· mem tobacco: etoh: drugs: sphysical examina bp hr t r pain scale 0-10 heent - teeth trachea...

MEM TOBACCO:

ETOH: DRUGS:

sPHYSICAL EXAMINA BP HR R T Pain Scale 0-10 HEENT - Teeth

Trachea • TPLUNeck Oropharnyx Nares

CHEST: cp... CARDIAC:

NV;

EXTREMITIES:

IV Access Ulnar Fill'

BACK:'

OTHER:

OrdX 41 -(7- effScark 1144C NPO Since Ai/ 14

HB/HCT: WA: OTHER:

(

5- 3r 3 o 1

CURRENT MEDICATIONS: 0 = ordered as premed

()

()

()

()

PREMEDICATIONS: None Yes (0 Hrs) /CC

mg P1 IPA PO mg IV IM PO

mg IV IM PO

LABORATORY STUDIES:

SEDATION KEY:

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

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

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

4. ANESTHESIA. Patient does not respond to painful stimulation.

Time:

Hrs

Prowinunc molitivu.

Age 33. DAYS MOS

PROPOSED PROCEDURE: SURGICAL SERVICE: NPO SINCE:

33 ye cr ANESTHESIA PLAN RE Ph=t2aagyRAL ASSESSMENT (Sedation/Aggagaba

Sex )MALE ( ) FEMALE

(039 )

PREOPERATIVE PAST MEDICAL HISTOR S REVIEW Cardiovascular: Sr Hypertension

Angina MI CVA Other

Pulmonary System: Asthma Bronchitis/UFO COPD Other

Renal System: Acute/Chronic RF

Gastrointestinal: Hepatitis Hiatal Hernia PUEVGERD

Endocrine System: Diabetes Steriods Thyroid

Neurological: Seizures Neuropathy Other

Gynecological : Pregnancy

Other Significant fix: N Y

ASSESSMENT PAST SURGICAL/ANESTHETIC

(Specify):

(3d. 7

at' It.`i fir 3114 OK 1,03

N N

Familial HX

N

ANESTHETIC { ) LOCAL ) MAC f Regi neral: Mask Intubation

ic e v(t

discussed with the patientfiegal guardian. INFORMED CONSENT/COUNSEUNG STATEMENT: Plan , alternatives and risks of anesthesia including death have been explained to and

The pate to

Signed: illPilltnstPr Ni4" 00)/bi- Z-- Date: I See G3

stand and agrees. Questions answered.

POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) { 1 NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER

Signed: Date: Time: Hrs

Patient Identification: (Ward) SCA.4.) ".. 1

iimidia couc)-ei

iiminp(b)(0-i/ MEDCOM - 20441

WAPAC Form 2300 (Revised) 15 Mar 01 MCXC-DOS

DOD-034015

ACLU-RDI 1657 p.1

EDICAL RECORD

N sib 0 INamsd REMARK

with art

Code dugs with numbers. eventt wit 1 1_2_ 14 Z(4)1 LOSSES

to L9 i

•

ii O

•

N ;

z

I- la i 1- ie z z -- u :2 .1 (.7 3 ; 'I; VOLAT < (2 , t 8 AGENT

% e.t. c..) P if:

.

0 Y AIR UMIn LU g r

H2OL/Min to 02 L/Min z SINOLE DOSE DUOS - MARK ON 0R1q, < WITH NUMBERS RENTER IN REMARKS '-

CRYSTALLOID-

FLUIDS - SUMMARY ralrimatiliirARIV/PEND

)w. TOTALS

TOTAL URINE

COLLOID-

BLOOD-

( U n ite )

MillmMaim .L'EME:„. ,:: , :: . : : :

::::::::::::::.:,,,„,:::::::::::::::::„.::::

illEM11 NE ::::::i:::::::::i:::::zonmEntsimminivni

.....::::: -•::.;:,;.':::N.i:::mmillam Erg:::ii:4::. , :: cr M.EuxiitiMen=mWnsmivElimv is

MUMensmumMonswomMossennuffnme um IIIIIIMMIIM MIIII

Ill i i i i NM NUMINSUESIVAMINKENNEIMENVO . rn

IE1AWME i inn rpkgotRow ,:- gliMenniE 2,4:: mg enommul ,,,,,,,,.::::,:.,:i:,: -,M

Oli ruritniumemmumni - mununn. um ismaingEgis .::0::: .::::::;::::::MINSMINMENION ,,__MIFIFITIVIriballil i i . i i i : Ermliall IffilligiSAMISMISHEREMEINEMVSKEI=MENMENO

TEE- 20 :. :..,. ft:41„.6.76,7k.a ,.. ........__Re • ro

2113 a 172-1;/111.14 4.11-mmirmtnallt IlL111K01101111111rall :W- F'AT:.. 1

V [CLINIMINEWIk-riNT. ,,.1 BP / oth W.IgL• iff.Mr."&iliticilAVAMIENVIIR

!. I ART line ,,,,simEramilrEpjffriMpnliffis ii I ''', IrricntirArimmorminvin i.m_lligt kier 91 nresWillartEMIIIITEISfrillialie

& N-m Block T/4 Runinew

Il lei ,.:1 • . A Cony wanner

MEEMERI TIME • ,#, SYMBOLS BO Y WEI

BP by cuff

V

A •

Heart rate

Resp rate

220

200

180

160

OK for PROCED

BP (transduced)

1.

TOURNIQUET

T —

/ ARES- X-X

PROC-0-0

RESP-

BP-

ONDtTION:

U (Specify)

j7-7Crizi VtiK;t1 I' 1 Ai tAl

SURGEONS: PROCEDURE LOCATION

PROCEDURES and CPT Codes

( PATIENT IDE

C) CATION Typed or written ankles: Nemo. Crodeinete.

Medicol tacitly

8 a. I Z.Z 12Y

AH:=STHETIC TECHNIQUES:Oast/be black technique under Remark:

GE714-

Ready Begin End

OP 376 REVISED PATIENT RECORD

1 Jan 99

MEDCOM - 20442

ANESTHESIA

DOD-034016

ACLU-RDI 1657 p.2

HOURS

ROOM NO.

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

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

PATIENT IDENTIFICATION

IMP DATE OF ORDER

TIME OF ORDER

/ 2 5

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT

,zzzyr)/c.,31

ROOM NO. BED


(L )119

DATE OF ORDER TIME OF ORDER

( Le) th)

NURSING UNIT ROOM NO. BED NO.


ci.,)(' )4

Vj

HOURS

C )0.a)- L

NURSING NIT .„,. t2) 1,6.) - z


ar mom )1 min

11101 ffimillw , 0_2 Ci4)1,6,2

11011111. 111116. 4 1$6. MILIII64.Pm"— fb. j_ka. A. ' ' tWin 4256 I,P i iv- i 4/arty-

/0' S EDITION OF 1 JUL 77, WHICH MAYBE USED.

02) /40 -1—

NURSING UNIT

(9) tb

DA ,FAOPRRM79

MEDCOM - 20443

DOD-034017

ACLU-RDI 1657 p.3


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.


HOURS

(10)(61.4

NURSING UNIT

(C,\N

PATIENT IDENTIFICATIO

1,7)(k P/

NW .7 blIERWL,

Kil AWL, ._. IIIIIIIIATAIMI Nfi go. Air.7' ,40,1ML___A .t.r.= .'—.4,ii.,/,•

•tl.:. ,:_;•.11 •

(b)4i 10 DATE O ^•RDER SME O' ORDER

411111111.11, Gra ..1EPATIO1 VIME...44

. . 1

istr"L reverniff

6.121 1 i2} - z

NURSING UNIT


NURSING UNIT


NURSING UNIT

DA 1 FAPRRM79 4256 REPLACES EDITION OF 1 JU 77, WHICH MAYBE USED

MEDCOM - 20444

DOD-034018

ACLU-RDI 1657 p.4

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

PA ENT IDENTIFICA

NURSING UNIT



NURSING UNIT

REP ES EDITION OF 1 JUL 77, WHICH MAY BE USE

00)/6) - Z

MEDCOM - 20445

DOD-034019

ACLU-RDI 1657 p.5

NURSING UNIT


LIST. TIME ORDER

NOTED AND SIGN

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see

AR 40-66, the proponent agency is OTSG SYSTEM IS USED, WRITE PROBLEM NUMBER

IN COLUMN INDICATED BY ARROW BELOW. PATIENT IDENTIFICATION

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD

NURSING UNIT

NURSING UNIT

*ter ) BED NO

reg El

IRV TIME OF ORDE t ta

dk iim e Amu' m_________

ni Lb 1 rilliallIIIIIIIINIF BED NO.

111.14m.inr:JIMIIIIMIlliiiiimil A a wil almMini

111 111 11 110111111111111111INIIIIIIIIII III

DATE OF ORDER

Lc-27y esJ TIME OF ORDER

HOURS

0/44NriraifirMalligall PATIENT IOENTIFICAT

(I) C4 DATE OF ORDER TIME OF ORDER

HOURS



HOURS

NURSING UNIT

DA , FAr,,m79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 20446

DOD-034020

ACLU-RDI 1657 p.6

,EDICAL RECORD - DOCTOR'S ORI.,.., For use of this form, see MEDCOM Circular 40-5

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.

ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS 7 • 29 ■ 03 /7Z5

ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS

POST ANESTHESIA ORDERS (circled Items)

0 VS q 5 min X 15 min, then q 15 min until discharge.

2 Supplemental oxygen. (1)/i)- 7.-

0 Morphine / Iviepeitinte- w and 1-1- mg q 3-5 min pm pain for a

max dose of / mg.

4 Zofran mg IV pm N/V q 15 min, may repeat x .

5 Metoclopramide mg IV prn N/V x 1. • 6 Droperidol mg IV prn N/V x 1.

Phenergan / 2 ' ,- mg IV pm N/V x 1.

8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.

9

63

IVF: Ca cc/hr.

Discharge from recovery status when PACU discharge criteria met.

11/1-P44-S (b)/ b) - 7—

i■-•(–C- .4444/7'


(4)(b) - ‘/

6

.

_

Complete the following information on page 1 only. Note any changes on subsequent pages.

Diagnosis:

Height: Weight: Diet:

Allergies:

Nursing Unit

PACUMEIN Room No. Bed No. Page No.

1 of 1 - (M HO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC V1.00

(4)Z z ) -z

MEDCOM - 20447

DOD-034021

ACLU-RDI 1657 p.7

BED NO!


NURSING UNIT


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

141

1111

61

(141t) - V

DATE OF ORDER

03

TIME OF ORDER

4);:e-e-21

( 1, ) 1 0 -1--

AN/ NURSING UNIT


NURSING UNIT


am) Ltozb)-Y

PURSING UNIT ROOM N

0

IA FORM 1 APR 79 4256

Cd CO -2_ REPLACES EDITION OF 1 JUL 77, WHICH MAY BE

(bl/N-L

MEDCOM - 20448

DOD-034022

ACLU-RDI 1657 p.8

MEDICAL RECORD PROGRESS NOTES

AUTHORIZED FOR LOCAL REPRODUCTION

ELATIONSHIP TO SPONSOR

TIENT'S IDENTIFICATION: (For typed or written entries, give: Name • last, first, middle; ID No or SSN; Sex; Dare of Birth; Rank/Grade,

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 - 20449

DOD-034023

ACLU-RDI 1657 p.9

T TIM ORDER

NOTED AND SIGN

NURSING UNIT


(b)lb)- z-

NURSING UNIT

lc w I 1-


eb)th -Z

CL)11.- .):- 2 NURSING Lf T

'ATIENT IDENTIFICATION

IRSING UNIT

FORM 1 APR 79 4256

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 20450

CLINICAL RECORD - OC T O'S ORDERS For use of this form, see AR 40-66D, the prop

Ronent agency is OTSG

NUMBER IN COLUMN INDICATED BY ARROW BELOW.

THE DOCTOR SHALL RECORD DATE SYSTEM IS USED, WRITE PROBLEM, TIME AND

SIGN EACH SET OF ORDER IF PROBLEM PATIENT ID ENTIFICATION

ORIENTED MEDICAL RECORD

DOD-034024

ACLU-RDI 1657 p.10

(6 ) 09 ) - -z-

/

-1■11111 ANL Arr./I&

< • /Li

■'110

•1• 4i is

„-- 2,5)-7/

ATIONSH/P TO SPONSOR

11(

MEDICAL RECORD

DATE

PROGRESS NOTES


NOTES

63' 03

WitAMINNIW./ ir „KAPY

1R T./SERVICE

JT'S IDENTIFICATION: (For typed or written entries,

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

111.11 k(b1-1

SPONSOR'S NAME

HOSPITAL OR MEDICAL FACILITY

RECORDS MAINTAINED AT

SPONSOR'S ID NUMBER ISSN or Other)

WARD NO.


STANDARD FORM 509 (REV. 511999)

Prescobec

by GSA/ICMR FPMR (41CFR) 101-11.203(15/(10)

USAPA v1.00

MEDCOM - 20451

DOD-034025

ACLU-RDI 1657 p.11




NURSING UNIT


(b)1 17 ) -z-

NURSING UNIT


NURSING UNIT


NURSING UNIT

DA , AP R^79 4256


/0 6 L, nUVHS

tir‘, MV!.

Atassowp: immirAmmimppp- nramiump.--


C

'23 2'

MEDCOM - 20452

DOD-034026

ACLU-RDI 1657 p.12

STANDARD FORM 509 (REV. 5119991 BACK USAPA VI .0C

MEDCOM - 20453

DOD-034027

ACLU-RDI 1657 p.13

.EDICAL RECORD - DOCTOR'S ORDERL For use of this form, see MEDCOM Circular 40-5

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new orderls1 are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.

ORDER NUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS

ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS

I C te 3 09 Co POST ANESTHESIA ORDERS (circled Items)

VS q 5 min X 15 min, then q 15 min until discharge.

1111 Sup, emental oxygen. r et3 9 orphm• / Meperidine 2_ mg IV now and Zing q 3-5 min pm pain for a

max dose of / mg.

• - _ • . mg • pm N/V q 15 min, may repeat x .

( -D Metoclopramide /(mg IV pm N/V x 1.

—6----B/vpurict mg V prn NN x 1 .

Phenergan LS—mg IV prn N/V x 1.

8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU. 0 IVF: L re-- 0 Trac/hr.

illp Discharge from recovery status when PACU discharge criteria met.

ek mor

41110 , • A _., . C _ 2- A'‘ • : . • S - en ic. ... E 'nn% :__ (6)(b)"

e •-) / •

,

Zio,ilbtZ-


AM No) 00 ) — 9

Complete the following information on page 1 only. changes on subsequent pages.

Diagnosis:

Note any


Allergies:

Nursing Unit

PACUMIIII Room No. Bed No. Page No.

I of 1 - I MAR 99 PREVIOUS EDITIONS ARE OBSOLETE (h,/ }t 2) -z_ MC V1.00

MEDCOM - 20454

DOD-034028

ACLU-RDI 1657 p.14

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or Birth; Rank/Grade.)

MEDICAL RECORD r,k, 11 ivr s I ct, rt.Jrc LLA,Pa- rcrrcuutiL. I IUN

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

taA2-_-.1 r--- 1/2_/4.e.r - 72-12:-.-

f',--1-0---- 1 ,•• pa- /

L....._,4 _,-..,.." I ._...„1- _.........

.. _... . L.)119 -z_

/)2})1 'L., - /Lit-c-j--

--2---- N C'

67 _ --))

4_,„..., Arr ,....---/.1-0-&-

--,--1-9-----)144--

---ef-4-4-S,-... 0-2--A-Q-,

79a1--C_AA.-,..., 7-2

10 b " 2-

HOSPITAL OR MEDICAL FACILITY!! STATUS DEPART./SERVICE!!


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

SSN; Sex; Date of REGISTER NO. I WARD NO.!!

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00

MEDCOM - 20455

DOD-034029

ACLU-RDI 1657 p.15

BED NO.




HOURS

i„. 10111.04 ( 4) 1 to

DATE OF ORDER TIME OF ORDER LIST- TIME ORDER

NOTED AND SIGN

,Loth

d) z_ ROOM NO. BED NO.

NURSING UNI x Co

PAT1E WE T1F !CATION

NURSING UNIT


TE OF ORDER

rt(—, Lc °P- ea/. 41

(L )16) - z

TIME OF ORDER

2:z-esD HOURS

1)1.6)-2 (6)16) -2


5-1 HOURS

Lwa2)--/ •

L WO - NURSI

CL) 1 11 DOI


Ch ) 1 6 ) -d/

dal 4.)C6)- 2


okb)-t ca4Vibio4-03 0161) DA 1 FAW419 4256

c9z DATE OF ORDER TIME OF ORDER

Ock 0 -\ 1(1200

r -70 cnY1— To yvwcro L.■_)

HOURS

REPLACES EDITION OF 1 JUL 77, WHICH MAY SE USED.

MEDCOM — 20456

DOD-034030

ACLU-RDI 1657 p.16

.EDICAL RECORD - DOCTOR'S ORDER._ For use of this form, see MEDCOM Circular 40-5

DIRECTIONS: list the time

require recopying.

The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not

They may be signed off, as completed, in the far right column.

ORDER NUMBER DAT 4, TIM f, & SIGNATUAE REQUIRED FOR EACH ORDER OR SET OF ORDERS

i'D//i- 7°3 11 I ) ORDER NOTED

TIME & INITIALS COMPLETED

TIME & INITIALS

POST ANESTHESIA ORDERS (circled Items) CD VS q 5 min X 15 min, then q 15 min until discharge.

2 Supplemental oxygen.

6) Morphine / Isdei9eridine" z..- i ,116 W now and 2 mg q 3-5 min pm pain for a max dose of /0 mg.

4 Zofran mg IV pm N/V q 15 min, may repeat x . 5 Metoclopramide mg IV pm N/V x 1. 6 Droperidol mg IV prn N/V x I.

0 Phenergan /L,. ung IV pm N/V x 1.

8 Benadryl 25-50mg IVP qI hr pm, itching while in PACU. 9 IVF: (a) cc/hr.

6) Discharge from recovery status when PACU discharge criteria met.

(L)(b) - 2- j1164-.....

PATIENT IDENTIFIr.A -rinm 4011 (6)(19)-y Complete the following information on page 1 only. Note any changes on subsequent pages.

Diagnosis:


Allergies:

Nursing Unit I Room No. Bed No. Page No. PACU 1 of 1

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE (

I mc v1.00

MEDCOM - 20457

DOD-034031

ACLU-RDI 1657 p.17

MEDICAL RECORD r,.., 11.../INILLLA run LtJUAL r(CrrilJLJUl, I ION

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

/ 4

Lc 2540'.0) ge

Allf■ Ar

A. ! -- , I ir FA ._* WA IIA 11111111 WA: • 400 41

. / ilir

, _................_ -7 Or rilLoo llir

k —...., A.: _,. 1.4111

.■ _,,,40,3•—•----_,--

/ Ile ..614 _.1 .../...t _A _.:11/A.- ......- A. /

-- -S

( 6)/b) - L

HOSPITAL OR MEDICAL FACILITY!! STATUS DEPART/SERVICE!! RECORDS MAINTAINED AT

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

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or Birth; Rank/Grade.)

SSN; Sex: Date of REGISTER NO. WARD NO.!!



MEDCOM - 20458

DOD-034032

ACLU-RDI 1657 p.18

NURSING UNIT q

(461-


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



L9 ) HOURS


-1z)(1 14-v3 -7-

LIST TIME ORDER

NOTED AND SIGN

b)(..19)-

( 6) 4 )--z (. 6 1 1 6) _

NURSING UNIT 1100m NO . 3A0/ (AV?

PATIENT IDENTIFICATION DATE OF ORDER

TIME OF ORDER

VOCP HOURS

ti 6L1)(6)-z_

(601 -2- -

6.4 ) L. ) M NO. BED NO.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

.d 6",) HOURS

NURSI G UNIT )- 2-


b HOURS

NURSING

DA FORM 1 APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 20459

DOD-034033

ACLU-RDI 1657 p.19


'MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

/74? e.).. Z-51v7,--4:::''

/I c6

P---1-1....4-,...%-fi--i ii ,.)

ifr -."...4--i.--,....10.1.; s'j ok.2(/1--•,--,Y2,16

Li.)(0-7---- /

c.‘"-.7‘..:-.5/ ..- --1„,..‹..— ...÷ 114-e_____.

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER (SSY or OHO LAST

• FIRST MI

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: /For typed of written arftiox err Nome • hut Thy. DIA* 10 No of SSN; Sec Date of Birth; Rank/Snide)

I REGISTER NO. WARD ND.

o co PROGRESS NOTES Medical Record

STANDARD FORM 509 IREV. SITDINH Prescribed by omeckin FPMR HICFRI 101-112030111M

USAPA V1.00

MEDCOM - 20460

DOD-034034

ACLU-RDI 1657 p.20

rituit-AL FitlAJKL) - DUL; I UR'S ORuE. For use of this form, see MEDCOM Circular 40-5


ORDER

°7 P

NUMpEk--y--) ) DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS ORDER NOTED COMPLETED

TIME & INITIALS TIME & INITIALS c)r} ..._ POST ANESTHESIA ORDERS (circled Items) (3--- ✓


2 Supplemental oxygen.

Morphine / Meperidine 3 mg IV now and "Zing q 3-5 min pm pain for a

max dose of / 5Mg.

Zofran L--(mg IV prn N/V q 15 min, may repeat x .

5 Metoclopramide mg IV prn N/V x 1.

6 Droperidol mg IV prn N/V x I.

7 Phenergan mg IV pm N/V x 1.

8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.

9 IVF: @ cc/hr.

0) Disc tatus when PACU dischar e criteria met.

( b) (6 ) - 7-

PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any

41111111111

(4)(61) -1 e.

n A r. e% ....... . ...,..

changes on subsequent pages.

Diagnosis:


Allergies:

-OHM .. - ... .- -.._ - {TEST) _ PACU 1 of 1

Nursing Unit Room No. Bed No. Page No.

- - 0) MAR 99

PREVIOUS EDITIONS ARE OBSOLETE MC V1. 00

(b)C-2-) - z

MEDCOM - 20461

DOD-034035

ACLU-RDI 1657 p.21

NURSING UNIT

1 ROOM NO. BED NO.



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

LIST TIME ORDER

NOTED AND SIGN

sir DATE OF ORDER TIME OF ORDER ,,,.? 9 e,_. .- ca , //..2/

HOURS

tal ( 10( 0 / -" V /

LC-1..,1 "7 Z/4. J 4) /24r-a 4-it+ 2221

C1), 17 IA/ '9 t) 46Z- 1ZS 22iLV < ,I-Cr/P iY6L1J

DATE OF ORDER TIME OF OR •

Et9)1(V) - 2-



6)L

121

i.45017*


3/ 6 HOURS

W1CIIII FF 40511 c iAIM* 1.1411=111111

I


PATIENT IDENTIFICATION DATE OF ORDER TIM OF O

NURSING UNIT

HOURS

ROOM NO. BED NO.

DA, FArRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAYBE USED

MEDCOM - 20462

DOD-034036

ACLU-RDI 1657 p.22


PROGRESS NOTES MEDICAL RECORD

DATE NOTES

.226z . IJ

. i 4(3 /2-,

(40) (6 ) - -2.-

11, .A/"...

.•.< 1 ' if :-Ve N4 '

2i-•-,- -1-.1-2--0---4- „../..,0"2—,"■

e )

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, D d (::-9,7_(,..__ ,....Zi s.- k_ ..

....• _.;../ _.........-..... _d .MF ,La .- MEW MOW

(4)(6) - ----

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER ISSN or Other) LAST FIRST MI


PATIENTS IDENTIFICATION: For typed at written swiss, give Name - ks& first, male; . MN° s ISM; Ser Date of Birth; fiankarirlel

REGISTER NO. WARD NO.


STANDARD FORM 509 IREY. 51999) Presabed by GSAIICMR FPMR CFR) 101-11.2D3IbIll

USAPA VIA°

MEDCOM - 20463

DOD-034037

ACLU-RDI 1657 p.23

LAST NAME

FIRST NAME

MIDDLE INITIAL

ID NUMBER

DATE

NOTES

069119)--z_

STANDARD FORM 509 REV. ENDEVIBACK

USAPA V1.00

MEDCOM - 20464

DOD-034038

ACLU-RDI 1657 p.24

00)/(7)


(10)l() 11

N RSING UNIT ROOM NO.


( L)1 19- z- (.6)/0)- -z_ (10)-


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


SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

DATE OF ORDER

cmto- 9 PATIENT IDENTIFICATION

iar J94.5' 0

A

TIME OF ORDER

(956---6:2C- a3 HOURS

LIST TIME ORDER

NOTED •ND SIG


tD1-°101 60 PATIENT IDENTIFICATION

TIME OF ORDER

1 17)22) HOURS

NURSING UNIT

F 1 APR 79

REPL S EDITION OF 1 JUL 77, WHICH MAY 8E USED.

MEDCOM - 20465

HOURS

cb)

HOURS

A,T-etcF ORDER IME OF ORDER


DATE OF ORDER

DOD-034039

ACLU-RDI 1657 p.25

MEDICAL RECORD - DOCTOR'S ORDEb. For use of this form, see MEDCOM Circular 40-5



ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS

cs/1 z., a_v0-5 i \i-cro POST ANESTHESIA ORDERS (circled Items)


0 Supplemental oxygen. eVP3 SCOL (__ C1,51-3

(----D (Morphi / Meperidine 2mg IV now and Zing q 3-5 min prn pain for a

/c.

max dose of 10 mg.

Zofran mg IV pm N/V q 15 min, may repeat x .

C, Metoclopramide Omg IV pm N/V x 1.

Droperidol mg IV pm N/V x 1.

)7<_ Phenergan mg IV pm N/V x 1.

0 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.

ip IVF: LK._ 0) 11(0 cc/hr.

11, Discharge from recovery status when PACU discharge criteria met.

CI4-

(') lb) - 7--

Ogitb)-


40 (imb)-9


Diagnosis:


Allergies:

Nursing Un

PACU, Room No. Bed No. Page No.

1 of 1 -R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC V1.00

/We 2) - z

MEDCOM - 20466

DOD-034040

ACLU-RDI 1657 p.26

77. NURSING UNIT

Pitt

TIME • ORDER

(L')(6)-1-- HOURS


1\[(11060 0

LIST TIME ORDER

NOTED AND SIGN

b)Co


NURSING UNIT (1)1121-z_

ROOM NO.

(6)(b)- z_

PATIENT IDENTIFICAT

Clee6 )-

L k1( 4 1- 1.-

( 11, 6

NURSI UN LT ROOM NO.

ENT IDENTIFICATION 61,46)-1'

0,04r4- DA 1FAOPARM79 4256

NURSING UNIT ROOM NO. I BED NO.


PA

MEDCOM - 20467

DATE OF ORDER

HOURS

HOURS



SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

DOD-034041

ACLU-RDI 1657 p.27

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40.66, the proponent agency is OTSG

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

PATIENT 10ENTIF IC TIME OF ORDER

7)6

6 gSb22Y 715 <02tv/c:.ey,r

Z 6.16)5 e,Pi< o)-7 2.,526-- P .

AT ION DATE OF ORDER

HOURS

LIST TIM E ORDER

NOTED AND SIGN

-

NURSING UNIT

(b101-1- PATIENT IDENTIFIC

cri ib L,A6?2) -evo•AL) ,);7 ✓LY, PZ,e,cr" 2,4/6-4Lzx 14,12zX vai/0

DATE OF ORDER TIME OF ORD

PO LiAl -Of /

PATIENT IDENTIF I CATION

NURSING UNIT ROOM NO.

PATIENT IDENTIFIC AT ION

(L)119

BED NO.


HOURS

BED NO.


HOURS

BED NO.

NURSING UNIT ROOM NO.

DA 1 FAOPRRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

NURSING UNIT

ROOM NO.

MEDCOM - 20468

DOD-034042

ACLU-RDI 1657 p.28



aso, 4),3 )-2_)53s . c-,A6v6e- w rie.),i

)6762,zzw U iv RELATIONSHIP TO SPONSOR

SPc SOR'S NAME NUMBER

HOSPITAL OR MEDICAL FACILITY

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

fir0 (421 )

REGISTER NO.


STANDARD 509 5/199) Prescribed by GSA/ICMR PMRFOR

141CFM

R) 101-1(REV.

1.203(b)1190)

USAPA V1.00

WARD NO.

DEPART./SERVICE

MEDCOM - 20469

DOD-034043

ACLU-RDI 1657 p.29

,EDICAL RECORD - DOCTOR'S ORDER_ Foruse of this form, see MEDCOM Circular 40-5

DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new orderls) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.


ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS


0 VS q 5 min X 15 min, then q 15 min until discharge.

010 Supplemental oxygen. ( 10) 4-1" (t )a )--1. MVP Imp-

(...)

41

5

Morphine / Meperidine 3 mg IV now and 2- mg q 3-5 min pm pain for a t,

max dose of / mg.

Zofran I/ mg IV pm N/V q 15 min, may repeat x .

Metoclopramide mg IV pm N/V x 1.

6 Droperidol mg IV prn N/V x 1.

7 Phenergan mg IV prn N/V x 1.

8 Benadryl 25-5Gmg IVP ql hr pm, itching while in PACU.

9 IVF: 0 cc/hr.

0 Disc status when PACU discharge criteria met.

i plk)4.— (b)tb)- -z-

c(2)o0)- 7—


Ci° ) lb )-1/


Diagnosis:

4.. Height: Weight: Diet:

Allergies:

Nursing Unit

PACIIIIIII. Room No. Bed No. Page No.

1 of I MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

)( ) -2- MC V1.00

MEDCOM - 20470

DOD-034044

ACLU-RDI 1657 p.30

.EDICAL RECORD - DOCTOR'S ORDElts. For use of this form, see MEDCOM Circular 40-5



ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS



Supplemental oxygen. ,76x v 91 7(-7 ktnne / Meperidine s_mg IV now and ) ng q 3-5 min prn pain for a

I

max dose of /6 mg.

