DOD 003749

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DOD 003752

ACLU-RDI 1058 p.4

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DOD 003753

ACLU-RDI 1058 p.5

I • I I • V " 6 1 Theater Trauma Registry Record For use of this form, see DA PAM XXX; the proponent agency is 0150

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LAW ENFORCEMENT USE ONLY

Chest omen ❑Thelvis ❑ Extremity (Upper/Lower) DOther

DMulti-organ failure DOther

EXHIBIT

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MEDCOM - 691

DOD 003754

ACLU-RDI 1058 p.6

MEDCOM - 692

RECORDS MAO/TAMED AT DEPART/SERVICE STATUS HOSPITAL OR MEDICAL FACLITY

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STANDARD FORM GOO (REV. 697) Prescribed by GSARCMR FIRMR (41 CFR) 201-9.202-1

EXHIBIT

PATENTS IDENTFICATION:

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DOD 003755

ACLU-RDI 1058 p.7

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CItRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

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MEDCOM - 693

DOD 003756

ACLU-RDI 1058 p.8

MEDICAL, RECORD CHRONOLOGICAL RECORD OF ME_ AL 1.:Art=

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EXHIBIT

MEDCOM - 694

DOD 003757

ACLU-RDI 1058 p.9

DEPARTJSERVICE RECORDS MAINTAINED AT STATUS

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MEDCOM - 695

DOD 003758

ACLU-RDI 1058 p.10

MEDICAL RECORD i

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DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGAN

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MEDCOM - 696

DOD 003759

ACLU-RDI 1058 p.11

0180-04-CID259-80227

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DOD 003760

ACLU-RDI 1058 p.12

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MEDCOM - 698

•

NAME:(LAST, FIRST) SSN: DOB: UNIT: RANK: SEX:

(b)(6)-4

EXHIBIT

DOD 003761

ACLU-RDI 1058 p.13

MEDICAL RECORD CHRONOLOGICAL RECORD OF ,ny on-ON- Lamm

DATE - SYMPTOMS, DIAtittiosis, ircr-Al mr.rg 1, in.,. —.— —•.._. ..

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FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT.

MEDCOM - 699

DOD 003762

ACLU-RDI 1058 p.14

0180-04-C1D259-80227 AUTHORIZED FOR LOCAL REPRODUCTION

1 ' CHRONOLOGICAL RECORD OF MEDICAL CARE MEDICAL RECORD

DATE

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MEDCOM - 700

DOD 003763

ACLU-RDI 1058 p.15

DEPART/SERVICE STATUS

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0180-04-CID25UN;woucT,c," ALITHORIZED FOR

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DATE

CHRONOLOGICAL RECORD OF MEDICAL CARE

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DOD 003764

ACLU-RDI 1058 p.16

0180-04-CID259-80227

MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE • DATE SYMPTOMS, DIAGNOSIS TREATMENT, TREATING ORGANIZATION • each

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CHRONOLOGICAL

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REGISTER NO.

RECORD OF MEDICAL CARE Medical Record FORM SOO (REV. II-07)

• • .- - - - - - -

RANK:

FRIAR (41 CFR) 201-9.202-1 UBAPA V2.00

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STOWFOOPIetAlt USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT

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MEDCOM - 702

DOD 003765

ACLU-RDI 1058 p.17

0180-04-CID259-80227

MEDICAL RECORD 1 3.3 ...1 3"..-,n.4.L, •VP, I.UCAl. REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (sign each entry)

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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 8-97) Prescribed by GSMCMR F1RMR (41 CFR) 201-9.202-1 USAPPC V1.00

FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT

MEDCOM - 703

DOD 003766

ACLU-RDI 1058 p.18

0180-04-C1D259-80227 AUTHORIZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) (p‘-tb.-4 ivhsroce_.A.t_ N v 17tr, / Pr ,414,0-Kg at>

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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-971 Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPPC VI 00

FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT

MEDCOM - 704

STATUS

SSN.ID !JO.

DOD 003767

MEDICAL RECORD

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DATE

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ACLU-RDI 1058 p.19

0180-04-CID259-80227 ALITHORIZtO FOR LOCAL

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RECORD

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STANDARD FORM 600 (REV. 8-97) Prescribed by GSAACMR FIRMR (41 CFR) 201-9.202-1 USAPPC V1.00

(b)(6)-4

FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT

MEDCOM - 705

DOD 003768

ACLU-RDI 1058 p.20

■ ...! ,.-.P , •;,1.,'S;::.,..ICE

I RELATIONSHIP TO SPONSOR

(Fcr typed or venire', entnas, give: Nem. - last, first. middle; ID No or SSN: Sax; REGISTER NO. Date or Birth; Renk/Gred6.1

PECURUS MAIN I Air.ED AT

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SS:ielD NO. •O N I7OR ?;;; NAwE

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0180-04-CID259-80227

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MEDCOM - 706

DOD 003769

ACLU-RDI 1058 p.21

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(-571-111-40tr,_ • At4144-4 10145

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MEDCOM - 707

DOD 003770

ACLU-RDI 1058 p.22

Other:

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MEDCOM - 708

DOD 003771

ACLU-RDI 1058 p.23

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MEDCOM - 709

DOD 003772

ACLU-RDI 1058 p.24

(b)(6)-4 u180-04-CID259-80227

AUTHORIZED FOR LOCAL REPRODUCTION. MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTOMS, DIAGNOSIS, TREATMENT, TRWING ORGANTION (Sign each enby)

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(Foe typed orwrItlen entries, give: Nemo - last Irst. middle; ID No of SSN: SeA: Date Of !With; Renk.Grede.)

