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TRANSCRIPT
DATE NOTES 0 0(000
pi -1 -ucik6 '7 -(1-23 '' 1-Las. p032.. ?--fral.-2_ —yla../
R39 99 61 1 f
1-1(01 as 7 9.z._ q i 97 Ian I 2 Is
Ht -c_ 3 ' 40 tivio 0- - 15- Y ILI
/1\, ,ano
94
LAST NAME
FIRST NAME MIDDLE INITIAL I ID NUMBER
STANDARD FORM 509 IREV. 6119991 BACK
USAPA MOO
MEDCOM - 22641
DOD-036217
ACLU-RDI 1673 p.1
DOD-036218
Ncfativc
9.8-13.6 sccs
21-34 scm
<1 .;)
<10 g En!
E I 1- LAST, FST. M1
RESULT FORM A:et of 1974) r
■ - •
TEST RES ULT R_E F. RANG C 4.8-10.8 x IC' 'csinr I
10'
Ugh
Hct
MC V
PlE
Lymph %
14-IS p, :al (N.f) 12-16 g/11(7) 42-52% 37-47% 80-94 fl (M) 81-99 fl
130-500 x 10 vaiticd
20.5-51.1%
TEST j RESCJIZ' REF. RANGE
RPR
Mono
NG VI/ Vr, H. pylori
S our ce
'N/A
Mono
Micro Parasites
0.2-1.0
Cell Count
: . .Blood:13.112k. Unit Grosso:latch' : : - - (NflUSiSUBM1T SF 5IS WITH EVERY uN.Tr OF BLOOD - - - RE UTSTED JV/7 .. TIT E CROSS VITCH
TEST TE F. R.4.NGE
FIE:VLARKS:
00-2-
MEDCOM - 22642
ACLU-RDI 1673 p.2
3203AA4 DR #: 000
0000100494
BASIC MET IC DISC LOT #: OPER #: 678 SERIAL #:
Hgb 12-17d.;.
' I CHEATUTRY RESC1_,T FORM (Subiect to the Privacy Azt of 1974.)
I TL\i I SSNRSFLIDO SSN:
===== PIC 0 31/10/03 REFERENCE RAN PATIENT #: LIVER PANEL DISC LOT #: OPER #: 678 SERIAL #: ............... ALB 3.8 3.3 ALP 93* 26- ALT 37 10- AMY 39 14- AST 61* 11- TBIL 0.9 0.2 GGT 14 5-65 TP 7.0 6.4-
INST QC: OK CHEM OC: OK HEM 2+, LIP 0 , ICT 0
PICCOLO 31/ 3 18:28 REFERENC NGE: MALE PATIENT #
GLU 96 73-118 MG/DL BUN 9 7-22 MG/DL CA++ 9.2 8.0 - 10.3 MG/DL CRE 1.3* 0.6-1.2 MG/DL NA+ 136 128-145 MMOVL K+ 4.5 3.3-4.7 MMOVL CL- 100 98-108 MMOVL tCO2 21 18-33 MMOVL
INST DC: OK CHEM OC: OK HEM 2+, LIP 1+, ICT 0
PCO2
pH
35-45mullig(.c-0 41-51 nurdiz
HCO3
TCO2
P02 80-105 mmHg (art) N/A (veul 23-27 mmol/L (art) 24-29 zorno1/1. (vea) 22-26 mmoVL (art) 7_3-78 mruoVL (vcn)
s02 95-98%
BEecf (-2)— (+3) mmuL/L
AnGap 10-20 mmoliL.
Ca 1.12-1.32 rnmol!L
BUN 8-26 mg/dl
GLU 70-105 mg/d1
Creat 0.7-1.5 mg/dl
Hct 38-51% PCV
3153AA7 DR #: 000
0000100689 ........... -5.5 ..6/DL 84 U/L 47 U/L 97 U/L 38 U/L -1.6 MG/DL
U/L 8.1 G/DL
•heitust
TEST 'RESULT REF. RANGE
Tropcnin - 1
Drug of Abuse
RE Ntk.RX S:
REPORTED BY: DATE: J LAB TO NO.: ,.,?1 cic."--0?
tCO: I Is-3) rr.,-no_.!
MEDCOM - 22643
DOD-036219
ACLU-RDI 1673 p.3
Ward/Section: (1),.k\
LAST, FIRST,IVII.
Other
REMARKS:
REPORTED BY: DATE: )
REQUESTING PHYSI LABORATORY RESULT FORM (subject to the Privacy Act of 1974)
4TT 0C3T
SSN/PEEUDO SSN:
atti Jrinafysis Misc. SeroiG
RESULT REF RANGE TEST TEST RESULT REF RANGE TEST RESULT REF RANGE Color 4.8-10.8 xi() BC N/A RPR Negative App R BC 4.7-6.1 x14 N/A Mono Negative
14- 18 g/c11(1‘1) 12 - 16 g/11(1)
Hgb Negative Microbiology 42-52%(M) 37-47%(F)
Hct Bili Negative Source
80-94 Ii(M) 81-99 fi(I;)
MCV K t Gram Stain
Negative
130-500 x 10' verified
Pit SG Occ Bld N/A Negative
Lymph °A, Bld IL pylori 20.5-51.1% Negative Negative
entatology) i:Ianual Differeii ti N/A p Micro Parasites
Segs
Bands
Lymph
Atyp
RBC
Morph
Spun Hem atocrit
Set Rate
Mono Prot Negative Malaria
Eos ['rob O&P 0.2-1.0
Baso Nit Negative Other
Imm Leuk Negative
HCG Negative
42-52%(M) 37-47%(F)
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
[Negative ABO/Rh Directigen
nagiatirogg:.1"0:tga; 0g014ttoilgSiiidjes..•
.MrgsSROPY.WITHOEVERVUNtit'01t. 611 nitgoimMEOM$Tx0).:'.11:6
1Mwm
TEST
PT
APTT
D dimer
FDP
RESULT REF RANGE UNIT TYPE CROSSMATCH
9.8-13.6 secs
21-34 SESS
<20 ug/ml
<10 ug /m1
LAB ID NO.:
MEDCOM - 22644
DOD-036220
ACLU-RDI 1673 p.4
\V arsiLS,ecti on: 1-- cAA. I
REQ - ' - ICIAN: LABORA ORY RESULT FORM (Sub' ect to the Privacy Act of 1974)
LAST, F :, MI DATE . 6 i itr4
TIME - SS P • es
• c iro tology) CBC .... - • _Urinalysis . • isc. - Serology: ..
T e'er' v LT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8x 10' Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14-18 d1 (M) 12- t6 .. dl (F)
Glu Negative • Microbiology
Hct 42-52% (M) . 37-47% (F)
Dili Negative Source
MCV 80-94 fl (M) 81-99 fl (F)
Ket Negative Gram Stain
-
Plt 130,-500x103 verified
SG N/A Occ Bld Negative
Lymph % 20.5 -51.1% Bld Negative H. pylori Negative
(Hematology). Manual Difkrential pH • N/A Micro
Segs • Mono Prot Negative Malaria '
Bands . Eos Urob 0.2-1.0 0 & P
Lymoh. Baso Nit Negative Other
. . . . . Atyp Imm Leuk Negative •...Microscopic Urinalysis:
- . ., : .. •• .., . .. ,. . . .,•
RBC Morph
HCG Negative
Spun Hematocrit
42-52%(M) 37L17% (F)
. CSF • • Blood.Bank , .
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
oagulatioll••S;ii •. ,.... .. .. -•'• :- . '
• .. .. - : " .-• .Bload.Raitk Unit - Cross:I:latch' : .-.'-• .. (MUST.SUBMIT SF,518.WITil EVERY UNIT OF BLOOD ..
' ..' ' . :: RE I tstslip) : i, - • — .. ..-.... .....: . ...
TEST RESULT REF. RANGE UNIT TYPE CROSSIVL4TCH
PT 9.8- 13.6 secs
AP-• 21-34 secs
D dimer <20 ug/m1 ,.
F DP <10 ug/ml
1 REMARKS:
REPORTED BY: DATE: LAB m. NO.: .
MEDCOM - 22645
DOD-036221
ACLU-RDI 1673 p.5
WarcUSection:
.5.--LCQ REQUESTING PHYSICIAN: ' CHEMISTRY RESULT FORM
Sub'ect to thc Privacy Act of 1974) LAST, FIRST, MI.
(:6)[ - L\ DATE TIME SSN/PSEUDO SSN:
TEST RESULT RE F. RANGE TEST RESULT REF. RAN
FVT or.orn- er, f ,,,,— T I
PICCOLO 22 : 02
RANGE: MALE
I ENT # : (6Y° .i* METABOLIC
LOT # : 3325AA4 # : 678 DR #: 000
AL #: 0000100494
119* 73-118 MG/DL 7 7-22 MG/DL
+ 6.7* 8.0-10.3 MG/DL 1.0 0.6-1.2 MG/DL 137 128-145 MMOtA_ 4.9* 3.3-4.7 MMOtA_
-- 112* 98-108 MMOVL 18 18-33 MMOtA_
DC: OK CHEM QC: OK 0 , LIP 0 , ICT 0
31/10/03 REFE:RENCE
/GE
Na iLt 0 138-!46 mmol/L ALB 3.5-5.5 g
K 4 . Li 3.5-4.9 mmoL/L. ALP 26-84 u/1
CI 98-109 mmol/L ALT 10-47 u/1 11 pH 7 1 i t) 7.31-7.45 ' AMY 14-97 lill PAT PCO2 5 D , j 4351 :4515 mmHg (art) AST 11-38 u/1 BASIC
DISC P02 45 18:al ?sempimFig (art) TBTL 0.2 - 1.6 .
in ‘ OPER TCO2 g, t)
,-,1 I 1
23-27 mmol/L (art) 24-29 mmol/L (yen) 22-26 mmoVL (an) 23-28 mmoVL (yen)
BUN
CA."
7 -22- Med SERI
8.0-10.3m GLU
HCO3
s02 441 i LI 95-98% CHOL 100-200 mi BUN
sH*. BEecf ,_, 1 u (-2) — (+3)
ramon CRE 0.6-1.2m1 CA+
CRE
b AnGap 10-20 mmol/L GLU 73-118 mg NM Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d K+
BUN 8-26 mg/di - CL i-- Ccilo)".1■Iet1 _p-..s. :::::, ,, ,4 tCO2
OW 70-105 mg/d1 1 TEST RESULT REF RANG I NST
Creat 0.7-1.5 mg/di GLU 73-118 rnE HEM Het 3 LI 38-51% PCV BUN 7-22 mg/til
Hgb iel„ 12-17 g/c11 I CRE 0.6-1.2 mg
CR 39-380 oil 30-190 un
TEST RESULT REF. RANGE NA+ 128- 145 m
Troponin-1 , ; 3.347 mm 3E
Drug of Abuse
_CL - 98-108 Mil '
tC 02 18-33 mm
•
REMARKS:
4 -16 1 r_.1111. - 9. REPORTED BY: DA : / LAB ID NO.:
MEDCOM - 22646
DOD-036222
ACLU-RDI 1673 p.6
1161: OK 63b Ikt
NC?; raj Pit LYZ LYN
Wri 31-10-03
18:24 Patient
14.5 H -"UL 4.5 10.5 4.96 x10'611. 4.00 6.00 14.8 gAL 11.0 18.0 .46.5 Z 35.0 60.0 93.6 1; 80.0 99.9 29.8 pg 27.0 31.0 31.8 L g/dL 33.0 37.0 16. x10A3AL 150. 450. 3.5 aLl 20.5 31.1
x1:1. '3AI 1.2 7.
W1 3.5 L x10'3/uL RBC 2.68 L x10'6/uL Hgi 7.8 L g/dL ct 25.3 L 1
Ni.V 54.3 19 tin; 29.2 pg Nc0-2,• 31.0 L g/dL Pit 176. * xi0A3/..d. LYZ 29.3 * Z LYI 1.0 *L x103./t
• ;-atient Limits
4.3 L x101,`, 1 4,5 110V ' JO 6.00 gAL 1:.0 18.0
7Z.0 60.0 fL 30,0 99.9
4 PS 27.G 31„0 :1. girl 310 37.0
15). 450. 20.5 51.1
1. 7 ,,,101u1_ 1.2 3.4
RAPIDPOINT COAG ANALYZER p464 SERIAL #005485 10/31/03, 18:30
Patient ID: Test Name . Test Result:= 13.5 sec. Ratio = 1.1 Calculated INR = 1.18 Sample Type:citrated wh. hl Test Date :10/31/03 Test Time :18:28 Card Lot :080201 Operator : STILLWEL
RAPIDPOINT COAG ANO_YZER V4.54 SERIAL #005485 4131/03 18:38
Patient ID: 111111 Test Name :APTT Test Result:= 27.1 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood
i Test Date :10/31/03 Test Time :18:35
1 .. Card Lot. : :030201 Opeqtqpi_ r: STEWART
. .
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 005485 10/31/03 22:07
ame11r Patient ID:
Test N Test Renit:= 17.3 sec. Rat' = 1.4
culated INR = 1.76 Sample Type:citrated wh. blood Test Date :10/31/03 Test Time :22:05 Card Lot :080201 Operator : JACKSON
RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 10/31/03 22:09
31-10-03
Patient
4.5 10.5 4.00 6.00
11.0 18.0 35.0 60.0 GO. 0 99.7
27.0 31.0 33.0 37.0 150. 450. 20.5 51.1 1.2 3,4
l"' --------- Patient ID:
Test Name
Test Result:= 34.3 sec. Sample Type:citrated MI, blood Test Date :10/31/03 Test Time :22:07 Ca rd Lot :030201
: JACKSON
MEDCOM - 22647
ACLU-RDI 1673 p.7
. Misc. Serology • • • REF. RANGE RESULT
LAST, FTRST,.MI.
Ward/Section: REQUESTING PHYSICIAN:
HP 1 DATE 10 -)1
LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
TIME SSN/PSEUDO SSN:
Urinalysis (Hematology BC •
TEST RESULT TEST RESULT REF. RANGE WBC
REF. RANGE
4.8-10.8 x 10' N/A Color
Mono 4.7-6.1 x 109 Negative
Negative N/A App RBC
TEST
RPR
Glu Hgb 14-18 Wdl (M) 12-16 g/d1(F) Microbiology Negative
Hct Negative Bili . Source 42-52% (M) 37-47% (F)
MCV Ket 80-94 11 (M) 81-99 fi (F)
Negative Gram Stain
130L500 x10' verified
Pit Occ Bld N/A SG Negative
Bld Lymph % 20.5-51.1% Negative H. pylori Negative
(Hematology} Manual Differential pH N/A .
Mono Prot Negative
Micro Parasites
Malaria
Urob
Segs
Bands 0 & P 0.2-1.0 Eos
Lymph Baso Nit Negative Other
.. .Microscopic Urinalysis ' Atyp Imm Leuk
HCG RBC Morph
Negative
Negative
Spun Hematocrit
42-52% (M) 37-47% (F)
CSF. - -
' :: . Blood Bank ,
Sed Rate . ,
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh I
COagulation"StUdiel: : :- .BloOd:Ballk Unit Crossmatch - ' , - - - ..: (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . _
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs - .
D dimer <20 ug/m1
FDP <10 ug/ml
REMARKS:
MEDCOM - 22648
DOD-036224
ACLU-RDI 1673 p.8
ifEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
TIME SSN/PSEUDO SSN: 00 R:7
DATE
igc011i):MetabOlie,Papet REF. RANGE TEST I RESULT REF.
RANGE TEST RESULT REF. RANGE
138-146 mmol/L ALB 3.5-5.5 g/dl GLU 26-84 BUN
73-118 mg/dl
7-22 mg/d1
8.0-10.3 mg/di
0.6-1.2 nag/d1
128-145 mmol/1
3.3 -4.7 mmol/1
98-108 mmol/1
18-33 mmo1/1
3.5-4.9 mmol/L` b ALP
98-109 mmol/L ALT CA" 10-47 u/1
1 11 7.31-7.45 AMY 1 14-97 u/I CRE
1-15.% 35-45 mmHg (art) 41-51 =OR (Yen) 80-105 mmHg (art) N/A (yen/
AST 11-38 u/I NA'
TBIL 0.2-1.6 mg/d1 1 0 23-27 mmol/L (art) 24-29 mmol/L (yen) lq BUN 7-22 mg/dl CL 22-26 mmol/L (art) 23-28 mmoUL (yen)
CA"" 8.0-103m01 11 tCO2
95-98% CHOL 100-200 mg/dl Picealti
TEST RESULT REF. RANGE (-2) — (+3) mmol/L
CRE 0.6-1.2 mg/d1 —10 10-20 mmol/L GLU 73-118 mg/di ALB 3.3-5.5 g/dI
26-84 u/I
10-47 till
14-97 till
11-38 u/1
0.271.6 mg/di
5-65 till
I.12-1.32 nunol/L TP 6.4-8.1 g/d1 ALP 8-26 mg/dl ( "Me I e ALT
70-105 mg/dl TEST RESULT REF. RANGE
AMY
0.7-1.5 mg/d1 GLU 73-118 mg/dl AST
LI D 38-51% PCV BUN 7-22 mg/d1 TBIL
0.6-1.2 mg/d1 GGT 12-17 g/dl CRE
CK 39-380 u/I (M) 30-190 u/I (F)
TP 6.4-8:1 g/dl
TEST RESULT REF. RANGE NA 128-145 mmol/1 iccoloYglects6 I
Troponin-1
Drug of Abuse
33-4.7 mmol/1 TEST
98-108 mrno1/1 NA .
RESULT REF. RANGE
_C 128-145 mmol/1
tCO2 18-33 mmol/1 3.3-4.7 mmol/1
CL" 98-108 mmoLl
tCO2 18-33 mmo1/1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 22649
DOD-036225
ACLU-RDI 1673 p.9
Vv'ard/Section: ORY R. SULl" FORM (4P
REQUES_ Lf
LAST, FIRST,, DATE 0— I No ,./
•-•...•-•
TIME C..)O -L-C,
,....% 1. ,./ us,. 1 Alva,. rl.k..l 01 1714)
SSN/PSEUDO SSN:
(HernatOlop) CBC .: Urina s* . . , . Misc. Serology , TEST RESULT REF. RANGE TEST RESULT REF RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10' App N/A Mono Negative
Hgb 14-18 Wdl (M) 12-16 g/d1 (I')
Glu Negative Microbiology
Hct 42-52% (M) 37-47% (F)
Bili -
Negative Source
---MCV 80-94 fl (M) 81-99 fl (F)
Ket Negative Gram Stain
Plt 130L500 x 103 verified
SG •N/A Occ Bid Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(HentatO ) Manual Differential ..... . :.. • . • • • . . ... -•••• • •-••
pH • N/A Micro Parasites
Segs Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 0 &
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative roscOpiC !Irina s ..,. . .
RBC Morph
I , C"f1 / •1, 11
HCG Negative
Hematocrit Blood Bank
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
37.47% (F)
Negative I ABO/Rh Other Directigen
TEST
Coagulation Studies
REF. RANGE
- : Blood Bank Unit crossinitch" . (MUST . SUBMIT SF.518.WITHEVERy UNIT OF. BLOOD .
. •
CROSS1114TCH RESULT :;. ,'REQUESTEDY
UNIT TYPE
9.8-1.3.6 secs PT
APTT 21-34 secs
<20 ug/m1
<10 ug/m1
D dimer
FDP
REMARKS:
REPORTED BY DATE: LAB ID. NO.:.
MEDCOM - 22650
DOD-036226
ACLU-RDI 1673 p.10
'at cllSection: REQ LABORATORY RESULT FORM . • 1 k3uoject to tne rrivacy Act of 1974) LAST, F1RST,..MI DATE
6 TIME •
r SSN/PSEUDO SSN:
etitatOogy) CB _Urina s'. . Misc.' Serology : RESULT . RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10 App N/A Mono Negative Hob
12-16 14-18
g/d1( F) Glu Negative • Microbiology
Hct 42-52% (M) 37-47% (F)
Bili . - .
Negative Source •• . MCV
.
80-94 fl (M) 81 -99 fl (F)
Ket Negative Gram Stain
Pit 130500 x 1O verified
SG
Bld
'WA J
Negative
Oce Bld
H. pylori
Negative
Negative Lymph % 20.5-51.1%
(Hematii ).Manual Differential . pH • N/A Micro Parasites
Segs . Mono Prot Negative Malaria Bands . Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative MicrosCopi Uritin s ' . .
RBC Morph
HCG Negative
Rnrin 19-.S1 0/- null
Blood.Bank . 3747%
Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Hematocrit
Sed Rate
Other ABO/Rh Negative Directigen
TEST
Coagulation Studies
REF. RANGE
Bank Unit CrOssinatcl• - '• (MUST.SUBMIT SF . 518 WITH EVERY UNIT OF. BLOOD
1,11EQUESTED)
CROSSM4TCH RESULT UNIT TYPE 9.8-13.6 secs
21-34 secs
D dimer
PT
APTT
<20 ug/m1
FDP <10 ug/m1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:.
MEDCOM - 22651
DOD-036227
ACLU-RDI 1673 p.11
Ward/Section: CHEM'S). tcY RESULT FORM 1111111.1101111P (Subject to the Privacy Act of 1974)
LAST, FIRST, MI. DA TIME SSN/PSEUDO SSN:
IS. '. (91)-1 - CCOLO RESULT REF. RANGE 01 /11 / 03 01 : 08
REFERENCE RANC : MALE
/40 138-146 mmol/L PAT I ENT #: 3.5-4.9 Inm°1/1; METLYTE 8
98-109 mrool/L DISC LOT # 3151 AA4 OPER #: 678 DR #: 000 •,
160 7.31-7.45 SERI AL #: 0000100494
qt, 6 35-45 mmHg (arc) 41-51 rnmHs (yen) GLU 122* 73-118 MG/DL 80-105 mrril-ig (art)
1 a N/A (veal BUN 8 7-22 MG/DL
2 0 23-27 mmol/L (art) 24-29 mmol/L (vco) CRE 1.3* 0.6-1.2 MG/DL
1 7 22-26 mmoVL (art) 23-28 mruol/L (yen)
CK 2647* 39-380 U/L NA+ 125* 128-145 MMOVL
Cti K+ 4.6 3.3-4.7 MMOIL -1 D (-2) — (+3) CL- 112* 98-108 MMOVL
rumon, tCO2 15* 18-33 MOW 10-20 mmol/L
E 1 2-1.32 mmo1/L INST QC OK CHEM QC: OK
8-26 ing/d1 HEM 0 , LIP 0 , I CT 0
'70-105 mg/d1.
0.7-1.5 mg/d1 38-51% PCV
13
12-17 g/dl
ChemiLStry
TEST
Na
Cl
K
pH
PCO2
P02
TCO2
HCO3
s02
BEecf
AnGap
Ca
BUN
GLU
Creat
Het
Hgb
itabdiCTaie1.',17:. .
TEST RESULT REF. RANGE
GLU
73-118 mg/dl
BUN
7-22 mg/dl
CA+1
8.0-10.3 roedl
CRE
0.6-1.2 mg/dI
NA+
128-145 mmoUl
K+
3.3-4.7 mmol
CL"
98-108 mmol/1
tCO2 18-33 mmoUl
P:k6lOPLA,ei Pan e1P1u;:'
TEST RESULT REF. RANGE
ALB
3.3-5.5 g/dl
ALP
26-84 u/I
ALT
10-47 u/I
AMY
14-97 u/I
AST
11-38 u/1
TBIL
0.2-1.6 medl
GGT
5-65 u/I
TP
6.4-8.1 g/dl
TEST RESULT REF. RANGE
Troponin-1 TEST RESULT REF. RANGE
Drug of
NA 1- 128-145 uno1/1
Abuse 3.3-4.7 mmo1/1
CL" 98-108 mmoLl
tCO2 18-33 rnmo1/1
DATE: LAB ID NO.:
MEDCOM - 22652
DOD-036228
ACLU-RDI 1673 p.12
411111111r patimt
18:37 01-11-03 12:51
Patient Likts
.„.3tC. 7.5 * x10"3/L 4„S 3.36 L x10'6/L 4.00 6.00
•':•p..!:446 • 10.0 L g/dL 10.0 18.0 ''t-it 31.0 L
92.3 MO 60.0
fL 60.1 99.9 21.is pg 27,0 31,0
0,471.1t 32.1 L gidL 33.0 37.0 197. x10 -'3/ti 150. 430.
4go. 21.5 *5 20.5 51.1 1Y.it
1.64 x10'3/iii_ 1.2 Z.4
Ari/A111111111 01-11-03 01:10
Patient Limita
2. 9 L 410'5/..1L 4.5 10.5 RiC 4.72 (1.0"6/11L 4.00 6.00 Hgb 13.9 g/dL 11.0 18.0 lict 45.3 5 35.0 60.0
71.9 FL 80.0 79.9 rCH 29.4 a
IC
27.0 31.0 ■ICHC 32.0 L gicIL 33.0 37.0 Flt 251. x10'3/uL 150. 450. LYS 37.3 ; % 20.5 51.1 LI 1.1 #1 t10'3/111 1.2 3.4
-
• ,j
MEDCOM - 22653
RAPIDPOINl LOAG ANALYZER V4 SERIAL 4005485 11/01/03 18.
riFT \ Patient ID:
Test Name Test Result:- 10 sec. Ratio = 1.5 Calculated IMP Sample Type:citrated 41 1- 1 , (1 Test Date :11/01/03 Test Time :18:41 Card Lot :080201 Operator : DAVIS
RAPIDPOINT LOAG ANALYZER V4.! SERIAL #005465 11/01/03 18:bi
Patient IDIOM Test Name :APTT Test Result: = 56.3 Se. ***RESULT NOT RANGE CHECKELJ*** Sample Type:citrated plasma Test Date :11/01/03 Test Time :18:52 Card Lot :030201 Operator : DAVIS
?APIDPOINT COAG ANA V4.54 3ERIAL #005485 11/01/03 04:46
Patient I04111111, Test Name :PT Test tsult:= 16.3 sec. Rat'o = 1.3 C. culated INR = 1.60 ample Type:citrated wh. blood Test Date :11/01/03 Test Time :04:45 Card Lot :080201 Operator : JACKSON
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005465 11/01/03 04:50
Patient Test Name :APT1 Test Result:= 49.4 sec, ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :04:48 Card Lot :030201 Operator : JACKSON
PINIF 01-11-0: 19:31
Patient LiNita
+.1 _ J/d.L. 4.5 .11,, g5 920 L75. L 4 .00 6.0 co-Pb g , e, 11.r, 18.0
o 'rk=7 17, 4L 3 35.0 60.0 71,7 4 1 90.: 99.9
MG; 52.1 H 2 70 31.0 t2RC 56.5 444 g/dL 32.0 57.0
F1 l- 122. 4- 150, 4' Pi!. 92, 20.5 51.1 LY4 0.7 .4L 1,10 5'uL ' 3.4
,
1111111111 4, 01-11-03
0443 Patient
1432 4.7 003M 4.5 10.5 FIC 4.87 x10'6/4! 400 6,00 kqh 14.5 gAIL 11.0 18.0 H.Et 44.6 S 35.0 60.0 MCV 91,5 fL 80.0 99.9 •1CN 29.4 Pc! 27.0 31.0 INC 32.1 L gla 32.0 37.0 Plt 257. x10'5AL 150. 450. ;OS 13.2 L 1 70.5 51.1 !Y4 0.9 4L a103/eL 1.2 3.
Liallts ;IC 4.2'L A10'5/6L 4.5 10.5 902 2.07 *4_ i106 ,V,_ 4.00 6.00 lipt, 10,2 4-L greL 11.0 18.0 iict 19.5 ti Z 35.0 60.0 ri 94.0 fL 80.0 99. 9 nch 49.3 a 27,0 31.0 rE4C 52.4 # gidl. 32. 0 37.0 Pit 170, LW3ij 150. 450. In 10.7 44_ % 20.5 50.1 1/1 0.5 L 0. '3/11L 1. 9 3,4
DOD-036229
ACLU-RDI 1673 p.13
Ward/Section: I
3ORATORY RESULT FORM
LAST, FERST,.MI. 0,1,-- ATE 0 1 /Jai
k..Ju ■.,
TIME lci 3 -D
,,t U./ 1.4.1c .r.iivat: Act OI .LY /4 SSN/PSEUDO SSN:
.-.. alernatols ,,_ ) Urina sis Misc. Serology TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST R.ESULT REF. RANGE
WBC 4.8-10.8x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10 App N/A Mono Negative figb 14-18 g dl (M)
12-16 &I(I.) Glu Negative • Yficrobiology
Het 42-52% (M) 37-47% (F)
Bili - -
Negative Source
MCV 80-94 fl (M) 81-99 fl (F)
Ket Negative Gram Stain
Pit 130c500 x io' verified
SG .N/A . Occ Bld Negative
.. Lymph % 20.5-51.1% Bld Negative H. pylori Negative
ematolOgy).Manual Differential .-..:,• . ,--• . - • •-• -
pH - N/A . Micro Parasites
Segs . Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 • & •
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative r .MicrusOpic Urina s ...
RBC Morph
A n couni ,n es
HCG
---
Negative
I Hematocrit
7 o
37247% (F)
Blood.Bank •
Sed Rate Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
TEST
PT
APTT
Coagulation 'Studies
REF. RANGE
9.8-1.3.6 secs
21-34 secs
:s . . • .-- (MUST..SUBMIT.SF,518.WITHyERy .UNIT OF. BLOOD
•• 1. • • • '..:!ittOtitsrkp) • • •-• • -•-•
CROSSNL4TCH RESULT UNIT TYPE
D dimer <20 ug/ml
FDP <10 ug/m1
REMARKS:
REPORTED BY: DATE: LAB ID NO.: .
MEDCOM - 22654
DOD-036230
ACLU-RDI 1673 p.14
(51(.\2 ORATORY RESULT FORM SuFect to the Privac Act of 1974
TIME SSN/PSEUDO SSN:
Urinalysis Misc. Serology
Ward/Section:
LAST, FIRST.,M.I.
(Hematology) CBC
TEST RESULT REF. RANGE TEST RESULT REF. RANGE Color N/A RPR Negative
App N/A Mono Negative
Glu Negative INEcrobiology
Bili Negative Source
Ket Negative Gram Stain
SG 'N/A Occ Bld Negative
Bld Negative H. pylori Negative
pH WA Micro Parasites
Prot Negative Malaria
Urob 0.2-1.0 O&P
Nit Negative Other
Leuk Negative Microscopic Urina
HCG Negative
Spun Hematocrit 42-52% (M) 37-47% (F)
. CSF •• - .
1 • Blood Bank •
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other Directigen I i Negative ABO/Rh
oagulation Studies. • ' -
. - .Blood Bank Unit Crossmatch . - ' - : :. . (MUST,SUBMIT SF,518.WITH EVERY UNIT OF. BLOOD .
,' REQUESTED). " -.. . ' . • ‘;-:.:,.. " TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT ' 9.8-13.6 secs
APTT 21-34 secs . .
D dimer <20 ug/m.1
FDP <10 ug/ml
REMARKS: c--, P '2 COQc-c3
D VIVA rvr -v -IN Tv _ .--- • -
Atyp
Lymph
RBC
Bands
Lymph %
Segs
MCV
Pit
Het
Hgb
RBC
TEST
WBC
ematology) Manual Differential
RESULT REF. RANGE
Imm
Baso
Eos
Mono
20.5-51.1%
130-500 x103 verified
42-52% (M) 37-47% (F) 80-94 fl (M) 81-99 fl (F)
4.76.1 x109
4.8-10.8 x 10'
14-18 g/dI (M) 12-16 g/dI (F)
MEDCOM - 22655
DOD-036231
ACLU-RDI 1673 p.15
Span Hematocrit
Sed Rate Cell Count
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Directigen Other Negative ABO/Rh
• Blood Bank . ••: - • ••• • • •
PT 9.8-13.6 secs
APTT 21 -34 secs
<10 tig/rn1
<20 nem] D dimer
FOP
REMARKS:
REPORTED BY: I DATE: LAB ID NO.:.
Coagulation Studies
• • • • -• .
•••• ..• •
TEST RESULT REF. RANGE TYPE CROSSA ,L4TCH UNIT
0 37.47% (F)
•BloOd:Baiik Unit Cross Watch' : UST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
• . REQUESTED) :
Ward/Section:
REQUESTING PHYSICIAN: LABORATORY RESULT FORM J.
LAST, FIRST.,,M1- DATE TIME w Luc rfivacy itcE cn 1Y/4) I
SSN/PSEUDO SSN:
mato! -.1tr •_Urinalysis .....- ..Misc..Serology : TEST RESVIT:.- —REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14- 18 gFdL (M) 12-16 g/c11(F)
Glu Negative . Microbiology . .• -. - .•
Hct 42-52% (M) 37-47% (F)
Bili • -
Negative Source
MCV 80-94 ti (M) 81-99 fl (F)
Ket Negative Gram Stain
Pit 130:600 x103 verified
SG 'N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
,.. gy)- Manual Differential ...: (IfematOlO. • .... • .,:..• .• . ,•••.• -.•...... . .....•
pH • N/A Micro Parasites
. ./
' Segs . Mono Prot Negative Malaria •
Bands Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
.• : .MicioscOptc iia lysis' • • • .• .. • . -. . . ..... : ...
. , . . , .. . . RBC Morph
HCG Negative
'
MEDCOM - 22656
DOD-036232
ACLU-RDI 1673 p.16
Ward/Section: 7-7: C41,
.,,__,JJESTING PHYSICIAN: ' CHEMISTRY RESULT FORM (Subiect to the Privacy Act of 1974)
LAST, FIRST, MI. _ ....--,. *I
Dizt14 TIME ' S
SSN/PSEUDO SSN:
cii5T,..., leotoych46, 5 . , -.1. ' - iogro:wtooiii!.:41iif..:. TEST SULT EF. RANGE
II TEST RESULT REF.
RANGE TEST RESULT REF RANGE
Na ((try 138-146 mmol/L ALB 3 . 5-5 . 5 g/d1 GLU 73-118 mg/di K D _ is:, 3.5-4.9 inmoUL ALP 26-84 u/1 BUN 7 -22 mg/dl Cl // ?'
98-109 mmol/L ALT 10-47 u/1 CA+4. 8.0-10.3 mg/dl
pH 7.31-7.45 AMY 14-97 u/I CRE 0.6-1.2 n3g/dI
PCO2 35-45 mmHg (w1) 41-5t mmHg, (yen)
AST 11-38 u/1 NAT 128-145 minoVI
P02 80-10.5mmHg(2A) N/A tveul
Kr 3.3-4.7 mmult1
TCO2 I ,243:,297 mmol/!- (0,arrca)) :.._ _ _ ._- = PICCOLO - - - — ' ' CL" 98-108 mmol/1
HCO3 22 -26 mmoVL (art) 01/11/03 13 : 00 23-28 mmoUL (yen) REFERENCE RANGE : MALE tCO2 18-33 mmoUl
SO2 95-98% PAT I ENT # : IMF •#0.140iir..4of. gonel'Pl60:;
. :;,::,-.Y-c; -.::: ...T..6.:...;.sh ,-.::.'...n3::::' ,i'.'. ---• BEecf (-2) - (+3) METLYTE 8 (b)(0-1
mmoi/L DISC LOT # : 3151AA4 TEST RESI)7,T REF. RANGE
AnGap 10-20 mmol/L opER # : 777 DR # : 000 , ALB 3.3 - 5.5 g/dl Ca L12-1.32 rnmon SERI AL # : 0000100194 • ALP 26-84 u/1
BUN 8-26 mg/d1 GLU 130* 73-118 MG/DL '
MG/DL
ALT 10-47 oil
GLU 12 7-22 70- 705 mg/dl BUN 1 CRE 1.4* 0.8-1.2 MG/DL
AMY 14-97 u/1
Creat 0.7-1.5 mg/di CK 3159* 39-380 U/L
NA+ 131 128- 145 MMOVL AST 11-38 u/1
Het . 38-51% PCV K+ 3.3 3.3-4.7 MMOVL TBIL 0.27 1.6 algid'
Hgb 12- 17 ydi CL- 109* 98-108 MMOVL GGT 5-65 u/I
- tCO2 17* 18-33 Mal_ "- - 7.,gts.t.-Xb.prAriSAry:. TP 6,4•81 g/d1
TEST RESULT REF RANGE INST GC: OK CHEM GC: OK HEM 1+, LIP 0 , ICT 0
cr61:9-4U041ibte
Troponin-1 TEST RESULT REF. RANGE
Drug of Abuse
NA' 128- 145 mmol/1
3.3-4.7 mmol/1
CL" 98-108 mmolll
tCO2 18-33 mmol
REMARKS:
•
REPORTED BY: DATE:
i/.N2./33
LAB ID NO.:
(c)(C1- L
MEDCOM - 22657
DOD-036233
ACLU-RDI 1673 p.17
WarcUSection:
C.)-f(-- REQ• c . .
' CHEMIS1 KY RESULT FORM Suliect to the Privacy Act of 1974)
LAST, FIRST, MI. DATE ip SSN/PSEUDO SSN:
.., ' 1,:5'llA:' ' ' 4ce,o4Ycli4=6 ; ico'16)'1*t4k4tirs4it' .-_
TEST RESULT REF. RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
Na 138-146 mmol/L ALB 3.5-5.5 01 GLU 73-118 mg/di K 3_5-4.9 rnmoUL' ALP 26-84 u/1 BUN 7-22 mg./d1
Cl 98-109 mmol/L ALT 10-47 u/1 CA+1 8.0-10.3 mg/dl
pH 7.31-7.45 AMY 14-97 u/I CRF 0.6-1.2 mg/d1
PCO2 35-45 mmHg ( 13n) 41-51 mmHg v.12)
AST 128-145 mmol
P02 80-A105 mmHg (art)
( veil) TBIL -- - - - - - PICCOLO •=7==::77- 3.3-4.7 mmol/l
TCO2 23-27 mmol/L WO 24-29 mmol/L (Inn)
BUN 01/11/03 04 : 20 : MALE
98-108 mm01/I
HCO3 22 -26 mmoUL (art) 23-28 mmoUL (von)
CA+* REFERENCE RANGE PATIENT # : Millirq(0 _Li 18-33 mmoUl
s02 95-98% CHOL METLYTE 8 ttr4110 Pliii:_;'i . - 3151004 .,-,-;:;:'- ,::-. .', .'.:, .t . i:...-.
BEecf (-2) - (+3) Imola,
CRE DISC I_OT #: OPER # : 678 DR it: 000 " REF. RANGE
3.3-5.5 g/d1 AnGap 10-20 mmol/L GLU SERI AL it: 0000100684
Ca 1.12-1.32 mmol/L TP GLU 124* 73-118 MG/DL 26-84 &I
BUN 8-26 nag/c11 . 1CCOOYA BUN 10 7-22 MG/DL
- ..r. .--- CRE 1.1 0.6-1.2 MG/DL ] 0-47 u/t
GLU 70-105 mg/d1 TEST
! GLU
RESULT' CK 3517 * 39_380 U/L 128-145 MMOtt.
14-97 &I
Creat 0.7-1.5 mg/di NA+ 129 K+ 4.6 3.3-4.7 MMO.PA_ 11-381.0
Hct 38-51% PCV BUN CL- 110* 98-108 WW1 0.27 1.6 mWdl
Hgb 12-17 g/cli CRE tCO2 17* 18-33 MMOI/L 5-65 u/I
- - .
