Administration of Fixed Hospitals : Zone of Interior

[Administration of Fixed Hospitals : Zone of Interior]
[From the U.S. Government Publishing Office, www.gpo.gov]

W 1.3^: 8“ AM?*0**
__ 1 OCT 45
TM 8-262
Document Reserve
NON-CIRCULATING
TECHNICAL MANUAL ADMINISTRATION OF FIXED HOSPITALS ZONE OF INTERIOR
WAR DEPARTMENT Washington 25, D. C., 1 October 1945
Remove page 4.1 and insert revised page 4.1 herewith.
Add sections 2 and 3, chapter IV.
[AG 300.7 (25 Sep 45')]
By order of the Secretary of War:
Official:
EDWARD F. WITSELL
Major General
Acting The Adjutant General
G. C. MARSHALL
Chief of Staff
Distribution:
AAF (2); AGF (2); ASF (2); S Div ASF (1); SvC (Surg) (2); Dep 8 (2); Army Med Purchasing O (2); Med Dept Repl Pools (5); T/O & E 8-650 (1). NO OVERSEA DISTRIBUTION.
Refer to FM 21-6 for explanation of distribution formula.
TM 8-262
CHAPTER IV
1 OCT 45
CONTENTS
CHAPTER IV. WARD ADMINISTRATION
Section 1. PROCEDURE FOR INTERWARD TRANSFERS
PAGE
Responsibility.......................................................................... 4,2
Authority for Transfers................................................................. 4.2
Interward Transfer Slip................................................................. 4.3
Interward Transfer Slip—Illustration.................................................... 4.2
Preparation of Interward Transfer Slip—Illustration..................................... 4.3
Transfer of Patient and Records......................................................... 4.4
Ward Morning Reports—Illustration. -.................................................... 4.4
Disposition of Interward Transfer Slip.................................................. 4.6
Emergency Transfers..................................................................... 4.6
Group Transfers......................................................................... 4.6
Interward Transfer Slip, Prepared for Group Transfers—Illustration...................... 4.5
Interward Transfers by Telephone...................................................... 4.6
Notice to Agencies Other Than the Information Office of Interward Transfer.............. 4.6
Section 2. WARD MORNING REPORT (WD AGO FORM 8-107)
Definition and Purpose.................................................................. 4.7
Responsibility and Period Covered....................................................... 4.7
Distribution............................................................................ 4.7
Contents................................................................................ 4.7
Source of Data......................................................*................... 4.7
Preparation............................................................................. 4.7
Ward Morning Report and Sources of Information—Illustration............................. 4.8
Instructions for Completion of Ward Morning Report—Illustration........................ 4.9
Preparation and Distribution of Ward Morning Report—Flow Chart........................ 4.11
Section 3. DIAGNOSIS SLIP (WD AGO FORM 8-176)
Definition and Purpose................................................................. 4.12
Diagnosis Slip—Illustration............................................................ 4,12
Use of the Diagnosis Slip.............................................................. 4.12
Responsibility......................................................................... 4.14
Period Covered......................................................................... 4.14
Number of Copies and Distribution...................................................... 4.14
Preparation............................................................................ 4.14
Diagnosis Slip, Spaces 1 Through 10—Illustration....................................... 4.14
Diagnosis Slip, Spaces 11 Through 14—Illustration...................................... 4.15
Diagnosis Slip, Spaces 15 Through 23................................................... 4.15
Care in Preparation.................................................................... 4.16
Additional Diagnosis Slip—Illustration................................................. 4.16
4.1
TM 8-262
CHAPTER IV
1 OCT 45
Section 2. WARD MORNING REPORT (WD AGO FORM 8-107)
10. DEFINITION AND PURPOSE
The Ward Morning Report (WD AGO Form 8-107) (formerly WD MD Form 72), is a consolidated report of all admissions and dispositions on a particular ward for a 24-hour period. Any event which effects a change in the ward census will be recorded, with the exception of enlisted patients absent on pass of less than 72 hours duration; and officers absent for periods of less than 24 hours, provided such absence is not charged against an officer’s accrued leave. This report is the basis for compiling the Consolidated Ward Morning Report (sec. 14, ch. III).
