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Transcript 
For use CLINICAL RECORD - DOCTOR'S ORDERS
of AND
this form,
AR 40the proponent agency is OTSG
SYSTEM
IT
THE DOCTOR
SHALL RECORD DATE, TIME
SIGNsee
EACH
SET66,OF
WRITE PROBLEM NUMBER IN COLUMN
I NDICATED By ARRO
PATIENT IDENTIFICATION
ORIENTED MEDICAL RECORD
ARROW BELOW.
ORDERS. IF P ROBLEM
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NURSING UNIT
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PATIENT IDENTIFICATION
DATE OF ORnco
mi
N URSING -
IN
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am
UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
DA
TFAcgh;9
4256
REPLACES
EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 17641
DOD-031230
For
THE
SYSTEM
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MEDCOM - 17642
DOD-031231
CLINICAL RECORD . DOCTOR'S ORDERS
For use of this form, see AR 40-66,
THE DOCTOR SHALL RECORD
the proponent agency is OTSG
SYSTEM IS USED, WRITE PROB DATE, TIME AND SIGN E
LEM NUMBER IN COLUMNACH
INDICATED
BY
SET OF ORDERS.
IF PROBLEM ORIENTED MEDICAL RECORD
PATIENT IDENTIFICATION
ARROW BELOW,
J -Li■
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
P AT IE N
T IDENTIFICATION
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■ TIENT IDENTIFIC
P
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5cE
SING UNIT
1 APRm79
D
4256
REPLACES EDITIO
'a U.S.
GOVERNMENT PRINTING
OFFICE: 1994- 363.710
MEDCOM - 17643
DOD-031232
p i- )-0 0.“
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MEDCOM - 17644
DOD-031233
CLINICAL RECORD - DOCTOR'S
ORDERS
onent
agency is OTSG
IF PROBLEM ORIENTED MEDICAL RECORD
For use of this form, see AR 40-66, the prop
SET OF ORDERS.
TI
LI
BY ARROW BELOW.
ORDER
OF
BER
IN COLUMN
INDICATED
THE DOCTOR SHALL RECORD DATE, TIME
AND
SIGN EACH
NOTED AND
71ME
, WRITE PROBLEM NUM
SIGN
SYSTEM IS USED
ICATiON
PATIENT IDENTIF
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
sisC
PATIENT IDENTIFICATION
11%.
PATIENT IDENTIFICATION
NURSING UNIT
DA
FtVA1 9
4256
PLACES ED N o
MEDCOM - 17645
DOD-031234
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
-DATE OF ORDER
TIME OF ORDER
/ -Jac AVG 03
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1 APR 79
OOM NO.
7-7,CPP
4256
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BED NO.
MEDCOM - 17646
DOD-031235
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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TIME OF ORDER
HOURS
NURSING UNIT
DA
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ROOM NO.
4256
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 17647
DOD-031236
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THERAPEUTIC D
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For
N
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40
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MEDCOM - 17648
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
DOD-031237
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MEDCOM - 17649
DOD-031238
CLINICAL RECORD
THERAPEUTIC DOCUMENTATION CARE PLAN
For use of this form.
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4677, 1 OCT 78
EDMON OF 1 DEC 77 MAY BE USED.
MEDCOM - 17650
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 V1.00
DOD-031239
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PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9
10 11 12 13 14
E 15 16 17 18 19 20
21 22
DA FORM 4678, 1 FEB 79
N 23 24 01 02 03 04
05 06
EDITION OF 1 DEC
77 WILL SE USED UNTIL EXHAUSTED.
MEDCOM - 17652
USAPA V1.00
DOD-031241
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N 23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 mni I tar I
MEDCOM - 17654
EXHAUSTED.
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DOD-031243
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MEDCOM - 17655
DOD-031244
MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA
For use of this hark see AR 40-86: the ptopenent agency is the Office et The surgeon &new.
REPORT TITLE
1
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date:
Time In:
Allergies:
Pre-op VIS:
Procedures:
Anesthesia Type (Circle)): General Spinal Epidural
a _, (3.0 IV Sedation Nerve Slick
OR Intake: Crystalloid "--"°
Colloid 100 COD
OR Output LIOP
EBL ' 4
i. Meds/Times:
Drains
Hemovac
NG
JP
T-tube
Foley
+K
Pre Op Med
OTSG APPROVED Woe/
Histo
Airway
Nasal
Oral
ETT
Trach
Other
TLS
Time
Sa02
FiO2
Methods
240
220
200
180
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Time
Solution
CZ—
PAC h
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Amount
Site •
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jtcso
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Codes
AIRWAY
A =Ambu
BB =Blow-by
M = Mask
FT = Face
Tent
= RoomAir
NC = Nasal
160
140
120
Cannula
ViS
X = A-line BP
= Cuff BP
= Pulse
1 00
80
Color
60
(2) Baseine coke d appearance
(1) Pale. rnotbert, jaundiced
(0) Cyanotic
40
Circulation (Peds < 5 Years)
(2) radial Pulse Palpable
(1) Axiiary palpable. not radai
(0) Carotid only reliable pulse
20
aa
TOTALS: Must be 9 or
greater to D/C. otherwise
needs anesthesia approval for
D/C.
RR
T
Time
Pain (0-10)
LOS
TEMP
S = Skin
0 =Oral
A = Axillary
T =Tympanic
R = Rectal
LOS
C = Cervical
I = Thoracic
L = Lumbar
S= Sacral
Patient teaching done; Wound Care, Pain Manage
T, C, •\08.. Incentive Spirometer, Comfort Measures
Sa ety. SR up X 2 Falls Precautions. Privacy Maintained
(V)
TIFICATION (For typed sr
TISERVICElaJNIC
Ituatilla MIEWSW
DATE
10-.)
Name —last
date; hospital or metal
❑ HISTORYIPHYSICAL
ID FLOW CHART
❑ OTHER EXAMINATION
OR EVALUATION
❑ OTHER aped&
❑ DIAGNOSTIC STUDIES
TREATMENT
DA FORM 4700, MAY 78
WAMC OP 173 E, (Revised) 1 Apr 01 (NICXC
DN)
-
-
Previous edition Is obsolete
USAPPC V2.00
MEDCOM - 17656
DOD-031245
_..k5SING NOTES
MEDICATIONS
Allergies:
Pain
Time
1-in
0
O?-
Medication &
Dnsaoe
(5.
Route Pain
1
By
UE
T-4-= pe_c9:301(--k-m‘,0 O
0,ccowvfx-t-r.%
iiiii =MEM 10 PA
IMINIGENSIVAI 10 In
MIXESFIERIX.
Site
Time
\vc(-N
NEUROVASCtilLAF
Range Sensory P
Of
10A-PM:gc4n o
ani
4
—Is
'cm NNV'm mkt
Cap
Refill
k)1 \ C 3rrki
Adm
15'
Pt•
-k")
516-f
3-S • biz)
30'
45'
60'
ASSv--c
90'
DIC
Movement/Sensation: + =present.-= absent Temp:C a Cool,
W =Warm Pulses: Pa Palpable, D Doppler, A = Absent
Color: C= Cyanotic,
P = Pale, Pk =Pink
Capillary Refill: B a Brisk, S = Sluggish
m
C-SECT10146
45'
30'
15'
D/C
Fund.Fleight
Lochia
Peripad#
Fund. Cond.
Time
Location
DRESSINGS
Type
Drainage
Adm
er-t -kz:c
30'
60'
D/C
PACU.OUTPUT
Discharge Criteria:
ate: rOkita..3 Time: Ce)3C- PARS: p,
HR: 16 (S RR: I
BP: V-1.02 T: '
CARDIAC RHYTHM
Rh hm
Time
(13
.4,G
s.
citc
Symptomatic?
s r\
Rhythm Strip Run?
Pain Level at D/C (0-10):
Intake: I t.-i.,
Additional a •
Transferred To: ..___ ,. A _.,
Report Given To: k"C`
Transferred Via: WIC
Transferred By: 4■1/\4 ±vCleared IAW Recovery R
Charge Nurse Signature
Output:
3 --
-1--iaC
MILOPIR
.E
Sa02:
n)
1-
WAMC OP 173-E
MEDCOM - 17657
DOD-031246
For use of i
REPORT TITLE
RECORD-SUPPLEMENTAL MEDICAL ,
this f nin, see AR 40-66; the proponent agency is the Office of The Sunteon General.
INTENSIVE CARE NURSING FLOW SHEET
OTSG APPROVED Ware))
QA APPR 08MAR8
C
A
R
D
I
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ADMISSION AND CODING INFORMATION
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OCTOBER 1976
MEDCOM - 17666
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USAPA V1.00
MEDCOM - 17669
DOD-031258
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM - 17670
DOD-031259
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM - 17672
DOD-031261
NSN 7540-00-634-4176
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6-97)
Prescribed by GSAACMR
FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17673
DOD-031262
DATE
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MEDCOM - 17674
DOD-031263
NSN 7540 -00- 634 - 4123
510-11
NURSING NOTES
MEDICAL RECORD
(Sign all notes)
HOUR
DATE
OBSERVATIONS
Include medication and treatment when indicated
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STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17675
DOD-031264
NURSING NOTES
(Sign all notes)
•
DATE
HOUR
A.M.
OBSERVATIONS
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'U.S. Government Printing dttice: 1995 - 404-763/20065
MEDCOM - 17676
DOD-031265
NSN 7540-01-075-3786
LOG NUMBER I TREATMENT FACILITY
EMERGENCY CARE
AND TREATMENT
(Patient)
MEDICAL RECORD
RECORDS
:..4 .1.
ARRI
PATIENTS HOME ADDRESS OR DUTY STATION
STREET ADDRESS
(Z A lA (I 1)3
CITY
AREA CODE
°S
ITEM
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PRP
HOM
AGE
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ADDITIONAL INSURANCE
..------
DD 2568 IN .CHART
EMERGENCY ROOM VISIT
INJURY OR OCCUPATIONAL ILLNESS
CURRENT MEDICATIONS
YES
ITEM
IS THIS AN INJURY?
n YES
1
HOW
3 1411
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CO
DATE LAST SHOT
INJURY/SAFETY FORMS
ALLERGIFS
0
TETANU
, WHERE
V
24 HOUR RETURN
DATE LAST VISIT
WHEN (Date)
NO
.
NAME -CSF INSURANCE COMPANY
1 MED1CAL,HISTORY OBTAINED FROM
AREA CODE7MBER
YES I NO
N/A
NO
FLYING STATUS
- ONE
DI- °
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THIRD PARTY INSURANCE
MILITARY STATUS
DUTY/LOCAL PHONE
SEX
I
TRANSPORTATION TO FACILITY
I ZIP CODE
STATE
A
TIME ...... t r.
DATE (Day, Month, Year)
0 YES
III NO
---
CHIEF COMPLAINT
❑
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TIME
TIME
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VITAL SIGNS
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HEAD CT
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MONITOR
•
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BY
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PATIENTS RESPONSE
TIME
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FULL DUTY
n
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n
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ADMIT TO UNIT/SERVICE
CONDITION UPON RELEASE
•
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RETURN TO DUTY
MODIFIED DUTY UNTIL
IMPROVED
n
•
DETERIORATE
UNCHANGED
REFERRED
►
. WHEN
TO
I
I have received and understand these instructions.
TIME OF RELEASE
PATIENTS SIGNATURE
PATIENTS IDENTIFICATION
ri
(For typed or wri ten entries, give: Name — last,
first, middle; ID no (SSN or other), hospital or
medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
P
411111 6‘.krA
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSNICMR
FPMR (41 CFR) 101-11.203(b)(10)
USAPA V1 00
MEDCOM - 17677
DOD-031266
C
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
1. AGE:
HEIGHT:
For use of this form, see AR 40-66; the proponent agency is TheAfrice of the Surgeon General
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
KVA.- c.:Ac-3. PREVIOUS SURGERY [...\-1 NO - -IrWYES (type):
WEIGHT:
4. PROPOSED SURGICAL PROCEDURE:
5. ADDITIONAL INFORMATION: Last PO: ?
Family waiting: yes/0
Jewelry removed: ye
%Neat:,
(.9 NID
6. PATIENT PROBLEMS AND NEEDS
Medical Ha:
Implants: ?
7. PATIENT GOALS AND EXPECTED OUTCOMES
A. PSYCHOSOCIAL
/Potential for anxiety
related to traumatic injury;
c
Pt. verbalizes any specific anxiety.
g
Pt. exhibits relaxed body posture.
language barrier;-ftmrity&&paratioo; surgical environment
B. AE:RATION
Potential for
--respiratory dysfunction due to
8. OR NURSING INTERVENTIONS
o Allow pt. to verbalize
f ely.
o Explain OR environment
a d answer questions
r garding surgery.
Offer comfort measures,
( .g., warm blanket, touch)
o Explain all nursing
p ocediires before they are
ne.
Remain with pt. whenever
ossible.
o Maintain family interface.
.„...ef PT. will be able to breathe without
difficulty during immediate intraoperative phase.
o Offer to elevate head of
litter or offer pillow.
Observe pt. while awaiting
urgery for signs of distress
o Assist anesthesia during
intubation and extubation
,ci..--VT. will not exhibit signs of impairment of skin integrity (e.g., reddened
areas.
Utilize pressure preventing
evices on OR table and
ccessories.
Check for proper
ositioning and support to
aintain good body alignment.
' Pad pressure points.
to
Place ESU ground pad on
non compromised skin surface
area.
o Keep prep fluids from
ooling,
sedation; positioning; injury
C. INTEGUMENT
_....Potential impairment
of skin integuity due to Bovie
Medications: 3
,
pad; position; fluid shift
9. PATIENT'S IDENTIFICATION (For typed or written entries
give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91
Previoius editions are obsolete.
USAPA V1.01
MEDCOM - 17678
DOD-031267
6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
Pt. will exhibit signs of adequate
tissue perfusion (e.g., color, warmth,
pedal pulse).
0 Check for support stockings or ace
wraps. If none, check with doctors.
.a--Check that safety straps are
correctly applied.
..."
------- Potential for inadequate tissue perfusion due to
o Offer pillow for under knees.
anesthesia; traumatic injury;
position; shock; previous surgery
0 Place and take down legs from
stirrups with slow bilateral motion.
.
o
E. NEUROMUSCULAR
CONTROL
E.1. ------ Potential impairment
of mobility due to sedation; pain;
injury
Pt. will be transferred to OR table
Have sufficient people
vailable for transfer.
Insure proper body
lignment.
Allow patient to lie in
sition of comfort while
siting for surgery.
Offer support (i.e., pillows,
athtowels, etc.) for'
positioning.
w ithout difficulty.
Pt. will not experience unnecessary
p hysical discomfort.
.
E 2 ------ Potential discomfort
due to injury; pain
F. NEUROMUSCULAR
CONTROL
F.1. ----- Disminished visual
perception due to being
injury;
sedation;
......--Potential for decreased
F2
communictaion due to language
barrier; sedation ---Ljo,c - Nam
-a- Check that rings have been
removed. L....,,,,—. }Die_ *9 '1"--^-.."(1,/°- 1
di
Introduce self. Keep pt.
i formed as to where he/she is
nd what is happening.
•
Inform pt. in which
rection to move and assist if
n cessary.
Speak clearly and slowly.
Address pt. from
—1—Ins-•-1 side.
9 Validate pt.'s
understanding of verbal
communications.
o Verify removal of dentures.
Pt. will be made aware of
urroundings prior to anesthesia
' duction.
Pt. will be transferred safely to
R
able.
Pt. will be able to understand
structions.
Minimize danger of injury during
intraop period.
F.3. Potential injury due to
dentures.
G. OTHER PATIENT PROBLEMS
OTHER PATIENT GOALS AND EXPECTED
OTHER NURSING
NEEDS. Or continuation of above
problems/needs.
OUTCOMES. Or continuation of above goals
and outcomes.
INTERVENTIONS.
Or continuation of above
interventions.
in (IR rut ict.iikir. iniTPRVFNMCNS C:nmpt PTED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
DATE
11. POSTOPERATIVE EV
5t4, e_ Wrt cA,
56-1-t-WW.And-0
12. PREOPERTIVEEV
(Signature and Titte)
DATE: RA,k4c°12,
TIME: t
4:%4C-G.'(
PREPARED BY
(RtYrk)
13. PREOPERTIVE EVALUATION PREPARED
BY (Signature and Title)
DATE: 13.
n
c4:41410
TIME: I-3_ ^2
I .711
USAPA Vi 01
REVERSE OF DA FORM 5179, JUN 91
MEDCOM - 17679
DOD-031268
INTRAOPERAM
MEDICAL RECORD
•
1. PATIEN
T TRANSPORTED TO OPERATING ROOM ,
VIA k tl..4.4
\-0,4 CP)
VERIFIED BY
ITE
ROCEDURE
CY \
4. PATIENT IN ROOM
b fc--
164 c""
TIME
`
5. PREOPERATIVE EMOTIONAL STATUS
0
VA CALM
COMMENTS:
,,, is the office of The Surgeon General.
