ACLU-RDI 1680 p
64
DOD-036955 ACLU-RDI 1680 p.1
Transcript of ACLU-RDI 1680 p
DOD-036955
ACLU-RDI 1680 p.1
Translation Bates page Medcom 23328:
Name is: WIROMNI Number:
DOD-036956
ACLU-RDI 1680 p.2
DOD-036957
CRE
BUN fAgsdL
13-3 m9/dL
DIAL.Wt) CA"- A/L (vcro
CERA,
CRE Na 145 mmol/L
4.0 mmol/L .I31/L CH.JJ
el ii0 mmol/L Tp
Tcoa mmolst_
mmol/L RnGap
31 %PCV Hct__ I 1 / L
, *via Hci
ph
-prna i00.7 mmH9 '7":!'"174
CK mmoi/L Nr:03 lE
-15 mmol/L BFpcf
1CO2
Sample Type_:
07NOV03 01:30
I .CL-
Physician: 98-103 mmoLl
tco, 13-33 rnmoill
Ward/Sect:0ns
_ :EST R_ESUT T R_EF.
mo;oi.l. „LLB
I ALP rranoi..1.
rr..31/L ALT
AMY
1:gifigtar0 AS — hi-fsz (yen)
Og ■ an) TEM, ca. (Jr* BUN on. (vco)
I 7-22 Ing/d1
I 8.0-10.3
I 0.6-1.2 in&Id!
OPER #:1111111 DR #: 000 SERIAL #i
)1QP W
ALB 3.1* 3.3-5.5 G/DL ALP 72 26-84 U/L ALT 88* 10-17 u/L AMY 78 14-97 u/L
131* 11-38 U/L AST TBIL 0.7 0.2-1.6 MG/DL GGT 9 5-65 U/L TP 5.9* 6.4-8.1 G/DL
INST OC: OK CHEM OC: OK HEM 1+, LIP 0 , ICT 0
1 1 -3 8
algh2
5 -65 Wt
6.4-3.1. g/d1
I 128-145 mrno1/1
3.3-4.7 girno14
dt TEST
CILU
B LIN
1 RE ciLTES TING Esi-IYSICIAN: ' CITEMISTRYRESULTFOIZNI (Subject to Clic Privacy Azt of 19-i41
I DATE TLME SSNRSELTDO SCN:
I 12g - i43 ,r.;no1/1
3.i-4.7 ran-..01/1
I 98-108 mmo1/1
1 10-47 12/1
I 14-97 WI
18-33 mm01/1
REFRAAk7E
i 3.3-5.5 0.1
1 26-84 ur,
I REPORTED BY: I DATE: , L.AB rD NO.:
MEDCOM - 23380
DISC LOT #: 3154AA7
------- PICCOLO 11/07/03 REFERENCE RAN PATIENT #: LIVER PANEL PLUS?
12:74 AM MALE \,-
C9--)
olo) 14,et4boiic. Ge:
RESUIT1 kEFRANGE
I 73-113 mgid1
ACLU-RDI 1680 p.3
r. •
.; D.1TE
t.f LT 'FORM (.111:D!C-ZI of 1.974) I T _-:-.-
'-r '
Rif.17).7(gE .57EYST
f- :010r
.
RAKE-,17-1 TES T . .
I REscv. I REFA-1,4,YGE
?..ei--.=Elyc N/rt 4.3-10.S x 10'
RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/07/03 01:34
f-- 1
L)
s( RAPIDPOINT COAG ANALIZER V4.54 SERIAL 4005485 11/01/03 01:37
Patient ID: 01111110V1i)-(1 Test Name :APTT Test Result:, 50.6 sec. ***RESULT DDT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/07/03 Test Time :01:34 Card Lot :10020'
1111111! Operator : \ , l, \.9 "
Patient 10:1111 4iC) (Or')
E Test Name :PT Test Result:., 20.4 sec. ***RESUL1 OUT OF RANGE*** Ratio . 1.7
----A
Operator Card Lot :1 Test Time :01:32 Test Date :11/0003 Sample Type:oitrated wh. blood Calculated INR = 2.30
-,--(1--
_ , , R ty
si H
- I iNc&--ativc
• I
I LA11 rD NO.: 1-DATE: ,
! RE? TALR:LTS:
Rjr',.-,TORTF.D BY:
r_ .4.. ST CC."'
t - f
• •
TES.'
.
[Ty
:2-Z/A .
.1NrcE;nt
I Nega
Negl
I 'N'A
07-/i-03 N
Patient 01:31
,, lie 23.5 H x1043/4 4.5 10.5 Limits
' ROC 3.45 L x10A6/aL 4.00 641 1 list 9.5 L ME 11.0- 18.0
1kt 30.6 L I 35.0 60.0 In 88.8 fl.
90.0 99.9 Fi-4 -
Irll 744 P9
27.0 31.0 /..___-
47/C 30.9L sht AO 37.0 ------1 LYZ 29.6 * Z
PI t 2210. 1/043AL
150. 450. LY8 7.0 *H 1101/eL 1.2 34 20.5 51.1
Bank
1,8:/1111N. 48 wow
) - JIT SF 51S WITH EVERY UA1T REQUESTED
' : •131c)<XIB•gb.k Pros:switch' • - : : • : T SUSNi/T SY 51s 'writ u.N-rr j31,0,OD . - RE E.Q._._r__ES.Tk,D) - •-••
• • rr _ r TYPE cAO,s,S.,' ("11
MEDCOM - 23381
DOD-036958 ACLU-RDI 1680 p.4
EMERGENCY RELEASE OF BLOOD COMPONENTS .
SECTION I - REQUISITION
c MPONENTS REQUESTED (Check One)
RED BLOOD CELLS (Crossmatch not performed)
OTHER (Specify)
THE FOLLOWING TESTS HAVE NOT BEEN PERFORMED:
ALANINE AMINOTRANSFERASE RETROVIRUS TESTS
CYTOMEGALOVIRUS TEST SYPHILIS SEROLOGY TEST
HEPATITIS TESTS
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THESE BLOOD
PRODUCTS FOR TRANSFUSION WITH ETE TESTING. I UNDERSTAND THE INCREASED RISk TO THE-PATIENT AND ACCEPT
RESPONSIBILITY FOR THE ADMI TFtANSFUSION.
PHYSICIAN'S SIGNATURE 4) .- / \ DATE
1- IV1V C) - ISSUE/TRANSFUSION DATA
TFtANSFUSION NUMBER RECIPIENT
ABO/Rh
Ot
NSP ature) IN TS
Cn}4' AT 0 _
Cat,;1 ' 11,40V D3
' , . UNIT NUMBER , ABOrRh
1ST VERIFIER 2D VERIFIER
(Signature)
DATE/TIME DATE/TIME
STARTED COMPLETED AMOUNT GIVEN REACTION YES/NC
- I (ANOI In 01 _?
i'')i t-) / MN ii.,)°1 C;
, . ) 1 IA_ l'i
op (30 01.36) IIA- N.)
IDENTIIICAT,I9N VERIFICATION The transfusionist (1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate Vat the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block. 1-
)2 V.(31'
TRANSFUSION REACTION
If reation is SUSPECTED - IMMEDIATELY:
1. Discontnue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Pi ocedures.
4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Descnalion
L j URTICARIA CHILL FEVER PAIN
OTHER OTHER DIFFICULTIES (EQUIPMENT, CLOTS.
0 YES (SPECIFY)
ETC.)
PRE-TRANSFUSION,
P: c? k, P LSE: 69 , B/ . I b lift 7(6 7/- 411 I/
WARD
k./ DAT,g
- )i\n/L) , ' N (NAME- LA , FIR.DT; SN)
in ,1 Lb( (1) 1
One copy is placed in the medical records. One copy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.
MEDCOM - 23382
DOD-036959 ACLU-RDI 1680 p.5
EMERGENCY RELEASE OF BLOOD COMPONENTS SECTION I - REQUISITION
MPONENTS REQUESTED (Check One)
' RED BLOOD CELLS (Crossmatch not performed)
)1k THER (Specify)
THE FOLLOWING TESTS HAVE NOT BEEN PERFORMED:
ALANINIE AMINOTRANSFERASE
HEPATITIS TESTS
RETROVIRUS TESTS
GYTOMEGALOVIRUS TEST SYPHILIS SEROLOGY TEST
DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THES BLOOD
PRODUCTS FOR TRANSFUS ' TE TESTING. I UN-DERSTAND THE INCREASED RISK. TO THE PATIENT AND ACCEPT
RESPONSIBILITY FOR IS TRANSFUSION.
PHYSICIAN'S SIGNATURE b ( cc.,- i_
......
DATE
1.),) N ov CD" - ISS NSFUSION DATA
TRANSFUSION NUMBER RECIPIENT ABO/Rh
INS 1
AT
OM. \-., Lit‘ - -z-
TS
7,07vaj UNIT NUMBER ABO/Rh
1ST VERIFIER 20 VERIFIEFi DATE/TIME
(Signature) (Signature)! STARTED , 1
DATE/TIME
COMPLVED AMOUNT GIVEN 7 REACTION YES/NG
, 0 .-- 17 _) K)
, n, i , ( Li 05 K.)
IDENTIFICATION VERIFICATION The transfusionist (1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches th..) patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate that the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block.
TRANSFUSION REACTION
If reation is SUSPECTED - IMMEDIATELY:
1. Discontnue transfusion, treat shock if present, keep intravenous line open.
2. Notify Physician and Transfusion Service.
3. Follow Transfusion Reaction Procedures.
4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Descnepon
11 URTICARIA CHILL FEVER PAIN
OTHER OTHER DIFFICULTIES (EQUIPMENT. CLOTS. ETC.)
0 YES (SPECIFY) ___b_b5L,__\51__________
R OF PERSON NOTIN
/ (.._.... PRE-TRANSFUSION
f-P Vto,
PULSE: L, k PV
ONIAME- LAST, F RST; SSN)
- Api 11 u 1) _ ji One copy is placed in the medical records. One copy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.
