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ATIENT TREATMENT RECORl.. .",- .; eR SHEET
For use of this form. see AR 40-400, the proponent agency is OT8G
11. Register Nbr
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2
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I 3. Grade
I
IAdmission Remarks
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4. Sex
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5. Age
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25Y
1
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6'. Race
X
//
I 9. ETS
10. PrevAdm j
~. _ _•
i21. Source of Admission
22. Hour Of Adm:
09:05
Direct from ER
23. Clinic Service
ABF - ORAL SURGERY
25. Type Disp
TRF·OTH
26. Date of Disp
2003-11-09
27b. Telephone No
28. Date This Adm:
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II
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.---------------+-------+-------------1
24. Name/Relation of Emergency Addressee
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20. Type ca:l
DIS
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--+
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19. UIC I ZIP
18. BranchCorps
K78-PRISONER OF WAR/INTER
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17. Dept I Ben
15. FlyStatus
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14. Ward
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99
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7. Religion
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27a. Address of Emergency Addressee
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AdmittingOfficer:
_.bL~J!-1.
2003-11-07
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Marital
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S~tus:
30.~~;_~~~~dm
32. Units Blood Componenls
DaB: _
,
In/Out Patient: Inpatient
MOS:
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134. Diagnosis' Operations and Special Procedures:
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SIP CLOSED REDUCTION OF MANDIBLE FX
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35. Total Days This Facility
Absent Sick Days
IOther Days
l. __ ._(L_L
I ConlY
0- L
I Coop Care Days
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Supplemental Care
o
Bed Days
1 Total Sick Days
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: 35. Total Days This Facility
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dical Officer
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MEDCOM - 23351
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000-036927
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MEDICAL· RECORD
ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION (Enter dar e 0if admlssron)
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REGISTER NO.
WARDND.
ABBREVIATED MEDICAL RECORD
Standard Form 539
GENERAL SERVICES AOMINISTRATION ANO
INTERAGENCY COMMITTEE ON MEDICAL RECORDS
flRMR 141 CfR120145.505
OCTOBER 19/5
USAPPC VLOO
.,
DOD-036928
ME.DICAL RECORD
PROGRESS NOTES
NOTES
DATE
SPONSOR'S NAME
I-LA-s-T---------~;:.;....::,:=.F.::..IR:..:..ST~:.::..:.:=------------rM-I--l
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name -last, first, middle;
10 No or SSN; Sex; Date of Birth; Rank/Gradel
.
SPONSOR'S 10 NUMBER
(SSN or Other)
RECORDS MAINTAINED AT
WARD NO.
PROGRESS NOTES
Medical Record
~,
STANDARD FORM 509 (REV. 5/1999
Prescribed by GSAIICMR FPMR (41CFR) 101-11.203Ib){10
USAPA Vl.00
MEDCOM - 23353
DOD-036929
LAST NAME
DATE
MIDDLE INITIAL ID NUMBER
FIRST NAME
NOTES
MEDCOM - 23354
STANDARD FORM 509 IREV. 5/1999\ BAC
USAPA'I1.I
DOD-036930
PROGRESS NOTES
MEDICAL RECORD
NOTES
DATE
D
RELATIONSHIP TO SPONSOR
I
-:-=----==--..r:SO::::..~?r~~~~~~~~~:x:::t.-----~:__~
SPONSOR'S 10 NUMBER
MI
(SSN or Other)
t-LAST
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name -last, first, middle;
ID No or SSN; Sex; Date of Birth; Rank/Grade}
RECORDS MAINTAINED AT
WARD NO.
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV. 5/1999
Prescribed by GSAIICMR FPMR C41CFR) 101-11.203IbH10
USAPAV1.OC
r
MEDCOM - 23355
DOD-036931
LAST NAME
DATE
MIDDLE INITIAL ID NUMBER
FIRST NAME
NOTES
MEDCOM - 23356
STANDARD FORM 509
(REV. 5/1999)
BACI
USAPA V1
':j
DOD-036932
KU I OUnlLc.u run LU,",'tI.. nLrnuuu,," I
PROGRESS NOTES
MEDICAL RECORD
NOTES
DATE
RELATIONSHIP TO SPONSOR
DEPART./SERVICE
lUI'
SPONSOR'S NAME
SPONSOR'S 10 NUMBER
f-LA"':-S:::T-----------=.:...:TF=JR-::ST:-=-:.::..::..:.::.----------.-MI--lrssNorOther)
HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
PATIENTS IDENTIFICATION: (For typed or written entries, give: Name .last, lirst, middle;
10 No or SSN; Sex; Oate 01 Birth; Rank/Grade)
WARD NO.
PROGRESS NOTES
Medical Record
STANDARD FORM 5091REV. 5/1999)
Proscribed by GSAlICMR FPMR 141CFRll0l·l1.203IblilOj
USAPA V1.DO
MEDCOM - 23357
DOD-036933
NSN 7540-00-63.
....510-112
==-=- ....
NURS, I'IJ\..J
"NOTES
MEDICAL RECORD
(Sign all r,otes)
HOUR
DATE
(0
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A.M.