2. PATIENT IDENTIF,I\ED ,
e/flO \
B ifkalthk
TIME PATIENT ARRIVED IN
3. DATE
CUMENT
For use of this form, see AR 40-66, the proponent ,_
.
• ANXIOUS
•
EXCITED
❑
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NUMBER
❑
ANGRY
WITHDRAWN
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• OTHER (Specify)
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6. NURSING PERSONNEL
S CI.N
ASSIGNED
SCRUB
RELIEF
SCRUB
_ z
GR T
ASSIGNED
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CIRCULATOR
7: POSITION AND POSITIONAL AIDS (Specify)
PRONE
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9. LOCATION OF EXTERNAL DEVICES
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11. PATIENT IDENTIFICATION (For typed or written entries give:
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l•-IP‘
12. ELECTROSURGERY DEVICE(S) (ESU)
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-
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USAPA VI 01
MEDCOM - 17680
DOD-031269
IF YES NAME: ID NUMBER; Ili
13. PROSTHESIS, IMPLANTS
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NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
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CULTURE (C)
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19. ADDITIONAL INFORMATION
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Surgeon
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./
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14
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MEDCOM - 17681
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DOD-031271
IECORD-SUPPLEMENTAL MEDICAL .
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. AR 40-66; the proponent agency is the Office of The Sury.
For use of this form,
General.
OTSG APPROVED (Dare)
REPORT TITLE
QA APPR 08MAR8
INTENSIVE CARE NURSING FLOW SHEET
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PATIENTS IDENTIFICATION
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REGISTER NO
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Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1
MEDCOM - 17685
DOD-031274
MEDICAL RECORD
VITAL SIGNS RECORD
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REGISTER NO
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STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 17686
DOD-031275
MEDICAL RECORD - ANESTHESIA
1.-0,0
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ANESTHETIC TECHNIQUES: Describe block technique under Remaas
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PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,
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For L
-
MEDCOM - 17687
c_)ej•-)
PAGE
NT'S MEDICAL RECORD
1
OF
USAPA V1.00
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MEDCOM - 17688
DOD-031277
•
74R'S ORDERS
13ECORD:;
C
use of this fanA, see AR 49-66, tbe•piVorlertt. agency is OTS
PF-toeLEm.ORIENTED MEDtCAL RECORD
TtiE pOCTQN SHALL RECOI913 , ::PATE, TIME AND SIGN EACH' SET OF ORDERS:
SYSTEM IS uSEO,
WAITE , PROiLEm NUMBER INi,cp-1,14MN INDICATED BY ARROW BELOW.
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MEDCOM - 17689
DOD-031278
.
CL iNlCA : RECORD
lipCTOWS ,,OTWERS
proponen't agertv, is OTSk?
For otpf•this form -see. AR. 11•D,8, the :
THE DOCTOR 'SHALL RECORD DATE, T{ME ;AND SIGN. EACH SET OF ORDERS, IP PROBLEM ORIENTED MEDICAL RECORD
WRITE PROBLEM :NUMBER IN •06.,m1s) INCrICATED BY ARROW BELOW;
SYSTEM 15 USED
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MEDCOM - 17690
DOD-031279
ITATION CARE PLAN (NON-MEDICATION)
THEIALFIL'EUTIC-- D0b6;i1Eisr
For use of this form, see AR 40-407;
CLINICAL RECORD
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is the Office of The Surgeon General.
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DATE
the Rropnent actenc
EDITION OF 1 DEC 77 MAY BE USED.
9
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12 13 14 15
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16 17
18 19 20 21
N
24 01
02 03 04 05 06 07
22 23
USAPA V1.00
MEDCOM - 17691
DOD-031280
Verify by
Initialing
Order
Date
Clerk
Nurse
THERAPEUTIC DOCUMENTATION CARE PLAN
Date to
be Done
SINGLE ACTIONS
17
/
„.
1
L- ait--k- 24A "o
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TIMEIDATE COMPLETED
USAPA VI 00
MEDCOM - 17692
DOD-031281
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ACTION 'TIMES
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, FENCII......;,-C1f1CLE
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MEDCOM - 17693
DOD-031282
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MEDCOM - 17694
DOD-031283
THERAPEUTIC DOCUMENTATION CARE PLAN
CLINICAL RECORD
VERIFY BY INITIALING
ORDER
DATE
(MEDICATIONS)
For use of this form. see AR 40-407;
theyroponent act. ncy is the Office of The Surgeon General
::::::::::::::::;W:Min::::::::;:;:ii,:::::: :MO:::::::::::::::::Wi::::;0::;ONO::::::::::
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
DATE DISPENSED
HR
RECURRING MEDICATIONS.
DOSE, FREDUENCY
CLERKI
NURSE
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ADDITIONAL PAGES IN USE
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EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
NO
PAGE NO.
csk- ■
DISPENSING TIMES
e
Aft
M
PENCIL. CIRCLE MED TIMES
0
7
8
9
10 11 12 13 14
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15
16
17
18
19
20
21
22
N
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24
01
02
03
04
05
06
USAPA 51.00
MEDCOM - 17695
DOD-031284
THERAPEUTIC DOCUMENTATION CARE PLAN
(MEDICATIONS)
Verify by
Initialing
Order
Date
Order/
Expir
Glerkl
Nurse
1pitill
40---e
_A- e---e9eCtt I - O.
(16 P r le It)
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Time Given
Initials
TIMEIDATE DISPENSED
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)
Time to
be Given
2003
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
PRN
MEDICATION, DOSE, FREQUENCY
Clerk!
Nurse
Date
)
Date to
be Given
SINGLE ORDER, PRE-OPERATIVES
Yr.
Mo.
0
,
MEDCOM - 17696
DOD-031285
•
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDIC477O1S)
CA
.,_,
. For use of this form, See AR 40-407;
Mo. L.) e.27' •D
'he:oroorin at acignc:y le the Mice at The Sermon General
1 A' 1T I A L P R OP ER (=OW FYI N F OL L 0 TIN C EA C I-I ADM I N 1 S T R 4 T.1 ON
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DA FORM 4678,1 FEB 79
USE PENCIL. CIRCLE MED TIMES .
D
7
8
9
10 11
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15 16
17
18
N
23 24 01
12 13 14
19 20 21
22 •
02 03 04 05 06
EDITION OF 1 DEC 77 WILL 'BEUSED UNTIL EXHAUSTED.
MEDCOM - 17697
DOD-031286
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MEDCOM - 17698
DOD-031287
MEDICAL•RECORD4UPPLEIVIENTAI, MEDICAL DATA
ka
tic 161m, se0.
:thi poporentaancy italic tOit of 71, Surgew -Ginval.
oft 40
APPROVED/
REPORT TiTil
Date:
Time
Allergies:
Pre-op V/S•
pr
post Anesthesia Care Unit (PACU) Flow Sheet
Anesthesia Type {0irete)): Gene
AM&
Oreir‘
Hemovac
pinal •Epidural •
IV eilatiOR NervE Block
(./ Cottoid
OR intake: Crysteldid
Nv
.
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OR Output UOP
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.: d>.11rflIrrhi-)
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Nasal
Oral
ETT
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JP.
T-tube
Foley
Other
Its
Pr 0 M d
. PeCu Intake
Time
Sa02
Amount-
—.Si:Action.
Site • :
► RMOVIMOMMOMMOO ■
WMOQIIIIMOMMIMOMM
240.
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NKWIRMEMOMOMMINI ■
tabs
220 •
MOOSSIMMIHIMMONIM !(..0aifSi.
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MONSMOMOMMINIMMOR
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Moves 1 ExImmities
180
11111111111111111111111111111111111111111 (1)(0)Ittoires
0 EXtrernIties
Airway
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1.6P
11111111011110111111111111111111111111111111111 (i)Dyspilea;timiled.broalhing
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20450
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SBP
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120
► MOMMOMMEMIIIIMMIIII (0) SBP BASO of
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100
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UDIIMPIONSMIHIMMMOM
MIIII111111111111111111111111111111111111 ■
4iveirance
115101MMMOMMIHIMMOM 10). Cyeredlic ,.
111111111111111111111110111111111111 ■ Circulation (Peds.<-5 'Nears)
111111111MMIMMOSIMMOM
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greater to D/,.OtherWide
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Pa ten teachina done; Wound Ca e. Pain Marta •
-
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trituVed
PiO2
Methods
.
..
.
POtt-Anestheeia ReeOVery store: ..
• ' •
': , • — "Codes.:
,, - ADM- '.
30! . - • .•'RIC
Criteria .. "
AIRWAY
.mbit.
. A= Ft
BB.Blovit-bv
M= Ma s k.
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Tent
-.
RA ;=FfeomAir
I4O, . Nasal
qatinuta
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of Pre-op
swop
WS. '.
X.---•A;:lilifi:'BP
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(2) ACV Awake: audible
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.
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.
TEMP'
S ,.---.‘ Skin
SO
Color
(i) Baseline:1:646ra
6) Oate.rnottled.tiundiaea
AO •
0- ... 0i01
A
T = Tyrn pa Die
"B = PacTel ...
radial Pulse Palpable, ;
(I) Aialary palpable. not radial
toy:Carotid only ithablepulse
L.05
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T. Thoracic
l: -.LOrobar
S. SaCral
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DS. Incentive Spirometer. Comfort Measures
T,
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Pain J0-10)
LOS
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PREPARED. BY difionve 6 rilkl
VICE
IN
1(.01finevn rtwerse,
BATE
Nome —lea
PATIENT'S IDENTIFICATION (Fe: typed or rialto 'o)der give:
first middle: grade•dale: hospital or medical finite
b
-
Aidllary
IOS.TORTIPHTSICAI
OTHER.EiMeNATTON
OR EVALUATION . S •
1-1
FLOW. WART
0 OTHER is,,,tdo
❑ DIAGNOSTIC STUDIES
0 TREATMENT
DA FORM 4700, MAY 78
WANIC OP 173E. (Revised) 1 Apr 01 (MCXC-IDN)
MEDCOM
-
Previous edition is obsolete
usorcvm
17699
DOD-031288
MEDICATIONS
NURSING NOTES
Allergies:
Pain Medication &
Time
I
•
TiPie
v
•
UROVASCUIAR . • , •
•
- Gt.46f
84'
Refill
Adm
15'
a
•
130'
_
.
.2
,
•
Movement/Sensation; 4- present, absent: Tempi:C coo,
--Affgent
W =Wenn- .-Putses:-P-a Paipable,
Color! C..--...dyanotic.
capillarRef
•
'
C-SECTIONS-..
• \
0,10.
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WAMC OP 173-E
MEDCOM - 17700
DOD-031289
1
1,
1
2
MTF LOCATION
2.
REPORTING MTF
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EIIIIIMPIIIIIMISIMI
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9
10
12
DATE OF BIRTH IY Y
6.
19
20
21
22
For use D1 this form,
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NAME airs), First, Middle )nitial!
REGISTER NUMBER
11
ADMISSION AND CODING INFORMATION
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8
4
3
ISII14
15
24
LENGTH OF SERVICE
32
33
4.
26
27
35
34
SEX
18
RELIGION
ETHNIC
31
29
28
5,
17
(-
T2. SOCIAL SECURITY NUMBER
in
37
38
40
39
41
42
43
44
45
rd,
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4
MARITAL STATUS
13.
ORGANIZATION lActtve Duty Only)
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11.
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PAY GRADE
16
0 a
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■
AGE AT ADMISSION
7.
25
AR 40-00: the proponent agency it 0150
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46
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14.
47
15.
FLYING STATUS
48
50
49
<A
17. UNIT LOCATION
/State or
Country Code/
62
20.
72
18.
64
63
51
53
52
73
19.
87
65
66
67
69
68
70
103
56
55
57
58
59
60
61
PREV. ADMISSION
YEAR
71
NO
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
WARD
SOURCE Of ADMISSION! AUTHORITY FOR
ADMISSION
ADDRESS OF EMERGENCY ADDRESSEE (Include DP Code)
) _ ,L,
(1
TELEPHONE NUMBER OF EMIERINCY ADDRESSEE
23, DATE OF DISPOSITION (V VMMD DI
TRANSFERRED TO
TYPE OF DISPO I
75
74
76
77
78
79
81
80
88
82
83
84
3)
3
CLINIC SVC • ADMITTING
89
90
91
LOCATION OF OCCURRENCE
(Barrie Casually Only)
104
FOR LOCAL USE
92
93
94
95
97
96
28.
105
107
108
109
86
ea
9B
100
99
101
102
MO Coll/A1111
29. DATE INITIAL ADMISSION (V YMM001
MTF OF INITIAL ADMISSION
106
85
26. DATE THIS ADMISSION 1Y YMMOD)
25. MTF TRANSFERRED FROM
AMU"
27.
54
TRAUMA
0 .
24.
ZIP CODE OF RESIDENCE
7MOS
Y`
21.
16.
BENEFICIARY CATEGORY
111
110
112
114
11.3
,
115
116
PlOr4eir aleia(--
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ADMITTING CLERK
ADMITTING OFFICER (Signature
el
USAPPCV1.0
DA FORM 2985, MAR
MEDCOM - 17701
DOD-031290
---_„
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40.400; the proponent agency is 13T5G
.
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GE
.
4.
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15.
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STATUS
16.
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13.
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18.
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17.
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7.
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8.
3.
NAME (Lam, Nut, IAD
19.
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22.
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14.
WARD
20.
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....--.....-21.
SOURCE OF ADMISSION/AUTRORITY FDR ADMISSION
MALV,
24.
NALMJFIELATIONSHIP DE EMERGENCY ADDRESSEE
27s.
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I
ems25.
NAME AND LOCAT
31.
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ADMITTING OFRCER
28.
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DATE OF DISPOSITION
id i v fip
Gal .GO DATE
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26.
TYPE DISPOSIT
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DATE OF I
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32.
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COMPONENT TFLUISPUSED
Chock if ConUrcad on Ravens
33.
CAUSE OF INJURY
34.
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
3,„.,
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35. Total Days This Facility
a.
b.
ABSENT SICK DAYS
c.
OTHER DAYS
CONY. LVICOOP
CARE DAYS
d.
CONY. LUDO?
CARE DAYS
d.
a.
SUPPLEMENTAL
CARE DAYS
3
0
g
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BED DAYS
TOTAL SICK DAYS
3
38. Total Days All Facilites
a.
ABSENT SICK DAYS
-
c.
SUPPLEMENTAL
CARE OATS
4.
BED OATS
I.
TOTAL SICK DAYS
SIGNATURE OF ATTE
DA FORM 4
EDITION
IS 0
USAPPC111.111
MEDCOM - 1770
DOD-031291
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
ME CAL EdORD
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USAPA V200
MEDCOM - 17703
DOD-031292
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD I
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REY. 6-97)
Prescribed by OSA/ICMR
FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17704
DOD-031293
-1As
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE
16 fitte7
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MEDCOM - 17705
DOD-031294
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE
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17
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DOD-031295
NSN 7540-00-634-4176
AUTHORIZED FOk LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
MEDICAL RECORD
SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Stgn each entry)
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RECORDS MAINTAINED AT
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CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600
(REV. 6-97)
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-9.202-1
MEDCOM
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17707
DOD-031296
NSN 7
LOG NUMBER
EMERGENCY CARE
AND TREATMENT
MEDICAL RECORD
PATIENT'S HOME ADDRESS OR DUTY STATION
ARRIVAL
STREET ADDRESS
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MEDICAL HISTORY OBTAINED FROM
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TRANSPORTATI N TO FACILITY
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FLYING STATUS
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AREA CODE
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NUMBER
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1-1 48 HRS. 1-1 78 HRS.
ADMIT TO UNIT/SERVICE
❑ UNCHANGED
TIME OF RELEASE
TO
REFERRED
WHEN
I have received and understand these Instructions.
PATIENT'S SIGNATURE
PATIENTS IDENTIFICATION
(For typed or written enfrfes, give: Name — last,
first, middle; 10 no. (SSN or other); hospital or
medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSMCMR
FPMR (41 CFR) 101-11.203(b)(10)
USAPA V1.00
MEDCOM - 17708
DOD-031297
NSN 7540-01-075-3786
EMERGENCY CARE AND TREATMENT
(Doctor)
MEDICAL RECORD
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EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9 96)
-
Prescribed by GSAIICMR
FPMR (41 CFR) 101-11.203(bX10)
USAPA V1.00
MEDCOM - 17709
DOD-031298
NSN 7540-00-634-4124
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98°
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99
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NMI
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HOSPITAL DAY
DAY
POST- WV.
