0 0(000 pi -1 -ucik6 '7 -(1-23 '' 1-Las. p032..--fral.-2 yla../ · 2019-12-12 · DATE NOTES 0...

DATE NOTES 0 0(000

pi -1 -ucik6 '7 -(1-23 '' 1-Las. p032.. ?--fral.-2_ —yla../

R39 99 61 1 f

1-1(01 as 7 9.z._ q i 97 Ian I 2 Is

Ht -c_ 3 ' 40 tivio 0- - 15- Y ILI

/1\, ,ano

94

LAST NAME

FIRST NAME MIDDLE INITIAL I ID NUMBER

STANDARD FORM 509 IREV. 6119991 BACK

USAPA MOO

MEDCOM - 22641

DOD-036217

ACLU-RDI 1673 p.1

DOD-036218

Ncfativc

9.8-13.6 sccs

21-34 scm

<1 .;)

<10 g En!

E I 1- LAST, FST. M1

RESULT FORM A:et of 1974) r

■ - •

TEST RES ULT R_E F. RANG C 4.8-10.8 x IC' 'csinr I

10'

Ugh

Hct

MC V

PlE

Lymph %

14-IS p, :al (N.f) 12-16 g/11(7) 42-52% 37-47% 80-94 fl (M) 81-99 fl

130-500 x 10 vaiticd

20.5-51.1%

TEST j RESCJIZ' REF. RANGE

RPR

Mono

NG VI/ Vr, H. pylori

S our ce

'N/A

Mono

Micro Parasites

0.2-1.0

Cell Count

: . .Blood:13.112k. Unit Grosso:latch' : : - - (NflUSiSUBM1T SF 5IS WITH EVERY uN.Tr OF BLOOD - - - RE UTSTED JV/7 .. TIT E CROSS VITCH

TEST TE F. R.4.NGE

FIE:VLARKS:

00-2-

MEDCOM - 22642

ACLU-RDI 1673 p.2

3203AA4 DR #: 000

0000100494

BASIC MET IC DISC LOT #: OPER #: 678 SERIAL #:

Hgb 12-17d.;.

' I CHEATUTRY RESC1_,T FORM (Subiect to the Privacy Azt of 1974.)

I TL\i I SSNRSFLIDO SSN:

===== PIC 0 31/10/03 REFERENCE RAN PATIENT #: LIVER PANEL DISC LOT #: OPER #: 678 SERIAL #: ............... ALB 3.8 3.3 ALP 93* 26- ALT 37 10- AMY 39 14- AST 61* 11- TBIL 0.9 0.2 GGT 14 5-65 TP 7.0 6.4-

INST QC: OK CHEM OC: OK HEM 2+, LIP 0 , ICT 0

PICCOLO 31/ 3 18:28 REFERENC NGE: MALE PATIENT #

GLU 96 73-118 MG/DL BUN 9 7-22 MG/DL CA++ 9.2 8.0 - 10.3 MG/DL CRE 1.3* 0.6-1.2 MG/DL NA+ 136 128-145 MMOVL K+ 4.5 3.3-4.7 MMOVL CL- 100 98-108 MMOVL tCO2 21 18-33 MMOVL

INST DC: OK CHEM OC: OK HEM 2+, LIP 1+, ICT 0

PCO2

pH

35-45mullig(.c-0 41-51 nurdiz

HCO3

TCO2

P02 80-105 mmHg (art) N/A (veul 23-27 mmol/L (art) 24-29 zorno1/1. (vea) 22-26 mmoVL (art) 7_3-78 mruoVL (vcn)

s02 95-98%

BEecf (-2)— (+3) mmuL/L

AnGap 10-20 mmoliL.

Ca 1.12-1.32 rnmol!L

BUN 8-26 mg/dl

GLU 70-105 mg/d1

Creat 0.7-1.5 mg/dl

Hct 38-51% PCV

3153AA7 DR #: 000

0000100689 ........... -5.5 ..6/DL 84 U/L 47 U/L 97 U/L 38 U/L -1.6 MG/DL

U/L 8.1 G/DL

•heitust

TEST 'RESULT REF. RANGE

Tropcnin - 1

Drug of Abuse

RE Ntk.RX S:

REPORTED BY: DATE: J LAB TO NO.: ,.,?1 cic."--0?

tCO: I Is-3) rr.,-no_.!

MEDCOM - 22643

DOD-036219

ACLU-RDI 1673 p.3

Ward/Section: (1),.k\

LAST, FIRST,IVII.

Other

REMARKS:

REPORTED BY: DATE: )

REQUESTING PHYSI LABORATORY RESULT FORM (subject to the Privacy Act of 1974)

4TT 0C3T

SSN/PEEUDO SSN:

atti Jrinafysis Misc. SeroiG

RESULT REF RANGE TEST TEST RESULT REF RANGE TEST RESULT REF RANGE Color 4.8-10.8 xi() BC N/A RPR Negative App R BC 4.7-6.1 x14 N/A Mono Negative

14- 18 g/c11(1‘1) 12 - 16 g/11(1)

Hgb Negative Microbiology 42-52%(M) 37-47%(F)

Hct Bili Negative Source

80-94 Ii(M) 81-99 fi(I;)

MCV K t Gram Stain

Negative

130-500 x 10' verified

Pit SG Occ Bld N/A Negative

Lymph °A, Bld IL pylori 20.5-51.1% Negative Negative

entatology) i:Ianual Differeii ti N/A p Micro Parasites

Segs

Bands

Lymph

Atyp

RBC

Morph

Spun Hem atocrit

Set Rate

Mono Prot Negative Malaria

Eos ['rob O&P 0.2-1.0

Baso Nit Negative Other

Imm Leuk Negative

HCG Negative

42-52%(M) 37-47%(F)

Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

[Negative ABO/Rh Directigen

nagiatirogg:.1"0:tga; 0g014ttoilgSiiidjes..•

.MrgsSROPY.WITHOEVERVUNtit'01t. 611 nitgoimMEOM$Tx0).:'.11:6

1Mwm

TEST

PT

APTT

D dimer

FDP

RESULT REF RANGE UNIT TYPE CROSSMATCH

9.8-13.6 secs

21-34 SESS

<20 ug/ml

<10 ug /m1

LAB ID NO.:

MEDCOM - 22644

DOD-036220

ACLU-RDI 1673 p.4

\V arsiLS,ecti on: 1-- cAA. I

REQ - ' - ICIAN: LABORA ORY RESULT FORM (Sub' ect to the Privacy Act of 1974)

LAST, F :, MI DATE . 6 i itr4

TIME - SS P • es

• c iro tology) CBC .... - • _Urinalysis . • isc. - Serology: ..

T e'er' v LT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8x 10' Color N/A RPR Negative

RBC 4.7-6.1 x 109 App N/A Mono Negative

Hgb 14-18 d1 (M) 12- t6 .. dl (F)

Glu Negative • Microbiology

Hct 42-52% (M) . 37-47% (F)

Dili Negative Source

MCV 80-94 fl (M) 81-99 fl (F)

Ket Negative Gram Stain

-

Plt 130,-500x103 verified

SG N/A Occ Bld Negative

Lymph % 20.5 -51.1% Bld Negative H. pylori Negative

(Hematology). Manual Difkrential pH • N/A Micro

Segs • Mono Prot Negative Malaria '

Bands . Eos Urob 0.2-1.0 0 & P

Lymoh. Baso Nit Negative Other

. . . . . Atyp Imm Leuk Negative •...Microscopic Urinalysis:

- . ., : .. •• .., . .. ,. . . .,•

RBC Morph

HCG Negative

Spun Hematocrit

42-52%(M) 37L17% (F)

. CSF • • Blood.Bank , .

Sed Rate Cell Count


Other Directigen Negative ABO/Rh

oagulatioll••S;ii •. ,.... .. .. -•'• :- . '

• .. .. - : " .-• .Bload.Raitk Unit - Cross:I:latch' : .-.'-• .. (MUST.SUBMIT SF,518.WITil EVERY UNIT OF BLOOD ..

' ..' ' . :: RE I tstslip) : i, - • — .. ..-.... .....: . ...

TEST RESULT REF. RANGE UNIT TYPE CROSSIVL4TCH

PT 9.8- 13.6 secs

AP-• 21-34 secs

D dimer <20 ug/m1 ,.

F DP <10 ug/ml

1 REMARKS:

REPORTED BY: DATE: LAB m. NO.: .

MEDCOM - 22645

DOD-036221

ACLU-RDI 1673 p.5

WarcUSection:

.5.--LCQ REQUESTING PHYSICIAN: ' CHEMISTRY RESULT FORM

Sub'ect to thc Privacy Act of 1974) LAST, FIRST, MI.

(:6)[ - L\ DATE TIME SSN/PSEUDO SSN:

TEST RESULT RE F. RANGE TEST RESULT REF. RAN

FVT or.orn- er, f ,,,,— T I

PICCOLO 22 : 02

RANGE: MALE

I ENT # : (6Y° .i* METABOLIC

LOT # : 3325AA4 # : 678 DR #: 000

AL #: 0000100494

119* 73-118 MG/DL 7 7-22 MG/DL

+ 6.7* 8.0-10.3 MG/DL 1.0 0.6-1.2 MG/DL 137 128-145 MMOtA_ 4.9* 3.3-4.7 MMOtA_

-- 112* 98-108 MMOVL 18 18-33 MMOtA_

DC: OK CHEM QC: OK 0 , LIP 0 , ICT 0

31/10/03 REFE:RENCE

/GE

Na iLt 0 138-!46 mmol/L ALB 3.5-5.5 g

K 4 . Li 3.5-4.9 mmoL/L. ALP 26-84 u/1

CI 98-109 mmol/L ALT 10-47 u/1 11 pH 7 1 i t) 7.31-7.45 ' AMY 14-97 lill PAT PCO2 5 D , j 4351 :4515 mmHg (art) AST 11-38 u/1 BASIC

DISC P02 45 18:al ?sempimFig (art) TBTL 0.2 - 1.6 .

in ‘ OPER TCO2 g, t)

,-,1 I 1

23-27 mmol/L (art) 24-29 mmol/L (yen) 22-26 mmoVL (an) 23-28 mmoVL (yen)

BUN

CA."

7 -22- Med SERI

8.0-10.3m GLU

HCO3

s02 441 i LI 95-98% CHOL 100-200 mi BUN

sH*. BEecf ,_, 1 u (-2) — (+3)

ramon CRE 0.6-1.2m1 CA+

CRE

b AnGap 10-20 mmol/L GLU 73-118 mg NM Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d K+

BUN 8-26 mg/di - CL i-- Ccilo)".1■Iet1 _p-..s. :::::, ,, ,4 tCO2

OW 70-105 mg/d1 1 TEST RESULT REF RANG I NST

Creat 0.7-1.5 mg/di GLU 73-118 rnE HEM Het 3 LI 38-51% PCV BUN 7-22 mg/til

Hgb iel„ 12-17 g/c11 I CRE 0.6-1.2 mg

CR 39-380 oil 30-190 un

TEST RESULT REF. RANGE NA+ 128- 145 m

Troponin-1 , ; 3.347 mm 3E

Drug of Abuse

_CL - 98-108 Mil '

tC 02 18-33 mm

•

REMARKS:

4 -16 1 r_.1111. - 9. REPORTED BY: DA : / LAB ID NO.:

MEDCOM - 22646

DOD-036222

ACLU-RDI 1673 p.6

1161: OK 63b Ikt

NC?; raj Pit LYZ LYN

Wri 31-10-03

18:24 Patient

14.5 H -"UL 4.5 10.5 4.96 x10'611. 4.00 6.00 14.8 gAL 11.0 18.0 .46.5 Z 35.0 60.0 93.6 1; 80.0 99.9 29.8 pg 27.0 31.0 31.8 L g/dL 33.0 37.0 16. x10A3AL 150. 450. 3.5 aLl 20.5 31.1

x1:1. '3AI 1.2 7.

W1 3.5 L x10'3/uL RBC 2.68 L x10'6/uL Hgi 7.8 L g/dL ct 25.3 L 1

Ni.V 54.3 19 tin; 29.2 pg Nc0-2,• 31.0 L g/dL Pit 176. * xi0A3/..d. LYZ 29.3 * Z LYI 1.0 *L x103./t

• ;-atient Limits

4.3 L x101,`, 1 4,5 110V ' JO 6.00 gAL 1:.0 18.0

7Z.0 60.0 fL 30,0 99.9

4 PS 27.G 31„0 :1. girl 310 37.0

15). 450. 20.5 51.1

1. 7 ,,,101u1_ 1.2 3.4

RAPIDPOINT COAG ANALYZER p464 SERIAL #005485 10/31/03, 18:30

Patient ID: Test Name . Test Result:= 13.5 sec. Ratio = 1.1 Calculated INR = 1.18 Sample Type:citrated wh. hl Test Date :10/31/03 Test Time :18:28 Card Lot :080201 Operator : STILLWEL

RAPIDPOINT COAG ANO_YZER V4.54 SERIAL #005485 4131/03 18:38

Patient ID: 111111 Test Name :APTT Test Result:= 27.1 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood

i Test Date :10/31/03 Test Time :18:35

1 .. Card Lot. : :030201 Opeqtqpi_ r: STEWART

. .

RAPIDPOINT COAG ANALYZER V4.54 SERIAL 005485 10/31/03 22:07

ame11r Patient ID:

Test N Test Renit:= 17.3 sec. Rat' = 1.4

culated INR = 1.76 Sample Type:citrated wh. blood Test Date :10/31/03 Test Time :22:05 Card Lot :080201 Operator : JACKSON

RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 10/31/03 22:09

31-10-03

Patient

4.5 10.5 4.00 6.00

11.0 18.0 35.0 60.0 GO. 0 99.7

27.0 31.0 33.0 37.0 150. 450. 20.5 51.1 1.2 3,4

l"' --------- Patient ID:

Test Name

Test Result:= 34.3 sec. Sample Type:citrated MI, blood Test Date :10/31/03 Test Time :22:07 Ca rd Lot :030201

: JACKSON

MEDCOM - 22647

ACLU-RDI 1673 p.7

. Misc. Serology • • • REF. RANGE RESULT

LAST, FTRST,.MI.

Ward/Section: REQUESTING PHYSICIAN:

HP 1 DATE 10 -)1

LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

TIME SSN/PSEUDO SSN:

Urinalysis (Hematology BC •

TEST RESULT TEST RESULT REF. RANGE WBC

REF. RANGE

4.8-10.8 x 10' N/A Color

Mono 4.7-6.1 x 109 Negative

Negative N/A App RBC

TEST

RPR

Glu Hgb 14-18 Wdl (M) 12-16 g/d1(F) Microbiology Negative

Hct Negative Bili . Source 42-52% (M) 37-47% (F)

MCV Ket 80-94 11 (M) 81-99 fi (F)

Negative Gram Stain

130L500 x10' verified

Pit Occ Bld N/A SG Negative

Bld Lymph % 20.5-51.1% Negative H. pylori Negative

(Hematology} Manual Differential pH N/A .

Mono Prot Negative

Micro Parasites

Malaria

Urob

Segs

Bands 0 & P 0.2-1.0 Eos

Lymph Baso Nit Negative Other

.. .Microscopic Urinalysis ' Atyp Imm Leuk

HCG RBC Morph

Negative

Negative

Spun Hematocrit

42-52% (M) 37-47% (F)

CSF. - -

' :: . Blood Bank ,

Sed Rate . ,

Cell Count


Other Directigen Negative ABO/Rh I

COagulation"StUdiel: : :- .BloOd:Ballk Unit Crossmatch - ' , - - - ..: (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . _

TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH

PT 9.8-13.6 secs

APTT 21-34 secs - .

D dimer <20 ug/m1

FDP <10 ug/ml

REMARKS:

MEDCOM - 22648

DOD-036224

ACLU-RDI 1673 p.8

ifEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)

TIME SSN/PSEUDO SSN: 00 R:7

DATE

igc011i):MetabOlie,Papet REF. RANGE TEST I RESULT REF.

RANGE TEST RESULT REF. RANGE

138-146 mmol/L ALB 3.5-5.5 g/dl GLU 26-84 BUN

73-118 mg/dl

7-22 mg/d1

8.0-10.3 mg/di

0.6-1.2 nag/d1

128-145 mmol/1

3.3 -4.7 mmol/1

98-108 mmol/1

18-33 mmo1/1

3.5-4.9 mmol/L` b ALP

98-109 mmol/L ALT CA" 10-47 u/1

1 11 7.31-7.45 AMY 1 14-97 u/I CRE

1-15.% 35-45 mmHg (art) 41-51 =OR (Yen) 80-105 mmHg (art) N/A (yen/

AST 11-38 u/I NA'

TBIL 0.2-1.6 mg/d1 1 0 23-27 mmol/L (art) 24-29 mmol/L (yen) lq BUN 7-22 mg/dl CL 22-26 mmol/L (art) 23-28 mmoUL (yen)

CA"" 8.0-103m01 11 tCO2

95-98% CHOL 100-200 mg/dl Picealti

TEST RESULT REF. RANGE (-2) — (+3) mmol/L

CRE 0.6-1.2 mg/d1 —10 10-20 mmol/L GLU 73-118 mg/di ALB 3.3-5.5 g/dI

26-84 u/I

10-47 till

14-97 till

11-38 u/1

0.271.6 mg/di

5-65 till

I.12-1.32 nunol/L TP 6.4-8.1 g/d1 ALP 8-26 mg/dl ( "Me I e ALT

70-105 mg/dl TEST RESULT REF. RANGE

AMY

0.7-1.5 mg/d1 GLU 73-118 mg/dl AST

LI D 38-51% PCV BUN 7-22 mg/d1 TBIL

0.6-1.2 mg/d1 GGT 12-17 g/dl CRE

CK 39-380 u/I (M) 30-190 u/I (F)

TP 6.4-8:1 g/dl

TEST RESULT REF. RANGE NA 128-145 mmol/1 iccoloYglects6 I

Troponin-1

Drug of Abuse

33-4.7 mmol/1 TEST

98-108 mrno1/1 NA .

RESULT REF. RANGE

_C 128-145 mmol/1

tCO2 18-33 mmol/1 3.3-4.7 mmol/1

CL" 98-108 mmoLl

tCO2 18-33 mmo1/1

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 22649

DOD-036225

ACLU-RDI 1673 p.9

Vv'ard/Section: ORY R. SULl" FORM (4P

REQUES_ Lf

LAST, FIRST,, DATE 0— I No ,./

•-•...•-•

TIME C..)O -L-C,

,....% 1. ,./ us,. 1 Alva,. rl.k..l 01 1714)

SSN/PSEUDO SSN:

(HernatOlop) CBC .: Urina s* . . , . Misc. Serology , TEST RESULT REF. RANGE TEST RESULT REF RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10' App N/A Mono Negative

Hgb 14-18 Wdl (M) 12-16 g/d1 (I')

Glu Negative Microbiology

Hct 42-52% (M) 37-47% (F)

Bili -

Negative Source

---MCV 80-94 fl (M) 81-99 fl (F)


Plt 130L500 x 103 verified

SG •N/A Occ Bid Negative

Lymph % 20.5-51.1% Bld Negative H. pylori Negative

(HentatO ) Manual Differential ..... . :.. • . • • • . . ... -•••• • •-••

pH • N/A Micro Parasites

Segs Mono Prot Negative Malaria

Bands Eos Urob 0.2-1.0 0 &


Atyp Imm Leuk Negative roscOpiC !Irina s ..,. . .

RBC Morph

I , C"f1 / •1, 11

HCG Negative

Hematocrit Blood Bank

Sed Rate Cell Count


37.47% (F)

Negative I ABO/Rh Other Directigen

TEST

Coagulation Studies

REF. RANGE

- : Blood Bank Unit crossinitch" . (MUST . SUBMIT SF.518.WITHEVERy UNIT OF. BLOOD .

. •

CROSS1114TCH RESULT :;. ,'REQUESTEDY

UNIT TYPE

9.8-1.3.6 secs PT

APTT 21-34 secs

<20 ug/m1

<10 ug/m1

D dimer

FDP

REMARKS:

REPORTED BY DATE: LAB ID. NO.:.

MEDCOM - 22650

DOD-036226

ACLU-RDI 1673 p.10

'at cllSection: REQ LABORATORY RESULT FORM . • 1 k3uoject to tne rrivacy Act of 1974) LAST, F1RST,..MI DATE

6 TIME •

r SSN/PSEUDO SSN:

etitatOogy) CB _Urina s'. . Misc.' Serology : RESULT . RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10 App N/A Mono Negative Hob

12-16 14-18

g/d1( F) Glu Negative • Microbiology

Hct 42-52% (M) 37-47% (F)

Bili . - .

Negative Source •• . MCV

.

80-94 fl (M) 81 -99 fl (F)


Pit 130500 x 1O verified

SG

Bld

'WA J

Negative

Oce Bld

H. pylori

Negative

Negative Lymph % 20.5-51.1%

(Hematii ).Manual Differential . pH • N/A Micro Parasites

Segs . Mono Prot Negative Malaria Bands . Eos Urob 0.2-1.0 0 & P


Atyp Imm Leuk Negative MicrosCopi Uritin s ' . .

RBC Morph

HCG Negative

Rnrin 19-.S1 0/- null

Blood.Bank . 3747%

Cell Count


Hematocrit

Sed Rate

Other ABO/Rh Negative Directigen

TEST

Coagulation Studies

REF. RANGE

Bank Unit CrOssinatcl• - '• (MUST.SUBMIT SF . 518 WITH EVERY UNIT OF. BLOOD

1,11EQUESTED)

CROSSM4TCH RESULT UNIT TYPE 9.8-13.6 secs

21-34 secs

D dimer

PT

APTT

<20 ug/m1

FDP <10 ug/m1

REMARKS:

REPORTED BY: DATE: LAB ID NO.:.

MEDCOM - 22651

DOD-036227

ACLU-RDI 1673 p.11

Ward/Section: CHEM'S). tcY RESULT FORM 1111111.1101111P (Subject to the Privacy Act of 1974)

LAST, FIRST, MI. DA TIME SSN/PSEUDO SSN:

IS. '. (91)-1 - CCOLO RESULT REF. RANGE 01 /11 / 03 01 : 08

REFERENCE RANC : MALE

/40 138-146 mmol/L PAT I ENT #: 3.5-4.9 Inm°1/1; METLYTE 8

98-109 mrool/L DISC LOT # 3151 AA4 OPER #: 678 DR #: 000 •,

160 7.31-7.45 SERI AL #: 0000100494

qt, 6 35-45 mmHg (arc) 41-51 rnmHs (yen) GLU 122* 73-118 MG/DL 80-105 mrril-ig (art)

1 a N/A (veal BUN 8 7-22 MG/DL

2 0 23-27 mmol/L (art) 24-29 mmol/L (vco) CRE 1.3* 0.6-1.2 MG/DL

1 7 22-26 mmoVL (art) 23-28 mruol/L (yen)

CK 2647* 39-380 U/L NA+ 125* 128-145 MMOVL

Cti K+ 4.6 3.3-4.7 MMOIL -1 D (-2) — (+3) CL- 112* 98-108 MMOVL

rumon, tCO2 15* 18-33 MOW 10-20 mmol/L

E 1 2-1.32 mmo1/L INST QC OK CHEM QC: OK

8-26 ing/d1 HEM 0 , LIP 0 , I CT 0

'70-105 mg/d1.

0.7-1.5 mg/d1 38-51% PCV

13

12-17 g/dl

ChemiLStry

TEST

Na

Cl

K

pH

PCO2

P02

TCO2

HCO3

s02

BEecf

AnGap

Ca

BUN

GLU

Creat

Het

Hgb

itabdiCTaie1.',17:. .

TEST RESULT REF. RANGE

GLU

73-118 mg/dl

BUN

7-22 mg/dl

CA+1

8.0-10.3 roedl

CRE

0.6-1.2 mg/dI

NA+

128-145 mmoUl

K+

3.3-4.7 mmol

CL"

98-108 mmol/1

tCO2 18-33 mmoUl

P:k6lOPLA,ei Pan e1P1u;:'


ALB

3.3-5.5 g/dl

ALP

26-84 u/I

ALT

10-47 u/I

AMY

14-97 u/I

AST

11-38 u/1

TBIL

0.2-1.6 medl

GGT

5-65 u/I

TP

6.4-8.1 g/dl


Troponin-1 TEST RESULT REF. RANGE

Drug of

NA 1- 128-145 uno1/1

Abuse 3.3-4.7 mmo1/1

CL" 98-108 mmoLl

tCO2 18-33 rnmo1/1

DATE: LAB ID NO.:

MEDCOM - 22652

DOD-036228

ACLU-RDI 1673 p.12

411111111r patimt

18:37 01-11-03 12:51

Patient Likts

.„.3tC. 7.5 * x10"3/L 4„S 3.36 L x10'6/L 4.00 6.00

•':•p..!:446 • 10.0 L g/dL 10.0 18.0 ''t-it 31.0 L

92.3 MO 60.0

fL 60.1 99.9 21.is pg 27,0 31,0

0,471.1t 32.1 L gidL 33.0 37.0 197. x10 -'3/ti 150. 430.

4go. 21.5 *5 20.5 51.1 1Y.it

1.64 x10'3/iii_ 1.2 Z.4

Ari/A111111111 01-11-03 01:10

Patient Limita

2. 9 L 410'5/..1L 4.5 10.5 RiC 4.72 (1.0"6/11L 4.00 6.00 Hgb 13.9 g/dL 11.0 18.0 lict 45.3 5 35.0 60.0

71.9 FL 80.0 79.9 rCH 29.4 a

IC

27.0 31.0 ■ICHC 32.0 L gicIL 33.0 37.0 Flt 251. x10'3/uL 150. 450. LYS 37.3 ; % 20.5 51.1 LI 1.1 #1 t10'3/111 1.2 3.4

-

• ,j

MEDCOM - 22653

RAPIDPOINl LOAG ANALYZER V4 SERIAL 4005485 11/01/03 18.

riFT \ Patient ID:

Test Name Test Result:- 10 sec. Ratio = 1.5 Calculated IMP Sample Type:citrated 41 1- 1 , (1 Test Date :11/01/03 Test Time :18:41 Card Lot :080201 Operator : DAVIS

RAPIDPOINT LOAG ANALYZER V4.! SERIAL #005465 11/01/03 18:bi

Patient IDIOM Test Name :APTT Test Result: = 56.3 Se. ***RESULT NOT RANGE CHECKELJ*** Sample Type:citrated plasma Test Date :11/01/03 Test Time :18:52 Card Lot :030201 Operator : DAVIS

?APIDPOINT COAG ANA V4.54 3ERIAL #005485 11/01/03 04:46

Patient I04111111, Test Name :PT Test tsult:= 16.3 sec. Rat'o = 1.3 C. culated INR = 1.60 ample Type:citrated wh. blood Test Date :11/01/03 Test Time :04:45 Card Lot :080201 Operator : JACKSON


Patient Test Name :APT1 Test Result:= 49.4 sec, ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :04:48 Card Lot :030201 Operator : JACKSON

PINIF 01-11-0: 19:31

Patient LiNita

+.1 _ J/d.L. 4.5 .11,, g5 920 L75. L 4 .00 6.0 co-Pb g , e, 11.r, 18.0

o 'rk=7 17, 4L 3 35.0 60.0 71,7 4 1 90.: 99.9

MG; 52.1 H 2 70 31.0 t2RC 56.5 444 g/dL 32.0 57.0

F1 l- 122. 4- 150, 4' Pi!. 92, 20.5 51.1 LY4 0.7 .4L 1,10 5'uL ' 3.4

,

1111111111 4, 01-11-03

0443 Patient

1432 4.7 003M 4.5 10.5 FIC 4.87 x10'6/4! 400 6,00 kqh 14.5 gAIL 11.0 18.0 H.Et 44.6 S 35.0 60.0 MCV 91,5 fL 80.0 99.9 •1CN 29.4 Pc! 27.0 31.0 INC 32.1 L gla 32.0 37.0 Plt 257. x10'5AL 150. 450. ;OS 13.2 L 1 70.5 51.1 !Y4 0.9 4L a103/eL 1.2 3.

Liallts ;IC 4.2'L A10'5/6L 4.5 10.5 902 2.07 *4_ i106 ,V,_ 4.00 6.00 lipt, 10,2 4-L greL 11.0 18.0 iict 19.5 ti Z 35.0 60.0 ri 94.0 fL 80.0 99. 9 nch 49.3 a 27,0 31.0 rE4C 52.4 # gidl. 32. 0 37.0 Pit 170, LW3ij 150. 450. In 10.7 44_ % 20.5 50.1 1/1 0.5 L 0. '3/11L 1. 9 3,4

DOD-036229

ACLU-RDI 1673 p.13

Ward/Section: I

3ORATORY RESULT FORM

LAST, FERST,.MI. 0,1,-- ATE 0 1 /Jai

k..Ju ■.,

TIME lci 3 -D

,,t U./ 1.4.1c .r.iivat: Act OI .LY /4 SSN/PSEUDO SSN:

.-.. alernatols ,,_ ) Urina sis Misc. Serology TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST R.ESULT REF. RANGE

WBC 4.8-10.8x 10' Color N/A RPR Negative RBC 4.7-6.1 x 10 App N/A Mono Negative figb 14-18 g dl (M)

12-16 &I(I.) Glu Negative • Yficrobiology

Het 42-52% (M) 37-47% (F)

Bili - -

Negative Source

MCV 80-94 fl (M) 81-99 fl (F)


Pit 130c500 x io' verified

SG .N/A . Occ Bld Negative

.. Lymph % 20.5-51.1% Bld Negative H. pylori Negative

ematolOgy).Manual Differential .-..:,• . ,--• . - • •-• -

pH - N/A . Micro Parasites

Segs . Mono Prot Negative Malaria

Bands Eos Urob 0.2-1.0 • & •


Atyp Imm Leuk Negative r .MicrusOpic Urina s ...

RBC Morph

A n couni ,n es

HCG

---

Negative

I Hematocrit

7 o

37247% (F)

Blood.Bank •

Sed Rate Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED

Other Directigen Negative ABO/Rh

TEST

PT

APTT

Coagulation 'Studies

REF. RANGE

9.8-1.3.6 secs

21-34 secs

:s . . • .-- (MUST..SUBMIT.SF,518.WITHyERy .UNIT OF. BLOOD

•• 1. • • • '..:!ittOtitsrkp) • • •-• • -•-•

CROSSNL4TCH RESULT UNIT TYPE

D dimer <20 ug/ml

FDP <10 ug/m1

REMARKS:

REPORTED BY: DATE: LAB ID NO.: .

MEDCOM - 22654

DOD-036230

ACLU-RDI 1673 p.14

(51(.\2 ORATORY RESULT FORM SuFect to the Privac Act of 1974


Urinalysis Misc. Serology

Ward/Section:

LAST, FIRST.,M.I.

(Hematology) CBC

TEST RESULT REF. RANGE TEST RESULT REF. RANGE Color N/A RPR Negative

App N/A Mono Negative

Glu Negative INEcrobiology

Bili Negative Source


SG 'N/A Occ Bld Negative

Bld Negative H. pylori Negative

pH WA Micro Parasites

Prot Negative Malaria

Urob 0.2-1.0 O&P

Nit Negative Other

Leuk Negative Microscopic Urina

HCG Negative

Spun Hematocrit 42-52% (M) 37-47% (F)

. CSF •• - .

1 • Blood Bank •

Sed Rate Cell Count


Other Directigen I i Negative ABO/Rh

oagulation Studies. • ' -

. - .Blood Bank Unit Crossmatch . - ' - : :. . (MUST,SUBMIT SF,518.WITH EVERY UNIT OF. BLOOD .

,' REQUESTED). " -.. . ' . • ‘;-:.:,.. " TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH

PT ' 9.8-13.6 secs

APTT 21-34 secs . .

D dimer <20 ug/m.1

FDP <10 ug/ml

REMARKS: c--, P '2 COQc-c3

D VIVA rvr -v -IN Tv _ .--- • -

Atyp

Lymph

RBC

Bands

Lymph %

Segs

MCV

Pit

Het

Hgb

RBC

TEST

WBC

ematology) Manual Differential

RESULT REF. RANGE

Imm

Baso

Eos

Mono

20.5-51.1%

130-500 x103 verified

42-52% (M) 37-47% (F) 80-94 fl (M) 81-99 fl (F)

4.76.1 x109

4.8-10.8 x 10'

14-18 g/dI (M) 12-16 g/dI (F)

MEDCOM - 22655

DOD-036231

ACLU-RDI 1673 p.15

Span Hematocrit

Sed Rate Cell Count


Directigen Other Negative ABO/Rh

• Blood Bank . ••: - • ••• • • •

PT 9.8-13.6 secs

APTT 21 -34 secs

<10 tig/rn1

<20 nem] D dimer

FOP

REMARKS:

REPORTED BY: I DATE: LAB ID NO.:.

Coagulation Studies

• • • • -• .

•••• ..• •

TEST RESULT REF. RANGE TYPE CROSSA ,L4TCH UNIT

0 37.47% (F)

•BloOd:Baiik Unit Cross Watch' : UST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD

• . REQUESTED) :

Ward/Section:

REQUESTING PHYSICIAN: LABORATORY RESULT FORM J.

LAST, FIRST.,,M1- DATE TIME w Luc rfivacy itcE cn 1Y/4) I

SSN/PSEUDO SSN:

mato! -.1tr •_Urinalysis .....- ..Misc..Serology : TEST RESVIT:.- —REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative

Hgb 14- 18 gFdL (M) 12-16 g/c11(F)

Glu Negative . Microbiology . .• -. - .•

Hct 42-52% (M) 37-47% (F)

Bili • -

Negative Source

MCV 80-94 ti (M) 81-99 fl (F)


Pit 130:600 x103 verified

SG 'N/A Occ Bld Negative

Lymph % 20.5-51.1% Bld Negative H. pylori Negative

,.. gy)- Manual Differential ...: (IfematOlO. • .... • .,:..• .• . ,•••.• -.•...... . .....•

pH • N/A Micro Parasites

. ./

' Segs . Mono Prot Negative Malaria •

Bands Eos Urob 0.2-1.0 0 & P


Atyp Imm Leuk Negative

.• : .MicioscOptc iia lysis' • • • .• .. • . -. . . ..... : ...

. , . . , .. . . RBC Morph

HCG Negative

'

MEDCOM - 22656

DOD-036232

ACLU-RDI 1673 p.16

Ward/Section: 7-7: C41,

.,,__,JJESTING PHYSICIAN: ' CHEMISTRY RESULT FORM (Subiect to the Privacy Act of 1974)

LAST, FIRST, MI. _ ....--,. *I

Dizt14 TIME ' S

SSN/PSEUDO SSN:

cii5T,..., leotoych46, 5 . , -.1. ' - iogro:wtooiii!.:41iif..:. TEST SULT EF. RANGE

II TEST RESULT REF.

RANGE TEST RESULT REF RANGE

Na ((try 138-146 mmol/L ALB 3 . 5-5 . 5 g/d1 GLU 73-118 mg/di K D _ is:, 3.5-4.9 inmoUL ALP 26-84 u/1 BUN 7 -22 mg/dl Cl // ?'

98-109 mmol/L ALT 10-47 u/1 CA+4. 8.0-10.3 mg/dl

pH 7.31-7.45 AMY 14-97 u/I CRE 0.6-1.2 n3g/dI

PCO2 35-45 mmHg (w1) 41-5t mmHg, (yen)

AST 11-38 u/1 NAT 128-145 minoVI

P02 80-10.5mmHg(2A) N/A tveul

Kr 3.3-4.7 mmult1

TCO2 I ,243:,297 mmol/!- (0,arrca)) :.._ _ _ ._- = PICCOLO - - - — ' ' CL" 98-108 mmol/1

HCO3 22 -26 mmoVL (art) 01/11/03 13 : 00 23-28 mmoUL (yen) REFERENCE RANGE : MALE tCO2 18-33 mmoUl

SO2 95-98% PAT I ENT # : IMF •#0.140iir..4of. gonel'Pl60:;

. :;,::,-.Y-c; -.::: ...T..6.:...;.sh ,-.::.'...n3::::' ,i'.'. ---• BEecf (-2) - (+3) METLYTE 8 (b)(0-1

mmoi/L DISC LOT # : 3151AA4 TEST RESI)7,T REF. RANGE

AnGap 10-20 mmol/L opER # : 777 DR # : 000 , ALB 3.3 - 5.5 g/dl Ca L12-1.32 rnmon SERI AL # : 0000100194 • ALP 26-84 u/1

BUN 8-26 mg/d1 GLU 130* 73-118 MG/DL '

MG/DL

ALT 10-47 oil

GLU 12 7-22 70- 705 mg/dl BUN 1 CRE 1.4* 0.8-1.2 MG/DL

AMY 14-97 u/1

Creat 0.7-1.5 mg/di CK 3159* 39-380 U/L

NA+ 131 128- 145 MMOVL AST 11-38 u/1

Het . 38-51% PCV K+ 3.3 3.3-4.7 MMOVL TBIL 0.27 1.6 algid'

Hgb 12- 17 ydi CL- 109* 98-108 MMOVL GGT 5-65 u/I

- tCO2 17* 18-33 Mal_ "- - 7.,gts.t.-Xb.prAriSAry:. TP 6,4•81 g/d1

TEST RESULT REF RANGE INST GC: OK CHEM GC: OK HEM 1+, LIP 0 , ICT 0

cr61:9-4U041ibte


Drug of Abuse

NA' 128- 145 mmol/1

3.3-4.7 mmol/1

CL" 98-108 mmolll

tCO2 18-33 mmol

REMARKS:

•

REPORTED BY: DATE:

i/.N2./33

LAB ID NO.:

(c)(C1- L

MEDCOM - 22657

DOD-036233

ACLU-RDI 1673 p.17

WarcUSection:

C.)-f(-- REQ• c . .

' CHEMIS1 KY RESULT FORM Suliect to the Privacy Act of 1974)

LAST, FIRST, MI. DATE ip SSN/PSEUDO SSN:

.., ' 1,:5'llA:' ' ' 4ce,o4Ycli4=6 ; ico'16)'1*t4k4tirs4it' .-_

TEST RESULT REF. RANGE TEST RESULT REF. RANGE


Na 138-146 mmol/L ALB 3.5-5.5 01 GLU 73-118 mg/di K 3_5-4.9 rnmoUL' ALP 26-84 u/1 BUN 7-22 mg./d1

Cl 98-109 mmol/L ALT 10-47 u/1 CA+1 8.0-10.3 mg/dl

pH 7.31-7.45 AMY 14-97 u/I CRF 0.6-1.2 mg/d1

PCO2 35-45 mmHg ( 13n) 41-51 mmHg v.12)

AST 128-145 mmol

P02 80-A105 mmHg (art)

( veil) TBIL -- - - - - - PICCOLO •=7==::77- 3.3-4.7 mmol/l

TCO2 23-27 mmol/L WO 24-29 mmol/L (Inn)

BUN 01/11/03 04 : 20 : MALE

98-108 mm01/I

HCO3 22 -26 mmoUL (art) 23-28 mmoUL (von)

CA+* REFERENCE RANGE PATIENT # : Millirq(0 _Li 18-33 mmoUl

s02 95-98% CHOL METLYTE 8 ttr4110 Pliii:_;'i . - 3151004 .,-,-;:;:'- ,::-. .', .'.:, .t . i:...-.

BEecf (-2) - (+3) Imola,

CRE DISC I_OT #: OPER # : 678 DR it: 000 " REF. RANGE

3.3-5.5 g/d1 AnGap 10-20 mmol/L GLU SERI AL it: 0000100684

Ca 1.12-1.32 mmol/L TP GLU 124* 73-118 MG/DL 26-84 &I

BUN 8-26 nag/c11 . 1CCOOYA BUN 10 7-22 MG/DL

- ..r. .--- CRE 1.1 0.6-1.2 MG/DL ] 0-47 u/t

GLU 70-105 mg/d1 TEST

! GLU

RESULT' CK 3517 * 39_380 U/L 128-145 MMOtt.

14-97 &I

Creat 0.7-1.5 mg/di NA+ 129 K+ 4.6 3.3-4.7 MMO.PA_ 11-381.0

Hct 38-51% PCV BUN CL- 110* 98-108 WW1 0.27 1.6 mWdl

Hgb 12-17 g/cli CRE tCO2 17* 18-33 MMOI/L 5-65 u/I

- - .