MEDCOM - 23383
DOD-036960
ACLU-RDI 1680 p.6
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 TRAUMA FLOWSHEET The proponent is Dept of Surgery
EMS' REPORT.' TIME: ETA: UNIT: .....--------
- ARRIVAL STATUS TIME eire 0 iv x , 0 0,
OTSG APPROVED (Daie)
QI Appr 11 Jun 97
. i'D 1 /min 0 C-Spine Immob
MED COM: Y N Meds: • KN 0 None 0 Yes:
Allergies: iL.4LiKN 0 None 0 Yes:
Tetanus: ,W.14C-N 0 Current Last Meal/Fluid Intake . hrs
- LMP; ... 0 .
-. ' PRIMARY . .-.
AIRWAY ' ' , BRETHING ; . , , .
SURVEY ; CIRDULATIOW: -. .. . ,. . . . ,
mural Patient ail N f ored 0 Unlabored 0 Absent PULSE: esent CI Absent
0 ETT 0 TRACHW6Adidline 0 Deviated L R BLEEDING: ow SKIN: 0 Warn Aefjool 0 Hot
0 Pink „)!Ce_a_le 0 Cyanotic 0
?!Ckecretions CHEST SYMMETRY: t ifiS L a R HEART TONES: 0 Clear Muffled : ' y 0 Moist 0 Diaphoretid
DISABILITY
, : SECONDARY, SURVEY
HE.AD ' HEART -
.,
ABDOMEN ' . -
GCS: PUPILS:XEqual 0 Fixe React 0 Dilated L R
TM: *Clear 0 Blood l'`.."-j5‘',S Lk— L R
RHYTHM: tliefLegular 0 0 Rigid 0 Non-Tender
PULSES: Xentral 0 Peripheral 0 Tender:
M NECK LUNGS FELvis
t SPHINCTER TONE:
0 WNL
• None
(AB)rasion
(AMPlutation
C-Spine Tenderness: NY BREATH SOUNDS:CI Bilat 0 Equal 0 Clear 0 Stable Unstable CI
Pain @ 14A-4 ii--1"--. Decreased L E Absent L R Blood at meatus/vagina: y N.
.USE.DIAGRAM'TCY:DOCUMENT
JVD: E N Wheezes L INJURIES AND. PAIIV ,
aft NJ
R Crackles L R
- VASCULAR
Hem.; - Prostate: 0 WNL 0 Abnl
ASSESSMENT •
(AV)ulsion e he-SA Battle's Signs
.--+-(A IBL)eeding
(Blum
IDIeformity
(E)cchymosis
Ql-tS k/L) C exc
(alS ) (F)oreign Body
'MI (H)ematoma
(LAC)eration
(P)uncture (W)ound
In\ ei,( I
%NI ou
(Pain)
(S)eatbelt (S)ign
(S)tab (W)ound
(GSW) Gun Shot Wound -- L.0 • .
ID(.0 - 2- Palpabie D Dopler
RN
- PREPARE BY (Sig .6 r (k.\\J--L
,_._
PHYSICIAN
DEPARTMENT ontinue on reverse)
DATE
.. (j PATIENTS IDE FICAT or type or waren entries give: Name-last, first, middle; grade; e; hospital or medical facduy)
ER j11111111 i cb ( (I2) - ki
• HISTORY/PHYSICAL • FLOW CHART
• OTHER EXAMINATION • OTHER (Specify) OR EVALUATION
El DIAGNOSTIC STUDIES
• TREATMENT
D A 1 Fey"; a 47 0 0 REQUIREMENT OF PRIVACY ACT OF 1974 IS COVERED BY DD FORM 2005. /LITE. MEDCOM - 23384 EAMC OP 503, 1 Dec 98
DOD-036961
ACLU-RDI 1680 p.7
DOD-036962
0 Oral
0 Nasal
0 OTHER
0 D-stick 0 SHct 0 Chest Post ET
0 1 0
CBC: INTAKE
Blood
Other
TOTAL
Other
TOTAL
ED Phys
Surgeon
Anes th
0'& PROCEDPRE: SIZE .
Intubation
CO2 Change
BS Post Int
0 Post CXR
CT Scan: 0 Contrast
0 Head Abd pelv.
ral
0 Nasal
Teeth
Gastric
Tube
Urinary
DPL
Chest
Tube #1
Chest
Tube #2
12 Lead
'AEG SITE
0 Air 0 Contents
CI Verified
Suction: Y N
0 Return
CI Heme Dip: + -
.0 Secured
0 Grossly: + -
I count
ent@
ood
01-Pleuravac cm
Autotransf user
CI Air CI Blood
Fleuravac cm
Q Autotransfuser
13°2 Q2 S°.t
C-Spine 01:11.-Spirie 0 Chest
A-Gram Site:
IV ACCESS & FLUIDS
EM11111111131MIE1111 rintlimmoluirmouromi 111111111
M E DICAT I ON S
Dos ;11 Rhythm:
TIME %01.
Comments
-RAYS
0 Chest Post CT BLOOD PRODUCTS C-Spine
INN LAB RESULTS,
TRAUMA TEAM ARRIVAL 'VALUABLES & CLOTHING -,.RESRONDED...
Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes
0 Home CI
Admitted to
Report Called to
Time Transferred
MEDCOM - 23385 i By
TIME
Given to Patient
Given to Family
X-Ray
RT
Ortho
Neuro
Chaplain
DISPOSITCON
ACLU-RDI 1680 p.8
MEDCOM - 23386
VITAL SIGNS
GCS:
RHy RR SAO Fl02 MODE E - V ice n
1111111111116 MOM IMIIIIIIIIIIIII MI Mil 1111111111111 itarargrain mono
Rectal Temp:
ME BP HR
@ 0 1 Ig - 0 ) - 5
IVEVIM 3 - To Voice
2 - To Pain
1 None
GLA OW COMA SCALE
ittet. itEsiON$E -MOTOR RESPONSE
5 - Oriented 6 - Me Commands
4 - Confused
3 - lnapp Words 4 - Withdraws to Pain
5 - Localizes Pain
2 - lncomp Speech
I - None 2 - Extension to Pain
3 - Flexion to Pain
1-- None
'PERFORMED BY: Backboard Removed
0 Downgraded
NOTES
4 - S ontaneous
DOD-036963
ACLU-RDI 1680 p.9
GCS:
2 - To Pain 3 - Inapp Words
2 - Income Speech
1 - Nona
5 - Oriented 4 - Spontaneous
.-!:„.1A9TOFCRESP.ONSE
6 - Obeys Commands
GLP OW COMA SCALE
3 • To Voice 4 - Contused
1 - None
0 Backboard Removed
0 Downgraded
NOTES
.2 '•"-DEI REST- I-LC(3C -hi.20 -;- v e(5-, a 0
@ c MODE
\Q)/1 111.111111VIE o EIM1111111111111111. )(D
_AILLIIIIIIM/11 VireiranteallINTIVES
Jal&-wilowitorrat
Rectal Temp:
TIME FZR SAO2 F102
5 - Localizes Pain
4 - Withdraws to Pain
3 - Flexion to Pain
2 - Extension to Pain
1-- None
PERFORMED BY: BY:
BY:
MEDCOM - 23386
DOD-036964
ACLU-RDI 1680 p.10
Admission Diagnosis Narrative: GSW LOWER BACK
Procedure Narrative(s):
Cause of Injury Narrative:
rb4)-2 Admitting Officer (Signature, as required)
Automated Facsimile - DA FORM 2985, MAR 2000
Signature of Admitting Clerk
MEDCOM - 23387 11■1111•■■•••■•=111.11
1. Reporting MTF VO-N.--
IIIIIIIIIIIII r-
2. MTE _ ca...
IZ Admission ai id Coding Information
For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number _
Name (Last, First, MI)
1-D l'a)--1
4. Pay Grade
FGN
5. Sex
M
6. DoB (YYYYMMDD) 7. Age at Admission 8. Race
X
9. Ethnicity
9
Religion ,
10. Length of Service ETS
_
11. FMP
99
12. Social Security Number
. _
Organization (Active Duty Only) 13. Marital Status Hour of Admission
00:55
Branch / Corps:
14. Flying Status 15. Beneficiary Category
K78-PRISONER OF WAR/INTERNEES
16. Zip Code of Residence:
17. Unit Location 18. MOS 19. Trauma
BC
Prey. Admission
NO
20. Source of Admission
Direct from ER
Ward: Name / Relationship of Emergency Addressee
Address of Emergency Addressee
Name and Location of Medical Treatme -cility:
)7 ( 7) — 2'
Telephone Number of Emergency Addressee
21. Type of Disposition
EXPIRED
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)
2003-11-07
r 24. Clinic Svc - Admitting
ABA - GENERAL SURGERY
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
2003-11-07
27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission
2003-11-07
FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
DOD-036965
ACLU-RDI 1680 p.11
I. FMP 12. SSN
99
15. FlyStatus
1t. Organiz4ion
((•<-‘)
17. Dept / Ben
K78-PRISONER OF WAR/INTER
35. Total Days This Facility
Absent Sick Days I Other Days
C) 0
Signature of Attending Medical
ConLv / Coop Care Days Supplemental Care Bed Days
11/42)
Signatu
Total Sick Days
ister Nbr
For use of this forrn, see AR 40-400, the proponent aye! v-
3. Grade
FGN
Admission Remarks
18. BranchCorps
8. LnthOfSvc
19. UIC / ZIP
9. ETS 10. PrevAdm
NO
14. Ward
ICW 1
20. Type Case
DIS
21. Source of Admission
Direct from ER
22. Hour Of Adm:
01:00
234'. Clinic Service #
AGG - FP ORTHOPEDICS
24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp
TRF-OTH 2003-11-18
27b. Telephone No
29. e rtingMTF
b
31. Selected Administrative Data
Marital Status: DoB:
In/Out Patient: Inpatient MOS:
33; Cause Of Injury:
34. Diagnosis !Operations and Special Procedures:
S/P GSW L GROIN R LEG
27a. Address of Emergency Addressee
—r 28. Date This Adm: Admittin Officer:
2003-11-07
30. Date Ira Adm 32. Units Blood Components
2003-11-07
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days
Total Sick Days
Automated Facsimile - DA FO
.
