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Finding the Right Clinical Notes: Improving Research Access to Personal Health ecords in Scotland 1600-1994

Classification and Examples of PHR

This section provides descriptions of PHRs according to the classifications of them that were developed during the Scottish survey. Subsequently these were used for database entries. As the language surrounding PHRs is susceptible to a range of different interpretations, brief descriptions of each classification are also given below. In addition, some digital examples are provided for Registers, Bound case notes, Folder-based case notes, Post mortem / pathology records, Manuscript case notes, Clinical lectures, Correspondence, Prescriptions and Reports/certificates. Examples of the remaining types of PHR will be added in due course.

The first four classifications make up the majority of the c.1100 searchable entries in the database and almost all of them are hospital rather than private practice or community health records. All the examples of these are taken from the Royal Infirmary of Edinburgh, which is the oldest voluntary hospital in Scotland, having been founded in 1729. Many of its early record formats were widely adopted by other hospitals later in the 18th Century and there is no reason to think that its subsequent record keeping practices were anything other than typical. Examples of the other classifications have been taken from Edinburgh University Library Special Collections and the Royal College of Physicians of Edinburgh Manuscript Collections.

Registers

This term is used for hospital registers of admission and dismission, whether general, maternity, psychiatric or specialist.

Bound case notes
Bound case books were the norm in hospital practice until the early 20th century. Typically, they record information at ward level.

Folder-based case notes
In the early 20th Century there was a general move towards loose leaf medical records of individuals held together by a folder or wallet. This was a convenient means of storing all aspects of a case history, which might feature biochemical and pathological test reports, correspondence, photographs, etc. as well as the case history per se.

Post Mortem/pathology
Almost all pathology records were originally registers of dissections or post mortems. Later they came to include organ and tissue assays.

Manuscript case notes
This is miscellaneous and includes examples not easily fitted into the other categories. It might include records associated with private practice. They might be bound, as in medical note books of practitioners or students or loose leaf, as in fragments of the full case history.

Clinical lectures
These are student transcriptions taken down viva voce by students during hospital clinic or dispensary based classes. Some were subsequently copied out after lectures and others were themselves copies of copies.

Clinical illustrations
These were used prior to the routine use of photography in medicine and also during the period of black and white only, when a more naturalistic representation was required. Subsequently medical artists were and still are employed in special circumstances.

Photographic material
Many case notes and some case books contain photographic material, but this category is reserved for photographic series and items held separately from other medical records to which they were once linked. Typically they include brief patient details on their versos.

Correspondence
Case notes also contain correspondence about patients, but this category is reserved for individual letters about patients and series of correspondence kept separately for administrative reasons.

Prescriptions
This is a familiar term and includes both single prescriptions and prescription books.

Patient cards
These are index and other cards typically containing summary details about patient episodes and treatments.

Reports / certificates
These were often required for legal, employment, insurance and other purposes these and were frequently kept separately from case notes for administrative reasons.

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