_. :. •.;K*.T .C.IieitiiSti-347. ' CK

INST OC: OK CI-EM GC: OK 6.4-8.1 g/d1

TEST RESULT REF. RANGE NA-' HEM 2+, LIP 0 , ICT 0 i‘eti.itti,.., , , ..,, ,

Troponin-1 K+ REF. RANGE

Drug of Abuse

_CL" 128-145 mmol/1

tCO2 3.3-4.7 mmol/1

98-108 mmoLl

18-33 mmo1/1

REMARKS:

. I -

REPORTED BY: DATE: 1 LAB ID NO.:

MEDCOM - 22658

DOD-036234

ACLU-RDI 1673 p.18

KT 0.2-1.6 mg/di

7-22 mg/di

tC 02 8.0-10.3mg/d1

100-200 mg/dl

0.6-1.2 mg/d1

73-118 mg/d1

7-22 mg/dl

0.6-1.2 mg/d1

73-118 mg/di

0 Ca Ward/Section:

LAST, FIRST, MI

RF^TJESTING PHYSICIAN:

ATN HEM S RY RESULT FORM (Subject to the Privacy Act of 1974)


•

ieco16 . -itabOtier.:atie

ALB

TEST RESULT RESULT RESULT

351

)5. C

a-5

3

REF. RANGE

138-146 mmol/L

3.5-4.9 mmoUL-

98-109 mmol/L

7.31-7.45

35-45 mmHg (art) 41-51 mmHg (Yen) 80-105 mmHg (art)

N/A (yen)

23-27 mmol/L (art)

24-29 mmol/L (yen) 22-26 mmoL/L (art) 23-28 mmoUL (yen)

95-98%

REF. RANGE

3.5-5.5 g/d1

26-84 u/1 BUN

10-47 u/1

14-97 u/1

11-38 u/1

REF. RANGE

73-118 mg/di

7-22 mg/dl

TEST

Na K

Cl

pH

PC 02

P02

TCO2

HCO3

s02

TEST

GLU

CA'

CRE

NA"

8.0-10.3 mg/d1

0.6-1.2 mg/d1

128-145 mmol/1

3.3-4.7 mmolul

98-108 mmol/1

18-33 mmoUl

PthitiPhi

TEST

(-2) — (+3) mmol/L 10-20 mmol/L

1.12-1.32 =OWL

8-26 mg/dl

70-105 mg/d1

0.7-1.5 mg/dl

.2(e 38-51% PCV

12-17 g/d1

CRE

eli*t

CK

RESULT REF. RANGE NA+

BEecf

AnGap Ca

BUN

GLU

Creat

Het

Hgb

GLU

BUN


39-380 u/I (M) 30-190 u/1(F) 128-145 mmol/1

ALT

AMY

AST

TBIL

GGT TP

10-47 u/1

14-97 u'I

11-38 u/1

0.2-1.6 mg/dl

5-65 u/t

6.4-8.1 g/dI

iccolo).Electrobte

TEST RESULT Troponin- 1

Drug of Abuse

tC0

REMARKS:

334.7 mmol/1

98-108 mmol/1

18-33 mmol/1

REF. RANGE

128-145 mmol/1

3.3-4.7 mmol/1

98-108 mmolll

18-33 mmol/1

CU

tCO2

_CL"

REPORTED lig& DATE:

Al U LAB 11) NO.:

MEDCOM - 22659

DOD-036235 ACLU-RDI 1673 p.19

RAPIOPOINT WAG ANALyMER V4.54 SERIAL #005485 11/02/03 01:53

** PRINT AHrELL 7 D **

i - 31- RT EGt-

RAPIDPOINI LOAF ANALYZER V4.1) SERIAL #005485 11/02/03 04:24

Paiient 113:111111, Test Nam: :PT lest Result: , 19.4 sec. ***WAPi 011 OF RANGE*** Ratio = 1.6 Calculated JN k - 2.12 Sample Type:citrated wh. blood Test Date :11/02/03 lest Time :04:23. Card Lot :80201 Operator

APTDPOINT WAG ANALY V4.54 f',EklAL #005485 11/ /03 04:29

/ • //katient ID

fest Name :ANT

1

lest Result:. 55.1 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated bloom Test Date :11/02/03 Test Time :04:2 Card Lot :03020 Operator

Patient 7.: Test Name :APT1 Test Result:= 56.1 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated plasma Test Date :11/02/03 Test Time :01:49 Card Lot :030201 Operator :MUM

Pt: 1111111W Pt Nam:

Ha 151 mmol/L

4.4 mmol/L

Tr:02 mmol/L

Hct 48 ;PCs)

Hb* 1 g/dL *via Hct

Rt 370

pH 7.410

P0A2 3.0 mmH;

P02 .,18 mmHg

HCO3 25 mmol.

BEel:f 0 mmol/L

s02* 54 %

*calcu1atPd

At Patient Temp

Ph 7.410

PCO2 3,1.0 mmHq

P02 68 mmtiq

Patient Temp: 98.6F FIO2 : 55

Sample Type_: ART

02H0V03 . 11:31

Jper:111111„-----

Physician:

Ser# 42015

Ver: JAMSO4eR CLEW A93

RAPIDPOIN COAG ANAL./ ER V4.54 SERIAL #005. 5. 11/02/03 01:28

Patient .14111111, lest Name , :PT Test Result:. 20.4 sec. ***RESULT DOT OF RANGE*** Ratio = 1.7 Calculated INR = 2.30 Sample Type:citrated wh. blood Test Date :11/02/03 Test Time :01:25 Thrd Lot :080201

.?rator 411111111111111

MEDCOM - 22660

DOD-036236

ACLU-RDI 1673 p.20

Ward/Section:

=': ,l) *----' AEQUESTING PHYSICIAN:

(4,)(0 :?-- LABORATORY RESULT FORM I

(Subject to the Privacy Act of 1974) LAST, FIRST, MI. DATE

ra -I• . I k 02—

TIME -

00 SSN/PSEUDO SSN:

(Hen a logY . . Urinalysis • Misc: Serology : .. TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC 4.7-6.1 x 104 App N/A Mono Negative

Hgb 14-18 dl (M) 12-16 g/d1(F)

Gilt Negative . Microbiology

Hct 42-52% (M) 37-47% (F)


MCV 80-94 11(M) 81-99 fl (F)


Plt 130-;500 x 10J verified

SG N/A Oce Bid Negative

Lymph % 20.5-51.1% Bid Negative H. pylori Negative

• Iiemato )./41a.nual Differential - -

pH . N/A Micro Parasites

' Segs Mono Prot Negative Malaria

Bands Eos Urob , 0.2-1.0 0 & P


Atyp Imm Leuk Negative .Microseivic If alysis

RBC Morph

HCG Negative

Spun Hematocrit

42-52% (M) 37-47% (F) . Blood Bank , • •

Sed Rate . _

Cell Count !


Other

.

Directigen Negative ABO/Rh

Coagulation Studies:: .':. - • . '.. - .- -. -Blood:Baal( Unit CrosSinatclf .. - -. : :.... - .•(MUST SUBMIt. SF 518 WITH EVERY UNIT: OF BLOOD .

TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH

PT 9.8-13.6 secs

APTT 21-34 secs

D dimer <20 ug/m1

FDP <10 ug/ml

REMARKS: , Lo a...,..

REPORTED BY: DATE: LAB ID NO.:. '

MEDCOM - 22661

DOD-036237

ACLU-RDI 1673 p.21

Ward/Section: - ---C__/,_---.\

RE I.17: '^' PHYSICIAN: t a.) RI) r? CHEMISI A Y RESULT FORM

(Subject to the Privacy Act of 1974) LAST, FIRS

Np-1 DATE TIME

itt. SSN/PSEUDO SSN:

iiis.. . , i'd.010-'010iiiJi. • ::. ' k•Or6 . tal4Qi - ,ilk

TEST RESULT REF. RANGE TEST

138-146 mmol/L f AL ;

3.5-4.9 mmol/L' A T tr

RESULT REF. RANGE

3 7 5-5 . 5 edi

TEST

GLU

RESULT

Y

l REF. RANGE

73-118 mg/c11 Na i 5 1

K 3 . / BUN 7 -22 mg/dl

CI 98 -109 rnrnol/L CA+ 8.0- 10.3 Ing/d1

pH I.. 435 7.31 -7.45 - . -7- L "L - . s = PICCOLO :---:=7::::: CRE 0.6- 1.2 mg/d1

PCO2 ,- 34. -..

35-45 mmHg (are 02/1 1/03 01 :25 41-51 mml-IE (ven)' 1-41FMLNCE RANGE: MALE NA' 128-145 mmol/1

P02 ( 3 ( SO-70.5 mmHg <art) N/A (vein PAT IENT It: oar K- 3.3-4.7 mmolil

TCO2 ,2/

23-27 rnmol/L (art) METLYTE 8 24-29

rnrnol/L (yen) 3151A M CL 98-108 mrno1/1

HCO3 (2 3 22-26 mmoUL (art) DISC LOT #: 23-2S mmol/L (yen) OPER # : 013 DR # : 000 tCO2

RESULT

ite00)%Nf.eii.!4n-el-pl6g,:;, ,....!:-....,,,::-.:,...--;.,,..:::,....::„:., :.....:.:::!!..a:

18-33 mmoUl

REF. RANGE

3.3-5.5 g/dl

S02 79 95-98% 0000100684 SERIAL # :

BEecf I

(-2)— (+3) rnmon GLU 91 73-118 MG/DL TEST

AnGap 10-20 mmol/L BUN 10 7-22 MG/DL ALB MG/DL

Ca 1.12-1.32 nunol/L CRE 1.0 0.6-1.2

CK >5000* 39-380 U/L ALP 26-84 all

BUN 8-26 mg/di NA+ 138 128-145 MMOR.- ALT

4.4 3.3- 4 .7 MMOUL K+

10-47 u/1

GLU 70-105 mg/d1 CL- 114* 98-108 MOM_ AMY 14-97 to

Creat tCO2 18 18-33 MMOUL 0.7-1.5 mg/di AST 11-38 u/1

Het - Jr a.,... 38-51% PCV : INST QC: OK CHEM OC: OK rBri. 0.2 7 1.6 Ingi, I

Hgb t.3 ar. 12-17 eidi +

4 HE_M 0 , LIP 0 , ICI 1 3GT . 5-65 u/1

4-,,g*.- kieniist . 1.—

7F. 6.4-3.1 Wdl

TEST RESULT REF. RANGE ; ..• .... ... • .

volo.I.X104011t0;,- ,

Troponin-1 X TEST RESULT REF. RANGE

Drug of Abuse

-C A' 128-145 mrnoVI

, 3.3-4.7 mmol/1

98-108 mmoL11

1 tCO2 18-33 mmo1/1

REMARKS: 0 t_b& . Cl.,esm (6

-.,..„,_ . '''''' ,(3,), c tX) 'ail .' REPORTED BY: DATE:

Q AA ki‘)

LAB ID NO.:

MEDCOM - 22662

DOD-036238

ACLU-RDI 1673 p.22

Ward/S ion:

1

REQUE ' • • • 'SICIAN: CHEMISTRY RESULT FORM Suliect to the Privacy Act of 1974)

LAST, FIRST , -

-r-A)60 -6 ,..

T.4. SS " - '' •• N:

;',',::,,..-:,--.:.:- . - - - - - • - , ,.. .. ... :

Metabolic.

,i0610',01i014i.4 .. ' ' -',:: i.0 ' - :Patiel.. ':.: is;::- 7::;':,.it"::-.::..;::;•', : .•..-'; ei.,;::! .'', ',..:.' . .'.---7:":',' •,' :•:,,i-; ;:j f'-.j . :if::"-: - !':'' ::•::::- -.: .',:,;',.;', TEST RESULT ". F. RANGE TEST RESULT REF. TEST

RANGE RESULT REF. RANGE

Na 1 5 -?. 138-146 na2o,RI/1.. ALB 3.5-5.5 g/d1 U 73-118 mg/d1

K 0 3.5-4.9 mmol./L . '".- I .m.sa,./1 t1UN 7-22 nag/d1

Cl 98-109 mrool/L A (Lqi - Ll A+ 8.0-10.3 rog/d1

pH 7 . ;1 7.31-7.45 A -- - PI COLO - - - - — RE 0.6-1.2 nag/di

PCO2 3 .7 43 15:4515 m TilFgr gZ) 11/03

REFERENCE L 04 : 17 A' (i :

MAI F 128-145 mmol/1

P02 -7 ‘

80-10.5 mmHg (art) N/A (veal

T PAT I ENT #' 3.3-4.7 mmolil

TCO2 1--

5 ,23:,279 i v mmolli./L ((artn)) 4 B frETLYTE 8 L. 98-108 mmo1 /1

HCO3 1 ,4 2232:2286 mmoovULL avrten) ) DISC LOT #• 3151M4 r ;0 - OPER #: 013 DR #: 000 2 18-33 mmolJl

s02 5

95-98% _ C SERIAI_ # : 0000100681 :,̀...' .: ..(giediilii)TLg'ii-Pdliil

'• k'.:),*:•.- ::V.:; -..7%7;. ";;;;:...;,: Pliii ,';i:'-:::-

',.,::.".:,:.: :::,,,;....::!!..::::::.?: '• ...:

BEecf . —

(-2) - (+3) nanol/L

C TEST GLU 92 73-118 MG/DL RESULT REF. RANGE

AnGap 10-20 mmol/L a BUN 9 7-22 MG/DI- LB 33-5 -5 8/c11 Ca 1. 12-1.32 mmol/L CRE 1.6* 0.6-1.2 MG/DL

LP CK >5000* 39-380 U/L

26-84u/1

BUN 8-26 ng/d1 ' NA+ 140 128-145 MMOL LT

K+ 4.9* 3.3-4.7 MMOVL

10-47 till

GLU 70- 105 mg/dt. : CL- 111* 98-108 MM0f/L MY

CO2

14-97 un

Creat 0.7-1_5 mg/d1 t 19 18-33 MMOIA_

G ST 11 -38 u/1

Hct Lf I 38-51% PCV .B INST QC: OK CF-EM 00 OK BIL 0.2-. 1.6 ro g/dl

Hgb I LA 12- 17g/dl 7 1-EM 0 , LIP 0 , ICT 1+ GT 5-65 tilt

...i7X!.Sijqh-einkifiy. 7_ . :, .!. ., :. - •i: , - , •7;:,-i,..% '.',,.;::. :1 ....: :.•:,—: .:*i '''

C P 6A-8.1 g/dI

TEST RESULT REF RANGE N :.:.--- Ota14Eletio6te...:-

Troponin-1 PEST RESULT REF. RANGE

Drug ofAbuse

- . 128-145 mmolfl

3.3-4.7 mmo1/1

1

- 98-108 mmolll

I.0O2 18-33 mo1/1

REMARKS:

REPORTED BY: J DATE: 1 .AB ID NO.:

_I

MEDCOM - 22663

DOD-036239

ACLU-RDI 1673 p.23

• CHEMISTRY RESULT FORM (Suliect to the Privacy Act of 1974)

DATE TIME SSN/PSEUDO SSN:

(-7-PLZ) (D-2)

Ward/Section: REQUESTING PHYSICIAN:

IA)

LAST, FIRST, FIRST, MI.

-Sm:

TEST

Na

CI

pH

PCO2

P02

TCO2

HCO3

s02

BBecf

AnGap

Ca

BUN

GLU

Creat

Hot

Rgb

TEST

Troponin- 1

Drug of Abuse

RESULT REF. RANGE

RESULT

•3.5-4.9 mmoUL

1 98-109 mrnol/L

38-51% PCV

70-105 mg/di

0.7-1.5 mg/dl

35-45 mmHg (art) 41 -5 1 mmilz (yen) 80-105 mmHg (an) N/A (veal 23-27 Imola. (art) 24 -29 mmol/L (yen) 22-26 mmol/L (art) 23-28 mmol/L (yen)

(-2) — (+3) nunol/L

8-26 mg/d1

95-98%

12-17 g/d1

7.31-7.45

10-20 mmol/L

1.12-1.32 mmol/L

138-146 intnol/L

REF. RANGE TEST RESULT REF. RANGE


ALB 3.5-5.5 g/d1 GLU 73-118 mg/di

ALP

ALT

26-84 u/1

10-47 till

BUN

CAH

7-22 mg/d1

8.0-10.3 men

AMY 14-97 u/1 CRE 0.6-1.2 ing/d1

AST 11-38 128-145 mmol/1

TBIL 0.2-1.6 mg/dl K4 3.3.4.7 alma!

BUN 7-22 mg/di CI; 98-108 mmo1/1

CA 8.0-10.3mWdl tCO2 18-33 mmol/

CHOL 100-200 mg/d]

CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE

GLU 73-118 mg/di ALB 3.3-5.5 g/d1

TP 6.4-8.1 g/d1 ALP 26-84 u/1

iicOYS etlyte; ALT 10-47 u/1


AMY 14-97 un

GLU 73 -118 mg/dl AST 11-38 u/1

BUN 7-22 mg/dl TBIL 0.2-1.6 rng/d1

CRE mg/dl GGT 5-65 u/1

CK 39-380 u/l(M) 30-190 u/l (F)

TP g/d1

NA+ 128-145 mmo1/1 lecolo)- 40a.

334.7 mmol/1 TEST RESULT REF. RANGE

CL 98-108 ramo1/1 NA+ 128-145 mmol/1

tCO2 18-33 mmol 3.3-4.7 mmol/3

CL: 95-108 mmol/1

tCO2 18-33 mmol/1

REPORTED BY: LAB ID NO.: DATE:

REMARKS: 7- 3, o 5-5—x

MEDCOM - 22664

DOD-036240

ACLU-RDI 1673 p.24

Ward/Section: /c."&( j---r. . REQUES rNG CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)

LAST, FIRST, MI.

(91 4);1

DA / 0 . 7

TIME AI ys' SSN/PSEUDO SSN:

,,

.. , TEST

- miooloY RESULT

oin,-4..., -.' - REF

RANGE TEST

(Piccolo)

RESULT

406lie.p.*40)„.,.

REF. RANGE TEST RESULT REF. RANGE

Na 138-146 nunol/L ALB 3.5-5.5 g/dl GLU 73-118 mg/d1 K 3.5-4.9 mmoUl.; ALP 26-84 u/1 BUN 7-22 mg/di

Cl 98-109 mrnol/L ALT 10-47 u/1 CA +' 8.0-10.3 mg/di

PH 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/d1

PCO2 35-45 mmHg (art) 41-51 mmHg (yen)

AST 11-38 u/I NA* 128-145 mmol/1

P02 8105 mmHg 010 N/A (yen)

TBIL 0.2-1.6 mWdl K+ 3.3-4.7 mmolil

TCO2 23-27 mmol/L (art) 24-29 mmol/1, (yen)

BUN 7-22 mg/di CI: 98-108 mmol/1

HCO3 22-26 mmoll (arr) 23-28 mruol/L (yen)

CA-H- 8.0-10.3med1 tCO2 18-33 010101/1

s02 95-98% CHOL 100-200 mg/d1 (Piccolo) ii*it PAiit't..hi" .:„

BEecf (-2)- (+3) rarnoUL

CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE

AnGap 10-20 mmol/L GLU 73-118 mg/c11 ALB 3.3-5.5 g/dl Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/dl ALP 26-84 u/I

BUN 8-26 mg/d1 ...4-.- -:;i ,:.... •::.P..1:,:.icq: ;;;.•' .i .&61:41i10,1ii v g; 4 •: - :i.; . 51,:. .; ,::: .k.:j-r........': -.: .::;.■;-.. ALT 10.47 u/1

GLU 70-105 mg/d1. TEST RESULT REF. RANGE

AY 14-97 u/1

Creat 0.7-1.5 mg/dl GLU 73-1 1 8 mWdl AST 11-38 u/1

RI 38-51% PCV BUN 7-22 mg/d1 TBIL 0.2-1.6 mg/d1

Hgb 12-17 g/d1 CRE 0.6-1.2 mg/dl GGT . 5-65 tilt

' ".- ;,-. ..4 •-_,NA..: ..iiiiiji :-.'' Z1 .fi.7: "': "-...;f? , -t

CK 39-38011/1(M) 30-390 u/1 (F)

TP 6.4-8:1 g/dl

TEST RESULT REF. RANGE NA+ 128- 145 mmol/1 • ,ect! O. 1ectroyte

Troponin-! + 33 -4.7 mmol/1 . TEST RESULT REF. RANGE

Drug of Abuse

_Cr 98-108 raino1/1 NA' 128- 145 mmol/1

tCO2 18-33 mmo1/1 K 3.3-4.7 mmol/1

• CL- 98-108 mmo1/1

. tCO2 18-33 mrno1/1

REMARKS: .--....-- .

./413 G f--/ 0,2 53" 4 / go_ -Ybeze-si s7/ifivr, REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 22665

DOD-036241

ACLU-RDI 1673 p.25

EG6+ .

Pt Pi NamP:

Pa , lent TemP

PH 7.308

PCn2 43.0 mmHg

P02 51 mmHg

Patient Temp: 94.eF FIO2 • •

Sample Type_:

02H0V03

Op er: 11111

IR 5.1 x10"3/aL

RBC 4.86 x1.0"6/uL

1/1-19b 14.5 gidt. Hct 44.8

try 92.1 fL

it14 29.8 pg mit: 32.4 L g/dL Pit 115. L x10'3/ii LIZ 8.6 *L. Z

LIT 0.4 *1 x10'3AL

RAPIDPOINi COAG ANALYZER V4.5 SERIAL 4005485 11/03/03 00:01

Test Nameir Patient ID:

Test Result: 22.7 sec. ***RESULT OUT RANGE•** Ratio = 1,2 CalcuFated -NR = 73 Sample Typelocitrate wh. blood Test Date :11/02/03 Test Time :23:58 Card Lot :180201 Operator

';)-- RAPIDPOINT COAG ANALYZER V4.54 SERIAL #005485 11/03/03 00:06

Patient ID: Test Name :APT`T\ Test Result:= 96'9 sed, ***RESULT OUT OF RA *** Sample Type:citrated wh. blood Test Date :11/03/03 Test Time :00:02 Card Lot :O208 Operator

.-RAPIDPOIN1 COAG ANALYZER V4,54 SERIAL #005485 11/02/03

Patient ID Test Name :PT Test Result:. 21.6 sec. ***RESULT OUT OF RANGE*** Ratio = 1.8 Calculated INR = 2.52 Sample Type:citrated wh. bloc Test Date :11/02/03 Test Time :19:55 Card Lot :080201 Operator 11111111111

RAPIDPOINT COAG ANALYZE V4.1)4 SERIAL #00.5485 11/02/ 3 20 . 0Y

Patient ID Test Namr- : TT Test Result:=102.8 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test. Date :11/02/03 Test Time :19:57 Card Lot Or- :

pia

DOD-036242

Ha 150 mmol/L

K 3.7 mmo 1 /L

TCO2 23 mmol/L

Hct %PCV

*via

At 37C

pH .

PCO2 45.1 mmHg

P02 55 mmHq

HCO3 22 mmol/L

BEecf , mmol/

s02* a4 % te

Z7. 7.2 27:C, 51.0 1,14C 31.6 L 91dL Pit 5. *. x10 L 150. 450, LIZ L.4 *1 20.5 51.1 LI 0,2 *L olO'3!uL 1.2 3.4

Ser# 42011

Ver: JAHSO4;A CLEW A5, 3

Physician:

'N-11-03 01:2+

atient Limits

a S.: (1.031.L. +.5 10.5 ▪ +-.)0 x10 46/uL 4.00 6.00 Hi 15.7 9/IL 11.0 19.0 ▪ 42.9 1 35.0 60.0 rg 91.6 OL 80,0 99.9 • 2=.2 Pg 27,0 31.0 117tC 31. 9 L g/dL 310 37.0

ell- 115. L x1.0`3/aL 150. 450. LIZ 8.4 4.X 20.5 51.1 LIT 0, 4 X10:ik6.hO 3.4

02-11-03 04:1'8

Patient Limits

4.5 10.5 4.00 6.00

11.0 18.0 .15,0 60.0

SILO 99.9 27.0 31.0 33.0 37.0 150. 450, 20.5 51.1 1.2 3.4

MEDCOM - 22666

ACLU-RDI 1673 p.26

i-sTAT EGe+

pt.

ria

Na__ _150 mmol/L

4.1 Tmol/L

712.02_ __17 mmol/L

mct 30 PCV

Hb*___ _10 q

*vla

Na 142 mmnl/L

3.7 mmol/L

T002 20 MM01/L

Hct 36 %Pcv HbiE 12 q/dL

*v.ia Hct

N.•


Patient ID111111 Test Nar 7: T. Test Result:= 16.9 sec. Ratio = 1.4 Calculated 1NR - 1.70 Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :01:10 Card Lot :080201 Operator :11111111111

RAPIDPOINT GOAD ANALYZER V4.54 SERIAL #005485 11/01/03 01:15

Patient ID ; lest Nan : PIT Test Result:= 37.5 sec. Sample Type:citrated wh. blood Test Date :11/01/03 Test Time :01:12 Card Lot : 30201 Operator

At Patient Temp

PH 7.47e

PCO2 22.1 mmHg

pnz ou mmHg

_ mmHg

02 3e mr419 ,9

HCO3 17 mmol/L

6EPcf -7 mmol/L

-702* 74 %

*calculated

At Patient Temp

pH 7.318

PCO2 3e.3 mmHg

P0a *** mmHg

Rt 37C

PH 7 .74..

P002 40.2 mmHg

P02 *** mmHg

H003 19 mmol/L

8Eecf -8 mmol/L

sn2* *** %

*calculated

patient Temp: 55.- - Patient Temp: 54.4F

FIO2 : 10,? FIO2 : 100

3ample Type_: 2RT Sample Type_:

, 11,111 0,

6A0V03 00:49

riper: 66-2_

Pny=ic - an:

02NOV03 25:c.S

Oper ;;),

Physician):

_ 4.5

20.0 27.0 31.0

at] 51.1 1.2 14

rfo / Ser# 4074e

ver; jAMSO4e2 CLEW 293

Ser# 42011

Ver; JANSO42 - CLEW A93

MEDCOM - 22667

DOD-036243

ACLU-RDI 1673 p.27

Ward/Section: REQUESTING PHYSICIAN: LABORATORY RESULT FORM - •

Other .

Coagulation Stu

'LAST, F. T„ . v..,..),,t

DATE TIME - tv Luc I i vektt:y Pict 01 150 / 4)

SSN/FSEUDO SSN:

: ..... ' . ....(Hen tOlogy) CBC .. • Urinalysis _Misc. Serology: TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

WBC ,—.. • 4.8-10.8 x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative

Hgb 14-18 g/d1(1vf) 12-16 wet' (F)

42-52% (M) 37-47% (F)

Glu

Bili

Negative

Negative

• . IyUerobiology .. .• •. :... . • .. • . . • — .

Hct Source

MCV 80-94 21 (M) 81-99 fl (F)

Ket Negative

Stain• Gram

Pit 130400 x10 verified

SG •N/A Occ Bld Negative

Lymph % 20.5-51.1% Bld

...

(Hematology) Manual Differential .,.:-•

Negative H. pylori Negative

. . -.. • • • - . • •• - • . • • ••• . : pH • N/A . Micro

Parasites Segs • Mono Prot Negative Malaria '

Bands . Eos Urob 0.2-1.0 0 & P


Atyp Imm Leuk 1 Negative • •Microscopic Urinalysi ... ,-.. . .. • ....., ... .- . ..-.... .

RBC Morph

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

HCG Negative

I - • Blood Bank , • .

•

Cell Count

Directigen

TEST RESULT REF. RANGE &WIT

PT 9.8-43.6 secs

APTT 21-34 secs

D dialer <20 ug/ml

FDP <10 ueircl

REMARKS: tc-‘

p Hematocrit

Sed Rate

-+,4 Jh7O 37:47% (F)

- Blood Bank Unit CrOssmatch . ' • (MUST.SUB1I-IIT SF 518 WITH EVERY UNIT OF BLOOD

- .•• REQUESTED) • • •-. ̀'• :


Negative I ABO/Rh

TYPE CROSSMAI.TCH

• I REPORTED BY: DATE: LAB ID NO.: .

MEDCOM - 22668

DOD-036244

ACLU-RDI 1673 p.28

i.5

73-118 MG/DL 4 u/1

7-22 MG/DL 7u/1 8.0 - 10.3 MG/DL 0.6-1.2 MG/DL 7 tilL

128-145 MMOVL 3.3-4.7 MMOVL .8u/1

98-108 MMOVL 18-33 MMOVL

INSI OC: OK CHEM OC: OK HEM 0 LIP 1+, IC1 1+

RESULT

L

GLO BUN rA+

CRE

NA+ K+ CL-tCO2

28* 14

7.7* 1.5* 144 4.3 114* 18

7

6

REMARKS:

clk.\ vta, V-AJ LAB ID NO.:

AntiV3 REPORTED BY:

DATE:

Ward/Section: (JESTING PHYSICIAN:

LAST, FIRST, l'

(c10 DATE TIME

)--

Z,MLSTRY RESULT FORM (Subject to the Privacy Act of 1974)

SSN/PSEUDO SSN:

(Piecol)),Ch&nistry 1

TEST

Na

Cl

PH PCO2

P02

TCO2

HCO3

s02

BEed

RESULT i ..../Z 1,T.

7.31-7.45 AMY IILL

GE

AST

TBIL

BUN

CA

CHOL

CRE

GLU

TP

TEST

GLU

BUN

CRE

CK

NAS

tCO2


PICCOLO ==-:--- 23:58

1M t 02/11/03 7- RL1tRENCE R1 )8 mmol/1

PATIENT #: BASIC METABOLIC DISC LOT #: 3325ml OPER #: 013 DR #: 000

SERIN #: 0000100684 F. RANGE

AnGap

Ca

BUN

GLU

Het

10-20 mmol/L

1.12-1.32 mmol/L

8-26 mg/dl

70-105 mg/dl

0.7-1.5 mg/dl

38-51% PCV

12-17 g/d1

RESULT REF. RANGE

35-45 mmHg (art) 41-51 mrnHz veal 80-105 mmHg (art) N/A (veul 23-27 mrnol/L (art) 24-29 mmol/L (yen) 22-26 mmoVL (art) 23-28 mmol/L (von)

95-98%

(-2)— (+3) rumon

138-146 mmol/L

3.5-4.9 mmol/L

98-109 mmoVL

3.5-5.5 g/dl

26-34 u/1

1047 u/1

1 1

TES RESULT REF. RANGE

GLU 73-118 mg/dl

BUN 7-22 mg/dl

8.0-10.3 mg/dl

' .2 roz/d1

45 mmol/1

7 mmolil

3 mmoVI

108 rr.mo1/1

33 mmol/1

MEDCOM - 22669

DOD-036245

ACLU-RDI 1673 p.29

Hematocrit

Sed Rate Cell Count

Negative Directigen Other ABO/Rh


•

Blood Bank .

PT 9.8-13.6 sees

21-34 secs Am

D dimer <20 tg/m1

• 37.47%

. : - - ' . . . - Blood: Bank Unit Crossmatclf - : - (MIJST SUBMIT SF 5. 18.WITH EVERY UNIT OF BLOOD

. '

. . , .

REQUESTED) ' :' ': • : ' TEST RESULT REF. RANGE UNTT TYPE CROSSM4TCH

Coagulation Studies.

FD.P <10 ug/m1

REMARKS: • -•40110‘...-

REPORTED BY: P—t. PT

DA1 E: LAB 103. NO.: .

Ward/Section:

• LABORATORY RESULT FORM •

REQUESTING PHYSICIAN:

touojeet to me Yrtvacy Act of 1974) I LAST, FIRST, ,MI. DA t 0

TIME

1 CI • SSN/PSEUDO SSN:

(Hematology) CBC :: yrina sis - . : . , misc. Serology ... _ TEST R1fT i - . NGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE

NBC 4.8-10.8x 10 Color N/A RPR Negative RBC 4.7-6.1 x 109 App N/A Mono Negative Hgb

14-18 dl (M)

12-16 dl (I') Glu Negative l!ilierobiology

Hct 42-52% (M) 37-47%(F)

80-94 11 (M) 81-99 fl OD

Bili

Ket

Negative

Negative

Source

Gram Stain

. • .. MCV

Pit i 30-,500 x 10 verified

SG N/A Occ Bid Negative

Lymph % 20.5-51.1% Bld Negative H. pylori Negative (Ifematti . . ) Manual Differential : .. -

• ' . , - pH N/A Micro

Parasites Segs Mono Prot Negative Malaria Bands . Eos Urob 0.2- 1.0 0 & P


Atvp Imm Leuk Negative

•

: .Mkrpscopic UrinaysiS

RBC Morph

CrItIn

HCG

,t, S1.01_ (?AN r ----

Negative .

MEDCOM - 22670

DOD-036246

ACLU-RDI 1673 p.30

FORM Ward/Section: (A.,,,(

LAST, FIRST,,MI. ..--------,------•-,—.

REQ

DATE v 3

C 0 16 TIME

Sub- ect LABORATORY RESULT

to the Privac Act of 1974 SSN/PSEUDO SSN:

(ilcmaOlogY) . •Urinalysis . .. Misc: Serology

REF. RANGE TEST , REF. RANGE TEST RESULT REF. RANGE

WBC 4:8-10.8 x 10' Color - N/A RPR Negative

RBC 4.7-6.1 x 10 App N/A Mono Negative

Hgb 14-18 &I (M) 12-16 di (F)

Glu Negative - • IYUCrobiology :. . • .. - . •

Hct 42-52% (M) 37-47% (F)


MCV 80-94 t1(M) 81-99 fl (F)


.N/A Occ Bld Negative Pit 130;500 x 10

verified SG

Lymph % 20.5-51.1% Bid Negative H. pylori Negative

pH - N/A . Micro Parasites (Hematology) Manual Differential .

Prot Negative Malaria ' Segs • Mono

Urob 0.2-1.0 0 & P Bands Eos

Nit Negative Other Lymph Baso

Atyp Imm Leuk Negative MIcinscopic Urinalysis; . ... •• • . ...... . .

RBC Morph

HCG Negative

Spun •Hematocrit

Sed Rate •

42-52% (M) .. Cell Count

. CSF. •

MUST SUBMIT EVERY 'UNIT

Blood. Bank ...- .-

SF 518 WITH REQUESTED

Other

.:.- COagulation - Studies. , - -.• , ..........•-... . ., ...•••..

Directigen

;!:. - - ' . (MUST

. ..-. .BloOrt SUBMIT

Negative

Bank Unit sr518.WITH

ABO/Rh .

Croisniatch-- EVERY

: s. - .. UNIT OF BLOOD ..

UNIT TYPE CROSSM4TCH TEST RESULT REF. RANGE

PT 9.8-13.6 set:::

• APTT 21-34 secs

D dimer , <20 ug/m1 •

FDP <10 ug/ml

REMARKS: ------

I REPORTED BY: I i _______

DATE: LAB ID NO.:. •

MEDCOM - 22671

DOD-036247

ACLU-RDI 1673 p.31

Ward/Section: REQUESTING PHYSICIAN: CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974).

LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN:

.1.7 T , • • i0610)'PIi6iiiteY::1 !Ctilb). ,1WtabliiPa ail • - .- -,...:::.D.:ic,•:., ::',..--•.::' , ., :f.,'' .:e: :"•:::,: 1,:::..,;:- .:?, ,

TEST RESULT REF. RANGE TEST RESULT REF. RANGE

TEST RESULT f REF. RANGE

Na 138-146 mmol/L ' 2 C-C i okli GLU 73-118 mg/dl

K 3.5,4.9 11=0UL- BUN 7-22 mg/di

Cl 98-109 mrool/L - PICCOLO - - 03/11,03

CA7f 8.0-10.3 mg/dl

PH 7.31-7.45 00 : 52 REFERENCE RANGE: MALE

CRE 0.6-1.2 rng/d1

PCO2 35-45 mmHg (gym pAT I ENT # : IffikYC)-1 41 -51 mrnffiz (ven) NA: 128 - 145 miro1/1

P02 80-105 mmHg (art) ME:TLY I L 8 NM. (yell)

K' 3.3-4.7 mmo1/1

TCO2 23-27 rnrnol/L (art) DISC LOT #: 3151AA4 24-29 mmol/L (ver OPER # : 013 DR # : 000

CE 98- 108 mmol/1

HCO3 22-26 mmoVL (art SERIAL # : 0000100494 23-28 nuvol./L (vcr tCO2 18-33 mmoV1

s02 95-98%

U21 * 73-118 MG/ P:iciiiltION!4:-P. dite.f pli4-...]::;,-,.-: ,

- ,(:;:,:j....;',;..'..-:; ,;.i.:.:,..'..:. f:..,,,•. ,.'..:z1 ,--. .:: BEecf (-2) - (+3) BUN 13 7-22 MG/DL runlon


AnGap 10-70 mmol/L CRE 1 .6* 0.6-1.2 MG/DL ALB 3.3-5.5 g/dl

Ca 1.12-1.32 nun& CK >5000* 39-380 U/L N9+ 131 128-145 MMOVL

ALP 26-84 u/1

BUN 8-267.301 K.f. 4 . 8* 3.3_ 4.7 mmovt_ . ALT 10-47 u /1

GLU . CL - 112* - 70-105 mg/d1 98 108 MMOLL tCO2 16* 18-33 MMOVL

AMY 14-97 u/1

Creat 0.7-1.5 mu/d1 INST QC: OK CFM

AST 11-38 u/1

Hut 38-51% PCV QC: OK HEM 0 , LIP 0 1 ICT 1+

TBIL 0.2 7 1.6 mg/d1

Hgb 12-17 g/cil GGT 5-65 oil

,;..r. :111,4sC;TCIiixiiiit .:: -,

TP 6.4-8.1 g/d1

TEST RESULT REF. RANG .ccol_ , , o:) •peetTolyte :::.


Drug of Abuse

l NA' 128- 145 mmol/1

IC 3.3-4.7 mmol/1

CL: 98-108 mmol/1

1 tCO-. 18-33 mrnoUl

REMARKS:

REPORTED BY:

Ma

DATE: 1 LAB ID NO.:

3AMV)3 j

NO r-

MEDCOM - 22672

DOD-036248

ACLU-RDI 1673 p.32

DOD-036249

k 1$ . NS 'Po

14,R P-r T 2,7,1 WP SG3 ( kt-S

FIct_bi soo o , E. oNT MEDICAL RECORD - ANESTHESIA itChit-`,..,

6.e.,..oktonstc.I.- v For use of this form, see AR 40-66; the proponent agency is the OTSG

th -OW -- ]::{Unita) : TOTALS .7.,..;g0t.::: "> 3- D'z . e ( 'Ir 1 --- ...----.- .... -Wee.. WS 0 iDEISM G/1:11

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INKgarellM11 IK-411 1111111111=1 _, 7',.

8=6 7 )- U

VOL AT .. AGE(i1T:

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INEEIRIIIIIIIIIIMIRL9111/LIMIREVERIVAIII 111111111111111111111

..„. . ..... CRx LLOID- r

k4 ° L. Z 12 AIR L/Min G \O L- z 0 Es) U N20 L/Min ' ID-

cry w 02 L/Min 2..--- --Z--- -2-- 2.,...- 7./ 2-- 7, '1-- z 4 to

SINGLE DOSE DRUGS-MARK ON GRID WITH NUMBERS & ENTER IN REMARKS

ximrierimusrminzmin IV , ❑ Warm

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BLOOD- . • ,./... 4:0414 .......................................n Code drugs with numbers, 1e MiziragiErame4 1111111111111.111111 ye is with lett! s ‘

LI Warmed I' Mili INN lTJ

, i-n ......--- 119.!S ES . : :::::::,:%:::::::.:::::::::. EST BLOOD LOSS

. / 00

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00 . itzegA,..--- ‘ - 0 , 4 . . pry . -..• ■ URINE - V, ICA

4111Y :.i.STAT ':. TIME • 1 40° 4; ID • tow • -50 • 2100 ' 30 , 413 4 5 :.::---..:.:1.:..::::.:::

zzo

200

18

160

140

120 100

BO

60

40

20

07_, . • 00074:V.E.101-1 611/1B6LS'. .::::,::::':::-ii::.::.:.:::: .

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if t-) BP by cuff • ,f1 my

1111=111111MLOW

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6. Heart rate R M &Tea

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iiirai°

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TIME 1,gao

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PR"- So •

V122162. .;,,t 1 0 acv •

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VT - ml

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Fin C MODE • s( on). Alssist). C(on) TAP/Auto Cuff C°2 ito") E11111EMPIllIMPIIIIMIE1111101111111EILMILW ii BP/oth I 102 (Frac or %I raCHIMMIMIIIIMIEVILMIarilMil mil PAC CP Specify)

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End Cony warmer 111=1 MN ' E.) Ready Merle with letters & symbols, EVENTS II Ta/ V! C3 explain under REMARKS Position —4.6-1 I N ," 1 [ 44, a. f5 ' lq ri, 7.1 z

PROCEDURES and CPT Codes: -- Colos.i.oiy‘

.?(Ici,R : st.9,,i4„.t::&Q,Q.0.0 ,k— ANESTHETIC TECHNIQUES: Describe block technique under Remarks

E. 1 (I-- R AY MA G MENT: Intubation route blade, techni ue, comments

1".'s F' 01 I ?. D ° al: at.12.- SUR 4_ , Tr°

PATIENT IDENTIFICATION: Aiped or od/rte d enrries: Name, Grade/Rare, liaical facility

Qrz i/ .-)K,)--c-1

, PROCEDURE -7 OCATION: ( _,..0

aft 3 er3a /41/rET PAGE / OF DA FORM 7389_ FFR 1998 .,..-r., .,........ .............-

i USA PA V1.00

ACLU-RDI 1673 p.33

)-r0. 0 MEDICAL RECWRD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

o

:ii

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3

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11 /- .4.-e il.. / " 0 Warmed cc- — ..

0 Warmed Code drugs with numbers, events with !enters

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180

160

140

120

100

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60

401

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A Heart rate

s Resp rate

BR (transduced)

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TOURNIQUET

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i

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--IP Auto Cuff ---1 02 (tort) ----

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OTHER

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Mark with let toss & syr Opts, EVENTS p if 1 explain under REMARKS Position E 6.-- Z1 CC Z:2-tf. 0 PROCEDURES and CPT Codes: ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICAT : Typed or written entries: Name, Grade/Rare, AIRWAY MANAGEMENT: lntugion route .e,technique, comments 0 Medical facility I A-7-.164Pia t ,t ( C 46...Cir ..."i f ee9 r..., 1400 ((7.19 la_ SURGEONS:

L6_10D) 1 .