OBSERVATIONS
Include medication and treatment when indicated
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PATIENT'S IDENTInCATJON (For tyr;ed or wnrten enrries give: Name-lase. firsr. middle: grade: rank: rare:
Msr;it31 or medical facility)
REGISTER NO.
I
WARD NO.
NURSING NOTES
Medical Record
MEDCOM - 23358
DOD-036934
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General.
1.
2. KNOWN ALLERGIC SENSITIVITIES (e.g .. Iodin, Tape. Medication)
ft(NKDA
0 PCN
0 LATEX
0 IODINE
0 TAPE 0 FOOD
REACTION:
2)"
AGE
HEIGHT:
WEIGHT:
3. PREVIOUS SURGERY
?0 lcc
[ jNO
4. PROPOSED SURGICAl,. PROCEDURE:
c.~
0\ t\A~d.A\o\e. ~X
5. ADDITIONAL 1~'pRMATION: (Previous surgical and medical history)
Tobacco
'ppd~vrs Body Piercing
Diabetes (Y)~
ROM I ....' ,
. SNMotrin W 72hr~
ETOH
Implants~"'tt-'-Respiratory Disea
sthma COPD) (Y)
nticoagulants (Y)~
Glasses/Contact (Y) ( )
Dentures
Hypertension (Y)
Herbal Medicines ( N
MEDS:
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
(V
;Jij.
4P--
A. PSYCHOSOCIAL
•__
- po ten t'la J f or anxle
. t
it
_.....-y re
a ed
to:
~ 1) Surgical Procedure&
PI. verbalizes any specific anxiety.
PI. Exhibits relaxed body posture.
Operating Room Environment
'/
'b k
(Child)
~ 3) Surgical Outcomes
I. will be able to breath without
B. AERATIQ,bV"
__
~_
otteennttii~al for respiratory
diffiCUlty during immediate intraoperative
dY~iOn due to:
___3) Medical/Smoking HismLY
C. INTEGJJMENT
of Skm
Offer to elevate head of litter or offer
·Uow.
bserve pI. While awaitfng surgery for
gns of distress.
sisi anesthesia during intubatior
and extubation.
phase.
. 1) positioning
(?'/2) Effects of Anesjhesia
__V_ PP'otenlJallmpalrment
Q5
. Offer comfort measures. (e.g. warm v'ZlS5, I-)
ankel. louch).
xplain all nursing procedures before
. t eyare ne. q 5 pO'Ss \
emain with pI. Whenever possible.
O. Maintain family Interface. Parents to
slay with pI.
__
. _ 2) Separation Anxiety
.
AIIl?w pI. to verbalize freely.
xplain Or environment and answer
eslio regarding surgery.
Pl will exhibit signs of impairment of
skin integrity (e.g., reddened areas).
In~Ydueto:
-::::,,-1) --=erative :~O~iJtt¥
~
ao Plac-!J1en.
-
-L.-3) Posil[Qnal Ai~
--,-3) ~esis
~5) EQ.Q1i.n9..Qf Pr51~Q!ill!QD.§
PATIENTS IDENTIFICATION: (For typed or written entries
!: Name-last. first. middle; grade. data; hospital or medical facility)
~ 6~)-V\ ~0W \
VERIFICATION~~T
HOLDING AREA: j,
! ID/Alzery Bandy! Dentures Removed/lf'(;l
! H& P
! Contacts Removed 1/
! NPO incei1ttW ! Jewelry Removed
'f-J
J-YIIOElfLMfi
bl-l.,)-L
! Body Pierce Removed
~
I ConsenUBlood Transfusi0}.ll-: /A..
SignedlWilnessed/Dated /Vn
! Surgical Site/Consent verif~}>y
Pt.lAnesthesialSurgeon
r
l
! Contact precautions (~
! Family/Friend,./'
~M
5179. JUN 91
Previous editions are obsolete.
USAPAVI.O
MEDCOM - 23359
000-036935
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
D. r Cj.RCULATION
. PI. will exhibit signs of adequate tissue
perfusion (e.g. color, warmth. pedal pulse.
K..Potential for inadequate lissue
p~sion due 10:
_ _ 1) Intraoperative Mobility
!:::...--2) Positioning
3) Existing Disease
];;2;.4) Safety DeYices
5) Hypothermia
...lI!.-
E. NEUROMUSCULAR
CON1;ROJ/
E.!. ~olentiallmpairment of
~ueto:
~pain
2) Intra operative Hazzards
-~~
'J?-'4)
~
[email protected] To/form OR table
E.2. ~Polential Discomfort Due to:
g:2f'"~ngth
of Surgery
_ '_~_.
2)·· P;;
Positioning
_ _ _ 3) Arthritis
~
~ self. keep pt informed as to
s~ses
F.1. _ _ Diminished visual perception
du~
~here he. sheis and what is happening.
orm pt. in which direction to moveQ "l.
tg..De1ng:
pre-medicated
_V"_"_ 11\)
nd assist if n e c e s s a r y . - 1 /
S
k-clearly and s\Rwly.
rS>'fb\.e...