11. RESPONSIBILITY AND PERIOD COVERED
The nurse in charge of each ward of the hospital at 2400 daily is responsible for the completion and dispatching of the report for the preceding 24-hour period, and for initiating a report form for the succeeding like period. During the period covered by the report, each nurse in charge of the ward will be responsible for the entries made during her time on duty; however, the accuracy of the completed report will be the responsibility of the nurse signing it.
12. DISTRIBUTION
The report will be prepared in one copy only, and immediately upon completion will be dis
patched by special messenger to the Admission and Disposition Branch of the Registrar’s Office.
13. CONTENTS
The report is designed to give a statistical picture of the census status of the ward for the period, showing all admissions, dispositions, transfers to and from other wards, and patients absent with and without authority.
14. SOURCE OF DATA
The information entered on the Ward Morning Report is obtained from the following sources:
a. The 5" x 3" locator card received from the Admission and Disposition Branch of the Registrar’s Office with each patient admitted to the ward (sec. 2, ch. II).
b. Interward Transfer Slip (WD AGO Form 8-169).
c. Further information for the report is obtained under the following circumstances:
(1) The departure or return of any patient, for any reason, will be noted on the report.
(2) Knowledge of the failure of any militarized personnel to return within 24 hours of the expiration of his pass, furlough, or leave will be noted on the report.
15. PREPARATION
The Ward Morning Report will be accomplished throughout the 24-hour period as described in the following illustrations.
4.7
TM 8-262
CHAPTER IV
1 OCT 45
4.8
WARD MORNING REPORT WARD BED86Er patients TOTAL TOTAL I pATIFNTo I VACANT । l
P -J A -1 t DATK NUMB KB PREVIOUS GAIN OF LOSS OF
Forward one copy daily to office ur report patients patients Remaining beds
compiling A & D Sheet at £400 _—__________________________________________________________
hour‘I | I // 1^ 7
LIST EVERY PATIENT GAINED OR LOST BY THIS WARD DURING 24 HOUR PERIOD ENDING 2400 HOURS ABOVE DATE
ADMISSIONS DISPOSITIONS
LAST NAME. FIRST NAME. MIDDLE INITIAL ,™R I-,—,
“nO^ NEW ™>« rnoM PROM ™ TO TO S'
AOU LOT.OH LkAVE iW01- SS" WTOH '-r-AVE ■‘W°L
r M
White GH Dodd, John C.
30 P No 32 164 11 067 928 Pfc f
Mrs. Lois M. Dodd (M) Inf Unasgd 17 Holly Street " .................................... r..... ............
Madison, Mees 22 W 3 4/12 10 Sep 45 V77..&27 7(77.4,
D Capt MWH Direct-Casual '
■ •. ...............................7.............
........7
HM■■■■■■■ - C?
.............................................................(Q...
..............................................................
.............................................................................................................. ______________________________________________......................................................................................
F0RM N0, 8-169 INTERWARD TRANSFER SLIP (^4
LA^T NAME firs! NAME MipDLE INITIAL ARMY SERI AL NUMBER
REMARKS HF NECESSARY) 7/ 7 TR AN S FE&RlNiECEI VI NG WARD /'DATE •.........7.......... 7.............
77 z> s । 7^---------------------------------------------
SI G^J'ISrOF TRANSFERRING AUTMORIT/ l ga1n & T^KLl^ //
7 (TYPED NAME AND GRADE NOT REQUIRED) / //
---------------------------------------------1 ■
TRANSFER COMPLETED ---... 77—_L£l--
—'■■ 1 ■ 1 ..... ....■,-■ , ,. .— .... . ----------------------- |,29 10—41617-1
REMARKS HF NECESSARY) HOUR DATE
//6>O //) 7^6 7^
SIGNATURE OF PERSONNEL ON RECEIVING WARD // ITYPED NAME ANO GRADE NOT REQUIRED)
INSTRUCTIONS J. Trantferring authority haa one copy only prepared at time of transfer. 2. Interward transfer slip will accompany patient and clinical records to new ward. 3. Forward slip to Information Office immediately after transfer is completed I. Required concurrences will normally be obtained by telephone and will be held to a minimum.