PROCEDURE( / LOCATION: DATE:

Z. drVO Y01-5

IIIIIIIIIIIPIIIIIIIII

PAGE / AGE / OF

M - 22674

COPY 1 - PATIENT'S MEDICAL RECORD USAPA V1.00

DOD-036250

ACLU-RDI 1673 p.34

NIP TREND 11/03/03 11/03/23

TIME HR/PR Sp82 SYS / DIA - MEAN RR FiME HR/PR Sp02 SYS / DIA - MEF RP

HH:MM BPM X mmHg RPM mm82 RPM

00:46 62 1U2 ERR 15 11 00:46 63 L ltd / Id2 14

00:41 100 Ig2 / 39 126 OFF 00:44 63 argi/ 1B8 IFI 25

30:36 86 12d ERR 15 22 00:42 50 V - / ig 10

n / Ig0 ■• IAA 12 00:40 122 / ILki Egg 16

P= / is 12U 18 00:38 1-1!ti4 j / 1g2 Igo 26

/ Mgg 111E1 18 00:36 89 Mrig / Idd Igg 16 00:15 Ugg 93 I2A / 122 18 00:34 117 86 itg / IC2 Igg 18

23:40 TA 96 81 / 39 . 54 18 00:18 • 188 IgA 18 23:35 ggg 95 79 / 40 . 54 18 00 :16 1.. / ig8 igd 18 23:30 119 95 75 / IgN a 122 18 00:14 Ltb, 94 lAd / s Kg 21 23:25 120 95 77 / 35 50 OFF WAt; 93 1_71 / s 23:21 120 96 160 / 35 126 OFF 30:10 ggg 94 IAN / Ogg 12A 18 '3:15 106 96 162 / 38 51 OFF 30:08 j 94 IAN / ICU 128 18 `3:10 120 96 79 / 40 a 54 OF= 00:06 ggg 94 IAA / Igg I2Y 18 3:05 my q 82 / 38 i 55 20 00:04 ggg 95 IA8 / p. 12g 18 23:30 121 07 83 / 40 . 55 1? 00:02 UM! 95 [1J / 1K1 I2g 18 ??.R? n- dA 00:00 !AM 95 12E / Ig2 122 18 22:66 LIN:: /. L 23:58 MD 96 ITU / ffq OUV 18 22:50 120 93 EU / INA Osi, 23:56 4D 95 /tom' 12C 18 22:45 uNg 94 I2A / 128 OFF 23:54 !}i 96 im / 35 lull 18 '2:40 Mdg 93 122 / lg lug OFF 23:52 dgg 96 I2g / Igg I2g 18 '2:55 120 92 126 / 1CW I2g OFF 23:50 WI 96 ITg / 1g2 122 18 ?2:30 NNU IA4 ITU / INN l2g OFF 23:48 119 96 76 / 41 53 18 - :25 119 '41NON / igg P OFF 23:46 Li 96 12g / gtgj J 18 ':20 LID 84 I213 / Ig21 - 18 23:44 ggg 96 F.1.1 / Ig2 122 18 :2:15 ggg [2I 84 /Igg 12U 9 23:42 udg 96 le / 35 12A 18 22:14 im ERR# 2 IgA 23:40 J 96 le / 35 12g 18

'1 :38 gtAg 96 )LTJ / 36 IM 18 3:36 ggd 95 162 / 36 126 18

1P4747 ,7474:74:PL' SYS- TEMS:

•

22:50 120 93 kAu / INA ft OFF 22:45 94 E / PAU El OFF 22:40 Lell 93 rffj / 1E4 ra OFF 22:35 120 92 ICIN / leg IEN OFF 22:30 NJ EEEI FAN / Irkt4 OFF 22:25 119 MNII I / t P OFF 22:20 WA 84 ra / • RiN 18 22:15 WA gig 84 / Wig rdri 9 22:14 LW AIM ERRS 2 P21

J:34 119 95 / 1g2 lug 1B .:32 119 95 I2g / p 8I (Ig 18 30 119 95 / 15X I2g 18

1:28 157 95 12d / ICU 122 OFF ,3:26 120 96 [SJ / 1C2 122 OFF 23:24 120 95 ITT / 36 12• OFF 23:22 120 95 IT2 / P2 12u OFF 23:20 144 95 ITg / 12d OFF 23:18 128 95 77 / 10.1 67 OFF 23:16 125 96 all / app pap OFF 23:14 MA 95 CCO / gab 18A OFF 23:12 121 95 16N / 36 12d OFF 23:10 120 96 idg / 35 LJJ 23 23:08 120 96 Idg / 35 I2d 18 23:06 TA 96 Idg / 35 126 19 23:04 MNM 96 76 / 35 126 30 23:02 gal 96 80 / 36 ION 18 23:00 LINU 97 86 / 38 52 10 22:58 86 97 96 lgg 59 OFF 22:56 i12 98 107 / 45 62 OFF 22:54 LINA 96 143 / 64 87 OFF 22:52 120 94 Egg / IgNINA OFF 22:50 121 94 I& / Egg P1 OFF 22:48 itg 94 ISS! / Igg ICA OFF 22:46 LINg 94 IA2 / Igg 12N OFF 22:44 Ugg 94 pg / igg OFF 22:42 jJ 93 EA! / IgN Igtd OFF 22:48 ggg 94 IAN / P12 ad OFF 22:38 TUN g 93 IAN / IgN IgN OFF 22:36 NJ 93 IN /e le OFF 22:34 120 91 12 / PJ P2 OFF 22:32 giNg ICU MAK / P2] Egd OFF 22:30 Ugg 82 Iv / ggij gsz OFF 22:22 120 :9NNU IAN / Igg 121 OFF 22:26 119 IA8 ICL] / IAN atir,!, OFF 22:24 119 / ICU Igij 24 22:22 120 84 eij / itg 12 22:20 LINg on 1A2 / !Ng NB 18 22:18 UNN 93 II; An ICA 18 22:16 WA P2] 12C ti56 1Y 8 22:14 WA AAAt 126 / J 12g 17 22:12 46 :NNINI OFF OFF OFF OFF 22:10 121 la OFF OFF OFF OFF 22:08 it2 OFF NOT ZEROED OFF 22:06 ggg OFF 126 / 56 75 OFF 22:04 gm OFF 84 / 39 53 OFF 22:02 LK] OFF 87 / 39 52 OFF 22:00 25 OFF NOT ZEROED OFF 21:58 9FF 95 / 40 55 OFF

ADULT

ADULT

ADULT

MEDCOM - 22675

00:10 gdg 94 igg / 122 18 00:32 119 89 12A / EN 18 00:05 iigg 94 1dg / Igg 12A 18 00:30 ikil igg IQ 18 00:82 ggy 95 INg / 35 .-12A 18 00:2S il!,4 1dd WU 18 00:0B NI 95 ERR# 11 18 00:26 iAF INA IAA 18 23:55 UNM 96 76 / 36 . Mb 18 BO:24 • ' INN 18 23:50 LtU 96 76 / 37 • 52 18 00:22 4:0 / IgN 18 23:46 ggg 96 77 / 36 . 51 18 00:20 1C8 21

DOD-036251

ACLU-RDI 1673 p.35

IBP TREND 11/81/03

TIME HP/PR Sp02 SYS / DIA - MEAN RR

HH:MM 5PM 7

01:25 142 ONO 103 / 52 70 14 01:21 140 ONO 96 / 48 67 18 01:15 141 ONO 95 / 48 66 16 01:10 143 4iN0U 95 / 54 69 14 01:05 141 ONO 100 / 52 73 17

00:55 141 ONO 92 / 48 66 14 00:50 141 ONO 92 / 48 66 15 00:45 141 99 88 / 47 64 14 00:40 144 1;Al 86 / 46 63 15 00:35 145 40qj 92 / 50 66 16 00:31 144 Mai 94 / 44 65 15 00:26 144 99 92 / 46 65 15 00:20 144 94 89 / 4? 64 15 00:15 SRCH 90 / 49 65 25 00:10 IN 91 92 / 51 69 27 00: 92 99 / 63 79 1E4 00:0 LV2 89 110 / 59 ?9 kg 6 it ti; 89 105 / 60 78 20 23:51 ! 91 113 / 71 • 83 21 23:45 ::;011 135 / 100 . 110 18 23:40 go 95 ERRt 15 19 23:35 ijal 90 117 / 59 83 13

23:30 On ONO 109 / 64 82 20 23:25 itki 90 99 / 66 . 76 21

23:20 WO 91 102 / 58 74 27

23:15 ONIC, 95 / 55 70 28 23:10 giR 96 103 / 56 76 126 23:05 144 97 105 / 63 • 79 3? CD) 145 77 la5 / 56 52 27 22:55 143 95 114 / 69 87 31 22:50 144 90 112 / 63 • 81 28 22:45 141 49 130 / 71 95 36

22:40 ilad 9? 132 / 6B 95 12

22:35 141 100 130 / 81 99 14

22:30 143 99 134 / 70 97 15

22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14

22:15 137 100 137 / 74 99 2B

22:10 131 100 126 / 77 97 22 22:05 ice'. 99 13? / 73 100 14

<Ort Mg! 98 138 / 69 97 14

21:56 On 97 120 / 62 86 14

21:50 UOU 94 108 / 56 76 18

21:46 On 88 128 / 56 85 14

21:40 j1 la 108 / 58 77 26 21:35 itIN 8[11 114 / 58 81 14 21:30 it OFF 107 / 59 79 OFF

ADULT

PRO TO C 0 L' 3"6" T E AC 6', :V•:.

NIBP TREND 11/01/03

HH:MH RPM X mmHg RPM 06:03 gn 89 87 / 49 66 26 06:00 ij 91 89 / 42 . 62 20 05:56 Td6 98 ERR 15 17 05:48 !In 98 96 / 52 • 70 19 05:46 irgU1 98 84 / 49 = 63 24 05:40 1E11 100 87 / 48 • 65 21 05:35 Ha/ 98 110 / 48 75 14 05:34 143 96 107 / 53 76 15 05:31 144 98 99 / 51 70 16 05:26 46.17 97 ERRS 15 15 05:20 141 93 107 / 61 79 26 05:15 154 95 105 / 62 80 20 05:10 144 98 109 / 62 88 22

05:07 ii 86 ERR# 15 24

05:00 139 98 106 / 59 77 16 04:55 .139 97 116 / 52 . 79 19

34;50 138 98 109 / 55 79 14

04:45 138 95 110 / 55 77 17

04:41 138 94 105 / 51 72 15

04:38 138 ONO 103 / 51 73 14

04:35 141 :1I) 101 / 49 71 15

.:30 140 # J 102 / 51 72 16

04:25 139 ONO 101 / 49 69 15

04:21 139 41N001 92 / 46 65 14

04:15 138 ;tin 89 / 46 63 14

04:10 139 90 / 47 64 14

04:06 139 .eNg 86 / 47 63 14

/04:03 139 AMU 86 / 47 62 14

04:00 140 Agn 89 / 53 65 17

03:57 139 416001 84 / 46 61 14

03:50 140 41011 88 / 49 65 1?

03:45 141 Mt 87 / 52 67 15

03:40 142 ma 95 / 54 71 16

03:35 144 ONO 93 / 55 77. 26

03:30 144 ONO 103 / 60 74 14

03:25 142 ONO 92 / 53 69 15

03:20 144 ONO 100 / 55 74 17

03:15 142 :!i j 95 / 56 72 16

03:10 142 .7;178

96 / 56 72 16

03:05 143 ONO 95 / 56 69 14

9:04 144 Mgt 92 / 61 71 14

3:00 144 .Agyt 95 / 53 70 14 02:56 144 41:10 ERRS 15 19

02:50 146 1lia 98 / 60 76 18

02:45 144 ma 97 / 55 73 17

02:40 143 kat 95 / 57 73 15 02:35 144 ga 96 / 55 72 16

02:30 144 ONO 95 / 53 71 17

02:25 144 gall 96 / 56 72 16

02:20 146 ONO 99 / 53 70 17

02:15 144 ONO 94 / 54 70 18

02:10 144 an 96 / 56 74 19

02:05 144 ONO 94 / 56 72 16

02:00 142 ONIV 99 / 56 72 17

01:56 143 Mgt 90 / 52 66 15

01:50 143 igal 99 / 53 72 17

5 140 41:1011 102 / 52 73 15

40 139 92 101 / 52 71 14

,-.36 140 ONO 98 / 51 70 18

01:30 141 99 102 / 53 71 16

01:25 142 ONO 103 / 52 70 14

01:21 140 4100 96 / 48 67 18

01:15 141 :gm 95 / 48 66 16

01:10 143 ONO 95 / 54 69 14

01:05 141 ONO 100 / 52 73 17

01:00 141 ONO 95 / 52 67 16

00:55 141 :W011 92 / 48 66 14

00:50 141 nNJ 92 / 48 66 15

00:45 141 99 88 / 47 64 14 00:40 144 :411:1 86 / 46 63 15

00:35 145 gMil 92 / 50 66 16

00:31 144 1INMIJ 94 / 44 65 15

00:26 144 99 92 / 46 65 15

00:20 144 94 89 / 47 64 15

00:15 S1J SRCH 90 / 49 65 25

00:10 ) 91 92 / 51 69 27

00:05 TA 92 99 / 63 79 ItO

00:01 0A 89 110 / 59 79 WIZ

23:56 ) 89 105 / 60 7B 20

23:51 O6.11 91 113 / 71 23 21 23:45 4,16 ga 135 / 100 ■ 110 18

23:40 gjg 95 ERRt 15 19

23:35 TV 90 117 / 59 B3 13

23:30 ira ONO 109 / 64 82 20 23:25 irdl 90 99 / 66 . 76 21

23:20 Ug 91 102 / 58 74 27

23:15 Lui ONO 95 / 55 70 28

23:10 LEM 96 103 / 56 76 mad 23:05 144 97 105 / 63 • 79 32

23:01 145 97 103 / 56 82 27

22:55 143 98 114 / 69 87 31 22:50 144 98 112 / 63 . 81 28

22:45 141 99 130 / 71 95 36

22:40 101 97 132 / 68 95 18

22:35 141 100 130 / 81 99 14

22:30 143 99 134 / 70 97 15

22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14

22:15 137 100 137 / 74 99 28

22:10 131 100 126 77 97 22

ADULT

+-WO TO C 0 5 E J N C. C.

mmHg RPM TIME HR/PR Sp02 SYS / DIA - MEAN RR

MEDCOM - 22676

DOD-036252

ACLU-RDI 1673 p.36

•

60

30 • - 20

10

cr; 11/83/03 0947:29 140--61 ART/!D CUP=80/21(24) .80=11 SPIPigt. 3

▪

9 • , -13 ION::

.... • .... . ........ ■ • • • • • • • • •

.:.

24FT ESIFIFF

PACER DISPLAY ON

• • • • • • • ■ • • • • •

• • •

•

ii 3103 00:48:32 HR=61 flih CL01,32/23(26) RR--28 512=0 RIOMFF . . . " -" .. •

E ) . • " " . ..

-• • . . • ... - PACER DISPIAY Eli -• • • •

. • : yu

T1=OFF I24ICF eTOFF : : .1

. . . . . . . .

•

• a .

• • • ■ • • • ... • ....

......... .

. • • • .... • • •

60 pp'

30 20

10 : cup-

•

MEDCOM - 22677

DOD-036253

ACLU-RDI 1673 p.37

EAD II }{1.9 HR=---- M mmE--MEMIIIMEEMEa EME=MEME=

Warn Mira IAIEEEMEEEMPIAMiEREEMINEEMIE.

MMEHMEMEMMEMENMEMEEMEMEMMENESEEMEMME MEMEMEEMEMEMEMEMEMEMEME MEEMEMMEMEM

EMEMEMEMMEEMEMEEMEME MEMEEMEEME EMEMEMEMEMEEMEMEM-EME ME" -ME

P/N 804700

)■ 15 , 13 432NO

PHYSOCONTROV

MEMMEEME -- MEM=LMEMEMEMEMEM ,±1MMMEIMIE _EM EMEMEMEEMEMMEMEMMEM MEMMMEME MM EMEEME. MMEMEMEEMM MEEEMEME MEMEMMEEME =MEE: nommmmEmmommommomm Immo m ,m1...m '1.171comiimmirsirmommommehmomim m or mem --.'

,i:-4t mom mommimm,,mmm m ME MEM MEMMEM , ME EIMIEWsE. RN ME M EINEM

EM ME i MEMEEMEME M M M ME PHYSIOCONTROV

P/N 804700

MEDCOM - 22678

DOD-036254

fj

1 - 1

ACLU-RDI 1673 p.38

P/N 804700

18 02NOV03 LEAD II X1 0 HR=- 1211151,11. PRIM -11111ENINMEERIMINEMIPIIMMINMEMBRIMMINME5Wr:11101.11

15: 16 02N LEAD II X1.0 HR=---

MEN MalaVEZZOM=1 mMEEMMEM EggEMEREMIAbstaMEMENEMM. EZEIRSI=F=EWMIUM ---L...NEMMME

TIEEM1ZMMS--- Eh-Mill1=E-W:a=t EMEMIZENZEIWIREMWJERE wEara EMBINEEMEIBEE.REMZERIMMEE=MENE IIMEN =MEARS=

P/N 804700 ■CCITM:c .

MOM MMEMEIMMUMENEME =MEM. MMMMMMMMMMMMM MMEMMEMEMMEM . EMEMMEMEMM EMMEMMEMEM MEM . MMEMMMMTHEMMEMMEMEMMEM —ME: MEMEMME . MEMMEMMEMMEMEMErM s M MEM= EMMEN= MEM= 'Pli4

-- MOMEMMEMAIMBEI =ME= A

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MEDCOM - 22679

DOD-036255

ACLU-RDI 1673 p.39

-6')/? 03, 1.)ov 03

1st VERI

2nd

PRE-TRA

TEMP. 2,— I PULSE 16)-3 TIME STARTED

3i 0 c+ 03 2.030 DATE OF TRA

B

4

518-123

MEDICAL RECORD

NSN 7540-00-634-4158

BLOOD OR BLOOD COMPONENT TRANSFUSION

SECTION I - REQUISITION COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

FRESH FROZEN PLASMA

PLATELETS (Pool of units)

CRYOPRECIPITATE (Pool of units)

Rh IMMUNE GLOBULIN

1.11 OTHER (Specify)

VOLUME REQUESTED (Ifplicable) A,

I Ow, REMARKS: lioc4.03 wurrei& /c/o

go

TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

[A" TYPE AND SCREEN

CROSSMATCH

DATE REQUESTED terl it j

DATE AND HOURRE/UIRE13.7_

KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

PATIENT IS FEMALE, IS THERE HISTORY OF:

RhIG TREATMENT? DATE GIVEN:

HEMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION TESTING

REQUESTING PHYSI

DIAGNOSIS OR 0

I have collected a blood specimen on the belo named patient, verified the name and ID No. of th patient and verified the specimen tube label to b correct.

SIGNATU

7

TIME VERIFIED

ML

UNIT NO.

1111111.

DONOR

ABO A Rh ?C)

EDURE

3/

ED DATE

TRANSFUSION NO.

ANTIBODY SCREEN

TEST INTERPRETATION

CROSSMATCH

PREVIOUS RECORD CHECK:

RECORD tia....LIO RECORD PATIENT NO.

RMING TEST vJ

RECIPIENT

REMARKS:

h s

SECTION III - RECORD OF TRANSFUSION

POST-TRANSFUSION DATA

AMOUNT GI

(AT IDENTIFICATION

TIME/DATE COMPLETED/INTERRUPTED

REAC ION

ML

PE Oc--1-°3 24D

ATURE PULSE BLOOD PRES URE

NE SUSPECTED O

I reaction is suspected—IMMEDIATELY: (g. J

Y-) 1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Alter Set, and I.V. Solutions to the Blood Bark.

DESCRIPTION OF REACTION

URTICARIA CHILL ❑ FEVER E PAIN

OTHER (Specify)

OTH DIFFICULTIES (Equipment, clots, etc.)

NO YES (Specify)

(Aim-

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named Component Transfusion Form and on the patient identification tag.

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last rate; hospital or medical facility)

MEDCOM - 22680

WARD617/01 rank; SEX

BLOOD OR BLOOD COMPONENT TRANSFUSIOI

Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.20-1

DOD-036256

ACLU-RDI 1673 p.40

COMPONENT REQUESTED (Check one)

RED BLOOD CELLS

O FRESH FROZEN PLASMA

O PLATELETS (Pool of units)

CRYOPRECIPITATE (Pool of units)

• Rh IMMUNE GLOBULIN

❑ OTHER (Specify)

VOLUME REQUEST \D (If applicable) \

U■... ML

DONOR

ABO A

Rh•cIOS

RECIPIENT

ABO

Rh ? s

UNIT NO.

11111111111101 TRANSFUSION NO.

PATIENT NO.

tiv

below f the

be

I have collected a blood specimen on th named patient, verified the name and ID No. patient and verified the specimen tube label correct.

DIAG RATIVE PROCED

CROSSMATCH

ci)


RECORD NO RECORD

TIME/DATE COMPLETE /INTERRUPTED

310c 3 t 1

/AO

BLOOD . OR BLOOD COMPONENT TRANSFUSION

Medical Record


NSF47§40-G0-634-4158 518-123

MEDICAL RECORD


SECTION I - REQUISITION

REMARKS:

i q to 3to


TYPE AND SCREEN

CROSSMATCH

DATE REQUESTED

-31 (-1'03 DATE AND H01111 REQUIRED

Itc5ik V KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:




TEST INTERPRETATION

ANTIBODY SCREEN

NA CROSSMATCH NOT REQ UIRED FOR THE COMPONE

REMARKS:

03,Nov o3 SECTION III - RECORD OF TRANSFUSION

REQUESTING PHYSICIAN (Print)

SIGNATURE OF VERIF

VERIFIED

I oc110 TIME VERIFIED

18

IDENTIFICATION 4::).S" (\.) I have examined the Blood Component container

information identi fying the container with t The recipient is the same perso

1/4.42on the patient identif

VERIFI

label and this form and I find all nt matches item by item. ent Transfusion Form and

AMOUNT GICiE

ML ION

ONE 0 SUSPECTED

If reaction is suspected—IMMEDIATELY:

1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Fitter Set, and I.V. Solutions to the Blood Bank.

PU SE BLOOD PR SSURE


URTICARIA LI CHILL FEVER 0 PAIN

OTHER (Specify)

OTHER DIFFICULTIES (Equipment, clots, etc.)

KNNO 0 YES (Spec,

it,SIGNA DATE OF TRANSFUSION

31 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first

rate; hospital or medical facility)

MEDCOM - 22681

DOD-036257

ACLU-RDI 1673 p.41


N.X,„.....RED BLOOD CELLS

U FRESH FROZEN PLASMA

• PLATELETS (Pool of units)

• CRYOPRECIPITATE (Pool of units)


OTHER (Specify)

DATE 31 .O cr 0_3

518-124 NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION MEDICAL RECORD

SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)

TYPE AND SCREEN

CROSSMATCH

DATEREQUESTED .

VIArC A.

DATE AND HO R REQUIRED •• KNOWN ANTIBODY FORMATI ∎ N/TRANSFUSION REACTION (Specify)

VOLUME REQUESTED (If applicable)

ML

I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be r correct.

SIGNATURE OF VERIFIER


DIA E PROCEDURE

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:



DATE RIFIED

TIME VERIFIED

ACC) \-D.-) 1

SECTION II - PRE-TRANSFUSION TESTING UNIT NO. TRANSFUSION NO.

ANTIBODY SCREEN

TEST INTERPRETATION

CROSSMATCH


ag. RECORD n NO RECORD

RMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPONENT R

REMARKS:

e 3 Nov 03

PATIENT NO.

RECIPIENT

ABO

Rh

DONOR

ARO A Rh po-5

SECTION III - RECORD OF TRANSFUSION PRE-TRANSFUSION DATA

INSPECT TIME/DoECOMPLETED4112 UPTED

2

PT(E.47 BLOOD PqSSt.t E by!, AT (Ho

ON (Date)

OcT o3 ID. IFICATION

3( TEMPERATURE

ction is suspected—IMMEDIATELY:

POST-TRANSFUSION DATA

REACT

ONE SUSPECTED

have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and

ification tag.

1. Discontinue transfusion, treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.


URTICARIA

CHILL 0 FEVER

PAIN

0 OTHER (Specify)

0TH • DIFFICULTIES (Equipment, clots, etc.)

NO 0 YES (Specify)

AivicITTpIVEN

ML

DAT

PATIENT IDENTIFICATIO

NAT RE

TIME STARTED €.2.,., 740

M(1)V?

(9)Lt')H MEDCOM - 22682

2N,

EMBOSSER (For typed or written entries give: Name—Last, fi rate; or medical facility)

OVE


Medical Record

STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

WARD) C u

DOD-036258

ACLU-RDI 1673 p.42

DIA

ABO

Rh FO5

DONOR

518-124 NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION

SECTION I - REQUISITION COMPONENT REQUESTED (Check one)

.RED RED BLOOD CELLS

FRESH FROZEN PLASMA

• PLATELETS (Pool of units)

• CRYOPRECIPITATE (Pool of units)


OTHER (Specify)


ML

REMARKS:


• TYPE AND SCREEN

• CROSSMATCH

DATE REQUESTED

03 -3 DATE AND HOUR REQUIRED

N vv KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)

PATIENT IS FEMALE, IS THERE HISTORY OF:




I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.


TIME yERIFIED

D

vcD \c9.0

SECTION II - PRE-TRANSFUSION TESTING TRANSFUSION NO.

PATIENT NO.

RECIPIENT

ABO

Rh po5


RECORD 0 NO RECORD

I SPIP n CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ

REMARKS:

ex :3 Nov 0

PRETATION

CROSSMATCH

TEST INTER

ANTIBODY SCREEN

IN C,6-fylp SIGN PERFORMING TEST

DATE 31 ocr bj


INSP TIME/DATE COMPLETED/INTERRUPTED

Mut oo :ic) AMOUNT GIVEN

ML

AT (Hour) . IDENTIFICATION

I have examined the, Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.

1

REACTION TEMPERATURE

77 NONE 0 SUSPECTED

If re 'on is suspected—IMMEDI TELY:



▪ URTICARIA El CHILL 0 FEVER 0 PAIN

OTHER (Specify)

ON (Date) 3 bc_fi- PUr VRES SURE

6 1 1)2._

TEMP.

FellCoV

DATE OF TptQNSWSIO

'1.7 i I) (4-

IBP (°1/,&/S7


O NO YES (Specify)

SIGNATURE OF PERSON NOTING ABOVE

TIME STAprp

I PULSE

PATIENT IDENTIFICATION—USE EMBOSSER For typed or written entries give: Name—Last, first, midd e; grade: rank; rate: hospital or medical facility)

11111PN (c 11 MEDCOM - 22683


Medical Record STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMR (41 CFR) 2014.202-1

MPflirtal Rpr.orri C",nnv

kit

DOD-036259

ACLU-RDI 1673 p.43

DATE OF TRANSFUSION TIME STARTED

DOD-036260

BP PULSE

eme MEDCOM - 22684

518-124

MEDICAL RECORD I BLOOD OR BLOOD COMPONENT TRANSFUSION

PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

RECIPIENT

A p o s

ABO

Rh

❑ NO

PERFOR

RECORD

MIN ST

DATE /A6 DONOR

ABO i1

AMOUNT GIVEN

UNIT NO. ousai TRANSFUSION NO.

PATIENT NO. 11

X? gAILA"

TEST INTERPRETATION

IQ! RECORD

SI




ANTIBODY SCREEN CROSSMATCH

(0' ❑ CROSSMATCH NOT REQUIRED FOR THE COMPONEN

REMARKS:

Af 4

Rh

NSN 7540-00-634-4159


:;OMPONE IT REQUESTED (Check one)

ED BLOOD CELLS

❑ FRESH FROZEN PLASMA

❑ PLATELETS (Pool of units)

units)


TYPE AND SCREEN

00.---tiROSSMATCH


DIAL E PROCED (--

❑ CRYOPRECIPITATE (Pool of DATE REQUVAD

Y1 v o L.) 0 '--'

I have collecte ood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be

correct.

Ei Rh IMMUNE GLOBULIN

❑ OTHER (Specify)

DATE AND HOUR REQUIRED

rs A— j VOLUME REQUESTED (If aptelic

Lik/P

)

ML


SIGNATU E VERIFIER C..„ t'D -." N.



DATE V ■ 1

HEMOLYTIC DISEASE OF NEWBORN? TIME V r ED


ML

REACTION

NONE ❑ SUSPECTED


1. Discontinue transfusion, treat shock if present, keep intravenous line open.

2. Notify Physician and Transfusion Service.

3. Follow Transfusion Reaction Procedures.

4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.


❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

❑ OTHER (Specify)

./

ER DIFFICULTIES (Equipment, clots, etc.)

NO ❑ YES (Specify)


AT (Hour) ON (Date)

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)

SEX

"Thitcki

P TEMP.

TEMPERATURE PULSE BLOOD PRESSURE

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and

on the patient identification tag.


Medical Record STANDARD FORM 518 (REV. 9-921 Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

ACLU-RDI 1673 p.44


CROSSMATCH

DONOR

ABO

Rh

NSN 7540-00-634-4159 518-124


units)

units)

TYPE OF REQUEST (Check ONLY if Red Blood Cell

Products are requested.)

TYPE AND SCREEN

CROSSMATCH


RED BLOOD CELLS

FRESH FROZEN PLASMA

❑ PLATELETS (Pool of

❑ CRYOPRECIPITATE (Pool of DATE REQUESTED

❑ Rh IMMUNE GLOBULIN

OTHER (Specify)

DATE AND HOUR REQUIRED


ML



DATE GIVEN: RhIG TREATMENT?



REQU YSICIAN (Print)

DIAL OPERATIVE PROCEDURE

6.51-u I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.

ySIGNATURE OF VERX

Q,

0, jot?) tp"S

DATE VERIFI

TEST INTERPRETATION TRANSFUSION NO.

ANTIBODY SCREEN


RECORD ❑ NO RECORD

RFORMING TEST PATIENT NO.

UNIT NO.

RECIPIENT

CROSSMATCH NOT REQUIRED FOR THE COMPONENT RE ES f I DATE )NOV REMARKS:

es. 3 go, 03

ABO

Rh poS

--

PRE-TRANSFUSION DATA

- - -- - POST-TRANSFUSION DATA

INSP AMOUNT GIVEN

ML


REACTION

❑ NONE ❑ SUSPECTED


AT (Ho ON (Date) 1 ked 0 5

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and

on the patient identification tag.


1. Discontinue transfusion, treat shock if present, keep intravenous line open.

2. Notify Physician and Transfusion Service. 3. Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

1st VERIFIER (Signature DESCRIPTION OF REACTION


❑ OTHER (Specify)


❑ NO ❑ YES (Specify)

TEMP. I PULSE IBP SIGNATURE OF PERSON NOTING ABOVE

DATE OF TRANSFUSION TIME STARTED

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)

SEX WI_ \ c.... L.i. )

N(C)--'1


Medical Record


MEDCOM - 22685 Medical Record Copy

DOD-036261

ACLU-RDI 1673 p.45

TRANSFUSION NO.

PATIENT NO.

TEST INTER PRETATION

CROSSMATCH

CD flip


RECORD ❑ NO RECORD

FOR MING T

UNIT NO.

ANTIBODY SCREEN

NA RECIPIENT

ABO

Rh r,

❑ CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ

REMARKS:

31140, D'3

DATE /A/OV05 DONOR

ABO

Rh poi

518-124

NSN 7540-00-634-4159




R ED BLOOD CELLS

❑ SH FROZEN PLASMA

❑ PLATELETS (Pool of units)

units)


❑ TYPE AND SCREEN

9CROSSMATCH


DI OPERATIVEPROC URE

WillaftiP I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be correct.

❑ CRYOPRECIPITATE (Pool of DATE `QUESTED

V) LJ C) -"Z> ❑ Rh IMMUNE GLOBULIN

❑ OTHER (Specii) DATE AND HOUR REQUIRED

SZ >4- -/--- VOLUME REtUEFED (If appicable)

ik Y- I. - ML


SIGN TU 0 VERIFIER

-V— QA.17' ( ?



DATE VERI 4r- / )09

HEMOLYTIC DISEASE OF NEWBORN? TIME VERI



PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

INSPECTED AND ISSUED BY (Signature)

our) .. e

AMOUNT GIVEN

ML


REACTION

NONE ❑ SUSPECTED


ON (Date) 1 4/0.10.3

IDENTIFICATION

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the patient identification tag.



1st VERIFIER Si

2nd

SE

JL_t



❑ OTHER (Specify)

BP

OTHER DIFFICULTIES (Equipment, clots, etc.) ❑ NO ❑ YES (Specify)


DATE OF TR SION TIME STARTED

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank;

rate; hospital or medical facility)_ SEX WAR


Medical Record STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR, FIRMA 141 CFR) 201-9.202-1

MEDCOM - 22686 Medical Record Copy

rn

DOD-036262

ACLU-RDI 1673 p.46

518-124

MEDICAL RECORD


RED BLOOD CELLS Ir FRESH FROZEN PLASMA

❑ PLATELETS (Pool of

❑CRYOPRECIPITATE

(Pool of

❑Rh IMMUNE GLOBULIN

OTHER (Specify)


11 --

REMARKS:

ML

units)

units)

TRANSFUSION NO,

UNIT NO.

ATIENT NO.

RECIPIENTp\

16

DONOR

ABO

Rh

0. ABO

Rh

CROSSMATCH FOR THE COMPONENT RE

ROSSMATCH NOT REQUIRE

REMARKS:

•

I have collected a blood specimen on e below

named patient, verified the name and ID No of the patient and verified the specimen tube label to be

correct.


r 5 D •TE

PREVIOUS RECORD CHECK: NO RECORD

RECORD

DATE

FORMIN

o5

WARD

T tit

BLOOD OR BLOOD COMPONENT TRANSF

Medical Record

STANDARD FORM 518 (REV. 9-924 prescribed by GSA/ICMR, FIRMR (1 CFR) 2(

Medical Record Copy

NSN 7540-00-634-4159



TYPE OF REQUEST (Check ONLY if Red Blood

Cell REQUESTING PHYSICIAN (Print)

Products are requested.)

DIAGN ERATIVE PROCEDURE

LL..) TYPE AND SCREEN

CROSSMATCH

DATE REQ9ESTED n 0 3

IV 0 LI

KNOWN ANTIBODY FORMATION/TRANSFUSION

REACTION (Specify)

DATE AND HOUR REr54._ -- 1

IF PATIENT IS FEMALE, IS THERE HISTORY OF:



ANTIBODY SCREEN

SECTION 11 – PRE-TRANSFUSION TESTING

TEST INTERPRETATION CROSSMATCH

CPT

SECTION III –

RECORD OF TRANSFUSION POST-TRANSFUSION DATA


BLOOD PRESSUR PRE-TRANSFUSION DATA

ignature) INSP

r

--) AT (Hou

L I have examined the Blood Component container label and thisent

form and I find all IDENTIFICATION

LS information identifying the cornontainer

named on with the

this Blood Comp

intended recipi matches item by item.

/Th The recipient is the same pes

onent Transfusion Form and

k_i on the patient identification tag.

C---)

BP

If reaction is suspected— IMMEDIATELY:

1.

Discontinue transfusion, treat shock if present, keep intravenous line open.

2.Notify Physician and Transfusion Service.

4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Ba 3.

Follow Transfusion Reaction Procedures.


LL 0 FEVER PAIN

❑ URTICARIA ❑

❑- OTHER (Specify)


❑NO

0 YES (Specify)


1st V

PULSE

TEMP. TIME STARTED

DATE OF TRANSFUSION

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank:

rate; hospital or medical facility)

MEDCOM - 22687 .4711111ae

DOD-036263

ACLU-RDI 1673 p.47

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

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

PATIENT IDENTIFICATION

OW N ,c..Y1

LI DATE OF ORDER TIME OF ORDER

'231 Opt 2.-/ -5' 0 HOURS

LIST TIM ORDER

NOTED AND SIGN

410

l,r.,,/ 71 Ter) /C I-/

c ,

Co A ,- :I, -' ,,,,4, cx_

zi i c /9 c.A (L-7- ' .,_s' • u---e

k.. inimmlimimimili ii0111 1111111111.1.11111111111.111111111 MI l■ PAWAIMIOMMMIMIMIMIIIII

NURSING UNIT

TLuu

ROOM NO. BED 11W 0..

a.,_t _ ,_e_.( ...c....._....—e-' Ar Lei/ _ /k/jC)


ii.

Il

ill 111

9 ATE OF ORDER TIME OF ORDER

HOURS

- M f- ‘)G-t.-4- ' ‘z...t.

/ .4.4-c.c. -- ,.....„,. cf

czA ..c.zi _.-- 0 --.....a., ./ , •

/1.). - - / t 2- ,u_.5 i z.c ) )..c_t__ 0 oc- c c

NURSING UNIT ROOM NO. all

BED NO. kittd-0 "- • :. 1,, V 08

1112111111M .36,c I, PATIENT IDENTIFICATION 'i ATE OF ORDER TIME OF ORDER

HOURS

lel 4-' 7,0 il 01, A" I( .31,4a .61 r: 1121

. /7160 /0e, - /Co e ZO De, .1 _ 1.111EMPIMINIM■ . - Illt ---. ' WM fe-z --- L. 7 4 .. ez,-- ,-- -76 .

NURSING UNIT ROOM NO. BED ' -..---

cot_c_4. e.ce...–cr-: — _ IIII


1111

IN

DATE OF ORDER TIME OF ORDER

/ - HOURS

7 G Sol,g- - (0 1 / Pjr---

.1 '4 6,,t I CU --- a I --/

T .- .'° -5 , --7 0, __ /err,

4 . 111111111.11111,1111111.111111.111 NURSING UNIT ROOM NO. BED NO'Ilk 1=1111110:111=11.1111111111111111M

/6..,

DA 1FAOPRPM79 4256 REPLACES EDITION OF 1

Mc) MEDCOM - 22688

DOD-036264

ACLU-RDI 1673 p.48

PATIENT IDENTIFICATION HOURS

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

THE DR SHALL REORD DATE, TIME AND IGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD

SYSTEM OCTO

IS USED, WRITE

C PROBLEM NUMBER NCO UMN INDICATED BY ARROW BELOW. LI TI

ORDER NOTED AND

SIGN


BED NO. URSING UNIT

3--

rs


ROOM NO.


et

NURSING UNIT BED NO.

NURSING UNIT ROOM NO.


OF ORDER

e_7 HOURS

ROOM NO.

DA, 4256 , A., 79

NURSING UNIT BED NO.

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

MEDCOM - 22689

DOD-036265

ACLU-RDI 1673 p.49

RS

DATE1 OF R(DNEIR


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

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

TIME OF ORDER

01 1.103 0 3 (.304`



PATIENT IDENTIFICATION DATE OF ORDER

LIST TIME ORDER

NOTED AND SIGN

NURSING UNIT ROOM NO. D NO.


NURSING UNIT ROOM NO. BED NO.



DA , FAOPRRM 79 4256

BED NO.

REPLACES EDITION OF 1 Jul. 77. WHICH MAY BE. USED.

MEDCOM - 22690

DOD-036266

ACLU-RDI 1673 p.50

OURS

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

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

TIME OF ORDER

10C-5

IST TIME nianF R

NOTED A SIGN

NURSING UNI ROOM NO. BED NO.

cA)

V'

ft

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

NURSING UNI ROOM NO. BED NO.

PATIENT IDEM IFICATION DATE OF ORDER TIME OF ORDER

HOURS

A/W 76,6---

BED NO.


db CS P`9t)


PATIENT IDENTIFICATION HOURS

5-60 7'ltz 71-p

6.4z

(

0-ear ,mss NURSING UNIT ROOM NO. BED NO.

DA IFA7:79 4256 REPLACES EDITION OF 1 JU

MEDCOM - 22691

DATIOF DER

ezv PATIENT IDENTIFICATION

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

DOD-036267

ACLU-RDI 1673 p.51

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

PATIENT IDENTIFICATION DATE OF ORDER LIST TIME

ORDER NOTED ANO

SIGN

BED NO. ROOM NO. NURSING UNIT

PATIENT IDENTIFICATION DATE OF ORDER

°If"

1 S



PATIENT IDENTIF CATION DATE



0,110)0 ,q 520

k-ko fneC1\ TY\ \°C)

TIME OF ORDER

I HOURS

ftry-P-1.- %, •


DAFOR1 APRM 79 4256 REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

MEDCOM - 22692

DOD-036268

ACLU-RDI 1673 p.52

AT ION PATIENT IDENTIFIC

( 1•.416 411.111

ATION PATIENT IDENTIFIC

ED. REPLACES EDITION OF 1 JUL 77. WHICH MAY BE

DA 1 APR79 4256


RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM 0TENTED MEDICAL RECORD ITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

TION

HOURS

THE DOCTOR SHALL SYSTEM IS USED. WR

PATIENT IDENTIFICA

NURSING UNIT


ROOM NO. BED NO.

ot t■loti 03

rI

1 DATE OF ORDER TIME OF ORDER

HOURS

? VeIACtLtk-- C- ic2,,

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LIST TIME ORDER

NOS AND

NURSING UNIT

1 '\ PATIENT IDENTIFIC

ROOM NO. BED NO

NkAci AT ION

HOURS

ceNi\pr foi• Lrc



HOURS


MEDCOM - 22693

DATE OF ORDER

DOD-036269

ACLU-RDI 1673 p.53

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD PROGRESS NOTES

DATE NOTES -CUAF-/z9

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(SSN or Other) LAST F IRST MI

DEPART.iSERVICE HOSPITAL OR MEDICAL 6ACILITY RECORDS MAINTAINED AT

ATIENT'S IDENTIFICATION: 1For typed or written enrries, give: Name - last, first, rnicdle;

ID No or SSN; Sex; Dare of Birth; Rank/Grade,

REGISTER NO. WARD NO.

110 PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.2030)/00/

USAPA V1.00

MEDCOM - 22694

DOD-036270

ACLU-RDI 1673 p.54


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.