Zofran N . mg * IV prn , .

5 Metoclopramide /(,) mg IV prn N/V x 1.

prn /V x 1.

1. _ x

8 Benartryl 25-50m IVP 1 hr ngqpljLgmAcrt while in P .

9 IVF: L-i 0 7-)' cc/hr.

10 Dis discharge criteria met.

cia4L(2) - 7--


0 (4)16) -


Diagnosis:


Allergies:

Nursing Unit

PACUMM Room No. Bed No. Page No.

1 of 1 -R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

(WO-) - z MC V 1.00

MEDCOM - 20471

DOD-034045 ACLU-RDI 1657 p.31

,EDICAL RECORD - DOCTOR'S ORDER._ For use of this form, see MEDCOM Circular 40-5



ORDER NOTED

TIME & INITIALS

COMPLETED

TIME & INITIALS


/ VS q 5 min X 15 min, then q 15 min until discharge.

0..

). Supplemental oxygen.

Morphine / Meperidine 2—mg IV now and -2-- mg q 3-5 min pm pain for a

max dose of II mg.

Zofran 4 mg IV pm N/V q 15 min, may repeat x . (7 4

Metoclopramide mg IV pm N/V x 1. 5

6 Droperidol mg IV pm N/V x 1.

7 Phenergan mg IV prn N/V x 1.

8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.

9 IVF: @ cc/hr.

Disc' ery status when PACU discharge criteria met.

C C 6)(0'7'

(0') —Z `


.1. .

-41M

09)1/9 ) — 9

Complete the following information on page 1 on y. Note any Dchiaanngoessiso:n subsequent pages.

9


Allergies:

Nursing Unit

PACUIIIIIIIII Room No. Bed No. Page No.

1 of I

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

MC V1.00

MEDCOM - 20472

DOD-034046

ACLU-RDI 1657 p.32

IIV/Z 6i 1

( 6 )( 6) - 4/

EDITION OF 1 DEC 77 MAY BE USED.

ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

12 13 14 15 20 21 22 23 04 05 06 07

DA FORM 4677, 1 OCT 78

D 8 9 10 11

E 16 17 18 19

N 24 01 02 03

/ i: :-.-__Y‘)P T1 1■,. >1 VERT

THERAPEUTIC DOuumENTATMI CARE PLAN

(NON-MENCAT/0/9 M For use of this form. see AR 40-407:

,4;'A;-T#- IS • I II .n U • ffi e f

INTIZ4L PROPER COLUMN FO FA

Mo. Yr. 2003 Q! COMPLETION

RECURRING ACTIONS, FREQUENCY, TIME rignmem4ATEcomTanumangs

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MONAL•PAGES IN•USE:

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CLINICAL RECORD

ORDER DATE

CLERK/NURSE

PATIENT IDENTIFICATION: Open 0 + 0, mu rh -c ampA. &di

-.- Cr"

USAPA V1 AO MEDCOM - 20473

DOD-034047

ACLU-RDI 1657 p.33

Verity by Initialing

o rder Clerk Date Nurse

THERAPEUTIC DOCUMENTATION CARE PLAN (NON -MED/CATTON)

SINGLE ACTIONS

Mo CID9 Yr 2003

Date to be Done

Time to be Done

Time Done Initials

-4 I CIA) i'q-/ 3 circLut-vv-1 n:1-e:t1 ,4

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T1MEIDATE COMPLETED / Order/ Expir Date

USAPA V1.00

MEDCOM - 20474

(bXb) - z ca -11

65

Clerk/ Nurse

DOD-034048

ACLU-RDI 1657 p.34

(L)4)-z

MEE

CLERK/ NURSE

ORDER DATE

CLINICAL RECORD VERIFY BY INITIALING

THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MED1CA7701V) - •For use of this form, see AR 40-407; • h f r nn I.

RECURRING ACTIONS. FREQUENCY. TIME

MV

DATE COMPLETED

Yr. INTILIL PROPER COLUMN FOLLOWING EACH COMPLETION

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143 TIONAL PAGES IN USE:

S O . NO

ALLERGIES: 0 YES 0 NO

PATIENT IDENTIFICATION:

PRIMARY DIAGNOSIS:

Pen 3- as GE NO:

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED.


D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

USAPA V1.00

MEDCOM - 20475

DOD-034049

ACLU-RDI 1657 p.35

0e4 evu CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE ( NON-MEDICATION )

the proponent agency Is the Office of The Surgeon General. Mo.\k Yr. 2003 VERIFY BY IN777ALING SEMZEIM 116,,, „, 4'','• 4, INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

• °_0! 0,0 ). L

CLERK/ NURSE

- Ali RECURRING ACTION, FREQUENCY, TIME

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HR DATE COMPLETED

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ALLERGIES: NM YES 11.11 NO PRIMARY DIAGNOSIS: t

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ADDITIONAL PAGES IN USE: MI YES MI NO

PAGE NO' PATIENT IDENTIFICATION:

101 (W(b ) -V USE PENCIL.

D 8 9 10

E 16 17 18

N 24 01 02

ACTION TIMES CIRCLE ACTION TIMES

11 12 13 14 15

19 20 21 22 23

03 04 05 06 07

USAPA V1.00

MEDCOM - 20476

DOD-034050

ACLU-RDI 1657 p.36

CLINICAL RECORD I i IltliArtU I IC DOCUMENTATION CARE PLAN • VIEDICATIONS) For use of this form, see AR 40-407;

the proponent agenc is the Office of The Surgeon General. Y r. Mo.K6 1" VERIFY BY

ORDER DATE

1 0-au3

INITIALING

CLERK/ NURSE

L jlv

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RECURRING MEDICATIONS,

INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION HR DATE DISPENSED

DOSE, FREQUENCY

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YES

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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 - 20477

DOD-034051

ACLU-RDI 1657 p.37

'0119-z_

Verify by Initialing

THERP- 'EUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. 10 Yr. Oa_

SINGLE ORDER, PRE -OPERATIVES Date to

be Given

Time to be Given

Time Given initials Order Date

Clerk/ Nurse

OA- anrimpIC__. --N`C_42...-F QYA- 00513

Wo7 0 geebt-k / U , fy)

/1)

Order/ Expir Date

Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED

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USAPA V1.00

MEDCOM - 20478

DOD-034052 ACLU-RDI 1657 p.38

DOD-034053

USTED. U SAPA V1 ,00

CLINICAL RECORD rtu I iuu ivitni I ATION CARE PLAN (MEDICAL; iNS) I 3 ncruA t, uu For use of this form, see AR 40-407;

the proponent aqenc is the Office of The Surgeon General. MO. 0 Yr. i VERIFY BY INITIALING ,- `0g-tn.Z. ,t.".:?,::-":::: -.,‘

RECURRING MEDICATIONS, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

ORDER DATE

CLERK/ NURSE

HR DATE DISPENSED 012

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. YES I. NO

PAGE NO.

USE:


DISPENSING TIMES if +riga 00}a2) - r


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E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06

DA FORM 467R I FFR 7Q

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MEDCOM - 20479

ACLU-RDI 1657 p.39


THERAPEUTIC DOCUMENTATION CARE PLAN' (MEDICATIONS) Yr. qa

Order Date

Clerk/ Nurse

SINGLE ORDER, PRE-OPERATIVES Date to be Given

Time to

be Given Time Given Initials

Order/ Expir Date

Clerk! Nurse



TIME/DATE DISPENSED

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USAPA V1.00

MEDCOM - 20480

DOD-034054

ACLU-RDI 1657 p.40

/0

VERIFY BY INITIALING

ORDER DATE

CLERK/ NURSE

RECORD


ncrukrtu I it.; DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407; the proponent agenc is the Office of The Surgeon General. Mo.01Yr. c5.3

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DISPENSING TIMES



D 7 8

E 15 16

N 23 24

MEDCOM - 20481

DA FORM 4678, 1 FEB 79

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

9 10 11 12 13 14

17 18 19 20 21 22

01 02 03 04 05 06

USAPA V1.00

DOD-034055

ACLU-RDI 1657 p.41


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. II Yr. CP3

Order

Date

Clerk/

Nurse SINGLE ORDER, PRE-OPERATIVES Date to

be Given

T'me to

be Given Time Given Initials

•

Order/ Expir Date

Clerk/ Nurse



TIME/DATE DISPENSED

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USAPA V1.00

MEDCOM - 20482

DOD-034056

ACLU-RDI 1657 p.42

ALLERGIES- n YES El N o PRIMARY DI AGNOSI

PATIENT IDENTIFICATION,

••• ADDITIONAL PAGES IN USES El YES ONO

PAGE NO

I THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) I Mo. Yr.

CLINICAL RECORD For use of this form, see AR 40-407; the proponent agency is the Office of The Surgeon General.

VERIFY BY INITIALING ■•■•■■10

DATE NURSE


ORDER CLERK/ HRI RECURRING MEDICATIONS, DOSE, FREQUENCY

DATE DISPENSED

DA1FFM9 4678

DISPENSING TIMES

Lb) 1b) 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 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHA

MEDCOM - 20483

'ED.

DOD-034057

ACLU-RDI 1657 p.43

/ivitb)-2.

( b )114 -2

Mo. Yr Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing L (MEDICATIONS)

Order Date

Clerk/Nurse

SINGLE ORDER, PRE-OPERATIVES Dote to

be Given Time to be Given

Time Given Initials

Order/ Expi Dote

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION Clerk/

PRN

Nurse MEDICATInN, DOSE, FREQUENCY TIME/DATE DISPENSED

AV t

M-A(61A an Pb 1: • .,

/woo J Viliaff

Iltv 40 2)3b OK 11451

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M F n(om - 20484 ' *U.S. GPO: 1998-454-110/95216

DOD-034058

ACLU-RDI 1657 p.44

DOD-034059

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this forrn, see AR 40-407; VERIFY BY INITIALING

the proponent agency is the Office of The Surgeon General.


HR DATE DISPENSED

IS 19 a

CLINICAL RECORD

MolOyr.

ORDER CLERK/ DATE NURSE


7 04-

CW(b)-

1 5

(01b)-

)2

(4,)z6/-1__

(CA ) -- 2-

ALLERGIES- ED YES ONO


PRIMARY DIAGNOSIS.

Q-Tva\p. iNv\AR.L51--pv--c\cc 5

PAGE NO.

TION AL PAGES IN USE: ES ONO

DISPENSING TIMES


D 7 8 9 10 11 12 13 14

E 1.5 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06 DA 1 FFOE F11119 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 20485

ACLU-RDI 1657 p.45

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN rYr.C75.

Initialing (MEDICATIONS) Mo.

Order Clerk/ Date to Time to Time SINGLE ORDER, PRE-OPERATIVES me Given Initials Dote Nurse be Given be Given

(3411111 [4-'6, a ,-Lv e--7

. I , ._, ,..,,,. at ► .. _ tt. _•

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Expir Nurse MEDICATION, DOSE, FREQUENCY TIME/DATE DISPENSED Dote e i

Order/ Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

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MEDCOM - 20486 U.S. GPO:1996-454-110/95216

DOD-034060

ACLU-RDI 1657 p.46

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

For use of this form see AR 40-407; the proponent agency is the Office of The Surgeon General.

I fr-

Mo. 1 t Yrs_

VERIFY BY INITIALING

CLERK/ NURSE

—


ORDER DATE


HR DATE DISPENSED

Elm rea ID

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10' r) CD —Ft b I ot., Mu Itipe OM pi i 47th GvlS

ADDITIONAL PAGES AYES El NO

PAGE NO

IN USES


MI (10)((2)-1

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

DA1FFOEIR3r19 4818

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 20487

3

Iv

DOD-034061

ACLU-RDI 1657 p.47

DOD-034062

'U.S. GPO: 1998-454-110/95216


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. I ( r

Order Dote

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES

Dote to be Given

Time to be Given Time Given Initials

on ibenacir 1 TV v I nov\l ?;kt\i r II / Pi ii

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Order/ ExpIr Date

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Nurse MEDICATISN, DOSE, FREQUENCY TIME/DATE DISPENSED

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ACLU-RDI 1657 p.48

ALLERGIES: J YES El NO PRIMARY DIAGNOSIS: AçIErIONAL PAGES IN USE:

ES ED NO

I <PhENO: 2--- PATIENT IDENTIFICATION:

ORDER DATE

/

CLINICAL RECORD I THERAPEUTIC DOCUNIEutleT0Airh1Oform, ER I:41...4Art■1 (NON-MEDICATION) A the proponent agency Is the Office

-ARE

Surgeon General. yERIFy BY IMTIALING Ma Yr. 2003 :-;:ebobliatemo.0 INITIAL PROPER COLUMN FOLLOWING EA CH COMPLETION HR DATE COMPLETED

NNW At NI Lial=1,1111M.

liRnIMMIIMPB111111117- Lind Army

Ar,111.„IP""1111111k. Mr- —

51- r""IIRMIPMPINSWA71111r - Loma

CLERK/ NURSE

RECURRING ACTION, FREQUENCY, TIME

N 24 01 02 03 04 05 06 07


D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23

DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

MEDCOM - 20489

"MEW IA.

DOD-034063

ACLU-RDI 1657 p.49


THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mn Yr 2003

SINGLE ACTIONS Date to

be Done Time Done Initials Order

Date Clerk Nurse

Time to be Done

— — — — /22,-4--"(--4-Ari2 v, 4 i .c 7).6.chi. fa-,V

s ouctZ) eleE..--Q_ c7c.e\f-\c5 occ---,c3

&tin,. i, )k out) (nil (IA f) FOIZ

1,,,,,,,,,,- oci

' 13Wrilt rOIN SP ca+V\ ijoa- /1400 d ill

Order/ Explr Date

Clerk/ Nurse


INITIAL PROPER COLUMN FOLLOWING COMP1 ETION

TIME/DATE COMPLETED

— — — — — — — —

_ _ _ _ _ ■ .■

NM ...MO MO WM OM Mil".

WI NM ■D MM.= NM I= WO

Pm., ow wow ■ ■ mar ow •••■

.... low ■ ■• am. IN. ■• ••••

•

re mo. v... =we ■ ■ .... ....

...

.... ■ ■ ■ ■ ..■ ■ ■

4.

USAPA V1.00 MEDCOM - 20490

DOD-034064

ACLU-RDI 1657 p.50

SINGLE ACTIONS Order Clerk

Date Nurse

Time to be Done

OCO )

INITIAL PROPER COLUMN FOLLOWING COMPLETION

MEDCOM - 20491

DOD-034065

ACLU-RDI 1657 p.51

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM HOURS

TO HOURS

ACCUMULATIVE TOTAL

BLOOD/BLOOD DERIVATIVES TIME

STARTED TIME COMPL

ACCUM TOTAL OTHER INTAKE

ACCUMULATIVE TOTAL

TIME COMPL

AMOUNT

AMOUNT

AMOUNT

USAPPO v1.00

(

2_1 OCT- 22cocor _ -ccopo

MEDCOM - 20492

DOD-034066

ACLU-RDI 1657 p.52

FF110171 C.

TO S

2 tRS COVE -0

TWENTY-FOUR HOUR PATIENT II KE AND OUTPUT WORKSHEET

INTAKE

DATE

-aaOCT

INTRAVENOUS

TIME ACCUM TOTAL

roai r\ Levaccuin

TYPE (Include Medications) TYPE

Nus jik1Unk3

AMOUNT

5W It

TIME AMOUNT STARTED

AMOUNT TIME ACCUM

RECD COMPL TOTAL

IRRIGATIONS (N/G, Bladder, etc.) ACCUMULATIVE

TOTAL TIME TYPE

BLOOD/BLOOD DERIVATIVES

AMOUNT

TIME COMPL

TIME AMOUNT

TIME STARTED

PRODUCT (i.e. BI, Alb. P. cells, etc.)

AMOUNT ACCUM TOTAL

OTHER INTAKE

TYPE ACCUMULATIVE

TOTAL

GRAND TOTAL INTAKE USAPPC V1.00

voi c t,x1911' 21 00- -2Z0c17 Coco oc000

MEDCOM - 20493

DOD-034067

ACLU-RDI 1657 p.53

(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET

AMOUNT ACCUM TOTAL

TIME STARTED TIME

COMPL ACCUM TOTAL

ACCUMULATIVE TOTAL

TIME STARTED

PRODUCT (i.e. BI, Alb, P. cells etc.)

TIME COMPL


AMOUNT

DD FORM 792, JAN 74 (EG) GRAND TOTAL INTAKE

EDITION OF 1 SEP 54 IS OBSOLETE.

6)(17) - Y

MED OM - 20494

Designed using Perform Pro, WHS/D/OR, Jun 94

)Boo


AMOUNT

FROM raw% RS

TORS

AL URS CO E

AMOUNT

DOD-034068

ACLU-RDI 1657 p.54

\

IJU I 1-1.) I ,,i ■ r ' , "•

URIN- F--_i p ea+h TIME AMOUNT AMOUNT ACCUM TOTAL T AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

WiD:CTS -aDaC-, .... 61-riC D5-c- bmwri.

..._

......_ _ ...

CHEST . , — ..___. .... _ ... ___. EMESIS

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

STOOLS

TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT

TIME AMOUNT TYPE ACCUM TOTAL

---

. _ __...... GRAND TOTAL OUTPUT

REMARKS

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

AIM (WI& ) - -

INTAKE EQUIVALENTS (Serving levels cc)

MEDICINE GLASS 11 az) . 30 HALF PINT MILK

SMALL FRUIT CUP

120 LARGE SOUP BOWL 240

160 LARGE WATER GLASS 240

JUICE CONTAINER

240

COFFEE MUG 180 PLASTIC OR PAPER

180

DD FORM 792, JAN 74 MEDCOM - 20495 ‘_ JD_

Page 2

DOD-034069

ACLU-RDI 1657 p.55

FROM CA. velU3iLIA TO CLODURS

TOTS DATE

TIME TYPE

GRAND TOTAL INTAKE



INTAKE °Cr ORAL

INTRAVENOUS TIME TYPE AMOUNT ACCUM

TOTAL TIME

STARTED TYPE

(Include Medications) AMOUNT

RECD TIME

COMPL ACCUM TOTAL

AMOUNT

IRRIGATIONS (N/G, Bladder, etc.)

TIME TYPE AMOUNT ACCUMULATIVE TOTAL


TIME STARTED

PRODUCT (i.e. BI, Alb, P. cells etc.)

TIME COMPL

ACCUM TOTAL . OTHER INTAKE

AMOUNT

AMOUNT ACCUMULATIVE TOTAL

DD FORM 792, JAN 74 (EG) EDITION OF 1 SEP 54 IS OBSOLETE.

Designed using Perform Pro, WHS/DIOR, Jun 94

(6)(b 1-11

COM - 20496

DOD-034070

ACLU-RDI 1657 p.56

OUTPUT IIMIII_M 0

URINE Gi p C a-1-h . 7.. .E.skrimwm

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL -TIME AMOUNT TYPE ACCUM TOTAL

T ICE 20E . 919OCC - - - coO I5a- brry 1 scc, rrc tnIs-, i--ur_c . 0 _or io_x__

.0,50 ? x„ voo ID i2e4_,

10) 2 . xi_ void tobcct

02DD x i NibtCf-tth-t0 .....

--6:D .2e)D Lgoe

CHEST • '" --- _.._ EMESIS


STOOLS



GRAND TOTAL OUTPUT

REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility) 26 --71...

41111W —C6CO

0:72t&i-

.. INTAKE EQUIVALENTS (Serving levels cc)

MEDICINE GLASS 11 oz) . 30 HALF PINT MILK 240

7 120 LARGE SOUP BOWL 240

SMALL FRUIT CUP 160 LARGE WATER GLASS ... 240


JUICE CONTAINER 180

DD FORM 792, JAN 74

-2 MEDCOM - 20497

Page 2

DOD-034071

ACLU-RDI 1657 p.57



INTAKE

FROM

TO

AMOUNT ACCUM TOTAL

TIME STARTED AMOUNT

RECD TIME

COMPL ACCUM TOTAL

INTRAVENOUS

TIME STARTED

TIME COMPL


DD FORM 792, JAN4EG) GRAND TOTAL INTAKE

EDITION OF 1 SEP 54 IS OBSOLETE.

Designed using Perform Pro, WHS/DIOR, Jun 94

MEDCOM - 20498

AMOUNT


AMOUNT

PATE TOTAL HOURS COVERED

HOURS

HOURS

AMOUNT

AMOUNT

DOD-034072

ACLU-RDI 1657 p.58

OUTPUT

----' URINE Va C

TIME AMOUNT ACC TAL TIME AMOUNT ACCUM TOT -TIME UNT TYPE ACC " .e .

1125 5„,a5 5 . - P-HS- ice- jfe.en)lorn , IOCC -gZ00400014-25 '

.._

...

_...

CHEST . .- -._ _ _ . _. _ .. EMESIS


STOOLS



..... - _ ..

GRAND TOTAL OUTPUT

REMARKS

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

"Ms COIW-11


MEDIC INE GLASS Cl oz) . 30 HALF PINT MILK

180 PLASTIC OR PAPER

240

SMALL FRUIT CUP

120 LARGE SOUP BOWL 240

160 LARGE WATER GLASS 240

COFFEE MUG

JUICE CONTAINER 180

DD FORM 792, JAN 74 MEDCOM - 20499

DOD-034073

ACLU-RDI 1657 p.59

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM HOURS TOTAL HOURS COVERED

DATE

TO HOURS

INTAKE

ORAL INTRAVENOUS

TIME TYPE AMOUNT ACCUM TOTAL

TIME STARTED AMOUNT TYPE


RECD TIME

COMPL ACCUM

- 8947— ..3-; 5tx .C„ x3 eon 'cock. ,,h

TOTAL

'.-.0c., 1 a ?Id 14 N ' .1-.. . too i tiObt.t. Le....4 • ,`,.1

-

20s

C) E 1 ft-51)1 a "Z20039-rh 3: -a .fir /00 C,C,

NM friz_n (0

di) Art) 17--ko 0 alp t-t7 r)



TIME

BLOOD/BLOOD

PRODUCT BI,

DERIVATIVES

STARTED (i.e.

AM , P. cells, etc.) TIME

COMPL AMOUNT ACCUM TOTAL OTHER INTAKE


GRAND TOTAL INTAKE

USAPPC V1.00

b iss (a i v b- 2.2NOCT-03 6r7-600

MEDCOM - 20500

DOD-034074

ACLU-RDI 1657 p.60

TOTAL HOURS COVERED

DATE

TWENTY-FOUR HOUR PATIENT II KE AND OUTPUT WORKSHEET FROM _ _HOURS

TO HOURS

IffiggigE. (C)Lpt ?„.„....--

4*Ittla.. 'a,•Fa--,I x Y^ INTRAVENOUS


TIME STARTED

AMOUNT TYPE (Include Medications)

AMOUNT RECD

TIME COMPL

ACCUM TOTAL

1930 C-Lea-1/ \ „ZO—Illi.Y■e_ I to el i too f)5Z darKv2,LiamPar.Q Roo 20




TIME STARTED

PRODUCT (i.e. BI, Alb, P. cells, etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

OTHER INTAKE


GRAND TOTAL INTAKE

USAPPC V1.00

44011 Nt io)- 11 -- P-40cT 0(000

MEDCOM - 20501

DOD-034075

ACLU-RDI 1657 p.61

firOMEN1111priltra■

_

TIME TIME STARTED TIME

COMPL ACCUM TOTAL 9

AMOUNT TYPE AMOUNT (Include Medications) RECD

NtbV - 3 11 cx--)cr,

INTAKE

"-Htillifigaira4G.66Ec"

TIME COMPL AMOUNT

TWENTY-FOUR HOUR PATIENT IN I AKE AND OUTPUT WORKSHEET FROM .,OURS

TO HOURS

TOTAL HOURS DATE COVERED


TYPE AMOUNT ACCUMULATIVE TOTAL

TIME

BLOOD/BLOOD DERIVATIVES TIME

STARTED PRODUCT (i.e. BI, Alb, P. cells, etc.)


AMOUNT ACCUMULATIVE TOTAL

TIME TYPE

GRAND TOTAL INTAKE

USAPPC V1.00

MEDCOM - 20502

DOD-034076

ACLU-RDI 1657 p.62

OUTPUT

11''''seTYPE )(n

0

URINE

ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL

t a I M5CE/ 10 15CC brown i F) cc. o

?ki• k mnEgra 0600 -e'-

, gilt/Laid 6 c 4,-

c`,1 Gaon 13-14) ico 1 9,00c

o 4W ,-,:30D

)034 esOD -1. (-_-2)C

CHEST EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL

STOOLS .



GRAND TOTAL OUTPUT REMARKS

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

4 IN


MEDICINE GLASS (J oz). . 30 HALF PINT MILK 240 SMALL FRUIT CUP 120 LARGE SOUP BOWL 240 COFFEE CUP 160 LARGE WATER GLASS . . . 240 (Otb) - LI IT

LARGE COFFEE MUG . . . .180 PLASTIC OR PAPER JUICE CONTAINER 180

DD FORM 7(39 IA1\1 7e EDITION OF - --- 54 IS ____ • . REPLACES DA FORM 3630ITEMP) 1 JUL 72 WHICH MAY BE USED. USAPPC Vim

MEDCOM - 20503

DOD-034077

ACLU-RDI 1657 p.63

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM ..4956 URS

TO el): RS C , _ a TOTAL Fe) COVR I

I

DATE

9(0ccr INTAKE

ORAL INTRAVENOUS


TIME STARTED

AMOUNT TYPE


RECD TIME

COMPL ACCUM TOTAL

WO 1-k2-0 500 (40c-c


TIME TYPE AMOUNT ACCUMULATIVE

TOTAL


TIME STARTED

PRODUCT (i.e. BI, Alb. P. cells. etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

OTHER INTAKE


TOTAL

GRAND TOTAL INTAKE

MEDCOM - 20504

DOD-034078

ACLU-RDI 1657 p.64

OUTPUT

Mal ii1111.111111TellEar-

MILW ; . • - URI ,. IIII UR

TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM OTAL TIME AMOUNT TYPE ACCUM TOTAL

_. .

' -

. _

CHEST — '"' _.__. EMESIS


STOOLS



.... .— -

GRAND TOTAL OUTPUT

REMARKS

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

tio)09) If

*


MEDICINE GLASS (1 oz) . 30 HALF PINT MILK

120 LARGE SOUP BOWL SMALL FRUIT CUP 160 LARGE WATER GLASS ...


JUICE CONTAINER

240

240

240

180

5oa Lou -P5i1r) MEDCOM - 20505

DOD-034079

ACLU-RDI 1657 p.65

15 OCr --co)

(10) Lb)

HIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)

TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FRO WI IS TO L H..)1/QC DATE

) T OURS

INTAKE

ORAL INTRAVENOUS (Csti.)Synirc—




RECD TIM

COMPL ACCUM TOTAL

._....

IRRIGATIONS (N/G, Bladder, etc.) . .


. _.. _._.


TIME STARTED

PRODUCT (i.e. Bl, Alb, P. cells etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

__ OTHER INTAKE


GRAND TOTAL INTAKE

DD FORM 792, JAN 74 (EG)

EDIT ON OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94

MEDCOM - 20506

DOD-034080

ACLU-RDI 1657 p.66

(6)110)-


THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION ) Mn )1 Yr 2003

order Date

Clerk Nurse SINGLE ACTIONS

Date to be Done

Time to be Done Time Done Initials

kov (C--i-CDOC e-Xl V\1 C%a0C\k?

111111 - Wen

-7 CP-if (_P:_ ,)()kaACAS2--- VCRS •

.. t I 11111VOICV\I Op \1\8?_.--, /S (

.

- - - -

- - - -

- - - -

- - - -

- - - -

- - —

- - - -

- - - -

- - - -

- - - -

Order/ Explr Date

Clerk/ Nurse


INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

'---A-4911111 Roti-force.oVsep-Q, „xi*

14W -,


DOD-034081

ACLU-RDI 1657 p.67

220

Color

(2) Baseirne coke d appearance (1) pale. mottled, jaundiced (0) Cyanotic

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

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

200

180

160

140

120

100

80

so

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4066; the proponent agency is the Office of The Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet USG APPROVED Warm

Date: Time In: Allergies: Pre-op V/S: Procedures:

Drains Hemovac

NG . JP

T-tube Foley

TLS

Anesthesia Type (Circle)): Gene Spinal Epidural

I ation Nerve Block Colloid 0(

EBL

)i PAT, • 0'

OR Intake: Crystalloid 0 D OR Output: UOP

tSr. Ii'/7 le (15 Meds/Times:

Pacu Intake

Pre Op Med

Time

Airway Nasal Oral ETT

Trach

Other Histor

Sa02 Infused Solution Time

F102 /0 Methods

240

IC/la

L

Amount Site By

42r cc.

Labs: X-rays:

20

40

Consciousness (2) Fully Awake, audible

n0 (1) Arousable to verbal or pain

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

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

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

Post-Anesthesia Recove score ADM 30' D/C Codes

/0 /0

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

FT = Face Tent RA = RoomAir NC Nasal

Cannula

Pa en teaching done; Wound Ca e. Pain Management, T, C, & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

DEPARTMENTISERVICE/CLINIC

Name - last,

❑ HISTORYIPHYSICAL

❑ OTHER EXAMINATION OR EVALUATION

❑ DIAGNOSTIC STUDIES

❑ TREATMENT

PREPARED BY 'Signature & Title) tcontsnue on reverse) DATE

25c/05 .....21flOW CHART

❑ OTHER asap./

V/S X - A-line BP -

=Cuff BP = Pulse

TEMP S= Skin 0 = Oral A = Axillary T =Tympanic R =Rectal

LOS C = Cervical T = Thoracic L = Lumbar S = Sacral

or typed or written entries give: e; Fade: date: hospital or medical faatyl

0 W ho ) -V

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 20508

Previous edition is obsolete mon 02.00

DOD-034082

ACLU-RDI 1657 p.68

NURSING NOTES

(b)(6)- /-e055 (4 7 e, Z ‘-e-•r vts e fr,--1 11111111

‘0441 . I to lGe-t.,1 7400.o/f- too, - 2,

/ X6 LIX6)-7— LT-

/LC

19/- 001M fie) 19 "P-C__ SP

igr) /3(.9121Leis. fp2s /0 010/ confirocc.J " (5 d

PACU OUTPUT

Time Source • Color/Appearance Amount

CARDIAC RHYTHM

Rhythm Symptomatic? Rhythm Strip Run? Time

/41 /0

MEDICATIONS Allergies: Time Pain

1-1n Medication & Dnsane

Route Pain 1-10

I/E By

t 1 rri So ci.