MEDCOM - 23388
DOD-036966
ACLU-RDI 1680 p.12
;
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM FIELDS MUST 6E. FILLED 1.N, IF A..PPLICABLE, UPON APPREHENSION
I !Offense against Civifian(s) [che.ck one] If "Other"-then describe: ( 1;,,,,,(1.P.C. 2-421 I Ia.:glory or ..-rousarrra..o.king 0.F.C..-::::.F. . i ISoL-ca...>.on of Forr::co--1:.or..;----ros!,•.:.:!ion r,i.F" C. .39-i.'" I IF_orz'..:_---1:Co--r.rn,:r.icrarir-7; "inta.acs 0.P.C.. 4:3i::)
Raptilrhionc,...--.4..SeaLai .4..ssats....3...c.'s (I.P.C. 393-93, 4'32) 117.1eft (1.P.C.. 4:19;. - I 'kilo:for Ci.P-..i_'. 4.05'; I 1C-estrucn of P:3E:or:Iv C..P.'C. 477) I I Azgrovated Assauy.)....ks..sx.. Vv:-..r! ;r!er-t To Ki!I ;:.P.0 4,10) i Ic.,t,a;:jour, a Pleoc High,...3:,-.1.1ace (.1.F-' C 437) I l!.,iairn:r4 (i.F.C.,'. 412), I IDiszOorging Fire_urn: Explcsi.,a in C.ityrTc,rniViitaga (C.P.C.1. 495". '
Sirr.pSO Assau; ci.P.C. 415) I f Riot or Sr'each of Peace :J.P.0 49.5(3,”
I .r..<.k.fnarcg (1..P,:::. 42 ;) I 01, her- .
ify\lOffense ac.jainst Coalition Forces [check one] If "Other" then describe: t ift-ii-<. ... . 1 I vicz-zfc..-; 0 ;:c ,.:.1.evi I. I 7:spass on Miiibri In: a!la:ion or Facrliry .
I I 1:-,`;a1 e 3'5: .."'-''' sion of .`2`i...:.-..on, - r—; Pt-toto;ra..oh.ing:Sor.,e-i'l.:-.G Uiiry tns;:alaor. or Facir:7„.
I Assaz.J:L'Altazk on Cc-zit'c,..-...Foroas- L labstrlictilg. P. arlurrtanza a' P.Uitary, Mission , : .. .. ... . I ,IT-,.'e4 cf..ccai;;;..s.., Frce Pp--parti : - j jCatt-,ef -.
..
Apprehendinalinit: • - I•Lccati.on:.Grid: .
• •Cate of Incident: (DM.,1tY} - .: :...1.7.rne efincident:,' .:. .., . •
. -: :,.41r,;1..:," ta.,::::,.-:/:--/ ,-,‘. ..... -: . ,c2 . 00.:ihisto:c_.?:/.00 h 7 . .. '''' (17. ' : -'' . I I ' -3 i - 4:2: . ' ' ''. :. ''....'" '' . . rs' Date of Report: (D/ftil/Y)
/ / Time of Report:
hrs
Detained-g- . . . ... .
:Key Connected Person: : Victim - IV/itnest ...
Last Name: ID:. 62' 7t LasZ Name::". First Nan-le: Given Nar.rie: First Narn' e: - ' Given-Name: i-iarr Color: ScarsiTanocs/Deformiries: Ha:r Color: Scars/Tat-toos/Deformities
Eye-Color: Vieight: lb ' h:: Eye-Color 1,,,ie:gnt: lb ii-leigh.: in Acdress: Accress: Place of Birth. Place of Sii-th:
==thniTri'-,e/
Sect'
Sex. 'Phonet-i. Ethrfinbe! S-ex: F-hor:e.t.:-
E:'.,(. i I Mc:-.1ie Sec.'• I :',1 DO6 DAVY: L_ jlk,lobile
I IF 1 IReg,i., IF Regular
Passport D'' license l Other (specify) Passpor• • Dr. iicanse Other (specify)
Document #: Doc.-.ument ;7:: -. TcZal Number of Perscns Invotved • !Os.: names/identrfying info cn.reliecse undeF"Ade;tiona 'Helpful information"}i
. . . Vehicle InfoiTnatic,n . • Vehicle Number ' ' Vehicle(s Owner: '
t.A.akel !Color: IVIN:: t,lodel• i "rya?: ,Plate No.: NtImber of Peopie iR Vehicle: Year: IName.s of T---.eoc:e irt Vehic!e:
C:4-;trabandAA/e.ap-ons in. Vehicle:
[ 1Proper.y./C!:‘,-,.;:.at;37rj Weac.cr: 1:----no:c Take.- c f Suspect ..v.::-. Weepcn/Co7i:ratz.,r.d. Yes! :o
-yoe I .‘...c.-..'el if.--c'.3',.Ca:ite
c2.e'a! :;-. 1:11,.; 7.r n-... 'Make I P.e:ei p: Frc....v:dec.4, '..o ..-;..,:ne..r ''F:st `:c 0:.^.er 2,etai:s 1.:V^.ere T.:curl:: 1.3w^er-
Nanti, cf AssIV.:r.-u ;nterr...--re.er: Emai:, Ph.cne, cr Con:act 17;fc.
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DOD-036967
ACLU-RDI 1680 p.13
COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON AF'PREHENSION
Offthrise againSt.Civilian(S).[check oriel .ff--Other.-,then d.escribe.:. . .. . . 7: .. " ••.::.,..::: .:-.-...-: . . .... , . . ... ..... ..
1 lAi'.;y947 0:P....C. .13..t.) .' 1 . .:.: 1 • . I Eir:glari.cc Housabraaking (r.P.C:: 428) . . .i.::.:-.: . . .
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1 •:- RapetInizit.:SexCial IssaulislAs (147.c. 343-9.3. 402):' :•. 1 • :-1Theft (.1.P.C, .4) : :: . ' - .-: • • -. .,. .. • •
. . - - • : •
Murder.(T.P.C, 41-.0.5).-: • Jp‘...st:i..:cri ci•PrOpary.(1.P.C. 4-h) ';- • . ... • •, •. • - . . . ... .. ... . • - • . :,•• •• • .• .: . •
I .- • kgrayated AssaLit/Assau?:I.N.'.h. Went To Kill (1.0%C. 4.10): . . . . - -. • ' • , •-• .. . .... - Ct-st.-..ictin a Fte_qic Highvoy:F.lace (1.P..C. 48.7) .
1 :......1i.laimirr,;(1.P.C.i. 412): •: I iCisc.r.:a;g1ng Fits*.a..-rnt Explosive in Cttyacwo/Vi9a.:ja (LP:C.: 495)
.. .- • - ••• • - •.•-:.• • " :.... ..... .
1 .Iii-r..pa-A.ssau:1 (I.P.C: 415) • 1 • [Riot or 6ieach'of Peace (I.P.C. 49.5(1.1)) :- : ' : ' - :• .. .., .. ..,..:
Kidnappi-ig (1.P.C. 421) ' - • Ct1-,..ar • :.: :. 1., - '
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Eye-Color: Weight: lb Height: in Eye-Color: Weight: lb Height' in
Address: Address:
Place of Birth: Place of Birth:
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Document #: Document #: --
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• Niake..::' H- Color: .. ' ' • VIN:..:::).,:- •-
t.lotleri Type.:: . Plafe No.: Number' of Peooi.e. in Vehicle:
`leae-... - . -...:. -- ' Nanies Of Pecofe inVehicle:
Cohtraband`ANeapons inVehiCle:- .
[ Propery/Contraband 'Weapon 1Phcto Taken of Suspect with ,,A/eapcn/Contratand. Yes! No
Type: 1 Model- IColor/Caiiter•
S=rial No : Make. !Receipt Prcv:ced to Owner. Yes/ No _Quantity'
Other Details. 1%/N/here Found 'Owner.
Name. cf Asss-tir.-g Interpreter: Email, Phone, or Contact Info..
• eqtr.-1-.2...scleies Nartrze
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MEDCOM - 23390
Zoy,
DOD-036968
ACLU-RDI 1680 p.14
Wh.y was this person detaine
0 COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM 0
4Vho witnessed this person being detained or the reason for detention? Give names, contact numbers, addresses.
Hot,v was this person traveling (car, bus, on foot)?
4iVho was with this person?
What weapons was this person carrying? /4),I, A 4-
What contraband was this person carrying?
What other weapons were seized?
What other information did you get from :nis person?
Ir.fcrma!ion:
MEDCOM - 23391
DOD-036969
ACLU-RDI 1680 p.15
PERT 'NEN HISTOR Y. CHIEF COMPLAINT. AND CONDITION ON AorAISSioN Ear,' .1”1, of
taL4/17.7) 676'.111.r1111-d (.5" 147
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PHYSICAL EXAMINATiOn
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GENE.AL SERVICES AC:PAINIS-74AT:ON ANO :::7F.P AGENCY COMMITTEE CP4 ME:.:1C-SL
CC7OFER 1075 5.39-106
MEDCOM - 23392
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DOD-036970 ACLU-RDI 1680 p.16
MEDCOM - 23393
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DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
NAME in /For typed or written entries, give: Name - last, first, middle; ID Date of Birth; Rank/GradeJ
No or SSN; Sex; REGISTER NO. WARD NO.
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STANDARD FORM 600 MEV. 6 - 97) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
USAPA V2.00
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DOD-036971
ACLU-RDI 1680 p.17
AUTHORIZED FOR Loum.
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SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign each entry)
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RECORDS MAINTAINED RV.
HOSPITAL OR MEDICAL FACIUrt
PATIENT'S IDENTIFICATION:
(For typed or written entries, g' :
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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
STANDARD FORM 600 'REV. 6-97)
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CFR) 201-9.202-1
MEDCOM - 23394
DEPART JSERVIC.E
RELATIONSHIP TO SPONSOR
REGISTER NO.
