aclu-rdi 1263 p
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Preop Labs (HSG, etc):
Dnia/Latex Allergies: Nonete"Yes NKDA
Test/Results: Allergy/Reaction:
Pre-Op Pain: 3 N
es Level
(0-I 0)
Action Taken: Location/type: In Chart: m, AT&P ❑ /es ❑ No 7 EKG 0 Yes ❑ No 3 OCR ❑ Yes ❑ No D Other:
Ski Condition: mad
0 Other:
Past Medical History: ❑-NOne known ❑Smoker ppd/yrs /
0 ETOH ❑ Asthma ❑HTN ❑ CAD ❑GERD 0 CBR exposure ❑Other: Past Surgical History: ❑None known :4•16.s
List:
Cultural Needs Addressed: ❑Yes JJ:lo List:
Last PO In/ake: (date/time) Solid: / v /r z, ■-■-)
Liquid: LH/ a 1/ 4 j z "
Limitations: 0 NIA IT6nguage
❑ Other:
Lc
0 Auditory ❑Visual 1:1 Prosthesis
Pers al Items: one
0 Military gear 0 Glasses 0 Dentures 0 Jewelry/wallet 0 Other
Disposition:
10(3)-1
erative Plan Of Care & Nursinf
Patient Assessment For Surgery - Potential For Injury - Outcome: Patient is free from signs and symptoms of injury ❑ Yes ❑ No
Trauma# or Patient #
b)(6)-2
. mac. rse Diagnosis: `Ti) t Procedure: Planned Pcedure: /
Date: t-/ ti ,, Arrival Time: / o u Interviewer:
a- 1.1
? d„..) {ic
1 Slae• n NIA n Right rrf rt
Age: HT: WT:
From: 0 CASREC 0 15,U Thud 3 OTHER:
Trassport Via: D•Grumey 0 Litter 0 Ambulated ❑Wheelchair O Other
Patient ID: 0 Trauma card 0 Verbal 0-ehart Q-emband 0 Other
Bloo rdered: /A Comments:
❑Yes 0 Consent q T/C #Units ❑ T/H #Units
Surgical/Anesthesia Consent Verified: ❑Procedure 0 Consent completes dated, signed q-Erhligent case; no consenk,MD note
Present On Admission: ❑NIA 0 Oxygen ❑-P/ Site: #1 (9 A-
#2 ❑Foley DEndotrachial Tube ❑Arterial Line Site: ❑Drain(s) 0 Chest Tube(s)
0 See RN Note #
Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological responses to an invasive procedure ❑ Yes ❑ No
ted sponsive
Mental/Emotional Status: 311ert/Oriented 0-K1; J Disoriented 0 Sed a 3 Anxious . ❑ Unre 3 Appropriate for age 3 Other
Comfort Measures Implemented: 0 Clear, concise explanations ❑Communicated patient concerns to other staff
members ❑Remain with patient during induction
Pre-op-Teaching Included: &IVA due to patient condition ❑Physical layout of OR ❑Personnel present during procedure ❑Environment (noise, temperature, etc.) ❑Post-op expectation (PACU, drains, etc.)
Potential For Im Dperative Position: 3-51-opine ❑ Beach chair J Prone ❑ Sitting 3 Jackknife ❑ Lateral L / R
Lithotomy ] Other: ?SU # 'ad Site: Q) e 'ad Lot # -1 —.) ;ite Clear at end of case? ID No ❑ Yes f No, see RN note # 3ipolar: Max Cut 4._) Coag
Related To Sur Positional Aids:
❑Airplane ❑Arms <90 Cefficture Table Armboard: 1:1- 0-R" ❑ Hand Table Tucked: OLOR ❑ Stirrups
0 Other: DVT Prevention:
SCD used 1;1-2Ci 0 Yes Pressure: ❑ Left ❑ Right
Teds: ❑ No 0 Yes Bair Hugger used: 0 No alg's
Other warming techniques:
ical Procedure — Outcome: Patient is injury free ❑ Yes 0 No Comments:
0 Axillary roll
❑ Bean Bag 0 Gel Pad
❑ Gel donut ❑Leg Holder ❑ Pillows 0 Tape ❑ Wilson Frame
Tourniquet: ❑Arm ❑ Leg 0 Left ORight 0 webril applied
Comments:
Applied by:
Total Min: •
aired Skin Inte rit
Comments: :6)(6)-4
USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page 1 of 2 (Rev 3/03)
M EDCOM - 5246
DOD 12458 ACLU-RDI 1263 p.1
Shave Prep:
Area: By:
( /1
Skip-Prep: netadine Scrub 0 Hibiclens 0 Duraprep ❑Other:
I 0 II ❑ III V 0 Shave 0 Clipper Vound Classificatiork, Solution..
EFIC-ormal saline 0 Sterile water ❑Local ❑Antibiotics
ations: ❑Other:
Date/Time Relief OR RN Signature 1JSNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page 2 of 2
' P ry agRN Signature
Potential For Infect' ̀uteome: Appropriate Actions Taken to P lfection es ❑ No
Tains/Packing: ❑ None 'Foley FR: / 2l'JP #1 Fr Location: #2 Fr Location: Hemovac: Size Location Chest tube: Location Size H2 0 Pressure . Packing: typellocation: See RN Note # for comments
mints: (initials) rub: RN: Correct?
Sharps 0 Yes 0 No 0 N/A S Sponges 0 Yes ❑ No 0 N/A
DI- Ivo- Instruments 0 Yes 0 No 0 N/A
Dressing: Location: (MI ((-•) (t Si 0 ABD ❑ Cervical Collar
0 Cohan ❑Bias ❑ Drip Pad ❑Band-Aid(s) 0 Fluffs ❑Cast OX rlix
0 Benzoin ❑Mastisol ❑Bacitracin
Kling 0 Steri-strips ❑Immobilizer ❑ Tape El-Prains 0 Webril ❑Sling EI-XEroforrn ❑Splint 0 Other:
Miscellaneous Xrav: Skirl,Integrity:
0 None 0 Other: aClear & Intact (other than incision) 0 Portable Comments:
AFF1X M MEM- RECORD Ihrulaybirol orblbtrbulod
SYNTHES° XLZI7:= 1 nol TI CANNULATED TIBIAL MIL
- STERILE CAT 8 485.138S ICH e 4499711 MP: 12/2011 MT: Ti-6A1-Tlib
See RN note #
for additional comments nplants:
/ Lot t# / Exp Date: ilk • 40
L/ J it m (-1,C
See RN note # for additional comments.
0 See RN note # for additional comments.
AFFIXTOPMIEWRECORD Manulbehred or INVYOU*1 by
q _el ,(
O WAY771,55r 11018ynNee Avenue
11MM TI CANNULATED THAL NAIL 380MM STERILE 1-5 'Leo
rcl FIN f $113inks rAP: 12/2011
MAT: TI-SAL-7NN g■ps.■ga■
omilications: one Comments:
See RN note # for additional comments
Discharge from Operating Room Transport From OR: 041-rney w/ siderails up 0 Litter w/ safety strap in place 0 w/ Oxygen ❑w/ Monitor ❑Other:
Transfer d To:
0 ICU 0 Medivac ❑Ward 0 Other
Report by: 0 Anesthesiaprovider 0 RN
argical Procedure Performed:
/ 1/-7
J 6
14. < , ;
N Note: (number each note to correspondMg area above)
Initial/Name Box: (please print)
MEDCOM - 5247
DOD 12459 ACLU-RDI 1263 p.2
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ACLU-RDI 1263 p.3
SURGEON
1r) L, (b)(6)-2
FIRST ASSISTANT SECOND ASSISTANT
ANE THFTIC b)(6)-2 i 1 2 ,s' TIME BEGAN: ANESTHETIST
b)(6)-2
CIRCULATING NURSE b)(6)-2
c OPERATIVE DIAGNOSES
UB NURSE
11.57.; I, 1,)(6)-2
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(b)(6)-2
TIME ENDED:
TIME OPERATION COM-P ETEO
1.) I'S 2 g
El Tr"- TIME OPERATION BEGAN
I -1- , 3 '4
76 14CD
DRAINS (Kind and number) di MATERIAL FORWARDED TO LABORATORY FOR EXAMINATION (
SPO Nlbc(61ist -r- ,Ic c r 1-1
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STANDARD FORM 516 (REV. 5 -83) Prescribed by GSA and ICMR, FPMR 101-11.006-8
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*O.S. GOVURNMENT PRINTING OFFICE, 1990 -255 - :501
516-1 0 B
SI-1757.0-00-634-4156
MEDICAL RECORD
OPERATION REPORT
PREOPERATIVE DIAGNOSIS
C— k C t.c ICK
— Fi
OPERATION PERFORMED
• 1•
DESCRIPTION OF OPERATION (Type(s) of suture used, gross findings. etc.) PROSTHETIC DEVICES (tot no.)
DATE OF OPERATION
(/ 1/111 —../ d 3 AFMXTOFMMENTRECORD
Manalboltred or DistrbAd q'0003
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AFFIX TO AkTENT RECORD M ..da Detributed by DOOM
SYNTHES . =COAT' MIN TI CANNULATED TIBIAL NAIL =CMS • STERILE
485.138S MCN 8 4493265 EP:12/2011 MAT: TiAIA1-716
Lf L
SIGNATURE OF SURGEON
PATIENT'S IDENTIFICATION T /38 or Lunt en en les give: ,Name kat, first, middle; Kturs rt Ft-71.u. NO. grade; date: hospital or medical raelitY)
WARD NO,
MEDCOM - 5249
DOD 12461 ACLU-RDI 1263 p.4
RUM
PRA SITS
DATE
UT? R I PAIR
• °LIE
C NOISATION
C
SIGNS OF ccmrAmmare PAIS OE SINSWE WiTIOS SYNDROME
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MEDCOM - 5250
DOD 12462 ACLU-RDI 1263 p.5
Illy AP r/CI NNMC 6320/16 (05/91)
RECOVERY ROOM RECORD .14AvmE0 6320/16 (REV. 11.771 S/N 0105-1S- 206- 3281
O se ' Po
RAT P IRP R ED AGENTS AND TECHNICS OF ANESTHESIA
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T•TUBES. HEMOVAC I
t 15 30 45
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EllEININMEINV61111111111111M111 E111111111111131MMILIMMOUSI ELIZIEUEMMitittithfttinatil 11111111/11111MUMMER11111111 : :
IQ 1111) HOUR (SI
TEMPS
Spiral .
Level:
EFS to ntnitor
1110
160
140
120
ICC 1 art PP 7 EP A cuff
Rase = . 40
% Sat: RESP., RATE
NUMBERS FOR REMARKS
URINARY OUTPUT EFAII■PM. TIME
Cd
TOTAL
_se. ori S/A
306
REMARKS (AS NUMBERED! AND PERTINENT PATIENT PROGRESS NOTES
1) 10.4 fLcm M R accatpanied Ly 4 6X6)-2
RC: •
Nawo: IN_ O r Pain Y ‘194 0);#48-7.47r44.
CAUDAL. SPINAL. OR EPIDURAL BLOCK MOVEMENT PRESENT AT SENSATION PRESENT AT
HRS HAS
Ott r: etart g4
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NAUSEA AND VOMITING: $'i10 0 YES 1 2 3 4 5 6 TIMES
A
CONDITION ON TOW: COD 0 FAIR 0 POOR 0 CRITICAL
DOD 12463
PATIENVS IDENTIFICATION:
(b)(6)-2 1 RECOVERY:
ICATED
• 4, uNEVEictrFut.
MEDCOM - 5251
bX6)-2
ANTIBIOTIC: TIME GIVIEN: OMER:
FLUID THERAPY
WARDPRE-Op BP, ..3.LT tiJBES: O N/G*AFOLEY
ACPA ISSPON
DISCHARGE
FROM MOR/SPEC. STUDY TO WARD
DATE 410..3 .HRS /5.45 DATE 11 0 MRS
OREA1N_M. :TT LOCATIONS (4) "-'b 4 gi-e- it. - 5"
STATUS:.
' 7/1r.-A-iN;a4,01 XLe cur
u-a -..-) two e-epil- IsAMmtro-4, • • Ary-P- 7-'---7-0- ,ENDOTRACHEALTUBE - ORAL OR NASAL
0 YES b YES
AIRWAY SINZ
CLEAR 0 PLAST STATUS: (11t,1- • AIRWAY
0 OBSTRUCTS EASILY
• POST•ANESTHES1A RECOVERY SCORE . (ALORETE SCORE(
Able to move 4 extremities voluntarily or on command 2 Able to move 2 exirernitieivoluntarily • en on command 1. • Activity Able telraVe (inftrelnit;ft edunurily or on command Able lo deep breathe and cough freely Dyspnee or limited breathing Apneic 8P±20% of preancrthetic level BPI20•50% of preanerthetic lewd
.BPI50% of preanerthelic level Fully wake
.Arousable on calling Not rerponding Pink 2 Pale, dusky, blotchy, (.undio;d, other 1 Cyanotic 0
b)(6)-2 SIGNATURE OF RECEIVING AND
. RELEASING OFFICERS /
6)(6).2
Al
2
0
2 1 0 2 1 0
Respiration
Circulation
C011aiOUSnen
WIN
TOTALS
ACLU-RDI 1263 p.6
. TEMPS:
Ilrirtha
EP 4 art
V EP A cuff
PEIL = .
% Sat: RESP.
-RATE
NUMBERS FOR REMARKS
1E0
160
140
120
1120
1 I ! II
1 I 1
)
I .1 I I -I I 1 1
I I
-
! I
I I I .1
1- 1
Pain: Yes/hb k tion:
FlAncnary:
CV: 5 5 Flyttln: 45/fr
cblcr of urine: IJue to void:
TIME DRUG DOSE
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MEDICATIONS
DOD 12464 ACLU-RDI 1263 p.7
MASK 15 30 45 15 70 45 15 30 45
TILER
/ mmHg WARD PRE-OP Bo
cc/hr XV/
IV IN or
OF AT
t I I 1 1
# PM.)
T E
$ \
, GR,
HRS
DISCHARGE URINARY OUTPUT
F: a M MOR/SPEC. STUDY TO WARD
DATE HRS (DATE
DRESSIIGS: LOCATIONS
ADMISSION
STATUS: SIA
REMARKS/AS NUMBERED) AND PERTINENT PATIENT PR RESS NOTES
(STATUS:
AIRWAY STATUS:
0 OBSTRUCTSEASILY
U PLAST
AIRWAY
0 CLEAR
2 I Circulation
10220% ol preanestnetic level BP±20-50% of preanerthetic level BP±50% of preanerthetic *41 Fully awake 2
.Arousable on calling 1 Consciousness • Not responding 0 Pink 2 Pale, dusky. blotchy. • iced, other 1 Color Cyanotic 0
A
TOW
SIGP4/4U6(OF RECEIV GAND
REL./ ASING OFFICERS
RECOVE : PATIENT'S IDENTIFICATION:
(b)(6)-4
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SIM APY
BLOOD LOSS IN OR- CC
TUBES: 0 PUG ❑ FOLEY
IV IN cC
OF AT cc/hr wrif
ART. LINE IN
I-TUBES. HEMOVAC IN
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VENTILAT,
ENDOTRACHEALT UBE — ORAL OR NASAL
: 0 YES 0 NO I D YES
• POSTANESTHESIARECOVERYSCORE . IALDRETE SCORE)
Able to move 4 exuemities . voluntarily or on command Able to more 2 extremitieivolunterily Of on command Able to move 0 extremities voluntarily or on command Able to deep breathe and cough freely Dyspnea or limited breathing • Apneic
Activity
2 I Respiration 0
TOTALS
1) PLW from KR acompanied ty
Pain Yes/tsb Pcticn:
CV:
(CONT'Othl REVERSE)
NAUSEA AND V e ITING: 0 NO 0 YES -• 1 2 3 4 S 6 TIMES
CAUDAL SPINAL 0 EPIDURAL BLOCK
MO MENT PRESENT AT HRS
SATION PRESENT AT HRS
DITION ON TOW: 0 0000 0 FAIR ❑ POOR 0 CRITICAL
MEDCOM -5253
DOD 12465
OXYGEN THERAPY
ROUTE UM %
ON OFF
❑ COMPLICATED
❑ UNEVENTFUL
AGENTS AND TECHNICS OF ANESTHESIA OPERATION PERFORMED
HOURISI
TEMPS
Spinal
Level:
EU to nrnitor an 1:74 RhytlIn •
art
EP A cuff
Ram = .