'''Llite. HOURS NOTED

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AND SIGN

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PATIENT IDENTIFICA ION DATE OF

'. C:

ORDER TIME OF ORDER

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HOURS

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PATIENT IDENTIFICATIO DATE OF ORDER TIME OF ORDER

(A -1.L.4 i ee„ J'ex. 16:4- /tea HOURS

f6

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DA 1FXRP79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 22695

DOD-036271

ACLU-RDI 1673 p.55

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )

For use of this form, see AR 40407; Surgeon General. Mo, Yr. 2003

the proponent agency Is the Office of The

VERIFY BY INITIALING ;:0.ANCAStegnighat INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK/ RECURRING ACTION, TIM FREQUENCY, E

HR DATE COMPLETED

31 -1-

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ALLERGIES: I. YES 11111 NO PRIMARY DIAGNOSIS:

vei( -IGni0) ef.,A41 cAl rlAvvAAlt) c -v-i-k-- NI

PAGE

ADDITIONAL PAGES IN USE: YES NI NO

NO•

PATIENT IDENTIFICATION: \t/"-'-1/1( 4---e6k,

ACTION TIMES

D 8 9 10 11 12 13 14 15 lib (01\ r-1

USE PENCIL. CIRCLE ACTION TIMES

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

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

MEDCOM - 22696

DOD-036272

ACLU-RDI 1673 p.56

Verity by Initialing

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

Order

Date Clerk Nurse SINGLE ACTI?NS Date to

be Done Time to be Done Time Done Initials

--- ajiliVA 1 CA-) /CA:1) — _ _ _ Pft 1■, k (1 L.) ;A03 i

- - - -

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Order/ Expir Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

— — — — — — — —

MEDCOM - 22697

USAPA V1.00

DOD-036273

ACLU-RDI 1673 p.57

THERAPEUTIC DOCUMENTATION tee

CARE PLAN (MEDICATIONS)

CLINICAL RECORD the pro nent a ency Is the Of4ice of The Surgeon General. WING EACH ADMI

For use of thls form AR 4G-407 ;

VERIFY BY INITIALJNG

:::: INIIIAL PROPER COLUMN FOLLO

NISTRATION

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

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

......................... to

DATE NURSE

DOSE. FREQUEN CY lb

a

a

ORDER CLERK/ RECURRING MEDICATIONS,

•DATE DISPENSED

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OY ES O NO

PAGE NO.

DISPENSING TIMES

P N IL CIRCLE MED TIM S

111111 (*)

OF I DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 22698

PATIENT IDENTIFICATION:

D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

h _Fgr49 4678

DOD-036274

ACLU-RDI 1673 p.58

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

SINGLE ORDER, PRE-OPERATIVES

Data to be Given

Order

Clerk/ Date

Nurse

Or Exp Date Clerk/ Nurse

Time to be Given Time Given Initials

cm

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'U.S. GPO: 1998454-110/95216

DOD-036275

ACLU-RDI 1673 p.59

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

For use o this form, see AR 40-407: the Proponent agency . is the Office of The Surgeon General.

Mo. Y r.

VERIFY BY INMALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION

ORDER DATE

CLERK/ NURSE

RECURRING MEDICATIONS, DOSE, FREQUENCY

HR DATE DISPENSED

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ALLERGIES: YES M NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:

- YES El NO

PAGE NO

PATIENT IDENTIFICATION: DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14 .

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

DA FORM 4678, 1 FEB 79

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00

MEDCOM - 22700

DOD-036276

ACLU-RDI 1673 p.60

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.

Order Date

Clerk/ Nurse

SINGLE ORDER, PRE-OPERATIVES Date to

be Given Tme to be Given

Time Given Ini '

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PRN MEDICATION, DOSE, FREQUENCY

I1V177AL PROPER COLUMN FOLLOWING ADMINIS7RA N

TIME/DATE DISPENSED

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USAPA V1.00

MEDCOM - 22701

DOD-036277 ACLU-RDI 1673 p.61

QI Appr 11 Jun 97

ARRIVALSTATUS

REPORT TITLE TRAUMA FLOWSHEET The proponent is Dept of Surgery

a MED COM:

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-86: the proponent agency is the Office of The Surgeon General.

OTSG APPROVED (Dare)

TIME: ETA: UNIT: TIME U IV x ❑ 02 1/min ❑ C-Spine Immob

Meds: 9eUKN ❑ None 0 Yes:

Allergies: 19(LIKN ❑ None ❑ Yes:

Tetanus: UKN ❑ Current Last Meal/Fluid Intake hrs

LMP:

PHYSICIAN

ue on reverse)

a a a > = <

❑ Tender:

Blood at meatus/vagina: a

LUNGS - ,

BREATH SOUNDS: ❑ Bilat ❑ Equal ❑ Clear

a Absent

Crackles

a a Decreased

Wheezes Ugii

Dopler + Strong + Palpable

RN / 1.-- l

❑ Natural Patient

❑ ETT ❑

❑ Secretions (

❑ Labored 'Unlabored ❑ Absent

TRACHEA: ft Midline ❑ Deviated

13

PULSE: 04Present ❑ Absent

BLEEDING:

HEART TONES: ❑ Clear ❑ Muffled

SKIN: ❑ Warn ❑ Cool ❑ Hot

❑ Pink ❑ Pale ❑ Cyanotic ❑

❑ Dry ❑ Moist ❑ Diaphoretic

ABDOMEN

CHEST SYMMETRY:

a SECONDARY SURVEY.

a a

USE DIAGRAM TO DOCUMENT INJURIES AND PAIN

(AB)rasion

(ANIPlutation kr

(AV)ulsion

Battle's Signs

(BL)eeding

(B)urn

(Dieformity

(Elcchymosis

(Floreign Body

(Hiematoma

(LAC)eration

(P)uncture (W)ound

(Pain)

(S)eatbelt (S)ign

(S)tab (W)ound

(GSW) Gun Shot Wound

GCS: E

V • TIN ❑ Clear ❑ Blood

M

.PUPILS: ❑ Equal ❑ Fixed ❑ React ❑ Dilated

`NECK

RHYTHM: ❑ Regular ❑

PULSES: ❑ Central ❑ Peripheral

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

DEPARTMENT/SERVI

❑ HISTORYIPHYSICAL()rBTLOW CHART

Cs- (01

El OTHER EXAMINATION OR EVALUATION

❑ DIAGNOSTIC STUDIES

1:1 TREATMENT

❑ OTHER (Specify)

U

HEART

❑ Soft ❑ Rigid ❑ Non-Tender

PELVIS

❑ Stable ❑ Unstable ❑

Hems+ / - Prostate: ❑ WNL ❑ Abnl

SPHINCTER TONE: ,

❑ WNL

❑ None

C-Spine Tenderness:

Pain @

JVD: VASCULAR ASSESSMENT

PREPARED BY (Signatur

,54 DATE

.(21

ACLU-RDI 1673 p.62

IVF Urine

NGT NGT

Blood

Other

TOTAL

Other

TOTAL

EBL

0 OTHER

LAB RESULTS INTAKE & OUTPUT CBC: Chem: ,NI,MC AMOUNT'. %INT T

1110 TIME PROCEDURE .SIZE , SITE BY RESULTS

-...■- TIME PROCEDURE ACCOMPANED BY RETURN

/ &;::9 ET

Intubation 5.6

Oral

0 Nasal

Teeth

110"/ _ 0 ETCO2 Change

CI BBS Post Int

0 Post CXR

CT Scan: 0 Contrast

0 Head 0 Abd 0 Pelvis

❑ C-Spine ❑ T/L Spine ❑ Chest

4,(Z

Gastric

Tube 1 , .

,p--) 0 Oral 70

Nasal it"

/ ,,jcz Air 0 Contents

Verified 0

Suction: Y N A-Gram Site:

IV ACCESS &FLUIDS. . TIME . , IW TYPE

— AMT UP , : AMT IN

1 vq.5 Urinary /4, 'f.„--

❑ Meatus

❑ Supra-Publi

PA' 0 Return cc

Home Dip: + •

0 Secured

DPL CI Opened

0 Closed ( 9()1L

0 Grossly: + -

Cell count

Sent@ e t.-.. ib ri c / i 1 I A

Chest

Tube #1 L R

0 Air 0 Blood

❑ Pleuravac—

cm

❑ Autotransfuser

/SA

(-' /. /r

1,72; ' -'

' MEDICATION N: TIME DOSE RTE

MEDICATIONS TIME

._ DOSE RTE

___ TIME DOSE

„, .. ,. • . FITE

Chest

Tube #2 L R 0Air CI Blood

0 Pleuravac cm

0 Autotransfuser

12 Lead Rhythm: Comments •

h fr • r A?/ • , ..,a,,. . ABG SITE' TIME pH pCO 02 1,4,-1 /co 01

1) j ,, . c ....0

/ tc..„ ,..1 • - ,---

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LABS ' )(RAYS i bo - , Lit c:,96 / Ve t=

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/0;25

F1/ O 0-stick 0 SHct 0 Chest Initial

❑ 0-stick 0 SHct . ❑ Chest Post ET A---/j/

;-START, , .... ......:

CVO AV

BLOOD PRODUCTS .': (irate MT ill

'CBC ai Chem )0 PT/PTT

0 ETCH Crt&S O&C x

❑ Chest Post CT

0 C-Spine

0 Tox Screen Pelvis

CI UA 0 HCG CI

0 OTHER ,■.

-: ,..grrtvi: TRAUMA TEAM

0..,. NAM i ,-

ARRIVAL . ,

irl S N

VALUABLES & CLOTHING

s A' ,-. -% :•f D Phys

None Found

urgeon Given to Patient

,nesth Given to Family

Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696

0 Home

Admitted

Report

Time

-

Other: See Nursing Notes •

DISPOSITION 0

X-Ray

RT

Ortho to

Neuro Called to

Chaplain Transferred

Accompanied BY

MEDCOM 22703 0 Wheelchair I

DOD-036279

ACLU-RDI 1673 p.63

Recta/ Temp:

7

RR

7 1

SAO2 F102 MODE

GCS:

E V M

EYE OPENING ; -

GLASGOW COMA

REBLE RESPONSE

SCALE

MOTOR RESPONSE TIME BP HR RHY

4 -Spontaneous 5 - Oriented

4 - Contused

6 - Obeys Commands

5 - Localizes

/ VC , —..Ki__ ie/ii///9"/S S --

3 - To Voice / I( /c99La, /,-- 2 - To Pain 3 - !nape Words

Pain

4 - Withdraws to Pain /e3= c ocv6f /3i= 1 - None 2 - Incomp Speech 3 - Flexion to Pain / y /Wicri /3 e/

1 - None 2 - Extension to Pain i '.i'12 - / .57 id 1 - None

/ TIME PROCEDURE: PERFORMED By /

0 Backboard Removed BY: /

❑ Downgraded BY: /

NOTES

/

/

/ .

/

/

/

/

/

.

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4.1■' A `..■Kank•Ml aWr riMiNteraMbertallnieSMenr

MEDCOM - 22704

DOD-036280

ACLU-RDI 1673 p.64

PAS - 1`..\,-kcc..; c_xo

)

OTSG APPROVED (Date) QA Appr 8Mar 89

INTILAS

)(0 -2

EDICAL RECORD -SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General

REPORT TITLE

PAGE 1 OF 4

INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIFT ASSESSMENT

.S9, I INTI An-vrn

RESPIRATION PATTERN

BREATH SOUNDS

SECRETIONS

-xe-ViTet-?;.F-).7 12. •

16NE • nAcItte07kca r

Mal. a - c"

N

E

U

R

O

R E S P

R A

O. R

S

N

LOCATION

CONDITION

E

ABDOMEN A S T

BOWEL SOUNDS

R

URINE

COLOR/CLARITY U

CARDIACRHYTHM

•

Cr - Creatinine

LEGEND Fi o - Fraction of inspired 02

Ft 02 - Bicarbonate

PREPARED BY (Signature & die)

PATIENTS INDICATIONS (For typed or written entries give: Name -

middle; grade; date; hospital or medical facility)

- CID-C eVNA \A-3 C-krf 2' I tlp Itt)C1(.,

Q•cetc14

PCO2 - PRESSURE OF ARTRIAL CO2

PEEP - Positive end Expiratory Pressure

CP - Intracranial Pressure S/A - Fractional

TRACH Tracheostomy

SAI - Saturation

(Continue on reverse) DEPARTMENT/SERVICE/CINC

El HISTORY/PHYSICAL ID FLOW CHART

10,{ j DATE& (),....r03

❑ OTHER EXAMINATION El OTHER (Specify) OR EVALUATION

❑ DIGNOSTIC STUDIES

❑ TRETMENT

C A .

A S

U L A R.

`‘. OCT

A 2-e0 &D 90—b

DA FORM 4700 1 MAY78

Proponent Dept of Nurs WAMC OP 375 (Redesignated) MEDCOM - 22705 1 APR 90 (HSXC - NU)

Last, First,

DOD-036281

PUPLIS

SENSORIUM

TIME

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COLOR

INTEGRITY

ACLU-RDI 1673 p.65

DRAINS

N\CAS:2Q.,

TOTALS

SOO st)C

PAGE 2 OF 4 DATE DX

I 02- 03 0 6 TIME ormatmegmram.

BP Cuff

smeatiomae 15/4mummul NI

EIIMILI PANIIIIIIIIIIIE III Pulse

EMICSIMMEMS 'TT cl 1 . Mini KIM= fg. EIRE=MI=

IMPIIEWIIIIII le Emu ailm

immlimm ENtimo

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ILIMOIRMIEILICII II

man toomptraran ii

min..0- mairmirs SEEM Mk

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I 14 15

HOSPITAL DAY

BP Arterial line

Temperature

Respiratory Rate

8 ° T

ACLU-RDI 1673 p.66

D.

G

ACUITY LEVEL CLASSIFICATION . 0

PAGE 3 OF 4 POST-OP bAY

21 22 23 TIME 1 19 20

MODE

F1 0 2

TV

RATE

PEEP

A A A PH

PCO 2 T

PO 2

HCO 3

SAT

BASE

TIME

18 19 20 21 22 23 8 ° 17

,ZZ

TIME TIME

SKIN CARE

FOLEY CARE

TRACH CARE

ROM EXERCISES

WT Yesterday wt Today

INTAKE

IV

Po

TOTAL TOTAL BAP ANr.F

MEDCOM - 22707

T

U

R

N

rriALs .

(9(()\

S U C

0 N

OUTPUT

Urine:

DOD-036283

ACLU-RDI 1673 p.67

OF 4

DICAL RECORD -SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General

C

A

Proponent Dept of Nurs

,R

T

R. O ;

BOWEL SOUNDS

E G ABDOMEN

I.

A

As

U

A CARDIACRHYTHM

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NREPORT TITLE

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URINE

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N

LOCATION

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DA FORM 1 MAY78 4 _ 700

OTSG APPROVED (Date) 8Mar 89

TIME

Qt k 9 ) 1 neo <ii4-rxx.. is,

ccuo.,,,.(t), (I..) tvc- tA- 'Vc-Yt(v5 e- 114-`"

f■-3Lvi d6w,X4-,y?- IA-TAD (c,<

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LEGEND

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slraNt-- -sur, Tv-'s30 0 ;

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0 ce.,<AA,;0,1 5

01.■ vro-A2-68-1-)

`Ar-14 5

pg1k4 1. frivi-\ 6', 40 -•

.S4

Cr - Creatinine

F, 0 - Fraction of inspired 02

F, 02 - Bicarbonate

)

INTIL

Intracranial Pressure PCO 2 - PRESSURE OF ARTRIAL CO,


StAve).sRo&dt%, cr-fkroicAef" • S'etrz

,txsz_t Voi4F-76 Si F ka7 Att. crig-r7 z le-2_ s e

S/A - Fractional SAI - Saturation

TRACH - Tracheostomy

DT- 61E) t`$

c_ct, -A -Vv-r., cocc% • %,...dc,cs4::‘.

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cif) ` -\ex.r•i=L — v-37%)

--ck(A-ZQJ`kkti

I Q) ( I DATE/ too 1. 03

❑ ❑ H 1 STORY/PHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ OTHER (specify) OR EVALUATION

❑ DIGNOSTIC STUDIES

❑ TRETMENT

,", WAMC OP 375 (Redesignated) MEDCOM - 22708 1 APR 90 (HSXC - NU)

INTENSIVE CARE NURSING FLOW SHEET— (q1C\ r- Z-

ipINITIAL SSMENT

RESPIRATION PATTERN

COLOR/CLARITY

DEPARTMENT/SERVICE/CINC PATIENTS INDICATIONS (For typed or written entries give: Name --- Last, First, middle; grade; date; hospital or medical facility)

PREPARED BY (Signature & Title)

11111111P

DOD-036284

ACLU-RDI 1673 p.68

4Z

d PAGE 2 OF 4 • •

MUM

4

BP Arterial line

BP Cuff

Temperature

Pulse

Respiratory Rate

TIME

MEM

11111111111MEN

MOW t+ IMISIMMIMEN allaimmum

Mum 1.4

ra 6'6 a Itanammoinal i ■■i ■■emurimul imanorms cis mu 9 Ivy W? iL1-0 13(- Ewan I 1+ V4 11111EIMIMMIrsin IIMINIMIONME811111 v MI v MIMI

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- 0 DRAINS

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MEDCOM - 22709

DOD-036285

ACLU-RDI 1673 p.69

POST- ACUITY LEVEL CLASSIFICATION

PAGE 3 OF 4

B r PEEP

A pH

PCO 2

p02 B 0

HCO3

SAT G

t10

TOTAL TOTAL

BALANCE

TIME

MODE

F.,0 2

TV D A RATE

I

BASE

TIME

/CO

67

CLUCOSE

Na/K

Cl/CO 2

R A BUN/Cr

0 .

A T WBC/PLATELET

WT Yesterday

INTAKE

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wt Today

OUTPUT

Urine:

C

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TIME

MOUTH CARE ■

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T SKIN CARE L

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.N ROM EXERCISES

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TIME

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ACLU-RDI 1673 p.70

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PAGE 1 OF 4

'MEDICAL RECORD-SliPPLV.aENTp4L D6TA qr.:" For•Ziee o(this form seeHIAR 4(frA66; the i_propqnpnt.agpncy:i64The:Qffice , of The Surgeoin Ggrferal REPORT TITLE

OTSG APPROVED (Dale) QA Appr 8Mar 89 INTENSIVE CARE NURSING FLOW SHEEJ.----- (9(-6'- ?_

i.,,,,, , INTILA

INITIAL SHIFT SMENT

SHIFT IN TILAS

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TIME t f4CNCr) I 1NTILA

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BREATH SOUNDS

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COLOR

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Ei 0 2 - Bicarbonate

URINE

COLOR/CLARITY

CARDIACRHYTHM

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V -es6 4,4

\ooPkii) ̂s S/A - Fractional SAI - Saturation TRACH - tracheostomy

fro, s-

LEGEND

PREPARED BY (Signature & Title)

DA 1 Fr 178 4700 Proponent Dept of Nurs

(Continue on reverse)

I DEPARTMENT/SERVICE/CINC K. 1 DATE (9Alfirst ni/03

❑ HISTORY/PHYSICAL ❑ FLOW CHART

❑ OTHER EXAMINATION ❑ .OTHER (Specify) OR EVALUATION

❑ [AGNOSTIC STUDIES

❑ TRETMENT

WAMC OP 375 (Redesignated) MEDCOM 22711 1 APR 90 (HSXC - NU) -

PATIENTS INDICATIONS (For typed or written entries give: Name - Last, F middle; grade; date; hospital or medical facility)

111./(6)(0-Lf

DOD-036287

ACLU-RDI 1673 p.71

uk"' 0.- - PAGE 2 OF 4

DATE DX

BP Arterial line

Temperature

Pulse

Respiratory Rate 1 40 167 1 .,

q C cIt=0

TOTALS

TOTAL

URINE

OUTPUT

GUIAC

EMESIS

STOOL

DRAINS

TOTALS

MEDCOM - 22712

DOD-036288

ACLU-RDI 1673 p.72

INTAKE

WT Yesterday wt Today

OUTPUT

Iv Urine:

Po

TOTAL TOTAL

BALANCE

INITLALS. ' S IGNATURE

OST- ACUITY LEVEL CL4SSIFICATION

PAGE 3 OF 4

0 Q5

c

og cig z

205 eq.

TIME

ROM EXERCISES

Lei

(61g-2_

;•24!)180 TOTALS

ACLU-RDI 1673 p.73

EMERGENCY RESUSCITATION RECORD - PART 1 For use of this form see MEDCOM Cir 40-5

Complete this report within 2 hours following the arrest/event. Place the original in the patient's record and provide a copy to the Nursing Supervisor.

1. DATE: 2. LOCATION

la41CU

❑ DIAGNOSTIC

OF

❑

RESUSCITATION

SICU ❑ CCU

I PROCEDURE

CLINIC:

EVENT

❑ NICU U ED • AREA:

PACU N OR ❑ WARD: 3. WITNESSED ARREST?

EYES • NO • UNKNOWN

• MONITORED AT ONSET? • OUTPATIENT

❑ OTHER (Specify): 35\-YES N NO

4. INTERVENTIONS ( ,/ - IN PLACE

1F:"PT/ Access

,—ndotrachael Tube

rtFMechanical Ventilation

,'Arterial Line

(4-5-Central Venous Line

❑ Pulmonary Artery Catheter

--lagasogastric Tube

AT START OF ARREST) I / - INSERTED DURING ARREST) COMMENTS

• Time: •

• • Time: •

• • Time: •

/ • Time: •

• Time: •

• Time: -

N Time: •

❑ Time: • Ili Pacing Device (Specify type):

❑ Time: - • Implantable Defibrillator / Cardioverter

❑ Other (Specify): • Time: •

6. IMMEDIATE CAUSE OF ARREST I EVENT (Check one)

❑ Lethal Arrhythmias

❑ Hypotension

❑ Respiratory Depression

❑ YES

6. RESUSCITATION

(Check all that

Chest Compressions

Defibrillation

Airway Management

(Check one)

False alarm/arrest

Do not attempt

Considered futile

ATTEMPTED

were used)

(BLS / ALS not needed)

resuscitation (DNAR)

7. INITIAL CONDITION

CONSCIOUS

• • Yes lailo

BREATHING

—Yes ❑ No

PULSE

7'es ❑ No

Site:

• •

❑ NO • Metabolic

❑ Myocardial Infarction or Ischemia

❑ Unknown

Other: rr ❑ (5

• ❑

❑ • Found dead

8. INITIAL RHYTHM p5 (J ►

(ROSC)

Never achieved

Rhythm

min

9. EVENT TIMES climes are required European Resuscitation

Collapse / Arrest

CPR Started:

1st Defibrillation:

Airway Achieved:

1st Dose Epinephrine:

Code Team Called:

❑ Yes

Code Team Arrived:

to calculate the American Heart Ass n and Council in-hospital chain of survIvel.1

HOUR MIN

Onset: •

10. GLASGOW COMA SCALE )Post-resuscitation)

Circle appropriate scores, then total.

EYE OPENING

4 - Spontaneously

3 - To voice

2 - To pain

1 - No response

VERBAL RESPONSE

• Ventricular Fibrillation ❑ Perfusing

❑ Ventricular Tachycardia ❑ Bradycardia

❑ Pulseless Electrical Activity ❑ Asystole

RETURN OF SPONTANEOUS CIRCULATION

. ❑ ❑ Returned at: '

• '

:

• Unsustained ROSC: ❑ < 20 min

CPR STOPPED AT: • .

• > 20 ' ' • • 5 - Oriented, converses

4 - Disoriented, converses

3 - Inappropriate responses

2 • Incomprehensible sounds

1 - No response

WHY: • ROSC • DNAR

Silo Time: 600: I♦ Considered futile ❑ Death

PATIENT DISPOSITION:

MOTOR RESPONSE

6 - Obeys verbal commands

5 - Localizes painful stimulus

4 - Withdraws from pain stimulus

3 - Flexion, decorticate posturiggt

2 • Extension, decerebrate

posturing

1 - No movement

SCORE:

■ Yes • No Time: (vo :


EPko ,

W4 Or°! --k

AGE:

GENDER:

HEIGHT (in):

WEIGHT (lbs):

MEDCOM FORM 679-R (TEST) (MCHO) AUG 99

PREVIOUS EDITIONS ARE OBSOLETE

MC V2.00

MEDCOM - 22714

DOD-036290

ACLU-RDI 1673 p.74

•

EMERGENCY RESUSCITATION RESUSCITATION RECORD - PART 2 FPLC) TIME (Hr/Min): if 7.-C ji LS- 113r. 24-71i 7--61 0

BLOOD PRESSURE 64/33 6 Y 2 3 I C3/S-7' 16-ire 175 1 HEART RATE (* = CPR) /4,e) Mt/ 12---e I 11 (24'

RHYTHM Pi/Jr ti5i/ r S 1- s r S r

PULSE PALPABLE (Y/N) Y '/ y y DEFIBRILLATION (Joules: 200, 300, 360)

____ —,.• —...- --

CARDIOVERSION (Joules: 60, 100, 200, 300, 360) ...._,. to 1/.

j.../ ....._

PACING PERFORMED (I) 200 30 45 36-o --

RESPIRATIONS 1(, fil /4 tv I< —

cc .'z >-

BAGGED w / l00% o2 ( ✓ ) '---

INTUBATED (V) %-"' L,

MASK (Specify type) •—■ --

% OXYGEN / 0 ° JO 0 / 0-0 fOO /0 0

02 SATS I17 is- ??-- qg Jo c IE

w 0

— L

I ci I—

— 0

Z 0

EPINEPHRINE (1 mg - IV I ET tube)

efut.iii

5- 1/41

,

7/— ATROPINE 10.5 -1 mg - IV / ET tube)

LIDOCAINE (1-1.5 mg / kg - IV / ET tube)

.1...z. 11

03 tit:, .06614LriC

a *4 ■

- arr •

— >

CI ec —

0. 0

)

LIDOCAINE ii am / 250.cc -

IV at 1 - 4 mg /mini

DOPAMINE (400 mg / 260cc - g./ et 1 - 20 mcg I kg /mln)

POTASSIUM (K) go 'auk,' a/L.4e .

GLUCOSE ,Q CALCIUM (Ca)

',—

'.5 ,9'. 6%---:

MAGNESIUM (Mg) T

PH

pCO2

II 0

p02

HCO3

PHYSICIAN (Signature & Title)

472A1 MM. /

NU (Si nature & Title)

MEDCOM FORM 679-R

T)(MCHO) AUG 99, Back (r)(0..._ 2_

MEDCOM - 22715

DOD-036291

ACLU-RDI 1673 p.75



1. DATE: Nov 2— 2. LOCATION

MICU -SICU

U DIAGNOSTIC

❑ OUTPATIENT

p---OTHER (Specify):

OF RESUSCITATION

❑ CCU

I PROCEDURE

CLINIC:

EVENT

PACU i t k.4-1 1

3. WITNESSED ARREST?

[I, YES ❑ NO ❑ UNKNOWN

MONITORED AT ONSET?

FA YES • NO

❑ NICU ❑ ED U

AREA:

U OR • WARD:

1 C..(. 0 I

4. INTF RVENTIONS ( V - IN PLACE AT START OF ARREST) (

ley Access

• E9dotrachael Tube

D /Mechanical Ventilation

12/Arterial Line

EKentral Venous Line s,c- 2- ❑

Nasogastric

Artery Catheter

E Nasogastric Tube

ii Pacing Device (Specify type):

V - INSERTED DURING ARREST) COMMENTS

• Time: •

- • Time: •

• • Time: •

U Time: • --

11 Time: •

• U Time: •

• ill Time: •

• U Time: •

• Implantable Defibrillator / Cardioverter

Ill Other (Specify):

• Time: -

U Time: -

6. IMMEDIATE CAUSE OF ARREST / EVENT (Check one)

U Lethal Arrhythmias

12/Hypotension

EKRespiratory Depression

• Metabolic

• Myocardial Infarction or lschemia

❑ Unknown

• Other:

YES

6. RESUSCITATION

[Chest

ATTEMPTED

(Check all that were used)

Compressions

Defibrillation

Airway Management

(Check one)

False alarm/arrest (BLS / ALS not needed)

Do not attempt resuscitation (DNAR)

Considered futile • Found dead


CONSCIOUS

❑ Yes ErNo

BREATHING II

• Yes ❑ NO> N\ V UV' -k--.

• NO PULSE

❑

❑

U

• Yes ErNo

Site:

8. INITIAL RHYTHM M .pc.... I Ventricular Fibrillation Perfusing

U Ventricular Tachycardia ❑ Bradycardia

U Pulseless Electrical Activity ❑ Asystole

RETURN OF SPONTANEOUS CIRCULATION

Er Returned at: 020 : I S- in Never

Perfusing

Q._ e, Ki Rhythm

(ROSC)

achieved

❑ > 20 min

mines

9. EVENT TIMES are required

European Re_suscitatIon

Collapse / Arrest

CPR Started:

1st Defibrillation:

Airway Achieved:


Code Teem Called:

to calculate the American Heart Ass'n and

Council in-hospital chain of survival.)

HOUR RAN

Onset: ICA : Ste—

10. GLASGOW COMA SCALE (Post-resuscftetion)

Circle appropriate scores, then total.

EYE OPENING

4 - Spontaneously 3 - To voice 2 - To pain

No response

VERBAL RESPONSE

I C\ : S5 A) 4 : NIA

In Unsustained ROSC: U < 20 min

CPR STOPPED AT: ..9 0 • i lA pku

il \.i AO ,w, rit, p 5 - Oriented, converses 4 - Disoriented, converses 3 - Inappropriate responses 2 - Incomprehensibl 1 - No response •-E .—cr

WHY: • ROSC M DNAR

II Considered futile M Death

I )1\ V3 a cy_

q Yes 13Y

Code jeam Arrived:

aYes

I No Time: \ C'' : g


❑ No Time: 9 : 9-4 MOTOR RESPONS

6 - Obeys verbal commands 5 - Localizes painful stimulus 4 - Withdraws from pain stimulus 3 - Flexion, decorticate posturing 2 - Extension, decerebrate

posturing - movement

SCORE: ,::;) Ell


V,: P v v 4Filib ([9)(o\ L'\

AGE:

GENDER: ItA

HEIGHT (in):

WEIGHT (lbs):

Q. Nirr

MEDCOM FOFIM 679-R (TEST) (MCHO) AUG 99

PREVIOUS EDITIONS ARE-OBSOLETE

MC V2.00

MEDCOM - 22716

DOD-036292

ACLU-RDI 1673 p.76

MEDCOM FORM 679-R T)(MCHO) AUG 99, Bach

EMERGENCY RESUSCITATION RECORD - PART 2

TIME (Hr/Min):h (-155 tl)vb 2thl kt)14 itb t c I kp i ,214 I>

— I—

< -

1 cl)

BLOOD PRESSURE li,

HEART RATE (* = CPR) 60 &cfb■Pck_ \

(4)Q__

1`'ficsv∎ -0 PeAurok V Cil,-)

\ '1 \D

5.1

\3(c) 51- RHYTHM

PULSE PALPABLE (Y/N) Ni 1---1 NA il —

`I —

NI —

\I DEFIBRILLATION !Joules: 200, 300, 360)

CARDIOVERSION (Joules: 60, 100, 200, 300, 360)

-- — — __. —

PACING PERFORMED (I) -- — — -_ ty\ V --

RESPIRATIONS IV. V -- — I CA I <—

<>- I

BAGGED ,. / 100% 02 (✓ ) ✓ / J o(Ny — tA V INTUBATED (✓ ) Ilg el- A 1041 " ) a

MASK (Specify type) —... —_, — ---

% OXYGEN SO IVO I ''''`-=' t co \ '00 1C:, , CD 02 SATS rim 1V0/. clGi. P1ii•

iln‘) St14.V _ ''t Mk/ aKa1 . 7canfvf...pitY I2 w

0 —

0 e

t I— —

0 Z

c6

EPINEPHRINE (1 mg - IV / ET tube)

ATROPINE 10.8 -1 mg IV / ET tube) 1 MS

LIDOCAINE 11-1.5 mg I kg - IV / ET tube)

i Avwfo

Cu C‘ i'lkwif 6 (\c,i\o i kvi,f'

• •

->

OC

C.-.C

LO

LIDOCAINE (1 GM / 250cc -

IV at 1 - 4 mg / min)

DOPAMINE (400 mg i 260cc •

IV at 1 • 20 mcg / kg / min) kltice

ca0 ilv i\E\ ...

i,(, 01 A-11,0_, .

.0bich,Ort IAA iAL

V\Cri

ik) ) A i

.

-I tz

t CO

CO

I POTASSIUM (K)

GLUCOSE

CALCIUM (Ca)

MAGNESIUM (Mg)

S6A PH 1 , 5\-- pCO2 ,9 1-

---.

ti C

p02 0 t A HCO3 I

CIE - 10 PHYSICIAN (Si nature & Title)

al- NURSE

667-1/b0

MEDCOM - 22717

6 z

DOD-036293

ACLU-RDI 1673 p.77

HOUR MIN

0 0 D

0 0 : 0 :

00 I

Time: 00 : W


No Time: O0 :

4.0

/1-.

GENDER:

HEIGHT (in):

WEIGHT (lbs):



1. DATE: 3 kov 2. LOCATION 0 RESUSCITATION EVENT 21 3. ITNESSED ARREST?

YES ❑ NO ❑ UNKNOWN

M9NITORED AT ONSET?

RfYES ❑ NO

❑ MICUigicu ❑ ccu ❑ NICU ❑ ED

❑ DIAGNOSTIC I PROCEDURE AREA:

❑ OUTPATIENT CLINIC:

❑ OTHER (Specify):

❑ PACU ❑ OR ❑ WARD:

4. INTERVENTIONS ( b,/ - IN PLACE AT START OF ARREST)

❑ IV Access

❑ Endotrachael Tube

❑ Mechanical Ventilation

❑ Arterial Line

❑ Central Venous Line

❑ Pulmonary Artery Catheter

❑ Nasogastric Tube

❑ Pacing Device (Specify type):

❑ Implantable Defibrillator / Cardioverter

❑ Other (Specify):

- INSERTED DURING ARREST)

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

❑ Time:

COMMENTS

6. IMMEDIATE CAUSE OF ARREST / EVENT (Check One)

❑ Lethal Arrhythmias

❑ Hypotension

❑ Respiratory Depression

❑ Metabolic

ri2r Myocardial Infarction or Ischemia

❑ Unknown

❑ Other:

6. RESUSCITATION ATTEMPTED

rZrYE, (Check all that were used)

IA Chest Compressions

❑ Eyfibrillation

NVAirway Management

❑ NO (Check one)

❑ False alarm/arrest (BLS / ALS not needed)

❑ Do not attempt resuscitation (DNAR)

❑ Considered futile ❑ Found dead


CONSCIOUS

❑ Yes ✓rNo

BREATHING

❑ Yes lieNo

PULSE

❑ Yes 12/No

Site:

8. INITIAL RHYTHM

❑ Ventricular Fibrillation ❑ Perfusing Rhythm

❑ Ventricular Tachycardia ErBradycardia

❑ Pulseless Electrical Activity ❑ Asystole

RETURN OF SPONTANEOUS CIRCULATION (ROSC)

❑ Returned at: • ▪ PrNever achieved

❑ Unsustained ROSC: ❑ < 20 min ❑ > 20 min

CPR STOPPED AT: OO : s4 WHY:

❑ ROSC ❑ DNAR

❑ Considered futile 12/Death


9. EVENT TIMES (n..* are required to calculate the American Heart Assn and

European Resuscitation Council In-hospital chain of survival.)

Collapse / Arrest Onset:

CPR Started:

1st Defibrillation:

Airway Achieved:


Code/earn Called:

Ling Yes ❑ No

Code Team Arrived:

VERBAL RESPONSE

5 - Oriented, converses 4 - Disoriented, converses

3 - Inappropriate responses

2 - Incomprehensible sounds cD No response

10. GLASGOW COMA SCALE (Post-resuscitation)

Circle appropriate =wee , then total.

EYE OPENING

4 - Spontaneously 3 - To voice

6-o pain

o response

Co polio 1 1-

MOTOR RESPONSE

- Obeys verbal commands

Localizes painful stimulus

- Withdraws from pain stimulus

3 - Flexion, decorticate posturing

2 - Extension, decerebrate

posturing

1 No movement

SCORE: J

MEDCOM FORM 679-R (TEST) (MCHO) AUG 99 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00

MEDCOM - 22718

DOD-036294

ACLU-RDI 1673 p.78

EMERGENCY RESUSCITATION RECORD - PART 2

TIME (Hr/Min): (Z)+)10 ()p (Al 6,-)n4to f 6)050 oo 5'2 009)

BLOOD PRESSURE WI '27/M 2/q .C71• tisb,a1.4

HEARTRATE (*= CPR) 444

Ga (,3 GP% szi T-C.. ce RHYTHM

PULSE PALPABLE (YIN) tics IV-(5 Aro

A DEFIBRILLATION (Joules: 200, 300, 3601

—....,

CARDIOVERSION (Joules: 60, 100, 200, 300, 360)

-;--

PACING PERFORMED ( ✓ ) nr

RESPIRATIONS 140,164,4 Icz—

cccx>-

BAGGED w r no% 02 (I ) ✓ 4

INTUBATED (I ) v/

MASK (Specify type)

% OXYGEN

02 SATS ( ODA 1 E

wC

i—Ci

<1--

OZ

U)

EPINEPHRINE 11 mg - IV / ET tube)

,7"V i '

&04_,/ 61.Df7- I or4.g.i

oogY Si 7/

c:,c47 pi c,c,Yrc>cpere,c

Tv g

ATROPINE (0.6 -1 mg - IV / ET tube) I C° 11

I I viedi PI 0 eVY

1.,,A,N CP42-

--,:ar 001

"Ate 00 Si)

LIDOCAINE (1-1-6 mg / kg - IV / ET tube)

D so -t-494-14.

Ov(17-

ext,it. Co TO

I—

> O

cc—

a-co

LIDOCAINE (1 am / 250cc -

IV et 1 - 4 mg / mi.)

DOPAMINE 1400 mg / 260cc

IV at 1 - 20 mcg / kg / min)

I...) <

02 ci)

POTASSIUM (K)

GLUCOSE

CALCIUM (Ca)

MAGNESIUM (Mg)

aIldtk 1- cotO. 1 6/0-- I

<D

5C

.9 DI

PH qtiq PCO2 -23,q p02 3C9 HCO3 17 % I

.

PHYSICIAN (Signature & Title) NURSE (Signature & Title)

VA I3 NI;,?-f- itiC9 full

MEDCOM FORM 679-R (TEST)(MCHO) AUG 99, Back

MEDCOM - 22719

DOD-036295

ACLU-RDI 1673 p.79

I. Keporung mit- ci,r,) 2. IV .:ion Admission and Coding Information IZ For use of this form, see AR 40-400; the proponent agency is OTSG _

3. Register Numb

,—.

ame (Last, Fi t, MI) 4. Pay Grade

FGN

5. Sex

M

6. DoB (YYYYMMDD)

1978-07-01

7. Age at Admission

25Y

8. Race

X

9. Ethnicity

9

Religion

10. Length of Service ETS 11. FMP

20

12. Social Security Number

(q(C)—(1

Organization (Active Duty Only) 13. Marital Status Hour of Admission

18:10

Branch / Corps:

14. Flying Status

NO

15. Beneficiary Category

K78-PRISONER OF WAR/INTERNEES

16. Zip Code of Residence:

17. Unit Location

IZ

18. MOS , 19. Trauma

BC

Prey. Admission

NO

20. Source of Admission

0rl Direct from ER 4-

Ward:

ICU1

Name / Relationship of Emergency Addressee

Address of Emergency Addressee

Nam d L tion of Medical Treatment Facility: 0580 ; No Install Provided

Telephone Number of Emergency Addressee

21. Type of Disposition

TRF-OTH

22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)

2003-11-02

24. Clinic Svc - Admitting

ABA- GENERAL SURGERY

25. MTF Transferred From 26. Date this Admission (YYYYMMDD)

2003-10-31

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission

2003-10-31

FOR LOCAL USE

Type Patient (Inpatient / Outpatient): Inpatient

Admission Diagnosis Narrative: DIVERTING COLOSTOMY/ SUPRAPUBI

- Procedure Narrative(s):

Cause of Injury Narrative: GSW BUTTOCKS

BE PER6JanAINAGE

by : nogic A 8-28

gt6.3cr 5141

Q0-71

49,s' eqq0-

)

00)N_ 'ZI --iiiignature Admitting Officer (Si •

of Adm .ng Clerk I

_....n- CI,

Automated Facsimile - DA FORM 2985, MAR 2000

MEDCOM - 22720

DOD-036296

ACLU-RDI 1673 p.80

1. Reporting MTF L) - 2. MTF Lo

IZ Admission _.,, Coding Information

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

3. Register Number Name (Last, First, MI) 4. Pay Grade

FGN

5. Sex

M

6. DoB (YYYY DD)

1984-01-01

7. Age at Admissi n

19Y

8. Race

X

9. Ethnicity

9

Religion

10. Length of Service TS (.g(,. ) (0 —

11. FMP 12. Social Security Number

—2T)

Organization (Active Duty Only) 13. Marital Status Hour of Admission

21:51

Branch / Corps:

14. Flying Status

N/A

15. Beneficiary Category

K78-PRISONER OF WAR/INTERNEES

16. Zip Code of Residence:

17. Unit Location 18. MOS 19. Trauma

BC

Prey. Admission

NO


D ----J-- I 9/

erect from ER

Ward:

ICW1

Name / Relationship of Emergency Addressee

Address of Emergency Addressee

Name an tion of Medical Treatment Facility: 0580 aq; No Install Provided

Telephone Number of Emergency Addressee

21. Type of Disposition

TRF-OTH

22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)

2003-11-09

24. Clinic Svc - Admitting

AAA - INTERNAL MEDICINE

25. MTF Transferred From 26. Date this Admission (YYYYMMDD)

2003-10-31

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission

2003-10-31

FOR LOCAL USE

Type Patient (Inpatient / Outpatient): Inpatient

Admission Diagnosis Narrative: FRAGMENT WNDS L THIGH

Procedure Narrative(s):

Cause of Injury Narrative:

Admitting Officer (Signature, as required) Signature of Admitting Clerk

Automated Facsimile - DA FORM 298 MEDCOM - 22721

DOD-036297

ACLU-RDI 1673 p.81

PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Eat, 'ha,

E"7

r‘A.a-143-Yti

IDENTIFICATION NO. ORGANIZATION

REGISTER NO. WARD NO,

PROGRESS (1.:nler date of din•Iir:rpr and final dings:mei.)

