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Historiography of PHRs in research

A Critique of Case Notes

Adapted from Gayle L. Davis, '"Lovers and Madmen have such Seething Brains": Historical Aspects of Neurosyphilis in Four Scottish Asylums, c.1880-1930', Ph.D. thesis, University of Edinburgh (2001), pp.14-19.

A serious consideration of the faults and merits of case notes, their purpose and construction, should be undertaken before using them for research. 1 Clinical records are a rich and under-utilised source. 2 They allow an insight into individual patients, bring together information from numerous sources, and contain unique information unobtainable elsewhere:

They contain … the details which never come to publication. In other words, they tell you what was really done to patients, and from this is to be derived the most trustworthy and complete assessment of what doctors believed and thought at any given time, and how their minds were working. 3

Although this view generously endows case notes with far more honesty and comprehensiveness than it should 4, such sources do, at the very least, allow the historian to 'clothe the bones' of bare statistics. 5 Historians have a growing interest in hospital and asylum clinical records, since their quality as evidence has been perceived to be more significant than the problems of using them. 6 Historical case notes are a valuable source concerning everyday clinical practice, and allow us to gain insight into contemporary concepts of disease and therapeutic strategies, since it is in them that the theory, discourse and practice of medicine converge. With case notes, we can respond to Ackerknecht's plea 7 to critically analyse what doctors did as well as what they wrote. Research based upon case notes does not actually study the ill or insane as such, but observations of them made by the employees of that institution. Such records are neither patients nor diseases but texts; yet the rich information which case notes offer the historian must not be discarded. Case notes further provide the most consistent and clearly-recorded examples of functions and techniques being integrated into the hospital by being given documentary status. Various tests and procedures, and the participation of specialist departments in patient care, including laboratories, were eventually recorded on unique forms which were filed in the case notes. However, sheets could be inserted rather than directly recording the results onto the case notes, thus introducing the risk of loss.

Despite recent interest and innovation in medical record design and use, medical records have been deemed 'chaotic repositories of information'. 8 Over time, the case notes have become fuller as new types of documents are generated, as more tests are carried out on patients, and as fear of legal action makes doctors reluctant to discard any documentation. The methods of data collection are almost always disparate, idiosyncratic and of doubtful consistency, having developed as much by tradition and in response to ad hoc demands as by any general or logical approach to the satisfaction of data needs. In fact, there was no formal legal requirement for Scottish asylums to keep case books but only to keep a General Register of Admissions (under the Lunacy (Scotland) Act, 1857). However, better records may have been equated with better patient care, thus ensuring that these institutions did keep such records.

After about 1880, printed forms produced by commercial suppliers were widely used by hospitals to achieve regularity and uniformity in the recording and presentation of information. The standardisation of records by using pre-printed proformas has had both supporters and opponents. The former claim that the criteria of thoroughness and reliability could not be satisfied by records which were open-ended or of a variable format. The latter claim that an individualistic approach to medicine was inhibited and that such forms may provide misleading indicators that a particular test or examination had been completed. Weed views the proforma medical record as static, containing medical observations and activities grouped in a meaningless fashion, for which reason he advocates the problem-oriented medical record. 9 Despite the introduction of the proforma in the Royal Edinburgh Asylum (REA) case notes in 1874, and Glasgow Royal Asylum in the 1920s, the records are frequently incomplete due to the inability of patients' relatives to provide information, the failure of staff to record information, or the failure of clerks to copy information. This explains the plethora of literature crying for standardisation. 10

Confusion is further exaggerated by the insertion of correspondence, both personal and professional, into the files; and by physicians beginning new cases in the record volumes before old ones were finished. Throughout the period after 1874, the REA retained a standard four-page proforma, so that supplementary loose material and details had to be inserted and long histories were continued on scattered pages throughout the volumes. Alongside this was the continuing habit of physicians to depend on memory for clinical facts, with many appearing to view records principally as notes to jog their memory. 11 In the asylum, a physician familiar with his patient might not feel it necessary to record many details. The records of pauper patients are generally less detailed than those of fee-payers, probably because few pauper patients complained about their treatment whereas numerous fee-payers did. The institution was most likely safeguarding itself. In short, there are often '"good" organizational reasons for "bad" clinic records'. 12 Obviously the clinicians were not gathering information for future historical research, so that we must understand their rationale for data collection rather than concentrating upon standardising records and thus losing their integrity.