% Sat: RESP. RATE
NUMBERS FOR REM S
180
160
140
120
00
40
NNMC 6320/16 (05/91) RECDVERY ROOM RECORD
.NAVMED 6320/16 (REV. 11.77) S/N 0105-LF-206-3281
ACLU-RDI 1263 p.8
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FOR REMARKS
I I I I I
EKG rthytha
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.. REMARKS IASVERElp AND PERTINENT PATIENT PROGRESS NOTES (CONT'D FROM FRONT)
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IS
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MEDICATIONS
TIME DRUG DOSE ROUTE NURSE
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MEDCOM - 5254
DOD 12466 ACLU-RDI 1263 p.9
Inhalation /IV
Attempts
Trauina
Cricoid Pressure, nee
w/o w/ Cuff
FOE / LW /Blind LMA
Mask Ventitadon easy Y 1 N
Stylet YIN ' Bil BS / &CO, x 3 / ON
DLT • Fr L / R
I Date
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OR et •„, See Page
-2. of 4-- Page One
Checklist -
D a 0 Suction 0 Machine ❑ Consent ❑ tt PO - D Sao. 0 ECG 0 no, ■
L 0 EtCO3 ❑ PCS ES 0 PIP CI Iarm Temp CI Mass Spec D V TEE 0 Fluid warner
Air Wenn ley 0 FHT D Palm Art cath iscocm.t.in'DOG/NG L/R
LIM Rad I Fein L / R
Position 0 Pm-sun:trawl padded CI Anna c 90' Supine Prone Lithotomy Sluing L/ R
Drawn, Used W Witn5
Drawn U Wasted • 'Mins IV - L / R Hand Wrist EM AC El
ANESTHESIA RECOR Pmcedurc
(It • 1 b)(6)-2
?A (kg) - ..;b)(6)-2
s„. Ht (in) -
Surgeon "4.11 S f) ,3_ j_
Ans. End Resident/SRNA
/00
100 670
• = Parse
0 =Sparc 9esp. 0 = AUL
Vowlatin
X =14AP • AIV. MAP
/ T >= A-line I - Intubate
E .Enutaiie .
ite^^f Lem 22,0 53ou
c'11111111=1
mlliskIlle1-rlatag Times I__
60 / 90 /120 /130 / 140 min - Samoans in/oared Antibiotics
Total Agent -
•-1.1 Orotal ins - Si 0. co Total over mindtes
Total 2.00 Ba
140
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Idfl.le
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Tube taped @
ainienance i Smooth• -
canon
: no. sition - PACU I ICU ‘F
a lien t Identification
Preottygenated Smooth
Giade view Tube Size
cm 4t / teeth / tutees
Cuff checked Eyes taped /
Reversed S S SV 'VS5 Awake / sleepy
Full T4 /Hud lift / Sustained tetanus Suctioned Awake / Deep
Etrabated /incubated III Sterile Tecimique 6Stiinel / Epidural nito-Caltrier out - up Mum Q oisposable kit 0 Tachy I Whitacre / Quincke 0 Level ❑ Betadine prep .3 ❑ Needk gauge b Last irtrdtratirin 0 Sitting 0. Site 0 Attempts
B • Pierite Stim _ nu%
0 Ttans ,anerial •
0 Dual can
/ L LOR to Air / NS
0 Paresthesia -- 0 Hama + / - 0 CST / -0 Tem dux e o CSF a ntirl
Lines O. Seldinger Technique
CVP manually tratuduced ❑ Cordia 4.51 8.5 Fr
St.IC . 0 2 / 3 • lumen
Conunents / DrUts:
MEDCOM - 5255
I. i It 0
DOD 12467 ACLU-RDI 1263 p.10
Rapid Sequence
w/o v.iff
LMA
Mask ventilation easy
Stylet N'
DLT Fr L/R taintenance
xtubation
nit:sashimi / ICU
ANESTIIF-51 RECOR Vt k - 1° It5Ht in - Pmeedure( (--J Lit )
\
6)(6)-2
OR # 0(6)-2 Surgeon boy,
."1.- ■ \014 ‘sir M. 1.10x; 3 • See Page
I Page of 7.--- One
Doe
-V11. ctS Ares. Stan
Ikoo n mien
1125
Sorg. Sun
Me 0 Sart. Eand............
1513 Me a End
1 535 Residen t/SRNA
--
Time t3/3 st \ 7.-41Q .% 31.7 s..1 1300 '30 '1C., I LI !_10 S o, 1 t/ i 1 1. i 1 I 1 % \ Checklist •
..121:r.; erguction .1;110% chine rrEonsent •••15-NPO Monitors -
Wil. um 7- 7- 2 7i 2 2. '2. "2. 2. -2.. rt va. Ha Sevn /Des
. 'A . 'A . sr . L. .1 ..„.1 ... .-1 . ri ., .-1
-1:31;0, -15106 -BTO; -8-NIBP 1.<2)cm -Ertico, 0 PCS / ES GMs -Erflp.1;1-remp ❑ Mass Spec ❑ Verbal ❑ TEE ❑ Fluid warner 12Ki Warm ,..ragley 0 FHT ❑ Pulm Art nth
.1:1CVP LI/SC/Fern L/R 00G/NG L/R
S1-7-6,P I Etomidate ZOO ua Cistracurium 1 C 0
ROI Raps ecZ
• • C 0 0 A-Line Rad / Fem L / R tieostigwie /Glyet, Position - -ItYfressure points padded F11<ts c 90°
lirgiin-P Prone lithotomy Sitting Lateral L/ R Ephedrine / Neo
Midazolam 1-.....0■••• Drawn__ Used Wasted Whits
ms0d Rani /Siii 2,50 )_S 0 1 0 usesXno used i I 51-Nvested ■ o %vie. 1\ --•.- Eige. tidal Burin / RoplY 1V- ,11..M _Gart.) R C.- ) Wrist FM AC El
❑ Tourniquet nunfig Times 11____ 1
60 /90 / 120/ 130 / 140 /150 min - Surteons informed . MdibiOttet
Agent -
Mg -
over minutes
•
I'Loci.-e. _ Tout
t.Total NS 2.0 0 - )100' Vico 10D • taro 1 bti-tr Total
EBL V f Tb......0 Total
• = Pulse
0 =Sport. Rasp. IN
0 t-. Mu Rap.
s Velttaillar 160
X MAP A/V=N1BP 140
_L / T =A.Line
1= Intubats Do E = &tame
180 :
160
._ . •
140
ICO
SO
+A
i,13
•
-
‘• V v Y VNI/ 11/ V
1.1 •
- • se Nit rrill / ICU SOO
s ------
IP - SO
60 tR -
ia0, •
:omps • + / - 4°
1 6. • a r e ow,aft,••
a
. 'N
•
7171
ECG G 2.- SR 5 R- a It 52 .(Z- 5 S2 .st"Fil, Or / Sk / Ax Temp - ^"5 Jr Si% -,..36 . 36 . Cs . . 2. --8,i,s -I L. 5 16 _5
2- 1 4, 34,1, .
%FA i .0 . a .. 3 . 3 . . s I • 3 .3 . 3 , 3 % sic). 1 cs v I on I tip loo lb° Lou lb° (bO (6o i t:so act), .A. s A 35 3c1 "1, L. 3 iz, 3 . I 31 -3 "7 I rl
."1-111C .1 1 li. ON cis.) '-‘( IA lv .,1 -rts 1, 4 Cg u c .4 -74 ° c 4 . v
c- PIP (aoH2O) VA . 2. 44 '2.4 Naz 1- 2- t. ' Rey. Rate ri ) '2.. 13 13 ‘`I I I.4
iduclion onito n n ififia="ir ► 4=1Ir Inhalation CC::) Cricoid Pressure
intubation - et/ Mil Grade view Tube Size TO Attempts 1cCA-:a Nasal L / R
Tube taped @ te,g, teeth stares Trauma Y rip FOB / LW / Blind
yes tape / tubed
Blocks cme Stun
❑ Trans.ertertial
❑ Dual a-di,
MEDCOM - 5256
1 ati rat 1.1..otifl,..ttnw b)(6)-4
Dee
Regional ❑ Catheter out - tip intact
❑ Level
Comments / Drugs:
lingers Technique
U CVP manually transduced
❑ Cordis 9.5 18.5 Fr
o SLIC .
❑ 2 1 3 • lumen
ft:oltat
❑ Smile Technique ❑ Spinal / Epidural
❑ Disposable kit ❑ Touhy I Whitacre / Quincke
❑ Bat-Wine prep x 3 ❑ Needle gouge bjy, ❑ Local MOM-mien ❑ Sitting
❑ Bite
❑ Miempts LOR to Air / NS
❑ Rareuhnsia + /
❑ Hems 4- / -
MA ❑ CSF + - ❑ Test dose 161
j=1 CSF e
DOD 12468 ACLU-RDI 1263 p.11
Olha
Hepatic: Renal; 0: Endo: Herne:
&OH: 7
Tobacco: .
Family Hz: 15 IIMOMIDI=Maggstra -
•csw s parol : 0'00
• Reviewed / pal10t,e4mined, • . bit004 .1400 dlscussed.With patient
pt q400).ni .1111Mi/.060' : 'au./ patehti,:60:114M undets4m4s and acCepts:titks
'after. • -clen! •-• SOlids Pun 6,v‘.A
NNW 61=79 fDis-110)
Pre / Pt:Kt-anesthetic Summary Age Weight Height
(kg) (n) .10 rit.14
ASA Status
(2) 2 3 4 5th
PC,3MA:teal:Inn
-11-,101 t-P
Allergies
r-no Chernistriel licmatolory
H / H -
Platelets •
WBCs -
Urinalysis / HCG NPO- /'"•4
Teeth - I )OCC
Airway - Mat II / IV
PROM, 3 FB FB HM
CNS / Skeletal
Seizure: CVk.
p LOC: Neuro: Muscle: — Skeletal:
Resairatory
Cough: Sputum; Asthma: COPD: Recent URI: TB:
Long Exam:
CXR:
a iv: CAD: MI; CHF: )
VHD: Arrythmias: Exerdse Tolerance:
3 Cardiac Exalt':
ECP1IL
tr
Previt.us Anestheti cs: Preineclication: Current Medications:
• Vitals
S BP HR:
Resp:
Terim:
FHR
Pre-op
341/6g
7
DOS
sicnature • b)(6)-2 b)(6)-2 b)(6)-2
(b)(6)-2
St Date v _S
Date 8t , tline II- t./.$
I °
Pmient identification Post-operative note kh)(6) -4
0 No apparent anesthetic complications
Signature Date
MEDCOM - 5257
DOD 12469 ACLU-RDI 1263 p.12
NPO — 17-.; 1\1 A
Teeth
11.,1) 11 / til I IV
FROM. FB O. FB HM
Da=
Hepati\s, Renal:
61: Endo: Hcmc:
PrevkAis Anesthetics: , 19-
/ A l■ 14% i--11.1
Family Hz:
TlinANr t)(
Current Medications: Premedication:
Post-operative note
: Pre / Post-anesthetic Sunlit Proposed Operation Age L Weight Height I ASA Slants
IT) FeillprtiA
s/7- (kg) (inr 3 4 5 E
MCMC 63201279 (Dec-1K9
Allergies
/VOA Chemistriris
Res.piratory
Cough: Sputum: Asthma: COPE): Recent URI: TB: ,
Lug Exam:
T A CXR:
liematoloev
H/H- 6,47111,1
Platelets -
WBCs -
a HTN: CAD: Ml: CHF: VHD: Arrythmias:. Exercise Tolerance:
Calfiettni: ECG:
Urinalvsis/HCG
CNS / Skeletal
Seizure: CVA: LOC: Neuro: Muscle: Skeletal:
EtOH:
Tobacco:
z
HR:
Resp:
Temp:
FHR:
Chart Reviewed / patient examined 0 Risks / benefits/ options diicussed with patient 0 Patient questions answered
parein! guardian understands and accepts risks
'Tule` liq clears solids Platt
Date & Time
^lt 4l03 Staff MD / CRNA sienanne Evaluator S gnature ;b)(6)-2
Patient identification
;b)(6)-4
402
MEDCOM - 5258
DOD 12470 ACLU-RDI 1263 p.13
b)(6)-2
131— spa
( b)(6)-2
Rua
%/Ng .1.0r161/.4tg
duct i on -
tubanan -
uintenanc
Aubation
7L. of (14- l'et& /o/s-- 4t*:e
env !L. I R.
ito / Rape Ve
alai MI
1,1S0d Rim* /SU
ESA& LW /RR*/ 4.01*
I. Deep. FAN TV•ReadfIft /.Su;iali;edt4tantia
Extubated/intubated. , acleei*ieeteOatve
• *400 EIR'1441.44.1!raan
L'/ R . P
BloCks Neel unN
atrint.itterial. •
Q
P ,Scididiit. T*4090.- CY.F,)1)*Oubieransiiced.
.0 c.oris* 9S / 0SLIC
' ❑ -2 , / • kiruin
:.Aretotttl kit4ow . /Oink .
Epiellita3 P CeritIne Out • iipieux, 114601.1y./Witituere / Quincke 0.lsVel .
Q .Oeiale &ate o S*Ilna
R / t. 13 I/3R ko Air I NS
+ / + /
CSF 4- I - El Tem dm a
CSF 1).irt p
ANESTHESIA RECOR .441;1, oh.dc.v.m al Or Dnc
CC,/
l
Halo / 410=1111111111111MINSEMEIF7-11. IiiIRCIPMERSECIPS "3 17 uvie .arr / WM Mg IMENIVAP„ ' „..
S 10i ECG. jg.Hor
1 (Ilan' -
Wasted .wit„,
11
RO
over
ird Cs
40* Total
160
..• bX6)-2
20
.11111111111111Kill irlIMICIACEIZIEMINWA a/i1111211 NINE HIEN MINIKAW FAS1 011111111111111114111111111111111111111111111 D°
1111111111111M111111111111111111111111111111111111111111111111111111NRIN MUM 111 N11111.111EINES11010111111MMEINICEMPNWES1111111M
altalitallit EMS 111 MEIN NAM 11111111r Via SINN ELI NMI MO NAM MEW MEW NW IMO 1111L11111111111117.0 MINN um 111M111151 IMMINFAI WAIII MAI 40,
b)(6)-2
- 1270 Ht (in) - Surgeon
• • g. es MO A-
OR tt
Time (.1( VT'
-4/2,Ead Resident/SRNA
CI, LA1 NIM11151E 110M MEI Mann Ina"
• STP Mei/ Etixiddi
Sue/ 111=1"1
IIII PFes;ustpopts padded .
uthoi*Y sitting
A MUM M RM I min =i• .111w,,4 mrainip. = vim rim 'Imiliginrn:ijaz
-• Artnbtonea Tof1 IIIIIII MM. 11111111 • "
EMI EMI Mill WIEN NUM MIMI 11111111111111111111MIIIIIIIIIINE111111111111111111111•11111111111111111111111 11111111111111111111111111111111111 MIN EMI MEIN MIMI 1111111111111111 110111111111111111111111111111111111111111111 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111121111 1111111111111111.1111111111 MIMI 1111®11111 WEE 111111VAI rwill111111111111111111111111111MENHIMIINIMPIENIIMI
ESL,
leo
.
TV PSP rettH2O).
VAR FEMS1 ERR EMIIVIDA Vitra WM Fa IFISAUE30 rit 1 Et Mel %IV! EMI .F. M1 %WA
SreA PAAIIIVW I Ill I it a 'A Mill lirgri gram Ma Irlig ° INES1111E- Irer.V KVA kr.:51a ULM Ut.
IMAM Will nom was mis re rfiZtilirAill DWI rAmmag LWAP, meza !vi(
rairmiliPrii: UM BMW IW4'al MEM
n
Wad MX EWE OM IP:MIME OW Ad** fY
Grade view Tube 0,4 2 .AttOtIPti . Yr4iuni Y
lobe
Nautii1:- .1 R . ■v./ Fog .t;ii..1431irid *4.
Iriukrinnlrladbo
Sty
vitt , ft
See Page
Page of One
action achier OrConscat $NPO
IMIN
WIS
7:.1.2 ilia MINI / R Hada:Oast Pm AC Li
IRS71.1 :Matt
Cheeldol
mitis laPc.$ / ES aP e,RAP temp 4e,c 1:1 ■400 TEE ❑ Flisid
Air Warm Xrcijoi NI., Art cath ■ OAP R DOG/NG 'L/R
.111d F.4., Arms <90*
Lateral. L/ R
Il tecr'Otigied ef 4-1 '03 .
/330/ I / urc itsjoifonecd
NS
pati
o
x m/up A/v..1,0P . 11T 'A-1ic
inigito0
;A' ilOU. •
/ ICU (skcpy
nient Identification b)(6)-4
MEDCOM - 5259
DOD 12471 ACLU-RDI 1263 p.14
Patient Identification
(b)(6)-4
ANESTHESIA RECOR Wt k .70 Ht in -
. ....wt) Cal Neu 1 ( 4 L .
• -••• „ler I I
4v tv me See Pay,e
of.3 One Arrs. Sun
14 I t 4 / 31 .
v
T A I ft D
0, LIM —
AWCAMENOil ❑ Consent ❑ NP • tow. Bak, Lso Se . /Des 4 ill
❑ BO, ❑ NIBP L arm ❑ E PNS ❑ PIP ■ Term ❑ Mass TEE ❑ El " wanner CI Air W FM ■ ' Im An cath 0 CVP U/ ■ OG I NG L / It ❑ A-Line Rad
mminov iamwdate 1.
Sus /Cistrannium . • RI) /Rape / Ve caronium
Lidocake
Nenstipaine /Gben —
PosIdon - 0 Pleas d ❑ Amu < 90*
Supine Prone IA Sitting Lateral L/ R Epheckke / Nen
Mideralam Drawn Used Wasted Willis
MSQ,?Read / So / fentanyt Drawn Used and itns
Epid. Larks / Bunn/ Reply IV - Cm Wrist FA. AC EJ
❑ Tourniquet Irtmkig T 1 I
60/90/120/1 min - umeons informed . Antibio
Agent-
mg -
over mi tea
@
• Total NS / LR
U/0
ESL
• = Pulse
. 0 .SponL Rasp. Ido
0 = tnsm. Req. •
0 4 VertabiOf 160
X =MAP AN . nue 140
1 / 1- - A-Line
1 ot Inaubate
. '
• •
Ifo
411 E c Ululate V
IOo PACU / ICU 100
. -
Pulse -
BP - to
Tempi; -
RR -
'
GO NS\
Sa0, - 40
Corps- + /
• .
