VPRS 18099 Patient Case History Files

Full description

This series comprises patient case history files for male and female patients at Kew (VA 2840). Each patient admitted into a psychiatric hospital was required by legislation to have a file created which documented their case history from time of admission to discharge or death.

Around 1954, case histories changed from the folio to foolscap files which contain various types of forms and medical paperwork, depending on the legislative requirements at the time; however, the purpose and information content is fairly consistent amongst all series of patient files.

The type of file cover may vary depending on the age and the legislative requirements at the time. All file covers will detail the patient's name. Some also have a file number and/or patient/file movement details as it was required that the file move with the patient. Many of the patients have multiple files often involving two or more different types of file covers.

Greater consistency of file contents occurred with the implementation of the Mental Health Regulations 1962, which made provision for colour coded sheets to be used within the files for specific purposes. These include, but are not limited to:
Sheet 1 (brown) - Face sheet providing personal details
Sheet 2 (purple) - Referring letters
Sheet 3 (red) - Superintendent's Examination
Sheet 4 (orange) - Special Examinations
Sheet 5 (yellow) - Physical Examination
Sheet 6 (blue) - Psychiatric History
Sheet 7 (black) - Psychiatric Examination
Sheet 8A (pink stripe) - Treatment Sheet
Sheet 9 (red) - Re-Admission and Re-Examination
Sheet 10 (green) - Social Worker's Report
Sheet 12 (orange) - Occupational Therapy
Sheet 16 (mauve) - Nursing Notes
Sheet 17 (pink) - Weight Chart
Sheet 18 (brown) - Temperature Chart
Sheet 20 (black) - Post Mortem Examination
Sheet 21 (turquoise) - Surgical Referral and Report
Sheet 22 (purple) - Operation Sheet
Sheet 24 (mid blue) - Eye Sheet
Sheet 26 (blue stripe) - Patient Accident Report

Other information contained within the files can include:
Admission Form
Discharge Summary
Correspondence
Coroner's Reports
Medical Consents
Pathology Results

In some cases an earlier folio, or the contents of another file, has been included in the new file to ensure all patient information was accessible. This was common with patients who were still current when legislation changed the Patient Histories from folio to file formats.

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 by the Office of Psychiatric Services (OPS). 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 at the front of the file.

During the mid 1980's there was a change in file covers to accommodate the numbering system. File covers now include patient's name, file volume number, U.R. number and a list of years which can be marked to indicate patient's last year of attendance. Contents of files reflect the current legislation {Mental Health Act 1986) and are colour coded as well as including an OPS form number.

N.B. Content date range can include reference to date of first admission within the system, i.e. at a different institution, as well as internal departmental correspondence which may have been added to the file many years later - e.g. file request slips, Freedom of Information requests.

For records of earlier date ranges see also VPRS 7397, VPRS 7398 and VPRS 7693.