_. :. •.;K*.T .C.IieitiiSti-347. ' CK
INST OC: OK CI-EM GC: OK 6.4-8.1 g/d1
TEST RESULT REF. RANGE NA-' HEM 2+, LIP 0 , ICT 0 i‘eti.itti,.., , , ..,, ,
Troponin-1 K+ REF. RANGE
Drug of Abuse
_CL" 128-145 mmol/1
tCO2 3.3-4.7 mmol/1
98-108 mmoLl
18-33 mmo1/1
REMARKS:
. I -
REPORTED BY: DATE: 1 LAB ID NO.:
MEDCOM - 22658
DOD-036234
ACLU-RDI 1673 p.18
KT 0.2-1.6 mg/di
7-22 mg/di
tC 02 8.0-10.3mg/d1
100-200 mg/dl
0.6-1.2 mg/d1
73-118 mg/d1
7-22 mg/dl
0.6-1.2 mg/d1
73-118 mg/di
0 Ca Ward/Section:
LAST, FIRST, MI
RF^TJESTING PHYSICIAN:
ATN HEM S RY RESULT FORM (Subject to the Privacy Act of 1974)
TIME SSN/PSEUDO SSN:
•
ieco16 . -itabOtier.:atie
ALB
TEST RESULT RESULT RESULT
351
)5. C
a-5
3
REF. RANGE
138-146 mmol/L
3.5-4.9 mmoUL-
98-109 mmol/L
7.31-7.45
35-45 mmHg (art) 41-51 mmHg (Yen) 80-105 mmHg (art)
N/A (yen)
23-27 mmol/L (art)
24-29 mmol/L (yen) 22-26 mmoL/L (art) 23-28 mmoUL (yen)
95-98%
REF. RANGE
3.5-5.5 g/d1
26-84 u/1 BUN
10-47 u/1
14-97 u/1
11-38 u/1
REF. RANGE
73-118 mg/di
7-22 mg/dl
TEST
Na K
Cl
pH
PC 02
P02
TCO2
HCO3
s02
TEST
GLU
CA'
CRE
NA"
8.0-10.3 mg/d1
0.6-1.2 mg/d1
128-145 mmol/1
3.3-4.7 mmolul
98-108 mmol/1
18-33 mmoUl
PthitiPhi
TEST
(-2) — (+3) mmol/L 10-20 mmol/L
1.12-1.32 =OWL
8-26 mg/dl
70-105 mg/d1
0.7-1.5 mg/dl
.2(e 38-51% PCV
12-17 g/d1
CRE
eli*t
CK
RESULT REF. RANGE NA+
BEecf
AnGap Ca
BUN
GLU
Creat
Het
Hgb
GLU
BUN
TEST RESULT REF. RANGE
39-380 u/I (M) 30-190 u/1(F) 128-145 mmol/1
ALT
AMY
AST
TBIL
GGT TP
10-47 u/1
14-97 u'I
11-38 u/1
0.2-1.6 mg/dl
5-65 u/t
6.4-8.1 g/dI
iccolo).Electrobte
TEST RESULT Troponin- 1
Drug of Abuse
tC0
REMARKS:
334.7 mmol/1
98-108 mmol/1
18-33 mmol/1
REF. RANGE
128-145 mmol/1
3.3-4.7 mmol/1
98-108 mmolll
18-33 mmol/1
CU
tCO2
_CL"
REPORTED lig& DATE:
Al U LAB 11) NO.:
MEDCOM - 22659
DOD-036235 ACLU-RDI 1673 p.19
RAPIOPOINT WAG ANALyMER V4.54 SERIAL #005485 11/02/03 01:53
** PRINT AHrELL 7 D **
i - 31- RT EGt-
RAPIDPOINI LOAF ANALYZER V4.1) SERIAL #005485 11/02/03 04:24
Paiient 113:111111, Test Nam: :PT lest Result: , 19.4 sec. ***WAPi 011 OF RANGE*** Ratio = 1.6 Calculated JN k - 2.12 Sample Type:citrated wh. blood Test Date :11/02/03 lest Time :04:23. Card Lot :80201 Operator
APTDPOINT WAG ANALY V4.54 f',EklAL #005485 11/ /03 04:29
/ • //katient ID
fest Name :ANT
1
lest Result:. 55.1 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated bloom Test Date :11/02/03 Test Time :04:2 Card Lot :03020 Operator
Patient 7.: Test Name :APT1 Test Result:= 56.1 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated plasma Test Date :11/02/03 Test Time :01:49 Card Lot :030201 Operator :MUM
Pt: 1111111W Pt Nam:
Ha 151 mmol/L
4.4 mmol/L
Tr:02 mmol/L
Hct 48 ;PCs)
Hb* 1 g/dL *via Hct
Rt 370
pH 7.410
P0A2 3.0 mmH;
P02 .,18 mmHg
HCO3 25 mmol.
BEel:f 0 mmol/L
s02* 54 %
*calcu1atPd
At Patient Temp
Ph 7.410
PCO2 3,1.0 mmHq
P02 68 mmtiq
Patient Temp: 98.6F FIO2 : 55
Sample Type_: ART
02H0V03 . 11:31
Jper:111111„-----
Physician:
Ser# 42015
Ver: JAMSO4eR CLEW A93
RAPIDPOIN COAG ANAL./ ER V4.54 SERIAL #005. 5. 11/02/03 01:28
Patient .14111111, lest Name , :PT Test Result:. 20.4 sec. ***RESULT DOT OF RANGE*** Ratio = 1.7 Calculated INR = 2.30 Sample Type:citrated wh. blood Test Date :11/02/03 Test Time :01:25 Thrd Lot :080201
.?rator 411111111111111
MEDCOM - 22660
DOD-036236
ACLU-RDI 1673 p.20
Ward/Section:
=': ,l) *----' AEQUESTING PHYSICIAN:
(4,)(0 :?-- LABORATORY RESULT FORM I
(Subject to the Privacy Act of 1974) LAST, FIRST, MI. DATE
ra -I• . I k 02—
TIME -
00 SSN/PSEUDO SSN:
(Hen a logY . . Urinalysis • Misc: Serology : .. TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 104 App N/A Mono Negative
Hgb 14-18 dl (M) 12-16 g/d1(F)
Gilt Negative . Microbiology
Hct 42-52% (M) 37-47% (F)
Bili Negative Source
MCV 80-94 11(M) 81-99 fl (F)
Ket Negative Gram Stain
Plt 130-;500 x 10J verified
SG N/A Oce Bid Negative
Lymph % 20.5-51.1% Bid Negative H. pylori Negative
• Iiemato )./41a.nual Differential - -
pH . N/A Micro Parasites
' Segs Mono Prot Negative Malaria
Bands Eos Urob , 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative .Microseivic If alysis
RBC Morph
HCG Negative
Spun Hematocrit
42-52% (M) 37-47% (F) . Blood Bank , • •
Sed Rate . _
Cell Count !
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Other
.
Directigen Negative ABO/Rh
Coagulation Studies:: .':. - • . '.. - .- -. -Blood:Baal( Unit CrosSinatclf .. - -. : :.... - .•(MUST SUBMIt. SF 518 WITH EVERY UNIT: OF BLOOD .
TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer <20 ug/m1
FDP <10 ug/ml
REMARKS: , Lo a...,..
REPORTED BY: DATE: LAB ID NO.:. '
MEDCOM - 22661
DOD-036237
ACLU-RDI 1673 p.21
Ward/Section: - ---C__/,_---.\
RE I.17: '^' PHYSICIAN: t a.) RI) r? CHEMISI A Y RESULT FORM
(Subject to the Privacy Act of 1974) LAST, FIRS
Np-1 DATE TIME
itt. SSN/PSEUDO SSN:
iiis.. . , i'd.010-'010iiiJi. • ::. ' k•Or6 . tal4Qi - ,ilk
TEST RESULT REF. RANGE TEST
138-146 mmol/L f AL ;
3.5-4.9 mmol/L' A T tr
RESULT REF. RANGE
3 7 5-5 . 5 edi
TEST
GLU
RESULT
Y
l REF. RANGE
73-118 mg/c11 Na i 5 1
K 3 . / BUN 7 -22 mg/dl
CI 98 -109 rnrnol/L CA+ 8.0- 10.3 Ing/d1
pH I.. 435 7.31 -7.45 - . -7- L "L - . s = PICCOLO :---:=7::::: CRE 0.6- 1.2 mg/d1
PCO2 ,- 34. -..
35-45 mmHg (are 02/1 1/03 01 :25 41-51 mml-IE (ven)' 1-41FMLNCE RANGE: MALE NA' 128-145 mmol/1
P02 ( 3 ( SO-70.5 mmHg <art) N/A (vein PAT IENT It: oar K- 3.3-4.7 mmolil
TCO2 ,2/
23-27 rnmol/L (art) METLYTE 8 24-29
rnrnol/L (yen) 3151A M CL 98-108 mrno1/1
HCO3 (2 3 22-26 mmoUL (art) DISC LOT #: 23-2S mmol/L (yen) OPER # : 013 DR # : 000 tCO2
RESULT
ite00)%Nf.eii.!4n-el-pl6g,:;, ,....!:-....,,,::-.:,...--;.,,..:::,....::„:., :.....:.:::!!..a:
18-33 mmoUl
REF. RANGE
3.3-5.5 g/dl
S02 79 95-98% 0000100684 SERIAL # :
BEecf I
(-2)— (+3) rnmon GLU 91 73-118 MG/DL TEST
AnGap 10-20 mmol/L BUN 10 7-22 MG/DL ALB MG/DL
Ca 1.12-1.32 nunol/L CRE 1.0 0.6-1.2
CK >5000* 39-380 U/L ALP 26-84 all
BUN 8-26 mg/di NA+ 138 128-145 MMOR.- ALT
4.4 3.3- 4 .7 MMOUL K+
10-47 u/1
GLU 70-105 mg/d1 CL- 114* 98-108 MOM_ AMY 14-97 to
Creat tCO2 18 18-33 MMOUL 0.7-1.5 mg/di AST 11-38 u/1
Het - Jr a.,... 38-51% PCV : INST QC: OK CHEM OC: OK rBri. 0.2 7 1.6 Ingi, I
Hgb t.3 ar. 12-17 eidi +
4 HE_M 0 , LIP 0 , ICI 1 3GT . 5-65 u/1
4-,,g*.- kieniist . 1.—
7F. 6.4-3.1 Wdl
TEST RESULT REF. RANGE ; ..• .... ... • .
volo.I.X104011t0;,- ,
Troponin-1 X TEST RESULT REF. RANGE
Drug of Abuse
-C A' 128-145 mrnoVI
, 3.3-4.7 mmol/1
98-108 mmoL11
1 tCO2 18-33 mmo1/1
REMARKS: 0 t_b& . Cl.,esm (6
-.,..„,_ . '''''' ,(3,), c tX) 'ail .' REPORTED BY: DATE:
Q AA ki‘)
LAB ID NO.:
MEDCOM - 22662
DOD-036238
ACLU-RDI 1673 p.22
Ward/S ion:
1
REQUE ' • • • 'SICIAN: CHEMISTRY RESULT FORM Suliect to the Privacy Act of 1974)
LAST, FIRST , -
-r-A)60 -6 ,..
T.4. SS " - '' •• N:
;',',::,,..-:,--.:.:- . - - - - - • - , ,.. .. ... :
Metabolic.
,i0610',01i014i.4 .. ' ' -',:: i.0 ' - :Patiel.. ':.: is;::- 7::;':,.it"::-.::..;::;•', : .•..-'; ei.,;::! .'', ',..:.' . .'.---7:":',' •,' :•:,,i-; ;:j f'-.j . :if::"-: - !':'' ::•::::- -.: .',:,;',.;', TEST RESULT ". F. RANGE TEST RESULT REF. TEST
RANGE RESULT REF. RANGE
Na 1 5 -?. 138-146 na2o,RI/1.. ALB 3.5-5.5 g/d1 U 73-118 mg/d1
K 0 3.5-4.9 mmol./L . '".- I .m.sa,./1 t1UN 7-22 nag/d1
Cl 98-109 mrool/L A (Lqi - Ll A+ 8.0-10.3 rog/d1
pH 7 . ;1 7.31-7.45 A -- - PI COLO - - - - — RE 0.6-1.2 nag/di
PCO2 3 .7 43 15:4515 m TilFgr gZ) 11/03
REFERENCE L 04 : 17 A' (i :
MAI F 128-145 mmol/1
P02 -7 ‘
80-10.5 mmHg (art) N/A (veal
T PAT I ENT #' 3.3-4.7 mmolil
TCO2 1--
5 ,23:,279 i v mmolli./L ((artn)) 4 B frETLYTE 8 L. 98-108 mmo1 /1
HCO3 1 ,4 2232:2286 mmoovULL avrten) ) DISC LOT #• 3151M4 r ;0 - OPER #: 013 DR #: 000 2 18-33 mmolJl
s02 5
95-98% _ C SERIAI_ # : 0000100681 :,̀...' .: ..(giediilii)TLg'ii-Pdliil
'• k'.:),*:•.- ::V.:; -..7%7;. ";;;;:...;,: Pliii ,';i:'-:::-
',.,::.".:,:.: :::,,,;....::!!..::::::.?: '• ...:
BEecf . —
(-2) - (+3) nanol/L
C TEST GLU 92 73-118 MG/DL RESULT REF. RANGE
AnGap 10-20 mmol/L a BUN 9 7-22 MG/DI- LB 33-5 -5 8/c11 Ca 1. 12-1.32 mmol/L CRE 1.6* 0.6-1.2 MG/DL
LP CK >5000* 39-380 U/L
26-84u/1
BUN 8-26 ng/d1 ' NA+ 140 128-145 MMOL LT
K+ 4.9* 3.3-4.7 MMOVL
10-47 till
GLU 70- 105 mg/dt. : CL- 111* 98-108 MM0f/L MY
CO2
14-97 un
Creat 0.7-1_5 mg/d1 t 19 18-33 MMOIA_
G ST 11 -38 u/1
Hct Lf I 38-51% PCV .B INST QC: OK CF-EM 00 OK BIL 0.2-. 1.6 ro g/dl
Hgb I LA 12- 17g/dl 7 1-EM 0 , LIP 0 , ICT 1+ GT 5-65 tilt
...i7X!.Sijqh-einkifiy. 7_ . :, .!. ., :. - •i: , - , •7;:,-i,..% '.',,.;::. :1 ....: :.•:,—: .:*i '''
C P 6A-8.1 g/dI
TEST RESULT REF RANGE N :.:.--- Ota14Eletio6te...:-
Troponin-1 PEST RESULT REF. RANGE
Drug ofAbuse
- . 128-145 mmolfl
3.3-4.7 mmo1/1
1
- 98-108 mmolll
I.0O2 18-33 mo1/1
REMARKS:
REPORTED BY: J DATE: 1 .AB ID NO.:
_I
MEDCOM - 22663
DOD-036239
ACLU-RDI 1673 p.23
• CHEMISTRY RESULT FORM (Suliect to the Privacy Act of 1974)
DATE TIME SSN/PSEUDO SSN:
(-7-PLZ) (D-2)
Ward/Section: REQUESTING PHYSICIAN:
IA)
LAST, FIRST, FIRST, MI.
-Sm:
TEST
Na
CI
pH
PCO2
P02
TCO2
HCO3
s02
BBecf
AnGap
Ca
BUN
GLU
Creat
Hot
Rgb
TEST
Troponin- 1
Drug of Abuse
RESULT REF. RANGE
RESULT
•3.5-4.9 mmoUL
1 98-109 mrnol/L
38-51% PCV
70-105 mg/di
0.7-1.5 mg/dl
35-45 mmHg (art) 41 -5 1 mmilz (yen) 80-105 mmHg (an) N/A (veal 23-27 Imola. (art) 24 -29 mmol/L (yen) 22-26 mmol/L (art) 23-28 mmol/L (yen)
(-2) — (+3) nunol/L
8-26 mg/d1
95-98%
12-17 g/d1
7.31-7.45
10-20 mmol/L
1.12-1.32 mmol/L
138-146 intnol/L
REF. RANGE TEST RESULT REF. RANGE
TEST RESULT REF. RANGE
ALB 3.5-5.5 g/d1 GLU 73-118 mg/di
ALP
ALT
26-84 u/1
10-47 till
BUN
CAH
7-22 mg/d1
8.0-10.3 men
AMY 14-97 u/1 CRE 0.6-1.2 ing/d1
AST 11-38 128-145 mmol/1
TBIL 0.2-1.6 mg/dl K4 3.3.4.7 alma!
BUN 7-22 mg/di CI; 98-108 mmo1/1
CA 8.0-10.3mWdl tCO2 18-33 mmol/
CHOL 100-200 mg/d]
CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE
GLU 73-118 mg/di ALB 3.3-5.5 g/d1
TP 6.4-8.1 g/d1 ALP 26-84 u/1
iicOYS etlyte; ALT 10-47 u/1
TEST RESULT REF. RANGE
AMY 14-97 un
GLU 73 -118 mg/dl AST 11-38 u/1
BUN 7-22 mg/dl TBIL 0.2-1.6 rng/d1
CRE mg/dl GGT 5-65 u/1
CK 39-380 u/l(M) 30-190 u/l (F)
TP g/d1
NA+ 128-145 mmo1/1 lecolo)- 40a.
334.7 mmol/1 TEST RESULT REF. RANGE
CL 98-108 ramo1/1 NA+ 128-145 mmol/1
tCO2 18-33 mmol 3.3-4.7 mmol/3
CL: 95-108 mmol/1
tCO2 18-33 mmol/1
REPORTED BY: LAB ID NO.: DATE:
REMARKS: 7- 3, o 5-5—x
MEDCOM - 22664
DOD-036240
ACLU-RDI 1673 p.24
Ward/Section: /c."&( j---r. . REQUES rNG CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FIRST, MI.
(91 4);1
DA / 0 . 7
TIME AI ys' SSN/PSEUDO SSN:
,,
.. , TEST
- miooloY RESULT
oin,-4..., -.' - REF
RANGE TEST
(Piccolo)
RESULT
406lie.p.*40)„.,.
REF. RANGE TEST RESULT REF. RANGE
Na 138-146 nunol/L ALB 3.5-5.5 g/dl GLU 73-118 mg/d1 K 3.5-4.9 mmoUl.; ALP 26-84 u/1 BUN 7-22 mg/di
Cl 98-109 mrnol/L ALT 10-47 u/1 CA +' 8.0-10.3 mg/di
PH 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/d1
PCO2 35-45 mmHg (art) 41-51 mmHg (yen)
AST 11-38 u/I NA* 128-145 mmol/1
P02 8105 mmHg 010 N/A (yen)
TBIL 0.2-1.6 mWdl K+ 3.3-4.7 mmolil
TCO2 23-27 mmol/L (art) 24-29 mmol/1, (yen)
BUN 7-22 mg/di CI: 98-108 mmol/1
HCO3 22-26 mmoll (arr) 23-28 mruol/L (yen)
CA-H- 8.0-10.3med1 tCO2 18-33 010101/1
s02 95-98% CHOL 100-200 mg/d1 (Piccolo) ii*it PAiit't..hi" .:„
BEecf (-2)- (+3) rarnoUL
CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE
AnGap 10-20 mmol/L GLU 73-118 mg/c11 ALB 3.3-5.5 g/dl Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/dl ALP 26-84 u/I
BUN 8-26 mg/d1 ...4-.- -:;i ,:.... •::.P..1:,:.icq: ;;;.•' .i .&61:41i10,1ii v g; 4 •: - :i.; . 51,:. .; ,::: .k.:j-r........': -.: .::;.■;-.. ALT 10.47 u/1
GLU 70-105 mg/d1. TEST RESULT REF. RANGE
AY 14-97 u/1
Creat 0.7-1.5 mg/dl GLU 73-1 1 8 mWdl AST 11-38 u/1
RI 38-51% PCV BUN 7-22 mg/d1 TBIL 0.2-1.6 mg/d1
Hgb 12-17 g/d1 CRE 0.6-1.2 mg/dl GGT . 5-65 tilt
' ".- ;,-. ..4 •-_,NA..: ..iiiiiji :-.'' Z1 .fi.7: "': "-...;f? , -t
CK 39-38011/1(M) 30-390 u/1 (F)
TP 6.4-8:1 g/dl
TEST RESULT REF. RANGE NA+ 128- 145 mmol/1 • ,ect! O. 1ectroyte
Troponin-! + 33 -4.7 mmol/1 . TEST RESULT REF. RANGE
Drug of Abuse
_Cr 98-108 raino1/1 NA' 128- 145 mmol/1
tCO2 18-33 mmo1/1 K 3.3-4.7 mmol/1
• CL- 98-108 mmo1/1
. tCO2 18-33 mrno1/1
REMARKS: .--....-- .
./413 G f--/ 0,2 53" 4 / go_ -Ybeze-si s7/ifivr, REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 22665
DOD-036241
ACLU-RDI 1673 p.25
EG6+ .
Pt Pi NamP:
Pa , lent TemP
PH 7.308
PCn2 43.0 mmHg
P02 51 mmHg
Patient Temp: 94.eF FIO2 • •
Sample Type_:
02H0V03
Op er: 11111
IR 5.1 x10"3/aL
RBC 4.86 x1.0"6/uL
1/1-19b 14.5 gidt. Hct 44.8
try 92.1 fL
it14 29.8 pg mit: 32.4 L g/dL Pit 115. L x10'3/ii LIZ 8.6 *L. Z
LIT 0.4 *1 x10'3AL
RAPIDPOINi COAG ANALYZER V4.5 SERIAL 4005485 11/03/03 00:01
Test Nameir Patient ID:
Test Result: 22.7 sec. ***RESULT OUT RANGE•** Ratio = 1,2 CalcuFated -NR = 73 Sample Typelocitrate wh. blood Test Date :11/02/03 Test Time :23:58 Card Lot :180201 Operator
';)-- RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 11/03/03 00:06
Patient ID: Test Name :APT`T\ Test Result:= 96'9 sed, ***RESULT OUT OF RA *** Sample Type:citrated wh. blood Test Date :11/03/03 Test Time :00:02 Card Lot :O208 Operator
.-RAPIDPOIN1 COAG ANALYZER V4,54 SERIAL #005485 11/02/03
Patient ID Test Name :PT Test Result:. 21.6 sec. ***RESULT OUT OF RANGE*** Ratio = 1.8 Calculated INR = 2.52 Sample Type:citrated wh. bloc Test Date :11/02/03 Test Time :19:55 Card Lot :080201 Operator 11111111111
RAPIDPOINT COAG ANALYZE V4.1)4 SERIAL #00.5485 11/02/ 3 20 . 0Y
Patient ID Test Namr- : TT Test Result:=102.8 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test. Date :11/02/03 Test Time :19:57 Card Lot Or- :
pia
DOD-036242
Ha 150 mmol/L
K 3.7 mmo 1 /L
TCO2 23 mmol/L
Hct %PCV
*via
At 37C
pH .
PCO2 45.1 mmHg
P02 55 mmHq
HCO3 22 mmol/L
BEecf , mmol/
s02* a4 % te
Z7. 7.2 27:C, 51.0 1,14C 31.6 L 91dL Pit 5. *. x10 L 150. 450, LIZ L.4 *1 20.5 51.1 LI 0,2 *L olO'3!uL 1.2 3.4
Ser# 42011
Ver: JAHSO4;A CLEW A5, 3
Physician:
'N-11-03 01:2+
atient Limits
a S.: (1.031.L. +.5 10.5 ▪ +-.)0 x10 46/uL 4.00 6.00 Hi 15.7 9/IL 11.0 19.0 ▪ 42.9 1 35.0 60.0 rg 91.6 OL 80,0 99.9 • 2=.2 Pg 27,0 31.0 117tC 31. 9 L g/dL 310 37.0
ell- 115. L x1.0`3/aL 150. 450. LIZ 8.4 4.X 20.5 51.1 LIT 0, 4 X10:ik6.hO 3.4
02-11-03 04:1'8
Patient Limits
4.5 10.5 4.00 6.00
11.0 18.0 .15,0 60.0
SILO 99.9 27.0 31.0 33.0 37.0 150. 450, 20.5 51.1 1.2 3.4
MEDCOM - 22666
ACLU-RDI 1673 p.26
i-sTAT EGe+
pt.
ria
Na__ _150 mmol/L
4.1 Tmol/L
712.02_ __17 mmol/L
mct 30 PCV
Hb*___ _10 q
*vla
Na 142 mmnl/L
3.7 mmol/L
T002 20 MM01/L
Hct 36 %Pcv HbiE 12 q/dL
*v.ia Hct
N.•
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/01/03 01:12
Patient ID111111 Test Nar 7: T. Test Result:= 16.9 sec. Ratio = 1.4 Calculated 1NR - 1.70 Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :01:10 Card Lot :080201 Operator :11111111111
RAPIDPOINT GOAD ANALYZER V4.54 SERIAL #005485 11/01/03 01:15
Patient ID ; lest Nan : PIT Test Result:= 37.5 sec. Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :01:12 Card Lot : 30201 Operator
At Patient Temp
PH 7.47e
PCO2 22.1 mmHg
pnz ou mmHg
_ mmHg
02 3e mr419 ,9
HCO3 17 mmol/L
6EPcf -7 mmol/L
-702* 74 %
*calculated
At Patient Temp
pH 7.318
PCO2 3e.3 mmHg
P0a *** mmHg
Rt 37C
PH 7 .74..
P002 40.2 mmHg
P02 *** mmHg
H003 19 mmol/L
8Eecf -8 mmol/L
sn2* *** %
*calculated
patient Temp: 55.- - Patient Temp: 54.4F
FIO2 : 10,? FIO2 : 100
3ample Type_: 2RT Sample Type_:
, 11,111 0,
6A0V03 00:49
riper: 66-2_
Pny=ic - an:
02NOV03 25:c.S
Oper ;;),
Physician):
_ 4.5
20.0 27.0 31.0
at] 51.1 1.2 14
rfo / Ser# 4074e
ver; jAMSO4e2 CLEW 293
Ser# 42011
Ver; JANSO42 - CLEW A93
MEDCOM - 22667
DOD-036243
ACLU-RDI 1673 p.27
Ward/Section: REQUESTING PHYSICIAN: LABORATORY RESULT FORM - •
Other .
Coagulation Stu
'LAST, F. T„ . v..,..),,t
DATE TIME - tv Luc I i vektt:y Pict 01 150 / 4)
SSN/FSEUDO SSN:
: ..... ' . ....(Hen tOlogy) CBC .. • Urinalysis _Misc. Serology: TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC ,—.. • 4.8-10.8 x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14-18 g/d1(1vf) 12-16 wet' (F)
42-52% (M) 37-47% (F)
Glu
Bili
Negative
Negative
• . IyUerobiology .. .• •. :... . • .. • . . • — .
Hct Source
MCV 80-94 21 (M) 81-99 fl (F)
Ket Negative
Stain• Gram
Pit 130400 x10 verified
SG •N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld
...
(Hematology) Manual Differential .,.:-•
Negative H. pylori Negative
. . -.. • • • - . • •• - • . • • ••• . : pH • N/A . Micro
Parasites Segs • Mono Prot Negative Malaria '
Bands . Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk 1 Negative • •Microscopic Urinalysi ... ,-.. . .. • ....., ... .- . ..-.... .
RBC Morph
.._ _...... .. _
HCG Negative
I - • Blood Bank , • .
•
Cell Count
Directigen
TEST RESULT REF. RANGE &WIT
PT 9.8-43.6 secs
APTT 21-34 secs
D dialer <20 ug/ml
FDP <10 ueircl
REMARKS: tc-‘
p Hematocrit
Sed Rate
-+,4 Jh7O 37:47% (F)
- Blood Bank Unit CrOssmatch . ' • (MUST.SUB1I-IIT SF 518 WITH EVERY UNIT OF BLOOD
- .•• REQUESTED) • • •-. ̀'• :
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Negative I ABO/Rh
TYPE CROSSMAI.TCH
• I REPORTED BY: DATE: LAB ID NO.: .
MEDCOM - 22668
DOD-036244
ACLU-RDI 1673 p.28
i.5
73-118 MG/DL 4 u/1
7-22 MG/DL 7u/1 8.0 - 10.3 MG/DL 0.6-1.2 MG/DL 7 tilL
128-145 MMOVL 3.3-4.7 MMOVL .8u/1
98-108 MMOVL 18-33 MMOVL
INSI OC: OK CHEM OC: OK HEM 0 LIP 1+, IC1 1+
RESULT
L
GLO BUN rA+
CRE
NA+ K+ CL-tCO2
28* 14
7.7* 1.5* 144 4.3 114* 18
7
6
REMARKS:
clk.\ vta, V-AJ LAB ID NO.:
AntiV3 REPORTED BY:
DATE:
Ward/Section: (JESTING PHYSICIAN:
LAST, FIRST, l'
(c10 DATE TIME
)--
Z,MLSTRY RESULT FORM (Subject to the Privacy Act of 1974)
SSN/PSEUDO SSN:
(Piecol)),Ch&nistry 1
TEST
Na
Cl
PH PCO2
P02
TCO2
HCO3
s02
BEed
RESULT i ..../Z 1,T.
7.31-7.45 AMY IILL
GE
AST
TBIL
BUN
CA
CHOL
CRE
GLU
TP
TEST
GLU
BUN
CRE
CK
NAS
tCO2
TEST RESULT REF. RANGE
PICCOLO ==-:--- 23:58
1M t 02/11/03 7- RL1tRENCE R1 )8 mmol/1
PATIENT #: BASIC METABOLIC DISC LOT #: 3325ml OPER #: 013 DR #: 000
SERIN #: 0000100684 F. RANGE
AnGap
Ca
BUN
GLU
Het
10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/dl
70-105 mg/dl
0.7-1.5 mg/dl
38-51% PCV
12-17 g/d1
RESULT REF. RANGE
35-45 mmHg (art) 41-51 mrnHz veal 80-105 mmHg (art) N/A (veul 23-27 mrnol/L (art) 24-29 mmol/L (yen) 22-26 mmoVL (art) 23-28 mmol/L (von)
95-98%
(-2)— (+3) rumon
138-146 mmol/L
3.5-4.9 mmol/L
98-109 mmoVL
3.5-5.5 g/dl
26-34 u/1
1047 u/1
1 1
TES RESULT REF. RANGE
GLU 73-118 mg/dl
BUN 7-22 mg/dl
8.0-10.3 mg/dl
' .2 roz/d1
45 mmol/1
7 mmolil
3 mmoVI
108 rr.mo1/1
33 mmol/1
MEDCOM - 22669
DOD-036245
ACLU-RDI 1673 p.29
Hematocrit
Sed Rate Cell Count
Negative Directigen Other ABO/Rh
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
•
Blood Bank .
PT 9.8-13.6 sees
21-34 secs Am
D dimer <20 tg/m1
• 37.47%
. : - - ' . . . - Blood: Bank Unit Crossmatclf - : - (MIJST SUBMIT SF 5. 18.WITH EVERY UNIT OF BLOOD
. '
. . , .
REQUESTED) ' :' ': • : ' TEST RESULT REF. RANGE UNTT TYPE CROSSM4TCH
Coagulation Studies.
FD.P <10 ug/m1
REMARKS: • -•40110‘...-
REPORTED BY: P—t. PT
DA1 E: LAB 103. NO.: .
Ward/Section:
• LABORATORY RESULT FORM •
REQUESTING PHYSICIAN:
touojeet to me Yrtvacy Act of 1974) I LAST, FIRST, ,MI. DA t 0
TIME
1 CI • SSN/PSEUDO SSN:
(Hematology) CBC :: yrina sis - . : . , misc. Serology ... _ TEST R1fT i - . NGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
NBC 4.8-10.8x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative Hgb
14-18 dl (M)
12-16 dl (I') Glu Negative l!ilierobiology
Hct 42-52% (M) 37-47%(F)
80-94 11 (M) 81-99 fl OD
Bili
Ket
Negative
Negative
Source
Gram Stain
. • .. MCV
Pit i 30-,500 x 10 verified
SG N/A Occ Bid Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative (Ifematti . . ) Manual Differential : .. -
• ' . , - pH N/A Micro
Parasites Segs Mono Prot Negative Malaria Bands . Eos Urob 0.2- 1.0 0 & P
Lymph Baso Nit Negative Other
Atvp Imm Leuk Negative
•
: .Mkrpscopic UrinaysiS
RBC Morph
CrItIn
HCG
,t, S1.01_ (?AN r ----
Negative .
MEDCOM - 22670
DOD-036246
ACLU-RDI 1673 p.30
FORM Ward/Section: (A.,,,(
LAST, FIRST,,MI. ..--------,------•-,—.
REQ
DATE v 3
C 0 16 TIME
Sub- ect LABORATORY RESULT
to the Privac Act of 1974 SSN/PSEUDO SSN:
(ilcmaOlogY) . •Urinalysis . .. Misc: Serology
REF. RANGE TEST , REF. RANGE TEST RESULT REF. RANGE
WBC 4:8-10.8 x 10' Color - N/A RPR Negative
RBC 4.7-6.1 x 10 App N/A Mono Negative
Hgb 14-18 &I (M) 12-16 di (F)
Glu Negative - • IYUCrobiology :. . • .. - . •
Hct 42-52% (M) 37-47% (F)
Bili Negative Source
MCV 80-94 t1(M) 81-99 fl (F)
Ket Negative Gram Stain
.N/A Occ Bld Negative Pit 130;500 x 10
verified SG
Lymph % 20.5-51.1% Bid Negative H. pylori Negative
pH - N/A . Micro Parasites (Hematology) Manual Differential .
Prot Negative Malaria ' Segs • Mono
Urob 0.2-1.0 0 & P Bands Eos
Nit Negative Other Lymph Baso
Atyp Imm Leuk Negative MIcinscopic Urinalysis; . ... •• • . ...... . .
RBC Morph
HCG Negative
Spun •Hematocrit
Sed Rate •
42-52% (M) .. Cell Count
. CSF. •
MUST SUBMIT EVERY 'UNIT
Blood. Bank ...- .-
SF 518 WITH REQUESTED
Other
.:.- COagulation - Studies. , - -.• , ..........•-... . ., ...•••..
Directigen
;!:. - - ' . (MUST
. ..-. .BloOrt SUBMIT
Negative
Bank Unit sr518.WITH
ABO/Rh .
Croisniatch-- EVERY
: s. - .. UNIT OF BLOOD ..
UNIT TYPE CROSSM4TCH TEST RESULT REF. RANGE
PT 9.8-13.6 set:::
• APTT 21-34 secs
D dimer , <20 ug/m1 •
FDP <10 ug/ml
REMARKS: ------
I REPORTED BY: I i _______
DATE: LAB ID NO.:. •
MEDCOM - 22671
DOD-036247
ACLU-RDI 1673 p.31
Ward/Section: REQUESTING PHYSICIAN: CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974).
LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN:
.1.7 T , • • i0610)'PIi6iiiteY::1 !Ctilb). ,1WtabliiPa ail • - .- -,...:::.D.:ic,•:., ::',..--•.::' , ., :f.,'' .:e: :"•:::,: 1,:::..,;:- .:?, ,
TEST RESULT REF. RANGE TEST RESULT REF. RANGE
TEST RESULT f REF. RANGE
Na 138-146 mmol/L ' 2 C-C i okli GLU 73-118 mg/dl
K 3.5,4.9 11=0UL- BUN 7-22 mg/di
Cl 98-109 mrool/L - PICCOLO - - 03/11,03
CA7f 8.0-10.3 mg/dl
PH 7.31-7.45 00 : 52 REFERENCE RANGE: MALE
CRE 0.6-1.2 rng/d1
PCO2 35-45 mmHg (gym pAT I ENT # : IffikYC)-1 41 -51 mrnffiz (ven) NA: 128 - 145 miro1/1
P02 80-105 mmHg (art) ME:TLY I L 8 NM. (yell)
K' 3.3-4.7 mmo1/1
TCO2 23-27 rnrnol/L (art) DISC LOT #: 3151AA4 24-29 mmol/L (ver OPER # : 013 DR # : 000
CE 98- 108 mmol/1
HCO3 22-26 mmoVL (art SERIAL # : 0000100494 23-28 nuvol./L (vcr tCO2 18-33 mmoV1
s02 95-98%
U21 * 73-118 MG/ P:iciiiltION!4:-P. dite.f pli4-...]::;,-,.-: ,
- ,(:;:,:j....;',;..'..-:; ,;.i.:.:,..'..:. f:..,,,•. ,.'..:z1 ,--. .:: BEecf (-2) - (+3) BUN 13 7-22 MG/DL runlon
TEST RESULT REF. RANGE
AnGap 10-70 mmol/L CRE 1 .6* 0.6-1.2 MG/DL ALB 3.3-5.5 g/dl
Ca 1.12-1.32 nun& CK >5000* 39-380 U/L N9+ 131 128-145 MMOVL
ALP 26-84 u/1
BUN 8-267.301 K.f. 4 . 8* 3.3_ 4.7 mmovt_ . ALT 10-47 u /1
GLU . CL - 112* - 70-105 mg/d1 98 108 MMOLL tCO2 16* 18-33 MMOVL
AMY 14-97 u/1
Creat 0.7-1.5 mu/d1 INST QC: OK CFM
AST 11-38 u/1
Hut 38-51% PCV QC: OK HEM 0 , LIP 0 1 ICT 1+
TBIL 0.2 7 1.6 mg/d1
Hgb 12-17 g/cil GGT 5-65 oil
,;..r. :111,4sC;TCIiixiiiit .:: -,
TP 6.4-8.1 g/d1
TEST RESULT REF. RANG .ccol_ , , o:) •peetTolyte :::.
Troponin-1 TEST RESULT REF. RANGE
Drug of Abuse
l NA' 128- 145 mmol/1
IC 3.3-4.7 mmol/1
CL: 98-108 mmol/1
1 tCO-. 18-33 mrnoUl
REMARKS:
REPORTED BY:
Ma
DATE: 1 LAB ID NO.:
3AMV)3 j
NO r-
MEDCOM - 22672
DOD-036248
ACLU-RDI 1673 p.32
DOD-036249
k 1$ . NS 'Po
14,R P-r T 2,7,1 WP SG3 ( kt-S
FIct_bi soo o , E. oNT MEDICAL RECORD - ANESTHESIA itChit-`,..,
6.e.,..oktonstc.I.- v For use of this form, see AR 40-66; the proponent agency is the OTSG
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SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS
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BLOOD- . • ,./... 4:0414 .......................................n Code drugs with numbers, 1e MiziragiErame4 1111111111111.111111 ye is with lett! s ‘
LI Warmed I' Mili INN lTJ
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4111Y :.i.STAT ':. TIME • 1 40° 4; ID • tow • -50 • 2100 ' 30 , 413 4 5 :.::---..:.:1.:..::::.:::
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200
18
160
140
120 100
BO
60
40
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6. Heart rate R M &Tea
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TIME 1,gao
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PR"- So •
V122162. .;,,t 1 0 acv •
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MN • arispr ia
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VT - ml
f - breaths/min 0 MIS"
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Fin C MODE • s( on). Alssist). C(on) TAP/Auto Cuff C°2 ito") E11111EMPIllIMPIIIIMIE1111101111111EILMILW ii BP/oth I 102 (Frac or %I raCHIMMIMIIIIMIEVILMIarilMil mil PAC CP Specify)
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PROCEDURES and CPT Codes: -- Colos.i.oiy‘
.?(Ici,R : st.9,,i4„.t::&Q,Q.0.0 ,k— ANESTHETIC TECHNIQUES: Describe block technique under Remarks
E. 1 (I-- R AY MA G MENT: Intubation route blade, techni ue, comments
1".'s F' 01 I ?. D ° al: at.12.- SUR 4_ , Tr°
PATIENT IDENTIFICATION: Aiped or od/rte d enrries: Name, Grade/Rare, liaical facility
Qrz i/ .-)K,)--c-1
, PROCEDURE -7 OCATION: ( _,..0
aft 3 er3a /41/rET PAGE / OF DA FORM 7389_ FFR 1998 .,..-r., .,........ .............-
i USA PA V1.00
ACLU-RDI 1673 p.33
)-r0. 0 MEDICAL RECWRD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
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URINE - 1,5V
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200
180
160
140
120
100
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401
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A Heart rate
s Resp rate
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PATIENT IDENTIFICAT : Typed or written entries: Name, Grade/Rare, AIRWAY MANAGEMENT: lntugion route .e,technique, comments 0 Medical facility I A-7-.164Pia t ,t ( C 46...Cir ..."i f ee9 r..., 1400 ((7.19 la_ SURGEONS:
L6_10D) 1 .
