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DOD-029830

ACLU-RDI 1637 p.1

PREPARED BY (Signature & Fidel

DEPARTMENTISERVICE/CLINIC t5b, DATE

PATIENT'S IDENTIFICATION /for typed or written entries give: first, middle; grade; date; hospital or medical facility)

tAi

[11 HISTORY/PHYSICAL

❑ OTHER EXAMINATION OR EVALUATION

111 DIAGNOSTIC STUDIES

❑ TREATMENT

❑ FLOW CHART

❑ OTHER apead

Name — last,

DA FORM 4700, MAY 78

MEDICAL RECORD-SUPPLEMENTAL MEDI, - ,or use of this form, see Ali 40-66; the proponent agency is the Office of The Surgeon General.

REPORT TITLE OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET QA APPR 08MAR89

INITIAL IFT SSESSMENT -,, '---,

N E U R 0

i Time: Cp .( Initals: Time: /960 Initals:11111111 Pupils 3mm P&12-R1---

_...,0_2_ 1 00(3.19- -c)1:>\\ (..A.3 II II _.-I__ 'ft AI a* aka • •

- SS y-)t. -eck) — 0 CP

4CdC Alec, 01-- ('iieelei X 3

g0/77/91eo-15. _f0//6v✓-.4

Sensorium

LOC / GCS

A/S4 C A R D I A C

Cardiac Rhythm

PRI: / QRS: Pulse Strength • 4_ - j • I i ' .

0 th re._.‘ t -<- .) 3^c.,

ek in&VC1

-i Z 4//5?_.6 0.// gxf,e07/1--& Cap Refil / JVD t'4,4 re//// 43 see Edema

Chest Pain r , ass., kiLab eheSt V Se_,

CT) -11/1 0. Ai' (7) In01--esi P --k-Ilf-li-e, G)Mnd

Pa etzi- £4/

R' E S P

!Respiratory Pattern

Breath Sounds

Secretions

Cough

S K I N

Color 1/∎ V.L. ?Or' f\OCfi-

141--1

IG..)_______a_kaaeailcr

(p 5/5ILInc±i_on

EUT.__ LA 301 A yid i---- clurn Ahrinal 714 rete e-

a• 2M --CV

Integrity Backside

I V

Access Devices

Location 0 SA o7C ii-77‘17c5r) Condition

G I

Abdomen 344' 1 ncrri-eindeP CO 'in a l I 4 c.,y,coccirctr*S

Soc/- 217 0.-- gor--)77054eb/e .// 41 'a. ti

Bowe] Sounds Stoma/Ostomy a) Irl6i--fd

G LJ

Device U-6((k N.A...__O MI _

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#4 ---e2r-i41 A f/ Jar C/ear- ///

i/7‘4,-- z/rir, (-- Color / Clarity

USAPPC V2 DO

MEDCOM - 16442

DOD-029831 ACLU-RDI 1637 p.2

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DOD-029832 ACLU-RDI 1637 p.3

,.:AL RECORD-SUPPLEMENTAL MEC ..,ATA For use of th.._..orm, see AR 40-66; the proponent agency is the Office -. he Surgeon General.

REPORT TITLE

INTENSIVE CARE NURSING FLOW SHEET OTSG APPROVED (Date)

QA APPR 08MAR8

INITIAL IF ASSESSMENT N

E U

• R 0

ime: )fps Initals: -,-) (c.t) - 2 Time: 2V-00 Initals: (6, - Z ecrlet Pupils /8-44//iti

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I V

Access Devices Pf6 /0/24A. 6,)/EC Location

/ • i-rif ae--

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---, -- _r at') . A ke 7 -.2,-) Or' _ls 1 r, I I trez-6,

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U Color / Clarity

____ _ I Irnntinuo nn reversPI

DEPARTMENT/SERVI E/CrC

ICU3, PATIENT IDENTIFICATION IFor t n entries give: Name —last, first, middle; grade; date; hospital or medical facility)

DATE

❑ FLOW CHART

❑ OTHER (Specify)

❑ HISTORY/PHYSICAL


❑ DIAGNOSTIC STUDIES

❑ TREATMENT

DA FORM 4700, MAY 78 USA PPC V2.00

MEDCOM - 16444

DOD-029833 ACLU-RDI 1637 p.4

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DOD-029834

ACLU-RDI 1637 p.5

1-e6P rJs

RECORD -SUPPLEMENTAL MEL DATA

For use of form, see AR 40-66; the proponent agency is the Office......fhe Surgeon General.

REPORT TITLE

INTENSIVE CARE NURSING ',V SHEET

INITIAL SHIFT ASSESSMENT

OTSG APPROVED /Date/

QA APPR 08MAR8

Time: Pupils

Sensorium

LOC / GCS

Initals:

C A

R D I

A

C

Cardiac Rhythm _ PRI: / QRS:

Pulse Strength

Cap Refil / JVD Edema

Chest Pain

Respiratory Pattern Breath Sounds Secretions

Cough

Color -- Integrity

Backside

Access Devices Location

Condition

P

DEPARTMENT/SERVICE/CLINIC

ICU3, or written

first, middle; grade; date; hckspitafrpr medical facility) entries give: Name —last,

DA FORM 4700, MAY 78

❑ HISTORY/PHYSICAL


❑ DIAGNOSTIC STUDIES

❑ TREATMENT

❑ FLOW CHART

❑ OTHER [Specify)

MEDCOM - 16446

USAPPC V2.00

DOD-029835

ACLU-RDI 1637 p.6

MEDCOM - 16447

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10 I 11

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12

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13

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14

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15

15

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16

16

16

17

171

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Total

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18 1

18

119

19

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20

20

20

21

21

21

22

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DOD-029836

ACLU-RDI 1637 p.7

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

For use of this torte, see AR 40-400: the proponent agency is GSSG

1 2 3 4 5 6 7 8 afore or Country Code.) A fl' ; , :

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

9 10 11 12 13 14 15

'CO') ,),, ( c.t) - LI 16 17

expo 6, DATE OF BIRTH (VVVYMMO 01 7. AGE AT 8. RACE 9. ETHNIC RELIGION

LA. A..)1(...__. 19 20 21 22 23 24 25 26 27 28 29 30 3 1 BACK-

GROUND (9--q7 a - z -2_ Ez 10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER

35 36 32 33 34 1 37 WI 39

HOUR OF ADMISSION

40 41 42 43 44 45

BRANCO-11 COR •--

10 ( c_ - Li ORGANIZATION (Active Duty Only) 13. MARITAL STATUS

46

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

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

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV, ADMISSION

62 in Country Code)

64 65 66 67 68 69 70 71 YEAR NO

. 20. SOURCE . . Of ADMISSION/ AUTHORITY FOR ..