1 OCT 45
TM 8-262
CHAPTER IV
INSTRUCTIONS FOR COMPLETION OF WARD MORNING REPORT
4.9
WARD MORNING REPORT WAR!) BFf» RFT PATIENTS TOTAL TOTAL pattrntr VACANT
DATE number rPREVIOUS GAIN OF LOSS OF pV'V'fZ.S, retm
Forward one copy daily to office nlmbeb UP R&ORT PATIENTS PATIENTS REMAINING BEDS
compiling A & D Sheet at £.',00 ______________________________________________* ______________ I
^22 I S3 \ 3/ I
Entries In the spaces at the top of the form will be made as follows:
DATE - flowering the period from 0000 to 2400 hours.
WARD NUMBER - Refers to the ward reporting. 'Where several rooms or similar small units are administered and otherwise considered to compose a ward, the ward number may refer to such units.
BEDS SET UP - The actual number of beds set up and available for occupancy without regard to the number authorized.
PATIENTS PREVIOUS REPORT - Figure will be the same as "Patients Remaining" on the previous report.
TOTAL GAIN OF PATIENTS - Figure will be the same as "Total Gain" at bottom of form.
TOTAL LOSS OF PATIENTS - Figure will be the same as "Total Loss" at bottom of form.
PATIENTS REMAINING - Number of patients actually to be accounted for at 2400 hours. Figure is proved by adding the figures of "Patients Previous Report" and "Total Gain of Patients" and subtracting from the total the figure of "Total Loss of Patients."
VACANT BEDS - Figure proved by subtracting figure in "Patients Remaining" from figure in "Beds Set Up."
LIST EVERY PATIENT GAINED OR LOST BY THIS WARD DURING 24 HOUR PERIOD ENDING 2400 HOURS ABOVE DATE
Entries under "ADMISSIONS" and "DISPOSITIONS" will be made aa follows: -----------------------------------------------
ADMISSIONS DISPOSITIONS
Admissions: FnoM inter- nT cn T0 inter.
NEW FROM FROM WARD VunM FUR. T0 TO WARD
■“>“ muo’h LEiT1: AWOL LOOTS ™
NEW ADM - Checked for a patient admitted to the ward for whom a clinical___________________________________________________________
record has first been opened on the date covered by the report. A //' S //■> /<> y )
transfer from quarters would not be entered here, unless a clinical 1(3-4', .................
record were being opened for the first time during this period of C
hospitalization. ...............................................
FROM FURLOUGH - Checked when an enlisted man returns from furlough. -2o2,
Example: Line 5. ............................-..................
Return from absence on detached service or temporary duty is also ^3
checked in this column. .............................
FROM LEAVE - Checked when an officer returns from leave. Example: Lines 2 and 19. See "From Furlough" above. ..................• ......
FROM AWOL - Return of a patient from absence without leave,. The hour and the date need not be shown. Example: Line 6. ..............t,................
A patient admitted from a status of absent without leave, not previously 7 /7 7„ J' )
a patient in the hospital, will be checked in the column "New Adm." \ V7 ' /................
INTERWARD TRF FROM - Transfers from another ward will be indicated by / *
the number of the transferring ward (Example: Lines 3 and 15); .....................................•••......
transfers from quarters by "Q"; transfers from convalescent facility [y'
by "CF" (Example: Line 11); transfers from reconditioning facility by "RF" (Example: Line 18). 377
Dispositions: dXZ
DISCH FROM HOSP - Checked for patient transferred to another hospital, (7/
discharged to duty, retired, discharged by CDD, or deceased. (Example: ............
Lines 4 and 17).
TO FURLOUGH - Checked when an enlisted man departs on furlough. (Example: .............................................
Line 8). (3.Z
Checked also for departure on detached service or temporary duty.
TO LEAVE - Checked when an officer departs on leave. (Example: Line 9). See "To Furlough" above.
TO AWOL - Checked when patient is absent without leave. The hour and date j
will be entered. (Example: Lines 1 and 7). If the absentee returns , I 1 .....
before the report is forwarded at 2400, the entry will be lined out.
INTERWARD TRF TO - Transfers to another ward, quarters, convalescent I y.
facility, or reconditioning facility will be indicated as described in |
"Interward Trf From" above. (Example: Lines 10, 12, 14, and 16). i
| ..............................................................................................