DOD-036972
ACLU-RDI 1680 p.18
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SPONSOR'S NAME
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MEDCOM - 23395
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DOD-036973
ACLU-RDI 1680 p.19
MEDCOM - 23396
DOD-036974
ACLU-RDI 1680 p.20
MEDICAL RECORD -- -------- - I PROGRESS NOTES
DATE NOTES
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USAPA V1.00
MEDCOM - 23397
DOD-036975
ACLU-RDI 1680 p.21
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
DATE NOTES
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ACLU-RDI 1680 p.22
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DOD-036977 ACLU-RDI 1680 p.23
AUTHORIZED FOR LOCAL REPRODUCTION
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DATE NOTES
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DOD-036978
ACLU-RDI 1680 p.24
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DOD-036979
ACLU-RDI 1680 p.25
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ACLU-RDI 1680 p.28
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USAPA V1.00
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ACLU-RDI 1680 p.31
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STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR 141CFR) 101-11.20303)00)
USAPA V1.00
MEDCOM -23410
DOD-036988
ACLU-RDI 1680 p.34
AUTHORIZED FOR LOCAL REPRODUCTION
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MEDCOM - 23411
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ACLU-RDI 1680 p.35
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MEDCOM - 23412
DOD-036990
ACLU-RDI 1680 p.36
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Gram Stair
Malaria
Micro Pares
H. pylori
Occ B Id
Ncp.ave
Negative
0 & P
Other
17P-sc .T.Irtn
RAPIOHINT COAG ANALYZER V4.54 •.SERIAL 4005485 11/07/03 01:46
: Test Name 11111,1_ Patient ID:
Test Result::: 13,6 sec. : Ratio = 1.1 Calculated INR = 1.19 Sample Type:citrated wh. blood Test Date :11/07/03
• Tal Time :01:45 C.11-(1 Lot Operator
. '
lood.Bank • . . .
kAPiWOINT COAG ANALYZER V4 SERIAL 4005485 11/07/03 :49 .
(--) Patient ID: /
Test Name PIP ' Test Result:. 32.8 sec.
Type:citrated wh. blood feEt Date :11/07/03 fet Time :01:41
Opel id Lot
LAB ID. NO.:
MEDCOM - 23413
DOD-036991
ACLU-RDI 1680 p.37
Pati
\\)- I 'fil; '
;
FE: LAB ED NO.:.
_ . •
! Ward/See . : '
L___ ---__ Kt.:QUI:I, l 'NO rtl- .:•:"1...,IA;N:N..
IP J. — t--(
„,-,
1...w...mmitiki tin i .M.C.31_11,1 rtntlY1
't to the Privacy Act of 1974)
' f..ASt , EMST,.N1-1
_ --.• (lierna . CBC ,
1 ___, .... __Ii.(2/1/0
DATE TIME
° . _ . .... . . . ..- • .Vrina ysis
TEST RESULT REF. RANGE i TE.ST RIESUL7' REF. RANGE TEST RE.SU.LT REF. R.17crG.E
Ni.rEC 4.3-10.3 x 10' Color' N/A RPR. Negative
RBC 4.7-6.1 x 109--- , App _ WA MORO . 7.4egativc
--7----:.• .H.gb 14-13 gicli (11,1)
12-16 gidI (F) Glu. . • Negative. . . . MiCrobiology
Het 42-52% (M) 37-47% (F)
Bili •
Negative Source
MeV 30-9=1 tl (1.4) 81-99 fl (17)
Ket Negative Grarn . Stain ,
Plt - 130-500 N 1 0' ; verified
SG -N/A . Occ Bld Negatiw
Lymph % 20.5-51.1% Bld Negati ve H.. pylori Nectarine
-• (lientatelogyMtilual Differential . pH N/A . N.' icro Parasites
. . . •. I .---
Segs 1 _J
Mono
Eos
Prot
Urob .
Negative
0.2 - 1.0
Malaria
0 & P Bands .
Ly mph Baso Nit Ncgatil,•e Other
Atyp Inun Leuk Negative - 11ficit.osccipic Krini sia " •
RBC
D; U.INI t:OAG AL 400S485
....„ ..
ANALYZER V1 .!)-1 11/10/03 04:46
--EGG Negative
•
• .. CSF -.. ent IO: .;._ • 1110111-- -.---..
. .Blood Ba.nk •:. ..7
• st Name. --,.. st Result:= 19.3 sec. *RESULT OUT OF RANGE***
!ell :ount
i MUST SUBMIT SF 518 WITH - EVERY UNIT REQUESTED
. inctigen ' 1 Negative ABOdth
• Lt i 0 ..,..ir : • tii-i-E14-84-1444-341M
i I. 1 ____J_____ itm)le Type:citrated wh, blood :st Date :11/10/03 :st Time :04:45
-- s - - - .: - . Blood' Bank Unit Cros.sroatch. . .. . 1 . (MUSTSUBMIT SF 518.WITH EVERY UNIT OF -131,00D . . .: ,. .
'. .. - --..- RE,. QUESTED) , •• - - .- • • -
ird Lot NUT TITE CROSSM-ITCII
perator \06d1.- ___---.
,, . 2 . IOPOINT COAG ANALYZER V4.54 ,'
1AL #005485 11/10/03 04:49 _..,,-/
"lent ID: `_ i e;., t iiditIE :APIT
. 1 .- 1
\\\\---
• • ist Result:z 50.9 sec. •- ,-**RESOLT OW OF RANGE*** • mmplelype:bitrated wh. blood fest Date :11/10/03
• fest Time :04:47 •.,'.7irri Ht.
MEDCOM - 23414
DOD-036992
ACLU-RDI 1680 p.38
TOTAL HOURS COVERED FROM __HOURS
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET HouRs
AMOUNT
TYPE (Include Medications)
AMOUNT RECD
ACCUM TOTAL
TIME COMPL AMOUNT
IRRIGATIONS (N/G, Bladder, etc.)
AMOUNT ACCUMULATIVE
TOTAL
TIME STARTED
TIME
OTHER INTAKE ACCUMULATIVE
TOTAL
BLOOD/BLOOD DERIVATIVES
TIME COMPlp
AMOUNT AMOUNT
ACCUM TOTAL
GRAND TOTAL INTAKE USAPPC V1.00
All11116 ouTpu-N6
(Lta- A
MEDCOM - 23415
DOD-036993
ACLU-RDI 1680 p.39
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon General.
MEDICAL RECORD
1. AGE: 3c) HEIGHT:
WEIGHT:
R 4. ,, OPOSEDVRGICAL PROCEDURE:
07? 8 . g --T4-0 5. ADDITIONAL INFORMATION: Last- PO: Jewelry removed: yes/C)Family waiting: yes
PAW po1/4--TA -b-kr-k; Zriat
1-1 -e--3/2(601-1-A) Medical I-Ix: ,51(/ Implants: /25" Medications:Ac
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
3. PREVIOUS SURGERY [ ] NO [ ] YES. (type):
L.)-/L-K
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NUFkSIN.G INTERVENTIONS
A. P YCHOSOCIAL
PotentiaLfor an e y
64---Pt. verbalizes any specific anxiety.
t--P-4-. exhibits relaxed body posture.
o Allow pt. to verbalize freely. o Explain OR environment and answer questions regarding surgery.
Offer comfort measures, (e.g., warm blanket, touch)
Explain all nursing p dures before they are done. 6<-Rernain with pt. whenever possible. o Maintain family interface.
r ted to - matic injur ;
language bar . r;., arndy,_...... ___,..\
separ, ribn; suQ.E.11 environment ,
‘.._______-_____—. -----
. ' - •TION Potential for
PT. will be able to breathe without difficu y during immediate intra- operative phase.
o Offer to elevate head of tte or offer pillow.
o bserve pt. while awaiting surgery for signs cif distress "r•---Assist anesthesia during intubation and extubation
spirat dysfunction e to
'datio • Nasitioning; if -
C. INT GUMENT
Potential impairment
. will not exhibit signs of impair- ent of skin integrity (e.g., reddened
areas.
-
o Utilize pressure preventing devices on OR table and accessories.
t9(__c_heck for proper positioning and support to maintain good body alignment. --
o _ ■ integuity due to offt) inl; I. lion; fluid shill
o Frad pressure points. ir.:......,place ESU ground pad on non Compromised skin surface area.
-e' Keep fluids from prep pooling.
9. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01
MEDCOM - 23416
DOD-036994
ACLU-RDI 1680 p.40
6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOIVIES 8. OR NURSING INTERVENTIONS
D. CIR ULATION
Potential for inade- ./ ,2rCheck
o Check for support stockings or ace ps. If none, check with doctors.
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 ck that rings have been
•emoved.
t. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse).
quate tissu a-Pfuc.,•ie-n--du to anesthesia, racimatic injury-
position; stir-Ric, previc us surgery
E. NEUROMUSCULAR .. CO E.1. Potential i • - ment
,-cc...._Pt. will be transferred to OR table without. difficulty. 6><Qt..,_will not experience unnecessary physical discomfort. ''13.„,..Allow
-In< Have sufficient people av 'table for transfer.
sure ro er bod alignment. P P Y
patient to lie in position of comfort while waiting for-surgery.
ffer support (i.e., pillows, bathtowe , etc.) for positioning.
q ility due to edit • tap
- --' in , Iv . E.2. Asp- • -ntiaThdiscomfort
due 'miry; pain
.F. NEUROMUSCULAR CONTROL F.1. Disminished visual , --
o Pt. will be made aware of surroundings prior to anesthesia induc-tion. ---- o Pt. will be transferred safely . OR
--- table. --'' o Pt. will be able,ld understand instructions. 7
o Minimizerfdanger of injury during intraop riod.
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 slo . o Address pt. fro
..----- --gide.
perception due to being injur •
seclation;
F.2 Potential for •ecreased communictaion due • language barrier; sedation .---
o Validate pt.'s understanding of verbal communications. o Verify removal of dentures.
