VPRS 18203 Patient Case History Files

Full description

This series comprises case histories of patients admitted at the Parkville Psychiatric Unit and Adolescent Unit (VA 5143).

Each patient admitted into Parkville Psychiatric Unit (PPU) (VA 5143) was required by legislation to have a file created which documented their case history from time of admission to discharge or death. The function of the records was to document the condition of clients, their treatment and care during their periods of admission and residence in the Unit.

Content of files will vary but may include a 'Statement of Personal Details of Patient', letters of referral, reports of the Superintendent's examinations, specialist reports, dental reports and reports of special investigations, physical examinations, psychiatric history and examinations, re-admissions, re-examinations and post- mortems and reports by nurses, occupational therapists and social workers. Information relating to treatment, procedures and medicines prescribed may also be present.

Some files include papers relating to admissions either to PPU or other institutions that predate the commencement date of this series.

The files have printed folder covers, bearing the words Hospital Record, that contain the complete medical history of patients during their stay at PPU and also records of previous institutional care if the patient had any such history. Dates of admission and discharge (or death or trial leave) are recorded in columns on the front covers of files.

Some files contain papers added after closure of the series. For example, while the files were in the custody of Archival Services of the Department of Health and Human Services, papers and copies of correspondence relating to matters such as freedom of information requests were added to files that were the subject to such requests. Placeholder files were sometimes included in this series when a patient's case history was transferred with the patient to another institution.