PROCEDURE( / LOCATION: DATE:
Z. drVO Y01-5
IIIIIIIIIIIPIIIIIIIII
PAGE / AGE / OF
M - 22674
COPY 1 - PATIENT'S MEDICAL RECORD USAPA V1.00
DOD-036250
ACLU-RDI 1673 p.34
NIP TREND 11/03/03 11/03/23
TIME HR/PR Sp82 SYS / DIA - MEAN RR FiME HR/PR Sp02 SYS / DIA - MEF RP
HH:MM BPM X mmHg RPM mm82 RPM
00:46 62 1U2 ERR 15 11 00:46 63 L ltd / Id2 14
00:41 100 Ig2 / 39 126 OFF 00:44 63 argi/ 1B8 IFI 25
30:36 86 12d ERR 15 22 00:42 50 V - / ig 10
n / Ig0 ■• IAA 12 00:40 122 / ILki Egg 16
P= / is 12U 18 00:38 1-1!ti4 j / 1g2 Igo 26
/ Mgg 111E1 18 00:36 89 Mrig / Idd Igg 16 00:15 Ugg 93 I2A / 122 18 00:34 117 86 itg / IC2 Igg 18
23:40 TA 96 81 / 39 . 54 18 00:18 • 188 IgA 18 23:35 ggg 95 79 / 40 . 54 18 00 :16 1.. / ig8 igd 18 23:30 119 95 75 / IgN a 122 18 00:14 Ltb, 94 lAd / s Kg 21 23:25 120 95 77 / 35 50 OFF WAt; 93 1_71 / s 23:21 120 96 160 / 35 126 OFF 30:10 ggg 94 IAN / Ogg 12A 18 '3:15 106 96 162 / 38 51 OFF 30:08 j 94 IAN / ICU 128 18 `3:10 120 96 79 / 40 a 54 OF= 00:06 ggg 94 IAA / Igg I2Y 18 3:05 my q 82 / 38 i 55 20 00:04 ggg 95 IA8 / p. 12g 18 23:30 121 07 83 / 40 . 55 1? 00:02 UM! 95 [1J / 1K1 I2g 18 ??.R? n- dA 00:00 !AM 95 12E / Ig2 122 18 22:66 LIN:: /. L 23:58 MD 96 ITU / ffq OUV 18 22:50 120 93 EU / INA Osi, 23:56 4D 95 /tom' 12C 18 22:45 uNg 94 I2A / 128 OFF 23:54 !}i 96 im / 35 lull 18 '2:40 Mdg 93 122 / lg lug OFF 23:52 dgg 96 I2g / Igg I2g 18 '2:55 120 92 126 / 1CW I2g OFF 23:50 WI 96 ITg / 1g2 122 18 ?2:30 NNU IA4 ITU / INN l2g OFF 23:48 119 96 76 / 41 53 18 - :25 119 '41NON / igg P OFF 23:46 Li 96 12g / gtgj J 18 ':20 LID 84 I213 / Ig21 - 18 23:44 ggg 96 F.1.1 / Ig2 122 18 :2:15 ggg [2I 84 /Igg 12U 9 23:42 udg 96 le / 35 12A 18 22:14 im ERR# 2 IgA 23:40 J 96 le / 35 12g 18
'1 :38 gtAg 96 )LTJ / 36 IM 18 3:36 ggd 95 162 / 36 126 18
1P4747 ,7474:74:PL' SYS- TEMS:
•
22:50 120 93 kAu / INA ft OFF 22:45 94 E / PAU El OFF 22:40 Lell 93 rffj / 1E4 ra OFF 22:35 120 92 ICIN / leg IEN OFF 22:30 NJ EEEI FAN / Irkt4 OFF 22:25 119 MNII I / t P OFF 22:20 WA 84 ra / • RiN 18 22:15 WA gig 84 / Wig rdri 9 22:14 LW AIM ERRS 2 P21
J:34 119 95 / 1g2 lug 1B .:32 119 95 I2g / p 8I (Ig 18 30 119 95 / 15X I2g 18
1:28 157 95 12d / ICU 122 OFF ,3:26 120 96 [SJ / 1C2 122 OFF 23:24 120 95 ITT / 36 12• OFF 23:22 120 95 IT2 / P2 12u OFF 23:20 144 95 ITg / 12d OFF 23:18 128 95 77 / 10.1 67 OFF 23:16 125 96 all / app pap OFF 23:14 MA 95 CCO / gab 18A OFF 23:12 121 95 16N / 36 12d OFF 23:10 120 96 idg / 35 LJJ 23 23:08 120 96 Idg / 35 I2d 18 23:06 TA 96 Idg / 35 126 19 23:04 MNM 96 76 / 35 126 30 23:02 gal 96 80 / 36 ION 18 23:00 LINU 97 86 / 38 52 10 22:58 86 97 96 lgg 59 OFF 22:56 i12 98 107 / 45 62 OFF 22:54 LINA 96 143 / 64 87 OFF 22:52 120 94 Egg / IgNINA OFF 22:50 121 94 I& / Egg P1 OFF 22:48 itg 94 ISS! / Igg ICA OFF 22:46 LINg 94 IA2 / Igg 12N OFF 22:44 Ugg 94 pg / igg OFF 22:42 jJ 93 EA! / IgN Igtd OFF 22:48 ggg 94 IAN / P12 ad OFF 22:38 TUN g 93 IAN / IgN IgN OFF 22:36 NJ 93 IN /e le OFF 22:34 120 91 12 / PJ P2 OFF 22:32 giNg ICU MAK / P2] Egd OFF 22:30 Ugg 82 Iv / ggij gsz OFF 22:22 120 :9NNU IAN / Igg 121 OFF 22:26 119 IA8 ICL] / IAN atir,!, OFF 22:24 119 / ICU Igij 24 22:22 120 84 eij / itg 12 22:20 LINg on 1A2 / !Ng NB 18 22:18 UNN 93 II; An ICA 18 22:16 WA P2] 12C ti56 1Y 8 22:14 WA AAAt 126 / J 12g 17 22:12 46 :NNINI OFF OFF OFF OFF 22:10 121 la OFF OFF OFF OFF 22:08 it2 OFF NOT ZEROED OFF 22:06 ggg OFF 126 / 56 75 OFF 22:04 gm OFF 84 / 39 53 OFF 22:02 LK] OFF 87 / 39 52 OFF 22:00 25 OFF NOT ZEROED OFF 21:58 9FF 95 / 40 55 OFF
ADULT
ADULT
ADULT
MEDCOM - 22675
00:10 gdg 94 igg / 122 18 00:32 119 89 12A / EN 18 00:05 iigg 94 1dg / Igg 12A 18 00:30 ikil igg IQ 18 00:82 ggy 95 INg / 35 .-12A 18 00:2S il!,4 1dd WU 18 00:0B NI 95 ERR# 11 18 00:26 iAF INA IAA 18 23:55 UNM 96 76 / 36 . Mb 18 BO:24 • ' INN 18 23:50 LtU 96 76 / 37 • 52 18 00:22 4:0 / IgN 18 23:46 ggg 96 77 / 36 . 51 18 00:20 1C8 21
DOD-036251
ACLU-RDI 1673 p.35
IBP TREND 11/81/03
TIME HP/PR Sp02 SYS / DIA - MEAN RR
HH:MM 5PM 7
01:25 142 ONO 103 / 52 70 14 01:21 140 ONO 96 / 48 67 18 01:15 141 ONO 95 / 48 66 16 01:10 143 4iN0U 95 / 54 69 14 01:05 141 ONO 100 / 52 73 17
00:55 141 ONO 92 / 48 66 14 00:50 141 ONO 92 / 48 66 15 00:45 141 99 88 / 47 64 14 00:40 144 1;Al 86 / 46 63 15 00:35 145 40qj 92 / 50 66 16 00:31 144 Mai 94 / 44 65 15 00:26 144 99 92 / 46 65 15 00:20 144 94 89 / 4? 64 15 00:15 SRCH 90 / 49 65 25 00:10 IN 91 92 / 51 69 27 00: 92 99 / 63 79 1E4 00:0 LV2 89 110 / 59 ?9 kg 6 it ti; 89 105 / 60 78 20 23:51 ! 91 113 / 71 • 83 21 23:45 ::;011 135 / 100 . 110 18 23:40 go 95 ERRt 15 19 23:35 ijal 90 117 / 59 83 13
23:30 On ONO 109 / 64 82 20 23:25 itki 90 99 / 66 . 76 21
23:20 WO 91 102 / 58 74 27
23:15 ONIC, 95 / 55 70 28 23:10 giR 96 103 / 56 76 126 23:05 144 97 105 / 63 • 79 3? CD) 145 77 la5 / 56 52 27 22:55 143 95 114 / 69 87 31 22:50 144 90 112 / 63 • 81 28 22:45 141 49 130 / 71 95 36
22:40 ilad 9? 132 / 6B 95 12
22:35 141 100 130 / 81 99 14
22:30 143 99 134 / 70 97 15
22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14
22:15 137 100 137 / 74 99 2B
22:10 131 100 126 / 77 97 22 22:05 ice'. 99 13? / 73 100 14
<Ort Mg! 98 138 / 69 97 14
21:56 On 97 120 / 62 86 14
21:50 UOU 94 108 / 56 76 18
21:46 On 88 128 / 56 85 14
21:40 j1 la 108 / 58 77 26 21:35 itIN 8[11 114 / 58 81 14 21:30 it OFF 107 / 59 79 OFF
ADULT
PRO TO C 0 L' 3"6" T E AC 6', :V•:.
NIBP TREND 11/01/03
HH:MH RPM X mmHg RPM 06:03 gn 89 87 / 49 66 26 06:00 ij 91 89 / 42 . 62 20 05:56 Td6 98 ERR 15 17 05:48 !In 98 96 / 52 • 70 19 05:46 irgU1 98 84 / 49 = 63 24 05:40 1E11 100 87 / 48 • 65 21 05:35 Ha/ 98 110 / 48 75 14 05:34 143 96 107 / 53 76 15 05:31 144 98 99 / 51 70 16 05:26 46.17 97 ERRS 15 15 05:20 141 93 107 / 61 79 26 05:15 154 95 105 / 62 80 20 05:10 144 98 109 / 62 88 22
05:07 ii 86 ERR# 15 24
05:00 139 98 106 / 59 77 16 04:55 .139 97 116 / 52 . 79 19
34;50 138 98 109 / 55 79 14
04:45 138 95 110 / 55 77 17
04:41 138 94 105 / 51 72 15
04:38 138 ONO 103 / 51 73 14
04:35 141 :1I) 101 / 49 71 15
.:30 140 # J 102 / 51 72 16
04:25 139 ONO 101 / 49 69 15
04:21 139 41N001 92 / 46 65 14
04:15 138 ;tin 89 / 46 63 14
04:10 139 90 / 47 64 14
04:06 139 .eNg 86 / 47 63 14
/04:03 139 AMU 86 / 47 62 14
04:00 140 Agn 89 / 53 65 17
03:57 139 416001 84 / 46 61 14
03:50 140 41011 88 / 49 65 1?
03:45 141 Mt 87 / 52 67 15
03:40 142 ma 95 / 54 71 16
03:35 144 ONO 93 / 55 77. 26
03:30 144 ONO 103 / 60 74 14
03:25 142 ONO 92 / 53 69 15
03:20 144 ONO 100 / 55 74 17
03:15 142 :!i j 95 / 56 72 16
03:10 142 .7;178
96 / 56 72 16
03:05 143 ONO 95 / 56 69 14
9:04 144 Mgt 92 / 61 71 14
3:00 144 .Agyt 95 / 53 70 14 02:56 144 41:10 ERRS 15 19
02:50 146 1lia 98 / 60 76 18
02:45 144 ma 97 / 55 73 17
02:40 143 kat 95 / 57 73 15 02:35 144 ga 96 / 55 72 16
02:30 144 ONO 95 / 53 71 17
02:25 144 gall 96 / 56 72 16
02:20 146 ONO 99 / 53 70 17
02:15 144 ONO 94 / 54 70 18
02:10 144 an 96 / 56 74 19
02:05 144 ONO 94 / 56 72 16
02:00 142 ONIV 99 / 56 72 17
01:56 143 Mgt 90 / 52 66 15
01:50 143 igal 99 / 53 72 17
5 140 41:1011 102 / 52 73 15
40 139 92 101 / 52 71 14
,-.36 140 ONO 98 / 51 70 18
01:30 141 99 102 / 53 71 16
01:25 142 ONO 103 / 52 70 14
01:21 140 4100 96 / 48 67 18
01:15 141 :gm 95 / 48 66 16
01:10 143 ONO 95 / 54 69 14
01:05 141 ONO 100 / 52 73 17
01:00 141 ONO 95 / 52 67 16
00:55 141 :W011 92 / 48 66 14
00:50 141 nNJ 92 / 48 66 15
00:45 141 99 88 / 47 64 14 00:40 144 :411:1 86 / 46 63 15
00:35 145 gMil 92 / 50 66 16
00:31 144 1INMIJ 94 / 44 65 15
00:26 144 99 92 / 46 65 15
00:20 144 94 89 / 47 64 15
00:15 S1J SRCH 90 / 49 65 25
00:10 ) 91 92 / 51 69 27
00:05 TA 92 99 / 63 79 ItO
00:01 0A 89 110 / 59 79 WIZ
23:56 ) 89 105 / 60 7B 20
23:51 O6.11 91 113 / 71 23 21 23:45 4,16 ga 135 / 100 ■ 110 18
23:40 gjg 95 ERRt 15 19
23:35 TV 90 117 / 59 B3 13
23:30 ira ONO 109 / 64 82 20 23:25 irdl 90 99 / 66 . 76 21
23:20 Ug 91 102 / 58 74 27
23:15 Lui ONO 95 / 55 70 28
23:10 LEM 96 103 / 56 76 mad 23:05 144 97 105 / 63 • 79 32
23:01 145 97 103 / 56 82 27
22:55 143 98 114 / 69 87 31 22:50 144 98 112 / 63 . 81 28
22:45 141 99 130 / 71 95 36
22:40 101 97 132 / 68 95 18
22:35 141 100 130 / 81 99 14
22:30 143 99 134 / 70 97 15
22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14
22:15 137 100 137 / 74 99 28
22:10 131 100 126 77 97 22
ADULT
+-WO TO C 0 5 E J N C. C.
mmHg RPM TIME HR/PR Sp02 SYS / DIA - MEAN RR
MEDCOM - 22676
DOD-036252
ACLU-RDI 1673 p.36
•
60
30 • - 20
10
cr; 11/83/03 0947:29 140--61 ART/!D CUP=80/21(24) .80=11 SPIPigt. 3
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9 • , -13 ION::
.... • .... . ........ ■ • • • • • • • • •
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24FT ESIFIFF
PACER DISPLAY ON
• • • • • • • ■ • • • • •
• • •
•
ii 3103 00:48:32 HR=61 flih CL01,32/23(26) RR--28 512=0 RIOMFF . . . " -" .. •
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. . . . . . . .
•
• a .
• • • ■ • • • ... • ....
......... .
. • • • .... • • •
60 pp'
30 20
10 : cup-
•
MEDCOM - 22677
DOD-036253
ACLU-RDI 1673 p.37
EAD II }{1.9 HR=---- M mmE--MEMIIIMEEMEa EME=MEME=
Warn Mira IAIEEEMEEEMPIAMiEREEMINEEMIE.
MMEHMEMEMMEMENMEMEEMEMEMMENESEEMEMME MEMEMEEMEMEMEMEMEMEMEME MEEMEMMEMEM
EMEMEMEMMEEMEMEEMEME MEMEEMEEME EMEMEMEMEMEEMEMEM-EME ME" -ME
P/N 804700
)■ 15 , 13 432NO
PHYSOCONTROV
MEMMEEME -- MEM=LMEMEMEMEMEM ,±1MMMEIMIE _EM EMEMEMEEMEMMEMEMMEM MEMMMEME MM EMEEME. MMEMEMEEMM MEEEMEME MEMEMMEEME =MEE: nommmmEmmommommomm Immo m ,m1...m '1.171comiimmirsirmommommehmomim m or mem --.'
,i:-4t mom mommimm,,mmm m ME MEM MEMMEM , ME EIMIEWsE. RN ME M EINEM
EM ME i MEMEEMEME M M M ME PHYSIOCONTROV
P/N 804700
MEDCOM - 22678
DOD-036254
fj
1 - 1
ACLU-RDI 1673 p.38
P/N 804700
18 02NOV03 LEAD II X1 0 HR=- 1211151,11. PRIM -11111ENINMEERIMINEMIPIIMMINMEMBRIMMINME5Wr:11101.11
15: 16 02N LEAD II X1.0 HR=---
MEN MalaVEZZOM=1 mMEEMMEM EggEMEREMIAbstaMEMENEMM. EZEIRSI=F=EWMIUM ---L...NEMMME
TIEEM1ZMMS--- Eh-Mill1=E-W:a=t EMEMIZENZEIWIREMWJERE wEara EMBINEEMEIBEE.REMZERIMMEE=MENE IIMEN =MEARS=
P/N 804700 ■CCITM:c .
MOM MMEMEIMMUMENEME =MEM. MMMMMMMMMMMMM MMEMMEMEMMEM . EMEMMEMEMM EMMEMMEMEM MEM . MMEMMMMTHEMMEMMEMEMMEM —ME: MEMEMME . MEMMEMMEMMEMEMErM s M MEM= EMMEN= MEM= 'Pli4
-- MOMEMMEMAIMBEI =ME= A
mysimocommov
15:16 02NOV03 1 X1 0 HR= 52 ,, ...I.!. marffirdill.91611111115.1 ,_.10.161... ilia
miliiiiiiMEIMINMERIMMINIMUNIIMMEMIERI IIIRMIIIIIIIMMIMMI119.111 ingffingurammEmmomiutairotilliegaiiii EMPROMMEMMilibidiffillEP pism.ristrammt.mraitimailloqu inikiimismiwroi ffirarrillipirpipp irirmsrmilipm el.simmuill dudir er 1-11qhjiiiirilhiligi nim...4.1— ini ill II Eh P I In ILI . 1 1 Ein ill . Ili ..... .eni: INNEUREMPWCattailiMMITitiPARIIR .JMIEWMMPMMPRIIIMIMIIPMNIPIMPIIFTVINI.
1 T,,, elminmillomommummissammitmommilimpum JimErgoullimilitoigH.I.d
il ls : thoraimummodampablaumh mllismalummundgaihmu.E...m.,16.,..m
MEDCOM - 22679
DOD-036255
ACLU-RDI 1673 p.39
-6')/? 03, 1.)ov 03
1st VERI
2nd
PRE-TRA
TEMP. 2,— I PULSE 16)-3 TIME STARTED
3i 0 c+ 03 2.030 DATE OF TRA
B
4
518-123
MEDICAL RECORD
NSN 7540-00-634-4158
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
PLATELETS (Pool of units)
CRYOPRECIPITATE (Pool of units)
Rh IMMUNE GLOBULIN
1.11 OTHER (Specify)
VOLUME REQUESTED (Ifplicable) A,
I Ow, REMARKS: lioc4.03 wurrei& /c/o
go
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
[A" TYPE AND SCREEN
CROSSMATCH
DATE REQUESTED terl it j
DATE AND HOURRE/UIRE13.7_
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
REQUESTING PHYSI
DIAGNOSIS OR 0
I have collected a blood specimen on the belo named patient, verified the name and ID No. of th patient and verified the specimen tube label to b correct.
SIGNATU
7
TIME VERIFIED
ML
UNIT NO.
1111111.
DONOR
ABO A Rh ?C)
EDURE
3/
ED DATE
TRANSFUSION NO.
ANTIBODY SCREEN
TEST INTERPRETATION
CROSSMATCH
PREVIOUS RECORD CHECK:
RECORD tia....LIO RECORD PATIENT NO.
RMING TEST vJ
RECIPIENT
REMARKS:
h s
SECTION III - RECORD OF TRANSFUSION
POST-TRANSFUSION DATA
AMOUNT GI
(AT IDENTIFICATION
TIME/DATE COMPLETED/INTERRUPTED
REAC ION
ML
PE Oc--1-°3 24D
ATURE PULSE BLOOD PRES URE
NE SUSPECTED O
I reaction is suspected—IMMEDIATELY: (g. J
Y-) 1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Alter Set, and I.V. Solutions to the Blood Bark.
DESCRIPTION OF REACTION
URTICARIA CHILL ❑ FEVER E PAIN
OTHER (Specify)
OTH DIFFICULTIES (Equipment, clots, etc.)
NO YES (Specify)
(Aim-
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 Component Transfusion Form and on the patient identification tag.
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last rate; hospital or medical facility)
MEDCOM - 22680
WARD617/01 rank; SEX
BLOOD OR BLOOD COMPONENT TRANSFUSIOI
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.20-1
DOD-036256
ACLU-RDI 1673 p.40
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
O FRESH FROZEN PLASMA
O PLATELETS (Pool of units)
CRYOPRECIPITATE (Pool of units)
• Rh IMMUNE GLOBULIN
❑ OTHER (Specify)
VOLUME REQUEST \D (If applicable) \
U■... ML
DONOR
ABO A
Rh•cIOS
RECIPIENT
ABO
Rh ? s
UNIT NO.
11111111111101 TRANSFUSION NO.
PATIENT NO.
tiv
below f the
be
I have collected a blood specimen on th named patient, verified the name and ID No. patient and verified the specimen tube label correct.
DIAG RATIVE PROCED
CROSSMATCH
ci)
PREVIOUS RECORD CHECK:
RECORD NO RECORD
TIME/DATE COMPLETE /INTERRUPTED
310c 3 t 1
/AO
BLOOD . OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
NSF47§40-G0-634-4158 518-123
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
REMARKS:
i q to 3to
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
CROSSMATCH
DATE REQUESTED
-31 (-1'03 DATE AND H01111 REQUIRED
Itc5ik V KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN
NA CROSSMATCH NOT REQ UIRED FOR THE COMPONE
REMARKS:
03,Nov o3 SECTION III - RECORD OF TRANSFUSION
REQUESTING PHYSICIAN (Print)
SIGNATURE OF VERIF
VERIFIED
I oc110 TIME VERIFIED
18
IDENTIFICATION 4::).S" (\.) I have examined the Blood Component container
information identi fying the container with t The recipient is the same perso
1/4.42on the patient identif
VERIFI
label and this form and I find all nt matches item by item. ent Transfusion Form and
AMOUNT GICiE
ML ION
ONE 0 SUSPECTED
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Fitter Set, and I.V. Solutions to the Blood Bank.
PU SE BLOOD PR SSURE
DESCRIPTION OF REACTION
URTICARIA LI CHILL FEVER 0 PAIN
OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
KNNO 0 YES (Spec,
it,SIGNA DATE OF TRANSFUSION
31 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first
rate; hospital or medical facility)
MEDCOM - 22681
DOD-036257
ACLU-RDI 1673 p.41
COMPONENT REQUESTED (Check one)
N.X,„.....RED BLOOD CELLS
U FRESH FROZEN PLASMA
• PLATELETS (Pool of units)
• CRYOPRECIPITATE (Pool of units)
• Rh IMMUNE GLOBULIN
OTHER (Specify)
DATE 31 .O cr 0_3
518-124 NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION MEDICAL RECORD
SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
CROSSMATCH
DATEREQUESTED .
VIArC A.
DATE AND HO R REQUIRED •• KNOWN ANTIBODY FORMATI ∎ N/TRANSFUSION REACTION (Specify)
VOLUME REQUESTED (If applicable)
ML
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 r correct.
SIGNATURE OF VERIFIER
REQUESTING PHYSICIAN (Print)
DIA E PROCEDURE
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
DATE RIFIED
TIME VERIFIED
ACC) \-D.-) 1
SECTION II - PRE-TRANSFUSION TESTING UNIT NO. TRANSFUSION NO.
ANTIBODY SCREEN
TEST INTERPRETATION
CROSSMATCH
PREVIOUS RECORD CHECK:
ag. RECORD n NO RECORD
RMING TEST
CROSSMATCH NOT REQUIRED FOR THE COMPONENT R
REMARKS:
e 3 Nov 03
PATIENT NO.
RECIPIENT
ABO
Rh
DONOR
ARO A Rh po-5
SECTION III - RECORD OF TRANSFUSION PRE-TRANSFUSION DATA
INSPECT TIME/DoECOMPLETED4112 UPTED
2
PT(E.47 BLOOD PqSSt.t E by!, AT (Ho
ON (Date)
OcT o3 ID. IFICATION
3( TEMPERATURE
ction is suspected—IMMEDIATELY:
POST-TRANSFUSION DATA
REACT
ONE SUSPECTED
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
ification tag.
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
URTICARIA
CHILL 0 FEVER
PAIN
0 OTHER (Specify)
0TH • DIFFICULTIES (Equipment, clots, etc.)
NO 0 YES (Specify)
AivicITTpIVEN
ML
DAT
PATIENT IDENTIFICATIO
NAT RE
TIME STARTED €.2.,., 740
M(1)V?
(9)Lt')H MEDCOM - 22682
2N,
EMBOSSER (For typed or written entries give: Name—Last, fi rate; or medical facility)
OVE
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
Medical Record Copy
WARD) C u
DOD-036258
ACLU-RDI 1673 p.42
DIA
ABO
Rh FO5
DONOR
518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION COMPONENT REQUESTED (Check one)
.RED RED BLOOD CELLS
FRESH FROZEN PLASMA
• PLATELETS (Pool of units)
• CRYOPRECIPITATE (Pool of units)
• Rh IMMUNE GLOBULIN
OTHER (Specify)
VOLUME REQUESTED (If applicable)
ML
REMARKS:
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
• TYPE AND SCREEN
• CROSSMATCH
DATE REQUESTED
03 -3 DATE AND HOUR REQUIRED
N vv KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
REQUESTING PHYSICIAN (Print)
I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.
SIGNATURE OF VERIFIER
TIME yERIFIED
D
vcD \c9.0
SECTION II - PRE-TRANSFUSION TESTING TRANSFUSION NO.
PATIENT NO.
RECIPIENT
ABO
Rh po5
PREVIOUS RECORD CHECK:
RECORD 0 NO RECORD
I SPIP n CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ
REMARKS:
ex :3 Nov 0
PRETATION
CROSSMATCH
TEST INTER
ANTIBODY SCREEN
IN C,6-fylp SIGN PERFORMING TEST
DATE 31 ocr bj
SECTION III - RECORD OF TRANSFUSION
INSP TIME/DATE COMPLETED/INTERRUPTED
Mut oo :ic) AMOUNT GIVEN
ML
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.
1
REACTION TEMPERATURE
77 NONE 0 SUSPECTED
If re 'on is suspected—IMMEDI TELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
▪ URTICARIA El CHILL 0 FEVER 0 PAIN
OTHER (Specify)
ON (Date) 3 bc_fi- PUr VRES SURE
6 1 1)2._
TEMP.
FellCoV
DATE OF TptQNSWSIO
'1.7 i I) (4-
IBP (°1/,&/S7
OTHER DIFFICULTIES (Equipment, clots, etc.)
O NO YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
TIME STAprp
I PULSE
PATIENT IDENTIFICATION—USE EMBOSSER For typed or written entries give: Name—Last, first, midd e; grade: rank; rate: hospital or medical facility)
11111PN (c 11 MEDCOM - 22683
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 2014.202-1
MPflirtal Rpr.orri C",nnv
kit
DOD-036259
ACLU-RDI 1673 p.43
DATE OF TRANSFUSION TIME STARTED
DOD-036260
BP PULSE
eme MEDCOM - 22684
518-124
MEDICAL RECORD I BLOOD OR BLOOD COMPONENT TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
RECIPIENT
A p o s
ABO
Rh
❑ NO
PERFOR
RECORD
MIN ST
DATE /A6 DONOR
ABO i1
AMOUNT GIVEN
UNIT NO. ousai TRANSFUSION NO.
PATIENT NO. 11
X? gAILA"
TEST INTERPRETATION
IQ! RECORD
SI
PREVIOUS RECORD CHECK:
SECTION III - RECORD OF TRANSFUSION
TIME/DATE COMPLETED/INTERRUPTED
ANTIBODY SCREEN CROSSMATCH
(0' ❑ CROSSMATCH NOT REQUIRED FOR THE COMPONEN
REMARKS:
Af 4
Rh
NSN 7540-00-634-4159
SECTION I - REQUISITION
:;OMPONE IT REQUESTED (Check one)
ED BLOOD CELLS
❑ FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN
00.---tiROSSMATCH
REQUESTING PHYSICIAN (Print)
DIAL E PROCED (--
❑ CRYOPRECIPITATE (Pool of DATE REQUVAD
Y1 v o L.) 0 '--'
I have collecte ood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be
correct.
Ei Rh IMMUNE GLOBULIN
❑ OTHER (Specify)
DATE AND HOUR REQUIRED
rs A— j VOLUME REQUESTED (If aptelic
Lik/P
)
ML
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
SIGNATU E VERIFIER C..„ t'D -." N.
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
DATE V ■ 1
HEMOLYTIC DISEASE OF NEWBORN? TIME V r ED
SECTION II - PRE-TRANSFUSION TESTING
ML
REACTION
NONE ❑ SUSPECTED
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Procedures.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER (Specify)
./
ER DIFFICULTIES (Equipment, clots, etc.)
NO ❑ YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
AT (Hour) ON (Date)
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)
SEX
"Thitcki
P TEMP.
TEMPERATURE PULSE BLOOD PRESSURE
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.
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record STANDARD FORM 518 (REV. 9-921 Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
Medical Record Copy
ACLU-RDI 1673 p.44
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
CROSSMATCH
DONOR
ABO
Rh
NSN 7540-00-634-4159 518-124
SECTION I - REQUISITION
units)
units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)
TYPE AND SCREEN
CROSSMATCH
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
❑ PLATELETS (Pool of
❑ CRYOPRECIPITATE (Pool of DATE REQUESTED
❑ Rh IMMUNE GLOBULIN
OTHER (Specify)
DATE AND HOUR REQUIRED
VOLUME REQUESTED (If applicable)
ML
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
DATE GIVEN: RhIG TREATMENT?
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
REQU YSICIAN (Print)
DIAL OPERATIVE PROCEDURE
6.51-u 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.
ySIGNATURE OF VERX
Q,
0, jot?) tp"S
DATE VERIFI
TEST INTERPRETATION TRANSFUSION NO.
ANTIBODY SCREEN
PREVIOUS RECORD CHECK:
RECORD ❑ NO RECORD
RFORMING TEST PATIENT NO.
UNIT NO.
RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT RE ES f I DATE )NOV REMARKS:
es. 3 go, 03
ABO
Rh poS
--
PRE-TRANSFUSION DATA
- - -- - POST-TRANSFUSION DATA
INSP AMOUNT GIVEN
ML
TIME/DATE COMPLETED/INTERRUPTED
REACTION
❑ NONE ❑ SUSPECTED
TEMPERATURE PULSE BLOOD PRESSURE
AT (Ho ON (Date) 1 ked 0 5
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and
on the patient identification tag.
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1st VERIFIER (Signature DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
❑ NO ❑ YES (Specify)
TEMP. I PULSE IBP SIGNATURE OF PERSON NOTING ABOVE
DATE OF TRANSFUSION TIME STARTED
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)
SEX WI_ \ c.... L.i. )
N(C)--'1
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22685 Medical Record Copy
DOD-036261
ACLU-RDI 1673 p.45
TRANSFUSION NO.
PATIENT NO.
TEST INTER PRETATION
CROSSMATCH
CD flip
PREVIOUS RECORD CHECK:
RECORD ❑ NO RECORD
FOR MING T
UNIT NO.
ANTIBODY SCREEN
NA RECIPIENT
ABO
Rh r,
❑ CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ
REMARKS:
31140, D'3
DATE /A/OV05 DONOR
ABO
Rh poi
518-124
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one)
R ED BLOOD CELLS
❑ SH FROZEN PLASMA
❑ PLATELETS (Pool of units)
units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
❑ TYPE AND SCREEN
9CROSSMATCH
REQUESTING PHYSICIAN (Print)
DI OPERATIVEPROC URE
WillaftiP 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.
❑ CRYOPRECIPITATE (Pool of DATE `QUESTED
V) LJ C) -"Z> ❑ Rh IMMUNE GLOBULIN
❑ OTHER (Specii) DATE AND HOUR REQUIRED
SZ >4- -/--- VOLUME REtUEFED (If appicable)
ik Y- I. - ML
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
SIGN TU 0 VERIFIER
-V— QA.17' ( ?
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
DATE VERI 4r- / )09
HEMOLYTIC DISEASE OF NEWBORN? TIME VERI
SECTION II - PRE-TRANSFUSION TESTING
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
INSPECTED AND ISSUED BY (Signature)
our) .. e
AMOUNT GIVEN
ML
TIME/DATE COMPLETED/INTERRUPTED
REACTION
NONE ❑ SUSPECTED
TEMPERATURE PULSE BLOOD PRESSURE
ON (Date) 1 4/0.10.3
IDENTIFICATION
I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.
If reaction is suspected—IMMEDIATELY:
1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1st VERIFIER Si
2nd
SE
JL_t
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
❑ OTHER (Specify)
BP
OTHER DIFFICULTIES (Equipment, clots, etc.) ❑ NO ❑ YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
DATE OF TR SION TIME STARTED
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank;
rate; hospital or medical facility)_ SEX WAR
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMA 141 CFR) 201-9.202-1
MEDCOM - 22686 Medical Record Copy
rn
DOD-036262
ACLU-RDI 1673 p.46
518-124
MEDICAL RECORD
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS Ir FRESH FROZEN PLASMA
❑ PLATELETS (Pool of
❑CRYOPRECIPITATE
(Pool of
❑Rh IMMUNE GLOBULIN
OTHER (Specify)
VOLUME REQUESTED (If applicable)
11 --
REMARKS:
ML
units)
units)
TRANSFUSION NO,
UNIT NO.
ATIENT NO.
RECIPIENTp\
16
DONOR
ABO
Rh
0. ABO
Rh
CROSSMATCH FOR THE COMPONENT RE
ROSSMATCH NOT REQUIRE
REMARKS:
•
I have collected a blood specimen on e below
named patient, verified the name and ID No of the patient and verified the specimen tube label to be
correct.
SIGNATURE OF VERIFIER
r 5 D •TE
PREVIOUS RECORD CHECK: NO RECORD
RECORD
DATE
FORMIN
o5
WARD
T tit
BLOOD OR BLOOD COMPONENT TRANSF
Medical Record
STANDARD FORM 518 (REV. 9-924 prescribed by GSA/ICMR, FIRMR (1 CFR) 2(
Medical Record Copy
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood
Cell REQUESTING PHYSICIAN (Print)
Products are requested.)
DIAGN ERATIVE PROCEDURE
LL..) TYPE AND SCREEN
CROSSMATCH
DATE REQ9ESTED n 0 3
IV 0 LI
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)
DATE AND HOUR REr54._ -- 1
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
ANTIBODY SCREEN
SECTION 11 – PRE-TRANSFUSION TESTING
TEST INTERPRETATION CROSSMATCH
CPT
SECTION III –
RECORD OF TRANSFUSION POST-TRANSFUSION DATA
TIME/DATE COMPLETED/INTERRUPTED
BLOOD PRESSUR PRE-TRANSFUSION DATA
ignature) INSP
r
--) AT (Hou
L I have examined the Blood Component container label and thisent
form and I find all IDENTIFICATION
LS information identifying the cornontainer
named on with the
this Blood Comp
intended recipi matches item by item.
/Th The recipient is the same pes
onent Transfusion Form and
k_i on the patient identification tag.
C---)
BP
If reaction is suspected— IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.
2.Notify Physician and Transfusion Service.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Ba 3.
Follow Transfusion Reaction Procedures.
DESCRIPTION OF REACTION
LL 0 FEVER PAIN
❑ URTICARIA ❑
❑- OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
❑NO
0 YES (Specify)
SIGNATURE OF PERSON NOTING ABOVE
1st V
PULSE
TEMP. TIME STARTED
DATE OF TRANSFUSION
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank:
rate; hospital or medical facility)
MEDCOM - 22687 .4711111ae
DOD-036263
ACLU-RDI 1673 p.47
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
OW N ,c..Y1
LI DATE OF ORDER TIME OF ORDER
'231 Opt 2.-/ -5' 0 HOURS
LIST TIM ORDER
NOTED AND SIGN
410
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NURSING UNIT
TLuu
ROOM NO. BED 11W 0..
a.,_t _ ,_e_.( ...c....._....—e-' Ar Lei/ _ /k/jC)
PATIENT IDENTIFICATION
ii.
Il
ill 111
9 ATE OF ORDER TIME OF ORDER
HOURS
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BED NO. kittd-0 "- • :. 1,, V 08
1112111111M .36,c I, PATIENT IDENTIFICATION 'i ATE OF ORDER TIME OF ORDER
HOURS
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NURSING UNIT ROOM NO. BED ' -..---
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PATIENT IDENTIFICATION
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DATE OF ORDER TIME OF ORDER
/ - HOURS
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/6..,
DA 1FAOPRPM79 4256 REPLACES EDITION OF 1
Mc) MEDCOM - 22688
DOD-036264
ACLU-RDI 1673 p.48
PATIENT IDENTIFICATION HOURS
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
THE DR SHALL REORD DATE, TIME AND IGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM OCTO
IS USED, WRITE
C PROBLEM NUMBER NCO UMN INDICATED BY ARROW BELOW. LI TI
ORDER NOTED AND
SIGN
DATE OF ORDER TIME OF ORDER
BED NO. URSING UNIT
3--
rs
PATIENT IDENTIFICATION
ROOM NO.
PATIENT IDENTIFICATION
et
NURSING UNIT BED NO.
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
OF ORDER
e_7 HOURS
ROOM NO.
DA, 4256 , A., 79
NURSING UNIT BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY SE :USED.
MEDCOM - 22689
DOD-036265
ACLU-RDI 1673 p.49
RS
DATE1 OF R(DNEIR
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.
TIME OF ORDER
01 1.103 0 3 (.304`
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION DATE OF ORDER
LIST TIME ORDER
NOTED AND SIGN
NURSING UNIT ROOM NO. D NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
NURSING UNIT ROOM NO.
DA , FAOPRRM 79 4256
BED NO.
REPLACES EDITION OF 1 Jul. 77. WHICH MAY BE. USED.
MEDCOM - 22690
DOD-036266
ACLU-RDI 1673 p.50
OURS
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.
TIME OF ORDER
10C-5
IST TIME nianF R
NOTED A SIGN
NURSING UNI ROOM NO. BED NO.
cA)
V'
ft
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
NURSING UNI ROOM NO. BED NO.
PATIENT IDEM IFICATION DATE OF ORDER TIME OF ORDER
HOURS
A/W 76,6---
BED NO.
DATE OF ORDER TIME OF ORDER
db CS P`9t)
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION HOURS
5-60 7'ltz 71-p
6.4z
(
0-ear ,mss NURSING UNIT ROOM NO. BED NO.
DA IFA7:79 4256 REPLACES EDITION OF 1 JU
MEDCOM - 22691
DATIOF DER
ezv PATIENT IDENTIFICATION
CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOD-036267
ACLU-RDI 1673 p.51
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED M SYSTEM IS USED, WRITE PROBLEM NUMB R IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER LIST TIME
ORDER NOTED ANO
SIGN
BED NO. ROOM NO. NURSING UNIT
PATIENT IDENTIFICATION DATE OF ORDER
°If"
1 S
NURSING UNIT ROOM NO. BED NO.
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIF CATION DATE
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
0,110)0 ,q 520
k-ko fneC1\ TY\ \°C)
TIME OF ORDER
I HOURS
ftry-P-1.- %, •
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DAFOR1 APRM 79 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
MEDCOM - 22692
DOD-036268
ACLU-RDI 1673 p.52
AT ION PATIENT IDENTIFIC
( 1•.416 411.111
ATION PATIENT IDENTIFIC
ED. REPLACES EDITION OF 1 JUL 77. WHICH MAY BE
DA 1 APR79 4256
CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM 0TENTED MEDICAL RECORD ITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
TION
HOURS
THE DOCTOR SHALL SYSTEM IS USED. WR
PATIENT IDENTIFICA
NURSING UNIT
DATE OF ORDER TIME OF ORDER
ROOM NO. BED NO.
ot t■loti 03
rI
1 DATE OF ORDER TIME OF ORDER
HOURS
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6/U
LIST TIME ORDER
NOS AND
NURSING UNIT
1 '\ PATIENT IDENTIFIC
ROOM NO. BED NO
NkAci AT ION
HOURS
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NURSING UNIT ROOM NO. BED NO.
DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
MEDCOM - 22693
DATE OF ORDER
DOD-036269
ACLU-RDI 1673 p.53
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES -CUAF-/z9
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MI 0 ---T ?ELATIONSHIP TO SPONSOR SPONSORS NAME SPONSOR'S ID NUMBER
(SSN or Other) LAST F IRST MI
DEPART.iSERVICE HOSPITAL OR MEDICAL 6ACILITY RECORDS MAINTAINED AT
ATIENT'S IDENTIFICATION: 1For typed or written enrries, give: Name - last, first, rnicdle;
ID No or SSN; Sex; Dare of Birth; Rank/Grade,
REGISTER NO. WARD NO.
110 PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.2030)/00/
USAPA V1.00
MEDCOM - 22694
DOD-036270
ACLU-RDI 1673 p.54
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
'''Llite. HOURS NOTED
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LIST TIME ORDER
AND SIGN
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'. C:
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
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PATIENT IDENTIFICATIO DATE OF ORDER TIME OF ORDER
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DA 1FXRP79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 22695
DOD-036271
ACLU-RDI 1673 p.55
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
For use of this form, see AR 40407; Surgeon General. Mo, Yr. 2003
the proponent agency Is the Office of The
VERIFY BY INITIALING ;:0.ANCAStegnighat INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER DATE
CLERK/ RECURRING ACTION, TIM FREQUENCY, E
HR DATE COMPLETED
31 -1-
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ALLERGIES: I. YES 11111 NO PRIMARY DIAGNOSIS:
vei( -IGni0) ef.,A41 cAl rlAvvAAlt) c -v-i-k-- NI
PAGE
ADDITIONAL PAGES IN USE: YES NI NO
NO•
PATIENT IDENTIFICATION: \t/"-'-1/1( 4---e6k,
ACTION TIMES
D 8 9 10 11 12 13 14 15 lib (01\ r-1
USE PENCIL. CIRCLE ACTION TIMES
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAYS USED.