5- •1147 I CIAO '7-

! 33 r m bOYI

r" T 3 /6/* tiON -1-

/- 7-- .

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T Color

Mm

MI

f e r. P-MMIIIIIIMIIIIIMMIIIIMIN PIMI

In IIMIIMMILMWAII

-MI

15 30' 45'

W IIIPIPAIIIIII ._,../11111

90' NMI MIN NM DiC ZIIIIMMIIIIIIMITAILIMMIIIMMI Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C= Cyanotic.

Capillary Rein: B= Brisk, 5= Sluggish P= Pale, Pk = Pink

C-SECTIONS Adm 15 37 45 67 9Q:.----156-

Fund. Height _..---------- Lochia ------------ Peripaclit

Fupricl. ....—

DRESSINGS

Time Location Type Drainage

Adm 6OCAI Le t • -f--

37 CP ir.r"( r _L. 67

D/C 69-11'N tr4 I CC-'t e 4-

WAMC OP 173-E

Discharge Criteria: Date: 2G5ert_Time: /WO BP:19/0 HR:G0 Pain Level at D/C (0-10): Intake: ( OO eC z Additional Data: Transferred To: /Gk./ Report Given To: Transferred Via: W/C Transferred By: Cleared IAW Recovery oo Charge Nurse Signature:

PARS: / 0 RR: -7 Sa02:

Output:

Gurney Ambulance W119

6)(L9 )- z

(10) (14-z_

MEDCOM - 20509

DOD-034083

ACLU-RDI 1657 p.69

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this tom see AR 40-66: the proponent agency is the Office of The Surgeon General.

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

Date: k. , ,43-k. Anesthesia Type (Circle)): General Spinal Epidural Drains Airway Time In: t`, IV Sedation Nerve Block \\ Hemovac

NG JP

T-tube Foley

TLS

Nasal Oral ETT

Trach

Other

Allergies: 1■31.0, OR Intake: Crystalloid Liv Colloid

Pre-op V/S: OR Output: UOP t EBL I %.A.,,L7,v-.."0) _,,r,_

Procedures: Meds/Times:

Pre Op Meds History

Time

11

'

FW77 Pacu Intake

Sa02 Mtrzc qef Time Solution Amount Site - By Infused

F102

Methods ktibAs A

240

220 X-rays:

• Post-Anesthesia Recoveryscore

200 Criteria ADM 30 D/C Codes Activity (2) Moves 4 Extremities (1) Moves 21 (0) Moves 0 Extremities

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

180

160 Airway

(1) Dyspnea, limited breathing

(0) APrlea

(2) Cough, D eep breath FT = Face Tent RA = RoomAir NC =Nasal 140

Blood Pressure (2) SBP =/- 20 of Pre-op (1)SBP =/- 20-50 of Pre-op (0) SBP =/- 5 of Pre-op

Cannula

V/S

X = A-line BP

120

100 4 v,V ‘., Consciousness (2) Fully Awake. audible Ming (1) Arousable lo verbal or pain

" =Cuff BP = Pulse

TEMP 80

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

S=SMn 0= Oral A = Axillary T =Tympanic

60 C I

A A /% A

40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable 4.1.).Axillarrpotpavrnanszor (0) Carotid only reliable pulse LOS

R = Rectal

C = Cervical 20 TOTALS: Must be 9 or greater to D/C, otherwise

ro needs anesthesia approval for DC,

T = Thoracic L = Lumbar S = Sacral

RR

T

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

Ilonloue on awful

PREPAR .

•(Al.') - --4.

•

DEPART T1 ERVICEICUNIC

C

DATE

(6 4( PATI or P entries give: Name -last,

list, middle,. grade,- date: hospital or medical lacskyl

Ck0) L 6 ) - 'lb

•

• HISTORYIPHYSICAL ❑ FLOW CHART

U OTHER EXAMINATION ❑ OTHER (4..44

OR EVALUATION

III DIAGNOSTIC STUDIES

• TREATMENT

DA FORM 4700, MAY 78

WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

Previous edition is obsolete USAPPC V2.00

MEDCOM - 20510

DOD-034084

ACLU-RDI 1657 p.70

MEDICATIONS Allergies

.......Medication f1nsa

Time Pain-. 1-10

Route Pain 1-10

TIE By 16

ttl AA tit

C/ I ,

'0,PA - AI_ k .4

k•-rj, 4) Qt171

PACU OUTPUT

Source • Color/Appearance Amount Time

Time Rhythm

CARDIAC RHYTHM

Symptomatic? Rhythm Str p Run?

WAMC OP 173-E

Discharge Criteria:Criteria: Date: t aLk Time: U T: b HR:6c)

Pain Level(at D/ 10-101: Intake: Additional Da : Transferred T :

Report Given To: S.

Transferred Via: W/C Transferred By: („7- Cleared IAW Recovery Roo Charge Nurse Signature:

PARS: RR: Sa02: iCa

y Ambulance

Output: C-

NEUROVASCULAR Time

Adm

5' 15'

Site Range Of

Motion

Sensory

-

O. Cap

Refill T Color

4.-.-, C.,---- WM

-7, / b)1.6 30'

45'

60'

90'

D/C

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

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

C-SECTIONS

15' 30' 45' 60' 90' DM

Fund. Height

Lochia .."----................................_

Peripad#

Fund. Cond. *---....,...........

NURSING NOTES

cL:) ,,,,i, ._ s04, ---- eA4,,, &, 5,_.

vr ,10,,ted-_, .... 46, - . ■ „ ,_____4__ A Lid _

LO

. CV \ (" (24% (N N4 a mac_

czb.._.., s1_,..t. • 62,2 cP/0 P\S Gvk ho

— DRESSINGS -rime Location Type Drainage

Adm.

30'

60' ------..„.................._

D/C

MEDCOM - 20511

DOD-034085

ACLU-RDI 1657 p.71

PRE lLonlinue an fraeffel

DATE (io)tb) - DEPARTMENTISERVICEICUNIC

Pilc

MEDICAL 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 Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED lOnel

Date: Anesthesia Type (Circle)) . General pinal Epidural, Drains Airway Time In: iR-S-- I 5e ation Nerve Block 19Srt" .f./. Hemovac

NG JP

T-tube Foley

TLS

Nasal Oral Err

Trach

Other

Allergies: f\-)1/... 0 A OR Intake: Crystalloid oto Colloid Pf----Q

Pre-op VIS: ritti<li 8(0 OR Output UOP Ii6 QS EBL y•-•-iNIN (...,,, s Procedures: c-tiS-Lsr...x.-2- Meds/Times: ,_.*- ,) r--0,-“... b tr-

:VP r c<-4---1-. 77.:4-- CI CI /.-;A t Pre Op Meds History ,..v:.,,.. 0.)..,...i.

Time $ , .N. Ig /01

■

4 Pacu Intake

Sa02 C4Cril 10:1009 Cd Time Solution Amount Site - By Infused

F102 FICI QC Pit gik 0 al ,=1- a f CAL _360

oc.) 9 c N S P

AI-- go C1 „,,,3 ...)

Methods 460 tc.vit , - / 6 ° PUS Pl4111 "-No sele

240

220 220 X-rays: . Labs:

• Post-Anesthesia Recovemscore

200 Criteria ADM 30' DIC Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extrernilies (0) Moves ( Extremities

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

180

160 Airway (2) Cough, Deep bre.3th (1) Dyspnea, limited breathing (0) Apnea

FT =Face Tent RA= RoomAir NC = Nasal 140

• /X Blood Pres sure (2) SBP 4• 20 of Pre-op (1) SBP .1- 20-50 of Pre-op (0) SBP =1- 50 of Pre-op

Cannula

VIS X =A-line BP

120 A , I,

. iS /t ft

100 e Consciousness

(2) Fully Awake, aucfible crying (1) Arousal le to verbal or pain

r( r(

' = Cuff BP = Pulse

TEMP

a o 80 a

SI i . Color (2)Baseline color a appearance (1) pate. monied. jaundiced (0) Cyanotic

S =Skin 0 = Oral

A = Axillary T =Tympanic

60 V

40 V ...• Circulation (Peds < 5 Years)

(2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

R = Rectal

LOS C = Cervical

20

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

T = Thoracic L = Lumbar S =Sacral

RR 11 i4 ia -1 T ri ? Time Patient teaching done; Wound Care, Pain Management. Pain (0-10) T, C. & DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained




❑ TREATMENT

❑ FLOW CHART

❑ OTHER /spade

Name —last, PAT r r or mitten eludes give: first, middle: glade; date: hospital or medical lanEtyl


WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition Is obsolete USAPPC V2.00

MEDCOM - 20512

DOD-034086

ACLU-RDI 1657 p.72

PACU OUTPUT

Time Source • Color/Appearance Amount

CARDIAC RHYTHM

Rhythm Time Symptomatic? Rhythm Strip Run?

'&00 Output: Pain Level at DIC (0-10): Intake: 43.e)-0 Additional Data:

WAMC OP 173-E

Discharge Critsria: Date:ch,Slic)°)Time: PARS:

BP: te rga T: HR: ( RR: 00 Sa02:

Transferred To: Report Given To: SPL 6)(b)- -z. Transferred Via: W/C fitter Gu Ambulance Transferred By: S clo /Lb )- z. Cleared lAW Recovery Room Charge Nurse Signature:

MEDICATIONS

Allergies: Time Pain

1-10 Medication & Dnsane

Route Pain 1-10

L:L.J. \ \\

By

r ----

/

L f

5Ap V\‘‘,4 '-^ A ,--$, g""(•°4 --yu e „..------ 16 , I 1

ti-M4 t" ()ros 0150t a_v Q r/

teed 14(c„, Q rwr.5 /4/St..hi TA/P .........--

RAT" r-,-eJL,_ (-lefty,: Pvlbd cotto-i-

ttP__ ..r-A-0 Leco ; „‘o>...c (. <-1.r.tr<C0

21A—i-e) , QSv =t c7"/of t„/<5 re, (b)(6) --z-

-ns-A-g- 44 5 rc-,•+. 7, Le

Y,2 pca.Q.A., PA cio • also+ (5AArt

5S61(..piu L 6) 6-b) -1-

iboo (-o-r4pL, pc,kle.67- st 610_4 LL:010-1. 1) ,_

• di C) "4 CV en Q.—.1 eCsk "VW

00


Of Motion

Sensory .

P Cap Refill

T Color

Adm

15'

30' -

45'

60'

90' DM

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

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

C-SECTIONS

Adm 15' 30' 45' 60' 90' D/C

Fund. Height

Lochia

Peripad#

Fund. Cond.

DRESSINGS


Adm

30'

60'

WC .

NURSING NOTES

MEDCOM - 20513

DOD-034087

ACLU-RDI 1657 p.73

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this torn see AR 40-66: the proponent agency is the Office of The Surgeon General.

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

Date: 6 f Od- I5 Anesthesia Type (Circle) Genera Spinal Epidurali _AAA Drains Airway Nasal Oral ETT

Trach

Other

Time In: jo3D IV align Nerve Block ry Hemovac

VPS T-tube

Allergies: NCAA OR Intake: Crystalloid 17/60re Colloid Pre-op V/S:1116/Kg $? 0 OR Output: UOP '00 EBL e..co cc. Procedures: /141) te leci medsrrimes: ,,,- ' ,,) 1:-Gt.fr .

7 JP rin-Mqe.or Pre Op Meds History

Time '', -. ■.*

i.e.' V. Pacu Intake

Sa02 'lb

JO e e lig Time Solution Amount Site - By Infused

Fi02 119.0 te 1 so 1 v Methods it‘gpwi a a, 240

220 X-rays: . Labs:

. Post-Anesthesia Recovery score

200 Criteria ADM 30' O/C Codes Activity

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

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

180

160 Ainvay (2) Cough. Deep breath (1) Dyspnea, limited breathing (0) Alma

FT = Face Tent RA = RoomAir NC =Nasal

1./ v 140 V %./V

• Blood Pressure (2)SBP =/- 20 of Pre-op (1)SBP --4- 20-50 of Pre-op (0) SBP =4- 50 of Pre-op

Cannula

V/S X = A-line BP

120

100 • Consciousness (2) Fully Awake, audible aYing

sa (1) /unuble to verbal or pain

)

." =Cuff BP = Pulse

TEMP

4-- 80 •

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

S =Skin 0 = Oral

Axillary T =Tympanic

60 •

A tit A 40 /\ Circulation (Peds < 5 Years)

(2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

R =Rectal

LOS C = Cervical

20

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

_

T =Thoracic L =Lumbar S = Sacral

RR to lc a° A it T ,i,c1

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

/continue on metro PREP

(Way ) —1- •

PA of typed or minim entries give

DEPARTMENTISERVICEICUNIC

?AC U

DATE DI 0 c- 74 °_Sc-- ive. Name — last,

lest, middle; grade; date; hospital or medical lauNtyl

d 0 6066) - Y 1111111 •

■ HISTORYIPHYSICAL • FLOW CHART

■ OTHER EXAMINATION

0

❑ OTHER overdo OR EVALUATION

DIAGNOSTIC STUDIES

■ TREATMENT




MEDCOM - 20514

DOD-034088

ACLU-RDI 1657 p.74

MEDICATIONS

Allergies: Time Pain

1 - 10 Medication & Dncnae

Route Pain 1-10

I/E By

roto Fig, ID , (b)04" L

/o lio Deine,,) ) v L (r

PACU OUTPUT

Source • Color/Appaar.ancr--- Amount Time

(e)03)-7- 0

NURSING NOTES

AiLotota, ,L)1 VSS. oz ,ate cWo -pf

aA,e, ,,i/p2r/ u ke <v4- :4A fr

jg. 5 W4 t)c„


Of Motion


T Color

Adm

15'

30'

45'

60'

90'

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

Capillary Refill: B= Brisk, S= S uggish P = Pale, Pk = Pini,c0„....

C-SECTIONS ---------

Adm 15' 30' 60' 90' D/C

Fund. Height

Locitia ---.'"----- Peripad#

. Cond.

DRESSINGS


Adm f;:e.`4 0 P.)40,01.--, 30' a

.( !C ()_,))

ei e. iv-0, . , J FA : 60'

D/C //1-16 X ( ec 0 f) dir 4 (-1

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

fr; "30 A.ic P 0 P-

WAMC OP 173-E

MEDCOM - 20515

Clo )00 )- L

y

Sa02:/O 0

Ambulance 0.4(.19

Discharge Criteria: Date: 01 Oct 03Time: Io s10 PARS: /-0

BP:/ t4' T: OR: 6 &• RR: Pain Level at D/C (0-10): 0 Intake: /00c G Output: Additional Data: /ve"P,-,e

Transferred To: e c,0

Report Given To: L Transferred Via: W Transferred By:

Cleared IAW Reco Charge Nurse Signature:

DOD-034089

ACLU-RDI 1657 p.75


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

Date: 4 (25,3 Anesthesia Type (Circle)): General Spinal Epidural Drains Airway Time In: 0-C-- IV Sedation Nerve Block ntri i Hemovac

NG . JP

T-tube

Nasal Or

I rach

Other

Allergies: 11 1 OR Intake: Crystalloid re,.." Colloid ---C--e-- Pre-op V/S: talEilliEwdr. OR Output: UOP. (Cr' . EBL ,

7'X

Procedures: 4 111111.41 ► 1 Meds/Times:ill'k-Ift \I-ZYSI..:T> I

C Foley"

TLS Pre Op Med ,. History

Time o ,•''' —, Pacu Intake

Sa02 .....- ii0 Time Solution Amount Site - By Infused

Fi02 LL 141/11110BEENK 3 OV-- _ _p Methods S -. d ,„..., 4-- 240 .

•

220 I X-rays: . Labs:

• Post-AneSthesia Recovery score

200 Criteria ADM 30' D/C Codes Activity


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

180

160 Ainvay

Cough (2) , Deep breath (1) Dyspnea foiled breathing (0) Apnea

FT = Face Tent RA =RoomAir NC =Nasal

140

V (2) SBP ,--/- 20 of Pre-op

(0) SBP =/- 50 of Pre-op

Blood Pre ssure Cannula

V/S X =A-line BP

120 •

V 4 NI

(1 ) SHP =/- 20-50 of Pre-op a

.

100 a

• Consciousness (2) Fully Awake, audible crying (1) Arousable to verbal or pain

N

N N

" =Cuff BP = Pulse

TEMP 80 A Color (2) Baseline color & appearance (1) pale, mottled, jaundiced (0) Cyanotic

S = Skin 0 = Oral A = Axillary T =Tympanic

60

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

R = Rectal

TO'S C =Cervical

20

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for DIC,


RR o Sc

T

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

rtonrmue on reverse] DEPARTM T SERVICEICLINIC DA i)

PATIENT'S or typ 4r written entries give: Name — last, Inst, middle• grade: date: hospital or medical facEtyl

11. 02)0o )— - ,

.

0 HISTORYIPHYSICAL 0 FLOW CHART

■ OTHER EXAMINATION ❑ OTHER tsi=art OR EVALUATION

• DIAGNOSTIC STUDIES

MI TREATMENT


WAMC OP 173 -E, (Revised) 1 Apr 01 (MCXC -DN)


MEDCOM - 20516

DOD-034090

ACLU-RDI 1657 p.76


1-10 Medication & nrmAcie

Pain 1-10

Route I/E By

PACU OUTPUT •

Color/Appeara Amount Time Source •


Of Motion

IMAM


ourminin. T Color

Adm t • 4 is • 30'

45'

60' 90'

0/C iraniturammurainummir Movement/Se IP ation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D =Doppler, A= Absent Color: C = Cyanotic,

Capillary Refill: B = Brisk, S= S uggish P=PalPink

C-SECTIONS

Adm 15' 3 45' 60' 90' D/C

Fund. Height

Lochia

Peripad#

F . .

DRESSINGS

'Time - Location Type Drainage

Adm ID .P ITMIZIFM 30' 0 a 60' i •

D/C IIMER= El A . 4 U P —....„..

NURSING NOTES

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? I07.5- F.:4 *-1:f.r . 01==-c

WAMC OP 173-E

Discharge Criteria: Datelvr Tirane: I iD PARS: Ci BP: R HR:qcf3 Sa02: t_ Pain Lee at D/C (0-101: Intake:

rney Ambulance Clo)(2)--z_

Additional Data: Transferred To: fit` Report Given To: TT Transferred Via: Transferred By: K. Cleared lAW Recovery Roo Charge Nurse Signature:

/C

Output:

MEDCOM - 20517 )4.10)- z_

DOD-034091

ACLU-RDI 1657 p.77


REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OT SG APPROVED IDatel

Date: Anesthesia Type (Circle)): General Spinal Epidural . • Airwa Time In: IV Sedation Nerve Block • e e ttIlli '

NG

JP T- e

Foe

TLS

4rin '-- Oral

ETT Trach

Other

Allergies: in,/ I/ 0 A OR Intake: Crystalloid SO 4' t-4_ Colloid C) fi Vt) ,d Wilt tl Pre-op WS: 9G OR Output: UOP EBL Ps",-. \ Jiro r=c,..- if-

Procedures: 7/...4--0 6)( ..z. Meds/Times: Es

Pre Op Meds History

Time a

(:", ...„

I.K.A, ..,.

-. L

-... 4 •,,,

3 .e. Pacu Intake

Sa02 341 Ti 5r 147 Ce Time Solution Amount Site - By Infused

F102 A 14 (IP IA itn 1r30 7.0e.PS --qc.$ c) 06 i 10 (Wtb) - 2.-

Methods

240 •

220 X-rays:

' Post-Anesthesia Recovery_score

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

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

180

160 Airway

Dr breath (2) Cough, D (1) Dyspnea , limited breathing (0) Apnea

FT = Face Tent RA - RoomAir NC = Nasal 140

Blood Pressure (2) SBP .1.- 2 of Pre-op (1) SBP =A 20-50 of Pre-op (0) SBP =A 50 of Pre-op

Cannula

V/S X =A-line BP

120

100 6

I

., 4 ..% Consciousness (2) Fully Awake. audible crying (1) ;Unusable to verbal or pain

"' = Cuff BP = Pulse

TEMP

r A

80 ^ • Color (2) Baseline color 8 appearance (1) pale. mottled, jaundiced (0) Cyanotic

S = Skin 0=Oral A = Axillary T =Tympanic

60 V V

v 40

✓ Ci Circulation Pd < 5 Y aton (es ears) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

R =Rectal

LOS C = Cervical 20

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for OIC .

T = Thoracic L =Lumbar

S = Sacral RR AA ibial T

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

1Connnue on reverse/

PREPARED • LW t 0 )- '7--

DEPARTMENT1SERVICEICLINIC

PA c u

DATE

i 0c403

PATIENT'S IDENTIFICATIal or typed or e.. Name -last, lig middle: grade; date: hospital or medic

ttLitillart L'' )1_ 0' )" V C/

rill CO Lb) - 4/ '

■ HISTORYIPHYSICAL ■ FLOW CHART

■ OTHER EXAMINATION OR EVALUATION ■ OTHER Nym;lrf

0 DIAGNOSTIC STUDIES

0 TREATMENT


WAMC OP 1T3-E, (Revised) 1 Apr 01 (MCXC-DN)

Previous edition is obsolete WNW V2.00

MEDCOM - 20518

DOD-034092

ACLU-RDI 1657 p.78

DOD-034093

CARDIAC RHYTHM


DRESSINGS


Adm

30'

60'

D/C

PACU OUTPUT

Time Source Color/Appearance Amount

WAMC OP 173-E

MEDCOM - 20519


Of Motion

Sensory .

P Cap Refill

T Color

Adm

15'

30'

45'

60'

90'

D/C

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

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

C-SECTIONS

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

Lochia

Peripadtt

Fund. Cond.

NURSING NOTES

(1) tpt 1_4—v3 c;)c,, 9e0 tiSS

OC' eactrs.—; ..31/

Discharge Cri ria: Date: ..?e7 iime: /6( 1 PARS: BP: clivyT: f? 3 HR: /4't RR: 1 Sa02: Pain Le el at D/C (0-10): Intake: a--0 O Output: Additional Data: Transferred To: "—Z.:X.4,J Report Given To:

Transferred Via: W/C Litter Transferred By: 5 C6-

Cleared IAW Recovery Room

Charge Nurse Signature:

(1.) 2—

urney Ambulance

66)112) z- -3

MEDICATIONS Allergies:

Medication DrAani,

Time Pain 1-10

Route I/E By Pain 1-10

ACLU-RDI 1657 p.79

DOD-034094

REPORT TITLE

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4066: the proponent agency is the Office of The Surgeon General

OTSG APPROVED (Date)

Post-Anesthesia Care Unit (PACU) Flow Sheet

History g L

Pre Op Meds


Trach

Other

Drains Hemovac

NG

JP

T-tube

Foley

TLS

Tr^

/ ° II o,

DATE

q- LO Q PREPARED BY rsip

) Lb 1- -L.

DEPARTMENTISERVICFJCLINIC

DA FORM 4700, MAY 78 Previous edition Is obsolete USAPPt V2.00


Date: I 0 0-14*-0 3 Anesthesia Type (Circle)): Spinal Epidural

Time In: I?b r IV Sedation Nerve Block

Allergies: 4, " K 0 4 OR Intake: Crystalloid 6 (4._ Colloid

Pre-op V/S: 6 1 OR Output: UOP EBL Qj

• Procedures: Meds/Times:

Pacu Intake

PATIENT'S WENT list. middle; grade: date: hospital or medical laciityl

-t)Lo )16

gwe . Name —last,




❑ TREATMENT

❑ FLOW CHART

❑ OTHER ryi.arr

MEDCOM - 20520

fLonhnue on levers?)

Site • Amount

Ye,

Time

/,16

Infused

le)tb)- Solution

L

X-rays: Labs:

a

a 2

ID 7 2

30' D/C ADM Codes

AIRWAY A= Ambu BB= Blow-by M = Mask FT = Face Tent RA =RoomAir NC =Nasal Cannula

V/S X =A-line BP - = Cuff BP

= Pulse

TEMP S =Skin 0= Oral A = Axillary T =Tympanic R= Rectal

LOS C = Cervical T = Thoracic I= Lumbar S = Sacral

Criteria Activity (2) Moves 4 Extremities

Moves 2 Extremities (0) Moves 0 Extremities

Airway (2) Cough. Deep breath (1) Dyspnea. limited breathing (0) Apnea

Blood Pressure (2) SBP 4- 20 of Pre-op (1) SBP 20-50 of Pre-op (0) SBP 4- 50 of Pre-op


aYin9 (1) Arousable to verbal or pain

Color (2) Baseline color & appearance

(1) pale. mottied, jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (I) Axillary palpable, not radial (0) Carotid only reliable pulse

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

RR

T

Time Pain (0-10) LOS

Pat en teaching done; Wound Ca e. Pain Management, T, C. & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

Post-Anesthesia Recovery score

40

20

Time

Sa02

F102

Methods

240

220

200

180

160

140

120

100

80

60

ACLU-RDI 1657 p.80

DOD-034095

CARDIAC RHYTHM


S • 111

(lo)110)-z

Gurney Ambulance 02) 142 ) 2—

P B-3

Report Given To: Transferred Via: W/C Transferred By:

Cleared IAW Recovery Charge Nurse Signature:


1.10 Medication &

Dosane Route Pain

1-10 I/E By

1,,t 4.7 q-Okr,-. A --rt In svci 7, t, (bAbil

azo 11oL . 2 fw6 )460 4 1-A (1461'L

0726 4-c411.,_ ( 64'S- 01° 4— It/ ooto-L


Of Motion


T Color

Adm

15'

30'

45'

60'

90'

D/C

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

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

C-SECT1ONS

Adm 15' 30' 45' 60' 90' D/C

Fund. Height

Lochia

Peripad#

Fund. Cond.

DRESSINGS


Adm

30'

60'

D/C

NURSING NOTES

1/-40 /17gh-T-c

U4(0 „S./iv -7-4-0

059 r P.Dy, Vac

-10 4.<.,

4-0

(-7)1c...) .41,14-faJ-f

77,..6/4 / 6c. t4

0 C

PACU OUTPUT

Time Source Color/Appearance Amount

WAMC OP 173-E

MEDCOM - 20521

Discharge Criteria: Date: toac-43Time: P PARS: BP: /*7 T: HR: SO RR: /SG Sa02:9,7/ Pain Level at D/C (0-101: Intake: br-v ■ Cc Output: S)o Additional Data: Transferred To: =Cc—)

ACLU-RDI 1657 p.81

Histor Pre Op Meds

❑ FLOW CHART

❑ OTHER


❑ OTHER EXAMINATION

OR EVALUATION


❑ TREATMENT

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA for use of this form. see AR 4066: the proponent agency is the Office of The Surgeon General.

RR 25 Ili

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

Date: (5 6) Anesthesia Type (Circle ))• Spinal Epidural Time In: I t IV er asion Nerve Block Allergies: /*DA' OR Intake: Crystalloid 400 Colloid Pre-op VIS: I Lt 0 OR Output: UOP EBL. g. Procedures: Meds/Times: 1 tti VC.44 ( 5n .r4.1.-- #


Trach

Other

Drains Hemovac

NG

• CF7 T-tube

Foley

TLS

Time Pain (0-10) LOS

DEPA TMENTISERVICEIGUNIC

cu Name —last,

(Oa) -4 Itonlinue on reverse,

DATE

Pact. Intake Time Solution Amount Site • By Infused

In° 1 t.)

X-rays: Labs:

Post-Anesthesia Recovertscore Criteria ADM 30' D/C Codes Adivity


AIRWAY A =Ambu BB= Blow-by M = Mask FT = Face Tent RA= RoornAir NC = Nasal Cannula

V/S X = A-line BP ' =Cuff BP

= Pulse

TEMP S = Skin 0= Oral A = Axillary T = Tympanic R =Rectal

LOS C = Cervical T = Thoracic L = Lumbar S = Sacral

Airway

(2) Cough, Deep breath (1) Dyspnea, limited breathing (0) Apnea

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


Ming (1) Arousable to verbal or pain

Color (2) Basel.* color & appearance (1) pate, mottled, jaundiced (0) Cyanotic

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

TOTALS: Must be 9 or greater to DEC, otherwise

needs anesthesia approval for WC, 1 0 b

Pat en teaching done: Wound Care, Pain Management,

Safety: SR up X 2, Falls Precautions. Privacy Maintained T, C, & DB,. Incentive Spirometer, Comfort Measures

to Time

Sa02

100

F102

Methods

240

220

200

180

160

140

120

Bo

60

40,

20

/ So c71-3 e or vmttea entries give:

list, middle; grade; date; hospital or medical leafy! 11.1 ziwkl-g

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC V2.170

MEDCOM - 20522

DOD-034096

ACLU-RDI 1657 p.82


Medication & Dosage

Time Pain 1-10

Route I/E By

1V3

Pain 1-10

NURSING NOTES

P

A A a_A. diallfflart - Arr f eit Fid 0

_ MIT -MN 12)

Discharge Criteria:

Date: 15000!) Time: I 211.0 PARS: /0 BP: 139/0 T: q63) HR: 5S RR: p, Sa02(0 Pain Level at D/C (0-10): 0 Intake: Output: 71 Additional Data: ,‘..4,1"4- Transferred To: PO/ Report Given To:

( t to - Transferred Via: W/C Wit. a rney Ambulance Transferred By: L. Cleared IAW Recovery oom SOP B-3 Charge Nurse Signature:


Of Motion

Sensory P

Ira

IMIEMIIIMEI irjr1/11NRIS

Cap Refill

MEM

T Color

P .

