1

HCO3 22-26 mmol/L (art) 23-28 mmol/L (ven)

! CA4 ; 9 ,( 8 . 0-10. 3m dl tC 02 1 8-3 3 mmo1/1

s02 95-98% CHOL ) il 100-200 mg/d1 • ..: .< ac!

BEecf (-2) — (+3) mmol/L

! CRE 1` 0

0.6- 1.2 mg/d1 TEST RESULT REF. RANGE AnGap 10-20 mmol/L , GLU 112 73-118 mg/c11 ALB 3.3-5.5 g/dl Ca 1.12-1.32 mmol/L TP

I c/ 6.4-8.1 g/dl ALP 26-84 u/1

BUN 8-26 mg/d1 ,s- t ALT 10-47 u/1

GLU 70-105 mg/dl TEST RESULT REF. , RANG

AMY 14-97 u/1

Creat 0.7-1.5 mg/dl ' GLU 73-1 1 8 mg/c11 AST 11-38 u/1 Hct 38-51% ' - BUN 7-22 mg/dl TBIL 0.2-1.6 mg/di Hgb ,

, CRE 0.6-1.2 mg/d1 GGT

4 '''' Ai.'4 .

''' 6, 4t.:,, CK 39-380u/1(M

30-190 u/1 TP 6.4-8.1

TEST = " F. RANGE NA+ 128- 145 mmol/1

I

h icco o 0

Troponin -1 + 3.3-4.7 mmol/ TEST RESULT F. RANGE

Drug of Abuse

CE 98-108 mmol/1

11-V2— 128-145 mmol/1

,: .-:.;0 tCO2 18-33 mmol/1 + 33 , 3.3-4.7 mmol/1

CL- 161

98-108 mmol/

1C 02 \

18-33 mmol/1

REMARKS:

MEDCOM - 13868

DOD-027420 ACLU-RDI 1623 p.28

BED NO.

DATE OF ORDER TIME OF ORDER

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

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

PATIENT IDENTIFICATION TIME OF ORDER LIST Tii..iE

2e7-1- HOURS NOTED

ORDER

SIGN

7e--y_e_

DATE 0 F ORDER

03

NURSING UNIT ROOM NO.

PATIENT IDENTIFICATION

HOURS

NURSING UNIT


NURSING UNIT ROOM NO. BED NO.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS

NURSING UNIT

rePIA) tf

ROOM NO. BED NO.

MEDCOM - 13869

DOD-027421

ACLU-RDI 1623 p.29

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

the proponent aoencv is the Office of The Surgeon General. Mo. 7 Y r. 03 VERIFY BY INTR./LUNG tF: ,,, ;,,1,5 -i4,:`,::4 - :: INTITAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

ORDER DATE

CLERK! NURSE

RECURRING MEDICATIONS, DOSE, FREQUENCY

HR DATE DISPENSED

.7 %v 9 f( i ( f)

1110 — /1"-p .75O o - 1 CDC rgt --)

N\0\1 ,- --- Jg / AO

6 -

- ,S) po -111r:<,:lOrarut •I \J 6 5 Ali 1 9 III

,...

, .

•

•

ALLERGIES: El YES

hi l' o a MI NO PRIMARY DIAGNOSIS:

421-4'./2/.2—e

(IL ) ifA.119._ ,f:24reewia."

ADDITIONAL PAGES IN USE:

/11 YES = NO

PAGE NO

PATIENT IDENTIFICATION: DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES

C PIA") 6 -"I D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

DA FORM 4678, 1 FEB 79

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

MEDCOM - 13870

DOD-027422

ACLU-RDI 1623 p.30

Verify by Initialing

Order Clerk/ Date Nurse

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

SINGLE ORDER, PRE-OPERATIVES

Mo. Yr.

Initials Time Given Data to

be Given Time to be Given

. Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUENCY

Order! Expir Date

3-Mf d-e,„,,,-e 650

INTIM PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED

MEDCOM - 13871

USAPA V1.00

DOD-027423

ACLU-RDI 1623 p.31

CLINICAL RECORD (NON-MEDICATION) THERAPEUTIC DOCUMENTATION CARE 40-407;

l 1 - • • • • 1 - I • . Si e f MO. Yr. 2003 VERIFY BY INITIALING '.,-..:,- . 3,rcS4P-7 4477.----;,•:.V. ":24pi

RECURRING ACTIONS, FREQUENCY, TIME

IATTIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK/ NURSE

HR DATE COMPLETED —7 ? cl 10 1 I

63 111111 — C4:1- 06, 7 .- /1,--

/ .2 . 'WA-4- e 7

P ►i.. U1 /

— (7. c.,„Ti ocp 2e-82-csa Q'S ,.) -

I

•

• .

•

. •

- - - - - -

ALLERGIES: MI YES

A) k_019

IN NO PRIMARY DIAGNOSIS: .

(i) %_„9___ „6-44.79,77,,4


YES 1.1 - NO

PAGE NO' PATIENT IDENTIFICATION:

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

. -i)(4)

- lin \:I L .... Li 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 , EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

MEDCOM - 13872

DOD-027424 ACLU-RDI 1623 p.32

Verif y- by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo f;-,--e- Yr 2003

Order Date

Clerk Nurse SINGLE GLE ACTIONS Date to

be Done be Time to

Done Time Done Initials

.. • 1

- 79.-1—__. Pk)

fa C... ' c, 1

YLk.- 4+1111111_771_0--

1.1 p-ca-x--÷--/--4N--- ...4.0--.--c2.2,6 D__JA-,-.-- d!c ei

V h

'C2-1/--ell

686-o Vo-)- li

/Qc=&0 "I G__i) ei-cr-Q S (

. . .

„ .

. Order/Expir Date

Cl erk/ -

Nurse

PRN ACTION. FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLMON TIMEMATE COMPLETED

• • - . • .

USAPA Nr1.0

MEDCOM - 13873

DOD-027425 ACLU-RDI 1623 p.33

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

For use of this form, see AR 40-400; the proponent agency is OTSG

1 2 3 4 5 6 7 8 (State Of

A i 1 ,. 1 WARM Country Code.)

3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX

lerillrill

. ATE OF IRTH (YYYYMMDD)

P\) \O I‘D -4 16 17 18

rA 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION

19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-GROUND

IM (all' In n 10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER

32 33 34 36 37 38

mgrameammr-- 39 40 41 42 43 44 45

61 ORGANIZATION (Active Duty Only)

Q /A

13. MARITAL STATUS HOUR ADMISSION

OF BRANCH / CORPS

e.?, O\VA ZIP CODE OF RESIDENCE

46

LA, 14. FLYING STATUS 15. BENEFICIARY CATEGORY 16.

47 48 149 50 51 52 53 54 55 56 57 58 59 60 61 [

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

62 1 63 1 Country Code) 1 64 65 66 67 68 69 70 YEAR

NO 7

i

1

20. SOURCE OF ADMISSION/ AUTHORITY FOR ADMISSION

WARD NAMEJRELATIONSHIP OF EMERGENCY ADDRESSEE


FACILITY TELEPHONE NI 1 WE_Emmauicya..pgREOSE.E---

2 • I. 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (Y YMMDD)

73 74 75 76 77 78 79 80 81

MLR 26. DATE

82 83

,0

84 85 86

8 A .0 24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM THIS ADMISSION (YYMMDD)

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

A- ani It; i':1

27. LOCATION OF OCCURRENCE (Battle

28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYMMDDI

103 104 .----- --- Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 116

FOR LOCAL

n

USE

Pi cw ,....,_ AN,_ .,,,,,, \-....))( ? en i

...

iyk4.5

ADMITTING OFFICER Si as•uired)

i) e..." A -10

r•

SIGNATURE OF ADMITTING CLERK

5 Pe / -

MEDCOM - 13874

DOD-027426

ACLU-RDI 1623 p.34

INPATIENT TREATMENT RECORD COVER SHE! - -

I. 2 . NAME (LaM, Fust, MI)

1 GRADE

6P1/0

ADMISSION REMARKS

4. SEX I6. AGE

(‘.1 I 20 6. E

UNK- 7. RELIGION 8. LENGTH OF SVC 9. ETS 10. PREVIOUS

ADMISSION

VAX- A )

11.

:4 619

SSN 1

P 6 13. ORGANIZATION 14. WARD

--clic 3 15. RYING

STATUS

Al

16. RATING/ DSG

17. DEPT) BEN

K -78 18. BRANCH/CORPS 19. UICIZIP 20. TYPE CASE

1/0,1:k

21. SOURCE OF ADMISSIOAVAUTHORTY FOR ADMISSION

d\ Nre CA- frovyv -t - ►e_ 22. HOURS OF

ADMISSION

it-r2-z_

23. CLINIC SERVICE

A-t3P - 4- 24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

U\ A) le-

25. TYPE DISPOSITION

60

28. DATE OF DISPOSITION

18 LA L-03 271. ADDRESS OF EMERGENCY ADDRESSEE (Weds ZIP Coda)

tA iu r- 27b. TELEPHONE NO.

IAA)t:--

28. DATE OF T115

06 Ju-L-03 ADMISSION

ADMITTING DR10ER

29. NAME AND LOCATION OF MEDICAL TREATMENT FAC1UTY

a-a 30. DATE OF INTIAL

ADMISSION 32.

COMPONENT TRANSRJSED

31. SELECTED ADASNISTRATIVE DAT

• Check LI Continued on Ramie

33. CAUSE OF INJURY

34. DIAGNOSESIOPERATIDNS AND SPECIAL PROCEDURES

etu\_) 0 trv‘atAcilbt-e_, C-vskA) 0 +(AL3

_ ..„... , p, A 3r131-1

'A • .....,

S .i

v ,

,.1 i . ‘,,;.•

,- -.; ',I-

k

- 7, , PI ,'

I %1,4,Ti ' A

•A r5 ct

) Cf, - - _, i

...., 2,..3.=D1 f . ,....‘' 3 , •-.),...:. ; j

,,. . , i ..„, • .... '-., I --, ' ' . • c"


a. ABSENT SICK DAYS b. OTHER DAYS

0

C. CONY. LVICOOP CARE DAYS

0 4. SUPPLEMENTAL

CARE DAYS

0 a. DEO DAYS

1b I. TOTAL SICK DAYS

I 0 36. Total Days AlFacilitos

a. ABSENT SICK DAYS h. OTHER DAYS C . CONY. LVICOOP CARE DAYS


a. BED DAYS

C R

I. TOTAL SICK DAYS

SIGNATURE

■--.... .C:1:1 (4, ••• ;..". ....---•.•"".

11A Encino 9R /17 A NAV ,o EDITION OF 1 A OBSOLETE

USAPPC V1.10

MEDCOM - 13875

DOD-027427 ACLU-RDI 1623 p.35

`,- A 4-0

I 1 1)/- -h,--

yped or written ontries sv. Name last, first, middle; grade: date; hospital or medical Inc lity)

WARD

MEDCOM - 13876

ABBREVIATED MEDICAL RECORD summit-a Form Sae

GENERAL SERVICES-ADMINIPRATJON AND- INTERAGENCY COMMITTEE ON MEDICAL FRIFIEMMARD(431 CFR/ 201-46.606- OCTOBER 1975

MEDICAL RECORD - ABBREVIATED MEDICAL RECORD_ PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION

(AV,' Jute of admiesion

21 ) I. 2 tz- cL. >-- 1 "f° Ri.-7

_ 4 dv) (4 a

F7"-4- L./D-%4( t" 1 `>-.4

r

h

PH YSICAL EXAMINATION

1—>w-a (• IY1 4 1, 1 L. Li ( "'r e

(et 1 ,,,A Jr- II /1 .4. ,

7 .41 /it ,-

6 u-et c /41- i-) 4

(Ak%-c" & C ni).1/

..-tee(

PROGRESS (Enter dart of oNicharoe and final diaenosis

DOD-027428 ACLU-RDI 1623 p.36

c BTOH:

PMHx:

2 C.—

ee/f1/1-r6....t-77c

MEDICAL RECORD

DATE

TIME: Z

R:

B/P:

P:

MED: •

ALLER: C-or-..->AV Crf

LMP:

TOB:

• • - ,•••• -

merrar.f

411■ G ORGANIZATION Sig) each entry) 2..4/0

ear

AUTHORIZED FOR LOCAL REPRODUCTI

CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS, DIAGNOSIS, TREATMENT, T' -AT

do

.7‘

gr-s4.)

C-1.) Est, (.6:3

'...".91°' VAIT oftssZkort /5 /4 . 4 ( 4,14, j‘e

(# -e+

/17.6,C4,

PSH: At-

I f S re ardin diagnosis, plan of care, medications,

Biwa*, p

FMHx:

Initials: HOSPITAL OR MEDICAL FACILITY

DISCOM AID STATION SPONSQR'S NAME

RELATIONSHIP TO SPONSOR PATIENT'S. IDENTIFICATION.

',War typed or written entries, give: Name - lest, first, middle; /0 No or SSN: Sex;

: •

Data of Birth; Rank/Grade.)

• • 4•••

REGISTER NO

.7=1:"; . • r

c

25:0 LE-

RECORDS MAINTAINED AT D.A.S.

6

MEDCOM - 13877

DOD-027429

ACLU-RDI 1623 p.37

PATIENT'S IDENTIFICATION: (Fo ped or written entries, give: Name - last, first, middle; No or SSN; Sex; of Binh; Rank/Grade.)

REGISTER NO

Component Requested MEDCOM - 13878

NSN 7540-00-634-4176 AUTHORIZED FOR LOCAL R

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

1,/,1.L 63 ogr) i j P-qq -761- 3 1b6 G tpq

05a) 15970, (9 L 5b I b 6 6160 169/i21 75 . 9---- 16_ 6 06 1-CliV15g- 11 16 0 Filo 1 I/qq 'fig 1o0 bi i5 ̀q9/y. 161 / 4/ a 6, b

41-Ei)s be_aftfT.

-v+ANQS v3 C 51/a) 141.

t.-_------ --- --...,

HOS 1-11. ,_ ORMIC4AIL.FA CILAff

6M /

STATUS DEPART./SERVICE RECORDS MAINTAINED AT

SPONSOR'S

\4\4# L'i SSN/ID NO RELATIONSHIP TO SPONSOR

DOD-027430

ACLU-RDI 1623 p.38

, 4

MEDICAL RECORD PROGRESS NOTES DATE — 417:-:'-'-'----- ---,,

, .

7(SI 0) 10 ' ( i LA/14 i'y S`

-... 3D ,4 1-e-G-ii; c)" 5 I 0 C-3 ) 1.1> . (.2...., C , L,,,t i".... c LI .4 L- C.; 1.■ ....(7...., ti.....e ,e1 f

k ' --k• 111 - \-1 1 t> e-.5 7 ,Akkt.cc e?-4 ,--,j,, l (,„,,k...X ,.i.t..c.r1cQ-e-A , p <, 4-(e-t.-( tvZ,i-t,te .a H ;--"--.2.

e it,,c,k ,,,,„t. u...., ,,i AA. kftA _. ( sic. 5e..,,,..- klce Ay (, k— 4.-„, ( . V-t: .1-

Incyst vev, 1 -Ai 44 t7 0,-- •) 4 „ .:. ..-i -1,› Ifuri ..A. ....,,/.. si c—c.

-Pi l"...,,,i ,A rGA Ill..ebtil k A1.1.4, tf.- lt:7 ► -, .¢...1e- ,-yc,..4-A n co-,. A 1,9(i-t...A;1,1

;iv l iteA y i 14 e i, 0 f- —4 k t1--4Acit - 2-c-> c-k.c...A—i -L. f.-1...., --, ixn- f s AA-4_5 %.

Ai, l.. (2(4 ,A..-0 A --c-----r_p...$)-1.1-0C 1 P tau-. Lle L”` ------Z--- t- ' t -

ct.4-k-,-- et) vwL ---t. t-, k-t C) wrkt (.., 5 ck C 1 0 l.c,c.c.i kvt.._ -..,.fr...<_ (..,--, 1,... La r i (

. _

,Ve /. 5J .--,e,,N,k • I-4 --7, (7-tS t- i->-. 1, t- 4. .1-,,t 4, tge,, ,,e. -tn.,. 0 o c_

-kr) .1-..• ., r,1 ,e. '.e. ,^c/14....s.i-c. I.,./. kl, 416 ( L pL. LA (--1..A -&C ()./1.0 LI „. c.,_,..,,6,...u..7 L-----__ __.--=,,----- --

( t ,..,..e.A piv OC, -6/t/ 1' e„n-,1 ci 2 k7 • 1 ,..1-4A h t k 4 L. i--- c q .,.-1 7,1--t , --, f. i 1)e,

(,, vt_ LA , h• 0 f MR 15:,.41 0 ," : I e ••4 LI" ii. f i' +I t 1 ,0 I.- 0 (...) 5

C ,Ai I t ,.'''{ w.2.1 tAv-(.. -. 1}— e Cr -, `''t. , -2-r-, .--, vz e. .1,.> --) ‘.s, ,, ce? : ?' 11 0 6 6 \

52.1, h 1,-ex . /A ,-. r . ,-, I ► i ., t,7 ,1 e 11 1,G. • CU-N. c. ,,,,r,i ,_ 6,_.%..) „,..)• le

1 ° i,t-%- ,11 e---, E.,. -4. ...,k 'U., 0 A 0 < :, ix- c 3 si 2 ..4_ 1:1 E--. ''5 e ...... 4---Jno

e utl-- iv 0 c,t- .07...S kv, c., 3 3 7,,,.., 0 l't 51H (AA- -TA k-C• 1 A. v., 7- w.--, ----- (-

17-EA2i -

/---- . _

(Continue on reverse side) PATIENT'S IDENTIFICATION IFor typed or written entries give: Name - last, first, middle;

grade; rank; rate; hospital or medical facility) REGISTER NO. WARD NO.

PROGRESS NOTES

Medical Record

STANDARD FORM 609 (REV. 7-91) Prescribed by GSAtICMR • FIRMR 141 CFR) USAPPC V1.00

MEDCOM - 13879

DOD-027431

ACLU-RDI 1623 p.39

PROGRESS NOTES

DATE NOTES

O 3 nea-A4:4-4-e;--,-/ /)e-t... : 30 / ---/- 0 o' 0-A.A_. _...e„2-a_e_....

ow - lto_z.. -

En , (007, Kr. (0 - I

P :' CS - I -, 4 .4t 211F '

(o 0 sn-1 ■1 - io TV - 700 5,07 1 ,--- i

P I /..4 . . /. `=i--- / / • , .I 3 2 e i . y_.■

' _4 2.1.I 4 0 .0%4If ''''

/ Am, ,,, I

' ' /V ,..4,_ _ / le -

AV

, .i110 / 4 4 -4 Pai-4,■-.0 e__4_....t,

,d ■ 0 ..,4 4 -c...' ../.. /1.1■

, 4 Al 4 , _.■ ___•_Lk17:f2e/1,42ftL_A--izi,.z,

_ _ _

/ - 11.1,..a.

4 r

1/ 1 4 Ae., "A . . r: .2 ' ' . Ai.' 0 •

Al, Aor ..' -/ "If.e12.' ' 1 _ j • ,

I 11•IdALA._ .., .r ,,..1 / /, ___ff._.• 1 --1-1._ ■ • -._d___t___44___,.?: , / ■

i

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- - 1 ... i....._.,

. ' .dAl 0 .........i

.4 ....._...

,

0-_..-/,■.. 0 6714_CJ2._ L.4)-12-.2-p

■

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la 4-V,:,,,,2

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AI! • 66 i V -

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- ......r r-

SPONSOR'S

it NAME

C.e2 s , INSHIP TO SPONSO

' ONSOR'S II LAST FIRST SN

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PROGRESS NOTES Medical Record

STANDARD FORM 50!

ALITHoRIZED FOR LOCA.

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C

MEDCOM - 13880

DOD-027432 ACLU-RDI 1623 p.40

DOD-027433

DATE NOTES

SPONSOR'S NAME NUMBER


PROGRESS NOTES

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WARD NO.

AUTHORIZED FOR LOCAL REPROD

MEDICAL RECORD


STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10

USAPA V1.0C

MEDCOM - 13881

-IA

ACLU-RDI 1623 p.41

STANDARD FOR USAPA V1.00

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MEDCOM - 13882

DOD-027434 ACLU-RDI 1623 p.42


MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

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PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999)

Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)

USAPA V1.00

MEDCOM - 13883

DOD-027435

ACLU-RDI 1623 p.43

LAST NAME

FIRST NAME

MIDDLE INITIAL ID NUMBER

DATE NOTES

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MEDCOM - 13884

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DOD-027436

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MEDCOM -13885

DOD-027437

ACLU-RDI 1623 p.45

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DOD-027438

ACLU-RDI 1623 p.46


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MEDCOM - 13887

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ACLU-RDI 1623 p.47

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MEDCOM - 13888

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DOD-027440 ACLU-RDI 1623 p.48


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MEDCOM - 13890

DOD-027442 ACLU-RDI 1623 p.50

DOD-027443

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MEDCOM - 13891

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MEDCOM - 13893

DOD-027445 ACLU-RDI 1623 p.53

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DOD-027446 ACLU-RDI 1623 p.54

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ACLU-RDI 1623 p.55

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SPONSOR'S NAME

FIRST SPONSOR'S ID NUMBEI (SSN or Oilier)

IDENTIFICATION /Pot ry ID No

ea or written entries. give: Name • last. first, middle; I REGISTER NO r SSN: Sex. Dare of Binh; Rank/Grader

WARD NO.

AL RECORD AU I HoHILED i-OR LOCAL REPRODUC

PROGRESS NOTES

E NOTES

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STANDARD FORM 509 (REV 5, Prescribetl by GSA/ICMR FPMR (41CFR) 107-11.203

USA PA

MEDCOM - 13896

DOD-027448 ACLU-RDI 1623 p.56

ST NAME

Fl

MIDULE INITIAL' 10 NUMBER

DATE NOTES

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MEDCOM - 13897

STANDARD FORM 509 iREV

DOD-027449 ACLU-RDI 1623 p.57

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Sh iP Ft , S PON S OR SPONSOR'S NAME

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MEDCOM - 13898

DOD-027450

ACLU-RDI 1623 p.58



DATE NOTES

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cd..... 4_," L-2 -t, div!

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME

LAST FIRST


PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle:

ID No or SSN; Sex: Dare of Birth; Rank/Gradei




Prescribed by GSA/ICMR FPMR 141CFR) 101-11.203(b)(10)

USAPA V1.00

MEDCOM - 13899

DOD-027451 ACLU-RDI 1623 p.59

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

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VI& STANDARD FORM 509 (REV. 5119991 BACK

USAPA V1.00

MEDCOM - 13900

DOD-027452 ACLU-RDI 1623 p.60

AUTHORIZED FOR LOCAL REPRODUC"

:AL RECORD PROGRESS NOTES

- E NOTES

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SHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBEF (SSN of Other/ LAST FIRST MI

;ERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

IDENTIFICATION: (For typed or wntren enrries. give: Name • last, first, middle:

ID No or SSN; Sex; Date of Birth; Ranx/Grader

I REGISTER NO. WARD NO .


STANDARD FORM 509 (REV sr Prescribed by GSA/ICMR FPMR (41CFRI 101-11.203(

" • n

MEDCOM - 13901

DOD-027453

ACLU-RDI 1623 p.61

AUTHORIZED FOR LOCAL REPRODUM

PROGRESS NOTES :AL RECORD

a-

- E NOTES

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SHIP TO SPONSOR SPONSORS NAME SPONSOR'S ID NUMBEF

ISSN or Other] LAST FIRST MI

SERVICE I HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

IDENTIFICATION (For typed or written entries, give: Name - last. first. middle:

ID No or SSN: Sex: Date of Birth: Rank/Grader



STANDARD FORM 509 (REV 51

Prescribed by GSA/ICMR FPMR 141CFR) 101 - 11.2031

MEDCOM - 13902

DOD-027454

ACLU-RDI 1623 p.62

AUTHORIZED


DATE NOTES

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LAST FIRST MI ISSN or Other,


PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle;

ID No or SSN; Sex; Dare of Birth; Rank/Grade)

REGISTER NO. WARD NO .



Prescribed by GSA/ICMR FPMR I41CFR) 101.11.203(bI(1O I

USAPA vi.00

MEDCOM - 13903

DOD-027455

ACLU-RDI 1623 p.63

If /4 0 4.44 I. I I/

NURSING NOTES (Sign all notes)

OBSERVATIONS Include medication and treatment when indicated

(10 e

9/5 t6 pit/K.) ori riks-c6 /9/ X_ t cani 10/1z -

C(4,14. (44_1_4 LI"

mad, TE4Da,u___f-ed_171,_ liecton

DATE A.M.

/5 :5-Lay 03 IMO

HOUR

P.M.

of.r.44-e ez

4./ ti-5111/

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al .411,.

moi _

le a A,

MEDCOM - 13904

LS. A_ IT

1 • lb A ! 1MA

DOD-027456 ACLU-RDI 1623 p.64

(Continue on reverse side)

• • •

WARD NO.

- —

NSN 7540-00-634-4123

NURSING NOTE (Sign all notes)

OBSERVATIONS Include medication and treatment when indicated

VIEDICAL RECORD

1.•••••••

4 rAttv-eA , .1"-;4.---1`-e- J. - A

ut-

PATIENT'S IDENTIFICATION (For typed or written entries give: Name—fast.

first, middle; grade; rank; rate;

hospital or medical facility)

MEDCOM - 13905

REGISTER NO.

NURSING NOTES

- Medical Record .

DOD-027457

ACLU-RDI 1623 p.65

,-va: .3.04,,,,,4,c't-•• El

C 4.02 9/974.;

23 (/ 7

• • •

558-103 0 • (See Instructions on Ba of this Sheet) NSN 7540-01-075-3786

P

rr.

DATE )AY MONTH Jin

I PRIVATE I VEHICLE I I AMBULANCE

jaL_. YR, .BOTHER (Specify),

, ATIENT'S HOME ADDRESS OR DUTY STATION (City, State and ZIP Code)

----NA NA/f) I bliklA

IEF COMPLAINTS) (Include symptom (s). duration)

CATEGORY (See reverse)

EMERGENT

EMERGENCY CARE AND TREATMENT (Medical Record)

--- ARRIVAL TRANSPORTATION T

(Attach core enroute sheet)

VITAL SIGNS

TIME

SEX FA. —A In f-4eAL Ek-t4E-. fri INA DESCRIS 1) Sub' ctive data (Pertinent History); (2) Objective data (Examination - include results of tests and x-rays); (3) Assessment (Diagno- sis): ( ) Plan (Treatment/Procedures • include medication given and follow-up)

g 0 . 9- x, 1(i 64 .123,,..)E.o (frf Lill- SK LP Ci).--i CiAts-i - ---po -1-- -,-; 13_,

oLIS LA .L-5 —c,w__. (0 , J) [Ih I ___

AL

Ac,iy_r_y (sip:

CURRENT MEDS. (tetanus ~nun- HISTORY OBTAINED FROM ization and other data)

I 'PATIENT I OTHER (Specify) I -

!LOG NUMBER

TIMbSpEB: PROVIDER

ALLERGIES

NA HOME TELE. NO. (Inc. area code)

POSSIBLE THIRD-RARTY PAYER?

tf LL .

YES 1 NO

URGENT

NON•URGENT

ORDERS )NITS.

y il{ 44 L ;1(F

A4-E

4,

Pte. /9'L , T 1 7ao, P-1,1

S SESSME/. /DIAGNOSIS

irc kJ J ig /1/ kpmd

DISPOSITION (Check all that apply)

HOME

[FULL DUTY

QUARTERS

24 Hrs.

MODIFIED DUTY UNTIL: DAY

REFERRED TO (Indica e clinic)

EMERGENCY

72 HOURS

ADMIT. TO HOSP. UNIT/SERVICE

(CONDITION UPON RELEASE

DETERIORATED

d-a n-41 5 k-as 0 vey 07, k/ A /7‹,

gLo YZ y c MfA

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y-10 TIME

01 i5 /-0-

48 Hrs. [ 72 Hrs.

MONTH YEAR

TODAY

ROUTINE

IM PRO VE D [UNCHANGED

jafr16,,( 1-7

gM 01•

ME OF RELEASE: 4:0 14 . - ;TIENT'S IDENTIFICATION ei- echanical imprint) DR WRITTEN ENTRIES GIVE: Name - last, first, middle; ;N: DOB, service status, name and relation of sponsor or next . kin. (IMPORTANT: LIST FACILITY HOLDING TREAT-ENT RECORD).

507, IF NEEDED) SIG ID STAMP

a ions ordered, any limitations and follow-up

..

MEDCOM - 13906

DOD-027458

ACLU-RDI 1623 p.66

(n PATIENT AcISF - 1

TIME: C{ SIGNAL URS.

vyfir" - IF ' - ASSESSMENT

AND MUCOUS MEM :RTIME . L...) 1%...-.1 IN rt I V 1 -11.- .