F.3. Potential/ jury due to dentures.
i G. OTHER PATIENT PROBLEMS NEEDS. Or continuatio 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/ADDIT1ONAL 1NTEROPERATIVE INTERVENTIONS Ncri-Fn
DATE
11. POSTOPERATIVE EVALUATION:
r-hD er-x-7C-s
12--7 197- r PREPAREIY
n/N—
TIME: -2- 2- 43-
13. PREOPERTIVE EVALUATION PREPARED le)
17 -11 (-1-) TE: 7/00003 TIME. • 0 -jz 4 C3'
REVER OF DA FORM 5179, JUN 91 USAPA V1.01
MEDCOM - 23417
DOD-036995
ACLU-RDI 1680 p.41
I- INTRAOPERATIv- r)OCUMENT ' MEDICAL RECORD 1 • For use of this form, see AR 40-407, the propc 'icy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATINL, .4 , VIA ...._0_,Ztaie-2, BY CLA-4....0.-tke/0..204,
2. PATIENT IDE - W D AND PROCEDURE VERIFIED B i iird
3._DATE TIME PATIENT ARRIVED IN SUITE YNO VOS
4.. PATIENT OM
TIME no5 NUMBER 1 -1 (1--) 5. PREOPERATIVE EMOTIONAL STATUS
lyl_CALM
COMMENTS:
p4 P,04-, s_o_Agid,A,
ANXIOUS WITHDRAWN 11 • EXCITED II CRYING 11 ANGRY • OTHER (Specify)
. .442-e-a-Ke/1 i-- ' -
6. NURSING PERSONNEL _ _ . ASSIGNED SCRUB
6 Pd_ 4 t DT- -;---:--- - """ - 'RELIEF SCRUB
I° f----d 6/ lb / , \ ASSIGNED CIRCULATOR
1 , &LI, ) UT- ., a- k--, RELIEF Iff (D(0-6
__CIRCULATOR .. iN1 .,
7. POSITION AND P051,TIONAL A rf, (Specify) got_ fij,l_q.. a::.-d, - Itz 0 1,-0-1,4- ai- -/-ca.,_7--Zo-r-) , . a_.4- ii,t_di,c- J-Ate.4.1)-ei-bi • V._-) lovy -40.4-% tr—Cfik-F b_...
4=7 /C1-14--ele&6( • Et SUPINE • LITHOTOMY • PROti---/ 11 KRASKE. LATERAL: • LEFT SIDE UP 11 RIGHT SIDE UP
. . COMMENTS: „4, 0._454.44-1 trrt-e d- 1)1. _ ____ _.. _
NI
• ._
8. SKIN PREPARATION . . _
BY HOM:e ifi-- BY WHOM:epT-
% pAg40 rke-ie GC-.
HAIR REMOVAL @ YEs • NO '''',-r.
DONE BY: 41 OR 111 NU G
METHOD: • DEPILATORY Z4 RAZOFI 11 CLIP
COMMENTS: 1-1,0 0 Lit EA GA 0_,Gt_to --yoz,,k4---
PREP UTION (Specify) , SITE:
SITE ii,('Irgei., hp - ,
COMMENTS: in„.0 p_o--0..._ 9. LOCATION OF EXTERNAL
.
-
Pad
DEVICES
.
...,,... ..
_ :at _ ----■-amilimiii..-
-- Safety Strap = = = Tourniquet.-
8. - p., ,• - - .11,-App-__
. ,. "..:
.,.---. - LEGEND X Ground
10. COUNTS
. - C ,= Correct I = Incorrect gt%;fieliir? Fciorsutnct losing FciontainItCiosing
SCRUB 6 (cel`J-- CIRCULATOR Sponge
Needle Sharp jj Instrument •
Yes Yes
Yes
• o a c_ mi. IF .._._ ...____ -Ge&
U :` a Other • Yes • o 11. PATIENT IDENTIFICATION For typed or written entries give: Name - Last, first, middle; Grade- Date; Hospital or Medical Facility;)
* cs2) , •
\?( -.-
um. a _''') - t rt A cf-H,RA r 4 -in . es An-r •-,-. --- --_ -
12. ELECTROSURGERY Lii
0 ESU NO: V #
DEVICE(S) IESU) i- _GA_
p:i YES • NO
6-0 A-6 S-c' , .• ‘ GROUND PAD:
:1' 1:174:0 NO:
BRAND V i ' / ' 1M 6. 7,.5-ti- LOT NO: 7*-5 ' c-00S--- 01
-- 'GROUND PAD: ., • BIPOLAR NO:
BRAND
LOT NO:
1 9-1 (TESTI, DEC.82, W.HICH IS OBSOLETE.
MEDCOM - 23418
USAPA V1.00
DOD-036996
ACLU-RDI 1680 p.42
13. PROSTHESIS, IMPLANTS ,L. YE ] NO IF YES NAME: ID NUMBE' JFACTURER
LoAPV3 of tiik-o-aArt S : - _ ____ _._ _
TiA IdAIL;Nb sef el trill Set 1 . . toci4403 Psciti- al 10 x330 mr.-1
3t, 3i ,
r,i, ..;:,,,,,i,:k*0 M E D I C AT IONS /0 R D E RS nna,_.: ''' . .,. V 4. :::',;: - ,..' , IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO •
'MEDICATIONS/SOLUTION DOSAGE TIME • METHOD PREPARED BY GIVEN BY C. I . -... -
- - ' ' • - _. . • .
,
-MOUND IRRIGATION El. YES • NO, TYPE(S):
o,q 7, o A e L___. „ :, .
'421THER ORDERS TIME CARRIED OUT BY :
; ----- _ . _
..PHYSICIAN'S SIGNATURE
; . : , 15. X-RAY IN OPERATING ROOM I PeY , ITE
YES tij NO • 0-- ' lej 16. - ' ' :''_' LA9PRATORY SY:E' CIMENS
SPECIMEN (S) YES • NO 11
. . .,
, , ---- ---- - NAME - -- - , NAME .
FROZEN SECTION (FS)
YES NO NAME ' NAME
CULTURE (CI YES • NO
NAME ______ __ - -----
NAME
NAME NAME NAME
NAME NAME 7 - .
_ ...._ -- -- - ----- 18. DRESSING/IMMOBILIZ TION (Specify)
a ;to i,t3 17. TUBES, DRAINS/PACKING YES K NO •
, 4
_ arte_ W h ale) 1 1 ' •
0-0 eir-- 6 i le Cyr) '
TYPE/SIZE 1. I 01.4.. i,v._. .U49 -1,1-cLi. iti 1. k
Si rbi- in
2.
2. 3. . .....-_-_ SITE
19. ADDITIONAL INFORMATION
C 1/1 VLF-011
.1),r. . :-2i:I.:,i.,..- . _.
LI_
0,-4--9---- c lorgillip
6 C6.6 , , .. .
' _ r-iJ Ce,izt q
20. OPERATION(S) PERFORMED
, , Titi /1.0...a.L.A1 ___ -
4 D Grirr.,01.. iir o—K-m-et:;- - - .
21. PATIENT TRANSFERRED WI 1.-ett. r A 0...tx....
TIME
ripe - METHOD
i2:tizzA) 22. REGISTERED NURSE SIGNATURE
11111111111111111Prr I hi b ( a -1-- REVER 00- DA FORM 5179-1, OCT 87
USAPA V1.00
MEDCOM - 23419
DOD-036997
ACLU-RDI 1680 p.43
INTRAOPERAT. - OCUMENT( (4-7_ MEDICAL RECORD For use of this form, see AFi 40-407, the propi cy is *he office of The Surgeon General.
1. PATENT TRANSPORTED TO OPERATINA;..- .1 . ..._
VIA 1A--110-1--- BY ./1.1-7
2. PATIENT IDENTIFIEL, *Al■ill ) P CEDURE $ VERIFIED BY e--ir f '''-1
3. DATE, , TIME PATIENT ARRIVED IN SUITE
1 AO/ 0 0,1---9---3 4.. PATIENT IN ROOM
TIME- : C-0-gS NUMBER C- / 5. PREOPERATIVE EMOTIONAL STATUS
CALM EXCITED. e5ri_DCIOUS
' C_Cri"--t-^zr---.4./ III CRYING 4 • ANGRY • WITHDRAWN • OTHER (Specify)
Cl.t.k.--LC-e____ eig COMMENTS: fe-f- -771' N r . .,-- , 7 r?, - -
Air--
6.__NURSING PERSONNEL
ASSIGNED SCRUB
561- -_..
5 9
..: . """ -RELIEF
.SCRUB _. ASSIGNED CIRCULATOR
11--11/41 , ___.-- RELIEF
_CIRCULATOR iNT ; .
.
ej , ..
7. VION AZD POSIT! NAL AIDS (Specify) ..c..,.k,;..-7.. tt - - . fA. „......,-1- Pte.- )--7.-,0"-- NrSgiPINE • LITHO,TOMY ,,, PRONE • KRA. KE, , TERAL: 0 LEFT SIDE UP D.RIGHTJIDE UP
hTIAA._ f nr"--- r-VAA ‘ -r-cP.-- A.-/ Si••,. • _, s,,..r ,:tA„,,-, J.,...„.) ./t--*--2---- COMMENTS: -. .--..........
bht.)---- 8. SKIN PREPARATION
HAIR REMOVAL E • NO "-
DONE BY: OR • RSING UNIT
METHOD: II DEPILA ORY, AZOR CLIP )...64-_-1_,.._
COMMENTS: C,..-t_A- f (rl Af--CA,a-r ,,,,,.1---.A .
PREPRLUT,ION (Spe SITE:\F-,) (51
IFC iirl BY WHOM: 6,
SITE 44- -""."7 BY WHOM:kit) --1'4"( 1.- . / , ._. .,_.
bdtvibitm-s: c(5 petn9-e----1 y r4--' 9. LOCATION F EXTERNAL DEVICES ...,,- .
' _ .-..:„ _._
• ..,';' '-1 t. ---- .';--- -1•1 :sa-___:aiRigairartaTh" .. _, ,• _ _
. -,,,-7j----„,------,..... 1.42/19"--Ager~ Now- , .