ADMISSION

WARD

.i',C(A. 5

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

lit AN., 72

ADDRESS OF EMERGENCY ADDRESSEE (Include .VP Code)

tA ./t)

NAM

2 . TYPE OF DISPOSITION , _ SFERRED TO

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

23. DATE OF DISPOSITION (V VMMOD1

73 74 b L I) L

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

0 42 1 ?

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

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

Pc- E Pt- ft" (1) 3 (1) 9 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IY VMMDO)

103 104 (Battle Casualty Only)

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

FOR LOCAL USE

U 1 (u 1 i -1-13

b Cc.6- Q

ADMITTING OFFICER (Signature, as required/

DA FORM 2985, MAR 89

MEDCOM - 16448

USAPPCV1.0

DOD-029837

ACLU-RDI 1637 p.8

SIGNATURE OF ATTE NG MEDICAL OFF

• DA FOR MEDCOM - CI,V1/1•1 rsr • • -re nne•on• r-rr

•

. INPATIENT TREATMENT RECORD COVER SHEET b(C52, For use of this form, see Ali 40-400; the proponent agency is OTSG

1. REGISTER NUMBER

411.111111 2. NAM La First. Mt

8tENGTWOF

4, SVC

791,A)

19. ETS

. DE

1 . PREVIOUS A DOB

ADMISSION REMARKS

i \ .

4. SEX

in 5. AGE

az; 6. RACE , 7. RELIGION

•••••••• 11 HAP

-O‘ 4 q 13.

-

12. SSN ORGANIZATION

4. _.... .

14. ' WARD ...---

15. FLYING STATUS

A ...) 0

16. R DSG

,...,..---

U. DEPT./ ,. BEN

K"-----iF 18.

. BRANCFUCORPS 19. uIC/ZIP 20. TYPE CASE

lobei- 21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

D/recr - ..om ,:e.e 22. HOURS OF

ADMISSION

IN5 23. CLINIC SERVICE

19--E /4-A- 24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

tLK-- 25. TYPE DISPOSITION ,

le.ev all 7 26. DATE OF DISPOSITION

17 i 27a. ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

a fLif--

27b. TELEPH• NE NO. .

61 /7.1C.

28. DATE OF TH‘4 ADMISSION

/161-u403

ADMITTING OFFI

pe,

29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

3 1 . SELECTEO ADMI NIS

30. DATE OF I

,

AL ADMISSION

32. UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED

Check if Continued on Reverse

33. CAUSE OF INJURY

34. OlAtNOSES/OPERATIONS AND SPECIAL PROCEDURES

.69,() czo CailA04it

35. Total Days Tis Facility

C. CONV. LV/COOP CARE D

a. ABSENT SICK DAYS

36. Total Days All Facilites

d. SUPPLEMENTAL BED DAYS CARE DAYS

0 e t. TOTAL SICK DAYS

3 b. OTHER DAYS

a. ABSENT SICK DAYS b. OTHER D YS .A\3 CONV. LV/COOP d. SUPPLEMENTAL CARE DAYS

I. TOTAL SICK DAYS BED DAYS

DICAL RECORDS OFFICER

CARE DAYS

DOD-029838

ACLU-RDI 1637 p.9

MDICAL - RECORD

PliYSICAL E XAMINATION :

. • ---ABBREVIATED-AEDICAL- -RECORD-- •

PERTINENT 14ISTORY.i.."FnErCOMPLARVLAX ON ADMISSION f F:atir rifift of

(

PROGRESS , 1•:ater dote of •if,filarge Grp/ distino.in

.midelle, &ids dAte: ',aspire: or rnecfrcel.tectiity)

SIGNATURE OF'PHYSICaff • - DATE IDENTiriCATION i 0.FAGANiZATiON

wARID NO.

(A. - ASBREVIATED MEDICAL RECORD

Standard 797311 dad GENERAL SERYtCES AbmiwTRATION ;AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA i41 CFR` 201-45,5C5. OCTOBER

MEDCOM - 16450

PATIENT'S IDENTIFICATiON (For typect ot written entrieb peer Name lasr. firer.

r 'MOISTER NO.

DOD-029839

ACLU-RDI 1637 p.10

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

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

IA k A(30 3

903o

\t, 0A„,___.ea Si P GS/,\DO, Ca

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A 0 ::14

46 UppeA-414cpih HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE i

RECORDS MAINTAINED AT \-/ '

SPONSOR'S NAME mu NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (for typed or weten entries, give . Name - last, first, middle, ID No or SSiV; Sex; Date of Birth;

,...41111111111

Rank/Graded REGISTER NO.

rn(>1)7— CHRONOLOGICAL RECORD OF MEDICAL CARE

• Medical Record STANDARD FORM BOO (REV. 6.97)

Prescribed by GSAIICMR FIRMR (41 CFR)201-9.202.1

MEDCOM - 16451

USAPA V2.00

DOD-029840 ACLU-RDI 1637 p.11

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USAPA V2.00

MEDCOM - 16452

DOD-029841 ACLU-RDI 1637 p.12

(

2 ) pc \I

MEDICAL RECORD I PROGRESS NOTES

DATE NOTES

V-PW uk..ii)3 0 55" •.-e--F1, ca IQ- 4ZP, V3C-7° — \L-S5"' r\ 0 C/ ?63‘1 @-;t\''‘--S

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER

(SSN or Other) LAST FIRST MI

OEPART.ISER VICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (Far typed or written entries, glee: Name . last. !'at. middle, I ID No or SSN; Sox Dote of Birth; Rank/Grade)

REGISTER NO.

vl_r_ti .. &J f? PROGRESS NOTES

Medical Recoid

ePkD MEDCOM - 16453

STANDARD FORM 509 (REV. 511989) Prescribed by csanon FPMR 141CFE0 101 - 11.20314)11 (4

USAPA V1.00

AUTHORDID FOR LOCAL REPRODUCTION

DOD-029842

ACLU-RDI 1637 p.13

: or typed or written entries, give: Name • last, lust, middle; ID No or SSN; Sex; Date of Birth; Rank/Gredel

No ( (fl 'H MEDCOM - 16454

MEDICAL RECORD rm.. caunvr...1 FUR WWII-nu-m.1u LI 1. Hun J PROGRESS NOTES .

DATE NOTES

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME UMBER LAST FIRST MI (SSN or °timid

OEPART.ISERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. snsas) Prescribed by GSAIICMR FPMR 14ICFRI 101.11203041W

USAPA VI 00

REGISTER NO. AR 0. 6,5-L._

DOD-029843

ACLU-RDI 1637 p.14

MEDICAL RECORD PROGRESS NOTES DATE

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

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

PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR 141

USAPPC V1.00

MEDCOM - 16455

DOD-029844 ACLU-RDI 1637 p.15

DOD-029845

MEDCOM - 16456 MI11111.011

yr

•■•11 .,aiNI4 NRIMNIMMOMPINIMMOIMMIIMMIMMINININ OA. 41...p.....1°..1.2."..1r2tocrl

MEDICAL RECORD CHRONOLOGICAL RECORD OF IIM3OICAL CARE

PATIENT'S 1111301i1CATINt rue tweet ar memo esurka. Ow= Mobs - bat Sat. mai= NM or SS* Se=

.13gase of Sith; 01011115)0000

CHRONOLOGICAL RECORD OF MEDICAL C Medical Record

STANDAbyRD FORM 60D akEv_ 6-971

Peaseas4 -66ANCINI FIRMA 141 M* 1 20/-9,202-1 - g2.