•
ECG
Es/Np /Or/Ski
Ir. 14% I /0 . 00
00 scoff
S".. Z./ 3
^ 44 E .
PIP wat-1,0) Itesp.Rm.A.1_, ra/
- _
Maint
▪
ena
Exfoliation - Smooth
Disposition - PACU / ICU
Induction - Monitors On
Intubation • Mac / Mil
Tube taped @
Csieoid Pressure Rapid Sequence
Oral /y / Cuff
/ LW /Blind LMA a
Blocks
0 Nerve Stint inn
❑ Trana•anerial
❑ Dual curl
Preoxygenated
Smooth Inhalation / IV
Gra • ______ vie ube Size Attempts
ern 0 qpe 1 Beth g Trauma Y I N Cuff checked Eyes tape• lobed
Reversed SV VSS
SV VSS Awake / sleepy Extubated / innibated
Awake / Dee Revlon* 0 Spinal / Epidural ha Citketer out - lip irliaCi ❑ Terahy / Whitacre / Quincke ❑ Level ❑ Neer* page
L / R ❑ Lateral R / L
❑ Paresthesia + / -
0 Ilsee
❑ Salim
0 LC* to Air / NS
❑ Seldinger Technique
❑ CVP rrunullly transduced
❑ Gordis 9.5 I 8.5 Fr
❑ sue
Lines
" 0 2 13 • lumen ❑ CSF + / -
0 Test dose 8 J:J COP 0 Oda
!Lee n s-n,, Tedwalue ❑ Disposable kit
❑ Betadine prep x
❑ Local infiltration
0 Site
❑ Attempts
d lift / Sustained tetanus Suctioned
Mask ventilation easy Y / N
Stylet YIN Bil BS I Eta), x 3 / CIN
DLT Fr L / R
Cotruneau /Drops:
M EDCOM - 5260
DOD 12472 ACLU-RDI 1263 p.15
Induction - Monitors On
Intubation. M
taped @
Maintenance Smooth
Eambation - Smooth
Disposiuon - PACU / ICU
IV Cricoid Pressure Rapi
Oral / Nasal L / R w/ Cuff
Y / N / Blind LMA
Mask ventilation easy Y / N
Stylet Y / N • BS / EtCO, x 3 I CRN LT Fr / R
ANESTHESIA RECOR (b)(6)-2
Wt (kg) - Ht (in) - . ies -
Pr'.F;-lnOtia, .14 i t 4103 ( &id;
ARS. Sian
.... Surge° b)(6)-2
nUSFWA
10 OR N
RI(b)(6)-2
Sec Page
Page One In Room Slog StVl Sorg. End Me . •
%LIM ..._ 1 — i
FAIMPall heddist -
_.
❑ Consent 0 NPO .•
Fi0. 0 NIBP Li'arm PNS ❑ PIP g Temp TEE ❑ d warmer FUT • ' Im An cadi
❑ 0G/NG L/R
°-r!VAI. IIM i''''' Hahn/
. 401;:l
..*1 *MIR= e•i''
---
IRE
WM 21 P.- .2— "Z.- • * ❑ Suction ❑ Machine
0 IEW WA WM •13111111E1E•111 m rs" ❑ ❑ So l t—i ECG 0
❑ EtCO3 0 PCS / ES ❑
❑ Mass S. ❑ Verbal ❑
❑ Air Warm 1 Foley ❑
❑ CVP U/SC Fern L/R
IIII
STP / Prop. / Etomidate
. Sun /Cistramarium
Ro/ Rapa/ Ve (uranium
Eldon:me ❑ Aline Rad / L / R Neostipoure /Glmo PosItion - 0 Pressure
padded 0 Arms < 90'
Sitting Lateral L/ R Epliedrie/ Neo Supine Prone y
Drawn U led Witns m90."ilterni/ S ttle „,,t5' 5o si) 1.-5 ,2S 6.•1. I-6 Drawn Was• d • iens Raid. Lido / Reply/ Ropiv IV • a L / R Hand • Mt PM AC EJ
lik-ntl1117111111 LE7I7MVESI 0 T - • t______mmHg
60/90/ 0/130 /140/ ISO
Times I I
EMI min- informed 1 r low Era
.!1, g=1 61 I P i ii- " . nal i''' 'i li la il wa 1" 49 il I il I I 0 I • P II i I I I. . 4 11 ,I . i ap rep.. is ii a prii m pArl m- Antibiotics
,40z,m, mg =I} =calm :--.420 11111 Total Agent-
Mg - over minutes
@
tNS Aki 'KIP iIrro gill= • i n il• Iv- • i i .1 ill sir II MEI hin i NI 1rig" Wel •■••■••■ NW Vrotal
t40 /P.,0 4 .; / Test
EBL Total • = Pube
. 0 =Sporn. Reap. IN
O. Venulator IN
x =MAP A/V=NIBP 140 1/TnA4.2be
I. Incubate
"
ild Um f4
'in i Aet4-ed
IS 0(6)-4
YE 160 al 5
0 /ll IC) .
■III FA illifilallYAM
■nrammminammumwmfinmoymming, ■ 111111W/1
11111.1111 HIECENFAVA"VI
■EN 1. ■ •
140 (b)(6)-2
Ilg / \ A mown' " • -1- • 1 "---
IBD /2,zs-_, c ri,2/ • • conie ore- a
1-`14- c& u nil,
. •
E = Eembaio
MIMI 1111WAVIPKA
PACU / ICU IDO
Pulse -
BP -
Temp -
RR -
SaD, -
comps. .
III rg AM ITES ill■111
" MI■WEEP..2.1:11iiiii .
III
'ZIII
1101111111111
1_11112111111 MENEM
IIIIIIMPIME1411111ENIIIIIIMININ II
■I MIMEOMIMI MEM
q
MI
I
ILIIIIMMEIG011111M1
•
10711 WW1
IMI
■GPM LIMN WW1
Ma
11F11.■111E4/11M;IIIMMIKill
■wainwazdamaktal IVA
WWI birAill
imam.
Illt•MINE III■
101■1 M■tila!
arm
III■II WAN
■ .
• .
• Mil
ECG .;-..tl :al WWI 54 Es I NP /C'r IS" / " 1-' 4 '
%5a° swkIltatlripzil!Erslrall ria rA MO
MIMILSel E1' I
era 51.5
q UMMIIICLIII
LL1• II aim
cox FAN V.FAI ViNil KM RIJIIIIIM7 Ited1J.711n was rea
TM Liza imin UPAILMIIIMMILI:11111 WM
IMIIIIIMII
U27107.111M11 NM MIIII WA ■
PIP (emthOl
Resp. Rate IM'AIPTAIIIFE111 21 IA
I Inc
Preintygenated Smooth Inhala "
Grade view Tube Size A
m@ lips / teeth / mites T uma
Eyes taped / lube
V VSS Full T4 / Head lift / Sustained tetanus Suctioned
Cuff the
Reversed
SV VSS
Patient Identification
(b)(6)-4
telt
❑ Sterile Technique
Disposable kit
❑ Bmadine prep n 3
❑ Local infiltration
0 site
L / R
❑ Attempts
Blocks
❑ Nerve Slim mA
❑ Tianennerial '
❑ Dual cuff'
Awake / Deep R cul Reginal
Comments Drugs: .
❑ Sphul / Epidural ❑ Catheter out - tip enact ❑ Touky Whitacre / Quincke ❑ Level
❑ Needk guagc
❑ Sitting
❑ Lateral R L
❑ LOR in Au/ NS
❑ Paresthesia /
❑ CSF + / -
❑ SUC . ❑ HEM< / ❑ 2 13 - bunco
Lines
❑ Seldinger Technique
❑ CVP manually sransduced
❑ Conks 9.5 / 5.5 Fr
0 Test dose 0
CSF 9 s ■tirl
Awake / sleepy
Extubated / incubated
RAFnr.nm - c9A1
DOD 12473 ACLU-RDI 1263 p.16
ROUTE
MASK
TSAR
VENTILAT.
LAA
tDL
FLUID THERAPY
OFF
TYPE
OPERATING ROOM
RECOVERY ROOM •
TOTAL
BLOOD LOSS IN OR: ,9a) CC
Alevd L BLOOD LINE OTHER
• st-
WARD PREOP BP / mmHg
TUBES: 0 PUG 0 FOLEY
' ADMISSION
DISCHARGE
FROM NOR/SPEC. STUDY TO WARD
DATE 41 13104 Ian- &
STATUS
STA
ENDOTRACHEAL TUBE - ORAL OR NASAL
OYES NO 0 YES NO
AIRWAY ARMIN scars
dEr‘EAR. O . PLAST AIRWAY
O OBSTRUCTS EASILY
STATUS:
• POSTANESTIIESIA RECOVERY SCORE IALDRETE SCORE1 A
DATE
5 MRS'
DRESSINGS: LOCATI
0
I I I !
PPCU
URINARY OUTPUT,
TIME -
cd
TOTAL
SP, GR
S/A
Oa, NCO
REMARKS /AS NUMBERED) AND PERTINENT PATIENT PROGRESS NOTES
1) .PEW fran MR amatpanied, .b)(6)-2
1W: As 2.
DURAL BLOCK MOVEMENT PRESENT SENSATION PRESENT AT
CONDITION ON T .3 00D 0 FAIR 0 POOR 0 CRITICAL
CAU
z_ HAS
FIRS
RECOVERY:
0 COMPLICATED
NEVEitrFUL
PATIE DENT IF !CATION:
:Is)(61-4
if& /
NNMC 6320/16 (05/91) RECOVERY ROOM RECORD
.NAVMED 6320/15 (REV. 11.771 SIN 0105.4F-206-32BI
TIME G 011-IER:
GlerriertA LCrn4 OPERATION PERFORMED AGFNTS min TH•PINICS OF ANESTHESIA
13)(6)-2 OXYGE NTHE RAPT
oral i'ai( HOURIS1 15 ,0 15 45 2 15 45•
220 11111111111111111111MINIUMUM MI 1111111111111111111111111111111111M11111 1111111111111EME11111E111111110:111
EEC to nrnitor 111111111111M111116111111111 + 111M1111 . IMO-1 - 11111E1M11111111111111 RhYthn
140
ME ; IIIIIIIIETUUMIIIIIIIINEWIN IIIIMIIIMMINEMENRINIUMES 11.611111111011- 111E1111111111111111111■1111 IIIIIIMMEMILLIERIMEMENIZIE _ 111111111110111 'r t' HIUMUNIMMINIUMIni IN "5_1 1111111111MINEZIONEMEINIIIMIE FRIMININIERNELVIUMERIME
l i
A6les- •-fD r(5.perwt tail Pain Ye Peal:
01: (re% ,
OU en st Is X 2 war ,darV-ets . 2
ICONT •ON REVERSE/ 1. Activity
NAUSEA AND VOMITING: 0 NO 0 YES • 1 2 3 4 5 6 TIMES
ip 4- art 1°3
V BO
IP A cuff
Ram = • 40
% Sat:
RATE
NUMBERS FOR REMARKS
TEMPS:
Spinal Level:
120
160
!BO
lp
V IN OF
ADS.4INC IN
dgyp cc AT u7A oeA,r AGAT •
AT
Able to move extremities voluntarily or on command Able to more 2 extremiiieivolumarily ow on command
Able to move 0 extremities volumarily
or on convnand Able to deep breathe and cough freely 2 Drronea or limited breathing . I Respiration Apneic 0 BPI20% of preenesthetic keel 2 . BP420.50% of preanerthelle keel I Circulation
.101.50% of preanettbetie keel 0• Fully wake 2
.Prrousable Oil calling 1 Consciousness Not responding 0 Pink 2 Pale, dusky, blotchy, laundie4d. other 1 Color Gyanmk o
TOTALS
,(1:4(6)-2
SIGNATURE OF RECEIVING AND . RELEASING
TOW . bX6)-2 OFFICERS
MEDCOM - 5262
DOD 12474 ACLU-RDI 1263 p.17
TEMPS:
SPirk ' • Level:
BG Ftritha
EP T art V
W A cuff
FWD = .
% Sat:
(i) RE MARKr:4NUAIHEREDI AND PERTINENT TIENT PROGRESS NOTES (CON
. I . 6,)r) ra-4-ncr) CeArc4 s et:ono-40 'A S 4kS
u..a5 rte, • 5 rs a 0
a P.. A,21,4
0 1.. ■
cr th ■
/4•ALd rIMMIEMEEMMEMEIIN '?CW Nbte:, Nano:
.11V.•
111,fflingif....pEEMPO111111111=1! A "11111' 0,1 11 0112"111M g
t.MMI Rrai• I(.• 1111 Pain: y"z.,
(.5 . siat walk EEG Fdlythn: Oa-
4411 • - - 11° Ocacr: • s • • 'if eT,
V. • GU: Ebley
bX6)-2
b)(6)-2
b)(6)-2 ,
Report called to:
'IDAlad to:
Instrirticna/Intervelticre in MU:
°Dior of urine:
•: 1991... 501-10120625
DOD 12475
MEDCOM - 5263
De to 'void:
NAVMED toxvIelertio MOURI:4 15 30 45 15 30 •5 16 15 46 16
150
MILTMENIIIIIIIIIIIM1111111112111=1UMMIIII mobinunualnammonwanamminiarain MICIUMUIUMIIIIKIINCIEMENE1111170111111:1 160
ElkillingE111111111111111111MIIIIIIMI=11
twanumummoolognommunnimusErsoffi musanimmurnammunanummissusin MERIIINE11.1.111111111111111111111111118MMICI
140
120
RESP. RATE
NUMBERS 1 FOR REMARKS I '1
L _t_L II I
I, ,
! I I I
1 n
1 L I 1 1 1 1 1 1- r _II 7
I T : I i It• II -I I I I
• MEDICATIONS
TIME DRUG ROUTE iniiir RSE MEM
iiK0711161=11111111111111111111■111111MMIIIIIIIIIIIIMMIN -
111.15t Iffif.M711"F..e.A.M.1111.111111.111111WRIA.
11111=M
IMMIMIIIIIIWO.. MN IMEZMITAINII t v,..42
Millgrallii 2601 MEINAIII
INIIMiatiMMINFAris
b 6 2 )17- cm b)(6 )-2
b)(6)-2
• °Sant
"61-2 b (6 2
r • . )(6)-2
?eiePt (ifi4-4t Etta •Yr.- 413.)
• Pulnrrentr,
CV: I 5 ScinAband
GI:
ACLU-RDI 1263 p.18
UNIT NO.
(b)(6)-4
(b)(6)-2
AT (Ho
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle: grade; rank; I SEX I rate: hospital or medical facility)
518-124 NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
PLATELETS (Pool of units)
CRYOPRECIPITATE(Pool of units)
❑ Rh IMMUNE GLOBULIN
OTHER (Specify)
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY i f Red Blood Cell Products are requested.)
1=1 TYPE AND SCREEN
CROSSMATCH
DATE RENUESTED
1— kP cHEO
DATE AND HOUR REQUIRED
P Er ..EQu STINT s PHYSICIAN (Print! b)(6)-2
DIAGNOSIS OR OPERATIVE PROCEDURE
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.
MEDICAL RECORD
VOLUME REQUESTED(If applicable)
\ WV- ML
REMARKS:
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY CP
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
CIrnI ATI inr (IC I/ ILIC
TIME VERIFIED
SECTION II PRE-TRANSFUSION TESTING TRANSFUSION NO.
(b)(6)-4
PF
RECIPIENT
ABC /4/3 Rh
TEST INTERPRETATION
CIC:h1/1TIlor nF oroc.ruu OrlareleonAski, TCCT
(b)(6)-2
❑ CROSSMATCH NOT REQUIREDFOR THE COMPONENT REQUESTED
REMARKS:
DONOR
ABO
0 Rh Pas
ANTIBODY SCREEN I CROSSMATCH
e&up
PREVIO RECORD CHECK:
RECORD ❑ NO RECORD
y//-)1:(3
it ote : BP/1-4/5-3 SECTION III - RECORD OF TRANSFUSION
PRE TRANSFUSION DATA POST-TRANSFUSION DATA
TIME/DATE COMPLETE I7FM INSPFCTPD AND ISSIIFD RV Icianaturpl
ON (Date)
CENT! TION
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.
REACT! TEMPERATUP;c PULSE RESS
ONE ❑ SUSPECTED 42122k ( r. 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, Filter Set and I.V. solutions to the Blood Bank.
AMOUNT GIVEN
c
ML
tfronir.u-n isCin,
',3)(6)-2 DESCRIPTION OF REACTION
❑ URTICARA ❑ CHILL ❑ FEVER ❑ PAIN
7r1ISR (Spec'fy)
(b)(6)-2
TEMP. tl 9 • I PULSE
DATE OF TRANSFUSION
PSCLQ-)6
Lecorer U5/V , I
TIME STAR1Eb
OTH DIFFICULTIES (Equipment, clots, etc.)