Address pI. from ~\ V\j.N'
side.
Idate pt.'s understanding of verbal
ommunication.
Verify removal of dentures.
2) W 0 GLASSES
F.2. ~Potential for Decreased
Communication due to:
1) Diminished Hearing
~2) Language Barrier
r,8 ...:.4..--.+ft.)lel'lliel h~Uij due to .........
Dentures:
_ _ _4) Caps
_ _ 1) Upper
_ _ _ 2) Lower
_ _ _ 5) Crowns
_ _ _ 3) Bridges
G. OTHER PATIENT PROBLEMS NEEDS
OR Continuation of AbOve problemslneeds.
I
o
OTHER NURSING INTERVENTIONS
OTHER PATIENT GOALS AND EXPECTED
OR continuation of above Interventions.
OUTCOMES. Or cOntinuation of above goals and
outcomes.
OMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
DATE
o Red ;s7N/A
SKIN INTEGRITY:
OPERATIVE EVALUATION:
Drowsy
A&O
LEVEL OF CONSCIOUSNE
LEVEL OF ACTIVITY:
VES ALL EXTREMITIES
o
o Transferred to
DRESSING DRY,&)tJ
(Y) (N)
IV I '1
PREPARED BY
7~
15:3C1
'--------~._---_
..
,
--------,-000-036936
,
MEDICAL RECORD
II'll nf\u .... enf\ live
, For use of this form. see AR 40-407, the
'JIVlel'l'
)Onenl
s the office of The Surgeon General.
2. PATIENT IDENTIF
VERIFIED BY
(l/TIME PATIENT ARRIVED IN SUITE
4.' PATIENT III! ROO
/
TIME: /.
/
-&
5. PREOPERATIVE EMOTIONAL STATUS
o
~ CALM
COMMENTS:
0
ANXIOUS
0
EXCITED,
0
CRYING
0
ANGRY
WITHDRAWN
o
OTHER (Specify)
N KA6. NURSING PERSONNEL
'C)f)
". ~"f-~-'
.
PYL
ASSIGNED
SCRUB
"
"
CPT
ASSIGNED
CIRCULATOR
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....... ""
7. POSIJION,ANqPOSIJIONALAIDS(Specify) 'T,q~,
:::\"l- Sj~ c:
SJvLeJ3
~, SUPINE
COMMENTS:
0
, -"'-'-REUEF
" ,SCRUB
....:.:.:.-'-"-c....:='--_ _;
(,Vrc.~
LIJ-P, F''''§er5
IA...
LITHOTOMY...
D
PRONE,
RELIEF
, • _~CIElCULATOR
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4a~/j':.
c.~v\-'bOc}.Av ~"'K""V"\~;.'~ ()vvv'..40~ \JI\.,
HAIR REMOVAL
DONE BY:
METHOD:
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o
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o
o
n
'~
,
#.
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'(yo
- - - :--......
0
ClAP
t'O/A)e!s UI1d..R....-
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KRAS,KE",
.'. LATERAL:
LEFT SIDE UP
0
'.
r'!1S
A.R.ej5~
.
RIGHT SIDE UP
__ ...
..:.
8. SKIN PREPARATlbN
YES
NO
OR
DEPILATORY
CLIP
o
o
NURSING UNIT
';LPREPSOLlITIOjJ (Spf!jify)
SITE:/·1o:-tf'ltfJOkJ/C)..IVI
RA~QJ:\,
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BY WHOM: U ..... , _ _ _ _
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COMMENTS: 11[)
00/' h of 5011A hoY/ h 0
:_;.."--:...:.:~.
COMMENTS:
I
artt'\
.
9. LOCATION OF EXTERNAL DEVICES
'~:-.-:;
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LEGEND
X Ground Pad
10. COUNTS
Sponge
Needle Sharp
Instrument
,0, ESU NO:
GROUND PAD:
!~ .. ~'''''~ .... ~~~~
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BRAND
--(
LOT NO:
-1
;;·'b:~s.D' NO:
~'.. ':~~OUND-P-A-D-:--B-R-A-N-D-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-:_-1-1
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LOT NO:
BIPOLAR NO:
, REPLACES DA FORM 5179·1 (TEST). DEC,52. WHICH IS OBSOLETE.
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USAPA V1.00
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MEDCOM - 23361
DOD-036937
·.u":":"FA:-:C~T:':"U~P~--------""
IF YES NAME: 10 NUM
P~LANTS
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15.
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YES
16.
SPECIMEN IS)
NAME
YES 0
NO
FROZEN SECTION IFS)
NAME
0
NO
0
NO
YES
CULTURE IC)
YES
NAME
.:.::D:::>·':
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NAME
NAME
.
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.:••• ';,.<:.
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17.
TYPE/SIZE
SITE
• .__ <
NAME
TUBES, DRAINS/PACKING
1.
1.
18. DRESSINGIIMMOBILIZATION (Specify)
YES
0
·rtfJ
NO
~
3.
2.
