VPRS 7693 Patient Clinical Notes

Patient Clinical Notes - Kew AsylumThis 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 NotesEach 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 FilesWith 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.

患者临床记录（Patient Clinical Notes）——基尤精神病院（Kew Asylum）
本数据集包含基尤精神病院的患者临床记录。女性患者的医疗详情可通过VPRS 7520《女性病例簿与患者临床记录索引》查阅。男性患者的出院日期可从VPRS 7681《出院登记册》获取，该登记册按患者姓名建立字母索引；若查询1912年至1937年的记录，则可参考VPRS 7690《患者名义登记册》，该登记册按患者姓氏字母顺序排列。

患者临床记录（Patient Clinical Notes）
根据立法要求，各机构需留存患者病例史档案，档案格式须遵循总督会同行政会议不时发布的指令。患者入院后须尽快、并于后续定期向病例档案录入以下信息：患者入院时的精神状态与身体状况；患者在院期间的历次病例记录；为治疗其病症所开具的药物及其他疗法的准确说明；若患者死亡，则须提供患者尸检（如实施）的详细记录。
此类档案最初以精装病例簿形式留存，须由根据现行立法任命的督察员或其他官员定期检视。
1912年，病例史档案的格式从精装病例簿改为活页对开纸格式，即后世所称的患者临床记录。格式变更后，当患者转往其他医院时，病例记录可随患者一同转移；若患者出院或死亡，则可将记录移交至精神疾病管理部门（Lunacy Department）。
患者临床记录中收录的信息包括：
- 个人详情：近亲属或友人的姓名与住址、患者的送治人、既往住址、患者年龄与性别、婚姻状况、是否育有子女、职业、生活习惯及出生地。
- 医疗详情：精神失常类型、本次发病时长、既往是否精神异常、病症是否具有遗传性、精神失常的特异性体征、是否存在自杀倾向、是否具有攻击性与破坏性，以及身体状况的简要说明。
档案右侧页面用于记录患者病史。按要求，患者入院时须完整录入其精神与身体状况，且至少在入院后的前六个月内，每月月末补充一则记录；之后则每六个月补充一次完整记录。但实际留存的档案并非总能保持如此细致准确的记录。
临床记录通常会记录患者在院期间是否被转院、出院或死亡。死亡病例中有时会附随尸检报告（Post-Mortem Examination Report）副本。入院时拍摄的患者照片也常被纳入档案。部分活页夹中还包含与患者相关的往来信函。
据推测，临床记录会留存于病房直至患者死亡或出院。患者最终出院或死亡后，病例史档案将按出院年份进行编年排序，同一年份的档案再按患者姓氏字母顺序排列。

患者档案
随着现代精神病学的发展，患者档案的内容愈发复杂详尽。1953年，病例史档案的格式从活页对开纸格式改为文件档案形式，其格式与内容也随时间推移发生了变化。1962年《精神卫生条例》及后续条例规定了各类档案的格式与内容，这些档案共同构成了患者档案或医院病历。此类档案包含「患者个人详情声明」、转诊信函、院长诊疗报告、专科报告、牙科报告、专项检查报告、体格检查报告、精神病史与诊疗记录、再入院记录、复诊记录、尸检报告，以及护士、作业治疗师与社会工作者出具的报告。部分档案中还包含治疗卡。