ACLU-RDI 1637 p.16

NSN 7540-00-634-4176 AUTHORIZED FOk LOCAL REPRODUCTION

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

4)YN:56,-:- C-

1 • . 1 x . `.- - 5 1 ? .SOC"- t_1SS (It- GSAOca(k-1A-k. le-

---Yce_--P,--ta -e asr.c ei./ Y-e-leir io■ ,--a d fe., SS \ il E-S _ate- Co c----\6 r....1"re- Ax-es_s ' , N-5 %I. S> uk r k \ tiNDou,,AAs gcci,L,L 0C+/—e-^—

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

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

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

REGISTER NO. WARD NO.

E 11111/ air MEDCOM - 16457

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR FIRMR (41 CFR) 2014.202-1

DOD-029846

ACLU-RDI 1637 p.17

NSN 7540-01-075-3786

MEDICAL RECORD EMERGED CARE AND TREATMENT

(Patient)

LOG NUMBER

RECORDS MAINTAI

TREATMENT F CI

AT

AO 2.) -7-/ PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL

STREET ADDRESS DATE (Day, Month, Year)

14A-Vel 0 3 TIME

10 5 CITY

,

STATE ZIP CODE TRANSPORTATION TO FACILITY -

A4,4/A-c., SEX

?...d.....

DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

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

AGE HOME PHONE FLYING STATUS DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

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

0 YES n NO IS THIS AN INJURY? WHERE TETANUS

ALLERGIES

i

INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTI IAL SERIES

0 YES 0 NO

CHIEF COMPLAINT

CATEGORY OF TREATMENT s.._..-

VITAL SlithrTS

❑ EMERGENT

1:1 URGENT

RNON URGENT

TIME TIME

BP NV V) PULSE c?

INITIALS RESP it TEMP

WT

LA

B O

RD

ER

S CBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT SM3O

U0

A

b1:1- X

CXR PA & LAT/PORTABLE C-SPINE URINE C&S UA MSCC/CATH CHEM: ACUTE ABDOMEN LS SPINE BLOOD C&S X SINUS HEAD CT

ANKLE R/L

ORDERS ri-RULS E OX MONITOR ECG TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION n HOME n FULL DUTY

DISPOSITION QUARTERS /OFF DUTY n 24 HRS. n 48 HRS. D 78 HRS.

PATIENT/DISCHARGE INSTRUCTIONS

MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE

❑ UNCHANGED • IMPROVED

• DETERIORATE

ADMIT TO UNIT/SERVICE REFERRED lop. TO WHEN

TIME OF RELEASE I have received and understand these instructions .

PATIENT'S SIGNATURE PATIENTS IDENTIFICATION (For typed or written entries, give: Name — last,

first, middle; ID no. (SSN or other); hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GS/VICMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 16458

DOD-029847 ACLU-RDI 1637 p.18

PROVIDER HISTORY/PHYSIC

65a.9 z

tr f,,eple•

S/7

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

I

TEST RESULTS

ABG/PULSE OX RADIOLOGY q Check if read by radiologist

WBC

H/H

3,6 PLT

A 711 -

7.'4N OTHER ' PCO2

DIP

MICRO

RESULTS

?ErAff A

EKG INTER RETATION

FPA-1) Vt° di/ ( 5'.

I/ :6 '0- eassof

BHCG ETOH

PT

U SUP 02 PH

SAT -- •

APTT

P02

CONSULT WITH ACTION REST

7-- - F9

Abti 0-toe /t,

RAZ-- .4 7z -cee-a-

5, 6-

kci

TIME

Scarte--- k 9, et.,

DENT/MEDICAL STU

Mtal

G -es

SK-

IGNATURE AND STA

5.A t

P

DIAGNOSIS 6,-4,, c /-1-4 0- ca

0

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

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(6)(10) USAPA V1.00

MEDCOM - 16459

.s-4‘,0752_ /,14-4144-

DOD-029848

ACLU-RDI 1637 p.19

4TH FORWARD SURGICAL TEAM PATIENT RECORD

DTG IN: - "1 / (3 I ,... f ..1

J TIME OF INJURY: ,

AIRWAY: ORAL NASAL TO OR: ,---'

DETAILS OF INJUR TNT: NbIrVI. (111(11 CalS

NAME: ilk gLO SSN: NI Je UNIT: CHEST: itcmtac ,scarc Or

GAL RIGHT BS= t-OkhO erctrikt@t.

WT LBS: WT KG1.\- ALLERGIES: TA

NEURO: GCS= ft+-0

.

TIME /

4.12.0

IV

2

SZ

11111Lii MIMI

SITE tM711S,111 , CS PRIOR TO ARRIVIAL= . _ .

-

I

TR.: Pa•k

a0

CT #1 & SITE:

HEAD, FACE, & NECK:

CiS- 4 ITERS OF FLUID IN:

t /..g. I L'Dp C,c,e9/0---\. 4_. --- Y.)

UNITS OF BLOOD IN:

BDOMEN: ' )( L( %OAS

PE & DOSE

lcil,c7, Atl i UPPER LEGS:

- squp.ramiL,„m , TIME INTERVENTION LOWER LEGS: 4) 3/- Si ep„,1s2_,--ptA9.4e_. +.0 i di 0-4112.4

1 I •

' OXYGEN ON & RATE: ETT SIZE: SURG. AIRWAY ARMS: 4a luD a,/-"W‘ CT #2 & SITE: FOLEY POSTERIOR: ir f

OAR 4AC14-1,431:71,v(161 0 GASTRIC

ix (;)

cn 44 = E. (et) W Z -*I

TIMES MEDICATIONS •FLUID- TOTALS VITAL SIGNS IN: MIDAZOAM CRYSTAL: -

COLLOID: -- TIME:

BP: q I S )5 e3

.3b 3g

i - INC [SION:

4TIBIOTIC: PENTOTHAL

PROC. END: ETOMIDATE FENTANYL EBV :

EBL: HR: RR:

.. / ,

9' 11,1 illirThil q

EN

MI TO AC W: REVERSAL:

MSO4 ANESTESIA TECH: SUCCINYL. UO.: Sp02: w .

