VPRS 18104 Patient Case History Files

Full description

This series consists of Case Histories of patients admitted to Beechworth Mental Hospital, Mayday Hills Mental Hospital and Mayday Hills Psychiatric Hospital (VA 2842).

Each patient admitted into Mayday Hills Hospital was required by legislation to have a file created which documents 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 consistent with the previous series (VPRS 18103).

The file covers vary depending on the legislative requirements at the time they were created. They include a file number, patient name and/or patient/file movement details. Many of the patients have multiple files often involving two or more different types of file covers.

Contents of the file were not consistent until the Mental Health Regulations 1962 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) - Cover sheet providing personal details of patient
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 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

Other information contained within the files can include:

Admission Form
Discharge Summary
Correspondence
Coroner's Reports
Medical Consents
Pathology Results

In some cases the earlier manila files had patients case notes from the previous recordkeeping system (VPRS 18103) included into the new file to ensure all patient information was accessible. This was common with patients who were still current when legislation changed the format of 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. This number has not been captured in the record listing for this series.

During the mid 1980's there was a change in file covers to accommodate for the U.R number 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 reflected the current legislation (Mental Health Act 1986) at the time and are colour coded as well as including an OPS form number.

N.B. Content date range includes a 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. 

Previous series: VPRS 18103 Patient Clinical Case Notes.