. '.'(~;:
:::~··::?t
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USA-.PA 'J
- - - - - - - - ... _-----
"-~--,------.
DOD-036938
NSN 7540-00-634--4124
511-119
VITAL SIGNS RECORD
M~DICAL RECORD
HOSPITAL DAY
DAY
POSTMONTH-YEAR
19
I
I
DAY
HOUR
PULSE
TEMP. F
(0)
(oJ
TEMP.
......
105°
~
~'
40.6°
180
104°
40.0°
170
103°
39.4°
160
102°
38.9°
150
101°
38.3°
a:
140
100°
37.8°
.2
ric:
>;
C
0
III
u
c:
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130
99°
98.6°
>:1.20,
:~. ,
110
100
..
98°
:..
LU
36.r
"0
..
36.1°
.
;.'1.'•
~:
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• . I,·
96°
..
~
95°
'5
37.2°
37.0°
cr
Q)
~
.~
97°
·d·
90
co>
Q)
~
35.6°
.
I'
:
35.0°
80
70
...
:
60
..
'0'
50
..
:.-K
40
RESPIRATION RECORD
BLOOD PRESSURE
Iu.,(If
{
HEIGHT:
PATIENT'S IDENTIRCATION (For typed or written entries give: Name-last. first. middle; ID No.
(SSN or other); hospital or medical facifity)
REGISTER NO,
WARD NO,
VITAL SIGNS RECORDS
Medical ~ecord
STANDARD FORM SU (REV. 7-95)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1
MEDCOM - 23363
DOD-036939
. '1\ )~~ g Ifl.?r~ '2 ~.rtfL - MEDICAL RECORD - ANESTHESIA
ANC--eJ[: IVJrr-~p~;o,use~form. see AR 40-66; the proponent agency is the OTSG
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SINGLE DOSE DRUGS·MARK ON GRID....
c( WITH NUMBERS & ENTER IN REMARKS'"
12.,0
TOTAL URINE
~hlh-?~I--'-'L!.
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._
~
<..
Cl
Iii
-z-"dO
(1»)~~I~~O~~~~~_~ __+_~__~_~__~_~__~_+~j~a~~~
C,A -:..:-:--: \.\ (.f:. IJ
"fh<.. 'l.J <::1 ( ~
wtI)<t
TOTALS
7~
I
I
,
,
,I
I
N
BP/Auta Cuff
BP/oth
ART line
ET C02 Itarr}
or
fsp02 1%)
1-~02 (Frac
+-
"/.7 ~. ~
%1~"0 I(~ ,b
1/7\0
r
-:i
hr~ h
1(0 I'"') -jeD
.3::z...... ~ IL
0:...:1:
im
I
• I,..,
"i,.,
\~
PACl't ICU -----1SpocllyJ
~Ir ./",
-J
100 .[.lJ.,L
1!1l.£Ot..+\.}<:()Io.\L2,()+--1---j---+---'~OT~HER
DA FORM 7389. FEB 1998
MEDCOM - 23364
--_
-._------------ ---DOD-036940
"" ........":,:I0ML
',?CUq"yUu
. ~.X~
. ~MAlE ( FEMAL
n~
PROPOSED PROCEDURE:;~...1,.~r..I..!=!~~~.L.'~k~,,---_ (J)' -n ~~ '(l,-
"Age
2S DAYS
MOS
vi~ .
MVV~S?9IV."I!'
SURGICAL SERVICE: r-~~~~-:-:--...-7V""-----'NPOSINCE:
Cardiovascu~r:
Hypertension
()=
0
--0 _ _- - - -
U1A:
WT; ~
,A::l::L:::E:.:.R.:.,:G:::.:'.:E::S::.:===t=t~====_.J
...
ASSESSMENT
PAST SURGICAUANESTHETIC
lEW
o
Y
®
N Y
N Y
N Y
'Y
HYSICAL EXAMINATION
BP 1btJ1l~ R£ T_
Pain
ale0-10_....,.-_
HEENT· Teeth ~ F'{';:
_
_
_
Neurological:
Seizures
,~~uropathy
Other
Gynecological :
Pregnancy
Other Significant
t:i1P
@
CHEST:
@
Hx:~
N Y
IV Access:
Ulnar Filling:
~/::=-
L/::!-=+.LC.!...~
_
_
BACK:
...
~_
_
OTHER: -,...
J
N Y
Y
Familial HX
_
EXTREMITIES:
'N Y
N YN Y
Y
J!11
Nares {f?!'t;;ffi.:t
TttlO-
CARDIAC:
N 'Y
N Y
N Y
N
.
S..();
Trachea-,-,~~~...lo~=~_ _
TMJlNeck -+5-<J2."""""r;f-1',.~--:-­
Oropham)')C
"1lL
0
Y
N' Y
N Y
Endocrine System:
Diabetes
Steriods
Thyroid
LABORATORY STUDIES:
OTHER:
I
Re":~~:;::;~nic R~N
y
.
