Prenatal Record - National Archives and Records Administration

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Reproduced at the National Archives 1-t 1-t • > • N nata Items Referencin~ Form OA-44, Pr~natRl Ohservatlnns OlTl JfF"\14 ITE\14 Jll ClRO TO F'JPI4 NIIM FP0\14 TO OAflf Tff.l4 Nli4F' 12Q& ••••••• 0144 6CJ IJO Blan~ 49A7 •••• VAR 4 5'5 '56 Prenatal visits, total numoer 49CJ7 •••• VAR & 8ft 88 Welnht natn (lbs) '\Oo9 •••• VAR B 104 11l4 Albu~tn~rta: orntP.lnurla '50tO •••• VAR R tO'\ 105 AJbum1nur1a: oroteinurla, orlor to 1.4 wee~s qestatlon '\011 •••• VAR 8 106 lOb AJb"mtn••rta: orotP.lnuri~, 24 wePKS qestAtlon to labor S212 •••• VAR 7 127. 3?2 Blond press"re systolic 140 or Qreater an1/or 11astolic 90 or 1reater; lhyoertensln~J "12t3•••• vA" 8 121 324 Albn•tnur1a: ornteinuriA, 2+ or •ore, nu•ber of urine soect•ens 5216 •••• VAA 9 327 328 Glu~osuria, 2+ or wore, nu•ber of urine soeci•ens 5217 •••• Y,R 1 ]2CJ J11 Blond '\2t8•••• YAR H7 H3 Blood oressure, oressurP., svstoltc, svstoltc, first ftrst recorded recorde~ Ccodedl li2t9 •••• YAR 7 134 H6 Blood oressurP., ~tastollc, first recorded "'i2?0•••• VAR 3]7 h8 Blood oressnre, diastolic, first recorded (co1ed) '5222•••• VAR 10 140 340 Acetonuria 5273 •••• VAR 631.2 •••• w-9 63?3 •••• 11-9 6 1 8 141 tt 14 343 11 14 welQht, prior to delivery, final flbsl Blood pressnre, ~fastollc, Maxlmu• Protetnnrta: urtne1 albu•tn, ~axl•um 0'1 N ~ ~ ~
..... C:Ol..llt-IOOa-44 1. PATIENT IDENTII"ICATION 08-44 PRENATAL OBSERVATIONS a) Record lindlnqa of aU prenatal clinic visitls, whether or not the patient Ia seen by a phystdan. b) Each prenatal visit at which th..-l"ltient is seen by a physician is to be summarized on Fonn 08-46. c) Findings at the initial clinic visit are to be recorded on this form, which is to be uaed in conjunction with 08-43. --~--. Record Initial I I --T--t TiaU here __ l._...J I I . 01 02 03 04 05 06 07 Z. PHYSICIAN 3. TITLE 4. DATE (Mo.-D-..Y..,) 5. WEEKS GESTATION BASED ON LMP 8. WEIGHT (Street Clotllea No Shoea) 7. BLOOD / / / / / / / PRESSURE / 7 / / / / 7 u 8. ALBUMIN R I I. GLUCOSE N 10. ACETONE E (lf d-•) HISTORY lndl..,• ,_w... fmrUnQa by (X) •d deacnbe on OB-4
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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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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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,;.-~ 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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!:: llil\41.0 ~ ~~ ~'~"'~ -N OB-9 -
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PRENATAL RECORD (Con 1 t) PRESENT P
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PRENATAL RECORD (Con 't) complete a
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PRENATAL RECORD (Can't) EVALUATION
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PRENATAL RECORD (Con't) GENERAL IDl
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OB-42 Past Medical History Form OB-
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-· eoL"-aooa-..a 08-42 PAST MEDICA
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Instruction Manual for Obstetric Fo
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OB-43 Initial Prenatal Examination
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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
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Page 247 and 248: DEFINITION OF CODES (Continued) FOB
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Page 253 and 254: Instruction Manual for Obstetric Fo
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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
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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
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Page 295 and 296: Instructional Manual for Obstetric
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Page 315 and 316: DEFJNITION OF CODES (continued) FIE
Page 317 and 318: DEFINITION OF CODES (continued) FOR
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Page 321 and 322: DEFTIUTION OF CODES (continued) FOR
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Page 327 and 328: DEFTIHTION OF CODES (continued) FIE
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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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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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