Prenatal Record - National Archives and Records Administration

More documents

Recommendations

Info

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
Instruction :\l:J.nual for Obstetric Forms OB-46 RECORD OF CURRENT PREGNANCY (Continued) obstetrical management are handled as in IV, E. 3. Outside Study hospital: Record the date, diagnoses, and treatment given as learned by patient history or direct communication with the facility which rendered care. 2. Study hospital, non-Study facilities: Re Submit supporting data such as abstracts cord as for consultations. or photostats when obtained. October 1962 Reproduced at the National Archives II.A.331 OB-46
Page 1 and 2:
NINCDS COLLABORATIVE PERINATAL PROJ
Page 3 and 4:
NINCDS COLLABORATIVE PERINATAL PROJ
Page 5 and 6:
INTRODUCTION DOCUMENT OBJECTIVES AN
Page 7 and 8:
Forms The first forms used in the s
Page 9 and 10:
Reproduced at the National Archives
Page 11 and 12:
selection. A n1n was used for patie
Page 13 and 14:
, researcher is more likely to look
Page 15 and 16:
TABLE 3. Abbreviations for Person,
Page 17 and 18:
TABLE 4. Definition of Person, Time
Page 19 and 20:
TABLE 4. Definition of Person, Time
Page 21 and 22:
CONTENTS AR-1/0B-1 OB-2 OB-3 OB
Page 23 and 24:
AR-1 Obstetrical Administrative Rec
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
DEFINITION OF CODES {Continued) FOR
Page 31 and 32:
... 1;:: I ~ .J.I'40JI.!9d jl5 !
Page 33 and 34:
ADMINISTRATIVE RECORD MANUAL PHS-30
Page 35 and 36:
ADMI!liSTRATIVE RECORD ;fl.A.TI.TUA
Page 37 and 38:
-· IID'~7-- '·"'-- ':!e- ~ l·-~
Page 39 and 40:
OB-1: OBSTETRICAL· ADMINISTRATIVE
Page 41 and 42:
Par. 3 10 - Religion. Record as Cat
Page 43 and 44:
OB-2 Reproductive History Form OB-2
Page 45 and 46:
Page 47 and 48:
COLIII:•IOoa-& ,.., REPRODUCTIVE
Page 49 and 50:
Page 51 and 52:
DEFTIITTION OF CODES (Continued) FI
Page 53 and 54:
1 Reproduced at the National Archiv
Page 55 and 56:
R~PRODUCTI\~ HISTORY (Con't.) C3-2
Page 57 and 58:
REPRODUCTIVE HISTORY (Con•t.) C3-
Page 59 and 60:
OB-3 History Since Last Menstrual P
Page 61 and 62:
Page 63 and 64:
eoL"-aooa.a ACV. n-et • HISTORY S
Page 65 and 66:
Page 67 and 68:
DEFINITION OF CODES (Continued) FOR
Page 69 and 70:
DEFJNITION OF CODES (Continued) FOR
Page 71 and 72:
"' 1: : ~~ :; "':J. !~ ~ ~ :~ ~ ; :
Page 73 and 74:
HISTORY SINCE LAST 1-ENSTRUAL PERIO
Page 75 and 76:
HISTORY SINCE ~T MENSTRQ~ P~RIOD {C
Page 77 and 78:
OB-4 Gynecological History Form OB-
Page 79 and 80:
Page 81 and 82:
COL.,.-aaaa-4 RIEV. tt-11 • GYNEC
Page 83 and 84:
DEFINITION OF CODES GYNECOLOGICAL H
Page 85 and 86:
DEFINITION OF CODES (Continued) FIE
Page 87 and 88:
'? I~ 1: :1\ j; t:: t; ....J 7 ,.
Page 89 and 90:
GY1~F..COLOGICAL HISTORY (Con't.) O
Page 91 and 92:
08-5 Recent Medical History Form 08
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
DEFINITION OF CODES RECENT MEDICAL
Page 101 and 102:
DEl!'INITION OF CODES (Continued) F
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
ILL..'1ESS OR DISABILITY CODES (Con
Page 109 and 110:
Page 111 and 112:
RECENT MEDICAL HISTORY (Con 1 t) OB
Page 113 and 114:
OB-6 Past Medical History Form OB-6
Page 115 and 116:
Page 117 and 118:
z PAST MEDICAL HISTORY (Interviewer
Page 119 and 120:
Page 121 and 122:
DEF'll'UTION OF CODES PAST MEDICAL
Page 123 and 124:
DEF'INli'ION OF CODES (Continued) F
Page 125 and 126:
DEFINITION OF CODES (Continued) u.
Page 127 and 128:
DEFINITION OF CODES (Continued) FOO
Page 129 and 130:
Page 131 and 132:
PAST HEDICAL HISTORY (Con't) Item 1
Page 133 and 134:
HISTORY TAKEN BY PAST MEDICAL HISTO
Page 135 and 136:
OB-7 Infectious Disease and System
Page 137 and 138:
Page 139 and 140:
COLIII.•I00 ..7 ,... INFECTIOUS D
Page 141 and 142:
C:OLft-IOOa-7 1··· INFECTIOUS DI
Page 143 and 144:
DEFINITION OF CODES nlFECTIOO'S DIS
Page 145 and 146:
DEl''ll'IITION OF C:JDES ( Conti:::
Page 147 and 148:
i i :a :: ·• 1: !: ! I! ::
Page 149 and 150:
l!:i i!;T!IJIJ;: IIJ;;:..f,;:l·: .
Page 151 and 152:
INF~TIOUS DIS~S~ ;~D SYSTEM REVIEW
Page 153 and 154:
OB-8 Repeat Prenatal History Form O
Page 155 and 156:
Page 157 and 158:
