56 TAC HOSPITAL ATH 12 DEC 90

File: 092396_aug96_decls19_0004.txt
Page: 0004
Total Pages: 7

Subject: 56 TAC HOSPITAL ATH 12 DEC 90                                   

Box  ID: BX000482

Document Number:         13

Folder Title: MEDSTAT - SITREPS  DEC 90  6 OF 6                                                               

Folder Seq #:         10

Unit: ARCENT      

Parent Organzation: CENTCOM     




                                                   (I FI CATIONOFPATiENT'SMEDICAL'STATU@

                                                                   IDENTIFICATION
                                GRADE, SSAN                                  DATE                            HOUR



                                                                             WARD                            REGISTER NO.
                                                                                  HA @ D                     66,360
                                                                             SERVICE                         PHYSICIAN



                                                                REASON FOR REPORT
                 COMMUNICABLE DISEASE                                           VERY SERIOUSLY       PATIENT
                 INJURY INCURRED AFTER ADMISSION                                SERIOUSLY ILL PATIENT
                 ANTICIPATED MEDICAL BOARD/PHYSICAL EVALUATION                  INCAPACITATING ELLNESSOR INJURY
                 BOARD ACTION
                                                                                REMOVE PATIENT FROM VERY SERIOUSLY ILL. SERIOUSLY
                 PROLONGED HOSPITALIZATION (90 d.y. .,I.gel)                    ILL OR INCAPACITATING ILLNESS OR INJURY LIST$
                                                                                REQUEST MEDICAL RECORDS
                 A DEATH                                                        OTHER (Sp..If, i@ ..@k.)
                                 ;cx
              111. DIAGNOSE5n




                                                          PROGNOSIS/NEXT OF KIN DATA
                                               EXPECTED                         NOT EXPECTED                 OT ASSURED. FURTHER
                                                                                I                       I TON BSERVATION NECESSARY
                                                 YES  NO

              PRESENCE OF RELATIVES DESIRED                                  NEXT OF KIN IS AT BEDSIDE


              CLEARANCE BY CHIEF OF SERVICE                                  NEXT OF KIN HAS BEEN NOTIFIED

              DATE                           NAME OF PHYSICIAN                              @NATUR
                                                 MICHAEL J.BUSCEMI,JR
                                                 MAJOR USAF MC
              V.                    ACTIO BY f
                                             N   I eiLgaR
                                                         ,aAgtRkVSITKIrIVE OFFICER OF THE:DAY ON VERY
                           SERIOUSLY ILL     ,SER             hdC@t"NG ILLNESS OR INJURY, AND DEATH CASES
                              ACTION                     DATE      HOUR                      ACTION                     DATE      HOUR

              REPORT RECEIVED                                                HOSPITAL PERSONNEL NOTIFIED
                                                                             (Sp.cit, b.i.@)

              SASE PERSONNEL RESPONSIOL @ FOR
              CASUALTY NOTIFICATION ADVISED
              OTHER BASE PERSONNEL NOTIFIED
              (Sp.cify b.f.@)

              A T@E                          NWM E 0 F R EG I ST R AR/ ADMI@STR A Ti V E 0 rFi c ER SIGNATURE
                                             Or @E DAY


              REMARKS











              AF FoRm, 570            SUPERSEDES AP,FORM 570. FEB 53, AF FORMS 1309
                JAN 7                 AND 1400, MAY 4 , WHICH ARE OBSOLETE.

Document 7 f:/Week-32/BX000482/MEDSTAT - SITREPS DEC 90 6 OF 6/56 tac hospital ath 12 dec 90:09069614065336
Control Fields 17
File Room = aug96_declassified
File Cabinet = Week-32
Box ID = BX000482
Unit = ARCENT
Parent Organization = CENTCOM
Folder Title = MEDSTAT - SITREPS DEC 90 6 OF 6
Folder Seq # = 10
Subject = 56 TAC HOSPITAL ATH 12 DEC 90
Document Seq # = 36
Document Date =
Scan Date = 14-AUG-1996
Queued for Declassification = 01-JAN-1980
Short Term Referral = 01-JAN-1980
Long Term Referral = 01-JAN-1980
Permanent Referral = 01-JAN-1980
Non-Health Related Document = 01-JAN-1980
Declassified = 06-SEP-1996