NO ❑ YES (Specify)
SIGNATIIPP nF PPPSnAl AICTIMP. Aprwr (b)(6)-2
WARD
5-RAD (b)(6)-4
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1 STANDARD RRA 518 (REV. 9-92)
MEDCOM - 5264 Medical Record Copy
DOD 12476 ACLU-RDI 1263 p.19
REQUESTING PHYSICIAN (Print) kb)(6)-2
OR CIPERAIIIVE PROCEDURE
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.
CROSSMATCH
INSPECTE0.414D-LSSUX) BY (Signature) (b)(6)-2
AMIUNT
L UA
518-124 NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
MEDICAL RECORD
COMPONIEf\fT REQUESTED (Check one)
1ZRED BLOOD CELLS
I=1 FRESH FROZEN PLASMA
El PLATELETS (Pool of units)
CRYOPRECIRTATE (Pool of units)
I=1 Rh IMMUNE GLOBULIN
I=1 OTHER (Specify)
VOLUME REQUESTED (If applicable)
ML
I TYPE CF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
0 TYPE AND SCREEN
CROSSMATCH
rDATE REQUES
DATE AND HO R R.E9
KNOWN ANTIB DY FOR AT REACTION (Specify)
N/TRANSFUSION SIGNATURE CF VERIFIER
REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY CF:
RhIG TREATMENT? DATE GIVEN; ----
HEML1MC- DISEASE OF NEWBORN?
DATE VIFS-11-j y/
TIME VERIFIED
SECTION II PRE-TRANSFUSION TESTING
TEST INTERPRETATION PREVI RECORD CHECK:
RECORD NO RECORD b)(6)-4
PATIENT NO.
RECIPIENT
ABO
Rh 1.90....c
ABO
Rh
ANTIBODY SCREEN
\Pb REMARKS:
CROSSMATCH NOT REQUIREDFCR THE COMPONENT REQUESTED •
(b)(6)-2 SIGNATIIRF OF PFRSON PFRFORMINK TFq'r
tbe yer! /7 /1-"A_ -3 SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSF A
5TION
ONE [II SUSPECTED
TIME/DATE
TE E TURE
NTERRUPTED
)3 aLn
PULSE BLOOD PR SSU E
AT (Hour)
ML
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.
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, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL 1=1 FEVER I=1 PAIN
OTHER (Specify)
rb)(6)-2
PULSE 90 I Bpi D TE F TRANSFUSION TIME STARTED
1.01),<- PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last,
rate; hospita or medical facility) p)(6)-4
MEDCOM - 5265
PRE-TR SFUSION
TEMP. Lig #5
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribedby GSMCW1R, FIRMR (41 CR 201-9.202-1
Medical Record Copy
OTHER DIFFICULTIES (Equipment, clots, etc.)
NO ❑ YES (Specify)
ionvpr rIF DCDCrINI toriurrns. nnnur 'b)(6)-2
irst, 1111U le, grace; rank;
a
DOD 12477 ACLU-RDI 1263 p.20
SECTION II - PRE-TRANSFUSIONTESTING
TTNCFI Nri b)(6)-4
PATIENT NO.
RECIPIENT
ABO
Rh ?Qs
TEST INTERPRETATION
,I,k111.1. 1 ru-nnn Ill,Nr1111,1• 1-11,1,1.
1(b)(6)-2
DONOR
Rh ?G•5
PREVIOUS RECORD CHECK:
111 RECORD NO RECORD
14? ZO3 SECTION III - RECORD d F TRANSFUSION
UNIT NO.
(b)(6) -4 ANTIBODY SCREEN
E
CROSSMATCH
Co CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED I DATE At 05
REMARKS:
518-124
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
TYPE OF REQUEST (Check ONLY filled Blood Cell Products are requested.)
TYPE AND SCREEN
CROSSMATCH
I REOUESTING PHYSICIAN (Print) b)(6)-2
DiAtNOSiS OR ERATIVE PROCEDURE
L ' i. '--(----- ? ❑ CRYOPRECIPITATE (Pool of units) DATE REQUESTED
./ '").-
- 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.
❑❑
- Rh IMMUNE GLOBULIN
DATE OTHER (Specify)
AND HOU QUIRED
,e' -c ;- /,
VOLUME REQUESTED (If applicable)
ML
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify) (b)(6)
SIGNATURE OF VERIFIER
-2
REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY OF: DAVIERIFIED
RhIG TREATMENT? DATE GIVEN: ...7„,..-....../.0.:./.......;__
HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED
0i00
WARD VOL,.
BLOOD CR BLOOD COMPONENT TRANSFUSION
Medical Record
STANDARDFCRIN 518 IRV. 9-92) Prescribed by GSA/ICA411, FIRMR (41 CFR) 201-9.202-1
Medical Record Copy
(b)(6)-4
PATIENT IDENTIFICATION-)SE EMBOSSER (For typed or written entries give: Name-Last &St, Mioaie, grace, rang, ratp• hnsnital or medical r= ■-ita+ , \
(b)(6)-4
MEDCOM - 5266
PRE.J.RANSP1J10 si DATA POST-TRANSFUSIONDATA
AMOUNT GIVEN
a?-5-40 ML
TIME/D TE COMPLETED/INTERRUPTED
4/17/ 44/03
(b)(6)-2
NrRour) OM -1 I ON (Date)
TEMPERATURE PULSE 1 BLOOD PRESSURE
317/ ( & S ia.(55
REACTION
NONE ❑ SUSPECTED
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.
If reaction Is suspected-IMMEDIATELY:
1 Discontinue transfusion. treat shock if present, keep intravenous line open. 2. Notify Physician and Transfusion Service. a Follow Transfusion Reaction Procedures. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN
▪ OTHER (Specify)
b)(6)-2 1st VERIFIER (Signature)
(b)(6)-2
2nd VERIFIER (Signature) (b)(6)-2
TEMP. 3 & 40 PULSE Pd7
PRE-TRANSI-USION V
TIME STARTED
/W :tr-
LCDR/USN ANESTHESIA
DAVARM
011-IER DIFFICULTIES (Equipment, clots, etc.)
M YES (Specify)
(b)(6)-2
(b)(6)-2 Cir'AIATi ion fIF DFPC/1N nicifirsin eoreic
LCDR/USN 2 ANESTHESIA
DOD 12478 ACLU-RDI 1263 p.21
518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED(Check one)
RED BLOOD CELLS
FRESH FROZEN PLASMA
❑ PLATELETS (Pool of units)
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
• TYPE AND SCREEN
)g- CROSSMATCH
RFOlIFSTING PHYSICIAN (Print) (b)(6)-2
UIHUNUJIJ IJII UV IA I I Vt 1-.111-1l,tULIlit
■
— •
? Z------ ❑
CRYOPRECIPITATE (Pool of units) DATE REQUESTED
'
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.
❑
I
Rh IMMUNE GLOBULIN
❑ OTHER (Specify) DATE AND HOUR RE D
....'fr.' JO) —7 VOLUME REQUESTED (If applicable)
ML
c.r.AIATI Inc nr VICOtricn KNOWN ANTIBODY DRMATION/TRANSFUSION REACTION (Specify)
(b)(6)-2
REMARKS: IF PATIENT IS FEMALE. IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
DATE VrRIEIED .
A or; 03 HEMOLYTIC DISEASE OF NEWBORN?
TIME VERIFIED
. '
SECTION I1 - PRE-TRANSFUSION TESTING
UNIT NO. TRA x S 1 ■ I TEST INTERPRETATION PREVIOUS RECORD CHFrw .
PATIN
b)(6)-4 ANTIBODY SCREEN CROSSMATCH ❑ RECORD NO RECORD
CI,KIATI Inc /IC nrnento rIFIICIVIKAIKI, TrIXT A., (b)(6)-4
CO r
I-- RECIPIENT
IV E DONOR
MO A
Rh r?:;/5
CROSSMATCH NUT REQUIRED FOR THE COMPONENT REQUESTED if (I DATE / - 1 of -U3
ABO A.-6
Rh 20.5
REMARKS:
C_4ept 44 A?P-03 SECTION III RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION De■TA
(b)(6)-2
AT (Hour) t d 7 ON (Date) 40'Cli'L.
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.
AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
_q/(i//03
F;U.
41141
BLOOD PRE 2k
iz 7 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.
INSPECTED AND ISSUED BY (Signature)
ML /Z ZS-
REAC 0 TEMPERATURE
XINONE ❑ SUSPECTED 3,7 reaction Is suspected—IMMEDIAirLA
DESCRIPTION OF REACTION
❑ URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN (h)(6)-2
❑ OTHER (Specify)
1st VERIFIER (Signature)
(b)(6)-2
2nd VERIFIER (Signature) (b)(6)-2
PRE-TRAN FU ION,
TEMP PULSE DATE QF TRANSFUS1ONI
Ofi
Tlyly 7213TED
PATIENT ICENTIFICATIO 1%4 DOSSER (For typed or wrinen entries give: Name—Last rate: hospital cr medical facility)
(b)(6)-4
LTS5 LCDR/LiSN ANESTHESIA
1k' I BP 11 146 ER DIFFICULTIES (Equipment, clots, etc.)
NO ❑
YES (Specify)
SIGNATURE OF PERSON NOTIbIG ABOVE (b)(6)-2
(b)(6)-2
LCDR/IJSN ANESTHESIA
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record smsuso Fcmi 518 (REV. 9-92) Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1
MEDCOM - 5267 Medical Record Copy
DOD 12479 ACLU-RDI 1263 p.22
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
DRUG ORDERS DOCTOR'S SIGNATURE
NURSE'S SIGNATURE START
RX STOP
I 7 Ob .b
Jb)(6) 2
ctrerqmFlei) 4(Dc( 1 ,
■
b)(6)-2
, RV 4 AI A li(T-CD
. ., „ _ UV/LC . P A__ A
•
• .
646, 2oy, MOOS ik • . i oA k . A4
b)(6)-2
wiLi. , i
D i op o?4;chtkA:-. Li-sqv,u3 ortPJ , I
_i: _ 2 6) c\-- 14,6 C_ A .,--(3-- qt-k-
0 31,4m, • A bX6)-2
IN b)(6)-2 (b)(6)-2
t O CAS • / b)(6)-2
• ••
(Continue on reverse side)
PATIENT ' S IDENTIFICATION (For typed or written enlries give: Name - last, first. middle; grade; rank; rate; hospital or medical facility)
b)(6)-4
REGISTER NO. WARD NO.
DOCTOR'S ORDERS
STANDARD FORM 608 (Rev. 1045) Prescribed by GSA and ICMR FPMR 101-11. 806-8 608110
MEDCOM - 5268
DOD 12480 ACLU-RDI 1263 p.23
=73
MEDICAL RECORD DOCTOR'S ORDERS (Sign all'orders)
DATE AND TIME
" DRUG ORDERS DOCTOWRS
SIGNATUE NURSE'S
SIGNOURE START STOP
I
2.1, 0 . . .. 1
4 . (6)-2
b)(6)-2
011 . . nzi s iinismaim IIII
% ■ b)(6)-2 S-A) t(-
ram b)(6Y2 We S(b)(6)-2
enammismarfimmarignm miumlimmram b)(6)-2 VI
III Illmit
6 b)(6)-2 IMMO
Miti MI th- :AIL .111M1111911p/IPMirr*6)-2
23 A • 3 011 A.,t, I ...s
.,.L. ■ •
1111 b)(6)-2
hilalMiler 4 k t 34M6 ,40
lag
=I ra 0 • ' '
b)(6)-2 suaku. i b)(6)-2 hiihh. . Ell b)(6)-2
AI IIIMION
lin...R..„ IM1111111■11■111111111111111111111• ■
animimumenimim ILIIIIIIIIIII■
111i._ awn
111■111111111■■111111M 111=111111111111■11■1111111111
1111
111111111M111111111M1111■1 tinue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: N last, first, middle; grade; rank; rate; hospital or medical facility)
(b)(6)-4
STANDARD PORN INS OW. 10451 Pilmer6m1 by GSA ard ICUS
FIR MR (41 CFR) 201-45.505 508-111 tr U.S. GPO: I0IS-201.710/10076
MEDCOM - 5269
DOD 12481 ACLU-RDI 1263 p.24
508-112 7540-01-044-5515
DOCTOR'S ORDERS MEDICAL RECORD
INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S
SIGNATURE NURSE'S
SIGNATURE START STOP DRUGORDERS
Rx
4 26)03 2.4(30 `Jt DR_ (b)(6)-2 / 0 .3& (b)(6)-2
0 g\ (-)C ...
2a_URANk, A I Qc)
(b)(6)-2
. ')( (b 6)-2
- 3 61 t dldAL
t .... rd Ja ,............. 5-2,0 4 (b)(6)-2
4" l--- VI I! ..-F
&11% ' -...t SiT7 _... "?....--
b)(6)-2
S.c.........14. a...- (L..- aza)-711.74,-...... r)_(.6)-2
) (b)(6)-2 —
\._.../..-- (b)(6)-2
(b)(6)-2
oa 0 i, (b)(6)-2
0 Poi/DO Yt) ata V,,tidttitk
(b)(6)-2
(2; i 4- ctlAnv, it, ecri) (b)(6)-2
/at \ (/'(A - (b)(6)-2
A)(°103 b' e4' 5 (b)(6) 2
ChnAt rofv, :,-0 (con.e on reverse side) ANO.
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last first, REGISTER NO.V1Pg—INIC
.e../ 1
(b)(6) -4 middle; grade; rank; rate; hospital or medical facility)
DOCTOR'S ORDERS 11.41..112.......1
STANDARD FORM 508 (Rev. 3-94) Prescribed by GSA/ICMR, FIRMR (41 CFR] 201-9.202-1
MEDCOM - 5270
DOD 12482 ACLU-RDI 1263 p.25
rative Plan Of Care & Nursin
Patieni AsseSiment For Sur er - Potential For In'ur - Outcome: Patient is free fr and s ptoms of injury es ONo
Diagnosis:
Date/1 ..,-,7Arrival Tr sport Via:
,eGumey 0 Litter ❑Ambulated 0 Wheelchair 0 Other
DruB/Latex Allergies: 0 A
llergy/Reaction:
Planned Procedure: b)(6)-2
Patient ID: 0 Trauma card herbal ?Chart FIA-rmband
Other at-w
Present On Admission: ❑N/A ❑Oxygen 121.-Kr Site: #1 r6co C-(A
#2 %a-Foley ❑Endotrachial Tube 0 Arterial Line Site: 0 Drain(s) 0 Chest Tube(s)
0 See RN Note #
Pasj.Medical History: one known
❑ Smoker ppd/yrs / 0 ETOH ❑ Asthma
❑HTN ❑ CAD 0 GERD ❑ CBR exposure 0 Other: Past Surgical History: 0 None known Nef es
List: ms's
Cultural Needs Addressed: ❑Yes KNo List:
Last PO Intake: (datdtime) Solid: -s aAIfig1111
A Liquid: SP.
frau ma# or ?atient #
:Trom: CASREC
a Ward I OTHER:
Su cal/Anesthesia Consent Verified: 0 Procedure
nsent complete, dated, signed 0❑Emergent case; no consent, MD note
Time
're-Op Pain: 2 No t30 Nble. 4o aces ] Yes Level (0-10) fiction Taken: Jocation/type:
?reap Labs (H 0, etc): ] None rest/Resul
Interviewer: Blood Ordered: 0 N/A Comments:
❑Consent ❑T/C #Units `2---
ibX6)-2
Li T/H #Units
Side: ❑ N/ Age:
Right ❑ Left T; WT:
❑Ai 0 Axill•roll ❑ Bean Bag ❑Gel donut ❑Pillows CI Wilson Frame
Tourniquet: IJ Ann ❑ Leg ❑Left ❑Right ❑webril appli
I' 4.
Applied by:
Total Min:
Comments:
. Comments:
firms <90/1 Annboardi❑ L 0 R Tooke
0 Hand Table ❑ Stirrups ❑Other:
DVT Prevent' . SCD used 0 No ❑ Yes
res • Right Teds: ❑ No ❑ Yes
Bair Hugger used: ❑ No Other warming techniques:
En Chart: I H&P &Yes 0 No J EKG 0 Yes Ei- o I CXR 0 Yes 'El-*Slo I Other:
Skin Condition: ❑ Intact FlOther:
Limitations: ❑ A ❑ Auditory
guage 0 Visual obility 0 Prosthesis
0 Other:
Personal Items: mwlone 0 Military gear ❑Glasses 0 Dentures 0 Jewelry/wallet 0 Other
Disposition:
Potential For Anxiety — Outcome: Patent demonstrates knowledge of psychological responses to an invasive procedure': Yes ❑ No
Mental/Emotional Status: omfort Measures Implemented: Pre-op Teaching Included: 3 Alert/Oriented /Calm 0 Clear, concise explanations ❑ UkA due to patient condition 3 Disoriented. 0 Sedated Communicated patient concerns to other staff
❑Unresponsive members Remain with patient during induction
Positional Aids:
ESU # AM. Pad Sit AIKIKTIMF Pad Lot • -
Site Clear at end o case? ❑ No 0 Yes If No, see RN note # Bipolar: Max Cut Coag
b)(6)-4
USNS COMFORT (T-AH 20) PenOperative Plan Of Care & Nursing Note Page 1 of 2 (Rev 3/03)
M EDCOM - 5271
DOD 12483
Anxious Appropriate for age
3 Other Potential For Impaired Skin Integrity Related To Surgical Procedure
Operative Position: Supine
0 Beach chair Prone
❑ Sitting 3 Jackknife
❑ Lateral L / R 3 Lithotomy 3 Other:
01?) ysical layout of OR sonnel present during procedure
nvironment (noise, temperature, etc.) st-op expectation (PACU, drains, etc.)