MAC: ROCURONIUM OTHER: DRAINS. TEMP: REGIONAL: VECURONIUM

AGENTS: ■

GENERAL: • L'146 4 FiD 4k)C4

a fra 0> U w g

TIME IN: 02 VIA IV SITE RE-EVALUATION POST-ANESTHESIA RECOVERY SCORE

SURGEON(S): .i. 1.\(.3 6)-7 IV SZ SITE RATE AB IN BAG

PROCEURE: Ig irk w. ',AI& wan ADMIT= 30 MIN= 1 '. 1)4" bg S

x, IfC,1 ILI " en4-1 Y 1" e,y.. ) f DIC=

>., fami iiriA

11 i ' •A 6 .4. S .: 12 A IW • LA Q .. di - ALM

'RES GS: KVAIIMINIElraMMICEEMMEI

POST-OP MEDICATIONS VITAL

ADM SIGNS IT D/

TIME MED & DOS ROUTE BP: INEMIleja P

MIAIIEVAI wom m in

7mummPonen= HR: 41 RR:

TEMP: 7 7 g20 2 q k ' I 1

1 CUMULATIVE I & 0

TUBES: INTAKE OUTPUT SOURCE AMT

PSOURCE AM/T

W ailarglir I

DRAINS:

TCY1' A T = TOTAL= niim-v-srInn _ I RA Pll

DOD-029849 ACLU-RDI 1637 p.20

i -STAT EG?+

Pt: 00

Pt Name

Ha 140 001/L

K 4.0 mmol/L

TCO2 27 mmol/L

iCa 1.21 mmol/L

HCL 45 '.PCV

Hb* 15 g/dL

*via Hct

At 7C

PH 7.424

PCna 38.8 mmHg

P02 62 mmHg

HCO3 25 mmol/L

6Eecf 1 mmol/L

s0a*

*calculated

Sample Type_:

14FE803 14: a2

Oper• 0000000

Physician:

l'Ser# fillip Ver: JRMSO44C

CLEW R89 JAO LOT 98 / 8bT 86 ZS 00:0T AJO ETT BB / E9T 66 ES 05:14 JAC VTT E6 / 6ST 96 S6 SS:17T AJO !MT 08 / EST 56 66 00:ST AJO TOT 08 / EtT 86 L8 90:ST AJO 90T T8 / 5bT 15815 88 OT:ST JAC 1011135 96 Co ST:ST AJO HMS 66 68 OE:ST AJO 46 41. / OET 0 Z8 TEST AO 96 9L / BET 46 SB SO:ST

HO sHuu % WIR WW:HB _____ BB NUN - UI0 / SAS ZOdS NIL

E0/0T/80 ON32l1 EIBIB

MEDCOM - 16461

•

DOD-029850

ACLU-RDI 1637 p.21

511-119

NSN 7540-00-634-4124

MEDICAL RECORD VITAL SIGNS RECORD • HOSPITAL DAY t

POST- DAY

MONTH-YEAR DAY 1 -i %'5 IL. I3. 1.., 19 HOUR

PULSE TEMP. F (0) (-)

180 104°

170 103°

160 102°

150 10

140 100

130 9

120 8°

110 7°

100 96°

90 9

80

70

60

50

40

4

RESPIRATION RECORD

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HEIGHT: WEIGHT .--1.

PATIENT'S IDENTIFICATION (For (SSN

typed or written entries give . Name—last, fist, or other); hospital or medical facility)

middle; ID No. REGISTER NO .

\c) VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 16462

DOD-029851

ACLU-RDI 1637 p.22

Ward/section: - : ! :11. : 11.i (f:

REQIX. ;17-.t.i..A.-:„.7,___ . - , 7. r' 7''il9'...7 ' 14' -...'

-

...CHEMISTRY_RESULTFORIYI . (Stil) r i to the Privacy Act of 1974) (:;::= '

LAST,.FiRS., ,b1

.

.. '.

DATE . T13.a - ,, SSN/PSEUPO S .1,1; ._ .,i .. i...Ji 1.;'4,! i

... P

. : ; 1 .., 4 , 1*.

:r. ..4., ,,,,,,, , :-...--,,,, ..), ,.::,.:c.... ,.... - _ ,et! . * -;oci,p, t ,,,„, TEST RESULT .

'i i . :,.' . - __REE RANGE LI i 1 ...1";

. __TEST_ I1 __RESULT • ' ; 1 1 •

I_REF. . ..: LI ZiAirr•ii I -". ...i - :

_TEST.::.:..R.ESULE : 3A 1 13,.._;

, &INGE _

• a ' 138-146 rnmp1/1- - _ ... ...

,, r ----73-118 mg7c11".•

3.5-4.9 %Ili:41914y' PI CCOLO 1

14/08/03 17:26 REFERENCE RANGE : MALE PATIENT # :111111 .::) IL.c.)) Li METLYTE 8 1 DISC LOT # : 3152AA4 0F;ER ft : 1.11 DR #: 000 SERIAL

3LNIAL #:

GLU 94 73-118 MG/DL BUN 11 7-22 MG/DL CRE 1 0.6-1.2 MG/DL CK 824* 39-380 U/L

Cl

-

___

- 7.77------' ---; - -7;22 eig/dl -- ...

,,,. ?8- Ig9 mm°vL CA++ :. ,...4, 1 r 8.0,10:3 nie/d1 - 7

pH —... .-. -. -7..31-7.45 -- -- 0.6-1.2 mg/dl..__..

PCO2 35 45 mmHg (T. 4i-51 miajg (yea)

,' - i 128- 1 triotil 45 rn

3.3 -4.7:mnolt1 i PO2 80-105 nunlig lam,

14/A (vela'_::..'': .._

+

TCO 23-27:Mniotil. Carr 24 -29 InrnoUL (vet

9.8:108 mmol/1

HCO3 22,..24 minwoo 2S.-28 nupol/L (vct

18-33 111117104 .1.::;

s02 95-98% ... -'''L . .. „ FAA - t- OA'

BE-ed -- • (-2):.- (t3) --;-;-- 1mn°11-;

-TEST --. -RESULT -REF:RANGE

AriGap ___....., 10-20 -amnia: '

• • - - ALB

__ . .. _T ,

I., , ; _ 3 5 _edi .__,.._ _

.3.5

- 73.: , , Ca V.12-1.32 mmobi NA+ 133 128-145 MDR._ . ■ ., ,

_ _26-84 a/A__ ____

BUN 8-26 rag/di Ki 4.7 3.3-4.7 MM0f/L CL- 99 98-108 11101?/L

T __, .... ____ ... i

1047 ail _._.... .,.. ._._...

GLU ' -' 70-105001 tCO2 19 18-33 11102/1._ AMY •- • ' ; 14-97 till1 • •

Creat 117-1.5 'g/di I NST GC: OK 01-EM GC: OK AST 11-38 u/1

Het 38-51% PC11 1--EM 0 , LIP 1+ , ICT 0 TBIL 0.27 1.6 rag/d1

Hgb .• . .. ,.......... - 4-1-17. ea_ 1 SST....._._

. . TP ; -..

__..__. 5-65 .1uAL . _

i ..7:::% .•:■.',

6.4-8.1 gidl ... .

