NVDH emergency room record (Form 2799), visit of 7-10-72
Document date 10 July 1972
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Id: Cooper-Part-86:055-055
Subject: Cooper Files: Cooper-Part-86:055-055 Document: NVDH emergency room record (Form 2799), visit of 7-10-72 Id: Cooper-Part-86:055-055 Page: https://cooper.theunsolved.net/documents/Cooper-Part-86%3A055-055 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 86 p. 55, Form, dated 10 Jul 1972 — cooper.theunsolved.net/documents/Cooper-Part-86%3A055-055
NORTHERN VIRGINIA DOCTORS HOSPITAL No. 2799 EMERGENCY ROOM RECORD 1 7089 S.S. or H.I.S. No.: [redacted] 4 / 3248
Last Name: [redacted] First Name: [redacted] Middle Name: Home Phone: [redacted] Admission Date: [redacted] A.M./P.M. 7-10-72 Hosp No. Address: [redacted] City: State: Age: [redacted] Date of Birth: [redacted] Sex: [redacted] M F Civil Status: M S W D Sep. Religion: Employer: [redacted] Address: [redacted] Compensation: Yes ☐ No ☐ Rel: [redacted] No: [redacted] Group No.: [redacted] Contract No.: [redacted] [redacted] Family Member ☐ Other hospitalization insurance: [redacted] Name: Address: Cert or Policy No. Group No Dependents ☐ Comprehensive ☐ Effective Date Family Doctor: [redacted] Notified: Yes/No ☐ Brought By: Self ☐ Police ☐ Fire ☐ Relative ☐ Other ☐ Type of Service: XR ☐ PH ☐ PT ☐ Lab ☐ Other ☐
Authorizations on Reverse Side Must be Signed by Patient or Authorized Person
EMERGENCY ROOM CHARGES OTHER SERVICES RENDERED Does Not Include Fee of Attending Physician ITEM CHARGE ITEM CHARGE Emergency Room ✓ Sutures X-ray _________ ☐ Anesthetic Tetanus Antitoxin Laboratory _____ ☐ Central Supply Cast Physical Therapy ☐ Dressings E.D.U. EKG ____________ ☐ Drugs ☐ Oxygen ☐
[handwritten: illegible] [handwritten: [guess: sthorned]] BRIEF HISTORY
If accident state where, when and how injured; If illness describe ___ [handwritten entry - largely illegible, multiple lines] NOTIFIED Relatives ☐ Coroner ☐ Police ☐ By Whom. Nurse's Signature: Officer's Signature: Badge: District: Time: AM/PM R.N. b6
PHYSICIAN'S REPORT b7C CONDITION ON ADMISSION Good ☐ Fair ☐ Poor ☐ Shock ☐ Hemorrhage ☐ Coma ☐ Temp. [guess: 196] Oral Rectal [guess: pulse] [guess: R] BP /10 Treatment: Tetanus Toxoid _________ cc. Tetanus Antitoxin Test _________ Tetanus Antitoxin _________ units
Diagnosis: [handwritten: Thrombophlebitis]
Disposition of Case: [handwritten: [guess: released/left]] Referred to Dr. _________ Date: 7/11/23 [guess: P.A.] b6 b7C INSTRUCTIONS TO PATIENT: ___________
(Date) 7/10/72 (Patient's Signature)
PATIENTS OFFICE NVDH #105