•

SIGNATURE OF PHYSICIAN

PATIENT'S IDENTiFIC

DATE

3/ pad or wrrtren ff,e• live Na e last. first, jra date: hoopir.1 or med

to 1..c,lity)

MEDICAL RECORD ABBREVIATED MEDICAL RECORD

t 9r F- „LI/EA? 6), q

," „ 2g

I . 731, 14-

(27 VOI R 0

LETw..1_ oc,11

PHYSICAL EXAMINATION EXAMINATION

PejAr (5

IIIIP e-Xo 4

ABBREVIATED MEDICAL RECORD Standard Forma Sao

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106

MEDCOM - 22722

DOD-036298

ACLU-RDI 1673 p.82

PROGRESS NOTES MEDICAL RECORD


DATE NOTES

,5 wJ0-3 Uc_S 4-J2,,-1- ,)- (/), , C/() ll:A_-.--- &. OPPT 4--ti oi& 2o 6)C) t n-.. ,C/LA-.--- 61---&12-1--7-__D )9X----e- 7'(,s Ac( L-..p.--, -i a-ct..4e

r),,,.,---Qok ) . • i--- =4--- 0 (r ,0 r'&2/1/7i-Lk- A f. I V i., ---1- V -V-

En- A '-t-- ' 44) T i ',• a/ i,3--- ..

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--_,,..----7,..___,e .._..y 7 5 -6-.)7 0 /-q cyty -L0,, Cbx-e--1 C1:1114/VI.Nre_.

`CA_ C.9—)-----)7 COLA0---2---,__0,-,-- (,c`l 1 -3,;,_t_- e

/Fmk cp (cpc136)-Ast -fyv cart:2_ cD cteig:51). 'ek-- <:‘,s2..(--\- -.,y.Q....__YLILK- Nce)sit___

Vss. (4D (---k 0 p...i._ Afr\ric) -i-t---) i24g.._ -Rx-- verscrN4) \(,<qe.r\.(2411.^

S rA■ kc....u\c‘-kd -1.c•-t --A-0 ..--\4rt\-\ L.Sc, NI.M. 4 5\S)c Nrced-U"'

* coe, VN c\-\\f--- ,..1) --01-,1's .>-,4\c-,G2... SL- :\r"•Q=:(41:123rrcl C-

ROS\(\aS \r4,211 SS)c. ‘kt-R\'‘,c-a--\-Nbcm, -Ircz::A. fQs di-e..A- we,), ■ . r

4 0\c‘- Z 6; V's cA_D\ a• 'vb. vrt- f=?S'N-...■ (171s. i\r\ Ns)\c_e. -1

v\A-\ ■ \_.(2_ \N bec:\ s SIS)‹. Co\iC-A-C-NS \III-\\ c-r.`/CW---. r

1INC. TYNICS,C110C,

((90-b v6I5 U s C_9-C_-J- 0 ri F n

2.000 OCASbcT---4_3r a- IA,a-c-i- . 11-- 14% d-- ditt.R-

IALAP Alv•--Q- 0 A Oci a , 4, 411.4.1.... • . ( x 1---)A fyi 0_, \ 1 #4

IA - ---...- f

I. ./t--- \ _,---A--%.,, ,..Q C CA--s-__ 0,2-- odc.44.,7\_p RELATIONSHIP TO SPONSOR SPONSOR'S NAME

LAST FIRST MI ISSN or Other)

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

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

PROGRESS NOTES Medical Record

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

USAPA V1.00

MEDCOM - 22723

DOD-036299

ACLU-RDI 1673 p.83

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

ii i 01 y .. • 0

16

ea .---4/,-.e ' el/ ; , 4634.- . ' r 4 2 - / t-Fe----

lci7 ... - _.. •011. 4r 4//

•___......t.."...s.v.,

--"pfL..:2e .....,,,e..". , y115* . -----7,4-4. 4...47 ,--. , % (1-4

_

. ,....<;...—iri ...,,,,

•••

"1"r .I-rl. a

,. 00 .. c 4, • y►-- Ga e-s 4.--✓"4-1( "-N\ . A •

- -.3 -00 C te...-4 f i"trtvl 6, t , ... b - 0 411 ,i5 k c p -- Pt :',\ ), 1 i, -k I poNic-+

111

1 otioo 01 6S5 46. L.) 0 ----d-- <5 Alm - St : Kszczd., 0

Os (... .11 . -4 .... ,--

O --k, a 43 ■IsS' , 79e. , e",-.4, 0-11 e--)-r-c.,?-",e-a ate . S' -I'

e ,... ea . 005°,4 ---f-- ( s ._.1- i•-.

47"4/1-

(._,-, C53,5 L.Stin 62.:1 A/401A93 vs A 4.-0 ot 0042 -r 6g . 4,1-40,1c.

/ c--0-0 - &--. lac53 C_,

c re - c ; - ( 0.7

L./yr

e-c. " L--

5 ,.(p__.e> I 0 IDJI-e., . 150- i ck l 'n 6; 2,

/ ./974/A/1/

--- 4- ,,, , 0 el , •

1_,

47n4._ 1..),"/ '6 ;vv-rw)13-0.r. --

/

----

--411111k (c)((ol MEDCOM - 22724

STANDARD FORM 509 (REV. 5/1999) BACK USAPA V1.00

DOD-036300

ACLU-RDI 1673 p.84

DATE 1 NOTES

L. Ilk At-N6 ith t G. 006

we Ur iP &A q5 111' •

CICie Vir-nopo t.-----T-N, CP AvA\r Cl)--T ,

S Q.,C

JC-C9 0 're 1)4 k s i ._c, &I? (Ni--) v -a- -t-- 2 471L Cif■A\C>\ ciA---ef-■

% 4 0\CI i

© 7k-e_j ‘\,(AA-- Ok C‘ic S \ • b -\---

-e--aho -- s a ill •.O. S I

lkt/m/cY3 /Vv. AL---; tk_s; Y_ _. i .,.., .... _

4t c , ,, ,

-".4, ". #.717 72-.2141•414

-441' dr -...u•

es....

...r 04.1,Le,e0I74 0....01.'eLe2‘4•4

a444.4-0.--- :„.,,

1/6e .___.,

■ .....

'.✓;E,e4-

.4 - .41•11,

1...../, _, _ •0) . 40 'LT a‘d..Y. 4,>04-

-...

.tea, , .4 .....-.............___........-- 4

. — alINCOUINUAL.Aa ..i -.L. g i _.

.1 1 0 1 / P i ■ 0 _. . - _LP 0

# c. -AL AL.-. ' Mr-0 _ A • r -.." i

"Litt. !t 4 ' / il • AP ----)_ I / / g Ild ...AA (XL

cf2(zn c ,..(7 IA 1 WC/C/1,–R it (6 f,,z._-_, -1,fai '1,-674 RELATIONSHIP TO SPONSOR SPON

(SS .

SPONSOR'S NAME

LAST FIRST MI---

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT ,.;.

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


El




STANDARD FORM 569 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)

USPre• V 1.00

MEDCOM - 22725

DOD-036301

ACLU-RDI 1673 p.85

DOD-036302

Ws, 441-70)( Azz2-

cp frz,- 114 ..„....e.e.e.a— ry

lot

I

MEDCOM - 22726

_4'007 63

ACLU-RDI 1673 p.86

MEDICAL RECORD PROGRESS N AUTHORIZED FOR LOCAL REPRODUCTION

DATE NOTES

3 -7 ftia rem 1111k vi a . E I -2-I 0 \A) _ ii. • h■ ' a-kr \ .... . q■

_ ► _114 • + cc-e Vv rap C..h .M__ L C ---M B (t) r)-) 101 i A --I- i< '3

v3,5 ca6 . Oi(N Cr-- ASCJI-AY I-- TV SI___ R AC__ cc4-' Pb

f Lk • ) 0

S _ INL- . 9.2° 1116 ' \

0 ) e 4-e, •. 11. ar ---- ,... • 4.0. -Vi Of1S -, (IL C")--1-- 1) 1 a II. Alh• a • e

2- p oiv\-+ \r\--\.- i .._ 3 3 -e C i .1_ S-Z. ff---e_C.--Er'TY

4 SX Cr - CiDmpV)

0700 C5-x- d - / ,t- , __ .

c.1.--- -t-/ 1 ,-4-- Ac-l- c--e- .R s ,-) (-e--- c,--t- A---j riao. 4.-1 L -r gpiA c_ r ,,,J _G_Ei.:,./ .e5- s./ x-, ,

k) ,- (1 cam- 4 .--/„....„„.:A---„x __ Wyn OtMiitirrua Mitt Glj pf 0 ( W . 41 `-iso, C(Vatt--. le,e/tt i . ra 4 Pitli;

Pt OC IP I-D e0/ 0-1) 1/S OM I fi5(S ■ TOO Ciii a -6 4)AL/1A°, 10..,-0

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2191- MS-11.0A14--fr M '14( of 46u4 ( co 04 691/frupuvv,f_c.) . Plcut: opti - Iv )c 1 uhluto--1 iailu 5: AK - 11-(2

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

ISSN or Other) LAST FIRST MI

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

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


,.

ell PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(131(101

USAPA V1.00

MEDCOM - 22727

kL)

DOD-036303 ACLU-RDI 1673 p.87

, LAST NAME NAME 7 A.1 ID NUMBER

DATE NOTES

44,LS - 1.4-oyc_.- 1S-- . Y--k Aief>" A., Adej- 4 4/, ,g7s (-) 0, /4, _4„, / , ____. - il--

Artatit

......_. _, _...6._ ngee).-w.__.a,/64,t2',...o., jeLiZ. i,e'te.4 2 a-( /

/4Z-Z ' -27 ) /iteeZer.L-7, --r7

. , 01° ----,,.

f ■ .1 / ---et-,e)/>i4ic-v . ,...w ),., j?"

----- ---",,L14-7li,c- ..--- G r , --/ ' 4._e_ • / AP

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11Q6j c)3 2-t 033 a9,A- ID i-uslii , (6 °-- JIM viv . 7,

Amo 04,-S,t,. --c-,- 41 C --LO: 1 4, : /1 AC .1.0.,_.... .. ,,,:ty • f P ..L .2 . 0 6

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avAII..- P

(f) iki /0"1 1)P i/j( (,1 6(V2/1--"-t (L(A-- 2--- (; , jaC/14-1,■-e.(

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/0z9 cD yerd,, -;,, - ,4-,.--4/6e, x / c.,4_, „),-.../.-e 7.4i /e"--- /...) ,,,,;-, . L.5:4, .,_ 4 i,i,e __,-7 -,4,4i, 7(_,.....0" "4,, ,,,i_e. / ,441

, _ . - 41 . . -I

ST NDARD FORM 509 (REV. 5/1999) ACK USAPA V1.00

MEDCOM - 22728

DOD-036304

ACLU-RDI 1673 p.88


CHRONOLOGICAL RECORD OF MEDICAL CARE

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

MEDICAL RECORD

b 5 6 cs.,r-Cc.S de, e,sy—c • ob) 2 diming

7 L b-sc-3 CLY0-z- i)sy 6 ito`ss , (tireA/-e-a A ,

ot/

6) AIN D17

DATE

HOSPITAL OR MEDICAL FACILITY

SPONSOR'S NAME

STATUS DEPART./SERVICE RECORDS MAINTAINED AT

SSN/ID NO. RELATIONSHIP TO SPONSOR

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

•

REGISTER NO. !WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

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

MEDCOM - 22729

DOD-036305

ACLU-RDI 1673 p.89

&SW

MEDCOM - 22730

EMERGENCY CARE AND TREATMENT (Patient] Medical Record

STANDARD FORM E58 IREV. 9.96) Prescribed by GSA/ICMR FPMFI 141 CFRJ 101-11.203Ib)(10I

SSZ-204

7540-01-075-378

LOG TREATMENT FACILITY

k°01r RECORDS MAINTAINED AT

EMERGENC AND TREAT

(Patient)

PATIENT'S HOME ADDRESS OR DUTY 4ATION

MEDICAL RECORD

ARRIVAL STREET ADDRESS I DATE (Day, Month, Year) TIME

• f Od- c3 2-2.6 STATE ZIP CODE TRANSPORTATION TO FACILITY

iMENVicte; SEX DUTY/LOCAL PHONE IL ITARY STATUS THIRD PAR SURANCE AREA CODE NUMBER

ITEM YES NO N/A YES NO PRP

ADDITIONAL INS NCE

DD 2a6B IN ART

NAME• SURANCE COMPANY

AGE ONE FLYING STATUS

AREA,COOC" NUMBER MEDICAL HISTORY OBTAINED FROM

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNE S EMERGENCY ROOM VISIT

WH •ate/ DATE LAST VISIT I24 HOUR RETU

S

ITEM YES N

NO IS THIS AN INJURY?

INJURY/SAFETY •RMS

WHERE ANUS ALLERGIES

CHIEF COMPLAINT

DATE LAST T COMPLETED INITIAL SERIES

❑ YES 0 NO

HOW

CATEGORY OF TREATMENT TIME

INITIALS A

1/1)

VITAL SIGNS 0 EMERGENT

0 URGENT

0 NON-URGENT

TIME

BP I 2_ PULSE

RESP

TEMP

WT

13HCG/URINE/EILOOD/QUANT

UA MSCC/CA CHEM: 7, c CXR PA & LAT/PORTABLE C•SPINE

>- < LJ CC 0

X Cr 0

ACUTE ABDOMEN 1.5 SPINE 00 C&S X SINUS HEAD CT

5 ANKLE FVL

ORDERS

DISPOSITION FDISPOSITION QUARTERS /OFF DUTY

7 24 HRS. ri 48 HRS

PA TIENTICASC.NA AGE INSTRUCTIONS , FULL DUTY

MODIFIED DUTY UNTIL HRS

I RETUFIN TO DUTY

CONDIT:ON UPON RELEASE !ADMIT TO UNIT!SERVICE

ITIME OF RELEASE

TO IWHEN 0 UN C I-IAN GE D REFERRED IMPRO`tED

DErERICRATED

I have received and understand these instructions. PATIENT'S SIGNATURE

PATIENTS IDENTIFICATION (For typed or Written P.171/1.23, give: Name - last first middle: JD no. (SSN or other); hospital or

DOD-036306

ACLU-RDI 1673 p.90

FIESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP CONSULT WITH TIME ACTION

PROVIDER SIGNATURE AND STAMP

,GNOSIS

TENT'S IDENTIFICATION (For typed or written entries. give: Name — ba. first. middle: ID no. ISSN or oltherl: hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 55B IREV. 9-96) • P:ascrib*d by GSA/ICMR

FP1IR 141 CFR) 1 01-11 . 203lb) I I 0)

#1) MEDCOM - 22731

EMERGE D TREATMENT (Doctor)

TIME SEEN BY PROVIDER . --• MEDICAL RECORD

TEST RESULTS

ABG/POLSE OX RADIOLOGY Check if road by radio log i st

SUP 02 PH P07 RESULTS

fee-4.A_ /0'Art-=

'cd' V./5T-

PCO2 AT OTHER

7

DIP EKG INTERPRETATION

MICRO

WBC

;9"

PLT

PIT

BHCG

ETOH

GLU

ROVIDER HISTORY/PHYSICAL

c7: r6(1"4

s ,

143 I/9 e•-"”

t-14-/- I )c)

,1111 cr

4 0s)(c) -1-

tizei_x" ,(4ntir

fr4-PAA/d-

DOD-036307

ACLU-RDI 1673 p.91

MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY

POST- DAY • MONTH-YEAR DAY 7 AA D-5 i(4/64 63 ifiwite.5

19 HOUR 6- . /41/ - •.... . . . . . . .

RESPIRATION a

PULSE

(0)

180

170

160

150

140

130

120

110

100

90

80

70

60

50 .

40

RECORD

TEMP. F

(•) 105°

102°

101°

100°

99° 98.6°

-

: .n.

g •

I— - 9

.,1 V it. ....

. : : : .".

• • • • • • ••

• • • • • • • • • • .".

• • TEMP. C

S--.

a) o

c a ) a ) a ) cc

L5

ui c a) To

." cr

Li,

-IT E.' op ..r.,

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40.6 °

103°

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.......

.......

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•

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98° l' ........ • . . ,

37.0°

97° . . . . . •

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36.7°

96 ° • • • -

36.1 °

35.6°

35.0° 95°

• • • .

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cc

co

BLOOD PRESSURE

,

fil OA 1 tfoi 4r . 11

T 1 4/1 HEIGHT: WEIGHT ......-0, iti.

0 sl ,.

17 7 . pixe

A9, ,/ ', 0 • • .7, ,

'ATIENT'S IDENTIFICATION (For typed or wri ten entries give Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)

,...„,


'.

STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 22732

DOD-036308

ACLU-RDI 1673 p.92

511-119

NSN 7540-00-634-4124


POST- DAY

MONTH-YEAR DAY g

P o J . A) V o 03 , / Off/ -(NIN 03 CI," 19 HOUR 24 • • 57012 •• •• Pr .f) '' • . • '

PULSE (0)

TEMP. F

105°

180 104°

170 103°

160 102°

150 101°

140 100°

130 99° 98.6°

120 98°

110 97°

100 96°

90 95°

80

70

60

40

RESPIRATION RECORD

. . . . . . Ilia .: • AM.' V1-6 . 1 • • : :

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'Rec

ord

spec

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ata

on

ly w

hen

so o

rder

ed BLOOD PRESSURE igo

04 REMEMIIIIIMEIIIIIMSMEMPIEND4 11M3.21 mi.=

Li% 99 % m Fammiral 11111EMRI

mai ran joa

primnrizauram ..mumio—lrinam liammum HEIGHT: WEIGHT —111.

4. PEINIMINIIIMMENIIIMIIIM1111111 01 III • 7t;

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

REGISTER NO WARD NO.

VITAL SIGNS RECQRDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 291-9.202-.1

MEDCOM - 22733

DOD-036309

ACLU-RDI 1673 p.93

Scg

Bands .

Mono

Eos

Nit Lymph Nega t ive

DATE: LAB ID NO.:,

,,yarcyscctioe.:

LAST, FaST.

:ernato - CB

i DATE 1 TL1L.P. 4-F-$31

_ • BORAT.O.RTR.ESULT FOR2',,1

to tae Friva4.: of 1.974) • "'SE. • SSN:

E

4.S-10.S x 10'

4.7-6.1-:: 10 ;

Gift

Bill

1-(ct

Pi:

Lymph %

(Eceraz te4O-6 v),,,i4n nal Differential . .

voIo7,..y r t

RESUL RE.F, I t•:./,-■ RPR Nc,iliv-e

Mono itic-gaLivc Ncg3tiN-c • . ?y,U.crobioiozy

I NcV t i Yr- Sou ce

I Ncg Crra Stain OCC B [Z.1

14-18 g -1:1 N) 12-16 /,-11 (71 42-52% (M) 37-47/. (I-)

i 80-94 (1•,f) 81-99 11(F)

130500 x to vc-i fled 20.5-51.1% Bid

Sc,

PH

Prot

0.2-1.0

Micro Parasites

Malaria

O&P

Other

Atyp

HCG RBC Morph

NCgitia YC

Nc .:LL ivc

42-52% (M) 37.47% (F) . CSF lood az k •

ABO/Rh I Dircci igen Nes:Ai vc

osauLltioit Studies •,. • .• '• .

REF. RANGE

_ • Blood Bank Unit Crossmatch . -• ' • (NIUST,SUBNICET SF 5IS VVITH EVERY uNrr OF BLOOD . .

• . RE Q UF_ST. ED) UNIT Ti:PE

, Spun Ficoaa.toit

Scd Rate

Other

RESULT

\AF

9.8-13.6 sc-..z

21-34

<20 ugizra


Cell Count

-• - ro-scon IC URA 111

• .

I. ED? I

REPORTED B

TZST

7v-SC

RBC

MC V

<10 uLical

ACLU-RDI 1673 p.94

114 111111 BUN

C

s02

BEc,cf

An Gap

HCO3

TCO2

P02

PH

PCO2

Cl

TEST

Na

LAST, FIRST,

REsuiri

31/10/03 22:42 !,-f.A 138' REFERENCE RAN PATIENT #: IVER PANEL ISC LOT #:

OPER #: 678 S ERIAL #:

38-51'

12-17

0.7-1..

............. _0,7arl_, .................. ,L,')

bLU 160* 73-118 3 DL „ ..

71 26-84 U/L .1.gd BUN 12 7-22 MG/DL ALT 18 10 -47 T:Gii CRE 1.0 0.6-1.2 MG/DL AMY 35 14-97 U/L ,_j_____ 0K

P 279 39-380 U/L AST 26 11-38 U/L NA+ 127*- 128-145 MMOVL TBIL 0.4 0.2-1.6 MG/CL 2°'8' K+ 4.2 3.3-4.7 GGT 13 5-65 U/L ni-Ti, CL- 109* 98-108 MMOtL TP 4.6* 6.4-8.1 G/DL Ti7,11. tCO2 19 18-33 MMOL 8-2.6 1 INST QC: OK CHEM QC: OK

70-10 HEM 1+, LIP 0 , ICT 0

1.12-

(-2) - 11 U.

10-2(

I t8Z1 - 23.2; ALB 2.5 24-25 ALp 22-26 n-zg 95-91

9S-I L 2.31 D

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

0000100494 ;:o SERIAL #: 0000100681

MALE Ti

MET PATIENT

8

1.0 3153AA7 DISC LOT #:

3151M4

DR #: 000 .1. 1 OPER #: 678 DR #: 000 -

A TE

INST OC: OK CHEM QC: OK RE HEM 0 , LIP 1+, ICT 0

,VG/ 1--agk

g, (11

TR•I:

PICCOLO 31/10/03

22:43 NCE RANGE: MALE

CITENTISTRY RESULT FORAT Sub'cc! to the Privac y .At of 1.974'j

•

RE UES -sciN 7 L,

TEST

Tropcnin-

RESULT I- r..ng/d

LJ1 (7 eli (F

5,:unc

rarool:

ir::011

RE Lk1 :

REPORTED BY: I DATE:

LAB ID NO.:

MEDCOM - 22735

DOD-036311

ACLU-RDI 1673 p.95

DUI/ LfD

'4PC 33.1 H

31-10-03 22:40

Patient Limits

11 3.11L x 10' ,S/L 4,01) 6.00 HO 8. 9 L 9/I 110 'tict 29.1 L 35.0 6. rl TV '71S fL 8-0.0 99•9 NCH 20.6 pg 7.0 31.0 rat 30. L Elf& 33.0 37.0 Pif 761, 150. 450, Ln *L 20.5 51.1

2.7 * ).!)3,d.. 1.2 3.4


Patient ID Test ne :PT T Result:- 15.5 sec. Natio = 1.3 Calculated INR 1.47 Sample Type:citrated wh. blood Test Date :1001/03 Test Time :22:48 Card Lot :080201 Operator

IDPOIN[ COAG ANALYZER V4.54 SER 4005485 10/31/03 22:52

Patient 10: Test Name :APIT Test Result: = 10.0 sec. ***RESULT OUT Of RANGE*** Sample Type:citrdted wh. blood Test Date :10/31/4 Test Time :22:50 Card Lot -;-• Operator

MEDCOM - 22736

ACLU-RDI 1673 p.96


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.


•

DATE 90/36R 133 TIME OF ORDER

HOURS

LIST TIME ORDER

NOTED AND SIGN

14■ 4A j- 1C 2

C.- i"--4= s44 V3 .s 44 7` •

"rc . t :.-- ,te ki r .... Is.,....-L . NURSING UNI ROOM NO.

4 Lt. ---- 4 ' tt- 9 4-

A . I vtks--: .- > I. PAT I ENT.IDENTIF ICATION

:7\ f "y tt VO

C..., ." \

DATE OF OR trER flaTIME OF ORDER

D :,1---:- $4 12- E HOURS

1 V S • 1-**. .

S t .,%./.

m a_l s .—

T -14.--,.; 'TT ef — P .

%. 0

NURSING IT liN

4)/ Ol LIST

ROOM NC/

PO i

D NC

4 O' °I• PATIENT IDENTIFICATION

it 6 "2.

DATE OF OR TIME OF ORDER

4 ,vim -.3 I 6414;1 HOURS

(4- 4 z..;,vAir---- ?--

NURSING UNIT .

PATIENT IDENTIFIC DATE OF ORDER TIME OF ORDER

HOURS


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

MEDCOM - 22737

DOD-036313

ACLU-RDI 1673 p.97

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION ) For use of this form, see AR 40-407;

the proponent agency Is the Office of The Surgeon General. MCIAWir 2003

VERIFY BY IMTIALING ‘w.,4:g: - ;:e,;-,, ;x.Art*, - ?,, INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

ORDER ATE

CLERK/ NURSE

RECURRING ACTION, FREQUENCY, TIME

HR DATE COMPLETED

51 MIEWSPANIF2 9 VS 5 Co '4w-

.... I Z 1 - — -ACT: ,,elly rt-tDC121 (.0

I a J11111111111

IIIV I .

i ...

I' -pi, 0F,

...... _. :

CVO.

. .

ALLERGIES:

Q NM YES MI NO PRIMARY DIAGNOSIS:

_.-- MC vIATA,

__, . _-- 7 k/5 i n

ADDITIONAL PAGES IN USE: I/ YES En NO

PAGE NO'

PATIENT IDENTIFICATION:

)

MI

ACTION TIMES -

C-I USE PENCIL. CIRCLE ACTIQN . TIMES

D 8 ,9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07

DA FORM 4677, 1 OCT 78 MEDCOM - 22738 USAPA V1.00

DOD-036314

ACLU-RDI 1673 p.98

Verity by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo i i yr 2003

SINGLE ACTIONS Date to

be Done Time to be Done Time Done Initials

Order

Date Clerk Nurse

ei ,-411111 atlytk,' + , aut_ A-1-g/21-e- 1 Ncvlillr'c--' ̀:`'. "r\'?" -'''Q

(4) - c

Order/ Expl r Date

Clerk/ Nurse

PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

— — — — — — — —

USAPA V1.00

MEDCOM - 22739

DOD-036315

ACLU-RDI 1673 p.99

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)

For use of this form, see AR 40407; the proponent agency is the Office of The Surgeon General. Yr. Z

VERIFY RY INITIALING

INITIAL PROPER COLUMN FOLLOWING EACH ADMI ISTRAT7ON

ORDER DATE

CLERK/ NURSE

RECURRING MEDICATIONS, DOSE, FREQUENCY

HR 1 DATE DISPENSED

j. 3 1 s' IT7 (7/ / /0 .. ..),__1 1 \) ' a- •...... ,

- • fr,....

A-11 C-17 . / 'DU' r

_ .

. .

. ALL ERG! ES- 11 y E VG\:14 0

Wo--A PRIMARY DIAGNOSI St ■ ,

-- va,--im, ,(2.-_-_ -717 i 5 h , ADDITIONAL PAGES IN USE: AYES E=I NO

PAGE NO PATIENT !DENTIFICATION:

DISPENSING TIMES

- USE PENCIL. CIRCLE MED TIMES

d\-\ IOW D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

D A I FF17349 4678

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 22740

DOD-036316

ACLU-RDI 1673 p.100

Verify by Initialing

. THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) M 21eAl r. 03

Order Dote

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES

Dote to be Given be

Time to Given Time Given Initials

Order/ Explr Date

Clerk/ Nurse

PRN MEDICATION, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED 0 ilJou ./ 3-0.) 11-1- 3 4_q4 -totp_vi 0 rt .

lAh

-1----

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

MEDCOM - 22741

DOD-036317

ACLU-RDI 1673 p.101

Sex:

M

F

II Dr. license nOther (specify)

Mobile

Regular

Phone# :

DOB D/M/Y:

ao

Phoned:

DO3 D/M/Y: Mobile

E Regular

Sex:

M

Or. license EOther (specify)

0

COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION

:1E3Cdiense ecirfst Ckrilin(41chect-c...Oneljt Other :then de11 :,.: 1 ' .: 1•: -

I' -." (?it.".1.(1.:17.-C1:''1):::::!:'.::::::1'E:-::::::: :: ' :::•;,.:.•. . -: .r.... 1 CtL141cY:c'ff3usl'br'''zkIng (EPC 428)

f.H.: -. ,:..4cifi t F f. Oi&tt tlii,i&i.iii.ith:4) ct.P.c.:*) ..,,. 1::::::.:. ' ::.. i.lpsorii;oivc...XTrni:ir#cOrig. -F,.$03:i.C.; 4.30

14 ...,.EDR.44.i.1S•Otiai:A..;eilii.,..cs•O:sF'..q-..rrEcs.1„:"40): :', .:- ' '" :, ;:t.*Pitj(i.p.'g'; ■4391

... .... ''' .. -. . 1---1 il)iii,4*663f Pr;perty.:(L -,0.c: .F.r.p ..

,, iiiii, .4-;:f44..:igiA:13,=40 ii01,,i .ni T. Km:of.c;:.:i19); I "

I6Estr-6ci.tliiii I: P.1411c i-lciall......:*01&cdrii..0.6.:.i.si.) i,....:F. !'4`10 !': ,..:..... ••• . . ... . .......

5.04.'.'!Osi: :P;Fil0:1 ........... s.,ii :: .;, ......' : ..... .. 1...:.:.::.:Aciscriaming Firearm). Exprosiv ,kul:Cityrrpvinivillasi■. (I.P.c.. :495) : :::

1..,.--::.-.%i:fikitir.lEirqadiiir.PeziicriILPC.. 495(3) y::: • :.

1::::P44011;14 :1). - : ;!.;:.1 .1..

1:::1041iiiiP: '.. ili. : . 6411.i1 -3:ii...Fdipe ..t0ifik:*.i..4 :lif: :•!.(”.h0e.;:- r.ti:eii,4et.e*. ...„..........• •••••••.:, ,_•• •••• . ..... . ...:•.,.......• • ....•.: . ... ... . .. ......... ............ .... "". ....-• ..- .. - ...

.... ... . . ‘......... . • .... .,....... 3:,i..iosoi4T..Allli.t:srylnitallatt0e: of F.salty ._

. ... . .. ..

Vii;,...e;l:C.i.i.:04::.*:::: '.',.::: . ::::::''::::::::-;.::'• ...... .......

i ii■Xf--ci'ilsaposl 1 - . ::•:,,,AF*./ogr-sphingtSurveitErigi.Aile:iri.Iiitalt4iir ■ of FacitAy

Ot4try,19*ii:j?.. ■*m:iiiCit . o.f. Miiniiriiil l isk::: :'

'!# i....;.9#101 *.s.'.400.:',': '

i*--;f:O§410;:,4,:iik::. difE:OF ,:::.: .

ib.04.0::P 11. Date of Report. (D/M/Y)

0

Time of Report:

c.a/St hrs

ey..qOnnected Victirn:.. Witness

Fittk.N14rri Hair Color:

Eye-Color:

Address:

Place of Birth:

Ethn/Tribe/

Sect:

LiPassport

Document

Make:-.: . ColOr.

Model: Tyoe:

Year :- .. Names of Peo le

Contrabaft&Weapons. in Vehicle: . .

II

Quart',

•

Given; Name:

Hair Color:

t.Jumber Of Peo

Photo Taken of Suspect with Weapon/Ccntraband: Yes/ No

Color/Caliber Receipt Provided to Owner: Yes/ No

Owner

Email, Phone, .or Contact Info:

Suparviskig Calie•es !.iarrxx

Property/Contraband

Serial No.:

Other Details:

Na-mect Assistirrg Interprete.r; •

NCieribOs.Of:P&setri:InVolveci:.- illtinarrieqvdentir

Vehicle Num r ................. . ..

. . .. . . . .

Plate In Vehicle: ,

attoos/Deformities:

Weight: lb Height in Eye -Color:

Address:

Place of Birth:

Ethn/Tribe/

Sect:

Passport

Document #:

inq in fa•'on reverse under "Addtonal.Helpfut;tnformationl

Scars/Tattoos/De formities:

Weight lb Height: En

Weapon

Model: Make:

Where Found:

::•--Cahr.ning.sok:946:Namo ••

Last, First tI . •

Last First Mi.

Signature:

Unit PhOce: bate

Un:t Ph.cne':

MEDCOM - 22742

DOD-036318

ACLU-RDI 1673 p.102

..... .

Who witnessed this person being detained or th e reason for detention. Give names contact numbers addresses; ..

. . :

How was this person traveling (car, bus, on foot)?

Who was with this person?

kljfiat: Weappgs:,.?oirasithis::persclni.ca rrY1

What contraband was this.'person carrying?'

What other weapons were seized?

What other information did you get from this person? r

Additional Helpful Information:

MEDCOM - 22743

•

COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM

Why was this Dersbn:detaine(? .1)7F 6:Tt.dry)-5 (;),:x2S:

r

DOD-036319

ACLU-RDI 1673 p.103

Automated Facsimile - DA FORM 364

Automated Facsimile livrATIENT TREATMENT RECORD G._ 402 SHEET For use of this form, see AR 40-400, the proponent agency is•OTSG

1. Re ister N r 2. Name 3. Grade FGN

Admission Remarks

•

4. Sex M

0 Age 19Y CG1

6. Race ) X (._(

7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP

20 12. SSN 13. Organization 14. Ward

ICW1

15. FlyStatus

N/A 17. Dept / Ben

K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case

BC


Direct from ER 22. Hour Of Adm:

21:51 23. Clinic Service AAA - INTERNAL MEDICINE

24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH

26. Date of Disp

2003-11-09

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:

2003-10-31

AdmittingOfficer:

MEW (LA) _. 32. Units Blood Components 29. ReportingMTF

0580 30. Date Ina Adm

2003-10-31

31. Selected Administrative Data

Marital Status: DoB: 1984-01-01

In/Out Patient: Inpatient MOS:

33. Cause Of Injury:

34. Diagnosis / Operations and Special Procedures:

FRAGMENT WNDS L THIGH . DY - -

Rot . 21

CS 610 ' 1 . . . V' -2-9

Cc.lk 1,1 •

35. Total Days This Facility

Absent Sick Days 0

Other Days (,) ConLv / Coop Care Days

0 Supplemental Care

c, Bed Days

/ 0 Total Sick Days

) 0 35. Total Days Thil Facility

Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days I Total Sick Days

Signature of Attending Medical Officer

_ _

Signature of P • " .

C--- `1 MEDCOM - 227441

MO-

DOD-036320

ACLU-RDI 1673 p.104

r. Automated Facsimile

INPATIENT TREATMENT RECORD CO, _R SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

1. Register Nbr 2. Name

NoFirstNameGiven 3. Grade

FGN Admission Remarks

' 4. Sex

M

5. Age

fj__ t.,,t

6. Race

X 7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP

99 12. S4I 13. Organization 14. Ward

ICU2

15. FlyStatus

N/A 17. Dept / Ben

K78-PRISONER OF WAR/INTER 18. BranchCorps 19. UIC / ZIP 20. Type Case

DIS


Direct from ER 22. Hour Of Adm:

07:30 23. Clinic Service AAJ - NEUROLOGY

24. Name/Relation of Emergency Addressee 25. Type Disp TRF C-ACF

26. Date of Disp

2003-12-09 27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: -.

2003-11-01 Admitt ngOfficer:

III O'')(G)--Z_ 29. VeportingMTF

8580 C6-)(Z) -7--

30. Date !nit Adm

2003-11-01 32. Units Blood Components


Marital Status: DoB:




HEAD TRAMA


Absent Sick Days

0 35. Total Days This

Other Days

0 Facility

ConLv / Coop Care Days

0 Supplemental Care

0 Bed Days

go Total Sick Days

1 0 Absent 90 Days Other Day Coop Care Days

0 Me

Supplemental Care

0 Signature of PAD or Medical

Bed Days

40 Records

Total Sick Days

4O Officer .

Signature of Attending

- • ---- -

Automated Facsimile - DA FO 79

MEDCOM - 22745

r

DOD-036321

ACLU-RDI 1673 p.105

Automated Facsithile

INPATIENT TREATMENT RECORD cc SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

1. Register Nbr 2. e .

NoFirstNameGiven

3. Grade

FGN Admission Remarks

4. Sex

M (9(6)--

5. Age /

9 6. Race

X

7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP

99

\

12. SSN \ 13. Organization 14. Ward

ICU2

15. FlyStatus

N/A

17. Dept / Ben

K78-PRISONER OF WAR/INTER

18. BranchCorps 19. UIC / ZIP 20. Type Case

DIS


Direct from ER

22. Hour Of Adm:

07:30

23. Clinic Service

AAJ - NEUROLOGY

24. Name/Relation of Emergency Addressee 25. Type Disp

TRF C-ACF

26. Date of Disp

2003-12-09

27a. Address of Emergency Addressee

1--

27b. Telephone No 28. Date This Adm:

2003-11-01

Admitt ngOfficer:

ille (,) (.C)--Z+

29. ReportingMTF

(6)(1);?

30. Date !nit Adm

2003-11-01

32. Units Blood Components


Marital Status: DoB:




HEAD TRAMA

S.sa .3 0 qq• .2 7 )1 e7. q4

S;>0.0 I 3•

33 i . 3

1-/ 8..2 . / C •


Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days


Absent Sick Days Other v / Coop Care Days Supplemental Care Bed Days Total Sick Days

Signature of Attending 04(),.._a Signatur., o fficer ---I

11 Arrst--.R ll nn, A,

Automated Facsimile - DA FOR 1 364

DOD-036322

ACLU-RDI 1673 p.106


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. I WARD NO.

MEDCOM - 22747

PROGRESS NOTES

Medical Record

STANDARD FORM 509 (REV. 7-91) Prescribed by GS/VICMR. FIRMR 141

CFR/ USAPPC V1.00

DOD-036323

ACLU-RDI 1673 p.107

AUTHORIZE° FOR LOCAL REFHOOMION

POOGRESS NOTES

DATE NOTES ,

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11011 MEDCOM - 22748

NQ- `1

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DOD-036324

ACLU-RDI 1673 p.108

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MEDCOM - 22749

DOD-036325

ACLU-RDI 1673 p.109


DATE NOTES

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ID No Of SSN; Sex: Date of Birth: Rankgradel

LAST

SPONSOR'S NAME

REGISTER NO. WARD NG

1110 MEDCOM - 22750


STANDARD FORM 5D9 MEV. E

P7asuibeti by GSAIICMR FPMR i41CFRI 01-1110:

LIEAN

DOD-036326

ACLU-RDI 1673 p.110

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MEDCOM - 22751

DOD-036327

ACLU-RDI 1673 p.111

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NOTES

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MEDCOM - 22752

DOD-036328

ACLU-RDI 1673 p.112

i kceOLE ;N;l:AL NUMBER FIR.7.1 NAME

NOTES DATE

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MEDCOM - 22753

6115 c'TANDAP.D I

DOD-036329

ACLU-RDI 1673 p.113


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MEDCOM - 22754

UTPORIZEO FOR LOCM. REP1i ,JOUCE:ON

DOD-036330

ACLU-RDI 1673 p.114

MiODLE ID NUMBER FIR5 1 NAME ;4 M.

NOTES DATE

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MEDCOM - 22755

DOD-036331

11,17/. ,i,f/A/z

ACLU-RDI 1673 p.115

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MEDCOM - 22756

DOD-036332

ACLU-RDI 1673 p.116

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MEDCOM - 22757

DOD-036333

ACLU-RDI 1673 p.117



DATE NOTES

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STANDARD FORM 509 (AID/. 5;1990 P•e:5cr:oe5 tr; GSA,ICNIR FPN1R;41CFP.) 101-11.203!blI1G

USAPA' 1 .00

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WARD NO.

MEDCOM - 22758

DOD-036334

ACLU-RDI 1673 p.118

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MEDCOM - 22759

Isi

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DOD-036335

ACLU-RDI 1673 p.119

----------- - EDIC.AL RECORD PROGRESS NOTES

D r E DTES

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-.a51c),: pvAn -0IYEN-12 Ilt-kfuttrit vsAkt0A - USAP A VI .00

MEDCOM - 22777

n

DOD-036353

ACLU-RDI 1673 p.137

AUTHORIZED FDR LOCAL REPRODUCTION

`MEDICAL RECORD

PROGRESS . NOTES

" DATE — ... . .. . . ... _ NOTES - ,

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-

.SPONSOR'S NAME SPONSORS ID NUMBER ISSN gr &kr) LAST RRST

.DEPARTJSERVICE i HOSPITAL DR MEDICAL FACILITY RECORDS MAINTAINED AT

PATENT'S JIDENTIRCATIM /Far tiped re wines orbits, plc Esme-, as4 firn nth* .1D • No or ZVI; Se. c Dots &Milt Rankaidel

RESISTER ND. I WARD NO.


STANDARD FORM 509 REV. snow Prosaisd by.SSARCMR FPMR 141M:11)101-1 unwital

USAPA VEIN

MEDCOM - 22778

DOD-036354

ACLU-RDI 1673 p.138

14, JAI., o-i ot p cc - *0-5, 3.

140

IMAM V1.00

LAST NAME FIRST MAME MIDDLE IMMAL ID NUMBER

DATE NOTES

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STANDARD FORM 509 wit

MEDCOM - 22779

DOD-036355

ACLU-RDI 1673 p.139

DOD-036356

(40 REGISTER NO.

,. kc(

WARD NO.


DATE f5 1 /142,k..-*..teu.-t NOT& ct,tee .c.,_ /wiz_

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-------....._

SPONSOR'S NAME litd 144,-e_. i43 SPONSOR'S ID NUMBER , LAST FIRST SSN or Other/

.s.,..—.424--- HOSPITAL OR MEDICAL FACILITY

PATIENT'S IDENTIFICATION: IF°, typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; Date of Birth; Rank/Gradel

4111, cqN)-ti, MEDCOM - 22780



STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(10)

USAPA V7.00

ACLU-RDI 1673 p.140


DATE NOTES

ra,k,..,-3 , 69. P1 /7.44„ A2.4. .-pi,k,y

( ih,,,......4. g-,- _Aja, 2 ,14/ 41, .,,;("0x-,c6rai

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(VC) ?