The case notes of a patient are multiple authored and compiled from a number of different sources brought together in such a way as to give quickly accessible information about the patient at any time whilst that patient is resident in the institution. This information reaches the record from the patient, his relatives, the family doctor, and special diagnostic departments. There is therefore a trade-off between multiple authorship and the standard categories of the proforma, with different authors trying to fit subtly different information into uniform categories, and thus losing certain nuances in the data. In the Scottish asylum case notes, the first page, including the medical certificates, was filled in primarily by family testimony. The interview of a psychiatric patient and his family served as a tool of investigation by the alienist, and as a technique for obtaining further information. This would include an account of the patient's illness, the facts of his background and the significant events of his life, in order to gain some understanding of his experiences, attitudes and symptoms. 13 As the patient was deemed unable to give an adequate or reliable history, the necessary information was largely obtained from other sources, usually relatives. 14 The admitting physician filled in the second page, examining the patient on entry. The history was concerned with symptoms conceived as subjective and which patients had noted for themselves or recalled through specific questioning. This was distinct from the physical examination, which addressed signs that were thought to be objective and noted by the examining clinician. These first two pages were probably taken from other sources and transcribed by a clerk onto the case notes, raising the possibility of transcription errors. The progress reports were then filled in by individual physicians directly onto the case notes. The progress notes provide a summary of the condition of the patient at the outset and a chronological record of the patient's progress throughout the duration of care. The rules on the front cover of the REA case notes state that: 'In all recent acute and interesting cases, very frequent if not daily entries are to be made at first.' All other cases were to be reviewed on the first day of January, April, July and October, although most cases were reviewed more frequently.

In modern records, the one piece of information that is routinely processed is the diagnostic classification. Unfortunately the records of many late-nineteenth and early-twentieth century asylum patients lacked even a tentative diagnosis, despite there being a space dedicated to diagnosis in the proforma. This is true of Glasgow Royal Asylum until 1917, and Midlothian and Peebles District Asylum until 1922. The REA recorded disease and Skae's classification until Clouston left in 1908, thereafter replacing this with prognosis, diagnosis and result. During Clouston's period of Physician Superintendency, he reserved the exclusive right to complete the 'diagnosis' section of the case notes, so that each diagnosis is in his handwriting. However, the medical background of these diagnostic and therapeutic decisions is not supplied, which is where annual reports and contemporary publications may supplement clinical material.

Case notes provide details of social characteristics (including name, age, gender, marital status and occupation), medical characteristics (including the dates of admission and discharge, the cause and symptoms of disease), progress reports and the results of treatment, although this format is fluid and variable through time and between institutions. For example, although the REA has sections on personal history (social characteristics), mental condition (including state of mind and general behaviour), and physical condition (such as height, disposition, and previous illnesses) by 1880, Midlothian and Peebles District Asylum does not follow suit until 1889. Barony Parochial Asylum in Glasgow kept photographs of patients attached to each case note from the 1900s onwards, as well as details of cranial measurements. The other Scottish asylums provided some photographs in the post-1890 case notes, though inconsistently. Although photographs are not an essential part of case notes, they are a potentially valuable and illuminating adjunct.

