Prenatal Record - National Archives and Records Administration

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PRENATAL RECORD (Can't) SUMMATION (Can't) PAGE 4 evaluated and described as either "Adequate" or "Contracted." If you feel that any of these planes may not be adequate, but are not sure, check the box marked "Contracted" and explain in the space at the bottom of the page (Item #27) that this item, although checked "Contr:.acted" is suspect only. Any item checked "Contracted" must be explained. Item #26. "X-Ray Pelvimetry" Item #27 GENERAL EXAMINATION This item must be filled in whenever this type of pelvimetry is obtained. Morphology refers to the Caldwell-Malloy classification. The OB conjugate refers to the anterior-posterior diameter of the inlet. ·The transverse of the inlet is self-explanatory. The interspinous refers to the transverse diameter of the midpelvis. In this space list by item number and describe any fi~1ing which has been che-..:ked as abnormal, either in the pelvic examination or in the evaluation of the pelvis. As on page two of this form, record the full name of the patient, the hospital history number, the NINDB number and record your name under "Examined By." Normal findings need not be described. A single check in the box marked "Normal" will suffice for each item if it has been evaluated and found normal. Any abnormality checked "Positive 11 must be listed by item number in Item #14, and adequately described. If an abnormal ity is present which is not specifically listed, check the box marked "Other" and descr:i:be the abnormality below. If, uhder unusual circumstances, an item cannot be evaluated, there is a box marked "Not Evaluated" which may be checked. Item #13. "Other System Not Evaluated Above" Item #14 Any abnormality found on general physical examination not covered in one of the above categories should be noted by checking this box and describing the system and abnormality in Item #14. Any abnormal finding must be listed by item number and described here. Reproduced at the National Archives II.A.l92 February (For Forms in Use April 1 OB-9
PRENATAL RECORD (Con't) GENERAL IDl~ATION {Con't) Item #15 If any clinical diagnosis .is made as a result of the first obstetrical visit, record it in this space. Record the a~proximate date of onset as nearly a-s· can be determined in the space marked "Date of Onset." II.A.l93 OB-9 Reproduced at the National Archives
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NINCDS COLLABORATIVE PERINATAL PROJ
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NINCDS COLLABORATIVE PERINATAL PROJ
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INTRODUCTION DOCUMENT OBJECTIVES AN
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Forms The first forms used in the s
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Reproduced at the National Archives
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selection. A n1n was used for patie
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, researcher is more likely to look
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TABLE 3. Abbreviations for Person,
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TABLE 4. Definition of Person, Time
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TABLE 4. Definition of Person, Time
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CONTENTS AR-1/0B-1 OB-2 OB-3 OB
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AR-1 Obstetrical Administrative Rec
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DEFINITION OF CODES {Continued) FOR
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... 1;:: I ~ .J.I'40JI.!9d jl5 !
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ADMINISTRATIVE RECORD MANUAL PHS-30
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ADMI!liSTRATIVE RECORD ;fl.A.TI.TUA
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-· IID'~7-- '·"'-- ':!e- ~ l·-~
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OB-1: OBSTETRICAL· ADMINISTRATIVE
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Par. 3 10 - Religion. Record as Cat
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OB-2 Reproductive History Form OB-2
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COLIII:•IOoa-& ,.., REPRODUCTIVE
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DEFTIITTION OF CODES (Continued) FI
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1 Reproduced at the National Archiv
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R~PRODUCTI\~ HISTORY (Con't.) C3-2
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REPRODUCTIVE HISTORY (Con•t.) C3-
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OB-3 History Since Last Menstrual P
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eoL"-aooa.a ACV. n-et • HISTORY S
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DEFINITION OF CODES (Continued) FOR
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DEFJNITION OF CODES (Continued) FOR
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"' 1: : ~~ :; "':J. !~ ~ ~ :~ ~ ; :
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HISTORY SINCE LAST 1-ENSTRUAL PERIO
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HISTORY SINCE ~T MENSTRQ~ P~RIOD {C
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OB-4 Gynecological History Form OB-
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COL.,.-aaaa-4 RIEV. tt-11 • GYNEC
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DEFINITION OF CODES GYNECOLOGICAL H
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DEFINITION OF CODES (Continued) FIE
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'? I~ 1: :1\ j; t:: t; ....J 7 ,.
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GY1~F..COLOGICAL HISTORY (Con't.) O
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08-5 Recent Medical History Form 08
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DEFINITION OF CODES RECENT MEDICAL
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DEl!'INITION OF CODES (Continued) F
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ILL..'1ESS OR DISABILITY CODES (Con
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RECENT MEDICAL HISTORY (Con 1 t) OB
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OB-6 Past Medical History Form OB-6
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z PAST MEDICAL HISTORY (Interviewer
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DEF'll'UTION OF CODES PAST MEDICAL
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DEF'INli'ION OF CODES (Continued) F
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DEFINITION OF CODES (Continued) u.
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DEFINITION OF CODES (Continued) FOO
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PAST HEDICAL HISTORY (Con't) Item 1
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HISTORY TAKEN BY PAST MEDICAL HISTO
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OB-7 Infectious Disease and System
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COLIII.•I00 ..7 ,... INFECTIOUS D
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C:OLft-IOOa-7 1··· INFECTIOUS DI
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DEFINITION OF CODES nlFECTIOO'S DIS
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DEl''ll'IITION OF C:JDES ( Conti:::
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i i :a :: ·• 1: !: ! I! ::
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l!:i i!;T!IJIJ;: IIJ;;:..f,;:l·: .
