VPRS 18434 Patient Clinical Notes and Files [SAMPLE ONLY]

Full description

Each institution was required by legislation to maintain records of patient case histories. These records were to be kept in such form as the Governor-in-Council was from time to time to direct. As soon as possible after the admission of any patient and periodically thereafter, the following details were to be entered into the case histories:

- the mental state and bodily condition of every patient on admission,
- the history of his/her case recorded from time to time while he/she continued to be a patient in the asylum,
- a correct description of the medicine and other remedies prescribed for the treatment of his/her disorder,
- and in the case of death, an exact account of the autopsy (if any) of the patient.

These records which were initially in the form of bound casebooks, were to be regularly inspected by an Inspector or other officer appointed under the provisions of the prevailing legislation.

In 1912 the format of case histories was altered from bound casebooks to a looseleaf folio format, known as Patient Clinical Notes. The change in format meant that the case notes could be transferred with the patient whenever they were removed to another hospital or forwarded to the Lunacy Department when the patient was discharged or died.

Information recorded in patient clinical notes included:

- personal details: name and address of nearest relative or friend, by whom brought (to the asylum), previous residence, age and sex of patient, marital status, if any family, occupation, habits of life and native place.

- medical details: the form of insanity, duration of present attack, if disordered before/if condition hereditary, specific signs of insanity, if suicidal, if dangerous and destructive and a brief description of bodily condition.


The page on the right records the medical history of the patient. It was expected that a full account of the mental and physical condition of the patient would be entered in the case notes on admission, with a further note at the end of each month at least for the first six months, and afterwards a full note every six months. However such thorough and accurate notes were not always maintained. The clinical notes usually record whether the patient was transferred elsewhere, discharged or died while in custody. A copy of the Post-Mortem Examination Report is sometimes included in cases of death. A photograph of the patient on admission is often included. Some folios contain correspondence relating to the patient.

Patient Files

With the development of modern psychiatry, increasingly complex and detailed patient records were created. In 1953 the format of case histories changed from a loose leaf folio format to files, the format and contents of which also changed over time. The Mental Health Regulations 1962 and subsequent regulations established the format and content of various records which together constituted the Patient File or Hospital Record. Such files contained 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. Some files included a treatment card.

These patient histories document the treatment and progress of individual patients whilst at Larundel Hospital, Bundoora until 1979. Information includes dates of admission and discharge, name, age, gender, provisional diagnosis, letters of referral, other correspondence, incident and accident reports, case notes regarding treatment, details of physical and psychiatric examinations, and medication prescribed whilst at the Hospital.

The file covers provide a history from when the subject became a mental health patient. Information includes:
- date when patient entered an institution
- section of Act or return from trial leave
- name of hospital
- date left hospital
- whether discharged or on trial leave or died e.t.c.

The files include clinical notes from when the patient was resident at other institutions, most notably Royal Park Hospital, Mont Park Hospital, Kew Mental Hospital and Sunbury Mental Hospital. The reorganisation of psychiatric services, which gave Melbourne another receiving house in 1959 at Larundel, proved to be successful. Many of the patients who previously would have gone to Royal Park went instead to Larundel. The number of patients admitted to Larundel in the next year was increased by a thousand and those admitted to Royal Park decreased by the same number. Clinical notes for many of the patients described in vprs 18095 and vprs 18096, being Patient Case History Files for patients of the Royal Park Hospital, were transferred to Larundel Hospital, Bundoora. Larundel is significant for being known as the birthplace of the drug Lithium.

This series comprises a sample of files to 1978. The remaining pre-1979 files have been destroyed. A large portion of pre-1979 files was badly affected by mould. This sample was constructed on the basis of surnames beginning with the letter "P". These are the only case histories extant for the period 1953-1978. The files have not been arranged in any particular order.