Record series
Clinical Notes and Patient Files
VPRS 18108
1912 - 1994
Closed, Not set, Open
North Melbourne
Agencies
This record series was created by:
Agencies responsible for this record series: Department of Health and Human Services ( VA 5037 ): 2015 - present
Date Range
Series date range: 1912 - 1994
Series in custody:
1912 - 1994
Contents in custody:
1912 - 2004
Function / Content
This series comprises patient records covering the period from 1912 and includes both clinical notes and the later patient files commencing in 1962. This series was designated to relate to discharged and deceased patients by archivists of the Department of Health and Human Services (VA 5037) who accessioned the files to that department's archives in circa 1994 (see notes below by DHHS transferring archivist).Each patient admitted into Ballarat Mental Hospital was required by legislation to have a file created which documented their case history from time of admission to discharge or death.
The format and content of patient case files varied over time. Between 1912 and 1953 the files were known as Patient Clinical Notes. From 1953 the format of the records changed to a file comprising a cover with papers contained within. File content was inconsistent until major changes in content brought about under the Mental Health Regulations 1962 saw standardisation of the use of forms and recording of patient information.
Each 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,
- in the case of death, an exact account of the autopsy (if any) of the patient.
These records, which were initially (pre 1912) 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.
Patient Clinical Notes
In 1912 the format of case histories was altered from bound casebooks to a loose-leaf 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 or admitted to another hospital, or separated from current files when a 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
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 sometimes 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 usually arranged chronologically by year of discharge and then alphabetically by patient surname within each year.
Patient Files
With the development of modern psychiatry, increasingly complex and detailed patient records were created. In 1953 the format of case histories changed from a loose-leaf 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.
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.
Other information contained within the files can include:
- Admission Form
- Discharge Summary
- Correspondence
- Coroner's Reports
- Medical Consents
- Pathology Results
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.
While the files in this series relate to patients who were discharged or who died by 1994, there are instances where later documents may have been added to individual files. For example, there are instances where correspondence associated with freedom of information requests submitted many years later have been inserted into files.
Note by DHHS transferring archivist, c. 1994 outlining original order.
Patient Files were accessioned during the Lakeside Hospital Records Disposal Project [c.1994]. Files documenting pre-1980 patient discharges or deaths were held in the male quarters whereas files documenting post-1980 discharges or deaths were located in a separate records storage location near Medical Records.
How to use the records
Consult the list of records in this series to locate the record of interest.For records prior to 1912, see the following previous series:
VPRS 7405 Case Books of Male Patients
VPRS 7406 Case Books of Female Patients
Recordkeeping system
Please note that although all files are listed, some are movement cards only. The movement cards indicate that a patient's file has been removed prior to transfer to PROV and their current location is unknown as of 2022.Firstly, files are grouped either by category of Death or Discharged. Secondly, within those groups, files are grouped by year of death or discharge. Finally, within the year groups files are arranged alphabetically by patient name.
Please note files may feature labels from a numbering system imposed by the controlling Department generated from TRIM electronic document and records management system. This system does not reflect the original recordkeeping system of the series.
Patient files were arranged chronologically by year of discharge or death and then alphabetically by patient surname within each year. Unfortunately, this arrangement was complicated, with subsequent movement of files into Male Quarters in recent times. Only pre-1952 files were maintained chronologically by year of discharge or death whereas files after this period were bundled in groups according to letter. Post 1980 discharges or death, however, were in no order whatsoever. Patient files from other provenances were also incorporated, e.g. Ballarat Receiving House, Parklands, Novar etc. Furthermore, outpatient files were simply stored amongst these files.
The Project Team arranged Lakeside Patient Files according to original order prior to their transfer [to archives].
In the instances where documents have been added after the date of discharge or date of death (such as Freedom of Information requests), the file may have been placed into the wrong year. The files should be in chronological order by year of discharge or death, however there may instances where the file is chronologically arranged by the most recent date of the most recent document in the file. Therefore, searching for some files by date of death or discharge may yield no results. Any files with a date range ending after 1994, may indicate the incorrect the date of discharge or date of death.