I Each column totaled.^ totals / \ / 37, 3 'J- 37, i / 3 J ■/-
I L . ~ '-----------------------------
[ Will Show the total ADMISSIONS and DISPOSITIONS. total gain total loss //
___________________________ " । --------------------------'---- ‘ ----------------------------------------------------------------------
SIGNATURE - The nurse who completes and forwards the Ward Morning Report monature yOy^.,
at 2400 signs her name and rank in this space. Her signature certifies 33
that she is responsible for the accuracy of the data in the report. ----------------
________________________2_____________[ 11 I. mnvmrl....... .fa.. ___2°__________
4.10
TM 8-262
1 OCT 45 CHAPTER IV
PREPARATION AND DISTRIBUTION OF WARD MORNING REPORT
LOCATOR LOCATOR | l LOCATOR LOCATOR WARD
CARD CARD ■■■■■ CARD CARD MORNING REPORT I
—At time of admission, patient —Uses locator card to record new receives locator card from ad- admission on Ward Morning
miffing clerk for delivery to the Report,
ward nurse.
’ r
wnFtCATtON ; ■■■ ■■MBMWMHHMMMIR wdfic Alto* morning report
DF OrSPOfitltOH ..'•• • w DISPOSITION .
—Registrar notifies ward nurse, by —Receives telephone call,
telephone, of date and hour of —When disposition is effected,
each discharge. makes appropriate entry on
Ward Morning Report.
INTERWARD |_____________INTERWARD
dfag TRANSFER SLIP HBHI HHSBHI TRANSFER SLIP
“ WD AGO 8-169 1^^ WD AGO 8-169
WU AUU r-urtm o-tos —----
—Notes fact and source of transfer —Initiated for each patient trans-
on Ward Morning Report. ferred to another ward. (WD (Transfers from this ward will be AGO Form 8-169 is also entered on Ward Morning initiated for transfers between
Report and Interward Transfer hospital and quarters, and to or
Slip forwarded with patient.) from convalescentor recondifion-
............. .. .................__________ ing facilities.) PvTvKfc W* ■ vn ____________ WARD
. ■ RETURN FROM !■■■■■» RETURN FROM mopninc pronpT
AUTWRIZEO ABSENCE I AOTHORtZEO ABSENCE MORNING REPORT
—Notes fact of departure or return on Ward Morning Report. (In the case of patients departing on or returning from passes, no entries will be made.) STruwn —MORNING REPORT
OR RS TURN . ;.A ■ OR RfcltWN
—Enters fact and hour of departure or return on Ward Morning
Report immediately.
—Lines out entry if patient returns from AWOL prior to closing of B
, ________ Ward Morning Report at 2400. ___________ WARD WARD______WARD
MORNING REPORT MORNING REPORT - MORNING REPORT I
WD AGO FORM 8-107 |
—Uses to check entries on Admis- —Nurse in charge of ward at 2400 checks
sion and Disposition Sheet. accuracy of Ward Morning Report.
-Consolidates all reports. —Signs and forwards to Admission and
-Prepares Consolidated Ward Disposition Branch by special messenger
Morning Report. immediately after 2400.
4.11
■
TM 8-262
CHAPTER IV 1 OCT 45
Section 3. DIAGNOSIS SLIP (WD AGO FORM 8-176)
16. DEFINITION AND PURPOSE
a. The Diagnosis Slip (WD AGO Form 8-176) is a record of each patient’s clinical status during his period of hospitalization in a particular installation.
b. The purpose of the record is to keep the Registrar and statistical clerk constantly informed of a patient’s medical status and any change therein, and it becomes, therefore, an important source of information in maintaining the statistical locator cards (sec. 2, ch. III).
r
FRONT
DIAGNOSIS SLIP 1. LAST NAME. FIRST NAME. MIDDLE INITIAL Sand. Herman L. •REQUIRED ONLY WHEN STENCIL PROCEDURE IS U3ED
2. REGISTER NO. 13 530 3. ARMY SERIAL No.* 31 760 110 4. GRADE* Pfc
5. ORGANIZATION AND ARM OR SERVICE* Inf unaatfd
6. AGE* 23 7. RACE* w 8. LENGTH OF SER.* 3 3/12 9. DATE OF ADMISSION* 2 Aug 45
10. SOURCE OF ADMISSION* Trfd. Letterman GH. Cal
INSTRUCTIONS: Original of INITIAL REPORT must be forwarded to Registrar by 1200 of the day following admission. File duplicate copy with clinical record. Answer all items. The information need only be tentative, but should be as correat as possible. A CORRECTED REPORT will be submitted without delay when any information submitted on the initial report is found to be incorrect, as in a change of diagnosis. AN ADDITIONAL REPORT will be submitted when supplemental information (including additional diagnoses) becomes available or when a condition is cured.
