Prenatal Record - National Archives and Records Administration

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Revised April. 1965 II.A.230 OB-43 Reproduced at the National Archives
Instruction Manual for Obstetric Forms OB-43 page 1 INITIAL PRENATAL EXAMINATION I. Purpose of form To record the results of the initial physical examination following selection of the patient into the P r o j e c t sample. II. General Instructions Item Number 10. Non-pregnant weight. Record known non-pregnant weight. the last 11. Height. Record measured height in inches, without shoes. 12. Pulse. Record. A. This form should be completed at the patient's initial or second prenatal visit. If examination of a particular patient cannot be done GENERAL EXAMINATION prior to admission for pregnancy termination, OB-43 may be completed during A. If a general examination is not done, hospitalization. mark "not done" and explain the reason. B. For each item, mark all boxes that describe positive findings. Describe positive findings 14. General appearance. Mark all boxes which in the space provided. If there are none, describe the general state of the patient. mark "normal" box. 15. Skin. Mark boxes applicable to skin of C. Indicate any items not evaluated by marking any area of the body. Operative scars, the appropriate box. wherever present on the patient, are reported on I y here. Scars other than operative are not considered important Ill. Specific Instructions unless indicative of major trauma, in which case record under "other." Item Number 16. Edema. If edema is present, designate 2. Date. Record the date of examination. the location by marking the appropriate box(es). In the space to the right, describe the degree of edema in each 4, 5. Examined by. Print the first initial and location, designating it as +1 to +4; last name, and title or position of the pitting or non-pitting. examining physician. 6. This exam was. a. Mark the box "completed using this form" when the examination findings are recorded directly on pages 1 and 2 of this form. b. Mark the box "other" when this examination is initially recorded on non Study forms. In this case, abstract the findings and stamp the form (pages 1 & 2) "Not according to protocol." 7-9. Re-examination. 19. Eyes. Severe visual impairment is described as any impairment which prohibits the patient, correctly fitted with glasses, from reading unmagnified news print. Description should include the degree of impairment of vision. Include under "other" such difficulties as tunnel vision, color-blindness, etc. a. Mark the appropriate box(es) if find ings are re-evaluated by a more senior physician. b. The senior examiner is to initial any changes made in the original report. 17. Lymph nodes. If any lymph nodes are enlarged, specify whether they are a single local group or all the superficial nodes by marking the appropriate box. If any lymph nodes are tender, mark the appro priate box. Describe the abnormal nodes and their location in the space provided. 18. ENT and mouth. Mark the appropriate boxes. Inflammation of the pharynx includes pharyngitis and tonsillitis. "Other inflammation" includes rhinitis, otitis, and abscessed teeth. October 1962 Reproduced at the National Archives II.A.231 OB-43
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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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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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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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OB-9 Prenatal Record Form OB-9, Pre
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C:OL.II.·- I•It NU\E IHOSPITAL
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•• 'HISTORY NO. diRIRXL IXXMI l
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~~J2ITTIGN OF CODES (Co~~i~ued) FCa
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DEFINITION OF CODES (Continued) FOF
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DEF~~ION OF CODES (Continued) PELVI
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DEFTIHTION OF CODES (Continued) FQR
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ZEFT1ITTIO:i OF CODES (Con"'c:..!!U
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Page 201 and 202: DEFINITION OF CODES ( Con~inued) FC
Page 203 and 204: DEFINITION OF CODES (Continued) FOR
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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 and 214: PRENATAL RECORD (Can't) EVALUATION
Page 215 and 216: PRENATAL RECORD (Con't) GENERAL IDl
Page 217 and 218: OB-42 Past Medical History Form OB-
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Page 221 and 222: -· eoL"-aooa-..a 08-42 PAST MEDICA
Page 225 and 226: DEFINITION OF CODES (Continued) FIE
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
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Page 257 and 258: I, I'ATIENT IDENTI,.ICATIDN OB-43 I
Page 259 and 260: OB-10 Return Visit and Laboratory R
Page 271 and 272: DEFTIUTION OF CODES (Continued) FOR
Page 273 and 274: DEFINITION OF CODES (Continued) FOB
Page 277 and 278: 4/16/61 OB-10 RETURN VISIT AND LAB
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Page 281 and 282: OB-44 Prenatal Observations Form OB
Page 285 and 286: ..... C:Ol..llt-IOOa-44 1. PATIENT
Page 289 and 290: :FDRMS 03-10 DEFINITION OF CODES (C
Page 291 and 292: DEFINITION OF CODES (Continued) ~·
Page 295 and 296: Instructional Manual for Obstetric
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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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