VPRS 7403 Case Books of Male Patients

From at least 1845 and the proclamation of An Act for the Regulation of the Care and Treatment of Lunatics (8 & 9 Vic c.100), each asylum was required to maintain a casebook of patients. The book was 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 casebook:the mental state and bodily condition of every patient on admissionthe history of his/her case recorded from time to time while he/she continued to be a patient in the asyluma correct description of the medicine and other remedies prescribed for the treatment of his/her disorderand in the case of death an exact account of the autopsy (if any) of the patient.Information recorded in the case histories includes personal and medical details as follows: date of admission; admission number; name and address of nearest relative; by whom brought to the asylum; previous residence; age and sex of patient; whether married, widowed or single; if any family; occupation; habits of life; form of insanity; duration of present attack; if disordered before/if disorder hereditary; specific signs of insanity; if suicidal; if dangerous and destructive; bodily condition; case notes; and a description of the medicine and other remedies prescribed for the treatment of his/her disorder. The Case Books usually record whether a patient was transferred elsewhere, discharged or died in custody. A copy of the post-mortem report was sometimes included in cases of death.In later years the content of the Case Books was altered slightly. Reference was made to the admission number of the patient and a photograph of the patient on admission was often included. Additional information such as extracts from the required medical certificates and a copy of the Medical Superintendent's report on the mental and physical condition of the patient were often incorporated and additional space was provided for recording the history of each patient.These books were to be regularly inspected by an Inspector or other officer appointed under the provisions of the prevailing legislation. It was expected that a full account of the mental and physical condition of the patient would be entered in the casebook on admission of the patient with a further note to be made at the end of each month at least for the first six months and subsequently a full note every six months. However such thorough and accurate notes were not always maintained.In 1912 the format of case histories was changed from bound Case Books to a looseleaf folio format, known as Patient Clinical Notes. The new format facilitated the transfer of case histories with the patients when they were sent to other institutions. Patient Clinical Notes are registered as a separate series.

自1845年《精神病人护理与治疗监管法案》（8 & 9 Vic c.100）正式颁布以来，每家精神病收容所均需为患者留存病例簿，且病例簿的格式需由总督会同枢密院随时指定。患者入院后需尽快完成信息录入，后续亦需定期更新，需录入的内容包括：患者入院时的精神状态与身体状况；患者在收容所住院期间的病史记录；为治疗其精神障碍开具的药物及其他治疗方案的准确说明；若患者死亡，则需附上尸检（如已实施）的完整记录。

病例档案中收录的个人与医疗信息具体包括：入院日期、入院编号、近亲属姓名与住址、送院人员信息、既往住址、患者年龄与性别、婚姻状况（已婚、丧偶或未婚）、是否有家庭、职业、生活习惯、精神障碍类型、本次发病时长、既往是否发病、是否存在遗传性精神障碍、精神障碍特异性体征、是否有自杀倾向、是否具有攻击性与破坏性、身体状况、病例备注，以及为治疗其精神障碍开具的药物及其他治疗方案说明。

该病例簿通常会记录患者是否被转院、出院或在收容所内死亡，死亡病例中有时会附带尸检报告副本。

后续年份中，病例簿的内容略有调整：新增患者入院编号标注项，且通常会附上患者入院时的照片。此外还会补充收录必要医疗证明的摘录、收容所医疗总监出具的患者身心状况报告副本等信息，并为每位患者的病史记录预留更多书写空间。

此类病例簿需由依据现行立法任命的督察员或其他官员定期核查。按照要求，患者入院时需完整记录其身心状况，且在入院后的首六个月内，每月月末均需补充更新记录，之后则每六个月更新一次完整记录。但实际操作中，此类详实准确的记录并非总能得到严格执行。

1912年，病例档案的格式从精装装订的病例簿改为活页卷宗形式，即患者临床记录（Patient Clinical Notes）。新格式便于患者转院时同步转移其病例档案。患者临床记录作为独立序列进行归档管理。