DAY
MONTH-YEAR
HOU R
eh:03
TEMP. F
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(0)
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07
1111115211=
Mil
To
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ct
PATIENT'S IDENTIRCATION (For typed or written entries give' Name—last, first, middle; ID No.
f$SN or other); hospital or medical facility)
■ ' iii.,
'Y
REGISTER NO
11
102___
VITAL SIGNS RECORDS
Medical Record
MEDCOM - 17710
STANDARD FORM 611 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
DOD-031299
i - STAT EC8+
Pt:
Pt Ne:
ci;e4
Glu
L
BUN
136
Ma
K
Cl
i-STAT a
104 mmol/L
TCO2
Pt: MIR 17(C11) - q
Pt Name:
23 mmol/L
•
AnGaP
14 mmol/L
Hct
46 %PCV
Hb*'
84 mg/dL
BUM
7 mg/dL
134 mmol/L
3.7 mmol/L
CI
16 9/dL
*viaHct
Glu
Na
E..
3.? mmol/L
4
PH
7.427
PCO2
Za mmol/L
BEecf
-2 mmol/L
103 mmol/L
Hct
40 /.PCV
Hb*
14 9/dL
Sample Typ e _:
48AUG03
*via Hct
e
t
04:37
\
Physician:
13:12
Opw:
Sample Type_:
19AUGO3
33.2 mmHg
HCO3
b ut)
Ser# 4111111
Ver: JAMSO46A
CLEW A53
Ser# 111,
Ver: JAMSO46R
CLE$I R93
MEDCOM - 17711
DOD-031300
LABORATORY RESULT FORM
(Sub'ect to the Privac Act of 1974
W ardl Se ctio:
TEST RESULT
REF. RANGE
REF. RANGE
Negative
Negative
4.8-10.8 x 10
Negative
Negative
Negative
Lymph %
20.5-51.1%
Gram
Stain
Negative
H. pylori
Negative
Micro
Parasites
Malaria
Negative
0.2-1.0
Negative
Lymph
Negative
RBC
Morph
Cell
Count
Directigen
Negative
REF. RANGE
PT
APTT
D dimer
FDP
9.8-13.6 sees
21-34 sees
<20 nem)
< 10 u g/m1
REMARKS:
REPORTED BY:
MEDCOM - 17712
DOD-031301
CHEMISTRY RESULT FORM
Sub' ect to the Privac Act of 1974
TEST
RESULT
REF. RANGE
'`btisfasmall
TEST
TEST
RESULT
REF. RANGE
Na
138-146 mmol/L
K
3.5-4.9 mmol/L
7-22 mg/di
0
98-109 Inman.
8.0-10.3 mg/dl
pH
7.31-7.45
PCO2
PO2
23-27 mmol/L (art)
24-29 mmol/L (Yen)
22-26 mind& (art)
23-28 nunol/L. (yen)
95-98%
TCO2
HCO3
s02
(-2)— (+3)
mmol/L
10-20 mmol/L
BEecf
AnGap
11111111111111111
BUN
1.12-1.32 mmol/L
8-26 mg/d1
70-105 mg/d1
Creat
0.7-1.5 medl
38-51% PCV
12-17 g/dt
Hgb
TEST
RESULT
Troponin-1
ALB
3.5-5.5 g/dl
GLU
======= PICCOLO == =====
18/08/03 13:13
REFERENCE
MA! 1PATIENT #:
) GENERAL CHEMISTRY 12
DISC LOT #:
3142AA4
OPER #
DR #: 000
SERIN,
. .1ak. ill 14
ALB 3.4 3.3-5.5 G/DL
ALP
81 26-84
U/L
ALT
22 10-47
U/L
AMY
26 14-97
U/L
AST
46* 11-38
U/L
TBIL 0.9 0.2-1.6 MG/DL
BUN 6* 7-22 MG/DL
CA++ 9.0 8.0-10.3 MG/DL 3T
CHOL 94* 100-200 MG/DL 311,
CRE 0.6 0.61.2 MG/DL GT
GLU 100 73-118 MG/DL
TP 6.6 6.4-8.1 G/DL
73-118 mg/di
0.6-1.2 mg/dl
128-145 mr.no1/1
3.3-4.7=14A
98-108 mtno1/1
18-33 mmol/1
RESULT
REF. RANGE
3.3-5.5 g/dl
26-84 IA
10.47 urt
14-97 u/1
11-38 till
0.21.6 mg/d1
5-65 till
6.4-8.1 g/dl
REF. RANGE
INST QC: OK
CHEM QC: OK
HEM 0 ) LIP 0 ) ICT 0
Drug of
Abuse
RESULT
REF. RANGE
128-145 mmo1/1
3.34.7 mmol/1
98-108 mmo111
18-33 Emma
REPORTED BY:
DATE:
LAB ID NO.:
MEDCOM - 17713
DOD-031302
MEDCOM - 17714
DOD-031303
Ward/4-c9ot ,--
ILEQUES
Ur
) L----ki
HYSICIA :
DATE
::
) - lk
tOato ogy) CTIL"-
,
TEST
RESULT
RBC
•
TEST
Het
MCV
Pit
Urinalysis
RESULT
:
REF. RANGE
c: Serology :
TEST
Negative
1.7 -6.1 x Pr
App
N/A
Mono
Negative
Negative
..
I Glu
to'
Bili
Negative
Ket
Negative
SG
20.5-51.1%
Mono
, Prot
Source
-
Negative
Negative
H. pylori
Negative
N/A
Negative
Micro
Parasites
Malaria
0.2-1.0
0&P
Lymph
Baso
Nit
Negative
Other
Atyp
Imm
Leuk
Negative
HCG
Negative
.:
.,...-'
Microscopic 1.rriallysi ' .
,
Spun
Hematocrit
Sed Rate
4252% (M)
3747% (F)
CSF
Directigen
.. REF. RANGE
9.8-13.6 secs
APIT
21-34 secs
D dimer
<20 ug/m)
FDP
<10 ugimi
REMARKS:
REPORTED BY:
MUST SUBMfT SF 518 WITH
EVERY UNIT REQUESTED
ABO/Rh
Negative
_I
' ., ' 'r: .:-: Blood Bank liPit Crossmatch . : ,:. ': ; . : • ; : ' .
(MUST SUBMIT SF 5.1. 8.*I.Tii EVERY
UNIT. O1 BLOOD
.
,. . .
•
Coagulation Studies
PT
4
' .
•
Other
RESULT
Blood Bank
Cell
Count
._
TEST
'
N/A
Urob
RBC
Morph
IVBerobiology
Gram
Stain
Occ Bid
Eos
.
REF. RANGE
RPR
Bid
(liernati*igy)-Monua1 Differential .1 pH
Bands
RESULT
N/A
130500 x
Segs
,-----;
:.
Color
verified
Lymph %
- ,'
4.8-10.8 x 10
14-18 g/di (M)
12-16 p/d1(F)
42- 5r/0 (M)
37-47% (F)
80-94 II (M)
899(1(F)
Hgb
(Subject tote Privacy Act of 1974)
S
SSN:
TIME
igAttet0.3 02(e-7
, .
REF. RANGE
WBC
LABORATORY RESULT FORM 1
UNIT
TYPE
CROSSMATCH
—
-.
•
.
.
_
1—"
LAB Iffi NO.:,
.. .
'
I
MEDCOM - 17715
DOD-031304
C,HEMISTRY RESULT FORM
(Suliect to the Privacy Act of 1974)
SN:
W
'6 41iikf
.
TEST RESULT REF. RANGE
nr
73-118
TT
26-84 u/1
pH
PCO2
P02
80-105 mmHg (an)
N/A veal
23-27 roma. (an)
24-29 mmoUL (veil)
22-26 mmoUL (art)
23-28 mmoUL (von)
AMY
AST
14-97 u/1
TBIL
0.2-1.6 mg/d
11.38 u/1
7-22 mg/dl
BUN
8.0-10.3ragq
CA++
PICCOLO ==::===
04:38
19/08/03
MALE
REFERENCE RANGE:
PATIENT #:
GENERAL CHEMISTRY 12
3142AA4
DISC LOT
t* #: 000
OPER #:
SERIAL #:
ION
100-20mord
ALB 3.0* 3.3-5.5 G/DL
U/L
64 26-84
ALP
U/L
73-118 met ALT
39 10-47
U/L
24 14-97
AMY
6.443.1edi
U/L
44* 11-38
AST
TBIL 0.6 0.2-1.6 MG/DL
MO/DL
5* 7-22
RN
1ER
RESULT
CA++
8.8
8.0-10.3
MG/DL
R14NGi
73-118 mg/ CHOL 53* 100-200 MG/DL
CRE 0.7 0.6-1.2 MG/DL
7-22 mg/d1
GLU 109 73-118 MG/DL
0.6-1.2 mgi
TP 5.0* 6.4-8.1 G/DL
0.6-1.2 me
BEecf
AnGap
Ca
BUN
Creat
Het
Hgb
39-3800
30-15* uA
128-145m
INST QC: OK
CHEM QC: OK
HEM 0 , LIP 0 , ICT 0
yE
3.3-4.7 tort
98-108 mr
Drug of
Abuse
18-33 min
1
REMARKS:
REPORTED BY:
DATE:
LAB ID NO.:
q
MEDCOM - 17716
DOD-031305
z
LABORATORY RESULT FORM
(Sub'ect to the Privacy Act of 1974)
0 SSN:
ROQUE
Wird/ ecno
cmatei14) CBC
WBC
RBC
Hgb
Urinalysis
"•
:
REF.
ULT
TEST
T
DATE
T, MI.
TEST RESULT
GE
Color
4.7-6.1 x 109
App
N/A
14 i 8 g/dt (M)
Glu
Negative
Bili
Negative
Source
Ket
Negative
• /A
Gram
Stain
Occ Bld
Negative
Negative
H. pylori
Negative
N/A
Negative
Micro!'
Parasites
Malaria
-
MCV
Negative
RPR
Mono
4.8-10.8 x 10'
12-16 gild'. (I')
42-52% (M)
37-47% (F)
80-94 11 (M)
81-99 fl (F)
Hot
13o•oo x to'
Pit
SG
verified
20.5-511%
Bid
Lymph %
• pH
(HematOlOgy)Nonual Differential
.. : .
•,,
Prot
Mono
Segs
—
Negative
Nlitrobiplegy
..
Bands
Eos
Urob
0.2-1.0
0&P
Lymph
Baso
Nit
Negative
Other
Atyp
Imm
Leuk
Negative
HCG
Negative
RBC
Morph
-
oa plittion'StOdiell.
.,..
-. .
TEST
RESULT
PT
9.8 13.6 secs
APTT
21 34 sees
D dimer
<20 ug/ml
FDP
<10 ug/ml
'
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED
ABO/Rh
Negative
• loaf Baltic IlOitCrossin'ateh - : - - ,
005t.St*tr.!F.: 503 .*IT.ii.tVERY Mrr OF' *:06
, :RE OUEFOD) i. :
REF. RANGE
-
. BlZrBook
Cell
COunt
Directigen
Other
•
Micioscopie Uri*
CSF
42;52% (M)
37,47% (F)
Spun
Hematocrit
Sed Rate
REF. RANGE
RESULT
TEST
REF. RANGE
N/A
•
Serology
'=
TYPE
UNIT
: '.
CROSSMATCH
-
.
-
REMARKS:
REPORTED BY:
DATE:
. (q /4.ti
..3
LAB ID NO.: .
MEDCOM - 17717
DOD-031306
LABORATORY RESULT FORM
Sub'ect to the privac: Act of 1974)
icroscopic Urine
Btood.. Hank Unit CTo3sniatcli
UNIr OI BLOOD .
(MUST SUBMIT. SF 518 WITH EVERY
MEDCOM
-
17718
DOD-031307
r
C_r
Clik,MISTRY RESULT FORM
REQUESTING PHYSICIAN:
secti. - •
W
1_
',400w.---TEST
TEST
REF. RANGE
RESULT
RESULT
Sub'ect to the Privac ' Act of 1974
SSN/PSEUDO SSN: .
TIME
DATE
AST,
...
cow,,.._
REF.
RANGE
TEST
RESUiT
,i _A
REF. RANGE
73 118 mg/dl
Na
"138 146 umiol/L
ALB
3.5 5.50
GLU
K
3.5 4.9 mmol/L'
ALP
26 84 tin
BUN
7 22 mg/di
C
2
-
-
-
-
98-109 mum
CI
pH
PCO2
n•,
-
-
6.10.3 medi
7.31-7.45
-
- PICCOLO
PICCOLO
----i'
06:07
20/08/03
20/08/03
05:51
MALE
REFERENCE RU6i
J____RUEREISID ,RANGE :
MALE
PATIENT #: 1111, 6kt)-L i
' PATIENT #11111,
24419 "di1 VETLYTE 8
1
GENERAL CHEMISTRY 12
22-26 mmoV1
o234 Emmoin DISC LOT #:qm)
DISC LOT #:
5., ,.. 3152AA4
3142AA1
OPER
'' DR-lr00--95 -9814,
OPER #:
DR #: 000
SERIAL
SERIAL
(.-2) - (+3)
35-45 mmili
41-5 immE152
8D-m5 m44
14/A Neol
23-27mmolA
P02
TCO2
HCO3.
#'
s02
BEecf
iallingi
mawn
GLU
GLU
BUN
CRE
8-26 mg/d1
CK
70-705 mg/ NA+
Creat
0.7-1.5 mg/
Hct'
38-51941PC
Hgb
12-17 g/clk
AnGap
Ca
Mammd
1.12-132m
BUN
1:.**!, 01* .
...,,,, ai, V4 ' '.
TEST RESULT RillfiAl
Tropm1
Drug of
Abuse
88
4*
1.1
932*
130
K+
3.5
96*
CLtCO2 24
73-118
7-22
0.6-1.2
39-380
128-145
3.3-4.7
98-108
18-33
MG/DL '
ALB 2.9* 3.3-5.5 G/DL
MG/DL
ALP
66 26-84
U/L
MG/DL .77. ALT
22 10-47
U/L
U/L A: AMY
39 14-97
U/L
VIMat
AST
33 11-38
U/L
WM,- : ----TBIE—'N-5---- 072=1 .6
MG/DL
MGR_
BUN
3* 7-22
MG/DL
MOLL -- CA+4 8.9 8.0-10.3 MG/DL
T- CHOL 115 100-200
INST GC: OK
CHEM GC: OK -- CRE 0.7 0.6-1.2 MG/DL
MG/DL
HEM 0 2 LIP 0 2 ICT 0
1 GLU
91
73-118 MG/DL
a TP
6.0* 6.4-8.1
G/DL '
iii INST GC: OK
CI-EM GC: OK
HEM 0 2 LIP 0 2
ICT 0 '
i
r
11
REMARKS:
DATE:
REPORTED BY:
LAB ID NO.:
/
MEDCOM - 17719
DOD-031308
\.:-, l's L.e. --
7....
TEST
REF. RANGE
4.8-10.8 x 10'
WBC
RBC
4.7-6.1 x log
. Mine Serology:
.
.1.001Y0s
REF. RANGE
RESULT
TEST
RPR
Negative
N/A
Mono
Negative
Negative
Bili
Negative
Source
Ket
Negative
13N500 x 103
SG
- N/A
Gram
Stain
Occ Bid
Lymph %
CifemaPOitigy) Manual Differential. .
Bld
Negative
pH
WA
Segs
Mono
Piot
Negative
H. pylori
Micro
Parasites
Malaria
Bands
Eos
Urob
0.2 1.0
0&P
Lymph
Baso
Nit
Negative
Other
Atyp
Imm
Lea
Negative
HCG
... Negative
MCV
Plt
•-
verified
20.5-51.1%
1
RBC
Morph
Mierobiology
-
42 ,52% (M)
3747% (F)
Spun
Hematocrit
Negative
Negative
:Microscopic Uritia
.
_
. Blood.Bank
CSI -
-
.
Sed Rate
Count
Negative
Directigen
.
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED
ABOIRh
Cell
Other
REF. RANGE
N/A
Glut
Hct
RESULT
Color
App
14-18 Vd1(M)
12-16 g/d1(F)
42-52% (M)
37-47% (F)
80-9411(M)
81-99 fl (F)
Hgb
.-
OLAri21,
nuitiilogy) CRC :
RESULT
SSN/PSEIJDO SSN:
TIME
DATE
LA
TEST
1 LABORATORY RESULT FORM
Sub ect to the Privacy Act of 1974
REQUESTING PHYSICIAN:
W d/Sectiox
I
OagulatiolkStUdies:
.,.
TEST
RESULT
• : -f -
9.8-1 3.6 secs
APTT
21-34 sees
D dimer
<20 ug/ml
FDP
<10 ug/m1
TYPE
UNIT
REF. RANGE
PT
.
. (MUS T stonier, .w: 518.*ITH:tvERy two CF. 01,coiD .Blptifl Bank Unit -CrOsstnatcli ..
.
CROSSIVL4TCH
.