11. DATE <2 12. WARD OFFICER Z2. Cunf ‘fat 13. WARD NO. /7
14. TYPE OF ALPORT (CAeefc one) 01NITIAL □ CORRECTED □ ADDITIONAL 15. TYPE OF PATI^IT (Check one) □ STA. HOSP. □ REG. HOSP. STgEN. HOSP.
16. SPECIALTY (.Check one)
GENERAL MEDICINE NEUROSURGERY TROPICAL DISEASES
GEN & ORTH SURGERY CLOSED WARD NP OPHTHALMOLOGIC SURGERY
OPEN WARD NP VASCULAR SURGERY TRENCH FOOT
THORACIC SURGERY TUBERCULOSIS SKIN DISEASES
PLAST ft MAX-FAC SUR ARTHRITIS
DEAF NEUROSYPHILIS FEMALE
BUND RHEUMATIC FEVER PW OFFICER
AMPUTEE NEUROLOGY PW EM
17. PROBABLE DISPOSITION (Cheek one) IN APPROXIMATELY /ftQ— DAYS □ FULL DUTY □ LIMITED DUTY □ RETIREMENT S^CDD TO OWN CARE □ TRANSFER TO VAF □ TRANSFER TO OTHER HOSPITAL
18. HOSPITAL RECORDS REQUESTED (For probabk CDD, record all previous hospitalization in U, S, Do not include records on ward.)
HOSPITAL DATE OF HOSPITALIZATION
A. a^.Je

c.
WD AGO FORMg_jyg 18—4M74-1
4.12
TM 8-262
CHAPTER IV
1 OCT 45
DIAGNOSIS SLIP WD AGO 8-176
--------------------------------------------------------------------------------------
19. DIAGNOSIS: 20. LINE OF DUTY (Chsck) ■ i
(If an injury is involved, boxes 21 and 22 must also be com- &■■
YES NO EPTS A|^5' ** UNO
_________________________ I _________________________ I
21. INJURY REPORT
A. DATE AND HOUR OF INJURY ~~
B. WHERE INCURRED
cThow^ncur^
____________________________________________________ I
22. IS INVESTIGATING OFFICER REQUIRED? YES fl NO □
23. REMARKS (Enter here additional fads not furnished elsewhere on this form; as clothing, pay data, decorations, etc., which may be due the soldier. Be complete.}
C^a, I
U. s. GOVERNMENT PRINTING OFFICE 10-45374~1
4.13
TM 8-262
CHAPTER IV
17. USE OF THE DIAGNOSIS SLIP
a. The Diagnosis Slip may be accomplished as an “initial”, “corrected”, or “additional” record, as defined below, depending upon current circumstances. The latter two forms are supple mental to the initial record. When a Diagnosis Slip is prepared, it will be checked in the appropriate box in space 14 to indicate whether it is an initial, corrected, or additional report. The three types are defined as follows:
(1) An initial report is prepared for each patient on admission to the hospital. It is initiated by the Admission and Disposition Branch of the Registrar’s Office and completed by the ward officer.
(2) A corrected report is accomplished when data submitted on the initial report are determined to have been in error, as in a change of diagnosis. It will indicate that the original data reported are no longer correct, and the records will be changed.
(3) An additional report will be submitted when supplemental information, such as an additional diagnosis, becomes available; or when a cured condition is reported. In such cases, it will be assumed that all previously reported data are still correct and are to remain on the records.
18. RESPONSIBILITY
Although initiated by the Admission and Disposition Branch of the Registrar’s Office, the prime responsibility for the completeness and accuracy of the Diagnosis Slip lies with the ward officer actually treating the patient concerned. Furthermore, he is responsible for accomplishing and forwarding corrected and additional forms of the record as described in paragraph 20.
19. PERIOD COVERED
The initial Diagnosis Slip, with any supplemental corrected or additional forms, will cover the entire period of a patient’s hospitalization at an individual medical installation.