Outcome: Patient is injury free 0 Yes 0 No Comments:
ACLU-RDI 1263 p.26
■•••& ormal sai. 0 Sterile water ❑Local ❑Antibiotics
0 Other:
See RN note # for additional comments.
Transferred To: ACU
0 ICU 0 Medivac 0 Ward 0 Other
Report by:
Knesthesia provider 0 RN
,//fe
,,(,..3.-0- 3
te Relief OR RN Signature Datc/Time USNS COMFORT (T-AH 20) PeriOperative Plan Of Care & Nursing Note Page-2 c'f9r
By:
Shave Prep: ❑Shave ❑ Clip Area:
31 y 0 III 0 IV Hound Classification:
Location: ze Location Location
H2O Pressure:
/rains/Packing: I Foley FR: I JP #1 Fr I Hemov I Chest to e: Size
0 Cervi D Coban 0 Drip Pad 0 Fluffs ❑Kerlix
Dressing: Location: 0 ABD 0 Ace ❑Bias 0 Band-Aid(s) 0 Cast
❑Steri-strips ❑Tape ❑Webril
eroform ❑Other:
Collar ■ Kling Immobilizer
Mains ❑Sling 0 Splint
v,fectiores ❑ No Solutions/r ions:
0 Benzoin 0 Mastisol 0 Bacitracin
'tcome: Appropriate Actions Taken to
erPrep:
Betadine Scrub ❑Hibiclens 0 Duraprep ❑Other:
None
Potential For Infec'
:ounts: ;b)(6)-2
Sha 46es 0 No 0 N/A Sponges iteYes 0 No 0 N/A Instruments 0 Yes 0 No 0 N/A
Xray: 0 None 0 Portable 1F(C-Arm
0 Other:
Dischar • e from 0 eratin Room !omnlications: Transport From OR:
t(tuitter w/ safety strap in place ❑
}'one Comments: mey w/ siderails up
w/ Oxygen D w/ Monitor
❑Other:
)
See RN note # for additionaltent
) orgical Procedure Performed: / / e
N Note: (number each note to corresponding area above)
14MM TI CANNULATED MORAL MIL 400MM-5TERILE cat r 474,4418 inn e 4455188 DPI 12/2011
MAT: Ti-MAI.TNN
Initial/Name Box: (please print)
kjn Integrity: Clear & Intact (other than incision) omments:
See RN note # for additional comments nplants: em I Lot # I Exp Date:
AFFIXTOMENTRECORD Membolone Etsvitulad by
ti SYNDIES.8"%t",7:7:.
0 See RN note # f o r additional comments.
ACLU-RDI 1263 p.27
508-112 7540-01444-5515
DOCTOR'S ORDERS MEDICAL RECORD INSTRUCTIONS: Place torm on firm surface; use pressure on ball point pen. Sign all orders.
Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME DOCTOR'S
SIGNATURE NURSES
SIGNATURE START DRUGORDERS
STOP Rx
14/.1)0 /lit, V° (b)(6)-2 ik. D..., (b)(6)-2
re ✓✓
Li Li-. 4,3q 1 4- f 4. S }J 84,,, le. 4LS o---et e. ICA .
b)(6)-2
a b)(6)-2 „'Eng• lalerldr-Wnr ...:■
i M Aar. -
c I 1 111 1
2 Io 3 A a " ._„ ... b)(6)-2
mlimil
si , ria .
IN, b)(6)-2 b)(6)-2
' ).b 0' a s It I, 6)
4 IA
(
MI J., ,. ._ - .. .. 4 ......./".....\--/'''''....''s•- ■•''....\.___., (b)(6)-2
= ,. .i D (2) ZZ b)(6)-1 (b)(6)-2
jeth
itnia 14050 ..)
2)
,........--. -v
■1....._ M1 i- -TA a Po a tpk\L Y‘e_ Slt 32-5 ttlier-- 0 CQ bAN .t-N.-
( )(6)-2
V 10 (6)(6)-2
174C6 0 in (b)(6)-2 OuminAiris
p on sine
PATIENT'S IDENTIFICATION (For typed or written entries give: Name--/asl,first, middle; grade; rank; rate; hospital or medical facility)
REGISTER NO. WARD NO.
1(b)(6)-4 DOCTOR'S ORDERS Medical Record
STANDARD FORM 508 (Rev. 3-84) Prescribed by GSAIICMR. FIRMR (41 CFR) 201-9.202-1
Q MEDCOM - 5273
DOD 12485 ACLU-RDI 1263 p.28
508-112 7540-01-044-5515
MEDICAL RECORD DOCTOR'S ORDERS
INSTRUCTIONS: Place form on firm surface; use pressure on ball point pen. Sign all orders. Nurse: Remove one copy and send to Pharmacy after each order is written.
DATE AND TIME
DRUG ORDERS DOCTOR'S SIGNATURE
NURSES SIGNATURE START STOP Rx
.....(b)(6)-2
_ -
2---2-zz, (........f e._ 6.....•_i_L_ (...„,-47 .., e2_,._ ; . /A - ci •
(b)(6)-2 (b)(6)-2
LtrYir
(b)(6)-2 (b)(6)-2
ten 'Ill C \ N IL "r-Al g ) '110 5 UL) , (b)(6)-2
V - ,5-4- i - '' --4̀ 4.47 ' - 7 b)p-Z—' ritatT"t''' ' 2Vraffi'MY-. - • 4,r_ZA v
4' 2-, 0 ) -...._------ b)(6)-2
4.6„,;( , t so a 4 -.), 0g I° Lk al e c i .A.: - Li , N-1—■----------,-----■---------
i Q.vii■ • . ■ Cr I, b)(6)-2
b)(6)-2
--. V•I 6' _____---....„
-1-1-4,-,--O N CA.,..e, -- .
■ i (Dc). 1 o 41-2.11- 03 „::::,(b)(6)-2
(b)(6)-2
(DD`
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; hospital or medical facility)
REGISTER NO. I WARD NO.
(b)(6)-4 DOCTOR'S ORDERS Medical Record
STANDARD FORM 508 (Rev. 3-94) Prescribedby GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 5274
DOD 12486 ACLU-RDI 1263 p.29
b)(6)-2
a z. (6)-2
EDICAL RECORD
TIME
STOP RX STOP
DOCTOR'S ORDERS (Sign; all ordrrs)
DOCTOR'S SIGNATURE
DRUG ORDERS
(hi),(2.
NURSES SIGNATURE
b)(6)-2
b)(6).
0(6)-2
(6)-2
0 3 pil-z
1..CniintAc P11, erse .side)
'AT ATION (For typed or written entries gt
middle; grade; rank; rate; hospital or medical facility)
b)(6)-2
DOCTOR'S ORDERS
STANDARD FORM 500 (Rev. 10-15)
Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 50E-112
MEDCOM - 5275
DOD 72487 ACLU-RDI 1263 p.30
DOCTOR'S ORDERS (Sign all orders) MEDICAL RECORD
NURSE'S SIGNATURE
DOCTOR'S SIGNATURE DRUGORDERS
(Continue on reverse side)
PATIENTS IDENTIFICATION (For typed or written entries give: Name - last, first, I REGISTER NO.
middle; grade; rank; rate; hospital or medical facility)
1 wrIA\10.
DOCTOR'S ORDERS 0(6)-4
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMA (41 CFR) 201-45-505 508-112
- MEDCOM 5276
DOD 12488 ACLU-RDI 1263 p.31
b)(6)-2
b)(6) -2
MEDICAL RECORD
DOCTOR'S ORDERS (Sign all orders)
NURSE'S SIGNATURE
DATE AND TIME
START
b)(6)-2
b)(6) -2
b)(6)-2
I DS b)(6)-2
MOM b)(6)-2
01"
4It` _va_i',41. UMW
AMP',
ketaillin 001111 ■
lirISWSMI"1"MjpWA i WAFTIFILILF-4L1.111111115 nin b)(6)-2
WPM ri
04■40 b)(6) 2
ing
I
4WRINI b)(6),At
_ 41 Immi"r4 olt7011
PATI NT'S IDENTIFICATION (For typed or wrier
mid •le; grade; tank; rate; hospital or medical facility) b)(6)-4
FIRMA (4 1 50S-112
f0 3 3Q
JEEP b)(6)-2
WARD
MEDCOM - 5277
DOD 12489 ACLU-RDI 1263 p.32
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
Rx DRUG ORDERS OCTOR S SIGNATURD
E NURSES
SIGNATURE START STOP
1 S4Pte03 15 9 30 0 0 e (fpwtejr eitt4Ard-ciskicl
a y-
A' XQ -6- 5 0 ..«. ..f?fr.(35, ' , e,o, b)(6)-2
_ ME ■ (b)(6)-2 4.40
1 SA 13 I 6-6I . 1 t 1111 0
,et:t (6)-2
b)(6)-2 c-_,O____e_r_j_cl,J--4) va-vic5 Lp4t_L-In
C 4701)
,I / OM ft
U. 0 b)(6)-2 E )4 5" b)(6)-2
b)(6)-2
. . I■
(A ) . ellfil io yuce;469-1 .th 0 ..13 • \ ,
1 q 5 4
''''............-...."-------._
il b)(6)-2
b)(6)-2
2.-CiOrC — Nyman 1111Pr- 5 ipc
- i 1 •
d.
U . (b)(6)-2
a (b)(6)-2
t1°----r- _
fir ,
IIM AIMI.11 .11,1grip-Millnil aif II 1r b)(6)-2
b)(6)-2
MI 11-MIMII 11111111 --
• ei 611611111A1 - i
(Continue on reverse side)
PATIE 'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)
REGISTER NO. WARD NO.
j1)(6)-4 DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-505 508-112
MEDCOM - 5278
DOD 12490
ACLU-RDI 1263 p.33
DOCTOR'S ORDERS (oRTHOPED7 .IT/POST OP) (Sign all orda
DRUG ORDERS DOCTOR'S NURSE'S SIGNATURE SIGNATURE
MEDICAL RECORD
DATE AND TIME START STOP
afiLv_ekcide
i f (65 iS0
ftr (?,?1(
MEDCOM - 5279
al il+;D ll ...A.-L.7 ---/
b)(6)-2
PArIENT'S IDENTIFICATION
6)(6)-4
d b)(6 )-2
C
1 ADMIT TO: ORTHO STAFF: M(6)-2
b)(6)-2
Dx:4rho Ifq
Pe44 A7,00c4,2, ,41f Aer4 / K CONDIIION: STABLE
ALLERGIES: 14/,e.LADAk- VITAL SIGNS: Q . 1 hr X 4 •THRU Q 4 hr X 2411r THEN Q 8 lir NURSING: - N/V CHECKS W/ VITALS - I &O's q 8 hr x 48 hrs
6. Foley to gravity (remove 6 A.M. on - drain to self.suction - Remove wound dressing and replace w/ sterile dressing on POD #2
7 Diet: Clears, advance as tolerated— -- 'On a t-1, Gto-kc-
8 .
is
• CHEM 7, CBC in AM; )CBC q AM POD # 2 & 3_1
IV: D5LRa0100cc/hr
MEM: - Ancef ig IV hr x 48 At-
- h - Lovenox 30mg SQ BID - MSO4 LO, mg IM or IV q 4hr : prn pain significant- - Phenergan 25 mg IM or I1014 hr prn - Percocet 1 - 2 tabs po q.3 hr prn pain moderate - Tylenol 650 mg po q 4 hrpin - MOM 30cc no qH4 hr prn - Benadryl 25mgpo'q 4 hr prn - Surfak 240mg po bid prn ii Other Meds: immommilf
Tbtivcpc,tc.4,1-1 1 9-0 0-7 (J
9_, .
12.
13.Call Ortho tech for casts, splints, traction equipment or cast bivalving .
14. X-rays: 011/41 (1-1"417 C;D)
Po-c_t_AL Transfuse units PRBC if HCT less than
15. Type and Hold for units Type and Screen for ' units
bX6)-2
DOD 12491
Activity:
LABS:
10.
11.
141 •••■•••••■
ACLU-RDI 1263 p.34
DATE AND TIME Rx
DOCTOR' BORDERS (ORTHOPEDICS ADMIT/POST .../P) (Sign all orders)
Doctor's Signature
Nurse's Signature START STOP
• t ,_. L15
Pin care - % strength H202 q 8 hr to all exposed 3_ gins
:-, •
■.. "Dressing Dressing changes
•
Traction - pin care to exposed pins
i
I
19.
20.
Misc: afat.-c--) C6)L E Lslii,a6 ,:)
.. •
If N / V changes occur, call Charge Nurse / Ward Medical Officer to assess and bivalve cast if
6,-,_a_ -'--- bx6)-2
it 5)-2
present 1
[
. 21:7 .
- '
If UOP < 30 cc/hr, bolus 500 cc NS and assess results. Call Ward Medical Officer if no
' improvement. i'• 22.
Oxygen:
23.
Physical Therapy: r
, I I=X6N
4 , lw NI
\..) Ifi 1511 1 SCO
A (b)(6)-2
(PErsicIAN-stsasuRE) ''y
iC 63 op_15 en^
PATIENT'S IDENTIFICATION
(b)(6)-4
MEDCOM - 5280 .-•
DOD 12492 ACLU-RDI 1263 p.35
506-U1
MEDICAL RECORD I DOCTOR'S OF,,--RS ' (Sign all orders)
DATE AND TIME
DOCTOR'S NURSE'S SIGNATURE SIGNATURE START I STOP '
RX DRUG•RDERS
IP'
ANES I HES1A PACU ORDERS
I I b)(6)-2 mit to
Allergies:
Vital signs per PACU Protocol.
4. 1 02: FM Ca; 10LYM, % Blowby,NI NP (a ,) / • '' - L. t - - LPM.: b)(6)-2
I ■-•••• - /
IVF: — at _____/:Th( )Whr . 1
-N On ward: 02 @ 2-3 LPM via NC: YES .1\10) /
k.,.....1.)r Pain medication: I
Isider 0.2-01 mg/kg) 1 Ketorolac mg IV xl dose (adults 30 mg max; peds
._._. MSO4 1=-. R" mg IV q--(LyIlin pm; max dose Z)mg _G...1 i
Fentanyl 025ncg IV q ._.5 min pm; max dose /1,0 mcg i e; b)(6)-2 Percocet tabe( p.o. with sip of water I e /_,....2, me -„ 1-0 agdvu-i-toil .4
Other: P it , or , .. , ' a 4 '-- ' I Ver 11
8. Antiemetics:
0 Ondansetron Li mg IVP, may repeat x 1 in 15 min (0 . 1 mg/kg: max 4 mg) ',
" Metoclopramide It) mg IV xl (0.15 mg/kgmax 11) mg)
a'.1 II • • - • • -..„. ...• • • e - ! . . .
1141-r available before administration. .„. .
Mi Other _
9. Clear liquids as tolerated: 411/0 NO
4111) Notify Anesthesia (pager (b)(3)-1 ;Dr airway issue , pain, nausea/vomiti 1 :.
not responsive to above orders or other patient piloblems/concerns
per PACU protocol.
40 vi 3/2002) - - (OVER)
(Continue on reverse side]
PATIENT'S !DENT! REGISTER NO. (b)(6) 2
DOCTOR' Medical Record
STANDARD CORM 508 I Rev. 3-04) Prescribed by GSA ICMR FIRMR 141 OFR} 201-9.202-1
!CATION (For type written entries give: Name-lest. first. nnielriln• morin • r,In• hernia I 'It
(b)(6)-4
1:77.7,17-CTWAT
MEDCOM - 5281
DOD 12493 ACLU-RDI 1263 p.36
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME 1 OPUG ORDERS
DOCTOR'S SIGNATURE
NURSES SIGNATURE START STOP RX
AIN ES 1 HES1A I'M- U * 9 I . fix 1
llischarge patient om PACU per protoco : Wile Alibl■.
I
0 I
1-2:- when ep urairspinal patipnts meet discharge criteria per PACU protodol,
discharge to ward. On war • bedrest pending ttill recovery of sensory and 1 1 I
/
.•• motor tUridtion;)rgress to ambulation with ass
ONLY'
stance. 1 1 c
-
SR PACU KEEP FA 1)1EINTS
13. Release patient from anesthesia care to KEEP st tus when patient meet is
anesthesia discharge criteria: YES NO • .
14. Notify anesthesia (1506) for airway management and: (circle if applicable)
a. Pain management
. . b. Fluid management
15. !
I C. Other
TOW patient i .
to ward in a.m. if patient meets disbharge criteria: i
YES NO
,• (b)(6)-2
■ .
; ! Signature Beeper
(b)(6)-2 b)(6)-2
LCDR/USH am i rmi , ir WM WArArro—A "A
1
. '
1 ' "
STANDARD FORM 5O (Rev 3-941 BACK
MEDCOM - 5282
DOD 12494 ACLU-RDI 1263 p.37
MEDICAL RECORD DOCTOR'S ORDERS
(Sign all atlas)
DATE AND TIME
FOC DRUG ORDERS
(b)(6)-2
DOCTR'S SIGNATURE SIGNATURE
START STOP
1 535 6 (o al(
..- lJ L c t__ J3C M 51,1 -_______-
1-•
.
