Prenatal Record - National Archives and Records Administration

SUMMARY OF HOSPITALIZATION FOR ANY ANTEPARTUM CONDITION
(For Form OB-12, Revised 7-59)
INSTRUCTIONS FOR OBSTETRICIAN
This form is to be used for summar~z~ng any antepartum admission, to
any service of any hospital, terminating in the discharge of a patient
who is either undelivered or delivered of a fetus of 400 gms. weight
or less, or less than 20 weeks gestational age (based on LMP).
Item #2 , "SUI!)miry .!By"
••
j
Insert your first and last name.
Item #3. "Title or Position"
Give your o:t:'ficial title, such as "medical student", "intern",
"resident", 'J.project obstetrician", etc.
It~m
#4. "Date Admitted"
Record the date the patient was admitted to the hospital: month, day,
and year.
'.,_,
It.eya #5. "Dat.e Dism.lM.pged"
' Recortfr :W~ dMe tl~e patient was di~~Etd'- from· the htri.spi tal: month,
day, mid tea:/. 1 "· ~' 'i.;:,.,~ '"'"'
1\· . ··-: ·: ' : 'l
iW #6. "Reaso;n for •·•·•J...iG>.n 11
Give as complet@ a description as li>®Ss-d.ble 0f the condition for which
the platiel'lt was hom~italized. This is ill'(!lortant in the event that
a speeific dill•f'li'l(iH!!is eamnot be mede. I'f a•dmitted to another hospital,
specify »a·me ®f liJ.iH.pi tal.
•·
If • .,.,.,;itemt neeivea anesthttsia ~il!il ~s hm-s;pi talization for any
rea~t0'lll·, fe'1!' ei~laei.ll' X". it tM p.etient did receive
anes~l!l,eeia, the ail!.l\e-stl