20. NUMBER OF COPIES AND DISTRIBUTION
a. The Diagnosis Slip, whether initial, corrected, or additional slips, will be prepared in one original and one carbon copy.
b. Distribution of the three types ot slips is as follows:
(1) Initial slip. Initiated by the Admission and Disposition Branch of the Registrar’s Office
1 OCT 45
and both copies forwarded to the ward with the patient. Upon completion by the ward officer, the original will be forwarded to the Registrar. The duplicate copy will become a part of the patient’s clinical records during his period of hospitalization, and will be destroyed at time of disposition of the patient.
(2) Corrected and additional slips. Initiated by the ward officer treating the patient, or by the representative of the Reconditioning Service actually giving exercises to the patient. The original is forwarded to the Registrar immediately on completion; the duplicate is retained with the patient’s clinical records. Final disposition of corrected and additional slips is the same as described in (1) above for initial slips.
21. PREPARATION
a. The initial Diagnosis Slip will be initiated by the Admission and Disposition Branch of the Registrar’s Office at the time of the patient’s admission to the hospital. The admitting clerk will enter on the form the information required by spaces 1 to 10, inclusive. In those hospitals using the mechanical method of reproducing admission records, the forms will be processed by mimeograph or similar device. The forms will be forwarded to the ward with the patient.
1. LAST NAME. FIRST NAME. MIDDLE INITIAL ————
—SansL,__________Saxman______L. ___________________________
2. REGISTER Na 3. ARMY SERIAL Na* 4. GRADE*
* n p m zs rv ** M ’REQUIRED
13 530---------101 760 110---------- K?------------------
DIAGNOSIS 5. ORGANIZATION AND ARM OR SERVICE* I ONL’ I
ai > STENCIL
SLIP Inf unaagd______________________________________________________
6. AGE* 17. RACE* 8. LENGTH OF SER.* 9. DATE OF ADMISSION* PROCEDURE
25 I W I 3 5/18_______I 2 Aug 45 ,SU5“
10. SOURCE OF ADMISSION*
________________ Trfdt Letterman GH, Gal_______________________________________
INSTRUCTIONS: Original of INITIAL REPORT must be forwarded to Registrar by 1200 of the day following admission. File duplicate copy with clinical record. Answer all items. The information need only be tentative, but should be as correct as possible.
4.14
1 OCT 45
TM 8-262
CHAPTER IV
b. On receipt of the slips, the ward officer will fill in spaces 11 to 14, inclusive.
DIAGNOSIS SLIP, SPACES II THROUGH 14
-WjppR
IL DATE
12. WARD OFFICER

lib__—_____ nrilhr^ , __________________________
additional diagnoses) becomes availableor when a condition is cured.
SPACES 11 THROUGH 14 COMPLETED BY WARD OFFICER IMMEDIATELY UPON RECEIPT OF THE FORM ON THE WARD.
c. After examination of the patient, the ward officer will complete the form by entering the
professional data as it may apply to the patient in the remaining spaces, and forward the original copy to the Registrar. Completion of an initial report will be accomplished within 48 hours after admission of the patient. The information entered thereon should be as exact as possible, but submission of the slips will not be delayed pending results of laboratory or other examinations, and will be forwarded even though the information is tentative.
d. Corrected and additional slips, when necessary as defined in paragraph 17a (2) and (3), will be initiated by the ward officer, or by the representative of the Reconditioning Service actually giving exercises to the patient concerned. On such slips, spaces 1 and 2 only will be completed in addition to the corrected or added professional information.