P(cd I'

Adm UM" -1i-

15. riffil 4 -(- 30' rairl te 45'

60'

90'

D/C UM 4) VIIIIIIMMIIIM1 ' G Movement/Se sation: + = present,- = absent Temp:C = Cool, W =Warm Pulses: P. Palpable, D =Doppler, A = Absent Color: C = Cyanotic,

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

C-SECTIONS

Adm 15' 30' 45' 60' 90' Fund. Height ...------------'- Lochia

Petipad# ....-----------.' FUTIC

DRESSINGS


Adm IIS O'' ,?.., 41:0 c/),141071 ti... „..„... 0' t 3at

VA ee..)

60'

D/C

PACU OUTPUT

Time

CARDIAC RHYTHM

Time Rhythm Symptomatic?

Rhythm Strip Run?

ti

0

WAMC OP 173-E

Source • or/Appearance Amount

MEDCOM - 20523

DOD-034097

ACLU-RDI 1657 p.83

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. are AR 40.66: the proponent agency 4 the Office of The Surgeon General.

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

Dale: )55 0C•1153 Anesthesia Type (Circle)): Spinal Epidural Drains Airway

Nasal Oral ETT

Trach

Other

Time In: 1(5-7 IV Sedation. Nerve Block Hemovac NG

JP T-tube Foley

TLS

Allergies: NK-)A OR Intake: Crystalloid Colloid 1460 Pre-op V/S: 1 ISO IS OR Output: UOP Ci EBL ( .3 Procedures: WO-5h but Meds/Times: 100 (1.4 ?f1) tz+r-1 On

Pre Op Meds History

Time , _IN -Z.°

Csi

Q.t.

f■pal

...Ir.. Pacu Intake ..,-/------- Sa02 P Cli CFI cri Time Solution Amount itel By Infused

F102

Methods

240

11( pl% *Rif

'-

220 X-rays:

. Post-Anesthesia err score

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

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

180

160 Airway y (2) Cough, Deep breath (1)Dyspnea, hailed breathing (0)Apnea

FT = Face Tent RA =.RoomAir NC = Nasal

V NI

140 Blood Pressure (2) SBP =1- 21 of Pre-op (1)SBP =/- 20-50 of Pre-op (0) SBP =1- 50 of Pre-op

Cannula

V/S X - A-line BP

120

• •

100 (2) Fully Awake, audible ang (1) Arousable to verbal or pain

Consci ousness ' =Cuff BP

=pulse

80 -

A TEMP

• Col or (2) Baseline cd A appearance (1) pate, mottled. jaundiced (0) Cyanotic

S =Skin 0 = Oral A = Axillary

= Tympanic fT

60

• /N

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

II= Rectal

LOS - C = Cervical

20

TOTALS: Must be 9 or greater to WC, otherwise needs anesthesia approval for 0/C,


RR ID y. V. jo T

Time Pa ien teaching done: Wound Care, Pain Management, Pain (0-10) T, C. 8 DB,. Incentive Spirometer, Comfort Measures LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained

Itonhnue on rerun/ PREPA

(0(19) ' 1 DEPARTMENTISERVICEICLINIC

0 DATE

I 601- 66 PATTEN S I or typed or written entries give: Name -last, Cyst, middle: grade; date; hospital Of medkal facility'

WI 061)119 ) - it

• HISTORY/PHYSICAL 0 FLOW CHART

■ OTHER EXAMINATION ❑ OTHER amidii OR EVALUATION

al DIAGNOSTIC STUDIES

O TREATMENT

OA FORM 4700, MAY 78


Previous edition is obsolete USAPPC 52.00

MEDCOM - 20524

DOD-034098

ACLU-RDI 1657 p.84

DOD-034099

Time Source • Color! •earance Amount


Of Motion

Sensory

-

P Cap Refill

T Color

Mm Lt t - -4- f3 W M., tit

V.

15' -le t r I.5 w,,,,...w,,,,... 30'

1,162 Li 4. Si 00 12— p..4,l4

45'

60'

90'

D/C u es ..4 "4" F t 1-4, 431c,

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

Capillary Refill: B = Brisk, S= Sluggish P= Pa= Pink

C-SECT1ON

Adm 15' .,39'--"- 45' 6• 90• D/C Fund. Height Lochia ..,..------P Peripad#

Fu . ond.

DRESSINGS


Adm l., lecl — " 1411(' '1A(A-11)---f. 30' 1,..I el -71 1(..-e...1c..p Sk•-•-•KiYn-

60' -.:

D/C LIQ —\ IC e et-G.)0 tet,t.6ti",,x

WAMC OP 173-E

MEDCOM - 20525

NURSING NOTES MEDICATIONS

Allergies: Medication & fln'ane

Time Route Pain t/E By Pain 1-10

PACU OUTPUT

CARDIAC RHYTHM

Symptomatic?

V5.

Time

N SYL ( Rhythm Rhythm Strip Run?

Discharge Cap: Date: WO. 'time:IX:1.S PARS: (13 BP: )147T: % o HR: 7•g RR: /0 Sa02:/ Pain Le el at DIC (0-10): 0 Intake: 0 Output: Additional Data: C-16,..--) Transferred To: 1C(A.2 Report Given To: b (lo)Liv ) - Transferred Via: Mir"' Ambulance Transferred By: ,09211 Cb -L Cleared IAW Recove 00 Charge Nurse Signature:

ACLU-RDI 1657 p.85

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For USE of this form, see AR 4066: the proponent witty is the Office of The Surgeon General.

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

Dale: .1 r (''..T Anesthesia Type (Circle)): liGlISpinal Epidural 1

Drains Airway

Time In: N12.3 — IV Sedation Nerve Block Hemovac NG

. JP T-tube Foley

TLS

Nasal Oral EU

Trach

Other

Allergies: — OR Intake: Crystalloid Colloid

Pre-op VIS: li14-/ -58 (ti OR Output: UOP r-2)00,50 EBL 50

Procedures: Meds/Times: .?.4) re--4- Or.r;‘,-R ,i,,,,fa I2 Ye.,..,,,/ __.5 - /-/-),

&Q7 -In aji Oi t-r, 6c.)..,,,,.) • Pre Op Meds Histor

Time ... i :z• 1.4 AI ... ai. .„.. Pacu Intake

Sa02

Fi02 1 1 PGV

Time Solution Amount Site • By Infused

Methods fie+ 1 pt if,A pi

240

220 X-rays: . Labs:

Post-Anesthesia Recovery score

200 Criteria ADM 30' INC Codes Acrwity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities

-..‘

ot g AIRWAY

ABB=.ABrniobwu -by

M. Mask

180 .

160 Airway (2) Cough. Deep breath (1) Cryspnea, limited breathing (0) Apnea

FT = Face Tent RA =RoomAlr NC...Nasal 140

✓ V Blood Pressure (2) SBP 4- 20 of Pre-op (1) SDP =A 20-50 of Pre-op (0) SBP =/- 50 of Pre-op

Cannula

Ws

X = A-line BP

120 •..

100 Consciousness (2) Fully Awake, audible crying (1) Arousable to verbal or pain 'I a

' =Cuff BP = Pulse

TEMP 80 Di

0 • Color (2) Baseline color & appearance (1) pale, mottled. jaundiced (0) Cyanotic •

S =Skin 0 =Oral A = Axillary T Tympanic

60 A A A .

/1° 40

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

R = Rectal

LOS C = Cervical 20

TOTALS: Must be 9 or greater to [VC.otherwise needs anesthesia approval for DIC.

1 D ID . T = Thoracic L = Lumbar S = Sacral RR 9713 P. 10 R

T

Time Patient teaching done; Wound Care, Pain Management.

Pain (0-10) T, C, & DB,. Incentive Spirometer, Comfort Measures

LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained ..__.._.._ __ __.........

PREPARED BY alipature a Thiel

DEPARTMENTISERVICEICLINIC

DATE

PATIENTS IDENTIFICATION (For typed or written entries give: Fist, middle; grade; date; hospital or medical laatyl

'iouo ll11111 0°) (6 ) - Name -last,




❑ TREATMENT

❑ FLOW CHART

❑ OTHER tro=dri

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

MEDCOM - 20526

DOD-034100

ACLU-RDI 1657 p.86

DOD-034101

PACU OUTPUT

Source • Time Color/Appearance Amount

CARDIAC RHYTHM



Of Motion


T Color

Adm

15'

30'

45'

60'

90'

D/C

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

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

C-SECTIONS

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

Lochia

Peripad#

Fund. Cond.

DRESSINGS


Adm lite/4 2,0.49 11.. 30' D: t0 rAtt

60' 0 D/C

NURSING NOTES

Cb01-2.-

WAMC OP 173-E

MEDCOM - 20527


Medication 11 sane

Time Pain 1-10

Route I/E By Pain 1-10

Discharge Criteria: Date- Time: /96(6 PARS:1 0 BP: t T%5 HR: -55 RR:I Sa02: Pain Level at D/C (0-10): Intake: - 15/ Addition I

1 Data:

Output: /:(

Transferred To: ((,U-3 Report Given To:

Transferred Via: W/C Gurney Ambulance Transferred By: Cleared IAW Re Charge Nurse Signatur

ACLU-RDI 1657 p.87

ABU GHARAIB MEDICAL TRANSFER REQUEST FORM b) C6) -z

c71 DATE altUE'Sq 9 e

REQUESTOR:

ISN #:

COMPOUND: ern) P Da1 PRIORITY: gThi-42

LITTER674BULATOR (CIRCLE)

0-3

111.1111111 (.1,g 09)(19) - Z_

dt,

DATE OF TRANSFER:

TIME OF TRANSFER:

DESTINATION:

POC AT DESTINATION:

ANTICIPATED LENGTH OF TRANSFER:

EQUIPMENT REQUESTS:

NOTE: COORIDINATION IS ALSO REQUIRED THROUGH MOVEMENT CONTROL FOR A TRIP TICKET.

MEDCOM - 20528

DOD-034102

ACLU-RDI 1657 p.88

USAPA V1.00 EDITION OF MAR :9 IS BSO

Ob-1 Li- v91 MEDCOM - 20529

ADMITTING OFFICER (Signature, as required)

(b)00) -Z_ (&) lb)" Z

SIGNATU

DOD-034103

DA FORM 2985,

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

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

1 2 3 4 5 6 7 8 (State or Country Code. ) A ..._,

3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX 9 10 11 12 13 14 15 16 17 18

00)00 ) - y 6. DATE OF BIRTH (YYYYMMDD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIG ON

19 20 21 22 23 24 25 26

11111M1V01111 27 28 29 30 31 BACK-

GROUND I) NI K AMI E

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

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

6/ 9 ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF

ADMISSION BRANCH / CORPS (d I b)- Li

46

1 6) 1 0

14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE

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

K —1 ei 17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION 62 63

Country Code) 64 65 66 67 68 69 70 71 YEAR

7 NO

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCYDDRESSEE

V 72 ADMISSION

(Ja*/) - 2- law( o ADDRESS OF EMERGENCY DRIZ (Include ZIP Code)

21. TYPE OF DISPOSITION

TELEPHONE NUMBER OF EMERGENCY

U

ADDRESSEE

NK 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (YYYYMMDD)

73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 111:11 AriPirMill111 1 1 1 24. CLINIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYYYMMOD) 89 90 91 92 93 94 95 96 97 98 99 100 101 102 Dim 105 106

A 27. LOCATION

MILIFil OF OCCURRENCE 28. MTF OF INITIAL ADMISSION

irAii irsukaingiminvan6,---1 __Atopzuoulinieurar,.._*.g.wi DATE INITIAL ADMISSION

107 108 (Battle Casualty Only)

109 110 111 112 113 114 115 116 117 118

(II

119

V V' V

120

M M #

121

i

122

FOR LOCAL USE

: (10 OPEN) 1,X.; 691 I TkixtAA,,,_ q 5p s DX 0A4 Es-r

pea-N ‘bAel< °kir)

-30. - ar i of AT) 7-201-rf ) N--A;,...,,,,,

ACLU-RDI 1657 p.89

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MEDCOM - 20530

DOD-034104

ACLU-RDI 1657 p.90

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MEDCOM - 20531

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DOD-034105

ACLU-RDI 1657 p.91

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MEDCOM - 20532

DOD-034106

ACLU-RDI 1657 p.92

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ACLU-RDI 1657 p.93

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ACLU-RDI 1657 p.94

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DOD-034109

ACLU-RDI 1657 p.95

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ACLU-RDI 1657 p.98


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ACLU-RDI 1657 p.99

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ACLU-RDI 1657 p.100

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ACLU-RDI 1657 p.101

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ACLU-RDI 1657 p.105



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DOD-034133

ACLU-RDI 1657 p.119

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MEDCOM - 20560

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DOD-034134

ACLU-RDI 1657 p.120


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MEDCOM - 20561

DOD-034135

ACLU-RDI 1657 p.121

MEDICAL RECORD PROGRESS AUTHORIZED FOR LOCAL REPRODUCTION

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MEDCOM - 20562

DOD-034136

ACLU-RDI 1657 p.122

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MEDCOM - 20564

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ACLU-RDI 1657 p.124

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MEDCOM - 20565

DOD-034139

ACLU-RDI 1657 p.125



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MEDCOM - 20566

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(3)(101

USAPA V1.00

DOD-034140 ACLU-RDI 1657 p.126


DATE NOTES

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MEDCOM - 20567

DOD-034141 ACLU-RDI 1657 p.127



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USA PA V1.00

MEDCOM - 20568

DOD-034142

ACLU-RDI 1657 p.128


DATE NOTES

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)1.1.1 -1

DOD-034143 ACLU-RDI 1657 p.129

MEDICAL RECORD

PROGRESS NOTES


DATE NOTES

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ISSN or Other) LAST FIRST MI

DEPART./SERVICE I HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade!


( d) PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0)

USAPA V1.00

MEDCOM - 20570

DOD-034144

ACLU-RDI 1657 p.130

MIIIIPPue9)Lb)-r STANDARD FORM 509 (REV. 5/1999) BAC USAPA 1/1


DATE NOTES

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DOD-034145

ACLU-RDI 1657 p.131



DATE NOTES

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STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(3)(10)

USAPA V1.00

MEDCOM - 20572

DOD-034146 ACLU-RDI 1657 p.132



DATE NOTES (•L)L1-- 1-

/1 AiiV I4L

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STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0)

USAPA V1.00

MEDCOM - 20573

DOD-034147

ACLU-RDI 1657 p.133

RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP CONSULT WITH ACTION TIME

cAo9) - tt EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

wn,

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00)1W -7- DIAGNOSIS

'ho

me.,( "mei, hi Ok

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

0 ,

TEST RESULTS

co

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Cl)

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STANDARD FORM 558 (REV. 9 -96) Prescribed by GSA/1CMR FPMR 141 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 20574

vo Tr",

DOD-034148

ACLU-RDI 1657 p.134

NSN 7540-01-075-3786

ICAL RECORD ME

ADDRESS STREET

DUTY/LOCAL PHONE

....„,,....,-- AREA CODE I NUMBER

E PHONE

SEX

M AGE

ADDITIONAL INSURANCE

2568 IN CHART PRP

FLYING STATUS

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CONDITION UPON RELEASE

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❑ DETERIORATED S.

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203(b)(10) USAPA V1.00

EMERGENCY CARE AND TREATMENT (Patient)

Medical Record

TREAT LOG NUMBER EMERGENCY CARE

AND TREATMENT

(Patient) RECORDS MAINTAINED AT 042),, L

ARRIVAL PATIENT'S HOME ADDRESS OR DUTY STATION

DATE. (Day Month, ear) TIME /0 y• 0 7

TRANS ORTAT N TO FACILITY

w li-ee ( ve4 .- 4 THIRD PARTY INSURANCE

ZIP CODE STATE CITY

MILITARY STATUS NO YES ITEM - N/A NO YES ITEM

NAME OF INSURANCE COMPANY MEDICAL HISTORY OBTAINED FROM NUMBER AREA CO

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1 DATE LAST VISIT 24 HOUR RETURN

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

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PATIENT'S SIGNATURE TIME OF RELEASE

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

Ali E. PIA/

MEDCOM - 20575

DOD-034149

ACLU-RDI 1657 p.135


MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each envy)

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PATIENTS IDENTIFICATION: (For typed or written entries, give: Nome - lost, first, middk; ID No or SSM• Sex; Dote of Birth: fionk1S/scied I REGISTER NO. WARD NO.


STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20576

DOD-034150

ACLU-RDI 1657 p.136

AUTHORIZED FOR LOCAL R E P

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

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

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

I REGISTER NO. I WARD NO.!!



MEDCOM - 20577

DOD-034151

ACLU-RDI 1657 p.137

NSN 7540-00-634-4124 511-119

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STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, RRMR (41 CFR) 201-9.202-1

MEDCOM - 20578

DOD-034152

ACLU-RDI 1657 p.138

VITAL SIGNS RECORD MEDICAL RECORD HOSPITAL DAY

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STANDARD FORM 511 (REV. 7-95) BACK

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DOD-034153

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STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 20580

DOD-034154

ACLU-RDI 1657 p.140

511-119

NSN 7540-00-634-4124

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STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20581 •••

DOD-034155

ACLU-RDI 1657 p.141

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(►o)co-if STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 20582

DOD-034156

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511-119 NSN 7540-00-634-4124


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DOD-034157

ACLU-RDI 1657 p.143

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. .

. . • • . .

•

• • •

•

• • •

• . . •

.

.

.

.

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. .

. • • •

•

• • •

...

4- ,

. . . . . . . . . . . . . . . . . . .

1Rec

ord s

pec

ial d

ata

onl

y w

hen

so o

rde

red BLOOD PRESSURE

—reA,

it% pfGel i JS:401

ri s5- rits' L%.? 973

HEIGHT: I WEIGHT

144- C-i,.IK urM 9 i% ..-2_



1111 deo )-- VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 51.1 (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20584

DOD-034158

ACLU-RDI 1657 p.144

"TWPITR=FEWHOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM HOURS TOTAL HOURS

COVERED DATE

Igi- ti Oor TO HOURS

.44-7A*E- ou-rpd-r- ORAL INTRAVENOUS


TIME STARTED

AMOUNT TYPE


RECD TIME

COMPL ACCUM TOTAL

.1P. bob ---Lgair-Aff*evs=mGFB CDt.


00 1 Q6 . ;?6cc P6ce_. 1(0-Ata PTC-1-11-30

! NIA FAIII

Z_DC. `?f c--

4S c c '15 cc

fIDS45 '5% ,,.. ,

. go, be) \ CD CC S C C


TIME STARTED

PRODUCT (i.e. B1, Alb, P. cells, etc.)

TIME COMPL

AMOUNT ACCUM TOTAL OTHER INTAKE


TOTAL

GRAND TOTAL INTAKE

USAPPC VI .00

MEDCOM - 20585

DOD-034159

ACLU-RDI 1657 p.145


TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET FROM Ey to HOURS TOTAL

COVEREDHOURS DATE

iq 0-0-t- TO 0 co HOURS

INTAKE

ORAL INTRAVENOUS

TIME TYPE AMOUNT .5,-- ....-

ACCUM TOTAL



RECD TIME

COMPL ACCUM TOTAL

(■. - ''-'-‘," -

.. ...

IRRIGATIONS (N/G, Bladder, etc.) . . .


. _ . ... ._


TIME STARTED

PRODUCT (i.e. Bl, Alb, P. cells etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

--- OTHER INTAKE


"nn prIonn 707 IAKI 7A A ICrst

GRAND TOTAL INTAKE

ON OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94

MEDCOM - 20586

DOD-034160

ACLU-RDI 1657 p.146

tVU OUTPUT .

Q0 t UR IE NASOGASTRIC


0966 30-3).., t 3c)----z›

ITS 200 s-b---v

1610 -2-e0 2v--z)

iieo z gorD .

090 230 1 [ 0 0 • • - .

C0.30 3b t. z-(5• 7)

(1400 `)co Isis 1-)

-zagcst. P--J,:,-, ,c- vv-,- ----b, ea, frA4 4, (,. EMESIS


t ra) t ' co 30 9. S'

ION zo 2)0 09co 10 I OS- 3 20 . 5--- ) s OGGID /0

1.(1() to Gz 5 STOOLS



_. GRAND TOTAL OUTPUT

REMARKS


11111 (b n.6 ) - I/

fin LflrIlla -7,1/1 , a ILI -1 A


MEDICINE GLASS II oz) . 30 HALF PINT MILK 120 LARGE SOUP BOWL

SMALL FRUIT CUP 160 LARGE WATER GLASS ... COFFEE MUG 180 PLASTIC OR PAPER

JUICE CONTAINER

240 240 240

180

Page 2

MEDCOM - 20587

DOD-034161

ACLU-RDI 1657 p.147

2o OUTPUT

\c- e) l.- sentA NASOGASTRIC


10s-0 0254, 62,-() _. . .

/7,57 501-5- 775

Y-Cp 35--D 1 32g--

. . . ..... _

..._ 5ut,19,Vt4. 1-ac, co:1=a 1:s-14(-ve,f - - - EMESIS


lia 6 O

A5-7 0 0 . OILY-2.) 0 45

STOOLS



... .. .,.... .._.

-- - ---- GRAND TOTAL OUTPUT

REMARKS


in (6) ( I \ L


... MEDICINE GLASS (1 oz) . 30 HALF PINT MILK 120 LARGE SOUP BOWL

SMALL FRUIT CUP 160 LARGE WATER GLASS ... COFFEE MUG 180 PLASTIC OR PAPER

• JUICE CONTAINER

240

240

240

180

DD FORM WO _IAN 7z1 Page 2

MEDCOM - 20588

DOD-034162

ACLU-RDI 1657 p.148

FROM Z1/4 .riS TOTAL HOURS COVERED

DATE

Zi .0C-17— TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET TO HOURS

INTAKE

tU 6 1 d pOr --1477-1 INTRAVENOUS


TIME STARTED

AMOUNT TYPE


RECD TIME

COMPL ACCUM TOTAL

6701) 0e (0,,

OVA eit,,,- e-ter_71_ 2-75-

46 id,/ -IRRIGATTC317717M-BiarhieFFetc-)--


TOTAL

61°-0 — Ci24X y d (a z,) 1--/•0 u. e . 0 CC

ocr. r,(e--erer /7.e--1 .• fe;'- Z--O v-c-


TIME STARTED

PRODUCT (i.e. BI, Alb, P. cells, etc.)

TIME COMPL

AMOUNT ACCUM TOTAL

OTHER INTAKE


GRAND TOTAL INTAKE

USAPPC V1.00

MEDCOM - 20589

DOD-034163

ACLU-RDI 1657 p.149

MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT

For use of this form, see AR 40-66: the proponent agency is The Office of the Surgeon General.

1. AGE:

HEIGHT:

WEIGHT:

2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):

3. PREVIOUS SURGERY [ ] NO [ ] YES (type):

4. PROPOSED SURGICAL PROCEDURE:

'11 dt-I

CeLtA_

5. ADDITIONAL INFORMATION: Last l'O: Medical 1-lx: Jewelry removed: yes/no Family waiting: yes/no

Implants: Medications:

6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS

A. PSYCHOSOCIAL

Potential for anxiety

o Pt. verbalizes any specific anxiety.

o Pt. exhibits relaxed body posture.

(e.g., warm blanket, touch)

0 Allow pt. to verbalize freely. o Explain OR environment and answer questions regarding surgery.

0 Offer comfort measures,

o Explain all nursing procedures before they are done. o Remain with pt. whenever possible. o Maintain family interface.

related to traumatic injury;

language barrier; family separation; surgical environment

B. AERATION Potential for

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

o Offer to elevate head of litter or offer pillow. o Observe pt. while awaiting surgery for signs of distress o Assist anesthesia during intubation and extubation

respiratory dysfunction due to sedation; positioning; injury

C. INTEGUMENT

Potential impairment

o PT. will not exhibit signs of impairment of skin integrity (e.g., reddened areas.

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

of skin integuity due to bovie

pad; position; fluid shill

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

Aga W )Lb) -

DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01

MEDCOM - 20590

DOD-034164

ACLU-RDI 1657 p.150

USAPA V1.01

13. PREOPER, BY (Signature an

DATE /d QCT

a IME: nbt970,.

12. PREOPERTIVE EVALUATION PREPARED BY nature and Title) la) L _Z

Ad DATE:

lo cs. ck_07

REVERSE OF DA FORM 5179, JUN 91 MEDCOM - 20591


D. CIRCULATION

Potential for inade -

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

- - •

o Check for support stockings or ace wraps. If none, check with doctors. o Check that safety straps are correctly applied.

o Offer pillow for under knees.

o Place and take down legs from stirrups with slow bilateral motion.

o Check that rings have been removed.

quate tissue perfusion due to anesthesia; traumatic injury; position; shock; previous surgery

E. NEUROMUSCULAR CONTROL E.1. Potential impairment

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

o Have sufficient people available for transfer. 0 Insure proper body alignment. o Allow patient to lie in position of comfort while waiting for surgery. o Offer support (i.e., pillows, bathtowels, etc.) for positioning.

of mobility due to sedation; pain; injury

E 2 Potential discomfort

due to injury; pain

F. NEUROMUSCULAR CONTROL F.1. Disminished visual

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

o Minimize danger of injury during intraop period.

o Introduce self. Keep pt. informed as to where he/she is and what is happening. o Inform pt. in which direction to move and assist if necessary. o Speak clearly and slowly. o Address pt. from

side.

perception due to being injury; sedation;

F 2 Potential for decreased communictaion due to language barrier; sedation

o Validate pt.'s understanding of verbal communications. o Verify removal of dentures.

F.3. Potential injury due to dentures.

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

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

OTHER NURSING INTERVENTIONS. Or continuation of above interventions.

10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTFFI

DATE

11. POSTOPERATIVE EVALUATION: (JJ)Lb) -2.-

DOD-034165

ACLU-RDI 1657 p.151


FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General

1 AGE

HEIGHT:

WEIGHT:

2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) ❑ NKDA D PCN ❑ LATEX ❑ IODINE 0 TAPE ❑ FOOD REACTION:

c Itc-A-C40--rOl"

3. PREVIOUS SURGERY [ ] NO 1..1-1(ES (type):

1,1.... "4,-Y-___,2"..p 4-,=7 A- --ayaziti ,

5. ADDITIONAL INFORMATION: (Previous surgical and medical history) Skin Condition (b ppd X____vrs Body Piercing Diabetes (Y) (N) ROM ASA/Motrin W 72hrs (Y) (N)

ETON Implants Respiratory Disease (Asthma COPD) (Y) (N) Anticoagulants (Y) (N) Hypertension (Y) (N) Herbal Medicines (Y) (N) MEDS:

8. OR NURSING INTERVENTIONS

ea:" Allow pt. to verbalize freely.

(2.r Explain Or environment and answer

questions regarding surgery.

(2<58er comfort measures. (e.g. warm blani,..1. touch).

Pl Explain all nursing procedures before

they are done.

Remain with p1. Whenever possible.


Glasses/Contact (Y) (N) Dentures

6. PATIENT PROBLEMS AND NEEDS

A. PSYCHOSOCIAL -/—potential for anxiety related

to: ---- 1) Surgical Procedure&

Operating Room Environment 2) Separation Anxiety

(Child)

Surgical Outcomes

7. PATIENT GOALS AND EXPECTED OUTCOMES

.Pr- Pt. verbalizes any specific anxiety.

ePt. Exhibits relaxed body posture.

B. ALWION Potential for respiratory

dysfunction due to: r ii. Positioning

Effects of AnestheAa

3) Medical/Smoking History

Cv=t. will be able to breath without

difficulty during immediate intraoperative

phase.

er°1-5-fer to elevate head of litter or offer

pillow.

Cr-Observe pt. While awaiting surgery for

signs of distress.

,,cte-giist anesthesia during intubatlor and extubation.

C. IN -tl,ENT

Potential Impairment of Skin Integrity due to:

......"1) Intraoperative Immobility

ESU Pad Placement

3) Positional Aids

-41.)Prosthe_SIS

5) Pooling of Prep Solutions

Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).

Utilize pressure preventing devices

on OR table and accessories.

Check for proper positioning and

support to maintain good body alignment.

0-.--rad pressure points.

epe—Place ESU ground pad on non

compromised skin surface area.

0 eep prep fluids form pooling.

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

411111 (,, )1.10-

1111111101 "7) 7- 007-

VERIFICATIONS AT HOLDIN REA: ! ID/Allergy Band ! Dentur- Removed ! H & P ! C acts Removed

! NPO Since 1 Jewelry Removed

! UHCG/LMP Body Pierce Removed

! Consenielood ransfusion Signed/Witnes-d/Dated

! Surgical to/Consent verified by 0011.10)/ Pt./Ane esia/Surgeon

! Co act precautions (Y) (N) ! mily/Friend:

DA FORM 5179, JUN 91 Previous editions are obsolete. USAPA VI.

MEDCOM - 20592

DOD-034166

ACLU-RDI 1657 p.152

Cio)tb )-


D. C162CULATION Potential for inadequate tissue t. will exhibit signs of adequate tissue

perfusion (e.g. color, warmth. pedal pulse.

.

Check foe support stocking or ace warps. if none, check with doctors.