REMARKS:
. LAB ID NO.:
REPORTED B
I
PAM CS--
I
MEDCOM - 17720
DOD-031309
Ward/ S ection:
CHEMISTRY RESULT FORM
(Subject to the Privac • Act of 1974)
SSN/PSEUDO SSN:
TIME
REQUESTING PHYSICIAN:
DATE
LA
,
TEST
RESULT
REE RANGE
()cal
■
LE
REF.
I RESULT
7E
1.7 21
TEST
===.=:: PICCOLO =.,==,.
04:49
21/08/03
MALE
731-7.45
REFERENCE RANGE:
35-45 mm PAT I ENT #:
4i-S1 midi
MLTLYTE 8
80405 oon1
3152AA4 i<
DISC LO1 #:
N/A Neal
0 ---DR #:
21-27 mmol!
#:
24-29 mmol/ OPER
22-26 mrool/. SERIAL
..... .
23-28 =ugh
....................
MG/DL
95-98%
GLU 96 73-118 MDL
G/
5* 7-22
(-2)-0-3), BUN
0.6-1,2
MG/OL
romol/L
CRE 1 . 0
U/L
10-2um&
432* 39-380
CK
.2.3111
128-145
MMOVL
1.12-13
NA+ 131
3.2* 3.3-4.7 MMOVL
K+
8-26mg/d1
97* 96-108 MMOVL
CLMMOVL
tCO2 23 18-33
70-14:6mWdi
98409 m,
CI
wir
PH
PCO2
PO2
TCO2
HCO3
02
BEecf
AnGap
Ca
BUN
GLU
Creat
Bet
0.7-1.5 rag/dt•
H
12-17 g/cli
TEST
RESULT REE RANGE
n
138-1461
Na
K
TEST
38-5194PCV
-
CHEM GC: OK
1NST QC: OK
' -EM 0 , LIP 0 , ICT 0
1 PICCOLO -21/08/03
04:33
MALE
-
PATIENT #:
II-NFRN_ CHEMISTRY i2
Dib' LOT #:
3204AA4
#:
DR
SERIAL # .
ii
ALB
ALP
ALT
AMY
AST
TIL
BUN
2.8*
57
12
80
25
0.5
3*
I"(1
FA
0
CRE
_ GLU
TP
0.7
102
5.8*
3.3-5.5
2684
10-47
14-97
11-38
0.2-1.6
7-22
8.0-10.3
100-200
0.6-1.2
73-118
6.4-8.1
G/DL
U/L
U/L
U/L
U/L
MG/DI.
MG/DL
MG/DL
MG/DL
MG/OL
MG/DL
G/DL
- INS1 QC: OK
CHEM QC: OK
HEM 0 ) LIP 0 ) ICT 0
RESULT.: . REF. RANG)
Troponin-1
Drug of
Abuse
REMARKS:
REPORTED BY:
bLe.2 DATE:
LAB ID NO.:
rg-3
MEDCOM - 17721
DOD-031310
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the propontnt agency is OTEG
+
THE DOCTOR SHALL RECORD DATE, TiME AND SIGN EACH SET OF ORDERS. IF PROBLEM OR)ENTED. MEDICAL nECCI ,rir,
PAT;ENT IDENTIFICAT I ON
SYTEMIUD,WRPOBLEMNURIC NDATEBYROWL-7 1:71•171' ■!'.,7
TIME CAT- ONDE Att
DATE OF ORDER
•
'
1541°
-
FD
p
Sip e
ecrka
LedA_______O
ROOM NO.
NURSING UNIT
Ben 'NO.
•1
•
ACC
St4-7
1-t) c.LA.
. 0,;,A
- UD'
4_ eOATE OF ORDER
P ATIENT 1 0E NT rFA CAT I O N
TIME OF 0-FiCAFI
HOOPS.
4-
uce
rt(50 14$
1 ,"; a LIciri"--Tr
PATV5rs7 rIDENT
NO.
v Q°
BED NO-
ICATION
S
Q
NURSING UNIT
ROOM NO.
1st()
,
NO.
TIME
OF ORDER
PATIENT :De:OAP:CATION
DP OPOER
ezie2j31- 6:p2vyt4j3
/
6S0
1•
NURSING tiNIT
'ROOF"! NO.
DA CCRM 4256
1,ero
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APR 79
MEDCOM - 17722
DOD-031311
Far
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PROBLEN1 ORIENTE!) MED-ICAL RECORD
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DOD-031313
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MEDCOM - 17725
DOD-031314
THERAPEUTIC DOCUI1AENTATION:CARE
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MEDCOM - 17726
DOD-031315
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DOD-031317
INPATIENT TREATMENT RECORD COVER SHEET
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•- MEDCOM - 17729
DOD-031318
•
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
MEDICAL RECORD
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REGISTER NO.
RECORDS MAINTAINED AT
WARD ND.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REY. 51199
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MEDCOM - 17730
DOD-031319
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
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PROGRESS NOTES
Medical Record
STANDARD FORM 509 DIM 511999)
Presented by GSATICMR FPMR MICFRI 10111.203114110I
USAPA V1.00
MEDCOM - 17731
DOD-031320
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MEDCOM - 17732
DOD-031321
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
0
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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PATIENT'S IDENTIFICATION:
(For typed or written entries, give. Name - last, first, middle; ID No or SSN• Sex;
Date of Birth; Rank/Grade.)
Lk
RECORDS MAINTAINED AT
REGISTER NO.
WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
STANDARD FORM 600 (REV. 6 97)
-
Prescribed by GSA/ICMR
FIRMR (41 CFR) 201-9.202-1
LISAPA V2.00
MEDCOM - 17733
DOD-031322
NSN 7540-01-075-3786
LOG NUMBER
EMERGENCY CARE
AND TREATMENT
MEDICAL RECORD
(Patient)
T
IT'
PATIENTS HOME ADDRESS OR DUTY STATION
ARRIVAL
DATE (Day, Month, Year)
TIME
/9
STATE
X--3
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DD 2568 IN CHART
MEDIC
NAME OF INSURANCE COMPANY
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YES
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NO
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24 HOUR RETURN
•
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YES
, •
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NO
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ADDITIONAL
----------
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CURRENT MEDICATIONS
A
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NUMBER
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0 YES
•
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TIME
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TIME OF RELEASE
NI DETERIORATE
PATIENTS SIGNATURE
PATIENTS IDENTIFICATION
(For typed or written entries, give: Name — last,
first, middle; ID no. (SSN or other); hospital or
medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSAACMR
•
FPMR (41 CFR) 101-11.203(b)(10)
USAPA V1.00
MEDCOM
-
17734
DOD-031323
NSN 7540-01-075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
ABG/PULSE OX
H/H
RADIOLOGY
SLIP 02
PH
P02
PCO2
SAT
OTHER
Check if read by
radiologist
RESULTS
2
PLT
DIP
PT
BHCG
APTT
MICRO
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EKG INTERPRETATION
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PATIENTS IDENTIFICATION
(For typed or written entries, give: Name — last, first, middle;
10 no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor)
•
Medical Record
STANDARD FORM 558 (REV.
I •
MEDCOM - 17735
9-96)'
Prescribed by GSAACMR
FPMR (41 CFR) 101-11.203(b)(10)
USAPA V1.00
ob
DOD-031324
NSN 7540-00-634-4123
510-112
NURSING NOTES
MEDICAL RECORD
DATE
IIAU6-0S
(Sign all notes)
HOUR
A.M.
OBSERVATIONS
Include medication and treatment when indicated
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(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate;
hospital or medical facility)
•
REGISTER NO.
1 ■1 1
r
'41111
0
.
Ut
-
lit'"
'i \
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WARD NO.
NURSING NOTES
Medical Record
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17736
DOD-031325
e•
511-119
NSN 7540-00-634-4124
VITAL SIGNS RECORD
MEDICAL RECORD
HOSPITAL DAY
DAY
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'
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Hit
PATIENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility)
REGISTER NO
WARD NO.
VITAL SIGNS RECORDS
••
Medical Record
STANDARD FORM 511 (REV. 7 -95)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17737
DOD-031326
REQUESTING PHYSICIAN:
..1 Ward/Section:
LAST, FIRST, Ml.
.. :
TEST
DATE
nlorey) .CBC ..,
__.!!nats
.
REF. RANGE
ULT
---7
,
LABORATORY RESULT FORM
.
Urinalysis
•
TEST
RESULT
Sub ect to the Privacy Act of 1974
• SSN/PSEUDO SSN:
TIME
:
' :.
REF. RANGE
, Mist: Serology:
TEST
,
REF. RANGE
RESULT
4.8-10.8 x 10
Color
N/A
RBC
4.7-61 x 109
App
N/A
Hgb
14-18 8/di (M)
12-16 g/di (F)
42-52% (M)
37-47%(F)
80-9411 (M)
81-99 fl (F)
130 500x los
verified
20.5-51.1%
Glu
Negative
Bili
Negative
Source
Ket
Negative
Gram
SG
N/A
Stain
Oce Bld
Negative
Bid
Negative
H. pylori
Negative
-: (llewatiilogY)r140Aual Differential :: ,-.. pH
N/A
Segs
Mono
Prot
Negative
Micro
Parasites
Malaria
Bands
Eos
Urob
0.2-1.0
0&P
Lymph
Baso
Nit
Negative
Other
Atyp
Imm
Leak
Negative
HCG
5
Negative
WBC
Het
1
MCV
.
Plt
-
Lymph %
RBC
Morph
RPR
Negative
Mono
Negative
—
.
..
,
-
.:
Microbiology
I-
/
.Microcopk 15riflhiysic
-
'
42-,5r/o (M)
3747% (F)
Spun
Hematocrit
Sed Rate
Cell
Count
,
.
Negative
Directigen
Other
• - ....: :
:::•':'-:'
oagulation5radicia: -. - r - -;
:-. . -Y.-.....:-. ..:::' ..: '.
. .
PT
RESULT
titc
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED
ABoah
: - ...:-: :Blood ilaik tilit -Craisinitch: .:,
(MUST SUBMIT Slr518.*ITHB*ERY UNIT (*.BLOOD
REQUESTED)
REF. RANGE
UNIT
TYPE
9.8-13.6 secs
'
21-34 secs
_
0111 ,41D dimer
•
•
-1T1
CROSSMATCH
'
-
<20 ug/tai -
•
-
FDP
<10 ug/m1
.
REMARKS:
REPORTED BY: 111
I
DATE:
LAB ID NO.:,
iCr
MEDCOM - 17738
DOD-031327
•
War Sec •
.
HYSICIAN:
10 1 , ,f.....`,
.
' T, M1.
CHEMISTRY RESULT FORM
4-
(Subject to the Privacy Act of 1 ,./ 4)
DAT
TIME
. . liji
;
TEST
RESULT
7e3
y:,`;',..; 15:.',&;:.;:. . :z P çC O..,..,);:.
,,....-.- 11 3';D:-. ,.
RESULT
REF.
RANGE
-
REF. RANGE
TE.
°-6
4
(I
00
.';::,..,,;;-;.--,-.:-.,-
TEST
':..c. :- ':: -'1- a1t,-
k
RESULT
■
REF. RANGE
Na
K
138-146 mmol/L
ALB
3.5-4.9 moon
ALP
3 .5-5.5 gidi
26-84 u/I
Cl
98-109 mmol/L
ALT
10-47 0
CA+1
8.0-10.3 mg/d1
pH
7.31-7.45
AMY
14-97u/1
CRE
0.6-1.2 mg/d1
35-45 mmHg (en)
AST
11-38 u/1
NA+
128-145 mmol/1
TBIL
0.2-1.6 mg/d1
IC
3.3-4.7 morn
BUN
7-22 mg/Ill
CI:
98-108 mmol/1
CA++
8.0-10.3mg/d1
tCO2
18-33 mmo1/1
CHOL
100-200100
CRE
0.6-1.2 mg/dl
GLU
TP
73.118 mg/dI
ALB
3.3-5.5 g/dl
6.4-8.1 g/d1
ALI,
26-84 u/I
ALT
1047 u/1
AMY
14-97 u/1
PCO2
41 -51 mmHg (yen)
80- 105 mmHg (art)
P02
N/A (Yen)
23-27 nuno1/1.. (art)
24-29 mmol/L (yen)
22-26 mmoUL (art)
23-28 mold& (yen)
95-98%
TCO2
HCO3
s02
Ca
(-2)- (+3)
moron
10-20 mino1/1.
1.12-1.32 mmo1/1..
BUN
8-26 mg/di
GLU
70-105 mg/d1
BEeof
AnGap
In; .
TEST
RESULT
•
Creat
0.7-1.5 mg/di
Het
Hgb
VI''
TEST
::!
.',..;i.- ,
RESULT
REF.
73-118 mg/d1
GLU
7-22 mg/c1.1
, BUN
[N'
aiii10 0vgdiel
TEST
RESULT
ra
REF. RANGE
RANGE
73-118 mg/dl
AST
11-38 u/1
38-51% PCV
GLU
BUN
7-22 meidt
0.2-1.6 mg/d1
12-17g/dl
CRE
0.6-1.2 mg/d1
CK
NA +
39-380 u/1 (IA)
30-190 u/1 (F)
128 145 mmo1/1
TBIL
GGT
TP
IC
3_3-4.7 mmo1/1 .
..CL"
98-108 mmol/1
NA+
128-145 mmol /l
tCO2
18-33 mmol/1
r
3.3-4.7 mmol/1
CI:
98-108 mmol/1
tCO2
18-33 mmol/1
:.,':r. , ,
REF. RANGE
Troponin-1.
i.
Drug of
Abuse
5-65 rill
6.4-8.1 g/d1
-
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RESULT
REF. RANGE
•
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DATE:
i
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A ve0.3
MEDCOM - 17739
DOD-031328
•
)(2,-.
1-STAT C8+
Pt:
Pt Hame:V_ ---Glu
_ 149 mg/dL
mg/dL
137 mmol/C
K ____ _____ 4.0 mmol/L
Cl _________ 109 mmol/L
TCOE ________ 26 mmof/L
AnGap ________ 8 mmol/L
Hct _________ %KV
14 g/dL
*via Hct
PH __ ___ 7.449
PCO2 ______ 36. 0 mmHg
25 mmol/L
8Eecf ________ 1 mmol/L
Sample Type_:
19AUG07- 20:Z8
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CLEW A53
MEDCOM - 17740
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.
DATE OF ORDER
PATIENT IDENTIFICATION
TIME OF ORDER
HOURS
LIST TIME
ORDER
NOTED AND
SIGN
:.•
NURSING UNIT
ROOM NO.
BED NO.
TIME OF ORDER
DATE OF OR
PATIENT IDENTIFICATION
HOURS
NURSING UNIT
NURSING UNIT
ROOM NO.
TIME OF ORDER
ATE OF ORDER
PATIENT IDENTIFICATION
BED NO.
TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
Mir
NURSING UNIT
De
t APR 79
1
ROOM NO.
4256
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
tr U.S.0
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MEDCOM - 17741
33.710
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DOD-031330
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DOD-031331
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MEDCOM - 17743
DOD-031332
RECORD-SUPPLEMENTAL MEDI
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Surgeon General.
OTSG APPROVED Ware!
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MEDCOM - 17744
DOD-031333
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72
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21.
73
TYPE OF DISPOSITION
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El
175
76
77
78
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79
80
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88
82
89
90
91
84
92
93
94
95
96
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104
105
106
107
108
109
85
86
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97
98
99
100
101
102
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103
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USAPPCV1.0
DOD-031334
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USAPPC 81.19
MEDCOM - 17746
DOD-031335
MEDICAL RECORD
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PERTINENT HISTORY. CHIEF COMPLAINT, AND CONDITION ON ADMISSION ( Enter date of nehnir$ion
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MEDCOM - 17747
DOD-031336
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DOD-031337
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DOD-031339
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MEDCOM - 17767
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MEDCOM - 17770
DOD-031359
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MEDCOM - 17771
DOD-031360
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MEDCOM - 17772
DOD-031361
PROGRESS NOTES
MEDICAL RECORD
DATE
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..P 1-et..osef‘r--
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Ala e last, first, middle;
REGISTER NO.
grade; rank; rate; hospital or medical facility)
Atd"til-5 /544 4,4 e
PROGRESS NOTES
('Medical Record
/4 J
CA-4 er:
STANDARD FORM 509 1REV. 7.91)
lit C
141
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USAPPC V1.00
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MEDCOM - 17773
DOD-031362
•
SSB-104
7S40-01-075-378
LOG NUMBER T
EMERGENCY CARE
AND TREATMENT
(Patient)
MEDICAL RECORD
(
RECORDS MAINT
PATIENT'S HOME ADDRESS OR DUTY STATION
STREET ADDRESS
ARRIVAL
C iv
CITY
DATE May, Month, Year)
STATE
SEX
cope
ZIP CODE
MILITARY STATUS
NUMBER
ITEM
THIRD PARTY INSURANCE
YES
NO
N/A
PRP
AGE
HOME PHON
AREA
2.`1
CODE
NO
NAME OF INSURANCE OMPANY
INJURY OR OCCUPATIONAL ILLNESS
ITEM
9
I YES
OD 2*613 IN CHART
MEDICAL HISTORY OBTAINED FROM
CURRENT MEDICATIONS
ITEM
ADDITIONAL INSURANCE
FLYING STATUS
NUMBER
YES
WHEN (Dare)
EMERGENCY ROOM VISIT
DATE LAST VISiT
NO
IS THIS AN INJURY?