\
-\\\
.\\\
\\*.\
\\*\
- \\N.
•
• —
. , fContrrrue on reverse it e
.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first,
middle; grade; tank; rate; hospital or medical facility)
REGISTER NO. WARD NO.
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (45 CFR) 201-45-505 500-112
MEDCOM - 5283
nnn 124AS
ACLU-RDI 1263 p.38
middle; grade; rank; rate; hospital or medical facility)
MEDICAL RECORD DOCTOR'S ORDERS (Sign all orders)
DATE AND TIME
RX I NURSE'S
SIGNATURE START STOP
DRUG ORDERS I DOCTOR'S SIGNATURE
. 1 4 -Lin, 3
5 (s-o (cap V .o Dr . QAmb -I (b)(6)-2
'''s (b)(6)-2
0),(6).2 f IliP CZ (1. ?,54—kv--tAs—
-.._ ■pA--4:tud5)
(b)(6)-2
if i8 .ra- -Lte--
G1 l ► 3 15. (P Wce. A 2_ --(b)(6)-2
C._46 e_cleift5 - 6 itif ff, j
144 Lei / r'-i?
`2----- ...-----
D Aszc4 7- 6 ,c(e.i.4 t-?
eA-,-(,,-, 4-g Dik.e.g.( -14 fr*CLIZA
cevp( b)(6)-2
4
b)(6)-2
i(b)(6)-2
(b) 6)-2
AL1 ‹._
E../ (b)(6)-2 -------------
i CO51-)Caf2 .ti C-5110.- .)‘. /k 00 ., /10-- 1- 2G rg (b)(6)-2
/X/ VI-XL 1,e3in.- a/ 0 . (b)(6)-2
N( c3 e -,--9,Li° cA,,,,,i--- 00---"-; Q-eL. in`h---v-, "e) / 03 6
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, I REGISTER NO. WED NO.
3 1)
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev.10-75) Prescribed by GSA and ICMR FIRMR (41 CFR1201-45-505 50B-112
M EDCOM - 5284
DOD 12496
ACLU-RDI 1263 p.39
b)(6)-2
C01/NCI
MEDICAL RECORD
DATE AND TIME
RX START STOP
DRUG ORDERS
DOCTOR'S ORDERS (Sign all orders)
DOCTOR'S SIGNATURE
NURSE'S SIGNATURE
o$ 7 —6 / S-,fel
lq 's°
;13)(6)-2
(b)(6)-2
Wir-4-C-0-54411 (b)(6)-2
b)(6)-2
6) -2
1 4 P
b)(6)-2
b)(6)-2 .1/ o o e 44_4 irip
(2/00'403 /P50 b)(6)-2
b)(6)-2
b)(6)-2
0 20
"rife)
/ 5
b)(6)-2
3 05
(Continue on reretue side) b)(6)-2
b)(6)-2 WARD NO. PAT NT's IDENT (CATION (For typed or written era
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45-5D5 505-112
middle; grade; rank; rate; a ay)
b)(6)-2
CSC,
/,
MEDCOM - 5285
DOD 12497 ACLU-RDI 1263 p.40
'6X6)-2 •
9
10.
11.
12.
13.
14.
15.
MEDICAL RECORD • .1
1„. DATE AND TIME START STOP
aA.Ar O.
,b)(6)-2
IADMIT TO: ORTHO STAFF:
DX : .5h:3 (
/ A/
CONDITION: STABLE
ALLERGIES:
DOCTOR'S NURSE'S
SIGNATURE 017491111mp____
— /-2 b)(6)-2
1-1
DOCTOR'S ORDERS (ORTHOPED
MIT/POST OP) (Sign all ordc
1.
2.
3. 11
4.
DRUG ORDERS b)(6)2
1X6)- 2
VITAL SIGNS: Q , 1 hr X 4 THRU Q 4 hr X 24 . hr.THEN 0 8 hr NURSING: - N/V CHECKS W/ VITALS - I & O's q 8 hr x 48 hrs - Foley to gravity Cremeve-6--A-41-,-en - drain- -to—se-11 —suction_ - Remove wound dressing and replace w/ sterile dressing on POD #2
Diet: Clears, advance as tolerated Activity;
• (t):c'F
LABS: CHEM 7, CBC in AM: CBC q AM POD # 2 & #3
IV: D5LR@lOOcc/hr LI MEDS: - Ancef lg IV q'S hr x 48 hr =,„ Gentamicin 80 mg IV q 8 hr x 48 hr OP-
- - Lovenox 30mg SQ BID - MSO4 mg IM or IV q 4#r prn pain significant - Phenergan 25 mg IM or IV;ci 4 hr prn - Percocet 1 - 2 tabs po q 3 hr prn pain moderate, - Tylenol 650 mg po q 4 hr prn ,
- MOM 30cc po q 4 hr prn - Benadryl 25mg!po'q 4 hr prn. Surfak 240mg po bid prn
Other Meds:
Call Ortho tech for casts, splints, traction equipment or cast bivalving
Transfuse ' units PRB 1C if HCT less than Type and Hold for units Type and Screen for units
X-rays: -11-^) L,t1-7
b)(6)-2
aq-eade. (414 [o) TCbntinue on reveragZalittil)
ZS)
PATIENT'S IDENTIFICATION ,bX6)-4
N(6 )-4
MEDCOM - 5286
DOD 12498 ACLU-RDI 1263 p.41
(b)(6)-2
qiu )03-
24 50
,b)(6)-2
( PHY SI CI
(b)(6)-2
DATE AND TINE START STOP
p0)-2
DOCTOR. ,RDERS (ORTHOPEDICS ADMIT/POS'.. / Doctor' ■ Nurs (sign all orders) Signature Signa ∎
Pin care - % strength H202 q e hr to all exposed pins_
' '.Dressing changes
Traction -pin care to exposed pins
Mis c:
19.
If R / V.changes.occur, call Charge Nurse / Ward 20. Medical Officer to assess and bivalve cast if .present
lf tRIP,<130 cc/hr, bolUs 500 cc NS and assess 21. results.' Call Ward Medical Officer if no
improvement. Oxygen:
Physical Therapy:
b)(6)-2
PATIENT' S IDENTIFICATION
(b)(6)-4
MEDCOM - 5287
DOD 12499
ACLU-RDI 1263 p.42
DOCTOR'S OR 3 EDICAL RECORD 1 (Sign all order
/ DRUG ORDERS
ANESTHESIA YALU ORDERS
Admit to PACU.
DOCTORS NURSE'S SIGNATURE SIGNATURE
DATE AND TIME
START I STOP
LA , til 0 3 tilICI pv3; it 1---. u r 1 Vital signs per PACU protocol.
NP () LPM.; . , 02: 'fM (allOLPM, % Blowby,
r IVF: LS,- at \--7.--u cc/ b)(6)-2
On ward: 02 @ 2-3 LPM via NC: YES WO
1 i • Pain medication: .....
1.- .
Ketorolac mg IV xl dose (adults 30 mg max; iieds cinsider 0.2-0.4 mg/kg) 7:7
a-- -t--I
% I C MSO) '2- ' 5 mg IV q -5 min pm; max dose1-7--0—mg
Fentanylc"a mcg IV q57-0 min pm; Max dclse 490 mcg r)(6)-2
/ b)(6)-2
7/ Percocet - ,_tab(s) p.o. with sip of water ilkiP / 2,
Other:
Antiemetics:
\ Ondansetro• • mg IVP, may repeat xi in 15 min (0:1 mg/kg; max 4 mg)
. 2,..... ∎ ► etoclosr, " 0 mg IV xl (0. IS mg/kg; max I D mg)
C Droperidol mg IV x I dos,- (4).°1 mg/kg; --t-in 011ili in-;,) r`1,-- t h.r'c 6.1e1;%. E
available before administration.
• Other --, I
b)(6)-2
1 Clear liquids as tolerated: E NO
, • 1 . Notify AnesthesiE (b)(3)-1 i for airway issuel, pain, nausea/vomiti
I not responsive to above orders or other patient piloblems/concerns I b)(6)-2
per PACU protocol. ,
rn i 0
(rev; 3/2002) (OVER) b)(6)-2 'b)(6)-2
.. , .__
.A1 IIIA. ANL ./M —
9ATIENT'S I DENTIFItATIO , (For typed or written entr as give: mieifilm• nrmrita• rank - rale hospital
RE ST NO. ARD NO.
(b)(6)-4
DOCTOR'S ORDERS Medical Record
STA)404RO FORM 508 !Rev.
Presc:18ed Cy )354-1CAIR FIRMR (41 CFR) 201-9.202-1 (b)(6)-4
MEDCOM - 5288
DOD 12500 ACLU-RDI 1263 p.43
b)(6)-2
t(b)(6) -2 ))(6)"
4ce%- eAm lift-) 4- .
STANDARD FOSR1 505 IRttv. 3-9 41 3,
S b)(b)-
MEDCOM - 5289
b)(6)-2
MEDICAL RECORD . DOCTOR'S ORDERS
(Sign all orders)
DATE AND TIME
I • DOCTOR'S
RX 1 DRUG ORDERS SIGNATURE NURSE'S
SIGNATURE START S • ID ,
( 0 II 11 si I ` I I
INN& • isc arge pa ien rom per protoco : • • •
en epi•ura spina patients me - isc arge criteria per protolo ,
• isc arge to war.. •1 are :-- e • rest pen• ing u recovery o sensor . d
motor _tpetion; progress to am •u ation wit ass stance. b)(6)-2
FOR PACU KEEP PATIENTS ONL IIIIMIE.„
13. I Release patient from anesth - ' are to KEEP st tus when patient meet
anesthesia disc e criteria: YES NO
i 14. I Notif esthesia(b)(3)-1 for airway management and: (circle Ie applicable)
a. Pain management
b. Fluid management b)(6)-2
/ c. Other 1
15. TOW pat' t to ward in a.m. if patient meets d sbharge criteria: i
Y NO
b)(6)-2
S ignatu ! Beeper
b)(6)-2 b)(6)-2
/-/-(/- ;,,,,-
0 3 0 / , - .o. 0 ic Nan - .-
ye
ffitti
Yr n.S ,, /S
IIMPA A I3)(6) ..
I -Ca
b)(6)-2 _z
DOD 12501
ACLU-RDI 1263 p.44
MEDICAL RECORD DOCTOR'S ORDERS (Sign all tiers)
DATE AND TIME
NURSES SIGNATURE SIGNATURE START STOP
RX DRUGORDERS
(b)(6)-2
14(AT TA).
oa- 0 c--10 vt,t IU
71A4A
fi6t, it ;4- t) /IAA-
Aocif i vk 0.Jrz,tra:t., b)(6)-2
t/
644 (e, c0 II 12's b 1 1Air > (4 Ceo L/P7ho'7:
(b)(6)-2
46947ect—:
(b)(6)-2
24 50
/upo -
OtreCPC_, fr1))4-644--4))6/ /5)0
IVA-401 /Lt.
zio b)(6)-2
Itolos )(6)-2
( )P-2
PATIENT'S IDENTIFICATION (For typed or written enn middle; grade; rank; rate; hospital or medical facility)
ast, t,
se
WARD NO.
(b)(6)-4
MEDCOM - 5290
DOCTOR'S ORDERS
STANDARD FORM 508 (Rev. 10-75) Prescribed by GSA aid ICMR FIRMR (41 CFR) 201-45-505 508-112
DOD 12502 ACLU-RDI 1263 p.45
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
NAVMED 6550/B (RE V.4-74) S/N 01l. .16-5581
SCHEDULED DRUGS
MEDICATION- DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION
I MO TH edi
b)(6)-2
--■-■amumml
„ter.2491 DATES GIVEN
HOURS /3 IWUMWINE:
13
•
INITIAL CODE
INITIAL FULL SIGNATURE & TM.E INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE bX6)-2 b)(5)-2
. •'
ADDRESSOGRAPH PLATE I WARD NO.
Injection Ste Ne Code
0 = Left Buttock ® = Left Leo C) = Right Buttock 0 . Right Leg SNGLE DOSE,
C) = Left Deltoid C) = Left Ann PRE- CP PRN
C) Right Deltoid(D Right Ann & VARIABLE DOSE CftDERS
0 = Abdomen SEE REVERSE
bX6)-4
MEDCOM - 5291
DOD 12503 ACLU-RDI 1263 p.46
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-2165581
SNGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE
ROUTE CF ADMINISTRATION
GIVEN MEDICATION-DOSAGE GNEN
DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
ORDER
DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
Li-t )1. --TA 4, Lisbiz. DATE
P R4° P TIME
DOSE
INIT.
4 t 0, ropm, 3kA__ po DATE
6? 4-° peiJ TIME 4 7.0
DOSE 3c0
INIT. b)(6)-2
41 11 ) 4 I ,„,,, ,, DATE 11 • ....------.....
T'
, iii a 1. , TI I , I ■ ./...
----(
DOS:
• )(6)-2 INIT.
it ( 1 ( 1.44 elk 2401146 DATE qk
1 ‘ P D 11 D 0 TIME 614
DOSE xiD
INIT. b)(6)-2
\----"
4/ IS ae teva-D avi 04---00,6DATE 4-7
I) 0 (06 . T RA) TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
MEDCOM - 5292
DOD 12504 ACLU-RDI 1263 p.47
Injection Site Code WARD NO ADDRESSOGRAPH PLATE
MEDCOM - 5293
0 = Left Buttock ® = Left Leg
(7)= Right Buttock 0 = Mont Leg SINGLE DOSE,
® Left Deltoid C) = Left Arm PRE- OP PRN
® Right Deltoid C) Right Arm & VAFRABLE
DOSE ORDERS 0 = Abdomen SE REVEFLSE
b)(6)-4
FULL SIGNATURE & TITLE INITIAL b)(6)-2
INITIAL Z.SiGNATUIC1T111 :b)(6)-2 'r< D)(6}2 b)(6)-2 b)(6)-2
b X6)-2 )(6)-2 b)(6)-2
V b)(6)-2
FULL SIGNATURE &TITLE INITIAL b)(6)-2
NAVMED 6550/8 (REV. 4-74)S/N 01t, 216-5581
M E D ICATI 0 N ADMINISTRATION RECORD MEDICAL RECORD
SCHEDULED DRUGS MONT ' . al—
01063 WEE:
ma it INEMI ORDER . ATE
TION- DOSAGE- FREQUEN MEDICAROUTE OF ADMINISTRATIO
CY
N HOURS
M ir LAMM rill DTMGIMI I CO 0 e. (19 CO MI 03 e giri PM
1
1
IMIERIMMri.
gatintk..-‘.
MERMIIIII
RIMINWAIMIlltillUir I ::. \)1):' 1,1 1 IT FA a a ifir al
ASIU'Ill iniliMPSIIWIIIPM.bX6■_,%man1011
nor * i CO
• oo
mod
IMIZIKSIW----
MIMI
hx6)_2
MINIM
VarilleffilMHIMI PAIMPaar
Adirl %,■.
m , Ki rim ,,, A . b),„ - - - - i 0 inivri/ MEW.:
■P
ll Fr._,AilIMBIWIMMIIII I1 I, 60 101KA b)(6Y2 maraca b)(6)-2 5112111M bX6)-2
✓jp21 ...),< im
MI' NW t:) i • ...,L 0
2• =FM
, 4 a co
simmutesnemr-Aummamirmormimsseit ..Ft:',... .__,v.. ---ts a & et. .AMIREIMIMINIIIIMILIMIr INIMIIIMINIIMIIM
wargirp EI
, , ;mum b)(6}2 .... 120 Com ( s?t541:€ _MIII.1 MIMI mmiimmloym ____„..a,
t)(6 }2 1 /1 Cle.pkr_ -r- (Do ik 0 9 6-0 bX6)-2 (3 YKD ht\ '3 o grc. 2 1 ID 10-0
a I ri)
INITIAL CODE
DOD 12505 ACLU-RDI 1263 p.48
MEDICATION- DOSAGE
GIVEN
ROUTE OF ADMINISTRATION
DATE
ith9
_DLL 4.0.LA fig
MEDICATION-DOSAGE FREQUENCY
DOSES GIVEN ROUTE OF ADMINISTRATION
DATE
TIME
rflEx iii„kt5-ionts I VD 2(!I 'fill VII 1 6 AO , 2o,A,
ORDER
DATE
4 )
INIT.
1 I T GQ*3 autto DATE
6)40 Piu) DOSE
(b)(6)-2 V
TIME
DATE 4 TIME
DOSE
if taii.vvu El+-s ► Tip P^
it l2 VI 113 en, Ise r
b)(6)-2
PATE
TIME
DOSE
INIT.
VASEMILTIEMEIVEI INSIMENTINITIMI
IsS110/1!!!!Itilffil!Migr' 2.140
6 INIT. b)(6)-2
i-f(u 'Plotopi*us-m r im.nok-nir &ft,
010 Imo
DATE
TIME
660 43/b
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION.. DOSAGE
ROUTE OF ADMINISTRATION
GIVEN
11101,1 A. I !b)(6)-2
DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
INIT. b)(6)-2
INIT.
DOSE
INIT.
