VPRS 7406 Case Books of Female Patients

Full description

From at least 1845 and the proclamation of An Act for the Regulation of the Care and Treatment of Lunatics (8 & 9 Vic c.100), each asylum was required to maintain a casebook of patients. The book was to be kept in such form as the Governor in Council was from time to time to direct. As soon as possible after the admission of any patient and periodically thereafter, the following details were to be entered into the casebook:
the mental state and bodily condition of every patient on admission
the history of his/her case recorded from time to time while he/she continued to be a patient in the asylum
a correct description of the medicine and other remedies prescribed for the treatment of his/her disorder
and in the case of death an exact account of the autopsy (if any) of the patient.

Information recorded in the case histories includes personal and medical details as follows: date of admission; admission number; name and address of nearest relative; by whom brought to the asylum; previous residence; age and sex of patient; whether married, widowed or single; if any family; occupation; habits of life; form of insanity; duration of present attack; if disordered before/if disorder hereditary; specific signs of insanity; if suicidal; if dangerous and destructive; bodily condition; case notes; and a description of the medicine and other remedies prescribed for the treatment of his/her disorder. The Case Books usually record whether a patient was transferred elsewhere, discharged or died in custody. A copy of the post-mortem report was sometimes included in cases of death.

In later years the content of the Case Books was altered slightly. Reference was made to the admission number of the patient and a photograph of the patient on admission was often included. Additional information such as extracts from the required medical certificates and a copy of the Medical Superintendent's report on the mental and physical condition of the patient were often incorporated and additional space was provided for recording the history of each patient.

These books were to be regularly inspected by an Inspector or other officer appointed under the provisions of the prevailing legislation. It was expected that a full account of the mental and physical condition of the patient would be entered in the casebook on admission of the patient with a further note to be made at the end of each month at least for the first six months and subsequently a full note every six months. However such thorough and accurate notes were not always maintained.

In 1912 the format of case histories was changed from bound Case Books to a looseleaf folio format, known as Patient Clinical Notes. The new format facilitated the transfer of case histories with the patients when they were sent to other institutions. Patient Clinical Notes are registered as a separate series.