. LEGEND X Gro d Pad -- Safety rap -= = = Tou iquet.....---1:::::1
‘7 (11-- t--
10. COUNTS
C = Correct I = Incorrect
Other• • First Closing Count .. rg..;
Final Closing Count •SCRUB / .4
-
CIRCULATOR r Sponge Pt Yes
Yes
o _ .11/1 am iilliff ■•••••""---- Needle Sharp "El 111111MUIPIP...-
Instrument mil - ' ,1--- 1.11PPPI.- Mir Other • Yes , o P
11. PATIENT IDENTIFICATI 61- (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
. TROSURGERY DEVICEIS) ESUI ll YES NO
in ESU NO: V r&E,& -it-- O. edY1A, I
_ GROUND PAD: BRAND .1 P d - , &AI— . -,..,.- LOT/NO. -11/0211
_ -; : m .4.4 NO: V t r . ?_ ..__ \Au)..-1)( - --.GRoUND PAD: RAND E2A4A-- 6-G-4-<-7 6)-4 ..: LOT NO: 4 '5 7 CG Z-lx,9.70f
MI BIPOLAR NO:
REPLACES DA FORM 5179-1 (TEST), DEC 82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 23420
DOD-036998
ACLU-RDI 1680 p.44
13. PROSTHESIS, IMPLANTS F YE N IF YES NAME: ID NUMBE FACTURER
. .._______ ,
.,1,::, , K•, MEDICATIONS/ORDERS 14, V
,
, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • N': ■ 'MEDICATIONS/SOLUTION . ., DOSAGE TIME METHOD PREPARED BY IVEN BY t ; _ , _ _
, . - .
.-
?NOUN IRRIGg2L YES NO, TYPE(S):
1PTHER ORDERS TIME CARRIED OUT BY
_______- _ ... . .
PHYSICIAN'S SIGNATURE , b ( a
. ,
15. X-RAY IN OPERATI IF YES, SITE i YES • NO
16. - ` LABORATORY SPECIMENS
SPECIMEN (S)
YES • NOV-
, . , NAME - ------ --- - -- ----- NAME
FROZEN SECTION (FSV
YES N NO/u
NAME NAME
CULTURE (C)
YES • NO
V NAME
----- --- NAME
NAME NAME NAME
NAME NAME . __ - ---- 18. DRESSING/IMMOBILIZATION (S.ecify) 12_, 6-42-OL/V•.- c___________ of , ..0
,4 ?( :1-- ion , I ,- ,(2
i _v-71,-/-A-er • ,..,,,, .. r
1 7. TUBES, DRAINS/PACKING YES NO • TYPE/SIZE 1. tGF..4, R,r6i 2. W. iLfj-r.„( .
3. SITE 1Valk Efit).(2. .G.0.14,,,,....._
19. ADDITIONAL INFORMATIDN ' ,i . S \J i40.4..), T141/4- ‘-tra---A--
. . - , .....-.--:- 0-1 _ il_si
N.A.:.c_ ,P...-4A._. ei-0--,...„ / _ „g_e__,;„ , 0_,4----,J---
ov-rzyy.A....„-r , /
20. OPERATION(S) PEliFORMED -- ft _ 1 (7))/(4/- di,p i _ T r E.2_ 0.:,../- (e_ 2 (5_01 ( g-e#-A___. , c„,,,_ 44.._,L.e.,4_ 6.e._,sD-C..-<_,,,
21. PATIENT TRANSFERRED TO kadt T I Mb 0 MEJE-21L)D114,1_
NURSE SIGNATUA7- bq N.
4) (_ C.c._ ) — Z_ _ _ —
REVERSE OF D 5179-1, OCT 87
USAPA V1.00
MEDCOM - 23421
DOD-036999
ACLU-RDI 1680 p.45
MEDICAL RECORD INTRAOPERATICUMENT , For use of this form, see AR 40-407, thig_proix( cy-is-th ice of The Surgeon General.
1. PATIENT RANSPORTED TO OPERAT...-
VIA L 1 1- r BY CPT- .----- 3,;.....PA-TIENT IDENTFIELJ, ..r_,: D D PROCERURE
VERIFIED BY / 1 6,1- , 1 ) b Y - Z 3. DATE., TIME PATIENT ARRIVED N SUITE
I S NOV- Q3 0 , 2 —/ 4.. PATIENT IN ROOM
TIME. , up--7 NUMBER 2 — t 5. PREOPERATIVE EMOTIONAL STATUS
...27CALM
COMMENTS:
ANXIOUS • • EXCITED. • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)
_ _...._.
6. NURSING PER.S.ONNEL .
ASSIGNED SCRUB
L_c*Q1 -
\--,
•: .... ----RELIEF
.SCRUB
ASSIGNED CIRCULATOR
Al RELIEF - .... —_C.IEtCULATOR
ANT; . 7. POSITION AND POSITIONAL
g4JPINE
COMMENTS:
AIDS (Specify)
LITHOTOMY
...-
LEFT SIDE UP RIGHT SIDE UP
..‘ . ',:Vi- , LATERAL:
. ,'
II • PRONE • KRASKE.'
8. SKIN PREPARATION HAIR REMOVAL • YES \-Er:.10
OR
DEPILATORY
CLIP
''.,
UNIT
.
...COMMENTS:
-PREP SOLUTION (Specify) CAA:ctrii--v- S-C iscu'Lls i- ffit-e4(CAr's. SITE: R.:•c- 2--91.-, BY WHOM:ftlitzi ' SITE ,..... BY WHOM: .
...._
A.i \ 0 c.) ‘ 1 liAl cif- e LLA.---t airs_ /i) _3'
DONE BY: 1111 111 NURSING METHOD: • • RAZOR
• ..._—____ ________.--.. COMMENTS:
9. LOCATION OF EXTERNAL
. .. -1.1 i. _-
-
LEGEND X Ground Pad
DEVICES
•
i
_-,
_ AllraimirrewAlog,-
': - -
= = Tourniquet----...--.:.-
/3 e4o,A*..4
:Lit• —e"mli■-•411Riaimasi6NP-
4,-
4.. • • °Lin t_eA.
- -
( - Safety Strap =
:.=-.--
10. COUNTS
Sponge B Yes iii C = Correct I = Incorrect
Other** First Closing Count ...ki...
Final Closing Cc:hint .SCRUB CIRCULATOR
-E1111M1111r —11MTE16., - -...iiiiiiIMIPP. ',MIL
Needle Sharp
Instrument
Yes
Yes
Yes
• a ••=mi
0 1....._
-Aaikii
11.1111111. 10"""......m11111111111
.
12. ELECTROSURGERY
ESU NO:
Other 0 DEVICE(S) IESU) YES Ea‘ ii. PATIENT IDENTIFICATION (For typed or written entries give:
Name - Last, first, midAlle; Grade; Date; Hospital or Medical Facility;) i I-)
.._ ._ __ . -Algiffiala .
b 1_(6 - L\
r% A i'll'IIIII • -.yrs • oN ...-1- ••■ •••
,GROUND PAD:
----:--,-,: • ;.E17,40-NO: „ . .._ ..
BRAND
LOT NO:
--- 7-GROUND PAD: ....,, • BIPOLAR NO:
BRAND
LOT NO:
— ,
1 9-1 (TEST), DEC.82. WHICH IS OBSOLETE. USAPA V1.00
MEDCOM - 23422
DOD-037000
ACLU-RDI 1680 p.46
13. PROSTHESIS, IMPLANTS YF I NO IF YES NAME: ID NUMBET -ACTURER
- - _____. : :-.-
. 4-.4, . , ..„ , -:gk'S M ED I C AT I ON S /0 RD E RS .P.K ., 'i., IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO •
:MEDICATIONS/SOLUTION DOSAGE . TIME METHOD PREPARED BY GIVEN BY _ . ...- , _ _
- . , . - - -
MOUND IRRIGATION i2"YES NO, TYPE(S): Ajt - . iI
;,OTHER ORDERS .; TIME CARRIED OUT BY t i, .
- • - 'PHYSICIAN'S SIGNATURE
, , __ ,, _ „ -_ . „„_„.„ __ .. - - - , ...... , .,, 15. X-RAY IN OPERATINVM
NO
. -
IF YES, SITE YES /
16. - ' : LABORATORY SPECIMENS
SPECIMEN (S)
YES
NO 6,2JAME -- -- --- --- - . ---2 -. -
NAME
FROZEN SECTION (FSL„),AME
YES - NO
NAME
CULTURE (C) NO 17r.„.,.-KIAME NAME YES • NAME NAME NAME
NAME NAME
. __ *
18. DRESSING/IMMOBILIZATION (Specify)
PI t k -* f- - -- 5
[C-Q-r- fi K 17. TUBES, DRAINS/PACKING YES 111 N 0 L Er - TYPE/SIZE 1. 2. ' -'-"
SITE 1. 2. 3.
19. ADDITIONAL INFORMATION
---CkV•9 -(1-01A 1, Ov" ..
a/A e_S s, C131—
LE .'-
r , ,..if, , __ _ _ , _
\ . - 20. OPERATION(S) PERRNMED - •
b fiC d2/- t -e--32 . _ _„. _ _ ..___
21. PATi5NT TRANSFERRED TO LA..
TIME
1010 - METHOD
Z._ I )44E4-
22. REGI
A/Vi-J itikr ________
OHM - , USAPA V1.00
MEDCOM - 23423
DOD-037001 ACLU-RDI 1680 p.47
-
MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONT DAY
HOUR
r> 6 il p. .
.
. . • • • . . _z .7_. . . . . . . . . . . . . PULSE TEMP. F
op) (*) 105°
• . 180 104°
170 103°
160 102°
150 101°
140 100°
130 99° 98.6°
120 98°
110 97°
100 96°
90 95°
80
70
60
50
40
RESPIRATION RECORD —
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0: .5
.
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40.0°
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38.3° Ix 8
vi
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To .>
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BLOOD PRESSURE 03(rEl 41 flyq r(11
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HEIGHT: WEIGHT —4. 9ffo 07 —MAO Prx ft
eAt
,ATIENT'S IDENTIFICATION (For typed or written entries give* Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)
REGISTER NO WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 23424
DOD-037002
ACLU-RDI 1680 p.48
511-119 NSN 7
MEDICAL RECORD
VITAL SIGNS RECORD HOSPITAL DAY
POST- DAY
MONTH-YEAR 1:74--tjAil Fs DAY 1 • 10 II I
19 Eft3 HOUR
0
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PULSE TEMP. F (0) (.)
