Standard Form 535 – Fill Out and Use This PDF

The Standard 535 form serves as a comprehensive clinical record for newborns, capturing detailed information ranging from the mother's health history and prenatal care to the baby's delivery, immediate condition at birth, and subsequent physical examination data. This intricate form ensures that every crucial aspect of both mother and child's health during the perinatal period is meticulously documented, contributing to the continuity and quality of healthcare provided. Ensure the well-being of your newborn by filling out the Standard 535 form, and click the button below to start this important process.

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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.

Question	Answer
Form Name	Standard Form 535
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	form 535, CFR, mongolism, serology

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CLINICAL RECORD

NEWBORN

MOTHER'S LAST NAME-FIRST NAME-MIDDLE NAME

AGE

RACE

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

PAST TRANSFUSION HISTORY

BLOOD GROUP

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.

YES

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.
PATIENT'S IDENTIFICATION	(For typed or written entries give: Name-last, first,
	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

Standard Form 535 – Fill Out and Use This PDF

Standard Form 535 PDF Details

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