VPRS 18100 Patient Case History Files

This series comprises patient case history files for male and female patients at Mont Park (VA 2846). Each patient admitted into a psychiatric hospital was required by legislation to have a file created which documented 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 fairly consistent amongst all series of patient files. The type of file cover may vary depending on the age and the legislative requirements at the time. All file covers will detail the patient's name. Some also have a file number and/or patient/file movement details as it was required that the file move with the patient. Many of the patients have multiple files, often involving two or more different types of file covers. Information contained within the earlier files can include: Hospital Records Treatment Cards X-ray and Pathology Requests Temperature Charts Superintendent Reports Greater consistency of file contents occurred with the implementation of the Mental Health Regulations 1962, which 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) - Face sheet providing personal details 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 8A (pink stripe) - Treatment Sheet Sheet 9 (red) - Re-Admission and Re-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 Sheet 22 (purple) - Operation Sheet Sheet 24 (mid blue) - Eye Sheet Sheet 26 (blue stripe) - Patient Accident Report Other information contained in these files can include: Admission Form Discharge Summary Correspondence Coroner's Reports Medical Consents Pathology Results In some cases an earlier folio, or the contents of another file, has been included in the new file to ensure all patient information was accessible. This was common with patients who were still current when legislation changed the 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. During the mid 1980's there was a change in file covers to accommodate this numbering system. These file covers 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 reflect the current legislation (Mental Health Act 1986) and are colour coded as well as including an OPS form number. Custody and arrangement of records prior to transfer to PROV This series comprises four sequences of Mont Park Hospital Patient Case Histories, which were discovered in separate locations at Mont Park Hospital, and were transferred to the in-house archives of the former Department of Health and Community Services around 1994. Each sequence were allocated an accession number by the Department. As best as can be determined, the sequence of each accession is as follows: 1. Patient Case Histories - Admission 1955-1977 - Discharge or Death up to 1971 2. Deceased Patient Case Histories - Admission 1955-1991 - Death post 1971 3. Discharged Patient Case Histories - Admission 1955-1991 - Discharge post 1975 4. Discharged Patient Case Histories - Admission circa 1950-1991 - Discharge up to 1975 It cannot be determined why there are two accessions (1 and 4) with an overlap of dates. The records of each accession can be identified by the Department Allocated Item No., as follows: Accession 1 - Item no. starts 94/18 Accession 2 - Item no. starts 94/494 Accession 3 - Item no. starts 94/501 Accession 4 - Item no. starts 94/508 All records in the series have been itemised by name. N.B. Content date range can include 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, Freedom of Information requests.本数据集包含蒙帕克医院（Mont Park，档案编号VA 2846）男女患者的病例档案文件。根据当时立法要求，所有入住精神科医院的患者均需建立档案，记录其从入院到出院或去世期间的病例历程。约1954年起，病例档案的载体从对开页档案改为大裁纸档案，此类档案包含各类表单与医疗文书，具体内容依当时立法要求而定；但所有患者档案系列的核心用途与信息内容大体一致。 档案封面的样式会随时间推移与当时的立法要求有所不同。所有档案封面均会标注患者姓名，部分封面还会包含档案编号及/或患者/档案流转详情——因立法要求档案需随患者一同流转。多数患者拥有多份档案，且通常涉及两种及以上不同样式的档案封面。早期档案内的信息可包括：医院记录、诊疗卡、X光与病理检查申请单、体温记录表、院长报告。 1962年《精神卫生条例》（Mental Health Regulations 1962）实施后，档案内容的规范性显著提升，该条例规定档案内需使用不同颜色的纸张以区分特定用途，具体包括但不限于： 第1页（棕色）：个人信息页，记录患者个人详情 第2页（紫色）：转诊函件 第3页（红色）：院长诊疗评估表 第4页（橙色）：专项检查记录表 第5页（黄色）：体格检查表 第6页（蓝色）：精神病史记录表 第7页（黑色）：精神科诊疗评估表 第8A页（粉色条纹）：诊疗记录表 第9页（红色）：再次入院与复评表 第10页（绿色）：社会工作者报告 第12页（橙色）：作业治疗记录表 第16页（淡紫色）：护理记录 第17页（粉色）：体重记录表 第18页（棕色）：体温记录表 第20页（黑色）：尸检记录表 第21页（青绿色）：外科转诊与报告表 第22页（紫色）：手术记录表 第24页（中蓝色）：眼科相关表单 第26页（蓝色条纹）：患者事故报告表 此类档案还可包含以下其他信息：入院登记表、出院小结、往来函件、验尸官报告、医疗知情同意书、病理检查结果。 部分情况下，早期对开页档案或其他档案的内容会被纳入新档案，以确保患者所有信息均可被查阅。这一情况在立法将患者病史档案从对开页改为大裁纸档案时仍在接受治疗的患者中尤为常见。 自1983年起，维多利亚州所有精神科与精神医疗机构的患者医疗记录控制系统已实现计算机化，由精神卫生服务办公室（Office of Psychiatric Services, OPS）管控的中央系统统一管理。该系统会为每位患者分配唯一记录编号（Unique Record, U.R.），患者每次入住维多利亚州任意精神科医疗机构时均需使用该编号，且编号会标注在档案首页。20世纪80年代中期，为适配该编号系统，档案封面样式进行了更新。新式档案封面包含患者姓名、档案卷号、U.R.编号，以及可勾选标记的年份列表，用于标注患者最后一次就诊的年份。档案内容符合现行《1986年精神卫生法》（Mental Health Act 1986）的要求，不仅采用颜色编码区分用途，还标注了OPS表单编号。 移交至维多利亚州公共档案馆（Public Record Office Victoria, PROV）前的档案保管与整理情况 本数据集包含四组蒙帕克医院患者病例档案，这些档案最初在蒙帕克医院的不同地点被发现，约于1994年移交至原卫生与社区服务部的内部档案馆。原卫生与社区服务部为每组档案分配了入藏编号。经尽可能查证，各组入藏档案的情况如下： 1. 患者病例档案：入院时间1955-1977年，出院或去世时间不晚于1971年 2. 已故患者病例档案：入院时间1955-1991年，去世时间晚于1971年 3. 已出院患者病例档案：入院时间1955-1991年，出院时间晚于1975年 4. 已出院患者病例档案：入院时间约1950-1991年，出院时间不晚于1975年 目前无法确定为何第1组与第4组档案存在日期重叠的情况。各组入藏档案可通过原部门分配的项目编号进行区分，具体如下： 入藏组1：项目编号以94/18开头 入藏组2：项目编号以94/494开头 入藏组3：项目编号以94/501开头 入藏组4：项目编号以94/508开头 本数据集内的所有档案均已按患者姓名进行编目。 注意：档案内容的日期范围可涵盖患者在本系统内的首次入院时间（即在其他机构的入院记录），也可包含多年后补充至档案中的部门内部往来函件——例如档案申请单、信息自由法申请相关文件。