SKIN AND MUCOUS MEMBRANES Si;ralr_cD3 Tight / Diaphoretic 1 Shiny / Dry Skin : Loose / Tight / Diaphoretic / Shiny / Dry

Skin : Temperature Skin : Temperature tarrnt_10401 Vit.) ..„ Color P ale I Cyanotic / Jaundiced 4 :., - 1 A Knot to R /1ill if

/ Cracked Color: Pale / Cyanotic / Jaundiced

Mucous Membranes: Moist / Dry / Cracked Mucous Membranes: oisDDry

Skin Breakdown: o22) Location: Size: NEUROLOGICAL

Skin Breakdown: None Location: Size:

NEUROLOGICAL Loc / lert Lethargic

--

SKIN

/ Unresponsive GCS: Pupils:1)612_1 3-i-

Loc [Alert / Lethargic / Unresponsive GCS:

Orientated / Disoriented Pupils: Extremity Movement: Full / Limited / None

Oriental I Disoriented

Extremity Movement: Full mite(t:eu/ None C.t.--5jAi -WO Opfr CARDIOVASCULAR . CARDIOVASCULAR Pulse ( 0 • 4): Radials-P -- - - Pedals+ Pulse ( 0 - 4): Radials Pedals Capillary Refill:q Seconds Homans sign - Capillary Refill: Seconds Homan's Sign Jugular Venous Distension Edema X Jugular Venous Distension Edema Heart Sounds lUtt(fArj...) .

Heart Sounds Rhythm KIATIA.G.' PRI: QRS: Rhythm ._

PRI: ORS: Vascular Catheter Central Arterial Peri.heral 1 Peripheral . 2

....

Vascular Catheter Central Arterial Peripheral 1 Peripheral 2 Wavetorms Waveforms Site J'Yti Site Solution 1)1Ajiak'h Solution Chest Pain

Christ Pain RESPIRATORY RESPIRATORY

Chest Expansion / S6Metricsil)/ Asymmetrical Chest Expansion / Symmetrical I - Asymmetrical Resonation /‘----D7s7its4 I SOB / Labored / Use of Access Muscles Respiration / No Distress /SOB / Labored I Qse of Access Muscles

Breathing Patterns: Breathing Patterns:LM(1_, O

Couch: Productive I Nonproductive i( 1\17

/ Odor . ( iii, %Ng Cough' Productive /Nonproductive / None Sputum: Color / Amount / Consistency / Odor

. hest Drainage System Gravity: Suction cm.

Sputum: Color / Amount I Consistency Chest Drainage System Gravity: 4-4" e-1-1.1 - Air Leak No Yes .- - Crepitus

._ Air Leak No Yes Crepitus Character of Drainage:

Character of Drainage: — Trachea / Midline / Deviated (R) I Deviated (L) Trachea I Midline / Deviated (R) / Deviated (L) Artificial Airway Size: Type: Position: Artificial Airway Size: Type: Position:

Breath Sounds .. Anterior/Location Posterior/Location Breath Sounds 'Anterior/Location ..4. Posterior/Location Crackles Vied' ihi tali ° lajAPia-41) Crackles

4 _.;

Wheezes Wheezes

Diminished Diminished

Absent Absent 't .; •

GASTROINTESTINAL / Hard / Distended CM Girth

GASTROINTESTINAL.- Abdomen( Sol)/ Firm

Abdomen: Soft / Firm / Hard / Distended cm birth Bowel Sounds: Norma)/ Hyperactive / Hypoactive / Absent Bowel Sounds: Normal / Hyperactive / Hypoactive / Absent Dressings 0 .

Suction/Dependent Drainage Dressings:

NG Tube: Clamped/inter. Suction/Cont. Suction/Dependent Drainage NG Tube: Clasped/Inter. Suction/Cont. NG Drainage: Color Character NG Drainage: Color Character Tube Feeding: Day No: Strength: Rate: Aspirate: Tube Feeding: Day No: Strength: Rate: Aspirate StooStool:Character P

Stool: Character Drains. -• - . Drains:

GENITOURINARY ._

GENITOURINARY Urine Color: K.) Character: Urine Color: Character Voicing. onti a t Incontinent / Catheter

EMOTIONAL/PSYCHOSDCIAL" Voiding: Continent / Incontinent / Catheter

EMOTIONAL/PSYCHOSOCIAL

OTHE R• o TkiPci• _

MEDCOM - 13907 Isswv,-4 DOD-027459

ACLU-RDI 1623 p.67

0

O w U

ACLU-RDI 1623 p.68

TIME: Z- SIGNAL

PATIENT AsSF - E \toto—') 1Ef 'ASSESSMENT

x SKIN AND MUCOUS ME B

744,-- iim: iLjNik I Ul-it: SKIN AND MUCOUS MEMBRANES Skin Loose / Tight / Diaphoretic I Shiny / r Skin : Loose / Tight / Diaphoretic / Shiny / er

Skin : Temperature i,/,..kl.--t A......._ Skin : Temperature /./...Ztrz.ws-- Color Pate / C anonc / Jaundiced - / •-- ec.,6j2....,

oist Dry 1-Cracked Color: Pale / Cyanotic / Jaundiced //fj4/74,0•J, "'T-1

Mucous Membranes: o sl Dry i Cracked Mucous Membranes

Skin Breakdown None Location: PC.:6 Size: Skin Breakdown: None Location:6 - ..„. 1 0 /4-.4..4 NEUROLO CAL

NEUROLOGICAL Loc / Lethar•ic I Unresponsive GCS: Loc Lethargic / Unresponsive GCS:

neprili/ Disoriented Pu•ils: • rientate• Disoriented upils: , kRe....4 Extremity Movement: Full Limited / one Extremity Movement:

Pulse ( 0 - 4):

Capillary Refill: "e_

Jugular Venous Distension Heart Sounds 5 1 Rhythm g Ot- Vascular Catheter

Site

Solution

Waveforms

dip i Limited

Radials

-3 Seconds

5 Z.

/ei?if-/.--...--P Can ral

ARDIOVASCULAR / None

--0

ref Edema

RI : Arterial

ItvaRZ C----01 0

Pedals

Homans Sign

FeleAVt

ORS:

Peripheral 1 Periphery l -

r .4 •

CARDIOV6SCUy1R Cl..-- - Pulse ( 0 - 4): Radials -i-(1-:,/-i-,3.4' Pedals ' •-f--•3 /-1- Capillary Refill: Seconds 4' 3 Homan's Sign

Jugular Venous Distension 0 Edema Faa,..00 Heart Sounds ..5/ 5-t Rnythm ),-).5k_ .3- g...z.4,-- PRI: ORS: Vascular Catheter Central Arterial Peripheral 1 Peripheral 2

• :;• Waveforms i: *l'' . Site 06riihel24.4,cow.

C.:4,-,62!-1 11C9 FA Solution i e Chest Pain

Chest Pain 4/2- T-5- kf RESPIRATORY

ri m,-

RESPIRATORY Chest Expansion / mnietrical Asymmetrical

Respiration / 0 •1 OB / Labored / Use of Access Muscles

Chest Expansion / ymr(5----T;TrinD. -.• Asymmetrical

/ Labored / Use2f Accen,Muscies Respiration / No Distress / SO:

Brea thin • P . : • L

• • 1 MEM onproductive

,.- (144aagy7 c?„..., Breathing Patterns: P 4-1-.,....,_ / None Cough: Productive /-Nonproductive / o

Sputum: Color / Amount / Consistency / Odort#627,LUZA, Sputum: Color / Amount / Consistency I Odor 7-,f,zii, 14' i C hest Drainage System Gravity: Suction cm: Chest Drainage System Gravity: Suction cm. Air Leak No Yes _...Crepitus Air Leak No Yes Crepitus C haracter of Drainage:

Character of Drainage: -- Trachea / Midline / Deviated (R) / Deviated (L)

Trachea / Midline / Deviated (R) / Deviated (L) Artificial Airway Size: - Type: Position: Artificial Airway Size: Type: Position:

Breath Sounds • Anterior/Location Posterior/Location Breath Sounds

Crackles ;Anterior/Location %.4„,•..

e.3-174- 5;2 ,kf Pot terior/Location

Crackles 6,2.4, g.. Wheezes d•..

- , ./....., Wheezes

Diminished e.11 „ t,agej Diminished 4-- 0 fti----/-4--1 Absent

Absent I 1

GASTROINTESTINAL GASTROINTESTINAL.' Abdomen:60/ Firm / Hard / Distended cm_girth Abdomen: .0 / Firli / Hard / Distended Binh : cm Bowel Sounds. Norm

...-----, yperactive / Hypoactive / Absent Bowel Sounds' Norma / Hypel ctive / Hypoactive / Absent

Dressings: 47> C.6 ir Dressings: G/&9 /. NG Tube: Clamped/Inter. Suction/Cont. Suction/Dependent Drainage NG Tube: Clamped/Inter. Suc ion/Cont. Suction/Dependent Drainage NG Drainage: Color Character NG Drainage: Color Character Tube Feeding: Day No: Strength: Rate: Aspirate: Tube Feeding) Day No: Strength: Rate: Aspirate Stool. Character

Stool: Character A.)()1M. ArAgE_TZ., ., __ Drains -- Drains: GENITOURINARY

GENITOURINARY ur Color.. 0240../L _goaaar.4,) Character: Incontinent / Catheter

Urine Color: - 01-, / //ict)Character: V0102.2.9. Continent / Voiding: :

MOTIONAL/eatCHO§OCIAL,. e-el-d-e,len,_u--rt

/ incontinent / Catheter

......s- .AA, .1,ri-p,.. /4"..4d i ll' _ I. s_. A i Or.. - L i - . .. •

EMOTIONAL/PSYCHOSOCIAL" j

0--a-11...e CO i . _ . 1... /... ..,-..

rvi- Li .4. OTHER

MEDCOM - 13909

DOD-027461

ACLU-RDI 1623 p.69

O

-J

0 I-

w 0

0 0.

ACLU-RDI 1623 p.70

l'ONOPAEUPtitATIVE/POSTOPEltr. LIVE NURSING DOCUMENT 7-tt.t

FOR Use of this form. see AR 40-407: the proponent agency is The Office of the Surgeon General. EDI AL,11 , e-OR

2. KNOWN ALLERGIC SENSITIVITIES (e.g.. Iodine, Tape, Medication) A 0 PCN 0 LATEX = IODINE 0 TAPE FOOD

ACTION:

3. PREVIOUS SURGERY [ NO

YES (type):

(.`J)

4. PROPOSED SURGICAL PROCEDURE:

I) 0 1;i /

1. AGE: 13

HEIGHT:

WEIGHTT)

5. ADDITIONAL INFORMATION: (Previous surgical and medical history) Skin Condition

Tobacco ppd X vrs. Body Piercing Diabetes (Y) (N) ROM ASA1Motrin w: 72 hrs (Y) (N)

ETOH Implants Respiratory Disease (Asthma:COPD) (Y) (N) Anticoagulants (Y) (N)

Glasses/Contact (Y) (N) Dentures Hypertension (Y) (N) Herbal Medicines (Y) (N) MEDS:

6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES S. OR NURSING INTERVENTIONS

A. PSYCHOSOCIAL o Pt. verbalizes any specific anxiety. c Allow pt. to verbalize freely.

X) Potential for anxiety related o Pt. Exhibits relaxed body posture. c Explain OR environment and answer

to: questions regarding surgery.

'X.) 1) Surgical Procedure 8 c Offer comfort measures. ie.e.. warm

Operatine Room Environment blanket. touch).

2) Separation Anxiety c Explain all nursing procedures before

(Child) they are done.

?CI 3) Surgical Outcomes a Remain with pt. whenever possible. c Maintain family interface. Parents to stay with pt.

B. AE TION )(-- Potential for respiratory

dysfunction due to: 1) Positioning `s.,(":2) Effects of Anesthesia 3) Medicanmokine History

o Pt. will be able to breathe without difficulty during immediate intraoperative

phase .

a Offer to elevate head of litter or offer pillow. a Observe pt. while awaiting surg.ery for sittris of distress. a Assist anesthesia during intubatior. and extubation.

c Utilize pressure preventing devices on OR table and accessories. c Check for proper positioning and support to maintain good body alignment. o Pad pressure points. o Place ESU ground pad on non compromised skin surface area. o Keep prep fluids from pooling.

9. PATIENT'S IDENTIFICATION: (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)

VERIFICATIONS AT HOLDING AREA: ! ID/Allerey Band ! Dentures Removed ! H & P ! Contacts Removed ! NPO Since ! Jewelry Removed ! UHCG/LMP ! Body Pierce Removed

! Consent/Blood Transfusion S i gne d/W i tnes sedD ate d ! Surgical Site!Consent verified by Pt./Anesthesia/Surgeon ! Contact Precautions (Y) (N) ! Family/Friend:

DA FORM 5179, JUN 91 Previous editions are obsolete. v; 9

MEDCOM - 13911

C. INTEGUMENT Potential impairment of skin

integrity due to: \)(-' I) Intraoperative Immobility

2) ESU Pad Placement 3) Positional Aids 4) Prosthesis ')0 5) Pooling of Prep Solutions

o Pt. will not exhibit siens of impairment of skin inteerity (e.g., reddened areas).

DOD-027463

ACLU-RDI 1623 p.71

. PATIENT GOALS AND EXPECTED OUTCOMES JR NURSING INTERVENTIONS o Check for support stockines or ace wraps. If none, check with doctors. o Check that safety straps are correctly applied. o Offer pillow for under knees. o Place and take down legs from stirrups with slow bilateral motion. o . Check that rings and all body niercing has been removed

o Pt. will exhibit signs of adequate tissue perfusion (e.g.. color, warmth, pedal pulse.

6. PATIENT PROBLEMS AND NEEDS CIRCULATION::?' : • Poteniiai: for inadequate tissue perfusion due to:

)(2) 1) Intraoperative Mobility • '')(3 2) Positioning

)0 3) Existing Disease sZ.7-t) Safety Devices \c") 5) Hypothermia

E. NEUROMUSCULAR CONTROL E.1. Potential impairment of mobility due to:

N7.)1) Pain 2) Intraoperative Hazards 3) Prosthesis

--off)

Positioning

y-J5) Transfer Pt. to/from OR table Potential discomfort due to: 1) Length of Surgery

<.%:72) Positioning , 1 ) Arthritis

-••• • --

o Pt. will be transferred to OR table without difficulty. o Pt. will not experience unnecessary physical discomfort.

o Have sufficient people available for transfer. o Insure proper body alignment. o Allow patient to lie in position of comfort while waiting for surgery. o Offer support (i.e.. pillows. bath towels. etc.) for positioning.

F. SPECIAL SENSES F.I. \.%). Duninished visual perception due;TerlIg.: 1) Pre-Medicated 2) \V 0 Glasses F.2. Potential for decreased cornr...unication due to: 1) Dirnir.isheci Hearin::

Language Barrier F.3. Potential injury due to dentures: I) Upper 2) Lower

3) Bridges

o Pt. will be made aware of sun.oundings prior to anesthesia induction. c Pt. will be transferred safely to OR table. c Pt. will be able to understand instructions.

Minimize danger of injury during intraop period.

c Introduce self. Keep pt. informed as.to where he. she is and what is happening. c Inform pt. in which direction to move and assist if necessary.

Speak clearly and slowly. • Address pt. from side. o Validate pt.'s understandin• of verbal communication. c Verify removal of dentures.

4) Cans 5) Crowns

G OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above mals and outcomes.

OTHER NURSING INTERVENTIONS Or continuation of above interventions

10.OR NURSING INTERVENTIONS COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTION S NOTED.

DATE

11. POSTOPERATIVE EVALUATION: SK INTEGRITY: Bovie Pad Site: :,,it(a&-and_Dry

LEVEL OF CONSCIOUSNESS: ❑ A&O Drowsy = Sleepy ❑ Intubated _ LEVEL OF ACTIVITY: 941:eraes-All Extremities _.: Moves Upper Extremities

❑ Transferred to liner with roller due to soinal 13. POSTOPERATIVE BY (Signature and Title)

DATE: G> j5 TIME:

MEDCOM - 13912 usAPA VIA)

Red 0 N/A D FCSNG DRY & INTACT:

(Y )

12. PREOPERATIVE , PREPARED BY (Signature and Title)

DATE: OC-j TIME: Vo

THING EASY:

REVERSE OF FORM 5179, JIM 91

DOD-027464 ACLU-RDI 1623 p.72

INTRAOPERATM7 DOCUMENT use of ttili-ornf---R-413=6"6, the proponent agency . iiThtfice orThe Surgeon General.

ne2%:../E JR- 8PCOTEMCrOPERAT WG- R001c4

AllA:f.-' 1- e lAt . .&.. P ,B Zi t-

2. PATIENT IDENTIFIED, RECORD REVIEW a 1 ► a . : • DURE VERIFIED BY ,P---- 6 ).-

3. DATE TIM PATIENT A RIVED IN SUITE

)03 a "10- 5 4. PATIENT IN ROOM

TIME 67(767

NUMBER

5. PREOPERATIVE EMOTIONAL STATUS

❑ CALM ❑ ANXIOUS • EXCITED • CRYING • ANGRY • WITHDRAWN • OTHER (Specify) ---„,

COMMENTS: 0 1 cf.! ref . ,-,

i — - 6. NURSING PERSONNEL

ASSIGNED SCRUB S (P---.

RELIEF \,.,(0 ..., ,;,..

r...° 44 SCRUB

ASSIGNED CIRCULATOR

C (---.)--1

RELIEF CIRCULATOR

-. _ ..

„,..

7. POSITION AND POSITIONAL AIDS (Specify)

SUPINE ❑ LITHOTOMY ❑ PRONE II KRASKE LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP

( ----C- - -- , COMMENTS: . '.-1A/S ( 4, k: ----2:(,-,7 C74,-.4 cif, /I--fr-e' 6. C ocS- c...e; icc 74

8. SKIN PREPARATION

HAIR REMOVAL r---1 YES

DONE BY: ❑ OR ❑ NURSING UNIT

METHOD: ❑ DEPILATORY ❑ RAZOR

❑ CLIP

COMMENTS:

PREP SOLUTION (Specify)

SITE: 74 —WHOM:

SITE: BY WHOM:

COMMENTS: f---..------ -

9. LOCATION OF EXTERNAL DEVICES

7 6-.. /---(4-`"---,.,

■

- I 1 . ■ at ..

- - . x , 1P-IPP--

re/ C, 1-,611

LEGEND X Ground Pad -- Safety Strap = = = Tourniquet

10. COUNTS

C = Correct I = Incorrect

Other•• First nIC,irg._, _ - Fcionuanl tClosing_ ______ SC RUT )kZ, ),--

6 I ) - CULATOR o — Sponge , g'Yes ❑ No -- <- / 2--

Needle Sharp ; ayes • No

Instrument • Yes ❑ No IWAIIII

Other • Yes • No

11. PATIENT IDENTIFICATION (For typed or written envies give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

Q ., t,,„,.. ti

12. ELECTROSURGERY DEVICE(S) (ESUI r..0., „̀(ES ❑ NO

1 2_iii-,ESU NO: C " ------1_6 - - — ..... ....- GROUND PAD: BRAND '

LOT NO:z f e

Lz:' .., 111_,ESUNO:;'', ` . -' ' ,`..2;_:::::Q , _

-iiitiarapai3 7 -"qrtISri.: ,777, -71RMR, MEDCOM - 13913

rryr.C.In D vcrrtr REF. RANGE

DOD-027465 ACLU-RDI 1623 p.73

15. X-RAY IN OPERATIN R M

YES 0 NO

SSING/IMMOBILIZATION (Specify)

mid

;

—

rY1-

20. OPERATIONIS) PERFORMED C:C4-

C9, 10 SS orean-

ta-9 0 3-- C,

REVERSE OF DA FORM 5179-1, OCT

19. ADDITIONAL INFORMATION

os pnau.vratudNi HUIHM 1:10.4 S3SOdBfld 1VdIONIEld

L.6£6 epi eit!In3ex3 pus epoo seMS Pellun 91M ,O9 PUB 1.£09 'Le• I. L01, SUOIPaS

NSW 831314111N Alitinoas 1VIOOS ONIGMONI NOLLVV41:10aNI AO NO11031100 80A AiwoHinv *1 noA as. ONINIVIII3d NOIlVWl1OdNI 38V0 H171/311 3sn 'JO 3SV373e1 01 IN3SNO0 V ION SI WI:I0d

,$(31:10030_31:1V-a-141-1-V3a-- IN B W31b1S-13-V AOVAIEld

MEDCOM - 13914

DOD-027466

ACLU-RDI 1623 p.74

•■•■•=.

• Fig

I - . . :.-.::... :;... .„ y,o, .-,;0 W OA' E $FIWIT-ElleTOPERATING

44-' .:.

. ,..11 ̀̀ . :' " - -, . ! . For use of this form,

- e e , •

IBJ

• INTRAOPERA. DOCUMENT see AR 40-68, the proponent agency is the office of The Surgeon General.

2. PATIENT IDENTIFIED, RECORD REVIEWED AND PROCEDURE

VERIFIED BY 1.---77 C-1:3-̀ ; "".---

‘3:' DATE , . TIME PTNT ARRIVED IN UITE

I J- ul 03 —;:o 4. PATIENT IN ROOM

TIME C5& (: , NUMBER


❑ CALM YekNXIOUS • EXCITED • CRYING • ANGRY • WITHDRAWN • OTHER (Specify) /

COMMENTS:

6. NURSING PERSONNEL

ASSIGNED

SCRUB C RELIEF

SCRUB

c' OM \i3 6 ASSIGNED CIRCULATOR

t__'r C

RELIEF CIRCULATOR

I 0 70e, -- ' 'VC;

7. P9SITION AND FrITAONAL fv

re9if

t.97-,■-, 1,- 6-1 1. • c..513• p„-.1. -T-i., -1-1,,rik• 0 i

,r;b 'UPINE LITHOTOMY ■

COMMENTS:

fi

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

8. SKIN PREPARATION

HAIR REMOVAL • YES ̂NO

DONE BY: ❑ OR • NURSING UNIT

METHOD: U DEPILATORY U RAZOR

• CLIP

COMMENTS:

PREP SOLUTION (Specify) geiTki ()wt. )1,-- .,..., „ ., SITE: ap' ID, BY WHOM: 6-1111.1 h (go ,,i SITE: FT„,......) 0!1b-ots Qt, BY WHOM: Lr

COMMENTS:

9. LOCATION OF EXTERNAL DEVICES

• — ■ t • :Ili' —

_

—... VIIIIK/PP—


,,, ‘ 6

10. COUNTS

C = Correct I = Incorrect ...,°--- \

Other•' - First Closing Count

Final Closing Count SCRUB CIRCULATO \

Sponge Dg Yes ❑ No

Needle Sharp El) Yes • No

Instrument Yes >No

Other • Yes p)No

0--- -

11. PATIENT IDENTIFICATION Name - Last, first, middle;

(For typed or written entries give: Grade; Date; Hospital or Medical Facility;)

12. ELECTROSURGERY DEVICEIS) IESU) MES U NO ..),

-"'/3.1.)

*-FIOESU NO: 9.)01 "t j 6 GROUND PAD

BRAND \AI

mpncom - 11915

LOT NO: 617 b

• ESU NO:

GROUND PAD: BRAND

LOT NO:

❑ BIPOLAR NO:

USAPA V1.01 DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179.1 (TEST). DEC 82, WHICH IS OBSOLETE.

DOD-027467 ACLU-RDI 1623 p.75

13. PROSTHESIS. IMPLANTS ❑ YES ❑ NO IF YES NAME: ID NUMBER; MANUFACTURER

14. - ----t W.,14-04:9-':‘41000A MEDICATIONS/ORDERSWWWWri"iV oi•--,•',:- • --,, ::4;..,, ;':- *,::

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO U

MEDICATIONS. SOLUTION DOSAGE TIME METHOD PREPA D BY GIVEN BY

1 (16i-444A i. Ef All 11) &jv C C., ___.3 SNIT, 60 .`f '-g") 1111.

a- il

01A-a,

WOUND IRRIGATION tzli., YES • NO, TYPE(S): GI' gi b', i E .

OTHER ORDERS TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE

- - - - 15. X-RAY IN OPERATING ROOM IF YES, SITE

YES L NO

16. LABORATORY LABORATORY SPECIMENS

SPECIMEN (SI

YES ❑ NO Y,

NAME NAME

FROZEN SECTION (FS)

YES ❑ NO gl

NAME NAME

CULTURE (C)

YES ❑ NO j

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

Flures ACe

Key 1 (-1--

17. TUBES, DRAINS/PACKING YES M NO

TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3.

19. ADDITIONAL INFO M N .„.,_._

civ i lo-). 1 _ ort.„,,,".„-•

pv23-tiots, - 11111 •

----irt400-. PisLie- lil G) Ciegi U0 DCI

0(1 20. OPERATION(S) PERM MED

c 1) Y lb

21. PATIENT TRANSFE ----r .....- TIME x METHOD LA . ...., ,. .1. ......, $•,..

....,,,„ 7.. ,,....1.„

22. TUR ki , , , ' . 1704''' " ::,/ 'i' : l'`', .1.- - 7 77 7.1,77-7 ":7" Cz%' .• :ii.t.74,3ia.3 ...,' J: - - '1' -._.::_- .„ _. - , - . :a., : .4

REV 87 r.

MEDCOM - 13916

W i USA POI .01 .!

•:","

DOD-027468

ACLU-RDI 1623 p.76

C = Correct I = Incorrect

Other" First Closing Count

Final Closing Count SCRUB CIRCULATOR

r

...••••• • ENT 17: "

1-balitkerria4r1=L4-1r, ''''''''' ' ............ _....

s • , ' ■ gtx. • 401,,...:f,..ii::- .00:;'1:y.," ..':: : Fortile of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.

MP 1:10.01TEWO.'CIPERATING1100M, I .

W LAO 44 41.AC7

2. PATIENT IDENTIFIED, RECORD ED//AND PROCEDURE

VERIFIED BY la

.3: ' DATE. - z . TIME PATIENT ARRIVE!? IN SUITE

if 0 3 07 3 r(

4. PATIENT IN ROOM ‘------,

,,..,, „,.,,,, TIME 0 7 3-- i. ,-,, NU BER /- 2- ,-ifill


• CALM 0..-ANXIOUS U EXCITED ❑ CRYING ❑ ANGRY ❑ WITHDRAWN U OTHER (Specify)

COMMENTS:

6. NURSING PERSONNEL

ASSIGNED SCRUB

,==V1111119 04 .9 RELIEF SCRUB

ASSIGNED CIRCULATOR

.o. --d---i--- RELIEF CIRCULATOR

7. POSITION AND F;951 y

ND

is: UPINE

COMMENTS:

IONAL AI VS (Specify) I) - itjlk i rr "---63 _./ 0 Ne„-- -e ail ym c 7/( yiv a,cv a ce_etui-e ---:-,___- 1 a 0/.14- zi -7_,.°A 4,,*a c-i--(ier

/ LITHOTOMY Li PRONE '-' 1111 K ASKS L- RAL: L. j LEFT IDE UP II RIGHT SIDE UP

8. SKIN PREPARATION

HAIR REMOVAL ❑ YES NO

DONE BY: I/ OR III NURSING UNIT

METHOD: ❑ DEPILATORY ill RAZOR

❑ CLIP

COMMENTS:

PREP SOLUTION (Specify) AWlie-7‘;54-

SITE: Y WHOM: Aim -")..

SITE: BY WHOM:

COMMENTS: r fidr,,ez. t•-• V Cfa l Le 74.1 A Of4'49

9. LOCATION OF EXTERNAL DEVICES R.GLI--° i. ct'Ad c, 1,04,

,9old - — At. .... -- ..

- , t . __. - •• k

IP' _- . Tilirag•-


10. COUNTS

Sponge

Needle Sharp

Instrument

DA FORM 5179-1, OCT 87

Other ❑ No 12. ELECTROSURGERY DEVICE(S) (ESU) 12F..YES ❑ 0.3.e.

40 ESU NO: 74 q GROUND PAD: BRAND 7;;La0..70' 7_s_zi

❑ ESU NO:

LOT NO:

GROUND PAD: BRAND

LOT NO:

❑ BIPOLAR NO:

MEDCOM 13917 REPLACES UM rursm o •VHICH IS OBSOLETE.

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

USAPA V1.01

DOD-027469

ACLU-RDI 1623 p.77

.rinVgiqiUSAY1;01::: •

13. PROSTHESIS, IMPLANTS ❑ YES p0 IF YES NAME: ID NUMBER; MANUFACTURER

14. -_:',..K1*-4:Ni# :Af .1§0,1M°' MEDICATIONS/ORDERS AgatWifOrgig4.0,„ ,--, & ,-4-i-: -' -1;?-§'" '‘-'-'-'.,.

