So what does it all mean? – part 2 – hospital records

In part 1 of this “so what does it all mean?” series I gave an overview of the Lloyd George case note used in English General Practices from 1911. Now to move to hospitals. The illustrations are from the Historical Hospital Admission Records Project.

Harry Haines

Looking at this case note, the structure is similar to the Lloyd George case note with a few extra details (and no NHS Number). The additions are:

• An admission and discharge date (what we now call a Hospital Provider Spell),
• A headline disease (what we now call a primary diagnosis)
• A date of attack (onset)
• A result (the outcome)

You can read the full record from a PDF copy. This shows the left hand column being used to record dates and supplementary information.

Alice Capell

Alice Capell was six years old when she was first admitted to the Hospital for Sick Children (HSC) suffering from acute rheumatism, a problem which was to plague her for the next few years. She was discharged, after a stay of one month, and pronounced cured. This proved optimistic, as 18 months later Alice was back, this time with subacute rheumatism, and a further diagnosis of morbus cordis (or heart disease).

Case notes provide not just a record of treatment and progress, but usually offer some insight into the child’s family background. Alice’s notes record that her mother had died in childbirth at the age of 40. She had given birth to ten children in total, but only four girls had survived, the rest had died from the effects of whooping cough. Her father’s health was reported to be good, as was hers immediately prior to her first attack. The case notes describe the development of Alice’s condition, starting with pains in her ankles spreading to other joints over the course of a few days. She also had a fever which had grown worse, rendering her delirious at times.  During her stay in hospital her condition and treatment was monitored and recorded. Among other drugs she was given colchicine, a potent drug extracted from the plant Colchicum, and an infusion of arnica, both used to treat joint pains. Her doctors seemed particularly interested to record that as her fever and joint pain subsided, a murmur appeared in her heart, which was still present when she was discharged. Other than that, Alice appeared to have fully recovered from her ordeal.

Historical Hospital Admission Records

Despite her recovery, Alice had two further admissions to Great Ormond Street for Haemoptysis (spitting blood) but was discharged after each. Alice appears to have a privileged background. Her family lived as sole occupiers of 3 Lansdown Terrace, next to Coram’s Fields around the corner from Great Ormond Street. This home was one of four built by James Burton in 1793. The family later moved to 17, St John’s Lane, again close by. She was living here when she died aged 16 and was buried in Tower Hamlets cemetery.

Using Unified Modelling Language

Compared to the Lloyd George note, the model has much in common but also has some significant differences:

• The structure is based on patients with distinct admissions, rather than a “cradle to grave” folder with a journal of contacts. This reflects the different operational needs of a General Practice and a hospital physician.
• The admitting physician is not included – later hospital records focus on that leading to the NHS developing an obsession with “Consultant Episodes” for commissioning hospital care.
• The name is a single item compared to the distinct surname and forenames
• The age is less precise (years) rather than a date of birth
• There is a distinct start and end to responsibility (admission date to discharge date) compared to the GP registration.
• There is a distinct “disease” showing each admission has a primary purpose rather than a continuing relationship.
• The narrative brings in a lot of social context both for Harry and Alice.
• Harry’s includes a clinical reference “It was not then known that he indulged in Self Abuse” associated with his poor vision which was then supplemented in the side note with “on occasion of admission addicted to much pertinacious masturbation.”

In the next part of this series I will look at how hospital case notes have evolved since the 19th century.