ALLERGIES
/7S-D
/
DUTY/LOCAL PHONE
AREA
TIME
/9 /9.-....., o 7
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24 OUR RETURN
YES
WHERE-
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HOW
/
DATE LAST SHOTCOMPLETED
INITIAL SERIES
❑
YES
0 NO
CHIEF COMPLAINT
7'.;4•14.1v1
CATEGORY OF TREATMENT
TIME
TIME
121 EMERGENT
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PATIENT'S RESPONSE
DISPOSITION QUARTERS /OFF 017177---"P.77771DISCHARGE INSTRUCTIONS
RELEASE
IMPRO'rED
E
TIME
TIME OF RELEASE
I
TO
REFERRED
WHEN
have received and understand these instructions.
(For typed or written entries, give: Name - last,
first, middle; ID no. ISSN Of other); hospital
or
medical facility)
PATIENT'S SIGNATURE
k.
EMERGENCY CARE AND TREATMENT (Patient'
Medical Record
STVIDARD FORM 558 (REV. 9.96)
Prescribed by GSA/ICMR
MIR 141 CFRI 101-11.20:3(b)(101
MEDCOM - 17774
DOD-031363
•
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
• ABC3/PULSE OX
U I-1/H
Q
03
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RADIOLOGY
SUP 02
PH
P02
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radiologist
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RESULTS
EKG INTERPRETATION
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RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP
PROVIDER SIGNATURE AND STA;k4P
AG?•IOSIS
CO
TENT'S liDENTIFICATION
(For typed Of written entries. give: Neale. – last, first,
10 no. (SSP! or other); hospital or rneeical facRitvl
middle:
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 553 IREV. 9-98)
' Pr3atrib•sd by GSA/ 101 R
RIM (41 CFR) 1 01-1 1.203(b)( 10)
MEDCOM - 17775
DOD-031364
NSN 7540-00-634-4123
510-112
NURSING NOTES
MEDICAL RECORD
(Sign all notes)
HOUR
DATE
A.M.
‘'s
0 -)13/51
ivarv; P+ 4-astral
itA,44;1)(.7
23(&3 4— 41>
-'9
OBSERVATIONS
Include medication and treatment when indicated
P.M.
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PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank, rate;
JCS
67-1_74.
ontin )4r-relerse si
REGISTER NO.
WARD NO.
hospital or medical facility)
S N NOTES
Medical Record
D FORM 510 (REV. 7-911
d by GSA/ICMR, FIRMA (41 CFR) 201-9.202-1
ME DCOM - 17776
DOD-031365
NURSING NOTES
(Sign all notes)
DATE
OBSERVATIONS
Include medication and treatment when indicated
HOUR
A.M.
P.M.
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STANDARD FORM 510 (REV. 7-91) BACK
'U.S. Government Printing Office: 1995 • 404-763/20065
MEDCOM - 17777
- -2_ A \ \
DOD-031366
25AUG2003 — 2133
Discharge Summary, Patient #
History: This is a patient who suffered multiple penetrating injuries during the UN
bombing on 19AUG2003. These included glass fragments embedded in and
causing lacerations to the left face, eye, and neck. He also suffered injuries to
his left arm and leg. He presented awake and alert with an admission glascow
coma score of 15. Left facial weakness was present on admission. He had no
central paresis of his extremities.
bCc.4)
Hospital Course: The patient wa transferred directly to the operating suite,
where repair of his facial lacerati ns was performed concurrently to irrigation and
debridement of his extremi inj ries. After facial injuries were repaired, his care
was turned over to Dr
from Ophthalmology. He performed initial
repair of the tissue loss in and around the left eye. Postoperatively the patient
was left intubated overnight. He was routinely extubated the following morning
and has been stable thereafter. Given his options of remaining in Baghdad or
being flown to Jordan for his ongoing care, he elected to travel to Jordan. He
was released on 26AUG2003.
02)
Dis osition: Sutures may be remov
the face at any time. Eye per Dr
Extremity injuries per Dr
Orthopedics. Treating
physi."
re encouraged to contact me with any questions or concerns.
MEDCOM - 17778
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-407; the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
1. AGE: iNe‘ C‘
ZkA
HEIGHT: k -23
9.
PREVIOUS SURGERY
WEIGHT: 910 \c`
1
4. PROPOSED SURGICAL PROCEDUE:
CGib'c
(5c;A\c^r
ON INFORMATION:
5. ADDI TIAL
1-6 L
4t)''
.
fti
vt,
PSYCHOSOCIAL
r
NO
[
YES (type):
_.<A1 gte,
7. PATIENT GOALS AND EXPECTED OUTCOMES
o
Pt. verbalizes any specific anxiety.
o
Pt. exhibits relaxed body posture.
Potential for anxiety
related to Traumatic injury;
language barrier; family
separation; surgical environment
•
B. AERATION
Potential for
resp iratory dysfunction due to
sedation; positioning; injury;
previus medical condition
C.
I
.
6. PATIENT PROBLEMS AND NEEDS
A.
cc5
ri
ENT
INTEGUMENT
%q Potential impairment
o PT. will be able to breathe without
difficulty during immediate intraoperative phase.
8. OR NURSING INTERVENTIONS
o Allow pt. to verbalize
freely.
0 Explain OR environment
and answer questions
regarding surgery.
o Offer comfort measures,
(e.g., warm blanket, touch)
o Explain all nursing
procedures before they are
done.
o Remain with pt. whenever
possible.
o Maintain family interface.
0 Offer to elevate head of
litter or offer pillow.
o Observe pt. while awaiting
surgery for signs of distress
o Assist anesthesia during
intubation and extubation
o PT. will not exhibit signs of impairment of skin integrity (e.g., reddened
areas.
of skin integuity due to
bovie pad; poistion; fluid shift
o Utilize pressure preventing
devices on OR table and
accessories.
o 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)
DA FORM 5179, JUN 91
Previoius editions are obsolete.
USAPA V1.0
MEDCOM - 17779
DOD-031368
6. PATIENT PROBLEMS AND NEEDS
D.
IRCULATION
Potential for inade IR
quate tissue perfusion due to
anesthesia; traumatic injury;
position; previous surgery
7. PATIENT GOALS AND EXPECTED OUTCOMES
o Pt. will exhibit signs of adequate
tissue perfusion (e.g., color, warmth,
pedal pulse).
8, OR NURSING INTERVENTIONS
o Check for support stockings or ace
wraps. If none, check with doctors.
0 Check that safety straps are
correctly applied.
o Offer pillow for under knees.
0 Place and take down legs from
stirrups with slow bilateral motion.
o Check that rings have been
removed.
E. NEUROMUSCULAR
CONTE_p
otential impairment
E.1.
of mobility due to sedation;
pain; injury
o Pt. will be transferred to OR table
without difficulty.
o Pt. will not experience unnecessary
physical discomfort.
f --Potential discomfort
E2
due to injury; pain
o Pt. will be made aware of
surroundings prior to anesthesia
induction.
o Pt. will be transferred safely to
perception due to being injury
OR
; sedation
table.
F 2 )0 Potential for decreased o Pt. will be able to understand
instructions.
communictaion due to languag
o Minimize danger of injury during
e barrier; sedation; pain; injury
F. NEUROMUSCULAR
CONTL
Disminished visual
F.1.
intraop period.
F.3.
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.
0 Offer support (i.e., pillows,
bathtowels, etc.) for
positioning.
o Introduce self. Keep pt.
informed as to where he/she is
and what is happening.
0 Inform pt. in which
direction to move and assist if
necessary.
o Speak clearly and slowly.
o Address pt. from
side.
0
Validate pt.'s
understanding of verbal
communications.
o Verify removal of dentures.
Potential injury due to
dentures.
G. OTHER PATIENT PROBLEMS
OTHER PATIENT GOALS AND EXPECTED
OTHER NURSING INTERVENTIONS.
NEEDS. Or continuation of above
OUTCOMES. Or continuation of above goals
and outcomes.
Or continuation of above
interventions.
problems/needs.
10.
11.
OR NURSIMP INTFRVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
(VI
DATE
POSTOPERATIVE EVALUATION:
,1!),
12. PREOPERTIVE EV
(Signature and Title
DATE:19
A tn<
TIME:
D BY
1P(U6
13. PREOPERTIVE E
BY (Signature and Titl
DATE:
/%01.0
TIME: 0331)
REVERSE OF DA ORM 5179, JUN 91
USAPA V1.0
MEDCOM - 17780
DOD-031369
MEDICAL RECORD
INTRAOPERA
I
1. PATIENT TRANSPORTED TO OPERATING R4
t,.. .\ $-.
VIA
BY
3. DATE
A...,)
0M,
2. PATIENT (DENT
i)i-V„.
ND PROCEWRE
VERIFIED BY
TIME PATIENT ARRIVED IN SUITE
(k( (Ai ----?
4. PATIENT IN RO
TIME OK)
CM'a
5. PREOPERATIVE EMOTIONAL STATUS
0.A1 03
U CALM
COMMENTS:
OCUMENT
For use of this form, see AR 40-407, the proponent agency is the office of The Surgeon General.
j
ANXIOUS
04.1 1 ID (DA
U EXCITED
...
• CRYING
NUMBER
❑
• ANGRY
WITHDRAWN
•
OTHER (Specify)
ace cI - rs exove
6. NURSING PERSONNEL
ASSIGNED
SCRUB
6 (c_9.
c‘.-C
-1-
RELIEF
SCRUB
4i
ASSIGNED
CIRCULATOR
RELIEF
CIRCULATOR
7. POSITION AND POSITIONAL
S (Specify/) %
bbx) ,Q;s1w..1, 6 Aar\ 1)(1h.9g4 le
(. ,-, Av.
SUPINE
'0 LIT OTOMY
PRONE
-15tgcZN ell1
(et tiAp'.
COMMENTS:
IA
•
‘,60/
4i ppc OA Alot OW, IA
KRASKE
ibt5 (1--drret Caleit
s.
42'01\4-5 q
LATERAL:
al A ( 1.^ At
''
❑ RIGHT SIDE UP
II LEFT SIDE UP
301t1'5f01 -ple•
8. SKIN PREPARATION
HAIR REMOVAL
DONE BY:
METHOD:
•
U
U
ll
YES
) NO
OR
DEPILATORY
CLIP
■
NURSING UNIT
M RAZOR
54(.'i
■ • II
COMMENTS
COMMENTS:
9. LOCATION OF EXTERNAL DEVICES
i.-I.
LEGEND
I
1/60
1
---""
4.-
PP
X Ground Pad
-- Safety Strap
C = Correct
10. COUNTS
Other • *
Sponge
Needle Sharp
Instrument
Yes
;-'
.
BY WHOM:ur
BY WHOM: MS
i 4
ez f •
0 1 Ulk4
: al.
(0/) re },j
CI)
-
Alli101
. _ milaw•-1171PP-
-
/----a....)
= = = Tourniquet
I = Incorrect
First Closing
Count
Final Closing
Count
C:Dl
(C.t3 ' -•-•
SCRUB
MI No
CIRCUL TO
cc6
:g2 Yes • No
C
,
❑ Yes
14
skti)A:t 56.A0
lc:poi L, at.l.t
--. 44,.9 411-t.
A
1
•
PREP SOLUTION (Specify)
SITE.,16 1 0, s-E410
SITE: '
6 , ,.....
c-r
No
(e-
Other
MI Yes
o
11. PATIENT IDENTIFICATION (For t ped or wri en entries give.
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
ii. 1 IS )9 ( (.0,_ - c-
12. ELECTROSURGERY DEVICE(S) (ESU)
X) ESU
NO:
GROUND PAD:
❑
'F ES
IN
NO
03
0
BRAND UCtlei
LOT NO:
G,T4)
ESU NO:
GROUND PAD:
BRAND
LOT NO:
❑
— - -- ---
BIPOLAR NO:
REPLACES DA FORM 5179-1 (TEST ► . DEC 82. WHICH IS OBSOLETE.
USAPA V1.00
MEDCOM - 17781
DOD-031370
❑ YES
13. PROSTHESIS, IMPLANTS
9 NO
IF YES NAME: ID NUMBER; MANUFACTURER
. .:i:Milg:5::;::00:NUM:::,annag MEDICATIONS/ORDERS MERMANIMOMMEMENSIMMEN
,
YES
NO II
?;MEDICATIONS/SOLUTION
DOSAGE
TIME
METHOD
PREPARED BY
BY
.14..
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA)
AWOUND IRRIGATION
i',
❑ NO, TYPEIS): 6 , 19,i) f i
163 YES
( 1■9\.) - 7e._,
r
OTHER ORDERS
TIME
CARRIED OUT BY
i
T HYSICIAN'S SIGNATURE
:„.„,. . . . . . ,. . .,. . . ._. . . . . .,.,. .„.,. . . . . . . . . . .,.,.
() -
of
X-RAY IN OPERATING - •0
15.
NO
YES •
IF YES, SITE
16.
YSPEESCITEI
IS)
2_
....•••••••••••,•••••••••••••••••••.________•••..•••••..••••••••••.................••••••••••..•••••••••••..„,....•.,...•_••••••••,•„,....,_:,
LABORATORY SPECIMENS
NAME
tw NAME
NO
FROZEN SECTION IFS)
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
18. DRESSING/IMMOBILIZATION
❑
YES
NO
[in
CULTURE IC)
YES
•
NO
Fio
17.
'
TUBES, DRAINS/PACKING
TYPE/SIZE
1. 3t
\
t
SITE
1
- 014
YES
(Se.,
; DODJ (G-S1 1,0Ca?
NO •
2.
3.
2.
3.
r) 1 1
(1u21)
(AP
(
19. ADDITIONALIIMATIONis ik.
ni- Or
r1-.
Or
(Specify)
A
-LM,
0(.1 - ir
ft
(gj
ofs.
04'9 Jkr3t(— CPc WI (PT
--L1( Awl_ f19..
.
4 6.1e Or ) ele (4,-) d-- NO ili ticper c,, lie. po;1 _ cp- uda
.,. .„,3 0 .1(1 D fl t i r___ , 6), . :,. 0
Rop_6,3 676ie igoolir, Os.-
26o
cp6
ER,:t-rio
4
N(sg,E7FIRL: 02,
D
,
4,,,,:, *0 4- LO„.0 ac21.
PATIENT TRANSFERRED TO .,3--.0A 1
22.
REGISTERED NURSE SIGNATURE
0
s4-10 4) 10 \
TIM
OE.3v 0
lc:),
6
( .1:1A''
METHOD vie_
—
REVERSE OF DA FORM 5179-7, OCT 8i -
USAPA V1.00
DOD-031371
INTRAOPERi
MEDICAL RECORD
I
PATIENIT TRANSPORTED TO OPERATIN G
1.
4//A/It ri iA,
3. DATE el
ai
2. PATIENT IDENTIFIED,
VERIFIED BY
BY
VIA
OCUMENT
For use of this form, see AR 40-407, the prop,..,.,It agency is the office of The Surgeon General.
lit-tteii•?4,0.
TIME PATIENT ARRIVED IN SUITE
D AND PROCEDURE
LT c
-6( cp -
4. PATIENT IN ROOM
67,
TIME
BER
0----
5. PREOPERATIVE EMOTIONAL STATUS
X CALM
•
ANXIOUS
EXCITED
❑
•
CRYING
• ANGRY
a
■
❑
• WITHDRAWN
OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL
ASSIGNED
SCRUB
SS
G[
RELIEF
SCRUB
1,T C
ASSIGNED
CIRCULATOR
RELIEF
CIRCULATOR
7. POSITION AND POSITIONAL AIDS (Specify)
14_ SUPINE
•
0 LITHOTOMY
PRONE
•
KRASKE
LATERAL:
•
❑ RIGHT SIDE UP
LEFT SIDE UP
COMMENTS:
8. SKIN PREPARATION
HAIR REMOVAL
DONE BY:
METHOD:
COMMENTS:
"g,
❑
❑
•
A,1
YES
• NO
OR
DEPILATORY
CLIP
--ni,ate6
I..ji... (AAA._
ted
BY WHOM:
BY WHOM:
ca..
( C,L-
COMMENTS:
--n ci
sof,
eg.,--facit.irke. SO
PREP SOLUTION (Specify)
SITE:
SITE:
• NURSING UNIT
rg..RAZOR
-1
9. LOCATION OF EXTERNAL DEVICES
r•- ) I
_
•
.
