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ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Adc&rfr_id=info%3Asid%2FANDS&rft_id=http://www.access.prov.vic.gov.au/public/component/daPublicBaseContainer?component=daViewSeries&breadcrumbPath=Home/Access%20the%20Collection/Browse%20The%20Collection/Series%20Details&entityId=7676&rft.title=Patient Medical Files&rft.identifier=VPRS 7676&rft.publisher=Public Record Office Victoria&rft.description=PATIENT CLINICAL NOTES AND PATIENT FILESHow to locate an individual case historyFollowing a patient's last discharge or death, the patient clinical notes and patient files were arranged chronologically by year of discharge or death and then alphabetically by patient surname within each year.To use patient case histories, researchers therefore need to know the patient's year of last discharge or death. This information was recorded in the Register of Patients, the Discharge Register and sometimes in the Nominal Register of Patients.Patient Clinical NotesEach institution was required by legislation to maintain records of patient case histories. These records were 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 case histories: 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.These records which were initially in the form of bound casebooks, were to be regularly inspected by an Inspector or other officer appointed under the provisions of the prevailing legislation. In 1912 the format of case histories was altered from bound casebooks to a looseleaf folio format, known as Patient Clinical Notes. The change in format meant that the case notes could be transferred with the patient whenever they were removed to another hospital or forwarded to the Lunacy Department when the patient was discharged or died.Information recorded in patient clinical notes included:Personal Details name and address of nearest relative or friend, by whom brought (to the asylum) previous residence age and sex of patient marital status if any family occupation habits of life and native placeMedical Details the form of insanity duration of present attack if disordered before/if condition hereditary specific signs of insanity if suicidal if dangerous and destructive a brief description of bodily conditionThe page on the right records the medical history of the patient. It was expected that a full account of the mental and physical condition of the patient would be entered in the case notes on admission, with a further note at the end of each month at least for the first six months, and afterwards a full note every six months. However such thorough and accurate notes were not always maintained. The clinical notes usually record whether the patient was transferred elsewhere, discharged or died while in custody. A copy of the Post-Mortem Examination Report is sometimes included in cases of death. A photograph of the patient on admission is often included. Some folios contain correspondence relating to the patient.It is thought that the clinical notes were kept in the wards until the death or discharge of a patient. Following the patient's last discharge or death, the case histories were arranged chronologically by year of discharge and then alphabetically by patient surname within each year.Patient FilesWith the development of modern psychiatry, increasingly complex and detailed patient records were created. In 1953 the format of case histories changed from a looseleaf folio format to files, the format and contents of which also changed over time. The Mental Health Regulations 1962 and subsequent regulations established the format and content of various records which together constituted the Patient File or Hospital Record. Such files contained a 'Statement of Personal Details of Patient' letters of referral, reports of the Superintendent's examinations, specialist reports, dental reports and reports of special investigations, physical examinations, psychiatric history and examinations, re-admissions, re-examinations and post- mortems and reports by nurses, occupational therapists and social workers. Some files included a treatment card.Since 1983 the control system for the medical records of all patients in psychiatric and mental institutions in Victoria has been computerised on a central system controlled from the central office of the Office of Psychiatric Services. This system allocates each patient a unique record (U.R.) number which is used every time that patient is admitted to any psychiatric institution in Victoria. This number is recorded on the front of the file. However files continue to be arranged alphabetically by surname within the year of discharge or death.Notes recorded in the files relate to the physical and mental condition of the patient while under care. Included in the files are pathology, x-ray, and E.E.G. reports, special investigations, nursing notes, temperature charts and operation notes. If the patient was transferred to another mental or psychiatric hospital the file may have medical notes recorded by a number of different hospitals.The files are arranged chronologically by year of the patient's last discharge or death and alphabetically by surname within each year. Dates of death or discharge can be found in the following series:VPRS 7681 Discharge Registers 1872-1988 (only for patients admitted prior to 1966)VPRS 7680 Registers of Patients 1871-1966VPRS 7682 Registers of Patients Admission and Discharge 1966-1988VPRS 7696 Registers of Patients Admission and Discharge Willsmere Unit 1982-1988The exception to this arrangement are the last five units of the R1 consignment. At the time of processing these files were overlooked and have been listed separately. The year listed is the year of discharge or death.System of Arrangement/ControlSeries: Chronologically by year of discharge of death and alphabetically by surname within each year.Range of Control SymbolsSeries: 1953 Ai-Ze &rft.creator=Department of Health and Human Services&rft.date=1985&rft.coverage=141.000000,-34.000000 142.919336,-34.145604 144.582129,-35.659230 147.742627,-35.873175 150.024219,-37.529041 150.200000,-39.200000 141.000000,-39.200000 141.000000,-34.000000 141.000000,-34.000000&rft_rights=Records held by Public Record Office Victoria (PROV) are covered by copyright. For information on reusing material from the collection see PROVguide 25 http://prov.vic.gov.au/provguide-25&rft_subject=HISTORICAL STUDIES&rft_subject=HISTORY AND ARCHAEOLOGY&rft.type=dataset&rft.language=English Access the data

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Records held by Public Record Office Victoria (PROV) are covered by copyright. For information on reusing material from the collection see PROVguide 25
http://prov.vic.gov.au/provguide-25

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PATIENT CLINICAL NOTES AND PATIENT FILES

How to locate an individual case history

Following a patient's last discharge or death, the patient clinical notes and patient files were arranged chronologically by year of discharge or death and then alphabetically by patient surname within each year.