MEDCOM - 22696
DOD-036272
ACLU-RDI 1673 p.56
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION ) Mo Yr 2003
Order
Date Clerk Nurse SINGLE ACTI?NS Date to
be Done Time to be Done Time Done Initials
--- ajiliVA 1 CA-) /CA:1) — _ _ _ Pft 1■, k (1 L.) ;A03 i
- - - -
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alel -11Q0
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Order/ Expir Date
Clerk/ Nurse
PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED
— — — — — — — —
MEDCOM - 22697
USAPA V1.00
DOD-036273
ACLU-RDI 1673 p.57
THERAPEUTIC DOCUMENTATION tee
CARE PLAN (MEDICATIONS)
CLINICAL RECORD the pro nent a ency Is the Of4ice of The Surgeon General. WING EACH ADMI
For use of thls form AR 4G-407 ;
VERIFY BY INITIALJNG
:::: INIIIAL PROPER COLUMN FOLLO
NISTRATION
.....................................................
..........................................
......................... to
DATE NURSE
DOSE. FREQUEN CY lb
a
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ORDER CLERK/ RECURRING MEDICATIONS,
•DATE DISPENSED
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OY ES O NO
PAGE NO.
DISPENSING TIMES
P N IL CIRCLE MED TIM S
111111 (*)
OF I DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 22698
PATIENT IDENTIFICATION:
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
h _Fgr49 4678
DOD-036274
ACLU-RDI 1673 p.58
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
SINGLE ORDER, PRE-OPERATIVES
Data to be Given
Order
Clerk/ Date
Nurse
Or Exp Date Clerk/ Nurse
Time to be Given Time Given Initials
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'U.S. GPO: 1998454-110/95216
DOD-036275
ACLU-RDI 1673 p.59
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use o this form, see AR 40-407: the Proponent agency . is the Office of The Surgeon General.
Mo. Y r.
VERIFY BY INMALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
ORDER DATE
CLERK/ NURSE
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR DATE DISPENSED
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ALLERGIES: YES M NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
- YES El NO
PAGE NO
PATIENT IDENTIFICATION: DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14 .
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA FORM 4678, 1 FEB 79
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
MEDCOM - 22700
DOD-036276
ACLU-RDI 1673 p.60
Verify by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.
Order Date
Clerk/ Nurse
SINGLE ORDER, PRE-OPERATIVES Date to
be Given Tme to be Given
Time Given Ini '
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I1V177AL PROPER COLUMN FOLLOWING ADMINIS7RA N
TIME/DATE DISPENSED
C41) .-.—
USAPA V1.00
MEDCOM - 22701
DOD-036277 ACLU-RDI 1673 p.61
QI Appr 11 Jun 97
ARRIVALSTATUS
REPORT TITLE TRAUMA FLOWSHEET The proponent is Dept of Surgery
a MED COM:
MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-86: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED (Dare)
TIME: ETA: UNIT: TIME U IV x ❑ 02 1/min ❑ C-Spine Immob
Meds: 9eUKN ❑ None 0 Yes:
Allergies: 19(LIKN ❑ None ❑ Yes:
Tetanus: UKN ❑ Current Last Meal/Fluid Intake hrs
LMP:
PHYSICIAN
ue on reverse)
a a a > = <
❑ Tender:
Blood at meatus/vagina: a
LUNGS - ,
BREATH SOUNDS: ❑ Bilat ❑ Equal ❑ Clear
a Absent
Crackles
a a Decreased
Wheezes Ugii
Dopler + Strong + Palpable
RN / 1.-- l
❑ Natural Patient
❑ ETT ❑
❑ Secretions (
❑ Labored 'Unlabored ❑ Absent
TRACHEA: ft Midline ❑ Deviated
13
PULSE: 04Present ❑ Absent
BLEEDING:
HEART TONES: ❑ Clear ❑ Muffled
SKIN: ❑ Warn ❑ Cool ❑ Hot
❑ Pink ❑ Pale ❑ Cyanotic ❑
❑ Dry ❑ Moist ❑ Diaphoretic
ABDOMEN
CHEST SYMMETRY:
a SECONDARY SURVEY.
a a
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN
(AB)rasion
(ANIPlutation kr
(AV)ulsion
Battle's Signs
(BL)eeding
(B)urn
(Dieformity
(Elcchymosis
(Floreign Body
(Hiematoma
(LAC)eration
(P)uncture (W)ound
(Pain)
(S)eatbelt (S)ign
(S)tab (W)ound
(GSW) Gun Shot Wound
GCS: E
V • TIN ❑ Clear ❑ Blood
M
.PUPILS: ❑ Equal ❑ Fixed ❑ React ❑ Dilated
`NECK
RHYTHM: ❑ Regular ❑
PULSES: ❑ Central ❑ Peripheral
PATIENTS IDENTIFICATI (For typed or written entries give: Name--last, first, middle; grade; date; hospital or medical facility)
DEPARTMENT/SERVI
❑ HISTORYIPHYSICAL()rBTLOW CHART
Cs- (01
El OTHER EXAMINATION OR EVALUATION
❑ DIAGNOSTIC STUDIES
1:1 TREATMENT
❑ OTHER (Specify)
U
HEART
❑ Soft ❑ Rigid ❑ Non-Tender
PELVIS
❑ Stable ❑ Unstable ❑
Hems+ / - Prostate: ❑ WNL ❑ Abnl
SPHINCTER TONE: ,
❑ WNL
❑ None
C-Spine Tenderness:
Pain @
JVD: VASCULAR ASSESSMENT
PREPARED BY (Signatur
,54 DATE
.(21
ACLU-RDI 1673 p.62
IVF Urine
NGT NGT
Blood
Other
TOTAL
Other
TOTAL
EBL
0 OTHER
LAB RESULTS INTAKE & OUTPUT CBC: Chem: ,NI,MC AMOUNT'. %INT T
1110 TIME PROCEDURE .SIZE , SITE BY RESULTS
-...■- TIME PROCEDURE ACCOMPANED BY RETURN
/ &;::9 ET
Intubation 5.6
Oral
0 Nasal
Teeth
110"/ _ 0 ETCO2 Change
CI BBS Post Int
0 Post CXR
CT Scan: 0 Contrast
0 Head 0 Abd 0 Pelvis
❑ C-Spine ❑ T/L Spine ❑ Chest
4,(Z
Gastric
Tube 1 , .
,p--) 0 Oral 70
Nasal it"
/ ,,jcz Air 0 Contents
Verified 0
Suction: Y N A-Gram Site:
IV ACCESS &FLUIDS. . TIME . , IW TYPE
— AMT UP , : AMT IN
1 vq.5 Urinary /4, 'f.„--
❑ Meatus
❑ Supra-Publi
PA' 0 Return cc
Home Dip: + •
0 Secured
DPL CI Opened
0 Closed ( 9()1L
0 Grossly: + -
Cell count
Sent@ e t.-.. ib ri c / i 1 I A
Chest
Tube #1 L R
0 Air 0 Blood
❑ Pleuravac—
cm
❑ Autotransfuser
/SA
(-' /. /r
1,72; ' -'
' MEDICATION N: TIME DOSE RTE
MEDICATIONS TIME
._ DOSE RTE
___ TIME DOSE
„, .. ,. • . FITE
Chest
Tube #2 L R 0Air CI Blood
0 Pleuravac cm
0 Autotransfuser
12 Lead Rhythm: Comments •
h fr • r A?/ • , ..,a,,. . ABG SITE' TIME pH pCO 02 1,4,-1 /co 01
1) j ,, . c ....0
/ tc..„ ,..1 • - ,---
( ,f✓2 0
1./C i?
/(4./2
i 87 2)
, . ..., nrA
.
LABS ' )(RAYS i bo - , Lit c:,96 / Ve t=
4 ,-,--,. L /d
?C -̀'''
/0;25
F1/ O 0-stick 0 SHct 0 Chest Initial
❑ 0-stick 0 SHct . ❑ Chest Post ET A---/j/
;-START, , .... ......:
CVO AV
BLOOD PRODUCTS .': (irate MT ill
'CBC ai Chem )0 PT/PTT
0 ETCH Crt&S O&C x
❑ Chest Post CT
0 C-Spine
0 Tox Screen Pelvis
CI UA 0 HCG CI
0 OTHER ,■.
-: ,..grrtvi: TRAUMA TEAM
0..,. NAM i ,-
ARRIVAL . ,
irl S N
VALUABLES & CLOTHING
s A' ,-. -% :•f D Phys
None Found
urgeon Given to Patient
,nesth Given to Family
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
0 Home
Admitted
Report
Time
-
Other: See Nursing Notes •
DISPOSITION 0
X-Ray
RT
Ortho to
Neuro Called to
Chaplain Transferred
Accompanied BY
MEDCOM 22703 0 Wheelchair I
DOD-036279
ACLU-RDI 1673 p.63
Recta/ Temp:
7
RR
7 1
SAO2 F102 MODE
GCS:
E V M
EYE OPENING ; -
GLASGOW COMA
REBLE RESPONSE
SCALE
MOTOR RESPONSE TIME BP HR RHY
4 -Spontaneous 5 - Oriented
4 - Contused
6 - Obeys Commands
5 - Localizes
/ VC , —..Ki__ ie/ii///9"/S S --
3 - To Voice / I( /c99La, /,-- 2 - To Pain 3 - !nape Words
Pain
4 - Withdraws to Pain /e3= c ocv6f /3i= 1 - None 2 - Incomp Speech 3 - Flexion to Pain / y /Wicri /3 e/
1 - None 2 - Extension to Pain i '.i'12 - / .57 id 1 - None
/ TIME PROCEDURE: PERFORMED By /
0 Backboard Removed BY: /
❑ Downgraded BY: /
NOTES
/
/
/ .
/
/
/
/
/
.
(1
_ flimgmaanr- t I'
A. ffiginaingl -----
ib Awe .. h.-. -■ 4--- t.G) '
IrMannakteillidi aftLi1111131- Ye INIAMMILIMMIEMPAR MOM • MC.
4.1■' A `..■Kank•Ml aWr riMiNteraMbertallnieSMenr
MEDCOM - 22704
DOD-036280
ACLU-RDI 1673 p.64
PAS - 1`..\,-kcc..; c_xo
)
OTSG APPROVED (Date) QA Appr 8Mar 89
INTILAS
)(0 -2
EDICAL RECORD -SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General
REPORT TITLE
PAGE 1 OF 4
INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIFT ASSESSMENT
.S9, I INTI An-vrn
RESPIRATION PATTERN
BREATH SOUNDS
SECRETIONS
-xe-ViTet-?;.F-).7 12. •
16NE • nAcItte07kca r
Mal. a - c"
N
E
U
R
O
R E S P
R A
O. R
S
N
LOCATION
CONDITION
E
ABDOMEN A S T
BOWEL SOUNDS
R
URINE
COLOR/CLARITY U
CARDIACRHYTHM
•
Cr - Creatinine
LEGEND Fi o - Fraction of inspired 02
Ft 02 - Bicarbonate
PREPARED BY (Signature & die)
PATIENTS INDICATIONS (For typed or written entries give: Name -
middle; grade; date; hospital or medical facility)
- CID-C eVNA \A-3 C-krf 2' I tlp Itt)C1(.,
Q•cetc14
PCO2 - PRESSURE OF ARTRIAL CO2
PEEP - Positive end Expiratory Pressure
CP - Intracranial Pressure S/A - Fractional
TRACH Tracheostomy
SAI - Saturation
(Continue on reverse) DEPARTMENT/SERVICE/CINC
El HISTORY/PHYSICAL ID FLOW CHART
10,{ j DATE& (),....r03
❑ OTHER EXAMINATION El OTHER (Specify) OR EVALUATION
❑ DIGNOSTIC STUDIES
❑ TRETMENT
C A .
A S
U L A R.
`‘. OCT
A 2-e0 &D 90—b
DA FORM 4700 1 MAY78
Proponent Dept of Nurs WAMC OP 375 (Redesignated) MEDCOM - 22705 1 APR 90 (HSXC - NU)
Last, First,
DOD-036281
PUPLIS
SENSORIUM
TIME
I INTILAS
vyNx-N&SLIA s_Aa\-(= c)(2.— FlAksEaks.
(ZIL AG roo PAD LAI "To Rc0.. Pimp
COLOR
INTEGRITY
ACLU-RDI 1673 p.65
DRAINS
N\CAS:2Q.,
TOTALS
SOO st)C
PAGE 2 OF 4 DATE DX
I 02- 03 0 6 TIME ormatmegmram.
BP Cuff
smeatiomae 15/4mummul NI
EIIMILI PANIIIIIIIIIIIE III Pulse
EMICSIMMEMS 'TT cl 1 . Mini KIM= fg. EIRE=MI=
IMPIIEWIIIIII le Emu ailm
immlimm ENtimo
IMn 96 com maw
ILIMOIRMIEILICII II
man toomptraran ii
min..0- mairmirs SEEM Mk
=IIII •LJVNIMMMFA17:1a MI MEM
I 14 15
HOSPITAL DAY
BP Arterial line
Temperature
Respiratory Rate
8 ° T
ACLU-RDI 1673 p.66
D.
G
ACUITY LEVEL CLASSIFICATION . 0
PAGE 3 OF 4 POST-OP bAY
21 22 23 TIME 1 19 20
MODE
F1 0 2
TV
RATE
PEEP
A A A PH
PCO 2 T
PO 2
HCO 3
SAT
BASE
TIME
18 19 20 21 22 23 8 ° 17
,ZZ
TIME TIME
SKIN CARE
FOLEY CARE
TRACH CARE
ROM EXERCISES
WT Yesterday wt Today
INTAKE
IV
Po
TOTAL TOTAL BAP ANr.F
MEDCOM - 22707
T
U
R
N
rriALs .
(9(()\
S U C
0 N
OUTPUT
Urine:
DOD-036283
ACLU-RDI 1673 p.67
PAGE 1 OF 4
DICAL RECORD -SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General
C
A
Proponent Dept of Nurs
,R
T
R. O ;
BOWEL SOUNDS
E G ABDOMEN
I.
A
As
U
A CARDIACRHYTHM
R. V
s COLOR
0
E SENSORIUM
A
NREPORT TITLE
U
R
0
R E SS BREATH SOUNDS
URINE
V CONDITION
INTEGRITY
N
LOCATION
SECRETIONS
PUPLIS
DA FORM 1 MAY78 4 _ 700
OTSG APPROVED (Date) 8Mar 89
TIME
Qt k 9 ) 1 neo <ii4-rxx.. is,
ccuo.,,,.(t), (I..) tvc- tA- 'Vc-Yt(v5 e- 114-`"
f■-3Lvi d6w,X4-,y?- IA-TAD (c,<
nv..401 7.-
cAr- 414 11?-1/k") ov4--
Piet(M;A-t. 0,5 X10; sum COI
LEGEND
§,.....) • 1-•--v iL
ler it-4_0k relvOsA- brecu
PIrvviN -c; e.f"L-N4 +" 5' r:-11.4A
slraNt-- -sur, Tv-'s30 0 ;
t-R-tA Etc,
0 ce.,<AA,;0,1 5
01.■ vro-A2-68-1-)
`Ar-14 5
pg1k4 1. frivi-\ 6', 40 -•
.S4
Cr - Creatinine
F, 0 - Fraction of inspired 02
F, 02 - Bicarbonate
)
INTIL
Intracranial Pressure PCO 2 - PRESSURE OF ARTRIAL CO,
PEEP - Positive end Expiratory Pressure
StAve).sRo&dt%, cr-fkroicAef" • S'etrz
,txsz_t Voi4F-76 Si F ka7 Att. crig-r7 z le-2_ s e
S/A - Fractional SAI - Saturation
TRACH - Tracheostomy
DT- 61E) t`$
c_ct, -A -Vv-r., cocc% • %,...dc,cs4::‘.
Itzegirff—Az71 --kirp -s,==oszA•-) • (T)
INTILWA
'F•ccerN u9Rte ICYN•c- c---A 6, 1 v-t._ cc:AT 6,0V;
—
E:TV4 S- 1
sue,46,603fr" neft\rfflis
%-so,o2
IFDoo
(Continue on reverse)
cif) ` -\ex.r•i=L — v-37%)
--ck(A-ZQJ`kkti
I Q) ( I DATE/ too 1. 03
❑ ❑ H 1 STORY/PHYSICAL ❑ FLOW CHART
❑ OTHER EXAMINATION ❑ OTHER (specify) OR EVALUATION
❑ DIGNOSTIC STUDIES
❑ TRETMENT
,", WAMC OP 375 (Redesignated) MEDCOM - 22708 1 APR 90 (HSXC - NU)
INTENSIVE CARE NURSING FLOW SHEET— (q1C\ r- Z-
ipINITIAL SSMENT
RESPIRATION PATTERN
COLOR/CLARITY
DEPARTMENT/SERVICE/CINC PATIENTS INDICATIONS (For typed or written entries give: Name --- Last, First, middle; grade; date; hospital or medical facility)
PREPARED BY (Signature & Title)
11111111P
DOD-036284
ACLU-RDI 1673 p.68
4Z
d PAGE 2 OF 4 • •
MUM
4
BP Arterial line
BP Cuff
Temperature
Pulse
Respiratory Rate
TIME
MEM
11111111111MEN
MOW t+ IMISIMMIMEN allaimmum
Mum 1.4
ra 6'6 a Itanammoinal i ■■i ■■emurimul imanorms cis mu 9 Ivy W? iL1-0 13(- Ewan I 1+ V4 11111EIMIMMIrsin IIMINIMIONME811111 v MI v MIMI
sl) rummer innouldr 5 \ minminnalia mumnimmmani
•
Emma= , 2atirtm Armintrmisraninui 8.
tw PAM= ,
R
ST)
ll 2
4:0 4o Co q_u a) —
tis 11)).-
STOOL
- 0 DRAINS
zso
)
MEDCOM - 22709
DOD-036285
ACLU-RDI 1673 p.69
POST- ACUITY LEVEL CLASSIFICATION
PAGE 3 OF 4
B r PEEP
A pH
PCO 2
p02 B 0
HCO3
SAT G
t10
TOTAL TOTAL
BALANCE
TIME
MODE
F.,0 2
TV D A RATE
I
BASE
TIME
/CO
67
CLUCOSE
Na/K
Cl/CO 2
R A BUN/Cr
0 .
A T WBC/PLATELET
WT Yesterday
INTAKE
IV
wt Today
OUTPUT
Urine:
C
Y
A
TIME
MOUTH CARE ■
0
*, BATCH
1111
T SKIN CARE L
FOLEY CARE
V TRACH CARE
.N ROM EXERCISES
;P F •
24 ° 180' TOTALS
ISMPAPIMINIPIMI
riVAIMMILITIBIP" raiPWAINIPSIMPRI PaP1/011921/Mill T A• Hct/Hgb
TIME
U
R
S U C
0 N
INITLALS
8 °T
Po
7 4 9q ILro ar5
4
Of —L. c1 -co
0
•
035 20 SIMV Sir
fa cJD
g 110
goo iy- 10
7.15
' 4
.30
goo
1,A6 117 tO 2 1
2:
Sb 10 11 -6-
• S( 1b1f
S-D
7
21
ty3 t-0
ACLU-RDI 1673 p.70
3'
1
Ste' cr %\c,
PAGE 1 OF 4
'MEDICAL RECORD-SliPPLV.aENTp4L D6TA qr.:" For•Ziee o(this form seeHIAR 4(frA66; the i_propqnpnt.agpncy:i64The:Qffice , of The Surgeoin Ggrferal REPORT TITLE
OTSG APPROVED (Dale) QA Appr 8Mar 89 INTENSIVE CARE NURSING FLOW SHEEJ.----- (9(-6'- ?_
i.,,,,, , INTILA
INITIAL SHIFT SMENT
SHIFT IN TILAS
,riz.,eGe-re.*€
PUPLIS
SENSORIUM
TIME t f4CNCr) I 1NTILA
2.* L•c=cw--
IfyiVe.c
N
E
R
0
R E S P
A T 0 R Y
RESPIRATION PATTERN
BREATH SOUNDS
SECRETIONS
COLOR
INTEGRITY
B 68 o-x) ..ike 4_6(t.t d271 G 4-e4164-4?
Of-e7-/-iAz.e.,Leltn--1) t
Ge C ) 44-47-4"(
kcif-x-t-.0.:_44etekiv4 pi 6,_-LGA
zve /7-5-
S
N
LOCTION
CONDITION
• PO
VU-Vt9c: v5-1Q c _. s:,t(
ABDOMEN
BOWEL SOUNDS
S.
G A S
R 0
C A •
-:•R'
•0 '• V.
• • C
A:
TV ,lis ,le /5 e-/-4.4 SP 4-e,-e
64-41L1 / 7>
LI3,eitc. cz.f_. /e
Cr - Creatinine Fi 0 - Fraction of inspired 0 2
Ei 0 2 - Bicarbonate
URINE
COLOR/CLARITY
CARDIACRHYTHM
ICP - Intracranial Pressure PCO, - PRESSURE OF ARTRIAL CO,
PEEP - Positive end Expiratory Pressure
V -es6 4,4
\ooPkii) ̂s S/A - Fractional SAI - Saturation TRACH - tracheostomy
fro, s-
LEGEND
PREPARED BY (Signature & Title)
DA 1 Fr 178 4700 Proponent Dept of Nurs
(Continue on reverse)
I DEPARTMENT/SERVICE/CINC K. 1 DATE (9Alfirst ni/03
❑ HISTORY/PHYSICAL ❑ FLOW CHART
❑ OTHER EXAMINATION ❑ .OTHER (Specify) OR EVALUATION
❑ [AGNOSTIC STUDIES
❑ TRETMENT
WAMC OP 375 (Redesignated) MEDCOM 22711 1 APR 90 (HSXC - NU) -
PATIENTS INDICATIONS (For typed or written entries give: Name - Last, F middle; grade; date; hospital or medical facility)
111./(6)(0-Lf
DOD-036287
ACLU-RDI 1673 p.71
uk"' 0.- - PAGE 2 OF 4
DATE DX
BP Arterial line
Temperature
Pulse
Respiratory Rate 1 40 167 1 .,
q C cIt=0
TOTALS
TOTAL
URINE
OUTPUT
GUIAC
EMESIS
STOOL
DRAINS
TOTALS
MEDCOM - 22712
DOD-036288
ACLU-RDI 1673 p.72
INTAKE
WT Yesterday wt Today
OUTPUT
Iv Urine:
Po
TOTAL TOTAL
BALANCE
INITLALS. ' S IGNATURE
OST- ACUITY LEVEL CL4SSIFICATION
PAGE 3 OF 4
0 Q5
c
og cig z
205 eq.
TIME
ROM EXERCISES
Lei
(61g-2_
;•24!)180 TOTALS
ACLU-RDI 1673 p.73
EMERGENCY RESUSCITATION RECORD - PART 1 For use of this form see MEDCOM Cir 40-5
Complete this report within 2 hours following the arrest/event. Place the original in the patient's record and provide a copy to the Nursing Supervisor.
1. DATE: 2. LOCATION
la41CU
❑ DIAGNOSTIC
OF
❑
RESUSCITATION
SICU ❑ CCU
I PROCEDURE
CLINIC:
EVENT
❑ NICU U ED • AREA:
PACU N OR ❑ WARD: 3. WITNESSED ARREST?
EYES • NO • UNKNOWN
• MONITORED AT ONSET? • OUTPATIENT
❑ OTHER (Specify): 35\-YES N NO
4. INTERVENTIONS ( ,/ - IN PLACE
1F:"PT/ Access
,—ndotrachael Tube
rtFMechanical Ventilation
,'Arterial Line
(4-5-Central Venous Line
❑ Pulmonary Artery Catheter
--lagasogastric Tube
AT START OF ARREST) I / - INSERTED DURING ARREST) COMMENTS
• Time: •
• • Time: •
• • Time: •
/ • Time: •
• Time: •
• Time: -
N Time: •
❑ Time: • Ili Pacing Device (Specify type):
❑ Time: - • Implantable Defibrillator / Cardioverter
❑ Other (Specify): • Time: •
6. IMMEDIATE CAUSE OF ARREST I EVENT (Check one)
❑ Lethal Arrhythmias
❑ Hypotension
❑ Respiratory Depression
❑ YES
6. RESUSCITATION
(Check all that
Chest Compressions
Defibrillation
Airway Management
(Check one)
False alarm/arrest
Do not attempt
Considered futile
ATTEMPTED
were used)
(BLS / ALS not needed)
resuscitation (DNAR)
7. INITIAL CONDITION
CONSCIOUS
• • Yes lailo
BREATHING
—Yes ❑ No
PULSE
7'es ❑ No
Site:
• •
❑ NO • Metabolic
❑ Myocardial Infarction or Ischemia
❑ Unknown
Other: rr ❑ (5
• ❑
❑ • Found dead
8. INITIAL RHYTHM p5 (J ►
(ROSC)
Never achieved
Rhythm
min
9. EVENT TIMES climes are required European Resuscitation
Collapse / Arrest
CPR Started:
1st Defibrillation:
Airway Achieved:
1st Dose Epinephrine:
Code Team Called:
❑ Yes
Code Team Arrived:
to calculate the American Heart Ass n and Council in-hospital chain of survIvel.1
HOUR MIN
Onset: •
10. GLASGOW COMA SCALE )Post-resuscitation)
Circle appropriate scores, then total.
EYE OPENING
4 - Spontaneously
3 - To voice
2 - To pain
1 - No response
VERBAL RESPONSE
• Ventricular Fibrillation ❑ Perfusing
❑ Ventricular Tachycardia ❑ Bradycardia
❑ Pulseless Electrical Activity ❑ Asystole
RETURN OF SPONTANEOUS CIRCULATION
. ❑ ❑ Returned at: '
• '
:
• Unsustained ROSC: ❑ < 20 min
CPR STOPPED AT: • .
• > 20 ' ' • • 5 - Oriented, converses
4 - Disoriented, converses
3 - Inappropriate responses
2 • Incomprehensible sounds
1 - No response
WHY: • ROSC • DNAR
Silo Time: 600: I♦ Considered futile ❑ Death
PATIENT DISPOSITION:
MOTOR RESPONSE
6 - Obeys verbal commands
5 - Localizes painful stimulus
4 - Withdraws from pain stimulus
3 - Flexion, decorticate posturiggt
2 • Extension, decerebrate
posturing
1 - No movement
SCORE:
■ Yes • No Time: (vo :
PATIENT IDENTIFICATION
EPko ,
W4 Or°! --k
AGE:
GENDER:
HEIGHT (in):
WEIGHT (lbs):
MEDCOM FORM 679-R (TEST) (MCHO) AUG 99
PREVIOUS EDITIONS ARE OBSOLETE
MC V2.00
MEDCOM - 22714
DOD-036290
ACLU-RDI 1673 p.74
•
EMERGENCY RESUSCITATION RESUSCITATION RECORD - PART 2 FPLC) TIME (Hr/Min): if 7.-C ji LS- 113r. 24-71i 7--61 0
BLOOD PRESSURE 64/33 6 Y 2 3 I C3/S-7' 16-ire 175 1 HEART RATE (* = CPR) /4,e) Mt/ 12---e I 11 (24'
RHYTHM Pi/Jr ti5i/ r S 1- s r S r
PULSE PALPABLE (Y/N) Y '/ y y DEFIBRILLATION (Joules: 200, 300, 360)
____ —,.• —...- --
CARDIOVERSION (Joules: 60, 100, 200, 300, 360) ...._,. to 1/.
j.../ ....._
PACING PERFORMED (I) 200 30 45 36-o --
RESPIRATIONS 1(, fil /4 tv I< —
cc .'z >-
BAGGED w / l00% o2 ( ✓ ) '---
INTUBATED (V) %-"' L,
MASK (Specify type) •—■ --
% OXYGEN / 0 ° JO 0 / 0-0 fOO /0 0
02 SATS I17 is- ??-- qg Jo c IE
w 0
— L
I ci I—
— 0
Z 0
EPINEPHRINE (1 mg - IV I ET tube)
efut.iii
5- 1/41
,
7/— ATROPINE 10.5 -1 mg - IV / ET tube)
LIDOCAINE (1-1.5 mg / kg - IV / ET tube)
.1...z. 11
03 tit:, .06614LriC
a *4 ■
- arr •
— >
CI ec —
0. 0
)
LIDOCAINE ii am / 250.cc -
IV at 1 - 4 mg /mini
DOPAMINE (400 mg / 260cc - g./ et 1 - 20 mcg I kg /mln)
POTASSIUM (K) go 'auk,' a/L.4e .
GLUCOSE ,Q CALCIUM (Ca)
',—
'.5 ,9'. 6%---:
MAGNESIUM (Mg) T
PH
pCO2
II 0
p02
HCO3
PHYSICIAN (Signature & Title)
472A1 MM. /
NU (Si nature & Title)
MEDCOM FORM 679-R
T)(MCHO) AUG 99, Back (r)(0..._ 2_
MEDCOM - 22715
DOD-036291
ACLU-RDI 1673 p.75
EMERGENCY RESUSCITATION RECORD - PART 1 For use of this form see MEDCOM Cir 40-5
Complete this report within 2 hours following the arrest/event. Place the original in the patient's record and provide a copy to the Nursing Supervisor.
1. DATE: Nov 2— 2. LOCATION
MICU -SICU
U DIAGNOSTIC
❑ OUTPATIENT
p---OTHER (Specify):
OF RESUSCITATION
❑ CCU
I PROCEDURE
CLINIC:
EVENT
PACU i t k.4-1 1
3. WITNESSED ARREST?
[I, YES ❑ NO ❑ UNKNOWN
MONITORED AT ONSET?
FA YES • NO
❑ NICU ❑ ED U
AREA:
U OR • WARD:
1 C..(. 0 I
4. INTF RVENTIONS ( V - IN PLACE AT START OF ARREST) (
ley Access
• E9dotrachael Tube
D /Mechanical Ventilation
12/Arterial Line
EKentral Venous Line s,c- 2- ❑
Nasogastric
Artery Catheter
E Nasogastric Tube
ii Pacing Device (Specify type):
V - INSERTED DURING ARREST) COMMENTS
• Time: •
- • Time: •
• • Time: •
U Time: • --
11 Time: •
• U Time: •
• ill Time: •
• U Time: •
• Implantable Defibrillator / Cardioverter
Ill Other (Specify):
• Time: -
U Time: -
6. IMMEDIATE CAUSE OF ARREST / EVENT (Check one)
U Lethal Arrhythmias
12/Hypotension
EKRespiratory Depression
• Metabolic
• Myocardial Infarction or lschemia
❑ Unknown
• Other:
YES
6. RESUSCITATION
[Chest
ATTEMPTED
(Check all that were used)
Compressions
Defibrillation
Airway Management
(Check one)
False alarm/arrest (BLS / ALS not needed)
Do not attempt resuscitation (DNAR)
Considered futile • Found dead
7. INITIAL CONDITION
CONSCIOUS
❑ Yes ErNo
BREATHING II
• Yes ❑ NO> N\ V UV' -k--.
• NO PULSE
❑
❑
U
• Yes ErNo
Site:
8. INITIAL RHYTHM M .pc.... I Ventricular Fibrillation Perfusing
U Ventricular Tachycardia ❑ Bradycardia
U Pulseless Electrical Activity ❑ Asystole
RETURN OF SPONTANEOUS CIRCULATION
Er Returned at: 020 : I S- in Never
Perfusing
Q._ e, Ki Rhythm
(ROSC)
achieved
❑ > 20 min
mines
9. EVENT TIMES are required
European Re_suscitatIon
Collapse / Arrest
CPR Started:
1st Defibrillation:
Airway Achieved:
1st Dose Epinephrine:
Code Teem Called:
to calculate the American Heart Ass'n and
Council in-hospital chain of survival.)
HOUR RAN
Onset: ICA : Ste—
10. GLASGOW COMA SCALE (Post-resuscftetion)
Circle appropriate scores, then total.
EYE OPENING
4 - Spontaneously 3 - To voice 2 - To pain
No response
VERBAL RESPONSE
I C\ : S5 A) 4 : NIA
In Unsustained ROSC: U < 20 min
CPR STOPPED AT: ..9 0 • i lA pku
il \.i AO ,w, rit, p 5 - Oriented, converses 4 - Disoriented, converses 3 - Inappropriate responses 2 - Incomprehensibl 1 - No response •-E .—cr
WHY: • ROSC M DNAR
II Considered futile M Death
I )1\ V3 a cy_
q Yes 13Y
Code jeam Arrived:
aYes
I No Time: \ C'' : g
PATIENT DISPOSITION:
❑ No Time: 9 : 9-4 MOTOR RESPONS
6 - Obeys verbal commands 5 - Localizes painful stimulus 4 - Withdraws from pain stimulus 3 - Flexion, decorticate posturing 2 - Extension, decerebrate
posturing - movement
SCORE: ,::;) Ell
PATIENT IDENTIFICATION
V,: P v v 4Filib ([9)(o\ L'\
AGE:
GENDER: ItA
HEIGHT (in):
WEIGHT (lbs):
Q. Nirr
MEDCOM FOFIM 679-R (TEST) (MCHO) AUG 99
PREVIOUS EDITIONS ARE-OBSOLETE
MC V2.00
MEDCOM - 22716
DOD-036292
ACLU-RDI 1673 p.76
MEDCOM FORM 679-R T)(MCHO) AUG 99, Bach
EMERGENCY RESUSCITATION RECORD - PART 2
TIME (Hr/Min):h (-155 tl)vb 2thl kt)14 itb t c I kp i ,214 I>
— I—
< -
1 cl)
BLOOD PRESSURE li,
HEART RATE (* = CPR) 60 &cfb■Pck_ \
(4)Q__
1`'ficsv∎ -0 PeAurok V Cil,-)
\ '1 \D
5.1
\3(c) 51- RHYTHM
PULSE PALPABLE (Y/N) Ni 1---1 NA il —
`I —
NI —
\I DEFIBRILLATION !Joules: 200, 300, 360)
CARDIOVERSION (Joules: 60, 100, 200, 300, 360)
-- — — __. —
PACING PERFORMED (I) -- — — -_ ty\ V --
RESPIRATIONS IV. V -- — I CA I <—
<>- I
BAGGED ,. / 100% 02 (✓ ) ✓ / J o(Ny — tA V INTUBATED (✓ ) Ilg el- A 1041 " ) a
MASK (Specify type) —... —_, — ---
% OXYGEN SO IVO I ''''`-=' t co \ '00 1C:, , CD 02 SATS rim 1V0/. clGi. P1ii•
iln‘) St14.V _ ''t Mk/ aKa1 . 7canfvf...pitY I2 w
0 —
0 e
t I— —
0 Z
c6
EPINEPHRINE (1 mg - IV / ET tube)
ATROPINE 10.8 -1 mg IV / ET tube) 1 MS
LIDOCAINE 11-1.5 mg I kg - IV / ET tube)
i Avwfo
Cu C‘ i'lkwif 6 (\c,i\o i kvi,f'
• •
->
OC
C.-.C
LO
LIDOCAINE (1 GM / 250cc -
IV at 1 - 4 mg / min)
DOPAMINE (400 mg i 260cc •
IV at 1 • 20 mcg / kg / min) kltice
ca0 ilv i\E\ ...
i,(, 01 A-11,0_, .
.0bich,Ort IAA iAL
V\Cri
ik) ) A i
.
-I tz
t CO
CO
I POTASSIUM (K)
GLUCOSE
CALCIUM (Ca)
MAGNESIUM (Mg)
S6A PH 1 , 5\-- pCO2 ,9 1-
---.
ti C
p02 0 t A HCO3 I
CIE - 10 PHYSICIAN (Si nature & Title)
al- NURSE
667-1/b0
MEDCOM - 22717
6 z
DOD-036293
ACLU-RDI 1673 p.77
HOUR MIN
0 0 D
0 0 : 0 :
00 I
Time: 00 : W
PATIENT IDENTIFICATION
No Time: O0 :
4.0
/1-.
GENDER:
HEIGHT (in):
WEIGHT (lbs):
EMERGENCY RESUSCITATION RECORD - PART 1 For use of this form see MEDCOM Cir 40-5
Complete this report within 2 hours following the arrest/event. Place the original in the patient's record and provide a copy to the Nursing Supervisor.
1. DATE: 3 kov 2. LOCATION 0 RESUSCITATION EVENT 21 3. ITNESSED ARREST?
YES ❑ NO ❑ UNKNOWN
M9NITORED AT ONSET?
RfYES ❑ NO
❑ MICUigicu ❑ ccu ❑ NICU ❑ ED
❑ DIAGNOSTIC I PROCEDURE AREA:
❑ OUTPATIENT CLINIC:
❑ OTHER (Specify):
❑ PACU ❑ OR ❑ WARD:
4. INTERVENTIONS ( b,/ - IN PLACE AT START OF ARREST)
❑ IV Access
❑ Endotrachael Tube
❑ Mechanical Ventilation
❑ Arterial Line
❑ Central Venous Line
❑ Pulmonary Artery Catheter
❑ Nasogastric Tube
❑ Pacing Device (Specify type):
❑ Implantable Defibrillator / Cardioverter
❑ Other (Specify):
- INSERTED DURING ARREST)
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
❑ Time:
COMMENTS
6. IMMEDIATE CAUSE OF ARREST / EVENT (Check One)
❑ Lethal Arrhythmias
❑ Hypotension
❑ Respiratory Depression
❑ Metabolic
ri2r Myocardial Infarction or Ischemia
❑ Unknown
❑ Other:
6. RESUSCITATION ATTEMPTED
rZrYE, (Check all that were used)
IA Chest Compressions
❑ Eyfibrillation
NVAirway Management
❑ NO (Check one)
❑ False alarm/arrest (BLS / ALS not needed)
❑ Do not attempt resuscitation (DNAR)
❑ Considered futile ❑ Found dead
7. INITIAL CONDITION
CONSCIOUS
❑ Yes ✓rNo
BREATHING
❑ Yes lieNo
PULSE
❑ Yes 12/No
Site:
8. INITIAL RHYTHM
❑ Ventricular Fibrillation ❑ Perfusing Rhythm
❑ Ventricular Tachycardia ErBradycardia
❑ Pulseless Electrical Activity ❑ Asystole
RETURN OF SPONTANEOUS CIRCULATION (ROSC)
❑ Returned at: • ▪ PrNever achieved
❑ Unsustained ROSC: ❑ < 20 min ❑ > 20 min
CPR STOPPED AT: OO : s4 WHY:
❑ ROSC ❑ DNAR
❑ Considered futile 12/Death
PATIENT DISPOSITION:
9. EVENT TIMES (n..* are required to calculate the American Heart Assn and
European Resuscitation Council In-hospital chain of survival.)
Collapse / Arrest Onset:
CPR Started:
1st Defibrillation:
Airway Achieved:
1st Dose Epinephrine:
Code/earn Called:
Ling Yes ❑ No
Code Team Arrived:
VERBAL RESPONSE
5 - Oriented, converses 4 - Disoriented, converses
3 - Inappropriate responses
2 - Incomprehensible sounds cD No response
10. GLASGOW COMA SCALE (Post-resuscitation)
Circle appropriate =wee , then total.
EYE OPENING
4 - Spontaneously 3 - To voice
6-o pain
o response
Co polio 1 1-
MOTOR RESPONSE
- Obeys verbal commands
Localizes painful stimulus
- Withdraws from pain stimulus
3 - Flexion, decorticate posturing
2 - Extension, decerebrate
posturing
1 No movement
SCORE: J
MEDCOM FORM 679-R (TEST) (MCHO) AUG 99 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00
MEDCOM - 22718
DOD-036294
ACLU-RDI 1673 p.78
EMERGENCY RESUSCITATION RECORD - PART 2
TIME (Hr/Min): (Z)+)10 ()p (Al 6,-)n4to f 6)050 oo 5'2 009)
BLOOD PRESSURE WI '27/M 2/q .C71• tisb,a1.4
HEARTRATE (*= CPR) 444
Ga (,3 GP% szi T-C.. ce RHYTHM
PULSE PALPABLE (YIN) tics IV-(5 Aro
A DEFIBRILLATION (Joules: 200, 300, 3601
—....,
CARDIOVERSION (Joules: 60, 100, 200, 300, 360)
-;--
PACING PERFORMED ( ✓ ) nr
RESPIRATIONS 140,164,4 Icz—
cccx>-
BAGGED w r no% 02 (I ) ✓ 4
INTUBATED (I ) v/
MASK (Specify type)
% OXYGEN
02 SATS ( ODA 1 E
wC
i—Ci
<1--
OZ
U)
EPINEPHRINE 11 mg - IV / ET tube)
,7"V i '
&04_,/ 61.Df7- I or4.g.i
oogY Si 7/
c:,c47 pi c,c,Yrc>cpere,c
Tv g
ATROPINE (0.6 -1 mg - IV / ET tube) I C° 11
I I viedi PI 0 eVY
1.,,A,N CP42-
--,:ar 001
"Ate 00 Si)
LIDOCAINE (1-1-6 mg / kg - IV / ET tube)
D so -t-494-14.