—
ligillillhallit*
"mall'Iw-411.1111•111•11
- -i
•--'Air
•11.
eTh..._...)
•
a..--
LEGEND
X Around Pad
-- Safety Strap
\
= = = Tourniquet
/
.- v-
L._
C = Correct
I .= Incorrect
First Closing Final Closing
10. COUNTS
Other• •
Sponge
Eg Yes
Needle Sharp
tg. Yes • No
i No
Count
SCRUB
Count
5
1/"
CIRCUL
s 6-
ATC
Instrument
• Yes j No
❑ Yes
No
PATIENT IDENTIFICATION (For typed or written entries give:
R
Other
11.
12.
ELECTROSURGERY DEVICEIS) IESUI
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
X ESU NO:
71Ze,,.e.4..,
GROUND PAD:
•
b4Z.Ce_
a43
,
B
ND
LOT ND:
17
P AtAii-ve. REM
&8 :3 C.-.
BRAND
LOT NO:
C(
❑
BIPOLAR NO:
C44-4-- ,
-I,
• NO
ESU NO:
GROUND PAD:
Q/,
CM YES
REPLACES D"
"
MEDCOM - 17783
''""CH IS OBSOLETE.
30
c,064-
30
USAPA VI .00
DOD-031372
13. PROSTHESIS, IMPLANTS
El
YES
DA
NO
IF YES NAME: ID NUMBER; MANUFACTURER
i .14. -::::=:::;:=402:::0020=013:CMIZOO.M, MEDICATIONS/ORDERS MreMbegN
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM
:MEDICATIONS/SOLUTION
(NOT BY
DOSAGE
Ei YES
::WOUND IRRIGATION
ANESTHESIA)
TIME
YES
METHOD
cg.
PREPARED BY
MM:;Mana
NO •
GIVEN BY
NO, TYPE(S):
t
6.9vo 16ee OTHER ORDERS
0 TIME
CARRIED OUT
BY
4
1
.PHYSICIAN'S
,::.,..............,..„.,..,.......„.
....„..........,..............„.„----.................
15. X-RAY IN
YES
IF YES, SITE
•
NO 13
16.
LABORATORY SPECIMENS
SPECIMEN ISI
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
NAME
18.
❑
YES
NO 114
FROZEN SECTION IFS)
❑
YES
CULTURE
YES
II
17.
TYPE/SIZE
12
NO
IX
IC)
TUBES,
1.
ya% " ezrotasiz 2.
DRAINS/PACKING
da
1. woun
AFL4
wire%
SITE
19.
NO
YES
•
/Specify)
Iif
NO •
i
3.
2.
DRESSING/IMMOBILIZATION
'
vtiteiyuf
3.
;/11.4'
At
ADDITIONAL INFORMATION
Strik
s1
kD (CP)
anis-As h-re
- - E.
cR AM
1
20.
OPERATIONS) PERFORMED
21.
PtIrIT
LJTNSFERRED
TO
T IME
TI
1130
/at
TUBE
METHOD
‘
via
At
t I C-L) - q
A rd
A
REVERSE OF DA FORM 5179-1, OC
MEDCOM - 17784
63
USAPA 1.00
DOD-031373
511-119
NSN 7540-00-634-4124
MEDICAL RECORD
VITAL SIGNS RECORD
HOSPITAL DAY
DAY
DAY
.
•
•
.
.
.
.
•
•
.
•
•
.
.
.
.
.
•
.
.
•
.
•
•
•
•
•
-
•
•
•
•• •
:
.
.
.
.
:
..
:
:
:
..
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
.
•
.
.
•
•
.
.
.
.
.
.
.
•
•
•
.
.
.
.
.
.
.
•
.
•
•
.
.
.
.
.
.
.
.
.
.
.
.
.
•
••
:
:
.
•
.
.
•
•
.
.
.
.
.
.
-
•
•
•
•
•
•
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
:
:
.
.
..
..
:
.
.
.
.
.
.
.
.
.
.
.
..
.
.
.
.
.
.
.
.
.
.
•
.
.
.
.
.
.
.
.
.
.
.
.
-
•
•
•
•
•
•
•
•
.
.
•
.
•
.
•
.
•
.
.
.
.
.
.
.
.
.
-
•
•
•
•
•
•
•
.
.
.
.
.
.
.
.
.
.
•
.
•• •
•
•
•
•.
•
•
•
•
:
II •
•
•
•
:
•
•
•
•
.
.".
••
•
•
•
•• •
•
•
•
•.
.
.
• ••
•
•
•
.
.
•.
.
•
•
••
:. . . .
•
•
•
.
.
.•
•• •
••
....
•
.'
.
.
• ••
40
•
•
•
•• •
•
60
50
•
•
•
•
•• •
70
.
•
•
•
•
•
•
•
•
•
.
.
.
.
.
•••
.
.
.
.
80
.
.
• ••
•
•
•
•
.
.
.
.
90
95.„
.
.
•
•••
•
•
•
.
.
.
.
.
.
•• •
.
.
•
.
.
.
.
.
.
•• •
•.
.
.
.
.
.
.
.
96°
.
.
.
.
•• •
•:
.
.
.
.
.
.
.
100
.
.
.
.
••.
•
•
.
97°
.
.
.
.
•••
•
•
.
110
:
.
.
.
.
.
.
.
....
.
•
.
.
.
.
.
.
.
.
.
.
.
•
•
.
•
.
.
.
.
.
.
.
•
•
.
•
.
.
.
.
.
.
..
.
•
.
.
•
•
•
.
•
.
.
•
.
.
•
•
•
.
.
.
.
.
.
•
•
•
.
•
.
.
•
•
•
.
.
.
.
•
•
•• •
98°
•
•
•
•• •
120
•
•
•
•
:
•
•
....
•
:
•
•
•
.
.
.
.
•
•
•
•
•
•• •
•
:
.
.
•
•
•
•
•
•
..
.
.
.
.
•
•
•.
.
.
.
.
.
.
.
.
•••
99°
98.6°
.
.
.
.
.
.
.
.
•
•
•
• ••
130
.
.
.
.
.
.
.
.
•
•
•
-
.
.
.
.
.
.
.
.
• • II
•
•
•
.
.
.
.
•
•
•
-
.
.
.
.
"
•
•
(Centigrade Eq u ivalen ts, for Refere nce on ly)
.
•
•
.
.
.
.
.
.
.
.
"
•
•
.
.
.
.
.
•
•
.
.
.
.
.
.
.
.
•
•
.
•
•
.
.
•
.
•
•
.
.
•
•
.
.
•
''
•
.
.
•
•
•
•-VD
100°
•
.
.
.±(J
140
•
•
• ••
101°
•
'
•
150
•
•
.
.
.
.
•
.
'''''
•
•.
.
.
.
•
•
••
.
.
.
.
•
.
•
•
102°
•
.
•
•
160
•
.
•
• ••
.
.
.
•
•
•
•• •
•
.
.
.
•
103°
•
.
•
•
• ••
170
•
•
•
•
:1
•
•
•
•
•
•
•
•
•
•
••
104°
180
•
•
•
•
1-•••
(*)
105°'
•
•
(0)
•
_ce"43/
TEMP. F
0 0) :13
0000
c..,
•
767
4•A
PULSE
0.•• q
HOUR
00
/ no .;
19
000
t
000
t te.
—1
4t. 414 m
p o
MONTH-YEAR
co co (...) co co co w w co co
al al a) a) -4 -4 —.I co co op
bis)
i— -40 M
CO4)Co .F.
POST-
Record specia l data on ly when so ordered
RESPIRATION RECORD
BLOOD PRESSURE
HEIGHT:
WEIGHT —0
PATIENT'S IDENTIFICATION (For typed or written entries give - Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility)
Co
REGISTER NO
WARD NO.
)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1
MEDCOM - 17785
DOD-031374
WarcUSection:
REQUES
r-il'Iq
BArE
LAST, RERST,
22
CHEMISTRY RESULT FORM
TIME
(Subject to the Privacy Act of 1974)
SSN/PSEUDO SS : i
( L.,..L
'
' .
Li
'
'..' E7.):7ff-eriT,':,r':71:.:4.."
RESULT
TEST
REF. RANGE
138-146 trtmo1/L
■
ed0 -,....s.•;;:. :,;,,,V .,4::„...,
"
s
:,,, ,, , I:i -,-,11,1.:
RESULT
TEST
,
`fr;
A-rt., :.-
.., -.;:; ar:,,,:,, :::::_l'f;f:,:f.F4'&t.;.::...";::(.:::-.,.. ,,::::.. '
RESULT
TEST
REF.
RANGE
REF. RANGE
GLU
73-118 mg/d1
BUN
7-22 wed)
CA4+
8.0-10.3 medl
K.
1 3.5-4.9 ternoUl.,'
ALP
CI
98-109 mmol/L
ALT
3-5-5.5 eldI
, 26-84 u/l
10-47 till
pH
7.31-745
AMY
14-97 u/1
CRE
0.6-1.2 mg/c11
PCO2
35-45 mmHg kart)
41-$1 mmHg (vat)
AST
11-38 u/1
NA+
128-145 mmol/1
TBIL
0.2-1.6 mg/di
1{.4
33-4.7
BuN
7-22 mg/d1
CU
98-108 mmol/1
CA
8.0-10.3:n01
tCO2
18-33 mmoUl
Na
so-zos mmHg (art)
P02
ALB
.
nunoW1
HCO3
WA (van)
23-27 mmolL (art)
24-29 =not& (yen)
22-26 mmoVL (wt)
23-28 mmo1/1.. (yen)
s02
95-98%
CHOL
Joa-zoo evjal
BEecf
( 2) (+3)
CRE
0.6 1.2 mg/di
AnGap
10-20 rranol/L
73-118 ung/d1
ALB
3.3-5.5 g/d1
Ca
GLU
L12-I.32 mmol/L TP
6.4-8.1 g/d1
ALp
26-84 u/1
BUN
8-26 mg/di
ALT
10-47 u/I
AMY
14-97 u/I
TCO2
-
-
inmon
GLU
AST
I1-38w1
38-51% PCV
7-22 me/di
TBIL
0.2-1.6 cog/d1
12-17 g/d1
CRE
0.6-1.2 mg/dl
GGT
TP
5-65 u/I
Hct
Hgb
TEST
RESULT
iVii.ii ' ', •is'::-:Z;;:'‘
,
-''' .
REF. RANGE
39-380 u/I (M)
30-190 u/I (F)
128-145 mmo3/1 il
'''. CK
NA+
3.3-4.7 mmoiA '
'
Troponin-1
Drug of
Abuse
6.4-8.1 g/c11
-
TEST
cat); '
e0:14rill .
.::::":,:Y::::::":::,•=5..;% . i".:;.:.:.:,:
RESULT
REF. RANGE
EL
98-108 romed/i
NA+
128-145 aundll
tCO2
18-33 rnmolfl
K
3.34.7 mmol/l
CL4
98-108 rrurioUl
tCO2
18-33 mmol/1
REMARKS:
.
LAB ID NO.:
DATE:
REPORTED BY.
,- .
REF. RANGE
73-11 g me/di
0.7-1.5 mg/di
•C 4
REF.
RANGE
RESULT
ow
BUN
Creat
,-,
RESULT
TEST
'(PiccolôjLivetf aneIPlu s
TEST
-
e
70-105 mg/dl
.
.,--
(xi '
1
9 p,
0
.
..,.
MEDCOM - 17786
DOD-031375
.••
i-STAT
P t:
Pt NamP:
Glu
r
moo
183 mg/dL
CREA
BUN
14 mg/dL
Na
140 mmal/L
Pt:
Ic
4.0 mmol/L
Pt Name:
Cl
109 mmol/L
Hct
24 %PCV
Hb*
3 g/dL
Crea
.•
•
1.2 mg/dL
Sample Type_:
*via Hct
i9AUG03.
Sample Type_:
1,AUGO3
20:05
Physician:
Oper: 11111
"b(0-Serf
Physician:
Ver: JAMSO46A
CLEW A93
Serf MP
Ver: JPO45046A
CLEW A93
•
Patient
Li Nits
4.5 10.5
•
10'11 1.
4.
13.0
PCU
9.3.3
ft
7,1
2.0 31.0
33.0 37.0
•.:10' ,11. 150. 450.
51,1
y1.01,,
IL`.1
*
MEDCOM
-
17787
20: 04
MEDICAL RECORD - ANESTHES'
at tnis form, see AR 40-66; the proponent agei
xikIN
AA,
DRUG
kfC34.71Neti 14 •
L..0 UTSG
kr 11 6:312, 44 •
.
TOTALSi/ iTAL iEBIt
Wn)ts)
z.
(tW.8 ) (1)--a
{
/0-0
( rt-LA
(
% del
10
)
lo
go
Is'
I
.7 OR
% e.t.
AIR
L/Min
IV 0
L/Min
CRYSTALLOID-
ci CeD
COLLOID-
9-
L/Min
02
ce
BL OD-
SINGLE DOSE DRUG
ARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
El
LINE site
(.1"103
Warmed
MPN
FAIIIE/511
0 Warmed
EST BLOOD LOSS
-F1.=111=Iiiiii1M1116
.1MIWlran,E:d • 4.
k= "----...111M11111111 0
Liil/E7M ■ IMida
1111111111,52.111111EnvAtIMII
oamoregg'1111ZITZ-VAZZAIIIIIIEE'
URINE -
"
lul
22D
Qle IV
LB
BP by cuff
41E1
' t
'
111111Miniii
z.t 36 MA
200
V
A
Code drugs with numbers,
events with lettters
180
Heart rate
$050.66
war"
160
•
140
Resp rate
BP-
c.011-r
• ••
004t1 tAlA
1 00 awarzorwmossoPP222111M1111PNEW2dr_taliEPORINPIr
,
MAIMIUM1111141112ridiiiiiffrAIRAWA
lia-LAAA/11
b PWC151 4' Z4441
'
IIMIINIENK.
80 1111111111MEMBEEMEMIMMEMENIUMMIEME
•
120
BR
(transduced)
HR-
..L
T
OK?-
1
TOURNIQUET
PATIENT NKHEOli"
OK for
PROCEDU
TIME- 136r
T --/1/
.
60 ME • PIIIIIIIMINIVIIPIEVOMMIIIIMIlkea1411311r"
a . .67 A.v4 ITATA
40
ANES- x-x
PROC-8_01
wirrintrovA EMEIVTAIIIMMEMINT31101111111111161111111111111A1
111111111MMIMINIX13111
MUM=
ME
20
I
1
•, ' .
'119 0 1,co
VT - m
,
' .. . .
'2 CIL
KW PrIMMEMMIN/111711•1111111310111
a
MMIE12111LiIIMIVEARCIIIII.111/111117111ITEMPTM
MODE on), Issist), C(on)
VATAII c- C- c- IIIIM e- c-- 11/4•MIIIMINII
BP/Auto Cuff r T CO2 (tort)
IIIIIREIM&11714111147/111.111111M1r7.1111MIKTAIIVNI
BP/oth
C 102 IFrac or %) IMPIIREEIIIMPFEIIIMEMIMPIrierirnitlabirlif
f- breaths/min
Peak inf pres / PEEP
ART line
I Steth- PC/ES
4,1
Gas analyzer
irmirm ,.
r 02 (%) PM WriAn--22wArDnaminwil
inimmurniummiinranninammagraa
rimrr.irra
ciarmw --- Mil---mll—.- Ilinilill Millilli
I N-M Block (T/41
ifLrW.:M/A
A
C) 2:s
Specify)
PAC
OTHER
failirrAnNfjp
211MOOWN/21.—
r
to Start Room End
Warming blkt
*b A
Z43,0
Cony warmer
Mark with letters & symbols,
explain under REMARKS
Ready Begin End
EVENTS__„„ °lc<
•••■•■•••••■■•••
Position
Ff. 'ZOO
PROCEDURES and CPT Codes:
(Dtta.m.
Typed or written entries: Name, Grade/Rate,
Medical facility
111.111
03i
&4r4
ICknx5(44.4 A-1_.
PATIENT IDENTIFICATION:
z4,4
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
M
640,4e,
AYIrcp,41 70 :. ;.t
6ub
on route, blati tekhr;klutine ts. coi....k.
asfrpb
SURGEON
PR EDURE p, ..-7
LOCATION:
CI \I
(66-1
441111.
V Fr....r....
DAIE:
I CrACI6jir3
PAGE
DA FORM 7389, FEB 1998
, 04.4
NT'S MEDICAL RECORD
.-1
OF (.
USAPA V1.00
MEDCOM - 17788
DOD-031377
/IEDICAL RECORD - ANESTHESI
,t this form, see AR 40-66; the proponent ager.
u rsG
040
TOTALS
)
r-IL
raimmmovni
0
r!!Tri-Will1=/01111
z
11111111MM
me-ftrir
z
tt}
1Q 1A3.
