Taking and Keeping: A Note on the Emergence and Function of Hospital Patient Records

Abstract

The paper attempts to reconstruct the emergence and the changing function of medical recording in psychiatry based on the records of the Charité Hospital in Berlin. The development of patient documentation was influenced by three aspects: firstly the earliest documents, from the early 18th century, became increasingly structured as diverse office technologies entered the hospital's ward at this time. Secondly while medical recording in the narrow sense remained private, the regular and formalized reporting system in the hospital wards of the Charité became an important part of clinical education. Finally the growing scientific role of the records became evident with the reorganisation of the hospital record into a double filing system in the late 1870s, thus allowing the clinicians to use and select patient files systematically for research purposes.

Notes

Risse, 1986.

Craig, 1989–1990; Craig, 1990; Howell, 1995; Timmermans und Berg, 2003, chapter 2.

The records of the Hotel Dieu in Paris go back to the 11th century (Riché. 2000).

Hähner-Rombach, 1995; Beddies und Dörries, 1999; Nolte, 2003; Meier et al., 2007; Klöppel, 2009; Goldberg, 1999, for psychiatric hospitals; Ikpektechi, 1983, for surgery; Roth, 1935, for internal medicine and Ritzmann, 2008, for pediatrics.

The project is funded by the German Funding Organisation (DFG) to whom we are grateful. We would also like to thank J. Andrew Mendelsohn for help and collaboration.

Hess and Mendelsohn, 2010.

The training function of the Charité was established as an element of a broader policy developing a non-academic, practical-oriented education in medicine and surgery for the Prussian military in the early 18^th century.

Instruction für den Pensionär-Chyrurgo von 1737, §10 (Neuhaus, 1971: 227).

Instruction für den Pensionär-Chyrurgo von 1737, Universitätsarchiv der Humboldt-Universität zu Berlin, (in the UAHUB at note 19), Akten der Charité-Direktion 1725–1945, No. 180, 99r.

The leading staff of the hospital administration was recruited from veteran sergeants and therefore trained in basic bureaucratic techniques.

Instruction für die Pensionäir-Chyrurgi im Maison de Charité von 1791, §2 (Neuhaus, 1971: 237).

Hess, 2010.

For venereal diseases, more specialized schemas were used to document the standardized treatment.

Dohrmann, 2011.

In the 1830s, the Charité Administration counted six leading physicians, 12 military surgeons and 35 interns from the Pépinière. The staff included 22 officers (registrars, recording secretaries, economy officers, chief nurses, clerks, apothecaries, priests). The service personnel comprised the chief cook, the chief wash woman, two orderlies, five porters, one bread-cutter, one beer tapper, two night-watchmen, four lamp clerks, one delivery boy, one bath attendant, one corpse watcher, three guards, two apothecary clerks, one corpse-washer, three bathwater-carriers, one cutter, four corpse and firewood-carriers, six servants (one for the military officers, two for the interns, two kitchenmaids, one kitchen servant, eight maidservants, nine washmaids, two stable boys, four housemaids).

Kittler, 1985.

Niehaus and Schmidt-Hannisa, 2005.

Pomata, 2005.

Engstrom, 2005.

UAHUB, Akten der Charité-Direktion 1725–1945, No 1238, 116. ‘Das ist ein fundamentaler Satz für den Aufbau unserer wissenschaftlichen Arbeit. Wie ein Kaufmann sich nicht sein Hauptbuch von anderen einsehen lässt, sondern das zu seiner geistigen Orientierung und geschäftlichen Disposition führt, so ist es auch unmöglich, dass wir die Blätter, in denen unser geistiges Material liegt, verborgen.’

Kohler, 2007; te Heesen and Spary, 2001.

See here the special issue of the Intellectual History Review 20 (2010), especially Blair, 2010.

Sommer, 1899: 154.

Dohrmann, 2011.

Mezzich, 2002; Haug und Stieglitz, 1997.