VPRS 18100 Patient Case History Files

Full description

This series comprises patient case history files for male and female patients at Mont Park (VA 2846). 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.

Information contained within the earlier files can include:
Hospital Records
Treatment Cards
X-ray and Pathology Requests
Temperature Charts
Superintendent Reports

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) - Superintendents 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 in these 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 this numbering system. These file covers 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.

Custody and arrangement of records prior to transfer to PROV

This series comprises four sequences of Mont Park Hospital Patient Case Histories, which were discovered in separate locations at Mont Park Hospital, and were transferred to the in-house archives of the former Department of Health and Community Services around 1994.  Each sequence were allocated an accession number by the Department.  As best as can be determined, the sequence of each accession is as follows:

1. Patient Case Histories - Admission 1955-1977 - Discharge or Death up to 1971
2. Deceased Patient Case Histories - Admission 1955-1991 - Death post 1971
3. Discharged Patient Case Histories - Admission 1955-1991 - Discharge post 1975
4. Discharged Patient Case Histories - Admission circa 1950-1991 - Discharge up to 1975

It cannot be determined why there are two accessions (1 and 4) with an overlap of dates.  The records of each accession can be identified by the Department Allocated Item No., as follows:

Accession 1 - Item no. starts 94/18
Accession 2 - Item no. starts 94/494
Accession 3 - Item no. starts 94/501
Accession 4 - Item no. starts 94/508

All records in the series have been itemised by name.

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.