Introduction
All patients admitted into a receiving house and mental (psychiatric) hospital were required by legislation to have files created documenting their case history from admission to discharge or death. These files were to be kept as directed by the Governor-in-Council.
The format and content of patient case files has varied over the years. Prior to 1912, records of all patients were kept together in the institutions in bound casebooks.
Between 1912 and 1953, records known as clinical notes were kept separately for individuals.
From 1953, the records changed to a file format – a cover containing papers.
Until 1962, file content was inconsistent, but major changes to mental health regulations saw forms and patient information recording standardised and each institution was required by legislation to maintain records of patient case histories.
As soon as possible after a patient was admitted, 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
- in the case of death, an exact account of the autopsy (if any) of the patient.
Warning about distressing information
This guide contains information that some people may find distressing. If you experienced abuse as a child or young person in an institution mentioned in this guide, it may be a difficult reading experience. Guides may also contain references to previous views, policies and practices that are regrettable and do not reflect the current views, policies or practices of the department or the State of Victoria. If you find this content distressing, please consult with a support person either from the Department of Health or another agency. There are also other support options available to you.
Disclaimer
Please note that this administrative history is provided for general information only and does not purport to be comprehensive. The department does not guarantee the accuracy of this administrative history.
Sources
Archival Services agency histories.
Lists of records
Casebooks (1862–1912)
These records were initially in the form of bound casebooks, and were regularly examined by an Inspector or other officer appointed under the provisions of the prevailing legislation.
Patient Clinical Notes (1912–53)
In 1912, the format of case histories was altered from bound casebooks to a loose-leaf folio format, known as patient clinical notes. This format meant that the case notes could be transferred with the patient when they moved 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
- a brief description of bodily condition.
The patient clinical notes also recorded the patient’s medical history. They were supposed to contain a full account of the patient’s mental and physical condition on admission, monthly notes at the end of each month for at least the first six months, and comprehensive notes twice a year (six-monthly).
Unfortunately, such thorough and accurate notes were not always maintained.
The clinical notes usually record when a patient was transferred elsewhere, discharged, or died while in custody. A photograph of the patient on admission is often included. Some files contain patient-related correspondence. In cases of death, a copy of the post-mortem examination report is sometimes included.
It is thought that the clinical notes were kept in the wards until a patient’s death or discharge, whereupon the case histories were arranged chronologically first by discharge year and then alphabetically by patient surname.
Patient files (1953– onwards)
With the development of modern psychiatry, increasingly complex and detailed patient records were created.
In 1953, case histories changed from a loose-leaf folio format to files containing various types of forms and medical paperwork, depending on the legislative requirements at the time.
The purpose of the files (and the patient’s clinical notes) was to record the patient’s history and clinical information.
The file covers vary depending on their age and the prevailing legislative requirements.
The file records the patient’s name, some have a file number and/or patient movement details.
Files were required to be transferred together with a patient moving between institutions. Many patients have multiple files often with two or more different types of file covers.
File contents were inconsistent until the Mental Health Regulations 1962 required the files to use colour-coded sheets 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 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.
Other information contained within the files can include:
- Admission form
- Discharge summary
- Correspondence
- Coroner’s reports
- Medical consents
- Pathology results.
In some cases, earlier manila files have been included in the new files to ensure all patient information was accessible. This was common with patients who were receiving care when legislation required the patient histories to change from folio to file formats.
Since 1983, the control system for Victorian psychiatric and mental institution patients’ medical records has been computerised on a central system controlled by the Office of Psychiatric Services (OPS). This system allocates each patient a unique record (UR) number, recorded at the front of the file and used every time that patient is admitted to any psychiatric institution in Victoria.
During the mid-1980s, the file covers changed to accommodate the UR numbering system. Subsequent file covers included patient’s name, file volume number, UR number and a list of years to select, indicating the last year of attendance.
The files include enclosures that reference the current legislation at the time, for example the Mental Health Act 1986, and are colour-coded and include an OPS form number.
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