Gastrointestinal:
Hepatitis
Hiatal ~rnia
PUDIGERD
PREMEDICATIONS:
None Yes (@ _ _ Hrs) ICC
_ _ • _ _ mg IV 1M PO
_ _ • _ _'mg IV 1M PO
_ _ , _ _ mgIVIMPO
I
.
,ysi~tate 1
Y
Y
Pulmonary System:
Asthma
BronchitislURI
COPD
Other
!l=#.r---
I
..~P
'ViS'S'
\1:)-~
CVA
Other
0-_---:----
-J
N
~~gina
CURRENT MEDICATIONS:
ordered as premed
HBIHCT:
S
PREOPERATIVE
PAST MEDICAL HISTORYISYSTEMS R
HABITS:
if rrf'\
TOBACCO:Jn.lJjjL,,!
ETOH:
_
DRUGS:,
_
~
V" lANU<::
U
--'-_
_
_
NPO Since
Time:
IS
/t:z. 0
ro ,f'rJO
Hrs
SEDATION KEY:
/i'.
S!gned: _ _ _ _ _ _ _ _ Date:
P~tientldentification:
Time:_ _ Hrs
(Ward)
1. MINIMAL (Anxiolysis) Patient
responds normally to verbal
commands
2. MODERATE (conscious sedation)
Patient responds purposefully to
verbal commands alone or
accompanied by light tactile
stimulation. Airway assistance is not
necessary.
3. DEEP SEDATION/ANALGESIA.
Patient responds purposefully
following rePeated or painfUl
, stimulation. Airway assistance may
be necessary.
4. ANESTHESIA. Patient does not
respond to painful stimula!ion.
WAMC
Form 2300 (Revised)
15 Mar 01 MC}{~p()S
.
..
..
..~
.. ~
Previous edition is obsolete
ANESTHESIA SERVICE RECORD
··u;s. GPO: 2001-629·1831.0002
-----------,----DOD-036941
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
TIME OF ORDER
!>ltD· (.,~
~
NURSING UNIT
ROOM NO.
BED NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
HOURS
NURSING UNIT
DA
FORM
, APR 79
ROOM NO.
4256
DOD-036942
.• ,iDICAl RECORD - DOCTOR'S ORDERS
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will
list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not
require recopying. They may be signed off, as completed, in the far right column.
ORDER
NUMBER
DATE. TIME. & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
ORDER NOTED
COMPLETED
TIME & INITIALS
TIME & INITIALS
VS q 5 min X 15 min, then q 15 min until discharge.
,.:J
Supplemental oxygen..
Sa-.~ C qS-
0
Morphine I Meperidine _ _mg IV now and _ _mg
<i 3-5
min pm pain for a
mg IV pm XIV q 15 JI1in.~"AaY repeat x _ _:-
Dmg TV pm NIV x 1.
Droperidol_ _mg IV pm N/V x I .
. Phenergan_ _mg IV pm N/V x 1.
Benadryl15-50mg IVP ql hr pm; itching wlrile in PACU.
@
:I"fCOcc/hr.
Discharge from recovery status when PACU discharge criteria met.
PATIENT IDENTIFICATION
Complete the following information on page 1 only. Note any
changes on subsequent pages.
Diagnosis:
Height:
Weight:
Diet:
-------..:t
Allergies:
,
Nursing Unit
MEDCOM MEDCOM
FORM I':RR-R
IT~c:.T\
11I1If'Unl 1111 1\ D 00
Page No.
23367 ~ .. _28_th_C_S_H_..J..-
DDC'/I""",'"
cn'T,,.,.,... n~
l.-._ _..J..._1
_ o_f_1_...J
.... n .. ,...' ~~
DOD-036943
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE. TIME AND IGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
HOURS
NURSING UNIT
LIST TIM
ORDER
NOTEO AND
SIGN
ROOM NO.
PATIENT IDENTIFICATION
NURSING UNIT
ROOM NO.
PATIENT IDENTIFICATION
DATE OF o.RDER
TIME OF ORDER
HOURS
NURSING UNIT
ROOM NO.
BED NO.
DATE OF ORDER
PATIENT IDENTIFICATION
TIME OF ORDER
HOURS
NURSING UNIT
DA
FORM
1 APR 79
ROOM NO.
4256
BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
MEDCOM - 23368
DOD-036944
CLINICAL RECORD
VERIFY BY INITIALING
.,.
ALLERGIES:
0
YES
~ NO
r
PRIMARY DIAGNOSIS:
'5
c;
r~",-c...
D ~
..
ADD!.llONAl PA GES I.•NUSE:
c.. \~. I.\~~
(Y1C,rdt/fl~fyDYESDNO
~&
.
r
PAGE NO:
PATIENT IDENTIFICATION:
ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES ..
o
DA FORM 4677, 1 OCT 78
EDITION OF 1 DEC n MAY BE USED,
E
8 9 10 1112 1314 15
16 17 18 19"202122 23
N
24 01 02 03 04 05 06 07
USAPAV1.DO
MEDCOM - 23369
DOD-036945
\
Verity by
Initialing
1----.