Check that safety straps are

correctly applied.

perfuses due to: t

1) Intraoperative Mobility

•---- 2) Positioning Or-CiffetFil ow ort.riettnees-7-- r j

-- heck that rings and all bo '-piercing has been removed. (AO- 7...

.- 3) Existing Disease 4) Safety Devices

5) Hypothermia

E. NEUROMUSCULAR

CONTRg— E.I. s---- Potential Impairment of

,,er—pl. will be transferred to OR table without difficu ly.

pt. will be not experience unnecessary physical discomfort.

wave sufficient people available for transfer.

sure proper body alignment.

er—krow patient to lie in position of

—comfort while waiting for surgery. 4eriliffer support (i,e..pillows. Bath

towel. etc) for positioning.

Mobility due to: Pain ,..,....1)

2) Intra operative Hazzards

3) prosthesis L_....- 4) Positioning

✓5) Transfer pt. To/form OR table

E.Z. L./Potential Discomfort Due to:

.7) Length of Surgery 2) Positioning 3) Arthritis

F. Special Senses F.I. Diminished visual perception

o pt. will be made aware of surroundings . prior to anesthesia induction.

o pt. will be transferred safely : SR table. o pt. will be able to unders - d instructions. o Minimize danger of jury during intraop

period. Speak clearly and .wly.

communis- on.

0 Introduce self. keep pt informed as to where he. she is and what is happening. 0 Inform pt. in ••which direction •• move and assist if necessary.

0 Address pt. fro • side.

due to being: 1) pre-medicated

2) W 0 GLASSES

F.2. Potential for t -creased

Communication due 1) Dimi hed Hearing 0 Validate p understanding of verbal

0 Ver removal of dentures. 2) L. guage Barrier

F.3. - otential Injury due to Dentures:

) Upper 4) Caps

2) Lower 5) Crowns 3) Bridges

G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs. OTHER PATIENT GOALS AND EXPECTED

OUTCOMES. Or continuation of above goa outcomes.

OTHER NURSING INTERVENTIONS OR continuation of above Interventions.

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

04,1 4111111111111111111111111 reo DATE

11. POSTOPERATIVE EVALUATION : SKIN INTEGRITY: Bovie Pad Site: ❑ Clean and Dry

LEVEL OF CONSCIOUSNESS: ❑ A&O ❑ Drowsy ❑ Sleepy ❑ Intubated

LEVEL OF ACTIVITY: ❑ MOVES ALL EXTREMITIES ❑ Moves Upper Extremities ❑ Transferred to Litter With roller due to spinal

PREPARED BY 13. PREOPERATIVE EVALU ON PREPARED

frtth/ 1-10

REVERS OF FORM 5179, JUN 91

Irrc5 I ( 5-0 MEDCOM - 20593 Ci 0

USAPA VI.0

❑ Red ❑ N/A DRESSING DRY & INTACT: (Y) (N) BREATHING EASY: (Y) (N)

12. PREOPERATIVE EVALUATION

TIME:

DOD-034167

ACLU-RDI 1657 p.153

5. ADDITIONAL INFORMATION: Last l'O: o yes

Medical 11x: ,542ei lniplonts: - MedicationsSaa e,41,„/ Jewelry remove


For use of this form, see AR 40-56: the proponent agency is The Office of the Surgeon General.

1. AGE:

HEIGHT:

WEIGHT:

2. KNO p ' ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):

IC Pr - 3. PREVIOUS SURGERY [ NO YES (type):



A. PSYCHOSOCIAL

Potential for anxiety

z--"-Pt. verbalizes any specific anxiety. •

_.9.- ---Pt. exhibits relaxed body posture.

, L,

t„...0

„0---Allow pt. to verbalize freely.

„0---"Explain OR environment and answer questions regarding surgery. 9-. Offer comfort measures, (e.g. warm blanket, touch)

0 6 Explain all nursing < procedures before they are Jet, do .

Remain with pt. whenever possible. o Maintain family interface. J

related to traumatic injury; ITIgtiage barrier; tinnily separation,<urgiaTi env!! onineTIP

B. AERATION %-"'" Potential for

6-15T. will be able to breathe without difficulty during immediate intraoperative phase.

.,-` IT" Offer to elevate head of ---- litter or offer pillow. 9"— Observe pt. while awaiting surgery for signs of distress

. 51.-- Assist anesthesia during intubation and extubation

r story dysfunction due to sedation ; ositioning: injury

C. INTEGUMENT

-̀-'/Potential impairment

-o T. will not exhibit signs of impair- ...-er"-- ment of skin integrity (e.g., reddened areas.

Utilize pressure preventing devices on OR table and accessories.

-Jia---theck for proper positioning and support to maintain good body alignment.

.ems Pad pressure points.

—cc" Place ESU ground pad on non compromised skin surfaEe area.

,2---. Keep prep fluids from pooling.

ofskin integuity due to c12ovie i .____., padposition: fluid slut'

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

,E41111 c6)(6)-1-/

DA FORM 5179, JUN 91 Previoius editions are obsolete.

A-11111P 0414

...10 t a c_,* df (17)(2) - z MEDCOM - 20594

USAPA V1.01

DOD-034168

ACLU-RDI 1657 p.154


D. CIRCULATION

•-----"Potential for inade-

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

o Check for support stockings or ace wraps. If none, check with doctors. 6.-efeck that safety straps are correctly applied.

o--Offer pillow for under knees.

0 Place and take down legs from stirrups wi h slow bilateral motion.

C ck that rings have been

removed.

u ue perfusion due to

• nesillesia• ratunatic injury;

<- NsilitT; shock; previous surgery

E. NEUROMUSCULAR CONTRO

E.1. Potential i airment

Pt. will be transferred to OR table --tr- Have without difficulty. :*.---t. will not experience unnecessary physical discomfort.

.--er---

sufficient people available for transfer. 0--- Insure proper body alignment.

--6-- Allow patient to lie in position of comfort while waiting for surgery.

Offer support (i.e., pillows, bathtowels, etc.) for positioning.

, • of mobility due t si...clatioil pain; . injury ,

',..-' E.2. _ _Potential discomfort

due to nitiry paii )

F. NEUROMUSCULAR •

CONTR9L

F.1. V Disminished visual

• Pt. will be made aware of surroundings prior to anesthesia induction. Q.IPt. will be transferred safely to OR table. 5D--iPt. will be able to understand instructions.

6Lpinimize danger of injury during

intraop period.

6---Introduce self. Keep pt. informed as to where he/she is and what is happening. (71,3 (9--- Inform pt. in which

fj5 direction to move and assist if ne9essary.

-fe"" Speak clearly and slowly. o-- Address pt. from

side. _e_l_gi..

perca tion due to being injury;

•eclail n;

F 2 Le" Potential for ear se

ornmunictaion due to langua , e

'irrie : sedation o Validate pt.'s understanding of verbal communications. o Verify removal of dentures.

F.3. Potential iniury due to dentures. Ai /4

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

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

OTHER NURSING INTERVENTIONS. Or continuation of above interventions.

10. G INTER ' LETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.

tt, /Vot, WM' 2.- c-/ (Zpo 3 DATE

OPCS EVALUATION:

(1–al-

K23p– teibrx-ed

5IS o c eaccAl-e 30i.),1,e 3)

REPARED BY N PREPARED Mt ,

C...°771,1L1 -6Pglirk"— avR

TIME: 50 MEDCOM - 20595 :9-10Cre3 TIME: j c9,5/3.--

DOD-034169

ACLU-RDI 1657 p.155

IP • TIME PATIENT ARRIVED IN SUITE

1. PATIENT TRANSPORTED TO OPERATING ROOM VIA BY ajt-ta3tXt,€26,‘U 3.1A" (49 0

MEDICAL RECORD

2. PATIENT ID

VERIFIED BY N PROM E1173

4. PATIENT IN

TIME

INTRAOPERATIVE DOCUMENT For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.

5. PREOPERATIVE EMOTIONAL STATUS

CALM ❑ ANXIOUS ❑ EXCITED ❑ CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify) COMMENTS. Allergies: II vitieNs_

(h)Lbl - / 6. NURSING PERSONNEL

RELIEF SCRUB

Lb) -7--

NUMBER

ASSIGNED SCRUB

ASSIGNED CIRCULATOR

- • er____JINONFJAke- RELIEF

_u_ii, A21 -

H-C-tllT.

1iJ

e-b)/-6 )- z- CIRCULATOR

7. POSITIQN AND ai(?,,2, -1 izi SUPINE

COMMENTS:

-Itis

POSITIONALAIDOzecify) 4cy,c,is v re d.... ---Lb Oil OVA Cot 1 iq 5■ YrStc.--V -.._ ,. s uAzto..,- c A.A.Prts •-,F/c.cc* ,-/ ■ LITHOTOMY ■ PRONE III l<RASKE LA E L: • LE SIDE UP • RIGHT SIDE UP

(k)i 12 )-• 1- 8. SKIN PREPARATION

HAIR REMOVAL YES lil NO

DONE BY: OR NURSING U

METHOD: • DEPILATORY .44 RAZOR ■ CLIP

COMMENTS: VIA) IA- -a) at...T2 ft,04o_it

PREP SOLUTION (Specify) SITE: BY WHOM: SITE: BY WHOM:

COMMENTS: 9. LOCATION OF EXTERNAL DEVICES

•

I. - -.....1....46.1......„- .: -

'44111

Cb) (b - 2--

..-

LEGEND - Safety Strap === Tourniquet

10. COUNTS

C = Correct I = Incorrect

Other* a First Closing Count

Final Closing Count SCRUB -10)tt, ) ---1 CIRCULAT

_ Sponge Yes • No Needle Sharp Yes • No Instrument IIII Yes No

c6 oar Other ■ Yes No 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first • Grade; Date; Hospital or Medical Facility;)

Lio) (io ) - y

L& L7-) J Z /

i/

12. ELECTROSURGERY DEVICE(S) (ESU) ■ YES VI NO

. ESU NO:

GROUND PAD: BRAND

LOT NO: ZI ESU NO:

GROUND PAD: BRAND

LOT NO: • BIPOLAR NO:

2-0 See49 ° MEDCOM - 20596 rtA • Vni-titio C 47A • o- • 0•••• n... .

DOD-034170

ACLU-RDI 1657 p.156

REV Rygirlfr=7977111FIRMINMIN°.°1°--- MEDCOM - 20597

allik AD.

USAPA V1.01

13. 1-11w I ritw, IIVIVLAIN I J H Yhb. pc l NU IF YES NAME: ID NUMBER; MANUFACTURER

. m00..:i:::0•,i.;::i.tg:,.;..:imi:*:::::::mhigiiiig:::::gfiii0:.ia;:HM.;.;;:::;IplEDICATIONS/ORDERS:ig::::,::ii:g:M:g::::S::::::;i;::::M::;.i.:;:i'ii:KROMM:i0.:::!:i::: IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO

;MEDICATIONS/SOLUTION ■ DOSAGE TIME METHOD PREPARED BY GIVEN BY

;WOUND IRRIGATION t YES • NO, TYPE(S): ..,, 0-17, A 1 4 a-C---

OTHERORDERS TIME k

CARRIED OUT BY

:PHYSICIAN'S SIGNATURE

.. ... - - ---....- -......- -------. - - 15. X-RAY IN OPERATING ROOM IF YES ITE

YES . NO •

a 16. LABORATORY SikIMEN(?-9 SPECIMEN (S)

YES tii- NO ❑

NAME

v--e---41---P-4-4-6t ,..sr) ,_..e....) NAME

FROZEN SECTION (FS)

YES • NO •

NAME NAME

CULTURE (C) YES Il- NO •

NAME , 0 Co9 NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

C-14,--A‘

-

. 17. TUBES, DRAINS/PACKING YES cs4 NO • TYPE/SIZE 1. 3/g

e2i,1A474_,

2. / 3.

SITE Q___.) 2. 3.

19. ADDITIONAL INFORMATIgl (b)L0)-Z- f.,,

(1:0)t 0 -1-- ‘SAlugeonsMiaria Anesthesia: —1— OFA'Anesthesia Type:

C,00°) -2-

(b)021 -1--- 02)(,b1 - 7., Bovie Pad site intact pre- Bovie Settings: Coag/Cut 3-0/3.0 Tourniquet Site intact pre-o Tourniquet Time: Up Down / A

0; )(42 ) --7-- 20. OPERATION(S) PERFORMED

D 1.....,6_ liv" 0 ■••-a. I.

21. PATIENT TRANSFIEEK 3 cot, 0 _ 2_ ' TIME 11 55

METHOD

22.22. RE NUR

C9717 f9-1V

,

DOD-034171

ACLU-RDI 1657 p.157

MEDICAL RECORD • INTRAOPERATIVE DOCUMENT • '-

For use of this form, see AR 40 -407, the r • ency is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERA ...,0M.

VIA i i tt er BY arlEibLI k 2. PATIENT WED AND ROCEDURE VERIFIED BY CPT "tr1/4)

4; PATIENT IN ROOM (10X0_

TIME:160 NUMBER q

3. DATE TIME PATIENT ARRIVED IN SUITE

Zq ep-i 'C'' fP)00 5. PREOPERATIVE EMOTIONAL STATUS

. 23 CALM • ANXIOUS • EXCITED. • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)

COMMENTS:

. .....:. . _ . ....._

6. NURSING PERSONNEL

ASSIGNED SCRUB

° FC- (-, ) 04.)4_____ .: ..

-- -RELIEF .S.CRUB

ASSIGNED CIRCULATOR

ff11111111 (..\0)1.6')-2_ RELIEF

—_C1BCULATOR .._-.. _ ..._ .

CPT L1/47)Lio ) --2,

7. POSITION AND POSITIONAL AIDS (Specify)

-• ;. . '• ..--,1:- -

SUPINE • LITHOTOMY • PRONE IIII KRASKE- • LATERAL: • LEFT SIDE UP • RIGHT SIDE UP

COMMENTS:

8. SKIN PREPARATION HAIR REMOVAL • YES g NO

DONE BY: •OR • NURSING UNIT METHOD: • DEPILATORY • RAZOR •:. .:. _ .

• CLIP

COMMENTS: . ___2.•-._ .

9. LOCATION OF EXTERNAL DEVICES f

PREP LUTION (Specify)ed0dAlt SITE:(1.... 1.0U-)er Lo_ci SITE: _ . . . ,.....

---..-----

.6C■141■AiNTS: fq, 1.1 N-i9

- seri) 8-01h BY WHOM: BY WHOM:

ftuAtts _ -...:.: • .., ...::.::, .

: .„.

- - . - • - ----

_.. . ..... .. .

I ..- P.' . I _ 746.4.V.7 ••;fifi. . ' --. - . - -

' t 11.01M-

- .. - -7-'--•:-.- !',.

, . . •

... • . „ • . . , . . ..

_. ,...._,.... LEGEND X Ground Pad -- Safety Strap = = = Tourniquet- , ,-,...,.----

10. COUNTS

-. . C = Correct I = Incorrect _

Other" First Closing Count _ -i..;,.;

Final Closing Cthint SCRUB CIRCULATOR

Sponge Yes IIJ No -_,•; Needle Sharp Yes No - ........_ Instrument Yes No . .--... ;...1Q•?1'.-A1.7.1'•:7 Other Yes • No „,....--------

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

12. ELECTROSURGERY DEVICE(S) (ESU) • YES kTA NO

U. ESU NO:

. .

GROUND PAD: BRAND

__ ..... ..____ LOT NO: ----- --- - .,....

" ,:0 . NO:

• _,. _: "lluUND PAD: BRAND

LOT NO: • BIPOLAR NO: MN - rt A P/1121111 Ma -7171 I nn-r ei--7 ---. ---- -- ----- ---- - ----- •

-1 (TEST). DEC.82. WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20598

DOD-034172

ACLU-RDI 1657 p.158

13. PROSTHESIS, IMPLANTS YEE' O IF YES NAME: ID NUMBER; CTURER

1 4. 10 ,K ) , ' MEDICATIONS/ORDERS " "4;, - , i ',,•-• >- ,

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES D NO tz MEDICATIONS/SOLUTION DOSAGE ' _ TIME METHOD PREPARED BY GIVEN BY

. .

I WOUND IRRIGATION 12 YES • NO; TYPE(S):

,...,"•': O ,crYo I■18 . . THER ORDERS TIME CARRIED OUT BY

Wont .. .........

PHYSICIAN'S SIGNATURE i Len.............—sm.6+,66.............,rAms.get« 6.'6 . 6. ...-1

'” „ E.

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

YES ■ NO el

16. - ̀f'±-LABORATORY SPECIMENS

SPECIMEN (S)

YES • NO Ki NAME -- ------ ----- ---- - NAME

FROZEN SECTION (FS)

YES ■ NO 10

NAME - -:.: NAME

CULTURE (C)

YES II NO VI NAME

- --

NAME

NAME NAME NAME


Huffs Verlix_

17. TUBES, DRAINS/PACKING YES • NO N TYPE/SIZE 1. 2. --- --

SITE 1. 2. 3.

19. ADDITIONAL INFORMATION -

, :.:.; 7

SiA- rg :NM ATLEzthi: WM -or ieral ,i3.17.:1T.;.:

(6)1.b)- .2__ _ . _ .. . 09,,,, ) „.,:-: - i _

. _.

20. OPERATION(S) PERFORMED

21. PATIENT TRANSFERRED TO

MU re_cove_red i- OR, TIME

1e43 - METHOD

/ . J tt-ei 22. R E

CP T7/11V CG) l_ lo) - -z._

FORM T 87

USAPA V1.00

MEDCOM - 20599

DOD-034173

ACLU-RDI 1657 p.159

INTRAOPERAT:" DOCUMENT MEDICAL RECORD , - '

For use of this form, see AR 40-407, the prop( . ncy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERA s%.,JM

VIA t,\ Yi-st-A7 BY / ei(1,\ (-0\ CA

2. PATIENT IDENTIFI VIEWED AND PROCEDURE

VERIFIED BY C..,VT 00)06) - -7_

3 . DATE TIME Pi. ..41- ARRIVED IN SUITE

t NA— T2- 4; PATIENT IN ROOM

TIME: : kti N BER FS"


RI CALM • ANXIOUS • EXCITED. • CRYING ❑ ANGRY • WITHDRAWN • OTHER (Specify)

COMMENTS:

- .-


ASSIGNED SCRUB

(b>1..)0) - 7_ --RELIEF

.SCRUB V

ASSIGNED CIRCULATOR

C...911-111111111111plr±)0) 001-1-

. - .— . ... RELIEF

__,-..CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) - -, = =-

a SUPINE • LITHOTOMY ❑ PRONE U KRASKE' .. LATERAL: • LEFT SIDE UP U RIGHT SIDE UP — pyp )00 °`-kykA ■-v-ti.i.AL-vtit"-°"^"V6)`;\\IL&) COMMENTS:

8. SKIN PREPARATION.

HAIR REMOVAL • YES El NO • v

DONE BY: ■ OR II NURSING UNIT

METHOD: • DEPILATORY • RAZOR. .... • CLIP

COMMENTS: ------ ...66MMENTS:

PREPe=3LUT I ON (Specify) SITE Le_ SITE: ... ,....

Air-)0

Vailto.-- I BY WHOM:

BY WHOM: C.,.(•b ' 7-

- . _ rion-t,v,, try C..,Lis, II I ..5 ‘Arickte

9. LOCATION OF EXTERNAL DEVICES ,..„... ____ -

0

• t. - !.1 • - Ai" .-- ■

t • ....... -wimarge.-444whowirms.-

• TilliVIIP-

ge ( W L ) ' Z LEGEND X Ground Pad - Safety Strap = = = Tourniquet.•-,4.

10. COUNTS


Other" First Closing Count ...1 ,-•,,

Final Closing Couht SCRUB . CI

Sponge g Yes NO

C....: (WO)) 7.- (.6) b Z

Needle Sharp ®Yes ...... Vo - •. . „ _,....

Instrument ■ Yes No /` - J.N.V...:7; " ,

Other I=1 Yes No V — ..;------------ 11. PATIENT IDENTIFICATION For typed or written entries give: Name - Last, first, middle; Grade- Date; Hospital or Medical Facility;)

C. 1.)(, 6 ) - y

12. 'ELECTROSURGERY DEVICE(S) (ESU)

M. ESU NO:

■ YES NO

1111 GROUND PAD: BRAND

• s.. - " - LOT NO:

.. .-•:...-:- ,`ID:,61--) NO:

, , ... •-,--:-GROUND PAD: BRAND

....,__. LOT NO:

MI

BIPOLAR NO:

REPLACES DA FORM 5179-1 (TESTI, DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20600

DOD-034174

ACLU-RDI 1657 p.160

13. PROSTHESIS, IMPLANTS • YE' a NO IF YES NAME: ID NUMBER CTURER

..., X143 , fi,-, ., 4MEDICATIONS/ORDERS:* , )

IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT.. BY ANESTHESIA) YES D NO WEDICATIONS/SOLUTION DOSAGE TIME • _ METHOD PREPARED BY GIVEN BY

_ . _, .........

WOUND IRRIGATION a YES • NO, TYPE(S):

0.9 °I0 00\-Cf2- ..

liOTHER ORDERS TIME

CARRIED OUT BY TZ\kk„

........-- - .... ._ __. .

_ . c

,PHYSICIAN'S SIGNATURE I

,....enws—r..sooe.sver.gelkw,—cat,kros N•Ass

15. X-RAY IN OPERATING ROOM IF YES, SITE NO YES ■

16. --: == `:LABORATORY SPEOIMENS SPECIMEN (5) NAME ..

. •,, , t

...',.•••••.^...- . . NAME -- --- -1 .- YES • NO M

FROZEN SECTION (FS)

NO r_!1 NAME

. NAME

YES •

CULTURE (C)

NO pg NAME - NAME

YES ■ NAME NAME NAME

NAME NAME - ,nr -- .._.

18. DRESSING/IMMOBILIZATION (Specify)

?

\ GA 17. TUBES, DRAINS/PACKING YES • NO Ar-

__ TYPE/SIZE 1. 2. _. SITE 1. 2. 3.

19. ADDITIONAL INFORMATION

6AL - C , 7- ' - X k Is A (v11-e-cc"\-"Ali tNk5 c../v,cs-et-y,\, .

,,.._ __ _.___. - kuqA<Ilkl,Cc - 'il\A.6\ki*.&

CI:, ) C6)--z.

- lh SlICk cv cAno-,N4:-.-\ -:. -. 0 d 5 AALAQ_oki

20. OPERATION(S) PERFORM . "E-sr t..e .

21. PATIENT TRANS,FERRED TO

VitUA ‘1&. 1CJW—k TIME SRI. -

-'1:Ack METHOD

ki'tki/A/ 22. REGISTER RE

„____ (-1=' L6 ) -- CA-17/+


DOD-034175

ACLU-RDI 1657 p.161

MEDICAL RECORD INTRAOPERA 7 DOCUMENT

• . For use of this form, see AR 40-407, the propor .ncy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPER.c .LAJM • ,

VIA BY 0.44.P.X1W-1%-g/Q-C-R., ...rgi 2.. PATIENT IDN OCEDURE

VERIFIED BY P,fr It A 3. DA TIME PATIENT ARRIVED IN SUITE

f)) O 0/7- 0 a 4; PATIENT IN ) 1,)z TIME: . i oi q NUMBER r^1 (g)


■ CALM

COMMENTS:

■ ANXIOUS III EXCITED. ■ CRYING ■ ANGRY ■ WITHDRAWN ❑ OTHER (Specify)

-

4,6k- 6. NURSING PERSONNEL

ASSIGNED SCRUB

f'Fc qt —RELIEF . .SCRUB

(..40)( 10 ) -7--

ASSIGNEDCIRCULATOR

OfTi. 6V/6- RELIEF --CIRCULATOR

- iNTh LWL.b) ---2-

7. POSITION AND POSITIONAL AIDS (Specify) ....-.,

NO SUPINE ■ LITHOTOMY ■ PRONE . KRASKE ,

COMMENTS:

; ',,-, '1' ; •

- LATERAL: .. LEFT SIDE UP

. ..

■ RIGHT SIDE UP

HAIR REMOVAL DONE BY: METHOD:

■ YES NO ,'' Ill OR ■ NURSING UNIT ■ DEPILATORY ■ RAZOR__

8. SKIN PREPARATION.

PREP S TION (Specify) A. SITE: BY W OM: SITE:.. . --„, BY WHOM:

■ CLIP ....—.:_..— • - - - -- • • Wl,)-2. _____ • .”----.-____- •

edMTHEniTS: if..4) m / ' COMMENTS: ...---- ._

9. LOCATION OF EXTERNAL DEVICES 7------

. .. •

,. Ai- - , ., . I. ■-- !Aripp-

. ,.

LEGEND p = = = Toumiquet.....- ,=.-

10. COUNTS


Other" First Closing Count _ : 3/4

Final Closing Count .. -SCRUB 1-)16) - )_.- CIRCULATOR W Lb) ' Z.

Sponge Yes 0 n

0

1) .- rAll

PA A - 1 .."

Needle Sharp Yes Instrument Yes , :`;.L:1:" Other Yes No 11. PATIENT IDENTIFICATION (For typed or written en fries give: 12. Name - Last, first, middle; Grad • Date; Hospital or Medical Facility;)

V _ III

•ELECTROSURGERY DEVICE(S) (ESU) 1111 YES N O

ESU NO: Ci..)4) --

- GROUND PAD: BRAND

_ . LOT NO: , .

CL)t -2--) - z '1_3.5,T.1 NO:

- . --- ,-.tliOUND PAD: BRAND ...,;__. LOT NO:

illifirillar

IIII BIPOLAR NO:

- I,

CES DA FORM 5179-1 (TEST), DEC.82,.WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20602

DOD-034176

ACLU-RDI 1657 p.162

13. PROSTHESIS, IMPLANTS ■ YES 1 NO IF YES NAME: ID NUMBER, :TURER

&-‘,7 7: 4,0,1 - ' ,:E-i :W',,,,i ar

MEDICATIONS/ORDERSO.Aik ,, „ - 7::'-* IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ■ NO

MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

r.

WOUND IRRIGATION p YES ❑ NO, TYPE(5):

1 o. 97 ) NACL- .: & OTHER ORDERS TIME CARRIED OUT BY I

.. -

P'HYSICIAN'S SIGNATURE

„ _ 15. X-RAY IN OPERATING ROOM -

IF YES, SITE

YES ■ NO 4, 16. --: ' --fLABORATORY SPECIMENS

SPECIMEN (S) 1

YES III NO 0

...„ r ,.. NAME ___ ____ ._____ .. _ ' NAME

FROZEN SECTION (FS)

YES ❑ NO ■ NAME NAME

CULTURE (C)

YES 111 NO ❑ NAME

___ ___. NAME

NAME NAME

' : ••.' NAME

NAME NAME (6)L6Vi..- .... .......

18. D .ESSING/IMMOBILIZATION (Specify) ,_

.-- 17. TUBES, DRAINS/PACKING YES I NO

TYPE/SIZE 1.j- , - .\014.4.2. 3.

SITE 1.1. C2i) . 2 3.


.. ,

20. OPERATION(S) PERFORMED,

I _..

... ....... 1110 , 21. PATIENT TRANSFER FUR

/ TIME ,,„,_4„:_:.__

I

METHOD

22. REGI

- 12f/.0 - ,----- REVERSE OF , 0 /

t6

MEDCOM - 20603 USAPA V1.00

DOD-034177

ACLU-RDI 1657 p.163

MEDICAL RECORD INTRAOPERAT•"- DOCUMENT - For use of this form, see AR 40-407, the prd ency is the office of The Surgeon General. .. .

1. PATIENT TRANSPORTED TO ()PEE' iOM

VIA ( Ili tr B., I ItSille-SICI

2. PATIENT IDE ITIF1 :ORD RE IEWED AND PROCEDURE

VERIFIED BY CPT t't.A./ (6 (- 6 ) - -7--- 3. DATE TIME PATIENT ARRIVED IN SUITE

6 ocl- O3 15 31 4. PATIENT I ROO

TIME. 1531 NUMBER 5. PREOPERATIVE EMOTIONAL STATUS

ANXIOUS ❑ WITHDRAWN IN CALM • • EXCITED. N CRYING • ANGRY • OTHER (Specify)

COMMENTS:


ASSIGNED SCRUB

(6"6.) -2- . Sr e- 1111111 - .. 7:77— --RELIEF ..,SCRUB

ASSIGNED CIRCULATOR

J..-_ 02)1.0-1- RELIEF

. ...- . __CIRCULATOR ;Ni.


LITHOTOMY

11C4 a Tin

.....-. _ ; . - .:''. i . •

LATERAL: 0 SUPINE N ■ PRONE . _ IIII KRASKE'', • LEFT SIDE UP • RIGHT SIDE UP

COMMENTS: I, ilri)pW 04 Infil ntantd.:-. --.. 8. SKIN PREPARATION

HAIR REMOVAL ❑ YES Egj NO ' ' UNIT

:. ,

PREP SOLUTION (Specify) g)e,tactinQ, c.-Y- ut) 5DIY) SITE: Li- • LDutr L9 BY WHOM: arr SITE:, BY WHOM: ,

---,-- -_„.,-- r , _, EbMIVItNTS: 0 phut ry 0 t J LIA u s 1 f

DONE BY: ■ OR ■ NURSING METHOD: • DEPILATORY • RAZPR. ..

• CLIP

COMMENTS:

_ .__.

________:__ ._ 9. LOCATION OF EXTERNAL

Pad

DEVICES

. 1

-- Safety

- ..;.;.--

S ffet-A.T. iii-

-

- - r .1

LEGEND X Ground

-

Strap = = = Toumiquet-----1;2:

iriscsop-,-.-_.

.

10. COUNTS

C = Correct I = Incorrect Tr. - - '7 b (10)1.b)- -t.

Other** First Closing Count _.N..:

Final Closing CciUnt SCRUB I;CU 1 OR

Sponge B Needle Sharp 1111

Yes •

IA '2A •

o

El o F

EllIAMIIIIITAIIMMIll VAIIIIIIITAIMINFAIIIIII

.;:::/.