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO -0-

MEDICATIONS SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

I. G

WOUND IRRIGATION 91 YES II NO, TYPE(S):

0 - 91 ANC,

OTHER ORDERS TIME CARRIED OUT BY f.

;

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE

YES ❑ NO

16. LABORATORY SPECIMENS

SPECIMEN (S)

YES ❑ NO ...Z:

NAME NAME

FROZEN SECTION (FS)

YES • NO 0

NAME NAME

CULTURE (C)

YES ❑ NO

NAME NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

ntANTS

.\-erit..,/.

ke- 17. TUBES, DRAINS/PACKING YES 4 NO ❑

TYPE/SIZE 1. -5° )0 rrlr) 2. 3.

SITE 'LEV fru it. 2. 3.

19. ADDITIONAL INFORMATION

CA VS6 ,../

. -- k"-fi IV\ CAag L 20. OPERATION(S) PERFORMED

21. PATIENT TRANSFERRED TO

\CU- t,4,9../... 22. REGISTER S

TIME 7 0

.;-, , •:.

gt::;:iiaU

METHOD -- ;A-- • • t7.--?4 ,1

::.;*(3- ,..1:-. ., -.:,'„vr.„,.

...I A:4 . • - . ' - -- ;rt.- 7-'7-- 7 74,V-;:-.,..rav '' , --.,4,., ,:. , 4. ar:. ,,,

REVERSE OF MNIRE77791 1,0 "--w Gam: L;Aitai

MEDCOM - 13918

DOD-027470 ACLU-RDI 1623 p.78

Warcneclion: CJ , ) GO I IINLI rri I 011-lri IN . ky—, . 1 V IN. 1 ILN. IL.) l. , L, IL I kJ MiVa

,1 to the Privacy Act of 1974) 1

LAST, FIRST, MI. rffNiPSEUDO SSN: tY

iiiitii - --;' ;ki k, ''''V ' .101 - Ate . ; kt";'̀ 6-:'' glatii. v 0 ' .; U:. , , i: : el'.. .. Serology

TEST RESULT . . RANGE TEST RESULT R RANGE TEST RESULT REE RANGE

WBC 4.8-10.8 x 10' Color N/Acy , , ---- RPR Negative

RBC "3-

4.7 -6.1 x 109 App NW Mono Negative

Hgb Ci j 14-18 Wdl (M) 12-16 e/d1(F)

Glu Negative A"'

Cilibiiiliti

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

Bili Negative Source

MCV CIO ,/

80-94 ft (M) 81-99 11(F)

130-500 x 103

Ket

SG verified

Negative

N/A Stain

Grim

Occ Bld Pit' 1-1

Negative

Lymph ''..i, v I -3,9 20.5-51.1% Bid Negative H. pylori ' Negative

V: ' '' :'-i 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 CrOSC.001 V.ripti S ' '41. - e--..i-n-

RBC Morph

HCG Negative

Hcmatocrit „

Sed Rate Cell Count

' MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative ABO/Rh

"-‘

TEST'

04. '4:4 % , , . ' ' : . -' ee,. „. - • A • --.4.,,m-p„,„..g. RESULT REF. RANGE

',',14,-4•:' '4'4 %,-,....: 1-02, .. 44,1„--,),,,.,—

UNIT

. 1 `..., ,. ,.. ;:0 -0101!).1q,.,,,i,,,,s,,,-,

,. ,

TYPE

,,,,F.: ,,, ,,,-4, i •

: , t „,,:e :tim .,

CROSSMATCH

PT 9.8-13.6 secs

APTT 21-34 sees

D dimer <20 tig/m1

FDP ,:t 0 ug/ml

REMARKS:

REPORTED BY: DATE. LAB ID NO.:

MEDCOM - 13919

DOD-027471 ACLU-RDI 1623 p.79

T ..

s(ts--,A,-

MEDCOM - 13920

: 1 AlISTRY RESULT FOR Suliect to the Privac Act of 1974)

SSMSEUDO SSN:

rd/Section:( Cu 3

ST, FIRST, MI.

EST -1.17..rtzgz ' REF. RANG

73-118 mg/d1

7-22. mg/d1

128-145 mmol/1

98-108 mmo1/1

18-33 inmo1/1

REF RANG

3.3-5.5 g/dI

26-84 u/1

7

02

03

.sap

Rff. RANG

128-J45 nunoUl

.r

g of Ise

DOD-027472 ACLU-RDI 1623 p.80

Ward/Section: ic,03 -

. \e, 6 — L, k IRY RESULT FORM LAST. FIRST. MI. DATE T6413 (s,..,..,:t

0 to tlie Privacy Act of 1974) I

SSNIPSEUDO SSN:

TEST ;

016WT . 4I , . . 011gYt A'- Exk-ag'",-'' . ...;„,„;:•:•;:i5,^ • .4- 1 . AP iJIJH REF. RANGE

- .: TEST

t ,. N- ,_ A RESULT

, Aq1P1J"104'54VORK44

REF. :‘" A, ViR4100'-

RANGE .-4Nfh•7t41q4

TEST

'1,13se:4306do'-' .:Q,..=1Q::::.i'::' -,. .::':.46'z.

RESULT - 'i.

REF. RANGE WBC

RBC

___________ 4."-1 118

x 10 Color N/A RPR Negative

2M 4.7-6.1 x 109 App N/A Mono Negative

Hgb ; 1 14-18 g/d1(M)

12-16 /d1 F) Glu Negative

4g;,' ' ''''" 1004161,0*k

Hct , 2_ 7- 4--

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

Bili ,.A:-,;(!•;: ,1-: - ':,.-i;:-,:;:;,?, ; ,;.,;,,

Negative Source MCV q t i 80-94 II (M) g 1-99 11(F)

Ket Negative Gram Stain Pit

g 1 verified 130-500 x 1 03 SG N/A 0cc Hid Negative

".4 Lymph ...------- 20.5-51.1% Bid Negative H. pylon Negative pH

Prot

' -:::::,--,:: P•.:.e1:;•tAN . '. • '.0. -''r , ,;. .• 1,, ''

N/A Micro Parasites Segs Mono Negative Malaria

Bands Eos Urob 0.2 - 1.0


Atyp lmm Leuk Negative . --

RBC Morph

HCG Negative

Spun Hematocrit

42-52% (M) 9 ' A.:1--Z• .•:k.4- trt- ,_ k. )i-, —

,,,,,,,,,,,• Sed Rate Cell Count

N.,

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative ABO/Rh I

. - ' . 130?-r`t, . .a0.0..7,,i .40-eeeNSt'{; * vatagetktk47:4*.z.; CROSSMATCH

;: . !: .,,tt,.,

.. 1-

TEST

4 ,,,, w • tirii - LNIt• 4"-4._;t-g„,

RESULT

4- -A ' '.' :I i, '1 r, {.,3

REF. RANGE

-J`,1■1,5 - guAigi 0_1:. tiIU !..47.,?.. , ..w,,, ,,,I.... 7.,, ,, ,, i,,, r 4TE14V '"Vaa)-

UNIT

F51 V

. CO ■ ,-,;- a 1- ,. . 6

TYPE

: ' ' . -'. r^ .- , .. a . ' 1 -

PT 9.8-13.6 sees

APTT 21 -34 sees

D dimer <20 ug/m1

FDP :JO tig/m1

REMARKS:

REPORTED BY: AC DATE:- 4.01"t3

ID NO.:

\

MEDCOM - 13921

ACLU-RDI 1623 p.81

MOW 0 CODM I 0 230

(i-STAT) ieCoIo) CheiniS - 12 - ' iceoloYMetabolit.Tane .. TEST RESULT REF. RANGE TEST RESULT REF.

RANGE TEST

- RESULT REF. RANGE

Na 138-146 mmoUL ALB 3.5-5.5 g/d1 GLU 73-118 mg/di K

( 3.5-4.9 mmol/L ALP 26-84 till BUN 7-22 mg/di

CI 98-109 mmol/L ALT 10-47 u/1 CA++ 8.0-10.3 mg/di ko pH ,79 r3 7.31-7.45 AMY 14-97 u/I CRE 0.6-1.2 mg/di

PCO2 3 2._ ca 43 15_4515 mmHg fv(earlo ) AST 11-38 till NA' 128-145 mmoUl P02 / 27 N8o/A-1005emomHg (art) TBIL 0.2-1.6 mg/di IC- 3.34 .7 mmoUl TCO2 2c-- 2243:2279 mrtunmoorLa, (

(avert)) BuN 7-22 mg/di CL" 98-108 mmo1/1

HCO3 2-44 22-26 mmol/L (art) 23-28 mmol/L (yen)

CA++ 8.0-10.3mg/d1 tC 02 18-33 mmol/1 s02 ci41 95-98% CHOL 100-200 mg/di 1C0)110:tifirt: ilit flit BEecf

( (-2)— (+3) mmol/Lmmol/L

CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE AnGap 10-20 mmol/L GLU 73 - 118 mg/dl ALB 3.3 -5.5 g/dI Ca 1.12 - 1.32 mmoUL TP 6.4-8.1 g/d1 ALP 26-84 u/1 BUN 8-26 mg/di iee040A ' S ALT 10-47 IA

GLU

Creat

70-105 mg/d1

0.7-1.5 mg/dl


AMY

AST

14-97 till

11-38 u/1 GLU 73-118 mg/di

Het 38-51% PCV BUN 7-22 mg/di TBIL 0.2-1.6 mg/c11 Hgb 12-17 g/dI CRE

CK 0.6-1.2 mg/dl

39-380 u/I (M) 30-190 u/I (F)

GGT

TP 5-65 u/I

6.4-8.1 g/d1 -- Chemistry

. ' TEST

Troponin-I

RESULT REF. RANGE NA+

+

128-145 mmo1/1 WC* 0i0115

3-347 111m01/1 TEST RESULT REF. RANGE Drug of Abuse

CI: 98-108 mmol/I + 128-145 mmol/1

tC 02 18-33 mmol/1 +

CL

tCO2

3.3-4.7 mmol/1

98-108 mmoUl

18-33 mmoUl

REMARKS:

REPORTED BY: DATE: LAB 1D NO.:

MEDCOM - 13922

DOD-027474 ACLU-RDI 1623 p.82

yilsyrty..4EsuLT FORM Sub'ectio the PriIi6c Act of 1974

,SN/PSEUDO SSN:

MEDCOM - 13923

DOD-027475 ACLU-RDI 1623 p.83

mAsTRy R...gstJA,T FORM Sub'ecftO the Privac Act of 1974

SW/PSEUDO SSN:

98-108 minolli

18-33 mmol/1

REF. RANGE

ARKS:

MEDCOM - 13924

DOD-027476

ACLU-RDI 1623 p.84

Ward/Section:

ICU REQUES N:

61.9--- LABORATORY RESULT FORM (Subject to the Privacy Act LAST, FIRST, MI.

l',Y111 DATE

1071.4L TIME

ai d of 1974)

SSN/PSEUDO SSN:

HeniaiolcigY.)'CBC :' Urinalysis `Miic. Serology ..,..: TEST

WBC

RBC

RESULT

II . 6 REF. RANGE

4.8-10.8x 10'

TEST

Color

RESULT REF. RANGE TEST RESULT REF RANGE N/A RPR Negative 2,6 4.7-6.1 x 10'' App N/A Mono Negative

Hob /.1 11 24:11 68 ://dd: ('M) Glu Negative . Microbiology

Hct e, 7,G

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

Bili Negative Source MCV a

''., 1 80-94 t1 (M) 81-9911 (F)

Ket Negative Gram Stain Plt

i I 0 N1.3eOri-fi5Nedx IO SG N/A Occ Bld Negative

Lymph % s ; Li 20.5-51.1% Bld Negative H. pylori Negative '(Hematology) Manual Differential pH N/A

Negative

Micro Parasites

Malaria Segs

Bands

Mono Prot

Eos Urob 0.2-1.0 0 & P Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative Microscopic Ul-inalsiS' ..- . . .

RBC Morph

HCG Negative

Spun Hematocrit Sed Rate

42-52% (M) 37-47,'0(F) . • . CSF ' , nd Bank

. , - Bla

Cell Count MUST SUBMIT SF 518 WITH

EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh

'COntillation Stndis" Blood BankUnit Crossmatch - 61,0ST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD

REQUESTED) TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH PT 9.8-13.6 sees

APTT

D dimer

21-34 sees

FDP

<20 ug/ml

<10 ug/m1

REMARKS: F i

MEDCOM - 13925

ACLU-RDI 1623 p.85

Ward/Section:

LAST, FIRS , MI.

REQ SICIAN: LABORATORY RESULT FORM I

(Subject to the Privacy Act of 1974) TIME SSN/PSEUDO SSN: 40 ,-.? 3 c)

DATE

TEST 4.8-10.8 x 10'

4.7-6.1 x 109

RESULT REF. RANGE TEST

N/A RPR

Misc. Serology

RESULT

Negative

thinalysts

Color REF. RANGE

Segs

Bands

Lymph

Atyp

RBC Morph

Lymph % t _61 20.5-51.1%

Pit

MCV

(ileinatologY) Manual Differential

as _ o

b i o 1 9 3 •

Imm

Mono

14-18 e/d1(M) 12-16 g/d1 (F) 42-52% (M) 37-47% (F)

HCG

Nit

Leuk

Urob

Prot

Bld

PH

SG

Ket

Negative Negative

Negative Source

Negative

N/A Occ Bld

Negative H. pylori NIA Micro

Parasites Negative Malaria

0.2-1.0 0 & P

Negative

Negative

Negative

Eos

Baso

80-94 fl (M) 81-99 (1(F)

130 -500 a 103 verified

Gram Stain

Other

Negative

Negative

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

Spun Hematocrit

Sed Rate

Other

Coagulation Studies'

TEST RESULT REF. RANGE TYPE CROSSMATCH PT ------ 9.8- 13.6 sees

APTT 21-34 secs

<20 ug/mI

<10 ug/m1 •

REMARKS:

MEDCOM - 13926

D dimer

FDP

ACLU-RDI 1623 p.86

3.3-4.7nuno1/1

98-108 mmolll

18-33 mmol/1 REMARKS:

MISTRY RIESULT FORM StiFectiO the-Priiiac .Act of 1974

8,5N/pWLIDO SSN:

73-118 mg/d1

7-22 mg/dl

1211111111111

11 PICCOLO ==:"': 11/07/03 03:38

REVERENCE RANGE: MALE C PATIENT #: 111111 61.0..q METLYTE 8 DISC LOT #: 311AA4 ( OPER #: 678 DR #: 000

( SERIAL #: 0000100697 ............. ............ GLU . 104 73-118 MG/DL BUN 10 7-22 MG/DL CRE 0.7 0.6-1.2 MG/DL

MY CK 140 39-380 U/L NA+ 129 128-145 MMOVL K4 3.7 3.3-4.7 MOW CL- 99 98-108 MMOft tCO2 26 18-33 MMOVL

INST QC: OK CHEM QC: OK HEM 0 , LIP 0 , ICF 0

pH PCO2 P02 TCO2 HCO3

35-45 mmHg (art) - 4] -51 van)

80-105 mmHg (art) N/A yen 23-27 =non (all) 24-29 mmon ven 22-26 mmol/L (art) 23-28 mmol/L yen

(-2) — (+3) mmol/L 10-20 mmol/L

1.12-1.32 mmol/L

8-26 mg/di

Creat

Troponin -1

Drug of Abuse

95-98% C )2

L.,P

LT

EST RESULT -

A3

3GT

[P

8.0t10.3 mg/d1

0.6-12 mg/di

128-145 mmol/l

3.3-4.7 mmo1/1

11-38 u/1

14 Q7 u/1

0.2-1.6 mg/d1

5-65 u/1

6.4-8.1 g/dl

1

MEDCOM - 13927

98-108 mmol/1

0.7-1.5 mg/dl _

38-51% PCV

12-17 gkil

DOD-027479 ACLU-RDI 1623 p.87

DATE TIME

0330

M ono

ORP

Other

TEST

WBC

RBC

Hgb

Het

Segs

Bands

Lymph

Atyp

RBC Morph

----- Spun Hematocrit

Sed Rate

Other

4.8-10.8 x 10 .

4.7-6.1 x I()

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

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

80-94 (1 (M) 81-99 11(F)

130-500 x verified

20.5-51.1%

1mm

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

Bili

Ket

Color

App

Glu

Negative

N/A '

Negative

REF. RANGE

Negative

Nega tive

0.2-1.0

Directigen

Cell Count

ABO/Rh

MUST SUBMIT SF 5(8 WITH EVERY UNIT REQUESTED

TEST L OD

RESULT

Negative

Legative

CROSSMATCH

FDP -

REMARKS:

REPORTED BY: AB ID NO.:

W'ard/Section: •

ICO3 LAST, FIRST, MI. RY RESULT FORN1

to the Privac y Astor 1974) SSN/PSEUDO SSN:

Source

Negative

IAN:

Gram Stain Occ BId

H. pylori

Micro Parasites Malaria

MEDCOM - 13928

DOD-027480 ACLU-RDI 1623 p.88

03 eAt

ILTS(JLT

.:+e=4:;-;!.-.:4 N„ ■ ,— f.•-•-, ,•e:,4,-.:4110.!....,:-F ,.- ." 7.4'''''''' '''4C.. RES UL7'

_ I AFT I. NIA

1.1-18 g/di (NI) 1 Gk.). 1 Negative 12-16 e/di r1:) i , ., 1,_________ -1_-:)...% N

(11 Piii I Neg 111 1\v . ! 37-47% th _

— ; i I

, ! N0-' 4 -1110,1)

, ,,, Ill) , , -

____ . i verified

20.5-51.1% _

Mono

! I Base r • - . f

; 1 . i 1--- : ,,,,,,, ,

. i ,..,.- -1--- 11ICG

•

I

REF.

Negative

!egative--

NGE BrUmalpo

Ylnph

10 - PV • • • .

Source

Gram Stain

si,r4Q,Sh;' MUST SUBMIT SF 518 WIT1 EVERY UNIT REQUESTED

RESUL'

0 .8-116 sees

• • • scis

1 dirnt_.r ! • 0 ug•;n1!

ug ntl 1

IMARKS:

l'e'RTED BY:

CROSSAIAI'lW

MEDCOM - 13929

DOD-027481 ACLU-RDI 1623 p.89

DOD-027482

T • T T .1,-.

_ • i I P fl l Leuk

:

CROSSMA lz•71!

RESTA 7'

0.8-13.6 secs

diritcr K201.12:011

iiES 1_ 11' REF_ RANGE

. .8 x

.7 x 10

H-18 gAlikM) '-10

0.1 ,

t-T) 110: )

30_.sou

verified

20.5-5

e,q Mono

Eos

---i -

Bast

MI.

N:A

Glu I Negative

-1,1 •j2gnii% c 11

Nc2:inve

Sc

Negati.-■.e.

NIA

Negative

0.2-1.0

NIA

Prot

Urob

Nit

REF. ILL

Ne..,2,alive

egalive

r l ti t•.

—1

1 " 4I Alb ..,,‘,.: 4t re....v. i fi

g tripci « 4 0 s' p-At. ,LA , A.. :;:,-,4,.g:Z .,,?;;Wii..S.:1A--- it „F4.; :Y-. .i,:;,,,.,V,..11

RESULT Colnr NM

Negative

2-52k'b ;7-47"6 I

MUST SUBMIT SF 518 •M EVERY UNIT REQUESTED

MEDCOM - 13930

Source

Gram Stain

10 u g . 01 1

14■ I A_RKS:

ACLU-RDI 1623 p.90

TEST

O&P

Other Negative

WardlSecii01:

Ctr3

LAST. Fl —

Misc.. Serology REF. RANGE

Color 4.8-10.8 x 10

4.7-6.1 x 10 Mono

14-18 g/dl (M) 12-16 /di (F)

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

R FE. RA N

Negative

. _ •Neg,tt tt ve

Negative

80-94 0 (M) 81-99 tl (F)

I 3u-500 x verified

20.5-51.1%

Negativ'e

Negative

NIA

Lymph

SG

Bld

pH

Negative

NIA

Segs

Bands Eos

Lymph Baso

Mono

Gram Slain

-

Occ Bld Negailve

H. pvlori I t\:,:e.iiive

Micro Parasites Malaria Prot

Urob 0.2-1.0

APIT 21-34 secs

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

• Crossmatch - ,

TYI F cw(),csil.4 UNIT 9.8-13.6 sees

/1••S7' RESULT

PT

b

RESULT

Negative

Negative

Negative


Negative ABO/Rh

Cell Count

Other Directigen

Atyp

R13C Morph

Spun Bcmatocru

Sed Rate

42-52% (M)

37-47% (F)

1 mm

LAB .ORY RESULT FORM (Sublet..i to the Priv;i Act ,of 1974) FrTiTE-

WBC

RBC

Hih

MCV

MEDCOM - 13931

DOD-027483

ACLU-RDI 1623 p.91

MEDCOM - 13932

Urob

Leuk

Mono

tios

Baso

Imm

REF. RANGE

MUST SUBMIT SF 518 WITH EVERY uNrr REQUESTED

Cell Count

Directigen ABO/Rh Negative

3 REQ IG PHYSICIAN: \e-t.

LAST, FIRST, MI.

0 61,A '""4 eina o ogy CBC

REF. RANGE

Co lor

APP

Glu

N•IC

Ph

Lvittpiit.Vo

(Hematology) Manual Differential

Segs

Bands

Lymph

Arvp

Rnc Morph

. . Spun 42-52% (M) Hem:not:Hi 37-47% (F)

LAB (Subject Privacy Ait of 102-11

SSNIPS

It °Li

RESUL' REF RANGE

Negative

Negative Source

Negative Gram Slain

N/A Oct; Bid Negative

N/A

Negative It pylori t Negaii ■ e

fyi iCro

Parasites Negative Malaria

- 0.2-1.0 0 & P

Negative Other

Negative

Negative

Blood Bank CSF

DATE

TEST RESULT

ThTICT.--

Hgb

lei

4.8-l0.8\ 10'

-1.7-6.1 x

I-1- 18 gitil 0.1) 12-16 wdl IF)

42-52% (M) .37-47% (F) 8U-94 11 (M) 81-99 0 (I.)

130-5(10 x I

'en lied 20.5-51.1%

T1ME

0 Urina ysis M Misc. Serology

Ni2gui hC

Microbiology

Microscopic Urinalysis

Blood Bank Unit Crossmatch (MUST SUBMIT SE 518 WIT.11 EVERY UNIT OF BLOOD

REQUESTED) TYPE CROSSAL4 7

.

TEST

PT

APTT

D dimer

Coagulation Studies

FDP

REMARKS:

REPORTED BY: LAB ID NO.: DATE:

—

Bid

pH

Sed Rate

Oilier I

ACLU-RDI 1623 p.92

PHYSICIAN: l C

1 LAST , F! S M.

LAB( 4 RESULT FORM (Subject t, rivacy Act of 1974)

_ DATE

l^sl^b_Ôy TIME SSNfPS IJni

Q''ato ogy) CBC- , Uranalysis Misc: Serology TEST :- NGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8x 10' Color N/A RPR Negative RBC 49-6.1 x 10 App N/A Mono Negative Hgb 14-18 g/dl (M)

12-16 g/dl (F) Glu Negative Microbiology

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

Bili Negative Source MCV 80-94 0 (M)

81-99 (1(F) Ket Negative Gram

Stain Pit 130-500 a I0^ verified

SG N/A OCC Bid Negative Lymph % I 20.5-51.1% Bid Negative H. pylori Negative

(Hematology Manual Di fereofial

- pH N/A Micro

Parasites Segs Mono Prot Negative Malaria Bands Eos Urob

r 0.2-1.0 O & P


Atyp Imm Leuk Negative 11TicroscopjC,Ullinalys>S RBC Morph

HCG Negative

Spun Hematocrit

42-52°/u (M) 3747°b (F) CSF Blood Bank

Sed Rate Cell' Count


Other Dtrecttgen Negative

SF 5:18 WITlî .REQUESTED

BloodBank'UnttCrossn>tatcb:

AJ O/Rh

^ EVERY

}:;, ,

J UNIT OF BLOOD,

CROSSMATCH

Coag l ). Stud><es

{ ,.... (MUST SUBMIT

s TEST RESULT REF. RANGE UNIT TYPE

PT 9.8-13.6 sees

APTT 21-34 sees

D dimer <20 ug/rnl

FDP <!0 ug/ml

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 13933

ACLU-RDI 1623 p.93

Lymph

A typ

Baso

ham

So( II

tleinaioera

Std Rate

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

• REF. RANGE TEST RESULT

9.8-13.6 secs

H. pylori

Micro Parasites Malaria

0& P

Other

) iogy

TEST kESU1 1 7- 10.7 kA N(57::7

RPR Nto..2.utke Mono Negzui\e

TYPE CROSS ..1-1A1Z'1-1

DATE: LAB ID NO.: 1

Ward ,Seci

RESULT :F. RANGE

130 -500 x 10 rrified

20.5-51.1%

(Hematology) .Manual Differential

r-See,s Mono

Bands Eos

RBC Nlorph

Other

Coagulation Studies

PT

APT] .

D dimer

EDP

4EMAliKS:

li FPO WC IF - '- Mb

Microbiology

1 MUST SUBMIT SE 518 WITH EVERY UNIT REQUESTED

LA BOR ESL! LT FORM )•■ (Subject DATE TWEE

Orivacy Aet ctl 1 ,474 §-STN/1) IDO SSN:

Cell Count

Directigen

Bid

pH

Prot

Urob

N't

Leak

HCG

SG


Urinalysis

CSF

Negative

Negative

Negative

N/A

Negative

N/A

Negative

0.2-1.0

Negauve

Negative

Negative

NIA N/A

Negative ABO/Rh


Blood Bank

Negative

Negative

Source

Grant Stain Occ Bid

TENT

Wt3C

RBC

Hgb

I let

MC V

Ph

Lymph %

21-34 secs

Blood Bank Unit Crossmatch (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD

REQUESTED) UNIT

4.8-10.8 x 1 0'

4.7-6_1 x 10 '

14-18 gidl (Mt 12-16 vLi1(1-') 42-52% (M) 37-47%0 80-94 11(M) 81-99 11 (1')

-z.20 tig/611

‹io ueimi

MEDCOM - 13934

Color

App

Glu

Bili

Ket

ACLU-RDI 1623 p.94

L. I AST. FIRST. N.11-

(Piccolo) Chemistry 12

a F. TEST

[ CIiEp. Is .CES ULT FORM (Subject io . acx Act 01'1974)

TIME SSNiPSTUDO SSN: O

(Piccolo) Metabolic Panel

RESULT REP. LEST RESULT REP. RAN(;E RANGE

73.5-5.5 y7a (31.[ j 73-118

BUN 7-22 Wig/al--

CA 8.0-10.3 16g7,11

CRE o 6-1.2 ing:c11

NA' 128-145 iummu

26-874

10-47 till

14-97 ill

11-38 WI

0.2:1 .6 mg.411

7-22

SI)- I 0.3012.:(11

1110-200 iill/ill

nigidI

K nunoll

(1: 98-108 inmoVI

lii i

h'CO

1'01

iCO2

I ICO3

s 12

111:eir

AnG 0 1 )

1311N

GLI

Crc:it

I let

lItb

138-1461001011. ALB •.5-4.0 mul01-1. ALP

9s-mo KET

7.31-7 AMY _

inning tall) AST

siCrIo5 innillg taro T13 II, A Rcn)

mmol I tarn BuN 2-1-2 , ) win& I

1111110i I (a)il CA' 7:1 . ■ 11. 111 ■ 1. 1. I mil l n

05-UN". (11-101,.

1CO, 18-33 mnioLl

(Piccolo) Liver Panel Plus

mrooi

(11-211 ollool. I. GL1J

TEST RESULT REP RANUE --

73-118 ingidI

6.4-8.1 011 1.12-1.32 Inn-ILA:L.

