Care of hospital records : according to the method of the Massachusetts General Hospital, Boston, Mass. / by Grave Whiting Myers.

  • Myers, Grace Whiting, 1859-1950.
Date:
[1911?]
Catalogue details

Licence: In copyright

Credit: Care of hospital records : according to the method of the Massachusetts General Hospital, Boston, Mass. / by Grave Whiting Myers. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    emergency cases, the house officer’s slip is held back for correction. On the chart sheet (see Fig. 2), the Hosp. No., O. P. D. No!, Re-entry, Transfer, Diagnosis, and Path. Nq. are entered by the house officer when he finishes the record preparatory to handing it in. When a patient is discharged, or transferred to an opposite service, the nurse sees that his chart sheet is complete as far as her work is concerned, and before giving it to the house officer to place with the written history (for which he is responsible) attaches her slip to it and sends it in to the Custodian of Records for inspection. This inspection will be referred to later. The Writing of the Record The completed history of a patient is the joint work of house officer and nurse. The charts of temperature, pulse, and respiration are kept by the nurse, and she also records all orders for medication. And her admission slip having been stamped “ Correct,” she fills in the data at the head of the chart sheet as illustrated in Fig. 2, with the exceptions before noted. The house officer then writes in, in red ink, the Hospital Number, which he copies from his admission slip ; the Out-Patient Number, if patient has been from there referred, and in which case a slip is sent from the out- patient department containing this number along with other information. In case of the patient’s being a re-entry, his former record, or records, must be looked up and reference made to such upon the line marked “ Re-entry, See.” If the patient has been transferred from another serv- ice, or is transferred to another service, reference to such transfer is made on the line indicated, mentioning the particular service and giving the Hospital Number, which is always the same as the one recorded on this chart, as this number follows a patient as long as he remains in the hos- pital, no matter how many times he may be transferred. If he comes in again he takes a new number. Diagnosis, and complications (if there be any), are written always by the house officer, and in case of death and autopsy the number of the autopsy is recorded as ‘‘ Path. No.” (See Directions for the Writing of Records, printed below.) The body of the record is written by the house officer and must care- fully cover, in the beginning, these points : family history, past history, present illness, and physical examination. Then follow the daily notes, special attention being paid to new symptoms which may appear, or to change of any sort. In surgical cases coming to operation, a full descrip- tion of the operation is required. Reports upon all X-ray examinations must be fully made. Daily notes continue to the time the patient is dis- charged, and his condition at this time is recorded; i.e., whether well, relieved, or otherwise ; and a statement made as to where he went, whether to the convalescent hospital, the out-patient department, to his own doctor, or to some other hospital. Throughout all records special use is made of red ink, analyses of all sorts, blood, urine, sputum, and feces being recorded in the color ; and in surgical cases, in addition to the analyses, a line at the head of a description of an operation notes in abbreviated form the place where the operation was done (which opera- ting room), the initials of the surgeon, and the anesthetic administered; and at the end of the description, on a separate line, the technical name of