/

1-1)1

STANDARD FORM 509 (REV. 5/1999) BACK USAPA V1.00 -

MEDCOM - 22781

DOD-036357

ACLU-RDI 1673 p.141


MEDICAL RECORD

PROGRESS NOTES

DATE NOTES

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t_,,,:-1 ..-S-t-Ce rt,J1-\

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

ISSN or Other) LAST FIRST MI

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

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

REGISTER NO. I WARD NO.

1111 (q(eo MEDCOM - 22782


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

USAPA V1.00

DOD-036358

ACLU-RDI 1673 p.142

"IlSAPA V2.00 •

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6.97) Prescribed by GSAIICMR FIRMA (41 CFR) 201-9.202.1

MEDCOM - 22783


CHRONOLOGICAL RECORD OF MEDICAL CARE

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

& ievtf'D - ard F cx±e, $g - 410li _..iv _ ,_-.',_

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STATUS DEPARTJSER VICE . RECORDS MAINTAINED AT

SPONSOR'S NAME SSNIID NO. ' • RELATIONSHIP TO SPONSOR

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name • last, first, middle; JO No or SSN; Se • Date of Birth. flank/Grade,) REGISTER NO. WARD NO.

1C0-

MEDICAL RECORD I

DOD-036359

ACLU-RDI 1673 p.143

SKIN AND WOUND ASSESSMENT MEDICAL RECORD PROGRESS NOTES

Admission Date:,-3,n na133 Diagnosis:

2

ci-ixt

(15U.) 14-fdkci, 5 TAB HD: a POD: .2 7 // y- t 1. 5 -411144-4:4 )

(See Braden Evaluation Table for Details)

Mobility No limitations 4 Slightly limited 3 Very limited Completely immobile

Braden Scale Evaluation

Sensory No impairment 4 Perception Slightly limited 3

Very limited Q Completed t

Moisture Rarely moist 4 Occasionally moist Moist Constantly moist I

3 Nutrition Excellent 4

Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor

Activity Walks frequently 4 Walks occasionally 3 Chairfast 2 Bedfast CD

Friction and No apparent problem 3 Shear Potential problems _CI)

Problems I

Add the total score

Above 20 Low Risk Between 16 and 20 Medium Risk Between I 1 and 15 High Risk Below 10 Very High Risk

Note: A Braden Scale Score of less than or equal

Total Score ,' (-D 1°

to 15 indicates HIGH RISK -Requires immediate Ulcer prevention program.

Surgical wound (s): Yes No Location: Size: Drainage: Tubes: Appearance: Dressing change:

Pressure Ulcer (s): Yes No Stage I, Il, III, IV-(Circle the one that applies and

1 Location:

_ •

describe below) 2 L\ 4 (,,) - -Z -

- - Wound character: Pint Moist Dry .n n tissue Yellow slough Odor Purulent discharge Es r

1

Exudates :: 11P'

Type of dressing change: Wet-to-dry Co . - el . , sing Carrasyn V-Gel Alginate f

Physician notified/consulted for wound • - • / ilemen CNS notified/consulted for Stage Il and G -ater: Nutrition Referral: Yes N.

es No es No

- Physical Therapy Referral: Yes I No - i Action Taken: Date & Time:

REGISTER NO. [ WARD NO.

Patient's Identification (For typed or written entries give: Name-last, first, middle:

Grade: rank: hospital or medical facilithy)

PROGRESS NOTES

Medical Record ST.kNDARD FORM 509

r.

MEDCOM - 22784

DOD-036360

ACLU-RDI 1673 p.144

dical Record Progress Notes Wound and Skin Assessment

Date and Time 2S WAS i 4-3 (3 Wound number A Stage l-f V lu / 64-- Location a) 51tou 14..et.-- Shape D61614 Measurements ja (0,4j ,.1( f, au w x . . “ ta 0 Tissue Color • . 4. yt Drains and Type se ,,, -0: afrA Dv-Dr.linage (amt and color) 0 e : Dressing Type t . ) .. ) -e 4- -4 aky Dressing Change Frequency -r,(0 Wound Cleansing. /j 6 Additional Info (turning, elevation -ofextremeties, etc.) -e $ur 42 +-4 i)-ri y4-h' wouyg -4146rdy/f( 7- K1 /1044— a k y c 5-fieri if y (.1 L.) ? P , y'a-et 47 6.:::7S.e tio. is-X (4 n .-tanuke I; 14 DT (0ficlei-stii* up',/,' avl t4u3=t , orev ars e , 4, 5-e c.-- c7- Uire -to.p-e . Date arfd Time zt. Any, /4e Wound number ' A< Stage I-IV j\1 /14- - Surgical or._ A rApx-e ( Locations L_LQd_Rj c,...— Shape Dill 61,4za

_14 Date and Time 2 q 1̀ 361163 i / 4636 Wound number ___Ak40 .a..

•: Stage I-IV t1/4) 1 It- - Stirgical or . -orr------1.---gica LI Locatibn (i›) 5- 441, Shape D k, )„ A&: Measurements 3 L iti /x i. 5 ca., i4-1. K 5 c.)etc ec.4 ( ?i ssue Color pc ilk i wilts-I— Drains and Type ietiAe..: • Drainage (amt and color) filf Ova a ►e- Dr::ssini2 Type (-01.14 .c ( Drssing Change Frequency Q c---7 t., Wound Cleansing ("lea a i. S _c , past . c_ ..v.:,-1. Honal Info (turninP. elevation or extr

met s, etc.) ;i

P a c rr_ ID: IY

k(,-1-, Unit No.

Standard Form 509

MEDCOM - 22785

or Non-Surgical Av !AAA

x Measurements A (44 L X 3 CriA. IAJ X I C_41) Tissue Color e ; vlirlf 14A6 i 5 -

Drains and Type Drainage (amt and color) 125. Oor . / 140 ..0 v401.-- by A e ctrovi-tvz_ 41`53 a •(' Dressing Type %.,4->41+:4- - vVir '--1 . _ Dressing Change Frequency ----7 I [. D Wound Cleansing 5.e 214AP a. 5 et 10 a Oe Additional Info (turning, elevation of extremeties, etc.)

g eat t!L%—

d_tr / Cci e

DOD-036361

ACLU-RDI 1673 p.145

Medical Record Progress Notes Wound and Skin Assessment

Lf- Date and Time '1 A)61/ 03, If? 6 Stage I-IV / Surgical Location yl,L ; 4 Shape n to t b i4b. Tissue Color Drains and Type Drainage (amt and color) Dressing Type Ll e O.. v-

—Dressing Change Frequency Additional Info (turning elev

a 4-0\ t.i i &is LW y •

Wound number or No

2 (144 x c , rev (

<4{/.4.4 P rks fire ui a US

Measurements U- -

0 la S ;

y---? d c,..6. Wound Cleansing ation of extrefneties,. etc.) LtP e

Date and Time Stage I-IV Location Shape Tissue Color

Wound number

•Surgical or Non-Surgical

Measurements

Drains and Type Drainage (amt and color) Dressing Type Dressing Change Frequency Wound Cleansing Additional Info (turning, elevation of ext:i -emeties, etc.)

Date and Time Wound number Stage I-IV Surgical or Non-Surgical Location Shape Measurements Tissue Color Drains and Type Drainage (amt and color) Dressing. Type Dressing Change Frequency Wound Cleansing_ Additional Info (turning. elevation'of extremeties, etc.)

Patient ID: Unit No. Standard Form 509

MEDCOM - 22786

DOD-036362

ACLU-RDI 1673 p.146

PLAN OF CARE FOR SKIN BREAKDOWN AND MEDICAL RECORD

w t- it..eei,( PROGRESS NOTES

Admission Date: 411 p447— Diagnosis HD: -2C( POD: 2 7//! /4

Dateg 1-bliai Time: RN Signature: 1+7 4f.*`-' Skin breakdown as evidence by immobility, friction, und, skin tear.

K .f iArx.clux it.r I

Wound type: Surgical wound (s) Location(V)514 ou - .s Siz ("It'° Drainage: Diabetic ulcer Tubes: 14 IC ` PiPins:7.:-.) Ati5PFala Va. ire: 14,(6156 0 Venous stasi,s-alcer Dressing change: —n 0 m lc-14.x tc.4.- • at.- orc Other 1,-- Describe _Sh vs,—si ct.4...( tArai-e-4.01_

Burn wound (s): % BSA Partial Full Location: Size Appearance: Dressing change:

Pressure Ulcer (s): Stage I, II, III, IV (Circle the one that applies and describe below)

Location: C) 5 litzd ike- Size: 3 Wound character: Pink 1"---Moist 1,./Dry Granulation tis ue ✓...---- Yellow slough

Tunneling clUndermining Odorpc Purulent discharge Eschar Exi.Es/e.

Refer to SOP for Dressing Change Instrucitons.

Please check the appropriate dressing Change:

LOCut,6 X Wet to Dry Dressing k

a .3-- ❑ Carrasyn-V GelDressing

❑ Alginate Dressing

4 Comfeel Dressing 4 3 csp-Szi-e ak Lf ❑ Pin Site Care

❑ J-Tube Care

❑ Colostomy Care

❑ Chest Tube Care

❑ Burn Care

NOTE: Document daily wound and dressing change on,Progress Note or

Mote.

Select the appropriate products used:

lia"§terile 4x4 gauze dressing ❑ Sterile 2x2 gauze dressing Er -§i-erile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage 12--gfeTile Normal Saline ❑ Sterile Water ❑ 8 x 4 Sponge gauze E:1-0p-site ❑ Tegaderm clear dressing ❑ Alkare skin prep El--Co—mfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel ❑ Alginate ❑ Bacitracin ❑ Silvadene Cream

itNursing

❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film

if3--STE-ile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ 0.125% Dakins so! ❑ Betadine Swab sticks ❑ I/2 Hydrogen Peroxide & V2

Sterile Normal Saline

Select the frequency of dressing changer t.

❑ b.i.d. ---t.i.d

MD Signature and Date:

()\ ---?—

4.,1'uda.-tt

Patient's Identification (For typed or Written entries give: Name-last, first, middle:

Grade; rank; hospital or medical facility) /Medical Record, SF 509

A AIM (6)'l

41/4A" WNW MEDCOM - 22787

DOD-036363 ACLU-RDI 1673 p.147

Date.: - Sensory Perception

Moisture

ACtiylry

No Irnoairrnen t

Sliuhtly Limited 3

Very Limited /

Completely Impaired 1 4

Rarely Moist .

Occasionally Moist 3 '

Moist 1 ' _

Constai-itly Moist 1_

Walks Frequently 4

Walks Occasionally 3

Chairfast 1 Bedfast

Low. Risk Med sk

4

1

No Limitations 1 ,

Slightly Limited 3

Very Limited /

Completely Immobile 1 4

Excellent Adequate (Eats >50% )

3

Adequa,:e. (rarely eats) 2

Very Poor I No Apparent Problem, 3 Potential Problem

1 _ 1

Proble.ms

Mobility

Nutrition

Friction and •

Shear

ical Record

Progress Notes

Braden Scale Evaluation

) ‘.5 3

:Notobilit‘

Very Limited Slit_11-

,:;.\• Limited

Con-,,,-,,letely Impaired 1

Occasionally Moist Rarely Moist

Moist Constantly Moist \oValks Frequently.

4

Walks Occasionally 3 1

) Chairfast Bedfast.

Low Risk Med Risk 1-iia"n Risk Verb High Risk

No Limitations Slic_htic Limited • 3

Very Limited Completely Imnto'oil.E.,

Adequate (Eats >50%) Aclequate (rarereats)

Very Poor No Apparent Pro'olen

potential Problem Problems

Total Score: .Score <15 requires Immediate Ulcer Prevention Program

Total Score:

Score <15 Immediate.

C1cer vention Proarani Pre

Cnit: No. Standarc.iForm 50'9

Nutrition

Friction and

Shear

Date: Sensory Perception

Ntoisture

Activity

Above 20 16-19 11-15 Below 10

MEDCOM - 22788

DOD-036364

ACLU-RDI 1673 p.148

iviclill,AAL ritLAJIILJ - VA! ItN I ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5

SECTION I - PATIENT ASSESSMENT DATE: I i 925 .(4-3 I PATIENT ACUITY LEVEL : ...Ur POST-OP DAY: ,g7.. iy HOSPITAL DAY:

T R A N

S

F

E R

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN ET To :-. C.CA-3-t/Q From T.C. U 31 c•• Time

- TELEPHONE REPORT:

II I AMBULATORY CRUTCHES I

Total ER/RR/PACU time Physician e,..../•-•' WHEELCHAIR I STRETCHER

Anesthesia (Specify): Procedure/Diagnosis 5- Z aip 110/G I P 110-120 33. pp R T i

--bro.c.41_, LOC 5), s ,., er Neurovascular

checks Dressing/cast SuitrreS -11C2. IneCitCP , Tubes Vn, IC4 CO:4140 Intake (IV, po) AO t gh(2114 Output (EBL, other) (9(C)--L./ 10 I Voided No Yes Amount: -

. Medication .95 /1/46 Z PO tCQ ka5 . , 'CIA iMs- ci-‘n r. i c 1 rikl--; 10 cc i 1 cAA .e coon+ Other 6-5- Us) 40 krtic g : mecrief pw -ctLis'I-s C) 51 Report From CPr

Received By LT AIIIII.6-111/1111110

T A L

S

I G

S

TIME: dig - \............ ______----- BP ARTERIAL LINE ........--•-••-•

(TM PIXA V 1°) lie BP CUFF

TEMPERATURE 9) 7 ) l.1 30

,,...."....

476 11 3 2-1_,

(15 '•,n

CM'S/ PULSE

RESPIRATORY RATE

OXYGEN (L/%)

PULSE OXIMETER CH- W. PI CI 02 METHOD 91% i2-t f797

N fith

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar mask

, ,

CI- < - Z

TIME: Oa y 702y. a 156

p E

I

L

E E D S

TIME: (9a5"

PAIN INTENSITY

10

•. • • •

. . • •

'Skin breakdown prevention

' Falls prevention protocol

'Restraint protocol

'Seizure precautions

' Isolation precautions

0 . .

___O_________/4

• • ' • . .

„L./

• •

. .

•

tA

• • • • . . . .

MED ADMINISTERED IYINI

RELIEF ACCEPTABLE IY/N)

ikt

/V14-

.._ ._.._

O TIME:

T FINGER STICK GLUCOSE

— _ ... ...

YESTERDAY'S WEIGHT: H INSULIN (Y/NI

TODAY'S WEIGHT: 1. E WEIGHT CHA R

'Per hospitil policy.

24 HOUR TOTALS

PO IV #1

.

IV #2 TOTAL IN Urine

211C0 Stool TOTAL OUT ,.


.

40 —C1 EPwlat C DIAGNOSIS: sha Crania / DAG: ADMISSION ATE: /6/ 3 1/9-3 — LOS: EXPECTED. R E SE:

CASE MANAGER: . t- C._ PRIMARY CARE MANAGER:

MEDCOM - 22789 EOUIRED (Specify :

4r,

DOD-036365

ACLU-RDI 1673 p.149

SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS

DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criterip are explanation of abnormal findings will be noted in the appropriate column.

TIME: 16ve, INITIALS: TIME: INITIALS: TIME:c5915 6 .,

time place and name. Responds appropriately. • Communication is adequate to express needs.

Pupils equal and reactive to light.

1. NEUROLOGICAL: Alert and oriented to I I AL-c-g-r II k leir--k-

within range for age. No dependent edema. ,,..c::, Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

2. CARDIOVASCULAR: Pulse regular & rate I 7:14tc-H F cilrfe-- E 1---1 I I

regular. No cough. No abnormal breath sounds.

3. PULMONARY: Respirations within normal I 774-clag•Pa-4C e 35-. 1 I I-1- fl 0_...,.. rate for age group; quiet and regular. Depth, is 1724.c..)..1 -6---,. bt41.4„i3),,qc„0 -rr .c., RR • h. VI vitc\-ed, ob. ,,.•

4. G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding. ,

I A

urgency, frequency, nocturia. Urine clear, 5. G.U.: Reports no dysuria, retention, I I V. +0 criA.4 1 yellow/amber. No unusual discharge. Qt RI td ' ■

development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

6. MUSCULOSKELETAL: Normal muscle I 1 i., /2.e9o, 're, Cl) 5,Dt_ i 1 - 1-1 go oiLstd.

No redness, blanching, irritation over bony j.,4c. 7-.:::.p,5T t.-f.._ prominences. Mucous membranes moist. Crr-A

7. SKIN: Warm, dry, intact. Good turgor. No I 1ScA-c-P C.-,9c-Tc'CSIOL I-1 1 Isecap kotit,, -fiz.s51 rashes, inflimmation, ulcers, breaks in skin. DsCs-ro ..., gsiez,Loia_icar

• .1;1-PLA°`-

8. PAIN: No complaints of pain/ discomfort. R07---Of/l,Ii-5 (See page 1 for documenting pain intensity.)

and appropriate to situation: Interacts appropriately with others.

9. PSYCHOSOCIAL: Behavior is appropriate I Prirp-**44-0 lmiliS1-1- I I I to to the situation. Anxiety is controlled or mild 72, SPe..4K,

10. IV SITE ASSESSMENT: (LEG • P Puffy I - Infiltrated R - Reddened OK - No swelling/redne s * - Central line) VICT9 TIME: INITIALS: TIME: INITIALS: TIME:c9 ( frb0 INITIALS

IV patency ✓ q 5 let IV patency I q hr: IV patency ✓ q %--- hr: p IV site care provided: 05s£55 IV site care provided: IV site care provided: 1A6g,e4SSRci IV tubing changed: IV tubing changed: IV tubing changed:

LOCATION • CONDITION • ATION CONDITION LOCATION CONDITION. IV Site #1: •02.012-1S-1' b K IV Site #1: IV Site #1: cDc•A OL_ IV Site #2: IV Site #2- IV Site #2: __

Comments: 03-4}5 ,...-2,or e,154.-- Co • Tents: Comments:

claskQA .1-1-T)__a

MEDCOM 22790 mplIrnm Fr)RM AR4.17 riTc7 -) (MCHOI MAR 99 Page 2 of 4 pages

DOD-036366

ACLU-RDI 1673 p.150

SECTION III - PATIENT INTERVENTIONS & TEACHING

N E

U

R

V

A, ✓

Si:

C

U

L

A R

SITE: TIME: r 1 cpc)

A F E

Y

T H

E R

TIME: (100 4%

COLOR P I \

S ID band visible/legible

CAPILLARY REFILL Orient to environment prn

Side rails (2/4) up

1111i TEMPERATURE (4. Al

ME 0 EDEMA •

Bed position low

SENSATION S Call light within reach

MOTION 2--CO Review & post lab results

IP la

'I PASSIVE FLEXION c: -- •N

PERIPHERAL PULSE . Notify MD abnormal labs

LEGEND

I

Plelli

I Ne-713 MO

Color: P-pink (normal); C-cyanotic; W-pale, white

Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-1> 5 secs)

Temperature: C-cool; W-warm; H-hot

Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting

Sensation: A-absent; N-numb; T-tingling; S-sensation (present)

Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM

Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Peripher .al Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable

Tum /reposition

Incontinent urine/stool

Linen change prn

Tu/reposition q2h

ROM q2h if immobile

Antiembolic hose IP'

o

W I-- 1

BREAKFAST LUNCH DINNER

TYPE: T YPE A ___C,,/-/ 50.1=-7- TYPE: 4A( ut ce:477-- PERCENT CONS ' • I; PERCENT CONSUMED: 1-165(--Z. PERCENT CONSUMED: 6C.., •

HOW Ti •ATED: HOW TOLERATED: LoLt- c_ HOW TOLERATED: /..,;E_ l_ (--.

il SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST V COMPLETE ❑ SELF ❑ ASSIST peCOMPLETE

A

D

L

S

T E. A C H

N G

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE CD SELF ❑ COMPLETE

5Y ASSIST ❑ TOTAL

❑ SELF J2I COMPLETE

❑ ASSIST ❑ TOTAL

El SELF '54 COMPLETE


TYPE OF ACTIVITY (Circle all that apply)

i .._ ❑ SELF ❑ SELF

AMBULATE CI ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

- Ff-----)7ThiE, ❑ SELF

AMBULATE !A ASSIST

BSC # TIMES/SHIFT

BRP

AMBULATE ❑ ASSIST

BSC

BRP # TIMES/SHIFT

'•.

CHAIR r (:1-IA

INITIALS: TIME: I/C-AD INITIALS: /..., TIME: INITIALS: TIME:

CONTENT: l'ec0,6 Ow Punt 0 (Frs ,c) ak-57/241-7-5

•ktsi-29/Air Pwrero )

ypatient,Fami, Verbalizes Understanding

CONTENT:

Prdi Patient/Family Verbalizes Understanding

CONTENT:

❑ Patient/Family Verbalizes Understanding PATIENT. IDENTIFICATION

()V)

C.9(6)--L1

INITIALS SI GNATURE SHIFT

ea-14 6 -1 )

i t w 'I ii%

-R ( CHO) MAR 99 Page 3 of 4 pages

MEDCOM - 22791

DOD-036367

ACLU-RDI 1673 p.151

SECTION III - INTERVENTIONS & TEACHING (Coat)

W

0 U N

A R

T

I M E

LOCATION OF WOUND APPEARANCE TREATMENTS

AND DRESSING CHANGE

---, Or

2( --D .s \A.Ci A dIii (g) `S\A0.0\69-► -

C

E'

SECTION IV - NOTES

•

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 4 of 4 pages

MEDCOM - 22792

DOD-036368

ACLU-RDI 1673 p.152

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40-5

SECTION I - PATIENT ASSESSMENT

DATE: &GI OW 0‘ PATIENT ACUITY LEVEL :'-i `( POST-OP DAY:RV1 1 .HOSPITAL DAY:

T • 13-

" .. N

S

R .

.!• t ■ PLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time To From

- TELEPHONE REPORT:

I AMBULATORY I II I STRETCHER CRUTCHES WHEELCHAIR

Total ER/RR/PACU, time Physician Anesthesia (Specify): •

Procedure/Diagnosis B/P P '' R T LOC Neurovascular checks Dressing/cast Tubes

Fr. (IV, po) Output (EBL, other) • ded Ill No I Yes Amount: Medication

Other

Report From Received By

Pe

.

-: 17.

-

CL

'

..,.

TIME: peb kr) efigib ----

BP ARTERIAL LINE i(",-

BP CUFF —) 1_ !CO 1 1

TEMPERATURE '11 ' q PULSE

1°S-' i RESPIRATORY RATE

" 1

OXYGEN (L/%) ///vim/ ./....'

PULSE OXIMETER ... l ta 02 METHOD if

N S

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask MT = Mist tent PR = Partial rebreather A =-- Aerosol TC = Trach collar

A

TIME: 109011:21

p

E D

TIME: • Skin breakdown

prevention

'Falls prevention protocol

'Restraint protocol - - - -

• Seizure precautions

'Isolation precautions

MO

PAIN INTENSITY

lo

o : . . . .

. . • •

MED ADMINISTERED IY/N)

RELIEF ACCEPTABLE IY/NI

-----..„,.......

- -„_____ 0 TIME:

T H INSULIN

FINGER STICK GLUCOSE

IY/NI

-"=:---, YESTERDAY'S WEIGHT:

TODAY'S WEIGHT:---...,,

E , WEIGHT CHANGE:.-

R Per hospital policy.

' 24 HOUR TOTALS

PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT


CLS)t)

illili (40-1

.

• DIAGNOSIS: Sr() °Can i DRG: ADMISSION E: 1-, 1 = QTS LOS: EXPECTED RELEASE:

CASE MANAGER: C4,0 7_ PRIMARY CARE MANAGER:

ISOLATION REQUIRED (Specify):

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.00

10.

MEDCOM - 22793

DOD-036369

ACLU-RDI 1673 p.153

........ _.. SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS

DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been ME . If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.

-C)':-Z--

1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately.

Communication is adequate to express needs.

PUpils equal and reactive to light.

`-poacterwt) tt° iAxe

TIME: 0 A INITIAL •

i'l 1-e.r+ - 47a..o4

kr"- i

ezb---d .. .,r) -e.cd31 c3i.)..-f .--b

,

-4-A.k. 11- c%

TIME: INITIALS:

LI TIME:. fire ea !Milt.

I ihiSirti,i9 Or ■ w' '10

t 2. 'CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity peffusion)

I Jr Lys

3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

—

i

11

-421,.l,t,itr1C11;14t3N7e15

6; h

Pr jNe-Q .)*.i

( iii, II 11101 OA .

a 4. G.I.: Abdomen soft and non-distended.

with eating and no problems chewing/

swallowing. Denies constipation, diarrhea or rectal bleeding.

Bowel sounds active. Reports no N/V/pain El"'''. ❑

5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

1.e 119 vi.

c lear y e /4,1,,L) t. ( .4 ' a -)*-)'")&16111 , Le 6: MUSCULOSKELETAL: Normal muscle

development and mass for age. No

deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

' (06C par .-...7

.",e.41c

/ '

dk a a bl-e er rei 1 I •12_

1,,,,,. ,4 -1.

I 1

OL1 \ feft1 14

5"/S" Na--.10 CITX-1 e)1 E.5

at f5)5 L9fvf\10Cgi_

7.- SKIN: Warm, dry, intact. Good turgor. No rashes. i nflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony , prominences. Mucous membranes moist.

❑ lieSULFt--- Se.a.).c) \AC-

.- (-. 1 -it, e se 4e -`f

Q I sscap ( a_c_. . .

8. PAIN: No complaints of pain/ discomfort. (See page 1 (or documenting pain intensiFy.)

n .

• p9 I - cee

' ❑

se)._ -()--P6 \ 9. PSYCHOSOCIAL: Behavior is appropriate I to the situation. Anxiety is controlled or mild and appropriate 40 situation. Interacts appropriately with others.

......_

J-- r..._ cble -to v.kv-Ite_ 'i)elocre..,Is4-G Grad

arxbic _a4-- @t fish kh

0 I I Corribt-A.ivQ• -if

. -to PAG1',,, sk

a/ YN:t‘- , k

((*)1- 10. IV SITE ASSESSMENT: (LEGEND: P Puff n i trated R - Reddened OK.- No swelling/redness * - Cei--711611iFret )

TIME: /0 i 0 INITIALS:

IV patency „/ q hr:

TIME: INITIALS: TIME: 25M_ INITIALS: IVpatency I q hr: IV patency ,/ q W hr: _

IV site care provided: IV site care provided: AIIIIII IV site care provided: IV tubing changed: IV tubing changed: AIIIIIIII IV tubing changed:

LOCATION CONDITION

IV Site #1: Pft oe- LOCAll• 4 CONDITION LOCATION CONDITION

IV Site #1: IV Site #1: () IV Site #2:

IV Site #2: IV Site #2:

Comments: ., . (OS .pj as-- f

V ' Comments: Comments:

• '

S

MEDCOM FORM 689-R (TEST) (MCH01 MAR 9 Page 2 of 4 pages

MEDCOM - 22794

DOD-036370

ACLU-RDI 1673 p.154

SECTION III - PATIENT INTERVENTIONS & TEACHING

N

E .u.

V

A.

S:'

• -

U L

A •

-

SITE: /..-C TIME: /00 p

..:edi P . S

A

F E T y

TIME: /0/0 ... Vok COLOR ID band visible/legible

CAPILLARY REFILL I I Orient to environment prn ---- Ali TEMPERATURE v.) lik- Side rails (2/4) up Alb- '-

EDEMA AS, Bed position low All SENSATION 5 Call light within reach

MOTION (.A

PASSIVE FLEXION 1-----•---Z--

a., .Q,.

O

T H

E

R

ROM q2h if immobile

Review & post lab results

PERIPHERAL PULSE Notify MD abnormal labs ,

LEGEND


Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-(> 5 secs)






Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn

Turn/reposition q2h

Antiembolic hose

I

BREAKFAST LUNCH DINNER ..

TYPE: /neck for7( TYPE: /yi ez,..47 sa (‘-/--- PERCENT CONSUMED: .0,5r)

TYPE: (NRQ00__(__. PERCENT CONSUMED: PERCENT CONSUMED: /00

HOW TOLERATED:• L.,,),,e_ge HOW TOLERATED: t,,....A.e121,1 HOW TOLERATED:

❑ SELF 0 ASSIST . cit COMPLETE ❑ SELF ASSIST ❑ COMPLETE ❑ SELF 4] ASSIST ❑ COMPLETE

D

L

0700-1500 1500-2300 2300-0700 •

❑ SELF ,:l C OMPLETE


❑ SELF 0 COMPLETE


❑ SELF 04 COMPLETE

0 ASSIST ❑ TOTAL 1-


- .. BRES Oa SELF ._ AMBULATE ,WASSIST BSC

BRP ' # TIMES/SHIFT

-

CHAIR

BEDREST ❑ SELF AMBULATE ❑ ASSIST

BSC . TIMES/SHIFT

BRP

CHAIR

BEDREST ❑ SELF AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

...„._RP

.4oCIAIR..)

TIME: /010 INITIALS: 111111 TIME: INITIALS: TIME: INITIALS:

CONTENT: €0 a4-yLed

T Fy4,,Nrk r V? 1 erYt e• ■-•.- E .

A — Ca-e -fir r- C

I . -74-4 .,- ii e.," ,r). Y-I-Le N h.,C5 f) 'ia4.' — by - raiz rp r G

AIWP,...or.._,

....jap, amily Verbalizes Understandi

CONTENT:

❑ Patient/Family Verbalizes Understanding

CONTENT:

❑ PatientiFamily Verbalizes Understanding PA '" WRPIPP- TIFICATION

INITIALS

Pig Mr go-ci ....._.__._

SIGNATURE SHIFT


MEDCOM - 22795

DOD-036371

ACLU-RDI 1673 p.155

JCL. I RAM III - IINI I CtiV CPI I IlJnIZI & I tALMING 1Conti

W

0

U N

...,

T

I M E

.

LOCATION O OF WOUND APPEARANCE TREATMENTS

AND DRESSING CHANGE

x

• -

_ ..---- .-- „--

.,-------- SECTION IV - NOTES •

1100 - Pt tAf -hp CkaA,A

..., ; /14/i/e0(

la

1.111 l' A

-e

/ Ft / I di AffirCiii .4L•I1 , •

/4- --...7121te - ,,,,.

ammo td • it 1_,Tb -- Fi • iitryl -1•-&,iocti - , ..

I . /1/

41- 9 -

III' -4111....■111.

CL17s- /

AIP 4 IllAll .41°F-110- gr erg 0

0 ),-1 oa-- A 1

1#1. A 0 ) j r

dad, e ',Ay V

_

4)4A \ Tyv la Allb.

'', 0I,Ir / ,_,.. „... Aril Are

_ L . 11 , rso,yrwezi II MAI Al Ca^ exa....

At;

•

MEDCOM FORM 689-R (TEST) MICRO) MAR 99 Page 4 of 4 pages

H

MEDCOM - 22796

DOD-036372

ACLU-RDI 1673 p.156



DATE: t)CAJ Ono I PATIENT ACUITY LEVEL : I POST-OP DAY: Koll / / ( p HOSPITAL DAY: (3 ( ..

T. :

N . S,

t

R .

.:• ,

, .,..

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time To From

- TELEPHONE REPORT:

a AMBULATORY In CRUTCHES a 111 WHEELCHAIR STRETCHER

Total ER/RR/PACU time Physician Anesthesia (Specify):

A. Procedure/Diagnosis B/P P R T LOC Neurovascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided U No . Yes Amount: Medication

Other


.. '.: '

•

-:.,'•

C:

TIME: '54.14) 013-0 04' . BP ARTERIAL LINE ..,./.

I 144,a, /Wye' qt -1

.

BP CUFF

WA TEMPERATURE

PULSE •-)1 /85- RESPIRATORY RATE t r 4 OXYGEN (L/%)

PULSE OXIMETER 00 AZ

02 METHOD

N

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask ' ` MT Mist tent . PR = Partial rebreather A = Aerosol

S{=

VM ,= Venturi mask TC = Trach collar

P.

N_.

TIME: pis arp

p

A

N E

D

I TIME: • '‘... . 1

PAIN INTENSITY s

"

• .. "

" '

• •

• ' .. " .. " .. " .. '

• • .. "

" . . • Skin breakdown

_ prevention

'Falls prevention protocol 11 'Restraint protocol

-- - -- - - --- 'Seizure precautions

•Isolation precautions RELIEF ACCEPTABLE IY/N) /tJ A

O. TIME: -

' FINGER STICK GLUCOSE

r H INSULIN (YM) es

S TODAY'S WEIGHT:

WEIGHT CHANGE: (--,

'Per hospital policy. R

24 HOUR TOTALS

PO IV #1 11.1 #2 . TOTAL Urine

7%9E)

Stool too TOTAL OUT (

a6kla PATIENT IDENTIFICATION

.:. PJ Ali 00

- , DIAGNOSIS: 6/f, orain levarm s t-1,646)11J DRG: ADMISSION I/W: I - 0)

LOS: EXPECTED RELEASE:

CASE MANAGER:

PRIMARY CARE MANAGE

_....----i/ ISOLATION REQUIRED (Specify):

\■.._ MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

Page 1 of 4 pages MC V1.00

MEDCOM - 22797

DOD-036373

ACLU-RDI 1673 p.157


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been M T. II all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. b

TIME: lb 41 .5 INITIAL IME:' I (D, INITIALS: JJJ

TIME: INITIALS:

1. NEUROLOGICAL: Alert and oriented to



-ftv mpg, Lorst+Ir% .

time place and name. Responds appropriately. I Le51‘ OL.05 SIAN'

C6r7.11Y)'ahillS •

Corn re, un t cz.jr,g

I I .--6-1;2e..eiu,-5 I I

2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

1 /

3. PULMONARY: Respirations within normal for age group; quiet and regular. Depth is

regular. No cough. No abnormal breath sounds.

'ira eke oz4ony . ft_ ..e. v.04.,,,hue.

C b1/45,6 1111t4IS 11

ek_rhnret •

I 0 4-0(07\

Ds5- cA-31- (-)

I fi

4. G.1.: Abdomen soft and non-distended.

Bowel sounds active. Reports no N/V/pain


swallowing. Denies constipation, diarrhea or

rectal bleeding.

Iq' I L.-V Li

5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

te1l0a) VtArre •

31( y 40 Tranit41 E ctfpr-

0 - • , • j..v.zi •

6. MUSCULOSKELETAL: Normal muscle


deformities. No assistive devices needed.

Normal active ROM without pain. No joint

swelling/tenderness, weakness or paresthesia.

ri 0,1.4.ict% yno.-6„ fora 10-17G> trE,

..sid body ., 4 ' 006 -e assrs+ )C 2

n * ino.tur .6,,,,e-fv•-> 6

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony prominences. Mucous membranes moist.

511rCLI Ine i WO tilLpi•

40 064, .eas-1-, 5 1+001 CLL.= •

-1-t-4--Q I I 54‘--•kr10

v- IA'L-0A

8. PAIN: No complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.) e..- I /r- ❑

9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others. Mu - 1_

10 I I

10. IV SITE ASSESSMENT: (LEGEND: Puffy I - Infiltrated R - Reddened OK - No swelling/redness - Central line)

TIME: IOU INITIALS:

IV patency 1 q pi hr: p

TIME:1?-)C1 INITIALS -- •

IV patency ✓ q....S hr: _

TIME: INITIALS:

IV patency I q hr: IV site care provided: as5r55eci IV site care provided: Q....;;"je,"›..0 IV site care provided: IV tubing changed: IV tubing changed: IV tubing changed:

LOCATION CONDITION ,

IV Site #1: sec'

r .LOCATION CONDITION

IV Site #1: )_ Ac...., c)K LOCATION CONDITION

IV Site #1: IV Site #2: IV Site #2: IV Site #2:

Comments: Tv F p -1-Kb Comments: Comments:

,

MEDCOM FORM 689-F? (TEST) (MC)/O1 MAR 99 Page 2 of 4 pages

MEDCOM - 22798

DOD-036374

ACLU-RDI 1673 p.158

JCL. I Il/1)1 III - rm ICII I III I LILY LII I 'VIII. UI I Lo,...111 ,11,7

SITE: LA) E t, (,F TIME: ../

/O 5° ,21(3i6

IC

f) < L

L 11J

TIME: =Ea

COLOR f J el2f. ID band visible/legible

CAPILLARY REFILL I I f I Orient to environment prn

TEMPERATURE J4) tA) W W Side rails (2/4) up

EDEMA P 0 0 o Bed position low 11111 SENSATION S , S S Call light within reach

MOTION *#11 19■.-NM[A4411 , PASSIVE FLEXION

PERIPHERAL PULSE

91"

/ // 1

at 94 2*

UJ CC


Notify MD abnormal labs

LEGEND


Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-1> 5 secs)

Temperatiire: C-cool; W-warm; H-hot



Motion: U-unable to move; M-move-no pain; ID-move-pain; R-full ROM





Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose Pir

- U

J H

I

BREAKFAST DINNER

TYPE: e, lll)_CeF, 1

TYPE: g----

TYPE:

PERCENT CONSUMER` Ser cit10,4) PERCENT CONSUMED: ac,--2 4--- PERCENT C ONSUMED: c..., HOW TOLERATED: 0, trit.f ' HOW TOLERATED: 51-xej HOW TOLERATED: S 1e—e---E

❑ SELF )c ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST 0 COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

D

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE ❑ SELF XCOMPLETE

0 • ASSIST ❑ TOTAL

❑ SELF ❑ COMPLETE


❑ SELF K COMPLETE

It1, ASSIST ❑ TOTAL


•

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

# TIMES/SHIFT 3 BRP

✓CHAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

Atia h # TIMES/SHIFT :RP

- AIR

; .

T E A C

TIME: It S INITIALS: TIME: INITIALS: TIME: gt 3 0 INITIALS:

— CONTENT:

0 iferSOInCti hy2iehe

,) ri v1.5-;46 r 3-- c Wowed


N

_ • T:


CONTENT:

. Cale ..-

,.

Patient amity Verbalizes Understanding


HIC )1

INITIALS SIGNATURE SHIFT

II AitAl

MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 3 of 4 pages

MEDCOM - 22799

DOD-036375

ACLU-RDI 1673 p.159

SECTION III - INTERVENTIONS & TEACHING (Cont)

ci<

ctui


AND DRESSING CHANGE

(g @GWCILI/ .

C CLIN' KU-SKI (teCt"

SECTION IV - NOTES

lo IS : %. MIS --ko On citr cyloi t5C 1 a‘10 : A cfo jtve,tp po, ■ 4 40 e4 . yids acct. fetal' 4c) 6. f). /119 ru II--cd c,-1 pqi,-, r3wcb arkori o roar-, / apm...- .

00-7--

MEDCOM FORM 68.9.R (TEST) (MOHO) MAR 99 MEDCOM - 22800

Page 4 of 4 pages

DOD-036376

ACLU-RDI 1673 p.160



DATE: I \-DQ c_0 --6 PATIENT ACUITY LEVEL : 'III -' POST-OP DAY: 39 v7 HOSPITAL DAY: i

T R A N

S'' F E R

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Time To From

- TELEPHONE REPORT:

. AMBULATORY I CRUTCHES . I WHEELCHAIR STRETCHER


Procedure/Diagnosis B/P P R T LOC Neurovascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided I o U Yes Amount: Medication

Other


SI

..11

T

•

TIME: 1()CD/IGCb C . AW BP ARTERIAL LINE ,------..../..-

BP CUFF J(9'4 14' 7e4

TEMPERATURE ,..-ifd 9551 PULSE 91 /0/

RESPIRATORY RATE 1( -...•

VD AO OXYGEN (L/%)

PULSE OXIMETER l' ///,

02 METHOD

N S

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask MT = Mist tent • PR = Partial rebreather A = Aerosol TC = Trach collar

A -

TIME: rly) . 0

s p

C

N E E D

TIME: Ot ___;•24.(2

PAIN

INTENSITY

io

. . . • • • . •

'Skin breakdown prevention


'Restraint protocol


.1solation precautions

_P& PM

0 . .

jc :

• • . .

MED ADMINISTERED (Y/N/ t,„) RELIEF ACCEPTABLE IY/NI pft N 9- A

O TIME:

H

FINGER STICK GLUCOSE YESTERD EIGHT:

TODAY'S WEIGH .

WEIGHT CHANGE:

'Per hospital policy.

INSULIN (Y/NI

E R

24 HOUR TOTALS

PO ./ #1 IV #2 TOTAL IN Urine Stool TOTAL OUT

PATIENT IDENTIFICAT ON

-EPLAJ 44-0

- , DIAGNOSIS: sir Cre(niottn 6614jOshinarhf DRG:

/ ADMISZN DATE: ?)) 0c21-0-

LOS: EXPECTED RELEASE:

CASE MANAGER:

PRIMARY CARE MANAGER:


MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE

Page 1 of 4 pages mc vi.o0

MEDCOM - 22801

DOD-036377

ACLU-RDI 1673 p.161


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria explanation of abnormal findings will be noted in the appropriate column.

havee JET.41 all the stated criteria are not met, a brief 4....„-).- ... ,..-^ >

Z

TIME: 09 30 INITIALS TIME: 0 INITIALS: TIME: INITIALS:


time place and name. Responds appropriately

Communication is adequate to express needs..


I-1 pt I-10_5 lime_ ' (fiih.o...re- ‘The. O.0

d QS\ -"" Lc.19„,_ eg-eAr\--:),10/ ° --i-olk_a_pt

Pr

i hi- ÷CP!"-e-r p- WitA I ' cfadc iv, Cottio1Vc.. -. ses-lcs.s 00-tcA -ho-e-r 11 o_e,+- c,„

ct.-1- mcv , j t kg. w i

u

ev- 4ranstaiut .

l—tY 0 2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)


7 "V 1Q li-ach Si le, J V54

I I

4. G.I.: Abdomen soft and non-distended.




rectal bleeding.