I. ftATIIMT IDfNTIPICATIOM REPEAT P
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
~ :: : j: ~ : I~ =r ; Ia ~ ~ !~ ;
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:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
C:OL.II.·- I•It NU\E IHOSPITAL
Page 179 and 180:
•• 'HISTORY NO. diRIRXL IXXMI l
Page 181 and 182:
Page 183 and 184:
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 193 and 194:
Page 195 and 196:
ZEFT1ITTIO:i OF CODES (Con"'c:..!!U
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
DEFINITION OF CODES ( Con~inued) FC
Page 203 and 204:
Page 205 and 206:
:t , I~ I ~ It II! I~ ::: .. ~ .. ~
Page 207 and 208:
!:: llil\41.0 ~ ~~ ~'~"'~ -N OB-9 -
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:
Page 221 and 222:
-· eoL"-aooa-..a 08-42 PAST MEDICA
Page 223 and 224:
Page 225 and 226:
Page 227 and 228:
Page 229 and 230:
Instruction Manual for Obstetric Fo
Page 231 and 232:
OB-43 Initial Prenatal Examination
Page 233 and 234:
Page 235 and 236:
Page 237 and 238:
COL ..-3008-41 UIIYe 10.U) 1. PATIE
Page 239 and 240:
Page 241 and 242:
DEFINITION OF CODES miTIAL PRENATAL
Page 243 and 244:
Page 245 and 246:
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:
Page 255 and 256:
Page 257 and 258:
I, I'ATIENT IDENTI,.ICATIDN OB-43 I
Page 259 and 260:
OB-10 Return Visit and Laboratory R
Page 261 and 262:
Page 263 and 264:
Page 265 and 266:
Page 267 and 268:
Page 269 and 270:
Page 271 and 272:
DEFTIUTION OF CODES (Continued) FOR
Page 273 and 274:
DEFINITION OF CODES (Continued) FOB
Page 275 and 276:
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 283 and 284:
Page 285 and 286:
..... C:Ol..llt-IOOa-44 1. PATIENT
Page 287 and 288:
Page 289 and 290:
:FDRMS 03-10 DEFINITION OF CODES (C
Page 291 and 292:
DEFINITION OF CODES (Continued) ~·
Page 293 and 294:
Page 295 and 296:
Instructional Manual for Obstetric
Page 297 and 298:
OB-45 Laboratory Record Form OB-45
Page 299 and 300:
Page 301 and 302: Reproduced at the National Archives
Page 313 and 314: DEFllUTION OF CODES LABJRATORY RECO
Page 315 and 316: DEFJNITION OF CODES (continued) FIE
Page 317 and 318: DEFINITION OF CODES (continued) FOR
Page 319 and 320: DEFINITIDN OF CODES (continued) FOR
Page 321 and 322: DEFTIUTION OF CODES (continued) FOR
Page 323 and 324: DEFINITION OF CODES (continued) FIE
Page 325 and 326: DEFINITION OF CODES (continuted) FI
Page 327 and 328: DEFTIHTION OF CODES (continued) FIE
Page 329 and 330: DEFTIUTION OF CODES (continued) FIE
Page 339 and 340: Instruction Manual for Obstetric Fo
Page 341 and 342: OB-11 Record of Current Pregnancy F
Page 343 and 344: CO~A·3C03·11 lltEV. '7·58 I. PAT
Page 345 and 346: RECORD OF CURRENT PREGNANCY (For Fo
Page 347 and 348: ,... RECORD OF CURRENT PREGNANCY IN
Page 349 and 350: OB-46 Physician•s Clinic Record,
Page 351: COLR-1001-4e 4-a I. PATIENT IDENTII
Page 355 and 356: OB-12 Summary of Hospitalization fo
Page 357 and 358: SUMMARY OF HOSPITALIZATION FOR ANY
Page 359 and 360: SUMMARY OF HOSPITALIZATION FOR ANY
Page 361 and 362: ':.::-•••suMMARY OF HOSPITALI
Page 363 and 364: OB-47 Summary of Antepartum Hospita
Page 365 and 366: · COLIII-IOOa..7 (CHANGIED 2-8a)
Page 367 and 368: Instruction Manual for Obstetric Fo
Page 369 and 370: OB-15 Drugs in Pregnancy Form OB-15
Page 373 and 374: PH S.300S.18 ..... PATIENT IDENTIFI
Page 375 and 376: .... PMS•3003•18 PATIENT IDENTI
Page 377 and 378: PHI·IOOI .. 1B P"TIENT IOENTIFIC"T
Page 379 and 380: PATI~NT IDENTIFICATION OB-15 DRUGS
Page 381 and 382: ..... PHS .. 3003 ... 11 PATII!NT I
Page 385 and 386: DEFINITION OF CODES DRUGS lN PREGN
Page 387 and 388: Drugs in Pregnancy (08-15) Blank 0
Page 389 and 390: Drugs in Pregnancy (cont.} 2128 Par
Page 391 and 392: Orugs in Pregnancy (cont.) 4256 Hyo
Page 393 and 394: . Drugs in Pregnancy (cont.) 7154 S
Page 395 and 396: 1 Drugs in Pregnancy (cont.) 7482 O
Page 397 and 398: Drugs in Pregnancy (cont.) 9169 917
Page 399 and 400: Drugs in Pregnancy (cont.) 9949 995
show all

Prenatal Record - National Archives and Records Administration

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?