•TEST ,

Tropirt-1

RESULT. REF.jRANG ..: . 616itile'ctiti '• • --e .

---.—"—;:'i77 REF: RANGE

Drug of Abuse .i.: 1 r." - IU-.

-;:::,.:::: !

:', .1 ' i L

-1284,45 mmol/1 --=

) ?:' .-.

3.3-4.7 mmol/i

, , ., : ■ ,. , _

Ty .- 11 ko I

CL.- . ---- ,..-;----, :-,i 4.4. 1

..21710111R.111.1J1-_, ! ..

.__ ..___ _ -- 1 I WO -- 1- -- - - 18 -33 torno1/1 _ I 1-..'11

REMARKS: ----- -- - - --- , ; -2, , Z.:b . _ . .

REPORTED BY: ------- - • - - -

---

DATE:- -- - ' -

.• 71:7/. ri.-..7-. q-,-Z-. .....,

-LAB ID NO.: .-------- -- .---- 1,------... ;; t .., ....-z, -.,..7-. ...-.1.-i ::-...1.r: 1,

-.... -- . . . .

MEDCOM - 16463

DOD-029852

ACLU-RDI 1637 p.23

Ward/Section: L. REQ

LAST, FIRST MI.

;;4114'gY) c.

(TEST RESULT REF. RANGE TES

I

"Color

App

Glu

Bili

•Ket ; -

SG

"Bld

pH

RBC -Morph

Spun Hematocrit

Count

Diectigen

...Negative

42-52% (M)" 37A7/0 (F)

Sed Rate

Other

CSF • . •1

IllogiBaqk • , -. 4... •

, MUST. STIOI4t.j.0.50 WITR -EVERY UNIT REQUESTED

Negative ABO/Rh

IAN: 1\0

DATE TIME

RESULT.- :REF.-TRANGE

N/A.

Negative

LABORATORY RESULT FORM (Subject to the Piivaeji A:a -01,1974)

SSN/PSEUDO SSINT:

Misc. Serology - -

TEST RESULT REF. RANGE

RPR- Negative

Mono'

motive

Microbiology

Negative .

Negative

Negative , ;

WA —

.S.curce. •• Gram-Staik "'" Oce Sid

r •

H. pylot

1 1

Negative:

IlegaqY9 ": ;

Parasites • Prot -

Negati

Malaria - .; -

Urob

0.241.0

0 & P —

ympti Baso

Nit

Negative Other .._

Atyp --Imm Leuk

Ne F9ropic

Coagulation Studies Blood. Bank thiit ST SUBMIT SF,SIBWITil gy.mx_Oar

:..14,EQUESTED) .

TEST_ RESULT REF. RANGE _ _ UNIT

TYPE -

r CROSSILITCH

PT

AM

D dimer

FDP

REMARKS:

9.8-13.6 secs

21-34 secs

<20 ug/ml

<10 ughni

'

REPORTED BY: Millignel DATE: LAB ID NO.: . ---

MEDCOM - 16464

DOD-029853

ACLU-RDI 1637 p.24

‘)

‘tk

C0141-CAL RECORD . DOCTOR'S ORDERS b ( z ek

For usn-of this toren, see AR 4D.;8.6., the priiparierrt agency is crrsp 00 ,c.."

RECORD DATE TIME AND SIGN- EACH SET•OF ORDERS. IF PROBI_EM ORIENTED MEDICAL RECORD SYSTEM. IS USED., WRITE PROBLEM NUMBER IN COLUMN, INGICATED BY ARROW BELOW. _....... •I'T..1F.NT LOENTlfreATION.:: • •,' •••• DATE 9 0. :'0-1'1601':: ... TIME:.::00,

1 4:: .A.A.1 . :...:0 ̀..-3, _ ,,.,:, •,,. - ..-...... .• - • , -..:. : ,.,..*-1664it. - . e f. 0 -..:.• - . _Art...„-J4---.:- • ., ,,..•...d...... . 5 c., s / . .6D. D. C...-Q-;'•

...L.-. :...•:-.44.7.t."...'''''' H' : . ' -1. .

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14.0TEO AND stoN.- •

ROOM

. PATIENT'

1110:I?

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NURS.UNIT ROOM.-NO

Jc-L 61) • • PATiEN T. TOBN•TIFIC:ATION

ROOM NO. alp [ A4TE.•:-00-000.Eft: :TYfME OF. ..0ROEFI:'}' -

•

•PATIE•NT 1.00.NTT•teArt.0N.

NURSING UNIT

REPLACES ern -riots' OF ,t - JUL- /7,1 WHICH MAY RE USED MEDCOM - 16465

DOD-029854

ACLU-RDI 1637 p.25

• - Uuric DOCUMENTATION CARE PLAN -ML,iv-ME:D/CATiON)

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

A4.0. DO -3 VERIFY BY INITIALING

CLERK/ NU

;41girialrig.r; ', .1;fte'tf: INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

RECURRING ACTIONS, FREQUENCY, TIME

HR COMPLETED ti 1 go 1 v DATE

, . 21

as -eot . ot(* 1 J vt)y t)

2..1

\i L

L

P.-

/to - 1., ' , )r- I , Atr?-0 ..., tig ...- / 1 -- - - S?,1 ' (,)a z.d..5& a) / (

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ALLERGIES: • YES IIII NO PRIMARY DIAGNOSIS:

GS i"- PO c-c'tC/44)9 ADDITIONAL PAGES IN USE:

I I NO

NO:

.YES

PAGE

PATIENT IDENTIFICATION:

. ...---7 LAJ

ACTION TIMES

U (Q - Li\

USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78

EDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00

MEDCOM - 16466

DOD-029855

ACLU-RDI 1637 p.26

Verify by Initialing

,,,,,../ 'THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) Mo g--.......;a::

Order Date

Clerk SINGLE ACTIONS Date to

be Done Time to be Done Time Done Initials

■ a C\O-4 \"Y —. Oc--. \. 0

t \ / 1 0(9 723

DE --,--caf)-C> 1/0 Cos ■,‘,.-c how t -,c)

At:

3

Order/ ExP ir Date

Clerk/ PRN Nurse ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

_ .. ._

USAPA V1.00

MEDCOM - 16467

DOD-029856 ACLU-RDI 1637 p.27

u)- CLINICAL RECORD THEPPEUTIC DOCUMENTATION

see AR CARE PLAN (ME viCATIONS)

For use of this form, 40-407; the proponent aggnc is the Office of The Surgeon General. gia5 Mo. Y

VERIFY BY INITIALING ig;;;M::;iiii;i:MENN•NCEi13>eingiiiin INITIAL PROP ER COLUMN FOLLOWING EACH A DMINISTR4TION

ORDtR '' DATE

CLERK! NURSE

RECURRING MEDICATIONS, HR DATE DISPENSED

DOSE, FREQUENCY li 1 _Ai ;

IIMIIIIIIIIii illEff

1111111.11 \ -

- - - - C18° il rCeK t ,,, I' ar..