4(1( pa.acd. 6230 PerJ TIME
DATE
DOSE
INIT.
til ke0
II II II
MEDCOM - 5294
DOD 12506
ACLU-RDI 1263 p.49
MEDICATIONADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION-DOSAGE
ROUTE CV ADMINISTRATION
• GIVEN II MEDICATION-DOSAGE
ROUTE OF ADMINISTRATION
GIVEN
DATE TIME INITIAL I I DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
ORDER
DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
L5kik 2-WIIF- NVPR1/4-4 L. DATE
m45 ....c...42 Mc cri TIME
C".0 irn c. P SZ.N. DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT. •
DATE
TIME
DOSE
INIT.
MEDCOM - 5295
DOD 12507 ACLU-RDI 1263 p.50
NAVM ED 6550/8 (REV. 4-74)51N.01%. [16-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
DATES
ORDER DATE
MEDICATION- DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION HOURS • .sr .
411RA
!IfilMil ol■ IIMP,
RM._ ti.Mal. le.■ :19. 'b
'VI% rfflilkSAIPII■11111111111 V? Vli *WORM \ OA)
b)(6)-2
N..1 ffi.Wal 6.4 A.siPli■
b)(6)-2
so XI! 4. --a910
b)(6)-2
. C • 1 ll WI
'IL .orP,s_gnffitilMil■ kik - MI , ,mgivile
7/ IINRIPR .i.../w/Ell.
Ft k/9
/ YOU b)(6)-2
i A2C90
INITIAL CODE
INITIAL FULL SIGNATURE & TITLE 1111.__.„.. (b)(6)-2
( FUL/SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE (b)(6)-2
„.......\ v 1 ,„
. .-
ADDRESSOGRAPHPLATE Injection Site Code l WARD NO.
b)(6) -4 C) - LeR Buttock 0 = Left Leg
C) = Right Buttock C) = Right Leg SPIGLE DOSE,
PRE- OP PRN
MEDCOM -5296
- a.vn uonvm v - won ..gym
= Right Deltoid C) = Right Arm
0 = Abdomen
&VARIABLE
DOSE ORDERS
SEE REVERSE
DOD 12508 ACLU-RDI 1263 p.51
MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SECLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE
ROUTE CF ADMINISTRATION
GIVEN MEDICATION- DOSAGE ROUTE OF ADMINISTRATION
GIVEN
DATE TIME INITIAL DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE
MEDICATION-DOSAGE FREQUENCY •
ROUTE OF ADMINISTRATION DOSES GIVEN
-V \ \ \mt .1k or.., c....A.AG DATE .4;13 X \\ ie "1-1t PS), TIME 1.‘: a92J'i"
c-C-1?'■ Ot GN-TfN-ri 0 6 DOSE . V4 -5.-1,4A
INIT. bX6)-2
....\ \ ". IP:Ali, . ., • ". DATE ...1\1 \ ..)I l.S...1 I (2) . .
J W. 0 v v TIME El t el* ,C,\AC"; OM • -
?NM cb\rItc\cc-akIN DOSE. kCV.1. ior'. (ot-4^ 1, -
INIT. 'b)(6}2 b)(6)-2
--V \ \ cArrepi,-- c2(.. 5..1/4.c, DATE
1 t...k) N 0bl...A c. 9v.....1..::1/2 TIME
DOSE
INIT.
.41/ \ \ PEP-Cr—c_.e-T. 1-,,a-ippc DATE 115 ,...\\5y,1
R.-) c.• PRI.) TIME ) ..$ \e/cl-f' 0..2,0
eFews ts..)<,A—..-14... DOSE g O. ;2 bX6)-2
INIT.
\/ ` k -rLik ,00 .1 (cfr nt„„tc.‘ DATE
Pr') Cg(.4 * PR t■ \ TIME
DOSE
INIT.
`‘•-•\ ) \ \ poi—ICI-1 ••(*h c. c- . DATE all .
P() C-. .),'' Pe.1 TIME `0
DOSE ■
INIT. b)(6)-2
LAil \ F-A.RFPX... D\-10 .4, DATE '-\\ \a'
VC) C1-]Kr) cl?-3% TIME ...64)C'''
DOSE 2..)y'
MIT. (b)(6)-2
MEDCOM - 5297
DOD 12509 ACLU-RDI 1263 p.52
.;-5581 NAVMED 6550/8 (REV. 4-74)SIN 0105
MEDICATION ADMINISTRATION RECORD M EDICAL RECORD
DATES MONTH 49- GIVEN SCHEDULED DRUGS
ORDER nATE
MEDICATION-DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION HOURS
I
INITIAL CODE
INITIAL FUU SIGNATURE& TITLE INITIAL FULL SIGNATURE& TITLE INITIAL FULL SIGNATURE & TITLE
;b)(6)-2 :b)(6)-2
. .'
ADDRESSOGRAPHPLATE
Infection Site Code
C) = Left Buttock C) = Left Leg
C) Right Buttock © = Right Leg
0 = Left Deltoid C) = Left Arm
C) = Right Deltoid C) = Right Arm
0 = Abdomen
WARD NO.
(b)(6)-4
SFIGLE DOSE, PRE- OP PRN
&VARIABLE
DOSE ORDERS SEE REVERSE
MEDCOM - 5298
DOD 12510 ACLU-RDI 1263 p.53
MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
GIVEN MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
GIVEN
DATE TIME INITIAL DATE TIME INITIAL
PRN AND VARIABLE DOSE MEDICATIONS
ORDER
DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
1-1 /it
c
jedrum 5- iv p DATE , ht.
-no p rek TIME 1445.
et(1: f eh(bleU DOSE g.
INIT. b)(6) -2
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
DATE
TIME
DOSE
INIT.
MEDCOM - 5299
DOD 12511 ACLU-RDI 1263 p.54
FULL SIGNATURE & TITLE INITIAL FUL2.75),,NATURE & TITLE ;b)(6}2
b)(6)-2
b)(6)-2
1'
FULLMNATURE & TITLE
b)(6)-2
INITIAL
:b)(6)-2
b)(6)-2
bX6}2
'bX6)-2 e)(6)-2
b)(6)-2
ADDRES S GRAPH PLATE bX6)-4
MEDCOM - 5300
NAVMED 655018 (REV. 4-74) SIN 010e-LF-218-5581
MEDICATION ADMINISTRATION RECORD MEDICAL RECORD
SCHEDULED DRUGS MONTH ILI ,9 Y 19 09105 DATES GIVEN
ORDER DATE
MEDICATION-DOSAGE-FREOU ENCY ROUTE OF ADMINISTRATION
HOURS I. Z
11 Z - I' a, •O*1 al, 04 Mei IREMCIIIIIIIIIIIIIIIRIIIIEMO
kf -
1g5 • f
7 Mina
Ir IMMINIVA
-
MRIPAL
- ___IPIIMMI 118 CI IMMEAMMOIREINITO
LRINIMIIII1111111111111=1 ,.. i o
le . 2 AnliMIWillarchvektfo
' f I
FM6* ,
b
_
— Illffil 1, •"
oti Co Li /5" ArNMEIMIrill bX6)-2
; imfannalli zi
3 ,
bX6)-2 •
bX6)-2 •K
141 i
• '11 I 3 C.,_b...._ r Po 1r b
14 i #
ft„-W I, C - Se 4e
Milt Li -....LOLIIMPIN.I.
b::: 0 0 0
• bX6)-2
LUZZ r1 0 -tl'- 1 P'434.5 PO 'T-10 ,. (2s. I, f
0
L.1 I i in, Po 0 1
i .
• 7 0 Pr oo
INITIAL CODE
CD = Left Buttock 0 = Left Leg
(g) = Right Buttock 0 = Right Leg
0 = Left Deltoid (2) = Left Arm
(4) = Right Deltoid = Right Arm
= Abdomen
WARD NO.
PRE-OP PRN &VARIABLE DOSE ORDERS SEE REVERSE
Injection Site Code
DOD 12512 ACLU-RDI 1263 p.55
MEDICATION ADMINISTRATION RECORD (Back) 0105-LF-216-5581
SINGLE ORDERS — PRE-OPERATIVE
MEDICATION-DOSAGE ROUTE OP ADMINISTRATION
GIVEN MEDICATION-DOSAGE GIVEN
DATE TIME INITIAL ROUTE OF ADMINISTRATION DATE TIME INITIAL
&'P
16/}111( 6617 6 el\e/i10/11 2cr/19 r 51.3 bX6)-2
2115
_6(42.xec (4z5-&_cusird i tt--,0 5-7zi b)(6)-2
&
PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE
NICIDICATKIN•DOSAGE
ROUTC OP ADMINISTRATION DOSES
2
S.. 1,
GIVEN
511/.,
61.01t0 4 1613 H113
(a3tIOVZ42"1 11440
1 _LI 14iPeruoc -els DATE iltillit1/1
75b ' .\‘131 5‘
ql Li y, __
crev 6
57 . .1
di 5] •/
A
t. (01‘64-c9tAlti
5/4 Di'75 0114 1 '. z. -TIN-9 S PZ3 TIME
(ALJ c' 17.-1k-1 DOSE 2 2. 2. _ 1. /, 1 2 INIT.
DATE
bX6)-2
gimpAraraltimg, . eg rt. 01-1 "1-10 A V Q-V-1° TIME 051/1 1036 153(1 1`33 •V 10 's LL: 11
DOSE jo-ym , st„,, ,,,,,,, c, 5 5. . INIT.
bX6)-2
•
enk C(.1--- _DATE 51-2I ,
'0 .
- ? 2 s po TIME 0 .
e.' S POJ DOSE 2. b)(6)-2
INIT. • -
. . PATE. ,
TIME
DOSE
INIT. .. , .• ..
DATE - . •
TIME
DOSE • 4
INIT. • -• .
DATE . .
TIME . •
• • DOSE
INIT.
DATE
TIME
DOSE
INIT.
.U.S • CPO, 1986-605-009/46155
MEDCOM - 5301
DOD 12513 ACLU-RDI 1263 p.56
MEDICATIONS
ID Olt
LI- 15- Ah-42_
MO, PO 6 4-3 'tip
4'
4
A DD RESSOG RA PR
MEDCOM - 5302
,b)(6)-4
(3
TIM C (HOURS TO BE GIVENI
DATE 1 LABORATORY/DIAGNOSTIC OF TESTS EXAMINATIONS/
ORDER CONSULTATIONS COltfir SENT
0 / I • / t2s Al.11164, AL ) 4L.1. 14.1 .*_■■ •1 6 L
. 11E.Mrl_Welferall '15131MINIM - ► / Gid11MMMani ill P.
4- 2_
DATE ORD.
DATE KNEW
ALLERGIES:
DOD 12514 ACLU-RDI 1263 p.57
f ; ACTIVITY DATE N./ BATH DATE DIET DATE ‘i VITAL. SIGNS FRED 4 SPECIAL NOTES
fr./Bedrest Bed bath NPO Temp A Li.o ';', Dentures
Bathroom Privileges Shower Pulse CA' 1- ( Ilk) Speech impediment
Up in chair 4, 1 Tub 1 11,12 1.1 III Resp h.4.131 L Language barrier
Ambulate Needs assistance (...) 0(4\1 2") Pro sthetic ,..,
B/P r. 0
1,, device
C ommode Other Visual impairment
Needs assistance r Blind
Restricted to unit • Contact lenses
Hospital Privileges ORAL HYGIENE DATE NN 1/ V •& Glasses
Other Self FEEDING DATE FLUIDS Hearing defect
./CLVAA)017 St e Li Needs assistance Self Forced to: Other
Special Needs assistance Restricted to:
Gavage I & 0 CZ3x i-g •
DATE 0 D.
DATE RENEW TREATMENTS/SPECIAL NOTES TIMES
DATE ORD.
DATE RENEW
TREATMENTS/SPECIAL NOTES : TIMES
t
(R
E ) 0 /4-0 6 ftw. 12)0 D 1s bstv. /00(k r 1 .... ),„7„
I (0 - gtiv.; .i, 4-, t. -_,64.... z;? to° 02 0t ,K,-2_0 t
, I A .,
td-- .
., .1 I r .,,,. ,,,-- 1 coi.,-. , ,-,_- kik...)
Cv-4-ELLLA',1 go iE) U6ki:b Th lANINA... kr
(11.iv
c ,..1 isks.55 4vog icklt -...i.:7-spc:citty.1 • - ....1. • •■•••
. 11 \ &7' ■-i-t):30,6, ca. r-t—, 1..e1ivis f''''.4.."--
4 - r ■)), /A) 6 N-= bU:).6 ')Lti (VI) /-4*-- i I .1)."..t.:6(t-,,,#'
1
1 <) 1 1(6 3(", IAA eij_tZ) Sbo ce., PJS QAC Acy:.,i..: -.) LA/40 (7 .( .!1 (I f , )01 0 if\
1`. J
. „,, 0:4.1-ittiv iror AireArt .1TO T
r ....,,Q - - t...---n r' g... - • ''' ' . r
6 L
, ./1 r) —
AO OR ESSOGRAPH 0.1AGNosi . .
..-
AGE HEIGHT WEIGHT
caAAA.U.A. c)f•- c Ex. )
PATIENT CLASSIFICATION
. ....6 f It SIP& I IA NajiA:4 Tthi'w
if pP/SPgCIAL PROCEITLI
14 SI to ) lik tiad,;Af Pitiy-ce,14,44,v, DATE
ON DATE OFF
SI
`,1'::**.-. • ,....1
A • IP;:•. ,„
MEDCOM
FINDINGS:
- 5303 RITES
VSI
RELIGIOUS
PATIENT PROFILE NAVMED 6550/12 (5-80) S/N 0105-LF-206-5560
DOD 12515 ACLU-RDI 1263 p.58
ALLERGIES:
DATE ORD.
TIME DATE LABORATORY/DIAGNOSTIC DATE DATE DATE
MEDICATIONS INCURS TO or TESTS EXAMINATIONS/ RENEW SENT COMP
BE GIVEN) ORDER CONSULTATIONS
i..---....
"VII
---. —77,7;:zr..,..:.....-- ------7r.:-;-Flmm --m • a EIMMIVILUMEMINIMPA ME/
1-111 .11- 7` .1-1. 11-a, jA 12) AilL11 11111 C 3C cc. • 1 b cl 1,1 anIIM111MKTPIIIM.
t3 cdc- 1 PO 1 cog Ea. . 7-- ' a-p, In I. be • . _ A 1 , 1 MI PT wil
. InNAIEMMEEMMM En - Vali ' Milrial. el
• 0 uhet ' -1, . 1et1
IEIIIIII[GI_MVL. IMEMIIIMELVIMMIE leir ' '. _i IS
4 t1 o au,L,„,i 4 6 (o) @ o a VAPNIMPIfflinta . • (41' c,060 MIR" ,.111 4212 -=1,--- ..______
4 cs MUM" •. Ca- i -2.0 Mil WIMP ai-IT '''' 'MI LI) - WM LI 74*:-- , - u.
146 ► L.....•• 'B1 raMIVAII PM In1214 A ins 4 b:z. of 12 00 „,_ ' • A = IM . Ori k Ilb P 0 f3 urriffillil
417_-J__ 3Z . - .._ '0 t WO Mil mmolASO_ 4- ;... uniimmrismi e 4 h2__ MIINIEFIIEIIWTPMIIIIM 0 41 too ` - 13 • IF K 4-,-, L.. X 3 • gwar-To MEI
4 'co itk504 2-10nst\I ();- -11 ° PA114 15R.N A A I • ,b, u 1,101-1) IF S ATt%)
,, ,-.- .-. , ii • WA/
4 iLl -61°Vkk . C'Si) PO &V Pfd if fq -1-(u/not (psbou Po G Li 6 po 41)4
I A If kert_el- 1-2-rtabo ?c, (V.` plao 4 (1 ¢vtQ d - im(/ 0 k-i 'PR_,,,. q, )4 I lon i io rohokm ADDRESSOGRAPH
b)(6) -4
MEDCOM - 5304
DOD 12516
ACLU-RDI 1263 p.59
PATIENT PROFILE NAVMEO 6550112 (5-80) S/N 0105 - 11 - 206 - 5560
ACTIVITY DATE BATH DATE DIET DATE VITAL SIGNS FRED SPECIAL NOTES
Bedrest Bed bath NPO Temp Dentures
:athrOOm Privileges Shower Pulse Speech Impediment
in chair Emu Tub 1 lin 11=MI7DIEMII Language barrier
Am late Needs assistance Prosthetic device
Comm e Other Visual impairment
Needs assi ance Blind
Restricted to nit Contact lenses
Ho pita! PrivIleg
a •
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- _ Self FEEDING DATE FLUIDS Hearing defect
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DATE ORD,
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TREATM TS/SPECIAL NOTES TIMES DATE 0 D.
DATE RENEW
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RELIGIOUS RITES
DOD 12517 ACLU-RDI 1263 p.60
ALLERGIES:
DATE ORD.
IFIDATE ENEW.
