Prenatal Record - National Archives and Records Administration

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Instruction l\lanual for Obstetric Forms OB-43 page 2 INITIAL PRENATAL EXAMINATION (Continued) Item :\umber 10-17. Pelvic examination. Record the information required for eachitem. Measurement of the posterior sagittal diameter of the outlet is optional for study purposes. 18. Other pelvic abnormality. Indicate gross asymmetry of the pelvis by marking the appropriate box. If any other pelvic abnormality is noted, mark "other" and describe. 19-21. Summation. For each plane of the pelvic bore, indicate estimation of the adequacy by marking the appropriate box. 22. DIAGNOSTIC IMPRESSIONS. Following completion of the initial prenatal history and physical examination, record all diagnostic impressions (including obstetric) made or considered at this time. 23. Consultation sought. Record by marking "X" in the column opposite the appropriate diagnostic impression, to indicate consultation is being sought. Item Number 24. Approximate date of onset. \\'hen appropriate, record the date of onset opposite each diagnostic impression, with particular emphasis on acute infectious processes and toxemia. The date ofonset\•·ill represent the physician's best estimate of the date on which the disease process began. 25-28. Editing. Report completion of the editing procedures for the past medical history and inital prenatal examination (forms OB-42.and OB-43) through completio:1 of these items. 25. Lay edit by. Initial upon completion. 26. Medical edit. Record whether editing was accomplished with or without the aid of the hospital chart. "Hospital chart" as used here includes all records of medical care during or prior to the current pregnancy which are in the Study institution. 27, 28. Medical edit by. Provides for the sig:J.ature and position of the medical editor. October 1962 Reproduced at the National Archives II.A.234 OB-43
I, I'ATIENT IDENTI,.ICATIDN OB-43 INITIAL PRENATAL EXAMINATION OBSTETRIC EXAMINATION 0 NOT DONO: (lbplabt) --.,..--, PAGE 2 I ~--r-, 1 I I '--·--· 0 ................... O evA T&•cawcaa O~tc•••• QoTM&a O•T ....... .. J. CORPUS UT!RI 0 •nc NOT cON•ATiaL.c WITM OATI8 D ......... ,.•• OX W&IIKI •• 9&1TATIO• QMOT &VALe 0TVMOR 4. EXTI!RMAL GI!MITALIA ~ MOaMAL 'lUI.'I ... YAAICOIITICI 0 g MOT C'f'A&.e 0 OTMIA s. IMTROITIJ$ 0 R&CTOCC\.1 gMOAMAL O•oT &VA&.. •• 1. VAGINA ~ ......... QMOTCVAto.. Oc'nTOCI:t.& 7. !iRVIX UTili QoLo I.ACUATIOM 0 CIRVICITII :J •OT CYAI.• •• 0 IL&IIDIH TMttoua• oa w........"' QIIOTC'IAt..• •• qoTMCJI a. ADMIXA 0 ...... 0 ....... CLINICAL PELVIC MENSuRAnOH oNoT ooNa(a_,_, 0 •&ACMIIO AT _____CMI I I c... o-· ' (It-o) I OwtDC •z. s~....u. IJ, ;oA"RVa..,ATII; MOn.H 14,~Do:wA"u c;J A'I&RAI& CUa¥& QA¥UMI o~........u . • QrL.AT 0•,..••• c;J • C01t¥11tiiMT I 9 AMULAHO r:;J••oa 9DIYIIHCMT II. OTHI!R I"I!LVIC AIMORMALITY O••ooe • 17, I"OST. SAG. OUTLI! 0 ..,......,..,. • c... c;J•,..... zz. DIAGNOSTIC IMPRI!SSIONS (It••"' "''· 1n.,_• ...,...,..,) 11. IMLI!T 9 AO&OUATI O•o..c.. 1 1.11111& SUMMATION ZO. MID I"I!LVIS c;J AOCOUATI QHaO&W• 1 I.IMC: 9 COMTaACTKD Zl. OUTLI!T c;J AOKQUATK O•••o•a 1 ...... Oc••ntACTI:D U. LAY I!DIT I•· MED QwiTM ;27, MEDICAL BY I EDIT 1 ~=::~TA&, ' EDIT BY COt...t...AeO.. ATIV ......A..CH ~...INA TAt.. .....A ..CH ...ANCH, MINOa. NIH e•TH.SOA 14, MO. ·- ;28. TITLE Oflt I ~ITION :~;~ 08-43 Reproduced at the National Archives II.A.235 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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"' 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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~ :: : j: ~ : I~ =r ; Ia ~ ~ !~ ;
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,;.-~ 1•1. 1J;,.... - ~ .. u;W'o'
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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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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 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-
Page 219 and 220: Reproduced at the National Archives
Page 221 and 222: -· eoL"-aooa-..a 08-42 PAST MEDICA
Page 225 and 226: DEFINITION OF CODES (Continued) FIE
Page 227 and 228: DEFINITION OF CODES (Continued) FOR
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 243 and 244: DEFINITION OF CODES (Continued) FOR
Page 247 and 248: DEFINITION OF CODES (Continued) FOB
Page 249 and 250: DEF'INITION OF CODES (Continued) FO
Page 251 and 252: I ,rnrn:r s YIN.Ct:l S6¥:;~rn I
Page 253 and 254: Instruction Manual for Obstetric Fo
Page 255: Instruction Manual for Obstetric Fo
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
Page 279 and 280: ~"........ ,... ~,_~.a., RETURN VIS
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
Page 297 and 298: 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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