Order
Clerk
Date
Nurse
THERAPEUTIC DOCUMENTATION CARE PLAN
SINGLE ACTIONS
.
Date
Clerk!
Nurse
PRN
ACnON, FREQUENCY
Date to
be Done
-
Time to
be Done
I
;!
Orderl
Explr
2003
( NON-MEDICATION)
INITIAL PROPER COLUMN FOllOWING COMPLETION.
TIME/DATE COMPLETED
MEDCOM - 23370
DOD-036946
CLINICAL RECORD
VBRIFY BY INITIALING
ORDER
DATE
A.... ERGIE:..
YES
"
For use of thll form see AR 40-407;
the proponent BlIency II the Office of The Surgeon Generel.
mmHmmmmmmHH~~mHHHHHHHHHHHHHHHH
RECURRING MEDICATIONS,
DOSE, FREQUENCY
CLERK/
NURSE
0
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
I )/_"
Mo.Lt-Yr./)-
t>
i)
INITIAL PROPBR COLUMN FOLLOWING BACH ADMINISTRATION
HR
DATE DISPENSED
~o
PATIENT IDENTIFICATION.
(
-
DISPENSING TIMES
USE PENCIL, CIRCLE MED TIMES
-
b(~~-~
EDITION OF 1 DEC 77 WILL BE
0
7 8 9 10 11
E
15 16 17 18 19 20, 21 22
N
23 24 01 02 03 04 05 06
uSl;n IINTII
12 13 14
EXHAUSTED.
MEDCOM - 23371
DOD-036947
-
b{
Verify
THERAPEUTIC DOCUMEl'(TATION CARE PLAN
~nitiali~.g
(MEDICA TlONS)
Cii ...k/
Order
DO'e
t---
1%
/11
~
}I
Ie.
'I
II
~
~
"
-
-
,--J
Dc:c/:U!I2(/y)
/in
r:2n /'--4.// --2
C?-.
/r£
()
("J
/L-L L
1/) £
IV 4-.~
U
c:a/L ~
-,. ...........
-.-_ .....
r--- """' ..........
-,
...
I
~
"
a
-
~
"--
-
LyC- pulVer
ot.f '·
JD ('-<.-'j -?~,\
......
i--"''' ..
- ......
ttd"':':i
DONC.
Initial ..
I
r--- ___ .. 0,
- -_
Time to
bl! GIven Time Given
£Jt,
L).J
Yro--'---
~.
.......
-' ....... r--- _.........
~
?tV
",.
~
:--.
-lMoo
Date to \
bo Given
SINGLE ORDER. PRE·OPERATIVES
N,.,-rse
\
",
...
lNI77AL PROPER COLUMN FOLLOWlNG ADM1N1STRA770N
PRN
MEDICATI:1N. DOSE. FREQUENCY
CI erk!
-
..
,.
TIME/DATE DISPENSED
n ~
. lore{ J.> I :30 In, I" VJ-r
r--\7
. - - - . ............. I;) fr., 0 ?/'-' tU 0"
Vi1
T
:-----.
~
. - - ... .. ..........
X' ,') d ~ 0:::Vr.
~
- - ., .............. ( 1) Ie 1~1J)0:, ") ,X"
p\'~ y) ~Y-<" ~h \ 2·'\- liT tc:I)J ?'X
. . ..
'2 s- , :r.J alI
~
1°,..
'
~
...
...
-
J
...
- I
---....
-
..............
;---t
- -, ............
r---r
- .. ..
(
Q
r?> ....
Dn..- hJ
I
~}V
~h
",
..............
~
- ... - -...........
;
---'
_.! ..
~
,-
.'
............
~.
.. .. . .. . ..
--'
. ,' 0 .............
-
·U.S. GPO: 1998-454·110195216
MEDCOM - 23372
000-036948
MEDICAL RECORD·SUPPLEMENTAL MEDICAL DATA
For use of 1his torm ne AR 40·66' the plapDflfftI 3Qtncy is the OfflCe oJ 1he Surgeon Gentf31
REPORT TITlE
I
OTSG APPROVED
Post-Anesthesia Care Unit (PACU) Flow Sheet
I l j 6 l(-J
Anesthesia Type (CirCle))~~pinalEpidural
Date:
IV sgation Nerve Block
Time In:
J 2/ V
Colloid
OR Inlake: Crystalloid
Allergies:
EBl
OR Output: UOP
Pre-op VIS: ~ It... ~lj
MedslTimes: 2 ..... a.. U .f::!l-:JaJ, ~ 0 t"<.... f-v<=.,..J ",'tf't L
Procedures:
Ie 'f\-j ('Jb~P~?,,·~s..
Drains
Hemovac
JON
r
Pre 00 M.eds
"
Itt
~
~~ q
5a02
FlO2
/ ,/ / ,/ .-' ./ I.....
Methods
~ €f" '0,;. (l,j
Airway
Nasal
Oral
NG
En
JP
T-tube
Foley
Trach
Olher
TLS
Histor'J
~ ~ l~ 'I~
.... ~
"l::l
'1 19C
~
Time ~.