8-26 ingi,11

Tp

(Piccolo) Metlyte 8

ALB

ALP

ALT

70-105 1lgjd1 TEST

0.7-1.5 nig dl

38-.51",,PCV

Misc. Cher list ry

JEST RESULT REF RANGE

3.3-5.5 gidl

26-84 u/I

..... 10-47 uil

14-97 till

11-38 Lid

0.2-1.6 ingidl

5-65 011

6.4-8.1 86.11

REF. AMY RANGE

73-11810gAil

7-22 mpfill

0.6-1.2 ntgfdl

39-lso (M) 30-190 oil (I') 128-145 mut01.1

AST

TBIL

TP

N-- 11'01)011111-I

I)1112. 111

AblISC

REA1 ARKS:

REPORTED BY:

(Piccolo) Electrolyte

3.3 - 4.7 lEST RESULT 'egain

Negative

Nicgauve

Negativ,.•

Negauve

REF RANGE

128-145 nimolil

3.3-4.7 minolll

98 - 108 mr001,1 NA

18 -33 ubblIloli K

Cl: 98-108 1 .06101/1

18-33 minol'I

MEDCOM - 13935

ACLU-RDI 1623 p.95

(70 Misc. Serology

WBC TEST RESULT REF. RANGE JEST kES (1 Frii , : W.Ti NT. TT: -

-1.8-10.8 x 10 Color N/A RBC - — ' 4. iVIT0 App N/A Ho — 7--- .--- -14-Is gitT1 (AT) Glu Negative 12-16 ak11 (F) IL:1 42-52% (M) Bili 37-47% (F)

8U-94 n (M) Ket 81-99 11 (I')

Bld

Prot

limb

N it

Leuk

HCG

c.:___Lionatology) C TEST Re-FSLIC T REF. 4.NGE

Segs Mono

Bands Eos

Lymph Baso

Atyp 1mm

-

- ------- -

tvlorph

_ . Lymph

(Ilematology).Manual Differential pH

130-500 x 10 3 %erilied 20.5-51.1%

SG N/A

Negative

N/A

Negative

0.2-1.0

Negative

Negative

Negative

Negative Source

Negative Gram Stain

Other Other

1-1. pylori -11

Micro Parasites Malaria i 0 P

Occ BId

RPR.

mon„

Microbiology

r I-


jNc4Li

Ward/Section: REQ

LAST, FIRST, MI.

G i

LAB.. .1

E z ( soyst .711,q1iy (11 L'114

RESULT FORM

TIME SSNiPSELJDO SSN:

Other

CF Blood Bank

Cell Count

Directigen

Spun 42-52% (M) Heinamecii 37 -47% (n Sed Rate

MUST SUBMIT SE 5l8 WITH EVERY UNIT REQUESTED

Negative ABO/Rh

TEST

PT

Coagulation Studies • ..• ' . .

REF. RANGE

9.8-13.6Tees

• Blood Bank Ui it Crossmatch (MUST SUBMIT SF 518 WITEI EVERY UNIT OF BLOOD

• • REQUESTE))

UNIT TYPE CROSSA4A RESULT

-•-

AMT

Ddimer

FDP

REMARkS:

R

2I-34 secs

<20 ughill

: 1 0

1

LAB ID NO.:

MEDCOM - 13936

ACLU-RDI 1623 p.96

MEDCOM - 13937

r t

VE

NT

FL

OW

SH

EE

T T

1110111N imenammumumni 1111111111111111111111111 cooN % ' 1111111Miji___

I I

ACLU-RDI 1623 p.97

MEDCOM - 13938

mil.D 1/L IL

Pt: 41111 pt

1 - 5TRT G3+

Pt Name:

TCO2 30 mmol/L

Pt 37C

PH 7.315

pr:m2 39•5 mmHg

PC2 127 NmHg

Hisn..7; 20 17, mo:s!

BEr.P - NI 0 S!

sr12*

*calcuiater' gmlair) V-lbz (lb

Ptient Temp -op

Pete 5 mmHg

:24

:fi.ert .0709

345p P91

-? mmol/L

Phgcici.;n:

er

At 37C

PCO2 mmHg

P02 107 mmHg

HCO3 29 mmol/L

BEek:f 4 mmol/L s02* '98

*calculated

At Patient Temp

PH 7.386

PCO2 48.8 mmHg

P02 116 mmHg

Patient Temp: 101.0F

FIO2 : 35

Sample Type_: ART

10JUL03 03:44

Oper 1678

Physivian:

Ser# 40763

Ver: 46A A93

1914 -Li_

ACLU-RDI 1623 p.98

03:3? PatigT!!:

At Patient IcpIy

PCO2 42.2 mmN9

PO2 ;2 mmNg

Patient Temp: GG.OF

7102 • 31

Sample Type_: ART

•

a

EC '3%6 RIC 42 L

•TAT GO ,

imp k 7-.7.; INN c,-L°1 Namel.

Tr:n2 33 mmol/L

OTAT G3•

Pt: GOGGG:2,001. (0 _Li

Pt NWAE:

I LoVi- 31 mmol/A.

At 370

pH_ 7,448

Pr:n2 45.1 mmHg

mmHg

HCO3 31 mmol/L

15EPcf 7 mmol/L

cn2* 93 %

174: .:31

P002

P02 3G .:mi;

NCOO 33 mmol/L

ULCLI 11 mmol/L

F:02: 91 %

xcalculated

At 070

7.474

41.0 •mNg

mmNg

NCOO 30 mmol/L

OCect 7 mmol/A.

E02: IA.

xcalculated

Sample Type; At Patient Tew.p

11JUL03 03:34

P002 00.7 mmNg npPr: 178

PO2 33 mm;;

Phqsician: Patient Temp: 100.27

Ser* 4073

Ver: 4eA 5a4•1e Type_: ART R53

12JULGO 0

Gper: 0022

Phsician:

-a=r# 42015

VEC: 1111r;

KIF:31 10 .'6/ Li!

4.5 4.00

35.0

10.5 6, 00

60: 0 f 30.0 99. 9 ps 27:0 31. 0

3:3.0 37.0 x10'3,1II 150. 450. Z •?0, 5 51,1

MEDCOM - 13939

DOD-027491

ACLU-RDI 1623 p.99

•1A1 00:

Pt: 0000000001111r

Pt Nar4e:

7002 Cl ;;a4c,i/L

At 370

i-4: - JP., f • .1. . ,

P002 42.0

P02 :xx nnNY

N003 OCec ; nnc,i/L

3021

xcalculated

At Patient TenP

P:; 7.457

PCO2 42.; nnU9

P02 ::: nnHS

TEW.p:

I :32 • 20

3awiple Typ•.) ART

1•JUL03 02:33

OpCI:

Physician:

3 e ,- #42015

lirv.._: 11

1 :JAI 33:

Val.) Pt: 00000000011111

Pt

TO02 00 ;4i4cii/L

At 370

14-2: H pN 7.443 ONN 4,ARS

P002 41.7 AA;

P32 77 77 rAnft9 97 „.7 di.:„ yyy N. 311 27.k) 003 :-zD r4nol/L

Nt 71-6 L

194. --.2:10'73/q; DEecr 4 nn61/L

rci 14:2 20.5 .51.1 s.02x 10 %

LI 1..6* 1.2 14 'fcalculated

At Patient Tenp

74; 7.43;

PC:02 42.5 r.,;:y

P02 73 mm;;;

Patient Tenp: 3,7;.4r

ri02 • 31

3anple Type_: ART

ATJULWIJ 0430

vrc ■ .

;111 Physiciar!:

117 7.10"72i 3ert 42013 \r) 6

2.91 L Ver omen

Atyti-, 27.1 L 6m)

Pit 25L Ln: 16:1;

MEDCOM - 13940

ACLU-RDI 1623 p.100

\cu> • 43c

- !.E•;b

2Z„

rIL

i -STAT G3+

Pt: \6-D

Pt Name:

TCO2 29 mmol/L

At 37C

PH 7.447

PCO2 40.5 mmHg

P02 32 mmHg

HCO3 28 mmol/L

BEecf 4 mmol/L

s02* es %

*calculated

Sample Type_:

18JUL03 04:09

nper: 1E:78

Physician:

Ser# 42011

Ver: AS)3

MEDCOM - 13941

DOD-027493

ACLU-RDI 1623 p.101

ete

Warned

BE ME 111211M2MIIMIMMIMIIMIMINIMINUMIM EMMORMEE

kM

PREMI&M, MMUS 2612WEIM .1/21=121MIMMII=11111=112102IMMINHEIIMMII WA' 1M2 IN • 212-1MME 111011211111.222711 NMI WM 2 IIMIIINNIMEZNIAZZ

4P1,222NRIEZITEI, NINE-222 Ie!rnrnmmrn1m innummummilmummismanaamimmaram Ma IN MaLieaUtimaillhalIMPIPSWIMIIIIMPIIMP22.19sair -IMA 1522%.22 i(CREARff R IMIIIIMMINMENNIIIMINNOMMEM11111111M111M11 IMUMMINIIMMIIMMEMIIMMOININHIUMIIMIM ic`MIN?"....araldWinflei_ININ:717;111MART171/ ..PTINV/VWf 21MbEilMammiumwaiirtiMIMMt; • 111121 11PkgifalffisnwLwallOinlat

11=111/11nmarynnigki2MMIIIIW.NIIIRIE 11 11.11=11111 .

TIME win* foe 11) 0049

CFR. firtulfoll-2727:" (og. LoID-

SVC? $LociDa

er- .

Code dugs wbh numbers. metres with Wars

0 90W) ?(2 1:13e.tC IDA

PO"

11- ,

Jegj- Ttt.i Ph-te,_4 BP ZO

HR- q z,

1113M, k SYMBOLS:

ri•

BP (transduced)

T TOURNIQUET

T

AWES- X-X PROC-®_0

BP by cuff

V

A

Heart rate

•

Resp rate

an.tM

P=M4

ifc,;:ea

V. V

MODE- S 0 ssIst C on BP/Auto C

BP I oth Time

Steth- PC/E

Gas anal zer

ET CO2 torr

SDO2 (%) ECG

P- site

111WEINEW BW=BE/CEMET!==m1/21i NM Block T/4

ANI:STHETIC T

AJRWAY MAN

OAT

Marc wbh totters tt symbols, EVEN TS Arrt,..s expire., under r REM4RKS Position (L.,/

'1

0/0 2-S a Ready Benin i End

HNIQUES:Describe bbck t.ohnr under Romer 11.1 "L, cif op_ ci-rte tt-ti C OtT

EMENT: Intubetion route, blade, toChtlique, Comm. n.r (56.

La 4 ce t

ea 0

PR )CEDURE LD .1ATION DATE

PA GE

mew

mraminams... 111111104/111rpr1„,21 711,7CIAGNICIAMILIMICIfilhilliMGY SINGLE DOSE DRUGS - MARK ON MTN NUMBERS &ENTER IN REMARKS

LINE see t4C12546 0 Wanma •-EP" 0 warmed

a o z a o E

.1.1.0.4 • MEDICAL RECORD ANESTHESIA

I 1- o r

-

11,411=TOMIMErz=1

rgiS4 I - t4JO22 V o3

O O l I 7_

ov-

TAMMOMFAIK OK for PROCEDU

TIME-

VIM

•re.mpt

er 134-tvv-4, +rad% tube ir,t'd 4 tufwili Aipo ica ine, -kale e,a51. -fr.'', vr> boo pie 1'1

PROCEDURES and CPT Codes

.P1D Typed written trebles: Mune Grode'Rete, Medcet featly

lik) 11.

PATIENT IDENTIFIC

LuJ 41 '

•41 123. GPO: 1999 - 528-336/10085

DOD-027494

SURGEONS:

PEA' RD - AMESTHESUl

6 REVISED 1 J - n 99

IOA-GFNT RECORD

MEDCOM - 13942

St,

fit

Warming blkt

Cony warmer

ACLU-RDI 1623 p.102

1 2 3 4 5 ' E

, :z 7qinxffimi: RECORD ANESTHESIA MEDICAL

AIR

1120 02

SINGLE DOSE DRUGS - MARK ON mug, WITH NUMBERS &ENTER IN REMARKS

LINE s

13 Warmed

cc

Q

lB

150 zideP: , lit/LI

UMin UMIn

UM In

&LW 1:1 Warmed 143 - ••••• a wanmd

o Warmed

c, 1

•

.) w 2

uj-

o

•

z

0

re " EST BLOOD LOSS URINE —

>e - •

11. r AV Srntl

Mal

11 •

TC TALS

.A = K for

D RE?

i TIME-

TIME SYMBOLS:

BP by cuff

V A Heart rate

iff

Resp rate

BP (transduced)

TOURNIQUET

—/

ANES— X-X

•R000-0

CONI

VT - ni l 51,0

EME=1 E=INIIMIIMAIIMMI

MIMI IMIll

IMMIIIMIMEMM

IIIMM::.;„:,::::

IIMMIIMMIIIUMI MI i : I IIMINIMIMINIM

III MINIIMMEINIMINI 100 - . 7.taiMMEMDEN PWASSIVEM MIMI MIIIMMOMEIMIMA 80 ":': ::'Sfft::::: ::::1•:::a.:::gi:g:'::: -::MW:::M;M:: gg Mt:.:: "*".'":X:^, .:.-M::■M.::: :?:.:M=

X120.6am„......*“.....„,,,.wmINMEEMINMMOINIMEMINEUMMIMIMOMMUIM Bo ':::.nl`.:::::

alik-cc IMMIIMAIIMIIMINNIMI 40 im x: M::::::...:: .A:w.::::: :nog :o::::::: .a gOW:i: i::il :% iggafi..:. ii.:Mf::::: ::-

EMEMIMIMUMUME ImmouiniumuMM:m

83

160

1443

120

220

200

180

20 NMI

:MST

)0L L0113—

111_00D— MLitt 11/

112277.:::•-•::,e. 'ANS: with been

Ofe4. oar-

055 (c1 3 Oz_ stox.116) 4 Aln4a 6114 GBi:it

ter TO eigrillip

ti 0

7 f - breaths/mi Peak inf ores / PEEP

C.-.. VERY AT MODE— S(ponl. Alssistl Cfon) BP/Auto Cuff y ET CO2 (torr( -2`/

t 6P / oth F102 (Frac or %) -T

: • T line Sp02 (%) Pc. kb-0

Pllu tU IC

Step- PC/ES ECG S 4 5g Gas analyzer TEMP- site

N-M Block (T/4) 0

no bud

Cony warmer

i Mark with ;eters 8 symbols. EVENTS ex Orin under REMARKS Position

PROCEDURES and C T Codes

0 1.44 rittikt dVlial 1 0 654./ PATIENT IDENT TYP.d wriiico onlr(6., Name. Or.do'n41..

Medical fectay

AliESTH C TEC IQUES:Dwate block

AJRWA MANAr T: route, blade. t

technique under 'teem lu

SURGEONS:

ANES

IDA•IENT RECORD

MEDCOM - 13943

CAA"- — MEDICAL RECORD - ANESTHESIA

OP 376 REVISED 1 Jan 9 9

DA

PA GE 0

* U.S. GPO: 1999 - 528-336/10095

DOD-027495 ACLU-RDI 1623 p.103

ASA Physical State 1 6) 3 4 5 E Wr: '`"1--69/LB ALLERGIES: L1 /1

POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) { } NO APPARENT ANESTHETIC COMPLICATIONS { OTHER

Signed: Date: Time: Hrs

SURGICAL SERVICE: NPO SINCE:

ABITS: PREOPERATIVE TOBACCO: _ PAST MEDICAL HISTORY/SYSTEMS REVIEW

ETOH: Cardiovascular: DRUGS: Hypertension

Angina MI

Age,lb SAYS MOS YRS

6044444.41— PROPOSED PROCEDURE:

) :FLA- 4. ;

1(9141r31- •

•

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

9.1-wc- .4.- 1 'iv

LABORATORY STUDIES:

HB/HCT: / 41 U/A:

L4-A/3C- / i? /9 1- 1- jg-&.

33

3 U / 2-

CVA Other

Pulmonary System: Asthma N Y Bronchitis/URI COPD

N

Renal System: Other N 6 Acute:Chronic RF

Gastrointestinal: Hepatitis Hiatal Hernia PUD/GRD

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

Neurological: Seizures N Y Neuropathy N Y Other N Y

Gynecological : Pregnancy N Y

Other Significapi x:

N Y N Y

Familial HX

N c.c." /-71-C ,

ASSESSMENT PASSU L/ANESTHETief

y- (R

#10-4/02t At;

toc _oir CvA° F<Tp. —

CHEST:

CARDIAC: 51

EXTREMITIES:

IV Access: *1(06Ad• i

e_s,c1-1-:, Al4ditum

Wrier Filling:

BACK:

OTHER:

vgAA.taa-41-(1-rci_ 1,4 res---- ted7

NPO Since

CURRENT MEDICATIONS: ( ) = ordered as premed

/06,

N Y N Y N Y N Y N Y

104-elt,

actial CC

PHYSICAL EXAMINATION BP/ 247 HR R T Pain le 0-10 HEENT - Teeth LLQ-ECZtO 8/44...42.

Trachea TMJ/Neck Orophamyx Nares

ANESTHETIC PLAN: } LOCAL AC Regional (Specify):

IF VP PA lirMarniffi

INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and sks of anest discussed with the patient/legal guardian.

The patient/legal guardian seems to understand and agrees. Questions swer Signed:

Date:

Patient identification: (Ward)

C),J

} General: Mask Intubation

esia including death have been explained to and

Time: pt-oo6- tics

SEDATION KEY:

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

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

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

MEDCOM - 13944

DOD-027496 ACLU-RDI 1623 p.104

5g7 PXS143a1 4

ate

Scale _ HEENT - Teen:

TM-I/Nee:it _ Oi opnarnr Mares _ ; _

5 CHES 1:

CARDiAC::

F_XTFO=MITIES:

1

OTHER:

•

Acce:ss: ;After li

POST-ANESTHES1A EVALUATION AN Ni ; (NON Aso) \.a - —

{ NO APPARENT ANESTHETIC COMPLICAriONS t OTHER

Time His j

Patient identification: (Ward)

1 SG:led :

laulikk e.Ms 900/e-ItyOzp-ics-

,

i :Diner ,, Ps lindeta:y SI.,s:iern:

( i .._ i As-ai Kai, i

I COPD I i Other

Renai Sy:steal:

PREMEDICATIONS: 1 Gash-ohne:A:mai: None Yes ,t 4 Hrs) ICC iteptildses ng IV WI PO 1

i i-hatai Hernia

__ • . _ itig IV iM PO II PUDICIERL.% f

mg IV I'M PO : Enc-ice S%-ysfifeirrt: 1 .DiziPetes

Ls:BORA -7-0R? STUDiE--.S: I 4..2..̀iersoizia. _

1 ThyToid HS/HCT : l i Netirologicial:

1 Neoropainy

WA:

Other

cl. 03 Pregnancy

Other Significant Hx r?.

1

Fairs iiiai

Y

Y

Ist Y

N Y

N Y

Y

IPROPO=e;E'D

SERViCE: NPO

Tr....;SA:.-...0•3: PRi.f..).0E114.1-1112?.

etT051:_ --i–. I 1...'tartlimasfic.s:Z,"

; P.::-..-..iT mr, Dit`li-iL ner;T:5'i.;-:\ iSV1E'...-iS. ,t-ZyilC .ti.'

.i.i.5-i,e•sil Y

i sa CV A Y

)

i4PO Since

ANESTHETiC PLAN: ) LOCAL t MAC } Regional (Specify): ItItuDatiat:

INFORMED CONS discussed with ti

LING STATEMENT: Plans alternatives and risks 31. nesthesta ciuding death nave traeit Ia guardian.

The patienVi —

Signed: fa; re.-es. Questions ensw fee.

Date: _JO

411111 \,(,

Ti -ne:

! 5EDAT%i) KEY:

(Anziolysis)P arent rezponzs norrralliy to vegtai Coin

1. 2. MODERATE Pazietat responds purposetutti verved comw.erics aiont o accompanier:lay light LiCTlie

1 z.tinui.suort. Airway assisraace is neoeasiiry.

3. DrEP SEDATIONJANALGESiA.

1 Pauerat rspailas Lpoajiiy

Taiiccw:ng repeated or pzriiniuf ;airway 3:St:1ST-S.-IC*. 1,1,13y 1 .

i-S

MEDCOM - 13945

OTHER:

DOD-027497 ACLU-RDI 1623 p.105

AIR

O LIM n

e t

02

L/M in SINGLE DOSE DRUGS - MARK ON GRI WITH NUMBERS &ENTER IN REMARKS

220

200

180

160

140

120

100

80

60

20

0)'070514...9# (tei LB

11' 2.-.;

P-R

'TO

0 K7—

ATATANgAral*

Vf°'

.1E- 015 OCEDURE?

N

BP by cuff

V A

Heart rate

•

Resp rate

BP (transduced)

1. T

TOURNIQUET

T —/ ARES- X-X PROC-®-Ø

Cede crags with numbers, event with lefle,

07 Z,6 Fr- 1), ?clop t 157. 41k/tit...so

0. ciepa-fut

Or/53— KrA Oz i koeu t Tag

o7 -For5

("Stet 00A- TV 1C(.4

ON& p,Fr- -r0 5p c-

- ATC-- ❑ Warmed

❑ Warmed a Warmed

al/ Warned

VERY AT 0/0

ICU ISpeci•

EMENT: Intubation route. Mode, technique, corm.Ios 11-4C4 tnJ

AIRWAY MAN

• • i 11 I

Warming blkt

Cony warmer

Merl with lenerr •S symbols. EVENTS eaplein undor REMARKS Position

ROCEDURES and CPT Codes \ ANI:STHETIC Ti CH NIOU ES:D...1b. Sleek technique under Rennie Ss

GET

uP- 133

ANNA.. :f Start I LI 07Z°

Read

01

Eno

014111710N:

IES1•- 5p02- 1 00

Medic./ hteilily

( L-v.'( D'ATIENT IDENTIFICATION- <Li.. .0 ttntrit. , N..... G.d.NAte•

•i• PAI;U

DTI SER

Peak Int Imes / PEEP MODE- SIpop.); Alssist) , C(on)

ET CO2 tort

2 (Frac or VII) 111602

pCG L/T MP- site

N-M Block (TM)

• 5 5

gS ti,‹

.Ra .54 IAD C6 LCD SO— 2. 'ft Vat

• I

BPIAuto Cuff

BP loth ART line

Steth- PC/ES

Gas analyzer

DICAL RECORD - ANESTHESIA

WAMC P 376 REVISED 1 Jan 99

MEDICAL RECORD ANES1rSIA

EffllEirATIMW,

!mon TC TALS

oo CRY STALLOID-

COL LOID- #

ISLO OD-

11•111•111d1111HIEIMIIIIMMIIIIIMIIIIIIIMMIIIIIIIIIIII BIEMEMEMMEMINIMENEIRESIMMOMES=MEMI IMIIIIIIIIIIIIIIIIMMEMIMEMIIIMMI MEMSMMIVINgsumBENI EM, ME 11•1•11111111 IMIIMMEINIMIMIIMIWINIA immilin. §Mmums

IIIIMIIIIIIIIMIUMINIMINN=INIINUMIIIMIIIIMIIIIIIM wimilMWMWM IMMISSIMINUMEEMENMEM

szammumaaamoassimmismemAlpiummim mmi. mmmarmomummum

Wil

7.7n•igi

NEVISEMENME minglESENEEN. •

M_ATiPNT RECORD

MEDCOM - 13946

PR N:EDURE LO :ATM N DA rE

PA GE I OF

1.../ U.S. GPO: 1999 - 528.336110

geWMEMERNIMEM monsime 1=1111111111111=1111MMI.1111111

OM IIINIMIMIIMMIX=11111.11111ME IMINIMENEIM311 EMENIERINEIME

al11111111.11 1111MIMMIIMINIIIIIMIIIIIIMM EMEILME NollYZERVEMEIBM" MIMINEIMINIIINEIMINNINIIMMIIIIIMI RM

MEM mikilmaaaumummiammmem

DOD-027498 ACLU-RDI 1623 p.106

OCEDURE

TRANSFUSION

PATIENT NO.

TEST INTER ANTIBODY SCREEN

Al#

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION

SECTION I — REQUISITION v1 c$14 COMPON T REQUESTED (Check one)

RED BLOOD CELLS

1-1 F

•

RESH FROZEN PLASMA

Ej P

•

LATELETS (Pool of units)

VOLUME REQUESTED (If applicable)

REMARKS:

(9--q UNIT NO

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

TYPE AND SCREEN

I c)(CROSSMATCH

DATE REQUESTED

Qs 3 I have collected a blood specime .n the below named patient, verified the name and ID No. of

D E AND HOUR REQUIRED the patient and verified the specimen tube label to

r 2 cnit.0 , et), itioup be correct.

KNOWN AN IB Y FORMATION/TRANSFU- SIGNATURE OF VERIFIER SION REACTION (Specify)

Ni 0 KV MAL,

IF PATIENT IS FEE, IS THERE HISTORY OF:

Rh IG TREATMENT? DATE GIVEN'

HEMOLYTIC DISEASE OF NEWBORN?

SECTION II — PRE-TRANSFUSION TESTING P EVIOUS RECORD CHECK:

RECORD E] NO RECORD

IGNAT

catIAPAIT- CROSSMATCH NOT REQUIRED FOR THE C

REMARKS:

III — RECORD OF TRANSFUSION ir 2e03 SECTIO

• CRYOPRECIPITATE (Pool of units)

n R

•

h . IMMUNE GLOBULIN

n OTHER (Specify)

\ra t) rz,

(.2 _iCift..5-/ Timm VERIFIED

PRETATION CROSSMATCH

OMPONE' STED I DATE

3

ML

DO

ABO O

ABO

Rh iPb Rh S

PRE-TRANSFUSION DATA POST-TRANSFUSION DA A----__ INSPECTED AND ISSUED BY (Signature) AMOUNT GIVEN TIME DATE

INTERRUPTED

ML /2:711.a..7-1 05 15

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all identifying the container with the intended recipient

The recipient is the same person named on this Blood on Form and on the patient identification tag.

\cA,0 0.)-•

PRE-TRANSFUSION

TEMP. i (Mk PULSE :!:) DATE OF TRANSFUSION TIME STARTED

TXIONE Ei SUSPECTED

If reaction is suspected — IMMEDIATELY: 1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blocci Bag, Filter Set, and I.V. solutions to

the137;5d Bank. DESCRIPTION

n URTICARIA n CHILL n FEVER PAIN

ri OTHER

FICULTIES (Equipment, clots, etc.) n YES (Specify)

ic-71,60 0 BP %

REACTION

OTHER

/2 7.17A-C.-/ / 2_ PATIENT IDENTIFICATION - USE EMBOSSER (For typed or written entriesgive: NAME - Last, first, middle; rank/rate; hospital number and name of facility.)

11111111, .-"1/4

MEDCOM - 13947

BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8-86) General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518-122

MEDICAL RECORD COPY

DOD-027499 ACLU-RDI 1623 p.107

DIAGNOSIS OR OPERATIVE PROCEDURE

TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH

NIS (014*49--

J CROSSMATCH NOT REQUIRED FOR THE COMPON

--. _ 2.00 3

PRE jUS RECORD CHECK:

ECORD El NO RECORD

DATE/, / 0-$ REMARKS:

RMING TEST

TRANSFUSION NO.

TIENT NO.

DONO

ABO

Rh

0 Po 5

RECIPIENT

ABO

Rh

ON (Date)

INSPEC

AT (Hour)

I DENTIFIC TIO

MEDCOM - 13948

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

L- 4

WARD

H BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8 -86) General Services AdministratiOn Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518.122

MEDICAL RECORD COPY

14,


SECTION I — REQUISITION COMPO ENT REQUESTED (Check one)

RE D BLOOD CELLS

El FRESH FROZEN PLASMA

VOLUME REQUESTED (If applicable)

1 N IT ML

REMARKS:


Li TYPE AND SCREEN

CROSSMATCH

DATE REQUESTED

DATE AND HOUR REQUIRED

AD. nuc s 03 loou, SION REACTION (Specify) USD

IF PATIENT IS FEMALE, IS THERE HISTORY DATE V

KNOWN ANTIBO Y FORMATION/TRANSFU- SIGNATU R

ED

RhIG TREATMENT? DATE GIVEN'


SECTION II — PRE-TRANSFUSION TESTING

0 PLATELETS (Pool of units)

CRYOPRECIPITATE (Pool of

units)

❑ Rh IMMUNE GLOBULIN

Ei OTHER (Specify)

OF:

T IMEc)-- -Crt Yit( (eir■2) VERIFIED

C” 3o

p dos r 1I •) to,

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

SECTION III — RECORD OF TRANSFUSION PRE-TRANSFUSION DATA

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)

PRE-TRAN US

TEMP. /00 PULSE /S DATE OF TRANSFUSION TIME STARTED

AMOUNT GIVEN POST-TRANSFUSION ATA

TIME DATE OMPLET INTERRUPTED

ML f )- tA Clo3i- ■46 REACTION

[LONE ❑ SUSPECTED

If reaction is suspected -- IMMEDIATELY: 1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4, Do NOT discard unit. Return Blocci Bag, Filter Set, and I.V. solutions to

the WoT5d Bank. DESCRIPTION

❑ URTICARIA El CHILL FEVER Fi PAIN

OTHER

OTHER FFICULTIES (Equipment, clots, etc.)

NO ❑ YES (Specify)

SIGNATURE OF PERSON NOTING ABOVE

ler tc) BP

DOD-027500

ACLU-RDI 1623 p.108

Rh IMMUNE GLOBULIN

ri OTHER (Specify)

I I DATE REQUEpTE1

,c)

R IPIENT

ABO

Rh

TRANSFUSION NO.