105°
180 104°
170 103°
160 - 102°
150 101°
140 100°
130 99°
120 98.6' 98°
110 97°
100 96°
90 95°
80 - 70
60
50
40
RESPIRATION RECORD
:
• . . . . . . . • " witt - : : i :- ir. 0E6 ! . • . • " . . " . . • . . " • . . . . . . • • . . 1 . . . . . . . . . . . . . . . . . . . . . .
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.: :. 111111111 :• :. 1111 :• :• IIII:• .:. :. ..• . : i:k .... .... immifiii :: :: IL: :: E. . . . . . . • • • • • •
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. . L ) . . PATIENT'S IDENTIFICATION (For typed or written entries give• Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility)
—.IL
REGISTER NO. WARD NO.
VITAL SIGNS RECORDS
Medical Record
(ct STANDARD FORM 311 (REV. 7-95) Prescribed by GSA/ICMR, r1RMR (41 CFR) 201-9.202-1
MEDCOM - 23425
DOD-037003
ACLU-RDI 1680 p.49
/49 PHYSICAL EXAMINATION BP HRAQ R I_ Pain le 0-10 3 HEENT - Teeth —74/—W-e-v:4-/
Trachea — 2- TIAJ/Neck Orophannyx Nares
CHEST: e
CARDIAC: /t/Cif
EXIREMMES:
IV Access: Ulnar Filling:
BACK:
OTHER:
PREOPERATIVE PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular:
Hypertension Angina MI CVA Other
Puktionary System: Asthma Bronchitis/URI COPD Other
Renal System: Acute/Chronic R Y
Gastrointestinal: Hepatitis Hiatal Hernia PUDIGERD
Endocrine System: Diabetes Steriods Thyroid
Neurological: Seizures Neuropathy Other
ncy N Y nificant Hx:
N Y N Y
Familial HX
N Y
NPO Since / YPC4f)
ASSESSMENT PAST SURGICAL/ANESTHETIC
TOBACCO: ETOH:
DRUGS:
CURRENT MEDICATIONS: ( ) = ordered as premed
( )
0
0
PREIAEDICATIONS: None Yes (0 Its) /CC
mg IV DA PO mg W IM PO mg W DA PO
LABORATORY STUDIES:
HI3/11CT: U/A: OTHER:
ANESTHETIC PLAN: { LOCAL { MAC { ) Regional (Specify):
)(General: Mask Intubation
ANESTESIA PLAN OF CARE PREPASSENRAL ASSESSMENT (Sedation/A=1=W Age3.12 DAYS MOS YRS Sex ( ) MALE ( ) FEMALE
ASA Physical State 1 2 3 4 5 E WT: FfT: IN. ALLERGI 4/e4-
PROPOSED PROCEDURE: SURGICAL SERVICE NPO SINCE: /17.,91)
Hts
The '
. Questions anwered.
Signed: Date: 0-0° / 493 TiMe:
POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) } NO APPARENT ANESTHETIC COMPUCATIONS { OTHER
Date: Time: Hrs
Patient Identification: (Ward)
SEDATION KEY:
1. MINIMAL (Anxiolysis) Patient responds normally to verbal commands
2. MODERATE (conscious sedadon) Patient responds purposefully to verbal commincts al0M) or accompanied by light tactile stimulation. Airway assistance is not necessary.
3. DEEP SEDATION/ANALGESUL Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.
4. ANESTHESIA. Patient does not respond to painful stimulation. V/1111111,-
INFORMED CONSENT/COUNSEIJNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and discussed with the patientfiegal guardian.
4010CCA--1--
WAMC Fonn 2300 (Revised) 15 Mar 01 MCXC-DOS MEDCOM - 23426
. FS Cl...•11./11,L, Y
Previous edition is obsolete * U.S. GPO: 2002-729-283
DOD-037004
ACLU-RDI 1680 p.50
At
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
I sp
ntia
CIN
V S
IN3911 311
3I-11.S3N
VI
NO
ISrldN
I IN
V1
SN
OD
=.1
. "11/1/0
011/DVI - sliN
n A
310
3cIS
son8
a 0
31
■13d3
U/S
flOrIN
II.NO
D
DRUG (Units) TOTALS TOTAL EBL
4/17/ ireA/ /C4 41* ,0 • &?-0 ) •'.3---iD
Zetire4,,trOrrlant i TOTAL URINE
( ) ( ) 5.—c..,0 ( )
VOLAT AGENT
rr rAirre.wo del - - FLUIDS - SUMMARY
CRYSTALLOID-
'2. yeeo % e.t. •
AIR L/Min
N20 L/Min COLLOID-
02 2._ L/Min SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS
BLOOD-
saunA
I
LIN site 0 Warmed —.es le"ideffilliiiiih- . A • , IIIIM=E
mit=
REMARKS rotanarm 0 Warmed
/ Code drugs with numbers, events with !enters
/15 1:4C Al
..",../644C.4)
j))/eitieu/ / ke) Altchlet ief'n V
ZA-444-6-4440/ # 6 (se — S fro c....Abr-._ Z.:
alpAded4/t„ / /,,
' &Aiwa( tfPgfi Aft C 14 ()Al id t h 4
. ,
,i ,,,, 4.-- ,
c."41 .ev4.4) /
sex.A6474if, / 7-0 te eeiv,"
ieir
rem= 0 Warmed ...- ----Eif4„.. E] Warmed
LOSSES EST BLOOD LOSS UR NE -
PHYS STATUS TIME . • 1 2 3 4 5 E SYMBOLS:
220
200
i so
160
140
12° 100
8° 60
40
20
. .
BODY WEIGHT: ,
KG LB
BP by cult
v A
Heart rate
• Resp rate
BR Itransduced)
J._ T
TOURNIQUET
T —4`.
ANES- X -X PROC- 0_125
i i__..,__.
i .
i i . . ' ' HEMATOCRIT: ' , , ,
. ,__ Nu" : ", : , / .
INITIAL DATA:
BP-
, .
. , . , , , ,
MI . , .
C _PP AIM , . . . MIIIIE111MIE . , . .
7-q o EQUIP CHECK
M SEMIKVAI MIIIINTARV
■ , . . EMMEN . . . . . Irrati'MW1121r.AVANK/41 . , IMO
IlleiMMIII • ,
MMUimmirtiaiNEWA NMI
sow . 01O- Y N Moor EN , PATIENT RECHECK ,
i T—T—i ■
OX for PROCEDURE?
TIME-
piaMPIra ___rn . , ,
IIIIINIIIIIIIN IMMEMEINE111 , ■ : , . , , ■ . IIMPUDIMa:-ANIBEEM
=MI , , . ■ , ,
1IJ.N3A
VT - ml
f - breaths/min ilFraiTa
... It 7 0 " . lan
Peak in( pres / PEEP A II-
DE - S( on), A sist), CIon) MI RECOVERY AT
S3180
SS
33
3V
/SIJ
OIIN
OIN
I
rBP/Auto Cull I BP/oth
CO2 Itorr)
F 2 (Frac or %) MI 4/
3 2- _ir_t Specify) PACU iCu ay fr7 0 6
OTHER I ART line r (oh,
CG 9,6 ' _A___Do .
' A 5---
l'i Ste - PC/ES CONDITION:a
RESP- Sp02-
BP./1_7/57 HR - 73 ARES HESIA / PROCEDURE TIMES
as analyzer TEMP-site
I N-M Block (7/4)
1
I e) Start Room End
Warming blkt I .1 tr 0.72 0,3S7C- Cony warmer Ready o Begin End
Me k with letters & symbols, EVENTS ---0- 1.....7 erg's'', under REMARKS PasitiOn & 411, 0 ci- Oaf 03
PROCEDURES and CPT Codes: A---ir-A henel-gfde
6044 5 . &C 9 14,f' 4reiCI ifipkii- ANESTH TIC TECHNIQUES: Describe block technique under Remarks
eA/C4ido fAIRV/AY MANAGEMENT: lntubation route, blade, technique, comments
fl7t0 -----,3 ft,er
PATIENT IDENTIFICATION: Typed or written entrie Name, Grade/Rate, Medical facility
-WCA ' (1
SURGEONS:
gr--- i \-- -
PROCEDURE "04 LOCATION: 1-.--
DATE:
0 /16,C93__ PAGE / OF /
A FORM 7389, FEB 1998 MEDCOM - 23427
ANESTHESIA DEPARTMENT USAPA V1.00
DOD-037005
ACLU-RDI 1680 p.51
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
U) LI a cc a a z *I tn I— Z uj
CI 4
0 P uj x i . - u) LAI <
tn CI 5 ...;
En 0 _I D2 z c c - cp .ca. ,?..R 1- 0 z 11 21.- a- . Z et U) 4 --. 1— I— (/) 2 U) DDz 0 0 D>- u Z LI- J I:: L)t- Z ti • 0 co U
DRUG (Units) TOTALS TOTAL EBL
a a '.. Af (1/__ . .111 1 av, ( mg) :1 N TOTAL URINE iv- ( /1,6 )
, (IV-wal i 37i ( )
( )
F1-44-41iiiAi iliMil • LAZIMIFM VOLAT AGENT
IP % del % e.t.
FLUIDS - SUMMARY
CRYS2AigS
COLLOID- elIi..'