10.,.1 "
Pacu Intake
Time
1\.
Amount
Solulion
111'1-
~
;1.'"2...
I1---L-
Sile"
I~
L~
/l>~
Lf::,
By
Infused
/!~'o .
~l'
'l,u
r~
240
Labs:
X-rays:
220
Post-Anesthesia Recovery score
ADM
30'
DIC
Criteria
200
Codes
Aclivily
(2) Moves 4 Extremities
(1) Moves 2 Extremities
(0) Moves 0 Exlremities
180
I~
160
r;;
~
Airway
(2) Cough. Deep breath
(1) Dyspnea. finj\ed breathing
(0) Apnea
~
1~
i5'":l
I-
140
tt
Blood Pressure
(2) SBP =1- 20 01 Pre-op
(1) SBP =1- 20-50 of Pre-op
(0) SBP =1- 50 01 Pre-op
120
Consciousness
(2) Fully Awake. audible
100
IF
~t"1
?Il '1'1
~
L
L..
1..
L,
I
crying
(1) Atousable to verbal or pain
~
80
'-
(2) Baseline mIor & appearance
2..
(1) pale, molUed, jaundiced
(0) Cyanotic
Circulalion (Peds < 5 Years)
(2) radial Pulse Palpable
(1) Axillary palpable. not radial
(0) Carotid only reliable pulse
40
20
,olt--
vI
RR
1'1 1< ~""~
TOTAlS; Must be 9 or
greater to D/C. otherwise
needs anesthesia approval Jor
DIC.
I
I
11(..
j,r
~\L-
n
I
I
Time
P"ain (0-10)
lOS
~
"L..
VIS
2-
X = A-line BP
• = Cuff BP
• Pulse
~
I
I
" I
M or writ/en entties give:
PATIEN
midd~
L,
=
'\ ~ I~
1
Iv
{~
Wound Care, Pain Manaaement.
IT, C. & DB •. Incentive Spirometer, Comfort Measures
I Safety: SR UP X 2, Falls Precautions. Privacy Maintained
I
DEPARTMENT/SERVICE/CUNIC
Nime
?r:- c Y..
-lJst,
r medicallaaity}
--
bl~~ ~~
OA FORM 4700, MAY7S
l-
TEMP
S"'Skin
O=Oral
A Axillary
T=Tympanic
R=Rectal
lOS
C~CerVical
T=Thoracic
L-Lumbar
S= Sacral
I Patient teachina done:
I
I
I
~
'" lL.r..':,".
W;
."
lirs"
~
Color
60
T
AIRWAY
A=Ambu
BB .. Blow-by
M=Mask
FT=Face
Tent
RA"'RoomAlr
NC .. Nasal
Cannula
on mu, on
,,~~,s.e.
10ATE
I'
I
()~{i;)'3
o HISTORY/PHYSICAL
o FLOW CHART
o
DDTHERapnil"
OTHER EXAMINATION
OR EVALUATION
o DIAGNOSTIC STUDIES
o TREATMENT
WAMC OP 173·E. (Revised) 1 Apr 01 (MCXC.DN)
Previous edition is obsolete
USAI'PCUOO
MEDCOM - 23373
DOD-036949
MEDICATIONS
Aller ies:
Time
Pain
Time
Medication &
NURSING NOTES
Route
NEUROVASCUUl.R
Range
Sensory
P
Site
Of
Malian
30'
Cap
Refill
T
Color
8;
- J - - ; - - - - t - - - - - I ' - - t - - - J - - - t - - - f / 7 s' g. -
1-=4=-=5:"""'
60'
F
,
~90=-'-f---+---+------1I--i---1---t---f~ - ~
o/c
I;.:s6l- ~ ~
t:?...-A
I
Movement/Sensation: + = present.- = absent Temp:C = Cool.
W .. Warm Pulses: p .. Palpable, 0 = Doppler, A = Absent
Color: C = Cyanotic.
Capillary Refill: B=Brisk. S=Sluggish
P=Pale. Pk=Pink
--Adm
Lochia
Perlpad#
Fund. Condo
C-SECTIONS
15'
30'
45'
50'
90'
L<JO ........
t7~/
ifs-s- ~
D/C
U)d
/.Y
·AA..«':'
~4~
~
--+---"--'--.......- - -
DRESSINGS
Time
Adm'
30'
60'
Location
-----
D/C
Type
Drainage
---- ---- ----
-L
........
PACU OUTPUT
Time'
Source
Color/A
earance
Amount
PARS: I
RR: }g
0
,
Sa02:97 ~
CARDIAC ~HYTHM
WAMC OP 173·E
MEDCOM - 23374
DOD-036950
- - .....
_-_._-_.
__ . _ - - - _ . , - - - - -
______0
1. Reporting MTF
._'4_
Admission arlU Coding Information
•••
I
For use of this form, see AR 40-400; the proponent agency is OTSG
l'J \.~~, ~c,{"
--==-
_______-+6. DoB (YYYYMMDD)
-,-
7. Age at Admission
_
4.
