VPRS 18099 Patient Case History Files

This series comprises patient case history files for male and female patients at Kew (VA 2840). 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. 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) - Superintendent's 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 within the 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 the numbering system. File covers now 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. 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. For records of earlier date ranges see also VPRS 7397, VPRS 7398 and VPRS 7693.

本系列馆藏为基尤精神病院（VA 2840）男女患者的病例档案文件。根据当时立法要求，凡入住精神病院的患者均需建立档案，记录其自入院至出院或去世期间的完整病史。约1954年起，患者病史档案的载体由对开纸档案改为大裁纸档案夹，此类档案夹会根据当时的立法要求包含各类表单与医疗文书，但所有患者档案系列的核心用途与信息内容基本一致。

档案封面样式会根据档案年代与当时的立法要求有所不同，所有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/档案流转信息——因立法要求档案需随患者同步流转。多数患者拥有多份档案，通常涉及两种及以上不同样式的档案封面。

1962年《精神卫生条例》实施后，档案内容的规范性大幅提升，该条例规定档案内需使用按颜色区分的纸张以对应不同用途，具体包括但不限于：
第1页（棕色）：个人信息扉页
第2页（紫色）：转诊函件
第3页（红色）：院长检查记录
第4页（橙色）：专项检查记录
第5页（黄色）：体格检查记录
第6页（蓝色）：精神病史记录
第7页（黑色）：精神检查记录
第8A页（粉色条纹）：治疗记录表
第9页（红色）：再次入院与复查记录
第10页（绿色）：社会工作者报告
第12页（橙色）：作业治疗记录
第16页（紫红色）：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
第21页（青绿色）：外科转诊与报告
第22页（紫色）：手术记录表
第24页（中蓝色）：眼科检查记录
第26页（蓝色条纹）：患者事故报告

档案内还可包含以下资料：入院登记表、出院小结、往来信函、验尸官报告、医疗同意书、病理检查结果。

部分新档案中会收录早期对开纸档案或其他档案的内容，以确保患者所有信息均可被查阅；在立法将患者病史载体由对开纸改为档案格式时，仍在院的患者常会出现此类情况。

自1983年起，维多利亚州所有精神病与精神卫生机构的患者病历管理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运行。该系统会为每位患者分配唯一档案编号（Unique Record, U.R.），患者每次入住维多利亚州任意精神病院时均需使用该编号，且编号会标注于档案首页。

20世纪80年代中期，为适配新的编号系统，档案封面样式进行了更新。新版封面包含患者姓名、档案卷号、U.R.编号以及可供勾选的就诊年份列表，用于标注患者最后一次就诊的年份。档案内容符合现行《1986年精神卫生法案》的要求，同样采用颜色编码分类，并标注有OPS表单编号。

注：档案的日期范围可涵盖患者在本系统内首次入院的日期（即曾在其他机构就诊的记录），也可包含多年后补入档案的部门内部往来函件，例如档案调取单、信息自由法申请相关文件。

如需获取更早年代范围的档案记录，可查阅VPRS 7397、VPRS 7398及VPRS 7693。