AIR L/Min
N20 L/Min
02 L/Min "WC IN
IMIII/1110. IrMIIIIFIN SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & EN ER IN REMARKS
LINE site NAT& armed
re,-„ g
'`". .1 WAgr Awrifai
41 CO wipm./te.tRY
1
R.E„M7rrY
I BLOOD-
r.olle A• KS
I] Warmed Code drugs with numbers, e ts WI lettters,
11) Warmed
El Warmed of ?,,---plo i LossEs EST BLOOD LOSS 6cti, 76 Oe
UR NE - PHYS STATUS TIME 110'. 30 C7 09 I 0/39 /Doc> , /cx10 f 94" / Alf2141.2;7
„,3 4 5 E SYMBOLS: ' P4v4/574, B Y WEIGHT: , laa 220
.._ 4 .o :1-ge,e 'A,
- Ci er Sdfahleal, LB BP by cuff
v A
Heart rate
• Resp rate
, BR
ftrensducedI
1.. T
TOURNIQUET
T —./1"
ANES- X-X PROC- 8_0
, • , 1. a 200 . . " MN
HEMATOCRIT:
40 C 18o ; : i , , , ' . , L ,,,,,,,,,,,„.„- Pa, _,_,_ "
, , • . I w INITIAL DATA:
160 . =MIEN . , IMMINII ,Pg per
1.0" BP - 140 „ '
1 2- 3 K• > ■ . rrA11711r ' FW411911.11111 41F4PM°!"1 120 MEM MillillAIR AT•211112r
' . ri AlIkr
:NE e,vi--'611.--cw, Z HR- P9/
100 x ,.„ IIIIIIINWIVaita= smig• , ERNIE
1612 111111111111111ENMEM , 11111 . .
EQUIP CHECK 80 • , . • . . 11111
OK? - N _,___■__ . 1111111111111111 60 M ' -AL • MN
PATIEN ECHECK PI vAY MLR OK for PROCEDURE?
TIME-?
40 =Mean
MilIMMI
' NEM . dk MIN IMIIIIII
20 ENE ' " ' 1111111 . . MN ' 11111111111111 ‘,. •
.
icu Specify) PlISCUaTaggalErAti,'
VT - ml IFM 4111 70 .0 CASEI • fp . - tik,71 r- f - breaths/min 0 0 10 IC, 0 0 MU Z w Peak int ores / PEEP 0 20 _L7 , i _l_g_ >
ODE - S( on), BP/Auto Cuff
A(ssist). C(on) CO2 (mu)
L C 3 IMI
(.. 50
L. ,3 0_ 2, Irra ilri IIMID/Efr.-
w
CC BP/oth F102 (Frac or %) 0 0 / 0 nell #. C, I . 0 h 0 4 II pit"' ' 1-Dc,a).---e_ „. THER ART line Sp02 (%) 69 0 / 0,0 WI / .00 ,90 a• '00 14,„1
COND ZIA ...119,43
"'ESP.' " Sp02- /DD /Li
0 tn CA in
Steth- PC/ES A IffrAlliralliMI • NE. 3 E 1
Gas analyzer TEMP -site -4° 31C1-1-- 3314 V C.) 0 N-M Block (T/4)
WW1 BP-4.94/0-- RR- /C.9 ANESTHESIA / PROCEDURE .1
CO Ce
M u, z 4 0 ci K
TIMES
Start Room End 0 I-- 2 0 Warming blkt °rill/S.- 1F-05- / ea
End 2 Cony warmer Ready Begin Me k with letters & symbols, EVENTS_,
- explain under REMARKS Position C2---A----, „9......., vaxs
..„. elpes
i / tr -
PROCEDURES and CPT Codes:
PCs ; 1 T419 Z Groli Criza4eati".
ANESTHET TECHNIQUES: Describe block technique under Rernarks
04 AIRWAY MANAGEMENT: lintub lion ro te, blade, tgnioue comments '
y I" m i 1 /tit 6-rae- t"rx...., k 1 C 02_ ÷ a ',ff, e r f . i*-..( PATIENT IDENTIFICATION: Typed or written entries; Name, Grade/Rate,
Medical facility *4,1
Mk r
11111111111‘11 --1' (
PROCEDuRE /- / LOCATION:
---? CJZ._ L(C..--- 0 DATE:
ANESTH - d'keti 0-3
4 PAGE i OF 7
DA FORM 7389, FEB 1998
COPY 3 - ANESTHESIA DEPARTMENT
USAPA V1.00
MEDCOM - 23428 /*-1 . Lair //r)/7) ,rf•
ge_
DOD-037006
ACLU-RDI 1680 p.52
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
TOTALS TOTAL EBL
AL URINE
-
/SI
/IN
I/Sf
N3!
lc • / ...-/ • - FLUIDS - S RY • CRYSTALL D-
*FA ' COLL• 11
2-
4/ B •OD-
u) o 5 -J 11
LINE siteatyli, 0 Warmed tiiii - .. . REMARKS 0 Warmed
Code drugs with numbers, events with letruLl
.•02-41.-
rj2-- e" _.....
4> e'vljP C,
_5L./ e-Di 5 X--vi.--
<5-()(-6.11- 113 gt.,-.4
r /
V P grfr4/1" 141/:
El Warmed
0 Warmed
LOSSES EST BLOOD LOSS
UR NE -
PHYS STATUS TIME IROI• , /8.00 3'-eV °C) 2 3 4 5 E / / Z ̀" / I
SYMBOLS: 220
200
180
160
140
. B 0 DY WEIGHT:
' : : , : : , '
KG LB
HE ATOCRIT:
BP by cuff
V
A Heart rate
• Resp rate
BR ltransduced)
_I_ T TOURNIQUET
T —4/
ANES- X-X PROC- 0_0
,_ •___ . .
, . , , . . .
' , ' i •• ■ '
!NIT L DATA: . B AWE : , , i
. 1 _,_.--
, , ,
6 dfr-
'1,2 ((..te-
re 1 201/0,/ ,
HR - AV , . ,
. . ■ . .
' ' 100o i „ , ,
En F. c lEll OK? - Y
, BO .
, •- • 60 . ___•___:__
. ,
PATIENT REC , : :
OK for PROCEDURE?
TIME-
01‘ A A , I I / I
20 " • • , i i , • , i — r-7--
, . , , „ i , i i . , •
. . ., .. i. i i . VT - ml 8160
P f - breaths/min Z >i
Peak inf pres / PEEP
MODE - Stpon), Mssist), Cion) RE i OVERY AT I i kElP/Auto Cuff ET CO2 (ton)
cf)„,
FE 0 01 Cn cm C.) C.) < U) tx o 1- 2 0 2
BP/oth 102 (Frac or TO PAC ICU Specify
OTHER ART line Sp02 WO Stelh- PC/ES CG CONDI Aik-nr : ,,,,, f
RESP - -3IP SpO
BP- H •
ANESTHESIA / • • OCEDURE A TIMES
Gas analyzer TEMP-site
N -M Block IT/41
ow mice MIL criffi Begin
.1 (I
n • Warming blkt
Cony warmer
Mark with letters & SYmboiS. EVENTS explain under REMARKS Position
End
cc o
PROCEZURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks
o.
-------*-4-- AIRWAY ANAGEM lion route, blade, technique, comments
1P--€/e-
PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate, Medical facility
b ( c.,t -4- nit Cf1C/11n 'T-aors ers ...-Ine,
ilw6.41 ...._.___ PROCEDURE DwAcTAE:Ts„roNecA: ,./4.3
PAGE Z OF 2
MEDCOM - 23429 COPY 3 - ANESTHESIA DEPARTMENT USAPA V1.00
DOD-037007
ACLU-RDI 1680 p.53
MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG
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DOD-037008
ACLU-RDI 1680 p.54
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DOD-037009
ACLU-RDI 1680 p.55
1(1 RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tornography Exa-minations)
wAR,cLiNic
PAW AGE SEXISSN (Sponsor)
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EXAMINATION(S) REQUESTED
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PREGNANT ri YES ri NO TELEPHONE/PAGE N,
gif0(6e MEDCOM - 23432
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LOCA ION OF- RADIOLOGIC FACILITY
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DATE OF EXAMINATION (Month. day, year) DATE OF REPORT (Month, day, year)
DATE OF TRANSCRIPTION (Month. day. year)
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DOD-037010
ACLU-RDI 1680 p.56
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MEDCOM - 23433
DOD-037011
ACLU-RDI 1680 p.57
ATION
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 ARFIOW BELOW. PATiENT IOENTIFIC
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DOD-037012
DA FORM 1 APR 79 4256
ACLU-RDI 1680 p.58
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CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DATE F ORDER TIME OF ORDER
HOURS
N U R S IN G U NIT ROOM NO.
NURSING UNIT ROOM NO.
N OF 1 JUL 77, WHICH MAY BE EDITI
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 TIM
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PATIENT IDENTIFICATION DATE OF ORDER
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PATIENT IDENTIFICATION
NURSING UNIT
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BED NO.
REPLAC
MEDCOM - 23435
PATIENT IDENTIFICATION
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DOD-037013
ACLU-RDI 1680 p.59
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 A 9,SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUM IN COLUMN INDICATED BY ARROW BELOw.
PAT:ENT JOENTiFICATioN
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MEDCOM - 23436
DOD-037014
ACLU-RDI 1680 p.60
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
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A FArRm79 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
MEDCOM - 23437
DOD-037015
ACLU-RDI 1680 p.61
DATE OF ORDER TIME OF ORDER
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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 PFIOBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICA TION
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DA IF:pr3m79 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
MEDCOM - 23438
DOD-037016
ACLU-RDI 1680 p.62
HR CLERK/ NURSE
ORDER DATE
RECURRING ACTION, FREQUENCY, TIME
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CLINICAL RECORD VERIFf'BY INITIALING
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION) For use of this form; see AR 40-407;
the proponent agency Is the Office of The Surgeon General.
an* DATE COMPLETED
GIUTAINMEIHMECIE1
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P- RY DIAGNOS : ADDITIONAL PAGES IN USE:
11 NO
PAGE NO*
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES
D 8 9 10 11 12 13 14 15 E 16 17 18 19 20 21 22 23
N 24 01 02 03 04 05 06 07 DA FORM 4677. 1 OCT 78 _MEDCOM: 23439_
JSED.
USAPA V1.00
DOD-037017
ACLU-RDI 1680 p.63
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Verity by Initialing
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICA770N) mo yr 2003
Initials Order Cleric Date Nurse SINGLE ACTIONS
Date to be Done
Time to be Done Time Done
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USAPA V1.00
MEDCOM- 23440
DOD-037018
ACLU-RDI 1680 p.64