,
pa;GG~ade
-+
X
25Y
.__ J
.
9. Ethnicity
8. Race
i
5. se:
--'-_-+-
I
Religion
i
9
I
.--------..- - - - - - + - - - - - - - - - - - - + - - - - - - + - - - - - - - - - - - ' - - , - - - - - - - - - - - - - - - - - - · - - -.. ----1
10. Length of Service
ETS
11. FMP
12. Social Security Number
99
~------'---------+-----'---..--------+------------_ ..
i
Organization (Active Duty Only)
13. Marital Status
Hour of Admission
Branch I Corps:
09:05
II
I
·------I
I
II
f----·----------,------------'----------!-----------'------·--------,-------I
14. Flying Status
15. Beneficiary Category
16. Zip Code of Residence:
I
-1-7-.-U-n-it_L_OC_a_ti_o_n
19
-+_1_8_._:_7:_~-P-R-IS-O-N-E-R-O-F-W-A-RJ_I_N_T_E_R_N_E,E_S_ __.-T-ra-u-m-a-'---------,-P-re-v-.-A-d-m-is-s-io-n--------------------I
DIS
I
!
NO
f--20-.-S-o-u-rc-e-o-f-A-d-m-j-ss-iO-n--'----.--W-a-rd-:--------+-N-a-m-e-I-R-e-l-at-jO-n-S-h-jp-O-f-E-m-'-e-r-ge-n-c-y-A-d-d-r-es-s-e-e-------------
Direct from ER
--I
Address of Emergency Addressee
ICW1
Telephone Number of Emergency Addressee
I
i
==,-_~le::-l.,---,-)_-_?-_---+21. Type of Disposition
.__._.
22. MTF Transferred To
TRF-OTH
_
.
!
I
23. Date of Disposition (YYVYMMDD)
"~I
2003-11-09
~_. __. _ - - - - - - - + - - - - - - - + - - - - - - - - - - - - - - - - - - - - - - - I
!
24. Clinic Svc - Admitting
25. MTF Transferred From
ABF - ORAL SURGERY
27. Location of Occurrence
I
26. Date this Admission (YYVYMMDD)
2003-11-07
28. MTF of Initial Admission
I
-------\
i
29. Date of Initial Admission
i
2003-11-07
- - - - - - - - - - - - - - - ' - - - - - - - - - - ' - - - - - - - - - - - - - - - - - - - - - - - - - - .. _---- ..I
FOR LOCAL USE
Type Patient (Inpatient I Outpatient): Inpatient
,
------.Dp-------
I
Admission Diagnosis Narrative: SIP CLOSEDREDUCTION OF MANDIBLE FX
/'
I
Dr:
,.
I
'//~X'I V\-\~q
Procedure Narrative(s):
f
,..-
,
\
:
'!
'..,""';!;.-,'r
\
Cause of Injury Narrative:
~
"'1C'\,/V
...-
nr '7!
-',"-
I \;;,/ .l9': VJ
)
G
,
/
/
C{ "'.1 I
v\,.; \
--------------_._--_
\
/
'........
...,,///
..
!
--------'--------...,#
- - - - - - - - - - - - - - - - - - ' : 7 ' ' ' ' ' ' ' - - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - -..-.. ---,
I
MEDCOM - 23375
DOD-036951
Automated Facsimile - .
Ih. ATIENT TREATMENT RECORD l...... tiER SHEET
For use of this form, see AR 40-400, the proponent agency is OTSG
' I~---~~~._....,
3. Grade
FGN
I
Admission Remarks
I
:
--I-~·-l~n-th-O-f-S-VC-'-~-9~.~E~T~S~~~:~-1o-.-~-~:mJ
6. Race
X
14. Ward
13. Organization
i
I:
'
'
'9lLt-j-L.(
---L------.,---L-----:;----.--------:-=~____;-_______.,-__+__-~_1
17. Dept! Ben
K78-PRISONER OF WAR/INTER
.18. BranchCorps
24. Name/Relation of Emergency Addressee
19. UIC / ZIP
22. Hour Of Adm:
00:55
23. Clinic Service
ABA-GENERAL SURGERY
25. Type Disp
26. Date of DiSP-------i
EXPIRED
I
I:
20. Type Cas
BC
i
t
I
t
I
2003.11·07
I
._----------------+-----+-------.----'-----------,
27a. Address of Emergency Addressee
27b. Telephone No
28. Date This Adm:
2003-11-07
Officer:
30. Date Init Adm
2003-11-07
b(~)-~
com~on~~;;-I
------ --"---------'-----·---1
I
131. Selected Administrative Data
'I'
32. Units Blood
I
Marital Status:
DoB:
In/Out Patient: Inpatient
MOS:
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33. Cause Of Injury:
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35. Total Days This Facility
Absent.Ok Days tther
!,35.
Total Days This Facility
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conlOCOOP Care
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ther Days
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I Conlv / Coop Care DaYs_I Supplemental Care
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! Bed Days
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I Total,ck DaY~
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Total SiC! Days
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MEDCOM - 23376
DOD-036952
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