Old Medical Records

Medical and health records are created primarily to provide patient care or improve the health of our society. They give a reliable account of events over a specific period of time, allowing efficient communication between health professionals in the interest of the patient or community.

Information that has been preserved at the of Ontario after its primary function has expired is used by many people other than those in the original circle of care.

This admission form to the psychiatric hospital in Toronto in 1864 provides the age, occupation, place of birth, place of residence, and other details about the patient.

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We can sympathize with the supposed “cause of the present attack” stated here as “Loss of wife, failure in business, & disappointment in love.”

Institutions such as the provincial psychiatric hospitals were communities where some patients stayed for many years. Mental illness in the family was often considered shameful and not discussed, so these records may be the only source of family information for later generations.

Medical records at the are sometimes used to ensure the accountability of practitioners and institutions or for legal purposes. Police officers and former inmates of government institutions have conducted research at the of Ontario to investigate cases of abuse or patient rights.

Father Surprised To Learn He Can't Gain Access To 12 Year Old Daughter's Medical Records Without Her Permission

Or example many individuals and organizations in the health care field were among those who provided records to the Walkerton Inquiry, including the local Board of Health, Ministry of Health, and others. The of Ontario was also those called upon to provide information. It now holds the records of the Walkerton Inquiry and makes them available for public access.

Medical researchers use archival records to study topics such as disease patterns and the effect of treatments over time. Those researching the relationship between genetics and disease try to establish a detailed family history documenting the mental and physical health of all blood relatives in the family tree. This methodology is being used in the research on hereditary factors and schizophrenia.

Policy makers and legislators use health information in order to make informed choices regarding plans and decisions about all aspects of our health care system. For example, statutes and regulations about health and safety issues are introduced following research and analysis of medical and other records.

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One of the early industrial diseases to be designated under the Workmen’s Compensation Act was silicosis, declared an industrial disease for compensation purposes in 1926. Annual chest x-ray examinations were required for all underground miners beginning in 1928.

Insurance providers use medical records to assess claims, and they establish rates based on statistics compiled from health records. Statistical health records are also used by health economists, planners, and policy analysts.

Medical records are sometimes used in teaching, so that practitioners-in-training can learn from the work of others or gain knowledge about the history of the health care professions. The has a collection of historical records from Ontario pharmacies that was used by the University of Toronto’s Faculty of Pharmacy. It includes pharmacy prescriptions, recipe books, medical almanacs, and other material.

Paper Tsunami: How The Move To Digital Medical Records Is Leaving Us Drowning In Old Paper Files

Researchers such as filmmakers and set designers have found the of Ontario’s photographs a valuable resource for illustrating the correct uniform or typical furnishings of a medical environment at a specific time period.Imagine being a three-year-old little boy getting your hand mangled in an accident. Imagine it’s the late 1930s to early 1940s and the closest doctor is nearly 10 miles away. Imagine a rural county doctor performs nothing less than a miracle to save your life.

After my first presentation on the Hunt murders at the West Texas Historical Association in 2009 various people started contacting me out of the blue. Some were legitimate – some not. My research skills took on becoming a detective in finding out who was telling me the truth vs. the oddballs.

One of those people who I’ve written into the Hunt book was that little boy named Jim. He contacted me to help him discover answers to questions he longed asked but had no answers for regarding his childhood accident.

Who Owns Or Can Access My Medical Records?

It was side story I decided I needed to tell in the Hunt story because it gave a small window in time on the surgical skills of Dr. Roy Hunt. While I’ve not found concrete evidence thus far on Jim’s accident to help him answer those specific questions (no I’ve not given up) the early medical record keeping discoveries along the way have been interesting.

My general doctor told me during my initial period of gathering this Hunt research that in those early days between 1900 – 1960s at most all the patient records were either kept on index cards or in small booklets. Doctors’ back then did not write extensive notes and there were not patient charts like they are today. In visiting a small, regional museum one of these patient booklets was discovered by my friend, Willa and I during a photographic endeavor.

The long, narrow book had yellowed pages along some of its edges and was remarkably not brittle. The handwriting had not faded. Turning the pages of this 1929 record book and seeing medical history pop from it was exciting. One date, in particular, Willa looked for was October 29, 1929 – the day of Black Tuesday. Remarkably no doctor notes were made on that day.

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Doctor’s handwriting was as bad back then as it is today. Hard to decipher and even harder to read. Most comments were just squiggly lines throughout the book. A majority of the notes were brief as their small lines permitted. Most of the prognoses in this book were listed as “good.”

Unlike our medical records of today that now are all computerized it’s amazing to have documents like this to look back on a simpler time for doctors. When quick notes were all they needed.I was recently in my hometown of New Martinsville visiting my dad, a retired family physician. When I arrived he had waiting for me a copy of one of my grandfather's medical records from the 1930s. My grandfather, Dr. Albert Coffield, practiced rural medicine in Wetzel County, West Virginia from 1911 until his death in 1936.

My dad was a doctor who practiced out of his house on Coffield Ridge in Wetzel County. After my dad died in 1936 our mother sold the household furnishing and his office equipment. I was 12 years old when he died and my older brother was a first year student at West Virginia University. Since my mother wasn't employed she decided to move us to Morgantown where the University was so that my older brother could continue his college education. As a way to continue the family income she rented rooms to college students - many who came to the University from Wetzel County. Included in the sale of the household and office furnishing was a wooden credenza with metal alphabetized slides. Behind some of the slides were some old medical records that were left in the credenza. Thirty years later a lady who was a patient of mine brought the wooden credenza to me and told me that she had bought the credenza at the auction of my family's household items in 1936. She told me that she thought I would appreciate having it. Here are photos of the medical record of a patient from 1934. The medical record format is simple yet complete. It contains all the important demographic and clinical information - including the patient statement, habits, family history, past history, physician examination and diagnosis. On the back is additional space for notes and a drawing of the internal organs that I suspect was meant to be used with the patient for education and instruction. It even has a built in billing record section that even the change:healthcare crowd would love.

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What can these photos tell us about the current health care reform debate. Compare these photos of a medical record from 1934 to those that cost .73 cents today. Could today's physician and his or her patient get meaningful use out of this record?