VPRS 18124 Patient Clinical Case Notes

Full description

This series contains patient clinical case notes from Mont Park (Hospital for the Insane 1912-1934; Mental Hospital 1934-1991) (VA 2846). Records in this series commenced in 1912. Prior to that date, mental health institution's patient case records were in bound case books that contained information on a large number of patients with one or two folios relating to an individual patient. From 1912 the folios relating to an individual patient were created separately in the form of a pale blue, loose-leaf, four-sided folio reinforced on the spine with cotton tape.

The front cover of these patient folios included: patient name; admission dates; trial leave dates; dates boarded out; date of discharge or date of death. The inside pages detail: all available personal details; admission details; medical details; as well as running notes by staff on the patient's condition and treatment. Some files include photographs of patients taken at the time of their admission and some have other documents attached or enclosed.

The thoroughness and accuracy of the patient details varied from folio to folio with some giving a full account of the patient's care, condition and treatment while others contain limited information.

This series includes a number of files in the format used after 1953 and it is most likely that they are included in this series because they were created in the transition period around 1953 to 1955 when new file types were introduced.

See also: Case Books: Male Patients (VPRS 18164). Also, subsequent series contain patient information files created from circa 1955.

Each patient admitted into a mental hospital was required by legislation to have a file created to document their case history from time of admission to discharge or death. In the period 1912 to 1953 the files were in a form that allowed each patient to have a unique file that contained information relevant only to him or her. The file could thus be moved between wards or institutions when the patient was moved or removed from current filing systems when the patient was discharged or died.

Depending on file format and patient circumstances, a file can include the patient's personal details in the form of a face sheet or 'Statement of Personal Details', superintendent's examination, special investigations, physical examination, psychiatric history, psychiatric examination, nursing notes and special treatments.