VPRS 7693 Patient Clinical Notes

Full description

Patient Clinical Notes - Kew Asylum

This series consists of patient clinical notes from the Kew Asylum.

Female patients' medical details can be accessed through VPRS 7520 Index to Female Case Books and Patient Clinical Notes.

Dates of discharge for male patients can be obtained from VPRS 7681 Discharge Registers which have an alphabetical index by patient name or for the period 1912-1937 refer to VPRS 7690 Nominal Register of Patients, arranged alphabetically by patient surname.

Patient Clinical Notes

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.

It is thought that the clinical notes were kept in the wards until the death or discharge of a patient. Following the patient's last discharge or death, the case histories were arranged chronologically by year of discharge and then alphabetically by patient surname within each year.

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 looseleaf 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.