. ..._.

. C

. _ _

: to l'c"\- Yes Mil Yes

- -- -- . :'-j-iclu5-7,-.• -: .

11011111...-

. _ Instrument III

Other • __-

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

......... .., 111111 Cb)(4') -4

..-:__:- . • '

11 A cf.\ r1 II A G •••• - 7, ru we .. r+-s- r,-• - — -

12. ELECTROSURGERY DEVICE(S) (ESU) • YES 0 NO

• N. ESU NO:

GROUND PAD:

..117Apt) NO:

BRAND V, 0,119 I ab LOT NO:

,e .__, _-- - - -:'GROUND PAD:

• •BIPOLAR NO:

BRAND

LOT NO:

-

ORM 5179-1 (TEST), DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20604

DOD-034178

ACLU-RDI 1657 p.164

13. PROSTHESIS, IMPLANTS YES' NO IF YES NAME: ID NUMBER; I

"' - --- ---

w `;14. 5- .., JMEDICATIONS/ORDERSM

IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA)

:TUBER

=r ' NO IZ] YES •

MEDICATIONS/SOLUTION DOSAGE:_.. TIME - METHOD PREPARED BY GIVEN BY

MOUND IRRIGATION

..

ta YES • NO TYPE(S): - _ ,

OTHER ORDERS TIME CARRIED OUT BY ' 1\101-LIZ

- . . . :

HYSICIAN'S SIGNATURE

q 14,f vs.t.o.V.R.,

15. X-RAY IN OPERATING ROOM IF YES, SITE . ..:1):: _ - N-..

YES • NO iN 16. - ' ..'.:' LABORATORY SPECIMENS SPECIMEN (S) NAME _ - ---- ------ --------- - , .

- NAME

YES ■ NO r i FROZEN SECTION (FS) NAME ,

- _ - NAME

YES ■ NO a CULTURE (C) NAME

— - NAME

YES • NO MI NAME NAME

. ..,.

NAME

NAME NAME - ..-1 . . _


1DbF)A1

F tit 4S

17. TUBES, DRAINS/PACKING YES NO 01 - TYPE/SIZE 1.

'•1 P bccan 2. 3 '

SITE 1. a . Wioer 49 2. 3.


S LIAly Dn e, AMIN _ • : . Alli-S Mnsfc - .

- -


21. PATIENT TRANSFERRED

COV- 6-1,4 PA-CLI TO TIME

I ( Z7 METHOD

U Ito- i 22. REGISTERED NURSE SIG URE

CPT I "-I\J rtrurc, 0 G., r /..... •'• —.

USAPA VI.00 MEDCOM - 20605

DOD-034179

ACLU-RDI 1657 p.165

MEDICAL RECORD - INTRAOPERATIvE DOCUMENT

' For t -- -tf this form, see AR 40-407, the propi incy is the office a` s Surgeon General.

1. PATIENT TRANSPORTED TO OPERA ,L,,,N1 . ... (6)63 )...-2_

VIA L-;-4.41....- BY AikftW

2. PATIENT IDENTIFL CORD R IEWEL, AND PROCEDURE VERIFIED BY pitii-j iIcab) --- -2-

3. DATE TIME PATIENT I SUITE

10 0 oit-- 0- 3 4.. PATIENT IN ROOM

TIME : . ; NUMBER 2 - 5. PREOPERATIVE EMOTIONAL STATUS

ANXIOUS ❑ EXCITED. III CALM ■ ■ CRYING ■ ANGRY III WITHDRAWN ■ OTHER (Specify)

COMMENTS: ...


ASSIGNED SCRUB

ec. ims OA (-13 1 -7. • .:7.-:Tr":7' --- • --RELIEF

.SCRUB

ASSIGNED CIRCULATOR

(6)1-0 - 2.. • A//44 RELIEF

_CIRCULATOR 11\19i:

...—.. ...—


LITHOTOMY

...,,_ • •

LATERAL:

':N ,-- ■ SUPINE IN 111 PRONE . ■ KRASKE, ', ■ LEFT SIDE UP 1111 RIGHT SIDE UP

COMMENTS: Y

8. SKIN PREPARATION. HAIR REMOVAL ■ YES ■ NO '

UNIT

- i• ::.

___ .

-PREP SOLUTION (Specify) f 4C,444,retx...4r Grin& GL-fa SITE: kat.H%-Lut./ BY WHOM; 4,t 4.4 Wag SITE: ... : _ ....—.. BY WHOM:

(../c2)Lt, ) ---2- COMMENTS: Af 0 a 0 0 4-,xf C-- cc tt, t 4 i z fr ...._

DONE BY: ■ OR ■ NURSING METHOD: DEPILATORY 111 ■ RAZP11._::....:.

■ CLIP • • :.

COMMENTS:

9. LOCATION OF EXTERNAL

•

Pad

DEVICES

• I. —/-i

-- Safety

•--- !%'::=E;

-

I

- i.

LEGEND X Ground

:I* I . --

Strap =

' TlerAIPI"—

= = Tourniquet... , ::7 -

10. COUNTS

C = Correct I = Incorrect .

Other•• First Closing Count ._..N..;

Final Closing Count .SCRUB CULATOR

Sponge yes Needle Sharp n No :-: ''-•- (Mila) -2' CIAl 61- 1 -

Yes

Yes

Yes'''n.'

❑

5"No

1

Vo .----"'"

_. __..--

:.

-

.-..-..--,

:. - tikqv _._

Instrument

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

.._...:._

4t1111 (6)Lb )- tt .

_.... , •-

-

n A LABRA C w -7 el 4 A INN. •■• ■• --- - - -- -

12. ELECTROSURGERY DEVICE(S) (ESU)

BRAND

YES III NO

02)1...k) ) - ti 111. ESU NO:

• GROUND PAD:

... . ,;`[TE-60 NO:

WA-. LOT NO 20 F19.4 2006 —:. y

:_„.i __ "-- -'GROUND PAD:

.- . ■ BIPOLAR NO:

BRAND

LOT NO:

.

-1 ITESTI, DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20606

DOD-034180

ACLU-RDI 1657 p.166

13. PROSTHESIS, IMPLAN' ■ YES' ,'NO IF YES NAME: I 'UMBER; :TUBER

t14. MEDICATIONS/ORDERS '1..&' -

IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY. ANESTHESIA) YES ❑ N tt:

MEDICATIONS/SOLUTION DOSAGE TIME - METHOD PREPARED BY GIVEN BY

'

a.

_....-- t /HOUND IRRIGATION .YES III NO TyF'E(S):.A/ .. 3:

,-- -

° THER ORDERS TIME CARRIED OUT BY

'PHYSICIAN'S SIGNATURE

t 15. X-RAY IN OPERATIN IG:FriOpM

YES ■ NO .

IF YES, SITE ' ..:1"). ,

16. - ' ."' . LABORATORY SPECIMENS

SPECIMEN (S)

YES ❑ NO ■ NAME .. NAME

•

FROZEN SECTION (FS)

YES ■ NO ■ NAME

..:._ NAME

CULTURE (C)

YES ■ NO ■ NAME

_ ........._ —..._ NAME

NAME NAME . , .. ..

NAME

NAME NAME _ _ .....„..1

- .


17. TUBES, DRAINS/PACKING YES ❑ NO •

TYPE/SIZE 1. 2. 3.

SITE 1. 2. 3. - -- ---

19. ADDITIONAL INFORMATION - .

c-5-4"-i-r-01^- .4 D r- _ • _ ....--

. . -

- --

-. .

20. OPERATION(S) PERFORMED - -

■,_

21. PATIEr TRANSFERRED TO

C (..k.

TIME 3-i-it_ tic S-.11

METHOD

(5-A-- 1 i 4-1w- 22.

/143U ki li ta 0 of-03 REVERSE OF DA FORM 5179-1, OCT 87

)-


DOD-034181

ACLU-RDI 1657 p.167

MEDICAL RECORD INTRAOPERATIVP IC ''CUMENT ." For use of this form, see AR 40-407, the propc icy is the office of The Surgeon General.

1. PAT ENT TRANSPORTED TO OPERA ...UM . •.. • VIA BY c4 V■t9S1;tki/A--

2. PATIENT IDENTIFI. - D AND PROCEDURE VERIFIED BY la ootb 1- 7._.

3. DATE TIME PATIENT ARRIVED IN SUITE

IS-DCA- ..../..--

4. PATIENT IN ROOM

TIME: lat(O NUMBER 5. PREOPERATIVE EMOTIONAL STATUS

4 CALM

COMMENTS:

1..ViA OD

ANXIOUS

to

Q ANGRY

''''

• • EXCITED. • CRYING • WITHDRAWN • OTHER (Specify)

T vvx __,... ____ 6. NURSING PERSONNEL

ASSIGNED SCRUB 6)1 10- 1-

f.. -It -- --RELIEF

.SCRUB . -.-,....

ASSIGNED CIRCULATOR

l.. -

IP)16) -2- _._. ....... .

RELIEF —X IBCULATOR

• . 7. POSITION AND POSITIONAL

EN SUPINE

COMMENTS: toorm=1

AIDS (Specify)

LITHOTOMY

&‘,iteirvv:e._

-- ,v- • ::C1; .

• -- LATERAL:

aV..cyyskiukt,

II U PRONE N KRASKE-• • LEFT SIDE UP • RIGHT SIDE UP ' •

Ai \ so:yozLvvtd 8. SKIN PREPARATION

HAIR REMOVAL ■ YES

DEPILATORY

NO NO ' ' .4- UNIT

_ .

PREP SOLUTION (Specify) LIM SITE: Lett ut,3 B WHOM: foi-amms SITE:. • ... ....._.... BY WHOM: t ,-_ 0.)(.6 1 .-2.

COMMENTS: I4.6 00‘,),A1 ti Ct,iLIMSZ._ fe061

DONE BY: • OR U NURSING METHOD: • ■ RAZPFI.

■ CLIP

COMMENTS:


• f. -P.' f •

•

olpt- LEGEND X G nd Pad

DEVICES

. 4/17#4020.41PAISC iiiri.-4 -% _ —..■....__ --...M11111..,401amimuseme.-

/ .

L.100).7,1 . . . L.

= = = Tournique•,•

I

CO thr-l-Safet

111:APPT-

e dreliffi

. . • ,

.-

, I 1

Pte-v3 'r tv► 'tial t

LT 10. COUNTS c6)6...,_

C = Correct I = Incorrect ..

Other•• First Closing Count ....1, :,_:

Final Closing

Ciiiint -SCRUB (-6)00)- 7- CIRCULATOR (-WU' "Z Sponge

Needle Sharp Yes

Yes

Yes

Yes

E

Vo

No

No

No

_

. ..-...... ...

..

;.*)1,.1.(1I5 Instrument .

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

_. -

f 111111h(b)(b) -41 . _-,.

_•

12. ELECTROSURGERY DEVICE(S) (ESU) N YES NO

N. ESU NO:

GROUND PAD:

:'1:ZOU NO:

BRAND

LOT NO:

•- - -. "GROUND PAD: . .. r .,_=.

• BIPOLAR NO:

BRAND

LOT NO: yy

DA FORM R174.1 nr-r Q-7 -1 , , IS OBSOLETE. USAPA V1.00

MEDCOM - 20608

DOD-034182

ACLU-RDI 1657 p.168

13. PROSTHESIS, IMPLANTS ■ YES 'NO IF YES NAME: ID NUMBER; TURER

. .

i1 _ ,A`.. '"`"_-,,4 'MEDICATIONS/ORDERS :. '' --,,‹

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

11MEDICATIONS/SOLUTION DOSAGE:... . TIME - METHOD PREPARED BY GIVEN BY

. ..

P . ..._

(WOUND IRRIGATION A YES 111 NO, TYPE(S):.,.

Ct 70 , .

, •:-,

THER ORDERS ... , TIME CARRIED OUT BY

PHYSICIAN'S SIGNATURE

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

YES ■ NO ■ 16. - - :=-ILABORATORY 'SPECIMENS

SPECIMEN (S)

YES ■ NO ■ ....,,

)ME -- =- `=='`- ---,---- — -

f hkod ■ . s< thhi\c6.)-ti ,(*&: - . .Cc ----, NAME

FROZEN SECTION (FS)

YES ■ NO ■ AME

-

NAME

CULTURE (C)

YES CC NO ■ NAME NAME

NAME NAME NAME

NAME NAME --- 18. DRESSING/IMMOBILIZATION (Specify)

F',u,k(s. tork,14.

17. TUBES, DRAINS/PACKING YES 1•111 NO ■ - _.7),.... ...._ TYPE/SIZE

/cAtti& 2. :

SITE 1

OV

2. 3.

19. ADDITIONAL INFORMATION 6)lb) --- --t_ • 0 oft V. - ;77; :2R1:-._!L; ,

______ l':1 0 , e. ' _ _

L17 )1_ 6 )---1--

_ .


1c4 _. .

21. PATIENT TRANSFERRED TO A TIME Sas...

tAlltn - --

METHOD

Wkef ---c- 02- 22. REGISTERED NURSE SIGNAT

REVERSE OF DA FORM 5179-1, , MEDCOM - 20609 USAPA V1.00

DOD-034183

ACLU-RDI 1657 p.169

I . . . INTRAOPERAT"F r)OCUMENT MEDICAL RECORD For use of this form, see AR 40-407, the pro . Incy i; the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERk. ROOM 60%1

VIA t_ i'L.g..r- BY A *. A (6X6 - PATIENT IDENTIF. £CORE) REVI WED AND PROCEDURE

In ikl BY NW LW Lb ) - -2-

UITE NT IN ROOM

TIME ; 12-00 NUMBER I el 3. DATE TIME PATIENT

I R 0 t-t- 6? I 2-46 5. PREOPERATIVE EMOTIONAL STATUS

)ALM

COMMENTS:

ANXIOUS ■ ■ EXCITED. ■ CRYING ■ ANGRY ■ WITHDRAWN ■ OTHER (Specify)


ASSIGNED SCRUB

• • - 5 Y Uv) Lb ).- T--• : '.7:* - --RELIEF .. .SCRUB

ASSIGNED CIRCULATOR

IAN (_10)uo )- 7- RELIEF _CIRCULATOR (6)10 2 . ,......._..,.., . ..„...04.

7. POSITION AND POSITIONAL

COMMENTS:

6 j2( OPINE

AIDS (Specify)

LITHOTOMY LATERAL: UP 0 RIGHT SIDE UP ■ ■ PRONE ■ KRASKE ■ LEFT SIDE ..... ,.;

8. SKIN PREPARATION HAIR REMOVAL

DONE BY: METHOD:

COMMENTS:

■ YES IN

DEPILATORY

N

- _

- "

_

UNIT ''-PREPoUTION (Specify) /3/....,/a-

SIT' BY SIT . BY

, _

COMMENTS:,

W 0 WHO

■ OR ■ NURSING II.

CLIP III RAZOR

-- -

________—.

■ (ie)00 )"7-

fr-4-64 tl /*of 9. LOCATION OF

,.

EXTERNAL

•

•

Ground Pad

DEVICES

.

.„.....„......._

• -p.I t •

LEGEND X

.1E --....M.11-**411116.111■•—

IlliriPP-

. - • '.',7'.

= = Tourniquet. ---7.,..:::::1

--..

-- Safety Strap =

10. COUNTS

C: Correct I = Incorrect (144+114First Oth ....„

Closing Count _ .1, ..:

Final Closing mint SCRUB ' L6)(...6 ) - 1-- CIRCULATOR 02 ) 1-17 ) -1-

Sponge

Needle Sharp Yes

Yes

■ III

No

Vo

-

— -__ "_ ....-....... CrllIllV Instrument Yes n No / . ... _ . _ : !..,.x4ia..5T, • - ......._ Other Yes II o 11. PATIENT IDENTIFICATIO (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

._._ . - _, .

L6) tw -/ .,...... _

.

1,L) L-2- ) "Z

MA CMF ICA C 4 "'NM 4 .-■ os-m- •-■ —. ---_ _ ___ _

12. ELECTROSURGERY

SU NO:

GROUND PAD:

„... `07,,E$1.1 NO:

DEVICE(S) (ESU)

BRAND

YES IIII NO

C6)L6)--

LOT N Err 20VS-"Ori

)-- . --,GROUND PAD:

■ BIPOLAR NO:

BRAND

LOT NO:

179.1 (TESTI, DEC.82. WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20610

DOD-034184

ACLU-RDI 1657 p.170

13. PROSTHESIS, IMPLANTS j YE. 'No IF YES NAME: ID NUMBEF 2TURER

_ s

,7 ,,.. -''' 40 , -_ ;.‘ MEDICATIONS/ORDERS ' 1*-- ''' • w s s. - a 1 ;;;,:?,.. ,, IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY ANESTHESIA) al NO 2

=MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY - -

. .

WOUND IRRIGATION YES ■ NO TYPE(S): A jc, , r z I,

,„..._

*OTHER ORDERS . TIME CARRIED OUT BY

. . . . -

. - -

PHYSICIAN'S SIGNATURE

v -J t.93.41W1hW

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

( YES NO ■ ...., V

16. - ':_-`:..'0080RATORY SPECIMENS

SPECIMEN IS)

YES ■ NO

, --, NAME - - ------ ----:- --- • ..

' -

NAME

FROZEN SECTION (FS

YES ■ NO

NAME _ _

:

• . ,,, NAME'

CULTURE IC)

YES ■ NO

NAME ---

NAME

NAME NAME NAME

NAME NAME 0,0) (A, )...--L: r, ,, . ___


4

\I/ ' el/e-i- til k 4.49 s

G YES 17. TUBES, DRAINS/PACKING . ___ NO 7 ,fr .. 1. o ill WJE

SITE

t.(2, .

. ..

3.

19. ADDITIONAL MAT

LWL6 ) -/ AO - 1-

)1)-1 D r- 1111111111111r 7 A

I 19)C 6 )-2 .

20. OPERATION(S) PERFORMED CL '

-1,- "7` 1 t' e-e-7 • j Pe, ty io ( , ( 4--e--4 DO I

wicr-Y-A-e ci_ et-p-A7 (c-c-cii--c-o-2___


I

TI

i 1 Y METH 49D

LI./i 22. REGISTEImorarialki at

it) Alf t6)U9F2::llIllIlIllIlkcp REVERSE OF DA FORM 5179-1, OCT 87 cs t


DOD-034185 ACLU-RDI 1657 p.171

MEDICAL RECORD For use

INTRAOPERATI\FE DOC, „ENT of this form, see AR 40-407, the prof envy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPER)• itk.,ursil

VIA 1-x: \42-1.• BY i IA,./i-J (1)1,6) _2. 1,6)•z

PATIENT IDENTIF .: WED AND PROCEDURE

VERIFIED BY CP 1 Lwa)- 7._

3. DATE TIME PATIENT A RI ITE

'4 a LA-- 03 010

4.• PATIENT IN ROOM

TIME.. // wi NUMBER / - 3 /-


VCALM ANXIOUS

COMMENTS:a ii, A.

EXCITED.

.

• ■ CRYING • ANGRY • WITHDRAWN • OTHER (Specify)

,.,


ASSIGNED SCRUB

(4 (.61 - . -,?,1 -"` -RELIEF

. .SCRUB

ASSIGNED CIRCULATOR

RELIEF __CIRCULATOR _ ,_. ......_ . .

,7. POSITION AND PPSIJIONAL, Alps [-trot -5 rieek or-T- )'D

SUPINE ❑ LITHOTO 6 -Aawe I c.4 11.112--r- COMMENTS: A

( -Or/ze e..--/

(Specify) iPi- on 134641-ed (5.9• 5 idLP S' 6_90'4 hi C-4-P

tl*t:id, 4757

2.eAlr'edff , LATERAL:

!,,,- - ,,,,,A irks

.. ''. ''' C7249-,11, i • '. ••• / C=1,- en 50 e".6Lej d 5-‘= 17 IN PRONE

el))112e / - / ' —y /h/,--07,1--1-0-..---t,

• KRASKE.' • LEFT SIDE UP ■ RIGHT SIDE UP I V

, 7:7 01 ,

8. SKIN PREPARATION .

HAIR REMOVAL ■ YEs

DEPILATORY

Ipa‘10 `

"...

, PREP SOLUTION (Specify) g iti,L,,,A rc evsk, A-5 dLIA.,Nei-A... SITE:LC-6 BY WHOM:C,o7M1111111101 SITE: BY WHOM:

(6)26 ) ' 7.- • __

h p A Gi(' C)/Cf 40nj 4C ...COMMENTS:

DONE BY: U OR ■ NURSING UNIT METHOD: ■ ■ RAZOR .

II

COMMENTS:

CLIP

-----


..

Pad

DEVICES

------P.k.--.Wi■ • 4t .4■41.1..._.■ _..........zzrolimmiliap„_...A„,_.....

9111rAPP-

- .

i

- e

-1.1 I •

LEGEND eund

i!'-.1§/her■-46'.-4.-rF. '''''

. 2.

Strap = = = umiquet...-a;.Z.:;: .-

. ....., ..,. . . . .

, .

10. COUNTS


Other" First Closing Count •..N.

Final Closing Cdilint SCRUB (b)Lb i - L CIRCULATOR Jo)(4) . --L-

Sponge U Yes EA

-ffi

- Z--

Grade•

co(.6.)-9

For

-21

Lna

...r-- 0

0 0

00

0

i 7'

■7 7

7

U. . .-

._

n \ I

Date;

„idill

'ped or Hospital

surAm

act-03

:

wr tten entries or Medical

0-1.11211rAillirAW11111..'—

IMIVAMERWRIE

give: Facility;)

.„.„

-

- .

:6100-,..7r‘ ,

12. 'ELECTROSURGERY DEVICE(S) (ESU) L1416 -

ESU NO:

.-

wilt Needle Sharp PAILIMIA

Yes

Yes

Instrument ❑ Other •

■ YES PI NO 11. PATIENT IDENTIFICATION Name - Last, first, middle;

2-)

—rid (.4 , Ill

CO(

111111/111111

GROUND: BRAND

LOT N :t esu NO:

a A,--- Erze 2-Q3--0 Li

- V • •- ,•::GROUND PAD:

■ BIPOLAR NO:

BRAND

LOT NO:

REPLACES DA FORM 5179-1 (TEST). DEC.82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 20612

DOD-034186

ACLU-RDI 1657 p.172

❑ YES I NO IF YES NAME: ID NUMBER;

,fi I ()rev 19;6: f

:TUBER 13. PROSTHESIS, IMPLANTS

. • __ IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT..BY. ANESTHESIA) YES 11 NO

MEDICATIONS/SOLUTION DOSAGE :. . TIME -: METHOD PREPARED BY GIVEN BY

•,... —.....„ ...,.,.„ ...., _ .....,...-- —..

...

I

o ith CARRIED OUT BY

(PHYSICIAN'S SIGNATURE

WOUND IRRIGATION [CAS ❑ NO; TYPE(S):.

10THER ORDERS TIME

15. X-RAY IN OPERATING ROOM

YES ❑ NO

IF YES, SITE

f."4 : CABORATORY SPECIMENS

SPECIMEN (SI

YES ❑ NO sr FROZEN SECTION (F

YES ❑ NO Nyl CULTURE (C)

YES ❑ NO

NAME

NAME


NAME NAME

NAME NAME

NAME NAME

NAME

NAME

NAME

17. TUBES, DRAINS/PACKING YES ❑ NO -

TYPE/SIZE

1. 2.

SITE

1. 2. 3.

1.1)C-71_11.— (*to" tio

Sovit. pad pre -Op- 051-;--072


'

vlQ. 11 DJ-

recirit44_


Tt't ,cct.

TIME • 21. PATIENT TRANSFERRED TO METHOD „

2 -

-1, OCT 87 MEDCOM - 20613

USAPA V1.00

DOD-034187

ACLU-RDI 1657 p.173

1 v

Wr=. AbiratP'4.1.4.9ttO sit" iyLiWie::' 2'':: . INTRAOPERA. clocumum 1 w

For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.

' OTA, .E : $, PTECAVID."9PERATING ROOM . , ' ,: ' -.1 • : 7

BY A-vulcith e 0, 2. PATIENT IDENTIFIED, RECORD REVIEW ROCEDURE

VERIFIED BY QCirr (6)U, ) -1- ..., 7'

•:"3:'b TE ,, ' , TIME PATIENT,RRIVED IN SUITE

k-, NJ 'ki-21

4. PATIENT IN ROOM

TIME 13 kik- 5 NUMBER


R CALM ■ ANXIOUS IN EXCITED ■ CRYING ■ ANGRY ❑ WITHDRAWN • OTHER (Specify) s

COMMENTS: % CC-yVit,i v kik -, U(ati


ASSIGNED SCRUB

/ RELIEF SCRUB

ASSIGNED CIRCULATOR

Cr Oa) tb ) - RELIEF CIRCULATOR


FA SUPINE I LITHOTOMY I PRONE II KRASKE _ LATERAL: , U LEFT SIDE UP ■ RIGHT SIDE UP

C. .q'( Nr-z_ Lk" L' o..1.5■cervy.2,,,,A- /,....o,AAA-1 -(xA V.)..ai

COMMENTS:

8. SKIN PREPARATION

HAIR REMOVAL IN YES 4 NO

DONE BY: I OR ❑ NURSING UNIT

METHOD: I DEPILATORY U RAZOR

❑ CLIP

COMMENTS:

PREP SOLUTION (Specify)

SITE: BY WHOM:

SITE: • BY WHOM:

COMMENTS:

9. LOCATION OF EXTERNAL DEVICES

• I • ■ li: ••

..- i t • - ••••• 1 • i

• 1.1111.0DP

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

10. COUNTS


Other" First Closing Count

Final Closing Count SCRUB CIRCULATOR

Sponge ❑ Yes fri No

Needle Sharp ■ Yes I No

Instrument • Yes N No •

Other U Yes g1 No

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

L)t-6 )t

(_12)C7-') - Z

j 0 1..; im 7-,

nAci-Nr-rias

12.

•

•

ELECTROSURGERY DEVICE(S) (ESU) ❑ YES giN0

ESU NO:

GROUND PAD: BRAND

LOT NO:

ESU NO:

GROUND PAD: BRAND

LOT NO:

• BIPOLAR NO:

')nca A

DA FORM 5179-1, OCT 87 REPLACES UM runny) 31 ru- .4. wirrlICH IS OBSOLETE. USAPA V1.01

DOD-034188

ACLU-RDI 1657 p.174

REVER MEDCOM - 20615

::*60/4p.:USAPAVI.01

•?'

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

14. i a ,., .:,:-,,,-- MEDICATIONS/ORDERS :”,k , - ;,., ,r1•':;: , 1. .i.,. 3 , ,‘,4-,1'.= .,' P WeiMMIN

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

MEDICATIONS. SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

WOUND IRRIGATION • YES co NO, TYPE(S):

OTHER ORDERS TIME CARRIED OUT BY V.IL,

r PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM IF YES, SITE YES E NO g--

16. LABORATORY SPECIMENS

SPECIMEN ISI

YES ❑ NO .2

NAME NAME

FROZEN SECTION IFS)

YES ■ NO 13,

NAME NAME

CULTURE IC)

YES ❑ NO a NAME NAME

NAME NAME NAME


17. TUBES, DRAINS/PACKING YES ❑ NO TYPE/SIZE . 1. 2. 3.

SITE 1. 2. 3.


je_CV\

AlkViAlk9- (\ck .. 6,Kb ) --/-

---`-bA s\--fq 0 ,-\. c)LokAA , 9- 4 S -LcA-coA,

20. OPERATIONIS) PERFORMED

(.9!\/■ - ■V 0-k. - L E e-.).-" A--;),e


yik-cAA C.- i-: C_KA --,) TIME •se;,t:

bil- sNi%t •!, ' METHOQ ;',

l.k•\--\-kA/ - ),, ,V g. ' :'• :.t? 22 g ,,,- ,.:, 4,

r I irk) (---La ) 1 b ) " ?--.., - - .;+ .7., ,,..A-, .t ',

DOD-034189

ACLU-RDI 1657 p.175

Ward/Section: Ti REQUESTIMISICAN: L)Lb) --

TIME / 3 u

DATE r

LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

SS SSN: N1_6)- 4)

LAST, FIRST,M1. lap Cid) Lb

Hct

MC'

Pit

Lym

Lymi

Atyp

RBC

MorE

Other Directigen

TEST RESULT REF: RANGE UNIT

Negative ABO/Rh

CROSSMATCH TYPE

l t,aWAVZ:Vkat 0 atk lls m SS ate oscoop

........ 4W4P-AMA

AWS

TEST

*WNW% mfAvw.4.%. rm

RESULT REF. RANGE

1 isc.Sero1og

TEST I RESULT REF RANGE

fti$W, .V.:AkVqa

WBC

4.8-10.8 x111

RBC

4.7-6.1 x16

Color App

N/A

N/A

Negative

Negative

RESULT REP: RANGE TEST

Hgb 14-18 g/d1(M) 12-1601(F)

Glu Negative

Bili

Negative

Ket

Negative

42-52%(M) 37-47 0hin

3G

DJ_ t6)11,,

75-09-03 3Id

MDC ROC

7.5 5.50

iO3/ti Y.10'6SuL

4.5 4.00

10.5 6.00

'rot

Hgb 15.5 q/dL 11.0 10.0 Jrob 'MEI 49.2 35.0 60.0

CV al 1 fL 00.0 99.5 it MCH 27.9 P9 27.0 31.0

xtik rCHC 31.6 L gAL 53.0 37.0 Pit 276. Y.10'.5/11L 150. 450.

