Prenatal Record - National Archives and Records Administration

Instruction Manual for Obstetric Forms
OB-~
RECORD OF CURRENT PREGNANCY
I. Purpose of form For physicians' information
pertaining to the p rena t a 1
examination aDd at each subsequent
prenatal clinic visit.
II. General Instructions
A. Date each entry.
B. Enter name and title of the physician whose
findings are being reported, following each
note.
C. If more than one physician sees the patient
at a particular visit, record the comments,
diagnoses, impressions, etc. of all physicians.
D. Report clearly the source of all data recorded
which is not obtained at a prenatal
visit; i.e., telephone conversation, perusal
of records, etc.
E. Summarize findings in sufficient detail to
demonstrate the logic of aay conclusions
reached.
F. Avoid repetition of facts adeqqately reported
elsewhere, if they do not coatribute to the
commentary and evaluation that these notes
should contain.
Ill. Initial note. In addition to data recorded as on
other visits (listed below), report the following
in the initial note:
A. Events noted in the past medioalorobstetric
histories which may influence the course of,
or treatment during, the current pregnancy.
B. The general health of the pa.Uent at the beginning
of pregnancy.
C. Description of the course of pregnancy to
the time of the initial note.
IV. All prenatal notes
A. Elaboration of history. Elaborate upon any
suggestive or positive history of disorder
obtained by the interviewer (OB-3, OB-8),
or the physician (OB-42, OB-44). This
should include onset, duration, and severity.
B. Elaboration of positive physical findings. Describe
in detail any abnormal physical findings
noted on OB-43 or OB-44.
C. Interpretation of laboratory findings. Interpret
findings indicative or suggestive of
pathological states, when laboratory reports
are first available.
D. Diagnoses. Record all diagnostic impressions
arrived at as a result of interpretation
of the history and physical findings.
E. Procedures or treatments. Record any diagnostic,
therapeutic, or prophylactic procedures
or treatments initiated or ordered,
including medication. Specify:
1. All medications administered at prenatal
visits (specify dosage, route).
2. All medication given to or prescribed
for the patient (specify daily dosage,
manner of use, total amount provided or
prescribed).
3. All medication discontinued (specify date).
4. Medication the ph y s i c i an knows the
patient is taking, obtained from other
sources. This will include medication
routinely taken for chronic diseases such
as epilepsy, diabetes, etc. (specify dosage,
change in dosage).
5. Medication given for research or prophylactic
purposes only.
F. Duration of pregnancy
1. Record original EDC.
2. Record any change in EDC as a result
of:
a. Re-evaluation of menstrual history.
b. Interpretation of obstetrical examination
findings.
G. Non-Study prenatal care (out-patient). This
will usually describe a positive mark in
item #22, OB-44 Prenatal Observations.
1. Consultations: Record the date of and
diagnoses made by consultation. Procedures,
treatments or changes in
October 1962
II.A.330
OB-46
Reproduced at the National Archives