STAIRMACMCRPAL USE CTNLY LAW ENFORCEMENT USE ONLY

MEDCOM - 710

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM SOO (REV. 6 -97) Proscribed by GSNICIAR FRAM (41 CFR) 201-9.202-1 USAF% V2.00

EXHIBIT •

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DOD 003773

ACLU-RDI 1058 p.25

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DOD 003774

ACLU-RDI 1058 p.26

(Lie

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MEDICAL RECORD PROGRESS NOTES

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PF-..OGRESS NOTE=

Medical Record

. c. STANDARD FORM 50S !REV 7.9%,

Prescribed Lv GSR•ICMR. F:RMR 41 CFR , 2:•:•"

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MEDCOM - 712

DOD 003775

ACLU-RDI 1058 p.27

4, DATE OF ORDER TIME OF ORDER

;2) rna- r 01 HOURS

4 T-v HA.t.ict 4,4e ^s ce l

0180-04-C1D259-80227 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

(b)(6)-4

',b)(6)-4

LIST- TIME ORDER

NOTED AND SIGN

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(b)(6)-2

(b)(6)-2

NURSING UNIT ROOM NO. BED NO. C .er1 tvr i u 51-1-

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

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PATIENT IDENTIFICAT ON DATE OF ORDER

TIME OF ORDER

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NURSING UNIT ROAM NO. BED NO. Ci r , 1146((Lsk-

DATE OF ORDER TIME OF ORDER PATIENT IDENTIFICAT

HOURS

NURSING UNIT ROOM NO. BED NO.

DA 1 FLARP479 4256 LAW ElitiperES EDITION OF 1 JUIcgtVICH MAY BE USED.

EXHIBIT

MEDCOM - 713

DOD 003776

ACLU-RDI 1058 p.28

HOURS

M Nv. BED NO.

01 80-04-C1D259-80227 cutccm_ J-IF.CORD DOCTOR'S ORDERS

For use of this /kJ,' 40.be, the proponent agency is OTSG TRF DOCTOR sHAt L RrICORD DATE. TIME ANO SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN .Iti_UMN INDICATED 8Y ARROW BELOW.

IDENTIFICATION 70-ATE Or ORDER TIME Of- ORDER 'FINE ORDER

F. t .. ,51 NOURS NOTt I AND

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MEDCOM - 714

11.1

DOD 003777

ACLU-RDI 1058 p.29

ASSESSMENT/01AG OSIS

//Anktkh pLc aiducT _ - C 04,4247D

DISPOSITION (Check all that apply)

HOME !FULL DUTY

QUARTERS

24 Hrs. 48 Hrs. 72 lirs

MODIFIED DUTY UNTIL: DAY MONTH YEAR

REFERRED TO (Indicate clinic)

EMERGENCY

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AND TREATMENT

558-103 (See Instructions on Back of this Sheet) 0180-04-CID259-80227 NSN 7540-01-075-37f

EMERGENCY CARE AND TREATMENT (Medical Record)

TREATMENT FACILITY (Stamp) LOG NUMBER

HISTORY OBT

DPATIENT

'ALLERGIEs

ARRIVAL

DATE MONTH YR.

(.;

TRANSPORTATION TO HOSPITAL (Attach care enroute sheet)

71 PRIVATE, AMBULANCE I I VEHICLE LJ OTHER (Specify)

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YES Li NO

CHIEF COMPLAINT(S) (Include symptom(s), duration) AGE

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NON-UR GENT

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DIRECTIONS To be wmple.ted by attending pruv:der and other staff at tone of ratn;nt release Ioio.3 an ,,; i tpd,„ent „ro c.. ;,j e j care:treatment or discharge from an inpatient hospital stay.

SECTION I TO BE COMPLETED BY PRIVILEGED PROVIDER

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PROGRESS NOTES Medical Record

STMIIMITIRM 509 (REV 519991

Prescribedy GSA/ICMR FPMR (41CFR) 101-11 203(b)(101

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DOD 003786

ACLU-RDI 1058 p.38

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0180-04-CID259-80227

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DOD 003789

ACLU-RDI 1058 p.41

0180-04-C1D259-80227 AUTHORIZED FOR LOCAL

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ACLU-RDI 1058 p.43

0180-04-C1D259-80227 AUTHORIZED FOR LOCAL REPRODUCTION

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