PAT

Nekt,-"A

0 RECORD D

PERSO PERFORMING TEST

DATE ctliTzek. 1_ OM

NONE 0 SUSPECTED

If reaction is suspected — IMMEDIATELY: 1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to

the Blood Bank. DESCRIPTION

n URTICARIA Il CHILL FEVER

PAIN

OTHER

REACTION


SECTION I — REQUISITION COMPONENT REQUESTED (Check one)

ED BLOOD CELLS

[ I FRESH FROZEN PLASMA

n PLATELETS (Pool of units)

CRYOPRECIPITATE (Pool of units)

VOLUME REQUESTED (If applicable )

ML


106—)— DIAGNOSIS OR OPERAS VE PRO—EDURE

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.

KNOWN ANTIBODY FORMATION/TRANSFU- SIGNATU SION REACTION (Specify)

I I TYPE AND SCREEN

CROSSMATCH

DATE AND HOUR REQUIRED

ND t't A

REMARKS:

UNIT NO.

11.11111111111

IF PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN


SECTION II — PRE-TRANSFUSION TESTING

TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH

AI( DONOR

ABO

Rh

coo

DA RI

-tag TIME VERIFIED

Co 20 PREVIOUS RECORD CHE K:

J CROSSMATCH NOT REQUIRED FOR THE REMARKS:

-4 ̀3

SECTION III — RECORD OF TRANSFUSION PRE -TRANSFUSION DATA

ED AND ISSUED BY (Signature)

AT -Hour) 0 S-1 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.

TEMP. 9-7 0 PULSE

DATE OF R NSFUSION TIME STARTED

POST-TRANSFUSION DATA AMOUNT GIVEN TIME DAT / COMPLETED INTERRUPTED

tr, A. ML ORO 7 /9(c 3

OTH R DIFFICULTIES (Equipment, clots, etc.)

NO YES (Specify)

SIGNA TING ABOVE

ON (Date)

BP

q et 03 ILPeo-O PATIEN ID NTIFICATION - USE EMBOSSER (For typed or written entries NAME - Last, first, middle; rank/rate; hospital number and name of facility.)

e vJ -i-111111w

MEDCOM - 13949

car v4- WARD

MEDICAL RECORD COPY

BLOOD OR BLOOD COMPONENT TRANSFUSION STANDARD FORM 518 (REV. 8 -86) General Services Administration Interagency Committee on Medical Records FIRMR (41CFR) 201-45.505 518-122

DOD-027501

ACLU-RDI 1623 p.109

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


NURSING UNIT


NURSING UNIT


NURSING UNIT

REPLACES EDITIOP • • vyrnt.r1 114A• bE USED.

DOD-027502

ACLU-RDI 1623 p.110




LIST TIM ORDER

NOTED AND SIGN

NURSING UNIT

C GU PATIENT IDENTIFICATION

NURSING UNIT

0 3 PATIENT IDENTIFICATION

NURSING UNIT

fc) 5 PATIENT IDENTIFICATION

aent

NURSING UNIT

DA IFAPPRA479 4256 REPLAcfifi EDIT ON MEDCOM - 13951 carf utece t71 rsrN In Ti

DOD-027503

ACLU-RDI 1623 p.111

HOURS

BED NO.




1(1 3

LEI:N.L1D ;̂

DATE OF ORDER TIME OF ORDER LIST TIME ORDER

NOTED AND SIGN

—VW." bit

03

NURSING UNIT


X- I

if Chart- Check 0 100 i DATE OF ORDER TIME OF ORDER

HOURS

NURSING UNIT ROOM NO. BED NO. I

PATIENT IDENTIFICATION DATE OF ORDER

bi 6 TIME OF ORDER

Ogg HOURS

NURSING UNIT ROOM NO.

PATIENT IDENTIFICATION 2.

NURSING UNIT ROOM NO. I

DA 1 FArRM79 4256

Chart- ClAe-

BED NO.

REPLACES EDITIOP MEDCOM - 13952 USED.

DOD-027504

BED NO.

ACLU-RDI 1623 p.112



PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

( Oa 0 HOURS NO

LIST TIME ORDER

ED AND ION

/ ,.

Ill A/ 6cd--, Ae. m.„

41510 / 3. 376), /VI 6 ° _4,

a .. , co- i./ .

\&-tA I (13


DATE OF ORDER

OURS


\ZAJ,4'


PATIENT IDENTIFICATION DATE OF °ROE• TIME OF ORDER

HOURS



MB- -

UP '.1'1/4

DATE OF ORDER TIME 0 ORDER

HOURS

NURSING UNIT

alte D.

ROOM NC

4/ .

ION

/ 31:,06r 3 D 70. 1 OF 1 JUL 77. WHICH BE USED. n A FfIRM A "Me

1 APR 79

MEDCOM - 13953

DOD-027505

ACLU-RDI 1623 p.113

ICiJ3 PATIENT IDENTIFICATION

TIM OF ORDER

ak&d HOURS

NURSING UNIT



PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME

ORDER NOTED AND

SIGN HOURS

gran) 12 014-d3


/3

te0 BED NO.


NURSING UNIT

DAIFLRR^^79

ROOM NO.

CILA4 - / 4256

BED NO.

44) 65li4..P,o -; REPLACES EDI JUL 77, WHICH MAY BE USE

MEDCOM - 13954

DATE OF ORDER

DATE OF ORDER

HOURS


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-027506

ACLU-RDI 1623 p.114

LIST TIM ORDER

NOTED AND SIGN

NURSING UNIT

/ 43 PATIENT IDENTIFICATION

NURSING UNIT


URSING UNIT

TIENT IDENTIFICATION

SING UNIT

1 4 FoRm 256 APR 79 REPLACES EDITION

OF 1 jut -iv -- -

MEDCOM - 13955

CLINICAL RECORD - DOCTOR'S ORDERS

, TIME AND SIGN EACH

p For use of this form, see AR 40-66, theproponent agency is OTSG THE DOCTOR SHALL RECORD SYSTEM IS USED

WRITE PROBLEM NUMBER IN COLUMN INDICATED BY

ARROW BELOW.

DATE

SET OF ORDRS. IF

PROBLEM ORIENTED MEDICAL RECORD


DOD-027507

ACLU-RDI 1623 p.115

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) For use of this form, see AR 40-407:

- • • •.• - • 0.3 i • IIVITIAL PROPER COLUMN FOLLOWING EACH COMPLETION AO

CLINICAL RECORD

PATIENT IDENTIFICATION:

EDITION OF 1 DEC 77 MAY BE USED. DA FORM 4677, 1 OCT 78

001111111111111011111111111 1 irePs‘ataBirla=111,1 ___ -12511NMENIS

Er"--- - BIPIIIMMENAMI

"PPM illinlinnin imull1111111111111111 IL Mt t ANIS

IL -""111211111111

11111111PEPRI 1111limmenwrisamium 111111111111111

Mit rsaM , 04WIM &I!

14 111111111111Mmimmillal sMAILMSIMANIMI ussionerm,

Wili . WINNE wrommulmanumum

RUIN =111111111111 EL A■ I■ ■limman■■11•11■1111111

IS "EWEIMMEMIUM: it

"e rr Inums11111111111111111111111111111111 , L ; cifrci r• r---------- 212,11111111

iiiidailla ____vaglIIIIIIIIIIINEVlrdIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ►MIIIIIIIIIIIIII .I■IIIIIIIIIII■IIIIIIIIII■IIII MR: _JIMMIE OM BE 111111111111111111111111

imiressinaIllsolmiludilmonumumum ADDITIONAL PAGES IN USE:

=I YES 0 NO

PAGE NO:

ALLERGIES: CD YES ED NO PRIMARY DIAGNOSIS:

&CAA).

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

usApA va.cr

MEDCOM - 13956

DOD-027508 ACLU-RDI 1623 p.116

Verity by Initiating THERAPEUTIC DOCUMENTATION CARE PLAN

(NO1V-MEDICATION) Mall— Yr 2003 Order Date

Clerk Nurse SINGLE ACTIONS Date to

be Don. be Time Done

to Done Initials

41 ( iA/ . A) A° ICA) Ct 3 S-1-11 pig-s-- au Mts-

ii,A,4 C- (1-6I-c-(- FAD 'ALL 2200 \014)-)-

•

4 (4 —2

- — - - _ •

. .

• .

. •

Order/

pier Dat

clerk/ ..

urse ACTION, FREQUENCY PRN INTIM, PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

• .

' .

.

•

""''"'" USAPA V1.00

MEDCOM - 13957

DOD-027509

ACLU-RDI 1623 p.117


I

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) For use ot this form, see AR 40407;

INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

Mo. Yr. 2003

!FY BY INMALTNG 44=4'-at .'nE:1172-rg :;:i

CLINICAL RECORD

I DATE NURSE FREQUENCY, TIME

RECURRING ACTIONS, gr PIIMININ 1 to MI INISPREI DATE COMPLETED

ORDER CLERK!

Millr-IMIMMINallanii- 31111111111 mummormainommut itiomm

r- -T mi. "Immo I mi ir-i

MIR EIR I MIER

Ma MINI

latilleal ,AMOL_ III IIIIIIII

NM 41121•1•111EILINIVW" rum%Il.

worn millA 111111111111

11111111 1111111L100 111111111111

111.1rint lfint 117.11150121111111111 IllingsgPMEMealli 1111/1011111 111111111111i1111111111111 i mensmso mmonommommum m.,__ ir--1 eoe z olket MLR' 4Fri Taal

111011110g111111111 . COL 1111111.31111 RIM

1111111111111011111111111111 1MMININNIIINmaillaulli Egliff"" , I .._. . ror,„ ■411 111117111

111111111001 li-ach IZO 40,. 1111111•2111 11111111111111111111111111111111 11111111111111111111111111111111111111111J111111A111

1011.11111111111111111 111111111111111111111111111111111111111111111111111111 IIIIKJSIIISIIIIIIIIIIIMIIIIIINIIIIIIIIIIIIIHIIIIIHIIIIIIIIIIIII Mil All IIIIIIIZEEIIIIIIIMIIMIIIIIMIIIIIIIIII IMIIEIIINIIIIIIIIMIIIIIIIIII

111111111111111 1111111111111111111111111111111111111111111111111

MIENIIMIM1111111.1.11111111111111111111111111111111111111111111111111

INIIBIIIIIIMIIIIIIIINIMIINIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

1111111011111111111111111111111 11111111111111111111111111111111111111111111111111111

11.11111111111111111111111111111111111111111111111111111111

1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 a ADDITIONAL PAGES IN USE:

CD YES 0 NO

PAGE NO:

r\ 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

I b

ALLERGIES:

un .1

YES :3 NO

k

INIA(FIZIGMIS66401:it_ollpc1T+n

dosoe 0 4or.5 Ue ScovC-44- .44Ssv -e

USAPA VI .0

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.

MEDCOM - 13958

DOD-027510 ACLU-RDI 1623 p.118

05

It

O

ra

2 1,

0

c c-;

CLINICAL RECORD I THERAPEUTIC DocunIESTATIoN CARE PLAN (NON-MEDICATION) TM For use of this form, see AR 40407; orotoretzmney is the Office of The Sur aeon General.

ojgr. 2003

VERIFY BY INMALING .q1::70.-V4SPViri sk,17 LNMAL PROPER COLUMN FOLLOWING EACH COMP ON

DATE COMPLETED

I+1 13 CLERK/ RECURRING ACTIO NURSE !FREI:WEN , IME

HR

bb Nip°

4 •

- L.-C- (es- ' 5/LA-1-11

A -4c) -it, 0--xl-t- ,7n_

cs eic-r //0 s

ALLERGIES: 11:1 YES E=1 NO I PRIMARY DIAGNOSIS:

411111111

USE PENCIL. CIRCLE ACTION TIMES ACTION TIMES -

D 8 9 10 11 12 13 14 15

E 21_ 22 23

N 24 01 02 03 04 05 06 07

r (1-4 4A—,/


faue ex (.5 icrz


ED YES E:1 NO

AGE NO:

USAPA V1.00

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.

MEDCOM - 13959

DOD-027511 ACLU-RDI 1623 p.119

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

the proponent aoenc is the Office of The Surgeon General. INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

CLINICAL RECORD

BY INHALING

et PS

ORDER DATE

HR

11101mInnomrSEM1111111111

11511ffilliNal

nr".1011111111 Enosi

yrs

1201-111111111111111111111151111 Awrirmumprom

. ,.....1'"11111111111

L.Aa inimmummommiimor LAI MIIIMPIREMIZIEVAIN I

I Ill AMOY El

FiNnuml

CLERK/ NURSE

RECURRING MEDICATIONS, DOSE, FREOUE

DATE DISPENSED

, 1143's) t

ALLERGIES: P YES

UV) V 4(1411\-)17) PATIENT IDENTIFICATION:

PRIMARY DIAGNOSIS:

&<AA) pc. cif 4"),

AGES IN USE:

El YES P NO

-)riu nri fa, PAGE NO.

DIS ENSING TIMES


9 10 11 12 13 14

17 18 19 20 21 22

01 02 03 04 05 06

D 7 8

E 15 16

N 23 24

EC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00

DA FORM 4678, 1 FEB 79 EDITION OF 1

MEDCOM - 13960

DOD-027512 ACLU-RDI 1623 p.120

Verfy by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. JV1-- Yr. 3

Order Date

Clerk/ Nurse SINGLE ORDER, R, PRE-OPERATIVES Date to

be Given Time to be Given Time Given Initials

4'6I - -

111111/UCCI

6f r 1 ar a X do en

, A

lb

(4:

5:73 C+

/ •

i t z.1

► Ai_ r>} r-N iv , X to 1000 076 (IYor r )(I coR, 0'- Do 090 t,

at #.9 ve oil f kn-i ocr Jul a

, an 18'.3 cri lace (I) -Rcurn Qi R

Nut e rmiisf-try.... -/A) vRi2)-(... ova'2./b"-e_a_e_,I,,, ) 0.3A to c. naQ- /poi. dio 7

7 I vi) eq - tu b \,,,i 15-14 -2.311 7?"1

" Order/

Exair Date

PRN MEDICATION, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION TIME/DATE DISPENSED

—,

uisi_ PheiVrya il. S-asn5 I vg (-Ppm ow

I52"e- ef cord- Tdi /- 2- Po I S' Q Y-6 Acs ?XA) ill

.

. rvi 5..,y 7 Kvt3 Il IP X 1 p . .

Pevg ?(SO4 2 _itIp 7 ili.i ci;:z

Q(`' P Po /1„:,,, °z.ti'l ire

USAPA V1.00

MEDCOM - 13961

z

DOD-027513 ACLU-RDI 1623 p.121

D 7 8 9 10

E 15 16 17 18

N 23 24 01 02

11 12 13 14

19 20 21 22

03 04 05 06

ALLERGIES: Q YES Q NO PRIMARY DIAGNOSIS:

&gird +(I •


EP0- 111111 USE PENCIL. CIRCLE MED TIMES

n YES ED NO

PAGE NO .

DISPENSING TIMES

/3 3

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

CLINICAL RECORD For use of this form, see AR 40-407: M0.61- Y T. the Proponent aaenc is the Office of The Surgeon General.

v F- ; '1-4 -74"- i; INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRA770N

FIR 'DATE DISPENSED

VI, "121711111111

\CZ .1:, •-').' _____ 11111 III

4/ ivr (1-k. --6-75cd° s" a r 7


1) ,-;q3"


EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA v1.00

MEDCOM - 13962 DA FORM 4678, 1 FEB 79

DOD-027514

ACLU-RDI 1623 p.122

PAGE 1 OF 4

EPORT TITLE

MEDICAL RECORD-SUI MEDICAL DATA For use of this ton. see AR 40-65; the proponent agency is the Office of The Surgeon General.

• -.V • • INTENSIVE. CARE NURSING FLOW SKEET.

Mar . . •

OTSG APPROVED (Date) _ . ___.

DA ,4`)Ar78 4700 Proponent Dept of Nurs

MEDCOM - 13963


- : M.Uahi-idAMe Et4N I NgiNiIMOMW" i

IE IIILIIIL IIIL 5A). 1mn

UIS 1 . ee L r eg2 rm bv SNOIM 0 „_A

_ .iEAINNMI .. L I 1:

;,, 4) Snpe 0inaii

:•

1 1 1 0 0 , rC jWn . RSIAOYPTEN r .. L4

,S, RAHSUD 1W1111111 .-r: ERTOS

er4•

lt5

. s '

.

5 ■ b Ve i FO_ A 9t2p5Ca e • ..

: CLR /O 4 i _._._ al-r :ITGIY 0 '40

OVIPM fsi b mnil I

PZIM111 MIIMT97IA f : : LCTO rrl701 11111111NOPrarMIM1cnrcum 4 7 ' ° (o Ac- ;;' :od

16A 7-AC io A.;1 A , _ 1 1.-- 1=.AL -u. FMII IP1

EZ MliIIl ie2_4'.-kr- 4: BOE IYIE11111 1E. .:. , 01.11111=.;:: OE ONS ■

IAA -.... ; 1 lI: .... , OT D - jiia:: .....-4 E

: 1

RN: F e- .--

f u-o C CLRCAIY' I , d44..

:. .. CRIC RYH 5- .

. , I M A I: 1,.. I 111 I EMII

. 45j001,11 .-11 r.0 i. .:

,-'.

gnig r - Cernre IP - ttarna rsue St rcinl'' ...F0 rcin0 ntm 2 PO Pesr fAtra O ;SI-Strto

: O C3-Bcroae PP oiieEdEprtr rar AH-Ircesoy

\ ) Cniu nrvre

RP i DPEATETSRIECII AE/_j•• 4 3

AIN' D arte nre ie aels,frt ide rd: dt:sio eclfclt) ❑ HSOYPYIA LWCAT

E TE XMNTO TE Seiy REAUTO

O\ ‘411/

IGOTCSUIS

U TETET

R

DOD-027515 ACLU-RDI 1623 p.123

DOD-027516

o5 eU, <;, 06 tvorlibfe f

6r 4' et

jeZPV3. Cig° 3Wf.'_, 109" "1/61),

OUTPUT' t5D NG PM

DRAINS

TOTALS

aaJ

K. PAGE 2 OF 4

>17,-

15 IL 125" 125 ,r1sTh

z.1 -CO

ioo #

it 2er ,/

IV) 124166. C5( 10 13 AtOrk

I /0 citr 93,100 13 l9 13 t SI $7 8g9too loo 100 MD de.t Vettf. Vet Vent-

,kto 40

teXA

iq 20— 8°T

125- 125 125 125 VS- 3,232 3.2 3.2- 17.D 5 5 5 G

100

OAT 6 g•3141--- 3

TIME

EP Arterial Line

BP Cuff

Temperature

Respiratory Rate

HAP

Pulse

TIME OQ efer 44 2.

at

L

vP6

1026 ,oz '

05 t(? 11)

tool, iool '

da,gt do.- 4.1" fAett

•

-Y-ttablifrosszonA I ?' I . 120

g . _ •• 11P 0 WI°

TOTALS

HOUR

TOTAL •

URINE IP 91 SIA

46114/1

'G WAG

MEDCOM - 13964

/7- /8

EMESIS

STOOL

Pk /5

iO 1(

71 77 13

HOSPITAL DAY

ACLU-RDI 1623 p.124

ECI ICENIIiiIgg NE la PM ISINIMITMLIMag

rffdflaNIIMPAINIPDPli

ACLU-RDI 1623 p.125

PAGE 4 OF 4

-";q:igiedeVi tellanitaniggiE,i,i , • M06 51a mMUOMMOMEMOMMMMMaEM- MMIIMMOMMEMUMM MEM MI

11111111111111111111

1 11111111111111111111111 11111111111111111111111

IIIIMMEMMEMMEMEMNIMEMMEMEMM

111111111111 11111111111111111

t4-

3

• 2 3 • 4

'E

U

7

P

V.

E

S

S..

C

Z

NW

NORMAL POWER

MILD WEAKNESS

`,3 SEVERE WEAKNESS

ABNORMAL FLEXION

ABNORMAL EX TENSION

NO RESPONSE

2

RIGHT

LEFT

NORMAL POWER

MILD WEAKNESS

St vERE WEAKNESS

ABNORMAL FLEW:4.i

A uNoRmAL EX TENSION

NO RESPONSE

EIF XION wiTNOTLAwAL

ABNORMAL Ft EX i01.4

TENS.ON 10 PAIN

NO MOTOR N. SPONSE

I OCALLZES PAIN

OmENTE0

CONFUSED 4

vERuALIZES

vOCALLcES 2

NO VOCALIZATION

Oat I'S COMMANDS

SPONTANEOUSLY 4

70 SPEECH 3

10 PAIN 2

NO EYE OPt KING

Sat

REACTION

SIZE

fiLActiort

HOURS

3

PUPIL SCALE

ICP


Rqfp61 SgS.spir

• - LEGEND

C Closed by swelling

T TrachiEnciel■

S Slurring

D Dysphasia

R Recepuve

E Expressive

41- Right

L Left

Record separately if there is a difference between the two sides.

• 6 ob

+ + Brisk

Slow

No Response

+ Intact

- Abnormal

G woommommosammosois WANONONNENIONNOBNINON INIONNIVANIONNOININNI NONONNOWANNOMMONNIONO MONOMONNIONIONINIMMOONON

HOURS cb 04:. 07 OW 09 10 II os

i LE SSSS

2/ 22 23 Ob 0 GEND 12 ri 17 tt

♦ 4. Normal

weak

Absent

O Doppler

R Right

Left

MEDCOM - 13966

DOD-027518 ACLU-RDI 1623 p.126

DOD-027519

FLOW SKEET REPORT TITLE

giSENISMOMINIEMANSIM . .. •

•••!1 •• • • • • INTEN SIvE CARE NURSING For use of this form. see AR 40-65; the proponent agency is the Office of The Surgeon

General.

MEDICAL RECORD—SUOPtIMENTAL MEDICAL DATA

ABDOMEN

BOWEL SOUNDS gp121110INIMS11111

TIME

PUPILS

P6R-P-U-1 3awn bra - oUo sinipte comtn

Able -to move eX 1.11-a!-G r 1 Sam

RESPIRATORY PATTERN

BREATH SOUNDS

SECRETIONS

COLOR

INTEGRITY

LOCATION

OTSG APPROVED (Dote)

SENSORIUM ER 1

n Pa ) SpOnp

QA Appr 8 Mar 89 t0.-

aggaag a:atitetgraSiniagengaglai INI TIALS 180D . INTI AL

URINE:

COLOR/CLARITY

CARDIAC RHYTHM

Creatinine F 102 FIACDOCI of inspired 02

tiCO3 - bicarbonate

ICP intracranial Pressure

PCO2 -Pressure of Arterial CO2

PEEP - Positive End E apratory Pressure

SiA • FraCti011•1

SitUr•bell

MACH - T racheostomy

PREPARED BY (Signature & Tide)

PATIENTS IDENTIFICATION ( For typed or written entries give: Name—last, first, middle: grade; date; hospital or medical facility)

(Continue on reverse)

❑ HISTORY/PHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER (Specify) OR EVALUATION


❑ TREATMENT

DA 1 FA ?Ain 8 4700 Proponent Dept of Nut's


MEDCOM - 13967

INITIALS

PAGE 1 OF 4

I DEPARTMENT/SERVICFJCUNIC

1 1 4 4 3 DATE

31.1t_

ACLU-RDI 1623 p.127

DATE 961410 ";

OI G51,0 -fp vvia-046 1 *4- 0 2. Oh qv 1L1

BP Cuff

TIME () 64,5 07 08 • BP Arterial Line 1,5

78 66±. N 9,0 Ito cce, to& 10 ,12_ 25 Is J it)0100 100 106

vent vent T-4, TC- TG 40 40 E0 E0 35

go 10 •

233.5 133.5 1335 t33.5- 324 13;K:,1 631i GIS el oi.o 10Y1,5 f 35S.t)

PAGE 2 OF 4

HOSPITAL DAY

tti 44 /7 /8 /q 2C iqty6s- 137/6 01" titi• is% 16175,

(110. 0 qtr.i cV241.(e_Pri el $9* h 85 83 N 14 12 Il lb la I 106 .qq . '6LO itb vent' vente, Vetit. Ven-[ 40 zit i 40 AO 4(\

2_

Temperature 46q Pulse 7o Respiratory Rate

Oz Sats ICC) 5ourc_e. Ve

Ft z/D

r18

10 10 to0 ID° vent v 40 40

Ia

•

TIME 09 0 b 06

IVF 1z5 ProrciFOI SiS rental 9 (

P6

4„3j. 1,5

4250 125 125 a5 35,35 5 5 5•

100

IL la 2er Err

125126 a.6. Joe,. 5 36 :36- 3s ,

5 g 5 5 Lio inn - • 100

09 Lfer

47—

125 126 11.b 125 35 8.5 3.5 3,5

5 5 IOC

&g_ 1500 v-ig 400 oP.- I II cocci

4111ropre

rte. 5- 2335 4.71°' Gz-6 .7: TOTALS

05

HOUR

110 TOTAL

URINE

'15 133' 0.L5-- 133.5 i335 zfra 1#00.,5.

b4SS ZAT q5

Igo 300 270 200 5 • -

!Pa \P 9r

OUTPUT •

NG

GuiAC

EMESIS

STOOL

DRAINS

TOTALS

MEDCOM - 13968

DOD-027520 ACLU-RDI 1623 p.128

ACLU-RDI 1623 p.129

YE

S O

PEN

r■i'Lw =." =2

>a. •-6^

LacC

tc

OZ

NW

1111111"11111113111filii shtltent

LEGEND

1111111 1/1111/1111111111111 T RD

SE Expressive

SRDiecrul:h rcepr:hnta Receptive

1111111111111111111 0110011111111111111

No Response

• 2 3 •4 •5 •6 07mm

4- Right

I Left

Record separately if there is a difference between the two sides.

*

♦ Brisk

Slow

ROLOGI • SESSM .. •

PAGE40F4

HOURS

SPONFANEOuSi Y

70 SPEECH 3

10 PAIN 2

NO EYE OPENING

OmENFEO

CONE USED

vERISAL S

3

VOCALIZES

2

NO VOCAL IZA NON

OBEYS COMMANDS

OCALUES PAIN

EL E XION WITHDRAWAL

ABNORMAL El EXION

x leNS.ON 10 PAIN

NO MOTOR Ni SPONSE

NORMAL POWER

MILD WEAKNESS

M

SEVERE WEAKNESS

ABNORMAL 'LEMON

ABNORMAL EXTENSION

110 RESPONSE

-v NORMAL POWER

MILD WEAKNESS

U SEVERE WEAKNESS

E ABNORMAL FLEXION

et ABNORMAL EX TENSION

NO RESPONSE

U • RIGHT SIZE

REACTION

SIZE

REACTION

LEFT

PUPIL SCALE

ICP


♦ Intact

- Abnormal

....... ...........

HOURS 1' 06

IMINNININNIONNON61/11 INONNIONNON11/1/1111/NO

NONOMMANININNIONNEN

MOVMWUM MI4M 11:1 17MIWV2225106MOCIS6 LEGEND

* Normal

Weak

Absent

D Doppler

Right

Lett

R L

R

R L

ONNOOMONIONNONIMOMONION MEDCOM — 13970

DOD-027522 ACLU-RDI 1623 p.130

PAGE 1 OF 4

REPORT TITLE

MEDICAL RECORD—SUIVLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.

INTENSIVE CARE NURSING FLOW

OTSG APPROVED (Date) — - . _ ,

Appr 8 Mar 89 MatignaggetegingnMENEMS . : ._. SE:tta 'ENEEI.S::::::Ina,;ga.:::::::Wilg:t.MERENOSSZO:: MV.0:i. TIME p&c,c) errlLALS 613-tru 1.-TIAL

I IN111ALS PUPILS rys ry-1 - rEle__ „

.- SENSORIUM S bt Au2,, IL;-j_

- . -

. 511 -6.),,, ,..e.e -vii . M.-blizz- 3.,..•ta vrt K.A? L

A... . -.'„._

e' ;--t_rvo x 1 T. ...--e...ca- (4.--,a-,.. .4

fa-'v 90eit..5 1J) n- (A/a..rysu1.4". RESPIRATORY PATTERN -RR TZ . t_rA ‘..,xt

-342P-i.-tt 4,-,-Z, BREATH SOUNDS 4 st.t10.t.co-,,, s651.., 1 16 )

.

....e. 0.....4.4,.......:4,i st (3 -

.

SECRETIONS -1-•(- c_L-, --TiC- " lis e„, it, - we ...4..ct t..---- :,, Obset.0

riDz 35-%

--- ..