[CG L % 51.0 20.5 HA LI 2. 1.2 3.4

11:31 Patient Limits

Source

Gram Stain Occ Bid

11. pylori

Micro Parasites

Malaria

0 & P

Other

Negative

Negative

Negative

N/A

Negative

N/A

Negative ati4kbrifelitinal '

Negative

0.2-1.0

Negative

Spun Hematocrit

42-41/4(4) 37-47%(F)

Set Rate / 5

CO Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

PT 9.8-13.6 secs

APTT 21-34 SESS

D dimer <20 ug/ml

FDP < 10 ug /m1

REMARKS:

REPORTED BY: go c6)Lb)-

DATE: 5-1r LAB ID NO.:

MEDCOM - 20616

DOD-034190

ACLU-RDI 1657 p.176

3 (D

r-cs 0 a

▪

) P4 0

cD

P4

cf)

0

0

5 0

co

CD .0

CD

m 0 1

3

ba

il 'P

ePLI

52

8

MEDCOM - 20617

DOD-034191

ACLU-RDI 1657 p.177

Staphylococcus aureus

1 S. aureus Druq MIC Amox/K Clay (c) >4/2 Amp/Sulbactam (c) <=8/4 Ampicillin >8 Azithromycin >4 Cefazolin >16 Cefepime >16 Cefotaxime (c) >32 Ceftriaxone (c) >32 Cephalothin >16 Chloramphenicol <=8 Ciprofloxacin <=1 Clindamycin >2 Erythromycin >4 Gatifloxacin <=2 Gentamicin >8 Imipenem (c) >8 Levofloxacin <=2 Linezolid 4 Moxifloxacin <=2 Nitrofurantoin <=32 Norfloxacin <=4 Ofloxacin <=2 Oxacillin >2 Penicillin >8 Rifampin >2 Synercid <=1 Tetracycline >8 Trimeth/Sulfa <=2/38 Vancomycin <=2

Status: Final

Interps R R BLAC R R R R R R S S R R S R R S S S

S R BLAC R S R S S

Drug. MIC Interps

>Sr fv 57, a LA. r-t(" 5-

Name: J Specimen: W027 Patient ID: L6)(.6) -- `/ Ward/Rm: OR/

Status: Final Collected: Req. Phys:

wr..• Minnnel/Ctcwil. cifc!

MEDCOM - 20618

Microbiology Report IBN SINA - HOSPITAL Laboratory

Name: am Specimen: W027 Status: Final

Patient ID: 04)001-- Source: Wound/Sterile site Collected:

Ward/Rm: OR/ Ward of Iso: Attd. Phys:

S = Susceptible NIR = Not Reported Blank = Data not available, or drug not advisable or tested

I = Intermediate — = Not Tested ESBL = Extended spectrum beta-lactamase

R = Resistance TFG = Thymidine-dependent strain Blac = Beta-lactamase positive

MIC = mcg/ml (mg/L)

= Resistant due to extended spectrum beta-lactamases (ESBL) EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

18 = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs.

Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, >16=R). Footnote (c) applies to this drug.

(c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.

(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100.S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints. For S. pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis. For non-meningitis infections, use <2=S, 2=1. >2=R.

1.)1 L.1—

DOD-034192

ACLU-RDI 1657 p.178

Status: Collected: Req. Phys:

Final (6)(6)- Z.


Specimen: W027 Source: Wound/Sterile site Ward of Iso:

Name: Patient ID: me (lo) Ltol Ward/Rm: OR/

Status: Final Collected: Attd. Phys:

Staphylococcus aureus -- Status: Final isx\- sv. oesP■

1 S. aureus Druq MIC Interps Druq MIC Interos Amox/K Clay (c) >4/2 R Amp/Sulbactam (c) <=8/4 R Ampicillin >8 BLAC Azithromycin >4 R Cefazolin >16 R Cefepime >16 R Cefotaxime (c) >32 R Ceftriaxone (c) >32 R Cephalothin >16 R Chloramphenicol <=8 S Ciprofloxacin <=1 S Clindamycin >2 R Erythromycin >4 R Gatifloxacin <=2 S Gentamicin >8 R Imipenem (c) >8 R Levofloxacin <=2 S Linezolid 4 S Moxifloxacin <=2 S Nitrofurantoin <=32 Norfloxacin <=4 Ofloxacin <=2 Oxacillin >2 Penicillin >8 • BLAC Rifampin >2 Synercid <=1 Tetracycline >8 Trimeth/Sulfa <=2/38 Vancomycin <=2

S = Susceptible N/R = Not Reported Blank = Data not available, or drug not advisable or tested I = Intermediate — = Not Tested ESBL = Extended spectrum beta-lactamase R = Resistance TFG = Thymidine-dependent strain Blac = Beta-lactamase positive MIC = mcg/m1(mg/L)

= Resistant due to extended spectrum beta-lactamases (ESBL) EBL? = Suspected ESBL Confirmatory tests needed to differentiate ESBL from other beta-lactamases. IB = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs.


For blood and CSF Isolates, a bela-lactamase test is recommended for Enterococcus species.

(a) Use meximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections. (b) Breakpoints based on parenteral dose. For cefuroxime axelll (PO) use (8=S, 8-16=1, >16=R). Footnote (c) applies to this drug. (c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococd, refer to the penicillin interpretation. (d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints. For S. pneumoniae. cefotaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis. For non-meningitis infections, use <2=S, 2=1, >2.R. Name: Specimen: W027 Patient ID: a (-ia)L6 Source: Wound/Sterile site Ward/Rm: OR/ W MEDCOM - 20619

DOD-034193

ACLU-RDI 1657 p.179

MEDCOM - 20620

CD

0 CCD

0

CD 0 CD

0

F

Cn 0) -0 Ca

o n- ‘< Q.

C) (D. 5.

N rb

:NS

S J

O #

;ueg

ed

CO 0) (0 Zr O. 0) 0.

0) _o

5' 0

0

cr.

co

CD

cn

0

3

"C3 CD 0,

CD

0

Cr 0 al

0

CD cn

DOD-034194

ACLU-RDI 1657 p.180

3 cD

:NS

S JO

# lu

ePd

r a)

0

0

23 CD Ci)

ri• CD O .

3 CD

a

MEDCOM - 20621

1 0 0" me•

0 0

CO ‘i<

(1) .0 • .0

cD Ci) rt

11 0 1 3

1Vild

SO

H V

NIS

-N81

N

DOD-034195

ACLU-RDI 1657 p.181

ev.

(/.3

UJ

0 0 O

cr ‘.<

(D.

CD -0

CD

3 0,

CD

O 17) O

CD

MEDCOM - 20622

DOD-034196

ACLU-RDI 1657 p.182


Name:

Patient ID: 864 Ward/Rm: OR/

Specimen:

Source: Ward of Iso:

W067

Wound/Sterile site Status: Final

Collected: Attd. Phys:

1 Staphylococcus aureus Status: Final 'MR---S A itaczA 1 S. aureus Drug MIC Interps Drug MIC Interps Amox/K Clay (c) >4/2 R Amp/Sulbactam (c) <=8/4 R Ampicillin >8 BLAC Azithromycin >4 R Cefazolin >16 R Cefepime >16 R Cefotaxime (c) >32 R Ceftriaxone (c) >32 R Cephalothin >16 R Chloramphenicol <=8 S Ciprofloxacin >2 R Clindamycin >2 R Erythromycin >4 R Gatifloxacin <=2 S Gentamicin >8 R Imipenem (c) >8 R Levofloxacin <=2 S Linezolid <=2 S Moxifloxacin <=2 S Nitrofurantoin <=32 Norfloxacin >8 Ofloxacin 4 Oxacillin >2 R Penicillin >8 BLAC Rifampin >2 R Synercid <=1 S Tetracycline >8 R Trimeth/Sulfa <=2/38 S Vancomycin <=2 S

S = Susceptible N/R = Not Reported = Intermediate = Not Tested

R = Resistance TFG = Thymidine-dependent strain MIC = mcg/m1(mg/L)

Blank = Data not available, or drug not advisable or tested ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive

Ft' = Resistant due to extended spectrum beta-lactamases (ESBL)

EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases. IB = Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases: potentially they may become resistant to all beta-lactam drugs.


For blood and CSF Isolates, a beta-lactamase lest is recommended for Enterococcus species.

(a) Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections. (b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, >16=R). Footnote (c) applies to this drug. (c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation. (d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints. For pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis. For non-meningitis infections, use <2=S, 2=1, ,2=R.

Status: Final Collected: Req. Phys:

Name: Patient ID1111 b Ward/Rm:

Specimen: W067 Source: Wound/Sterile site Ward of Iso:

do ) (..6)- z-

Printed 10/17/2003 1:45:52 PM MEDCOM - 20623 Tech: (b)0. )-- 2-

DOD-034197

ACLU-RDI 1657 p.183

SSMATCH

Ward/Section= I REQUESTI

LAST, FIRST,MI. C140)( ) -

sotweep 43-ke%.

TEST RESULT REE RANGE TEST WBC 4.8-10.8 xib Color

app RBC 4.74.1 x14

Hgb 144801(M) n4601(F)

Glu

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

Bili

MCV 80-94 fi(M) 81-99 fi(F)

Ket

Pit 130-500 x10' verified

SG Ly Bld

PH

S. Prot

B; Urob

L3 Nit

At Leuk

HCG

Cia)(6)--

DATE I (OCT

RESULT R;. ''RANGE TEST ' , . r:if, . - - '111-1,v4, 0**.or ":

,,, ,ee ,„ 1410

't RPR

RESULT 1REE RANGE N/A

N/A N

Negative

ative

Tli;iEzy2) I LABORATORY RESULT FORM

(Subject to the Privacy Act of 1974)

SSN/PEEUDO SSN: (LX 61-

Neg PICCOLO 1

DISC LOT #: 04.3151AA4 Nc co/ OPER AIM 00 NI. SERIAL T!'"

...........

N. GLU 99 73-118 MG/DL. a

BUN 10 7-22 MG/DL CRE 1.1 0.6- 1.2 MG/DL

N CK 65 39-380 U/L N NA4 135 128- 145 MMOt.L

Kt 4.5 3.3- 4.7 MMOi/L t CL -- 101 98-108 MMOtL

tCO2 24 18-33 MMOtL

Neg 11/10/03 05:17 HfFETUCA: RANT: MALE Neg PATIENT AIM Cbgb)-Y

N/i MEILYTE 8 e ga tive

4.{,6ft04 410 ,0K%

• 1.A1516111111L,„ .•

TEST

PT

APTT

D dimer

FDP

RESULT REE RANGE

21-34 SESS

9.8-13.6 secs

< 10 ug /m1

<20 ug/ml

4 '

Cell Count

Directigen

psi

„x, NON UNIT

[ INST QC: OK CHEM QC: OK HEM 0 , LIP 0 , ICT 0

/18 WITH ESTED

H

REMARKS:

DATE: REPORTED BY: LAB ID NO.:

MEDCOM - 20624

DOD-034198

ACLU-RDI 1657 p.184

LABORATORY RESULTWATT-1 Sub ect to the Privacy Act of 1974)

WardiSei-- tion: :17)1JE7 NN: C6)(10) -7--

i______LLA4--.1 t S '

1Z)S0 0 _ f .A ST. 1 DATE

(4i) Cie )- &PM)

TIME

ema gy BC . 1 hsi,-

, ,, • Urina- ..Misc.Ser ogy•

TEST ; RESULT REF. RANGE TEST RESULT . _

WEE RANGE TEST RESULT REF. RANGE.

I 4.8-10.8 N. 10' Coloi NIA RPR Negative

R.E1C• 4.7-6.1 -x 13' App NIA Mono _ .

Negative

Etib ---7- 14-18 gidl (MI 12-16 L./ii1 (V)

41-52% (M) 37-47% (F) !

Glu

Bili

• .Negative

Nc.-gativc

Microbiology

Hct 1

e Source

. MCA/ 1 "^ " ' 1 (M) (F)

Ket Negative Gram Stain

x10' ' SG NIA OCC Bid Nezzative.

1 1% 131d Negative H. pylori -Negative

rential pH N/A M icro Parasites

.

Prot i Neptive Maiaria

Urob 0.2 - 1.0 O&P •

• Nit Negative Other

"Lcuk Negative •Nficroscopic Urinalysis

hCG Negative

I) CSF - Blood Bank -.

Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other 1 Directigen ; Negative

____... ABO/Rh

; ... Coagulation Studies. .:.. Blood Bank Unit Crossmatch . . • . (MUST . SUBMIT SF 518 WITH . EVERY UNIT OF. BLOOD .

.-.• REQUESTED)

TEST RESULT 1 REF. RAPZE (WiT TYPE CROSSMATCH

PT r 9.8-13.6 secs 1

APTT 21-34 SLY'S

D dinner <-20 ligluil

FDP <10 ug!nil

--------

1

..

0 REMARKS: 1

REPORTED BY: I' DATE: LAB ID N(.: .

MEDCOM - 20625

DOD-034199

ACLU-RDI 1657 p.185

A i T AT E r.2+

Pt 00)1101-

. TRY RESULT FORM Sub . ect to the Privacy Act of 1974)

SSN.'PSEUDO SSN:

Ward/Section: 1:.EA,z-or,STING PHYSICIAN:

LAST, FIRST, MI. DATE TIME

REF. TES'T RESULT REF. RANGE RANGE

3.5-5.5 gidt GLU 73 - 118 rf- k11

TEST RESULT REF. RANGE ,

a 138-146 =obi:

15-4.9 trunon,'

Cl 98-109 mrooL/1„

pH 7.31-7.45

pcoo

i-STAT

Pal

Pt Name:

UREA

(k) ) (.6

c46 mmFir, i,,t)

1

) )-t

TEST RESULT

ALB

-- UN

RE

i 7-22 mg/i1

i 128-145 rumon

8.0-10.31'n/di

3.3-4.7 mmult1

98-108 mmolil

18-33 mmo1.11

7r/dl

. . (Piccolo) Liver Panel Plus

RESUI T I REF. RANGE •

3.3 -5.5 gi(11

: p Pt NamP: i ! c 02 1 1 c G 1'J

FMN

102 mq/dL

1E; rg/dL ' C "EST 1

Ha 137 mmol/L

1 G ' 3.1 mmolIL A . Crea 1.5 mg/dL

- ; I CI 37 mmo 1 /L

Samp 1 e Type_: ..:,

TOn2 35 ronol/L

AnGap 9 m m o 1 ...' L

26-84

10-47 till

0eH0V03 0540 vlY

Hct 3e .PCV

oper: G Hb* 12 gidL 31"

Physician: ___LB__ *v i a Hct

ictio1(x) e

_,T

14-97 tit

11-38 u/1

C PH 7. 449 (yr sell= (:) (A, i- 1 C PCU2 48.2 mmHg

Ver : JAHSO4‘A HCO -]• 33 mmol/L CLEW R93

5-65 till

6.4-8.1 el:

1L 0.2 7 1.6 mgldl

Drug of Abuse

REMARKS:

bEerf mmol/L

Sample Type_:

oemovo3

-t( Oper

Phwsic i an:

Ver: JAHSO4eA CLEW A93

'EST RESULT. REF. RANGE

128-145 nunolil

3.3-4.7 mmol/1

P-

REPORTED BY:

MEDCOM - 20626

LAB ID NO::

DOD-034200

ACLU-RDI 1657 p.186

-ABORATORY RESULT FORM g' (Subject to the Privacy Act of 1974)

‘Vard/Section: (6)L6 L-- z_ LAST, FIP..ST„N•11. I FA"T-TI . 1 TIME

010(10) - 9 1061\tAictS1 1430 SSNIPSEU DO SSN:

.... (Ilematokob) CBC . .

- Urinalysis. . • . . . Misc. S-erology ._____71

TE .. ' v INGE TEST Kit:RIO' REF. R42N1GE TEST RESULT REF RANGE

WBC 4.8-10.8 x 10' - Color N/A RPR ■

Necative

N/A Mono . r Negative

Microbiology APP . .....

Billi 09)021 " "i. GB-1114-03 41 WB

Glu. Ne.ative

Patient Limits

10.5 Bili Negative Source

at 9.4 t10A3/uL 4.5

RBC 4.32 11.0"6/eL 4.00 6.00 !

11.0 18.0 K.et Negative Gram

Stain H911 11.6 . 9/di_ Hct 37.1 X 35.0 60.0 '

90.0 99.9 SG N/A Occ Bld Negative

0 85.9 fl_ L to 27.0 L Pg 27.0 31.0 j

MCHC 31.4 L 9/dL 33.0 37.0

Plt 457. H t1.0"3/uL 15. 450.

20.5 51.1

B10

pH

Negative H. pylori Negative

N/A Micro Parasites

L'a 18.8 A_ 7:

' LY# 1.8 * x10"3/uL 1.2 3.4 Prot Negaiive Malaria •

Ba Urob 0.2 - 1.0 0 & P

Nit Negative Other

Atyp • ltnni . Leuk Negative rcrscopie Urinalysis

R BC I Morph 1

HCG Negative

Spun Hematacrit

42 -52%cM 3747% (F)

CSF Blood Bank -.

Sed Rate Cell Count

1 ' MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED .

• -... Other Directigen I

1 Negative ABO/Rh

. - ;Coagulation Studies. . .. Blood Bank Unit Crossnotiteb • • . (NIUST,SUBMITSF 518 WITH EVERY UNIT OF.-BLOOD . .•

'... REQUESTED} : •

TEST RESULT ?El... RANGE UNIT TYPE CROS:SALITCH

PT 9.8- 13.6 secs . I •

1.71-1 . 21-34 sees •

D dimer : Z20 ligaril

F DP i <10 130111 I , ,-.-

REMARKS:

hzEpORTED BY: 4 '

I; DATE: LAB ID NO.:

MEDCOM - 20627

DOD-034201

ACLU-RDI 1657 p.187

Ward/Section: 1 i....44......i.STING PHYSICIAN: s Cry,. . .CRY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST,_.‘10)(.1,0

—

) 1.1 DATE 1 TIME SSN/PSEIJDO SSN:

I.STATI: ...:' .(1!:i .c00) .:Pli4ititiiri :'.-.-( ic016)1'it0b011000: -

TEST RESULT REF. RANGE , TEST RESULT REF RANGE

TEST RESULT I REF. RA.NGE

Na 138-146 mmol/L ALB 3.5-5.5 g/d1 GI,U 1 73-118 me/d1

K 3.5-4.9 tr,.(n.on: ALP 26-84 u/1 BUN • • - 7-22 rag/d1

CI 98-109 mmol/I. ALT I 10-47 WI CA". 8.0-10.3 ingidi

P1-1 7.31-7.45 ZE ; 0.6-1.2 mg/dl

PCO2 35-45 mmHg (art) 41-51 mmHg (vca)

. V' PICCOLO

! 128-145 tumuli:

P02 80-105 mmHg or') 4,4/..1. (veal

' 08/11/03 14 : 40 . 3.34.7 mmulil

TCO2 23-27mmota. (art) 24-29 mrnal,'L (veal

- REFERENCE RANGE : MALE PATI ENT # : Lb) Lb )." V ill,

98-108 mmolil

HCO3 22-26 mmt4IL (art) 23-28 =AIL (vca)

i 03 METLYTE 8

18-33 mmo111

s02 95-98% 1 DISC LOT # : 0,) Lb)"' 3151 AA4 ...7..: --:-.: 10;c04071.:;04-. .zand. flo...,.

BEe-zf mmon

(-2) - (+3) 1 OPER # : 000 'EST SERI AL # :

RESULT REF. RANGE

AnGap 10-20 mmoltl. l Clog. o)" .B 3.3-5.5 gkil

Ca L12-1.32 nunolIL - GU) 100 73-118 MG/DL :p 26-84 u/I

BUN BUN 19 7-22 MG/DL

8-26 mg/dl BUN CRE 2.0* 0.6-1.2 MG/DL

10-47 till

MU 70-105 mg/dl CK 58 39-380 U/L Ay

NA+ 130 128-145 MOIL

14-97 till

Creat 0.7-1.5ragitil 4 K+ 3.6 3.3-4.7 MMOVL rr I 11-38 till

Het 38-51% PCV I CL- 90* 98-108 MMOL'L In,

18-33 MMOVL 0.2:1.6 mg dl

Hgb t CO2 26

12-17 g/cil 4 3T 5-65 u/I

is:;- clieniii •..,

INST OC: OK CHEM OC: OK ' 6.4-33 girl!

TEST RESULT REF RANGE . HEM 0 1 L IP 0 7 ICT 0

i )i0:41).-E. 14tr. 61: ec •....,...-;.... • .. - .:.; ..-

Troponin-1 I 'EST RESULT _REF. RANGE

Drug of AbLi3e

. 128-145 =Ion

3.3-4.7 moll'

- 98-108 [moll'

02 18-33 nuno1/1

REMARKS:

REPORTED B • DATE: LAB ID NO.: Cb)(6)' a ,

MEDCOM - 20628

DOD-034202

ACLU-RDI 1657 p.188

00) War&Section: REQUESTING PH-VS TLABORATORY RESULT FORM

(Subject to the Privacy Act 0 4)

LAST, FIRST, MI. 1 - - SSN/PS (..10 ) Lb ) - 0•641111r1474. P (b)04-

(-Hematology C - Ur.-itta)y.,is /. Misc: rology .- .

TEST RESULT REF RANGE RESULT 4. . RANGE TEST — -

RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color

App -

Glu

Bili

y

, 1 rtiy ,

rJ

N/A -

NIA

Negative

Negative

RPR.

Mono

'I

Source

legative

Negative

Microbio ogv RBC 4.7-5.1 x 109--

I tgb 14-18 g-kit(M) 12-16 p/d1 (F) 42-52% (M) 37-47% (F)

Hct

MCV 80-94 11(M) I 81-99 fl (F)

Ket M. 0 cl

Negative Gram Stain

Plt 130-500 x 10' verified

I SG - i3O3c)

'N/A 0.....c. Bld Neeative

Lymph % 20.5-51.1% Bld 'p,„ Negative H. pylori - Negative

(Heinatalogy)-MaintaI Differential pH 5 -

N/A Micro Parasites

Segs Mono Prot I- +-I, 4 Negative Malaria

Bands Eos Urob N 0.2 - 1.0 0 & P

Lymph Baso Nit A.) Negative Other

Atyp Imm Leuk ) Negative • - Nritroscopic Urinalysii •

• RBC - Morph

HCG Negative

. • $ S Ck: <:••3 Wirt.- . /var.- .

- kc.As,..1- I. 1-kroesr g4 c"' i-3 I F,,,ity.<4s..... -AA u d 4""1". : Noy I Cact: At.

Blood. Bank ... Spun Hematocrit

-1 ;

42 -52% (M) . .. CSF . .

37-47% (F-) _

L': Sed Rate 1

Cell Count

- -

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED i ,....

Other Directigen f Negative ABO/Rh

. :-: . Coagulation Studies. r .. Blood Bank Unit Crossmatch . (MUST.SUBMIT SF 518 WITH - EVERY UNIT OF.BLOOD .

. REQUESTED) .• -.: ...

TEST RESULT-I REF RANGE UNIT TYPE CRO.S'SAL4TCH

PT r 9.8-13.6 secs

Avi-r 21-34 SM.'S

D dinner <20 notil

IF DP <10 uoul

REMARKS:

■ REPORTED BY: II...DATE: LAB 11) NO.: . I . . .

MEDCOM - 20629

DOD-034203

ACLU-RDI 1657 p.189

5T RE SULT I REF.

3.3-4.7 anuolli

98-108 rmuoill

18-33 un:noL'I

UPr

TEr

Na

Cl

pH

PCO

PO2

TCC

sCC

BEe

AnC

Ca

BIB

GLI

Crei

Hct

Hgt

TI

Dru

rer

Abi

wow 3151AA1 00

73-118 MG/I)! 7-22 MG/DI 0.6-1.2 MG/DI 39-380 U/L 128-145 MMOM 3.3-1.7 MMOM 98-108 MMOW 18-33 MMOM_

000)-1

PICCOLO 09/11/03 11:57 REFERENCE RANGE: MN F PATIENT ill (10)114) - 9 METLYTE 8 DISC LOT #: OPER # SERIAL #:

GLU 95 BUN 26* CRE 2.0* CK 58 NA+ 131 K+ 3.9 CL- 88* tCO2 21

INST DC: OK CHEM DC: OK HEM 2+, LIP 0 , ICT 0

Ch . FRY RESULT FORM (Subject to the Privacy Act of 1974)

PAT TiME SSN/PSEUDO SSN:

Ward/Section:

Rh„...r.STLNG PHYSICIAN:

LAST, FIRST, MI.

kco1o).Cheruiitry 12:. , . . .

-Tiq-01Ort4b0PT.00 TEST IRES(T7 REF. RANGE r

- f== PICCOLO ---- 09/11./03 15:06 RE!- EI RANGE: MALL PATIENT #:

r.,1 .1 PANEL PLUS UI:L LOT #: c6002) 3154AA7 OPLP # ' 000

#: GoAtwv

IL ALB 4.S G/DL NF. 118* A U/L AL! 9* 1C 17 U/L

72 lm U/L ,IST 39* U/L HIL 1.2 MG/DL

28 U/L ST1 9.3* 64 G/DI

INS OC: OK I. ICT 0

128-145 nuno1/1

73- 118 rug/d1

7 -22 rug/d1

8.0-10.3 rug/d1

0.6-1.2 mg/d1

128-145 tumuli:

3.3-4.7 rurnu1/1

RESULT RANG E •• •

3.3-5.5 g/d1

2644 n/1

10-47 nil

14-97 u/ I

0.2-1.6 rogidl

11 -381.0

et REPORTED BY: DATE:

MEDCOM - 20630

DOD-034204

ACLU-RDI 1657 p.190

fiun;

• \

-

-

I LAST, FIRST MI.

(..:,tj'EMISTRY RESULT FORM (Subject to the Privacy Act of 1974'.

DATE, T[1\41 SSWPSEUDO SSN:

DOJ C1C(--)

i;STAT) it.c(Bo).Clitimikrri. 12, ,

TEST RESULT REF. RA_AIGE TEST RESULT REF. RANGE

gtabolic ;. and

RESULT REF. RANGE 1 TEST

GLU

BUN

CA"

3.5-5.5 g/c11

26-8-4u/1

73-118 mg/di

7-22 rue/d1

8.0-10.3 ragidi

P02

TCO2

HCO3

1'7)2

pH •

PCO2

BEeef

AnGap

Ci

BUN

GLU

CRE

Creat I

Hct

7.31-7.45

35-45 mini-liar.,0 41-51 rumEle 80-105 mmH

23-27 mmol/1 24-29 rnmall

NIA. (yen)

22-26 mrrapa 23-28 mrnon.

10/11/03 04:52

REFERENCE RANGE: MALE

PATIENT AIM u)u0)-y

METLYIE 8 DISC LOT #: uorz- 3151AAA

OPER # DR #: 000

PICCOLO

tCO2

ALB SERI AL T ............. 04410:Y ...... 1.12-1.32 mm

GLU 98 73-118 MG/DL 8-26 meld!

BUN 27* 7-22 MG/DC

CRE 2.2* 0.6-1.2 MG/DL 70-105 mgldl

CK 40 39-380 U/L

NA+ AMA 128-145 MMOVL

K4 3.6 3.3-4.7 MMOVL

CL- 88* 98-108 MMOVL tCO2 25 18-33 MMCVL jsChenthtry

AMY 0.6-1.2 mgrdl

95-98%

(-2) - (+3) mown 10-20 mmol/1

0.7-1.5 mgh:11

38-51% PCV

12- 17 gill

NA-

CU

ALP

ALT

AMY

AST

TB1L

TP

GOT

128-145 ruulkili1

3.34.7 mmotq

98-108 mmo1,1

18-33 inmal

3.3-5.5 gidl

26-84 wi

10-47 IA

0.2-1.6 mg/dl

14-97 Lill

11 -38 u/1

5-65 till

- gid1

(P1ccoloILher Panel Plus.

TEST RESULT REF. RANGE'

Cl

3.5-4.9 mrilobl.. -

98-109 =non

138-146 minot/L ALB ALP

ALT

(Ficcao) Electrolyte, •.. • .

[.. ---T—EST— IRESLIT REF RANGE

irc7pani1

Drug of Abuse

.... . .. .... . . .. . ...... REMARKS:

INST QC: OK CHEM OC: OK

HEM 0 , LIP 0 ICT 0

NK

CO2

TEST RESULT REF. RANGE

3.3-4.7 airno1/1

98-108 mmaill

128-145 mmol/1

18-33 =NCI

REPORTED BY:

I

MEDCOM - 20631

DOD-034205

ACLU-RDI 1657 p.191

OK for

PNOCE. AMES- X-X

PROC-0- 0

(Unite)

cw_s

(

VOLAT .CO AGENT

AIR UMIn

SINOLE DOSE DRUOS - MARK ON ORI WITH NUMBERS &ENTER IN REMARKS

MEDICAL RECORD ANESTHESIA TOTALS

TOTAL URINE

FLUIDS - SUMMARY CRYSTALLOID--7 66

COLLOID- 0

BLOOD—

REMARKS-

%

Cods cr uge with numbs t. themes

with Wars

to LIME %Ili

c warm.d

EST BLOOD LOSS LOSSES

PHYS STATUS

H..

4vpr.,...4::::: : ::: •i.:.:. :,::::ka

TM 71 :137 •1

• .:. KIM AIIVIIIIIIM::::::mr.::

AIRPAr allana.::if:1::

IF :: ::: :: ,::::,1 : :,.,:: Milli:d.::::i,

7i I .: .: _ J ..,,:::: ,:4:::: HAM MN 1 Milimilan ::::;: MIMI 7.t.:1:::i:10=1/111111111111111111•

IrAtiiNIMMIIIIMMIIMIIIIIMMINE

BP by cuff

V A

Heart rate

Resp rate

BP (transduced)

T TOURNIQUET

T

)."ERV AT MOE ICU (sPecitY)

OTHER

omonlool:

1•1121TIMMITEMP- site . '91 N-M Block TI4 1111.1ffi girAriff

Ii I AIL

spoz- HR-

RESP-

BP-

Start Room End

Cony warmer

PROCEDURES andC Codes

PATIENT IDENTIFICATION— ryp.d.-wirr....nfrie., Nome, Grwitr7rato.

felorlecol &citify

(..„„i

L' .1-00,6

Ready Begin End

CLo ) Lb) ANESTHETIS

(6) /1-e)- WA C OP 376 REVISED

1 Jan 99 I PAGE OF

MEDCOM - 20632

BODY WE

ET CO2 torr

AN ESTHETIC TECHNIQUES:D*44,rib* block tochnktuo under frornerite

DOD-034206

ACLU-RDI 1657 p.192

a

L,3 z

(

r°4401% del e.t.

