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•G r umey 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: 3-5 1- 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
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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
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
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
FITEDMI11111111111121111011MEHIMIIIIIIMMUNIMMISI , FA
r
r
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
1111111101111111111111111111111.1211111 1111011111111111111E11111111CIE1121111111E "AR III
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
IIIIIMIEF-- 11111111M111111111111111 OPERATING
MIIIIIINEN113=1111E111111111111E 1111110111111115111=111111111111111111111-152.11 1111111111111M- 1111111111111111111111111111111111" r 11111112111111111111N1111111111=11111111111310 11112111111E11111111111111111111N111/511111 MEM + r 11111111111DMMIE
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
Ilia 311111111111111111111111111111111011•1. II' ME NM *MI VRial MIME ZOWNNZ MEM II ill IMO
• II••I■•I•MIIII•IIIIIIIII•I•III•I•II •1•1111111•111■ IEVAPMEISWAZTIMINIIIIIIIMIIIIIII 111111 MI 11111/111111111111111111111111111111MIMME MI IIID • II•IIIIIIIIII•I♦•IIIIIIIIIII♦III•IIIIII• 1111111111111111111110 • il• Ina 1111111111111111111111111111111 II 11111111•11.11111■ 1111111111111111111101311111111121111211111 II 1111111111111111•111 Mil Mill INN 1111111111111111MMIIIII NM ME .
111111111111111111•111•1111111•11111111•1111111• MI Ell 130 -1> ii-r5Tgfilk
160 .
160
'AC lieu, too, use :4 •
1$y11Mitp ar%%. x -
c■•
PIP 0:411110)
Idfl.le
Bunion - .10115irittirs On tobation - Mir'/Mil
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 •
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
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
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.:./.......;__
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
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.
■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.
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
0 Rigo -1)R. :13)(6)-2
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
SI
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
. 7 a S766 • -)0 ► Mr1111 i‘The
Ce...x 2 0,19 Po 7:2no C4160
7, I 00
2_1 r o -0.s- 5 Oq GO)
yh^ A
:b)(6)-2 INMAL
b)(6)-2 I INITIAL b)(6)-2
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 •
•
L
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
' - P r) a9 0 7qZ/\) TIME tEll' j4T°12‘ DOSE IP (05-70 a
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
..)ktotii\ A 9`k 6-1-1 fT4 509 z3nr Nal d ; C serial-eii INIT.
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
14122— !X.-W.0( 2Orry.c0b Bin oc)00 -< -4. .. .....›<.... am -im„.....„4 b)(6)-2
4 2-1-- NI I " --IN• ;.. PO ik D') 00 411.■ MR.% k 422— F • • ...• cP• lb ► " • 9tro I -'11111*-4 111'" ►
I-- g- 9 e to - - i 0 . 1... ,a) X >e. ■ . rice;
I NMAL CODE
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
„„Iii =Va.— , .
A b)(6)-2
If - z. "I.A.MiiiIIIIIM
i imi o.-
PRN AND VARIABLE DOSE MEDICATIONS
ORDER DATE
MEDICATION-DOSAGE FREQUENCY
ROUTE OF ADMINISTRATION DOSES GIVEN
.
ff-f--,miarwairmulitgoingrt tp3 r. d 1 3 TIME di 14 plii 55 ig 421, vi a.
p c-,.. DOSE r ir -Tr- -21 "t.-
INIT. b)(6)-2
71/ L( I k kJ, ella 1 DATE 21
TIME eff15 rttl a ti_ p g
V
DOSE
INIT.
/) it -7- (e ISL! i DATE
p 0 TIME 4,„, 3 DOSE
INIT.
lilif (Ylon? DATE
3ncn p 0 TIME .
- io ir‘si
II A– 1
DOSE I
INIT. I • Pi ,r3 e n c tp 1 r L DATE
/ 25 nig 0 TIME
.,,2i Li A,.. ,oRA/ DOSE
INIT.
I 1 1 01 6. 61 It cO, -) Q, 7) c DATE lible
-r i) a 3 -If A) TIME PIP
Ll
T? .
-lain PIN DOSE 16., id 6,, r t C ij 1 f' ,5ettifdPNIT. :b)(6)-2