To use patient case histories, researchers therefore need to know the patient's year of last discharge or death. This information was recorded in the Register of Patients, the Discharge Register and sometimes in the Nominal Register of Patients.

Patient Clinical Notes

Each institution was required by legislation to maintain records of patient case histories. These records were 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 case histories:

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.

These records which were initially in the form of bound casebooks, were to be regularly inspected by an Inspector or other officer appointed under the provisions of the prevailing legislation.

In 1912 the format of case histories was altered from bound casebooks to a looseleaf folio format, known as Patient Clinical Notes. The change in format meant that the case notes could be transferred with the patient whenever they were removed to another hospital or forwarded to the Lunacy Department when the patient was discharged or died.

Information recorded in patient clinical notes included:

Personal Details

name and address of nearest relative or friend,
by whom brought (to the asylum)
previous residence
age and sex of patient
marital status
if any family
occupation
habits of life and native place

Medical Details

the form of insanity
duration of present attack
if disordered before/if condition hereditary
specific signs of insanity
if suicidal
if dangerous and destructive
a brief description of bodily condition

The page on the right records the medical history of the patient. It was expected that a full account of the mental and physical condition of the patient would be entered in the case notes on admission, with a further note at the end of each month at least for the first six months, and afterwards a full note every six months. However such thorough and accurate notes were not always maintained. The clinical notes usually record whether the patient was transferred elsewhere, discharged or died while in custody. A copy of the Post-Mortem Examination Report is sometimes included in cases of death. A photograph of the patient on admission is often included. Some folios contain correspondence relating to the patient.

It is thought that the clinical notes were kept in the wards until the death or discharge of a patient. Following the patient's last discharge or death, the case histories were arranged chronologically by year of discharge and then alphabetically by patient surname within each year.

Patient Files

With the development of modern psychiatry, increasingly complex and detailed patient records were created. In 1953 the format of case histories changed from a looseleaf folio format to files, the format and contents of which also changed over time. The Mental Health Regulations 1962 and subsequent regulations established the format and content of various records which together constituted the Patient File or Hospital Record. Such files contained a 'Statement of Personal Details of Patient' letters of referral, reports of the Superintendent's examinations, specialist reports, dental reports and reports of special investigations, physical examinations, psychiatric history and examinations, re-admissions, re-examinations and post- mortems and reports by nurses, occupational therapists and social workers. Some files included a treatment card.

Since 1983 the control system for the medical records of all patients in psychiatric and mental institutions in Victoria has been computerised on a central system controlled from the central office of the Office of Psychiatric Services. This system allocates each patient a unique record (U.R.) number which is used every time that patient is admitted to any psychiatric institution in Victoria. This number is recorded on the front of the file. However files continue to be arranged alphabetically by surname within the year of discharge or death.

Notes recorded in the files relate to the physical and mental condition of the patient while under care. Included in the files are pathology, x-ray, and E.E.G. reports, special investigations, nursing notes, temperature charts and operation notes. If the patient was transferred to another mental or psychiatric hospital the file may have medical
notes recorded by a number of different hospitals.


The files are arranged chronologically by year of the patient's last discharge or death and alphabetically by surname within each year. Dates of death or discharge can be found in the following series:

VPRS 7681 Discharge Registers 1872-1988 (only for patients admitted prior to 1966)
VPRS 7680 Registers of Patients 1871-1966
VPRS 7682 Registers of Patients Admission and Discharge 1966-1988
VPRS 7696 Registers of Patients Admission and Discharge Willsmere Unit 1982-1988

The exception to this arrangement are the last five units of the R1 consignment. At the time of processing these files were overlooked and have been listed separately. The year listed is the year of discharge or death.

System of Arrangement/Control

Series: Chronologically by year of discharge of death and alphabetically by surname within each year.

Range of Control Symbols

Series: 1953 Ai-Ze


Created: 1930 to 1985

Data time period: 1930 to 1985

Data time period: Series date range : 1953 - 1988
Series in custody date range : 1953 - 1984
Contents in custody date range : 1930 - 1985

141.000000,-34.000000 142.919336,-34.145604 144.582129,-35.659230 147.742627,-35.873175 150.024219,-37.529041 150.200000,-39.200000 141.000000,-39.200000 141.000000,-34.000000 141.000000,-34.000000

145.6,-36.6

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  • Local : VPRS 7676