7 I P - ' I. i V

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4 . I Ira.

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- - - 6? \A> lz riqr 18

ALLERGIES: n YES - NO PRIMARY DIAGNOW, - ADDITIONAL

s IADQ-j• C° ICI-ONI% \-N

PAGES IN USE:

IIII YES I. NO

PAGE NO.

PATIENT IDENTIFICATION: DISPENSING TIMES

ecit USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14

11111 NE3 ( 4) - V, 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 - 16468

DOD-029857

ACLU-RDI 1637 p.28

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) 7Mo. Yr.

Order

Date Clerk/ Nurse

SINGLE ORDER, PRE -OPERATIVES Date to be Given

Time to be Given

Time Given initials

; .

- .

,..

, .

Orderf Clem

txaPteir Nur e PRN

MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED

- Ilk - 1-4Z)41 (DSD a.._! 141K` ,. • ffklA3 I%di ' • <

al

'.. V.

I 0 - - - - C (;) Op r-_?gir■ 1

_ _A__ r0C6/- * - Pa gal liA 4' 1144 ick30 Alo.., _411F

,,, ,-,,r to

USAPA V1.00

MEDCOM - 16469

DOD-029858

ACLU-RDI 1637 p.29

7. LAST NAMI. PAST NAME /NOM ET MINOT/ RAM/ GRADE MALE , HOMME

PENAL/ /FEMME

SSKI NUMEAO MATRACULE SPECALTY CODE /GPM RELIGION/ RELIGION

X LAMT/UNAlt

WKS ELEMENT NATIONALITY I uArioftwure

Alt AF/AI WM MVM

BC/ BC I NEN / BNC 1

DISEASE 1 MALAO ■ E I I PSYCH /PSYCH

3. INJURY

FRON

/ ILESSURE

I' / DEIMOS

..,

le _IL_

BACA

S.I

/ ARRIERE

AIRWAY i TRACHEE

HEAD/ TETE

!r

WOUND / BLESSURE

NECK/BACK NIAJRy I

BLESSURE AU COU/AU DOS

BURN /111AOLuRE

AMPutATION A AMPUTATION

STRESS/TENSION _

OTHER (Specify), AUTRE (SptuReN

A. LEVEL OF CONSCIOUSNESS / NIVEAU DE CONSCIENCE

ALERT, ALERTS PAIN RESPONSE /REPONSE A US DOULEUR

VERBAL RESPONSE , REPONSE AERIALS UNRESPONSIVE , SANS REPONSE

S. PULSE /FOULS TIME /HELM S. TOURNIQUET I CARROT

n .0 , HON r---1 YES/QUI

TAAE ; HEWN

T. M °RPM! A MORPHINE

1"-1NO/ NON f--1 YES / Ow

DOSE 'DOSE TIME /INURE IL IV / P., 1 Mst.A.,-.I.RE

/ .

S. TREATMENT /OBSERVATIONS , CURRENT MEDICAThALIERGAII / ANC (ANTIDOTE) TRAITEMENT/ OBSERVATIONS • AREHART MEDSCA / ALLEKIES / ANTIDOTES 1

',... ,.._ A 6..S A -4:2 i(Z;)

04 .,.-

/6- C." r Li C,.....44e - Satt a..s.A./5

#1 57.

ID DISPOSITION I DISPOSAPON RETURNED TO DUTY / FIETO ' ME / Wpm

A EVACUATED / EVACUE

DECEASED A DECE OE

It. PROVIDER/UNIT/OFFICER Mil:OCALA /UNIT/ DATE/DATE (rrupADD)

DD FQPRN , mb PORN relation ARA NO teRtiOnS DEC tI al OD Fens IMO *Rd DO F.,

1380 (TIM whkh Pn otemgett.

U.S. FIELD MEDICAL CARD FICHE MEDICALE OE L-AVA/IT ETATS-WEBS

MEDCOM - 16470

ACLU-RDI 1637 p.30

1 . REPORTING NM 2. MTF LOCATION )MISSION AND CODING INFORMATION

For OW ot this torm. see AR 40-400: the proponent agency is OTSG

1 2 3 4 7 a (Stare or

ccoc,ounar.7 A D ..

-- 3. REGISTER NUMBER NA erra'st, First, Middle Initial)

b1 0)-

4. PAY GRADE 5. SEX

9 12 13 14 15 1.6 17

er 18

6. ATE OF BIRTH IVY YYMMDDI 7. AGE AT ADMISSION 8. RACE 9. ETIIC

ex_ OUND

RELIC! ON

OPZZ-, 19 20 21 22 23 24 25 26 27 28 29 31 a-r3-

1 30

10. LENGTH OF SERVICE ETS 11. MP 12. SO AL SECURITY NUMBER

32 33 34 35 1 36 MeelliierUMMETIIIPTIIIINIIIrml

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

ADMISSION .

:7214.)t?

BRANCH ! CORPS

-OW 46

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

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

17. UNIT LOCATION (Stare or 18. MOS 19. TRAUMA PREV. ADMISSION

64 65 cun 68 69 70 YEAR NO

62 63 Country Code)

20. SOURCE .ADMISSION

Of ADMISSION/ AUTHORITY FOR

(_1) '--P--

WARD

224

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

0404.-- - 72

ADDRESS OF EMERGEV;EZSEE (Include ZIP Code)

2 .

_ 1TELEPH0NE NUMBER OF EY ADDRESSEE ,0

RRED TO 23. DATE OF DISPOSITION (t' YM/HD D)

73 74 75 76 77 78 79 80 81 82 83 84 85 86

5 3 0 S i g•-• 24. CI. NIC SVC - ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y YM MOD)

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

72 .

Ammo" Num 3 - D

0dm 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IYYMMDDI

103 104 Mettle Casualty Only)

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

FOR LOCAL USE

bk .. CeSw*-(9-, CaJf/V-4,6jii, roc, • g A4,5

,9---.

et V

1 ‘ .

ADMITTIN OFFICER ISignalur , as required) CLERK

DA FORM 2985, MAR 89 ' MEDCOM - 16471 USAPPCV1.0

DOD-029860

ACLU-RDI 1637 p.31

, 5.1F.N7 Si . s•

DA FORM 364,,

_1 INPATIENT TREATMENT REDOR far use ef this tom:, see AR 40-400, the p:cpcnerl i> OTSG

Ar.,.4'.SS::.N

Um kvio, Ll'ac-ir KRA—c- O SNS

1

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MEDCOM - 16472

DOD-029861

ACLU-RDI 1637 p.32

PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Enter dare of admission)

PROGRESS (Enter date of discharge and final diagnosis)

141.2

MEDICAL RECORD ABBREVIATED MEDICAL RECORD

t PHYSICAL EXAMINATION

14e,c 2 01

e; grade; dare: hospital or medical facility) or wrinen entries give Name last, first, WARD NO.