Ov(17-
ext,it. Co TO
I—
> O
cc—
a-co
LIDOCAINE (1 am / 250cc -
IV et 1 - 4 mg / mi.)
DOPAMINE 1400 mg / 260cc
IV at 1 - 20 mcg / kg / min)
I...) <
02 ci)
POTASSIUM (K)
GLUCOSE
CALCIUM (Ca)
MAGNESIUM (Mg)
aIldtk 1- cotO. 1 6/0-- I
<D
5C
.9 DI
PH qtiq PCO2 -23,q p02 3C9 HCO3 17 % I
.
PHYSICIAN (Signature & Title) NURSE (Signature & Title)
VA I3 NI;,?-f- itiC9 full
MEDCOM FORM 679-R (TEST)(MCHO) AUG 99, Back
MEDCOM - 22719
DOD-036295
ACLU-RDI 1673 p.79
I. Keporung mit- ci,r,) 2. IV .:ion Admission and Coding Information IZ For use of this form, see AR 40-400; the proponent agency is OTSG _
3. Register Numb
,—.
ame (Last, Fi t, MI) 4. Pay Grade
FGN
5. Sex
M
6. DoB (YYYYMMDD)
1978-07-01
7. Age at Admission
25Y
8. Race
X
9. Ethnicity
9
Religion
10. Length of Service ETS 11. FMP
20
12. Social Security Number
(q(C)—(1
Organization (Active Duty Only) 13. Marital Status Hour of Admission
18:10
Branch / Corps:
14. Flying Status
NO
15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location
IZ
18. MOS , 19. Trauma
BC
Prey. Admission
NO
20. Source of Admission
0rl Direct from ER 4-
Ward:
ICU1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Nam d L tion of Medical Treatment Facility: 0580 ; No Install Provided
Telephone Number of Emergency Addressee
21. Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-02
24. Clinic Svc - Admitting
ABA- GENERAL SURGERY
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-10-31
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-10-31
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: DIVERTING COLOSTOMY/ SUPRAPUBI
- Procedure Narrative(s):
Cause of Injury Narrative: GSW BUTTOCKS
BE PER6JanAINAGE
by : nogic A 8-28
gt6.3cr 5141
Q0-71
49,s' eqq0-
)
00)N_ 'ZI --iiiignature Admitting Officer (Si •
of Adm .ng Clerk I
_....n- CI,
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 22720
DOD-036296
ACLU-RDI 1673 p.80
1. Reporting MTF L) - 2. MTF Lo
IZ Admission _.,, Coding Information
For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number Name (Last, First, MI) 4. Pay Grade
FGN
5. Sex
M
6. DoB (YYYY DD)
1984-01-01
7. Age at Admissi n
19Y
8. Race
X
9. Ethnicity
9
Religion
10. Length of Service TS (.g(,. ) (0 —
11. FMP 12. Social Security Number
—2T)
Organization (Active Duty Only) 13. Marital Status Hour of Admission
21:51
Branch / Corps:
14. Flying Status
N/A
15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
BC
Prey. Admission
NO
20. Source of Admission
D ----J-- I 9/
erect from ER
Ward:
ICW1
Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Name an tion of Medical Treatment Facility: 0580 aq; No Install Provided
Telephone Number of Emergency Addressee
21. Type of Disposition
TRF-OTH
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-09
24. Clinic Svc - Admitting
AAA - INTERNAL MEDICINE
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-10-31
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-10-31
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: FRAGMENT WNDS L THIGH
Procedure Narrative(s):
Cause of Injury Narrative:
Admitting Officer (Signature, as required) Signature of Admitting Clerk
Automated Facsimile - DA FORM 298 MEDCOM - 22721
DOD-036297
ACLU-RDI 1673 p.81
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Eat, 'ha,
E"7
r‘A.a-143-Yti
IDENTIFICATION NO. ORGANIZATION
REGISTER NO. WARD NO,
PROGRESS (1.:nler date of din•Iir:rpr and final dings:mei.)
•
SIGNATURE OF PHYSICIAN
PATIENT'S IDENTiFIC
DATE
3/ pad or wrrtren ff,e• live Na e last. first, jra date: hoopir.1 or med
to 1..c,lity)
MEDICAL RECORD ABBREVIATED MEDICAL RECORD
t 9r F- „LI/EA? 6), q
," „ 2g
I . 731, 14-
(27 VOI R 0
LETw..1_ oc,11
PHYSICAL EXAMINATION EXAMINATION
PejAr (5
IIIIP e-Xo 4
ABBREVIATED MEDICAL RECORD Standard Forma Sao
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106
MEDCOM - 22722
DOD-036298
ACLU-RDI 1673 p.82
PROGRESS NOTES MEDICAL RECORD
AUTHORIZED FOR LOCAL REPRODUCTION
DATE NOTES
,5 wJ0-3 Uc_S 4-J2,,-1- ,)- (/), , C/() ll:A_-.--- &. OPPT 4--ti oi& 2o 6)C) t n-.. ,C/LA-.--- 61---&12-1--7-__D )9X----e- 7'(,s Ac( L-..p.--, -i a-ct..4e
r),,,.,---Qok ) . • i--- =4--- 0 (r ,0 r'&2/1/7i-Lk- A f. I V i., ---1- V -V-
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--_,,..----7,..___,e .._..y 7 5 -6-.)7 0 /-q cyty -L0,, Cbx-e--1 C1:1114/VI.Nre_.
`CA_ C.9—)-----)7 COLA0---2---,__0,-,-- (,c`l 1 -3,;,_t_- e
/Fmk cp (cpc136)-Ast -fyv cart:2_ cD cteig:51). 'ek-- <:‘,s2..(--\- -.,y.Q....__YLILK- Nce)sit___
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ROS\(\aS \r4,211 SS)c. ‘kt-R\'‘,c-a--\-Nbcm, -Ircz::A. fQs di-e..A- we,), ■ . r
4 0\c‘- Z 6; V's cA_D\ a• 'vb. vrt- f=?S'N-...■ (171s. i\r\ Ns)\c_e. -1
v\A-\ ■ \_.(2_ \N bec:\ s SIS)‹. Co\iC-A-C-NS \III-\\ c-r.`/CW---. r
1INC. TYNICS,C110C,
((90-b v6I5 U s C_9-C_-J- 0 ri F n
2.000 OCASbcT---4_3r a- IA,a-c-i- . 11-- 14% d-- ditt.R-
IALAP Alv•--Q- 0 A Oci a , 4, 411.4.1.... • . ( x 1---)A fyi 0_, \ 1 #4
IA - ---...- f
I. ./t--- \ _,---A--%.,, ,..Q C CA--s-__ 0,2-- odc.44.,7\_p RELATIONSHIP TO SPONSOR SPONSOR'S NAME
LAST FIRST MI ISSN or Other)
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION.. /For typed or written entries give: Name - last, first, middle; I REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Grade) .A.
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USAPA V1.00
MEDCOM - 22723
DOD-036299
ACLU-RDI 1673 p.83
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
ii i 01 y .. • 0
16
ea .---4/,-.e ' el/ ; , 4634.- . ' r 4 2 - / t-Fe----
lci7 ... - _.. •011. 4r 4//
•___......t.."...s.v.,
--"pfL..:2e .....,,,e..". , y115* . -----7,4-4. 4...47 ,--. , % (1-4
_
. ,....<;...—iri ...,,,,
•••
"1"r .I-rl. a
,. 00 .. c 4, • y►-- Ga e-s 4.--✓"4-1( "-N\ . A •
- -.3 -00 C te...-4 f i"trtvl 6, t , ... b - 0 411 ,i5 k c p -- Pt :',\ ), 1 i, -k I poNic-+
111
1 otioo 01 6S5 46. L.) 0 ----d-- <5 Alm - St : Kszczd., 0
Os (... .11 . -4 .... ,--
O --k, a 43 ■IsS' , 79e. , e",-.4, 0-11 e--)-r-c.,?-",e-a ate . S' -I'
e ,... ea . 005°,4 ---f-- ( s ._.1- i•-.
47"4/1-
(._,-, C53,5 L.Stin 62.:1 A/401A93 vs A 4.-0 ot 0042 -r 6g . 4,1-40,1c.
/ c--0-0 - &--. lac53 C_,
c re - c ; - ( 0.7
L./yr
e-c. " L--
5 ,.(p__.e> I 0 IDJI-e., . 150- i ck l 'n 6; 2,
/ ./974/A/1/
--- 4- ,,, , 0 el , •
1_,
47n4._ 1..),"/ '6 ;vv-rw)13-0.r. --
/
----
--411111k (c)((ol MEDCOM - 22724
STANDARD FORM 509 (REV. 5/1999) BACK USAPA V1.00
DOD-036300
ACLU-RDI 1673 p.84
DATE 1 NOTES
L. Ilk At-N6 ith t G. 006
we Ur iP &A q5 111' •
CICie Vir-nopo t.-----T-N, CP AvA\r Cl)--T ,
S Q.,C
JC-C9 0 're 1)4 k s i ._c, &I? (Ni--) v -a- -t-- 2 471L Cif■A\C>\ ciA---ef-■
% 4 0\CI i
© 7k-e_j ‘\,(AA-- Ok C‘ic S \ • b -\---
-e--aho -- s a ill •.O. S I
lkt/m/cY3 /Vv. AL---; tk_s; Y_ _. i .,.., .... _
4t c , ,, ,
-".4, ". #.717 72-.2141•414
-441' dr -...u•
es....
...r 04.1,Le,e0I74 0....01.'eLe2‘4•4
a444.4-0.--- :„.,,
1/6e .___.,
■ .....
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.4 - .41•11,
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-...
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. — alINCOUINUAL.Aa ..i -.L. g i _.
.1 1 0 1 / P i ■ 0 _. . - _LP 0
# c. -AL AL.-. ' Mr-0 _ A • r -.." i
"Litt. !t 4 ' / il • AP ----)_ I / / g Ild ...AA (XL
cf2(zn c ,..(7 IA 1 WC/C/1,–R it (6 f,,z._-_, -1,fai '1,-674 RELATIONSHIP TO SPONSOR SPON
(SS .
SPONSOR'S NAME
LAST FIRST MI---
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT ,.;.
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; I ID No or SSN; Sex; Date of Birth; RanklGradel
REGISTER NO. WARD NO.
El
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES MEDICAL RECORD
PROGRESS NOTES Medical Record
STANDARD FORM 569 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)
USPre• V 1.00
MEDCOM - 22725
DOD-036301
ACLU-RDI 1673 p.85
DOD-036302
Ws, 441-70)( Azz2-
cp frz,- 114 ..„....e.e.e.a— ry
lot
I
MEDCOM - 22726
_4'007 63
ACLU-RDI 1673 p.86
MEDICAL RECORD PROGRESS N AUTHORIZED FOR LOCAL REPRODUCTION
DATE NOTES
3 -7 ftia rem 1111k vi a . E I -2-I 0 \A) _ ii. • h■ ' a-kr \ .... . q■
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c.1.--- -t-/ 1 ,-4-- Ac-l- c--e- .R s ,-) (-e--- c,--t- A---j riao. 4.-1 L -r gpiA c_ r ,,,J _G_Ei.:,./ .e5- s./ x-, ,
k) ,- (1 cam- 4 .--/„....„„.:A---„x __ Wyn OtMiitirrua Mitt Glj pf 0 ( W . 41 `-iso, C(Vatt--. le,e/tt i . ra 4 Pitli;
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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER
ISSN or Other) LAST FIRST MI
DEPART./SERVICE I HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)
REGISTER NO. WARD NO.
,.
ell PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(131(101
USAPA V1.00
MEDCOM - 22727
kL)
DOD-036303 ACLU-RDI 1673 p.87
, LAST NAME NAME 7 A.1 ID NUMBER
DATE NOTES
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, _ . - 41 . . -I
ST NDARD FORM 509 (REV. 5/1999) ACK USAPA V1.00
MEDCOM - 22728
DOD-036304
ACLU-RDI 1673 p.88
AUTHORIZED FOR LOCAL REPRODUCTION
CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry!
MEDICAL RECORD
b 5 6 cs.,r-Cc.S de, e,sy—c • ob) 2 diming
7 L b-sc-3 CLY0-z- i)sy 6 ito`ss , (tireA/-e-a A ,
ot/
6) AIN D17
DATE
HOSPITAL OR MEDICAL FACILITY
SPONSOR'S NAME
STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: 'For typed or 'mitten entries, give: Name - last, first, middle; ID No or SSN• Sex; Date of Birth; Rank/Grade./
•
REGISTER NO. !WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/IPAR FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22729
DOD-036305
ACLU-RDI 1673 p.89
&SW
MEDCOM - 22730
EMERGENCY CARE AND TREATMENT (Patient] Medical Record
STANDARD FORM E58 IREV. 9.96) Prescribed by GSA/ICMR FPMFI 141 CFRJ 101-11.203Ib)(10I
SSZ-204
7540-01-075-378
LOG TREATMENT FACILITY
k°01r RECORDS MAINTAINED AT
EMERGENC AND TREAT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY 4ATION
MEDICAL RECORD
ARRIVAL STREET ADDRESS I DATE (Day, Month, Year) TIME
• f Od- c3 2-2.6 STATE ZIP CODE TRANSPORTATION TO FACILITY
iMENVicte; SEX DUTY/LOCAL PHONE IL ITARY STATUS THIRD PAR SURANCE AREA CODE NUMBER
ITEM YES NO N/A YES NO PRP
ADDITIONAL INS NCE
DD 2a6B IN ART
NAME• SURANCE COMPANY
AGE ONE FLYING STATUS
AREA,COOC" NUMBER MEDICAL HISTORY OBTAINED FROM
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNE S EMERGENCY ROOM VISIT
WH •ate/ DATE LAST VISIT I24 HOUR RETU
S
ITEM YES N
NO IS THIS AN INJURY?
INJURY/SAFETY •RMS
WHERE ANUS ALLERGIES
CHIEF COMPLAINT
DATE LAST T COMPLETED INITIAL SERIES
❑ YES 0 NO
HOW
CATEGORY OF TREATMENT TIME
INITIALS A
1/1)
VITAL SIGNS 0 EMERGENT
0 URGENT
0 NON-URGENT
TIME
BP I 2_ PULSE
RESP
TEMP
WT
13HCG/URINE/EILOOD/QUANT
UA MSCC/CA CHEM: 7, c CXR PA & LAT/PORTABLE C•SPINE
>- < LJ CC 0
X Cr 0
ACUTE ABDOMEN 1.5 SPINE 00 C&S X SINUS HEAD CT
5 ANKLE FVL
ORDERS
DISPOSITION FDISPOSITION QUARTERS /OFF DUTY
7 24 HRS. ri 48 HRS
PA TIENTICASC.NA AGE INSTRUCTIONS , FULL DUTY
MODIFIED DUTY UNTIL HRS
I RETUFIN TO DUTY
CONDIT:ON UPON RELEASE !ADMIT TO UNIT!SERVICE
ITIME OF RELEASE
TO IWHEN 0 UN C I-IAN GE D REFERRED IMPRO`tED
DErERICRATED
I have received and understand these instructions. PATIENT'S SIGNATURE
PATIENTS IDENTIFICATION (For typed or Written P.171/1.23, give: Name - last first middle: JD no. (SSN or other); hospital or
DOD-036306
ACLU-RDI 1673 p.90
FIESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP CONSULT WITH TIME ACTION
PROVIDER SIGNATURE AND STAMP
,GNOSIS
TENT'S IDENTIFICATION (For typed or written entries. give: Name — ba. first. middle: ID no. ISSN or oltherl: hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor) Medical Record
STANDARD FORM 55B IREV. 9-96) • P:ascrib*d by GSA/ICMR
FP1IR 141 CFR) 1 01-11 . 203lb) I I 0)
#1) MEDCOM - 22731
EMERGE D TREATMENT (Doctor)
TIME SEEN BY PROVIDER . --• MEDICAL RECORD
TEST RESULTS
ABG/POLSE OX RADIOLOGY Check if road by radio log i st
SUP 02 PH P07 RESULTS
fee-4.A_ /0'Art-=
'cd' V./5T-
PCO2 AT OTHER
7
DIP EKG INTERPRETATION
MICRO
WBC
;9"
PLT
PIT
BHCG
ETOH
GLU
ROVIDER HISTORY/PHYSICAL
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DOD-036307
ACLU-RDI 1673 p.91
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY • MONTH-YEAR DAY 7 AA D-5 i(4/64 63 ifiwite.5
19 HOUR 6- . /41/ - •.... . . . . . . .
RESPIRATION a
PULSE
(0)
180
170
160
150
140
130
120
110
100
90
80
70
60
50 .
40
RECORD
TEMP. F
(•) 105°
102°
101°
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'ATIENT'S IDENTIFICATION (For typed or wri ten entries give Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
,...„,
REGISTER NO. WARD NO.
'.
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 22732
DOD-036308
ACLU-RDI 1673 p.92
511-119
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONTH-YEAR DAY g
P o J . A) V o 03 , / Off/ -(NIN 03 CI," 19 HOUR 24 • • 57012 •• •• Pr .f) '' • . • '
PULSE (0)
TEMP. F
105°
180 104°
170 103°
160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96°
90 95°
80
70
60
40
RESPIRATION RECORD
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PATIENT'S IDENTIFICATION (For typed or wrI ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
REGISTER NO WARD NO.
VITAL SIGNS RECQRDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 291-9.202-.1
MEDCOM - 22733
DOD-036309
ACLU-RDI 1673 p.93
Scg
Bands .
Mono
Eos
Nit Lymph Nega t ive
DATE: LAB ID NO.:,
,,yarcyscctioe.:
LAST, FaST.
:ernato - CB
i DATE 1 TL1L.P. 4-F-$31
_ • BORAT.O.RTR.ESULT FOR2',,1
to tae Friva4.: of 1.974) • "'SE. • SSN:
E
4.S-10.S x 10'
4.7-6.1-:: 10 ;
Gift
Bill
1-(ct
Pi:
Lymph %
(Eceraz te4O-6 v),,,i4n nal Differential . .
voIo7,..y r t
RESUL RE.F, I t•:./,-■ RPR Nc,iliv-e
Mono itic-gaLivc Ncg3tiN-c • . ?y,U.crobioiozy
I NcV t i Yr- Sou ce
I Ncg Crra Stain OCC B [Z.1
14-18 g -1:1 N) 12-16 /,-11 (71 42-52% (M) 37-47/. (I-)
i 80-94 (1•,f) 81-99 11(F)
130500 x to vc-i fled 20.5-51.1% Bid
Sc,
PH
Prot
0.2-1.0
Micro Parasites
Malaria
O&P
Other
Atyp
HCG RBC Morph
NCgitia YC
Nc .:LL ivc
42-52% (M) 37.47% (F) . CSF lood az k •
ABO/Rh I Dircci igen Nes:Ai vc
osauLltioit Studies •,. • .• '• .
REF. RANGE
_ • Blood Bank Unit Crossmatch . -• ' • (NIUST,SUBNICET SF 5IS VVITH EVERY uNrr OF BLOOD . .
• . RE Q UF_ST. ED) UNIT Ti:PE
, Spun Ficoaa.toit
Scd Rate
Other
RESULT
\AF
9.8-13.6 sc-..z
21-34
<20 ugizra
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
Cell Count
-• - ro-scon IC URA 111
• .
I. ED? I
REPORTED B
TZST
7v-SC
RBC
MC V
<10 uLical
ACLU-RDI 1673 p.94
114 111111 BUN
C
s02
BEc,cf
An Gap
HCO3
TCO2
P02
PH
PCO2
Cl
TEST
Na
LAST, FIRST,
REsuiri
31/10/03 22:42 !,-f.A 138' REFERENCE RAN PATIENT #: IVER PANEL ISC LOT #:
OPER #: 678 S ERIAL #:
38-51'
12-17
0.7-1..
............. _0,7arl_, .................. ,L,')
bLU 160* 73-118 3 DL „ ..
71 26-84 U/L .1.gd BUN 12 7-22 MG/DL ALT 18 10 -47 T:Gii CRE 1.0 0.6-1.2 MG/DL AMY 35 14-97 U/L ,_j_____ 0K
P 279 39-380 U/L AST 26 11-38 U/L NA+ 127*- 128-145 MMOVL TBIL 0.4 0.2-1.6 MG/CL 2°'8' K+ 4.2 3.3-4.7 GGT 13 5-65 U/L ni-Ti, CL- 109* 98-108 MMOtL TP 4.6* 6.4-8.1 G/DL Ti7,11. tCO2 19 18-33 MMOL 8-2.6 1 INST QC: OK CHEM QC: OK
70-10 HEM 1+, LIP 0 , ICT 0
1.12-
(-2) - 11 U.
10-2(
I t8Z1 - 23.2; ALB 2.5 24-25 ALp 22-26 n-zg 95-91
9S-I L 2.31 D
............
0000100494 ;:o SERIAL #: 0000100681
MALE Ti
MET PATIENT
8
1.0 3153AA7 DISC LOT #:
3151M4
DR #: 000 .1. 1 OPER #: 678 DR #: 000 -
A TE
INST OC: OK CHEM QC: OK RE HEM 0 , LIP 1+, ICT 0
,VG/ 1--agk
g, (11
TR•I:
PICCOLO 31/10/03
22:43 NCE RANGE: MALE
CITENTISTRY RESULT FORAT Sub'cc! to the Privac y .At of 1.974'j
•
RE UES -sciN 7 L,
TEST
Tropcnin-
RESULT I- r..ng/d
LJ1 (7 eli (F
5,:unc
rarool:
ir::011
RE Lk1 :
REPORTED BY: I DATE:
LAB ID NO.:
MEDCOM - 22735
DOD-036311
ACLU-RDI 1673 p.95
DUI/ LfD
'4PC 33.1 H
31-10-03 22:40
Patient Limits
11 3.11L x 10' ,S/L 4,01) 6.00 HO 8. 9 L 9/I 110 'tict 29.1 L 35.0 6. rl TV '71S fL 8-0.0 99•9 NCH 20.6 pg 7.0 31.0 rat 30. L Elf& 33.0 37.0 Pif 761, 150. 450, Ln *L 20.5 51.1
2.7 * ).!)3,d.. 1.2 3.4
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 10/31/03 22:49
Patient ID Test ne :PT T Result:- 15.5 sec. Natio = 1.3 Calculated INR 1.47 Sample Type:citrated wh. blood Test Date :1001/03 Test Time :22:48 Card Lot :080201 Operator
IDPOIN[ COAG ANALYZER V4.54 SER 4005485 10/31/03 22:52
Patient 10: Test Name :APIT Test Result: = 10.0 sec. ***RESULT OUT Of RANGE*** Sample Type:citrdted wh. blood Test Date :10/31/4 Test Time :22:50 Card Lot -;-• Operator
MEDCOM - 22736
ACLU-RDI 1673 p.96
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 90/36R 133 TIME OF ORDER
HOURS
LIST TIME ORDER
NOTED AND SIGN
14■ 4A j- 1C 2
C.- i"--4= s44 V3 .s 44 7` •
"rc . t :.-- ,te ki r .... Is.,....-L . NURSING UNI ROOM NO.
4 Lt. ---- 4 ' tt- 9 4-
A . I vtks--: .- > I. PAT I ENT.IDENTIF ICATION
:7\ f "y tt VO
C..., ." \
DATE OF OR trER flaTIME OF ORDER
D :,1---:- $4 12- E HOURS
1 V S • 1-**. .
S t .,%./.
m a_l s .—
T -14.--,.; 'TT ef — P .
%. 0
NURSING IT liN
4)/ Ol LIST
ROOM NC/
PO i
D NC
4 O' °I• PATIENT IDENTIFICATION
it 6 "2.
DATE OF OR TIME OF ORDER
4 ,vim -.3 I 6414;1 HOURS
(4- 4 z..;,vAir---- ?--
NURSING UNIT .
PATIENT IDENTIFIC DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO.
DA 1 FAOPRRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 22737
DOD-036313
ACLU-RDI 1673 p.97
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION ) For use of this form, see AR 40-407;
the proponent agency Is the Office of The Surgeon General. MCIAWir 2003
VERIFY BY IMTIALING ‘w.,4:g: - ;:e,;-,, ;x.Art*, - ?,, INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER ATE
CLERK/ NURSE
RECURRING ACTION, FREQUENCY, TIME
HR DATE COMPLETED
51 MIEWSPANIF2 9 VS 5 Co '4w-
.... I Z 1 - — -ACT: ,,elly rt-tDC121 (.0
I a J11111111111
IIIV I .
i ...
I' -pi, 0F,
...... _. :
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. .
ALLERGIES:
Q NM YES MI NO PRIMARY DIAGNOSIS:
_.-- MC vIATA,
__, . _-- 7 k/5 i n
ADDITIONAL PAGES IN USE: I/ YES En NO
PAGE NO'
PATIENT IDENTIFICATION:
)
MI
ACTION TIMES -
C-I USE PENCIL. CIRCLE ACTIQN . TIMES
D 8 ,9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07
DA FORM 4677, 1 OCT 78 MEDCOM - 22738 USAPA V1.00
DOD-036314
ACLU-RDI 1673 p.98
Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo i i yr 2003
SINGLE ACTIONS Date to
be Done Time to be Done Time Done Initials
Order
Date Clerk Nurse
ei ,-411111 atlytk,' + , aut_ A-1-g/21-e- 1 Ncvlillr'c--' ̀:`'. "r\'?" -'''Q
(4) - c
Order/ Expl r Date
Clerk/ Nurse
PRN ACTION, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING COMPLETION
TIME/DATE COMPLETED
— — — — — — — —
USAPA V1.00
MEDCOM - 22739
DOD-036315
ACLU-RDI 1673 p.99
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
For use of this form, see AR 40407; the proponent agency is the Office of The Surgeon General. Yr. Z
VERIFY RY INITIALING
INITIAL PROPER COLUMN FOLLOWING EACH ADMI ISTRAT7ON
ORDER DATE
CLERK/ NURSE
RECURRING MEDICATIONS, DOSE, FREQUENCY
HR 1 DATE DISPENSED
j. 3 1 s' IT7 (7/ / /0 .. ..),__1 1 \) ' a- •...... ,
- • fr,....
A-11 C-17 . / 'DU' r
_ .
. .
. ALL ERG! ES- 11 y E VG\:14 0
Wo--A PRIMARY DIAGNOSI St ■ ,
-- va,--im, ,(2.-_-_ -717 i 5 h , ADDITIONAL PAGES IN USE: AYES E=I NO
PAGE NO PATIENT !DENTIFICATION:
DISPENSING TIMES
- USE PENCIL. CIRCLE MED TIMES
d\-\ IOW 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
D A I FF17349 4678
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM - 22740
DOD-036316
ACLU-RDI 1673 p.100
Verify by Initialing
. THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) M 21eAl r. 03
Order Dote
Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES
Dote to be Given be
Time to Given Time Given Initials
Order/ Explr Date
Clerk/ Nurse
PRN MEDICATION, DOSE, FREQUENCY
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
TIME/DATE DISPENSED 0 ilJou ./ 3-0.) 11-1- 3 4_q4 -totp_vi 0 rt .
lAh
-1----
U.S. GPO: 1998-454-110/95216
MEDCOM - 22741
DOD-036317
ACLU-RDI 1673 p.101
Sex:
M
F
II Dr. license nOther (specify)
Mobile
Regular
Phone# :
DOB D/M/Y:
ao
Phoned:
DO3 D/M/Y: Mobile
E Regular
Sex:
M
Or. license EOther (specify)
0
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION
:1E3Cdiense ecirfst Ckrilin(41chect-c...Oneljt Other :then de11 :,.: 1 ' .: 1•: -
I' -." (?it.".1.(1.:17.-C1:''1):::::!:'.::::::1'E:-::::::: :: ' :::•;,.:.•. . -: .r.... 1 CtL141cY:c'ff3usl'br'''zkIng (EPC 428)
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'!# i....;.9#101 *.s.'.400.:',': '
i*--;f:O§410;:,4,:iik::. difE:OF ,:::.: .
ib.04.0::P 11. Date of Report. (D/M/Y)
0
Time of Report:
c.a/St hrs
ey..qOnnected Victirn:.. Witness
Fittk.N14rri Hair Color:
Eye-Color:
Address:
Place of Birth:
Ethn/Tribe/
Sect:
LiPassport
Document
Make:-.: . ColOr.
Model: Tyoe:
Year :- .. Names of Peo le
Contrabaft&Weapons. in Vehicle: . .
II
Quart',
•
Given; Name:
Hair Color:
t.Jumber Of Peo
Photo Taken of Suspect with Weapon/Ccntraband: Yes/ No
Color/Caliber Receipt Provided to Owner: Yes/ No
Owner
Email, Phone, .or Contact Info:
Suparviskig Calie•es !.iarrxx
Property/Contraband
Serial No.:
Other Details:
Na-mect Assistirrg Interprete.r; •
NCieribOs.Of:P&setri:InVolveci:.- illtinarrieqvdentir
Vehicle Num r ................. . ..
. . .. . . . .
Plate In Vehicle: ,
attoos/Deformities:
Weight: lb Height in Eye -Color:
Address:
Place of Birth:
Ethn/Tribe/
Sect:
Passport
Document #:
inq in fa•'on reverse under "Addtonal.Helpfut;tnformationl
Scars/Tattoos/De formities:
Weight lb Height: En
Weapon
Model: Make:
Where Found:
::•--Cahr.ning.sok:946:Namo ••
Last, First tI . •
Last First Mi.
Signature:
Unit PhOce: bate
Un:t Ph.cne':
MEDCOM - 22742
DOD-036318
ACLU-RDI 1673 p.102
..... .
Who witnessed this person being detained or th e reason for detention. Give names contact numbers addresses; ..
. . :
How was this person traveling (car, bus, on foot)?
Who was with this person?
kljfiat: Weappgs:,.?oirasithis::persclni.ca rrY1
What contraband was this.'person carrying?'
What other weapons were seized?
What other information did you get from this person? r
Additional Helpful Information:
MEDCOM - 22743
•
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM
Why was this Dersbn:detaine(? .1)7F 6:Tt.dry)-5 (;),:x2S:
r
DOD-036319
ACLU-RDI 1673 p.103
Automated Facsimile - DA FORM 364
Automated Facsimile livrATIENT TREATMENT RECORD G._ 402 SHEET For use of this form, see AR 40-400, the proponent agency is•OTSG
1. Re ister N r 2. Name 3. Grade FGN
Admission Remarks
•
4. Sex M
0 Age 19Y CG1
6. Race ) X (._(
7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
NO
11. FMP
20 12. SSN 13. Organization 14. Ward
ICW1
15. FlyStatus
N/A 17. Dept / Ben
K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case
BC
21. Source of Admission
Direct from ER 22. Hour Of Adm:
21:51 23. Clinic Service AAA - INTERNAL MEDICINE
24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH
26. Date of Disp
2003-11-09
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:
2003-10-31
AdmittingOfficer:
MEW (LA) _. 32. Units Blood Components 29. ReportingMTF
0580 30. Date Ina Adm
2003-10-31
31. Selected Administrative Data
Marital Status: DoB: 1984-01-01
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
FRAGMENT WNDS L THIGH . DY - -
Rot . 21
CS 610 ' 1 . . . V' -2-9
Cc.lk 1,1 •
35. Total Days This Facility
Absent Sick Days 0
Other Days (,) ConLv / Coop Care Days
0 Supplemental Care
c, Bed Days
/ 0 Total Sick Days
) 0 35. Total Days Thil Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days I Total Sick Days
Signature of Attending Medical Officer
_ _
Signature of P • " .
C--- `1 MEDCOM - 227441
MO-
DOD-036320
ACLU-RDI 1673 p.104
r. Automated Facsimile
INPATIENT TREATMENT RECORD CO, _R SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr 2. Name
NoFirstNameGiven 3. Grade
FGN Admission Remarks
' 4. Sex
M
5. Age
fj__ t.,,t
6. Race
X 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
NO
11. FMP
99 12. S4I 13. Organization 14. Ward
ICU2
15. FlyStatus
N/A 17. Dept / Ben
K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case
DIS
21. Source of Admission
Direct from ER 22. Hour Of Adm:
07:30 23. Clinic Service AAJ - NEUROLOGY
24. Name/Relation of Emergency Addressee 25. Type Disp TRF C-ACF
26. Date of Disp
2003-12-09 27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: -.
2003-11-01 Admitt ngOfficer:
III O'')(G)--Z_ 29. VeportingMTF
8580 C6-)(Z) -7--
30. Date !nit Adm
2003-11-01 32. Units Blood Components
31. Selected Administrative Data
Marital Status: DoB:
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
HEAD TRAMA
35. Total Days This Facility
Absent Sick Days
0 35. Total Days This
Other Days
0 Facility
ConLv / Coop Care Days
0 Supplemental Care
0 Bed Days
go Total Sick Days
1 0 Absent 90 Days Other Day Coop Care Days
0 Me
Supplemental Care
0 Signature of PAD or Medical
Bed Days
40 Records
Total Sick Days
4O Officer .
Signature of Attending
- • ---- -
Automated Facsimile - DA FO 79
MEDCOM - 22745
r
DOD-036321
ACLU-RDI 1673 p.105
Automated Facsithile
INPATIENT TREATMENT RECORD cc SHEET For use of this form, see AR 40-400, the proponent agency is OTSG
1. Register Nbr 2. e .
NoFirstNameGiven
3. Grade
FGN Admission Remarks
4. Sex
M (9(6)--
5. Age /
9 6. Race
X
7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm
NO
11. FMP
99
\
12. SSN \ 13. Organization 14. Ward
ICU2
15. FlyStatus
N/A
17. Dept / Ben
K78-PRISONER OF WAR/INTER
18. BranchCorps 19. UIC / ZIP 20. Type Case
DIS
21. Source of Admission
Direct from ER
22. Hour Of Adm:
07:30
23. Clinic Service
AAJ - NEUROLOGY
24. Name/Relation of Emergency Addressee 25. Type Disp
TRF C-ACF
26. Date of Disp
2003-12-09
27a. Address of Emergency Addressee
1--
27b. Telephone No 28. Date This Adm:
2003-11-01
Admitt ngOfficer:
ille (,) (.C)--Z+
29. ReportingMTF
(6)(1);?
30. Date !nit Adm
2003-11-01
32. Units Blood Components
31. Selected Administrative Data
Marital Status: DoB:
In/Out Patient: Inpatient MOS:
33. Cause Of Injury:
34. Diagnosis / Operations and Special Procedures:
HEAD TRAMA
S.sa .3 0 qq• .2 7 )1 e7. q4
S;>0.0 I 3•
33 i . 3
1-/ 8..2 . / C •
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
35. Total Days This Facility
Absent Sick Days Other v / Coop Care Days Supplemental Care Bed Days Total Sick Days
Signature of Attending 04(),.._a Signatur., o fficer ---I
11 Arrst--.R ll nn, A,
Automated Facsimile - DA FOR 1 364
DOD-036322
ACLU-RDI 1673 p.106
MEDICAL RECORD PROGRESS NOTES
DATE
). De_c_ D3 ■ 1k II OA I\J bie.,.- 7 _, IA . „ I A ii,Igii Mb XI 1 ' ■_....A -11P■a
lb lq \ -ZS t 1/67) E&) KY\ 110 Cp ____A *1-et . aLetkle_ (j u).
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- 0.)tmLi 119 -Cyr/v.\ .t., s ore.,(Vuts . P+ j ca-3 y-wz.vk Acco, f),,d-
vi_t_Q Ccs 6t4A4 p . ,1.45L,11V.. -PILLS ' - --(--iwicks - i-C siv,e..K.....
y9) a. 4, wetr_de& ovntietin-LcA . Pk-s M 1 214w- X.b0 )e.;2,tj e, AJA,,, (30-35" 1cfit,t/L1) °`I (A -1 -2,40. Pi/ (i.3 - 5 1•'55/ in). ---p2rzy14.24,k0AAA 0,47-whylAstio 5 Nize-.,a_co r,liP:t -6- 2. CA4Sore. -1) )4S ' nk_o_oLQ. Lp EKSo re ---P1 u,s7c1 WC' i os , pro)
---enyvtd.e. 21 OD _fice,- . lniebourioilcit-eA • 1, -A ■ .1 i
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Val CC5WhIrtal- tb tAll/CMTIE rinka-kt., 4 itystirtA)
(6)(()) -7
(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. I WARD NO.
MEDCOM - 22747
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 7-91) Prescribed by GS/VICMR. FIRMR 141
CFR/ USAPPC V1.00
DOD-036323
ACLU-RDI 1673 p.107
AUTHORIZE° FOR LOCAL REFHOOMION
POOGRESS NOTES
DATE NOTES ,
`:CFS
(61,36) k.ISS pc, n Pt --1-rArnS an 0\14n, O irlitt-Q Go otiknaN
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;0 5t cam-- ikral.-iltA-62, . P t --13,A1113 0a 01Wr\.- 4-1A NQS til 'ajat-S 1 n IC NUMBS
RELATIONSHIP TO SPONSOR i SPONSOF.,'S NAME
SPGNSCR'S
r• .4.." vdirri
1 UST I FIRST i mi
DEPArJSERVICE I-ICS:TAt. OR MEDICAL FA CIUT?
F TIEr:T'S [DENT IFIC.: TION: (For typed or r717 Tom_ 1C.:. ;in.: Nome • WI, tio7t, ;77;dele: RE;;;s7FR N.
Pc Se:: ro st Sm. hank15.-rde)
11011 MEDCOM - 22748
NQ- `1
SMO MOTES Medical Rur:tIrd
4.2,701W:30 FORM 5E2 !REV
r,",;:bee •.;',14 ■ C:P.! IC ;-1 .1.:
RECORDS MAINTAINED AT
DOD-036324
ACLU-RDI 1673 p.108
1.• 1..-)i/1 <
Mr: FIRST NAME WIDDLE INITIAL I ID NUMBER
D:, TE NOTES
9 be 03 1 - A s P 3. 11
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USAPR
MEDCOM - 22749
DOD-036325
ACLU-RDI 1673 p.109
PROGRESS NOTES MEDICAL RECORD
DATE NOTES
Ca r Ilk
• IP itA mr"
•
Jer
or _ ,ILA 4.4•"
ont 1
I,
S o
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RECORDS MAINTAIN
AUTHORIZED FOR LOCAL REPRODUCTION
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FIRST
DEPARTJSERVICE
HOSPITAL OR MEDICAL FACILITY
PATIENT'S IDENTIFICATION: (Fox typed or mitten tattles, give: Nome • !ast, frxt. mildk;
ID No Of SSN; Sex: Date of Birth: Rankgradel
LAST
SPONSOR'S NAME
REGISTER NO. WARD NG
1110 MEDCOM - 22750
PROGRESS NOTES Medical Record
STANDARD FORM 5D9 MEV. E
P7asuibeti by GSAIICMR FPMR i41CFRI 01-1110:
LIEAN
DOD-036326
ACLU-RDI 1673 p.110
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NOTES
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MEDCOM - 22751
DOD-036327
ACLU-RDI 1673 p.111
7 .4*
-.or •- 0 I-. .01,11r,
.0.
DATE
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'IOWA IAA •
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AUTHCAZEC FOB ICE31.1qPrCUISTION
MEDICAL RECORD PROGRESS NOTES
NOTES
ii2CC.ICS MAINTA!NED Ar ICS?!TA!, ^bE71CA.. TT
? 7. ENT'S 'for rypricr o.nr0n enrrc. J.ve: •,,arne • •.?:t.
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SIV.PICAP,D FORM
MEDCOM - 22752
DOD-036328
ACLU-RDI 1673 p.112
i kceOLE ;N;l:AL NUMBER FIR.7.1 NAME
NOTES DATE
Qo 1 -9 W-)
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MEDCOM - 22753
6115 c'TANDAP.D I
DOD-036329
ACLU-RDI 1673 p.113
PROGRESS NOTES MEDICAL RECORD
Aro _ 0, • -) D E- C 1q5 5 by).2
• A 1--
Alm "•••••••■••••...41
At L. I
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SPONSOR'S NAME SSNIID NO. ' • RELATIONSHIP TO SPONSOR
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name • last, first, middle; JO No or SSN; Se • Date of Birth. flank/Grade,) REGISTER NO. WARD NO.
