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OCR Page 1 of 2Standard Form 520
Promulgated August 1948
By Bureau of the Budget
Circular A-32
CLINICAL RECORD
PREVIOUS ECG
ELECTROCARDIOGRAPHIC REPORT
YES
NO
CLINICAL IMPRESSION
MEDICATION
EMERGENCY
BEDSIDE
40%
Van
ROUTINE
AMBULANT
AGE
SEX
RACE
HEIGHT
WEIGHT
B.P.
SIGNATURE OF WARD PHYSICIAN
DATE
66
M
W
7131
175
Gen Graham
15 Nov. 50
RHYTHM
AXIS DEVIATION (QRS)
RATES
Normal Sinus
AURIC
80
VENT. 80
INTERVALS
P WAVES
PR
.20
QRS
06
QT
Normal
QRS COMPLEXES
RS-T SEGMENT
T WAVES
PRECORDIAL LEADS (Specify)
Normal
SUMMARY, SERIAL CHANGES, AND IMPLICATIONS:
A-1
3
N-A
A-2
NORMAL ECG.
NO.
SIGNATURE
TITLE
DATE
ECG
Structly
T.W. Mattingly Col.
Ma
15 Nov 50
MOUNT TRACINGS HERE
(co)
NARA
3
(Continue on reverse)
PATIENT'S LAST NAME-FIRST NAME-MIDDLE NAME
REGISTER NO.
WARD NO.
H.S. Truman
ELECTROCARDIOGRAPHIC REPORT
(NAME OF HOSPITAL OR OTHER MEDICAL FACILITY)
Standard Form 520
u. s. GOVERNMENT PRINTING OFFICE
16-56209-1
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