MEDICATIONS
TIME (HOURS TO
BE GIVEN)
DATE OF
ORDER
LABORATORY/DIAGNOSTIC TESTS EXAMINATIONS/
CONSULTATIONS
DATE
SENT
I
DATE
COMP
Lib hk0 M 30 c.c. TO 'BID 09 - 2.1 1/1:::eild-? ,..1mrc.6 a ._de,, ,ey,„„ LOG SURFAK r.AP P 0 CO 0900 ,a,t-kle ̀Av ',LI, _- A Lqi 5 0 G. Tp ;LLhtags tAt_q eL3L1LZ1 - 61:t
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4114 TIAE_NERGA si DS rof.L6 11011V 0 21° PRO ADORESSOGRAPH
;b)(6)-4
MEDCOM - 5306
DOD 12518 ACLU-RDI 1263 p.61
PATIENT PROFILE NAVMED 6550/12 (540) S/N 0105 -LF-206-S560
ACTIVITY DATE V OATH DATE DIET DATE */ VITAL SIGNS FRED si SPECIAL NOTES
Bedrest Bed both NPO Temp Dentures
Bathroom Privileges Shower RE.. G 41114 Pulse 3 .3 Speech impediment
'..4 Up i.chalr 4i(I4 Tub Rasp Language barrier
Ambulate Needs assistance B/P Proithetle device
Commode Other ti tv Visual Impairment
•its Needs assistance 11h4 Blind
Restricted to unit Contact lenses
Hospital Privileges ORAL HYGIENE DATE D l
Other Self FEEDING DATE FLUIDS Hearing d fact
x1•40)3 3et. 4114 Needs assistance Self Forced to Other
Special Needs assistance Restricted to:
Gevags I & 0 45 D ATA ORD.
DATE RENEW NESTS/SPECIAL NOTES TIMES
DATE ORD.
DATE TREATMENTS/SPECIAL NOTES
RENEW TIM ES
4
W-4 b in.EsstaCT -r0 tistto% 1- CALM E-S .
4 - R• 2.11.. LE
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ADDRESSOGRAPH bIAGNOSIS
.(t1 YE.PAORfN L F X 6 'TM -FIB FX
AGE HEIGHT WEIGHT
PATIENT CLASSIFICATION (b)(6) -4
OP/SPECIAL PROCEDURES
51P NimuNG 01 TF-INUK MA ROD -nsIA )42-
DATE ON
DATE OFF
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FINDINGS. VEI
MEDCOM - 5307 RELIGIOUS
RITES
DOD 12519
ACLU-RDI 1263 p.62
MEDICATION ADMINISTRATION RECCRD MEDICALRECORD
SCHEDULED DRUGS A DATES
MONTH 11A( -4,9""°202) GIV N
HOURS MEDICATION- DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION
NAVMED 6550/8 (REV. 9-74) SIN 0 •216-5581
NiVAVAIME GgrfAl rrimm b)("2
b)(6)-2
b)(6)-2
b)(6)-2
0 DER ATE
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FULL 'SIGNATURE &TTTLE b)(6)-2
INITIAL b)(6)-2
b)(6)-2
,b 6)-
FULL SIGNATURE & TITLE FULL SIGNATURE & 1TTLE
INITIAL CODE
ADDRESSOGRAPHPLATE
injection SiteCode
0 = Left Buttock.. 0 Left Leg
02 o Right Buttock, 0 = Right Leg
(a'=....._Left Deltoid 0 = Left Arm
0 = Right Deltoid C Right Arm
0 = Abdomen
WARD NO.
:bX6)-4
SPIGLE DOSE. PRE- OP PRN
& VARIABLE
DOSE ORDERS SEE REVERSE
MEDCOM - 5308
DOD 12520 ACLU-RDI 1263 p.63
MEDICATION ADMINISTRATION RECORD (Back) S/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
GIVEN MEDICATION-,thsAGE
ROUTE OF ADMINISTRATION
GIVEN
DATE TIME INITIAL DATE TIME INITIAL
I •
•
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PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
1/1 '?P /- Z DATE IMMIITEVIIIIMIZEMITIEFEEMPEPARTZ q ,t,,. 7,0 e• 1 ° TIME Iff MEErilIMOMMEMINirS118=El 0 7°A A) 7 A I A) DOSE 1,- 11021AMIBM 1, Fs t in -7, ,i, ,)-- 7 2
INIT. b)(6)-2
/11 NtnAr:5 0,1 1 \l/ DATE
7-71-1 ?). Lt° '1"Z. Ni TIME
DOSE •
INIT.
17// CI Ty /e .t, 0 1 2-0 f,,,, DATE 40.5 0,1 Ili
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INIT. (b)(6)-2
9//q /116147 .-?0,c, DATE
rj 7,0 (/ el .p-k A) TIME DOSE
INIT.
120 Li pile, dry i DATE Ifil.5 Aq24. '
ZS' 1'79 0 TIME 11i$ 2-3{6 .
' Rk) DOSE 2,3 2 ...) 6)(6)-2
INIT.
CO Al eo L./ z ... 1 0 A c, DATE IP M2\ :Or 4tk Alt kV% qh15 42A-04 VI 74 413) :7:-.:v al -LI ° ") TIME 0)."161 VO 104). iv) 0 fo4 ooter)32- 0 4
...rh,N) ?/:1 i N DOSE I 0 nt4 5 5 ? < (b)(6)-2
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DATE
TIME
DOSE
INIT.
MEDCOM - 5309
DOD 12521
ACLU-RDI 1263 p.64
1.1OLD IF' SEDATE D
ORDER
(IPATE ROUTE OF ADMINISTRATION
\iktibiA 5frrviPO "Tib
MEDICATION- DOSAGE- FREQUENCY
22.
NAVMED 6550/8 (REV. 4-74)SIN .--216-5581
MEDICAL RECORD
MEDICATION ADMINISTRATION RECORD
SCHEDULED DRUGS
MONTH APR) L t432.._00 3 DATESGIVEN
412-1-• NVITAIN %Mfr....16,M 11 D Oh og 11 040 )
b)(6)-2 '-'<'- .<
...■- (b)(6)-2
2100
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INITIAL FULL SIGNATURE & Trfft INITIAL FULL SIGNATURE & TITLE INITIAL Fy ly9GNATURElli TITLE
b)(6)-2 b)(6)-2 b)(6)-2 (b)(6)-2
l
ail
( )(6)-2 (b)(6)-2
/ •oe
(b)(6)-2
momme...--
II nIb76)p-Tno.POPI-1 PI ATF
Injection Site Code
Left Buttock 0 Leh Leg
Right Buttock 0 = Right Leg
Left Deltoid C) = left Arm
Right Deltoid 0 = Right Arm
0 = Abdomen
I WARD NO.
SINGLE DOSE.
PRE- OP PRN
&VARIABLE
DOSE ORDERS SEE REVERSE
MEDCOM - 5310
DOD 12522 ACLU-RDI 1263 p.65
MEDICATION ADMINISTRATION RECORD (Back) 5/N 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
MEDICATION-DOSAGE ROUTE a: ADMINISTRATION
GIVEN 1 I MEDICATION-DOSAGE
ROUTE OF ADMINISTRATION.
GIVEN
DATE THE ITIMA. DATE TIME INITIAL
1 • NIT IC N'' K I VI 0 L4 5 ; b :b)(6)-2
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ORDER DATE
MEDICATION-DOSAGE FREQUENCY
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MEDCOM - 531 1
DOD 12523 ACLU-RDI 1263 p.66
a
NAVMED 6550/ (REV. 4-74) SN -216-5581
MEDICAL RECORD MEDICATION ADMINISTRATION RECORD
SCHEDULED DRUGS MONTH teic>0 s GDATnEENS
ORDER DATE
MEDICATION- DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION HOURS 1 i 1
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INITIAL j FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE INITIAL FULL SIGNATURE & TITLE
(b)(6)-2 1/1"A l
r—la
(b)(6)-2 (b)(6)-2 (b)(6)-2 b)(6)-2 (b)(6)-2
b)(6)-2 (b)(6)-2
,b)(6)-2
ri_41 ,b)(6)-2
JL Ot741.'-' b)(6)-2 EMI (b)(6)-2
b)(6)-2 ,
idkVIL 4
(b)(6 ) -2 b)(6)-2 .ir 0 ADDRESSOGRAPH PLATE I
Injection Site Code WARD NO.
b)(6)-4 CT) .. Lett BUSIOCK (1) = Len Leg
® = Right Buttock 0 = Right Leg SINGLE DOSE.
0 = Left Deltoid C) = Left Ami PRE- OP PRN
0 = Right Deltoid 0 = Right Arm & VARIABLE
C) = Abdomen SEE REVERSE
MEDCOM - 5312
DOD 12524 ACLU-RDI 1263 p.67
GIVEN MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION INITIAL DATE TIME TIME INITIAL DATE
GIVEN
. ILL "ta () Valit ory, 10in
d Vet 1, Prb-5-m
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PRN AND VARIABLE DOSE MEDICATIONS
catane) ei>11r co Liax sitpf Pik M.A4 REP EAT TO ri1o12.11_ov,1 PR. eJ
MEDICATION ADMINISTRATION RECORD (Back) SIN 0105-LF-216-5581
SINGLE ORDERS - PRE-OPERATIVE
ORDER DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
4 14 idtcyvkg, 11,1,.) DATE
cPS—akk kW TIME 04 6 Tie0 DOSE
INIT.
11211111 DATE MEM fill IDESIMIMENIERVIIMEM ..2't-- IN ,... eR .Willito TIME WAIIMOSO 012-EMU DS, ,, A. a:: ;:_ IA A. 2,° :, . or = CeuX 7
(r) ee4,1 DOSE ail 7.- M 2 --ir .2.. --6..„ A 2._ EM 0._ 2_ e__. O ill 6.
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tp. orLA t-)6 TIME )1A Q 4 —p lezi,..) DOSE 44114,
INIT. 'b)(6)-2
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INIT. b)(6)-2
DATE varmiummi mrgagroom ORMUZ HAMM TIME foSITEM z355
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bX Y 11111 I II 4 .6 DATE BEINIIMMIRMIE11112,1
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TIME
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MEDCOM - 5313
DOD 12525 ACLU-RDI 1263 p.68
MEDICATION ADMINISTRATION RECORD
MONTH coo3 DATES
GIVEN
lc
de. 1 • :b)(6)-2
V
MEDICATION- DOSAGE- FREQUENCY
ROUTE OF ADMINISTRATION HOURS
NpA x ()GOO '&"n
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b)(6)-2
FULL SIGNATURE &TTTLE
b)(6)-2
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MEINUI=.1111111
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INITIAL
b)(6)-2
b)(6)-2 FULL SIGNATURE & TITLE INITIAL
b)(6)-2 b)(6)-2
b)(6)-2
ADDRESSOGRAPH PLATE
Injection Site Code
0 = Left Buttock C) = Left Leg
0 = Right Buttock © = Right Leg
0 = Left Deltoid 0 = Left Arm
= Right DeltoidBQ = Right Arm
0 = Abdomen
WARD NO.
-9=nEtz::1--- _,, ‘.... SPIGLE DOSE.
PRE- OP PRN &VARIABLE
DOSE ORDERS SEE REVERSE
MEDCOM - 5314
NAVMED 6550/8 (REV. 4-74)5/N L -216-5581
MEDICAL RECORD
SCHEDULED DRUGS
II/IEIBIIIIIIEMIMMIE!44V'ZFMEMfgv MITIVIWIPANI*Wnier Wit-
b)(6)-2
ORDER ATE
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DOD 12526 ACLU-RDI 1263 p.69
GIVEN GIVEN
DATE TIME INITIAL DATE TIME INITIAL
MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
MEDICATION- DOSAGE
ROUTE OF ADMINISTRATION
14\11- 1et0 _CDO.[N-N-xei;AN tOnK1
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riliNAMMIVINIZIELIFIMINIZEI11111111111 MIMMEETEMENdegiMMUM mmamorsoloammunmero
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SINGLE ORDERS - PRE-OPERATIVE
PRN AND VARIABLE DOSE MEDICATIONS
MIIP MIN DATE 7418E2211111112/200.10;91012111111111111•11 TIME FENNEIMMEITMENIIEMIIIIII
MM DOSE EIDIMMIElla- FIE111801119111111141■■■ b)(6) 2
INIT. MENEM Lvtundlosn DATE
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al to Cito
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MEDCOM - 5315
MEDICATION ADMINISTRATIONRECORD (Back) S/N 0105-LF-216-5581
DOSE
DOD 12527 ACLU-RDI 1263 p.70
11 4111e; (b)(6)-4
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Date: !// /_ ct
Time 07
08 09
10
200
180
11111111111111.111111111111111111111M1111111111111111•111111111111111111•11111111111111111111•IMINIMIIMMINI 1
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MEDCOM - 5316
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ACLU-RDI 1263 p.71
NURSING FLOW SHEET MEDTFtEFAC 6550/l2/Temp Eben
20
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Time 07 08 09 10 11 12 23 24 01 02 03 04 105 06
Date:
13 14 16 17 15 18 19 21 22
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ACLU-RDI 1263 p.72
Time
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MEDCOM - 5318
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ACLU-RDI 1263 p.73
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MEDCOM - 5324
DOD 12536 ACLU-RDI 1263 p.79
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ACLU-RDI 1263 p.80
DOD 12538
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ACLU-RDI 1263 p.81
. •
FREQ. VI SIGNS
TIME BP • HR RR TEMP SAO2.
INPUT/OUTPUT
IN m PO 0 IVPB O
cn CA)
07 08 09 10 12 13 • 14 15 16 1 .7 18 . TOTAL- 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
11 :-OVY Nomommom I
07 08 09 10 11 12 13 14 15 16 17 18 TOTAL
mum 111119 1' INII mum= 1 19 20 21 22 23 24 01 02 03 04 05 1
,0 mt_mmeimmnam:m■ I
• C
SZ le
CI o
R
PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT
PREVIOUS WEIGHT
PRESENT/4HOUR INPUT PRESENT 24 HOUR OUTPUT
PRESENT WEIGHT
ACLU-RDI 1263 p.82
j
9 00 0
0
0
0
7i1 A
1 01•
181:
140,
4::
VI 0
0 0
0 O
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DOD 12540 ACLU-RDI 1263 p.83
1 1
-
g 1 rn B o -
-cn —
07 08 09 10 11 12 13
.,•
14 15 16 - 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
OUT FOLEY UOP
BM
07 08 09 10 r 11 12 tab
13 14 15 116 17 18 D• 510
TOTAL 19 20 21 22 23 24 01 02 03 05 06 TOTAL
PREVIOUS 24 HOUR INPUT
PRESENT.24HOUR INPUT
PREVIOUS 24 HOUR OUTPUT
PRESENT 24 HOUR OUTPUT,
PREVIOUS WEIGHT
PRESENT WEIGHT
FREI); VI
SIGNS
TIME BP • HR RR TEMP SA02.
Notes:
INPUT/OUTPUT
ACLU-RDI 1263 p.84
m ME
ME MEM m •
MEM MEMMEM MEM II EN MINIMMEM UM MEM • M ME
NURSING SHEET tabrIkEFAC.6550112fienp Forrn
Date; • 0350
0 Time 06 03 04 05 21 7 19 20 18 22 4 15
60
40
9 10 16 1 23 24 01 02
L
V
4
•1r
1'
100
80
V
V
441•41■■■•■•
RR TEMP MIIMMMMIIMMMMIMMOMMI
MMIMMIIIIMIMMUR MIM . M MUM 1=1111MIMMI ENE ABM III IIIII ■ IIIMMIMMIMIMMIMIMMIMI =MEM
MO= MEM=
11111=IM MOM.=M11.11 MI IMI= 11111111====== MEM MEM EMI=
P-11,
Lim
M E DCOM - 5330
AM
IND
R
ACLU-RDI 1263 p.85
111013M IN3S311d
IHOIHM S1101Aa2ld
Llano loon PZ imasaud 111d.1110 11(10}1 PZ S1101A31Id
IfldNI 11110H PZINHSDId
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ACLU-RDI 1263 p.86
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0
7i1A
BIGI
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DOD 12544
ACLU-RDI 1263 p.87
DO
D 12
545
FREQ. VITAL SIGNS
Notes!
INPUT/OUTPUT
• IN 07 08 '09 10 11 12 13 14 15 16 17 18 ' TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
PO IVPB
. .
0 v
OUT 07 08 09 10 11 12 13 14 .15 16 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TO 1
FOLEY 100 WO UOP
BM
PREVIOUS 21 HOUR INPUT PREVIOUS 24 HOUR OUTPUT
PREVIOUS WEIGHT
PRESENT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT
Cf) Lc)
2 0 C.) 0
ACLU-RDI 1263 p.88
1• ID
N 1■11
O
130 0
N 0
00
N
0
N O
O
(NI ti
N
■■•••■••■■■■■■■■■•■
.7- I P,1 O1 0 0 'aI 0 :, 0 I *&"
Fi I 4
D10
101FA
I!1:
1 ‘10
!
cn • Ig
DOD 12546 ACLU-RDI 1263 p.89
19 20 21 22 23 24 01 02 03 04 05 06 TOT
S<Dv OUT 07 08 09 10 11. 12 13 14 .15 16 17 18 TOTAL
FOLE)'r UOP i..
BM
PREVIOUS WEIGHT
PRESENT WEIGHT
PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT
PRES INT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT
FREO. VITAL SIGNS
TIME BP HR
zoo 4117 1... 70o
009. 11,9/5-0
/02—
1p TEM
SA02I
/06),S
(41% /o/. 0
q7
Notes.i ,
INPUT/OUTPUT
Alg
EM
]iM
tnN
N,
D 1
254
IN
07
08
09
10
11
12
13
14
15
16
17
18
TOTAL
PO IVPB
1-k
19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
ACLU-RDI 1263 p.90
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