DIAGNOSIS SLIP, SPACES 15 THROUGH 23
4.15
——----------------------------------------------------------------------------------------------------------
18. DUGNQS4S: 3L UNE OF DUTY (€3Uc£)
(If an injury i» ineohed, boxes tl and tf must also be com-YES NO EFTS ** UNO
______________________________ ______________________________
_ | 15. TYPE OF PATI|ffrr (CA«:^ on«) ---------------------------------------------------------------------------------------------
•,HJURY REPORT
________□ STA. HOSP. □ REG. HOSP. gGEN. HOSP._________ bATE’AND"H6UR-OF INJURY----------------------------------------------------------------------
16. SPECIALTY (Chech one)_____ ।।-1^
GENERAL MEDICINE NEUROSURGERY TROPICAL DISEASES WHERE INCURRED V «
GEN a ORTH SURGERY CLOSED WARD NP OPHTHALMOLOGIC SURGERY
OPEN WARD NP__________________VASCULAR SURGERY_______________TRENCH FOOT__________________
THORACIC SURGERY TUBERCULOSIS SKIN DISEASES __________
PLAST a MAX-FAC SUR___________ARTHRITIS__________________________________________________ HOW INCURRED
DEAF _____________________ NEUROSYPHILIS____________________FEMALE_______________________
BUND _____________________ RHEUMATIC FEVER__________________PW OFFICER___________________
^AMPUTEE ___ NEUROLOGY_____________________PW EM ______________
PROBABLE DISPOSITION {CK.A 0«) IN APPROXIMATELY /&Q_. DAYS . IS INVESTIGATING OFFICER REQUIRED! YES □ NO □______________________________________________
□ full DUTY □ LIMITED DUTY □ RETIREMENT REMARKS (BiUer oddrtional .lAnpUn CURED. CURE REPORTED TO OFFICE OF THE REGISTRAR BY MEANS OF AN ADDITIONAL DIAGNOSIS SLIP.
4.16
U. S. GOVERNMENT PRINTING OFFICE : 1945 O - 668715
T 1 '
^T9. DIAGNOSIS: 20. LINE OF DUTY (Check) ... ■
(If an injury is involved, boxes fl and ft must also be com- La
p YES NO EPTS *2^ UND
a. । I I il 1 f ■ 1 IM
^1. LAST^AME. FIRST NAME. MIDDLE INITIAL
2. Register no. a. army serial no." a grade"
Z? ttQ___________________________________________________‘RE0U'RED
zTFhjury rep< DIAGNOSIS I 5l ORGANIZATION AND ARM OR SERVICE* * ONLY WHEN I
—----------_ C| in STENCIL
A. DATE AND H< SLIP ___________________ _____________________________________
6. AGE* 7. RACE* 8. LENGTH OF SER.* 9. DATE OF ADMISSION* PROCEDURE
----------- IS USED B. WHERE INCH ___________________________________I—_________
10. SOURCE OF ADMISSION*
c. how incurr INSTRUCTIONS: Original of INITIAL REPORT must be forwarded to Registrar by
1200 of the day following admission. File duplicate copy with clinical record. Answer all items. The information need only be tentative, but should be as correct as possible.
A CORRECTED REPORT will be submitted without delay when any information sub-____________ mitted on the initial report is found to be incorrect, as in a change of diagnosis. AN 22. is investig) ADDITIONAL REPORT will be submitted when supplemental information (including ____________ additional diagnoses) becomes available or when a condition is cured.
23. remarks (£ 7T77Z7--------------------------——-------------------------------------------------------
tions, etc. MTE >2- WARD OFFICER __ 13. WARD No.
14. TYPE OF RE£0RT (Check one) IS. TYPE OF PATIENT (Check one)
□ INITIAL □ CORRECTED BIdPHIONAL___________ □ STA. HOSP. □ REG. HOSP. ®€eK HOSP.
16. SPECIALTY (Check one)_____________
___ GENERAL MEDICINE____________NEUROSURGERY_____________ TROPICAL DISEASES
___GEN ft ORTH SURGERY__________CLOSED WARD NP___________ OPHTHALMOLOGIC SURGERY
___ OPEN WARD NP________________VASCULAR SURGERY_________ TRENCH FOOT
THORACIC SURGERY____________TUDERCULOSIS_____________ SKIN DISEASES
PLAST & MAX FAC SUR_________ARTHRITIS________________
___ DEAF._______________________NEUROSYPHIUS_____________ FEMALE________________________
___ BUND_________________________RHEUMATIC FEVER_________ PW OFFICER_______________
AMPUTEE_________________ NEUROLOGY___________________ PW EM_________________________
17. PROBABLE DISPOSITION (Check one) IN APPROXIMATELY__DAYS
□ FULL DUTY □ UMITED DUTY □ RETIREMENT
□ CDD TO OWN CARE □ TRANSFER TO VAF □ TRANSFER TO OTHER HOSPITAL
18. HOSPITAL RECORDS REQUESTED (For probable CDD, record all previous hospiializaiion in U. 8. Z)o not include records on ward.)
_____________________________________________HOSPITAL________________________ DATE OF HOSPITALIZATION I—— A.
,w° AG °1 8- 1 76 »—>«

DENTON TX 7g?°l
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