N20
.G
1111.
111111•111
miii
VEIN=
EVIIIIMEPIPMFM111101111MINIMI
Ill
L/Min
02
z
NroilIM
h del
mil rorm111/
um
Eat
-4=1
.0
IMIT,.
MEN
ID-
COLLOID-
L/Min
SINGLE DOSE DRUGS•MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS
LINE site
MArrrcill=1111111V-:
BLOOD-
❑ Warmed
erAri.."
Z.ctt
Warmed
Warmed
rillr211
- 11
... ''I'.
:}SE
11M71111011.111.----- UI; CO
11:5111 Mile=•.
111
ET
Code drugs with numbers,
'
Warmed
events with /enters
EST BLOOD LOSS
UR NE
'
•
TIME
345
1513'S:
o
BP by cuff
LB
30
•
220
200
V
ATO
A
180
•
Heart rate
160
•
Resp• rate
BP-
140
120 0
BR
(transduced) 100
HR-
I
11112311
PRIS111111111UriiiMILKAA
IMIlp1P7411W.WATAl21110MIMI
—AX219"
MIN
80
OK?-
TOURNIQUET
T
OK for
PROCE
TIME- Zerc
60
MIELAWLAILIEFAILMILIBRIE
40
ANES- x-x
PROC- 0_0
2
VT-ml
MODE SI
• • n1 A(ssist), Cion)
BP/Auto Cuff
T CO2 (ton')
BP/oth
02 (Frac or %I
ART Fine
p 2 1%)
Steth- PC/ES
Gas analyzer
1.-
CG
TEMP-site
N-M Block (174)
it
0
715 .
00 eb
IV°
illiffM/01111011FAMIEMMIFEEMMW/411
tralW1111111alliffilIZAWRIMIC/111 7-0
112111112MCNIMINWillallErMI
Vallillira
f - breaths/min
Peak mf pres I PEEP
U
111111/1111111111111111
MarlailMilMillinallr11117p lEI'WlVrRlFAI' P7'M
,
EMINTINff,
00
Etillffar3"AreillilarldIffillIMMIlri MEM t...!?1,0 =Iminummilirarimmenwiamman.
0 Ln GM UM Erigat://a Vel I MI 11:7M1:7
11•111MINSIMMINIIMIMIMill
MEM
Cob
Warming blkt
.....
PACU ICU
Sped I
OTHER
CONDITION:
RESP-
S
BP•
a.0
Room
End
Begin
End
z
Cony warmer
eady
Mark with letters & symbols, EVENTS_,
explain under REMARKS
Position
PROCEDURES a • CPT Codes;
0,00,/
ANESTHETIC TECHNIQUES: Describe block technique und
11611Ight:..k.a,16111 ft' •/
PATIENT IDE FICA ION:
yped or written entries: N me, rade/Ra e,
AIRWAY MANAG
Medical facility
124.°
arks
intubation route, blade, technique, comments
PROCEDURE
LOCATION:
H
PAGE
DA FORM 7389, FEB 1998
PY 1
MEDCOM - 17789
-
PATIENT'S MEDICAL RECORD
OF
u5nrtc vi.00
DOD-031378
AEDICAL RECORD - ANESTHESI
A this form, see AR 40-66; the proponent agen,
OTSG
TOTALS
CC
t
5
Icu Z
oo t.
cn
3z --. ■-tta CO
mZ
0 0
n >0
Z 11.▪
Z Lair
Z So)
N20
L/Min
COLLOI
02
L/Min
2
a SINGLE DOSE DRUGS-MARK ON GRID
BLOO
WITH NUMBERS & ENTER IN REMARKS
LINE site
Warmed
0
0
0
Warmed
r:SbE)
Code drugs with numbers,
events with !eaters
Warmed
warmed
EST BLOOD LOSS
LOSSES
UR NE -
TIME
zy-'
BP by cuff
A
Heart rate
•
Resp rate
BR
(transduced)
OK7-
N
OURNIQUET
*OW
T
OK for
PROCE
ANES- X-X
PROC- 0_0
TIME-
f breaths/min
Peak int pres / PEEP
MODE Slpon), Alssist), C(on)
COVER
a
BP/oth
F102 (Frac or %) cot'.
ART fine
Sp02 (%)
Steth- PC/ES
ECG
Gas analyzer
TEMP-site
N-M Block (T/4)
sr
Pt,
itSe
1741
Warming blkt
Cony warmer
Mark with letters & symbols,
explain under REMARKS
Begin
EVENTS_,.
Position
PROCEDURES and CP.I Codes:
PATIENT IDENTIFICATION:
ANESTHETIC TECHNIQUES: Describe block technique under Remarks
Typed or written entries: Name, Grade/Rate,
Medical facility
AIRWAY MAN EMENT: Int b
e, bled
que, comments
SURGEONS:
PAGE
DA FORM 7389, FEB 1998
MEDCOM - 17790
IENT'S MEDICAL RECORD
OF
USAPA V1.00
DOD-031379
Jo Jeri,
MEDICAL RECORD - ANESTHESr
EL„
0,
00'0
8 .„,-,
0
:...
........"—AA'
(
/I
)
i I
1 ,71)
n't
,5`,- t_ 1, _,N4,_,......-,.4 2. A - ) ( - x €r )
D
_:VOLA ::
D > U :KGENTi
-
.0..
ri .a454
)(2-‘"i i
is (""
la
z
02
3
.
3
4 .-- -r1(e"--- +J.. ^ Lt.
1 ..s'
% e.t.
AIR
N20
I
/A..)/k
I
L/Min
4 -- •,-^
2 --
2-
—
L.
•-I
• Warmed
l'it..90 ---r-.>43 -'•-•• J--9-..1-0 ---
/161-0
-.—
L
)
/2 0'0
❑ Warmed
❑ Warmed
3
BLOOD-
/94o
---.--
:IN:I....:.
TIME 011.- ogy,- 4,5
n
x
:,.:,..:
12
BP by cuff
LB
V
AM
......,,,..::„..:,..,..
:i::::Ogt....
/o
...1(
,r
7"
q . .4..4.,.....4-- ,-
1
'la' s
010_/0,-
i
A
180
Heart rate
•
160
Resp rate
140
120
r
1014
+
90
TOURNIQUET
so
:. . *:Vi,W
(NV N
: 04)-4gCV1).15Pg
ON for
PROCEDURE?Yi4
I —4
40
ANES- X-X
PROC- €.0
20-
u.:
-...-..
-
pi-x t
.
BP/Auto Cuff
44
a/Glu2P''
/6/.:„.4' °-*/
/
fIC
0
'
us
$A
t
F102 (Frac or %)
Sp02
Steth- PC/ES
ECG
Gas analyzer
TEMP-site
1%)
i. 7
f
1 ..
7-
1
N-M Block IT/4) Yip.
if0.
".r,A,.1.4.7‘......P,
9...A
,
R9c,
ART line
De .4".cfr-z 5 '' '
ruraimmilugolvvzorATATAyzermaiditrarr
MIME
_—
mow W7BIAILOINIMINICAMMIIIIIIIIIII
ET CO2 (torr}
IBP/oth
"a /A..—
..1 4....k 't ic,c--
20
Stpon), Alssist), cIon)
e'" r 1-1A4
A-wiz- .
f - breaths/min
Peak inf pres / PEEP
MODE
.
.
VT - ml
:::
-C. V, Ol'Aratf2L
BR
(transduced) 100
HR-
(44%7
-
..se:t - LY, on.
I
1200
1-7-3- , 67
TIME- 0
,,,.. 10,04
%..W.11.404,....1
• py:::wgi:00.:.i: : : Ar.11.!.%!1!::: 220
OK?-
i'Ai:i::::::.g:•::::
Code drugs with numbers,
events with lettrers
URINE -
i$::SIATO:
.'::
.
-
•
, rii•
..:
-
r---r ,rd
103 4 5 ..E
BP
's>>< tugs
COLLa-
I=1 Warmed
.
co-c)
EST BLOOD LOSS
— ,...:*
'.$i:
$#
::::iii:ii:iiiiNi
to
CRYSTALLOID.1.- i?... /-7.t:/
L/Min
L/Min
aA
g
1_1
ir — L )--/.
SINGLE DOSE DRUGS-MARK ON GRID.*
.g WITH NUMBERS S. ENTER IN REMARKS
.,,.. LINE site
i
1
Avis-
> SA ve) % del
g
at 1- 2!-Op)
,,,,, (..)
9-c,
*04:::iikt -i.::
4
sP
,
';
CD <
TOTALS
1C
A,.
(
)
( .,.. )
g: <' 20 Jeic.07
LT_ . 'i 4441;....N),,,t.
LU
.........„,..
::(000)-:..
z i..",.., 4....)
:j6: F222
OTSG
,
0-1
,.,
tnis form, see AR 40-66; the proponent age!.
(30
?
4S
.0
23
(.,.
1/
C
33
. 7
lo p
Joe
si
:0
-
ISA; 11 lo 9610 9;0
3 . It
g'
g
21
T-S
2-3 .1 7
Q
17...
.7
e-
C.,
31
so
.7
0.1
,-7
00
Lit
100
1-00
‘
#00
rt
0
Y
47
ji
.1
. T.
se..
G.
23
6;A
go
s.
•3
G.
z?
Nam,
,.
r,
1-11-
L4 i
7W
i,
12
LI-
let
97
.1
`fit
.7
JD
10 0
C.
32
cid\
....,,c
.7
fa%)
6.4...„
70..., 42... .2117
ii7x,
)2
fc 07/1,.
4 ,,.. /I,
J
.i: §004....
4.?
e7
/ 0-°
....,.x.
/16.
'-.
.
Tr:
...1 g)Th
PActC29
li S
ISpecity)
OTHER
CONDITION:
i?'
RESPSp02101.11 i
BP- /10,2 HR- h e,
A .4-1
PROC ANES
*OfaTflgl0tioc0.:..iw:::::::
ovia:::::::::::;:;::::::::::::::::::::::::::::::::::::::.:::.:.••••
i
Warming blkt
1
Cony warmer i
I
Mark with letters & symbols,
explain under REMARKS
EVENTS._,
Position
PROCEDURES and CPT Codes:
PATIENT IDENTIFICA710 i
..--,,:
-
"..
r
Room
End
Ready
v gala
Begin
End
6 9 / 0 firkie
ANESTHETIC TECHNIQUES: Describe block technique a der Remarks
yped or written entries: Name, Grade/Rate,
Medical facility
Start
c / 2'0 rdrarr.` //$5
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
13f -- /I:
SURGEONS:
b (I2
L
-2.
PROCEDURE
LOCATION:
DATE:
d
e4
2 i qiieel
PAGE
..... ........... ----- - - -_
MEDCOM - 17791
1 - PATIENT'S MEDICAL RECORD
) OF
USAPA V1.00
DOD-031380
.
SOX fl KALE
Agar', DAYS MOS
PROPOSED PROCEDURE.:
a. r
SURGICAL SERVICE
• PSI AI
NPO SINCE:
■•
11;
•
.
i)
r
4/..;
Alez.k-u4--
( ) FEMALE
.L
•
e 1 &la
ASA
WT:
ALLERGIES:
TIME
MAIM
TOBACCO:
ETON:
DRUGS:
SILWELMIWADMISI
()= ordered as premed
(
)
()
()
(
()
PREMEDICATIONS:
Mrs) /CC
None Yes (0
mg IV IM PO
•
mg IV MI PO
mg NSA PO
.
LaSskaalOTM
RYS U
HEIMCT:
WA:
OTHER:
^A MEDICAL HISTORY
HYPentension
.
Angina
111
CVA
Other
Pulmonary System:
Asthma
Bronchitis/URI
COPD
Other
Renal System: las RF
Ac a
Martina,:
msposis
Hiatal Hernia
PtfD1GERD
Endocrine System :
Diabets
Steriods
Thyroid
• I:
Selman
Neuropathy
Other
N Y
N
N
N
9.jkf i
.,„44L e
N
N
N
N
N
Y
Y
Y
Y
3s
/
N Y
N Y
N
gda
J.14✓
CARDIAC:
N
N
RR 1- Ft
BP
Pain Scale 0- O
HEENT -Teeth
Trachea
MU/Neck
Oropharnyx
Wares
CHEST:
Y
EXTREMITIES:
N
N Y
N
Y
N Y
IV Access:
Ulnar
BACK:
N
Pregnancy
Other Significant Rx:
N
N
N
Familial HX
Y
OTHER:
Y
Y
Y
NPO Since
{ Regional (Specify):
ANESTHETIC PLAN: ( } LOCAL ( } MAC
General: Mask intubation
INFORMED CONSENT/COUNSEUNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
discussed with the patienVlegal guardian.
The patient/legal'
Signed:
P-
answered.
nd and agrees.
te4h
to u ndere
Date: 2 1 *O. O
rf—c."&41
POST-ANESTHESIA EVALUATION AND NOTE (NON ASU)
( ) NO APPARENT ANESTHETIC COMPLICATIONS { )'OTHER
0 CJ
Hrs
SEDATION KEY:
I. MINIMAL (Arrdolysis) Patient
respond* normally to verbal
commands
Signed:
Patient Identification: (Ward)
Date:
Time:
Hrs
2. MODERATE (conscious sedation)
Patient responds purposefully to
verbal commands atone or
accompanied by light tactile
stintuladon. Airway assistance is not
*
necessary.
3. DEEP SEDATION/ANALGESIA.
Patient responds purposefully
following repeated or painful
stimuialion. Airway maelstrom may
MIN ck--) —
faINOWIMININ011
be necessary.
S. ANESTHESIA. Patient does not
MEDCOM - 17792
DOD-031381
•
BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDICAL RECORD
SECTION I — REQUISITION
COMP ENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood
REQUESTING PHYSICIAVint)
Cell Products are requested.)
-
BLOOD CELLS
TYPE AND SCREEN
0 FRESH FROZEN PLASMA
PLATELETS
ri
CRYOPRECIPITATE (Pool of
O
Rh IMMUNE GLOBULIN
O
OTHER (Specify)
aprE1ROSSMATCH
units)
units)
5/?&/..--)
DATE REQUESTED
I have collected a blood specimen on the below
named patient, verified the name and ID No. of
the patient and verified the specimen tube label to
be correct.
1'
DATE AND HOUR REQUI
VOLUME REQUESTED (If applicable )
E
DIAGNO
[1
(Pool of
7
KNOWN ANTIBODY FO ATION/TRANSFUSION REACTION (Specify)
SIGNATURE OF VERIFIER
IF PATIENT IS FEMALE, IS THERE HISTORY
OF:
DATE VERIF
RhIG TREATMENT? DATE GIVEN'
TI
ML
REMARKS:
e
"7 0
VERIFIED
HEMOLYTIC DISEASE OF NEWBORN'
SECTION II — PRE-TRANSFUSION TESTING
...LUNIT NO.
TRANSFUSION NO.
PREVIOUS RECORD CHECK:
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
El RECORD
PATIENT NO.
DONOR
RECIPIENT
ABO
ABO
Rh
Rh
NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
/44
CROSSMATCH NOT REQUIRED FOR THE COMPONENT
REMARKS:
26/4 e
SECTION III
—
RECORD OF TRANSFUSION
PRE - TRANSFUSION DATA
INSPECTED AND ISSUED BY. (Signature)
/ V IN".-4
REACTION
I have
find
lood Component container label and this form and I
tifying the container with the intended recipient
e recipient is the same person named on this Blood
Form and on the patient identification tag.
m
POST-TRANSFUSION DATA
TIME DATE COMP
TEE.
/
AMOUNT GIVEN
tja
r‘.4
INTERRUPTED
'07
EKIE 0 SUSPECTED
If reaction is suspected — IMMEDIATELY:
1. Discontinue transfusion, treat shock If prent, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Procedures.
4. Do NOT discard unit. Return BlocA.I Bag. Filter Set, and I.V. solutions to
the SrEad Bank.
DESCRIPTION
URTICARIA 0 CHILL
n
PULSE /C
DATE OF TjtANSFUSION jTIME STARTED
ig
PATIENT I
NAME - Las
LTIES (Equipment. clots, etc.)
0
ION
TEMP.
FEVER 0 PAIN
OTHER
OT
PRE- RA
Ej
YES (Specify)
ERSON NOTING ABOVE
BP
/ 5
TIFICATION USE EMBOSSER (For typed or written e
'rst, middle: rank/rate; hospital number and name of facilf
SEX
WARD
O
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
MEDCOM - 17793
DOD-031382
518-124
NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I
COMPONENT REQUESTED (Check one)
3
" RED BLOOD CELLS
D
FRESH FROZEN PLASMA
❑
PLATELETS (Pool of
Rh IMMUNE GLOBULIN
Ill
OTHER (Specify)
REQUISITION
REQUESTING PHYSICIAN (Print)
N.---TYPE AND SCREEN
E
units)
CRYOPRECIPITATE (Pool of
❑
-
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)
units)
DIAGNO
CROSSMATCH
DATE REQUESTGQ,
3 ,1-->c,..,
ML
REMARKS:
(\54
:hi
[ '--) t
DATE AND HOUR REQUIRED
VOLUME REQUESTED Of applicable)
-6, ( (0
0
1
I have collected a blood specimen on the below
named patient, verified the name and ID No. of the
and
ified the specimen tube label to be
correct. icoret.