1C0-
MEDICAL RECORD I
DOD-036359
ACLU-RDI 1673 p.143
SKIN AND WOUND ASSESSMENT MEDICAL RECORD PROGRESS NOTES
Admission Date:,-3,n na133 Diagnosis:
2
ci-ixt
(15U.) 14-fdkci, 5 TAB HD: a POD: .2 7 // y- t 1. 5 -411144-4:4 )
(See Braden Evaluation Table for Details)
Mobility No limitations 4 Slightly limited 3 Very limited Completely immobile
Braden Scale Evaluation
Sensory No impairment 4 Perception Slightly limited 3
Very limited Q Completed t
Moisture Rarely moist 4 Occasionally moist Moist Constantly moist I
3 Nutrition Excellent 4
Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor
Activity Walks frequently 4 Walks occasionally 3 Chairfast 2 Bedfast CD
Friction and No apparent problem 3 Shear Potential problems _CI)
Problems I
Add the total score
Above 20 Low Risk Between 16 and 20 Medium Risk Between I 1 and 15 High Risk Below 10 Very High Risk
Note: A Braden Scale Score of less than or equal
Total Score ,' (-D 1°
to 15 indicates HIGH RISK -Requires immediate Ulcer prevention program.
Surgical wound (s): Yes No Location: Size: Drainage: Tubes: Appearance: Dressing change:
Pressure Ulcer (s): Yes No Stage I, Il, III, IV-(Circle the one that applies and
1 Location:
_ •
describe below) 2 L\ 4 (,,) - -Z -
- - Wound character: Pint Moist Dry .n n tissue Yellow slough Odor Purulent discharge Es r
1
Exudates :: 11P'
Type of dressing change: Wet-to-dry Co . - el . , sing Carrasyn V-Gel Alginate f
Physician notified/consulted for wound • - • / ilemen CNS notified/consulted for Stage Il and G -ater: Nutrition Referral: Yes N.
es No es No
- Physical Therapy Referral: Yes I No - i Action Taken: Date & Time:
REGISTER NO. [ WARD NO.
Patient's Identification (For typed or written entries give: Name-last, first, middle:
Grade: rank: hospital or medical facilithy)
PROGRESS NOTES
Medical Record ST.kNDARD FORM 509
r.
MEDCOM - 22784
DOD-036360
ACLU-RDI 1673 p.144
dical Record Progress Notes Wound and Skin Assessment
Date and Time 2S WAS i 4-3 (3 Wound number A Stage l-f V lu / 64-- Location a) 51tou 14..et.-- Shape D61614 Measurements ja (0,4j ,.1( f, au w x . . “ ta 0 Tissue Color • . 4. yt Drains and Type se ,,, -0: afrA Dv-Dr.linage (amt and color) 0 e : Dressing Type t . ) .. ) -e 4- -4 aky Dressing Change Frequency -r,(0 Wound Cleansing. /j 6 Additional Info (turning, elevation -ofextremeties, etc.) -e $ur 42 +-4 i)-ri y4-h' wouyg -4146rdy/f( 7- K1 /1044— a k y c 5-fieri if y (.1 L.) ? P , y'a-et 47 6.:::7S.e tio. is-X (4 n .-tanuke I; 14 DT (0ficlei-stii* up',/,' avl t4u3=t , orev ars e , 4, 5-e c.-- c7- Uire -to.p-e . Date arfd Time zt. Any, /4e Wound number ' A< Stage I-IV j\1 /14- - Surgical or._ A rApx-e ( Locations L_LQd_Rj c,...— Shape Dill 61,4za
_14 Date and Time 2 q 1̀ 361163 i / 4636 Wound number ___Ak40 .a..
•: Stage I-IV t1/4) 1 It- - Stirgical or . -orr------1.---gica LI Locatibn (i›) 5- 441, Shape D k, )„ A&: Measurements 3 L iti /x i. 5 ca., i4-1. K 5 c.)etc ec.4 ( ?i ssue Color pc ilk i wilts-I— Drains and Type ietiAe..: • Drainage (amt and color) filf Ova a ►e- Dr::ssini2 Type (-01.14 .c ( Drssing Change Frequency Q c---7 t., Wound Cleansing ("lea a i. S _c , past . c_ ..v.:,-1. Honal Info (turninP. elevation or extr
met s, etc.) ;i
P a c rr_ ID: IY
k(,-1-, Unit No.
Standard Form 509
MEDCOM - 22785
or Non-Surgical Av !AAA
x Measurements A (44 L X 3 CriA. IAJ X I C_41) Tissue Color e ; vlirlf 14A6 i 5 -
Drains and Type Drainage (amt and color) 125. Oor . / 140 ..0 v401.-- by A e ctrovi-tvz_ 41`53 a •(' Dressing Type %.,4->41+:4- - vVir '--1 . _ Dressing Change Frequency ----7 I [. D Wound Cleansing 5.e 214AP a. 5 et 10 a Oe Additional Info (turning, elevation of extremeties, etc.)
g eat t!L%—
d_tr / Cci e
DOD-036361
ACLU-RDI 1673 p.145
Medical Record Progress Notes Wound and Skin Assessment
Lf- Date and Time '1 A)61/ 03, If? 6 Stage I-IV / Surgical Location yl,L ; 4 Shape n to t b i4b. Tissue Color Drains and Type Drainage (amt and color) Dressing Type Ll e O.. v-
—Dressing Change Frequency Additional Info (turning elev
a 4-0\ t.i i &is LW y •
Wound number or No
2 (144 x c , rev (
<4{/.4.4 P rks fire ui a US
Measurements U- -
0 la S ;
y---? d c,..6. Wound Cleansing ation of extrefneties,. etc.) LtP e
Date and Time Stage I-IV Location Shape Tissue Color
Wound number
•Surgical or Non-Surgical
Measurements
Drains and Type Drainage (amt and color) Dressing Type Dressing Change Frequency Wound Cleansing Additional Info (turning, elevation of ext:i -emeties, etc.)
Date and Time Wound number Stage I-IV Surgical or Non-Surgical Location Shape Measurements Tissue Color Drains and Type Drainage (amt and color) Dressing. Type Dressing Change Frequency Wound Cleansing_ Additional Info (turning. elevation'of extremeties, etc.)
Patient ID: Unit No. Standard Form 509
MEDCOM - 22786
DOD-036362
ACLU-RDI 1673 p.146
PLAN OF CARE FOR SKIN BREAKDOWN AND MEDICAL RECORD
w t- it..eei,( PROGRESS NOTES
Admission Date: 411 p447— Diagnosis HD: -2C( POD: 2 7//! /4
Dateg 1-bliai Time: RN Signature: 1+7 4f.*`-' Skin breakdown as evidence by immobility, friction, und, skin tear.
K .f iArx.clux it.r I
Wound type: Surgical wound (s) Location(V)514 ou - .s Siz ("It'° Drainage: Diabetic ulcer Tubes: 14 IC ` PiPins:7.:-.) Ati5PFala Va. ire: 14,(6156 0 Venous stasi,s-alcer Dressing change: —n 0 m lc-14.x tc.4.- • at.- orc Other 1,-- Describe _Sh vs,—si ct.4...( tArai-e-4.01_
Burn wound (s): % BSA Partial Full Location: Size Appearance: Dressing change:
Pressure Ulcer (s): Stage I, II, III, IV (Circle the one that applies and describe below)
Location: C) 5 litzd ike- Size: 3 Wound character: Pink 1"---Moist 1,./Dry Granulation tis ue ✓...---- Yellow slough
Tunneling clUndermining Odorpc Purulent discharge Eschar Exi.Es/e.
Refer to SOP for Dressing Change Instrucitons.
Please check the appropriate dressing Change:
LOCut,6 X Wet to Dry Dressing k
a .3-- ❑ Carrasyn-V GelDressing
❑ Alginate Dressing
4 Comfeel Dressing 4 3 csp-Szi-e ak Lf ❑ Pin Site Care
❑ J-Tube Care
❑ Colostomy Care
❑ Chest Tube Care
❑ Burn Care
NOTE: Document daily wound and dressing change on,Progress Note or
Mote.
Select the appropriate products used:
lia"§terile 4x4 gauze dressing ❑ Sterile 2x2 gauze dressing Er -§i-erile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage 12--gfeTile Normal Saline ❑ Sterile Water ❑ 8 x 4 Sponge gauze E:1-0p-site ❑ Tegaderm clear dressing ❑ Alkare skin prep El--Co—mfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel ❑ Alginate ❑ Bacitracin ❑ Silvadene Cream
itNursing
❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film
if3--STE-ile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ 0.125% Dakins so! ❑ Betadine Swab sticks ❑ I/2 Hydrogen Peroxide & V2
Sterile Normal Saline
Select the frequency of dressing changer t.
❑ b.i.d. ---t.i.d
MD Signature and Date:
()\ ---?—
4.,1'uda.-tt
Patient's Identification (For typed or Written entries give: Name-last, first, middle:
Grade; rank; hospital or medical facility) /Medical Record, SF 509
A AIM (6)'l
41/4A" WNW MEDCOM - 22787
DOD-036363 ACLU-RDI 1673 p.147
Date.: - Sensory Perception
Moisture
ACtiylry
No Irnoairrnen t
Sliuhtly Limited 3
Very Limited /
Completely Impaired 1 4
Rarely Moist .
Occasionally Moist 3 '
Moist 1 ' _
Constai-itly Moist 1_
Walks Frequently 4
Walks Occasionally 3
Chairfast 1 Bedfast
Low. Risk Med sk
4
1
No Limitations 1 ,
Slightly Limited 3
Very Limited /
Completely Immobile 1 4
Excellent Adequate (Eats >50% )
3
Adequa,:e. (rarely eats) 2
Very Poor I No Apparent Problem, 3 Potential Problem
1 _ 1
Proble.ms
Mobility
Nutrition
Friction and •
Shear
ical Record
Progress Notes
Braden Scale Evaluation
) ‘.5 3
:Notobilit‘
Very Limited Slit_11-
,:;.\• Limited
Con-,,,-,,letely Impaired 1
Occasionally Moist Rarely Moist
Moist Constantly Moist \oValks Frequently.
4
Walks Occasionally 3 1
) Chairfast Bedfast.
Low Risk Med Risk 1-iia"n Risk Verb High Risk
No Limitations Slic_htic Limited • 3
Very Limited Completely Imnto'oil.E.,
Adequate (Eats >50%) Aclequate (rarereats)
Very Poor No Apparent Pro'olen
potential Problem Problems
Total Score: .Score <15 requires Immediate Ulcer Prevention Program
Total Score:
Score <15 Immediate.
C1cer vention Proarani Pre
Cnit: No. Standarc.iForm 50'9
Nutrition
Friction and
Shear
Date: Sensory Perception
Ntoisture
Activity
Above 20 16-19 11-15 Below 10
MEDCOM - 22788
DOD-036364
ACLU-RDI 1673 p.148
iviclill,AAL ritLAJIILJ - VA! ItN I ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT DATE: I i 925 .(4-3 I PATIENT ACUITY LEVEL : ...Ur POST-OP DAY: ,g7.. iy HOSPITAL DAY:
T R A N
S
F
E R
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN ET To :-. C.CA-3-t/Q From T.C. U 31 c•• Time
- TELEPHONE REPORT:
II I AMBULATORY CRUTCHES I
Total ER/RR/PACU time Physician e,..../•-•' WHEELCHAIR I STRETCHER
Anesthesia (Specify): Procedure/Diagnosis 5- Z aip 110/G I P 110-120 33. pp R T i
--bro.c.41_, LOC 5), s ,., er Neurovascular
checks Dressing/cast SuitrreS -11C2. IneCitCP , Tubes Vn, IC4 CO:4140 Intake (IV, po) AO t gh(2114 Output (EBL, other) (9(C)--L./ 10 I Voided No Yes Amount: -
. Medication .95 /1/46 Z PO tCQ ka5 . , 'CIA iMs- ci-‘n r. i c 1 rikl--; 10 cc i 1 cAA .e coon+ Other 6-5- Us) 40 krtic g : mecrief pw -ctLis'I-s C) 51 Report From CPr
Received By LT AIIIII.6-111/1111110
T A L
S
I G
S
TIME: dig - \............ ______----- BP ARTERIAL LINE ........--•-••-•
(TM PIXA V 1°) lie BP CUFF
TEMPERATURE 9) 7 ) l.1 30
,,...."....
476 11 3 2-1_,
(15 '•,n
CM'S/ PULSE
RESPIRATORY RATE
OXYGEN (L/%)
PULSE OXIMETER CH- W. PI CI 02 METHOD 91% i2-t f797
N fith
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar mask
, ,
CI- < - Z
TIME: Oa y 702y. a 156
p E
I
L
E E D S
TIME: (9a5"
PAIN INTENSITY
10
•. • • •
. . • •
'Skin breakdown prevention
' Falls prevention protocol
'Restraint protocol
'Seizure precautions
' Isolation precautions
0 . .
___O_________/4
• • ' • . .
„L./
• •
. .
•
tA
• • • • . . . .
MED ADMINISTERED IYINI
RELIEF ACCEPTABLE IY/N)
ikt
/V14-
.._ ._.._
O TIME:
T FINGER STICK GLUCOSE
— _ ... ...
YESTERDAY'S WEIGHT: H INSULIN (Y/NI
TODAY'S WEIGHT: 1. E WEIGHT CHA R
'Per hospitil policy.
24 HOUR TOTALS
PO IV #1
.
IV #2 TOTAL IN Urine
211C0 Stool TOTAL OUT ,.
PATIENT IDENTIFICATION
.
40 —C1 EPwlat C DIAGNOSIS: sha Crania / DAG: ADMISSION ATE: /6/ 3 1/9-3 — LOS: EXPECTED. R E SE:
CASE MANAGER: . t- C._ PRIMARY CARE MANAGER:
MEDCOM - 22789 EOUIRED (Specify :
4r,
DOD-036365
ACLU-RDI 1673 p.149
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criterip are explanation of abnormal findings will be noted in the appropriate column.
TIME: 16ve, INITIALS: TIME: INITIALS: TIME:c5915 6 .,
time place and name. Responds appropriately. • Communication is adequate to express needs.
Pupils equal and reactive to light.
1. NEUROLOGICAL: Alert and oriented to I I AL-c-g-r II k leir--k-
within range for age. No dependent edema. ,,..c::, Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
2. CARDIOVASCULAR: Pulse regular & rate I 7:14tc-H F cilrfe-- E 1---1 I I
regular. No cough. No abnormal breath sounds.
3. PULMONARY: Respirations within normal I 774-clag•Pa-4C e 35-. 1 I I-1- fl 0_...,.. rate for age group; quiet and regular. Depth, is 1724.c..)..1 -6---,. bt41.4„i3),,qc„0 -rr .c., RR • h. VI vitc\-ed, ob. ,,.•
4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding. ,
I A
urgency, frequency, nocturia. Urine clear, 5. G.U.: Reports no dysuria, retention, I I V. +0 criA.4 1 yellow/amber. No unusual discharge. Qt RI td ' ■
development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
6. MUSCULOSKELETAL: Normal muscle I 1 i., /2.e9o, 're, Cl) 5,Dt_ i 1 - 1-1 go oiLstd.
No redness, blanching, irritation over bony j.,4c. 7-.:::.p,5T t.-f.._ prominences. Mucous membranes moist. Crr-A
7. SKIN: Warm, dry, intact. Good turgor. No I 1ScA-c-P C.-,9c-Tc'CSIOL I-1 1 Isecap kotit,, -fiz.s51 rashes, inflimmation, ulcers, breaks in skin. DsCs-ro ..., gsiez,Loia_icar
• .1;1-PLA°`-
8. PAIN: No complaints of pain/ discomfort. R07---Of/l,Ii-5 (See page 1 for documenting pain intensity.)
and appropriate to situation: Interacts appropriately with others.
9. PSYCHOSOCIAL: Behavior is appropriate I Prirp-**44-0 lmiliS1-1- I I I to to the situation. Anxiety is controlled or mild 72, SPe..4K,
10. IV SITE ASSESSMENT: (LEG • P Puffy I - Infiltrated R - Reddened OK - No swelling/redne s * - Central line) VICT9 TIME: INITIALS: TIME: INITIALS: TIME:c9 ( frb0 INITIALS
IV patency ✓ q 5 let IV patency I q hr: IV patency ✓ q %--- hr: p IV site care provided: 05s£55 IV site care provided: IV site care provided: 1A6g,e4SSRci IV tubing changed: IV tubing changed: IV tubing changed:
LOCATION • CONDITION • ATION CONDITION LOCATION CONDITION. IV Site #1: •02.012-1S-1' b K IV Site #1: IV Site #1: cDc•A OL_ IV Site #2: IV Site #2- IV Site #2: __
Comments: 03-4}5 ,...-2,or e,154.-- Co • Tents: Comments:
claskQA .1-1-T)__a
MEDCOM 22790 mplIrnm Fr)RM AR4.17 riTc7 -) (MCHOI MAR 99 Page 2 of 4 pages
DOD-036366
ACLU-RDI 1673 p.150
SECTION III - PATIENT INTERVENTIONS & TEACHING
N E
U
R
V
A, ✓
Si:
C
U
L
A R
SITE: TIME: r 1 cpc)
A F E
Y
T H
E R
TIME: (100 4%
COLOR P I \
S ID band visible/legible
CAPILLARY REFILL Orient to environment prn
Side rails (2/4) up
1111i TEMPERATURE (4. Al
ME 0 EDEMA •
Bed position low
SENSATION S Call light within reach
MOTION 2--CO Review & post lab results
IP la
'I PASSIVE FLEXION c: -- •N
PERIPHERAL PULSE . Notify MD abnormal labs
LEGEND
I
Plelli
I Ne-713 MO
Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-1> 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripher .al Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Tum /reposition
Incontinent urine/stool
Linen change prn
Tu/reposition q2h
ROM q2h if immobile
Antiembolic hose IP'
o
W I-- 1
BREAKFAST LUNCH DINNER
TYPE: T YPE A ___C,,/-/ 50.1=-7- TYPE: 4A( ut ce:477-- PERCENT CONS ' • I; PERCENT CONSUMED: 1-165(--Z. PERCENT CONSUMED: 6C.., •
HOW Ti •ATED: HOW TOLERATED: LoLt- c_ HOW TOLERATED: /..,;E_ l_ (--.
il SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST V COMPLETE ❑ SELF ❑ ASSIST peCOMPLETE
A
D
L
S
T E. A C H
N G
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE CD SELF ❑ COMPLETE
5Y ASSIST ❑ TOTAL
❑ SELF J2I COMPLETE
❑ ASSIST ❑ TOTAL
El SELF '54 COMPLETE
❑ ASSIST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
i .._ ❑ SELF ❑ SELF
AMBULATE CI ASSIST
BSC # TIMES/SHIFT
BRP
CHAIR
- Ff-----)7ThiE, ❑ SELF
AMBULATE !A ASSIST
BSC # TIMES/SHIFT
BRP
AMBULATE ❑ ASSIST
BSC
BRP # TIMES/SHIFT
'•.
CHAIR r (:1-IA
INITIALS: TIME: I/C-AD INITIALS: /..., TIME: INITIALS: TIME:
CONTENT: l'ec0,6 Ow Punt 0 (Frs ,c) ak-57/241-7-5
•ktsi-29/Air Pwrero )
ypatient,Fami, Verbalizes Understanding
CONTENT:
Prdi Patient/Family Verbalizes Understanding
CONTENT:
❑ Patient/Family Verbalizes Understanding PATIENT. IDENTIFICATION
()V)
C.9(6)--L1
INITIALS SI GNATURE SHIFT
ea-14 6 -1 )
i t w 'I ii%
-R ( CHO) MAR 99 Page 3 of 4 pages
MEDCOM - 22791
DOD-036367
ACLU-RDI 1673 p.151
SECTION III - INTERVENTIONS & TEACHING (Coat)
W
0 U N
A R
T
I M E
LOCATION OF WOUND APPEARANCE TREATMENTS
AND DRESSING CHANGE
---, Or
2( --D .s \A.Ci A dIii (g) `S\A0.0\69-► -
C
E'
SECTION IV - NOTES
•
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 4 of 4 pages
MEDCOM - 22792
DOD-036368
ACLU-RDI 1673 p.152
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: &GI OW 0‘ PATIENT ACUITY LEVEL :'-i `( POST-OP DAY:RV1 1 .HOSPITAL DAY:
T • 13-
" .. N
S
R .
.!• t ■ PLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
Time To From
- TELEPHONE REPORT:
I AMBULATORY I II I STRETCHER CRUTCHES WHEELCHAIR
Total ER/RR/PACU, time Physician Anesthesia (Specify): •
Procedure/Diagnosis B/P P '' R T LOC Neurovascular checks Dressing/cast Tubes
Fr. (IV, po) Output (EBL, other) • ded Ill No I Yes Amount: Medication
Other
Report From Received By
Pe
.
-: 17.
-
CL
'
..,.
TIME: peb kr) efigib ----
BP ARTERIAL LINE i(",-
BP CUFF —) 1_ !CO 1 1
TEMPERATURE '11 ' q PULSE
1°S-' i RESPIRATORY RATE
" 1
OXYGEN (L/%) ///vim/ ./....'
PULSE OXIMETER ... l ta 02 METHOD if
N S
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask MT = Mist tent PR = Partial rebreather A =-- Aerosol TC = Trach collar
A
TIME: 109011:21
p
E D
TIME: • Skin breakdown
prevention
'Falls prevention protocol
'Restraint protocol - - - -
• Seizure precautions
'Isolation precautions
MO
PAIN INTENSITY
lo
o : . . . .
. . • •
MED ADMINISTERED IY/N)
RELIEF ACCEPTABLE IY/NI
-----..„,.......
- -„_____ 0 TIME:
T H INSULIN
FINGER STICK GLUCOSE
IY/NI
-"=:---, YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:---...,,
E , WEIGHT CHANGE:.-
R Per hospital policy.
' 24 HOUR TOTALS
PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
PATIENT IDENTIFICATION
CLS)t)
illili (40-1
.
• DIAGNOSIS: Sr() °Can i DRG: ADMISSION E: 1-, 1 = QTS LOS: EXPECTED RELEASE:
CASE MANAGER: C4,0 7_ PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.00
10.
MEDCOM - 22793
DOD-036369
ACLU-RDI 1673 p.153
........ _.. SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been ME . If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
-C)':-Z--
1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately.
Communication is adequate to express needs.
PUpils equal and reactive to light.
`-poacterwt) tt° iAxe
TIME: 0 A INITIAL •
i'l 1-e.r+ - 47a..o4
kr"- i
ezb---d .. .,r) -e.cd31 c3i.)..-f .--b
,
-4-A.k. 11- c%
TIME: INITIALS:
LI TIME:. fire ea !Milt.
I ihiSirti,i9 Or ■ w' '10
t 2. 'CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity peffusion)
I Jr Lys
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
—
i
11
-421,.l,t,itr1C11;14t3N7e15
6; h
Pr jNe-Q .)*.i
( iii, II 11101 OA .
a 4. G.I.: Abdomen soft and non-distended.
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or rectal bleeding.
Bowel sounds active. Reports no N/V/pain El"'''. ❑
5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
1.e 119 vi.
c lear y e /4,1,,L) t. ( .4 ' a -)*-)'")&16111 , Le 6: MUSCULOSKELETAL: Normal muscle
development and mass for age. No
deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
' (06C par .-...7
.",e.41c
/ '
dk a a bl-e er rei 1 I •12_
1,,,,,. ,4 -1.
I 1
OL1 \ feft1 14
5"/S" Na--.10 CITX-1 e)1 E.5
at f5)5 L9fvf\10Cgi_
7.- SKIN: Warm, dry, intact. Good turgor. No rashes. i nflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony , prominences. Mucous membranes moist.
❑ lieSULFt--- Se.a.).c) \AC-
.- (-. 1 -it, e se 4e -`f
Q I sscap ( a_c_. . .
8. PAIN: No complaints of pain/ discomfort. (See page 1 (or documenting pain intensiFy.)
n .
• p9 I - cee
' ❑
se)._ -()--P6 \ 9. PSYCHOSOCIAL: Behavior is appropriate I to the situation. Anxiety is controlled or mild and appropriate 40 situation. Interacts appropriately with others.
......_
J-- r..._ cble -to v.kv-Ite_ 'i)elocre..,Is4-G Grad
arxbic _a4-- @t fish kh
0 I I Corribt-A.ivQ• -if
. -to PAG1',,, sk
a/ YN:t‘- , k
((*)1- 10. IV SITE ASSESSMENT: (LEGEND: P Puff n i trated R - Reddened OK.- No swelling/redness * - Cei--711611iFret )
TIME: /0 i 0 INITIALS:
IV patency „/ q hr:
TIME: INITIALS: TIME: 25M_ INITIALS: IVpatency I q hr: IV patency ,/ q W hr: _
IV site care provided: IV site care provided: AIIIIII IV site care provided: IV tubing changed: IV tubing changed: AIIIIIIII IV tubing changed:
LOCATION CONDITION
IV Site #1: Pft oe- LOCAll• 4 CONDITION LOCATION CONDITION
IV Site #1: IV Site #1: () IV Site #2:
IV Site #2: IV Site #2:
Comments: ., . (OS .pj as-- f
V ' Comments: Comments:
• '
S
MEDCOM FORM 689-R (TEST) (MCH01 MAR 9 Page 2 of 4 pages
MEDCOM - 22794
DOD-036370
ACLU-RDI 1673 p.154
SECTION III - PATIENT INTERVENTIONS & TEACHING
N
E .u.
V
A.
S:'
• -
U L
A •
-
SITE: /..-C TIME: /00 p
..:edi P . S
A
F E T y
TIME: /0/0 ... Vok COLOR ID band visible/legible
CAPILLARY REFILL I I Orient to environment prn ---- Ali TEMPERATURE v.) lik- Side rails (2/4) up Alb- '-
EDEMA AS, Bed position low All SENSATION 5 Call light within reach
MOTION (.A
PASSIVE FLEXION 1-----•---Z--
a., .Q,.
O
T H
E
R
ROM q2h if immobile
Review & post lab results
PERIPHERAL PULSE Notify MD abnormal labs ,
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-(> 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine/stool
Linen change prn
Turn/reposition q2h
Antiembolic hose
I
BREAKFAST LUNCH DINNER ..
TYPE: /neck for7( TYPE: /yi ez,..47 sa (‘-/--- PERCENT CONSUMED: .0,5r)
TYPE: (NRQ00__(__. PERCENT CONSUMED: PERCENT CONSUMED: /00
HOW TOLERATED:• L.,,),,e_ge HOW TOLERATED: t,,....A.e121,1 HOW TOLERATED:
❑ SELF 0 ASSIST . cit COMPLETE ❑ SELF ASSIST ❑ COMPLETE ❑ SELF 4] ASSIST ❑ COMPLETE
D
L
0700-1500 1500-2300 2300-0700 •
❑ SELF ,:l C OMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF 0 COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF 04 COMPLETE
0 ASSIST ❑ TOTAL 1-
TYPE OF ACTIVITY (Circle all that apply)
- .. BRES Oa SELF ._ AMBULATE ,WASSIST BSC
BRP ' # TIMES/SHIFT
-
CHAIR
BEDREST ❑ SELF AMBULATE ❑ ASSIST
BSC . TIMES/SHIFT
BRP
CHAIR
BEDREST ❑ SELF AMBULATE ❑ ASSIST
BSC # TIMES/SHIFT
...„._RP
.4oCIAIR..)
TIME: /010 INITIALS: 111111 TIME: INITIALS: TIME: INITIALS:
CONTENT: €0 a4-yLed
T Fy4,,Nrk r V? 1 erYt e• ■-•.- E .
A — Ca-e -fir r- C
I . -74-4 .,- ii e.," ,r). Y-I-Le N h.,C5 f) 'ia4.' — by - raiz rp r G
AIWP,...or.._,
....jap, amily Verbalizes Understandi
CONTENT:
❑ Patient/Family Verbalizes Understanding
CONTENT:
❑ PatientiFamily Verbalizes Understanding PA '" WRPIPP- TIFICATION
INITIALS
Pig Mr go-ci ....._.__._
SIGNATURE SHIFT
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 3 of 4 pages
MEDCOM - 22795
DOD-036371
ACLU-RDI 1673 p.155
JCL. I RAM III - IINI I CtiV CPI I IlJnIZI & I tALMING 1Conti
W
0
U N
...,
T
I M E
.
LOCATION O OF WOUND APPEARANCE TREATMENTS
AND DRESSING CHANGE
x
• -
_ ..---- .-- „--
.,-------- SECTION IV - NOTES •
1100 - Pt tAf -hp CkaA,A
..., ; /14/i/e0(
la
1.111 l' A
-e
/ Ft / I di AffirCiii .4L•I1 , •
/4- --...7121te - ,,,,.
ammo td • it 1_,Tb -- Fi • iitryl -1•-&,iocti - , ..
I . /1/
41- 9 -
III' -4111....■111.
CL17s- /
AIP 4 IllAll .41°F-110- gr erg 0
0 ),-1 oa-- A 1
1#1. A 0 ) j r
dad, e ',Ay V
_
4)4A \ Tyv la Allb.
'', 0I,Ir / ,_,.. „... Aril Are
_ L . 11 , rso,yrwezi II MAI Al Ca^ exa....
At;
•
MEDCOM FORM 689-R (TEST) MICRO) MAR 99 Page 4 of 4 pages
H
MEDCOM - 22796
DOD-036372
ACLU-RDI 1673 p.156
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: t)CAJ Ono I PATIENT ACUITY LEVEL : I POST-OP DAY: Koll / / ( p HOSPITAL DAY: (3 ( ..
T. :
N . S,
t
R .
.:• ,
, .,..
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
Time To From
- TELEPHONE REPORT:
a AMBULATORY In CRUTCHES a 111 WHEELCHAIR STRETCHER
Total ER/RR/PACU time Physician Anesthesia (Specify):
A. Procedure/Diagnosis B/P P R T LOC Neurovascular checks
Dressing/cast Tubes
Intake (IV, po) Output (EBL, other) Voided U No . Yes Amount: Medication
Other
Report From Received By
.. '.: '
•
-:.,'•
C:
TIME: '54.14) 013-0 04' . BP ARTERIAL LINE ..,./.
I 144,a, /Wye' qt -1
.
BP CUFF
WA TEMPERATURE
PULSE •-)1 /85- RESPIRATORY RATE t r 4 OXYGEN (L/%)
PULSE OXIMETER 00 AZ
02 METHOD
N
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask ' ` MT Mist tent . PR = Partial rebreather A = Aerosol
S{=
VM ,= Venturi mask TC = Trach collar
P.
N_.
TIME: pis arp
p
A
N E
D
I TIME: • '‘... . 1
PAIN INTENSITY s
"
• .. "
" '
• •
• ' .. " .. " .. " .. '
• • .. "
" . . • Skin breakdown
_ prevention
'Falls prevention protocol 11 'Restraint protocol
-- - -- - - --- 'Seizure precautions
•Isolation precautions RELIEF ACCEPTABLE IY/N) /tJ A
O. TIME: -
' FINGER STICK GLUCOSE
r H INSULIN (YM) es
S TODAY'S WEIGHT:
WEIGHT CHANGE: (--,
'Per hospital policy. R
24 HOUR TOTALS
PO IV #1 11.1 #2 . TOTAL Urine
7%9E)
Stool too TOTAL OUT (
a6kla PATIENT IDENTIFICATION
.:. PJ Ali 00
- , DIAGNOSIS: 6/f, orain levarm s t-1,646)11J DRG: ADMISSION I/W: I - 0)
LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGE
_....----i/ ISOLATION REQUIRED (Specify):
\■.._ MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages MC V1.00
MEDCOM - 22797
DOD-036373
ACLU-RDI 1673 p.157
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been M T. II all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. b
TIME: lb 41 .5 INITIAL IME:' I (D, INITIALS: JJJ
TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
Communication is adequate to express needs.
Pupils equal and reactive to light.
-ftv mpg, Lorst+Ir% .
time place and name. Responds appropriately. I Le51‘ OL.05 SIAN'
C6r7.11Y)'ahillS •
Corn re, un t cz.jr,g
I I .--6-1;2e..eiu,-5 I I
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
1 /
3. PULMONARY: Respirations within normal for age group; quiet and regular. Depth is
regular. No cough. No abnormal breath sounds.
'ira eke oz4ony . ft_ ..e. v.04.,,,hue.
C b1/45,6 1111t4IS 11
ek_rhnret •
I 0 4-0(07\
Ds5- cA-31- (-)
I fi
4. G.1.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
Iq' I L.-V Li
5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
te1l0a) VtArre •
31( y 40 Tranit41 E ctfpr-
0 - • , • j..v.zi •
6. MUSCULOSKELETAL: Normal muscle
development and mass for age. No
deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tenderness, weakness or paresthesia.
ri 0,1.4.ict% yno.-6„ fora 10-17G> trE,
..sid body ., 4 ' 006 -e assrs+ )C 2
n * ino.tur .6,,,,e-fv•-> 6
7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony prominences. Mucous membranes moist.
511rCLI Ine i WO tilLpi•
40 064, .eas-1-, 5 1+001 CLL.= •
-1-t-4--Q I I 54‘--•kr10
v- IA'L-0A
8. PAIN: No complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.) e..- I /r- ❑
9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others. Mu - 1_
10 I I
10. IV SITE ASSESSMENT: (LEGEND: Puffy I - Infiltrated R - Reddened OK - No swelling/redness - Central line)
TIME: IOU INITIALS:
IV patency 1 q pi hr: p
TIME:1?-)C1 INITIALS -- •
IV patency ✓ q....S hr: _
TIME: INITIALS:
IV patency I q hr: IV site care provided: as5r55eci IV site care provided: Q....;;"je,"›..0 IV site care provided: IV tubing changed: IV tubing changed: IV tubing changed:
LOCATION CONDITION ,
IV Site #1: sec'
r .LOCATION CONDITION
IV Site #1: )_ Ac...., c)K LOCATION CONDITION
IV Site #1: IV Site #2: IV Site #2: IV Site #2:
Comments: Tv F p -1-Kb Comments: Comments:
,
MEDCOM FORM 689-F? (TEST) (MC)/O1 MAR 99 Page 2 of 4 pages
MEDCOM - 22798
DOD-036374
ACLU-RDI 1673 p.158
JCL. I Il/1)1 III - rm ICII I III I LILY LII I 'VIII. UI I Lo,...111 ,11,7
SITE: LA) E t, (,F TIME: ../
/O 5° ,21(3i6
IC
f) < L
L 11J
TIME: =Ea
COLOR f J el2f. ID band visible/legible
CAPILLARY REFILL I I f I Orient to environment prn
TEMPERATURE J4) tA) W W Side rails (2/4) up
EDEMA P 0 0 o Bed position low 11111 SENSATION S , S S Call light within reach
MOTION *#11 19■.-NM[A4411 , PASSIVE FLEXION
PERIPHERAL PULSE
91"
/ // 1
at 94 2*
UJ CC
Review & post lab results
Notify MD abnormal labs
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-1> 5 secs)
Temperatiire: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; ID-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine/stool
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose Pir
- U
J H
I
BREAKFAST DINNER
TYPE: e, lll)_CeF, 1
TYPE: g----
TYPE:
PERCENT CONSUMER` Ser cit10,4) PERCENT CONSUMED: ac,--2 4--- PERCENT C ONSUMED: c..., HOW TOLERATED: 0, trit.f ' HOW TOLERATED: 51-xej HOW TOLERATED: S 1e—e---E
❑ SELF )c ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST 0 COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE
D
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE ❑ SELF XCOMPLETE
0 • ASSIST ❑ TOTAL
❑ SELF ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF K COMPLETE
It1, ASSIST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
•
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
# TIMES/SHIFT 3 BRP
✓CHAIR
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC # TIMES/SHIFT
BRP
CHAIR
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
Atia h # TIMES/SHIFT :RP
- AIR
; .
T E A C
TIME: It S INITIALS: TIME: INITIALS: TIME: gt 3 0 INITIALS:
— CONTENT:
0 iferSOInCti hy2iehe
,) ri v1.5-;46 r 3-- c Wowed
❑ Patient/Family Verbalizes Understanding
N
_ • T:
❑ Patient/Family Verbalizes Understanding
CONTENT:
. Cale ..-
,.
Patient amity Verbalizes Understanding
PATIENT IDENTIFICATION
HIC )1
INITIALS SIGNATURE SHIFT
II AitAl
MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 3 of 4 pages
MEDCOM - 22799
DOD-036375
ACLU-RDI 1673 p.159
SECTION III - INTERVENTIONS & TEACHING (Cont)
ci<
ctui
LOCATION OF WOUND APPEARANCE TREATMENTS
AND DRESSING CHANGE
(g @GWCILI/ .
C CLIN' KU-SKI (teCt"
SECTION IV - NOTES
lo IS : %. MIS --ko On citr cyloi t5C 1 a‘10 : A cfo jtve,tp po, ■ 4 40 e4 . yids acct. fetal' 4c) 6. f). /119 ru II--cd c,-1 pqi,-, r3wcb arkori o roar-, / apm...- .
00-7--
MEDCOM FORM 68.9.R (TEST) (MOHO) MAR 99 MEDCOM - 22800
Page 4 of 4 pages
DOD-036376
ACLU-RDI 1673 p.160
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: I \-DQ c_0 --6 PATIENT ACUITY LEVEL : 'III -' POST-OP DAY: 39 v7 HOSPITAL DAY: i
T R A N
S'' F E R
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
Time To From
- TELEPHONE REPORT:
. AMBULATORY I CRUTCHES . I WHEELCHAIR STRETCHER
Total ER/RR/PACU time Physician Anesthesia (Specify):
Procedure/Diagnosis B/P P R T LOC Neurovascular checks
Dressing/cast Tubes
Intake (IV, po) Output (EBL, other) Voided I o U Yes Amount: Medication
Other
Report From Received By
SI
..11
T
•
TIME: 1()CD/IGCb C . AW BP ARTERIAL LINE ,------..../..-
BP CUFF J(9'4 14' 7e4
TEMPERATURE ,..-ifd 9551 PULSE 91 /0/
RESPIRATORY RATE 1( -...•
VD AO OXYGEN (L/%)
PULSE OXIMETER l' ///,
02 METHOD
N S
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask MT = Mist tent • PR = Partial rebreather A = Aerosol TC = Trach collar
A -
TIME: rly) . 0
s p
C
N E E D
TIME: Ot ___;•24.(2
PAIN
INTENSITY
io
. . . • • • . •
'Skin breakdown prevention
'Falls prevention protocol
'Restraint protocol
'Seizure precautions
.1solation precautions
_P& PM
0 . .
jc :
• • . .
MED ADMINISTERED (Y/N/ t,„) RELIEF ACCEPTABLE IY/NI pft N 9- A
O TIME:
H
FINGER STICK GLUCOSE YESTERD EIGHT:
TODAY'S WEIGH .
WEIGHT CHANGE:
'Per hospital policy.
INSULIN (Y/NI
E R
24 HOUR TOTALS
PO ./ #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
PATIENT IDENTIFICAT ON
-EPLAJ 44-0
- , DIAGNOSIS: sir Cre(niottn 6614jOshinarhf DRG:
/ ADMISZN DATE: ?)) 0c21-0-
LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages mc vi.o0
MEDCOM - 22801
DOD-036377
ACLU-RDI 1673 p.161
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria explanation of abnormal findings will be noted in the appropriate column.
havee JET.41 all the stated criteria are not met, a brief 4....„-).- ... ,..-^ >
Z
TIME: 09 30 INITIALS TIME: 0 INITIALS: TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately
Communication is adequate to express needs..
Pupils equal and reactive to light.
I-1 pt I-10_5 lime_ ' (fiih.o...re- ‘The. O.0
d QS\ -"" Lc.19„,_ eg-eAr\--:),10/ ° --i-olk_a_pt
Pr
i hi- ÷CP!"-e-r p- WitA I ' cfadc iv, Cottio1Vc.. -. ses-lcs.s 00-tcA -ho-e-r 11 o_e,+- c,„
ct.-1- mcv , j t kg. w i
u
ev- 4ranstaiut .
l—tY 0 2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
7 "V 1Q li-ach Si le, J V54
I I
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
yellow/amber. No unusual discharge.
t ks■ -
urge ncy, frequency, nocturia. Urine clear, n l%
• ,,•'' . • e ,..11
C9-41_ 0-.A : ‘
1 I Ctle-e,-y-4° I. [1
6. MUSCULOSKELETAL: Normal muscle 1 I Pk, 0../YACUI-C-$1- -4-0 development and mass for age. No
■-ArriN-ert-e-Ct • deformities. No assistive devices needed. : Normal active ROM without pain. No joint ..•v-I.JC..._di.
swelling/tenderness, weakness or paresthesia. di" 43-7%-r'r.C-1
CGILE ItheCASLR
L.h!.t.4.1.4:a..c GI/
9-orvt Sue eu...2J/ , hi
lAp-sd s i i Pr
I I
7. SKIN: Warm, dry, intact. Good turgor. No ,( , 9,.._.,„--1-c) rashes, inflammation, ulcers, breaks in skin. •-•1/412.rrNeSA0.(1 0-1\12-0■1 No redness, blanching, irritation over bony c).55s k" 5 -gyp bc,--Ct prominences. Mbcous membranes moist.