ABBREVIATED MEDICAL RECORD Standard Form 539

GENERAL SERVICES ADMINISTRATION ANO INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR i41 CFR) 201-45 505 0000E91975 OSAPEC Vi 00

MEDCOM - 16473

GATE ORGANIZATION IDENTIFICATION NO.

REGISTER NO.

DOD-029862

ACLU-RDI 1637 p.33

CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE

/ 05.

SYMPTOMS, DIAGNOSIS, TREATMENT, TREAT' -,ANIZATION (Sign each entry)

_ ---

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SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: If& typed or written entries, give: Name - last first, middle:10 No or SSN; Sex; Date of Birth; Rank/Grade.! REGISTER NO. WARD NO.


STANDARD FORM 600 IREV. 6.97) Prescribed by GSAIICMR FIRMR 141 CFR) 201-9.202-1

USAPA 02.00

MEDCOM - 16474

DOD-029863

ACLU-RDI 1637 p.34

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USAPA V1.

MEDCOM - 16475

DOD-029864

ACLU-RDI 1637 p.35


MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE

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

1(‘' 41-r -Refe\AA fit-Proyy) .71/C, i Tab, p.wp 5, F

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SPONSOR'S NAME SSNII0 NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: 1 REGISTER NO. (for typed or written entries, give: Name - last, first, middle; ID No or SStV; Sex; Cate of Birth; Rank/Grade.)

ex \Ss'

V MEDCOM - 16476

WARD NO


STANDARD FORPA 600 1REV. 6.97) Prescribed by GSAIICMR FIRMA 141 CFR) 201.9.202-1 USAPA V2.00

DOD-029865

ACLU-RDI 1637 p.36

\D C - 2 -\,\

DOD-029866

DATE C°A"—Ar Pie L2, r , BP 11,/aos- . ---17161-744ad

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MEDCOM -16477

(REV. 5-971 BACK U•V2

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

ACLU-RDI 1637 p.37

► SN 7540-00434-4176 AUTHORIZED FOR LOCAL R

MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE 1 SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)

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MEDCOM - 16478

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DOD-029868

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DOD-029875 ACLU-RDI 1637 p.46

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MEDCOM - 16503


STANDARD FORM 509 (REV. 5/19991 Prescribed by GSA)1CMR FPMR (41CFR) 101-M203(6)(1 01

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DOD-029892 ACLU-RDI 1637 p.63

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MEDCOM - 16504

DOD-029893

ACLU-RDI 1637 p.64

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MEDCOM - 16505 0 58

DOD-029894 ACLU-RDI 1637 p.65


MEDICAL RECORD

PROGRESS NOTES

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


MEDCOM - 16506


STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.2030311101

u-SAFA vi.00

0 D

DOD-029895

ACLU-RDI 1637 p.66

PROGRESS NOTES

MEDICAL RECORD

PATIENT'S IDENTIFICATION

fFor typed or written entries give: Name • last, first, middle;

grade; rank; rate; hospital or medical facility)

\,\

PROGRESS NOTES

Medical Record

STANDARD FORM 509 MEV. 7.911 Prescribed by GSAIICMR. FRMR 141 CFRI USAPPC V1.00

MEDCOM - 16507

DOD-029896

ACLU-RDI 1637 p.67

REGiS-CE F.O.

- • • D 1-T

MEDCOM - 16508

PROGRESS NO-TES

MEDlCAL RECORD

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DOD-029897

ACLU-RDI 1637 p.68

DATE NOTES

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MEDCOM - 16509

DOD-029898

ACLU-RDI 1637 p.69

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MEDCOM - 16510

DOD-029899 ACLU-RDI 1637 p.70

MEDICAL RECORD PROGRESS NOTES

DATE

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PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 7911 " Prescribed by GSA/ICMR. FIRMA 141

CFR) USAPPC V1.00

MEDCOM - 16511

DOD-029900

ACLU-RDI 1637 p.71


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Cbt (0- _,./. 410-6 uL, PROG

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STANDARD FORM 509 MEV. 7.91) Prescribed by GSAIICMR. FIRMR 141

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MEDCOM - 16512

DOD-029901

ACLU-RDI 1637 p.72

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MEDCOM - 16513

DOD-029902

ACLU-RDI 1637 p.73


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

REGISTER NO, WARD NO.

MEDCOM - 16514

PROGRESS NOTES

Medical Record

STANDARD FORM 509 7 - 911 Prescribed by GSA/IC/AR. FIRMR 141 CFRI USAPPC V1.00

DOD-029903

ACLU-RDI 1637 p.74

PROGRESS NOTES

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MEDCOM - 16515

DOD-029904 ACLU-RDI 1637 p.75


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REGISTER NO. WARD IAD. PATIENTS IDENTIFICATION (For typed Of written entries give: Name • last, first, middle;

grade; rank; rare; hospital or medical facility)

PROGRESS NOTES

Medical Record

MEDCOM - 16516

STANDARD FORM 509 IREV. 7•911 Prescribed by GSA/ICMR, FIRMA 141

CFR) USAPPC V1.00

DOD-029905 ACLU-RDI 1637 p.76

PROGRESS NOTES DATE

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MEDCOM - 16517

DOD-029906

ACLU-RDI 1637 p.77

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DOD-029909 ACLU-RDI 1637 p.80

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DOD-029911 ACLU-RDI 1637 p.82

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DOD-029913 ACLU-RDI 1637 p.84

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MEDCOM - 16525 IMP DOD-029914

ACLU-RDI 1637 p.85

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ACLU-RDI 1637 p.86

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DOD-029922 ACLU-RDI 1637 p.93


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DOD-029926 ACLU-RDI 1637 p.97

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ACLU-RDI 1637 p.98

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DOD-029931

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MEDCOM - 16544

DOD-029933

ACLU-RDI 1637 p.104

PROGRESS NOTES DATE

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DOD-029934 ACLU-RDI 1637 p.105


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MEDCOM - 16546

DOD-029935

ACLU-RDI 1637 p.106

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DOD-029936

ACLU-RDI 1637 p.107


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MEDCOM - 16548

DOD-029937 ACLU-RDI 1637 p.108


MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

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MEDCOM - 16549

DOD-029938 ACLU-RDI 1637 p.109

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ACLU-RDI 1637 p.110


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DOD-029940 ACLU-RDI 1637 p.111

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DOD-029941 ACLU-RDI 1637 p.112

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MEDCOM - 16553

DOD-029942 ACLU-RDI 1637 p.113




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MEDCOM - 16554

DOD-029943

ACLU-RDI 1637 p.114




STANDARD FORM 509 (REV. WINS) Prescribed by OSARCMRIPANTIAICFR) 101.11.2030NT°)


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MEDCOM - 16555

DOD-029944 ACLU-RDI 1637 p.115

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MEDCOM - 16556

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64011 re0.9a-S de(.6

DOD-029945

ACLU-RDI 1637 p.116

AURIENNZED FOR LOCAL REPRODUCTION

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STANDARD FORM 509 IREV . 511999) Prescribed by GSAIICMR FPMR I4ICFRI 10141.2030M