5. G.U.: Reports no dysuria, retention,

yellow/amber. No unusual discharge.

t ks■ -

urge ncy, frequency, nocturia. Urine clear, n l%

• ,,•'' . • e ,..11

C9-41_ 0-.A : ‘

1 I Ctle-e,-y-4° I. [1

6. MUSCULOSKELETAL: Normal muscle 1 I Pk, 0../YACUI-C-$1- -4-0 development and mass for age. No

■-ArriN-ert-e-Ct • deformities. No assistive devices needed. : Normal active ROM without pain. No joint ..•v-I.JC..._di.

swelling/tenderness, weakness or paresthesia. di" 43-7%-r'r.C-1

CGILE ItheCASLR

L.h!.t.4.1.4:a..c GI/

9-orvt Sue eu...2J/ , hi

lAp-sd s i i Pr

I I

7. SKIN: Warm, dry, intact. Good turgor. No ,( , 9,.._.,„--1-c) rashes, inflammation, ulcers, breaks in skin. •-•1/412.rrNeSA0.(1 0-1\12-0■1 No redness, blanching, irritation over bony c).55s k" 5 -gyp bc,--Ct prominences. Mbcous membranes moist.

I PSG'S 4--- 15606- ..10-r-P

-11.7 & km-eir‘d2 stActri. M/s- epr

1 8. PAIN: No complaints of pain/ discomfort. X (See page 1 for documenting pain intensity.)

9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

10. IV SITE ASSESSMENT: ILEGR:155<-

I I 6-Q-41.4D-kz-r

cra...p.ct ka0_cernitr,....00,

-'----- (-qC 1\ -L Puffy I - Infiltrated R - Redden

D

d OK - No swelling/redness * - Central line/

TIME: 09 ) INITIALS:

IV patency ✓ q e hr:

TIME: _212'40 INITIAL

IV patency ✓ q ____. hr:

TIME: INITIALS:

IV patency ✓

IV site care provided:

IV tubing changed:

IV Site # 1:

q hr: IV site care prOvided:

IV

IV


IV tubing changed: IV tubing changed:

LOCATION CONDITION

IV !"rte #1: liell • 1.-

OCATION CONDITION

Site #1: t_ 61( LOCATION CONDITION

IV Site #2: eb )5-k- C)Ce— Site #2: IV Site #2:

, Comments: Comments:

14 Comments:


MEDCOM - 22802

DOD-036378

ACLU-RDI 1673 p.162

Ski. ION III - I ItN I IN I thVt14 I IONS 64 I tAl.r1161(.2

SITE: TIME:

U- U.1

I- ›

-

TIME: 0930 ;91-0

COLOR ID band visible/legible

CAPILLARY REFILL Orient to environment prn

TEMPERATURE Side rails (2/4) up

EDEMA Bed position low

SENSATION Call light within reach

MOTION

PASSIVE FLEXION

0 I-

= w CC


PERIPHERAL PULSE Notify MD abnormal labs

LEGEND

Color: P-pink (normal); C -cy. - otic; W-pale, white

Capillary Refill: 1-10-2 se ; 2-13-5 secs); 3-(>5 secs)

Temperature: C-coo • -warm; H-hot

Edema: 0-None; -mild; 2-moderate; 3-severe; 4-pitting

Sensation: A ..sent; N-numb; T-tingling; S-sensation (present)

Motion: liable to move; M-move-no pain; P-move-pain; R-full ROM

Passiv- lexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Peri. eral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;



Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose

w H

. I


TYPE: e6.. _ ( 00(1.erisitie, TYPE: TYPE:

PERCENT CON 15% .niale c41-5c.,eii PERCENT CO SUMED: 7cpto vy, PERCENT CONSUMED: TT' 5-1f0

HOW TOLERATED: 50-- 5o HOW TOLERATED: u,Sii HOW TOLERATED: VjCf2,1 ❑ SELF j:::ASSIST ❑ COMPLETE ❑ SELF KT ASSIST ❑ COMPLETE JCJ SELF ❑ ASSIST ❑ COMPLETE

A

D

L

3.

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE ❑ SELF ❑ COMPLETE

j ASSIST ❑ TOTAL




IST ❑ TOTAL


EI:€)LlEsDr ❑ SELF

A BULATE 0 ASSIST olgio

it...TITI-40 # TIMES/SHIFT

CHAIR .......

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP

CHAIR

BEDREST ❑ SELF

ATE ❑ ASSIST

BSC # TIMES/SHIFT

CFP—EialA

. TIME: (j)V,JZ) INITIALS: TIME 9,240 INITIALS: TIME: INITIALS:

CONTENT:

T -"- CC)NbjC-C) Ctr\O■J• tr- . E--- \i)e-1.0 t V

—1 _ .\()---k-od.kri.MC-kkoa,41-12,kr c v...Y.A.\\N\Quiss

N G

atie Family Verbalizes Understanding

CONTENT:

v,re,g_. --PhAA f

(q

Mr' it/Family Verbalizes Underst nding it p

CONTENT:


PATIENT IDENTIFICATION INITIALS SIGNATURE SHIFT

S /I boa,

MEDCOM FORM 689-ft (TEST) (MCHO) MAR 99

Page 3 of 4 pages

MEDCOM -22803

DOD-036379

ACLU-RDI 1673 p.163



DATE: ' ARCO PATIENT ACUITY LEVEL : ) POST-OP DAY:31 1 g HOSPITAL DAY:

T R

A N

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT T NSFER IN - TELEPHONE REPORT:

Time To From III AMBULATORY [1] CRUTCHES II WHEELCHAIR TRETCHER

Total ERiRR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P R T LOC N ascular checks

Dressing/cast Tubes

Intake (IV, pc)) O BL, other) Voided U No II Yes Amount: Medication

Other

R rom Received By

. .

•

> "

Z cn

•

TIME: fit' OW BP ARTERIAL LINE

BP CUFF .P11

qc... IVO

f 6,

la/ .1 Q

re)

l (1 1

6.--

TEMPERATURE

PULSE

RESPIRATORY RATE

OXYGEN (L/%)

PULSE OXIMETER "..:01er qQ

q-6 02 METHOD

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask MT = Mist tent PR = Partial rebrea h A = Aerosol TC = Trach collar

I •

•

TIME: --Zfrn 22C0

..._

E

D

vi u

i —

ate

Z LLI

0

V)

TIME: law -22cp

PAIN INTENSITY

10 • • • • • • . .

• • - • . .

• • • • . .

• •

. .

• •

. •

• • . .

. .

• • . . . . • .

• Skin breakdown ion


'Restraint protocol OC\ '

4 Seizure precautions

• Isolation precautions

D

. .

. . . . . . . .

. .

. .

. .

. .

. . . •

. . •

• . .

. . • • . .

. . • • . .

MED ADMINISTERED IY/N1 ___ ... ___

RELIEF ACCEPTABLE IYINI A

0 TIME:

T H

ANGER STICK GLUCOSE ---. -• • . - - --- -------- -----

YESTERDAY'S WEIGHT:

TODAY'S WEIGHT: INSULIN (YIN)

E WEIGHT CHANGE:

•Per hospital policy. R ----.....,,,,...„

24 HOUR TOTALS

PO IV #1 IV #2 TOTAL IN Urine S tool TOTAL OUT

PATIENT IDENTIFI ATION

DIAGNOSIS: sip . e_fail i o-i-bryi _ 6stiu Os ,'

b i2(A) 1:11P 1.))j\

DRG: ADMISSIQ DATE: ?Aix...11)3 LOS: EXPECTED REOASE: ,

CASE MANAGER: 1)( (0 -7_,



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE


MEDCOM - 22804

DOD-036380

ACLU-RDI 1673 p.164

01- ......11,./1• 11 Ir, it_t• III- • 11..•• vi vi %../ I ■-••• ■-•

DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have beep MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. (--

TIME: 1,203 INITIALS. IME: 1., INITIALS: TIME: INITIALS:


time place and name. Responds appropriately.



FV 1 1.---pt- E l.41,11'\ Irt ‘tfirj,n

i4eArnitteAlf 0{40f it -

e7120

Calfel

lAta_

eJA

kk‘r2/30

I I I 2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema.

Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extrerni,-/ perfusion)

3. PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath

sounds.

11

4, G.I.: Abdomen soft and non-distended.




rectal bleeding.

5. G.U.: Reports no dysuria, retention,

urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

Li FOI.e/ Di Cu -

VO i On it-e CtrlaK

tellbuJ lkirv.g.

1.4/


development and mass for age. No deformities. No assistive devices needed.

Normal active ROM without pain. No joint swellinoienderness, v.eakness or paresthesia.

ri e4Thr-vy\a-V4

46\PerVeArt .0

El— Qs p1

• 1 le 0

— ft reiAltkill

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation,utcers, breaks in skin.

No redness, blanching, ,rritation over bony

prominences. Mucous membranes moist.

I I (14-Cf +re-Cit^t Siky I I''` .+01C-KSL Re_

cl,002V1V9 40 @/51-00rEgg• ,- uSU/NOCC (-0 (gq;'-0 giNak-QCOK

`*" .1 g-01/444-121 )( /

le--------- .

0 CO 6(A.4,‘-/

pi


(See pace 1 for documenting pain intensity.)

- 9, PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

'e Li- NWT° locAtccd2 1 f -AVIrt

(10 -:Z___

Li

10. IV SITE ASSESSMENT: (LECEN P Pul ry I - Infiltrated R - Reddene OK - No swelling/redness * - Central line)

TIME: igoo INITIALS:

IV patency J q •25/ hr:I)

TIME: Z.-2W INITIALS: TIME: INITIALS: IV patency .1 q ei hr: _ IV patency I q hr:

IV site care provided: ,a e-to■-5 T t/ • IV site care provided:'Mid ‘00 ,_1A IV site care provided:

IV tubing changed: IV tubing changed: IV tubing changed:

LOCATION CONDITION

IV Site #1:

IV Site #2:

Comments:

LocAnor, CC!:DITION

IV Site #1: PA— 0& LOCATION CONDITION

IV Site #1: 0 if- OK_

IV Site #2: IV Site #2:

Comments: 14-C , comme,,,s, il.

MEDCOM FORM 699.R (TEST) (MCHO) MAR 99 ' Page 2 of 4 pages

MEDCOM - 22805

DOD-036381

ACLU-RDI 1673 p.165

zw

pcc

o>

<c4

0.=

-1<

cc

SITE: W TIME: W''200

W a

U-

›-

0

LU CC

ROM q2h if immobile

TIME: .900 ' el

ID band visible/legible

Orient to environment prn i 1

,-

COLOR p J

e . CAPILLARY REFILL 1

TEMPERATURE IA) Side rails (2/4) up Pr" 1 A EDEMA 0 Bed position low MI

Call light within reach SENSATION 5

4 Plr

. tA

X

0 Review & post lab results

MOTION ,SKIAII PASSIVE FLEXION

Notify MD abnormal labs PERIPHERAL. PULSE

LEGEND


Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-(> 5 secs)


Edema: C-None; 1-mild; 2-moderate; 3-severe; 4-pitting






Incontinent urine/stool A 0 Linen change prn

Turn/reposition q2h

Antiembolic hose


TYPE: TYPE: itai PERCENT CONSUMED: offt'p./

TYPE:

PERCENT CONSUMED: PERCENT CONSUMED:

HOW TOLERATED: HOW TOLERATED: ‘,..,/12/( HOW TOLERATED:

❑ SELF ❑ ASSIST ❑ COMPLETE lerS5ELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

C:1t*

I LU

<

02

.- Z

0700-1500 1500-2300 2300-0700


14ASSIST ❑ TOTAL

❑ SELF ❑ CO •LETE

❑ ASSIST ill OTAL


XASS1ST ❑ TOTAL


TIME: INITIAL

BEDREST ❑ SELF

AMBULATE 1:3 ASSIST

BSC # TIMES/SHIFT

BRP

BEDREST ❑ SELF

AMBULA ❑ ASSIST

BSC # TIMES/SHIFT

BR

'HAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

cHitiB 2 fair - 4 reol-raiAt AIR

TIME: INITIALS: A TIME: -2,20) INITIALS:

CONTENT: t .

4A54-- ecr\--0 fu)i \ v„)( Ao nc ,1__ ..\.02e -t-fcs

Patient/Family Verbalizes Understanding

TENT:

, N„ N

II Patient/Family Verbalizes Underslai ling

CONTENT:

— oso A's

. • atient/ amily Verbalizes Understanding


(9P1

INITIALS G • SHIFT

pj ) •

MEDCOM FORM 689-P (TEST) (MCHO) MAR 99

Page 3 of 4 pages

MEDCOM - 22806

DOD-036382

ACLU-RDI 1673 p.166

W

0

U

N

A

R

E

I M E

LOCATION OF WOUND APPEARANCE TREAT vEN IS

AND

DRESSING CHANGE /to Skeujebor 5cop.ieL

skould{ . Ti

CJT'E--3' 011- %1 ..6

C

--' .

SECTION IV - NOTES

I / f L../uJee.--,___ 4.,.4- D 57t ef. f ,

5 e'di / /

/

•

/ _ I ,. .-- 1-1...1 -e.S --.- _AT' , -e -/

/ If ir 1 '

L

..„___.,....1..._. ..... r,-- , , e

/ 0 . /4111001, imPlr'---

ir

--- _ ...........

T C VL

A •

... 4

- -•_ ..■-■■■ ,

11.4,, ■■■■ • ■ ....... ■ .. ■- - - _

(TEST) (MC/-1O) MAR 99 Page 4 of 4 pi-gcs

MEDCOM - 22807

DOD-036383

ACLU-RDI 1673 p.167

HR = Non rebreather PR = Partai rebreather

24 HOUR I PO IV #1

TOTALS

TIENT !DENTFICATION

MEDCOM FORM 639 - R (TEST) (MOHO) MAR 99

IV #2

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEE For use of this form, see MEDCOM Circular 40-5


PATIENT ACUITY LEVEL POST-OP DAY:3IV i g

7E: —Ta Dp.iC., 0 1..

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Tine To From 0 Amuu,...,c, ,,, El CRU7CFIES ❑ ,VHEELCHAIri CI stREIchEA

Total ER,RRiP,-NCU ;ime Physician Anesthesia (Specify):

BY P R T

Procedure:Diagnosis Ne.uruvascular checks

Tubes

Output (ESL, other) Voided No ❑ Yes Amount:

Other

Report From

TIME:

LOC

Dressing:cast

Intake (IV, po)

Medication

BR ARTERIAL LINE

BP CUFF

TEMPERATURE

PULSE

RESPIRATORY RATE

OXYGEN (Li%)

I

L

PULSE OXIMETER

02 METHOD

N FM = Face mask

VM = Venturi mask

A = Aerosol TC = Trach collar

TIME 1100 NC = Nasal cannu:a

04gen Method Key:

MT = Mist tent

' Skin breakdown prevention .

• Falls prevention protocol

'Restraint protocol

C ' Seizure precaut : ons

'isolation precautions

E

A

N MED ADMINISTERED IV:NI

- - - •-

RELIEF ACCEPTABLE IV NI

FINGER STICK GLUCOSE

INSULIN IT.N)

YESTERDAY'S

TODAY S V:EIGHT:

WEIGHT 'CHANGE:

'Per hosp , lal F_

E

TOTAL OUT Stool Urine 'TOTAL IN

DIAGNOSIS d • kg 0/1 •

ADM ..ION DATE. $__L_Oct

EXPECTED RELEASE - DRG:

LOS:

CASE MANAGER:


!SOLATION REQUIRED (Specify):

EDIT!CI'S ARE OBSOLETE Page 1 of 4 paces

MEDCOM - 22808

DOD-036384

ACLU-RDI 1673 p.168

IRECT:C.'.5.. A cl;cs.;. ,./ in ;he s.ma:': boy inclica;es patient assessment criteria have been MET. If all the sra:ed criieria are not mar, a br;a1 ex plana..;c" of obirirm.v!.-7::iiiis will L , : -.• no;ed in ;ha appropriate column,

r:...F..-. ir:ITIA , 'TIME: INITIALS: TIME: [WTI

t,rie plac2 ;.:Id liarr:C. 7..25;., C, .1j7, :1,•_..,,,.1.11c1v. Zorn7s.:.: -...::.:,on is:.-..Je:;:.:::::: , ;0 ,2xp!css )CCCS. ?ups eq•-7:: 3nd rci:ZZIV ,2 ;..) IlgI1Z.

1. NEUROLOGICAL: Idcr: a:1d orienled ',o

Cl;) ((.0 - ?__-.

V 2. CARDi3VASCULAF-S: ..:Ise reguiar F. ! -::e .-., ithin ran:...2 for a:ie. N: ..-2e3endent o.-'e7 , :a.

'‘Iailbeds ::.---_-: illucr.v.:s :,..0-.-1)rones ,..,..',. No .all ;cndernE.555. ;Soc. p350 2 .' ,:..1" e k5.• c r;.;,; .,.•

..-ierfusicni

..---: ..._.• LI

3. puLmo % ARy; P.cs;:a:-3:::; v.- ;11' ■ ::: n.;;;:i;a!

7ate for 2',....2. -.:roup; r.-,u . CZ 3 -..1.: :Izir. Ci.,0'.h is

sounds.

: —rfach sli_( OCA' CU-ka •

U FIT 11P, 6 \A.e_ ON...5) • Aorei,

cLAAY-4.4 % -

mn 4. G.I.: A .,: :.:ae sc,;; a: -:d r.on-::!s(!ed.

. Bowel sc...: -..is af:tive. Re;or -.5 nc N:V:pa;n

with ea:in; and no prcb:ers chewing/

: swalloN -J:n:.. Denies cons::;la:ion, tharrhea or

• ectal btee:::no.

!' L_— Ls/

. 5. G.U.: :zeports r'10 ::','S...'7:0., re:en:ion,

.:rgenc.,, frequenc'. r.c.c1..r.a. Urne C:C.,37, yellov..,, a7r.te!. No unusue! ischarge.

— ineprI-14 R9.X14, i 1 t49.-i)( 1

14,41sLsSitl '

kr t-Y10611 r-kAR

5. M'JSCULCSKELETAL: Normal :-:-....:sc:e

JaV7....?...le. f.e.formi'.:es. s ..:3 asz:sl've :.-....'ices reec:cd. :orrr.al a: -.1.-2 ROM '..':Th::;aain. No jo in:

3,„;:in g :,-, :ierness......es,:-.ess cr 20 - es'.7esia.

.._ r, st azza--toi cr6iVk1i. :___, ADwebgksk- b_ect4 t-ti

10 RA r.,-10,--- J I ' 5-

"‘n v1,144„rt uce.-_L 7. SK:N: . ...s!rr.. dr,', in:acz. Good :urc.r. No

• rashe.s, I: .-.,"%rna:ion, •,..;-....-2rs, breaks m skin.

:rornHenc:s. tvluco ,..:s ^.• ,.-: —.brancs n - c:s:.

T .51,v-•040...e../ COCW10(9:71 1 g-4.S . 1

1A-1- .- 0 di /:p.

. C. - 03 r6

(gJuizki' usQA—Yd

• B. PA;N: :':.: cornp:z. --,s c..: pain.: rils!ort. 1:_------ IT ..__:

See pace 7 ffd- c.., ':',.77C,7:,' -: ;:a;:: /::,"er.Siry.) I

I

7-1 1 I L___1 I 4:Sek_.• 1

.- 3. PSYC2i-ECSOCIAL: E....2`.::: .-• or :5 a;;;:,r'::::” aze ! :0 the si'..-.:: .,cri. Ar..;- ,...., cor.;roIlec and appfa72 - ,ale :o s:: ,..;a1. ,:n. :r.:: -,racts

I ICY ‘

10, IV SITE ASSESSI'.:ENT: y._:::"...; 7 '.3: • ' •;• I - Inft;I:a:ed R Reccened OK - No swellnc.. - •edn.r.ss - t at lo

IME: ) 100 :,ITIALS __Flf.lE: INITIALS: I TIME: (96....e INITIAL

IV pate:-..:.. - ,,,/ ...,- <;i0 -, , 7: f? •..; 2V.CnCy ../ q :ir: ;\./ pa/enc,- j q -a: p IV ,,,,. ;25-, ,,...ici..2,-2: ci ... i IV S''.ar_.•.:1:C.. orov ■ ded: i'1 site care ,:;r::yrded: AS_Se.= •,.,

IV tubing changed: IV “.::::,,-..:. -_- -.D.:I: IV ',..:bir.r.; changed:

C .:.•.:::7: ,3:4 I LOCAT i; CC' — ' -'10tJ !'./ Site r 1 : g'C OK IV :_". : ...3 :1:

1.0C.r.TION CCUOITICN

IV Site g t: Ca•All :._

\/ Ste :2: iv S .; ,2. .1 2 : IV Site g2:

:om.,-e.- .. -.-: -- rd g C ...: ,-.--. - ell; _ _

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

Commf;;-:3: __

_

1..:,^ori 99

2 of 4 par;as

MEDCOM - 22809

DOD-036385

ACLU-RDI 1673 p.169

D C

cn

< c

m z

SITE: t ilit_7_ TIME: 11001 110%651

OH

IW

CG

TIME: I P , 7 _ COLOR

_

CAPILLARY REFILL

0 1 47 ID band visible:(0;;ible Air■•----

Orient to environment prn

41 [ I — A IVA TEMPERATURE kA) Side rails (214) up Wil

Bed position low EDEMA i/

.

SENSATION f di,

r

/

/7

1 Se

Call light within reach


MOTION Pl. f D PASSIVE FLEXION

Notify MD ablinrmal labs PERIPHERAL PULSE O'r

LEGEND

Color: P-pink (normal); C-eyanotic.; W-pale, %•..liite

Capi;lary Refill: 1-10-2 secs); 2.13-5 secs): 3-(> 5 secs)

Ww m Temperature: C-cool; -ar; H•hot


Sensation: A-absent; N-numb; T-tingling: S-sensation (presen:)

Motion: U-unable to move; M-inove-no pain; P-n.lovc-pain; P.-(;.:il Rom Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain



Incontinent unne.szool

A 1111 L.. Linen change pm •

Turn 'reposition q2h _

ROM q2h if immobile ENE Antiembolic hos..i

f


TYPE: TYPE: TYPE:

PERCENT CONSUMED: 30 7g PERCENT CCNS:...;ED: n) PERCENT CONSUMED:7412"e7

HOW TOLERATED: (4/5../4,-, . HOW TOLERATED: 4,11,7/ HOW TOLERATED: ti..,,,(

SELF I-1 ASSIST E: COMPLETE . ...;:ifSELF Li ASSIST ❑ CON.PLETE '6 SEL:' U ASSIS.

70

r..1 COMPLETE

C.,) .

0700-1E00 1500-2300 I 2300-0700

EATH2ORAL CARE E SELF ❑ COMPLETE ; LJ SELF E.] COMPLETE I i__: SELF COMPLETE

0 ASSIST Li- TOTAL r-1 ASSIST F__.7 TOTAL IASSIST :21 TOTAL

TYPE OF ACTIVITY (Circle all that a; ) 3ply

B E D R F Eil SELF BEDREST (-_-: SELF 4211W E SELF

;,....1 BULATE,, ASSIST -• AMBULATE ......"3"-ASSIST AMBULATE D ASSIST

--- I SSC BSC 4.' TIMESISH.IFT # TiMES.SHIFT l•I TIMESiSHIFT

BRP BRP I E.RP

4 ara 07 CHAIR ....HAI

TIME: INITIALS: TIMF: INITIALS: i TIME401. II/ INITIAL'

CONTENT: ! CONTENT: ,' CONTENT: I

(-3 P ,-,tient;Farn.iy Verbalizes Lin r!,-■ r s i nn(11:) , ) L_J Patient F.-::- :.,. \-/Qrhall/. ,:s li , ;rlersiandnnr; Patier! Family Verbalizes Uncle landing

PATIENT. IDENTIFICATION INITIALS TUBE SHIFT

MEDCO,Y FORM 639-R (TEST) (MCHO) MAR 99

Pala 3 of 4 pagcs

MEDCOM - 22810

DOD-036386

ACLU-RDI 1673 p.170

IO

D-2

10

U

.:ft:C

ul

l

7

LC:C.ATiO: OF v.',DUND

E ! :C=PEARANCE

1 1 i

TP.E.5,7".•E:.;TS

___, ,r ,,,,D.

DRESS::C: C-..A^:GE ri'

I .0 0 sh00 • es " • ff2L-laaadZi(_____ .

ici yuza...\ .1/4. v , SSUe- `...61..,-S/

4) le-, 6 s\ 5(2- i

Lk) --- ) "-- 7::

rthts\eyi et(4..%3".

__ - - _ _______ ■

2 1, ci

_

SECTION IV - NOTES

. ,

__ __

!

■

r _._ — I

.

. , . . . , , . . . .

. ,

, . _ .

_ _

_ __. . .

_ ___ i

. . .._ __ _.. ._ _ _ __ ___ ___..-

..., 6 .... ____ . _ _

. --- _ . . . _ . _ . .._ _ ___

--- ------- -- . --- _ - _ _ .. __ _ ___

_ ___ _ _ _ _______ .._.... __

. 4,.'41-7 ..7.7 FORM 65.9.1-; frEsT) MAP, 99 Page 4 of 4 pa ,":CS

MEDCOM - 22811

DOD-036387

ACLU-RDI 1673 p.171



DATE: 4 pgc,05 I PATIENT ACUITY LEVEL : POST-OP DAY: HOSPITAL DAY:

t

Q Z

ft) L

I - LII C

r

....• COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Tare To From 0 •muut.•.ToRY 111 cRuTcrirs II v:HEELCHAM Il sIRE7c,,ER


ProcedureilDiagnosis BY P -

LOC ∎ . ascular checks

Dressingicast Tubes

Intake (IV, po) utput (ESL, other) Voided III No U Yes Amount:

Medication

Other

Report From Received Sy

>

U) -1.

Z cn

TIME: (1,(jD 3199 0400

OP ARTERIAL LINE ,,...........' „../-

BP CUFF Ilio

eti C 1(

KO

NG) % e3

10‘4,9

/7' 6c-

TEMPERATURE

PULSE

RESPIRATORY RATE

OXYGEN (Li%)

PULSE OXIMETER A i7 iii i i

I A 02 METHOD

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = :=ace mask VM = Venturi mask

MT = Mist tent PR = Partial rebrea her A = Aerosol TC = Trach collar

eL <

— Z

TIME: riAja 124564 On TIME: 9,2,10

'Skin breakdown prevention ...._


'Restraint protocol


.Isolation precautions

PAIN

INTENSITY

io

5

. .

. .

..

. .

. .

..

. .

. . . .

• • .. • • • • ./74

..

. .

• .

. .

• • X.-

• • . .

. .

• •

. .

• • . .

• •

• • . . . .

MED ADMINISTERED IY.INI

RELIEF ACCEPTABLE IY NI

t,1

—<

si.

.. .. . OH

ziu

cc

TIME:

YESTERDAY'S . .';EiGHT: FINGER STICK GLUCOSE ___... . _ ...

TODAY'S V;EIGHT: INSULIN l'fifil

W.EIGHT CHANGE:

• P...r h:Dsp.:31 ool:cy.

24 HOUR TOTALS

PO I IV 01 IV #2 I TOTAL IN Urine Stool

I

TOTAL OUT

PATIENT IDENTFICATION

(. (G )

/

DIAGNOSIS: //i9 0/00% "I f litl.° 5 4cA- -f 1.---1 1.7

-- DRG: ADMISSION DATE: /1/0a ••••'

,

LOS: '" 7 T F SE .(

CAS C( o)

CASE MANAGER: o)M,,7-?._


ISOLATION REOUIRED (Specify):

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PnEYIOUS E D ITIO%S ARE ORSOLETE -are 1 of 4 pages

MEDCOM - 22812

DOD-036388

ACLU-RDI 1673 p.172

Jt1... I ION II - VMIOI\JI mooLOJiv ■ Liv • may itvw hr O tOIOVIO

,RECT:...C: A c' - ..::.: ./ in arc sn;alf box. indicates patient assessment criteria have been MET, IT all the s:a.'ed criteria ate not met, a brief plana:ion of a.')::: - •::3' h•:cf:ngs wi2 be notal in the appropriate cohrmn.

1 r..!E : 15 it) INITIALS: TIME: z...:" INITIA TIME: INITIALS:

1. NEUROLOGICA'_: AIer; and oriented to

:me place 3:1d ire-' app:coriateIy.

',.jpils eq...ial and re7::::ve ;0 :;LINt.

Zon -17-1 ,-ic;.:Ion is ,.:::.:1::::' I0 C5OlCs5 needs,

.,—.0.7, I .

i L. I I

2. CARDIOVASCL,LAR: Pulse :egula: & :ale ...ithin :ono Icr a:.e. .....: i-Jcpendent edema. Nailbeds ai -.:.: mu -..-:.-a : ,-.e7. - Iiranes p:n.k. No ,calf :enderness. (See .1- 3.7..? 2 .'t- eytremi;/

:serfusic.-4:1

L.L../.... • ;

3. PULrACNARY: -.2 es.:::•a:,ails v..i.,1)In nornial - ate for a-,:e group: 7.... Cl a . -.f.1:eguiar. Depth is

egular. NJ cough. No a .._.: -..iortra! broach

SJL:ftdS.

. G.I.: ,:-,.00:-.lar: a:ft sna: nor.-distencled.

Bowel owel sounds aCti.- e, FI.epor;s ni: N:V:pain

with eat:n -g and co :::o1;:e.iris chewing/

swa:lo•.ving,. Denies zonstipation, diarrhea or

- ectal bleeongi

L---(1)' 6/0 1-'fri D VORPAr :V11 1.'5

i/ 1

5. G.U.: Reports - i.: jisi.;:lo, re:en:ion,

,rgency, frerene ,•. 7iacturia. LI;:ne clear,

• ello ■-:;a:-.•.bar. No _ -.L;sual c:schargc.

! CV' : r •

Li

5. MUSCULOSKELETAL: Normal muscle117 7-- ;--i ,

tevelc;:i7 , artt. ai -i.d 77 ass ftit age.. No i at-,A) _

teformI;:es. No asa . at've ,teviaes needed.

';orr-r.e.1 ac:: -....o R',...! ....:-: per. No joint

3.-vie;:inc landerness. iii..es.: -.ess or pa•esthesia.

7. SKIN: ..I.Iarrn. ,•.:-.. :::lac:. Good turgor. No - ashes, infIa-i:-.-.az . o - . :.:::.'e:'s, b:eaks in skin.

=rominencos. Mcc: - .s rre:-..braricis mo:st.

No :ed7ciss, bianc! .. n over bony

I i (•, '—' lq) C,•6\iql(n)

CA-3-

7-1

, B. PAIN: No. corr.::. ,:--•: - Is cf pain' discomfo:t. See pace , !::::- .7:::_ -.7C.II:i'":.7 ,:),Ia: irt ■ Or:Si%V)

\-

S j2li-C-AA. i

.

!I -! . i CA:: 0/.9 ? lilt )IC.,

i 60. in 4/ 5r a/7 , .. - ,..9

Arc o ce -1--r1-705:1/44

D

B. PSYCHOSOCIAL: -3.:::- .a '::::/: :5 a;:propriale i ' .0 the si*.ualion. A - •.:-.1t-, Is centrsIled or rn:io I — 0, )124 and appropriate to a : .,;.:C....7 -I.

',Dp1Opr,r,:e:y v.'1:h :.. I _ cloyo !'79i

-L._ n

,.. ,\., SITE ASSES-:-:!:.=NT: ;LECiENC.:: P I • Infiiied R - Reodened OK - No sweIling:-edriess * - Centraline)

- IME: \5\E) INITIALS: i TIE: "2;240 INITIALS: I TIME: INITIALS: _

IV pate --,:-.- I 7: :-.:. i I'.' ,-:eIency ../ Pt- !),: ; IV patcncy I O hr: —

IV site aa'e ;, :C'; , 7 2 f: IV a:le Cafe IJI0vI ,Je.z.I: IV SI;C! Care ;.:rovidcd:

iV tuti,: -.; chn-igc:: IV 7. ,,iblirli.; chanced: IV tubing changed:

1- ; C.:ND:T:0:4

'`./ Site :1: -..-- P-- ot-

CATICN CC::DrriCni

:v S o. g: : 6'

Locivriorii CCNDITIC,J

IV Site ',,I i:

V Sue -, 2: IV c:.zie 0 2:r IV Site

".-.o,--.-.e,•:5- _ _ _.__.....

______.. ______ ...... ..._.

Con•i- - erits:

---•- -- - --• -

Co..e,-..:3:

._______..._ ______... _

'TEST) Milf;

2 of 4 p.3gOS

MEDCOM - 22813

DOD-036389

ACLU-RDI 1673 p.173

SITE: TIME: I TIME: Wib , -z3t, band visible:Icible

Orient to environment prn .

COLOR -------------

—

CAPILLARY REFILL

ilY4 Side rail(20) up TEMPERATURE

Bed position low EDEMA

Call light within reach SENSATION

MOTION

PASSIVE FLEXION Review & post lab results

Notify MD abnornIal labs PERIPHERAL PULSE

_ LEGEND

Color: P-pink (normal) -cyanotic; W-pale, white

Capillary Refill: 1-( -2 secs); 2-13-5 secs); 3-(> 5 secs)

Temperature: cool; W-worm; H-hot

Edema: 0- •ne; 1-miId; 2-moderate; 3-severe; 4-pitting

Sensatio : A-absent; N-numb; T-tingling: S-sensation (present)

Motio U-unable to move; M-move-no pain; P-i:love-pain; R-f;.:II ROM

Pas,-ive Flexion: 0-dorsal flexion pain; P-pinntar flexion pain; 0-no pain

Peripheral Pulse:

0-absent; 1 -weak; 2-normal; 3-strong; 4-bounding;

D-dopplar, P-palpable

Incontinent urine:szool

Linen change pin

ir --......'

Turn:reposition (1211 _______. ____ __

ROM q2h if immobile

Antiembnlic hose


TYPE: TYPE: 0 TYPE:

PERCENT CONSUMED: ID PERCENT CONSUMED: PERCENT C -UMED:

HOW TOLERATED: t.....,,e,‘,..\ HOW TOLERATED: HOW TOLERATED:

fET-SELF 0 ASSIST E COMPLETE i E SELF L2 ASSIST 0 COMPLETE. '''''sE,_:: EJ ASSIST 0 CC,'MPLE - E

0700-1500 . 1500-2300 230-0-0700

BATKORAL CARE COMPLETE SELF i COMPLETE

E ASSIST 0 TOTAL ■ 0 ASSIST 0 TOTAL

:=2: SELF E COMPLETE

0 ASSIST E TOTAL

TYPE OF ACTIVITY (Circle all that appy)

BEDREST .....--"-S-E-LF ; BEDREST L_‘-/SELF SEDP.EST E SELF

AMBULATE 1_.1 A'S:3:ST

BSC # TIMESISHIFT

ERP

CHAIR

AMBULATE D ASSIST _ _ E ASSIST

BSC I6 # TIMES/SHIFT . # TIMES:SHIFT BRP ; BR?

CHAIR : CHAIR

TIME; KID INIT;1-.L. , TIME: "7 r/P INITIA' TIME: :NITIALS:

CONTENT:

-•.•!>1. -

(•-\›0„..J.,--- CASY\K\i"-(5A

gel- Patient;Famiiy Vnrhall,-.1s Undcrstrincliivi

CONTENT: CONTENT:

•

---" -itiont' rt - •!'y Verbillilms 1 ,'1C ■ CrSilt1 .1111 ' 0 Patio , zes Understanding


.111111, ,

1

INITIALS

INYIka

/7/ : . _ _

SHIFT

1

5---

MEDCOM FORM 689-R frEsr) (IVICHO) MAR 99

Page 3 of 4 pages

MEDCOM - 22814

NJ

DOD-036390

ACLU-RDI 1673 p.174

r_O

DZ

I21 0

<C

r ud

,.. CCAiION OF wou::0

E

A=?EARANCE

T.,..EAT:.•E'.7S

A% -1 DESS I-:G ■.7.-, ACE

la, jtai.L...e \ 5 (0 • 6,\-,-- . cic-).-

- ----• -------

SECTION IV - NOTES

, 7r in )027, 1,,./ ./ / c-, -1--er , , ___/_____ ____

O.W FORM 689-R /TEST) :,Ci-IO) MAC 99

PO3,24014

MEDCOM - 22815

DOD-036391

ACLU-RDI 1673 p.175

MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET For use of this form, see MEDCOM Circular 40.5


DATE: PATIENT ACUITY LEVEL : POST-OP DAY. HOSPITAL DAY:

cr: <

( f) ti cc

COP. PLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN

Tirre To From II

- TELEPHONE REPORT:

AmsuLArcity IIII CRUTCHES V.'HEELCPA:R III STRETChErt

Total ER: . RR/Pi:k ' inle Physician Anesthesia (Speedy):

Proc-_=,:fureiDiagnos:s B,P P R T

LOC Neurovascular checks

Dressig.'cast '''.----......................_

Tubes

Inta:e IPJ, pc)) Output IEBL, other) Voided In No ❑ Yes Amount:

Med:Z:37ion

Other .

Repo , : From Received By 11

>

(7

TIME: joy,. 4' : a , EP ARTERIAL LINE ........--

BP CUFF =gm , ,

TEMPERATURE M. i g

PULSE MEI

4'

g°1

RESPIRATORY RATE irmorin /1

jk, OXYCEN (L/9'd Wall

PULSE OXIMETER efet 02 METHOD PA

NC = Nasal cannu:a NR = Ncn rebreatl et - Frvi = Face mask VM = Ven:L: i mask Ovr z:er, Method Key:

MT = Mist. tent PR = Partied rebreather A = Aeroso TC = Trach collar

< Z

TIME: ii" 13c{.0°

LU

<

Z L

IJ

11-1 0 C

D

TIME: ! MO &WM

o

5 ,.TENSITY

PAIN

' • •

• • ' ' •

Skin breakdown .

prevention ...._. A 'Falls prevention protocol

'Restraint protocol

'Seizure precaucns i f4 1

. .

• •

. . .

• • . . . . . .

• • . .

. .

• • . .

. .

• • . .

. .

• • . . • . . .

ACED ...DMINISTERED IY.NI

RELIEF ..CCEPTABLE iY NI 'ISOlatiOn precautions

0 I—

w cc

T I M"-- : . o'• "IFA,,, YESTERDAY'S '.•..EIGHT: FINGEF. STICK GLUCOSE

_....... _... INSULIN 11'.741 TODAY'S 7., EIGHT:

• EIGHT CHANGE:

Per hOSC,13! Co!..:-.

24 HOUR TOTALS

PO i IV #1 i

IV #2 I C. AL IN Urine Stool TOTAL OUT

PATIENT . DENTr'ICATION

EN 00)(0—Li

DIAGNOSIS:5 19 Q.,(Cui ( ■ 14 011it 1 0

DRG: ADMISSION D SI ()eV cr- LOS: EXPECTED RELEASE:

CASE MANAGER:


ISOLATION REQUIRED (Spec y

NIED=.1 FORM 639-R (TEST) (MCHO) MAR 99

EDiTIONS ARE OBSOLETE

,--age I of 4 paces

MEDCOM - 22816

DOD-036392

ACLU-RDI 1673 p.176


'- ,'F.r..ci-- T.'..C. - A dic..:-..; „/ ,:n 1 110 so:3U .5,9X indicates atient assessment criteria r. lave been MET. if all the sated criteria are Oct mer, a rtel ,i..\p /ana..tc , of ob7;w:::.3 : !: , !7.2,7/i/S Wiil be noted the appropriate column.

. TIME: 1100 /NITIALS 'MC- INITIALS: TIMEEPK3D INITIA

1. NEUROLOGICAL: ; , :e.r: nod onented to

:':r.e ....d name. .r-:-,:sponds appropriately.

:or--- -- u -.; - : , :lun is ;...de- - ,•-, :o express needs. == u pils ec.....ai and :...e :CI Liht.

, • A -

tcu[-VP; x 94 ,.■ • , .r

(00Y1^R.AC COY-IV

ke '5- 5erifa- 1 •

I 1 Pk-VW-

afka3) \61

ef14-C-4

Li 2. CARL,, i3VASCULAR: ;'-'LlIse regular & r. -,:e within rance for n_.'. ts:. doprIndent cdon , a. %:allbeds a ,-.d mucous n..e.-.-branes pr.. No calf :enderness. /Site P390 2 .',:r e.vrtemit'y .:-., er;us,- 0 ,3)

;1 (q1 CY7---

3. PULMONARY: TRes,:a:,ons v..i:hin norn;a1

ate Io: abe group: q;.:,-; ---f - o:.• ,-)i- Dep:h is . ogular. N.:, cough. No s:: -.orrral brea:h

sounds.

____ _ I

:ly

4. 0.1.: ,:sf .::or: , en sc..!1 nod non-distended.

-.4owel sc.::27-.ts a:-,ti ,.a. Roports lc N.V1pain

with said; and CIO p:.cf:ems che ■.-..ingt

swallo ,..,..n;:.,. Denies consic.,aion, diarrhea or

'act a) fleeting.

_ 19A- L CIO 0/7_151,4ra+)01.-,... p la UAS <P,C.'Yr")

CW tOtCLAt 5-'42'0 •

5. G.U.:

=:eports no t., - suria, retenn tio, ..rgency, f , equency. nfcturia. Unne clear, ,-ellos,...;a:-.•.fer. No ...;nus ...:2! discharge.

71 • Li k•-•',

(19--Q-0--S Ltti

5. MUSCULOSKELETAL: Normal muscle 1141 mak; /Ii, tt E 1_, T-itis)e0,-.4mssAl . i

teveic -: , :::-.: no mass ' or age. No ,)1 deforrnit'es. No ass:s::ve .fevifes r.e.eded. glil /J4 SiYr71eg7) '•;c-srmar a.::: . -"2 Rom .... - .: - :-...: Pa:o. NO .Z)ir.t

sweilinc ..e , derness. '... - ea..: -.ess cr pa•es:hes:a. 4,ran-yt-c,--oo - : 7. SKIN: ':'srm, d:y, intgc:. Good turgor. No ! 1...4/...--- ash ,- S. rnf' ,-..:mation, :.:::ors, bucoks in skin. i —

No red.-.ess, bIancllic_;. : , ::::,..7:cr, over bony Pfon ..inenzes. Muc:-..-.•-:s n!c: -..crancs roust. 1 i

3. PAIN: No comp;a:: - ts cf pain., disco:-0.fort. 1: : 'See ,:.:ace I for o'ocur. -70'7::"73 ;00I:7 if;;;.'n51:Y.%

9. PSYC.:-::::SOCIAL: F...:7ay . :;• ..s appropriat:7! fl.

_. controlled or 71,i'..1

sod a7'P , 0::::.ale :0 5::ud:• ,:.-- :u.:C:0C.:s

eoproora:e.Y vith o:hrs.