COLOR ,Th. f R. I 0 esi ' Cyr - ,- A L.-. •). . INTEGRITY

Z Ce I ..e. 10--,i coak_ t.: . - .:]e: LOCATION N -1.,:-.42..„ 1,0,( ---/-,. ,

S C._ - ' 1. rkz5 L ...

r:-..coN'641orist" ' : -.t.L_) A n

,

(± 'Qu.,...t: I,

— " ABDOMEN i -t - 16 X q c-1.1.7s.o( 54f+ -1-ns ,tqtaiei- fla-ete I6*

BOWEL SOUNDS .to-,, CU. ZI.,.4.a Co•-4,1 -0, Ce---4.1--itt--,4 Zell

URINE: MP,- 1 p r 4_, - .,-- t ..,, V-3. (11-Q COLOR/CLARITY TA, cyvo,v 51- 1.-

Zr•rtt'T A 9---,,,A ai,--, ... CARDIAC RHYTHM .' z ?"13)"),E. "3 462 Y 4 .04,, • ft. 1? s' J. ......J.,„ o-r eLefro, C\T re I a >3.,otc 10 j't..-,--04,0-..L./o, 01.,p

22 , Z. _?0-2-c •

vIVZ."

Ugl

.1.:E F op7 - FtaCI,01, 011,1%Pred 02 PCO -Pressure of Arterial CO2

(Continue on reverse) PREPARED BV (Si ) \tz 6_ ,..)... DEPAIRTMENT/SERVICFJCUNIC 4LI 3 DATE

jt:XTVL- 40.3 PATIENT'S IDENTIFICA II or t : Name—last, first, middle; grade: date; hospito or me Ca r Y

dill, V Q LO — i 4 .

— - -- --

U HISTORY/PHYSICAL IIII

U • OTHER EXAMINATION OR EVALUATION


❑ TREATMENT

FLOW CHART

OTHER (Specify)

1 MAY 78 4700 Proponent Dept of Nurs

MEDCOM - 13971

WAMC OP 375 (Redesignated) 1 Apr 90 (HSXC—NU)

DOD-027523

ACLU-RDI 1623 p.131

DOD-027524

rib

-7C TC---

58 56 5.3

00 '-C -35 35 35

8a /

PAGE 2 OF 4

Di

TIME

is BP Arterial Line

BP Cuff

HOSPITAL DAY

en- 44 /5 p / Ia 1 . 7

71,03111_03 06(

91.

5 -1 5 5

1 Li- )0 19, I pc

Oc-b0 0 O

,t -)1 ,35 35 f3s-- ' a 91

Pulse

Respiratory Rate

:•k:: DE

og Tc_

tO eft 4z. 8° T 43 At I I6 if- 18 iq atr 8°T •

TIME 09 01, , 61- s-Tiels---ta, kb° 0 /2,s----).ps- 5-1.xs 14.5 1,1.5 /as

P5 b 5 - s S --S N5'

t Z_ ( r 5

A

TOTALS

URINE

SIA

OU TPUT'

NG cn

GWA C

EMESIS

STOOL

DRAINS

TOTALS

MEDCOM - 13972

B o 6 elq 44.

Temperature

ACLU-RDI 1623 p.132

24-

24 22 z5" co OP to-s /3__s s.

o3- of -1 / 9e 60

Tc-

01,0 g • o# 8°T

)ea.S

1111111 APPAIRVAII21111211M AIIVAPAPPAPIMPINIMI IISIVAPJIPAOZIAIMIPAPAS

MOVIII1VAPAIMISTI

22 ". ADO 124> az TIME

MODE

TV

RATE

PEEP

PH

A PCO2

PO2

B HCO3

SAT

G BASE

TIME

GLUCOSE

Na/K

Cl/CO2

BUN/Cr

WBC/PLATELET

Hct/Hgb

TIME E

MOUTH CARE

BATH

SKIN CARE

FOLEY CARE

U

R

:S V TRACH CARE

ROM EXERCISES

U C T

0

47180 TOT NURSE'S SIGNATURE A stITIALS

wt Yesterday wt Today

INTAKE

OUTPUT IV • Urine:

Po

TOTAL

TOTAL

BALANCE

tOn

ACLU-RDI 1623 p.133

S. BREATH SOUNDS

ICP intracranial Pressure

PCO2 - Pressure of Arterial CO2

PEEP - Positive End Expiratory Pressure

G. -14

MEDICAL RECORD—SUIVItMENTAL. MEDICAL DATA For use of this torn. see AR 40-66; the proponent agency is the Office of The Surgeon General

IEPORT TITLE

INTENSIVE CARE NURSING FLOW SHEET

PUPILS

SENSORIUM

RESPIRATORY PATTERN

OTSG APPROVED (Date) QA Appr 8 Mar 89

COLOR

INTEGRITY

LOCATION

CONDITION

ABDOMEN

BOWEL SOUNDS

URINE:

COLOR/CLARITY

CARDIAC RHYTHM

e.,

DEPARTMENT/SERVICE/CUNIC

/GCS



IT

.)LI .) -1-)

❑ FLOW CHART

❑ OTHER (Specify)

ENT'S ID btri die: grade; date: hospita

n entries give: Name—last, first, or medical facility)

MEDCOM - 13974

PAGE '


DOD-027526 ACLU-RDI 1623 p.134

AEDICAL RECORD-SUPPLEMENTAL MEDICAL DAT,. For use al this form, see AR 4066: the proponent agency is the Office of The Surgeon General

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

OTSG APPROVED Omer

---

Date: VI 66 . . Anesthesia Type (Circle)): Spinal Epidural Ggner Drains Airway Time In: ■•• J\ .* 1.., IV Sedation Nerve Block

Allergies. 1` 10:)i4 OR Intake: Crystalloid 'DOD Li \ Colloid Hemovac

fri>' T-tube

Foley

TLS

Nasal

Oral

ETT Pre-op V/S: OR Output: UOP 100 EBL Tfl, (y"-t•r....4, i Procedures: . . ,---4,-. D . , c.,--

,

Meds/Times. V ,--521,2,K,I...,..) C-C• haI-L .5 cv— \ I V, v.0.1 YY-) s o t(

Trach

Other Pre Op Meds

0 ifl History

Time cr‘ - -

,

.t • A e

IY 5:, S

tr \ '''' Pacu Intake

Sa02 1/-17 TA %."0

5 Time Solution Amount Site By Infused

Fi02

Methods

240

220 X-rays:

Post-Anesthesia Recovery score 200 Criteria ADM 30' D/C Codes

Activity

(2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

AIRWAY

A = Ambu

BB = Blow-by

180

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

FT = Face Tent

M — Mask

RA = RoomAir 140 A

I\ N A n 4 Blood Pressure (2) SBP 1-I- 20 of Pre-op (1) SBP =1- 20-50 of Pre-op (0) SBP =1- 50 of Pre-op

.....?

NC = Nasal

Cannula

VIS

120

•

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

.■■

■

= Cuff BP

X = A-line BP

-

= Pulse

80

Y\rvvvv Color (2) Baseline color & appearance (1) pale, mottled, jaundiced (0) Cyanotic

0 = Oral = Axillary

TEMP S =Skin

A

T

60

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

=Tympanic

R = Rectal

20

I{R 011 .71 Vtit TOTALS: Must be 9 or

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

C =Cervical

T = Thoracic

L = Lumbar

S= Sacral

RR )1 e 11.13 A I )̀.L T "rf iff`10'NW Time riz. Patient teaching done; Wound Care, Pain Management, Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

on mut, on revere

PR

'cV

gna DEPARTMENTISERVICEICLINIC

03

DATE

1 1 3 )

PA E S I 7 AT ped or written entries give:

first, middle: grade: dare: hospital or medical facility, Name — last,

❑ HISTORY/PHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION D OTHER rsx‘dy ,

OR EVALUATION


O TREATMENT

MEDCOM - 13975

DOD-027527 ACLU-RDI 1623 p.135

GRAINS

11 lo • iz) faell01510Vs , 1 1 ) MEI MIMI 811M11111kiiMMOIMINFAIIIIIIIIMMUIME:211111 /06 TT

1111•1111111111111511MEIETIIIIMEEMERIMMEM MUMIIIIMMILEINIMINICINEMNIMIETREIREI 7o S

MIIIMINIRLEMBITEEIMISINIMI161)° 6 qc EREEMIIII 7MIEME117141111MMMICSIE1111211=111111

IV P?)

TOTALS

DATE

11 IV L03 TIME

BP Arterial Lme

BP Cuff

Temperature

Pulse

Respiratory e

bz Sovresz_ F-?o-z

Ca p C

PAGE 2 OF 4 HOSPITAL DAY

MinliiinEini:MESTAFAMMENEffa

11111111111101 Milaritffiero n. NWEMMEM

1111111111111111

OTANIIMIMEIMPALMNIE

ammummunnumommul.

II I 11111111 ob (3

3D

TOTALS 106

MEDCOM - 13976

DOD-027528 ACLU-RDI 1623 p.136

s

:^

r

F fo

, .

■

TIME 43Z7 T -31

12.2 2

30 q2 SAT

6 BASE

7


INTAKE

Iv SD PO a a

L

OUTPUT

Urine: 1 SCO • 10 tV

ICO /On

or2-J32- -757) siso ov)

PP 00 AD ID 10 0 4

Ai A.

oz. 1 .7 . MOUTH CARE

BATH

SKIN CARE

".` FOLEY CARE

TRACH CARE

.1:!" ROM EXERCISES

a4 I.? 72-11

[ma 111, 1±tilwr.4.7.1.111

kit I

,;•■ •

IND

•■■■■■■■■„,.

ToTAt-bb (0 TOTAL 165 MEDCOM - 13977 —

le ...Inn

U

R

,f

c

0

• R ".

t 11.14

00- 2G0 TIv

IP

•

DO

POST-OP DAY

230 0¢a Di AO 8T

ICCC 5

5 , /PO

I e0

3

TIME

GLUCOSE

NaIK

BUNK:

WBOPLATELET •

Hist/Hob

.AIMIMPAPALTIMMI

_____%1_411rdrAdrASIMBEN MAl21/111/12/1

TIME

DOD-027529

ACLU-RDI 1623 p.137

❑ FLOW CHART

❑ OTHER (Specify)

1:=1 HISTORY/PHYSICAL



❑ TREATMENT

REPORT TITLE

CARE RE NURSING FLOW SHEET. . • t• 4/6 •• • •••

kiENZROMMENtanaggandinV etS

r m m, P7,R PUPILS

SENSORIUM

TIME

MEDICAL RECORD—SUliPLrMENTAL MEDICAL DATA For use of this torte. see AR 40-66; the proponent agency is the Office of The Surgeon Genera!

INITLq ES

pA Appr 8 Mar 89

inigfigniM:82.618EWROMMENNINa INITIALS

OTSG APPROVED (Date)

PAGE 1 OF 4

RESPIRATORY PATTERN

BREATH SOUNDS

SECRETIONS

ABDOMEN

BOWEL SOUNDS

URINE;

COLOR/CLARITY

CARDIAC RHYTHM

ICP Intracranial Premum PCO2. PreSSure Of Arterial CO2

PEEP - Positive End Earxiatory Pim.;

PREPARED BY (Signature & Tide)

PATIENT'S IDENTIFICATION (Far typed or written entries giue: Name—last, first, middle; grade: date: hospital or medical facility)

1 DEPARTMENT/SERVICEJCUNIC

H

(Con inue on reverse)

1W.E.3-mo3 I C 1.4 3

DA 1 rACAT 17 8 4700 Proponent Dept of Nurs

WAMC OP 375 (Redesignated)

MEDCOM 13978 1 Apr 90 (HSXC-NU) -

DOD-027530

ACLU-RDI 1623 p.138

PAGE 2 OF 4

MOSPTTAL DAY

-% 11p /2940 %fir Ilry03 iqz (4%.7 t!ytt6

1C703 loO 100 IUS 06Y jab,' Po ./po i

AV 7E5 gi 20 al :3,6 W qb 100 co ql q? 97 TC C. TC, Te., Tr, "re- *r .L 41.,

63 73 75 zq

DATE 12,3UL

DX

TIME Oc; 611,!, 07 os ott 4,G- 44 4$2 BP Arterial Line 1%

.1 BP Cuff

Temperature

100 6)0o9col,tco6 joo' ko It s riA,0%1,"%i "z"Y,e,

qc, 50 iute /6133 Pulse

Respiratory Rate al 1/ ,50 .?n Nil 46 PO 5302 96 CIL/ Zi . 1=10 qo &X) too 04.fur ce re,,TC, TC, TC Fi02- all. 311. 31t. -w 3ti, 317.

TIME o5 ob 61.1- oet oq ito- 44- 47— 8°T 4)3 14 IL 2er 8°T

I VF toc) 15 b.25 tzs 125 12-5 r2b cm /25 12, 12,6 (Lc) 126 12S PS- Iz5 Icon an f 6 5 5 5 S 6 6 fit le 'to to (ip jo io

t V tvo mo 200 Nto Y-# 1%4 V*, 350 of

K

TOTALS

31 /. 31 t,3)111 31 3t 3( `6 ► frLi- 86 V3

ZOO

HOUR

TOLL ‘tf

stio two 24/ 167

id A0 Aess URINE

1P9r

STA

OUTPUT'

NG

GUI* C

EMESIS

STOOL

DRAINS

•

TOTALS

MEDCOM - 13979

DOD-027531

ACLU-RDI 1623 p.139

24 ,zz tzs /25 tz5

to /a

0 SY 8°T

/ZS- /Zs- 125 /-"K

75-7)

GLUCOSE

Na/K

CL CO2

BUN/Cr

WBC/PLATELET

Hct/Hgb

co 04,

4•3&O 11:fT

wt Yesterday wi Today

101 19,16eikr,l156?* MEDCOM - 13980

ciP SKIN CARE

FOLEY CARE

TRACH CARE

TIME

MOUTH CARE

BATH

INTAKE OUTPUT

IV urine:

,vr3

pida-

TOTAL -2c0s TOTAL 3 titir) BALANCE

tt,

••••••■•:

ROM EXERCISES

31/,

PAGE 3 OF 4

SAT

BASE

TIME

Al /A IIKKIMPAPIMPAII ParterIMPPAPAPPr IrdlirailMMI

DOD-027532

ACLU-RDI 1623 p.140

, TIME (

INITIALS

PUPILS

SENSORIUM

ICP Intracranial PreAura

PCO? -PrelSWC of Arterial CO2

PEEP • Posiii.e End Exprratory Pressure

- Fractional

SAl - Saturatton

TAACN-Inidleomomy

(Continue on reverse) PREPARED


PATIENT'S iDEMTIP Ti - s Luc: Name—last, middle: grade: date: hospi or medLca acility)

-41101P 1\f - 1-1




❑ TREATMENT

FLOW CHART

❑ OTHER (Specify)

/CO 3

INTENSIVE CARE.NURSING FLOW SHEET. •_ M.Wgtdgggg:EgfnaggnMggnggaga a


6- pA Appr B Mar 89

...A.

Pott ?0,AA. /14-c›,t3, -hva.e..44.,/

A.9-0 3

.e,‘ ,4 7 &ALS

RESPIRATORY PATTERN

BREATH SOUNDS

SECRETIONS

COLOR

INTEGRITY

ABDOMEN

BOWEL SOUNDS

URINE:

COLOR/CLARITY

CARDIAC RHYTHM

DATE

/

DA I Mr 78 4700 Proponent Dept of Nurs

WAMC OP 375 (Redesignated) 1 Apr 90 (1-1.5XC-NU)

MEDCOM - 13981

PAGE 1 OF a

REPORT TITLE

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

DOD-027533

ACLU-RDI 1623 p.141

DOD-027534

5163 05 DA TE f 5

44 42. 8°T 4,3 IA+

019

NG pH

TIME OS; 614y

BP Arterial Line 13/2 13;5;7

BP Cuff

ogt #o-

7, 13y.57 44 02- 44- "sz?' 1.3X. izoits...

Temperature

: 4erg: Pulse

Respiratory Rate

5A 0z-0 11,42

005 63 6,5"

ZS 90 93 VI 16 3143)4 "Tc.

61 57 zei 2) 819' _63 97 re6 . 3170 3170 rc. iG

Q5 6 62 71 )1 SS / gg-

100 100 30e 317,

67

`74 /00 too 317A 3i7

67

15" 3/1 -r&

•

TIME 09 Ob 03 DS

tzs-- _11__ 75- 7.5_

50

TOTALS

IL If 1,61 19 2er 8°T 16' 75- 75.- 45- 75 z

co 7g- iZ5—TS

7, <1C 7 5-- 7K 75

108

HOUR 6° 66' 101AL

URINE so 9,

". • qo 460 it

SIA

GUM C r EMESIS

STOOL

,)P DRAINS

L TOTALS

„..

MEDCOM - 13982

5o /Too 250

Oq 496r 76 7c

7,5 75" 75— 760 7S 75"

HOSPITAL DAY

ACLU-RDI 1623 p.142

yo /00 Z5"

16,

CitZT,Lf lay"7-1, t97- ?f5- 1) /5- r5,91- 9( W,/ 1/ z./

9-3" `not_c! (-1z. gq- 3/ ZS 41 (71 31

Tc- Tc_ Tc- 3/ ,Tc

T

U

R

N

TIME

MOUTH CARE

BATH

PEEP

GLUCOSE

141■41PAVAPP'IPSIIIIPAINV

TRACH CARE

:2•11•i&O TUT

ROM EXERCISES

wt Yesterday vet Today

. INTAKE

iv •

Po

OUTPUT

Urine:

TOTAL TOTAL

BALANCE

, ..

22. n co 04 02.0* ay T

5- 7-.(7c

too s-o

rYt°7/Y(7774/7'7- SKIN CARE

FOLEY CARE

MEDCOM - 13983

DOD-027535 ACLU-RDI 1623 p.143

0(2 INITIALS

❑ FLOW CHART

❑ OTHER (Specify)



• DIAGNOSTIC STUDIES

❑ TREATMENT

55ES muTtALs

1.l IN111AL$

je4)414.-A

efspivif ?Lc veh/ puiti

0 x6 PUP I LS

SENSORIUM ,

Cr • Creatinine

F 1 02 Frectson of 'mooed 02 sc03 - Bicarbonate

ICP • intraeranial Pressure

PCO2 - Pressure of Arterial CO2

PEEP - Positi.e Ergs Exp.ratory Pressure

- FraCtit0f41

SAl - Satur.uon

TRACK tracheostomy

PREPA

PATIENT middle

ipp /CO 3

or typed or written tries give: Name—last, first, spitaL or medical facility)

1 DEPARTMENT/SERVICE/CUNIC

IDATE1,14460

DA 1 FORM 4700 Proponent Dept of Nurs

WAMC OP 375 (Redesignated) 1 Apr 90 (HSXC - NU) MEDCOM- 13984

DOD-027536

TIME


MEDICAL RECORD—SUIVLrNIENTAL MEDICAL DATA For use of this term, see AR 40-66; the Proponent agency is the Office of The Surgeon General.

iNTENS.IVE.CARENUEISING FLOW SKEET. _ REPORT TITLE

OTSG APPROVED (Date) ,QA Appr 8 Mar 89

PAGE 1 OF 4

ACLU-RDI 1623 p.144

PAGE 2 OF 4 D[ mosion-AL DAY

DATE

"'AI OS ea o013 at? 4,6-- 44 #2..,„/ itg- 'pi. .15 M 17._

BP Arterial Line c* 6— Vki l;

BP Cuff A) 4-‘‘ Cil ($ g Temperature :21 en, 6, Pulse ) ( -4C+ 72/ G7g 0 -7 / ').".Z. V) ./a.3 2 i, -/i Respiratory Rate

1/N2 1 ` 11 .:2-7 a o-1,5typt 41rG '5( i Im-s-zio -NA RA Ria 13A112

TIME or ob as oq 4to- 42. r-r 44 I . II If-

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foci ,te?

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NG

GUMC

EMESIS

STOOL

DRAINS

TOTALS

MEDCOM - 13985

DOD-027537

ACLU-RDI 1623 p.145

IV

Po

INTAKE

POST-O► DAY ACUITY LEVEL CLASSIFKATION

ri TV

RATE

wt Today wt Yesterday

OUTPUT Urine: 'taco

111

TIME

MODE

F 1

PCO2

PO,

HCO3

SAT

BASE

A

G

TIME

GLUCOSE 8° T "

III NM MEI REIRENERNIMI

1

Na/K

C l/CO2

BUN Cr

WBCJPLATELET

Hct/Hgb

TIME

MOUTH CARE

BATH

SKIN CARE

FOLEY CARE

TRACH CARE

ROM EXERCISES

•:•

TOTAL tS i3 TOTAL tocto BALANCE 4- 12-43

S U C T

0 '

TIME ,

PEEP

PH

ACLU-RDI 1623 p.146

-


Appr 8 Mar 89

MEDICAL RECORD—SUPPLtMENTAL MEDICAL DATA For use of this form, see AR 4046; the proponent agency is the Office of The Surgeon General.

INTENSIVE CARE . NURSING FLOW SHEET.. 0 ••• ina MEM 21MM lialangaaaf ES NNE: SE iMaganagenel M:*

DA 1vICAIYM 78 4700 Proponent Dept of Nurs

MEDCOM - 13987

WAMC OP 375 (Redesignated) 1 Apr 90 (1-1SXC-NU)

Cr • Creatinine

F,02 - Fracuon of inspired 02 Sc03 - Bicarbonate

ICP. IntraCranial Pressure

PCO2 - PresSure Of Arterial CO2 PEEP Posati ■re End Expiratory Pressure

SJA Fracbon.4 SAi - Saturation

tRACH - I racheostomr

(Continue on reverse) PREPARED BY (Signature & Title)

PATIEtu•s laEhrnFicATIon, ( For typed or written entries gins: Name—last, first, middle; grade; date; hospital or medical facility)

OPP 'otp-` 1

ICLI 3 !DATE

❑ FLOW CHART

❑ OTHER (Specify)


DOD-027539




❑ TREATMENT

PAGE 1 OF a

REPORT TITLE

ACLU-RDI 1623 p.147

la 9 2ar 8° T

DATE

Ds HOSPITAL DAY

TIME 06( e‘ 07 08 act Oer 44 0 2- etii• t6 II- /6' BP Arterial Line

.; BP Cuff 13P Iitt .:0 I • 5 1 AIMIIIIIIKIMMTWAIMM

Temperature iot) 99 61b8 etat r Tr' cal qq6 Pulse (D5 tp6

/2 1 14 45 10 a (fil is (0(0

Respiratory Rate I N 151 4 g-q :15.3.2 3a 31 i 3 FL Z

Stio/. ql 95 GIS 92 ,96 q2 q3 4n qt, T7 cm? Smurc -e_ 4 RSA A RA Pi4 Ri).1 2.4-12_14

TIME 05 Ob 08 Oq d20- 44 42- 8" 423 44 /4 II If riC is 15 ls 7515 1615 tc0 14) "15 15 -n 0 1 t i3 1

(10 251) 3236 ;50

TOTALS

HOUR

i; • f4 t 41* • 14

A. At° URINE

'ID vs'

SIA

OUTPUT •

NG

GuLA C

EMESIS

STOOL

DRAINS

L TOTALS

MEDCOM - 13988

ti. -

DOD-027540

ACLU-RDI 1623 p.148

TV

RATE

PEEP

PH

A PCO2

1302

B HCO3

SAT

G BASE

24 n co 043' 02- 0

PAGE 3 OF 4 POST-0P DAY ACUITY LEVEL CLASSIFICATION

I Y 22 O2F Ot. 0 TIME E

ROM EXERCISES

TDT.

U

R

S U — C T

0 -hi I

NSE.SSIGNATURE.., 'N. INITIALS


9

7-P Z z

?

0

INTAKE OUTPUT IV • Unne:

Po

TOTAL

TOTAL

BALANCE

MEDCOM - 13989

DOD-027541

ACLU-RDI 1623 p.149

DOD-027542

:itEGE SJA - Fractional

SAl Saturation

RACH - 1 rodteOstOrny

CY • Creatinuse

F 102 Fraction of inspred 02

SCO3 - Bicarbonate

ICP Intracranial Pressure

PCO2 - Pressure of Jartenal CO2

PEEP - Posit's? End Exptratory Pressure

S.

RESPIRATORY PATTERN

BREATH SOUNDS

SECRETIONS

-4 IFOTLALS

PAGE '

IEPORT TITLE

INTENSIVE CARE NURSING FLOW SHEET

MEDICAL RECORD-SUMP MENTAL MEDICAL DATA For use of this form. see AR 40-66; the proponent agency is the Office of The Surgeon Genera!

OTSG APPROVED (Date) QA Appr B Mar 89

TIME

PUPILS

SENSORIUM

R:.

COLOR

INTEGRITY

LOCATION

CONDITION

ABDOMEN

BOWEL SOUNDS

URINE:

• • Po 6 • mi.:rm. a-- r- I •

a•

)1\* L a Se.i • •

RfA 1-

64, 4 oil/

G, fnuliALS PE IR •

•

IL11.41 W-N-1 .0,

57)r,NI Q.j•e_o.r•

' -10 _ s PLA s,zsla NOT cl t

iyelsc ca.' fte.0(1. Pe t 4 a • f) 'ackn.k

CARDIAC RHYTHM

449 rS + Ma. 1

COLOR/CLARITY

PARED BY (Signature & Title 41

(j lit ENT'S IDE faTiFSCA TIM (For typed or written entries glue: Name—Last, first, die: grade: date: hospital or medzeal facility)


DATE

tA.1 O3 ❑ FLOW CHART

❑ OTHER (Specify)

DEPARTMENT/SERVICE/CLINIC

)cu3



MEDCOM - 13990

ACLU-RDI 1623 p.150

Respiratory Rare

I . 7011111113#1111111 Pke..

MEDCOM - 13991

BP Arterial Line

BP Cu ff

Temperature

Pulse

PAGE 2 OF 4 HOSPITAL DAY

. 41

&1111111111111WM1111111111117/ 1111.911111 immums

1111111KE tot

al:V.IIIIII■remml•1111=1111EM

IIMMW711.1111111

DA" Zkl QJ DR

TIME

II <)0

TIME

513 EVEIIPL1 irIMFAINIMMINFICEMES 1111

E .

TOTALS

irAPAPAMFAMIM=E1111■111 ,‘ URINE SP 9,

Anf OLITPuT •

NG P“

GUIA.0

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STOOL

DRAINS

TOTALS

DOD-027543

ACLU-RDI 1623 p.151

PAG' 3 OF 4

;o5S-00 DAY warm( LEVEL OASSIEICATION

,.:

A

6:

.., 1

0.... '.-) ,

y t :i. TIME

i5:,,, . 11.4' Ar RATE

se. PEEP .,.?.:..:.•

; -'.4:V: .y.e...s. : 5 . ..-.4:

PH

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HCO3 SAT

BASE '

-<,0` "-:. TIME

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' GLUCOSE

121.1111MINVAPArdaMMINES ....

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ROM EXERCISES T 1 0 N

.:.."..".,:.':'' ,.... ,.: .:• ____-. ,:... :4::::,:tj:,.. :1% .-:)5 .:. Z-:. _. _.:.:: . •

4.4*.74:. 47A° M4.4'-. :OUZPV5tig ..!POI4E 5P°PlATURE:.tC surws V.:e.::7f

WI Yesterday wt Today

INTAKE OUTPUT

IV • .Urine:

Po

TOTAL TOTAL

BALANCE ■

MEDCOM - 13992

DOD-027544 ACLU-RDI 1623 p.152

DOD-027545


ADMISSION

14. FLYING STATUS

47 4$ 49 49 i 50 51

L1 . 11 I

17. UNIT LOCATION (State or 18. MOS Country Code)

621 63 I 64 65

1 20. SOURCE OF ADMISSION! AUTHORITY FOR

ADMISSION

16. BENERCIARY CATEGORY

ADDRESS OF EMERGENCY ADDRESSEE (Include 21P Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

IA A)

REPORTING MTF •

1 1 2 3 4

A

3. REGISTER NUMBER

9 10 . 11 12

For use of this form, se,. .. 40-400; the proponent agency is OTSG

4. PAY GRADE

(State or Country Code.)

BACK- GROUND

10. LENGTH OF SERVICE

32 33 34

12. SOCIAL SECURITY NUMBER

35 36 37 38 - 39 40 -41 42 43 44 45

19. TRAUMA

21. TYPE OF DISPOSITION

73 74 1

22. MTF TRANSFERRED TO

6 03 24. CLINIC SVC - ADMITTING 26. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMODI

28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y YMMOD)

MEDCOM - 13993

BRANCH / CORPS

16. ZIP CODE OF RESIDENCE

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

7. AGE AT ADMISSION

rvkanclktole_ 67 5 (A.)

ACLU-RDI 1623 p.153

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MEDCOM - 13994

DOD-027546

11] U

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ACLU-RDI 1623 p.154

INPATIENT For use of this form,

TREATMENT RECORD COVER SHEET see AR 40-400; the proponent agency is OTSG

1. REGISTER NUMBER NAME (Last, Hist, MI) ' 3. GRADE ADMISSION REMARKS

4. SEX

YV\

5. AGE 6. RACE 7.

..a.

