Standard Form 535 PDF Details

The Standard Form 535, often integral to documenting the crucial first moments and conditions of a newborn’s life, stands as a thorough record encompassing a multitude of details necessary for ensuring the well-being of both the infant and the mother. This form meticulously captures a wide range of data starting from the basic identification details of the newborn and the parents, including mother's and father's names, ages, and races, to more detailed medical history and records crucial for any future healthcare needs. Notably, it records the health status of the mother prior to pregnancy, any abnormalities in previous pregnancies, and detailed accounts of the current delivery and the infant's condition immediately after birth. Sections covering the prenatal care administered, the course of delivery including analgesia and anesthesia details, resuscitation maneuvers employed, and the infant's physical condition post-delivery, make this form a comprehensive clinical record. Essential aspects like blood group information, Rh factors, prenatal serology, and a detailed physical examination of the newborn are also included, ensuring that healthcare providers have a full spectrum of information. Moreover, the form extends to note any complications or observations post-delivery, feeding patterns, and recommendations for follow-up nursing or social service engagements, crucially supporting a holistic approach to both immediate and long-term healthcare planning for the newborn.

QuestionAnswer
Form NameStandard Form 535
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 535, CFR, mongolism, serology

Form Preview Example

CLINICAL RECORD

 

 

 

 

 

 

 

 

 

 

NEWBORN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTHER'S LAST NAME-FIRST NAME-MIDDLE NAME

 

AGE

RACE

REGISTER NO.

FATHER'S LAST NAME-FIRST NAME-MIDDLE NAME

AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXPECTED DATE OF

 

 

 

MOTHER'S HEALTH PRIOR TO PREGNANCY

ABNORMALITIES OF PREVIOUS PREGNANCIES

 

 

CONFINEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRAVIDA

PARA

 

STILLBIRTHS

ABORTIONS

LIVING CHILDREN

FATHER'S RH

MOTHER'S

 

ANTI

RH

 

PAST TRANSFUSION HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOOD GROUP

RH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRENATAL CARE BY (Name of Physician)

 

LAST MENSTRUAL

 

SEROLOGY-TREATMENT IF POSITIVE

VIT. K

 

COMPLICATIONS OF DELIVERY

 

 

 

 

 

 

 

 

 

 

PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRENATAL COURSE: (Include illnesses, contacts with diseases. Details under remarks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANALGESIA (State whether scopolamine, barbiturate or opiate; dosage and hours of administration)

 

 

 

 

 

 

 

 

ANESTHESIA (Length of adminis-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

tration, kind, and amount)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

METHOD OF DELIVERY

 

LENGTH OF FIRST STAGE

LENGTH OF SECOND STAGE

 

INFANT'S CONDITION AT BIRTH

 

 

 

 

 

 

 

 

 

 

HRS.

 

MIN.

 

 

 

HRS.

 

MIN.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHARACTER OF CRY

 

RESUSCITATION USED (Type)

SUCTION USED (Type)

 

RESPIRATORY STIMULANT USED (Type)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESPIRATION ESTABLISHED IN

 

RESPIRATION NORMAL IN

OXYGEN IN DELIVERY ROOM

 

 

DURATION

 

 

EYE PROPHYLAXIS (State type)

 

 

 

 

 

MIN.

 

 

 

 

MIN.

 

 

YES

NO

 

 

 

 

HRS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMARKS (Summary of complications, etc., of pregnancy and birth, and nature of therapy)

SIGNATURE OF OBSTETRICIANDATE

INITIAL

To be completed within twenty-four hours of birth:

Note especially sutures, hemorrhage, clavicles, cephalhematoma, fontanelles, cleft palate, heart rate

PHYSICAL

and rhythm, anus, skin blemishes, jaundice, sternocleidomastoid, umbilicus, hernia, clubfeet, fingers, tumors, mongolism, character of cry, other

EXAMINATION deformities. Use progress sheet for abnormalities, description, and elaboration.

 

 

 

 

 

 

GEN. APPEARANCE

FACIES

BIRTH WEIGHT

 

TEMPERATURE

CHARACTER OF CRY

MEASUREMENTS:

 

 

 

 

 

 

 

 

 

LENGTH

HEAD

CHEST

ABDOMEN

 

 

 

 

 

 

 

 

 

 

 

 

BREATHING

 

CYANOSIS

SKIN

 

VERNIX

SUBCUT. TISSUE

PALLOR

 

ICTERUS

 

 

 

 

 

 

 

 

 

 

HEAD

 

FONTANELLES

SUTURES

 

EYES

EARS

NOSE

 

MOUTH

 

 

 

 

 

 

 

 

 

 

 

 

THROAT

 

NECK

CHEST

 

LUNGS

HEART

MURMURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABDOMEN

 

LIVER

SPLEEN

 

CORD

GENITALS

ANUS

 

MECONIUM

 

 

 

 

 

 

 

 

 

 

SPINE

 

EXTREMITIES

MUSCLE TONE

 

PARALYSES

REFLEXES

MORO

 

JOINTS

 

 

 

 

 

 

 

 

 

 

 

 

ABNORMAL FINDINGS ON PHYSICAL EXAMINATION:

SIGNATURE OF PHYSICIAN

 

DATE

 

SEX

 

RACE

 

 

 

 

 

 

 

PATIENT'S IDENTIFICATION

(For typed or written entries give: Name-last, first,

REGISTER NO.

 

WARD NO.

 

 

 

 

 

middle; grade; date; hospital or medical facility)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEWBORN

 

 

 

 

 

STANDARD FORM 535

 

 

 

 

 

PRESCRIBED BY GSA/ICMR

 

 

 

 

 

FIRMR (4 1 CFR)

 

 

 

 

 

201-45.505

 

 

 

 

 

OCTOBER 1975 535-105

 

 

 

 

 

 

USAPPC V1.00

CONDITION ON DISCHARGE: (Record any significant physical findings and summarize any unusual observations or therapy during hospitalization.)

DISCHARGE FEEDING: (Use progress notes to record unusual feeding behavior)

BREAST

BREAST AND COMPLEMENT

FORMULA

(Amount)

(Number of feedings)

SPECIFY FORMULA

FOLLOW-UP

NURSING VISIT ORDERED

OFFICE OF PRIVATE PHYSICIAN

(Location)(Date)

REFERRED TO CLINIC

(Location)

(Date)

SOCIAL SERVICE FOLLOW-UP ADVISED.

REFERRED TO

(Name of social service agency)

SIGNATURE OF EXAMINING PHYSICIAN

DATE OF DISCHARGE

WEIGHT ON DISCHARGE

PROGRESS NOTES (Sign and date all notes)

USAPPC V1.00