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INF~TIOUS DIS~S~ ;~D SYSTEM REVIEW
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OB-8 Repeat Prenatal History Form O
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I. ftATIIMT IDfNTIPICATIOM REPEAT P
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Page 163 and 164: DEFINITION OF CODES (Continued) FIE
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Page 167 and 168: ,;.-~ 1•1. 1J;,.... - ~ .. u;W'o'
Page 169 and 170: OB-9 Prenatal Record Form OB-9, Pre
Page 171 and 172: Reproduced at the National Archives
Page 177 and 178: C:OL.II.·- I•It NU\E IHOSPITAL
Page 179 and 180: •• 'HISTORY NO. diRIRXL IXXMI l
Page 185 and 186: ~~J2ITTIGN OF CODES (Co~~i~ued) FCa
Page 187 and 188: DEFINITION OF CODES (Continued) FOF
Page 189 and 190: DEF~~ION OF CODES (Continued) PELVI
Page 191 and 192: DEFTIHTION OF CODES (Continued) FQR
Page 195 and 196: ZEFT1ITTIO:i OF CODES (Con"'c:..!!U
Page 197 and 198: DEFINITION OF CODES (Continued) FOR
Page 201 and 202: DEFINITION OF CODES ( Con~inued) FC
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Page 209 and 210: PRENATAL RECORD (Con 1 t) PRESENT P
Page 211 and 212: PRENATAL RECORD (Con 't) complete a
Page 213: PRENATAL RECORD (Can't) EVALUATION
Page 217 and 218: OB-42 Past Medical History Form OB-
Page 221 and 222: -· eoL"-aooa-..a 08-42 PAST MEDICA
Page 229 and 230: Instruction Manual for Obstetric Fo
Page 231 and 232: OB-43 Initial Prenatal Examination
Page 237 and 238: COL ..-3008-41 UIIYe 10.U) 1. PATIE
Page 241 and 242: DEFINITION OF CODES miTIAL PRENATAL
Page 247 and 248: DEFINITION OF CODES (Continued) FOB
Page 249 and 250: DEF'INITION OF CODES (Continued) FO
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Page 257 and 258: I, I'ATIENT IDENTI,.ICATIDN OB-43 I
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DEFTIUTION OF CODES (Continued) FOR
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DEFINITION OF CODES (Continued) FOB
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4/16/61 OB-10 RETURN VISIT AND LAB
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~"........ ,... ~,_~.a., RETURN VIS
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OB-44 Prenatal Observations Form OB
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..... C:Ol..llt-IOOa-44 1. PATIENT
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:FDRMS 03-10 DEFINITION OF CODES (C
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DEFINITION OF CODES (Continued) ~·
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Instructional Manual for Obstetric
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OB-45 Laboratory Record Form OB-45
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DEFllUTION OF CODES LABJRATORY RECO
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DEFJNITION OF CODES (continued) FIE
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DEFINITION OF CODES (continued) FOR
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DEFINITIDN OF CODES (continued) FOR
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DEFTIUTION OF CODES (continued) FOR
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DEFINITION OF CODES (continued) FIE
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DEFINITION OF CODES (continuted) FI
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DEFTIHTION OF CODES (continued) FIE
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DEFTIUTION OF CODES (continued) FIE
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Instruction Manual for Obstetric Fo
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OB-11 Record of Current Pregnancy F
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CO~A·3C03·11 lltEV. '7·58 I. PAT
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RECORD OF CURRENT PREGNANCY (For Fo
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,... RECORD OF CURRENT PREGNANCY IN
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OB-46 Physician•s Clinic Record,
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COLR-1001-4e 4-a I. PATIENT IDENTII
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Instruction :\l:J.nual for Obstetri
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OB-12 Summary of Hospitalization fo
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SUMMARY OF HOSPITALIZATION FOR ANY
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SUMMARY OF HOSPITALIZATION FOR ANY
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':.::-•••suMMARY OF HOSPITALI
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OB-47 Summary of Antepartum Hospita
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· COLIII-IOOa..7 (CHANGIED 2-8a)
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Instruction Manual for Obstetric Fo
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OB-15 Drugs in Pregnancy Form OB-15
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PH S.300S.18 ..... PATIENT IDENTIFI
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.... PMS•3003•18 PATIENT IDENTI
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PHI·IOOI .. 1B P"TIENT IOENTIFIC"T
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PATI~NT IDENTIFICATION OB-15 DRUGS
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..... PHS .. 3003 ... 11 PATII!NT I
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DEFINITION OF CODES DRUGS lN PREGN
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Drugs in Pregnancy (08-15) Blank 0
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Drugs in Pregnancy (cont.} 2128 Par
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Orugs in Pregnancy (cont.) 4256 Hyo
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. Drugs in Pregnancy (cont.) 7154 S
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1 Drugs in Pregnancy (cont.) 7482 O
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Drugs in Pregnancy (cont.) 9169 917
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Drugs in Pregnancy (cont.) 9949 995
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Prenatal Record - National Archives and Records Administration

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