Case files

“After the turn of the century, casebooks were replaced by flexible case files which contained a variety of different forms and types of documents. Separate activities, tests, and procedures were provided with their own forms, and these were collected together with the clinical history and progress notes to form the case file (Craig I, 63). . . . Between c. 1850 and c. 1950, three major influences had a direct impact on hospitals and their records in both London and Ontario: the involvement of outside groups with the hospital; developments in administrative practices; and developments in hospital medicine (64). . . . [Re #3] The increasingly complex diagnostic and therapeutic environment produced more records and stimulated the development of new series of records and of documents to record the details of procedures, the nature of patient responses, and the administration of departments. The development of hospital medical practice is reflected directly in the clinical case file, which records the participation of new departments, functions, and services in the care of in- and out-patients. Three factors worked in combination to increase the complexity and size of hospital case records: new techniques, the extension of care, and the establishment of standards in the composition of case files. . . . Between 1880 and 1940, the following departments and specialist services were established or extended at the selected hospitals: pathology, dental, photographic, electrical, out-patient, follow-up, x-ray, pharmacy, isolation, dietary, and cardiology” (77).