O. IV SITE ASSESS:VIENT: ;LEGEND: P Pi;!'y I . Infiitra:ed R - :-3e.dcencd OK - No swelling.''edness * - Central line)

- IME: 1100 :%:TIALS: TIME: l !NIrTIALS: TIME:cQ, lt:ITIALS: , V pa:-:..7'.: .../ ..- q vg . i'-' • - -••,cy / q

w

-:. ' • '''. • IVain,' ,/ q ''' .41..... Al

• 7--- IV s::e fsce ;•ro ...idof: 05-51::$ r,./ .st2 care r;f0'1,_;:r.': :V site 87..7:7'..' .7.:7;V:ded.

AIM Z4—.. :V lilt:r.c7, :ha - god: 1 IV t ,,,fing changed: AIIIIIIIII IV tubing changed: •

c-f%D:7:3!,

17,49-- Or,

LOCA - ii CC::::::IIT::)

, :V 5::c .7'1:

jer CCGDITIC!! ‘

IV Site

V St.' =2: IV S.Ie e2: IV Site 52: ----

1. --6- fc, co.-:-. :,.. , Ai,

6,17 .%•!":: S MAR 99

2 of 4 pages

MEDCOM - 22817

DOD-036393

ACLU-RDI 1673 p.177

(6) 7J D

r- C

O W

D<

0 C

m

SITE:- LLE T its! E: 1_10 -9741)

LL L

1J

>-•

TIME:

COLOR

CAPILLARY REFILL

V ID band vis.ble.10pble

Orient to environment pin ) 1--

TEMPERATURE 110 Side rails 12/4) up

EDEMA 4 Bed position low

SENSATION 5 S Call light ‘-iithin reach

MOTION 777—c)

PASSIVE FLEXION

0

CC

Review & post loh results

Notify MD abnnr.11ai labs PERIPHERAL PULSE f-i- LEGEND

Color: P-pink (normal); C-eyanotie; W• pale. hi :e

Capliary Fletill: 1-i0-2 secs); 2-(3-5 secs); 3-(> 5 secs)



Sensation: A-absent; N-numb; 1-tingling; S-sensation (presen:)

Motion: U-unable to move; N1 , 11tove-no pain; P-move-pain; R-ft.:II ROM

Passive Flexion: 0-dorsal flexion pain; P-plantar flexion pain; 0- no Paw,



Incontinent urine:stool

Linen change pm

Turn.reposilon ci.2h

ROM ,.-12h if immobile -.. :o Antembolic hse I

I • o - w

BREAKFAST . LUNCH DINNER ...-

TYPE: jt......:.■ - . TYPE: rZ. e. TYPE:

, .c---) PERCENT CONSU%tED 111. 0 fy,gtAfe, PERCENT CONStED: Kiev ii-0.1.4kii PERCENT CONSUMED: 50 eh HOW TOLERATE -2J: kir.. 1 HOW TOLERATED: HOW TOLERATED:

E SELF frK ASSIST !=_—] COMPLETE ,..._1 SEI F L.: ASSIST 0 (2.0%".PLETS. . 0 SELF L..] ASS:ST 0 COMPLETE

<

6

t--_ w <

C_) - Z

0700-1500 1E00-2300 2303-0700

E.ATHiORAL CARE E SELF E COMPLETE E SELF 0 COMPLETE ,__.: SELF Ei COMPLETE

:. 1 ASSIST L_i TOTAL ni ASSIST n TOTAL "; ASSIST E TOTAL

TYPE OF ACTIVITY (Circle all that a pply)

TIME: INITIALS:

SELF

Toe ATE E E ASSIST

BSC

4' TIMES/SHIFT 1

ERP I

BEDREST E SELF -3EDREST LJ SELF

AMBULATE 0 ASSIST AMBULATE 0 ASSIST

SSC .. 4' TiMES.SHIFT

E..SC ;-' TIMES/SHIFT

BRP EF"--.P

CHAIR ,...,-...r-k

: TIME: INITIALS: I TIME: (9.11-X..... :NITIALS

CONTENT: .: ! CONTENT: ] CONTENT:

•

.• '

&LI Gr 0 ‘%f•• ••

0 Pltient:Faimly Vefbali/es Ur.,..-rstrindin ,-. 1 . i_J Patient . P.- : ,--'y Vwbolilesl)-.ders:.-Inding 4P,Then P.rniIy Vert.,:izcs Understanding

PATIENT IDENTIFICAT;ON INITIALS SIGN TURE SHIFT

. • - - 12,Pr

. e)

\

MEDCOM FORM 6,99-R (TESTI IMCHO) MAR 99

Pafje 3 of 4 pa505

MEDCOM - 22818

DOD-036394

ACLU-RDI 1673 p.178

H o

o <cc

T 1

•.-1 E

L 2 CATION 0:-• •,...C.L;ND AT•PF_.•..7;.ANCE

_

`1 ,:E.:17!.•E'-.7S- .!-%::

DRESS::G C.- , .:..^:3E

7,----- . 0

_ _ _ ---

----- - ----- __

SECTION IV - NOTES

()nal fa.4 frlf 1'121 ,

. . _. ()(k,) -7

.

.

i .

______________ _ . . - _ __ _____

_ . ___________ -' - .. _ . ._ .._ .. . _____ __ ____

_ , . . , .

__ .. _

_ _ _ _.. __ __.. _ _ _ _ __ _ ._._ __ _ _ ____

A.:SOC.:5M FORM 6.3.1.3 -R (TEST) 171.-fC1-101 MAR 99

Page 4 of 4:

MEDCOM - 22819

DOD-036395

ACLU-RDI 1673 p.179

LOS:

CASE MANAGER:

PRIMARY CARE MANA — 1111111111

ISOLATION REQUIRED -SPeci 1 1

EXPECTED RELEASE:

MEDICAL RECORD - PATIENT ACTIVITIES FLOV/SHEET For use of this form, see MEDCOM Circular 40-5


)ATE: ,-.-..) ---•zejyr5 I PATIENT ACUITY LEVEE :tr_ POST-OP DAY:SA gi HOSPITAL DAY:

CL < Z

Cf) U

IL

I Cr

[COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Titre To From ❑ At.-isuLATorly II CRUTCHES ❑ WHEELCHAIR -.111. TRE7CHER

Total ERiRRiPACU time Physician Anesthesia (S

Procedure/Diagnosis DJ., P R T


Dressingicast Tubes

Intake (iV, IEBL. other) Voided U No ❑ Yes Amount: po) utput

Medication

Other

Rep rom Received By

>

Q—

I u)

cn

TIME: h_co 2 1 0,00

BP ARTERIAL LINE

'Webs/

Nie 75rat

f'%

i7

• i• ip

"ire( 4/5741 7)

no

BP CUFF

TEMPERATURE

PULSE

RESPIRATORY RATE

OXYGEN (Li%)

PULSE OXIMETER fiq-767

2.A- f.77 ktr

it7a

02 METHOD

I

NC = Nasal cannu,a NR = Non rebreather FM = Face mask VM = Venturi mask Oxygen Method Key:

MT = Mist tent PR = Partial rebreather A = Aeroso TC = Trach collar

< —

Z

TIME: ticia 12eto I vx, 7)..(yj i

c/)Ci

wU

—Q

w Z

U

J C

I 0

I

TIME. 1 0 X 2 1 30 • Skin breakdown

ti prevention " . . .. _

PAIN

INTENSITY

' • . . • •

' ' " . . • • • •

• ' . . • • • • • Falls prevention protocol

'Restraint protocol m9_. • • . . . .

• • . .

• • . . . .

• • •

. .

- • . .

" •• • Seizure precautons

1 .Isolation precautions

MED ADMINISTERED IY.,11

RELIEF ACCEPTABLE IT NI

I

Y —Ij

Nle ___ —_

_ . . _...._

Ad 0 I —

I: C

u C

r

TIME: Ir•

YESTERDAY'S ••EiGH.T: FINGER STICK GLUCOSE ___.. INSULIN MN) TODAY'S V. EIGHT:

WEIGHT CHANGE:

• Per !losP.• 31 poi:-•.

24 HOUR TOTALS

PO IV #1 V #2 TOTAL IN Urine Stool TOTAL OUT 1 1

PATIENT !DENTIt'ICATION

r---"._r\--7 ..--'\

DIAGNOSIS: VP Cra,41kdi ..._...arla II'I °

nP.r,• Anm:SSION D - 1 MT ca."-,

MEDCOM FORM 689 - R (TEST) (MCHO) MAR 99

P:70..10LIS EDITIONS ARE OBSOLETE

Pa c 1 of 4 pages

MEDCOM - 22820

DOD-036396

ACLU-RDI 1673 p.180


".- lf-:CT::--- ...c: A C/; ■:'.":. :C i i:I ;in: small box indicates patient assessment criteria have been MET. If all ;he s:a:ed co:or:a a:e not met, a brief a.xPlanza:-=:: , of 0 :'" .!--'' ,,3: l , ' , G.-"'gs will be nore,1 in the appropriate column.

TIME: INITI

:Me p:,2 6 , ),J.na'r:e. E.......s .,?; -)ails r,...p:upria:cIy. :0,-71,--.:::Jon is adi:::::::i:c: to expicss ncects. jpils ec-.o1 and rei::',:ve to

a INITIALS: TIME INITIALS:

T. NEUF-+OLOGFCAL: /der'. iii-ii,I orien: e d t o iiiiiek+e-A

at ' 41

I I

2. CARDIOVASCULAR: ?;.:!se regular .F.. :r!:e ..ithin r3r.s.,..2 fc.r arie. No .d.120ritfew, crdrainn.

-Nailbeds cii -ii2 tri -Jor;t.:s , i;crri•Iiiinirits pi:. NO ,-..elf

tenderness. f.S. , -::::,73-;•.7 3 /or eyriemi; :„..

.-..-.e.rfusipr:j

!L.,:ie"."--- i I

3. PULMONARY: Fricspiratiions i....i:Iiiin •ri.- r• ioi

'ate for a',:e crcuO; cL'et and :c.gtriar. Dep:: is

"7:9J1E3r. NJ cc.-.t.,, gh. No a."..r:0r:-.-0! D7C3;i1

sounds.

Oid4raeltisit5

cv"-F4 c, Vx. v

:-- i i I, 1

1. G.I.:A5don....2n se .3:)d r"on.if:slended.

''''.ovvel sc...:nds a .-.1r.re. Reports no N..V.'pain

...fah eat;ng and no e:cbiems chev:ir.g/

swalIowit -Ig. Denies constipation. diarrhea or

14---

ef2-taira PO

is 'l 441k-P

ivir .__.

5. G.U.: Repor:s no dysu:ia, retention,

....rgenc,. fregLe:-.::y, ncctur:a. Urino clear,

yeIlov.•,ate.r. No '._:nusua! dischargo.

FT W...?1 , LI • -,

5. MUSCULCSKELETAL: Normal muscle

fevelo .,77.. -•er..: .2 , e. mass for ace. No

teformi:'es. ND 2S3:5::\'C ..-"-:.vices fleeted.

s;vei!ini: 7.:.erress, wea.,ness cc pa•es:! -Iesia.

- 1 (///e) d/

rl''. 4 - Pan +° ©1"-- . I

,...i. -, --CiSig4C1 tl-, Ct-PAI`094 m ai, IJILI t- Li-

I n7b.. ( ca1'€5 -t-1-

7ashes, :::;!.-: -.1:rtion, ....::::::.:75, brcaks in skin.

o red7C'SS : D:Znf.::::7g, ::• ■ !,.:,-. ,.;cn over bony

7. SKIN: ...'a , rn, Ory, in;acz. Geod tumor. No ..

--- ad-446 0Jh 11.b

•

I

■

9. PSYCHOSOCIAL: F.',.z., !-.av:or :s aDpropria:e ' .

and r.i .,Dpro..7ririte to si:LiaIit'an. ii.:i -Nacts

i , i .

I

O. IV SITE ASSESSMENT. '.1_ ,, f,:=';D: P - F-',;!•, , I - Inflitra*.ed R - Reordened OK - No sviellingi-s&ness * - Ce -“ral line)

I - .ME: INITIALS: iTIME: INITIALS: TIME: INITiALS:

i\./ patia. - .7y I '.1 I -..:: i I'.., pe'.ency i qlilt: IV patcricy I q _

V 5:10 .7:Cf.."' 7: . :-:.,--,...:•2j: IV one core oro.vided: IV SIC c.:;7e .or•-_,•vided:

:v rut-,..-.g- c!--.Ded: IV :"..11:...ing cha d: W AV AII IV tubing c!lancied:

C:...D;7::::.'i

:,./ Site r', 1: \

LOCA .; t4 IC; ;TION LOCATION CCP:017'10N

IV Site 51:

../ S.: ..e ,r2: IV S.:e -12: Illy IV Site 52:

:-.,-,-.-:-..-.. •:s

■

ro,.--.-i7,-n:s:

.----

r ;.'":CO ! TEST.- 99

Pge 2 ol 4 pages

der MEDCOM - 22821

DOD-036397

ACLU-RDI 1673 p.181

Z

r*: 0

>

(/) D

<

CC

SITE: Lt TIME

COLOR

.90,111,.. 0

i m

TIME: '•

ID band vis.ble:!eqible

Orient to environment pen

..Iiiio..--,,.... . , .- .1 ink

Sir I Li

•

CAPILLARY REFILL I — TEMPERATURE V-5

Side rails I2/' u'

Bed position low ECEMA

Call light within reach roil SENSATION

oli

I

MOTION

PASSIVE FLEXION 9

CC

LEGEND

Review & post !oh results I Notify MD abnormal labs PERIPf-IERAL PULSE

•• Par

Incontinent urine stool A Color: P-pink (normall; C-cyanotic; W-pale, white

Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-1> 5 secs)

Temperature: C-cool; W-1,varrn; H-hot

Edema:. 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting


Motion: U-unable to move; M-move-no pain; P-move-pain; R-!(.:11 ROM

Passive Flexion: D-dorsal flexion pain; P-piantar flexion pain; 0-no pain

Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-beunding;

0-doppler, P-palpable

Linen change pen

Turn.'reposition q<, 111061 RO;v1 q2h if iirmobiic

Antic:1)1)01,c linen

I


TYPE: I TYPE: l_.,..!-L41. TYPE:

PERCENT CONSUMED: V--y'ej I PERCENT CONSU:',1ED: 'Go I PERCENT CONSUME

HOW TOLERATED: HOW TOLERATED: tt i Led HOW TOLERATED:

E SELF ❑ ASS:ST ❑ COMPLETE i : SELF L__: ASSIST ❑ COMPLETE ❑ SELF J ASSIST ❑ COMPLETE

0700-1500 i 500-2300 2300-0700

SATRORAL CARE ❑ SELF ❑ COMPLETE i ❑ SELF Li CC..':-..1PLFT I Li SELF F__:1 COMPLETE

ASSIST ❑ TOTAL ri ASSIST ❑ TOT L ASSIST ❑ TOTAL


cEL, RES ❑ SELF BEDREST ;__: SELF 41333111

--D SELF

',.ASSIST AMSULATE ASSIST AMBULAT= Li ASSIST 4410531,

-, cr BSC ,,.:......

-ti TIvi,_S;SHIFT # TIMES:SHIFT I z 4' TIMESiSHIFT

BRP SRP P.P

(...1- 1-cd....D i AIR I CHAIR

QU

I-Z

0

TIME: INITIALS: TIME: INITIALS: I TIME: 2(-( 1,76 :NIT:AL

CONTENT: i CONTENT: I CONTENT:

s

60"

1 I •--- Vahli\

- Oc& &' • s - - caOf ,frf- or , if f

❑ p,,,;,ent."Fan,,iy veri,a1,7,,s urd,-,,,,,,,,,J,, , , a Patient (-- .-::—'y Verbalii.es lj•Iclerstandinri moat nmily ✓erba(izes Understanding

PATIENT IDENTIFICAT:ON INITIALS SHIFT

mom HP -L\ MEDCOM FORM 659-R (TEST) (AICHQ) MAR 99

Page 3 of 4 pagos

MEDCOM - 22822

DOD-036398

ACLU-RDI 1673 p.182

17

?:, .O

DZ

O -

-- C)

<C

tu

i

T L.C.- ZATION OF

!E.: WOL.:!:D

TP.EAT%'F.,%7S

DRESS!::G CANGE

111 v. • v. viva

fi) e hadak * -17-1 fr. 7014-Cei

- 25 direti IN adde- I Vii-Ot titrer 770S&F±MS

SECTION Iv - NOTES

i -i LIO rr r--- C.C/1.)/)

0 A.) 2;r- tivrAc:r ; 0

./1.-"' PICO _Z----- , f_/)

p9,p,A7 2c .7-/2,9mrio ---,04--___"7-- r...,, .,779c 7- 7 r1..-

- 5.3e.: c.

C) — Z

...

9.5

R-5-7-Piii,v(

.4 ,cpc.,

I L.,..-•,-;4-4.

4)077 t_-7- A.-2 E.cci2c)c.-tgr_r_s 6.-c.--..,g.

-i--19 Lc- C../--1 'LI< 5 - - ,..

A....FL:I.:Ca ..' FORM 6,99-R AMR 99

Page 4 of 4 ,7;77o5

MEDCOM - 22823

DOD-036399

ACLU-RDI 1673 p.183



DATE: /0ebOS PATIENT ACUITY LEVEL :---10:r POST-OP DAY, a.to, HOSPITAL DAY:. '3 S

T R . A. N. s•

F

E R.

, .

I. A . L::

1 ; . G. N S.

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE

Time To From I AMBULATORY

REPORT:

El CRUTCHES ❑ WHEELCHAIR I STRETCHER

Anesthesia (Specify): Total ER/RR/PACU time Physician

Procedure/Diagnosis B/P P R T

LOC Neuroirascular checks

Dressing/cast Tubes

Intake (IV, po) Output (EBL, other) Voided I No I Yes Amount:

Medication

Other


TIME: .1..U0 25taa:06

BP ARTERIAL LINE ,.

j1/5"z WI

147 BP CUFF

TEMPERATURE 'TY kra :( _ PULSE 5-2.- 7

RESPIRATORY RATE t(p 16 '

..

•

OXYGEN (L/%)

PULSE OXIMETER Iftex 1024

02 METHOD i ■ \

. NC = Nasal cannula. NR = Non rebreather ... FM = Face mask VM = Venturi mask

Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

A

N

TIME: j') TIME: e)

PAIN INTENSITY

5

•

• •

:

• •

• •

•

• •

•

: :

• •

• •

• •

• •

• •

• •

• •

s p

• Skin breakdown prevention a

• Falls prevention protocol 1--

. . . . . . . • • • • • • • • • E . Restraint protocol ci,;) LA- * Seizure precautions ADMINISTERED (WM Kl MED I

RELIEF ACCEPTABLE IV/NI .

A • Isolation precautions

- . L

N

0 '

T H

E R

TIME: E E YESTERDAY'S WEIGHT: FINGERSTICK GLUCOSE '

INSULIN lY/NI D S

TODAY'S WEIGHT:

..------- ....... WEIGHT CHANGE:

•Per hospital policy.

24 HOUR TOTALS

PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT


..{7(-) ,) -

40 ,--t.\,-uk

DIAGNOSIS: S7fiereitith'

DRG: ADMI ON DATE: 1 on LOS: EXPECTED RELEASE:

CASE MANAGER:



MEDCOM FORM 689-R (TEST) (MCI-10) MAR 99


Page 1 of 4 pages

MC V1.00

MEDCOM - 22824

DOD-036400

ACLU-RDI 1673 p.184

ate I ION II - VA I !UN I ASSESSMENT - REVIEW OF SYSTEMS

DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated explanation of abnormal findings will be rioted in the appropriate column.

C61C\--q-

criteria are not met, a brief

TIME: INITIALS: TIME: INITIALS: TIME: INITIALS: 1

1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately.



I I .../I µ V,/ -Ir m o'


'

3. PULMONARY: Respirations within. norma!

rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

n I I


Bowel sounds active. Reports no NN/pain


swallowing. Denies constipation, diarrhea or rectal bleeding.

.,,

I I

f 5. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

-(5- f00( 0❑ Unit&



deformities. No assistive devices needed.

Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

e --, pm. •oor--_,..,_ . _ _ ,1,1410./17k

1 5 Ude/IV-Vt ._ a cb -am

•

$' Willr i fe -

/ c

lir • •P 7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony


8. PAIN: Nc complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.)

9. PSYCHOSOCIAL: Behavior is app;opriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

LJ

10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line) TIME:___ INITIALS:

IV

IV

TIME: INITIALS: TIME: INITIALS: IV patency ✓ q hr• IV patency I q hr: IV patency . ✓


IV tubing changed:

IV Site #1:

q hr: IV site care provided: IV site care provided:

IV tubing changed: f IV tubing changed:

: cA N CONDITION

IV Site #17 LOCATION CONDITION

Site #1: LOCATION CONDITION

IV Site Feb Site #2: IV Site #2:

Comments: comments: Comments:

I

MEDCOM FORM 689-R (TFST1 (MCH01 MAR 99 Page 2 of 4 pages

MEDCOM - 22825

DOD-036401

ACLU-RDI 1673 p.185

SITE::C-Dt .„, TIME: j

cna

ww1--

>- 0

i— =

w CC

TIME:

COLOR ID band visible/legible

CAPILLARY REFILL I Orient to environment prn

TEMPERATURE IA) Side rails (2/4) up

EDEMA Bed position low

SENSATION Call light within reach

MOTION 1L (.6( Review id post lab results PASSIVE FLEXION

PERIPHERAL PULSE r'rn der-

Notify MD abnormal labs

LEGEND ...1----

ilff --/ Color: P-pink (normal); C-cyanotic; W-pale, white

Capillary Refill: 1-10-2 secs); 2-(3-5 secs); 3-1> 5 secs)









Linen change prn

Turn/reposition q2h

ROM q2h if immobile

Antiembolic hose

Li --


TYPE: TYPE: TYPE:

PERCENT CONSUMED: PERCENT CONSUMED: PERCENT CON MED: /75-leY0

HOW TOLERATED: HOW TOLERATED: HOW TOLERATED: ICO ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST 0 COMPLETE X SELF ❑ ASSIST ❑ COMPLETE

.

L

E,...._

N G

0700-1500 1500-2300 2300-0700



❑ SELF - ❑ COMPLETE


❑ SELF " ❑ COMPLETE

)4. ASSIST ❑ TOTAL


TIME:1SW INITIALS

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC

BRP # TIMES/SHIFT

CHAI

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC # TIMES/SHIFT

BRP CHAIR

BED" ❑ -SELF

..0m14:2100 X ASSIST

BSC # TIMES/SHIFT BRP

e.(6--IAIR-)

TIME INITIALS: TIME: INITIALS:

CONTENT:

paArk,- fyyLcumItiviAldvct,

Pa tien t/ .

amily Verbalizes Understanding

i, abiAZA-- CONTENT:

(9,5.)'

❑ Patient/Family Verbalize Understanding

CONTENT:



f)Iti°

INITIAL

-

411111111111111111 11—

I SIGNATURE SHIFT

—

MEDCOM FORM 639 -R (TEST) (MCHO) MAR 99

Pagc 3 of 4 pages -t

MEDCOM - 22826

DOD-036402 ACLU-RDI 1673 p.186

tt.. I ION III - IN I EAVENTIONS e„, TEACHING (Cont)

W

0 u

c A .

R

E

T

1 M E

LOCATION OF WOUND APPEARANCE

_Iviocitra...4e. ,

TREATMENTS AND

DRESSING CHANGE

aviD0 K6veAr- puiviemi- _ hi, i_t 1

AI ousla r-el P i VoiiG____i aly__

i UU -sz D (Aso b.

uo-/ ID ds(0_,& 51(1)3u.id-w —

_____

SECTION IV - NOTES

MFDCOM FORM 689-R (TEST] (MCHOJ MAR 99 Page 4 of 4 pages

MEDCOM - 22827

DOD-036403

ACLU-RDI 1673 p.187


SECTION I - PATIENT ASSESSMENT — •

DATE: Der,- I PATIENT ACUITY LEVEL : 11, J POST-OP DAY: 947. !HOSPITAL DAY:

.

A:

R

...

I A.

N S

COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:

Time To From III AMBULATORY ♦ CRUTCHES a WHEELCHAIR I STRETCHER

T. Total ER/RR/PACU time Physician Anesthesia (Specify): Procedure/Diagnosis B/P P R T

N LOC NeuroVascular checks

S - Dressing/cast Tubes

F Intake (IV, po) Output lEBL, other) Voided El No I Yes Amount:

E Medication

Other Report From Received By

TIME: MI6 a covoiril'' 1

.;.!.. BP ARTERIAL LINE 149 *Sg__ V: BP CUFF WeV" le_ c PM

TEMPERATURE 91' - .

• PULSE 4 RESPIRATORY RATE / Cr

(' \IlIp OXYGEN (L/%) PULSE OXIMETER i420 jylE, • Cm,

02 METHOD I.. ir .

Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar

TIME: Pia) /24o it-go09 TIME: 13C10-0

PAIN • • • • • • • • • • • • • • p 'Falls prevention protocol

10 prevention °A

•Skin breakdown — —

P INTENSITY • • • • • • • • - • - •

• • • • • • • • • • • . . E . Restraint protocol

•).( . . . . . . . . . .

MED ADMINISTERED IY/NI 0 I • Seizure precautions

RELIEF ACCEPTABLE IYIN) 1,6 A • Isolation precautions L

N._._.._

TIME:

T. FINGER STICK. GLUCOSE E YESTERDAY'S WEIG

0 I

H INSULIN IY/NI --- D TODAY'S WEIGHT:

E R 'Per hospital policy. .......—:—

$ WEIGHT CHANGE:

24 HOUR

r

TOTALS PO I IV #1 1 IV #2 TOTAL IN Uri ne Stool TOTAL OUT


UF - '49V4111—

A,.

go

- PRIMARY CARE MANAGER: u\ ISOLATION REQUIRED (Spec,

VP DIAGNOSIS: C... M. 1,1 DRG:

. 4(‘ at-GYYLA-S.-- ADMISSION DATE:

LOS: EXPECTED RELEASE: ISM CASE MANAGER:

MEDCOM FORM 689-R (TEST) (MHO) MAR 99


Page 1 of 4 pages

MC V1.00

MEDCOM - 22828

DOD-036404

ACLU-RDI 1673 p.188


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have b I MET If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column. e', C.);L

TIME: oci INITIAL TIME: iti5 INITIAL

I 'horkenArrili-e4A, . M1119e- C Nijg 4*

71 .

TIME: INITIALS:


time place and name. Responds appropriately.



H (\aro sr■l-p(-0, ) sf,_____r‘ .1 w.

rty_r_s,--n 1.-31\-)\--

2. CARDIOVASCULAR: Pulse regular & rate

within range for age. No dependent edema.

Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)

1 1,7

3. PULMONARY: Respirations within. normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath

sounds.





rectal bleeding.

•.

q. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge,

4[4 I 1


development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

0n S431 iVii ata

CIO ' .•. VV"e_aVA-R-24-:z--N .

-\-612-)(10' MOM —9 2-CrArl -A ILID - )1--

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin.

No redness, blanching, irritation over bony


V5(vbr -(3

Ak-.0.k., (5A) 1,-N_Qa_09_


(See page 1 for documenting pain intensity.) rt LJ

Li 9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

I1 IV .

10. IV SITE ASSESSMENT: (LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)

TIME: INITIALS: TIME: INITIALS: TIME: INITIALS: IV patency ..// q hr. IV patency ✓ q hr: IV patency ✓ q hr:


IV tubing changed:

LOCATION CONDITION

IV Site #1:

IV Site #2:

Comments:

IV site care provided:_ • IV site care provided: • IV tubing changed: \I IV tubing changed:

1101 • FHOtI CONDITION

IV Site #1: 0111r ION CONDITION

IV Site #1:

IV S:100,,, !V Site #2:

Comme Comments-

MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 Page 2 of 4 pages

MEDCOM - 22829

DOD-036405

ACLU-RDI 1673 p.189

Fl f .Dct.,.; tvil■ ill - rt, 1 icim , ;Iv 1 cnvciv I li 64 I tHl...11INCi Or

E 11,

•

V

.

U

TIME: 4O On0

COLOR P ID band visible/legible

CAPILLARY REFILL I i Orient to environment pm N TEMPERATURE 0.- tiO Side rails (2/4) up A

SENSATION N Call light within reach I I Bed position low / EDEMA

32,,t c9p

SITE: TIME: 1€59- I

(f)

LLI

>••

0 I-

u..1

MJ3TION U PASSIVE FLEXION

75 Review & post lab results PERIPHERAL PULSE Notify MD abnormal labs

S LEGEND Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stool

. - Capillary Refill: 1-(0-2 secs); 2-13-5 secs); 3-1> 5 secs) Linen change prn Temperature: C-cool; W-warm; H-hot

L Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting I A Sensation: A-absent; N•numb; T-tingling; S-sensation (present) R Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Antiembolic hose '• Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable

Tum/reposition q2h 411/k ROM q2h if immobile

1

- LU

I

BREAKFAST LUNCH DINNER TYPE: 111, l4 ye' TYPE: TYPE: ,-- PERCENT C4UMED: (7;15 Jo PERCENT NSUMED: 6070 PERCE T C SUMED: 1/4:714.D HOW TOLERATED: ‘&...lei. HOW TOLERATED: ce j y,,i, /" HOW TOLERATED: l(/0-e 3:RII SELF ❑ ASSIST ❑ COMPLETE 1?1 SELF ❑ ASSIST ❑ COMPLETE . SELF ❑ ASSIST ❑ COMPLETE

a.o

_1" I- LU

0700-1500 1500-2300 2300-0700

BATH/ORAL CARE A SELF ❑ COMPLETE ❑ SELF ❑ COMPLETE ❑ SELF , ❑ COMPLETE ❑ ASSIST ❑ TOTAL ASSIST ❑ TOTAL ❑ ASSIST ' ❑ TOTAL

❑ SELF IEDREST ❑ SELF BEDREST ❑ SELF TYPE OF ACTIVITY

AWRE JR! ASSIST A : U ATE Nr ASSIST AMBULATE ❑ ASSIST (Circle all that apply) BSC BSC BSC # TIMES/SHIFT # TIMES/SHIFT # TIMES/SHIFT BRP B" BRP

A lEra) CHAIR TIME: INITIALS: TIME: F,.. INITIALS: TIME: INITIALS:

Cali Ct5;%1

1 ell-1-

CONTENT: CONTENT: CONTENT:

L \-12.-Og iq:j,

(ill'i_C

21,1€133/Family Verbalizes Understanding /,(,Eatielt/Family Verbalizes Unclerstanriina ..1, Pationtignrelit., N/.1;,...r. I ... ..1 .. GII 10.1........A..... PATIENT IDENTIFICATION

•a• rii y •-• •-•• ■ IV 1,11V

INITIALS SIGNATURE

SHIFT

MEDCOM FORM 689-R (TEST) IMCHO) MAR 99 Page 3 of 4 pages

MEDCOM - 22830

DOD-036406

ACLU-RDI 1673 p.190

Stu I (Lint III - INTERVENTIONS & TEACHING (Cont) _.

W

0

U

N

A . R

E

T 1

m E


AND DRESSING CHANGE

a&

Plie

iAatildec

Sc./(.) k

zit/9_

,Pri-... 7LA. -- #-27---

P--,9- v - A ..A..t_

SECTION IV - NOTES

I j / ..• A .. ,.1 -_.- .....4.... .." ,

....._ , /

0 ---7

MED COM FORM 639-R (TEST) (MCHOI MAR 99 Page 4 of 4 pages

MEDCOM - 22831

DOD-036407

ACLU-RDI 1673 p.191



DATE: Ck--- .C.,, PATIENT ACUITY LEVEL : 14_, POST-OP DAY: HOSPITAL DAY: eta__

CC. ••=4 z

u- W

CC >

cr

Cn "

. Z

(/)

COMPLETE ONLY AT TIME OF ADMISSION O.P. PATIENT TRANSFER IN Time To From

- TELEPHONE REPORT:

. AMBULATORY ❑ CRUTCHES II WHEELCHAIR ❑ STRETCHER


Procedure/Diagnosis B/P P R T


Dressingicast Tubes

Intake (IV, po) Output (EBL, other) Ve'cled U No U Yes Amount:

Medication

Other


TIME: OW

BP ARTERIAL LINE

BP CUFF "VW TEMPERATURE 5‘r

PULSE Va

RESPIRATORY RATE I(1,

OXYGEN (LI%)

PULSE OXIMETER Ctil•

02 METHOD Or

NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Venturi mask Oxygen Method Key: MT =-- Mist tent PR = Partial rebrea her A = Aerosol TC --- Trach collar

TIME: OCMS-- TIME:

PAIN INTENSITY

to

. .

• • . . . . • •

• Skin breakdown prevention

• Falls prevention protocol .. . . .

0 . . . .

. . • • . .

• • . .

• • . . • • . .

• Restraint protocol ... _ .

MED ADMINISTERED IY/NI IA

) -


RELIEF ACCEPTABLE It'/N) 1 ' Isolation precautions

. _

0 T

"

H

E R

TIME:

FINGER STICK GLUCOSE — YESTERDAY'S WEIGHT:

INSULIN IYrNI D TODAY'S WEIGHT: S

WEIGHT CHANGE:

•Der hospital policy.

24 HOUR PO IV #1 IV #2 i TOTALS

TO - AL IN Urine Stool TOTAL OUT


5 \ Ni lir

( -)l-L)7\

DIAGNOSIS: 1.4--) OA-AA( DRG: ADMISSION DATE: /MN 03 LOS: EXPECTE EtU\SEt CASE MANAGER: __



MEDCOM FORM 689-R (TEST) (MCHO) MAR 99



MEDCOM - 22832

DOD-036408

ACLU-RDI 1673 p.192


DIRECTIONS: A check ✓ in the small box indicates patient assessment criteria have been MET. If all the stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.

TIME: 09 1.15- INITIALS TIME: INITIALS: TIME: INITIALS:

1. NEUROLOGICAL: Alert and oriented to time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.

Pki0)(2-

Yi yo Xtz-1"."-> -)\'

c.-. y V. 1-(,k- rt---x%/ ut ) 6., ,

ID si:ck-, v---triu-e s ,%

U/1 F-1


i


U.../ i 1 I 1



with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or riirtal bleeding.

E

S. G.U.: Reports no dysuria, retention, urgency, frequency, nocturia. Urine clear, yellow/amber. No unusual discharge.

--q---

6. MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.

Elg •s.■cis v..3 or.A.V.-ING li

S.s? 1: 0--4 sk -

7. SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

n ..,\t-C S A-6 2 G-1 cm -AP v... ty...-v..,,‘, %-...t..., .i1.- Asa .% ..,,44

W. Ar s) -Ito oesk.--y.s

LI

8. PAIN: No complaints of pain/ discomfort. (See page 1 for documenting pain intensity.)

9. PSYCHOSOCIAL: Behavior is appropriate to the situation. Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.

4' 10. IV SITE ASSESSMENT: ILEGE ■ : P P

—

3-

fly I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)

TIME: a 5L\ C INITIALS: __Ag TIME: INITIALS: TIME: • INITIALS: IV patency ✓ qhr:

_ Addl. IV patency ✓ q hr: IV patency ✓


IV tubing changed:

IV Site #1:

q hr: IV site care provided: ANN IV site care provided:

IV tubing changed: A1111.111

IV

IV

IV tubing changed:

LOCAT •N CONDITION

IV Site #1: LOCATION CONDITION

Site #1: LOCATION CONDITION

IV Site #2: Site #2: IV Site #2:

Comments- Comments: Comments:

/

MEDCOM FORM 689-R (TEST) (MCNO) MAR 99

Page 2 of 4 pages

MEDCOM - 22833

DOD-036409

ACLU-RDI 1673 p.193

MEDCOM FORM 639-A (TEST/ (MCH01 MAR 99 Page 3 of 4 pages


MEDCOM - 22834

• - - .3E, I ovro III - r, I eINI I ov I .n vcvi I iviva CU I cmur-iinno

N 1,.E. ....u.,

•

. R .0. V

A

• •. 0 . •

9 .L A R -t.

-..

SITE: TIME:

S

A

F E

Y

T H

E R

ROM q2h if immobile

TIME: , r Cl_ COLOR 1 11_11_ ID band visible/legible

I il CAPILLARY REFILL Orient to environment pm

TEMPERATURE MI Side rails (2/4) up

11.1 , EDEMA Bed position low

SENSATION -r

■ Call light within reach

. MOTION


2

PASSIVE FLEXION

PERIPHERAL PULSE Notify MD abnormal labs

Ir

MI f GEND

0 Incontinent urine/stool

-"MP'

,

S . Color: P-pink (normal); C-cyan c; W-pale, white

Capillary Refill: 1-10-2 sec 2-(3-5 secs); 3-(> 5 secs)

Temperature: C-cool; warm; H-hot

Edema: 0-None; 1 ild; 2-moderate; 3-severe; 4-pitting

Sensation: A--.sent; N-numb; T-tingling; S-sensation (present)

Motion: U- able to move; M-move-no pain; P-move-pain; 11-full ROM

Passive exion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain

Perip rat Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;


Linen change prn

II Turn/reposition q2h MI

". Antiembolic hose

:

E .

BREAKFAST LUNCH DINNER TYPE: 12R-C) TYPE: TYPE:

PERCENT CONSUMED: riot. PERCENT CONSUMED: PERCENT CONSUMED:

HOW TOLERATED: 6 V) HOW TOLERATED: HOW TOLERATED: pv4 SELF ❑ ASSIST 0 COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE ❑ SELF ❑ ASSIST ❑ COMPLETE

D L

- : s.

'

T E.

H ,i H I

N G

0700-1500 1500.2300 2300-0700

BATH/ORAL CARE /SELF ❑ COMPLETE


❑ SELF • ❑ COMPLETE


❑ SELF . ❑ COMPLETE

❑ ASSIST • ❑ TOTAL


BEDREST zn--SELF

AMBULATE ❑ ASSIST

BSC BRP

11 TIMES/SHIFT

CHAIR

BEDREST ❑ SELF AMBULATE ❑ ASSIST BSC

11 TIMES/SHIFT BRP

CHAIR

BEDREST ❑ SELF

AMBULATE ❑ ASSIST

BSC 11 TIMES/SHIFT

BRP

CHAIR

TIME: INITIALS: TIME: INITIALS: TIME: INITIALS:

,211

CONTENT: •

-OO?) --i-u d-tot....w- -i, rkA.-c.t,. 1-3

--- 30:> E o—,,,y(--._ s 04,(?,..46,_--

kms' Al Of

patient/Family Verbalizes Understanding

- 170--:-. Ca--1..1r2ri

CONTENT:


CONTENT:

❑ SidiNIIIILLFanli!v VeDrhali>ne I Irirlerctne.pi;.,e.

DOD-036410

ACLU-RDI 1673 p.194

Emikamimmomil F111611/411111

1,1 1111111M1•1111ra

1 99Z4*

511-119

NSN 7540-00-634-4124

M EDICAL RECORD VITAL SIGNS RECORD

POST-

MONT H-YEAR

19

PULSE (0)

HOSPITAL DAY

DAY

TEMP. F (.) 105°

DAY

HOUR Eih•Emi. 2'

D. TEMP. C

40.6°

40.0°

39.4 ° 0

38.9°

a) a)

38.3° 0

37.8 ° ui

a)

.> 37.2°

37.0° Cr

36.7° -o

00

36.1 ° a)

35.0 °

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

timmorismommura IIMMENNIUMONEBEI 1111111111111111 INIONEMMINEMMIlit PINIIIIMINEMINME110

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RESPIRATION RECORD

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R4


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

• ..

VITAL SIGNS RECORDS

Medical Record


MEDCOM - 22835

DOD-036411

ACLU-RDI 1673 p.195


POST- DAY _ MONTH-YEAR DAY P!D LI 2.1-- ..A1 ...

19 HOUR 3111Mini - • E.- ffillE111011111 . . i. 0 • 11111 • - I. • MIMI PULSE TEMP. F

(0) (*) 105°

180

170 103°

160 102°

150 101°

140 100°

130 98.6°

120

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70

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MEDCOM - 22836

DOD-036412

ACLU-RDI 1673 p.196

511-119

NSN 7540-00-634-4124


POST- DAY MONTH-YEAR DAY Mani

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170 103°

160 102°

150 101°

140 100°

130 99° 98.6°

120 98°

110 97°

100 96°

90

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80

70

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VITAL SIGNS RECORDS

Medical Record


MEDCOM - 22837

DOD-036413

ACLU-RDI 1673 p.197


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MEDCOM - 22838

STANDARD FORM 511. (REV. 7-95) SACK

DOD-036414

ACLU-RDI 1673 p.198


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REGISTER NO

IPP STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 22839

DOD-036415

ACLU-RDI 1673 p.199

511-119

NSN 7540-00-634-412


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ICAN 1

1111r-V:d\ MEDCOM - 22840

ITAL SIGNS RECORDS

Medical Record

STANDARD ORM 51.1. (REV. 7-95) Prescnbecl GSA/ICMR. FiRMR (41 CFR) 201-9.202-1

DOD-036416

ACLU-RDI 1673 p.200

0 0(000 pi -1 -ucik6 '7 -(1-23 '' 1-Las. p032..--fral.-2 yla../ · 2019-12-12 · DATE NOTES 0...

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