I PSG'S 4--- 15606- ..10-r-P
-11.7 & km-eir‘d2 stActri. M/s- epr
1 8. PAIN: No complaints of pain/ discomfort. X (See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT: ILEGR:155<-
I I 6-Q-41.4D-kz-r
cra...p.ct ka0_cernitr,....00,
-'----- (-qC 1\ -L Puffy I - Infiltrated R - Redden
D
d OK - No swelling/redness * - Central line/
TIME: 09 ) INITIALS:
IV patency ✓ q e hr:
TIME: _212'40 INITIAL
IV patency ✓ q ____. hr:
TIME: INITIALS:
IV patency ✓
IV site care provided:
IV tubing changed:
IV Site # 1:
q hr: IV site care prOvided:
IV
IV
IV site care provided:
IV tubing changed: IV tubing changed:
LOCATION CONDITION
IV !"rte #1: liell • 1.-
OCATION CONDITION
Site #1: t_ 61( LOCATION CONDITION
IV Site #2: eb )5-k- C)Ce— Site #2: IV Site #2:
, Comments: Comments:
14 Comments:
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 2 of 4 pages
MEDCOM - 22802
DOD-036378
ACLU-RDI 1673 p.162
Ski. ION III - I ItN I IN I thVt14 I IONS 64 I tAl.r1161(.2
SITE: TIME:
U- U.1
I- ›
-
TIME: 0930 ;91-0
COLOR ID band visible/legible
CAPILLARY REFILL Orient to environment prn
TEMPERATURE Side rails (2/4) up
EDEMA Bed position low
SENSATION Call light within reach
MOTION
PASSIVE FLEXION
0 I-
= w CC
Review & post lab results
PERIPHERAL PULSE Notify MD abnormal labs
LEGEND
Color: P-pink (normal); C -cy. - otic; W-pale, white
Capillary Refill: 1-10-2 se ; 2-13-5 secs); 3-(>5 secs)
Temperature: C-coo • -warm; H-hot
Edema: 0-None; -mild; 2-moderate; 3-severe; 4-pitting
Sensation: A ..sent; N-numb; T-tingling; S-sensation (present)
Motion: liable to move; M-move-no pain; P-move-pain; R-full ROM
Passiv- lexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peri. eral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine/stool
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
w H
. I
BREAKFAST LUNCH DINNER
TYPE: e6.. _ ( 00(1.erisitie, TYPE: TYPE:
PERCENT CON 15% .niale c41-5c.,eii PERCENT CO SUMED: 7cpto vy, PERCENT CONSUMED: TT' 5-1f0
HOW TOLERATED: 50-- 5o HOW TOLERATED: u,Sii HOW TOLERATED: VjCf2,1 ❑ SELF j:::ASSIST ❑ COMPLETE ❑ SELF KT ASSIST ❑ COMPLETE JCJ SELF ❑ ASSIST ❑ COMPLETE
A
D
L
3.
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE ❑ SELF ❑ COMPLETE
j ASSIST ❑ TOTAL
❑ SELF ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF ❑ COMPLETE
IST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
EI:€)LlEsDr ❑ SELF
A BULATE 0 ASSIST olgio
it...TITI-40 # TIMES/SHIFT
CHAIR .......
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC # TIMES/SHIFT
BRP
CHAIR
BEDREST ❑ SELF
ATE ❑ ASSIST
BSC # TIMES/SHIFT
CFP—EialA
. TIME: (j)V,JZ) INITIALS: TIME 9,240 INITIALS: TIME: INITIALS:
CONTENT:
T -"- CC)NbjC-C) Ctr\O■J• tr- . E--- \i)e-1.0 t V
—1 _ .\()---k-od.kri.MC-kkoa,41-12,kr c v...Y.A.\\N\Quiss
N G
atie Family Verbalizes Understanding
CONTENT:
v,re,g_. --PhAA f
(q
Mr' it/Family Verbalizes Underst nding it p
CONTENT:
❑ Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION INITIALS SIGNATURE SHIFT
S /I boa,
MEDCOM FORM 689-ft (TEST) (MCHO) MAR 99
Page 3 of 4 pages
MEDCOM -22803
DOD-036379
ACLU-RDI 1673 p.163
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: ' ARCO PATIENT ACUITY LEVEL : ) POST-OP DAY:31 1 g HOSPITAL DAY:
T R
A N
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT T NSFER IN - TELEPHONE REPORT:
Time To From III AMBULATORY [1] CRUTCHES II WHEELCHAIR TRETCHER
Total ERiRR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P R T LOC N ascular checks
Dressing/cast Tubes
Intake (IV, pc)) O BL, other) Voided U No II Yes Amount: Medication
Other
R rom Received By
. .
•
> "
Z cn
•
TIME: fit' OW BP ARTERIAL LINE
BP CUFF .P11
qc... IVO
f 6,
la/ .1 Q
re)
l (1 1
6.--
TEMPERATURE
PULSE
RESPIRATORY RATE
OXYGEN (L/%)
PULSE OXIMETER "..:01er qQ
q-6 02 METHOD
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask MT = Mist tent PR = Partial rebrea h A = Aerosol TC = Trach collar
I •
•
TIME: --Zfrn 22C0
..._
E
D
vi u
i —
ate
Z LLI
0
V)
TIME: law -22cp
PAIN INTENSITY
10 • • • • • • . .
• • - • . .
• • • • . .
• •
. .
• •
. •
• • . .
. .
• • . . . . • .
• Skin breakdown ion
'Falls prevention protocol
'Restraint protocol OC\ '
4 Seizure precautions
• Isolation precautions
D
. .
. . . . . . . .
. .
. .
. .
. .
. . . •
. . •
• . .
. . • • . .
. . • • . .
MED ADMINISTERED IY/N1 ___ ... ___
RELIEF ACCEPTABLE IYINI A
0 TIME:
T H
ANGER STICK GLUCOSE ---. -• • . - - --- -------- -----
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT: INSULIN (YIN)
E WEIGHT CHANGE:
•Per hospital policy. R ----.....,,,,...„
24 HOUR TOTALS
PO IV #1 IV #2 TOTAL IN Urine S tool TOTAL OUT
PATIENT IDENTIFI ATION
DIAGNOSIS: sip . e_fail i o-i-bryi _ 6stiu Os ,'
b i2(A) 1:11P 1.))j\
DRG: ADMISSIQ DATE: ?Aix...11)3 LOS: EXPECTED REOASE: ,
CASE MANAGER: 1)( (0 -7_,
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages MC V1.00
MEDCOM - 22804
DOD-036380
ACLU-RDI 1673 p.164
01- ......11,./1• 11 Ir, it_t• III- • 11..•• vi vi %../ I ■-••• ■-•
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have beep MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. (--
TIME: 1,203 INITIALS. IME: 1., INITIALS: TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
FV 1 1.---pt- E l.41,11'\ Irt ‘tfirj,n
i4eArnitteAlf 0{40f it -
e7120
Calfel
lAta_
eJA
kk‘r2/30
I I I 2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extrerni,-/ perfusion)
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath
sounds.
11
4, G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
5. G.U.: Reports no dysuria, retention,
urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
Li FOI.e/ Di Cu -
VO i On it-e CtrlaK
tellbuJ lkirv.g.
1.4/
6. MUSCULOSKELETAL: Normal muscle
development and mass for age. No deformities. No assistive devices needed.
Normal active ROM without pain. No joint swellinoienderness, v.eakness or paresthesia.
ri e4Thr-vy\a-V4
46\PerVeArt .0
El— Qs p1
• 1 le 0
— ft reiAltkill
7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation,utcers, breaks in skin.
No redness, blanching, ,rritation over bony
prominences. Mucous membranes moist.
I I (14-Cf +re-Cit^t Siky I I''` .+01C-KSL Re_
cl,002V1V9 40 @/51-00rEgg• ,- uSU/NOCC (-0 (gq;'-0 giNak-QCOK
`*" .1 g-01/444-121 )( /
le--------- .
0 CO 6(A.4,‘-/
pi
8. PAIN: No complaints of pain/ discomfort.
(See pace 1 for documenting pain intensity.)
- 9, PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
'e Li- NWT° locAtccd2 1 f -AVIrt
(10 -:Z___
Li
10. IV SITE ASSESSMENT: (LECEN P Pul ry I - Infiltrated R - Reddene OK - No swelling/redness * - Central line)
TIME: igoo INITIALS:
IV patency J q •25/ hr:I)
TIME: Z.-2W INITIALS: TIME: INITIALS: IV patency .1 q ei hr: _ IV patency I q hr:
IV site care provided: ,a e-to■-5 T t/ • IV site care provided:'Mid ‘00 ,_1A IV site care provided:
IV tubing changed: IV tubing changed: IV tubing changed:
LOCATION CONDITION
IV Site #1:
IV Site #2:
Comments:
LocAnor, CC!:DITION
IV Site #1: PA— 0& LOCATION CONDITION
IV Site #1: 0 if- OK_
IV Site #2: IV Site #2:
Comments: 14-C , comme,,,s, il.
MEDCOM FORM 699.R (TEST) (MCHO) MAR 99 ' Page 2 of 4 pages
MEDCOM - 22805
DOD-036381
ACLU-RDI 1673 p.165
zw
pcc
o>
<c4
0.=
-1<
cc
SITE: W TIME: W''200
W a
U-
›-
0
LU CC
ROM q2h if immobile
TIME: .900 ' el
ID band visible/legible
Orient to environment prn i 1
,-
COLOR p J
e . CAPILLARY REFILL 1
TEMPERATURE IA) Side rails (2/4) up Pr" 1 A EDEMA 0 Bed position low MI
Call light within reach SENSATION 5
4 Plr
. tA
X
0 Review & post lab results
MOTION ,SKIAII PASSIVE FLEXION
Notify MD abnormal labs PERIPHERAL. PULSE
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-(> 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: C-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine/stool A 0 Linen change prn
Turn/reposition q2h
Antiembolic hose
BREAKFAST LUNCH DINNER
TYPE: TYPE: itai PERCENT CONSUMED: offt'p./
TYPE:
PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: HOW TOLERATED: ‘,..,/12/( HOW TOLERATED:
❑ SELF ❑ ASSIST ❑ COMPLETE lerS5ELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE
C:1t*
I LU
<
02
.- Z
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE ❑ SELF ❑ COMPLETE
14ASSIST ❑ TOTAL
❑ SELF ❑ CO •LETE
❑ ASSIST ill OTAL
❑ SELF ❑ COMPLETE
XASS1ST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
TIME: INITIAL
BEDREST ❑ SELF
AMBULATE 1:3 ASSIST
BSC # TIMES/SHIFT
BRP
BEDREST ❑ SELF
AMBULA ❑ ASSIST
BSC # TIMES/SHIFT
BR
'HAIR
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC # TIMES/SHIFT
cHitiB 2 fair - 4 reol-raiAt AIR
TIME: INITIALS: A TIME: -2,20) INITIALS:
CONTENT: t .
4A54-- ecr\--0 fu)i \ v„)( Ao nc ,1__ ..\.02e -t-fcs
Patient/Family Verbalizes Understanding
TENT:
, N„ N
II Patient/Family Verbalizes Underslai ling
CONTENT:
— oso A's
. • atient/ amily Verbalizes Understanding
PATIENT IDENTIFICATION
(9P1
INITIALS G • SHIFT
pj ) •
MEDCOM FORM 689-P (TEST) (MCHO) MAR 99
Page 3 of 4 pages
MEDCOM - 22806
DOD-036382
ACLU-RDI 1673 p.166
W
0
U
N
A
R
E
I M E
LOCATION OF WOUND APPEARANCE TREAT vEN IS
AND
DRESSING CHANGE /to Skeujebor 5cop.ieL
skould{ . Ti
CJT'E--3' 011- %1 ..6
C
--' .
SECTION IV - NOTES
I / f L../uJee.--,___ 4.,.4- D 57t ef. f ,
5 e'di / /
/
•
/ _ I ,. .-- 1-1...1 -e.S --.- _AT' , -e -/
/ If ir 1 '
L
..„___.,....1..._. ..... r,-- , , e
/ 0 . /4111001, imPlr'---
ir
--- _ ...........
T C VL
A •
... 4
- -•_ ..■-■■■ ,
11.4,, ■■■■ • ■ ....... ■ .. ■- - - _
(TEST) (MC/-1O) MAR 99 Page 4 of 4 pi-gcs
MEDCOM - 22807
DOD-036383
ACLU-RDI 1673 p.167
HR = Non rebreather PR = Partai rebreather
24 HOUR I PO IV #1
TOTALS
TIENT !DENTFICATION
MEDCOM FORM 639 - R (TEST) (MOHO) MAR 99
IV #2
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEE For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
PATIENT ACUITY LEVEL POST-OP DAY:3IV i g
7E: —Ta Dp.iC., 0 1..
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Tine To From 0 Amuu,...,c, ,,, El CRU7CFIES ❑ ,VHEELCHAIri CI stREIchEA
Total ER,RRiP,-NCU ;ime Physician Anesthesia (Specify):
BY P R T
Procedure:Diagnosis Ne.uruvascular checks
Tubes
Output (ESL, other) Voided No ❑ Yes Amount:
Other
Report From
TIME:
LOC
Dressing:cast
Intake (IV, po)
Medication
BR ARTERIAL LINE
BP CUFF
TEMPERATURE
PULSE
RESPIRATORY RATE
OXYGEN (Li%)
I
L
PULSE OXIMETER
02 METHOD
N FM = Face mask
VM = Venturi mask
A = Aerosol TC = Trach collar
TIME 1100 NC = Nasal cannu:a
04gen Method Key:
MT = Mist tent
' Skin breakdown prevention .
• Falls prevention protocol
'Restraint protocol
C ' Seizure precaut : ons
'isolation precautions
E
A
N MED ADMINISTERED IV:NI
- - - •-
RELIEF ACCEPTABLE IV NI
FINGER STICK GLUCOSE
INSULIN IT.N)
YESTERDAY'S
TODAY S V:EIGHT:
WEIGHT 'CHANGE:
'Per hosp , lal F_
E
TOTAL OUT Stool Urine 'TOTAL IN
DIAGNOSIS d • kg 0/1 •
ADM ..ION DATE. $__L_Oct
EXPECTED RELEASE - DRG:
LOS:
CASE MANAGER:
PRIMARY CARE MANAGER:
!SOLATION REQUIRED (Specify):
EDIT!CI'S ARE OBSOLETE Page 1 of 4 paces
MEDCOM - 22808
DOD-036384
ACLU-RDI 1673 p.168
IRECT:C.'.5.. A cl;cs.;. ,./ in ;he s.ma:': boy inclica;es patient assessment criteria have been MET. If all the sra:ed criieria are not mar, a br;a1 ex plana..;c" of obirirm.v!.-7::iiiis will L , : -.• no;ed in ;ha appropriate column,
r:...F..-. ir:ITIA , 'TIME: INITIALS: TIME: [WTI
t,rie plac2 ;.:Id liarr:C. 7..25;., C, .1j7, :1,•_..,,,.1.11c1v. Zorn7s.:.: -...::.:,on is:.-..Je:;:.:::::: , ;0 ,2xp!css )CCCS. ?ups eq•-7:: 3nd rci:ZZIV ,2 ;..) IlgI1Z.
1. NEUROLOGICAL: Idcr: a:1d orienled ',o
Cl;) ((.0 - ?__-.
V 2. CARDi3VASCULAF-S: ..:Ise reguiar F. ! -::e .-., ithin ran:...2 for a:ie. N: ..-2e3endent o.-'e7 , :a.
'‘Iailbeds ::.---_-: illucr.v.:s :,..0-.-1)rones ,..,..',. No .all ;cndernE.555. ;Soc. p350 2 .' ,:..1" e k5.• c r;.;,; .,.•
..-ierfusicni
..---: ..._.• LI
3. puLmo % ARy; P.cs;:a:-3:::; v.- ;11' ■ ::: n.;;;:i;a!
7ate for 2',....2. -.:roup; r.-,u . CZ 3 -..1.: :Izir. Ci.,0'.h is
sounds.
: —rfach sli_( OCA' CU-ka •
U FIT 11P, 6 \A.e_ ON...5) • Aorei,
cLAAY-4.4 % -
mn 4. G.I.: A .,: :.:ae sc,;; a: -:d r.on-::!s(!ed.
. Bowel sc...: -..is af:tive. Re;or -.5 nc N:V:pa;n
with ea:in; and no prcb:ers chewing/
: swalloN -J:n:.. Denies cons::;la:ion, tharrhea or
• ectal btee:::no.
!' L_— Ls/
. 5. G.U.: :zeports r'10 ::','S...'7:0., re:en:ion,
.:rgenc.,, frequenc'. r.c.c1..r.a. Urne C:C.,37, yellov..,, a7r.te!. No unusue! ischarge.
— ineprI-14 R9.X14, i 1 t49.-i)( 1
14,41sLsSitl '
kr t-Y10611 r-kAR
5. M'JSCULCSKELETAL: Normal :-:-....:sc:e
JaV7....?...le. f.e.formi'.:es. s ..:3 asz:sl've :.-....'ices reec:cd. :orrr.al a: -.1.-2 ROM '..':Th::;aain. No jo in:
3,„;:in g :,-, :ierness......es,:-.ess cr 20 - es'.7esia.
.._ r, st azza--toi cr6iVk1i. :___, ADwebgksk- b_ect4 t-ti
10 RA r.,-10,--- J I ' 5-
"‘n v1,144„rt uce.-_L 7. SK:N: . ...s!rr.. dr,', in:acz. Good :urc.r. No
• rashe.s, I: .-.,"%rna:ion, •,..;-....-2rs, breaks m skin.
:rornHenc:s. tvluco ,..:s ^.• ,.-: —.brancs n - c:s:.
T .51,v-•040...e../ COCW10(9:71 1 g-4.S . 1
1A-1- .- 0 di /:p.
. C. - 03 r6
(gJuizki' usQA—Yd
• B. PA;N: :':.: cornp:z. --,s c..: pain.: rils!ort. 1:_------ IT ..__:
See pace 7 ffd- c.., ':',.77C,7:,' -: ;:a;:: /::,"er.Siry.) I
I
7-1 1 I L___1 I 4:Sek_.• 1
.- 3. PSYC2i-ECSOCIAL: E....2`.::: .-• or :5 a;;;:,r'::::” aze ! :0 the si'..-.:: .,cri. Ar..;- ,...., cor.;roIlec and appfa72 - ,ale :o s:: ,..;a1. ,:n. :r.:: -,racts
I ICY ‘
10, IV SITE ASSESSI'.:ENT: y._:::"...; 7 '.3: • ' •;• I - Inft;I:a:ed R Reccened OK - No swellnc.. - •edn.r.ss - t at lo
IME: ) 100 :,ITIALS __Flf.lE: INITIALS: I TIME: (96....e INITIAL
IV pate:-..:.. - ,,,/ ...,- <;i0 -, , 7: f? •..; 2V.CnCy ../ q :ir: ;\./ pa/enc,- j q -a: p IV ,,,,. ;25-, ,,...ici..2,-2: ci ... i IV S''.ar_.•.:1:C.. orov ■ ded: i'1 site care ,:;r::yrded: AS_Se.= •,.,
IV tubing changed: IV “.::::,,-..:. -_- -.D.:I: IV ',..:bir.r.; changed:
C .:.•.:::7: ,3:4 I LOCAT i; CC' — ' -'10tJ !'./ Site r 1 : g'C OK IV :_". : ...3 :1:
1.0C.r.TION CCUOITICN
IV Site g t: Ca•All :._
\/ Ste :2: iv S .; ,2. .1 2 : IV Site g2:
:om.,-e.- .. -.-: -- rd g C ...: ,-.--. - ell; _ _
......_..._. ...
Commf;;-:3: __
_
1..:,^ori 99
2 of 4 par;as
MEDCOM - 22809
DOD-036385
ACLU-RDI 1673 p.169
D C
cn
< c
m z
SITE: t ilit_7_ TIME: 11001 110%651
OH
IW
CG
TIME: I P , 7 _ COLOR
_
CAPILLARY REFILL
0 1 47 ID band visible:(0;;ible Air■•----
Orient to environment prn
41 [ I — A IVA TEMPERATURE kA) Side rails (214) up Wil
Bed position low EDEMA i/
.
SENSATION f di,
r
/
/7
1 Se
Call light within reach
Review & post lab results
MOTION Pl. f D PASSIVE FLEXION
Notify MD ablinrmal labs PERIPHERAL PULSE O'r
LEGEND
Color: P-pink (normal); C-eyanotic.; W-pale, %•..liite
Capi;lary Refill: 1-10-2 secs); 2.13-5 secs): 3-(> 5 secs)
Ww m Temperature: C-cool; -ar; H•hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling: S-sensation (presen:)
Motion: U-unable to move; M-inove-no pain; P-n.lovc-pain; P.-(;.:il Rom Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent unne.szool
A 1111 L.. Linen change pm •
Turn 'reposition q2h _
ROM q2h if immobile ENE Antiembolic hos..i
f
BREAKFAST LUNCH DINNER
TYPE: TYPE: TYPE:
PERCENT CONSUMED: 30 7g PERCENT CCNS:...;ED: n) PERCENT CONSUMED:7412"e7
HOW TOLERATED: (4/5../4,-, . HOW TOLERATED: 4,11,7/ HOW TOLERATED: ti..,,,(
SELF I-1 ASSIST E: COMPLETE . ...;:ifSELF Li ASSIST ❑ CON.PLETE '6 SEL:' U ASSIS.
70
r..1 COMPLETE
C.,) .
0700-1E00 1500-2300 I 2300-0700
EATH2ORAL CARE E SELF ❑ COMPLETE ; LJ SELF E.] COMPLETE I i__: SELF COMPLETE
0 ASSIST Li- TOTAL r-1 ASSIST F__.7 TOTAL IASSIST :21 TOTAL
TYPE OF ACTIVITY (Circle all that a; ) 3ply
B E D R F Eil SELF BEDREST (-_-: SELF 4211W E SELF
;,....1 BULATE,, ASSIST -• AMBULATE ......"3"-ASSIST AMBULATE D ASSIST
--- I SSC BSC 4.' TIMESISH.IFT # TiMES.SHIFT l•I TIMESiSHIFT
BRP BRP I E.RP
4 ara 07 CHAIR ....HAI
TIME: INITIALS: TIMF: INITIALS: i TIME401. II/ INITIAL'
CONTENT: ! CONTENT: ,' CONTENT: I
(-3 P ,-,tient;Farn.iy Verbalizes Lin r!,-■ r s i nn(11:) , ) L_J Patient F.-::- :.,. \-/Qrhall/. ,:s li , ;rlersiandnnr; Patier! Family Verbalizes Uncle landing
PATIENT. IDENTIFICATION INITIALS TUBE SHIFT
MEDCO,Y FORM 639-R (TEST) (MCHO) MAR 99
Pala 3 of 4 pagcs
MEDCOM - 22810
DOD-036386
ACLU-RDI 1673 p.170
IO
D-2
10
U
.:ft:C
ul
l
7
LC:C.ATiO: OF v.',DUND
E ! :C=PEARANCE
1 1 i
TP.E.5,7".•E:.;TS
___, ,r ,,,,D.
DRESS::C: C-..A^:GE ri'
I .0 0 sh00 • es " • ff2L-laaadZi(_____ .
ici yuza...\ .1/4. v , SSUe- `...61..,-S/
4) le-, 6 s\ 5(2- i
Lk) --- ) "-- 7::
rthts\eyi et(4..%3".
__ - - _ _______ ■
2 1, ci
_
SECTION IV - NOTES
. ,
__ __
!
■
r _._ — I
.
. , . . . , , . . . .
. ,
, . _ .
_ _
_ __. . .
_ ___ i
. . .._ __ _.. ._ _ _ __ ___ ___..-
..., 6 .... ____ . _ _
. --- _ . . . _ . _ . .._ _ ___
--- ------- -- . --- _ - _ _ .. __ _ ___
_ ___ _ _ _ _______ .._.... __
. 4,.'41-7 ..7.7 FORM 65.9.1-; frEsT) MAP, 99 Page 4 of 4 pa ,":CS
MEDCOM - 22811
DOD-036387
ACLU-RDI 1673 p.171
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: 4 pgc,05 I PATIENT ACUITY LEVEL : POST-OP DAY: HOSPITAL DAY:
t
Q Z
ft) L
I - LII C
r
....• COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Tare To From 0 •muut.•.ToRY 111 cRuTcrirs II v:HEELCHAM Il sIRE7c,,ER
Total ER/RR/PACU time Physician Anesthesia (Specify):
ProcedureilDiagnosis BY P -
LOC ∎ . ascular checks
Dressingicast Tubes
Intake (IV, po) utput (ESL, other) Voided III No U Yes Amount:
Medication
Other
Report From Received Sy
>
U) -1.
Z cn
TIME: (1,(jD 3199 0400
OP ARTERIAL LINE ,,...........' „../-
BP CUFF Ilio
eti C 1(
KO
NG) % e3
10‘4,9
/7' 6c-
TEMPERATURE
PULSE
RESPIRATORY RATE
OXYGEN (Li%)
PULSE OXIMETER A i7 iii i i
I A 02 METHOD
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = :=ace mask VM = Venturi mask
MT = Mist tent PR = Partial rebrea her A = Aerosol TC = Trach collar
eL <
— Z
TIME: riAja 124564 On TIME: 9,2,10
'Skin breakdown prevention ...._
'Falls prevention protocol
'Restraint protocol
'Seizure precautions
.Isolation precautions
PAIN
INTENSITY
io
5
. .
. .
..
. .
. .
..
. .
. . . .
• • .. • • • • ./74
..
. .
• .
. .
• • X.-
• • . .
. .
• •
. .
• • . .
• •
• • . . . .
MED ADMINISTERED IY.INI
RELIEF ACCEPTABLE IY NI
t,1
—<
si.
.. .. . OH
ziu
cc
TIME:
YESTERDAY'S . .';EiGHT: FINGER STICK GLUCOSE ___... . _ ...
TODAY'S V;EIGHT: INSULIN l'fifil
W.EIGHT CHANGE:
• P...r h:Dsp.:31 ool:cy.
24 HOUR TOTALS
PO I IV 01 IV #2 I TOTAL IN Urine Stool
I
TOTAL OUT
PATIENT IDENTFICATION
(. (G )
/
DIAGNOSIS: //i9 0/00% "I f litl.° 5 4cA- -f 1.---1 1.7
-- DRG: ADMISSION DATE: /1/0a ••••'
,
LOS: '" 7 T F SE .(
CAS C( o)
CASE MANAGER: o)M,,7-?._
PRIMARY CARE MANAGER:
ISOLATION REOUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PnEYIOUS E D ITIO%S ARE ORSOLETE -are 1 of 4 pages
MEDCOM - 22812
DOD-036388
ACLU-RDI 1673 p.172
Jt1... I ION II - VMIOI\JI mooLOJiv ■ Liv • may itvw hr O tOIOVIO
,RECT:...C: A c' - ..::.: ./ in arc sn;alf box. indicates patient assessment criteria have been MET, IT all the s:a.'ed criteria ate not met, a brief plana:ion of a.')::: - •::3' h•:cf:ngs wi2 be notal in the appropriate cohrmn.
1 r..!E : 15 it) INITIALS: TIME: z...:" INITIA TIME: INITIALS:
1. NEUROLOGICA'_: AIer; and oriented to
:me place 3:1d ire-' app:coriateIy.
',.jpils eq...ial and re7::::ve ;0 :;LINt.
Zon -17-1 ,-ic;.:Ion is ,.:::.:1::::' I0 C5OlCs5 needs,
.,—.0.7, I .
i L. I I
2. CARDIOVASCL,LAR: Pulse :egula: & :ale ...ithin :ono Icr a:.e. .....: i-Jcpendent edema. Nailbeds ai -.:.: mu -..-:.-a : ,-.e7. - Iiranes p:n.k. No ,calf :enderness. (See .1- 3.7..? 2 .'t- eytremi;/
:serfusic.-4:1
L.L../.... • ;
3. PULrACNARY: -.2 es.:::•a:,ails v..i.,1)In nornial - ate for a-,:e group: 7.... Cl a . -.f.1:eguiar. Depth is
egular. NJ cough. No a .._.: -..iortra! broach
SJL:ftdS.
. G.I.: ,:-,.00:-.lar: a:ft sna: nor.-distencled.
Bowel owel sounds aCti.- e, FI.epor;s ni: N:V:pain
with eat:n -g and co :::o1;:e.iris chewing/
swa:lo•.ving,. Denies zonstipation, diarrhea or
- ectal bleeongi
L---(1)' 6/0 1-'fri D VORPAr :V11 1.'5
i/ 1
5. G.U.: Reports - i.: jisi.;:lo, re:en:ion,
,rgency, frerene ,•. 7iacturia. LI;:ne clear,
• ello ■-:;a:-.•.bar. No _ -.L;sual c:schargc.
! CV' : r •
Li
5. MUSCULOSKELETAL: Normal muscle117 7-- ;--i ,
tevelc;:i7 , artt. ai -i.d 77 ass ftit age.. No i at-,A) _
teformI;:es. No asa . at've ,teviaes needed.
';orr-r.e.1 ac:: -....o R',...! ....:-: per. No joint
3.-vie;:inc landerness. iii..es.: -.ess or pa•esthesia.
7. SKIN: ..I.Iarrn. ,•.:-.. :::lac:. Good turgor. No - ashes, infIa-i:-.-.az . o - . :.:::.'e:'s, b:eaks in skin.
=rominencos. Mcc: - .s rre:-..braricis mo:st.
No :ed7ciss, bianc! .. n over bony
I i (•, '—' lq) C,•6\iql(n)
CA-3-
7-1
, B. PAIN: No. corr.::. ,:--•: - Is cf pain' discomfo:t. See pace , !::::- .7:::_ -.7C.II:i'":.7 ,:),Ia: irt ■ Or:Si%V)
\-
S j2li-C-AA. i
.
!I -! . i CA:: 0/.9 ? lilt )IC.,
i 60. in 4/ 5r a/7 , .. - ,..9
Arc o ce -1--r1-705:1/44
D
B. PSYCHOSOCIAL: -3.:::- .a '::::/: :5 a;:propriale i ' .0 the si*.ualion. A - •.:-.1t-, Is centrsIled or rn:io I — 0, )124 and appropriate to a : .,;.:C....7 -I.
',Dp1Opr,r,:e:y v.'1:h :.. I _ cloyo !'79i
-L._ n
,.. ,\., SITE ASSES-:-:!:.=NT: ;LECiENC.:: P I • Infiiied R - Reodened OK - No sweIling:-edriess * - Centraline)
- IME: \5\E) INITIALS: i TIE: "2;240 INITIALS: I TIME: INITIALS: _
IV pate --,:-.- I 7: :-.:. i I'.' ,-:eIency ../ Pt- !),: ; IV patcncy I O hr: —
IV site aa'e ;, :C'; , 7 2 f: IV a:le Cafe IJI0vI ,Je.z.I: IV SI;C! Care ;.:rovidcd:
iV tuti,: -.; chn-igc:: IV 7. ,,iblirli.; chanced: IV tubing changed:
1- ; C.:ND:T:0:4
'`./ Site :1: -..-- P-- ot-
CATICN CC::DrriCni
:v S o. g: : 6'
Locivriorii CCNDITIC,J
IV Site ',,I i:
V Sue -, 2: IV c:.zie 0 2:r IV Site
".-.o,--.-.e,•:5- _ _ _.__.....
______.. ______ ...... ..._.
Con•i- - erits:
---•- -- - --• -
Co..e,-..:3:
._______..._ ______... _
'TEST) Milf;
2 of 4 p.3gOS
MEDCOM - 22813
DOD-036389
ACLU-RDI 1673 p.173
SITE: TIME: I TIME: Wib , -z3t, band visible:Icible
Orient to environment prn .
COLOR -------------
—
CAPILLARY REFILL
ilY4 Side rail(20) up TEMPERATURE
Bed position low EDEMA
Call light within reach SENSATION
MOTION
PASSIVE FLEXION Review & post lab results
Notify MD abnornIal labs PERIPHERAL PULSE
_ LEGEND
Color: P-pink (normal) -cyanotic; W-pale, white
Capillary Refill: 1-( -2 secs); 2-13-5 secs); 3-(> 5 secs)
Temperature: cool; W-worm; H-hot
Edema: 0- •ne; 1-miId; 2-moderate; 3-severe; 4-pitting
Sensatio : A-absent; N-numb; T-tingling: S-sensation (present)
Motio U-unable to move; M-move-no pain; P-i:love-pain; R-f;.:II ROM
Pas,-ive Flexion: 0-dorsal flexion pain; P-pinntar flexion pain; 0-no pain
Peripheral Pulse:
0-absent; 1 -weak; 2-normal; 3-strong; 4-bounding;
D-dopplar, P-palpable
Incontinent urine:szool
Linen change pin
ir --......'
Turn:reposition (1211 _______. ____ __
ROM q2h if immobile
Antiembnlic hose
BREAKFAST LUNCH DINNER
TYPE: TYPE: 0 TYPE:
PERCENT CONSUMED: ID PERCENT CONSUMED: PERCENT C -UMED:
HOW TOLERATED: t.....,,e,‘,..\ HOW TOLERATED: HOW TOLERATED:
fET-SELF 0 ASSIST E COMPLETE i E SELF L2 ASSIST 0 COMPLETE. '''''sE,_:: EJ ASSIST 0 CC,'MPLE - E
0700-1500 . 1500-2300 230-0-0700
BATKORAL CARE COMPLETE SELF i COMPLETE
E ASSIST 0 TOTAL ■ 0 ASSIST 0 TOTAL
:=2: SELF E COMPLETE
0 ASSIST E TOTAL
TYPE OF ACTIVITY (Circle all that appy)
BEDREST .....--"-S-E-LF ; BEDREST L_‘-/SELF SEDP.EST E SELF
AMBULATE 1_.1 A'S:3:ST
BSC # TIMESISHIFT
ERP
CHAIR
AMBULATE D ASSIST _ _ E ASSIST
BSC I6 # TIMES/SHIFT . # TIMES:SHIFT BRP ; BR?
CHAIR : CHAIR
TIME; KID INIT;1-.L. , TIME: "7 r/P INITIA' TIME: :NITIALS:
CONTENT:
-•.•!>1. -
(•-\›0„..J.,--- CASY\K\i"-(5A
gel- Patient;Famiiy Vnrhall,-.1s Undcrstrincliivi
CONTENT: CONTENT:
•
---" -itiont' rt - •!'y Verbillilms 1 ,'1C ■ CrSilt1 .1111 ' 0 Patio , zes Understanding
PATIENT IDENTIFICATION
.111111, ,
1
INITIALS
INYIka
/7/ : . _ _
SHIFT
1
5---
MEDCOM FORM 689-R frEsr) (IVICHO) MAR 99
Page 3 of 4 pages
MEDCOM - 22814
NJ
DOD-036390
ACLU-RDI 1673 p.174
r_O
DZ
I21 0
<C
r ud
,.. CCAiION OF wou::0
E
A=?EARANCE
T.,..EAT:.•E'.7S
A% -1 DESS I-:G ■.7.-, ACE
la, jtai.L...e \ 5 (0 • 6,\-,-- . cic-).-
- ----• -------
SECTION IV - NOTES
, 7r in )027, 1,,./ ./ / c-, -1--er , , ___/_____ ____
O.W FORM 689-R /TEST) :,Ci-IO) MAC 99
PO3,24014
MEDCOM - 22815
DOD-036391
ACLU-RDI 1673 p.175
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40.5
SECTION I - PATIENT ASSESSMENT
DATE: PATIENT ACUITY LEVEL : POST-OP DAY. HOSPITAL DAY:
cr: <
( f) ti cc
COP. PLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
Tirre To From II
- TELEPHONE REPORT:
AmsuLArcity IIII CRUTCHES V.'HEELCPA:R III STRETChErt
Total ER: . RR/Pi:k ' inle Physician Anesthesia (Speedy):
Proc-_=,:fureiDiagnos:s B,P P R T
LOC Neurovascular checks
Dressig.'cast '''.----......................_
Tubes
Inta:e IPJ, pc)) Output IEBL, other) Voided In No ❑ Yes Amount:
Med:Z:37ion
Other .
Repo , : From Received By 11
>
(7
TIME: joy,. 4' : a , EP ARTERIAL LINE ........--
BP CUFF =gm , ,
TEMPERATURE M. i g
PULSE MEI
4'
g°1
RESPIRATORY RATE irmorin /1
jk, OXYCEN (L/9'd Wall
PULSE OXIMETER efet 02 METHOD PA
NC = Nasal cannu:a NR = Ncn rebreatl et - Frvi = Face mask VM = Ven:L: i mask Ovr z:er, Method Key:
MT = Mist. tent PR = Partied rebreather A = Aeroso TC = Trach collar
< Z
TIME: ii" 13c{.0°
LU
<
Z L
IJ
11-1 0 C
D
TIME: ! MO &WM
o
5 ,.TENSITY
PAIN
' • •
• • ' ' •
Skin breakdown .
prevention ...._. A 'Falls prevention protocol
'Restraint protocol
'Seizure precaucns i f4 1
. .
• •
. . .
• • . . . . . .
• • . .
. .
• • . .
. .
• • . .
. .
• • . . • . . .
ACED ...DMINISTERED IY.NI
RELIEF ..CCEPTABLE iY NI 'ISOlatiOn precautions
0 I—
w cc
T I M"-- : . o'• "IFA,,, YESTERDAY'S '.•..EIGHT: FINGEF. STICK GLUCOSE
_....... _... INSULIN 11'.741 TODAY'S 7., EIGHT:
• EIGHT CHANGE:
Per hOSC,13! Co!..:-.
24 HOUR TOTALS
PO i IV #1 i
IV #2 I C. AL IN Urine Stool TOTAL OUT
PATIENT . DENTr'ICATION
EN 00)(0—Li
DIAGNOSIS:5 19 Q.,(Cui ( ■ 14 011it 1 0
DRG: ADMISSION D SI ()eV cr- LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Spec y
NIED=.1 FORM 639-R (TEST) (MCHO) MAR 99
EDiTIONS ARE OBSOLETE
,--age I of 4 paces
MEDCOM - 22816
DOD-036392
ACLU-RDI 1673 p.176
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
'- ,'F.r..ci-- T.'..C. - A dic..:-..; „/ ,:n 1 110 so:3U .5,9X indicates atient assessment criteria r. lave been MET. if all the sated criteria are Oct mer, a rtel ,i..\p /ana..tc , of ob7;w:::.3 : !: , !7.2,7/i/S Wiil be noted the appropriate column.
. TIME: 1100 /NITIALS 'MC- INITIALS: TIMEEPK3D INITIA
1. NEUROLOGICAL: ; , :e.r: nod onented to
:':r.e ....d name. .r-:-,:sponds appropriately.
:or--- -- u -.; - : , :lun is ;...de- - ,•-, :o express needs. == u pils ec.....ai and :...e :CI Liht.
, • A -
tcu[-VP; x 94 ,.■ • , .r
(00Y1^R.AC COY-IV
ke '5- 5erifa- 1 •
I 1 Pk-VW-
afka3) \61
ef14-C-4
Li 2. CARL,, i3VASCULAR: ;'-'LlIse regular & r. -,:e within rance for n_.'. ts:. doprIndent cdon , a. %:allbeds a ,-.d mucous n..e.-.-branes pr.. No calf :enderness. /Site P390 2 .',:r e.vrtemit'y .:-., er;us,- 0 ,3)
;1 (q1 CY7---
3. PULMONARY: TRes,:a:,ons v..i:hin norn;a1
ate Io: abe group: q;.:,-; ---f - o:.• ,-)i- Dep:h is . ogular. N.:, cough. No s:: -.orrral brea:h
sounds.
____ _ I
:ly
4. 0.1.: ,:sf .::or: , en sc..!1 nod non-distended.
-.4owel sc.::27-.ts a:-,ti ,.a. Roports lc N.V1pain
with said; and CIO p:.cf:ems che ■.-..ingt
swallo ,..,..n;:.,. Denies consic.,aion, diarrhea or
'act a) fleeting.
_ 19A- L CIO 0/7_151,4ra+)01.-,... p la UAS <P,C.'Yr")
CW tOtCLAt 5-'42'0 •
5. G.U.:
=:eports no t., - suria, retenn tio, ..rgency, f , equency. nfcturia. Unne clear, ,-ellos,...;a:-.•.fer. No ...;nus ...:2! discharge.