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MEDCOM - 16557

DOD-029946

ACLU-RDI 1637 p.117

DOD-029947

USAPA VI.00

MEDCOM - 16558

ACLU-RDI 1637 p.118

PROGRESS NOTES

DATE

RELATIONSHIP TO SPONSOR SPONSOR'S NAME

DEPARTJSERVICE RECORDS MAINTAINED AT HOSPITAL OR MEDICAL FACILITY

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STANDARD FORM 509 IREV. 511999) Ptagnibet1 by GSAIICMR FPMR I41CfRI 101.11.2031WD 0)

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DOD-029950

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MEDCOM - 16562

DOD-029951

ACLU-RDI 1637 p.122


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DOD-029952 ACLU-RDI 1637 p.123

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ACLU-RDI 1637 p.124


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ACLU-RDI 1637 p.125



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DOD-029955 ACLU-RDI 1637 p.126


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MEDCOM - 16567

DOD-029956

ACLU-RDI 1637 p.127


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DOD-029957 ACLU-RDI 1637 p.128

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DOD-029958 ACLU-RDI 1637 p.129


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USAPA V1 .00

MEDCOM - 16588

DOD-029977 ACLU-RDI 1637 p.148



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DOD-029978 ACLU-RDI 1637 p.149


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DOD-029979 ACLU-RDI 1637 p.150

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MEDCOM - 16596

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DOD-029987

ACLU-RDI 1637 p.158

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1 REGISTER NO. WARD NO.


STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203lbil1

USAPA V1.00

MEDCOM - 16620 i;•

DOD-030009

ACLU-RDI 1637 p.180

DATE NOTES

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MEDCOM - 16621

DOD-030010 ACLU-RDI 1637 p.181

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-1111101 PROGRESS NOTES

Medical Record

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

USAPA V1.00

MEDCOM - 16622

DOD-030011 ACLU-RDI 1637 p.182

MEDICAL RECORD

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STANDARD FORM 509 IREV. 5/1999: Prescribed by GSA/ICMR FPMR 141CFR) 101-11.203(b)(10:

USAPA V1.00

MEDCOM - 16623 D1C Sion lorvadti

DOD-030012 ACLU-RDI 1637 p.183

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ACLU-RDI 1637 p.184

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MEDCOM - 16625

DOD-030014

ACLU-RDI 1637 p.185

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PROGRESS NOTES Medidal Record

STANDARD FORM 509/ (REV. 5/1999) Prescribed by GSA/ICMR .OPMR 141CFR) 101-11.203(61110)

USAPA V1.00

MEDCOM - 16626

DOD-030015 ACLU-RDI 1637 p.186

SEX

ITEM

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n PATIENT'S RESPONSE

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

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MEDCOM - 16627

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSMCMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

' NSN 7540-01-075-3786

EMERGENCY CARE AND TREATMENT

(Patient) MEDICAL RECORD

RECORDS MAIN AT

PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS

DATE (Day, Month, Year) J TIME

C, Aro G3 dor (/ ZIP CODE TRANSPORT TION TO FACILITY

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CONDITION UPON RELEASE

❑ IMPROVED 0 UNC 0 DETERIORATE

REFERRED Ob. J TO WHEN HANGED

I have received and understand these instructions. PATIENTS SIGNATUR PATIENT'S IDENTIFICATION (For

first me

typed or written entries, give; Name -- last, middle; ID no. (SSN or other); hospital or ical facility)

DOD-030016

ACLU-RDI 1637 p.187

ABG/PULSE OX Check if read by radiologist

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(Doctor)

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

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 16628

DOD-030017 ACLU-RDI 1637 p.188

510-112

NSN 7540-00-634-41 3

MEDICAL RECORD NURSING NOTES (Sign all notes)

DATE

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MEDCOM - 16629

NURSING NOTES

Medical Record

STANDARD FORM 510 IREV. 7-91) Prescribed by GSA,ICMR. FIRMR !Si. CFR) 201-0.202-1

DOD-030018

ACLU-RDI 1637 p.189

NURSING NOTES (Sign all notes)

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A.M.P.M.

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ACLU-RDI 1637 p.190

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DOD-030020

ACLU-RDI 1637 p.191

CATION (For typed or written entries give: Name—last, first, middle; grade; rank: rate: hospital or medical lad itY)

MEDCOM - 16632


NURSING NOTEli

Medical Record

STaNOARD FORM 510 (REV. 7-Si;

510-112 - • - - -,

MEDICAL RECORD NURSING NOTES -,Gs

(Sign all notes)

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DOD-030021 ACLU-RDI 1637 p.192

MEDCOM - 16633

510-112

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NURSING NOTES

Medical Record

STANDARD. FORM 510 (REV. 7-91) Prescnbeci by GSA/ICMR. F1RMR 141 CFR) ::01-9.202-1

DOD-030022 ACLU-RDI 1637 p.193

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MEDCOM - 16634

DOD-030023 ACLU-RDI 1637 p.194

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ACLU-RDI 1637 p.195

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NURSING NOTES

Medical Record

MEDCOM - 16636 STANDARD FORM 510 iFtEV. 7-911 Prescribed ty GSA/1CMR. FIRMS (41 CFR; ::01-9.202-1

DOD-030025 ACLU-RDI 1637 p.196

510-112

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NURSING NOTES

Medical Record

IMP MEDCOM - 16637 STANDARD FORM 510 jRF.V. 7-91) Plescrted Iry GSA/ICA/IR. FIRMR CFR: 201-9.202-1

DOD-030026

ACLU-RDI 1637 p.197

PATIENT'S IDENTIFICATION For typed or written en ries give: Name—last, first, middle; grade; rank: rate: hospital or medical lac, ity) REGISTER NO. WARD NO .

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NURSING NOTES

Medical Record

MEDCOM - 16638

STANDARD FORM 510 [REV. 7-91) Prescribed by GSA/ICMR, FIRMR ;41 CFR) 201-9.202-1

DOD-030027 ACLU-RDI 1637 p.198

'U.S. Government Printing Office: 1995 • 404-763/20065

NURSING NOTES

DATE HOUR

v OBSERVATIONS I A.M. P•M. Include medication and treatment when indicated

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MEDCOM - 16639

DOD-030028

ACLU-RDI 1637 p.199

510-112

MEDICAL RECORD

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NURSING NOTES . ,-...• •./...,,,-+.1..0

(Sign all notes)


when indicated A.M. P.M. Include medication and treatment

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hospital or medical fedi ity)

MEDCOM - 16640

REGISTER NO. WARD NW4

NURSING NOTES

Medical Record

STANDARD FORM 510 ;REV. 7-91) Prescribed by GSA/ICMR, FIRMR i41 CFR) 201-0.202-1

DOD-030029

ACLU-RDI 1637 p.200

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