RELIGION

g. 13.

H OF SVC

._ )1i, ORGANIZATION

Wp1/4

9. ETS

10) A

10. PREVIOUS ADMISSION

o

14. WARD 11. FMP

ck 15. FLYING

STATUS

k..1p,

16. RATING/ r OSS BEN

4.1-,Ai

16. BRANCH/CORPS

.1Jr A

19. UICIZIP 20. TYPE CASE

N'iL. \ 21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

v-Z)ICe.C.ike VC"CPAN..- E P.-


23. CLINIC SERVICE

A 6 NA- 24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 25. TYPE DISPOSITION

SZ 28. DATE OF DISPOSITION

GI- 31.e.( Fp 27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b. TELEPHONE NO. 26. DATE OF THIS

ADMISSION

5 likI.,3

ADMITTING OFFICER

r„ '.,J is, ..-')- 29 NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

(19.2'

30. DATE OF INTIAL ADMISSION

32. UNIT LE BLOOD/ COMPONENT TRANSFUSED

31. SE MINISTRATIVE DATA

Cheek if Ccsninued en Reverse

33. CAUSE OF INJURY

34. DIAGNOSES/OPERATIONS AND SPECIAL PRO

t

CEDURES

7/9/ //6-

Cg6 g

ozi, ki


a. ABSENT SICK OATS b. OTHER DAYS c. CONY. LVICOOP CARE OATS


e. BED DAYS

•

L. TOTAL SICK DAYS

36. Total Days AD Facilites

a. ABSENT SICK DAYS b. OTHER DAYS V. LVICOOP RE DAYS

\A6 .,, vv..

d. SUPPLEMENTAL CARE DAYS ,

-.): e. BED DAYS ' t. TOTAL SICK DAYS

SIGNATURE OF ATTENDING MEDICAL OFFICER

nit rnonn 3C1I1 RMAV 70

../.

14-9 S

SIGNATURE 0 MEDICAL RECORDS OFFICER

or

MEDCOM - 13995

USAFPC V1.10

DOD-027547

ACLU-RDI 1623 p.155

SUP 02

PCO2

DIP

MICRO APTT

PT

U

WBC

H/H

PLT

U

2

BHCG ETOH GLU

ABG/PULSE OX

PH P02

RADIOLOGY Check if read by ❑

radiologist

SAT OTHER

RESULTS

>O-1- //le'

EKG INTERPRETATION

<

lia) 1"-A—

Alar ° °T 1-41''LL4e47-- Po

ae 1 v,p ct-Ni PO- (ck h- t

sztv4>

14kr`-'-U • e A -1)72C--c-

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)


TEST RESULTS

PROVIDER HISTORY/PHYSICAL

7 1p " LeaZ 6-4 tf

cc,

01 pree.,_ tr-

J-N

TIME ACTION CONSULT WITH RESIDENT/MEDICAL STU

D STAMP

PROVIDER SIGNA

- kt,p DIAGNOSIS

-PYL".411 O U

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

cloth -1-1 '


STANDARD FORM 558 (REV. 9 -96) Prescribed by GSAIICMR FPMR 141 CFR) 101-11.2030,1110) USAPA V1.00

MEDCOM - 13996

DOD-027548 ACLU-RDI 1623 p.156

MEDICAL RECORD ERGENC ARE EM Y C

AND TREATMENT (Patient)

LOG NUMBER er-i

--1

TITMTIvIENT FACILITY


PATIENT'S HOME ADIDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS DgE (Day, Month, Year) .S\J t._. ■1 ̀1

TIME ,--

le CITY STATE ZIP CODE TRANSPORTATION TO FACILITY

SEX DUTY/LOCAL PHO N E MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES NO N/A rrEm YES NO

PRP ADDITIONAL INSUR • •

AGE,

4

".., I

HOME PHONE FLYING STATUS DD 2568 IN CHART

AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN n YES n NO

IS THIS AN INJURY? WHERE TETANUS

DATE LAST SHOT COMPLETED INTITIAL SERIES

. YES NO ALLERGIES

P -v...c Ae■

I NJIU RY/SAFETY FORMS

K.A.,

CHIEF COMPLAINT PFJ t,2{ '-

VITAL SIGNS

II EMERGENT TIN

1

E

,p, i./-7-D

1 / - TIME / %F0 BP 4rn

URGENT PULSE

1 INIT \I:Apo-REV /4.

TEMP 7e,/ • NON-URGENT wr cs-tn

ILA

B O

RD

ER

S'

CBC/DIFF ABG PIPTT BHCG/URINE/BLOOD/QUANT SEI301:1

0

AV

II-X

CXR PA & LAT/PORTABLE C-SPINE

ACUTE ABDOMEN LS SPINE URINE MS UA IIISCCIC.ATH CHEM:

SINUS HEAD CT BLOOD C&S X ANKLE R/L "r< 1 -" Pe- I v1.5 1166/

• ORDERS

MONITOR

ECG

TIME -,"'

ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION

n HOME n FULL DUTY

DISPOSITION QUARTERS /OFF DUTY

El 24 MS. n '48 HRS. n 78 FIRS.

PATIENT/DISCHARGE INSTRUCTIONS

MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION

IMPROVED

UPON RELEASE

UNCHANGED

• DETERIORATED

ADMIT TO UNIT/SERVICE REFERRED ill* 'TO WHEN

TIME OF RELEASE I have received and understand these instructions.

PATIENT'S SIGNATURE

PATIENT'S IDENTIFICATION Fo r typed or written entries, give; Name -- lest, first milogle; 0 ria. ISSN or other); hospital or mike! leerily)

111,\ \(\i) EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9 - 961 Prescribed by GSA/ICMR MIR 141 CFR) 101-11.2031611101 USAPA V1.00

MEDCOM - 13997 fht

DOD-027549 ACLU-RDI 1623 p.157

CL:AfiCAL RECORD - DOCTOR'S ORDERS For use of this form, sea AR 40-66', the proponent agency is OTSG

HE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM OR ;'6‘4 f ED YSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARRO ELOw.

I iutNTiFICATION

0 MI \( (s,

URSING

DATE OF OFiDER TIME Or OF■ DEFI

j --- 05 2-1(33 iLtOU RS

LIST T-$ DrIDE

NO T E D SIGN

0 Ad,_ /

U.) a

SI,x6(,_ • (D

1 O 4 U ; -6 tv_ IA, t. -_,_,..e_ UNIT ROOM NO. BED NO.

Q15 I

A &t-,

DATE OF ORDER TIME OF ORDER irqr

HOU'

ATIENT IDENTIFICATION

URSING

it120 2- 1. fi, GO C.S.- (..i..- I

, •

Lv.. ea3 .....A i CO

0 PL-- ' r . • , I . a • ..,...._ .

_ • IF-- ........._ _ UNIT ROOM NO.

6X/ CV.5 9,33O

BED NO.

Ill A,

if . ,,.., , ,

DATE OF ORDER TI

HOURS

AI A ATIENT IDENTIFICATION

URSING UNIT ROOM NO. BED NO.

ATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS

•

i • URSING UNIT' • 1 ROOM NO. BED NO. . _

MEDCOM - 13998

DOD-027550

ACLU-RDI 1623 p.158

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

For use of this form, see AR 40-400; the proponent agency is OTSG

1 2 3 4 5 6 7 8 (State or Country Code.) A 1 k \-> -..

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

C t 1 3'1,6"

4. PAY GRADE 5. SEX

9 10 11 12 13 14 15 16 17 18

6. DATE OF BIRTH (YYYYMMDDI 7. AGE AT AD ISSION 8. RACE 9. ETHNIC RELIGION

LA.A.N.V.-

19 20 21 22 23 24 25 26 27 28 29

Li

30 31 8AC:K GROUND

10. LENGTH OF SERVICE ETS

y.)/ks

11. FMP a 12. SOCIAL SECURITY NUMBER

32 33 34 35 36 37 38 39 40 41 42 43 44 45..

ct q ,e500- 000 ORGANIZATION (Active Duty Only) .

N.)1 Pc


ADMISSION BRANCH I CORPS

\f11.4 '''9

"I /Pc

46

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

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

V--, 1- q

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

62 63 Country Code)

64 65 66 67 68 69 70 71 YEAR

IN NO 20. SOURCE OF ADMISSION/ AUTHORITY FOR •

ADMISSION WARD

I c....k.aa...

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

72 ADDRESS OF EMERGENCY

-- ADDRESSEE (Include 2112 Code)

ICJ NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

W- CS 4 So tA4A.,

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE -

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION /V YMMD Di

73 74 75 76 78 79 80 81 82 83 84 85 86

le kr - 2 24. CLINIC SVC - ADMITTING 25! MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)

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

A--- & ,Ae At' Aei 3 o 1- be. 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (Y YMMOD)

103 104 Wattle Casualty Only)

105 106 107 108 109 110 111 112 113 114 115 -116 """--............,,,

FOR LOCAL USE

Cts_5-/6 Irv.,4? 1 cenwa" Gors.€, V.Si 0 rt 1 DyliceD I p roc 0 5-3 i

1 r.Q u rit.9 9 ••••- iv j q (401 L....

\A ■,) -- \.0 --1111111` ADMITTING OFFICER (Signature, SIGNATURE OF ADMITTING CLERIC,.................._

-------------'

11 A LA nAA nnne AAA rs

MEDCOM - 13999

DOD-027551

ACLU-RDI 1623 p.159

IDENTIFICATION NO. SIGNATURE OF PHYSICIAN

DATE ORGANIZATION

PATIENT'S IDENTIFICATION (For typed ur written entries give Name last, first, middle; grade; dale; hospital or medical facility)


• • MEDICAL RECORD ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter date of admission)

PHYSICAL EXAMINATION

PROGRESS (Enter date of discharge and final diagnosis)

ABBREVIATED MEDICAL RECORD , Standard Form 539

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR 141 CFR) 201.45.505 OCTOBER 1975 USAPPC V1.00

MEDCOM - 14000

DOD-027552 ACLU-RDI 1623 p.160

AL/ I i 101:1:1. I• L CrCAL

PROGRESS NOTES

SPONSOR'S NAME

FIRST

1. 0 !..:PONSOR

AST

SPONSORS IC.

I" SSPJ or


,1 -4:NIIF ION. (Fn type:: or mato" a:Jtnes, give: Name - last, first, ID No ot SSN: SCX: Date of Bruit: Ranh:Grad.)

RECORDS MAIM .,,INE .1) A 1 -1--

I REGISTER NO . Vv ARO AI,

PROGRESS NOTES Medic.il Recordd

:DICAL RECORD

[FA 1E-. NOTES

D360

M i1/4/

irrarrefQ d)," _b_24 cr/en-in-46a,

C-71Q 3 D--)'s Js,gx.c_4„ . I2/

)r-■

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DS Cloacraci p± cola tan 1 itnt6 \i5 to iwrpC:rq,atc1_60,4 reaericky(

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STANDARD FORM 505

\ Li

MEDCOM - 14001

DOD-027553

ACLU-RDI 1623 p.161

511-119

NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY

MONTH-YEAR DAY Ci

11.3...\( 1,13 90,5 1 HOUR

• .

PULS TEMP. F

105°

180 104°

170 103°

160 102°

150 101°

140 100°

130 99°

120 98°

110 --°

100

90 950

80

70

60

50

40

RESPIRATION RECORD

. • • • • .

. . . . . . .

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REGISTER NO WARD NO.

VITAL SIGNS RECORDS

Medical Record • • MEDCOM - 14002

STANDARD FORM 511 (REV. 7-95) Prescribed by GSVICMR, FIRMR (41 CFR) 201-9.202-1 •

DOD-027554

ACLU-RDI 1623 p.162

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) For use of this form, see AR 40-407;

Lthe ore nent aaencv is the Office of The Etimeon General. Mo. Yr. 2003 T

VERIFY BY INTI7ALING -ig.liggSg.,-**1 INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK! NURSE

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HR DATE COMPLETED

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EDITION OF 1 DEC 77 MAY BE USED.

MEDCOM - 14003

DOD-027555

ACLU-RDI 1623 p.163

Verit y by Initiating

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo Yr 2003

Order Date

Clerk Nurse SINGLE ACTIONS • Date to

be Done lime to be Done

Time Done initials

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USAPA VI.00 • MEDCOM - 14004

• DOD-027556

ACLU-RDI 1623 p.164

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

For use of this form, see AR 40-407: the or000nent aaenc' is the Office of The Summon General. Mo. Y r.

VERIFY BY INITIALING - -,, - _ ='- -,:,=-;:: INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

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DA FORM 4678, 1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. •

MEDCOM - 14005

DOD-027557

ACLU-RDI 1623 p.165

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.

Order Date

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to

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USAPA V1.00 • MEDCOM - 14006

DOD-027558

ACLU-RDI 1623 p.166

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DOD-027559

ACLU-RDI 1623 p.167

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MEDCOM - 14008

DOD-027560

ACLU-RDI 1623 p.168

INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400; the proponent agency is OTSG

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DOD-027561

ACLU-RDI 1623 p.169

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Standard Form 539

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MEDCOM - 14010

DOD-027562 ACLU-RDI 1623 p.170


SPONSOR'S NAME



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MEDCOM - 14011

DOD-027563 ACLU-RDI 1623 p.171


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MEDCOM - 14012

DOD-027564 ACLU-RDI 1623 p.172

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MEDCOM - 14013

• • A i . 11 „ a

DOD-027565

ACLU-RDI 1623 p.173

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MEDCOM - 14014

MIDDLE INITIAL

DOD-027566

ACLU-RDI 1623 p.174

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DOD-027567

ACLU-RDI 1623 p.175

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i it ill 0 3 A SS Uitej eT aw, p,05---co , Pr friem-T 40 ue,,,v,fre. et; ,,,h, ,u0 P h170 AT -itu-, 41,11-. . vs—s. Gr'iv-le,_ 40 Ae_ctc doepicAy 51,4). Pet.a04-( 14,-e jay AA 1,t)Mer AV ,(fr o4 Jeaccu , Lii 504 zi, L. loktpIL cl,ei.t.. ,

An, oileloptiolt Arteurio.., (17SX -1, Goad Use- AcgrOt, -Pc,..)Olict- 0 cv 1 .44( 05- 10 9 -71 " ›,-rke--..,/y. Az, (--i (A✓ 4-.4A. II- Dry - 6., /1 rc2Ai).(j-tp 10 fren4 ,1/4,,- ,

I Li Moil 0 96-% 1, 6--.)..-

aaela

111 0163 - -9% eirerf ties, :fie ,rte -6 Live Ji-a-C 000 thee 4..mle oaf ' e ci i Ca.,&1-ptke 13 mow)--rok_ e-i- /......--------

, a I ,...t.,- ._......

0 4-,,L.,-tet , 1-...,„ P-t r Ai 4-14- '

\ 1 -Al L. ,,r IA , _ 4 V 1—.‹.- 0 -4' (.0 4.4.0=0 "..--

17711 0400 -- Ct) . ll "n5. -r (

'..,......-/A■ ' •.L. . A =vr'_ • - -4 ..444-ar e.4.-0 1.A.,.4..._ Rem—, r-el D.- 1--- 02 , frar • - 1 d ki A N, • ,,,/ ')) "\

.1 ., . A. .40. e,-1 ..- ,. s•-• 1 a A -4.0li D _ -i--- , i . ..I. .


STANDARD FORM 509 (REV. 511999) Prescribed by GSAIICMR FPMR (41CFR) 10111.20316)(10)

USAPA VT.00

MEDCOM - 14017

DOD-027569 ACLU-RDI 1623 p.177


DATE NOTES

1 LIS '' >( ./1--A.ez,4->...-P— 2%12- e-O-A-Z.

,P1.11.0g- : eh era t'ir

' cit 6Aatzd- Ada

() j00.

.e _ils

6,4F±e..,.

vs,_s' -7 ...4

41-6:ee, r" ye" taA_ _ eel,eK, 4c.iilp

e., • .,-t4- --.0( ♦

- --(-1- :4_(? . &it- --r-

q--#.-6, MiX COt=e4;T<,_.t ,74 ---111pr/4" la Lk -

STANDARD FORM 509 IREV. 511999) BACK USAPA V1,00

MEDCOM - 14018

DOD-027570

ACLU-RDI 1623 p.178

DICAL RECORD

DATE PROGRESS NOTES

NOTES

AUTHORIZED FOR LOCAL REPR(

Of

15

UNSHIP TO SPONSOR

T./SERVICE

'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)

\e6

SPONSOR'S ID NUP (SSN or Other)

WARD NO.

PROGRESS NOTES Medical Record STA 59 Prescribed by GS/VIC

NMR FDARD

PMR FORM

(41CFR)0

01 (R 1-11 E

MEDCOM - 14019

DOD-027571

ACLU-RDI 1623 p.179

ite(A4-1-- CATEGORY OF TREATMENT

TIME

BP

PULSE

RESP

TEMP

*Or

BC/DIFF . ABG I PT/PTT

URINE C&S UA MSCC/CATH BLOOD C&S X

rn cc

0 cc 0

EMERGENT

GENT

NON URGENT

TIME

/7eft) INITIALS

VITAL SIGNS

A€617049.•

n/31 /1 /0

1°G/s-3 / 2- 3 341

1(1(e

XR PA & LAT/PORTABLE

ACUTE ABDOMEN

SINUS

C-SPINE

LS SPINE

HEAD CT

/7 BHC /URINE/BLOOD/QUANT

CHEM: /./14.r fir

ANKLE R/L

n PULSE OX ORDERS

MONITOR

NSN 7540-01- 75-


(Patient)

LOG NUMBER TR

2c4 1


PATIENT'S HOME ADDRESS OR DUTY STATION . ARRIVAL STREET ADDRESS

tPiA1 -e4 - Lk

DA ( TE Dr Mont

0 q

TI

MEI 3-0-4- CITY STATE ZIP CODE TRANS ORTATIL TO FACILITY A DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO PRP ADDITIONAL INSURANCE

AGE HOME PHONE FLYING STATUS DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS

7 INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN n YES n NO

IS THIS AN INJURY? WHERE TETANUS ALLERGIES INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTITIAL SERIES

. YES . NO HOW

TIME ORDERS BY COMPLETED BY TIME 1 1 .-s-s,

PATIENT'S RESPONSE /70 0 1,775 ,e_ec I CUitqc

/ grir frif /17- 4 , ...., /710 Cr, id - €. ol-lisuw Si - ' ii 0/5"" - - _.aI P-04 FT/Neiver..)7125., r • -riCaularfilifilL.47,49.1 .• (c. ;,.. t. !veY /7/7 ip-c., s-oce_ DISPOSITION

11 HOME n FULL DUTY

DISPOSITION QUARTERS /OFF DUTY n 24 HRS. n 48 HRS. ri 78 HRS.

PATIENT/DISCHARGE INSTRUCTIONS _

MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE

• IMPROVED UNCHANGED • DETERIORATED

ADMIT TO UNIT/SERVICE REFERRED

100. TO WHEN

TIME OF RELEASE I have received and understand these instructions.

PATIENT'S SIGNATURE PATIENT'S IDENTIFICATION /For typed or written entries, give: Name -- last,

first, middle; ID no. ISSN or other); hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-961 Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203H:4(10/ USAPA V1.00

MEDCOM - 14020

DOD-027572 ACLU-RDI 1623 p.180

Check if read by radiologist

WBC ABG/PULSE OX RADIOLOGY

<51--PCO2

RESULTS

C,KJL C H/H PH P02

PLT SAT OTHER

SUP 02

PT DIP EKG INTERPRETATION

APTT BHCG ETOH MICRO GLU

itillirMe

O

RESI DENT/MEDICAL STUDENT SIGNATURE AND STAMP

PROV IDER SIGNATURE AND STAMP

CONSULT WITH TIME ACTION

DIAGNOSIS

14,(1 r v,,

btit;v10,- P

IN ?lap!. cf5 PDY- 1

NSN 7540-01-075-3786


(Doctor)


TEST RESULTS

4-17 ..0-t-t-e_ -(,--4-te to5r-Ar g/-44-0-P-2rdt."-4J-c

t-teack-tf -(rt e soc ror: clke) 9,-kt Ly

,)bfi:424M-6e1Y7-1) 1-)0 CCAets-fLeot:3

P-Aj/JP (05 ; ", W-14 S tv\io ,

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


STANDARD FORM 558 ( REV. 9-96) Prescribed by GSA/1CMR FPMR 141 CFR) 101-11.2031611101 USAPA V1.00

MEDCOM - 14021

Wei , C" 211'13/l 3cr- effm

CCS ; a P601-12-C-

1>41% (A431 - sfrAz, frOAAA-a-_

PROVIDER "ISTORY/PHLY3ICA

2it e,i-e12;467 PA"-UK.

S

c/ at of A)" 01-A (s% po

ree-StA,Ca Loco .

57-° qt )t-t/tez(, r)b

gsfc,; 3ifa, as Ledk CR

DOD-027573

ACLU-RDI 1623 p.181

ACLU-RDI 1623 p.182

MEDCOM - 14023

DOD-027575

ACLU-RDI 1623 p.183

I 115:73701

1111111111111111111111111101 1111111111111001111111111111111101111111k 111111111101111111110111111111111111111111

111111111111111111111111

110111111111111111111111011101110k 11111111111111111111111111111111101111111 0 II

CO -I OZCC) -I -I >0 -I073c 0 r- 0 -4 2 H H 73 0

13 73 73 c

O

2,

O co

--a 0

-a

ACLU-RDI 1623 p.184

M

POST-

NONT

35.0°

RE4PIRATION RECORD

BLOOD PRESSURE

PATItm.

it4

ctg 931 57 ci0t

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

\42

EDICAL RECORD HOSPITAL DAY

DAY

H-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°

110 97°

100 96°

90 95°

80

70

60

50

40

' 1

L•

• :3 : o:

VITAL SIGNS RECORD

NY:

:

• A_

0 TEMP. C

40.6°

35.6°

36.1°

37.2° 37.0°

36.7 °

40.0°

39.4 °

38.9°

38.3°

37.8°

Q

4.

• STANDARD FORM 51.V . 7-95) BACK

MEDCOM - 14025

HEIGHT: I WEIGHT .•—•♦ p7d

DOD-027577

ACLU-RDI 1623 p.185

warEiem: 1,..■••

REQ A I G P 1 t,

- LABORATORY RESULT FORM Suliect

LASS" • • t

n*0

. -.

''CBC , ft

/45 ''')- Wit Till - .10 UrinalUrinalysis

--

to the Privac Act of 1974

SSN/PSEUDO •

T RESUL . .-•0 GE TES ! -

1 F. RANGE TEST RESULT REF. RANGE WBC - —1..s 4.8-10.8 x 10' Color N/A RPR Negative RBC 51 ,), 4.7-6.1 x 109 App N/A Mono Negative Hgb 1 ,./ .. D 14- 18 01 (M)

12-16 g/d1(F) Glu Negative

= Hct 45, 1 34 27 -45 72 :// (tr)) Bili Negative Source MCV ,_,

a - .3 80-94 fl (M) 81-99 fl (F)

Ket Negative Gram Stain

Pit 11 9 130-500 x 103

verified SG N/A OCC Bld Negative

Lymph % a . 1 20.5-51.1% Bld Negative H. pylori Negative • 00ts1ii

0zyzi : liitit '- iiiiiii

,,, 6.;g:,.-4,, tii, -;:....:.,. . Micro Parasites

Segs Mono Prot Negative Malaria Bands Eos Urob 0.2-1.0 0 & P


Atyp Imm Leuk Negative

RBC Morph

HCG Negative

Spun Hematocrit

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

4.:,

Sed Rate Cell Count


Other Directigen I Negative

-q;Aw v ,442i ,-,-- v c.co,,, 44.f.-. Olike'VM11;P

ii.411: 0 '''g41A

M ., YtIta 00

.it5 NOt--§ Msina ' -

TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH PT c

'

9.8-13.6 secs

APTT , tg 21 -34 secs

D dimer <20 ug/ml

FDP <10 ug/m1

REMARKS:

REPORTED BY: kl, 6"A

DAjwv, to ,,.).1 LAB ID NO.:

.k/("0`1' MEDCOM - 14026

ACLU-RDI 1623 p.186

)(N, 11111111* • •

le oa \(D-1-i cT4 o3

(i SQA:. iccolo) eons

`'ecolo TEST RESULT TEST REF.

RANGE a 138-146 mmoUL ALB

Cl

K

98-109 mmol/L

pH

PCO2 11-38 u/1

80-105 mmHg (art) N/A (yen) 23-27 mrnoUL (art) 24-29 mmol/L (yen) 22-26 mmoVL (art) 23-28 mmol/L (yen)

35-45 mmHg (art) AST 41-51 mmHg(yen)

7.31-7.45

3.5-4.9 mmol/L

REF. RANGE

ALT

ALP

AMY

RESULT

26-84 u/I

3.5-5.5 g/dl

14-97 u/I

10-47 u/I

NA+

BUN

CA++

CRE

GLU

TEST

eta o anl.:,

RESULT ' REF. RANGE

73-118 mg/d1

7-22 mg/dl

8.0-10.3 mg/di

0.6-1.2 mg/di

128-145 mmol/1

33-4.7 mmol/1

9R-108 mmol/1

P02 TBIL K+ 0.2-1.6 mg/d1

TCO2 CI

HCO3 tC

BUN

CA++ 8.0-10.3mg/d1

7-22 mg/di

95-98%

(-2)— (+3) mmol/L 10-20 mmol/L

1.12-1.32 mmol/L

8-26 mg/d1

70-105 mg/di

0.7-1.5 mg/di

38-51% PCV

12-17 g/dI

$

RESULT REF. RANGE

REMARKS:

s02

BEecf

AnGap

Ca

BUN

GLU

Creat

Hct

Hgb

TEST

Troponin-1

Drug of Abuse

100-200 mg/di

0.6-1.2 mg/di

- = PICCOLO 09/07/03 17 : 21 RLFEHt NCL RANGE ' MALE PATIENT #: 011111

ki) — MET LYTE 8 DISC LOT #: 3141AA4 OPER #: 432 DR #: 000 SERI AL # 0000100697

GLU 137* 73-118 MG/DL BUN 58* 7-22 MG/DL GRE 1.9* 0.6-1.2 MG/DL CK 243 39-380 U/L NA+ 125* 128-145 N'TIOVL K+ 4.1 3.3-4.7 MMOVL CL- 99 98-108 NIMOVL tCO2 21 18-33 MMOVL

INST OC: OK CHEM 0C: OK HEM 0 , LIP 0 , ICT 0

9.75-2)

09/.2.7:03 17;21

- z PICCOLO = =

FRE Na MALE- I ER : URI (40

A L. I VER PANEL Pr, Uo A )1`....--X1 0! . it:

'OPER #: 43! 31j5BA4

DR #: 00 00001 00684

2.3* 3.3-5.5 G/DL

48

26.84 U/L

21

10-47 U/L

61 14-97 U/L

33

11-38 U/L

1.4

0.2-1.6 MG/DL 34 5 5

5.6*

6.4-8.1 G/ Li. ?

1NST GC: OK CHEM 0C: OK HEM 1+, LIP 0 , ICT 0

REPORTED BY:

OR In

I

CHOL

CRE

is A SERI AL # :

HLEI ALP ALT ANY AST IBIl 313T TP

MEDCOM - 14027

DOD-027579 ACLU-RDI 1623 p.187

DOD-027580

CMISTRY RESULT FORM (Subject to the Privac Act of 1974

SSN/PSEUDO SSN:

T RESULT REF. RANGE

138-146 mmol/L

3.5-4.9 mmol/L

98-109 mmol/L

7.31-7.45

35-45 mmHg (art) 41-51 matH . yen 80-105 mmHg (art) N/A (yen) 23-27 mmol/L (art) 24-29 nunol/L yen) 22-26 mmol/L (art) 23-28 mmol/L (yen)

95-98%

(-2) — (+3) mmol/L

1 10-20 mmol/L

1.12-1.32 mmol/L

8-26 mg/d1

70-105 mg/d1

0.7-1.5 mg/di

38-51% Cy

12-17 g/dl

--III-,:"."': 6,5,,,,5,......4q, ,

RESULT REF. RANGE

-1

RKS:

7-22 mg/dl

02-1.6 mg/di

11-38 u/1

26-84 u/1

14-97 u/1

3.5-5.5 g/dl

100-200 mg/c11

8.0-10.3mg/d1

PICCOLO 10/07/03 04:52 REFEkENCE RAW MALE PATIENT #: V)6-14-1 GENERAL CHEM 'WY 12 DISC LOT #: 3082AA4 OPER #: 678 DR #: 00 SERIAL #: 0000100684

T T 12 1 1 0

MEDCOM - 14028

RESULT

0.6-1.2 mg/dl

73-118 mg/di

7-22 mg/di

8.0-10.3 mg/dl

0.6-1.2 mg/dl

128-145 mmol/1

GLU

BUN

CA++

CRE

NA+

CL

K+

RESULT REF. RANGE

3.3-4.7 mmo1/1

3.3-5.5 g/dl

26-84 u/1

10-47 u/1

14-97 u/1

11-38 u/1

0.2-1.6 mg/di

5-65 u/1

6.4-8.1 g/dl

• . .