71 • Li k•-•',
(19--Q-0--S Ltti
5. MUSCULOSKELETAL: Normal muscle 1141 mak; /Ii, tt E 1_, T-itis)e0,-.4mssAl . i
teveic -: , :::-.: no mass ' or age. No ,)1 deforrnit'es. No ass:s::ve .fevifes r.e.eded. glil /J4 SiYr71eg7) '•;c-srmar a.::: . -"2 Rom .... - .: - :-...: Pa:o. NO .Z)ir.t
sweilinc ..e , derness. '... - ea..: -.ess cr pa•es:hes:a. 4,ran-yt-c,--oo - : 7. SKIN: ':'srm, d:y, intgc:. Good turgor. No ! 1...4/...--- ash ,- S. rnf' ,-..:mation, :.:::ors, bucoks in skin. i —
No red.-.ess, bIancllic_;. : , ::::,..7:cr, over bony Pfon ..inenzes. Muc:-..-.•-:s n!c: -..crancs roust. 1 i
3. PAIN: No comp;a:: - ts cf pain., disco:-0.fort. 1: : 'See ,:.:ace I for o'ocur. -70'7::"73 ;00I:7 if;;;.'n51:Y.%
9. PSYC.:-::::SOCIAL: F...:7ay . :;• ..s appropriat:7! fl.
_. controlled or 71,i'..1
sod a7'P , 0::::.ale :0 5::ud:• ,:.-- :u.:C:0C.:s
eoproora:e.Y vith o:hrs.
O. IV SITE ASSESS:VIENT: ;LEGEND: P Pi;!'y I . Infiitra:ed R - :-3e.dcencd OK - No swelling.''edness * - Central line)
- IME: 1100 :%:TIALS: TIME: l !NIrTIALS: TIME:cQ, lt:ITIALS: , V pa:-:..7'.: .../ ..- q vg . i'-' • - -••,cy / q
w
-:. ' • '''. • IVain,' ,/ q ''' .41..... Al
• 7--- IV s::e fsce ;•ro ...idof: 05-51::$ r,./ .st2 care r;f0'1,_;:r.': :V site 87..7:7'..' .7.:7;V:ded.
AIM Z4—.. :V lilt:r.c7, :ha - god: 1 IV t ,,,fing changed: AIIIIIIIII IV tubing changed: •
c-f%D:7:3!,
17,49-- Or,
LOCA - ii CC::::::IIT::)
, :V 5::c .7'1:
jer CCGDITIC!! ‘
IV Site
V St.' =2: IV S.Ie e2: IV Site 52: ----
1. --6- fc, co.-:-. :,.. , Ai,
6,17 .%•!":: S MAR 99
2 of 4 pages
MEDCOM - 22817
DOD-036393
ACLU-RDI 1673 p.177
(6) 7J D
r- C
O W
D<
0 C
m
SITE:- LLE T its! E: 1_10 -9741)
LL L
1J
>-•
TIME:
COLOR
CAPILLARY REFILL
V ID band vis.ble.10pble
Orient to environment pin ) 1--
TEMPERATURE 110 Side rails 12/4) up
EDEMA 4 Bed position low
SENSATION 5 S Call light ‘-iithin reach
MOTION 777—c)
PASSIVE FLEXION
0
CC
Review & post loh results
Notify MD abnnr.11ai labs PERIPHERAL PULSE f-i- LEGEND
Color: P-pink (normal); C-eyanotie; W• pale. hi :e
Capliary Fletill: 1-i0-2 secs); 2-(3-5 secs); 3-(> 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; 1-tingling; S-sensation (presen:)
Motion: U-unable to move; N1 , 11tove-no pain; P-move-pain; R-ft.:II ROM
Passive Flexion: 0-dorsal flexion pain; P-plantar flexion pain; 0- no Paw,
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine:stool
Linen change pm
Turn.reposilon ci.2h
ROM ,.-12h if immobile -.. :o Antembolic hse I
I • o - w
BREAKFAST . LUNCH DINNER ...-
TYPE: jt......:.■ - . TYPE: rZ. e. TYPE:
, .c---) PERCENT CONSU%tED 111. 0 fy,gtAfe, PERCENT CONStED: Kiev ii-0.1.4kii PERCENT CONSUMED: 50 eh HOW TOLERATE -2J: kir.. 1 HOW TOLERATED: HOW TOLERATED:
E SELF frK ASSIST !=_—] COMPLETE ,..._1 SEI F L.: ASSIST 0 (2.0%".PLETS. . 0 SELF L..] ASS:ST 0 COMPLETE
<
6
t--_ w <
C_) - Z
0700-1500 1E00-2300 2303-0700
E.ATHiORAL CARE E SELF E COMPLETE E SELF 0 COMPLETE ,__.: SELF Ei COMPLETE
:. 1 ASSIST L_i TOTAL ni ASSIST n TOTAL "; ASSIST E TOTAL
TYPE OF ACTIVITY (Circle all that a pply)
TIME: INITIALS:
SELF
Toe ATE E E ASSIST
BSC
4' TIMES/SHIFT 1
ERP I
BEDREST E SELF -3EDREST LJ SELF
AMBULATE 0 ASSIST AMBULATE 0 ASSIST
SSC .. 4' TiMES.SHIFT
E..SC ;-' TIMES/SHIFT
BRP EF"--.P
CHAIR ,...,-...r-k
: TIME: INITIALS: I TIME: (9.11-X..... :NITIALS
CONTENT: .: ! CONTENT: ] CONTENT:
•
.• '
&LI Gr 0 ‘%f•• ••
0 Pltient:Faimly Vefbali/es Ur.,..-rstrindin ,-. 1 . i_J Patient . P.- : ,--'y Vwbolilesl)-.ders:.-Inding 4P,Then P.rniIy Vert.,:izcs Understanding
PATIENT IDENTIFICAT;ON INITIALS SIGN TURE SHIFT
. • - - 12,Pr
. e)
\
MEDCOM FORM 6,99-R (TESTI IMCHO) MAR 99
Pafje 3 of 4 pa505
MEDCOM - 22818
DOD-036394
ACLU-RDI 1673 p.178
H o
o <cc
T 1
•.-1 E
L 2 CATION 0:-• •,...C.L;ND AT•PF_.•..7;.ANCE
_
`1 ,:E.:17!.•E'-.7S- .!-%::
DRESS::G C.- , .:..^:3E
7,----- . 0
_ _ _ ---
----- - ----- __
SECTION IV - NOTES
()nal fa.4 frlf 1'121 ,
. . _. ()(k,) -7
.
.
i .
______________ _ . . - _ __ _____
_ . ___________ -' - .. _ . ._ .._ .. . _____ __ ____
_ , . . , .
__ .. _
_ _ _ _.. __ __.. _ _ _ _ __ _ ._._ __ _ _ ____
A.:SOC.:5M FORM 6.3.1.3 -R (TEST) 171.-fC1-101 MAR 99
Page 4 of 4:
MEDCOM - 22819
DOD-036395
ACLU-RDI 1673 p.179
LOS:
CASE MANAGER:
PRIMARY CARE MANA — 1111111111
ISOLATION REQUIRED -SPeci 1 1
EXPECTED RELEASE:
MEDICAL RECORD - PATIENT ACTIVITIES FLOV/SHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
)ATE: ,-.-..) ---•zejyr5 I PATIENT ACUITY LEVEE :tr_ POST-OP DAY:SA gi HOSPITAL DAY:
CL < Z
Cf) U
IL
I Cr
[COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Titre To From ❑ At.-isuLATorly II CRUTCHES ❑ WHEELCHAIR -.111. TRE7CHER
Total ERiRRiPACU time Physician Anesthesia (S
Procedure/Diagnosis DJ., P R T
LOC Neurovascular checks
Dressingicast Tubes
Intake (iV, IEBL. other) Voided U No ❑ Yes Amount: po) utput
Medication
Other
Rep rom Received By
>
Q—
I u)
cn
TIME: h_co 2 1 0,00
BP ARTERIAL LINE
'Webs/
Nie 75rat
f'%
i7
• i• ip
"ire( 4/5741 7)
no
BP CUFF
TEMPERATURE
PULSE
RESPIRATORY RATE
OXYGEN (Li%)
PULSE OXIMETER fiq-767
2.A- f.77 ktr
it7a
02 METHOD
I
NC = Nasal cannu,a NR = Non rebreather FM = Face mask VM = Venturi mask Oxygen Method Key:
MT = Mist tent PR = Partial rebreather A = Aeroso TC = Trach collar
< —
Z
TIME: ticia 12eto I vx, 7)..(yj i
c/)Ci
wU
—Q
w Z
U
J C
I 0
I
TIME. 1 0 X 2 1 30 • Skin breakdown
ti prevention " . . .. _
PAIN
INTENSITY
' • . . • •
' ' " . . • • • •
• ' . . • • • • • Falls prevention protocol
'Restraint protocol m9_. • • . . . .
• • . .
• • . . . .
• • •
. .
- • . .
" •• • Seizure precautons
1 .Isolation precautions
MED ADMINISTERED IY.,11
RELIEF ACCEPTABLE IT NI
I
Y —Ij
Nle ___ —_
_ . . _...._
Ad 0 I —
I: C
u C
r
TIME: Ir•
YESTERDAY'S ••EiGH.T: FINGER STICK GLUCOSE ___.. INSULIN MN) TODAY'S V. EIGHT:
WEIGHT CHANGE:
• Per !losP.• 31 poi:-•.
24 HOUR TOTALS
PO IV #1 V #2 TOTAL IN Urine Stool TOTAL OUT 1 1
PATIENT !DENTIt'ICATION
r---"._r\--7 ..--'\
DIAGNOSIS: VP Cra,41kdi ..._...arla II'I °
nP.r,• Anm:SSION D - 1 MT ca."-,
MEDCOM FORM 689 - R (TEST) (MCHO) MAR 99
P:70..10LIS EDITIONS ARE OBSOLETE
Pa c 1 of 4 pages
MEDCOM - 22820
DOD-036396
ACLU-RDI 1673 p.180
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
".- lf-:CT::--- ...c: A C/; ■:'.":. :C i i:I ;in: small box indicates patient assessment criteria have been MET. If all ;he s:a:ed co:or:a a:e not met, a brief a.xPlanza:-=:: , of 0 :'" .!--'' ,,3: l , ' , G.-"'gs will be nore,1 in the appropriate column.
TIME: INITI
:Me p:,2 6 , ),J.na'r:e. E.......s .,?; -)ails r,...p:upria:cIy. :0,-71,--.:::Jon is adi:::::::i:c: to expicss ncects. jpils ec-.o1 and rei::',:ve to
a INITIALS: TIME INITIALS:
T. NEUF-+OLOGFCAL: /der'. iii-ii,I orien: e d t o iiiiiek+e-A
at ' 41
I I
2. CARDIOVASCULAR: ?;.:!se regular .F.. :r!:e ..ithin r3r.s.,..2 fc.r arie. No .d.120ritfew, crdrainn.
-Nailbeds cii -ii2 tri -Jor;t.:s , i;crri•Iiiinirits pi:. NO ,-..elf
tenderness. f.S. , -::::,73-;•.7 3 /or eyriemi; :„..
.-..-.e.rfusipr:j
!L.,:ie"."--- i I
3. PULMONARY: Fricspiratiions i....i:Iiiin •ri.- r• ioi
'ate for a',:e crcuO; cL'et and :c.gtriar. Dep:: is
"7:9J1E3r. NJ cc.-.t.,, gh. No a."..r:0r:-.-0! D7C3;i1
sounds.
Oid4raeltisit5
cv"-F4 c, Vx. v
:-- i i I, 1
1. G.I.:A5don....2n se .3:)d r"on.if:slended.
''''.ovvel sc...:nds a .-.1r.re. Reports no N..V.'pain
...fah eat;ng and no e:cbiems chev:ir.g/
swalIowit -Ig. Denies constipation. diarrhea or
14---
ef2-taira PO
is 'l 441k-P
ivir .__.
5. G.U.: Repor:s no dysu:ia, retention,
....rgenc,. fregLe:-.::y, ncctur:a. Urino clear,
yeIlov.•,ate.r. No '._:nusua! dischargo.
FT W...?1 , LI • -,
5. MUSCULCSKELETAL: Normal muscle
fevelo .,77.. -•er..: .2 , e. mass for ace. No
teformi:'es. ND 2S3:5::\'C ..-"-:.vices fleeted.
s;vei!ini: 7.:.erress, wea.,ness cc pa•es:! -Iesia.
- 1 (///e) d/
rl''. 4 - Pan +° ©1"-- . I
,...i. -, --CiSig4C1 tl-, Ct-PAI`094 m ai, IJILI t- Li-
I n7b.. ( ca1'€5 -t-1-
7ashes, :::;!.-: -.1:rtion, ....::::::.:75, brcaks in skin.
o red7C'SS : D:Znf.::::7g, ::• ■ !,.:,-. ,.;cn over bony
7. SKIN: ...'a , rn, Ory, in;acz. Geod tumor. No ..
--- ad-446 0Jh 11.b
•
I
■
9. PSYCHOSOCIAL: F.',.z., !-.av:or :s aDpropria:e ' .
and r.i .,Dpro..7ririte to si:LiaIit'an. ii.:i -Nacts
i , i .
I
O. IV SITE ASSESSMENT. '.1_ ,, f,:=';D: P - F-',;!•, , I - Inflitra*.ed R - Reordened OK - No sviellingi-s&ness * - Ce -“ral line)
I - .ME: INITIALS: iTIME: INITIALS: TIME: INITiALS:
i\./ patia. - .7y I '.1 I -..:: i I'.., pe'.ency i qlilt: IV patcricy I q _
V 5:10 .7:Cf.."' 7: . :-:.,--,...:•2j: IV one core oro.vided: IV SIC c.:;7e .or•-_,•vided:
:v rut-,..-.g- c!--.Ded: IV :"..11:...ing cha d: W AV AII IV tubing c!lancied:
C:...D;7::::.'i
:,./ Site r', 1: \
LOCA .; t4 IC; ;TION LOCATION CCP:017'10N
IV Site 51:
../ S.: ..e ,r2: IV S.:e -12: Illy IV Site 52:
:-.,-,-.-:-..-.. •:s
■
ro,.--.-i7,-n:s:
.----
r ;.'":CO ! TEST.- 99
Pge 2 ol 4 pages
der MEDCOM - 22821
DOD-036397
ACLU-RDI 1673 p.181
Z
r*: 0
>
(/) D
<
CC
SITE: Lt TIME
COLOR
.90,111,.. 0
i m
TIME: '•
ID band vis.ble:!eqible
Orient to environment pen
..Iiiio..--,,.... . , .- .1 ink
Sir I Li
•
CAPILLARY REFILL I — TEMPERATURE V-5
Side rails I2/' u'
Bed position low ECEMA
Call light within reach roil SENSATION
oli
I
MOTION
PASSIVE FLEXION 9
CC
LEGEND
Review & post !oh results I Notify MD abnormal labs PERIPf-IERAL PULSE
•• Par
Incontinent urine stool A Color: P-pink (normall; C-cyanotic; W-pale, white
Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-1> 5 secs)
Temperature: C-cool; W-1,varrn; H-hot
Edema:. 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-!(.:11 ROM
Passive Flexion: D-dorsal flexion pain; P-piantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-beunding;
0-doppler, P-palpable
Linen change pen
Turn.'reposition q<, 111061 RO;v1 q2h if iirmobiic
Antic:1)1)01,c linen
I
BREAKFAST LUNCH DINNER
TYPE: I TYPE: l_.,..!-L41. TYPE:
PERCENT CONSUMED: V--y'ej I PERCENT CONSU:',1ED: 'Go I PERCENT CONSUME
HOW TOLERATED: HOW TOLERATED: tt i Led HOW TOLERATED:
E SELF ❑ ASS:ST ❑ COMPLETE i : SELF L__: ASSIST ❑ COMPLETE ❑ SELF J ASSIST ❑ COMPLETE
0700-1500 i 500-2300 2300-0700
SATRORAL CARE ❑ SELF ❑ COMPLETE i ❑ SELF Li CC..':-..1PLFT I Li SELF F__:1 COMPLETE
ASSIST ❑ TOTAL ri ASSIST ❑ TOT L ASSIST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
cEL, RES ❑ SELF BEDREST ;__: SELF 41333111
--D SELF
',.ASSIST AMSULATE ASSIST AMBULAT= Li ASSIST 4410531,
-, cr BSC ,,.:......
-ti TIvi,_S;SHIFT # TIMES:SHIFT I z 4' TIMESiSHIFT
BRP SRP P.P
(...1- 1-cd....D i AIR I CHAIR
QU
I-Z
0
TIME: INITIALS: TIME: INITIALS: I TIME: 2(-( 1,76 :NIT:AL
CONTENT: i CONTENT: I CONTENT:
s
60"
1 I •--- Vahli\
- Oc& &' • s - - caOf ,frf- or , if f
❑ p,,,;,ent."Fan,,iy veri,a1,7,,s urd,-,,,,,,,,,J,, , , a Patient (-- .-::—'y Verbalii.es lj•Iclerstandinri moat nmily ✓erba(izes Understanding
PATIENT IDENTIFICAT:ON INITIALS SHIFT
mom HP -L\ MEDCOM FORM 659-R (TEST) (AICHQ) MAR 99
Page 3 of 4 pagos
MEDCOM - 22822
DOD-036398
ACLU-RDI 1673 p.182
17
?:, .O
DZ
O -
-- C)
<C
tu
i
T L.C.- ZATION OF
!E.: WOL.:!:D
TP.EAT%'F.,%7S
DRESS!::G CANGE
111 v. • v. viva
fi) e hadak * -17-1 fr. 7014-Cei
- 25 direti IN adde- I Vii-Ot titrer 770S&F±MS
SECTION Iv - NOTES
i -i LIO rr r--- C.C/1.)/)
0 A.) 2;r- tivrAc:r ; 0
./1.-"' PICO _Z----- , f_/)
p9,p,A7 2c .7-/2,9mrio ---,04--___"7-- r...,, .,779c 7- 7 r1..-
- 5.3e.: c.
C) — Z
...
9.5
R-5-7-Piii,v(
.4 ,cpc.,
I L.,..-•,-;4-4.
4)077 t_-7- A.-2 E.cci2c)c.-tgr_r_s 6.-c.--..,g.
-i--19 Lc- C../--1 'LI< 5 - - ,..
A....FL:I.:Ca ..' FORM 6,99-R AMR 99
Page 4 of 4 ,7;77o5
MEDCOM - 22823
DOD-036399
ACLU-RDI 1673 p.183
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: /0ebOS PATIENT ACUITY LEVEL :---10:r POST-OP DAY, a.to, HOSPITAL DAY:. '3 S
T R . A. N. s•
F
E R.
, .
I. A . L::
1 ; . G. N S.
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE
Time To From I AMBULATORY
REPORT:
El CRUTCHES ❑ WHEELCHAIR I STRETCHER
Anesthesia (Specify): Total ER/RR/PACU time Physician
Procedure/Diagnosis B/P P R T
LOC Neuroirascular checks
Dressing/cast Tubes
Intake (IV, po) Output (EBL, other) Voided I No I Yes Amount:
Medication
Other
Report From Received By
TIME: .1..U0 25taa:06
BP ARTERIAL LINE ,.
j1/5"z WI
147 BP CUFF
TEMPERATURE 'TY kra :( _ PULSE 5-2.- 7
RESPIRATORY RATE t(p 16 '
..
•
OXYGEN (L/%)
PULSE OXIMETER Iftex 1024
02 METHOD i ■ \
. NC = Nasal cannula. NR = Non rebreather ... FM = Face mask VM = Venturi mask
Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar
A
N
TIME: j') TIME: e)
PAIN INTENSITY
5
•
• •
:
• •
• •
•
• •
•
: :
• •
• •
• •
• •
• •
• •
• •
s p
• Skin breakdown prevention a
• Falls prevention protocol 1--
. . . . . . . • • • • • • • • • E . Restraint protocol ci,;) LA- * Seizure precautions ADMINISTERED (WM Kl MED I
RELIEF ACCEPTABLE IV/NI .
A • Isolation precautions
- . L
N
0 '
T H
E R
TIME: E E YESTERDAY'S WEIGHT: FINGERSTICK GLUCOSE '
INSULIN lY/NI D S
TODAY'S WEIGHT:
..------- ....... WEIGHT CHANGE:
•Per hospital policy.
24 HOUR TOTALS
PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
PATIENT IDENTIFICATION
..{7(-) ,) -
40 ,--t.\,-uk
DIAGNOSIS: S7fiereitith'
DRG: ADMI ON DATE: 1 on LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCI-10) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages
MC V1.00
MEDCOM - 22824
DOD-036400
ACLU-RDI 1673 p.184
ate I ION II - VA I !UN I ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated explanation of abnormal findings will be rioted in the appropriate column.
C61C\--q-
criteria are not met, a brief
TIME: INITIALS: TIME: INITIALS: TIME: INITIALS: 1
1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
I I .../I µ V,/ -Ir m o'
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
'
3. PULMONARY: Respirations within. norma!
rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
n I I
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no NN/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or rectal bleeding.
.,,
I I
f 5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
-(5- f00( 0❑ Unit&
6. MUSCULOSKELETAL: Normal muscle
development and mass for age. No
deformities. No assistive devices needed.
Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
e --, pm. •oor--_,..,_ . _ _ ,1,1410./17k
1 5 Ude/IV-Vt ._ a cb -am
•
$' Willr i fe -
/ c
lir • •P 7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
prominences. Mucous membranes moist.
8. PAIN: Nc complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is app;opriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
LJ
10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line) TIME:___ INITIALS:
IV
IV
TIME: INITIALS: TIME: INITIALS: IV patency ✓ q hr• IV patency I q hr: IV patency . ✓
IV site care provided:
IV tubing changed:
IV Site #1:
q hr: IV site care provided: IV site care provided:
IV tubing changed: f IV tubing changed:
: cA N CONDITION
IV Site #17 LOCATION CONDITION
Site #1: LOCATION CONDITION
IV Site Feb Site #2: IV Site #2:
Comments: comments: Comments:
I
MEDCOM FORM 689-R (TFST1 (MCH01 MAR 99 Page 2 of 4 pages
MEDCOM - 22825
DOD-036401
ACLU-RDI 1673 p.185
SITE::C-Dt .„, TIME: j
cna
ww1--
>- 0
i— =
w CC
TIME:
COLOR ID band visible/legible
CAPILLARY REFILL I Orient to environment prn
TEMPERATURE IA) Side rails (2/4) up
EDEMA Bed position low
SENSATION Call light within reach
MOTION 1L (.6( Review id post lab results PASSIVE FLEXION
PERIPHERAL PULSE r'rn der-
Notify MD abnormal labs
LEGEND ...1----
ilff --/ Color: P-pink (normal); C-cyanotic; W-pale, white
Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-1> 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Incontinent urine/stool
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
Li --
BREAKFAST LUNCH DINNER
TYPE: TYPE: TYPE:
PERCENT CONSUMED: PERCENT CONSUMED: PERCENT CON MED: /75-leY0
HOW TOLERATED: HOW TOLERATED: HOW TOLERATED: ICO ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST 0 COMPLETE X SELF ❑ ASSIST ❑ COMPLETE
.
L
E,...._
N G
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE ❑ SELF ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF - ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF " ❑ COMPLETE
)4. ASSIST ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
TIME:1SW INITIALS
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC
BRP # TIMES/SHIFT
CHAI
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC # TIMES/SHIFT
BRP CHAIR
BED" ❑ -SELF
..0m14:2100 X ASSIST
BSC # TIMES/SHIFT BRP
e.(6--IAIR-)
TIME INITIALS: TIME: INITIALS:
CONTENT:
paArk,- fyyLcumItiviAldvct,
Pa tien t/ .
amily Verbalizes Understanding
i, abiAZA-- CONTENT:
(9,5.)'
❑ Patient/Family Verbalize Understanding
CONTENT:
❑ Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION
f)Iti°
INITIAL
-
411111111111111111 11—
I SIGNATURE SHIFT
—
MEDCOM FORM 639 -R (TEST) (MCHO) MAR 99
Pagc 3 of 4 pages -t
MEDCOM - 22826
DOD-036402 ACLU-RDI 1673 p.186
tt.. I ION III - IN I EAVENTIONS e„, TEACHING (Cont)
W
0 u
c A .
R
E
T
1 M E
LOCATION OF WOUND APPEARANCE
_Iviocitra...4e. ,
TREATMENTS AND
DRESSING CHANGE
aviD0 K6veAr- puiviemi- _ hi, i_t 1
AI ousla r-el P i VoiiG____i aly__
i UU -sz D (Aso b.
uo-/ ID ds(0_,& 51(1)3u.id-w —
_____
SECTION IV - NOTES
MFDCOM FORM 689-R (TEST] (MCHOJ MAR 99 Page 4 of 4 pages
MEDCOM - 22827
DOD-036403
ACLU-RDI 1673 p.187
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT — •
DATE: Der,- I PATIENT ACUITY LEVEL : 11, J POST-OP DAY: 947. !HOSPITAL DAY:
.
A:
R
...
I A.
N S
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Time To From III AMBULATORY ♦ CRUTCHES a WHEELCHAIR I STRETCHER
T. Total ER/RR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P P R T
N LOC NeuroVascular checks
S - Dressing/cast Tubes
F Intake (IV, po) Output lEBL, other) Voided El No I Yes Amount:
E Medication
Other Report From Received By
TIME: MI6 a covoiril'' 1
.;.!.. BP ARTERIAL LINE 149 *Sg__ V: BP CUFF WeV" le_ c PM
TEMPERATURE 91' - .
• PULSE 4 RESPIRATORY RATE / Cr
(' \IlIp OXYGEN (L/%) PULSE OXIMETER i420 jylE, • Cm,
02 METHOD I.. ir .
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar
TIME: Pia) /24o it-go09 TIME: 13C10-0
PAIN • • • • • • • • • • • • • • p 'Falls prevention protocol
10 prevention °A
•Skin breakdown — —
P INTENSITY • • • • • • • • - • - •
• • • • • • • • • • • . . E . Restraint protocol
•).( . . . . . . . . . .
MED ADMINISTERED IY/NI 0 I • Seizure precautions
RELIEF ACCEPTABLE IYIN) 1,6 A • Isolation precautions L
N._._.._
TIME:
T. FINGER STICK. GLUCOSE E YESTERDAY'S WEIG
0 I
H INSULIN IY/NI --- D TODAY'S WEIGHT:
E R 'Per hospital policy. .......—:—
$ WEIGHT CHANGE:
24 HOUR
r
TOTALS PO I IV #1 1 IV #2 TOTAL IN Uri ne Stool TOTAL OUT
PATIENT IDENTIFICATION
UF - '49V4111—
A,.
go
- PRIMARY CARE MANAGER: u\ ISOLATION REQUIRED (Spec,
VP DIAGNOSIS: C... M. 1,1 DRG:
. 4(‘ at-GYYLA-S.-- ADMISSION DATE:
LOS: EXPECTED RELEASE: ISM CASE MANAGER:
MEDCOM FORM 689-R (TEST) (MHO) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages
MC V1.00
MEDCOM - 22828
DOD-036404
ACLU-RDI 1673 p.188
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have b I MET If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. e', C.);L
TIME: oci INITIAL TIME: iti5 INITIAL
I 'horkenArrili-e4A, . M1119e- C Nijg 4*
71 .
TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately.
Communication is adequate to express needs.
Pupils equal and reactive to light.
H (\aro sr■l-p(-0, ) sf,_____r‘ .1 w.
rty_r_s,--n 1.-31\-)\--
2. CARDIOVASCULAR: Pulse regular & rate
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
1 1,7
3. PULMONARY: Respirations within. normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath
sounds.
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/
swallowing. Denies constipation, diarrhea or
rectal bleeding.
•.
q. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge,
4[4 I 1
6. MUSCULOSKELETAL: Normal muscle
development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
0n S431 iVii ata
CIO ' .•. VV"e_aVA-R-24-:z--N .
-\-612-)(10' MOM —9 2-CrArl -A ILID - )1--
7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.
No redness, blanching, irritation over bony
prominences. Mucous membranes moist.
V5(vbr -(3
Ak-.0.k., (5A) 1,-N_Qa_09_
8. PAIN: No complaints of pain/ discomfort.
(See page 1 for documenting pain intensity.) rt LJ
Li 9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
I1 IV .
10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)
TIME: INITIALS: TIME: INITIALS: TIME: INITIALS: IV patency ..// q hr. IV patency ✓ q hr: IV patency ✓ q hr:
IV site care provided:
IV tubing changed:
LOCATION CONDITION
IV Site #1:
IV Site #2:
Comments:
IV site care provided:_ • IV site care provided: • IV tubing changed: \I IV tubing changed:
1101 • FHOtI CONDITION
IV Site #1: 0111r ION CONDITION
IV Site #1:
IV S:100,,, !V Site #2:
Comme Comments-
MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 2 of 4 pages
MEDCOM - 22829
DOD-036405
ACLU-RDI 1673 p.189
Fl f .Dct.,.; tvil■ ill - rt, 1 icim , ;Iv 1 cnvciv I li 64 I tHl...11INCi Or
E 11,
•
V
.
U
TIME: 4O On0
COLOR P ID band visible/legible
CAPILLARY REFILL I i Orient to environment pm N TEMPERATURE 0.- tiO Side rails (2/4) up A
SENSATION N Call light within reach I I Bed position low / EDEMA
32,,t c9p
SITE: TIME: 1€59- I
(f)
LLI
>••
0 I-
u..1
MJ3TION U PASSIVE FLEXION
75 Review & post lab results PERIPHERAL PULSE Notify MD abnormal labs
S LEGEND Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stool
. - Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-1> 5 secs) Linen change prn Temperature: C-cool; W-warm; H-hot
L Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting I A Sensation: A-absent; N•numb; T-tingling; S-sensation (present) R Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Antiembolic hose '• Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
Tum/reposition q2h 411/k ROM q2h if immobile
1
- LU
I
BREAKFAST LUNCH DINNER TYPE: 111, l4 ye' TYPE: TYPE: ,-- PERCENT C4UMED: (7;15 Jo PERCENT NSUMED: 6070 PERCE T C SUMED: 1/4:714.D HOW TOLERATED: ‘&...lei. HOW TOLERATED: ce j y,,i, /" HOW TOLERATED: l(/0-e 3:RII SELF ❑ ASSIST ❑ COMPLETE 1?1 SELF ❑ ASSIST ❑ COMPLETE . SELF ❑ ASSIST ❑ COMPLETE
a.o
_1" I- LU
0700-1500 1500-2300 2300-0700
BATH/ORAL CARE A SELF ❑ COMPLETE ❑ SELF ❑ COMPLETE ❑ SELF , ❑ COMPLETE ❑ ASSIST ❑ TOTAL ASSIST ❑ TOTAL ❑ ASSIST ' ❑ TOTAL
❑ SELF IEDREST ❑ SELF BEDREST ❑ SELF TYPE OF ACTIVITY
AWRE JR! ASSIST A : U ATE Nr ASSIST AMBULATE ❑ ASSIST (Circle all that apply) BSC BSC BSC # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT BRP B" BRP
A lEra) CHAIR TIME: INITIALS: TIME: F,.. INITIALS: TIME: INITIALS:
Cali Ct5;%1
1 ell-1-
CONTENT: CONTENT: CONTENT:
L \-12.-Og iq:j,
(ill'i_C
21,1€133/Family Verbalizes Understanding /,(,Eatielt/Family Verbalizes Unclerstanriina ..1, Pationtignrelit., N/.1;,...r. I ... ..1 .. GII 10.1........A..... PATIENT IDENTIFICATION
•a• rii y •-• •-•• ■ IV 1,11V
INITIALS SIGNATURE
SHIFT
MEDCOM FORM 689-R (TEST) IMCHO) MAR 99 Page 3 of 4 pages
MEDCOM - 22830
DOD-036406
ACLU-RDI 1673 p.190
Stu I (Lint III - INTERVENTIONS & TEACHING (Cont) _.
W
0
U
N
A . R
E
T 1
m E
LOCATION OF WOUND APPEARANCE TREATMENTS
AND DRESSING CHANGE
a&
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,Pri-... 7LA. -- #-27---
P--,9- v - A ..A..t_
SECTION IV - NOTES
I j / ..• A .. ,.1 -_.- .....4.... .." ,
....._ , /
0 ---7
MED COM FORM 639-R (TEST) (MCHOI MAR 99 Page 4 of 4 pages
MEDCOM - 22831
DOD-036407
ACLU-RDI 1673 p.191
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5
SECTION I - PATIENT ASSESSMENT
DATE: Ck--- .C.,, PATIENT ACUITY LEVEL : 14_, POST-OP DAY: HOSPITAL DAY: eta__
CC. ••=4 z
u- W
CC >
cr
Cn "
. Z
(/)
COMPLETE ONLY AT TIME OF ADMISSION O.P. PATIENT TRANSFER IN Time To From
- TELEPHONE REPORT:
. AMBULATORY ❑ CRUTCHES II WHEELCHAIR ❑ STRETCHER
Total ER/RR/PACU time Physician Anesthesia (Specify):
Procedure/Diagnosis B/P P R T
LOC Neurovascular checks
Dressingicast Tubes
Intake (IV, po) Output (EBL, other) Ve'cled U No U Yes Amount:
Medication
Other
Report From Received By
TIME: OW
BP ARTERIAL LINE
BP CUFF "VW TEMPERATURE 5‘r
PULSE Va
RESPIRATORY RATE I(1,
OXYGEN (LI%)
PULSE OXIMETER Ctil•
02 METHOD Or
NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask Oxygen Method Key: MT =-- Mist tent PR = Partial rebrea her A = Aerosol TC --- Trach collar
TIME: OCMS-- TIME:
PAIN INTENSITY
to
. .
• • . . . . • •
• Skin breakdown prevention
• Falls prevention protocol .. . . .
0 . . . .
. . • • . .
• • . .
• • . . • • . .
• Restraint protocol ... _ .
MED ADMINISTERED IY/NI IA
) -
'Seizure precautions
RELIEF ACCEPTABLE It'/N) 1 ' Isolation precautions
. _
0 T
"
H
E R
TIME:
FINGER STICK GLUCOSE — YESTERDAY'S WEIGHT:
INSULIN IYrNI D TODAY'S WEIGHT: S
WEIGHT CHANGE:
•Der hospital policy.
24 HOUR PO IV #1 IV #2 i TOTALS
TO - AL IN Urine Stool TOTAL OUT
PATIENT IDENTIFICATION
5 \ Ni lir
( -)l-L)7\
DIAGNOSIS: 1.4--) OA-AA( DRG: ADMISSION DATE: /MN 03 LOS: EXPECTE EtU\SEt CASE MANAGER: __
PRIMARY CARE MANAGER:
ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
PREVIOUS EDITIONS ARE OBSOLETE
Page 1 of 4 pages MC V1.00
MEDCOM - 22832
DOD-036408
ACLU-RDI 1673 p.192
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
TIME: 09 1.15- INITIALS TIME: INITIALS: TIME: INITIALS:
1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.
Pki0)(2-
Yi yo Xtz-1"."-> -)\'
c.-. y V. 1-(,k- rt---x%/ ut ) 6., ,
ID si:ck-, v---triu-e s ,%
U/1 F-1
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
i
3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.
U.../ i 1 I 1
4. G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V/pain
with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or riirtal bleeding.
E
S. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.
--q---
6. MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
Elg •s.■cis v..3 or.A.V.-ING li
S.s? 1: 0--4 sk -
7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.
n ..,\t-C S A-6 2 G-1 cm -AP v... ty...-v..,,‘, %-...t..., .i1.- Asa .% ..,,44
W. Ar s) -Ito oesk.--y.s
LI
8. PAIN: No complaints of pain/ discomfort. (See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
4' 10. IV SITE ASSESSMENT: ILEGE ■ : P P
—
3-
fly I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)
TIME: a 5L\ C INITIALS: __Ag TIME: INITIALS: TIME: • INITIALS: IV patency ✓ qhr:
_ Addl. IV patency ✓ q hr: IV patency ✓
IV site care provided:
IV tubing changed:
IV Site #1:
q hr: IV site care provided: ANN IV site care provided:
IV tubing changed: A1111.111
IV
IV
IV tubing changed:
LOCAT •N CONDITION
IV Site #1: LOCATION CONDITION
Site #1: LOCATION CONDITION
IV Site #2: Site #2: IV Site #2:
Comments- Comments: Comments:
/
MEDCOM FORM 689-R (TEST) (MCNO) MAR 99
Page 2 of 4 pages
MEDCOM - 22833
DOD-036409
ACLU-RDI 1673 p.193
MEDCOM FORM 639-A (TEST/ (MCH01 MAR 99 Page 3 of 4 pages
PATIENT IDENTIFICATION
MEDCOM - 22834
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SITE: TIME:
S
A
F E
Y
T H
E R
ROM q2h if immobile
TIME: , r Cl_ COLOR 1 11_11_ ID band visible/legible
I il CAPILLARY REFILL Orient to environment pm
TEMPERATURE MI Side rails (2/4) up
11.1 , EDEMA Bed position low
SENSATION -r
■ Call light within reach
. MOTION
Review & post lab results
2
PASSIVE FLEXION
PERIPHERAL PULSE Notify MD abnormal labs
Ir
MI f GEND
0 Incontinent urine/stool
-"MP'
,
S . Color: P-pink (normal); C-cyan c; W-pale, white
Capillary Refill: 1-10-2 sec 2-(3-5 secs); 3-(> 5 secs)
Temperature: C-cool; warm; H-hot
Edema: 0-None; 1 ild; 2-moderate; 3-severe; 4-pitting
Sensation: A--.sent; N-numb; T-tingling; S-sensation (present)
Motion: U- able to move; M-move-no pain; P-move-pain; 11-full ROM
Passive exion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Perip rat Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
D-doppler, P-palpable
Linen change prn
II Turn/reposition q2h MI
". Antiembolic hose
:
E .
BREAKFAST LUNCH DINNER TYPE: 12R-C) TYPE: TYPE:
PERCENT CONSUMED: riot. PERCENT CONSUMED: PERCENT CONSUMED:
HOW TOLERATED: 6 V) HOW TOLERATED: HOW TOLERATED: pv4 SELF ❑ ASSIST 0 COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE
D L
- : s.
'
T E.
H ,i H I
N G
0700-1500 1500.2300 2300-0700
BATH/ORAL CARE /SELF ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF • ❑ COMPLETE
❑ ASSIST ❑ TOTAL
❑ SELF . ❑ COMPLETE
❑ ASSIST • ❑ TOTAL
TYPE OF ACTIVITY (Circle all that apply)
BEDREST zn--SELF
AMBULATE ❑ ASSIST
BSC BRP
11 TIMES/SHIFT
CHAIR
BEDREST ❑ SELF AMBULATE ❑ ASSIST BSC
11 TIMES/SHIFT BRP
CHAIR
BEDREST ❑ SELF
AMBULATE ❑ ASSIST
BSC 11 TIMES/SHIFT
BRP
CHAIR
TIME: INITIALS: TIME: INITIALS: TIME: INITIALS:
,211
CONTENT: •
-OO?) --i-u d-tot....w- -i, rkA.-c.t,. 1-3
--- 30:> E o—,,,y(--._ s 04,(?,..46,_--
kms' Al Of
patient/Family Verbalizes Understanding
- 170--:-. Ca--1..1r2ri
CONTENT:
❑ Patient/Family Verbalizes Understanding
CONTENT:
❑ SidiNIIIILLFanli!v VeDrhali>ne I Irirlerctne.pi;.,e.
DOD-036410
ACLU-RDI 1673 p.194
Emikamimmomil F111611/411111
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511-119
NSN 7540-00-634-4124
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100 96°
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80
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• ..
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22835
DOD-036411
ACLU-RDI 1673 p.195
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY _ MONTH-YEAR DAY P!D LI 2.1-- ..A1 ...
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STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 22836
DOD-036412
ACLU-RDI 1673 p.196
511-119
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY MONTH-YEAR DAY Mani
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170 103°
160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96°
90
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80
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50
40
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VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22837
DOD-036413
ACLU-RDI 1673 p.197
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY MONTH-YEAR DAY EriV". w.MTMEIMMVIIIMMINIMINIETIMMIIIIM
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MEDCOM - 22838
STANDARD FORM 511. (REV. 7-95) SACK
DOD-036414
ACLU-RDI 1673 p.198
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
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170 103°
160 102°
150 101°
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REGISTER NO
IPP STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 22839
DOD-036415
ACLU-RDI 1673 p.199
511-119
NSN 7540-00-634-412
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
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REGISTER NO WARD NO.
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1111r-V:d\ MEDCOM - 22840
ITAL SIGNS RECORDS
Medical Record
STANDARD ORM 51.1. (REV. 7-95) Prescnbecl GSA/ICMR. FiRMR (41 CFR) 201-9.202-1
DOD-036416
ACLU-RDI 1673 p.200