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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    the operation is written: e.g., Gastro-enterostomy, or Cholecystostomy, etc. All medications are recorded in red ink. This is valuable in direct- ing the eye quickly to certain data, and it is also ornamental, a point which need not be ignored, even in scientific work. In Fig. 2 will be noticed lines marked “ Patient’s Physician,” etc. This is intended for the name of the family physician ; and if there is none, no name should be recorded here. It is for use in hunting up a patient long after he has left the hospital. The case may be one of special interest to some doctor, or it may be one of a series of cases ; a letter addressed to the patient may fail of response, but a letter written to this doctor, whose address is likely to be a permanent one, often brings a reply and locates the patient. This, and the two other addresses mentioned in the description of the admission slip, are used for this purpose, and have proved most valuable when groups of cases were being studied, and patients asked to return for examination in order that end results might be obtained. A large percentage of patients are found. In addition to the chart sheet and the ordinary ones used for the history, there are a number of accessory sheets, to be used, or not, as may be required. For cases of diabetes mellitus there is a special urine chart ; for cases of pernicious anemia there is a special blood chart; there is a sheet for urine analysis to be used in cases of long duration, where fre- quent examinations are necessary ; and there are forms for recording sputum and feces ; and for infants, a special form for recording feedings. Then there are consultation slips, pathological reports, and bacteriologi- cal reports. These must be carefully kept together in the ward, and after the patient is discharged and the history completed, sent with the history to the Record Room at the proper time. Directions for the Writing of Records Name. — Write name'of patient in full; initials are not sufficient. Age, etc. — Do not omit age, nor to indicate whether patient is married, widowed, or single ; white or colored. Residence. — Give Street and No., if possible ; and always place (even if it is Boston), and State. Patient’s Physician. —Give full name and full address (Street and No.) of patient’s physician. This is very important, as a patient can often be found in after years through his physician when all other means have failed. Continual work in research demands as full particulars as possible. Date. — Do not omit the year ; and in Records admitted through the Accident Ward, give hour at which such case was admitted, also whether a.m. or P.M. Place the date of entrance on the first page of each Record in the date column (as well as on the chart sheet), and be careful always to carry forward date from the bottom of one page to the top of the next. Hospital and O. P. D. Numbers. — Write in red ink. Diagnosis. —Write in red ink, and do not give name of Operation for diagnosis ; write the former in the body of the Record immediately after description of Operation. Re-Entries and Transfers.—Give re-entry and transfer references,