1. For an overview of the historical development of case notes, see, for instance, S. Reiser, 'The Clinical Record in History', two parts, Annals of Internal Medicine, 114 (1991), 902-7 & 980-5. Top
2. The closure period of 100 years in England and 75 years in Scotland has acted as a disincentive to historical research use, as has their volume and technical content. Top
3. A. Nicol and J. Sheppard, 'Why Keep Hospital Clinical Records?', British Medical Journal, 290 (1985), p.264. Top
4. For a more balanced treatment of the pros and cons of clinical records, see G. Risse and J. Warner, 'Reconstructing Clinical Activities: Patient Records in Medical History', Social History of Medicine, 5 (1992), 183-205. Top
5. D. Dow, 'The Archives of the Greater Glasgow Health Board', in O. Checkland and M. Lamb (eds), Health Care as Social History: The Glasgow Case (Aberdeen, Aberdeen University Press, 1982), p.166. Top
6. See, for example, J. Geller, 'A Historical Perspective of the Role of State Hospitals Viewed from the Era of the "Revolving Door"', American Journal of Psychiatry, 149:11 (1992), 1526-33; R. Persaud, 'The Reporting of Psychiatric Symptoms in History: The Memorandum Book of Samuel Coates, 1785-1825', History of Psychiatry, 4 (1993), 499-510; O. Riha, 'Surgical Case Records as an Historical Source: Limits and Perspectives', Social History of Medicine, 8:2 (1995), 271-83. Top
7. E. Ackerknecht, 'A Plea for a "Behaviourist" Approach in Writing the History of Medicine', Journal of the History of Medicine and Allied Sciences, 22 (1967), 211-4. Top
8. J. Petrie and N. McIntyre (eds), The Problem Oriented Medical Record: Its Use in Hospitals, General Practice and Medical Education (Edinburgh, Churchill Livingstone, 1979), p.2. Top
9. For an explanation of the problem-oriented medical record, see, especially, L. Weed, 'Medical Records that Guide and Teach', New England Journal of History, 278:11 (1968), 593-600; Petrie and McIntyre (eds), The Problem Oriented Medical Record. Top
10. See, for instance, Audit Commission for Local Authorities and the National Health Service in England and Wales, Setting the Record Straight: A Study of Hospital Medical Records (London, HMSO, 1995); Central Health Services Council Standing Medical Advisory Committee, The Standardisation of Hospital Medical Records: Report of the Sub-Committee (London, HMSO, 1965). Top
11. Contemporary studies which compare medical records with actual behaviour using audiotapes have found that doctors record little more than half of the information gathered in the history-taking segment of a consultation. See J. Gordon, M. Kearney and P. Watson, 'Medical Records in General Practice', The Medical Journal of Australia, 156 (1992), p.704. Top
12. H. Garfinkel, '"Good" Organizational Reasons for "Bad" Clinic Records', in H. Garfinkel, Studies in Ethnomethodology (New Jersey, Prentice-Hall, 1967), p.186. Top
13. For the importance of history-taking interviews to the diagnostic process, see, for example,
J. Stoekle and J. Billings, 'A History of History-Taking: The Medical Interview', Journal of General Internal Medicine, 2 (1987), 119-27; H. Guly, History Taking, Examination, and Record Keeping in Emergency Medicine (Oxford, Oxford University Press, 1996). Top
14. H. Brody, '"My Story is Broken; Can you Help Me Fix It?': Medical Ethics and the Joint Construction of Narrative', Literature and Medicine, 13:1 (1994), 79-92, analyses how patients, relatives and doctors jointly construct narratives to help them to make sense of illness. On the value of stories and narrative to medical records and medical knowledge, and the value of textual analysis to historians of medicine, see, also, K. Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, Princeton University Press, 1991); A. Kleinman, The Illness Narrative: Suffering, Healing, and the Human Condition (New York, Basic Books, 1988); J. Clark and E. Mishler, 'Attending to Patients' Stories: Reframing the Clinical Task', Sociology of Health and Illness, 14:3 (1992), 344-72. Top

This material © Gayle Davis 2002. All enquiries should be directed to Lothian Health Services Archive - lhsa@ed.ac.uk

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