Medial Office Treatment Forms - DOC

							NSN 7540-00- 634-4176                                                                                                                           600-108


    HEALTH RECORD                                   CHRONOLOGICAL RECORD OF MEDICAL CARE
          DATE                           SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)




 Date________                       374th MDG                Yokota AB Japan
 Time_______
          S:_______y/o c/o L/R ankle pain for ______days. Male/Female
 HCP_______
 Tob Y/N             (for females: Pregnant Yes/No , LMP _________ , pregnancy test neg / pos date________)
 __Ppd x __yrs
 All_________
                  Injury mechanism of injury:
 ___________
 Meds_______
 ___________
 ___________
 ___________
 Update
                  O: Skin –    intact       abraded (dermis intact)      open
 1480A/2766
                              Bruising – none              medial                    lateral               both

                              Ankle Swelling – medial                  lateral                both             including foot


                              Tender – medial maleolus                       lateral maleolus               both medial and lateral maleolus

                                           metatarsal bases (Lisfranc)                                     5 th Metatarsal base

                                           proximal fibula                   other ______________________________

                              Able to bear weight on injured limb – Yes/No

                              Anterior Drawer – stable/instable

                              Perfusion – adequate/compromised

                              Pulses – posterior tibial___________                dorsalis pedis___________

                             Sensation – grossly intact/deficits _________________

                             Motor – all motor groups functioning/deficits ____________________
                                                                                            (continued on back of page)
PATIENT’S IDENTIFICATION ( Use this space for Mechanical     RECORDS
Imprint)                                                   MAINTAINED AT:
                                                           PATIENT’S NA ME (Last, First, Middle Initial)                            SEX


                                                           RELATIONSHIP TO SPONSOR                          STATUS                  RANK/GRADE


                                                           SPONSOR’S NAME                                               ORGANIZATION


                                                           DEPART./SERVICE            SSN/IDENTIFICATION NO.                        DATE OF BIRTH


                                                                                                                       STAND ARD FORM 600 (REV. 5-84)
                                                           CHRONOL OGICAL RECORD OF M EDICAL CARE                      Prescribed by GSA and ICMR
374 MDG Form 00-06 (overprint), Jun 00                                                                                 FIRMR (41 CFR) 201-45.505
          DATE                                    SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

                                (Continued from other side)
                                 X-ray-




                                A:       L/R ankle sprain                     fracture_______________________


                                P:




                                The Ottawa Rules for Radiographs in Acute Ankle Injuries:

                                     Y/N         Pregnant, if female
                                     Y/N         presents for the first time for this problem




                                Ankle x-rays are only required if there is any pain in the malleolar zone, AND any one of these
                                findings:

                                     Y/N         Bone tenderness at the posterior edge or tip of the lateral malleolus (A) or
                                     Y/N         Bone tenderness at the posterior edge or tip of the medial malleolus (B) or
                                     Y/N         Inability to bear weight both immediately and at the clinic

                                Foot x-rays are only required if there is any pain in the midfoot zone and any one of these
                                findings:

                                     Y/N         Bone tenderness over the navicular (D) or
                                     Y/N         Bone tenderness over the base of the 5 th metatarsal C) or
                                     Y/N         Inability to bear weight both immediately and in the clinic

                                *Inability to bear weight immediately = the patient cannot walk unaided for four steps within the
                                first hour of the injury
*U.S. Government Printing Office: 1991 — 312-071/40213                                                         STAND ARD FORM 600 B ACK (REV. 5-84)




374 MDG Form 00-07 (overprint), Jun 00 (REVERSE)