AIR I/Min

N20 L/Min 02 LiMin

7 t 0 z..0/2-cvie1/21

1-

U) (.7 re

0 z

z w

0 17- w

w z

VOLAT AGENT

MEDICAL RECORD

SINGLE DOSE DRUGS -MARK ON WrTH NUMBERS &ENTER IN REMARKS

IU I- r

r-- •

5 5

ANESTHESIA TOTALS

t 11 TOTAL URINE

FLUIDS - SUMMARY

PS

1 2 3 4 5 E

BODY WEIG

MOW

BP _ rug

HR- to

OK?- 17 N

OK for

PROCEDURE7

rE-

SYMBOLS:

BP by cuff

V A

Heart rate

•

Resp rate

BP (transduced)

i

TOURNIQUET

1 —/

ARES- X-X

PROC-0- 0

220

200

180

160

140.

120

100

80

60

40

20

5 LL

El Warrrad Warmed

O Warrtad

El Warm.d

LOSSES!

PHYS STATUS

EST BLOOD LOSS URINE -

TIME ■1•4*-

Cods caws with numbers. events with letters e Pr ;0_, _ /77-

70 Rem-0 r 4u/ti

C

.17 0-0

BP loth ART line

/1- Steth- PCIE 51 E 4

Gas analyzer

Room Start

t751)

Ready ..;

trre)

Benin

iszo 8

MOPE- SI n Alsslst) • Cionl BPIAuto Cu CO2 torr

02 (Frac or %) 02 %

P- site -M Block T14 I

I ng bikt

Cony wanner

Mork rah loessa rymbols. EVENTS rphnin under REMARXS Position

PACU ICU (SpacKy)

OTHER t hatn•A-G1

CONDMON:

RESP- Sp02-

It/fri‘ HR- HP-

- • • • • • •

End

IMO

End

IWO

PAT1EN T IDE N TIFICATION - Typod or written warier: Memo. GrodoRoto.

Mi foeMly

REMARKS-

• •

? E HITT:7

NM • •

. . • •

::::y•.]:i::::::: .::: :

.., ii:i:24_, :.::::.:::4:::,:

iffitEmil,. i LiTh " th:::::.

:::::,::::: ::3::::::1::::::: ii6r1

Millitilligiliallill

WEN

Pit 1-• :.::::371::::-::::::::it:::::- :7,d.,:::::. .::.:.:.:„.:„.

iri, am mim i ....,

WIIIIIIIIIIIIIMMIlitailitilfill M INIIIIIII,:::::0„,,,,migMNMM

ni 114/4/ LITAltr v AV /

LI

1

•CsAlleMigia 9

L=1}Leath3/mIn P k

RECOVERY AT

PROCEDURES and CPT Codes Aft :zsTHET1C TECHNIQUES: "41'. block t'em4que atm

AIRWAY MANAGEMENT: Intubetlon pichnicue comments 1..nvie I veg./

lL f77- 7•D kat., /0174 A C4-0 f eige150EledZ

cwtf.)-2.

10-1

PROCEDURE LOCATION

4_

DATE w 03

W A M 376 REVISED PAGE OF

1 Jan 9 9

SURGEONS:

ANESTHETIST

MEDCOM -20633

DOD-034207

ACLU-RDI 1657 p.193

1/11

SC

U)

D

(:)

z

U) I-

LU

I- Di

I- U) Ui

ANESTHESIA

0'

(

VOLAT AGENT

(Unite)', MEDICAL RECORD

A del e t

NR UMIn

N20 UMIn

On 02 A Vic LIMIn SINGLE DOSE DRUGS - MARK ON GRILI.

WITH NUMBERS &ENTER IN REMARKS

TOTALS

/14 t tj TOTAL URINE

C./ FLUIDS - SUMMARY

CRYSTALLOID- 3 co COLLOID-

BLOOD-

''' ...."

Start

Room

End

Rs' tb End

!

a U) LINE sir

5

I LOSSES'

PHYS STATUS

1 1)3 4 5

BODY WEIGHT

Q Warned

fl Warmed

CI Warned

El Warned

EST BLOOD LOSS URINE —

TIME

SYMBOLS; 220

BP by cuff

V

200

A 180

Heart rate 160

•

Resp rate

140

120 BP

(transduced)

.1.

•

I rr

111181111113118 $111112111111111

12111111{1111VIAIIIMEMIffilli

REMARKS- Carle dogs with number& events

with Jolters

X,5/4 710 ae

/6 1 tc / / 61-i9/ to 77/ /69/6 271/ syA,

1,67/z. /

Sr:v/1 i 1 r

1.

1.

uuimi II ME Al

EOM maw BREMER

100

80

60

20

OK?- Y N TOURNIQUET

OK for

PROCEDURE? AMES- X-X

TME- pRoc-0_0

EVIMIRMIEJEMENI twos .11111 11111111IMM

111111WIRTAYATACITMIIIMIDEVIIIMIIIIMEIBIM

11=141=1111121111=1WIMINIMOMMIIIIIKM1=111111111115

1111PAIMIIIIMMI111 • .• • rZWe

riT111/144

—

RECOVERY AT MODE- Si n) Ass(s1)C(on)

BPJAuto Cu ET CO2 torr

g LaY4 27747111A I ENIffinIMEM IMMO= IESIGAMPAM

11102Mg ORTMEEEPAINTAff41111 1.11MIIIMINOTMISMISINTM,

BP I oth ART Ilne

8 A-

( 275 AIC caTIIETIC TECH N IQUES:D•mribe block techniquo on R./m.1

/067/(K e/a / „.2. t1 iq /yer A

A* win lottecr d symbol& EVENTS explain under REPAARdS Posjbon


PATIENT IDEN-TI ICATION- rmed cr written eviler Nom, Grwdeliehr. Medical foellay

AIRWAY MANAGEMENT: Intubatlon rout*, Nods. tochnIgare. commends

filaCK ./OZOR-1-7/el SU RGEO

L PROCEDURE ,„"/2 LOCATION Url

I./ AN ESTH

DATE /

/ WAMC OP 376 REVISED PAGE / OF/

MEDCOM - 20634 1 Jan 9 9

DOD-034208

ACLU-RDI 1657 p.194

RECOVERY AT

AC ICU (Spocifyi

BPIAuto Cu

BP loth ET CO2 (ton)

DRUG MED. ,HL RECORD ANESTHESIA (Unite) TOTALS

TOTAL URINE

AIR UMIn

N20 UMin 02 UMIn

SINGLE DOSE DRUGS - MARK ON 019. WITH NUMBERS &ENTER IN REMARKS

Mrr. niref=1:1110Mill■

LOSSES

BODY WEIGHT

BP by cuff

V A

Heart rate

•

Resp rate

BP (transduced)

T TOURNIQUET

T

FLUIDS - SUMMARY

CRY sTALLOID—

COLLOID-

BLOOD-

REMARKS- Code drew wkh numbers. events

with Wen

C4 /4/4N_

(:) - r'rL'ajlr̂ "■- TX) OctAl

ce,)t— V4,vog"

4-v

SYMBOLS:

OK for PROCEDURE?

ARES- X-X

PROC-0-0

ART Ilne S.02 •h ta9 WO e■

Steth - PCIE ECG sp g Gas analyzer TEMP- site

11-M Block T/4

nning blkt

Cony vrarmer Ready Begin End

Mei wlh Fences a symbols. EVENTS phin under REA44RKS position


PATIENT IDENTIFICATION- Typed er written •nHer Nome CreclwR•fe.

4411 * 00)10)-. `i

a. I CaY re

AN c ,THET1C TECHNIQUES:D....Th. 1,4.0, t*cimid., under R.mnha

ANESTHET1S

SURGEONS cioL6)-z

MEDCOM - 20635

WAMC OP 376 REVISED 1 Jan 99

T'r---"'r;"17 " • ..

AIRWAY MANAGEMENT: lauballon rout.. Node. NcMJq.ae, comm.

DOD-034209

ACLU-RDI 1657 p.195

/

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

AN

EST

HE

TI C

AG

EN

TS

AN

D D

RU

GS

I

CO

NTI

NU

OU

S/R

EPE

AT

ED

DR

UG

S SP

EC

I FY

UN

ITS

- M

G/M

CG

/ML,

'I

' =C

ON

ST

AN

T I

NFU

SIO

N

DRUG (Units) TOTALS TOTAL EBL

"PC ( 1 /0 /0 /C 36-.4•- )41(z'7 /(Pride s, ( ,>_._a_

( TOTAL URINE

( (

(

VOLAT AGENT

1.494-(ael - FLUIDS - SUMMARY

% e.t. CRYSTALLOID-

4/() AIR L/Min

N20 L/Min COLLOID-

•4164,02 L/Min SINGLE DOSE DRUGS-MARK ON GRID —I,. WITH NUMBERS & ENTER IN REMARKS

BLOOD-

FL

UID

S LINE site LI< ❑ Warmed 4( REMAR S

❑ Warmed Code drugs with numbers, events with lettters

/ 3C1/..,i-OK - ,,,,,), ,I.r.f afj.? it l''

_Irk/ ce/ii-e - i AC ..,/,-c--16.74.dY/r/

S -la //To/

1 .3/d- Tare I

(.35410.:3-- - -i:C1(/ a fr/SU ert'' ,

Op E.7-(

- /1

a ic: .

/ 8-74, ..” ee a 1,-egY

f-fite fa re

13.5v ,-"Lres-rveJ axyre kg-ber"

i_rahriPverif-c9 i/nCel' -

RECOVERY ATI /3 -CS--

ID Warmed

❑ Warmed

LOSSES EST BLOOD LOSS

UR NE -

PHYS STATUS TIME / 6/, I-71 63 4 5 E

SYMBOLS:

BP by cuff

V

A Heart rate

•

Resp rate

BR (transduced)

-L T

TOURNIQUET

T --.-1/

ANES- X-X PROC- 0_25

220

200

180

160

140

...., .,....

100

80

60

.

: BODY WEIGHT:

..W -70 LB

, .

. ' '

,

HEMATOCRIT: . .

: INITIAL DATA:

BP- (8 1/5- --,—,—

A nallEr. ,

Illriraragliral. maziamilmirAmm AIME

, ,

_r_ , _,_, HR- .-f,

EQUIP CECK

. . „ . . : : c 010- d) N Mmimm.

:11146111E11111 , .,--,— —,—,--

. PATIENT RECHECK

, OK for PROCEDURE?

TIME- /0.?4-'-

, , , .

1 20

. I I I 1 , ■

,

111N3A

VT-ml .5 V f - breaths/min ir /0

Peak inf pres / PEEP III MODE - Slpon), A slat), C(onl

I MO

NIT

OR

S/A

CC

ES

SO

RIE

S

-4P/Auto Cuff T CO2 (toff(

nn nil

.1.1

.- I

It/AMR

, Specify) BP/oth I

ART line I Steth- PC/ES a

02 (Frac or %)

p02 I%) ECG

Block (T/4)

Gas analyzer NIMISIEVErMaill

IN-M

AC)CU

OTHER

CONDITION:

RESP- _q> Sp02 - 45

BP- /A-S7C3HR-

ANESTHESIA I PROCEDURE TIMES

LO Start Room End

Warming blkt `lui I ge-,36t it/0 ' Cone warmer r.) Ready Begin End

Mark with letters & symbols, EVENTS_ explain under REMARKS Position - 6-1

o E I3A31 3)57-W6

PROCEDURES and CPT Codes:

CO a s - It acd (4_9 i. te - ANESTHETIC TECHNIQUES: Describe block technique under Remarks

*1 l'IC 1 f /Z a:2_ AIRWAY MANAGEMENT: Intubation route, blade, technique, comments PATIENT IDENTIFICATION: Typed or w tten entries: Name, Grade/Rate,

Medical facility

111111. 00(6H SURGEONS:

C a) 00 )- 1 PROCEDURE „, LO CAT ION: --,"\ DATE:

/6/1 ir/e 10)050 ) - Z- PAGE / OF/

DA FORM 7389. FEB 19911 MEDC - 0636 rnpv 7 _ A I-IFcIA PRnVInFR lISAPA V1.00

fee'

DOD-034210

ACLU-RDI 1657 p.196

/ VI KJ /1- -1- IVICUIL../AL ncutirsti - HINCJ I rirt/-% For use of this form, see AR 40-66; the proponent agency is the 0

N CD = cc 0

o Z

ci) I••• Z

9 -"" 0 I- ui i

v)

Z <

to 0_1 , 2 z

08,7,

222 1-0z

°- Z ''' ma --- t- I-

0D D0Z p›- 0 z Li- ii F*2!-- Z Ow

DRUG (Units) tI 4s'90 4 /2(3' TOTALS TOTAL EBL k/-e-■/1-,ef-- ( Inn. -( ,L-

lx -0 LI 0 - 0 i,r }Cr)

( TOTAL URINE -rriy. 1— ( vik,;..) ..00 ,-

( 41 4 f

,

VOLAT AGENT

t-o-,: % • - 4 ' —29- X„t____ FLUIDS - SUMMARY % et. CRYSTALLOID-

La .5-45J0 COLLOID - y .

AIR L/Min

N20 L/Min a)--- 4 --t>— ''/

U 02 . L/Min SINGLE DOSE DRUGS-MARK ON GRID _..1„. WITH NUMBERS & ENTER IN REMARKS

BLOOD- ...&

CI

a-

LINE site II. r ay/armed .

s-

'444. s-------1......"---,,.... REMARKS ❑ Warmed — Code drugs with numbers,

events with tattlers

Or V!. 1W -1-

/r-f--•-4.-- 1 ;2̂ )

CI Warmed

ID Warmed

LOSSES EST BLOOD LOSS UR NE -

PHYS STATUS TIME NO' . - 0 136° it, 45 E SYMBOLS:

220

200

160

140

120

100

80

60

20

. I ■

BODY WEIGHT: r--, I ---j I

--r -1--- I

'7g fag.) LB

BP by cuff

V

A 180

Heart rate • Resp rate

BR Itransduced)

. 1.1

-

T —,1"

ANES- X-X PROC- 5 10

. .

11 E MA T 0 C R I T : ' , , ' . , . --1-1-

'

4 '4 i 0 c-1- . , '

.--- ,--- , ,

-, .

INITIAL DATA: , .

BP- , . . . . . " '

• ' . •

/ a..r • ,

, • - •

HR- p - Le . ' , , '

EQUIP CHECK ' .

•

: . o

—.--.--

,

TOURNIQUET OK?- Ly? N

PATIENT RECHECK

. . __I_ ___*___I_ 1.__I ___1_1_ ___.1 --,--,- ___L 1_ . /,' 1 . • 1 1 1 1 1 .rt .

I-- I r

/ft A ■ 1 .1_1_ _L_I___ ___I. —1— 1—

OK for PROCEDURE?

TIME-

/,' , , .

. , , . .__L___. —I —r— ■ 1 ■

: ,

' . . . .

I>j

VT - ml 40,- qv ,,bc '-EGA,

Z I- f - breaths/min a 4`.L-

-- )2

- o-f

Peak inf pros / PEEP

MODE - Slpon), A(ssist). Cfon) .<

d--) -'7444'

..5 1-1 1

S Lri

RECOVERY AT

(17 u, E 0 cn

w 0

.1 V) CC 0 I--

0

BP/Auto Cuff ET CO2 (torr) minikapicu specify)

O THER

BP/oth F102 (Frac or %) /00 L-a? :-.) I CPC, ( CO ART line Sp02 1%) ‘ 0 . / C.' cici

S 'it

e:- .:.

5 Steth - PC/ES ECG "CA" _g ' 2 CONDITION:

? RESP- Sp02• 5 BP- / • HR- 4, /

Gas analyzer TEMP-site

N-M Block (T/4)

ANESTHESIA / PROCEDURE TIMES

2 - - V) Start Room End

Warming blkt ,. - - - ...i;./ ie, ...tZ

Cony warmer 0 Ready Begin End

Mark with letters & symbols, EVENTS _, explain under REMARKS Position -

o E /-23c) 4;2 e6

PROCEDURES and CPT Codes:

X '. 1

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

. M. i." az-91/ AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

i''14732

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility

ttill. to ci / 3z-/ 78 UV) L6) - y

SURGEONS:

L6) tta 1 - -Z.

PROCEDURc-) p i LOCATION: ' DATE:

A.I --,:sc: i---- ..23 A NES

C 4)l6 ) --Z PAGE / OF /

COPY 2 - ANESTHESIA PROVIDER

USAPA V1.00

MEDCOM - 20637

DOD-034211

ACLU-RDI 1657 p.197

mLL..1....mLniz....01-m,-,-,11111r1i_.2'm For use of this form, see AR 40-66; the proponent agency is the OTSG

to (7 D

pix

n Z < (I) F- L , (.9

tai P Lu x c1...n Z ..:(

rn t..7_/ n 2 z Ot.-- 3

S,3 2t_ l- 0 z atn ,_ ea ' z cc la 4 iii tz

0 D D z0 (-) z D ii

Z m O

0 w


ti -er,cr" ( ki./ ) 1/7- 5--),-,,,,, vs..0

OTAL URINE

14:? ' ( _5,,t(ea ,7-4/jo o 2 .) _5117- ___- S

st, ..4, MC/ )

/ //d. b ef ) .-- 3°457

'/tc" 5 (!ed- ) 10 e o ciic/rN"Le fri4 614.,)-t a.) 0 ...--

VOLAT AGENT

1-Olelie% del ,(..5- 2- /•.s— f,s-- 3. 4. a_ -. j/.5 FLUIDS - SUMMARY

% e.t. CRYSTAMo

COLLOID- AIR L/Min 17 ,19= N20 L/Min

02 L/Min SINGLE DOSE DRUGS-MARK ON GRID _., WITH NUMBERS & ENTER IN REMARKS

BLOOD -

fn 1:)

LL

LINE site kr., Warmed 3 (X) `300 1(00 I 5-c oci,,c> 7,60 REMARKS Warmed Code drugs with numbers,

events with !enters

4,2 08 4'; -- Oi. kt40 yr ite, rf 4-,o/d/ 401°.

0 ai_r e----- 0 r

e grE° 69 66"'

I tig ebitil /e .

fele 246n 0 Yd (

4 VOtrai 114 of 04 LO

/fin/2/

2 0(71"‘a /

io ,',1v,/-,pue,' t2

. ,

❑ Warmed

❑ Warmed

LOSSES EST BLOOD LOSS / CO ltO0._:4CD if P UR NE -

PHYS STATUS TIME * 21,6 30 (3 36 X o X /I( 119 4 5 E

SYMBOLS: 220

200

1130

140

120

100

80

60

40 20

BODY WEIGHT: , ,

,

-- -'3 BP BP by cuff

V

A Heart rate

• Resp rate

BR (transducer!)

J.. 7

TOURNIQUET

T ---,,(

ANES- X-X PROC-0_0

, . . , ,

HEMATOCRIT: . . . . . .

‘77 - 7 . .

/Bo . , . ,

INITIAL DATA:

BR- 1 IAA

, , --,

, . . ,

I I , , 1. /

I P

7 WI

. 'AM

Wil

arm IMINIMMIIININIYAREI

mitirArAximvaiwie

ISM

AMEN I MIIIAIV V rrCG( .7.1; r -

I-IR- ,,,,,c,, 00 e2

MIMI EQUIP CHECK

I I

1 ,- , samorAug

VOA 010 - Y N JILL_ &t_ . LBW • ,

/WA ira.. PATIENT RECHECK •

1mi Mit/ •d. ,

OK for PROCEDURE?

TIME-

--r— ,

--r--r—

. I I I I 111... 111 MINI 1 I I I I

I-

VT-ml '1 0 (?Q7

I

•

_I U

52 e.

11_1C.

__ ____ At

ir

Nig •,, ii

LW f - breaths/min

Peak int pres / PEEP

ir MODE - SI on), Aissist). C(on) - RECOVERY AT

sp.c,,,, u9

rz r 0i)

. L.)

0 Q if, CC

F

g

/(3P/Auto Cuff 1E7 CO2 (torr) 3e... 0 g

-

4__147

, ME nil "5 NO

, .,z 51t---

BP/oth

g S p 0 2 1%)

r , , Pi 102 (Frac or %) 0, rei

1 • D. o I OTHER ART line /0 0 /41 64 OD ino u_1..,

61C. Ix, sk

_Lt

La,

Steth- PC/ES !'ECG C .... 7 - CONDITION:

e.,„oeent ,,,,,e,, RESP- V Sp02- 7 BP- 1.4' 7.2 HR- / 3

Gas analyzer al EMP-site il i.,) : i--- ,,s-

l'in

Sse M Block (T/4)

ANES $1A / PROCEDURE TIMES

0 V) Start w Room End

Warming blkt I 4 011 . fa.,

Cony warmer (,) Ready o °- /0116)

Begin

1)41

End

/010 Mark with letters & symbols, EVENTS,

1 explain under REMARKS Position ' 6

PROCEDURES and CPT Codes: c As ,--/

41-'6- t,.(_, flail( f/ t—)e rIX ,

ANESTHETIC TECHNIQUES: Describe block technique under Remarks •6 F74 AIRWAY MANAGEMENT: Iniubation'vine, blade, technique, comments Yea 6-,/are, -e-.3/0,ger bield'e dhe a die'42/7 /--a,,,,e• AA i fe..u• 6) 4--- Tro.x • ‘‘...

PATIENT IDENTIFICATION: Typed or ritten entries: Name, Grade/Rate,

Medical facility

11/ OA 6)-f UAW- Z. PROCEDURE evl. i. LOCATION: DATE:

/ 0// 6 ./65 /44 HT fi, A,Ax PAGE / OF /

389, FEB 1998 Cla)(b)--1_ COPY 2 - ANESTHESIA PROVIDER

USAPA V1.00

MEDCOM - 20638

DOD-034212

ACLU-RDI 1657 p.198

11/11-.1111 'ill I-It-1'111411 it my.... ...I....A it

For use of this form, see AR 40-66; the proponent agency is the OTSG

03 (..9

z, 0

.1 to F- Lu

,„.1-9 --"' U 17. Lu = 1... co

Z -1-

w

v) 0j'

0(9 0 .

e, 2 2

ct- , Z ,W ma

I- U3 tr) (

z

jD2

oz D

0 F: (j = Z tit .

LA 0

DRUG (Units)

(.8)- j v 00

TOTALS TOTAL EBL Ll. 00 (

-f-key,,,-/ (

5-5- c I e=e7 TOTAL URINE A ,_F-

f

(

VOLAT 6.egm--% del j.

COLLOID-

- II AGENT % e.t. AIR L/Min 0

6:::i

-----S

4 0

9 '

—LL---

'EL (t.

N20 . L/Min

02 L/Min Z

z <

SINGLE DOSE DRUGS-MARK ON GRID ,...%., WITH NUMBERS & ENTER IN REMARKSI

tal 0 0

cO LINE site ❑ Warmed

REMARKS CI III Warmed

..., u- 0 Warmed

❑ Warmed

LOSSES EST BLOOD LOSS UR NE -

PHYS STATUS TIME ♦ - t 'I 03 4 5 E

SYMBOLS: 220 BODY WEIGHT.

KG LB

HEMATOCRIT:

. ,, ,, . ■ ■ I I . ,

BP by cuff

V

A Heart rate

•

Resp rate

BR Inansduced)

T TOURNIQUET

T ----T/

ANES. X-X PROC.0_0

200

180

160

140

120

100

BO

60

40

20

,

......

„

. . , . I

. . "

" ' , . . , , . . ,

,, .. ,, . , INITIAL DATA: .

BP-

, ■ . . 1 . ■ V , .

0 rim mw, Vir.A.WAII,VAIMAY i ' 2 , I

A , '

HR-

EQUIP CHECK

OK? - Y N

-I- --r---,

Mr . PATIENT RECHECK rim ' . .

• , ANIMINION OK for PROCEDURE?

TIME-

wp,

, . . .

. — VT - ml

P I - breaths/min Z / 0 0 I wPeek inf Pres / PEEP >

" \ LI D-b MODE - S( ton), AIssist), Mon) C__

RE ' VERY AT IBP/Auto Cuff I ET CO2 (torr)

1E102 (Frac or %)

Sp02 1%)

-7

FOLD

i By

__ .01 C?"

0

1

I W I BP/oth

OTHER 0 . to . V) meail •

8 I .%

Ix I' line Steth- PC/ES Gas analyzer

ECG

TEMP-site 1-10-

--1\-- CONDITION:

/ 57

TIMES

N-M Block (T/4)

'cg 1 0 i= I z yr Start Room End

0 Warming blkt `I 'i

Cony warmer Ready Begin End Mark with letters & symbols, EVENTS_,

exam n under REMARKS Position -- (3- --,/ * -.2 PROCEDURES and CPT Codes:

ifld 2 , , -- ANESTHETIC TECHNIQUES: Describe block technique under Remarks

- AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

CC-

PATIENT IDENTIFICATION: Typed idli linenentries: Name, Grade/Rate, Medical facility la

00)1b) — 4

nA rnrthn 7q1Za rrn •.I or

SURGEONS:

(6)00) - 2- —

PROCEDURE ov / LOCATION: DATE:

.9_ i O r---0 7 ANESTHEI ISTS:

oc000) - 2- PAGE / OF

COPY 2 - ANESTHESIA PROVIDER USAPA V1.00

MEDCOM - 20639

DOD-034213

ACLU-RDI 1657 p.199

For use of this form, see AR 40-66; the proponent agency is the OTSG E

ST

HE

TIC

AG

EN

TS

AN

D D

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GS

to

2z 0 19 .V-

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<IT1 i )

TOTAL URINE ) )

th 2 th )

rookie_ % del I-3- .2-F VOLA? AGENT FLUIDS - SUMMARY

% e.t. CRYSTALLOID-

AIR L/Min 313' N20 L/Min COLLOID- 02 _, L/Min

SINGLE DOSE DRUGS -MARK ON GRID WITH NUMBERS & ENTER IN REMARKS BLOOD-

cn LINE site O Warmed REMARKS

Code drugs with numbers, events with lettlers

5 I3

❑-- O Warmed

f-.—..--A. J Ti,--rx,

❑ Warmed

❑ Warmed

LOSSES EST BLOOD LOSS URINE -

PHYS TAT US TIME '.03K-- /5----_fes7 ; ‘---- /CO 0 is— i 0 Yr / ''

(7)Vded/

2

ee}.

' obr(v- -17

--7),( r;vikd )7 0'

: /00

I N1 Ot_. 3 n-oc,„4,‹ I-,

1 4 5 E SYMBOLS:

220

200

180

1 60

140

120

100

80

60

40

20

BODY WEIGHT: i , ! KG

LB

HEMATOCRIT:

BP by cuff

V

A Heart rate

• Resp rate

BR (Transduced)

..I.. T

T —

ANES- X-x PROC- 00

—1_1 ,,___ , . _.-I

, .

Heart I I

INITIAL DATA: I I

• , . . . r I

I

BP- . 1 1 NIAI i ,

/frf /Y-12- . D Z

7 //e 6e-(4/c__

z S-7

a-- i

‘2.e1- IX% i

24 ....,to 0 /

7r deiVe7

HR- g" phi ,

. ., AdrO' '

In . ,

, , --,—,--

—,--,— EQUIP CHECK

OK? - Y N

„

-- ' TOURNIOUET PATIENT RECHECK

' T-1- rr-- --i---,

OK for PROCEDURE?

TIME-

—L' -r— MINI

MEP% . '

_1_1_ "

.

40 i ,

.►

, i i

/- E

VT - ml

f breaths/min / e_ __ Peak int pres / PEEP

Ars— ODE - S(pon)..prissistl. Clon) As- RECOVERY AT

PACU ICU Specify, in w Ec

<A ur C../ 0

CC O Z 0

BP/Auto Cuff _,VE CO2 (torr) 3.2- 33 BPloth

ART line

F 2 (Prat or %)

02 (%)

ECG

TEMP-site

l 7

A. 2.7Y /TR

57—

bs-- dO

5", OTHER

S eth- PC/ES . CONDITION:

Sp02

- 6:1( HR- /7 RESP-

BP-

as analyzer

CO

N - WI Block (1- /4)

ANE RES isrPROCE URE S TI

to Start Room End Warming blkt

(32 f /3,7 /5$1 Cony warmer c) Ma lc with letters & SYmbuis, EVENTS Ready Begin End

erpla n under REMARKS Position o MA ff -5.-*- /31> PROCEDURES and PT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks $...

eitiDall ..t,ti —M c . %.-- -ti /7 ;-

PA TIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, AIRWA Y MANAGEMENT: Intubation route, blade, technique, comments Medical facility _/

5- 4AI fit-

(_6)119 ) - 1.-- (19)L6 ) --- Y PROCEDURE LOCATION: DAT E,/:/e) ,Nov ,,y

2111111.-^

PAGE / OF DA FORM 71RA FFR 1 CICIQ

00)1.12 )-z

COPY 3 - ANESTHESIA DEPARTMENT USAPA V1.00

MEDCOM - 20640

DOD-034214

ACLU-RDI 1657 p.200

· mem tobacco: etoh: drugs: sphysical examina bp hr t r pain scale 0-10 heent - teeth trachea...

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