Sample of Patient Record System

Full description

Series comprises of a sample of a number of distinct records which together constitute the medical record of patients admitted to the Springvale and District Community Hospital prior to July 1979. The sample was created to detail the working of a hospital record keeping system in respect to patient information from this period.

Series comprises four types of records.

Nursery Books

Created to detail particulars of baby patients in the hospital nursery. Detail was entered daily for each patient and includes the surname, weight and sex of the baby, name of doctor, details regarding feeding and very brief comments.

Daily Report Books

Contains brief reports on the general condition of patient. Three reports were made daily; day, evening and night.

Temperature and Pulse Record (or TPR) Books

Details daily readings of temperature, pulse, heartbeat rate and blood pressure made of each patient.

Admission Cards

General detail obtained from the patient on admission including hospital registration number, health insurance details, information regarding last admission (if any), anaesthetic permission, special observation charts may also be included. Discharge detail was later added.

Use of this system of patient information was discontinued by the agency on 20 June 1979 in favour of a system which consolidated all the various pieces of information into a single patient file (VPRS 7729).

Sample

The sample comprises:

- all nursery, report and TPR Books for a single calender year (1969) and

- the admission card and relevant books for one patient selected from each of the years 1971 - 1979.

All remaining cards and books have been destroyed under the provisions of Public Record Office Standard 85/09.

The admission registers which details the names of all persons admitted to the hospital for the period has been permanently retained as VPRS 7726.