"r,t1

128-145 mino1/1

98-108 mmol/1

18-33 mmol/1

AST

TBIL

GGT

TP

Section:

FURST W.

ULT 1111400

ALB 3.3 3.3-5.5 (3/DL ALP 52 26-84 U/L ALT 29 10-47 U/L AMY 239* 14-97 U/L AST 47* 11-38 U/L TBIL 1.8* 0.2-1.6 MG/DL BUN 47* 7-22 MG/DL CA+4 7.8* 8.0-10.3 MG/DL CHOL 134 100-200 MG/DL CRC 1.G* 0.6-1.2 MG/DL GLU 107 73-118 MG/DL TP 5.9* 6.4-8.1 G/DL

INST DC: OK CHEM OC: OK HEM 0 , LIP 0 , ICI 0

ACLU-RDI 1623 p.188

ALB ALP

ALT

.Niarr . InfOilt.PAA:qa4,1;tinat6;InIttt464.4-,, . - TEST RESULT REF. RANGE

11-38 u/1

0.2-1.6 mg/d1

5-65 u/1

6.4-8.1 g/c11

AST

TBIL

GGT TP

AMY

3.3-5.5 g/dl

26-84 u/1

10-47 u/1

14-97 till

Section:.

FIRST, MI. It

S1CIAN: 3T1N Cl....r.MISTRY RESULT FORM

(Subject to the Privacy Act of 1974) SSN/PS4

\r4

RESULT REF. RANGE TEST

138-146 mmol/L ALB 3.5-4.9 mmol/L ALP

ALT

AMY 35-45 mmHg (art) AST 41-51 mmHg (yen) 80-105 mmHg (art) T N/A (yen)

98-109 mmol/L

7.31-7.45

RESULT

1LARuA

26-84 u/1

14-97 u/1

10-47 u/1

3.5-5.5 g/dl

REF. RANGE

NA+

K+

CRE

CA++

BUN

GLU

TEST RESULT

mmo

0.6-1.2 mg/dl

128-145 mmol/1

8.0-10.3 mg/dl

7-22 mg/d1

73-118 mg/di

REF. RANGE

PI 1 0/0(2/03

C ff_f L NUL R

23-27 mirtol/L (art) 24-29 mmol/L (yen)

22-26 mmol/L (art) 23-28 mmol/L (yen)

95-98%

C

C

HUN 70-105 mg/c11. CRL

CK c NA t

K + CL-

12-17 01

C

SCOL 0 == - 12:46

ANGE : MALE 111 IrAD

3141AA4 UR #: 000

0000100104

92 73-118 MG/DL 2* 1-22 MG/DL

1.1 Q.8-1.2 MG/DL tw7* 38-380 U/L I'd() 128-145 MMOft

3.3-4.? HM0fiL ,-J8. 108 MMOV

Li 1P,-33 Mak

C

(-2) — (+3) mmol/L

10-20 mmol/L

1.12-1.32 mmol/L

8-26 mg/di

38-51% PCV

0.7-1.5 mg/dl

C t CrY.

PATIENT if: ME TL YTE 8 DISC LOT if : 0I-LR ft : 2 -33 SERI AL II:

uipllr- 1NST OC: (I( CHEM RESULT REF. RANGE /s HEm 0 , TIP 0 , ICI 0

CL' 98-108 mmoln

tCO2 18-33 mmol/1

CU

tCO2

3.3-4.7 mmol/I

98-108 mmol/1

18-33 mmol/1

DATE:

/0 JO;

V la

LAB LD NO.:

RICS:

ITED BY:

MEDCOM - 14029

DOD-027581

ACLU-RDI 1623 p.189

ING PHYSICIAN:

DATE

4er, ,c ,„,..

ptILLIMISTRYFUESULTFORNI (Subject to the Privacy Act of 1974)

SSN/PSEUDO TIME

RESULT REF. RANGE

RESULT TEST

3.5-5.5 g/dl

26-84 u/1 73-118 mg/di

7-22 mg/di

8.0-10.3 mg/dl •

A 4 1 •'f

B

P

T

_ Li

PICCOLO ==L- . :: 1110r/03 06:55

ERI- ":k RANGE: PATIENT #: MLFLYTE 8 DI:-;C LOT #: OPER 1/: 210 SERIAL #:

------- PICCOLO 11/07/03 06:54 REFERENCE R : MALE PATIENT #: \,; (.0 _14 LIVER PANEL S JO DISC LOT #: 3135BA4 OPER #: 210 DR #: 000 SERIAL #: 0000100676

MAIL

it, -LI

3111M4 DR #: J00

0000100697

OLU 80 BUN 10 CRC 0.3 CK 654* NA+ 130 K+ 3.5 CL- 106 tCO2 21

73-118 MG/DL 7-22 MG/DL 0.6-1.2 MO/DL 39-380 U/L 28-145 MMOL

3.3- 4.7 MMOVL 98-108 tipaL 18-33 MMOVL

ALB ALP ALT AMY AST TBIL GGT TP

2.8* 49 85* 136* 74* 1.8* 24

5.2*

3.3-5.5 G/DL 26-84 U/L 10-47 U/L 14-97 U/L 11-38 U/L 0.2-1.6 MG/DL 5-65 U/L 6.4-8.1 G/DL

INST OC: OK CHEM QC: OK HEM 0 LIP 0 , ICI 0

INST OC: OK CHEM OC: OK HEM 0 , LIP 0 , ICT 0

\.4

MEDCOM - 14030

tTED BY: DATE: ) 10v\lo3

LAB ID NO.:

Section:..

FIRST, MI. , (.)

—RE`

T

to Lti

i, ,

RESULT

, , , 7

REF. RANGE

138-146 mmol/L

3.5-4.9 mmol/L

98-109 mmol/L

7.31-7.45

35-45 mmHg (art) 41-51 mm1-1 yen 80-105 mmHg (art) N/A (yen) 23-27 mmo1/L (art) 24-29 mmol/L (ven) 22-26 mmol/L (art) 23-28 mmol/L (yen

(

95-98%

1

(-2) — (+3) mmol/L 10•20 mmol/LL

1.12-1.32 mmol/L

8-2 mg/d1

70-105 mg/dl

0.7-1.5 mg/dl

38-51%PCV

12- g/dI

4 RESULT

-. , ,..? I N7k“

% , ....r. '1.1', _2:2-z. ' REF RANGE

I- I^

----

DOD-027582

ACLU-RDI 1623 p.190

/234/V03 i&37

•o(otre.a t`D- Or.

I ! J

lematology) CBC Urina/ysis r- __. 1

Misc. Serology —1! t 1 REF R4 ,\.(.7.;/-: fl TE.c1T - REUT.7 . REF'. R.4.k(il:- P 11:-.C7-- T Hi-.:_ci - .0' ■ -lay: R ,--i A: i ;/-11

. g i

• " -1-3.-S—( 1 t'. — 1-c=ri7-', N,. .A 1-TITIT ; ,__________.1

I 1 A 1 ' - I

N'

i , kpi-,

1 ! N.'.A i 1\10110 1

1

--i 1

_,...

! 14-1X eLiii).1i I -in . JI 1

1 Clio i Net:now

11

VilicrObi 0

oi l gN:te.giiiike

:, . ■ ;.-, , 1 -12 -f N 2" ...- ; \ 1: Bili i —t—i —

Ni;. ,.-)..alivc., -111hC; , -- I , 1 t'--17",, II- ! ,_ I, —01.1FCC 11 i ■ .- : 1 • II

I ti(3-I; i !I( NI) K et r , N,,,at,„ -,,,-,(... „ ..,... ,

_,,,,!,„.) ii„ ,i,L,,,, . ,

_ 1K- .

._ii_Ii _ST CI I II SG

.1----

II Oce Rid ..,_ _ ---. -- -4

i 1 NelaiieJ ; -,, s i 1 1 ,,

ITIpri '',!, I 1 Bld

Negtiti ■ c II p.■ ! ' or' Nig:II IN

- --1- il

(liernatology) Manual Differenti pi i VAai . . _. . _._ .. 11 1 Micro

1 - 7;

m,

1 ono ! Proi ____4, Parasites

1 N1/4:..:LitiNi_• Ilii Malaria . i ,

! V os

1

I !rob I_

0. 1 -1.0 il o : Lialh.is , ji () I)

3 : # —h— 11- _ 4 I A Illilil I 1 k'...1S0 i - ir

Nit N ie. i ive ir-

■ 1 I I „I1 Other

H ---

i il

1,1 i . -r--

, ■ - Ai% i) ' , l ,

. Ncgai i ve -11 r Letik

:Microscopic imo

c Urinalysis t , i. . — L

P D 1 3

II - II- ---- ------ -- -- ------------ - - , CSF 1 Blood Bank

i 1. Cell -7---------- - 11711L7S,73' SUBMIT SF 518N-'1,--7111-1 Count l EVERY UNIT REQUESTED ,

1.._:' ' Dirte TiEz- eri T I

1 Negative A 13040i 1 i ,, ,--- _ 11 i i Coagulation Studies II Blood Bank Unit Crossmatch

(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD

I

r -----.7-7- 77---7.--7----7-- . - REQUESTED) RES1:1 -1 RE1- RA ..\;(i.L. L ,,Ain --1

1 TYPE ( ROS. ,. .1'/.41 If C ,

i i i i ; 9 si- I ; ei – ••• il —

; -12-5 ” X.1) „

- -

Other I

[DP •10

?, REMARKS:

- .t IIIp

4 1

A T 1 . A NO •

MEDCOM - 14031

3 ,

i: i te ■ 11;11: /CI li i

DOD-027583

ACLU-RDI 1623 p.191

4->

in'-) (Heinato o BC I ____,__________,,r_

r— _It Urinalysis

fi Misc. Serology A •_,\ ( - /. i ■ nt.1-- bc.,1-\01: ,4 TES] RESUT I . I REF. R.4 A.V-F: ill, iTS7 nki-:C . 1

it Coi,.•.1 - , N/A I; 1Z PR i --I

4

' .,-- — -•,._._ .--- _

II ■ - h, , '1i 1. 7 4).1 ,, i ir ..\ op

Motto 1 I Neua: 1 ■. c 1 14-th ,,,L110.-1) (nit

_ ! 1 I

Microbiolog,y !1

1 ----t--- --. b i IL. t 1 1 .1

.)- rS'" 0 )-.1i liili =:1 Negative ;7_470„ • ■ @

4 SGUIrCe 4 i i C V

. . • 1 j 80-cil 11 (N11 Ki.

___, ;1 G ram i

• _ I 1 —

_Li; I. il (la Nepii ,, e

Stain • II ‘_i - il

- - ------ .1- I , 1.iLf , {1. 1 0 - SU N . \ 11 ()cc 131d Ni1-1..atiN 1.2 -. il

-1- -,--

• !...,1.1 .1p,i .s ! I 1 : 1 .5-S I 110 1 Bid Negatil_c; Nel!-aii)e.

i 1 . !

_I_ E I . p \ lori

iIieniatology) Manual Differential pi- ! 1 Micro

k ii

it Para ites 11 - , + . . i ; Mon() Prot Negatke ii Malaria y 1 r . t - 0.-., 0.2-10 1 i Uroi) . la 0 & P , , • il

i vinpn ! • .

1 Nit Negative 1, Other li . I I •.. ____ 'I1F i -l:, p iiniii L eh k e

II Ni lc roscop tc Urinalysis • ■ i Negi-lik

1 ..—___– n----7.--

;I

1 Negative 1

a ! a II g i 1 !

•

! 1 .z.! ti , ! tt_

t ............■■■..- ,t. 1.) .i t :no r i 1 - 211 it 2: 1n1 It , I ■

I 11 ,

I; '1)!' i 4- — 1 i I.) t tt,2.,tly, 1. it i tt

t i _ -------: . --,

E ON . 1 VD ri7.! ri.AR NC) •

MEDCOM - 14032

i . . . . ■ j 42-L1L-nri N. 1) g 1 CSF o Blood Bank li 4 1 'hitt:Jim:61 1 37-17% ill

Sod Rate 1

. 17 Cell ! r li MUS1' SUBMIT SF 518 WITH II Count I E • , r '

. ,

r 11 EVERY uNIT REQuEs.t.ED 11

i Direct itzen : 1 ivegame 11—A i3O/R11 i ,. •

_____._-—.---•-•-----•••------.— __JI__ ■

Coagulation Studies -1- Blood Bank Unit Crossmatch

11, OlUST SUBMIT SF 518 WITH EVERN' UNIT OF BLOOD it REQUESTED)

.-.--71-7::_■7 ! Ri.-... ■ i. J. i - 7-/?/...): R. ,INGE !I t ',Ail/. 7.)7).E: i L 11 ! CROSS.II. -1 1( V/ i t .

DOD-027584

ACLU-RDI 1623 p.192

k5 45 41 1.• tccr

u lu; Wool lc t;11 N

I 1.111

11111101

L' 211 ithtiol i (art 2 3 2S nun"! I t,c

( 4c;ti it 7- 1.5 fl y. dl

liC1 38-51". "1 .

t.th 12-17 dl . _

Misc. Chemistry

i ■

1)4111.t. 1 -Nli.0111 ■ •

itttSe

•

DATE: LAB ID NO.: RrvoRTFD

(I iccolo) Metabolic Panel

REV R.

(

73-1 IS

1311N

7-T2 u ,gJ, ll

S.11-1(1.3

CRE

0 .11:172H .6..c11

NA

I .25-1 45 uunohl

K

('L

9t5-108 multi! I

R .02 15-33

(Piccolo) Liver Panel Plus

A S .1. 1 - 1 1:, S 1

l/Ab (i-STAT) (Piccolo) Chemistry 12

TEsi si 1 l' REI'' RA TEST R EsuL REF.

R.1NGE 13S-1411 11111101..1. A1.13 1.5-5.5 I.d1

7.• •4.'; mmol ALP

9t:- tti; nimoi

------- PICCOLO -------- 12/07/03 04:55 REFERENCE RN\JGE_: MALE PATIENT #: lez L5 -4-1 METLYTE 8 DISC LOT #: 3141AA4 OPER #: 878 DR #: 000 SERIAL #: 0000100494

1'(s5' l'

GLU 80 73-118 MG/DL 111II BUN 13 7-22 MG/DL AI,1'

CRE 0.8 0.6-1.2 MG/DL ALT CK 762* 39-380 U/L NA+ 131 128-145 MMOVL AMY

K+ 3.4 3.3-4.7 Nt'10M CL- 105 98-108 MOM_ AS1

tCO2 24 18-33 MMOVL GGT

\tz cHE, RN' R[ [.;l' FORM

DA'It — TINIF — (sL11*: ti;SN•PSIiI !DO StiN:

!Lille Privacy Act 1974)

1193:01 . 0 24

INST QC: OK CHEM QC: OK HEM 0 , LIP 0 , ICI 0

(Piccolo) ElLetrolyte

REF'. RANGE I

125-145 'untold

3 3-4.7 nmol - (

Oti• I ON

I itimt;111

RESULT

RES1 ,7.1' REP. ILINGE _ .

2ft-s4 till

111-47 0 , 1

I

. I I -IN 11(1

11.2-1 it Wig dl

.3.65 it:I

t 14:di

NA

K

L IRIIVIAIIKS:

MEDCOM — 14033

ACLU-RDI 1623 p.193

DOD-027586

•

.

.... „.„.4-„. , Patient - Limits 141€ 9.8 x10'3/uL 4.5 10.5 RIC 5.15 xW6/uL 4.00 6.00 Hgb 14.1 9/41 11.0 18.0 I-Ict 46.7 Z 35.0 60.0 TV 90.6 ft 80.0 99.9 ■1.:"M 27.4 pg 27.0 -31.0 rETIC 30.3 L g/dL 310 37.0 Pit 79. L x10'3/IL 150. 450. L1'I 23.0 * Z 20.5 51.1 LY# 2.2 * xl0h3/iL 1.2 3.4

W31: RH-

ikt ND; 1.31-1 ICHC

II Lt 4

Pit

Nr0 •

•

8.2 x10'3AL

5:06 x.10'6/!.I1

14.2 ..- ML 46.1

1.0 IL 28.19

:30.8 g/dL

54. L x10'3/ti

24.5 Z

2.0 x10A3AL

IS 0301

Patient Limits

4.5 10.5 4.0.0 6.00

11.0 18.0

35.0 60.0

80.0 59.9

27.0 31.0 ..3.0 37.0

150. 450.

2° 1: 5 :`

OCO (06 Li 12_0 7-03 04:57

Patient Limits

a 8.7 x10'3/tg_ 4.5 10.5 RIC 4,69 x10'6/111. 4.00 6.00 F.,.# 13.5 gilt 11.0 10.0 'Act 42.9 X 35.0 60.0 itil n 91.4 229

pg g 80.0

27.0 99.9

31.0 I'M 31.6 L gill 33.0 37.0 Pit 51. *L xl0A3AL 150. 450. Lt 24.4 X 20.5 51.1 LY0 2.1 x10'3/ut 1.2 3.4

*61 MEDCOM - 14034

4. „. •

• 't .

crt.' • .7 .1.7: _ _ 1 -

.

1t -4 0011 12-37-03 WB 04:12

Patient Limits

180 8.7 x10"3/uL 4.5 10.5 4.82 x10 -6/uL 4.00 6.00

Hb 13.8 g/dL 11.0 18.0 Hct 44.0 X 35.0 60.0 Mt) 91.2 ft 810 99.9 ro 28.6 pg 27.0 31.0 trriC 31.3 L g/dt. 33.0 37.0 Pit 51. * x10'3/fi 150. 450. LY . 3.4 74 215 51.1 LY# 2.2 x103/tiL 1.2 3.4

ACLU-RDI 1623 p.194

-.01 i Ci-10 i!

Unnalysis Misc. Serology h

ii i I RI-:, • -, ! kJ +- RA Arliii . Li TEST 1 RESt.. ,1 T 1 REF. R.4.VGE -0!-ST r RE.C1 If ,k

i REF R4N(;i- 71

: .r.- ■ o

,t1L__

i ;1 ‘

. 18-10S -- !!).' C7 11 NIA RP R lir

I N IA 0 L, ono I' r, i .._ ...,i 1.• ;

1 APP 1 Neguikc il I-I-1X p tti (Nn (ill., i Negative P i I ti..) ! 011

! Microbiology . o —t-

-r— ! ; 1 ;7-47', ti• -t

1 Hifi i i D otir-c.i..2

-12-:•■ 2' 011 ! Neaative r•-- — — If=4:

V i Kel 1 N „Ai\ e ; •••• kirarn i -- • ---- -- : NO- ,;• , 1 11 CM)

+-- ; 1 - 1 81-9( 1 !I 11 . )

17 •

i I it air! 1 ---f , —11--ST i____

eri ilc,I i II ()Cc 131J d i i

h 1

. 1

- o

!; !..:, t1iPP, 20.5 -50,, I Negat i\ e

. - - 1 H. Pylori 1

r .Nctiiiiile

I 1_11L1 ii

lii ( teirtaatology) Manual Differential pi ; NIA i m ,—. __....

1 ! Mono ! Prot -I' . 1 I

l_ 1 Ncgatite I li Malaria i

i IL L !!

L _I - i

I, _ ha! itit, i i Fos ' •

i t ;rob i --I-

0.2-1.0 . A.

J. ti I

! 0& P

Nit

i

---ir ii 1-- . Negative ()tiler

1 1 1-- i I mill l i Negative i ! . ii

Microscopic Urinalysis 1„ i_etik

p 1 ai eif-4- ; HCG i.. _L__ HI-- .Nk.,i 1 i ve . I-

li1 ,

1 11 _______ ,-....-L•. ■-■13,17...-.-....._%-..• .-----.---.-

1 CSF 1 Blood Bank -II II

il C'eil ; IVRIS1' MAMIE SF 518 WITH i I Count i , ,

1 EVERY UNIT REQUESTED Directigen ! 1 Negative A BO/R11 i

l I:•• . __ .._______ ...____ __ _ _ • i

Coagulation Studies —i. Blood Bank Unit Crossmatch II (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD

;• REQUESTED)

..q.„■ /. ; RL.t..././ ‘ •. RAMA: CV!. TYPE 1 C . RO,s'1::114111 —1

! (7.S-1 -,.() sous 1 • i.li i i

L.. 4 ' i 0 ' '-

, !

D . jiMel . i 1 •-20 lig/MI

I 'DP JL • 10 ti/n! I i

REMARKS:

. . . . . R 't fl

- I . it—ft I f) Nit) •

MEDCOM - 14035

! Baso i

! ■

! !

, 1 1

•.: I iciimicicrit i 1 37-17. i 1•')

i !

:-. -

DOD-027587

ACLU-RDI 1623 p.195

I.

; 11)1)

Ji — ir-

lit N .1 •

- V27)

2 :) CBC Urinalysis Misc. Serology 1 0:"S i . REF R4 :VG TEST T RESTITT F7REF RA A'GF R FTC! I 7 . I R4,VirT ; 10:

C0i0i•

; N/A It I A I r •pp N/A

1 .--..-... , --

! 1 ; Nes.v.alilc

, AlierobiOlOgy /—

r I

ill i; ! ■ l.. i ; N.:1! III 1 Negati ■ c T 1 1"--4 -M b!, 1 ! 1 fiili i

I I i ... , ..a.ln...L. I i; !!

II

L .

1;: (1)- :: (-1) il ,11 ( IN. ! ) III Kci 1— ! •?.\:.-.ative. -.4.1 11 I

10 t._:".,_ Tr:I li :111 1 il

i. _ 1 i - I-- ---- - ',u.5!.:i)x

1 \ crilicd II SG ! 11 1 N/.1

1 ill )cc i

. i

' '!!5-'31.1"0 1 ; Bid _ . I

El . p\ lori !

.g , o i,

i Nci2arn c 1 1 pl I i II

. NI, I

PM . Z.Ni

Ni i l:I . (7 iI II , i...Lr.N ! I k10111)

i i PI-01 1 N ‘ iti‘c

_ ii 3

[Via iaria I 1 r. ... . i

1 !rob i - i o i:i:11RiS if OS I

I 11 1 1 .1 IiI1 0 4!L P

i ,,-• , -t. I-- 1 !, I VIlinn

• .a SO 1 1111- N it ---

Ncsiiiive

i ,111 Other

1 , • : 1 i 1 I '

11 Leu k i Ne....U:\ c

Y i I" 1 v . I

_L__ I 1 Nlier0Seopec Urinalysis i . , ' , ..: .., .

f„ !-, rd.

pt.bot Negzitive - r--.

s 1 iiCt:i

Ili t Pti- 1 r, , „ li (i) ---------- T CSF Blood Bank l i iennu(usf II !

i

1

_ 5 ('eil i I ■ MUST S1 1 131\111' SF 518 \VIM ' ! ,--. , I

UMI R il

■

i EVElt.Y EQUESTED 1 k_ t. 4.1111 1

i li I)ircctigen 1 1 Negati‘c ii A i'10/1-Zii 1

II

ilfier i

. —777— --) , li Conciliation Studies 11 Blood Bank Unit (:rossniatch ,

1 5 (MUST SUBMIT SF 518 WITH EVERN' UNIT OF' BLOOD 5 I____ REQUESTED) 11 L

}1 ) f::

9 i; - i 1 r, • ,• • - ---,r- -- 1

T

0 .1 , 21101-2/rni r

li -_- ---* IL

0 uwrril ., 11

UM AR KS:

REPORTED WV: k)LAT-F-

(Hematology) Manual Differential

.11

MEDCOM - 14036

DOD-027588

ACLU-RDI 1623 p.196

======= PICCOLO =====-: 13/07/03 04:28 REFERENCE RAN MALE PATIENT #: METLYTE 8

\‘'.•./111 I.

It F.NI.k1;1■ S:

_ . R•1'ORIF1) R\ :

I,Ali 11) NO.:

• 1 \ d i d :'- 1,•‘.'11 _._. _-- _. . -----..--.• .., .. - !..R! IN( i 1 1 . 11 . >■ ICIAN: CUL. ,Z V RA:NI.' i ..1 . F(jitNi \ ■ I ' . -

I DkILH I '.

i . (_ ,1 1'1 1 - .•• 111., ' Pl.\ :R V .\/..1

NSN 11 ..11)() - .

(i-s.i..\44.) . _

(Piccolo) Chemistry 1 . 2(I iccoli)Nleialmlic Ilancl f 1 kl:I. R.I.Stik: lESI• 1-7,7.T..7 ,7:/7 --- ---0..'il .. - //...s/• I Ki...171 .1 I kk../.. A IS

■ N 1-1(1I11,1i.,11 AI I; 1 t ., - s s !. Ai II 61 i i 1: t•ii:.. m:.,I1•

! : , •i " ...AI 1 1;1 iN : 7 -.!..' 111i •11

• I.S•111. 1 I l itli,/1 1

DISC LOT #: 3141AA4 '' OPER #: 678 DR #: 000 - ( 1"-i-ccolo) !ALT Panel Plus SERIAL #: 1;1 ,...s.t 0000100494 A.:,4.• • A o i' ...v , i 1. 1.\, 1:'[ . R IN( 'I' .......................... GLU 90 73-118 MG/OL -R BUN 9 7-22 MG/OL V 121,•s•-i i CRE 1.1 0.6-1.2 MG/OL - . - 1 CK 384* 39-380 U/L

111 I NA + 136 128-145 MMOVL ' , FY i I.4.,7 u 1 K+ 3.2* 3.3-4.7 MMOI/L • H I.% 11 CL- 101 98-be mmom_ 1 I I 1- iS ii

- ILI 1 ;;.-)1"„ l'i \ 1 tCO2 27 18-33 MM0e/L hill i 02 I () ul di

! I Ni' 1.•!-1 :-..11

(.I I . • N (1 .■ li 1 !

Misc. Chemistry INST OC: OK CHEM OC: OK i, HEM 0 , LIP 0 , ICT 0

!t/-.l I. r ; /,'/../ kI.51;./... i . (Picc)lo) riecirolyie

r REF. /1.

— 1 I '.N-1-1. ■ uun.,1.1

S. ; uuuul 1

- 11;:, 'Jun.! I 1

IN-; ims.11 1 I t 1.1.

MEDCOM - 14037

; • 1 • .1,

DOD-027589 ACLU-RDI 1623 p.197

Sti 754o-m-165-72:m

SPEC.FIC REASONES) FOR REQUEST iCornplaint.Tand [hidings)

515-301 ,DIOLOGiC CONSULTATION REQUEST/AEI-011T

(Radiology/Nuclear Modicineillirrasound/Computed Tomography Examinations) AGE SEX SSN (Sponsor

FILM NO.

RECIGES ED P •'n

SIGNATURE OF c. TOR

EXAMINAT!ONiS) REQUESTED

F

WA R DiCLIN IC

10

REGISTER NO.

YES NO

TELEPHOIVE/PAGE NO,

DATE REQUESTED.

I I

7,ATE ::)TEXAMiNATION Jth ATL OF REPORT (Month, daYY) OATE OF TRANSCRIPTION I.°,/oruh, ZbiY,

EPORT

am, - lest, first, middle, Medical Facility)

"ATIENT'S IDENTIFICATION (For typed or written entries give: L CATID—N OF !MEDICAL RECORDS

LOCATION OF RADIOLOGIC FACILITY

MEDCOM - 14038

DOD-027590

ACLU-RDI 1623 p.198

MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION

PROGRESS NOTES

DATE NOTES

(I i Ma__

/ / (---

MN AATAWN V I MAL/i dAii- F In

731WM:r1 STAMIREAMME IF ,

.AYMI 0 I.,_:,WWIAME PO I" /WI A I I I I 1131 INV,Al 0 C_Nla ,

a'

IL Ji g

"WI I/WA I Eft A I ■ ii_l'eMill

LAST


DEPART./SERVICE

SPONSOR'S NAME

FIRST


MI


SPONSOR'S ID NUMBER ISSN or Other,

'ATIENT'S IDENTIFICATION: (For ryped or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Dare of Bum Rank/Grade)

REGISTER NO WARD NO


STANDARD FORM 509 (REV 5/19991 Prescribed by GSA/ICMR FPMR 1 41 CFR) 101 - 1 1.203(b)(1 0)

MEDCOM - 14039

DOD-027591

ACLU-RDI 1623 p.199

• () ion& a A

7b / e--vt

1,1

• •Y

MEDCOM - 14040

DOD-027592

ACLU-RDI 1623 p.200

Documents

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