3
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)
SIGNATURE OF VERIFIER
IF PATIENT IS FEMALE. IS THERE HISTORY OF:
DATE VE
Fl
_
RhIG TREATMENT? DATE GIVEN:
/41---3
• --)
c
Ce
al-)
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
-CbCA Ch
SECTION II - PRE-TRANSFUSION TESTING
UNIT N(:)‘:
.)
TRANSFUSION NO.
24-
TEST INTERPRETATION
ANTIBODY SCREEN
PREVIOUS RECORD CHECK:
CROSSMATCH
RECORD
❑
N
PATIENT NO.
DONOR
RECIPIENT
ABO
ABO
Rh
Rh
RECORD
SIGNATUREOFP RMINGTES
C
O/ente'
CROSSMATCH NOT
REQUIRED FOR THE COMPONENT REQUESTED
REMARKS:
DATE
(I'
9
24 SI (23
."
1
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
POST-TRANSFUSION DATA
AMOUNT GIVEN
INSPECTED AND ISSUED BY (Signature)
TIME/DATE COMPLETED/INTERRUPTED
ML
REACT!
AT (Hour)
ONE
ON (Date)
IDENTIFICATION
I ha
inf
nent container label and this form and I find all
with the intended recipient matches item by item.
ed on this Blood Component Transfusion Form and
1.
2.
3.
4.
/ ZIP
14 ad- er
DESCRIPTION OF REACTION
URTICARIA
❑ CHILL
❑ FEVER
❑ PAIN
OTHER (Specify)
0TH
PRE-TRANSFUSION
P2144V-6-105
BLOOD PPR URE
Discontinue transfusion, treat shock if present, keep intravenous line open.
Notify Physician and Transfusion Service.
Follow Transfusion Reaction Procedures.
Do NOT discard unit. Return Blood Bag, Fitter Set, and I.V. solutions to the Blood Bank.
❑
DATE OF TRANSFUSION
PULSE
SUSPECTED
If reaction is suspected—IMMEDIATELY:
(cP
TEMP.
TEMPERATURE
❑
S (Equipment, clots, etc.)
YES (Specify)
I PULSE
-0
.7
BP
142/ r■Z
OVE
TIME STARTED
24N
(s): -
2
,
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—
rate; hospital or medical facility)
grade; rank;
SEX
WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV 9-92)
Prescribed by GSA/ICMR, RRMR (41 CHR) 201-9.202-1
MEDCOM - 17794
Medical Record Copy
DOD-031383
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
TYPE OF REQUEST (Check ONLY If Red Blood
Cell Products are requested.)
COMPONENT REQUESTED (Check one)
gs
RED BLOOD CELLS
El TYPE AND SCREEN
0 FRESH FROZEN PLASMA
PLATELETS (Pool of
CROSSMATCH
units)
CRYOPRECIPITATE (Pool of
units)
O
Rh IMMUNE GLOBULIN
I I OTHER
frattAmcciga ourro
DATE REQUESTED
I have collected a blood specimen on the below
named patient, verified the name and ID No. of
the patient and verified the specimen tube label to
be correct.
)
DATE AND HO REQUIRED
(Specify)
0
( ?
VOLUME REQUESTED (If applicable )
2(10
sTAT
e
KNOWN NTIBmDY RMATION/TRANSFU•
SION REACTI
(Specify)
SIGNATURE OF VERIFIER
IF PATIENT IS FEMALE, IS THERE HISTORY
DATE VERIFIED
RhIG TREATMENT? DATE GIVEN'
TIME VERIFIED
ML
REMARKS:
OF:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II — PRE-TRANSFUSION TESTING
UNIT N
cv6(
62)-7
TRANSFUSION NO.
PREVIOUS RECORD CHEC
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
RECORD
PATIENT NO.
DOOR
RECIPIENT
ABO
ABO
/1)S
Rh
Rh
4
/00
NO RECORD
SIGNATURE OF PERSON PERFORMING TEST
NOT REQUIRED FOR THE COMPONENT R
REMARKS:
'51e
s
2445
TION III — RECORD OF TRANSFUSION
POSTTRANSFUSION DATA
INSPECTED AND
AMOUNT GIVEN
—Z
4,A44 •
ACTION
TIME DATE —67)1TATLETED
INTERRUPTED
ML
131(C-)NE
0 SUSPECTED
AT (Hour)
IDENTIFICATION'
I have examined the Blood Component container label and this form and I
find all information identifying the container with the intended recipient
matches item by item. The recipient is the same person named on this Blood
Component Transfusion Form and on the patient identification tag,
1st VERIFIE
attire)
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 Blom; Bag, Filter Set, and I.V. solutions to
the 131 cd Bank.
DESCRIPTION
URTICARIA Ej CHILL
ri
ri
FEVER
PAIN
OTHER
OTHER DIFFICULTIES (Equipment, clots, etc.)
0
ION
TEMP.
PULSE
DATE OF TRANSFUSION
TIME STARTED
BP
YES (Specify)
RSON NOTING ABOVE
/?
1/11+4"0(3
PATIENT IDENTIFICATION • USE EMBOSSER (For typed or written entries
NAME - Last, first, middle; rank/rate; hospital number and name of facility.)
EX
A
1:241—C=1;100--
0/2
BLOOD OR BLOOD COMPONENT TRANSFUSION
STANDARD FORM 518 (REV. 846)
General Services Administration
interagency Committee on Medical Records
FIRMR (41CFR) 201-45.505
518.122
MEDICAL RECORD COPY
MEDCOM - 17795
DOD-031384
BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDICAL RECORD
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood
Cell Products are requested.)
REQUESTING PHYSICIAN (Print)
RED BLOOD CELLS
12
0 FRESH FROZEN PLASMA
TYPE AND SCREEN
DIAGNO
T VE
-
PLATELETS (Pool of
CRYOPRECIPITATE (Pool of
,*4
CROSSMATCH
units)
units)
I have collected a blood specimen on the below
named patient, verified the name and ID No. of
the patient and verified the specimen tube label to
be correct.
Rh IMMUNE GLOBULIN
DATE AND OUR EQU1RED
OTHER (specify)
/9
VOLUME REQUESTED (If applicable )
dt,„y --arm Ac.
c irna
"
DATE REQUESTED
D
0
1 I Sar
KNOWN A 1BOD F MATION/TRANSFUSION REA
ION (Specify)
SIGNATURE OF VERIFIER
ML
REMARKS:
e
IF PATIENT IS FEMALE, IS THERE HISTORY
OF:
;.17
DATE VERIFIED
RhIG TREATMENT? DATE GIVEN•
TIME VERIF1E
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II — PRE-TRANSFUSION TESTING
TRANSFUSION NO.
PREVIOUS RECORD CHECK:
TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH
(S6 —
11111111111111. PATIENT NO.
❑
RECORD
NO RECORD
SIGNATURE OF PER •N PERFORMING TEST
DONOR
-
ABO
RECIPIENT
J
ABO
CROSSMATCH NOT REQUIRED FOR THE COMPONE
REMARKS:
PUS
Rh
SECTION III — RECORD OF TRANSFUSION
INSPECTED A
POST-TRANSFUSION DATA
TIME DATE
COMPLETED INTERRUPTED
AMOUNT GIVEN
‘ 74'647M L
4/4
REACTION
AT (Hour)
❑
ate)
I DENTIFICATI
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.
DATE OF TRANSFUSION
fLI
TIME STARTED
❑ 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 Blocti Bag, Filter Set, and I.V. solutions to
the -n:7E1d Bank.
DESCRIPTION
❑
URTICARIA
❑
OTHER
OTHER
PULSE
NONE
Alf/41/1„5
❑
1FEVER
❑ PAIN
FICULTIES (Equipment, clots, etc.)
0
BP I I
CHILL I
YES (Specify)
RSON NOTING ABOVE
5-0
PATIENT IDEIII IFICATION - USE EMBOSSER (For typed or written en
NAME - Last, first, middle: rank/rate: hospital number and name of faciii tY.)
WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION
STANDARD FORM 518 (REV. 8-861
General Services AdministratiOn
Interagency Committee on Medical Records
FIRMR (41CFR) 201-45.505
518-122
MEDCOM - 17796
MEDICAL RECORD COPY
DOD-031385
CiiilICAL RECORD - DOCTOR'S ORDERS
4f-se, ttie CgopOrtent agehoy is OTSG
.
For use of Nis form, se0 AR
--,--1-7.---7-h-z•-v-; -, T'7."-11.';'?'
: ,,...THE DOCTOR SHALL . RECORD DATE, TIME AND SIGN EACH gET Of ORDERS. iF !'Rt EM ORtENTeD ME:CitCAL Ri t.'Ci::::4,
SYSTEMMUSED; WRITE PROBLEM NUMBER tH COLUMN tNDICATEO BY ARROW BELOW.
P'ATIE-Nn- roeNTsp (CATION
/-' Ìm-E •••OF OROgr.""----7-1
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trOM•-•
-DATE OP 'OtioER
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NURSING UN tr
ROOM NO.: •
RED NO
1.1,A 1
•
PAT LENT town F LOATION
crioefi
DATE 0
blizairt4
14
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NUPSING VN-1T
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DATE
!ROOM NO. 71E13 NO-
OF -ORDER
i/eA 7cio
7,2e c-;
DA
„ 4256
REPLACES
EDITION OF
1 JUL 77. MULCH MAY BE USED.
MEDCOM - 17797
DOD-031386
TT
S
CLINICAL RECORD
-
DOCTOR'S ORDERS
For use of this form. see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATE OF ORDER
0-,/1
X.A (i . 03
0 1-1e/,41
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ROOM NO.
•
BED NO,
DATE OF ORDER
TI
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1
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HOURS
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ORDER
NOTED AND
SIGN
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PATIENT IDENTIFICATION
NURSING UNIT
HOURS
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OE'Cii
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NURSING UNIT
LIST TIME
TIME OF ORDER
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BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
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r,? 3,z.
HOURS
lonol 6,-K , Po 9 4-(ao
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bf
NURSING UNIT
ROOM NO.
.)
BED NO,
PATIENT IDENTIFICATION
DATE OF ORDER
TIME OF ORDER
HOURS
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[ROOM NO.
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1FAO,RF,M79 4256
JUL 77, WH1
-
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REPLACE •ITI• N •
-
MAY
t' U,4. nOVERNMENT PRINTING OFFICE: ?936-409-524
•
"USE BALL. POINT PE -
MEDCOM - 17798
APER REQUIRED"
DOD-031387
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
DATEF ORDER
y
"--4/'S
TIME OF ORDER
7-0/-(5--
HOURS
LIST TIME
ORDER
NOTED AND
SIGN
NURSING UNIT
PATIENT IDENTIFIC
DATE OF ORDER
■
NURSING UNIT
leM2
PATIENT IDENTIFICATION
OF ORDER
NURSING UNIT
Air
PATIENT IDENTIFICATION
\<.7(_ L1,
NURSING UNIT
DA
,FAOPR
IIM79
4256
REPLACES EDITION OF 1 JUL 77
BE USED.
MEDCOM - 17799
DOD-031388
)0!
CLINICAL RE ORD
VERIFY BY IMPALING
ORDER
DATE
r
THERA P EUTIC DOCUMENTATION P ' RE PLAN (Nthv-MEDICATION)
For use of this f. . see AR 40.407;
000.0060a:,6006* in.:,)iaroznei
,
l.n.,:tnev is the 0 fico of The Surgeon
CLEW/
HR
RECURRING ACTIONS.
FREQUENCY. TIME
NUR
..
Yr.
2003
PROPER COLUMN FOLLOWING EACH COMPLETION
DATE COMPLETED
7.
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PRIMARY DIAGNOSIS: igtift4i4.)
Fa-e...442,
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ADDITIONAL PAGES IN USE
• ii4 --ee'4-.C42-i ,
71/..A.TIZG•teei'
YES
i. 1411-4-e--
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PATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
8 9 10 11 12 13 14 ,15
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---
USAPA V1.00
MEDCOM - 17800
DOD-031389
,
Verify by
Initialing
Order
Date
THL...-,r1EUTIC DOCUMENTATION CARE PLAN
(NON-MEDICATION)
Clerk
Nurse
24
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SINGLE ACTIONS
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2003
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Date
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Nurse
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIMEIDATE COMPLETED
Li
USAPA 01 00
MEDCOM - 17801
DOD-031390
4/L
..../
/
THERAPEUTIC DOCUMEN ATION CARE PLAN (MEZ4C42:70P1,9-
CL ICAL RECORD
For use of this form, see AR 40-407:
is the Office of The Suraeon General
the !Torment men
-..'744 T.
4 ,
VERIFY BY INITIALING
Mo.
Y r.
IAITLIL PROPER COLUMN FOLLOWING EACH ADMINIS7RAZION
MAINE
,
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ALLERGIES: n YES
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PATIENT IDENTIFICATION:
fi
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ADDITIONAL PAGES IN USE:
Q YES El NO
(13
PAGE NO.
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
DA FORM 4678, 1 FEB 79
D
7 8 9 10 11 12 13 14
E
15 16 17 18 19 20 21 22
N
23 24 01 02 03 04 05 06
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
USAPA V1.00
MEDCOM - 17802
DOD-031391
..
Verify by
THERAPEUTIC DOCUMENTATION CARE PLAIO
(MEDICATIONS)
Initialing
Order
Clerk/
Date
NUItie
0
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t■ArigAIII
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2A
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TIME/DATE DISPENSED
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USAPA V1.00
MEDCOM - 17803
DOD-031392
r
CLINICAL RECORD
MEM= a tinNagaggin.;:t;
CLERK,
NURSE
G2A e
TV
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DATE DISPENSED
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INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HA
RECURRING MEDICATIONS,
DOSE, FREQUENCY
Y r, 2003
Mo.
the proponent arcncy is the Office of The Surgeon General .
VERIFY B Y INITIALING
ORDER
DATE
THERAPEUTIC DOCUleynAtallImCM4pi LAN (,....3D/ZAT/ONS)
r ictz os 2..2
I'
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PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE
I
I YES
I
' / 1— t
El ND
PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
c --
.L
DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
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
USAPA VI.00
MEDCOM - 17804
DOD-031393
•
CLINICAL RECORD
VERIFY BY INITIALING
ORDER
DATE
:26 a44
t, 1
Minignanningaffigni•
CLERK,
NURSE
-
THERAPEUTIC DOCUMENTATION CARE PLAN 1,,AEDICATIONS)
Far use of this form, see AR 40407;
the proponent agency is the Office of The Surgeon General
RR
RECURRING-MEDICATIONS,
DOSE, FREQUENCY
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DATE DISPENSED
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INITIAL PROPER C OL UMNFOLLOWING EA CH ADMINISTRATION
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1
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PRIMARY DIAGNOSIS:
ADDITIONAL PAGES IN USE
4,-“A-. :0-..;
Fer..”A/12We,-, *-64•
IN
YES I I NO
PAGE NO.
PATIENT IDENTIFICATION:
DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
111111 1 .
D
7
8
9
10 11 12 13 14
E
15
16
17
18
19
20
21
22
N
23
24
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02
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04
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DOD-031394
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DOD-031396
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DOD-031400
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Surgeon General.
For use of this form, see AR 40-66; the proponent agency is the Office of i
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DOD-031404
ADMISSION AND CODING INFORMATION
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NAME
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23. DATE OF DISPOSITION
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USAPPCV1.0
MEDCOM - 17816
DOD-031405
INPATIENT TREATMENT RECORD COVER SHEET
For use of this tom, see AR 40.400; the proponent agency is OTSG
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MEDCOM - 17817
DOD-031406
MEDICAL RECORD
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FintleR 1975 201-45505
539-106
MEDCOM - 17818
DOD-031407
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MEDCOM - 17819
DOD-031408
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NOTES
DATE
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MEDCOM - 17822
DOD-031411
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
AND SIGN EACH SET OF O BRY DERS. IF PROBLEM ORIENTED MEDICAL RECORD
ARROW BELOW.
OR DATE, TIME
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MEDCOM - 17823
DOD-031412
MEDCOM - 17824
DOD-031413
Checklist
Air Evacuation
Initial
when
complete,
.
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Category: RP U (circle one)
Ambulatory or (circle one)
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Prescriptions written for evac.
Narrative Summary Completed
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✓Prescriptions sent to Pharmacy
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Nursing Discharge Note written
MEDCOM - 17825
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